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Kadesjö E, Cyon L, Edgren G, Roos A. Low-Risk Chest Pain Patients: Exploring the Impact of Socioeconomy on Emergency Department Revisits. Am J Med 2024:S0002-9343(24)00629-6. [PMID: 39370031 DOI: 10.1016/j.amjmed.2024.09.033] [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: 06/04/2024] [Revised: 08/26/2024] [Accepted: 09/25/2024] [Indexed: 10/08/2024]
Abstract
BACKGROUND Patients with chest pain and undetectable high-sensitivity cardiac troponin T (hs-cTnT) in the emergency department (ED) have a low short-term risk of cardiovascular events, but the frequency of ED revisits in this group is unknown. This study investigated the associations between disposable income and risk of ED revisits in patients with chest pain and undetectable hs-cTnT. METHODS All first visits to 7 EDs in Sweden from 2010 to 2017 by patients with chest pain and hs-cTnT <5 ng/l were included. Incidence rate ratios (IRR) were calculated to estimate the ED revisit risk in relation to disposable income according to data obtained from Swedish government agencies (Statistics Sweden). RESULTS Altogether, 61,539 patients with a first ED visit were included, in whom 126,650 revisits occurred. The adjusted 30-day risk of a revisit was 1.3- (IRR 1.32, 95% CI: 1.23-1.42) and 1.5-fold (IRR 1.50, 95% CI: 1.40-1.60), and for any revisit during the follow-up 1.6- (IRR 1.63, 95% CI: 1.59-1.66) and 1.8-fold (IRR 1.78, 95% CI 1.72-1.79), in patients with middle-low and low versus high income, respectively. During a median follow-up of 6.8 years, 1714 (2.8%) deaths occurred, and the adjusted cumulative incidence of major adverse cardiovascular events at 1 and 5 years was only 0.3% (95% CI: 0.2-0.4%) and 1.1% (95% CI: 0.8-1.4%) higher in patients with the lowest versus highest income levels. CONCLUSIONS Disposable income level is inversely associated with the risk of ED revisits among patients presenting with chest pain and undetectable hs-cTnT, in whom cardiovascular risks are low.
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Affiliation(s)
- Erik Kadesjö
- Theme of Acute and Reparative Medicine, Karolinska University Hospital, Huddinge, Stockholm, Sweden.; Department of Medicine, Karolinska Institutet, Solna, Stockholm, Sweden.
| | - Love Cyon
- Theme of Acute and Reparative Medicine, Karolinska University Hospital, Huddinge, Stockholm, Sweden.; Department of Medicine, Clinical Epidemiology Division, Karolinska Institutet, Solna, Stockholm, Sweden
| | - Gustaf Edgren
- Department of Medicine, Clinical Epidemiology Division, Karolinska Institutet, Solna, Stockholm, Sweden.; Department of Cardiology, Södersjukhuset, Stockholm, Sweden
| | - Andreas Roos
- Theme of Acute and Reparative Medicine, Karolinska University Hospital, Huddinge, Stockholm, Sweden.; Department of Medicine, Clinical Epidemiology Division, Karolinska Institutet, Solna, Stockholm, Sweden
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Saeed N, Steiro OT, Langørgen J, Tjora HL, Bjørneklett RO, Skadberg Ø, Bonarjee VVS, Mjelva ØR, Norekvål TM, Steinsvik T, Vikenes K, Omland T, Aakre KM. Diagnosing Myocardial Injury in an Acute Chest Pain Cohort; Long-Term Prognostic Implications of Cardiac Troponin T and I. Clin Chem 2024; 70:1241-1255. [PMID: 39119917 DOI: 10.1093/clinchem/hvae110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2024] [Accepted: 07/01/2024] [Indexed: 08/10/2024]
Abstract
BACKGROUND There are limited data regarding the utility of follow-up cardiac troponin (cTn) measurements after admission for acute chest pain and how long-term stability of myocardial injury and prognostic value differ when using cardiac troponin T (cTnT) or I (cTnI). METHODS We measured high-sensitivity (hs)-cTnT (Roche Diagnostics) and hs-cTnI (Siemens Healthineers) during hospitalization for acute chest pain and after 3 months. Acute myocardial injury was defined as concentrations > sex-specific upper reference limit (URL) during hospitalization and ≤URL at 3-months. Chronic myocardial injury (CMI) was defined as concentrations > URL at both time points. Patients were followed from the 3-month sampling point for a median of 1586 (IQR 1161-1786) days for a primary composite endpoint of all-cause mortality, myocardial infarction (MI), revascularization, and heart failure, and a secondary endpoint of all-cause mortality. RESULTS Among 754 patients, 33.8% (hs-cTnT) and 19.2% (hs-cTnI) had myocardial injury during hospitalization. The rate of CMI was 5 times higher by hs-cTnT (20%) assay than hs-cTnI (4%), while acute myocardial injury was equally common; 14% (hs-cTnT) and 15% (hs-cTnI), respectively (6% and 5% when excluding index non-ST-elevation MI (NSTEMI). For hs-cTnT, peak index concentration, 3-month concentration and classification of CMI predicted the primary endpoint; hazard ratios (HRs) 1.38 (95% CI 1.20-1.58), 2.34 (1.70-3.20), and 2.31 (1.30-4.12), respectively. For hs-cTnI, peak index concentration predicted the primary endpoint; HR 1.14 (1.03-1.25). This association was nonsignificant after excluding index NSTEMI. CONCLUSIONS Acute myocardial injury is equally frequent, whereas CMI is more prevalent using hs-cTnT assay than hs-cTnI. Measuring hs-cTnT 3 months after an acute chest pain episode could assist in further long-term risk assessment. ClinicalTrials.gov Registration Number: NCT02620202.
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Affiliation(s)
- Nasir Saeed
- Department of Clinical Science, University of Bergen, Bergen, Norway
| | - Ole-Thomas Steiro
- Department of Heart Disease, Haukeland University Hospital, Bergen, Norway
| | - Jørund Langørgen
- Department of Heart Disease, Haukeland University Hospital, Bergen, Norway
| | - Hilde L Tjora
- Emergency Care Clinic, Haukeland University Hospital, Bergen, Norway
| | - Rune O Bjørneklett
- Emergency Care Clinic, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Øyvind Skadberg
- Laboratory of Medical Biochemistry, Stavanger University Hospital, Stavanger, Norway
| | | | - Øistein R Mjelva
- Department of Medicine, Stavanger University Hospital, Stavanger, Norway
| | - Tone M Norekvål
- Department of Clinical Science, University of Bergen, Bergen, Norway
- Department of Heart Disease, Haukeland University Hospital, Bergen, Norway
| | - Trude Steinsvik
- Department of Laboratory Medicine, Vestre Viken Hospital Trust, Bærum, Norway
| | - Kjell Vikenes
- Department of Clinical Science, University of Bergen, Bergen, Norway
- Department of Heart Disease, Haukeland University Hospital, Bergen, Norway
| | - Torbjørn Omland
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- K.G. Jebsen Centre for Cardiac Biomarkers, Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Kristin M Aakre
- Department of Clinical Science, University of Bergen, Bergen, Norway
- Department of Heart Disease, Haukeland University Hospital, Bergen, Norway
- Department of Medical Biochemistry and Pharmacology, Haukeland University Hospital, Bergen, Norway
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Aakre KM, Lyngbakken MN, Faaren AL, Røsjø H, Dalen H, Omland T. Reference intervals of circulating secretoneurin concentrations determined in a large cohort of community dwellers: the HUNT study. Clin Chem Lab Med 2024; 62:2030-2036. [PMID: 38564801 DOI: 10.1515/cclm-2024-0154] [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: 01/31/2024] [Accepted: 03/07/2024] [Indexed: 04/04/2024]
Abstract
OBJECTIVES Secretoneurin (SN) is a novel cardiac biomarker that associates with the risk of mortality and dysfunctional cardiomyocyte Ca2+ handling in heart failure patients. Reference intervals for SN are unknown. METHODS SN was measured with a CE-marked ELISA in healthy community dwellers from the fourth wave of the Trøndelag Health Study (HUNT4) conducted in 2017-2019. The common, sex and age specific 90th, 95th, 97.5th and 99th percentiles were calculated using the non-parametric method and outlier exclusion according to the Reed test. The applicability of sex and age specific reference intervals were investigated using Harris and Boyd test. We also estimated the percentiles in a subset with normal findings on echocardiographic screening. RESULTS The total cohort included 887 persons (56.4 % women). After echocardiographic screening 122 persons were excluded, leaving a total of 765 persons (57.8 % women). The 97.5th percentile (95 % CI in brackets) of SN was 59.7 (57.5-62.1) pmol/L in the total population and 58.6 (57.1-62.1) pmol/L after echocardiography screening. In general, slightly higher percentiles were found in women and elderly participants, but less than 4 % in these subgroups had concentrations deviating from the common 97.5th percentile. Low BMI or eGFR was also associated with higher concentrations of SN. CONCLUSIONS Upper reference limits for SN were similar amongst healthy adult community dwellers regardless of prescreening including cardiac echocardiography or not. Women and elderly showed higher concentrations of SN, but the differences were not sufficiently large to justify age and sex stratified upper reference limits.
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Affiliation(s)
- Kristin M Aakre
- Department of Medical Biochemistry and Pharmacology, 60498 Haukeland University Hospital , Bergen, Norway
- Department of Heart Disease, 60498 Haukeland University Hospital , Bergen, Norway
- Department of Clinical Science, University of Bergen, Bergen, Norway
| | - Magnus N Lyngbakken
- Department of Cardiology, Division of Medicine, 60483 Akershus University Hospital , Lørenskog, Norway
- K.G. Jebsen Centre for Cardiac Biomarkers, 60504 Institute of Clinical Medicine, University of Oslo , Oslo, Norway
| | | | - Helge Røsjø
- K.G. Jebsen Centre for Cardiac Biomarkers, 60504 Institute of Clinical Medicine, University of Oslo , Oslo, Norway
- Akershus Clinical Research Center (ACR), Division of Research and Innovation, 60483 Akershus University Hospital , Lørenskog, Norway
| | - Håvard Dalen
- Department of Circulation and Medical Imaging, Norwegian University of Science and Technology, Trondheim, Norway
- Clinic of Cardiology, St Olav's University Hospital, Trondheim, Norway
- Department of Medicine, Levanger Hospital, Nord-Trøndelag Hospital Trust, Levanger, Norway
| | - Torbjørn Omland
- Department of Cardiology, Division of Medicine, 60483 Akershus University Hospital , Lørenskog, Norway
- K.G. Jebsen Centre for Cardiac Biomarkers, 60504 Institute of Clinical Medicine, University of Oslo , Oslo, Norway
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Astin-Chamberlain R, Pott J, Cole E, Bloom BM. Sex and gender reporting in UK emergency medicine trials from 2010 to 2023: a systematic review. Emerg Med J 2024:emermed-2024-214054. [PMID: 39266055 DOI: 10.1136/emermed-2024-214054] [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: 05/01/2024] [Accepted: 08/30/2024] [Indexed: 09/14/2024]
Abstract
BACKGROUND Female participants are underrepresented in randomised control trials conducted in urgent care settings. Although sex and gender are frequently reported within demographic data, it is less common for primary outcomes to be disaggregated by sex or gender. The aim of this review is to report sex and gender of participants in the primary papers published on research listed on the National Institute of Health and Care Research (NIHR) Trauma and Emergency Care (TEC) portfolio and how these data are presented. METHODS This is a systematic review of the published outputs of interventional trials conducted in UK EDs. Interventional trials were eligible to be included in the review if they were registered on the NIHR TEC research portfolio from January 2010, if the primary paper was published before 31 December 2023 and if the research was delivered primarily in the ED. Trials were identified through the NIHR open data platform and the primary papers were identified through specific searches using MedLine, EMBASE and PubMed. The primary objective of the review is to quantify the proportion of sex-disaggregated or gender-disaggregated primary outcomes in clinical trials within UK emergency medicine. RESULTS The initial search revealed 169 registered research projects on the NIHR TEC portfolio during the study period, of which 24 met the inclusion criteria. Overall, 76 719 participants were included, of which 31 374 (40%) were female. Only one trial (CRYOSTAT-2) reported a sex-disaggregated analysis of the effect of the intervention on either primary or secondary outcomes, and no sex-based difference in treatment effect was detected. CONCLUSIONS Fewer females than males were included in TEC trials from 2010 to 2023. One trial reported the primary outcome stratified by sex. There is significant scope to increase the scientific value of TEC trials to females by funders.
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Affiliation(s)
| | - Jason Pott
- Emergency Department, Barts Health NHS Trust, London, UK
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Hasselbalch RB, Jørgensen N, Kristensen J, Strandkjær N, Kock TO, Lange T, Ostrowski SR, Nissen J, Larsen MH, Pedersen OBV, Bor MV, Afzal S, Kamstrup PR, Dahl M, Hilsted L, Torp-Pedersen C, Bundgaard H, Iversen KK. Sex and Population-Specific 99th Percentiles of Troponin for Myocardial Infarction in the Danish Population (DANSPOT). J Appl Lab Med 2024:jfae088. [PMID: 39206666 DOI: 10.1093/jalm/jfae088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2024] [Accepted: 06/20/2024] [Indexed: 09/04/2024]
Abstract
BACKGROUND Sex- and population-specific 99th percentiles of high-sensitivity cardiac troponin (hs-cTn) are recommended in guidelines although the evidence for a clinical utility is sparse. The DANSPOT trial will investigate the clinical effect of sex- and population-specific 99th percentiles of cTn. We report the 99th percentiles derived from this trial and their dependency on kidney function. METHODS We used samples from healthy Danish blood donors and measured hemoglobin A1c, N-terminal pro-brain natriuretic peptide and creatinine, and calculated an estimated glomerular filtration rate (eGFR). We compared 2 cutoffs for the eGFR of healthy participants (60 vs 90 mL/min/1.73 m2). The cTn assays investigated were Siemens Atellica and Dimension Vista hs-cTnI, Abbott hs-cTnI, and Roche hs-cTnT. RESULTS A total of 2287 participants were sampled, of which 71 (3.1%) were excluded due to a history of heart disease (n = 4), insufficient material (n = 7), or a screening biomarker (n = 60). Of the remaining 2216 participants, 1325 (59.8%) had an eGFR ≥90 mL/min/1.73 m2. Compared to a cutoff of 60 mL/min/1.73 m2 for eGFR, using 90 mL/min/1.73 m2 resulted in lower 99th percentiles for females; Siemens Vista (46 vs 70 ng/L), Abbott (14 vs 18 ng/L), and Roche cTnT (10 vs 13 ng/L), and decreased the number of measurements above the manufacturers' 99th percentiles for all assays. CONCLUSIONS We present reference values for 4 cTn assays for eGFR cutoffs of 60 and 90 mL/min/1.73 m2. These cutoffs differ based on the eGFR threshold for inclusion indicating that any chosen cutoff is also valuable with moderately reduced kidney function.
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Affiliation(s)
- Rasmus Bo Hasselbalch
- Department of Emergency Medicine, Copenhagen University Hospital-Herlev and Gentofte, Copenhagen, Denmark
- Department of Cardiology, Copenhagen University Hospital-Herlev and Gentofte, Copenhagen, Denmark
| | - Nicoline Jørgensen
- Department of Emergency Medicine, Copenhagen University Hospital-Herlev and Gentofte, Copenhagen, Denmark
- Department of Cardiology, Copenhagen University Hospital-Herlev and Gentofte, Copenhagen, Denmark
| | - Jonas Kristensen
- Department of Emergency Medicine, Copenhagen University Hospital-Herlev and Gentofte, Copenhagen, Denmark
- Department of Cardiology, Copenhagen University Hospital-Herlev and Gentofte, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Nina Strandkjær
- Department of Emergency Medicine, Copenhagen University Hospital-Herlev and Gentofte, Copenhagen, Denmark
- Department of Cardiology, Copenhagen University Hospital-Herlev and Gentofte, Copenhagen, Denmark
| | - Thilde Olivia Kock
- Department of Emergency Medicine, Copenhagen University Hospital-Herlev and Gentofte, Copenhagen, Denmark
- Department of Cardiology, Copenhagen University Hospital-Herlev and Gentofte, Copenhagen, Denmark
| | - Theis Lange
- Section of Biostatistics, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Sisse Rye Ostrowski
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Department of Clinical Immunology, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark
| | - Janna Nissen
- Department of Clinical Immunology, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark
| | - Margit Hørup Larsen
- Department of Clinical Immunology, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark
| | - Ole Birger Vesterager Pedersen
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Department of Clinical Immunology, Zealand University Hospital, Køge, Denmark
| | - Mustafa Vakur Bor
- South West Jutland Hospital, Department of Clinical Biochemistry, Esbjerg, Denmark
| | - Shoaib Afzal
- Department of Clinical Biochemistry, Copenhagen University Hospital-Herlev and Gentofte, Copenhagen, Denmark
| | - Pia Rørbæk Kamstrup
- Department of Clinical Biochemistry, Copenhagen University Hospital-Herlev and Gentofte, Copenhagen, Denmark
| | - Morten Dahl
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Department of Clinical Biochemistry Medicine, Koge University Hospital, Department of Clinical Biochemistry, Koege, Denmark
| | - Linda Hilsted
- Department of Clinical Biochemistry Medicine, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark
| | | | - Henning Bundgaard
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Department of Cardiology, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark
| | - Kasper Karmark Iversen
- Department of Emergency Medicine, Copenhagen University Hospital-Herlev and Gentofte, Copenhagen, Denmark
- Department of Cardiology, Copenhagen University Hospital-Herlev and Gentofte, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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Perez-Vicencio D, Thurston AJF, Doudesis D, O'Brien R, Ferry A, Fujisawa T, Williams MC, Gray AJ, Mills NL, Lee KK. Risk scores and coronary artery disease in patients with suspected acute coronary syndrome and intermediate cardiac troponin concentrations. Open Heart 2024; 11:e002755. [PMID: 39097328 PMCID: PMC11298728 DOI: 10.1136/openhrt-2024-002755] [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: 06/05/2024] [Accepted: 07/12/2024] [Indexed: 08/05/2024] Open
Abstract
BACKGROUND Guidelines recommend the use of risk scores to select patients for further investigation after myocardial infarction has been ruled out but their utility to identify those with coronary artery disease is uncertain. METHODS In a prospective cohort study, patients with intermediate high-sensitivity cardiac troponin I concentrations (5 ng/L to sex-specific 99th percentile) in whom myocardial infarction was ruled out were enrolled and underwent coronary CT angiography (CCTA) after hospital discharge. History, ECG, Age, Risk factors, Troponin (HEART), Emergency Department Assessment of Chest Pain Score (EDACS), Global Registry of Acute Coronary Event (GRACE), Thrombolysis In Myocardial Infarction (TIMI), Systematic COronary Risk Evaluation 2 and Pooled Cohort Equation risk scores were calculated and the odds ratio (OR) and diagnostic performance for obstructive coronary artery disease were determined using established thresholds. RESULTS Of 167 patients enrolled (64±12 years, 28% female), 29.9% (50/167) had obstructive coronary artery disease. The odds of having obstructive disease were increased for all scores with the lowest and highest increase observed for an EDACS score ≥16 (OR 2.2 (1.1-4.6)) and a TIMI risk score ≥1 (OR 12.9 (3.0-56.0)), respectively. The positive predictive value (PPV) was low for all scores but was highest for a GRACE score >88 identifying 39% as high risk with a PPV of 41.9% (30.4-54.2%). The negative predictive value (NPV) varied from 77.3% to 95.2% but was highest for a TIMI score of 0 identifying 26% as low risk with an NPV of 95.2% (87.2-100%). CONCLUSIONS In patients with intermediate cardiac troponin concentrations in whom myocardial infarction has been excluded, clinical risk scores can help identify patients with and without coronary artery disease, although the performance of established risk thresholds is suboptimal for utilisation in clinical practice. TRIAL REGISTRATION NUMBER NCT04549805.
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Affiliation(s)
- Daniel Perez-Vicencio
- Centre for Cardiovascular Science, The University of Edinburgh, Edinburgh, UK
- Usher Institute, The University of Edinburgh, Edinburgh, UK
| | | | - Dimitrios Doudesis
- Centre for Cardiovascular Science, The University of Edinburgh, Edinburgh, UK
- Usher Institute, The University of Edinburgh, Edinburgh, UK
| | - Rachel O'Brien
- Emergency Medicine Research Group, Department of Emergency Medicine, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Amy Ferry
- Centre for Cardiovascular Science, The University of Edinburgh, Edinburgh, UK
| | - Takeshi Fujisawa
- Centre for Cardiovascular Science, The University of Edinburgh, Edinburgh, UK
| | | | - Alasdair J Gray
- Usher Institute, The University of Edinburgh, Edinburgh, UK
- Emergency Medicine Research Group, Department of Emergency Medicine, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Nicholas L Mills
- Centre for Cardiovascular Science, The University of Edinburgh, Edinburgh, UK
- Usher Institute, The University of Edinburgh, Edinburgh, UK
| | - Kuan Ken Lee
- Centre for Cardiovascular Science, The University of Edinburgh, Edinburgh, UK
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Cyon L, Kadesjö E, Edgren G, Roos A. Acute Kidney Injury and High-Sensitivity Cardiac Troponin T Levels in the Emergency Department. JAMA Netw Open 2024; 7:e2419602. [PMID: 39212992 PMCID: PMC11365000 DOI: 10.1001/jamanetworkopen.2024.19602] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2024] [Accepted: 04/30/2024] [Indexed: 09/04/2024] Open
Abstract
Importance The clinical implications of high-sensitivity cardiac troponin T (hs-cTnT) measurements in patients with acute kidney injury (AKI) in the emergency department (ED) are largely unknown. Objectives To investigate associations between serum creatinine (SCr) concentrations and hs-cTnT kinetics, as well as the clinical accuracy of hs-cTnT for myocardial infarction (MI) in patients with AKI. Design, Setting, and Participants This retrospective cohort study included 15 111 patient visits to 7 EDs in Sweden from December 9, 2010, to August 31, 2017, by patients 18 years or older fulfilling AKI criteria with 2 or more SCr measurements and 1 or more hs-cTnT measurement. Statistical analysis was performed from October 2, 2022, to September 28, 2023. Exposure Dynamic change in SCr during the ED visits. Main Outcomes and Measures Linear mixed-effects models were used to estimate the log-linear regression of kinetic change in hs-cTnT. Logistic regression models were applied to calculate odds ratios (ORs) for change in hs-cTnT indicating acute myocardial injury (Δhs-cTnT >20% and elevated hs-cTnT >14 ng/L) in association with change in SCr, and to assess the diagnostic performance of hs-cTnT for MI in patients with chest pain. Results There was a total of 15 211 visits by 13 638 patients (median age, 74 years [IQR, 64-83 years]; 8709 men [57%]), of whom 1174 (8%) had an MI. Overall, 11 353 of patients at 14 037 visits without an MI diagnosis (81%) had myocardial injury, and 4396 patients at 14 037 visits (31%) had acute myocardial injury. The change in hs-cTnT among patients without MI was 1.8-fold higher in the highest vs the lowest change in SCr quartile (64.7% [95% CI, 58.4%-71.5%] vs 36.3% [95% CI, 32.4%-40.7%]; exponentiated β coefficient, 1.78 [95% CI, 1.62-1.96]). Patients in the former group were twice as likely to have acute myocardial injury (39% [1378 of 3516 visits] vs 23% [817 of 3507 visits]; adjusted OR, 2.32 [95% CI, 2.08-2.59]). Using a 0 hours hs-cTnT cutoff value of 52 ng/L or higher assigned 627 of 2388 patients (26%) with chest pain to a high-risk group in whom the specificity and positive predictive value for MI was low (78.5% [95% CI, 76.7%-80.2&] and 27.6% [95% CI, 24.1%-31.3%], respectively). Conclusions and Relevance This cohort study of patients in the ED suggests that dynamic change in SCr among patients with AKI was associated with hs-cTnT concentrations indicative of acute myocardial injury. These observations were accompanied by poor performance of recommended hs-cTnT-based algorithms for MI risk stratification.
