超敏肌钙蛋白Ⅰ在急诊胸痛患者急性心肌梗死早期预测中的价值
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摘要
目的探讨超敏肌钙蛋白I(hs-cTnI)的动态变化,明确不同时间点的诊断截点及变化范围,为早期诊断急性心肌梗死(AMI)提供有效预测工具。方法纳入2016年11月～2017年12月就诊于上海中医药大学附属普陀医院的急诊胸痛患者142例,最终诊断为AMI患者75例,不稳定性心绞痛(UA)患者37例,并选择同期健康体检者30名作为健康对照组。采用直接化学发光免疫分析法检测三组患者入院即刻(T_0)、入院3 h(T_3)的血清hs-cTnI值,并计算T_3-T_0 hs-cTnI的绝对变化值及其hs-cTnI的变化斜率(△hs-cTnI)。根据受试者工作特征曲线(ROC)及Youden指数判断不同时间点的最佳诊断截点及最佳变化范围。结果①急诊胸痛患者胸痛症状明显改善,(T_0)hs-cTnI≥0.04 ng/mL,(T_3)hs-cTnI≥0.48 ng/mL [AUC:0.994,最佳截断值:0.48 ng/mL]或T_3-T_0 hs-cTnI绝对变化值≥0.45 ng/mL [AUC:0.952,最佳截断值:0.45 ng/mL],诊断AMI价值较大;②如果胸痛症状持续不能改善,T3-T0 hs-cTnI绝对变化值≥1.001 ng/mL [AUC:0.945,最佳截断值:1.001 ng/mL],诊断AMI价值较大;③而对于只有一过性胸痛症状发生,(T_0)hs-cTnI≥0.05 ng/mL [AUC:0.483,最佳截断值:0.05 ng/mL],随访3 h hs-cTnI绝对变化值下降≥0.015ng/mL[AUC:0.686,最佳截断值:-0.015 ng/mL],诊断UA价值大。④AMI组△hs-cTnI较UA组明显升高(P<0.01)。结论单独使用(T_0)及(T_3)hs-cTnI不能有效诊断AMI,使用hs-cTnI单点诊断数值(T_0或T_3)结合hs-cTnI绝对变化值诊断AMI有效性较高。
Objective To provide an effective predictive tool in patients with acute myocardial infarction(AMI) via exploring the dynamic changes of the high-sensitive troponin I(hs-cTnI) at different time points, and to identify the range of changes at different diagnostic cut-off point. Methods A total of 142 chest paining patients in Putuo Hospital Affiliated to Shanghai Traditional Chinese Medicine University were collected from November 2016 to December 2017.Seventy-five AMI patients and 37 unstable angina(UA) patients were finally diagnosed. Thirty healthy subjects who underwent physical examination in the same period were selected as the healthy control group. Serum levels of hs-cTnI were measured at admission to hospital(T_0) and 3 hours later(T_3) by direct chemiluminescence immunoassay. The absolute change value of hs-cTnI and slop coefficient of hs-cTnI(△hs-cTnI) were calculated based on the two time points. The receiver operating characteristic curve(ROC) and Youden index were determined to provide the best diagnostic cut-off point and the optimal ranges. Results ① If chest pain symptoms were improved significantly,(T_0) hs-cTnI≥0.04 ng/mL,(T_3) hs-cTnI≥0.48 ng/mL [AUC: 0.994, the cutoff: 0.48 ng/mL] or T_3-T_0 hs-cTnI absolute changes≥0.45 ng/mL [AUC: 0.952, the cutoff: 0.45 ng/mL] were valuable to diagnosis of AMI. ② If chest pain symptoms were persisted, the absolute changes T_3-T_0 hs-cTnI≥1.001 ng/mL [AUC: 0.945, the cutoff: 1.001 ng/mL] were valuable to diagnosis of AMI. ③ If chest pain transiently occurred,(T_0) hs-cTnI≥0.05 ng/mL [AUC: 0.483, the cutoff: 0.05 ng/mL],and the absolute changes hs-cTnI falling≥0.015 ng/mL [AUC: 0.686,the cutoff:-0.015 ng/mL] were valuable to diagnosis of UA. ④ △hs-cTnI in the AMI group increased significantly compared with the UA group(P < 0.01). Conclusion AMI can not be effectively diagnosed by hs-cTnI of T_0 or T_3. The △hs-cTnI single point diagnostic values(T_0 or T_3) combined with the absolute changes of hs-cTnI are valuable for AMI diagnosis.
