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Troponin Cut-Offs for Acute Myocardial Infarction in Patients with Impaired Renal Function—A Systematic Review and Meta-Analysis. Diagnostics (Basel) 2022; 12:diagnostics12020276. [PMID: 35204367 PMCID: PMC8871519 DOI: 10.3390/diagnostics12020276] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Revised: 01/14/2022] [Accepted: 01/19/2022] [Indexed: 11/27/2022] Open
Abstract
Identifying acute myocardial infarction in patients with renal disease is notoriously difficult, due to atypical presentation and chronically elevated troponin. The aim of this study was to identify a specific troponin T/troponin I cut-off value for diagnosis of acute myocardial infarction in patients with renal impairment via meta-analysis. Two investigators screened 2590 publications from MEDLINE, Embase, PubMed, Web of Science, and the Cochrane library. Only studies that investigated alternative cut-offs according to renal impairment were included. Fifteen articles fulfilled the inclusion criteria. Six studies were combined for meta-analysis. The manufacturer’s upper reference level for troponin T is 14 ng/L. Based on the meta-analyses, cut-off values for troponin in patients with renal impairment with myocardial infarction was 42 ng/L for troponin I and 48 ng/L for troponin T. For patients on dialysis the troponin T cut-off is even higher at 239 ng/L. A troponin I cut-off value for dialysis patients could not be established due to lack of data. The 15 studies analyzed showed considerable diversity in study design, study population, and the definition of myocardial infarction. Further studies are needed to define a reliable troponin cut-off value for patients with kidney disease, especially in dialysis patients, and to allow necessary subanalysis.
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ÖZBIÇER S, KALKAN G, URGUN ÖD, NEŞELİOĞLU S, EREL Ö. Ischemia modified albumin levels in distinguishing NSTEMI patients from non-ischemic controls and correlation with disease severity. CUKUROVA MEDICAL JOURNAL 2021. [DOI: 10.17826/cumj.976875] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
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53
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Clerico A, Zaninotto M, Aimo A, Dittadi R, Cosseddu D, Perrone M, Padoan A, Masotti S, Belloni L, Migliardi M, Fortunato A, Trenti T, Malloggi L, Cappelletti P, Galli GA, Bernardini S, Sciacovelli L, Plebani M. Use of high-sensitivity cardiac troponins in the emergency department for the early rule-in and rule-out of acute myocardial infarction without persistent ST-segment elevation (NSTEMI) in Italy. Clin Chem Lab Med 2021; 60:169-182. [PMID: 34927403 DOI: 10.1515/cclm-2021-1085] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Accepted: 11/26/2021] [Indexed: 12/15/2022]
Abstract
Serial measurements of cardiac troponin are recommended by international guidelines to diagnose myocardial infarction (MI) since 2000. However, some relevant differences exist between the three different international guidelines published between 2020 and 2021 for the management of patients with chest pain and no ST-segment elevation. In particular, there is no agreement on the cut-offs or absolute change values to diagnose non-ST-segment elevation MI (NSTEMI). Other controversial issues concern the diagnostic accuracy and cost-effectiveness of cut-off values for the most rapid algorithms (0 h/1 h or 0 h/2 h) to rule-in and rule-out NSTEMI. Finally, another important point is the possible differences between demographic and clinical characteristics of patients enrolled in multicenter trials compared to those routinely admitted to the Emergency Department in Italy. The Study Group of Cardiac Biomarkers, supported by the Italian Scientific Societies Società Italiana di Biochimica Clinica, Italian Society of the European Ligand Assay Society, and Società Italiana di Patolgia Clinica e Medicina di Laboratorio decided to revise the document previously published in 2013 about the management of patients with suspected NSTEMI, and to provide some suggestions for the use of these biomarkers in clinical practice, with a particular focus on the Italian setting.
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Affiliation(s)
- Aldo Clerico
- Fondazione CNR Regione Toscana G. Monasterio e Scuola Superiore Sant'Anna, Pisa, Italy
| | - Martina Zaninotto
- Department of Laboratory Medicine, University Hospital of Padova, Padova, Italy.,Department of Medicine-DIMED, University of Padova, Padova, Italy
| | - Alberto Aimo
- Fondazione CNR Regione Toscana G. Monasterio e Scuola Superiore Sant'Anna, Pisa, Italy
| | - Ruggero Dittadi
- Ospedale dell'Angelo ULSS 3 Serenissima, Laboratorio di Analisi Cliniche, Mestre, Italy
| | - Domenico Cosseddu
- S.C. Laboratorio Analisi, A.O. Ordine Mauriziano di Torino, Torino, Italy
| | - Marco Perrone
- Division of Cardiology and Clinical Biochemistry, University of Rome Tor Vergata, Rome, Italy
| | - Andrea Padoan
- Department of Laboratory Medicine, University Hospital of Padova, Padova, Italy
| | - Silvia Masotti
- Fondazione CNR Regione Toscana G. Monasterio e Scuola Superiore Sant'Anna, Pisa, Italy
| | - Lucia Belloni
- Dipartimento di Medicina di laboratorio, Arcispedale Santa Maria Nuova - IRCCS, Reggio Emilia, Italy
| | - Marco Migliardi
- S.C. Laboratorio Analisi, A.O. Ordine Mauriziano di Torino, Torino, Italy
| | | | - Tommaso Trenti
- Azienda Ospedaliero - Universitaria Policlinico di Modena c/o Ospedale Civile di Baggiovara, Modena, Italy
| | - Lucia Malloggi
- Laboratorio Analisi, Azienda Ospedaliera-Universitaria di Pisa, Pisa, Italy
| | | | | | - Sergio Bernardini
- Division of Cardiology and Clinical Biochemistry, University of Rome Tor Vergata, Rome, Italy
| | - Laura Sciacovelli
- Department of Laboratory Medicine, University Hospital of Padova, Padova, Italy
| | - Mario Plebani
- Department of Laboratory Medicine, University Hospital of Padova, Padova, Italy
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54
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(Overview and application of validated algorithms using high-sensitivity cardiac troponin assays for early diagnosis of acute myocardial infarction). COR ET VASA 2021. [DOI: 10.33678/cor.2021.064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Affiliation(s)
- Matthew T H Lowry
- BHF Centre for Cardiovascular Science, The University of Edinburgh, Edinburgh, UK
| | - Atul Anand
- BHF Centre for Cardiovascular Science, The University of Edinburgh, Edinburgh, UK
| | - Nicholas L Mills
- BHF Centre for Cardiovascular Science, The University of Edinburgh, Edinburgh, UK
- Usher Institute, The University of Edinburgh, Edinburgh, UK
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Gärtner C, Langhammer R, Schmidt M, Federbusch M, Wirkner K, Löffler M, Isermann B, Laufs U, Wachter R, Kaiser T. Revisited Upper Reference Limits for Highly Sensitive Cardiac Troponin T in Relation to Age, Sex, and Renal Function. J Clin Med 2021; 10:5508. [PMID: 34884210 PMCID: PMC8658212 DOI: 10.3390/jcm10235508] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Revised: 10/15/2021] [Accepted: 11/13/2021] [Indexed: 12/03/2022] Open
Abstract
(1) Background: Highly sensitive cardiac troponin T (hs-cTnT) plays an essential role in the diagnosis of myocardial injury. The upper reference limit of the respective assay is generally applied, irrespective of age, renal function, or sex. We aimed to identify age-adjusted and sex-adjusted upper reference limits in relation to renal function in a large population-based cohort without cardiac diseases. (2) Methods: We included 5428 subjects of the population-based LIFE-Adult cohort, free of diagnosed cardiac diseases. Sex-adjusted and age-adjusted 99th percentiles for hs-cTnT in subjects with preserved renal function were obtained. (3) Results: The hs-cTnT values were higher in men of all age groups. In both sexes, an increasing age positively correlated with higher hs-cTnT values. Hs-cTnT weakly correlated with serum creatinine. The three-dimensional analysis of age, creatinine, and hs-cTnT showed no relevant additional effect of creatinine on hs-cTnT. In men aged above 60 and women above 70, the calculated 99th percentiles clearly exceeded the commonly applied thresholds. (4) Conclusion: Age and sex have a major impact on the serum concentration of hs-cTnT, while renal function does not. We propose to consider age-adjusted and sex-adjusted reference values.
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Affiliation(s)
- Christiane Gärtner
- Institute for Laboratory Medicine, Clinical Chemistry and Molecular Diagnostics, University of Leipzig Medical Center and Medical Faculty, 04109 Leipzig, Germany; (C.G.); (M.S.); (M.F.); (B.I.)
| | - Romy Langhammer
- Clinic and Polyclinic for Cardiology, University of Leipzig Medical Center, 04103 Leipzig, Germany; (R.L.); (U.L.); (R.W.)
| | - Maria Schmidt
- Institute for Laboratory Medicine, Clinical Chemistry and Molecular Diagnostics, University of Leipzig Medical Center and Medical Faculty, 04109 Leipzig, Germany; (C.G.); (M.S.); (M.F.); (B.I.)
| | - Martin Federbusch
- Institute for Laboratory Medicine, Clinical Chemistry and Molecular Diagnostics, University of Leipzig Medical Center and Medical Faculty, 04109 Leipzig, Germany; (C.G.); (M.S.); (M.F.); (B.I.)
| | - Kerstin Wirkner
- LIFE—Leipzig Research Center for Civilization Diseases, University of Leipzig, 04109 Leipzig, Germany; (K.W.); (M.L.)
- Institute for Medical Informatics, Statistics, and Epidemiology (IMISE), University of Leipzig, 04109 Leipzig, Germany
| | - Markus Löffler
- LIFE—Leipzig Research Center for Civilization Diseases, University of Leipzig, 04109 Leipzig, Germany; (K.W.); (M.L.)
- Institute for Medical Informatics, Statistics, and Epidemiology (IMISE), University of Leipzig, 04109 Leipzig, Germany
| | - Berend Isermann
- Institute for Laboratory Medicine, Clinical Chemistry and Molecular Diagnostics, University of Leipzig Medical Center and Medical Faculty, 04109 Leipzig, Germany; (C.G.); (M.S.); (M.F.); (B.I.)
| | - Ulrich Laufs
- Clinic and Polyclinic for Cardiology, University of Leipzig Medical Center, 04103 Leipzig, Germany; (R.L.); (U.L.); (R.W.)
| | - Rolf Wachter
- Clinic and Polyclinic for Cardiology, University of Leipzig Medical Center, 04103 Leipzig, Germany; (R.L.); (U.L.); (R.W.)
| | - Thorsten Kaiser
- Institute for Laboratory Medicine, Clinical Chemistry and Molecular Diagnostics, University of Leipzig Medical Center and Medical Faculty, 04109 Leipzig, Germany; (C.G.); (M.S.); (M.F.); (B.I.)
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Dietl A, Zimmermann ME, Brandl C, Wallner S, Burkhardt R, Maier LS, Luchner A, Heid IM, Stark KJ. Distribution and specificity of high-sensitivity cardiac troponin T in older adults without acute cardiac conditions: cross-sectional results from the population-based AugUR study. BMJ Open 2021; 11:e052004. [PMID: 34728452 PMCID: PMC8565570 DOI: 10.1136/bmjopen-2021-052004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
OBJECTIVE European guidelines recommended a uniform upper reference limit of high-sensitivity cardiac troponin T (hsTnT) to rule out non-ST segment elevation myocardial infarction. Our study aimed to provide a hsTnT reference distribution and to assess the specificity of the 14 ng/L cut-off value in the mobile population ≥70 years of age. DESIGN A cross-sectional analysis was performed in the German AugUR study (Altersbezogene Untersuchungen zur Gesundheit der University of Regensburg). SETTING Study population was the mobile population aged 70+ years living in the city and county of Regensburg, Germany. PARTICIPANTS A random sample was derived from the local population registries of residence. Of the 5644 individuals invited, 1133 participated (response ratio=20.1%). All participants came to the study centre and were mentally and physically mobile to conduct the protocol (face-to-face interview, blood draw and standardised transthoracic echocardiography). None of the participants was in an acute state of myocardial infarction. RESULTS Among the 1129 individuals with hsTnT measurements (overall median=10.0 ng/L(25th, 75th percentile)=(7.0, 15.0 ng/L)), hsTnT was higher among the older individuals and higher among men (men 70-74 years median=9.6 ng/L (7.2, 13.1 ng/L); men 90-95 years median=21.2 ng/L (14.6, 26.0 ng/L); women 70-74 years median=6.3 ng/L (4.7, 8.7 ng/L); and women 90-95 years median=18.0 ng/L (11.0, 21.0 ng/L)). In participants with impaired kidney function (eGFRcrea <60 mL/min/1.73 m2), hsTnT was elevated (median=13.6 ng/L (9.4, 20.6 ng/L)).Specificity of recommended upper reference limit, 14 ng/L, is 68%. Most false positives were among men aged >79 years (specificity=34%). In a healthy subgroup (n=96, none of the following: overt heart disease, impaired renal function, blood pressure >160/100 mm Hg, left ventricular hypertrophy and diastolic/systolic dysfunction), specificity was 90%. CONCLUSION In the elderly population without acute myocardial infarction, hsTnT further increases with age showing different levels for men and women. The specificity of the 14 ng/L cut-off is considerably lower than 99%, even in healthy subjects.
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Affiliation(s)
- Alexander Dietl
- Department of Internal Medicine II, University Hospital Regensburg, Regensburg, Germany
| | - Martina E Zimmermann
- Department of Genetic Epidemiology, University of Regensburg, Regensburg, Germany
| | - Caroline Brandl
- Department of Genetic Epidemiology, University of Regensburg, Regensburg, Germany
- Department of Ophthalmology, University Hospital Regensburg, Regensburg, Germany
| | - Stefan Wallner
- Institute of Clinical Chemistry and Laboratory Medicine, University Hospital Regensburg, Regensburg, Germany
| | - Ralph Burkhardt
- Institute of Clinical Chemistry and Laboratory Medicine, University Hospital Regensburg, Regensburg, Germany
| | - Lars S Maier
- Department of Internal Medicine II, University Hospital Regensburg, Regensburg, Germany
| | - Andreas Luchner
- Department of Cardiology, Krankenhaus Barmherzige Brueder Regensburg, Regensburg, Germany
| | - Iris M Heid
- Department of Genetic Epidemiology, University of Regensburg, Regensburg, Germany
| | - Klaus J Stark
- Department of Genetic Epidemiology, University of Regensburg, Regensburg, Germany
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58
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Alushi B, Jost-Brinkmann F, Kastrati A, Cassese S, Fusaro M, Stangl K, Landmesser U, Thiele H, Lauten A. High-Sensitivity Cardiac Troponin T in Patients with Severe Chronic Kidney Disease and Suspected Acute Coronary Syndrome. J Clin Med 2021; 10:4216. [PMID: 34575325 PMCID: PMC8471888 DOI: 10.3390/jcm10184216] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2021] [Revised: 09/08/2021] [Accepted: 09/14/2021] [Indexed: 11/17/2022] Open
Abstract
(1) Background: Patients with severe chronic kidney disease (CKD G4-G5) often have chronically elevated high-sensitivity cardiac troponin T (hs-cTnT) values above the 99th percentile of the upper reference limit. In these patients, optimal cutoff levels for diagnosing non-ST-elevation acute coronary syndrome (NSTE-ACS) requiring revascularization remain undefined. (2) Methods: Of 11,912 patients undergoing coronary angiography from 2012 to 2017 for suspected NSTE-ACS, 325 (3%) had severe CKD. Of these, 290 with available serial hs-cTnT measurements were included, and 300 matched patients with normal renal function were selected as a control cohort. (3) Results: In the CKD cohort, 222 patients (76%) had NSTE-ACS with indication for coronary revascularization. Diagnostic performance was high at presentation and similar to that of the control population (AUC, 95% CI: 0.81, 0.75-0.87 versus 0.85, 0.80-0.89, p = 0.68), and the ROC-derived cutoff value was 4 times higher compared to the conventional 99th percentile. Combining the ROC-derived cutoff levels for hs-cTnT at presentation and absolute 3 h changes, sensitivity increased to 98%, and PPV and NPV improved up to 93% and 86%, respectively. (4) Conclusions: In patients with severe CKD and suspected ACS, the diagnostic accuracy of hs-cTnT for the diagnosis of NSTE-ACS requiring revascularization is improved by using higher assay-specific cutoff levels combined with early absolute changes.
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Affiliation(s)
- Brunilda Alushi
- Department of Cardiovascular Diseases, Campus Benjamin Franklin, Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Hindenburgdamm 30, 12203 Berlin, Germany; (F.J.-B.); (U.L.); (A.L.)
