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Collinson P, Hammerer-Lercher A, Aakre KM, Gruson D, Suvisaari J, Pulkki K, Stankovic S, Baum H, Lowry MT, Mills NL, Laitinen P. Implementation of high sensitivity troponin into routine clinical practice - results of the extended CARdiac MArkers guideline uptake in Europe group (CARMAGUE) survey. Clin Chim Acta 2024; 558:117900. [PMID: 38580139 DOI: 10.1016/j.cca.2024.117900] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2024] [Revised: 04/02/2024] [Accepted: 04/02/2024] [Indexed: 04/07/2024]
Abstract
BACKGROUND Measurement of cardiac troponin (cTn) by a high sensitivity method is now the recommended strategy for the detection of myocardial injury. An international survey was undertaken to assess how this has been implemented. METHODS A questionnaire based around 14 domains on cardiac biomarkers was distributed electronically with the aid of professional societies accessed by a web link within the invitation. Results were returned electronically then extracted into a relational database for analysis. RESULTS Responses were obtained from 663 laboratories across 76 countries ranging from 1 to 69 largest country. The majority of responses (79.6%) came from the European area. Responses were grouped into broad geographic areas for analysis. Most responses came from hospitals providing a local and regional service of which the majority provided angioplasty. cTn measurement was the dominant biomarker. The majority of laboratories include creatine kinase (CK) in their cardiac profile and approximately 50% also offer the MB isoenzyme of CK. The majority of laboratories (91.9%) measure cTn by a high sensitivity method. Sex specific reference ranges were typically implemented for cardiac troponin I but not for cardiac troponin T. The preferred unit of measurement was nanograms/L. A structured decision-making pathway utilising high sensitivity cTn measurement was used by 83.3% of laboratories who responded. Single sample rule out is common but the majority used serial sampling strategy based on measurement on admission and three hours. CONCLUSIONS Measurement of cTn by a high sensitivity method is now well established internationally, the use of rapid diagnostic protocols lags behind.
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Affiliation(s)
| | | | - Kristin M Aakre
- Department of Medical Biochemistry and Pharmacology and Department of Heart Disease, Haukeland University Hospital, Bergen, Norway; Department of Clinical Science, University of Bergen, Bergen, Norway.
| | - Damien Gruson
- Department of Clinical Biochemistry, Cliniques Universitaires St-Luc and Universite Catholique de Louvain, Brussels, Belgium.
| | - Janne Suvisaari
- Clinical Chemistry, HUS Diagnostic Center, University of Helsinki and Helsinki University Hospital, Helsinki, Finland.
| | - Kari Pulkki
- Clinical Chemistry, HUS Diagnostic Center, University of Helsinki and Helsinki University Hospital, Helsinki, Finland.
| | - Sanja Stankovic
- Center for Medical Biochemistry, University Clinical Center of Serbia, Belgrade, Serbia; Faculty of Medical Sciences University of Kragujevac, Kragujevac, Serbia.
| | - Hansjorg Baum
- Institute for Laboratory Medicine and Transfusion Medicine, Regionale Kliniken Holding RKH GmbH, Ludwigsburg, Germany.
| | - Matthew T Lowry
- Centre for Cardiovascular Sciences, University of Edinburgh, Edinburgh, United Kingdom.
| | - Nicholas L Mills
- Centre for Cardiovascular Sciences, University of Edinburgh, Edinburgh, United Kingdom; Usher Institute, University of Edinburgh, Edinburgh, United Kingdom.
| | - Paivi Laitinen
- Clinical Chemistry, HUS Diagnostic Center, University of Helsinki and Helsinki University Hospital, Helsinki, Finland.
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Collinson P, Aakre KM, Saenger A, Body R, Hammarsten O, Jaffe AS, Kavsak P, Omland T, Ordonez-Lianos J, Karon B, Apple FS. Cardiac troponin measurement at the point of care: educational recommendations on analytical and clinical aspects by the IFCC Committee on Clinical Applications of Cardiac Bio-Markers (IFCC C-CB). Clin Chem Lab Med 2023; 61:989-998. [PMID: 36637984 DOI: 10.1515/cclm-2022-1270] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Accepted: 12/16/2022] [Indexed: 01/14/2023]
Abstract
The International Federation of Clinical Chemistry and Laboarator Medicine (IFCC) Committee on Clinical Applications of Cardiac Bio-Markers (C-CB) has provided evidence-based educational resources to aid and improve the understanding of important analytical and clinical aspects of cardiac biomarkers. The present IFCC C-CB educational report focuses on recommendations for appropriate use, analytical performance, and gaps in clinical studies related to the use of cardiac troponin (cTn) by point of care (POC) measurement, often referred to as a point of care testing (POCT). The use of high-sensitivity (hs)-cTn POC devices in accelerated diagnostic protocols used in emergency departments or outpatient clinics investigating acute coronary syndrome has the potential for improved efficacy, reduction of length of stay and reduced costs in the health care system. POCT workflow integration includes location of the instrument, assignment of collection and testing responsibility to (non-lab) staff, instrument maintenance, in-service and recurrent training, quality control, proficiency assessments, discrepant result trapping, and troubleshooting and inventory management.
