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Hinton J, Mariathas MN, Gabara L, Allan R, Nicholas Z, Kwok CS, Ramamoorthy S, Calver A, Corbett S, Jabbour RJ, Mahmoudi M, Rawlins J, Sirohi R, Wilkinson JR, Cook P, Martin GP, Mamas MA, Curzen N. Association between troponin level and medium-term mortality in 20 000 hospital patients. Heart 2023; 109:1772-1777. [PMID: 37550072 DOI: 10.1136/heartjnl-2023-322463] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2023] [Accepted: 06/20/2023] [Indexed: 08/09/2023] Open
Abstract
INTRODUCTION Cardiac troponin (cTn) concentrations above the manufacturer recommended upper limit of normal (ULN) are frequently seen in hospital patients without a clinical presentation consistent with type 1 myocardial infarction, and the significance of this is uncertain. The aim of this study was to assess the relationship between medium-term mortality and cTn concentration in a large consecutive hospital population, regardless of whether there was a clinical indication for performing the test. METHOD This prospective observational study included 20 000 consecutive in-hospital and outpatient patients who had a blood test for any reason at a large teaching hospital, and in whom a hs-cTnI assay was measured, regardless of the original clinical indication. Mortality was obtained via NHS Digital. RESULTS A total of 20 000 patients were included in the analysis and 18 282 of these (91.4%) did not have a clinical indication for cardiac troponin I (cTnI) testing. Overall, 2825 (14.1%) patients died at a median of 809 days. The mortality was significantly higher if the cTnI concentration was above the ULN (45.3% vs 12.3% p<0.001 log rank). Multivariable Cox analysis demonstrated that the log10 cTnI concentration was independently associated with mortality (HR 1.76 (95% CI 1.65 to 1.88)). Landmark analysis, excluding deaths within 30 days, showed the relationship between cTnI concentration and mortality persisted. CONCLUSION In a large, unselected hospital population, in 91.4% of whom there was no clinical indication for testing, cTnI concentration was independently associated with medium-term cardiovascular and non-cardiovascular mortality in the statistical model tested.
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Affiliation(s)
- Jonathan Hinton
- University of Southampton, Southampton, UK
- Cardiology, University Hospital Southampton NHS Trust, Southampton, UK
| | - Mark Nihal Mariathas
- University of Southampton, Southampton, UK
- Cardiology, University Hospital Southampton NHS Trust, Southampton, UK
| | - Lavinia Gabara
- University of Southampton, Southampton, UK
- Cardiology, University Hospital Southampton NHS Trust, Southampton, UK
| | - Rick Allan
- Biochemistry, University Hospital Southampton NHD Foundation Trust, Southampton, UK, Southampton, UK
| | - Zoe Nicholas
- Cardiology, University Hospital Southampton NHS Trust, Southampton, UK
| | - Chun Shing Kwok
- Cardiovascular Research Group, Keele University, Stoke-on-Trent, UK
| | - Sanjay Ramamoorthy
- Emergency Department, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Alison Calver
- Cardiology, University Hospital Southampton NHS Trust, Southampton, UK
| | - Simon Corbett
- Cardiology, University Hospital Southampton NHS Trust, Southampton, UK
| | - Richard J Jabbour
- Cardiology, University Hospital Southampton NHS Trust, Southampton, UK
| | - Michael Mahmoudi
- Cardiology, University Hospital Southampton NHS Trust, Southampton, UK
| | - John Rawlins
- Cardiology, University Hospital Southampton NHS Trust, Southampton, UK
| | - Rohit Sirohi
- Cardiology, University Hospital Southampton NHS Trust, Southampton, UK
| | | | - Paul Cook
- Biochemistry, University Hospital Southampton NHD Foundation Trust, Southampton, UK, Southampton, UK
| | - Glen Philip Martin
- Farr Institute, University of Manchester Institute of Population Health, Manchester, UK
| | - Mamas A Mamas
- Cardiovascular Research Group, Keele University, Stoke-on-Trent, UK
- Keele University, Keele, UK
| | - Nick Curzen
- University of Southampton, Southampton, UK
- Cardiology, University Hospital Southampton NHS Trust, Southampton, UK
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Hinton J, Augustine M, Gabara L, Mariathas M, Allan R, Borca F, Nicholas Z, Gillett N, Kwok CS, Cook P, Grocott MPW, Mamas M, Curzen N. Is high sensitivity troponin, taken regardless of a clinical indication, associated with 1 year mortality in critical care patients? J Intensive Care Soc 2023; 24:392-398. [PMID: 37841295 PMCID: PMC10572482 DOI: 10.1177/17511437231160078] [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] [Indexed: 10/17/2023] Open
Abstract
The aim of this study was to assess whether high sensitivity troponin (hs-cTnI) is associated with 1 year mortality in critical care (CC). One year mortality data were obtained from NHS Digital for a consecutive cohort of patients admitted to general CC unit (GCCU) and neuroscience CC unit (NCCU) who had hs-cTnI tests performed throughout their CC admission, regardless of whether the test was clinically indicated. Cox proportional hazards were used to estimate the risk of 1-year mortality. A landmark analysis was undertaken to assess whether any relationship at 1 year was driven by mortality within the first 30 days. A total of 1033 consecutive patients were included. At 1 year 254 (24.6%) patients had died. The admission log(10)hs-cTnI concentration in the entire cohort (HR 1.35 (95% CI 1.05-1.75) p = 0.009 with a bootstrap of 1000 samples) was independently associated with 1 year mortality. On landmark analysis the association with 1 year mortality was driven by 30 day mortality. These results indicate that admission hs-cTnI concentration is independently associated with 1 year mortality in CC and this relationship may be driven by differences in mortality at 30 days.
