联合测定心型脂肪酸结合蛋白、肌钙蛋白T诊断早期急性心肌损伤

目的:联合测定心型脂肪酸结合蛋白(h-FABP)、肌钙蛋白T(cTnT)对早期诊断急性心肌损伤的意义.方法:对76例急性冠脉综合征(ACS)患者,自胸痛发生后1 h开始每小时连续监测心型脂肪酸结合蛋白、肌钙蛋白T至胸痛发生后6 h,共6次.结果:在早期急性心肌损伤中,h-FABP阳性结果出现的时间早于cTnT,二者对比有统计学意义(P＜0.05).在cTnT升高患者中,h-FABP升高率为98.7%,二者对比无统计学差异(P＞0.05).结论:在诊断早期急性心肌损伤时,h-FABP出现阳性结果时间早于cTnT,而联合测定h-FABP、cTnT对提高ACS患者早期确诊率,指导临床急救具有重要的价值.     

Heart-type fatty acid binding protein--a reliable marker of myocardial necrosis in a heterogeneous group of patients with acute coronary syndrome without persistent ST elevation

BACKGROUND: Myocardial infarction (MI) is one of the most serious challenges of contemporary cardiology. Among biochemical markers, heart-type specific fatty acid binding protein (h-FABP) has a high potential as a marker for the early diagnosis of acute MI. The h-FABP is released early to the bloodstream and may be useful for both rapid confirmation and exclusion of infarction. As opposed to patients with ST segment elevation MI (STEMI), patients with unstable angina (UA)/non-ST segment elevation MI (NSTEMI) present a heterogeneous group in which the confirmation of MI often meets diagnostic difficulties. A rapid, qualitative immunoenzymatic 'point of care' type test, revealing h-FABP in blood, has recently been made available (CardioDetect med). AIM: To evaluate diagnostic value of early measurements of h-FABP and other markers of necrosis (cTnT, CK-MB, CK-MB mass) in a group of 100 patients with an acute coronary syndrome (ACS) without persistent ST segment elevation (NSTE ACS). METHODS: We studied 100 consecutive patients (34 women, 66 men; mean age 61.6 years) with strong suspicion of NSTE ACS and chest pain lasting <24 h before admission. During admission and after 3 and 6 hours patients had measured a panel of conventional biomarkers as well as quantitative measurements of h-FABP (on admission and 3 hours later) using CardioDetect med. The ultimate diagnosis of infarction (NSTEMI) was confirmed in case of a second (6 h after admission) positive quantitative result of cardiac troponin. Non-ST segment elevation MI was finally diagnosed in 56 patients. RESULTS: The comparison of diagnostic utility of all analysed biomarkers of necrosis revealed that h-FABP was superior to other parameters, when measured on admission, and was characterised by 94.7% sensitivity, 100% specificity, 100% positive predictive value, 93.4% negative predictive value and 97% accuracy. Other biomarkers had on admission lower sensitivity - 70.1% for CK-MB mass, 66.7% for CK-MB, 64.9% for cTnT, whereas their specificity was 97.6% for CK-MB mass, 93% for CK-MB and 100% for cTnT. CONCLUSIONS: Qualitative h-FABP test (CardioDetect med) showed excellent sensitivity, higher than measurements of CK-MB mass, CK-MB, and cTnT on hospital admission, and high specificity in the patient group with NSTE ACS. The h-FABP seems to be an excellent biochemical cardiac marker for diagnosing NSTEMI, especially in its early phase, allowing exclusion of myocardial necrosis.     

Cardiac troponins in suspected acute coronary syndrome: a meta-analysis of published trials.

We performed a meta-analysis of published trials to determine the predictive value of cardiac troponin I (cTnI) and T (cTnT) levels for adverse events (death and myocardial infarction) in acute coronary syndrome without ST elevation (ACS). The accumulated odds ratio (OR) for adverse events (30 days) in ACS with elevated cTnI (n = 5,759) and cTnT (n = 5,483) was 4.9 (95% confidence interval, CI, 3.9-6.2) and 4.6 (95% CI 3.8-5.5), respectively. Trials that mandated timed serum sampling (6 or more hours after symptom onset) had an improved predictive value for elevated cTnI (n = 2,807, OR 8.8; 95% CI 5.9-13.2) and cTnT (n = 1,990, OR 8.5; 95% CI 5.9-12.5). In conclusion, cTnI and cTnT provide similar information in ACS. The risk of adverse events is 4-fold higher in patients with suspected ACS and elevated serum cTn. For patients with an elevated timed (6-hour) sample the risk is over 8-fold higher.     

