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Machanahalli Balakrishna A, Reddi V, Belford PM, Alvarez M, Jaber WA, Zhao DX, Vallabhajosyula S. Intermediate-Risk Pulmonary Embolism: A Review of Contemporary Diagnosis, Risk Stratification and Management. Medicina (B Aires) 2022; 58:medicina58091186. [PMID: 36143863 PMCID: PMC9504600 DOI: 10.3390/medicina58091186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Revised: 08/19/2022] [Accepted: 08/22/2022] [Indexed: 11/25/2022] Open
Abstract
Pulmonary embolism (PE) can have a wide range of hemodynamic effects, from asymptomatic to a life-threatening medical emergency. Pulmonary embolism (PE) is associated with high mortality and requires careful risk stratification for individualized management. PE is divided into three risk categories: low risk, intermediate-risk, and high risk. In terms of initial therapeutic choice and long-term management, intermediate-risk (or submassive) PE remains the most challenging subtype. The definitions, classifications, risk stratification, and management options of intermediate-risk PE are discussed in this review.
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Affiliation(s)
| | - Vuha Reddi
- Department of Medicine, Danbury Hospital/Yale University School of Medicine, Danbury, CT 06810, USA
| | - Peter Matthew Belford
- Section of Cardiovascular Medicine, Department of Medicine, Wake Forest University School of Medicine, Winston-Salem, NC 27262, USA
| | - Manrique Alvarez
- Section of Cardiovascular Medicine, Department of Medicine, Wake Forest University School of Medicine, Winston-Salem, NC 27262, USA
| | - Wissam A. Jaber
- Section of Cardiovascular Medicine, Department of Medicine, Emory University School of Medicine, Atlanta, GA 30307, USA
| | - David X. Zhao
- Section of Cardiovascular Medicine, Department of Medicine, Wake Forest University School of Medicine, Winston-Salem, NC 27262, USA
| | - Saraschandra Vallabhajosyula
- Section of Cardiovascular Medicine, Department of Medicine, Wake Forest University School of Medicine, Winston-Salem, NC 27262, USA
- Department of Implementation Science, Division of Public Health Sciences, Wake Forest University School of Medicine, Winston-Salem, NC 27262, USA
- Correspondence: ; Tel.: +1-(336)-878-6000
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ALTUĞ T, ŞENTÜRK A, ALIŞIK M, BİÇER C. Clinical value of heart type fatty acid binding protein (H-FABP) in acute pulmonary thromboembolism. JOURNAL OF HEALTH SCIENCES AND MEDICINE 2022. [DOI: 10.32322/jhsm.1093848] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Introduction: To investigate factors which could possibly be prognostic, to decide on thrombolytic therapy as soon as possible, and to determine the prognostic value of H-FABP, which is a new marker, in pulmonary thromboembolism.
Material and Method: In our study, a patient group, consisting of 58 patients diagnosed with PTE and a control group of 30 healthy individuals were investigated. According to their risk of mortality, patients were analyzed in three groups: high, moderate and low. The moderate mortality risk groups were categorized into two groups according to PAP and patients with PAP≥45 mmHg were “Group 1” and PAP
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Affiliation(s)
- Tuba ALTUĞ
- Public Hospital, Department of Chest Diseases, Kayseri, Turkey
| | - Ayşegül ŞENTÜRK
- Ankara Ataturk Chest Disease and Chest Surgery Education and Research Hospital, Department of Chest Diseases, Ankara, Turkey
| | - Murat ALIŞIK
- Bolu Abant İzzet Baysal University Department of Biochemistry, Bolu, Turkey
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Nithianandan H, Reilly A, Tritschler T, Wells P. Applying rigorous eligibility criteria to studies evaluating prognostic utility of serum biomarkers in pulmonary embolism: A systematic review and meta-analysis. Thromb Res 2020; 195:195-208. [DOI: 10.1016/j.thromres.2020.07.037] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Revised: 06/21/2020] [Accepted: 07/17/2020] [Indexed: 12/14/2022]
