B-型钠尿肽系列测定判定急性冠脉综合征患者预后的价值

目的探索对急性冠脉综合征（ACS）患者，B-型钠尿肽（BNP）系列测定联合TnT、CRP与不良心脏事件发生率的关系。方法对83例ACS患者分别在入院时、48h、72h测定其BNP、TnT、CRP值，以死亡、心肌梗死、症状性心衰为随访终点，平均随访12个月，对BNP等生化指标与心脏事件发生率的相关性进行统计学分析。结果随访中发现，BNP〉250ng／L的患者与BNP≤250ng／L的患者相比，心脏事件的发生率显著升高，为9％和27％（OR3．7，95％CI：2．3-5．7，P〈0．01）。在TnT阴性的患者，高BNP组与低BNP组相比，其危险比为5．9（95％CI2．6-13.3，P〈0．01）。在临床稳定、没有难治性心肌缺血的患者，BNP值快速下降，基线、48h、72h时的BNP值分别为248．6±10、188．9±8（-24％）、126．8±11（-49％），与基线相比，48h、72h差异均有统计学意义（P〈0．01）。BNP在基线时水平较低，而在72h显著升高的患者，预后较差，OR值为24．0（95％CI：8．4-32．5，P〈0．01）。而在基线时BNP值较高，72h时明显下降者，MACE发生率显著降低，与持续升高者相比，为16％vs38％（OR18．5，95％CI：7．6-21-3，P〈0．01）。结论对ACS患者，BNP是一个强有力的预后判断指标，并且BNP的系列测定与单一基线水平测定相比，其预后判断价值显著增加。     

Prognostic value of serum hepatocyte growth factor in patients with acute coronary syndromes.

The present study examined whether or not hepatocyte growth factor (HGF), an endothelium-specific growth factor that stimulates regeneration of the endothelium, is increased or has a prognostic significance in patients with acute coronary syndromes. HGF was measured in 106 patients with coronary artery disease (20 stable effort angina, 12 unstable angina without adverse events, 24 unstable angina with adverse events and 50 acute myocardial infarction) on admission and 21 normal volunteers. The measurements in all patients were recorded before administration of heparin, and in acute myocardial infarction patients they were recorded from days 2 to 6 after heparin discontinuation on day 1. HGF levels (ng/ml) were 0.30+/-0.06 for the controls, 0.31+/-0.08 for stable effort angina patients, 0.31+/-0.08 for unstable angina patients without adverse events, 0.40+/-0.20 for unstable angina patients with adverse events and in acute myocardial infarction patients they were 0.45+/-0.18 on day 0, 0.57+/-0.45 on day 2, 0.50+/-0.35 on day 3, 0.48+/-0.32 on day 4, 0.44+/-0.20 on day 5, and 0.38+/-0.14 on day 6. HGF plays a crucial role in the restoration of injured endothelial cells and is a predictor of adverse events in patients with acute coronary syndromes.     

血清尿酸、肌钙蛋白I和高敏C反应蛋白对急性冠状动脉综合征患者预后的预测价值

目的:观察急性冠状动脉综合征(ACS)患者血清尿酸(UA)、肌钙蛋白I(cTnI)和高敏C反应蛋白(hs-CRP)含量并探讨对其临床预后的预测价值。方法:入选确诊ACS的住院患者592例,收集入院24h内UA、cTnI和hs-CRP的数值,并对患者出院后的心血管事件进行随访,分为心血管事件组和无心血管事件组。结果:UA、cTnI和hs-CRP在2组之间的差异均有统计学意义;校正了年龄、职业、吸烟史、BMI、高血压、糖尿病等相关因素后,血清UA、cTnI和hs-CRP能独立预测ACS患者再发心血管事件。结论:血清UA、cTnI和hs-CRP水平升高与ACS患者的再发心血管事件显著相关,具有较强的预测价值。     

Prognostic value of uric acid in patients with ST-elevated myocardial infarction undergoing primary coronary intervention