Cardiovascular risk and therapeutic benefit of coronary interventions for patients with unstable angina according to the troponin T status.

AIMS: Elevation of troponin T in patients with unstable angina is predictive of adverse outcomes. Since no advanced therapeutic concept for such high-risk patients has been established, we investigated cardiac risk prior to, during, and after coronary revascularization in patients with unstable angina stratified according to the troponin T status. METHODS AND RESULTS: Out of 351 patients with unstable angina, troponin was elevated for 36% of the patients as determined by qualitative bedside tests. The patients were followed during hospitalization and 30 days after discharge for incidence of death and myocardial infarction. In troponin-positive patients, clinical symptoms were more refractory to medical treatment than in troponin-negative patients (78% vs 44%;P=0.002). Although these patients were catheterized earlier (1.6 vs 3.4 days;P=0.005) and more frequently (95% vs 69%;P<0.001), troponin-positive patients suffered a higher incidence of cardiac events prior to scheduled revascularization (death, myocardial infarction; 6.4% vs 0.4%;P<0.001). The angiogram for troponin-positive patients confirmed a more severe coronary artery disease requiring revascularization (69% vs 50%;P=0.001). Also the following coronary intervention was more complicated (death, myocardial infarction; 15.3% vs 4.8%;P=0.02). During the 30-day follow-up period, cardiac risk remained elevated for troponin-positive patients. CONCLUSIONS: Troponin T rapid testing reliably identified high-risk patients with unstable angina. A higher event rate was observed prior to and particularly in association with the coronary intervention. Coronary revascularization did not abrogate the increased risk of troponin-positive patients during the 30-day follow-up.     

Risk stratification with a point-of-care cardiac troponin T test in acute myocardial infarction. GUSTOIII Investigators. Global Use of Strategies To Open Occluded Coronary Arteries

Troponin T has been used successfully to risk stratify patients with acute coronary syndromes, but the utility of this approach using a rapid bedside assay in patients undergoing thrombolysis for ST-segment elevation acute myocardial infarction has not been assessed in a large population. We assessed whether a point-of-care, qualitative troponin T test at enrollment could independently risk-stratify patients randomized to receive alteplase or reteplase in the GUSTO-III trial. Complete troponin T data were available for 12,666 patients (84%) enrolled at 550 hospitals. The primary end point was mortality at 30 days, and the predictive ability of an elevated baseline troponin T level was analyzed (after adjustment for baseline characteristics) with multiple logistic regression. Patients with an elevated troponin T result at enrollment (8.9%) had significantly higher mortality at 30 days (unadjusted 15.7% vs 6.2% for negative patients; p = 0.001), which persisted even after adjustment for age, heart rate, location of infarction, Killip class, and systolic blood pressure. In a multivariable regression model, a positive troponin T result added independently to the prediction of 30-day mortality (chi-square 46, p = 0.001). A positive result with qualitative troponin T testing on admission is an independent marker of higher 30-day mortality. Troponin T testing could be a valuable addition to the evaluation strategy for patients with acute myocardial infarction.     

A population-based evaluation of the thrombolysis in myocardial infarction risk score for unstable angina and non-ST elevation myocardial infarction