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Affiliation(s)
- Jonathan Hinton
- Coronary Research Group, University Hospital Southampton NHS Foundation Trust, Southampton, UK
- Faculty of Medicine, University of Southampton, Southampton, UK
| | - Maclyn Augustine
- Coronary Research Group, University Hospital Southampton NHS Foundation Trust, Southampton, UK
- Faculty of Medicine, University of Southampton, Southampton, UK
| | - Lavinia Gabara
- Coronary Research Group, University Hospital Southampton NHS Foundation Trust, Southampton, UK
- Faculty of Medicine, University of Southampton, Southampton, UK
| | - Mark Mariathas
- Coronary Research Group, University Hospital Southampton NHS Foundation Trust, Southampton, UK
- Faculty of Medicine, University of Southampton, Southampton, UK
| | - Rick Allan
- Department of Biochemistry, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Florina Borca
- NIHR Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Zoe Nicholas
- Coronary Research Group, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Neil Gillett
- Department of Biochemistry, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Chun Shing Kwok
- Keele Cardiovascular Research Group, Centre for Prognosis Research, Keele University, Stoke on Trent, UK
| | - Paul Cook
- Department of Biochemistry, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Michael PW Grocott
- Faculty of Medicine, University of Southampton, Southampton, UK
- Anaesthesia and Critical Care Group, NIHR Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Mamas Mamas
- Keele Cardiovascular Research Group, Centre for Prognosis Research, Keele University, Stoke on Trent, UK
| | - Nick Curzen
- Coronary Research Group, University Hospital Southampton NHS Foundation Trust, Southampton, UK
- Faculty of Medicine, University of Southampton, Southampton, UK
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Cardiac Biomarkers in 2022 – a Vital Tool for Emergency Care. JOURNAL OF CARDIOVASCULAR EMERGENCIES 2022. [DOI: 10.2478/jce-2022-0012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
Abstract
The role of cardiac biomarkers in diagnosing acute myocardial infarction is undoubted. In the 2020 guidelines of the European Society of Cardiology, the measurement of cardiac peptides to gain prognostic information has a class IIa indication in all patients with ACS. In emergency care, ruling out a non-ST elevation myocardial infarction requires documentation of normal levels of cardiac biomarkers, which remain stable or have very small variations within several hours. This review aims to summarize the current knowledge and recent progresses in the field of cardiac biomarker discovery, from their routine use in emergency rooms to their prognostic roles in modern risk assessment tools. Integrated approaches combining cardiac troponin with other biomarkers of ventricular dysfunction or inflammation, or with modern cardiac imaging in emergency care are also presented, as well as the role of modern algorithms for serial troponin measurement in the modern management of emergency departments.
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Hinton J, Bashar H, Curzen N. Atheroma or ischemia: which is more important for managing patients with stable chest pain? Future Cardiol 2022; 18:417-429. [PMID: 35360934 DOI: 10.2217/fca-2021-0053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
In the evaluation and management of patients with stable chest pain/chronic coronary syndrome, cardiologists need to be able to weigh up the relative merits of managing these patients using either optimal therapy alone or optimal therapy plus revascularization. These decisions rely on an understanding of both the presence and the degree of coronary atheroma and myocardial ischemia, and the impact that these have on patients' symptoms and their prognosis. In this review the authors examine the relative impact of the anatomical and physiological assessment of patients with chronic coronary syndrome and how it can be used to achieve optimal and tailored therapy.