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Affiliation(s)
- Paul Collinson
- Departments of Clinical Blood Sciences and Cardiology, St George's University Hospitals NHS Foundation Trust, London, UK.,St George's University of London, London, UK
| | - Kristin M Aakre
- Department of Medical Biochemistry and Pharmacology and Department of Heart Disease, Haukeland University Hospital, Bergen, Norway.,Department of Clinical Science, University of Bergen, Bergen, Norway
| | - Amy Saenger
- Department of Laboratory Medicine and Pathology, Hennepin Healthcare/HCMC, Minneapolis, MN, USA.,Department of Laboratory Medicine and Pathology, University of Minnesota, Minneapolis, MN, USA
| | - Rick Body
- Emergency Department, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK.,Division of Cardiovascular Sciences, The University of Manchester, Manchester, UK.,Healthcare Sciences Department, Manchester Metropolitan University, Manchester, UK
| | - Ole Hammarsten
- Department of Clinical Chemistry and Transfusion Medicine, University of Gothenburg, Gothenburg, Sweden
| | - Allan S Jaffe
- Departments of Laboratory Medicine and Pathology and Cardiology, Mayo Clinic, Rochester, MN, USA
| | - Pete Kavsak
- Department of Pathology and Molecular Medicine, McMaster University, Hamilton, ON, Canada
| | - Torbjørn Omland
- Department of Cardiology, Akershus University Hospital, Lørenskog, Norway.,Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Jordi Ordonez-Lianos
- Servicio de Bioquímica Clínica, Institut d'Investigacions Biomèdiques Sant Pau, Barcelona, Spain.,Departamento de Bioquímica y Biología Molecular, Universidad Autònoma de Barcelona, Barcelona, Spain
| | - Brad Karon
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | - Fred S Apple
- Department of Laboratory Medicine and Pathology, Hennepin Healthcare/HCMC, Minneapolis, MN, USA.,Department of Laboratory Medicine and Pathology, University of Minnesota, Minneapolis, MN, USA
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Collinson P, Dakshi A, Khand A. Rapid diagnostic strategies using high sensitivity troponin assays: what is the evidence and how should they be implemented? Ann Clin Biochem 2023; 60:37-45. [PMID: 35491935 DOI: 10.1177/00045632221100347] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
The introduction of high sensitivity measurement of cardiac troponin T (hs cTnT) and cardiac troponin I (hs cTnI) has given the laboratory the ability to measure very low levels of cardiac troponin. The limit of detection of these assays is well below the 99th percentile. These low levels can also be measured with small values of imprecision. A range of algorithms combining presentation measurement with repeat sample intervals of as little as one to 2 hours have been developed. These are able to predict with acceptable accuracy the diagnosis that would be achieved with continued repeat sampling out to six to 12 hours from presentation. In this article, we review the evidence for the diagnostic accuracy of these approaches and the practical aspects of implementation into routine clinical practice.
