Incomplete Data Reporting in Studies of Emergency Department Patients with Potential Acute Coronary Syndromes Using Troponins

OBJECTIVES: A multidisciplinary panel of experts is developing standardized reporting criteria for risk stratification studies of emergency department (ED) patients with potential acute coronary syndromes (ACS). The authors assessed the need for such criteria by reviewing published studies to determine whether these core criteria currently are being reported. METHODS: Studies published during 2000-2001 in eight journals representing emergency medicine, cardiology, and general medicine that evaluated the cardiac troponins for risk stratification of ED patients with chest pain were identified by a systematic MEDLINE review. Two raters independently analyzed each study with a structured tool. The presence or absence of 47 core criteria in eight major reporting categories, which were determined by expert consensus, was abstracted from the articles. When the two raters disagreed, discrepancies were resolved by consensus. Data are presented as percent frequency of occurrence with 95% confidence intervals. RESULTS: Twenty-two articles met inclusion criteria. The two reviewers had a median of 7.5 initial discrepancies per article (interquartile range = 6 to 10) but achieved consensus on all. The median of the percent of articles reporting the core criteria within each major reporting category is shown [table: see text].CONCLUSIONS: Many of the 47 items considered core criteria by the expert committee writing standardized reporting guidelines for risk stratification studies of potential ACS patients were not reported often in major cardiology and emergency medicine journals. There seems to be a need for standardized reporting guidelines because important information is not currently being reported.     

肌钙蛋白Ⅰ和高敏C反应蛋白与急性冠状动脉综合征的临床研究

目的通过肌钙蛋白Ⅰ和高敏C反应蛋白水平探讨两种标志物与急性冠状动脉综合征的关系，及其在急性心肌梗死（AMI）中发生心脏事件的特点。方法受试者共113例，SAP40例、UAP43例、AMI30例，对照组35例。删采用荧光标记免疫测定；hs—CRP采用散射比浊法检测。结果①UA组cTnI明显高于SAP组及对照组（P〈0．01）；②AMI组明显高于UAP组（P〈0．01）；（1）AMI组hs-CRP与其它组相比显著增高，差异有显著意义（P〈0．05），（2）UAP组与SAP组相比差异有统计学意义（P〈0．01），与对照组相比差异有统计学意义（P〈0．01），（3）而SAP组与对照组相比差异无统计学意义（P〉0．05）。结论AMI时cTnI增高显著，是诊断急性心肌损伤的“金标准”；AMI时hs-CRP增高显著，表明AMI过程中存在炎症反应，并在一定程度上反映心肌损伤及坏死的严重程度。而联合评估这两项标志物的水平则可以识别心脏高风险的病人。     

A case of hypothyroidism mimicking acute coronary syndrome

Hypothyroid patients have increased concentrations of creatinine kinase that is mostly due to increased CK-MM. However, CK-MB has also been reported to increase above reference values in hypothyroid patients without apparent myocardial damage. This may create confusion during the evaluation of myocardial injury in a hypothyroid patient presenting with chest pain. Troponin I is considered as a superior marker for the diagnosis of myocardial infarction in hypothyroid patients. However, there are some reports showing an increase in the level of troponin I without any myocardial damage in hypothyroid patients as in our case. In this report, we present a 47 years old male hypothyroid patient who had chest pain, abnormal electrocardiographic findings and increased cardiac enzymes suggesting acute coronary syndrome although he had normal coronary arteriogram. Address for correspondence: Huseyin Gunduz, MD, Department of Internal Medicine and Cardiology, Izzet Baysal Medical Faculty, Izzet Baysal University, Bolu, 14100 Turkey Tel.: +90-374-217-65-20 E-mail: drhuseyingunduz@yahoo.com     

探讨高敏肌钙蛋白T在急性冠脉综合征中的应用价值

目的：探讨高敏肌钙蛋白T（hs-cTnT）在急性冠脉综合征（ACS）中的应用价值。方法共检测因胸痛就诊患者198例,其中急性心梗（AMI）患者105例,不稳定性心绞痛（UA）患者93例,健康体检者83例,均检测了 hs-cTnT、肌酸激酶（CK）和肌酸激酶同工酶（CK-MB）。结果确诊为 AMI 患者的 hs-cTnT、CK、CK-MB 阳性率分别为88．6％、48．6％、71．4％,均高于 UA 患者及健康体检人群,且 AMI 早期患者检测 hs-cTnT 阳性率高于 CK 和 CK-MB。结论hs-cTnT 与心肌酶谱中的 CK、CK-MB 相比,对心肌损伤具有很高的灵敏度和特异度,能够减少 ACS 的误诊和漏诊,是 ACS 早期诊断的心肌损伤标志物。     

