急诊高龄患者肌钙蛋白检查现状及诊断价值分析
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摘要
目的探讨急诊高龄患者肌钙蛋白检测现状及对急性心肌梗死(AMI)的诊断价值。方法选择北京大学人民医院急诊内科就诊患者69 757例,其中<60岁患者46 404例(非老年组),60～84岁患者20 122例(老年组),≥85岁患者3231例(高龄组)。2018年9～12月高龄组肌钙蛋白检测313例,其中肌钙蛋白阳性组120例,肌钙蛋白阴性组193例。肌钙蛋白阳性组又分为AMI组47例,非AMI组73例。采集入选患者病史信息及实验室检查结果,包括血常规及N末端B型钠尿肽前体(NT-proBNP)。对高龄肌钙蛋白阳性患者和阴性患者进行比较,logistic回归分析影响肌钙蛋白检测因素,并绘制ROC曲线,比较肌钙蛋白在不同年龄组中对AMI诊断的价值。结果高龄组肌钙蛋白阳性比例明显高于非老年组和老年组(18.5%vs 8.4%、14.9%,P<0.01),且基础肌钙蛋白水平明显高于非老年组和老年组[(0.10±0.74)μg/L vs (0.03±0.25)μg/L、(0.05±0.39)μg/L,P<0.05]。肌钙蛋白阳性组发病<6h、胸痛、高血压、丙氨酸转氨酶、肌酸激酶、乳酸脱氢酶和NT-proBNP水平明显高于肌钙蛋白阴性组,恶性肿瘤、估算肾小球滤过率(eGFR)明显低于肌钙蛋白阴性组(P<0.05,P<0.01)。多因素logistic回归分析显示,发病<6h、eGFR、NT-proBNP水平是影响高龄组肌钙蛋白阳性的主要影响因素。胸痛、初始肌钙蛋白、空腹血糖与高龄组肌钙蛋白阳性诊断AMI相关(P<0.01)。高龄组肌钙蛋白诊断AMI的敏感性100.00%、特异性72.56%、阳性预测值39.17%,ROC曲线下面积0.65,较非老年组和老年组下降。结论高龄患者肌钙蛋白阳性率较高,但其在AMI中的诊断价值下降。
Objective To study the measurement of serum troponin level and its value in diagnosis of acute myocardial infarction(AMI).Methods A total of 69757 patients admitted to our hospital were divided into<60 years old group(n=46 404),60-84 years old group(n=20 122)and≥85 years old group(n=3231).Three hundred and thirteen very old patients with their serum troponin level measured in the Emergency Department of our hospital from September 2018 to December 2018 were divided into troponin-positive group(n=120)and troponin-negative group(n=193).The patients in troponin-positive group were further divided into AMI group(n=47)and AMI-free group(n=73).Their medical history and laboratory examination parameters such as blood routine examination data and serum NT-proBNP level were recorded.The factors influencing the measurement of serum troponin level were compared in very old patients with positive or negative troponin.The sensitivity,specificity,positive and negative predictive value of troponin in diagnosis of AMI were compared.The ROC curve for troponin in diagnosis of AMI was plotted.Results The positive rate of troponin and basic serum troponin level were significantly higher in≥85 years old group than in<60 years old group and 60-84 years old group(18.5% vs 8.4%,14.9%,P<0.01;0.10±0.74μg/L vs 0.03±0.25μg/L,0.05±0.39μg/L,P<0.01).The onset time of AMI was<6 hin troponin-positive group.The incidence of chest pain and hypertension,and the serum levels of creatine kinase,lactate dehydrogenase and NT-proBNP were significantly higher while the incidence of malignant tumors and eGFR were significantly lower in troponinpositive group than in troponin-negative group(P<0.05,P<0.01).The onset time of AMI,eGFR and serum NT-proBNP level were the main factors influencing the measurement of serum troponin level.Multivariate logistic regression analysis showed that chest pain and serum troponin and FBG levels were the independent risk factors for AMI in ovry old patients with positive troponin(P<0.01).The specificity and positive predictive value of troponin were 72.56%and 39.17%respectively in diagnosis of AMI in very old patients.The area under the ROC curve for troponin in diagnosis of AMI was 0.65,which decreases with the age.Conclusion The positive rate of troponin is rather high in very old patients,but its value is decreased in diagnosis of AMI.
Objective To study the measurement of serum troponin level and its value in diagnosis of acute myocardial infarction(AMI).Methods A total of 69757 patients admitted to our hospital were divided into<60 years old group(n=46 404),60-84 years old group(n=20 122)and≥85 years old group(n=3231).Three hundred and thirteen very old patients with their serum troponin level measured in the Emergency Department of our hospital from September 2018 to December 2018 were divided into troponin-positive group(n=120)and troponin-negative group(n=193).The patients in troponin-positive group were further divided into AMI group(n=47)and AMI-free group(n=73).Their medical history and laboratory examination parameters such as blood routine examination data and serum NT-proBNP level were recorded.The factors influencing the measurement of serum troponin level were compared in very old patients with positive or negative troponin.The sensitivity,specificity,positive and negative predictive value of troponin in diagnosis of AMI were compared.The ROC curve for troponin in diagnosis of AMI was plotted.Results The positive rate of troponin and basic serum troponin level were significantly higher in≥85 years old group than in<60 years old group and 60-84 years old group(18.5% vs 8.4%,14.9%,P<0.01;0.10±0.74μg/L vs 0.03±0.25μg/L,0.05±0.39μg/L,P<0.01).The onset time of AMI was<6 hin troponin-positive group.The incidence of chest pain and hypertension,and the serum levels of creatine kinase,lactate dehydrogenase and NT-proBNP were significantly higher while the incidence of malignant tumors and eGFR were significantly lower in troponinpositive group than in troponin-negative group(P<0.05,P<0.01).The onset time of AMI,eGFR and serum NT-proBNP level were the main factors influencing the measurement of serum troponin level.Multivariate logistic regression analysis showed that chest pain and serum troponin and FBG levels were the independent risk factors for AMI in ovry old patients with positive troponin(P<0.01).The specificity and positive predictive value of troponin were 72.56%and 39.17%respectively in diagnosis of AMI in very old patients.The area under the ROC curve for troponin in diagnosis of AMI was 0.65,which decreases with the age.Conclusion The positive rate of troponin is rather high in very old patients,but its value is decreased in diagnosis of AMI.
