心肌肌钙蛋白Ⅰ在急性冠状动脉综合征中的应用

急性冠状动脉综合征（ACS）是指不稳定型心绞痛（UA）、Q波型心肌梗死（NQMI）和心源性猝死这样一组临床病征。心肌肌钙蛋白I(cTnl)是新近发展的心肌组织所特有的心肌酶学标志物。本文对cTnl的生物化学特点、检测方法、cTnl与ACS的联系进行评价。cTnl在诊断心肌损害方面敏感性高,特异性强,诊断时间窗口宽,明显优于传统心肌酶,对ACS可进行危险度分层及预后评价,并可预测UA患者复杂冠状动脉形态,值得推广使用。     

国内急性冠状动脉综合征诊治现状

急性冠状动脉综合征(ACS)系一组急性冠状动脉事件,是临床上常见的心血管病急症,若不及时处理会导致严重后果甚至危及生命,己成为临床研究热点。现根据国内有关资料将 ACS 诊治现状作一简述。1 ACS 的概念、分型及病理生理ACS 包括不稳定型心绞痛(UA)、非 Q 波心肌梗死(NQMI)、Q 波心肌梗死(QMI)及缺血性心脏猝死。UA 是一种静息心绞痛或进行加重的心绞痛,包括WHO 分型中的自发型心绞痛、混合型心绞痛、初发劳累型心绞痛、恶化劳累型心绞痛。既往所称的卧位心绞     

肌钙蛋白Ⅰ测定及其在ACS诊治中的应用

急性冠状动脉综合征（ACS）包括不稳定型心绞痛（UAP）、非Q波心肌梗死（NQMI）和Q波心肌梗死（QMI）等。近年研究发现，心肌肌钙蛋白（cTnI）Nm于UAP和稳定型心绞痛（SAP）的分型和鉴别诊断。现将cTnI及其在ACS诊治中的应用总结如下。     

重视糖尿病合并急性冠状动脉综合征的治疗

急性冠状动脉综合征(acute coronary syn—drome，ACS)临床包括(1)急性心肌梗死(acute myocardial infarction，AMI)，分ST段抬高型(Q波型)和下降型(非Q波型)；(2)不稳定型心绞痛(unstable angina，UA)。ACS的发生机理绝大部分为冠状动脉(简称冠脉)内粥样硬化斑块破裂出血、血栓形成、不同程度阻塞冠脉所致，     

急性冠状动脉综合征的治疗进展

急性冠状动脉综合征 (ACS)涵盖了从不稳定型心绞痛到ST段抬高心肌梗死的一系列临床急症。其可分为两类 ,即 ST段抬高的 ACS(Q波心肌梗死 ) ;ST段不抬高的 ACS,包括ST段不提高的心肌梗死 (无 Q波心肌梗死 )和不稳定性心绞痛。这种分类方法简单易行 ,对 ACS的治疗决策有指导意义。1　 ST段抬高 ACS的治疗决策ST段抬高的 ACS即 Q波急性心肌梗死。急性心肌梗死(AMI)是由于冠状动脉粥样硬化斑块破裂后 ,在血小板激活和聚集的基础上有血栓形成 ,致冠状动脉急性闭塞的结果。因此 ,治疗 AMI的关键是迅速使闭塞的梗塞相关冠脉 (IRC…     

急性冠脉综合征的分型及危险分层

近年来对缺血性心脏病急性冠状动脉综合征(ACS)的发病机理研究,已证实在动脉粥样硬化不稳定斑块破裂的基础上触发血小板激活和凝血酶形成,导致血栓形成,是不稳定性心绞痛(UA)、非Q波心肌梗死(NQMI)和急性Q波心肌梗死(AQMI)的重要发病机理,同时也已肯定,炎症也是ACS发病的重要因     

