A multimarker risk stratification approach to non-ST elevation acute coronary syndrome: implications of troponin T, CRP, NT pro-BNP and fibrin D-dimer levels

Evaluation of various blood biomarkers associated with the outcomes of patients with COVID‑19 treated in intensive care units

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and the resulting coronavirus disease 2019 (COVID-19) represented a global public health crisis and the most significant pandemic in modern times. Transmission characteristics, and the lack of effective antiviral treatment protocol and protective vaccines, pushed healthcare systems, particularly intensive care units (ICUs), to their limits and led to extreme quarantine measures to control the pandemic. It was evident from an early stage that patient stratification approaches needed to be developed to better predict disease progression. In the present study, the predictive value of clinical and blood biomarkers for the outcomes of patients with COVID-19 hospitalized in the ICU were investigated, taking age and sex into consideration. The present study analyzed blood samples from 3,050 patients with COVID-19 hospitalized in the ICU. The analysis revealed that the levels of procalcitonin, N-terminal pro-B-type natriuretic peptide, D-dimer, ferritin, liver enzymes, C-reactive protein and lactate dehydrogenase were increased and were associated with disease progression, resulting in a prolonged hospitalization period and severe COVID-19 related complications. Additionally, significant age and sex disparities among these biomarkers were documented and discussed in specific cases. On the whole, the results of the present study suggest a potential association of the demographic characteristics and blood biomarkers with prolonged hospitalization in the ICU and the mortality of patients with COVID-19.

Unstable Angina: Risk Stratification for Significant Coronary Artery Disease in The Era of High-Sensitivity Cardiac Troponin

Introduction

High-sensitivity troponin (hsTn) has a very high diagnostic accuracy for myocardial infarction (MI), and patients who were formerly diagnosed with unstable angina (UA) are being reclassified as having NSTEMI in the era of hsTn. This paradigm shift has changed the clinical features of UA, which remain poorly characterized, specifically the occurrence of obstructive coronary artery disease (CAD) and the need for myocardial revascularization. The main purpose of this study was to clinically characterize contemporary UA patients, assess predictors of obstructive CAD, and develop a risk model to predict significant CAD in this population.

Methods

We conducted a retrospective cohort study of 742 patients admitted to the hospital with UA. All patients underwent coronary angiography. The endpoint of the study was the presence of obstructive CAD on angiography. The cohort was divided into two groups: patients with significant coronary artery disease (CAD+) and those without CAD (CAD-). We developed a score (UA CAD Risk) based on the multivariate model and compared it with the GRACE, ESC, and TIMI risk scores using ROC analysis.

Results

Obstructive CAD was observed on angiography in 53% of the patients. Age, dyslipidemia, troponin level, male sex, ST-segment depression, and wall motion abnormalities on echocardiography were independent predictors of obstructive CAD. hsTn levels (undetectable vs. nonsignificant detection) had a negative predictive value of 81% to exclude obstructive CAD. We developed a prediction model with obstructive CAD as the outcome (AUC: 0.60).

Conclusions

In a contemporary UA cohort, approximately 50% of the patients did not have obstructive CAD on angiography. Commonly available cardiac tests at hospital admission show limited discrimination power in identifying patients at risk of obstructive CAD. A revised diagnostic and etiology algorithm for patients with UA is warranted.

Prognostic modelling of clinical outcomes after first-time acute coronary syndrome in New Zealand

OBJECTIVE

The Multi-Ethnic New Zealand Study of Acute Coronary Syndromes (MENZACS) was established to investigate the drivers of secondary events after first-time acute coronary syndrome (ACS), including addressing inequitable outcomes by ethnicity. Herein, the first clinical outcomes and prognostic modelling approach are reported.

METHODS

First, in 28 176 New Zealanders with first-time ACS from a national registry, a clinical summary score for predicting 1-year death/cardiovascular readmission was created using Cox regression of 20 clinical variables. This score was then calculated in the 2015 participant MENZACS study to represent clinical risk. In MENZACS, Cox regression was used to assess N-terminal pro-B-type natriuretic peptide (NT-proBNP) as a prognostic marker for death/cardiovascular readmission in four models, adjusting for (1) age and sex; (2) age, sex, ethnicity; (3) clinical summary score; (4) clinical summary score and ethnicity.

RESULTS

Of the 2015 MENZACS participants (mean age 61 years, 79% male, 73% European, 14% Māori, 5% Pacific people), 2003 were alive at discharge. Of the 2003, 416 (20.8%) experienced all-cause death/cardiovascular readmission over a median of 3.5 years. In a simple model, age, male sex, Māori ethnicity and NT-proBNP levels were significant predictors of outcome. After adjustment for the clinical summary score, which includes age and sex, NT-proBNP and ethnicity were no longer statistically significant: log₂(NT-proBNP) hazard ratio (HR) 1.03, 95% confidence interval (95% CI) 0.98 to 1.08, p=0.305; Māori ethnicity HR 1.26, 95% CI 0.97 to 1.62, p=0.084.

CONCLUSIONS

In 2015 patients with first-time ACS, recurrent events were common (20.8%). Increasing NT-proBNP levels and Māori ethnicity were predictors of death/cardiovascular readmission, but not after adjustment for the 20 clinical risk factors represented by the clinical summary score.

TRIAL REGISTRATION NUMBER

ACTRN12615000676516.

Validation of plasma D-dimer in Chinese patients with acute non-ST segment elevation myocardial infarction

Objective

To analyze the predictive values of D-dimer in Chinese patients with non-ST-segment elevation myocardial infarction (NSTEMI).

Methods

We retrospectively retrieved consecutive patients hospitalized due to acute NSTEMI from January 2015 to December 2018 from the Electronic Medical Record (EMR) library. Clinical and follow-up data were collected. The primary endpoint was major adverse composite cardiovascular events (MACEs), such as all-cause death, non-fatal myocardial infarction, and non-fatal stroke. The secondary endpoints included all-cause death, non-fatal myocardial infarction, non-fatal stroke, heart failure, and severe arrhythmias. The Cox regression model was used to evaluate the association between risk factors and clinical outcomes in Chinese patients with NSTEMI.

Results

A total of 673 patients were included; the median age was 64.0 (53.0–75.0) years old and 76.2% were men. Patients with higher D-dimer levels were more often women, older, had a higher Charlson Comorbidity Index, and had a higher incidence of MACEs (59.9 vs. control 9.0%; p < 0.001) and all-cause death (49.1 vs. control 2.2%; p < 0.001). The multivariate Cox analysis suggested that the D-dimer level was an independent predictor of MACEs (hazard ratio [HR]: 1.069, 95% CI: 1.010–1.132, p = 0.021). The receiver operating characteristic (ROC) analysis suggested that D-dimer levels were better than the Charlson Comorbidity Index in all-cause death.

Conclusion

In Chinese patients with acute NSTEMI, higher D-dimer levels on admission suggest a poor long-term prognosis.

Association of D-dimer with long-term prognosis in type 2 diabetes mellitus patients with acute coronary syndrome

BACKGROUND AND AIMS

Type 2 diabetes mellitus (DM) accounts for more and more individuals worldwide. D-dimer has been demonstrated to be associated with cardiovascular diseases. The aim is to study the potential impact of D-dimer on the long-term prognosis of acute coronary syndrome (ACS) in the special population with type 2 DM.

METHODS AND RESULTS

A total of 2265 consecutive patients with DM and ACS were eligible in the study. Patients were divided into four groups according to quartiles of D-dimer concentration. Univariate and multivariate Cox regression analysis were conducted to explore the prognostic value of D-dimer for future outcomes. Patients with higher level of D-dimer presented with higher percentage of major adverse cardiovascular events (MACEs) (23.7%), all-cause death (18.3%) and cardiovascular (CV) death (9.4%) in Quartile 4. In multivariate Cox regression analysis, D-dimer was demonstrated to be independently associated with MACEs, all-cause death and CV death. The prognostic value of D-dimer is still significant in subgroups of HbA1C <7% and ≥7%. In Kaplan-Meier analysis, higher D-dimer showed poorer prognosis in MACEs, all-cause death and CV death (all log rank p < 0.001). The area under the curve (AUC) by receiver operating characteristic (ROC) curve analysis is 0.609 for MACEs, 0.708 for all-cause death, 0.747 for CV death (p < 0.001).

CONCLUSION

The present study demonstrated the independent predictive value of D-dimer for outcomes in DM patients with ACS. In addition, for the first time, we explored the prognostic value in different glucose control status.