Elevated uric acid (UA) levels have been associated with cardiovascular disease in epidemiologic studies. The relation between UA levels and long-term outcomes in patients with ST-segment elevation myocardial infarction who undergo primary percutaneous coronary intervention is not known. Data from 2,249 consecutive patients with ST-segment elevation myocardial infarction who underwent primary percutaneous coronary intervention were evaluated. Patients were divided into 2 groups with high or low UA using upper limits of normal of 6 mg/dl for women and 7 mg/dl for men. There were 1,643 patients in the low-UA group (mean age 55.9 ± 11.6 years, 85% men) and 606 patients in the high-UA group (mean age 60.5 ± 12.6 years, 76% men). Serum UA levels were 8.0 ± 1.5 mg/dl in the high-UA group and 5.2 ± 1.0 mg/dl in the low-UA group (p <0.001). The in-hospital mortality rate was significantly higher in patients with high UA levels (9% vs 2%, p <0.001), as was the rate of adverse outcomes in patients with high UA. The mean follow-up time was 24.3 months. Cardiovascular mortality, reinfarction, target vessel revascularization, heart failure, and major adverse cardiac events were all significantly higher in the high-UA group. In a multivariate analyses, high plasma UA levels were an independent predictor of major adverse cardiac events in the hospital (odds ratio 2.03, 95% confidence interval 1.25 to 3.75, p = 0.006) and during long-term follow-up (odds ratio 1.64, 95% confidence interval 1.05 to 2.56, p = 0.03). In conclusion, high UA levels on admission are independently associated with in-hospital and long-term adverse outcomes in patients with ST-segment elevation myocardial infarction who undergo primary percutaneous coronary intervention.     

血尿酸水平对急性冠脉综合征的预测价值

目的:探讨血尿酸水平对急性冠脉综合征(ACS)的预测意义。方法:收集49例稳定性心绞痛(SAP),50例不稳定性心绞痛(UAP)及52例急性心肌梗死(AMI)病人的空腹血标本,测定尿酸(UA)、甘油三酯(TG)、总胆固醇(TC)、低密度总胆固醇(LDL-C)、空腹血糖(FBG)、肌酐(Cr)的含量,并进行对照比较。结果:3组间TG、TC、LDL-C、FBG及Cr水平无明显差异;UAP组及AMl组的尿酸水平接近,无统计学意义,但明显高于SAP组(P<0.05)。UAP组及AMI组的尿酸异常者比例相似,但也明显高于SA组(P<0.05)。结论:高尿酸血症是CHD的独立危险因子,能促进并预示ACS的发生。     

Prognostic value of troponins in patients with non-ST-segment elevation acute coronary syndromes and chronic kidney disease

BACKGROUND: The prognostic value of cardiac troponins (cTn) in patients with non-ST-segment elevation acute coronary syndromes (NSTE ACS) and chronic kidney disease (CKD) is debated. HYPOTHESIS: We tested the performance of cTnI and cTnT for risk stratification in patients with CKD and evaluated the prognostic significance of cTnI and cTnT elevations by their magnitude across the range of CKD severity. METHODS: We examined correlations among cTn elevation, CKD, and in-hospital mortality in 31,586 high-risk patients with NSTE ACS included in the Can Rapid Risk Stratification of Unstable Angina Patients Suppress ADverse Outcomes with Early Implementation of the American College of Cardiology/American Heart Association Guidelines initiative (CRUSADE). Cardiac tropinins I and T levels were categorized as ratios of each site's upper limit of normal (ULN) for myocardial necrosis: normal (cTn ratio < or =1 x ULN), mild (cTn ratio > 1-3 x ULN), and major (cTn ratio > 3 x ULN) elevation. Estimated glomerular filtration rate (eGFR) was calculated using the abbreviated Modification of Diet in Renal Disease equation. Stages of CKD were categorized as normal to mild (eGFR > 60 mL/min), moderate (eGFR 30-60 mL/min), or severe (eGFR < 30 mL/min). RESULTS: Mortality increased more steeply across CKD stages (2.0%-12.9%) than across cTn ratio categories (2.7%-5.4%). In normal or mild CKD, mortality was low regardless of cTn elevations. In moderate CKD, mortality increased incrementally with cTnI (3.3% versus 5.4% versus 7.4%) and cTnT (3.7% versus 5.3% versus 7.3%) elevation. Among severe CKD patients, only major cTn elevations further distinguished risk (cTnI: 10.1% versus 9.7% versus 14.6%; cTnT: 7.0% versus 5.7% versus 14.0%). CONCLUSIONS: In patients with CKD, cTnI and cTnT perform equally in differentiating short-term prognosis following NSTE ACS; however, the prognostic impact of cTn is dependent upon the degree of CKD severity.     