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Affiliation(s)
- Love Cyon
- Department of Medicine, Clinical Epidemiology Division, Karolinska Institutet, Solna, Stockholm, Sweden
- Department of Emergency and Reparative Medicine, Karolinska University Hospital, Huddinge, Stockholm, Sweden
| | - Erik Kadesjö
- Department of Emergency and Reparative Medicine, Karolinska University Hospital, Huddinge, Stockholm, Sweden
| | - Gustaf Edgren
- Department of Medicine, Clinical Epidemiology Division, Karolinska Institutet, Solna, Stockholm, Sweden
- Department of Cardiology, Södersjukhuset, Stockholm, Sweden
| | - Andreas Roos
- Department of Medicine, Clinical Epidemiology Division, Karolinska Institutet, Solna, Stockholm, Sweden
- Department of Emergency and Reparative Medicine, Karolinska University Hospital, Huddinge, Stockholm, Sweden
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McDermott M, Kimenai DM, Anand A, Huang Z, Houston A, Williams S, Evison F, Gallier S, Carenzo C, Glampson B, Hasan M, Robertson A, Phillips T, Davis C, Sapey E, Mayer E, Mason S, Stammers M, Mills NL. Adoption of high-sensitivity cardiac troponin for risk stratification of patients with suspected myocardial infarction: a multicentre cohort study. THE LANCET REGIONAL HEALTH. EUROPE 2024; 43:100960. [PMID: 38975590 PMCID: PMC11227019 DOI: 10.1016/j.lanepe.2024.100960] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/26/2024] [Revised: 05/24/2024] [Accepted: 05/28/2024] [Indexed: 07/09/2024]
Abstract
Background Guidelines recommend high-sensitivity cardiac troponin to risk stratify patients with possible myocardial infarction and identify those eligible for discharge. Our aim was to evaluate adoption of this approach in practice and to determine whether effectiveness and safety varies by age, sex, ethnicity, or socioeconomic deprivation status. Methods A multi-centre cohort study was conducted in 13 hospitals across the United Kingdom from November 1st, 2021, to October 31st, 2022. Routinely collected data including high-sensitivity cardiac troponin I or T measurements were linked to outcomes. The primary effectiveness and safety outcomes were the proportion discharged from the Emergency Department, and the proportion dead or with a subsequent myocardial infarction at 30 days, respectively. Patients were stratified using peak troponin concentration as low (<5 ng/L), intermediate (5 ng/L to sex-specific 99th percentile), or high-risk (>sex-specific 99th percentile). Findings In total 137,881 patients (49% [67,709/137,881] female) were included of whom 60,707 (44%), 42,727 (31%), and 34,447 (25%) were stratified as low-, intermediate- and high-risk, respectively. Overall, 65.8% (39,918/60,707) of low-risk patients were discharged from the Emergency Department, but this varied from 26.8% [2200/8216] to 93.5% [918/982] by site. The safety outcome occurred in 0.5% (277/60,707) and 11.4% (3917/34,447) of patients classified as low- or high-risk, of whom 0.03% (18/60,707) and 1% (304/34,447) had a subsequent myocardial infarction at 30 days, respectively. A similar proportion of male and female patients were discharged (52% [36,838/70,759] versus 54% [36,113/67,109]), but discharge was more likely if patients were <70 years old (61% [58,533/95,227] versus 34% [14,428/42,654]), from areas of low socioeconomic deprivation (48% [6697/14,087] versus 43% [12,090/28,116]) or were black or asian compared to caucasian (62% [5458/8877] and 55% [10,026/18,231] versus 46% [35,138/75,820]). Interpretation Despite high-sensitivity cardiac troponin correctly identifying half of all patients with possible myocardial infarction as being at low risk, only two-thirds of these patients were discharged. Substantial variation in the discharge of patients by age, ethnicity, socioeconomic deprivation, and site was observed identifying important opportunities to improve care. Funding UK Research and Innovation.
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Affiliation(s)
- Michael McDermott
- British Heart Foundation (BHF) Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Dorien M. Kimenai
- British Heart Foundation (BHF) Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Atul Anand
- British Heart Foundation (BHF) Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Zen Huang
- Usher Institute, University of Edinburgh, Edinburgh, UK
| | - Andrew Houston
- Bart's Health Life Science, Bart's Health NHS Trust, London, UK
| | - Sophie Williams
- Bart's Health Life Science, Bart's Health NHS Trust, London, UK
| | - Felicity Evison
- PIONEER Health Data Hub and NIHR Birmingham Biomedical Research Centre, Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK
| | - Suzy Gallier
- PIONEER Health Data Hub and NIHR Birmingham Biomedical Research Centre, Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK
| | - Catalina Carenzo
- Imperial Clinical Analytics, Research & Evaluation (iCARE) Secure Data Environment, NIHR Imperial Biomedical Research Centre, St Mary's Hospital, London, UK
| | - Ben Glampson
- Imperial Clinical Analytics, Research & Evaluation (iCARE) Secure Data Environment, NIHR Imperial Biomedical Research Centre, St Mary's Hospital, London, UK
| | - Madina Hasan
- CURE Group, Sheffield Centre for Health and Related Research, The University of Sheffield, Sheffield, UK
| | - Alexander Robertson
- CURE Group, Sheffield Centre for Health and Related Research, The University of Sheffield, Sheffield, UK
| | - Thomas Phillips
- Research Data Sciences Team, SETT Centre, University Hospital Southampton, Southampton, UK
| | - Cai Davis
- Research Data Sciences Team, SETT Centre, University Hospital Southampton, Southampton, UK
| | - Elizabeth Sapey
- PIONEER Health Data Hub and NIHR Birmingham Biomedical Research Centre, Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK
| | - Erik Mayer
- Imperial Clinical Analytics, Research & Evaluation (iCARE) Secure Data Environment, NIHR Imperial Biomedical Research Centre, St Mary's Hospital, London, UK
| | - Suzanne Mason
- CURE Group, Sheffield Centre for Health and Related Research, The University of Sheffield, Sheffield, UK
| | - Matthew Stammers
- Research Data Sciences Team, SETT Centre, University Hospital Southampton, Southampton, UK
| | - Nicholas L. Mills
- British Heart Foundation (BHF) Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
- Usher Institute, University of Edinburgh, Edinburgh, UK
| | - HDRUK Regional Linked Data Driven Evidence Network
- British Heart Foundation (BHF) Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
- Usher Institute, University of Edinburgh, Edinburgh, UK
- Bart's Health Life Science, Bart's Health NHS Trust, London, UK
- PIONEER Health Data Hub and NIHR Birmingham Biomedical Research Centre, Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK
- Imperial Clinical Analytics, Research & Evaluation (iCARE) Secure Data Environment, NIHR Imperial Biomedical Research Centre, St Mary's Hospital, London, UK
- CURE Group, Sheffield Centre for Health and Related Research, The University of Sheffield, Sheffield, UK
- Research Data Sciences Team, SETT Centre, University Hospital Southampton, Southampton, UK
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9
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Zalama-Sánchez D, del Pozo Vegas C, Sanz-García A, de Santos-Castro PÁ, Presencio-Dominguez J, González-Izquierdo P, Sánchez-Ramón S, Pinilla-Arribas LT, Baladrón-Segura M, Cheayeb-Morán J, Fernandez-García M, Velasco de Cos G, López-Izquierdo R, Martín-Rodríguez F. Diagnostic Performance of Point-of-Care High-Sensitivity Troponin in the Exclusion of Non-ST-Elevation Myocardial Infarction in the Emergency Department. J Pers Med 2024; 14:762. [PMID: 39064016 PMCID: PMC11277698 DOI: 10.3390/jpm14070762] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2024] [Revised: 07/12/2024] [Accepted: 07/14/2024] [Indexed: 07/28/2024] Open
Abstract
BACKGROUND This study evaluates the diagnostic performance of high-sensitivity troponin using point-of-care testing (POCT) devices compared with main laboratory measurements for ruling out non-ST-elevation myocardial infarction (NSTEMI) in emergency department (ED) patients presenting with non-traumatic chest pain. METHODS This multicenter, observational, prospective, non-interventional study was conducted in two Spanish hospitals from 1 June to 31 December 2023 and included adult patients presenting with non-traumatic chest pain admitted to the ED. High-sensitivity troponin levels were measured using both the Siemens Atellica® VTLi POCT device and main laboratory testing, with data collected on analytical results and measurement times. RESULTS Of the 201 patients who met the inclusion criteria, a significant correlation was observed between the POCT and laboratory assays. The area under the curve (AUC) of the ROC curve was consistently greater than 0.9, indicating a high diagnostic accuracy for ruling out NSTEMI. In addition, measurement times were significantly reduced using POCT compared to the core laboratory. CONCLUSION These results suggest that high-sensitivity troponin POCT devices offer comparable diagnostic performance to traditional laboratory methods for the diagnosis of NSTEMI in the emergency department, potentially speeding up clinical decisions and optimizing resource utilization.
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Affiliation(s)
- Daniel Zalama-Sánchez
- Emergency Department, Hospital Universitario Virgen de la Victoria, 29010 Málaga, Spain;
| | - Carlos del Pozo Vegas
- Faculty of Medicine, University of Valladolid, 47002 Valladolid, Spain; (C.d.P.V.); (R.L.-I.); (F.M.-R.)
- Emergency Department, Hospital Clínico Universitario, 47003 Valladolid, Spain; (P.Á.d.S.-C.); (P.G.-I.); (L.T.P.-A.); (J.C.-M.)
| | - Ancor Sanz-García
- Faculty of Health Sciences, University of Castilla la Mancha, 45600 Talavera de la Reina, Spain
- Technological Innovation Applied to Health Research Group (ITAS Group), Faculty of Health Sciences, University of Castilla La Mancha, 45004 Toledo, Spain
- Evaluación de Cuidados de Salud (ECUSAL), Instituto de Investigación Sanitaria de Castilla-La Mancha (IDISCAM), 45071 Toledo, Spain
| | - Pedro Ángel de Santos-Castro
- Emergency Department, Hospital Clínico Universitario, 47003 Valladolid, Spain; (P.Á.d.S.-C.); (P.G.-I.); (L.T.P.-A.); (J.C.-M.)
| | | | - Pablo González-Izquierdo
- Emergency Department, Hospital Clínico Universitario, 47003 Valladolid, Spain; (P.Á.d.S.-C.); (P.G.-I.); (L.T.P.-A.); (J.C.-M.)
| | - Susana Sánchez-Ramón
- Emergency Department, Hospital Universitario Rio Hortega, 47012 Valladolid, Spain; (J.P.-D.); (S.S.-R.)
| | - Leyre Teresa Pinilla-Arribas
- Emergency Department, Hospital Clínico Universitario, 47003 Valladolid, Spain; (P.Á.d.S.-C.); (P.G.-I.); (L.T.P.-A.); (J.C.-M.)
| | - Manuel Baladrón-Segura
- Clinical Analysis Department, Hospital Universitario Rio Hortega, 47012 Valladolid, Spain; (M.B.-S.); (M.F.-G.)
| | - Jaldún Cheayeb-Morán
- Emergency Department, Hospital Clínico Universitario, 47003 Valladolid, Spain; (P.Á.d.S.-C.); (P.G.-I.); (L.T.P.-A.); (J.C.-M.)
| | - María Fernandez-García
- Clinical Analysis Department, Hospital Universitario Rio Hortega, 47012 Valladolid, Spain; (M.B.-S.); (M.F.-G.)
| | | | - Raúl López-Izquierdo
- Faculty of Medicine, University of Valladolid, 47002 Valladolid, Spain; (C.d.P.V.); (R.L.-I.); (F.M.-R.)
- Emergency Department, Hospital Universitario Rio Hortega, 47012 Valladolid, Spain; (J.P.-D.); (S.S.-R.)
- CIBER of Respiratory Diseases (CIBERES), Institute of Health Carlos III, 28029 Madrid, Spain
| | - Francisco Martín-Rodríguez
- Faculty of Medicine, University of Valladolid, 47002 Valladolid, Spain; (C.d.P.V.); (R.L.-I.); (F.M.-R.)
- Advanced Life Support, Emergency Medical Services (SACYL), 47007 Valladolid, Spain
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10
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Li J, Liu Y, Wu T, Xiao Z, Du J, Liang H, Zhou C, Zhou J. Barbed arrow-like structure membrane with ultra-high rectification coefficient enables ultra-fast, highly-sensitive lateral-flow assay of cTnI. Nat Commun 2024; 15:5603. [PMID: 38961073 PMCID: PMC11222510 DOI: 10.1038/s41467-024-49810-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Accepted: 06/20/2024] [Indexed: 07/05/2024] Open
Abstract
Acute myocardial infarction (AMI) has become a public health disease threatening public life safety due to its high mortality. The lateral-flow assay (LFA) of a typical cardiac biomarker, troponin I (cTnI), is essential for the timely warnings of AMI. However, it is a challenge to achieve an ultra-fast and highly-sensitive assay for cTnI (hs-cTnI) using current LFA, due to the limited performance of chromatographic membranes. Here, we propose a barbed arrow-like structure membrane (BAS Mem), which enables the unidirectional, fast flow and low-residual of liquid. The liquid is rectified through the forces generated by the sidewalls of the barbed arrow-like grooves. The rectification coefficient of liquid flow on BAS Mem is 14.5 (highest to date). Using BAS Mem to replace the conventional chromatographic membrane, we prepare batches of lateral-flow strips and achieve LFA of cTnI within 240 s, with a limit of detection of 1.97 ng mL-1. The lateral-flow strips exhibit a specificity of 100%, a sensitivity of 93.3% in detecting 25 samples of suspected AMI patients. The lateral-flow strips show great performance in providing reliable results for clinical diagnosis, with the potential to provide early warnings for AMI.
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Affiliation(s)
- Juanhua Li
- School of Biomedical Engineering, Shenzhen Campus of Sun Yat-sen University, Shenzhen, Guangdong, China
- Key Laboratory of Sensing Technology and Biomedical Instruments of Guangdong Province, School of Biomedical Engineering, Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Yiren Liu
- School of Biomedical Engineering, Shenzhen Campus of Sun Yat-sen University, Shenzhen, Guangdong, China
- Key Laboratory of Sensing Technology and Biomedical Instruments of Guangdong Province, School of Biomedical Engineering, Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Tianyu Wu
- School of Biomedical Engineering, Shenzhen Campus of Sun Yat-sen University, Shenzhen, Guangdong, China
- Key Laboratory of Sensing Technology and Biomedical Instruments of Guangdong Province, School of Biomedical Engineering, Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Zihan Xiao
- School of Biomedical Engineering, Shenzhen Campus of Sun Yat-sen University, Shenzhen, Guangdong, China
- Key Laboratory of Sensing Technology and Biomedical Instruments of Guangdong Province, School of Biomedical Engineering, Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Jianhang Du
- Guangdong Innovative Engineering and Technology Research Center for Assisted Circulation, the Eighth Affiliated Hospital of Sun Yat-sen University, Shenzhen, Guangdong, China
| | - Hongrui Liang
- School of Biomedical Engineering, Shenzhen Campus of Sun Yat-sen University, Shenzhen, Guangdong, China
- Key Laboratory of Sensing Technology and Biomedical Instruments of Guangdong Province, School of Biomedical Engineering, Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Cuiping Zhou
- Department of Emergency, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, China
| | - Jianhua Zhou
- School of Biomedical Engineering, Shenzhen Campus of Sun Yat-sen University, Shenzhen, Guangdong, China.
- Key Laboratory of Sensing Technology and Biomedical Instruments of Guangdong Province, School of Biomedical Engineering, Sun Yat-sen University, Guangzhou, Guangdong, China.
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11
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Młynarska E, Czarnik W, Fularski P, Hajdys J, Majchrowicz G, Stabrawa M, Rysz J, Franczyk B. From Atherosclerotic Plaque to Myocardial Infarction-The Leading Cause of Coronary Artery Occlusion. Int J Mol Sci 2024; 25:7295. [PMID: 39000400 PMCID: PMC11242737 DOI: 10.3390/ijms25137295] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2024] [Revised: 06/30/2024] [Accepted: 07/01/2024] [Indexed: 07/16/2024] Open
Abstract
Cardiovascular disease (CVD) constitutes the most common cause of death worldwide. In Europe alone, approximately 4 million people die annually due to CVD. The leading component of CVD leading to mortality is myocardial infarction (MI). MI is classified into several types. Type 1 is associated with atherosclerosis, type 2 results from inadequate oxygen supply to cardiomyocytes, type 3 is defined as sudden cardiac death, while types 4 and 5 are associated with procedures such as percutaneous coronary intervention and coronary artery bypass grafting, respectively. Of particular note is type 1, which is also the most frequently occurring form of MI. Factors predisposing to its occurrence include, among others, high levels of low-density lipoprotein cholesterol (LDL-C) in the blood, cigarette smoking, chronic kidney disease (CKD), diabetes mellitus (DM), hypertension, and familial hypercholesterolaemia (FH). The primary objective of this review is to elucidate the issues with regard to type 1 MI. Our paper delves into, amidst other aspects, its pathogenesis, risk assessment, diagnosis, pharmacotherapy, and interventional treatment options in both acute and long-term conditions.
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Affiliation(s)
- Ewelina Młynarska
- Department of Nephrocardiology, Medical University of Lodz, ul. Zeromskiego 113, 90-549 Lodz, Poland
| | - Witold Czarnik
- Department of Nephrocardiology, Medical University of Lodz, ul. Zeromskiego 113, 90-549 Lodz, Poland
| | - Piotr Fularski
- Department of Nephrocardiology, Medical University of Lodz, ul. Zeromskiego 113, 90-549 Lodz, Poland
| | - Joanna Hajdys
- Department of Nephrocardiology, Medical University of Lodz, ul. Zeromskiego 113, 90-549 Lodz, Poland
| | - Gabriela Majchrowicz
- Department of Nephrocardiology, Medical University of Lodz, ul. Zeromskiego 113, 90-549 Lodz, Poland
| | - Magdalena Stabrawa
- Department of Nephrocardiology, Medical University of Lodz, ul. Zeromskiego 113, 90-549 Lodz, Poland
| | - Jacek Rysz
- Department of Nephrology, Hypertension and Family Medicine, Medical University of Lodz, ul. Zeromskiego 113, 90-549 Lodz, Poland
| | - Beata Franczyk
- Department of Nephrocardiology, Medical University of Lodz, ul. Zeromskiego 113, 90-549 Lodz, Poland
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12
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Lopez-Ayala P, Boeddinghaus J, Nestelberger T, Koechlin L, Zimmermann T, Bima P, Glaeser J, Spagnuolo CC, Champetier A, Miro O, Martin-Sanchez FJ, Keller DI, Christ M, Wildi K, Breidthardt T, Strebel I, Mueller C. External validation of the myocardial-ischaemic-injury-index machine learning algorithm for the early diagnosis of myocardial infarction: a multicentre cohort study. Lancet Digit Health 2024; 6:e480-e488. [PMID: 38906613 DOI: 10.1016/s2589-7500(24)00088-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2024] [Revised: 04/18/2024] [Accepted: 04/22/2024] [Indexed: 06/23/2024]
Abstract
BACKGROUND The myocardial-ischaemic-injury-index (MI3) is a novel machine learning algorithm for the early diagnosis of type 1 non-ST-segment elevation myocardial infarction (NSTEMI). The performance of MI3, both when using early serial blood draws (eg, at 1 h or 2 h) and in direct comparison with guideline-recommended algorithms, remains unknown. Our aim was to externally validate MI3 and compare its performance with that of the European Society of Cardiology (ESC) 0/1h-algorithm. METHODS In this secondary analysis of a multicentre international diagnostic cohort study, adult patients (age >18 years) presenting to the emergency department with symptoms suggestive of myocardial infarction were prospectively enrolled from April 21, 2006, to Feb 27, 2019 in 12 centres from five European countries (Switzerland, Spain, Italy, Poland, and Czech Republic). Patients were excluded if they presented with ST-segment-elevation myocardial infarction, did not have at least two serial high-sensitivity cardiac troponin I (hs-cTnI) measurements, or if the final diagnosis remained unclear. The final diagnosis was centrally adjudicated by two independent cardiologists using all available medical records, including serial hs-cTnI measurements and cardiac imaging. The primary outcome was type 1 NSTEMI. The performance of MI3 was directly compared with that of the ESC 0/1h-algorithm. FINDINGS Among 6487 patients, (median age 61·0 years [IQR 49·0-73·0]; 2122 [33%] female and 4365 [67%] male), 882 (13·6%) patients had type 1 NSTEMI. The median time difference between the first and second hs-cTnI measurement was 60·0 mins (IQR 57·0-70·0). MI3 performance was very good, with an area under the receiver-operating-characteristic curve of 0·961 (95% CI 0·957 to 0·965) and a good overall calibration (intercept -0·09 [-0·2 to 0·02]; slope 1·02 [0·97 to 1·08]). The originally defined MI3 score of less than 1·6 identified 4186 (64·5%) patients as low probability of having a type 1 NSTEMI (sensitivity 99·1% [95% CI 98·2 to 99·5]; negative predictive value [NPV] 99·8% [95% CI 99·6 to 99·9]) and an MI3 score of 49·7 or more identified 915 (14·1%) patients as high probability of having a type 1 NSTEMI (specificity 95·0% [94·3 to 95·5]; positive predictive value [PPV] 69·1% [66·0-72·0]). The sensitivity and NPV of the ESC 0/1h-algorithm were higher than that of MI3 (difference for sensitivity 0·88% [0·19 to 1·60], p=0·0082; difference for NPV 0·18% [0·05 to 0·32], p=0·016), and the rule-out efficacy was higher for MI3 (11% difference, p<0·0001). Specificity and PPV for MI3 were superior (difference for specificity 3·80% [3·24 to 4·36], p<0·0001; difference for PPV 7·84% [5·86 to 9·97], p<0·0001), and the rule-in efficacy was higher for the ESC 0/1h-algorithm (5·4% difference, p<0·0001). INTERPRETATION MI3 performs very well in diagnosing type 1 NSTEMI, demonstrating comparability to the ESC 0/1h-algorithm in an emergency department setting when using early serial blood draws. FUNDING Swiss National Science Foundation, Swiss Heart Foundation, the EU, the University Hospital Basel, the University of Basel, Abbott, Beckman Coulter, Roche, Idorsia, Ortho Clinical Diagnostics, Quidel, Siemens, and Singulex.