- German Centre for Cardiovascular Research (DZHK), Partner Site Berlin, Potsdamer Str. 58, 10785 Berlin, Germany;
- Department of General and Interventional Cardiology, Helios Klinikum Erfurt, Nordhäuser Str. 74, 99089 Erfurt, Germany
| | - Fabian Jost-Brinkmann
- Department of Cardiovascular Diseases, Campus Benjamin Franklin, Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Hindenburgdamm 30, 12203 Berlin, Germany; (F.J.-B.); (U.L.); (A.L.)
- Department of Hepatology and Gastroenterology, Campus Virchow Klinikum (CVK) and Campus Charité Mitte (CCM), Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Augustenburger Platz 1, 13353 Berlin, Germany
| | - Adnan Kastrati
- German Heart Center Munich, Technische Universität München, Lazarettstraße 36, 80636 Munich, Germany; (A.K.); (S.C.); (M.F.)
- German Centre for Cardiovascular Research (DZHK), Partner Site Munich Heart Alliance, 80336 Munich, Germany
| | - Salvatore Cassese
- German Heart Center Munich, Technische Universität München, Lazarettstraße 36, 80636 Munich, Germany; (A.K.); (S.C.); (M.F.)
- German Centre for Cardiovascular Research (DZHK), Partner Site Munich Heart Alliance, 80336 Munich, Germany
| | - Massimiliano Fusaro
- German Heart Center Munich, Technische Universität München, Lazarettstraße 36, 80636 Munich, Germany; (A.K.); (S.C.); (M.F.)
- German Centre for Cardiovascular Research (DZHK), Partner Site Munich Heart Alliance, 80336 Munich, Germany
| | - Karl Stangl
- German Centre for Cardiovascular Research (DZHK), Partner Site Berlin, Potsdamer Str. 58, 10785 Berlin, Germany;
- Department of Cardiovascular Diseases, Campus Charité Mitte (CCM), Charité—Universitätsmedizin Berlin, Charitéplatz 1, 10117 Berlin, Germany
| | - Ulf Landmesser
- Department of Cardiovascular Diseases, Campus Benjamin Franklin, Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Hindenburgdamm 30, 12203 Berlin, Germany; (F.J.-B.); (U.L.); (A.L.)
- Department of General and Interventional Cardiology, Helios Klinikum Erfurt, Nordhäuser Str. 74, 99089 Erfurt, Germany
- Berlin Institute of Health at Charité—Universitätsmedizin Berlin, Charitéplatz 1, 10117 Berlin, Germany
| | - Holger Thiele
- Department of Internal Medicine/Cardiology, Heart Center Leipzig at University of Leipzig, Strümpellstraße 39, 04289 Leipzig, Germany;
- Leipzig Heart Institute, Russenstraße 69a, 04289 Leipzig, Germany
| | - Alexander Lauten
- Department of Cardiovascular Diseases, Campus Benjamin Franklin, Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Hindenburgdamm 30, 12203 Berlin, Germany; (F.J.-B.); (U.L.); (A.L.)
- German Centre for Cardiovascular Research (DZHK), Partner Site Berlin, Potsdamer Str. 58, 10785 Berlin, Germany;
- Department of General and Interventional Cardiology, Helios Klinikum Erfurt, Nordhäuser Str. 74, 99089 Erfurt, Germany
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Gallacher PJ, Miller-Hodges E, Shah AS, Anand A, Dhaun N, Mills NL. Use of High-Sensitivity Cardiac Troponin in Patients With Kidney Impairment: A Randomized Clinical Trial. JAMA Intern Med 2021; 181:1237-1239. [PMID: 34096969 PMCID: PMC8185626 DOI: 10.1001/jamainternmed.2021.1184] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Accepted: 01/18/2021] [Indexed: 11/14/2022]
Affiliation(s)
- Peter J. Gallacher
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, Scotland
| | - Eve Miller-Hodges
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, Scotland
- Department of Renal Medicine, Royal Infirmary of Edinburgh, Edinburgh, Scotland
| | - Anoop S.V. Shah
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, Scotland
- London School of Hygiene and Tropical Medicine, London, England
| | - Atul Anand
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, Scotland
| | - Neeraj Dhaun
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, Scotland
- Department of Renal Medicine, Royal Infirmary of Edinburgh, Edinburgh, Scotland
| | - Nicholas L. Mills
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, Scotland
- Usher Institute, University of Edinburgh, Edinburgh, Scotland
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Kaier TE, Alaour B, Marber M. Cardiac troponin and defining myocardial infarction. Cardiovasc Res 2021; 117:2203-2215. [PMID: 33458742 PMCID: PMC8404461 DOI: 10.1093/cvr/cvaa331] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Revised: 09/12/2020] [Indexed: 12/19/2022] Open
Abstract
The 4th Universal Definition of Myocardial Infarction has stimulated considerable debate since its publication in 2018. The intention was to define the types of myocardial injury through the lens of their underpinning pathophysiology. In this review, we discuss how the 4th Universal Definition of Myocardial Infarction defines infarction and injury and the necessary pragmatic adjustments that appear in clinical guidelines to maximize triage of real-world patients.
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Affiliation(s)
- Thomas E Kaier
- King’s College London BHF Centre, The Rayne Institute, 4th Floor, Lambeth Wing, St Thomas’ Hospital, Westminster Bridge Road, London SE1 7EH, UK
| | - Bashir Alaour
- King’s College London BHF Centre, The Rayne Institute, 4th Floor, Lambeth Wing, St Thomas’ Hospital, Westminster Bridge Road, London SE1 7EH, UK
| | - Michael Marber
- King’s College London BHF Centre, The Rayne Institute, 4th Floor, Lambeth Wing, St Thomas’ Hospital, Westminster Bridge Road, London SE1 7EH, UK
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61
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Andersen CF, Bang C, Lauridsen KG, Frederiksen CA, Schmidt M, Jensen T, Hornung N, Løfgren B. External validation of a high-sensitive troponin I algorithm for rapid evaluation of acute myocardial infarction in a Danish cohort. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2021; 10:1056-1064. [PMID: 34423355 DOI: 10.1093/ehjacc/zuab062] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Revised: 05/19/2021] [Accepted: 07/14/2021] [Indexed: 11/14/2022]
Abstract
AIMS An accelerated diagnostic algorithm for ruling-in or ruling-out myocardial infarction (MI) after 1 hour (1 h) has recently been derived and internally validated for the Siemens ADVIA Centaur TNIH assay. We aimed to validate the diagnostic performance of the TNIH 0 h/1 h algorithm ad modum Boeddinghaus in a Danish cohort. METHODS AND RESULTS Patients with chest pain suggestive of MI were prospectively enrolled. High-sensitive troponin I (TNIH) was measured at admission (0 h) and after 30 minutes (30 m), 1 h, and 3 hours (3 h). We externally validated the TNIH 0 h/1 h algorithm ad modum Boeddinghaus in Danish patients. Moreover, we applied the algorithm using the second TNIH measurement at 30 m instead of 1 h. We enrolled 1003 patients: median (Q1-Q3) age 64 (52-74) years, 42% female, and 23% with previous MI. Myocardial infarction was the final diagnosis in 9% of patients. Median (Q1-Q3) times from admission to 30 m and 1 h blood draw were 35 min (30-37 min) and 67 min (62-75 min), respectively. Using the 0 h and 1 h results, 468 (47%) patients were assigned to rule-out, 104 (10%) to rule-in, and 431 (43%) to the observational zone. This resulted in a negative predictive value of 100% (95% confidence interval: 99.2-100%), sensitivity of 100% (95.9-100%), positive predictive value of 79.8 (70.8-87.0%), and specificity of 97.7% (96.5-98.6%). The diagnostic performance after 30 m was similar. CONCLUSIONS The TNIH 0 h/1 h algorithm ad modum Boeddinghaus performed excellently for rule-out of MI in a Danish cohort. The Boeddinghaus algorithm also performed excellently after only 30 m. TRIAL REGISTRATION NUMBER NCT03634384. TRIAL REGISTRY NAME AND URL Rapid Use of High-Sensitive Cardiac Troponin I for Ruling-in and Ruling-out Acute Myocardial Infarction (RACING-MI), https://clinicaltrials.gov/ct2/show/NCT03634384.
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Affiliation(s)
- Camilla Fuchs Andersen
- Research Center for Emergency Medicine, Aarhus University, Palle Juul-Jensens Boulevard 99, J103, Aarhus N 8200, Denmark.,Clinical Research Unit, Randers Regional Hospital, Skovlyvej 15, Randers 8930, Denmark.,Department of Internal Medicine, Randers Regional Hospital, Skovlyvej 15, 8930 Randers, Denmark.,Department of Cardiology, Herlev and Gentofte University Hospital, Borgmester Ib Juuls Vej, 1, Herlev, Hellerup 2730, Denmark
| | - Camilla Bang
- Research Center for Emergency Medicine, Aarhus University, Palle Juul-Jensens Boulevard 99, J103, Aarhus N 8200, Denmark.,Clinical Research Unit, Randers Regional Hospital, Skovlyvej 15, Randers 8930, Denmark.,Department of Internal Medicine, Randers Regional Hospital, Skovlyvej 15, 8930 Randers, Denmark
| | - Kasper Glerup Lauridsen
- Research Center for Emergency Medicine, Aarhus University, Palle Juul-Jensens Boulevard 99, J103, Aarhus N 8200, Denmark.,Clinical Research Unit, Randers Regional Hospital, Skovlyvej 15, Randers 8930, Denmark.,Department of Internal Medicine, Randers Regional Hospital, Skovlyvej 15, 8930 Randers, Denmark
| | | | - Morten Schmidt
- Department of Cardiology, Regional Hospital West Jutland, Gl Landevej 61, Herning 7400, Denmark.,Department of Clinical Epidemiology, Aarhus University Hospital, Olof Palmes Allé 43-45, Aarhus N 8200, Denmark
| | - Tage Jensen
- Department of Internal Medicine, Randers Regional Hospital, Skovlyvej 15, 8930 Randers, Denmark
| | - Nete Hornung
- Department of Clinical Biochemistry, Regional Hospital West Jutland, Gl Landevej 61, Herning 7400, Denmark
| | - Bo Løfgren
- Research Center for Emergency Medicine, Aarhus University, Palle Juul-Jensens Boulevard 99, J103, Aarhus N 8200, Denmark.,Department of Internal Medicine, Randers Regional Hospital, Skovlyvej 15, 8930 Randers, Denmark.,Department of Clinical Medicine, Aarhus University Hospital, Incuba Skejby, building 2, Palle Juul-Jensens Boulevard 82, Aarhus N 8200, Denmark
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Wereski R, Kimenai DM, Taggart C, Doudesis D, Lee KK, Lowry MT, Bularga A, Lowe DJ, Fujisawa T, Apple FS, Collinson PO, Anand A, Chapman AR, Mills NL. Cardiac Troponin Thresholds and Kinetics to Differentiate Myocardial Injury and Myocardial Infarction. Circulation 2021; 144:528-538. [PMID: 34167318 PMCID: PMC8360674 DOI: 10.1161/circulationaha.121.054302] [Citation(s) in RCA: 41] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Accepted: 07/07/2021] [Indexed: 11/16/2022]
Abstract
BACKGROUND Although the 99th percentile is the recommended diagnostic threshold for myocardial infarction, some guidelines also advocate the use of higher troponin thresholds to rule in myocardial infarction at presentation. It is unclear whether the magnitude or change in troponin concentration can differentiate causes of myocardial injury and infarction in practice. METHODS In a secondary analysis of a multicenter randomized controlled trial, we identified 46 092 consecutive patients presenting with suspected acute coronary syndrome without ST-segment-elevation myocardial infarction. High-sensitivity cardiac troponin I concentrations at presentation and on serial testing were compared between patients with myocardial injury and infarction. The positive predictive value and specificity were determined at the sex-specific 99th percentile upper reference limit and rule-in thresholds of 64 ng/L and 5-fold of the upper reference limit for a diagnosis of type 1 myocardial infarction. RESULTS Troponin was above the 99th percentile in 8188 patients (18%). The diagnosis was type 1 or type 2 myocardial infarction in 50% and 14% and acute or chronic myocardial injury in 20% and 16%, respectively. Troponin concentrations were similar at presentation in type 1 (median [25th-75th percentile] 91 [30-493] ng/L) and type 2 (50 [22-147] ng/L) myocardial infarction and in acute (50 [26-134] ng/L) and chronic (51 [31-130] ng/L) myocardial injury. The 99th percentile and rule-in thresholds of 64 ng/L and 5-fold upper reference limit gave a positive predictive value of 57% (95% CI, 56%-58%), 59% (58%-61%), and 62% (60%-64%) and a specificity of 96% (96%-96%), 96% (96%-96%), and 98% (97%-98%), respectively. The absolute, relative, and rate of change in troponin concentration were highest in patients with type 1 myocardial infarction (P<0.001 for all). Discrimination improved when troponin concentration and change in troponin were combined compared with troponin concentration at presentation alone (area under the curve, 0.661 [0.642-0.680] versus 0.613 [0.594-0.633]). CONCLUSIONS Although we observed important differences in the kinetics, cardiac troponin concentrations at presentation are insufficient to distinguish type 1 myocardial infarction from other causes of myocardial injury or infarction in practice and should not guide management decisions in isolation. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT01852123.
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Affiliation(s)
- Ryan Wereski
- British Heart Foundation Centre for Cardiovascular Science (R.W., C.T., D.D., K.K.L., M.T.H.L., A.B., T.F., A.A., A.R.C., N.L.M.), University of Edinburgh, UK
| | | | - Caelan Taggart
- British Heart Foundation Centre for Cardiovascular Science (R.W., C.T., D.D., K.K.L., M.T.H.L., A.B., T.F., A.A., A.R.C., N.L.M.), University of Edinburgh, UK
| | - Dimitrios Doudesis
- British Heart Foundation Centre for Cardiovascular Science (R.W., C.T., D.D., K.K.L., M.T.H.L., A.B., T.F., A.A., A.R.C., N.L.M.), University of Edinburgh, UK
- Usher Institute (D.M.K., D.D., N.L.M.), University of Edinburgh, UK
| | - Kuan Ken Lee
- British Heart Foundation Centre for Cardiovascular Science (R.W., C.T., D.D., K.K.L., M.T.H.L., A.B., T.F., A.A., A.R.C., N.L.M.), University of Edinburgh, UK
| | - Matthew T.H. Lowry
- British Heart Foundation Centre for Cardiovascular Science (R.W., C.T., D.D., K.K.L., M.T.H.L., A.B., T.F., A.A., A.R.C., N.L.M.), University of Edinburgh, UK
| | - Anda Bularga
- British Heart Foundation Centre for Cardiovascular Science (R.W., C.T., D.D., K.K.L., M.T.H.L., A.B., T.F., A.A., A.R.C., N.L.M.), University of Edinburgh, UK
| | - David J. Lowe
- University of Glasgow, School of Medicine, UK (D.J.L.)
| | - Takeshi Fujisawa
- British Heart Foundation Centre for Cardiovascular Science (R.W., C.T., D.D., K.K.L., M.T.H.L., A.B., T.F., A.A., A.R.C., N.L.M.), University of Edinburgh, UK
| | - Fred S. Apple
- Department of Laboratory Medicine and Pathology, Hennepin Healthcare/Hennepin County Medical Center and University of Minnesota, Minneapolis (F.S.A.)
| | - Paul O. Collinson
- Department of Clinical Blood Sciences and Cardiology, St. George’s University of London, UK (P.O.C.)
| | - Atul Anand
- British Heart Foundation Centre for Cardiovascular Science (R.W., C.T., D.D., K.K.L., M.T.H.L., A.B., T.F., A.A., A.R.C., N.L.M.), University of Edinburgh, UK
| | - Andrew R. Chapman
- British Heart Foundation Centre for Cardiovascular Science (R.W., C.T., D.D., K.K.L., M.T.H.L., A.B., T.F., A.A., A.R.C., N.L.M.), University of Edinburgh, UK
| | - Nicholas L. Mills
- British Heart Foundation Centre for Cardiovascular Science (R.W., C.T., D.D., K.K.L., M.T.H.L., A.B., T.F., A.A., A.R.C., N.L.M.), University of Edinburgh, UK
- Usher Institute (D.M.K., D.D., N.L.M.), University of Edinburgh, UK
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63
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Haller PM, Neumann JT, Sörensen NA, Hartikainen TS, Goßling A, Lehmacher J, Keller T, Zeller T, Blankenberg S, Westermann D. The association of anaemia and high-sensitivity cardiac troponin and its effect on diagnosing myocardial infarction. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2021; 10:1187-1196. [PMID: 34350455 DOI: 10.1093/ehjacc/zuab066] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Revised: 05/13/2021] [Accepted: 07/20/2021] [Indexed: 11/14/2022]
Abstract
AIMS Anaemia is common in patients with acute myocardial infarction (MI). We investigated the association of high-sensitivity cardiac troponin (hs-cTn) and haemoglobin (Hb) and the influence of anaemia on the performance of diagnostic protocols for suspected MI. METHODS AND RESULTS Patients with suspected MI were consecutively enrolled at a tertiary centre. Final diagnoses were independently adjudicated by two cardiologists. Performance measures of hs-cTn-based algorithms were compared for anaemic and non-anaemic patients (Hb <12 g/dL in women and <13 g/dL in men). The influence of anaemia on survival (median follow-up 1.7 years) was investigated using multivariable cox-regression analysis and the association of Hb and hs-cTn by multivariable linear regression analysis. Overall, 2223 patients were included, of whom 415 (18.7%) had anaemia. In anaemic patients, the incidence of MI was similar; however, chronic myocardial injury was significantly more prevalent (20.1% vs. 48.2%). The negative predictive value to rule-out MI was similar for both algorithms and all assays in patients with anaemia, although the positive predictive value to rule-in MI was partly reduced for the 0/3-h algorithm. Fewer anaemic patients were triaged after 1 h. Anaemia was an independent predictor of death. Adjusted for patient characteristics, Hb was significantly associated with hs-cTn. By providing a point-based tool, the Hb-associated hs-cTn concentration and thus chronic myocardial injury may be predicted. CONCLUSION Anaemia partly affects the rule-in, but not the rule-out of MI in hs-cTn-based diagnostic protocols. Hs-cTn concentrations and thus chronic myocardial injury may be predicted by clinical variables and Hb. TRIAL REGISTRATION clinicaltrials.gov (NCT02355457 and NCT03227159).
