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Ali F, Arshad K, Szpunar S, Daher E. Elevated Troponins and Diagnosis of Non-ST-Elevation Myocardial Infarction in the Emergency Department. Cureus 2024; 16:e59910. [PMID: 38854192 PMCID: PMC11161129 DOI: 10.7759/cureus.59910] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/08/2024] [Indexed: 06/11/2024] Open
Abstract
Background In the emergency department (ED), the diagnosis of non-ST-elevation myocardial infarction (NSTEMI) is primarily based on the presence or absence of elevated cardiac troponin levels, ECG changes, and clinical presentation. However, limited data exist regarding the incidence, clinical characteristics, and predictive value of different cardiac diagnostic tests and outcomes in patients with non-acute coronary syndrome (ACS)-related troponin elevation. Our study aimed to determine the percentage of patients with elevated troponin levels who had true ACS and identify various risk factors associated with true ACS in these patients. Methodology This was a single-center retrospective study. We performed a chart review of patients who presented to the ED from January 1, 2016, to December 31, 2017, and were admitted to the hospital with an elevated cardiac troponin I level in the first 12 hours after ED presentation with a diagnosis of NSTEMI. True ACS was defined as (a) patients with typical symptoms of ischemia and ECG ischemic changes and (b) patients with atypical symptoms of myocardial ischemia or without symptoms of ischemia and new segmental wall motion abnormalities on echocardiogram or evidence of culprit lesion on angiography. A logistic regression model was used to determine the association between risk factors and true ACS. Results A total of 204 patients were included in this study. The mean age of the study group was 67.4 ± 14.5 years; 53.4% (n = 109) were male, and 57.4% (n = 117) were Caucasian. In our study, 51% of patients were found to have true ACS, and the remaining 49% had a non-ACS-related elevation in troponins. Most patients without ACS had alternate explanations for elevated troponin levels. The presence of chest pain (odds ratio (OR) = 3.7, 95% confidence interval (CI) = 1.8-7.7, p = 0.001), tobacco smoking (OR = 4, 95% CI = 1.06-3.8, p = 0.032), and wall motion abnormalities on echocardiogram (OR = 3.8, 95% CI = 1.8-6.5, p = 001) were associated with increased risk of true ACS in patients with elevated troponins. Conclusions Cardiac troponin levels can be elevated in hospitalized patients with various medical conditions, in the absence of ACS. The diagnosis of ACS should not be solely based on elevated troponin levels, as it can lead to expensive workup and utilization of hospital resources.
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Affiliation(s)
- Farman Ali
- Medicine, Ascension St. John Hospital and Medical Center, Detroit, USA
| | - Khurram Arshad
- Internal Medicine, Corewell Health East Dearborn, Dearborn, USA
| | - Susan Szpunar
- Biomedical Investigations and Research, Ascension St. John Hospital and Medical Center, Detroit, USA
| | - Edouard Daher
- Cardiology, Ascension St. John Hospital and Medical Center, Detroit, USA
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2
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Peng D, Zhai H. Application of Antithrombotic Drugs in Different Age-Group Patients with Upper Gastrointestinal Bleeding. Gastroenterol Res Pract 2024; 2024:1710708. [PMID: 38606387 PMCID: PMC11008970 DOI: 10.1155/2024/1710708] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Revised: 03/02/2024] [Accepted: 03/21/2024] [Indexed: 04/13/2024] Open
Abstract
Objective This study aimed at exploring the safety and timing of antithrombotic drugs in different age-group patients with UGIB. Methods An observational study retrospectively based on the single-center database with 713 patients with UGIB. Result Among the 713 patients, 62.13% were elderly patients (aged > 60 years) and the mortality was 2.9%. In elderly patients with UGIB, we found that previous medication history, resumption of medication, and time of resumption did not affect the in-hospital mortality. The resumption of anticoagulants increased the risk of rebleeding. The independent risk factors of mortality were CHF, cirrhosis, creatine kinase, and albumin. The independent risk factors of rebleeding were the application of anticoagulants during hospitalization, variceal bleeding, black stool, red blood cells (lab), platelets (lab), and heart rate. Conclusions In UGIB patients, a history of antiplatelet or antithrombotic drugs and the use of antiplatelet drugs after UGIB did not affect the patient's prognosis. In elderly UGIB patients, although antithrombotic drugs did not increase the risk of death, the increased risk of rebleeding after resumption of use deserved careful treatment. It was safe to recover anticoagulant drugs as soon as possible in young UGIB patients.
