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de Bakker M, Scholte NTB, Oemrawsingh RM, Umans VA, Kietselaer B, Schotborgh C, Ronner E, Lenderink T, Aksoy I, van der Harst P, Asselbergs FW, Maas A, Oude Ophuis AJ, Krenning B, de Winter RJ, The SHK, Wardeh AJ, Hermans W, Cramer GE, van Schaik RH, de Rijke YB, Akkerhuis KM, Kardys I, Boersma E. Acute Coronary Syndrome Subphenotypes Based on Repeated Biomarker Measurements in Relation to Long-Term Mortality Risk. J Am Heart Assoc 2024; 13:e031646. [PMID: 38214281 PMCID: PMC10926784 DOI: 10.1161/jaha.123.031646] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2023] [Accepted: 11/22/2023] [Indexed: 01/13/2024]
Abstract
BACKGROUND We aimed to identify patients with subphenotypes of postacute coronary syndrome (ACS) using repeated measurements of high-sensitivity cardiac troponin T, N-terminal pro-B-type natriuretic peptide, high-sensitivity C-reactive protein, and growth differentiation factor 15 in the year after the index admission, and to investigate their association with long-term mortality risk. METHODS AND RESULTS BIOMArCS (BIOMarker Study to Identify the Acute Risk of a Coronary Syndrome) was an observational study of patients with ACS, who underwent high-frequency blood sampling for 1 year. Biomarkers were measured in a median of 16 repeated samples per individual. Cluster analysis was performed to identify biomarker-based subphenotypes in 723 patients without a repeat ACS in the first year. Patients with a repeat ACS (N=36) were considered a separate cluster. Differences in all-cause death were evaluated using accelerated failure time models (median follow-up, 9.1 years; 141 deaths). Three biomarker-based clusters were identified: cluster 1 showed low and stable biomarker concentrations, cluster 2 had elevated concentrations that subsequently decreased, and cluster 3 showed persistently elevated concentrations. The temporal biomarker patterns of patients in cluster 3 were similar to those with a repeat ACS during the first year. Clusters 1 and 2 had a similar and favorable long-term mortality risk. Cluster 3 had the highest mortality risk. The adjusted survival time ratio was 0.64 (95% CI, 0.44-0.93; P=0.018) compared with cluster 1, and 0.71 (95% CI, 0.39-1.32; P=0.281) compared with patients with a repeat ACS. CONCLUSIONS Patients with subphenotypes of post-ACS with different all-cause mortality risks during long-term follow-up can be identified on the basis of repeatedly measured cardiovascular biomarkers. Patients with persistently elevated biomarkers have the worst outcomes, regardless of whether they experienced a repeat ACS in the first year.
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Affiliation(s)
- Marie de Bakker
- Department of CardiologyErasmus MC, University Medical Center RotterdamRotterdamThe Netherlands
| | - Niels T. B. Scholte
- Department of CardiologyErasmus MC, University Medical Center RotterdamRotterdamThe Netherlands
| | | | - Victor A. Umans
- Department of CardiologyNoordwest ZiekenhuisgroepAlkmaarThe Netherlands
| | | | - Carl Schotborgh
- Department of CardiologyHagaZiekenhuisDen HaagThe Netherlands
| | - Eelko Ronner
- Department of CardiologyReinier de Graaf HospitalDelftThe Netherlands
| | - Timo Lenderink
- Department of CardiologyZuyderland HospitalHeerlenThe Netherlands
| | - Ismail Aksoy
- Department of CardiologyAdmiraal de Ruyter HospitalGoesThe Netherlands
| | - Pim van der Harst
- Department of CardiologyUniversity Medical Center UtrechtUtrechtThe Netherlands
| | - Folkert W. Asselbergs
- Amsterdam University Medical Centers, Department of CardiologyUniversity of AmsterdamAmsterdamThe Netherlands
- Health Data Research UK and Institute of Health InformaticsUniversity College LondonLondonUnited Kingdom
| | - Arthur Maas
- Department of CardiologyGelre HospitalZutphenThe Netherlands
| | | | - Boudewijn Krenning
- Department of CardiologyErasmus MC, University Medical Center RotterdamRotterdamThe Netherlands
- Department of CardiologyFranciscus Gasthuis & VlietlandRotterdamThe Netherlands
| | - Robbert J. de Winter
- Amsterdam University Medical Centers, Department of CardiologyUniversity of AmsterdamAmsterdamThe Netherlands
| | - S. Hong Kie The
- Department of CardiologyTreant ZorggroepEmmenThe Netherlands
| | | | - Walter Hermans
- Department of CardiologyElizabeth‐Tweesteden HospitalTilburgThe Netherlands
| | - G. Etienne Cramer
- Department of CardiologyRadboud University Medical Center NijmegenNijmegenThe Netherlands
| | - Ron H. van Schaik
- Department of Clinical ChemistryErasmus MC, University Medical Center RotterdamRotterdamThe Netherlands
| | - Yolanda B. de Rijke
- Department of Clinical ChemistryErasmus MC, University Medical Center RotterdamRotterdamThe Netherlands
| | - K. Martijn Akkerhuis
- Department of CardiologyErasmus MC, University Medical Center RotterdamRotterdamThe Netherlands
| | - Isabella Kardys
- Department of CardiologyErasmus MC, University Medical Center RotterdamRotterdamThe Netherlands
| | - Eric Boersma
- Department of CardiologyErasmus MC, University Medical Center RotterdamRotterdamThe Netherlands
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Bhatnagar R, Berge K, Røysland R, Høiseth AD, Brynildsen J, Christensen G, Omland T, Røsjø H, Lyngbakken MN. Cardiac Troponin T and NT-proBNP for Prediction of 30-Day Readmission or Death in Patients with Acute Dyspnea: Data from the Akershus Cardiac Examination 2 Study. Cardiology 2023; 148:506-516. [PMID: 37544298 PMCID: PMC10733942 DOI: 10.1159/000533266] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Accepted: 07/24/2023] [Indexed: 08/08/2023]
Abstract
INTRODUCTION N-terminal pro-B-type natriuretic peptide (NT-proBNP) and cardiac troponin T (cTnT) measurements are recommended in patients with acute dyspnea. We aimed to assess the prognostic merit of cTnT compared to NT-proBNP for 30-day readmission or death in patients hospitalized with acute dyspnea. METHODS We measured cTnT and NT-proBNP within 24 h in 314 patients hospitalized with acute dyspnea and adjudicated the cause of the index admission. Time to first event of readmission or death ≤30 days after hospital discharge was recorded, and cTnT and NT-proBNP measurements were compared head-to-head. RESULTS Patients who died (12/314) or were readmitted (71/314) within 30 days had higher cTnT concentrations (median: 32.6, Q1-Q3: 18.4-74.2 ng/L vs. median: 19.4, Q1-Q3: 8.4-36.1 ng/L; p for comparison <0.001) and NT-proBNP concentrations (median: 1,753.6, Q1-Q3: 464.2-6,862.0 ng/L vs. median 984, Q1-Q3 201-3,600 ng/L; for comparison p = 0.027) compared to patients who survived and were not readmitted. cTnT concentrations were associated with readmission or death within 30 days after discharge both in the total cohort (adjusted hazard ratio [aHR]: 1.64, 95% confidence interval [CI]: 1.30-2.05) and in patients with heart failure (HF) (aHR: 1.58, 95% CI: 1.14-2.18). In contrast, NT-proBNP concentrations were not associated with short-term events, neither in the total cohort (aHR: 1.10, 95% CI: 0.94-1.30) nor in patients with adjudicated HF (aHR: 1.06, 95% CI: 0.80-1.40). CONCLUSION cTnT concentrations are associated with 30-day readmission or death in patients hospitalized with acute dyspnea, as well as in patients adjudicated HF.
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Affiliation(s)
- Rahul Bhatnagar
- Department of Cardiology, Division of Medicine, Akershus University Hospital, Lørenskog, Norway,
- K.G. Jebsen Center for Cardiac Biomarkers, University of Oslo, Oslo, Norway,
| | - Kristian Berge
- Department of Cardiology, Division of Medicine, Akershus University Hospital, Lørenskog, Norway
- K.G. Jebsen Center for Cardiac Biomarkers, University of Oslo, Oslo, Norway
| | - Ragnhild Røysland
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Division for Diagnostics and Technology, Akershus University Hospital, Lørenskog, Norway
| | - Arne Didrik Høiseth
- Department of Cardiology, Division of Medicine, Akershus University Hospital, Lørenskog, Norway
| | - Jon Brynildsen
- Department of Cardiology, Division of Medicine, Akershus University Hospital, Lørenskog, Norway
| | - Geir Christensen
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Institute for Experimental Medical Research, Oslo University Hospital and University of Oslo, Oslo, Norway
| | - Torbjørn Omland
- Department of Cardiology, Division of Medicine, Akershus University Hospital, Lørenskog, Norway
- K.G. Jebsen Center for Cardiac Biomarkers, University of Oslo, Oslo, Norway
| | - Helge Røsjø
- K.G. Jebsen Center for Cardiac Biomarkers, University of Oslo, Oslo, Norway
- Division of Research and Innovation, Akershus University Hospital, Lørenskog, Norway
| | - Magnus Nakrem Lyngbakken
- Department of Cardiology, Division of Medicine, Akershus University Hospital, Lørenskog, Norway
- K.G. Jebsen Center for Cardiac Biomarkers, University of Oslo, Oslo, Norway
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Jean G, Mogensen NSB, Clavel MA. Aortic Valvular Stenosis and Heart Failure: Advances in Diagnostic, Management, and Intervention. Heart Fail Clin 2023; 19:273-283. [PMID: 37230643 DOI: 10.1016/j.hfc.2023.02.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
Up to 30% of patients with aortic stenosis (AS) present with heart failure (HF) symptoms with either reduced or preserved left ventricular ejection fraction. Many of these patients present with a low-flow state, reduced aortic-valve-area (≤1.0 cm2) with low aortic-mean-gradient and aortic-peak-velocity (<40 mm Hg and <4.0 m/s). Thus, determination of true severity is essential for correct management, and multi-imaging evaluation must be performed. Medical treatment of HF is imperative and should be optimized concurrently with the determination of AS-severity. Finally, AS should be treated according to guidelines, keeping in mind that HF and low-flow increase interventions risks.
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Affiliation(s)
- Guillaume Jean
- Institut Universitaire de Cardiologie et de Pneumologie de Québec, Université Laval (IUCPQ-UL)/ Québec Heart & Lung Institute, Laval University, 2725 Chemin Sainte-Foy, Québec City, QC G1V 4G5, Canada
| | - Nils Sofus Borg Mogensen
- Institut Universitaire de Cardiologie et de Pneumologie de Québec, Université Laval (IUCPQ-UL)/ Québec Heart & Lung Institute, Laval University, 2725 Chemin Sainte-Foy, Québec City, QC G1V 4G5, Canada; Department of Cardiology, Odense University Hospital, University of Southern Denmark, J. B. Winsløws Vej 4, 5000 Odense, Denmark
| | - Marie-Annick Clavel
- Institut Universitaire de Cardiologie et de Pneumologie de Québec, Université Laval (IUCPQ-UL)/ Québec Heart & Lung Institute, Laval University, 2725 Chemin Sainte-Foy, Québec City, QC G1V 4G5, Canada; Department of Cardiology, Odense University Hospital, University of Southern Denmark, J. B. Winsløws Vej 4, 5000 Odense, Denmark.
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Hadziselimovic E, Greve AM, Sajadieh A, Olsen MH, Kesäniemi YA, Nienaber CA, Ray SG, Rossebø AB, Wachtell K, Nielsen OW. Association of high-sensitivity troponin T with outcomes in asymptomatic non-severe aortic stenosis: a post-hoc substudy of the SEAS trial. EClinicalMedicine 2023; 58:101875. [PMID: 36915288 PMCID: PMC10006443 DOI: 10.1016/j.eclinm.2023.101875] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Revised: 01/30/2023] [Accepted: 02/01/2023] [Indexed: 03/02/2023] Open
Abstract
BACKGROUND High-sensitivity Troponin T (hsTnT), a biomarker of cardiomyocyte overload and injury, relates to aortic valve replacement (AVR) and mortality in severe aortic stenosis (AS). However, its prognostic value remains unknown in asymptomatic patients with AS. We aimed to investigate if an hsTnT level >14 pg/mL (above upper limit of normal 99th percentile) is associated with echocardiographic AS-severity, subsequent AVR, ischaemic coronary events (ICE), and mortality in asymptomatic patients with non-severe AS. METHODS In this post-hoc sub-analysis of the multicentre, randomised, double-blind, placebo-controlled SEAS trial (ClinicalTrials.gov, NCT00092677), we included asymptomatic patients with mild to moderate-severe AS. We ascertained baseline and 1-year hsTnT concentrations and examined the association between baseline levels and the risk of the primary composite endpoint, defined as the first event of all-cause mortality, isolated AVR (without coronary artery bypass grafting (CABG)), or ICE. Multivariable regressions and competing risk analyses examined associations of hsTnT level >14 pg/mL with clinical correlates and 5-year risk of the primary endpoint. FINDINGS Between January 6, 2003, and March 4, 2004, a total of 1873 patients were enrolled in the SEAS trial, and 1739 patients were included in this post-hoc sub-analysis. Patients had a mean (SD) age of 67.5 (9.7) years, 61.0% (1061) were men, 17.4% (302) had moderate-severe AS, and 26.0% (453) had hsTnT level >14 pg/mL. The median hsTnT difference from baseline to 1-year was 0.8 pg/mL (IQR, -0.4 to 2.3). In adjusted linear regression, log(hsTnT) did not correlate with echocardiographic AS severity (p = 0.36). In multivariable Cox regression, a hsTnT level >14 pg/mL vs. hsTnT ≤14 pg/mL was associated with an increased risk of the primary composite endpoint (HR, 1.41; 95% CI, 1.18-1.70; p = 0.0002). In a competing risk model of first of the individual components of the primary endpoint, a hsTnT level >14 pg/mL was associated with ICE risk (HR 1.71; 95% CI, 1.23-2.38; p = 0.0013), but not with isolated AVR (p = 0.064) or all-cause mortality (p = 0.49) as the first event. INTERPRETATION hsTnT level is within the reference range (≤14 pg/mL) in 3 out of 4 non-ischaemic patients with asymptomatic mild-to-moderate AS and remains stable during a 1-year follow-up regardless of AS-severity. An hsTnT level >14 pg/mL was mainly associated with subsequent ICE, which suggest that hsTnT concentration is primarily a risk marker of subclinical coronary atherosclerotic disease. FUNDING Merck & Co., Inc., the Schering-Plough Corporation, the Interreg IVA program, Roche Diagnostics Ltd., and Gangstedfonden. Open access publication fee funding provided by prof. Olav W. Nielsen and Department of Cardiology, Bispebjerg University Hospital, Denmark.
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Affiliation(s)
- Edina Hadziselimovic
- Department of Cardiology, Bispebjerg University Hospital, Copenhagen, Denmark
- Corresponding author. Department of Cardiology, Bispebjerg University Hospital, Bispebjerg Bakke 23, 2400, Copenhagen, Denmark.
| | - Anders M. Greve
- Department of Clinical Biochemistry, 3011, Rigshospitalet, Copenhagen, Denmark
| | - Ahmad Sajadieh
- Department of Cardiology, Bispebjerg University Hospital, Copenhagen, Denmark
- Faculty of Health and Medical Sciences, University of Copenhagen, Denmark
| | - Michael H. Olsen
- Department of Internal Medicine 1, Holbæk Hospital, Denmark
- Department of Regional Health Research, University of Southern Denmark, Denmark
| | - Y. Antero Kesäniemi
- Research Unit of Internal Medicine, Medical Research Center Oulu, Oulu University Hospital and University of Oulu, Oulu, Finland
| | | | | | - Anne B. Rossebø
- Department of Cardiology, Oslo University Hospital, Ullevål, Oslo, Norway
| | | | - Olav W. Nielsen
- Department of Cardiology, Bispebjerg University Hospital, Copenhagen, Denmark
- Faculty of Health and Medical Sciences, University of Copenhagen, Denmark
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Filomena D, Monosilio S, Cimino S, Maestrini V, Luongo F, Neccia M, Salvi N, Colantonio R, Mancone M, Sardella G, Fedele F, Agati L. Prognostic role of pre- and postinterventional myocardial injury in patients undergoing transcatheter aortic valve implantation. Minerva Cardiol Angiol 2023; 71:77-82. [PMID: 33944532 DOI: 10.23736/s2724-5683.21.05630-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Chronic pre-procedural and acute post-procedural myocardial injury are frequently observed in patients with aortic stenosis undergoing transcatheter aortic valve implantation (TAVI). The aim of our study was to investigate the prognostic role of high sensitivity cardiac troponins (hs-cTns) elevation before and after TAVI. METHODS 106 patients with severe aortic stenosis who underwent TAVI were enrolled. High sensitivity cardiac troponin T (hs-cTnT) was measured before and after TAVI (6, 24, 48, 72 hours). Post-procedural myocardial damage was defined as a 15-fold rise in hs-cTnT upper reference limit (URL) after TAVI. The clinical endpoints were all cause death, cardiovascular death and re-hospitalization at 24 months follow-up. RESULTS Before TAVI, hs-cTnT median value was 0.03 μg/L (2.3±2.1 fold over URL). After TAVI procedure, myocardial damage (MD), as defined by VARC-2 criteria, was observed in 40 patients (38%) (MD group). In our population, logarithmically transformed hs-cTnTs were independently associated with all-cause mortality at 24 months F/U (pre-TAVI hs-cTnT: Hazard ratio [HR] 2.2, 95% confidence interval [CI]: 1.1 to 4.4, P=0.027). No significant differences were observed between the MD and non-MD groups for the three endpoints of all cause death (p log rank: 0.15), cardiovascular death (p log rank: 0.86) and re-hospitalization (p log rank: 0.87). CONCLUSIONS Only baseline hs-cTnT levels correlated with outcomes at 24 months of follow-up. Chronic pre-procedural myocardial injury significantly affects prognosis after TAVI.
