High-sensitivity cardiac troponin T levels are increased in stable COPD

High-Sensitivity Cardiac Troponin T and Frailty Predict Short-Term Mortality in Patients ≥75 Years Undergoing Emergency Abdominal Surgery: A Prospective Observational Study

BACKGROUND

An elevated cardiac troponin concentration is a prognostic factor for perioperative cardiac morbidity and mortality. In elderly patients undergoing emergency abdominal surgery, frailty is a recognized risk factor, but little is known about the prognostic value of cardiac troponin in these vulnerable patients. Therefore, we investigated the prognostic significance of elevated high-sensitivity cardiac troponin T (hs-cTnT) concentration and frailty in a cohort of elderly patients undergoing emergency abdominal surgery.

METHODS

We included consecutive patients ≥75 years of age who presented for emergency abdominal surgery, defined as abdominal pathology requiring surgery within 72 hours, in a university hospital in Norway. Patients who underwent vascular procedures or palliative surgery for inoperable malignancies were excluded. Preoperatively, frailty was assessed using the Clinical Frailty Scale (CFS), and blood samples were measured for hs-cTnT. We evaluated the predictive power of CFS and hs-cTnT concentrations using receiver operating characteristic (ROC) curves and Cox proportional hazard regression with 30-day mortality as the primary outcome. Secondary outcomes included (1) a composite of 30-day all-cause mortality and major adverse cardiac event (MACE), defined as myocardial infarction, nonfatal cardiac arrest, or coronary revascularization; and (2) 90-day mortality.

RESULTS

Of the 210 screened and 156 eligible patients, blood samples were available in 146, who were included. Troponin concentration exceeded the 99th percentile upper reference limit (URL) in 83% and 89% of the patients pre- and postoperatively. Of the participants, 53% were classified as vulnerable or frail (CFS ≥4). The 30-day mortality rate was 12% (18 of 146). Preoperatively, a threshold of hs-cTnT ≥34 ng/L independently predicted 30-day mortality (hazard ratio [HR] 3.14, 95% confidence interval [CI], 1.13-9.45), and the composite outcome of 30-day mortality and MACE (HR 2.58, 95% CI, 1.07-6.49). In this model, frailty (continuous CFS score) also independently predicted 30-day mortality (HR 1.42, 95% CI, 1.01-2.00) and 30-day mortality or MACE (HR 1.37, 95% CI, 1.02-1.84). The combination of troponin and frailty, 0.14 × hs-cTnT +4.0 × CFS, yielded apparent superior predictive power (area under the receiver operating characteristics curve [AUC] 0.79, 95% CI, 0.68-0.88), compared to troponin concentration (AUC 0.69, 95% CI, 0.55-0.83) or frailty (AUC 0.69, 95% CI, 0.57-0.82) alone.

CONCLUSIONS

After emergency abdominal surgery in elderly patients, increased preoperative troponin concentration and frailty were independent predictors of 30-day mortality. The combination of increased troponin concentration and frailty seemed to provide better prognostic information than troponin or frailty alone. These results must be validated in an independent sample.

RV in COPD - The complicated matters of the heart - Correlation of ECHO and biomarker with COPD severity and outcome

BACKGROUND

Patients with chronic obstructive pulmonary disease (COPD) have an increased risk of cardiovascular involvement, which is among the leading causes of morbidity and mortality worldwide. Echocardiography (ECHO) could be a reliable, non-invasive tool for predicting the risk of cardiovascular modalities in patients with COPD. Combining the ECHO parameters with highly selective cardiac troponin could predict the severity and outcome of patients with COPD.

METHODS

This prospective observational study was conducted at a tertiary care hospital in South India. All patients who met the criteria were included. Patients with other concomitant chronic lung diseases were excluded. An echocardiographic examination was performed, and blood samples for hs-Tnt were taken on admission for patients admitted with COPD. Categorical variables were analyzed using Pearson's Chi-square test, and the T-test was used to compare the means. One-way analysis of variance (ANOVA) followed by the Bonferroni multiple comparison tests was done to compare different echo parameters concerning COPD severity.

RESULTS

The mean tricuspid annulus plane systolic excursion (TAPSE) and right ventricle (RV) fraction area change (FAC) values were lower with the increase in the disease severity (P < 0.001). There was a significant increase in the mean systolic pressures in the right atrium and ventricle in patients with severe COPD (P < 0.001). The mean hs-TnT values were significantly higher in patients with severe COPD (18.86 ± 18.12) and correlated well with the increase in the severity of the disease (P < 0.001). Changes in the echo parameters, such as mean TAPSE and RV FAC values, negatively correlated with COPD severity. There was an increase in systolic pressure in both atria and ventricles with the progression of COPD. Troponin helped predict mortality during hospitalization.

CONCLUSION

Comprehensive echocardiographic parameters, such as TAPSE and RV FAC, help assess the disease's severity, predict mortality, and evaluate whether the proper ventricular function is reliable. Troponin is a valuable adjunct that is an independent and strong predictor of overall mortality in patients with COPD.

Clinical Interpretation of Serum Troponin in the Era of High-Sensitivity Testing

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.

It is unlikely that oxygen supplementation in COPD patients with chronic respiratory failure reduce cardiac troponin level

BACKGROUND

Cardiac troponin T (cTnT) is a biomarker of myocardial injury frequently elevated in COPD patients, potentially because of hypoxemia. This non-randomised observational study investigates whether long-term oxygen treatment (LTOT) reduces the cTnT level.

METHODS

We compared cTnT between COPD patients who were candidates for LTOT (n = 20) with two reference groups. Patients from both reference groups were matched with the index group using propensity score.Reference groups consists of institutional pulmonary rehabilitation patients (short-term group) (n = 105 after matching n = 11) and outpatients at a pulmonary rehabilitation clinic (long-term group)(n = 62 after matching n = 10). Comparison was done within 24 h after LTOT initiation in first reference group and within 6 months after inclusion in the second group.

RESULTS

The geometric mean of (standard deviation in parentheses) cTnT decreased from 17.8 (2.3) ng/L (between 8 and 9 a.m.) to 15.4 (2.5) ng/L between 1 and 2 p.m. in the LTOT group, and from 18.4 (4.8) ng/L to15.4 (2.5) ng/L in group (1) The corresponding long-term results were 17.0 (2.9) ng/L at inclusion (between 10 and 12 a.m.) to 18.4 (2.4) ng/L after 3 months in the LTOT-group, and from 14.0 (2.4) ng/L to 15.4 (2.5) ng/L after 6 months in group (2) None of the differences in cTnT during the follow-up between the LTOT-group and their matched references were significant.

CONCLUSION

Initiation of LTOT was not associated with an early or sustained reduction in cTnT after treatment with oxygen supplementation.

Systemic inflammation induced by exacerbation of COPD or pneumonia in patients with COPD induces cardiac troponin elevation

Background

Troponin is a biomarker of myocardial injury. In chronic obstructive pulmonary disease (COPD), troponin is an important determinant of mortality after acute exacerbation. Whether acute exacerbation of COPD (AECOPD) causes troponin elevation is not known. Here, we investigated whether troponin is increased in AECOPD compared to stable COPD.

Methods

We included 320 patients with COPD in the stable state and 63 random individuals from Akershus University hospital’s catchment area. All participants were ≥40 years old (mean 65·1 years, SD 7·6) and 176 (46%) were females. The geometric mean of high-sensitivity cardiac troponin T (hs-cTnT) was 6·9 ng/L (geometric-SD 2·6). They were followed regarding hospital admission for the subsequent 5 years.

Results

During the 5-year follow-up, we noted 474 hospitalisations: Totally, 150 and 80 admissions were due to AECOPD or pneumonia, respectively. The geometric mean ratio with geometric SE (GSE) between cTnT at admission and stable state in AECOPD and pneumonia was 1·27 (GSE=1.11, p=0·023) and 1·28 (GSE=1.14, p=0·054), respectively. After inclusion of blood leucocyte count and C reactive protein at hospitalisation, these ratios attenuated to zero. However, we estimated an indirect of AECOPD and pneumonia on the ratio between hs-cTnT at admission and the stable state to 1·16 (p=0·022) and 1·22 (p=0·008), representing 91% (95% CI 82% to 100%) and 95% (95% CI 83% to 100%) of the total effects, respectively.

