High-sensitivity cardiac troponin I at presentation in patients with suspected acute coronary syndrome: a cohort study.
High-sensitivity cardiac troponin I at presentation in patients with suspected acute coronary syndrome: a cohort study.
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DOI：
10.1016/s0140-6736(15)00391-8
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发表时间：
2015-12-19
期刊：
影响因子：
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通讯作者：
High-STEACS investigators
中科院分区：
文献类型：
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作者：
Shah AS;Anand A;Sandoval Y;Lee KK;Smith SW;Adamson PD;Chapman AR;Langdon T;Sandeman D;Vaswani A;Strachan FE;Ferry A;Stirzaker AG;Reid A;Gray AJ;Collinson PO;McAllister DA;Apple FS;Newby DE;Mills NL;High-STEACS investigators
疑似急性冠脉综合征是紧急入院的最常见原因，也是卫生保健资源的巨大负担。确定适合立即出院的低风险患者的策略将有重大好处。我们对苏格兰四家二级和三级护理医院连续登记的6304名疑似急性冠脉综合征患者进行了前瞻性队列研究。我们用一种高灵敏度的心肌肌钙蛋白I测定法测定了入院时的血浆肌钙蛋白浓度。在推导和验证队列中，我们评估了一系列肌钙蛋白浓度对30天后指标性心肌梗死或随后的心肌梗死或心源性死亡的主要预后的负面预测价值。这项试验在ClinicalTrials.gov(编号NCT01852123)注册。在派生队列中的4870名患者中，782名(16%)有指标性心肌梗死，另有32名(1%)在30天内再次出现心肌梗死，75名(2%)心脏病死亡。在无心肌梗死的患者中，肌钙蛋白浓度<5 ng/L者2311例(61%)，对主要预后的阴性预测值为99.6%(95%可信区间为99.3~99.8)。在按年龄、性别、危险因素和既往心血管疾病分层的组中，阴性预测值是一致的。在两个独立的验证队列中，1061名患者中有594名(56%)肌钙蛋白浓度<5 ng/L，总体阴性预测值为99.4%(98.8-99.9)。1年后，与肌钙蛋白浓度在5 ng/L或以上的患者相比，这些患者发生心肌梗死和心脏性死亡的风险较低(0.6%比3.3%；调整后的危险比为0.41，95%CI为0.21~0.80；P<；0.0001)。低血浆肌钙蛋白浓度确定了三分之二的心脏事件风险非常低的患者可以出院。实施这一方法可以大大减少入院人数，并对患者和医疗保健提供者都有重大好处。英国心脏基金会和首席科学家办公室(苏格兰)。
Suspected acute coronary syndrome is the commonest reason for emergency admission to hospital and is a large burden on health-care resources. Strategies to identify low-risk patients suitable for immediate discharge would have major benefits. We did a prospective cohort study of 6304 consecutively enrolled patients with suspected acute coronary syndrome presenting to four secondary and tertiary care hospitals in Scotland. We measured plasma troponin concentrations at presentation using a high-sensitivity cardiac troponin I assay. In derivation and validation cohorts, we evaluated the negative predictive value of a range of troponin concentrations for the primary outcome of index myocardial infarction, or subsequent myocardial infarction or cardiac death at 30 days. This trial is registered with ClinicalTrials.gov (number NCT01852123). 782 (16%) of 4870 patients in the derivation cohort had index myocardial infarction, with a further 32 (1%) re-presenting with myocardial infarction and 75 (2%) cardiac deaths at 30 days. In patients without myocardial infarction at presentation, troponin concentrations were less than 5 ng/L in 2311 (61%) of 3799 patients, with a negative predictive value of 99·6% (95% CI 99·3–99·8) for the primary outcome. The negative predictive value was consistent across groups stratified by age, sex, risk factors, and previous cardiovascular disease. In two independent validation cohorts, troponin concentrations were less than 5 ng/L in 594 (56%) of 1061 patients, with an overall negative predictive value of 99·4% (98·8–99·9). At 1 year, these patients had a lower risk of myocardial infarction and cardiac death than did those with a troponin concentration of 5 ng/L or more (0·6% vs 3·3%; adjusted hazard ratio 0·41, 95% CI 0·21–0·80; p<0·0001). Low plasma troponin concentrations identify two-thirds of patients at very low risk of cardiac events who could be discharged from hospital. Implementation of this approach could substantially reduce hospital admissions and have major benefits for both patients and health-care providers. British Heart Foundation and Chief Scientist Office (Scotland).