Role of biomarkers in assessment of early infarct size after successful p-PCI for STEMI

Clinically Acquired High Sensitivity Cardiac Troponin T is a Poor Predictor of Reduced Left Ventricular Ejection Fraction After ST Elevation Myocardial Infarction: A National Cohort Study-ANZACS-QI 65

OBJECTIVE

Cardiac troponins (cTn) have been used historically to estimate infarct size in ST elevation myocardial infarction (STEMI). Within a resource constrained health care environment, cTn could therefore be used for prioritisation of patients for cardiac imaging, in particular echocardiography. We aimed to determine how useful routinely collected cTn would be in predicting significant left ventricular (LV) impairment.

METHODS

All patients in the All New Zealand Acute Coronary Syndrome Quality Improvement (ANZACS-QI) registry with their first episode of STEMI between January 2013 and November 2018, who had high sensitivity troponin T measured, were included. We excluded patients with no left ventricular ejection fraction (LVEF) assessment, known LV dysfunction, or prior myocardial infarction.

RESULTS

In total, 3,698 patients were included in the analysis. A higher mean hsTnT (admission and peak) was seen in patients with more severely impaired LV function but there was significant overlap in the range of hsTnT between the different LVEF categories. Cardiac troponins demonstrated poor discriminative ability to either predict or exclude significant LV impairment (LVEF <40%). At an optimal cutpoint of 3,405 ng/L, peak hsTnT had a sensitivity of 56.5% (95% confidence interval [CI] 42-62%), a specificity of 65.3% (95% CI 62-79%) and an area under the receiver operating curve of 0.62 (95% CI 0.60-0.64).

CONCLUSION

This is the largest study comparing clinically measured troponin levels and LV function in patients presenting with STEMI. A definite, but weak, association was seen between peak troponin and the degree of LV dysfunction, with significant overlap in troponin levels between levels of myocardial dysfunction. Routinely acquired troponin is not suitable for clinical use as a method of prioritising patients for cardiac imaging.

Short-term exposure to traffic-related air pollution and STEMI events: Insights into STEMI onset and related cardiac impairment

AIMS

Evidence on the impacts of traffic-related air pollution (TRAP) on ST-segment elevation myocardial infarction (STEMI) events is limited. We aimed to assess the acute effects of TRAP exposure on the clinical onset of STEMI and related cardiac impairments.

METHODS AND RESULTS

We recruited patients who were admitted for STEMI and underwent primary percutaneous coronary intervention at Peking University Third Hospital between 2014 and 2020. Indicators relevant to cardiac impairments were measured. Concomitantly, hourly concentrations of traffic pollutants were monitored throughout the study period, including fine particulate matter, black carbon (BC), particles in size ranges of 5-560 nm, oxides of nitrogen (NO_X), nitrogen dioxide, and carbon monoxide. The mean (SD) age of participants was 62.4 (12.5) years. Daily average (range) concentrations of ambient BC and NO_X were 3.9 (0.1-25.0) μg/m³ and 90.8 (16.6-371.7) μg/m³. Significant increases in STEMI risks of 5.9% (95% CI: 0.1, 12.0) to 21.9% (95% CI: 6.0, 40.2) were associated with interquartile range increases in exposure to TRAP within a few hours. These changes were accompanied by significant elevations in cardiac troponin T levels of 6.9% (95% CI: 0.2, 14.1) to 41.7% (95% CI: 21.2, 65.6), as well as reductions in left ventricular ejection fraction of 1.5% (95% CI: 0.1, 2.9) to 3.7% (95% CI: 0.8, 6.4). Furthermore, the associations were attenuated in participants living in areas with higher residential greenness levels.

CONCLUSIONS

Our findings extend current understanding that short-term exposure to higher levels of traffic pollution was associated with increased STEMI risks and exacerbated cardiac impairments, and provide evidence on traffic pollution control priority for protecting vulnerable populations who are at greater risks of cardiovascular events.

Association of plasma interleukin-6 with infarct size, reperfusion injury, and adverse remodelling after ST-elevation myocardial infarction

AIMS

Little is known about the clinical relevance of interleukin (IL)-6 in patients with acute ST-elevation myocardial infarction (STEMI). This study examined the possible associations of plasma IL-6 concentrations with infarct size (IS), reperfusion injury and adverse left ventricular remodelling (LVR), in STEMI patients treated with primary percutaneous coronary intervention (PCI).

