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Mu D, Zhong J, Li L, Cheng J, Zou Y, Qiu L, Cheng X. Copeptin with high-sensitivity cardiac troponin to rule out non-ST-elevation myocardial infarction early on: A systematic review and meta-analysis. Clin Biochem 2023; 112:24-32. [PMID: 36435204 DOI: 10.1016/j.clinbiochem.2022.11.009] [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: 07/14/2022] [Revised: 11/18/2022] [Accepted: 11/19/2022] [Indexed: 11/25/2022]
Abstract
High-sensitivity cardiac troponin (hs-cTn) with copeptin in rapidly ruling out non-ST-elevation myocardial infarction (NSTEMI) remains controversial. We aimed to evaluate the diagnostic accuracy of this combination compared to hs-cTn alone. A literature search of electronic databases was performed from inception to 26 March 2022. Primary studies that evaluated the diagnostic accuracy of hs-cTn with and without copeptin in patients with NSTEMI were eligible. The reference standard consisted of all available medical results, including a significant rise or fall of cTn with at least one value above the 99th percentile of the reference population. The QUality Assessment of Diagnostic Accuracy Studies (QUADAS-2) was used to assess the quality of the included studies. Thirteen studies involving 8,966 patients, 1,405 of whom were diagnosed with NSTEMI (prevalence, 15.67 %), were included. Combining copeptin with hs-cTn (99th percentile of the healthy population as the threshold) at admission improved the sensitivity from 0.89 to 0.96 (95 % confidence interval [CI] 0.84-0.93 vs 0.93-0.98); the specificity reduced from 0.79 to 0.56 (95 % CI 0.71-0.86 vs 0.51-0.60). In five studies with 6,073 participants (900 NSTEMI), the hs-cTn alone (with 'very low' or limit of detection [LoD] threshold) had higher diagnostic sensitivity than the dual-marker strategy (0.98 vs 0.96). Combining copeptin with hs-cTn (99th percentile of the population as the threshold) at admission improved sensitivity in NSTEMI identification at the expense of specificity. However, with the LoD threshold for hs-cTn, copeptin had no additional value, deterring the widespread use of copeptin if the hs-cTn assay is clinically available.
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Affiliation(s)
- Danni Mu
- Department of Laboratory Medicine, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Science, Beijing 100730, China
| | - Jian Zhong
- Department of Laboratory Medicine, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Science, Beijing 100730, China
| | - Lei Li
- Department of Laboratory Medicine, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Science, Beijing 100730, China
| | - Jin Cheng
- Department of Laboratory Medicine, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Science, Beijing 100730, China
| | - Yutong Zou
- Department of Laboratory Medicine, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Science, Beijing 100730, China
| | - Ling Qiu
- Department of Laboratory Medicine, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Science, Beijing 100730, China; State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China.
| | - Xinqi Cheng
- Department of Laboratory Medicine, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Science, Beijing 100730, China.
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Mu D, Cheng J, Qiu L, Cheng X. Copeptin as a Diagnostic and Prognostic Biomarker in Cardiovascular Diseases. Front Cardiovasc Med 2022; 9:901990. [PMID: 35859595 PMCID: PMC9289206 DOI: 10.3389/fcvm.2022.901990] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Accepted: 06/07/2022] [Indexed: 12/11/2022] Open
Abstract
Copeptin is the carboxyl-terminus of the arginine vasopressin (AVP) precursor peptide. The main physiological functions of AVP are fluid and osmotic balance, cardiovascular homeostasis, and regulation of endocrine stress response. Copeptin, which is released in an equimolar mode with AVP from the neurohypophysis, has emerged as a stable and simple-to-measure surrogate marker of AVP and has displayed enormous potential in clinical practice. Cardiovascular disease (CVD) is currently recognized as a primary threat to the health of the population worldwide, and thus, rapid and effective approaches to identify individuals that are at high risk of, or have already developed CVD are required. Copeptin is a diagnostic and prognostic biomarker in CVD, including the rapid rule-out of acute myocardial infarction (AMI), mortality prediction in heart failure (HF), and stroke. This review summarizes and discusses the value of copeptin in the diagnosis, discrimination, and prognosis of CVD (AMI, HF, and stroke), as well as the caveats and prospects for the application of this potential biomarker.
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Affiliation(s)
- Danni Mu
- Department of Laboratory Medicine, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Jin Cheng
- Department of Laboratory Medicine, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Ling Qiu
- Department of Laboratory Medicine, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China.,State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Xinqi Cheng
- Department of Laboratory Medicine, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
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Pintado MC, Maceda L, Trascasa M, Arribas I, De Pablo R. Prognostic tools at hospital arrival in acute myocardial infarction: copeptin and hepatocyte growth factor. Egypt Heart J 2022; 74:35. [PMID: 35482134 PMCID: PMC9050999 DOI: 10.1186/s43044-022-00275-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Accepted: 04/20/2022] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Prompt evaluation and treatment of acute coronary syndrome has demonstrated to reduce mortality. Although several biomarkers have been studied for risk stratification and prognostic purposes, none is recommended to guide treatment based on its prognostic value. Copeptin and hepatocyte growth factor have been associated with poor outcome in patients with acute myocardial infarction. The aim of this study is to evaluate the early prognostic value of measurements of copeptin and hepatocyte growth factor for hospital mortality risk and 1-year-follow-up mortality, in patients with acute myocardial infarction. In our retrospective observational study, we measured hepatocyte growth factor and copeptin in blood samples collected at hospital arrival in patients with acute myocardial infarction; and follow-up them until 1-year. RESULTS 84 patients with were included in the study, mainly male (65%) with a median age of 70.3 ± 13.56 years. Hospital mortality was 11.9%. Plasma levels of copeptin at hospital arrival were statistically significant higher in patients who died during hospital admission (145.60 pmol/L [52.21-588.50] vs. 24.79 pmol/L [10.90-84.82], p 0.01). However, we found no statistically significant association between plasma levels of hepatocyte growth factor and hospital mortality (381.05 pg/ml [189.95-736.65] vs. 355.24 pg/ml [175.55-521.76], p 0.73). 1-year follow-up mortality was 21.4%. Plasma levels of copeptin at hospital arrival were higher in those patients who died in the following year (112.28 pmol/L [25.10-418.27] vs. 23.82 pmol/L [10.96-77.30], p 0.02). In the case of HGF, we also find no association between hepatocyte growth factor plasma levels and 1 -year follow-up mortality (350.00 pg/ml [175.05-555.08] vs. 345.53 pg/ml [183.68-561.15], p 0.68). CONCLUSIONS In patients with acute myocardial infarction measurement of copeptin at hospital arrival could be a useful tool to assess the prognosis of these patients, since their elevation is associated with a higher hospital mortality and higher 1-year follow-up mortality. We have not found this association in the case of hepatocyte growth factor measurement.
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Affiliation(s)
- María-Consuelo Pintado
- Critical Care Unit, Hospital Universitario Príncipe de Asturias, Carretera Alcalá-Meco SN, 28805, Alcalá de Henares, Madrid, Spain.
- University of Alcalá, Alcalá de Henares, Madrid, Spain.
| | - Lara Maceda
- Department of Biochemistry, Hospital Universitario Príncipe de Asturias, Carretera Alcalá-Meco SN, 28805, Alcalá de Henares, Madrid, Spain
| | - María Trascasa
- Critical Care Unit, Hospital Universitario Príncipe de Asturias, Carretera Alcalá-Meco SN, 28805, Alcalá de Henares, Madrid, Spain
| | - Ignacio Arribas
- Department of Biochemistry, Hospital Universitario Ramón y Cajal, Carretera de Colmenar Viejo Km 9.100, 28034, Madrid, Spain
| | - Raúl De Pablo
- University of Alcalá, Alcalá de Henares, Madrid, Spain
- Critical Care Unit, Hospital Universitario Ramón y Cajal, Carretera de Colmenar Viejo Km 9.100, 28034, Madrid, Spain
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Szarpak L, Lapinski M, Gasecka A, Pruc M, Drela WL, Koda M, Denegri A, Peacock FW, Jaguszewski MJ, Filipiak KJ. Performance of Copeptin for Early Diagnosis of Acute Coronary Syndromes: A Systematic Review and Meta-Analysis of 14,139 Patients. J Cardiovasc Dev Dis 2021; 9:6. [PMID: 35050216 PMCID: PMC8780262 DOI: 10.3390/jcdd9010006] [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] [Received: 11/12/2021] [Revised: 12/18/2021] [Accepted: 12/23/2021] [Indexed: 12/28/2022] Open
Abstract
Diagnosis of acute coronary syndrome (ACS) based on copeptin level may enable one to confirm or rule-out acute myocardial infarction (AMI) with higher sensitivity and specificity, which may in turn further reduce mortality rate and decrease the economic costs of ACS treatment. We conducted a systematic review and meta-analysis to investigate the relationship between copeptin levels and type of ACS. We searched Scopus, PubMed, Web of Science, Embase, and Cochrane to locate all articles published up to 10 October 2021. We evaluated a meta-analysis with random-effects models to evaluate differences in copeptin levels. A total of 14,139 patients (4565 with ACS) were included from twenty-seven studies. Copeptin levels in AMI and non-AMI groups varied and amounted to 68.7 ± 74.7 versus 14.8 ± 19.9 pmol/L (SMD = 2.63; 95% CI: 2.02 to 3.24; p < 0.001). Copeptin levels in the AMI group was higher than in the unstable angina (UAP) group, at 51.9 ± 52.5 versus 12.8 ± 19.7 pmol/L (SMD = 1.53; 95% CI: 0.86 to 2.20; p < 0.001). Copeptin levels in ST-elevation myocardial infarction (STEMI) versus non-ST elevation myocardial infarction (NSTEMI) patient groups were 54.8 ± 53.0 versus 28.7 ± 46.8 pmol/L, respectively (SMD = 1.69; 95% CI: = 0.70 to 4.09; p = 0.17). In summary, elevated copeptin levels were observed in patients with ACS compared with patients without ACS. Given its clinical value, copeptin levels may be included in the assessment of patients with ACS as well as for the initial differentiation of ACS.