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Affiliation(s)
- Paul Michael Haller
- Department of Cardiology, University Heart & Vascular Center Hamburg, Martinistrasse 52, 20246 Hamburg, Germany.,German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - Johannes T Neumann
- Department of Cardiology, University Heart & Vascular Center Hamburg, Martinistrasse 52, 20246 Hamburg, Germany.,German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany.,Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Nils A Sörensen
- Department of Cardiology, University Heart & Vascular Center Hamburg, Martinistrasse 52, 20246 Hamburg, Germany.,German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - Tau S Hartikainen
- Department of Cardiology, University Heart & Vascular Center Hamburg, Martinistrasse 52, 20246 Hamburg, Germany
| | - Alina Goßling
- Department of Cardiology, University Heart & Vascular Center Hamburg, Martinistrasse 52, 20246 Hamburg, Germany
| | - Jonas Lehmacher
- Department of Cardiology, University Heart & Vascular Center Hamburg, Martinistrasse 52, 20246 Hamburg, Germany
| | - Till Keller
- Department of Internal Medicine I, Cardiology, Justus-Liebig-University Gießen, Gießen, Germany
| | - Tanja Zeller
- Department of Cardiology, University Heart & Vascular Center Hamburg, Martinistrasse 52, 20246 Hamburg, Germany.,German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - Stefan Blankenberg
- Department of Cardiology, University Heart & Vascular Center Hamburg, Martinistrasse 52, 20246 Hamburg, Germany.,German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - Dirk Westermann
- Department of Cardiology, University Heart & Vascular Center Hamburg, Martinistrasse 52, 20246 Hamburg, Germany.,German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany
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64
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Delombaerde D, Vervloet D, Franssen C, Croes L, Gremonprez F, Prenen H, Peeters M, Vulsteke C. Clinical implications of isolated troponinemia following immune checkpoint inhibitor therapy. ESMO Open 2021; 6:100216. [PMID: 34271309 PMCID: PMC8287144 DOI: 10.1016/j.esmoop.2021.100216] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Revised: 06/18/2021] [Accepted: 06/28/2021] [Indexed: 01/27/2023] Open
Abstract
Cardiovascular adverse events induced by immune checkpoint inhibitors (ICIs) have gained significant interest over the past decade due to their impact on short- and long-term outcomes. They were initially thought to be rare, but the increasing use of ICIs in the treatment of both advanced and early stages of various malignancies has resulted in a substantial increase in their incidence. Different guidelines have proposed screening measures for ICI-induced myocarditis by incorporating troponin measurements at baseline and during the first few weeks of treatment. However, no specific guidelines have been developed yet regarding the interpretation of an asymptomatic rise in troponins. This state-of-the art review aims to provide an overview of the clinical relevance of elevated troponins during checkpoint inhibition and recommendations on how to manage elevated troponin levels during ICI therapy.
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Affiliation(s)
- D Delombaerde
- Integrated Cancer Center Ghent, Department of Medical Oncology, AZ Maria Middelares, Ghent, Belgium; Center for Oncological Research (CORE), Integrated Personalized and Precision Oncology Network (IPPON), University of Antwerp, Wilrijk, Belgium.
| | - D Vervloet
- Department of Cardiology, AZ Maria Middelares, Ghent, Belgium
| | - C Franssen
- Department of Cardiology, Antwerp University Hospital, Edegem, Belgium
| | - L Croes
- Integrated Cancer Center Ghent, Department of Medical Oncology, AZ Maria Middelares, Ghent, Belgium; Center for Oncological Research (CORE), Integrated Personalized and Precision Oncology Network (IPPON), University of Antwerp, Wilrijk, Belgium
| | - F Gremonprez
- Integrated Cancer Center Ghent, Department of Medical Oncology, AZ Maria Middelares, Ghent, Belgium
| | - H Prenen
- Center for Oncological Research (CORE), Integrated Personalized and Precision Oncology Network (IPPON), University of Antwerp, Wilrijk, Belgium; Multidisciplinary Oncologic Center Antwerp (MOCA), Antwerp University Hospital, Edegem, Belgium
| | - M Peeters
- Center for Oncological Research (CORE), Integrated Personalized and Precision Oncology Network (IPPON), University of Antwerp, Wilrijk, Belgium; Multidisciplinary Oncologic Center Antwerp (MOCA), Antwerp University Hospital, Edegem, Belgium
| | - C Vulsteke
- Integrated Cancer Center Ghent, Department of Medical Oncology, AZ Maria Middelares, Ghent, Belgium; Center for Oncological Research (CORE), Integrated Personalized and Precision Oncology Network (IPPON), University of Antwerp, Wilrijk, Belgium
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65
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Clerico A, Aimo A, Zaninotto M, Plebani M. Diagnostic algorithms for non-ST-segment elevation myocardial infarction: open issues. Clin Chem Lab Med 2021; 59:1761-1771. [PMID: 34225387 DOI: 10.1515/cclm-2021-0550] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2021] [Accepted: 06/22/2021] [Indexed: 11/15/2022]
Abstract
The use of serial measurement of cardiac troponin (cTn) is recommended by international guidelines for the diagnosis of myocardial infarction (MI) since 2000. This article focuses on factors influencing temporal changes in high-sensitive cTn (hs)-cTn and the impact of these factors on the diagnosis of non-ST-segment elevation MI (NSTEMI). The recommendations proposed by three different international guidelines published in 2020-2021 for the management of acute coronary syndromes (ACS) in patients presenting without persistent ST-segment elevation (NSTE) show some discrepancies. In particular, there is no agreement among these guidelines about cut-off or absolute change values to be used for the rule-in, especially regarding the use of sex-specific cut-off values. Furthermore, there are no sufficient evidences on the diagnostic accuracy and cost effectiveness related to cut-off values suggested for algorithms to be used by some hs-cTnI methods.
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Affiliation(s)
- Aldo Clerico
- Scuola Superiore Sant'Anna e Fondazione CNR - Regione Toscana G. Monasterio, Pisa, Italy
| | - Alberto Aimo
- Scuola Superiore Sant'Anna e Fondazione CNR - Regione Toscana G. Monasterio, Pisa, Italy
| | - Martina Zaninotto
- Dipartimento di Medicina di Laboratorio, Azienda Ospedaliera Universitaria di Padova, e Dipartimento di Medicina - Università di Padova, Padova, Italy
| | - Mario Plebani
- Dipartimento di Medicina di Laboratorio, Azienda Ospedaliera Universitaria di Padova, e Dipartimento di Medicina - Università di Padova, Padova, Italy
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66
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Lopez-Ayala P, Boeddinghaus J, Koechlin L, Nestelberger T, Mueller C. Early Rule-Out Strategies in the Emergency Department Utilizing High-Sensitivity Cardiac Troponin Assays. Clin Chem 2021; 67:114-123. [PMID: 33279982 DOI: 10.1093/clinchem/hvaa226] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Accepted: 09/09/2020] [Indexed: 11/14/2022]
Abstract
BACKGROUND Over the past decade, intense collaboration between academic investigators and the diagnostic industry have allowed the integration of high-sensitivity cardiac troponin (hs-cTn) assays into clinical practice worldwide. The hs-cTn assays, with their increased diagnostic accuracy for acute myocardial infarction (AMI), have facilitated the maturation of early rule-out strategies. The first iteration was complex and required the combination of a biomarker panel, the electrocardiogram, and a clinical risk score and allowed the safe rule-out of AMI in only 10% of patients with acute chest pain. In contrast, the latest iterations, including the European Society of Cardiology (ESC) 0/1-h algorithm, are simple. They are based on hs-cTn concentrations only and allow the safe rule-out or rule-in of AMI in up to 75% of patients. CONTENT The purposes of this minireview are (a) to describe the best validated hs-cTn-based strategies for early rule-out of AMI, (b) to discuss the advantages and limitations of the different strategies, (c) to identify patient subgroups requiring particular attention, (d) to recognize challenges for widespread clinical implementation, and (e) to provide guidance on strategies for their safe and effective clinical implementation. SUMMARY Physicians and institutions may choose among several well-validated rule-out algorithms. The ESC 0/1-h algorithm for hs-cTnT or hs-cTnI seems to be the most attractive option today. It best balances safety and efficacy, and it has been derived and validated for all currently available hs-cTnT/I assays, facilitating widespread clinical implementation.
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Affiliation(s)
- Pedro Lopez-Ayala
- Department of Cardiology, Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Switzerland.,GREAT Network, Rome, Italy
| | - Jasper Boeddinghaus
- Department of Cardiology, Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Switzerland.,GREAT Network, Rome, Italy
| | - Luca Koechlin
- Department of Cardiology, Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Switzerland.,GREAT Network, Rome, Italy.,Department of Cardiac Surgery, University Hospital Basel, Switzerland
| | - Thomas Nestelberger
- Department of Cardiology, Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Switzerland.,GREAT Network, Rome, Italy.,Division of Cardiology, Vancouver General Hospital, University of British Columbia, Vancouver, BC, Canada
| | - Christian Mueller
- Department of Cardiology, Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Switzerland.,GREAT Network, Rome, Italy
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67
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Collet JP, Thiele H, Barbato E, Barthélémy O, Bauersachs J, Bhatt DL, Dendale P, Dorobantu M, Edvardsen T, Folliguet T, Gale CP, Gilard M, Jobs A, Jüni P, Lambrinou E, Lewis BS, Mehilli J, Meliga E, Merkely B, Mueller C, Roffi M, Rutten FH, Sibbing D, Siontis GC. Guía ESC 2020 sobre el diagnóstico y tratamiento del síndrome coronario agudo sin elevación del segmento ST. Rev Esp Cardiol (Engl Ed) 2021. [DOI: 10.1016/j.recesp.2020.12.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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68
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Chan K, Moe SM, Saran R, Libby P. The cardiovascular-dialysis nexus: the transition to dialysis is a treacherous time for the heart. Eur Heart J 2021; 42:1244-1253. [PMID: 33458768 DOI: 10.1093/eurheartj/ehaa1049] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2019] [Revised: 08/13/2020] [Accepted: 12/15/2020] [Indexed: 02/06/2023] Open
Abstract
Chronic kidney disease (CKD) patients require dialysis to manage the progressive complications of uraemia. Yet, many physicians and patients do not recognize that dialysis initiation, although often necessary, subjects patients to substantial risk for cardiovascular (CV) death. While most recognize CV mortality risk approximately doubles with CKD the new data presented here show that this risk spikes to >20 times higher than the US population average at the initiation of chronic renal replacement therapy, and this elevated CV risk continues through the first 4 months of dialysis. Moreover, this peak reflects how dialysis itself changes the pathophysiology of CV disease and transforms its presentation, progression, and prognosis. This article reviews how dialysis initiation modifies the interpretation of circulating biomarkers, alters the accuracy of CV imaging, and worsens prognosis. We advocate a multidisciplinary approach and outline the issues practitioners should consider to optimize CV care for this unique and vulnerable population during a perilous passage.
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Affiliation(s)
- Kevin Chan
- National Institute of Diabetes and Digestive and Kidney Disease, Division of Kidney, Urology, and Hematology, 6707 Democracy Blvd, Bethesda, MD 20892-5458, USA
| | - Sharon M Moe
- Division of Nephrology, Indiana University School of Medicine, 950 W. Walnut Street R2-202, Indianapolis, IN 46202, USA
| | - Rajiv Saran
- Division of Nephrology, Department of Internal Medicine, University of Michigan, 1500 E Medical Center Dr # 31, Ann Arbor, MI 48109, USA
| | - Peter Libby
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, 77 Ave. Louis Pasteur, NRB-741-G, Boston, MA 02115, USA
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69
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Mueller C, Giannitsis E, Jaffe AS, Huber K, Mair J, Cullen L, Hammarsten O, Mills NL, Möckel M, Krychtiuk K, Thygesen K, Lindahl B. Cardiovascular biomarkers in patients with COVID-19. EUROPEAN HEART JOURNAL. ACUTE CARDIOVASCULAR CARE 2021; 10:310-319. [PMID: 33655301 PMCID: PMC7989520 DOI: 10.1093/ehjacc/zuab009] [Citation(s) in RCA: 37] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Accepted: 02/12/2021] [Indexed: 01/08/2023]
Abstract
The coronavirus disease 2019 (COVID-19) pandemic has increased awareness that severe acute respiratory distress syndrome coronavirus-2 (SARS-CoV-2) may have profound effects on the cardiovascular system. COVID-19 often affects patients with pre-existing cardiac disease, and may trigger acute respiratory distress syndrome (ARDS), venous thromboembolism (VTE), acute myocardial infarction (AMI), and acute heart failure (AHF). However, as COVID-19 is primarily a respiratory infectious disease, there remain substantial uncertainty and controversy whether and how cardiovascular biomarkers should be used in patients with suspected COVID-19. To help clinicians understand the possible value as well as the most appropriate interpretation of cardiovascular biomarkers in COVID-19, it is important to highlight that recent findings regarding the prognostic role of cardiovascular biomarkers in patients hospitalized with COVID-19 are similar to those obtained in studies for pneumonia and ARDS in general. Cardiovascular biomarkers reflecting pathophysiological processes involved in COVID-19/pneumonia and its complications have a role evaluating disease severity, cardiac involvement, and risk of death in COVID-19 as well as in pneumonias caused by other pathogens. First, cardiomyocyte injury, as quantified by cardiac troponin concentrations, and haemodynamic cardiac stress, as quantified by natriuretic peptide concentrations, may occur in COVID-19 as in other pneumonias. The level of those biomarkers correlates with disease severity and mortality. Interpretation of cardiac troponin and natriuretic peptide concentrations as quantitative variables may aid in risk stratification in COVID-19/pneumonia and also will ensure that these biomarkers maintain high diagnostic accuracy for AMI and AHF. Second, activated coagulation as quantified by D-dimers seems more prominent in COVID-19 as in other pneumonias. Due to the central role of endothelitis and VTE in COVID-19, serial measurements of D-dimers may help physicians in the selection of patients for VTE imaging and the intensification of the level of anticoagulation from prophylactic to slightly higher or even therapeutic doses.