Conclusion

AECOPD and pneumonia in patients with COPD is associated with higher cTnT levels. This association appears to be mediated by systemic inflammation.

Mechanisms Underlying the Association of Chronic Obstructive Pulmonary Disease With Heart Failure

OBJECTIVES

The purposes of this study were to determine why chronic obstructive pulmonary disease (COPD) is associated with heart failure (HF). Specific objectives included whether COPD is associated with myocardial fibrosis, whether myocardial fibrosis is associated with hospitalization for HF and death in COPD, and whether COPD and smoking are associated with myocardial inflammation.

BACKGROUND

COPD is associated with HF independent of shared risk factors. The underlying pathophysiological mechanism is unknown.

METHODS

A prospective, multicenter, longitudinal cohort study of 572 patients undergoing cardiac magnetic resonance (CMR), including 450 patients with COPD and 122 age- and sex-matched patients with a median: 726 days (interquartile range: 492 to 1,160 days) follow-up. Multivariate analysis was used to examine the relationship between COPD and myocardial fibrosis, measured using cardiac magnetic resonance (CMR). Cox regression analysis was used to examine the relationship between myocardial fibrosis and outcomes; the primary endpoint was composite of hospitalizations for HF or all-cause mortality; secondary endpoints included hospitalizations for HF and all-cause mortality. Fifteen patients with COPD, 15 current smokers, and 15 healthy volunteers underwent evaluation for myocardial inflammation, including ultrasmall superparamagnetic particles of iron oxide CMR.

RESULTS

COPD was independently associated with myocardial fibrosis (p < 0.001). Myocardial fibrosis was independently associated with the primary outcome (hazard ratio [HR]: 1.14; 95% confidence interval [CI]: 1.08 to 1.20; p < 0.001), hospitalization for HF (HR: 1.25 [95% CI: 1.14 to 1.36]); p < 0.001), and all-cause mortality. Myocardial fibrosis was associated with outcome measurements more strongly than any other variable. Acute and stable COPD were associated with myocardial inflammation.

CONCLUSIONS

The associations between COPD, myocardial inflammation and myocardial fibrosis, and the independent prognostic value of myocardial fibrosis elucidate a potential pathophysiological link between COPD and HF.

Elevated Cardiac Troponin Levels in Geriatric Patients Without ACS: Role of Comorbidities

Background

Elevated levels of cardiac troponin T as measured by a high-sensitivity test (hscTnT) are common in geriatric patients with a large spectrum of comorbidities but without acute coronary syndrome (ACS). However, the relative contribution of individual comorbidities has never been clearly addressed. This study aimed to determine the relationship between hscTnT elevation as a response variable and individual comorbidities, and to estimate the impact of individual comorbidities on hscTnT elevation in geriatric patients free of ACS.

Methods

A nonexperimental, retrospective, matched, longitudinal cohort study was designed to evaluate the files of 7062 geriatric patients (aged ≥ 65 years) without ACS. The hscTnT levels of the patients have already been measured in all evaluated medical records. The dataset was split into 2 groups (0 and 1) based on the individual comorbidity (0 and 1) and hscTnT levels (≤ 14 ng/L = 0 and > 14 ng/L = 1).

Results

Our results show that although age was positively and significantly correlated with hscTnT (r = 0.17, P < 0.0001), the likelihood of experiencing elevated hscTnT levels in older individuals after having excluded ACS was related to the presence of comorbidities independently of their number (P < 0.0001). The regression coefficients (β) associated with renal insufficiency (0.71), cardiomyopathy (0.63), chronic obstructive pulmonary disease (0.30), diabetes (0.25), and anemia (0.22) indicated that there exists a significant association between these comorbidities and the elevated hscTnT levels (P < 0.001). The receiver operating characteristic curve for predictive modeling was estimated at 71% (P < 0.0001).

Conclusions

Elevated hscTnT levels were mostly associated with renal insufficiency, cardiac myopathies, chronic obstructive pulmonary disease, diabetes, and anemia in geriatric patients without ACS. Developing guidelines to accurately evaluate hscTnT elevation in geriatric patients with comorbidities, without ACS, is clinically essential.

Elevation of High-sensitive Troponin T Predicts Mortality After Open Pancreaticoduodenectomy

BACKGROUND

Open pancreaticoduodenectomy has a high complication and measurable mortality rate. Recent reports (based across multiple surgical disciplines) demonstrate that elevated postoperative high sensitivity troponin T (hsTnT) predicts adverse outcomes in non-cardiac surgery. The aim of this study was to evaluate postoperative hsTnT as a prognostic marker of mortality, major adverse cardiovascular events (MACE), post-operative non-cardiac complications and length of stay (including intensive care stay) in open pancreaticoduodenectomy.

METHODS

A retrospective review of open pancreaticoduodenectomy patients was undertaken from 01/10/2017-31/03/2019. Receiver operating characteristic (ROC) curves were calculated to identify ideal cut-off values for hsTnT. Univariate and multivariate analyses were performed to scrutinize the relationship between mean hsTnT and 30-day, 90-day mortality, MACE, post-operative non-cardiac complications and length of stay.

RESULTS

One hundred and nine patients were identified. ROC curves demonstrated a strong correlation between elevated mean hsTnT and 30-day, 90-day mortality and MACE (AUC = 0.937, AUC = 0.852, AUC = 0.779, respectively). Multivariate analysis showed mean hsTnT > 21 ng/l was significantly associated with 90-day mortality (OR 43.928, p = 0.004) and MACE (OR 8.177, p = 0.048).

CONCLUSIONS

HsTnT is predictive of mortality and MACE in the context of open pancreaticoduodenectomy. Association between hsTnT and prolonged critical care stay was less significant. Non-cardiac complications and length of stay show no significant association with hsTnT.

Conventional vs high-sensitive troponins in acute exacerbations of chronic obstructive pulmonary disease

BACKGROUND

Cardiac troponins (cTn), either conventional or high-sensitive (hscTn) assays, are often performed during acute exacerbations of chronic obstructive pulmonary disease (AECOPD).

OBJECTIVES

To compare factors affecting abnormal conventional cTn and hscTn.

METHODS

We retrospectively studied data from AECOPD patients with conventional or hscTn performed at presentation. Binary logistic regression was used to identify predictors for abnormal conventional cTn (>0.5 ug/L) and hscTn (>40 ng/L).

RESULTS

There were 466 patients in the conventional cTn and 313 patients in the hscTn groups. Ischaemic electrocardiographic change was the only significant predictor for abnormal conventional cTn (OR 6.662 [CI 1.233-35.990], p = 0.028) while B-type natriuretic peptide levels (Adj OR 1.004 [CI 1.000-1.006], p = 0.010) and SpO₂/FiO₂ ratio (Adj OR 0.115 [CI 0.017-0.069], p = 0.026) were significant predictors of abnormal hscTn.

CONCLUSIONS

Predictors of abnormal cTn differ between assays and should be taken into consideration when interpreting cTn during AECOPD.

Myocardial involvement in eosinophilic granulomatosis with polyangiitis evaluated with cardiopulmonary magnetic resonance

Patients with eosinophilic granulomatosis with polyangiitis (EGPA) most commonly die from cardiac causes, however, cardiac involvement remains poorly characterised and the relationship between cardiac and pulmonary disease is not known. This study aimed to characterise myocardial and pulmonary manifestations of EGPA, and their relationship. Prospective comprehensive cardiopulmonary investigation, including a novel combined cardiopulmonary magnetic resonance imaging (MRI) technology, was performed in 13 patients with stable EGPA. Comparison was made with 11 prospectively recruited matched healthy volunteers. Stable EGPA was associated with focal replacement and diffuse interstitial myocardial fibrosis (myocardial extracellular volume 26.9% vs. 24.7%; p = 0.034), which drove a borderline increase in left ventricular mass (56  ±  9 g/m2 vs. 49  ±  8 g/m2; p = 0.065). Corrected QT interval was significantly prolonged and was associated with the severity of myocardial fibrosis (r = 0.582, p = 0.037). Stable EGPA was not associated with increased myocardial capillary permeability or myocardial oedema. Pulmonary tissue perfusion and capillary permeability were normal and there was no evidence of pulmonary tissue oedema or fibrosis. Forced expiratory volume in one second showed a strong inverse relationship with myocardial fibrosis (r = -0.783, p = 0.038). In this exploratory study, stable EGPA was associated with focal replacement and diffuse interstitial myocardial fibrosis, but no evidence of myocardial or pulmonary inflammation or pulmonary fibrosis. Myocardial fibrosis was strongly associated with airway obstruction and abnormal cardiac repolarisation. Further investigation is required to determine the mechanisms underlying the association between heart and lung disease in EGPA and whether an immediate immunosuppressive strategy could prevent myocardial fibrosis formation.

