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Azzahhafi J, Chan Pin Yin DR, Epping M, Bofarid H, Rikken SA, Verhagen T, Boomars R, Radstok A, Houtgraaf J, Bikker A, Ten Berg JM. Pre-hospital evaluation of chest pain patients using the modified HEART-score: rationale and design. Future Cardiol 2024:1-10. [PMID: 38940186 DOI: 10.1080/14796678.2024.2356995] [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: 11/16/2023] [Accepted: 05/15/2024] [Indexed: 06/29/2024] Open
Abstract
Background: This study assesses how ambulance paramedics using the modified HEART-score with a point-of-care cardiac troponin (cTn) compare to the emergency physicians using the modified HEART-score with a high-sensitive cTn (hs-cTn) in patients with suspected non-ST-elevation acute coronary syndrome (NSTE-ACS), focusing on interobserver agreement and diagnostic performance. Methods: In this prospective multicenter cohort, we compare four cTn testing strategies (serial point of care and hs-cTn cTn measurement) with and without the HEART-score. Outcomes include the HEART-score's interobserver agreement, NSTE-ACS at discharge, major adverse cardiovascular events (MACE) after 30 days, and diagnostic accuracy of the different strategies. Conclusion: The POPular HEART study aims to improve NSTE-ACS diagnostic pathways, promoting pre-hospital detection and ruling out of NSTE-ACS to minimize unnecessary hospitalizations and associated costs.Clinical Trial Registration: NCT04851418 (ClinicalTrials.gov).
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Affiliation(s)
- Jaouad Azzahhafi
- Department of Cardiology, St. Antonius Hospital, Nieuwegein 3435CM, The Netherlands
| | | | - Mirjam Epping
- Department of Cardiology, Diakonessenhuis Hospital, Utrecht 3582 KE, The Netherlands
| | - Hajar Bofarid
- Department of Cardiology, St. Antonius Hospital, Nieuwegein 3435CM, The Netherlands
| | - Sem Aof Rikken
- Department of Cardiology, St. Antonius Hospital, Nieuwegein 3435CM, The Netherlands
| | - Thijs Verhagen
- Regionale Ambulance Voorziening Utrecht, Utrecht 3723 BC, The Netherlands
- Department of Emergency Medicine, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Rene Boomars
- Regionale Ambulance Voorziening Utrecht, Utrecht 3723 BC, The Netherlands
| | - Anja Radstok
- Regionale Ambulance Voorziening Utrecht, Utrecht 3723 BC, The Netherlands
| | - Jaco Houtgraaf
- Department of Cardiology, Diakonessenhuis Hospital, Utrecht 3582 KE, The Netherlands
| | - Angela Bikker
- Department of Clinical Chemistry - Saltro part of Unilabs, Utrecht 3565 CE, The Netherlands
- Department of Clinical Chemistry - St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Jurriën M Ten Berg
- Department of Cardiology, St. Antonius Hospital, Nieuwegein 3435CM, The Netherlands
- Department of Cardiology, University Medical Center Maastricht, Maastricht 6229 HX, The Netherlands
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Li Y, Fang Q, Wu Z, Huang S, Ge W, Shen J, Zhu H. Population pharmacokinetics and dosage optimization of linezolid in Chinese older patients. Eur J Clin Pharmacol 2024:10.1007/s00228-024-03702-9. [PMID: 38801422 DOI: 10.1007/s00228-024-03702-9] [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: 02/18/2024] [Accepted: 05/13/2024] [Indexed: 05/29/2024]
Abstract
PURPOSE To assess the pharmacokinetics and pharmacodynamics of linezolid in a retrospective cohort of hospitalized Chinese older patients. METHODS Patients > 60 years of age, who received intravenous linezolid (600 mg), were included. A population pharmacokinetics (PPK) model was established using nonlinear mixed-effects modeling. The predictive performance of the final model was assessed using goodness-of-fit plots, bootstrap analyses, and visual predictive checks. Monte Carlo simulations were used to evaluate the achievement of a pharmacodynamics target for the area under the serum concentration-time curve/minimum inhibitory concentration (AUC0-24/MIC). RESULTS A total of 210 samples were collected from 120 patients. A one-compartment PPK model with linear elimination best predicted the linezolid plasma concentrations. Linezolid clearance (CL) was 4.22 L h-1 and volume of distribution (Vd) was 45.80 L; serum uric acid (SUA) was a significant covariate of CL. CONCLUSION The results of this study indicated that the standard dose was associated with a risk of overexposure in older patients, particularly those with high SUA values; these patients would benefit from a lower dose (300 mg every 12 h).
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Affiliation(s)
- Yuanchen Li
- Department of Pharmacy, Nanjing Drum Tower Hospital, China Pharmaceutical University, Nanjing, China
| | - Qiu Fang
- Department of Pharmacy, Nanjing Drum Tower Hospital, Nanjing Drum Tower Hospital Clinical College, Nanjing University of Chinese Medicine, 321 Zhongshan Road, Nanjing, Jiangsu, 210008, China
| | - Zejun Wu
- Department of Pharmacy, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, 321 Zhongshan Road, Nanjing, Jiangsu, 210008, China
| | - Siqi Huang
- Department of Pharmacy, Nanjing Drum Tower Hospital, Nanjing Drum Tower Hospital Clinical College, Nanjing University of Chinese Medicine, 321 Zhongshan Road, Nanjing, Jiangsu, 210008, China
| | - Weihong Ge
- Department of Pharmacy, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, 321 Zhongshan Road, Nanjing, Jiangsu, 210008, China
- Nanjing Medical Center for Clinical Pharmacy, Nanjing, China
| | - Jizhong Shen
- Department of Pharmacy, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, 321 Zhongshan Road, Nanjing, Jiangsu, 210008, China.
- Nanjing Medical Center for Clinical Pharmacy, Nanjing, China.
| | - Huaijun Zhu
- Department of Pharmacy, Nanjing Drum Tower Hospital, Nanjing Drum Tower Hospital Clinical College, Nanjing University of Chinese Medicine, 321 Zhongshan Road, Nanjing, Jiangsu, 210008, China.
- Nanjing Medical Center for Clinical Pharmacy, Nanjing, China.
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3
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Boeddinghaus J, Doudesis D, Lopez-Ayala P, Lee KK, Koechlin L, Wildi K, Nestelberger T, Borer R, Miró Ò, Martin-Sanchez FJ, Strebel I, Rubini Giménez M, Keller DI, Christ M, Bularga A, Li Z, Ferry AV, Tuck C, Anand A, Gray A, Mills NL, Mueller C. Machine Learning for Myocardial Infarction Compared With Guideline-Recommended Diagnostic Pathways. Circulation 2024; 149:1090-1101. [PMID: 38344871 DOI: 10.1161/circulationaha.123.066917] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Accepted: 01/16/2024] [Indexed: 02/29/2024]
Abstract
BACKGROUND Collaboration for the Diagnosis and Evaluation of Acute Coronary Syndrome (CoDE-ACS) is a validated clinical decision support tool that uses machine learning with or without serial cardiac troponin measurements at a flexible time point to calculate the probability of myocardial infarction (MI). How CoDE-ACS performs at different time points for serial measurement and compares with guideline-recommended diagnostic pathways that rely on fixed thresholds and time points is uncertain. METHODS Patients with possible MI without ST-segment-elevation were enrolled at 12 sites in 5 countries and underwent serial high-sensitivity cardiac troponin I concentration measurement at 0, 1, and 2 hours. Diagnostic performance of the CoDE-ACS model at each time point was determined for index type 1 MI and the effectiveness of previously validated low- and high-probability scores compared with guideline-recommended European Society of Cardiology (ESC) 0/1-hour, ESC 0/2-hour, and High-STEACS (High-Sensitivity Troponin in the Evaluation of Patients With Suspected Acute Coronary Syndrome) pathways. RESULTS In total, 4105 patients (mean age, 61 years [interquartile range, 50-74]; 32% women) were included, among whom 575 (14%) had type 1 MI. At presentation, CoDE-ACS identified 56% of patients as low probability, with a negative predictive value and sensitivity of 99.7% (95% CI, 99.5%-99.9%) and 99.0% (98.6%-99.2%), ruling out more patients than the ESC 0-hour and High-STEACS (25% and 35%) pathways. Incorporating a second cardiac troponin measurement, CoDE-ACS identified 65% or 68% of patients as low probability at 1 or 2 hours, for an identical negative predictive value of 99.7% (99.5%-99.9%); 19% or 18% as high probability, with a positive predictive value of 64.9% (63.5%-66.4%) and 68.8% (67.3%-70.1%); and 16% or 14% as intermediate probability. In comparison, after serial measurements, the ESC 0/1-hour, ESC 0/2-hour, and High-STEACS pathways identified 49%, 53%, and 71% of patients as low risk, with a negative predictive value of 100% (99.9%-100%), 100% (99.9%-100%), and 99.7% (99.5%-99.8%); and 20%, 19%, or 29% as high risk, with a positive predictive value of 61.5% (60.0%-63.0%), 65.8% (64.3%-67.2%), and 48.3% (46.8%-49.8%), resulting in 31%, 28%, or 0%, who require further observation in the emergency department, respectively. CONCLUSIONS CoDE-ACS performs consistently irrespective of the timing of serial cardiac troponin measurement, identifying more patients as low probability with comparable performance to guideline-recommended pathways for MI. Whether care guided by probabilities can improve the early diagnosis of MI requires prospective evaluation. REGISTRATION URL: https://www.clinicaltrials.gov; Unique identifier: NCT00470587.
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Affiliation(s)
- Jasper Boeddinghaus
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology (J.B., P.L.-A., L.K., K.W., T.N., R.B., I.S., M.R.G., C.M.), University Hospital Basel, University of Basel, Switzerland
- BHF/University Centre for Cardiovascular Science (J.B., D.D., K.K.L., A.B., Z.L., A.V.F., C.T., A.A., N.L.M.), University of Edinburgh, UK
| | - Dimitrios Doudesis
- BHF/University Centre for Cardiovascular Science (J.B., D.D., K.K.L., A.B., Z.L., A.V.F., C.T., A.A., N.L.M.), University of Edinburgh, UK
- Usher Institute (D.D., K.K.L., A.G., N.L.M.), University of Edinburgh, UK
| | - Pedro Lopez-Ayala
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology (J.B., P.L.-A., L.K., K.W., T.N., R.B., I.S., M.R.G., C.M.), University Hospital Basel, University of Basel, Switzerland
| | - Kuan Ken Lee
- BHF/University Centre for Cardiovascular Science (J.B., D.D., K.K.L., A.B., Z.L., A.V.F., C.T., A.A., N.L.M.), University of Edinburgh, UK
- Usher Institute (D.D., K.K.L., A.G., N.L.M.), University of Edinburgh, UK
| | - Luca Koechlin
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology (J.B., P.L.-A., L.K., K.W., T.N., R.B., I.S., M.R.G., C.M.), University Hospital Basel, University of Basel, Switzerland
- Departments of Cardiac Surgery (L.K.), University Hospital Basel, University of Basel, Switzerland
| | - Karin Wildi
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology (J.B., P.L.-A., L.K., K.W., T.N., R.B., I.S., M.R.G., C.M.), University Hospital Basel, University of Basel, Switzerland
- Intensive Care (K.W.), University Hospital Basel, University of Basel, Switzerland
| | - Thomas Nestelberger
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology (J.B., P.L.-A., L.K., K.W., T.N., R.B., I.S., M.R.G., C.M.), University Hospital Basel, University of Basel, Switzerland
| | - Raphael Borer
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology (J.B., P.L.-A., L.K., K.W., T.N., R.B., I.S., M.R.G., C.M.), University Hospital Basel, University of Basel, Switzerland
| | - Òscar Miró
- Emergency Department, Hospital Clinic, Barcelona, Catalonia, Spain (Ò.M.)
| | | | - Ivo Strebel
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology (J.B., P.L.-A., L.K., K.W., T.N., R.B., I.S., M.R.G., C.M.), University Hospital Basel, University of Basel, Switzerland
| | - Maria Rubini Giménez
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology (J.B., P.L.-A., L.K., K.W., T.N., R.B., I.S., M.R.G., C.M.), University Hospital Basel, University of Basel, Switzerland
| | - Dagmar I Keller
- Emergency Department, University Hospital Zurich, Switzerland (D.I.K.)
| | - Michael Christ
- Emergency Department, Kantonsspital Luzern, Switzerland (M.C.)
| | - Anda Bularga
- BHF/University Centre for Cardiovascular Science (J.B., D.D., K.K.L., A.B., Z.L., A.V.F., C.T., A.A., N.L.M.), University of Edinburgh, UK
| | - Ziwen Li
- BHF/University Centre for Cardiovascular Science (J.B., D.D., K.K.L., A.B., Z.L., A.V.F., C.T., A.A., N.L.M.), University of Edinburgh, UK
| | - Amy V Ferry
- BHF/University Centre for Cardiovascular Science (J.B., D.D., K.K.L., A.B., Z.L., A.V.F., C.T., A.A., N.L.M.), University of Edinburgh, UK
| | - Chris Tuck
- BHF/University Centre for Cardiovascular Science (J.B., D.D., K.K.L., A.B., Z.L., A.V.F., C.T., A.A., N.L.M.), University of Edinburgh, UK
| | - Atul Anand
- BHF/University Centre for Cardiovascular Science (J.B., D.D., K.K.L., A.B., Z.L., A.V.F., C.T., A.A., N.L.M.), University of Edinburgh, UK
| | - Alasdair Gray
- Usher Institute (D.D., K.K.L., A.G., N.L.M.), University of Edinburgh, UK
- Emergency Medicine Research Group Edinburgh, Royal Infirmary of Edinburgh, UK (A.G.)