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Affiliation(s)
- Christian Mueller
- Department of Cardiology and Cardiovascular Research Institute Basel, University Hospital Basel, University of Basel, Petersgraben 4, CH-4031 Basel, Switzerland
| | | | | | - Kurt Huber
- Department of Medicine, Cardiology and Intensive Care Medicine, Wilhelminenhospital, and Sigmund Freud University, Medical School, Vienna, Austria
| | - Johannes Mair
- Department of Internal Medicine III—Cardiology and Angiology, Medical University Innsbruck, Innsbruck, Austria
| | - Louise Cullen
- Emergency and Trauma Centre, Royal Brisbane and Women`s Hospital, University of Queensland, St Lucia, QLD, Australia
| | - Ola Hammarsten
- Department of Clinical Chemistry and Transfusion Medicine, University of Gothenburg, Gothenburg, Sweden
| | - Nicholas L Mills
- University/BHF Centre for Cardiovascular Science and Usher Institute, University of Edinburgh, Edinburgh, UK
| | - Martin Möckel
- Division of Emergency Medicine, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Konstantin Krychtiuk
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, Vienna, Austria
| | - Kristian Thygesen
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
| | - Bertil Lindahl
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden
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70
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Westwood M, Ramaekers B, Grimm S, Worthy G, Fayter D, Armstrong N, Buksnys T, Ross J, Joore M, Kleijnen J. High-sensitivity troponin assays for early rule-out of acute myocardial infarction in people with acute chest pain: a systematic review and economic evaluation. Health Technol Assess 2021; 25:1-276. [PMID: 34061019 PMCID: PMC8200931 DOI: 10.3310/hta25330] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Early diagnosis of acute myocardial infarction is important, but only 20% of emergency admissions for chest pain will actually have an acute myocardial infarction. High-sensitivity cardiac troponin assays may allow rapid rule out of myocardial infarction and avoid unnecessary hospital admissions. OBJECTIVES To assess the clinical effectiveness and cost-effectiveness of high-sensitivity cardiac troponin assays for the management of adults presenting with acute chest pain, in particular for the early rule-out of acute myocardial infarction. METHODS Sixteen databases were searched up to September 2019. Review methods followed published guidelines. Studies were assessed for quality using appropriate risk-of-bias tools. The bivariate model was used to estimate summary sensitivity and specificity for meta-analyses involving four or more studies; otherwise, random-effects logistic regression was used. The health economic analysis considered the long-term costs and quality-adjusted life-years associated with different troponin testing methods. The de novo model consisted of a decision tree and a state-transition cohort model. A lifetime time horizon (of 60 years) was used. RESULTS Thirty-seven studies (123 publications) were included in the review. The high-sensitivity cardiac troponin test strategies evaluated are defined by the combination of four factors (i.e. assay, number and timing of tests, and threshold concentration), resulting in a large number of possible combinations. Clinical opinion indicated a minimum clinically acceptable sensitivity of 97%. When considering single test strategies, only those using a threshold at or near to the limit of detection for the assay, in a sample taken at presentation, met the minimum clinically acceptable sensitivity criterion. The majority of the multiple test strategies that met this criterion comprised an initial rule-out step, based on high-sensitivity cardiac troponin levels in a sample taken on presentation and a minimum symptom duration, and a second stage for patients not meeting the initial rule-out criteria, based on presentation levels of high-sensitivity cardiac troponin and absolute change after 1, 2 or 3 hours. Two large cluster randomised controlled trials found that implementation of an early rule-out pathway for myocardial infarction reduced length of stay and rate of hospital admission without increasing cardiac events. In the base-case analysis, standard troponin testing was both the most effective and the most costly. Other testing strategies with a sensitivity of 100% (subject to uncertainty) were almost equally effective, resulting in the same life-year and quality-adjusted life-year gain at up to four decimal places. Comparisons based on the next best alternative showed that for willingness-to-pay values below £8455 per quality-adjusted life-year, the Access High Sensitivity Troponin I (Beckman Coulter, Brea, CA, USA) [(symptoms > 3 hours AND < 4 ng/l at 0 hours) OR (< 5 ng/l AND Δ < 5 ng/l at 0 to 2 hours)] would be cost-effective. For thresholds between £8455 and £20,190 per quality-adjusted life-year, the Elecsys® Troponin-T high sensitive (Roche, Basel, Switzerland) (< 12 ng/l at 0 hours AND Δ < 3 ng/l at 0 to 1 hours) would be cost-effective. For a threshold > £20,190 per quality-adjusted life-year, the Dimension Vista® High-Sensitivity Troponin I (Siemens Healthcare, Erlangen, Germany) (< 5 ng/l at 0 hours AND Δ < 2 ng/l at 0 to 1 hours) would be cost-effective. CONCLUSIONS High-sensitivity cardiac troponin testing may be cost-effective compared with standard troponin testing. STUDY REGISTRATION This study is registered as PROSPERO CRD42019154716. FUNDING This project was funded by the National Institute for Health Research (NIHR) Evidence Synthesis programme and will be published in full in Health Technology Assessment; Vol. 25, No. 33. See the NIHR Journals Library website for further project information.
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Affiliation(s)
| | - Bram Ramaekers
- Department of Clinical Epidemiology and Medical Technology Assessment, Maastricht University, Maastricht, the Netherlands
| | - Sabine Grimm
- Department of Clinical Epidemiology and Medical Technology Assessment, Maastricht University, Maastricht, the Netherlands
| | | | | | | | | | | | - Manuela Joore
- Department of Clinical Epidemiology and Medical Technology Assessment, Maastricht University, Maastricht, the Netherlands
| | - Jos Kleijnen
- Kleijnen Systematic Reviews Ltd, York, UK
- School for Public Health and Primary Care, Care and Public Health Research Institute, Maastricht University, Maastricht, the Netherlands
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71
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Fernández-Cisnal A, Valero E, García-Blas S, Pernias V, Pozo A, Carratalá A, González J, Noceda J, Miñana G, Núñez J, Sanchis J. Clinical History and Detectable Troponin Concentrations below the 99th Percentile for Risk Stratification of Patients with Chest Pain and First Normal Troponin. J Clin Med 2021; 10:jcm10081784. [PMID: 33923925 PMCID: PMC8073372 DOI: 10.3390/jcm10081784] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Revised: 04/15/2021] [Accepted: 04/18/2021] [Indexed: 11/16/2022] Open
Abstract
Decision-making is challenging in patients with chest pain and normal high-sensitivity cardiac troponin T (hs-cTnT; <99th percentile; <14 ng/L) at hospital arrival. Most of these patients might be discharged early. We investigated clinical data and hs-cTnT concentrations for risk stratification. This is a retrospective study including 4476 consecutive patients presenting to the emergency department with chest pain and first normal hs-cTnT. The primary endpoint was one-year death or acute myocardial infarction, and the secondary endpoint added urgent revascularization. The number of primary and secondary endpoints was 173 (3.9%) and 252 (5.6%). Mean hs-cTnT concentrations were 6.9 ± 2.5 ng/L. Undetectable (<5 ng/L) hs-cTnT (n = 1847, 41%) had optimal negative predictive value (99.1%) but suboptimal sensitivity (90.2%) and discrimination accuracy (AUC = 0.664) for the primary endpoint. Multivariable analysis was used to identify the predictive clinical variables. The clinical model showed good discrimination accuracy (AUC = 0.810). The addition of undetectable hs-cTnT (≥ or <5 ng/L; HR, hazard ratio = 3.80; 95% CI, confidence interval 2.27–6.35; p = 0.00001) outperformed the clinical model alone (AUC = 0.836, p = 0.002 compared to the clinical model). Measurable hs-cTnT concentrations (between detection limit and 99th percentile; per 0.1 ng/L, HR = 1.13; CI 1.06–1.20; p = 0.0001) provided further predictive information (AUC = 0.844; p = 0.05 compared to the clinical plus undetectable hs-cTnT model). The results were reproducible for the secondary endpoint and 30-day events. Clinical assessment, undetectable hs-cTnT and measurable hs-cTnT concentrations must be considered for decision-making after a single negative hs-cTnT result in patients presenting to the emergency department with acute chest pain.
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Affiliation(s)
- Agustín Fernández-Cisnal
- Cardiology Department, University Clinic Hospital of València, Instituto de Investigación Sanitaria (INCLIVA), University of València, Centro de Investigación Biomédica en Red Enfermedades Cardiovaculares (CIBERCV), 46010 València, Spain; (A.F.-C.); (E.V.); (S.G.-B.); (V.P.); (A.P.); (J.G.); (G.M.); (J.N.)
| | - Ernesto Valero
- Cardiology Department, University Clinic Hospital of València, Instituto de Investigación Sanitaria (INCLIVA), University of València, Centro de Investigación Biomédica en Red Enfermedades Cardiovaculares (CIBERCV), 46010 València, Spain; (A.F.-C.); (E.V.); (S.G.-B.); (V.P.); (A.P.); (J.G.); (G.M.); (J.N.)
| | - Sergio García-Blas
- Cardiology Department, University Clinic Hospital of València, Instituto de Investigación Sanitaria (INCLIVA), University of València, Centro de Investigación Biomédica en Red Enfermedades Cardiovaculares (CIBERCV), 46010 València, Spain; (A.F.-C.); (E.V.); (S.G.-B.); (V.P.); (A.P.); (J.G.); (G.M.); (J.N.)
| | - Vicente Pernias
- Cardiology Department, University Clinic Hospital of València, Instituto de Investigación Sanitaria (INCLIVA), University of València, Centro de Investigación Biomédica en Red Enfermedades Cardiovaculares (CIBERCV), 46010 València, Spain; (A.F.-C.); (E.V.); (S.G.-B.); (V.P.); (A.P.); (J.G.); (G.M.); (J.N.)
| | - Adela Pozo
- Cardiology Department, University Clinic Hospital of València, Instituto de Investigación Sanitaria (INCLIVA), University of València, Centro de Investigación Biomédica en Red Enfermedades Cardiovaculares (CIBERCV), 46010 València, Spain; (A.F.-C.); (E.V.); (S.G.-B.); (V.P.); (A.P.); (J.G.); (G.M.); (J.N.)
| | - Arturo Carratalá
- Clinical Biochemistry Department, University Clinic Hospital of València, Instituto de Investigación Sanitaria (INCLIVA), 46010 València, Spain;
| | - Jessika González
- Cardiology Department, University Clinic Hospital of València, Instituto de Investigación Sanitaria (INCLIVA), University of València, Centro de Investigación Biomédica en Red Enfermedades Cardiovaculares (CIBERCV), 46010 València, Spain; (A.F.-C.); (E.V.); (S.G.-B.); (V.P.); (A.P.); (J.G.); (G.M.); (J.N.)
| | - José Noceda
- Emergency Department, University Clinic Hospital of València, Instituto de Investigación Sanitaria (INCLIVA), 46010 València, Spain;
| | - Gema Miñana
- Cardiology Department, University Clinic Hospital of València, Instituto de Investigación Sanitaria (INCLIVA), University of València, Centro de Investigación Biomédica en Red Enfermedades Cardiovaculares (CIBERCV), 46010 València, Spain; (A.F.-C.); (E.V.); (S.G.-B.); (V.P.); (A.P.); (J.G.); (G.M.); (J.N.)
| | - Julio Núñez
- Cardiology Department, University Clinic Hospital of València, Instituto de Investigación Sanitaria (INCLIVA), University of València, Centro de Investigación Biomédica en Red Enfermedades Cardiovaculares (CIBERCV), 46010 València, Spain; (A.F.-C.); (E.V.); (S.G.-B.); (V.P.); (A.P.); (J.G.); (G.M.); (J.N.)
| | - Juan Sanchis
- Cardiology Department, University Clinic Hospital of València, Instituto de Investigación Sanitaria (INCLIVA), University of València, Centro de Investigación Biomédica en Red Enfermedades Cardiovaculares (CIBERCV), 46010 València, Spain; (A.F.-C.); (E.V.); (S.G.-B.); (V.P.); (A.P.); (J.G.); (G.M.); (J.N.)
- Correspondence:
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72
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Collet JP, Thiele H, Barbato E, Barthélémy O, Bauersachs J, Bhatt DL, Dendale P, Dorobantu M, Edvardsen T, Folliguet T, Gale CP, Gilard M, Jobs A, Jüni P, Lambrinou E, Lewis BS, Mehilli J, Meliga E, Merkely B, Mueller C, Roffi M, Rutten FH, Sibbing D, Siontis GCM. 2020 ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation. Eur Heart J 2021; 42:1289-1367. [PMID: 32860058 DOI: 10.1093/eurheartj/ehaa575] [Citation(s) in RCA: 2717] [Impact Index Per Article: 905.7] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
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73
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Wettersten N, Horiuchi Y, Maisel A. Advancements in biomarkers for cardiovascular disease: diagnosis, prognosis, and therapy. Fac Rev 2021; 10:34. [PMID: 33977287 PMCID: PMC8103908 DOI: 10.12703/r/10-34] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Biomarkers are essential tools in the practice of cardiology. They assist with diagnosis, prognosis, and guiding therapy in many different cardiovascular diseases. Numerous biomarkers have become strongly associated with different cardiovascular conditions, such as troponin with acute coronary syndrome and natriuretic peptides with heart failure. Even though these biomarkers have been in practice for almost two decades, their uses continue to expand beyond their original roles. Additionally, many new biomarkers have been discovered with increasing utility in cardiovascular disease, including soluble suppression of tumorigenicity 2, galectin 3, and biomarkers of fibrosis, metabolism, and inflammation. How these old and new biomarkers are being expanded into clinical practice is constantly in evolution. This review will highlight some of the recent major advancements in the rapidly evolving field of biomarkers.
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Affiliation(s)
- Nicholas Wettersten
- Division of Cardiology, Veterans Affairs Medical Center, San Diego, CA, USA
- Division of Cardiovascular Medicine, University of California San Diego, La Jolla, CA, USA
| | - Yu Horiuchi
- Division of Cardiology, Mitsui Memorial Hospital, Tokyo, Japan
| | - Alan Maisel
- Division of Cardiovascular Medicine, University of California San Diego, La Jolla, CA, USA
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74
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Dongxu C, Yannan Z, Yilin Y, Chenling Y, Guorong G, Kouqiong W, Wei G, Dongwei S, Zhenju S, Chaoyang T. Evaluation of the 0 h/1 h high-sensitivity cardiac troponin T algorithm in diagnosis of non-ST-segment elevation myocardial infarction (NSTEMI) in Han population. Clin Chem Lab Med 2021; 59:757-764. [PMID: 33554576 DOI: 10.1515/cclm-2020-0367] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2020] [Accepted: 10/12/2020] [Indexed: 11/15/2022]
Abstract
OBJECTIVES A rapid 0 h/1 h algorithm using high-sensitivity cardiac troponin T (hs-cTnT) for rule-out and rule-in of non-ST-segment elevation myocardial infarction (NSTEMI) is recommended by the European Society of Cardiology. We aim to prospectively evaluate the diagnostic performance of the algorithm in Chinese Han patients with suspected NSTEMI. METHODS In this prospective diagnostic cohort study, 577 patients presenting to the emergency department with suspected NSTEMI and recent (<12 h) onset of symptoms were enrolled. The levels of serum hs-cTnT were measured on admission, 1 h later and 4-14 h later. All patients underwent the initial clinical assessment and were triaged into three groups (rule-out, rule-in and observe) according to the 0 h/1 h algorithm. The major cardiovascular events (MACE) were evaluated at the 7-day and 30-day follow-ups. RESULTS Among 577 enrolled patients, NSTEMI was the final diagnosis for 106 (18.4%) patients. Based on the hs-cTnT 0 h/1 h algorithm, 148 patients (25.6%) were classified as rule-out, 278 patients (48.2%) as rule-in and 151 patients (26.2%) were assigned to the observe group. The rule-out approach resulted in a sensitivity of 100% and negative predictive value of 100%. The rule-in approach resulted in a specificity of 62.9% [95% CI (58.5-67.2%)] and positive predictive value of 37.1% [95%CI (31.3-42.8%)]. No MACE was observed in the rule-out group within 30-day follow-up. CONCLUSIONS The hs-cTnT 0 h/1 h algorithm is a safe tool for early rule-out of NSTEMI, while probably not an effective strategy for accurate rule-in of NSTEMI in Chinese Han population.
