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Revaiah PC, Tsai TY, Wang B, Renkens M, Kageyama S, Wlodarczak A, Lemoine J, Mollmann H, Sabate M, Sharif F, Zaman A, Wykrzykowska J, Benit E, Qiang HX, Miyashita K, Tobe A, Muramatsu T, Tanabe K, Ozaki Y, Garg S, McEvoy JW, Neumann FJ, Baumbach A, Smits PC, Stone G, Onuma Y, Serruys PW. Frequency of periprocedural myocardial injury and infarction stratified by cardiac troponin I and cardiac troponin T. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2024:S1553-8389(24)00491-3. [PMID: 38789340 DOI: 10.1016/j.carrev.2024.05.022] [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: 01/30/2024] [Revised: 04/13/2024] [Accepted: 05/17/2024] [Indexed: 05/26/2024]
Abstract
BACKGROUND There are different definitions of periprocedural myocardial infarction (PPMI) both in terms of thresholds for cardiac biomarkers and the ancillary criteria for myocardial ischemia. Cardiac Troponin I (cTnI) and cardiac Troponin T (cTnT) are used interchangeably to diagnose PPMI. OBJECTIVES This study evaluated the frequency of periprocedural myocardial injury and infarction as defined by the Society of Cardiovascular Angiography & Interventions (SCAI), the Academic Research Consortium-2 (ARC-2), and the 4th Universal definition of MI (4UDMI) stratified using cTnT versus cTnI, among patients with chronic coronary syndrome (CCS) and unstable angina. RESULTS Among 830 patients, PPMI rates according to the SCAI, ARC2 and 4UDMI criteria were 4.34 %, 2.05 %, and 4.94 % respectively, with higher rates seen for all definitions when using cTnI versus cTnT (SCAI: 9.84 % vs. 1.91 %, p < 0.001; ARC 2: 3.15 % vs. 1.56 %, p = 0.136; and 4UDMI 5.91 % vs. 4.51 %, p = 0.391). Minor and major periprocedural myocardial injury was respectively observed in 58.31 % and 27.10 % of patients, with rates of both significantly higher when using cTnI versus cTnT (Minor: 69.29 % vs. 53.47 %, p < 0.001, Major: 49.21 % vs. 17.36 %, p < 0.001). CONCLUSIONS Among patients with CCS and unstable angina, PPMIs defined by SCAI occurred more frequently when using cTnI as opposed to cTnT, whereas the type of troponin had no impact on the incidence of PPMIs according to the ARC-2 and 4UDMI.
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Affiliation(s)
- Pruthvi C Revaiah
- CORRIB Research Centre for Advanced Imaging and Core Laboratory, University of Galway, Ireland
| | - Tsung-Ying Tsai
- CORRIB Research Centre for Advanced Imaging and Core Laboratory, University of Galway, Ireland
| | - Bo Wang
- CORRIB Research Centre for Advanced Imaging and Core Laboratory, University of Galway, Ireland
| | - Mick Renkens
- CORRIB Research Centre for Advanced Imaging and Core Laboratory, University of Galway, Ireland; Amsterdam University Medical Centers, Heart Center, University of Amsterdam, the Netherlands
| | - Shigetaka Kageyama
- CORRIB Research Centre for Advanced Imaging and Core Laboratory, University of Galway, Ireland
| | - Adrian Wlodarczak
- Department of Cardiology, Miedziowe Centrum Zdrowia SA, Lubin, Poland
| | - Julien Lemoine
- Department of Cardiology, Clinique Louis Pasteur, Nancy, France
| | - Helge Mollmann
- Department of Cardiology, St-Johannes-Hospital Dortmund, Dortmund, Germany
| | - Manel Sabate
- Department of Cardiology, Cardiovascular Institute (ICCV), Hospital Clinic, University of Barcelona, Barcelona, Spain
| | - Faisal Sharif
- Department of Cardiology, Saolta Group, Galway University Hospital Health Service Executive and University of Galway, Galway, Ireland
| | - Azfar Zaman
- Freeman Hospital, Newcastle upon Tyne Hospitals NHS Trust and Newcastle University, Newcastle-upon-Tyne, UK
| | | | - Edouard Benit
- Department of Cardiology, Jessa Hospital, Hasselt, Belgium
| | - He Xing Qiang
- CORRIB Research Centre for Advanced Imaging and Core Laboratory, University of Galway, Ireland
| | - Kotaro Miyashita
- CORRIB Research Centre for Advanced Imaging and Core Laboratory, University of Galway, Ireland
| | - Akihiro Tobe
- CORRIB Research Centre for Advanced Imaging and Core Laboratory, University of Galway, Ireland
| | - Takashi Muramatsu
- Department of Cardiology, Fujita Health University Hospital, Toyoake, Japan
| | - Kengo Tanabe
- Department of Cardiology, Kindai University Faculty of Medicine, Osakasayama, Japan
| | - Yukio Ozaki
- Department of Cardiology, Fujita Health University Okazaki Medical Center, Okazaki, Japan
| | - Scot Garg
- Department of Cardiology, Royal Blackburn Hospital, Blackburn, UK
| | - John William McEvoy
- National Institute for Prevention and Cardiovascular Health and University of Galway, Galway, Ireland
| | | | - Andreas Baumbach
- Department of Cardiology, Barts Heart Centre, Barts Health NHS Trust, West Smithfield, London, UK; Centre for Cardiovascular Medicine and Devices, William Harvey Research Institute, Queen Mary University of London, London, UK
| | - Peter C Smits
- Cardiology Department, Maasstad Hospital, Rotterdam, the Netherlands
| | - Gregg Stone
- Department of Cardiology, The Zena and Michael A. Weiner Cardiovascular Institute, Ichan School of Medicine at Mount Sinai, New York, NY, United States of America
| | - Yoshinobu Onuma
- CORRIB Research Centre for Advanced Imaging and Core Laboratory, University of Galway, Ireland
| | - Patrick W Serruys
- CORRIB Research Centre for Advanced Imaging and Core Laboratory, University of Galway, Ireland.
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Wu AHB, Jaffe AS, Peacock WF, Kavsak P, Greene D, Christenson RH. The Role of Artificial Intelligence for Providing Scientific Content for Laboratory Medicine. J Appl Lab Med 2024; 9:386-393. [PMID: 38102068 DOI: 10.1093/jalm/jfad095] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Accepted: 09/25/2023] [Indexed: 12/17/2023]
Abstract
BACKGROUND Artificial intelligence (AI) promises to become an important tool in the practice of laboratory medicine. AI programs are available online that can provide concise medical and laboratory information within seconds after a question is submitted. METHODS We posed the following contemporary and relevant question for clinical chemists using an AI program: "Should labs eliminate CK-MB testing?" The results of this inquiry were critically reviewed by a cardiologist, emergency department physician, and clinical laboratorians for accuracy and appropriateness. RESULTS An AI report answering this question was generated within 15 s. The experts felt that the information was inaccurate with the statements that CK-MB results are released earlier than cardiac troponin (cTn), and are more useful for detection of myocardial injury in patients with renal insufficiencies. The summary omitted discussion on the ongoing debate for periprocedural detection of acute myocardial infarction (MI), the perceived value for detection of reinfarction, the value in risk stratification compared to cTn, the economic justification for testing both CK-MB and cTn, and medicolegal aspects of testing when results are discordant. CONCLUSIONS At this time, AI does not appear to be ready to be used by clinical laboratories for answering important practice questions.
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Affiliation(s)
- Alan H B Wu
- Department of Laboratory Medicine, University of California, San Francisco, San Francisco, CA, United States
| | - Allan S Jaffe
- Departments of Cardiology and Laboratory Medicine, Mayo Clinic, Rochester, MN, United States
| | | | - Pete Kavsak
- Department of Pathology and Molecular Medicine, McMaster University, Hamilton, ON, Canada
| | - Dina Greene
- Department of Laboratory Medicine, University of Washington, Seattle, WA, United States
- LetsGetChecked Laboratories, Monrovia, CA, United States
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Ozcan MS, Savran M, Kumbul Doguc D, Kubra Dogan H, Altintas M, Cosan S. Dexpanthenol ameliorates lipopolysaccharide-induced cardiovascular toxicity by regulating the IL-6/HIF1α/VEGF pathway. Heliyon 2024; 10:e24007. [PMID: 38268590 PMCID: PMC10806266 DOI: 10.1016/j.heliyon.2024.e24007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Revised: 12/13/2023] [Accepted: 01/02/2024] [Indexed: 01/26/2024] Open
Abstract
Introduction Lipopolysaccharide (Lps) is an essential component responsible for the virulence of gram-negative bacteria. Lps can cause damage to many organs, including the heart, kidneys, and lungs. Dexpanthenol (Dex) is an agent that exhibits anti-oxidative and anti-inflammatory effects and stimulates epithelialization. In this study, we aimed to investigate the effects of Dex on Lps-induced cardiovascular toxicity. Methods Rats were divided into four groups: control, Lps (5 mg/kg, intraperitoneal), Dex (500 mg/kg, intraperitoneal), and Lps + Dex. The control group received saline intraperitoneally (i.p.) once daily for three days. The Lps group received saline i.p. once daily for three days and a single dose of Lps i.p. was administered on the third day. The Dex group received Dex i.p. once daily for three days and saline on the third day. The Lps + Dex group received Dex i.p. once daily for three days and a single dose of Lps i.p. on the third day. Heart and aortic tissues were taken for biochemical, histopathological, immunohistochemical, and genetic analysis. Results Lps injection caused histopathological changes in both heart and aortic tissues and significantly increased total oxidant status and oxidative stress index levels. Interleukin-6, and Tumor necrosis factor-α mRNA expressions were significantly altered in heart and aorta, likely do to the anti-inflammatory and antioxidative effects of Dex. Furthermore, Dex affected Caspase-3 and Hypoxia-inducible factor 1-α staining patterns. Conclusions Our results show that Dex treatment has a protective effect on Lps-induced cardiac and endothelial damage in rats by reducing inflammation, oxidative stress, and apoptosis.