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Affiliation(s)
- Paul Collinson
- Departments of Clinical Blood Sciences and Cardiology, 4968St George's University Hospitals NHS Foundation Trust and St George's University of London, London, UK
| | - Ahmed Dakshi
- 4595Liverpool University Hospital NHS Foundation Trust, Liverpool, UK
| | - Aleem Khand
- 4595Liverpool University Hospital NHS Foundation Trust, Liverpool, UK
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Evaluation of the Practice Guideline Used for Rule-Out of Myocardial Infarction at a Tertiary Cardiology Center. Crit Pathw Cardiol 2022; 21:183-190. [PMID: 36413397 DOI: 10.1097/hpc.0000000000000300] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
INTRODUCTION With the current high burden on the healthcare system and limited resources, the efficient utilization of facilities is of utmost importance. We sought to present the practice guideline used at a high prevalence tertiary cardiology center and compare its safety and efficacy performance with the single high-sensitivity cardiac troponin T strategy, conventional and modified HEART score. METHODS In this prospective cohort study, consecutive patients presenting to the emergency department with chest pain or an angina equivalent were recruited. The primary endpoints consisted of major adverse cardiac events at index visits and 30-day follow-up. Patients were managed according to the practice guideline, and sensitivity and negative predictive values were compared. RESULTS Of the total 1548 patients, the mean age was 50.4 ± 15.7 years. Ninety-nine (10.9%) patients were admitted at the index visit, and 89 patients were consequently diagnosed with acute coronary symptoms. Six (0.007%) patients experienced major adverse cardiac events within the 30-day follow-up among discharged patients. Among 911 patients with at least 1 troponin, using single high-sensitivity cardiac troponin T, HEART score, and modified HEART score would have further admitted 805, 450, and 609 patients, respectively. The negative predictive value for all 4 algorithms did not significantly differ (99.2% vs. 100% vs. 99.3% vs. 99.6%, respectively). CONCLUSIONS The Tehran Herat Center protocol was a relatively safe protocol with high efficacy. Despite the high safety of the other diagnostic pathways, the high volume of patients needing additional evaluation could impose a high burden on the health care system.
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Kanani F, Zubairi AM, Zubairy M, Maqsood S. High-Sensitivity Cardiac Troponin I Levels Below 99th Percentile Upper Reference Limit in Patients Presenting with Suspicion of Acute Coronary Syndrome (ACS) in Emergency Department at a Tertiary Care Hospital in Karachi, Pakistan. High Blood Press Cardiovasc Prev 2022; 29:445-450. [PMID: 35767149 DOI: 10.1007/s40292-022-00532-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Accepted: 06/13/2022] [Indexed: 11/26/2022] Open
Abstract
INTRODUCTION Troponin I levels are biomarkers of choice for diagnosis of acute myocardial infarction (AMI). However, prognostic significance of values below the 99th percentile upper reference limit (URL) in patients presenting with symptoms suggestive of Acute coronary syndrome (ACS) need further evaluation. AIM The objectives of the study were to find the association of High sensitivity (hs)-Troponin I values below 99th percentile URL with age and the Emergency Department (ED) outcome, to determine single cut-off for safe discharge of these patients from the ED and to determine the 30-day outcome of the patients admitted under cardiac speciality. METHODS This is a retrospective study of patients presenting with suspicion of ACS in the ED between January 2019 till April 2021 and hs-Troponin I values below 99th percentile URL. RESULTS Among 15,441 patients, 8034 (52%) were males and 7407 (48%) were females. 9677 (63%) of the patients had hs-Troponin I values < 5 ng/L while 5764 (37%) had values between 5 ng/L and 99th percentile URL. Higher hs-Troponin I values were associated with a worse ED outcome. Serial troponin I levels were performed in only 2.4% of the cohort. Receiver operating characteristics for ACS demonstrated an AUC of 0.84 at a cut off value of 12.75 ng/L, with sensitivity (76.9%) and specificity was 75.1%. The 30-day outcome of the patients admitted under cardiac speciality revealed no mortality in either group. CONCLUSION An overall single cut-off value of 12.75 ng/L can be used in our population for ruling our ACS provided it is unaccompanied by other supportive clinical and ECG findings.
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Affiliation(s)
- Fatima Kanani
- Chemical Pathology Section, Department of Pathology, Indus Hospital and Health Network, Opposite Darussalam Society, Korangi Crossing, Karachi, 75190, Pakistan.
