O valor da troponina de alta sensibilidade na exclusão de síndrome coronariana aguda na sala de emergência
O valor da troponina de alta sensibilidade na exclusão de síndrome coronariana aguda na sala de emergência
Data
2018
Autores
Dutra, Ana Amaral Ferreira
Journal Title
Journal ISSN
Volume Title
Publisher
Instituto Nacional de Cardiologia
Resumo
Introdução: A grande procura pelas Unidade de Emergência (UE) por sintomas de síndrome coronariana aguda (SCA) e a falta de uniformidade de estratificação de risco coronariano estimulam a busca de um biomarcador de rápida e segura execução, para se poder liberar os pacientes para o domicílio. Objetivo: Mostrar a utilidade da Troponina de alta sensibilidade (TnT-Hs) na tomada de decisão clínica na liberação precoce de pacientes com suspeita de SCA na UE, avaliar a associação entre a TnT-Hs e a Troponina Convencional (Tc), além de demostrar a acurácia diagnóstica da TnT-Hs para SCA sem supra do segmento ST ( SCA SSST). Metodologia: Foram incluídos pacientes admitidos em uma UE, com suspeita diagnóstica de SCA, no período de março a outubro de 2016. Houve estratificação de risco por meio de rotas institucionais de avaliação de dor torácica, já vigentes nesse setor. Foi acrescentada a realização de exames de TnT-Hs (SIEMENS®) conforme protocolo desenhado para esse estudo. Avaliou-se a associação do resultado negativo da TnT-Hs com a liberação dos pacientes pelo protocolo institucional, a concordância com os valores da Tc, assim como a acurácia diagnóstica para SCA desse biomarcador. Foram também testados protocolos validados na Europa como o sugerido pela Sociedade Européia de Cardiologia e o do BACC Trial na presente população. Para a análise estatística das variáveis categóricas foi feita a associação através de teste de Qui-Quadrado ou Teste Exato de Fisher, e as variáveis numéricas foram comparadas a partir da ANOVA ou Kruskal- Wallis. Resultados: Foram avaliados 208 pacientes consecutivos, com idade média de 62,5 anos, sendo 52,2% do sexo masculino, 56,7% eram hipertensos, 20,1% diabéticos, 25,9% portadores de doença arterial coronariana (DAC), 24,7% dislipidêmicos, 12,5% história familiar positiva para DAC, 9,6% obesos, 6% tabagistas, 7% ex tabagistas, 7,6% já submetidos da revascularização miocárdica cirúrgica e 18,2% submetidos a angioplastia percutânea. A mediana do escore de risco GRACE foi de 96 (73-122) e a mediana do escore TIMI RISK foi de 1 (0-2). A correlação entre as troponinas ( TC e TnT-Hs) foi moderada tanto na rota 2 acelerada ( 2a) quanto na 2 convencional ( 2c) na admissão (0,52 com valor de p=0,000541 e 0,40 com valor de p= 0,000091). A acurácia diagnóstica da TnT-Hs nas rotas 2a e 2c foi testada tanto em 1 hora (T1) como em 3 horas (T3) da admissão, tendo especificidade de 96,8% e sensibilidade de 71,4% para rota 2a no T1, especificidade de 70% e sensibilidade de 80% para rota 2c também no T1. Para a terceira hora, na rota 2a apresentou especificidade de 96,7% com sensibilidade de 71,4% e na rota 2c os valores encontrados foram de 60,9% de especificidade e 86,7% de sensibilidade. Quando aplicados o protocolo sugerido pela ESC e pelo BACC na população do presente estudo, observa-se um número elevado de pacientes ficaram na zona de observação (60% e 82,9%), quanto a internação seriam 14,4% e 11,2%, e em relação a liberação seriam 28,7% e 6% respectivamente. Quando foi aplicado o novo fluxograma proposto, obteve-se um alto percentual de liberação precoce 86,8% e 13,1% foram internados. Conclusão: A utilização da TnT-Hs permite uma liberação precoce dos paciente admitidos na UE quando comparado com o protocolo institucional vigente. Há uma associação de correlação moderada entre a TnT-Hs e a Tc. A TnT-Hs mostrou ter uma acurácia boa diagnóstica especialmente na rota 2a.