BACKGROUND: The Thrombolysis in Myocardial Infarction risk score (TIMI-RS) for unstable angina/non-ST elevation myocardial infarction (MI) was developed in patients presenting with unstable angina accompanied by high-risk features or non-ST elevation MI to determine early risk stratification. HYPOTHESIS: The validity in patients presenting for emergency care with symptoms suggestive of acute coronary syndrome (ACS) has not been well established, and the present study sought to do so by evaluating the TIMI-RS in a prospective fashion. METHODS: A prospective TIMI-RS using seven variables was calculated in 245 patients admitted to the hospital with symptoms suggestive of ACS: (1) age > 65, (2) three or more cardiac risk factors, (3) ST deviation, (4) aspirin use within 7 days, (5) two or more anginal events over 24 h, (6) history of coronary stenosis, and (7) elevated troponin. Patients were contacted at 30 days and data were collected concerning major adverse cardiac events. RESULTS: In patients presenting with chest pain, a higher TIMI-RS was associated with an increase in major adverse cardiac events within 30 days. We found that the 30-day event rate was 0% for a score of 1, 20% for a score of 2, 24% for a score of 3, 42% for a score of 4, 52% for a score of 5, and 70% for a score of 6 or 7 (p < 0.0001). CONCLUSIONS: The TIMI-RS successfully differentiates early risk for major adverse cardiac events in a general population presenting with symptoms suggestive of acute coronary syndrome. A simple bedside calculation of the TIMI-RS provides rapid risk stratification, allowing facilitation of therapeutic decision making in patients with symptoms suggestive of ACS.     

Time to Positivity of a Rapid Bedside Assay for Cardiac-Specific Troponin T Predicts Prognosis in Acute Coronary Syndromes: A Thrombolysis in Myocardial Infarction (TIMI) 11A Substudy

Objectives. We sought to determine whether the rapid bedside assay for troponin T identified patients at risk for a more complicated hospital stay and a higher rate of adverse clinical events.Background. In patients with an acute coronary syndrome, the amount of cardiac-specific troponin T released bears a stoichiometric relation to the extent of myocardial damage.Methods. In 597 patients with unstable angina or non–Q wave myocardial infarction participating in the Thrombolysis in Myocardial Infarction (TIMI) 11A substudy, a rapid bedside assay and simultaneous quantitative serum measurement for troponin T were obtained at enrollment.Results. The composite end point of the sum of death, nonfatal myocardial infarction or recurrent ischemia through day 14 occurred in 33.6% of patients with a positive assay compared with only 22.5% of patients with a negative assay (p = 0.01). Those patients in whom the rapid assay became positive in ≤10 min had the highest mortality rate of 4.2% through day 14 compared with 1.1% in those patients who had either a late-appearing positive assay (>10 min) or a negative assay. The duration of hospital stay in the 116 patients (19%) with a positive rapid assay at enrollment was a median of 5 days compared with only 3 days in the 481 patients (81%) with a negative rapid assay at enrollment (p = 0.002).Conclusions. A positive rapid assay for troponin T at presentation identifies those patients at risk for higher rates of adverse clinical events and longer, more complicated hospital stays. Stratification of patients by time to development of a positive rapid assay identifies those patients at highest mortality risk.     

C-reactive protein as an independent marker of prognosis in acute coronary syndrome: comparison with troponin T

BACKGROUND: It has been suggested that inflammatory processes play a role in the pathogenesis of acute coronary syndromes (ACS). C-reactive protein (CRP) is a classic acute phase protein. It is yet unclear whether, in addition to established markers as troponin T (TnT), determination of CRP in patients admitted for ACS contributes significantly to the diagnosis and prognosis of ACS. PATIENTS AND METHODS: We investigated 50 patients with ACS (59.4 SD 13.9 years) in the first hour after admission and 4-24 h later with respect to TnT (Elecsys, Roche Diagnostics) and CRP (biokit, modified Quantex CRP plus, analytical sensitivity 0.02 mg/dL). Fifty percent of the patients were classified as having unstable angina retrospectively. All patients were followed in the 6 weeks post discharge regarding death and recurrent ACS. RESULTS: The cumulative event rate at 6 weeks after discharge was 62.5% for patients being CRP and TnT positive compared to 35.3% in TnT positive and CRP negative patients. In TnT negative patients a positive CRP test predicted 33.3% of events and 28.8% of patients negative for CRP and TnT had events at 42 days post discharge. Logistic regression analysis regarding the primary endpoint including TnT and CRP (4-24 h values), age, gender and diagnosis resulted in independent prediction of ACS or death by TnT (cutoff 0.1 microgram/L, p = 0.048, odds ratio = 7.5) and CRP (cutoff 0.862 mg/dL, p = 0.026, odds ratio = 5.3). Sensitivity/specificity for AMI diagnosis were 69.6%/75% for TnT and 12%/72% for CRP in the first hour and 91.3%/68.2% for TnT and 68%/72% for CRP 4-24 h later. CONCLUSIONS: Besides TnT, high sensitivity CRP determination has no additional value for early AMI diagnosis. The prognosis of these patients during the first 24 hours is significantly and independently predicted by CRP measurements in addition to troponin T.     

