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Kriechbaum SD, Wiedenroth CB, Keller T, Wolter JS, Ajnwojner R, Peters K, Haas MA, Roller FC, Breithecker A, Rieth AJ, Guth S, Rolf A, Bandorski D, Hamm CW, Mayer E, Liebetrau C. Dynamics of high-sensitivity cardiac troponin T during therapy with balloon pulmonary angioplasty for chronic thromboembolic pulmonary hypertension. PLoS One 2018; 13:e0204683. [PMID: 30252896 PMCID: PMC6155553 DOI: 10.1371/journal.pone.0204683] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2018] [Accepted: 09/12/2018] [Indexed: 01/05/2023] Open
Abstract
Aims Balloon pulmonary angioplasty (BPA) is an interventional treatment modality for inoperable chronic thromboembolic pulmonary hypertension (CTEPH). Therapy monitoring, based on non-invasive biomarkers, is a clinical challenge. This post-hoc study aimed to assess dynamics of high-sensitivity cardiac troponin T (hs-cTnT) as a marker for myocardial damage and its relation to N-terminal pro-B-type natriuretic peptide (NT-proBNP) levels as a marker for cardiac wall stress. Methods and results This study included 51 consecutive patients who underwent BPA treatment and completed a 6-month follow-up (6-MFU) between 3/2014 and 3/2017. Biomarker measurement was performed consecutively prior to each BPA and at 6-MFU. In total, the 51 patients underwent an average of 5 BPA procedures. The 6-month survival rate was 96.1%. The baseline (BL) meanPAP (39.5±12.1mmHg) and PVR (515.8±219.2dyn×sec×cm-5) decreased significantly within the 6-MFU (meanPAP: 32.6±12.6mmHg, P<0.001; PVR: 396.9±182.6dyn×sec×cm-5, P<0.001). At BL, the median hs-cTnT level was 11 (IQR 6–16) ng/L and the median NT-proBNP level was 820 (IQR 153–1872) ng/L. The levels of both biomarkers decreased steadily after every BPA, showing the first significant difference after the first procedure. Within the 6-MFU, hs-cTnT levels (7 [IQR 5–12] ng/L; P<0.001) and NT-proBNP levels (159 [IQR 84–464] ng/l; P<0.001) continued to decrease. The hs-cTnT levels correlated with the PVR (rrs = 0.42; p = 0.005), the meanPAP (rrs = 0.32; p = 0.029) and the NT-proBNP (rrs = 0.51; p<0.001) levels at BL. Conclusion Non-invasive biomarker measurement provides valuable evidence for the decreasing impairment of myocardial function and structure during BPA therapy. Changes in hs-cTNT levels are suggestive for a reduction in ongoing myocardial damage.
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Affiliation(s)
- Steffen D. Kriechbaum
- Kerckhoff Heart and Thorax Center, Department of Cardiology, Bad Nauheim, German Center for Cardiovascular Research (DZHK), Partner Site Rhine-Main, Frankfurt am Main, Germany
- * E-mail:
| | | | - Till Keller
- Kerckhoff Heart and Thorax Center, Department of Cardiology, Bad Nauheim, German Center for Cardiovascular Research (DZHK), Partner Site Rhine-Main, Frankfurt am Main, Germany
| | - Jan Sebastian Wolter
- Kerckhoff Heart and Thorax Center, Department of Cardiology, Bad Nauheim, German Center for Cardiovascular Research (DZHK), Partner Site Rhine-Main, Frankfurt am Main, Germany
| | - Ruth Ajnwojner
- Kerckhoff Heart and Thorax Center, Department of Cardiology, Bad Nauheim, German Center for Cardiovascular Research (DZHK), Partner Site Rhine-Main, Frankfurt am Main, Germany
| | - Karina Peters
- Kerckhoff Heart and Thorax Center, Department of Cardiology, Bad Nauheim, German Center for Cardiovascular Research (DZHK), Partner Site Rhine-Main, Frankfurt am Main, Germany
| | - Moritz A. Haas
- Kerckhoff Heart and Thorax Center, Department of Cardiology, Bad Nauheim, German Center for Cardiovascular Research (DZHK), Partner Site Rhine-Main, Frankfurt am Main, Germany
| | - Fritz C. Roller
- Justus Liebig University Giessen, Department of Radiology, Giessen, Germany
| | | | - Andreas J. Rieth
