心肌损伤的特异性标志物——心肌肌钙蛋白

心血管疾病是严重威胁人类生命健康的疾病,由于心脏疾病的早期症状不典型而对患者造成的危害极大,因此恰当地应用与心脏疾病发病密切相关的标志物,就能有助于对这些患者作出准确及时的诊断和治疗。一般认为,理想的反映急性心肌损伤的生化标志物应具备的特点主要有:具有高度的特异性、具有高度的灵敏性、血中的心肌损伤标志物浓度与损伤程度呈一定关系,窗口期应足够长,检测方法应该操作简便、费用合理、速度快(在1h内);其诊断价值已经临床证实。尽管还没有一个心脏标志物完全达到这些要求,但心肌肌钙蛋白(cTn)满足了上述大部分要求,成为目前…     

心肌损伤早期诊断的一些生化指标

急性心肌梗塞（AMl）是临床常见的急性心血管疾病,也是发病率和死亡率较高的疾病之一。大量的临床实践发现,AMI患者中约1／4早期没有典型的临床症状,约55％没有特异的心电图改变,在这种情况下,心肌损伤生化标志物的检测在诊断AMI时尤为重要,这使得血清生化标志物在AMI的诊断中居重要地位。随着医学科学研究的进展,心肌损伤的血液生化标志物已从旱先的以酶活性为主的检测发展到目前的以蛋白质检测为主的一系列生化指标,包括多种早期标志物（如肌红蛋白,脂肪酸结合蛋白、碳酸酐酶Ⅲ,C反应蛋白,血栓前体蛋白,糖原磷酸化酶BB,等等）和确定标志物[如心肌肌钙蛋白（cTn）等],诊断的敏感性、特异性更趋增强。现在临床常用的一些早期心肌损伤的生化标志物现分别简述如下：     

心肌标志物即时定性检测对诊断早期急性心肌梗死的意义

文章对疑似急性心肌梗死患者分别行心肌标志物肌钙蛋白Ⅰ(CTnI)、肌酸激酶同工酶(CK-MB)、肌红蛋白(Mb)即时定性检测及送实验室化学发光法检测,比较两种方法检测结果、周转时间及敏感度与特异度,探讨心肌标志物即时定性检测对早期急性心肌梗死患者的诊断价值.结果显示,即时定性检测CTnI、CK-MB及Mb具有方便快捷等优势,且检测结果可靠,有利于早期急性心肌梗死的诊断.     

人心肌肌钙蛋白Ⅰ的测定及临床应用进展

心肌肌钙蛋白Ⅰ（Cardiac Troponin Ⅰ，cTnI）作为心肌损伤标志物，在临床上已应用了多年。大量的临床研究证实，心肌cTnI为心肌损伤最特异、最敏感的血清标志物之一，由于其高度的心肌特异性，对于心肌损伤的高度敏感性及较长的窗口期，cTnI已取代CK—MB，被广泛应用于临床诊断。本文就cTnI的测定及临床应用进展作一综述。     

急性心肌梗死的生化标志物研究新进展

随着心脏介入技术和溶栓技术的应用，早期诊断急性心肌梗死变得至关重要，而早期诊断的关键是心肌生化标志物的检测。在临床研究和应用发展的同时，除了肌红蛋白、肌酸激酶同工酶、肌钙蛋白等已应用于临床的标志物外，出现了许多新的生化标志物，对急性心肌梗死的诊断具有重要价值。     

心肌损伤标志物联合检测诊断急性心肌梗死的临床价值探讨

随着环境恶化及居民饮食习惯的变化,急性心肌梗死（Acute Myocardial Infarction,AMI）诱发的病死率迅速攀升[1]。AMI的早期诊断特别是发病6h之内进行确诊,对患者康复及预后具有重要作用。AMI确诊须符合下列标准[2-3]：（1）缺血性胸痛;（2）心电图特征改变;（3）血清心肌损伤标志物水平变化。     