Acute coronary syndrome vs nonspecific troponin elevation: clinical predictors and survival analysis

BACKGROUND: Although troponin is considered a specific marker for the diagnosis of acute coronary syndrome (ACS), recent studies have shown troponin elevation in a variety of nonischemic conditions. Our aim was to determine the predictors for the diagnosis of ACS in the presence of an abnormal troponin level. METHODS: All patients with abnormal troponin T levels were analyzed. Demographic and clinical data were collected and death was recorded. The study group was divided into 2 subgroups: ACS vs nonthrombotic troponin elevation. A multivariate logistic regression analysis was performed to define variables that predict the diagnosis of ACS. The positive predictive value (PPV) for ACS diagnosis was calculated, and a survival analysis was performed. RESULTS: During the study period, 615 patients had elevated troponin T levels. Only 326 patients (53%) received a main diagnosis of ACS, while 254 (41%) had nonthrombotic troponin elevation; for 35 patients (6%), the diagnosis was not conclusive. Positive predictors for the diagnosis of ACS were age between 40 and 70 years, history of hypertension or ischemic heart disease, normal renal function, and a troponin T level higher than 1.0 ng/mL. The overall PPV of troponin T for ACS diagnosis was only 56% (95% CI, 52%-60%). The PPV of troponin T level higher than 1.0 ng/mL in the presence of normal renal function was 90% but was as low as 27% for values of 0.1 to 1.0 ng/mL for elderly patients with renal failure. In-hospital and long-term survival rates were significantly better (P<.001) for patients with ACS. CONCLUSIONS: Nonspecific troponin elevation is a common finding among hospitalized patients and correlates with worse prognosis. The diagnosis of myocardial infarction should still mostly be based on the clinical presentation. The predictors and algorithm suggested in this study might increase the diagnostic accuracy of ACS and direct the appropriate treatment.     

A rapid troponin I assay is not optimal for determination of troponin status and prediction of subsequent cardiac events at suspicion of unstable coronary syndromes

BACKGROUND: Troponin is a specific marker of myocardial damage. For early prediction of coronary events in patients with suspicion of acute coronary syndromes the assay also needs to be highly sensitive. METHODS AND RESULTS: A rapid troponin I assay was performed prior to inclusion in 4447 acute coronary syndrome patients in the GUSTO-IV trial. A quantitative troponin T analysis was later performed on blood samples obtained at randomization by a central laboratory. There was an agreement between the rapid troponin I assay and troponin T (< or =/>0.1 microg/l) in 3596 (80.9%) patients. A positive rapid troponin I was identifying any elevation of troponin T (>0.01 microg/l) in 1990 patients (90.4%) whereas a negative rapid troponin I was corresponding to negative troponin T (< or =0.01 microg/l) in only 1217 patients (54.2%). Patients with a positive versus negative rapid troponin I had an increased risk of death or myocardial infarction at 30 days (9.3 vs. 5.9%; odds ratio, O.R. 1.64; 95% confidence interval, 1.31-2.06). Troponin T elevation (>0.1 microg/l) provided a better (10.5 v. 4.9%, O.R. 2.26; C.I. 1.79-2.85) risk stratification. Regardless of a positive or a negative rapid troponin I, the troponin T result (>0.1 vs. < or =0.1 microg/l) stratified the patients into high and low risk of events at 30 days, (10.3 vs. 5.7%, P=0.002) and (11.5 vs. 4.8%, P<0.001), respectively. CONCLUSION: In a population with non-ST elevation acute coronary syndrome a positive rapid troponin I assay is a specific indicator of troponin elevation and a predictor of early outcome. However, a negative rapid troponin I is not a reliable indicator of the absence of myocardial damage and does not indicate a low risk of subsequent cardiac events. A rapid troponin I assay was performed prior to inclusion in 4447 acute coronary syndrome patients in the GUSTO-IV trial and related to a centrally analyzed quantitative troponin T test. A positive rapid troponin I was well corresponding to any elevation of troponin T (>0.01 microg/l) and predicted an unfavorable outcome at 30 days. However, a negative rapid troponin I was corresponding to troponin T < or =0.01 microg/l in only half of the patients. Troponin T >0.1 microg/l vs. < or =0.1 microg/l provided a better risk stratification than the rapid troponin I result. For patients with troponin T elevation (>0.1 microg/l) the 30 day event rate was high regardless of the rapid troponin I result.     