Objective To provide an effective predictive tool in patients with acute myocardial infarction(AMI) via exploring the dynamic changes of the high-sensitive troponin I(hs-cTnI) at different time points, and to identify the range of changes at different diagnostic cut-off point. Methods A total of 142 chest paining patients in Putuo Hospital Affiliated to Shanghai Traditional Chinese Medicine University were collected from November 2016 to December 2017.Seventy-five AMI patients and 37 unstable angina(UA) patients were finally diagnosed. Thirty healthy subjects who underwent physical examination in the same period were selected as the healthy control group. Serum levels of hs-cTnI were measured at admission to hospital(T_0) and 3 hours later(T_3) by direct chemiluminescence immunoassay. The absolute change value of hs-cTnI and slop coefficient of hs-cTnI(△hs-cTnI) were calculated based on the two time points. The receiver operating characteristic curve(ROC) and Youden index were determined to provide the best diagnostic cut-off point and the optimal ranges. Results ① If chest pain symptoms were improved significantly,(T_0) hs-cTnI≥0.04 ng/mL,(T_3) hs-cTnI≥0.48 ng/mL [AUC: 0.994, the cutoff: 0.48 ng/mL] or T_3-T_0 hs-cTnI absolute changes≥0.45 ng/mL [AUC: 0.952, the cutoff: 0.45 ng/mL] were valuable to diagnosis of AMI. ② If chest pain symptoms were persisted, the absolute changes T_3-T_0 hs-cTnI≥1.001 ng/mL [AUC: 0.945, the cutoff: 1.001 ng/mL] were valuable to diagnosis of AMI. ③ If chest pain transiently occurred,(T_0) hs-cTnI≥0.05 ng/mL [AUC: 0.483, the cutoff: 0.05 ng/mL],and the absolute changes hs-cTnI falling≥0.015 ng/mL [AUC: 0.686,the cutoff:-0.015 ng/mL] were valuable to diagnosis of UA. ④ △hs-cTnI in the AMI group increased significantly compared with the UA group(P < 0.01). Conclusion AMI can not be effectively diagnosed by hs-cTnI of T_0 or T_3. The △hs-cTnI single point diagnostic values(T_0 or T_3) combined with the absolute changes of hs-cTnI are valuable for AMI diagnosis.
引文
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[14]Roffi M,Patrono C,Collet J,et al.2015 ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation[J]Eur Heart J,2016,37(3):267-315.
[15]Hamm CW,Bassand JP,Agewall S,et al.ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation:The Task Force for the management of acute coronary syndromes(ACS)in patients presenting without persistent ST-segment elevation of the European Society of Cardiology(ESC)[J].Eur Heart J,2011,32(23):999-3054.
[16]Neumann JT,Havulinna AS,Zeller T,et al.Comparison of three troponins as predictors of future cardiovascular events--prospective results from the FINRISK and BiomaCaRE studies[J].PLoS One,2014,9(3):e90063.
[17]Apple FS,Ler R,Murakami MM.Determination of 19 cardiac troponin I and T assay 99th percentile values from a common presumably healthy population[J].Clin Chem,2012,58(11):1574-1581.
[18]Pickering JW,Greenslade JH,Cullen L,et al.Validation of presentation and 3 h high-sensitivity troponin to rulein and rule-out acute myocardial infarction[J].Heart,2016,102(16):1270-1278.
[19]Cullen L,Parsonage WA,Greenslade J,et al.Delta troponin for the early diagnosis of AMI in emergency patients with chest pain[J].Int J Cardiol,2013,168(3):2602-2608.