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Barco S, Ende-Verhaar YM, Becattini C, Jimenez D, Lankeit M, Huisman MV, Konstantinides SV, Klok FA. Differential impact of syncope on the prognosis of patients with acute pulmonary embolism: a systematic review and meta-analysis. Eur Heart J 2019; 39:4186-4195. [PMID: 30339253 DOI: 10.1093/eurheartj/ehy631] [Citation(s) in RCA: 45] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2018] [Accepted: 09/18/2018] [Indexed: 01/08/2023] Open
Abstract
Aims Controversial reports exist in the literature regarding the prognostic role and therapeutic implications of syncope in patients with acute pulmonary embolism (PE). We conducted a systematic review and meta-analysis to investigate the association between syncope and short-term adverse outcomes, taking into account the presence or absence of haemodynamic compromise at acute PE presentation. Methods and results The literature search identified 1664 studies, 29 of which were included for a total of 21 956 patients with PE (n = 3706 with syncope). Syncope was associated with higher prevalence of haemodynamic instability [odds ratio (OR) 3.50; 95% confidence interval (CI) 2.67-4.58], as well as with echocardiographic signs of right ventricular (RV) dysfunction (OR 2.10; CI 1.60-2.77) at presentation. Patients with syncope had a higher risks of all-cause early (either in-hospital or within 30 days) death (OR 1.73; CI 1.22-2.47) and PE-related 30-day adverse outcomes (OR 2.00; CI 1.11-3.60). The absolute risk difference (95% CI) for all-cause death was +6% (+1% to +10%) in studies including unselected patients, but it was -1% (-2% to +1%) in studies restricted to normotensive patients. We observed no prognostic impact of syncope in studies with a lower score at formal quality assessment and in those conducted retrospectively. Conclusion Syncope as a manifestation of acute PE was associated with a higher prevalence of haemodynamic instability and RV dysfunction at presentation, and an elevated risk for early PE-related adverse outcomes. The association with an increased risk of early death appeared more prominent in studies including unselected patients, when compared with those focusing on normotensive patients only.
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Affiliation(s)
- Stefano Barco
- Center for Thrombosis and Haemostasis (CTH), University Medical Center of the Johannes Gutenberg University, Langenbeckstraße 1, Mainz, Germany
| | - Yvonne M Ende-Verhaar
- Department of Thrombosis and Hemostasis, Leiden University Medical Centre, Albinusdreef 2, RC, Leiden, the Netherlands
| | - Cecilia Becattini
- Internal Vascular and Emergency Medicine - Stroke Unit, University of Perugia, via Dottori 1, Perugia, Italy
| | - David Jimenez
- Respiratory Department, Hospital Ramón y Cajal and Medicine Department, Universidad de Alcalá (IRYCIS), Ctra. Colmenar Km. 9,100, Madrid, Spain
| | - Mareike Lankeit
- Center for Thrombosis and Haemostasis (CTH), University Medical Center of the Johannes Gutenberg University, Langenbeckstraße 1, Mainz, Germany.,Department of Internal Medicine and Cardiology, Campus Virchow Klinikum (CVK), Charité - University Medicine Berlin, Augustenburger Platz 1, Berlin, Germany.,Clinic for Cardiology and Pneumology, Georg-August University of Göttingen, Göttingen, Germany
| | - Menno V Huisman
- Department of Thrombosis and Hemostasis, Leiden University Medical Centre, Albinusdreef 2, RC, Leiden, the Netherlands
| | - Stavros V Konstantinides
- Center for Thrombosis and Haemostasis (CTH), University Medical Center of the Johannes Gutenberg University, Langenbeckstraße 1, Mainz, Germany.,Department of Cardiology Democritus University of Thrace, University General Hospital, Alexandroupolis, Greece
| | - Frederikus A Klok
- Center for Thrombosis and Haemostasis (CTH), University Medical Center of the Johannes Gutenberg University, Langenbeckstraße 1, Mainz, Germany.,Department of Thrombosis and Hemostasis, Leiden University Medical Centre, Albinusdreef 2, RC, Leiden, the Netherlands
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El-Menyar A, Sathian B, Al-Thani H. Elevated serum cardiac troponin and mortality in acute pulmonary embolism: Systematic review and meta-analysis. Respir Med 2019; 157:26-35. [PMID: 31476570 DOI: 10.1016/j.rmed.2019.08.011] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2019] [Revised: 08/08/2019] [Accepted: 08/20/2019] [Indexed: 11/27/2022]
