急性心力衰竭與心肌肌鈣蛋白指數(shù)的關(guān)系與臨床結(jié)果分析英文

1、急性心力衰竭與心肌肌鈣蛋白指數(shù)的關(guān)系與臨床結(jié)果分析英文Background Cardiac troponin provides diagnostic and prognostic information in acute coronary syndromes, but its role in acute decompensated heart failure is unclear. The purpose of our study was to describe the association between elevated cardiac troponin levels and adver

2、se e v e n t s i n h o s p i t a l i z e d p a t i e n t s w i t h a c u t e decompensated heart failure. With the use of data from the Acute Decompensated Heart Failure National Registry (ADHERE), we analyzed outcomes associated with elevated troponin levels in patients with acute decompensated hea

3、rt failure.Briefly,ADHERE is an observational registry, involving patients with an ultimate discharge diagnosis of acute decompensated heart failure.第1頁(yè)/共29頁(yè)Methods We examined records from 274 hospitals, from October 2001 through Januar y 2004. Inclusion criteria were hospitalization and documentat

4、ion of the measurement of cardiac troponin I or cardiac troponin T at the initial evaluation (defined as within 24 hours after admission). Because renal dysfunction may influence cardiac troponin concentrations, patients with a serum creatinine level higher than 2.0 mg per deciliter (176.8 mol per l

5、iter) were excluded from the study. A positive troponin test was defined as a cardiac troponin I level of 1.0 g per liter or higher or a cardiac troponinT level of 0.1 g per liter or higher.第2頁(yè)/共29頁(yè)Methods Measurement of cardiac troponin T is performed on a uniform platform in the United States, and

6、 the cutoff point of 0.1 g per liter or higher. Because troponin I has different cutoff points that are dependent on the platform used (more than a dozen different assays), a predefined cutoff point was set at 1.0 g per liter or higher. This cutoff point was based on exper t consensus, approximating

7、 values defined from a ROC curve that was optimized for the detection of myocardial infarction. 第3頁(yè)/共29頁(yè)Methods The primar y outcome was in-hospital mortality from all causes, and the secondary outcomes included differences in medical management, procedures,and length of stay between the troponin-po

8、sitive and troponin-negative cohorts. We also examined associations between therapy and mor tality in patients who received inotropes or vasodilators, but not both. Analysis of variance, Wilcoxon rank-sum tests, or chi-square tests were used for univariate for this analysis.Overall, 1.2% of the reco

9、rds were excluded because of missing values. Analyses were performed with the use of SAS software, version 8.2 (SAS Institute).第4頁(yè)/共29頁(yè)第5頁(yè)/共29頁(yè)Results 急性急性G-CSF干預(yù)下，模擬缺血條件下心室肌細(xì)胞干預(yù)下，模擬缺血條件下心室肌細(xì)胞ICa.L的的I-V曲線發(fā)生曲線發(fā)生了改變，呈劑量依賴性增加；失活曲線未發(fā)生變化，激活曲線在了改變，呈劑量依賴性增加；失活曲線未發(fā)生變化，激活曲線在300g/kg的時(shí)候向右偏移，表明離子通道更容易激活；的時(shí)候向右偏移

10、，表明離子通道更容易激活；300g/kg G-CSF同同100g/kg G-CSF相比，電流密度無明顯統(tǒng)計(jì)學(xué)差異。相比，電流密度無明顯統(tǒng)計(jì)學(xué)差異。 給予最大劑量給予最大劑量 （300g/kg）G-CSF對(duì)缺氧條件下心室肌細(xì)胞急性干預(yù)，對(duì)缺氧條件下心室肌細(xì)胞急性干預(yù)，INa的的 I-V曲線、激活曲線、失活曲線和靜態(tài)失活曲線均無明顯變化。曲線、激活曲線、失活曲線和靜態(tài)失活曲線均無明顯變化。第6頁(yè)/共29頁(yè)第二部分第二部分 心臟整體電生理研究心臟整體電生理研究第7頁(yè)/共29頁(yè)第8頁(yè)/共29頁(yè)第9頁(yè)/共29頁(yè)第10頁(yè)/共29頁(yè)第11頁(yè)/共29頁(yè)第12頁(yè)/共29頁(yè)第13頁(yè)/共29頁(yè)ResultsTrop

11、onin was measured at the time of admission in 84,872 of 105,388 patients(80.5%) who were hospitalized for acute decompensated heart failure. Of these patients, 67,924 had a creatinine level of less than 2.0 mg per deciliter. Cardiac troponin I was measured in 61,379 patients, and cardiac troponin T

12、in 7880 patients(both proteins were measured in 1335 patients). Overall, 4240 patients (6.2%) were positive for troponin. Patients who were positive for troponin had lower systolic blood pressure on admission, a lower ejection fraction, and higher in-hospital mortality(8.0% vs. 2.7%, P0.001) than th