| | - Nicholas L Mills
- BHF/University Centre for Cardiovascular Science (J.B., D.D., K.K.L., A.B., Z.L., A.V.F., C.T., A.A., N.L.M.), University of Edinburgh, UK
- Usher Institute (D.D., K.K.L., A.G., N.L.M.), University of Edinburgh, UK
| | - Christian Mueller
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology (J.B., P.L.-A., L.K., K.W., T.N., R.B., I.S., M.R.G., C.M.), University Hospital Basel, University of Basel, Switzerland
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Ohno M, Shiomi H, Baba O, Yano M, Aizawa T, Nakano-Matsumura Y, Yamagami S, Kato M, Ohya M, Chen PM, Nagao K, Ando K, Yokomatsu T, Kadota K, Kouchi I, Inada T, Valentine C, Kitagawa T, Kurokawa M, Ohtsuru S, Morimoto T, Kimura T, Nishi E. Auxiliary roles of nardilysin in the early diagnosis of acute coronary syndrome: a prospective cohort study, the Nardi-ACS study. Intern Emerg Med 2024; 19:649-659. [PMID: 38233578 PMCID: PMC11039555 DOI: 10.1007/s11739-023-03508-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Accepted: 12/06/2023] [Indexed: 01/19/2024]
Abstract
Acute coronary syndrome (ACS) includes myocardial infarction (MI) and unstable angina (UA). MI is defined by elevated necrosis markers, preferably high-sensitivity cardiac troponins (hs-cTn). However, it takes hours for cTn to become elevated after coronary occlusion; therefore, difficulties are associated with diagnosing early post-onset MI or UA. The aim of this prospective cohort study was to examine the diagnostic ability of serum nardilysin (NRDC) for the early detection of ACS. This study consisted of two sequential cohorts, the Phase I cohort, 435 patients presenting to the emergency room (ER) with chest pain, and the Phase II cohort, 486 patients with chest pain who underwent coronary angiography. The final diagnosis was ACS in 155 out of 435 patients (35.6%) in the phase I and 418 out of 486 (86.0%) in the phase II cohort. Among 680 patients who presented within 24 h of onset, 466 patients (68.5%) were diagnosed with ACS. Serum NRDC levels were significantly higher in patients with ACS than in those without ACS. The sensitivity of NRDC in patients who presented within 6 h after the onset was higher than that of hsTnI, and the AUC of NRDC within 1 h of the onset was higher than that of hsTnI (0.718 versus 0.633). Among hsTnI-negative patients (300 of 680 patients: 44.1%), 136 of whom (45.3%) were diagnosed with ACS, the sensitivity and the NPV of NRDC were 73.5 and 65.7%, respectively. When measured in combination with hsTnI, NRDC plays auxiliary roles in the early diagnosis of ACS.
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Affiliation(s)
- Mikiko Ohno
- Department of Pharmacology, Shiga University of Medical Science, Seta Tsukinowa-Cho, Otsu, Shiga, 520-2192, Japan.
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University, 54 Shogoin-Kawahara-Cho, Sakyo-Ku, Kyoto, 606-8507, Japan.
| | - Hiroki Shiomi
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University, 54 Shogoin-Kawahara-Cho, Sakyo-Ku, Kyoto, 606-8507, Japan
| | - Osamu Baba
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University, 54 Shogoin-Kawahara-Cho, Sakyo-Ku, Kyoto, 606-8507, Japan
- Preemptive Medicine and Lifestyle Disease Research Center, Kyoto University Hospital, 54 Shogoinkawahara-Cho, Sakyo-Ku, Kyoto, 606-8507, Japan
| | - Mariko Yano
- Kokura Memorial Hospital, 3-2-1 Asano, Kita-Ku, Kokura, Kitakyushu, Fukuoka, 802-8555, Japan
| | - Takanori Aizawa
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University, 54 Shogoin-Kawahara-Cho, Sakyo-Ku, Kyoto, 606-8507, Japan
| | - Yukiko Nakano-Matsumura
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University, 54 Shogoin-Kawahara-Cho, Sakyo-Ku, Kyoto, 606-8507, Japan
| | - Shintaro Yamagami
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University, 54 Shogoin-Kawahara-Cho, Sakyo-Ku, Kyoto, 606-8507, Japan
| | - Masashi Kato
- Mitsubishi Kyoto Hospital, 1, Katsuragoshomachi, Nishikyo-Ku, Kyoto, 615-8087, Japan
| | - Masanobu Ohya
- Kurashiki Central Hospital, 1-1-1 Miwa, Kurashiki, Okayama, 710-8602, Japan
| | - Po-Min Chen
- Saiseikai Noe Hospital, 1-3-25, Furuichi, Joto-Ku, Osaka, 536-0001, Japan
| | - Kazuya Nagao
- Osaka Red-Cross Hospital, 5-30 Fudegasakicho, Tennoji-Ku, Osaka, 543-8555, Japan
| | - Kenji Ando
- Kokura Memorial Hospital, 3-2-1 Asano, Kita-Ku, Kokura, Kitakyushu, Fukuoka, 802-8555, Japan
| | - Takafumi Yokomatsu
- Mitsubishi Kyoto Hospital, 1, Katsuragoshomachi, Nishikyo-Ku, Kyoto, 615-8087, Japan
| | - Kazushige Kadota
- Kurashiki Central Hospital, 1-1-1 Miwa, Kurashiki, Okayama, 710-8602, Japan
| | - Ichiro Kouchi
- Saiseikai Noe Hospital, 1-3-25, Furuichi, Joto-Ku, Osaka, 536-0001, Japan
| | - Tsukasa Inada
- Osaka Red-Cross Hospital, 5-30 Fudegasakicho, Tennoji-Ku, Osaka, 543-8555, Japan
| | - Cindy Valentine
- Sanyo Chemical Industries, 11-1 Hitotsubashi Nomoto, Higashiyama, Kyoto, 605-0995, Japan
| | - Takahiro Kitagawa
- Sanyo Chemical Industries, 11-1 Hitotsubashi Nomoto, Higashiyama, Kyoto, 605-0995, Japan
| | - Masato Kurokawa
- Sanyo Chemical Industries, 11-1 Hitotsubashi Nomoto, Higashiyama, Kyoto, 605-0995, Japan
| | - Shigeru Ohtsuru
- Department of Primary Care and Emergency Medicine, Graduate School of Medicine, Kyoto University, 54 Shogoinkawahara-Cho, Sakyo-Ku, Kyoto, 606-8507, Japan
| | - Takeshi Morimoto
- Hyogo College of Medicine, 1-1, Mukogawa-Cho, Nishinomiya, Hyogo, 663-8501, Japan
| | - Takeshi Kimura
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University, 54 Shogoin-Kawahara-Cho, Sakyo-Ku, Kyoto, 606-8507, Japan
- Hirakata Kosai Hospital, 1-2-1, Fujibanto-Cho, Hirakata, Osaka, 573-0153, Japan
| | - Eiichiro Nishi
- Department of Pharmacology, Shiga University of Medical Science, Seta Tsukinowa-Cho, Otsu, Shiga, 520-2192, Japan.
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University, 54 Shogoin-Kawahara-Cho, Sakyo-Ku, Kyoto, 606-8507, Japan.
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Rao C, Zhong Q, Wu R, Li Z, Duan Y, Zhou Y, Wang C, Chen X, Wang R, He K. Impact of body mass index on long-term outcomes in patients undergoing percutaneous coronary intervention stratified by diabetes mellitus: a retrospective cohort study. BMC Cardiovasc Disord 2024; 24:113. [PMID: 38365597 PMCID: PMC10874050 DOI: 10.1186/s12872-024-03770-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Accepted: 02/05/2024] [Indexed: 02/18/2024] Open
Abstract
BACKGROUND Patients with diabetes mellitus (DM) caused by obesity have increased in recent years. The impact of obesity on long-term outcomes in patients undergoing percutaneous coronary intervention (PCI) with or without DM remains unclear. METHODS We retrospectively analysed data from 1918 patients who underwent PCI. Patients were categorized into four groups based on body mass index (BMI, normal weight: BMI < 25 kg/m2; overweight and obese: BMI ≥ 25 kg/m2) and DM status (presence or absence). The primary endpoint was the occurrence of major adverse cardiac and cerebrovascular events (MACCE; defined as all-cause death, myocardial infarction, stroke, and unplanned repeat revascularization). RESULTS During a median follow-up of 7.0 years, no significant differences in MACCE, myocardial infarction, or stroke were observed among the four groups. Overweight and obese individuals exhibited lower all-cause mortality rates compared with normal-weight patients (without DM: hazard ratio [HR]: 0.54, 95% confidence interval [CI]: 0.37 to 0.78; with DM: HR: 0.57, 95% CI: 0.38 to 0.86). In non-diabetic patients, the overweight and obese group demonstrated a higher risk of unplanned repeat revascularization than the normal-weight group (HR:1.23, 95% CI:1.03 to 1.46). After multivariable adjustment, overweight and obesity were not significantly associated with MACCE, all-cause death, myocardial infarction, stroke, or unplanned repeat revascularization in patients with and without diabetes undergoing PCI. CONCLUSION Overweight and obesity did not demonstrate a significant protective effect on long-term outcomes in patients with and without diabetes undergoing PCI.
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Affiliation(s)
- Chongyou Rao
- Medical Big Data Research Center, Medical Innovation Research Division of Chinese, PLA General Hospital, 28 Fuxing RD, Beijing, 100853, China
- Graduate School of Chinese, PLA General Hospital, Beijing, 100853, China
| | - Qin Zhong
- Medical Big Data Research Center, Medical Innovation Research Division of Chinese, PLA General Hospital, 28 Fuxing RD, Beijing, 100853, China
- Graduate School of Chinese, PLA General Hospital, Beijing, 100853, China
| | - Rilige Wu
- Medical Big Data Research Center, Medical Innovation Research Division of Chinese, PLA General Hospital, 28 Fuxing RD, Beijing, 100853, China
| | - Zongren Li
- Medical Big Data Research Center, Medical Innovation Research Division of Chinese, PLA General Hospital, 28 Fuxing RD, Beijing, 100853, China
| | - Yongjie Duan
- Medical Big Data Research Center, Medical Innovation Research Division of Chinese, PLA General Hospital, 28 Fuxing RD, Beijing, 100853, China
| | - You Zhou
- School of Medicine, Nankai University, Tianjin, 300071, China
| | - Chi Wang
- Medical Big Data Research Center, Medical Innovation Research Division of Chinese, PLA General Hospital, 28 Fuxing RD, Beijing, 100853, China
| | - Xu Chen
- Medical Big Data Research Center, Medical Innovation Research Division of Chinese, PLA General Hospital, 28 Fuxing RD, Beijing, 100853, China
| | - Ruiqing Wang
- Medical Big Data Research Center, Medical Innovation Research Division of Chinese, PLA General Hospital, 28 Fuxing RD, Beijing, 100853, China
| | - Kunlun He
- Medical Big Data Research Center, Medical Innovation Research Division of Chinese, PLA General Hospital, 28 Fuxing RD, Beijing, 100853, China.
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Byrne RA, Rossello X, Coughlan JJ, Barbato E, Berry C, Chieffo A, Claeys MJ, Dan GA, Dweck MR, Galbraith M, Gilard M, Hinterbuchner L, Jankowska EA, Jüni P, Kimura T, Kunadian V, Leosdottir M, Lorusso R, Pedretti RFE, Rigopoulos AG, Rubini Gimenez M, Thiele H, Vranckx P, Wassmann S, Wenger NK, Ibanez B. 2023 ESC Guidelines for the management of acute coronary syndromes. EUROPEAN HEART JOURNAL. ACUTE CARDIOVASCULAR CARE 2024; 13:55-161. [PMID: 37740496 DOI: 10.1093/ehjacc/zuad107] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/24/2023]
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7
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Alazrag W, Idris H, Saad YM, Etaher A, Ren S, Ferguson I, Juergens C, Chew DP, Otton J, Middleton PM, French JK. Management and outcomes with 5-year mortality of patients with mildly elevated high-sensitivity troponin T levels not meeting criteria for myocardial infarction. Emerg Med Australas 2024; 36:62-70. [PMID: 37705175 DOI: 10.1111/1742-6723.14298] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Revised: 05/12/2023] [Accepted: 08/08/2023] [Indexed: 09/15/2023]
Abstract
OBJECTIVES To examine management and outcomes of patients presenting to EDs with symptoms suggestive of acute coronary syndrome, who have mild non-dynamically elevated high-sensitivity troponin T (HsTnT) levels, not meeting the fourth universal definition of myocardial infarction (MI) criteria (observation group). METHODS Consecutive patients presenting to the ED with symptoms suggestive of acute coronary syndrome at Liverpool Hospital, Sydney, Australia, those having ≥2 HsTnT levels after initial assessment were adjudicated according to the fourth universal definition of MI, as MI ruled-in, MI ruled-out, or myocardial injury in whom MI is neither ruled-in nor ruled-out (>1 level ≥15 ng/L, called observation group); follow-up was 5 years. RESULTS Of 2738 patients, 547 were in the observation group, of whom 62% were admitted to hospital, 52% to cardiac services, whereas 97% of MI ruled-in patients and 21% of MI ruled-out patients were admitted; P < 0.001. Non-invasive testing occurred in 42% of observation group patients (36% had echo-cardiography), and 16% had coronary angiography. Of observation group patients, MI rates were 1.5% during hospitalisation and 4% during the following year, similar to that in those with MI ruled-in, among those with MI ruled-out, the MI rate was 0.2%. The 1-year death rate was 13% among observation group patients and 11% MI ruled-in patients (P = 0.624), whereas at 5 years among observation group patients, type 1 MI and type 2 MI were 48%, 26% and 58%, respectively (P = 0.001). CONCLUSION Very few unselected consecutive patients attending ED, with minor stable HsTnT elevation, had MI, although most had chronic myocardial injury. Late mortality rates among observation group patients were higher than those with confirmed type 1 MI but lower than those with type 2 MI.