Abstract
OBJECTIVES To evaluate whether elevated levels of cardiac troponin increases the risk of mortality in patients with acute PE. METHODS We conducted a systematic review and meta-analysis with rigorous statistical evaluation using publications (2000-2018) from Cochrane Library, MEDLINE, PubMed, Scopus, Cochrane Central Register of Controlled Trials (CENTRAL), WHO International Clinical Trials Registry Platform, and Google Scholar databases. We searched for retrospective, prospective, and randomized controlled trials (RCT) or quasi-RCT studies that assessed the effect of elevated troponin versus normal levels on the outcomes of PE. The main outcome of interest was all-cause mortality. Extracted data included authors, the origin of studies, source population, study settings and duration, inclusion/exclusion criteria, data sources and measurement, sample size, and mortality. Data heterogeneity was assessed using the Cochrane Q homogeneity test with a significance set at p < 0.10. If the studies were statistically homogeneous, a fixed effect model was selected. RESULTS Out of 1825 references, 46 analytical studies were included with a total of 10842 patients with PE. The effect of elevated troponin on mortality had a pooled odd ratio (OR) of 4.33 for all studies, 3.7for HsTnT, 14.81 for HsTnI, 7.85 for cTnT, 2.81 for cTnI, 9.02 for low-risk PE and 4.80 for 90-day mortality. The pooled negative likelihood ratios for all-cause mortality using HsTnI, cTnI and cTnT assay were 0.21, 0.33 and 0.65, respectively. CONCLUSION Regardless of the troponin assay, pooled analysis indicates that elevated troponin is significantly associated with higher mortality in patients with PE.
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Affiliation(s)
- Ayman El-Menyar
- Department of Surgery, Clinical Research, Trauma & Vascular Surgery, Hamad Medical Corporation (HMC), Doha, Qatar; Clinical Medicine, Weill Cornell Medical College, Doha, Qatar.
| | - Brijesh Sathian
- Department of Surgery, Clinical Research, Trauma & Vascular Surgery, Hamad Medical Corporation (HMC), Doha, Qatar
| | - Hassan Al-Thani
- Department of Surgery, Trauma & Vascular Surgery, HMC, Doha, Qatar
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Peacock WF, Singer AJ. Reducing the hospital burden associated with the treatment of pulmonary embolism. J Thromb Haemost 2019; 17:720-736. [PMID: 30851227 PMCID: PMC6849869 DOI: 10.1111/jth.14423] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Indexed: 12/14/2022]
Abstract
Pulmonary embolism (PE) is the most feared clinical presentation of venous thromboembolism (VTE). Patients with PE have traditionally been treated in hospital; however, many are at low risk of adverse outcomes and current guidelines suggest outpatient treatment as an option. Outpatient treatment of PE offers several advantages, including reduced risk of hospital-acquired conditions and potential cost savings. Despite this, patients with low-risk PE are still frequently hospitalized for treatment. This narrative review summarizes current guideline recommendations for the identification of patients with low-risk PE who are potentially suitable for outpatient treatment, using prognostic assessment tools (e.g. the Pulmonary Embolism Severity Index [PESI] and simplified PESI) and clinical exclusion criteria (e.g. Hestia criteria) alone or in combination with additional cardiac assessments. Treatment options are discussed along with recommendations for the follow-up of patients managed in the non-hospital environment. The available data on outpatient treatment of PE are summarized, including details on patient selection, anticoagulant choice, and short-term outcomes in each study. Accumulating evidence suggests that outcomes in patients with low-risk PE treated as outpatients are at least as good as, if not better than, those of patients treated in the hospital. With mounting pressures on health care systems worldwide, increasing the proportion of patients with PE treated as outpatients has the potential to reduce health care burdens associated with VTE.
