Peak troponin T in STEMI: a predictor of all-cause mortality and left ventricular function

Background

The clinical significance of peak troponin levels following ST-elevation myocardial infarction (STEMI) has not been definitively established. The purpose of this study was to examine the relationship between peak high-sensitivity cardiac troponin T (hs-cTnT) and all-cause mortality at 30 days and 1 year, and left ventricular ejection fraction (LVEF) in STEMI.

Methods

A single-centre retrospective observational study was conducted of all patients with STEMI between January 2015 and December 2017. Demographics and clinical data were obtained through electronic patient records. Standard Bayesian statistics were employed for analysis.

Results

During the study period, 568 patients presented with STEMI. The mean age was 63.6±12 years and 76.4% were men. Of these, 535 (94.2%) underwent primary percutaneous coronary intervention, 12 (2.1%) underwent urgent coronary artery bypass and 21 (3.7%) were treated medically. Mean peak hs-cTnT levels were significantly higher in those who died within 30 days compared with those who survived (12 238 ng/L vs 4657 ng/L, respectively; p=0.004). Peak hs-cTnT levels were also significantly higher in those who died within 1 year compared with those who survived (10 319 ng/L vs 4622 ng/L, respectively; p=0.003). The left anterior descending artery was associated with the highest hs-cTnT and was the most common culprit in those who died at 1 year. An inverse relationship was demonstrated between peak hs-cTnT and LVEF (Pearson’s R=0.379; p<0.00001).

Conclusions

In STEMI, those who died at 30 days and 1 year had significantly higher peak troponin levels than those who survived. Peak troponin is also inversely proportional to LVEF with higher troponins associated with lower LVEF.

Performance of the 0-Hour/1-Hour Algorithm for Diagnosing Myocardial Infarction in Patients With Chest Pain in the Emergency Department ― A Systematic Review and Meta-Analysis ―

Background: This study assessed the diagnostic performance of the 0-hour/1-hour (0/1-h) algorithm to rule in and rule out acute myocardial infarction (MI) in patients presenting to the emergency department (ED) for suspected acute coronary syndrome without ST-segment elevation, as recommended in the 2015 European Society of Cardiology (ESC) guideline.

Methods and Results: Following the Preferred Reporting Items for a Systematic Review and Meta-analysis of Diagnostic Test Accuracy (PRISMA-DTA) guidelines, a systematic review was conducted using the PubMed database from inception to March 31, 2020. We included any article published in English investigating the diagnostic performance of the ESC 0/1-h algorithm for diagnosing MI in patients with chest pain visiting the ED. Of 651 studies identified as potentially available for the study, 7 studies including 16 databases were analyzed. A meta-analysis of the diagnostic accuracy of the 0/1-h algorithm using high-sensitivity cardiac troponin I (hs-cTn) with 6 observational databases showed a pooled sensitivity of 99.3% (95% confidence interval [CI] 98.5–99.7%) and a pooled specificity of 90.1% (95% CI 80.7–95.2%). A meta-analysis of the diagnostic accuracy of 10 observational databases of the ESC 0/1-h algorithm using hs-cTn revealed a pooled sensitivity of 99.3% (95% CI 96.9–99.9%) and a pooled specificity of 91.7% (95% CI 83.5–96.1%).

Conclusions: Our results demonstrate that the ESC 0/1-h algorithm can effectively rule in and rule out patients with non-ST-segment elevation MI.

Performance of the European Society of Cardiology 0/1-hour algorithm in the diagnosis of myocardial infarction with high-sensitivity cardiac troponin: Systematic review and meta-analysis

INTRODUCTION

A rapid rule-out or rule-in protocol based on the 0-hour/1-hour algorithm using high-sensitivity cardiac troponin (hs-cTn) is recommended by the European Society of Cardiology (ESC); recently multiple studies have validated it in their settings. We aimed to assess the diagnostic accuracy of the 2015 ESC guidelines for management of acute coronary syndrome in patients without ST-segment elevation 0-hour/1-hour algorithm using hs-cTn for the early rule-out and rule-in of acute myocardial infarction (AMI) on presentation.

METHODS

Systematic searches were conducted using PubMed, the Cochrane Library and the International Clinical Trials Registry Platform to identify prospective studies from 2015 to October 2019 involving adults presenting to the emergency department with possible acute coronary syndrome in which hs-cTn measurements were obtained according to the ESC algorithm and AMI outcomes were adjudicated during the initial hospitalization.

