D-二聚体对伴肌钙蛋白Ⅰ升高的急性主动脉夹层与急性非ST段抬高型心肌梗死的鉴别诊断意义

The Significance of D-dimer in Differential Diagnosis Between Acute Aortic Dissection with Elevated Cardiac TroponinⅠand Acute Non-ST Elevation Myocardial Infarction

目的探讨D-二聚体对伴肌钙蛋白Ⅰ(cTnⅠ)升高的急性主动脉夹层(AAD)和急性非ST段抬高型心肌梗死(NSTEMI)患者在症状出现24 h内的鉴别诊断价值。方法回顾性分析2017年7月-2022年6月我院收治的AAD患者41例(AAD组),入选的AAD患者均在急性胸痛24 h内就诊,同时伴有cTnⅠ升高且不合并可引起D-二聚体升高的常见疾病;随机选取同时期因急性胸痛在24 h内于我院就诊最终被诊断为NSTEMI的患者48例作为对照组(NSTEMI组),比较两组患者的一般资料和D-二聚体及cTnⅠ水平,并通过受试者工作特征曲线(ROC)分析D-二聚体对伴cTnⅠ升高的AAD的诊断价值。结果AAD组白细胞计数、肌酐、hs-CRP水平及伴心包积液患者比例明显高于NSTEMI组,而血红蛋白、血小板计数、总胆固醇水平和合并糖尿病患者比例明显低于NSTEMI组,差异均有统计学意义(P<0.05),两组患者在性别、年龄、发病时长、合并高血压和心电图改变方面比较无明显差异(P>0.05)。AAD组患者D-二聚体水平高于NSTEMI组[9.37(3.64~12.83)μg/ml vs 0.22(0.19~0.45)μg/ml],cTnⅠ水平明显低于NSTEMI组[0.20(0.09~0.96)ng/ml vs 1.97(0.52~9.14)ng/ml],差异均有统计学意义(P<0.05)。D-二聚体诊断伴cTnⅠ升高的AAD的ROC曲线下面积为0.992(95%CI:0.980~1.000,P<0.05),最佳截断值1.43μg/ml,以D-二聚体>1.43μg/ml为标准,其敏感度为95.12%,特异度为97.92%,阳性预测值为97.50%,阴性预测值为95.92%。结论在症状出现24 h内就诊的伴cTnⅠ升高的急性胸痛患者中,D-二聚体对伴cTnⅠ升高的AAD和NSTEMI有鉴别诊断意义,有助于临床医师做出正确的诊断。

Objective To investigate the value of D-dimer in the differential diagnosis of acute aortic dissection(AAD)with elevated cardiac troponinⅠ(cTnⅠ)and acute non-ST elevation myocardial infarction(NSTEMI)within 24 hours after symptom onset.Methods A retrospective analysis was performed on 41 patients with AAD(AAD group)admitted to our hospital from July 2017 to June 2022.The selected AAD patients were all treated within 24 hours of acute chest pain,accompanied by elevated cTnⅠand without common diseases that can cause elevated D-dimer;at the same time,48 patients who were finally diagnosed with NSTEMI in our hospital within 24 hours due to acute chest pain were randomly selected as the control group(NSTEMI group).The general data,D-dimer and cTnⅠlevels of the two groups were compared,and the diagnostic value of D-dimer for AAD with elevated cTnⅠwas analyzed by receiver operating characteristic curve(ROC).Results The white blood cell count,creatinine,hs-CRP level and the proportion of patients with pericardial effusion in the AAD group were significantly higher than those in the NSTEMI group,while the hemoglobin,platelet count,total cholesterol level and the proportion of patients with diabetes were significantly lower than those in the NSTEMI group,the differences were statistically significant(P<0.05).There was no significant difference in gender,age,duration of onset,hypertension and ECG changes between the two groups(P>0.05).The level of D-dimer in the AAD group was higher than that in the NSTEMI group[9.37(3.64-12.83)μg/ml vs 0.22(0.19-0.45)μg/ml],and the level of cTnⅠwas significantly lower than that in the NSTEMI group[0.20(0.09-0.96)ng/ml vs 1.97(0.52-9.14)ng/ml],the differences were statistically significant(P<0.05).The area under the ROC curve of D-dimer in the diagnosis of AAD with elevated cTnⅠwas 0.992(95%CI:0.980-1.000,P<0.05),and the optimal cut-off value was 1.43μg/ml.Taking D-dimer>1.43μg/ml as the standard,the sensitivity was 95.12%,the specificity was 97.92%,the positive predictive value was 97.50%,and the negative predictive value was 95.92%.Conclusion In patients with acute chest pain with elevated cTnⅠwithin 24 hours of symptom onset,D-dimer has differential diagnostic significance for AAD with elevated cTnⅠand NSTEMI,which is helpful for clinicians to make correct diagnosis.