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Article(id=1199335056339727164, tenantId=1146029695717560320, journalId=1189873630562394117, issueId=1199335049175859209, articleNumber=null, orderNo=null, doi=10.11855/j.issn.0577-7402.2392.2023.1007, pmid=null, cstr=null, oa=null, hot=null, price=null, onlineType=0, articleFormat=0, articleType=null, articleTypeStr=research-article, receivedDate=1669132800000, receivedDateStr=2022-11-23, revisedDate=null, revisedDateStr=null, acceptedDate=1685894400000, acceptedDateStr=2023-06-05, onlineDate=1763873359998, onlineDateStr=2025-11-23, pubDate=1711555200000, pubDateStr=2024-03-28, doiRegisterDate=null, doiRegisterDateStr=null, onlineIssueDate=1763873359998, onlineIssueDateStr=2025-11-23, onlineJustAcceptDate=null, onlineJustAcceptDateStr=null, onlineFirstDate=null, onlineFirstDateStr=null, sourceXml=null, magXml=null, createTime=1763873359998, creator=13701087609, updateTime=1763873359998, updator=13701087609, issue=Issue{id=1199335049175859209, tenantId=1146029695717560320, journalId=1189873630562394117, year='2024', volume='49', issue='3', pageStart='245', pageEnd='366', issueExtLink='null', onlineDate='null', pubDate='null', beforeIssueId=null, nextIssueId=null, price=null, status=1, issueComplete=1, articleOrder=1, issueType=-1, specialIssue=0, createTime=1763873358291, creator=13701087609, updateTime=1763874044185, updator=13701087609, preIssue=null, nextIssue=null, ext={EN=IssueExt(id=1199337926086721596, tenantId=1146029695717560320, journalId=1189873630562394117, issueId=1199335049175859209, language=EN, specialIssueTitle=, coverIllustrator=null, specialIssueEditor=, specialIssueAbout=), CN=IssueExt(id=1199337926086721597, tenantId=1146029695717560320, journalId=1189873630562394117, issueId=1199335049175859209, language=CN, specialIssueTitle=, coverIllustrator=null, specialIssueEditor=, specialIssueAbout=)}, issueFiles=null}, startPage=329, endPage=334, ext={EN=ArticleExt(id=1199335057182782295, articleId=1199335056339727164, tenantId=1146029695717560320, journalId=1189873630562394117, language=EN, title=Research progress of high-sensitivity troponin in chronic kidney disease with acute myocardial infarction, columnId=1190243275882729994, journalTitle=Medical Journal of Chinese People’s Liberation Army, columnName=Review, runingTitle=null, highlight=null, articleAbstract=

The progress and clinical application of troponin detection technology have continuously improved the diagnosis rate of acute myocardial infarction (AMI), which effectively shortens the time of necrotic myocardial reperfusion. Earlier studies have found that high-sensitivity troponin (hs-cTn) is elevated to varying degrees in patients with chronic kidney disease (CKD). Therefore, when patients with CKD have AMI, the application of hs-cTn is limited to a certain extent, and with the lack of chest pain symptoms and the non-specificity of electrocardiogram performance in patients with CKD, it is particularly difficult to make a quick and accurate diagnosis of such patients. Based on this, this article will summarize the application of hs-cTn in AMI, the clinical characteristics of patients with CKD combined with AMI, how to improve the diagnostic accuracy of patients with CKD combined with AMI, and the value of hs-cTn in risk stratification and prognosis assessment of such patients to provide clinical medical staff with reference for early intervention or revascularization of patients.

, correspAuthors=Ping Xie, authorNote=null, correspAuthorsNote=
E-mail:
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肌钙蛋白检测技术的进步及临床应用，使急性心肌梗死(AMI)的诊断率不断提高，有效缩短了坏死心肌再灌注时间。研究发现，慢性肾脏病(CKD)患者超敏肌钙蛋白(hs-cTn)水平存在不同程度的升高，因此，当CKD患者发生AMI时，hs-cTn的应用受到一定限制，加之CKD患者缺乏非特异性的胸痛症状及心电图表现，如何快速准确地诊断此类患者变得尤为困难。基于此，本文从hs-cTn在AMI中的应用、CKD合并AMI患者的临床特征、如何改善CKD合并AMI患者的诊断准确率，以及hs-cTn在此类患者风险分层及预后评估中的价值等方面进行综述，旨在为患者进行早期干预或血运重建提供参考。

