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高敏肌钙蛋白在疑似心肌梗死中的应用
Application of High-Sensitivity Troponin in Suspected Myocardial Infarction


Johannes T. Neumann ... 心脑血管疾病 • 2019.06.27
相关阅读
• 利用高敏肌钙蛋白连续测定值进行风险分层 • 用于评估非ST段抬高型心肌梗死的0/1小时方案 • 高敏肌钙蛋白阴性和非缺血性ECG可排除急性心肌梗死 • 高敏肌钙蛋白检测可在1小时内排除心肌梗死

摘要


背景

对于因心肌梗死提示症状到急诊科就诊的患者,其高敏肌钙蛋白浓度数据可能有助于确定心肌梗死的概率和后续30日结局。

 

方法

在因心肌梗死提示症状到急诊科就诊的患者所组成的15个国际队列中,我们测定了患者就诊时及早期或后期连续采样后的高敏肌钙蛋白I或高敏肌钙蛋白T浓度。我们使用推导-验证的方法评估了高敏肌钙蛋白临界值的多种组合所具有的诊断和预后性能。我们基于这些数据开发了风险评估工具,用于估计首次心肌梗死的风险以及30日时后续心肌梗死或死亡的风险。

 

结果

在22,651例患者中(推导数据集9,604例,验证数据集13,047例),心肌梗死的患病率为15.3%。就诊时较低的高敏肌钙蛋白浓度和连续采样期间较小的绝对变化幅度这两项与较低的心肌梗死概率和较低的心血管事件近期风险相关。例如低于6 ng/L的高敏肌钙蛋白I浓度和45~120分钟后(早期连续采样)小于4 ng/L的绝对变化幅度所产生的心肌梗死的阴性预测值为99.5%,相关的30日后续心肌梗死或死亡风险为0.2%;总共有56.5%的患者将被归类为低危患者。这些研究结果在外部验证数据集中得到了证实。

 

结论

我们开发了一种风险评估工具,该工具综合了急诊科就诊时的高敏肌钙蛋白I或肌钙蛋白T浓度、连续采样期间的动态变化以及采样的时间间隔,用于估计急诊科就诊时的心肌梗死概率和30日结局(由德国心血管研究中心[German Center for Cardiovascular Research,DZHK]资助;在ClinicalTrials.gov注册号为NCT00470587、NCT02355457、NCT01852123、NCT01994577和NCT03227159;在澳大利亚新西兰临床试验注册系统(Australian New Zealand Clinical Trials Registry)注册号为ACTRN12611001069943、ACTRN12610000766011、ACTRN12613000745741和ACTRN12611000206921)。





