Early diagnosis of acute myocardial infarction in patients with mild elevations of cardiac troponin
Early diagnosis of acute myocardial infarction in patients with mild elevations of cardiac troponin
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DOI：
10.1007/s00392-016-1075-9
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发表时间：
2017-06-01
影响因子：
5
通讯作者：
Mueller, Christian
中科院分区：
文献类型：
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作者：
Boeddinghaus, Jasper;Reichlin, Tobias;Mueller, Christian
在高敏心肌肌钙蛋白(hs-cTn)轻度升高的患者中早期诊断急性心肌梗死(AMI)是一项挑战。目前尚不清楚内源性应激的标志物Copeptin和1h-hs-cTn变化是否更适合于满足这一重要的临床需求。我们前瞻性地招募了出现急性心肌梗死症状的患者到急诊科(ED)。两名独立的心脏病专家做出了最终诊断。Hs-cTnI轻度升高定义为26.2 ng/L(第99个百分位数)至75 ng/L，hs-cTnI为14 ng/L(第99个百分位数)至50 ng/L(生物学相当于75 ng/L)。在这组患者中，39例(49%)最终诊断为急性心肌梗死。以受试者工作特征曲线下面积为指标，诊断急性心肌梗死的准确率hs-cTnI为0.51(95%CI 0.39-0.64)，cTnI为0.58(95%CI 0.45-0.71)，1h-hs-cTnI变化为0.78(95%CI 0.68-0.88)，显著高于单纯cTnI(p=0.001)或cTnI(p=0.02)。额外使用1h-hs-cTnI改变，但不使用Copeptin，提高了hs-cTnI在临床表现时的诊断准确性(AUC0.80，95%CI0.70-0.90；p=0.002)。在轻度hs-cTnT升高的患者中，对于Copeptin和1h-hs-cTnT/i的变化也有类似的发现。在提示有急性心肌梗死到ED的患者中，大约6%-22%的患者在出现时有轻微的hs-cTnT/i升高。与Copeptin相比，1h-hs-cTn的加入显著提高了对急性心肌梗死的早期诊断。
The early diagnosis of acute myocardial infarction (AMI) in patients with mild elevations of high-sensitivity cardiac troponin (hs-cTn) is a challenge. It is unclear whether copeptin, a marker of endogenous stress, or 1h-hs-cTn changes are better suited to address this important unmet clinical need.We prospectively enrolled patients presenting with symptoms suggestive of AMI to the emergency department (ED). Two independent cardiologists adjudicated the final diagnosis. Mild hs-cTn elevations were defined as 26.2 ng/L (99th percentile) to 75 ng/L for hs-cTnI, and 14 ng/L (99th percentile) to 50 ng/L (biological-equivalent to 75 ng/L for hs-cTnI) for hs-cTnT.Among 1356 patients, 80 (6%) had mild hs-cTnI elevations at presentation. Within this group, AMI was the final diagnosis in 39 patients (49%). The diagnostic accuracy for the diagnosis of AMI as quantified by the area under the receiver operating characteristic curve (AUC) was 0.51 (95% CI 0.39-0.64) for hs-cTnI at presentation, 0.58 (95% CI 0.45-0.71) for copeptin at presentation, and 0.78 (95% CI 0.68-0.88) for 1h-hs-cTnI changes, which was significantly higher as compared to copeptin (p = 0.02) or hs-cTnI alone (p < 0.001). The additional use of 1h-hs-cTnI changes, but not of copeptin, improved diagnostic accuracy of hs-cTnI at presentation (AUC 0.80, 95% CI 0.70-0.90; p = 0.002 for comparison). Similar findings regarding copeptin and 1h-hs-cTnT/I changes were obtained for mild hs-cTnT elevations.About 6-22% of patients presenting with suggestive AMI to the ED have mild hs-cTnT/I elevations at presentation. In contrast to copeptin, the addition of 1h-hs-cTn changes substantially improves the early diagnosis of AMI.