Relationship of pulmonary function with myocardial microdamage and oxidative stress in the Japanese population without a history of cardiopulmonary disease

An association between pulmonary and cardiovascular impairment has been reported, but studies are lacking that focus on individuals without advanced impairment in the pulmonary or cardiovascular system. We aimed to investigate the relationship between myocardial microdamage and reduced pulmonary function in the Japanese population without a history of cardiopulmonary disease and to assess whether oxidative stress links the 2 features.We enrolled patients undergoing an annual health check-up and measured serum high-sensitivity cardiac troponin I (hs-cTnI) and derivatives of reactive oxygen metabolites (d-ROM) to evaluate myocardial microdamage and oxidative stress. To assess pulmonary function, we calculated forced vital capacity as a percentage of predicted value, forced expiratory volume in 1 second as a percentage of predicted value, and the ratio of forced expiratory volume in 1 second to forced vital capacity. Possible associations between each parameter of pulmonary function, hs-cTnI, and d-ROM were cross-sectionally investigated.The study included 1265 participants (57 ± 12 years). In multivariate regression analysis, the forced vital capacity as a percentage of predicted value was inversely associated with hs-cTnI levels after adjustment for possible confounders. In another multivariate model, all indices of pulmonary function were inversely correlated with d-ROM levels. We observed similar relationships in a multivariate regression model that included hs-cTnI and d-ROM simultaneously as independent variables. Levels of d-ROM and hs-cTnI also were significantly associated.These results highlight an inverse association of pulmonary function with hs-cTnI and d-ROM in the Japanese population without a history of cardiopulmonary disease. The findings suggest that in individuals without obvious cardiovascular and pulmonary diseases, reduced pulmonary function could reflect myocardial microdamage, at least in part through increased oxidative stress.

[Diagnostic and Prognostic Markers of Chronic Heart Failure in Patients with Occupational Chronic Obstructive Pulmonary Disease]

Aim      Heart failure (HF) and chronic obstructive pulmonary disease (COPD) are a common comorbidity. Professional chronic obstructive pulmonary disease (PCOPD) is a specific phenotype, which suggests peculiarities in the development of HF. Difficulties of HF diagnosis in such patients determine the relevance of searching for additional markers. The aim of the study was identifying HF markers in patients with PCOPD.Material and methods  This single-site, cohort, prospective, observational study included 345 patients. The main group consisted of PCOPD patients; the comparison group consisted of patients with COPD induced by tobacco smoking; and the control group included conventionally healthy individuals. The groups were matched by the index of coincidence; pairs were matched at 1:1 by the "nearest neighbor index"; covariates for matching included COPD duration, sex, and age. Each group included 115 patients. The major professional adverse factors were silica-containing dust and organic solvents. COPD was diagnosed according to GOLD criteria; HF was diagnosed in accordance with Russian clinical guidelines. The markers were determined by multifactorial logistic regression. Likelihood of events with allowance for the time to the event was analyzed by the Kaplan-Meier method.Results HF in PCOPD patients was characterized by biventricular damage, preserved left ventricular ejection fraction, and frequent hospitalizations for decompensation (17.5 % vs. 9.5 % for COPD in smokers). HF markers in patients with PCOPD included the length of work of more than 20 years, pulmonary artery systolic pressure (PASP) higher than 35 mm Hg according to data of Doppler echocardiography, diffusing capacity of lungs for carbon monoxide (DLCO) less than 50 %, increased serum concentrations of CC-chemokine ligand 18 (CCL18), S-100‑beta protein, and N-terminal pro-brain natriuretic peptide (NT-pro-BNP). Diagnostic sensitivity of the multifactorial model was 84 % and specificity was 81 %. Two models were proposed for purposes of screening, which included the following parameters: length of work, exposure to aromatic hydrocarbons, decreased distance in 6-min walk test by more than 60 m per year and length of work, exposure to inorganic dust, and decreased forced expiratory volume during the first second by more than 55 ml per year.Conclusion      The markers for development of HF in PCOPD patients are length of work &gt;20 years, PASP &gt;35 mm Hg, DLCO &lt;50 %, and increased serum concentrations of CCL18, S-100‑beta protein, and NT-pro-BNP.

Association of lung function with overall mortality is independent of inflammatory, cardiac, and functional biomarkers in older adults: the ActiFE-study

Reduced lung function is associated with overall and cardiovascular mortality. Chronic low grade systemic inflammation is linked to impaired lung function and cardiovascular outcomes. We assessed the association of lung function with overall 8-year mortality in 867 individuals of the Activity and Function in the Elderly study using confounder-adjusted Cox proportional hazards models (including gait speed and daily walking time as measures of physical function) without and with adjustment for inflammatory and cardiac markers. Forced expiratory volume in 1 s/forced vital capacity (FEV₁/FVC) but not FVC was related to mortality after adjustment for physical function and other confounders. Additional adjustment for inflammatory and cardiac markers did not change the hazard ratios (HR) markedly, e.g. for a FEV₁/FVC below 0.7 from 1.55 [95% confidence-interval (CI) 1.14-2.11] to 1.49 (95% CI 1.09-2.03). These independent associations were also observed in the apparently lung healthy subpopulation with even higher HRs up to 2.76 (95% CI 1.52-4.93). A measure of airflow limitation but not vital capacity was associated with overall mortality in this community-dwelling older population and in the subgroup classified as lung healthy. These associations were independent of adjustment for inflammatory and cardiac markers and support the role of airflow limitation as independent predictor of mortality in older adults.

Management of cardiovascular comorbidities in chronic obstructive pulmonary disease patients

Chronic obstructive pulmonary disease (COPD) is а highly prevalent, complex and heterogeneous clinical condition which is associated with significant concomitant diseases. COPD and cardiovascular diseases (CVDs) often coexist due to the high prevalence of each of these pathological conditions separately as well as the common risk factors (particularly smoking), mechanisms of interaction and influence of systemic inflammation. In addition, decreased pulmonary function in COPD is closely associated with an increased risk of congestive CVDs. One of the most important pathophysiological markers of COPD—lung hyperinflation—plays a significant role in the appearance of functional limitations of the pumping function of the heart, creating unfavorable conditions by exerting a compression effect on the heart muscle. The latter was confirmed by significant correlation between the COPD severity according to GOLD classification and the basic dimensions of the heart chambers. Several decades ago, the term “microcardia” was commonly used and indicated a radiological sign of emphysema. Some studies demonstrated a close relationship between the chance of occurrence of CVD and the severity of pulmonary dysfunction. Such an association has been demonstrated for the whole spectrum of CVD—including cerebrovascular disease, congestive heart failure (CHF) and rhythm disturbances—and was detected in the early stages of the disease. A large proportion of patients with mild and moderate COPD die due to CVD, which is much more likely than deaths in the same group due to respiratory insufficiency. COPD patients have a higher rate of hospitalization and death, the cause of which are coronary heart disease (CHD), stroke and CHF. Treatment of COPD today is mainly determined by national and international clinical guidelines, which should pay more attention to the problems of the treatment of COPD patients with comorbid conditions.

Cardiac biomarkers of prognostic importance in chronic obstructive pulmonary disease

Background

Ischemic heart disease is common in COPD and associated with worse prognosis. This study aimed to investigate the presence and prognostic impact of biomarkers of myocardial injury and ischemia among individuals with COPD and normal lung function, respectively.