Prognostic performance of multiple biomarkers in patients with acute coronary syndrome without standard cardiovascular risk factors

Background and aims

Acute coronary syndrome (ACS) without standard modifiable cardiovascular risk factors (SMuRFs) represents a special case of ACS. Multiple biomarkers have been shown to improve risk stratification in patients with ACS. However, the utility of biomarkers for prognostic stratification in patients with ACS without SMuRFs remains uncertain. The aim of the present study was to evaluate the prognostic value of various biomarkers in patents with ACS without SMuRFs.

Methods

Data of consecutive patients with ACS without SMuRFs who underwent coronary angiography in Tianjin Chest Hospital between January 2014 and December 2017 were retrospectively collected. The primary outcome was the occurrence of major adverse cardiovascular event (MACE), defined as a composite of cardiovascular death, myocardial infarction and stroke. Seven candidate biomarkers analyses were analyzed using models adjusted for established risk factors.

Results

During a median 5-year follow-up, 81 of the 621 patients experienced a MACE. After adjustment for important covariates, elevated fibrinogen, D-dimer, N-terminal proB-type natriuretic peptide (NT-proBNP), and lipoprotein (a) [Lp(a)] were found to be individually associated with MACE. However, only D-dimer, NT-proBNP and Lp(a) significantly improved risk reclassification for MACE (all P < 0.05). The multimarker analysis showed that there was a clear increase in the risk of MACE with an increasing number of elevated biomarkers and a higher multimarker score. The adjusted hazard ratio- for MACE (95% confidential intervals) for patients with 4 elevated biomarkers was 6.008 (1.9650–18.367) relative to those without any elevated biomarker-. Adding- the 4 biomarkers or the multimarker score to the basic model significantly improved the C-statistic value, the net reclassification index and the integrated discrimination index (all P < 0.05).

Conclusion

Fibrinogen, D-dimer, NT-proBNP and Lp(a) provided valuable prognostic information for MACE when applied to patients with ACS without SMuRFs. The multimarker strategy, which combined multiple biomarkers reflecting different pathophysiological process with traditional risk factors improved the cardiovascular risk stratification.

Copeptin as a Diagnostic and Prognostic Biomarker in Cardiovascular Diseases

Copeptin is the carboxyl-terminus of the arginine vasopressin (AVP) precursor peptide. The main physiological functions of AVP are fluid and osmotic balance, cardiovascular homeostasis, and regulation of endocrine stress response. Copeptin, which is released in an equimolar mode with AVP from the neurohypophysis, has emerged as a stable and simple-to-measure surrogate marker of AVP and has displayed enormous potential in clinical practice. Cardiovascular disease (CVD) is currently recognized as a primary threat to the health of the population worldwide, and thus, rapid and effective approaches to identify individuals that are at high risk of, or have already developed CVD are required. Copeptin is a diagnostic and prognostic biomarker in CVD, including the rapid rule-out of acute myocardial infarction (AMI), mortality prediction in heart failure (HF), and stroke. This review summarizes and discusses the value of copeptin in the diagnosis, discrimination, and prognosis of CVD (AMI, HF, and stroke), as well as the caveats and prospects for the application of this potential biomarker.

Higher BNP/NT-pro BNP levels stratify prognosis equally well in patients with and without heart failure: a meta-analysis

AIMS

The initial and dynamic levels of B-type natriuretic peptide (BNP) and N-terminal-prohormone BNP (NT-proBNP) are routinely used in clinical practice to identify patients with acute and chronic heart failure. In addition, BNP/NT-proBNP levels might be useful for risk stratification in patients with and without heart failure. We performed a meta-analysis to investigate, whether the value of BNP/NT-proBNP as predictors of long-term prognosis differentiates in cohorts with and without heart failure.

METHODS AND RESULTS

We systematically searched established scientific databases for studies evaluating the prognostic value of BNP or NT-proBNP. Random effect models were constructed. Data from 66 studies with overall 83 846 patients (38 studies with 46 099 patients with heart failure and 28 studies with 37 747 patients without heart failure) were included. In the analysis of the log-transformed BNP/NT-proBNP levels, an increase in natriuretic peptides by one standard deviation was associated with a 1.7-fold higher MACE rate (hazard ratio [95% confidence interval]: 1.74[1.58-1.91], P < 0.0001). The effect sizes were comparable, with a substantial overlap in the confidence intervals, when comparing studies involving patients with and without heart failure (1.75[1.54-2.0], P < 0.0001 vs. 1.74[1.47-2.06], P < 0.0001). Similar results were observed when stratifying by quartiles of BNP/NT-proBNP. In studies using pre-defined cut-off-values for BNP/NT-proBNP, elevated levels were associated with the long-term prognosis, independent of the specific cut-off value used.

CONCLUSIONS

BNP/NT-proBNP levels are predictors for adverse long-term outcome in patients with and without known heart failure. Further research is necessary to establish appropriate thresholds, especially in non-heart failure cohorts.

A patient with severe metformin-associated lactic acidosis complicated by acute coronary syndrome: a case report

Introduction

Metformin-associated lactic acidosis (MALA) is a rare but life-threatening condition. Here, we report the outcome of a patient with MALA complicated by acute coronary syndrome.

Case presentation

A 47-year-old obese woman of Caucasian ethnicity was admitted for syncope and tachypnea with Kussmaul breathing. She had a type-2 diabetes and was on oral antidiabetic therapy. Hemoglobin A1c was 6.6%. On admission, a severe acute kidney injury (serum creatinine: 1251 µmol/L) with hyperkalemia (7.5 mmol/L) and severe lactic acidosis (ph:7.042, bicarbonate: 9.9 mmol/L, partial pressure of carbon dioxide: 21.8 mmHg, lactate: 20.0 mmol/L) was found. Despite bicarbonate therapy, ph further decreased. Within 2.5 h of admission, a temporary hemodialysis catheter was placed, and one session of a high-efficiency hemodialysis was performed. 8 h after admission, a continuous venovenous hemodiafiltration was initiated and maintained for 2 days. The metformin therapy was stopped. Supplemental oxygen, intravenous catecholamines (4 days) and antibiotic therapy (7 days) were applied. During this therapy of lactic acidosis, an acute coronary syndrome evolved by day 2 after admission and resolved by day 5 in hospital. After recovery, the patient was transferred to a general ward on day 7 and left the hospital on day 11. By discharge, both the acute kidney injury and the acute coronary syndrome were reversible.

Conclusion

In the patient with MALA complicated by acute coronary syndrome, the combination of a high-efficiency hemodialysis and, consecutively, continuous venovenous hemodiafiltration led to a favorable outcome.

Serum Albumin to Creatinine Ratio and Short-Term Clinical Outcomes in Patients With ST-Elevation Myocardial Infarction

There is a lack of evidence regarding the short-term predictive value of serum albumin to creatinine ratio (sACR) in patients with ST-segment elevation myocardial infarction (STEMI). This study aims to investigate the relationship between sACR and short-term outcomes in these patients. We retrospectively enrolled 3057 patients with STEMI who underwent primary percutaneous coronary interventions (PCI) (median age was 58 years, and 74.3% were male). In-hospital mortality occurred in 114 (3.7%) patients. Contrast-induced nephropathy (CIN) was reported in 381 (12.4%) patients. During a 30-day follow-up, stent thrombosis (ST) occurred in 28 (.9%) patients and 30-day death in 147 (4.8%) patients. Multivariable logistic regression analysis reported that sACR was inversely associated with 30-day mortality (adjusted odds ratio (aOR): .51, 95% confidence interval (CI) .31-.82, P < .001). The sACR was also inversely associated with in-hospital mortality (aOR: .71, 95% CI .56-.90, P = .009), CIN (aOR: .60, 95% CI .52-.68, P < .001), congestive heart failure (CHF) (aOR: .64, 95% CI .47-.87, P = .007), and ST (aOR .61, 95% CI .41-.92, P = .001) at 30 days. Our findings suggest that sACR is inversely associated with short-term clinical outcomes in patients with STEMI after PCI.

Prognostic role of inflammatory cytokines and novel adipokines in acute myocardial infarction: An updated and comprehensive review

Acute myocardial infarction (AMI) is one of the major causes of morbidity and mortality worldwide. The inflammation response during and after AMI is common and seems to play a key role in the peri-AMI period, related with ischaemia-reperfusion injury, adverse cardiac remodelling, infarct size and poor prognosis. In this article, we provide an updated and comprehensive overview of the most important cytokines and adipokines involved in the complex pathophysiology mechanisms in AMI, summarizing their prognostic role post-AMI. Data so far support that elevated levels of the major proinflammatory cytokines TNFα, IL-6 and IL-1 and the adipokines adiponectin, visfatin and resistin, are linked to high mortality and morbidity. In contrary, there is evidence that anti-inflammatory cytokines and adipokines as IL-10, omentin-1 and ghrelin can suppress the AMI-induced inflammatory response and are correlated with better prognosis. Mixed data make unclear the role of the novel adipokines leptin and apelin. After all, imbalance of pro-inflammatory and anti-inflammatory cytokines may result in worst AMI prognosis. The incorporation of these inflammation biomarkers in established prognostic models could further improve their prognostic power improving overall the management of AMI patients.