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Affiliation(s)
- Lukasz Szarpak
- Institute of Outcomes Research, Maria Sklodowska-Curie Medical Academy, 03-411 Warsaw, Poland
- Research Unit, Maria Sklodowska-Curie Bialystok Oncology Center, 15-027 Bialystok, Poland;
- Research Unit, Polish Society of Disaster Medicine, 05-806 Warsaw, Poland;
| | - Marcin Lapinski
- 1st Chair and Department of Cardiology, Medical University of Warsaw, 02-097 Warsaw, Poland; (M.L.), (A.G.)
| | - Aleksandra Gasecka
- 1st Chair and Department of Cardiology, Medical University of Warsaw, 02-097 Warsaw, Poland; (M.L.), (A.G.)
- Laboratory of Experimental Clinical Chemistry, Amsterdam University Medical Center, 1105 Amsterdam, The Netherlands
| | - Michal Pruc
- Research Unit, Polish Society of Disaster Medicine, 05-806 Warsaw, Poland;
| | - Wiktoria L. Drela
- Students Research Club, Maria Sklodowska-Curie Medical Academy, 04-311 Warsaw, Poland;
| | - Mariusz Koda
- Research Unit, Maria Sklodowska-Curie Bialystok Oncology Center, 15-027 Bialystok, Poland;
| | - Andrea Denegri
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, 41121 Modena, Italy;
| | - Frank W. Peacock
- Henry JN Taub Department of Emergency Medicine, Baylor College of Medicine, Houston, TX 77030, USA;
| | | | - Krzysztof J. Filipiak
- Institute of Clinical Medicine, Maria Sklodowska-Curie Medical Academy, 00-001 Warsaw, Poland;
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Giannitsis E, Slagman A, Hamm CW, Gehrig S, Vollert JO, Huber K. Copeptin combined with either non-high sensitivity or high sensitivity cardiac troponin for instant rule-out of suspected non-ST segment elevation myocardial infarction. Biomarkers 2020; 25:649-658. [DOI: 10.1080/1354750x.2020.1833084] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Affiliation(s)
- Evangelos Giannitsis
- Department of Cardiology, Angiology and Pulmology, Medizinische Klinik III, University Hospital of Heidelberg, Heidelberg, Germany
| | - Anna Slagman
- Division of Emergency Medicine and Chest Pain Units, Campus Virchow and Mitte, Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Christian W. Hamm
- Department of Cardiology, Kerckhoff Heart and Thorax Centre, Bad Nauheim, Germany
| | - Stefan Gehrig
- Cardiovascular Biomarkers, Thermo Fisher Scientific, Hennigsdorf, Germany
| | - Joern O. Vollert
- Cardiovascular Biomarkers, Thermo Fisher Scientific, Hennigsdorf, Germany
| | - Kurt Huber
- 3rd Department of Internal Medicine, Cardiology and Intensive Care Medicine, Wilhelminenhospital, Vienna, Austria
- Medical School, Sigmund Freud University, Vienna, Austria
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Shin H, Jang BH, Lim TH, Lee J, Kim W, Cho Y, Ahn C, Choi KS. Diagnostic accuracy of adding copeptin to cardiac troponin for non-ST-elevation myocardial infarction: A systematic review and meta-analysis. PLoS One 2018; 13:e0200379. [PMID: 29979797 PMCID: PMC6034895 DOI: 10.1371/journal.pone.0200379] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2018] [Accepted: 06/24/2018] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION This study aimed to determine the diagnostic accuracy of adding copeptin to cardiac troponin (cTn) on admission to the emergency department (ED) for non-ST elevation myocardial infarction (NSTEMI) compared to cTn alone. MATERIALS AND METHODS A literature search of MEDLINE, EMBASE, and the Cochrane Library was performed (search date: April 13, 2018). Primary studies were included if they accurately reported on patients with symptoms suggestive of acute myocardial infarction and measured both cTn alone and cTn with copeptin upon admission to the ED. The patients with evidence of ST elevation myocardial infarction were excluded. To assess the risk of bias for the included studies, the QUADAS-2 tool was used. RESULTS The study participants included a total of 7,998 patients from 14 observational studies. The addition of copeptin to cTn significantly improved the sensitivity (0.81 [0.74 to 0.87] vs. 0.92 [0.89 to 0.95], respectively, p <0.001) and negative predictive value (0.96 [0.95 to 0.98] vs. 0.98 [0.96 to 0.99], respectively, p <0.001) at the expense of lower specificity (0.88 [0.80 to 0.97] vs. 0.57 [0.49 to 0.65], respectively, p <0.001) compared to cTn alone. Furthermore, adding copeptin to cTn showed significantly lower diagnostic accuracy for NSTEMI compared to cTn alone (0.91[0.90 to 0.92] vs. 0.85 [0.83 to 0.86], respectively, p < 0.001). CONCLUSIONS Adding copeptin to cTn improved the sensitivity and negative predictive value for the diagnosis of NSTEMI compared to cTn alone. Thus, adding copeptin to cTn might help to screen NSTEMI early upon admission to the ED.
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Affiliation(s)
- Hyungoo Shin
- Department of Emergency Medicine, College of Medicine, Hanyang University, Seoul, Korea
| | - Bo-Hyoung Jang
- Department of Preventive Medicine, College of Korean Medicine, Kyung Hee University, Seoul, Korea
| | - Tae Ho Lim
- Department of Emergency Medicine, College of Medicine, Hanyang University, Seoul, Korea
- Convergence Technology Center for Disaster Preparedness, Hanyang University, Seoul, Korea
| | - Juncheol Lee
- Department of Emergency Medicine, College of Medicine, Hanyang University, Seoul, Korea
| | - Wonhee Kim
- Department of Emergency Medicine, College of Medicine, Hallym University, Seoul, Korea
- Department of Biomedical Engineering, Graduate School of Medicine, Hanyang University, Seoul, Korea
| | - Youngsuk Cho
- Department of Emergency Medicine, College of Medicine, Hallym University, Seoul, Korea
- Department of Biomedical Engineering, Graduate School of Medicine, Hanyang University, Seoul, Korea
| | - Chiwon Ahn
- Department of Biomedical Engineering, Graduate School of Medicine, Hanyang University, Seoul, Korea
- Department of Emergency Medicine, Armed Forces Yangju Hospital, Yangju, Korea
| | - Kyu-Sun Choi
- Department of Neurosurgery, College of Medicine, Hanyang University, Seoul, Korea
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Kip MM, Steuten LM, Koffijberg H, IJzerman MJ, Kusters R. Using expert elicitation to estimate the potential impact of improved diagnostic performance of laboratory tests: a case study on rapid discharge of suspected non-ST elevation myocardial infarction patients. J Eval Clin Pract 2018; 24:31-41. [PMID: 27761961 DOI: 10.1111/jep.12626] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2016] [Revised: 07/11/2016] [Accepted: 07/11/2016] [Indexed: 12/26/2022]
Abstract
Early health technology assessment can provide insight in the potential cost-effectiveness of new tests to guide further development decisions. This can increase their potential benefit but often requires evidence which is lacking in early test development stages. Then, expert elicitation may be used to generate evidence on the impact of tests on patient management. This is illustrated in a case study on a new triple biomarker test (copeptin, heart-type fatty acid binding protein, and high-sensitivity troponin [HsTn]) at hospital admission. The elicited evidence enables estimation of the impact of using the triple biomarker on time to exclusion of non-ST elevation myocardial infarction compared with current serial HsTn measurement (performed 0, 2, and 6 h after admission). Cardiologists were asked to estimate the effect of the triple biomarker on patient's discharge rates and interventions performed, depending on its diagnostic performance. This elicited evidence was combined with Dutch reimbursement data and published evidence into a decision analytic model. Direct hospital costs and patients' discharge rates were assessed for 3 testing strategies including this triple biomarker (ie, only at admission or combined with HsTn measurements after 2 and 6 h). Direct hospital costs of suspected non-ST elevation myocardial infarction patients using serial HsTn measurements are estimated at €1825 per patient. Combining this triple biomarker with HsTn measurements after 2 and 6 hours is expected to be the most cost-effective strategy. Depending on the diagnostic performance of the triple biomarker, this strategy is estimated to reduce costs with €66 to €205 per patient (ie, 3.6%-11.3% reduction). Expert elicitation can be a valuable tool for early health technology assessment to provide an initial estimate of the cost-effectiveness of new tests prior to their implementation in clinical practice. As demonstrated in our case study, improved diagnostic performance of the triple biomarker may have benefits that should be further explored.
