初次高敏肌钙蛋白T升高的胸痛患者纳入与排除急性心肌梗死的最佳策略
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摘要
目的探讨初次高敏肌钙蛋白T(hs-cTnT)升高的胸痛患者纳入与排除急性心肌梗死(AMI的最佳策略。方法纳入于2017年1月至2018年6月因胸痛就诊于四川大学华西医院急诊科,初次hs-cTnT水平> 14 ng/L且心电图表现为非典型ST改变的患者,3 h后再次采集患者血液分析hs-cTnT,收集患者基本信息,建立0/3 h动态观察初次高敏肌钙蛋白T升高的胸痛患者纳入与排除AMI的最佳策略。结果心电图非典型改变伴初次hs-cTnT> 14 ng/L动态观察的绝对变化诊断价值优于相对变化,差异有统计学意义(P <0.05),灵敏度、特异度、阴性预测值和阳性预测值分别为86.96%、80.41%、100.00%、75.62%。结论对心电图无典型改变、初次hs-cTnT入与排除AMI结果可靠。
Objective The study was to investigate the optimal strategy for the dynamic observation of high-sensitivity troponin T(hs-cTnT)for the first time in patients with chest pain and exclude acute myocardial infarction(AMI). Methods We enrolled the chest-pain patients with initial hs-cTnT > 14 ng/L but atypical ECG changes of AMI,who visited the emergency department in West China hospital of Sichuan university from January2017 to June 2018. We collected the basic clinical information and hs-cTnT values at the time of 0 and 3 hours to assess the best strategy for rule out and rule in AMI in patients with chest pain. Results For patients with the hs-cTnT > 14 ng/L,the best cutoff values of absolute change and relative change were 49.40 ng/L and 33.84%respectively. The ROC curve and the area under the curve(AUC)showed that the diagnostic value of the absolute change of 3 h dynamic observation was better than that of the relative change(P < 0.05). The specificity and positive predictive value of AMI were 80.41% and 75.62% for rule in,while the sensitivity and negative predictive value were 86.96% and 100.00% for rule out in chest-pain patients. Conclusion The strategy of 0/3 h hs-cTnT absolute change in patients with chest pain with no typical changes in ECG and initial hs-cTnT > 14 ng/L was reliable for rule in and rule out AMI.
Objective The study was to investigate the optimal strategy for the dynamic observation of high-sensitivity troponin T(hs-cTnT)for the first time in patients with chest pain and exclude acute myocardial infarction(AMI). Methods We enrolled the chest-pain patients with initial hs-cTnT > 14 ng/L but atypical ECG changes of AMI,who visited the emergency department in West China hospital of Sichuan university from January2017 to June 2018. We collected the basic clinical information and hs-cTnT values at the time of 0 and 3 hours to assess the best strategy for rule out and rule in AMI in patients with chest pain. Results For patients with the hs-cTnT > 14 ng/L,the best cutoff values of absolute change and relative change were 49.40 ng/L and 33.84%respectively. The ROC curve and the area under the curve(AUC)showed that the diagnostic value of the absolute change of 3 h dynamic observation was better than that of the relative change(P < 0.05). The specificity and positive predictive value of AMI were 80.41% and 75.62% for rule in,while the sensitivity and negative predictive value were 86.96% and 100.00% for rule out in chest-pain patients. Conclusion The strategy of 0/3 h hs-cTnT absolute change in patients with chest pain with no typical changes in ECG and initial hs-cTnT > 14 ng/L was reliable for rule in and rule out AMI.
引文
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[12]都向阳,黄华兰,王伟青,等.急性心肌梗死患者高敏肌钙蛋白T水平与发病时间的关系研究[J].四川大学学报(医学版),2017,48(5):768-771.
[13]PICKERING J W,GREENSLADE J H,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.
[14]BAHRMANN P,CHRIST M,BAHRMANN A,et al.A 3-hour diagnostic algorithm for non-ST-elevation myocardial infarction using high-sensitivity cardiac troponin T in unselected older patients presenting to the emergency department[J].J Am Med Dir Assoc,2013,14(6):409-416.
[15]ICHISE T,TADA H,SAKATA K,et al.Impact of aging on high-sensitivity cardiac troponin T in patients suspected of acute myocardial infarction[J].Intern Med,2017,56(16):2097-2102.
[16]FAN L Y,YU P,YU S S,et al.Age-specific 99th percentile cutoff of high-sensitivity cardiac troponin T for early prediction of non-ST-segment elevation myocardial infarction(NSTEMI)in middle-aged patients[J].J Clin Lab Anal,2014,28(1):10-15.
[2]SHIYOVICH A,PLAKHT Y,GILUTZ H.Serum calcium levels independently predict in-hospital mortality in patients with acute myocardial infarction[J].Nutr Metab Cardiovasc Dis,2018,28(5):510-516.
[3]GOODACRE S,CROSS E,ARINOLD J,et al.The health care burden of acute chest pain.[J].Heart,2005,91(2):229-230.
[4]SHIELDS E,SEIDEN I,MASSIE S,et al.Analytical validation and establishment of reference intervals for a‘high-sensitivity’cardiac troponin-T assay in horses[J].BMC Vet Res,2016,12(1):104.
[5]中华医学会心血管病学分会.高敏心肌肌钙蛋白在急性冠状动脉综合征中的应用中国专家共识[J].中华检验医学杂志,2012,35(12):1073-1076.
[6]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,2015,37(3):267-315.
[7]罗薇,郭英,聂虎,等.高敏肌钙蛋白T在胸痛患者急诊室留观时间的价值[J].实用医学杂志,2018,34(6):1016-1018.
[8]DAMMAN P,HOF A W,BERG M T,et al.2015 ESC guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation:Comments from the Dutch ACS working group[J].Neth Heart J,2017,25(3):181-185.
[9]SHIYOVICH A,PLAKHT Y,GILUTZ H.Serum calcium levels independently predict in-hospital mortality in patients with acute myocardial infarction[J].Nutr Metab Cardiovasc Dis,2018,28(5):510-516.
[10]POPE J H,AUFDERHEIDE T P,RUTHAZER R,et al.Missed diagnoses of acute cardiac ischemia in the emergency department[J].N Engl J Med,2000,44(16):1163-1170.
[11]GUANGQUANG L,HUALAN H,XIN N,et al.Time from symptom onset influences high-sensitivity troponin T diagnostic accuracy for the diagnosis of acute myocardial infarction[J].Clin Chem Lab Med,2016,54(1):133-142.
[12]都向阳,黄华兰,王伟青,等.急性心肌梗死患者高敏肌钙蛋白T水平与发病时间的关系研究[J].四川大学学报(医学版),2017,48(5):768-771.
[13]PICKERING J W,GREENSLADE J H,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.
[14]BAHRMANN P,CHRIST M,BAHRMANN A,et al.A 3-hour diagnostic algorithm for non-ST-elevation myocardial infarction using high-sensitivity cardiac troponin T in unselected older patients presenting to the emergency department[J].J Am Med Dir Assoc,2013,14(6):409-416.
[15]ICHISE T,TADA H,SAKATA K,et al.Impact of aging on high-sensitivity cardiac troponin T in patients suspected of acute myocardial infarction[J].Intern Med,2017,56(16):2097-2102.
[16]FAN L Y,YU P,YU S S,et al.Age-specific 99th percentile cutoff of high-sensitivity cardiac troponin T for early prediction of non-ST-segment elevation myocardial infarction(NSTEMI)in middle-aged patients[J].J Clin Lab Anal,2014,28(1):10-15.
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