心型脂肪酸结合蛋白在急性心肌梗死早期诊断中的应用

目的探讨心型脂肪酸结合蛋白在急性心肌梗死早期诊断中的应用价值。方法选择在胸痛发作3h以内就诊的患者150例,分别于胸痛发作0~3h、3~6h和6~12h检测血清心型脂肪酸结合蛋白(hearty fatty acid binding protein,H-FABP)、心肌肌钙蛋白Ⅰ(cardiac troponin Ⅰ,cTnI)、肌酸激酶同工酶(creatine kinase isoenzyme MB,CK-MB)和肌红蛋白(myoglobin,MYO)的水平变化,并比较4种心肌标志物诊断早期AMI的敏感性、特异性、阳性预测值和阴性预测值,同时比较胸痛患者发作≤8h时不同心肌标志物联合诊断AMI的敏感性和特异性。结果 AMI患者在胸痛发作3个时间段内血清H-FABP水平均明显高于非AMI组和对照组(P<0.05),非AMI组与对照组差异无统计学意义(P>0.05)。胸痛患者发作0~3 h内H-FABP的敏感性、阳性预测值、阴性预测值均比cTnI、CKMB和MYO高(P<0.05);3~6 h内H-FABP的敏感性、特异性在4者当中最高(P<0.05)。胸痛发作≤8 h,HFABP+cTnI+MYO联合检测对AMI早期诊断的敏感性最高(94.1%)。结论 H-FABP对于诊断早期AMI具有较高敏感性和良好的特异性,在早期AMI诊断方面是一项具有巨大潜力的生化心肌标志物。胸痛发作≤8 h时,HFABP+cTnI+MYO联合检测可进一步提高AMI早期诊断的敏感性,优于传统的cTnI+CK-MB+MYO联合检测。     

肌钙蛋白I和CK-MB在心肌损伤中的诊断价值

目的:评估肌钙蛋白I(c Tn I)和肌酸激酶同工酶(CK-MB)应用于心肌损伤的诊断价值。方法:回顾本院收治的AMI病人80例,有较为明确的发病时间;正常健康人(排除心脏病患者)70例,检查心肌酶学、c Tn I,并对上述指标加以分析、对比研究。结果:AMI患者发病后,4~6h c Tn I值比标准值0.16ug/L明显升高,16~24h后达到峰值,持续7~10d。而CK-MB在患者发病后,6~8h升高,16~24h达到峰值,48h后下降,逐渐恢复正常。c Tn I检测结果敏感性为92.5%,特异性为97.1%,CK-MB检测结果敏感性为73.7%,特异性为95.7%。均高于对照组,分别为c Tn I83.7,CK-MB为59.1,P<0.01。结论:在诊断AMI中,c Tn I比CK-MB敏感性更高,将二者检测手段联合,可以提高其诊断率,为梗死时间判断提供重要的信息。     

急性心肌梗死实验室诊断评价分析

目的通过实验室诊断的评价分析，选择急性心肌梗死（AMI）最佳的检查项目。方法对历年来AMI的实验室检查项目如GOT、LDH、CK—MB、肌钙蛋白等项目的特异性、敏感性的评价和患病后各项出现异常的时间的分析等。结果CK、CK—MB、CtnI、CtnT、Mb分别可在AMI患病后1—6h出现异常升高，可做为早期诊断指标；AST（GOT）在6—12h才出现升高，且无特异性可作为AMI中期诊断的参考指标；a—HBD可作为晚期诊断指标；而LDH／a—HBD有助于肝病与心梗的鉴别诊断。结论对AMI、ACS的诊断选用CK、CK—MB同时选用cTn与Mb合并检测，可以作为AMI确诊的早期标志物。     