METHODS AND RESULTS

We prospectively included 170 consecutive STEMI patients (median age 57 years, 14% women) treated with primary PCI between 2017 and 2019. Blood samples for biomarker analyses including IL-6 were collected on Day 2. Left ventricular ejection fraction (LVEF), IS, and reperfusion injury [microvascular obstruction (MVO) and intramyocardial haemorrhage (IMH)] were determined using cardiac magnetic resonance (CMR) imaging on Day 4. Left ventricular remodelling was defined as ≥10% increase in left ventricular end-diastolic volume from baseline to 4 months CMR follow-up. Patients with IL-6 concentrations ≥median (17 ng/L) showed a significantly lower LVEF (43% vs. 52%, P < 0.001), larger IS (22% vs. 13%, P < 0.001), larger MVO (1.9% vs. 0.0%, P < 0.001), and more frequent IMH (52% vs. 18%, P < 0.001). Left ventricular remodelling was more common in patients with IL-6 ≥ median (24% vs. 9%, P = 0.005). In both linear and binary multivariable regression analyses, IL-6 remained independently associated with lower LVEF [odds ratio (OR): 0.10, 95% confidence interval (CI) 0.02-0.42, P = 0.002], larger IS (OR: 5.29, 95% CI 1.52-18.40, P = 0.009), larger MVO (OR: 5.20, 95% CI 1.30-20.85, P = 0.020), with presence of IMH (OR: 3.73, 95% CI 1.27-10.99, P = 0.017), and adverse LVR (OR: 2.72, 95% 1.06-6.98, P = 0.038).

CONCLUSIONS

High concentrations of circulating plasma IL-6 on Day 2 after STEMI were independently associated with worse myocardial function, larger infarct extent, more severe reperfusion injury, and a higher likelihood for LVR, suggesting IL-6 as a useful biomarker of more serious outcome and potential therapeutic target.

CLINICAL TRIAL REGISTRATION

https://clinicaltrials.gov/ct2/show/NCT04113356;NCT04113356.

Unique role of admission hyperglycemia on myocardial infarction size and area at risk following an acute ST-elevation myocardial infarction

Background

Hyperglycemia can adversely affect patients with acute ST-elevation myocardial infarction (STEMI) in both diabetic and non-diabetic patients. The majority of the studies had investigated the impact of admission hyperglycemia (AH) on cardiovascular morbidity and mortality while, in ours, we entailed its impact on final infarction size (FIS) and more interestingly, on the area at risk (AAR), both were estimated by cardiac magnetic resonance (CMR) imaging.

Results

AH showed significant positive correlations to FIS and AAR. Moreover, AH group had higher summation of ST segment elevation (sum STE), more maximum ST segment elevation (max STE), higher echocardiographic wall motion score index (WMSI), higher CMR estimated WMSI, and lower segmental ejection fraction (EF). Multivariate analysis showed that AH was independently associated with increased FIS.

Conclusion

Current study showed an association between AH and large FIS in STEMI patients.

Complete versus simplified Selvester QRS score for infarct severity assessment in ST-elevation myocardial infarction

Background

Complete and simplified Selvester QRS score have been proposed as valuable clinical tool for estimating myocardial damage in patients with ST-elevation myocardial infarction (STEMI). We sought to comprehensively compare both scoring systems for the prediction of myocardial and microvascular injury assessed by cardiac magnetic resonance (CMR) imaging in patients with acute STEMI.

Methods

In this prospective observational study, 201 revascularized STEMI patients were included. Electrocardiography was conducted at a median of 2 (interquartile range 1–4) days after the index event to evaluate the complete and simplified QRS scores. CMR was performed within 1 week and 4 months thereafter to determine acute and chronic infarct size (IS) as well as microvascular obstruction (MVO).

Results

Complete and simplified QRS score showed comparable predictive value for acute (area under the curve (AUC) = 0.64 vs. 0.67) and chronic IS (AUC = 0.63 vs. 0.68) as well as for MVO (AUC = 0.64 vs. 0.66). Peak high sensitivity cardiac troponin T (hs-cTnT) showed an AUC of 0.88 for acute IS and 0.91 for chronic IS, respectively. For the prediction of MVO, peak hs-cTnT represented an AUC of 0.81.

Conclusions

In reperfused STEMI, complete and simplified QRS score displayed comparable value for the prediction of acute and chronic myocardial as well as microvascular damage. However, both QRS scoring systems provided inferior predictive validity, compared to peak hs-cTnT, the clinical reference method for IS estimation.

Predictive Value of High-Sensitivity Troponin T for Systolic Dysfunction and Infarct Size (Six Months) After ST-Elevation Myocardial Infarction

The association of markers of myocardial injury and dysfunction with infarct size (IS) and ejection fraction (EF) are well documented. However, limited data are available on the newer high-sensitivity troponin assays and comparison with morphologic and functional assessment with cardiac magnetic resonance imaging. We aimed to examine the associations of high-sensitivity cardiac Troponin-T (hs-cTnT), creatine kinase MB iso-enzyme (CKMB), and N-terminal pro B-type Natriuretic Peptide (NT-proBNP) to IS and EF at 6 months. Blood samples from 119 ST-segment elevation myocardial infarction patients from the Rapid Endovascular Catheter Core Cooling Combined With Cold Saline solution as an Adjunct to Percutaneous Coronary Intervention for the Treatment of Acute Myocardial Infarction trial were collected at baseline, 6, 24, and 48 hours after admission. Cardiac magnetic resonance was performed at 4 ± 2 days and 6 months. The association of biomarker levels to IS and EF was tested with Pearson's correlation coefficients and linear regression models with bootstrap resampling. The correlation coefficient of biomarker to IS was (CKMB: r = 0.71); (NT-proBNP: r = 0.55); (hs-cTnT: r = 0.80); and for EF (CKMB: r = 0.57); (NT-proBNP: r = 0.48); and (peak hs-cTnT: r = 0.68). IS and EF at 4 ± 2 days had the strongest correlations with IS and EF at 6 months respectively (IS: r = 0.84) and (EF: r = 0.74). Receiver operating characteristic of peak hs-cTnT for predicting EF ≤40% at 6 months was 0.87 compared with 0.75 for early IS. Early EF was a negative predictor of late EF <40%, 1-area under curve = 0.93. In conclusion, high-sensitivity Troponin T is a rapid, cheap, generally available tool for accurate prediction of systolic dysfunction in patients 6 months after first-time ST-segment elevation myocardial infarction.