- Kerckhoff Heart and Thorax Center, Department of Cardiology, Bad Nauheim, German Center for Cardiovascular Research (DZHK), Partner Site Rhine-Main, Frankfurt am Main, Germany
| | - Stefan Guth
- Kerckhoff Heart and Thorax Center, Department of Thoracic Surgery, Bad Nauheim, Germany
| | - Andreas Rolf
- Kerckhoff Heart and Thorax Center, Department of Cardiology, Bad Nauheim, German Center for Cardiovascular Research (DZHK), Partner Site Rhine-Main, Frankfurt am Main, Germany
- Justus Liebig University Giessen, Medical Clinic I, Division of Cardiology, Giessen, Germany
| | - Dirk Bandorski
- Justus Liebig University of Giessen, Department of Internal Medicine, Division of Pulmonology, Giessen, Germany
| | - Christian W. Hamm
- Kerckhoff Heart and Thorax Center, Department of Cardiology, Bad Nauheim, German Center for Cardiovascular Research (DZHK), Partner Site Rhine-Main, Frankfurt am Main, Germany
- Justus Liebig University Giessen, Medical Clinic I, Division of Cardiology, Giessen, Germany
| | - Eckhard Mayer
- Kerckhoff Heart and Thorax Center, Department of Thoracic Surgery, Bad Nauheim, Germany
| | - Christoph Liebetrau
- Kerckhoff Heart and Thorax Center, Department of Cardiology, Bad Nauheim, German Center for Cardiovascular Research (DZHK), Partner Site Rhine-Main, Frankfurt am Main, Germany
- Justus Liebig University Giessen, Medical Clinic I, Division of Cardiology, Giessen, Germany
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2
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Prognostic relevance of elevated pulmonary arterial pressure assessed non-invasively: Analysis in a large patient cohort with invasive measurements in near temporal proximity. PLoS One 2018; 13:e0191206. [PMID: 29351312 PMCID: PMC5774714 DOI: 10.1371/journal.pone.0191206] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2017] [Accepted: 12/30/2017] [Indexed: 12/13/2022] Open
Abstract
Background The clinical relevance of non-invasively derived pulmonary arterial pressure (PAP) by Doppler echocardiography (DE) has been questioned in the past. However, transthoracic echocardiography is used as a cornerstone examination for patients with dyspnea and suspected pulmonary hypertension (PH). This study aimed to evaluate the prognostic value of non-invasive assessed PAP in a large population of patients with known or suspected cardiopulmonary disease. Methods The analyses are based on data of patients of a tertiary cardiology center that received right heart catheterization (RHC) as well as non-invasively assessed PAP by DE within five days, and includes serological and clinical parameters in a retrospective follow-up for up to eight years. Results Of 1,237 patients, clinical follow-up was possible in 1,038 patients who were included in the statistical analysis. The mean-follow up time was 1,002 days. The composite endpoint of heart transplantation (HTx) or death occurred in n = 308 patients. Elevated PAP measured non-invasively as well as invasively had significant prognostic impact (hazard ratio (HR) 2.32; 95% confidence interval (CI) 1.78–3.04; χ2 = 37.9; p<0.001 versus HR 2.84; 95%CI 2.11–3.82; χ2 = 51.9; p<0.001, respectively). By multivariate analysis, NYHA functional class, N-terminal pro-brain natriuretic peptide, cardiac troponin T, left ventricular ejection fraction, and right ventricular dysfunction remained independently predictive. Incremental prognostic information in a multimodal approach was highly relevant. Conclusions In this comprehensive study, elevated pulmonary arterial pressure measured by DE offers similar prognostic information on survival or need for HTx as right heart catheterization. Furthermore, the addition of functional capacity and serological biomarkers delivered incremental prognostic information.