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Affiliation(s)
- Chen Dongxu
- Department of Emergency Medicine, Zhongshan Hospital, Fudan University, Shanghai, P.R. China
| | - Zhou Yannan
- Department of Emergency Medicine, Zhongshan Hospital, Fudan University, Shanghai, P.R. China
| | - Yang Yilin
- Department of Emergency Medicine, Zhongshan Hospital, Fudan University, Shanghai, P.R. China
| | - Yao Chenling
- Department of Emergency Medicine, Zhongshan Hospital, Fudan University, Shanghai, P.R. China
| | - Gu Guorong
- Department of Emergency Medicine, Zhongshan Hospital, Fudan University, Shanghai, P.R. China
| | - Wang Kouqiong
- Department of Laboratory Medicine, Zhongshan Hospital, Fudan University, Shanghai, P.R. China
| | - Guo Wei
- Department of Laboratory Medicine, Zhongshan Hospital, Fudan University, Shanghai, P.R. China
| | - Shi Dongwei
- Department of Emergency Medicine, Zhongshan Hospital, Fudan University, Shanghai, P.R. China
| | - Song Zhenju
- Department of Emergency Medicine, Zhongshan Hospital, Fudan University, Shanghai, P.R. China
| | - Tong Chaoyang
- Department of Emergency Medicine, Zhongshan Hospital, Fudan University, Shanghai, P.R. China
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75
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McCord J, Hana A, Cook B, Hudson MP, Miller J, Akoegbe G, Mueller C, Moyer M, Jacobsen G, Nowak R. The role of cardiac testing with the 0/1-hour high-sensitivity cardiac troponin algorithm evaluating for acute myocardial infarction. Am Heart J 2021; 233:68-77. [PMID: 33373603 DOI: 10.1016/j.ahj.2020.12.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Accepted: 12/22/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND The role of cardiac testing in the 3 zones (rule-out, observation, and rule-in) of the 0/1-hour algorithm to evaluate for acute myocardial infarction (AMI) has not been well studied. This study evaluated the 0/1-hour algorithm with a high-sensitivity cardiac troponin (hs-cTnI) assay and investigated cardiac testing in the 3 zones. METHODS Patients (n = 552) at a single urban center were enrolled if they were evaluated for AMI. Blood samples were obtained at presentation, 1 hour, and 3 hours for hs-cTnI. Follow-up at 30 to 45 days for death/AMI was done. The results of echocardiograms, stress testing, and coronary angiography were recorded. RESULTS In total, 45 (8.2%) had AMI (27 Type 1 and 18 Type 2) during the index hospitalization while at follow-up death/AMI occurred in 11 (2.0%) of patients. The rule-out algorithm had a negative predictive value for AMI of 99.6% while the rule-in zone had a positive predictive value of 56.6%. The MACE rate at follow-up was 0.4% for those in the rule-out group. There were 6/95 (6.3%) abnormal stress tests in the rule-out zone and 4 of these were false positives. CONCLUSIONS The 0/1-hour algorithm had high diagnostic sensitivity and negative predictive value for AMI, and adverse events were very low in patients in the rule-out zone. Noninvasive testing in rule-out zone patients had low diagnostic yield.
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76
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Raber I, McCarthy CP, Januzzi JL. A Test in Context: Interpretation of High-Sensitivity Cardiac Troponin Assays in Different Clinical Settings. J Am Coll Cardiol 2021; 77:1357-1367. [PMID: 33706879 DOI: 10.1016/j.jacc.2021.01.011] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Revised: 01/03/2021] [Accepted: 01/05/2021] [Indexed: 12/14/2022]
Abstract
High-sensitivity cardiac troponin (hs-cTn) assays have the ability to detect minute troponin concentrations and resolve minor changes in biomarker concentrations. Clinically, this allows for the ability to rapidly identify or exclude acute myocardial injury in the setting of acute chest discomfort-thus providing more rapid evaluation for acute myocardial infarction-but the improvements in troponin assays also create avenues for other applications where troponin release from the cardiomyocyte might confer prognostic information. These situations include cardiovascular risk assessment across a wide range of clinical circumstances, including apparently-well individuals, those at risk for heart disease, and those with prevalent cardiovascular disorders. The optimal hs-cTn threshold for each circumstance varies by the assay used and by the population assessed. This review will provide context for how hs-cTn assays might be interpreted depending on the application sought, reviewing results from studies leveraging hs-cTn for applications beyond "acute myocardial infarction diagnostic evaluation."
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Affiliation(s)
- Inbar Raber
- Division of Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA. https://twitter.com/InbarRaber
| | - Cian P McCarthy
- Division of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA. https://twitter.com/CianPMcCarthy
| | - James L Januzzi
- Division of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA; Baim Institute for Clinical Research, Boston, Massachusetts, USA.
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77
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Ren D, Huang T, Liu X, Xu G. High-sensitive cardiac troponin for the diagnosis of acute myocardial infarction in different chronic kidney disease stages. BMC Cardiovasc Disord 2021; 21:100. [PMID: 33596833 PMCID: PMC7888109 DOI: 10.1186/s12872-020-01746-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Accepted: 10/19/2020] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Chronic kidney disease (CKD) are associated with acute myocardial infarction (AMI). High-sensitive cardiac troponin (hs-cTn) has been evidenced to enhance the early diagnostic accuracy of AMI, but hs-cTn levels are often chronically elevated in CKD patients, which reduces their diagnostic utility. The aim of this study was to derive optimal cutoff-values of hs-cTn levels in patients with CKD and suspected AMI. METHODS In this retrospective paper, a total of 3295 patients with chest pain (2758 in AMI group and 537 in Non-AMI group) were recruited, of whom 23.1% were had an estimated glomerular filtration rate (eGFR) of < 60 mL min-1 (1.73 m2)-1. Hs-cTnI values were measured at presentation. RESULTS AMI was diagnosed in 83.7% of all patients. The optimal value of hs-TnI in diagnosing AMI was 1.15 ng mL-1, which were higher in males than females comparing different cutoff-values of subgroups divided by age, gender and renal function, and which increased monotonically with decreasing of eGFR because in patients with CKD without AMI, the correlation between hs-cTnI and renal function is low but significant (r2 = 0.067, P < 0.001). CONCLUSIONS Different optimal cutoff-values of hs-cTnI in the diagnosis of AMI in patients with CKD were helpful to the clinical diagnosis of AMI in various populations and were higher in males than females, but which was needed to be validated by multicenter randomized controlled clinical studies in the future.
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Affiliation(s)
- Daijin Ren
- Department of Nephrology, The Second Affiliated Hospital of Nanchang University, No. 1, Minde Road, Donghu District, Nanchang, 330006, People's Republic of China
| | - Tianlun Huang
- Department of Nephrology, The Second Affiliated Hospital of Nanchang University, No. 1, Minde Road, Donghu District, Nanchang, 330006, People's Republic of China
| | - Xin Liu
- Department of Nephrology, The Second Affiliated Hospital of Nanchang University, No. 1, Minde Road, Donghu District, Nanchang, 330006, People's Republic of China
| | - Gaosi Xu
- Department of Nephrology, The Second Affiliated Hospital of Nanchang University, No. 1, Minde Road, Donghu District, Nanchang, 330006, People's Republic of China.
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78
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Allen BR, Christenson RH, Cohen SA, Nowak R, Wilkerson RG, Mumma B, Madsen T, McCord J, Huis In't Veld M, Massoomi M, Stopyra JP, Montero C, Weaver MT, Yang K, Mahler SA. Diagnostic Performance of High-Sensitivity Cardiac Troponin T Strategies and Clinical Variables in a Multisite US Cohort. Circulation 2021; 143:1659-1672. [PMID: 33474976 DOI: 10.1161/circulationaha.120.049298] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
BACKGROUND European data support the use of low high-sensitivity troponin (hs-cTn) measurements or a 0/1-hour (0/1-h) algorithm for myocardial infarction to exclude major adverse cardiac events (MACEs) among patients in the emergency department with possible acute coronary syndrome. However, modest US data exist to validate these strategies. This study evaluated the diagnostic performance of an initial hs-cTnT measure below the limit of quantification (LOQ: 6 ng/L), a 0/1-h algorithm, and their combination with history, ECG, age, risk factors, and initial troponin (HEART) scores for excluding MACE in a multisite US cohort. METHODS A prospective cohort study was conducted at 8 US sites, enrolling adult patients in the emergency department with symptoms suggestive of acute coronary syndrome and without ST-elevation on ECG. Baseline and 1-hour blood samples were collected, and hs-cTnT (Roche; Basel, Switzerland) was measured. Treating providers blinded to hs-cTnT results prospectively calculated HEART scores. MACE (cardiac death, myocardial infarction, and coronary revascularization) at 30 days was adjudicated. The proportion of patients with initial hs-cTnT measures below the LOQ and risk according to a 0/1-h algorithm was determined. The negative predictive value (NPV) was calculated for both strategies when used alone or with a HEART score. RESULTS Among 1462 participants with initial hs-cTnT measures, 46.4% (678 of 1462) were women and 37.1% (542 of 1462) were Black with an age of 57.6±12.9 (mean±SD) years. MACEs at 30 days occurred in 14.4% (210 of 1462) of participants. Initial hs-cTnT measures below the LOQ occurred in 32.8% (479 of 1462), yielding an NPV of 98.3% (95% CI, 96.7-99.3) for 30-day MACEs. A low-risk HEART score with an initial hs-cTnT below the LOQ occurred in 20.1% (294 of 1462), yielding an NPV of 99.0% (95% CI, 97.0-99.8) for 30-day MACEs. A 0/1-h algorithm was complete in 1430 patients, ruling out 57.8% (826 of 1430) with an NPV of 97.2% (95% CI, 95.9-98.2) for 30-day MACEs. Adding a low HEART score to the 0/1-h algorithm ruled out 30.8% (441 of 1430) with an NPV of 98.4% (95% CI, 96.8-99.4) for 30-day MACEs. CONCLUSIONS In a prospective multisite US cohort, an initial hs-cTnT below the LOQ combined with a low-risk HEART score has a 99% NPV for 30-day MACEs. The 0/1-h hs-cTnT algorithm did not achieve an NPV >99% for 30-day MACEs when used alone or with a HEART score. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT02984436.
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Affiliation(s)
- Brandon R Allen
- Department of Emergency Medicine, College of Medicine (B.R.A., S.A.C., C.M.), University of Florida, Gainesville
| | - Robert H Christenson
- Departments of Pathology (R.H.C.), University of Maryland School of Medicine, Baltimore
| | - Scott A Cohen
- Department of Emergency Medicine, College of Medicine (B.R.A., S.A.C., C.M.), University of Florida, Gainesville
| | - Richard Nowak
- Department of Emergency Medicine (R.N.), Henry Ford Hospital, Detroit, MI
| | - R Gentry Wilkerson
- Emergency Medicine (R.G.W., M.H.i.V.), University of Maryland School of Medicine, Baltimore
| | - Bryn Mumma
- Department of Emergency Medicine, School of Medicine, University of California Davis, Sacramento (B.M.)
| | - Troy Madsen
- Division of Emergency Medicine, University of Utah School of Medicine, Salt Lake City (T.M.)
| | - James McCord
- Heart and Vascular Institute (J.M.), Henry Ford Hospital, Detroit, MI
- Department of Internal Medicine (J.M.), Henry Ford Hospital, Detroit, MI
| | - Maite Huis In't Veld
- Emergency Medicine (R.G.W., M.H.i.V.), University of Maryland School of Medicine, Baltimore
| | - Michael Massoomi
- Division of Cardiology, Department of Internal Medicine, College of Medicine (M.M.), University of Florida, Gainesville
| | - Jason P Stopyra
- Department of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, NC (J.P.S., S.A.M.)
| | - Cindy Montero
- Department of Emergency Medicine, College of Medicine (B.R.A., S.A.C., C.M.), University of Florida, Gainesville
| | - Michael T Weaver
- Department of Biobehavioral Nursing Science, College of Nursing (M.T.W.), University of Florida, Gainesville
| | - Kai Yang
- Department of Biostatistics, College of Public Health and Health Professions (K.Y.), University of Florida, Gainesville
| | - Simon A Mahler
- Department of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, NC (J.P.S., S.A.M.)
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Azar RR, Sarkis A, Giannitsis E. A Practical Approach for the Use of High-Sensitivity Cardiac Troponin Assays in the Evaluation of Patients With Chest Pain. Am J Cardiol 2021; 139:1-7. [PMID: 33164762 DOI: 10.1016/j.amjcard.2020.10.037] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Revised: 10/11/2020] [Accepted: 10/13/2020] [Indexed: 01/12/2023]
Abstract
Chest pain is a common clinical presentation, especially in the emergency department. Both rapid identification of patients with myocardial infarction as well as those with noncardiac chest pain is important in order to start therapy in the former and avoid unnecessary investigations and delay in discharge in the latter. Beside electrocardiogram, cardiac biomarkers are a key element in decision making. Conventional creatinine kinase and troponin assays are not sensitive enough and have to be repeated at least 6 to 12 hours after initial evaluation. New high-sensitivity cardiac troponin (hs-cTn) tests are currently available and if used appropriately can substantially improve management. Because of their high sensitivity and accuracy, these tests allow measurement of very low serum troponin levels, such as those present in healthy individuals and can detect small changes in troponin concentration within a short time frame. These tests are thus, very useful for the early diagnosis of myocardial infarction but can also be elevated in several other conditions that result in myocardial injury. A good understanding of the analytical characteristics of these assays is of uppermost importance for their appropriate use in clinical practice.
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Affiliation(s)
- Rabih R Azar
- Hotel Dieu de France Hospital and the St. Joseph University Faculty of Medicine, Beirut, Lebanon.
| | - Antoine Sarkis
- Hotel Dieu de France Hospital and the St. Joseph University Faculty of Medicine, Beirut, Lebanon
| | - Evangelos Giannitsis
- Medizinische Klinik III, Department of Cardiology, Angiology and Pneumology, University Hospital of Heidelberg, Heidelberg, Germany
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Albert C, Haase M, Albert A, Zapf A, Braun-Dullaeus RC, Haase-Fielitz A. Biomarker-Guided Risk Assessment for Acute Kidney Injury: Time for Clinical Implementation? Ann Lab Med 2021; 41:1-15. [PMID: 32829575 PMCID: PMC7443517 DOI: 10.3343/alm.2021.41.1.1] [Citation(s) in RCA: 38] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Revised: 05/23/2020] [Accepted: 08/02/2020] [Indexed: 01/01/2023] Open
Abstract
Acute kidney injury (AKI) is a common and serious complication in hospitalized patients, which continues to pose a clinical challenge for treating physicians. The most recent Kidney Disease Improving Global Outcomes practice guidelines for AKI have restated the importance of earliest possible detection of AKI and adjusting treatment accordingly. Since the emergence of initial studies examining the use of neutrophil gelatinase-associated lipocalin (NGAL) and cycle arrest biomarkers, tissue inhibitor metalloproteinase-2 (TIMP-2) and insulin-like growth factor-binding protein (IGFBP7), for early diagnosis of AKI, a vast number of studies have investigated the accuracy and additional clinical benefits of these biomarkers. As proposed by the Acute Dialysis Quality Initiative, new AKI diagnostic criteria should equally utilize glomerular function and tubular injury markers for AKI diagnosis. In addition to refining our capabilities in kidney risk prediction with kidney injury biomarkers, structural disorder phenotypes referred to as "preclinical-" and "subclinical AKI" have been described and are increasingly recognized. Additionally, positive biomarker test findings were found to provide prognostic information regardless of an acute decline in renal function (positive serum creatinine criteria). We summarize and discuss the recent findings focusing on two of the most promising and clinically available kidney injury biomarkers, NGAL and cell cycle arrest markers, in the context of AKI phenotypes. Finally, we draw conclusions regarding the clinical implications for kidney risk prediction.
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Affiliation(s)
- Christian Albert
- Medical Faculty, University Clinic for Cardiology and Angiology, Otto-von-Guericke-University Magdeburg, Magdeburg,
Germany
- Diaverum Renal Services, MVZ Potsdam, Potsdam,
Germany
| | - Michael Haase
- Diaverum Renal Services, MVZ Potsdam, Potsdam,
Germany
- Medical Faculty, Otto-von-Guericke University Magdeburg, Magdeburg,
Germany
| | - Annemarie Albert
- Diaverum Renal Services, MVZ Potsdam, Potsdam,
Germany
- Department of Nephrology and Endocrinology, Klinikum Ernst von Bergmann, Potsdam,
Germany
| | - Antonia Zapf
- Department of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf,
Germany
| | | | - Anja Haase-Fielitz
- Department of Cardiology, Immanuel Diakonie Bernau, Heart Center Brandenburg, Brandenburg Medical School Theodor Fontane (MHB),
Germany
- Institute of Social Medicine and Health Systems Research, Otto-von-Guericke University Magdeburg, Magdeburg,
Germany
- Faculty of Health Sciences Brandenburg, Potsdam,
Germany
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81
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Snaedal S, Bárány P, Lund SH, Qureshi AR, Heimbürger O, Stenvinkel P, Löwbeer C, Szummer K. High-sensitivity troponins in dialysis patients: variation and prognostic value. Clin Kidney J 2020; 14:1789-1797. [PMID: 34221386 PMCID: PMC8243265 DOI: 10.1093/ckj/sfaa215] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2019] [Revised: 09/08/2020] [Indexed: 11/23/2022] Open
Abstract
Background Dialysis patients have a high prevalence of cardiovascular mortality but also elevated cardiac troponins (cTns) even without signs of cardiac ischaemia. The study aims to assess variation and prognostic value of high-sensitivity cTnI and cTnT in prevalent dialysis patients. Methods In 198 prevalent haemodialysis (HD) and 78 peritoneal dialysis (PD) patients, 4-monthly serum troponin I and T measurements were obtained. Reference change values (RCVs) were used for variability assessment and competing-risk regression models for survival analyses; maximal follow-up was 50 months. Results HD and PD patients had similar troponin levels [median (interquartile range) troponin I: 25 ng/L (14–43) versus 21 ng/L (11–37), troponin T: 70 ng/L (44–129) versus 67 ng/L (43–123)]. Of troponin I and T levels, 42% versus 98% were above the decision level of myocardial infarction. RCVs were +68/−41% (troponin I) and +29/−23% (troponin T). Increased variability of troponins related to higher age, male sex, protein-energy wasting and congestive heart failure, but not ischaemic heart disease or dialysis form. Elevated troponin T, but not troponin I, predicted death after adjusting for confounders. Conclusions A large proportion of prevalent dialysis patients without current established or ongoing cardiac events have elevated levels of high-sensitivity cTns. Mortality risk was doubled in patients with persistently high troponin T levels. The large intraindividual variation of cTns suggests that serial measurements and reference change levels may be used to improve diagnostic utility. However, evidence-based recommendations require more data from large studies of dialysis patients with cardiac events.
