Implications of the complex biology and micro-environment of cardiac sarcomeres in the use of high affinity troponin antibodies as serum biomarkers for cardiac disorders

Diagnostic and prognostic value of the sex-specific 99th percentile of four high-sensitivity cardiac troponin assays in patients with suspected myocardial infarction

AIMS

High-sensitivity cardiac troponin (hs-cTn) assays are used for detection of myocardial infarction (MI). Ninety-ninth percentiles show wide inter-assay variation. The use of sex-specific cut-offs is recommended as definitory cut-off for MI. We compared diagnostic performance and prognostic value of sex-specific 99th percentiles of four hs-cTn assays in patients with suspected MI.

METHODS AND RESULTS

Concentrations of four hs-cTn assays were measured at presentation and after 3 h in patients with suspected MI. Final diagnoses were adjudicated according to the 4th Universal Definition of MI. Unisex and sex-specific 99th percentiles were evaluated as diagnostic cut-offs following the ESC 0/3 h algorithm. These cut-offs were used in Cox-regression analyses to investigate the association with a composite endpoint of MI, revascularization, cardiac rehospitalization, and death. Non-ST-elevation MI was diagnosed in 368 of 2718 patients. Applying the unisex 99th percentile, Elecsys hs-cTnT provided highest negative predictive value (NPV) of 99.7 and a positive predictive value (PPV) of 75.9. The analysed hs-cTnI assays showed slightly lower NPVs and comparable PPVs [Architect (NPV 98.0, PPV of 71.4); Atellica (NPV 97.7, PPV of 76.1); Pathfast (NPV 97.7, PPV of 66.6)]. Application of sex-specific 99th percentiles did not significantly affect diagnostic performance. Concentrations above 99th percentile were independent predictors for impaired long-term outcome (hazard ratios 1.2-1.5, P < 0.001).

CONCLUSION

We describe a good diagnostic accuracy of four hs-cTn assays using the assay-specific 99th percentile for detection of MI. Application of sex-specific 99th percentiles did neither affect diagnostic performance nor prognostic value significantly. Finally, values above the 99th percentile were associated with poor long-term outcome.

Constructed a self-powered sensing platform based on nitrogen-doped hollow carbon nanospheres for ultra-sensitive detection and real-time tracking of double markers

Acute myocardial infarction (AMI) is acute necrosis of a portion of the myocardium caused by myocardial ischemia, which seriously threatens people's health and life safety. Its early diagnosis is a difficult problem in clinical medicine. Research has found that the abnormal expression of microRNA-199a (miR-199a) and microRNA-499 (miR-499) was closely related to AMI disease. In this work, we took advantage of the structural advantages of nitrogen-doped hollow carbon nanospheres (N-HCNSs) to design an ultra-sensitive, portable real-time monitoring visual self-powered biosensor system, which based on dual-target miRNAs triggered catalytic hairpin assembly (CHA) for sensitive detection of miR-199a and miR-499. In addition, the capacitor and the smartphone are introduced into the system to realize the secondary improvement of system sensitivity and portable real-time visual monitoring. Under optimized conditions, in the linear range of 0.1-100000 aM, the detection limits of miR-199a and miR-499 are 0.031 and 0.027 aM, respectively. At the same time, the ultra-sensitive detection of miRNAs is realized in the serum sample, and the recovery rate of miR-199a and miR-499 are 98.0-106.0% (RSD: 0.6-8.1%) and 94.0-109.7% (RSD: 1.8-7.7%), respectively. The method is simple, sensitive and can be used for real-time tracking and portable monitoring of related diseases.

Myocardial injury defined as elevated high-sensitivity cardiac troponin T is associated with higher mortality in patients seeking care at emergency departments with acute dyspnea

BACKGROUND

Elevated levels of cardiac troponin T has been observed in patients seeking care at the emergency department (ED) presenting with chest pain but without myocardial infarction (MI). The clinical importance of this observation remains, however, still unclear. Our main aim was to study the role of cardiac troponin T in patients admitted to the emergency department with acute dyspnea, a group of patients with a high cardiovascular comorbidity, but no primary acute MI.