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Affiliation(s)
- Pedro Lopez-Ayala
- Cardiovascular Research Institute Basel, University Hospital Basel, University of Basel, Basel, Switzerland; Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland; GREAT Association, Rome, Italy.
| | - Jasper Boeddinghaus
- Cardiovascular Research Institute Basel, University Hospital Basel, University of Basel, Basel, Switzerland; Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland; GREAT Association, Rome, Italy; BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Thomas Nestelberger
- Cardiovascular Research Institute Basel, University Hospital Basel, University of Basel, Basel, Switzerland; Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland; GREAT Association, Rome, Italy
| | - Luca Koechlin
- Cardiovascular Research Institute Basel, University Hospital Basel, University of Basel, Basel, Switzerland; Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland; Department of Cardiac Surgery, University Hospital Basel, University of Basel, Basel, Switzerland; GREAT Association, Rome, Italy
| | - Tobias Zimmermann
- Cardiovascular Research Institute Basel, University Hospital Basel, University of Basel, Basel, Switzerland; Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland; GREAT Association, Rome, Italy
| | - Paolo Bima
- Cardiovascular Research Institute Basel, University Hospital Basel, University of Basel, Basel, Switzerland; Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland; GREAT Association, Rome, Italy
| | - Jonas Glaeser
- Cardiovascular Research Institute Basel, University Hospital Basel, University of Basel, Basel, Switzerland; Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland; GREAT Association, Rome, Italy
| | - Carlos C Spagnuolo
- Cardiovascular Research Institute Basel, University Hospital Basel, University of Basel, Basel, Switzerland; Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland; GREAT Association, Rome, Italy
| | - Arnaud Champetier
- Cardiovascular Research Institute Basel, University Hospital Basel, University of Basel, Basel, Switzerland; Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland; GREAT Association, Rome, Italy
| | - Oscar Miro
- GREAT Association, Rome, Italy; Emergency Department, Hospital Clinic, University of Barcelona, Barcelona, Spain
| | | | | | - Michael Christ
- Department of Emergency Medicine, Luzerner Kantonsspital, Luzern, Switzerland
| | - Karin Wildi
- Cardiovascular Research Institute Basel, University Hospital Basel, University of Basel, Basel, Switzerland; Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Tobias Breidthardt
- Cardiovascular Research Institute Basel, University Hospital Basel, University of Basel, Basel, Switzerland; Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland; GREAT Association, Rome, Italy
| | - Ivo Strebel
- Cardiovascular Research Institute Basel, University Hospital Basel, University of Basel, Basel, Switzerland; Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland; GREAT Association, Rome, Italy
| | - Christian Mueller
- Cardiovascular Research Institute Basel, University Hospital Basel, University of Basel, Basel, Switzerland; Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland; GREAT Association, Rome, Italy.
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13
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Lei Y, Jiang M, Liu X, Zhang S, Li M, Wang Y, Chen M, Guo N, Liu Y, Cao X, Yan L. Comparison of Fractional Flow Reserve and Resting Full-Cycle Ratio in the Functional Assessment of Coronary Artery Stenosis in Patients with Non-ST-Segment Elevation Acute Coronary Syndrome. Rev Cardiovasc Med 2024; 25:260. [PMID: 39139424 PMCID: PMC11317337 DOI: 10.31083/j.rcm2507260] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Revised: 02/09/2024] [Accepted: 02/21/2024] [Indexed: 08/15/2024] Open
Abstract
Background This study investigated factors influencing discrepancies between fractional flow reserve (FFR) and resting full-cycle ratio (RFR) in the functional assessment of coronary artery stenosis in patients with non-ST-segment elevation acute coronary syndrome (NSTE-ACS). Methods We included 320 diseased vessels from 253 consecutive patients with NSTE-ACS. Vessels were categorized into four groups based on FFR ≤ 0.80 and RFR ≤ 0.89 thresholds: group 1 concordant negative (RFR-/FFR-), group 2 positive RFR and negative FFR (RFR+/FFR-), group 3 negative RFR and positive FFR (RFR-/FFR+), and group 4 concordant positive (RFR+/FFR+). Univariate and multivariate logistic regression analyses were conducted to identify predictors of diagnostic discrepancy between FFR and RFR. Results Of the 320 diseased vessels, 182 (56.9%) were in group 1 (RFR-/FFR-), 33 (10.3%) in group 2 (RFR+/FFR-), 31 (9.7%) in group 3 (RFR-/FFR+), and 74 (23.1%) in group 4 (RFR+/FFR+). The concordance between FFR and RFR was 80.0%. Notably, left anterior descending artery (LAD) lesions exhibited significantly lower consistency compared to non-LAD lesions (p = 0.001), with distinct differences in FFR and RFR values between these groups (p < 0.001). The presence of a LAD lesion emerged as an independent predictor of diagnostic inconsistency between positive RFR and negative FFR measurements (p = 0.001). Conclusions LAD involvement independently predicts diagnostic discrepancies between FFR and RFR in evaluating functional coronary artery stenosis in NSTE-ACS patients.
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Affiliation(s)
- Yumeng Lei
- Department of Cardiology, Dongguan Songshan Lake Central Hospital, Guangdong Medical University, 523109 Dongguan, Guangdong, China
- Department of Cardiology, Cangzhou Central Hospital, Hebei Medical University, 061007 Cangzhou, Hebei, China
| | - Mao Jiang
- Department of Cardiology, Cangzhou Central Hospital, Hebei Medical University, 061007 Cangzhou, Hebei, China
| | - Xu Liu
- Department of Cardiology, Cangzhou Central Hospital, Hebei Medical University, 061007 Cangzhou, Hebei, China
| | - Shuaiyong Zhang
- Department of Cardiology, Cangzhou Central Hospital, Hebei Medical University, 061007 Cangzhou, Hebei, China
| | - Mengyao Li
- Department of Cardiology, Cangzhou Central Hospital, Hebei Medical University, 061007 Cangzhou, Hebei, China
| | - Yunfei Wang
- Department of Cardiology, Cangzhou Central Hospital, Hebei Medical University, 061007 Cangzhou, Hebei, China
| | - Ming Chen
- Department of Cardiology, Cangzhou Central Hospital, Hebei Medical University, 061007 Cangzhou, Hebei, China
| | - Nan Guo
- Department of Cardiology, Cangzhou Central Hospital, Hebei Medical University, 061007 Cangzhou, Hebei, China
| | - Yongxing Liu
- Department of Cardiology, Cangzhou Central Hospital, Hebei Medical University, 061007 Cangzhou, Hebei, China
| | - Xufen Cao
- Department of Cardiology, Cangzhou Central Hospital, Hebei Medical University, 061007 Cangzhou, Hebei, China
| | - Liqiu Yan
- Department of Cardiology, Dongguan Songshan Lake Central Hospital, Guangdong Medical University, 523109 Dongguan, Guangdong, China
- Department of Cardiology, Cangzhou Central Hospital, Hebei Medical University, 061007 Cangzhou, Hebei, China
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14
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Miller J, Cook B, Gandolfo C, Mills NL, Mahler S, Levy P, Parikh S, Krupp S, Nour K, Klausner H, Gindi R, Lewandowski A, Hudson M, Perrotta G, Zweig B, Lanfear D, Kim H, Dangoulian S, Tang A, Todter E, Khan A, Keerie C, Bole S, Nasseredine H, Oudeif A, Abou Asala E, Mohammed M, Kazem A, Malette K, Singh-Kucukarslan G, Xu N, Wittenberg S, Morton T, Gunaga S, Affas Z, Tabbaa K, Desai P, Alsaadi A, Mahmood S, Schock A, Konowitz N, Fuchs J, Joyce K, Shamoun L, Babel J, Broome A, Digiacinto G, Shaheen E, Darnell G, Muller G, Heath G, Bills G, Vieder J, Rockoff S, Kim B, Colucci A, Plemmons E, McCord J. Rapid Acute Coronary Syndrome Evaluation Over One Hour With High-Sensitivity Cardiac Troponin I: A United States-Based Stepped-Wedge, Randomized Trial. Ann Emerg Med 2024:S0196-0644(24)00235-X. [PMID: 38888531 DOI: 10.1016/j.annemergmed.2024.04.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Revised: 04/17/2024] [Accepted: 04/19/2024] [Indexed: 06/20/2024]
Abstract
STUDY OBJECTIVE The real-world effectiveness and safety of a 0/1-hour accelerated protocol using high-sensitivity cardiac troponin (hs-cTn) to exclude myocardial infarction (MI) compared to routine care in the United States is uncertain. The objective was to compare a 0/1-hour accelerated protocol for evaluation of MI to a 0/3-hour standard care protocol. METHODS The RACE-IT trial was a stepped-wedge, randomized trial across 9 emergency departments (EDs) that enrolled 32,609 patients evaluated for possible MI from July 2020 through April 2021. Patients undergoing high-sensitivity cardiac troponin I testing with concentrations less than or equal to 99th percentile were included. Patients who had MI excluded by the 0/1-hour protocol could be discharged from the ED. Patients in the standard care protocol had 0- and 3-hour troponin testing and application of a modified HEART score to be eligible for discharge. The primary endpoint was the proportion of patients discharged from the ED without 30-day death or MI. RESULTS There were 13,505 and 19,104 patients evaluated in the standard care and accelerated protocol groups, respectively, of whom 19,152 (58.7%) were discharged directly from the ED. There was no significant difference in safe discharges between standard care and the accelerated protocol (59.5% vs 57.8%; adjusted odds ratio (aOR)=1.05, 95% confidence interval [CI] 0.95 to 1.16). At 30 days, there were 90 deaths or MIs with 38 (0.4%) in the standard care group and 52 (0.4%) in the accelerated protocol group (aOR=0.84, 95% CI 0.43 to 1.68). CONCLUSION A 0/1-hour accelerated protocol using high-sensitivity cardiac troponin I did not lead to more safe ED discharges compared with standard care.
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Affiliation(s)
| | | | - Chaun Gandolfo
- Heart and Vascular Institute Henry Ford Health, Detroit, MI
| | | | - Simon Mahler
- Wake Forest University School of Medicine Winston-Salem, NC
| | - Phillip Levy
- Wayne State University School of Medicine, Detroit, MI
| | - Sachin Parikh
- Heart and Vascular Institute Henry Ford Health, Detroit, MI
| | | | - Khaled Nour
- Heart and Vascular Institute Henry Ford Health, Detroit, MI
| | | | - Ryan Gindi
- Heart and Vascular Institute Henry Ford Health, Detroit, MI
| | | | - Michael Hudson
- Heart and Vascular Institute Henry Ford Health, Detroit, MI
| | | | - Bryan Zweig
- Heart and Vascular Institute Henry Ford Health, Detroit, MI
| | - David Lanfear
- Heart and Vascular Institute Henry Ford Health, Detroit, MI
| | - Henry Kim
- Heart and Vascular Institute Henry Ford Health, Detroit, MI
| | | | - Amy Tang
- Henry Ford Hospital, Detroit, MI
| | | | | | | | | | | | | | | | | | | | | | | | - Nicole Xu
- Wayne State University School of Medicine, Detroit, MI
| | | | | | | | - Ziad Affas
- Henry Ford Macomb Hospital, Clinton Township, MI
| | | | - Parth Desai
- Wayne State University School of Medicine, Detroit, MI
| | | | | | | | | | | | | | - Lance Shamoun
- Wake Forest University School of Medicine Winston-Salem, NC
| | - Jacob Babel
- The Usher Institute, University of Edinburgh, Edinburgh, UK
| | - Andrew Broome
- Wake Forest University School of Medicine Winston-Salem, NC
| | | | | | | | | | | | - Gust Bills
- Henry Ford West Bloomfield Hospital, West Bloomfield, MI, USA
| | | | - Steven Rockoff
- Henry Ford West Bloomfield Hospital, West Bloomfield, MI, USA
| | - Brian Kim
- Henry Ford Allegiance Hospital, Jackson, MI
| | | | | | - James McCord
- Heart and Vascular Institute Henry Ford Health, Detroit, MI.
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15
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Pickering JW, Devlin G, Body R, Aldous S, Jaffe AS, Apple FS, Mills N, Troughton RW, Kavsak P, Peacock WF, Cullen L, Lord SJ, Müller C, Joyce L, Frampton C, Lacey CJ, Richards AM, Pitama S, Than M. Protocol for Improving Care by FAster risk-STratification through use of high sensitivity point-of-care troponin in patients presenting with possible acute coronary syndrome in the EmeRgency department (ICare-FASTER): a stepped-wedge cluster randomised quality improvement initiative. BMJ Open 2024; 14:e083752. [PMID: 38871661 PMCID: PMC11177684 DOI: 10.1136/bmjopen-2023-083752] [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: 01/22/2024] [Accepted: 06/03/2024] [Indexed: 06/15/2024] Open
Abstract
INTRODUCTION Clinical assessment in emergency departments (EDs) for possible acute myocardial infarction (AMI) requires at least one cardiac troponin (cTn) blood test. The turn-around time from blood draw to posting results in the clinical portal for central laboratory analysers is ~1-2 hours. New generation, high-sensitivity, point-of-care cardiac troponin I (POC-cTnI) assays use whole blood on a bedside (or near bedside) analyser that provides a rapid (8 min) result. This may expedite clinical decision-making and reduce length of stay. Our purpose is to determine if utilisation of a POC-cTnI testing reduces ED length of stay. We also aim to establish an optimised implementation process for the amended clinical pathway. METHODS AND ANALYSIS This quality improvement initiative has a pragmatic multihospital stepped-wedge cross-sectional cluster randomised design. Consecutive patients presenting to the ED with symptoms suggestive of possible AMI and having a cTn test will be included. Clusters (comprising one or two hospitals each) will change from their usual-care pathway to an amended pathway using POC-cTnI-the 'intervention'. The dates of change will be randomised. Changes occur at 1 month intervals, with a minimum 2 month 'run-in' period. The intervention pathway will use a POC-cTnI measurement as an alternate to the laboratory-based cTn measurement. Clinical decision-making steps and logic will otherwise remain unchanged. The POC-cTnI is the Siemens (Erlangen Germany) Atellica VTLi high-sensitivity cTnI assay. The primary outcome is ED length of stay. The safety outcome is cardiac death or AMI within 30 days for patients discharged directly from the ED. ETHICS AND DISSEMINATION Ethics approval has been granted by the New Zealand Southern Health and Disability Ethics Committee, reference 21/STH/9. Results will be published in a peer-reviewed journal. Lay and academic presentations will be made. Māori-specific results will be disseminated to Māori stakeholders. TRIAL REGISTRATION NUMBER ACTRN12619001189112.
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Affiliation(s)
- John W Pickering
- Medicine, University of Otago Christchurch, Christchurch, New Zealand
- Emergency, Christchurch Hospital, Christchurch, New Zealand
| | - Gerard Devlin
- Waikato District Health Board, Hamilton, New Zealand
- Heart Foundation of New Zealand, Auckland, New Zealand
| | - Richard Body
- Division of Cardiovascular Sciences, University of Manchester, The Victoria University of Manchester Campus, Manchester, UK
| | - Sally Aldous
- Cardiology, Christchurch Hospital, Christchurch, New Zealand
| | | | - Fred S Apple
- University of Minnesota, Minneapolis, Minnesota, USA
| | - Nicholas Mills
- The University of Edinburgh Centre for Cardiovascular Science, Edinburgh, UK
| | - Richard W Troughton
- Medicine, University of Otago Christchurch, Christchurch, New Zealand
- Cardiology, Christchurch Hospital, Christchurch, New Zealand
| | | | - W Frank Peacock
- Emergency Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Louise Cullen
- Institute of Health and Biomedical Innovation and School of Public Health and Social Work, Queensland University of Technology, Brisbane, Queensland, Australia
- Emergency and Trauma Centre, Royal Brisbane and Woman's Hospital Health Service District, Herston, Queensland, Australia
| | - Sarah J Lord
- The School of Medicine, University of Notre Dame Australia - Darlinghurst Campus, Darlinghurst, New South Wales, Australia
- NHMRC Clinical Trials Centre, Camperdown, New South Wales, Australia
| | - Christian Müller
- Division of Cardiology, University Hospital Basel, Basel, Switzerland
| | - Laura Joyce
- Emergency, Christchurch Hospital, Christchurch, New Zealand
- Surgery and Critical Care, University of Otago Christchurch, Christchurch, New Zealand
| | - Chris Frampton
- Medicine, University of Otago Christchurch, Christchurch, New Zealand
| | - Cameron James Lacey
- Māori Indigenous Health Institute, University of Otago Christchurch, Christchurch, New Zealand
| | - Arthur M Richards
- Medicine, University of Otago Christchurch, Christchurch, New Zealand
| | - Suzanne Pitama
- Māori Indigenous Health Institute, University of Otago Christchurch, Christchurch, New Zealand
| | - Martin Than
- Medicine, University of Otago Christchurch, Christchurch, New Zealand
- Emergency, Christchurch Hospital, Christchurch, New Zealand
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16
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Koirala S, Danley K, Kerolos M, Chu J, Yucebay E, Purim-Shem-Tov Y, Volgman AS, Attanasio S. Effect of transitioning from conventional cardiac troponin to high-sensitivity cardiac troponin on resource utilization- a single center experience. Am J Emerg Med 2024; 80:174-177. [PMID: 38613986 DOI: 10.1016/j.ajem.2024.04.007] [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: 09/15/2023] [Revised: 03/09/2024] [Accepted: 04/06/2024] [Indexed: 04/15/2024] Open
Abstract
BACKGROUND Compared to conventional cardiac troponin (cTn), the high-sensitivity cardiac troponin (hs-cTn) assay is associated with improved detection of myocardial infarction (MI). METHODS We performed a descriptive retrospective analysis of resource utilization at Rush University Medical Center over the transition period (July 1, 2021) from a cTn to a hs-cTn assay. Inclusion criteria included emergency department (ED) encounters between January 1 to December 31, 2021, with chief complaints of "chest pain" or "dyspnea" with associated troponin orders. The primary endpoint was the percentage of ED discharges. Secondary endpoints included the number of cardiac studies ordered. Univariable comparisons of these endpoints were performed using Student's t-test for continuous variables and Chi-square tests for binary/categorical variables. RESULTS A total of 5113 encounters were analyzed. Hs-cTn was associated with an overall increase in ED patient discharges with negative troponin tests (44.1% vs. 29.9%, P < 0.01). In terms of cardiac testing per encounter, hs-cTn was associated with significant increases in the number of troponin tests (1.9 vs. 1.6, P < 0.01), electrocardiograms (3.0 vs. 2.9, P = 0.01), and echocardiograms (0.5 vs. 0.4, P < 0.01). There was a significant decrease in the utilization of stress testing (0.21 vs. 0.26, P < 0.01). There was a significant increase in total coronary angiography use during the hs-cTn period compared to cTn (227/2471 (9.2%) vs. 195/2642 (7.4%), P = 0.02). CONCLUSION Transitioning from cTn to hs-cTn was associated with significantly increased ED discharges and an increase in troponin tests, ECG, echocardiograms, and coronary angiograms. There was a decrease in the number of stress tests.
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Affiliation(s)
- Sushant Koirala
- Department of Internal Medicine, Rush University Medical Center, 600 S. Paulina St., Chicago, IL 60612, USA.
| | - Kelsey Danley
- Department of Internal Medicine, Rush University Medical Center, Chicago, IL, USA.
| | - Mina Kerolos
- Department of Internal Medicine, Rush University Medical Center, Chicago, IL, USA.
| | - Jian Chu
- Department of Internal Medicine, Rush University Medical Center, Chicago, IL, USA.
| | - Elif Yucebay
- Department of Emergency Medicine, Rush University Medical Center, Chicago, IL, USA.
| | | | - Annabelle Santos Volgman
- Division of Cardiology, Department of Internal Medicine, Rush University Medical Center, Chicago, IL, USA.
| | - Steve Attanasio
- Division of Cardiology, Department of Internal Medicine, Rush University Medical Center, Chicago, IL, USA.
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17
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Lan NSR, Goh A, Dwivedi G, Hillis GS, Rankin JM, Chew DP, Ihdayhid AR. Low-level elevations in high-sensitivity cardiac troponin predict obstructive coronary artery disease and revascularisation in rural patients with non-ST-elevation myocardial infarction referred for coronary angiography. Intern Med J 2024; 54:1035-1039. [PMID: 38808795 DOI: 10.1111/imj.16412] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2024] [Accepted: 04/29/2024] [Indexed: 05/30/2024]
Abstract
Rural patients with non-ST-elevation myocardial infarction (NSTEMI) are transferred to metropolitan hospitals for invasive coronary angiography (ICA). Yet, many do not have obstructive coronary artery disease (CAD). In this analysis of rural Western Australian patients transferred for ICA for NSTEMI, low-level elevations in high-sensitivity cardiac troponin (≤5× upper reference limit) were associated with less obstructive CAD and revascularisation. Along with other factors, this may help identify rural patients not requiring transfer for ICA.
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Affiliation(s)
- Nick S R Lan
- Department of Cardiology, Fiona Stanley Hospital, Perth, Western Australia, Australia
- Medical School, The University of Western Australia, Perth, Western Australia, Australia
| | - Angela Goh
- Department of Cardiology, Fiona Stanley Hospital, Perth, Western Australia, Australia
| | - Girish Dwivedi
- Department of Cardiology, Fiona Stanley Hospital, Perth, Western Australia, Australia
- Medical School, The University of Western Australia, Perth, Western Australia, Australia
- Harry Perkins Institute of Medical Research, Perth, Western Australia, Australia
| | - Graham S Hillis
- Medical School, The University of Western Australia, Perth, Western Australia, Australia
- Department of Cardiology, Royal Perth Hospital, Perth, Western Australia, Australia
| | - James M Rankin
- Department of Cardiology, Fiona Stanley Hospital, Perth, Western Australia, Australia
| | - Derek P Chew
- Victorian Heart Hospital, Monash University, Melbourne, Victoria, Australia
| | - Abdul Rahman Ihdayhid
- Department of Cardiology, Fiona Stanley Hospital, Perth, Western Australia, Australia
- Harry Perkins Institute of Medical Research, Perth, Western Australia, Australia
- Medical School, Curtin University, Perth, Western Australia, Australia
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18
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Ruperti‐Repilado FJ, Tran F, Haaf P, Lopez‐Ayala P, Greutmann M, Schwerzmann M, Bouchardy J, Gabriel H, Stambach D, Rutz T, Schwitter J, Wustmann K, Freese M, Mueller C, Tobler D. Prognostic Value and Determinants of High-Sensitivity Cardiac Troponin T in Patients With a Systemic Right Ventricle: Insights From the SERVE Trial. J Am Heart Assoc 2024; 13:e034776. [PMID: 38726920 PMCID: PMC11179810 DOI: 10.1161/jaha.123.034776] [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: 02/15/2024] [Accepted: 04/17/2024] [Indexed: 05/22/2024]
Abstract
BACKGROUND The determinants and prognostic value of high-sensitivity cardiac troponin T (hs-cTnT) among patients with a systemic right ventricle are largely unknown. METHODS AND RESULTS Ninety-eight patients from the randomized controlled SERVE (Effect of Phosphodiesterase-5 Inhibition With Tadalafil on Systemic Right Ventricular Size and Function) trial were included. The correlation between baseline hs-cTnT concentrations and biventricular volumes and function quantified by cardiac magnetic resonance or cardiac multirow detector computed tomography was assessed by adjusted linear regression models. The prognostic value of hs-cTnT was assessed by adjusted Cox proportional hazards models, survival analysis, and concordance statistics. The primary outcome was time to the composite of clinically relevant arrhythmia, hospitalization for heart failure, or all-cause death. Median age was 39 (interquartile range, 32-48) years, and 32% were women. Median hs-cTnT concentration was 7 (interquartile range, 4-11) ng/L. Coefficients of determination for the relationship between hs-cTnT concentrations and right ventricular end-systolic volume index and right ventricular ejection fraction (RVEF) were +0.368 (P=0.046) and -0.381 (P=0.018), respectively. The sex- and age-adjusted hazard ratio for the primary outcome of hs-cTnT at 2 and 4 times the reference level (5 ng/L) were 2.89 (95% CI, 1.14-7.29) and 4.42 (95% CI, 1.21-16.15), respectively. The prognostic performance quantified by the concordance statistics for age- and sex-adjusted models based on hs-cTnT, right ventricular ejection fraction, and peak oxygen uptake predicted were comparable: 0.71% (95% CI, 0.61-0.82), 0.72% (95% CI, 0.59-0.84), and 0.71% (95% CI, 0.59-0.83), respectively. CONCLUSIONS Hs-cTnT concentration was significantly correlated with right ventricular ejection fraction and right ventricular end-systolic volume index in patients with a systemic right ventricle. The prognostic accuracy of hs-cTnT was comparable to that of right ventricular ejection fraction and peak oxygen uptake predicted. REGISTRATION URL: https://www.clinicaltrials.gov; Unique identifier: NCT03049540.