Prognostic Value of Age-Adjusted D-Dimer Cutoff Thresholds in Patients with Acute Coronary Syndrome Treated by Percutaneous Coronary Intervention

BACKGROUND

Associations between D-dimer and outcomes of patients with acute coronary syndrome (ACS) remain controversial. Using age-adjusted D-dimer cutoff thresholds improve the diagnostic accuracy for thrombotic diseases. This study aimed to investigate the prognostic value of age-adjusted D-dimer in ACS patients treated by percutaneous coronary intervention (PCI).

METHODS

A total of 3972 consecutive patients with ACS treated by PCI were retrospectively recruited. The basal age-adjusted D-dimer threshold was 500 ng/mL and was calculated as age × 10 in patients older than 50 years. Cox regression was used for outcome analysis. C-index, net reclassification index (NRI), and integrated discrimination improvement (IDI) were calculated to assess the additional prognostic value of age-adjusted D-dimer when combined with established clinical risk factors. The primary outcome was all-cause death.

RESULTS

During a median follow-up of 720 days, a total of 225 deaths occurred. High D-dimer level, as defined by age-adjusted thresholds, was an independent predictor for all-cause death (hazard ratio [HR]: 1.75, 95% confidence interval [CI]: 1.32-2.31, P < 0.001), cardiac death (HR: 1.84, 95% CI: 1.30-2.60, P = 0.001), and MACE (HR: 1.48, 95% CI: 1.19-1.83, P < 0.001). Sensitivity and subgroup analysis showed that high D-dimer levels were constantly associated with worse outcomes across common risk factors and comorbidities. Besides, age-adjusted elevation of D-dimer significantly improved the risk predictions for all-cause death when added to the model of established risk factors (C-index: 0.846 vs 0.838, Δ C-index: 0.008, 95% CI: 0.001-0.015, Pdifference = 0.027; NRI: 0.645, 95% CI: 0.464-0.826, P < 0.001; IDI: 0.008, 95% CI: 0.001-0.017, P = 0.048).

CONCLUSION

In ACS patients treated by PCI, age-adjusted elevation of D-dimer was an independent predictor for adverse outcomes and improved the risk predictions for long-term mortality.

D-dimer for risk stratification and antithrombotic treatment management in acute coronary syndrome patients: asystematic review and metanalysis

BACKGROUND

Data on the prognostic role of D-dimer in patients with acute coronary syndrome (ACS) are controversial. Our aim was to summarize current evidence on the association between D-dimer levels and short/long-term poor prognosis of ACS patients. We also investigated the association between D-dimer and no-reflow phenomenon.

METHODS

Systematic review and metanalysis of observational studies including ACS patients and reporting data on D-dimer levels. PubMed and SCOPUS databases were searched. Data were combined with hazard ratio (HR) and metanalysed. The principal endpoint was a composite of cardiovascular events (CVEs) including myocardial infarction, all-cause and cardiovascular mortality.

RESULTS

Overall, 32 studies included in the systematic review with 28,869 patients. Of them, 6 studies investigated in-hospital and 26 studies long-term outcomes. Overall, 23 studies showed positive association of high D-dimer levels with CVEs. D-dimer levels predicted poor prognosis in all studies reporting in-hospital outcomes. Five studies satisfied inclusion criteria and were included in the metanalysis, with a total of 8616 patients. Median follow-up was 13.2 months with 626 CVEs. The pooled HR for D-dimer levels and CVEs was 1.264 (95% CI 1.134-1.409). Five out of 7 studies (4195 STEMI patients) investigating the association between D-dimer levels and no-reflow showed a positive correlation of D-dimer levels with no-reflow.

CONCLUSIONS

In patients with ACS, D-dimer was associated with higher in-hospital and short/long-term complications. D-dimer was also higher in patients with no-reflow phenomenon. The use of D-dimer may help to identify patients with residual thrombotic risk after ACS.

TRIAL REGISTRATION

The review protocol was registered in PROSPERO International Prospective Register of Systematic Reviews: CRD42021267233 .

Prognostic Value of Baseline d-Dimer Level in Patients With Coronary Artery Disease: A Meta-Analysis

The prognostic significance of d-dimer level in patients with coronary artery disease (CAD) is not fully established. This meta-analysis aimed to examine the association between elevated d-dimer level at baseline and adverse outcomes in patients with CAD. Two independent authors comprehensively searched PubMed and Embase databases from their inception to December 31, 2020. All observational studies reporting the values of baseline d-dimer level in predicting the major adverse cardiovascular events (MACEs) or survival outcomes in patients with CAD were included. The prognostic values were calculated by pooling adjusted RR with 95% CI for the highest versus the lowest d-dimer level. Thirteen studies consisting of 25 600 patients with CAD were identified. Comparison between the highest and lowest d-dimer level showed that the pooled multivariable adjusted RR was 1.69 (95% CI, 1.53-1.86) for all-cause mortality, 2.37 (95% CI, 1.52-3.69) for cardiovascular mortality, and 1.44 (95% CI, 1.19-1.74) for MACEs, respectively. Elevated blood level of d-dimer at baseline was independently associated with higher risk of MACEs, cardiovascular death, and all-cause mortality in patients with CAD. The baseline d-dimer level may have important prognostic value in patients with CAD.

Prognostic Value of D-dimer in patients with acute coronary syndrome treated by percutaneous coronary intervention: a retrospective cohort study

BACKGROUND

Associations between D-dimer and outcomes of patients with acute coronary syndromes (ACS) remain controversial. This study aimed to investigate the prognostic value of D-dimer in ACS patients treated by percutaneous coronary intervention (PCI).

METHODS

In this observational study, 3972 consecutive patients with ACS treated by PCI were retrospectively recruited. The X-tile program was used to determine the optimal D-dimer thresholds for risk stratifications. Cox regression with multiple adjustments was used for outcome analysis. Restricted cubic spline (RCS) analysis was performed to assess the dose-response association between D-dimer and outcomes. The C-index was calculated to evaluate the additional prognostic value of D-dimer when added to clinical risk factors and commonly used clinical risk scores, with internal validations using bootstrapping methods. The primary outcome was all-cause death.

RESULTS

During a median follow-up of 720 days, 225 deaths occurred. Based on the thresholds generated by X-tile, ACS-PCI patients with median (420-1150 ng/mL, hazard ratio [HR]: 1.58, 95 % confidence interval [CI]: 1.14-2.20, P = 0.007) and high (≥ 1150 ng/mL, HR: 1.98, 95 % CI: 1.36-2.89, P < 0.001) levels of D-dimer showed substantially higher risk of death compared to those with low D-dimer (< 420 ng/mL). RCS analysis depicted a constant relation between D-dimer and various outcomes. The addition of D-dimer levels significantly improved risk predictions for all-cause death when combined with the fully adjusted models (C-index: 0.853 vs. 0.845, P difference = 0.021), the GRACE score (C-index: 0.826 vs. 0.814, P difference = 0.027), and the TIMI score (C-index: 0.804 vs. 0.776, P difference < 0.001). The predicted mortality at the median follow-up (two years) was 1.7 %, 5.2 %, and 10.9 % for patients with low, median, and high D-dimer, respectively, which was well matched with the observed mortality (low D-dimer group: 1.2 %, median D-dimer group: 5.2 %, and high D-dimer group: 12.6 %).

CONCLUSIONS

For ACS patients treated by PCI, D-dimer level was an independent predictor for adverse outcomes, and provided additional prognostic value when combined with clinical risk factors and risk scores. Risk stratifications based on D-dimer was plausible to differentiate ACS-PCI patients with higher risk of death.

Analysis of risk factors for different subtypes of acute coronary syndrome

AIMS

To investigate the different risk factors among different subtypes of patients with acute coronary syndrome (ACS).

METHODS

A total of 296 patients who had ACS were retrospectively enrolled. Blood and echocardiographic indices were assessed within 24 hours after admission. Differences in risk factors and Gensini scores of coronary lesions among three groups were analyzed.