, correspAuthors=谢萍, authorNote=null, correspAuthorsNote=
谢萍，E-mail：
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马玉娇，硕士研究生，主要从事心血管疾病方面的研究

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马玉娇，硕士研究生，主要从事心血管疾病方面的研究

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马玉娇，硕士研究生，主要从事心血管疾病方面的研究

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J Nephrol, 2020, 33(1): 129-136., articleTitle=Prognostic value of high-sensitive cardiac troponin I in asymptomatic chronic hemodialysis patients, refAbstract=null)], funds=[Fund(id=1199335062203363374, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1199335056339727164, awardId=81860047, language=EN, fundingSource=National Natural Science Foundation of China(81860047), fundOrder=null, country=null), Fund(id=1199335062341775409, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1199335056339727164, awardId=81860047, language=CN, fundingSource=国家自然科学基金(81860047), fundOrder=null, country=null)], companyList=[AuthorCompany(id=1199335057920979842, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1199335056339727164, xref=1, ext=[AuthorCompanyExt(id=1199335057929368451, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1199335056339727164, companyId=1199335057920979842, language=EN, country=null, province=null, city=null, postcode=null, companyName=null, departmentName=null, remark=1First Clinical Medical College, Lanzhou University, Lanzhou, Gansu 730000, China), AuthorCompanyExt(id=1199335057937757060, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1199335056339727164, companyId=1199335057920979842, language=CN, country=null, province=null, city=null, postcode=null, companyName=null, departmentName=null, remark=1兰州大学第一临床医学院，甘肃兰州 730000)]), AuthorCompany(id=1199335058000671626, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1199335056339727164, xref=2, ext=[AuthorCompanyExt(id=1199335058009060235, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1199335056339727164, companyId=1199335058000671626, language=EN, country=null, province=null, city=null, postcode=null, companyName=null, departmentName=null, remark=2Department of Cardiology, Gansu Provincial Hospital, Lanzhou, Gansu 730000, China), AuthorCompanyExt(id=1199335058017448844, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1199335056339727164, companyId=1199335058000671626, language=CN, country=null, province=null, city=null, postcode=null, companyName=null, departmentName=null, remark=2甘肃省人民医院心内科，甘肃兰州 730000)]), AuthorCompany(id=1199335058097140623, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1199335056339727164, xref=3, ext=[AuthorCompanyExt(id=1199335058109723537, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1199335056339727164, companyId=1199335058097140623, language=EN, country=null, province=null, city=null, postcode=null, companyName=null, departmentName=null, remark=3Department of Cardiology of Cadres, Gansu Provincial Hospital, Lanzhou, Gansu 730000, China), AuthorCompanyExt(id=1199335058118112146, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1199335056339727164, companyId=1199335058097140623, language=CN, country=null, province=null, city=null, postcode=null, companyName=null, departmentName=null, remark=3甘肃省人民医院干部心内科，甘肃兰州 730000)])], figs=[ArticleFig(id=1199335061540663317, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1199335056339727164, language=EN, label=Tab.1, caption=

Raise the threshold of hs-cTn to improve the diagnostic efficiency of patients with CKD and AMI

, figureFileSmall=null, figureFileBig=null, tableContent=
研究参考上限的第99百分位值(ng/L)最佳阈值(ng/L)eGFR[ml/(min·1.73 m2)]AUC
Kavsak等[30]雅培：265230~600.904
<300.816
罗氏：193830~600.798
58<300.735
Limkakeng等[31]西门子Atellica：45600<60未获得
Alushi等[32]罗氏Cobas e602：1455<300.810
任带金[33]雅培：30男性(≥60岁)：50030~600.959
女性(≥60岁)：5900.952
), ArticleFig(id=1199335061687463964, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1199335056339727164, language=CN, label=表1, caption=

提高hs-cTn的阈值来改善CKD合并AMI患者的诊断效能

, figureFileSmall=null, figureFileBig=null, tableContent=
研究参考上限的第99百分位值(ng/L)最佳阈值(ng/L)eGFR[ml/(min·1.73 m2)]AUC
Kavsak等[30]雅培：265230~600.904
<300.816
罗氏：193830~600.798
58<300.735
Limkakeng等[31]西门子Atellica：45600<60未获得
Alushi等[32]罗氏Cobas e602：1455<300.810
任带金[33]雅培：30男性(≥60岁)：50030~600.959
女性(≥60岁)：5900.952
), ArticleFig(id=1199335061968482336, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1199335056339727164, language=EN, label=Tab.2, caption=

