急性心肌梗死诊断中心肌损伤标志物联合应用的临床价值

Combined Myocardial Injury Markers for Diagnosis of Acute Myocardial Infarction

目的比较不同心肌损伤标志物组合诊断急性心肌梗死(AMI)的临床价值。方法观察四川大学华西医院2005年7月至2006年10月住院的急性胸痛症状患者,根据2007ESC/ACCF/AHA/WHF标准将研究对象分为确诊AMI患者与心梗疑似患者。计算临床常用的心肌损伤标志物〔AST,CK,CK-MB,LDH,HBDH,肌钙蛋白I(cTnI),CK-MB mass〕各指标诊断AMI的敏感性、特异性、准确性、阳性预测值、阴性预测值、阳性似然比和阴性似然比,采用t检验或方差分析比较不同心肌损伤标志物单项及多项联合指标检测浓度、阳性率、诊断符合率的差异。结果①cTnI的敏感性和特异性分别为85%和92.5%,其临床诊断的符合率最高,且差异具有统计学意义(P<0.05);②心肌酶谱和cTnI并联诊断AMI的敏感性和特异性分别为100%和37.29%,其临床诊断符合率较其它并联组高,且差异具有统计学意义(P<0.05);③心肌酶谱和cTnI串联诊断AMI的敏感性和特异性分别为50%和100%,临床诊断符合率较其它串联组高,且其差异均有统计学意义(P<0.05)。结论cTnI具有最高的敏感性和特异性,是诊断和鉴别诊断AMI的较好指标;心肌酶谱的敏感性、特异性较差,应联合cTnI、CK-MB mass进行AMI的诊断和鉴别诊断;纳入cTnI的心肌酶谱组合表现出了最高的敏感性和特异性,即并联试验明显提高了灵敏度,串联试验明显提高了特异性。

Objective To compare the diagnostic accuracy of different myocardial injury markers and their combinations in diagnosing acute myocardial infarction（AMI）.Methods The myocardial injury markers： AST,CK,CK-MB,LDH,HBDH,cTnI,CK-MB mass were detected in patients with acute chest pain-onset who were hospitalized in Sichuan University West China Hospital from July 2005 to October 2006.The accuracy of those markers in diagnosing AMI were evaluated by their sensitivity,specificity,positive predictive value,negative predictive value,positive likelihood ratio,and negative likelihood ratio.Student t-test and one-way ANOVA were performed to compare the diagnostic accuracy of the markers.Results cTnI had the highest diagnostic accuracy,with 85% of sensitivity and 92.5% of specificity（P〈0.05）.cTnI in parallel with myocardial enzymes produced the highest combined diagnostic accuracy,with 100% of sensitivity and 37.29% of specificity（P〈0.05）.Myocardial enzymes in sequence with cTnI produced the highest sequential diagnostic accuracy,with 50% of sensitivity and 100% of specificity（P〈0.05）.Conclusion cTnI is the best indicator for diagnosis and differential diagnosis of AMI.Myocardiozymogram is poor in sensitivity and specificity,which should be used only in combination with cTnI or CK-MB mass.Parallel testing can increase sensitivity,while sequential testing can improve specificity.