RESULTS

Univariate analysis of risk factors for ACS subtypes showed that age, and levels of fasting plasma glucose, amino-terminal pro-brain natriuretic peptide, and creatine kinase isoenzyme were significantly higher in patients with non-ST-segment elevation myocardial infarction (NSTEMI) than in those with unstable angina pectoris (UAP). Logistic multivariate regression analysis showed that amino-terminal pro-brain natriuretic peptide and the left ventricular ejection fraction (LVEF) were related to ACS subtypes. The left ventricular end-diastolic diameter was an independent risk factor for UAP and ST-segment elevation myocardial infarction (STEMI) subtypes. The severity of coronary stenosis was significantly higher in NSTEMI and STEMI than in UAP. Gensini scores in the STEMI group were positively correlated with D-dimer levels (r = 0.429) and negatively correlated with the LVEF (r = -0.602).

CONCLUSION

Different subtypes of ACS have different risk factors. Our findings may have important guiding significance for ACS subtype risk assessment and clinical treatment.

Elevated high-sensitivity C-reactive protein concentrations may be associated with increased postdischarge mortality in patients with myocardial injury after noncardiac surgery: A retrospective observational study

BACKGROUND

Myocardial injury after noncardiac surgery (MINS) is one of the most common cardiovascular complications associated with mortality and morbidity during the first 2 years after surgery. However, the relevant variables associated with mortality after discharge in patients with MINS have not been fully investigated.

OBJECTIVES

This study aimed to evaluate the association between persistent inflammation detected by high-sensitivity C-reactive protein (hsCRP) at discharge and postdischarge mortality after MINS.

DESIGN

Retrospective observational analysis of acquired data from Samsung Medical Center Troponin in Noncardiac Operation (SMC-TINCO) registry.

SETTING

A tertiary hospital from January 2010 to June 2019.

PATIENTS

Patients who were discharged alive after a diagnosis of MINS.

MAIN OUTCOME MEASURES

The primary endpoint was postdischarge 1-year mortality, and 30-day mortality and the mortality from 30 days to 1 year was also compared.

RESULTS

Data from a total of 4545 adult patients were divided into two groups according to hsCRP concentration at discharge. There were 757 (16.7%) patients in the normal hsCRP group and 3788 (83.3%) patients in the elevated hsCRP group. After inverse probability weighting, 1-year mortality was significantly higher in the elevated group than the normal group (hazard ratio 1.93, 95% CI 1.45 to 2.57, P  < 0.001). Thirty-day mortality and the mortality from 30 days to 1 year were also increased in the elevated group.

CONCLUSION

In patients with MINS, an elevated hsCRP concentration at discharge appeared to be associated with increased mortality. Further research is needed to determine whether controlling inflammation can be helpful in reducing mortality.

Biomarkers of coagulation and fibrinolysis in acute myocardial infarction: a joint position paper of the Association for Acute CardioVascular Care and the European Society of Cardiology Working Group on Thrombosis

The formation of a thrombus in an epicardial artery may result in an acute myocardial infarction (AMI). Despite major advances in acute treatment using network approaches to allocate patients to timely reperfusion and optimal antithrombotic treatment, patients remain at high risk for thrombotic complications. Ongoing activation of the coagulation system as well as thrombin-mediated platelet activation may both play a crucial role in this context. Whether measurement of circulating biomarkers of coagulation and fibrinolysis could be useful for risk stratification in secondary prevention is currently not fully understood. In addition, measurement of such biomarkers could be helpful to identify thrombus formation as the leading mechanism for AMI. The introduction of biomarkers of myocardial injury such as high-sensitivity cardiac troponins made rule-out of AMI even more precise. However, elevated markers of myocardial injury cannot provide proof of a type 1 AMI, let alone thrombus formation. The combined measurement of markers of myocardial injury with biomarkers reflecting ongoing thrombus formation might be helpful for the fast and correct diagnosis of an atherothrombotic type 1 AMI. This position paper gives an overview of the current knowledge and possible role of biomarkers of coagulation and fibrinolysis for the diagnosis of AMI, risk stratification, and individualized treatment strategies in patients with AMI.

Prognostic value of serum albumin-to-creatinine ratio in patients with acute myocardial infarction: Results from the retrospective evaluation of acute chest pain study

The long-term association between serum albumin-to-creatinine ratio (sACR) and poor patient outcomes in acute myocardial infarction (AMI) remains unclear. This study aimed to determine whether sACR was a predictor of poor long-term survival in patients with AMI.This was a study of patients with AMI in the emergency department (ED) from the retrospective multicenter study for early evaluation of acute chest pain (REACP) study. The patients were categorized into tertiles (T1, T2, and T3) based on the admission sACR (0.445 and 0.584 g/μmol). Baseline sACR at admission to the ED was predictive of adverse outcomes. The primary outcome was all-cause mortality within the follow-up period. Cox proportional hazards models were performed to investigate the association between sACR and all-cause mortality in patients with AMI.A total of 2250 patients with AMI were enrolled, of whom 229 (10.2%) died within the median follow-up period of 10.7 (7.2-14.6) months. Patients with a lower sACR had higher all-cause mortality and adverse outcomes rates than patients with a higher sACR. Kaplan-Meier survival analysis showed that patients with a higher sACR had a higher cumulative survival rate (P < .001). Cox regression analysis showed that a decreased sACR was an independent predictor of all-cause mortality [T2 vs T1: hazard ratio (HR); 0.550, 95% confidence interval (95% CI), 0.348-0.867; P = .010 and T3 vs T1: HR, 0.305; 95% CI, 0.165-0.561; P < .001] and cardiac mortality (T2 vs T1: HR, 0.536; 95% CI, 0.332-0.866; P = .011 and T3 vs T1: HR, 0.309; 95% CI, 0.164-0.582, P < .001).The sACR at admission to ED was independently associated with adverse outcomes, indicating that baseline sACR was a useful biomarker to identify high-risk patients with AMI at an early phase in ED.

D-dimer as a thrombus biomarker for predicting 2-year mortality after percutaneous coronary intervention

Background:

D-dimer has predictive value for mortality in some diseases. This study aimed to evaluate the correlation between D-dimer and mortality in patients undergoing percutaneous coronary intervention (PCI).

Methods:

We examined 10,724 consecutive patients who underwent PCI between January 2013 and December 2013. The primary endpoint was all-cause mortality, and the secondary endpoint was cardiac mortality. Patients were divided according to the median D-dimer level of 0.28 μg/ml. Multivariable model were including age, sex, and risk factors after stepwise selection.

Results:

After a 2-year follow up, 8565 patients with D-dimer data were analyzed. There were 116 (1.35%) all-cause deaths and 64 (0.75%) cardiac deaths. D-dimer levels were significantly higher in the all-cause mortality group [0.42 (0.29, 0.68) μg/ml] and cardiac mortality group [0.48 (0.30, 0.81) μg/ml] than in the survival group [0.28 (0.20, 0.41) μg/ml] (both p < 0.001). Multivariate-adjusted Cox hazard analysis showed that high D-dimer levels (⩾0.28 μg/ml) were significantly associated with all-cause mortality in the total population [hazard ratio (HR): 2.35, 95% confidence interval (CI): 1.44–3.84, p = 0.001], acute coronary syndrome (ACS) subgroup (HR: 1.91, 95% CI: 1.08–3.38, p = 0.027), and stable coronary artery disease (SCAD) subgroup (HR: 3.82, 95% CI: 1.45–10.10, p = 0.007). High D-dimer levels were significantly associated with cardiac mortality in the total population (HR: 3.44, 95% CI: 1.61–7.36, p = 0.001) and the ACS subgroup (HR: 3.33, 95% CI: 1.38–8.03, p = 0.007), but not in the SCAD subgroup (HR: 3.68, 95% CI: 0.80–16.91, p = 0.094).

Conclusions:

D-dimer levels are independently associated with 2-year all-cause mortality and cardiac mortality in patients undergoing PCI.

Targeting high-sensitivity C-reactive protein levels in acute coronary syndrome patients undergoing contemporary lipid-lowering therapy: a sub-analysis of the HIJ-PROPER trial

BACKGROUND

The effects of high-sensitivity C-reactive protein (hs-CRP) levels on clinical outcomes in chronic-phase acute coronary syndrome (ACS) patients undergoing aggressive lipid-lowering therapy remain unclear. We examined the effects of hs-CRP levels on the prognosis of ACS patients who underwent aggressive lipid-lowering therapy and determined treatment targets for hs-CRP value.

METHODS

This post-hoc sub-analysis of a prospective randomized control trial (HIJ-PROPER) included 1734 ACS patients with dyslipidemia, who were divided into hs-CRP quartiles after 3 months of treatment. Primary endpoints were combined all-cause death, non-fatal myocardial infarction, non-fatal stroke, unstable angina, and ischemia-driven coronary revascularization. Secondary endpoint was all-cause death.