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Affiliation(s)
- W. Frank Peacock
- Department of Emergency MedicineBaylor College of MedicineHoustonTXUSA
| | - Adam J. Singer
- Department of Emergency MedicineStony Brook School of MedicineStony BrookNYUSA
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Darwish OS, Mahayni A, Patel M, Amin A. Cardiac Troponins in Low-Risk Pulmonary Embolism Patients: A Systematic Review and Meta-Analysis. J Hosp Med 2018; 13:706-712. [PMID: 29694453 DOI: 10.12788/jhm.2961] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Patients with low-risk pulmonary embolism (PE) should be considered as per current scoring systems for ambulatory treatment. However, there is uncertainty whether patients with low scores and positive troponins should require hospitalization. METHODS We searched MEDLINE, SCOPUS, and Cochrane Library databases from inception to December 2016 and collected longitudinal studies that evaluated the prognostic value of troponins in patients with low-risk PE. The primary outcome measure was 30-day all-cause mortality. We calculated odds ratio (OR), likelihood ratios (LRs), and 95% confidence intervals (CI) by using randomeffects models. RESULTS The literature search identified 117 candidate articles, of which 16 met the criteria for review. Based on pulmonary embolism severity index (PESI) or simplified PESI score, 1.2% was the all-cause mortality rate across 2,662 participants identified as low-risk. A positive troponin status in patients with low-risk PE was associated with an increased risk of 30-day all-cause mortality (odds ratio [OR]: 4.79; 95% confidence interval [CI]: 1.11 to 20.68). The pooled likelihood ratios (LRs) for all-cause mortality were positive LR 2.04 (95% CI, 1.53 to 2.72) and negative LR 0.072 (95% CI, 0.37 to 1.40). CONCLUSIONS The use of positive troponin status as a predictor of increased mortality in low-risk PE patients exhibited relatively poor performance given the crossed negative LR CI (1.0) and modest positive LR. Larger prospective trials must be conducted to elucidate if patients with low-risk PE and positive troponin status can avoid hospitalization.
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Affiliation(s)
- Omar S Darwish
- University of California, Irvine, UCI Medical Center, Orange, California, USA.
| | - Abdullah Mahayni
- Mr. Mahayni is now with King Saud bin Abdulaziz University for Health Sciences, University in Riyadh, Saudi Arabia
| | - Mukti Patel
- University of California, Irvine, UCI Medical Center, Orange, California, USA
| | - Alpesh Amin
- University of California, Irvine, UCI Medical Center, Orange, California, USA
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Risk stratification of acute pulmonary embolism based on clinical parameters, H-FABP and multidetector CT. Int J Cardiol 2018; 265:223-228. [DOI: 10.1016/j.ijcard.2018.04.066] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2017] [Revised: 02/05/2018] [Accepted: 04/16/2018] [Indexed: 12/17/2022]
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Barrios D, Morillo R, Yusen RD, Jiménez D. Pulmonary embolism severity assessment and prognostication. Thromb Res 2017; 163:246-251. [PMID: 28911787 DOI: 10.1016/j.thromres.2017.09.007] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2017] [Revised: 07/04/2017] [Accepted: 09/04/2017] [Indexed: 01/08/2023]
Abstract
For patients who have acute symptomatic pulmonary embolism (PE), risk of short-term death and adverse outcomes should drive the initial treatment decisions. Practice guidelines recommend that patients who have a high-risk of PE-related death and adverse outcomes, determined by the presence of haemodynamic instability (i.e., shock or hypotension), should receive systemically administered thrombolytic therapy. Intermediate-high risk patients might benefit from close observation, and some should undergo escalation of therapy beyond standard anticoagulation, particularly if haemodynamic deterioration occurs. Low-risk for adverse outcomes should lead to early hospital discharge or full treatment at home. Validated prognostic tools (i.e., clinical prognostic scoring systems, imaging studies, and cardiac laboratory biomarkers) assist with risk classification of patients who have acute symptomatic PE.
