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D-Dimer檢測可提供早期診斷冠狀動脈缺血的額外信息，顯著提高心絞痛患者的診斷準確性。此項研究證明，D-Dimer水平高於500 μg/L能有效預測心肌梗死，對急診中心的臨床決策模型具有重大價值。
D -Dimer is an early diagnostic marker of coronary ischemia in patients with chest pain
D-二聚體是胸痛患者冠狀動脈缺血的早期診斷標誌物。
Antoni Bayes-Genis MD, PhDa，Jose Mateo MDb，Miquel Santaló MDc，Artur Oliver MDd，Josep Guindo MDa，Lina Badimon PhDa，Antoni Martínez-Rubio MD, PhDa，Jordi Fontcuberta MD, PhDb，Robert S. Schwartz MDe，Antoni Bayés de Luna MD, PhDa，Barcelona, Spain, and Rochester, Minn
From the Departments of aCardiology and Cardiac Surgery, bHematology, and the cEmergency Department, Hospital de la Santa Creu I Sant Pau, Barcelona; the dHematology Unit, Fundació Puigvert, Barcelona; and the eDivision of Cardiovascular Diseases and Internal Medicine, Mayo Clinic, Rochester
Abstract
Background Chest pain is a frequent symptom in the emergency department and often presents a diagnostic challenge. Because coronary thrombosis is a hallmark of acute ischemic syndromes, the substrates of the coagulation and fibrinolysis cascades may be markers of coronary ischemia. The objective of this study was to determine the diagnostic value of several hemostatic markers in patients presenting to the emergency department (ED) with chest pain syndromes. Methods Two hundred fifty-seven consecutive patients with acute chest pain were studied in this prospective study conducted in an urban ED. D- Dimer levels were measured at admission to the ED in all patients. We also measured thrombin-antithrombin complexes, prothrombin fragment 1+2, activated factor VII, and fibrinogen. We used regression analysis to estimate the likelihood of myocardial infarction and the diagnostic value of D -dimer. Results D -Dimer and fibrinogen levels were significantly higher in patients with acute ischemic events (myocardial infarction and unstable angina) than in nonischemic patients (P <.01 and P =.02, respectively). The other hemostatic markers were not significantly elevated in patients with ischemic events. D -Dimer level >500 μg/L had an independent diagnostic value for myocardial infarction and increased the diagnostic sensitivity of the electrocardiogram and history from 73% to 92%. Conclusion D -Dimer, an expression of ongoing thrombus formation and lysis, is a marker of substantial incremental value for the early diagnosis of acute coronary syndromes presenting with chest pain. It adds independent information to the traditional assessment for myocardial infarction. D -Dimer can be incorporated into clinical decision models in the ED. (Am Heart J 2000;140:379-84.)
摘要
背景 胸痛是急診室常見的症狀，通常構成診斷挑戰。由於冠狀動脈血栓形成是急性缺血綜合症的標誌，凝血和纖維蛋白溶解途徑的基質可能是冠狀動脈缺血的標誌物。本研究的目的是確定多種止血標誌物在急診室（ED）出現胸痛症狀患者中的診斷價值。
方法 這項前瞻性研究在都市急診室進行，研究了 257 名連續的急性胸痛患者。所有患者在入院時測量了 D-二聚體水平。我們還測量了凝血酶-抗凝血酶複合物、凝血酶原片段 1+2、活化第 VII 因子和纖維蛋白原。我們使用回歸分析來估計心肌梗塞的可能性以及 D-二聚體的診斷價值。
結果 D-二聚體和纖維蛋白原水平在急性缺血事件（心肌梗塞和不穩定型心絞痛）患者中顯著高於非缺血性患者（分別為 P <.01 和 P =.02）。其他止血標誌物在缺血性事件患者中無顯著升高。D-二聚體水平 >500 μg/L 對心肌梗塞具有獨立診斷價值，並將心電圖和病史的診斷敏感性從 73% 提高至 92%。
結論 D-二聚體，作為持續血栓形成和溶解的表現，是早期診斷以胸痛表現的急性冠狀動脈綜合症的重要標誌物，為心肌梗塞的傳統評估提供了獨立的資訊。D-二聚體可納入急診室的臨床決策模型中。
部分摘錄
方法
這項前瞻性研究於1996年9月15日至1997年1月18日期間，在某教學醫院的急診室招募了300名連續入院的急性胸痛患者。所有患者年齡均在25歲或以上，並以中央或左側胸痛為主要症狀來到急診室。僅症狀發作少於6小時的患者符合參加研究的資格。所有患者均獲得知情同意，研究方案亦經當地倫理委員會批准。
當值醫師負責進行病史記錄…
結果
162名患者（63%）被診斷為非缺血性胸痛，原因包括：肌肉骨骼疼痛（n = 79）、焦慮（n = 50）、胃腸源性疼痛（n = 15）、心律失常（房撲和房顫）（n = 10）、心包炎（n = 2）、氣胸（n = 2）、肺栓塞（n = 1）、支氣管哮喘（n = 1）、肺炎（n = 1）、及蕁麻疹（n = 1）。
58名患者（23%）被診斷為不穩定型心絞痛（UA），37名患者（14%）發展為心肌梗塞（MI）。其中21名患者（57%）…
討論
這些結果表明，D-二聚體測量可改善臨床決策模型，促進風險分層。我們發現心肌梗塞（MI）和不穩定型心絞痛（UA）患者的D-二聚體水平顯著增加。我們的研究還提供了一個臨床上有用的心肌梗塞D-二聚體閾值（>500 μg/L），該閾值補充了急診室中的傳統診斷，將心肌梗塞的診斷敏感性從73%提高到92%。TAT、F1+2和活化的第VII因子對患者的診斷無附加資訊…
致謝
我們感謝急診團隊的支持。同時感謝Rosa Felices女士的技術協助，並感謝J. Soler博士的批判性審查。
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