RESULTS

The median follow-up period was 3.7 years. Overall, 1415 patients were evaluated retrospectively. No significant among-group differences were noted in low-density lipoprotein cholesterol (LDL-C) levels over time (p = 0.44). Kaplan-Meier analyses revealed that the incidence of the primary and secondary endpoints was significantly higher in the highest hs-CRP group than in the other groups [hazard ratio (HR) = 1.52, 95% confidence interval (CI) = 1.16-2.00, p < 0.01; HR = 5.30, 95% CI = 2.47-11.32, p < 0.01, respectively]. The cut-off hs-CRP level to predict all-cause death was 0.74 mg/L (receiver operating characteristic curve: sensitivity: 68%, specificity: 62%). Multivariate analyses revealed that hs-CRP ≥0.74 mg/L　at 3 months was correlated with an increased risk of all-cause death (adjusted HR = 3.68, 95% CI = 2.22-6.10, p < 0.01).

CONCLUSION

Elevated hs-CRP levels independently predicted a worse prognosis, regardless of LDL-C levels, suggesting that interventions against elevated inflammatory responses plus intensive lipid-lowering therapy and coronary revascularization are encouraging options for secondary prevention in ACS patients.

TRIAL REGISTRATION

This trial is registered with the UMIN Clinical Trials Registry number UMIN000002742. Trial name: Proper level of lipid lowering with pitavastatin and ezetimibe in acute coronary syndrome (HIJ-PROPER) URL: https://upload.umin.ac.jp/cgi-open-bin/ctr/ctr-view.cgi?recptno=R000003334.

Complementary Diagnostic Value of Heart Type Fatty Acid-binding Protein in Early Detection of Acute Myocardial Infarction

BACKGROUND

Heart-type fatty acid-binding protein (H-FABP) is a novel biomarker for myocardial injury. We compared the use of H-FABP with serum levels of cardiac troponin-T (cTnT) and creatine kinase-MB (CK-MB) in the diagnosis of patients suspicious to acute myocardial infarction (AMI).

METHODS

From October 2013 to December 2014, 182 consecutive patients suspicious to acute coronary syndrome were enrolled in this study, who presented within the past 6 hours from the onset of symptoms. Venous blood samples were drawn at baseline to measure serum biochemistry, high-sensitive cardiac troponin T (hs-cTNT), creatine kinase-MB, and H-FABP, and the measurements were repeated after 8 hours. The patients were categorized into 3 groups based on the baseline and second measurements of cTnT and general characteristics, and changes of H-FABP levels were then compared between the groups. Sensitivity and specificity of H-FABP in predicting the presence of AMI was calculated.

RESULTS

A total of 91 patients had AMI. Changes of H-FABP through time were also significantly different between the AMI and non-AMI patients (P < 0.001). A cutoff point of 7.15 for H-FABP could predict AMI with a sensitivity of 51.5%, specificity of 96.3%, and diagnostic accuracy of 68.3%. The area under the receiver operating characteristic curve for H-FABP at 8 hours was 79.4% (95% confidence interval: 73.0-85.9; P < 0.001). Positive predictive value and negative predictive value for H-FABP were 85% and 60%, respectively.

CONCLUSIONS

H-FABP can be used as an additional cardiac biomarker in the diagnosis of AMI.

Prognostic Value of Combined C-Reactive Protein, Body Mass Index, and Left Ventricular Ejection Fraction in Predicting Cardiovascular Events in Patients ≥80 Years of Age With Acute Myocardial Infarction

Elevated high-sensitivity C-reactive protein (hsCRP) and low body mass index (BMI) are linked to increased mortality in the elderly population. However, the combined value for predicting adverse cardiovascular events in the oldest-old (≥80 years old) with acute myocardial infarction (AMI) remains undetermined. A total of 463 AMI patients, who were ≥80 years old, were enrolled in this study between January 2012 and June 2017. A nested case-control study was implemented in 106 deaths and 212 controls, who were matched for age, gender, time of inclusion, and myocardial infarction type. Furthermore, the individual and additive values of hsCRP, BMI, and left ventricular ejection fraction (LVEF) were assessed using adjusted hazard ratio, unadjusted Kaplan-Meier analysis, and receiver-operating characteristic curve models. The median follow-up time was 19.15 months, and there were 106 deaths (33.3%). Furthermore, HsCRP, BMI, and LVEF were significantly associated with all-cause mortality (p <0.05, respectively). In addition, a negative correlation between BMI and LVEF, and the positive association of hsCRP with all-cause mortality in the fully adjusted Cox proportional hazards model were detected. The combination of hsCRP, BMI, and LVEF was found to exhibit an enhanced predictive value for all-cause mortality (0.733 in jointly vs 0.623 in cardiovascular risk factors, p = 0.0007) in these oldest-old AMI patients. HsCRP, BMI, and LVEF are the independent risk factors for all-cause mortality for the oldest-old patients with AMI, and this combination offers more appreciable and reliable predictive value for all-cause mortality.

Mass Spectrometry-Based Biomarkers in Drug Development

Advances in mass spectrometry, proteomics, protein bioanalytical approaches, and biochemistry have led to a rapid evolution and expansion in the area of mass spectrometry-based biomarker discovery and development. The last decade has also seen significant progress in establishing accepted definitions, guidelines, and criteria for the analytical validation, acceptance and qualification of biomarkers. These advances have coincided with a decreased return on investment for pharmaceutical research and development and an increasing need for better early decision making tools. Empowering development teams with tools to measure a therapeutic interventions impact on disease state and progression, measure target engagement and to confirm predicted pharmacodynamic effects is critical to efficient data-driven decision making. Appropriate implementation of a biomarker or a combination of biomarkers can enhance understanding of a drugs mechanism, facilitate effective translation from the preclinical to clinical space, enable early proof of concept and dose selection, and increases the efficiency of drug development. Here we will provide descriptions of the different classes of biomarkers that have utility in the drug development process as well as review specific, protein-centric, mass spectrometry-based approaches for the discovery of biomarkers and development of targeted assays to measure these markers in a selective and analytically precise manner.

Inter-relation between Altered Nutritional Status and Clinical Outcomes in Patients with Acute Myocardial Infarction Admitted in a Tertiary Intensive Cardiac Care Unit

Background: The impact of nutritional status on the early outcome of subjects with acute myocardial infarction (AMI) is still not completely elucidated. This study aimed to assess the correlation between nutritional status, as expressed by the CONUT and PIN scores, and (1) clinical and laboratory characteristics, (2) complication rates, and (3) length of hospitalization, in patients with AMI.

Materials and methods: We included 56 consecutive patients with AMI who underwent primary percutaneous intervention and stenting. Evaluation of the nutritional status was comprised in the calculation of the CONUT and PNI scores. The study population was divided into 2 groups according to the calculated CONUT score, as follows: group 1 – CONUT score <3 points (normal to mildly impaired nutritional status) and group 2 – CONUT score ≥3 points (moderate to severe malnutrition). The primary end-point of the study was the rate of in-hospital complications (left ventricular free wall rupture, hemodynamic instability requiring inotropic medication, high-degree atrioventricular block, the need for temporary cardiostimulation, supraventricular and ventricular arrhythmias and in-hospital cardiac arrest). The secondary end-points included the duration of hospitalization and the length of stay in the intensive cardiac care unit.

Results: In total, 56 patients (44.64% with STEMI, 55.35% with NSTEMI) with a mean age of 61.96 ± 13.42 years, 58.92% males were included in the study. Group distribution was: group 1 – 76.78% (n = 43), group 2 – 23.21% (n = 23). There were no differences between the two groups regarding age, gender, cardiovascular risk factors, or comorbidities. PNI index in group 1 was 54.4 ± 10.4 and in group 2 41.1 ± 2.8, p <0.0001. Serum albumin was significantly lower in group 1 – 4.1 ± 0.3 vs. group 2 – 3.6 ± 0.3 (p <0.0001), similarly to total cholesterol levels (group 1 – 194.9 ± 41.5 vs. group 2 – 161.2 ± 58.2, p = 0.02). The complete blood cell count showed that group 2 presented lower levels of hematocrit (p = 0.003), hemoglobin (p = 0.002), and lymphocytes (p <0.0001) compared to group 1, but a significantly higher platelet count (p = 0.001), mean platelet volume (p = 0.03), neutrophil/lymphocyte (p <0.0001) and platelet/lymphocyte (p <0.0001) ratios, indicating enhanced blood thrombogenicity and inflammation. Regarding in-hospital complications, group 2 presented a higher rate of hemodynamic instability (group 1 – 11.6% vs. group 2 – 38.4%, p = 0.02). The overall hospitalization period was 7.7 ± 1.4 days in group 1 vs. 10.2 ± 4.8 days in group 2, p = 0.06; while the duration of stay in the intensive cardiac care unit was 2.6 ± 0.5 days in group 1 vs. 4.0 ± 2.5 days in group 2, p = 0.02.