Prognostic value of low-level cardiac troponin-I elevations in patients without definite acute coronary syndromes

Background

Low-level cardiac troponin-I (cTn-I) elevations predict adverse cardiovascular outcomes in patients with definite acute coronary syndromes (ACS), as defined by the presence of chest pain accompanied by ischemic electrocardiographic changes. However, their prognostic value in other clinical situations remains unclear.

Methods

We studied 366 patients with suspected myocardial infarction (MI) but without definite ACS, including 57 patients with low-level cTn-I elevations (1.0 to 3.0 ng/mL) and 309 patients with cTn-I <1.0 ng/mL. All cTn-I measurements were made with the Dade Stratus II analyzer. We determined the adjusted 1-year risk of nonfatal MI or death from coronary heart disease (CHD death) in each group by using Cox proportional hazards models.

Results

Among patients with cTn-I elevations between 1.0 and 3.0 ng/mL, 6 (11%) had a nonfatal MI or CHD death at 1 year compared with 12 (4%) patients in the cTn-I <1.0 ng/mL group [hazard ratio (HR), 3.5; 95% CI, 1.4 to 8.8]. After adjusting for baseline clinical characteristics, cTn-I levels between 1.0 and 3.0 ng/mL remained strongly associated with nonfatal MI or CHD death (adjusted HR, 3.4; 95% CI, 1.3 to 9.4). This association persisted even in the 215 patients who presented without chest pain (adjusted HR, 4.3; 95% CI, 1.4 to 13).

Conclusions

Low-level cTn-I elevations identify a subset of patients at increased risk for future cardiovascular events, even when obtained outside the context of definite ACS or presentation with chest pain.     

Prognostic value of cardiac troponin I re-elevation following percutaneous coronary intervention in high-risk patients with acute coronary syndromes.

Troponin I is a predictive marker of short- and intermediate-term adverse cardiac events in patients with acute coronary syndromes (ACS). These high-risk patients may benefit from early percutaneous coronary intervention. However, whether additional myocardial injury, defined as postprocedural troponin I elevation, may be associated with adverse short- and intermediate-term outcomes has not been fully explored. Accordingly, we studied 132 consecutive patients with non-ST-elevation ACS (62% with non-Q-wave myocardial infarction) and elevated troponin I levels at admission (>0.15 ng/ml) who underwent percutaneous coronary intervention > or =48 hours after admission. Troponin I levels were routinely measured at 6 and 18 to 24 hours after intervention and patients were stratified according to the presence or absence of troponin I re-elevation, defined as postprocedural troponin I levels >1 times the admission levels. In-hospital and cumulative 6-month clinical outcomes were compared between groups. Patients with troponin I re-elevation (n = 51) were older (68 +/- 13 vs 64 +/- 12 years, p = 0.05) and had experienced prior myocardial infarction more frequently (92.5 vs 82.1, p = 0.09), but otherwise had similar baseline clinical characteristics. Patients with troponin I re-elevation had significantly higher in-hospital mortality (9.8% vs 0%, p = 0.016) and a higher 6-month cumulative death rate (24% vs 3.7%, p = 0.001). There was a trend for an increased 6-month myocardial infarction rate in patients with troponin I re-elevation (13.7% vs 3.7%, p = 0.11) and target vessel revascularization was similar between groups (16.7% vs 17.4%, p = 0.92). By multivariate analysis, troponin I re-elevation (odds ratio [OR] 6.2, p = 0.011) and diabetes mellitus (OR 5.7, p = 0.014) were the strongest independent predictors for increased 6-month cumulative mortality, whereas creatine kinase MB-fraction re-elevation had no prognostic value. We conclude that troponin I re-elevation after percutaneous coronary intervention in high-risk patients with ACS is associated with a substantial increase in mortality and reduced event-free survival at 6-month follow-up.     