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Affiliation(s)
- Ding Peng
- Department of Gastroenterology, Xuanwu Hospital, Capital Medical University, Beijing 100053, China
| | - Huihong Zhai
- Department of Gastroenterology, Xuanwu Hospital, Capital Medical University, Beijing 100053, China
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Maayah M, Grubman S, Allen S, Ye Z, Park DY, Vemmou E, Gokhan I, Sun WW, Possick S, Kwan JM, Gandhi PU, Hu JR. Clinical Interpretation of Serum Troponin in the Era of High-Sensitivity Testing. Diagnostics (Basel) 2024; 14:503. [PMID: 38472975 DOI: 10.3390/diagnostics14050503] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2024] [Revised: 02/03/2024] [Accepted: 02/05/2024] [Indexed: 03/14/2024] Open
Abstract
Cardiac troponin (Tn) plays a central role in the evaluation of patients with angina presenting with acute coronary syndrome. The advent of high-sensitivity assays has improved the analytic sensitivity and precision of serum Tn measurement, but this advancement has come at the cost of poorer specificity. The role of clinical judgment is of heightened importance because, more so than ever, the interpretation of serum Tn elevation hinges on the careful integration of findings from electrocardiographic, echocardiographic, physical exam, interview, and other imaging and laboratory data to formulate a weighted differential diagnosis. A thorough understanding of the epidemiology, mechanisms, and prognostic implications of Tn elevations in each cardiac and non-cardiac etiology allows the clinician to better distinguish between presentations of myocardial ischemia and myocardial injury-an important discernment to make, as the treatment of acute coronary syndrome is vastly different from the workup and management of myocardial injury and should be directed at the underlying cause.
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Affiliation(s)
- Marah Maayah
- Yale School of Medicine, Yale University, New Haven, CT 06520, USA
| | - Scott Grubman
- Yale School of Medicine, Yale University, New Haven, CT 06520, USA
| | - Stephanie Allen
- Department of Internal Medicine, Yale School of Medicine, Yale University, New Haven, CT 06520, USA
| | - Zachary Ye
- Department of Internal Medicine, Temple University Medical Center, Philadelphia, PA 19140, USA
| | - Dae Yong Park
- Department of Internal Medicine, Cook County Hospital, Chicago, IL 60612, USA
| | - Evangelia Vemmou
- Department of Internal Medicine, Yale School of Medicine, Yale University, New Haven, CT 06520, USA
| | - Ilhan Gokhan
- Yale School of Medicine, Yale University, New Haven, CT 06520, USA
| | - Wendy W Sun
- Department of Emergency Medicine, Yale School of Medicine, Yale University, New Haven, CT 06520, USA
| | - Stephen Possick
- Section of Cardiovascular Medicine, Yale School of Medicine, Yale University, New Haven, CT 06520, USA
| | - Jennifer M Kwan
- Section of Cardiovascular Medicine, Yale School of Medicine, Yale University, New Haven, CT 06520, USA
| | - Parul U Gandhi
- Section of Cardiovascular Medicine, Yale School of Medicine, Yale University, New Haven, CT 06520, USA
- Department of Cardiology, Veterans Affairs Connecticut Health Care System, West Haven, CT 06516, USA
| | - Jiun-Ruey Hu
- Section of Cardiovascular Medicine, Yale School of Medicine, Yale University, New Haven, CT 06520, USA
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Yang Y, Xue Y, Li W, Yang F, Guo X, Zhou Z. The Incidence and Risk Factors of Acute Myocardial Infarction Among Patients with Gastrointestinal bleeding: A Retrospective Study. Int J Gen Med 2023; 16:4091-4097. [PMID: 37706013 PMCID: PMC10497049 DOI: 10.2147/ijgm.s422358] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Accepted: 08/25/2023] [Indexed: 09/15/2023] Open
Abstract
Purpose Patients with gastrointestinal bleeding (GIB) and acute myocardial infarction (AMI) have higher mortality than that with either GIB or AMI alone. The aims of this study were to determine the incidence and risk factors of AMI in patients with GIB. Patients and Methods From January 2015 to January 2018, we retrospectively studied 1287 patients with GIB in Renmin Hospital of Wuhan University. Various demographic, laboratory and outcome data were reviewed by charts. Results Thirty-seven patients had AMI and were placed in AMI group and the rest 1250 patients were in non-AMI group. Patients with AMI were more likely to be older than 70 years, have hypertension, coronary heart disease, chronic kidney disease, and have the recent history of taking aspirin before admission. The ROC curve of hemoglobin (HB) on admission showed area under curve was 0.762, the optimal cut-off value is 76.5g/L. Logistic regression analysis showed that age ≥ 70 years old, coronary heart disease and HB < 76.5g/L on admission were independent risk factors of AMI in patients with GIB. The mortality of patients during hospitalization in AMI group and in non-AMI group were 45.95% and 5.48%, respectively. Patients who displayed a history of liver disease and HB < 76.5g/L on admission had a higher death rate. Conclusion GIB increased the risk of subsequent AMI, especially in patients over 70 years old, with history of coronary heart disease and HB < 76.5g/L on admission. Patients with GIB and AMI who had history of liver disease and HB < 76.5g/L on admission had a higher mortality rate. Clinicians should identify the high-risk patients of AMI among the GIB population early and prevent AMI.