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Affiliation(s)
- Weaam Alazrag
- Department of Cardiology, Liverpool Hospital, Sydney, New South Wales, Australia
- South Western Sydney Clinical School, The University of New South Wales, Sydney, New South Wales, Australia
| | - Hanan Idris
- Department of Cardiology, Liverpool Hospital, Sydney, New South Wales, Australia
- South Western Sydney Clinical School, The University of New South Wales, Sydney, New South Wales, Australia
| | - Yousef Me Saad
- Department of Cardiology, Liverpool Hospital, Sydney, New South Wales, Australia
- South Western Sydney Clinical School, The University of New South Wales, Sydney, New South Wales, Australia
| | - Aisha Etaher
- Department of Cardiology, Liverpool Hospital, Sydney, New South Wales, Australia
- South Western Sydney Clinical School, The University of New South Wales, Sydney, New South Wales, Australia
| | - Shiquan Ren
- South Western Sydney Clinical School, The University of New South Wales, Sydney, New South Wales, Australia
- Ingham Institute for Applied Medical Research, Sydney, New South Wales, Australia
| | - Ian Ferguson
- South Western Sydney Clinical School, The University of New South Wales, Sydney, New South Wales, Australia
- Department of Emergency Medicine, Liverpool Hospital, Sydney, New South Wales, Australia
| | - Craig Juergens
- Department of Cardiology, Liverpool Hospital, Sydney, New South Wales, Australia
- South Western Sydney Clinical School, The University of New South Wales, Sydney, New South Wales, Australia
| | - Derek P Chew
- College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia
- South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia
- South Australian Department of Health, Adelaide, South Australia, Australia
| | - James Otton
- Department of Cardiology, Liverpool Hospital, Sydney, New South Wales, Australia
- South Western Sydney Clinical School, The University of New South Wales, Sydney, New South Wales, Australia
| | - Paul M Middleton
- South Western Sydney Clinical School, The University of New South Wales, Sydney, New South Wales, Australia
- Ingham Institute for Applied Medical Research, Sydney, New South Wales, Australia
- Department of Emergency Medicine, Liverpool Hospital, Sydney, New South Wales, Australia
| | - John K French
- Department of Cardiology, Liverpool Hospital, Sydney, New South Wales, Australia
- South Western Sydney Clinical School, The University of New South Wales, Sydney, New South Wales, Australia
- Ingham Institute for Applied Medical Research, Sydney, New South Wales, Australia
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8
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Hasselbalch RB, Alaour B, Kristensen JH, Couch LS, Kaier TE, Nielsen TL, Plesner LL, Strandkjær N, Schou M, Rydahl C, Goetze JP, Bundgaard H, Marber M, Iversen KK. Hemodialysis and biomarkers of myocardial infarction - a cohort study. Clin Chem Lab Med 2024; 62:361-370. [PMID: 37556843 DOI: 10.1515/cclm-2023-0071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Accepted: 07/24/2023] [Indexed: 08/11/2023]
Abstract
OBJECTIVES End-stage renal disease is associated with a high risk of cardiovascular disease. We compared the concentration and prognostic ability of high sensitivity cardiac troponin T (hs-cTnT) and I (hs-cTnI) and cardiac myosin-binding protein C (cMyC) among stable hemodialysis patients. METHODS Patients were sampled before and after hemodialysis. We measured hs-cTnI, hs-cTnT and cMyC and used Cox regressions to assess the association between quartiles of concentrations and all-cause mortality and a combination of cardiovascular events and all-cause mortality during follow-up. RESULTS A total of 307 patients were included, 204 males, mean age 66 years (SD 14). Before dialysis, 299 (99 %) had a hs-cTnT concentration above the 99th percentile, compared to 188 (66 %) for cMyC and 35 (11 %) for hs-cTnI. Hs-cTnT (23 %, p<0.001) and hs-cTnI (15 %, p=0.049) but not cMyC (4 %, p=0.256) decreased during dialysis. Follow-up was a median of 924 days (492-957 days); patients in the 3rd and 4th quartiles of hs-cTnT (3rd:HR 3.0, 95 % CI 1.5-5.8, 4th:5.2, 2.7-9.8) and the 4th quartile of hs-cTnI (HR 3.8, 2.2-6.8) had an increased risk of mortality. Both were associated with an increased risk of the combined endpoint for patients in the 3rd and 4th quartiles. cMyC concentrations were not associated with risk of mortality or cardiovascular event. CONCLUSIONS Hs-cTnT was above the 99th percentile in almost all patients. This was less frequent for hs-cTnI and cMyC. High cTn levels were associated with a 3-5-fold higher mortality. This association was not present for cMyC. These findings are important for management of hemodialysis patients.
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Affiliation(s)
- Rasmus Bo Hasselbalch
- Department of Cardiology, Copenhagen University Hospital - Herlev and Gentofte Hospital, Copenhagen, Denmark
- Department of Emergency Medicine, Copenhagen University Hospital - Herlev and Gentofte Hospital, Copenhagen, Denmark
| | - Bashir Alaour
- King's College London British Heart Foundation Centre, Rayne Institute, St Thomas' Hospital, London, UK
| | - Jonas Henrik Kristensen
- Department of Cardiology, Copenhagen University Hospital - Herlev and Gentofte Hospital, Copenhagen, Denmark
- Department of Emergency Medicine, Copenhagen University Hospital - Herlev and Gentofte Hospital, Copenhagen, Denmark
| | - Liam S Couch
- King's College London British Heart Foundation Centre, Rayne Institute, St Thomas' Hospital, London, UK
| | - Thomas E Kaier
- King's College London British Heart Foundation Centre, Rayne Institute, St Thomas' Hospital, London, UK
| | - Ture Lange Nielsen
- Department of Cardiology, Copenhagen University Hospital - Herlev and Gentofte Hospital, Copenhagen, Denmark
| | - Louis Lind Plesner
- Department of Cardiology, Copenhagen University Hospital - Herlev and Gentofte Hospital, Copenhagen, Denmark
| | - Nina Strandkjær
- Department of Cardiology, Copenhagen University Hospital - Herlev and Gentofte Hospital, Copenhagen, Denmark
- Department of Emergency Medicine, Copenhagen University Hospital - Herlev and Gentofte Hospital, Copenhagen, Denmark
| | - Morten Schou
- Department of Cardiology, Copenhagen University Hospital - Herlev and Gentofte Hospital, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Casper Rydahl
- Department of Nephrology, Copenhagen University Hospital - Herlev and Gentofte Hospital, Copenhagen, Denmark
| | - Jens P Goetze
- Department of Clinical Biochemistry, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Henning Bundgaard
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Department of Cardiology, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Michael Marber
- King's College London British Heart Foundation Centre, Rayne Institute, St Thomas' Hospital, London, UK
| | - Kasper Karmark Iversen
- Department of Cardiology, Copenhagen University Hospital - Herlev and Gentofte Hospital, Copenhagen, Denmark
- Department of Emergency Medicine, Copenhagen University Hospital - Herlev and Gentofte Hospital, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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9
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Hti Lar Seng NS, Zeratsion G, Pena Zapata OY, Tufail MU, Jim B. Utility of Cardiac Troponins in Patients With Chronic Kidney Disease. Cardiol Rev 2024; 32:62-70. [PMID: 35617248 DOI: 10.1097/crd.0000000000000461] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Cardiovascular disease is a major cause of death worldwide especially in patients with chronic kidney disease (CKD). Troponin T and troponin I are cardiac biomarkers used not only to diagnose acute myocardial infarction (AMI) but also to prognosticate cardiovascular and all-cause mortality. The diagnosis of AMI in the CKD population is challenging because of their elevated troponins at baseline. The development of high-sensitivity cardiac troponins shortens the time needed to rule in and rule out AMI in patients with normal renal function. While the sensitivity of high-sensitivity cardiac troponins is preserved in the CKD population, the specificity of these tests is compromised. Hence, diagnosing AMI in CKD remains problematic even with the introduction of high-sensitivity assays. The prognostic significance of troponins did not differ whether it is detected with standard or high-sensitivity assays. The elevation of both troponin T and troponin I in CKD patients remains strongly correlated with adverse cardiovascular and all-cause mortality, and the prognosis becomes poorer with advanced CKD stages. Interestingly, the degree of troponin elevation appears to be predictive of the rate of renal decline via unclear mechanisms though activation of the renin-angiotensin and other hormonal/oxidative stress systems remain suspect. In this review, we present the latest evidence of the use of cardiac troponins in both the diagnosis of AMI and the prognosis of cardiovascular and all-cause mortality. We also suggest strategies to improve on the diagnostic capability of these troponins in the CKD/end-stage kidney disease population.
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Affiliation(s)
- Nang San Hti Lar Seng
- From the Division of Nephrology/Department of Medicine, Jacobi Medical Center at Albert Einstein College of Medicine, Bronx, NY
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10
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Zilinyi RS, Fertel BS, Chang BC, Abrukin L, Suh EH, Sayan OR, McCarty M, Stant JA, Chuich T, Smyth ET, Neuberg G, Collins MB, Kirtane AJ, Moses J, Rabbani L. Updating a Healthcare System-wide Clinical Pathway for Managing Chest Pain and Acute Coronary Syndromes. Crit Pathw Cardiol 2023; 22:103-109. [PMID: 37782621 DOI: 10.1097/hpc.0000000000000334] [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] [Indexed: 10/04/2023]
Abstract
Clinical pathways are useful tools for conveying and reinforcing best practices to standardize care and optimize patient outcomes across myriad conditions. The NewYork-Presbyterian Healthcare System has utilized a clinical chest pain pathway for more than 20 years to facilitate the timely recognition and management of patients presenting with chest pain syndromes and acute coronary syndromes. This chest pain pathway is regularly updated by an expanding group of key stakeholders, which has extended from the Columbia University Irving Medical Center to encompass the entire regional healthcare system, which includes 8 hospitals. In this 2023 update of the NewYork-Presbyterian clinical chest pain pathway, we present the key changes to the healthcare system-wide clinical chest pain pathway.
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Affiliation(s)
- Robert S Zilinyi
- From the Division of Cardiology, Department of Medicine, NewYork-Presbyterian Hospital/Columbia University Irving Medical Center, New York, NY
| | - Baruch S Fertel
- Quality and Patient Safety, NewYork-Presbyterian Hospital/Columbia University Irving Medical Center, New York, NY
- Department of Emergency Medicine, NewYork-Presbyterian Hospital/Columbia University Irving Medical Center, New York, NY
| | - Betty C Chang
- Department of Emergency Medicine, NewYork-Presbyterian Hospital/Columbia University Irving Medical Center, New York, NY
| | - Liliya Abrukin
- Department of Emergency Medicine, NewYork-Presbyterian Hospital/Columbia University Irving Medical Center, New York, NY
| | - Edward H Suh
- Department of Emergency Medicine, NewYork-Presbyterian Hospital/Columbia University Irving Medical Center, New York, NY
| | - Osman R Sayan
- Department of Emergency Medicine, NewYork-Presbyterian Hospital/Columbia University Irving Medical Center, New York, NY
| | - Matthew McCarty
- Department of Emergency Medicine, NewYork-Presbyterian Hospital/Weill Cornell Medical Center, New York, NY
| | - Jennifer A Stant
- From the Division of Cardiology, Department of Medicine, NewYork-Presbyterian Hospital/Columbia University Irving Medical Center, New York, NY
| | | | - Emily T Smyth
- Department of Emergency Medicine, NewYork-Presbyterian Hospital/Weill Cornell Medical Center, New York, NY
| | - Gerald Neuberg
- Division of Cardiology, Department of Medicine, NewYork-Presbyterian Hospital/Allen Hospital, New York, NY
| | - Michael B Collins
- From the Division of Cardiology, Department of Medicine, NewYork-Presbyterian Hospital/Columbia University Irving Medical Center, New York, NY
| | - Ajay J Kirtane
- From the Division of Cardiology, Department of Medicine, NewYork-Presbyterian Hospital/Columbia University Irving Medical Center, New York, NY
| | - Jeffrey Moses
- From the Division of Cardiology, Department of Medicine, NewYork-Presbyterian Hospital/Columbia University Irving Medical Center, New York, NY
| | - LeRoy Rabbani
- From the Division of Cardiology, Department of Medicine, NewYork-Presbyterian Hospital/Columbia University Irving Medical Center, New York, NY
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11
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Wagner B, Weidner N, Hug A. Elevated high-sensitivity cardiac troponin T serum concentration in subjects with spinal cord injury. Int J Cardiol 2023; 391:131284. [PMID: 37619878 DOI: 10.1016/j.ijcard.2023.131284] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Revised: 08/13/2023] [Accepted: 08/20/2023] [Indexed: 08/26/2023]
Abstract
BACKGROUND The biochemical analysis of high-sensitivity cardiac troponins (hs-cTn) from peripheral blood specimens has been established as biomarker for myocardial injury. Independently of myocardial injury, increased serum hs-cTn concentrations have been described in patients with myopathies. The relevance and frequency of noncardiac hs-cTn elevations in spinal cord injury (SCI) is unknown. Our study aimed to 1) determine the frequency of increased hs-cTn concentrations of supposedly noncardiac origin above the 99th percentile (upper reference limit, URL) in an unselected SCI population and 2) compare the two protagonist analytes cTnT and cTnI with respect to these noncardiac elevations. METHODS In this monocentric, cross-sectional study, we sampled blood from n = 30 SCI subjects without cardiac symptoms to test for hs-cTnT and hs-cTnI serum concentrations. RESULTS 18/30 (60%) of SCI subjects showed increased hs-cTnT concentrations above the URL of 14 ng/l (p < 0.001). In 4 subjects (22.2%) concentrations were >50 ng/l. Moreover, 3 of these four subjects fulfilled the 6-h troponin dynamics criterion for acute myocardial injury in serial hs-cTnT testing. In contrast, no subject demonstrated increased hs-cTnI concentrations according to the URL of 40 ng/l. 6-h troponin dynamics were also unremarkable for hs-cTnI testing. CONCLUSIONS SCI subjects frequently have increased hs-cTnT concentrations without clinical and hs-cTnI evidence of myocardial injury. Clinicians must be aware of cTnT "skeletal muscle false-positives" in SCI, which applies to elevated baseline cTnT concentrations and troponin dynamics in serial measurements. In case of diagnostic uncertainty, simultaneous analysis of cTnI might be helpful.