Dynamic changes in hs-cTn levels to improve the diagnostic efficiency of patients with CKD and AMI

, figureFileSmall=null, figureFileBig=null, tableContent=
研究测量法eGFR[ml/(min.1.73 m2)]AUC
Gunsolus等[34]0/3 h30~600.87(0.82~0.92)
<300.79(0.71~0.87)
Twerenbold等[35]0/1 h<60未获得(0.88~0.92)
Hsu等[11]0/3 h<600.82(0.76~0.88)
), ArticleFig(id=1199335062090117156, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1199335056339727164, language=CN, label=表2, caption=

根据hs-cTn水平的动态变化来改善CKD合并AMI患者的诊断效能

, figureFileSmall=null, figureFileBig=null, tableContent=
研究测量法eGFR[ml/(min.1.73 m2)]AUC
Gunsolus等[34]0/3 h30~600.87(0.82~0.92)
<300.79(0.71~0.87)
Twerenbold等[35]0/1 h<60未获得(0.88~0.92)
Hsu等[11]0/3 h<600.82(0.76~0.88)
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超敏肌钙蛋白在慢性肾脏病合并急性心肌梗死中的作用研究进展
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马玉娇 1 , 谢萍 1, 2, * , 汪蒙 3 , 王茸 1
解放军医学杂志 | 综述 2024,49(3): 329-334
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解放军医学杂志 | 综述 2024, 49(3): 329-334
超敏肌钙蛋白在慢性肾脏病合并急性心肌梗死中的作用研究进展
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马玉娇1, 谢萍1, 2, * , 汪蒙3, 王茸1
作者信息
  • 1兰州大学第一临床医学院，甘肃兰州 730000
  • 2甘肃省人民医院心内科，甘肃兰州 730000
  • 3甘肃省人民医院干部心内科，甘肃兰州 730000

    • 马玉娇，硕士研究生，主要从事心血管疾病方面的研究

通讯作者:

谢萍，E-mail：
Research progress of high-sensitivity troponin in chronic kidney disease with acute myocardial infarction
Yu-Jiao Ma1, Ping Xie1, 2, * , Meng Wang3, Rong Wang1
Affiliations
  • 1First Clinical Medical College, Lanzhou University, Lanzhou, Gansu 730000, China
  • 2Department of Cardiology, Gansu Provincial Hospital, Lanzhou, Gansu 730000, China
  • 3Department of Cardiology of Cadres, Gansu Provincial Hospital, Lanzhou, Gansu 730000, China
出版时间: 2024-03-28 doi: 10.11855/j.issn.0577-7402.2392.2023.1007
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摘要
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肌钙蛋白检测技术的进步及临床应用，使急性心肌梗死(AMI)的诊断率不断提高，有效缩短了坏死心肌再灌注时间。研究发现，慢性肾脏病(CKD)患者超敏肌钙蛋白(hs-cTn)水平存在不同程度的升高，因此，当CKD患者发生AMI时，hs-cTn的应用受到一定限制，加之CKD患者缺乏非特异性的胸痛症状及心电图表现，如何快速准确地诊断此类患者变得尤为困难。基于此，本文从hs-cTn在AMI中的应用、CKD合并AMI患者的临床特征、如何改善CKD合并AMI患者的诊断准确率，以及hs-cTn在此类患者风险分层及预后评估中的价值等方面进行综述，旨在为患者进行早期干预或血运重建提供参考。

超敏肌钙蛋白  /  急性心肌梗死  /  慢性肾脏疾病

The progress and clinical application of troponin detection technology have continuously improved the diagnosis rate of acute myocardial infarction (AMI), which effectively shortens the time of necrotic myocardial reperfusion. Earlier studies have found that high-sensitivity troponin (hs-cTn) is elevated to varying degrees in patients with chronic kidney disease (CKD). Therefore, when patients with CKD have AMI, the application of hs-cTn is limited to a certain extent, and with the lack of chest pain symptoms and the non-specificity of electrocardiogram performance in patients with CKD, it is particularly difficult to make a quick and accurate diagnosis of such patients. Based on this, this article will summarize the application of hs-cTn in AMI, the clinical characteristics of patients with CKD combined with AMI, how to improve the diagnostic accuracy of patients with CKD combined with AMI, and the value of hs-cTn in risk stratification and prognosis assessment of such patients to provide clinical medical staff with reference for early intervention or revascularization of patients.

