Mustafa ŞAHİN, Mehmet KABALCI, Ünsal SAVCI

Akut koroner sendrom tanısında kardiyak belirteçlerin kesme değerlerinin incelenmesi

Amaç: Akut göğüs ağrısı şikâyeti ile acil servise başvuran hasta sayısı oldukça fazladır ancak bunların çoğu akut koroner sendrom (AKS) tanısı almaz. Gerçek kardiyak hastaları belirleyebilmek için ilk aşamada non-kardiyak nedenleri dışlamak gerekir. Troponinler, kalp kasının yapısal proteinleri olup kardiyak hasara duyarlı ve özgün molekülleridir. Bu çalışmada AKS tanısı için kreatin kinaz MB (CKMB) testinin kesme değerini kardiyak troponin T (cTnT) sonuçlarından ve ROC analizinden faydalanarak belirlemeyi amaçladık. Ayrıca akut miyokard infarktüsü (AMI) hasta yönetiminde kardiyak belirteçlerin ve klinik bilgilerin birlikte kullanımını değerlendirdik.Gereç ve Yöntem: Akut göğüs ağrısı ile acil servise başvuran 390 hastanın elektrokardiyografi (EKG) ve kardiyak belirteçler (cTnT, CKMB seviyeleri) de dahil olmak üzere laboratuvar ve klinik verileri retrospektif olarak toplandı ve bu veriler kullanılarak bir strateji geliştirmeye çalışıldı. Olgular (yaş:58.65 ± 13,29) iki gruba ayrıldı: birinci grup AMI ve ikinci grup iskemik hasar olmayanlardı. CKMB seviyeleri Dimension Xpand Plus (Dade Behring Inc, Newark, ABD) marka biyokimya otoanalizöründe immünoinhibisyon yöntemiyle ölçüldü. cTnT için Cardiac T Quantitative Rapid Assay (Roche Diagnostics GmbH, Mannheim, Almanya) hasta başı cihazı kullanıldı. Bulgular: Çalışmamızda 390 hastanın 36'sında (% 9,2) AMI saptandı. AMI öngörmede CKMB'nin tanısal özgüllüğü ve tanısal duyarlılığı, 16 U/L düzeyi için %92 ve %44; 12 U/L düzeyi için %86 ve %50; 9 U/L düzeyi için %79 ve %61, 6 U/L düzeyi için %63 ve %69 olarak bulundu. CKMB için eğri altındaki alan 0,72 (SE:0,055, p<0,001) idi. Sonuç: Acil serviste AMI erken teşhisinde her ne kadar cTnT en önemli marker olsa da CKMB düzeyleri de hem yalancı negatifliği hem de yalancı pozitifliği azaltmak için birlikte kullanılması gereken güvenilir bir markerdir.

Anahtar Kelimeler:

Akut koroner sendrom, CKMB, duyarlılık, özgüllük, cTnT, özgüllük

Investigation of cardiac markers cut off values in the diagnosis of acute coronary syndrome

Aim: The number of patients applying to the emergency service with acute chest pain complaint are rather high, however most of them are not diagnosed with acute coronary syndrome (ACS). Firstly non-cardiac causes should be excluded to be able to determine true cardiac patients. Troponins are structural proteins of the cardiac muscle, also sensitive and specific molecules of cardiac damage. In this study, we aimed to determine cut off value of creatine kinase MB (CKMB) test for ACS diagnosis by using cardiac troponin T (cTnT) results and ROC analysis. We also evaluated the combined use of cardiac markers and clinical finding in acute myocardial infarction (AMI) patient management.Material and Method: Laboratory and clinical data, including electrocardiography (ECG) and cardiac markers (cTnT, CKMB levels) of 390 patients applying to emergency service with acute chest pain were retrospectively collected and attempted to develop a strategy using these data. The cases (age: 58.65±13.29) were divided into two groups: first group AMI and second group non-ischemic injury. CKMB levels were measured by the immunoinhibition method in Dimension Xpand Plus (Dade Behring Inc, Newark, USA) chemistry autoanalyzer. The Cardiac T Quantitative Rapid Assay (Roche Diagnostics GmbH, Mannheim, Germany) was used for cTnT measurement. Result: In our study, AMI was detected in 36 of 390 patients (9.2%). In prediction of AMI, the diagnostic specificity and diagnostic sensitivity of CKMB was 92% and 44% for 16 U/L; 86% and 50% for 12 U/L; 79% and 61% for 9 U/L, 63% and 69% for 6 U/L, respectively. The area under the curve for CKMB was 0.72 (SE: 0.055, p <0.001). Conclusion: Although cTnT is the most important marker in early diagnosis of AMI in emergency department, CKMB levels are a reliable marker that should be used together to reduce both false negative and false positives.