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Smetana M, Besik J, Netuka I, Maly J, Maluskova J, Lodererova A, Hoskova L, Franeková J, Pokorna E, Pirk J, Szarszoi O. Sensitivity to perioperative ischemia/reperfusion injury in male and female donor myocardium. Physiol Res 2017; 66:949-957. [PMID: 28937258 DOI: 10.33549/physiolres.933514] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Many functions of the cardiovascular apparatus are affected by gender. The aim of our study was find out whether markers of cell death present in the donor myocardium differ in male and female hearts. The study involved 81 patients undergoing heart transplantation from September 2010 to January 2013. Patients were divided into two groups: male allograft (n=49), and female allograft (n=32). Two types of myocardial cell death were analyzed. High-sensitive cardiac troponin T as a necrosis marker and protein bcl-2, caspase 3 and TUNEL as apoptosis markers were measured. We observed a significantly higher level of high-sensitive cardiac troponin T after correcting for predicted ventricular mass in female donors before transplantation as well as in the female allograft group after transplantation throughout the monitored period (P=0.011). There were no differences in apoptosis markers (bcl-2, caspase 3, TUNEL) between male and female hearts before transplantation. Both genders showed a significant increase of TUNEL-positive myocytes one week after transplantation without differences between the groups. Moreover, there were no differences in caspase 3 and bcl-2 expression between the two groups. Our results demonstrated the presence of necrotic and apoptotic cell death in human heart allografts. High-sensitive cardiac troponin T adjusted for predicted ventricular mass as a marker of myocardial necrosis was higher in female donors, and this gender difference was even more pronounced after transplantation.
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Affiliation(s)
- M Smetana
- Department of Cardiovascular Surgery, Institute for Clinical and Experimental Medicine, Prague, Czech Republic.
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Barcan A, Suciu Z, Rapolti E. Monitoring Acute Myocardial Infarction Complicated with Cardiogenic Shock — from the Emergency Room to Coronary Care Units. JOURNAL OF CARDIOVASCULAR EMERGENCIES 2017. [DOI: 10.1515/jce-2017-0013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Abstract
Cardiogenic shock remains the leading cause of death in patients hospitalized for acute myocardial infarction, despite many advances encountered in the last years in reperfusion, mechanical, and pharmacological therapies addressed to stabilization of the hemodynamic condition of these critical patients. Such patients require immediate initiation of the most effective therapy, as well as a continuous monitoring in the Coronary Care Unit. Novel biomarkers have been shown to improve diagnosis and risk stratification in patients with cardiogenic shock, and their proper use may be especially important for the identification of the critical condition, leading to prompt therapeutic interventions. The aim of this review was to evaluate the current literature data on complex biomarker assessment and monitoring of patients with acute myocardial infarction complicated with cardiogenic shock in the Coronary Care Unit.
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Affiliation(s)
| | | | - Emese Rapolti
- Cardiovascular Rehabilitation Hospital , Covasna, Romania
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5
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Szarszoi O, Besik J, Smetana M, Maly J, Urban M, Maluskova J, Lodererova A, Hoskova L, Tucanova Z, Pirk J, Netuka I. Biomarkers of cellular apoptosis and necrosis in donor myocardium are not predictive of primary graft dysfunction. Physiol Res 2015; 65:251-7. [PMID: 26447521 DOI: 10.33549/physiolres.933105] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Primary graft dysfunction (PGD) is a life-threatening complication among heart transplant recipients and a major cause of early mortality. Although the pathogenesis of PGD is still unclear, ischemia/reperfusion injury has been identified as a predominant factor. Both necrosis and apoptosis contribute to the loss of cardiomyocytes during ischemia/reperfusion injury, and this loss of cells can ultimately lead to PGD. The aim of our prospective study was to find out whether cell death, necrosis and apoptosis markers present in the donor myocardium can predict PGD. The prospective study involved 64 consecutive patients who underwent orthotopic heart transplantation at our institute between September 2010 and January 2013. High-sensitive cardiac troponin T (hs-cTnT) as a marker of minor myocardial necrosis was detected from arterial blood samples before the donor's pericardium was opened. Apoptosis (caspase-3, active + pro-caspase-3, bcl-2, TUNEL) was assessed from bioptic samples taken from the right ventricle prior graft harvesting. In our study, 14 % of transplant recipients developed PGD classified according to the standardized definition proposed by the ISHLT Working Group. We did not find differences between the groups in regard to hs-cTnT serum levels. The mean hs-cTnT value for the PGD group was 57.4+/-22.9 ng/l, compared to 68.4+/-10.8 ng/l in the group without PGD. The presence and severity of apoptosis in grafted hearts did not differ between grafts without PGD and hearts that subsequently developed PGD. In conclusion, our findings did not demonstrate any association between measured myocardial cell death, necrosis or apoptosis markers in donor myocardium and PGD in allograft recipients. More detailed investigations of cell death signaling pathways in transplanted hearts are required.
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Affiliation(s)
- O Szarszoi
- Department of Cardiovascular Surgery, Institute for Clinical and Experimental Medicine, Prague, Czech Republic.