| | - Adnan M Zubairi
- Chemical Pathology Section, Department of Pathology, Indus Hospital and Health Network, Opposite Darussalam Society, Korangi Crossing, Karachi, 75190, Pakistan
| | - Maliha Zubairy
- Chemical Pathology Section, Department of Pathology, Indus Hospital and Health Network, Opposite Darussalam Society, Korangi Crossing, Karachi, 75190, Pakistan
| | - Sidra Maqsood
- Indus Hospital Research Centre, Indus Hospital and Health Network, Karachi, Pakistan
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Wyatt L, Kamat G, Moyer J, Weaver AM, Diaz-Sanchez D, Devlin RB, Di Q, Schwartz JD, Cascio WE, Ward-Caviness CK. Associations between short-term exposure to PM 2.5 and cardiomyocyte injury in myocardial infarction survivors in North Carolina. Open Heart 2022; 9:openhrt-2021-001891. [PMID: 35750420 PMCID: PMC9234784 DOI: 10.1136/openhrt-2021-001891] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Accepted: 05/23/2022] [Indexed: 12/20/2022] Open
Abstract
Objective Short-term ambient fine particulate matter (PM2.5) is associated with adverse cardiovascular events including myocardial infarction (MI). However, few studies have examined associations between PM2.5 and subclinical cardiomyocyte damage outside of overt cardiovascular events. Here we evaluate the impact of daily PM2.5 on cardiac troponin I, a cardiomyocyte specific biomarker of cellular damage. Methods We conducted a retrospective cohort study of 2924 patients identified using electronic health records from the University of North Carolina Healthcare System who had a recorded MI between 2004 and 2016. Troponin I measurements were available from 2014 to 2016, and were required to be at least 1 week away from a clinically diagnosed MI. Daily ambient PM2.5 concentrations were estimated at 1 km resolution and assigned to patient residence. Associations between log-transformed troponin I and daily PM2.5 were evaluated using distributed lag linear mixed effects models adjusted for patient demographics, socioeconomic status and meteorology. Results A 10 µg/m3 elevation in PM2.5 3 days before troponin I measurement was associated with 0.06 ng/mL higher troponin I (95% CI=0.004 to 0.12). In stratified models, this association was strongest in patients that were men, white and living in less urban areas. Similar associations were observed when using 2-day rolling averages and were consistently strongest when using the average exposure over the 5 days prior to troponin I measurement. Conclusions Daily elevations in PM2.5 were associated with damage to cardiomyocytes, outside of the occurrence of an MI. Poor air quality may cause persistent damage to the cardiovascular system leading to increased risk of cardiovascular disease and adverse cardiovascular events.
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Affiliation(s)
- Lauren Wyatt
- Center for Public Health and Environmental Assessment, US Environmental Protection Agency Center for Public Health and Environmental Assessment, Research Triangle Park, North Carolina, USA
| | - Gauri Kamat
- Brown University, Providence, Rhode Island, USA
| | - Joshua Moyer
- US Environmental Protection Agency Center for Public Health and Environmental Assessment, Research Triangle Park, North Carolina, USA
| | - Anne M Weaver
- US Environmental Protection Agency Center for Public Health and Environmental Assessment, Research Triangle Park, North Carolina, USA
| | - David Diaz-Sanchez
- US Environmental Protection Agency Center for Public Health and Environmental Assessment, Research Triangle Park, North Carolina, USA
| | - Robert B Devlin
- US Environmental Protection Agency Center for Public Health and Environmental Assessment, Research Triangle Park, North Carolina, USA
| | - Qian Di
- Vanke School of Public Health, Tsinghua University, Beijing, China
| | - Joel D Schwartz
- Harvard T.H. Chan School of Public Health, Department of Environmental Health, Harvard University, Boston, Massachusetts, USA
| | - Wayne E Cascio
- US Environmental Protection Agency Center for Public Health and Environmental Assessment, Research Triangle Park, North Carolina, USA
| | - Cavin K Ward-Caviness
- US Environmental Protection Agency Center for Public Health and Environmental Assessment, Research Triangle Park, North Carolina, USA
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Berezin AE, Berezin AA. Point-of-care heart failure platform: where are we now and where are we going to? Expert Rev Cardiovasc Ther 2022; 20:419-429. [PMID: 35588730 DOI: 10.1080/14779072.2022.2080657] [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: 10/18/2022]
Abstract
INTRODUCTION Heart failure (HF) remains a leading cause of cardiovascular (CV) mortality in patients with CV disease. The point-of-care (POC) HF platform seems to be an ideal non-invasive workflow-adapted system for personally adjusted management of patients with HF. AREAS COVERED In the present manuscript, we reviewed the literature covering some relevant studies regarding the role of point-of care heart failure platform in the risk stratification, earlier diagnosis and prognostically beneficial treatment of patients with different phenotypes of HF. EXPERT OPINION POC HF platform including personal consultation, optimization of the comorbidity treatment, step-by-step HF diagnostic algorithm, single biomarker measurements, has also partially been provided in the current guidelines. Although there are several obstacles to implement POC in routine practice, such as education level, aging, affordability of health care, even partial implementation of POC can also improve clinical outcomes. POC seems to be an evolving model, more research studies are required to clearly see whether it helps to make better decisions with diagnosis and care of HF, as well helps to achieve better clinical outcomes.In summary, the POC HF platform is considered to be a more effective tool than conventional algorithm of HF management.
