《急性心肌梗塞AMI》PPT课件

ComparisonofPlasmaCardiacTroponinsTanIinChronicallyHemodialyzedPatientsinRelationtoCardiacStatusandAgeClinChemLabMed2002;40(3):240–245©2002byWalterdeGruyter·Berlin·NewYorkSpeaker:劉秋菁中华医生网收集http://www.doctor-cn.net/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-cn.net/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-cn.net/中华医生网收集http://www.doctor-cn.net/有用的心臟標記TroponinTTroponinIMyoglobinCKCK-MBCK-MBIsoformsLDHEarlydetectionofAMIUsedtodetectAMIElevatedin3-4hoursCardiacspecificElevatedafter10daysDetectsMMDRiskstratifi-cationinUAPPrognosticvaluePOCTnT7.e中华医生网收集http://www.doctor-cn.net/中华医生网收集http://www.doctor-cn.net/AMI血清標記<0.1ng/ml1-6h10-24h5-14d因方法不同而異3-6h18-20h5-7d<1.51-6h4-8h1-2d5-10ng/ml10-25U/l3-6h12-24h2-3d<6%60-80ng/ml1-2h6-12h0.5-1.5d參考範圍開始上昇高峰期回復正常TnTTnIMyoglobinCK-MBIsoformsMB2/MB1CK-MB/CKPOCTnT3.e中华医生网收集http://www.doctor-cn.net/中华医生网收集http://www.doctor-cn.net/TroponinsComplexTroponinI具有抑制acitin-myosinATPase的作用(具心肌專一性)TroponinC負責與Ca離子的結合(不具心肌專一性)TroponinT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)TroponinsComplex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-cn.net/SUMMARYIntroductionPatientsMaterialsandMethodsResultsDiscussion中华医生网收集http://www.doctor-cn.net/IntroductionthereisalackofcorrelationbetweenthetwomarkersinCRFpatientsandithasbeensuggestedthatthediscreanciesmaybeduetogreatersensitivityofthecTnTassaycomparedtothecTnIassayTheclinicalvalueofcardiactroponinI(cTnI)andtroponinT(cTnT)inpatientswithchronicrenalfailure(CRF)remains,howeverasubjectofdebate.ManyinvestigatorshavereportedthatcTnTmaybeelevatedinCRFpatientsintheabsenceofischemicheartdisease.FalseelevationsofcTnIaremorecontroversial:somestudieshavedemonstratedanadvantageofcTnIovercTnTinrenalinsufficiency,buttherearerecentindicationsofcTnIelevationsinCRFpatientswithoutischemicheartdisease中华医生网收集http://www.doctor-cn.net/Abbreviations:AMI,acutemyocardialinfarctionCHD,coronaryheartdiseaseCRF,chronicrenalfailurecTnI,cardiactroponinIcTnT,cardiactroponinThsCRP,highsensitivityC-reactiveproteinStratusCS,StratusCardiacSystemURL,upperreferencelimit中华医生网收集http://www.doctor-cn.net/PatientsThemeanageofthepatientswas60.1±14.8years(range:23–88years)Thelengthofdialysisaveraged7.2years(SD:7.1,range:1–30years)49位patients----------CHD(+)group48位patients-----------CHD(-)groupn=97CRFpatients中华医生网收集http://www.doctor-cn.net/SampleCollectedThepatientswerefollowedduringaperiodof9monthsandbloodsamplesweretakenat3-monthintervals(T1,T2,T3andT4)SampleswereobtainedbeforethefirstdialysisoftheweektoavoidpossiblechangesintroponinlevelsduringdialysisVenousbloodwascollectedimmediatelybeforedialysisandtubeswerecentrifuged(5minat1000×g)uponarrivalinthelaboratorycTnTcTnTwasdeterminedbythirdgenerationimmunoassayUsingElecsysanalyzer(RocheDiagnostics,Mannheim,Germany)Sampletube------EDTA-plasmaPrinciple:ThisassayusestwomonoclonalantibodiesspecificallydirectedagainsthumancTnTThedetectionlimitis0.01µg/l.Theupperreferencelimit(URL)is0.04µg/lAcutemyocardialinfarction(AMI)is0.1µg/l.中华医生网收集http://www.doctor-cn.net/cTnIcTnIwasatwo-sitefluorimetricimmunoassayusingtheStratusCardiacSystem(StratusC;DadeBehringS.A.,Paris)Sampletube-------LithiumheparinPrinciple:twomonoclonalantibodiesrecognizingbothfreeandcomplexedcTnIThedetectionlimitis(0.01µg/l)TheURLis0.08µg/lThecut-offvalueforAMIis0.4µg/l(packageinsert).中华医生网收集http://www.doctor-cn.net/Figure1ComparisonofpercentagesofcTnTelevationsaboveURL(0.04µg/l)andtresholdlimitsforAMI(0.1and0.2µl)inCHD(–)andCHD(+)CRFpatients.Percentagesaregivenateachmeasurementtime(T1toT4).T1,T2,T3,T4.Figure1cTnTinCHD(-)patients1.abovetheURLof0.04µg/l(upto48.6%)2.abovethecut-offforAMI0.1ug/l(21.6%)3.Over0.2ug/l(2.7%)24patients(50%)hadplasmalevels<0.04µg/l17patients(35.4%)hadcTnTvaluesconsistentlyincreasedabovetheURL7patientshadcTnTlevelswhichfluctuatedwithtimearoundtheURL.