high-sensitivity troponin  /  acute myocardial infarction  /  chronic kidney disease
马玉娇, 谢萍, 汪蒙, 王茸. 超敏肌钙蛋白在慢性肾脏病合并急性心肌梗死中的作用研究进展. 解放军医学杂志, 2024 , 49 (3) : 329 -334 . DOI: 10.11855/j.issn.0577-7402.2392.2023.1007
Yu-Jiao Ma, Ping Xie, Meng Wang, Rong Wang. Research progress of high-sensitivity troponin in chronic kidney disease with acute myocardial infarction[J]. Medical Journal of Chinese People’s Liberation Army, 2024 , 49 (3) : 329 -334 . DOI: 10.11855/j.issn.0577-7402.2392.2023.1007
正文
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急性心肌梗死(acute myocardial infarction，AMI)是心血管疾病的急危重症，其早期识别、诊断及治疗至关重要[1-2]。慢性肾脏病(chronic kidney disease，CKD)作为心血管疾病的独立危险因素[3]，往往与AMI患者的发病率、不良预后密切相关[4]。超敏肌钙蛋白(hypersensitive troponin，hs-cTn)的应用在很大程度上提高了AMI诊断的敏感性，但CKD患者的hs-cTn等心肌损伤标志物水平亦存在不同程度的升高，导致心肌损伤标志物诊断的特异度降低或假阳性率升高[5]。此外，CKD合并AMI患者由于肾功能受损及造影剂的肾毒性等原因并非冠状动脉造影检查的适宜者。因此，如何提高此类患者的诊断准确性成为临床难题。hs-cTn还可用于急性冠脉综合征患者的危险分层和预后评估，但在CKD患者中是否具有同样的作用已成为研究热点。目前，研究者根据临床情况提出了不同的建议来解决上述问题，本文从hs-cTn在AMI中的应用、CKD合并AMI患者的临床特征、如何改善CKD合并AMI患者的诊断准确率，以及hs-cTn在CKD合并AMI患者中的风险分层及预后评估价值等方面进行综述，以期为临床上此类患者的识别、诊断、治疗和管理提供参考。
1 hs-cTn在AMI中的应用
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在临床上，许多患者因出现类似AMI的症状而就诊于急诊科，心肌损伤标志物成为此类患者快速诊断的重要依据之一。2009年，Reichlin等[6]证实，hs-cTn对早期AMI的诊断具有良好的效能[受试者工作特征(ROC)曲线下面积(AUC)为0.92~0.98]，尤其是新近出现胸痛的AMI患者。近期一项纳入2494例疑似AMI患者的研究发现，超敏肌钙蛋白I(hs-cTnI)的敏感度和特异度均>90%，阴性和阳性预测值分别为≥98%和>60%，可早期、安全有效地诊断AMI[7]。hs-cTn的检测还可用于AMI患者的危险分层和预后评估，使用西门子Atellica检测hs-cTnI水平时，最佳阈值<10 ng/L，可排除50%以上患者30 d内发生心肌梗死的风险[8]。有研究发现，hs-cTnT在预测患者长期病死率及预后方面优于hs-cTnI[9]，这可能与hs-cTnT检测时间窗较宽有关。此外，年轻患者hs-cTn水平升高可能对预后预测的价值更大[10]。
2 CKD合并AMI患者的临床特征
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CKD合并AMI患者通常缺少发生AMI时的典型胸痛症状。有研究对240例CKD合并AMI患者进行分析发现，出现呼吸困难的患者最多，占57%左右，其次是胸痛、心源性休克、意识障碍、腹痛等症状[11]。同时，由于肾小球滤过率下降是发生无痛性心肌梗死的独立危险因素[12]，在CKD患者中仍需警惕无痛性心肌梗死的存在。可能的原因是尿毒症末梢神经病变和毒素(如胺类)的排泄障碍增加了毛细血管的通透性，促进了肺水肿和腹水的发生，同时也可能与并发急性心力衰竭有关。CKD患者易发生左心室肥厚、左束支传导阻滞、右束支传导阻滞及电解质紊乱等，因此在发生心肌梗死时，患者的心电图改变并不明显[13]，从而导致非ST段抬高型心肌梗死的发病率明显增高。最近的研究发现，接受血运重建可能有利于CKD合并AMI患者的长期预后[14]。但CKD合并AMI患者的血运重建率低于肾功能正常患者[15]，这可能与首份心电图表现不典型及心肌损伤标志物特异度降低等导致的诊断延迟和(或)造影剂对肾功能的损害、出血风险等有关。