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Affiliation(s)
- Mustafa Soner Ozcan
- Department of Anesthesiology and Reanimation, Faculty of Medicine, Suleyman Demirel University, Isparta, Turkey
| | - Mehtap Savran
- Department of Pharmacology, Faculty of Medicine, Suleyman Demirel University, Isparta, Turkey
| | - Duygu Kumbul Doguc
- Department of Biochemistry, Faculty of Medicine, Suleyman Demirel University, Isparta, Turkey
| | - Hatice Kubra Dogan
- Department of Bioengineering, Institute of Science, Suleyman Demirel University, Isparta, Turkey
| | - Melike Altintas
- Department of Pathology, Faculty of Veterinary Medicine, Burdur Mehmet Akif Ersoy University, Burdur, Turkey
| | - Samet Cosan
- Department of Pharmacology, Faculty of Medicine, Suleyman Demirel University, Isparta, Turkey
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Kittipeerapat N, Fabian R, Bernsen S, Weydt P, Castro-Gomez S. Creatine Kinase MB Isoenzyme Is a Complementary Biomarker in Amyotrophic Lateral Sclerosis. Int J Mol Sci 2023; 24:11682. [PMID: 37511443 PMCID: PMC10380590 DOI: 10.3390/ijms241411682] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2023] [Revised: 07/14/2023] [Accepted: 07/17/2023] [Indexed: 07/30/2023] Open
Abstract
Amyotrophic lateral sclerosis (ALS) is an invariably fatal neurodegenerative disease with limited therapeutic options. There is an urgent need for novel biomarkers to be used as surrogates for new therapeutic trials and disease monitoring. In this study, we sought to systematically study creatine kinase isoenzyme MB (CK-MB) in a real-world cohort of ALS patients, assess the diagnostic performance, and evaluate its association with other laboratory and clinical parameters. We reviewed data from 194 consecutive patients that included 130 ALS patients and 64 disease control patients (primary lateral sclerosis [PLS], benign fasciculations syndrome [BFS], Huntington's disease [HD] and Alzheimer's disease [AD]). CK-MB was elevated in the sera of more than half of all patients with ALS. In patients with spinal-onset ALS, CK-MB levels were significantly higher than in patients with other neurodegenerative diseases. Patients with slower rates of functional decline had a significantly higher baseline CK-MB. Furthermore, CK-MB elevations correlated with cardiac troponin T (cTnT) and with revised ALS Functional Rating Scale (ALSFRS-R) bulbar subcategory. We posit that measuring CK-MB in ALS patients in a complimentary fashion could potentially aid in the diagnostic workup of ALS and help discriminate the disease from some ALS mimics and other neurodegenerative diseases. CK-MB levels also may provide valuable prognostic information regarding disease aggressiveness as well as correlations with specific phenotypic presentations.
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Affiliation(s)
- Natsinee Kittipeerapat
- Department of Neurodegenerative Diseases/Neurology, University Hospital Bonn, 53127 Bonn, Germany
| | - Rachel Fabian
- Department of Neurodegenerative Diseases/Neurology, University Hospital Bonn, 53127 Bonn, Germany
| | - Sarah Bernsen
- Department of Neurodegenerative Diseases/Neurology, University Hospital Bonn, 53127 Bonn, Germany
| | - Patrick Weydt
- Department of Neurodegenerative Diseases/Neurology, University Hospital Bonn, 53127 Bonn, Germany
- German Center for Neurodegenerative Diseases (DZNE), 53127 Bonn, Germany
| | - Sergio Castro-Gomez
- Department of Neurodegenerative Diseases/Neurology, University Hospital Bonn, 53127 Bonn, Germany
- German Center for Neurodegenerative Diseases (DZNE), 53127 Bonn, Germany
- Institute of Physiology II, University Hospital Bonn, 53115 Bonn, Germany
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Kumar S, Shih CM, Tsai LW, Dubey R, Gupta D, Chakraborty T, Sharma N, Singh AV, Swarup V, Singh HN. Transcriptomic Profiling Unravels Novel Deregulated Gene Signatures Associated with Acute Myocardial Infarction: A Bioinformatics Approach. Genes (Basel) 2022; 13:genes13122321. [PMID: 36553589 PMCID: PMC9777571 DOI: 10.3390/genes13122321] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Revised: 12/03/2022] [Accepted: 12/05/2022] [Indexed: 12/14/2022] Open
Abstract
Acute myocardial infarction (AMI) is a severe disease with elevated morbidity and mortality rate worldwide. This is attributed to great losses of cardiomyocytes, which can trigger the alteration of gene expression patterns. Although several attempts have been made to assess the AMI biomarkers, to date their role in rescuing myocardial injury remains unclear. Therefore, the current study investigated three independent microarray-based gene expression datasets from AMI patients (n = 85) and their age-sex-matched healthy controls (n = 70), to identify novel gene signatures that might be involved in cardioprotection. The differentially expressed genes (DEGs) were analyzed using 'GEO2R', and weighted gene correlation network analysis (WGCNA) was performed to identify biomarkers/modules. We found 91 DEGs, of which the number of upregulated and downregulated genes were 22 and 5, respectively. Specifically, we found that the deregulated genes such as ADOR-A3, BMP6, VPS8, and GPx3, may be associated with AMI. WGCNA revealed four highly preserved modules among all datasets. The 'Enrichr' unveiled the presence of miR-660 and STAT1, which is known to affect AMI severity. Conclusively, these genes and miRNA might play a crucial role the rescue of cardiomyocytes from severe damage, which could be helpful in developing appropriate therapeutic strategies for the management of AMI.
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Affiliation(s)
- Sanjay Kumar
- Department of Life Science, Sharda School of Basic Sciences and Research, Sharda University, Knowledge Park-III, Greater Noida 201310, India
| | - Chun-Ming Shih
- Division of Cardiology, Department of Internal Medicine, Taipei Medical University Hospital, Taipei 111031, Taiwan
- Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei 111031, Taiwan
| | - Lung-Wen Tsai
- Department of Medicine Research, Taipei Medical University Hospital, Taipei 111031, Taiwan
- Department of Information Technology Office, Taipei Medical University Hospital, Taipei 11031, Taiwan
- Graduate Institute of Data Science, College of Management, Taipei Medical University, Taipei 11031, Taiwan
| | - Rajni Dubey
- Division of Cardiology, Department of Internal Medicine, Taipei Medical University Hospital, Taipei 111031, Taiwan
| | - Deepika Gupta
- Department of Neurology, All India Institute of Medical Sciences, New Delhi 110029, India
| | - Tanmoy Chakraborty
- Department of Chemistry and Biochemistry, Sharda School of Basic Sciences and Research, Sharda University, Knowledge Park-III, Greater Noida 201310, India
| | - Naveen Sharma
- Biomedical Informatics Division, Indian Council of Medical Research, New Delhi 110029, India
| | | | - Vishnu Swarup
- Department of Neurology, All India Institute of Medical Sciences, New Delhi 110029, India
- Correspondence: (V.S.); or (H.N.S.)
| | - Himanshu Narayan Singh
- Department of System Biology, University of Columbia Irving Medical Center, New York, NY 10032, USA
- Correspondence: (V.S.); or (H.N.S.)
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Prognostic Value of High-Sensitivity Cardiac Troponin in Women. Biomolecules 2022; 12:biom12101496. [DOI: 10.3390/biom12101496] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Revised: 10/13/2022] [Accepted: 10/14/2022] [Indexed: 11/16/2022] Open
Abstract
High-sensitivity cardiac troponin assays have become the gold standard for diagnosing acute and chronic myocardial injury. The detection of troponin levels beyond the 99th percentile is included in the fourth universal definition of myocardial infarction, specifically recommending the use of sex-specific thresholds. Measurable concentrations below the proposed diagnostic thresholds have been shown to inform prognosis in different categories of inpatients and outpatients. However, clinical investigations from the last twenty years have yielded conflicting results regarding the incremental value of using different cut-offs for men and women. While advocates of a sex-specific approach claim it may help reduce gender bias in cardiovascular medicine, particularly in acute coronary syndromes, other groups question the alleged incremental diagnostic and prognostic value of sex-specific thresholds, ultimately asserting that less is more. In the present review, we aimed to synthesize our current understanding of sex-based differences in cardiac troponin levels and to reappraise the available evidence with regard to (i) the prognostic significance of sex-specific diagnostic thresholds of high-sensitivity cardiac troponin assays compared to common cut-offs in both men and women undergoing cardiovascular disease risk assessment, and (ii) the clinical utility of high-sensitivity cardiac troponin assays for cardiovascular disease prevention in women.
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Panteghini M, Dolci A, Birindelli S, Szoke D, Aloisio E, Caruso S. Pursuing appropriateness of laboratory tests: a 15-year experience in an academic medical institution. Clin Chem Lab Med 2022; 60:1706-1718. [PMID: 35998662 DOI: 10.1515/cclm-2022-0683] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Accepted: 08/08/2022] [Indexed: 02/04/2023]
Abstract
Appropriateness in Laboratory Medicine has been the object of various types of interventions. From published experiences, it is now clear that to effectively manage the laboratory test demand it is recommended to activate evidence-based preventative strategies stopping inappropriate requests before they can reach the laboratory. To guarantee appropriate laboratory test utilization, healthcare institutions should implement and optimize a computerized provider order entry (CPOE), exploiting the potential of electronic requesting as "enabling factor" for reinforcing appropriateness and sustaining its effects over time. In our academic institution, over the last 15 years, our medical laboratory has enforced various interventions to improve test appropriateness, all directly or indirectly based on CPOE use. The following types of intervention were implemented: (1) applying specific recommendations supported by monitoring by CPOE as well as a continuous consultation with clinicians (tumour markers); (2) removing outdated tests and avoiding redundant duplications (cardiac markers, pancreatic enzymes); (3) order restraints to selected wards and gating policy (procalcitonin, B-type natriuretic peptide, homocysteine); (4) reflex testing (bilirubin fractions, free prostate-specific antigen, aminotransferases, magnesium in hypocalcemia); and (5) minimum retesting interval (D-Dimer, vitamin B12, C-reactive protein, γ-glutamyltranspeptidase). In this paper, we reviewed these interventions and summarized their outcomes primarily related to the changes in total test volumes and cost savings, without neglecting patient safety. Our experience confirmed that laboratory professionals have an irreplaceable role as "stewards" in designing, implementing, evaluating, and maintaining interventions focused to improving test appropriateness.