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Affiliation(s)
- Alexander E Berezin
- Internal Medicine Department, Zaporozhye State Medical University, 26, Mayakovsky av., Zaporozhye, Ukraine
| | - Alexander A Berezin
- Internal Medicine Department, Zaporozhye Medical Academy of Postgraduate Education, Zaporozhye, Ukraine
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van den Berg P, Collinson P, Morris N, Body R. Diagnostic accuracy of a high-sensitivity troponin I assay and external validation of 0/3 h rule out strategies. EUROPEAN HEART JOURNAL. ACUTE CARDIOVASCULAR CARE 2022; 11:127-136. [PMID: 35136994 DOI: 10.1093/ehjacc/zuab102] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Revised: 10/06/2021] [Accepted: 10/26/2021] [Indexed: 06/14/2023]
Abstract
AIMS The timely diagnosis and exclusion of acute coronary syndromes in the Emergency Department (ED) remains a challenge. This study aims to evaluate the diagnostic accuracy of a high-sensitivity cardiac troponin I assay (Siemens TNIH) on serial sampling for ED patients as standalone test and in rule-out algorithms as recommendations remain assay specific. METHODS AND RESULTS This secondary analysis from a prospective diagnostic accuracy study at 14 centres included ED patients presenting with chest pain of suspected cardiac nature. Serum drawn on arrival and 3 h later was batchtested for TNIH. The target condition was an adjudicated diagnosis of acute myocardial infarction (AMI). We evaluated the diagnostic accuracy of absolute and relative delta criteria and four rule-out strategies. Of 802 included patients, 13.8% had AMI. Absolute delta criteria had superior accuracy to relative criteria (C-statistic 0.94 vs. 0.76, P < 0.001). However, no delta criteria achieved >95.5% sensitivity for AMI when used alone. Ruling out AMI with TNIH below the 99th percentile at 0 and 3 h had 88.3% (95% confidence interval 80.8-93.6%) sensitivity. The adapted European Society of Cardiology (ESC) 0/2 h algorithm had higher sensitivity (98.2%) than both High-STEACS (93.7%, P = 0.03) and the ESC 0/3 h algorithm (79.3%, P < 0.001). These pathways ruled out 63%, 74%, and 88% patients, respectively. CONCLUSION With serial sampling over 3 h, the Siemens TNIH assay should be used with a validated algorithm incorporating bespoke cut-offs and absolute delta criteria. In our analysis, the adapted ESC 0/2 h algorithm had greatest sensitivity. 'Ruling out' AMI using the 99th percentile of the assay cannot be recommended.
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Affiliation(s)
- Patricia van den Berg
- Manchester University NHS Foundation Trust, Oxford Road, Manchester M13 9WL, UK
- Division of Cardiovascular Science, The University of Manchester, Oxford Road, Manchester M13 9PL, UK
| | - Paul Collinson
- St George's University Hospitals NHS Foundation Trust and St Georges University of London, Cranmer Terrace, London SW17 0QT, UK
| | - Niall Morris
- Manchester University NHS Foundation Trust, Oxford Road, Manchester M13 9WL, UK
- Division of Cardiovascular Science, The University of Manchester, Oxford Road, Manchester M13 9PL, UK
| | - Richard Body
- Manchester University NHS Foundation Trust, Oxford Road, Manchester M13 9WL, UK
- Division of Cardiovascular Science, The University of Manchester, Oxford Road, Manchester M13 9PL, UK
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Zhang X, Zheng Y, Geng C, Guan J, Wang L, Zhang X, Cheng Y, Li J, Lu X. Isometric exercise promotes arteriogenesis in rats after myocardial infarction. J Biomed Res 2021; 35:436-447. [PMID: 34776455 PMCID: PMC8637657 DOI: 10.7555/jbr.35.20210062] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Isometric exercise (IE) is a promising intervention of noninvasive revascularization in patients with acute myocardial infarction (AMI). This study aimed to investigate the impact and mechanisms of IE training on arteriogenesis in AMI. Male Sprague-Dawley rats were randomly assigned into the sham-operation group (SO), myocardial infarction (MI) group, and 13 IE subgroups treated according to training intensity, frequency, duration, or monocyte chemoattractant protein-1 (MCP-1), or/and fibroblast growth factor-2 (FGF-2) inhibitors for eight weeks. Our results demonstrated that the IE group achieved superior improvement compared with the MI group in terms of left ventricular ejection fraction (LVEF), myocardial infarction size (MIS), arterial density (AD), monocytes (MNCs), smooth muscle cells (SMCs), endothelial cells (ECs), relative collateral blood flow (RCBF), MCP-1, and FGF-2 at the endpoint. Positive correlations between MCP-1 and MNCs, MNCs and FGF-2, FGF-2 and SMCs, SMCs and AD, as well as AD and RCBF were observed. This study demonstrated that with MI of 100% load 20 times daily for eight weeks, the arteriogenesis was improved, which may be attributed to the recruitment of MNCs and SMCs in remote ischemic myocardium caused by increases in MCP-1 and FGF-2 expression.