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Affiliation(s)
- Yan Yang
- Department of Gastroenterology, The First Affiliated Hospital of Xinxiang Medical University, Weihui, People’s Republic of China
| | - Yaofeng Xue
- Department of Gastroenterology, The First Affiliated Hospital of Xinxiang Medical University, Weihui, People’s Republic of China
| | - Wenjing Li
- Department of Gastroenterology, The First Affiliated Hospital of Xinxiang Medical University, Weihui, People’s Republic of China
| | - Fang Yang
- Department of Gastroenterology, The First Affiliated Hospital of Xinxiang Medical University, Weihui, People’s Republic of China
| | - Xiaohe Guo
- Department of Gastroenterology, The First Affiliated Hospital of Xinxiang Medical University, Weihui, People’s Republic of China
| | - Zhongyin Zhou
- Department of Gastroenterology, Renmin Hospital of Wuhan University, Hubei Key Laboratory of Digestive System Disease, Wuhan, People’s Republic of China
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Liu B, Li Q, Ding H, Wang S, Pang L, Li L. Myocardial injury is a risk factor for 6-week mortality in liver cirrhosis associated esophagogastric variceal bleeding. Sci Rep 2023; 13:6237. [PMID: 37069298 PMCID: PMC10107553 DOI: 10.1038/s41598-023-33325-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Accepted: 04/11/2023] [Indexed: 04/19/2023] Open
Abstract
This study sought to investigate risk factors for 6-week mortality of patients with decompensated liver cirrhosis associated esophagogastric variceal bleeding (EGVB) and clinical characteristics of myocardial injury in cirrhotic patients with EGVB. This retrospective cohort study included 249 patients with decompensated liver cirrhosis associated EGVB in the Department of Emergency. Patients were divided into two groups including liver cirrhosis associated EGVB without myocardial injury and liver cirrhosis associated EGVB with myocardial injury. Myocardial injury, recurrent bleeding, total bilirubin (TBIL) level and dyslipidemia are independent risk factors for 6-week mortality in liver cirrhosis associated EGVB. Among all patients with liver cirrhosis associated EGVB, 90 (36.2%) had myocardial injury and 159 individuals (63.8%) not. The 6-week mortality in the group with myocardial injury was 21%, which was significantly higher than that of 7% in the group without myocardial injury. More patients in the myocardial injury group smoked, had moderate to severe esophageal varices, liver failure, and Child-Pugh C liver function compared to the non-myocardial injury group. Myocardial injury, recurrent bleeding, TBIL level and dyslipidemia are independent risk factors for death within 6 weeks in liver cirrhosis associated EGVB. The 6-week mortality is considerably higher in patients with myocardial injury in liver cirrhosis associated EGVB than those without myocardial injury.
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Affiliation(s)
- Bihan Liu
- Department of Gastroenterology and Hepatology, Beijing You'an Hospital, Capital Medical University, Beijing, 100069, China
| | - Qi Li
- Department of Gastroenterology and Hepatology, Beijing You'an Hospital, Capital Medical University, Beijing, 100069, China
| | - Huiguo Ding
- Department of Gastroenterology and Hepatology, Beijing You'an Hospital, Capital Medical University, Beijing, 100069, China
| | - Shanshan Wang
- Department of Molecular Biology, Beijing Institute of Hepatology, Beijing You'an Hospital, Capital Medical University, Beijing, 100069, China
| | - Lifang Pang
- Department of Electrocardiography, Beijing You'an Hospital, Capital Medical University, Beijing, 100069, China
| | - Lei Li
- Department of Gastroenterology and Hepatology, Beijing You'an Hospital, Capital Medical University, Beijing, 100069, China.
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Kousa O, Addasi Y, Machanahalli Balakrishna A, Pajjuru VSK, Bardwell JK, Walters RW, Ponamgi S, Alla VM. Elevated troponin in patients with acute gastrointestinal bleeding: prevalence, predictors and outcomes. Future Cardiol 2022; 18:709-717. [PMID: 35770979 DOI: 10.2217/fca-2021-0143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Background: Cardiac troponin (cTn) can also be elevated in patients with non-cardiac illnesses. The utility of elevated cTn in patients with acute gastrointestinal bleeding (AGIB) is unclear. Methods: We retrospectively identified all patients admitted with AGIB who had cTn ordered. We assessed the prevalence, predictors and mortality. Results: A total of 172 patients with AGIB were included in the study, of whom 17% had abnormal cTn. Predictors of elevated cTn were advanced age, lower BMI, coronary artery disease and chronic kidney disease. The abnormal cTn group had more cardiac consultation and procedures and longer length of stay. However, there was no difference in mortality between the two groups. Conclusion: Elevated cTn in patients with AGIB was associated with more cardiology consultation and downstream cardiac testing, greater delay to endoscopic evaluation and longer length of stay, without significantly affecting the mortality.