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Affiliation(s)
- Jonathan Hinton
- Coronary Research Group, University Hospital Southampton NHS Foundation Trust, Southampton, SO16 6YD, UK.,Faculty of Medicine, University of Southampton, Southampton, SO17 1BJ, UK
| | - Hussein Bashar
- Coronary Research Group, University Hospital Southampton NHS Foundation Trust, Southampton, SO16 6YD, UK
| | - Nick Curzen
- Coronary Research Group, University Hospital Southampton NHS Foundation Trust, Southampton, SO16 6YD, UK.,Faculty of Medicine, University of Southampton, Southampton, SO17 1BJ, UK
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Distribution of High-Sensitivity Troponin Taken Without Conventional Clinical Indications in Critical Care Patients and Its Association With Mortality. Crit Care Med 2021; 49:1451-1459. [PMID: 33852443 DOI: 10.1097/ccm.0000000000005024] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To describe the distribution of high-sensitivity troponin in a consecutive cohort of patients in critical care units, regardless of clinical indication, and its association with clinical outcomes. DESIGN Prospective observational study. SETTING Single-center teaching hospital. PATIENTS Consecutive patients admitted to two adult critical care units (general critical care unit and neuroscience critical care unit) over a 6-month period. INTERVENTIONS All patients had high-sensitivity troponin tests performed at admission and tracked throughout their critical care stay, regardless of whether the supervising team felt there was a clinical indication. The results were not revealed to patients or clinicians unless clinically requested. MEASUREMENTS AND MAIN RESULTS There were 1,033 patients in the study cohort (general critical care unit 750 and neuroscience critical care unit 283). The median high-sensitivity troponin was 21 ng/L (interquartile range, 7-86 ng/L), with 560 patients (54.2%) above the upper limit of normal as defined by the manufacturer. Admission high-sensitivity troponin concentrations above the upper limit of normal in general critical care unit and neuroscience critical care unit were associated with increasing age, comorbidity, markers of illness severity, and the need for organ support. On adjusted analysis, the high-sensitivity troponin concentration remained an independent predictor of critical care mortality in general critical care unit and neuroscience critical care unit. CONCLUSIONS High-sensitivity troponin elevation, taken outside the context of conventional clinical indications, was common in the critically ill. Such elevations were associated with increasing age, comorbidity, illness severity, and the need for organ support. Admission high-sensitivity troponin concentration is an independent predictor of critical care mortality and as such may represent a novel prognostic biomarker at admission.
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Stege NM, de Boer RA, van den Berg MP, Silljé HHW. The Time Has Come to Explore Plasma Biomarkers in Genetic Cardiomyopathies. Int J Mol Sci 2021; 22:2955. [PMID: 33799487 PMCID: PMC7998409 DOI: 10.3390/ijms22062955] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Revised: 03/09/2021] [Accepted: 03/11/2021] [Indexed: 12/17/2022] Open
Abstract
For patients with hypertrophic cardiomyopathy (HCM), dilated cardiomyopathy (DCM) or arrhythmogenic cardiomyopathy (ACM), screening for pathogenic variants has become standard clinical practice. Genetic cascade screening also allows the identification of relatives that carry the same mutation as the proband, but disease onset and severity in mutation carriers often remains uncertain. Early detection of disease onset may allow timely treatment before irreversible changes are present. Although plasma biomarkers may aid in the prediction of disease onset, monitoring relies predominantly on identifying early clinical symptoms, on imaging techniques like echocardiography (Echo) and cardiac magnetic resonance imaging (CMR), and on (ambulatory) electrocardiography (electrocardiograms (ECGs)). In contrast to most other cardiac diseases, which are explained by a combination of risk factors and comorbidities, genetic cardiomyopathies have a clear primary genetically defined cardiac background. Cardiomyopathy cohorts could therefore have excellent value in biomarker studies and in distinguishing biomarkers related to the primary cardiac disease from those related to extracardiac, secondary organ dysfunction. Despite this advantage, biomarker investigations in cardiomyopathies are still limited, most likely due to the limited number of carriers in the past. Here, we discuss not only the potential use of established plasma biomarkers, including natriuretic peptides and troponins, but also the use of novel biomarkers, such as cardiac autoantibodies in genetic cardiomyopathy, and discuss how we can gauge biomarker studies in cardiomyopathy cohorts for heart failure at large.
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Affiliation(s)
| | | | | | - Herman H. W. Silljé
- Department of Cardiology, University Medical Center Groningen, University of Groningen, Hanzeplein 1, AB43, 9713 GZ Groningen, The Netherlands; (N.M.S.); (R.A.d.B.); (M.P.v.d.B.)
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