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Affiliation(s)
- Björn Wagner
- Spinal Cord Injury Center, Heidelberg University Hospital, Germany
| | - Norbert Weidner
- Spinal Cord Injury Center, Heidelberg University Hospital, Germany
| | - Andreas Hug
- Spinal Cord Injury Center, Heidelberg University Hospital, Germany.
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12
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Byrne RA, Rossello X, Coughlan JJ, Barbato E, Berry C, Chieffo A, Claeys MJ, Dan GA, Dweck MR, Galbraith M, Gilard M, Hinterbuchner L, Jankowska EA, Jüni P, Kimura T, Kunadian V, Leosdottir M, Lorusso R, Pedretti RFE, Rigopoulos AG, Rubini Gimenez M, Thiele H, Vranckx P, Wassmann S, Wenger NK, Ibanez B. 2023 ESC Guidelines for the management of acute coronary syndromes. Eur Heart J 2023; 44:3720-3826. [PMID: 37622654 DOI: 10.1093/eurheartj/ehad191] [Citation(s) in RCA: 468] [Impact Index Per Article: 468.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/26/2023] Open
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13
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Bima P, Lopez-Ayala P, Koechlin L, Boeddinghaus J, Nestelberger T, Okamura B, Muench-Gerber TS, Sanzone A, Skolozubova D, Djurdjevic D, Rubini Gimenez M, Wildi K, Miro O, Martínez-Nadal G, Martin-Sanchez FJ, Christ M, Keller D, Lindahl B, Giannitsis E, Mueller C. Chest Pain in Cancer Patients: Prevalence of Myocardial Infarction and Performance of High-Sensitivity Cardiac Troponins. JACC CardioOncol 2023; 5:591-609. [PMID: 37969646 PMCID: PMC10635894 DOI: 10.1016/j.jaccao.2023.08.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Revised: 08/06/2023] [Accepted: 08/07/2023] [Indexed: 11/17/2023] Open
Abstract
Background Little is known about patients with cancer presenting with acute chest discomfort to the emergency department (ED). Objectives The aim of this study was to assess the prevalence of acute myocardial infarction (AMI), outcomes, and the diagnostic utility of recommended diagnostic tools in this population. Methods Patients presenting with chest pain to the ED were prospectively enrolled in an international multicenter diagnostic study with central adjudication. Cancer status was assessed prospectively and additional cancer details retrospectively. Findings were externally validated in an independent multicenter cohort. Results Among 8,267 patients, 711 (8.6%) had cancer. Patients with cancer had a higher burden of cardiovascular risk factors and pre-existing cardiac disease. Total length of stay in the ED (5.2 hours vs 4.3 hours) and hospitalization rate (49.8% vs 34.3%) were both increased in patients with cancer (P < 0.001 for both). Among 8,093 patients eligible for the AMI analyses, those with cancer more often had final diagnoses of AMI (184 of 686 with cancer [26.8%] vs 1,561 of 7,407 without cancer [21.1%]; P < 0.001). In patients with cancer, high-sensitivity cardiac troponin T (hs-cTnT) but not high sensitivity cardiac troponin I (hs-cTnI) concentration had lower diagnostic accuracy for non-ST-segment elevation myocardial infarction (for hs-cTnT, area under the curve: 0.89 [95% CI: 0.86-0.92] vs 0.94 [95% CI: 0.93-0.94] [P < 0.001]; for hs-cTnI, area under the curve: 0.93 [95% CI: 0.91-0.95] vs 0.95 [95% CI: 0.94-0.95] [P = 0.10]). In patients with cancer, the European Society of Cardiology 0/1-hour hs-cTnT and hs-cTnI algorithms maintained very high safety but had lower efficacy, with twice the number of patients remaining in the observe zone. Similar findings were obtained in the external validation cohort. Conclusions Patients with cancer have a substantially higher prevalence of AMI as the cause of chest pain. Length of ED stay and hospitalization rates are increased. The diagnostic performance of hs-cTnT and the efficacy of both the European Society of Cardiology 0/1-hour hs-cTnT and hs-cTnI algorithms is reduced. (Advantageous Predictors of Acute Coronary Syndromes Evaluation [APACE] Study; NCT00470587).
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Affiliation(s)
- Paolo Bima
- Cardiovascular Research Institute Basel and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT Network, Rome, Italy
- Department of Medical Sciences, University of Torino, Torino, Italy
| | - Pedro Lopez-Ayala
- Cardiovascular Research Institute Basel and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT Network, Rome, Italy
| | - Luca Koechlin
- Cardiovascular Research Institute Basel and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT Network, Rome, Italy
- Department of Cardiac Surgery, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Jasper Boeddinghaus
- Cardiovascular Research Institute Basel and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT Network, Rome, Italy
- BHF/University Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
| | - Thomas Nestelberger
- Cardiovascular Research Institute Basel and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT Network, Rome, Italy
| | - Bernhard Okamura
- Cardiovascular Research Institute Basel and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT Network, Rome, Italy
| | - Tamar S. Muench-Gerber
- Cardiovascular Research Institute Basel and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT Network, Rome, Italy
| | - Alessandra Sanzone
- Cardiovascular Research Institute Basel and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT Network, Rome, Italy
| | - Daria Skolozubova
- Cardiovascular Research Institute Basel and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - David Djurdjevic
- Cardiovascular Research Institute Basel and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Maria Rubini Gimenez
- Cardiovascular Research Institute Basel and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- Cardiology Department, Herzzentrum Leipzig, Leipzig, Germany
| | - Karin Wildi
- Cardiovascular Research Institute Basel and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT Network, Rome, Italy
| | - Oscar Miro
- Emergency Department, Hospital Clinic, Barcelona, Spain
| | | | | | - Michael Christ
- Department of Emergency Medicine, Luzerner Kantonsspital, Luzern, Switzerland
| | - Dagmar Keller
- Emergency Department, University Hospital Zurich, Zurich, Switzerland
| | - Bertil Lindahl
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - Evangelos Giannitsis
- Department of Medicine III, University Hospital Heidelberger, Heidelberg, Germany
| | - Christian Mueller
- Cardiovascular Research Institute Basel and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT Network, Rome, Italy
| | - APACE and TRAPID-AMI Investigators
- Cardiovascular Research Institute Basel and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT Network, Rome, Italy
- Department of Medical Sciences, University of Torino, Torino, Italy
- Department of Cardiac Surgery, University Hospital Basel, University of Basel, Basel, Switzerland
- BHF/University Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
- Cardiology Department, Herzzentrum Leipzig, Leipzig, Germany
- Emergency Department, Hospital Clinic, Barcelona, Spain
- Emergency Department, Hospital Clínico San Carlos, Madrid, Spain
- Department of Emergency Medicine, Luzerner Kantonsspital, Luzern, Switzerland
- Emergency Department, University Hospital Zurich, Zurich, Switzerland
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden
- Department of Medicine III, University Hospital Heidelberger, Heidelberg, Germany
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14
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Van Assche L, Peeters B, Vorlat A, Monsieurs K, Heidbuchel H, Claeys MJ. Safety and effectiveness of the short (0-1h) high sensitive troponin protocol in real-life practice. Acta Cardiol 2023; 78:937-944. [PMID: 37264905 DOI: 10.1080/00015385.2023.2218028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Accepted: 05/19/2023] [Indexed: 06/03/2023]
Abstract
AIM Recent guidelines recommend the use of a short 0-1h high sensitive cardiac troponin (hs-cTn) algorithm in patients presenting with chest pain at the emergency department (ED). This retrospective observational study evaluates the safety and effectiveness of the new 0-1h hs-cTn I protocol in comparison with the standard 0-3h cTn I protocol for the diagnosis of acute myocardial infarction (AMI). METHODS A total of two times 100 consecutive chest pain patients presenting at the ED in November/December 2018 (standard 0-3h cTn I group) and in November/December 2020 (short 0-1h hs-cTn I group) were enrolled. Decision making was based upon validated assay-specific cut-off values. RESULTS The new 0-1h hs-cTn I protocol had a sensitivity of 100% (95% CI 83.2-100) and a negative predictive value of 100% to rule out AMI. The accuracy of rule-in was slightly lower with a specificity of 92.5% (95% CI 84.4-97.2). The overall protocol accuracy was 94% (95% CI 87.4-97.8) in the short 0-1h hs-cTn I group compared to 88% (95% CI 80.0-93.6) in the standard 0-3h cTn I group (p-value 0.14). The 0-1h hs-cTn I protocol was associated with a numerically higher rate of early hospital discharge compared to the conventional 0-3h cTn I protocol (47% versus 59%; p-value 0.09) and with a shorter median length of stay for those patients (mean 316 min versus 289 min; p-value 0.09). CONCLUSION The abbreviated protocol based on the 0-1h hs-cTn I assays is effective and safe for the exclusion of AMI at the ED.
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Affiliation(s)
| | - Bart Peeters
- Department of Clinical Biology, Antwerp University Hospital, Antwerp, Belgium
| | - Anne Vorlat
- Department of Cardiology, Antwerp University Hospital, Antwerp, Belgium
| | - Koen Monsieurs
- Department of Emergency Medicine, Antwerp University Hospital, Antwerp, Belgium
| | - Hein Heidbuchel
- Department of Cardiology, Antwerp University Hospital, Antwerp, Belgium
| | - Marc J Claeys
- Department of Cardiology, Antwerp University Hospital, Antwerp, Belgium
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15
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Fanaroff AC, Sun LL. High-Sensitivity Troponin in Patients With Cancer: Sensitive But Not Specific. JACC CardioOncol 2023; 5:610-612. [PMID: 37969645 PMCID: PMC10635870 DOI: 10.1016/j.jaccao.2023.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2023] Open
Affiliation(s)
- Alexander C. Fanaroff
- Division of Cardiovascular Medicine, Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Penn Cardiovascular Outcomes, Quality and Evaluative Research Center, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Leonard Davis Institute, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Lova L. Sun
- Division of Hematology Oncology, Department of Medicine, Abramson Cancer Center, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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16
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Echefu G, Stowe I, Burka S, Basu-Ray I, Kumbala D. Pathophysiological concepts and screening of cardiovascular disease in dialysis patients. FRONTIERS IN NEPHROLOGY 2023; 3:1198560. [PMID: 37840653 PMCID: PMC10570458 DOI: 10.3389/fneph.2023.1198560] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 04/01/2023] [Accepted: 08/10/2023] [Indexed: 10/17/2023]
Abstract
Dialysis patients experience 10-20 times higher cardiovascular mortality than the general population. The high burden of both conventional and nontraditional risk factors attributable to loss of renal function can explain higher rates of cardiovascular disease (CVD) morbidity and death among dialysis patients. As renal function declines, uremic toxins accumulate in the blood and disrupt cell function, causing cardiovascular damage. Hemodialysis patients have many cardiovascular complications, including sudden cardiac death. Peritoneal dialysis puts dialysis patients with end-stage renal disease at increased risk of CVD complications and emergency hospitalization. The current standard of care in this population is based on observational data, which has a high potential for bias due to the paucity of dedicated randomized clinical trials. Furthermore, guidelines lack specific guidelines for these patients, often inferring them from non-dialysis patient trials. A crucial step in the prevention and treatment of CVD would be to gain better knowledge of the influence of these predisposing risk factors. This review highlights the current evidence regarding the influence of advanced chronic disease on the cardiovascular system in patients undergoing renal dialysis.