Introduction: The great demand by the Emergency Unit (EU) for symptoms of acute coronary syndrome (ACS) and the lack of uniformity of stratification of coronary risk, stimulates the search for a biomarker of fast and safe execution in order to be able to release the patients to home. Objectives: To show the utility of high-sensitivity Troponin (TnT-Hs) in clinical decision-making in the early release of patients with suspected ACS in the EU, to assess the association between TnT-Hs and Conventional Troponin (Tc) in addition to demonstrating the accuracy Diagnosis of TnT-Hs for ACS. Methods: Patients admitted to an EU with diagnostic suspicion of ACS were included in the period from March to October 2016. There was a risk stratification by means of institutional routes for the evaluation of chest pain, already in force in this sector. The collection of TnT-Hs exams (SIEMENS®) was added according to the protocol designed for this study. The association of negative TnT-Hs result with the release of the patients, by institutional protocol, the concordance with the Tc values, as well as the diagnostic accuracy for the ACS of this biomarker were evaluated. Validated protocols in Europe were also tested as suggested by the European Society of Cardiology and the BACC Trial in the present population. For the statistical analysis of the categorical variables, the association was made through Chi-square test or Fisher's exact test, and the numerical variables were compared using ANOVA or Kruskal-Wallis. Results: A total of 208 consecutive patients, with a mean age of 62.5 years, 52.2% were male, 56.7% were hypertensive, 20.1% were diabetics, 25.9% had coronary artery disease, 24.7% had dyslipidemic, 12.5% had a positive family history for CAD, 9.6% had obese, 6% had smokers, 7% had ex-smokers, 7.6% had undergone surgical myocardial revascularization, and 18.2% underwent percutaneous angioplasty . The median GRACE risk score was 96 (73-122) and the median TIMI RISK score was 1 (0-2). The correlation between the troponins (TC and TnT-Hs) was moderate in both accelerated route 2 (2a) and conventional 2 (2c) on admission (0.52 with p value = 0.000541 and 0.40 with value of P = 0.000091). The diagnostic accuracy of TnTHs on routes 2a and 2c was tested in both 1 hour (T1) and 3 hours (T3) of admission, with specificity of 96.8% and sensitivity of 71.4% for route 2a in T1 , Specificity of 70% and sensitivity of 80% for route 2c also in T1. For the third hour, route 2a presented specificity of 96.7% with sensitivity of 71.4% and in route 2c the values found were 60.9% of specificity and 86.7% of sensitivity. When the protocol suggested by ESC and BACC was applied in the population of the present study, a large number of patients were observed in the observation zone (60% and 82.9%), in relation to hospitalization was 14.4% and 11, 2%, and in relation to the release would be 28.7% and 6% respectively. When the new flowchart proposed was applied, a high percentage of early release was obtained, 86.8% and 13.1% were hospitalized. Conclusions: The use of TnT-Hs allows an early release of patients admitted to the EU when compared to the current institutional protocol. There is a moderate correlation between TnT-Hs and Tc. TnT-Hs has been shown to have good diagnostic accuracy especially on Route 2a.
Introduction: The great demand by the Emergency Unit (EU) for symptoms of acute coronary syndrome (ACS) and the lack of uniformity of stratification of coronary risk, stimulates the search for a biomarker of fast and safe execution in order to be able to release the patients to home. Objectives: To show the utility of high-sensitivity Troponin (TnT-Hs) in clinical decision-making in the early release of patients with suspected ACS in the EU, to assess the association between TnT-Hs and Conventional Troponin (Tc) in addition to demonstrating the accuracy Diagnosis of TnT-Hs for ACS. Methods: Patients admitted to an EU with diagnostic suspicion of ACS were included in the period from March to October 2016. There was a risk stratification by means of institutional routes for the evaluation of chest pain, already in force in this sector. The collection of TnT-Hs exams (SIEMENS®) was added according to the protocol designed for this study. The association of negative TnT-Hs result with the release of the patients, by institutional protocol, the concordance with the Tc values, as well as the diagnostic accuracy for the ACS of this biomarker were evaluated. Validated protocols in Europe were also tested as suggested by the European Society of Cardiology and the BACC Trial in the present population. For the statistical analysis of the categorical variables, the association was made through Chi-square test or Fisher's exact test, and the numerical variables were compared using ANOVA or Kruskal-Wallis. Results: A total of 208 consecutive patients, with a mean age of 62.5 years, 52.2% were male, 56.7% were hypertensive, 20.1% were diabetics, 25.9% had coronary artery disease, 24.7% had dyslipidemic, 12.5% had a positive family history for CAD, 9.6% had obese, 6% had smokers, 7% had ex-smokers, 7.6% had undergone surgical myocardial revascularization, and 18.2% underwent percutaneous angioplasty . The median GRACE risk score was 96 (73-122) and the median TIMI RISK score was 1 (0-2). The correlation between the troponins (TC and TnT-Hs) was moderate in both accelerated route 2 (2a) and conventional 2 (2c) on admission (0.52 with p value = 0.000541 and 0.40 with value of P = 0.000091). The diagnostic accuracy of TnTHs on routes 2a and 2c was tested in both 1 hour (T1) and 3 hours (T3) of admission, with specificity of 96.8% and sensitivity of 71.4% for route 2a in T1 , Specificity of 70% and sensitivity of 80% for route 2c also in T1. For the third hour, route 2a presented specificity of 96.7% with sensitivity of 71.4% and in route 2c the values found were 60.9% of specificity and 86.7% of sensitivity. When the protocol suggested by ESC and BACC was applied in the population of the present study, a large number of patients were observed in the observation zone (60% and 82.9%), in relation to hospitalization was 14.4% and 11, 2%, and in relation to the release would be 28.7% and 6% respectively. When the new flowchart proposed was applied, a high percentage of early release was obtained, 86.8% and 13.1% were hospitalized. Conclusions: The use of TnT-Hs allows an early release of patients admitted to the EU when compared to the current institutional protocol. There is a moderate correlation between TnT-Hs and Tc. TnT-Hs has been shown to have good diagnostic accuracy especially on Route 2a.
Description
Palavras-chave
Infarto agudo do miocárdio, Síndrome coronariana aguda, Unidades de dor torácica, Troponina de alta sensibilidade, Liberação precoce, Myocardial infarction, Acute coronary syndrome, Chest pain units, Troponin with high sensitivity, Early release
Citação
Dutra AAF. O valor da troponina de alta sensibilidade na exclusão de síndrome coronariana aguda na sala de emergência. Rio de Janeiro. Dissertação [Mestrado Profissional em Ciências Cardiovasculares] - Instituto Nacional de Cardiologia; 2017