Conclusions: This study proved that nutritional deficit in acute myocardial patients who undergo revascularization is associated with an increased rate of in-hospital complications and with a longer observation time in a tertiary intensive cardiac care unit.

Diagnostic Value of D-Dimer in Acute Myocardial Infarction Among Patients With Suspected Acute Coronary Syndrome

Background

The role of D-dimer as a diagnostic marker in myocardial infarction (MI) and acute coronary syndrome (ACS) is still a question. The aim of this study was to evaluate the diagnostic value of D-dimer in the diagnosis of AMI in patients suspected with ACS.

Methods

This cross-sectional study was conducted on patients suspected with ACS. Serial standard 12-lead electrocardiogram (ECG), D-dimer, and troponin tests were done for all the patients. According to the examinations, ECG changes, and troponin, patients were allocated into two groups of MI and unstable angina (UA). Chi-square, independent t-test, and Pearson correlation test were used by SPSS ver, 17. Cut-off point of D-dimer for MI diagnosis was evaluated by receiver operating characteristic (ROC) curve analysis.

Results

Seventy-five patients with a mean age of 63.1 ± 9.75 years were studied in two groups of MI (n = 34) and UA (n = 41). Patients were homogeneous based on age, gender, and risk factors for diabetes and dyslipidemia. D-dimer in patients with MI patients was higher than in patients with UA (P = 0.001). The optimal cut-off point of D-dimer for diagnosis of MI was 548 mEq/L with sensitivity and specifity of 63.4% and 91.2%, respectively.

Conclusions

Based on the results of this study, it seems that the measurement of D-dimer serum level can be appropriate as a marker with high sensitivity and relatively high specificity for differentiating MI from UA in patients with suspected ACS.

The heart remains the core: cardiac causes of poor performance in horses compared to human athletes

Cardiac remodelling occurs in response to exercise and is generally beneficial for athletic performance due to the increase in cardiac output. However, this remodelling also may lead to an increased prevalence of cardiac murmurs and arrhythmias. In most cases, these are not considered to be significant. However, in some cases, there may be potentially deleterious consequences. Whilst sudden cardiac death (SCD) is a rare occurrence, the consequences are catastrophic for both the horse and potentially the rider or driver. Furthermore, the sudden death of a horse in the public arena has negative connotations in regards to public perception of welfare during equestrian sports. Prediction of which individuals might be susceptible to potential deleterious effects of exercise is a focus of interest in both human and equine athletes but remains a challenge because many athletes experience cardiac murmurs and exercise-induced arrhythmias that are clinically irrelevant. This review summarises the effects of exercise on cardiac remodelling in the horse and the potential effects on athletic performance and SCD. The use of biomarkers and their future potential in the management of athletic horses is also reviewed.

Predictive value of NT-proBNP for 30-day mortality in patients with non-ST-elevation acute coronary syndromes: a comparison with the GRACE and TIMI risk scores

Background

The biomarker N-terminal pro-brain natriuretic peptide (NT-proBNP) predicts outcome in patients with non-ST-elevation acute coronary syndromes (NSTE-ACS). Whether NT-proBNP has incremental prognostic value beyond established risk strategies is still questionable.

Purpose

To evaluate the predictive value of NT-proBNP for 30-day mortality over and beyond the Global Registry of Acute Coronary Events (GRACE) and Thrombolysis In Myocardial Infarction (TIMI) risk scores in patients with NSTE-ACS.

Methods

Patients included in our ACS registry were candidates. NT-proBNP levels on admission were measured and the GRACE and TIMI risk scores were assessed. We compared the predictive value of NT-proBNP to both risk scores and evaluated whether NT-proBNP improves prognostication by using receiver operator curves and measures of discrimination improvement.

Results

A total of 1324 patients were included and 50 patients died during follow-up. On logistic regression analysis NT-proBNP and the GRACE risk score (but not the TIMI risk score) both independently predicted mortality at 30 days. The predictive value of NT-proBNP did not differ significantly compared to the GRACE risk score (area under the curve [AUC]) 0.85 vs 0.87 p=0.67) but was considerably higher in comparison to the TIMI risk score (AUC 0.60 p<0.001). Adjustment of the GRACE risk score by adding NT-proBNP did not improve prognostication: AUC 0.86 (p=0.57), integrated discrimination improvement 0.04 (p=0.003), net reclassification improvement 0.12 (p=0.21).

Conclusion

In patients with NSTE-ACS, NT-proBNP and the GRACE risk score (but not the TIMI risk score) both have good and comparable predictive value for 30-day mortality. However, incremental prognostic value of NT-proBNP beyond the GRACE risk score could not be demonstrated.

How to use D-dimer in acute cardiovascular care

D-dimer testing is important to aid in the exclusion of venous thromboembolic events (VTEs), including deep venous thrombosis and pulmonary embolism, and it may be used to evaluate suspected aortic dissection. D-dimer is produced upon activation of the coagulation system with the generation and subsequent degradation of cross-linked fibrin by plasmin. Many different assays for D-dimer testing are currently used in routine care. However, these tests are neither standardized nor harmonized. Consequently, only clinically validated assays and assay specific decision limits should be used for routine testing. For the exclusion of pulmonary embolism/deep vein thrombosis, age-adjusted cut-offs are recommend. Clinicians must be aware of the validated use of their hospital's D-dimer assay to avoid inappropriate use of this biomarker in routine care.

Biomarkers Investigation for In-Hospital Death in Patients With Stanford Type A Acute Aortic Dissection

This retrospective study aimed to investigate the predictive value of biomarkers for in-hospital mortality of patients with Stanford type A acute aortic dissection (AAD).AAD is a life-threatening disease with an incidence of about 2.6-3.6 cases per 100,000/year.A total of 67 consecutive Stanford type A AAD patients admitted to hospital were divided into a deceased group and survival group. The baseline information of the patients between two groups was systematically compared, followed by examination of the electrocardiograms (ECG). Based on the follow-up during hospitalization, we investigated the simultaneous assessment of indexes like fragmented QRS complex (fQRS), admission systolic blood pressure (SBP), aortic diameter, surgical management, troponin I (TnI), white blood cell (WBC) count, N-terminal pro-brain natriuretic peptide (NT-proBNP), and D-dimer.The levels of TnI and NT-proBNP, WBC counts, and rate of fQRS (+) in patients of the deceased group were significantly higher than those in the survival group. The male sex (hazard ratio, 10.88; P = 0.001), admission SBP (hazard ratio, 0.98; P = 0.012), NT-proBNP (hazard ratio, 1.00; P = 0.001), and WBC count (hazard ratio, 1.10; P = 0.033) were independently related with in-hospital death. As a single marker, WBC count had the highest sensitivity at 84.6% (specificity 65.9%).Admission SBP, NT-proBNP, and WBC count were potential independent risk factors of in-hospital death in Stanford type A AAD patients. WBC count may be a more accurate predictor of type A AAD than either alone.

Multimarker Risk Stratification in Patients With Acute Myocardial Infarction

BACKGROUND

Several biomarkers have individually been shown to be useful for risk stratification in patients with acute myocardial infarction (MI). The optimal multimarker strategy remains undefined.

METHODS AND RESULTS

Biomarkers representing different pathobiological axes were studied, including myocardial stress/structural changes (NT-pro B-type natriuretic peptide [NT-proBNP], midregional proatrial natriuretic peptide [MR-proANP], suppression of tumorigenicity 2 [ST2], galectin-3, midregional proadrenomedullin [MR-proADM], and copeptin), myonecrosis (troponin T), and inflammation (myeloperoxidase [MPO], high sensitivity C-reactive protein [hsCRP], pregnancy-associated plasma protein A [PAPP-A], and growth-differentiation factor-15 [GDF-15]), in up to 1258 patients from Clopidogrel as Adjunctive Reperfusion Therapy-Thrombolysis in Myocardial Infarction 28 (CLARITY-TIMI 28), a randomized trial of clopidogrel in ST-elevation MI (STEMI). Patients were followed for 30 days. Biomarker analyses were adjusted for traditional clinical variables. Forward step-wise selection was used to assess a multimarker strategy. After adjustment for clinical variables and using a dichotomous cutpoint, 7 biomarkers were each significantly associated with a higher odds of cardiovascular death or heart failure (HF) through 30 days, including NT-proBNP (adjusted odds ratio [ORadj], 2.54; 95% CI, 1.47-4.37), MR-proANP (2.18; 1.27-3.76), ST2 (2.88; 1.72-4.81), troponin T (4.13; 1.85-9.20), MPO (2.75; 1.20-6.27), hsCRP (1.96, 1.17-3.30), and PAPP-A (3.04; 1.17-7.88). In a multimarker model, 3 biomarkers emerged as significant and complementary predictors of cardiovascular death or HF: ST2 (ORadj, 2.87; 1.61-5.12), troponin T (2.34; 1.09-5.01 and 4.13, 1.85-9.20, respectively for intermediate and high levels), and MPO (2.49; 1.04-5.96). When added to the TIMI STEMI Risk Score alone, the multimarker risk score significantly improved the C-statistic (area under the curve, 0.75 [95% CI, 0.69-0.81] to 0.82 [0.78-0.87]; P=0.001), net reclassification index (0.93; P<0.001), and integrated discrimination index (0.09; P<0.001).