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Affiliation(s)
- Gift Echefu
- Division of Cardiovascular Medicine, The University of Tennessee Health Science Center, Memphis, TN, United States
| | - Ifeoluwa Stowe
- Department of Internal Medicine, Baton Rouge General Medical Center, Baton Rouge, LA, United States
| | - Semenawit Burka
- Department of Internal Medicine, University of Texas Rio Grande Valley, McAllen, TX, United States
| | - Indranill Basu-Ray
- Department of Cardiology, Memphis Veterans Affairs (VA) Medical Center, Memphis, TN, United States
| | - Damodar Kumbala
- Nephrology Division, Renal Associates of Baton Rouge, Baton Rouge, LA, United States
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17
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Clerico A, Zaninotto M, Aimo A, Cardinale DM, Dittadi R, Sandri MT, Perrone MA, Belloni L, Fortunato A, Trenti T, Plebani M. Variability of cardiac troponin levels in normal subjects and in patients with cardiovascular diseases: analytical considerations and clinical relevance. Clin Chem Lab Med 2023; 61:1209-1229. [PMID: 36695506 DOI: 10.1515/cclm-2022-1285] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Accepted: 01/09/2023] [Indexed: 01/26/2023]
Abstract
In accordance with all the most recent international guidelines, the variation of circulating levels of cardiac troponins I and T, measured with high-sensitivity methods (hs-cTnI and hs-cTnT), should be used for the detection of acute myocardial injury. Recent experimental and clinical evidences have demonstrated that the evaluation of hs-cTnI and hs-cTnT variations is particularly relevant: a) for the differential diagnosis of Acute Coronary Syndromes (ACS) in patients admitted to the Emergency Department (ED); b) for the evaluation of cardiovascular risk in patients undergoing major cardiac or non-cardiac surgery, and in asymptomatic subjects of the general population aged >55 years and with co-morbidities; c) for the evaluation of cardiotoxicity caused by administration of some chemotherapy drugs in patients with malignant tumors. The aim of this document is to discuss the fundamental statistical and biological considerations on the intraindividual variability of hs-cTnI and hs-cTnT over time in the same individual. Firstly, it will be discussed in detail as the variations of circulating levels strictly depend not only on the analytical error of the method used but also on the intra-individual variability of the biomarker. Afterwards, the pathophysiological interpretation and the clinical relevance of the determination of the variability of the hs-cTnI and hs-cTnT values in patients with specific clinical conditions are discussed. Finally, the evaluation over time of the variation in circulating levels of hs-cTnI and hs-cTnT is proposed for a more accurate estimation of cardiovascular risk in asymptomatic subjects from the general population.
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Affiliation(s)
- Aldo Clerico
- Scuola Superiore Sant'Anna e Fondazione CNR, Regione Toscana G. Monasterio, Pisa, Italy
| | - Martina Zaninotto
- Dipartimento di Medicina di Laboratorio, Università-Ospedale di Padova, Padova, Italy
- Azienda Ospedaliera Universitaria di Padova, e Facoltà di Medicina e Chirurgia, Università di Padova, Padova, Italy
| | - Alberto Aimo
- Scuola Superiore Sant'Anna e Fondazione CNR, Regione Toscana G. Monasterio, Pisa, Italy
| | | | - Ruggero Dittadi
- Unità di Medicina di Laboratorio, Ospedale dell'Angelo, e Centro Regionale dei Biomarcatori, Dipartimento di Patologia Clinica, Azienda ULSS 3, Mestre, Italy
| | - Maria T Sandri
- Laboratorio Bianalisi, Carate Brianza, Monza e Brianza, Italy
| | - Marco Alfonso Perrone
- Dipartimento di Biochimica Clinica e Divisione di Cardiologia, Università e Ospedale di Tor Vergata, Rome, Italy
| | - Lucia Belloni
- Unità di Immunologia Clinica, Allergia e Biotecnologie Avanzate, Arcispedale Santa Maria Nuova-IRCCS, Reggio Emilia, Italy
| | | | - Tommaso Trenti
- Dipartimento di Patologia Clinica e Laboratorio, Azienda USL of Modena, Modena, Italy
| | - Mario Plebani
- Dipartimento di Medicina di Laboratorio, Università-Ospedale di Padova, Padova, Italy
- Azienda Ospedaliera Universitaria di Padova, e Facoltà di Medicina e Chirurgia, Università di Padova, Padova, Italy
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18
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Haller PM, Sörensen NA, Hartikainen TS, Goßling A, Lehmacher J, Toprak B, Twerenbold R, Richter J, Banko T, Korschid S, Schmidt J, Keller T, Zeller T, Blankenberg S, Westermann D, Neumann JT. Rising and Falling High-Sensitivity Cardiac Troponin in Diagnostic Algorithms for Patients With Suspected Myocardial Infarction. J Am Heart Assoc 2023; 12:e027166. [PMID: 37158171 DOI: 10.1161/jaha.122.027166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/10/2023]
Abstract
Background High-sensitivity cardiac troponin (hs-cTn)-based diagnostic algorithms are recommended for the management of patients with suspected myocardial infarction (MI) without ST elevation. Although mirroring different phases of myocardial injury, falling and rising troponin patterns (FPs and RPs, respectively) are equally considered by most algorithms. We aimed to compare the performance of diagnostic protocols for RPs and FPs, separately. Methods and Results We pooled 2 prospective cohorts of patients with suspected MI and stratified patients to stable, FP, and RP during serial sampling separately for hs-cTnI and hs-cTnT and applied the European Society of Cardiology 0/1- and 0/3-hour algorithms comparing the positive predictive values to rule in MI. Overall, 3523 patients were included in the hs-cTnI study population. The positive predictive value for patients with an FP was significantly reduced compared with patients with an RP (0/1-hour: FP, 53.3% [95% CI, 45.0-61.4] versus RP, 76.9 [95% CI, 71.6-81.7]; 0/3-hour: FP, 56.9% [95% CI, 42.2-70.7] versus RP, 78.1% [95% CI, 74.0-81.8]). The proportion of patients in the observe zone was larger in the FP using 0/1-hour (31.3% versus 55.8%) and 0/3-hour (14.6% versus 38.6%) algorithms. Alternative cutoffs did not improve algorithm performances. Compared with stable hs-cTn, the risk for death or MI was highest in those with an FP (adjusted hazard ratio [HR], hs-cTnI 2.3 [95% CI, 1.7-3.2]; RP adjusted HR, hs-cTnI 1.8 [95% CI, 1.4-2.4]). Findings were similar for hs-cTnT tested in 3647 patients overall. Conclusions The positive predictive value to rule in MI by the European Society of Cardiology 0/1- and 0/3-hour algorithms is significantly lower in patients with FP than RP. These are at highest risk for incident death or MI. REGISTRATION: URL: https://www.clinicaltrials.gov; Unique identifiers: NCT02355457, NCT03227159.
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Affiliation(s)
- Paul M Haller
- Department of Cardiology University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf Hamburg Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck Hamburg Germany
| | - Nils A Sörensen
- Department of Cardiology University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf Hamburg Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck Hamburg Germany
| | - Tau S Hartikainen
- Department of Cardiology University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf Hamburg Germany
| | - Alina Goßling
- Department of Cardiology University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf Hamburg Germany
| | - Jonas Lehmacher
- Department of Cardiology University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf Hamburg Germany
| | - Betül Toprak
- Department of Cardiology University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf Hamburg Germany
| | - Raphael Twerenbold
- Department of Cardiology University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf Hamburg Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck Hamburg Germany
- University Center of Cardiovascular Science University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf Hamburg Germany
| | - Janine Richter
- Department of Cardiology University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf Hamburg Germany
| | - Thorben Banko
- Department of Cardiology University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf Hamburg Germany
| | - Solaf Korschid
- Department of Cardiology University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf Hamburg Germany
| | - Jakob Schmidt
- Department of Cardiology University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf Hamburg Germany
| | - Till Keller
- Department of Internal Medicine I, Cardiology Justus-Liebig-University Gießen Gießen Germany
| | - Tanja Zeller
- Department of Cardiology University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf Hamburg Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck Hamburg Germany
- University Center of Cardiovascular Science University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf Hamburg Germany
| | - Stefan Blankenberg
- Department of Cardiology University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf Hamburg Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck Hamburg Germany
| | - Dirk Westermann
- Department of Cardiology University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf Hamburg Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck Hamburg Germany
- Department of Cardiology University Heart Center Freiburg Bad Krotzingen Bad Krotzingen Germany
| | - Johannes T Neumann
- Department of Cardiology University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf Hamburg Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck Hamburg Germany
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine Monash University Melbourne Australia
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19
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Abstract
Cardiovascular disease (CVD) is prevalent in patients with chronic kidney disease (CKD) and it is responsible for approximately half of all CKD-related deaths. CVDs are the primary cause of death in hemodialysis patients due to major adverse cardiovascular events. Therefore, better approaches for differentiating chronic hemodialysis patients at higher cardiovascular risk will help physicians improve clinical outcomes. Hence, there is an urgent need to discover feasible and reliable cardiac biomarkers to improve diagnostic accuracy, reflect myocardial injury, and identify high-risk patients. Numerous biomarkers that have significant prognostic value with respect to adverse CVD outcomes in the setting of mild to severe CKD have been identified. Therefore, a better understanding of the positive clinical impact of cardiac biomarkers on CVD patient outcomes is an important step toward prevention and improving treatment in the future. In this review, we address the relationship between cardiovascular biomarkers and CKD treatment strategies to elucidate the underlying importance of these biomarkers to patient outcomes.
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Affiliation(s)
- Ying-Ju Chen
- Division of Laboratory Medicine, Asia University Hospital, Asia University, Taichung, Taiwan
| | - Chih-Chieh Chen
- Institute of Medical Science and Technology, National Sun Yat-sen University, Kaohsiung, Taiwan
| | - Tze-Kiong Er
- Division of Laboratory Medicine, Asia University Hospital, Asia University, Taichung, Taiwan; Department of Medical Laboratory Science and Biotechnology, Asia University, Taichung, Taiwan.
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20
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Doudesis D, Lee KK, Boeddinghaus J, Bularga A, Ferry AV, Tuck C, Lowry MTH, Lopez-Ayala P, Nestelberger T, Koechlin L, Bernabeu MO, Neubeck L, Anand A, Schulz K, Apple FS, Parsonage W, Greenslade JH, Cullen L, Pickering JW, Than MP, Gray A, Mueller C, Mills NL. Machine learning for diagnosis of myocardial infarction using cardiac troponin concentrations. Nat Med 2023; 29:1201-1210. [PMID: 37169863 PMCID: PMC10202804 DOI: 10.1038/s41591-023-02325-4] [Citation(s) in RCA: 17] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Accepted: 03/28/2023] [Indexed: 05/13/2023]
Abstract
Although guidelines recommend fixed cardiac troponin thresholds for the diagnosis of myocardial infarction, troponin concentrations are influenced by age, sex, comorbidities and time from symptom onset. To improve diagnosis, we developed machine learning models that integrate cardiac troponin concentrations at presentation or on serial testing with clinical features and compute the Collaboration for the Diagnosis and Evaluation of Acute Coronary Syndrome (CoDE-ACS) score (0-100) that corresponds to an individual's probability of myocardial infarction. The models were trained on data from 10,038 patients (48% women), and their performance was externally validated using data from 10,286 patients (35% women) from seven cohorts. CoDE-ACS had excellent discrimination for myocardial infarction (area under curve, 0.953; 95% confidence interval, 0.947-0.958), performed well across subgroups and identified more patients at presentation as low probability of having myocardial infarction than fixed cardiac troponin thresholds (61 versus 27%) with a similar negative predictive value and fewer as high probability of having myocardial infarction (10 versus 16%) with a greater positive predictive value. Patients identified as having a low probability of myocardial infarction had a lower rate of cardiac death than those with intermediate or high probability 30 days (0.1 versus 0.5 and 1.8%) and 1 year (0.3 versus 2.8 and 4.2%; P < 0.001 for both) from patient presentation. CoDE-ACS used as a clinical decision support system has the potential to reduce hospital admissions and have major benefits for patients and health care providers.
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Grants
- FS/18/25/33454 British Heart Foundation
- MR/V007254/1 Medical Research Council
- CH/F/21/90010 British Heart Foundation
- RG/20/10/34966 British Heart Foundation
- MR/N013166/1 Medical Research Council
- RE/18/5/34216 British Heart Foundation
- MR/W000598/1 Medical Research Council
- British Heart Foundation (BHF)
- RCUK | Medical Research Council (MRC)
- The University of Basel, the University Hospital of Basel, the Swiss Academy of Medical Sciences, the Gottfried and Julia Bangerter-Rhyner Foundation, the Swiss National Science Foundation
- Swiss Heart Foundation, the University of Basel, the Swiss Academy of Medical Science, the Gottfried and Julia Bangerter-Rhyner Foundation, and the “Freiwillige Akademische Gesellschaft Basel.”
- Advance Queensland Fellowship
- the Swiss National Science Foundation, the Swiss Heart Foundation, the Commission for Technology and Innovation, and the University Hospital Basel.
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Affiliation(s)
- Dimitrios Doudesis
- British Heart Foundation/University Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
- Usher Institute, University of Edinburgh, Edinburgh, UK
| | - Kuan Ken Lee
- British Heart Foundation/University Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Jasper Boeddinghaus
- British Heart Foundation/University Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
- Cardiovascular Research Institute Basel and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Anda Bularga
- British Heart Foundation/University Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Amy V Ferry
- British Heart Foundation/University Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Chris Tuck
- British Heart Foundation/University Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Matthew T H Lowry
- British Heart Foundation/University Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Pedro Lopez-Ayala
- Cardiovascular Research Institute Basel and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Thomas Nestelberger
- Cardiovascular Research Institute Basel and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Luca Koechlin
- Cardiovascular Research Institute Basel and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- Department of Cardiac Surgery, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Miguel O Bernabeu
- Usher Institute, University of Edinburgh, Edinburgh, UK
- The Bayes Centre, The University of Edinburgh, Edinburgh, UK
| | - Lis Neubeck
- School of Health and Social Care, Edinburgh Napier University, Edinburgh, UK
| | - Atul Anand
- British Heart Foundation/University Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Karen Schulz
- Cardiac Biomarkers Trials Laboratory, Hennepin Healthcare Research Institute, Minneapolis, MN, USA
| | - Fred S Apple
- Departments of Laboratory Medicine and Pathology, Hennepin County Medical Center and University of Minnesota, Minneapolis, MN, USA
| | - William Parsonage
- Australian Centre for Health Service Innovation, Centre for Healthcare Transformation, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Jaimi H Greenslade
- Emergency and Trauma Centre, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
- School of Medicine, University of Queensland, Brisbane, Queensland, Australia
- Faculty of Health, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Louise Cullen
- Emergency and Trauma Centre, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
- School of Medicine, University of Queensland, Brisbane, Queensland, Australia
- Faculty of Health, Queensland University of Technology, Brisbane, Queensland, Australia
| | - John W Pickering
- Department of Medicine, University of Otago, Christchurch, New Zealand
- Emergency Department, Christchurch Hospital, Christchurch, New Zealand
| | - Martin P Than
- Department of Medicine, University of Otago, Christchurch, New Zealand
| | - Alasdair Gray
- Emergency Medicine Research Group Edinburgh, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Christian Mueller
- Cardiovascular Research Institute Basel and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Nicholas L Mills
- British Heart Foundation/University Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK.