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Affiliation(s)
- Francisco Javier Ruperti‐Repilado
- Division of CardiologyUniversity Hospital of BaselBaselSwitzerland
- Division of CardiologyCardiovascular Research Institute Basel, University Hospital Basel, SwitzerlandBaselSwitzerland
| | - Fabian Tran
- Division of CardiologyCardiovascular Research Institute Basel, University Hospital Basel, SwitzerlandBaselSwitzerland
| | - Philip Haaf
- Division of CardiologyUniversity Hospital of BaselBaselSwitzerland
| | - Pedro Lopez‐Ayala
- Division of CardiologyCardiovascular Research Institute Basel, University Hospital Basel, SwitzerlandBaselSwitzerland
| | - Matthias Greutmann
- Department of CardiologyUniversity Heart Center, University of ZurichZurichSwitzerland
| | - Markus Schwerzmann
- University Clinic of Cardiology, Center for Congenital Heart DiseaseInselspital, University HospitalBernSwitzerland
- Division of CardiologyUniversity of Ottawa Heart InstituteOttawaOntarioCanada
| | - Judith Bouchardy
- Division of CardiologyLausanne University HospitalLausanneSwitzerland
- Division of CardiologyHôpitaux Universitaires de Genève (HUG)GenèveSwitzerland
| | - Harald Gabriel
- Department of CardiologyMedical University of Vienna, Adult Congenital Heart Disease ProgramViennaAustria
| | - Dominik Stambach
- Department of CardiologyKantonsspital St GallenSt GallenSwitzerland
| | - Tobias Rutz
- University Clinic of Cardiology, Center for Congenital Heart DiseaseInselspital, University HospitalBernSwitzerland
| | - Juerg Schwitter
- Division of CardiologyLausanne University HospitalLausanneSwitzerland
- Cardiac MR Center of the University Hospital Lausanne, CHUVLausanneSwitzerland
- Faculty of Biology&MedicineUniversity of Lausanne, UniLLausanneSwitzerland
| | - Kerstin Wustmann
- Division of CardiologyLausanne University HospitalLausanneSwitzerland
- Cardiac MR Center of the University Hospital Lausanne, CHUVLausanneSwitzerland
- Department of Congenital Heart Defects and Paediatric Cardiology, German Heart Center MunichTechnical University MunichMunichGermany
| | - Michael Freese
- Division of CardiologyCardiovascular Research Institute Basel, University Hospital Basel, SwitzerlandBaselSwitzerland
| | - Christian Mueller
- Division of CardiologyUniversity Hospital of BaselBaselSwitzerland
- Division of CardiologyCardiovascular Research Institute Basel, University Hospital Basel, SwitzerlandBaselSwitzerland
| | - Daniel Tobler
- Division of CardiologyUniversity Hospital of BaselBaselSwitzerland
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19
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Li Z, Wereski R, Anand A, Lowry MTH, Doudesis D, McDermott M, Ferry AV, Tuck C, Chapman AR, Lee KK, Shah ASV, Mills NL, Kimenai DM. Uniform or Sex-Specific Cardiac Troponin Thresholds to Rule Out Myocardial Infarction at Presentation. J Am Coll Cardiol 2024; 83:1855-1866. [PMID: 38537916 DOI: 10.1016/j.jacc.2024.03.365] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2024] [Revised: 03/05/2024] [Accepted: 03/06/2024] [Indexed: 07/18/2024]
Abstract
BACKGROUND Myocardial infarction can be ruled out in patients with a single cardiac troponin measurement. Whether use of a uniform rule-out threshold has resulted in sex differences in care remains unclear. OBJECTIVES The purpose of this study was to evaluate implementation of a uniform rule-out threshold in females and males with possible myocardial infarction, and to derive and validate sex-specific thresholds. METHODS The implementation of a uniform rule-out threshold (<5 ng/L) with a high-sensitivity cardiac troponin I assay was evaluated in consecutive patients presenting with possible myocardial infarction. The proportion of low-risk patients discharged from the emergency department and incidence of myocardial infarction or cardiac death at 30 days were determined. Sex-specific thresholds were derived and validated, and proportion of female and male patients were stratified as low-risk compared with uniform threshold. RESULTS In 16,792 patients (age 58 ± 17 years; 46% female) care was guided using a uniform threshold. This identified more female than male patients as low risk (73% vs 62%), but a similar proportion of low-risk patients were discharged from the emergency department (81% for both) with fewer than 5 (<0.1%) patients having a subsequent myocardial infarction or cardiac death at 30 days. Compared with a uniform threshold of <5 ng/L, use of sex-specific thresholds would increase the proportion of female (61.8% vs 65.9%) and reduce the proportion of male (54.8% vs 47.8%) patients identified as low risk. CONCLUSIONS Implementation of a uniform rule-out threshold for myocardial infarction was safe and effective in both sexes. Sex-specific rule-out thresholds should be considered, but their impact on effectiveness and safety may be limited.
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Affiliation(s)
- Ziwen Li
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom. https://twitter.com/ZiwenCassLi
| | - Ryan Wereski
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
| | - Atul Anand
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
| | - Matthew T H Lowry
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
| | - Dimitrios Doudesis
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
| | - Michael McDermott
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
| | - Amy V Ferry
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
| | - Chris Tuck
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
| | - Andrew R Chapman
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom; Department of Cardiology, Auckland City Hospital, Auckland, New Zealand
| | - Kuan Ken Lee
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
| | - Anoop S V Shah
- Department of Non-Communicable Disease, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Nicholas L Mills
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom; Usher Institute, University of Edinburgh, Edinburgh, United Kingdom
| | - Dorien M Kimenai
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom.
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20
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Strandkjær N, Jørgensen N, Hasselbalch RB, Kristensen J, Knudsen MSS, Kock TO, Lange T, Lindholm MG, Bruun NE, Holmvang L, Terkelsen CJ, Pedersen CK, Christensen MK, Lassen JF, Hilsted L, Ladefoged S, Nybo M, Bor MV, Dahl M, Hansen AB, Kamstrup PR, Bundgaard H, Torp‐Pedersen C, Iversen KK. DANSPOT: A Multicenter Stepped-Wedge Cluster-Randomized Trial of the Reclassification of Acute Myocardial Infarction: Rationale and Study Design. J Am Heart Assoc 2024; 13:e033493. [PMID: 38639348 PMCID: PMC11179950 DOI: 10.1161/jaha.123.033493] [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: 11/09/2023] [Accepted: 03/13/2024] [Indexed: 04/20/2024]
Abstract
BACKGROUND Cardiac troponins are the preferred biomarkers for the diagnosis of acute myocardial infarction. Although sex-specific 99th percentile thresholds of troponins are recommended in international guidelines, the clinical effect of their use is poorly investigated. The DANSPOT Study (The Danish Study of Sex- and Population-Specific 99th percentile upper reference limits of Troponin) aims to evaluate the clinical effect of a prospective implementation of population- and sex-specific diagnostic thresholds of troponins into clinical practice. METHODS This study is a nationwide, multicenter, stepped-wedge cluster-randomized trial of the implementation of population- and sex-specific thresholds of troponins in 22 of 23 clinical centers in Denmark. We established sex-specific thresholds for 5 different troponin assays based on troponin levels in a healthy Danish reference population. Centers will sequentially cross over from current uniform manufacturer-derived thresholds to the new population- and sex-specific thresholds. The primary cohort is defined as patients with symptoms suggestive of acute coronary syndrome having at least 1 troponin measurement performed within 24 hours of arrival with a peak troponin value between the current uniform threshold and the new sex-specific female and male thresholds. The study will compare the occurrence of the primary outcome, defined as a composite of nonfatal myocardial infarction, unplanned revascularization, and all-cause mortality within 1 year, separately for men and women before and after the implementation of the new sex-specific thresholds. CONCLUSIONS The DANSPOT Study is expected to show the clinical effects on diagnostics, treatment, and clinical outcomes in patients with myocardial infarction of implementing sex-specific diagnostic thresholds for troponin based on a national Danish reference population. REGISTRATION URL: https://www.clinicaltrials.gov; Unique identifier: NCT05336435.
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Affiliation(s)
- Nina Strandkjær
- Department of Emergency MedicineCopenhagen University Hospital—Herlev and GentofteHerlevDenmark
- Department of CardiologyCopenhagen University Hospital—Herlev and GentofteHerlevDenmark
- Department of Clinical MedicineUniversity of CopenhagenDenmark
| | - Nicoline Jørgensen
- Department of Emergency MedicineCopenhagen University Hospital—Herlev and GentofteHerlevDenmark
- Department of CardiologyCopenhagen University Hospital—Herlev and GentofteHerlevDenmark
| | - Rasmus Bo Hasselbalch
- Department of Emergency MedicineCopenhagen University Hospital—Herlev and GentofteHerlevDenmark
- Department of CardiologyCopenhagen University Hospital—Herlev and GentofteHerlevDenmark
- Department of Clinical MedicineUniversity of CopenhagenDenmark
| | - Jonas Kristensen
- Department of Emergency MedicineCopenhagen University Hospital—Herlev and GentofteHerlevDenmark
- Department of CardiologyCopenhagen University Hospital—Herlev and GentofteHerlevDenmark
- Department of Clinical MedicineUniversity of CopenhagenDenmark
| | - Marie Sophie Sander Knudsen
- Department of Emergency MedicineCopenhagen University Hospital—Herlev and GentofteHerlevDenmark
- Department of CardiologyCopenhagen University Hospital—Herlev and GentofteHerlevDenmark
| | - Thilde Olivia Kock
- Department of CardiologyCopenhagen University Hospital—Herlev and GentofteHerlevDenmark
| | - Theis Lange
- Department of Public HealthUniversity of CopenhagenDenmark
| | | | - Niels Eske Bruun
- Department of Clinical MedicineUniversity of CopenhagenDenmark
- Department of CardiologyZealand University HospitalRoskildeDenmark
| | - Lene Holmvang
- Department of CardiologyCopenhagen University Hospital—RigshospitaletCopenhagenDenmark
| | | | | | | | | | - Linda Hilsted
- Department of Clinical BiochemistryCopenhagen University Hospital—RigshospitaletCopenhagenDenmark
| | - Søren Ladefoged
- Department of Clinical BiochemistryAarhus University HospitalAarhusDenmark
| | - Mads Nybo
- Department of Clinical BiochemistryOdense University HospitalOdenseDenmark
| | - Mustafa Vakur Bor
- Department of Clinical BiochemistryUniversity of Hospital of South DenmarkEsbjergDenmark
| | - Morten Dahl
- Department of Clinical MedicineUniversity of CopenhagenDenmark
- Department of Clinical BiochemistryZealand University HospitalKøgeDenmark
| | | | - Pia Rørbæk Kamstrup
- Department of Clinical BiochemistryCopenhagen University Hospital—Herlev and GentofteHerlevDenmark
| | - Henning Bundgaard
- Department of Clinical MedicineUniversity of CopenhagenDenmark
- Department of CardiologyCopenhagen University Hospital—RigshospitaletCopenhagenDenmark
| | - Christian Torp‐Pedersen
- Department of Public HealthUniversity of CopenhagenDenmark
- Department of CardiologyCopenhagen University Hospital—North ZealandHillerødDenmark
| | - Kasper Karmark Iversen
- Department of Emergency MedicineCopenhagen University Hospital—Herlev and GentofteHerlevDenmark
- Department of CardiologyCopenhagen University Hospital—Herlev and GentofteHerlevDenmark
- Department of Clinical MedicineUniversity of CopenhagenDenmark
- Department of Internal MedicineCopenhagen University Hospital—Herlev and GentofteHerlevDenmark
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21
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Alkhalaileh H, Wei R, Cordero Rivera A, Goksel M, Lee JKY, Mazzaferri, Jr. E, Jones J, Li J. Evaluation of Age and Sex Differences in Contemporary versus High-Sensitivity Troponin I Measurement in Hospitalized Patients. J Clin Med 2024; 13:2428. [PMID: 38673701 PMCID: PMC11051137 DOI: 10.3390/jcm13082428] [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: 03/13/2024] [Revised: 04/13/2024] [Accepted: 04/19/2024] [Indexed: 04/28/2024] Open
Abstract
Background: With the transition from the contemporary (cTnI) to high-sensitivity troponin assay (hs-cTnI), concerns have arisen regarding the diagnostic differences between these two assays due to analytical distinctions. This study aims to evaluate the age and sex differences between these two assays, as well as the differences resulting from using two different 99th percentile values of the high-sensitivity troponin assay. Method: A retrospective observational study was conducted at an academic medical center, encompassing a total of 449 lithium heparin plasma samples included in the dataset. Both contemporary and high-sensitivity troponin were simultaneously measured using Siemens ADVIA Centaur analyzers. Two sets of sex-specific 99th percentile URLs from the Siemens study (cutoff-1) and Universal Sample Bank data (cutoff-2) were used for the data analysis. Results: The use of cutoff-1 or cutoff-2 had a negligible impact on troponin classification. Troponin elevation significantly increased in individuals > 50 years old for males and >40 years old for females, with both troponin assays. A receiver operating characteristic analysis did not find significant differences between the two assays. The Kaplan-Meier curves showed no differences in survival in cTnI according to the non-sex-specific 99th URL or hs-cTnI (cutoff-2) but showed a slight difference in survival in hs-cTnI (cutoff-1). Conclusions: Overall, there were no significant differences in age and sex in the diagnostic performance between the contemporary and high-sensitivity troponin assays. Selection criteria for the establishment of the 99th percentile URL should be standardized to avoid the misinterpretation of the troponin results.
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Affiliation(s)
- Hussam Alkhalaileh
- The Ohio State College of Medicine, The Ohio State University, Columbus, OH 43210, USA;
| | - Ruhan Wei
- Department of Pathology, Duke University School of Medicine, Durham, NC 27710, USA;
| | - Ashly Cordero Rivera
- Department of Pathology, Wexner Medical Center, The Ohio State University, 410 W 10th Ave., Columbus, OH 43210, USA; (A.C.R.); (M.G.); (J.J.)
| | - Mustafa Goksel
- Department of Pathology, Wexner Medical Center, The Ohio State University, 410 W 10th Ave., Columbus, OH 43210, USA; (A.C.R.); (M.G.); (J.J.)
| | - Jason K. Y. Lee
- Department of Clinical Laboratory, University Hospital, The Ohio State University, Columbus, OH 43210, USA;
| | - Ernest Mazzaferri, Jr.
- Division of Cardiovascular Medicine, Department of Internal Medicine, Wexner Medical Center, The Ohio State University, Columbus, OH 43210, USA;
| | - JoAnna Jones
- Department of Pathology, Wexner Medical Center, The Ohio State University, 410 W 10th Ave., Columbus, OH 43210, USA; (A.C.R.); (M.G.); (J.J.)
| | - Jieli Li
- Department of Pathology, Wexner Medical Center, The Ohio State University, 410 W 10th Ave., Columbus, OH 43210, USA; (A.C.R.); (M.G.); (J.J.)
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22
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Gallacher PJ, Yeung D, Bell S, Shah ASV, Mills NL, Dhaun N. Kidney replacement therapy: trends in incidence, treatment, and outcomes of myocardial infarction and stroke in a nationwide Scottish study. Eur Heart J 2024; 45:1339-1351. [PMID: 38426727 PMCID: PMC11015953 DOI: 10.1093/eurheartj/ehae080] [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: 05/26/2023] [Revised: 12/21/2023] [Accepted: 01/29/2024] [Indexed: 03/02/2024] Open
Abstract
BACKGROUND AND AIMS Patients with kidney failure have a higher risk of cardiovascular disease compared with the general population. Whilst temporal trends of myocardial infarction and stroke are declining in the general population, these have not been evaluated in patients with kidney failure. This study aimed to describe national trends in the incidence, treatment, and outcomes of myocardial infarction and stroke in patients with kidney failure (i.e. on dialysis or with a kidney transplant) over a 20-year period, stratified by age and sex. METHODS In this retrospective national data linkage study, all patients with kidney failure in Scotland (UK) receiving kidney replacement therapy between January 1996 and December 2016 were linked to national hospitalization, prescribing, and death records. The primary outcomes were the incidence of myocardial infarction and stroke, and subsequent cardiovascular death. Generalized additive models were constructed to estimate age-standardized, sex-stratified incidence rates and trends in cardiovascular and all-cause death. RESULTS Amongst 16 050 patients with kidney failure [52 (SD 15) years; 41.5% women], there were 1992 [66 (SD 12) years; 34.8% women] and 996 [65 (SD 13) years; 45.1% women] incident myocardial infarctions and strokes, respectively, between January 1996 and December 2016. During this period, the age-standardized incidence of myocardial infarction per 100 000 decreased in men {from 4376 [95% confidence interval (CI) 3998-4785] to 1835 (95% CI 1692-1988)} and women [from 3268 (95% CI 2982-3593) to 1369 (95% CI 1257-1491)]. Similarly, the age-standardized incidence of stroke per 100 000 also decreased in men [from 1978 (95% CI 1795-2175) to 799 (95% CI 729-875)] and women [from 2234 (95% CI 2031-2468) to 903 (95% CI 824-990)]. Compared with the general population, the incidence of myocardial infarction was four- to eight-fold higher in patients with kidney failure, whilst for stroke it was two- to four-fold higher. The use of evidence-based cardioprotective treatment increased over the study period, and the predicted probability of cardiovascular death within 1 year of myocardial infarction for a 66-year-old patient with kidney failure (mean age of the cohort) fell in men (76.6% to 38.6%) and women (76.8% to 38.8%), and also decreased in both sexes following stroke (men, from 63.5% to 41.4%; women, from 67.6% to 45.8%). CONCLUSIONS The incidence of myocardial infarction and stroke has halved in patients with kidney failure over the past 20 years but remains significantly higher than in the general population. Despite improvements in treatment and outcomes, the prognosis of these patients following myocardial infarction and stroke remains poor.
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Affiliation(s)
- Peter J Gallacher
- BHF/University Centre for Cardiovascular Science, Little France Crescent, University of Edinburgh, Edinburgh EH16 4SA, UK
| | - David Yeung
- BHF/University Centre for Cardiovascular Science, Little France Crescent, University of Edinburgh, Edinburgh EH16 4SA, UK
| | - Samira Bell
- Division of Population Health and Genomics, University of Dundee, Dundee, UK
- Scottish Renal Registry, Scottish Health Audits, Public Health Scotland, Glasgow, UK
| | - Anoop S V Shah
- Department of Non-Communicable Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
| | - Nicholas L Mills
- BHF/University Centre for Cardiovascular Science, Little France Crescent, University of Edinburgh, Edinburgh EH16 4SA, UK
- Usher Institute, University of Edinburgh, Edinburgh, UK
| | - Neeraj Dhaun
- BHF/University Centre for Cardiovascular Science, Little France Crescent, University of Edinburgh, Edinburgh EH16 4SA, UK
- Department of Renal Medicine, Royal Infirmary of Edinburgh, Edinburgh, UK
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23
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Boeddinghaus J, Doudesis D, Lopez-Ayala P, Lee KK, Koechlin L, Wildi K, Nestelberger T, Borer R, Miró Ò, Martin-Sanchez FJ, Strebel I, Rubini Giménez M, Keller DI, Christ M, Bularga A, Li Z, Ferry AV, Tuck C, Anand A, Gray A, Mills NL, Mueller C. Machine Learning for Myocardial Infarction Compared With Guideline-Recommended Diagnostic Pathways. Circulation 2024; 149:1090-1101. [PMID: 38344871 DOI: 10.1161/circulationaha.123.066917] [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: 08/28/2023] [Accepted: 01/16/2024] [Indexed: 02/29/2024]
Abstract
BACKGROUND Collaboration for the Diagnosis and Evaluation of Acute Coronary Syndrome (CoDE-ACS) is a validated clinical decision support tool that uses machine learning with or without serial cardiac troponin measurements at a flexible time point to calculate the probability of myocardial infarction (MI). How CoDE-ACS performs at different time points for serial measurement and compares with guideline-recommended diagnostic pathways that rely on fixed thresholds and time points is uncertain. METHODS Patients with possible MI without ST-segment-elevation were enrolled at 12 sites in 5 countries and underwent serial high-sensitivity cardiac troponin I concentration measurement at 0, 1, and 2 hours. Diagnostic performance of the CoDE-ACS model at each time point was determined for index type 1 MI and the effectiveness of previously validated low- and high-probability scores compared with guideline-recommended European Society of Cardiology (ESC) 0/1-hour, ESC 0/2-hour, and High-STEACS (High-Sensitivity Troponin in the Evaluation of Patients With Suspected Acute Coronary Syndrome) pathways. RESULTS In total, 4105 patients (mean age, 61 years [interquartile range, 50-74]; 32% women) were included, among whom 575 (14%) had type 1 MI. At presentation, CoDE-ACS identified 56% of patients as low probability, with a negative predictive value and sensitivity of 99.7% (95% CI, 99.5%-99.9%) and 99.0% (98.6%-99.2%), ruling out more patients than the ESC 0-hour and High-STEACS (25% and 35%) pathways. Incorporating a second cardiac troponin measurement, CoDE-ACS identified 65% or 68% of patients as low probability at 1 or 2 hours, for an identical negative predictive value of 99.7% (99.5%-99.9%); 19% or 18% as high probability, with a positive predictive value of 64.9% (63.5%-66.4%) and 68.8% (67.3%-70.1%); and 16% or 14% as intermediate probability. In comparison, after serial measurements, the ESC 0/1-hour, ESC 0/2-hour, and High-STEACS pathways identified 49%, 53%, and 71% of patients as low risk, with a negative predictive value of 100% (99.9%-100%), 100% (99.9%-100%), and 99.7% (99.5%-99.8%); and 20%, 19%, or 29% as high risk, with a positive predictive value of 61.5% (60.0%-63.0%), 65.8% (64.3%-67.2%), and 48.3% (46.8%-49.8%), resulting in 31%, 28%, or 0%, who require further observation in the emergency department, respectively. CONCLUSIONS CoDE-ACS performs consistently irrespective of the timing of serial cardiac troponin measurement, identifying more patients as low probability with comparable performance to guideline-recommended pathways for MI. Whether care guided by probabilities can improve the early diagnosis of MI requires prospective evaluation. REGISTRATION URL: https://www.clinicaltrials.gov; Unique identifier: NCT00470587.