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Affiliation(s)
- Xintong Zhang
- Department of Rehabilitation Medicine, the First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu 210029, China
| | - Yu Zheng
- Department of Rehabilitation Medicine, the First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu 210029, China
| | - Canru Geng
- Department of Rehabilitation Medicine, the Affiliated Suzhou Hospital of Nanjing Medical University, Suzhou, Jiangsu 215000, China
| | - Juntao Guan
- Department of Rehabilitation Medicine, the Affiliated Suzhou Hospital of Nanjing Medical University, Suzhou, Jiangsu 215000, China
| | - Lu Wang
- Department of Rehabilitation Medicine, the First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu 210029, China
| | - Xiu Zhang
- Department of Rehabilitation Medicine, the First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu 210029, China
| | - Yihui Cheng
- Department of Rehabilitation Medicine, the First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu 210029, China
| | - Jian'an Li
- Department of Rehabilitation Medicine, the First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu 210029, China
| | - Xiao Lu
- Department of Rehabilitation Medicine, the First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu 210029, China
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Clerico A, Aimo A, Zaninotto M, Plebani M. Diagnostic algorithms for non-ST-segment elevation myocardial infarction: open issues. Clin Chem Lab Med 2021; 59:1761-1771. [PMID: 34225387 DOI: 10.1515/cclm-2021-0550] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2021] [Accepted: 06/22/2021] [Indexed: 11/15/2022]
Abstract
The use of serial measurement of cardiac troponin (cTn) is recommended by international guidelines for the diagnosis of myocardial infarction (MI) since 2000. This article focuses on factors influencing temporal changes in high-sensitive cTn (hs)-cTn and the impact of these factors on the diagnosis of non-ST-segment elevation MI (NSTEMI). The recommendations proposed by three different international guidelines published in 2020-2021 for the management of acute coronary syndromes (ACS) in patients presenting without persistent ST-segment elevation (NSTE) show some discrepancies. In particular, there is no agreement among these guidelines about cut-off or absolute change values to be used for the rule-in, especially regarding the use of sex-specific cut-off values. Furthermore, there are no sufficient evidences on the diagnostic accuracy and cost effectiveness related to cut-off values suggested for algorithms to be used by some hs-cTnI methods.
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Affiliation(s)
- Aldo Clerico
- Scuola Superiore Sant'Anna e Fondazione CNR - Regione Toscana G. Monasterio, Pisa, Italy
| | - Alberto Aimo
- Scuola Superiore Sant'Anna e Fondazione CNR - Regione Toscana G. Monasterio, Pisa, Italy
| | - Martina Zaninotto
- Dipartimento di Medicina di Laboratorio, Azienda Ospedaliera Universitaria di Padova, e Dipartimento di Medicina - Università di Padova, Padova, Italy
| | - Mario Plebani
- Dipartimento di Medicina di Laboratorio, Azienda Ospedaliera Universitaria di Padova, e Dipartimento di Medicina - Università di Padova, Padova, Italy
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Fernández-Cisnal A, Valero E, García-Blas S, Pernias V, Pozo A, Carratalá A, González J, Noceda J, Miñana G, Núñez J, Sanchis J. Clinical History and Detectable Troponin Concentrations below the 99th Percentile for Risk Stratification of Patients with Chest Pain and First Normal Troponin. J Clin Med 2021; 10:jcm10081784. [PMID: 33923925 PMCID: PMC8073372 DOI: 10.3390/jcm10081784] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Revised: 04/15/2021] [Accepted: 04/18/2021] [Indexed: 11/16/2022] Open
Abstract
Decision-making is challenging in patients with chest pain and normal high-sensitivity cardiac troponin T (hs-cTnT; <99th percentile; <14 ng/L) at hospital arrival. Most of these patients might be discharged early. We investigated clinical data and hs-cTnT concentrations for risk stratification. This is a retrospective study including 4476 consecutive patients presenting to the emergency department with chest pain and first normal hs-cTnT. The primary endpoint was one-year death or acute myocardial infarction, and the secondary endpoint added urgent revascularization. The number of primary and secondary endpoints was 173 (3.9%) and 252 (5.6%). Mean hs-cTnT concentrations were 6.9 ± 2.5 ng/L. Undetectable (<5 ng/L) hs-cTnT (n = 1847, 41%) had optimal negative predictive value (99.1%) but suboptimal sensitivity (90.2%) and discrimination accuracy (AUC = 0.664) for the primary endpoint. Multivariable analysis was used to identify the predictive clinical variables. The clinical model showed good discrimination accuracy (AUC = 0.810). The addition of undetectable hs-cTnT (≥ or <5 ng/L; HR, hazard ratio = 3.80; 95% CI, confidence interval 2.27–6.35; p = 0.00001) outperformed the clinical model alone (AUC = 0.836, p = 0.002 compared to the clinical model). Measurable hs-cTnT concentrations (between detection limit and 99th percentile; per 0.1 ng/L, HR = 1.13; CI 1.06–1.20; p = 0.0001) provided further predictive information (AUC = 0.844; p = 0.05 compared to the clinical plus undetectable hs-cTnT model). The results were reproducible for the secondary endpoint and 30-day events. Clinical assessment, undetectable hs-cTnT and measurable hs-cTnT concentrations must be considered for decision-making after a single negative hs-cTnT result in patients presenting to the emergency department with acute chest pain.