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Affiliation(s)
- Michelle Ma Kip
- MIRA institute for Biomedical Technology and Technical Medicine, department of Health Technology and Services Research, University of Twente, Enschede, Overijssel, The Netherlands
| | - Lotte Mg Steuten
- Fred Hutchinson Cancer Research Center, Seattle, USA.,Panaxea bv, Amsterdam, Noord-Holland, The Netherlands
| | - Hendrik Koffijberg
- MIRA institute for Biomedical Technology and Technical Medicine, department of Health Technology and Services Research, University of Twente, Enschede, Overijssel, The Netherlands
| | - Maarten J IJzerman
- MIRA institute for Biomedical Technology and Technical Medicine, department of Health Technology and Services Research, University of Twente, Enschede, Overijssel, The Netherlands
| | - Ron Kusters
- MIRA institute for Biomedical Technology and Technical Medicine, department of Health Technology and Services Research, University of Twente, Enschede, Overijssel, The Netherlands.,Laboratory for Clinical Chemistry and Haematology, Jeroen Bosch Ziekenhuis, Den Bosch, Noord-Brabant, The Netherlands
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Recent Advances in Biomarker Discovery — from Serum to Imaging-based Biomarkers for a Complex Assessment of Heart Failure Patients. JOURNAL OF INTERDISCIPLINARY MEDICINE 2016. [DOI: 10.1515/jim-2016-0045] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Abstract
Over the last years, a vast majority of serum biomarkers and imaging techniques have been used alone or combined in the diagnosis, management and prognosis of numerous pathologies. This review provides a brief insight into the novelties from the last 6 years (2010–2016) regarding serum and imaging markers in heart failure (HF). New information about natriuretic peptides (NPs), soluble ST2 (Sst2), growth differentiation factor 15 (GDF-15), myeloperoxidase (MPO), C-reactive protein (CRP), procalcitonin (PCT), troponins (Tns), myoglobin (Mb), galectin-3 (Gal-3), micro ribonucleic acids (microRNAs) and long non-coding ribonucleic acids (IncRNAs), copectin and cardiac magnetic resonance (CMR) measurements were summarized in this review in order to guide the practitioner.
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Westwood M, van Asselt T, Ramaekers B, Whiting P, Thokala P, Joore M, Armstrong N, Ross J, Severens J, Kleijnen J. High-sensitivity troponin assays for the early rule-out or diagnosis of acute myocardial infarction in people with acute chest pain: a systematic review and cost-effectiveness analysis. Health Technol Assess 2016; 19:1-234. [PMID: 26118801 DOI: 10.3310/hta19440] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Early diagnosis of acute myocardial infarction (AMI) can ensure quick and effective treatment but only 20% of adults with emergency admissions for chest pain have an AMI. High-sensitivity cardiac troponin (hs-cTn) assays may allow rapid rule-out of AMI and avoidance of unnecessary hospital admissions and anxiety. OBJECTIVE To assess the clinical effectiveness and cost-effectiveness of hs-cTn assays for the early (within 4 hours of presentation) rule-out of AMI in adults with acute chest pain. METHODS Sixteen databases, including MEDLINE and EMBASE, research registers and conference proceedings, were searched to October 2013. Study quality was assessed using QUADAS-2. 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 (QALYs) associated with different troponin (Tn) testing methods. The de novo model consisted of a decision tree and Markov model. A lifetime time horizon (60 years) was used. RESULTS Eighteen studies were included in the clinical effectiveness review. The optimum strategy, based on the Roche assay, used a limit of blank (LoB) threshold in a presentation sample to rule out AMI [negative likelihood ratio (LR-) 0.10, 95% confidence interval (CI) 0.05 to 0.18]. Patients testing positive could then have a further test at 2 hours; a result above the 99th centile on either sample and a delta (Δ) of ≥ 20% has some potential for ruling in an AMI [positive likelihood ratio (LR+) 8.42, 95% CI 6.11 to 11.60], whereas a result below the 99th centile on both samples and a Δ of < 20% can be used to rule out an AMI (LR- 0.04, 95% CI 0.02 to 0.10). The optimum strategy, based on the Abbott assay, used a limit of detection (LoD) threshold in a presentation sample to rule out AMI (LR- 0.01, 95% CI 0.00 to 0.08). Patients testing positive could then have a further test at 3 hours; a result above the 99th centile on this sample has some potential for ruling in an AMI (LR+ 10.16, 95% CI 8.38 to 12.31), whereas a result below the 99th centile can be used to rule out an AMI (LR- 0.02, 95% CI 0.01 to 0.05). In the base-case analysis, standard Tn testing was both most effective and most costly. Strategies considered cost-effective depending upon incremental cost-effectiveness ratio thresholds were Abbott 99th centile (thresholds of < £6597), Beckman 99th centile (thresholds between £6597 and £30,042), Abbott optimal strategy (LoD threshold at presentation, followed by 99th centile threshold at 3 hours) (thresholds between £30,042 and £103,194) and the standard Tn test (thresholds over £103,194). The Roche 99th centile and the Roche optimal strategy [LoB threshold at presentation followed by 99th centile threshold and/or Δ20% (compared with presentation test) at 1-3 hours] were extendedly dominated in this analysis. CONCLUSIONS There is some evidence to suggest that hs-CTn testing may provide an effective and cost-effective approach to early rule-out of AMI. Further research is needed to clarify optimal diagnostic thresholds and testing strategies. STUDY REGISTRATION This study is registered as PROSPERO CRD42013005939. FUNDING The National Institute for Health Research Health Technology Assessment programme.
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Affiliation(s)
| | - Thea van Asselt
- Department of Clinical Epidemiology and Medical Technology Assessment, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Bram Ramaekers
- Department of Clinical Epidemiology and Medical Technology Assessment, Maastricht University Medical Centre, Maastricht, The Netherlands
| | | | - Praveen Thokala
- Health Economics and Decision Science Group, School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Manuela Joore
- Department of Clinical Epidemiology and Medical Technology Assessment, Maastricht University Medical Centre, Maastricht, The Netherlands
| | | | | | - Johan Severens
- Institute of Health Policy and Management, Erasmus University Rotterdam, Rotterdam, The Netherlands
| | - Jos Kleijnen
- School for Public Health and Primary Care (CAPHRI), Maastricht University, Maastricht, The Netherlands
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Stallone F, Schoenenberger AW, Puelacher C, Rubini Gimenez M, Walz B, Naduvilekoot Devasia A, Bergner M, Twerenbold R, Wildi K, Reichlin T, Hillinger P, Erne P, Mueller C. Incremental value of copeptin in suspected acute myocardial infarction very early after symptom onset. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2016; 5:407-15. [PMID: 27013743 DOI: 10.1177/2048872616641289] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/04/2015] [Accepted: 03/04/2016] [Indexed: 01/30/2023]
Abstract
BACKGROUND Patients presenting very early after chest pain onset may provide a diagnostic challenge even when using a high-sensitivity cardiac troponin (hs-cTnT). We hypothesized that in these patients the incremental value of copeptin in the early diagnosis of acute myocardial infarction (AMI) may be substantial. METHODS We aimed to investigate the incremental value of copeptin in a pre-specified subgroup analysis of patients presenting with suspected AMI to the emergency department within 2 hours of symptom onset in a multicenter study. Copeptin was measured in a blinded fashion. Two independent cardiologists adjudicated the final diagnosis using all available clinical informations, including high-sensitivity cardiac troponin T (hs-cTnT). RESULTS Overall, 2000 patients were enrolled, of whom 519 (26%) arrived within 2 hours of symptom onset. Of these, 102 patients (20%) had an AMI. The additional use of copeptin did not increase diagnostic accuracy as quantified by the area under the receiver-operating characteristic curve (AUC) of hs-cTnT (0.87 (95% confidence interval (CI): 0.83-0.90) for hs-cTnT alone to 0.86 (95% CI: 0.82-0.90) for the combination; p = NS). Copeptin (using 9 pmol/L as a cut-off) increased the negative predictive value (NPV) of hs-cTnT (using 14 ng/L as a cut-off) alone from 93% (95% CI: 90-95%) to 96% (95% CI: 93-98%). The NPV for the combination of hs-cTnT and copeptin was lower in patients arriving in the first 2 hours than in those arriving after 2 hours: 96% (95% CI: 93-98%) versus 99% (95% CI: 99-100%), respectively. CONCLUSIONS The additional use of copeptin on top of hs-cTnT seems to lead to a small increase in NPV, but no increase in AUC. Routine use of copeptin in early presenters does not seem warranted.