三种心肌损伤标志物联合快速检测在急性心肌梗死早期诊断中的价值

目的 探讨三种心肌损伤标志物肌红蛋白(Mb)、心肌肌钙蛋白I(cTnI)、肌酸激酶MB同工酶(CK-MB)对急性心肌梗死(AMI)的早期诊断价值。方法 发病4～6小时因胸痛疑诊AMI而入住CCU的病人101例,就诊时即刻检测Mb、cTnI及CK-MB,对比分析它们对AMI的早期诊断价值。结果 101例患者最终确诊为AMI66例,三种标志物早期检测比较,Mb的阳性率最高,敏感性及阴性预测价值高于cTnI和CK-MB(P<0.05);cTnI和CK-MB的特异性高于Mb(P<0.01),而以cTnI特异性最好。结论 以三种标志物Mb、cTnI和CK-MB为组合联合检测,有助于早期诊断或排除AMI,方法快速、简便,适于在基层医院及社区推广。     

Appropriate roles of cardiac troponins in evaluating patients with chest pain.

BACKGROUND: Diagnosis of acute myocardial infarction relies upon the clinical history, interpretation of the electrocardiogram, and measurement of serum levels of cardiac enzymes. Newer biochemical markers of myocardial injury, such as cardiac troponin I and cardiac troponin T, are now being used instead of or along with the standard markers, the MB isoenzyme of creatine kinase (CK-MB) and lactate dehydrogenase. METHODS: We performed a MEDLINE literature search (1987 to 1997) using the key words "troponin I," "troponin T," and "acute myocardial infarction." We reviewed selected articles related to the diagnostic and prognostic usefulness of these cardiac markers in evaluating patients with suspected myocardial infarction. RESULTS: We found that (1) troponin I is a better cardiac marker than CK-MB for myocardial infarction because it is equally sensitive yet more specific for myocardial injury; (2) troponin T is a relatively poorer cardiac marker than CK-MB because it is less sensitive and less specific for myocardial injury; and (3) both troponin I and troponin T may be used as independent prognosticators of future cardiac events. CONCLUSIONS: Troponin I is a sensitive and specific marker for myocardial injury and can be used to predict the likelihood of future cardiac events. It is not much more expensive to measure than CK-MB. Overall, troponin I is a better cardiac marker than CK-MB and should become the preferred cardiac enzyme when evaluating patients with suspected myocardial infarction.     

肌钙蛋白对心脏外科手术后急性心肌梗死的诊断价值

目的 探讨肌钙蛋白对心脏外科手术后急性心肌梗死的诊断价值.方法 采用前瞻性研究方法,选择134例心脏手术患者作为观察组,同期36例胸科手术患者作为对照组,两组患者术后持续心电监护,检测肌钙蛋白I,并对结果进行比较.结果 两组麻醉前肌钙蛋白I比较差异无统计学意义（P＞0.05）.观察组术后4h肌钙蛋白I为（13.010±14.829） μg,/L,与对照组的（0.019±0.007） μg/L比较差异有统计学意义（P＜0.05）.观察组发生急性心肌梗死1例,其肌钙蛋白Ⅰ＞40.000 μg/L.结论 心脏外科手术后早期绝大部分患者的肌钙蛋白明显增高,根据肌钙蛋白诊断术后急性心肌梗死的假阳性率较高,有待更多循证医学证据制定肌钙蛋白对心脏外科手术后急性心肌梗死的诊断标准.     