Methods

In 2002–04, all individuals with airway obstruction (FEV₁/VC < 0.70, n = 993) were identified from population-based cohorts, together with age and sex-matched non-obstructive referents. At re-examination in 2005, spirometry, Minnesota-coded ECG and analyses of high-sensitivity cardiac troponin I (hs-cTnI) were performed in individuals with COPD (n = 601) and those with normal lung function (n = 755). Deaths were recorded until December 31st, 2010.

Results

Hs-cTnI concentrations were above the risk stratification threshold of ≥5 ng/L in 31.1 and 24.9% of those with COPD and normal lung function, respectively. Ischemic ECG abnormalities were present in 14.8 and 13.4%, while 7.7 and 6.6% had both elevated hs-cTnI concentrations and ischemic ECG abnormalities. The 5-year cumulative mortality was higher in those with COPD than those with normal lung function (13.6% vs. 7.7%, p < 0.001). Among individuals with COPD, elevated hs-cTnI both independently and in combination with ischemic ECG abnormalities were associated with an increased risk for death (adjusted hazard ratio [HR]; 95% confidence interval [CI] 2.72; 1.46–5.07 and 4.54; 2.25–9.13, respectively). Similar associations were observed also among individuals with COPD without reported ischemic heart disease.

Conclusions

In this study, elevated hs-cTnI concentrations in combination with myocardial ischemia on the electrocardiogram were associated with a more than four-fold increased risk for death in a population-based COPD-cohort, independent of disease severity.

Molecular characterization of troponin T in Scylla paramamosain and its role in Vibrio alginolyticus and white spot syndrome virus (WSSV) infection

This study investigated the function of Troponin T (TnT) in the mud crab, Scylla paramamosain. The 1952 bp cDNA sequence of TnT was cloned from S. paramamosain using rapid amplification of cDNA ends (RACE) PCR. The quantitative real-time PCR analysis showed that TnT was highly expressed in the muscle and heart of S. paramamosain. Challenging with white spot syndrome virus (WSSV) or Vibrio alginolyticus (VA), two common pathogens that infect mud crabs, enhanced the expression of TnT in S. paramamosain. Knockdown of TnT using TnT-dsRNA led to up-regulating the expression of immune-related genes, such as c-type-lectin, toll-like-receptor, crustin antimicrobial peptide and prophenoloxidase. The cumulative mortality of WSSV- and VA-infected crabs was significantly increased following TnT knockdown. After WSSV or VA infection, TnT knockdown caused a significant reduction in phenoloxidase (PO) activity, superoxide dismutase (SOD) activity and total hemocyte count (THC), indicating a regulatory role of TnT in the innate immune response of S. paramamosain to pathogens. Apoptosis of hemocytes was higher in crabs treated with TnT-dsRNA compared with control crabs treated with phosphate-buffered saline. Knockdown of TnT increased apoptosis of hemocytes following VA infection, but reduced hemocyte apoptosis following WSSV infection. In summary, TnT may enhance the immune response of S. paramamosain to WSSV infection by regulating apoptosis, THC, PO activity and SOD activity. And TnT may play a positive role in the immune response against VA infection by regulating apoptosis, THC, SOD activity and PO activity.

High-sensitivity troponin I and all-cause mortality in patients with stable COPD: an analysis of the COSYCONET study

Chronic obstructive pulmonary disease (COPD) is a leading cause of death with a considerable part of the population dying from cardiovascular diseases. High-sensitivity troponin I (hs-TnI) might help to better identify COPD patients at high risk of mortality. We aimed to study the predictive value of hs-TnI for all-cause mortality beyond established COPD assessments, and after consideration of relevant cardiovascular risk factors and prevalent cardiovascular diseases, in a broad population with stable COPD.Circulating hs-TnI concentrations together with a wide range of respiratory and cardiovascular markers were evaluated in 2085 patients with stable COPD across all severity stages enrolled in the multicentre COSYCONET cohort study. The primary outcome was all-cause mortality over 3 years of follow-up.Hs-TnI was detectable in 2020 (96.9%) patients. The median hs-TnI concentration was 3.8 ng·L^-1 (interquartile range 2.5-6.6 ng·L^-1), with levels above the 99th percentile reference limit of 27 ng·L^-1 observed in 1.8% of patients. In Cox regression analyses including adjustments for airflow limitation, dyspnoea grade, exercise capacity and history of severe exacerbations, as well as traditional cardiovascular risk factors, estimated glomerular filtration rate, ankle-brachial index, N-terminal pro-brain natriuretic peptides and prevalent cardiovascular diseases, hs-TnI was a significant predictor for all-cause mortality, both as a continuous variable (hazard ratio (HR) for log hs-TnI 1.28, 95% CI 1.01-1.62) and categorised according to the cut-off of 6 ng·L^-1 (HR 1.63, 95% CI 1.10-2.42).In patients with stable COPD, hs-TnI is a strong predictor of all-cause mortality beyond established COPD mortality predictors, and independent of a broad range of cardiovascular risk factors and prevalent cardiovascular diseases. Hs-TnI concentrations well below the upper reference limit provide further prognostic value for all patients with COPD when added to established risk assessments.

Preoperative hypoxemia in patients with type A acute aortic dissection: a retrospective study on incidence, related factors and clinical significance

Background

Pre-operative hypoxemia (HO) is a serious complication occurring in acute type A aortic dissection (AAD) patients.

Methods

This was a retrospective study of 505 patients who underwent Stanford type A acute aortic dissection surgery in Anzhen hospital, Beijing, China, between January 2015 to February 2018. Patients were divided into a HO(+) group (PaO₂/FiO₂ ≤300) and a HO(-) group (PaO₂/FiO₂ >300) according to preoperative arterial blood gas (ABG) analysis. The incidence of preoperative hypoxemia in patients undergoing surgery for AAD was calculated as the main outcome. Multivariable binary logistic regression analysis was used to identify independent prognostic factors of HO.

Results

Preoperative HO occurred in 46.5% (235/505) of patients. Mean patient age was 47.8±9.6 years, and 189 (80.4%) were male. Multivariable logistic regression analysis showed a correlation between preoperative serum level of fibrinogen [95% confidence interval (CI), 0.95-0.99], white blood cell count (WBC) (95% CI, 1.07-1.18), systolic blood pressure (95% CI, 0.98-1.00), history of smoking (95% CI, 1.05-2.11) and pleural effusion (95% CI, 1.14-2.71) with preoperative HO. The HO(+) group had a significantly higher mortality than the HO(-) group (8.1% vs. 5.9%, P=0.38). The median of intubation time (P<0.01), the length of stay in the intensive care unit (P<0.01) and the length of hospital stay (P<0.01) were significantly longer in patients with HO. The activity of daily living scale score was significantly lower in the HO(+) group (P<0.01).

Conclusions

AAD patients were easy to have pre-operative HO, which had a higher morbidity than those without HO. Altered fibrinogen, WBC, systolic blood pressure levels, positive smoking history, and pleural effusion were associated with the presence of HO. More monitoring and treatment should be given to these patients.

[Chronic obstructive pulmonary disease and cardiovascular comorbidity]

In recent years, a greater understanding of the heterogeneity and complexity of chronic obstructive pulmonary disease (COPD) has come from the point of view of an integrated clinical assessment of severity, pathophysiology, and the relationship with other pathologies. A typical COPD patient suffers on average 4 or more concomitant diseases and every day about a third of patients take from 5 to 10 different drugs. The mechanisms of the interaction of COPD and cardiovascular disease (CVD) include the effects of systemic inflammation, hyperinflation (hyperinflation) of the lungs and bronchial obstruction. The risk of developing CVD in patients with COPD is on average 2-3 times higher than in people of a comparable age in the general population, even taking into account the risk of smoking. The prevalence of coronary heart disease, heart failure, and rhythm disturbances among COPD patients is significantly higher than in the general population. The article discusses in detail the safety of prescribing various groups of drugs for the treatment of CVD in patients with COPD. Achieving success in understanding and managing patients with COPD and CVD is possible using an integrated multidisciplinary approach.