RESULTS

Eleven studies, involving 19,213 patients, were identified. Pooled prevalence of AMI during the index hospitalization was 11.3% (95% confidence interval (CI) 3.9-18.8%). Summary sensitivity and specificity in diagnosing AMI were 99% (95% CI 98-99%; I2 63%) and 91% (95% CI 91-92%; I2 96%) respectively. The summary positive likelihood ratio was 11.6 (95% CI 8.5-15.8; I2 97%) and the pooled likelihood ratio negative 0.02 (0.01-0.03; I2 52%). Cumulative all-cause mortality at 30 days in the rule-out group was 0.11%, and 2.8% in the rule-in group, and 30 days AMI in the rule-out group was 0.08%.

CONCLUSION

The ESC 0-hour/1-hour algorithm using high-sensitivity cardiac troponin has high diagnostic accuracy; it allows safe rule-out as well as accurate rule-in of AMI, with low cumulative 30-day mortality and AMI in patients assigned the rule-out zone.

Baseline High Sensitivity Cardiac Troponin I Level Below Limit of Quantitation Rules Out Acute Myocardial Infarction in the Emergency Department

The objective of our study was to determine the utility of a baseline high sensitivity cardiac troponin (hs-cTnI) value below the limit of quantitation to rule-out acute myocardial infarction (AMI) in patients presenting to the emergency department (ED) with any suspicious symptoms of a cardiac etiology. We enrolled subjects presenting to the ED with symptoms suspicious for AMI. Blood specimens were collected within 1 hour after a triage electrocardiogram. Cardiac troponin I was measured using the Beckman Coulter Access hs-cTnI assay. The diagnosis of AMI was adjudicated by 2 cardiologists using the Third Universal Definition of AMI and Roche Diagnostics Troponin T Generation 5 assay with all available clinical data at 30 days after presentation. A total of 567 subjects had all data required for data analyses. AMI was diagnosed in 46 (8.1%) patients. Two hundred thirty-two (40.9%) individuals had presentation hs-cTnI results <4.0 ng/L. None of the patients with baseline hs-cTnI <4.0 ng/L had an AMI, yielding a negative predictive value of 100.0% and a sensitivity of 100%, and a good prognosis (no AMIs or cardiac-related deaths at 30 days). In this single-center ED study, a baseline presenting novel hs-cTnI value of <4.0 ng/L effectively ruled out AMI in 40.9% of all patients presenting to the ED and having any symptoms suspicious for AMI. Importantly all patients, not only those with chest pain, and those having symptoms for any duration or those with end-stage renal disease requiring dialysis were included.

High-sensitivity cardiac troponin I in women with a history of early-onset preeclampsia

OBJECTIVE

Preeclampsia is associated with an elevated risk of cardiovascular disease later in life. Women with a history of preeclampsia are at risk of developing hypertension as well as ischemic heart disease. Identification of women at the highest risk is important to initiate preventive strategies. We investigated whether high-sensitivity cardiac troponin I (hs-cTnI) levels are associated with a history of early-onset preeclampsia, and with hypertension in these high-risk women.

METHODS

Approximately 9-10 years after pregnancy, hs-cTnI levels were measured for 339 women of the Preeclampsia Risk Evaluation in FEMales cohort, consisting of 177 women with a history of early-onset preeclampsia and 162 women with a previous uncomplicated index pregnancy. Associations were analyzed using several statistical tests and linear regression analysis.

RESULTS

The median hs-cTnI levels (IQR) were 2.50 ng/l (2.30) in women with a history of early-onset preeclampsia and 2.35 ng/l (2.50) in women without a history of preeclampsia, P = 0.53. Among women with a history of early-onset preeclampsia, the hs-cTnI levels were higher in women who were hypertensive compared with their normotensive counterparts (medians 2.60 versus 2.30; P = 0.03). In addition, blood pressure levels increased with increasing hs-cTnI levels.

CONCLUSION

We did not find a difference in hs-cTnI levels between women with and without a history of early-onset preeclampsia. Nonetheless, hs-cTnI levels were statistically significantly higher in current hypertensive women with a history of preeclampsia compared with their normotensive counterparts. Therefore, hs-cTnI levels might improve risk prediction for women at the highest risk of cardiovascular disease.