CKD合并AMI患者中血清白蛋白和血红蛋白水平均低于肾功能正常的AMI患者[16]。白蛋白水平降低可使患者免疫功能受损，易引发感染；血红蛋白水平降低可导致患者贫血、诱发心肌缺血缺氧加重，易发生心血管意外。此外，CKD合并AMI患者尿酸和胱抑素C等指标均明显高于未合并CKD的AMI患者[16]。在血管病变方面，非ST段抬高型心肌梗死合并CKD患者冠状动脉狭窄的发生率约为70%，明显高于未合并CKD的患者[17]。有回顾性研究也发现，CKD合并AMI患者的多血管明显狭窄与CKD4期和5期明显相关[18]。可能的原因是，随着CKD病程的进展，炎症对血管的损伤更明显，钙磷代谢紊乱也促进了血管钙化的发生。2020年的一项研究发现，CKD患者易发生近端冠状动脉病变，如累及右冠状动脉、左前降支、左冠状动脉主干等[19]。近端血管的病变，使CKD合并AMI时更易出现心肌严重缺血、恶性心律失常及其他不良预后。以上研究结果提示，通过AMI的诊断标准(心肌缺血的表现及心电图改变)来诊断CKD患者的AMI可能缺乏可靠性。考虑到CKD患者受传统心血管危险因素和CKD特异性危险因素的共同影响，这些危险因素协同作用可能会引起更严重的血管病变。因此，当CKD患者存在这些危险因素时，早期干预可能是预防病变发生并改善预后的良好选择。
3 提高CKD合并AMI的诊断准确率
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研究发现，肾功能受损患者的肌钙蛋白浓度是肾功能正常患者的3倍[20]，且CKD患者中超过50% hs-cTn水平高于参考上限的第99百分位值[21]。关于CKD患者中肌钙蛋白升高的机制，目前认为急性和慢性心肌损伤是主要原因，其次是肾小球清除率下降，以及代谢产物(如吲哚类化合物)蓄积而激活芳烃受体，从而增强血小板聚集等，导致动脉粥样硬化和血栓形成，促使CKD患者心肌缺血及心肌梗死的发生，最终引起心肌细胞坏死[22-23]。同时，吲哚类化合物激活芳烃受体还可直接诱导细胞衰老及凋亡[24]。此外，CKD患者常伴心力衰竭，使左心室射血分数降低，一方面肌节代偿性延长可增强心肌收缩力(但当肌节延长超过3.6 μm时，则粗、细肌丝丧失重叠能力而失去收缩力)，且心肌收缩力增强后，可使氧耗、能量消耗增多，使心肌细胞坏死凋亡[25]；另一方面CKD患者体内神经内分泌因子、炎性介质等的持续作用，可加重心力衰竭及心肌细胞坏死凋亡，进一步影响肾功能，形成恶性循环。其他机制还包括交感-肾上腺-髓质系统的激活、冠脉小分支的阻塞、严重贫血、氧化应激等[26-27]。对于透析患者，透析过程中的低血压和心肌顿抑也可能是导致心肌损伤、肌钙蛋白水平升高的原因[28-31]。近年来研究发现，估算肾小球滤过率(estimated glomerular filtration rate，eGFR)平均值降低5 ml/(min.1.73 m2)时，患者的基线hs-cTn水平即可升高8.2%[29-32]。因此，在CKD患者中，基线hs-cTn超过参考上限的第99百分位值可能不能准确地诊断心肌梗死的发生。对于如何提高hs-cTn在CKD患者中的诊断性能，部分研究者建议在CKD和血液透析患者中使用更高的临界值[30-33]，而另一部分研究者则认为应该依赖于对hs-cTn水平动态变化的分析[11,34-35]。
3.1 提高hs-cTn阈值对改善CKD合并AMI患者诊断的价值