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Affiliation(s)
- Deisy Barrios
- Respiratory Department, Ramón y Cajal Hospital, IRYCIS, Alcala de Henares University, Madrid, Spain
| | - Raquel Morillo
- Respiratory Department, Ramón y Cajal Hospital, IRYCIS, Alcala de Henares University, Madrid, Spain
| | - Roger D Yusen
- Divisions of Pulmonary and Critical Care Medicine and General Medical Sciences, Washington University School of Medicine, St. Louis, MO, USA
| | - David Jiménez
- Respiratory Department, Ramón y Cajal Hospital, IRYCIS, Alcala de Henares University, Madrid, Spain.
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Giannitsis E, Katus HA. Biomarkers for Clinical Decision-Making in the Management of Pulmonary Embolism. Clin Chem 2017; 63:91-100. [DOI: 10.1373/clinchem.2016.255240] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2016] [Accepted: 07/12/2016] [Indexed: 12/13/2022]
Abstract
Abstract
BACKGROUND
Pulmonary embolism (PE) is associated with high all-cause and PE-related mortality and requires individualized management. After confirmation of PE, a refined risk stratification is particularly warranted among normotensive patients. Previous prognostic models favored combinations of echocardiography or computed tomography suggestive of right ventricular (RV) dysfunction together with biomarkers of RV dysfunction (natriuretic peptides) or myocardial injury (cardiac troponins) to identify candidates for thrombolysis or embolectomy. In contrast, current predictive models using clinical scores such as the Pulmonary Embolism Severity Index (PESI) or its simplified version (sPESI) rather seek to identify patients, not only those at higher risk requiring observation for early detection of hemodynamic decompensation, and the need for initiation of rescue reperfusion therapy, but also those at low risk qualifying for early discharge and outpatient treatment. Almost all prediction models advocate the additional measurement of biomarkers along with imaging of RV dysfunction as part of a comprehensive algorithm.
CONTENT
The following mini-review will provide an updated overview on the individual components of different algorithms with a particular focus on guideline-recommended and new, less-established biomarkers for risk stratification, and how biomarkers should be implemented and interpreted.
SUMMARY
Ideally, biomarkers should be part of a comprehensive risk stratification algorithm used together with clinical risk scores as a basis, and/or imaging. For this purpose, cardiac troponins, including high-sensitivity troponin generations, natriuretic peptides, and h-FABP (heart-type fatty acid–binding protein) are currently recommended in guidelines. There is emerging evidence for several novel biomarkers that require further validation before being applied in clinical practice.
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Affiliation(s)
- Evangelos Giannitsis
- Department of Internal Medicine III, Cardiology, University Hospital Heidelberg, Heidelberg, Germany
| | - Hugo A Katus
- Department of Internal Medicine III, Cardiology, University Hospital Heidelberg, Heidelberg, Germany
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Qian HY, Huang J, Yang YJ, Yang YM, Li ZZ, Zhang JM. Heart-type Fatty Acid Binding Protein in the Assessment of Acute Pulmonary Embolism. Am J Med Sci 2016; 352:557-562. [PMID: 27916210 DOI: 10.1016/j.amjms.2016.08.018] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2016] [Revised: 08/08/2016] [Accepted: 08/25/2016] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To explore the predictive value of heart-type fatty acid binding protein (H-FABP) in the stratification and prognosis of patients with acute pulmonary embolism (APE). METHODS According to risk stratification, 69 patients with APE admitted into the emergency department within 24 hours after onset were divided into the following 3 groups: high-risk group, moderate-risk group and low-risk group. H-FABP- and cardiac troponin I (cTNI)-positive rates of all groups were analyzed and compared, and the correlation between major adverse events (death, endotracheal intubation and cardiopulmonary resuscitation) and the cardiac markers (heart rate, arterial partial pressure of oxygen, right ventricular