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Affiliation(s)
- Fabio Stallone
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Switzerland Department of Internal Medicine, University Hospital Basel, Switzerland
| | - Andreas W Schoenenberger
- Division of Geriatrics, Department of General Internal Medicine, Inselspital, Bern University Hospital, Switzerland University of Bern, Switzerland
| | - Christian Puelacher
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Switzerland Department of Internal Medicine, University Hospital Basel, Switzerland
| | - Maria Rubini Gimenez
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Switzerland Department of Internal Medicine, University Hospital Basel, Switzerland
| | - Brigitte Walz
- Central Laboratory, Luzerner Kantonsspital, Switzerland
| | - Allwin Naduvilekoot Devasia
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Switzerland
| | - Michael Bergner
- Department of Intensive Care Medicine, University Hospital Basel, Switzerland
| | - Raphael Twerenbold
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Switzerland
| | - Karin Wildi
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Switzerland Department of Intensive Care Medicine, University Hospital Basel, Switzerland
| | - Tobias Reichlin
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Switzerland
| | - Petra Hillinger
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Switzerland Department of Internal Medicine, University Hospital Basel, Switzerland
| | - Paul Erne
- Department of Cardiology, Luzerner Kantonsspital, Switzerland
| | - Christian Mueller
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Switzerland
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11
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Ricci F, Di Scala R, Massacesi C, Di Nicola M, Cremonese G, De Pace D, Rossi S, Griffo I, Cataldo I, Martinotti S, Rotondo D, Jaffe AS, Zimarino M, De Caterina R. Ultra-Sensitive Copeptin and Cardiac Troponin in Diagnosing Non-ST-Segment Elevation Acute Coronary Syndromes--The COPACS Study. Am J Med 2016; 129:105-14. [PMID: 26169889 DOI: 10.1016/j.amjmed.2015.06.033] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2015] [Revised: 06/13/2015] [Accepted: 06/15/2015] [Indexed: 11/15/2022]
Abstract
OBJECTIVES We tested the noninferiority of a fast-track rule-out protocol for the diagnosis of non-ST-segment elevation myocardial infarction vs noncoronary chest pain based on the single-sampling combined assessment of medium-sensitivity cardiac troponin I and ultra-sensitive copeptin compared with the serial assessment of medium-sensitivity cardiac troponin I. METHODS Ultra-sensitive copeptin and medium-sensitivity cardiac troponin I levels were measured at presentation in 196 consecutive patients admitted to the emergency department for acute nontraumatic chest pain within 6 hours from symptoms onset and without ST-segment elevation on a 12-lead electrocardiogram. The diagnostic performance for non-ST-segment elevation myocardial infarction diagnosis of the dual-marker single-sampling strategy with medium-sensitivity cardiac troponin I and ultra-sensitive copeptin on admission was compared with that of the serial 0- and 3-hour medium-sensitivity cardiac troponin I sampling in reference to the adjudicated postdischarge diagnosis, using both the comparison of area under the curve (AUC) receiver operating characteristic and the McNemar chi-square test. RESULTS The diagnosis of non-ST-segment elevation myocardial infarction was adjudicated in 29 patients (14.8%). The combination of medium-sensitivity cardiac troponin I and ultra-sensitive copeptin generated an AUC of 0.87 (95% confidence interval, 0.82-0.91), which was noninferior with respect to the 3-hour interval medium-sensitivity cardiac troponin I serial sampling (P = .194 for AUC difference). The combination of medium-sensitivity cardiac troponin I and ultra-sensitive copeptin also yielded a numerically higher diagnostic sensitivity (100% vs 89.7%; P = not significant). CONCLUSIONS A single-sampling strategy of combined ultra-sensitive copeptin and medium-sensitivity cardiac troponin I is noninferior to a 0- and 3-hour serial medium-sensitivity cardiac troponin I sampling in ruling out non-ST-segment elevation myocardial infarction and thus may allow an earlier discharge of patients who are ruled out for non-ST-segment elevation myocardial infarction (ClinicalTrials.gov Identifier NCT01962506).
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Affiliation(s)
- Fabrizio Ricci
- Institute of Cardiology and Center of Excellence on Aging, "G. d'Annunzio" University, Chieti, Italy
| | - Rosa Di Scala
- Institute of Cardiology and Center of Excellence on Aging, "G. d'Annunzio" University, Chieti, Italy
| | - Cristiano Massacesi
- Institute of Cardiology and Center of Excellence on Aging, "G. d'Annunzio" University, Chieti, Italy
| | - Marta Di Nicola
- Laboratory of Biostatistics, Department of Experimental and Clinical Science, "G. d'Annunzio" University, Chieti, Italy
| | - Gianni Cremonese
- Institute of Cardiology and Center of Excellence on Aging, "G. d'Annunzio" University, Chieti, Italy
| | - Doranna De Pace
- Institute of Cardiology and Center of Excellence on Aging, "G. d'Annunzio" University, Chieti, Italy
| | - Serena Rossi
- Institute of Cardiology and Center of Excellence on Aging, "G. d'Annunzio" University, Chieti, Italy
| | - Irma Griffo
- Department of Biomedical Sciences, "G. d'Annunzio" University, Chieti, Italy
| | - Ivana Cataldo
- Department of Biomedical Sciences, "G. d'Annunzio" University, Chieti, Italy
| | - Stefano Martinotti
- Department of Biomedical Sciences, "G. d'Annunzio" University, Chieti, Italy
| | - Domenico Rotondo
- Emergency Department, Azienda Sanitaria Locale 2 Abruzzo Lanciano-Vasto-Chieti Hospitals, Chieti, Italy
| | | | - Marco Zimarino
- Institute of Cardiology and Center of Excellence on Aging, "G. d'Annunzio" University, Chieti, Italy
| | - Raffaele De Caterina
- Institute of Cardiology and Center of Excellence on Aging, "G. d'Annunzio" University, Chieti, Italy.
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12
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Slagman A, Searle J, Müller C, Möckel M. Temporal Release Pattern of Copeptin and Troponin T in Patients with Suspected Acute Coronary Syndrome and Spontaneous Acute Myocardial Infarction. Clin Chem 2015; 61:1273-82. [DOI: 10.1373/clinchem.2015.240580] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2015] [Accepted: 07/10/2015] [Indexed: 11/06/2022]
Abstract
Abstract
BACKGROUND
The release pattern of copeptin during the initial 36 h of spontaneous acute myocardial infarction (AMI) has received relatively little investigation but may provide important information on optimal timing of diagnostic measurements.
METHODS
We investigated the release pattern of copeptin and cardiac troponin T in patients with suspected acute coronary syndrome (ACS). Blood samples were collected in the ambulance, at admission, and after 2, 4, 6, and 12–36 h. Copeptin and high-sensitivity cardiac troponin T (hs-cTnT) were measured in heparin plasma samples.
RESULTS
Of 93 patients studied, 37 (39.8%) had ST-elevation myocardial infarction (STEMI), 20 (21.5%) non-STEMI, 20 (21.5%) unstable angina pectoris (UAP), and 16 (17.2%) non-ACS diagnoses. Peak copeptin concentrations were detected during ambulance transport for NSTEMI patients [median 94.0 pmol/L, interquartile range (IQR) 53.3–302.1 pmol/L] and at admission for patients with STEMI (70.0 pmol/L, 22.0–144.8 pmol/L). In patients with AMI, copeptin decreased significantly over time (P < 0.0001). This was true for patients with STEMI (P = 0.005) and non-STEMI (P = 0.021). The diagnostic performance during ambulance transport was similar for hs-cTnT (area under the ROC curve 0.75, 95% CI 0.62–0.88) and copeptin (0.81, 0.69–0.92). In early presenters (n = 52), no patient with AMI was initially (in ambulance or at admission) negative for copeptin, resulting in an area under the ROC curve of 0.963 for ambulance values and a negative predictive value of 100%. In late presenters, the negative predictive value of copeptin was 50% in ambulance and at admission.
CONCLUSIONS
Our analysis is the first to show a consistent early increase in copeptin at first medical contact in the ambulance and a decrease to routine values within 12–36 h in patients presenting early with spontaneous AMI.
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Affiliation(s)
| | | | - Christian Müller
- Department of Laboratory Medicine, Charité University Hospital, Berlin, Germany
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13
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Copeptin improves the sensitivity of cardiac troponin in patients 70 years or older, but not enough to rule out myocardial infarction at emergency department presentation. Eur J Emerg Med 2015; 24:142-148. [PMID: 26375360 DOI: 10.1097/mej.0000000000000316] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
OBJECTIVES We aimed to evaluate the diagnostic performance of the combination of cardiac troponin (cTn) and copeptin in a population older than 70 years of age to rule out non-ST-elevation myocardial infarction (NSTEMI) at emergency department (ED) presentation. METHODS Among 885 analyzed patients with acute chest pain presenting to the ED, 218 (25%) were aged at least 70 years. RESULTS Patients with elevated copeptin values at presentation were more often aged at least 70 years and had higher blood pressure. Patients at least 70 years without NSTEMI more frequently had elevated copeptin values than younger counterparts (42 vs. 25%, P<0.0001). Bootstrap analysis for the diagnosis of NSTEMI indicated an optimal copeptin threshold value at 8.1 pmol/l in patients less than 70 years and at 10.7 pmol/l in patients at least 70 years. In patients at least 70 years, the combination of copeptin with cTnI significantly improved the sensitivity for the diagnosis of NSTEMI, at all copeptin thresholds tested, but the negative predictive value remained below 95%. CONCLUSION The combination of copeptin with conventional cTnI significantly improved sensitivity for the diagnosis of NSTEMI in patients at least 70 years. However, this improvement was not enough to rule out NSTEMI with a single draw strategy at ED presentation.
