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肌钙蛋白指南:何时检测和如何解读结果

Troponin Guidelines Sort Out When to Order, How to Read
来源:EGMN 2012-11-14 10:08点击次数:209发表评论

美国心脏病学院(ACC)基金会等7个专业学会在《美国心脏病学会杂志》(JACC 2012;60)上发表共识声明指出,随着肌钙蛋白检测方法的敏感性提高,临床医生必须改善开具此类检测医嘱的方式及加强对此类检测的解读能力。该声明可通过ACC网站获取。


自20世纪90年代早期起,临床上就将肌钙蛋白作为心肌梗死的生物标志物。然而,虽然肌钙蛋白水平升高提示心肌坏死,但不一定意味着心肌梗死已经发生。还有其他多种因素可导致肌钙蛋白升高。


这份共识声明回顾了近期有关肌钙蛋白检测及其临床意义的研究,并探讨了一些常被问及的问题,如肌钙蛋白水平意味着什么,什么时候应进行检测,以及阳性检测结果提示何种预后等。此外,该声明还通过图解方式探讨了导致肌钙蛋白检测阳性的潜在原因,分缺血性和非缺血性两大类,并由此进一步细分。


声明编委会联合主席L. Kristin Newby博士表示,临床医生在开具肌钙蛋白检测医嘱前需考虑为什么要进行此类检测。肌钙蛋白升高的原因包括心力衰竭、手术、创伤、肾病或肺栓塞等。在脓毒症患者或使用一些已知可导致心脏损害的化疗药物(如蒽环类药物和环磷酰胺)的患者中,肌钙蛋白水平也可能会升高。如果不加鉴别地进行肌钙蛋白检测或不关注具体的临床情况,就可能会遗漏某些重要问题。


声明指出,虽然美国国立临床生化科学院发表了有关如何检测心脏肌钙蛋白的建议,但此类检测尚无标准,而且临床上各种检测方法的质量不一。声明还指出,由于肌钙蛋白水平升高与预后不良相关,因此有必要查明原因。Newby博士表示,在肺栓塞或晚期肾病患者中,如果肌钙蛋白水平升高,预后通常较差。


此外,声明指出,对于临床医生而言,肌钙蛋白检测的最佳价值仍在于诊断心肌梗死,但即使是在这方面应用,也需要结合具体的临床情况,因为治疗可能存在显著差异。


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By: ALICIA AULT, Cardiology News Digital Network


As the sensitivity of troponin testing improves, so must clinicians refine the way they order and interpret such tests, according to a new consensus statement issued by seven professional societies.


Clinicians have used troponin as a biomarker for myocardial infarction since the early 1990s. However, while an elevated level indicates myocardial necrosis, it does not necessarily mean that a myocardial infarction has occurred. There can be other myriad reasons for an increase in troponin.


The consensus statement – written by a 14-member group of experts – reviews the most recent research on troponin testing and its clinical applications. It also addresses frequently asked questions on what an elevated troponin level means, when the test should be ordered, and prognosis with a positive test. The statement also gives a schematic look at potential causes of a positive troponin test. The schematic is divided into ischemic and nonischemic causes, and then further broken down.


"We need to be thinking about why we are ordering the troponin test before we order it," said Dr. L. Kristin Newby, cochair of the writing committee for the ACCF 2012 Expert Consensus Document on Practical Clinical Considerations in the Interpretation of Troponin Elevations. "We hope this document provides a road map to help clinicians be more deliberate when ordering these tests and interpreting the results," said Dr. Newby, who is a professor of medicine in the division of cardiovascular medicine at Duke University Medical Center, Durham, N.C.


Troponin may be elevated because of heart failure, surgery, trauma, kidney disease, or pulmonary embolism, among other conditions. The biomarker may also show up in patients with sepsis or those taking certain chemotherapies, such as anthracyclines and cyclophosphamide, which are known to cause cardiac damage.


"If we are indiscriminate in how we order these tests or we aren’t paying attention to the clinical scenario before us, we may miss something important," said Dr. Newby.


Further complicating testing, the statement warns clinicians that "all troponin assays are not created equal," and that there "is a wide spectrum of assay quality in practice." The measurement of cardiac troponin is also not standardized, though there have been recommendations by the National Academy of Clinical Biochemistry on how to do so.


Most assays, however, are "able to selectively detect cardiac troponin to the exclusion of troponin from other tissues," according to the statement.


The statement also documents that elevated troponin deserves investigation because it is associated with worse outcomes.


"If you have a pulmonary embolism or end-stage renal disease and your troponin is elevated, your prognosis – how you are expected to do – is worse," said Dr. Newby.


According to the statement, for clinicians, the "best value of troponin testing remains in the diagnosis of MI." But even with that use, "it is important to understand the clinical context as treatment may vary considerably."


The 37-page statement was developed by the American College of Cardiology Foundation, the American Association for Clinical Chemistry, the American College of Chest Physicians, the American College of Emergency Physicians, the American College of Physicians, the American Heart Association, and the Society for Cardiovascular Angiography and Interventions.


The statement was published online (JACC 2012;60) and will also be available on the ACC’s website.


学科代码:心血管病学 检验病学   关键词:肌钙蛋白检测共识声明
来源: EGMN
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