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Affiliation(s)
- Mauro Panteghini
- UOC Patologia Clinica, ASST Fatebenefratelli-Sacco, Milan, Italy.,Dipartimento di Scienze Biomediche e Cliniche, Università degli Studi, Milan, Italy
| | - Alberto Dolci
- UOC Patologia Clinica, ASST Fatebenefratelli-Sacco, Milan, Italy.,Dipartimento di Scienze Biomediche e Cliniche, Università degli Studi, Milan, Italy
| | - Sarah Birindelli
- UOC Patologia Clinica, ASST Fatebenefratelli-Sacco, Milan, Italy
| | - Dominika Szoke
- UOC Patologia Clinica, ASST Fatebenefratelli-Sacco, Milan, Italy
| | - Elena Aloisio
- UOC Patologia Clinica, ASST Fatebenefratelli-Sacco, Milan, Italy
| | - Simone Caruso
- UOC Patologia Clinica, ASST Fatebenefratelli-Sacco, Milan, Italy
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Zhu F, Arshi B, Leening MJG, Aribas E, Ikram MA, Boersma E, Ikram MK, Kavousi M. Sex-specific added value of cardiac biomarkers for 10-year cardiovascular risk prediction. Eur J Prev Cardiol 2022; 29:1559-1567. [PMID: 35512434 DOI: 10.1093/eurjpc/zwac091] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Revised: 04/28/2022] [Accepted: 04/30/2022] [Indexed: 11/14/2022]
Abstract
AIMS To evaluate the sex-specific predictive value of N-terminal pro B-type natriuretic peptide (NT-proBNP), high sensitivity cardiac troponin T (hs-cTnT) and creatine kinase myocardial band (CK-MB) for 10-year risk prediction of coronary heart disease (CHD), stroke, heart failure (HF) and composite outcomes. METHODS Five-thousand four-hundred thirty individuals (mean age 68.6 years, 59.9% women) from the Rotterdam Study, with biomarker measurements between 1997 and 2001, were included. Participants were followed until 2015. We fitted 'basic' models using traditional cardiovascular risk factors. Improvements in c-statistics and net reclassification improvement (NRI) for events and non-events were calculated. RESULTS During a median follow-up of 14 years, 747 (13.8%), 563 (10.4%), and 664 (12.2%) participants were diagnosed with CHD, stroke, and HF, respectively. NT-proBNP improved the discriminative performance of the 'basic' model for all endpoints (c-statistic improvements ranging from 0.007 to 0.050) and provided significant event-NRI for HF (14.3% in women; 10.7% in men) and for stroke in men (9.3%). The addition of hs-cTnT increased c-statistic for CHD in women by 0.029 (95% CI, 0.011-0.047) and for HF in men by 0.034 (95% CI, 0.014-0.053), and provided significant event-NRI for CHD (10.3%) and HF (7.8%) in women, and for stroke (8.4%) in men. The added predictive value of CK-MB was limited. CONCLUSION NT-proBNP and hs-cTnT provided added predictive value for various cardiovascular outcomes above traditional risk factors. Sex differences were observed in the predictive performance of these biomarkers.
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Affiliation(s)
- Fang Zhu
- Department of Epidemiology, Erasmus MC-University Medical Center Rotterdam, PO Box 2040, Rotterdam, 3000 CA, The Netherlands
| | - Banafsheh Arshi
- Department of Epidemiology, Erasmus MC-University Medical Center Rotterdam, PO Box 2040, Rotterdam, 3000 CA, The Netherlands
| | - Maarten J G Leening
- Department of Epidemiology, Erasmus MC-University Medical Center Rotterdam, PO Box 2040, Rotterdam, 3000 CA, The Netherlands
- Department of Cardiology, Erasmus MC-University Medical Center Rotterdam, PO Box 2040, Rotterdam, 3000 CA, The Netherlands
| | - Elif Aribas
- Department of Epidemiology, Erasmus MC-University Medical Center Rotterdam, PO Box 2040, Rotterdam, 3000 CA, The Netherlands
| | - M Arfan Ikram
- Department of Epidemiology, Erasmus MC-University Medical Center Rotterdam, PO Box 2040, Rotterdam, 3000 CA, The Netherlands
| | - Eric Boersma
- Department of Cardiology, Erasmus MC-University Medical Center Rotterdam, PO Box 2040, Rotterdam, 3000 CA, The Netherlands
| | - M Kamran Ikram
- Department of Epidemiology, Erasmus MC-University Medical Center Rotterdam, PO Box 2040, Rotterdam, 3000 CA, The Netherlands
| | - Maryam Kavousi
- Department of Epidemiology, Erasmus MC-University Medical Center Rotterdam, PO Box 2040, Rotterdam, 3000 CA, The Netherlands
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Zhang Q, Qu H, Chen Y, Luo X, Chen C, Xiao B, Ding X, Zhao P, Lu Y, Chen AF, Yu Y. Atorvastatin Induces Mitochondria-Dependent Ferroptosis via the Modulation of Nrf2-xCT/GPx4 Axis. Front Cell Dev Biol 2022; 10:806081. [PMID: 35309902 PMCID: PMC8927716 DOI: 10.3389/fcell.2022.806081] [Citation(s) in RCA: 36] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2021] [Accepted: 02/03/2022] [Indexed: 01/25/2023] Open
Abstract
As one of the cornerstones of clinical cardiovascular disease treatment, statins have an extensive range of applications. However, statins commonly used have side reactions, especially muscle-related symptoms (SAMS), such as muscle weakness, pain, cramps, and severe condition of rhabdomyolysis. This undesirable muscular effect is one of the chief reasons for statin non-adherence and/or discontinuation, contributing to adverse cardiovascular outcomes. Moreover, the underlying mechanism of muscle cell damage is still unclear. Here, we discovered that ferroptosis, a programmed iron-dependent cell death, serves as a mechanism in statin-induced myopathy. Among four candidates including atorvastatin, lovastatin, rosuvastatin, and pravastatin, only atorvastatin could lead to ferroptosis in human cardiomyocytes (HCM) and murine skeletal muscle cells (C2C12), instead of human umbilical vein endothelial cell (HUVEC). Atorvastatin inhibits HCM and C2C12 cell viability in a dose-dependent manner, accompanying with significant augmentation in intracellular iron ions, reactive oxygen species (ROS), and lipid peroxidation. A noteworthy investigation found that those alterations particularly occurred in mitochondria and resulted in mitochondrial dysfunction. Biomarkers of myocardial injury increase significantly during atorvastatin intervention. However, all of the aforementioned enhancement could be restrained by ferroptosis inhibitors. Mechanistically, GSH depletion and the decrease in nuclear factor erythroid 2-related factor 2 (Nrf2), glutathione peroxidase 4 (GPx4), and xCT cystine–glutamate antiporter (the main component is SLC7A11) are involved in atorvastatin-induced muscular cell ferroptosis and damage. The downregulation of GPx4 in mitochondria-mediated ferroptosis signaling may be the core of it. In conclusion, our findings explore an innovative underlying pathophysiological mechanism of atorvastatin-induced myopathy and highlight that targeting ferroptosis serves as a protective strategy for clinical application.
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Affiliation(s)
- Qi Zhang
- Institute for Developmental and Regenerative Cardiovascular Medicine, Xinhua Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Hang Qu
- Institute for Developmental and Regenerative Cardiovascular Medicine, Xinhua Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Yinghui Chen
- Institute for Developmental and Regenerative Cardiovascular Medicine, Xinhua Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Xueyang Luo
- Institute for Developmental and Regenerative Cardiovascular Medicine, Xinhua Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Chong Chen
- Institute for Developmental and Regenerative Cardiovascular Medicine, Xinhua Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Bing Xiao
- Institute for Developmental and Regenerative Cardiovascular Medicine, Xinhua Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Xiaowei Ding
- Institute for Developmental and Regenerative Cardiovascular Medicine, Xinhua Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Pengjun Zhao
- Department of Pediatric Cardiology, Xinhua Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Yanan Lu
- Department of Pediatric Cardiology, Xinhua Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Alex F. Chen
- Institute for Developmental and Regenerative Cardiovascular Medicine, Xinhua Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
- *Correspondence: Yu Yu, ; Alex F. Chen,
| | - Yu Yu
- Institute for Developmental and Regenerative Cardiovascular Medicine, Xinhua Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
- *Correspondence: Yu Yu, ; Alex F. Chen,
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10
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Wang GM. The combination of creatine kinase-myocardial band isoenzyme and point-of-care cardiac troponin/contemporary cardiac troponin for the early diagnosis of acute myocardial infarction. World J Emerg Med 2022; 13:163-168. [DOI: 10.5847/wjem.j.1920-8642.2022.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Accepted: 12/20/2021] [Indexed: 11/19/2022] Open
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11
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Jaffe AS, Lindahl B, Giannitsis E, Mueller C, Cullen L, Hammarsten O, Mockel M, Mair J, Krychtiuk KA, Huber K, Mills NL, Thygesen K. ESC Study Group on Cardiac Biomarkers of the Association for Acute CardioVascular Care: A fond farewell at the retirement of CKMB. Eur Heart J 2021; 42:2260-2264. [PMID: 33486520 DOI: 10.1093/eurheartj/ehaa1079] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Revised: 10/22/2020] [Indexed: 11/13/2022] Open
Affiliation(s)
- Allan S Jaffe
- Department of Cardiology, Mayo Clinic, 200 First St SW, Rochester, MN 55905, USA
| | - Bertil Lindahl
- Department of Laboratory Medicine and Pathology, Mayo Clinic, 200 First St SW, Rochester, MN 55905, USA.,Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | | | - Christian Mueller
- Medizinische Klinik III, Department of Cardiology, University of Heidelberg, Heidelberg, Germany
| | - Louise Cullen
- Department of Cardiology and Cardiovascular Research Institute Basel, University Hospital Basel, Basel, Switzerland
| | - Ola Hammarsten
- Emergency and Trauma Center, Royal Brisbane and Women Hospital, University of Queensland, Australia
| | - Martin Mockel
- Department of Clinical Chemistry and Transfusion Medicine, University of Gothenburg, Gothenburg, Sweden.,Division of Emergency Medicine, Department of Cardiology, Charite-Universitätsmedizin, Berlin, Germany
| | - Johannes Mair
- Department of Internal Medicine III-Cardiology and Angiology, Heart Center, Medical University Innsbruck, Innsbruck, Austria
| | | | - Kurt Huber
- Department of Medicine, Cardiology and Intensive Care Medicine, Wilhelminen Hospital, and Sigmund Freud Univeristy Medical School, Vienna, Austria
| | - Nicholas L Mills
- University/BHF Centre for Cardiovascular Science and Usher Institute, University of Edinburgh, Edinburgh, UK
| | - Kristian Thygesen
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
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12
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Sandoval Y, Apple FS, Saenger AK, Collinson PO, Wu AHB, Jaffe AS. 99th Percentile Upper-Reference Limit of Cardiac Troponin and the Diagnosis of Acute Myocardial Infarction. Clin Chem 2021; 66:1167-1180. [PMID: 32871000 DOI: 10.1093/clinchem/hvaa158] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Accepted: 07/02/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Concerns exist regarding how the 99th percentile upper reference limit (URL) of cardiac troponin (cTn) is determined and whether it should be derived from normal healthy individuals. CONTENT The 99th percentile URL of cTn is an important criterion to standardize the diagnosis of myocardial infarction (MI) for clinical, research, and regulatory purposes. Statistical heterogeneity in its calculation exists but recommendations have been proposed. Some negativity has resulted from the fact that with some high-sensitivity (hs) cTn assays, a greater number of increases above the 99th percentile are observed when transitioning from a contemporary assay. Increases reflect acute or chronic myocardial injury and provide valuable diagnostic and prognostic information. The etiology of increases can sometimes be difficult to determine, making a specific treatment approach challenging. For those reasons, some advocate higher cutoff concentrations. This approach can contribute to missed diagnoses. Contrary to claims, neither clinical or laboratory guidelines have shifted away from the 99th percentile. To support the diagnosis of acute MI, the 99th percentile URL remains the best-established approach given the absence of cTn assay standardization. Importantly, risk stratification algorithms using hs-cTn assays predict the possibility of MI diagnoses established using the 99th percentile. SUMMARY The 99th percentile of cTn remains the best-established criterion for the diagnosis of acute MI. While not perfect, it is analytically and clinically evidence-based. Until there are robust data to suggest some other approach, staying with the 99th percentile, a threshold that has served the field well for the past 20 years, appears prudent.