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14
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Poldervaart JM, Röttger E, Dekker MS, Zuithoff NPA, Verheggen PWHM, de Vrey EA, Wildbergh TX, van ‘t Hof AWJ, Mosterd A, Hoes AW. No Added Value of Novel Biomarkers in the Diagnostic Assessment of Patients Suspected of Acute Coronary Syndrome. PLoS One 2015; 10:e0132000. [PMID: 26177390 PMCID: PMC4503345 DOI: 10.1371/journal.pone.0132000] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2015] [Accepted: 06/09/2015] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Despite the availability of high-sensitive troponin (hs-cTnT), there is still room for improvement in the diagnostic assessment of patients suspected of acute coronary syndrome (ACS). Apart from serial biomarker testing, which is time-consuming, novel biomarkers like copeptin have been proposed to expedite the early diagnosis of suspected ACS in addition to hs-cTnT. We determined whether placenta derived growth factor (PlGF), soluble Fms-like tyrosine kinase 1 (sFlt-1), myoglobin, N-terminal prohormone B-type Natriuretic Peptide (NT-proBNP), growth-differentiation factor 15 (GDF-15) and copeptin improved early assessment of chest pain patients. METHODS This prospective, single centre diagnostic FAME-ER study included patients presenting to the ED with symptoms suggestive of ACS. Blood was collected to measure biomarkers, notably, hs-cTnT was retrospectively assessed. Added value of markers was judged by increase in AUC using multivariable logistic regression. RESULTS Of 453 patients enrolled, 149 (33%) received a final diagnosis of ACS. Hs-cTnT had the highest diagnostic value in both univariable and multivariable analysis. PPVs of the biomarkers ranged from 23.5% (PlGF) to 77.9% (hs-cTnT), NPVs from 67.0% (PlGF) to 86.4% (hs-cTnT). Only myoglobin yielded diagnostic value in addition to clinical symptoms and electrocardiography (ECG) (AUC of clinical model 0.80) with AUC of 0.84 (p<0.001). However, addition of hs-cTnT was superior (AUC 0.89, p<0.001). Addition of the biomarkers to our clinical model and hs-cTnT did not or only marginally (GDF-15) improved diagnostic performance. CONCLUSION When assessing patients suspected of ACS, only myoglobin had added diagnostic value beyond clinical symptoms and ECG. However, when combined with hs-cTnT, it yields no additional diagnostic value. PlGF, sFlt-1, NT-proBNP, GDF-15 and copeptin had no added value to the clinical model or hs-cTnT.
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Affiliation(s)
- Judith M. Poldervaart
- Julius Center for Health Sciences and Primary Care, University Medical Center, Universiteitsweg 100, 3584 CG, Utrecht, the Netherlands
- * E-mail:
| | - Emma Röttger
- Faculty of Medicine, Utrecht University, Universiteitsweg 98, 3584 CG, Utrecht, the Netherlands
| | - Marieke S. Dekker
- Department of Cardiology, Isala Clinics, Dokter van Heesweg 2, 8025 AB, Zwolle, the Netherlands
- Department of Cardiology, Meander Medical Center, Maatweg 3, 3813 TZ, Amersfoort, the Netherlands
| | - Nicolaas P. A. Zuithoff
- Julius Center for Health Sciences and Primary Care, University Medical Center, Universiteitsweg 100, 3584 CG, Utrecht, the Netherlands
| | - Peter W. H. M. Verheggen
- Department of Cardiology, Meander Medical Center, Maatweg 3, 3813 TZ, Amersfoort, the Netherlands
| | - Evelyn A. de Vrey
- Department of Cardiology, Meander Medical Center, Maatweg 3, 3813 TZ, Amersfoort, the Netherlands
| | - Thierry X. Wildbergh
- Department of Cardiology, Meander Medical Center, Maatweg 3, 3813 TZ, Amersfoort, the Netherlands
| | - Arnoud W. J. van ‘t Hof
- Department of Cardiology, Isala Clinics, Dokter van Heesweg 2, 8025 AB, Zwolle, the Netherlands
| | - Arend Mosterd
- Department of Cardiology, Meander Medical Center, Maatweg 3, 3813 TZ, Amersfoort, the Netherlands
| | - Arno W. Hoes
- Julius Center for Health Sciences and Primary Care, University Medical Center, Universiteitsweg 100, 3584 CG, Utrecht, the Netherlands
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15
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Copeptin testing in acute myocardial infarction: ready for routine use? DISEASE MARKERS 2015; 2015:614145. [PMID: 25960596 PMCID: PMC4415476 DOI: 10.1155/2015/614145] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/06/2014] [Accepted: 01/12/2015] [Indexed: 01/11/2023]
Abstract
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.
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16
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Effectiveness of practices for improving the diagnostic accuracy of Non ST Elevation Myocardial Infarction in the Emergency Department: A Laboratory Medicine Best Practices™ systematic review. Clin Biochem 2015; 48:204-12. [PMID: 25661303 DOI: 10.1016/j.clinbiochem.2015.01.014] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2014] [Revised: 01/26/2015] [Accepted: 01/28/2015] [Indexed: 11/21/2022]
Abstract
OBJECTIVES This article is a systematic review of the effectiveness of four practices (assay selection, decision point cardiac troponin (cTn) threshold selection, serial testing, and point of care testing) for improving the diagnostic accuracy Non-ST-Segment Elevation Myocardial Infarction (NSTEMI) in the Emergency Department. DESIGN AND METHODS The CDC-funded Laboratory Medicine Best Practices (LMBP) Initiative systematic review method for quality improvement practices was used. RESULTS The current ACC/AHA guidelines recommend using cardiac troponin assays with a 99th percentile upper reference limit (URL) diagnostic threshold to diagnose NSTEMI. The evidence in this systematic review indicates that contemporary sensitive cTn assays meet the assay profile requirements (sensitivity, specificity, PPV, and NPV) to more accurately diagnose NSTEMI than alternate tests. Additional biomarkers did not increase diagnostic effectiveness of cTn assays. Sensitivity, specificity, and NPV were consistently high and low PPV improved with serial sampling. Evidence for use of point of care cTn testing was insufficient to make recommendation, though some evidence suggests that use may result in reduction to patient length of stay and costs. CONCLUSIONS Based on the review of and the LMBP(TM) A-6 Method criteria, we recommend the use of cardiac troponin assays without additional biomarkers using the 99th percentile URL as the clinical diagnostic threshold for the diagnosis of NSTEMI. We recommend serial sampling with one sample at presentation and at least one additional second sample taken at least 6h later to identify a rise or fall in the troponin level. No recommendation is made either for or against the use of point of care tests. DISCLAIMER The findings and conclusions in this article are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention/the Agency for Toxic Substances and Disease Registry (CDC/ATSDR).
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17
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Abstract
The concentration of copeptin, the C-terminal part of pro-arginine vasopressin, has been shown to increase early after acute and severe events. Owing to complementary pathophysiology and kinetics, the unspecific marker copeptin, in combination with highly cardio-specific troponin, has been evaluated as an early-rule-out strategy for acute myocardial infarction in patients presenting with signs and symptoms of acute coronary syndrome. Overall, most studies have reported a negative predictive value between 97 and 100 % for the diagnosis of acute myocardial infarction in low- to intermediate-risk patients with suspected acute coronary syndrome. Additionally, a recent multicenter, randomized process study, where patients who tested negative for copeptin and troponin were discharged from the emergency department, showed that the safety of the new process was comparable to that of the current standard process. Further interventional trials and data from registries are needed to ensure the effectiveness and patient benefit of the new strategy.
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18
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Lipinski MJ, Baker NC, Escárcega RO, Torguson R, Chen F, Aldous SJ, Christ M, Collinson PO, Goodacre SW, Mair J, Inoue K, Lotze U, Sebbane M, Cristol JP, Freund Y, Chenevier-Gobeaux C, Meune C, Eggers KM, Pracoń R, Schreiber DH, Wu AHB, Ordoñez-Llanos J, Jaffe AS, Twerenbold R, Mueller C, Waksman R. Comparison of conventional and high-sensitivity troponin in patients with chest pain: a collaborative meta-analysis. Am Heart J 2015; 169:6-16.e6. [PMID: 25497242 DOI: 10.1016/j.ahj.2014.10.007] [Citation(s) in RCA: 68] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2014] [Accepted: 10/10/2014] [Indexed: 02/07/2023]
Abstract
BACKGROUND Multiple studies have evaluated the diagnostic and prognostic performance of conventional troponin (cTn) and high-sensitivity troponin (hs-cTn). We performed a collaborative meta-analysis comparing cTn and hs-cTn for diagnosis of acute myocardial infarction (AMI) and assessment of prognosis in patients with chest pain. METHODS MEDLINE/PubMed, Cochrane CENTRAL, and EMBASE were searched for studies assessing both cTn and hs-cTn in patients with chest pain. Study authors were contacted and many provided previously unpublished data. RESULTS From 17 included studies, there were 8,644 patients. Compared with baseline cTn, baseline hs-cTn had significantly greater sensitivity (0.884 vs 0.749, P < .001) and negative predictive value (NPV; 0.964 vs 0.935, P < .001), whereas specificity (0.816 vs 0.938, P < .001) and positive predictive value (0.558 vs 0.759, P < .001) were significantly reduced. Based on summary receiver operating characteristic curves, test performance for the diagnosis of AMI was not significantly different between baseline cTn and hs-cTn (0.90 [95% CI 0.85-0.95] vs 0.92 [95% CI 0.90-0.94]). In a subanalysis of 6 studies that alternatively defined AMI based on hs-cTn, cTn had lower sensitivity (0.666, P < .001) and NPV (0.906, P < .001). Elevation of baseline hs-cTn, but negative baseline cTn, was associated with increased risk of death or nonfatal myocardial infarction during follow-up (P < .001) compared with both negative. CONCLUSION High-sensitivity troponin has significantly greater early sensitivity and NPV for the diagnosis of AMI at the cost of specificity and positive predictive value, which may enable early rule in/out of AMI in patients with chest pain. Baseline hs-cTn elevation in the setting of negative cTn is also associated with increased nonfatal myocardial infarction or death during follow-up.