Cardiac Troponin I and Cardiovascular Risk in Patients With Chronic Obstructive Pulmonary Disease

Background

Patients with chronic obstructive pulmonary disease (COPD) have increased risk of cardiovascular events.

Objectives

This study evaluated the association between high-sensitivity cardiac troponin I concentration and cardiovascular events in patients with COPD and heightened cardiovascular risk.

Methods

In a double-blind randomized controlled trial, 16,485 patients with COPD and cardiovascular disease or risk factors were randomized to once daily inhaled placebo, fluticasone furoate (100 μg), vilanterol (25 μg), or their combination. Plasma high-sensitivity cardiac troponin I concentrations were measured in a subgroup of 1,599 patients. Outcomes were on-treatment cardiovascular events and COPD exacerbations over a median of 18 months, and cardiovascular death over a median of 27 months.

Results

Baseline plasma cardiac troponin I concentrations were above the limit of detection (1.2 ng/l) in 1,542 (96%) patients. Concentrations were unaffected by inhaled therapies at 3 months (p > 0.05). Compared with the lowest quintile (cardiac troponin <2.3 ng/l), patients in the highest quintile (≥7.7 ng/l) were at greater risk of cardiovascular events (hazard ratio [HR] 3.7; 95% confidence interval [CI]: 1.3 to 10.1; p = 0.012) and cardiovascular death (HR: 20.1; 95% CI: 2.4 to 165.2; p = 0.005) after adjustment for risk factors. By contrast, there were no differences in exacerbations between quintiles (HR: 1.1; 95% CI: 0.8 to 1.5; p = 0.548).

Conclusions

In patients with COPD and heightened cardiovascular risk, plasma cardiac troponin I concentrations are a specific and major indicator of future cardiovascular events and cardiovascular death. Inhaled therapies did not affect cardiac troponin I concentrations consistent with their neutral effect on mortality and cardiovascular outcomes. (Study to Evaluate the Effect of Fluticasone Furoate/Vilanterol on Survival in Subjects With Chronic Obstructive Pulmonary Disease [SUMMIT]; NCT01313676)

[A review on the clinical application of high-sensitivity cardiac troponin T in neonatal diseases]

In recent years, high-sensitivity cardiac troponin T (hs-cTnT) has been recognized as an effective marker for myocardial injury in adults and can be used to diagnose acute myocardial injury and predict major adverse cardiovascular events. It is the gold standard for the diagnosis of acute myocardial infarction in adults. Neonates are a special group, and due to the changes of various physiological processes during the perinatal period, many laboratory markers used in adults may have a low clinical value in neonates. So far, for example, there is still no suitable cardiac serum biomarker that can reflect the true condition of neonatal myocardial injury. In recent years, new breakthroughs have been made in the application of hs-cTnT in the field of neonates. In order to fully understand the role of hs-cTnT in neonatal diseases, this article reviews the research advances in the biological and physiological features of hs-cTnT and its application in neonates.

Association of Cardiovascular Disease With Respiratory Disease

BACKGROUND

The relationship between respiratory diseases and individual cardiovascular diseases, and the impact of cardiovascular diseases on mortality in patients with respiratory disease, are unclear.

OBJECTIVES

This study sought to determine the relationship between chronic obstructive pulmonary disease (COPD), asthma and interstitial lung disease (ILD), and individual cardiovascular diseases, and evaluate the impact of individual cardiovascular diseases on all-cause mortality in respiratory conditions.

METHODS

The authors conducted a cohort study of all patients admitted to 7 National Health Service hospitals across the North West of England, between January 1, 2000, and March 31, 2013, with relevant respiratory diagnoses, with age-matched and sex-matched control groups.

RESULTS

A total of 31,646 COPD, 60,424 asthma, and 1,662 ILD patients were included. Control groups comprised 158,230, 302,120, and 8,310 patients, respectively (total follow-up 2,968,182 patient-years). COPD was independently associated with ischemic heart disease (IHD), heart failure (HF), atrial fibrillation, and peripheral vascular disease, all of which were associated with all-cause mortality (e.g., odds ratio for the association of COPD with HF: 2.18 [95% confidence interval (CI): 2.08 to 2.26]; hazard ratio for the contribution of HF to mortality in COPD: 1.65 [95% CI: 1.61 to 1.68]). Asthma was independently associated with IHD, and multiple cardiovascular diseases contributed to mortality (e.g., HF hazard ratio: 1.81 [95% CI: 1.75 to 1.87]). ILD was independently associated with IHD and HF, both of which were associated with mortality. Patients with lung disease were less likely to receive coronary revascularization.

CONCLUSIONS

Lung disease is independently associated with cardiovascular diseases, particularly IHD and HF, which contribute significantly to all-cause mortality. However, patients with lung disease are less likely to receive coronary revascularization.

Comparison of prognostic values of high-sensitivity cardiac troponin T and N-terminal prohormone brain natriuretic peptide to assess mortality in elderly inpatients

BACKGROUND

Studies have shown that increases in low-level high-sensitivity cardiac troponin T (hs-cTnT) and N-terminal prohormone brain natriuretic peptide (NT-proBNP) in the elderly population lead to high risk of adverse clinical outcomes, such as mortality. In this study, associations between the two biomarkers and long-term mortality in elderly patients hospitalized for medical conditions other than acute cardiovascular events were investigated. A comparison of the predictive value of hs-cTnT and NT-proBNP for all-cause mortality was conducted.

METHODS

A cohort of 715 elderly inpatients free of acute cardiovascular events was initially recruited. Based on tertiles of baseline hs-cTnT and NT-proBNP levels, the elderly were arranged into low, middle, and high groups. The mortality of each group was observed and the predictive values of hs-cTnT and NT-proBNP compared. Additionally, all-cause mortality was analyzed for hs-cTnT and NT-proBNP combined.

RESULTS

There were 135 (18.9%) all-cause mortality cases identified during follow-up (median 47 months). The upper tertile of hs-cTnT was significantly associated with an increased risk of mortality (HR 3.29, 95% CI 1.85-5.85), even after adjustment for potential confounders. However, there were no significant differences observed in mortality rates among the three NT-proBNP groups after adjustment for potential confounders (HR 1.77, 95% CI 0.83-3.17). Compared to NT-proBNP, hs-cTnT was a better predictor of mortality, as area under curves for hs-cTnT and NT-proBNP at 60 months were 0.712 (95% CI 0.616-0.809) and 0.585 (95% CI 0.483-0.6871), respectively. Also, the combination of the two cardiac biomarkers did not render a better predictive value for mortality than hs-cTnT alone.

CONCLUSION

Unlike hs-cTnT, baseline NT-proBNP levels failed to show an independent association with all-cause mortality in hospitalized elderly without acute cardiovascular events. hs-cTnT provided significant prognostic value for mortality in the study cohort.

Significance of prolonged QTc in acute exacerbations of COPD requiring hospitalization

Background

A prolonged QT interval is associated with increased risk of Torsade de Pointes and cardiovascular death. The prevalence and clinical relevance of QT prolongation in acute exacerbations of COPD (AECOPD), with high risk for cardiac morbidity and mortality, is currently unclear.

Methods

A dual cross-sectional study strategy was therefore designed. A retrospective study evaluated 140 patients with an AECOPD requiring hospitalization, half of which had prolonged QTc on the admission ECG. Univariate and multivariate analyses were conducted to determine associated factors; Kaplan–Meier and Cox regression analyses to assess prognostic significance. A prospective study evaluated 180 pulmonary patients with acute respiratory problems requiring hospitalization, to determine whether a prolonged QTc at admission represents an AECOPD-specific finding and to investigate the change in QTc-duration during hospitalization.

Results

Retrospectively, hypokalemia, cardiac troponin T and conductance abnormalities on ECG were significantly and independently associated with QTc prolongation. A prolonged QTc was associated with increased all-cause mortality (HR 2.698 (95% CI 1.032–7.055), p=0.043), however, this association was no longer significant when corrected for age, FEV₁ and cardiac troponin T. Prospectively, QTc prolongation was observed in 1/3 of the patients diagnosed with either an AECOPD, lung cancer, pulmonary infection or miscellaneous acute pulmonary disease, and was not more prevalent in AECOPD. The QTc-duration decreased significantly during hospitalization in patients with and without COPD.