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Affiliation(s)
- Agustín Fernández-Cisnal
- Cardiology Department, University Clinic Hospital of València, Instituto de Investigación Sanitaria (INCLIVA), University of València, Centro de Investigación Biomédica en Red Enfermedades Cardiovaculares (CIBERCV), 46010 València, Spain; (A.F.-C.); (E.V.); (S.G.-B.); (V.P.); (A.P.); (J.G.); (G.M.); (J.N.)
| | - Ernesto Valero
- Cardiology Department, University Clinic Hospital of València, Instituto de Investigación Sanitaria (INCLIVA), University of València, Centro de Investigación Biomédica en Red Enfermedades Cardiovaculares (CIBERCV), 46010 València, Spain; (A.F.-C.); (E.V.); (S.G.-B.); (V.P.); (A.P.); (J.G.); (G.M.); (J.N.)
| | - Sergio García-Blas
- Cardiology Department, University Clinic Hospital of València, Instituto de Investigación Sanitaria (INCLIVA), University of València, Centro de Investigación Biomédica en Red Enfermedades Cardiovaculares (CIBERCV), 46010 València, Spain; (A.F.-C.); (E.V.); (S.G.-B.); (V.P.); (A.P.); (J.G.); (G.M.); (J.N.)
| | - Vicente Pernias
- Cardiology Department, University Clinic Hospital of València, Instituto de Investigación Sanitaria (INCLIVA), University of València, Centro de Investigación Biomédica en Red Enfermedades Cardiovaculares (CIBERCV), 46010 València, Spain; (A.F.-C.); (E.V.); (S.G.-B.); (V.P.); (A.P.); (J.G.); (G.M.); (J.N.)
| | - Adela Pozo
- Cardiology Department, University Clinic Hospital of València, Instituto de Investigación Sanitaria (INCLIVA), University of València, Centro de Investigación Biomédica en Red Enfermedades Cardiovaculares (CIBERCV), 46010 València, Spain; (A.F.-C.); (E.V.); (S.G.-B.); (V.P.); (A.P.); (J.G.); (G.M.); (J.N.)
| | - Arturo Carratalá
- Clinical Biochemistry Department, University Clinic Hospital of València, Instituto de Investigación Sanitaria (INCLIVA), 46010 València, Spain;
| | - Jessika González
- Cardiology Department, University Clinic Hospital of València, Instituto de Investigación Sanitaria (INCLIVA), University of València, Centro de Investigación Biomédica en Red Enfermedades Cardiovaculares (CIBERCV), 46010 València, Spain; (A.F.-C.); (E.V.); (S.G.-B.); (V.P.); (A.P.); (J.G.); (G.M.); (J.N.)
| | - José Noceda
- Emergency Department, University Clinic Hospital of València, Instituto de Investigación Sanitaria (INCLIVA), 46010 València, Spain;
| | - Gema Miñana
- Cardiology Department, University Clinic Hospital of València, Instituto de Investigación Sanitaria (INCLIVA), University of València, Centro de Investigación Biomédica en Red Enfermedades Cardiovaculares (CIBERCV), 46010 València, Spain; (A.F.-C.); (E.V.); (S.G.-B.); (V.P.); (A.P.); (J.G.); (G.M.); (J.N.)