Clinical predictors for the manifestation of late gadolinium enhancement after acute myocardial infarction

Despite prompt revascularization, some patients with acute myocardial infarction (AMI) develop myocardial scars, which can be visualized by late gadolinium enhancement (LGE) in cardiovascular magnetic resonance imaging (CMR). Our goal was to identify angiographic findings that were predictive for scar development in patients after reperfused AMI.We examined 136 patients after first ST-elevated myocardial infarction by CMR after a median of 4 days (range: 2-7). Patients with manifestation of LGE were matched to patients without LGE by means of age and gender. Clinical follow-up with a combined primary endpoint including myocardial reinfarction, congestive heart failure, stroke, death and development of left ventricular thrombus was reported after 24 months.Patients with manifestation of LGE had a significant longer time of symptom-to-intervention, a higher prevalence of anterior AMI, and more proximal culprit lesions. Furthermore, left ventricular ejection fraction was significantly decreased, and peak values of infarct markers were significantly higher in these patients. Preinterventional thrombolysis in myocardial infarction-0-flow was significantly more frequent in patients with LGE manifestation. The presence of 3-vessel disease (odds ratio 53.99, 95% confidence interval 8.22-354.63, P <.001), a proximal culprit lesion, and high creatine kinase myocardial band (CK-MB) values were identified as independent predictors of LGE. Follow-up demonstrated a higher incidence of clinical events in the group with LGE, with the most common cause of heart failure (38.2% vs 7.4%, P <.001).The extent of angiographic findings in AMI plays a major role in the manifestation of LGE. The presence of a multivessel disease, a proximal culprit lesion, and high values of CK-MB are strong independent predictors for LGE manifestation.

Cardioprotective Effect of Anisodamine Against Myocardial Ischemia Injury and its Influence on Cardiomyocytes Apoptosis

Anisodamine is an ancient Chinese medicine derived from Tibet as a belladonna alkaloid, which is usually used for improvement of blood circulation in patients with organ phosphorus poisoning or shock. In this study, for the first time, we report its cardioprotective effects on preventing ischemia/reperfusion (I/R) injury of patients with acute myocardial infarction (AMI), and decreasing the myocardial infarction area and severity in heart of Sprague-Dawley (SD) rats. Our results suggest a potential molecular mechanism of anisodamine against the I/R injury in cardiomyocytes is associated with its anti-apoptotic effect. Anisodamine treatment decreases the expression of caspase-3 and caspase-8, and increases Bcl-2/Bax ratio in cardiomyocytes. Our data suggest that anisodamine can provide significant cardioprotection against I/R injury, potentially through the suppression of cardiomyocytes apoptosis.

Novel biomarkers predicting cardiac function after acute myocardial infarction

BACKGROUND

Measurement of biomarkers provides a cost-effective and widely available method to estimate cardiac dysfunction and clinical outcome of patients with acute myocardial infarction (AMI).

SOURCES OF DATA

PubMed entries with terms 'myocardial infarction' and the respective biomarker.

AREAS OF AGREEMENT

Cardiac troponins and natriuretic peptides are closely related to left ventricular dysfunction and the occurrence of adverse clinical events following AMI.

AREAS OF CONTENTION

The incremental value of novel biomarkers is controversial.

FUTURE DIRECTIONS

The combination of traditional and novel biomarkers might further improve risk stratification of patients with AMI.

SEARCH STRATEGY

We searched all entries on the PubMed database with the MeSH terms 'myocardial infarction' and 'cardiac troponins', 'natriuretic peptides', 'copeptin', galectin-3', 'corin', 'fetuin-A', 'adiponectin' and 'microRNA'.

Aortic stiffness is associated with elevated high-sensitivity cardiac troponin T concentrations at a chronic stage after ST-segment elevation myocardial infarction

OBJECTIVES

Aortic pulse wave velocity (PWV)--the proposed gold standard for the assessment of aortic stiffness--is a major determinant of left ventricular after-load and coronary perfusion. We aimed to investigate the association between aortic PWV and subclinical elevation of high-sensitivity cardiac troponin T (hs-TnT) concentrations at a chronic stage after acute ST-segment elevation myocardial infarction (STEMI).

