《急性心肌梗塞AMI》PPT课件.ppt

1、Comparison of Plasma Cardiac Troponins T an I in Chronically Hemodialyzed Patients in Relation to Cardiac Status and Age,Clin Chem Lab Med 2002; 40(3):240245 2002 by Walter de Gruyter Berlin New York Speaker: 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

2、 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

3、,Troponin T Troponin I Myoglobin CK CK-MB CK-MB Isoforms LDH,Early detectionof AMI,Used to detect AMI,Elevated in 3-4 hours,Cardiacspecific,Elevatedafter 10 days,DetectsMMD,Risk stratifi- cation in UAP,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, 0.1 ng/ml 1

4、- 6 h 10 - 24 h 5 - 14 d,因方法 不同而異 3 - 6 h 18 - 20 h 5 - 7 d, 1.5 1 - 6 h 4 - 8 h 1 - 2 d,5 - 10 ng/ml 10 - 25 U/l 3 - 6 h 12 - 24 h 2 - 3 d, 6 %,60 - 80 ng/ml 1 - 2 h 6 - 12 h 0.5 - 1.5 d,參考範圍,開始上昇,高峰期,回復正常,TnT,TnI,Myoglobin,CK-MB,Isoforms MB2/MB1,CK-MB/CK,POCTnT3.e,中华医生网收集http:/www.doctor-,中华医生网收集h

5、ttp:/www.doctor-,Troponins Complex,Troponin I 具有抑制acitin-myosin ATPase 的作用(具心肌專一性) Troponin C 負責與Ca離子的結合 (不具心肌專一性) Troponin T 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) Troponins Complex 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 Materials and Methods Results Discussion,中

6、华医生网收集http:/www.doctor-,Introduction,there is a lack of correlation between the two markers in CRF patients and it has been suggested that the discreancies may be due to greater sensitivity of the cTnT assay compared to the cTnI assay,The clinical value of cardiac troponin I (cTnI) and troponin T (c

7、TnT) in patients with chronic renal failure (CRF) remains, however a subject of debate. Many investigators have reported that cTnT may be elevated in CRF patients in the absence of ischemic heart disease. False elevations of cTnI are more controversial: some studies have demonstrated an advantage of

8、 cTnI over cTnT in renal insufficiency, but there are recent indications of cTnI elevations in CRF patients without ischemic heart disease,中华医生网收集http:/www.doctor-,Abbreviations: AMI, acute myocardial infarction CHD,coronary heart disease CRF, chronic renal failure cTnI, cardiac troponin I cTnT, car

9、diac troponin T hs CRP, high sensitivity C-reactive protein Stratus CS, Stratus Cardiac System URL, upper reference limit,中华医生网收集http:/www.doctor-,Patients The mean age of the patients was 60.114.8 years (range: 2388 years) The length of dialysis averaged 7.2 years (SD: 7.1, range: 130 years) 49位 pa

10、tients-CHD(+)group 48位patients-CHD(-)group n=97 CRF patients,中华医生网收集http:/www.doctor-,Sample Collected The patients were followed during a period of 9 months and blood samples were taken at 3-month intervals (T1, T2, T3 andT4) Samples were obtained before the first dialysis of the week to avoid poss

11、ible changes in troponin levels during dialysis Venous blood was collected immediately before dialysis and tubes were centrifuged (5 min at 1000 g) upon arrival in the laboratory,cTnT cTnT was determined by third generation immunoassay Using Elecsys analyzer (Roche Diagnostics,Mannheim,Germany) Samp

12、le tube-EDTA-plasma Principle: This assay uses two monoclonal antibodies specifically directed against human cTnT,The detection limit is 0.01 g/l. The upper reference limit (URL) is 0.04 g/l Acute myocardial infarction (AMI) is 0.1g/l.,中华医生网收集http:/www.doctor-,cTnI cTnI was a two-site fluorimetric i

13、mmunoassay using the Stratus Cardiac System (Stratus C; Dade Behring S.A., Paris) Sample tube-Lithium heparin Principle: two monoclonal antibodies recognizing both free and complexed cTnI The detection limit is (0.01 g/l) The URL is 0.08 g/l The cut-off value for AMI is 0.4 g/l (package insert).,中华医

14、生网收集http:/www.doctor-,Figure 1 Comparison of percentages of cTnT elevations above URL (0.04 g/l) and treshold limits for AMI (0.1 and 0.2 l) in CHD() and CHD(+) CRF patients. Percentages are given at each measurement time (T1 to T4). T1, T2, T3, T4.,Figure 1 cTnT in CHD(-) patients 1.above the URL o