POPULATION AND METHODS

Patients from the age of 18 seeking care at the ED for dyspnea, without an acute cardiac syndrome, and with a recorded assessment of high-sensitivity cardiac troponin T (hs-cTnT), were included (n = 1001). Patients were categorized into 3 groups by hs-cTnT level, i.e. <15, 15-100 and > 100 µg/l. Cox regression with Hazard Ratios (HRs) and 95% Confidence Intervals (CI) for 3-months mortality was performed, with adjustment for sex, age, respiratory frequency, saturation, CHF, renal disease, and BMI.

RESULTS

Fully adjusted HRs (95% CI) for 3-month mortality, with hs-cTnT < 15 µg/l as reference level, showed for hs-cTnT 15-100 a HR of 3.682 (1.729-7.844), and for hs-cTnT > 100 a HR of 10.523 (4.465-24.803).

CONCLUSION

Elevated hs-cTnT seems to be a relevant marker of poor prognosis in patients with acute dyspnea without MI and warrants further validation and clinical testing.

Implications of S-glutathionylation of sarcomere proteins in cardiac disorders, therapies, and diagnosis

The discovery that cardiac sarcomere proteins are substrates for S-glutathionylation and that this post-translational modification correlates strongly with diastolic dysfunction led to new concepts regarding how levels of oxidative stress affect the heartbeat. Major sarcomere proteins for which there is evidence of S-glutathionylation include cardiac myosin binding protein C (cMyBP-C), actin, cardiac troponin I (cTnI) and titin. Our hypothesis is that these S-glutathionylated proteins are significant factors in acquired and familial disorders of the heart; and, when released into the serum, provide novel biomarkers. We consider the molecular mechanisms for these effects in the context of recent revelations of how these proteins control cardiac dynamics in close collaboration with Ca2+ fluxes. These revelations were made using powerful approaches and technologies that were focused on thin filaments, thick filaments, and titin filaments. Here we integrate their regulatory processes in the sarcomere as modulated mainly by neuro-humoral control of phosphorylation inasmuch evidence indicates that S-glutathionylation and protein phosphorylation, promoting increased dynamics and modifying the Frank-Starling relation, may be mutually exclusive. Earlier studies demonstrated that in addition to cTnI as a well-established biomarker for cardiac disorders, serum levels of cMyBP-C are also a biomarker for cardiac disorders. We describe recent studies approaching the question of whether serum levels of S-glutathionylated-cMyBP-C could be employed as an important clinical tool in patient stratification, early diagnosis in at risk patients before HFpEF, determination of progression, effectiveness of therapeutic approaches, and as a guide in developing future therapies.

Breviscapine remodels myocardial glucose and lipid metabolism by regulating serotonin to alleviate doxorubicin-induced cardiotoxicity

Aims: The broad-spectrum anticancer drug doxorubicin (Dox) is associated with a high incidence of cardiotoxicity, which severely affects the clinical application of the drug and patients’ quality of life. Here, we assess how Dox modulates myocardial energy and contractile function and this could aid the development of relevant protective drugs.

Methods: Mice were subjected to doxorubicin and breviscapine treatment. Cardiac function was analyzed by echocardiography, and Dox-mediated signaling was assessed in isolated cardiomyocytes. The dual cardio-protective and anti-tumor actions of breviscapine were assessed in mouse breast tumor models.

Results: We found that Dox disrupts myocardial energy metabolism by decreasing glucose uptake and increasing fatty acid oxidation, leading to a decrease in ATP production rate, an increase in oxygen consumption rate and oxidative stress, and further energy deficits to enhance myocardial fatty acid uptake and drive DIC development. Interestingly, breviscapine increases the efficiency of ATP production and restores myocardial energy homeostasis by modulating the serotonin-glucose-myocardial PI3K/AKT loop, increasing glucose utilization by the heart and reducing lipid oxidation. It enhances mitochondrial autophagy via the PINK1/Parkin pathway, eliminates damaged mitochondrial accumulation caused by Dox, reduces the degree of cardiac fibrosis and inflammation, and restores cardiac micro-environmental homeostasis. Importantly, its low inflammation levels reduce myeloid immunosuppressive cell infiltration, and this effect is synergistic with the anti-tumor effect of Dox.