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Affiliation(s)
- Michael J Lipinski
- MedStar Cardiovascular Research Network, MedStar Heart Institute, Medstar Washington Hospital Center, Washington, DC
| | - Nevin C Baker
- MedStar Cardiovascular Research Network, MedStar Heart Institute, Medstar Washington Hospital Center, Washington, DC
| | - Ricardo O Escárcega
- MedStar Cardiovascular Research Network, MedStar Heart Institute, Medstar Washington Hospital Center, Washington, DC
| | - Rebecca Torguson
- MedStar Cardiovascular Research Network, MedStar Heart Institute, Medstar Washington Hospital Center, Washington, DC
| | - Fang Chen
- MedStar Cardiovascular Research Network, MedStar Heart Institute, Medstar Washington Hospital Center, Washington, DC
| | - Sally J Aldous
- Department of Cardiology, Christchurch Hospital, Christchurch, New Zealand
| | - Michael Christ
- Department of Emergency and Critical Care Medicine, Paracelsus Medical University, Nuremberg, Germany
| | - Paul O Collinson
- Clinical Blood Sciences Laboratory, St George's Hospital, London, United Kingdom
| | - Steve W Goodacre
- School of Health and Related Research, University of Sheffield, Sheffield, United Kingdom
| | - Johannes Mair
- Department of Internal Medicine, Innsbruck Medical University, Innsbruck, Austria
| | - Kenji Inoue
- Department of Cardiology, Juntendo University Nerima Hospital, Tokyo, Japan
| | - Ulrich Lotze
- Department of Internal Medicine, DRK-Manniske-Krankenhaus Bad Frankenhausen, Frankenhausen, Germany
| | - Mustapha Sebbane
- Départment des urgences, Centre Hospitalier Régional Universitaire Lapeyronie, Montpellier, France
| | - Jean-Paul Cristol
- Département de Biochimie, Centre Hospitalier Régional Universitaire Lapeyronie, Montpellier, France
| | - Yonathan Freund
- Department of Emergency Medicine and Surgery, Hôspital Pitié-Salpétrière, APHP, Université Pierre et Marie Curie-Paris 6 (UPMC), Paris, France
| | - Camille Chenevier-Gobeaux
- Clinical Chemistry Laboratory, Groupe Hospitalier Cochin-Broca-Hôtel Dieu, Université Paris Descartes, Assistance Publique des Hôpitaux de Paris, Paris, France
| | - Christophe Meune
- Cardiology Department, Groupe Hospitalier Cochin-Broca-Hôtel Dieu, Université Paris Descartes, Assistance Publique des Hôpitaux de Paris, Paris, France; Cardiology Department, Paris XIII University, Avicenne Hospital, Bobigny, France
| | - Kai M Eggers
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - Radosław Pracoń
- Department of Coronary and Structural Heart Diseases, National Insititute of Cardiology, Warsaw, Poland
| | - Donald H Schreiber
- Division of Emergency Medicine, Stanford University School of Medicine, Stanford, CA
| | - Alan H B Wu
- Department of Laboratory Medicine, University of California, San Francisco, CA
| | - Jordi Ordoñez-Llanos
- Servei de Bioquímica Clínica, Hospital de Sant Pau, Barcelona, Spain; Biochemistry and Molecular Biology Department, Universitat Autònoma, Barcelona, Spain
| | - Allan S Jaffe
- Division of Cardiology, Mayo Clinic College of Medicine, Rochester, MN; Department of Laboratory Medicine and Pathology, Mayo Clinic College of Medicine, Rochester, MN
| | - Raphael Twerenbold
- Department of Cardiology, University Hospital Basel, Basel, Switzerland; Universitäres Herz-Zentrum Bad Krozingen, Bad Krozingen, Germany
| | - Christian Mueller
- Department of Cardiology, University Hospital Basel, Basel, Switzerland
| | - Ron Waksman
- MedStar Cardiovascular Research Network, MedStar Heart Institute, Medstar Washington Hospital Center, Washington, DC.
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Searle J, Slagman A, Stockburger M, Vollert JO, Müller C, Muller R, Möckel M. Use of copeptin in emergency patients with cardiac chief complaints. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2014; 4:393-402. [DOI: 10.1177/2048872614554197] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Affiliation(s)
- Julia Searle
- Department of Cardiology and Division of Emergency Medicine, Campus Virchow Klinikum (CVK) and Campus Mitte (CCM), Charité Universitätsmedizin Berlin, Germany
| | - Anna Slagman
- Department of Cardiology and Division of Emergency Medicine, Campus Virchow Klinikum (CVK) and Campus Mitte (CCM), Charité Universitätsmedizin Berlin, Germany
| | | | | | - Christian Müller
- Department of Cardiology and Division of Emergency Medicine, Campus Virchow Klinikum (CVK) and Campus Mitte (CCM), Charité Universitätsmedizin Berlin, Germany
| | - Reinhold Muller
- School of Public Health, James Cook University and Tropical Health Solutions Pty Ltd, Australia
| | - Martin Möckel
- Department of Cardiology and Division of Emergency Medicine, Campus Virchow Klinikum (CVK) and Campus Mitte (CCM), Charité Universitätsmedizin Berlin, Germany
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20
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Thelin J, Melander O, Öhlin B. Early rule-out of acute coronary syndrome using undetectable levels of high sensitivity troponin T. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2014; 4:403-9. [DOI: 10.1177/2048872614554107] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/12/2014] [Accepted: 09/14/2014] [Indexed: 11/17/2022]
Affiliation(s)
- Johan Thelin
- Department of Clinical Sciences, Lund University, Sweden
- Deparment of Internal Medicine, Skåne University Hospital, Sweden
| | - Olle Melander
- Department of Clinical Sciences, Lund University, Sweden
- Deparment of Internal Medicine, Skåne University Hospital, Sweden
| | - Bertil Öhlin
- Department of Clinical Sciences, Lund University, Sweden
- Deparment of Internal Medicine, Skåne University Hospital, Sweden
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21
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Stallone F, Twerenbold R, Wildi K, Reichlin T, Rubini Gimenez M, Haaf P, Fuechslin N, Hillinger P, Jaeger C, Kreutzinger P, Puelacher C, Radosavac M, Moreno Weidmann Z, Moehring B, Honegger U, Schumacher C, Denhaerynck K, Arnold C, Bingisser R, Vollert JO, Osswald S, Mueller C. Prevalence, characteristics and outcome of non-cardiac chest pain and elevated copeptin levels. Heart 2014; 100:1708-14. [DOI: 10.1136/heartjnl-2014-305583] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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22
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Lipinski MJ, Escárcega RO, D'Ascenzo F, Magalhães MA, Baker NC, Torguson R, Chen F, Epstein SE, Miró Ò, Llorens P, Giannitsis E, Lotze U, Lefebvre S, Sebbane M, Cristol JP, Chenevier-Gobeaux C, Meune C, Eggers KM, Charpentier S, Twerenbold R, Mueller C, Biondi-Zoccai G, Waksman R. A systematic review and collaborative meta-analysis to determine the incremental value of copeptin for rapid rule-out of acute myocardial infarction. Am J Cardiol 2014; 113:1581-91. [PMID: 24731654 DOI: 10.1016/j.amjcard.2014.01.436] [Citation(s) in RCA: 98] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2013] [Revised: 01/20/2014] [Accepted: 01/20/2014] [Indexed: 02/08/2023]
Abstract
Multiple studies have evaluated copeptin, a surrogate for arginine vasopressin, in the diagnosis of acute myocardial infarction (AMI) with mixed results. A systematic review and collaborative meta-analysis were performed for diagnosis of AMI and assessment of prognosis in patients presenting to the emergency department with chest pain. MEDLINE/PubMed, Cochrane CENTRAL, and EMBASE were searched for studies assessing copeptin in such patients. Study investigators were contacted, and many provided previously unpublished data. Random-effects methods were used to compare the data for copeptin, troponin, and their combination. There were a total of 9,244 patients from the 14 included studies. Mean age was 62 years; 64% were men; and 18.4% were ultimately diagnosed with AMI. Patients with AMI had a higher presentation copeptin level than those without AMI (22.8 vs 8.3 pmol/L, respectively, p <0.001). Although troponin had better diagnostic accuracy than copeptin for AMI, the combination of copeptin and troponin significantly improved the sensitivity (0.905 [0.888 to 0.921] vs 0.686 [0.661 to 0.710], respectively, p <0.001) and negative predictive value (0.97 [0.964 to 0.975] vs 0.93 [0.924 to 0.936], respectively, p <0.001) compared with troponin alone. Elevation in copeptin carried a similar risk of all-cause mortality to an elevation in troponin (odds ratio 5.84 vs 6.74, respectively, p = 0.67). In conclusion, copeptin not only identifies patients at risk of all-cause mortality, but its addition to troponin improved the sensitivity and negative likelihood ratio for diagnosis of AMI compared with troponin alone. Thus, copeptin may help identify patients who may be safely discharged early from the emergency department.
