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1、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中华医生网收集http:/www.doctor- WHO 急性心肌梗塞急性心肌梗塞（AMIAMI）的黃金準則的黃金準則 患者患者胸痛的病史胸痛的病史最少持續最少持
2、續3030分鐘分鐘心電圖心電圖單一階段單一階段 ST 上昇上昇而且其後出現而且其後出現 Q 波波檢驗室檢驗室特有的酵素活性特有的酵素活性(CK, CK-MB, LDH)POCTnT1.e中华医生网收集中华医生网收集http:/www.doctor- WHO 準則的缺點準則的缺點AMI 患者中患者中約有約有1/31/3為非典型為非典型或沒有胸痛或沒有胸痛約有約有50% AMI 患者患者早期早期ECG無診斷特徵無診斷特徵約有約有20% AMI 患者患者晚期晚期ECG會診斷失誤會診斷失誤由於其他症狀導致由於其他症狀導致敏感性及特異性降低敏感性及特異性降低一般的血清標記一般的血清標記特異性不高特異性不
3、高(CK, LDH 和異構物和異構物)CK 和和 LDH也存在於正常人血中也存在於正常人血中患者病史患者病史ECG 變化變化血清標記血清標記POCTnT2.e中华医生网收集中华医生网收集http:/www.doctor- TTroponin IMyoglobinCKCK-MBCK-MB IsoformsLDHEarly detectionof AMIUsed to detect AMIElevatedin 3-4 hoursCardiacspecificElevatedafter 10 daysDetectsMMDRisk stratifi-cation in UAPPrognosticval
4、uePOCTnT7.e中华医生网收集中华医生网收集http:/www.doctor- AMI 血清標記血清標記 0.1 ng/ml1 - 6 h10 - 24 h5 - 14 d因方法因方法不同而異不同而異3 - 6 h18 - 20 h5 - 7 d 1.51 - 6 h4 - 8 h1 - 2 d5 - 10 ng/ml10 - 25 U/l3 - 6 h12 - 24 h2 - 3 d 6 %60 - 80 ng/ml1 - 2 h6 - 12 h0.5 - 1.5 d參考範圍參考範圍開始上昇開始上昇高峰期高峰期回復正常回復正常TnTTnIMyoglobinCK-MBIsoformsMB
5、2/MB1CK-MB/CKPOCTnT3.e中华医生网收集中华医生网收集http:/www.doctor- Complexn nTroponinTroponin I I 具有抑制具有抑制acitinacitin-myosin -myosin ATPaseATPase 的作用的作用( (具心肌專一性具心肌專一性) ) TroponinTroponin C C 負責與負責與CaCa離子的結合離子的結合 ( (不具心肌專一性不具心肌專一性) ) TroponinTroponin T T 是將是將TnITnI與與TnCTnC的結合訊息傳的結合訊息傳 遞至其它調節收縮蛋白遞至其它調節收縮蛋白 ( (具心
6、肌專一性具心肌專一性) ) TroponinsTroponins Complex Complex 在心肌及骨骼肌中扮演在心肌及骨骼肌中扮演 調節肌肉收縮的重要角色調節肌肉收縮的重要角色中华医生网收集中华医生网收集http:/www.doctor- SUMMARY Introduction Patients Materials and Methods Results Discussion中华医生网收集中华医生网收集http:/www.doctor- Introduction there is a lack of correlation between the two markers in CRF
7、 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 inves
8、tigators 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
9、patients without ischemic heart disease中华医生网收集中华医生网收集http:/www.doctor- 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 re
10、ference limit 中华医生网收集中华医生网收集http:/www.doctor- PatientsThe 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中华医生网收集中华医生网收集http:/www.doctor- Sample Col
11、lected 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 di
12、alysis and tubes were centrifuged (5 min at 1000 g) upon arrival in the laboratory 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 ag
13、ainst 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.中华医生网收集中华医生网收集http:/www.doctor- cTnI cTnI was a two-site fluorimetric immunoassay using the Stratus Cardiac System (Stratus C; Dade Behring S.A., Paris) Sample tu
14、be-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). 中华医生网收集中华医生网收集http:/www.doctor- 1 Comparison of percentages of cTnT elevations above URL (0.04
15、 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. 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
16、%) 24 patients (50%) had plasma levels 60 years (: up-perreference limit; : limit for AMI). CHD(), CHD(+). Figure 5cTnI age over 60 years in the CHD() group :0.0190.018ug/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 pat
17、ient only (4.5%). 中华医生网收集中华医生网收集http:/www.doctor- 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 patientsIn contrast, no patient had cTnI above the threshold value for AMI in this group. Fift
18、y percent of the CHD() patients had cTnT levels above the URL中华医生网收集中华医生网收集http:/www.doctor- 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
19、 less important in the eldest individuals.中华医生网收集中华医生网收集http:/www.doctor- 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 c
20、TnT 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.中华医生网收集中华医生网收集http:/www.doctor- Discussion 4Subclinical 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.中华医生网收集中华医生网收集http:/www.doctor-