Plasma angiogenin levels in acute coronary syndromes: implications for prognosis.

AIMS: Angiogenin is a member of the ribonuclease superfamily, which has been implicated as a mitogen of endothelial cells and activator of matrix metalloproteinases and plasminogen-activated plasmin pathways. We hypothesized abnormalities of angiogenin levels in acute coronary syndrome (ACS), with prognostic implications for predicting adverse events. METHODS AND RESULTS: We measured plasma angiogenin levels (ELISA) in 396 consecutive patients (63.4% males; mean age 67 years, SD 13) admitted with ACS, who were compared with 44 'disease controls' (patients with stable coronary artery disease) and 76 healthy controls. Clinical follow-up at 6 months was performed for adverse endpoints (cardiovascular death, recurrent ACS, revascularization and heart failure). ACS patients had significantly elevated plasma angiogenin levels compared with both disease controls and healthy controls (P < 0.001). After adjusting for baseline characteristics, raised troponin T levels and electrocardiographic changes, raised angiogenin levels were independently associated with more adverse events at 6 months' follow-up [HR 1.44 (95% CI: 1.10-1.89); P = 0.008]. CONCLUSION: Plasma angiogenin levels are significantly increased in ACS, and may be involved in the pathogenesis of this condition. High angiogenin levels were predictive of adverse events during follow-up.     

The prognostic value of troponin in patients with non-ST elevation acute coronary syndromes: a meta-analysis

OBJECTIVES: This study was designed to compare the prognostic value of an abnormal troponin level derived from studies of patients with non-ST elevation acute coronary syndromes (ACS). BACKGROUND: Risk stratification for patients with suspected ACS is important for determining need for hospitalization and intensity of treatment. METHODS: We identified clinical trials and cohort studies of consecutive patients with suspected ACS without ST-elevation from 1966 through 1999. We excluded studies limited to patients with acute myocardial infarction and studies not reporting mortality or troponin results. RESULTS: Seven clinical trials and 19 cohort studies reported data for 5,360 patients with a troponin T test and 6,603 with a troponin I test. Patients with positive troponin (I or T) had significantly higher mortality than those with a negative test (5.2% vs. 1.6%, odds ratio [OR] 3.1). Cohort studies demonstrated a greater difference in mortality between patients with a positive versus negative troponin I (8.4% vs. 0.7%, OR 8.5) than clinical trials (4.8% if positive, 2.1% if negative, OR 2.6, p = 0.01). Prognostic value of a positive troponin T was also slightly greater for cohort studies (11.6% mortality if positive, 1.7% if negative, OR 5.1) than for clinical trials (3.8% if positive, 1.3% if negative, OR 3.0, p = 0.2) CONCLUSIONS: In patients with non-ST elevation ACS, the short-term odds of death are increased three- to eightfold for patients with an abnormal troponin test. Data from clinical trials suggest a lower prognostic value for troponin than do data from cohort studies.     