Conclusion

A prolonged QTc is a marker of underlying cardiovascular disease during an AECOPD. It is not COPD-specific, but a common finding during the acute phase of a pulmonary disease requiring urgent hospital admission.

Relationship between high-sensitivity cardiac troponin T and the prognosis of elderly inpatients with non-acute coronary syndromes

Objective

Low-level high-sensitivity cardiac troponin T (hs-cTnT) increases in elderly population. In this study, the relationship between hs-cTnT level and all-cause death of elderly inpatients with non-acute coronary syndrome (non-ACS) after discharge from the hospital was investigated.

Materials and methods

Non-ACS patients aged >65 years admitted in the General Practice Wards and Department of Geriatrics of Fuxing Hospital Affiliated to Capital Medical University were enrolled in the study. The patients were grouped according to the tertiles of hs-cTnT levels. Biochemical markers, hs-cTnT, and amino-terminal pro-brain natriuretic peptide were measured. The median follow-up period was 47 months, and all-cause deaths of the patients were observed.

Results

A total of 722 patients, including 473 males and 249 females, aged 65-98 (82.43±5.98) years were enrolled in the study. The level of hs-cTnT was found to be higher in males, and increased with age and comorbidities (P<0.01). Compared with low-level group, NT-proBNP level of patients in high-level group was higher, while hemoglobin (Hb), estimated glomerular filtration rate (eGFR), and left ventricular ejection fraction (LVEF) levels were lower (P<0.001). The mortality rate increased significantly with increased hs-cTnT levels (P<0.001). The total number of deaths was 136 (18.8%), and of these, 108 (79.4%) were noncardiac deaths. Risk of all-cause deaths in the highest hs-cTnT level group was 7.3 times higher than that of the lowest hs-cTnT level group (95% CI: 4.29-12.51, P<0.001). After adjusting for gender, age, comorbidities, NT-proBNP, Hb, eGFR, and LVEF, hs-cTnT level still affected the patient's survival time (HR: 3.01, 95% CI: 1.67-5.43, P<0.001).

Conclusion

These findings suggest that low-level hs-cTnT was increased in elderly inpatients without ACS. They further highlight that baseline hs-cTnT level was associated with increased risk of all-cause deaths among patients after their discharge, and most deaths were from non-cardiovascular diseases.

Chronic Obstructive Pulmonary Disease and Cardiac Diseases. An Urgent Need for Integrated Care

Chronic obstructive pulmonary disease (COPD) is a global health issue with high social and economic costs. Concomitant chronic cardiac disorders are frequent in patients with COPD, likely owing to shared risk factors (e.g., aging, cigarette smoke, inactivity, persistent low-grade pulmonary and systemic inflammation) and add to the overall morbidity and mortality of patients with COPD. The prevalence and incidence of cardiac comorbidities are higher in patients with COPD than in matched control subjects, although estimates of prevalence vary widely. Furthermore, cardiac diseases contribute to disease severity in patients with COPD, being a common cause of hospitalization and a frequent cause of death. The differential diagnosis may be challenging, especially in older and smoking subjects complaining of unspecific symptoms, such as dyspnea and fatigue. The therapeutic management of patients with cardiac and pulmonary comorbidities may be similarly challenging: bronchodilators may have cardiac side effects, and, vice versa, some cardiac medications should be used with caution in patients with lung disease. The aim of this review is to summarize the evidence of the relationship between COPD and the three most frequent and important cardiac comorbidities in patients with COPD: ischemic heart disease, heart failure, and atrial fibrillation. We have chosen a practical approach, first summarizing relevant epidemiological and clinical data, then discussing the diagnostic and screening procedures, and finally evaluating the impact of lung-heart comorbidities on the therapeutic management of patients with COPD and heart diseases.

The prognostic value of measurement of high-sensitive cardiac troponin T for mortality in a cohort of stable chronic obstructive pulmonary disease patients

Background

Cardiovascular disease (CVD) is a common comorbidity in chronic obstructive pulmonary disease (COPD). Cardiac troponin (cTn) elevation, indicating myocardial injury, is frequent during acute COPD exacerbations and associated with increased mortality. The prognostic value of circulating cTnT among COPD patients in the stable state of the disease is still unknown.

The purpose of the present study was to assess the association between circulating cTnT measured by a high sensitive assay (hs-cTnT) and all-cause mortality among patients with stable COPD without overt CVD.

Methods

In a prospective cohort study we included 275 patients from the Akershus University Hospital’s outpatient clinic and from Glittre, a pulmonary rehabilitation clinic. COPD-severity and cardiovascular risk factors were assessed, and time to all-cause death was recorded during a mean follow-up time of 2.8 years.

Results

One hundred-eighty patients (65%) had hs-cTnT concentrations ≥ the level of detection (5.0 ng/L) and 66 patients (24%) had hs-cTnT above the normal range (≥14.0 ng/L). In total, 47 patients (17%) died. hs-cTnT concentrations in the ranges <5.0, 5.0–13.9 and ≥14 ng/L were associated with crude mortality rates of 2.8, 4.4 and 11.0 per 100 patient-years, respectively. In adjusted analyses the hazard ratios (95% confidence intervals) for death were 1.7 (0.8–3.9) and 2.9 (1.2–7.2) among patients with hs-cTnT concentrations 5.0–13.9 and ≥14 ng/L, respectively, compared to patients with hs-cTnT <5.0 ng/L.

Conclusions

hs-cTnT elevation is frequently present in patients with stable COPD without overt CVD, and associated with increased mortality, independently of COPD-severity and other cardiovascular risk factors.

Electronic supplementary material

The online version of this article (doi:10.1186/s12890-016-0319-9) contains supplementary material, which is available to authorized users.

Influence of cigarette smoking on cardiac biomarkers: the Atherosclerosis Risk in Communities (ARIC) Study

AIMS

Cigarette smoking has been associated with incident heart failure independent of coronary artery disease (CAD), but the mechanisms linking smoking to cardiac damage are not well understood. This study sought to evaluate the relationship between smoking and N-terminal pro-brain natriuretic peptide (NT-proBNP) and high-sensitivity Troponin T (hs-TnT), which are, respectively, biomarkers of myocardial wall stress and injury, in a large community-based cohort.

METHODS AND RESULTS

We examined the association between smoking history and NT-proBNP and hs-TnT in 9649 participants free of overt CAD or heart failure from the Atherosclerosis Risk in Communities (ARIC) Study who attended Visit 4 (1996-1998), as well as the association with change in these biomarkers from Visit 4 to Visit 5 (2011-2013) in 3151 participants. At Visit 4, higher cumulative cigarette exposure, assessed by total pack-years, was associated with elevated levels of NT-proBNP (P < 0.001) and hs-TnT (P = 0.01) among ever smokers in multivariable analyses adjusted for potential confounders. After 15 years of follow-up, participants who were active smokers at Visit 4 had greater incidence of elevated NT-proBNP {adjusted proportion = 48% [95% confidence interval (CI) 41, 54] vs. 35 (95% CI 32, 39); P = 0.006} and hs-TnT [adjusted proportion = 32% (95% CI 26, 38) vs. 23 (95% CI 20, 26); P = 0.021] compared with never smokers, adjusting for baseline and follow-up covariates.

CONCLUSIONS

In a large community-based cohort free of overt CAD and heart failure, cigarette smoking was associated with biomarkers of myocardial wall stress and injury at baseline as well as with a continued measurable increase in these biomarkers after 15 years of follow-up.

Lung function and airway obstruction: associations with circulating markers of cardiac function and incident heart failure in older men-the British Regional Heart Study

Aims

The association between lung function and cardiac markers and heart failure (HF) has been little studied in the general older population. We have examined the association between lung function and airway obstruction with cardiac markers N-terminal pro-brain natriuretic peptide (NT-proBNP) and cardiac troponin T (cTnT) and risk of incident HF in older men.