Prognostic value of N-terminal pro-B-type natriuretic peptide in patients with acute coronary syndromes undergoing left main percutaneous coronary intervention

BACKGROUND: Patients undergoing acute left main (LM) coronary artery revascularization have a high mortality and natriuretic peptides such as N-terminal pro-B-type (NT-proBNP) have been shown to have prognostic value in patients with acute coronary syndromes. The present study looked at the prognostic value of NT-proBNP in these patients. METHODS AND RESULTS: We studied all consecutive patients undergoing acute LM coronary artery percutaneous coronary intervention between January 2005 and December 2008 in whom NT-proBNP was measured (n=71). We analyzed the clinical characteristics and the short- and long-term outcomes in relation to NT-proBNP level at admission. Median NT-proBNP was 1,364 ng/L, ranging from 46 to 70,000 ng/L. NT-proBNP was elevated in 63 (89%) patients and was ≥1,000ng/L in 42 (59%). Log NT-proBNP (hazard ratio [HR] 3.51, 95% confidence interval [CI] 1.55-7.97, P=0.003) and left ventricular ejection fraction (HR 0.95, 95%CI 0.91-0.99, P=0.007) were predictors for all-cause mortality. Log NT-proBNP was the only independent significant predictor of cardiovascular mortality. In-hospital mortality was 0% for patients with NT-proBNP <1,000, but 17% for those with NT-proBNP ≥1,000 (P=0.036). Conclusions: NT-proBNP is a strong predictor of outcome in patients undergoing acute LM coronary artery stenting. Mortality in such patients is high, but those with NT-proBNP < 1,000ng/L may have a favorable short- and long-term prognosis. Further research, including a larger patient population, is needed to determine the optimal cut-off value for NT-proBNP in patients undergoing acute LM coronary artery intervention.     

C-反应蛋白、P-选择素和心肌钙蛋白对急性冠状动脉综合征患者的近期预后意义

目的　探讨 C-反应蛋白 ( CRP)、P-选择素和心肌钙蛋白 I( c Tn I)对急性冠状动脉综合征 ( ACS)患者短期预后意义。方法　分别测定 70例非 ST段抬高 ACS患者入院时 CRP、P-选择素和 c Tn I水平 ,随诊 1个月 ,终点为心脏事件 (急性心肌梗死 ,心源性猝死 ,需急再血管化治疗和顽固性心绞痛 ) ,并测定 18例健康成人 P-选择素作对照。以 CRP>8mg/ L、P-选择素 >15μg/ L和 c Tn I>0 .4μg/ L 为界值 ,追踪观察各因子正常组与增高组心脏事件发生率。结果　ACS组的 P-选择素水平 ( 15 .2 6± 5 .5 5 ) μg/ L,较正常对照组 ( 10 .0 5± 2 .3 0 )μg/ L高 ( P<0 .0 5 ) ;在 70例 ACS中 ,CRP升高 2 3例 ,P-选择素升高 2 7例 ,c Tn I升高 3 8例 ,随诊期共发生心脏事件 14例 ,各因子增高组心脏事件发生率均较正常组高 ( P<0 .0 5 ) ;三种因子的联合试验对 ACS预后判断的阳性预测值为42 .9%。结论　 P-选择素与 ACS发生有关 ;CRP、P-选择素和 c Tn I分别与 ACS的短期预后有关 ,可作为危险分层的指标之一 ;联合检测意义更大。     

Prognostic value of preoperative cardiac troponin I in patients with non-ST-segment elevation acute coronary syndromes undergoing coronary artery bypass surgery