血清C-反应蛋白凝血因子Ⅰ与急性冠状动脉综合征的相关研究

目的 :探讨C 反应蛋白 (CRP)、凝血因子Ⅰ (FG)在急性冠状动脉综合征 (ACS)发病中的作用及意义。方法 :用速率散射比浊法测定ACS患者各组与非急性冠状动脉综合征 (NACS)组患者血清CRP、FG、肌钙蛋白I(cT nI)、肌酸磷酸激酶(CPK)、肌酸磷酸激酶同工酶 (CPK MB)、乳酸脱氢酶 (LDH)、α 羟丁酸脱氢酶 (α HAD)和谷草转氨酶 (GOT)水平。结果 :ACS患者血清CRP、FG、cTnI、心肌酶谱 (CPK、CPK MB、LDH、α HAD、GOT)峰值水平均显著高于NACS组 (P <0 .0 1 ) ;ACS患者中ST段抬高的心肌梗死 (STAMI)、非ST段抬高的心肌梗死 (NSTAMI)患者组血清CRP、FG、cTnI、心肌酶谱峰值水平均显著高于NACS组 (P <0 .0 1 ) ;不稳定型心绞痛 (UAP)患者组CRP、FG水平显著高于对照组 (P <0 .0 1 ) ,而cTnI、血清心肌酶谱水平与对照组相比差异无统计学意义 (P >0 .0 5 ) ;ACS患者CRP水平与血清cTnI、心肌酶谱峰值水平呈显著正相关 (P <0 .0 1 ) ;FG水平与α HAD峰值水平呈显著正相关 (P <0 .0 1 )。结论 :ACS患者血清CRP与疾病严重程度 (心肌损害)呈正相关。提示CRP可作为ACS发病和预后的预测因子     

重视非ST段抬高急性冠状动脉综合征的诊断与治疗

急性冠状动脉综合征 (ACS)这一概念的提出 ,是在对急性心肌梗死 (AMI)病理生理了解取得进展的基础上 ,重新认识了AMI的表现形式而提出的。ACS是指急性心肌缺血引起的一组临床征候群 ,有3种不同表现形式 :①ST段抬高的AMI(STEAMI) ,大多数患者最终发生急性Q波心肌梗死 ,少数发生非Q波心肌梗死 (NQMI) ;②非ST段抬高AMI(NSTEAMI) ,多数患者 1 2导联心电图上没有Q波 ,仅少数患者心电图表现有Q波 ;③不稳定型心绞痛 (UA)。虽然ACS的基本病理基础是以冠状动脉斑块不稳定性为特点 ,然而 3种形式的临床表现与治疗原则却明显不…     

急性冠脉综合征的研究进展

急性冠脉综合征（ACS）是以冠状动脉粥样硬化斑块破溃，继发完全或不完全闭塞性血栓形成为病理基础的一组临床综合征，它包括不稳定型心绞痛（UA）、Q波型心肌梗死（QMI）和非Q波型心肌梗死（NQMI）及心源性猝死（CSD）。     

室性早搏形态在心肌梗死诊断中的意义

目的 探讨室性早搏(PVS)心电形态的改变对心肌梗死(MI)的诊断意义.方法 收集PVS伴有异常Q波或有明显ST-T动态改变者,进行心肌酶检查、心肌肌钙蛋白、超声心动图、冠脉造影(CAG)检查,结合临床症状综合分析判断.结果 符合条件的24例中出现异常Q波19例,ST段抬高4例,T波高尖1例,通过结合临床资料分析可诊断为MI者23例.结论 PVS伴有异常Q波或有明显ST-T动态改变者,诊断MI符合率高,可以作为早期MI的诊断.     

白细胞介素-18与急性冠状动脉综合征的相关性研究

目的 探讨不同类型冠状动脉粥样硬化性心脏病(冠心病)患者中白细胞介素(IL)-18水平与疾病严重程度以及冠状动脉粥样硬化狭窄程度是否相关.方法 冠心病患者包括急性冠状动脉综合征(ACS)和稳定型心绞痛(SAP)共86例;酶联免疫吸附法检测IL-18水平;对不稳定型心绞痛(UAP)患者进行Braunwald分级,对急性心肌梗死患者进行Killip分级,冠状动脉粥样硬化病变程度按Gensini评分,用SPSS软件包进行统计学分析.结果 ACS患者血清IL-18水平与疾病严重程度存在良好相关性.ACS组IL-18水平高于SAP组(P＜0.01),且与Gensini法评分呈线性正相关(r=0.357,P=0.005).结论 ACS患者IL-18浓度与疾病的严重程度有一定的相关性,与冠状动脉粥样硬化狭窄病变程度呈正相关.     

急性冠状动脉综合征患者血清BNP水平与hs-CRP、cTNI水平的相关性研究

目的探讨急性冠状动脉综合征(ACS)患者血清脑利钠肽(BNP)与高敏C反-应蛋白(hs-CRP)、心肌肌钙蛋白I(cTNI)指标的相关性及其在ACS患者危险分层中可能的临床意义。方法ACS患者41例包括急性心肌梗死患者21例和不稳定型心绞痛患者20例;稳定型心绞痛患者29例和与之年龄、性别等相匹配的30例对照者进入本研究。酶联免疫吸附法测定血清BNP水平,免疫比浊法测定hs-CRP水平,化学发光法测定cTNI水平。结果急性心肌梗死组和不稳定型心绞痛组患者的血清BNP水平均明显高于稳定型心绞痛和对照组患者,差异均具有统计学意义(P<0.01和P<0.05);在ACS组中,BNP与cTNI和hs-CRP具有相关性(r分别为0.67和0.91,P<0.05)。结论①血清BNP水平在ACS患者中明显升高,可作为辅助诊断指标之一。②ACS患者血清BNP水平升高程度与同期测定的血清hs-CRP、cTNI水平呈显著正相关。     