Methods and results

Prospective study of 3242 men aged 60–79 years without prevalent HF or myocardial infarction followed up for an average period of 13 years, in whom 211 incident HF cases occurred. Incident HF was examined in relation to % predicted FEV1 and FVC. The Global Initiative on Obstructive Lung Diseases spirometry criteria were used to define airway obstruction. Reduced FEV1, but not FVC in the normal range, was significantly associated with increased risk of HF after adjustment for established HF risk factors including inflammation. The adjusted HRs comparing men in the 6–24th percentile with the highest quartile were 1.91 (1.24 to 2.94) and 1.30 (0.86 to 1.96) for FEV1 and FVC, respectively. FEV1 and FVC were inversely associated with NT-proBNP and cTnT, although the association between FEV1 and incident HF remained after adjustment for NT-proBNP and cTnT. Compared with normal subjects (FEV1/FVC ≥0.70 and FVC≥80%), moderate or severe (FEV1/FVC <0.70 and FEV1 <80%) airflow obstruction was independently associated with HF ((adjusted relative risk 1.59 (1.08 to 2.33)). Airflow restriction (FEV1/FVC ≥0.70 and FVC <80%) was not independently associated with HF.

Conclusions

Reduced FEV1 reflecting airflow obstruction is associated with cardiac dysfunction and increased risk of incident HF in older men.

The influence of heart failure co-morbidity on high-sensitivity troponin T levels in COPD exacerbation in a prospective cohort study: data from the Akershus cardiac examination (ACE) 2 study

CONTEXT

Troponin (hs-TnT) levels predict mortality after acute exacerbation of COPD (AECOPD). Whether this is independent of heart failure (HF) is not established.

MATERIAL AND METHODS

Prospectively included AECOPD patients adjudicated for acute HF categorized into three groups: (A) AECOPD, but acute HF the primary cause for hospitalization; (B) AECOPD the primary cause, but co-existing myocardial dysfunction and (C) AECOPD without myocardial dysfunction.

RESULTS

About 103 AECOPD patients; 18% A, 27% B and 54% C. Hs-TnT level differed between the groups: (ng/l, median) A: 41, B: 25 and C: 15, p = 0.03 for A versus B and p = 0.005 for B versus C. During a median 826 days, 47% died. In Cox analysis, hs-TnT levels remained associated with mortality (hazard ratio per 10 ng/l 1.3, p < 0.0001).

CONCLUSION

hs-TnT levels are influenced by myocardial dysfunction/HF in AECOPD, but provide independent prognostic information. The prognostic merit of hs-TnT cannot be attributed to HF alone.

Inflammation in chronic obstructive pulmonary disease and its role in cardiovascular disease and lung cancer

Chronic obstructive pulmonary disease (COPD) is characterized by lung inflammation that persists after smoking cessation. This inflammation is heterogeneous but the key inflammatory cell types involved are macrophages, neutrophils and T cells. Other lung cells may also produce inflammatory mediators, particularly the epithelial cells. The main inflammatory mediators include tumor necrosis factor alpha, interleukin-1, interleukin-6, reactive oxygen species and proteases. COPD is also associated with systemic inflammation and there is a markedly increased risk of cardiovascular disease (particularly coronary artery disease) and lung cancer in patients with COPD. There is strong associative evidence that the inflammatory cells/mediators in COPD are also relevant to the development of cardiovascular disease and lung cancer. There are a large number of potential inhibitors of inflammation in COPD that may well have beneficial effects for these comorbidities. This is a not well-understood area and there is a requirement for more definitive clinical and mechanistic studies to define the relationship between the inflammatory process of COPD and cardiovascular disease and lung cancer.

Copeptin testing in acute myocardial infarction: ready for routine use?

Suspected acute myocardial infarction is one of the leading causes of admission to emergency departments. In the last decade, biomarkers revolutionized the management of patients with suspected acute coronary syndromes. Besides their pivotal assistance in timely diagnosis, biomarkers provide additional information for risk stratification. Cardiac troponins I and T are the most sensitive and specific markers of acute myocardial injury. Nonetheless, in order to overcome the remaining limitations of these markers, novel candidate biomarkers sensitive to early stage of disease are being extensively investigated. Among them, copeptin, a stable peptide derived from the precursor of vasopressin, emerged as a promising biomarker for the evaluation of suspected acute myocardial infarction. In this review, we summarize the currently available evidence for the usefulness of copeptin in the diagnosis and risk stratification of patients with suspected acute myocardial infarction in comparison with routine biomarkers.

High sensitivity troponin: Does the 50% delta change alter clinical outcomes in chest pain presentations to the emergency room?

BACKGROUND

The National Heart Foundation (NHF) and Cardiac Society of Australia and New Zealand (CSANZ) Acute Coronary Syndrome (ACS) guidelines recommend the use of a high sensitivity troponin assay (hsTrop) in the assessment of patients presenting with ACS. A troponin delta of 50% compared with the previously recommended 20% is advocated by the guidelines to aid in the clinical diagnosis of ACS. We sought to determine the clinical impact of the updated recommendation to use 50% troponin delta for patients presenting with chest pain to the emergency department.

METHOD

We retrospectively collected data for all patients >18 years presenting with chest or abdominal pain with a hsTrop test performed between January-June 2012. Patients with a STEMI, lacked serial hsTrop, were on dialysis or had trauma-related pain were excluded.

RESULTS

Of the 1054 eligible patients, 422 (40%) with serial hsTrop had at least one abnormal troponin (>14 ng/ml). 73 (6.9%) fell within 20-50%. Twenty-seven had clinical or ECG evidence suggestive of ACS and were referred for further cardiac investigations. Of the remainder, five patients were medically managed for ACS, 38 patients with non-cardiac chest pain had no further tests. At 1 year follow-up, of the patients that did not undergo further investigations, 6 patients represented with ACS; there was no cardiac mortality.

CONCLUSION

Our data showed a number of patients that would be potentially missed with the implementation of a 50% troponin. However, this loss of sensitivity was mitigated by the use of clinical acumen.

Closing the mortality gap after a myocardial infarction in people with and without chronic obstructive pulmonary disease

Objective

Patients with chronic obstructive pulmonary disease (COPD) have increased mortality following myocardial infarction (MI) compared with patients without COPD. We investigated the extent to which differences in recognition and management after MI could explain the mortality difference.

Methods

300 161 patients with a first MI between 2003 and 2013 were identified in the UK Myocardial Ischaemia National Audit Project database. Logistic regression was used to compare mortality in hospital and at 180 days postdischarge between patients with and without COPD. Variables relating to inhospital factors (delay in diagnosis, use of reperfusion and time to reperfusion/use of angiography) and use of secondary prevention were sequentially added to models.

Results

Mortality was higher for patients with COPD both inhospital (4.6% vs 3.2%) and at 180 days (12.8% vs 7.7%). After adjusting for inhospital factors, the effect of COPD on inhospital mortality after MI was reduced for both ST-elevation myocardial infarctions (STEMIs) and non-STEMIs (STEMIs OR 1.24 (95% CI 1.10 to 1.41) to 1.13 (95% CI 0.99 to 1.29); non-STEMIs OR 1.34 (95% CI 1.24 to 1.45) to 1.16 (95% CI 1.07 to 1.26)). Adjusting for inhospital factors reduced the effect of COPD on mortality after non-STEMI at 180 days (OR 1.56 (95% CI 1.47 to 1.65) to 1.37 (95% CI 1.31 to 1.44)). Adjusting for use of secondary prevention also reduced the effect of COPD on mortality at 180 days for STEMIs and non-STEMIs (STEMIs OR 1.45 (95% CI 1.31 to 1.61) to 1.25 (95% CI 1.11 to 1.41); non-STEMIs OR 1.37 (95% CI 1.31 to 1.44) to 1.26 (95% CI 1.17 to 1.35).

Conclusions

Delayed diagnosis, timing and use of reperfusion of a STEMI, use of angiography after a non-STEMI and use of secondary prevention medicines are all potential explanations for the mortality gap after MI in people with COPD.