作者信息

Johannes T. Neumann, M.D., Raphael Twerenbold, M.D., Francisco Ojeda, Ph.D., Nils A. Sörensen, M.D., Andrew R. Chapman, M.D., Anoop S.V. Shah, M.D., Atul Anand, M.D., Jasper Boeddinghaus, M.D., Thomas Nestelberger, M.D., Patrick Badertscher, M.D., Arash Mokhtari, M.D., Ph.D., John W. Pickering, Ph.D., Richard W. Troughton, M.D., Jaimi Greenslade, Ph.D., William Parsonage, M.D., Matthias Mueller-Hennessen, M.D., Tommaso Gori, M.D., Tomas Jernberg, M.D., Niall Morris, M.D., Christoph Liebetrau, M.D., Christian Hamm, M.D., Hugo A. Katus, M.D., Thomas Münzel, M.D., Ulf Landmesser, M.D., Veikko Salomaa, M.D., Licia Iacoviello, M.D., Ph.D., Marco M. Ferrario, M.D., Simona Giampaoli, M.D., Frank Kee, M.D., Barbara Thorand, M.D., Annette Peters, Ph.D., Rossana Borchini, M.D., Torben Jørgensen, M.D., Stefan Söderberg, M.D., Susana Sans, M.D., Hugh Tunstall-Pedoe, M.D., Kari Kuulasmaa, Ph.D., Thomas Renné, M.D., Ph.D., Karl J. Lackner, M.D., Andrew Worster, M.D., Richard Body, M.B., Ch.B., Ph.D., Ulf Ekelund, M.D., Ph.D., Peter A. Kavsak, Ph.D., Till Keller, M.D., Bertil Lindahl, M.D., Philipp Wild, M.D., Evangelos Giannitsis, M.D., Martin Than, M.D., Louise A. Cullen, M.D., Nicholas L. Mills, M.D., Christian Mueller, M.D., Tanja Zeller, Ph.D., Dirk Westermann, M.D., and Stefan Blankenberg, M.D.
From the University Heart Center Hamburg (J.T.N., R.T., F.O., N.A.S., T.Z., D.W., S.B.), German Center for Cardiovascular Research (DZHK) Partner Site Hamburg–Kiel–Lübeck (J.T.N., N.A.S., T.Z., D.W., S.B.), and the Institute of Clinical Chemistry and Laboratory Medicine, University Medical Center Hamburg–Eppendorf (T.R.), Hamburg, the Department of Cardiology, Heidelberg University Hospital (M.M.-H., H.A.K., E.G.), and DZHK Partner Site Heidelberg–Mannheim (M.M.-H., H.A.K., E.G.), Heidelberg, Cardiology I (T.G., T.M.) and Preventive Cardiology and Preventive Medicine (P.W.), Center for Cardiology, and the Center for Thrombosis and Hemostasis (P.W.), University Medical Center of Johannes Gutenberg University Mainz, and the Institute of Clinical Chemistry and Laboratory Medicine, University Medical Center Mainz (K.J.L.), Mainz, DZHK Partner Site Rhine–Main and the Department of Cardiology, Kerckhoff Heart and Thorax Center, Bad Nauheim (C.L., C.H., T.K.), the Department of Cardiology, Justus Liebig University of Giessen and Marburg, Giessen (C.L., C.H.), the Department of Cardiology, Charité Universitätsmedizin Berlin, Campus Benjamin Franklin, Berlin Institute of Health, and DZHK Partner Site Berlin, Berlin (U.L.), and the Institute of Epidemiology, Helmholtz Zentrum, German Research Center for Environmental Health (B.T., A.P.), and DZHK Partner Site Munich Heart Alliance (A.P.), Munich — all in Germany; the Cardiovascular Research Institute Basel and the Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland (R.T., J.B., T.N., P.B., C.M.); the British Heart Foundation Centre for Cardiovascular Science (A.R.C., A.S.V.S., A.A., N.L.M.) and the Usher Institute of Population Health Sciences and Informatics (A.S.V.S., N.L.M.), University of Edinburgh, Edinburgh, the University of Manchester and Manchester University Foundation Trust, Manchester (N.M., R. Body), U.K. Clinical Research Collaboration for Public Health, Queens University of Belfast, Belfast (F.K.), and the Cardiovascular Epidemiology Unit, Institute of Cardiovascular Research, University of Dundee, Dundee (H.T.-P.) — all in the United Kingdom; the Department of Internal and Emergency Medicine, Lund University, Skåne University Hospital, Lund (A.M., U.E.), the Department of Clinical Sciences, Danderyd University Hospital, Karolinska Institutet, Stockholm (T. Jernberg), the Department of Public Health and Clinical Medicine, and Heart Center, Cardiology, Umeå University, Umeå (S. Söderberg), and the Department of Medical Sciences and Uppsala Clinical Research Center, Uppsala University, Uppsala (B.L.) — all in Sweden; the Department of Medicine, University of Otago Christchurch, and Emergency Department, Christchurch Hospital, Christchurch, New Zealand (J.W.P., R.W.T., M.T.); the Departments of Emergency Medicine (J.G., L.A.C.) and Cardiology (W.P.), Royal Brisbane and Women’s Hospital, Herston, QLD, and the Institute of Health and Biomedical Innovation, Queensland University of Technology, Kelvin Grove (J.G., W.P., L.A.C.) — all in Australia; the National Institute for Health and Welfare, Helsinki, Finland (V.S., K.K.); the Department of Epidemiology and Prevention, Istituto di Ricovero e Cura a Carattere Scientifico Neuromed, Pozzilli (L.I.), the Department of Medicine and Surgery, Research Center in Epidemiology and Preventive Medicine, University of Insubria, Varese (L.I., M.M.F., R. Borchini), and the Department of Cardiovascular, Dysmetabolic, and Aging-Associated Diseases, National Institutes of Health, Rome (S.G.) — all in Italy; the Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen (T. Jørgensen), the Research Center for Prevention and Health, Capital Region of Denmark, Glostrup (T. Jørgensen), and the Medical Faculty, Aalborg University, Aalborg (T. Jørgensen) — all in Denmark; the Catalan Department of Health, Barcelona (S. Sans); and the Division of Emergency Medicine (A.W.) and the Department of Pathology and Molecular Medicine (P.A.K.), McMaster University, Hamilton, ON, Canada. Address reprint requests to Dr. Blankenberg at the University Heart Center Hamburg, Department of General and Interventional Cardiology, Martinistr. 52, 20246 Hamburg, Germany, or at s.blankenberg@uke.de.

 

参考文献

1. Niska R, Bhuiya F, Xu J. National Hospital Ambulatory Medical Care Survey: 2007 emergency department summary. Natl Health Stat Report 2010;1-31.

2. Roffi M, Patrono C, Collet JP, et al. 2015 ESC guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation: Task Force for the Management of Acute Coronary Syndromes in Patients Presenting without Persistent ST-Segment Elevation of the European Society of Cardiology (ESC). Eur Heart J 2016;37:267-315.

3. Westermann D, Neumann JT, Sörensen NA, Blankenberg S. High-sensitivity assays for troponin in patients with cardiac disease. Nat Rev Cardiol 2017;14:472-483.

