Influence of Age on the Diagnosis of Myocardial Infarction.
Influence of Age on the Diagnosis of Myocardial Infarction.
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DOI：
10.1161/circulationaha.122.059994
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发表时间：
2022-10-11
期刊：
影响因子：
37.8
通讯作者：
High-STEACS Investigators
中科院分区：
文献类型：
--
作者：
Lowry MTH;Doudesis D;Wereski R;Kimenai DM;Tuck C;Ferry AV;Bularga A;Taggart C;Lee KK;Chapman AR;Shah ASV;Newby DE;Mills NL;Anand A;High-STEACS Investigators
建议将来自健康参考人群的心肌肌钙蛋白的第 99 个百分位作为心肌梗塞的诊断阈值，但肌钙蛋白浓度受年龄影响很大。我们的目的是评估心肌肌钙蛋白对疑似心肌梗塞的老年患者的诊断性能。在对连续疑似心肌梗死患者进行的多中心试验的二次分析中，我们使用指南推荐的性别特异性和年龄调整的 99 百分位数阈值，评估了三个年龄组（<50、50-74 和≥75 岁）中高敏心肌肌钙蛋白 I 诊断 1 型、2 型或 4b 型心肌梗死的诊断准确性。在 46,435 名年龄在 18-108 岁（平均 61±17 岁）的连续患者中，5,216 名（11%）被诊断为心肌梗死。在 <50 (n=12,379)、50-74 (n=22,380) 和 ≥75 (n=11,676) 岁的患者中，指南推荐阈值的敏感性相似，分别为 79.2%（95% 置信区间 [CI] 75.5-82.9）、80.6%（95% CI 79.2-82.1）和 81.6% (95% CI 79.8-83.2)。随着年龄的增长，特异性从 98.3% (95% CI 98.1-98.5) 下降至 95.5% (95% CI 95.2-95.8) 和 82.6% (95% CI 81.9-83.4)。使用年龄调整后的第 99 个百分位数阈值提高了≥75 岁但失败的心肌梗死患者的特异性（91.3% [90.8-91.9%] 与 82.6% [95% CI 81.9-83.4]）和阳性预测值（59.3% [57.0-61.5%] 与 51.5% [49.9-53.3%]）防止任一参数随年龄增加而下降，并导致与使用指南推荐阈值相比敏感性显着降低（55.9% [53.6-57.9%] 与 81.6% [79.8-83.3%]。年龄改变心肌肌钙蛋白的诊断性能，在应用指南推荐或年龄调整的第 99 个百分位时，老年患者的特异性和阳性预测值降低。个体化诊断方法而不是二元调整人口老龄化需要阈值医学研究委员会和英国心脏基金会。
The 99th centile of cardiac troponin, derived from a healthy reference population, is recommended as the diagnostic threshold for myocardial infarction, but troponin concentrations are strongly influenced by age. Our aim was to assess the diagnostic performance of cardiac troponin in older patients presenting with suspected myocardial infarction. In a secondary analysis of a multicentre trial of consecutive patients with suspected myocardial infarction, we assessed the diagnostic accuracy of high-sensitivity cardiac troponin I at presentation for the diagnosis of type 1, type 2 or type 4b myocardial infarction across three age groups (<50, 50-74 and ≥75 years) using guideline recommended sex-specific and age-adjusted 99th centile thresholds. In 46,435 consecutive patients aged 18-108 years (mean 61±17 years), 5,216 (11%) had a diagnosis of myocardial infarction. In patients <50 (n=12,379), 50-74 (n=22,380) and ≥75 (n=11,676) years, the sensitivity of the guideline recommended threshold was similar at 79.2% (95% confidence interval [CI] 75.5-82.9), 80.6% (95% CI 79.2-82.1) and 81.6% (95% CI 79.8-83.2), respectively. The specificity decreased with advancing age from 98.3% (95% CI 98.1-98.5) to 95.5% (95% CI 95.2-95.8) and 82.6% (95% CI 81.9-83.4). The use of age-adjusted 99th centile thresholds improved the specificity (91.3% [90.8-91.9%] versus 82.6% [95% CI 81.9-83.4]) and positive predictive value (59.3% [57.0-61.5%] versus 51.5% [49.9-53.3%]) for myocardial infarction in patients ≥75 years but failed to prevent the decrease in either parameter with increasing age and resulted in a marked reduction in sensitivity compared to use of the guideline recommended threshold (55.9% [53.6-57.9%] versus 81.6% [79.8-83.3%]. Age alters the diagnostic performance of cardiac troponin, with reduced specificity and positive predictive value in older patients when applying the guideline recommended or age-adjusted 99th centiles. Individualised diagnostic approaches rather than the adjustment of binary thresholds are needed in an aging population. Medical Research Council and British Heart Foundation