GRACE评分和D二聚体在CK-MB正常NSTE-ACS人群中诊断和危险分层的价值

目的探讨联合其他指标提高cTnI升高而CK-MB正常的疑诊NSTE-ACS患者的诊断准确率。方法回顾性分析2018年1月至2018年12月疑诊非ST段抬高型急性冠脉综合征于广州医科大学附属第一医院心血管内科行冠脉造影且cTnI升高而CK-MB正常的患者143例,收集包括其血液生化指标、GRACE评分、冠脉病变程度和是否需要PCI治疗等资料。基于GRACE评分、冠脉主支狭窄率、是否有需要PCI术、年龄等指标分别分组。对不同GRACE评分组进行冠脉病变发生率及PCI术治疗率的比较和相关性分析。同时对cTnI、血小板(Plt)、D二聚体对冠心病诊断及预测是否需要PCI术治疗应用ROC曲线分析并计算曲线下面积(areaunderthecurveAUC),选取AUC值最大时曲线图中最左上方的点对应的值为诊断临界值。结果①不同GRACE评分分组的冠脉病变发生率及PCI术治疗率有统计学差异,Spearman相关分析结果显示,GRACE评分分组与疑诊ACS患者冠脉病变发生率及需要PCI处理率呈正相关。②有冠脉病变组患者cTnI、Plt水平比无冠脉病变组高(P<0.05),在年龄≥70岁亚组中,有无接受PCI术治疗组之间D二聚体水平有统计学差异(P<0.05),PCI治疗组D二聚体水平比非PCI治疗组高。③cTnI对有冠脉病变的诊断界值为0.315μg/L,诊断的灵敏度为50.5%;特异度为68.2%;cTnI对预测是否行需要接受PCI的界值为0.34μg/L,灵敏度为57%,特异度为70%;Plt对有冠脉病变的诊断界值为193×10^9/L,诊断的灵敏度为84.9%;特异度为44.2%;Plt对预测是否需要接受PCI的界值为178.5×10^9/L,灵敏度为91.9%,特异度为33.8%;在高龄组(≥70岁)中,D二聚体对预测是否行需要接受PCI的界值为939ug/L,灵敏度为94%,特异度为47%。结论cTnI升高但CK-MB水平正常的疑诊NSTE-ACS患者中,通过结合GRACE评分、Plt和cTnI升高程度能有助于早期诊断及PCI治疗的判断;而对于高龄(≥70岁)患者,D二聚体升高到一定程度提示需要PCI术治疗的可能性会增大。

The Effects of GRACE Scores and D-dimer for Diagnosis and Risk Stratification in Patients with Non-ST-Segment Elevation Acute Coronary Syndrome with Normal CK-MB

Objective To study the combine other indicators increase the accuracy of diagnosis in elevated Troponin-I(cTnI)and normal creatine kinase-MB isoenzyme(CK-MB)of NSTE-ACS patients.Methods A retrospective analysis 143 cases non st-elevation acute coronary syndrome,Department of Cardiology of guangzhou medical university of first affiliated hospital between January 2018 to December 2018,all of cases were elevated cTnI and normal CK-MB,collected including its blood biochemical indexes and GRACE score,stenosis rate of coronary artery lesions and whether PCI treatment of such information is needed.Based on GRACE score,stenosis rate of main coronary artery,whether PCI is needed or not,age and other indicators were divided into several groups.The rate of coronary artery lesions and the rates of PCI were compared and the correlation was analyzed.At the same time,ROC curve was used to analyze whether cTnI,Platelet,and D-dimer needed PCI for the diagnosis and prediction of coronary heart disease,and the area under the curve was calculated.When the AUC value was the maximum,the corresponding value of the point at the top left of the curve was selected as the diagnostic critical value.Results(1)there was a statistical difference in the incidence of coronary artery lesions and the treatment rate of PCI in different GRACE score groups.Spearman analysis showed that the GRACE score group was positively correlated with the incidence of coronary artery lesions and the rate of requiring PCI in suspected ACS patients.The levels of cTnI and Platelet in the group with coronary artery disease were higher than that in the group without coronary artery disease(P<0.05).In the subgroup aged≥70 years,there was a statistical difference in the d-dimer level between the groups with and without PCI treatment(P<0.05).The d-dimer level in the PCI group was higher than that in the non-PCI group.The diagnostic threshold of cTnI for coronary artery lesions was 0.315 g/L,and the diagnostic sensitivity was 50.5%.The specificity was 68.2%.The threshold value of PCI for cTnI was 0.34 g/L,with a sensitivity of 57%and a specificity of 70%.The diagnostic threshold of Platelet for coronary artery lesions was 193×10^9/L,and the diagnostic sensitivity was 84.9%.The specificity was 44.2%.The threshold for Plt to accept PCI is 178.5×10^9/L,the sensitivity is 91.9%,and the specificity is 33.8%.In the elderly group(≥70 years old),the threshold value of d-dimer for predicting whether to accept PCI was 939 ug/L,the sensitivity was 94%,and the specificity was 47%.Conclusion In suspected NSTE-ACS patients with elevated cTnI but normal CK-MB levels,the combination of GRACE scores,Platelet and cTnI elevation can be helpful for early diagnosis and judgment of PCI.However,for elderly patients(≥70 years old),the elevation of d-dimer to a certain extent indicates that the possibility of requiring PCI treatment will be increased.