CONCLUSIONS

In patients with STEMI, a multimarker strategy that combines biomarkers across pathobiological axes of myocardial stress, myocyte necrosis, and inflammation provides incremental prognostic information for prediction of cardiovascular death or HF.

Novel Biomarkers: Utility in Patients with Acute Chest Pain and Relationship to Coronary Artery Disease on Coronary CT Angiography

Acute chest pain remains one of the most common patient presentations encountered in the emergency department. With the evolution of biomarkers and improvement in cardiac imaging there has been advancement in risk stratification of patients, but millions of dollars continue to be spent in the assessment of chest pain. Investigators have explored possible comparative alternatives to the traditional work up of chest pain. In this review, we will discuss the current state of biomarker use in the evaluation of acute chest pain. We will review established and emerging circulating biomarkers and their addition to cardiac CT for appropriate diagnosis of coronary artery disease.

Predictive value of elevated D-dimer in patients undergoing primary angioplasty for ST elevation myocardial infarction

The aim of this study was to evaluate the prognostic value of D-dimer in patients with STEMI undergoing primary percutaneous coronary intervention (PCI). The prognostic value of D-dimer has been documented in patients with acute coronary syndrome without ST-segment elevation. However, its value in acute ST-segment elevation myocardial infarction (STEMI) remains unclear. We prospectively enrolled 453 consecutive STEMI patients (mean age 55.6 ± 12.4 years, 364 male, 89 female) undergoing primary PCI. The study population was divided into tertiles based on admission D-dimer values. The high D-dimer group (n = 151) was defined as a value in the third tertile [>0.72 ug/ml fibrinogen equivalent units (FEU)], and the low D-dimer group (n = 302) included those patients with a value in the lower two tertiles (≤0.72 ug/ml FEU). Clinical characteristics, in-hospital and 6-month outcomes of primary PCI were analyzed. The patients of the high D-dimer group were older (mean age 60.1 ± 13.5 versus 52.4 ± 10.6, P < 0.001). Higher in-hospital cardiovascular mortality and 6-month all-cause mortality rates were observed in the high D-dimer group (7.2 versus 0.6%, P < 0.001 and 13.9 versus 2%, P < 0.001, respectively). In Cox multivariate analysis; a high admission D-dimer value (>0.72 ug/ml FEU) was found to be a powerful independent predictor of 6-month all-cause mortality (odds ratio: 10.1, 95% confidence interval: 1.24-42.73, P = 0.03). These results suggest that a high admission D-dimer, level was associated with increased in-hospital cardiovascular mortality and 6-month all-cause mortality in patients with STEMI undergoing primary PCI.

Clinical criteria replenish high-sensitive troponin and inflammatory markers in the stratification of patients with suspected acute coronary syndrome

OBJECTIVES

In patients with suspected acute coronary syndrome (ACS), rapid triage is essential. The aim of this study was to establish a tool for risk prediction of 30-day cardiac events (CE) on admission. 30-day cardiac events (CE) were defined as early coronary revascularization, subsequent myocardial infarction, or cardiovascular death within 30 days.

METHODS AND RESULTS

This single-centre, prospective cohort study included 377 consecutive patients presenting to the emergency department with suspected ACS and for whom troponin T measurements were requested on clinical grounds. Fifteen biomarkers were analyzed in the admission sample, and clinical parameters were assessed by the TIMI risk score for unstable angina/Non-ST myocardial infarction and the GRACE risk score. Sixty-nine (18%) patients presented with and 308 (82%) without ST-elevations, respectively. Coronary angiography was performed in 165 (44%) patients with subsequent percutaneous coronary intervention--accounting for the majority of CE--in 123 (33%) patients, respectively. Eleven out of 15 biomarkers were elevated in patients with CE compared to those without. High-sensitive troponin T (hs-cTnT) was the best univariate biomarker to predict CE in Non-ST-elevation patients (AUC 0.80), but did not yield incremental information above clinical TIMI risk score (AUC 0.80 vs 0.82, p = 0.69). Equivalence testing of AUCs of risk models and non-inferiority testing demonstrated that the clinical TIMI risk score alone was non-inferior to its combination with hs-cTnT in predicting CE.

CONCLUSIONS

In patients presenting without ST-elevations, identification of those prone to CE is best based on clinical assessment based on TIMI risk score criteria and hs-cTnT.

High-sensitivity cardiac troponin T and N-terminal pro-B-type natriuretic peptide predict mortality in stable coronary artery disease: results from the Ludwigshafen Risk and Cardiovascular Health (LURIC) study

BACKGROUND

The simultaneous assessment of high-sensitivity cardiac troponin T (hscTnT) and NT-proBNP for predicting death in stable coronary artery disease (CAD) has yet not been examined. We investigated the additional contribution of hscTnT to the risk of mortality prediction of NT-proBNP in patients with stable CAD.

METHODS

We studied 1469 patients with stable CAD enrolled in the Ludwigshafen Risk and Cardiovascular Health Study (LURIC). hscTnT and NT-proBNP were measured in baseline samples using immunoassays (Roche Diagnostics, Germany).

RESULTS

Thirty-five percent (n=525) of the patients died during a median follow-up of 7 and a half years. In total 59.0% of the non-survivors and 25.2% of the survivors exhibited concentrations of hscTnT≥14 ng/L. Logistic regression analysis identified hscTnT and NT-proBNP as independent risk markers for short-term (1-year follow-up) and long-term (9-years follow-up) mortality. ROC curve analysis determined optimal univariate cut-offs at 14 ng/L and 443 µg/L for hscTnT (AUC 0.725, p<0.0001) and NT-proBNP (AUC 0.742, p<0.0001), respectively. Kaplan-Meier survival analysis based on optimized cut-offs for the simultaneous determination of both biomarkers confirmed the usefulness of additive hscTnT especially in prediction of short-term mortality. The prognostic benefit of the combined assessment of hscTnT and NT-proBNP could be confirmed by a significantly increased reclassification index (NRI) of 24.2%.

CONCLUSIONS

The majority of non-survivors exhibited increased hscTnT concentrations above 14 ng/L. The simultaneous determination of NT-proBNP and hscTnT was superior for risk stratification compared to determining either marker alone. Especially the prediction of the clinically important 1-year mortality was significantly improved by addition of hscTnT to NT-proBNP.

Biomarkers in atrial fibrillation: an overview

Atrial fibrillation (AF) confers a raised risk of stroke and death, and this risk of adverse events is increased by the coexistence of other cardiovascular risk factors. The pathophysiology of AF is complex, involving the role of inflammation, structural remodelling with apoptosis, inflammation or fibrosis. These changes confer a prothrombotic or hypercoagulable state in this arrhythmia. Despite being easy to use for decision-making concerning oral anticoagulant therapy in AF, clinical risk scores used for stratification have shown modest capability in predicting thromboembolic events, and biomarkers may improve our identification of 'high risk' patients. Biomarkers, whether measured in the peripheral blood, urine or imaging-based may improve our knowledge of the pathophysiology of AF. Importantly these biomarkers could help in the assessment of AF prognosis. The aim of this review was to summarise the published data about biomarkers studied in AF, with focus on data from randomised prospective clinical trials and large community-based cohorts. We will also review the application of these biomarkers to prognosis on the main schemes used to help stratify risk in AF.

Multimarker approach with cystatin C, N-terminal pro-brain natriuretic peptide, C-reactive protein and red blood cell distribution width in risk stratification of patients with acute coronary syndromes

INTRODUCTION AND AIM

Biomarkers have emerged as interesting predictors of risk in patients with acute coronary syndromes (ACS). The aim of this study was to determine the utility of the combined measurement of cystatin C (CysC), C-reactive protein (CRP), N-terminal pro-brain natriuretic peptide (NT-proBNP) and red blood cell distribution width (RDW) in the risk stratification of patients with ACS.