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Affiliation(s)
- Omar Kousa
- Department of Cardiology, Creighton University School of Medicine, Omaha, Nebraska, NE 68124, USA
| | - Yazan Addasi
- Department of Internal Medicine, Creighton UniversitySchool of Medicine, Omaha, Nebraska, NE 68124, USA
| | | | | | - Josiah K Bardwell
- Department of Internal Medicine, Creighton UniversitySchool of Medicine, Omaha, Nebraska, NE 68124, USA
| | - Ryan W Walters
- Department of Clinical Research, Creighton University School of Medicine, Omaha, Nebraska, NE 68124, USA
| | - Shiva Ponamgi
- Department of Cardiology, Creighton University School of Medicine, Omaha, Nebraska, NE 68124, USA
| | - Venkata Mahesh Alla
- Department of Cardiology, Creighton University School of Medicine, Omaha, Nebraska, NE 68124, USA
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7
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Fraser M, Agdamag ACC, Maharaj VR, Mutschler M, Charpentier V, Chowdhury M, Alexy T. COVID-19-Associated Myocarditis: An Evolving Concern in Cardiology and Beyond. BIOLOGY 2022; 11:biology11040520. [PMID: 35453718 PMCID: PMC9025425 DOI: 10.3390/biology11040520] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Revised: 03/21/2022] [Accepted: 03/23/2022] [Indexed: 01/08/2023]
Abstract
Simple Summary Coronavirus disease-2019 (COVID-19) affects many organs in the body, including the heart. One complication of particular concern is inflammation of the heart muscle, called myocarditis. This paper presents updated research data on COVID-19-associated myocarditis. Specifically, we review the incidence, potential mechanisms, blood and imaging tests that can be used to detect the disease. We emphasize that, in contrast with early reports, recent data suggest that myocarditis in the setting of COVID-19 is relatively uncommon, yet infected individuals are at a substantially increased risk for poor outcomes. It is important to continue research in this area. Abstract The direct and indirect adverse effects of SARS-CoV-2 infection on the cardiovascular system, including myocarditis, are of paramount importance. These not only affect the disease course but also determine clinical outcomes and recovery. In this review, the authors aimed at providing an update on the incidence of Coronavirus disease-2019 (COVID-19)-associated myocarditis. Our knowledge and experience relevant to this area continues to evolve rapidly since the beginning of the pandemic. It is crucial for the scientific and medical community to stay abreast of current information. Contrasting early reports, recent data suggest that the overall incidence of SARS-CoV-2-associated myocarditis is relatively low, yet infected individuals are at a substantially increased risk. Therefore, understanding the pathophysiology and diagnostic evaluation, including the use of serum biomarkers and imaging modalities, remain important. This review aims to summarize the most recent data in these areas as they relate to COVID-19-associated myocarditis. Given its increasing relevance, a brief update is included on the proposed mechanisms of myocarditis in COVID-19 vaccine recipients.
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Affiliation(s)
- Meg Fraser
- Department of Medicine, Division of Cardiology, University of Minnesota, Minneapolis, MN 55455, USA; (M.F.); (A.C.C.A.); (V.R.M.); (M.M.)
| | - Arianne Clare C. Agdamag
- Department of Medicine, Division of Cardiology, University of Minnesota, Minneapolis, MN 55455, USA; (M.F.); (A.C.C.A.); (V.R.M.); (M.M.)
| | - Valmiki R. Maharaj
- Department of Medicine, Division of Cardiology, University of Minnesota, Minneapolis, MN 55455, USA; (M.F.); (A.C.C.A.); (V.R.M.); (M.M.)
| | - Melinda Mutschler
- Department of Medicine, Division of Cardiology, University of Minnesota, Minneapolis, MN 55455, USA; (M.F.); (A.C.C.A.); (V.R.M.); (M.M.)
| | | | | | - Tamas Alexy
- Department of Medicine, Division of Cardiology, University of Minnesota, Minneapolis, MN 55455, USA; (M.F.); (A.C.C.A.); (V.R.M.); (M.M.)
- Correspondence: ; Tel.: +1-612-625-9100
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Long B, Long DA, Tannenbaum L, Koyfman A. An emergency medicine approach to troponin elevation due to causes other than occlusion myocardial infarction. Am J Emerg Med 2020; 38:998-1006. [DOI: 10.1016/j.ajem.2019.12.007] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2019] [Revised: 11/18/2019] [Accepted: 12/04/2019] [Indexed: 02/06/2023] Open
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Mathews L, Ishigami J, Ding N, Hoogeveen RC, Kucharska-Newton A, Ballantyne CM, Gottesman R, Selvin E, Matsushita K. Cardiac Biomarkers and Subsequent Risk of Hospitalization With Bleeding in the Community: Atherosclerosis Risk in Communities Study. J Am Heart Assoc 2020; 9:e013560. [PMID: 32114886 PMCID: PMC7335570 DOI: 10.1161/jaha.119.013560] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Background hs‐cTnT (high‐sensitivity cardiac troponin T), but not NT‐proBNP (N‐terminal pro–B natriuretic peptide), has been shown to predict bleeding in patients with atrial fibrillation. Whether these biomarkers are independently associated with bleeding in the general population is unknown. Methods and Results We used Cox proportional hazards models to examine the association of hs‐cTnT and NT‐proBNP with incident bleeding (defined by International Classification of Diseases, Ninth Revision [ICD‐9] codes) among 9550 middle‐aged men and women without a history of cardiovascular disease or bleeding. There were 847 hospitalizations with bleeding (92% from gastrointestinal bleeding) during a median follow‐up of 9.0 years. Serum levels of hs‐cTnT were associated with bleeding in a graded fashion, with a hazard ratio of 1.28 (95% CI, 1.06–1.59) for 6 to <9 ng/L, 1.52 (1.21–1.91) for 9 to <14, and 2.05 (1.56–2.69) for ≥14 versus <3 ng/L. For NT‐proBNP, the highest category (≥264 versus <42 pg/mL) showed a hazard ratio of 2.00 (1.59–2.61), and the remaining 3 categories had hazard ratios ranging from 1.2 to 1.3. Individuals in the highest category of both hs‐cTnT and NT‐proBNP had a hazard ratio of 3.03 (1.97–4.68) compared with those in the lowest categories. Conclusions In a community‐based population, elevated hs‐cTnT and NT‐proBNP were associated with bleeding‐related hospitalizations. These biomarkers may have a high utility in identifying people at high risk for bleeding. There is a need for research on the underlying mechanisms linking subclinical cardiac abnormalities and bleeding.