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Expeditious exclusion of acute coronary syndrome diagnosis by combined measurements of copeptin, high-sensitivity troponin, and GRACE score. Am J Emerg Med 2014; 32:293-6. [DOI: 10.1016/j.ajem.2013.11.043] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2013] [Revised: 11/17/2013] [Accepted: 11/27/2013] [Indexed: 10/25/2022] Open
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Sukul D, Bonaca MP, Ruff CT, Kosowsky J, Conrad M, Murphy SA, Sabatine MS, Jarolim P, Morrow DA. Diagnostic performance of copeptin in patients with acute nontraumatic chest pain: BWH-TIMI ED chest pain study. Clin Cardiol 2014; 37:227-32. [PMID: 24452775 DOI: 10.1002/clc.22244] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2013] [Revised: 12/05/2013] [Indexed: 11/07/2022] Open
Abstract
BACKGROUND Arginine-vasopressin (AVP) is an acute marker of physiologic stress. Copeptin is the C-terminal fragment of vasopressin precursor hormone that is more easily measured than AVP. Studies assessing the utility of copeptin in the diagnosis of myocardial infarction (MI) have demonstrated mixed results. HYPOTHESIS The aim of this study was to test the hypothesis that copeptin improves diagnostic performance when added to troponin for detecting MI in patients presenting to the emergency department with nontraumatic chest pain. METHODS We measured copeptin, local cardiac troponin I (local cTnI), and a contemporary sensitive cardiac troponin I (sensitive cTnI) at presentation and serially in patients who presented with acute chest pain. A copeptin cutoff of 14 pmol/L was utilized. RESULTS MI was diagnosed in 25.7% of patients. Noncoronary acute cardiopulmonary causes of chest pain occurred in 12.8%. Patients with MI had significantly higher copeptin levels than patients with noncardiac chest pain (P < 0.001). The area under the receiver operating characteristic curve (AUC) for copeptin was 0.60 (95% confidence interval: 0.54-0.66), significantly less than the AUC for local cTnI (0.92) or sensitive cTnI (0.96). The combination of copeptin with either the local or sensitive troponin assay (c-statistics 0.92 and 0.95, respectively) did not significantly improve the AUC as compared to either troponin assay alone. This finding persisted in the subgroup of early presenters (≤ 6 hours from symptom onset). CONCLUSIONS Copeptin did not improve the diagnostic performance for detecting MI when used alone or in combination with a contemporary sensitive cTnI assay, though our cohort had relatively few early presenters.
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Affiliation(s)
- Devraj Sukul
- TIMI Study Group, Cardiovascular Division, Department of Medicine, Harvard Medical School, Boston, Massachusetts
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Dobsa L, Edozien KC. Copeptin and its potential role in diagnosis and prognosis of various diseases. Biochem Med (Zagreb) 2013; 23:172-90. [PMID: 23894863 PMCID: PMC3900057 DOI: 10.11613/bm.2013.021] [Citation(s) in RCA: 81] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
The need for faster diagnosis, more accurate prognostic assessment and treatment decisions in various diseases has lead to the investigations of new biomarkers. The hope is that this new biomarkers will enable early decision making in clinical practice. Arginine vasopressin (AVP) is one of the main hormones of the hypothalamic-pituitary-adrenal axis. Its main stimulus for secretion is hyperosmolarity, but AVP system is also stimulated by exposure of the body to endogenous stress. Reliable measurement of AVP concentration is difficult because it is subject to preanalytical and analytical errors. It is therefore not used in clinical practice. Copeptin, a 39-aminoacid glycopeptide, is a C-terminal part of the precursor pre-provasopressin (pre-proAVP). Activation of AVP system stimulates copeptin secretion into the circulation from the posterior pituitary gland in equimolar amounts with AVP. Therefore, copeptin directly reflects AVP concentration and can be used as surrogate biomarker of AVP secretion. Even mild to moderate stress situations contribute to release of copeptin. These reasons have lead to a handful of research on copeptin in various diseases. This review summarizes the current achievements in the research of copeptin as a diagnostic and prognostic marker and also discusses its association in different disease processes.
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Affiliation(s)
- Lidija Dobsa
- Health Institution Varaidin County, Medical Biochemistry Laboratory, Varazdin, Croatia.
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Thelin J, Borna C, Erlinge D, Öhlin B. The combination of high sensitivity troponin T and copeptin facilitates early rule-out of ACS: a prospective observational study. BMC Cardiovasc Disord 2013; 13:42. [PMID: 23777442 PMCID: PMC3698067 DOI: 10.1186/1471-2261-13-42] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2012] [Accepted: 06/13/2013] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND The combination of the new high sensitivity troponin T (hsTnT) assays and copeptin, a biomarker of endogenous stress, has been suggested to have the potential of early rule-out of acute coronary syndrome (ACS). The aim of this study was to examine the ability of this combination to rule out ACS in patients presenting with chest pain and to compare the diagnostic performance to hsTnT alone. METHOD In this prospective observational study, patients with chest pain admitted for observation were consecutively included. Patients presenting with ST elevation were excluded. Copeptin and hsTnT were analyzed at admission and hsTnT was thereafter determined approximately every 3rd hour as long as clinically indicated. The follow-up period was 60 days. A combined primary endpoint of ACS, non-elective percutanous coronary intervention, non-elective coronary artery bypass surgery and death of all causes was used. RESULTS 478 patients were included. 107 (22%) patients were diagnosed with ACS during hospital stay. 70 (14%) had non-ST-segment elevation myocardial infarction (NSTEMI) and 37 (8%) had unstable angina pectoris (UAP). CONCLUSIONS In patients presenting with chest pain admitted for observation, the combination of hsTnT and copeptin analyzed at admission had a significantly higher sensitivity to diagnose ACS than hsTnT alone. We report a sensitivity of 83% and a NPV of 91% for the combination of hsTnT and copeptin and we conclude that biomarkers alone are not sufficient to rule out ACS. However, the combination of hsTnT and copeptin seems to have a significantly higher sensitivity to identify ACS than a repeated hsTnT test, and thus enables an earlier risk stratification of chest pain patients. This can be time-saving and beneficial for the individual patient by contributing to early decisions on treatment, need of further assessment and level of care.
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Affiliation(s)
- Johan Thelin
- Department of Clinical Sciences at Lund, Lund University, Lund, Sweden
- Skånes Universitetssjukhus, Akutmottagningen, Klinikgatan 15, 221 85, Lund, Sweden
| | - Catharina Borna
- Department of Clinical Sciences at Lund, Lund University, Lund, Sweden
- Skånes Universitetssjukhus, Akutmottagningen, Klinikgatan 15, 221 85, Lund, Sweden
| | - David Erlinge
- Department of Clinical Sciences at Lund, Lund University, Lund, Sweden
- Skånes Universitetssjukhus, Kranskärlskliniken, 221 85, Lund, Sweden
| | - Bertil Öhlin
- Department of Clinical Sciences at Lund, Lund University, Lund, Sweden
- Skånes Universitetssjukhus, Akutmottagningen, Klinikgatan 15, 221 85, Lund, Sweden
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Abstract
Copeptin, the C-terminal part of the prohormone of vasopressin (AVP), is released together with AVP in stoichiometric concentrations reflecting an individual's stress level. Copeptin has come to be regarded as an important marker for identifying high-risk patients and predicting outcomes in a variety of diseases. It improves the clinical value of commonly used biomarkers and the tools of risk stratification. Elevated AVP activation and higher copeptin concentrations have been previously described in acute systemic disorders. However, the field that could benefit the most from the introduction of copeptin measurements into practice is that of cardiovascular disease. Determination of copeptin level emerges as a fast and reliable method for differential diagnosis, especially in acute coronary syndromes. A particular role in the diagnosis of acute myocardial infarction (AMI) is attributed to the combination of copeptin and troponin. According to available sources, such a combination allows AMI to be ruled out with very high sensitivity and negative predictive value. Moreover, elevated copeptin levels correlate with a worse prognosis and a higher risk of adverse events after AMI, especially in patients who develop heart failure. Some authors suggest that copeptin might be valuable in defining the moment of the introduction of treatment and its monitoring in high-risk patients. The introduction of copeptin into clinical practice might also provide a benefit on a larger scale by suggesting changes in the allocation of financial resources within the health system. Although very promising, further larger trials are required in order to assess the clinical benefits of copeptin in everyday practice and patient care.
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Affiliation(s)
- Beata Morawiec
- Second Department of Cardiology, Silesian Medical University of Katowice, Katowice, Poland.
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Chenevier-Gobeaux C, Freund Y, Claessens YE, Guérin S, Bonnet P, Doumenc B, Leumani F, Cosson C, Allo JC, Riou B, Ray P. Copeptin for rapid rule out of acute myocardial infarction in emergency department. Int J Cardiol 2013; 166:198-204. [DOI: 10.1016/j.ijcard.2011.10.098] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2011] [Revised: 09/20/2011] [Accepted: 10/18/2011] [Indexed: 10/15/2022]
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Folli C, Consonni D, Spessot M, Salvini L, Velati M, Ranzani G, Maiavacca R, Monzani V. Diagnostic role of copeptin in patients presenting with chest pain in the emergency room. Eur J Intern Med 2013; 24:189-93. [PMID: 23063248 DOI: 10.1016/j.ejim.2012.09.006] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2012] [Accepted: 09/06/2012] [Indexed: 12/20/2022]
Abstract
BACKGROUND Chest pain is a frequent symptom leading patients to the Emergency Room. Copeptin, the C-terminal fragment of arginin-vasopressin, is a marker of stressful situations. Recent studies showed that normal levels of copeptin combined with normal troponin accurately rule out the diagnosis of acute coronary syndrome (ACS). In this observational, prospective, multicenter study we evaluated if negative levels of copeptin combined with negative troponin (Tn-T) can correctly rule out the diagnosis of ACS and also of other life-threatening causes of chest pain. RESULTS Of 472 enrolled patients (64.6% males, mean age 60.1yrs), 28 (5.9%) were diagnosed with ST-elevation myocardial infarction (STEMI), 28 (5.9%) with non ST-elevation myocardial infarction (NSTEMI), 43 (9.1%) with unstable angina (UA), 13 (2.8%) with potentially life-threatening non-ACS pathologies (aortic dissection, pulmonary embolism, pulmonary edema, sepsis), 360 (76.2%) with benign causes of chest pain. Copeptin levels were significantly higher in ACS patients with STEMI and NSTEMI than in those with other diagnoses, but not in those with UA. The combination of copeptin and troponin-T attained a negative predictive value of 86.6% for ACS, of 97.9% for other potentially life-threatening non-ACS diseases and of 85% for all potentially lethal diseases (ACS plus others). CONCLUSIONS The combined use of troponin and copeptin significantly improved the diagnostic accuracy of troponin alone both in ACS (STEMI and NSTEMI) and in other life-threatening diseases. Measurement of this marker might be therefore considered not only for a rule-out strategy but also as a warning sign of a life-threatening disease.
