急性心肌梗塞(AMI).ppt

ComparisonofPlasmaCardiacTroponinsTanIinChronicallyHemodialyzedPatientsinRelationtoCardiacStatusandAge ClinChemLabMed2002 40 3 240 245 2002byWalterdeGruyter Berlin NewYorkSpeaker 劉秋菁 中华医生网收集http www doctor WHO急性心肌梗塞 AMI 的黃金準則 患者胸痛的病史最少持續30分鐘 心電圖單一階段ST上昇而且其後出現Q波 檢驗室特有的酵素活性 CK CK MB LDH POCTnT1 e 中华医生网收集http www doctor WHO準則的缺點 AMI患者中約有1 3為非典型或沒有胸痛 約有50 AMI患者早期ECG無診斷特徵約有20 AMI患者晚期ECG會診斷失誤由於其他症狀導致敏感性及特異性降低 一般的血清標記特異性不高 CK LDH和異構物 CK和LDH也存在於正常人血中 患者病史 ECG變化 血清標記 POCTnT2 e 中华医生网收集http www doctor 中华医生网收集http www doctor 有用的心臟標記 TroponinTTroponinIMyoglobinCKCK MBCK MBIsoformsLDH EarlydetectionofAMI UsedtodetectAMI Elevatedin3 4hours Cardiacspecific Elevatedafter10days DetectsMMD Riskstratifi cationinUAP Prognosticvalue POCTnT7 e 中华医生网收集http www doctor 中华医生网收集http www doctor AMI血清標記 0 1ng ml1 6h10 24h5 14d 因方法不同而異3 6h18 20h5 7d 1 51 6h4 8h1 2d 5 10ng ml10 25U l3 6h12 24h2 3d 6 60 80ng ml1 2h6 12h0 5 1 5d 參考範圍 開始上昇 高峰期 回復正常 TnT TnI Myoglobin CK MB IsoformsMB2 MB1 CK MB CK POCTnT3 e 中华医生网收集http www doctor 中华医生网收集http www doctor TroponinsComplex TroponinI具有抑制acitin myosinATPase的作用 具心肌專一性 TroponinC負責與Ca離子的結合 不具心肌專一性 TroponinT是將TnI與TnC的結合訊息傳遞至其它調節收縮蛋白 具心肌專一性 TroponinsComplex在心肌及骨骼肌中扮演調節肌肉收縮的重要角色 中华医生网收集http www doctor SUMMARY Introduction Patients MaterialsandMethods Results Discussion 中华医生网收集http www doctor Introduction thereisalackofcorrelationbetweenthetwomarkersinCRFpatientsandithasbeensuggestedthatthediscreanciesmaybeduetogreatersensitivityofthecTnTassaycomparedtothecTnIassay TheclinicalvalueofcardiactroponinI cTnI andtroponinT cTnT inpatientswithchronicrenalfailure CRF remains howeverasubjectofdebate ManyinvestigatorshavereportedthatcTnTmaybeelevatedinCRFpatientsintheabsenceofischemicheartdisease FalseelevationsofcTnIaremorecontroversial somestudieshavedemonstratedanadvantageofcTnIovercTnTinrenalinsufficiency buttherearerecentindicationsofcTnIelevationsinCRFpatientswithoutischemicheartdisease 中华医生网收集http www doctor Abbreviations AMI acutemyocardialinfarctionCHD coronaryheartdiseaseCRF chronicrenalfailurecTnI cardiactroponinIcTnT cardiactroponinThsCRP highsensitivityC reactiveproteinStratusCS StratusCardiacSystemURL upperreferencelimit 中华医生网收集http www doctor PatientsThemeanageofthepatientswas60 1 14 8years range 23 88years Thelengthofdialysisaveraged7 2years SD 7 1 range 1 30years 49位patients CHD group48位patients CHD groupn 97CRFpatients 中华医生网收集http www doctor SampleCollectedThepatientswerefollowedduringaperiodof9monthsandbloodsamplesweretakenat3 monthintervals T1 T2 T3andT4 SampleswereobtainedbeforethefirstdialysisoftheweektoavoidpossiblechangesintroponinlevelsduringdialysisVenousbloodwascollectedimmediatelybeforedialysisandtubeswerecentrifuged 5minat1000 g uponarrivalinthelaboratory cTnTcTnTwasdeterminedbythirdgenerationimmunoassayUsingElecsysanalyzer RocheDiagnostics Mannheim Germany Sampletube EDTA plasmaPrinciple ThisassayusestwomonoclonalantibodiesspecificallydirectedagainsthumancTnT Thedetectionlimitis0 01 g l Theupperreferencelimit URL is0 04 g lAcutemyocardialinfarction AMI is0 1 g l 中华医生网收集http www doctor cTnIcTnIwasatwo sitefluorimetricimmunoassayusingtheStratusCardiacSystem StratusC DadeBehringS A Paris Sampletube LithiumheparinPrinciple twomonoclonalantibodiesrecognizingbothfreeandcomplexedcTnIThedetectionlimitis 0 01 g l TheURLis0 08 g lThecut offvalueforAMIis0 4 g l packageinsert 中华医生网收集http www doctor