Intraoperative Troponin Elevation in Liver Transplantation Is Independently Associated With Mortality: A Prospective Observational Study

Intraoperative factors implicated in postoperative mortality after liver transplantation (LT) are poorly understood. Because LT is a particularly demanding procedure, we hypothesized that intraoperative myocardial injury may be frequent and independently associated with early postoperative outcomes. We aimed to determine the association between intraoperative high-sensitivity troponin (hsTn) elevation during LT and 30-day postoperative mortality. A total of 203 adult patients undergoing LT were prospectively included in the cohort and followed during 1 year. Advanced hemodynamic parameters and serial high-sensitivity troponin T (hsTnT) measurements were assessed at 6 intraoperative time points. The optimal hsTnT cutoff level for intraoperative troponin elevation (ITE) was identified. Patients were classified into 2 groups according to the presence of ITE. Independent impact of ITE on survival was assessed through survival curves and multivariate Cox regression analysis. Intraoperative cardiac function was compared between groups. Troponin levels increased early during surgery in the ITE group. Troponin values at abdominal closure were associated with 30-day mortality (area under the receiver operating caracteristic curve, [AUROC], 0.73; P = 0.005). Patients with ITE showing values of hsTnT ≥61 ng/L at abdominal closure presented higher 30-day mortality (29.6% versus 3.4%; P < 0.001). ITE was independently associated with 30-day mortality (hazard ratio, 3.8; 95% confidence interval, 1.1-13.8; P = 0.04) and with worse overall intraoperative cardiac function. The hsTnT upper reference limit showed no discriminant capacity during LT. Intraoperative myocardial injury identified by hsTn elevation is frequently observed during LT, and it is associated with myocardial dysfunction and short-term mortality. Determinations of hsTn may serve as a valuable intraoperative monitoring tool during LT.

The Asia-Pacific Society of Cardiology (APSC) Expert Committee Consensus Recommendations for Assessment of Suspected Acute Coronary Syndrome Using High-Sensitivity Cardiac Troponin T in the Emergency Department

The Asia-Pacific Society of Cardiology (APSC) high-sensitivity troponin T (hs-TnT) consensus recommendations and rapid algorithm were developed to provide guidance for healthcare professionals in the Asia-Pacific region on assessing patients with suspected acute coronary syndrome (ACS) using a hs-TnT assay. Experts from Asia-Pacific convened in 2 meetings to develop evidence-based consensus recommendations and an algorithm for appropriate use of the hs-TnT assay. The Expert Committee defined a cardiac troponin assay as a high-sensitivity assay if the total imprecision is ≤10% at the 99th percentile of the upper reference limit and measurable concentrations below the 99th percentile are attainable with an assay at a concentration value above the assay's limit of detection for at least 50% of healthy individuals. Recommendations for single-measurement rule-out/rule-in cutoff values, as well as for serial measurements, were also developed. The Expert Committee also adopted similar hs-TnT cutoff values for men and women, recommended serial hs-TnT measurements for special populations, and provided guidance on the use of point-of-care troponin T devices in individuals suspected of ACS. These recommendations should be used in conjunction with all available clinical evidence when making the diagnosis of ACS.

High-sensitivity troponin assays: development and utility in a modern health-care system

Introduction: The introduction of cardiac troponin (cTn) assays have revolutionized the diagnosis and management of acute myocardial infarction in Emergency Departments worldwide. Its success has led to significant research and development investment in this area culminating in the development of newer high-sensitivity cardiac troponin assays (hs-cTn). While these newer assays allow for more rapid diagnosis by decreasing the time interval between serial data points, there is an inevitable trade off between increasing sensitivity and specificity. This review examines in detail the introduction and implementation of hs-cTN and its implications for clinical practice.Areas covered: This article reviews the history and development of high-sensitivity troponin assays and their application to clinical practice and current evidence base. It also discusses both the positive and negative aspects of the continuing increasing sensitivity of biochemical assays and the translation of this into clinical practice. Potential future developments are also discussed.Expert commentary: It is clear that there are many benefits to detecting extremely low concentration of cardiac troponin including the development of rapid rule out algorithms and the cost and time-saving advantages associated with the quicker movement of patients through the health-care system. It is important to note however that detecting troponin at very low concentrations also dramatically increases the false-positive rates and leads to a potentially large increase in invasive testing and diagnosis of myocardial infarction.