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Affiliation(s)
- Domenico Filomena
- Department of Clinical, Internal, Anesthesiological and Cardiovascular Sciences, Sapienza University, Rome, Italy -
| | - Sara Monosilio
- Department of Clinical, Internal, Anesthesiological and Cardiovascular Sciences, Sapienza University, Rome, Italy
| | - Sara Cimino
- Department of Clinical, Internal, Anesthesiological and Cardiovascular Sciences, Sapienza University, Rome, Italy
| | - Viviana Maestrini
- Department of Clinical, Internal, Anesthesiological and Cardiovascular Sciences, Sapienza University, Rome, Italy
| | - Federico Luongo
- Department of Clinical, Internal, Anesthesiological and Cardiovascular Sciences, Sapienza University, Rome, Italy
| | - Matteo Neccia
- Department of Clinical, Internal, Anesthesiological and Cardiovascular Sciences, Sapienza University, Rome, Italy
| | - Nicolò Salvi
- Department of Clinical, Internal, Anesthesiological and Cardiovascular Sciences, Sapienza University, Rome, Italy
| | - Riccardo Colantonio
- Department of Clinical, Internal, Anesthesiological and Cardiovascular Sciences, Sapienza University, Rome, Italy
| | - Massimo Mancone
- Department of Clinical, Internal, Anesthesiological and Cardiovascular Sciences, Sapienza University, Rome, Italy
| | - Gennaro Sardella
- Department of Clinical, Internal, Anesthesiological and Cardiovascular Sciences, Sapienza University, Rome, Italy
| | - Francesco Fedele
- Department of Clinical, Internal, Anesthesiological and Cardiovascular Sciences, Sapienza University, Rome, Italy
| | - Luciano Agati
- Department of Clinical, Internal, Anesthesiological and Cardiovascular Sciences, Sapienza University, Rome, Italy
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Aagaard EN, Lyngbakken MN, Kvisvik B, Berge T, Pervez MO, Ariansen I, Tveit A, Steine K, Røsjø H, Omland T. Associations between cardiovascular risk factors, biomarkers, and left ventricular mechanical dispersion: insights from the ACE 1950 Study. EUROPEAN HEART JOURNAL OPEN 2022; 2:oeac006. [PMID: 35919126 PMCID: PMC9242045 DOI: 10.1093/ehjopen/oeac006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Revised: 01/22/2022] [Indexed: 11/14/2022]
Abstract
Aims Mechanical dispersion measures left ventricular contraction heterogeneity and is associated with the risk of sudden cardiac death. However, the associations between mechanical dispersion and cardiovascular risk factors in early mid-life, and established biomarkers of sub-clinical myocardial injury and dysfunction are not known. We aimed to examine this in the general population. Methods and results During 2012–15, we included 2527 Norwegian individuals from the general population born in 1950, with measurements of mechanical dispersion by 2D speckle tracking echocardiography and concentrations of high-sensitivity cardiac troponin T (hs-cTnT) and N-terminal pro-B-type natriuretic peptide (NT-proBNP) available. Mechanical dispersion was calculated as the standard deviation of the contraction duration of 17 strain segments. We assessed the associations between mechanical dispersion, concentrations of hs-cTnT and NT-proBNP, and cardiovascular risk factors collected at a national health screening survey two decades earlier. At echocardiography baseline, median age was 64 (interquartile range 63.5–64.5) years, 49.8% were women, 59.1% had hypertension, and 5.9% reported established coronary artery disease. Median mechanical dispersion was 38.0 (29.5–47.0) ms, median hs-cTnT concentration 6 (4–8) ng/L, and the median NT-proBNP concentration 54 (34–93) ng/L. Mechanical dispersion was associated with both hs-cTnT and NT-proBNP concentrations in multivariable models adjusted for clinical and echocardiographic variables. High body mass index, serum triglyceride concentrations, and low resting heart rate at Age 40 were independently associated with increased mechanical dispersion two decades later. Conclusion Established risk factors at Age 40 are associated with mechanical dispersion two decades later, and mechanical dispersion is cross-sectionally associated with biomarkers of subclinical myocardial injury and dysfunction.
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Affiliation(s)
- Erika N Aagaard
- Division of Medicine, Department of Cardiology, Akershus University Hospital , Lørenskog, Norway
- Faculty of Medicine, Institute for Clinical Medicine, University of Oslo , Oslo, Norway
| | - Magnus N Lyngbakken
- Division of Medicine, Department of Cardiology, Akershus University Hospital , Lørenskog, Norway
- Faculty of Medicine, Institute for Clinical Medicine, University of Oslo , Oslo, Norway
| | - Brede Kvisvik
- Division of Medicine, Department of Cardiology, Akershus University Hospital , Lørenskog, Norway
- Faculty of Medicine, Institute for Clinical Medicine, University of Oslo , Oslo, Norway
| | - Trygve Berge
- Department of Medical Research, Bærum Hospital, Vestre Viken Hospital Trust , Norway
| | - Mohammad O Pervez
- Division of Medicine, Department of Cardiology, Akershus University Hospital , Lørenskog, Norway
| | - Inger Ariansen
- Department of Chronic Diseases and Ageing, Norwegian Institute of Public Health , Oslo, Norway
| | - Arnljot Tveit
- Faculty of Medicine, Institute for Clinical Medicine, University of Oslo , Oslo, Norway
- Department of Medical Research, Bærum Hospital, Vestre Viken Hospital Trust , Norway
| | - Kjetil Steine
- Division of Medicine, Department of Cardiology, Akershus University Hospital , Lørenskog, Norway
- Faculty of Medicine, Institute for Clinical Medicine, University of Oslo , Oslo, Norway
| | - Helge Røsjø
- Faculty of Medicine, Institute for Clinical Medicine, University of Oslo , Oslo, Norway
- Division of Research and Innovation, Akershus University Hospital , Sykehusveien 25, 1478 Lørenskog, Norway
| | - Torbjørn Omland
- Division of Medicine, Department of Cardiology, Akershus University Hospital , Lørenskog, Norway
- Faculty of Medicine, Institute for Clinical Medicine, University of Oslo , Oslo, Norway
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7
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Seoudy H, Lambers M, Winkler V, Dudlik L, Freitag-Wolf S, Frank J, Kuhn C, Rangrez AY, Puehler T, Lutter G, Bramlage P, Frey N, Frank D. Elevated high-sensitivity troponin T levels at 1-year follow-up are associated with increased long-term mortality after TAVR. Clin Res Cardiol 2021; 110:421-428. [PMID: 33098469 PMCID: PMC7907029 DOI: 10.1007/s00392-020-01759-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Accepted: 10/05/2020] [Indexed: 11/04/2022]
Abstract
BACKGROUND Elevated pre-procedural high-sensitivity troponin T (hs-TnT) levels predict adverse outcomes in patients with severe aortic stenosis (AS) undergoing transcatheter aortic valve replacement (TAVR). It is unknown whether elevated troponin levels still provide prognostic information during follow-up after successful TAVR. We evaluated the long-term implications of elevated hs-TnT levels found at 1-year post-TAVR. METHODS AND RESULTS The study included 349 patients who underwent TAVR for severe AS from 2010-2019 and for whom 1-year hs-TnT levels were available. Any required percutaneous coronary interventions were performed > 1 week before TAVR. The primary endpoint was survival time starting at 1-year post-TAVR. Optimal hs-TnT cutoff for stratifying risk, identified by ROC analysis, was 39.4 pg/mL. 292 patients had hs-TnT < 39.4 pg/mL (median 18.3 pg/mL) and 57 had hs-TnT ≥ 39.4 pg/mL (median 51.2 pg/mL). The high hs-TnT group had a higher median N-terminal pro-B-type natriuretic peptide (NT-proBNP) level, greater left ventricular (LV) mass, higher prevalence of severe diastolic dysfunction, LV ejection fraction < 35%, severe renal dysfunction, and more men compared with the low hs-TnT group. All-cause mortality during follow-up after TAVR was significantly higher among patients who had hs-TnT ≥ 39.4 pg/mL compared with those who did not (mortality rate at 2 years post-TAVR: 12.3% vs. 4.1%, p = 0.010). Multivariate analysis identified 1-year hs-TnT ≥ 39.4 pg/mL (hazard ratio 2.93, 95% CI 1.91-4.49, p < 0.001), NT-proBNP level > 300 pg/mL, male sex, an eGFR < 60 mL/min/1.73 m2 and chronic obstructive pulmonary disease as independent risk factors for long-term mortality after TAVR. CONCLUSIONS Elevated hs-TnT concentrations at 1-year after TAVR were associated with a higher long-term mortality.
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Affiliation(s)
- Hatim Seoudy
- Department of Internal Medicine III, Cardiology and Angiology, University Hospital Schleswig-Holstein Kiel, Arnold-Heller-Str.3, Haus K3, 24105 Kiel, Germany
- DZHK (German Centre for Cardiovascular Research), Partner Site Hamburg/ Kiel/ Lübeck, Kiel, Germany
| | - Moritz Lambers
- Department of Cardiology and Angiology, Contilia Heart and Vascular Centre Elisabeth-Krankenhaus, Essen, Germany
| | - Vincent Winkler
- Department of Internal Medicine III, Cardiology and Angiology, University Hospital Schleswig-Holstein Kiel, Arnold-Heller-Str.3, Haus K3, 24105 Kiel, Germany
| | - Linnea Dudlik
- Department of Internal Medicine III, Cardiology and Angiology, University Hospital Schleswig-Holstein Kiel, Arnold-Heller-Str.3, Haus K3, 24105 Kiel, Germany
| | - Sandra Freitag-Wolf
- Department of Medical Informatics and Statistics, University Hospital Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Johanne Frank
- Department of Internal Medicine III, Cardiology and Angiology, University Hospital Schleswig-Holstein Kiel, Arnold-Heller-Str.3, Haus K3, 24105 Kiel, Germany
- DZHK (German Centre for Cardiovascular Research), Partner Site Hamburg/ Kiel/ Lübeck, Kiel, Germany
| | - Christian Kuhn
- Department of Internal Medicine III, Cardiology and Angiology, University Hospital Schleswig-Holstein Kiel, Arnold-Heller-Str.3, Haus K3, 24105 Kiel, Germany
- DZHK (German Centre for Cardiovascular Research), Partner Site Hamburg/ Kiel/ Lübeck, Kiel, Germany
| | - Ashraf Yusuf Rangrez
- Department of Internal Medicine III, Cardiology and Angiology, University Hospital Schleswig-Holstein Kiel, Arnold-Heller-Str.3, Haus K3, 24105 Kiel, Germany
- DZHK (German Centre for Cardiovascular Research), Partner Site Hamburg/ Kiel/ Lübeck, Kiel, Germany
| | - Thomas Puehler
- DZHK (German Centre for Cardiovascular Research), Partner Site Hamburg/ Kiel/ Lübeck, Kiel, Germany
- Department of Cardiovascular Surgery, University Hospital Schleswig-Holstein, Kiel, Germany
| | - Georg Lutter
- DZHK (German Centre for Cardiovascular Research), Partner Site Hamburg/ Kiel/ Lübeck, Kiel, Germany
- Department of Cardiovascular Surgery, University Hospital Schleswig-Holstein, Kiel, Germany
| | - Peter Bramlage
- Institute for Pharmacology and Preventive Medicine, Cloppenburg, Germany
| | - Norbert Frey
- Department of Internal Medicine III, Cardiology and Angiology, University Hospital Schleswig-Holstein Kiel, Arnold-Heller-Str.3, Haus K3, 24105 Kiel, Germany
- DZHK (German Centre for Cardiovascular Research), Partner Site Hamburg/ Kiel/ Lübeck, Kiel, Germany
| | - Derk Frank
- Department of Internal Medicine III, Cardiology and Angiology, University Hospital Schleswig-Holstein Kiel, Arnold-Heller-Str.3, Haus K3, 24105 Kiel, Germany
- DZHK (German Centre for Cardiovascular Research), Partner Site Hamburg/ Kiel/ Lübeck, Kiel, Germany
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8
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High-sensitivity cardiac troponin T and N-terminal pro-B-type natriuretic peptide in acute heart failure: Data from the ACE 2 study. Clin Biochem 2020; 88:30-36. [PMID: 33245872 DOI: 10.1016/j.clinbiochem.2020.11.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Revised: 10/13/2020] [Accepted: 11/11/2020] [Indexed: 01/08/2023]
Abstract
BACKGROUND To assess if cardiac troponins can improve diagnostics of acute heart failure (AHF) and provide prognostic information in patients with acute dyspnea. METHODS We measured cardiac troponin T with a high-sensitivity assay (hs-cTnT) in 314 patients hospitalized with acute dyspnea. The index diagnosis was adjudicated and AHF patients were stratified into AHF with reduced or preserved ejection fraction (HFrEF/HFpEF). The prognostic and diagnostic merit of hs-cTnT was compared to the merit of N-terminal pro-B-type natriuretic peptide (NT-proBNP). RESULTS In the total population, median age was 73 (quartile [Q] 1-3 63-81) years and 48% were women. One-hundred-forty-three patients were categorized as AHF (46%) and these patients had higher hs-cTnT concentrations than patients with non-AHF-related dyspnea: median 38 (Q1-3 22-75) vs. 13 (4-25) ng/L; p < 0.001. hs-cTnT concentrations were similar between patients with HFrEF and HFpEF (p = 0.80), in contrast to NT-proBNP, which was higher in HFrEF (p < 0.001). C-statistics for discriminating HFpEF from non-AHF-related dyspnea was 0.80 (95% CI 0.73-0.86) for hs-cTnT, 0.79 (0.73-0.86) for NT-proBNP, and 0.83 (0.76-0.89) for hs-cTnT and NT-proBNP in combination. Elevated hs-cTnT remained associated with HFpEF in logistic regression analysis after adjusting for demographics, comorbidities and renal function. During median 27 months of follow-up, 114 (36%) patients died in the total population. Higher hs-cTnT concentrations were associated with increased risk of all-cause mortality after adjustment for clinical variables and NT-proBNP: hazard ratio 1.30 (95% CI 1.07-1.58), p = 0.009. CONCLUSION hs-cTnT measurements improve diagnostic accuracy for HFpEF and provide independent prognostic information in unselected patients with acute dyspnea.
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9
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Hinton J, Gabara L, Curzen N. Is the true clinical value of high-sensitivity troponins as a biomarker of risk? The concept that detection of high-sensitivity troponin 'never means nothing'. Expert Rev Cardiovasc Ther 2020; 18:843-857. [PMID: 32966128 DOI: 10.1080/14779072.2020.1828063] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
INTRODUCTION High-sensitivity troponin (hs-cTn) assays are central to the diagnosis of myocardial infarction (MI). Their increased sensitivity has facilitated rapid pathways for the exclusion of MI. However, hs-cTn is now more readily detectable in patients without symptoms typical of MI, in whom a degree of myocardial injury is assumed. Recently, the practice of using the 99th centile of hs-cTn as a working 'upper reference limit' has been challenged. There is increasing evidence that hs-cTn may provide useful prognostic information, regardless of any suspicion of MI, and as such these assays may have potential as a general biomarker for mortality. This raises the concept that detection of hs-cTn 'never means nothing.' AREAS COVERED In this review, we will evaluate the evidence for the use of hs-cTn assays outside their common clinical indication to rule out or diagnose acute MI. EXPERT OPINION The data presented suggest that hs-cTn testing may in the future have a generalized role as a biomarker of mortality risk and may be used less as a test for ruling in acute MI, but will remain a frontline test to exclude that diagnosis in ED. Further, the data suggest that the detection of hs-cTn 'never means nothing.'