Performance of a sensitive troponin assay in the early diagnosis of acute myocardial infarction in the emergency department

Aim: Troponin assays have high diagnostic value for myocardial infarction (MI), but sensitivity has been weak early after chest pain onset. New, so‐called ‘sensitive’ troponin assays have recently been introduced. Two studies report high sensitivity for assays taken at ED presentation, but studied selected populations. Our aim was to evaluate the diagnostic performance for MI of a sensitive troponin assay measured at ED presentation in an unselected chest pain population without ECG evidence of ischaemia. Methods: This is a sub‐study of a prospective cohort study of adult patients with potentially cardiac chest pain who underwent evaluation for acute coronary syndrome. Patients with clear ECG evidence of acute ischaemia or an alternative diagnosis were excluded. Data collected included demographic, clinical, ECG, biomarker and outcome data. A ‘positive’ troponin was defined as >99th percentile of the assay used. MI diagnosis was as judged by the treating cardiologist. The outcomes of interest were sensitivity, specificity and likelihood ratios (LR) for positive troponin assay taken at ED presentation. Data were analysed by clinical performance analysis. Results: Totally 952 were studied. Median age was 61 years; 56.4% were male and median TIMI score was 2. There were 129 MI (13.6, 95% CI 11.5–15.9). Sensitivity of TnI at ED presentation was 76.7% (95% CI 68.5–83.7%), specificity 93.6% (95% CI 91.7–95.1%), with LR positive 11.92 and LR negative 0.25. Conclusion: Sensitive TnI assay at ED presentation has insufficient diagnostic accuracy for detection of MI. Serial biomarker assays in patients with negative initial TnI are required.     

Trigemino-cardiac reflex and antecedent transient ischemic attacks

Under normal circumstances, most intracellular troponin is part of the muscle contractile apparatus, and only a small percentage (<2–8%) is free in the cytoplasm. The presence of a cardiac-specific troponin in the circulation at levels above normal is good evidence of damage to cardiac muscle cells, such as myocardial infarction, myocarditis, trauma, unstable angina, cardiac surgery or other cardiac procedures. Troponins are released as complexes leading to various cut-off values depending on the assay used. This makes them very sensitive and specific indicators of cardiac injury. As with other cardiac markers, observation of a rise and fall in troponin levels in the appropriate time-frame increases the diagnostic specificity for acute myocardial infarction. They start to rise approximately 4–6 h after the onset of acute myocardial infarction and peak at approximately 24 h, as is the case with creatine kinase-MB. They remain elevated for 7–10 days giving a longer diagnostic window than creatine kinase. Although the diagnosis of various types of acute coronary syndrome remains a clinical-based diagnosis, the use of troponin levels contributes to their classification. This Editorial elaborates on the nature of troponin, its classification, clinical use and importance, as well as comparing it with other currently available cardiac markers.     

IL-27在急性冠脉综合征中的临床应用价值

目的探讨IL-27在急性冠脉综合征(ACS)中的临床应用价值。方法入选208例ACS患者,其中ST段抬高的心肌梗死(STEMI)76例、非ST段抬高的心肌梗死(NSTEMI)58例和不稳定心绞痛(UAP)74例;根据冠脉病变数分为单支、双支和三支病变组;以同期62例胸痛综合征(CPS)患者作为对照组。用酶联免疫吸附试验(ELISA)检测各组血浆IL-27的表达水平并进行统计学分析。结果与对照组100.66(68.98,228.86)pg/m L比较,STEMI组、NSTEMI组、UAP组血浆IL-27表达水平[分别为308.64(245.17,359.26)、256.88(181.52,332.51)、218.12(165.33,312.46)pg/m L]均明显升高(P均0.01);组间两两比较结果表明,STEMI组血浆IL-27浓度明显高于NSTEMI组和UAP组(P均0.05);,在TnI阴性的ACS患者中,IL-27阳性率为54.24%(32/59);IL-27在胸痛患者中预测ACS发生的敏感性和特异性分别为80.29%和58.06%。冠脉三支病变组IL-27表达水平明显高于单支病变组(P0.05)。结论 IL-27在ACS患者外周血中表达明显升高,可能参与了ACS的发病机制。IL-27对TnI阴性的ACS患者以及ACS病情判断具有一定临床价值。     