[20]Melloni C,Roe MT.Cardiac troponin and risk stratification in ischemic heart disease[J].N Engl J Med,2015,373(7):672-674.
[2]Goodacre S,Cross E,Arnold J,et al.The health care burden of acute chest pain[J].Heart,2005,91(2):229-230.
[3]薛军,韩占红,王明晓,等.北京市急诊胸痛的病因学调查分析[J].中国综合临床,2012,28(10):1042-1046.
[4]Roffi M,Patrono C,Collet JP,et al.2015 ESC guidelines for the management of acute coronary syndromes in patients presenting without persisent ST-segment elevation:task force the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation of the European Society of Cardiology(ESC)[J].Eur Heart J,2016,37(3):267-315.
[5]中华医学会心血管病学分会,中华心血管病杂志编辑委员会.急性ST段抬高型心肌梗死诊断和治疗指南[J].中华心血管病杂志,2015,43(5):380-393.
[6]中华医学会心血管病学分会,中华医学会检验医学分会.高敏感方法检测心肌肌钙蛋白临床应用中国专家共识(2014)[J].中华内科杂志,2015,54(10):899-904.
[7]Mueller C,Giannitsis E,Christ M,et al.Multicenter evaluation of a 0-hour/1-hour algorithm in the diagnosis of myocardial infarction with high-sensitivity cardiac troponin T[J].Ann Emerg Med,2016,68(1):76-87.
[8]Reichlin T,Schindler C,Drexler B,et al.One-hour ruleout and rule-in of acute myocardial infarction using highsensitivity cardiac troponin T[J].Arch Intern Med,2012,172(16):1211-1218.
[9]O′Gara PT,Kushner FG,Ascheim DD,et al.2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction:a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines[J].Circulation,2013,127(4):e362-e425.
[10]Steg PG,James SK,Atar D,et al.ESC guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation[J].Eur Heart J,2012,33(20):2569-2619.
[11]Anderson JL,Adams CD,Antman EM,et al.2012 ACCFAHA focused update incorporated into the ACCF/AHA2007 guidelines for the management of patients with unstable angina/non-ST-elevation myocardial infarction:a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines[J].J Am Coll Cardiol,2013,61(23):e179-e347
[12]Gong X,Zhang B,Piao J,et al.High sensitive and multiple detection of acute myocardial infarction biomarkers based on a dual-readout immunochromatography test strip[J].Nanomedicine,2018,14(4):1257-1266.
[13]Andruchow JE,Kavsak PA,McRae AD.Contemporary E-mergency Department Management of Patients with Chest Pain:A Concise Review and Guide for the High-Sensitivity Troponin Era[J].Can J Cardiol,2018,34(2):98-108.
[14]Roffi M,Patrono C,Collet J,et al.2015 ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation[J]Eur Heart J,2016,37(3):267-315.
[15]Hamm CW,Bassand JP,Agewall S,et al.ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation:The Task Force for the management of acute coronary syndromes(ACS)in patients presenting without persistent ST-segment elevation of the European Society of Cardiology(ESC)[J].Eur Heart J,2011,32(23):999-3054.
[16]Neumann JT,Havulinna AS,Zeller T,et al.Comparison of three troponins as predictors of future cardiovascular events--prospective results from the FINRISK and BiomaCaRE studies[J].PLoS One,2014,9(3):e90063.
[17]Apple FS,Ler R,Murakami MM.Determination of 19 cardiac troponin I and T assay 99th percentile values from a common presumably healthy population[J].Clin Chem,2012,58(11):1574-1581.
[18]Pickering JW,Greenslade JH,Cullen L,et al.Validation of presentation and 3 h high-sensitivity troponin to rulein and rule-out acute myocardial infarction[J].Heart,2016,102(16):1270-1278.
[19]Cullen L,Parsonage WA,Greenslade J,et al.Delta troponin for the early diagnosis of AMI in emergency patients with chest pain[J].Int J Cardiol,2013,168(3):2602-2608.
[20]Melloni C,Roe MT.Cardiac troponin and risk stratification in ischemic heart disease[J].N Engl J Med,2015,373(7):672-674.