STUDY OBJECTIVES: Elevated levels of cardiac troponin I (cTnI) have been associated with adverse short-term and long-term outcomes in acute coronary syndrome (ACS) patients and in patients who underwent coronary artery bypass grafting (CABG); however, the prognostic implications of preoperative cTnI determination have not been investigated so far. DESIGN AND SETTING: Retrospective study in a department of cardiothoracic surgery of a university hospital. PATIENTS AND METHODS: A possible correlation between preoperative cTnI levels and major adverse cardiac events (MACE) and in-hospital mortality in CABG patients with non-ST-segment elevation ACS (NSTE-ACS) was investigated. cTnI was determined in 1,978 of 3,124 consecutive CABG patients. Among these, 1,592 patients had preoperative cTnI levels < 0.1 ng/mL and therefore served as control subjects (group 1), 265 patients had NSTE-ACS with cTnI levels from 0.11 to 1.5 ng/mL (group 2), and 121 patients had NSTE-ACS with cTnI levels > 1.5 ng/mL (group 3). cTnI levels, clinical data, MACE, and in-hospital mortality were recorded prospectively. Logistic regression and receiver operating characteristic analyses were applied to determine prognostic cutoff values of cTnI. RESULTS: Perioperative myocardial infarction was found in 5.8% of the patients in group 1, 8.3% of the patients in group 2 (odds ratio [OR], 1.5; 95% confidence interval [CI], 0.9 to 2.5), and 18.2% patients in group 3 (OR, 3.6; 95% CI, 2.1 to 6.2; p < 0.0001, Cochran-Armitage trend test). Low cardiac output syndrome occurred in 1.5% of patients in group 1, 4.2% of patients in group 2 (OR, 2.8; 95% CI, 1.3 to 6.1), and 10.9% patients in group 3 (OR, 6.5; 95% CI, 2.9 to 14.4; p < 0.0001). In-hospital mortality was 1.5% in group 1, 3.0% in group 2 (OR, 2.0; 95% CI, 0.8 to 4.8), but 6.6% in group 3 (OR, 4.6; 95% CI, 1.9 to 11.1; p < 0.0001). Univariate and multivariate logistic regression analyses identified cTnI as the strongest preoperative predictor for MACE and in-hospital mortality, respectively. CONCLUSIONS: Preoperative cTnI measurement before CABG appears as a powerful and independent determinant of short-term surgical risk in patients with NSTE-ACS.     

脑利钠肽和C-反应蛋白在急性冠状动脉综合征介入治疗患者的预后价值

目的探讨急性冠状动脉综合征(ACS)行经皮冠状动脉介入治疗术(PCI)患者血浆脑利钠肽(BNP)和C-反应蛋白(CRP)水平与临床预后的关系。方法连续性入选189例行PCI治疗的ACS患者。测定症状发作平均(34·2±16·3)h的血浆BNP和CRP水平,随访患者住院期间,30天,3个月病死率及主要心脏不良事件(MACE)(心原性死亡,再次心肌梗死,再发心绞痛,继发心衰和再入院的复合终点)发生率。结果189例ACS患者根据血浆BNP水平分为四组:≤100ng/L组;>100~≤300ng/L组;>300~≤600ng/L组和>600ng/L组。随血浆BNP水平的升高,各组病死率及MACE发生率呈明显递增趋势。3个月时,各组病死率分别为0%、1·4%、7·7%、48·3%;MACE发生率分别为7·9%、17·1%、57·7%、79·3%。在多变量的logistic回归分析中,BNP独立于年龄、性别、家族史、吸烟、高脂血症、高血压、糖尿病及LVEF等危险因素,预测30天(r=0·8515,P<0·01)和3个月(r=0·9201,P<0·01)病死率及30天(r=0·7066,P<0·01)和3个月(r=0·7090,P<0·01)MACE发生率。其中141例患者根据血浆CRP水平分为三组:≤8·0mg/L组;>8·0~≤32·0mg/L组;>32·0mg/L组。随着血浆CRP水平的升高,各组死亡事件及MACE发生率亦呈明显递增趋势。3个月时,病死率分别为2·7%、7·7%、28·6%;MACE发生率分别为28·4%、41·0%、60·7%。在多变量的logistic回归分析中,CRP独立于年龄等其他冠心病危险因素,预测30天(r=0·5882,P=0·0044)和3个月(r=0·5235,P=0·0038)病死率。经年龄因素校正后,CRP独立于性别等其他冠心病危险因素,预测30天(r=0·2705,P=0·0380)和3个月(r=0·2290,P=0·0429)MACE发生率。当将CRP、BNP和年龄等其他冠心病危险因素放入同一模型预测ACS的预后时,血浆CRP水平失去了预测效能,而血浆BNP水平升高独立于各因素预测30天和3个月病死率及MACE发生率。结论BNP和CRP能够很好地对ACS患者行PCI治疗后进行危险分层,预测近期病死率和MACE发生率。BNP可能是较CRP更好的预测ACS患者近期临床预后的指标。     