- Usher Institute, University of Edinburgh, Edinburgh, UK.
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21
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Ho YJ, Chen CH, Sung CW, Fan CY, Lin SY, Chen JW, Edward Pei-Chang Huang S. Risk stratification of patients with chest pain who have an unscheduled revisit to the emergency department. Int J Cardiol 2023:S0167-5273(23)00596-X. [PMID: 37116755 DOI: 10.1016/j.ijcard.2023.04.043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2022] [Revised: 03/11/2023] [Accepted: 04/23/2023] [Indexed: 04/30/2023]
Abstract
AIMS Acute cardiovascular (CV) emergencies are critical conditions that require urgent attention in the emergency department (ED). Failure to make a timely diagnosis may result in unscheduled ED revisits and severe outcomes. Therefore, this study aimed to investigate the risk factors associated with potentially missed acute CV emergencies. METHODS AND RESULTS This retrospective study enrolled adult patients who presented with chest pain and returned to the ED within 72 h. Demographic information, pre-existing medical conditions, chief complaints, triage level and vital signs, electrocardiography (ECG) reports, and laboratory data were collected from medical charts by independent physicians. The primary outcome was the diagnosis of acute CV diseases, including ACS, pulmonary embolism, unstable arrhythmia, acute decompensated heart failure, and aortic dissection. Multivariable logistic regression was used to analyze the association between variables and acute CV emergencies. A total of 453 eligible patients were included, with 60 (13.2%) patients diagnosed as acute CV emergencies at the ED revisit. Risk factors for acute CV emergencies included male gender (adjusted odds ratio [aOR] = 2.71, 95% confidence interval [CI] = 1.17-6.25), abnormal ECG rhythm (aOR = 10.33, 95% CI = 4.68-22.83), and abnormal changes in high sensitivity Troponin-T (hs-cTnT) during sequential follow-up (aOR = 6.52, 95% CI = 2.19-19.45). CONCLUSIONS Male gender, abnormal ECG rhythm, and a significant increase in sequential follow-up hs-cTnT levels were identified as significant risk factors for acute CV emergencies. ED physicians should recognize these high-risk patients with chest pain to prevent misdiagnosis and potential severe complications.
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Affiliation(s)
- Yi-Ju Ho
- Department of Emergency Medicine, National Taiwan University Hospital, No.7, Chung-Shan S. Road, Taipei 100, Taiwan
| | - Chi-Hsin Chen
- Department of Emergency Medicine, National Taiwan University Hospital Hsin-Chu Branch, No. 25, Ln. 442, Sec. 1, Jing-guo Rd., North Dist., Hsinchu 310, Taiwan
| | - Chih-Wei Sung
- Department of Emergency Medicine, National Taiwan University Hospital Hsin-Chu Branch, No. 25, Ln. 442, Sec. 1, Jing-guo Rd., North Dist., Hsinchu 310, Taiwan
| | - Cheng-Yi Fan
- Department of Emergency Medicine, National Taiwan University Hospital Hsin-Chu Branch, No. 25, Ln. 442, Sec. 1, Jing-guo Rd., North Dist., Hsinchu 310, Taiwan
| | - Shao-Yung Lin
- Department of Emergency Medicine, National Taiwan University Hospital, No.7, Chung-Shan S. Road, Taipei 100, Taiwan
| | - Jiun-Wei Chen
- Department of Emergency Medicine, National Taiwan University Hospital Hsin-Chu Branch, No. 25, Ln. 442, Sec. 1, Jing-guo Rd., North Dist., Hsinchu 310, Taiwan
| | - S Edward Pei-Chang Huang
- Department of Emergency Medicine, National Taiwan University Hospital, No.7, Chung-Shan S. Road, Taipei 100, Taiwan; Department of Emergency Medicine, National Taiwan University Hospital Hsin-Chu Branch, No. 25, Ln. 442, Sec. 1, Jing-guo Rd., North Dist., Hsinchu 310, Taiwan.
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22
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邓 钰, 陈 华, 李 功, 陈 立, 傅 强. [Effect of co-morbid chronic kidney disease on the accuracy of cardiac troponin levels for diagnosis of acute myocardial infarction]. NAN FANG YI KE DA XUE XUE BAO = JOURNAL OF SOUTHERN MEDICAL UNIVERSITY 2023; 43:300-307. [PMID: 36946052 PMCID: PMC10034548 DOI: 10.12122/j.issn.1673-4254.2023.02.20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Indexed: 03/23/2023]
Abstract
OBJECTIVE To evaluate the accuracy of cardiac troponin (cTn) levels in the diagnosis of acute myocardial infarction (AMI) in patients with chronic kidney disease (CKD) and explore a potential strategy for improving the diagnostic accuracy. METHODS We retrospectively analyzed the data from patients with high-risk chest pain admitted in Zhujiang Hospital from January, 2018 to December, 2020, including 126 patients with and 272 patients without CKD, and 122 patients diagnosed to have AMI and 276 patients without AMI. The baseline clinical data of the patients and blood test results within 12 h after admission were collected. RESULTS In patients without AMI, cTnT level was significantly higher in those with co-morbid CKD than in those without CKD (P < 0.001), and showed a moderate negative correlation with eGFR (rs=- 0.501, P < 0.001), while cTnI level did not differ significantly between the two groups (P=0.72). In patients with CKD, the optimal cutoff level was 0.177 μg/L for cTnT and 0.415 ng/mL for cTnI for diagnosis of AMI, for which cTnI had a higher specificity than cTnT. The diagnostic model combining both cTnT and cTnI levels [P=eY/(1+ eY), Y=6.928 (cTnT)-0.5 (cTnI)-1.491] had a higher AUC value than cTn level alone. CONCLUSION In CKD patients, the cutoff level of cTn is increased for diagnosing AMI, and cTnI has a higher diagnostic specificity than cTnT. The combination of cTnT and cTnI levels may further improve diagnostic efficacy for AMI.
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Affiliation(s)
- 钰莹 邓
- 南方医科大学珠江医院心血管内科,广东 广州 510282Department of Cardiovascular Disease, Zhujiang Hospital, Southern Medical University, Guangzhou 510280, China
| | - 华锋 陈
- 南方医科大学珠江医院内分泌代谢科,广东 广州 510282Department of Endocrinology and Metabolism, Zhujiang Hospital, Southern Medical University, Guangzhou 510280, China
| | - 功辉 李
- 南方医科大学珠江医院心血管内科,广东 广州 510282Department of Cardiovascular Disease, Zhujiang Hospital, Southern Medical University, Guangzhou 510280, China
| | - 立桁 陈
- 南方医科大学珠江医院心血管内科,广东 广州 510282Department of Cardiovascular Disease, Zhujiang Hospital, Southern Medical University, Guangzhou 510280, China
| | - 强 傅
- 深圳医院心血管内科,广东 深圳 518101Department of Cardiovascular Disease, Shenzhen Hospital, Southern Medical University, Shenzhen 518101, China
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23
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Rubini Gimenez M, Boeddinghaus J, Nestelberger T, Koechlin L, López-Ayala P, Müller C. Implementation of the ESC 0 h/1 h high-sensitivity troponin algorithm for decision-making in the emergency department. REVISTA ESPANOLA DE CARDIOLOGIA (ENGLISH ED.) 2023; 76:468-472. [PMID: 36669731 DOI: 10.1016/j.rec.2023.01.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/10/2022] [Accepted: 12/12/2022] [Indexed: 01/19/2023]
Abstract
Diagnosis of non-ST-segment elevation acute coronary syndromes (NSTEACS) is based on 3 cornerstones: clinical presentation, 12-lead electrocardiogram, and cardiac troponin measurement. Advances in the development of high-sensitivity cardiac troponin (hs-cTn) assays have substantially improved the detection of cardiomyocyte injury in a shorter time period, and hs-cTn has consequently been established as the gold-standard biomarker for the assessment of patients with suspected NSTEACS. The implementation of these assays in clinical practice allows a faster "rule-out", especially among low-risk patients, as well as a safer and more rapid "rule-in", with its therapeutic consequences. Current guidelines for the diagnosis of NSTEACS recommend the use of hs-cTn applied in rapid diagnostic algorithms based on serial hs-cTn sampling within the first few hours. The current work provides an overview of the use of hs-cTn for the early detection of NSTEACS.
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Affiliation(s)
- Maria Rubini Gimenez
- Department of Cardiology and internal Medicine, University Heart Center Leipzig, Leipzig, Germany; Cardiovascular Research Institute of Basel, University Hospital Basel, Basel, Switzerland.
| | - Jasper Boeddinghaus
- Cardiovascular Research Institute of Basel, University Hospital Basel, Basel, Switzerland; BHF/University Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
| | - Thomas Nestelberger
- Cardiovascular Research Institute of Basel, University Hospital Basel, Basel, Switzerland
| | - Luca Koechlin
- Cardiovascular Research Institute of Basel, University Hospital Basel, Basel, Switzerland
| | - Pedro López-Ayala
- Cardiovascular Research Institute of Basel, University Hospital Basel, Basel, Switzerland
| | - Christian Müller
- Cardiovascular Research Institute of Basel, University Hospital Basel, Basel, Switzerland
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Koechlin L, Boeddinghaus J, Lopez-Ayala P, Nestelberger T, Wussler D, Mais F, Twerenbold R, Zimmermann T, Wildi K, Köppen AM, Miró Ò, Martin-Sanchez FJ, Kawecki D, Geigy N, Keller DI, Christ M, Buser A, Giménez MR, Bernasconi L, Hammerer-Lercher A, Mueller C. Diagnostic discrimination of a novel high-sensitivity cardiac troponin I assay and derivation/validation of an assay-specific 0/1h-algorithm. Am Heart J 2023; 255:58-70. [PMID: 36243111 DOI: 10.1016/j.ahj.2022.10.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Revised: 10/04/2022] [Accepted: 10/05/2022] [Indexed: 06/16/2023]
Abstract
BACKGROUND We aimed to assess the diagnostic utility of the Dimension EXL LOCI High-Sensitivity Troponin I (hs-cTnI-EXL) assay. METHODS This multicenter study included patients with chest discomfort presenting to the emergency department. Diagnoses were centrally and independently adjudicated by two cardiologists using all available clinical information. Adjudication was performed twice including serial measurements of high-sensitivity cardiac troponin (hs-cTn) I-Architect (primary analysis) and serial measurements of hs-cTnT-Elecsys (secondary analysis) in addition to the clinically used (hs)-cTn. The primary objective was to assess and compare the discriminatory performance of hs-cTnI-EXL, hs-cTnI-Architect and hs-cTnT-Elecsys for acute myocardial infarction (MI). Furthermore, we derived and validated a hs-cTnI-EXL-specific 0/1h-algorithm. RESULTS Adjudicated MI was the diagnosis in 204/1454 (14%) patients. The area under the receiver operating characteristics curve for hs-cTnI-EXL was 0.94 (95%CI, 0.93-0.96), and comparable to hs-cTnI-Architect (0.95; 95%CI, 0.93-0.96) and hs-cTnT-Elecsys (0.93; 95%CI, 0.91-0.95). In the derivation cohort (n = 813), optimal criteria for rule-out of MI were <9ng/L at presentation (if chest pain onset >3h) or <9ng/L and 0h-1h-change <5ng/L, and for rule-in ≥160ng/L at presentation or 0h-1h-change ≥100ng/L. In the validation cohort (n = 345), these cut-offs ruled-out 56% of patients (negative predictive value 99.5% (95%CI, 97.1-99.9), sensitivity 97.8% (95%CI, 88.7-99.6)), and ruled-in 9% (positive predictive value 83.3% (95%CI, 66.4-92.7), specificity 98.3% (95%CI, 96.1-99.3)). Secondary analyses using adjudication based on hs-cTnT measurements confirmed the findings. CONCLUSIONS The overall performance of the hs-cTnI-EXL was comparable to best-validated hs-cTnT/I assays and an assay-specific 0/1h-algorithm safely rules out and accurately rules in acute MI. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov number, NCT00470587.