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Affiliation(s)
- Lena Mathews
- Department of Epidemiology Johns Hopkins Bloomberg School of Public Health Baltimore MD.,Division of Cardiology Johns Hopkins School of Medicine Baltimore MD
| | - Junichi Ishigami
- Department of Epidemiology Johns Hopkins Bloomberg School of Public Health Baltimore MD
| | - Ning Ding
- Department of Epidemiology Johns Hopkins Bloomberg School of Public Health Baltimore MD
| | - Ron C Hoogeveen
- Department of Medicine Baylor College of Medicine Houston TX
| | - Anna Kucharska-Newton
- Gillings School of Global Public Health University of North Carolina at Chapel Hill NC.,College of Public Health University of Kentucky Lexington KY
| | | | - Rebecca Gottesman
- Department of Neurology Johns Hopkins School of Medicine Baltimore MD
| | - Elizabeth Selvin
- Department of Epidemiology Johns Hopkins Bloomberg School of Public Health Baltimore MD
| | - Kunihiro Matsushita
- Department of Epidemiology Johns Hopkins Bloomberg School of Public Health Baltimore MD
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Li M, Guo Z, Zhang D, Xu X, Romeiro FG, Mancuso A, Zhang J, Feng R, Zhou X, Hong C, Qi X. Correlation of Serum Cardiac Markers with Acute Decompensating Events in Liver Cirrhosis. Gastroenterol Res Pract 2020; 2020:4019289. [PMID: 33029132 PMCID: PMC7532360 DOI: 10.1155/2020/4019289] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Revised: 09/01/2020] [Accepted: 09/14/2020] [Indexed: 02/06/2023] Open
Abstract
METHODS Cirrhotic patients who were consecutively hospitalized between January 2016 and March 2019 were screened. Serum cardiac biomarkers at admission, including N-Terminal pro-B-type natriuretic peptide (NT-pro BNP), high-sensitivity cardiac troponin T (hs-cTnT), creatine kinase (CK), creatine kinase MB (CK-MB), and lactate dehydrogenase (LDH), were collected. Acute decompensating events at admission, primarily including ascites, acute gastrointestinal hemorrhage, and acute-on-chronic liver failure (ACLF), were recorded. RESULTS The NT-pro BNP level was significantly higher in cirrhotic patients with acute decompensating events than in those without any decompensating events (median: 140.75 pg/mL versus 41.86 pg/mL, P < 0.001). The NT-pro BNP level significantly correlated with ascites, acute gastrointestinal hemorrhage, and ACLF. The hs-cTnT level was significantly higher in cirrhotic patients with acute decompensating events than in those without decompensating events (median: 0.008 ng/mL versus 0.006 ng/mL, P = 0.007). The hs-cTnT level significantly correlated with acute gastrointestinal hemorrhage, but not ascites or ACLF. LDH (185.0 U/L versus 173.5 U/L, P = 0.281), CK (71 U/L versus 84 U/L, P = 0.157), and CK-MB (29.5 U/L versus 33.0 U/L, P = 0.604) levels were not significantly different between cirrhotic patients with and without acute decompensating events. CONCLUSION The elevated NT-pro BNP level seems to be closely related to the development of acute decompensating events in liver cirrhosis.