引文
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[5]Shin H,Jang BH,Lim TH,et al.Diagnostic accuracy of adding copeptin to cardiac troponin for non-ST-elevation myocardial infarction:a systematic review and meta-analysis[J].PLoSOne,2018,13(7):e0200379.DOI:10.1371/journal.pone.0200379.
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[7]Stacy SR,Suarez-Cuervo C,Berger Z,et al.Role of troponin in patients with chronic kidney disease and suspected acute coronary syndrome:a systematic review[J].Ann Intern Med,2014,161(7):502-512.DOI:10.7326/m14-0746.
[8]Sherwood MW,Kristin Newby L.High-sensitivity troponin assays:evidence,indications,and reasonable use[J].J Am Heart Assoc,2014,3(1):e000403.DOI:10.1161/JAHA.113.000403.
[9]Eggers KM,Lindahl B.Application of cardiac troponin in cardiovascular diseases other than acute coronary syndrome[J].Clin Chem,2017,63(1):223-235.DOI:10.1373/clinchem.2016.261495.
[10]Bjurman C,Petzold M,Venge P,et al.High-sensitive cardiac troponin,NT-proBNP,hFABP and copeptin levels in relation to glomerular filtration rates and a medical record of cardiovascular disease[J].Clin Biochem,2015,48(4-5):302-307.DOI:10.1016/j.clinbiochem.2015.01.008.
[11]McKeeman GC,Auld PW.A national survey of troponin testing and recommendations for improved practice[J].Ann Clin Biochem,2015,52(Pt 5):527-542.DOI:10.1177/0004563214568163.
[12]Normann J,Mueller M,Biener M,et al.Effect of older age on diagnostic and prognostic performance of high-sensitivity troponin T in patients presenting to an emergency department[J].Am Heart J,2012,164(5):698-705.DOI:10.1016/j.ahj.2012.08.003.
[2]Shah ASV,Anand A,Strachan FE,et al.High-sensitivity troponin in the evaluation of patients with suspected acute coronary syndrome:a stepped-wedge,cluster-randomised controlled trial[J].Lancet,2018,392(10151):919-928.DOI:10.1016/S0140-6736(18)31923-8.
[3]Kotani K,Ishii J.High-sensitivity cardiac troponin I in the clinical setting:a rapidly developing field[J].Ann Clin Biochem,2015,52(Pt 3):414.DOI:10.1177/0004563215575036.
[4]Mueller-Hennessen M,Lindahl B,Giannitsis E,et al.Diagnostic and prognostic implications using age-and gender-specific cut-offs for high-sensitivity cardiac troponin T-sub-analysis from the TRAPID-AMI Study[J].Int J Cardiol,2016,209:26-33.DOI:10.1016/j.ijcard.2016.01.213.
[5]Shin H,Jang BH,Lim TH,et al.Diagnostic accuracy of adding copeptin to cardiac troponin for non-ST-elevation myocardial infarction:a systematic review and meta-analysis[J].PLoSOne,2018,13(7):e0200379.DOI:10.1371/journal.pone.0200379.
[6]Lee KK,Noaman A,Vaswani A,et al.Prevalence,determinants,and clinical associations of high-sensitivity cardiac troponin in patients attending emergency departments[J].Am JMed,2019,132(1):110.DOI:10.1016/j.amjmed.2018.10.002.
[7]Stacy SR,Suarez-Cuervo C,Berger Z,et al.Role of troponin in patients with chronic kidney disease and suspected acute coronary syndrome:a systematic review[J].Ann Intern Med,2014,161(7):502-512.DOI:10.7326/m14-0746.
[8]Sherwood MW,Kristin Newby L.High-sensitivity troponin assays:evidence,indications,and reasonable use[J].J Am Heart Assoc,2014,3(1):e000403.DOI:10.1161/JAHA.113.000403.
[9]Eggers KM,Lindahl B.Application of cardiac troponin in cardiovascular diseases other than acute coronary syndrome[J].Clin Chem,2017,63(1):223-235.DOI:10.1373/clinchem.2016.261495.
[10]Bjurman C,Petzold M,Venge P,et al.High-sensitive cardiac troponin,NT-proBNP,hFABP and copeptin levels in relation to glomerular filtration rates and a medical record of cardiovascular disease[J].Clin Biochem,2015,48(4-5):302-307.DOI:10.1016/j.clinbiochem.2015.01.008.
[11]McKeeman GC,Auld PW.A national survey of troponin testing and recommendations for improved practice[J].Ann Clin Biochem,2015,52(Pt 5):527-542.DOI:10.1177/0004563214568163.
[12]Normann J,Mueller M,Biener M,et al.Effect of older age on diagnostic and prognostic performance of high-sensitivity troponin T in patients presenting to an emergency department[J].Am Heart J,2012,164(5):698-705.DOI:10.1016/j.ahj.2012.08.003.