Keywords:

Acute coronary syndrome, sensitivity, specificity, cTnT, CKMB, specificity,

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1. Green GB, Hill PM. Cardiovascular disease: Approach to chest pain. In: Tintinalli JE, Kelen GD, Stapczynski JS, editors. Emergency medicine: a comprehensive study guide. 6th ed. North Carolina: McGraw-Hill; 2004; p. 333-43.
2. P.O. Collinson, S. Premachandram, K. Hashemiet al. Prospective audit of incidence of prognostically important myocardial damage in patients discharged from emergency department. BMJ. 2000; 324:1702–05. 3. The Joint European Society of Cardiology/American College of Cardiology Committee. Myocardial infarction redefined-a consensus document of The Joint European Society of Cardiology/American College of Cardiology Committee for the redefinition of myocardial infarction. Euro Heart J. 2000; 21(18): 1502-13 4. Pierce GF, Jaffe AS: Increased creatine kinase MB in the absence of acute myocardial infarction. Clin Chem 1986; 32:2044-51 5. Dillon MC, Calbreath DF, Dixon AM, Rivin BE, Roark SF, Ideker RE et al. Diagnostic problem in acute myocardial infarction: CK - MB in the absence of abnormally elevated total creatine kinase levels. Arch.Int.Med 1982; 142:33-8 6. Ray P, Charpentier S, Chenevier-Gobeaux C, Reichlin T, Twerenbold R, Claessens YE, et al. Combined copeptin and troponin to rule out myocardial infarction in patients with chest pain and a history of coronary artery disease. Am J Emerg Med 2012;30:440-8. 7. Katus HA, Remppis A, Neumann FJ, Scheffold T, Diederich KW, Vinar G et al. Diagnostic efficiency of troponin T measurements in acute myocardial infarction. Circulation 1991; 83:902-12 8. Porela P, Pulkki K, Helenius H, Antila KJ, Petterson K, Wacker M. et al. Prediction of short–term outcome in patients with suspected miyocardial infarction. Ann Emerg Med 2000; 35: 413–20 9. Rationale and design of the GRACE (Global Registry of Acute Coronary Events) Project: a multinational registry of patients hospitalized with acute coronary syndromes. Am Heart J 2001;141:190-99. 10. Rosamond TL. Initial appraisal of acute coronary syndrome: understanding the mechanisms, identifying patient risk. Postgrad Med 2002;112:29-42. 11. Chu WW, Dieter RS, Stone CK. A review of clinically relevant cardiac biochemical markers. WMJ. 2002;101:40-8. 12. Hamm CW, Bassand JP, Agewall S, Bax J, Boersma E, Bueno H. et al. ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation: The Task Force for the management of acute coronary syndromes (ACS) in patients presenting without persistent ST-segment elevation of the European Society of Cardiology (ESC). Eur Heart J. 2011;32(23):2999-3054. 13. Wright RS, Anderson JL, Adams CD, Bridges CR, Casey DE Jr, Ettinger SM et al. 2011 ACCF/AHA focused update incorporated into the ACC/AHA 2007 Guidelines for the Management of Patients with Unstable Angina/Non-ST-Elevation Myocardial Infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines developed in collaboration with the American Academy of Family Physicians, Society for Cardiovascular Angiography and Interventions, and the Society of Thoracic Surgeons. J Am Coll Cardiol. 2011; 10;57(19):215-367 14. Karras DJ, Kane DL. Serum markers in the emergency department diagnosis of acute myocardial infarction. Emerg Med Clin North Am. 2001;19:321-37.
15. McCord J, Nowak RM, McCullough PA, Foreback C, Borzak S, Tokarski G et al. Ninety-minute exclusion of acute myocardial infarction by use of quantitative point-of-care testing of myoglobin and troponin I. Circulation. 2001;25;104(13):1483-8. 16. Garbarz E, Iung B, Lefevre G, Makita Y, Farah B, Michaud P.et al. Frequency and prognostic value of cardiac troponin I elevation after coronary stenting. Am J Cardiol. 1999;84:515-8 17. Talasz H, Genser N, Mair J, Dworzak EA, Friedrich G, Moes N. et al. Side-branch occlusion during percutaneous transluminal coronary angioplasty. Lancet. 1992; 339:1380-2. 18. Genser N, Mair J, Talasz H, Puschendorf B, Calzolari C, Larue C et al. Cardiac troponin I to diagnose percutaneous transluminal coronary angioplasty-relatedmyocardial injury. Clin Chim Acta. 1997;265:207-17.