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Affiliation(s)
- Miaomiao Li
- 1Liver Cirrhosis Group, Department of Gastroenterology, General Hospital of Northern Theater Command (Formerly General Hospital of Shenyang Military Area), Shenyang, China
- 2Department of Clinical Laboratory, The First Hospital of Lanzhou University, Lanzhou, China
| | - Zeqi Guo
- 1Liver Cirrhosis Group, Department of Gastroenterology, General Hospital of Northern Theater Command (Formerly General Hospital of Shenyang Military Area), Shenyang, China
| | - Dan Zhang
- 3Department of General Surgery, General Hospital of Northern Theater Command (Formerly General Hospital of Shenyang Military Area), Shenyang, China
| | - Xiangbo Xu
- 1Liver Cirrhosis Group, Department of Gastroenterology, General Hospital of Northern Theater Command (Formerly General Hospital of Shenyang Military Area), Shenyang, China
- 4Department of Pharmaceutical Sciences, Shenyang Pharmaceutical University, Shenyang, China
| | | | - Andrea Mancuso
- 6Department of Internal Medicine, ARNAS Civico, Palermo, Italy
| | - Jingqiao Zhang
- 1Liver Cirrhosis Group, Department of Gastroenterology, General Hospital of Northern Theater Command (Formerly General Hospital of Shenyang Military Area), Shenyang, China
- 4Department of Pharmaceutical Sciences, Shenyang Pharmaceutical University, Shenyang, China
| | - Ruirui Feng
- 1Liver Cirrhosis Group, Department of Gastroenterology, General Hospital of Northern Theater Command (Formerly General Hospital of Shenyang Military Area), Shenyang, China
| | - Xinmiao Zhou
- 1Liver Cirrhosis Group, Department of Gastroenterology, General Hospital of Northern Theater Command (Formerly General Hospital of Shenyang Military Area), Shenyang, China
| | - Cen Hong
- 1Liver Cirrhosis Group, Department of Gastroenterology, General Hospital of Northern Theater Command (Formerly General Hospital of Shenyang Military Area), Shenyang, China
| | - Xingshun Qi
- 1Liver Cirrhosis Group, Department of Gastroenterology, General Hospital of Northern Theater Command (Formerly General Hospital of Shenyang Military Area), Shenyang, China
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Ng JC, Yeomans ND. <em>Helicobacter pylori</em> infection and the risk of upper gastrointestinal bleeding in low dose aspirin users: systematic review and meta-analysis. Med J Aust 2019; 209:306-311. [PMID: 30257623 DOI: 10.5694/mja17.01274] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2017] [Accepted: 05/25/2018] [Indexed: 12/16/2022]
Abstract
OBJECTIVE To determine whether the risk of upper gastrointestinal bleeding in patients taking low dose aspirin (≤ 325 mg/day) is increased in people with Helicobacter pylori infections. STUDY DESIGN A systematic search for all publications since 1989 (when H. pylori was named) using search term equivalents for "upper gastrointestinal haemorrhage" and "aspirin". Articles were assessed individually for inclusion of data on H. pylori infection, as not all relevant papers were indexed with this term. Data that could be pooled were then subjected to meta-analysis, using a random effects model. DATA SOURCES MEDLINE, Embase, Scopus, the Cochrane Library. DATA SYNTHESIS Of 7599 retrieved publications, reports for seven case-control studies contained data suitable for meta-analysis; four were deemed high quality on the Newcastle-Ottawa scale. Upper gastrointestinal haemorrhage was more frequent in aspirin users infected with H. pylori than in those who were not (odds ratio [OR], 2.32; 95% CI, 1.25-4.33; P = 0.008). The heterogeneity of the studies was significant (Q = 19.3, P = 0.004; I<sup>2</sup> = 68.9%, 95% CI, 31.5-85.9%), but the pooled odds ratio was similar after removing the two studies that contributed most to heterogeneity (OR, 2.34; 95% CI, 1.56-3.53; P < 0.001). The number needed to treat to prevent one bleeding event annually was estimated to be between 100 and more than 1000. CONCLUSIONS The odds of upper gastrointestinal bleeding in patients taking low dose aspirin is about twice as great in those infected with H. pylori. Testing for and treating the infection should be considered in such patients, especially if their underlying risk of peptic ulcer bleeding is already high.
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12
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Provoking conditions, management and outcomes of type 2 myocardial infarction and myocardial necrosis. Int J Cardiol 2016; 218:196-201. [PMID: 27236114 DOI: 10.1016/j.ijcard.2016.05.045] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2016] [Accepted: 05/12/2016] [Indexed: 11/23/2022]
Abstract
BACKGROUND Type 2 myocardial infarction (MI) is defined as myocardial necrosis (myonecrosis) due to an imbalance in supply and demand with clinical evidence of ischemia. Some clinical scenarios of supply-demand mismatch predispose to myonecrosis but limit the identification of symptoms and ECG changes referable to ischemia; therefore, the MI definition may not be met. Factors that predispose to type 2 MI and myonecrosis without definite MI, approaches to treatment, and outcomes remain poorly characterized. METHODS Patients admitted to an academic medical center with an ICD-9 diagnosis of secondary myocardial ischemia or non-primary diagnosis of non-ST-elevation MI were retrospectively reviewed. Cases were classified as either MI (n=255) or myonecrosis without definite MI (n=220) based on reported symptoms, ischemic ECG changes, and new wall motion abnormalities. RESULTS Conditions associated with type 2 MI or myonecrosis included non-cardiac surgery (38%), anemia or bleeding requiring transfusion (32%), sepsis (31%), tachyarrhythmia (23%), hypotension (22%), respiratory failure (23%), and severe hypertension (8%). Inpatient mortality was 5%, with no difference between patients with MI and those with myonecrosis (6% vs. 5%, p=0.41). At discharge, only 43% of patients received aspirin and statin therapy. CONCLUSIONS Type 2 MI and myonecrosis occur frequently in the setting of supply-demand mismatch due to non-cardiac surgery, sepsis, or anemia. Myonecrosis without definite MI is associated with similar in-hospital mortality as type 2 MI; both groups warrant further workup for cardiovascular disease. Antiplatelet and statin prescriptions were infrequent at discharge, reflecting physician uncertainty about the role of secondary prevention in these patients.
