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CC BY-NC-ND 4.0 · Dtsch Med Wochenschr 2020; 145(05): e24-e31
DOI: 10.1055/a-0988-5332
Originalarbeit
© Georg Thieme Verlag KG Stuttgart · New York

Troponin-Test im Alltag – Unterschiede der Gütekriterien in der Diagnose des akuten Myokardinfarkts unter Berücksichtigung klinischer Leitsymptome: eine Querschnittsstudie

Troponin test in clinical daily practice – Differences in the quality criteria for the diagnosis of acute myocardial Infarction considering clinical leading symptoms: A cross-sectional study
Mohammad Al Mawed
1   Klinik für Kardiologie, Angiologie und internistische Intensivmedizin, Klinikum Lippe-Detmold, Detmold, Deutschland
,
Harm-Christian Mendrok
1   Klinik für Kardiologie, Angiologie und internistische Intensivmedizin, Klinikum Lippe-Detmold, Detmold, Deutschland
,
Fiete John
1   Klinik für Kardiologie, Angiologie und internistische Intensivmedizin, Klinikum Lippe-Detmold, Detmold, Deutschland
,
Rainer Högel
2   Klinik für Nephrologie, Klinikum Lippe-Detmold, Detmold, Deutschland
,
Ulrich Tebbe
1   Klinik für Kardiologie, Angiologie und internistische Intensivmedizin, Klinikum Lippe-Detmold, Detmold, Deutschland
› Author Affiliations
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Publication History

Publication Date:
27 September 2019 (online)

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Zusammenfassung

Einleitung Die kardialen Troponine sind die bevorzugten kardialen Biomarker in der Diagnostik eines akuten Myokardinfarkts. Sie sind jedoch bei jeglichen Myokardzellschäden, egal welcher Pathophysiologie, nachweisbar. Das Ziel dieser Studie ist, zu beurteilen, wie die Gütekriterien des Troponin-Tests in der Diagnose des akuten Myokardinfarkts im Alltag sind und ob klinische Leitsymptome einen Einfluss darauf haben.

Methode Es handelt sich um eine retrospektive Querschnittsstudie, in welche alle Patienten, die sich in der Notaufnahme des Klinikums Lippe-Detmold zwischen dem 01.01.2014 und dem 31.05.2014 vorstellten und einen Troponin-Test hatten, eingeschlossen wurden. Die Diagnose akuter Myokardinfarkt bezog sich auf den Myokardinfarkt Typ I und wurde durch den diensthabenden Kardiologen gestellt. Die Patienten wurden in 4 Subgruppen entsprechend der Leitsymptome unterteilt. Die Gütekriterien des Troponin-Tests wurden berechnet.

Ergebnisse 1046 Patienten wurden eingeschlossen. Bei 15 % lag ein akuter Myokardinfarkt vor, 97 % von diesen hatten thorakale Schmerzen. Die Sensitivitäten und die negativen prädiktiven Werte lagen über 90 %. Die Spezifitäten lagen zwischen 56 % und 81 %. Die positiven prädiktiven Werte waren bescheiden und am besten bei den thorakalen Schmerzen mit 58 %.

Schlussfolgerung Bei allen klinischen Leitsymptomen hatte der Troponin-Test einen guten negativen prädiktiven Wert. Ein akuter Myokardinfarkt konnte somit mit hoher Präzision ausgeschlossen werden. Der positive prädiktive Wert war hingegen niedrig. Lediglich bei dem Leitsymptom Thoraxschmerz konnten akzeptable Werte erreicht werden.

Abstract

Introduction Cardiac troponins are the prefered cardial biomarker in the diagnosis of acute myocardial infarction. Because they are detectable by myocardial cell damage, no matter what pathophysiology, the interpretation of a positive test is difficult. The aim of this study is to assess the quality criteria of the troponin test in the diagnosis of acute myocardial infarction in everyday life and whether clinical leading symptoms have an influence on it.

Methods This is a retrospective cross-sectional study, in which all patients who presented themselves in the emergency department of the Klinikum Lippe-Detmold between 01.01.2014 and 31.05.2014, and had a Troponin-I test were included. The diagnosis “acute myocardial infarction” referred to myocardial infarction type I and was made by the cardiologist on-duty. The patients were divided into four subgroups according to the leading symptoms. The quality criteria of the Troponin-test were calculated.

Results 1046 patients were included. In 15 %, acute myocardial infarction was present, of which 97 % had thoracic pain. The sensitivities and the negative predictive values were over 90 %. The specificities ranged between 56 % and 81 %. The positive predictive values were modest and best in case of thoracic pain 58 %.

Conclusion The Troponin test had a good negative predictive value for all clinical symptoms. Thus, an acute myocardial infarction could be excluded with high precision. However, the positive predictive value was low. The only direct symptom that achieved acceptable levels was thoracic pain.