Conclusion: Our findings suggest that disruption of the cardiac metabolic network by Dox is an important driver of its cardiotoxicity and that serotonin is an important regulator of myocardial glucose and lipid metabolism. Myocardial energy homeostasis and timely clearance of damaged mitochondria synergistically contribute to the prevention of anthracycline-induced cardiotoxicity and improve the efficiency of tumor treatment.

Utility of cardiac bioenzymes in predicting cardiovascular outcomes in SARS-CoV-2

BACKGROUND

Cardiovascular complications have been increasingly recognized in the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) associated coronavirus disease 2019 (COVID-19). Cardiac biomarkers are released because of this ongoing cardiovascular injury and can act as surrogate markers to assess the disease severity.

AIM

To review the variation and utility of these biomarkers in COVID-19 to ascertain their role in diagnosis, prognosis and clinical outcomes of the disease.

METHODS

We performed a literature search in PubMed, Medline and the Reference Citation Analysis (RCA), using the search terms “COVID-19” and “cardiac bioenzymes” or “cardiac biomarkers”. Additionally, we also used the latest reference citation analysis tool to identify more articles.

RESULTS

Cardiac troponin has been consistently elevated in patients with COVID-19 associated myocarditis, and strongly correlated with adverse prognosis. Natri-uretic peptides including brain natriuretic peptide (BNP) and pro-BNP is elevated in patients with COVID-19 associated cardiac injury, irrespective of their prior heart failure status, and independently correlated with worst outcomes. Alongside these traditional biomarkers, novel cardiac bioenzymes including presepsin, soluble ST2 and copeptin, are also increasingly recognized as markers of cardiovascular injury in COVID-19 and can be associated with poor outcomes.

CONCLUSION

Assessment of cardiac bioenzymes at admission and their serial monitoring can help assess the severity of disease and predict mortality in patients with SARS-CoV-2 infection. Future studies are needed to elude the critical importance of novel biomarkers.

Truncation of the N-terminus of cardiac troponin I initiates adaptive remodeling of the myocardial proteosome via phosphorylation of mechano-sensitive signaling pathways

The cardiac isoform of troponin I has a unique N-terminal extension (~ 1-30 amino acids), which contributes to the modulation of cardiac contraction and relaxation. Hearts of various species including humans produce a truncated variant of cardiac troponin I (cTnI-ND) deleting the first ~ 30 amino acids as an adaption in pathophysiological conditions. In this study, we investigated the impact of cTnI-ND chronic expression in transgenic mouse hearts compared to wildtype (WT) controls (biological n = 8 in each group). We aimed to determine the global phosphorylation effects of cTnI-ND on the cardiac proteome, thereby determining the signaling pathways that have an impact on cardiac function. The samples were digested and isobarically labeled and equally mixed for relative quantification via nanoLC-MS/MS. The peptides were then enriched for phospho-peptides and bioinformatic analysis was done with Ingenuity Pathway Analysis (IPA). We found approximately 77% replacement of the endogenous intact cTnI with cTnI-ND in the transgenic mouse hearts with 1674 phospho-proteins and 2971 non-modified proteins. There were 73 significantly altered phospho-proteins; bioinformatic analysis identified the top canonical pathways as associated with integrin, protein kinase A, RhoA, and actin cytoskeleton signaling. Among the 73 phospho-proteins compared to controls cTnI-ND hearts demonstrated a significant decrease in paxillin and YAP1, which are known to play a role in cell mechano-sensing pathways. Our data indicate that cTnI-ND modifications in the sarcomere are sufficient to initiate changes in the phospho-signaling profile that may underly the chronic-adaptive response associated with cTnI cleavage in response to stressors by modifying mechano-sensitive signaling pathways.