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Affiliation(s)
- Yader Sandoval
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN
| | - Fred S Apple
- Department of Laboratory Medicine and Pathology, Hennepin Healthcare/Hennepin County Medical Center and University of Minnesota, Minneapolis, MN
| | - Amy K Saenger
- Department of Laboratory Medicine and Pathology, Hennepin Healthcare/Hennepin County Medical Center and University of Minnesota, Minneapolis, MN
| | - Paul O Collinson
- Department of Clinical Blood Sciences and Cardiology, St. George's University Hospitals NHS Foundation Trust and St. George's University of London, London, UK
| | - Alan H B Wu
- Department of Laboratory Medicine, University of California, San Francisco, CA
| | - Allan S Jaffe
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN.,Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
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13
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Chapman AR, Sandoval Y. Type 2 Myocardial Infarction: Evolving Approaches to Diagnosis and Risk-Stratification. Clin Chem 2021; 67:61-69. [PMID: 33418588 PMCID: PMC7793229 DOI: 10.1093/clinchem/hvaa189] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Accepted: 07/21/2020] [Indexed: 01/09/2023]
Abstract
BACKGROUND Type 2 myocardial infarction (T2MI) is frequently encountered in clinical practice and associated with adverse outcomes. CONTENT T2MI occurs most frequently due to noncoronary etiologies that alter myocardial oxygen supply and/or demand. The diagnosis of T2MI is often confused with acute nonischemic myocardial injury, in part because of difficulties in delineating the nature of symptoms and misunderstandings about disease categorization. The use of objective features of myocardial ischemia using electrocardiographic (ECG) or imaging abnormalities may facilitate more precise T2MI diagnosis. High-sensitivity cardiac troponin (hs-cTn) assays allow rapid MI diagnosis and risk stratification, yet neither maximum nor delta values facilitate differentiation of T2MI from T1MI. Several investigational biomarkers have been evaluated for T2MI, but none have robust data. There is interest in evaluating risk profiles among patients with T2MI. Clinically, the magnitude of maximum and delta cTn values as well as the presence and magnitude of ischemia on ECG or imaging is used to indicate disease severity. Scoring systems such as GRACE, TIMI, and TARRACO have been evaluated, but all have limited to modest performance, with substantial variation in time intervals used for risk-assessment and endpoints used. SUMMARY The diagnosis of T2MI requires biomarker evidence of acute myocardial injury and clear clinical evidence of acute myocardial ischemia without atherothrombosis. T2MIs are most often caused by noncoronary etiologies that alter myocardial oxygen supply and/or demand. They are increasingly encountered in clinical practice and associated with poor short- and long-term outcomes. Clinicians require novel biomarker or imaging approaches to facilitate diagnosis and risk-stratification.
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Affiliation(s)
- Andrew R Chapman
- BHF Centre for Cardiovascular Science, University of Edinburgh, UK
| | - Yader Sandoval
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN
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14
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Mohammad OH, Naushad VA, Purayil NK, Sinan L, Ambra N, Chandra P, Paramba FC, Mohammad J, Chalihadan S, Varikkodan I, Palol A. Diagnostic Performance of Point-of-Care Troponin I and Laboratory Troponin T in Patients Presenting to the ED with Chest Pain: A Comparative Study. Open Access Emerg Med 2020; 12:247-254. [PMID: 33116960 PMCID: PMC7575355 DOI: 10.2147/oaem.s259726] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Accepted: 09/21/2020] [Indexed: 11/23/2022] Open
Abstract
Background Chest pain is a common symptom in patients visiting the emergency department (ED). Diagnosing acute coronary syndrome is a challenging task for emergency physicians. Evaluation of chest pain depends on clinical symptoms and signs, ECG, and cardiac enzymes. Here, we aimed to compare the diagnostic performance of the point-of-care troponin I assay with laboratory HsTnT assay in patients presenting to the ED with chest pain. Methods A prospective study was done at the ED of Alkhor Hospital, Hamad Medical Corporation, between March 2016 and December 2016. Patients more than 18 years old who presented to the ED with chest pain were enrolled. Patients with renal failure, initial ECG showing ST-elevation MI, or arrhythmias, and hemodynamically unstable patients were excluded. A blood sample was collected at 0 and 3 hours post-admission for POC TnI and laboratory HsTnT assay. The sensitivity, specificity, PPV, NPV, and AUC were determined and compared. Results Out of 313 patients enrolled, ten were excluded. At 0 hour, the POC TnI assay had a lower sensitivity (72.5% versus 97.5%) and had almost equal specificity (99.24% versus 93.2%) when compared to lab HsTnT assay. At 3 hours post-admission, the sensitivity increased to 95% versus 100%, and specificity was 100% versus 94.3% when compared to lab HsTnT. The POC TnI assay had a higher PPV than HsTnT, whereas both assays showed a high NPV at 0 and 3 hours. Conclusion Although the diagnostic performance of POC TnI was lower than that of Lab HsTnT at 0 hour, at 3 hours post-admission, the diagnostic performance was almost equal to that of HsTnT. Hence we conclude that chest pain in patients with a negative POC TnI at 3 hours post-admission is unlikely to be due to NSTEMI.
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Affiliation(s)
- Osama H Mohammad
- Department of General Internal Medicine, Hamad Medical Corporation, Doha, Qatar
| | - Vamanjore A Naushad
- Department of General Internal Medicine, Hamad Medical Corporation, Doha, Qatar
| | - Nishan K Purayil
- Department of General Internal Medicine, Hamad Medical Corporation, Doha, Qatar
| | | | - Naseem Ambra
- Department of General Internal Medicine, Hamad Medical Corporation, Doha, Qatar
| | - Prem Chandra
- Medical Research Center, Hamad Medical Corporation, Doha, Qatar
| | - Firjeeth C Paramba
- Department of General Internal Medicine, Hamad Medical Corporation, Doha, Qatar
| | - Jassim Mohammad
- Accident & Emergency Department, Hamad Medical Corporation, Doha, Qatar
| | - Sajid Chalihadan
- Department of General Internal Medicine, Hamad Medical Corporation, Doha, Qatar
| | - Irfan Varikkodan
- Department of General Internal Medicine, Hamad Medical Corporation, Doha, Qatar
| | - Azeez Palol
- Department of General Internal Medicine, Hamad Medical Corporation, Doha, Qatar
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15
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Harb R, Hajdasz D, Landry ML, Sussman LS. Improving laboratory test utilisation at the multihospital Yale New Haven Health System. BMJ Open Qual 2019; 8:e000689. [PMID: 31637323 PMCID: PMC6768328 DOI: 10.1136/bmjoq-2019-000689] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2019] [Revised: 07/26/2019] [Accepted: 08/20/2019] [Indexed: 02/05/2023] Open
Abstract
Background Waste persists in healthcare and negatively impacts patients. Clinicians have direct control over test ordering and ongoing international efforts to improve test utilisation have identified multifaceted approaches as critical to the success of interventions. Prior to 2015, Yale New Haven Health lacked a coherent strategy for laboratory test utilisation management. Methods In 2015, a system-wide laboratory formulary committee was formed at Yale New Haven Health to manage multiple interventions designed to improve test utilisation. We report here on specific interventions conducted between 2015 and 2017 including reduction of (1) obsolete or misused testing, (2) duplicate orders, and (3) daily routine lab testing. These interventions were driven by a combination of modifications to computerised physician order entry, test utilisation dashboards and physician education. Measurements included test order volume, blood savings and cost savings. Results Testing for a number of obsolete/misused analytes was eliminated or significantly decreased depending on alert rule at order entry. Hard stops significantly decreased duplicate testing and educational sessions significantly decreased daily orders of routine labs and increased blood savings but the impact waned over time for select groups. In total, we realised approximately $100 000 of cost savings during the study period. Conclusion Through a multifaceted approach to utilisation management, we show significant reductions in low-value clinical testing that have led to modest but significant savings in both costs and patients’ blood.
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Affiliation(s)
- Roa Harb
- Department of Laboratory Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - David Hajdasz
- Clinical Redesign, Office of Strategy Management, Yale New Haven Health System, New Haven, Connecticut, USA
| | - Marie L Landry
- Departments of Laboratory Medicine and Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - L Scott Sussman
- Clinical Redesign, Department of Medicine, Yale New Haven Health System, New Haven, Connecticut, USA
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16
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Wiens EJ, Arbour J, Thompson K, Seifer CM. Routine creatine kinase testing does not provide clinical utility in the emergency department for diagnosis of acute coronary syndromes. BMC Emerg Med 2019; 19:37. [PMID: 31288735 PMCID: PMC6617848 DOI: 10.1186/s12873-019-0251-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Accepted: 06/25/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Despite the high sensitivity and negative predictive value of contemporary high-sensitivity troponin T assays (hsTnT), creatine kinase (CK) continues to be routinely tested for the diagnosis of acute coronary syndrome (ACS). We conducted a study to identify the clinical utility of routine CK measurement, its relevance in clinical decision making in the era of hsTnT, and the potential cost-savings achievable by limiting its use. METHODS We conducted a retrospective review of all adult patients presenting to a tertiary care center in the year 2017. We identified patients presenting with cardiac complaints who had non-diagnostic hsTnT and positive CK. These patients underwent chart review to determine whether a diagnosis of AMI was made. RESULTS A total of 36,251 presentations were reviewed. 9951 had cardiac complaints and 8150 had CK measured. 82% of these patients had hsTnT and CK measured; 2012 of these patients had non-diagnostic hsTnT with positive CK. Of these 2012 patients, only 1 was subsequently diagnosed with AMI (0.012%). CK provided no diagnostic benefit over hsTnT alone in > 99.9% of cases. With a cost for CK of $4/test, we estimated that routine CK testing costs at least $32,000 per year in our center, and over $100,000 per year across the region. CONCLUSION Routine CK testing does not provide a significant benefit to patient care and therefore represents an unnecessary system cost. Routine CK testing for the diagnosis of AMI should be eliminated from emergency departments in the era of hsTnT assays.