Prognostic value of serum biomarkers in association with TIMI risk score for acute coronary syndromes

BACKGROUND: Markers of neurohormonal activation and inflammation play a pivotal role in non-ST-elevation acute coronary syndromes (NSTE-ACS). HYPOTHESIS: We hypothesized that other biochemical markers could add prognostic value on Thrombolysis In Myocardial Infarction (TIMI) risk score to predict major cardiovascular events in patients with NSTE-ACS. METHODS: In a cohort of 172 consecutive patients with NSTE-ACS, TIMI score was assessed in the first 24 h, and blood samples were collected for measurement of N-terminal pro-brain natriuretic peptide (NT-proBNP), high-sensitivity C-reactive protein, CD40 ligand, and creatinine. Major clinical outcomes (death and cardiovascular hospitalization) were accessed at 30 days and 6 months. Multivariate logistic regression was applied to identify markers significantly associated with outcomes and, based on individual coefficients, an expanded score was developed. RESULTS: Of 172 patients, 42% had acute myocardial infarction. The unadjusted 30-day event rate increased with age (odds ratio [OR] = 1.03; 95% confidence interval [CI] 1.00-1.06), creatinine (OR = 2.4; 1.4-4.1), TIMI score (OR = 1.6; 1.2-2.2), troponin I (OR = 3.4; 1.5-7.7), total CK (OR = 2.7; 1.2-6.1), and NT-proBNP (OR = 2.9; 1.3-6.3) levels. In multivariate analysis, TIMI risk score, creatinine, and NT-proBNP remained associated with worse prognosis. Multimarker Expanded TIMI Risk Score [TIMI score + (2 X creatinine [in mg/dl]) + (3, if NT-proBNP > 400 pg/ml)] showed good accuracy for 30-day (c statistic 0.77; p < 0.001) and 6-month outcomes (c statistic 0.75; p < 0.001). The 30-day event rates according to tertiles of expanded score were 7, 26, and 75%, respectively (p < 0.01). CONCLUSION: In NSTE-ACS, baseline levels of NT-proBNP and creatinine are independently related to cardiovascular events. Both markers combined with TIMI risk score provide a better risk stratification than either test alone.     

正五聚蛋白-3及血脂水平与急性冠状动脉综合征患者近期预后的关系

目的:探讨正五聚蛋白-3(pentraxin-3,PTX-3)、血脂水平与急性冠状动脉综合征(ACS)患者近期预后的关系。方法:分别测定123例ACS患者入院时的PTX-3和血脂水平,随访3个月,终点为冠状动脉事件(冠心病性死亡、因ACS引起的再住院、因心力衰竭引起的再住院)。结果:123例患者中发生冠心病猝死3例,ACS引起的再住院17例,心力衰竭引起的再住院5例,PTX-3异常组较PTX-3正常组冠状动脉事件发生率显著增高(OR=3.001,95%CI:1.023～8.801,P=0.045,RR=2.390);血脂异常组较正常组冠状动脉事件发生率显著增高(OR=2.714,95%CI:1.053～6.995,P=0.039,RR=2.160);血脂及PTX-3均异常组较均正常组冠状动脉事件发生率显著升高(OR=6.125,95%CI:1.245～30.130,P=0.026,RR=4.237)。结论:PTX-3或(和)血脂水平异常的ACS患者近期冠状动脉事件发生率显著升高,并以两者均异常者为著,因此联合检测可能有助于识别冠心病二级预防中的高危个体。