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Affiliation(s)
- Jonathan Hinton
- Coronary Research Group, University Hospital Southampton NHS Foundation Trust , Southampton, UK.,Faculty of Medicine, University of Southampton , Southampton, UK
| | - Lavinia Gabara
- Coronary Research Group, University Hospital Southampton NHS Foundation Trust , Southampton, UK.,Faculty of Medicine, University of Southampton , Southampton, UK
| | - Nick Curzen
- Coronary Research Group, University Hospital Southampton NHS Foundation Trust , Southampton, UK.,Faculty of Medicine, University of Southampton , Southampton, UK
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10
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Spampinato RA, Bochen R, Sieg F, Weiss S, Kornej J, Haunschild J, von Aspern K, Strotdrees E, Noack T, Lehmann S, Etz C, Borger MA. Multi-biomarker mortality prediction in patients with aortic stenosis undergoing valve replacement. J Cardiol 2020; 76:154-162. [DOI: 10.1016/j.jjcc.2020.02.019] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2019] [Revised: 11/25/2019] [Accepted: 02/18/2020] [Indexed: 11/30/2022]
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11
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Røsjø H, Hijazi Z, Omland T, Westerbergh J, Lyngbakken MN, Alexander JH, Gersh BJ, Granger CB, Hylek EM, Lopes RD, Siegbahn A, Wallentin L. Cardiac troponin is associated with cardiac outcomes in men and women with atrial fibrillation, insights from the ARISTOTLE trial. J Intern Med 2020; 288:248-259. [PMID: 32350915 DOI: 10.1111/joim.13072] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Revised: 03/11/2020] [Accepted: 03/30/2020] [Indexed: 12/26/2022]
Abstract
BACKGROUND Cardiac troponin T (cTnT) and I (cTnI) concentrations provide strong prognostic information in anticoagulated patients with atrial fibrillation (AF). Whether the associations between cardiac troponin concentrations and mortality and morbidity differ by sex is not known. OBJECTIVES To assess whether men and women have different concentrations and prognostic value of cTnT and cTnI measurements in anticoagulated patients with AF. METHODS cTnT and cTnI concentrations were measured with high-sensitivity (hs) assays in EDTA plasma samples obtained from the multicentre ARISTOTLE trial, which randomized patients with AF and at least one risk factor for stroke or systemic embolic event to warfarin or apixaban. Patients were stratified according to sex and the associations between hs-troponin concentrations, and all-cause death, cardiac death, myocardial infarction, stroke or systemic embolic event and major bleeding were assessed in multivariable regression models. RESULTS We found higher cardiac troponin concentrations in men (n = 9649) compared to women (n = 5331), both for hs-cTnT (median 11.8 [Q1-3 8.1-18.0] vs. 9.6 [6.7-14.3] ng L-1 , P < 0.001) and hs-cTnI (5.8 [3.4-10.8] vs. 4.9 [3.1-8.8] ng L-1 , P < 0.001). Adjusting for baseline demographics, comorbidities and medications, men still had significantly higher hs-troponin concentrations than women. C-reactive protein and N-terminal pro-B-type natriuretic peptide concentrations were higher in female patients. Both hs-cTnT and hs-cTnI concentrations were associated with all clinical outcomes similarly in men and women (p-value for interaction >0.05 for all end-points). CONCLUSION Men have higher hs-troponin concentrations than women in AF. Regardless of sex, hs-troponin concentrations remain similarly associated with adverse clinical outcomes in anticoagulated patients with AF.
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Affiliation(s)
- H Røsjø
- Department of Medical Sciences, Cardiology, Uppsala University, Uppsala, Sweden.,Division of Research and Innovation, Akershus University Hospital, Lørenskog, Norway.,Institute of Clinical Medicine, University of Oslo, Oslo, Norway.,Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - Z Hijazi
- Department of Medical Sciences, Cardiology, Uppsala University, Uppsala, Sweden.,Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - T Omland
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway.,Department of Cardiology, Division of Medicine, Akershus University Hospital, Lørenskog, Norway
| | - J Westerbergh
- Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - M N Lyngbakken
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway.,Department of Cardiology, Division of Medicine, Akershus University Hospital, Lørenskog, Norway
| | - J H Alexander
- Duke Clinical Research Institute, Duke Health, Durham, NC, USA
| | - B J Gersh
- Mayo Clinic College of Medicine, Rochester, MN, USA
| | - C B Granger
- Duke Clinical Research Institute, Duke Health, Durham, NC, USA
| | - E M Hylek
- Boston University Medical Center, Boston, MA, USA
| | - R D Lopes
- Duke Clinical Research Institute, Duke Health, Durham, NC, USA
| | - A Siegbahn
- Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden.,Department of Medical Sciences, Clinical Chemistry, Uppsala University, Uppsala, Sweden
| | - L Wallentin
- Department of Medical Sciences, Cardiology, Uppsala University, Uppsala, Sweden.,Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
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12
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Patient Management in Aortic Stenosis: Towards Precision Medicine Through Protein Analysis, Imaging and Diagnostic Tests. J Clin Med 2020; 9:jcm9082421. [PMID: 32731585 PMCID: PMC7463596 DOI: 10.3390/jcm9082421] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Revised: 07/22/2020] [Accepted: 07/24/2020] [Indexed: 01/12/2023] Open
Abstract
Aortic stenosis is the most frequent valvular disease in developed countries. It progresses from mild fibrocalcific leaflet changes to a more severe leaflet calcification at the end stages of the disease. Unfortunately, symptoms of aortic stenosis are unspecific and only appear when it is too late, complicating patients' management. The global impact of aortic stenosis is increasing due to the growing elderly population. The disease supposes a great challenge because of the multiple comorbidities of these patients. Nowadays, the only effective treatment is valve replacement, which has a high cost in both social and economic terms. For that reason, it is crucial to find potential diagnostic, prognostic and therapeutic indicators that could help us to detect this disease in its earliest stages. In this article, we comprehensively review several key observations and translational studies related to protein markers that are promising for being implemented in the clinical field as well as a discussion about the role of precision medicine in aortic stenosis.
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13
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Peeters FECM, Dudink EAMP, Weijs B, Fabritz L, Chua W, Kietselaer BLJH, Wildberger JE, Meex SJR, Kirchhof P, Crijns HJGM, Schurgers LJ. Biomarkers Associated With Aortic Valve Calcification: Should We Focus on Sex Specific Processes? Front Cell Dev Biol 2020; 8:604. [PMID: 32754594 PMCID: PMC7366171 DOI: 10.3389/fcell.2020.00604] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Accepted: 06/19/2020] [Indexed: 12/21/2022] Open
Abstract
Objective Circulating biomarkers are useful in detection and monitoring of cardiovascular diseases. However, their role in aortic valve disease is unclear. Mechanisms are rapidly elucidated and sex differences are suggested to be involved. Therefore, we sought to identify biomarkers involved in aortic valve calcification (AVC) stratified by sex. Methods Blood samples of 34 patients with AVC (without further overt cardiovascular disease, including absence of hemodynamic consequences of valvular calcification) were compared with 136 patients without AVC. AVC was determined using computed tomography calcium scoring. Circulating biomarkers were quantified using a novel antibody-based method (Olink Proseek Multiplex Cardiovascular Panel I) and 92 biomarkers were compared between patients with and without AVC. Results In the overall population, Interleukin-1 Receptor Antagonist and pappalysin-1 were associated with increased and decreased odds of having AVC. These differences were driven by the male population [IL1RA: OR 2.79 (1.16-6.70), p = 0.022; PAPPA: OR 0.30 (0.11-0.84), p = 0.021]. Furthermore, TNF-related activation-induced cytokine (TRANCE) and fibroblast growth factor-23 were associated decreased odds of having AVC, and monocyte chemotactic protein-1 was associated with increased odds of having AVC [TRANCE: OR 0.32 (0.12-0.80), p = 0.015; FGF23: OR 0.41 (0.170-0.991), p = 0.048; MCP1: OR 2.64 (1.02-6.81), p = 0.045]. In contrast, galanin peptides and ST2 were associated with increased odds of having AVC in females [GAL: OR 12.38 (1.31-116.7), p = 0.028; ST2: OR13.64 (1.21-153.33), p = 0.034]. Conclusion In this exploratory study, we identified biomarkers involved in inflammation, fibrosis and calcification which may be associated with having AVC. Biomarkers involved in fibrosis may show higher expression in females, whilst biomarkers involved in inflammation and calcification could associate with AVC in males.
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Affiliation(s)
- Frederique E C M Peeters
- Department of Cardiology and CARIM, Maastricht University Medical Center+, School for Cardiovascular Diseases, Maastricht, Netherlands
| | - Elton A M P Dudink
- Department of Cardiology and CARIM, Maastricht University Medical Center+, School for Cardiovascular Diseases, Maastricht, Netherlands
| | - Bob Weijs
- Department of Cardiology and CARIM, Maastricht University Medical Center+, School for Cardiovascular Diseases, Maastricht, Netherlands
| | - Larissa Fabritz
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, United Kingdom
| | - Winnie Chua
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, United Kingdom
| | - Bas L J H Kietselaer
- Department of Cardiology and CARIM, Maastricht University Medical Center+, School for Cardiovascular Diseases, Maastricht, Netherlands
| | - Joachim E Wildberger
- Department of Radiology and Nuclear Medicine and CARIM, Maastricht University Medical Center+, School for Cardiovascular Diseases, Maastricht, Netherlands
| | - Steven J R Meex
- Department of Clinical Chemistry and CARIM, Maastricht University Medical Center+, School for Cardiovascular Diseases, Maastricht, Netherlands
| | - Paulus Kirchhof
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, United Kingdom
| | - Harry J G M Crijns
- Department of Cardiology and CARIM, Maastricht University Medical Center+, School for Cardiovascular Diseases, Maastricht, Netherlands
| | - Leon J Schurgers
- Department of Biochemistry and CARIM, Maastricht University, School for Cardiovascular Diseases, Maastricht, Netherlands
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14
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McCarthy CP, Raber I, Chapman AR, Sandoval Y, Apple FS, Mills NL, Januzzi JL. Myocardial Injury in the Era of High-Sensitivity Cardiac Troponin Assays: A Practical Approach for Clinicians. JAMA Cardiol 2020; 4:1034-1042. [PMID: 31389986 DOI: 10.1001/jamacardio.2019.2724] [Citation(s) in RCA: 77] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Importance Traditionally, elevated troponin concentrations were synonymous with myocardial infarction. But with improvements in troponin assays, elevated concentrations without overt myocardial ischemia are now more common; this is referred to as myocardial injury. Physicians may be falsely reassured by the absence of myocardial ischemia; however, recent evidence suggests that myocardial injury is associated with even more detrimental outcomes. Accordingly, this article reviews the definition, epidemiology, differential diagnosis, diagnostic evaluation, and management of myocardial injury. Observations Current epidemiological evidence suggests that myocardial injury without overt ischemia represents about 60% of cases of abnormal troponin concentrations when obtained for clinical indications, and 1 in 8 patients presenting to the hospital will have evidence of myocardial injury. Myocardial injury is a concerning prognosis; the 5-year mortality rate is approximately 70%, with a major adverse cardiovascular event rate of 30% in the same period. The differential diagnosis is broad and can be divided into acute and chronic precipitants. The initial workup involves an assessment for myocardial ischemia. If infarction is ruled out, further evaluation includes a detailed history, physical examination, laboratory testing, a 12-lead electrocardiogram, and (if there is no known history of structural or valvular heart disease) an echocardiogram. Unfortunately, no consensus exists on routine management of patients with myocardial injury. Identifying and treating the underlying precipitant is the most practical approach. Conclusion and Relevance Myocardial injury is the most common cause of abnormal troponin results, and its incidence will likely increase with an aging population, increasing prevalence of cardiovascular comorbidities, and greater sensitivity of troponin assays. Myocardial injury represents a challenge to clinicians; however, given its serious prognosis, it warrants a thorough evaluation of its underlying precipitant. Future strategies to prevent and/or manage myocardial injury are needed.
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Affiliation(s)
- Cian P McCarthy
- Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston
| | - Inbar Raber
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Andrew R Chapman
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
| | - Yader Sandoval
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Fred S Apple
- Department of Laboratory Medicine and Pathology, Hennepin Healthcare/Hennepin County Medical Center and University of Minnesota, Minneapolis
| | - Nicholas L Mills
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom.,Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, United Kingdom
| | - James L Januzzi
- Division of Cardiology, Massachusetts General Hospital, Boston.,Baim Institute for Clinical Research, Boston, Massachusetts
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15
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Lyngbakken MN, Aagaard EN, Kvisvik B, Berge T, Pervez MO, Brynildsen J, Tveit A, Steine K, Røsjø H, Omland T. Cardiac Troponin I and T Are Associated with Left Ventricular Function and Structure: Data from the Akershus Cardiac Examination 1950 Study. Clin Chem 2020; 66:567-578. [DOI: 10.1093/clinchem/hvaa023] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2019] [Accepted: 01/06/2020] [Indexed: 12/27/2022]
Abstract
Abstract
Background
Concentrations of cardiac troponin I (cTnI) and T (cTnT) are associated with clinical cardiac outcomes, but do not correlate closely in subjects recruited from the general population. Accordingly, we hypothesized that cTnI and cTnT concentrations would be influenced by different cardiovascular (CV) and non-CV risk factors and reflect different CV phenotypes.
Methods
We measured cTnI and cTnT with last generation assays in 1236 women and 1157 men with no known CV disease participating in the prospective observational Akershus Cardiac Examination 1950 Study. All study participants underwent extensive CV phenotyping at baseline, including detailed echocardiography.
Results
Concentrations of cTnI were measurable in 60.3% and cTnT in 72.5% of study participants (P < 0.001), and correlated moderately (r = 0.53; P < 0.001). cTnI was more strongly associated with male sex (P = 0.018), higher education (P < 0.001), history of hypertension (P < 0.001), and age (P < 0.001), whereas cTnT was more strongly associated with eGFR (P = 0.015). Both cTnI and cTnT were inversely associated with global longitudinal strain and positively associated with LV mass index (LVMI) in analyses adjusted for CV risk factors. The association between cTnI and LVMI was stronger than the association between cTnT and LVMI (P = 0.035). Concentrations of cTnI improved diagnostic accuracy for LV hypertrophy when added to established CV risk factors, but concentrations of cTnT did not improve these models further.
Conclusions
In a large community-based cohort examined with extensive echocardiography, concentrations of cTnI and cTnT are associated with subclinical LV hypertrophy and dysfunction. Concentrations of cTnI appear superior to cTnT in predicting subclinical LV hypertrophy.
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Affiliation(s)
- Magnus Nakrem Lyngbakken
- Department of Cardiology, Division of Medicine, Akershus University Hospital, Lørenskog, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Erika Nerdrum Aagaard
- Department of Cardiology, Division of Medicine, Akershus University Hospital, Lørenskog, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Brede Kvisvik
- Department of Cardiology, Division of Medicine, Akershus University Hospital, Lørenskog, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Trygve Berge
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Department of Medical Research, Bærum Hospital, Vestre Viken Hospital Trust, Norway
| | - Mohammad Osman Pervez
- Department of Cardiology, Division of Medicine, Akershus University Hospital, Lørenskog, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Jon Brynildsen
- Department of Cardiology, Division of Medicine, Akershus University Hospital, Lørenskog, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Arnljot Tveit
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Department of Medical Research, Bærum Hospital, Vestre Viken Hospital Trust, Norway
| | - Kjetil Steine
- Department of Cardiology, Division of Medicine, Akershus University Hospital, Lørenskog, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Helge Røsjø
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Division of Research and Innovation, Akershus University Hospital, Lørenskog, Norway
| | - Torbjørn Omland
- Department of Cardiology, Division of Medicine, Akershus University Hospital, Lørenskog, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
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16
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Takagi H, Hari Y, Nakashima K, Kuno T, Ando T. Meta-analysis of impact of troponins on mortality after transcatheter aortic valve implantation. THE JOURNAL OF CARDIOVASCULAR SURGERY 2020; 61:98-106. [DOI: 10.23736/s0021-9509.19.11023-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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17
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18
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Barbieri F, Senoner T, Adukauskaite A, Dobner S, Holfeld J, Semsroth S, Lambert T, Zweiker D, Theurl T, Rainer PP, Schmidt A, Feuchtner GM, Steinwender C, Hoppe UC, Hintringer F, Bauer A, Müller S, Grimm M, Pfeifer BE, Dichtl W. Long-Term Prognostic Value of High-Sensitivity Troponin T Added to N-Terminal Pro Brain Natriuretic Peptide Plasma Levels Before Valve Replacement for Severe Aortic Stenosis. Am J Cardiol 2019; 124:1932-1939. [PMID: 31699359 DOI: 10.1016/j.amjcard.2019.09.014] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2019] [Revised: 09/12/2019] [Accepted: 09/12/2019] [Indexed: 11/18/2022]
Abstract
Natriuretic peptide plasma levels help to manage patients with severe aortic stenosis (AS). The role of troponin plasma levels in this patient cohort remains speculative. A consortium of 4 university hospital centers in Austria analyzed retrospectively 3,595 patients admitted for valve replacement because of severe AS since 2007. The aim was to compare the additive preprocedural value of high-sensitivity troponin T (hsTnT) to N-terminal pro brain natriuretic peptide (NT-proBNP) plasma levels in predicting postoperative long-term survival in a large cohort undergoing either surgical (57.8%) or transcatheter (42.2%) aortic valve replacement. During a median follow-up of 2.93 (1.91 to 4.92) years, 919 patients (25.6%) died, in them 556 (15.5%) due to cardiovascular causes. Both normal hsTnT (<14 ng/l) and NT-proBNP (within age- and sex-corrected normal range) plasma levels were found in 481 patients (14.3%, group 1). Normal hsTnT but elevated NT-proBNP plasma levels were found in 748 patients (22.3%, group 2). Elevated hsTnT but normal NT-proBNP plasma levels were found in 258 patients (7.7%, group 3). Both elevated hsTnT and elevated NT-proBNP plasma levels were found in 1,869 patients (55.7%, group 4). Using Log Rank tests for comparison there was a highly significant difference in both cardiovascular mortality (p <0.0001) and all-cause mortality (p <0.0001). All-cause mortality rates after 1, 3, and 5 years were 2.1%, 5.4%, 7.7% in group 1; 4.0%, 7.5%, 11.5% in group 2; 5.8%, 8.9%, 14.0% in group 3; and 12.3%, 22.6%, 28.4% in group 4. In conclusion, hsTnT adds additional impact to NT-proBNP as a routinely available biomarker for risk stratification concerning postoperative survival in patients with severe AS admitted for valve replacement. The present study supports the concept to integrate hsTnT plasma levels in the management of severe AS.