METHODS

Seventy-four patients with acute STEMI were included in this cross-sectional single-centre study at the University Hospital of Innsbruck. All patients underwent cardiac MRI for the assessment of left ventricular function, morphology, infarct size and aortic PWV 12 months after acute STEMI. Blood samples were drawn at 12 months by peripheral venipuncture. Levels of hs-TnT were measured by a commercially available immunoassay (Roche Diagnostics).

RESULTS

hs-TnT levels (6.4 ng/l, inter-quartile range 5.0-8.6) were significantly associated with age (r = 0.417, P < 0.001), plasma creatinine levels (r = 0.257, P = 0.027), high-sensitivity C-reactive protein levels (r = 0.281, P = 0.015) and aortic PWV (r = 0.435, P < 0.001). Multiple linear regression analysis revealed aortic PWV (ß = 0.330, P = 0.025), apart from plasma creatinine concentrations (ß = 0.279, P = 0.010), to be independently associated with hs-TnT concentrations (model: R = 0.597, P < 0.001).

CONCLUSION

The present study showed an association of aortic stiffness and hs-TnT concentrations at a chronic stage after STEMI.

A hospital-wide system to ensure rapid treatment time across the entire spectrum of emergency percutaneous intervention

OBJECTIVES

This study's aim was to describe a hospital-wide system to deliver rapid door-to-balloon time across the entire spectrum of emergency percutaneous intervention.

BACKGROUND

Many patients needing emergency PCI are excluded from door-to-balloon public reporting metric; these groups do not achieve door-to-balloon times ≤90 min and have increased mortality rates.

METHODS

We prospectively implemented a protocol for patients with STEMI or other emergency indication for catheterization mandating (1) emergency department physician or cardiologist activation of the catheterization lab and (2) immediate patient transfer to an immediately available catheterization lab by an in-house nursing transfer team.

RESULTS

From September 1, 2005 to December 31, 2008, 526 consecutive patients underwent emergency PCI. Median door-to-balloon time was 68 min with 85.7% ≤90 min overall. Important subgroups included primary emergency department (62.5 min), cardiorespiratory arrest (71 min), cardiogenic shock (68 min), need for temporary pacemaker or balloon pump (67 min), initial ECG without ST-elevation (66.5 min), transfer from another ED (84 min), in-hospital (70 min), and activation indications other than STEMI (68 min). Patients presenting to primary ED and in transfer were compared to historical controls. Treatment ≤90 min increased (28%-85%, P < 0.0001). Mean infarct size decreased, as did hospital length-of-stay and admission total hospital costs. Acute myocardial infarction all-cause 30-day unadjusted mortality and risk-standardized mortality ratios were substantially lower than national averages.

CONCLUSION

A hospital-wide systems approach applied across the entire spectrum of emergency PCI leads to rapid door-to-balloon time, reduced infarct size and hospitals costs, and low myocardial infarction 30-day all-cause mortality. © 2015 Wiley Periodicals, Inc.

Prognostic value of high sensitivity troponin T after ST-segment elevation myocardial infarction in the era of cardiac magnetic resonance imaging

Aims

To determine if high sensitivity troponin T (hs-TnT) measurements performed during the 'plateau phase' of troponin release (≥48 h) following ST-segment elevation myocardial infarction (STEMI) can predict major adverse cardiovascular endpoints (MACE), and to evaluate its prognostic value compared with cardiac magnetic resonance imaging (CMRI) parameters.

Methods and results

We prospectively recruited 201 first presentation STEMI patients. Serial hs-TnT levels were measured at admission, peak (highest), 24, 48 and 72 h. CMRI and transthoracic echocardiography were performed (4 days median) post-STEMI, evaluating infarct scar characteristics and left ventricular ejection fraction (LVEF). Associations were determined between hs-TnT levels and CMRI parameters early after STEMI with MACE (comprising mortality, re-infarction, new or worsening of heart failure, cerebrovascular accident, and sustained ventricular arrhythmias) at medium-term follow-up. After 602 days (median), 33 (17%) patients had MACE. Upper tertile hs-TnT levels at 48 and 72 h were associated with MACE (Kaplan-Meier P = 0.002 and P = 0.012, respectively). Multivariate Cox analyses, incorporating diabetes, CMRI scar size, LVEF and hs-TnT levels (applied at a single hs-TnT time point) showed that 48 and 72 h hs-TnT levels were independent predictors for MACE (HR = 1.20, P = 0.002, and HR = 1.21, P = 0.035 respectively).

Conclusion

Measurement of hs-TnT in the plateau phase after STEMI is an inexpensive method of prognostic risk assessment.

N-terminal pro-B-type natriuretic peptide is associated with aortic stiffness in patients presenting with acute myocardial infarction

BACKGROUND

Aortic stiffness is associated with increased left ventricular (LV) afterload, a process which is accompanied by a release of natriuretic peptides. Aortic pulse wave velocity (PWV) has been demonstrated to be the functional surrogate of aortic stiffness. We sought to investigate the impact of aortic PWV on N-terminal pro-B-type natriuretic peptide (NT-proBNP) concentrations in patients with acute myocardial infarction (AMI).