急性冠状动脉综合征血清缺血修饰白蛋白的动态变化

目的:探讨血清缺血修饰白蛋白(IMA)对急性冠状动脉综合征早期的诊断价值。方法:将56例急性冠状动脉综合征患者分为三组,不稳定性心绞痛组(n=25),ST抬高心肌梗死组(n=20),非ST抬高心肌梗死组(n=11),另选50例健康体检者为正常对照组。分别于胸痛发作2、4、6、12及24 h抽血检测56例急性冠状动脉综合征患者的血清缺血修饰白蛋白、肌钙蛋白Ⅰ(cTnI)、肌酸激酶MB同工酶(CK-MB),分析缺血修饰白蛋白对急性冠状动脉综合征的诊断价值。结果:在急性冠状动脉综合征患者中缺血修饰白蛋白水平于胸痛发作2小时已明显增高并达高峰,4小时仍持续增高,明显高于正常对照组(P<0．01),6小时降至正常。而CK-MB、cTnI水平在胸痛发作4小时开始增高,6小时明显增高,以后逐步递增并在24小时达高峰。不稳定型心绞痛、ST抬高的心肌梗死、非ST抬高的心肌梗死三组中,缺血修饰白蛋白水平升高以不稳定型心绞痛组最明显。结论:缺血修饰白蛋白是诊断急性冠状动脉综合征的早期敏感指标,是目前唯一的诊断心肌缺血的生化标志物。     

A prospective survey of the characteristics, treatments and outcomes of patients with acute coronary syndromes in Europe and the Mediterranean basin; the Euro Heart Survey of Acute Coronary Syndromes (Euro Heart Survey ACS).

AIMS: To better delineate the characteristics, treatments, and outcomes of patients with acute coronary syndromes (ACS) in representative countries across Europe and the Mediterranean basin, and to examine adherence to current guidelines. METHODS AND RESULTS: We performed a prospective survey (103 hospitals, 25 countries) of 10484 patients with a discharge diagnosis of acute coronary syndromes. The initial diagnosis was ST elevation ACS in 42.3%, non-ST elevation ACS in 51.2%, and undetermined electrocardiogram ACS in 6.5%. The discharge diagnosis was Q wave myocardial infarction in 32.8%, non-Q wave myocardial infarction in 25.3%, and unstable angina in 41.9%. The use of aspirin, beta-blockers, angiotensin converting enzyme inhibitors, and heparins for patients with ST elevation ACS were 93.0%, 77.8%, 62.1%, and 86.8%, respectively, with corresponding rates of 88.5%, 76.6%, 55.8%, and 83.9% for non-ST elevation ACS patients. Coronary angiography, percutaneous coronary interventions, and coronary bypass surgery were performed in 56.3%, 40.4%, and 3.4% of ST elevation ACS patients, respectively, with corresponding rates of 52.0%, 25.4%, and 5.4% for non-ST elevation ACS patients. Among patients with ST elevation ACS, 55.8% received reperfusion treatment; 35.1% fibrinolytic therapy and 20.7% primary percutaneous coronary interventions. The in-hospital mortality of patients with ST elevation ACS was 7.0%, for non-ST elevation ACS 2.4%, and for undetermined electrocardiogram ACS 11.8%. At 30 days, mortality was 8.4%, 3.5%, and 13.3%, respectively. CONCLUSIONS: This survey demonstrates the discordance between existing guidelines for ACS and current practice across a broad region in Europe and the Mediterranean basin and more extensively reflects the outcomes of ACS in real practice in this region.     

Efficacy of multislice computed tomography for the detection of acute coronary syndrome in the emergency department.

BACKGROUND: The diagnosis of acute coronary syndrome (ACS), especially non-ST-elevation myocardial infarction and unstable angina in the emergency department (ED) still remains a challenge. Multislice computed tomography (MSCT) allows assessment of not only coronary artery stenoses and occlusions, but also assessment of coronary artery plaques and myocardial perfusion status. METHODS AND RESULTS: MSCT was performed in 31 patients who were admitted to the ED because of chest pain persisting at least 30 min and non-diagnostic ECG changes and normal serum enzyme concentrations. Using MSCT, ACS was defined by coronary artery stenosis > or = 75% accompanied by computed tomography (CT)-low-density plaques, and/or by the presence of myocardial perfusion defects. ACS was confirmed by coronary stenosis > or = 75% by coronary angiography and/or subsequent elevation of troponin I concentration. In total, 22 patients were diagnosed as having ACS. MSCT detected stenoses with CT-low-density plaques in 21 and non-transmural myocardial perfusion defect in 3 patients. There was 1 false-positive and 1 false-negative result. The sensitivity and specificity of MSCT to identify ACS was 95.5% and 88.9%, respectively. CONCLUSION: MSCT provides diagnostic operating characteristics suitable for triage of patients with ACS in the ED.     