Figure1ComparisonofpercentagesofcTnTelevationsaboveURL 0 04 g l andtresholdlimitsforAMI 0 1and0 2 l inCHD andCHD CRFpatients Percentagesaregivenateachmeasurementtime T1toT4 T1 T2 T3 T4 Figure1cTnTinCHD patients1 abovetheURLof0 04 g l upto48 6 2 abovethecut offforAMI0 1ug l 21 6 3 Over0 2ug l 2 7 24patients 50 hadplasmalevels 0 04 g l17patients 35 4 hadcTnTvaluesconsistentlyincreasedabovetheURL7patientshadcTnTlevelswhichfluctuatedwithtimearoundtheURL 中华医生网收集http www doctor cTnTinCHD patients1 abovetheURLof0 04 g l upto79 6 2 abovethecut offforAMI0 1ug l upto37 8 3 over0 2ug l upto18 4 中华医生网收集http www doctor Figure2ComparisonofpercentagesofcTnIelevationsaboveURL 0 08 g l andtresholdlimitforAMI 0 04 g l inCHD andCHD CRFpatients Percentagesaregivenateachmeasurementtime T1toT4 T1 T2 T3 T4 中华医生网收集http www doctor Figure2cTnIinCHD patients1 NoCHD patientshadcTnIplasmalevelsabovethecut offforAMI 0 4 g l 2 abovetheURLof0 08ug l 2 1 8 1 cTnIintheCHD patients1 abovetheAMIof0 4ug l upto5 4 2 abovetheURLof0 08ug l 13 0 22 2 中华医生网收集http www doctor Figure3CorrelationbetweencTnTplasmalevelsandageintheCHD andCHD patients upperreferencelimit limitforAMI 中华医生网收集http www doctor Figure3cTnTintheCHD patientsovertheageof60 cTnTwasabovetheURLinmorethan50 ofthecases 0 059 0 042 g l Ascomparedto28 inthepatients 60years 0 032 0 029 g l 中华医生网收集http www doctor Figure4CorrelationbetweencTnIplasmalevelsandageintheCHD andCHD patients upperreferencelimit limitforAMI 中华医生网收集http www doctor Figure5ComparisonofmeanplasmacTnTandcTnIlevelsinCHD andCHD patients 60and 60years up perreferencelimit limitforAMI CHD CHD Figure5cTnIageover60yearsintheCHD group 0 019 0 018ug lage 60yearsintheCHD group 0 049 0 054ug l 中华医生网收集http www doctor Discussion1AlthoughcTnTandcTnIelevationwithageseemstobeparallelinCRFpatientsandtheirplasmalevelsarecorrelated therearequantitativedifferencesbetweenthetwomarkers intheCHD group themeancTnTlevelsarealreadyclosetotheURLintheyoungestpatientsandlargelyexceedthislimitinthepatientsagedabove60years ThesamedissimilaritybetweenthetwotroponinswasalsoobservedintheCHD patients theaveragecTnTconcentrations wereabovethecut offlevelforAMIinallageclasses whilecTnIremainedbelowtheURL 中华医生网收集http www doctor Forexample RicchiutiV 17 1998InmoststudiescomparingcTnTtoCK MBand orcTnIinchronichemodialysispatients cTnTshowedmorefrequentelevationabovecut offthanCK MBandcTnIForexample Frankeletal 18 1996reportedthatcTnTwaselevatedin71 of28CRFpatientswithoutchestpainorAMIundergoinghemodialysis whereasonlyone 2 6 hadCK MBabovecut off 中华医生网收集http www doctor ForexampleHafneretal 19 1994foundanelevatedcTnTin31samples 46 3 anelevatedCKMBinnine 13 4 andcTnI usingacut offof2 2 g linonepatientonly 1 5 ForexampleWillgingS 20 1998themostfrequentcTnTelevations 54 wereseeninthe22patientsonlong termhemodialysis 1year inthesepatientsnoindividualhadcTnIvalueabovecut off 2 0 g l andCK MBelevationwasrecordedinonepatientonly 4 5 中华医生网收集http www doctor Forexample Mussoetal 21 1999WealsofoundasubstantialproportionofcTnTresults 21 6 abovethecut offconcentrationforAMIintheCHD renalpatientsIncontrast nopatienthadcTnIabovethethresholdvalueforAMIinthisgroup FiftypercentoftheCHD patientshadcTnTlevelsabovetheURL 中华医生网收集http www doctor Discussion2cTnIfailedtodiscriminatebetweentheabsenceandpresenceofCHDintheeldestpatientsForthesamereason differencesincTnTbetweenpatientswithandwithoutcoronaryeventstendedtobelessimportantinthe