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Affiliation(s)
- Sunna Snaedal
- Department of Clinical Science, Intervention and Technology, Division of Renal Medicine, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden.,Landspitali University Hospital, Reykjavik, Iceland
| | - Peter Bárány
- Department of Clinical Science, Intervention and Technology, Division of Renal Medicine, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Sigrún H Lund
- Faculty of Medicine, University of Iceland, Reykjavik, Iceland
| | - Abdul R Qureshi
- Department of Baxter Novum, Karolinska Institutet, Stockholm, Sweden
| | - Olof Heimbürger
- Department of Clinical Science, Intervention and Technology, Division of Renal Medicine, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Peter Stenvinkel
- Department of Clinical Science, Intervention and Technology, Division of Renal Medicine, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Christian Löwbeer
- Department of Laboratory Medicine, Division of Clinical Chemistry, Karolinska Institutet, Stockholm, Sweden.,Department of Clinical Chemistry, SYNLAB Medilab, Täby, Sweden
| | - Karolina Szummer
- Department of Medicine (Huddinge), Karolinska Institutet, Stockholm, Sweden.,Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden
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82
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Lee SH, Park J, Lee JH, Min JJ, Hong KY, Cho H, Carriere K, Ahn J. Comparison of pre- and postoperative myocardial injuries on mortality after non-cardiac surgery: a retrospective analysis using an inverse probability weighting adjustment. Sci Rep 2020; 10:21050. [PMID: 33273559 PMCID: PMC7713127 DOI: 10.1038/s41598-020-78023-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Accepted: 11/11/2020] [Indexed: 11/30/2022] Open
Abstract
Although both pre- and postoperative myocardial injuries are strongly associated with an increased postoperative mortality, no study has directly compared the effects of pre- and postoperative myocardial injuries on 30-day mortality after non-cardiac surgery. Therefore, we evaluated and compared the effects of pre- and postoperative myocardial injury on 30-day mortality after non-cardiac surgery. From January 2010 to December 2016, patients undergoing non-cardiac surgery were stratified into either the normal (n = 3182), preoperative myocardial injury (n = 694), or postoperative myocardial injury (n = 756) groups according to the peak cardiac troponin value. Myocardial injury was defined as a sole elevation of cardiac troponin value above the 99th percentile upper reference limit without ischemic symptom using the 4th universal definition of myocardial infarction. Patients in the preoperative myocardial injury group were further divided into the attenuated (n = 177) or persistent myocardial injury group (n = 517) according to the normalization of cardiac troponin level in postoperative period. As the primary outcome, postoperative 30-day mortalities were compared among the groups using the weighted Cox proportional-hazards regression models with the inverse probability weighting. Compared with the normal group, postoperative 30-day mortality was increased significantly both in the pre- and postoperative myocardial injury groups (1.4% vs. 10.7%; hazard ratio [HR] 3.12; 95% confidence interval [CI] 1.62-6.01; p = 0.001 and 1.4% vs. 7.4%; HR 4.49; 95% CI 2.34-8.60; p < 0.001, respectively), however, there was no difference between the pre- and postoperative myocardial injury groups (HR, 1.44; 95% CI 0.79-2.64; p = 0.45). In addition, the attenuated myocardial injury group showed a significantly lower postoperative 30-day mortality than the persistent myocardial injury group (5.6% vs. 12.4%; HR 2.23; 95% CI 1.17-4.44; p = 0.02). In patients undergoing non-cardiac surgery, preoperative myocardial injury also increased postoperative 30-day mortality to a similar degree of postoperative myocardial injury. Further studies on the importance of preoperative myocardial injury are needed.Clinical trial number and registry URL: KCT0004348 ( www.cris.nih.go.kr ).
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Affiliation(s)
- Seung-Hwa Lee
- Division of Cardiology, Department of Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jungchan Park
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, Korea
| | - Jong-Hwan Lee
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, Korea.
| | - Jeong Jin Min
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, Korea
| | - Kwan Young Hong
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, Korea
| | - Hyojin Cho
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, Korea
| | - Keumhee Carriere
- Department of Mathematical and Statistical Sciences, University of Alberta, Edmonton, AB, Canada
- Statistics and Data Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Joonghyun Ahn
- Statistics and Data Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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83
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Pudil R, Mueller C, Čelutkienė J, Henriksen PA, Lenihan D, Dent S, Barac A, Stanway S, Moslehi J, Suter TM, Ky B, Štěrba M, Cardinale D, Cohen‐Solal A, Tocchetti CG, Farmakis D, Bergler‐Klein J, Anker MS, Von Haehling S, Belenkov Y, Iakobishvili Z, Maack C, Ciardiello F, Ruschitzka F, Coats AJ, Seferovic P, Lainscak M, Piepoli MF, Chioncel O, Bax J, Hulot J, Skouri H, Hägler‐Laube ES, Asteggiano R, Fernandez TL, Boer RA, Lyon AR. Role of serum biomarkers in cancer patients receiving cardiotoxic cancer therapies: a position statement from the
Cardio‐Oncology Study Group
of the
Heart Failure Association
and the
Cardio‐Oncology Council of the European Society of Cardiology. Eur J Heart Fail 2020; 22:1966-1983. [DOI: 10.1002/ejhf.2017] [Citation(s) in RCA: 89] [Impact Index Per Article: 22.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2020] [Revised: 06/14/2020] [Accepted: 09/25/2020] [Indexed: 12/19/2022] Open
Affiliation(s)
- Radek Pudil
- 1st Department Medicine – Cardioangiology Charles University Prague, Medical Faculty and University Hospital Hradec Kralove Prague Czech Republic
| | - Christian Mueller
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology University Hospital Basel, University of Basel Basel Switzerland
| | - Jelena Čelutkienė
- Clinic of Cardiac and Vascular Diseases Institute of Clinical Medicine, Faculty of Medicine, Vilnius University Vilnius Lithuania
- State Research Institute Centre For Innovative Medicine Vilnius Lithuania
| | | | - Dan Lenihan
- Cardio‐Oncology Center of Excellence Washington University in St Louis St Louis MO USA
| | - Susan Dent
- Duke Cancer Institute Duke University Durham NC USA
| | - Ana Barac
- MedStar Heart and Vascular Institute Georgetown University Washington DC USA
| | | | - Javid Moslehi
- Cardio‐Oncology Program, Department of Medicine Vanderbilt University Medical Center Nashville TN USA
| | - Thomas M. Suter
- Department of Cardiology Bern University Hospital, Inselspital, University of Bern Bern Switzerland
| | - Bonnie Ky
- University of Pennsylvania Philadelphia PA USA
| | - Martin Štěrba
- Department of Pharmacology Faculty of Medicine in Hradec Kralove, Charles University Hradec Kralove Czech Republic
| | - Daniela Cardinale
- Cardioncology Unit European Institute of Oncology, IRCCS Milan Italy
| | - Alain Cohen‐Solal
- UMR‐S 942, Paris University, Cardiology Department, Lariboisiere Hospital, AP‐HP Paris France
| | - Carlo Gabriele Tocchetti
- Department of Translational Medical Sciences and Interdepartmental Center for Clinical and Translational Research (CIRCET) ‘Federico II’ University Naples Italy
| | - Dimitrios Farmakis
- University of Cyprus Medical School Nicosia Cyprus
- Cardio‐Oncology Clinic, Heart Failure Unit, ‘Attikon’ University Hospital Athens Greece
- National and Kapodistrian University of Athens Medical School Athens Greece
| | | | - Markus S. Anker
- Division of Cardiology and Metabolism, Department of Cardiology Charité and Berlin Institute of Health Center for Regenerative Therapies (BCRT) and DZHK (German Centre for Cardiovascular Research), partner site Berlin and Department of Cardiology, Charité Campus Benjamin Franklin Berlin Germany
| | - Stephan Von Haehling
- Department of Cardiology and Pneumology University of Goettingen Medical Center Goettingen Germany
- German Center for Cardiovascular Research (DZHK), partner site Goettingen Goettingen Germany
| | | | - Zaza Iakobishvili
- Department of Community Cardiology Tel Aviv Jaffa District, Clalit Health Fund and Sackler Faculty of Medicine, Tel Aviv University Tel Aviv Israel
| | - Christoph Maack
- Comprehensive Heart Failure Center University Clinic Würzburg Würzburg Germany
| | - Fortunato Ciardiello
- Department of Precision Medicine ‘Luigi Vanvitelli’ University of Campania Naples Italy
| | - Frank Ruschitzka
- University Heart Center, Department of Cardiology University Hospital Zurich Zurich Switzerland
| | - Andrew J.S. Coats
- University of Warwick Warwick UK
- Pharmacology Centre of Clinical and Experimental Medicine, IRCCS San Raffaele Pisana Rome Italy
| | - Petar Seferovic
- Faculty of Medicine and Serbian Academy of Sciences and Arts University of Belgrade Belgrade Serbia
| | | | - Massimo F. Piepoli
- Cardiac Department ‘Guglielmo da Saliceto’ Polichirurgico Hospital AUSL Piacenza Piacenza Italy
| | - Ovidiu Chioncel
- Emergency Institute for Cardiovascular Diseases ‘Prof. C.C. Iliescu’ Bucharest Romania
- University of Medicine Carol Davila Bucharest Romania
| | - Jereon Bax
- Department of Cardiology Leiden University Medical Centre Leiden The Netherlands
| | - Jean‐Sebastien Hulot
- Université de Paris CIC1418, Paris Cardiovascular Research Center, INSERM Paris France
| | - Hadi Skouri
- Cardiology Division, Internal Medicine Department at American University of Beirut Medical Center Beirut Lebanon
| | | | | | - Teresa Lopez Fernandez
- Cardiology Service Cardio‐Oncology Unit, La Paz University Hospital and IdiPAz Research Institute, Ciber CV Madrid Spain
| | - Rudolf A. Boer
- Department of Cardiology University of Groningen, University Medical Center Groningen Groningen The Netherlands
| | - Alexander R. Lyon
- Cardio‐Oncology Service Royal Brompton Hospital and Imperial College London London UK
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84
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Park J, Hyeon CW, Lee SH, Kim J, Kwon JH, Yang K, Min JJ, Lee JH, Lee SM, Yang JH, Song YB, Hahn JY, Choi JH, Choi SH, Kim K, Ahn J, Gwon HC. Mildly Elevated Cardiac Troponin below the 99th-Percentile Upper Reference Limit after Noncardiac Surgery. Korean Circ J 2020; 50:925-937. [PMID: 32812403 PMCID: PMC7515753 DOI: 10.4070/kcj.2020.0088] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2020] [Revised: 06/04/2020] [Accepted: 06/21/2020] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND AND OBJECTIVES In patients with perioperative cardiac troponin (cTn) I below the 99th-percentile upper range of limit (URL), mortality according to cTn I level has not been fully evaluated. This study evaluated the association between postoperative cTn I level above the lowest limit of detection but within the 99th-percentile URL and 30-day mortality after noncardiac surgery. METHODS Patients with cTn I values below the 99th-percentile URL during the perioperative period were divided into a no-elevation group with cTn I at the lowest limit of detection (6 ng/L) and a minor elevation group with cTn I elevation below the 99th percentile URL (6 ng/L < cTn I < 40 ng/L). The primary outcome was 30-day mortality. RESULTS Of the 5,312 study participants, 2,582 (48.6%) were included in the no-elevation group and 2,730 (51.4%) were included in the minor elevation group. After propensity score-matching, the minor elevation group showed significantly increased 30-day mortality (0.5% vs. 2.3%; hazard ratio, 4.30; 95% confidence interval, 2.23-8.29; p<0.001). The estimated cutoff value of cTn I to predict 30-day mortality was 6 ng/L with the area under the receiver operating characteristic curve 0.657. CONCLUSIONS A mild elevation of cTn I within the 99th-percentile URL after noncardiac surgery was significantly associated with increased 30-day mortality as compared with the lowest limit of detection. TRIAL REGISTRATION Clinical Research Information Service Identifier: KCT0004244.
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Affiliation(s)
- Jungchan Park
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Cheol Won Hyeon
- Division of Cardiology, Department of Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Seung Hwa Lee
- Division of Cardiology, Department of Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.
| | - Jihoon Kim
- Division of Cardiology, Department of Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Ji Hye Kwon
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Kwangmo Yang
- Center for Health Promotion, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jeong Jin Min
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jong Hwan Lee
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Sangmin Maria Lee
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jeong Hoon Yang
- Division of Cardiology, Department of Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Young Bin Song
- Division of Cardiology, Department of Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Joo Yong Hahn
- Division of Cardiology, Department of Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jin Ho Choi
- Division of Cardiology, Department of Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
- Department of Emergency Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Seung Hyuk Choi
- Division of Cardiology, Department of Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Kyunga Kim
- Statistics and Data Center, Research Institute for Future Medicine, Samsung Medical Center, Seoul, Korea
- Department of Digital Health, Samsung Advanced Institute for Health Sciences & Technology (SAIHST), Sungkyunkwan University, Seoul, Korea
| | - Joonghyun Ahn
- Statistics and Data Center, Research Institute for Future Medicine, Samsung Medical Center, Seoul, Korea
| | - Hyeon Cheol Gwon
- Division of Cardiology, Department of Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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85
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Park J, Lee SH, Lee JH, Min JJ, Kwon JH, Oh AR, Carriere K, Ahn J. Volatile versus total intravenous anesthesia for 30-day mortality following non-cardiac surgery in patients with preoperative myocardial injury. PLoS One 2020; 15:e0238661. [PMID: 32915840 PMCID: PMC7485855 DOI: 10.1371/journal.pone.0238661] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Accepted: 08/20/2020] [Indexed: 11/19/2022] Open
Abstract
We evaluated whether volatile anesthetics can improve the postoperative outcomes of non-cardiac surgery in patients with preoperative myocardial injury defined by the cardiac troponin elevation. From January 2010 to June 2018, 1254 adult patients with preoperative myocardial injury underwent non-cardiac surgery under general anesthesia and were enrolled in this study. Patients were stratified into following two groups according to anesthetic agents; 115 (9.2%) patients whose anesthesia was induced and maintained with continuous infusion of propofol and remifentanil (TIVA group) and 1139 (90.8%) patients whose anesthesia was maintainted with volatile anesthetics (VOLATILE group). The primary outcome was 30-day mortality. To diminish the remifentanil effect, a further analysis was conducted after excluding the patients who received only volatile anesthetics without remifentanil infusion. In a propensity-score matched analysis, 30-day mortality was higher in the TIVA group than the VOLATILE group (17.0% vs. 9.1%; hazard ratio [HR] 2.60; 95% confidence interval [CI], 1.14-5.93; p = 0.02). In addition, the TIVA group showed higher 30-day mortality than the VOLATILE group, even after eliminating the effect of remifentanil infusion (15.8% vs. 8.3%; HR 4.62; 95% CI, 1.82-11.74; p = 0.001). In our study, the use of volatile anesthetics showed the significant survival improvement after non-cardiac surgery in patients with preoperative myocardial injury, which appears to be irrelevant to the remifentanil use. Further studies are needed to confirm this beneficial effect of volatile anesthetics. Clinical trial number and registry URL: KCT0004349 (www.cris.nih.go.kr).