The sensitivity of cardiac markers stratified by symptom duration

We compared the sensitivity of three commonly used cardiac markers between two subpopulations, those who came to the Emergency Department (ED) late (6–24 h) after their symptoms began, and those who arrived earlier (<6 h), in a prospective comparative trial. Among all adult patients who presented to our ED with symptoms suggestive of acute myocardial infarction (MI), we drew serum for myoglobin, CK-MB, and troponin I upon arrival (time 0) and 2 h later. Outcomes, including acute MI, were determined. Sensitivities for all three markers between the subpopulations who arrived fewer than 6 h from symptom onset were compared to those who arrived later (6–24 h). We enrolled 346 eligible subjects, 36% of whom described cardiac symptoms as beginning 6 or more hours earlier; 14% suffered acute MIs. For time 0, the sensitivity of all three markers for acute MI was significantly higher among those subjects with symptoms of 6 or more hours’ duration as compared to those with less. For troponin I, the increase in sensitivity between these two subpopulations approached 300%. At the time of the 2-h sample, the differences in sensitivities were much less and were not statistically significant. We conclude that cardiac marker values obtained at time 0 among Emergency Department patients who arrive 6 or more hours after cardiac symptom onset provide significantly higher sensitivities as compared to those obtained in patients who arrive earlier. For troponin I, the increase in sensitivity approaches threefold.     

超敏C反应蛋白在临床检验中的应用及意义

目的研究超敏C反应蛋白(hs-CRP)对诊断急性冠脉综合征(ACS)疾病的临床意义。方法选取该院2013~2014年期间ACS患者77例(观察组);并选取同一时期的体检身体健康者75例(对照组)。对两个组群的hs-CRP指标进行定量检验,并比较得出其临床意义。结果患有ACS的观察组hs-CRP指标显著高于对照组的指标,差异有统计学意义(P0.05)。观察组中患有不稳定型心绞痛的hs-CRP指标显著高于患有稳定型心绞痛的指标,差异具有统计学意义(P0.05)。观察组中患有心肌梗死的hs-CRP指标显著高于不稳定型心绞痛的指标,差异具有统计学意义(P0.05)。结论 hs-CRP可以进一步明确ACS的诊断。其指标的变化与ACS疾病的发生发展密切相关。该临床检验技术应当得到广泛的推广普及。     

Frequency of Acute Coronary Syndrome in Patients with Normal Electrocardiogram Performed during Presence or Absence of Chest Pain

Objectives: The authors hypothesized that patients with active chest pain at the time of a normal electrocardiogram (ECG) have a lower frequency of acute coronary syndrome (ACS) than patients being evaluated for chest pain but with no active chest pain at the time of a normal ECG. The study objective was to describe the association between chest pain in patients with a normal ECG and the diagnosis of ACS. Methods: This was a prospective observational study of emergency department (ED) patients with a chief complaint of chest pain and an initial normal ECG admitted to the hospital for chest pain evaluation over a 1-year period. Two groups were identified: patients with chest pain during the ECG and patients without chest pain during the ECG. Normal ECG criteria were as follow: 1) normal sinus rhythm with heart rate of 55–105 beats/min, 2) normal QRS interval and ST segment, and 3) normal T-wave morphology or T-wave flattening. “Normal” excludes pathologic Q waves, left ventricular hypertrophy, nonspecific ST-T wave abnormalities, any ST depression, and discrepancies in the axis between the T wave and the QRS. Patients’ initial ED ECGs were interpreted as normal or abnormal by two emergency physicians (EPs); differences in interpretation were resolved by a cardiologist. ACS was defined as follows: 1) elevation and characteristic evolution of troponin I level, 2) coronary angiography demonstrating >70% stenosis in a major coronary artery, or 3) positive noninvasive cardiac stress test. Chi-square analysis was performed and odds ratios (ORs) are presented. Results: A total of 1,741 patients were admitted with cardiopulmonary symptoms; 387 met study criteria. The study group comprised 199 males (51%) and 188 females (49%), mean age was 56 years (range, 25–90 years), and 106 (27%) had known coronary artery disease (CAD). A total of 261 (67%) patients experienced chest pain during ECG; 126 (33%) patients experienced no chest pain during ECG. There was no difference between the two groups in age, sex, cardiac risk factors, or known CAD. The frequency of ACS for the total study group was 17% (67/387). There was no difference in prevalence of ACS based on the presence or absence of chest pain (16% or 42/261 vs. 20% or 25/126; OR = 0.77, 95% confidence interval = 0.45 to 1.33, p = 0.4). Conclusions: Contrary to our hypothesis concerning patients who presented to the ED with a chief complaint of chest pain, our study demonstrated no difference in the frequency of acute coronary syndrome between patients with chest pain at the time of acquisition of a normal electrocardiogram and those without chest pain during acquisition of a normal electrocardiogram.     