不同血液检验指标用于冠心病患者检测中的临床价值分析

目的：分析不同血液检验指标用于冠心病患者检测中的临床价值。方法：选取2013-2014年来本院进行治疗的冠心病患者70例,其中心绞痛为40例,急性心肌梗死为30例,选取同时期来本院进行健康体检人员40例做为对照组。测量三组人群的红细胞分布宽度（RDW）、血小板计数（PLT）、心肌肌钙蛋白T（c Tn T）、心肌肌钙蛋白I（c Tn I）、及肌酸激酶同工酶（CK-MB）、血小板分布宽度（PDW）、平均血小板体积（MPV）、血小板压积（PCT）、高敏心肌肌钙蛋白T（hs-c Tn T）。结果：RDW：心绞痛组（13.67±0.57）%,心肌梗死组（14.23±0.67）%,对照组（12.99±0.52）%。心绞痛组与急性心肌梗死组患者的红细胞分布宽度要显著高于健康对照组,差异有统计学意义（P〈0.05）;三组患者在平均血小板体积、血小板压积、血小板分布宽度、血小板计数上均差异无统计学意义（P〉0.05）。急性心肌梗死组患者的心肌肌钙蛋白T、心肌肌钙蛋白I、及肌酸激酶同工酶、高敏心肌肌钙蛋白T的水平要显著高于健康对照组和心绞痛组,差异有统计学意义（P〈0.05）,在多次的检测中笔者发现对于急性心肌梗死患者而言,心肌肌钙蛋白I的升高倍率最大。结论：诊断心肌损伤的最佳实验室指标是心肌肌钙蛋白I,对于冠心病患者而言,与血小板相关的参数在发病后不同时间段内会有变化。     

Interpretation of highly sensitive troponin assays: acute or chronic myocardial damage?

Troponin is the first choice in the diagnosis of acute myocardial infarction. Correct interpretation is challenging, because high sensitive troponin tests used today detect even the smallest cardiac damage. Methods: High sensitive troponin T (Roche) and troponin I (Mitsubishi Pathfast) and creatine-kinase activity were measured in 20 patients, each having two samples with the time lapse 3-9 hours. Results: In the group without acute myocardial infarction (n = 10) no significant increase in creatine-kinase and creatine-kinase-MB levels were seen, and the mild raise of troponins was due to other cardiovascular problems (atrial fibrillation, paroxysmal supraventricular tachycardia). With acute myocardial infarction (n = 10) a dramatic increase of troponin levels was found in the second samples, and also an increase of creatine-kinase and creatine-kinase-MB activity. According to Fischer-probe a twofold or higher increase of troponin implies 19-times higher risk of acute myocardial infarction in the case of troponin T and 8-times odds ratio at troponin I. Conclusions: The patient's accompanying diseases should always be considered. If the troponin level is elevated, the measurement should be repeated within 3-6 hours. When troponin shows at least a twofold increase and the patient has chest pain or positive ECG, AMI is likely, and the patient needs special medical care. Although the first troponin level might be elevated if accompanying diseases cause chronic cardiac damage, it can be differentiated by a second troponin measurement.     

Determination of cardiac troponins for diagnosis of 'acute myocardial infarct'

The diagnosis of 'myocardial infarction' was recently redefined by a commission of European and American cardiologists. The main element of the new definition is a raised serum level of heart-specific troponin (T or I). In healthy adults virtually no cardiac troponin is demonstrable, so that every rise of the level of the heart-specific troponin in the blood means that there is myocardial damage. An infarction during a coronary bypass operation and myocardial damage during skeletomuscular injury can be diagnosed almost faultlessly by a troponin assay. A raised troponin level in acute coronary ischaemia is associated with a raised mortality risk. However, even when the level is normal, a risk of cardiac complications is present. For the diagnosis of a recurrent infarction during a developing infarction, determination of the peak level of the creatine kinase muscle brain mass (CK-MBmass) is most appropriate. Also, the value of including troponin in the existing rule-out protocols has not yet been proven. Now that most Dutch hospitals shortly will be capable of troponin assays, cardiologists and clinical chemists should consider the implementation of this assay in clinical practice.     