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Affiliation(s)
- Christian Folli
- UO Medicina d'Urgenza e Pronto Soccorso IRCCS Fondazione Policlinico Milano, Italy.
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Yalta K, Yalta T, Sivri N, Yetkin E. Copeptin and cardiovascular disease: a review of a novel neurohormone. Int J Cardiol 2013; 167:1750-9. [PMID: 23298558 DOI: 10.1016/j.ijcard.2012.12.039] [Citation(s) in RCA: 62] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2012] [Revised: 10/23/2012] [Accepted: 12/05/2012] [Indexed: 12/18/2022]
Abstract
Neurohormones (NHs) in the cascade of the arginine vasopressin (AVP) system have drawn particular attention in the recent years. Copeptin, the C-terminal portion of provasopressin, is a novel NH of the AVP system, and is known to be co-released with AVP from hypothalamus (neurohypophysis). As a surrogate marker of the AVP system, copeptin has gradually replaced AVP in several clinical studies largely due to its structural and methodological advantages. Copeptin has been regarded as a marker of non-specific stress response, and has also been suggested to have clinical implications in a variety of non-cardiovascular (pneumonia, sepsis, etc.) and cardiovascular conditions (heart failure and acute coronary syndromes (ACSs, etc.)). However, current data on relation of copeptin with other cardiovascular conditions ( arrhythmias, etc.) are still insufficient. The present review primarily focuses on general features of copeptin, its general clinical implications, and specifically aims to cover its potential clinical value in a variety of cardiovascular conditions.
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Affiliation(s)
- Kenan Yalta
- Trakya University, Cardiology Department, Edirne, Turkey.
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New/actual cardiac biomarkers in patients with suspected acute myocardial infarction: are we close to identifying the 'Holy Grail'? Arch Cardiovasc Dis 2012. [PMID: 23177482 DOI: 10.1016/j.acvd.2012.08.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Eggers KM, Venge P, Lindahl B. High-sensitive cardiac troponin T outperforms novel diagnostic biomarkers in patients with acute chest pain. Clin Chim Acta 2012; 413:1135-40. [DOI: 10.1016/j.cca.2012.03.011] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2012] [Revised: 03/06/2012] [Accepted: 03/13/2012] [Indexed: 11/26/2022]
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Charpentier S, Maupas-Schwalm F, Cournot M, Elbaz M, Botella JM, Lauque D. Combination of copeptin and troponin assays to rapidly rule out non-ST elevation myocardial infarction in the emergency department. Acad Emerg Med 2012; 19:517-24. [PMID: 22594355 DOI: 10.1111/j.1553-2712.2012.01350.x] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
OBJECTIVES The aim of this study was to analyze the diagnostic accuracy and the clinical usefulness of the combination of troponin I (cTnI) and copeptin measured at presentation with an automated assay to rapidly rule out non-ST elevation myocardial infarction (NSTEMI) in patients with suspected cardiac chest pain presenting to an emergency department (ED). METHODS This study was an ancillary analysis of a prospective observational study. Copeptin and cTnI levels were sampled at presentation in 641 consecutive patients admitted to the ED for chest pain with onset within the last 12 hours and without ST elevation on a 12-lead electrocardiogram (ECG). Copeptin was measured with an automated assay and troponin with conventional assay. The performance of a combination of cTnI and copeptin for NSTEMI diagnosis was studied, the clinical utility was assessed by multivariate analysis, and an area under the curve (AUC) calculation was used to determine accuracy. RESULTS NSTEMI was diagnosed in 95 patients (15%). The sensitivity and negative predictive value (NPV) of the combination of copeptin and cTnI measures were 90.4% (95% confidence interval [CI] = 88.2% to 92.7%) and 97.6% (95% CI = 96.4% to 98.7%) versus 55.3% (95% CI = 51.5% to 59.2%) and 92.8% (95% CI = 90.8% to 94.8%) with cTnI alone. The AUC of the combination of copeptin and cTnI was 0.89 (95% CI = 0.85% to 0.92%) and was significantly higher than the AUC of cTnI alone (0.77, 95% CI = 0.72% to 0.82%, p < 0.05). The patient classification was slightly improved when copeptin was added to the usual diagnostic tools used for NSTEMI management. CONCLUSIONS In this study, determination of copeptin, in addition to cTnI, improves early diagnostic accuracy of NSTEMI. However, the sensitivity of this combination even using a conventional troponin assay remains insufficient to safely rule out NSTEMI at the time of presentation.
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Combined copeptin and troponin to rule out myocardial infarction in patients with chest pain and a history of coronary artery disease. Am J Emerg Med 2012; 30:440-8. [DOI: 10.1016/j.ajem.2011.12.008] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2011] [Revised: 11/29/2011] [Accepted: 12/09/2011] [Indexed: 11/22/2022] Open
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Karakas M, Januzzi JL, Hoffmann U, Koenig W. In Reply. Clin Chem 2012. [DOI: 10.1373/clinchem.2011.175422] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Mahir Karakas
- Department of Internal Medicine II – Cardiology University of Ulm Medical Center Ulm, Germany
| | | | - Udo Hoffmann
- Department of Radiology Massachusetts General Hospital Boston, MA
| | - Wolfgang Koenig
- Department of Internal Medicine II – Cardiology University of Ulm Medical Center Ulm, Germany
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Gu YL, Voors AA, Zijlstra F, Hillege HL, Struck J, Masson S, Vago T, Anker SD, van den Heuvel AFM, van Veldhuisen DJ, de Smet BJGL. Comparison of the temporal release pattern of copeptin with conventional biomarkers in acute myocardial infarction. Clin Res Cardiol 2011; 100:1069-76. [PMID: 21766239 PMCID: PMC3222827 DOI: 10.1007/s00392-011-0343-y] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2011] [Accepted: 07/01/2011] [Indexed: 01/02/2023]
Abstract
Background Early detection of acute myocardial infarction (AMI) using cardiac biomarkers of myocardial necrosis remains limited since these biomarkers do not rise within the first hours from onset of AMI. We aimed to compare the temporal release pattern of the C-terminal portion of provasopressin (copeptin) with conventional cardiac biomarkers, including creatine kinase isoenzyme (CK-MB), cardiac troponin T (cTnT), and high-sensitivity cTnT (hs-cTnT), in patients with ST-elevation AMI. Methods We included 145 patients undergoing successful primary percutaneous coronary intervention (PCI) for a first ST-elevation AMI presenting within 12 h of symptom onset. Blood samples were taken on admission and at four time points within the first 24 h after PCI. Results In contrast to all other markers, copeptin levels were already elevated on admission and were higher with a shorter time from symptom onset to reperfusion and lower systolic blood pressure. Copeptin levels peaked immediately after symptom onset at a maximum of 249 pmol/L and normalized within 10 h. In contrast, CK-MB, cTnT, and hs-cTnT peaked after 14 h from symptom onset at a maximum of 275 U/L, 5.75 μg/L, and 4.16 μg/L, respectively, and decreased more gradually. Conclusions Copeptin has a distinct release pattern in patients with ST-elevation AMI, peaking within the first hour after symptom onset before conventional cardiac biomarkers and falling to normal ranges within the first day. Further studies are required to determine the exact role of copeptin in AMI suspects presenting within the first hours after symptom onset.
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Affiliation(s)
- Youlan L. Gu
- Department of Cardiology, Thorax Center, University Medical Center Groningen, University of Groningen, Hanzeplein 1, PO Box 30001, 9700 RB Groningen, The Netherlands
| | - Adriaan A. Voors
- Department of Cardiology, Thorax Center, University Medical Center Groningen, University of Groningen, Hanzeplein 1, PO Box 30001, 9700 RB Groningen, The Netherlands
| | - Felix Zijlstra
- Thorax Center, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Hans L. Hillege
- Department of Cardiology, Thorax Center, University Medical Center Groningen, University of Groningen, Hanzeplein 1, PO Box 30001, 9700 RB Groningen, The Netherlands
| | - Joachim Struck
- Research Department, B.R.A.H.M.S. GmbH (Part of ThermoFisher Scientific), Hennigsdorf, Germany
| | - Serge Masson
- Department of Cardiovascular Research, Instituto Mario Negri, Milan, Italy
| | - Tarcisio Vago
- Laboratory of Endocrinology, Ospedale Luigi Sacco, Milan, Italy
| | - Stefan D. Anker
- Applied Cachexia Research, Department of Cardiology, Charité, Campus Virchow-Klinikum, Berlin, Germany
| | - Ad F. M. van den Heuvel
- Department of Cardiology, Thorax Center, University Medical Center Groningen, University of Groningen, Hanzeplein 1, PO Box 30001, 9700 RB Groningen, The Netherlands
| | - Dirk J. van Veldhuisen
- Department of Cardiology, Thorax Center, University Medical Center Groningen, University of Groningen, Hanzeplein 1, PO Box 30001, 9700 RB Groningen, The Netherlands
| | - Bart J. G. L. de Smet
- Department of Cardiology, Thorax Center, University Medical Center Groningen, University of Groningen, Hanzeplein 1, PO Box 30001, 9700 RB Groningen, The Netherlands
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