急性心力衰竭与心肌肌钙蛋白指数的关系与临床结果分析.ppt

W.FrankPeacockIV,M.D.,TeresaDeMarco,M.D.,GreggC.Fonarow,M.D.,DeborahDiercks,M.D.,JanetWynne,M.S.,FredS.Apple,Ph.D.,andAlanH.B.Wu,fortheADHEREInvestigatorsUniversityofCaliforniaatSanFrancisco,SanFrancisco;NEnglJMed2019;358:2117-26.,CardiacTroponinandOutcomeinAcuteHeartFailure,Background,Cardiactroponinprovidesdiagnosticandprognosticinformationinacutecoronarysyndromes,butitsroleinacutedecompensatedheartfailureisunclear.Thepurposeofourstudywastodescribetheassociationbetweenelevatedcardiactroponinlevelsandadverseeventsinhospitalizedpatientswithacutedecompensatedheartfailure.WiththeuseofdatafromtheAcuteDecompensatedHeartFailureNationalRegistry(ADHERE),weanalyzedoutcomesassociatedwithelevatedtroponinlevelsinpatientswithacutedecompensatedheartfailure.Briefly,ADHEREisanobservationalregistry,involvingpatientswithanultimatedischargediagnosisofacutedecompensatedheartfailure.,Methods,Weexaminedrecordsfrom274hospitals,fromOctober2019throughJanuary2019.InclusioncriteriawerehospitalizationanddocumentationofthemeasurementofcardiactroponinIorcardiactroponinTattheinitialevaluation(definedaswithin24hoursafteradmission).Becauserenaldysfunctionmayinfluencecardiactroponinconcentrations,patientswithaserumcreatininelevelhigherthan2.0mgperdeciliter(176.8molperliter)wereexcludedfromthestudy.ApositivetroponintestwasdefinedasacardiactroponinIlevelof1.0gperliterorhigheroracardiactroponinTlevelof0.1gperliterorhigher.,Methods,MeasurementofcardiactroponinTisperformedonauniformplatformintheUnitedStates,andthecutoffpointof0.1gperliterorhigher.BecausetroponinIhasdifferentcutoffpointsthataredependentontheplatformused(morethanadozendifferentassays),apredefinedcutoffpointwassetat1.0gperliterorhigher.Thiscutoffpointwasbasedonexpertconsensus,approximatingvaluesdefinedfromaROCcurvethatwasoptimizedforthedetectionofmyocardialinfarction.,Methods,Theprimaryoutcomewasin-hospitalmortalityfromallcauses,andthesecondaryoutcomesincludeddifferencesinmedicalmanagement,procedures,andlengthofstaybetweenthetroponin-positiveandtroponin-negativecohorts.Wealsoexaminedassociationsbetweentherapyandmortalityinpatientswhoreceivedinotropesorvasodilators,butnotboth.Analysisofvariance,Wilcoxonrank-sumtests,orchi-squaretestswereusedforunivariateforthisanalysis.Overall,1.2%oftherecordswereexcludedbecauseofmissingvalues.AnalyseswereperformedwiththeuseofSASsoftware,version8.2(SASInstitute).,results,Results,急性G-CSF干预下，模拟缺血条件下心室肌细胞ICa.L的I-V曲线发生了改变，呈剂量依赖性增加；失活曲线未发生变化，激活曲线在300g/kg的时候向右偏移，表明离子通道更容易激活；300g/kgG-CSF同100g/kgG-CSF相比，电流密度无明显统计学差异。给予最大剂量（300g/kg）G-CSF对缺氧条件下心室肌细胞急性干预，INa的I-V曲线、激活曲线、失活曲线和静态失活曲线均无明显变化。,第二部分心脏整体电生理研究,ResultsTroponinwasmeasuredatthetimeofadmissionin84,872of105,388patients(80.5%)whowerehospitalizedforacutedecompensatedheartfailure.Ofthesepatients,67,924hadacreatinineleveloflessthan2.0mgperdeciliter.CardiactroponinIwasmeasuredin61,379patients,andcardiactroponinTin7880patients(bothproteinsweremeasuredin1335patients).Overall,4240patients(6.2%)werepositivefortroponin.Patientswhowerepositivefortroponinhadlowersystolicbloodpressureonadmission,alowerejectionfraction,andhigherin-hospitalmortality(8.0%vs.2.7%,P0.001)thanthosewhowerenegativefortroponin.to2.89;P0.001bytheWaldtest).,Discussion,Inourdataset,whichincludeddatafrom105,388patients,troponinwasmeasuredin80.5%ofthehospitalizedpatientswithacutedecompensatedheartfailure.Ofthesepatients,6.2%werefoundtobepositivefortroponin,includingthosewithandthosewithoutahistoryofcoronaryarterydiseaseormyocardialinfarction.patientspresentingwithacutedecompensatedheartfailureandapositivetroponinstatuswerefoundtobeahigh-riskcohort.Patientsinthiscohort,ascomparedwiththosewhowerenegativefortroponin,requiredmorecardiacproceduresandlongerhospitalizationandhadahigherriskofin-hospitaldeath,evenafteradjustmentforotherriskfactors.Theseresultssuggestthatmeasurementoftroponinaddsimportantprognosticinformationtotheinitialevaluationofpatientswithacutedecompen-satedheartfailureandshouldbeconsideredaspartofanearlyassessmentofrisk.,Discussion,Ourfindingsaddtotheexistingrisk-stratificationdataforpredictingtheshort-termriskofdeathamongpatientswithacutedecompensatedheartfailure.Patientswithaninitialbloodureanitrogenlevelofmorethan43mgperdeciliter(15.4mmolperliter),systolicbloodpressureoflessthan115mmHg,oracreatininelevelofmorethan2.75mgperdeciliter(243.1molperliter)havehighshort-termmortality,exceeding22%ifallthreefactorsarepresent.,Discussion,Nationalguidelinesfortheevaluationofanacutecoronarysyndromerecommendthatlevelsofcardiactroponinandbrainnatriureticpeptidebeusedforprognosisandriskstratification.Currentguidelinesfortheevaluationofheartfailuredonotmentiontroponinandrecommendthemeasurementofbrainnatriureticpeptideonlyincasesinwhichthediagnosisisuncertain.Ourdatasuggestthatthemeasurementoftroponinlevelsinpatientswhopresentwithheartfailureprovidesindependentprognosticinformationregardingin-hospitaldeathandotherclinicaloutcomes.,Discussion,First,weusedtheresultsofvariouscardiactroponinIassaysforwhichwedefinedcutoffpoints,ratherthancorelaboratoryresults.However,thegeneralizabilityofourdataallowsthefindingstobeconsideredinactualpatient-carescenarios.Second,wewereunabletoanalyzethosepatientswithheartfailureinwhomtroponinwasnotassessed.Becausetroponinwasmeasuredonlyatthetimeofadmissiontothehospital,wecannotcommentonthenumberofpatientswithanacutemyocardialinfarction.Finally,theotherbiomarkers,suchasbrainnatriureticpeptide,wasnotexploredinthisstudy.,Limitations,Severallimitationsofthestudyareafunctionoftheregistryitself.InclusioninADHERErequiredadischargediagnosisofheartfailure.Becausethediagnosiswasnotobjectivelyascertained,somepatientswithbothheartfailureandanacutecoronarysyndromemayhavebeenincludedinouranalysis.Ho