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Affiliation(s)
- Luca Koechlin
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Basel, Switzerland; Department of Cardiac Surgery, University Hospital Basel, University of Basel, Basel, Basel, Switzerland; GREAT network, Basel, Basel, Switzerland.
| | - Jasper Boeddinghaus
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Basel, Switzerland; GREAT network, Basel, Basel, Switzerland; Division of Internal Medicine, University Hospital Basel, University of Basel, Basel, Basel, Switzerland; BHF/University Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Pedro Lopez-Ayala
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Basel, Switzerland; GREAT network, Basel, Basel, Switzerland
| | - Thomas Nestelberger
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Basel, Switzerland; GREAT network, Basel, Basel, Switzerland; Division of Cardiology, Vancouver General Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Desiree Wussler
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Basel, Switzerland; GREAT network, Basel, Basel, Switzerland; Division of Internal Medicine, University Hospital Basel, University of Basel, Basel, Basel, Switzerland
| | - Felix Mais
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Basel, Switzerland; Emergency Department, University Hospital Zurich, Zurich, Zurich, Switzerland
| | - Raphael Twerenbold
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Basel, Switzerland; University Center of Cardiovascular Science & Department of Cardiology, University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Hamburg, Germany
| | - Tobias Zimmermann
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Basel, Switzerland; GREAT network, Basel, Basel, Switzerland
| | - Karin Wildi
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Basel, Switzerland; GREAT network, Basel, Basel, Switzerland; Critical Care Research Group and the University of Queensland, Brisbane, Queensland, Australia
| | - Anne Marie Köppen
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Basel, Switzerland
| | - Òscar Miró
- GREAT network, Basel, Basel, Switzerland; Emergency Department, Hospital Clinic, Barcelona, Catalonia, Spain
| | - F Javier Martin-Sanchez
- GREAT network, Basel, Basel, Switzerland; Servicio de Urgencias, Hospital Clínico San Carlos, Madrid, Madrid, Spain
| | - Damian Kawecki
- GREAT network, Basel, Basel, Switzerland; 2nd Department of Cardiology, School of Medicine with the Division of Dentistry in Zabrze, Medical University of Katowice, Silesian, Poland
| | - Nicolas Geigy
- Emergency Department, Kantonsspital Liestal, Liestal Liestal, Switzerland
| | - Dagmar I Keller
- Emergency Department, University Hospital Zurich, Zurich, Zurich, Switzerland
| | - Michael Christ
- Emergency Department, Kantonsspital Luzern, Luzern, Luzern, Switzerland
| | - Andreas Buser
- Department of hematology and Blood Bank, University Hospital Basel, University of Basel, Basel, Basel Switzerland
| | - Maria Rubini Giménez
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Basel, Switzerland; Department of Cardiology, Heart Center Leipzig, University of Leipzig, Leipzig, Saxony, Germany
| | - Luca Bernasconi
- Institute of Laboratory Medicine, County Hospital Aarau, Aarau, Aarau, Switzerland
| | | | - Christian Mueller
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Basel, Switzerland; GREAT network, Basel, Basel, Switzerland.
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Yan N, Wei L, Li Z, Song Y. Establishment of a nomogram model for acute chest pain triage in the chest pain center. Front Cardiovasc Med 2023; 10:930839. [PMID: 37025691 PMCID: PMC10070711 DOI: 10.3389/fcvm.2023.930839] [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: 04/28/2022] [Accepted: 03/02/2023] [Indexed: 04/08/2023] Open
Abstract
Background Acute myocardial infarction (AMI) is the leading life-threatening disease in the emergency department (ED), so rapid chest pain triage is important. This study aimed to establish a clinical prediction model for the risk stratification of acute chest pain patients based on the Point-of-care (POC) cardiac troponin (cTn) level and other clinical variables. Methods We conducted a post-hoc analysis of the database from 6,019 consecutive patients (excluding prehospital-diagnosed non-cardiac chest pain patients) attending a local chest pain center (CPC) in China between October 2016 and January 2019. The plasma concentration of cardiac troponin I (cTnI) was measured using a POC cTnI (Cardio Triage, Alere) assay. All the eligible patients were randomly divided into training and validation cohorts by a 7:3 ratio. We performed multivariable logistic regression to select variables and build a nomogram based on the significant predictive factors. We evaluated the model's generalization ability of diagnostic accuracy in the validation cohort. Results We analyzed data from 5,397 patients that were included in this research. The median turnaround time (TAT) of POC cTnI was 16 min. The model was constructed with 6 variables: ECG ischemia, POC cTnI level, hypotension, chest pain symptom, Killip class, and sex. The area under the ROC curve (AUC) in the training and validation cohorts was 0.924 and 0.894, respectively. The diagnostic performance was superior to the GRACE score (AUC: 0.737). Conclusion A practical predictive model was created and could be used for rapid and effective triage of acute chest pain patients in the CPC.
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Affiliation(s)
- Na Yan
- Department of Emergency, TEDA International Cardiovascular Hospital, Clinical School of Cardiovascular Disease, Tianjin Medical University, Tianjin, China
| | - Ling Wei
- Department of Emergency, TEDA International Cardiovascular Hospital, Clinical School of Cardiovascular Disease, Tianjin Medical University, Tianjin, China
- Department of Emergency, TEDA Hospital, Tianjin, China
| | - Zhiwei Li
- Department of Pathophysiology, State Key Laboratory of Medical Molecular Biology, Institute of Basic Medical Sciences Chinese Academy of Medical Sciences, School of Basic Medicine Peking Union Medical College, Beijing, China
| | - Yu Song
- Department of Emergency, TEDA International Cardiovascular Hospital, Clinical School of Cardiovascular Disease, Tianjin Medical University, Tianjin, China
- Department of Emergency, TEDA Hospital, Tianjin, China
- Correspondence: Yu Song
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26
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Roos A, Edgren G. Using historical cardiac troponins to identify patients at a high risk of myocardial infarction. HEART (BRITISH CARDIAC SOCIETY) 2023; 109:127-133. [PMID: 35948410 PMCID: PMC9811078 DOI: 10.1136/heartjnl-2022-321198] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Accepted: 07/18/2022] [Indexed: 02/04/2023]
Abstract
OBJECTIVE Many patients who present with chest pain have previous measurements of high-sensitivity cardiac troponin T (hs-cTnT). The clinical usefulness of incorporating these measurements in identifying patients who are at a high risk of myocardial infarction (MI) is unknown. We investigated if the relative change between a historical hs-cTnT and the admission hs-cTnT could improve early identification of patients with a high risk of MI. METHODS We included all patients presenting with chest pain to seven different emergency departments (EDs) in Sweden from December 2009 to December 2016, who had at least one hs-cTnT measurement at the presentation and at least one available prior measurement. We used logistic regression to investigate the diagnostic performance of using various combinations of current and historical hs-cTnT measurements in diagnosing MI within 30 days. RESULTS A total of 27 809 visits were included, among whom 2686 (9.7%) had an MI within 30 days. A cut-off value for historical hs-cTnT-adjusted admission hs-cTnT with similar specificity (91.2%) as an admission hs-cTnT of ≥52 ng/L identified 4% more MIs (43% vs 39%) and had a higher positive predictive value, 42.6% (95% CI, 41.0% to 44.3%) vs 38.9% (95% CI 37.4% to 40.4%), as well as a higher positive likelihood ratio, 6.95 (95% CI 6.69 to 7.22) vs 5.95 (95% CI 5.73 to 6.18). Among patients with an admission hs-cTnT of <52 ng/L who were classified as high-risk patients when incorporating past hs-cTnT measurements, 28% suffered an MI. CONCLUSIONS Historical hs-cTnT levels can be used with admission hs-cTnT to improve early risk stratification of MI in the ED.
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Affiliation(s)
- Andreas Roos
- Department of Emergency and Reparative Medicine, Karolinska University Hospital, Huddinge Stockholm, Sweden,Department of Medicine Clinical Epidemiology Division, Karolinska Institutet, Solna Stockholm, Sweden
| | - Gustaf Edgren
- Department of Medicine Clinical Epidemiology Division, Karolinska Institutet, Solna Stockholm, Sweden
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Ohtake H, Terasawa T, Zhelev Z, Iwata M, Rogers M, Peters JL, Hyde C. Serial high-sensitivity cardiac troponin testing for the diagnosis of myocardial infarction: a scoping review. BMJ Open 2022; 12:e066429. [PMID: 36414302 PMCID: PMC9685223 DOI: 10.1136/bmjopen-2022-066429] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVES We aimed to assess the diversity and practices of existing studies on several assays and algorithms for serial measurements of high-sensitivity cardiac troponin (hs-cTn) for risk stratification and the diagnosis of myocardial infarction (MI) and 30-day outcomes in patients suspected of having non-ST-segment elevation MI (NSTEMI). METHODS We searched multiple databases including MEDLINE, EMBASE, Science Citation Index, the Cochrane Database of Systematic Reviews and the CENTRAL databases for studies published between January 2006 and November 2021. Studies that assessed the diagnostic accuracy of serial hs-cTn testing in patients suspected of having NSTEMI in the emergency department (ED) were eligible. Data were analysed using the scoping review method. RESULTS We included 86 publications, mainly from research centres in Europe, North America and Australasia. Two hs-cTn assays, manufactured by Abbott (43/86) and Roche (53/86), dominated the evaluations. The studies most commonly measured the concentrations of hs-cTn at two time points, at presentation and a few hours thereafter, to assess the two-strata or three-strata algorithm for diagnosing or ruling out MI. Although data from 83 studies (97%) were prospectively collected, 0%-90% of the eligible patients were excluded from the analysis due to missing blood samples or the lack of a final diagnosis in 53 studies (62%) that reported relevant data. Only 19 studies (22%) reported on head-to-head comparisons of alternative assays. CONCLUSION Evidence on the accuracy of serial hs-cTn testing was largely derived from selected research institutions and relied on two specific assays. The proportions of the eligible patients excluded from the study raise concerns about directly applying the study findings to clinical practice in frontline EDs. PROSPERO REGISTRATION NUMBER CRD42018106379.
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Affiliation(s)
- Hirotaka Ohtake
- Department of Emergency and General Internal Medicine, Fujita Health University, Toyoake, Aichi, Japan
| | - Teruhiko Terasawa
- Department of Emergency and General Internal Medicine, Fujita Health University, Toyoake, Aichi, Japan
| | - Zhivko Zhelev
- University of Exeter Medical School, University of Exeter, Exeter, UK
| | - Mitsunaga Iwata
- Department of Emergency and General Internal Medicine, Fujita Health University, Toyoake, Aichi, Japan
| | - Morwenna Rogers
- NIHR CLAHRC South West Peninsula, University of Exeter, Exeter, UK
| | - Jaime L Peters
- Peninsula Technology Assessment Group (PenTAG), University of Exeter, Exeter, UK
- Peninsula Technology Assessment Group (PenTAG), University of Exeter, Exeter, UK
| | - Chris Hyde
- Exeter Test Group, University of Exeter, Exeter, UK
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28
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Kontos MC, de Lemos JA, Deitelzweig SB, Diercks DB, Gore MO, Hess EP, McCarthy CP, McCord JK, Musey PI, Villines TC, Wright LJ. 2022 ACC Expert Consensus Decision Pathway on the Evaluation and Disposition of Acute Chest Pain in the Emergency Department: A Report of the American College of Cardiology Solution Set Oversight Committee. J Am Coll Cardiol 2022; 80:1925-1960. [PMID: 36241466 PMCID: PMC10691881 DOI: 10.1016/j.jacc.2022.08.750] [Citation(s) in RCA: 40] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Airaksinen KEJ, Aalto R, Hellman T, Vasankari T, Lahtinen A, Wittfooth S. Novel Troponin Fragmentation Assay to Discriminate Between Troponin Elevations in Acute Myocardial Infarction and End-Stage Renal Disease. Circulation 2022; 146:1408-1410. [PMID: 36315607 DOI: 10.1161/circulationaha.122.060845] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Affiliation(s)
- K E Juhani Airaksinen
- Heart Center (K.E.J.A., T.V.), Turku University Hospital and University of Turku, Finland
| | - Rami Aalto
- Biotechnology Unit, Department of Life Technologies, University of Turku, Finland (R.A., A.L., S.W.)
| | - Tapio Hellman
- Kidney Center (T.H.), Turku University Hospital and University of Turku, Finland
| | - Tuija Vasankari
- Heart Center (K.E.J.A., T.V.), Turku University Hospital and University of Turku, Finland
| | - Akseli Lahtinen
- Biotechnology Unit, Department of Life Technologies, University of Turku, Finland (R.A., A.L., S.W.)
| | - Saara Wittfooth
- Biotechnology Unit, Department of Life Technologies, University of Turku, Finland (R.A., A.L., S.W.)