Impact of in-stent restenosis on death and myocardial infarction

Although drug-eluting stents reduce restenosis and target lesion revascularization compared with bare metal stents (BMSs), the specter of late stent thrombosis has curbed enthusiasm for the widespread use of drug-eluting stents. Alternatively, increasing BMS use would increase restenosis and potentially increase adverse events. The presentation and outcomes of BMS restenosis are controversial. We evaluated 2,539 patients with BMS restenosis referred for repeat revascularization. Major adverse cardiac events, including mortality and myocardial infarction (MI), were assessed at clinical presentation, 30 days, and 6 months. Patients with acute presentation (i.e., unstable angina requiring hospitalization or MI) were compared with patients with stable presentation. At presentation, 19.2% of patients were asymptomatic, 27.5% had exertional angina, 46.6% had unstable angina, and 6.7% had MI. Mortality and MI rates were 1.1% and 1.4%, respectively, at 30 days and 3.3% and 4.5%, respectively, at 6 months. Patients with acute coronary syndrome (ACS) and those without ACS had similarly low mortality rates at 30 days (1.2% ACS vs 1.0% non-ACS, p = 0.65) and 6 months (3.4% ACS vs 3.3% non-ACS, p = 0.93) and MI rates at 30 days (1.3% ACS vs 1.4% non-ACS, p = 0.87) and 6 months (4.7% ACS vs 4.3% non-ACS, p = 0.65). Combined major adverse cardiac events were similar at 30 days (2.5% vs 2.1%, p = 0.53) and 6 months (7.4% ACS vs 6.9%, non-ACS, p = 0.65). In conclusion, although BMS restenosis often manifests as an ACS, it is associated with a low incidence of 6-month major adverse cardiac events and does not predict a negative outcome.     

Short- and long-term prognostic value of cardiac troponin I and dobutamine echocardiography in patients with stabilized acute coronary syndromes

Background: This study investigated the short- and long-term prognostic values of cardiac troponin I (cTnI) and dobutamine echocardiography (DE) in patients with acute coronary syndrome (ACS) who stabilized after medical treatment. Methods and results: 171 consecutive patients of ACS accepted blood sampling for cTnI at the emergency department and DE at 4.9±0.6 days after admission. The prognostic values of cTnI, DE, and combined cTnI and DE were separately investigated at follow up periods of 30 days, 1 year and 3 years for hard events (cardiac death and non-fatal myocardial infarction) and all spontaneous events. CTnI was elevated in 55 (32%) patients and DE was positive in 114 (67%) patients. Elevated cTnI with positive DE were found in 44 (26%) patients. Within 30 days, the combination of elevated cTnI and positive DE provided more accurate prognostic information than each test result alone, and was the only independent predictor for both hard (p=0.014) and all events (p=0.012). After 1 year, cTnI alone had no prognostic value. The combination of an elevated cTnI level and a positive DE only had a prognostic value for all events (p=0.015). However, DE was an independent predictor for both hard (p=0.006) and all events (p=0.002). Neither cTnI alone nor cTnI combined with DE had a significant 3-year prognostic value. However, DE maintained its prognostic value and was still an independent predictor after 3 years for both hard (p=0.024) and all events (p=0.004). Conclusions: For patients with stabilized ACS, the diagnostic finding of elevated cTnI combined with a positive DE has a better short-term prognostic value than each test alone. However, DE alone has a better long-term prognostic value.     

Modified Thrombolysis in Myocardial Infarction (TIMI) risk score to risk stratify patients in the emergency department with possible acute coronary syndrome

Objective To assess the prognostic utility of the Thrombolysis in Myocardial Infarction (TIMI) risk score in patients in the emergency department (ED) evaluated for possible acute coronary syndrome (ACS). Background The ability of the TIMI risk score to risk stratify patients at initial presentation in the ED with chest pain of unclear etiology is uncertain. Methods We investigated the prognostic utility of the TIMI risk score in 947 consecutive patients evaluated in the ED for possible ACS. A multivariate analysis was done to evaluate the independent predictive power of the individual components of the TIMI risk score to predict an adverse event at 30 days (all-cause death, myocardial infarction, and coronary revascularization). Results There were 151 (16%) patients diagnosed with ACS. At 30 days there were 48 (5%) deaths, 84 (9%) myocardial infarctions, and 49 (5%) coronary revascularization procedures. The mean TIMI risk score was significantly higher in patients with an adverse event compared with those without (2.6 ± 1.3 vs. 1.7 ± 1.2, P < 0.0001). Four of the 7 TIMI risk factors (age ≥65 years, ST segment deviation ≥0.5 mm elevated troponin I, and coronary stenosis ≥50%) were independently associated with adverse events. A simplified TIMI risk score was computed and was found to have similar prognostic ability as the 7 variable TIMI risk score. Conclusion A modified TIMI risk score may simplify risk stratification of ED patients with undifferentiated chest pain.     