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Affiliation(s)
- Jasper Boeddinghaus
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology (J.B., P.L.-A., L.K., K.W., T.N., R.B., I.S., M.R.G., C.M.), University Hospital Basel, University of Basel, Switzerland
- BHF/University Centre for Cardiovascular Science (J.B., D.D., K.K.L., A.B., Z.L., A.V.F., C.T., A.A., N.L.M.), University of Edinburgh, UK
| | - Dimitrios Doudesis
- BHF/University Centre for Cardiovascular Science (J.B., D.D., K.K.L., A.B., Z.L., A.V.F., C.T., A.A., N.L.M.), University of Edinburgh, UK
- Usher Institute (D.D., K.K.L., A.G., N.L.M.), University of Edinburgh, UK
| | - Pedro Lopez-Ayala
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology (J.B., P.L.-A., L.K., K.W., T.N., R.B., I.S., M.R.G., C.M.), University Hospital Basel, University of Basel, Switzerland
| | - Kuan Ken Lee
- BHF/University Centre for Cardiovascular Science (J.B., D.D., K.K.L., A.B., Z.L., A.V.F., C.T., A.A., N.L.M.), University of Edinburgh, UK
- Usher Institute (D.D., K.K.L., A.G., N.L.M.), University of Edinburgh, UK
| | - Luca Koechlin
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology (J.B., P.L.-A., L.K., K.W., T.N., R.B., I.S., M.R.G., C.M.), University Hospital Basel, University of Basel, Switzerland
- Departments of Cardiac Surgery (L.K.), University Hospital Basel, University of Basel, Switzerland
| | - Karin Wildi
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology (J.B., P.L.-A., L.K., K.W., T.N., R.B., I.S., M.R.G., C.M.), University Hospital Basel, University of Basel, Switzerland
- Intensive Care (K.W.), University Hospital Basel, University of Basel, Switzerland
| | - Thomas Nestelberger
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology (J.B., P.L.-A., L.K., K.W., T.N., R.B., I.S., M.R.G., C.M.), University Hospital Basel, University of Basel, Switzerland
| | - Raphael Borer
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology (J.B., P.L.-A., L.K., K.W., T.N., R.B., I.S., M.R.G., C.M.), University Hospital Basel, University of Basel, Switzerland
| | - Òscar Miró
- Emergency Department, Hospital Clinic, Barcelona, Catalonia, Spain (Ò.M.)
| | | | - Ivo Strebel
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology (J.B., P.L.-A., L.K., K.W., T.N., R.B., I.S., M.R.G., C.M.), University Hospital Basel, University of Basel, Switzerland
| | - Maria Rubini Giménez
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology (J.B., P.L.-A., L.K., K.W., T.N., R.B., I.S., M.R.G., C.M.), University Hospital Basel, University of Basel, Switzerland
| | - Dagmar I Keller
- Emergency Department, University Hospital Zurich, Switzerland (D.I.K.)
| | - Michael Christ
- Emergency Department, Kantonsspital Luzern, Switzerland (M.C.)
| | - Anda Bularga
- BHF/University Centre for Cardiovascular Science (J.B., D.D., K.K.L., A.B., Z.L., A.V.F., C.T., A.A., N.L.M.), University of Edinburgh, UK
| | - Ziwen Li
- BHF/University Centre for Cardiovascular Science (J.B., D.D., K.K.L., A.B., Z.L., A.V.F., C.T., A.A., N.L.M.), University of Edinburgh, UK
| | - Amy V Ferry
- BHF/University Centre for Cardiovascular Science (J.B., D.D., K.K.L., A.B., Z.L., A.V.F., C.T., A.A., N.L.M.), University of Edinburgh, UK
| | - Chris Tuck
- BHF/University Centre for Cardiovascular Science (J.B., D.D., K.K.L., A.B., Z.L., A.V.F., C.T., A.A., N.L.M.), University of Edinburgh, UK
| | - Atul Anand
- BHF/University Centre for Cardiovascular Science (J.B., D.D., K.K.L., A.B., Z.L., A.V.F., C.T., A.A., N.L.M.), University of Edinburgh, UK
| | - Alasdair Gray
- Usher Institute (D.D., K.K.L., A.G., N.L.M.), University of Edinburgh, UK
- Emergency Medicine Research Group Edinburgh, Royal Infirmary of Edinburgh, UK (A.G.)
| | - Nicholas L Mills
- BHF/University Centre for Cardiovascular Science (J.B., D.D., K.K.L., A.B., Z.L., A.V.F., C.T., A.A., N.L.M.), University of Edinburgh, UK
- Usher Institute (D.D., K.K.L., A.G., N.L.M.), University of Edinburgh, UK
| | - Christian Mueller
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology (J.B., P.L.-A., L.K., K.W., T.N., R.B., I.S., M.R.G., C.M.), University Hospital Basel, University of Basel, Switzerland
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24
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Taggart C, Roos A, Kadesjö E, Anand A, Li Z, Doudesis D, Lee KK, Bularga A, Wereski R, Lowry MTH, Chapman AR, Ferry AV, Shah ASV, Gard A, Lindahl B, Edgren G, Mills NL, Kimenai DM. Application of the Universal Definition of Myocardial Infarction in Clinical Practice in Scotland and Sweden. JAMA Netw Open 2024; 7:e245853. [PMID: 38587840 PMCID: PMC11002705 DOI: 10.1001/jamanetworkopen.2024.5853] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Accepted: 02/13/2024] [Indexed: 04/09/2024] Open
Abstract
Importance Whether the diagnostic classifications proposed by the universal definition of myocardial infarction (MI) to identify type 1 MI due to atherothrombosis and type 2 MI due to myocardial oxygen supply-demand imbalance have been applied consistently in clinical practice is unknown. Objective To evaluate the application of the universal definition of MI in consecutive patients with possible MI across 2 health care systems. Design, Setting, and Participants This cohort study used data from 2 prospective cohorts enrolling consecutive patients with possible MI in Scotland (2013-2016) and Sweden (2011-2014) to assess accuracy of clinical diagnosis of MI recorded in hospital records for patients with an adjudicated diagnosis of type 1 or type 2 MI. Data were analyzed from August 2022 to February 2023. Main Outcomes and Measures The main outcome was the proportion of patients with a clinical diagnosis of MI recorded in the hospital records who had type 1 or type 2 MI, adjudicated by an independent panel according to the universal definition. Characteristics and risk of subsequent MI or cardiovascular death at 1 year were compared. Results A total of 50 356 patients were assessed. The cohort from Scotland included 28 783 (15 562 men [54%]; mean [SD] age, 60 [17] years), and the cohort from Sweden included 21 573 (11 110 men [51%]; mean [SD] age, 56 [17] years) patients. In Scotland, a clinical diagnosis of MI was recorded in 2506 of 3187 patients with an adjudicated diagnosis of type 1 MI (79%) and 122 of 716 patients with an adjudicated diagnosis of type 2 MI (17%). Similar findings were observed in Sweden, with 970 of 1111 patients with adjudicated diagnosis of type 1 MI (87%) and 57 of 251 patients with adjudicated diagnosis of type 2 MI (23%) receiving a clinical diagnosis of MI. Patients with an adjudicated diagnosis of type 1 MI without a clinical diagnosis were more likely to be women (eg, 336 women [49%] vs 909 women [36%] in Scotland; P < .001) and older (mean [SD] age, 71 [14] v 67 [14] years in Scotland, P < .001) and, when adjusting for competing risk from noncardiovascular death, were at similar or increased risk of subsequent MI or cardiovascular death compared with patients with a clinical diagnosis of MI (eg, 29% vs 18% in Scotland; P < .001). Conclusions and Relevance In this cohort study, the universal definition of MI was not consistently applied in clinical practice, with a minority of patients with type 2 MI identified, and type 1 MI underrecognized in women and older persons, suggesting uncertainty remains regarding the diagnostic criteria or value of the classification.
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Affiliation(s)
- Caelan Taggart
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
| | - Andreas Roos
- Department of Emergency and Reparative Medicine, Karolinska University Hospital, Stockholm, Sweden
- Department of Medicine, Clinical Epidemiology Division, Karolinska Institutet, Stockholm, Sweden
| | - Erik Kadesjö
- Department of Emergency and Reparative Medicine, Karolinska University Hospital, Stockholm, Sweden
- Department of Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Atul Anand
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
| | - Ziwen Li
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
| | - Dimitrios Doudesis
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
| | - Kuan Ken Lee
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
| | - Anda Bularga
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
| | - Ryan Wereski
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
| | - Matthew T. H. Lowry
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
| | - Andrew R. Chapman
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
| | - Amy V. Ferry
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
| | - Anoop S. V. Shah
- Department of Non-communicable Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Anton Gard
- Department of Cardiology, Uppsala University, Uppsala, Sweden
| | - Bertil Lindahl
- Department of Cardiology, Uppsala University, Uppsala, Sweden
| | - Gustaf Edgren
- Department of Medicine, Clinical Epidemiology Division, Karolinska Institutet, Stockholm, Sweden
- Department of Cardiology, Södersjukhuset, Stockholm, Sweden
| | - Nicholas L. Mills
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
- Usher Institute, University of Edinburgh, Edinburgh, United Kingdom
| | - Dorien M. Kimenai
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
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25
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Pareek M, Kristensen AMD, Vaduganathan M, Byrne C, Biering-Sørensen T, Lassen MCH, Johansen ND, Skaarup KG, Rosberg V, Pallisgaard JL, Mortensen MB, Maeng M, Polcwiartek CB, Frangeskos J, McCarthy CP, Bonde AN, Lee CJY, Fosbøl EL, Køber L, Olsen NT, Gislason GH, Torp-Pedersen C, Bhatt DL, Kragholm KH. Serial troponin-I and long-term outcomes in subjects with suspected acute coronary syndrome. Eur J Prev Cardiol 2024; 31:615-626. [PMID: 38057157 PMCID: PMC11109926 DOI: 10.1093/eurjpc/zwad373] [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: 07/18/2023] [Revised: 11/28/2023] [Accepted: 11/30/2023] [Indexed: 12/08/2023]
Abstract
AIMS It is unclear how serial high-sensitivity troponin-I (hsTnI) concentrations affect long-term prognosis in individuals with suspected acute coronary syndrome (ACS). METHODS AND RESULTS Subjects who underwent two hsTnI measurements (Siemens TnI Flex® Reagent) separated by 1-7 h, during a first-time hospitalization for myocardial infarction, unstable angina, observation for suspected myocardial infarction, or chest pain from 2012 through 2019, were identified through Danish national registries. Individuals were stratified per their hsTnI concentration pattern (normal, rising, persistently elevated, or falling) and the magnitude of hsTnI concentration change (<20%, >20-50%, or >50% in either direction). We calculated absolute and relative mortality risks standardized to the distributions of risk factors for the entire study population. A total of 20 609 individuals were included of whom 2.3% had died at 30 days, and an additional 4.7% had died at 365 days. The standardized risk of death was highest among persons with a persistently elevated hsTnI concentration (0-30 days: 8.0%, 31-365 days: 11.1%) and lowest among those with two normal hsTnI concentrations (0-30 days: 0.5%, 31-365 days: 2.6%). In neither case did relative hsTnI concentration changes between measurements clearly affect mortality risk. Among persons with a rising hsTnI concentration pattern, 30-day mortality was higher in subjects with a >50% rise compared with those with a less pronounced rise (2.2% vs. <0.1%). CONCLUSION Among individuals with suspected ACS, those with a persistently elevated hsTnI concentration consistently had the highest risk of death. In subjects with two normal hsTnI concentrations, mortality was very low and not affected by the magnitude of change between measurements.
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Affiliation(s)
- Manan Pareek
- Center for Translational Cardiology and Pragmatic Randomized Trials, Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
- Department of Cardiology, Copenhagen University Hospital – Rigshospitalet, Copenhagen, Denmark
- Brigham and Women’s Hospital Heart & Vascular Center, Harvard Medical School, Boston, MA, USA
| | | | - Muthiah Vaduganathan
- Brigham and Women’s Hospital Heart & Vascular Center, Harvard Medical School, Boston, MA, USA
| | - Christina Byrne
- Department of Cardiology, Copenhagen University Hospital – Rigshospitalet, Copenhagen, Denmark
| | - Tor Biering-Sørensen
- Center for Translational Cardiology and Pragmatic Randomized Trials, Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
- Department of Cardiology, Copenhagen University Hospital – Herlev and Gentofte, Denmark
| | - Mats Christian Højbjerg Lassen
- Center for Translational Cardiology and Pragmatic Randomized Trials, Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
- Department of Cardiology, Copenhagen University Hospital – Herlev and Gentofte, Denmark
| | - Niklas Dyrby Johansen
- Center for Translational Cardiology and Pragmatic Randomized Trials, Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
- Department of Cardiology, Copenhagen University Hospital – Herlev and Gentofte, Denmark
| | - Kristoffer Grundtvig Skaarup
- Center for Translational Cardiology and Pragmatic Randomized Trials, Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
- Department of Cardiology, Copenhagen University Hospital – Herlev and Gentofte, Denmark
| | - Victoria Rosberg
- Center for Translational Cardiology and Pragmatic Randomized Trials, Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Jannik L. Pallisgaard
- Department of Cardiology, Copenhagen University Hospital – Herlev and Gentofte, Denmark
| | | | - Michael Maeng
- Department of Cardiology, Aarhus University Hospital, Skejby, Aarhus, Denmark
| | | | - Julia Frangeskos
- Department of Cardiology, Peconic Bay Medical Center at Northwell Health, Riverhead, NY, USA
| | - Cian P. McCarthy
- Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Anders Nissen Bonde
- Department of Cardiology, Copenhagen University Hospital – Herlev and Gentofte, Denmark
| | - Christina Ji-Young Lee
- Department of Cardiology, Copenhagen University Hospital – Rigshospitalet, Copenhagen, Denmark
| | - Emil L. Fosbøl
- Department of Cardiology, Copenhagen University Hospital – Rigshospitalet, Copenhagen, Denmark
| | - Lars Køber
- Department of Cardiology, Copenhagen University Hospital – Rigshospitalet, Copenhagen, Denmark
| | - Niels Thue Olsen
- Department of Cardiology, Copenhagen University Hospital – Herlev and Gentofte, Denmark
| | - Gunnar H. Gislason
- Department of Cardiology, Copenhagen University Hospital – Herlev and Gentofte, Denmark
| | - Christian Torp-Pedersen
- Department of Cardiology, Copenhagen University Hospital – North Zealand Hospital, Hillerød, Denmark
| | - Deepak L. Bhatt
- Mount Sinai Heart, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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26
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Aakre KM, Apple FS, Mills NL, Meex SJR, Collinson PO. Lower Limits for Reporting High-Sensitivity Cardiac Troponin Assays and Impact of Analytical Performance on Patient Misclassification. Clin Chem 2024; 70:497-505. [PMID: 38102065 DOI: 10.1093/clinchem/hvad185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Accepted: 09/27/2023] [Indexed: 12/17/2023]
Abstract
BACKGROUND Cardiac troponin measurements are indispensable for the diagnosis of myocardial infarction and provide useful information for long-term risk prediction of cardiovascular disease. Accelerated diagnostic pathways prevent unnecessary hospital admission, but require reporting cardiac troponin concentrations at low concentrations that are sometimes below the limit of quantification. Whether analytical imprecision at these concentrations contributes to misclassification of patients is debated. CONTENT The International Federation of Clinical Chemistry Committee on Clinical Application of Cardiac Bio-Markers (IFCC C-CB) provides evidence-based educational statements on analytical and clinical aspects of cardiac biomarkers. This mini-review discusses how the reporting of low concentrations of cardiac troponins impacts on whether or not assays are classified as high-sensitivity and how analytical performance at low concentrations influences the utility of troponins in accelerated diagnostic pathways. Practical suggestions are made for laboratories regarding analytical quality assessment of cardiac troponin results at low cutoffs, with a particular focus on accelerated diagnostic pathways. The review also discusses how future use of cardiac troponins for long-term prediction or management of cardiovascular disease may require improvements in analytical quality. SUMMARY Clinical guidelines recommend using cardiac troponin concentrations as low as the limit of detection of the assay to guide patient care. Laboratories, manufacturers, researchers, and external quality assessment providers should extend analytical performance monitoring of cardiac troponin assays to include the concentration ranges applicable in these pathways.
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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
| | - Fred S Apple
- Department of Laboratory Medicine and Pathology, Hennepin Healthcare/HCMC, Minneapolis, MN, United States
- Department of Laboratory Medicine and Pathology, University of Minnesota, Minneapolis, MN, United States
| | - Nicolas L Mills
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
- Usher Institute, University of Edinburgh, Edinburgh, United Kingdom
| | - Steven J R Meex
- Central Diagnostic Laboratory, Maastricht University Medical Center, Maastricht, the Netherlands
- CARIM School for Cardiovascular Diseases, Maastricht University, Maastricht, the Netherlands
| | - Paul O Collinson
- Department of Clinical Blood Sciences and Cardiology, St.George's University Hospitals NHS Foundation Trust, London, United Kingdom
- St.George's University of London, London, United Kingdom
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27
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Kite TA, Ladwiniec A, Moss AJ. Prehospital triage in suspected myocardial infarction: a calculated risk? Heart 2024; 110:385-386. [PMID: 38040447 DOI: 10.1136/heartjnl-2023-323567] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2023] Open
Affiliation(s)
- Thomas A Kite
- Department of Cardiovascular Sciences and the NIHR Leicester Biomedical Research Centre, Glenfield Hospital, University of Leicester and University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Andrew Ladwiniec
- Department of Cardiovascular Sciences and the NIHR Leicester Biomedical Research Centre, Glenfield Hospital, University of Leicester and University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Alastair James Moss
- Department of Cardiovascular Sciences and the NIHR Leicester Biomedical Research Centre, Glenfield Hospital, University of Leicester and University Hospitals of Leicester NHS Trust, Leicester, UK
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Budzianowski J, Faron W, Rzeźniczak J, Słomczyński M, Hiczkiewicz D, Olejniczak J, Hiczkiewicz J, Burchardt P. Predictors of Revascularization in Patients with Unstable Angina. J Clin Med 2024; 13:1096. [PMID: 38398410 PMCID: PMC10889168 DOI: 10.3390/jcm13041096] [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: 01/23/2024] [Revised: 02/06/2024] [Accepted: 02/12/2024] [Indexed: 02/25/2024] Open
Abstract
BACKGROUND The factors that determine the necessity of coronary artery revascularization in patients with unstable angina (UA) have been supported by limited data. Therefore, this study aimed to identify the predictors of revascularization in patients with UA. METHODS The study included the recorded data of 3668 patients with UA who underwent cardiac catheterization (age 66 ± 9.2, men 70%); 2615 of them (71%) underwent revascularization (percutaneous transluminal coronary angioplasty (PTCA), coronary artery bypass graft (CABG), or hybrid revascularization. The remaining 1053 patients (29%) had no significant coronary stenosis and were regarded as controls. Multivariable logistic regression analysis was performed to separate the predictors of revascularization. RESULTS It was found that severe angina (OR 2.7, 95%CI 1.9-3.7), male gender (OR 1.4, 95%CI 1.1-1.7), and hyperlipidemia were the predictors of revascularization. It was also noted that intraventricular conduction disorders including left and right bundle branch blocks and a history of previous revascularization and myocardial infarction were associated with lower odds of revascularization. CONCLUSION Overall, however, the predictive value of the studied factors proved to be poor and may still point to the multifactorial nature of significant coronary artery stenosis and the need for revascularization in patients with UA.
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Affiliation(s)
- Jan Budzianowski
- “Club 30”, Polish Cardiac Society, 93-338 Łódź, Poland;
- Department of Interventional Cardiology and Cardiac Surgery, Collegium Medicum, University of Zielona Góra, 65-046 Zielona Góra, Poland; (D.H.); (J.H.)
- Department of Cardiology, Nowa Sól Multidisciplinary Hospital, 67-100 Nowa Sól, Poland;
| | - Wojciech Faron
- Department of Cardiology, Nowa Sól Multidisciplinary Hospital, 67-100 Nowa Sól, Poland;
| | - Janusz Rzeźniczak
- Department of Cardiology, J. Strus Hospital, 61-285 Poznań, Poland; (J.R.); (M.S.)
| | - Marek Słomczyński
- Department of Cardiology, J. Strus Hospital, 61-285 Poznań, Poland; (J.R.); (M.S.)
| | - Dariusz Hiczkiewicz
- Department of Interventional Cardiology and Cardiac Surgery, Collegium Medicum, University of Zielona Góra, 65-046 Zielona Góra, Poland; (D.H.); (J.H.)
- Department of Cardiology, Nowa Sól Multidisciplinary Hospital, 67-100 Nowa Sól, Poland;
| | | | - Jarosław Hiczkiewicz
- Department of Interventional Cardiology and Cardiac Surgery, Collegium Medicum, University of Zielona Góra, 65-046 Zielona Góra, Poland; (D.H.); (J.H.)
- Department of Cardiology, Nowa Sól Multidisciplinary Hospital, 67-100 Nowa Sól, Poland;
| | - Paweł Burchardt
- “Club 30”, Polish Cardiac Society, 93-338 Łódź, Poland;
- Department of Cardiology, J. Strus Hospital, 61-285 Poznań, Poland; (J.R.); (M.S.)
- Department of Hypertension, Angiology, and Internal Medicine, Poznan University of Medical Sciences, 61-848 Poznań, Poland
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Lehmacher J, Sörensen NA, Twerenbold R, Goßling A, Haller PM, Hartikainen TS, Schock A, Toprak B, Zeller T, Westermann D, Neumann JT. Diagnostic and prognostic value of the sex-specific 99th percentile of four high-sensitivity cardiac troponin assays in patients with suspected myocardial infarction. EUROPEAN HEART JOURNAL. ACUTE CARDIOVASCULAR CARE 2024; 13:3-12. [PMID: 37890108 DOI: 10.1093/ehjacc/zuad131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Revised: 09/28/2023] [Accepted: 10/23/2023] [Indexed: 10/29/2023]
Abstract
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.
