PERFORMANCE OF MULTIPLE CARDIAC BIOMARKERS MEASURED
IN THE EMERGENCY DEPARTMENT IN PATIENTS WITH CHRONIC KIDNEY DISEASE AND CHEST
PAIN.
McCullough PA, et al. Acad Emerg Med 2002 Dec;9(12):1389-96.
OBJECTIVE: To evaluate the individual components of a cardiac multimarker panel
in the detection of acute myocardial infarction (AMI) in patients with chest
pain across a spectrum of renal dysfunction.
METHODS: A total of 817 consecutive patients
evaluated for a possible AMI in the emergency department (ED) enrolled in a
prospective study of cardiac biomarkers assessed using a point-of-care device
with myoglobin (MYO), cardiac troponin I (cTnI), and creatine kinase myocardial
band (CK-MB), recorded at 0, 1.5, 3, and 9 hours. This study did not exclude
patients on the basis of renal dysfunction. Baseline renal function was
available in 808 patients. Patients were stratified by corrected creatinine
clearance (CorrCrCl) into quartiles, and those on dialysis (n = 51) were
considered as a fifth comparison group. Those patients with advanced renal
dysfunction (CorrCrCl < 47/mL/min/72 kg) or on dialysis had higher rates of
diabetes, hypertension, and prior coronary disease. Agreement for the diagnosis
of AMI was required of two independent cardiologists using criteria based on
history, electrocardiogram, and central laboratory assessment of serial cardiac
markers.
RESULTS: More than 99% of all patients were admitted
to a chest pain observation unit or the hospital. Mean MYO levels were elevated
in the presence of renal dysfunction in those with and without myocardial
infarction. Both MYO and CK-MB were correlated with CorrCrCl, (r = -0.36, p
< 0.01, and r = -0.10, p = 0.01, respectively), while cTnI was not (r =
-0.10, p = 0.12). Using multiple receiveer operating characteristic curve
testing, cTnI was found to be the most consistent marker across all strata of
renal dysfunction, including end-stage renal disease on dialysis. The authors
did not find a trend for false-positive cTnI and renal dysfunction.
CONCLUSIONS: A point-of-care, rapid cardiac
biomarker strategy utilizing cTnI is applicable and superior to MYO or CK-MB in
the evaluation of chest pain in patients with renal dysfunction.