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Affiliation(s)
- Fabian Barbieri
- University Clinic of Internal Medicine III, Medical University Innsbruck, Innsbruck, Austria
| | - Thomas Senoner
- University Clinic of Internal Medicine III, Medical University Innsbruck, Innsbruck, Austria
| | - Agne Adukauskaite
- University Clinic of Internal Medicine III, Medical University Innsbruck, Innsbruck, Austria
| | - Stephan Dobner
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Johannes Holfeld
- University Clinic of Heart Surgery, Medical University Innsbruck, Innsbruck, Austria
| | - Severin Semsroth
- University Clinic of Heart Surgery, Medical University Innsbruck, Innsbruck, Austria
| | - Thomas Lambert
- Department of Cardiology, Kepler University Hospital, Medical Faculty, Johannes Kepler University Linz, Austria
| | - David Zweiker
- Department of Internal Medicine, Division of Cardiology, Medical University Graz, Graz, Austria
| | - Thomas Theurl
- University Clinic of Internal Medicine II, Paracelsus Medical University, Salzburg, Austria
| | - Peter Paul Rainer
- Department of Internal Medicine, Division of Cardiology, Medical University Graz, Graz, Austria
| | - Albrecht Schmidt
- Department of Internal Medicine, Division of Cardiology, Medical University Graz, Graz, Austria
| | | | - Clemens Steinwender
- Department of Cardiology, Kepler University Hospital, Medical Faculty, Johannes Kepler University Linz, Austria
| | - Uta Charlotte Hoppe
- University Clinic of Internal Medicine II, Paracelsus Medical University, Salzburg, Austria
| | - Florian Hintringer
- University Clinic of Internal Medicine III, Medical University Innsbruck, Innsbruck, Austria
| | - Axel Bauer
- University Clinic of Internal Medicine III, Medical University Innsbruck, Innsbruck, Austria
| | - Silvana Müller
- University Clinic of Internal Medicine III, Medical University Innsbruck, Innsbruck, Austria
| | - Michael Grimm
- University Clinic of Heart Surgery, Medical University Innsbruck, Innsbruck, Austria
| | - Bernhard Erich Pfeifer
- Institute of Clinical Epidemiology, Tirol Kliniken, Innsbruck, Austria; Institute of Electrical and Biomedical Engineering, University for Health Sciences, Medical Informatics and Technology (UMIT), Hall in Tirol, Austria
| | - Wolfgang Dichtl
- University Clinic of Internal Medicine III, Medical University Innsbruck, Innsbruck, Austria.
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19
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Brynildsen J, Myhre PL, Lyngbakken MN, Klaeboe LG, Stridsberg M, Christensen G, Edvardsen T, Omland T, Røsjø H. Circulating secretoneurin concentrations in patients with moderate to severe aortic stenosis. Clin Biochem 2019; 71:17-23. [PMID: 31228433 DOI: 10.1016/j.clinbiochem.2019.06.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2019] [Revised: 05/31/2019] [Accepted: 06/18/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND Secretoneurin (SN) concentrations provide important prognostic information in patients with myocardial dysfunction. Whether preoperative SN concentrations improve risk assessment in patients with moderate to severe aortic stenosis (AS) is unknown. METHODS We included 57 patients with moderate to severe AS referred for presurgical evaluation. All patients were examined with comprehensive echocardiography, electrocardiogram (ECG), and biochemical measurements and compared to 10 age- and sex-matched healthy subjects. RESULTS Median (quartile 1-3) SN concentrations were 141 (121-163) pmol/L in AS patients and 132 (106-148) pmol/L in control subjects (p = .17). Lower estimated creatinine clearance and use of diuretics, but not standard ECG or echocardiographic indices and cardiac biomarkers, were associated with increasing SN concentrations. Fifteen patients (26%) died during 3.5 years median follow-up. SN concentrations were higher in non-survivors than survivors: 156 (133-209) vs. 140 (116-155) pmol/L, p = .007. Higher SN concentrations were associated with increased risk of mortality also after adjustment for established risk indices, biomarkers, and status regarding valvular surgery: hazard ratio per lnSN 15.13 (95% CI 1.05-219.00); p = .046. Receiver operating characteristics area under the curve for SN to predict mortality was 0.74 (95% CI 0.60-0.88) compared to 0.73 (0.59-0.87) for high-sensitivity cardiac troponin T and 0.67 (0.51-0.82) for N-terminal pro-B-type natriuretic peptide. The previously identified cut-off of SN >204 pmol/L in cardiac surgical patients predicted mortality also in this cohort. CONCLUSIONS SN concentrations improve risk assessment in patients with moderate to severe AS by providing additional prognostic information to established risk indices such as echocardiography, ECG, and established cardiac biomarkers.
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Affiliation(s)
- Jon Brynildsen
- Department of Cardiology, Division of Medicine, Akershus University Hospital, Lørenskog, Norway; Center for Heart Failure Research, Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Peder L Myhre
- Department of Cardiology, Division of Medicine, Akershus University Hospital, Lørenskog, Norway; Center for Heart Failure Research, Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Magnus N Lyngbakken
- Department of Cardiology, Division of Medicine, Akershus University Hospital, Lørenskog, Norway; Center for Heart Failure Research, Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Lars Gunnar Klaeboe
- Center for Heart Failure Research, Institute of Clinical Medicine, University of Oslo, Oslo, Norway; Department of Cardiology, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | - Mats Stridsberg
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - Geir Christensen
- Center for Heart Failure Research, Institute of Clinical Medicine, University of Oslo, Oslo, Norway; Institute for Experimental Medical Research, Oslo University Hospital, Ullevål, Norway
| | - Thor Edvardsen
- Center for Heart Failure Research, Institute of Clinical Medicine, University of Oslo, Oslo, Norway; Department of Cardiology, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | - Torbjørn Omland
- Department of Cardiology, Division of Medicine, Akershus University Hospital, Lørenskog, Norway; Center for Heart Failure Research, Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Helge Røsjø
- Center for Heart Failure Research, Institute of Clinical Medicine, University of Oslo, Oslo, Norway; Division of Research and Innovation, Akershus University Hospital, Lørenskog, Norway.
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20
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Peeters FECM, Kietselaer BLJH, Hilderink J, van der Linden N, Niens M, Crijns HJGM, Meex SJR. Biological variation of cardiac markers in patients with aortic valve stenosis. Open Heart 2019; 6:e001040. [PMID: 31168392 PMCID: PMC6519418 DOI: 10.1136/openhrt-2019-001040] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2019] [Revised: 03/31/2019] [Accepted: 04/14/2019] [Indexed: 12/02/2022] Open
Abstract
Objective Cardiac biomarkers hold promise for follow-up and management of aortic valve stenosis (AVS). When interpreting serial biomarker measurements of patients with AVS, it can be challenging to distinguish ‘real changes’ from ‘random fluctuation’. Hence, robust estimation of the biological variation of these biomarkers is essential. In the present study we assessed biological variation of B-type natriuretic peptide (BNP), N-terminus pro-brain natriuretic peptide (NT-proBNP), high-sensitivity troponin-T and high-sensitivity troponin-I (hs-TnT and hs-TnI), and ST2 in subjects with stable AVS. Methods Serial blood sampling was performed in 25 subjects with moderate AVS—confirmed by echocardiography—and all free from acute cardiovascular events in the past 6 months. Blood samples were taken on seven standardised occasions during 1 year. Analytical variation (CVA), within-subject biological variation (CVI), between-subject biological variation (CVG), index of individuality (II) and reference change values were calculated for all cardiac biomarkers. Results CVI was highest for BNP (62.0%, 95% CI 52.5 to 75.4) and lowest for hs-TnI (9.2%, 95% CI 2.8 to 13.8). CVG exceeded the CVI for all biomarkers except BNP, and ranged from 19.8% (95% CI 13.8 to 33.4) for ST2 to 57.2% (95% CI 40.4 to 97.3) for hs-TnT. NT-proBNP, hs-TnT and ST2 revealed CVA <5%, while BNP and hs-TnI showed a higher CVA (19.7 and 14.9, respectively). All biomarkers except BNP showed marked individuality, with II ranging from 0.21 to 0.67 (BNP 1.34). Conclusion This study provides the first biological variation estimates of cardiac biomarkers in patients with stable AVS. These estimates allow a more evidence-based interpretation of biomarker changes in the follow-up and management of patients with AVS. Trial registration number NCT02510482
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Affiliation(s)
| | - Bas L J H Kietselaer
- Cardiology, Zuyderland Medisch Centrum Heerlen, Heerlen, Limburg, The Netherlands
| | - Judith Hilderink
- Clinical Chemistry, Maastricht University Medical Center+ and CARIM, Maastricht, The Netherlands
| | - Noreen van der Linden
- Clinical Chemistry, Maastricht University Medical Center+ and CARIM, Maastricht, The Netherlands
| | - Marijke Niens
- Clinical Chemistry, Laurentius Ziekenhuis, Roermond, The Netherlands
| | - Harry J G M Crijns
- Cardiology, Maastricht University Medical Center+ and CARIM, Maastricht, The Netherlands
| | - Steven J R Meex
- Clinical Chemistry, Maastricht University Medical Center+ and CARIM, Maastricht, The Netherlands
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21
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Akodad M, Spaziano M, Chevalier B, Garot P, Benamer H, Dinan‐Zannier A, Troussier X, Unterseeh T, Champagne S, Hovasse T, Lefèvre T. Prognostic Impact of Pre-Transcatheter and Post-Transcatheter Aortic Valve Intervention Troponin: A Large Cohort Study. J Am Heart Assoc 2019; 8:e011111. [PMID: 30866687 PMCID: PMC6475053 DOI: 10.1161/jaha.118.011111] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2018] [Accepted: 01/17/2019] [Indexed: 02/06/2023]
Abstract
Background Biomarkers were advocated as prognostic factors in patients undergoing transcatheter aortic valve intervention, with contradictory results concerning prognostic impact of troponin. Our aim was to assess the prognostic impact of preprocedural and postprocedural troponin in transcatheter aortic valve intervention. Methods and Results Preprocedural and postprocedural high-sensitivity troponin levels were measured in all patients undergoing transcatheter aortic valve intervention. Primary end point was 1-year mortality. This study included 1390 patients, with a mean age of 83.4±6.8 years. Patients were divided into 3 tertiles according to preprocedural troponin values: tertile 1: 0.001 to 0.023 μg/L; tertile 2: 0.024 to 1.80 μg/L; and T3: 1.81 to 12.1 μg/L. One-year mortality was higher in patients in tertile 2 (hazard ratio, 2.1; P=0.001) and T3 (hazard ratio, 1.8; P=0.009) compared with those in tertile 1. Myocardial injury was predictive of 1-year mortality (hazard ratio, 1.7; P=0.01). This effect may be stronger in the tertile 1 subgroup (hazard ratio, 5.1; P=0.03 [ P value for interaction: 0.18]). Conclusions Elevated preprocedural troponin and myocardial injury are associated with 1-year mortality after transcatheter aortic valve intervention.
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Affiliation(s)
- Mariama Akodad
- Interventional Cardiology DepartmentRamsay Générale de SantéInstitut Cardiovasculaire Paris SudMassyFrance
| | - Marco Spaziano
- Interventional Cardiology DepartmentRamsay Générale de SantéInstitut Cardiovasculaire Paris SudMassyFrance
| | - Bernard Chevalier
- Interventional Cardiology DepartmentRamsay Générale de SantéInstitut Cardiovasculaire Paris SudMassyFrance
| | - Philippe Garot
- Interventional Cardiology DepartmentRamsay Générale de SantéInstitut Cardiovasculaire Paris SudMassyFrance
| | - Hakim Benamer
- Interventional Cardiology DepartmentRamsay Générale de SantéInstitut Cardiovasculaire Paris SudMassyFrance
| | | | - Xavier Troussier
- Intensive Care UnitRamsay Générale de SantéInstitut Cardiovasculaire Paris SudMassyFrance
| | - Thierry Unterseeh
- Interventional Cardiology DepartmentRamsay Générale de SantéInstitut Cardiovasculaire Paris SudMassyFrance
| | - Stéphane Champagne
- Interventional Cardiology DepartmentRamsay Générale de SantéInstitut Cardiovasculaire Paris SudMassyFrance
| | - Thomas Hovasse
- Interventional Cardiology DepartmentRamsay Générale de SantéInstitut Cardiovasculaire Paris SudMassyFrance
| | - Thierry Lefèvre
- Interventional Cardiology DepartmentRamsay Générale de SantéInstitut Cardiovasculaire Paris SudMassyFrance
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22
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Ferrer-Sistach E, Lupón J, Cediel G, Teis A, Gual F, Serrano S, Vallejo N, Juncà G, López-Ayerbe J, Bayés-Genís A. High-sensitivity troponin T in asymptomatic severe aortic stenosis. Biomarkers 2019; 24:334-340. [PMID: 30632403 DOI: 10.1080/1354750x.2019.1567818] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/09/2023]
Abstract
Background: In asymptomatic severe aortic stenosis (ASAS), treatment decisions are made on an individual basis, and case management presents a clinical conundrum. Methods: We prospectively phenotyped consecutive patients with ASAS using echocardiography, exercise echocardiography, cardiac MRI and biomarkers (NT-proBNP, high-sensitivity troponin T (hs-TnT) and ST2) (n = 58). The primary endpoint was a composite of cardiovascular death, new-onset symptoms, cardiac hospitalization, guideline-driven indication for valve replacement and cardiovascular death at 12 months. Results: During the first year, 46.6% patients met primary endpoint. In multivariable analysis, aortic regurgitation ≥2 (p = 0.01) and hs-TnT (p = 0.007) were the only independent predictors of the primary endpoint. The best cutoff value was identified as hs-TnT >10ng/L, which was associated with a ∼10-fold greater risk of the primary endpoint (HR, 9.62; 95% CI, 2.27-40.8; p = 0.002). A baseline predictive model including age, sex and variables showing p < 0.10 in univariable analyses showed an area under the curve (AUC) of 0.79(0.66-0.91). Incorporation of hs-TnT into this model increased the AUC to 0.90(0.81-0.98) (p = 0.03). Patient reclassification with the model including hs-TnT yielded an NRI of 1.28(0.46-1.78), corresponding to 43% adequately reclassified patients. Conclusions: In patients with ASAS, hs-TnT >10ng/L was associated with high risk of events within 12 months. Including hs-TnT in routine ASAS management markedly improved prediction metrics.
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Affiliation(s)
- Elena Ferrer-Sistach
- a Heart Institute, Hospital Universitari Germans Trias i Pujol , Badalona , Spain.,b Department of Medicine, CIBERCV , Autonomous University of Barcelona , Barcelona , Spain
| | - Josep Lupón
- a Heart Institute, Hospital Universitari Germans Trias i Pujol , Badalona , Spain.,b Department of Medicine, CIBERCV , Autonomous University of Barcelona , Barcelona , Spain
| | - Germán Cediel
- a Heart Institute, Hospital Universitari Germans Trias i Pujol , Badalona , Spain.,b Department of Medicine, CIBERCV , Autonomous University of Barcelona , Barcelona , Spain
| | - Albert Teis
- a Heart Institute, Hospital Universitari Germans Trias i Pujol , Badalona , Spain.,b Department of Medicine, CIBERCV , Autonomous University of Barcelona , Barcelona , Spain
| | - Francisco Gual
- a Heart Institute, Hospital Universitari Germans Trias i Pujol , Badalona , Spain.,b Department of Medicine, CIBERCV , Autonomous University of Barcelona , Barcelona , Spain
| | - Sílvia Serrano
- a Heart Institute, Hospital Universitari Germans Trias i Pujol , Badalona , Spain.,b Department of Medicine, CIBERCV , Autonomous University of Barcelona , Barcelona , Spain
| | - Nuria Vallejo
- a Heart Institute, Hospital Universitari Germans Trias i Pujol , Badalona , Spain.,b Department of Medicine, CIBERCV , Autonomous University of Barcelona , Barcelona , Spain
| | - Gladys Juncà
- a Heart Institute, Hospital Universitari Germans Trias i Pujol , Badalona , Spain.,b Department of Medicine, CIBERCV , Autonomous University of Barcelona , Barcelona , Spain
| | - Jorge López-Ayerbe
- a Heart Institute, Hospital Universitari Germans Trias i Pujol , Badalona , Spain.,b Department of Medicine, CIBERCV , Autonomous University of Barcelona , Barcelona , Spain
| | - Antoni Bayés-Genís
- a Heart Institute, Hospital Universitari Germans Trias i Pujol , Badalona , Spain.,b Department of Medicine, CIBERCV , Autonomous University of Barcelona , Barcelona , Spain
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23
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Castro LTD, Santos IDS, Goulart AC, Pereira ADC, Staniak HL, Bittencourt MS, Lotufo PA, Bensenor IM. Elevated High-Sensitivity Troponin I in the Stabilized Phase after an Acute Coronary Syndrome Predicts All-Cause and Cardiovascular Mortality in a Highly Admixed Population: A 7-Year Cohort. Arq Bras Cardiol 2019; 112:230-237. [PMID: 30916200 PMCID: PMC6424029 DOI: 10.5935/abc.20180268] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2018] [Accepted: 08/02/2018] [Indexed: 11/20/2022] Open
Abstract
Background High-sensitivity cardiac troponin I (hs-cTnI) has played an important role in
the risk stratification of patients during the in-hospital phase of acute
coronary syndrome (ACS), but few studies have determined its role as a
long-term prognostic marker in the outpatient setting. Objective To investigate the association between levels of hs-cTnI measured in the
subacute phase after an ACS event and long-term prognosis in a highly
admixed population. Methods We measured levels of hs-cTnI in 525 patients 25 to 90 days after admission
for an ACS event; these patients were then divided into tertiles according
to hs-cTnI levels and followed for up to 7 years. We compared all-cause and
cardiovascular mortality using Cox proportional hazards models and adopting
a significance level of 5%. Results After a median follow-up of 51 months, patients in the highest tertile had a
greater hazard ratio (HR) for all-cause mortality after adjustment for age,
sex, known cardiovascular risk factors, medication use, and demographic
factors (HR: 3.84, 95% CI: 1.92-8.12). These findings persisted after
further adjustment for estimated glomerular filtration rate < 60
ml/min/1.73 m2 and left ventricular ejection fraction < 0.40
(HR: 6.53, 95% CI: 2.12-20.14). Cardiovascular mortality was significantly
higher in the highest tertile after adjustment for age and sex (HR: 5.65,
95% CI: 1.94-16.47) and both in the first (HR: 4.90, 95% CI: 1.35-17.82) and
second models of multivariate adjustment (HR: 5.89, 95% CI: 1.08-32.27). Conclusions Elevated hs-cTnI levels measured in the stabilized phase after an ACS event
are independent predictors of all-cause and cardiovascular mortality in a
highly admixed population.