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Affiliation(s)
- Jonas Lehmacher
- Department of Cardiology, University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246 Hamburg, Germany
- Deutsches Zentrum für Herz-Kreislauf-Forschung (DZHK), site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - Nils Arne Sörensen
- Department of Cardiology, University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246 Hamburg, Germany
- Deutsches Zentrum für Herz-Kreislauf-Forschung (DZHK), site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - Raphael Twerenbold
- Department of Cardiology, University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246 Hamburg, Germany
- Deutsches Zentrum für Herz-Kreislauf-Forschung (DZHK), site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - Alina Goßling
- Department of Cardiology, University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246 Hamburg, Germany
| | - Paul Michael Haller
- Department of Cardiology, University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246 Hamburg, Germany
- Deutsches Zentrum für Herz-Kreislauf-Forschung (DZHK), site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - Tau Sarra Hartikainen
- Deutsches Zentrum für Herz-Kreislauf-Forschung (DZHK), site Hamburg/Kiel/Lübeck, Hamburg, Germany
- Department of Cardiology, University Heart Center Freiburg, Bad Krozingen, Germany
| | - Alina Schock
- Department of Cardiology, University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246 Hamburg, Germany
| | - Betül Toprak
- Department of Cardiology, University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246 Hamburg, Germany
- Deutsches Zentrum für Herz-Kreislauf-Forschung (DZHK), site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - Tanja Zeller
- Department of Cardiology, University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246 Hamburg, Germany
- Deutsches Zentrum für Herz-Kreislauf-Forschung (DZHK), site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - Dirk Westermann
- Deutsches Zentrum für Herz-Kreislauf-Forschung (DZHK), site Hamburg/Kiel/Lübeck, Hamburg, Germany
- Department of Cardiology, University Heart Center Freiburg, Bad Krozingen, Germany
| | - Johannes Tobias Neumann
- Department of Cardiology, University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246 Hamburg, Germany
- Deutsches Zentrum für Herz-Kreislauf-Forschung (DZHK), site Hamburg/Kiel/Lübeck, Hamburg, Germany
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, 553 St Kilda Road, Melbourne, VIC 3004, Australia
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Byrne RA, Rossello X, Coughlan JJ, Barbato E, Berry C, Chieffo A, Claeys MJ, Dan GA, Dweck MR, Galbraith M, Gilard M, Hinterbuchner L, Jankowska EA, Jüni P, Kimura T, Kunadian V, Leosdottir M, Lorusso R, Pedretti RFE, Rigopoulos AG, Rubini Gimenez M, Thiele H, Vranckx P, Wassmann S, Wenger NK, Ibanez B. 2023 ESC Guidelines for the management of acute coronary syndromes. EUROPEAN HEART JOURNAL. ACUTE CARDIOVASCULAR CARE 2024; 13:55-161. [PMID: 37740496 DOI: 10.1093/ehjacc/zuad107] [Citation(s) in RCA: 32] [Impact Index Per Article: 32.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/24/2023]
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Norris CM, Mullen KA, Foulds HJ, Jaffer S, Nerenberg K, Gulati M, Parast N, Tegg N, Gonsalves CA, Grewal J, Hart D, Levinsson AL, Mulvagh SL. The Canadian Women's Heart Health Alliance ATLAS on the Epidemiology, Diagnosis, and Management of Cardiovascular Disease in Women - Chapter 7: Sex, Gender, and the Social Determinants of Health. CJC Open 2024; 6:205-219. [PMID: 38487069 PMCID: PMC10935698 DOI: 10.1016/j.cjco.2023.07.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Accepted: 07/31/2023] [Indexed: 03/17/2024] Open
Abstract
Women vs men have major differences in terms of risk-factor profiles, social and environmental factors, clinical presentation, diagnosis, and treatment of cardiovascular disease. Women are more likely than men to experience health issues that are complex and multifactorial, often relating to disparities in access to care, risk-factor prevalence, sex-based biological differences, gender-related factors, and sociocultural factors. Furthermore, awareness of the intersectional nature and relationship of sociocultural determinants of health, including sex and gender factors, that influence access to care and health outcomes for women with cardiovascular disease remains elusive. This review summarizes literature that reports on under-recognized sex- and gender-related risk factors that intersect with psychosocial, economic, and cultural factors in the diagnosis, treatment, and outcomes of women's cardiovascular health.
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Affiliation(s)
- Colleen M. Norris
- Faculty of Nursing, University of Alberta, Edmonton, Alberta, Canada
| | - Kerri-Anne Mullen
- Division of Prevention and Rehabilitation, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Heather J.A. Foulds
- College of Kinesiology, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Shahin Jaffer
- Department of Medicine/Community Internal Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Kara Nerenberg
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Martha Gulati
- Barbra Streisand Women’s Heart Centre, Cedars-Sinai Smidt Heart Institute, Los Angeles, California, USA
| | - Nazli Parast
- Division of Prevention and Rehabilitation, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Nicole Tegg
- Faculty of Nursing, University of Alberta, Edmonton, Alberta, Canada
| | | | - Jasmine Grewal
- Department of Medicine/Community Internal Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Donna Hart
- Canadian Women’s Heart Health Alliance, Ottawa, Ontario, Canada
| | | | - Sharon L. Mulvagh
- Division of Cardiology, Dalhousie University, Halifax, Nova Scotia, Canada
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
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32
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Koechlin L, Boeddinghaus J, Lopez-Ayala P, Wildi K, Nestelberger T, Wussler D, Guzman Tacla CA, Holder T, Muench-Gerber T, Glaeser J, Sanchez AY, Miró Ò, Martin-Sanchez FJ, Kawecki D, Buergler F, Buser A, Huré G, Giménez MR, Keller DI, Christ M, Mueller C. External validation of the 0/1h-algorithm and derivation of a 0/2h-algorithm using a new point-of-care Hs-cTnI assay. Am Heart J 2024; 268:104-113. [PMID: 38042459 DOI: 10.1016/j.ahj.2023.11.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Revised: 11/14/2023] [Accepted: 11/18/2023] [Indexed: 12/04/2023]
Abstract
BACKGROUND The high-sensitivity cardiac troponin (hs-cTn) I point-of-care (POC) hs-cTnI-PATHFAST assay has recently become clinically available. METHODS We aimed to externally validate the hs-cTnI-PATHFAST 0/1h-algorithm recently developed for the early diagnosis of non-ST-segment-elevation myocardial infarction (NSTEMI) and derive and validate a 0/2-algorithm in patients presenting to the emergency department with acute chest discomfort included in a multicenter diagnostic study. Two independent cardiologists centrally adjudicated the final diagnoses using all the clinical and study-specific information available including serial measurements of hs-cTnI-Architect. RESULTS Among 1,532 patients (median age 60 years, 33% [n = 501] women), NSTEMI was the final diagnosis in 13%. External validation of the hs-cTnI-PATHFAST 0/1h-algorithm showed very high negative predictive value (NPV; 100% [95%CI, 99.5%-100%]) and sensitivity 100% (95%CI, 98.2%-100%) for rule-out of NSTEMI. Positive predictive value (PPV) and specificity for rule-in of NSTEMI were high (74.9% [95%CI, 68.3%-80.5%] and 96.4% [95%CI, 95.2%-97.3%], respectively). Among 1,207 patients (median age 61 years, 32% [n = 391] women) available for the derivation (n = 848) and validation (n = 359) of the hs-cTnI-PATHFAST 0/2h-algorithm, a 0h-concentration <3 ng/L or a 0h-concentration <4 ng/L with a 2h-delta <4ng/L ruled-out NSTEMI in 52% of patients with a NPV of 100% (95%CI, 98-100) and sensitivity of 100% (95%CI, 92.9%-100%) in the validation cohort. A 0h-concentration ≥90ng/L or a 2h-delta ≥ 55ng/L ruled-in 38 patients (11%): PPV 81.6% (95%CI, 66.6-90.8), specificity 97.7% (95%CI, 95.4-98.9%). CONCLUSIONS The POC hs-cTnI-PATHFAST assay allows rapid and effective rule-out and rule-in of NSTEMI using both a 0/1h- and a 0/2h-algorithm with high NPV/sensitivity for rule-out and high PPV/specificity for rule-in. CLINICAL TRIAL REGISTRATION NCT00470587.
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Affiliation(s)
- Luca Koechlin
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland; Department of Cardiac Surgery, University Hospital Basel, University of Basel, Switzerland; GREAT network.
| | - Jasper Boeddinghaus
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland; GREAT network; BHF/University Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
| | - Pedro Lopez-Ayala
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland; GREAT network
| | - Karin Wildi
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland; GREAT network; Critical Care Research Group and the University of Queensland, Brisbane, Queensland, Australia
| | - Thomas Nestelberger
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland; GREAT network
| | - Desiree Wussler
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland; GREAT network
| | - Caroline A Guzman Tacla
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland; GREAT network
| | - Timothy Holder
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Tamar Muench-Gerber
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland; GREAT network
| | - Jonas Glaeser
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland; GREAT network
| | - Ana Yufera Sanchez
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland; GREAT network
| | - Òscar Miró
- GREAT network; Emergency Department, Hospital Clinic, Barcelona, Catalonia, Spain
| | | | - Damian Kawecki
- GREAT network; 2nd Department of Cardiology, School of Medicine with the Division of Dentistry in Zabrze, Medical University of Katowice, Zabrze, Poland
| | - Franz Buergler
- Emergency Department, Kantonsspital Liestal, LIestal, Switzerland
| | - Andreas Buser
- Department of hematology and Blood Bank, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Gabrielle Huré
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland; GREAT network
| | - Maria Rubini Giménez
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland; Department of Cardiology, Heart Center Leipzig, University of Leipzig, Leipzig, Germany
| | - Dagmar I Keller
- Emergency Department, University Hospital Zurich, Zurich, Switzerland
| | - Michael Christ
- Emergency Department, Kantonsspital Luzern, Luzern, Switzerland
| | - Christian Mueller
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland; GREAT network.
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Singer AJ, Heslin S, Skopicki H, On C, Senzel LB, Tharakan M, Thode HC, Peacock F. Introduction of a high sensitivity troponin reduces ED length of stay. Am J Emerg Med 2024; 76:82-86. [PMID: 38006636 DOI: 10.1016/j.ajem.2023.11.028] [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: 09/20/2023] [Revised: 11/08/2023] [Accepted: 11/16/2023] [Indexed: 11/27/2023] Open
Abstract
BACKGROUND High sensitivity cardiac troponins (hs-cTn) allow earlier identification and exclusion of acute myocardial infarction. We determined if transitioning from contemporary to high sensitivity troponin T (hs-cTnT) would reduce ED length of stay in chest pain (CP) patients. METHODS We conducted a pragmatic, prospective, before and after study of implementing a hs-cTnT by reviewing the electronic health records in all adult ED patients presenting to a large, suburban academic medical center during the 3 months before and after transitioning from a 4th generation troponin to a 5th generation hs-cTnT (Elecsys® Troponin T-high sensitive, Roche Diagnostics, Indianapolis, IN). RESULTS There were 1431 and 1437 CP patients before and after the intervention. Mean (SD) age was 51.5 (18) yrs. and 54.3% were female. The median (IQR) ED LOS for chest pain patients directly discharged to home was 6.2 (4.7-8.4) and 5.3 (4.0-7.2) hours before and after introducing hs-cTn respectively; difference 47 min (95%CI, 35-59); P < 0.001. The median (IQR) ED LOS for chest pain patients admitted to the hospital was 9.5 (6.6-13.8) and 8.1 (5.7-11.2) hours before and after introducing hs-cTn respectively; difference 77 min (95%CI, 35-121); P < 0.001. Overall admission rates (22 vs 21% both before and after) did not change during the study. The rates of computed tomography coronary angiography before and after the intervention were 21 and 20.4% respectively. The rates of invasive coronary angiography before and after the intervention were 5.8 and 5.6% respectively. CONCLUSIONS Transitioning to a hs-cTnT is associated with a clinically relevant and statistically significant reduction in ED LOS for both discharged and admitted patients with and without CP with no increase in admission or coronary angiography rates.
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Affiliation(s)
- Adam J Singer
- Department of Emergency Medicine, Renaissance School of Medicine at Stony Brook University, Stony Brook, NY, United States of America.
| | - Samita Heslin
- Department of Emergency Medicine, Renaissance School of Medicine at Stony Brook University, Stony Brook, NY, United States of America
| | - Hal Skopicki
- Division of Cardiology, Department of Medicine, Renaissance School of Medicine at Stony Brook University, Stony Brook, NY, United States of America
| | - Chen On
- Division of Cardiology, Department of Medicine, Renaissance School of Medicine at Stony Brook University, Stony Brook, NY, United States of America
| | - Lisa B Senzel
- Department of Clinical Pathology, Renaissance School of Medicine at Stony Brook University, Stony Brook, NY, United States of America
| | - Mathew Tharakan
- Division of Cardiology, Department of Medicine, Renaissance School of Medicine at Stony Brook University, Stony Brook, NY, United States of America
| | - Henry C Thode
- Department of Emergency Medicine, Renaissance School of Medicine at Stony Brook University, Stony Brook, NY, United States of America
| | - Frank Peacock
- Department of Emergency Medicine, Baylor College of Medicine, Houston, TX, United States of America
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Bar O, Elias A, Halhal B, Marcusohn E. Time to coronary catheterization in patients with non-ST-segment elevation acute coronary syndrome and high Global Registry of Acute Coronary Events score. J Cardiovasc Med (Hagerstown) 2024; 25:104-113. [PMID: 38064345 DOI: 10.2459/jcm.0000000000001568] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2023]
Abstract
AIMS Current guidelines recommend an early (<24 h) invasive coronary angiography (ICA) strategy in non-ST-segment elevation acute coronary syndrome (NSTE-ACS) patients with Global Registry of Acute Coronary Events (GRACE) score over 140. Evidence for this recommendation is based on older trials. METHODS AND RESULTS Between 1 February 2016 and 31 July 2021, 1767 patients with a primary diagnosis of NSTE-ACS without indication for urgent ICA underwent ICA during index hospitalization. Six hundred and fifty-five patients underwent early invasive ICA (within 24 h) and 1112 underwent late ICA (between 24 h and 1 week). One hundred and seven patients had a GRACE risk score of 140 or above and 1660 had a GRACE risk score under 140. The primary composite outcome was all-cause mortality, stroke, and recurrent myocardial infarction (MI). Median time from admission to ICA was 13.3 h (IQR 6.0-20.6) for the early group and 59.9 h for the late group (IQR 23.5-96.3). There was no difference between the early and late ICA groups in the primary composite outcome [late catheterization >24 h hazard ratio 1.196, 95% confidence interval (CI) 0.969-1.475, P -value 0.096]. A multivariable Cox regression model for the composite outcome revealed no difference between the early and late ICA groups (late catheterization >24 h hazard ratio 1.0735, 95% CI 0.862-1.327, P -value 0.512) with no effect for performing early ICA in patients with GRACE score over 140 (hazard ratio 1.291, 95% CI 0.910-1.831, P -value 0.151). CONCLUSION An early ICA strategy in patients with NSTE-ACS patients and GRACE risk score over 140, compared with late ICA, was not associated with improved composite outcome of death, myocardial infarction, and stroke at 1 year.
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Affiliation(s)
- Omer Bar
- Department of Cardiology, Rambam Health Care Campus
- Rappaport Faculty of Medicine, Technion, Israel Institute of Technology, Haifa, Israel
| | - Adi Elias
- Department of Cardiology, Rambam Health Care Campus
- Rappaport Faculty of Medicine, Technion, Israel Institute of Technology, Haifa, Israel
| | - Basheer Halhal
- Department of Cardiology, Rambam Health Care Campus
- Rappaport Faculty of Medicine, Technion, Israel Institute of Technology, Haifa, Israel
| | - Erez Marcusohn
- Department of Cardiology, Rambam Health Care Campus
- Rappaport Faculty of Medicine, Technion, Israel Institute of Technology, Haifa, Israel
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Abstract
Rapid and accurate triage of patients presenting with chest pain to an emergency department (ED) is critical to prevent ED overcrowding and unnecessary resource use in individuals at low risk of acute myocardial infarction (AMI) and to efficiently and effectively guide patients at high risk to definite therapy. The use of biomarkers for rule-out or rule-in of suspected AMI has evolved substantially over the last several decades. Previously well-established biomarkers have been replaced by cardiac troponin (cTn). High-sensitivity cTn (hs-cTn) assays represent the newest generation of cTn assays and offer tremendous advantages, including improved sensitivity and precision. Still, implementation of these assays in the United States lags behind several other areas of the world. Within this educational review, we discuss the evolution of biomarker testing for detection of myocardial injury, address the specifics of hs-cTn assays and their recommended use within triage algorithms, and highlight potential challenges in their use. Ultimately, we focus on implementation strategies for hs-cTn assays, as they are now clearly ready for prime time.
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Affiliation(s)
| | - L Kristin Newby
- Duke Clinical Research Institute, Durham, North Carolina, USA; ,
- Division of Cardiology, Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
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Lambrakis K, Khan E, van den Merkhof A, Papendick C, Chuang A, Zhai Y, Eng-Frost J, Rocheleau S, Lehman SJ, Blyth A, Briffa T, Quinn S, French JK, Cullen L, Chew DP. Impacts of high sensitivity troponin T reporting on care and outcomes in clinical practice: Interactions between low troponin concentrations and participant sex within two randomized clinical trials. Int J Cardiol 2023; 393:131396. [PMID: 37769972 DOI: 10.1016/j.ijcard.2023.131396] [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: 12/07/2022] [Revised: 09/10/2023] [Accepted: 09/22/2023] [Indexed: 10/03/2023]
Abstract
BACKGROUND The impacts of high sensitivity cardiac troponin (hs-cTn) reporting on downstream interventions amongst suspected acute coronary syndrome (ACS) in the emergency department (ED), especially amongst those with newly identified hs-cTn elevations and in consideration of well-established sex-related disparities, has not been critically evaluated to date. This investigation explores the impact of hs-cTnT reporting on care and outcomes, particularly by participant sex. METHODS Two similarly ED-based randomized controlled trials conducted between July 2011 to March 2013 (n = 1988) and August 2015 to April 2019 (n = 3378) were comparatively evaluated. Clinical outcomes were adjudicated to the Fourth Universal Definition of MI. Changes in practice were assessed at 30 days, and death or MI were explored to 12 months. RESULTS The HS-Troponin study demonstrated no difference in death or MI with unmasking amongst those with hs-cTnT <30 ng/L, whereas the RAPID TnT study demonstrated a significantly higher rate. In RAPID TnT, there was significant increase in death or MI associated with unmasking for females with hs-cTnT <30 ng/L (masked: 11[1.5%], unmasked: 25[3.4%],HR: 2.27,95%C.I.:1.87-2.77,P < 0.001). Less cardiac stress testing with unmasking amongst those <30 ng/L was observed in males in both studies, which was significant in RAPID TnT (masked: 92[12.0%], unmasked: 55[7.0%], P = 0.008). In RAPID TnT, significantly higher rates of angiography in males were observed with unmasking, with no such changes amongst females <30 ng/L (masked: 28[3.7%], unmasked: 51[6.5%],P = 0.01). CONCLUSION Compared with males, there were no evident impacts on downstream practices for females with unmasking in RAPID TnT, likely representing missed opportunities to reduce late death or MI.
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Affiliation(s)
- Kristina Lambrakis
- College of Medicine & Public Health, Flinders University of South Australia, Adelaide, Australia; South Australian Department of Health, Adelaide, Australia.
| | - Ehsan Khan
- College of Medicine & Public Health, Flinders University of South Australia, Adelaide, Australia; South Australian Department of Health, Adelaide, Australia
| | - Anke van den Merkhof
- College of Medicine & Public Health, Flinders University of South Australia, Adelaide, Australia; Faculty of Medical Sciences, University of Groningen, the Netherlands
| | - Cynthia Papendick
- South Australian Department of Health, Adelaide, Australia; School of Medicine, University of Adelaide, Adelaide, Australia
| | - Anthony Chuang
- College of Medicine & Public Health, Flinders University of South Australia, Adelaide, Australia; South Australian Department of Health, Adelaide, Australia
| | - Yuze Zhai
- College of Medicine & Public Health, Flinders University of South Australia, Adelaide, Australia
| | | | | | - Sam J Lehman
- College of Medicine & Public Health, Flinders University of South Australia, Adelaide, Australia; South Australian Department of Health, Adelaide, Australia
| | - Andrew Blyth
- College of Medicine & Public Health, Flinders University of South Australia, Adelaide, Australia; South Australian Department of Health, Adelaide, Australia
| | - Tom Briffa
- School of Population and Global Health, University of Western Australia, Perth, Australia
| | - Stephen Quinn
- Department of Statistics, Data Science and Epidemiology, Swinburne University of Technology, Melbourne, Australia
| | - John K French
- Department of Cardiology, Liverpool Hospital, University of New South Wales, Sydney, Australia
| | - Louise Cullen
- Emergency and Trauma Centre, Royal Brisbane and Women's Hospital, Brisbane, Australia; School of Public Health, Queensland University of Technology, Brisbane, Australia; School of Medicine, University of Queensland, Brisbane, Australia
| | - Derek P Chew
- College of Medicine & Public Health, Flinders University of South Australia, Adelaide, Australia; South Australian Department of Health, Adelaide, Australia
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Yore M, Sharp A, Wu YL, Kawatkar A, Lee MS, Ferencik M, Redberg R, Shen E, Zheng C, Sun B. Emergency Department Cardiac Risk Stratification With High-Sensitivity vs Conventional Troponin HEART Pathway. JAMA Netw Open 2023; 6:e2348351. [PMID: 38113042 PMCID: PMC10731477 DOI: 10.1001/jamanetworkopen.2023.48351] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2023] [Accepted: 10/26/2023] [Indexed: 12/21/2023] Open
Abstract
Importance Patients presenting to the emergency department with chest pain are routinely risk stratified for major adverse cardiac events using the HEART (History, Electrocardiogram, Age, Risk factors, and Troponin) score pathway, which incorporates clinical features, risk factors, electrocardiography findings, and initial serum troponin testing. A new HEART pathway incorporating high-sensitivity troponin level may improve risk stratification among patients with possible acute myocardial infarction (AMI). Objective To compare health outcomes and resource use among emergency department patients undergoing cardiac risk stratification with a HEART pathway using conventional vs high-sensitivity serum troponin. Design, Setting, and Participants This multicenter pre-post cohort study was conducted between January 1 and September 6, 2021, at 16 Kaiser Permanente Southern California hospitals during uptake of a high-sensitivity serum troponin assay and included 17 384 adult patients who presented to an emergency department with chest pain and were risk stratified with a HEART pathway based on conventional troponin or high-sensitivity troponin. Exposures A HEART pathway incorporating either conventional or high-sensitivity serum troponin was used to stratify study groups for risk of major adverse cardiac events within 30 days. Main Outcomes and Measures The primary outcome was detection of AMI in the emergency department and within 30 days. Results Of the 17 384 patients (median age, 58 years [IQR, 45-69 years]; 9767 women [56.2%]), 12 440 (71.6%) were risk stratified with a HEART pathway based on conventional troponin, and 4944 (28.4%) were risk stratified with a HEART pathway based on high-sensitivity troponin. Detection of AMI within 30 days was higher for the high-sensitivity troponin group than the conventional troponin group (288 [5.8%] vs 545 [4.4%]; P < .001), while the 30-day all-cause mortality rate was unchanged (16 [0.3%] vs 50 [0.4%]; P = .50). In the emergency department, 228 of 4944 patients (4.6%) in the high-sensitivity troponin group received a diagnosis of AMI compared with 251 of 12 440 patients (2.0%) in the conventional troponin group (P < .001). Among those who did not receive a diagnosis of AMI in the emergency department, an additional 60 patients (1.2%) in the high-sensitivity troponin group and 294 (2.4%) in the conventional troponin group (P < .001) received a diagnosis within 30 days. Patients in the high-sensitivity troponin group had lower rates of health care use compared with the conventional troponin group, including admission (605 [12.2%] vs 1862 [15.0%]; P < .001), stress testing within 7 days (506 [10.2%] vs 1591 [12.8%]; P < .001), and coronary revascularization within 30 days (51 [1.0%] vs 244 [2.0%]; P < .001). Conclusions and Relevance This multicenter pre-post cohort study suggests that a new HEART pathway incorporating high-sensitivity troponin may improve detection of AMI and decrease resource use among emergency department patients with chest pain.