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Affiliation(s)
- Evan J Wiens
- Department of Internal Medicine, Max Rady College of Medicine, University of Manitoba, Room GC430, Health Sciences Center, 820 Sherbrook Street, Winnipeg, Manitoba, R3A 1R9, Canada.
| | - Jorden Arbour
- Department of Emergency Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Kristjan Thompson
- Department of Emergency Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Colette M Seifer
- Department of Internal Medicine, Max Rady College of Medicine, University of Manitoba, Room GC430, Health Sciences Center, 820 Sherbrook Street, Winnipeg, Manitoba, R3A 1R9, Canada.,Section of Cardiology, Department of Internal Medicine, University of Manitoba, Winnipeg, MB, Canada
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17
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Mariathas M, Allan R, Ramamoorthy S, Olechowski B, Hinton J, Azor M, Nicholas Z, Calver A, Corbett S, Mahmoudi M, Rawlins J, Simpson I, Wilkinson J, Kwok CS, Cook P, Mamas MA, Curzen N. True 99th centile of high sensitivity cardiac troponin for hospital patients: prospective, observational cohort study. BMJ 2019; 364:l729. [PMID: 30867154 PMCID: PMC6415647 DOI: 10.1136/bmj.l729] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To determine the distribution, and specifically the true 99th centile, of high sensitivity cardiac troponin I (hs-cTnI) for a whole hospital population by applying the hs-cTnI assay currently used routinely at a large teaching hospital. DESIGN Prospective, observational cohort study. SETTING University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom, between 29 June 2017 and 24 August 2017. PARTICIPANTS 20 000 consecutive inpatients and outpatients undergoing blood tests for any clinical reason. Hs-cTnI concentrations were measured in all study participants and nested for analysis except when the supervising doctor had requested hs-cTnI for clinical reasons. MAIN OUTCOME MEASURES Distribution of hs-cTnI concentrations of all study participants and specifically the 99th centile. RESULTS The 99th centile of hs-cTnI for the whole population was 296 ng/L compared with the manufacturer's quoted level of 40 ng/L (currently used clinically as the upper limit of normal; ULN). Hs-cTnI concentrations were greater than 40 ng/L in one in 20 (5.4%, n=1080) of the total population. After excluding participants diagnosed as having acute myocardial infarction (n=122) and those in whom hs-cTnI was requested for clinical reasons (n=1707), the 99th centile was 189 ng/L for the remainder (n=18 171). The 99th centile was 563 ng/L for inpatients (n=4759) and 65 ng/L for outpatients (n=9280). Patients from the emergency department (n=3706) had a 99th centile of 215 ng/L, with 6.07% (n=225) greater than the recommended ULN. 39.02% (n=48) of all patients from the critical care units (n=123) and 14.16% (n=67) of all medical inpatients had an hs-cTnI concentration greater than the recommended ULN. CONCLUSIONS Of 20 000 consecutive patients undergoing a blood test for any clinical reason at our hospital, one in 20 had an hs-cTnI greater than the recommended ULN. These data highlight the need for clinical staff to interpret hs-cTnI concentrations carefully, particularly when applying the recommended ULN to diagnose acute myocardial infarction, in order to avoid misdiagnosis in the absence of an appropriate clinical presentation. TRIAL REGISTRATION Clinicaltrials.gov NCT03047785.
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Affiliation(s)
- Mark Mariathas
- Coronary Research Group, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Rick Allan
- Biochemistry Department, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Sanjay Ramamoorthy
- Emergency Medicine Department, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Bartosz Olechowski
- Coronary Research Group, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Jonathan Hinton
- Coronary Research Group, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Martin Azor
- Coding Department, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Zoe Nicholas
- Coronary Research Group, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Alison Calver
- Wessex Cardiothoracic Unit, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Simon Corbett
- Wessex Cardiothoracic Unit, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Michael Mahmoudi
- Coronary Research Group, University Hospital Southampton NHS Foundation Trust, Southampton, UK
- Wessex Cardiothoracic Unit, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - John Rawlins
- Wessex Cardiothoracic Unit, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Iain Simpson
- Wessex Cardiothoracic Unit, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - James Wilkinson
- Wessex Cardiothoracic Unit, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Chun Shing Kwok
- Keele Cardiovascular Research Group, Centre for Prognosis Research, Institute of Primary Care and Health Sciences, Keele University, Stoke on Trent, UK
| | - Paul Cook
- Biochemistry Department, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Mamas A Mamas
- Keele Cardiovascular Research Group, Centre for Prognosis Research, Institute of Primary Care and Health Sciences, Keele University, Stoke on Trent, UK
| | - Nick Curzen
- Coronary Research Group, University Hospital Southampton NHS Foundation Trust, Southampton, UK
- Wessex Cardiothoracic Unit, University Hospital Southampton NHS Foundation Trust, Southampton, UK
- Faculty of Medicine, University of Southampton, Southampton, UK
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18
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Nugent JP, Wang J, Louis LJ, O'Connell TW, Khosa F, Wong GC, Saw JWL, Nicolaou S, McLaughlin PD. CCTA in patients with positive troponin and low clinical suspicion for ACS: a useful diagnostic option to exclude obstructive CAD. Emerg Radiol 2019; 26:269-275. [PMID: 30631994 DOI: 10.1007/s10140-019-01668-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2018] [Accepted: 01/02/2019] [Indexed: 01/10/2023]
Abstract
PURPOSE It is uncertain whether patients with elevated troponin and non-classical presentation of acute coronary syndrome (ACS) should receive coronary CT angiography (CCTA). A proportion of these patients will have no coronary artery disease (CAD) and would benefit from non-invasive investigations and expedited discharge. Objectives were to determine most common diagnoses and rate of ACS among patients with positive troponin and low clinical suspicion of ACS who received CCTA. METHODS IRB approved retrospective analysis of 491 consecutive patients in a level I trauma center ED referred for CCTA between April 4, 2015 to April 2, 2017. Patients were included if there was an elevated troponin (TnI > 0.045 μg/L) and atypical chest pain within 24 h prior to imaging. One hundred one patients met inclusion criteria; 17 excluded due to technical factors or history. Scans performed on dual-source CT. RESULTS Eighty-four patients (47 men, 37 women) with median TnI of 0.11 ± 0.21 μg/L underwent CCTA 8.20 ± 6.41 h after first elevated Tn. Mean age was 53.2 ± 14.6 years. CCTA demonstrated absence of CAD in 39 patients (46.4%; 20 M, 19 F). CAD < 25% stenosis was observed in 24 (28.6%; 9 M, 15 F). CAD with 25-50% stenosis was observed in seven (8.3%; six M, one F). CAD > 50% stenosis was observed in 11 (13.1%; 9 M, 2 F), and non-diagnostic in three (3.6%, 3 M, 0 F). Forty-six (56.8%) were discharged directly from ED with median stay 15.82 ± 6.41 h. CONCLUSIONS Use of CCTA in ED patients with elevated troponin and low clinical suspicion for ACS allowed obstructive CAD to be excluded in 83%.
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Affiliation(s)
- James P Nugent
- Radiology Department, Vancouver General Hospital, 889 West 12th Avenue, Vancouver, BC, V5Z 1M9, Canada.
| | - Jun Wang
- Radiology Department, Vancouver General Hospital, 889 West 12th Avenue, Vancouver, BC, V5Z 1M9, Canada
| | - Luck J Louis
- Radiology Department, Vancouver General Hospital, 889 West 12th Avenue, Vancouver, BC, V5Z 1M9, Canada
| | - Tim W O'Connell
- Radiology Department, Vancouver General Hospital, 889 West 12th Avenue, Vancouver, BC, V5Z 1M9, Canada
| | - Faisal Khosa
- Radiology Department, Vancouver General Hospital, 889 West 12th Avenue, Vancouver, BC, V5Z 1M9, Canada
| | - Graham C Wong
- Cardiology Department, Vancouver General Hospital, Vancouver, Canada
| | | | - Savvas Nicolaou
- Radiology Department, Vancouver General Hospital, 889 West 12th Avenue, Vancouver, BC, V5Z 1M9, Canada
| | - Patrick D McLaughlin
- Radiology Department, Vancouver General Hospital, 889 West 12th Avenue, Vancouver, BC, V5Z 1M9, Canada
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19
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Abstract
Isoforms of creatine kinase (CK) generate and use phosphocreatine, a concentrated and highly diffusible cellular "high energy" intermediate, for the main purpose of energy buffering and transfer in order to maintain cellular energy homeostasis. The mitochondrial CK isoform (mtCK) localizes to the mitochondrial intermembrane and cristae space, where it assembles into peripherally membrane-bound, large cuboidal homooctamers. These are part of proteolipid complexes wherein mtCK directly interacts with cardiolipin and other anionic phospholipids, as well as with the VDAC channel in the outer membrane. This leads to a stabilization and cross-linking of inner and outer mitochondrial membrane, forming so-called contact sites. Also the adenine nucleotide translocator of the inner membrane can be recruited into these proteolipid complexes, probably mediated by cardiolipin. The complexes have functions mainly in energy transfer to the cytosol and stimulation of oxidative phosphorylation, but also in restraining formation of reactive oxygen species and apoptosis. In vitro evidence indicates a putative role of mtCK in mitochondrial phospholipid distribution, and most recently a role in thermogenesis has been proposed. This review summarizes the essential structural and functional data of these mtCK complexes and describes in more detail the more recent advances in phospholipid interaction, thermogenesis, cancer and evolution of mtCK.
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20
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Mariathas M, Olechowski B, Mahmoudi M, Curzen N. High sensitivity troponins in contemporary cardiology practice: are we turning a corner? Expert Rev Cardiovasc Ther 2017; 16:49-57. [PMID: 29260921 DOI: 10.1080/14779072.2018.1419063] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Troponin is considered to be the gold standard biomarker for ruling out MI. There has been a drive to improve the diagnostic speed, and as such the high sensitivity cardiac troponin (hs-cTn) assays have been introduced into clinical practice and are now part of international guidelines. Their novel value in clinical practice more generally is becoming apparent. Areas covered: In this review we will evaluate the evidence for the use of hs-cTn assays in clinical practice, the issues with the assay and how the hs-cTn can be utilized in the future as a biomarker of cardiovascular risk. Expert commentary: The use of the hs-cTn assays as a 'rule out' test for MI is compelling, as a 'rule in' there are significant issues relating the specificity of the assay for MI. The future of the assay may lie in population screening and risk modeling.