METHODS

This prospective observational study included 86 consecutive patients undergoing percutaneous coronary intervention for AMI. Aortic PWV was determined 47 h (interquartile range (IQR) 27-64 h) after AMI using an established oscillometric device. NT-proBNP values were measured using a commercially available immunoassay.

RESULTS

The mean age of the study cohort was 60±11 years; 19% were female. Median aortic PWV was 7.8 m/s (IQR 6.8-9.4 m/s). Patients with a PWV above the median showed significantly higher NT-proBNP peak concentrations (median=1330 ng/l, IQR: 729-3180 ng/l vs median=498 ng/l, IQR: 124-1575 ng/l, p=0.001). Aortic PWV (beta=0.373, p=0.014) was independently associated with NT-proBNP peak concentrations even after correction for LV function, cardiac troponin T levels, heart rate, blood pressure, body mass index and the primary prevention European Society of Cardiology (ESC) SCORE (model: R=0.542, p=0.014).

CONCLUSION

In patients with AMI, aortic PWV is independently associated with NT-proBNP concentrations. This finding suggests an impact of aortic PWV on myocardial wall stress after AMI.

High-sensitivity troponin T predicts infarct scar characteristics and adverse left ventricular function by cardiac magnetic resonance imaging early after reperfused acute myocardial infarction

BACKGROUND

Late gadolinium enhancement cardiac magnetic resonance imaging (CMRI) is the current standard for evaluation of myocardial infarct scar size and characteristics. Because post-ST-segment elevation myocardial infarction (STEMI) troponin levels correlate with clinical outcomes, we sought to determine the sampling period for high-sensitivity troponin T (hs-TnT) that would best predict CMRI-measured infarct scar characteristics and left ventricular (LV) function.

METHODS AND RESULTS

Among 201 patients with first presentation with STEMI who were prospectively recruited, we measured serial hs-TnT levels at admission, peak, 24 hours, 48 hours, and 72 hours after STEMI. Indexed LV volumes, LV ejection fraction (LVEF) and infarct scar characteristics (scar size, scar heterogeneity, myocardial salvage index, and microvascular obstruction) were evaluated by CMRI at a median of 4 days post-STEMI. Peak and serial hs-TnT levels correlated positively with early indexed LV volumes and infarct scar characteristics, and negatively correlated with myocardial salvage index and LVEF. Both 48- and 72-hour hs-TnT levels similarly predicted "large" total infarct scar size (odds ratios [ORs] 3.08 and 3.53, both P < .001), myocardial salvage index (ORs 1.68 and 2.30, both P < .001), and LVEF <40% (ORs 2.16 and 2.17, both P < .001) on univariate analyses. On multivariate analyses, 48- and 72-hour hs-TnT levels independently predicted large infarct scar size (ORs 2.05 and 2.31, both P < .001), reduced myocardial salvage index (OR 1.39 [P = .031] and OR 1.55 [P = .009]), and LVEF <40% (OR 1.47 [P = .018] and OR 1.43 [P = .026]). All measured hs-TnT levels had a modest association and similar capacity to predict microvascular obstruction.

CONCLUSIONS

Levels of hs-TnT at 48 and 72 hours, measured during the "plateau phase" post-STEMI, predicted infarct scar size, poor myocardial salvage, and LVEF. These levels also correlated with scar heterogeneity and microvascular obstruction post-STEMI. Since ascertaining peak levels after STEMI is challenging in routine practice, based on the biphasic kinetics of hs-TnT, a measurement at 48 to 72 hours (during the plateau phase) provides a useful and simple method for early evaluation of LV function and infarct scar characteristics.

High-sensitivity troponin T for prediction of left ventricular function and infarct size one year following ST-elevation myocardial infarction

BACKGROUND

Data relating high-sensitivity cardiac troponin T (hs-cTnT) to long-term myocardial function and infarct size in patients after ST-elevation myocardial infarction (STEMI) are lacking. We aimed to evaluate the use of early hs-cTnT concentrations for prediction of myocardial function and infarct size assessed by cardiac magnetic resonance imaging (CMR) one year following STEMI.

METHODS

Sixty-six patients, revascularized by primary percutaneous coronary intervention (PCI) for first-time STEMI, were enrolled in this observational study. Serial hs-cTnT, creatine kinase (CK), high-sensitivity C-reactive protein (hs-CRP) and lactate dehydrogenase (LDH) levels were measured on admission, 6 h, 12 h, and 24 h post-PCI. Patients underwent CMR within the first week and 12months thereafter.

