床旁肌钙蛋白在急诊非ST段抬高型胸痛患者早期危险分层中的价值

Value of Point-of-Care Cardiac Troponin in Early Risk Stratification of Emergency Patients with Non-ST-Segment Elevation Chest Pain

摘要: 目的：探讨床旁心肌肌钙蛋白T (point-of-care cardiac troponin T, POCT cTnT)定性检测在急诊非ST段抬高型胸痛患者早期危险分层中的应用价值。方法：回顾性收集2023年1月~2026年7月珠海市中西医结合医院急诊科就诊、最终诊断为非ST段抬高型心肌梗死(non-ST-segment elevation myocardial infarction, NSTEMI)的胸痛患者90例，入院后均行POCT cTnT定性检测、实验室高敏肌钙蛋白T(high-sensitivity cardiac troponin T, hs-cTnT)定量检测及GRACE危险评分，比较不同GRACE危险分层患者及POCT cTnT阳性与阴性患者的临床特征，采用Spearman相关分析及受试者工作特征(ROC)曲线评价肌钙蛋白检测在早期危险分层中的价值。30 d主要不良心血管事件(MACE)作为临床硬终点进行描述性分析。结果：90例患者中男75例(83.3%)，年龄(60.3 ± 15.0)岁；POCT cTnT阳性76例(87.4%)，检测周转时间为12 (8, 24) min。hs-cTnT水平随GRACE危险分层升高呈上升趋势[低危组127 (58, 296) ng/L、中危组136 (48, 224) ng/L、高危组192 (89, 945) ng/L，H = 5.638，P = 0.060]，与GRACE评分呈弱正相关(r = 0.199, P = 0.070)；POCT cTnT阳性组hs-cTnT水平显著高于阴性组[172 (84, 376)比40 (40, 40) ng/L，P < 0.001]，阴性组发病至就诊时间显著短于阳性组[1.7 (0.9, 4.1)比6.4 (2.1, 23.1) h, P = 0.031]。hs-cTnT预测GRACE高危的ROC曲线下面积为0.626 (95% CI 0.487~0.756)，最佳截断值为449 ng/L (灵敏度43.3%、特异度88.9%)；POCT cTnT阳性预测GRACE高危的灵敏度为86.7%、特异度为11.1%。高危组住院天数显著长于低危组和中危组(P = 0.012)，GRACE评分与住院天数呈正相关(r = 0.303, P = 0.007)。30 d MACE以紧急血运重建为主(78/81, 96.3%)，心源性死亡3例(3.7%)，无再发心肌梗死；因组分事件数有限，未行多变量Logistic回归。结论：床旁POCT cTnT检测快速便捷，对急诊非ST段抬高型胸痛患者心肌损伤具有良好的早期筛查价值，但其定性结果单独用于危险分层的价值有限；发病早期(<6 h)单次POCT cTnT阴性不能排除心肌损伤，临床应结合hs-cTnT定量水平及GRACE评分进行综合危险分层。其对30 d MACE的独立增量预测价值仍需事件数更充分的前瞻性研究验证。

Abstract: Objective: To investigate the value of point-of-care cardiac troponin T (POCT cTnT) qualitative testing in early risk stratification of emergency patients with non-ST-segment elevation chest pain. Methods: Clinical data of 90 patients with non-ST-segment elevation chest pain who were finally diagnosed as non-ST-segment elevation myocardial infarction (NSTEMI) in the Emergency Department of Zhuhai Hospital of Integrated Traditional Chinese and Western Medicine from January 2023 to July 2026 were retrospectively collected. POCT cTnT qualitative testing, laboratory high-sensitivity cardiac troponin T (hs-cTnT) quantitative testing and GRACE risk score were performed after admission. Clinical characteristics were compared among patients with different GRACE risk stratifications and between POCT cTnT-positive and POCT cTnT-negative patients. Spearman correlation analysis and receiver operating characteristic (ROC) curve were used to evaluate the value of troponin testing in early risk stratification. Thirty-day major adverse cardiovascular events (MACE) were recorded as the clinical hard endpoint and analyzed descriptively. Results: Of the 90 patients, 75 (83.3%) were male, with a mean age of (60.3 ± 15.0) years. POCT cTnT was positive in 76 cases (87.4%), with a turnaround time of 12 (8, 24) min. hs-cTnT levels showed an upward trend with increasing GRACE risk stratification [low-risk 127 (58, 296) ng/L, intermediate-risk 136 (48, 224) ng/L, high-risk 192 (89, 945) ng/L; H = 5.638, P = 0.060], and were weakly positively correlated with GRACE score (r = 0.199, P = 0.070). hs-cTnT levels in the POCT cTnT-positive group were significantly higher than those in the negative group [172 (84, 376) vs 40 (40, 40) ng/L, P < 0.001], and the time from symptom onset to admission in the negative group was significantly shorter than that in the positive group [1.7 (0.9, 4.1) vs 6.4 (2.1, 23.1) h, P = 0.031]. The area under the ROC curve of hs-cTnT for predicting GRACE high risk was 0.626 (95% CI 0.487~0.756), with an optimal cut-off value of 449 ng/L (sensitivity 43.3%, specificity 88.9%). The sensitivity and specificity of positive POCT cTnT for predicting GRACE high risk were 86.7% and 11.1%, respectively. The length of hospital stay in the high-risk group was significantly longer than that in the low- and intermediate-risk groups (P = 0.012), and GRACE score was positively correlated with the length of hospital stay (r = 0.303, P = 0.007). The 30-day MACE profile was dominated by urgent revascularization (78/81, 96.3%), with 3 cardiac deaths (3.7%) and no recurrent myocardial infarction; multivariable Logistic regression was not performed because component events were too few. Conclusion: POCT cTnT testing is rapid and convenient, and has good value for early screening of myocardial injury in emergency patients with non-ST-segment elevation chest pain, but its qualitative result alone is of limited value for risk stratification. A single negative POCT cTnT result within 6 hours of symptom onset cannot exclude myocardial injury, and comprehensive risk stratification combining hs-cTnT quantification and GRACE score is recommended. The independent incremental prognostic value for 30-day MACE requires validation in prospective studies with adequate events.