急性冠脉综合征患者血清炎性指标及肌钙蛋白Ⅰ的临床研究

目的研究急性冠脉综合征患者（ACS）血清炎性指标的水平与肌钙蛋白Ⅰ的关系及临床意义。方法测定冠脉造影阳性的ACS患者74例、稳定型心绞痛（SAP）患者58例和造影阴性的冠心病患者46例（对照组）血清超敏C-反应蛋白（hs-CRP）、白介素-6（IL-6）、可溶性P-选择素（sP-sel）和肌钙蛋白I（cTnI）的水平,并采集相应的各项临床资料。结果ACS组患者血清各项炎性指标分别为hs-CRP（7.40±2.90）mg/L、IL-6（235.62±87.03）ng/L、sP-sel（87.82±36.02）mg/L、cTnI（4.38±3.85）mg/L,高于SAP组患者和对照组,差异均有统计学意义（t分别=6.52、4.94、2.97、7.23、8.96、5.63、3.32、8.67,P均〈0.05）;cTnI增高患者各血清炎性指标分别为hs-CRP（8.74±1.61）mg/L、IL-6（265.33±66.62）ng/L、sP-sel（99.43±25.42）mg/L,明显高于cTnI正常者,差异均有统计学意义（t分别=4.59、3.92、3.65,P均〈0.05）。结论血清炎性指标在ACS患者中均表现为增高。cTnI与血清各项炎性指标具有相关性。cTnI及血清各项炎性指标与冠脉内斑块的不稳定状态具有相关性。     

缺血修饰白蛋白在急性胸痛患者中早期诊断价值研究

目的：探讨血清缺血修饰白蛋白（Ischemia modified albumin,IMA）在急性胸痛患者中的早期诊断价值。方法：随机选取以急性胸痛症状入院的患者113例。根据高敏肌钙蛋白（hs-TnT）检测结果,最终确诊为ACS（Acute coronary syndrome）胸痛组59例,非ACS胸痛组54例。另选择同期来我院体检的健康者60例作为对照组。分别于入院后即刻、4~8h、24h采血检测患者血清IMA及hs-TnT。组间比较采用t检验,并通过ROC曲线取得IMA诊断ACS最佳cut-off值。结果：ACS胸痛组与非ACS胸痛组、对照组相比,IMA水平明显增高,差异具有统计学意义（P〈0.05）;ACS胸痛组3次IMA测量值间均有显著统计学差异（P〈0.05）,且IMA在入院后4~8h达到最高;ROC曲线下面积为0.872,选择81.3Uoml-1为诊断临界点时,特异度为88.9%,灵敏度为74.6%。结论：血清IMA可能是急性胸痛患者早期诊断ACS的重要指标。     

Sensitivity, specificity and predictive value of the echocardiography and troponin-T test combination in patients with non-ST elevation acute coronary syndromes

INTRODUCTION: Patients with a negative troponin (TnT) result showed 1.4% mortality during a mean follow-up of 9-10 weeks. Mortality was greater in patients with an evidence of ischemic ECG changes and a negative TnT test (1.6-4.4%). Few studies have examined the efficacy of echocardiography (2DE) in patients with chest pain. The purpose of the present study was to determine the clinical utility, sensitivity and specificity of the combination of TnT levels and 2DE in patients presenting with chest pain, ST-depression, T-wave negative and no diagnostic ECG. METHODS: 280 consecutive patients with chest pain and presence of ST depression, T-wave inversion, and non-diagnostic ECG, acceptable 2DE window, evidence or no evidence of alterations of the segmentary motion, and evidence and no evidence of injury, as assessed by TnT and normal value of CK-CK MB, were enrolled. 2DE, blood CK, and TnT levels were controlled at entry and subsequent samples were obtained every 4 h for the first 12 h and then every 12 h. All patients performed angiography within 12-72 from admission. PTCA or CABG were performed according to angiographic findings and left ventricular function. RESULTS: The 280 patients (98 F/M 182), mean age 59.7+/-11.9 years, who met the entry criteria, were divided as follows: group 1: ST-segment depression (192 patients); group 2: T-wave inversion (36 patients); and group 3: non-diagnostic ECG (52 patients). The combination of positive TnT and wall motion alterations showed a higher sensitivity, specificity and predictive values in comparison with alone TnT or 2DE. Patients, with the concordance between TnT and 2DE, were at higher risk. Patients with negative combination in all groups (94), showed a low incidence of coronary stenosis (10.6%), as well as negative 2DE alone (102 patients) (12.7%), while patients with negative TnT (128) showed higher incidence of coronary stenosis (39%), p < 0.0001. CONCLUSION: Our results suggest that the combination of negative TnT test and negative 2DE in patients presenting to EDs with chest pain either with ECG changes or without ECG changes is a useful tool to identify those who can be discharged safely. We think that our data are important because by the combination we can identify the high risk (when positive) patients, reduce incidence of the false negative, but mostly it allows us to identify true negative patients to discharge safely.