RESULTS

Except for admission hs-cTnT, all single time point and peak hs-cTnT concentrations showed significant correlations with left ventricular ejection fraction (LVEF: r=-0.404 to -0.517, all ps<0.01) and infarct size (IS: r=0.421 to 0.700, all ps<0.01) at baseline and follow-up. The area under the curve (AUC) of peak hs-cTnT was 0.82 (95% CI 0.71-0.92) for the prediction of decreased LVEF (<55%) and 0.89 (95% CI 0.81-0.97) for the prediction of large IS (>8%) at 12months. The combination of all four biomarkers resulted in an AUC of 0.82 and 0.92 for the prediction of reduced LVEF and large IS at 12months, respectively (both ps>0.05).

CONCLUSION

In stable STEMI patients successfully revascularized by primary PCI, serial and peak concentrations of hs-cTnT are closely correlated to long-term LVEF and IS. Combination of hs-cTnT with CK, hs-CRP, or LDH did not add any significant prognostic value as compared with hs-cTnT alone.

Copeptin testing in acute myocardial infarction: ready for routine use?

Suspected acute myocardial infarction is one of the leading causes of admission to emergency departments. In the last decade, biomarkers revolutionized the management of patients with suspected acute coronary syndromes. Besides their pivotal assistance in timely diagnosis, biomarkers provide additional information for risk stratification. Cardiac troponins I and T are the most sensitive and specific markers of acute myocardial injury. Nonetheless, in order to overcome the remaining limitations of these markers, novel candidate biomarkers sensitive to early stage of disease are being extensively investigated. Among them, copeptin, a stable peptide derived from the precursor of vasopressin, emerged as a promising biomarker for the evaluation of suspected acute myocardial infarction. In this review, we summarize the currently available evidence for the usefulness of copeptin in the diagnosis and risk stratification of patients with suspected acute myocardial infarction in comparison with routine biomarkers.

Comparison of an oscillometric method with cardiac magnetic resonance for the analysis of aortic pulse wave velocity

Objectives

Pulse wave velocity (PWV) is the proposed gold-standard for the assessment of aortic elastic properties. The aim of this study was to compare aortic PWV determined by a recently developed oscillometric device with cardiac magnetic resonance imaging (CMR).

Methods

PWV was assessed in 40 volunteers with two different methods. The oscillometric method (PWV_OSC) is based on a transfer function from the brachial pressure waves determined by oscillometric blood pressure measurements with a common cuff (Mobil-O-Graph, I.E.M. Stolberg, Germany). CMR was used to determine aortic PWV_CMR with the use of the transit time method based on phase-contrast imaging at the level of the ascending and abdominal aorta on a clinical 1.5 Tesla scanner (Siemens, Erlangen, Germany).

Results

The median age of the study population was 34 years (IQR: 24–55 years, 11 females). A very strong correlation was found between PWVOSC and PWVCMR (r = 0.859, p < 0.001). Mean PWV_OSC was 6.7 ± 1.8 m/s and mean PWVCMR was 6.1 ± 1.8 m/s (p < 0.001). Analysis of agreement between the two measurements using Bland-Altman method showed a bias of 0.57 m/s (upper and lower limit of agreement: 2.49 m/s and -1.34 m/s). The corresponding coefficient of variation between both measurements was 15%.

Conclusion

Aortic pulse wave velocity assessed by transformation of the brachial pressure waveform showed an acceptable agreement with the CMR-derived transit time method.

Short-term outcome of patients with ST-segment elevation myocardial infarction (STEMI) treated with an everolimus-eluting bioresorbable vascular scaffold

OBJECTIVES

To evaluate safety and efficacy of the everolimus-eluting bioresorbable scaffold (BVS) in patients with ST-segment elevation myocardial infarction (STEMI).

BACKGROUND

According to the current guidelines, drug-eluting stents are the treatment of choice in patients with STEMI. BVS represents a new technology capable to restore the native vessel vasomotion and potentially avoiding long-term limitations such as stent thrombosis.

METHODS

From October 2012 to May 2013, patients with evidence of STEMI eligible for BVS implantation were included in this study. Exclusion criteria were not defined.

RESULTS

A total of 25 patients, respectively 31 lesions, were treated. Procedural success was achieved in 97%. Two major adverse cardiac events occurred during hospitalization and follow-up: one patient with cardiogenic shock at the index procedure subsequently died. One patient suffered from instable angina with need for interventional revascularization of a previously untreated vessel. One target vessel failure as a consequence of an intra-procedural dissection was seen. However, no target lesion failure was noted. During 132.7 ± 68.7 days of follow-up none of the patients died.

CONCLUSION

Our findings suggest that implantation of BVS in STEMI patients is feasible in this small cohort of highly selected patients. Further evaluation in randomized-controlled trials is needed.

Relationship between ST-segment resolution and anterior infarct size after primary percutaneous coronary intervention: analysis from the INFUSE-AMI trial

AIMS

ST-segment resolution (STR) after reperfusion therapy has been shown to correlate with prognosis in patients with ST-segment elevation myocardial infarction (STEMI). We investigated whether acute ECG measurements also correlate with ultimate infarct size.