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Affiliation(s)
- Mackensie Yore
- Department of Emergency Medicine, Veterans Affairs/University of California Los Angeles National Clinician Scholars Program, Los Angeles
| | - Adam Sharp
- Clinical Science Department, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, California
| | - Yi-Lin Wu
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena
| | - Aniket Kawatkar
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena
| | - Ming-Sum Lee
- Department of Cardiology, Kaiser Permanente Los Angeles Medical Center, Los Angeles, California
| | - Maros Ferencik
- Knight Cardiovascular Institute, Oregon Health & Science University, Portland
| | - Rita Redberg
- Division of Cardiology, University of California, San Francisco
- Philip R. Lee Institute for Health Policy Studies, University of California, San Franciscio
| | - Ernest Shen
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena
| | - Chengyi Zheng
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena
| | - Benjamin Sun
- Department of Emergency Medicine, Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
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Lee PY, Saad K, Hossain A, Lieu I, Allencherril J. Initial Evaluation and Management of Patients Presenting with Acute Chest Pain in the Emergency Department. Curr Cardiol Rep 2023; 25:1677-1686. [PMID: 37889421 DOI: 10.1007/s11886-023-01984-6] [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] [Accepted: 10/17/2023] [Indexed: 10/28/2023]
Abstract
PURPOSE OF THE REVIEW To review the initial evaluation of chest pain in the emergency department (ED), with a focus on coronary artery disease (CAD) and acute coronary syndromes (ACS), using consensus statements from major cardiovascular disease organizations. RECENT FINDINGS Major cardiovascular organizations have released consensus statements on this topic, notably the 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain and the 2022 ACC Expert Consensus Decision Pathway on the Evaluation and Disposition of Acute Chest Pain in the Emergency Department. Also, recent studies have evaluated the use of high sensitivity troponin (hs-cTn) to safely rule out myocardial infarction (MI), with the development of rule-out pathways designed to be utilized in the ED. This review highlights the comprehensive differential diagnoses of chest pain in the ED and urgent management of these etiologies, with a focus on cardiovascular etiologies. There exist a few rule-out pathways recommended by major cardiovascular organizations, notably the high-STEACS and the ESC 0/1 and 0/2 pathways that can safely and quickly discharge patients with low risk of MI.
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Affiliation(s)
- Paul Y Lee
- Department of Medicine, Rutgers New Jersey Medical School, 150 Bergen Street, UH I-248, Newark, NJ, 07101, USA.
| | - Kyrollos Saad
- Department of Medicine, Rutgers New Jersey Medical School, 150 Bergen Street, UH I-248, Newark, NJ, 07101, USA
| | - Afif Hossain
- Department of Cardiology, Rutgers New Jersey Medical School, Newark, NJ, USA
| | - Irene Lieu
- Department of Emergency Medicine, Rutgers New Jersey Medical School, Newark, NJ, USA
| | - Joseph Allencherril
- Department of Medicine, Division of Cardiovascular Medicine, The University of Texas Medical Branch at Galveston, Galveston, TX, USA
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Odqvist M, Bandstein N, Tygesen H, Eggers KM, Andersson PO, Holzmann MJ. Outcomes in patients with chest pain in emergency departments using high-sensitivity versus conventional troponins. SCAND CARDIOVASC J 2023; 57:2190546. [PMID: 37160719 DOI: 10.1080/14017431.2023.2190546] [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: 05/11/2023]
Abstract
Objectives. There is a paucity of data regarding the association between the use of high-sensitivity troponin (hs-cTn) compared with conventional troponin (cTn) and outcomes in chest pain patients in emergency departments (EDs). This study examined the impact of hs-cTnT on prognosis in chest pain patients in EDs. Design. In an observational cohort study, we included chest pain patients visiting the EDs of 14 hospitals in Sweden from 2011 to 2016. The study population was retrieved from each hospital, and information on characteristics and outcomes was collected from nationwide registries. Cox regression was used to estimate adjusted hazard ratios with 95% confidence intervals (HR, 95% CI) for (1) 1-year all-cause mortality, (2) missed acute coronary syndromes (ACSs), (3) use of coronary angiography, and (4) revascularizations within 30 days. Results. We included 170461 patients with chest pain where 62669 patients were tested with cTn while 107792 patients were tested with hs-cTnT. We found 4149 (4.6%) deaths in the cTn group and 6087 (3.7%) deaths in the hs-cTnT group. Patients in the hs-cTnT group had 9% lower mortality (0.91, 0.87-0.94), and were 14% more likely to undergo coronary angiography (1.14, 1.10-1.17), and 12% more likely to be revascularized (1.12, 1.08-1.17) than patients in the cTn group. Conclusions. Patients with chest pain visiting EDs using hs-cTnT had lower mortality and a higher likelihood of undergoing coronary angiographies and revascularizations than those using cTn. There may be a survival benefit of being tested with hs-cTnT compared with cTn in patients seeking medical attention for chest pain.
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Affiliation(s)
- Maria Odqvist
- Department of Medicine, South Älvsborg Hospital, Borås, Sweden
- Department of Medicine, Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden
| | - Nadia Bandstein
- Functional Area of Emergency Medicine, Karolinska University Hospital, Huddinge, Stockholm, Sweden
- Department of Internal Medicine, Solna, Karolinska Institutet, Stockholm, Sweden
| | - Hans Tygesen
- Department of Medicine, South Älvsborg Hospital, Borås, Sweden
- Department of Medicine, Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden
| | - Kai M Eggers
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - Per-Ola Andersson
- Department of Medicine, South Älvsborg Hospital, Borås, Sweden
- Department of Medicine, Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden
| | - Martin J Holzmann
- Functional Area of Emergency Medicine, Karolinska University Hospital, Huddinge, Stockholm, Sweden
- Department of Internal Medicine, Solna, Karolinska Institutet, Stockholm, Sweden
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Wan G, Wu X, Zhang X, Sun H, Yu X. Development of a novel machine learning model based on laboratory and imaging indices to predict acute cardiac injury in cancer patients with COVID-19 infection: a retrospective observational study. J Cancer Res Clin Oncol 2023; 149:17039-17050. [PMID: 37747525 DOI: 10.1007/s00432-023-05417-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Accepted: 09/07/2023] [Indexed: 09/26/2023]
Abstract
PURPOSE Due to the increased risk of acute cardiac injury (ACI) and poor prognosis in cancer patients with COVID-19 infection, our aim was to develop a novel and interpretable model for predicting ACI occurrence in cancer patients with COVID-19 infection. METHODS This retrospective observational study screened 740 cancer patients with COVID-19 infection from December 2022 to April 2023. The least absolute shrinkage and selection operator (LASSO) regression was used for the preliminary screening of the indices. To enhance the model accuracy, we introduced an alpha index to further screen and rank the indices based on their significance. Random forest (RF) was used to construct the prediction model. The Shapley Additive Explanation (SHAP) and Local Interpretable Model-Agnostic Explanation (LIME) methods were utilized to explain the model. RESULTS According to the inclusion criteria, 201 cancer patients with COVID-19, including 36 variables indices, were included in the analysis. The top eight indices (albumin, lactate dehydrogenase, cystatin C, neutrophil count, creatine kinase isoenzyme, red blood cell distribution width, D-dimer and chest computed tomography) for predicting the occurrence of ACI in cancer patients with COVID-19 infection were included in the RF model. The model achieved an area under curve (AUC) of 0.940, an accuracy of 0.866, a sensitivity of 0.750 and a specificity of 0.900. The calibration curve and decision curve analysis showed good calibration and clinical practicability. SHAP results demonstrated that albumin was the most important index for predicting the occurrence of ACI. LIME results showed that the model could predict the probability of ACI in each cancer patient infected with COVID-19 individually. CONCLUSION We developed a novel machine-learning model that demonstrates high explainability and accuracy in predicting the occurrence of ACI in cancer patients with COVID-19 infection, using laboratory and imaging indices.
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Affiliation(s)
- Guangcai Wan
- Department of Clinical Laboratory, Jilin Cancer Hospital, Changchun, 130012, China
| | - Xuefeng Wu
- Department of Clinical Laboratory, Jilin Cancer Hospital, Changchun, 130012, China
| | - Xiaowei Zhang
- Department of Clinical Laboratory, Jilin Cancer Hospital, Changchun, 130012, China
| | - Hongshuai Sun
- Department of Clinical Laboratory, Jilin Cancer Hospital, Changchun, 130012, China
| | - Xiuyan Yu
- Department of Clinical Laboratory, Jilin Cancer Hospital, Changchun, 130012, China.
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Lee KK, Doudesis D, Ferry AV, Chapman AR, Kimenai DM, Fujisawa T, Bularga A, Lowry MTH, Taggart C, Schulberg S, Wereski R, Tuck C, Strachan FE, Newby DE, Anand A, Shah ASV, Mills NL. Implementation of a high sensitivity cardiac troponin I assay and risk of myocardial infarction or death at five years: observational analysis of a stepped wedge, cluster randomised controlled trial. BMJ 2023; 383:e075009. [PMID: 38011922 PMCID: PMC10680066 DOI: 10.1136/bmj-2023-075009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/18/2023] [Indexed: 11/29/2023]
Abstract
OBJECTIVE To evaluate the impact of implementing a high sensitivity assay for cardiac troponin I on long term outcomes in patients with suspected acute coronary syndrome. DESIGN Secondary observational analysis of a stepped wedge, cluster randomised controlled trial. SETTING 10 secondary and tertiary care centres in Scotland, UK. PARTICIPANTS 48 282 consecutive patients with suspected acute coronary syndrome. Myocardial injury was defined as any high sensitivity assay result for cardiac troponin I >99th centile of 16 ng/L in women and 34 ng/L in men. INTERVENTION Hospital sites were randomly allocated to either early (n=5 hospitals) or late (n=5 hospitals) implementation of a high sensitivity cardiac troponin I assay with sex specific diagnostic thresholds. MAIN OUTCOME MEASURE The main outcome was myocardial infarction or death at five years. RESULTS 10 360 patients had cardiac troponin concentrations greater than the 99th centile, of whom 1771 (17.1%) were reclassified by the high sensitivity assay. The five year incidence of subsequent myocardial infarction or death before and after implementation of the high sensitivity assay was 29.4% (5588/18 978) v 25.9% (7591/29 304), respectively, in all patients (adjusted hazard ratio 0.97, 95% confidence interval 0.93 to 1.01), and 63.0% (456/720) v 53.9% (567/1051), respectively, in those reclassified by the high sensitivity assay (0.82, 0.72 to 0.94). After implementation of the high sensitivity assay, a reduction in subsequent myocardial infarction or death was observed in patients with non-ischaemic myocardial injury (0.83, 0.75 to 0.91) but not in those with type 1 or type 2 myocardial infarction (0.92, 0.83 to 1.01 and 0.98, 0.84 to 1.14). CONCLUSIONS Implementation of a high sensitivity cardiac troponin I assay in the assessment of patients with suspected acute coronary syndrome was associated with a reduced risk of subsequent myocardial infarction or death at five years in those reclassified by the high sensitivity assay. Improvements in outcome were greatest in patients with non-ischaemic myocardial injury, suggesting a broader benefit beyond the identification of myocardial infarction. TRIAL REGISTRATION ClinicalTrials.gov NCT01852123.
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Affiliation(s)
- Kuan Ken Lee
- British Heart Foundation (BHF) Centre for Cardiovascular Science, University of Edinburgh, Edinburgh EH16 4SA, UK
| | - Dimitrios Doudesis
- British Heart Foundation (BHF) Centre for Cardiovascular Science, University of Edinburgh, Edinburgh EH16 4SA, UK
- Usher Institute, University of Edinburgh, Edinburgh, UK
| | - Amy V Ferry
- British Heart Foundation (BHF) Centre for Cardiovascular Science, University of Edinburgh, Edinburgh EH16 4SA, UK
| | - Andrew R Chapman
- British Heart Foundation (BHF) Centre for Cardiovascular Science, University of Edinburgh, Edinburgh EH16 4SA, UK
| | - Dorien M Kimenai
- British Heart Foundation (BHF) Centre for Cardiovascular Science, University of Edinburgh, Edinburgh EH16 4SA, UK
| | - Takeshi Fujisawa
- British Heart Foundation (BHF) Centre for Cardiovascular Science, University of Edinburgh, Edinburgh EH16 4SA, UK
| | - Anda Bularga
- British Heart Foundation (BHF) Centre for Cardiovascular Science, University of Edinburgh, Edinburgh EH16 4SA, UK
| | - Matthew T H Lowry
- British Heart Foundation (BHF) Centre for Cardiovascular Science, University of Edinburgh, Edinburgh EH16 4SA, UK
| | - Caelan Taggart
- British Heart Foundation (BHF) Centre for Cardiovascular Science, University of Edinburgh, Edinburgh EH16 4SA, UK
| | - Stacey Schulberg
- British Heart Foundation (BHF) Centre for Cardiovascular Science, University of Edinburgh, Edinburgh EH16 4SA, UK
| | - Ryan Wereski
- British Heart Foundation (BHF) Centre for Cardiovascular Science, University of Edinburgh, Edinburgh EH16 4SA, UK
| | - Chris Tuck
- British Heart Foundation (BHF) Centre for Cardiovascular Science, University of Edinburgh, Edinburgh EH16 4SA, UK
| | | | - David E Newby
- British Heart Foundation (BHF) Centre for Cardiovascular Science, University of Edinburgh, Edinburgh EH16 4SA, UK
| | - Atul Anand
- British Heart Foundation (BHF) Centre for Cardiovascular Science, University of Edinburgh, Edinburgh EH16 4SA, UK
| | - Anoop S V Shah
- British Heart Foundation (BHF) Centre for Cardiovascular Science, University of Edinburgh, Edinburgh EH16 4SA, UK
- London School of Hygiene and Tropical Medicine, London, UK
| | - Nicholas L Mills
- British Heart Foundation (BHF) Centre for Cardiovascular Science, University of Edinburgh, Edinburgh EH16 4SA, UK
- Usher Institute, University of Edinburgh, Edinburgh, UK
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Gebre AK, Sim M, Schultz C. Do high sensitivity cardiac troponin assays improve patient outcomes? BMJ 2023; 383:2741. [PMID: 38011934 DOI: 10.1136/bmj.p2741] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2023]
Affiliation(s)
- Abadi K Gebre
- Nutrition and Health Innovation Research Institute, School of Medical and Health Sciences, Edith Cowan University, Joondalup, WA 6027, Australia
- School of Pharmacy, College of Health Sciences, Mekelle University, Mekelle, Tigray, Ethiopia
| | - Marc Sim
- Nutrition and Health Innovation Research Institute, School of Medical and Health Sciences, Edith Cowan University, Joondalup, WA 6027, Australia
- Medical School, The University of Western Australia, Perth, WA, Australia
| | - Carl Schultz
- Medical School, The University of Western Australia, Perth, WA, Australia
- Department of Cardiology, Royal Perth Hospital, Perth, WA, Australia
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Fernández-Cisnal A, Lopez-Ayala P, Valero E, Koechlin L, Catarralá A, Boeddinghaus J, Noceda J, Nestelberger T, Miró Ò, Julio N, Mueller C, Sanchis J. Derivation and external validation of machine-learning models for risk stratification in chest pain with normal troponin. EUROPEAN HEART JOURNAL. ACUTE CARDIOVASCULAR CARE 2023; 12:743-752. [PMID: 37531633 DOI: 10.1093/ehjacc/zuad089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Revised: 07/18/2023] [Accepted: 07/26/2023] [Indexed: 08/04/2023]
Abstract
AIMS Risk stratification of patients with chest pain and a high-sensitivity cardiac troponin T (hs-cTnT) concentration METHODS AND RESULTS Four machine-learning-based models and one logistic regression (LR) model were trained on 4075 patients (single-centre Spanish cohort) and externally validated on 3609 patients (international prospective Advantageous Predictors of Acute Coronary syndromes Evaluation cohort). Models were compared with GRACE and HEART scores and a single undetectable hs-cTnT-based strategy (u-cTn; hs-cTnT < 5 ng/L and time from symptoms onset >180 min). Probability thresholds for safe discharge were derived in the derivation cohort. The endpoint occurred in 105 (2.6%) patients in the training set and 98 (2.7%) in the external validation set. Gradient boosting full (GBf) showed the best discrimination (area under the curve = 0.808). Calibration was good for the reduced neural network and LR models. Gradient boosting full identified the highest proportion of patients for safe discharge (36.7 vs. 23.4 vs. 27.2%; GBf vs. LR vs. u-cTn, respectively) with similar safety (missed endpoint per 1000 patients: 2.2 vs. 3.5 vs. 3.1, respectively). All derived models were superior to the HEART and GRACE scores (P < 0.001). CONCLUSION Machine-learning and LR prediction models were superior to the HEART, GRACE, and u-cTn for risk stratification of patients with chest pain and a baseline hs-cTnT CLINICAL TRIAL REGISTRATION ClinicalTrials.gov number, NCT00470587, https://clinicaltrials.gov/ct2/show/NCT00470587.
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Affiliation(s)
- Agustín Fernández-Cisnal
- Cardiology Department, Hospital Clínico Universitario de València, Instituto de Investigación Sanitaria (INCLIVA), University of València, Centro de Investigación Biomédica en Red Enfermedades Cardiovaculares (CIBERCV), València, Spain
| | - Pedro Lopez-Ayala
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Heart Center Basel, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Ernesto Valero
- Cardiology Department, Hospital Clínico Universitario de València, Instituto de Investigación Sanitaria (INCLIVA), University of València, Centro de Investigación Biomédica en Red Enfermedades Cardiovaculares (CIBERCV), València, Spain
| | - Luca Koechlin
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Heart Center Basel, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Arturo Catarralá
- Clinical Biochemistry Department, Hospital Clínico Universitario de València, Instituto de Investigación Sanitaria (INCLIVA), València 46010, Spain
| | - Jasper Boeddinghaus
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Heart Center Basel, University Hospital Basel, University of Basel, Basel, Switzerland
| | - José Noceda
- Emergency Department, Hospital Clínico Universitario de València, Instituto de Investigación Sanitaria (INCLIVA), València 46010, Spain
| | - Thomas Nestelberger
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Heart Center Basel, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Òscar Miró
- Emergency Department, Hospital Clinic, Barcelona, Catalonia, Spain
| | - Núñez Julio
- Cardiology Department, Hospital Clínico Universitario de València, Instituto de Investigación Sanitaria (INCLIVA), University of València, Centro de Investigación Biomédica en Red Enfermedades Cardiovaculares (CIBERCV), València, Spain
| | - Christian Mueller
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Heart Center Basel, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Juan Sanchis
- Cardiology Department, Hospital Clínico Universitario de València, Instituto de Investigación Sanitaria (INCLIVA), University of València, Centro de Investigación Biomédica en Red Enfermedades Cardiovaculares (CIBERCV), València, Spain
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Thangaraj PM, Khera R. Accelerating chest pain evaluation with machine learning. EUROPEAN HEART JOURNAL. ACUTE CARDIOVASCULAR CARE 2023; 12:753-754. [PMID: 37793075 PMCID: PMC11004857 DOI: 10.1093/ehjacc/zuad117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Accepted: 09/29/2023] [Indexed: 10/06/2023]
Affiliation(s)
- Phyllis M Thangaraj
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, 330 Cedar Street, Boardman 110, New Haven, CT 06520, USA
| | - Rohan Khera
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, 330 Cedar Street, Boardman 110, New Haven, CT 06520, USA
- Section of Health Informatics, Department of Biostatistics, Yale School of Public Health, 60 College Street, New Haven, CT 06510, USA
- Section of Biomedical Informatics and Data Science, Yale School of Medicine, 100 College Street, Floor 9, New Haven, CT 06510, USA
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, 195 Church Street, 6th Floor, New Haven, CT 06510, USA
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Byrne RA, Rossello X, Coughlan JJ, Barbato E, Berry C, Chieffo A, Claeys MJ, Dan GA, Dweck MR, Galbraith M, Gilard M, Hinterbuchner L, Jankowska EA, Jüni P, Kimura T, Kunadian V, Leosdottir M, Lorusso R, Pedretti RFE, Rigopoulos AG, Rubini Gimenez M, Thiele H, Vranckx P, Wassmann S, Wenger NK, Ibanez B. 2023 ESC Guidelines for the management of acute coronary syndromes. Eur Heart J 2023; 44:3720-3826. [PMID: 37622654 DOI: 10.1093/eurheartj/ehad191] [Citation(s) in RCA: 779] [Impact Index Per Article: 779.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/26/2023] Open
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Katsioupa M, Kourampi I, Oikonomou E, Tsigkou V, Theofilis P, Charalambous G, Marinos G, Gialamas I, Zisimos K, Anastasiou A, Katsianos E, Kalogeras K, Katsarou O, Vavuranakis M, Siasos G, Tousoulis D. Novel Biomarkers and Their Role in the Diagnosis and Prognosis of Acute Coronary Syndrome. Life (Basel) 2023; 13:1992. [PMID: 37895374 PMCID: PMC10608753 DOI: 10.3390/life13101992] [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: 09/04/2023] [Revised: 09/23/2023] [Accepted: 09/28/2023] [Indexed: 10/29/2023] Open
Abstract
The burden of cardiovascular diseases and the critical role of acute coronary syndrome (ACS) in their progression underscore the need for effective diagnostic and prognostic tools. Biomarkers have emerged as crucial instruments for ACS diagnosis, risk stratification, and prognosis assessment. Among these, high-sensitivity troponin (hs-cTn) has revolutionized ACS diagnosis due to its superior sensitivity and negative predictive value. However, challenges regarding specificity, standardization, and interpretation persist. Beyond troponins, various biomarkers reflecting myocardial injury, neurohormonal activation, inflammation, thrombosis, and other pathways are being explored to refine ACS management. This review article comprehensively explores the landscape of clinically used biomarkers intricately involved in the pathophysiology, diagnosis, and prognosis of ACS (i.e., troponins, creatine kinase MB (CK-MB), B-type natriuretic peptides (BNP), copeptin, C-reactive protein (CRP), interleukin-6 (IL-6), d-dimers, fibrinogen), especially focusing on the prognostic role of natriuretic peptides and of inflammatory indices. Research data on novel biomarkers (i.e., endocan, galectin, soluble suppression of tumorigenicity (sST2), microRNAs (miRNAs), soluble oxidized low-density lipoprotein receptor-1 (sLOX-1), F2 isoprostanes, and growth differentiation factor 15 (GDF-15)) are further analyzed, aiming to shed light on the multiplicity of pathophysiologic mechanisms implicated in the evolution of ACS. By elucidating the complex interplay of these biomarkers in ACS pathophysiology, diagnosis, and outcomes, this review aims to enhance our understanding of the evolving trajectory and advancements in ACS management. However, further research is necessary to establish the clinical utility and integration of these biomarkers into routine practice to improve patient outcomes.
