超敏心肌肌钙蛋白I联合D-二聚体对急性主动脉夹层与急性心肌梗死的鉴别诊断价值

Value of hs-cTnI Combined with D-dimer in the Differential Diagnosis between Acute Aortic Dissection and Acute Myocardial Infarction

目的 分析超敏心肌肌钙蛋白I(hs-cTnI)联合D-二聚体对急性主动脉夹层(AAD)与急性心肌梗死(AMI)的鉴别诊断价值。方法 选取2015年6月—2017年12月在中山大学附属东华医院住院的AAD患者37例(AAD组),非ST段抬高型心肌梗死患者107例(NSTEMI组),ST段抬高型心肌梗死(STEMI)患者183例(STEMI组)。比较3组患者一般资料、实验室检查指标、入院后首次hs-cTnI及D-二聚体水平;绘制ROC曲线以分析hs-cTnI、D-二聚体及二者联合对AAD与AMI的鉴别诊断价值。结果 (1)3组患者男性比例、年龄,高血压病史、丙氨酸氨基转移酶、血肌酐、总胆固醇、低密度脂蛋白胆固醇比较,差异无统计学意义(P>0.05);NSTEMI组、STEMI组患者中有糖尿病病史者所占比例高于AAD组(P<0.05)。(2)NSTEMI组、STEMI组患者hs-cTnI水平及其升高发生率高于AAD组,D-二聚体水平及其升高发生率低于AAD组(P<0.05)。(3)ROC曲线显示,hs-cTnI鉴别诊断AAD与NSTEMI的曲线下面积(AUC)为0.929,最佳截断值为0.95μg/L,灵敏度为93.5%,特异度为83.8%,阳性预测值为94.3%,阴性预测值为81.6%,而鉴别诊断AAD与STEMI的AUC为0.914,最佳截断值为0.95μg/L,灵敏度为84.7%,特异度为83.8%,阳性预测值为96.3%,阴性预测值为52.5%;D-二聚体鉴别诊断AAD与NSTEMI的AUC为0.977,最佳截断值为1.20mg/L,灵敏度为94.6%,特异度为88.8%,阳性预测值为74.4%,阴性预测值为97.9%,而鉴别诊断AAD与STEMI的AUC为0.914,最佳截断值为1.20mg/L,灵敏度为94.6%,特异度为91.8%,阳性预测值为70.0%,阴性预测值为98.8%。hs-cTnI联合D-二聚体(hs-cTnI<0.95μg/L且D-二聚体>1.20mg/L)鉴别诊断AAD与NSTEMI的灵敏度、特异度、阳性预测值、阴性预测值均为100.0%,而鉴别诊断AAD与STEMI的灵敏度、特异度、阳性预测值、阴性预测值分别为100.0%、98.6%、93.5%和100.0%。结论 hs-cTnI联合D-二聚体对AAD与AMI的鉴别诊断价值较高,hs-cTnI<0.95μg/L且D-二聚体>1.20mg/L时AMI可能性较小而AAD可能性非常大。

Objective To analyze the value of hs-cTnI combined with D-dimer in the differential diagnosis between acute aortic dissection(AAD)and acute myocardial infarction(AMI). Methods From June 2015 to December 2017 in Donghua Hospital Affiliated to Sun Yat-sen University,37 inpatients with AAD(served as AAD group),107 inpatients with NSTEMI(served as NSTEMI group)and 183 in patients with STEMI(served as STEMI group)were enroll in this study. General information,laboratory examination results,hs-cTnI and D-dimer that first detected after admission were compared in the three groups,and ROC curve was drawn to analyze the value of hs-cTnI,D-dimer and combination of the above two in the differential diagnosis between AAD and AMI. Results (1)No statistically significant difference of male proportion, age,medical history of hypertension,ALT,Scr,TC or LDL-C was found in the there groups(P>0.05),while proportion of patients with medical history of diabetes in NSTEMI group and STEMI group was statistically significantly higher than that in AAD group,respectively(P<0.05).(2)Compared with that in AAD group,hs-cTnI and incidence of elevated hs-cTnI in NSTEMI group and STEMI group were statistically significantly higher,while D-dimer and incidence of elevated D-dimer in NSTEMI group and STEMI group were statistically significantly lower(P<0.05).(3)ROC curve showed that,the AUC, optimum cut-off value,sensitivity,specificity,positive predictive value(PPV)and negative predictive value(NPV)of hscTnI in the differential diagnosis between AAD and NSTEMI was 0.929,0.95 μg/L,93.5%,83.8%,94.3% and 81.6%, respectively,that between AAD and STEMI was 0.914,0.95 μg/L,84.7%,83.8%,96.3% and 52.5%,respectively;the AUC,optimum cut-off value,sensitivity,specificity,PPV and NPV of D-dimer in the differential diagnosis between AAD and NSTEMI was 0.977,1.20 mg/L,94.6%,88.8%,74.4% and 97.9%,respectively,that between AAD and STEMI was 0.914, 1.20 mg/L,94.6%,91.8%,70.0% and 98.8%,respectively.The sensitivity,specificity,PPV and NPV of hs-cTnI combined with D-dime(hs-cTnI<0.95 μg/L and D-dimer>1.20 mg/L)in the differential diagnosis between AAD and NSTEMI were all 100.0%,that between AAD and STEMI was 100.0%,98.6%,93.5% and 100.0%,respectively. Conclusion Combination of hs-cTnI and D-dimer has relatively high differential diagnostic value between AAD and AMI,patients with hs-cTnI<0.95 μg/L and D-dimer>1.20 mg/L are less likely to be AMI but very likely to be AAD.