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Affiliation(s)
| | - Itamar de Souza Santos
- Centro de Pesquisa Clínica e Epidemiológica da Universidade de São Paulo (USP), São Paulo, SP - Brazil
| | - Alessandra C Goulart
- Centro de Pesquisa Clínica e Epidemiológica da Universidade de São Paulo (USP), São Paulo, SP - Brazil
| | - Alexandre da Costa Pereira
- Instituto do Coração (InCor) - Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP - Brazil
| | - Henrique Lane Staniak
- Centro de Pesquisa Clínica e Epidemiológica da Universidade de São Paulo (USP), São Paulo, SP - Brazil
| | - Marcio Sommer Bittencourt
- Centro de Pesquisa Clínica e Epidemiológica da Universidade de São Paulo (USP), São Paulo, SP - Brazil
| | - Paulo Andrade Lotufo
- Centro de Pesquisa Clínica e Epidemiológica da Universidade de São Paulo (USP), São Paulo, SP - Brazil
| | - Isabela Martins Bensenor
- Centro de Pesquisa Clínica e Epidemiológica da Universidade de São Paulo (USP), São Paulo, SP - Brazil
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24
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Tevaearai Stahel HT, Do PD, Klaus JB, Gahl B, Locca D, Göber V, Carrel TP. Clinical Relevance of Troponin T Profile Following Cardiac Surgery. Front Cardiovasc Med 2018; 5:182. [PMID: 30619889 PMCID: PMC6301188 DOI: 10.3389/fcvm.2018.00182] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2018] [Accepted: 12/03/2018] [Indexed: 11/13/2022] Open
Abstract
Background: Peak post-operative cardiac troponin T (cTnT) independently predicts mid- and long-term outcome of cardiac surgery patients. A few studies however have reported two peaks of cTnT over the first 48–72 h following myocardial reperfusion. The aim of the current study was to better understand underlying reasons of these different cTnT profiles and their possible relevance in terms of clinical outcome. Methods: All consecutive adult cardiac surgical procedures performed with an extra-corporeal circulation during a >6 years period were retrospectively evaluated. Patients with a myocardial infarction (MI) < 8 days were excluded. cTnT profile of patients with at least one value ≥1 ng/mL value were categorized according to the time occurrence of the peak value. Univariable and multivariable analysis were performed to identify factors influencing early vs. late increase of cTnT values, and to verify the correlation of early vs. late increase with clinical outcome. Results: Data of 5,146 patients were retrieved from our prospectively managed registry. From 953 with at least one cTnT value ≥1 ng/mL, peak occurred ≤ 6 h (n = 22), >6 to ≤ 12 h (n = 366), >12 to ≤ 18 h (n = 176), >18 to ≤ 24 h (171), >24 h (218). Age (OR: 1.023; CI: 1.016–1.030) and isolated CABG (OR: 1.779; CI: 1.114–2.839) were independent predictors of a late increase of cTnT over a limit of 1 ng/ml (p < 0.05), whereas isolated valve procedures (OR: 0.685; CI: 0.471–0.998) and cross-clamp duration (OR: 0.993; CI: 0.990–0.997) independently predicted an early elevation (p < 0.05). Delayed elevation as opposed to early elevation correlated with a higher rate of post-operative complications including MI (19.8 vs. 7.2%), new renal insufficiency (16.3 vs. 6.7%), MACCE (32.0 vs. 15.5%), or death (7.4 vs. 4.4%). Conclusion: Profile of cTnT elevation following cardiac surgery depends on patients' intrinsic factors, type of surgery and duration of cross-clamp time. Delayed increase is of higher clinically relevance than prompt post-operative elevation.
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Affiliation(s)
- Hendrik T Tevaearai Stahel
- Department of Cardiovascular Surgery, Bern University Hospital and University of Bern, Bern, Switzerland
| | - Peter D Do
- Department of Cardiovascular Surgery, Bern University Hospital and University of Bern, Bern, Switzerland
| | - Jeremias Bendicht Klaus
- Institute of Radiology, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
| | - Brigitta Gahl
- Department of Cardiovascular Surgery, Bern University Hospital and University of Bern, Bern, Switzerland
| | - Didier Locca
- Department of Cardiology, Barts Heart Center, Barts Health NHS Trust, London, United Kingdom.,William Harvey Institute, Queen Mary University London, United Kingdom
| | - Volkhard Göber
- Department of Cardiovascular Surgery, Bern University Hospital and University of Bern, Bern, Switzerland
| | - Thierry P Carrel
- Department of Cardiovascular Surgery, Bern University Hospital and University of Bern, Bern, Switzerland
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25
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Sandoval Y, Sharain K, Saenger AK, Smith SW, Apple FS, Jaffe AS. Clinical use of cardiac troponin for acute cardiac care and emerging opportunities in the outpatient setting. Minerva Med 2018; 110:139-156. [PMID: 30484592 DOI: 10.23736/s0026-4806.18.05874-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Cardiac troponin (cTn) testing has evolved significantly in recent times. Because of increased sensitivity, its use has shifted from a marker used to help diagnose acute myocardial infarction (MI) to a marker than can be used in the outpatient setting, as well as for both detection of myocardial injury and risk-stratification. Its main role remains in the diagnosis of acute MI and the risk-stratification of patients presenting with suspected acute coronary syndrome. The analytical improvements in assays leading to precise high-sensitivity cTn assays have contributed to the development of numerous strategies to identify patients at both low- and high-risk for acute MI within a few hours. These approaches should reduce overcrowding in the emergency room and expedite triaging. The ability of measuring cTn in most patients using high-sensitivity (hs) assays has allowed for the opportunity to examine its use in the detection of cardiotoxicity in patients undergoing chemotherapy, as well as exploring the application in both primary and secondary prevention of coronary artery disease. This particular field of research has become increasingly complex, partly due to the numerous cTn assays available (I and T; point-of-care, contemporary, hs) and an array of approaches in which one can use the test. The purpose of this document is to summarize the analytical and clinical information relevant to cTn assays, in particular, hs-cTn assays, and describe present and future opportunities for use of cTn in acute cardiac care and in the outpatient setting.
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Affiliation(s)
- Yader Sandoval
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA -
| | - Korosh Sharain
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Amy K Saenger
- Department of Laboratory Medicine and Pathology, University of Minnesota, Minneapolis, MN, USA.,Department of Laboratory Medicine and Pathology, Hennepin County Medical Center, Minneapolis, MN, USA
| | - Stephen W Smith
- Department of Emergency Medicine, Hennepin County Medical Center and University of Minnesota, Minneapolis, MN, USA
| | - Fred S Apple
- Department of Laboratory Medicine and Pathology, University of Minnesota, Minneapolis, MN, USA.,Department of Laboratory Medicine and Pathology, Hennepin County Medical Center, Minneapolis, MN, USA
| | - Allan S Jaffe
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA.,Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
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26
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Myhre PL, Omland T, Sarvari SI, Ukkonen H, Rademakers F, Engvall JE, Hagve TA, Nagel E, Sicari R, Zamorano JL, Monaghan M, D'hooge J, Edvardsen T, Røsjø H. Cardiac Troponin T Concentrations, Reversible Myocardial Ischemia, and Indices of Left Ventricular Remodeling in Patients with Suspected Stable Angina Pectoris: a DOPPLER-CIP Substudy. Clin Chem 2018; 64:1370-1379. [DOI: 10.1373/clinchem.2018.288894] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2018] [Accepted: 06/01/2018] [Indexed: 11/06/2022]
Abstract
Abstract
BACKGROUND
Cardiac troponin T concentrations measured with high-sensitivity assays (hs-cTnT) provide important prognostic information for patients with stable coronary artery disease (CAD). However, whether hs-cTnT concentrations mainly reflect left ventricular (LV) remodeling or recurrent myocardial ischemia in this population is not known.
METHODS
We measured hs-cTnT concentrations in 619 subjects with suspected stable CAD in a prospectively designed multicenter study. We identified associations with indices of LV remodeling, as assessed by cardiac MRI and echocardiography, and evidence of myocardial ischemia diagnosed by single positron emission computed tomography.
RESULTS
Median hs-cTnT concentration was 7.8 ng/L (interquartile range, 4.8–11.6 ng/L), and 111 patients (18%) had hs-cTnT concentrations above the upper reference limit (>14 ng/L). Patients with hs-cTnT >14 ng/L had increased LV mass (144 ± 40 g vs 116 ± 34 g; P < 0.001) and volume (179 ± 80 mL vs 158 ± 44 mL; P = 0.006), lower LV ejection fraction (LVEF) (59 ± 14 vs 62 ± 11; P = 0.006) and global longitudinal strain (14.1 ± 3.4% vs 16.9 ± 3.2%; P < 0.001), and more reversible perfusion defects (P = 0.001) and reversible wall motion abnormalities (P = 0.008). Age (P = 0.009), estimated glomerular filtration rate (P = 0.01), LV mass (P = 0.003), LVEF (P = 0.03), and evidence of reversible myocardial ischemia (P = 0.004 for perfusion defects and P = 0.02 for LV wall motion) were all associated with increasing hs-cTnT concentrations in multivariate analysis. We found analogous results when using the revised US upper reference limit of 19 ng/L.
CONCLUSIONS
hs-cTnT concentrations reflect both LV mass and reversible myocardial ischemia in patients with suspected stable CAD.
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Affiliation(s)
- Peder L Myhre
- Division of Medicine, Akershus University Hospital, Lørenskog, Norway and Center for Heart Failure Research, University of Oslo, Oslo, Norway
- Division of Cardiovascular Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Torbjørn Omland
- Division of Medicine, Akershus University Hospital, Lørenskog, Norway and Center for Heart Failure Research, University of Oslo, Oslo, Norway
| | - Sebastian I Sarvari
- Department of Cardiology, Oslo University Hospital, Rikshospitalet and Center for Heart Failure Research, University of Oslo, Oslo, Norway
| | - Heikki Ukkonen
- Department of Medicine, Turku University Hospital, Turku, Finland
| | - Frank Rademakers
- Department of Cardiovascular Sciences, University Hospitals Leuven and KU Leuven, Leuven, Belgium
| | - Jan E Engvall
- Department of Clinical Physiology Linköping University, Linköping, Sweden and Center for Medical Image Science and Visualization (CMIV), Linköping University, Linköping, Sweden
| | - Tor-Arne Hagve
- Division of Diagnostics and Technology, Akershus University Hospital, Lørenskog and Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Eike Nagel
- Kings College Hospital, Department of Non-invasive Cardiology, Denmark Hill, London, UK
| | - Rosa Sicari
- CNR, Istituto di Fisiologia Clinica, Pisa, Italy
| | - Jose L Zamorano
- Hospital Universitario Ramón y Cajal, Cardiovascular Imaging Unit, Madrid, Spain
| | - Mark Monaghan
- Kings College Hospital, Department of Non-invasive Cardiology, Denmark Hill, London, UK
| | - Jan D'hooge
- Department of Cardiovascular Sciences, University Hospitals Leuven and KU Leuven, Leuven, Belgium
| | - Thor Edvardsen
- Department of Cardiology, Oslo University Hospital, Rikshospitalet and Center for Heart Failure Research, University of Oslo, Oslo, Norway
| | - Helge Røsjø
- Division of Medicine, Akershus University Hospital, Lørenskog, Norway and Center for Heart Failure Research, University of Oslo, Oslo, Norway
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Treibel TA, Kozor R, Fontana M, Torlasco C, Reant P, Badiani S, Espinoza M, Yap J, Diez J, Hughes AD, Lloyd G, Moon JC. Sex Dimorphism in the Myocardial Response to Aortic Stenosis. JACC Cardiovasc Imaging 2018; 11:962-973. [PMID: 29153564 PMCID: PMC6278887 DOI: 10.1016/j.jcmg.2017.08.025] [Citation(s) in RCA: 67] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2017] [Revised: 07/16/2017] [Accepted: 08/15/2017] [Indexed: 01/19/2023]
Abstract
OBJECTIVES The goal of this study was to explore sex differences in myocardial remodeling in aortic stenosis (AS) by using echocardiography, cardiac magnetic resonance (CMR), and biomarkers. BACKGROUND AS is a disease of both valve and left ventricle (LV). Sex differences in LV remodeling are reported in AS and may play a role in disease phenotyping. METHODS This study was a prospective assessment of patients awaiting surgical valve replacement for severe AS using echocardiography, the 6-min walking test, biomarkers (high-sensitivity troponin T and N-terminal pro-brain natriuretic peptide), and CMR with late gadolinium enhancement and extracellular volume fraction, which dichotomizes the myocardium into matrix and cell volumes. LV remodeling was categorized into normal geometry, concentric remodeling, concentric hypertrophy, and eccentric hypertrophy. RESULTS In 168 patients (age 70 ± 10 years, 55% male, indexed aortic valve area 0.40 ± 0.13 cm2/m2, mean gradient 47 ± 4 mm Hg), no sex or age differences in AS severity or functional capacity (6-min walking test) were found. CMR captured sex dimorphism in LV remodeling not apparent by using 2-dimensional echocardiography. Normal geometry (82% female) and concentric remodeling (60% female) dominated in women; concentric hypertrophy (71% male) and eccentric hypertrophy (76% male) dominated in men. Men also had more evidence of LV decompensation (pleural effusions), lower left ventricular ejection fraction (67 ± 16% vs. 74 ± 13%; p < 0.001), and higher levels of N-terminal pro-brain natriuretic peptide (p = 0.04) and high-sensitivity troponin T (p = 0.01). Myocardial fibrosis was higher in men, with higher focal fibrosis (late gadolinium enhancement 16.5 ± 11.2 g vs. 10.5 ± 8.9 g; p < 0.001) and extracellular expansion (matrix volume 28.5 ± 8.8 ml/m2 vs. 21.4 ± 6.3 ml/m2; p < 0.001). CONCLUSIONS CMR revealed sex differences in associations between AS and myocardial remodeling not evident from echocardiography. Given equal valve severity, the myocardial response to AS seems more maladaptive in men than previously reported. (Regression of Myocardial Fibrosis After Aortic Valve Replacement [RELIEF-AS]; NCT02174471).
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Affiliation(s)
- Thomas A Treibel
- Barts Heart Centre, St Bartholomew's Hospital, London, United Kingdom; Institute of Cardiovascular Science, University College London, London, United Kingdom
| | - Rebecca Kozor
- Barts Heart Centre, St Bartholomew's Hospital, London, United Kingdom; Sydney Medical School, University of Sydney, Sydney, Australia
| | - Marianna Fontana
- Institute of Cardiovascular Science, University College London, London, United Kingdom
| | - Camilla Torlasco
- Barts Heart Centre, St Bartholomew's Hospital, London, United Kingdom
| | - Patricia Reant
- University Hospital Center of Bordeaux, and University of Bordeaux, Bordeaux, France
| | - Sveeta Badiani
- Barts Heart Centre, St Bartholomew's Hospital, London, United Kingdom
| | - Maria Espinoza
- Barts Heart Centre, St Bartholomew's Hospital, London, United Kingdom
| | - John Yap
- Barts Heart Centre, St Bartholomew's Hospital, London, United Kingdom
| | - Javier Diez
- Program of Cardiovascular Diseases, Center for Applied Medical Research, University of Navarra, Pamplona, Spain; CIBERCV, Carlos III Institute of Health, Madrid, Spain
| | - Alun D Hughes
- Institute of Cardiovascular Science, University College London, London, United Kingdom
| | - Guy Lloyd
- Barts Heart Centre, St Bartholomew's Hospital, London, United Kingdom; Institute of Cardiovascular Science, University College London, London, United Kingdom
| | - James C Moon
- Barts Heart Centre, St Bartholomew's Hospital, London, United Kingdom; Institute of Cardiovascular Science, University College London, London, United Kingdom.