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Affiliation(s)
- Maria Katsioupa
- 3rd Department of Cardiology, Thoracic Diseases General Hospital “Sotiria”, National and Kapodistrian University of Athens, 11527 Athens, Greece; (M.K.); (I.K.); (E.O.); (V.T.); (I.G.); (K.Z.); (A.A.); (E.K.); (K.K.); (O.K.); (M.V.)
| | - Islam Kourampi
- 3rd Department of Cardiology, Thoracic Diseases General Hospital “Sotiria”, National and Kapodistrian University of Athens, 11527 Athens, Greece; (M.K.); (I.K.); (E.O.); (V.T.); (I.G.); (K.Z.); (A.A.); (E.K.); (K.K.); (O.K.); (M.V.)
| | - Evangelos Oikonomou
- 3rd Department of Cardiology, Thoracic Diseases General Hospital “Sotiria”, National and Kapodistrian University of Athens, 11527 Athens, Greece; (M.K.); (I.K.); (E.O.); (V.T.); (I.G.); (K.Z.); (A.A.); (E.K.); (K.K.); (O.K.); (M.V.)
| | - Vasiliki Tsigkou
- 3rd Department of Cardiology, Thoracic Diseases General Hospital “Sotiria”, National and Kapodistrian University of Athens, 11527 Athens, Greece; (M.K.); (I.K.); (E.O.); (V.T.); (I.G.); (K.Z.); (A.A.); (E.K.); (K.K.); (O.K.); (M.V.)
| | - Panagiotis Theofilis
- 1st Department of Cardiology, “Hippokration” General Hospital, National and Kapodistrian University of Athens, 11527 Athens, Greece; (P.T.); (D.T.)
| | - Georgios Charalambous
- Department of Emergency Medicine, “Hippokration” General Hospital, National and Kapodistrian University of Athens, 11527 Athens, Greece;
| | - George Marinos
- Department of Hygiene, Epidemiology and Medical Statistics, Medical School, National and Kapodistrian University of Athens, 11527 Athens, Greece;
| | - Ioannis Gialamas
- 3rd Department of Cardiology, Thoracic Diseases General Hospital “Sotiria”, National and Kapodistrian University of Athens, 11527 Athens, Greece; (M.K.); (I.K.); (E.O.); (V.T.); (I.G.); (K.Z.); (A.A.); (E.K.); (K.K.); (O.K.); (M.V.)
| | - Konstantinos Zisimos
- 3rd Department of Cardiology, Thoracic Diseases General Hospital “Sotiria”, National and Kapodistrian University of Athens, 11527 Athens, Greece; (M.K.); (I.K.); (E.O.); (V.T.); (I.G.); (K.Z.); (A.A.); (E.K.); (K.K.); (O.K.); (M.V.)
| | - Artemis Anastasiou
- 3rd Department of Cardiology, Thoracic Diseases General Hospital “Sotiria”, National and Kapodistrian University of Athens, 11527 Athens, Greece; (M.K.); (I.K.); (E.O.); (V.T.); (I.G.); (K.Z.); (A.A.); (E.K.); (K.K.); (O.K.); (M.V.)
| | - Efstratios Katsianos
- 3rd Department of Cardiology, Thoracic Diseases General Hospital “Sotiria”, National and Kapodistrian University of Athens, 11527 Athens, Greece; (M.K.); (I.K.); (E.O.); (V.T.); (I.G.); (K.Z.); (A.A.); (E.K.); (K.K.); (O.K.); (M.V.)
| | - Konstantinos Kalogeras
- 3rd Department of Cardiology, Thoracic Diseases General Hospital “Sotiria”, National and Kapodistrian University of Athens, 11527 Athens, Greece; (M.K.); (I.K.); (E.O.); (V.T.); (I.G.); (K.Z.); (A.A.); (E.K.); (K.K.); (O.K.); (M.V.)
| | - Ourania Katsarou
- 3rd Department of Cardiology, Thoracic Diseases General Hospital “Sotiria”, National and Kapodistrian University of Athens, 11527 Athens, Greece; (M.K.); (I.K.); (E.O.); (V.T.); (I.G.); (K.Z.); (A.A.); (E.K.); (K.K.); (O.K.); (M.V.)
| | - Manolis Vavuranakis
- 3rd Department of Cardiology, Thoracic Diseases General Hospital “Sotiria”, National and Kapodistrian University of Athens, 11527 Athens, Greece; (M.K.); (I.K.); (E.O.); (V.T.); (I.G.); (K.Z.); (A.A.); (E.K.); (K.K.); (O.K.); (M.V.)
| | - Gerasimos Siasos
- 3rd Department of Cardiology, Thoracic Diseases General Hospital “Sotiria”, National and Kapodistrian University of Athens, 11527 Athens, Greece; (M.K.); (I.K.); (E.O.); (V.T.); (I.G.); (K.Z.); (A.A.); (E.K.); (K.K.); (O.K.); (M.V.)
| | - Dimitris Tousoulis
- 1st Department of Cardiology, “Hippokration” General Hospital, National and Kapodistrian University of Athens, 11527 Athens, Greece; (P.T.); (D.T.)
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Vergallo R, Patrono C. Machine learning and myocardial infarction diagnosis: sometimes you can't make it on your own. Eur Heart J 2023; 44:3309-3310. [PMID: 37525543 DOI: 10.1093/eurheartj/ehad467] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/02/2023] Open
Affiliation(s)
- Rocco Vergallo
- Interventional Cardiology Unit, Cardiothoracic and Vascular Department (DICATOV), IRCCS Ospedale Policlinico San Martino, Viale Benedetto XV, Genova 6-16132, Italy
- Department of Internal Medicine and Medical Specialties (DIMI), Università di Genova, Viale Benedetto XV, Genova 6-16132, Italy
| | - Carlo Patrono
- Department of Pharmacology, Catholic University School of Medicine, Largo F. Vito, 8, 00168 Rome, Italy
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Yufera-Sanchez A, Lopez-Ayala P, Nestelberger T, Wildi K, Boeddinghaus J, Koechlin L, Rubini Gimenez M, Sakiz H, Bima P, Miro O, Martín-Sánchez FJ, Christ M, Keller DI, Gualandro DM, Kawecki D, Rentsch K, Buser A, Mueller C. Combining glucose and high-sensitivity cardiac troponin in the early diagnosis of acute myocardial infarction. Sci Rep 2023; 13:14598. [PMID: 37670005 PMCID: PMC10480296 DOI: 10.1038/s41598-023-37093-1] [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: 03/15/2023] [Accepted: 06/15/2023] [Indexed: 09/07/2023] Open
Abstract
Glucose is a universally available inexpensive biomarker, which is increased as part of the physiological stress response to acute myocardial infarction (AMI) and may therefore help in its early diagnosis. To test this hypothesis, glucose, high-sensitivity cardiac troponin (hs-cTn) T, and hs-cTnI were measured in consecutive patients presenting with acute chest discomfort to the emergency department (ED) and enrolled in a large international diagnostic study (NCT00470587). Two independent cardiologists centrally adjudicated the final diagnosis using all clinical data, including serial hs-cTnT measurements, cardiac imaging and clinical follow-up. The primary diagnostic endpoint was index non-ST-segment elevation MI (NSTEMI). Prognostic endpoints were all-cause death, and cardiovascular (CV) death or future AMI, all within 730-days. Among 5639 eligible patients, NSTEMI was the adjudicated final diagnosis in 1051 (18.6%) patients. Diagnostic accuracy quantified using the area under the receiver-operating characteristics curve (AUC) for the combination of glucose with hs-cTnT and glucose with hs-cTnI was very high, but not higher versus that of hs-cTn alone (glucose/hs-cTnT 0.930 [95% CI 0.922-0.937] versus hs-cTnT 0.929 [95% CI 0.922-0.937]; glucose/hs-cTnI 0.944 [95% CI 0.937-0.951] versus hs-cTnI 0.944 [95% CI 0.937-0.951]). In early-presenters, a dual-marker strategy (glucose < 7 mmol/L and hs-cTnT < 5/hs-cTnI < 4 ng/L) provided very high and comparable sensitivity to slightly lower hs-cTn concentrations (cTnT/I < 4/3 ng/L) alone, and possibly even higher efficacy. Glucose was an independent predictor of 730-days endpoints. Our results showed that a dual marker strategy of glucose and hs-cTn did not increase the diagnostic accuracy when used continuously. However, a cutoff approach combining glucose and hs-cTn may provide diagnostic utility for patients presenting ≤ 3 h after onset of symptoms, also providing important prognostic information.
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Affiliation(s)
- Ana Yufera-Sanchez
- Department of Cardiology, University Heart Center Basel, and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT Network, Basel, Switzerland
| | - Pedro Lopez-Ayala
- Department of Cardiology, University Heart Center Basel, and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT Network, Basel, Switzerland
| | - Thomas Nestelberger
- Department of Cardiology, University Heart Center Basel, and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT Network, Basel, Switzerland
| | - Karin Wildi
- Department of Cardiology, University Heart Center Basel, and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT Network, Basel, Switzerland
- Department of Intensive Care, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Jasper Boeddinghaus
- Department of Cardiology, University Heart Center Basel, and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT Network, Basel, Switzerland
- Department of Cardiology, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Luca Koechlin
- Department of Cardiology, University Heart Center Basel, and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT Network, Basel, Switzerland
- Department of Cardiac Surgery, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Maria Rubini Gimenez
- Department of Cardiology, University Heart Center Basel, and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Basel, Switzerland
- Cardiology Department, Heart Center Leipzig, Leipzig, Germany
| | - Hüseyin Sakiz
- Department of Cardiology, University Heart Center Basel, and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT Network, Basel, Switzerland
| | - Paolo Bima
- Department of Cardiology, University Heart Center Basel, and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT Network, Basel, Switzerland
- Department of Medical Sciences, University of Turin, Turin, Italy
| | - Oscar Miro
- GREAT Network, Basel, Switzerland
- Emergency Department, Hospital Clinic, Barcelona, Catalonia, Spain
| | - F Javier Martín-Sánchez
- GREAT Network, Basel, Switzerland
- Emergency Department, Hospital Clínico San Carlos, Madrid, Spain
| | - Michael Christ
- Department of Emergency Medicine, Luzerner Kantonsspital, Luzern, Switzerland
| | - Dagmar I Keller
- Emergency Department, University Hospital Zurich, Zurich, Switzerland
| | - Danielle M Gualandro
- Department of Cardiology, University Heart Center Basel, and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT Network, Basel, Switzerland
| | - Damian Kawecki
- 2nd Department of Cardiology, School of Medicine in Zabrze, Medical University of Sielsia, Katowice, Poland
| | - Katharina Rentsch
- Laboratory Medicine, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Andreas Buser
- Blood Transfusion Centre, Swiss Red Cross, Basel, Switzerland
- Department of Hematology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Christian Mueller
- Department of Cardiology, University Heart Center Basel, and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Basel, Switzerland.
- GREAT Network, Basel, Switzerland.
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49
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Neumann JT, Twerenbold R, Ojeda F, Aldous SJ, Allen BR, Apple FS, Babel H, Christenson RH, Cullen L, Di Carluccio E, Doudesis D, Ekelund U, Giannitsis E, Greenslade J, Inoue K, Jernberg T, Kavsak P, Keller T, Lee KK, Lindahl B, Lorenz T, Mahler SA, Mills NL, Mokhtari A, Parsonage W, Pickering JW, Pemberton CJ, Reich C, Richards AM, Sandoval Y, Than MP, Toprak B, Troughton RW, Worster A, Zeller T, Ziegler A, Blankenberg S. Personalized diagnosis in suspected myocardial infarction. Clin Res Cardiol 2023; 112:1288-1301. [PMID: 37131096 PMCID: PMC10449973 DOI: 10.1007/s00392-023-02206-3] [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: 03/15/2023] [Accepted: 04/11/2023] [Indexed: 05/04/2023]
Abstract
BACKGROUND In suspected myocardial infarction (MI), guidelines recommend using high-sensitivity cardiac troponin (hs-cTn)-based approaches. These require fixed assay-specific thresholds and timepoints, without directly integrating clinical information. Using machine-learning techniques including hs-cTn and clinical routine variables, we aimed to build a digital tool to directly estimate the individual probability of MI, allowing for numerous hs-cTn assays. METHODS In 2,575 patients presenting to the emergency department with suspected MI, two ensembles of machine-learning models using single or serial concentrations of six different hs-cTn assays were derived to estimate the individual MI probability (ARTEMIS model). Discriminative performance of the models was assessed using area under the receiver operating characteristic curve (AUC) and logLoss. Model performance was validated in an external cohort with 1688 patients and tested for global generalizability in 13 international cohorts with 23,411 patients. RESULTS Eleven routinely available variables including age, sex, cardiovascular risk factors, electrocardiography, and hs-cTn were included in the ARTEMIS models. In the validation and generalization cohorts, excellent discriminative performance was confirmed, superior to hs-cTn only. For the serial hs-cTn measurement model, AUC ranged from 0.92 to 0.98. Good calibration was observed. Using a single hs-cTn measurement, the ARTEMIS model allowed direct rule-out of MI with very high and similar safety but up to tripled efficiency compared to the guideline-recommended strategy. CONCLUSION We developed and validated diagnostic models to accurately estimate the individual probability of MI, which allow for variable hs-cTn use and flexible timing of resampling. Their digital application may provide rapid, safe and efficient personalized patient care. TRIAL REGISTRATION NUMBERS Data of following cohorts were used for this project: BACC ( www. CLINICALTRIALS gov ; NCT02355457), stenoCardia ( www. CLINICALTRIALS gov ; NCT03227159), ADAPT-BSN ( www.australianclinicaltrials.gov.au ; ACTRN12611001069943), IMPACT ( www.australianclinicaltrials.gov.au , ACTRN12611000206921), ADAPT-RCT ( www.anzctr.org.au ; ANZCTR12610000766011), EDACS-RCT ( www.anzctr.org.au ; ANZCTR12613000745741); DROP-ACS ( https://www.umin.ac.jp , UMIN000030668); High-STEACS ( www. CLINICALTRIALS gov ; NCT01852123), LUND ( www. CLINICALTRIALS gov ; NCT05484544), RAPID-CPU ( www. CLINICALTRIALS gov ; NCT03111862), ROMI ( www. CLINICALTRIALS gov ; NCT01994577), SAMIE ( https://anzctr.org.au ; ACTRN12621000053820), SEIGE and SAFETY ( www. CLINICALTRIALS gov ; NCT04772157), STOP-CP ( www. CLINICALTRIALS gov ; NCT02984436), UTROPIA ( www. CLINICALTRIALS gov ; NCT02060760).
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Affiliation(s)
- Johannes Tobias Neumann
- Department of Cardiology, University Heart and Vascular Center, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
- German Center for Cardiovascular Research (DZHK), Partner SiteHamburg/Kiel/Lübeck, Hamburg, Germany
- Population Health Research Department, University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Raphael Twerenbold
- Department of Cardiology, University Heart and Vascular Center, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
- German Center for Cardiovascular Research (DZHK), Partner SiteHamburg/Kiel/Lübeck, Hamburg, Germany
- Population Health Research Department, University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- University Center of Cardiovascular Science, University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Francisco Ojeda
- Department of Cardiology, University Heart and Vascular Center, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
- Population Health Research Department, University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Sally J Aldous
- Department of Cardiology, Christchurch Hospital, Christchurch, New Zealand
| | - Brandon R Allen
- Department of Emergency Medicine, College of Medicine, University of Florida, Gainesville, FL, USA
| | - Fred S Apple
- Departments of Laboratory Medicine and Pathology, Hennepin Healthcare/HCMC and University of Minnesota, Minneapolis, MN, USA
| | - Hugo Babel
- Cardio-CARE, Medizincampus Davos, Davos, Switzerland
| | - Robert H Christenson
- Department of Pathology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Louise Cullen
- Department of Emergency Medicine, Royal Brisbane and Women's Hospital, Herston, QLD, Australia
| | | | - Dimitrios Doudesis
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Ulf Ekelund
- Department of Internal and Emergency Medicine, Lund University, Skåne University Hospital, Lund, Sweden
| | | | - Jaimi Greenslade
- Department of Emergency Medicine, Royal Brisbane and Women's Hospital, Herston, QLD, Australia
| | - Kenji Inoue
- Juntendo University Nerima Hospital, Tokyo, Japan
| | - Tomas Jernberg
- Department of Clinical Sciences, Danderyd University Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Peter Kavsak
- Department of Pathology and Molecular Medicine, McMaster University, Hamilton, ON, Canada
| | - Till Keller
- Department of Cardiology, Kerckhoff Heart and Thorax Center, Bad Nauheim, Germany
| | - Kuan Ken Lee
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Bertil Lindahl
- Department of Medical Sciences and Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - Thiess Lorenz
- Department of Cardiology, University Heart and Vascular Center, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
- German Center for Cardiovascular Research (DZHK), Partner SiteHamburg/Kiel/Lübeck, Hamburg, Germany
- Population Health Research Department, University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Simon A Mahler
- Department of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Nicholas L Mills
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Arash Mokhtari
- Department of Internal Medicine and Emergency Medicine and Department of Cardiology, Lund University, Skåne University Hospital, Lund, Sweden
| | - William Parsonage
- Australian Centre for Health Service Innovation, Queensland University of Technology, Kelvin Grove, Australia
| | - John W Pickering
- Department of Medicine, Christchurch and Emergency Department, University of Otago, Christchurch Hospital, Christchurch, New Zealand
| | - Christopher J Pemberton
- Department of Medicine, Christchurch Heart Institute, University of Otago, Christchurch, New Zealand
| | - Christoph Reich
- Department of Cardiology, Heidelberg University Hospital, Heidelberg, Germany
| | - A Mark Richards
- Department of Medicine, Christchurch and Emergency Department, University of Otago, Christchurch Hospital, Christchurch, New Zealand
| | - Yader Sandoval
- Minneapolis Heart Institute, Abbott Northwestern Hospital, and Minneapolis Heart Institute Foundation, Minneapolis, MN, USA
| | - Martin P Than
- Department of Medicine, Christchurch and Emergency Department, University of Otago, Christchurch Hospital, Christchurch, New Zealand
| | - Betül Toprak
- Department of Cardiology, University Heart and Vascular Center, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
- German Center for Cardiovascular Research (DZHK), Partner SiteHamburg/Kiel/Lübeck, Hamburg, Germany
- Population Health Research Department, University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- University Center of Cardiovascular Science, University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Richard W Troughton
- Department of Medicine, Christchurch Heart Institute, University of Otago, Christchurch, New Zealand
| | - Andrew Worster
- Division of Emergency Medicine, McMaster University, Hamilton, ON, Canada
| | - Tanja Zeller
- Department of Cardiology, University Heart and Vascular Center, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
- German Center for Cardiovascular Research (DZHK), Partner SiteHamburg/Kiel/Lübeck, Hamburg, Germany
- Population Health Research Department, University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- University Center of Cardiovascular Science, University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Andreas Ziegler
- Cardio-CARE, Medizincampus Davos, Davos, Switzerland
- School of Mathematics, Statistics and Computer Science, University of KwaZulu-Natal, Pietermaritzburg, South Africa
| | - Stefan Blankenberg
- Department of Cardiology, University Heart and Vascular Center, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany.
- German Center for Cardiovascular Research (DZHK), Partner SiteHamburg/Kiel/Lübeck, Hamburg, Germany.
- Population Health Research Department, University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
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50
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Yildirim M, Mueller‐Hennessen M, Milles BR, Biener M, Hund H, Frey N, Giannitsis E, Salbach C. Real-World Evidence on Disparities on the Initiation of Ticagrelor Versus Prasugrel in Patients With Acute Coronary Syndrome. J Am Heart Assoc 2023; 12:e030879. [PMID: 37581388 PMCID: PMC10492934 DOI: 10.1161/jaha.123.030879] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Accepted: 07/20/2023] [Indexed: 08/16/2023]
Abstract
Background Management of patients with non-ST-segment-elevation acute coronary syndrome (NSTE-ACS) is based on 2020 European Society of Cardiology guidelines, which recommend the preferential use of prasugrel over ticagrelor. Because the selection of the respective P2Y12 inhibitor has to consider label restrictions, we sought to evaluate the proportion of patients qualifying for either ticagrelor or prasugrel and reasons for noneligibility in an unselected cohort of patients with acute coronary syndrome. Methods and Results In this retrospective observational study, patients with ST-segment-elevation myocardial infarction (STEMI) or NSTE-ACS presenting consecutively during a 24-month period were enrolled. The eligibility of patients for a dual antiplatelet therapy option was assessed retrospectively. A total of 1502 patients had confirmed acute coronary syndrome (287 STEMI and 1215 NSTE-ACS). Eligibility for ticagrelor and full-dose prasugrel differed significantly for STEMI and NSTE-ACS (93% versus 51%, P<0.0001 versus 80% versus 31%, P<0.0001). Eligibility remained significantly lower (STEMI 78% versus NSTE-ACS 52%) if low-dose prasugrel was considered. Patients eligible for full-dose prasugrel had lower ischemic risk per GRACE (Global Registry of Acute Coronary Events) score (109 points [90-129 points] versus 121 points [98-146 points], P<0.0001) and lower bleeding risk (14 points [13-15 points] versus 20 points [12-29 points], P<0.0001) per PRECISE-DAPT (Predicting Bleeding Complications in Patients Undergoing Stent Implantation and Subsequent Dual Antiplatelet Therapy) score. Conclusions In real life, eligibility for prasugrel in patients requiring dual antiplatelet therapy is considerably lower than for ticagrelor, even in a cohort with high rates of coronary angiography and percutaneous coronary interventions. The recommended use of prasugrel over ticagrelor in current acute coronary syndrome guidelines contrasts with our observations of a substantial disparity on the eligibility. This important aspect has not received appropriate attention yet. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT05774431.
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Affiliation(s)
- Mustafa Yildirim
- Department of Internal Medicine III, CardiologyUniversity Hospital of HeidelbergHeidelbergGermany
| | | | - Barbara Ruth Milles
- Department of Internal Medicine III, CardiologyUniversity Hospital of HeidelbergHeidelbergGermany
| | - Moritz Biener
- Department of Internal Medicine III, CardiologyUniversity Hospital of HeidelbergHeidelbergGermany
| | - Hauke Hund
- Department of Internal Medicine III, CardiologyUniversity Hospital of HeidelbergHeidelbergGermany
| | - Norbert Frey
- Department of Internal Medicine III, CardiologyUniversity Hospital of HeidelbergHeidelbergGermany
| | - Evangelos Giannitsis
- Department of Internal Medicine III, CardiologyUniversity Hospital of HeidelbergHeidelbergGermany
| | - Christian Salbach
- Department of Internal Medicine III, CardiologyUniversity Hospital of HeidelbergHeidelbergGermany
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