中华医生网收集http://www.doctor-cn.net/cTnTinCHD(+)patients1.abovetheURLof0.04µg/l(upto79.6%)2.abovethecut-offforAMI0.1ug/l(upto37.8%)3.over0.2ug/l(upto18.4%)中华医生网收集http://www.doctor-cn.net/Figure2ComparisonofpercentagesofcTnIelevationsaboveURL(0.08µg/l)andtresholdlimitforAMI(0.04µg/l)inCHD(–)andCHD(+)CRFpatients.Percentagesaregivenateachmeasurementtime(T1toT4).T1,T2,T3,T4.中华医生网收集http://www.doctor-cn.net/Figure2cTnIinCHD(-)patients1.NoCHD(–)patientshadcTnIplasmalevelsabovethecut-offforAMI(0.4µg/l)2.abovetheURLof0.08ug/l(2.1---8.1%)cTnIintheCHD(+)patients1.abovetheAMIof0.4ug/l(upto5.4%)2.abovetheURLof0.08ug/l(13.0---22.2%)中华医生网收集http://www.doctor-cn.net/Figure3CorrelationbetweencTnTplasmalevelsandageintheCHD(–)andCHD(+)patients.(–·–·–·–·:upperreferencelimit;–––––:limitforAMI).中华医生网收集http://www.doctor-cn.net/Figure3cTnTintheCHD(-)patientsovertheageof60,cTnTwasabovetheURLinmorethan50%ofthecases(0.059±0.042µg/l)Ascomparedto28%inthepatients≦60years(0.032±0.029µg/l)中华医生网收集http://www.doctor-cn.net/Figure4CorrelationbetweencTnIplasmalevelsandageintheCHD(–)andCHD(+)patients.(–·–·–·–·:upperreferencelimit;–––––:limitforAMI).中华医生网收集http://www.doctor-cn.net/Figure5ComparisonofmeanplasmacTnTandcTnIlevelsinCHD(–)andCHD(+)patients.60and>60years(–·–·–·–·:up-perreferencelimit;–––––:limitforAMI).CHD(–),CHD(+).Figure5cTnIageover60yearsintheCHD(–)group:0.0190.018ug/lage<60yearsintheCHD(+)group:0.0490.054ug/l中华医生网收集http://www.doctor-cn.net/Discussion1AlthoughcTnTandcTnIelevationwithageseemstobeparallelinCRFpatientsandtheirplasmalevelsarecorrelated,therearequantitativedifferencesbetweenthetwomarkers:intheCHD(–)group,themeancTnTlevelsarealreadyclosetotheURLintheyoungestpatientsandlargelyexceedthislimitinthepatientsagedabove60yearsThesamedissimilaritybetweenthetwotroponinswasalsoobservedintheCHD(+)patients:theaveragecTnTconcentrationswereabovethecut-offlevelforAMIinallageclasses,whilecTnIremainedbelowtheURL中华医生网收集http://www.doctor-cn.net/Forexample,RicchiutiV.(17)1998InmoststudiescomparingcTnTtoCK-MBand/orcTnIinchronichemodialysispatients,cTnTshowedmorefrequentelevationabovecut-offthanCK-MBandcTnIForexample,Frankeletal.(18)1996reportedthatcTnTwaselevatedin71%of28CRFpatientswithoutchestpainorAMIundergoinghemodialysis,whereasonlyone(2.6%)hadCK-MBabovecut-off.中华医生网收集http://www.doctor-cn.net/ForexampleHafneretal.(19)1994foundanelevatedcTnTin31samples(46.3%),anelevatedCKMBinnine(13.4%)andcTnI,usingacut-offof2.2µg/linonepatientonly(1.5%)ForexampleWillgingS(20)1998themostfrequentcTnTelevations(54%)wereseeninthe22patientsonlong-termhemodialysis(>1year);inthesepatientsnoindividualhadcTnIvalueabovecut-off(2.0µg/l)andCK-MBelevationwasrecordedinonepatientonly(4.5%).中华医生网收集http://www.doctor-cn.net/Forexample,Mussoetal.(21)1999WealsofoundasubstantialproportionofcTnTresults(21.6%)abovethecut-offconcentrationforAMIintheCHD(–)renalpatientsIncontrast,nopatienthadcTnIabovethethresholdvalueforAMIinthisgroup.FiftypercentoftheCHD(–)patientshadcTnTlevelsabovetheURL中华医生网收集http://www.doctor-cn.net/Discussion2cTnIfailedtodiscriminatebetweentheabsenceandpresenceofCHDintheeldestpatientsForthesamereason,differencesincTnTbetweenpatientswithandwithoutcoronaryeventstendedtobelessimportantintheeldestindividuals.中华医生网收集http://www.doctor-cn.net/Discussion3Inconclusion,uremicconditionsinCRFpatientsinducemodificationsinplasmalevelsofcardiactroponins,andadvancedageappearstoamplifythesechanges.TheconsequenceisthattheprobabilityofpositivecTnTandcTnIresultsincreasesinpatientsaged≧60years,evenintheabsenceofclinicalsymptomsofCHD.BothcTnTandcTnIarequalitativelyaffectedbytheseconditions,butthechangesincTnTinrelationtotheURLarequantitativelymoreimportant.中华医生网收集http://www.doctor-cn.net/Discussion4Subclinicalmyocardiallesioncouldalsoberesponsiblefortheelevationofcardiacmarkersintheblood.Thesemorphologicchangesorlesionsareprobablymorefrequentintheeldestrenalpatients,explainingtherelationshipbetweentroponinelevationandage.中华医生网收集http://www.doctor-cn.net/中华医生网收集http://www.doctor-cn.net/