Positive troponin in diabetic ketoacidosis without evident acute coronary syndrome predicts adverse cardiac events

BACKGROUND: Elevated troponin I has been associated with increased mortality in critically ill patients without acute coronary syndrome (ACS). However, the prognostic significance of troponin elevation in patients with diabetic ketoacidosis (DKA) without evident ACS has not been studied. METHODS: Retrospective study of all patients admitted to a U.S. tertiary center between 01/98 and 12/00 with DKA and had troponin I level measured. Patients with evidence of ACS or who met the American College of Cardiology/European Society of Cardiology (ACC/ESC) definition for myocardial infarction were excluded. Baseline characteristics, cardiac evaluation and 2 year major adverse coronary event (MACE) rate were compared between patients with positive and negative troponin. RESULTS: Ninety-six patients fulfilled the inclusion criteria of this study, 26 had positive troponin. There were no differences in baseline characteristics between the two groups. After a 2 year follow-up, there was significantly increased mortality in patients with elevated troponin (50.0% versus 27.1%, hazard-ratio (HR) 2.3, 95% confidence interval (CI) 1.2-4.8, p = 0.02). Patients with elevated troponin also had significantly increased MACE rate at 2 years (50.0% versus 28.6%, HR 2.6, 95% CI 1.3-5.3, p = 0.007) driven primarily by mortality. Using Cox Proportional Hazard Analysis, elevated troponin was a predictor of increased MACE after adjusting for confounding variables. (Adjusted HR 2.3, 95% CI 1.1-4.6, p = 0.02) CONCLUSIONS: Elevated troponin I in diabetic patients admitted with DKA identifies a group at very high risk for future cardiac events and mortality. Whether cardiac risk stratification of these patients will improve long term outcome remains to be studied.     

非ST段抬高急性冠状动脉综合征的预后危险因素与危险评分

目的：探讨非 ST 段抬高急性冠状动脉综合征的预后危险因素及不同危险评分的预测预后价值。方法：2003年1月至2004年4月期间,连续入院且资料完整的非 ST 段抬高急性冠状动脉综合征患者337例,随访 30天与1年的终点事件(心原性死亡和非致命性心肌梗死)。根据入院时的临床指标分别计算每例患者的心肌梗死溶栓治疗临床试验(TIMI)评分和全球急性冠状动脉事件注册(GRACE)评分,进行多变量回归分析,筛查30天和1年时心血管事件的预测危险因素(根据有无终点事件发生分为30天事件组、30天无事件组和1年事件组、1年无事件组)；分析 TIMI 评分和 GRACE 评分的预后价值,以及与血运重建的相互关系。结果：随访1年共发生终点事件57例(16.9%)。死亡19例(5.6%),非致死性心肌梗北38例(11.3%)。预测危险因素包括：年龄、血肌酐升高、入院时心率、左心室射血分数＜0.40和高血压。TIMI 评分和 GRACE 评分方法预测30天终点事件的敏感性和特异性相似,但 GRACE 评分预测1年终点事件的敏感性和特异性优于 TIMI 评分,GRACE 评分＞ 133分的患者进行血运重建治疗后远期终点事件发生率明显下降(P=0.01)。结论：除传统危险因素外,血肌酐水平升高是非 ST 段抬高急性冠状动脉综合征患者预后的重要危险因素；GRACE 评分较 TIMI 评分能更好的预测非 ST 段抬高急性冠状动脉综合征患者1年的终点事件危险,GRACE 评分＞133分的患者进行血运重建的获益更多。     

Cardiac troponin I elevation in hospitalized patients without acute coronary syndromes

Increase of cardiac troponins occurs in a variety of clinical situations in the absence of an acute coronary syndrome (ACS). Few data exist regarding the incidence, clinical characteristics, and predictive value of various cardiac diagnostic tests and outcome of patients with a non-ACS-related troponin increase. We studied 883 consecutive hospitalized patients with increased cardiac troponin I levels. The discharge diagnosis was reclassified and troponin increase attributed to ACS or another process. Clinical data and results of cardiac diagnostic tests were collected. Patients were followed for a median of 30 months. Three hundred eleven patients were classified as having a non-ACS-related troponin increase (35.2%). An alternative explanation for troponin increase was found in 99% of these patients. Troponin level had poor accuracy in discriminating patients with and without ACS (area under the receiver operating characteristics curve 0.63). Coronary angiography was frequently unhelpful in excluding a non-ACS-related troponin increase because 77% of patients in the non-ACS group had significant flow-limiting coronary artery disease. Patients with non-ACS-related troponin increase had significantly higher in-hospital (hazard ratio 2.8, 95% confidence interval 2.0 to 3.8) and long-term (hazard ratio 2.0, 95% confidence interval 1.6 to 2.5) mortalities compared with patients with ACS. In conclusion, cardiac troponin level is frequently increased in hospitalized patients in the absence of an ACS and portends poor short- and long-term outcomes. Most of these patients have an alternative explanation for cardiac troponin increase. Cardiac diagnostic procedures are frequently unhelpful in excluding a non-ACS-related troponin increase.     