研究发现，hs-cTn水平与eGFR呈负相关，当CKD患者的eGFR<30 ml/(min.1.73 m2)时，几乎所有患者的hs-cTn水平均高于参考上限的第99百分位值[30-33]。鉴于此，有研究通过提高诊断的阈值来提高诊断率。其中，2018年的一项研究建议，对eGFR<30 ml/(min.1.73 m2)的患者采取hs-cTnI>52 ng/L(雅培Architect i2000)，hs-cTnT>58 ng/L(罗氏E-modular)作为诊断阈值，可使敏感度及阴性预测值均较参考上限的第99百分位值作为诊断阈值时有所提高[30-33]。一项纳入29家急诊室共2271例患者的前瞻性研究发现，将hs-cTnI的临界值从120 ng/L提高至600 ng/L时，诊断的特异度增高，同时保持了较高的敏感度，且在eGFR 15~30 ml/(min.1.73 m2)的患者中达到100%的敏感度和阴性预测值[31]。Alushi等[32]研究发现，将hs-cTn的最佳阈值定为55 ng/L时，诊断重度CKD合并非ST段抬高型心肌梗死的敏感度和特异度分别达83%和65%。任带金[33]按年龄和性别分层统计了CKD合并AMI患者hs-cTnI的最佳阈值，发现通过这类方法能更好地提高诊断效能。以上研究提示，在诊断CKD患者的AMI时，可根据CKD的不同阶段选取最佳阈值，以达到更好的诊断效能。上述研究结果的具体诊断效能见表1，其中，eGFR为30~60 ml/(min.1.73 m2)的患者阈值约高于参考上限第99百分位值的2倍，eGFR<30 ml/(min.1.73 m2)的患者高2~4倍，相差倍数的跨度相对稳定。此外，以上研究由于所选研究对象人口学特征的差异及分层的不同，出现了高于参考上限的第99百分位的13~19倍的最佳阈值。同时，任带金[33]的研究中，在选取最佳阈值时性别及年龄的差异也是需要考虑的影响因素，因为目前已有研究报道男性的肌钙蛋白浓度是女性的1.5~2.5倍[36]。
3.2 hs-cTn水平的动态变化对改善CKD合并AMI患
者诊断的价值临床上经常发现CKD和终末期肾病患者的hs-cTn水平呈慢性升高，因此，部分学者建议，在诊断AMI时必须强调hs-cTn水平变化的重要性。有研究发现，肾功能变化对hs-cTnI诊断的敏感度或阴性预测值无明显影响，而特异度会从功能正常时的94%左右下降到肾功能严重受损时[eGFR<30 ml/(min.1.73 m2)]的59%至透析时的40%[35]。该研究检测了基线和3 h时hs-cTnI水平的变化情况，诊断eGFR为30~60 ml/(min.1.73 m2)的患者AMI时敏感度较基线时增加40%，而特异度几乎保持不变(基线：78.7%，3 h：77.3%)；而eGFR<30 ml/(min.1.73 m2)时敏感度达100%，且特异度只下降了3%[35]。有研究采用欧洲心脏病学会(ESC) 0/1 h算法，发现可使肾功能损害患者诊断的阳性预测值升高至70.8%[36]。Hsu等[11]的前瞻性研究检测了CKD患者初始及中位数3 h时的hs-cTnT水平，结果发现hs-cTnT水平变化值为16%时，诊断的敏感度为77%左右、特异度为84%左右，对CKD患者的AMI有较好的诊断效能。上述研究结果的具体诊断效能见表2，提示根据hs-cTn水平的变化可使CKD合并AMI患者的诊断效能有所提高，使AUC达到0.8以上。但这种诊断算法在临床实施时存在一定的难度，因为在这种诊断算法中患者往往需要一个基线值作为参考，这个基线值可以是患者上次或此次入院时测得，且必须完成至少两次hs-cTn水平的检测，一方面增加了就医费用，另一方面AMI属于急危重症，需要争取时间恢复血液再灌注，间隔一定时间在一定程度上增加了病情的凶险程度。
4 hs-cTn在CKD合并AMI患者风险分层及预后评估中的价值
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hs-cTn作为心脏疾病的重要标志物[37]，其水平与CKD合并AMI患者的预后及风险分层密切相关。2018年一项前瞻性多中心研究发现，随访1年后，hs-cTn水平高于参考上限的第99百分位值的CKD患者[eGFR<60 ml/(min.1.73 m2)]发生心肌梗死的风险是肾功能正常患者的2倍，且推荐hs-cTnI<5 ng/L作为排除CKD患者心肌梗死风险分层的阈值[38]。近期Georgianos等[39]发现，hs-cTnT是轻中度CKD患者不良心血管事件的一个强有力的独立预测因子。因此，CKD患者hs-cTn水平升高可能是亚临床心肌损伤的表现，且提示患者心血管疾病已经发生，临床医师及患者应予以重视。最近的研究发现，hs-cTn水平升高可使肾功能受损患者的不良预后风险增加50%，尤其是CKD合并1型心肌梗死(由于冠状动脉斑块破裂，使冠状动脉内血栓形成，导致缺血而发生的AMI)患者的预后更差[20]，这可能与CKD合并1型心肌梗死患者接受血运重建率较低和缺乏循证治疗方案有关。此外，有研究发现，hs-cTn水平较高的患者，其三支病变发生率及Gensini评分更高，且预后不良[40]。由于糖尿病、高血压、高脂血症、高龄等危险因素的存在，CKD患者中需要透析者日益增多[41]，hs-cTn水平也可用于透析合并AMI患者的危险分层和预后评估[42]，建议定期监测肌钙蛋白以早期识别无症状血液透析患者的心脏状况。因此，hs-cTn作为临床中比影像学检查更易获得的指标，可作为CKD，尤其是eGFR<60 ml/(min.1.73 m2)CKD患者的住院监测项目，以早期评估CKD患者心血管系统的健康状况。