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Gottlieb M, Long B, Koyfman A. Evaluation and Management of Aortic Stenosis for the Emergency Clinician: An Evidence-Based Review of the Literature. J Emerg Med 2018. [PMID: 29525246 DOI: 10.1016/j.jemermed.2018.01.026] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Aortic stenosis is a common condition among older adults that can be associated with dangerous outcomes, due to both the disease itself and its influence on other conditions. OBJECTIVE This review provides an evidence-based summary of the current emergency department (ED) evaluation and management of aortic stenosis. DISCUSSION Aortic stenosis refers to significant narrowing of the aortic valve and can be caused by calcific disease, congenital causes, or rheumatic valvular disease. Symptoms of advanced disease include angina, dyspnea, and syncope. Patients with these symptoms have a much higher mortality rate than asymptomatic patients. Initial evaluation should include an electrocardiogram, complete blood count, basic metabolic profile, coagulation studies, troponin, brain natriuretic peptide, type and screen, and a chest radiograph. Transthoracic echocardiogram is the test of choice, but point-of-care ultrasound has been found to have good accuracy when a formal echocardiogram is not feasible. Initial management should begin with restoring preload and ensuring a normal heart rate, as both bradycardia and tachycardia can lead to clinical decompensation. For patients with high blood pressure and heart failure symptoms, nitrate agents may be reasonable, but hypotension should be avoided. Dobutamine can increase inotropy. For hypotensive patients, vasopressors should be used at the lowest effective dose. The treatment of choice is valve replacement, but extracorporeal membrane oxygenation and percutaneous balloon dilatation of the aortic valve have been described as temporizing measures. CONCLUSION Aortic stenosis is an important condition that can lead to dangerous outcomes and requires prompt recognition and disease-specific management in the ED.
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Affiliation(s)
- Michael Gottlieb
- Department of Emergency Medicine, Rush University Medical Center, Chicago, Illinois
| | - Brit Long
- Department of Emergency Medicine, San Antonio Military Medical Center, Fort Sam Houston, Texas
| | - Alex Koyfman
- Department of Emergency Medicine, The University of Texas Southwestern Medical Center, Dallas, Texas
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Shen M, Tastet L, Bergler-Klein J, Pibarot P, Clavel MA. Blood, tissue and imaging biomarkers in calcific aortic valve stenosis: past, present and future. Curr Opin Cardiol 2018; 33:125-133. [PMID: 29194051 DOI: 10.1097/hco.0000000000000487] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
PURPOSE OF REVIEW Calcific aortic valve stenosis is the most prevalent valvular heart disease in the high-income countries. To this date, no medical therapy has been proven to prevent or to stop the progression of aortic valve stenosis. The physiopathology of aortic valve stenosis is highly complex and involves several signalling pathways, as well as genetic related factors, which delay the elaboration of effective pharmacotherapies. Moreover, it is difficult to predict accurately the progression of the valve stenosis and finding the optimal timing for aortic valve replacement remains challenging. Therefore, the present review makes an inventory of the most recent and promising circulating and imaging biomarkers related to the underlying mechanisms involved in the physiopathology of aortic valve stenosis, as well as the biomarkers associated with the left ventricular (LV) remodelling and subsequent dysfunction in patients with aortic valve stenosis. RECENT FINDINGS Over the last decade, several blood, tissue and imaging biomarkers have been investigated in aortic valve stenosis patients. At the aortic valve level, these biomarkers are mostly associated and/or involved with processes such as lipid infiltration and oxidation, chronic inflammation and fibrocalcific remodelling of the valve. Moreover, recent findings suggest that aging and sex hormones might interact with these multiple processes. Several studies demonstrated the usefulness of circulating biomarkers such as lipoprotein(a), brain natriuretic peptides and high-sensitivity cardiac troponin, which are very close to clinical routine. Furthermore, noninvasive imaging biomarkers including positron emission tomography and cardiac magnetic resonance, which provide a detailed view of the disease activity within the aortic valve and its repercussion on the left ventricle, may help to improve the understanding of aortic valve stenosis physiopathology and enhance the risk stratification. Other biomarkers such as von Willebrand factor and microRNAs are promising but further studies are needed to prove their additive value in aortic valve stenosis. SUMMARY Most of the biomarkers are used in research and thus, are still being investigated. However, some biomarkers including plasma level of lipoprotein(a), F-sodium fluoride, brain natriuretic peptides and high-sensitivity cardiac troponin can be or are very close to be used for the clinical management of patients with aortic valve stenosis. Moreover, a multibiomarker approach might provide a more global view of the disease activity and improve the management strategies of these patients.
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Affiliation(s)
- Mylène Shen
- Institut Universitaire de Cardiologie et de Pneumologie de Québec (Quebec Heart and Lung Institute), Université Laval, Québec, Canada
| | - Lionel Tastet
- Institut Universitaire de Cardiologie et de Pneumologie de Québec (Quebec Heart and Lung Institute), Université Laval, Québec, Canada
| | | | - Philippe Pibarot
- Institut Universitaire de Cardiologie et de Pneumologie de Québec (Quebec Heart and Lung Institute), Université Laval, Québec, Canada
| | - Marie-Annick Clavel
- Institut Universitaire de Cardiologie et de Pneumologie de Québec (Quebec Heart and Lung Institute), Université Laval, Québec, Canada
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31
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High sensitivity troponin and valvular heart disease. Trends Cardiovasc Med 2017; 27:326-333. [DOI: 10.1016/j.tcm.2017.01.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2016] [Revised: 01/12/2017] [Accepted: 01/15/2017] [Indexed: 11/23/2022]
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32
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Fröhlich GM, Leistner DM. The relevance of periprocedural troponin rise: the never ending story! Open Heart 2017; 4:e000590. [PMID: 28766585 PMCID: PMC5515128 DOI: 10.1136/openhrt-2017-000590] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/29/2017] [Indexed: 11/04/2022] Open
Affiliation(s)
- Georg Marcus Fröhlich
- Department of Cardiology, Charité-Universitätsmedizin Berlin, Campus Benjamin Franklin, Berlin, Germany
| | - David Manuel Leistner
- Department of Cardiology, Charité-Universitätsmedizin Berlin, Campus Benjamin Franklin, Berlin, Germany
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33
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Xiao W, Cao R, Liu Y, Wang F, Bai Y, Wu H, Ye P. Association of high-sensitivity cardiac troponin T with mortality and cardiovascular events in a community-based prospective study in Beijing. BMJ Open 2017; 7:e013431. [PMID: 28652289 PMCID: PMC5541394 DOI: 10.1136/bmjopen-2016-013431] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
OBJECTIVE The prognostic value of cardiac troponins in apparently healthy populations is not well established. The aim of this study was to investigate the prognostic properties of high-sensitivity cardiac troponin T (hs-cTnT) for long-term adverse outcomes. SETTING A community-dwelling prospective survey of residents from two communities in Beijing. PARTICIPANTS From September 2007 to January 2009, 1680 participants were initially enrolled. Of these, 1499 (870 females, mean age: 61.4 years) participants completed the survey and were followed up for a median of 4.8 years (IQR: 4.5-5.2). OUTCOME MEASURES The primary outcome was the occurrence of all-cause mortality and major cardiovascular events. RESULTS Overall, 820 individuals (54.7%) had detectable hs-cTnT levels. During the follow-up, 52 participants (3.5%) died, 154 (10.3%) had major cardiovascular events and 99 (6.6%) experienced new-onset coronary events. Compared with those with undetectable hs-cTnT levels, participants with hs-cTnT levels in the highest category (≥14 ng/L) had a significantly increased risk for all-cause mortality (adjusted HR (aHR): 2.07, 95% CI 1.05 to 3.01), major cardiovascular events (aHR: 3.27, 95% CI 1.88 to 5.70) and coronary events (aHR: 4.50, 95% CI 2.26 to 9.02) in covariate-adjusted analyses. No differences in stroke incidence were found (aHR: 1.27, 95% CI 0.69 to 2.62). Also, significant associations were presented when hs-cTnT levels were modelled as a continuous variable and when analysing changes in hs-cTnT levels over time with adverse outcomes. The addition of troponin T levels to clinical variables led to significant increases in risk prediction with a marked improvement in the C-statistics (p=0.003 or lower). CONCLUSIONS In this cohort of individuals from a community-based population, cTnT levels measured with a highly sensitive assay were associated with increases in the subsequent risk for all-cause mortality and major cardiovascular events. These results might support screening for at-risk individuals.
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Affiliation(s)
- Wenkai Xiao
- Department of Geriatric Cardiology, Chinese PLA General Hospital, Beijing, China
| | - Ruihua Cao
- Department of Geriatric Cardiology, Chinese PLA General Hospital, Beijing, China
| | - Yuan Liu
- Department of Geriatric Cardiology, Chinese PLA General Hospital, Beijing, China
| | - Fan Wang
- Department of Geriatric Cardiology, Chinese PLA General Hospital, Beijing, China
| | - Yongyi Bai
- Department of Geriatric Cardiology, Chinese PLA General Hospital, Beijing, China
| | - Hongmei Wu
- Department of Geriatric Cardiology, Chinese PLA General Hospital, Beijing, China
| | - Ping Ye
- Department of Geriatric Cardiology, Chinese PLA General Hospital, Beijing, China
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Redfors B, Furer A, Lindman BR, Burkhoff D, Marquis-Gravel G, Francese DP, Ben-Yehuda O, Pibarot P, Gillam LD, Leon MB, Généreux P. Biomarkers in Aortic Stenosis: A Systematic Review. STRUCTURAL HEART-THE JOURNAL OF THE HEART TEAM 2017. [DOI: 10.1080/24748706.2017.1329959] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Affiliation(s)
- Björn Redfors
- Cardiovascular Research Foundation, New York, NY, USA
- Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Ariel Furer
- Cardiovascular Research Foundation, New York, NY, USA
| | | | - Daniel Burkhoff
- Cardiovascular Research Foundation, New York, NY, USA
- NewYork-Presbyterian Hospital/Columbia University Medical Center, New York, NY, USA
| | | | | | - Ori Ben-Yehuda
- Cardiovascular Research Foundation, New York, NY, USA
- NewYork-Presbyterian Hospital/Columbia University Medical Center, New York, NY, USA
| | - Philippe Pibarot
- Pulmonary Hypertension and Vascular Biology Research Group, Institut Universitaire de Cardiologie et de Pneumologie de Québec, Laval University, Québec, Québec, Canada
| | - Linda D. Gillam
- Gagnon Cardiovascular Institute, Morristown Medical Center, Morristown, NJ, USA
| | - Martin B. Leon
- Cardiovascular Research Foundation, New York, NY, USA
- NewYork-Presbyterian Hospital/Columbia University Medical Center, New York, NY, USA
| | - Philippe Généreux
- Cardiovascular Research Foundation, New York, NY, USA
- Hôpital du Sacré-Coeur de Montréal, Montréal, Québec, Canada
- Gagnon Cardiovascular Institute, Morristown Medical Center, Morristown, NJ, USA
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35
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Banovic MD. Changing concept in treatment of asymptomatic severe aortic stenosis and normal ejection fraction: time for biomarkers reappraisal. Biomark Med 2017; 11:369-376. [PMID: 28290210 DOI: 10.2217/bmm-2016-0369] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
The uncertainty of whether/how to treat asymptomatic patients with isolated severe aortic stenosis and normal left ventricular ejection fraction is one of the most topical in cardiovascular medicine. Recently, the AVATAR trial: first ever randomized trial in the setting of aortic stenosis has been started in an attempt to adequately address this 'burning issue'. In light of this fact it is important to identify biomarkers which might help in risk stratification of these patients, not only in the referring physician's office during a routine exam, but also for preoperative patients scheduled for surgical replacement/transcatheter aortic valve implantation. This report is focusing on novel laboratory parameters which might be helpful in this risk stratification.
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Affiliation(s)
- Marko D Banovic
- Cardiology Department, University Clinical Center of Serbia, Belgrade, Serbia.,Belgrade Medical School, University of Belgrade, Belgrade, Serbia
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36
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Frank J, Frey N, Frank D. Editorial commentary: High-sensitive troponin: A new tool for clinical decision-making in valvular heart disease? Trends Cardiovasc Med 2017; 27:334-335. [PMID: 28274655 DOI: 10.1016/j.tcm.2017.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2017] [Accepted: 02/03/2017] [Indexed: 10/20/2022]
Affiliation(s)
- Johanne Frank
- Department of Internal Medicine III (Cardiology and Angiology), University Hospital Schleswig-Holstein, Campus Kiel, Germany.
| | - Norbert Frey
- Department of Internal Medicine III (Cardiology and Angiology), University Hospital Schleswig-Holstein, Campus Kiel, Germany; DZHK (German Centre for Cardiovascular Research), partner site Hamburg/Kiel/Lübeck, Kiel, Germany.
| | - Derk Frank
- Department of Internal Medicine III (Cardiology and Angiology), University Hospital Schleswig-Holstein, Campus Kiel, Germany; DZHK (German Centre for Cardiovascular Research), partner site Hamburg/Kiel/Lübeck, Kiel, Germany.
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37
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Eggers KM, Lindahl B. Application of Cardiac Troponin in Cardiovascular Diseases Other Than Acute Coronary Syndrome. Clin Chem 2017; 63:223-235. [DOI: 10.1373/clinchem.2016.261495] [Citation(s) in RCA: 63] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2016] [Accepted: 07/18/2016] [Indexed: 12/13/2022]
Abstract
Abstract
BACKGROUND
Increased cardiac troponin concentrations in acute coronary syndrome (ACS) identify patients with ongoing cardiomyocyte necrosis who are at increased risk. However, with the use of more precise assays, cardiac troponin increases are commonly noted in other cardiovascular conditions as well. This has generated interest in the use of cardiac troponin for prognostic assessment and clinical management of these patients. In this review, we have summarized the data from studies investigating the implications of cardiac troponin concentrations in various acute and chronic conditions beyond ACS, i.e., heart failure, myocarditis, Takotsubo cardiomyopathy, aortic dissection, supraventricular arrhythmias, valve disease, pulmonary arterial hypertension, stroke, and in the perioperative setting.
CONTENT
Cardiac troponin concentrations are often detectable and frankly increased in non-ACS conditions, in particular when measured with high-sensitivity (hs) assays. With the exception of myocarditis and Takotsubo cardiomyopathy, cardiac troponin concentrations carry strong prognostic information, mainly with respect to mortality, or incipient and/or worsening heart failure. Studies investigating the prognostic benefit associated with cardiac troponin–guided treatments however, are almost lacking and the potential role of cardiac troponin in the management of non-ACS conditions is not defined.
SUMMARY
Increased cardiac troponin indicates increased risk for adverse outcome in patients with various cardiovascular conditions beyond ACS. Routine measurement of cardiac troponin concentrations can however, not be generally recommended unless there is a suspicion of ACS. Nonetheless, any finding of an increased cardiac troponin concentration in a patient without ACS should at least prompt the search for possible underlying conditions and these should be managed meticulously according to current guidelines to improve outcome.
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Affiliation(s)
| | - Bertil Lindahl
- Department of Medical Sciences and
- Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
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38
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Kvisvik B, Mørkrid L, Røsjø H, Cvancarova M, Rowe AD, Eek C, Bendz B, Edvardsen T, Gravning J. High-Sensitivity Troponin T vs I in Acute Coronary Syndrome: Prediction of Significant Coronary Lesions and Long-term Prognosis. Clin Chem 2016; 63:552-562. [PMID: 27974383 DOI: 10.1373/clinchem.2016.261107] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2016] [Accepted: 08/22/2016] [Indexed: 12/20/2022]
Abstract
BACKGROUND High-sensitivity cardiac troponin (hs-cTn) T and I assays are established as crucial tools for the diagnosis of acute myocardial infarction (AMI), as they have been found superior to old troponin assays. However, eventual differences between the assays in prediction of significant coronary lesions and long-term prognosis in patients with acute coronary syndrome (ACS) have not been fully unraveled. METHODS Serum concentrations of hs-cTnT (Roche), hs-cTnI (Abbott), and amino-terminal pro-B-type natriuretic peptide (NT-proBNP; Roche) in 390 non-ST-elevation (NSTE) ACS patients were evaluated in relation to significant coronary lesions on coronary angiography (defined as a stenosis >50% of the luminal diameter, with need for revascularization) and prognostic accuracy for cardiovascular mortality, all-cause mortality, as well as the composite end point of cardiovascular mortality and hospitalizations for AMI or heart failure. RESULTS The mean (SD) follow-up was 2921 (168) days. Absolute hs-cTnI concentrations were significantly higher than the hs-cTnT concentrations. The relationship between analyzed biomarkers and significant coronary lesions on coronary angiography, as quantified by the area under the ROC curve (AUC), revealed no difference between hs-cTnT [AUC, 0.81; 95% CI, 0.77-0.86] and hs-cTnI (AUC, 0.81; 95% CI, 0.76-0.86; P = NS). NT-proBNP was superior to both hs-cTn assays regarding prognostic accuracy for both cardiovascular and all-cause mortality and for the composite end point during follow-up, also in multivariate analyses. CONCLUSIONS The hs-cTnT and hs-cTnI assays displayed a similar ability to predict significant coronary lesions in NSTE-ACS patients. NT-proBNP was superior to both hs-cTn assays as a marker of long-term prognosis in this patient group.
