Relationship Between Troponin on Presentation and In-Hospital Mortality in Patients With ST-Segment-Elevation Myocardial Infarction Undergoing Primary Percutaneous Coronary Intervention
Relationship Between Troponin on Presentation and In-Hospital Mortality in Patients With ST-Segment-Elevation Myocardial Infarction Undergoing Primary Percutaneous Coronary Intervention
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DOI：
10.1161/jaha.119.013551
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发表时间：
2019-10-01
影响因子：
5.4
通讯作者：
Gurm, Hitinder S.
中科院分区：
文献类型：
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作者：
Wanamaker, Brett L.;Seth, Milan M.;Gurm, Hitinder S.
ST段抬高型心肌梗死（STEMI）的肌钙蛋白释放具有可预测的动力学，其早期水平反映了缺血持续时间。很少有研究探讨接受直接经皮冠状动脉介入治疗的STEMI患者入院肌钙蛋白水平的价值。我们调查了肌钙蛋白对介绍和死亡率之间的关系，在一个大的，现实世界的队列STEMI患者接受直接经皮冠状动脉介入治疗。方法和结果，我们使用多变量自适应回归模型来研究入院肌钙蛋白水平和住院死亡率之间的关联，为STEMI患者接受直接经皮冠状动脉介入治疗。我们使用来自NCDR（国家心血管数据登记处）CathPCI数据库的经验证的死亡率风险模型对已知的临床风险因素进行了调整，并使用相同的模型根据临床和人口统计学因素计算患者的预测死亡率。然后按肌钙蛋白组对患者进行分层，以比较预测死亡率与观察死亡率。在纳入队列的14061例患者中，47.2%的初始肌钙蛋白水平不可检测或在参考范围内。入院肌钙蛋白是院内死亡率的独立预测因子，任何高于参考范围的数值均与死亡率增加相关（1.8% vs 5.1%，[标准化差异，18.2%]）。在最高入院肌钙蛋白分组中，预测死亡风险最高的患者（13%预测值）的观察死亡率为19.5%。低肌钙蛋白组的患者始终表现出低于预测的死亡率根据其临床和人口统计学的riskprofile.Conclusions，近一半的患者接受直接经皮冠状动脉介入治疗有正常的肌钙蛋白的介绍，并有一个相对良好的结果。死亡率随入院肌钙蛋白水平升高而增加，与基线临床风险无关。大量肌钙蛋白明显升高的患者及其相对较差的结局突出了院前STEMI检测和护理的持续改善。
Background-Troponin release in ST-segment-elevation myocardial infarction (STEMI) has predictable kinetics with early levels reflective of ischemia duration. Little research has examined the value of admission troponin levels in STEMI patients undergoing primary percutaneous coronary intervention. We investigated the relationship between troponin on presentation and mortality in a large, real-world cohort of STEMI patients undergoing primary percutaneous coronary intervention.Methods and Results-We used multivariable adaptive regression modeling to examine the association between admission troponin levels and in-hospital mortality for patients who underwent primary percutaneous coronary intervention for STEMI. We adjusted for known clinical risk factors using a validated mortality risk model derived from the NCDR (National Cardiovascular Data Registry) CathPCI database, and this same model was used to calculate patients' predicted mortality based on clinical and demographic factors. Patients were then stratified by troponin groups to compare predicted versus observed mortality. Of the 14 061 patients included in the cohort, 47.2% had initial troponin levels that were undetectable or within the reference range. Admission troponin was an independent predictor of in-hospital mortality, and any value above the reference range was associated with increased mortality (1.8% versus 5.1%, [standardized difference, 18.2%]). Patients with the highest predicted risk for mortality (13% predicted) in the highest admission troponin grouping experienced an observed mortality of 19.5%. Patients in low troponin groupings consistently demonstrated lower than predicted mortality based on their clinical and demographic risk profile.Conclusions-Nearly half of patients undergoing primary percutaneous coronary intervention had normal troponin on presentation and had a relatively good outcome. Mortality increases with elevated admission troponin levels, regardless of baseline clinical risk. The substantial number of patients who present with markedly elevated troponin and their relatively worse outcomes highlights the need for continued improvement in prehospital STEMI detection and care.