| | - Julio Núñez
- Cardiology Department, University Clinic Hospital of València, Instituto de Investigación Sanitaria (INCLIVA), University of València, Centro de Investigación Biomédica en Red Enfermedades Cardiovaculares (CIBERCV), 46010 València, Spain; (A.F.-C.); (E.V.); (S.G.-B.); (V.P.); (A.P.); (J.G.); (G.M.); (J.N.)
| | - Juan Sanchis
- Cardiology Department, University Clinic Hospital of València, Instituto de Investigación Sanitaria (INCLIVA), University of València, Centro de Investigación Biomédica en Red Enfermedades Cardiovaculares (CIBERCV), 46010 València, Spain; (A.F.-C.); (E.V.); (S.G.-B.); (V.P.); (A.P.); (J.G.); (G.M.); (J.N.)
- Correspondence:
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12
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Apple FS, Collinson PO, Kavsak PA, Body R, Ordóñez-Llanos J, Saenger AK, Omland T, Hammarsten O, Jaffe AS. Getting Cardiac Troponin Right: Appraisal of the 2020 European Society of Cardiology Guidelines for the Management of Acute Coronary Syndromes in Patients Presenting without Persistent ST-Segment Elevation by the International Federation of Clinical Chemistry and Laboratory Medicine Committee on Clinical Applications of Cardiac Bio-Markers. Clin Chem 2021; 67:730-735. [PMID: 33377906 DOI: 10.1093/clinchem/hvaa337] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2020] [Accepted: 12/18/2020] [Indexed: 11/13/2022]
Affiliation(s)
- Fred S Apple
- Department of Laboratory Medicine and Pathology, Hennepin Healthcare/HCMC, Minneapolis, MN, USA.,Department of Laboratory Medicine and Pathology, University of Minnesota, Minneapolis, MN, USA
| | - Paul O Collinson
- Departments of Clinical Blood Sciences and Cardiology, St George's University Hospitals NHS Foundation Trust and St George's University of London, London, UK
| | - Peter A Kavsak
- Department of Pathology and Molecular Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Richard Body
- Department of Pathology and Molecular Medicine, McMaster University, Hamilton, Ontario, Canada.,Cardiovascular Sciences Research Group, Core Technology Facility, Manchester, UK.,Healthcare Sciences Department, Manchester Metropolitan University, Manchester, UK
| | - Jordi Ordóñez-Llanos
- Servicio de Bioquímica Clínica, Institut d'Investigacions Biomèdiques Sant Pau, Barcelona, Spain.,Departamento de Bioquímica y Biología Molecular, Universidad Autònoma de Barcelona, Barcelona, Spain
| | - Amy K Saenger
- Department of Laboratory Medicine and Pathology, Hennepin Healthcare/HCMC, Minneapolis, MN, USA.,Department of Laboratory Medicine and Pathology, University of Minnesota, Minneapolis, MN, USA
| | - Torbjorn Omland
- Department of Cardiology, Akershus University Hospital, Lørenskog, Norway.,Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Ola Hammarsten
- Department of Clinical Chemistry and Transfusion Medicine, Sahlgrenska University Hospital, Sahlgrenska Academy at the University of Gothenburg, Sweden
| | - Allan S Jaffe
- Departments of Laboratory Medicine and Pathology and Cardiology, Mayo Clinic, Rochester, MN, USA
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Abstract
The measurement of cardiac troponin (cTn) is recommended by all guidelines as the gold standard for the differential diagnosis of Acute Coronary Syndromes. The aim of this review is to discuss in details some key issues regarding both analytical and clinical characteristics of the high-sensitivity methods for cTn (hs-cTn), which are still considered controversial or unresolved. In particular, the major clinical concern regarding hs-cTn methods is the difficulty to differentiate the pathophysiological mechanism responsible for biomarker release from cardiomyocytes after reversible or irreversible injury, respectively. Indeed, recent experimental and clinical studies have demonstrated that different circulating forms of cTnI and cTnT can be respectively measured in plasma samples of patients with reversible or irreversible myocardial injury. Accordingly, a new generation of hs-Tn methods should be set up, based on immunometric immunoassays or chromatographic techniques, specific for circulating peptide forms more characteristics for reversible or irreversible myocardial injury. It is conceivable that this new generation of hs-cTn methods will complete the mission regarding the laboratory tests for specific cardiac biomarkers, started more than 20 years ago, which has already revolutionized the diagnosis, prognosis and management of patients with cardiac diseases.
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