METHODS AND RESULTS

The INFUSE-AMI trial randomized 452 patients with anterior STEMI to intracoronary bolus abciximab vs. no abciximab, and to thrombus aspiration vs. no aspiration. Infarct size as percentage of total LV mass was calculated by cardiac magnetic resonance imaging (MRI) 30 days post intervention. Five ECG methods were analysed for their ability to predict MRI infarct mass: (1) summed STR across all infarct-related ECG leads (ΣSTR); (2) STR in the single lead with maximum baseline ST-segment elevation (maxSTR); (3) summed residual ST-segment elevation across all infarct-related leads at 60 min post intervention (ΣST residual); (4) maximum residual ST-segment elevation in the worst single lead at 60 min post intervention (maxST residual); (5) number of new significant Q-waves (Qwave) at 60 min. All ECG methods strongly correlated with 30-day MRI infarct mass (all p<0.003). Simpler ECG measurements such as maxSTresidual and Qwave were as predictive as more complex measurements. A subset analysis of 158 patients who had microvascular obstruction (MVO) determined by MRI 5 days post intervention also showed strong correlations of MVO with the ECG measures.

CONCLUSIONS

ST-segment and Q-wave changes after primary PCI in anterior STEMI strongly correlated with 30-day infarct size by MRI. In particular, maxST residual and Qwave at 60 min are simple ECG parameters that offer rapid analysis for prognostication.

Assessing myocardial recovery following ST-segment elevation myocardial infarction: short- and long-term perspectives using cardiovascular magnetic resonance

Myocardial recovery after revascularization for ST-segment elevation myocardial infarction (STEMI) remains a significant diagnostic and, despite novel treatment strategies, a therapeutic challenge. Cardiovascular magnetic resonance (CMR) has emerged as a valuable clinical and research tool after acute STEMI. It represents the gold standard for functional and morphological evaluation of the left ventricle. Gadolinium-based perfusion and late-enhancement viability imaging has expanded our knowledge about the underlying pathologies of inadequate myocardial recovery. T2-weighted imaging of myocardial salvage after early reperfusion of the infarct-related artery underlines the effectiveness of current invasive treatment for STEMI. In the last decade, the number of publications on CMR after acute STEMI continued to rise, with no plateau in sight. Currently, CMR research is gathering robust prognostic data on standardized CMR protocols with the aim to substantially improve patient care and prognosis. Beyond established CMR protocols, more specific methods such as magnetic resonance relaxometry, myocardial tagging, 4D phase-contrast imaging and novel superparamagnetic contrast agents are emerging. This review will discuss the currently available data on the use of CMR after acute STEMI and take a brief look at developing new methods currently under investigation.

Peak and fixed-time high-sensitive troponin for prediction of infarct size, impaired left ventricular function, and adverse outcomes in patients with first ST-segment elevation myocardial infarction receiving percutaneous coronary intervention

The clinical use of advanced imaging modalities for early determination of infarct size and prognosis is limited. As a specific indicator of myocardial necrosis, cardiac troponin T (cTnT) can be used as a surrogate measure for this purpose. The present study sought to investigate the use of peak and serial 6-hour fixed-time high-sensitive (hs) cTnT for estimation of infarct size, left ventricular (LV) function, and prognosis in consecutive patients with ST-segment elevation myocardial infarction. The infarct size was expressed as the 48-hour cumulative creatine kinase release. LV function at 3 months was assessed using the echocardiographic wall motion score index and LV ejection fraction using radionuclide ventriculography. Adverse outcomes, comprising all-cause death, implantable cardioverter-defibrillator implantation, or hospitalization for heart failure, were recorded at 1 year of follow-up. In 188 patients, the peak and all fixed-time values correlated significantly with the 48-hour cumulative creatine kinase release, wall motion score index, and LV ejection fraction. The hs-cTnT value at 24 hours demonstrated the greatest correlation (r = 0.86, r = 0.47, and r = -0.59, respectively; p <0.001 for all). In the multivariate regression models adjusted for the clinical parameters, almost all were independently associated with the 48-hour cumulative creatine kinase release, wall motion score index, and LV ejection fraction, with the hs-cTnT value at 24 hours having the largest effect. Moreover, all cTnT values independently predicted adverse outcomes, again, with the hs-cTnT value at 24 hours showing the largest influence (hazard ratio 3.77, 95% confidence interval 2.12 to 6.73, p <0.001). In conclusion, not only peak, but all fixed-time hs-cTnT values were associated with infarct size, LV function at 3 months, and adverse outcomes 1 year after ST-segment elevation myocardial infarction. The value 24 hours after the onset of symptoms had the closest associations with all outcomes. Therefore, serial sampling for a peak value might be redundant.

Relationship and prognostic value of microvascular obstruction and infarct size in ST-elevation myocardial infarction as visualized by magnetic resonance imaging

BACKGROUND

Both infarct size and microvascular obstruction (MO) assessed by cardiac magnetic resonance imaging (CMR) are known to be predictors for adverse clinical outcome after ST-elevation myocardial infarction (STEMI). We hypothesized that a ratio of MO and infarct size (MO/infarct size) might be an even stronger predictor for outcome after STEMI, which has not been investigated yet.