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Affiliation(s)
- Jungchan Park
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Seung-Hwa Lee
- Department of Cardiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jong-Hwan Lee
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
- * E-mail:
| | - Jeong Jin Min
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Ji-Hye Kwon
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Ah-ran Oh
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Keumhee Carriere
- Statistics and Data Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
- Department of Mathematical and Statistical Sciences, University of Alberta, Edmonton, AB, Canada
| | - Joonghyun Ahn
- Statistics and Data Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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86
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Junarta J, Fernandez M, Chung I, Salha A, Klaud Francheska BD, Lowe-Jones R, Sharma R, Firoozi S, Banerjee D. Role of a cardio-renal multi-disciplinary team meeting in managing cardiovascular risk in patients on kidney transplant waitlists. Clin Transplant 2020; 34:e14061. [PMID: 32780546 DOI: 10.1111/ctr.14061] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Revised: 07/26/2020] [Accepted: 08/03/2020] [Indexed: 12/17/2022]
Abstract
BACKGROUND Waitlisted kidney transplant patients suffer from excess cardiovascular events. The benefits of regular cardiac investigations, potentially harmful and expensive, are unknown. We investigate the effectiveness of a cardio-renal MDT in managing high cardiovascular risk waitlisted transplant patients to prevent events and enable transplantation. METHODS Clinical outcomes in waitlisted transplant candidates managed by our cardio-renal MDT protocol were compared against our standard protocol. Data compared include the transplantation, event, and death rates, cost of cardiac investigations and procedures, and graft, patient survival, and re-hospitalization rates in transplanted patients. RESULTS 207 patients were studied (81 standard, 126 cardio-renal MDT). Over 2.7 years, the cardio-renal MDT protocol transplanted more patients than the standard group (35% vs 21%; P = .02). The managing cost per patient per year was higher in the standard group (£692 vs £610). This was driven by more echocardiograms and more tests per patient in the standard group (P < .01). There was no difference in adverse events or death. There was no difference in re-hospitalization, graft or patient survival rate in transplanted patients. CONCLUSIONS Our cardio-renal MDT was effective in managing high-risk kidney transplant candidates with greater rates of transplantation and low rates of events at a lower cost.
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Affiliation(s)
- Joey Junarta
- Renal and Transplantation Unit, St George's University Hospitals NHS Foundation Trust, London, UK.,Cardiology Clinical Academic Group, Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
| | - Maria Fernandez
- Renal and Transplantation Unit, St George's University Hospitals NHS Foundation Trust, London, UK
| | - Isaac Chung
- Renal and Transplantation Unit, St George's University Hospitals NHS Foundation Trust, London, UK
| | - Ahmad Salha
- Renal and Transplantation Unit, St George's University Hospitals NHS Foundation Trust, London, UK
| | | | - Racquel Lowe-Jones
- Renal and Transplantation Unit, St George's University Hospitals NHS Foundation Trust, London, UK
| | - Rajan Sharma
- Cardiology Clinical Academic Group, Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
| | - Sami Firoozi
- Cardiology Clinical Academic Group, Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
| | - Debasish Banerjee
- Renal and Transplantation Unit, St George's University Hospitals NHS Foundation Trust, London, UK.,Cardiology Clinical Academic Group, Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
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87
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Widimsky P, Crea F, Binder RK, Lüscher TF. The year in cardiology 2018: acute coronary syndromes. Eur Heart J 2020; 40:271-282. [PMID: 30601993 DOI: 10.1093/eurheartj/ehy904] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2018] [Accepted: 12/26/2018] [Indexed: 01/05/2023] Open
Affiliation(s)
- Petr Widimsky
- Cardiocenter, Third Faculty of Medicine, Charles University, Hospital Kralovske Vinohrady, Ruska 87, Prague 10, Czech Republic
| | - Filippo Crea
- Department of Cardiovascular and Thoracic Sciences, Policlinico A. Gemelli-IRCCS, Catholic University, Roma, Italy
| | - Ronald K Binder
- Cardiology and Intensive Care, University Teaching Hospital Klinikum Wels Grieskirchen, A-4600 Wels, Austria
| | - Thomas F Lüscher
- Royal Brompton and Harefield Hospitals and Imperial College, London, UK.,Center for Molecular Cardiology, University of Zurich, Zurich, Switzerland
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88
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Interpreting troponin in renal disease: A narrative review for emergency clinicians. Am J Emerg Med 2020; 38:990-997. [DOI: 10.1016/j.ajem.2019.11.041] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2019] [Revised: 11/16/2019] [Accepted: 11/26/2019] [Indexed: 01/11/2023] Open
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89
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Sundaram V, Rothnie K, Bloom C, Zakeri R, Sahadevan J, Singh A, Nagai T, Potts J, Wedzicha J, Smeeth L, Simon D, Timmis A, Rajagopalan S, Quint JK. Impact of comorbidities on peak troponin levels and mortality in acute myocardial infarction. Heart 2020; 106:677-685. [PMID: 32102896 DOI: 10.1136/heartjnl-2019-315844] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2019] [Revised: 12/13/2019] [Accepted: 12/15/2019] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVES To characterise peak cardiac troponin levels, in patients presenting with acute myocardial infarction (AMI), according to their comorbid condition and determine the influence of peak cardiac troponin (cTn) levels on mortality. METHODS We included patients with the first admission for AMI in the UK. We used linear regression to estimate the association between eight common comorbidities (diabetes mellitus, previous angina, peripheral arterial disease, previous myocardial infarction (MI), chronic kidney disease (CKD), cerebrovascular disease, chronic heart failure (CHF) and chronic obstructive pulmonary disease (COPD)) and peak cTn. Peak cTn levels were adjusted for age, sex, smoking status and comorbidities. Logistic regression and restricted cubic spline models were employed to investigate the association between peak cTn and 180-day mortality for each comorbidity. RESULTS 330 367 patients with ST elevation myocardial infarction and non-ST elevation myocardial infarction were identified. Adjusted peak cTn levels were significantly higher in patients with CKD (adjusted % difference in peak cTnT for CKD=42%, 95% CI 13.1 to 78.4) and significantly lower for patients with COPD, previous angina, previous MI and CHF when compared with patients without the respective comorbidities (reference group) (cTnI; COPD=-21.7%, 95% CI -29.1 to -13.4; previous angina=-24.2%, 95% CI -29.6 to -8.3; previous MI=-13.5%, 95% CI -20.6 to -5.9; CHF=-28%, 95% CI -37.2 to -17.6). Risk of 180-day mortality in most of the comorbidities did not change substantially after adjusting for peak cTn. In general, cTnI had a stronger association with mortality than cTnT. CONCLUSIONS In this nationwide analysis of patients presenting with AMI, comorbidities substantially influenced systemic concentrations of peak cTn. Comorbid illness is a significant predictor of mortality regardless of peak cTn levels and should be taken into consideration while interpreting cTn both as a diagnostic and prognostic biomarker.
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Affiliation(s)
- Varun Sundaram
- National Heart and Lung Institute, Imperial College London, London, UK.,Cardiovascular Medicine, University Hospitals Harrington Heart and Vascular Institute,Case Western Reserve University, Cleveland, United States
| | - Kieran Rothnie
- National Heart and Lung Institute, Imperial College London, London, UK
| | - Chloe Bloom
- National Heart and Lung Institute, Imperial College London, London, UK
| | - Rosita Zakeri
- National Heart and Lung Institute, Imperial College London, London, UK.,Department of Cardiology, Royal Brompton and Harefield NHS Foundation Trust, London, UK
| | | | - Ajay Singh
- Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | | | - James Potts
- National Heart and Lung Institute, Imperial College London, London, UK
| | - Jadwiga Wedzicha
- National Heart and Lung Institute, Imperial College London, London, UK
| | - Liam Smeeth
- Department of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Daniel Simon
- Cardiovascular Medicine, University Hospitals Harrington Heart and Vascular Institute,Case Western Reserve University, Cleveland, United States
| | - Adam Timmis
- NIHR Cardiovascular Biomedical Research Unit, Bart's Heart Centre, london, UK
| | - Sanjay Rajagopalan
- Cardiovascular Medicine, University Hospitals Harrington Heart and Vascular Institute,Case Western Reserve University, Cleveland, United States
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90
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Nowak RM, Christenson RH, Jacobsen G, McCord J, Apple FS, Singer AJ, Limkakeng A, Peacock WF, deFilippi CR. Performance of Novel High-Sensitivity Cardiac Troponin I Assays for 0/1-Hour and 0/2- to 3-Hour Evaluations for Acute Myocardial Infarction: Results From the HIGH-US Study. Ann Emerg Med 2020; 76:1-13. [PMID: 32046869 DOI: 10.1016/j.annemergmed.2019.12.008] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2019] [Revised: 11/27/2019] [Accepted: 12/04/2019] [Indexed: 11/15/2022]
Abstract
STUDY OBJECTIVE We determine the accuracy of high-sensitivity cardiac troponin I (hs-cTnI), European-derived, rapid, acute myocardial infarction, rule-out/rule-in algorithms applied to a US emergency department (ED) population. METHODS Adults presenting to the ED with suspected acute myocardial infarction were included. Plasma samples collected at baseline and between 40 and 90 minutes and 2 and 3 hours later were analyzed in core laboratories using the Siemens Healthineers hs-cTnI assays. Acute myocardial infarction diagnosis was independently adjudicated. The sensitivity, specificity, and negative and positive predictive values for rapid acute myocardial infarction rule-out/rule-in using European algorithms and 30-day outcomes are reported. RESULTS From 29 US medical centers, 2,113 subjects had complete data for the 0/1-hour algorithm analyses. With the Siemens Atellica Immunoassay hs-cTnI values, 1,065 patients (50.4%) were ruled out, with a negative predictive value of 99.7% and sensitivity of 98.7% (95% confidence interval 99.2% to 99.9% and 96.3% to 99.6%, respectively), whereas 265 patients (12.6%) were ruled in, having a positive predictive value of 69.4% and specificity of 95.7% (95% confidence interval 63.6% to 74.7% and 94.7% to 96.5%, respectively). The remaining 783 patients (37.1%) were classified as having continued evaluations, with an acute myocardial infarction incidence of 5.6% (95% confidence interval 4.2% to 7.5%). The overall 30-day risk of death or postdischarge acute myocardial infarction was very low in the ruled-out patients but was incrementally increased in the other groups (rule-out 0.2%; continued evaluations 2.1%; rule-in 4.8%). Equivalent results were observed in the 0/2- to 3-hour analyses and when both algorithms were applied to the hs-cTnI ADVIA Centaur measurements. CONCLUSION The European rapid rule-out/rule-in acute myocardial infarction algorithm hs-cTnI cut points can be harmonized with a demographically and risk-factor diverse US ED population.
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Affiliation(s)
- Richard M Nowak
- Department of Emergency Medicine, Henry Ford Health System, Detroit, MI.
| | | | - Gordon Jacobsen
- Department of Epidemiology and Statistics, Henry Ford Health System, Detroit, MI
| | - James McCord
- Heart and Vascular Institute, Henry Ford Health System, Detroit, MI
| | - Fred S Apple
- Department of Laboratory Medicine and Pathology, Hennepin County Medical Center of Hennepin Healthcare and University of Minnesota-Minneapolis, Minneapolis, MN
| | - Adam J Singer
- Department of Emergency Medicine, SUNY Stony Brook, Stony Brook, NY
| | - Alexander Limkakeng
- Department of Medicine, Division of Emergency, Medicine, Duke University School of Medicine, Durham, NC
| | - William F Peacock
- Department of Emergency Medicine, Baylor College of Medicine, Houston, TX
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91
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Haller PM, Boeddinghaus J, Neumann JT, Sörensen NA, Hartikainen TS, Goßling A, Nestelberger T, Twerenbold R, Lehmacher J, Keller T, Zeller T, Blankenberg S, Mueller C, Westermann D. Performance of the ESC 0/1-h and 0/3-h Algorithm for the Rapid Identification of Myocardial Infarction Without ST-Elevation in Patients With Diabetes. Diabetes Care 2020; 43:460-467. [PMID: 31843947 PMCID: PMC9162128 DOI: 10.2337/dc19-1327] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2019] [Accepted: 11/09/2019] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Patients with diabetes mellitus (DM) have elevated levels of high-sensitivity cardiac troponin (hs-cTn). We investigated the diagnostic performance of the European Society of Cardiology (ESC) algorithms to rule out or rule in acute myocardial infarction (AMI) without ST-elevation in patients with DM. RESEARCH DESIGN AND METHODS We prospectively enrolled 3,681 patients with suspected AMI and stratified those by the presence of DM. The ESC 0/1-h and 0/3-h algorithms were used to calculate negative and positive predictive values (NPV, PPV). In addition, alternative cutoffs were calculated and externally validated in 2,895 patients. RESULTS In total, 563 patients (15.3%) had DM, and 137 (24.3%) of these had AMI. When the ESC 0/1-h algorithm was used, the NPV was comparable in patients with and without DM (absolute difference [AD] -1.50 [95% CI -5.95, 2.96]). In contrast, the ESC 0/3-h algorithm resulted in a significantly lower NPV in patients with DM (AD -2.27 [95% CI -4.47, -0.07]). The diagnostic performance for rule-in of AMI (PPV) was comparable in both groups: 0/1-h (AD 6.59 [95% CI -19.53, 6.35]) and 0/3-h (AD 1.03 [95% CI -7.63, 9.7]). Alternative cutoffs increased the PPV in both algorithms significantly, while improvements in NPV were only subtle. CONCLUSIONS Application of the ESC 0/1-h algorithm revealed comparable safety to rule out AMI comparing patients with and without DM, while this was not observed with the ESC 0/3-h algorithm. Although alternative cutoffs might be helpful, patients with DM remain a high-risk population in whom identification of AMI is challenging and who require careful clinical evaluation.
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Affiliation(s)
- Paul M Haller
- Department for Cardiology, University Heart and Vascular Center Hamburg, Hamburg, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - Jasper Boeddinghaus
- Department of Cardiology, Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Basel, Switzerland
- Division of Internal Medicine, University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT (Global Research on Acute Conditions Team) Network, Rome, Italy
| | - Johannes T Neumann
- Department for Cardiology, University Heart and Vascular Center Hamburg, Hamburg, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - Nils A Sörensen
- Department for Cardiology, University Heart and Vascular Center Hamburg, Hamburg, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - Tau S Hartikainen
- Department for Cardiology, University Heart and Vascular Center Hamburg, Hamburg, Germany
| | - Alina Goßling
- Department for Cardiology, University Heart and Vascular Center Hamburg, Hamburg, Germany
| | - Thomas Nestelberger
- Department of Cardiology, Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT (Global Research on Acute Conditions Team) Network, Rome, Italy
| | - Raphael Twerenbold
- Department of Cardiology, Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT (Global Research on Acute Conditions Team) Network, Rome, Italy
| | - Jonas Lehmacher
- Department for Cardiology, University Heart and Vascular Center Hamburg, Hamburg, Germany
| | - Till Keller
- Kerckhoff Herzforschungsinstitut, University Giessen, Bad Nauheim, Germany
| | - Tanja Zeller
- Department for Cardiology, University Heart and Vascular Center Hamburg, Hamburg, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - Stefan Blankenberg
- Department for Cardiology, University Heart and Vascular Center Hamburg, Hamburg, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - Christian Mueller
- Department of Cardiology, Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT (Global Research on Acute Conditions Team) Network, Rome, Italy
| | - Dirk Westermann
- Department for Cardiology, University Heart and Vascular Center Hamburg, Hamburg, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany
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92
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Tan WCJ, Inoue K, AbdelWareth L, Giannitsis E, Kasim S, Shiozaki M, Aw TC, Cheng F, Dung HT, Li YH, Lim SH, Lukito AA, Than M, Chu FY, Devasia T, Lee CC, Phrommintikul A, Youn JC, Chew DP. The Asia-Pacific Society of Cardiology (APSC) Expert Committee Consensus Recommendations for Assessment of Suspected Acute Coronary Syndrome Using High-Sensitivity Cardiac Troponin T in the Emergency Department. Circ J 2019; 84:136-143. [PMID: 31852863 DOI: 10.1253/circj.cj-19-0874] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
The Asia-Pacific Society of Cardiology (APSC) high-sensitivity troponin T (hs-TnT) consensus recommendations and rapid algorithm were developed to provide guidance for healthcare professionals in the Asia-Pacific region on assessing patients with suspected acute coronary syndrome (ACS) using a hs-TnT assay. Experts from Asia-Pacific convened in 2 meetings to develop evidence-based consensus recommendations and an algorithm for appropriate use of the hs-TnT assay. The Expert Committee defined a cardiac troponin assay as a high-sensitivity assay if the total imprecision is ≤10% at the 99th percentile of the upper reference limit and measurable concentrations below the 99th percentile are attainable with an assay at a concentration value above the assay's limit of detection for at least 50% of healthy individuals. Recommendations for single-measurement rule-out/rule-in cutoff values, as well as for serial measurements, were also developed. The Expert Committee also adopted similar hs-TnT cutoff values for men and women, recommended serial hs-TnT measurements for special populations, and provided guidance on the use of point-of-care troponin T devices in individuals suspected of ACS. These recommendations should be used in conjunction with all available clinical evidence when making the diagnosis of ACS.