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Affiliation(s)
- Mark Mariathas
- a Coronary Research Group , University Hospital Southampton NHS Foundation Trust , Southampton , UK.,b Faculty of Medicine , University of Southampton , Southampton , UK
| | - Bartosz Olechowski
- a Coronary Research Group , University Hospital Southampton NHS Foundation Trust , Southampton , UK.,b Faculty of Medicine , University of Southampton , Southampton , UK
| | - Michael Mahmoudi
- a Coronary Research Group , University Hospital Southampton NHS Foundation Trust , Southampton , UK.,b Faculty of Medicine , University of Southampton , Southampton , UK
| | - Nick Curzen
- a Coronary Research Group , University Hospital Southampton NHS Foundation Trust , Southampton , UK.,b Faculty of Medicine , University of Southampton , Southampton , UK
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21
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Alexander W, Schneider HG, Smith C, Cleland H. The Incidence and Significance of Raised Troponin Levels in Acute Burns. J Burn Care Res 2017; 39:729-735. [DOI: 10.1093/jbcr/irx020] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- William Alexander
- Plastic, Burns, and Reconstructive Surgery Registrar, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Hans-Gerhard Schneider
- Clinical Biochemistry Unit, Alfred Pathology Service, The Alfred Hospital and Department of Medicine, Central Clinical School, Monash University, Melbourne, Australia
| | - Catherine Smith
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Heather Cleland
- Victorian Adult Burn Service, The Alfred Hospital, Melbourne, Victoria and Department of Surgery Central Clinical School, Monash University, Melbourne, Australia
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22
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Affiliation(s)
- Jeffrey C Trost
- Division of Cardiology, Department of Medicine, Johns Hopkins Bayview Medical Center, Baltimore, MD, USA
| | - Christine Soong
- Division of General Internal Medicine, Department of Medicine, Sinai Health System, Toronto, ON, Canada.
- Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, ON, Canada
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Utilization Management in a Large Community Hospital. UTILIZATION MANAGEMENT IN THE CLINICAL LABORATORY AND OTHER ANCILLARY SERVICES 2017. [PMCID: PMC7123185 DOI: 10.1007/978-3-319-34199-6_14] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
The utilization management of laboratory tests in a large community hospital is similar to academic and smaller community hospitals. There are numerous factors that influence laboratory utilization. Outside influences like hospitals buying physician practices, increasing numbers of hospitalists, and hospital consolidation will influence the number and complexity of the test menu that will need to be monitored for over and/or under utilization in the central laboratory and reference laboratory. CLIA’88 outlines the four test categories including point-of-care testing (waived) and provider-performed microscopy that need laboratory test utilization management. Incremental cost analysis is the most efficient method for evaluating utilization reduction cost savings. Economies of scale define reduced unit cost per test as test volume increases. Outreach programs in large community hospitals provide additional laboratory tests from non-patients in physician offices, nursing homes, and other hospitals. Disruptive innovations are changing the present paradigms in clinical diagnostics, like wearable sensors, MALDI-TOF, multiplex infectious disease panels, cell-free DNA, and others. Obsolete tests need to be universally defined and accepted by manufacturers, physicians, laboratories, and hospitals, to eliminate access to their reagents and testing platforms.
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Abstract
Acute coronary syndrome (ACS) encompasses a pathophysiological spectrum of cardiovascular diseases, all of which have significant morbidity and mortality. ACS was once considered an acute condition; however, new treatment strategies and improvements in biomarker assays have led to ACS being an acute and chronic disease. Cardiac troponin is the preferred biomarker for the diagnosis of myocardial infarction, and there is considerable interest and efforts toward development and implementation of high-sensitivity cardiac troponin (hs-cTn) assays worldwide. Analytical and clinical performance characteristics of hs-cTn assays as well as testing limitations are important for laboratorians and clinicians to understand in order to utilize testing appropriately. Furthermore, expanding the clinical utility of hs-cTn into other cohorts such as asymptomatic community dwelling populations, heart failure, and chronic kidney disease populations supports novel opportunities for improved short- and long-term prognosis.
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Apple FS, Sandoval Y, Jaffe AS, Ordonez-Llanos J. Cardiac Troponin Assays: Guide to Understanding Analytical Characteristics and Their Impact on Clinical Care. Clin Chem 2017; 63:73-81. [DOI: 10.1373/clinchem.2016.255109] [Citation(s) in RCA: 220] [Impact Index Per Article: 31.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2016] [Accepted: 08/17/2016] [Indexed: 11/06/2022]
Abstract
Abstract
BACKGROUND
Cardiac troponin I (cTnI) and cardiac troponin T (cTnT) determinations are fixtures in clinical practice and research. Cardiac troponin testing has been the standard of practice for the diagnosis of acute myocardial infarction (AMI), early rule-out, risk stratification, and outcomes assessment in patients presenting with acute coronary syndrome (ACS) and non-ACS myocardial injury. We recognize from reading the literature over the past several years how poorly understood the analytical characteristics are for cTnI and cTnT assays by laboratorians, clinicians, and scientists who use these assays.
CONTENT
The purposes of this mini-review are (a) to define limit of blank, limit of detection, limit of quantification, and imprecision, (b) overview the analytical characteristics of the existing cardiac troponin assays, (c) recommend approaches to define a healthy (normal) reference population for determining the 99th percentile and the appropriate statistic to use for this calculation, (d) clarify how an assay becomes designated as “high sensitivity,” and (e) provide guidance on determining delta (Δ) change values.
SUMMARY
This review raises important educational information regarding cTnI and cTnT assays, their 99th percentile upper reference limits (URL) differentiated by sex, and specifically addresses high-sensitivity (hs)-assays used to measure low concentrations. Recommendations are made to help clarify the nomenclature and analytical and clinical characteristics to define hs-assays. The review also identifies challenges for the evolving implementation of hs-assays into clinical practice. It is hoped that with the introduction of these concepts, laboratorians, clinicians and researchers can develop a more unified view of how these assays should be used worldwide.
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Affiliation(s)
- Fred S Apple
- Department of Laboratory Medicine and Pathology, Hennepin County Medical Center, and University of Minnesota, Minneapolis, MN
| | - Yader Sandoval
- Division of Cardiology, Department of Medicine, Hennepin County Medical Center and Minneapolis Heart Institute, Abbott-Northwestern Hospital, Minneapolis, MN
| | - Allan S Jaffe
- Mayo Clinic and Mayo College of Medicine, Rochester, MN
| | - Jordi Ordonez-Llanos
- Servei Bioquimica, IBB-Hospital de la Santa Creu i Sant Pau and Department de Bioquimica i Biologia Molecular, Universitat Autònoma, Barcelona, Spain
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Liu Q, Aroonyadet N, Song Y, Wang X, Cao X, Liu Y, Cong S, Wu F, Thompson ME, Zhou C. Highly Sensitive and Quick Detection of Acute Myocardial Infarction Biomarkers Using In 2O 3 Nanoribbon Biosensors Fabricated Using Shadow Masks. ACS NANO 2016; 10:10117-10125. [PMID: 27934084 DOI: 10.1021/acsnano.6b05171] [Citation(s) in RCA: 51] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/22/2023]
Abstract
We demonstrate a scalable and facile lithography-free method for fabricating highly uniform and sensitive In2O3 nanoribbon biosensor arrays. Fabrication with shadow masks as the patterning method instead of conventional lithography provides low-cost, time-efficient, and high-throughput In2O3 nanoribbon biosensors without photoresist contamination. Combined with electronic enzyme-linked immunosorbent assay for signal amplification, the In2O3 nanoribbon biosensor arrays are optimized for early, quick, and quantitative detection of cardiac biomarkers in diagnosis of acute myocardial infarction (AMI). Cardiac troponin I (cTnI), creatine kinase MB (CK-MB), and B-type natriuretic peptide (BNP) are commonly associated with heart attack and heart failure and have been selected as the target biomarkers here. Our approach can detect label-free biomarkers for concentrations down to 1 pg/mL (cTnI), 0.1 ng/mL (CK-MB), and 10 pg/mL (BNP), all of which are much lower than clinically relevant cutoff concentrations. The sample collection to result time is only 45 min, and we have further demonstrated the reusability of the sensors. With the demonstrated sensitivity, quick turnaround time, and reusability, the In2O3 nanoribbon biosensors have shown great potential toward clinical tests for early and quick diagnosis of AMI.