4. Twerenbold R, Boeddinghaus J, Nestelberger T, et al. Clinical use of high-sensitivity cardiac troponin in patients with suspected myocardial infarction. J Am Coll Cardiol 2017;70:996-1012.

5. Keller T, Zeller T, Peetz D, et al. Sensitive troponin I assay in early diagnosis of acute myocardial infarction. N Engl J Med 2009;361:868-877.

6. Reichlin T, Hochholzer W, Bassetti S, et al. Early diagnosis of myocardial infarction with sensitive cardiac troponin assays. N Engl J Med 2009;361:858-867.

7. Chapman AR, Lee KK, McAllister DA, et al. Association of high-sensitivity cardiac troponin I concentration with cardiac outcomes in patients with suspected acute coronary syndrome. JAMA 2017;318:1913-1924.

8. Pickering JW, Than MP, Cullen L, et al. Rapid rule-out of acute myocardial infarction with a single high-sensitivity cardiac troponin T measurement below the limit of detection: a collaborative meta-analysis. Ann Intern Med 2017;166:715-724.

9. Neumann JT, Sörensen NA, Schwemer T, et al. Diagnosis of myocardial infarction using a high-sensitivity troponin I 1-hour algorithm. JAMA Cardiol 2016;1:397-404.

10. 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. Ann Emerg Med 2016;68(1):76-87.e4.

11. Rubini Gimenez M, Twerenbold R, Jaeger C, et al. One-hour rule-in and rule-out of acute myocardial infarction using high-sensitivity cardiac troponin I. Am J Med 2015;128(8):861-870.e4.

12. Chapman AR, Anand A, Boeddinghaus J, et al. Comparison of the efficacy and safety of early rule-out pathways for acute myocardial infarction. Circulation 2017;135:1586-1596.

13. Keller T, Zeller T, Ojeda F, et al. Serial changes in highly sensitive troponin I assay and early diagnosis of myocardial infarction. JAMA 2011;306:2684-2693.

14. Mokhtari A, Borna C, Gilje P, et al. A 1-h combination algorithm allows fast rule-out and rule-in of major adverse cardiac events. J Am Coll Cardiol 2016;67:1531-1540.

15. Kavsak PA, Jaffe AS, Greene DN, Christenson RH, Apple FS, Wu AHB. Total analytic error for low cardiac troponin concentrations (≤10 ng/L) by use of a high-sensitivity cardiac troponin assay. Clin Chem 2017;63:1043-1045.

16. Cullen L, Mueller C, Parsonage WA, et al. Validation of high-sensitivity troponin I in a 2-hour diagnostic strategy to assess 30-day outcomes in emergency department patients with possible acute coronary syndrome. J Am Coll Cardiol 2013;62:1242-1249.

17. Blankenberg S, Salomaa V, Makarova N, et al. Troponin I and cardiovascular risk prediction in the general population: the BiomarCaRE consortium. Eur Heart J 2016;37:2428-2437.

18. Shortt C, Ma J, Clayton N, et al. Rule-in and rule-out of myocardial infarction using cardiac troponin and glycemic biomarkers in patients with symptoms suggestive of acute coronary syndrome. Clin Chem 2017;63:403-414.

19. Shah AS, Anand A, Sandoval Y, et al. High-sensitivity cardiac troponin I at presentation in patients with suspected acute coronary syndrome: a cohort study. Lancet 2015;386:2481-2488.

20. Than M, Cullen L, Aldous S, et al. 2-Hour accelerated diagnostic protocol to assess patients with chest pain symptoms using contemporary troponins as the only biomarker: the ADAPT trial. J Am Coll Cardiol 2012;59:2091-2098.

21. Body R, Carlton E, Sperrin M, et al. Troponin-only Manchester Acute Coronary Syndromes (T-MACS) decision aid: single biomarker re-derivation and external validation in three cohorts. Emerg Med J 2017;34:349-356.

22. Rubini Giménez M, Hoeller R, Reichlin T, et al. Rapid rule out of acute myocardial infarction using undetectable levels of high-sensitivity cardiac troponin. Int J Cardiol 2013;168:3896-3901.

23. Zeller T, Hughes M, Tuovinen T, et al. BiomarCaRE: rationale and design of the European BiomarCaRE project including 300,000 participants from 13 European countries. Eur J Epidemiol 2014;29:777-790.

24. Goldstein SA, Newby LK, Cyr DD, et al. Relationship between peak troponin values and long-term ischemic events among medically managed patients with acute coronary syndromes. J Am Heart Assoc 2017;6(4):e005334-e005334.

25. Kavsak PA, Worster A, Hill SA, MacRae AR, Jaffe AS. Analytical comparison of three different versions of a high-sensitivity cardiac troponin I assay over 10 years. Clin Chim Acta 2017;475:51-55.

26. Zeller T, Tunstall-Pedoe H, Saarela O, et al. High population prevalence of cardiac troponin I measured by a high-sensitivity assay and cardiovascular risk estimation: the MORGAM Biomarker Project Scottish Cohort. Eur Heart J 2014;35:271-281.

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