13、ose who were negative for troponin. to 2.89; P0.001 by the Wald test).第14頁(yè)/共29頁(yè)Discussion第15頁(yè)/共29頁(yè)In our data set, which included data from 105,388 patients, troponin was measured in 80.5% of the hospitalized patients with acute decompensated heart failure. Of these patients, 6.2% were found to be p

14、ositive for troponin, including those with and those without a history of coronary artery disease or myocardial infarction. patients presenting with acute decompensated heart failure and a positive troponin status were found to be a high-risk cohort. Patients in this cohort, as compared with those w

15、ho were negative for troponin, required more cardiac procedures and longer hospitalization and had a higher risk of in-hospital death, even after adjustment for other risk factors. These results suggest that measurement of troponin adds important prognostic information to the initial evaluation of p

16、atients with acute decompen-sated heart failure and should be considered as part of an early assessment of risk.Discussion第16頁(yè)/共29頁(yè)Our findings add to the existing risk-stratification data for predicting the short-term risk of death among patients with acute decompensated heart failure. Patients wit

17、h an initial blood urea nitrogen level of more than 43 mg per deciliter (15.4 mmol per liter), systolic blood pressure of less than 115 mm Hg, or a creatinine level of more than 2.75 mg per deciliter (243.1 mol per liter) have high short-term mortality, exceeding 22% if all three factors are present

18、. Discussion第17頁(yè)/共29頁(yè)National guidelines for the evaluation of an acute coronary syndrome recommend that levels of cardiac troponin and brain natriuretic peptide be used for prognosis and risk stratification. Current guidelines for the evaluation of heart failure do not mention troponin and recommen

19、d the measurement of brain natriuretic peptide only in cases in which the diagnosis is uncertain. Our data suggest that the measurement of troponin levels in patients who present with heart failure provides independent prognostic information regarding in-hospital death and other clinical outcomes.Di

20、scussion第18頁(yè)/共29頁(yè) First, we used the results of various cardiac troponin I assays for which we defined cutoff points, rather than core laboratory results. However, the generalizability of our data allows the findings to be considered in actual patient-care scenarios. Second, we were unable to analyz

21、e those patients with heart failure in whom troponin was not assessed. Because troponin was measured only at the time of admission to the hospital, we cannot comment on the number of patients with an acute myocardial infarction.Finally, the other biomarkers,such as brain natriuretic peptide, was not

22、 explored in this study.Limitations第19頁(yè)/共29頁(yè)Several limitations of the study are a function of the registry itself. Inclusion in ADHERE required a discharge diagnosis of heart failure. Because the diagnosis was not objectively ascertained,some patients with both heart failure and an acute coronary s

23、yndrome may have been included in our analysis. However, when only data from patients who were categorized as having nonischemic heart failure were analyzed, troponin levels retained their prognostic significance. In addition, ADHERE did not consistently report the cause of death, and noncardiac eve

24、nts may have contributed to the mortality rate. Finally, ADHERE recorded only in-hospital outcomes, not deaths after discharge. Our findings may underrepresent adverse outcomes,since others have found that mortality at 30 days may exceed in-hospital mortality.Discussion第20頁(yè)/共29頁(yè)Conclusions In patien

25、ts with acute decompensated heart failure, a positive cardiac troponin test is associated with higher in-hospital mortality, independently of other predictive variables.第21頁(yè)/共29頁(yè)第22頁(yè)/共29頁(yè)Methods We examined records from 274 hospitals, from October 2001 through Januar y 2004. Inclusion criteria were

26、hospitalization and documentation of the measurement of cardiac troponin I or cardiac troponin T at the initial evaluation (defined as within 24 hours after admission). Because renal dysfunction may influence cardiac troponin concentrations, patients with a serum creatinine level higher than 2.0 mg

27、per deciliter (176.8 mol per liter) were excluded from the study. A positive troponin test was defined as a cardiac troponin I level of 1.0 g per liter or higher or a cardiac troponinT level of 0.1 g per liter or higher.第23頁(yè)/共29頁(yè)Methods Measurement of cardiac troponin T is performed on a uniform pla

28、tform in the United States, and the cutoff point of 0.1 g per liter or higher. Because troponin I has different cutoff points that are dependent on the platform used (more than a dozen different assays), a predefined cutoff point was set at 1.0 g per liter or higher. This cutoff point was based on exper t consensus, approximating values defined from a ROC curve that was optimized for the detection of myocardial infarction. 第24頁(yè)/共29頁(yè)第二部分第二部分 心臟整體電生理研究心臟整體電生理研究第25頁(yè)/共29