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Affiliation(s)
- Brede Kvisvik
- Department of Cardiology, Division of Medicine, Akershus University Hospital, Lørenskog, Norway.,Center for Heart Failure Research, University of Oslo, Norway
| | - Lars Mørkrid
- Department of Medical Biochemistry, Oslo University Hospital, Rikshospitalet, and Institute for Clinical Medicine, University of Oslo, Norway
| | - Helge Røsjø
- Department of Cardiology, Division of Medicine, Akershus University Hospital, Lørenskog, Norway.,Center for Heart Failure Research, University of Oslo, Norway
| | - Milada Cvancarova
- Department of Cardiology, Division of Medicine, Akershus University Hospital, Lørenskog, Norway
| | - Alexander D Rowe
- Department of Medical Biochemistry, Oslo University Hospital, Rikshospitalet, and Institute for Clinical Medicine, University of Oslo, Norway.,Norwegian National Unit for newborn screening, Woman and Children's division, Oslo University Hospital, Rikshospitalet, Norway
| | - Christian Eek
- Department of Cardiology, Oslo University Hospital, Rikshospitalet, Norway
| | - Bjørn Bendz
- Department of Cardiology, Oslo University Hospital, Rikshospitalet, Norway
| | - Thor Edvardsen
- Center for Heart Failure Research, University of Oslo, Norway.,Department of Cardiology, Oslo University Hospital, Rikshospitalet, Norway
| | - Jørgen Gravning
- Department of Cardiology, Division of Medicine, Akershus University Hospital, Lørenskog, Norway. .,Center for Heart Failure Research, University of Oslo, Norway
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Cardinaels EPM, Altintas S, Versteylen MO, Joosen IA, Jellema LJC, Wildberger JE, Das M, Crijns HJ, Bekers O, van Dieijen-Visser MP, Kietselaer BL, Mingels AMA. High-Sensitivity Cardiac Troponin Concentrations in Patients with Chest Discomfort: Is It the Heart or the Kidneys As Well? PLoS One 2016; 11:e0153300. [PMID: 27096420 PMCID: PMC4838230 DOI: 10.1371/journal.pone.0153300] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2015] [Accepted: 03/11/2016] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND High-sensitivity cardiac troponins (hs-cTn) are the preferred biomarkers to detect myocardial injury, making them promising risk-stratifying tools for patients with symptoms of chest pain. However, circulating hs-cTn are also elevated in other conditions like renal dysfunction, complicating appropriate interpretation of low-level hs-cTn concentrations. METHODS A cross-sectional analysis was performed in 1864 patients with symptoms of chest discomfort from the cardiology outpatient department who underwent cardiac computed tomographic angiography (CCTA). Serum samples were analyzed using hs-cTnT and hs-cTnI assays. Renal function was measured by the estimated glomerular filtration rate (eGFR), established from serum creatinine and cystatin C. On follow-up, the incidence of adverse events was assessed. RESULTS Median hs-cTnT and hs-cTnI concentrations were 7.2(5.8-9.2) ng/L and 2.6(1.8-4.1) ng/L, respectively. Multivariable regression analysis revealed that both assay results were more strongly associated with eGFR (hs-cTnT:stβ:-0.290;hs-cTnI:stβ:-0.222) than with cardiac imaging parameters, such as coronary calcium score, CCTA plaque severity score and left ventricular mass (all p<0.01). Furthermore, survival analysis indicated lower relative risks in patients with normal compared to reduced renal function for hs-cTnT [HR(95%CI), 1.02(1.00-1.03) compared to 1.07(1.05-1.09)] and hs-cTnI [1.01(1.00-1.01) compared to 1.02(1.01-1.02)] (all p<0.001). CONCLUSION In patients with chest discomfort, we identified an independent influence of renal function on hs-cTn concentrations besides CAD, that affected the association of hs-cTn concentrations with adverse events. Estimating renal function is therefore warranted when interpreting baseline hs-cTn concentrations.
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Affiliation(s)
- Eline P. M. Cardinaels
- Central Diagnostic Laboratory, Department of Clinical Chemistry, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center (MUMC+), Maastricht, the Netherlands
| | - Sibel Altintas
- Department of Cardiology, CARIM, MUMC+, Maastricht, the Netherlands
| | | | - Ivo A. Joosen
- Department of Cardiology, CARIM, MUMC+, Maastricht, the Netherlands
| | - Laurens-Jan C. Jellema
- Department of Clinical Chemistry and Hematology, Gelre Hospitals, Apeldoorn, the Netherlands
| | | | - Marco Das
- Department of Radiology, CARIM, MUMC+, Maastricht, the Netherlands
| | - Harry J. Crijns
- Department of Cardiology, CARIM, MUMC+, Maastricht, the Netherlands
| | - Otto Bekers
- Central Diagnostic Laboratory, Department of Clinical Chemistry, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center (MUMC+), Maastricht, the Netherlands
| | - Marja P. van Dieijen-Visser
- Central Diagnostic Laboratory, Department of Clinical Chemistry, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center (MUMC+), Maastricht, the Netherlands
| | - Bastiaan L. Kietselaer
- Department of Cardiology, CARIM, MUMC+, Maastricht, the Netherlands
- Department of Radiology, CARIM, MUMC+, Maastricht, the Netherlands
| | - Alma M. A. Mingels
- Central Diagnostic Laboratory, Department of Clinical Chemistry, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center (MUMC+), Maastricht, the Netherlands
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40
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Martin AK, Malhotra AK, Sullivan BL, Ramakrishna H. Troponin elevations in patients with chronic cardiovascular disease: An analysis of current evidence and significance. Ann Card Anaesth 2016; 19:321-7. [PMID: 27052076 PMCID: PMC4900336 DOI: 10.4103/0971-9784.179638] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Serum troponin elevation above the 99th percentile of the upper reference limit in healthy subjects (<0.01 ng/ml measured using currently available high-sensitivity cardiac troponin laboratory assays) is required to establish the diagnosis the diagnosis of myocardial necrosis in acute cardiovascular syndromes, as well as guide prognosis and therapy. In the perioperative period, for patients with cardiac disease undergoing noncardiac surgery, it is a particularly critical biomarker universally used to assess the myocardial damage. The value of troponin testing and elevation (as well as its significance) in patients with chronic cardiac valvular, vascular, and renal disease is relatively less well understood. This evidence-based review seeks to examine the currently available data assessing the significance of troponin elevation in certain chronic valvular and other disease states.
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Affiliation(s)
| | | | | | - Harish Ramakrishna
- Division of Cardiovascular and Thoracic Anesthesiology, Mayo Clinic Arizona, AZ, USA
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Abstract
Calcific aortic stenosis (AS) is the most prevalent heart valve disorder in developed countries. It is characterized by progressive fibro-calcific remodelling and thickening of the aortic valve leaflets that, over years, evolve to cause severe obstruction to cardiac outflow. In developed countries, AS is the third-most frequent cardiovascular disease after coronary artery disease and systemic arterial hypertension, with a prevalence of 0.4% in the general population and 1.7% in the population >65 years old. Congenital abnormality (bicuspid valve) and older age are powerful risk factors for calcific AS. Metabolic syndrome and an elevated plasma level of lipoprotein(a) have also been associated with increased risk of calcific AS. The pathobiology of calcific AS is complex and involves genetic factors, lipoprotein deposition and oxidation, chronic inflammation, osteoblastic transition of cardiac valve interstitial cells and active leaflet calcification. Although no pharmacotherapy has proved to be effective in reducing the progression of AS, promising therapeutic targets include lipoprotein(a), the renin-angiotensin system, receptor activator of NF-κB ligand (RANKL; also known as TNFSF11) and ectonucleotidases. Currently, aortic valve replacement (AVR) remains the only effective treatment for severe AS. The diagnosis and staging of AS are based on the assessment of stenosis severity and left ventricular systolic function by Doppler echocardiography, and the presence of symptoms. The introduction of transcatheter AVR in the past decade has been a transformative therapeutic innovation for patients at high or prohibitive risk for surgical valve replacement, and this new technology might extend to lower-risk patients in the near future.
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Affiliation(s)
- Brian R Lindman
- Cardiovascular Division, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Marie-Annick Clavel
- Québec Heart and Lung Institute, Department of Medicine, Laval University, 2725 Chemin Sainte-Foy, Québec City, Québec G1V 4G5, Canada
| | - Patrick Mathieu
- Québec Heart and Lung Institute, Department of Medicine, Laval University, 2725 Chemin Sainte-Foy, Québec City, Québec G1V 4G5, Canada
| | - Bernard Iung
- Cardiology Department, AP-HP, Bichat Hospital, Paris, France
- Paris-Diderot University, DHU Fire, Paris, France
| | - Patrizio Lancellotti
- University of Liège Hospital, GIGA Cardiovascular Sciences, Department of Cardiology, Heart Valve Clinic and CHU Sart Tilman, Liège, Belgium
- Grupo Villa Maria Care and Research, Anthea Hospital, Bari, Italy
| | - Catherine M Otto
- Division of Cardiology, Department of Medicine, University of Washington School of Medicine, Seattle, USA
| | - Philippe Pibarot
- Québec Heart and Lung Institute, Department of Medicine, Laval University, 2725 Chemin Sainte-Foy, Québec City, Québec G1V 4G5, Canada
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Abstract
Calcified aortic stenosis is one of the most common causes of heart failure in the elderly. Current guidelines recommend aortic valve replacement in patients with severe disease and evidence of decompensation based on either symptoms or impaired systolic ejection fraction. However, symptoms are often subjective whilst impaired ejection fraction is not a sensitive marker of ventricular decompensation. Interest has surrounded the use of cardiac biochemical markers as objective measures of left ventricular decompensation in aortic stenosis. We will first examine mechanisms of release of biochemical markers associated with myocardial wall stress (BNP/NT-proBNP), myocardial fibrosis (markers of collagen metabolism, galectin-3, soluble ST2) and myocyte death/myocardial ischemia (high-sensitivity cardiac troponins, heart-type fatty acid binding protein, myosin-binding protein C); and discuss future directions of these markers.
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Affiliation(s)
- Calvin W L Chin
- a Department of Cardiovascular Medicine , National Heart Center Singapore , Singapore .,b Duke-NUS Graduate Medical School , Singapore
| | - Andie H Djohan
- c Barts and the London School of Medicine & Dentistry, Queen Mary, University of London , London , UK , and
| | - Chim C Lang
- d Division of Cardiovascular and Diabetes Medicine , University of Dundee , Dundee , UK
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43
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Koskinas KC, Stortecky S, Franzone A, O'Sullivan CJ, Praz F, Zuk K, Räber L, Pilgrim T, Moschovitis A, Fiedler GM, Jüni P, Heg D, Wenaweser P, Windecker S. Post-Procedural Troponin Elevation and Clinical Outcomes Following Transcatheter Aortic Valve Implantation. J Am Heart Assoc 2016; 5:JAHA.115.002430. [PMID: 26896474 PMCID: PMC4802442 DOI: 10.1161/jaha.115.002430] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Background Biomarkers of myocardial injury increase frequently during transcatheter aortic valve implantation (TAVI). The impact of postprocedural cardiac troponin (cTn) elevation on short‐term outcomes remains controversial, and the association with long‐term prognosis is unknown. Methods and Results We evaluated 577 consecutive patients with severe aortic stenosis treated with TAVI between 2007 and 2012. Myocardial injury, defined according to the Valve Academic Research Consortium (VARC)‐2 as post‐TAVI cardiac troponin T (cTnT) >15× the upper limit of normal, occurred in 338 patients (58.1%). In multivariate analyses, myocardial injury was associated with higher risk of all‐cause mortality at 30 days (adjusted hazard ratio [HR], 8.77; 95% CI, 2.07–37.12; P=0.003) and remained a significant predictor at 2 years (adjusted HR, 1.98; 95% CI, 1.36–2.88; P<0.001). Higher cTnT cutoffs did not add incremental predictive value compared with the VARC‐2–defined cutoff. Whereas myocardial injury occurred more frequently in patients with versus without coronary artery disease (CAD), the relative impact of cTnT elevation on 2‐year mortality did not differ between patients without CAD (adjusted HR, 2.59; 95% CI, 1.27–5.26; P=0.009) and those with CAD (adjusted HR, 1.71; 95% CI, 1.10–2.65; P=0.018; P for interaction=0.24). Mortality rates at 2 years were lowest in patients without CAD and no myocardial injury (11.6%) and highest in patients with complex CAD (SYNTAX score >22) and myocardial injury (41.1%). Conclusions VARC‐2–defined cTnT elevation emerged as a strong, independent predictor of 30‐day mortality and remained a modest, but significant, predictor throughout 2 years post‐TAVI. The prognostic value of cTnT elevation was modified by the presence and complexity of underlying CAD with highest mortality risk observed in patients combining SYNTAX score >22 and evidence of myocardial injury.
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Affiliation(s)
| | - Stefan Stortecky
- Department of Cardiology, Bern University Hospital, Bern, Switzerland
| | - Anna Franzone
- Department of Cardiology, Bern University Hospital, Bern, Switzerland
| | | | - Fabien Praz
- Department of Cardiology, Bern University Hospital, Bern, Switzerland
| | - Katazyrna Zuk
- Department of Cardiology, Bern University Hospital, Bern, Switzerland
| | - Lorenz Räber
- Department of Cardiology, Bern University Hospital, Bern, Switzerland
| | - Thomas Pilgrim
- Department of Cardiology, Bern University Hospital, Bern, Switzerland
| | - Aris Moschovitis
- Department of Cardiology, Bern University Hospital, Bern, Switzerland
| | - Georg M Fiedler
- Center for Laboratory Medicine, Inselspital, University Hospital Bern, Bern, Switzerland
| | - Peter Jüni
- Institute of Primary Health Care, University of Bern, Switzerland
| | - Dik Heg
- Institute of Social and Preventive Medicine, University of Bern, Switzerland
| | - Peter Wenaweser
- Department of Cardiology, Bern University Hospital, Bern, Switzerland
| | - Stephan Windecker
- Department of Cardiology, Bern University Hospital, Bern, Switzerland
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Høiseth AD, Brynildsen J, Hagve TA, Christensen G, Søyseth V, Omland T, Torbjørn O, Røsjø H. The influence of heart failure co-morbidity on high-sensitivity troponin T levels in COPD exacerbation in a prospective cohort study: data from the Akershus cardiac examination (ACE) 2 study. Biomarkers 2016; 21:173-9. [PMID: 26754170 DOI: 10.3109/1354750x.2015.1126645] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
CONTEXT Troponin (hs-TnT) levels predict mortality after acute exacerbation of COPD (AECOPD). Whether this is independent of heart failure (HF) is not established. MATERIAL AND METHODS Prospectively included AECOPD patients adjudicated for acute HF categorized into three groups: (A) AECOPD, but acute HF the primary cause for hospitalization; (B) AECOPD the primary cause, but co-existing myocardial dysfunction and (C) AECOPD without myocardial dysfunction. RESULTS About 103 AECOPD patients; 18% A, 27% B and 54% C. Hs-TnT level differed between the groups: (ng/l, median) A: 41, B: 25 and C: 15, p = 0.03 for A versus B and p = 0.005 for B versus C. During a median 826 days, 47% died. In Cox analysis, hs-TnT levels remained associated with mortality (hazard ratio per 10 ng/l 1.3, p < 0.0001). CONCLUSION hs-TnT levels are influenced by myocardial dysfunction/HF in AECOPD, but provide independent prognostic information. The prognostic merit of hs-TnT cannot be attributed to HF alone.
