Clinical chemistry score versus high-sensitivity cardiac troponin I and T tests alone to identify patients at low or high risk for myocardial infarction or death at presentation to the emergency department
Clinical chemistry score versus high-sensitivity cardiac troponin I and T tests alone to identify patients at low or high risk for myocardial infarction or death at presentation to the emergency department
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DOI：
10.1503/cmaj.180144
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发表时间：
2018-08-20
影响因子：
14.6
通讯作者：
Worster, Andrew
中科院分区：
文献类型：
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作者：
Kavsak, Peter A.;Neumann, Johannes T.;Worster, Andrew
背景：检测高敏感性心肌肌钙蛋白(hs-cTn)有助于急诊科就诊的急性冠脉综合征患者的分诊和临床决策；然而，由于分析变异或实验室错误，这可能导致风险的错误分类。我们试图评估一种新的基于实验室的风险分层工具，该工具结合了hs-cTn、血糖水平和估计的肾小球滤过率的测试，以确定急诊科就诊时有心肌梗死或死亡的风险。方法：我们构建了临床化学评分(CCS)(范围0-5分)，并使用4项队列研究的数据验证其为30天心肌梗死(MI)或死亡的预测因子，该研究涉及急诊科出现急性冠脉综合征症状的患者。我们分别使用高敏心肌肌钙蛋白I(hs-cTnI)和高敏心肌肌钙蛋白T(hs-cTnT)计算CCS评分的诊断参数。结果：在联合队列(n=4245)中，17.1%的参与者在30天内发生心肌梗死或死亡。CCS评分为0分最能识别低危人群：hs-cTnI CCS的敏感性为100%(95%可信区间为99.5%~100%)，8.9%(95%可信区间8.1%~9.8%)的人群被归类为30天内发生心肌梗死或死亡的低危人群；Hs-cTnT CCS的敏感性为99.9%(95%CI为99.2%~100%)，其中10.5%(95%CI为9.6%~11.4%)为低危人群。CCS的敏感性高于hs-cTn(5 ng/L：96.6%，95%CI 95.0%-97.8%；hs-cTnT<；6 ng/L：98.2%，95%CI 97.0%-99.0%)。CCS评分为5分的高危人群(hs-cTnI CCS：特异性96.6%，95%CI 96.0%-97.2%；高危人群11.2%[95%CI 10.3%-12.2%]；hs-cTnT CCS：特异性94.0%，95%CI 93.1%-94.7%；13.1%[95%CI 12.1%-14.1%]高危人群与hs-cTn总第99个百分位数比较(hs-cTnI的特异度为93.2%，95%CI为92.3-94.0；hs-cTnT的特异度为73.8%，95%CI为72.3-75.2)。
BACKGROUND: Testing for high-sensitivity cardiac troponin (hs-cTn) may assist triage and clinical decision-making in patients presenting to the emergency department with symptoms of acute coronary syndrome; however, this could result in the misclassification of risk because of analytical variation or laboratory error. We sought to evaluate a new laboratory-based risk-stratification tool that incorporates tests for hs-cTn, glucose level and estimated glomerular filtration rate to identify patients at risk of myocardial infarction or death when presenting to the emergency department.METHODS: We constructed the clinical chemistry score (CCS) (range 0-5 points) and validated it as a predictor of 30-day myocardial infarction (MI) or death using data from 4 cohort studies involving patients who presented to the emergency department with symptoms suggestive of acute coronary syndrome. We calculated diagnostic parameters for the CCS score separately using high-sensitivity cardiac troponin I (hs-cTnI) and high-sensitivity cardiac troponin T (hs-cTnT).RESULTS: For the combined cohorts (n = 4245), 17.1% of participants had an MI or died within 30 days. A CCS score of 0 points best identified low-risk participants: the hs-cTnI CCS had a sensitivity of 100% (95% confidence interval [CI] 99.5%-100%), with 8.9% (95% CI 8.1%-9.8%) of the population classified as being at low risk of MI or death within 30 days; the hs-cTnT CCS had a sensitivity of 99.9% (95% CI 99.2%-100%), with 10.5% (95% CI 9.6%-11.4%) of the population classified as being at low risk. The CCS had better sensitivity than hs-cTn alone (hs-cTnI < 5 ng/L: 96.6%, 95% CI 95.0%-97.8%; hs-cTnT < 6 ng/L: 98.2%, 95% CI 97.0%-99.0%). A CCS score of 5 points best identified patients at high risk (hs-cTnI CCS: specificity 96.6%, 95% CI 96.0%-97.2%; 11.2% [95% CI 10.3%-12.2%] of the population classified as being at high risk; hs-cTnT CCS: specificity 94.0%, 95% CI 93.1%-94.7%; 13.1% [95% CI 12.1%-14.1%] of the population classified as being at high risk) compared with using the overall 99th percentiles for the hs-cTn assays (specificity of hs-cTnI 93.2%, 95% CI 92.3-94.0; specificity of hs-cTnT 73.8%, 95% CI 72.3-75.2).INTERPRETATION: The CCS score at the chosen cut-offs was more sensitive and specific than hs-cTn alone for risk stratification of patients presenting to the emergency department with suspected acute coronary syndrome.