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de Boer RA, Daniels LB, Maisel AS, Januzzi JL. State of the Art: Newer biomarkers in heart failure. Eur J Heart Fail 2015; 17:559-69. [DOI: 10.1002/ejhf.273] [Citation(s) in RCA: 137] [Impact Index Per Article: 15.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2015] [Revised: 03/11/2015] [Accepted: 03/23/2015] [Indexed: 12/11/2022] Open
Affiliation(s)
- Rudolf A. de Boer
- University of Groningen, University Medical Center; Department of Cardiology; Groningen The Netherlands
| | - Lori B. Daniels
- Division of Cardiology; University of California at San Diego; La Jolla CA USA
| | - Alan S. Maisel
- Division of Cardiology; University of California at San Diego; La Jolla CA USA
- Division of Cardiology; Veterans Affairs San Diego Medical Center; La Jolla CA USA
| | - James L. Januzzi
- Cardiology Division of the Department of Medicine; Massachusetts General Hospital, Harvard Medical School; Boston MA USA
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Gupta MK, Halley C, Duan ZH, Lappe J, Viterna J, Jana S, Augoff K, Mohan ML, Vasudevan NT, Na J, Sossey-Alaoui K, Liu X, Liu CG, Tang WHW, Naga Prasad SV. miRNA-548c: a specific signature in circulating PBMCs from dilated cardiomyopathy patients. J Mol Cell Cardiol 2013; 62:131-41. [PMID: 23735785 DOI: 10.1016/j.yjmcc.2013.05.011] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2013] [Revised: 04/29/2013] [Accepted: 05/19/2013] [Indexed: 12/19/2022]
Abstract
High fidelity genome-wide expression analysis has strengthened the idea that microRNA (miRNA) signatures in peripheral blood mononuclear cells (PBMCs) can be potentially used to predict the pathology when anatomical samples are inaccessible like the heart. PBMCs from 48 non-failing controls and 44 patients with relatively stable chronic heart failure (ejection fraction of ≤ 40%) associated with dilated cardiomyopathy (DCM) were used for miRNA analysis. Genome-wide miRNA-microarray on PBMCs from chronic heart failure patients identified miRNA signature uniquely characterized by the downregulation of miRNA-548 family members. We have also independently validated downregulation of miRNA-548 family members (miRNA-548c & 548i) using real time-PCR in a large cohort of independent patient samples. Independent in silico Ingenuity Pathway Analysis (IPA) of miRNA-548 targets shows unique enrichment of signaling molecules and pathways associated with cardiovascular disease and hypertrophy. Consistent with specificity of miRNA changes with pathology, PBMCs from breast cancer patients showed no alterations in miRNA-548c expression compared to healthy controls. These studies suggest that miRNA-548 family signature in PBMCs can therefore be used to detect early heart failure. Our studies show that cognate networking of predicted miRNA-548 targets in heart failure can be used as a powerful ancillary tool to predict the ongoing pathology.
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Affiliation(s)
- Manveen K Gupta
- Department of Molecular Cardiology, Lerner Research Institute, Cleveland Clinic, USA
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8
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Stahrenberg R, Niehaus CF, Edelmann F, Mende M, Wohlfahrt J, Wasser K, Seegers J, Hasenfuß G, Gröschel K, Wachter R. High-sensitivity troponin assay improves prediction of cardiovascular risk in patients with cerebral ischaemia. J Neurol Neurosurg Psychiatry 2013; 84:479-87. [PMID: 23355808 PMCID: PMC3623028 DOI: 10.1136/jnnp-2012-303360] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND AND PURPOSE Clinical scores are recommended for predicting cardiovascular risk in patients with cerebral ischaemia to inform secondary prevention. Blood biomarkers may improve prediction beyond clinical scores. METHODS Within the observational Find-AF trial (ISRCTN46104198), 197 patients >18 years of age with cerebral ischaemia and without atrial fibrillation had blood sampled at baseline. The predictive value of five biomarkers for a combined vascular endpoint (acute coronary syndrome, stroke, cardiovascular death) and all-cause mortality was determined, alone and in addition to the Essen Stroke Risk Score (ESRS), Stroke Prognostic Instrument 2 (SPI-2) and National Institutes of Health Stroke Scale (NIH-SS). RESULTS There were 23 vascular events (11.7%) and 13 deaths (6.6%) to 1 year follow-up. In multivariate analyses of all markers, only high-sensitivity troponin T (hsTropT) remained independently predictive for vascular events (p=0.045) and all-cause mortality (p=0.004). hsTropT was higher in patients with a vascular event (median 12.7 ng/ml vs 5.1 ng/ml), and patients with hsTropT above the median of 6.15 ng/ml had vascular events more frequently (HR 3.86, p=0.008). For prediction of vascular events as well as all-cause mortality, hsTropT significantly improved multivariate Cox regression models with ESRS, SPI-2 or NIH-SS. The c-statistic increased non-significantly from 0.695 (ESRS) or 0.710 (hsTropT) to 0.747 (ESRS+hsTropT) and from 0.699 (SPI-2) to 0.763 (SPI-2+hsTropT). No patient with a low-risk ESRS and an hsTropT below the median had a vascular event or died. CONCLUSIONS hsTropT predicts vascular events and all-cause mortality in patients with acute cerebral ischaemia and improves prediction beyond established clinical scores.