METHODS

In this prospective study including 682 patients consecutively admitted to a coronary care unit for ACS, baseline measurements of CysC, CRP, NT-proBNP and RDW were performed. Patients were categorized on the basis of the number of elevated biomarkers at presentation. The primary outcome was 6-month mortality.

RESULTS

The number of biomarkers elevated on admission (study score) was an independent predictor of 6-month mortality; patients with four biomarkers elevated on admission had a significantly higher risk of 6-month mortality compared with patients with none or one. In addition, in patients with high risk defined by the GRACE score, our multimarker score was able to further categorize their risk of 6-month mortality.

CONCLUSIONS

A multimarker approach using CysC, NT-proBNP, CRP and RDW was an independent predictor of 6-month mortality and added prognostic information to the GRACE risk score in patients with ACS and high risk defined by GRACE, with increasing mortality in patients with a higher number of elevated biomarkers on admission.

Interleukin-6 as a predictor of cardiovascular events in troponin-negative non-ST elevation acute coronary syndrome patients

AIM

Risk stratification in acute coronary syndrome without ST-segment elevation (NSTE-ACS) and troponin-negative remains a challenge. We evaluated the value of interleukin-6 (IL-6) and amino-terminal pro-B-type natriuretic peptide (NT-proBNP) in the prognosis assessment of low-moderate risk NSTE-ACS and troponin-negative, and whether these biomarkers could improve the predictive performance of the established thrombolysis in myocardial infarction (TIMI) risk score.

METHODS

A total of 212 low-moderate risk patients with NSTE-ACS and troponin-negative were prospectively studied. Clinical follow up at 6 months was performed for adverse endpoints.

RESULTS

A total of 28 patients (13.5%) presented adverse clinical events. Those with adverse clinical events were associated with higher levels of IL-6 [8.58 (5.13-20.95) ng/l vs. 6.12 (4.16-9.14) ng/l, p = 0.043] and NT-proBNP [275.3 (108.6-548.2) ng/l vs. 126.8 (55.97-430.20) ng/l, p = 0.046]. In moderate risk group, we observed a higher event rate in patients with troponin-negative but elevated levels of IL-6 (p = 0.024). Only elevated IL-6 (> 12.40 ng/l) was an independent predictor of adverse outcomes [hazard ratios: 3.62, 95% confidence interval (CI) 1.69-7.75, p = 0.001]. The addition of IL-6 and history of ischaemic heart disease (IHD) to TIMI risk score significantly improved both the discrimination (integrated discrimination improvement, p = 0.003) and reclassification (Clinical Net reclassification improvement, p = 0.010) of the model for adverse events.

CONCLUSIONS

Interleukin-6 is an independent predictor of adverse events in low-moderate risk patients with NSTE-ACS and troponin-negative. Its use identifies a higher risk population in moderate-risk patients. This provides together with history of IHD a better discrimination and reclassification beyond that achieved with clinical risk variables from TIMI risk score in these patients.

Will global transcriptome analysis allow the detection of novel prognostic markers in coronary artery disease and heart failure?

Coronary artery disease (CAD) is one of the leading causes of death in the developed countries. Myocardial infarction (MI) is an acute episode of CAD that results in myocardial injury and subsequent heart failure (HF). In the acute phase of MI several risk factors for future cardiovascular events have been found. The molecular mechanisms of these disorders are still unknown, but altered gene expression may play an important role in the development and progression of cardiovascular diseases. High-throughput techniques should greatly facilitate the elucidation of the mechanisms and provide novel insights into the pathophysiology of cardiovascular diseases. In this review we focus on the perspectives of gene-expression profiling conducted on cardiac tissues and blood for the determination of novel diagnostic and prognostic markers and therapeutic targets.

Mass spectrometry-based biomarkers in drug development

Advances in mass spectrometry, proteomics, protein bioanalytical approaches, and biochemistry have led to a rapid evolution and expansion in the area of mass spectrometry-based biomarker discovery and development. The last decade has also seen significant progress in establishing accepted definitions, guidelines, and criteria for the analytical validation, acceptance, and qualification of biomarkers. These advances have coincided with a decreased return on investment for pharmaceutical research and development and an increasing need for better early decision making tools. Empowering development teams with tools to measure a therapeutic interventions impact on disease state and progression, measure target engagement, and to confirm predicted pharmacodynamic effects is critical to efficient data-driven decision making. Appropriate implementation of a biomarker or a combination of biomarkers can enhance understanding of a drugs mechanism, facilitate effective translation from the preclinical to clinical space, enable early proof of concept and dose selection, and increase the efficiency of drug development. Here we will provide descriptions of the different classes of biomarkers that have utility in the drug development process as well as review specific, protein-centric, mass spectrometry-based approaches for the discovery of biomarkers and development of targeted assays to measure these markers in a selective and analytically precise manner.

High-sensitivity C-reactive protein and atherosclerotic disease: from improved risk prediction to risk-guided therapy

There is compelling experimental and clinical evidence suggesting a crucial role for inflammation in the initiation and also the progression of atherosclerosis. Numerous biomarkers involved at various levels of the inflammation cascade have been shown to be associated with adverse cardiovascular outcomes. Yet, to date, it is not clear whether inflammation simply accompanies the atherosclerotic process or represents a major driver. Among all blood biomarkers, C-reactive protein (CRP), the classical acute phase reactant that can be measured with high-sensitivity (hs) assays seems to be the most promising candidate. It has already found its way into the guidelines in primary prevention. Hs-CRP can also be used to identify a high-risk group for recurrent events in patients with manifest atherosclerosis. Several post hoc analyses of large-scale randomized clinical trials testing various statins have indicated that, besides low density lipoprotein (LDL) cholesterol, hs-CRP levels might also further aid in tailoring statin treatment. The large JUPITER trial has prospectively confirmed these findings in primary prevention in patients with elevated hs-CRP but normal LDL cholesterol levels. Still, statin therapy is not a specific anti-inflammatory regime acting on the inflammation cascade. Thus, to directly test the inflammation hypothesis, a novel, more proximally located cytokine-based approach is needed. Canakinumab, a fully human monoclonal antibody against interleukin-1β, might represent a promising compound in this regard and provide a proof of concept. If successful, this may become a novel strategy to treat high-risk patients with stable atherosclerotic disease to prevent recurrent events on top of standard medical care.

Biomarkers in acute myocardial injury

Acute coronary syndrome (ACS) is a significant cause of morbidity and mortality worldwide. The proper diagnosis of ACS requires reliable and accurate biomarker assays to detect evidence of myocardial necrosis. Currently, troponin is the gold standard biomarker for myocardial injury and is used commonly in conjunction with creatine kinase-MB (CK-MB) and myoglobin to enable a more rapid diagnosis of ACS. A new generation of highly sensitive troponin assays with improved accuracy in the early detection of ACS is now available, but the correct interpretation of assay results will require a careful consideration of assay characteristics and the clinical setting prior to incorporation into routine practice. B-type natriuretic peptides, copeptin, ischemia-modified albumin, heart-type fatty-acid-binding protein, myeloperoxidase, C-reactive protein, choline, placental growth factor, and growth-differentiation factor-15 make up a promising group of other biomarkers that have shown the ability to improve prognosis and diagnosis of ACS compared with traditional markers.

High-sensitivity troponin T and copeptin in non-ST acute coronary syndromes: implications for prognosis and role of hsTnT and copeptin in non-STEACS

High-sensitivity TnT (hsTnT) has been proposed to improve the diagnosis and stratification in acute coronary syndromes. Copeptin has been proposed for a rapid and accurate rule out of acute myocardial infarction, but some doubts exist about its use out of the first hours from admission. Abnormalities of serum hsTnT and copeptin levels in non-STEACS and negative TnT, could have prognostic implications. Methods. We included 122 non-STEACS patients without raised TnT, 33 disease controls and 43 healthy controls. We measured hsTnT and copeptin levels. Clinical follow-up at 12 months was performed for adverse endpoints. Results. Non-STEACS patients had raised hsTnT compared with both control groups (P = 0.036 and P < 0.001). Copeptin levels were higher in non-STEACS patients than healthy controls (P = 0.021), without differences with disease controls. Raised levels of hs-TnT presented prognostic implications [HR 3.29 (95%CI: 1.33–7.49), P = 0.010]. hs-TnT could be used for invasive approach decision, as it shows prognostic relevance in conservative approach-patients whereas remains unrelevant for catheterized-patients. Copeptin levels were not associated with adverse events. Conclusion. hsTnT levels increased in non-STEACS, were predictive of adverse events and could be important for recommending an invasive management. We cannot confirm a predictive role of copeptin out of the first hours from admission.