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Affiliation(s)
- Qingzhou Liu
- Mork Family Department of Chemical Engineering and Materials Science, ‡Ming Hsieh Department of Electrical Engineering, and §Department of Chemistry, University of Southern California , Los Angeles, California 90089, United States
| | - Noppadol Aroonyadet
- Mork Family Department of Chemical Engineering and Materials Science, ‡Ming Hsieh Department of Electrical Engineering, and §Department of Chemistry, University of Southern California , Los Angeles, California 90089, United States
| | - Yan Song
- Mork Family Department of Chemical Engineering and Materials Science, ‡Ming Hsieh Department of Electrical Engineering, and §Department of Chemistry, University of Southern California , Los Angeles, California 90089, United States
| | - Xiaoli Wang
- Mork Family Department of Chemical Engineering and Materials Science, ‡Ming Hsieh Department of Electrical Engineering, and §Department of Chemistry, University of Southern California , Los Angeles, California 90089, United States
| | - Xuan Cao
- Mork Family Department of Chemical Engineering and Materials Science, ‡Ming Hsieh Department of Electrical Engineering, and §Department of Chemistry, University of Southern California , Los Angeles, California 90089, United States
| | - Yihang Liu
- Mork Family Department of Chemical Engineering and Materials Science, ‡Ming Hsieh Department of Electrical Engineering, and §Department of Chemistry, University of Southern California , Los Angeles, California 90089, United States
| | - Sen Cong
- Mork Family Department of Chemical Engineering and Materials Science, ‡Ming Hsieh Department of Electrical Engineering, and §Department of Chemistry, University of Southern California , Los Angeles, California 90089, United States
| | - Fanqi Wu
- Mork Family Department of Chemical Engineering and Materials Science, ‡Ming Hsieh Department of Electrical Engineering, and §Department of Chemistry, University of Southern California , Los Angeles, California 90089, United States
| | - Mark E Thompson
- Mork Family Department of Chemical Engineering and Materials Science, ‡Ming Hsieh Department of Electrical Engineering, and §Department of Chemistry, University of Southern California , Los Angeles, California 90089, United States
| | - Chongwu Zhou
- Mork Family Department of Chemical Engineering and Materials Science, ‡Ming Hsieh Department of Electrical Engineering, and §Department of Chemistry, University of Southern California , Los Angeles, California 90089, United States
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White HD, Thygesen K, Alpert JS, Jaffe AS. Republished: clinical implications of the third universal definition of myocardial infarction. Postgrad Med J 2016; 90:502-10. [PMID: 25140007 DOI: 10.1136/postgradmedj-2012-302976rep] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Affiliation(s)
- Harvey D White
- Cardiology Department, Green Lane Cardiovascular Service, Auckland City Hospital, Auckland, New Zealand
| | - Kristian Thygesen
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
| | - Joseph S Alpert
- Department of Medicine, University of Arizona College of Medicine, Tucson, Arizona, USA
| | - Allan S Jaffe
- Cardiovascular Division, Department of Medicine, Laboratory Medicine and Pathology, Mayo Clinic and Medical School, Rochester, Minnesota, USA
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Fanning JP, Nyong J, Scott IA, Aroney CN, Walters DL. Routine invasive strategies versus selective invasive strategies for unstable angina and non-ST elevation myocardial infarction in the stent era. Cochrane Database Syst Rev 2016; 2016:CD004815. [PMID: 27226069 PMCID: PMC8568369 DOI: 10.1002/14651858.cd004815.pub4] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND People with unstable angina and non-ST elevation myocardial infarction (UA/NSTEMI) are managed with a combination of medical therapy, invasive angiography and revascularisation. Specifically, two approaches have evolved: either a 'routine invasive' strategy whereby all patients undergo coronary angiography shortly after admission and, if indicated, coronary revascularisation; or a 'selective invasive' (also referred to as 'conservative') strategy in which medical therapy alone is used initially, with a selection of patients for angiography based upon evidence of persistent myocardial ischaemia. Uncertainty exists as to which strategy provides the best outcomes for these patients. This Cochrane review is an update of a Cochrane review originally published in 2006, to provide a robust comparison of these two strategies in the early management of patients with UA/NSTEMI. OBJECTIVES To determine the benefits and harms associated with the following.1. A routine invasive versus a conservative or 'selective invasive' strategy for the management of UA/NSTEMI in the stent era.2. A routine invasive strategy with and without glycoprotein IIb/IIIa receptor antagonists versus a conservative strategy for the management of UA/NSTEMI in the stent era. SEARCH METHODS We searched the following databases and additional resources up to 25 August 2015: the Cochrane Central Register of Controlled Trials (CENTRAL) on the Cochrane Library, MEDLINE and EMBASE, with no language restrictions. SELECTION CRITERIA We included prospective randomised controlled trials (RCTs) that compared invasive with conservative or 'selective invasive' strategies in participants with acute UA/NSTEMI. DATA COLLECTION AND ANALYSIS Two review authors screened the records and extracted data in duplicate. Using intention-to-treat analysis with random-effects models, we calculated summary estimates of the risk ratio (RR) with 95% confidence intervals (CIs) for the primary endpoints of all-cause death, fatal and non-fatal myocardial infarction (MI), combined all-cause death or non-fatal MI, refractory angina and re-hospitalisation. We performed further analysis of included studies based on whether glycoprotein IIb/IIIa receptor antagonists were used routinely. We assessed the heterogeneity of included trials using Pearson χ² (Chi² test) and variance (I² statistic) analysis. Using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach, we assessed the quality of the evidence and the GRADE profiler (GRADEPRO) was used to import data from Review Manager 5.3 (Review Manager) to create Summary of findings (SoF) tables. MAIN RESULTS Eight RCTs with a total of 8915 participants (4545 invasive strategies, 4370 conservative strategies) were eligible for inclusion. We included three new studies and 1099 additional participants in this review update. In the all-study analysis, evidence did not show appreciable risk reductions in all-cause mortality (RR 0.87, 95% CI 0.64 to 1.18; eight studies, 8915 participants; low quality evidence) and death or non-fatal MI (RR 0.93, 95% CI 0.71 to 1.2; seven studies, 7715 participants; low quality evidence) with invasive strategies compared to conservative (selective invasive) strategies at six to 12 months follow-up. There was appreciable risk reduction in MI (RR 0.79, 95% CI 0.63 to 1.00; eight studies, 8915 participants; moderate quality evidence), refractory angina (RR 0.64, 95% CI 0.52 to 0.79; five studies, 8287 participants; moderate quality evidence) and re-hospitalisation (RR 0.77, 95% CI 0.63 to 0.94; six studies, 6921 participants; moderate quality evidence) with routine invasive strategies compared to conservative (selective invasive) strategies also at six to 12 months follow-up.Evidence also showed increased risks in bleeding (RR 1.73, 95% CI 1.30 to 2.31; six studies, 7584 participants; moderate quality evidence) and procedure-related MI (RR 1.87, 95% CI 1.47 to 2.37; five studies, 6380 participants; moderate quality evidence) with routine invasive strategies compared to conservative (selective invasive) strategies.The low quality evidence were as a result of serious risk of bias and imprecision in the estimate of effect while moderate quality evidence was only due to serious risk of bias. AUTHORS' CONCLUSIONS In the all-study analysis, the evidence failed to show appreciable benefit with routine invasive strategies for unstable angina and non-ST elevation MI compared to conservative strategies in all-cause mortality and death or non-fatal MI at six to 12 months. There was evidence of risk reduction in MI, refractory angina and re-hospitalisation with routine invasive strategies compared to conservative (selective invasive) strategies at six to 12 months follow-up. However, routine invasive strategies were associated with a relatively high risk (almost double the risk) of procedure-related MI, and increased risk of bleeding complications. This systematic analysis of published RCTs supports the conclusion that, in patients with UA/NSTEMI, a selectively invasive (conservative) strategy based on clinical risk for recurrent events is the preferred management strategy.
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Affiliation(s)
- Jonathon P Fanning
- The Prince Charles HospitalSchool of Medicine, The University of QueenslandRode RoadChermsideBrisbaneAustralia4032
| | - Jonathan Nyong
- FARR Institute UCLClinical Epidemiology222 Euston RoadLondonGreater LondonUKNW1 2DA
| | - Ian A Scott
- Princess Alexandra HospitalInternal Medicine Department and Clinical Services Evaluation UnitBrisbaneAustralia
| | - Constantine N Aroney
- The Prince Charles HospitalDepartment of CardiologyRode RdChermsideBrisbaneAustralia
| | - Darren L Walters
- The Prince Charles HospitalExecutive Chair Prince Charles Heart and Lung InstituteRoad RdBrisbaneQueenslandAustralia4032
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Cummins BM, Ligler FS, Walker GM. Point-of-care diagnostics for niche applications. Biotechnol Adv 2016; 34:161-76. [PMID: 26837054 PMCID: PMC4833668 DOI: 10.1016/j.biotechadv.2016.01.005] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2015] [Revised: 01/28/2016] [Accepted: 01/28/2016] [Indexed: 01/26/2023]
Abstract
Point-of-care or point-of-use diagnostics are analytical devices that provide clinically relevant information without the need for a core clinical laboratory. In this review we define point-of-care diagnostics as portable versions of assays performed in a traditional clinical chemistry laboratory. This review discusses five areas relevant to human and animal health where increased attention could produce significant impact: veterinary medicine, space travel, sports medicine, emergency medicine, and operating room efficiency. For each of these areas, clinical need, available commercial products, and ongoing research into new devices are highlighted.
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Affiliation(s)
- Brian M Cummins
- Joint Department of Biomedical Engineering, University of North Carolina - Chapel Hill and North Carolina State University, Raleigh, NC, 27695, USA
| | - Frances S Ligler
- Joint Department of Biomedical Engineering, University of North Carolina - Chapel Hill and North Carolina State University, Raleigh, NC, 27695, USA
| | - Glenn M Walker
- Joint Department of Biomedical Engineering, University of North Carolina - Chapel Hill and North Carolina State University, Raleigh, NC, 27695, USA.
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Saenger AK, Haymond S. Utilization of cardiac troponin assays in adult and pediatric populations: Guideline recommendations vs. reality. Clin Biochem 2015; 48:1213-8. [DOI: 10.1016/j.clinbiochem.2015.08.008] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2015] [Revised: 08/06/2015] [Accepted: 08/07/2015] [Indexed: 11/28/2022]
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Trost J, Feldman L. Creatine kinase-myocardial band for chest pain and suspected acute coronary syndrome. J Hosp Med 2015; 10:827-9. [PMID: 26769081 DOI: 10.1002/jhm.2384] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2014] [Revised: 03/26/2015] [Accepted: 04/28/2015] [Indexed: 11/08/2022]
Affiliation(s)
- Jeff Trost
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Leonard Feldman
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
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Faruq O, Vecchione A. microRNA: Diagnostic Perspective. Front Med (Lausanne) 2015; 2:51. [PMID: 26284247 PMCID: PMC4523054 DOI: 10.3389/fmed.2015.00051] [Citation(s) in RCA: 49] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2015] [Accepted: 07/17/2015] [Indexed: 12/15/2022] Open
Abstract
Biomarkers are biological measures of a biological state. An ideal marker should be safe and easy to measure, cost efficient, modifiable with treatment, and consistent across gender and ethnic groups. To date, none of the available biomarkers satisfy all of these criteria. In addition, the major limitations of these markers are low specificity, sensitivity, and false positive results. Recently identified, microRNAs (miRNAs) are endogenous, evolutionarily conserved small non-coding RNA (about 22–25 nt long), also known as micro-coordinators of gene expression, which have been shown to be an effective tools to study the biology of diseases and to have great potential as novel diagnostic and prognostic biomarkers with high specificity and sensitivity. In fact, it has been demonstrated that miRNAs play a pivotal role in the regulation of a wide range of developmental and physiological processes and their deficiencies have been related to a number of disease. In addition, miRNAs are stable and can be easily isolated and measured from tissues and body fluids. In this review, we provide a perspective on emerging concepts and potential usefulness of miRNAs as diagnostic markers, emphasizing the involvement of specific miRNAs in particular tumor types, subtypes, cardiovascular diseases, diabetes, infectious diseases, and forensic test.
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Affiliation(s)
- Omar Faruq
- Division of Pathology, Department of Clinical and Molecular Medicine, Faculty of Medicine and Psychology, Ospedale Santo Andrea, Sapienza University of Rome , Rome , Italy
| | - Andrea Vecchione
- Division of Pathology, Department of Clinical and Molecular Medicine, Faculty of Medicine and Psychology, Ospedale Santo Andrea, Sapienza University of Rome , Rome , Italy
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Sarlak H, Tanriseven M, Ardic S, Duran E. Creatine kinase-MB may lead to confusion in the ED. Am J Emerg Med 2015; 33:719. [PMID: 25682578 DOI: 10.1016/j.ajem.2015.01.050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2015] [Accepted: 01/27/2015] [Indexed: 11/29/2022] Open
Affiliation(s)
- Hakan Sarlak
- Department of Internal Medicine, Diyarbakır Military Hospital, Diyarbakır, Turkey.
| | - Mustafa Tanriseven
- Department of General Surgery, Diyarbakır Military Hospital, Diyarbakır, Turkey
| | - Sukru Ardic
- Department of Emergency, Elazıg Military Hospital, Elazıg, Turkey
| | - Eyup Duran
- Department of General Surgery, Elazıg Military Hospital, Elazıg, Turkey
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Utility of circulating microRNAs as clinical biomarkers for cardiovascular diseases. BIOMED RESEARCH INTERNATIONAL 2015; 2015:821823. [PMID: 25710029 PMCID: PMC4330947 DOI: 10.1155/2015/821823] [Citation(s) in RCA: 64] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/14/2014] [Accepted: 11/26/2014] [Indexed: 01/06/2023]
Abstract
MicroRNAs (miRNAs) are small noncoding RNA molecules that regulate gene and protein expression by translational repression and/or mRNA degradation. miRNAs are implicated in the pathogenesis of various cardiovascular diseases and have become potential targets for therapeutic intervention. Their stability and presence in variety of readily accessible cell types including whole blood, serum, plasma, and other body fluids render them as potential source of a clinical biomarker. This review provides a brief overview of miRNA biogenesis and function, the diagnostic potential of circulating extracellular miRNA and their specific role in vivo in various cardiovascular settings, and their future perspective as clinical biomarkers. It is clearly evident from experimental studies that miRNAs are responsible for the regulation of several biological functions and alterations in cardiovascular diseases. Current data supports the concept of using circulating miRNAs as a biomarker in cardiovascular disease. It remains to be seen, however, whether circulating miRNAs can fulfil this role to improve risk and severity prediction.