METHODS

STEMI patients reperfused by primary angioplasty (n = 438) within 12 h after symptom onset underwent contrast-enhanced CMR at a median of 3 days (interquartile range [IQR] 2;4) after the index event. MO and infarct size were measured 15 min after intravenous gadolinium injection. Follow-up was conducted after 19 months (IQR 10;27). The primary end point was defined as a composite of death, non-fatal myocardial reinfarction and congestive heart failure (major adverse cardiac events [MACE]).

RESULTS

The extent of MO was only weakly correlated with infarct size (r = 0.21, p < 0.001). In a first multivariate analysis including extent of MO, infarct size, ejection fraction, end-systolic and end-diastolic volume, the extent of MO was independently associated with MACE (hazard ratio [HR] 1.03, 95%CI 1.02–1.05, p < 0.001). In a second multivariate analysis including MO/infarct size on top of the extent of MO, infarct size, ejection fraction, end-systolic and end-diastolic volume, MO/infarct size was identified as the strongest independent predictor for MACE (HR 2.22 [95%CI 1.60–3.08, p < 0.001]).

CONCLUSIONS

In contrast to infarct size, MO is associated with adverse clinical outcome after STEMI even after adjustment for other CMR parameters. However, MO/infarct size is a more powerful predictor for long-term outcome after STEMI than either parameter alone.

Prognostic value at 5 years of microvascular obstruction after acute myocardial infarction assessed by cardiovascular magnetic resonance

BACKGROUND

Early and late microvascular obstruction (MVO) assessed by cardiovascular magnetic resonance (CMR) are prognostic markers for short-term clinical endpoints after acute ST-elevation myocardial infarction (STEMI). However, there is a lack of studies with long-term follow-up periods (>24 months).

METHODS

STEMI patients reperfused by primary angioplasty (n = 129) underwent MRI at a median of 2 days after the index event. Early MVO was determined on dynamic Gd first-pass images directly after the administration of 0.1 mmol/kg bodyweight Gd-based contrast agent. Furthermore, ejection fraction (EF, %), left ventricular myocardial mass (LVMM) and total infarct size (% of LVMM) were determined with CMR. Clinical follow-up was conducted after a median of 52 months. The primary endpoint was defined as a composite of death, myocardial re-infarction, stroke, repeat revascularization, recurrence of ischemic symptoms, atrial fibrillation, congestive heart failure and hospitalization.

RESULTS

Follow-up was completed by 107 patients. 63 pre-defined events occurred during follow-up. Initially, 74 patients showed early MVO. Patients with early MVO had larger infarcts (mean: 24.9 g vs. 15.5 g, p = 0.002) and a lower EF (mean: 39% vs. 46%, p = 0.006). The primary endpoint occurred in 66.2% of patients with MVO and in 42.4% of patients without MVO (p < 0.05). The presence of early MVO was associated with a reduced event-free survival (log-rank p < 0.05). Early MVO was identified as the strongest independent predictor for the occurrence of the primary endpoint in the multivariable Cox regression analysis adjusting for age, ejection fraction and infarct size (hazard ratio: 2.79, 95%-CI 1.25-6.25, p = 0.012).

CONCLUSION

Early MVO, as assessed by first-pass CMR, is an independent long-term prognosticator for morbidity after AMI.

Serum vitamin D concentration status and its correlation with early biomarkers of remodeling following acute myocardial infarction

BACKGROUND

Low serum level of vitamin D was shown to be associated with cardiovascular diseases as well as the presence of diabetes, dyslipidemia, and hypertension. Vitamin D deficiency is a global problem, and is an Iranian problem as well. To the best of our knowledge, this was the first study on acute myocardial infarction that evaluates the correlation of vitamin D level with inpatients' outcomes, particularly on the early biomarkers of myocardial remodeling.

METHODS

In a prospective study, patients with acute ST segment elevation myocardial infarction were included. The patients' 25 (OH) D levels were identified and the associations with clinical characteristics, including early remodeling biomarkers and in-hospital outcomes, were investigated.

RESULTS

From the 139 included patients, 80.5% were male. The 25 (OH) deficiency was present in 72.7% of the patients. Hypertension and positive history of cardiovascular drug use were risk factors for the presence of low vitamin D levels (OR = 2.92; CI = 1.34-6.37, P < 0.05) and (OR = 2.36; CI = 1.05-5.29, P < 0.05), respectively. Moreover, a significant positive relationship between the inpatients' survival and the concentration of vitamin D was present (P < 0.001). By performing a multivariate analysis, we found that there was a significant inverse relationship between the level of 25 (OH) D and the level of MMP-9 after 72 h (P = 0.011).

CONCLUSION

The results of our study revealed a significant inverse relationship between serum MMP-9 as a biomarker of early remodeling and the level of 25(OH) D in patients after an acute myocardial infarction. Moreover, low level of vitamin D was associated with patients' mortality in this study.