急性心肌梗塞AMI

按一下以編輯母片標題樣式,按一下以編輯母片本文樣式,第二階層,第三階層,第四階層,第五階層,*,Comparison of Plasma Cardiac Troponins T an I in Chronically,Hemodialyzed Patients in Relation to Cardiac Status and Age,Clin Chem Lab Med 2002; 40(3):240245, 2002 by Walter de Gruyter Berlin New York,Speaker: 劉秋菁,中华医生网收集,1,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,2,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,3,中华医生网收集,4,有用的心臟標記,Troponin T,Troponin I,Myoglobin,CK,CK-MB,CK-MB Isoforms,LDH,Early detectionof AMI,Used to,detect AMI,Elevated,in 3-4 hours,Cardiacspecific,Elevatedafter 10 days,DetectsMMD,Risk stratifi-,cation in UAP,Prognosticvalue,POCTnT7.e,中华医生网收集,5,中华医生网收集,6,AMI,血清標記,0.1 ng/ml,1 - 6 h,10 - 24 h,5 - 14 d,因方法,不同而異,3 - 6 h,18 - 20 h,5 - 7 d, 1.5,1 - 6 h,4 - 8 h,1 - 2 d,5 - 10 ng/ml,10 - 25 U/l,3 - 6 h,12 - 24 h,2 - 3 d, 6 %,60 - 80 ng/ml,1 - 2 h,6 - 12 h,0.5 - 1.5 d,參考範圍,開始上昇,高峰期,回復正常,TnT,TnI,Myoglobin,CK-MB,Isoforms,MB,2,/MB,1,CK-MB/CK,POCTnT3.e,中华医生网收集,7,中华医生网收集,8,Troponins Complex,Troponin,I,具有抑制,acitin,-myosin,ATPase,的作用,(,具心肌專一性,),Troponin,C,負責與,Ca,離子的結合,(,不具心肌專一性,),Troponin,T,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,),Troponins,Complex,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,9,SUMMARY,Introduction,Patients,Materials,and,Methods,Results,Discussion,中华医生网收集,10,Introduction,there is a lack of correlation between the two markers in,CRF patients and it has been suggested that the discreancies,may be due to greater sensitivity of the cTnT assay compared,to the cTnI assay,The clinical value of cardiac troponin I (cTnI) and troponin T (cTnT) in patients with chronic renal failure (CRF) remains,however a subject of debate.,Many investigators have reported that cTnT may be elevated,in CRF patients in the absence of ischemic heart disease.,False elevations of cTnI are more controversial: some studies,have demonstrated an advantage of cTnI over cTnT in renal,insufficiency, but there are recent indications of cTnI elevations,in CRF patients without ischemic heart disease,中华医生网收集,11,Abbreviations,:,AMI, acute myocardial infarction,CHD,coronary heart disease,CRF, chronic renal failure,cTnI, cardiac troponin I,cTnT, cardiac troponin T,hs CRP, high sensitivity C-reactive protein,Stratus CS, Stratus Cardiac System,URL, upper reference limit,中华医生网收集,12,Patients,The mean age of the patients was 60.114.8 years,(range: 2388 years),The length of dialysis averaged 7.2 years,(SD: 7.1, range: 130 years),49位 patients-CHD(+)group,48位patients-CHD(-)group,n=97 CRF patients,中华医生网收集,13,Sample Collected,The patients were followed during a period of 9 months and,blood samples were taken at 3-month intervals,(T1, T2, T3 andT4),Samples were obtained before the first dialysis of the week,to avoid possible changes in troponin levels during dialysis,Venous blood was collected immediately before dialysis,and tubes were centrifuged (5 min at 1000,g,) upon arrival,in the laboratory,14,cTnT,cTnT was determined by third generation immunoassay Using,Elecsys analyzer (Roche Diagnostics,Mannheim,Germany),Sample tube-EDTA-plasma,Principle: This assay uses two monoclonal antibodies,specifically directed against human cTnT,The detection limit is 0.01 g/l.,The upper reference limit (URL) is 0.04 g/l,Acute myocardial infarction (AMI) is 0.1g/l.,中华医生网收集,15,cTnI,cTnI was a two-site fluorimetric immunoassay using the Stratus Cardiac System (Stratus C; Dade Behring S.A., Paris),Sample tube-Lithium heparin,Principle: two monoclonal antibodies recognizing both free,and complexed cTnI,The detection limit is (0.01 g/l),The URL is 0.08 g/l,The cut-off value for AMI is 0.4 g/l (package insert).,中华医生网收集,16,17,Figure 1,Comparison of percentages of cTnT elevations above URL (0.04 g/l) and treshold limits,for AMI (0.1 and 0.2 l) in CHD() and CHD(+) CRF patients. Percentages are given at each,measurement time (T1 to T4). T1, T2, T3, T4.,18,Figure 1,cTnT in CHD(-) patients,1.above the URL of 0.04 g/l (up to 48.6% ),2. above the cut-off for AMI 0.1ug/l (21.6% ),3. Over 0.2ug/l(2.7%),24 patients (50%) had plasma levels 60 years (: up-per,reference limit; : limit for AMI). CHD(), CHD(+).,26,Figure 5,cTnI,age over 60 years,in the CHD() group :0.019,0.018ug/l,age 1 year); in these patients no individual had cTnI value above cut-off (2.0 g/l) and CK-MB elevation was recorded in one patient only (4.5%).,中华医生网收集,30,For example,Musso et al.(21) 1999,We also found a substantial proportion of cTnT results( 21.6%) above the cut-off concentration for AMI in the CHD() renal patients,In contrast, no patient had cTnI above the threshold value for AMI in this group. Fifty percent of the CHD() patients had cTnT levels above the URL,中华医生网收集,31,Discussion 2,cTnI,failed to discriminate between the absence and presence,of CHD in the eldest patients,For the same reason, differences in,cTnT,between patients,with and without coronary events tended to be less,important in the eldest individuals.,中华医生网收集,32,Discussion 3,In conclusion, uremic conditions in CRF patients induce,modifications in plasma levels of cardiac troponins,and advanced age appears to amplify these changes.,The consequence is that the probability of positive cTnT,and cTnI results increases in patients aged,60 years,even in the absence of clinical symptoms of CHD.,Both cTnT and cTnI are qualitatively affected by these,conditions, but the changes in cTnT in relation to the URL,are quantitatively more important.,中华医生网收集,33,Discussion 4,Subclinical myocardial lesion could also be responsible for,the elevation of cardiac markers in the blood.,These morphologic changes or lesions are probably,more frequent in the eldest renal patients,explaining the,relationship between troponin elevation and age,.,中华医生网收集,34,中华医生网收集,35,