dimension, pulmonary arterial pressure, etc.) during the in-hospital period were statistically analyzed. Then the prognosis (death, embolic pulmonary hypertension, right heart failure and recurrence of APE) at 6 months after onset of APE was followed-up on and compared between groups. RESULTS The admission time of high-risk group patients was earlier than non-high-risk group (7.1 ± 2.9 versus 13.5 ± 6.7 versus 15.2 ± 10.7 hours, P = 0.001), had larger right ventricular dimension (33.1 ± 10.4 versus 26.7 ± 7.3 versus 20.5 ± 8.9mm, P = 0.002) and higher pulmonary arterial pressure (45.8 ± 14.6 versus 29.4 ± 13.9 versus 23.1 ± 12.6mmHg, P = 0.001). The major adverse events during in-hospital period, including death, endotracheal intubation and cardiopulmonary resuscitation, were more prevalent in the high-risk group than those in the other 2 risk groups. Further analysis indicated that the positive rate of H-FABP was remarkably higher than cTNI (52/69, 75.4% versus 28/69, 40.6%, P = 0.003). The H-FABP (r = 0.881, P = 0.020) was significantly correlated to the major adverse events; however, this was not so regarding cTNI (r = 0.115, P = 0.059). At 6 months after onset of APE, the follow-up data indicated that cTNI and H-FABP were both significantly correlated with the major adverse events. CONCLUSIONS The positive rate of H-FABP was higher than cTNI during the 24 hours after the onset of APE. The H-FABP was significantly correlated to the major adverse events during hospitalization and to the primary prognosis at 6 months after onset of APE.
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Affiliation(s)
- Hai-Yan Qian
- Center for Coronary Heart Disease, Department of Cardiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Ji Huang
- 15th Ward, Department of Cardiology, Beijing Anzhen Hospital, Beijing Institute of Heart, Lung and Blood Vessel Diseases, Capital Medical University, Beijing, PR China.
| | - Yue-Jin Yang
- Center for Coronary Heart Disease, Department of Cardiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yan-Min Yang
- Center for Coronary Heart Disease, Department of Cardiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Zhi-Zhong Li
- 15th Ward, Department of Cardiology, Beijing Anzhen Hospital, Beijing Institute of Heart, Lung and Blood Vessel Diseases, Capital Medical University, Beijing, PR China
| | - Jing-Mei Zhang
- 15th Ward, Department of Cardiology, Beijing Anzhen Hospital, Beijing Institute of Heart, Lung and Blood Vessel Diseases, Capital Medical University, Beijing, PR China
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Copeptin improves the sensitivity of cardiac troponin in patients 70 years or older, but not enough to rule out myocardial infarction at emergency department presentation. Eur J Emerg Med 2015; 24:142-148. [PMID: 26375360 DOI: 10.1097/mej.0000000000000316] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
OBJECTIVES We aimed to evaluate the diagnostic performance of the combination of cardiac troponin (cTn) and copeptin in a population older than 70 years of age to rule out non-ST-elevation myocardial infarction (NSTEMI) at emergency department (ED) presentation. METHODS Among 885 analyzed patients with acute chest pain presenting to the ED, 218 (25%) were aged at least 70 years. RESULTS Patients with elevated copeptin values at presentation were more often aged at least 70 years and had higher blood pressure. Patients at least 70 years without NSTEMI more frequently had elevated copeptin values than younger counterparts (42 vs. 25%, P<0.0001). Bootstrap analysis for the diagnosis of NSTEMI indicated an optimal copeptin threshold value at 8.1 pmol/l in patients less than 70 years and at 10.7 pmol/l in patients at least 70 years. In patients at least 70 years, the combination of copeptin with cTnI significantly improved the sensitivity for the diagnosis of NSTEMI, at all copeptin thresholds tested, but the negative predictive value remained below 95%. CONCLUSION The combination of copeptin with conventional cTnI significantly improved sensitivity for the diagnosis of NSTEMI in patients at least 70 years. However, this improvement was not enough to rule out NSTEMI with a single draw strategy at ED presentation.
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