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Smilowitz NR, Naoulou B, Sedlis SP. Diagnosis and management of type II myocardial infarction: increased demand for a limited supply of evidence. Curr Atheroscler Rep 2015; 17:478. [PMID: 25620276 DOI: 10.1007/s11883-014-0478-1] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Type 2 myocardial infarction (type 2 MI) is defined as myocardial necrosis that results from an imbalance of myocardial oxygen supply and demand. Although type 2 MI is highly prevalent and strongly associated with mortality, the pathophysiology remains poorly understood. Discrepancies in definitions, frequency of screening, diagnostic approaches, and methods of adjudication lead to confusion and misclassification. To date, there is no consensus on the diagnostic criteria for type 2 MI. No guidelines exist for the optimal management of this condition, and further investigation is urgently needed. This review explores the existing evidence on the pathophysiology, diagnosis, prognosis, and management of type 2 MI.
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Affiliation(s)
- Nathaniel R Smilowitz
- Division of Cardiology, Department of Medicine, New York University School of Medicine, New York, NY, USA
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Impact of troponin testing in noncardiac admissions. Crit Pathw Cardiol 2014; 13:147-51. [PMID: 25396291 DOI: 10.1097/hpc.0000000000000027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND There is little data to support Troponin I (TNI) use in the management of noncardiac patients. We studied the use of TNI in patients on our gastroenterology service, to determine whether there was a change in management as a result of TNI testing. METHODOLOGY Patients admitted from September 2011 to June 2012 to our gastroenterology service who had TNI performed were included. Data collected included symptoms, cardiovascular risk factors, medical treatment, and testing. RESULTS Sixty-three of 295 patients had a positive TNI. The mean length of stay was significantly longer with a positive troponin (180 vs. 108 hours, P<0.001). Age, hypertension, diabetes, coronary artery disease, and chronic kidney disease were associated with a positive TNI. Cardiac consultation and echocardiography were performed in a higher proportion of TNI positive patients (P<0.0001). There were no statistically significant changes in treatment with clopidogrel, beta-blockers, angiotensin converting enzyme inhibitors, or statins between both groups. CONCLUSIONS TNI testing in patients admitted to the gastroenterology service was associated with increased length of stay and echocardiography, without any change in management. This study supports adherence to national guidelines for the use of TNI, to reduce TNI testing and length of hospital stay.
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Nakamura Y, Yoshihisa A, Takiguchi M, Shimizu T, Yamauchi H, Iwaya S, Owada T, Miyata M, Abe S, Sato T, Suzuki S, Oikawa M, Kobayashi A, Yamaki T, Sugimoto K, Kunii H, Nakazato K, Suzuki H, Saitoh SI, Takeishi Y. High-Sensitivity Cardiac Troponin T Predicts Non-Cardiac Mortality in Heart Failure. Circ J 2014; 78:890-5. [DOI: 10.1253/circj.cj-13-1372] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Yuichi Nakamura
- Department of Cardiology and Hematology, Fukushima Medical University
| | - Akiomi Yoshihisa
- Department of Cardiology and Hematology, Fukushima Medical University
| | - Mai Takiguchi
- Department of Cardiology and Hematology, Fukushima Medical University
| | - Takeshi Shimizu
- Department of Cardiology and Hematology, Fukushima Medical University
| | - Hiroyuki Yamauchi
- Department of Cardiology and Hematology, Fukushima Medical University
| | - Shoji Iwaya
- Department of Cardiology and Hematology, Fukushima Medical University
| | - Takashi Owada
- Department of Cardiology and Hematology, Fukushima Medical University
| | - Makiko Miyata
- Department of Cardiology and Hematology, Fukushima Medical University
| | - Satoshi Abe
- Department of Cardiology and Hematology, Fukushima Medical University
| | - Takamasa Sato
- Department of Cardiology and Hematology, Fukushima Medical University
| | - Satoshi Suzuki
- Department of Cardiology and Hematology, Fukushima Medical University
| | - Masayoshi Oikawa
- Department of Cardiology and Hematology, Fukushima Medical University
| | - Atsushi Kobayashi
- Department of Cardiology and Hematology, Fukushima Medical University
| | - Takayoshi Yamaki
- Department of Cardiology and Hematology, Fukushima Medical University
| | - Koichi Sugimoto
- Department of Cardiology and Hematology, Fukushima Medical University
| | - Hiroyuki Kunii
- Department of Cardiology and Hematology, Fukushima Medical University
| | - Kazuhiko Nakazato
- Department of Cardiology and Hematology, Fukushima Medical University
| | - Hitoshi Suzuki
- Department of Cardiology and Hematology, Fukushima Medical University
| | - Shu-ichi Saitoh
- Department of Cardiology and Hematology, Fukushima Medical University