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Affiliation(s)
- Raoul Stahrenberg
- Department of Cardiology and Pneumology, University of Göttingen, Robert-Koch-Str. 40, Göttingen 37075, Germany.
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Erbel C, Taskin R, Doesch A, Dengler TJ, Wangler S, Akhavanpoor M, Ruhparwar A, Giannitsis E, Katus HA, Gleissner CA. High-sensitive Troponin T measurements early after heart transplantation predict short- and long-term survival. Transpl Int 2012; 26:267-72. [DOI: 10.1111/tri.12024] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2012] [Revised: 05/15/2012] [Accepted: 10/30/2012] [Indexed: 11/29/2022]
Affiliation(s)
| | - Rukiye Taskin
- Department of Cardiology; University of Heidelberg; Germany
| | - Andreas Doesch
- Department of Cardiology; University of Heidelberg; Germany
| | | | | | | | - Arjang Ruhparwar
- Department of Cardiac Surgery; University of Heidelberg; Germany
| | | | - Hugo A. Katus
- Department of Cardiology; University of Heidelberg; Germany
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10
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Diagnostic and prognostic performance of a novel high-sensitivity cardiac troponin T assay compared to a contemporary sensitive cardiac troponin I assay in patients with acute coronary syndrome. Clin Res Cardiol 2012; 101:837-45. [DOI: 10.1007/s00392-012-0469-6] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2011] [Accepted: 04/26/2012] [Indexed: 10/28/2022]
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11
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Irfan A, Twerenbold R, Reiter M, Reichlin T, Stelzig C, Freese M, Haaf P, Hochholzer W, Steuer S, Bassetti S, Zellweger C, Freidank H, Peter F, Campodarve I, Meune C, Mueller C. Determinants of high-sensitivity troponin T among patients with a noncardiac cause of chest pain. Am J Med 2012; 125:491-498.e1. [PMID: 22482847 DOI: 10.1016/j.amjmed.2011.10.031] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2011] [Revised: 10/23/2011] [Accepted: 10/24/2011] [Indexed: 01/20/2023]
Abstract
BACKGROUND It is unknown to what extent noncardiac causes, including renal dysfunction, may contribute to high-sensitivity cardiac troponin T levels. METHODS In an observational international multicenter study, we enrolled consecutive patients presenting with acute chest pain to the emergency department. Of 1181 patients enrolled, 572 were adjudicated by 2 independent cardiologists to have a noncardiac cause of chest pain. Multiple linear regression analyses were used to determine the important predictors of log-transformed high-sensitivity cardiac troponin T. Kaplan-Meier curve was used to assess the prognostic significance of high-sensitivity cardiac troponin T>0.014 μg/L (99th percentile). RESULTS A total of 88 patients (15%) had high-sensitivity cardiac troponin T>0.014 μg/L. Less than 50% of cardiac troponins could be explained by known cardiac or noncardiac diseases. In decreasing order of importance, age, estimated glomerular filtration rate, hypertension, previous myocardial infarction, and chronic kidney disease (adjusted r(2) 0.44) emerged as significant factors in linear regression analysis to predict high-sensitivity cardiac troponin T. High-sensitivity cardiac troponin T was best explained by a linear curve with age as ≤0.014 μg/L. Patients with high-sensitivity cardiac troponin T levels>0.014 μg/L were at increased risk for all-cause mortality (hazard ratio 3.0; 95% confidence interval, 0.8-10.6; P=.02) during follow-up. CONCLUSION Among the known covariates, age and not renal dysfunction is the most important determinant of high-sensitivity cardiac troponin T. Because known cardiac and noncardiac factors, including renal dysfunction, explain less than 50% of high-sensitivity cardiac troponin T levels among patients with a noncardiac cause of chest pain, unknown or underestimated cardiac involvement during the acute presenting condition seems to be the major cause of elevated high-sensitivity cardiac troponin T.