Relationship between serum cardiac troponin T level and cardiopulmonary function in stable chronic obstructive pulmonary disease

Background

High-sensitivity cardiac troponin T (hs-cTnT) in serum is a useful marker of acute myocardial injury, yet information is limited in patients with chronic obstructive pulmonary disease. We aimed to explore the association between hs-cTnT levels and cardiac and pulmonary dysfunction in patients with stable chronic obstructive pulmonary disease and at-risk individuals.

Methods

We examined community-dwelling adults with/without chronic obstructive pulmonary disease, with a life-long smoking history, current symptoms of dyspnea during exertion, prolonged coughing, and/or sputum. Serum hs-cTnT concentrations were measured, and subjects underwent pulmonary function tests, high-resolution computed tomography of the chest, an echocardiogram, and a 6-minute walking test.

Results

Eighty-six stable patients were identified (mean age 65.5 years; predicted forced expiratory volume in 1 second [FEV₁% predicted] 75.0%). Their overall mean hs-cTnT level was 0.008 ng/mL. Logarithmically transformed hs-cTnT levels significantly and positively correlated with age, smoking index, serum high-sensitivity C-reactive protein levels, right ventricle systolic pressure, low attenuation area percentage, and brain natriuretic peptide levels (range r=0.231–0.534, P=0.000 to P=0.042). Further, logarithmically transformed hs-cTnT values significantly and negatively correlated with forced vital capacity, FEV₁% predicted, diffusion capacity, arterial oxygen tension, and 6-minute walking distance (range r= −0.482 to −0.377, P=0.000 to P=0.002). Multivariate analyses showed that hs-cTnT values varied independently according to the following three parameters: high-sensitivity C-reactive protein levels (B=0.157, β=0.450, t=3.571, P=0.001), age (B=0.008, β=0.352, t=2.789, P=0.009), and right ventricular systolic pressure (B=0.008, β=0.280, t=2.202, P=0.035).

Conclusion

Even in patients with stable chronic obstructive pulmonary disease, the serum troponin T concentration was controlled by at least three major factors, ie, systemic inflammation, advancing age, and right cardiac overload.

Cardiovascular function and prognosis of patients with heart failure coexistent with chronic obstructive pulmonary disease

BACKGROUND

Chronic obstructive pulmonary disease (COPD) often coexists with heart failure (HF), and is considered to be associated with adverse outcomes in HF patients. However, the features of cardiovascular function and the detailed all-cause mortality of HF with COPD remain unclear.

METHODS AND RESULTS

Consecutive 378 patients admitted for HF who underwent spirometry were divided into three groups: HF without COPD (non-COPD group, n=272), HF with mild COPD (GOLD I group, n=82), and HF with moderate COPD (GOLD II group, n=24). The GOLD II group, as compared to non-COPD group, had (1) higher troponin T (p=0.009); (2) greater cardio-ankle vascular index (p=0.032); and (3) similar cardiac systolic and diastolic function of the right and left ventricle. In addition, rates of cardiac (p=0.049), non-cardiac (p=0.001), and all-cause mortality (p=0.002) were higher in GOLD II group than in non-COPD and GOLD I groups. Importantly, in the Cox proportional hazard analyses, the GOLD stage II was an independent predictor of cardiac (p=0.038), non-cardiac (p=0.036), and all-cause mortality (p=0.015) in HF patients.

CONCLUSIONS

HF patients with coexistent moderate COPD (GOLD stage II) have greater myocardial damage, greater arterial stiffness, and higher cardiac and non-cardiac mortality.

Acute exacerbation of chronic obstructive pulmonary disease: cardiovascular links

Chronic obstructive pulmonary disease (COPD) is a chronic, progressive lung disease resulting from exposure to cigarette smoke, noxious gases, particulate matter, and air pollutants. COPD is exacerbated by acute inflammatory insults such as lung infections (viral and bacterial) and air pollutants which further accelerate the steady decline in lung function. The chronic inflammatory process in the lung contributes to the extrapulmonary manifestations of COPD which are predominantly cardiovascular in nature. Here we review the significant burden of cardiovascular disease in COPD and discuss the clinical and pathological links between acute exacerbations of COPD and cardiovascular disease.

High sensitivity troponin T in acute medicine; more questions than answers?

BACKGROUND

Troponin testing in acute medicine is routine. The introduction of a high sensitivity assay (hs Tn T) has created uncertainty regarding the clinical significance of 'abnormal' troponin T levels. The previous assay could not detect troponin levels <30 ng/l.

AIMS AND METHODS

To characterize those with a hs Tn T ≥14 ng/l. Prospective cohort study of consecutive admissions to an acute medical unit.

RESULTS

Troponin was measured in 564 consecutive patients (∼50% of all admissions) over 1 month; was ≥14 ng/l in 224 (40%) of which 220 patients had demographic data for this analysis. Median (inter-quartile range) peak troponin was 47.5 ng/l (24-130) and 36% had a Tn T between 14 and 30 ng/l. Mean [standard deviation (SD)] age was 72 (12) years and 57% were male. Only 44 patients (20%) had an acute myocardial infarction, reflecting the increased sensitivity but reduced specificity of the assay. Prognosis was poor with 31% mortality at 1 year. Over a mean (SD) follow-up of 648 (61) days, there were 87 deaths (40%). Those with a primary non-cardiac diagnosis (n = 126) had poorer survival than those with a primary cardiac diagnosis (n = 94). Troponin elevation related to sepsis conferred a very poor prognosis with 24 deaths (70%) over the follow-up period.

CONCLUSION

Elevated hs Tn T is very common in acute medicine, but myocardial infarction as an explanation is uncommon. Overall, the prognosis is poor with a tendency to worse outcomes in those with a primary 'non-cardiac' diagnosis.

The clinical value of serial measurement of high-sensitivity cardiac troponin T in acute exacerbations ofchronic obstructive pulmonary disease

Objective

To assess the prevalence and long-term prognostic value of a dynamic (rise/fall) pattern of cardiac troponin T (hs-cTnT) elevation during acute exacerbation of chronic obstructive pulmonary disease (AECOPD) compared with a stable hs-cTnT elevation.

Methods

Prospective cohort study of unselected patients admitted with AECOPD to the emergency room of a university hospital. Serial hs-cTnT measurements were made during admission. Survival after a median of 1.8 years was recorded.

Results

83 patients with a mean age of 72 years and a mean forced expiratory volume in 1 s (FEV₁) of 0.9 L. The mortality rate was 62%. The median hs-cTnT at admission was 27 ng/L (IQR 13.4–51)). 65 patients (78%) had at least one hs-cTnT measurement ≥14 ng/L, and among these the median change in hs-cTnT was 50.7% (IQR 25.2–89.4). Of the patients with serial hs-cTnT measurements, 53 (82%) had a dynamic pattern (ie, ΔTnT ≥20%). In multivariate analysis, stable hs-cTnT elevation was associated with increasing age (OR per 5 years with 95% CI 1.9 (1.01 to 3.7), p=0.045) and low Hb (OR 7.3 (1.1 to 49), p=0.039). Stable hs-cTnT elevation was associated with increased mortality with an HR of 2.4 (95%CI 1.1 to 5.3, p=0.027) in the multivariate Cox regression analysis.

Conclusions

Among the patients with at least one hs-cTnT above the 99th centile, 82% had a rise/fall pattern, as requested to make a diagnosis of myocardial infarction. Compared to a dynamic rise/fall pattern of hs-cTnT, a stable and moderately elevated hs-cTnT during AECOPD is associated with poor long-term prognosis.

High-sensitivity cardiac troponins: no more 'negatives'

According to recently published expert guidelines, cardiac troponins are the only accepted biomarkers to define acute myocardial infarction. New high sensitivity cardiac troponin assays provide exciting opportunities for early rule-out and rule-in strategies and for identifying high-risk patients early in their presentation to guide early treatment and intervention. This review briefly discusses the history of troponin testing, before going on to cover clinical uses of the new highly sensitive assays in the early assessment of acute myocardial infection. Common clinical pitfalls with the use of these assays are discussed, as is the use of highly sensitive troponins more widely as prognostic markers. Likely future developments in this area are discussed.