Prospective analysis of creatine kinase muscle-brain fraction and comparison with troponin T to predict cardiac risk and benefit of an invasive strategy in patients with non-ST-elevation acute coronary syndromes

OBJECTIVE: We sought to determine whether elevation of plasma creatine kinase muscle-brain fraction (CK-MB) would be useful to triage patients with acute coronary syndromes (ACS) to early angiography/revascularization. BACKGROUND: It is unknown whether the measurement of CK-MB is effective for triage to an aggressive management strategy. METHOD: Patients in the Treat Angina With Aggrastat and Determine Cost of Therapy With an Invasive or Conservative Strategy (TACTICS-TIMI) 18 study received aspirin, heparin, and tirofiban for treatment of ACS, were randomized to an invasive or a conservative strategy (angiography/revascularization between 4 and 48 h), and were followed up for a composite end point of death, myocardial infarction, or rehospitalization for ACS.Of 2,220 patients, CK-MB was elevated in 826 (37%). Of the patients with negative CK-MB, troponin T was elevated in 361 (31.2%). Event rates at 30 and 180 days were twice as high in patients with elevated CK-MB than in patients without elevated CK-MB. Both groups had similar benefit from an invasive strategy; there was no evidence of interaction between CK-MB elevation and strategy on the composite end point at 30 or 180 days. When patients were stratified according to both CK-MB and troponin status, there was evidence of a benefit in the invasive strategy among patients who were CK-negative but troponin-positive (odds ratios [95% confidence interval]: 0.13 [0.04 to 0.39] at 30 days and 0.29 [0.16 to 0.52] at 180 days). CONCLUSION: Patients with minimal amounts of recent onset myonecrosis but elevated risk as indicated by CK-MB and troponin, respectively, benefit most from invasive management. Determination of troponin levels yielded significant information regarding triage to an invasive strategy, particularly in CK-MB-negative patients.     

非ST段抬高急性冠状动脉综合征的危险因素分析及早期干预

目的　探讨非ST段抬高急性冠状动脉综合征(ACS)的临床高危因素及早期有创干预的价值。方法　在 2001年 10月至 2003年 10月期间连续入院的非ST段抬高的ACS患者共 545例,随机分成早期保守治疗组与早期有创干预组;随访 30天与 6个月患者的复合心血管事件 (包括心脏性死亡、非致命性心肌梗死、非致命性心力衰竭、因反复缺血性心绞痛发作住院 )发生率,将患者一般临床特征及辅助检查指标对复合心血管事件做多变量回归分析,筛查主要的高危因素;评价早期保守治疗与早期有创干预对患者预后的影响。结果　随访 513例患者, 30天与 6个月的复合心血管事件发生率分别为 14 0%与 25 7%;多变量Logistic回归分析,显示ST段压低、肌钙蛋白Ⅰ (TnI)水平升高、高敏C反应蛋白(hs CRP)增高、左室射血分数(LVEF)值下降以及心肌梗死溶栓疗法(TIMI)危险评分高分者与 6个月的复合心血管事件增高密切相关,它们分别是患者复合心血管事件危险性增加的独立预测因子;与早期保守治疗组比较,早期有创干预组随访 30天时反复心绞痛发作住院率减少,复合心血管事件减少;随访 6个月时复合心血管事件也减少 (P均 <0 05)。结论　ST段压低、TnI水平升高、hs CRP增高、LVEF值下降或TIMI危险评分增高是非ST段抬高ACS患者的高危因素,早期有创干预能