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Affiliation(s)
- Affan Irfan
- Department of Internal Medicine, University Hospital Basel, Switzerland
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12
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Abstract
Cardiotoxicity remains a major limitation of chemotherapy, strongly affecting the quality of life and the overall survival of cancer patients, regardless of their oncologic prognosis. The time elapsed from the end of cancer therapy to the beginning of heart failure therapy for chemotherapy-induced cardiac dysfunction is an important determinant of the extent of recovery. This highlights the need for a real-time diagnosis of cardiac injury. The current standard for monitoring cardiac function detects cardiotoxicity only when a functional impairment has already occurred, precluding any chance of preventing its development. In the last decade, early identification, assessment, and monitoring of cardiotoxicity, by measurement of serum cardiospecific biomarkers, have been proposed as an effective alternative. In particular, the role of troponin I in identifying patients at risk for cardiotoxicity and of angiotensin-converting enzyme inhibitors in preventing left ventricular ejection fraction reduction and cardiac events has clearly proved to be an effective strategy for this complication. In addition, novel biomarkers for the identification of cardiotoxicity are emerging. The use of a multimarker approach may provide a unique opportunity for advancement in this field, allowing for better stratification of the cardiac risk in cancer patients treated with anticancer drugs.
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Affiliation(s)
- D Cardinale
- Cardiology Unit, European Institute of Oncology, Milan, Italy.
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Abstract
Patients with critical illness are heterogeneous, with differing physiologic requirements over time. Goal-directed therapy in the emergency room demonstrates that protocolized care could result in improved outcomes. Subsequent studies have confirmed benefit with such a "bundle-based approach" in the emergency room and in preoperative and postoperative scenarios. However, this cannot be necessarily extrapolated to the medium-term and long-term care pathway of the critically ill patient. It is likely that the development of mitochondrial dysfunction could result in goal-directed types of approaches being detrimental. Equally, arterial pressure aims are likely to be considerably different as the patient's physiology moves toward "hibernation." The agents we utilize as sedative and pressor agents have considerable effects on immune function and the inflammatory profile, and should be considered as part of the total clinical picture. The role of gut failure in driving inflammation is considerable, and the drive to feed enterally, regardless of aspirate volume, may be detrimental in those with degrees of ileus, which is often a difficult diagnosis in the critically ill. The pathogenesis of liver dysfunction may be, at least in part, related to venous engorgement that will contribute toward portal hypertension and gut edema. This, in association with loss of the hepatosplanchnic buffer response, it is likely to contribute to venous pooling in the abdominal cavity, impaired venous return, and decreased central blood volumes. Therapies such as those used in "small-for-size syndrome" may have a role in the chronic stages of septic vascular failure.
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Hallén J, Atar D. A window into your heart: taking cardiac troponin to the next level. Biomark Med 2010; 4:889-94. [DOI: 10.2217/bmm.10.103] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
The cardiac troponins are important cardiovascular biomarkers for myocardial necrosis and are measured in thousands of patients daily. In parallel with the widespread adoption of troponin testing for the diagnosis of myocardial infarction during the last two decades, the analytical sensitivity of assays has progressively improved, which has allowed the identification of more acute coronary syndrome patients at risk of future cardiac events. In addition, using novel high-sensitivity assays, circulating troponin can be observed not only in acute settings, but also in many patients suffering from chronic diseases such as coronary artery disease, heart failure and diabetes. We believe that these findings provide a compelling case for exploring whether troponin levels may be a useful tool for guiding clinical decision-making directly in the management of some of these chronic conditions. Sampling of troponin in such patient populations may allow for more refined risk stratification and, importantly, help clinicians individualize care beyond what is currently possible.
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Affiliation(s)
| | - Dan Atar
- Department of Cardiology, Oslo University Hospital, Aker & Ullevål, Oslo, Norway
- Faculty of Medicine, University of Oslo, Oslo, Norway
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