心脏肌钙蛋白Ⅰ与肌红蛋白比值诊断急性心肌梗死

目的研究心脏肌钙蛋白I／肌红蛋白比值在诊断急性心肌梗死中的价值。方法选择2006年1月1日-2008年12月31日在苏州大学附属第一医院行肌红蛋白和肌钙蛋白检测的患者1075例，采用回归分析研究肌钙蛋白，肌钙／肌红蛋白比值以及肌红蛋白诊断急性心肌梗死的价值。接受者工作特征曲线（ROC）分析上述3个指标诊断急性心肌梗死临床界值。结果Logistic回归分析表明，肌红蛋白的估计值为0．00106，标准误为0．000293，卡方值为13．0451，P值为0．0003，标准偏回归系数为0．1731；肌钙蛋白的估计值为0．0994，标准误为0．0194，卡方值为26．3095，P〈0．0001，标准偏回归系数为1．9595；肌钙／肌红蛋白的估计值为4．7482，标准误为1．2454，卡方值为14．5367，P值为0．0001，标准偏回归系数为0．7561。ROC分析表明，肌钙蛋白曲线下面积（AUC）为0．918，95％可信区间0．898-0．936，P值为0．0001，界值为0．21；灵敏度为96．32％，95％可信区间为93．3％-98．2％；特异度为77．45％，95％可信区间为73．8％-80．8％。肌红蛋白AUC为0．635，95％可信区问为0．602-0．668，P值为0．0001，界值为112；灵敏度为51．47％，95％CI为45．4％-57．5％；特异度为71．26％，95％可信区间为67．4％-74．9％。肌钙／肌红蛋白比值AUC为0．815，95％可信区间0．787-0．840，P值为0．0001，界值为0．0112；灵敏度为72．79％，95％可信区间为67．1％-78．0％；特异度为82．79％，95％可信区间为79．5％-85．8％。ROC分析结果表明，两两相比肌钙蛋白诊断效能优于肌钙／肌红蛋白比值，而肌钙／肌红蛋白比值又优于肌红蛋白，差异均有统计学意义（P〈0．05）。．结论心脏肌钙蛋白／肌红蛋白比值是诊断急性心肌梗死的又一个有意义的指标。     

心脏型脂肪酸结合蛋白在急性心肌梗死早期诊断中的价值

目的 探讨心脏型脂肪酸结合蛋白(H-FABP)在急性心肌梗死(AMI)早期诊断中的应用价值.方法 检测60例疑似AMI患者H-FABP、心肌肌钙蛋白(cTn)T、肌酸激酶同工酶-MB(CK-MB)水平,按发病时间分为<6h、6～12h两个时段,计算各项指标诊断AMI的灵敏度,同时测定15例非AMI疑似患者及45例健康体检者的H-FABP、cTnT、CK-MB水平,计算各项指标诊断AMI的特异度.结果 H-FABP在发病<6 h诊断AMI的灵敏度为94%,明显优于cTnT的50%、CK-MB的56%,差异均有统计学意义(P<0.05);在发病6～12 h,H-FABP诊断AMI的灵敏度为100%、cTnT为92%、CK-MB为92%,差异无统计学意义.三项指标诊断AMI的特异度比较差异无统计学意义.结论 H-FABP对AMI早期诊断有较高的灵敏度和特异度,适用于胸痛患者的筛查及早期诊断AMI.     

