D-二聚体、肌钙蛋白Ⅰ在鉴别急性心肌梗死、急性主动脉夹层、急性肺栓塞所致的致命性胸痛病因诊断中的作用

摘要/Abstract

摘要： 目的：探讨急诊科床旁快速检测（POCT）D-二聚体、肌钙蛋白Ⅰ（TnI）对急性心肌梗死（AMI）、急性主动脉夹层（AAD）、急性肺栓塞（APE）所致致命性胸痛的鉴别意义。方法：回顾性分析2015年1月至2017年1月因胸痛于急诊科就诊，并确诊为AMI、AAD、APE的270例患者的临床资料，分为AMI组（200例）、AAD组（35例）、APE组（35例），分析患者的D-二聚体、TnI水平对致命性胸痛鉴别诊断的临床指导意义，通过绘制ROC曲线，评估D-二聚体、TnI的鉴别效果。结果： 270例患者，经冠脉造影明确诊断AMI 200例，经主动脉CTA明确诊断AAD 35例，经肺动脉CTA明确诊断APE 35例，对3组D-二聚体、TnI进行统计学分析。①D-二聚体：结果显示APE组高于AAD组，AAD组高于AMI组。D-二聚体区分AMI、AAD效果的ROC曲线下面积是（0.958±0.013），理想界点值为314 ng·mL-1，其敏感性为0.971，特异性为0.910，区分AMI、APE效果的ROC曲线下面积是（0.995±0.003），理想界点值为435 ng·mL-1，其敏感性为1，特异性为0.950，区分AAD、APE效果的ROC曲线下面积是（0.942±0.029），理想界点值为670 ng·mL-1，其敏感性为0.886，特异性为0.943。②TnI：结果显示AMI组高于AAD组和APE组，而AAD组和APE组之间无统计学差异，TnI区分AMI、AAD效果的ROC曲线下面积是（0.939±0.015），理想界点值为0.390 ng·mL-1，其敏感性为0.84，特异性为1，区分AMI、APE效果的ROC曲线下面积是（0.941±0.015），理想界点值为0.365 ng·mL-1，其敏感性为0.845，特异性为1，区分AAD、APE效果的ROC曲线下面积是（0.513±0.070），诊断价值较低。③TnI与D-二聚体数据拟合后的ROC曲线：区分AMI、AAD效果的ROC曲线下面积是（0.995±0.004），理想界点值PRE-1为0.212 596 4，其敏感性为1，特异性为0.975，区分AMI、APE效果的ROC曲线下面积是（0.999±0.001），理想界点值PRE-1为0.171 704 0，其敏感性为1，特异性为0.995，区分AAD、APE效果的ROC曲线下面积是（0.955±0.026），理想界点值PRE-1为0.573 510 9，其敏感性为0.857，特异性为1。结论：POCT检测D-二聚体、TnI有助于致命性胸痛的鉴别诊断，可提高疾病的诊断率。

Abstract: Objective： To explore the differential significance of point of care testing (POCT) of D-dimers， troponin Ⅰ (TnI) to chest pain caused by acute myocardial infarction (AMI)， acute aortic dissection (AAD)， and acute pulmonary embolism (APE). Methods： A retrospective analysis of the clinical data from January 2015 to January 2017 of 270 patients with chest pain in emergency department. 270 patients were diagnosed as AMI， AAD， APE.To analyze the clinical significance of D-dimers， TnI levels in differential diagnosis of patients with fatal chest pain， by drawing the ROC curve， assessment D-dimers， TnI differential effect. Results： In 270 patients， AMI 200 cases were diagnosed by coronary angiography，AAD 35 cases were diagnosed by aortic CTA，APE 35 cases were diagnosed by pulmonary artery CTA.D-dimer and TnI of the three groups were statistically analyzed.①D-dimers： the results showed that group APE was higher than group AAD， group AAD was higher than group AMI. D-dimer ROC curve area body to distinguish AMI， AAD effect is (0.958±0.013)， the ideal cut-off point of 314 ng·mL-1， the sensitivity was 0.971， specificity was 0.910； the area of ROC curve to distinguish AMI， APE effect is (0.995±0.003)， the ideal cut-off point of 435 ng·mL-1. The sensitivity was 1， specificity was 0.950； the area of ROC curve to distinguish AAD， APE effect is (0.942±0.029)， the ideal cut-off point of 670 ng·mL-1， the sensitivity was 0.886， specificity was 0.943. ②TnI： the results showed that group AMI was higher than that of AAD group and APE group， but there was no difference between AAD group and APE group； ROC curve area of TnI to distinguish AMI， AAD effect is (0.939±0.015)， the ideal cut-off point of 0.390 ng·mL-1， the sensitivity was 0.84， specificity was 1； and the area of ROC curve to distinguish AMI， APE effect is (0.941±0.015)， the ideal cut-off point of 0.365 ng·mL-1， the sensitivity was 0.845， specificity was 1； the area of ROC curve to distinguish AAD， APE effect is (0.513±0.070)， low diagnostic value. ③ROC curves fitted by TnI and D-dimer：ROC curve area to distinguish AMI， AAD effect is (0.995±0.004)， the ideal cut-off point of 0.212 596 4， the sensitivity was 1， specificity was 0.975； and the area of ROC curve to distinguish AMI， APE effect is (0.999±0.001)， the ideal cut-off point of 0.171 704 0， the sensitivity was 1， specificity was 0.995； the area of ROC curve to distinguish AAD， APE effect is (0.955±0.026)， the ideal cut-off point of 0.573 510 9， the sensitivity was 0.857， specificity was 1. Conclusion： POCT detection of D-dimers and TnI can be helpful in the differential diagnosis of fatal chest pain， and can improve the diagnostic rate of the disease.

高春雨,赵艳军. D-二聚体、肌钙蛋白Ⅰ在鉴别急性心肌梗死、急性主动脉夹层、急性肺栓塞所致的致命性胸痛病因诊断中的作用[J]. .

gaochunyu and zhaoyanjun. Evaluation of the Role of Emergency D-Dimer and Troponin Ⅰ in Etiological Diagnosis of Fatal Chest Pain Due to Acute Myocardial Infarction，Acute Aortic Dissection and Acute Pulmonary Embolism[J]. .

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