15、f 0.04 g/l (up to 48.6% ) 2. above the cut-off for AMI 0.1ug/l (21.6% ) 3. Over 0.2ug/l(2.7%) 24 patients (50%) had plasma levels 0.04 g/l 17 patients (35.4%) had cTnT values consistently increased above the URL 7 patients had cTnT levels which fluctuated with time around the URL.,中华医生网收集http:/www.d

16、octor-,cTnT in CHD(+) patients 1.above the URL of 0.04g/l (up to 79.6%) 2.above the cut-off for AMI 0.1ug/l(up to 37.8%) 3.over 0.2ug/l(up to 18.4%),中华医生网收集http:/www.doctor-,Figure 2 Comparison of percentages of cTnI elevations above URL (0.08 g/l) and treshold limit for AMI (0.04 g/l) in CHD() and

17、CHD(+) CRF patients. Percentages are given at each measurement time (T1 to T4). T1, T2, T3, T4.,中华医生网收集http:/www.doctor-,Figure 2 cTnI in CHD(-)patients 1.No CHD() patients had cTnI plasma levels above the cut-off for AMI (0.4 g/l) 2.above the URL of 0.08ug/l (2.1-8.1%),cTnI in the CHD(+) patients 1

18、.above the AMI of 0.4ug/l(up to 5.4%) 2.above the URL of 0.08ug/l (13.0-22.2%),中华医生网收集http:/www.doctor-,Figure 3 Correlation between cTnT plasma levels and age in the CHD() and CHD(+) patients. (: upper reference limit; : limit for AMI).,中华医生网收集http:/www.doctor-,Figure 3 cTnT in the CHD(-) patients

19、over the age of 60, cTnT was above the URL in more than 50% of the cases (0.0590.042 g/l) As compared to 28% in the patients 60 years (0.0320.029 g/l),中华医生网收集http:/www.doctor-,Figure 4 Correlation between cTnI plasma levels and age in the CHD() and CHD(+) patients. (: upper reference limit; : limit

20、for AMI).,中华医生网收集http:/www.doctor-,Figure 5 Comparison of mean plasma cTnT and cTnI levels in CHD() and CHD(+) patients .60 and 60 years (: up-per reference limit; : limit for AMI). CHD(), CHD(+).,Figure 5 cTnI age over 60 years in the CHD() group :0.0190.018ug/l age 60 years in the CHD(+) group:0.0

21、490.054ug/l,中华医生网收集http:/www.doctor-,Discussion 1 Although cTnT and cTnI elevation with age seems to be parallel in CRF patients and their plasma levels are correlated, there are quantitative differences between the two markers: in the CHD() group, the mean cTnT levels are already close to the URL i

22、n the youngest patients and largely exceed this limit in the patients aged above 60 years,The same dissimilarity between the two troponins was also observed in the CHD(+) patients: the average cTnT concentrations,were above the cut-off level for AMI in all age classes, while cTnI remained below the

23、URL,中华医生网收集http:/www.doctor-,For example,Ricchiuti V.(17) 1998 In most studies comparing cTnT to CK-MB and/or cTnI in chronic hemodialysis patients,cTnT showed more frequent elevation above cut-off than CK-MB and cTnI For example, Frankel et al. (18) 1996 reported that cTnT was elevated in 71% of 28

24、 CRF patients without chest pain or AMI undergoing hemodialysis,whereas only one (2.6%) had CK-MB above cut-off.,中华医生网收集http:/www.doctor-,For example Hafner et al. (19) 1994 found an elevated cTnT in 31 samples (46.3%), an elevated CKMB in nine (13.4%) and cTnI, using a cut-off of 2.2 g/l in one pat

25、ient only (1.5%),For example Willging S (20) 1998 the most frequent cTnT elevations (54%) were seen in the 22 patients on long-term hemodialysis (1 year); in these patients no individual had cTnI value above cut-off (2.0 g/l) and CK-MB elevation was recorded in one patient only (4.5%).,中华医生网收集http:/

26、www.doctor-,For example,Musso et al.(21) 1999 We also found a substantial proportion of cTnT results( 21.6%) above the cut-off concentration for AMI in the CHD() renal patients In contrast, no patient had cTnI above the threshold value for AMI in this group. Fifty percent of the CHD() patients had cTnT levels above the URL,中华医生网收集http:/www.doctor-,Discussion 2 cTnI failed to discriminate between the absence and presence of CHD in the eldest patients For the same reason, differences in cTnT between patients with and without coronary events tended to be less i