New Biochemical Tools for Diagnosing Acute Coronary Syndromes

This article reviews the value of myoglobin, troponins, and creatine kinase, MB fraction (CK-MB) in diagnosis, risk stratification, and prognosis in patients presenting to hospital emergency departments (ED) with symptoms suggestive of acute coronary syndromes. Because the three markers differ in specificities and their sensitivities vary with time after the onset of chest pain, the authors suggest that serial measurements for all three markers by point-of-care methods will optimize patient outcomes and reduce resource utilization. The rationale for this strategy is examined from the viewpoint of ED physicians who must make diagnoses, risk stratify patients, and make treatment decisions in patients presenting with non-diagnostic ECGs.The articles reviewed show that despite its elevation in renal and skeletal muscle disease, myoglobin offers more sensitivity for the early diagnosis of acute myocardial infarction (MI) than either CK-MB or troponins. The most important characteristic of myoglobin is its high negative predictive value for acute MI. Myoglobin also shows promise as a non-invasive marker of reperfusion status in patients undergoing thrombolytic therapy.Articles are examined which indicate that cardiac troponin I and troponin T, despite standardization problems for troponin I, offer greater specificity than either CK-MB or myoglobin in detecting MI, particularly when measurements are made with third-generation assays at presentation and 6–12 hours later. Because troponin elevation persists for days after CK-MB and myoglobin have returned to normal, troponins have high sensitivity for detecting MIs in patients presenting days after the onset of chest pain.The use of troponins in evaluating prognosis in patients with acute coronary syndromes — including those at low risk for MI, without ECG changes, triaged to a chest pain unit, with renal disease, undergoing noncardiac surgery, and undergoing treatment for MI — is discussed in detail because troponin concentrations may help to guide ED clinicians in diagnosis, risk stratification, and treatment.Finally, key reports suggesting that rapid serial measurements of myoglobin, troponin, and CK-MB may improve patient outcomes and conserve hospital resources compared with laboratory-based testing are examined in detail.Measurements of troponin, myoglobin, and CK-MB are useful in emergency care settings. Point-of-care tests are easy to perform and provide results rapidly enough to permit the use of marker concentrations in diagnosis and risk stratification. They offer an opportunity for clinicians to initiate prompt and aggressive treatments only when necessary, thus conserving hospital resources.     

急性心肌梗死应用心肌肌钙蛋白T检测的临床分析

目的总结笔者所在医住院部急性心肌梗死（AMI）患者的诊断资料,评价和分析急性心肌梗死应用心肌肌钙蛋白T（cTnT）检测的应用诊断价值。方法收集住院部急性心肌梗死的临床资料（包括临床病史、心电图、心肌酶谱、心脏彩色超声）,对每例的首发症状、起病时间、既往史等进行归类和总结,分析比较cTnT与肌酸肌酶同工酶CK—MB、心电图（EGG）检测结果,进行统计学分析。结果cTnT检测对早期急诊AMI（2—6h）的阳性率不高（74．42％）,在发病时间6h至8d内,具有较高特异性和准确性（其阳性率〉90．0％）,明显高于ECG、CK—MB检测的阳性率,差异具有显著性;cTnT检测对于心内膜微小心肌损伤、心肌毒性物质及机械损伤等原因所致的心脏病患者（9例）不具有明显的特异性。结论cTnT检测用于急性心肌梗死的诊断具有灵敏度高、特异性强、持续时间长、报告结果快速准确等特点,效果明显优于ECG、CK—MB检测,是快速确诊AMI较为理想的生化标志物,与其联合检测可以提高早期AMI的检出率及诊断时间窗。     

心肌型脂肪酸结合蛋白（H—FABP）、cTnI与CK—MB在诊断早期AMI中的比较

目的研究血清心肌型脂肪酸结合蛋白(H-FABP)在早期急性心肌梗死(AMI)诊断中的价值。方法选择82例疑似急性心肌梗死的胸痛患者,采用快速检测法检测患者发病0~3h、3~6h和6h后血清的H-FABP,并与心肌肌钙蛋白I(cTnI)、肌酸激酶同工酶(CK-MB)的检测结果进行比较,分析3种心肌标志物在诊断不同发病时间段AMI的敏感性和特异性。结果H-FABP检测诊断AMI的敏感性在0~3h(66.7%)和3~6h(100%)时间段显著高于cTnI(33.3%、66.7%)和CK-MB(0%、61%);在诊断特异性上,H-FABP高于cTnI,比CK-MB低;H-FABP诊断AMI的准确率高达94.15%。结论H-FABP对于诊断早期AMI具有较高的敏感性和良好的特异性,更适合于临床AMI的早期诊断。