HEART评分联合系列心肌肌钙蛋白在急诊胸痛患者中的危险分层价值  

Risk stratification value of HEART score combined with serial cardiac troponin in emergency patients with chest pain

作　　者：俞尧 陈东旭 廖凤卿 周燕南 蔡灿光 阿丽玛·胡马尔别克 陈琛 周思颖 姚晨玲 顾国嵘 Yu Yao;Chen Dongxu;Liao Fengqing;Zhou Yannan;Cai Canguang;Alima·Humaerbieke;Chen Chen;Zhou Siying;Yao Chenling;Gu Guorong(Department of Emergency Medicine,Zhongshan Hospital,Fudan University,Shanghai 200032,China)

机构地区：[1]复旦大学附属中山医院急诊科,上海200032

出　　处：《中华急诊医学杂志》2023年第4期531-539,共9页Chinese Journal of Emergency Medicine

基　　金：中山医院临床研究专项基金资助(2020ZSLC46);中山医院智慧医疗专项基金(2020ZHZS33);上海市科委临床创新专项基金资助(21Y11902200)。

摘　　要：目的探讨HEART评分联合系列心肌肌钙蛋白(cardiac troponin,cTn)在急诊胸痛患者中的危险分层价值。方法回顾性收集2019年1月至12月就诊于复旦大学附属中山医院急诊科的胸痛患者11583例,排除年龄<18岁、未完成高敏心肌肌钙蛋白T(high-sensitivity cardiac troponin T,hs-cTnT)检测或心电图检查、诊断ST段抬高型心肌梗死(ST-segment elevation myocardial infarction,STEMI)及失访患者,最终纳入7057例患者。通过电话及查阅病史随访患者最终胸痛诊断以及是否发生6月主要心血管不良事件(major adverse cardiovascular events within 6 months,6 m MACEs)。由两位主治医生分别计算每位患者的HEART评分,根据最终得分将患者分为低危组(0~3分)、中危组(4~6分)和高危组(7~10分),观察分析HEART评分的危险分层性能及安全性。将1884例完成≥2次hs-cTnT检测的患者分别采用HEART评分(0~3分为低危组)、HEART评分联合系列心肌肌钙蛋白路径(HEART评分≤3且2次hs-cTnT<0.03 ng/mL为低危组)进行分组,通过绘制诊断四格表分别计算两种诊断方法预测患者发生非ST段抬高型心肌梗死(non-ST-segment elevation myocardial infarction,NSTEMI)、6 m MACEs、6月内心梗及心源性死亡事件的灵敏度(sensitivity,SE)、特异度(specifi city,SP)、阳性预测值(positive predictive value,PPV)和阴性预测值(negative predictive value,NPV),比较两者诊断性能的优劣。结果HEART评分将患者分为3组,2765(39.2%)例为低危组,3438(48.7%)例为中危组,854(12.1%)例为高危组,各组患者6 m MACEs的发生率依次为1.2%、18%、55.3%。当低危阈值为2时,23.1%的患者进入低危组,6 m MACEs的发生率为0.9%。绘制受试者工作特征(receiver operating characteristic,ROC)曲线评估HEART评分对患者发生6 m MACEs的预测性能,最终ROC曲线下面积(area under the curve,AUC)为0.831(P=0.006,95%CI:0.819~0.843)。对于患者本次就诊时是否发生NSTEMI,单独使用HEART评分有4(0.8%)例患者Objective To explore the risk stratifi cation value of HEART score combined with cardiac troponin(cTn)in emergency patients with chest pain.Methods A total of 11583 patients with chest pain who visited the Emergency Department of Zhongshan Hospital Affi liated to Fudan University from January to December 2019 were retrospectively collected.Patients who unfi nished 0 h high-sensitivity cardiac troponin T(hs-cTnT)or electrocardiogram diagnosed ST-segment elevation myocardial infarction(STEMI)or lost to follow-up were excluded,and 7057 patients were fi nally included.The fi nal diagnosis of chest pain and the occurrence of major adverse cardiovascular events within 6 mon(6 m MACEs)were followed up by telephone and medical history.The HEART score of each patient was calculated by two attending physicians,and the patients were divided into the low-risk group(0-3 points),intermediate-risk group(4-6 points)and high-risk group(7-10 points)according to the final score.The risk stratification performance and safety of HEART score were observed and analyzed.A total of 1884 patients who completed serial hs-cTnT tests were divided into groups according to HEART score(≤3 as low-risk group)and HEART score combined with serial hscTnT pathway(HEART score≤3 and two hs-cTnT measurements<0.03 ng/mL as the low-risk group).The sensitivity(SE),specifi city(SP),positive predictive value(PPV)and negative predictive value(NPV)of each diagnostic method were calculated to compare the diagnostic performance of the two predictive values.Results The patients were divided into 3 groups by HEART score:2765(39.2%)patients in the low-risk group,3438(48.7%)in the intermediate-risk group,and 854(12.1%)in the high-risk group.The incidence of 6 m MACEs in each group was 1.2%,18%and 55.3%,respectively.When the low-risk threshold was 2,23.1%of patients entered the low-risk group and the incidence of 6 m MACEs was 0.9%.The receiver operating characteristic(ROC)curve was drawn to evaluate the predictive performance of the HEART score for 6 m MACEs,and

关 键 词：胸痛 急性冠脉综合征 HEART评分 HEART路径 主要心血管不良事件 

分 类 号：R54[医药卫生—心血管疾病]