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Affiliation(s)
- Arne Didrik Høiseth
- a Division of Medicine , Akershus University Hospital , Lørenskog , Norway .,b Center for Heart Failure Research and K.G. Jebsen Cardiac Research Centre, Institute of Clinical Medicine; University of Oslo , Oslo , Norway
| | - Jon Brynildsen
- a Division of Medicine , Akershus University Hospital , Lørenskog , Norway .,b Center for Heart Failure Research and K.G. Jebsen Cardiac Research Centre, Institute of Clinical Medicine; University of Oslo , Oslo , Norway
| | - Tor-Arne Hagve
- c Division of Diagnostics and Technology , Akershus University Hospital , Lørenskog , Norway , and.,d Institute for Experimental Medical Research, Oslo University Hospital , Oslo , Norway
| | - Geir Christensen
- b Center for Heart Failure Research and K.G. Jebsen Cardiac Research Centre, Institute of Clinical Medicine; University of Oslo , Oslo , Norway
| | - Vidar Søyseth
- a Division of Medicine , Akershus University Hospital , Lørenskog , Norway .,d Institute for Experimental Medical Research, Oslo University Hospital , Oslo , Norway
| | | | - Omland Torbjørn
- a Division of Medicine , Akershus University Hospital , Lørenskog , Norway .,b Center for Heart Failure Research and K.G. Jebsen Cardiac Research Centre, Institute of Clinical Medicine; University of Oslo , Oslo , Norway
| | - Helge Røsjø
- a Division of Medicine , Akershus University Hospital , Lørenskog , Norway .,b Center for Heart Failure Research and K.G. Jebsen Cardiac Research Centre, Institute of Clinical Medicine; University of Oslo , Oslo , Norway
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45
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Mawad W, Abadir S, Fournier A, Bigras JL, Curnier D, Kadem L, Dahdah N. Timing of Dynamic NT-proBNP and hs-cTnT Response to Exercise Challenge in Asymptomatic Children with Moderate Aortic Valve Regurgitation or Moderate Aortic Valve Stenosis. Pediatr Cardiol 2015; 36:1735-41. [PMID: 26123813 DOI: 10.1007/s00246-015-1225-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2015] [Accepted: 06/16/2015] [Indexed: 10/23/2022]
Abstract
Patients with congenital aortic valve stenosis (AVS) can remain asymptomatic but may develop progressive and often underestimated exercise intolerance. The risk of increased left ventricular (LV) wall stress, irreversible myocardial fibrosis and sudden death in untreated patients warrants earlier intervention. The timing for curative therapy for severe AVS is clear, but optimal timing for moderate stenosis (modAS) is unknown. AVS often coexists with aortic regurgitation, which adds a volume overload to an already pressure-overloaded LV, adding an additional challenge to the estimation of disease severity. We investigated the possible value of N-terminal pro-brain natriuretic peptide (NT-proBNP) and high-sensitivity cardiac troponin T (hs-cTnT) upon treadmill exercise challenge in children with asymptomatic modAS versus moderate regurgitation (modAR). The aim was to determine optimal timing of peak biochemical response. Blood samples were obtained at rest, and then at 20, 40 and 60 min after peak exercise comparing modAS and modAR to healthy controls. Exercise performance was equivalent in all groups, with no difference for biomarker levels at rest. The increase in NT-proBNP was significant in modAR at 40 min (99.2 ± 48.6 ng/L; p = 0.04) and 60 min into recovery (100.0 ± 53.7 ng/L; p = 0.01), but not in modAS. The increase in hs-cTnT was significant only at 60 min into recovery for modAS and modAR. NT-proBNP and hs-cTnT following exercise challenge are possible discriminant biomarkers of modAR from modAS and controls at 60 min into recovery despite comparable exercise performance. This offers a promising avenue for future stratification of aortic valve disease and optimal timing of intervention.
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Affiliation(s)
- Wadi Mawad
- Division of Pediatric Cardiology, CHU Sainte-Justine, University of Montreal, 3175, Cote Sainte-Catherine, Montréal, QC, H3T 1C5, Canada
| | - Sylvia Abadir
- Division of Pediatric Cardiology, CHU Sainte-Justine, University of Montreal, 3175, Cote Sainte-Catherine, Montréal, QC, H3T 1C5, Canada
| | - Anne Fournier
- Division of Pediatric Cardiology, CHU Sainte-Justine, University of Montreal, 3175, Cote Sainte-Catherine, Montréal, QC, H3T 1C5, Canada
| | - Jean-Luc Bigras
- Division of Pediatric Cardiology, CHU Sainte-Justine, University of Montreal, 3175, Cote Sainte-Catherine, Montréal, QC, H3T 1C5, Canada
| | - Daniel Curnier
- Department of Kinesiology, University of Montréal, Montréal, Canada
| | - Lyes Kadem
- Mechanical and Industrial Engineering Department, Concordia University, Montréal, QC, Canada
| | - Nagib Dahdah
- Division of Pediatric Cardiology, CHU Sainte-Justine, University of Montreal, 3175, Cote Sainte-Catherine, Montréal, QC, H3T 1C5, Canada.
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Agrawal S, Van Eyk J, Sobhani K, Wei J, Bairey Merz CN. Sex, Myocardial Infarction, and the Failure of Risk Scores in Women. J Womens Health (Larchmt) 2015; 24:859-61. [PMID: 26288193 DOI: 10.1089/jwh.2015.5412] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Affiliation(s)
- Shilpa Agrawal
- 1 David Geffen School of Medicine, University of California Los Angeles , Los Angeles, California
| | - Jennifer Van Eyk
- 2 Barbra Streisand Women's Heart Center, Cedars-Sinai Heart Institute , Cedars-Sinai Medical Center, Los Angeles, California
| | - Kimia Sobhani
- 3 Pathology and Laboratory Medicine, Cedars-Sinai Heart Institute , Cedars-Sinai Medical Center, Los Angeles, California
| | - Janet Wei
- 1 David Geffen School of Medicine, University of California Los Angeles , Los Angeles, California
| | - C Noel Bairey Merz
- 2 Barbra Streisand Women's Heart Center, Cedars-Sinai Heart Institute , Cedars-Sinai Medical Center, Los Angeles, California
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47
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Maznyczka A, Kaier T, Marber M. Troponins and other biomarkers in the early diagnosis of acute myocardial infarction. Postgrad Med J 2015; 91:322-30. [DOI: 10.1136/postgradmedj-2014-133129] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2014] [Accepted: 05/08/2015] [Indexed: 12/24/2022]
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Biomarkers in Cardiology - Part 2: In Coronary Heart Disease, Valve Disease and Special Situations. Arq Bras Cardiol 2015; 104:337-46. [PMID: 26083777 PMCID: PMC4495448 DOI: 10.5935/abc.20150061] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2014] [Accepted: 01/01/2015] [Indexed: 01/25/2023] Open
Abstract
Cardiovascular diseases are the main causes of mortality and morbidity in Brazil.
Their primary and secondary preventions are a priority for the health system and
require multiple approaches for increased effectiveness. Biomarkers are tools used to
identify with greater accuracy high-risk individuals, establish a faster diagnosis,
guide treatment, and determine prognosis. This review aims to highlight the
importance of biomarkers in clinical cardiology practice and raise relevant points
regarding their application and perspectives for the next few years. This document
was divided into two parts. This second part addresses the application of biomarkers
in coronary heart disease, valvular diseases, cardio-oncology, pulmonary embolism,
and cardiorenal syndrome.
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49
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Omland T, de Lemos JA, Holmen OL, Dalen H, Benth JŠ, Nygård S, Hveem K, Røsjø H. Impact of Sex on the Prognostic Value of High-Sensitivity Cardiac Troponin I in the General Population: The HUNT Study. Clin Chem 2015; 61:646-56. [DOI: 10.1373/clinchem.2014.234369] [Citation(s) in RCA: 74] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
Abstract
BACKGROUND
A new, high-sensitivity assay for cardiac troponin I (hs-cTnI) permits evaluation of the prognostic value of cardiac troponins within the reference interval. Men have higher hs-cTnI concentrations than women, but the underlying pathophysiological mechanisms and prognostic implications are unclear. The aim of this study was to assess the potential impact of sex on the association between hs-cTnI and cardiovascular death.
METHODS
By use of the Architect STAT High-Sensitive Troponin assay, we measured hs-cTnI in 4431 men and 5281 women aged ≥20 years participating in the prospective observational Nord-Trøndelag Health Study (HUNT).
RESULTS
hs-cTnI was detectable in 98.5% of men and 94.7% of women. During a mean follow-up period of 13.9 years, 708 cardiovascular deaths were registered. hs-cTnI was associated with the incidence of cardiovascular death [adjusted hazard ratio (HR) per 1 SD in log hs-cTnI 1.23 (95% CI 1.15–1.31)], with higher relative risk in women than men [HR 1.44 (1.31–1.58) vs 1.10 (1.00–1.20); Pinteraction < 0.001]. This finding was mediated by both lower risk associated with low hs-cTnI concentrations in women than in men and higher risk associated with high concentrations of hs-cTnI in women than in men. Male sex was associated with a higher risk of cardiovascular death [HR 1.28 (1.11–1.49)], but after adjustment for hs-cTnI, this association disappeared [HR 0.87 (0.75–1.02)].
CONCLUSIONS
The prognostic value of hs-cTnI concentrations in the general population is stronger in women than in men. Subtle impairment of cardiovascular status may contribute to higher hs-cTnI concentrations in men, reflecting sex-dependent differences in cardiovascular risk.
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Affiliation(s)
- Torbjørn Omland
- Division of Medicine and
- Center for Heart Failure Research and K.G. Jebsen Cardiac Research Centre and
| | - James A de Lemos
- Division of Cardiology, University of Texas Southwestern Medical Center, Dallas, TX
| | - Oddgeir L Holmen
- HUNT Research Centre, Department of Public Health and General Practice, Norwegian University of Science and Technology, Levanger, Norway
| | - Håvard Dalen
- Department of Medicine, Levanger Hospital, Nord-Trøndelag Health Trust, Levanger, Norway
- MI Laboratory and Department of Circulation and Medical Imaging, Norwegian University of Science and Technology, Trondheim, Norway
| | - Jūratė Šaltytė Benth
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- HØKH Research Centre, Akershus University Hospital, Lørenskog, Norway
| | - Ståle Nygård
- Center for Heart Failure Research and K.G. Jebsen Cardiac Research Centre and
- Institute for Experimental Medical Research and
- Bioinformatics Core Facility, Institute for Medical Informatics, Oslo University Hospital and University of Oslo, Oslo, Norway
| | - Kristian Hveem
- HUNT Research Centre, Department of Public Health and General Practice, Norwegian University of Science and Technology, Levanger, Norway
| | - Helge Røsjø
- Division of Medicine and
- Center for Heart Failure Research and K.G. Jebsen Cardiac Research Centre and
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50
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Fernández‐Jiménez R, Silva J, Martínez‐Martínez S, López‐Maderuelo MD, Nuno‐Ayala M, García‐Ruiz JM, García‐Álvarez A, Fernández‐Friera L, Pizarro TG, García‐Prieto J, Sanz‐Rosa D, López‐Martin G, Fernández‐Ortiz A, Macaya C, Fuster V, Redondo JM, Ibanez B. Impact of left ventricular hypertrophy on troponin release during acute myocardial infarction: new insights from a comprehensive translational study. J Am Heart Assoc 2015; 4:e001218. [PMID: 25609414 PMCID: PMC4330053 DOI: 10.1161/jaha.114.001218] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2014] [Accepted: 11/16/2014] [Indexed: 12/29/2022]
Abstract
BACKGROUND Biomarkers are frequently used to estimate infarct size (IS) as an endpoint in experimental and clinical studies. Here, we prospectively studied the impact of left ventricular (LV) hypertrophy (LVH) on biomarker release in clinical and experimental myocardial infarction (MI). METHODS AND RESULTS ST-segment elevation myocardial infarction (STEMI) patients (n=140) were monitored for total creatine kinase (CK) and cardiac troponin I (cTnI) over 72 hours postinfarction and were examined by cardiac magnetic resonance (CMR) at 1 week and 6 months postinfarction. MI was generated in pigs with induced LVH (n=10) and in sham-operated pigs (n=8), and serial total CK and cTnI measurements were performed and CMR scans conducted at 7 days postinfarction. Regression analysis was used to study the influence of LVH on total CK and cTnI release and IS estimated by CMR (gold standard). Receiver operating characteristic (ROC) curve analysis was performed to study the discriminatory capacity of the area under the curve (AUC) of cTnI and total CK in predicting LV dysfunction. Cardiomyocyte cTnI expression was quantified in myocardial sections from LVH and sham-operated pigs. In both the clinical and experimental studies, LVH was associated with significantly higher peak and AUC of cTnI, but not with differences in total CK. ROC curves showed that the discriminatory capacity of AUC of cTnI to predict LV dysfunction was significantly worse for patients with LVH. LVH did not affect the capacity of total CK to estimate IS or LV dysfunction. Immunofluorescence analysis revealed significantly higher cTnI content in hypertrophic cardiomyocytes. CONCLUSIONS Peak and AUC of cTnI both significantly overestimate IS in the presence of LVH, owing to the higher troponin content per cardiomyocyte. In the setting of LVH, cTnI release during STEMI poorly predicts postinfarction LV dysfunction. LV mass should be taken into consideration when IS or LV function are estimated by troponin release.
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Affiliation(s)
- Rodrigo Fernández‐Jiménez
- Centro Nacional de Investigaciones Cardiovasculares Carlos III (CNIC), Madrid, Spain (R.F.J., S.M.M., D.M., M.N.A., J.M.G.R., A.G., L.F.F., T.G.P., J.G.P., D.S.R., G.M., V.F., J.M.R., B.I.)
- Hospital Universitario Clínico San Carlos, Madrid, Spain (R.F.J., J.S., A.F.O., C.M., B.I.)
| | - Jacobo Silva
- Hospital Universitario Clínico San Carlos, Madrid, Spain (R.F.J., J.S., A.F.O., C.M., B.I.)
| | - Sara Martínez‐Martínez
- Centro Nacional de Investigaciones Cardiovasculares Carlos III (CNIC), Madrid, Spain (R.F.J., S.M.M., D.M., M.N.A., J.M.G.R., A.G., L.F.F., T.G.P., J.G.P., D.S.R., G.M., V.F., J.M.R., B.I.)
| | - Mª Dolores López‐Maderuelo
- Centro Nacional de Investigaciones Cardiovasculares Carlos III (CNIC), Madrid, Spain (R.F.J., S.M.M., D.M., M.N.A., J.M.G.R., A.G., L.F.F., T.G.P., J.G.P., D.S.R., G.M., V.F., J.M.R., B.I.)
| | - Mario Nuno‐Ayala
- Centro Nacional de Investigaciones Cardiovasculares Carlos III (CNIC), Madrid, Spain (R.F.J., S.M.M., D.M., M.N.A., J.M.G.R., A.G., L.F.F., T.G.P., J.G.P., D.S.R., G.M., V.F., J.M.R., B.I.)
| | - José Manuel García‐Ruiz
- Centro Nacional de Investigaciones Cardiovasculares Carlos III (CNIC), Madrid, Spain (R.F.J., S.M.M., D.M., M.N.A., J.M.G.R., A.G., L.F.F., T.G.P., J.G.P., D.S.R., G.M., V.F., J.M.R., B.I.)
- Hospital Universitario Central de Asturias, Oviedo, Spain (J.M.G.R.)
| | - Ana García‐Álvarez
- Centro Nacional de Investigaciones Cardiovasculares Carlos III (CNIC), Madrid, Spain (R.F.J., S.M.M., D.M., M.N.A., J.M.G.R., A.G., L.F.F., T.G.P., J.G.P., D.S.R., G.M., V.F., J.M.R., B.I.)
- Hospital Clinic, Barcelona, Spain (A.G.)
| | - Leticia Fernández‐Friera
- Centro Nacional de Investigaciones Cardiovasculares Carlos III (CNIC), Madrid, Spain (R.F.J., S.M.M., D.M., M.N.A., J.M.G.R., A.G., L.F.F., T.G.P., J.G.P., D.S.R., G.M., V.F., J.M.R., B.I.)
- Hospital Universitario Montepríncipe, Madrid, Spain (L.F.F.)
| | - Tech Gonzalo Pizarro
- Centro Nacional de Investigaciones Cardiovasculares Carlos III (CNIC), Madrid, Spain (R.F.J., S.M.M., D.M., M.N.A., J.M.G.R., A.G., L.F.F., T.G.P., J.G.P., D.S.R., G.M., V.F., J.M.R., B.I.)
- Hospital Universitario Quirón Madrid UEM, Madrid, Spain (T.G.P.)
| | - Jaime García‐Prieto
- Centro Nacional de Investigaciones Cardiovasculares Carlos III (CNIC), Madrid, Spain (R.F.J., S.M.M., D.M., M.N.A., J.M.G.R., A.G., L.F.F., T.G.P., J.G.P., D.S.R., G.M., V.F., J.M.R., B.I.)
| | - David Sanz‐Rosa
- Centro Nacional de Investigaciones Cardiovasculares Carlos III (CNIC), Madrid, Spain (R.F.J., S.M.M., D.M., M.N.A., J.M.G.R., A.G., L.F.F., T.G.P., J.G.P., D.S.R., G.M., V.F., J.M.R., B.I.)
| | - Gonzalo López‐Martin
- Centro Nacional de Investigaciones Cardiovasculares Carlos III (CNIC), Madrid, Spain (R.F.J., S.M.M., D.M., M.N.A., J.M.G.R., A.G., L.F.F., T.G.P., J.G.P., D.S.R., G.M., V.F., J.M.R., B.I.)
| | | | - Carlos Macaya
- Hospital Universitario Clínico San Carlos, Madrid, Spain (R.F.J., J.S., A.F.O., C.M., B.I.)
| | - Valentin Fuster
- Centro Nacional de Investigaciones Cardiovasculares Carlos III (CNIC), Madrid, Spain (R.F.J., S.M.M., D.M., M.N.A., J.M.G.R., A.G., L.F.F., T.G.P., J.G.P., D.S.R., G.M., V.F., J.M.R., B.I.)
- The Zena and Michael A. Wiener CVI, Mount Sinai School of Medicine, New York, NY (V.F.)
| | - Juan Miguel Redondo
- Centro Nacional de Investigaciones Cardiovasculares Carlos III (CNIC), Madrid, Spain (R.F.J., S.M.M., D.M., M.N.A., J.M.G.R., A.G., L.F.F., T.G.P., J.G.P., D.S.R., G.M., V.F., J.M.R., B.I.)
| | - Borja Ibanez
- Centro Nacional de Investigaciones Cardiovasculares Carlos III (CNIC), Madrid, Spain (R.F.J., S.M.M., D.M., M.N.A., J.M.G.R., A.G., L.F.F., T.G.P., J.G.P., D.S.R., G.M., V.F., J.M.R., B.I.)
- Hospital Universitario Clínico San Carlos, Madrid, Spain (R.F.J., J.S., A.F.O., C.M., B.I.)
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