Van Lente F, McErlean E S, DeLuca S A, Peacock W F, Rao J S, Nissen S E
Department of Clinical Pathology, The Cleveland Clinic Foundation, Ohio 44195, USA.
J Am Coll Cardiol. 1999 Feb;33(2):471-8. doi: 10.1016/s0735-1097(98)00592-0.
The purpose of this study was to investigate the utility of cardiac troponin T and troponin I for predicting outcomes in patients presenting with suspected acute coronary syndromes and renal insufficiency relative to that observed in similar patients without renal disease.
Cardiac troponin T and troponin I have shown promise as tools for risk stratification of patients with acute coronary syndromes. However, there is uncertainty regarding their cardiac specificity and utility in patients with renal disease.
We measured troponin T, troponin I and creatine kinase MB in 51 patients presenting with suspected acute coronary syndromes and renal insufficiency and in 102 patients without evidence of renal disease matched for the same peak troponin T or I value, selected from a larger patient cohort. Blood samples were obtained at presentation to an emergency room 4 hours, 8 hours and 16 hours later. The ability of biochemical markers to predict adverse outcomes in both groups including infarction, recurrent ischemia, bypass surgery, heart failure, stroke, death or positive angiography/angioplasty during hospitalization and at six months was assessed by receiver-operator curve analysis. The performance of both troponins was compared between groups.
Thirty-five percent of patients in the renal group and 45% of patients in the nonrenal group experienced an adverse initial outcome; over 50% of patients in all groups had experienced an adverse outcome by 6 months, but these differences were not significant. The area under the curve (AUC) for the ROC curve for troponin T as predictor of initial outcomes was significantly lower in the renal group than in the nonrenal group: 0.56+/-0.07 and 0.75+/-0.07, respectively. The area under the curve was also significantly lower in the renal group compared with the nonrenal group for troponin T as predictor of six month outcomes: 0.59+/-0.07 and 0.74+/-0.07, respectively. The area under the curve was also significantly lower in the renal group compared to the nonrenal group for troponin I as predictor of both initial and six month outcomes: 0.54+/-0.06 vs. 0.71+/-0.07 and 0.53+/- 0.06 vs. 0.65+/-0.07, respectively. The sensitivity of troponin T for both initial and six month adverse outcomes was significantly lower in the renal group than in the nonrenal group at a similar level of specificity (0.87): 0.29 vs. 0.60 and 0.45 vs. 0.56, respectively. Troponin I also exhibited similar differences in sensitivity in the renal group (0.29 vs. 0.50 and 0.33 vs. 0.40, respectively).
The ability of cardiac troponin T and troponin I to predict risk for subsequent adverse outcomes in patients presenting with suspected acute coronary syndromes is reduced in the presence of renal insufficiency.
本研究旨在探讨心肌肌钙蛋白T和肌钙蛋白I在预测疑似急性冠脉综合征和肾功能不全患者预后方面的效用，并与无肾脏疾病的类似患者进行比较。
心肌肌钙蛋白T和肌钙蛋白I已显示出有望成为急性冠脉综合征患者风险分层的工具。然而，其在肾脏疾病患者中的心脏特异性和效用尚不确定。
我们测量了51例疑似急性冠脉综合征和肾功能不全患者以及102例无肾脏疾病证据且肌钙蛋白T或I峰值相同的患者的肌钙蛋白T、肌钙蛋白I和肌酸激酶同工酶MB，这些患者选自一个更大的患者队列。在患者到急诊室就诊时、4小时后、8小时后和16小时后采集血样。通过受试者操作特征曲线分析评估生化标志物预测两组患者不良结局的能力，包括住院期间和6个月时的梗死、复发性缺血、搭桥手术、心力衰竭、中风、死亡或血管造影/血管成形术阳性。比较两组中两种肌钙蛋白的表现。
肾脏疾病组35%的患者和非肾脏疾病组45%的患者出现了不良初始结局；所有组中超过50%的患者在6个月时出现了不良结局，但这些差异无统计学意义。肾脏疾病组中，肌钙蛋白T作为初始结局预测指标的ROC曲线下面积（AUC）显著低于非肾脏疾病组：分别为0.56±0.07和0.75±0.07。对于肌钙蛋白T作为6个月结局预测指标，肾脏疾病组的曲线下面积也显著低于非肾脏疾病组：分别为0.59±0.07和0.74±0.07。对于肌钙蛋白I作为初始和6个月结局的预测指标，肾脏疾病组的曲线下面积也显著低于非肾脏疾病组：分别为0.54±0.06对0.71±0.07和0.53±0.06对0.65±0.07。在相似的特异性水平（0.87）下，肾脏疾病组中肌钙蛋白T对初始和6个月不良结局的敏感性显著低于非肾脏疾病组：分别为0.29对0.60和0.45对0.56。肌钙蛋白I在肾脏疾病组中的敏感性也表现出类似差异（分别为0.29对0.50和0.33对0.40）。
在存在肾功能不全的情况下，心肌肌钙蛋白T和肌钙蛋白I预测疑似急性冠脉综合征患者后续不良结局风险的能力降低。