Novel insights into sarcomere regulatory systems control of cardiac thin filament activation

Our review focuses on sarcomere regulatory mechanisms with a discussion of cardiac-specific modifications to the three-state model of thin filament activation from a blocked to closed to open state. We discuss modulation of these thin filament transitions by Ca²⁺, by crossbridge interactions, and by thick filament–associated proteins, cardiac myosin–binding protein C (cMyBP-C), cardiac regulatory light chain (cRLC), and titin. Emerging evidence supports the idea that the cooperative activation of the thin filaments despite a single Ca²⁺ triggering regulatory site on troponin C (cTnC) cannot be considered in isolation of other functional domains of the sarcomere. We discuss long- and short-range interactions among these domains with the regulatory units of thin filaments, including proteins at the barbed end at the Z-disc and the pointed end near the M-band. Important to these discussions is the ever-increasing understanding of the role of cMyBP-C, cRLC, and titin filaments. Detailed knowledge of these control processes is critical to the understanding of mechanisms sustaining physiological cardiac state with varying hemodynamic load, to better defining genetic and acquired cardiac disorders, and to developing targets for therapies at the level of the sarcomeres.

Mechanisms of troponin release into serum in cardiac injury associated with COVID-19 patients

Serum levels of thin filament proteins, cardiac troponin T (cTnT) and cardiac troponin I (cTnI) employing high sensitivity antibodies provide a state-of-the art determination of cardiac myocyte injury in COVID-19 patients. Although there is now sufficient evidence of the value of these determinations in patients infected with SARS-CoV-2, mechanisms of their release have not been considered in depth. We summarize the importance of these mechanisms with emphasis on their relation to prognosis, stratification, and treatment of COVID-19 patients. Apart from frank necrotic cell death, there are other mechanisms of myocyte injury leading to membrane fragility that provoke release of cTnT and cTnI. We discuss a rationale for understanding these mechanisms in COVID-19 patients with co-morbidities associated with myocyte injury such as heart failure, hypertension, arrythmias, diabetes, and inflammation. We describe how understanding these significant aspects of these mechanisms in the promotion of angiotensin signaling by SARS-CoV-2 can affect treatment options in the context of individualized therapies. Moreover, with likely omic data related to serum troponins and with the identification of elevations of serum troponins now more broadly detected employing high sensitivity antibodies, we think it is important to consider molecular mechanisms of elevations in serum troponin as an element in clinical decisions and as a critical aspect of development of new therapies.

A Perspective on Personalized Therapies in Hypertrophic Cardiomyopathy

ABSTRACT

A dominant mechanism of sudden cardiac death in the young is the progression of maladaptive responses to genes encoding proteins linked to hypertrophic cardiomyopathy. Most are mutant sarcomere proteins that trigger the progression by imposing a biophysical defect on the dynamics and levels of myofilament tension generation. We discuss approaches for personalized treatments that are indicated by recent advanced understanding of the progression.

NH2-Terminal Cleavage of Cardiac Troponin I Signals Adaptive Response to Cardiac Stressors

Cardiac sarcomeres express a variant of troponin I (cTnI) that contains a unique N-terminal extension of ~30 amino acids with regulatory phosphorylation sites. The extension is important in the control of myofilament response to Ca²⁺, which contributes to the neuro-humoral regulation of the dynamics of cardiac contraction and relaxation. Hearts of various species including humans express a stress-induced truncated variant of cardiac troponin I (cTnI-ND) missing the first ~30 amino acids and functionally mimicking the phosphorylated state of cTnI. Studies have demonstrated that upregulation of cTnI-ND potentially represents a homeostatic mechanism as well as an adaptive response in pathophysiology including ischemia/reperfusion injury, beta adrenergic maladaptive activation, and aging. We present evidence showing that cTnI-ND can modify the trigger for hypertrophic cardiomyopathy (HCM) by reducing the Ca²⁺ sensitivity of myofilaments from hearts with an E180G mutation in α-tropomyosin. Induction of this truncation may represent a therapeutic approach to modifying Ca²⁺-responses in hearts with hypercontractility or heat failure with preserved ejection fraction.