Mital Praveen, Forrester John, Abecassis Samuel, Haverty John, Arata Ximena, Gorlin Margaret, Perera Thomas
Department of Emergency Medicine North Shore University Hospital Northwell Health Manhasset New York USA.
J Am Coll Emerg Physicians Open. 2024 Jul 4;5(4):e13228. doi: 10.1002/emp2.13228. eCollection 2024 Aug.
In emergency department (ED) patients with renal impairment, troponin concentrations can be positive without myocardial ischemia. When there is clinical concern for acute coronary syndrome (ACS), guidelines recommend obtaining a delta troponin measurement to identify acute myocardial injury. However, evidence supporting the use of delta troponin to rule in or out ACS in patients with renal impairment and initial elevated troponin levels is limited.
This retrospective, observational study assessed the diagnostic value of a 20% delta troponin cutoff in the prediction of ACS events in ED patients (estimated glomerular filtration rate [eGFR] <60 mL/min/1.72 m) with renal impairment, clinical concern for ACS, and an initial positive troponin concentration using either conventional troponin (cTnT) or high-sensitivity troponin (hsTnT). Clinical concern for ACS was based on initial ED physician-reported diagnoses. Patients with an initial diagnosis of ST-elevation myocardial infarction were not included. A positive initial troponin was identified at a threshold of ≥0.06 ng/mL for cTnT and ≥52 ng/L for hsTnT, and delta troponin measurements were obtained within 24 h of the initial troponin. The primary composite outcome, termed ACS event, included (1) cardiac-related mortality, (2) coronary revascularization (or its recommendation), or a (3) clinically diagnosed type-1 myocardial infarction within 6 weeks of the ED presentation. Sensitivities, specificities, negative predictive values, positive predictive values, and negative and positive likelihood ratios were calculated for these 6-week ACS events.
A total of 608 ED patients with renal impairment, an initial positive troponin, and clinical concern for ACS were included in the study. Of these patients, 234 had an initial positive cTnT (median eGFR 18 mL/min/1.72 m) and 374 had an initial positive hsTnT (median eGFR 25 mL/min/1.72 m). The overall ACS event rate was 38% in the cTnT group and 33% in the hsTnT group. In those with a negative delta, the 6-week ACS event rate was 32% when using cTnT, compared to 24% using hsTnT. Conversely, a positive delta was associated with an ACS event rate of 47% when cTnT was utilized versus 61% when hsTnT was utilized.
In this study, approximately one-third of ED patients with renal impairment who had an initial positive troponin and clinical concern for ACS developed ACS events at 6 weeks. A delta troponin did not appear to provide clinically meaningful assistance in the prediction or exclusion of 6-week ACS events in this cohort.
在急诊科（ED）肾功能损害患者中，肌钙蛋白浓度可能呈阳性，但并无心肌缺血。当临床上怀疑急性冠状动脉综合征（ACS）时，指南建议进行肌钙蛋白增量测定以识别急性心肌损伤。然而，支持使用肌钙蛋白增量来判断肾功能损害且初始肌钙蛋白水平升高的患者是否患有ACS的证据有限。
这项回顾性观察性研究评估了在估计肾小球滤过率（eGFR）<60 mL/min/1.72 m²、临床上怀疑ACS且初始肌钙蛋白浓度呈阳性的ED肾功能损害患者中，使用传统肌钙蛋白（cTnT）或高敏肌钙蛋白（hsTnT）时，20%的肌钙蛋白增量临界值对预测ACS事件的诊断价值。对ACS的临床怀疑基于急诊科医生最初报告的诊断。最初诊断为ST段抬高型心肌梗死的患者未纳入研究。cTnT初始阈值≥0.06 ng/mL和hsTnT初始阈值≥52 ng/L时确定初始肌钙蛋白呈阳性，且在初始肌钙蛋白检测后24小时内进行肌钙蛋白增量测定。主要复合结局称为ACS事件，包括（1）心脏相关死亡率，（2）冠状动脉血运重建（或其建议），或（3）在急诊科就诊后6周内临床诊断的1型心肌梗死。计算了这6周ACS事件的敏感性、特异性、阴性预测值、阳性预测值以及阴性和阳性似然比。
本研究共纳入608例有肾功能损害、初始肌钙蛋白呈阳性且临床上怀疑ACS的ED患者。其中，234例患者初始cTnT呈阳性（eGFR中位数为18 mL/min/1.72 m²），374例患者初始hsTnT呈阳性（eGFR中位数为25 mL/min/1.72 m²）。cTnT组的总体ACS事件发生率为38%，hsTnT组为33%。在肌钙蛋白增量为阴性的患者中，使用cTnT时6周ACS事件发生率为32%，使用hsTnT时为24%。相反，当使用cTnT时，肌钙蛋白增量为阳性与ACS事件发生率47%相关，而使用hsTnT时为61%。
在本研究中，约三分之一初始肌钙蛋白呈阳性且临床上怀疑ACS的ED肾功能损害患者在6周时发生了ACS事件。在该队列中，肌钙蛋白增量似乎并未为预测或排除6周ACS事件提供具有临床意义的帮助。