急性冠状动脉综合征患者N末端B型钠尿肽前体和肌钙蛋白Ⅰ水平与冠状动脉病变的关系

目的探讨急性冠状动脉综合征患者血清N末端B型钠尿肽前体(NT-proBNP)和肌钙蛋白I(cTnI)含量与冠状动脉病变程度的关系。方法选择急性冠状动脉综合征患者98例,分为急性ST段抬高心肌梗死(STEMI)组46例,急性非ST段抬高心肌梗死(NSTEMI)组16例,不稳定性心绞痛(UAP)组36例,均于入院时或发病24 h内测定患者血清NT-proBNP、cTnI含量,冠状动脉造影了解冠状动脉病变情况,并行心脏彩色多普勒超声检测,以评估患者的心功能。结果与UAP组比较,STEMI组和NSTEMI组NT-proBNP明显升高;与NSTEMI组比较,STEMI组cTnI明显升高(P<0.05)。NT-proBNP与冠状动脉病变积分呈正相关(r=0.156,P<0.05),与LVEF呈负相关(r=-0.196,P<0.01);cTnI与冠状动脉病变积分呈正相关(r=0.247,P<0.01)。结论急性冠状动脉综合征患者NT-proBNP与cTnI无关,但两者均可反映冠状动脉病变的严重程度。NT-proBNP的高低能反映患者的心功能状态,cTnI则与心功能无关。     

Improved identification of acute coronary syndromes with delta cardiac serum marker measurements during the emergency department evaluation of chest pain patients

Current findings from the American College of Emergency Physicians (ACEP) are that no serum marker reliably identifies or excludes acute myocardial infarction (AMI) within 6 h of symptom onset. The ACEP recommends repeat serum marker testing 6–10 h after symptom onset for CK-MB mass and subform, and 8–12 h after symptom onset for cardiac troponin I and T before making an exclusionary diagnosis of non-AMI chest pain. A new approach for identifying myocardial necrosis is to rely on time changes in the serum marker value over an abbreviated time interval (slope or delta values) as opposed to the traditional approach of relying on a value exceeding the threshold of normalcy. As assays become ever more sensitive and precise, this approach has the potential for both reliably identifying and excluding AMI (and subsets of high-risk unstable angina) at earlier time intervals with no loss in specificity. This article discusses some of the experimental evidence for this delta approach and some preliminary evidence for the potential of utilizing second-generation cTnl assays for the identification of acute coronary syndromes. Finally, we discuss a unique way of viewing receiver-operating characteristic (ROC) curves as catalogs of likelihood ratios, which we believe will be more useful to the clinician in the proper interpretation of serum marker values.     

Usefulness of myocardial necrosis triad markers for predicting 4-year mortality in patients with suspected acute coronary syndrome

OBJECTIVE: Cardiac troponins (cTn), creatine kinase-MB (CK-MB), myoglobin (MYO) are commonly used biochemical markers for risk stratification and diagnosis in patients with suspected acute coronary syndrome (ACS). The aim of the study was to analyse the prognostic implications of 3 myocardial necrosis markers measured at admission in the long-term observation. METHODS: The study group consisted of 336 consecutive patients whose concentration of cTnl, CK-MB and MYO were measured at admission. Patients were categorized into 4 groups according to the number of positive myocardial necrosis markers. RESULTS: There was a significant increase in the mean marker levels with increasing numbers of positive markers (over upper normal range): cTnl (0.02 +/- 0.06; 0.7 +/- 1.9; 3.4 +/- 8.8; 5.1 +/- 9.2 ng/ml; P < 0.001), CK-MB (1.3 +/- 1.1; 3.3 +/- 3.9; 21.9 +/- 39.4; 37.5 +/- 48.4 ng/ml; P < 0.001), MYO (39.4 +/- 16.5; 94.5 +/- 91; 202.2 +/- 172.2; 320.3 +/- 234.3 ng/ml; P < 0.001). There was a statistically significant increase in the 4-year all-cause mortality with increasing numbers of positive markers; P value for trend < 0.0001. CONCLUSIONS: All 3 marker levels at admission may be an important addition to the risk stratification of patients with suspected ACS and a potentially important target for therapy. They have prognostic implications in the long-term observation of patients with chest pain and suspected ACS.     