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Clinical and financial impact of removing creatine kinase-MB from the routine testing menu in the emergency setting. Am J Emerg Med 2015; 33:72-5. [DOI: 10.1016/j.ajem.2014.10.017] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2014] [Revised: 10/09/2014] [Accepted: 10/11/2014] [Indexed: 11/18/2022] Open
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The impact of cost displays on ordering. J Gen Intern Med 2014; 29:1331. [PMID: 24993087 PMCID: PMC4175660 DOI: 10.1007/s11606-014-2944-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Baron JM, Lewandrowski EL, Januzzi JL, Bajwa EK, Thompson BT, Lewandrowski KB. Measurement of high-sensitivity troponin T in noncardiac medical intensive care unit patients. Correlation to mortality and length of stay. Am J Clin Pathol 2014; 141:488-93. [PMID: 24619748 DOI: 10.1309/ajcplvqqy35xtfvn] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
Abstract
OBJECTIVES To assess the frequency, magnitude, and prognostic significance of elevations in cardiac troponin T in noncardiac critically ill patients, including elevations at levels below the limit of detection of traditional assays. METHODS Using a high-sensitivity assay, we measured troponin T (high-sensitivity troponin T [hsTnT]) in 451 unique patients within 12 hours of their admission to a noncardiac medical intensive care unit. Outcomes of patients, grouped by hsTnT level, were compared. RESULTS Overall, 98% of the study patients had detectable levels of hsTnT (>3 ng/L), and 33% had levels above the diagnostic cutoff of a traditional fourth-generation cardiac troponin T assay. Patient groups with higher hsTnT levels had markedly higher rates of in-hospital mortality (P < .001) and longer stays in the hospital and intensive care unit (P < .01). CONCLUSIONS In noncardiac critically ill patients, cardiac troponin T elevations are common but often at levels undetectable by traditional assays. hsTnT elevations predict a more complex clinical course and an increased risk of death.
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Affiliation(s)
- Jason M. Baron
- Department of Pathology and Divisions of Harvard Medical School, Boston, MA
- Harvard Medical School, Boston, MA
| | - Elizabeth L. Lewandrowski
- Department of Pathology and Divisions of Harvard Medical School, Boston, MA
- Harvard Medical School, Boston, MA
| | - James L. Januzzi
- Harvard Medical School, Boston, MA
- Cardiology, Massachusetts General Hospital, and Harvard Medical School, Boston, MA
| | - Ednan K. Bajwa
- Harvard Medical School, Boston, MA
- Pulmonary/Critical Care, Massachusetts General Hospital, and Harvard Medical School, Boston, MA
| | - B. Taylor Thompson
- Harvard Medical School, Boston, MA
- Pulmonary/Critical Care, Massachusetts General Hospital, and Harvard Medical School, Boston, MA
| | - Kent B. Lewandrowski
- Department of Pathology and Divisions of Harvard Medical School, Boston, MA
- Harvard Medical School, Boston, MA
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Abstract
OBJECTIVES To evaluate the clinical utility of and demand for the creatine kinase (CK)-MB assay. METHODS We examined the number of CK-MB tests from 2007 through 2013 while we progressively deemphasized their use. We first removed CK-MB from the acute coronary syndrome (ACS) panel and then from the main menu and observed the demand for the test. We also reviewed patient medical records to assess the appropriateness of its use. RESULTS After removing CK-MB from the ACS panel, the test volume dropped from around 12,000 per year to about 150 per year. In reviewing the records of 171 patients who had CK-MB determination done over a 28-month period, we discovered that CK-MB contributed to the diagnosis in only one patient, although it was not essential. Since removing CK-MB from the laboratory menu, two CK-MB tests were ordered in 4 months, and neither added value. CONCLUSIONS CK-MB determinations do not add value to information available from the troponin assay and can be safely removed from the laboratory menu.
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Affiliation(s)
- Gurmukh Singh
- School of Medicine, University of Missouri–Kansas City, Kansas City
- Truman Medical Center, Kansas City, MO
- Heritage Labs International, Olathe, KS
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40
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Blick KE. The Benefits of a Rapid, Point-of-Care “TnI-Only” Zero and 2-Hour Protocol for the Evaluation of Chest Pain Patients in the Emergency Department. Clin Lab Med 2014; 34:75-85, vi. [DOI: 10.1016/j.cll.2013.11.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Abstract
Cardiac troponins I and T have been the cornerstone of diagnostics of acute coronary syndrome for almost 20 years. Natriuretic peptides have established themselves in heart failure during the last decade. These and additional promising biomarkers, such as ST-2, galectin-3, GDF-15, copeptin, midregional proadrenomedullin, and the markers of glomerular filtration rate and kidney injury, are reviewed in groups corresponding to the pathophysiological processes they probe--cardiomyocyte injury, myocyte stress, inflammation, oxidative stress, plaque instability, extracellular-matrix remodeling, or those markers grouped in the neurohormone category. Biomarkers linking the renal and cardiac functions and microRNAs and metabolomic markers are addressed as well.
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Affiliation(s)
- Petr Jarolim
- Department of Pathology, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA.
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Abstract
The field of diagnosis is hardly static. Taking a step back, advances in diagnosis have been dramatic over the past few decades, and promise to accelerate going forward. Progress will be created through three main drivers: Continuing advances in the tools we use for diagnosis, adoption and use of electronic resources, and applying quality improvement strategies to reduce diagnostic error and variability.
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Affiliation(s)
- Mark L Graber
- 1RTI International and the Society to Improve Diagnosis in Medicine, 1 Breezy Hollow, St James, New York 11780, USA
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44
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Athamneh H, Basnawi A, Siler-Fisher A. CKMB and Acute Myocardial Infarction in the Emergency Department. J Emerg Med 2013; 45:617-8. [DOI: 10.1016/j.jemermed.2013.01.031] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2012] [Revised: 01/24/2013] [Accepted: 01/27/2013] [Indexed: 10/26/2022]
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45
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White HD, Thygesen K, Alpert JS, Jaffe AS. Clinical implications of the Third Universal Definition of Myocardial Infarction. Heart 2013; 100:424-32. [DOI: 10.1136/heartjnl-2012-302976] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
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Pleister A, Selemon H, Elton SM, Elton TS. Circulating miRNAs: novel biomarkers of acute coronary syndrome? Biomark Med 2013; 7:287-305. [PMID: 23547823 DOI: 10.2217/bmm.13.8] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Acute coronary syndrome refers to any group of clinical symptoms compatible with acute myocardial infarction (AMI). AMI is a major cause of death and disability worldwide with the greatest risk of death within the first hours of AMI onset. Therefore, delays in ‘ruling in’ AMI may increase morbidity and mortality due to the time lag in initiating therapy. Likewise, since the majority of patients presenting with acute chest pain do not have AMI, the rapid ‘ruling out’ of AMI in those patients would increase emergency department triage efficiency, decrease medical costs, and reduce morbidity and mortality. Thus, the identification of novel biomarkers that improve current strategies and/or accurately identify subjects who are at risk of developing acute and chronic manifestations of cardiovascular disease are desperately needed. This article discusses the potential of peripheral blood microRNAs as clinical biomarkers for the diagnosis and prognosis of cardiovascular diseases such as AMI.
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Affiliation(s)
- Adam Pleister
- Department of Internal Medicine, Division of Cardiovascular Medicine, The Ohio State University, 473 West 12th Avenue, OH 43210, USA
| | - Helina Selemon
- Davis Heart & Lung Research Institute, The Ohio State University, 473 West 12th Avenue, OH 43210, USA
| | | | - Terry S Elton
- College of Pharmacy, Division of Pharmacology, The Ohio State University, 473 West 12th Avenue, OH 43210, USA
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Akinina SA. PERIPROCEDURAL MYOCARDIAL DAMAGE. КАРДИОВАСКУЛЯРНАЯ ТЕРАПИЯ И ПРОФИЛАКТИКА 2013. [DOI: 10.15829/1728-8800-2013-1-95-101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
Percutaneous coronary intervention (PCI), as a method of myocardial revascularisation, is widely and effectively used for the treatment of coronary heart disease (CHD), with immediate success rates of >90%. Depending on the diagnostic criteria, 5–30% of these patients could develop the signs of periprocedural myocardial damage (PMD) or periprocedural myocardial infarction (PMI). PMD predictors, mechanisms of PMD development, and its specific clinical features play an important role in the PMI prevention. At present, there is no universal agreement on the definition and diagnostics of periprocedural myocardial necrosis and PMI, or on their impact on the clinical outcomes. According to the results of the recent studies, which are presented in this review, the current criteria of PMI might need to be modified, due to the increasingly high sensitivity of the modern threshold levels of troponin.
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Affiliation(s)
- S. A. Akinina
- Khanty-Mansiysk Autonomous District — Yugra, District Clinical Hospital, Khanty-Mansiysk
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Troponins in the definition of myocardial infarction after percutaneous coronary interventions. COR ET VASA 2013. [DOI: 10.1016/j.crvasa.2012.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Dong SY, Sun XN, Zeng Q, Xu Y, Sun J, Ma LH. Proteomic analysis of adverse outcomes in patients with acute coronary syndromes. Clin Chim Acta 2013. [DOI: 10.1016/j.cca.2012.11.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Abstract
The first intracellular Ca(2+)-sensor protein to be described was the troponin complex. Only later it was -discovered that cardiac-specific isoforms of troponin I (cTnI) and troponin T (cTnT) exist, and nowadays, measurement of cardiac troponins is a corner stone in the diagnosis of patients with acute coronary syndrome (ACS). High-sensitivity (hs-) assays have been developed that can record slightly elevated plasma concentrations of cardiac troponins as early as 3 h after onset of clinical symptoms. International guidelines defined a diagnostic cut-off at cardiac troponin levels corresponding to the 99th percentile of a healthy reference population and require that hs-assays measure this concentration with an interassay coefficient of variation ≤10%. This review provides an overview of the diagnostic and prognostic use of cardiac troponins.
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Affiliation(s)
- Danielle Hof
- Institute for Clinical Chemistry, University Hospital Zürich, Zürich, Switzerland
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