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Puymirat Y, Hachouf M, Doassans-Cazaban G, Poullenot F, Lefévre L, Winnock S, Ouattara A. [Predictive factors of organ failure in patients admitted in intensive care unit for acute gastrointestinal bleeding]. ACTA ACUST UNITED AC 2013; 32:560-4. [PMID: 23948027 DOI: 10.1016/j.annfar.2013.06.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2012] [Accepted: 06/14/2013] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Gastrointestinal hemorrhage is an emergency requiring usually an admission in intensive care unit (ICU), which may prove abusive secondarily. The aim of this study was to identify predictive risk factors of organ failure in patients admitted for GH in our ICU. DESIGN Retrospective and observational METHODS AND MEASUREMENTS Between January 2008 and December 2011, all patients admitted in our ICU for gastrointestinal hemorrhage were consecutively included. The primary endpoint was the occurrence of at least an organ failure. We realized an univariate analysis then a backward regression to identify independent risk factors associated with the occurrence of at least one organ failure during the ICU hospitalization. RESULTS During this period study, 441 consecutive patients with a mean age of 67±15years were included. The median ICU length of stay was of 4 (3-7) days and 116 (26% [IC95%: 22-30]) patients presented at least one organ failure. The multivariate analysis identified predictive risk factors of organ failure: history of cirrhosis (OR=3.5 [IC95%: 1.9-6.7], P<0.001) and an increase in troponin at the admission above the 99th percentile (OR=3.1 [IC95%: 1.8-5.5], P<0.001). CONCLUSION Our results confirmed that a large proportion of patients admitted in ICU for the primary diagnosis of gastrointestinal hemorrhage developed any organ failure. The history of cirrhosis and the systemic consequences of the hemorrhagic syndrome as myocardial damage represents important risk factors of morbidity and mortality and thus should be considered during the management.
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Affiliation(s)
- Y Puymirat
- Service d'anesthésie-réanimation II, hôpital du Haut-Lévêque, CHU de Bordeaux, avenue Magellan, 33000 Bordeaux, France; U1034, adaptation cardiovasculaire à l'ischémie, université de Bordeaux, 33000 Bordeaux, France
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Monitoring the patient at risk of hemodynamic instability in remote locations. Int Anesthesiol Clin 2012; 50:141-72. [PMID: 22481561 DOI: 10.1097/aia.0b013e318250ebb1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
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Koracevic GP. Troponin Units Should be Unified. J Emerg Med 2011; 40:445-6. [DOI: 10.1016/j.jemermed.2009.02.041] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2008] [Accepted: 02/20/2009] [Indexed: 10/20/2022]
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Kelley WE, Januzzi JL, Christenson RH. Increases of cardiac troponin in conditions other than acute coronary syndrome and heart failure. Clin Chem 2009; 55:2098-112. [PMID: 19815610 DOI: 10.1373/clinchem.2009.130799] [Citation(s) in RCA: 147] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Although cardiac troponin (cTn) is a cornerstone marker in the assessment and management of patients with acute coronary syndrome (ACS) and heart failure (HF), cTn is not diagnostically specific for any single myocardial disease process. This narrative review discusses increases in cTn that result from acute and chronic diseases, iatrogenic causes, and myocardial injury other than ACS and HF. CONTENT Increased cTn concentrations have been reported in cardiac, vascular, and respiratory disease and in association with infectious processes. In cases involving acute aortic dissection, cerebrovascular accident, treatment in an intensive care unit, and upper gastrointestinal bleeding, increased cTn predicts a longer time to diagnosis and treatment, increased length of hospital stay, and increased mortality. cTn increases are diagnostically and prognostically useful in patients with cardiac inflammatory diseases and in patients with respiratory disease; in respiratory disease cTn can help identify patients who would benefit from aggressive management. In chronic renal failure patients the diagnostic sensitivity of cTn for ACS is decreased, but cTn is prognostic for the development of cardiovascular disease. cTn also provides useful information when increases are attributable to various iatrogenic causes and blunt chest trauma. SUMMARY Information on the diagnostic and prognostic uses of cTn in conditions other than ACS and heart failure is accumulating. Although increased cTn in settings other than ACS or heart failure is frequently considered a clinical confounder, the astute physician must be able to interpret cTn as a dynamic marker of myocardial damage, using clinical acumen to determine the source and significance of any reported cTn increase.
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Affiliation(s)
- Walter E Kelley
- Department of Pathology, University of Maryland School of Medicine, Baltimore, MD, USA.
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