Schlüsselwörter

kardiale Troponine - akuter Myokardinfarkt - Myokardverletzung - thorakale Schmerzen - Dyspnoe

Key words

cardiac troponins - acute myocardial infarction - myocardial injury - thoracic pain - dyspnea
 

  • Literatur

  • 1 Nomenclature and criteria for diagnosis of ischemic heart disease. Report of the Joint International Society and Federation of Cardiology/World Health Organization task force on standardization of clinical nomenclature. Circulation 1979; 59: 607-609
    CrossrefPubMedGoogle Scholar
  • 2 Danese E, Montagnana M. A historical approach to the diagnostic biomarkers of acute coronary syndrome. Ann Transl Med 2016; 4: 194
    CrossrefPubMedGoogle Scholar
  • 3 Katus HA, Looser S, Hallermayer K. Development and in vitro characterization of a new immunoassay of cardiac troponin T. Clin Chem 1992; 38: 386-393
    CrossrefPubMedGoogle Scholar
  • 4 Katus HA, Remppis A, Looser S. et al. Enzyme linked immuno assay of cardiac troponin T for the detection of acute myocardial infarction in patients. J Mol Cell Cardiol 1989; 21: 1349-1353
    CrossrefPubMedGoogle Scholar
  • 5 Alpert JS, Thygesen A, Antman EM. et al. Myocardial infarction redefined – a consensus document of the joint European Society of Cardiology/American College of Cardiology Committee for the Redefinition of Myocardial Infarction. J Am Coll Cardiol 2000; 36: 959-969
    CrossrefPubMedGoogle Scholar
  • 6 Thygesen K, Alpert JS, White HD. et al. Universal definition of myocardial infarction. Circulation 2007; 116: 2634-2653
    CrossrefPubMedGoogle Scholar
  • 7 Thygesen K, Alpert JS, Jaffe AS. et al. Third universal definition of myocardial infarction. J Am Coll Cardiol 2012; 60: 1581-1598
    CrossrefPubMedGoogle Scholar
  • 8 Giannitsis E, Kurz K, Hallermayer K. et al. Analytical validation of a high-sensitivity cardiac troponin T assay. Clin Chem 2010; 56: 254-261
    CrossrefPubMedGoogle Scholar
  • 9 Roffi M, Patrono C, Collet J. et al. Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation: Task Force for the Management of Acute Coronary Syndromes in Patients Presenting without Persistent ST-Segment Elevation of the European Society of Cardiology (ESC). Eur Heart J 2016; 37: 267-315
    CrossrefPubMedGoogle Scholar
  • 10 Thygesen K, Alpert JS, Jaffe AS. et al. Fourth universal definition of myocardial infarction. Eur Heart J 2019; 40 (03) 237-269
    CrossrefPubMedGoogle Scholar
  • 11 Reichlin T, Twerenbold R, Reiter M. et al. Introduction of high sensitivity troponin assays: impact on myocardial infarction incidence and prognosis. Am J Med 2012; 125: 1205-1213.e1
    CrossrefPubMedGoogle Scholar
  • 12 Dolci A, Panteghini M. The exciting story of cardiac biomarkers: from retrospective detection to gold diagnostic standard for acute myocardial infarction and more. Clin Chim Acta 2006; 369: 179-187
    CrossrefPubMedGoogle Scholar
  • 13 Cummins B, Auckland ML, Cummins P. Cardiac-specific troponin-I radioimmunoassay in the diagnosis of acute myocardial infarction. Am Heart J 1987; 113: 1333-1344
    PubMedGoogle Scholar
  • 14 Sarkisian L, Saaby L, Poulsen TS. et al. Clinical Characteristics and Outcomes of Patients with Myocardial Infarction, Myocardial Injury, and Nonelevated Troponins. Am J Med 2016; 129: 446.e5-446.e21
    CrossrefPubMedGoogle Scholar
  • 15 McFalls EO, Larsen G, Johnson GR. et al. Outcomes of hospitalized patients with non- acute coronary syndrome and elevated cardiactroponin level. Am J Med 2011; 124: 630-635
    CrossrefPubMedGoogle Scholar
  • 16 El-Menyar A, Zubaid M, Sulaiman K. et al. Atypical presentation of acute coronary syndrome: a significant independent predictor of in-hospital mortality. J Cardiol 2011; 57: 165-171
    PubMedGoogle Scholar
  • 17 Malik MA, Alam Khan S, Safdar S. et al. Chest Pain as a presenting complaint in patients with acute myocardial infarction (AMI). Pak J Med Sci 2013; 29: 565-568
    PubMedGoogle Scholar
  • 18 Berg J, Björck L, Dudas K. et al. Symptoms of a first acute myocardial infarction in women and men. Gend Med 2009; 6: 454-462
    CrossrefPubMedGoogle Scholar
  • 19 Pelter MM, Riegel B, McKinley S. et al. Are there symptom differences in patients with coronary artery disease presenting to the ED ultimately diagnosed with or without ACS?. Am J Emerg Med 2012; 30: 1822-1828
    CrossrefPubMedGoogle Scholar
  • 20 Berliner D, Schneider N, Welte T. et al. The Differential Diagnosis of Dyspnea. Dtsch Arztebl Int 2016; 113: 834-845
    PubMedGoogle Scholar
  • 21 Kociol RD, Peter S, Pang MD. et al. Troponin Elevation in Heart Failure: Prevalence, Mechanisms, and Clinical Implications. J Am Coll Cardiol 2010; 56: 1071-1078
    CrossrefPubMedGoogle Scholar
  • 22 Thelin J, Melander O. Dynamic high-sensitivity troponin elevations in atrial fibrillation patients might not be associated with significant coronary artery disease. BMC Cardiovascular Disorders 2017; 17: 169
    CrossrefPubMedGoogle Scholar
  • 23 Wijesurendra RS, Liu A, Notaristefano F. et al. Myocardial Perfusion Is Impaired and Relates to Cardiac Dysfunction in Patients with Atrial Fibrillation Both Before and After Successful Catheter Ablation. J Am Heart Assoc 2018; 7: e009218
    PubMedGoogle Scholar
  • 24 Lanza GA, Crea F. Primary coronary microvascular dysfunction: clinical presentation, pathophysiology, and management. Circulation 2010; 121: 2317-2325
    CrossrefPubMedGoogle Scholar