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Affiliation(s)
- Wei Chieh Jack Tan
- Department of Cardiology, National Heart Centre Singapore.,Department of Cardiology, Sengkang General Hospital
| | - Kenji Inoue
- Department of Cardiology, Juntendo University Nerima Hospital
| | | | - Evangelos Giannitsis
- Departments of Cardiology, Angiology and Pulmonology, University Hospital Heidelberg
| | | | | | - Tar Choon Aw
- Department of Laboratory Medicine, Changi General Hospital
| | | | - Ho Thuong Dung
- Cardiovascular Center and Interventional Cardiology, Thong Nhat Hospital
| | - Yi-Heng Li
- Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University
| | - Swee Han Lim
- Department of Emergency Medicine, Singapore General Hospital
| | | | - Martin Than
- Department of Emergency Medicine, Christchurch Public Hospital
| | - Fang-Yeh Chu
- Department of Clinical Pathology, Far Eastern Memorial Hospital.,Graduate School of Biotechnology and Bioengineering, Yuan Ze University.,Department of Medical Laboratory Science and Biotechnology, Yuanpei University of Medical Technology
| | - Tom Devasia
- Department of Cardiology, Kasturba Medical College, Manipal Academy of Higher Education
| | - Chien-Chang Lee
- Department of Emergency Medicine, National Taiwan University Hospital
| | | | - Jong-Chan Youn
- Division of Cardiology, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea
| | - Derek P Chew
- Department of Cardiovascular Medicine, Flinders University
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93
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Banerjee D, Perrett C, Banerjee A. Troponins, Acute Coronary Syndrome and Renal Disease: From Acute Kidney Injury Through End-stage Kidney Disease. Eur Cardiol 2019; 14:187-190. [PMID: 31933690 PMCID: PMC6950405 DOI: 10.15420/ecr.2019.28.2] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2019] [Accepted: 08/07/2019] [Indexed: 12/27/2022] Open
Abstract
The diagnosis of acute coronary syndromes (ACS) is heavily dependent on cardiac biomarker assays, particularly cardiac troponins. ACS, particularly non-ST segment elevation MI, are more common in patients with acute kidney injury, chronic kidney disease (CKD) and end-stage kidney disease (ESKD), are associated with worse outcomes than in patients without kidney disease and are often difficult to diagnose and treat. Hence, early accurate diagnosis of ACS in kidney disease patients is important using easily available tools, such as cardiac troponins. However, the diagnostic reliability of cardiac troponins has been suboptimal in patients with kidney disease due to possible decreased clearance of troponin with acute and chronic kidney impairment and low levels of troponin secretion due to concomitant cardiac muscle injury related to left ventricular hypertrophy, inflammation and fibrosis. This article reviews the metabolism and utility of cardiac biomarkers in patients with acute and chronic kidney diseases. Cardiac troponins are small peptides that accumulate in both acute and chronic kidney diseases due to impaired excretion. Hence, troponin concentrations rise and fall with acute kidney injury and its recovery, limiting their use in the diagnosis of ACS. Troponin concentrations are chronically elevated in CKD and ESKD, are associated with poor prognosis and decrease the sensitivity and specificity for diagnosis of ACS. Yet, the evidence indicates that the use of high-sensitivity troponins can confirm or exclude a diagnosis of ACS in the emergency room in a significant proportion of kidney disease patients; those patients in whom the results are equivocal may need longer in-hospital assessment.
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Affiliation(s)
- Debasish Banerjee
- Renal and Transplantation Unit, St George’s University Hospital NHS Foundation TrustLondon, UK
- Cardiology Clinical Academic Group, Molecular and Clinical Sciences Research Institute, St George’s, University of LondonLondon, UK
| | - Charlotte Perrett
- Renal and Transplantation Unit, St George’s University Hospital NHS Foundation TrustLondon, UK
| | - Anita Banerjee
- Women’s Health, Guy’s and St Thomas’ NHS Foundation TrustLondon, UK
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94
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Lan NSR, Bell DA. Revisiting the Biological Variability of Cardiac Troponin: Implications for Clinical Practice. Clin Biochem Rev 2019; 40:201-216. [PMID: 31857741 PMCID: PMC6892703 DOI: 10.33176/aacb-19-00032] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
The diagnosis of acute myocardial injury requires a rise and/or fall of cardiac troponin (cTn) on serial testing, with at least one concentration above the 99th percentile value of a normal reference population according to the recently published Fourth Universal Definition of Myocardial Infarction.1 However, the magnitude of change in cTn that constitutes a significant rise and/or fall was again not specified in detail. High-sensitivity cardiac troponin (hs-cTn) assays can measure ten-fold lower concentrations of cTn with more precision than older assays, and can accurately quantify cTn in more than 50% of healthy individuals with a coefficient of variation of less than 10% at the 99th percentile. These hs-cTn assays are also able to detect the normal variations in cTn results that are due to biological variability. Understanding and quantifying the normal variations in cTn is important as this would allow significant changes to be better defined. Numerous studies have sought to investigate the biological variability of cTn over the last ten years. Such studies are usually conducted in healthy individuals, however individuals with chronic cardiac disease or chronic renal failure have also been examined. These studies have yielded varying results in regards to significant change values for cTn. In light of the recent redefinition for myocardial infarction, the purpose of this mini-review is to revisit the biological variability of cTn. In particular, we outline concepts for determining a significant change value, review the results of previous studies on the biological variation of cTn and discuss potential considerations for clinical practice.
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Affiliation(s)
- Nick S R Lan
- Department of Cardiology, Fiona Stanley Hospital, Perth, WA
- Medical School, The University of Western Australia, Perth, WA
| | - Damon A Bell
- Medical School, The University of Western Australia, Perth, WA
- Department of Cardiology, Lipid Disorders Clinic, Royal Perth Hospital, Perth, WA
- Department of Clinical Biochemistry, PathWest Laboratory Medicine, Royal Perth and Fiona Stanley Hospitals, Perth, WA
- Department of Clinical Biochemistry, Clinipath Pathology, Perth, WA, Australia
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95
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Monneret D, Hausfater P, Riou B, Bonnefont-Rousselot D. Estimated GFR-specific 99th percentiles for high-sensitive cardiac troponin T based on the adjusted analytical change limit (adjACL) in hospitalized patients. Clin Chem Lab Med 2019; 57:e5-e7. [PMID: 30004901 DOI: 10.1515/cclm-2018-0485] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2018] [Accepted: 06/12/2018] [Indexed: 11/15/2022]
Affiliation(s)
- Denis Monneret
- Department of Metabolic Biochemistry, Pitié Salpêtrière-Charles Foix University Hospital, AP-HP, Paris, France
| | - Pierre Hausfater
- Emergency Department, Pitié Salpêtrière-Charles Foix University Hospital, AP-HP, Paris, France.,Sorbonne University, GRC-UPMC BIOSFAST, Paris, France
| | - Bruno Riou
- Emergency Department, Pitié Salpêtrière-Charles Foix University Hospital, AP-HP, Paris, France.,Sorbonne University, GRC-UPMC BIOSFAST, Paris, France
| | - Dominique Bonnefont-Rousselot
- Department of Metabolic Biochemistry, Pitié Salpêtrière-Charles Foix University Hospital, AP-HP, Paris, France.,Sorbonne Paris Cité, Paris Descartes University, CNRS UMR8258-INSERM U1022, Faculty of Pharmacy, Paris, France
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96
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Ünlü S, Nurkoç SG, Sezenöz B, Cingirt M, Gülbahar Ö, Abacı A. Impact of statin use on high sensitive troponin T levels with moderate exercise. Acta Cardiol 2019; 74:380-385. [PMID: 30328783 DOI: 10.1080/00015385.2018.1510801] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Background: High-sensitive cardiac troponin (hsTn) levels can be elevated due to non-pathological events such as strenuous exercise. However, the effect of statins on circulating hsTnT levels with moderate exercise is uncertain. Therefore, we evaluated the impact of statins on hsTnT level with moderate exercise. Methods: We enrolled a total of 56 patients: 26 statin users and 30 non-users. All patients were shown to have no coronary artery disease before participating in the study. Participants performed a fixed-protocol moderate level exercise. HsTnT levels were measured before and 4 h after the exercise. Participants were also grouped based on their hsTnT levels, as proposed in the recent European Society of Cardiology guideline (0-1 hour algorithm) for acute coronary syndromes without persistent ST-segment elevation. Results: Statin users showed a significant increase in serum hsTnT levels with moderate exercise (p = .004), whereas the control group showed a modest increase without statistical significance (p = .664). The percentage of patients whose hsTnT levels exceeded the rule-out limits for non-ST-segment myocardial infarction diagnosis (according to the 0-1 algorithm) after moderate exercise varied significantly between groups (p = .024). Conclusions: Statin therapy can cause a significant increase in hsTnT levels after moderate exercise. This increase can jeopardise the accuracy of clinical diagnoses based on the newly implemented algorithms. The awareness of these adverse effects of statins, mainly used by patients with high risk of coronary events, can prevent misdiagnosis or unnecessary hospitalisations.
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Affiliation(s)
- Serkan Ünlü
- Department of Cardiology, University Hospital of Gazi University, Ankara, Turkey
| | - Serdar Gökhan Nurkoç
- Department of Cardiology, University Hospital of Gazi University, Ankara, Turkey
| | - Burak Sezenöz
- Department of Cardiology, University Hospital of Gazi University, Ankara, Turkey
| | - Mehmet Cingirt
- Department of Medicinal Biochemistry, University Hospital of Gazi University, Ankara, Turkey
| | - Özlem Gülbahar
- Department of Medicinal Biochemistry, University Hospital of Gazi University, Ankara, Turkey
| | - Adnan Abacı
- Department of Cardiology, University Hospital of Gazi University, Ankara, Turkey
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97
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Twerenbold R, Costabel JP, Nestelberger T, Campos R, Wussler D, Arbucci R, Cortes M, Boeddinghaus J, Baumgartner B, Nickel CH, Bingisser R, Badertscher P, Puelacher C, du Fay de Lavallaz J, Wildi K, Rubini Giménez M, Walter J, Meier M, Hafner B, Lopez Ayala P, Lohrmann J, Troester V, Koechlin L, Zimmermann T, Gualandro DM, Reichlin T, Lambardi F, Resi S, Alves de Lima A, Trivi M, Mueller C. Outcome of Applying the ESC 0/1-hour Algorithm in Patients With Suspected Myocardial Infarction. J Am Coll Cardiol 2019; 74:483-494. [DOI: 10.1016/j.jacc.2019.05.046] [Citation(s) in RCA: 83] [Impact Index Per Article: 16.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2019] [Revised: 05/07/2019] [Accepted: 05/10/2019] [Indexed: 01/28/2023]
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98
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Su T, Shao X, Zhang X, Han Z, Yang C, Li X. Initial Concentrations of miR-1 MicroRNA Precursor and High-Sensitivity Troponin in the Diagnosis of Non-ST Myocardial Infarction among Patients with and Those without Chronic Kidney Disease. Cardiorenal Med 2019; 9:274-283. [DOI: 10.1159/000499834] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2018] [Accepted: 03/19/2019] [Indexed: 11/19/2022] Open
Abstract
Background: The early diagnosis of non-ST-segment elevation myocardial infarction (NSTEMI) in patients with chronic kidney disease (CKD) remains a challenge. Methods: The study consecutively enrolled patients who had suffered from chest pain within 3 h whose electrocardiogram had no elevation in the ST segment. CKD was defined as an estimated glomerular filtration rate (eGFR) <60 mL/min/1.73 m2, and the diagnostic criteria for NSTEMI were defined according to the recommended guideline. Circulating microRNA-1 was collected and determined by quantitative real-time reverse transcription polymerase chain reaction. Results: A total of 456 patients with suspected NSTEMI were included. There were 115 patients in the CKD group, including 67 with NSTEMI, 20 with stable angina, 7 with unstable angina, 18 with heart failure, and 3 with other disorders. Compared with the NSTEMI group, the non-NSTEMI group just had significant differences in microRNA-1 and high-sensitivity cardiac troponin I (hs-cTnI) (both p < 0.05). The relative expression of microRNA-1 was significantly increased in the NSTEMI group as compared with that in the other disease groups (all p < 0.05). A receiver operating characteristic (ROC) curve analysis suggested that microRNA-1 and hs-cTnI had advantages in the early diagnosis of NSTEMI with CKD (AUC [area under the ROC curve] 0.879 and 0.812, respectively, both p < 0.05). Compared with that in the non-CKD group, the accuracy of microRNA-1 was almost as good in the CKD group (84.3 vs. 89.4%, p > 0.05). However, the diagnostic accuracy of hs-cTnI was significantly decreased (79.1 vs. 91.5%, p < 0.05), as was its specificity (75.0 vs. 95.5%, p < 0.05). There was no significant difference in the correlation between microRNA-1 and eGFR (p > 0.05), but a statistically significantly negative correlation between hs-cTnI and eGFR (p < 0.05). Conclusion: Circulating microRNA-1 is capable of early diagnosis of NSTEMI in patients with CKD suffering from chest pain.
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99
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Antukh DE, Shchekochikhin DY, Nesterov AP, Gilarov MY. Diagnosis and treatment of myocardial infarction in patient with end - stage renal disease on chronic hemodialysis. TERAPEVT ARKH 2019; 91:137-144. [DOI: 10.26442/00403660.2019.06.000203] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Indexed: 11/22/2022]
Abstract
This review represents different aspects of myocardial infarction in patient with end - stage renal disease on chronic hemodialysis. We discuss difficulties in diagnosis, optimal method of coronary revascularization, timing of hemodialysis session, medical therapy, as well as epidemiology and prognosis. There are no unambiguous answers to these problems because patients with end - stage renal disease were excluded from most of the studies.
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100
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Januzzi JL, Mahler SA, Christenson RH, Rymer J, Newby LK, Body R, Morrow DA, Jaffe AS. Recommendations for Institutions Transitioning to High-Sensitivity Troponin Testing: JACC Scientific Expert Panel. J Am Coll Cardiol 2019; 73:1059-1077. [PMID: 30798981 DOI: 10.1016/j.jacc.2018.12.046] [Citation(s) in RCA: 95] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2018] [Revised: 12/05/2018] [Accepted: 12/06/2018] [Indexed: 02/07/2023]
Abstract
High-sensitivity cardiac troponin (hs-cTn) I or T methods have been in use in certain regions for years but are now increasingly globally adopted, including in the United States. Accordingly, inevitable challenges are created for institutions transitioning from conventional cardiac troponin (cTn) assays. hs-cTn assays have higher analytic precision at lower concentrations, yielding greater clinical sensitivity for myocardial injury and allowing accurate recognition of small changes in troponin concentration (rise or fall) within a short time frame. Although much of the knowledge regarding troponin biology that was applicable with older troponin assays still holds true, considerable education regarding the differences between conventional cTn and hs-cTn is needed before medical systems convert to the newer methods. This includes a basic understanding of how hs-cTn testing differs from conventional cTn testing and how it is best deployed in different settings, such as the emergency department and inpatient services. This Expert Panel will review important concepts for institutional transition to hs-cTn methodology, providing recommendations useful for education before implementation.
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Affiliation(s)
- James L Januzzi
- Cardiology Division, Massachusetts General Hospital, Harvard Medical School, Baim Institute for Clinical Research, Boston, Massachusetts.
| | - Simon A Mahler
- Departments of Emergency Medicine, Implementation Science, and Epidemiology and Prevention, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Robert H Christenson
- Core Laboratories and Point of Care Services, University of Maryland School of Medicine, Baltimore, Maryland
| | - Jennifer Rymer
- Division of Cardiology, Department of Medicine and Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina
| | - L Kristin Newby
- Division of Cardiology, Department of Medicine and Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina
| | - Richard Body
- Division of Cardiovascular Sciences, The University of Manchester, Emergency Department, Manchester Royal Infirmary, School of Healthcare Science, Manchester Metropolitan University, Manchester, United Kingdom
| | - David A Morrow
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Allan S Jaffe
- Cardiology Department and Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota
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