5 总结与展望
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hs-cTn为普通人群AMI诊断的可靠证据，但其在CKD合并AMI患者中的诊断效能并不理想。通过监测hs-cTn水平的动态变化虽然会提高诊断效能，但在一定程度上增加了医疗费用，且在临床上部分患者可能会拒绝短时间内连续抽血进行检查，因此，提高最佳诊断阈值可能是一种好的方法，但在关注最佳阈值时，需要考虑年龄、性别、种族、eGFR等因素的影响，并需要在高质量、切实可行的多中心临床研究中验证。此外，hs-cTn在CKD合并AMI患者的风险分层和预后评估中也有一定的参考价值，CKD患者院外应定期检测hs-cTn水平，这对此类患者早期干预的管理具有一定的指示意义。由于CKD患者存在多支血管严重病变和血流动力学不稳定的频发，因此，有必要在急诊室应用心脏彩超来确定室壁运动障碍的严重程度及进行左心室射血分数的估计，这将有助于优化对CKD合并AMI患者治疗和出院康复计划的制定。此外，目前大多数研究是针对eGFR<60 ml/(min.1.73 m2)的患者进行的，同样的阈值及动态测量方法是否适用于eGFR 60~90 ml/(min.1.73 m2)患者AMI的诊断仍需进一步探讨。
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  • 国家自然科学基金(81860047)
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doi: 10.11855/j.issn.0577-7402.2392.2023.1007
  • 接收时间：2022-11-23
  • 首发时间：2025-11-23
  • 出版时间：2024-03-28
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  • 收稿日期：2022-11-23
  • 录用日期：2023-06-05
基金
National Natural Science Foundation of China(81860047)
国家自然科学基金(81860047)
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    1兰州大学第一临床医学院，甘肃兰州 730000
    2甘肃省人民医院心内科，甘肃兰州 730000
    3甘肃省人民医院干部心内科，甘肃兰州 730000

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2种不同金属材料的力学参数
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Family		 属数
Number of
genus		 种数
Number of
species		 占总种数比例
Percentage of
total species (%)		 属
Genus		 种数
Number of
species		 占总种数比例
Percentage of total
species (%)
鹅膏菌科Amanitaceae 2 11 5.26 鹅膏菌属 Amanita 10 4.78
小菇科 Mycenaceae 2 12 5.74 丝盖伞属 Inocybe 5 2.39
多孔菌科 Polyporaceae 8 14 6.70 蜡蘑属 Laccaria 5 2.39
红菇科 Russulaceae 3 23 11.00 小皮伞属 Marasmius 6 2.87
小菇属 Mycena 11 5.26
光柄菇属 Pluteus 5 2.39
红菇属 Russula 17 8.13
栓菌属 Trametes 5 2.39
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