The Erlanger chest pain evaluation protocol: a one-year experience with serial 12-lead ECG monitoring,two-hour delta serum marker measurements,and selective nuclear stress testing to identify and exclude acute coronary syndromes

STUDY OBJECTIVE: We determine the overall use of a 6-step accelerated chest pain protocol to identify and exclude acute coronary syndrome (ACS) and to confirm previous findings of the use of serial 12-lead ECG monitoring (SECG) in conjunction with 2-hour delta serum marker measurements to identify and exclude acute myocardial infarction (AMI). METHODS: A prospective observational study was conducted over a 1-year period from January 1, 1999, through December 31, 1999, in 2,074 consecutive patients with chest pain who underwent our accelerated evaluation protocol, which includes 2-hour delta serum marker determinations in conjunction with automated SECG for the early identification and exclusion of AMI and selective nuclear stress testing for identification and exclusion of ACS. In patients not undergoing emergency reperfusion therapy, physician judgment was used to determine patient disposition at the completion of the 2-hour evaluation period: admit for ACS, discharge or admit for non-ACS condition, or immediate emergency department nuclear stress scan for possible ACS. A positive protocol was defined as a positive result in 1 or more of the 6 incremental steps in our chest pain evaluation protocol: (1) initial ECG diagnostic of acute injury or reciprocal injury; (2) baseline creatine kinase (CK)-MB level of 10 ng/mL or greater and index of 5% or greater or cardiac troponin I level of 2 ng/mL or greater; (3) new/evolving injury or new/evolving ischemia on SECG; (4) increase in CK-MB level of +1.5 ng/mL or greater or cardiac troponin I level of +0.2 ng/mL or greater in 2 hours; (5) clinical diagnosis of ACS despite a negative 2-hour evaluation; and (6) reversible perfusion defect on stress scan compared with on resting scan. All patients were followed up for 30-day ACS, which was defined as myocardial infarction (MI), percutaneous coronary intervention/coronary artery bypass grafting, coronary arteriography revealing stenosis of major coronary artery of 70% or greater not amenable to percutaneous coronary intervention/coronary artery bypass grafting, life-threatening complication, or cardiac death within 30 days of ED presentation. RESULTS: Discharge diagnosis in the 2,074 study patients consisted of 179 (8.6%) patients with AMI, 26 (1.3%) patients with recent AMI (decreasing curve of CK-MB), and 327 (15.8%) patients with 30-day ACS. At 2 hours, sensitivity and specificity for MI (AMI or recent AMI) of SECG plus delta serum marker measurements was 93.2% and 93.9%, respectively (positive likelihood ratio 15.3; negative likelihood ratio 0.07). At the completion of the full ED evaluation protocol (positive result in >or=1 of the 6 incremental steps), sensitivity and specificity for 30-day ACS was 99.1% and 87.4%, respectively (positive likelihood ratio 7.9; negative likelihood ratio 0.01). CONCLUSION: An accelerated chest pain evaluation strategy consisting of SECG, 2-hour delta serum marker measurements, and selective nuclear stress testing in conjunction with physician judgment identifies and excludes MI and 30-day ACS during the initial evaluation of patients with chest pain.     

Antiphospholipid antibodies in acute coronary syndrome

Antiphospholipid (aPL) antibodies entailing anticardiolipin (aCL) and anti-beta2 glycoprotein I (anti-beta2GPI) antibodies may be involved in a number of vascular diseases including coronary artery diseases (CAD) or stroke. Here we assessed the presence of aPL antibodies in acute coronary syndrome (ACS). The frequency of anti-beta2GPI antibodies was significantly higher (14.4%) in ACS in comparison to control healthy subjects (2%). In addition, serum concentrations of anti-beta2GPI antibodies were also increased in ACS. Anti-beta2GPI antibodies of the IgA isotype might be the most relevant for the onset and outcome of ACS. Regarding subclasses of ACS, anti-beta2GPI IgA antibodies were elevated in unstable angina (UA) and myocardial infarction with ST elevation (STEMI), but not in myocardial infarction without ST elevation (NSTEMI). The involvement of anti-beta2GPI antibodies in ACS was more pronounced in men than women, and in younger rather than older patients. Finally, anti-beta2GPI antibodies in ACS were associated with previous stroke, but not with hypertension or previous myocardial infarction. Thus, anti-beta2GPI antibodies may be involved in the thrombotic events underlying ACS.