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High Sensitivity Troponins. Emerg Med Clin North Am 2022; 40:809-821. [DOI: 10.1016/j.emc.2022.07.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Ricci F, Neumann JT, Rübsamen N, Sörensen NA, Ojeda F, Cataldo I, Zeller T, Schäfer S, Hartikainen TS, Golato M, Palermi S, Zimarino M, Blankenberg S, Westermann D, De Caterina R. High-sensitivity troponin I with or without ultra-sensitive copeptin for the instant rule-out of acute myocardial infarction. Front Cardiovasc Med 2022; 9:895421. [PMID: 36017085 PMCID: PMC9395923 DOI: 10.3389/fcvm.2022.895421] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2022] [Accepted: 07/26/2022] [Indexed: 12/26/2022] Open
Abstract
Background The instant, single-sampling rule-out of acute myocardial infarction (AMI) is still an unmet clinical need. We aimed at testing and comparing diagnostic performance and prognostic value of two different single-sampling biomarker strategies for the instant rule-out of AMI. Methods From the Biomarkers in Acute Cardiac Care (BACC) cohort, we recruited consecutive patients with acute chest pain and suspected AMI presenting to the Emergency Department of the University Medical Center Hamburg-Eppendorf, Hamburg, Germany. We compared safety, effectiveness and 12-month incidence of the composite endpoint of all-cause death and myocardial infarction between (i) a single-sampling, dual-marker pathway combining high-sensitivity cardiac troponin I (hs-cTnI) and ultra-sensitive copeptin (us-Cop) at presentation (hs-cTnI ≤ 27 ng/L, us-Cop < 10 pmol/L and low-risk ECG) and (ii) a single-sampling pathway based on one-off hs-cTnI determination at presentation (hs-cTnI < 5 ng/L and low-risk ECG). As a comparator, we used the European Society of Cardiology (ESC) 0/1-h dual-sampling algorithm. Results We enrolled 1,136 patients (male gender 65%) with median age of 64 years (interquartile range, 51–75). Overall, 228 (20%) patients received a final diagnosis of AMI. The two single-sampling instant rule-out pathways yielded similar negative predictive value (NPV): 97.4% (95%CI: 95.4–98.7) and 98.7% (95%CI: 96.9–99.6) for dual-marker and single hs-cTnI algorithms, respectively (P = 0.11). Both strategies were comparably safe as the ESC 0/1-h dual-sampling algorithm and this was consistent across subgroups of early-comers, low-intermediate risk (GRACE-score < 140) and renal dysfunction. Despite a numerically higher rate of false-negative results, the dual-marker strategy ruled-out a slightly but significantly higher percentage of patients compared with single hs-cTnI determination (37.4% versus 32.9%; P < 0.001). There were no significant between-group differences in 12-month composite outcome. Conclusions Instant rule-out pathways based on one-off determination of hs-cTnI alone or in combination with us-Cop are comparably safe as the ESC 0/1 h algorithm for the instant rule-out of AMI, yielding similar prognostic information. Instant rule-out strategies are safe alternatives to the ESC 0/1 h algorithm and allow the rapid and effective triage of suspected AMI in patients with low-risk ECG. However, adding copeptin to hs-cTn does not improve the safety of instant rule-out compared with the single rule-out hs-cTn at very low cut-off concentrations.
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Affiliation(s)
- Fabrizio Ricci
- Department of Neuroscience, Imaging and Clinical Sciences, “G. d’Annunzio” University, Chieti-Pescara, Italy
- Department of Clinical Sciences, Lund University, Malmö, Sweden
- Casa di Cura Villa Serena, Città Sant’Angelo, Pescara, Italy
- *Correspondence: Fabrizio Ricci,
| | - Johannes T. Neumann
- Department of General and Interventional Cardiology, University Heart Center Hamburg, Hamburg, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany
- Johannes T. Neumann,
| | - Nicole Rübsamen
- Department of General and Interventional Cardiology, University Heart Center Hamburg, Hamburg, Germany
| | - Nils A. Sörensen
- Department of General and Interventional Cardiology, University Heart Center Hamburg, Hamburg, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - Francisco Ojeda
- Department of General and Interventional Cardiology, University Heart Center Hamburg, Hamburg, Germany
| | - Ivana Cataldo
- Unit of Clinical Pathology, SS. Annunziata University Hospital, Chieti, Italy
| | - Tanja Zeller
- Department of General and Interventional Cardiology, University Heart Center Hamburg, Hamburg, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - Sarina Schäfer
- Department of General and Interventional Cardiology, University Heart Center Hamburg, Hamburg, Germany
| | - Tau S. Hartikainen
- Department of General and Interventional Cardiology, University Heart Center Hamburg, Hamburg, Germany
| | - Maria Golato
- Unit of Clinical Pathology, SS. Annunziata University Hospital, Chieti, Italy
| | - Stefano Palermi
- Public Health Department, University of Naples Federico II, Naples, Italy
| | - Marco Zimarino
- Department of Neuroscience, Imaging and Clinical Sciences, “G. d’Annunzio” University, Chieti-Pescara, Italy
| | - Stefan Blankenberg
- Department of General and Interventional Cardiology, University Heart Center Hamburg, Hamburg, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - Dirk Westermann
- Department of General and Interventional Cardiology, University Heart Center Hamburg, Hamburg, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany
- Dirk Westermann,
| | - Raffaele De Caterina
- Casa di Cura Villa Serena, Città Sant’Angelo, Pescara, Italy
- Cardiology Division, Pisa University Hospital and University of Pisa, Pisa, Italy
- Raffaele De Caterina,
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Gallacher PJ, Miller-Hodges E, Shah ASV, Farrah TE, Halbesma N, Blackmur JP, Chapman AR, Adamson PD, Anand A, Strachan FE, Ferry AV, Lee KK, Berry C, Findlay I, Cruickshank A, Reid A, Gray A, Collinson PO, Apple FS, McAllister DA, Maguire D, Fox KAA, Keerie C, Weir CJ, Newby DE, Mills NL, Dhaun N. High-sensitivity cardiac troponin and the diagnosis of myocardial infarction in patients with kidney impairment. Kidney Int 2022; 102:149-159. [PMID: 35271932 DOI: 10.1016/j.kint.2022.02.019] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Revised: 01/25/2022] [Accepted: 02/08/2022] [Indexed: 01/01/2023]
Abstract
The benefit and utility of high-sensitivity cardiac troponin (hs-cTn) in the diagnosis of myocardial infarction in patients with kidney impairment is unclear. Here, we describe implementation of hs-cTnI testing on the diagnosis, management, and outcomes of myocardial infarction in patients with and without kidney impairment. Consecutive patients with suspected acute coronary syndrome enrolled in a stepped-wedge, cluster-randomized controlled trial were included in this pre-specified secondary analysis. Kidney impairment was defined as an eGFR under 60mL/min/1.73m2. The index diagnosis and primary outcome of type 1 and type 4b myocardial infarction or cardiovascular death at one year were compared in patients with and without kidney impairment following implementation of hs-cTnI assay with 99th centile sex-specific diagnostic thresholds. Serum creatinine concentrations were available in 46,927 patients (mean age 61 years; 47% women), of whom 9,080 (19%) had kidney impairment. hs-cTnIs were over 99th centile in 46% and 16% of patients with and without kidney impairment. Implementation increased the diagnosis of type 1 infarction from 12.4% to 17.8%, and from 7.5% to 9.4% in patients with and without kidney impairment (both significant). Patients with kidney impairment and type 1 myocardial infarction were less likely to undergo coronary revascularization (26% versus 53%) or receive dual anti-platelets (40% versus 68%) than those without kidney impairment, and this did not change post-implementation. In patients with hs-cTnI above the 99th centile, the primary outcome occurred twice as often in those with kidney impairment compared to those without (24% versus 12%, hazard ratio 1.53, 95% confidence interval 1.31 to 1.78). Thus, hs-cTnI testing increased the identification of myocardial injury and infarction but failed to address disparities in management and outcomes between those with and without kidney impairment.
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Affiliation(s)
- Peter J Gallacher
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Eve Miller-Hodges
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK; Department of Renal Medicine, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Anoop S V Shah
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Tariq E Farrah
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK; Department of Renal Medicine, Royal Infirmary of Edinburgh, Edinburgh, UK
| | | | - James P Blackmur
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Andrew R Chapman
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Philip D Adamson
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK; Christchurch Heart Institute, University of Otago, Christchurch, New Zealand, Australia
| | - Atul Anand
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Fiona E Strachan
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Amy V Ferry
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Kuan Ken Lee
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Colin Berry
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Iain Findlay
- Department of Cardiology, Royal Alexandra Hospital, Paisley, UK
| | - Anne Cruickshank
- Department of Biochemistry, Queen Elizabeth University Hospital, Glasgow, UK
| | - Alan Reid
- Department of Biochemistry, Queen Elizabeth University Hospital, Glasgow, UK
| | - Alasdair Gray
- Emergency Medicine Research Group Edinburgh, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Paul O Collinson
- Departments of Clinical Blood Sciences and Cardiology, St. George's, University Hospitals National Health Service Trust and St. George's University of London, London, UK
| | - Fred S Apple
- Department of Laboratory Medicine and Pathology, Hennepin Healthcare/Hennepin County Medical Center, Minneapolis, Minnesota, USA; University of Minnesota, Minneapolis, Minnesota, USA
| | | | - Donogh Maguire
- Emergency Medicine Department, Glasgow Royal Infirmary, Glasgow, UK
| | - Keith A A Fox
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Catriona Keerie
- Usher Institute, University of Edinburgh, Edinburgh, UK; Edinburgh Clinical Trials Unit, University of Edinburgh, Edinburgh, UK
| | - Christopher J Weir
- Usher Institute, University of Edinburgh, Edinburgh, UK; Edinburgh Clinical Trials Unit, University of Edinburgh, Edinburgh, UK
| | - David E Newby
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Nicholas L Mills
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK; Usher Institute, University of Edinburgh, Edinburgh, UK
| | - Neeraj Dhaun
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK; Department of Renal Medicine, Royal Infirmary of Edinburgh, Edinburgh, UK.
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Okasha KM, Aboufreikha MH, Elrefaey W, Ashmawy MM, Mourad H, Elsebaey MA, Elnaggar MH, Mashaal RG, Metwally S, Mashal SSA, Shalaby NA, Elhoseny SA, Alkassas A, Elbarbary M, Shoeib O, Ali DA, Baiomy N, Alnabawy SM. Association of Serum Osteoprotegerin Level With Myocardial Injury and Cardiovascular Calcification in Chronic Kidney Disease Patients. Front Med (Lausanne) 2022; 9:814970. [PMID: 35814784 PMCID: PMC9257085 DOI: 10.3389/fmed.2022.814970] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2021] [Accepted: 05/26/2022] [Indexed: 11/17/2022] Open
Abstract
Background Chronic kidney disease has emerged as a significant independent risk factor for cardiovascular disease. Cardiovascular calcification is an active process involving a complex interaction of inducers and inhibitors. High sensitivity cardiac troponin T assay detects troponin T with higher sensitivity and precision at an earlier point of time than the conventional assays, and is associated with poor outcomes. Serum osteoprotegerin is classed as an inhibitory factor for cardiovascular calcification. It is involved in the pathological processes of vascular damage and linked to the excess cardiovascular morbidity. The aim of the present study was to evaluate the extent of cardiovascular calcification and serum high sensitivity cardiac troponin T level, and their association with serum osteoprotegerin level in patients with chronic kidney disease stages 3-5. Methods 90 chronic kidney disease patients were enrolled in this study, and they were divided into two groups: group (1) included 45 non-dialysis-dependent chronic kidney disease patients (stages 3-5) and group (2) included 45 chronic hemodialysis patients. Each group further subdivided according to the presence of cardiovascular calcification into subgroup A and B. Vascular calcifications were assessed by lateral lumbar, pelvis and hands X-ray radiographs. Valvular calcification was assessed by echocardiography. Serum cardiac troponin T was measured by high sensitivity assay and serum osteoprotegerin was measured by ELISA. Results Cardiovascular calcification distribution was 22.2% in group (1) and 33.3% in group (2). Serum osteoprotegerin and troponin T in calcification groups (1A and 2A) were significantly higher than non-calcification groups (1B and 2B; P < 0.001). Osteoprotegerin correlated positively with high sensitivity cardiac troponin T (rs = 0.72, P < 0.001). cardiovascular calcification correlated positively with osteoprotegerin, troponin T, and phosphorus. osteoprotegerin and phosphorus were significant independent predictors of cardiovascular calcification at cut-off values ≥4.6 ng/L and ≥6.95 mg/dl, respectively (P < 0.001). Serum phosphorus and creatinine were independent predictors of osteoprotegerin (P < 0.001 and 0.048, respectively). Conclusion Osteoprotegerin is strongly associated with cardiovascular calcification and high sensitivity cardiac troponin T. In addition, there is a positive association between calcification and troponin T. This suggests a role for osteoprotegerin in the pathogenesis and risk stratification of cardiovascular calcification and myocardial injury in chronic kidney disease patients with a potential role as a therapeutic target.
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Affiliation(s)
- Kamal M. Okasha
- Internal Medicine Department, Faculty of Medicine, Tanta University, Tanta, Egypt
| | | | - Waleed Elrefaey
- Internal Medicine Department, Faculty of Medicine, Tanta University, Tanta, Egypt
| | - Medhat M. Ashmawy
- Cardiovascular Medicine Department, Faculty of Medicine, Tanta University, Tanta, Egypt
| | - Heba Mourad
- Clinical Pathology Department, Faculty of Medicine, Tanta University, Tanta, Egypt
| | - Mohamed A. Elsebaey
- Internal Medicine Department, Faculty of Medicine, Tanta University, Tanta, Egypt
| | - Mohammed H. Elnaggar
- Internal Medicine Department, Faculty of Medicine, Tanta University, Tanta, Egypt
| | - Raghda Gabr Mashaal
- Internal Medicine Department, Faculty of Medicine, Tanta University, Tanta, Egypt
| | - Sama Metwally
- Internal Medicine Department, Faculty of Medicine, Tanta University, Tanta, Egypt
| | | | - Neveen A. Shalaby
- Internal Medicine Department, Faculty of Medicine, Tanta University, Tanta, Egypt
| | - Shireen Ali Elhoseny
- Internal Medicine Department, Faculty of Medicine, Tanta University, Tanta, Egypt
| | - Amr Alkassas
- Cardiovascular Medicine Department, Faculty of Medicine, Tanta University, Tanta, Egypt
| | - Mohammed Elbarbary
- Cardiovascular Medicine Department, Faculty of Medicine, Tanta University, Tanta, Egypt
| | - Osama Shoeib
- Cardiovascular Medicine Department, Faculty of Medicine, Tanta University, Tanta, Egypt
| | - Dina A. Ali
- Clinical Pathology Department, Faculty of Medicine, Tanta University, Tanta, Egypt
| | - Nivin Baiomy
- Clinical Pathology Department, Faculty of Medicine, Tanta University, Tanta, Egypt
| | - Sherein M. Alnabawy
- Internal Medicine Department, Faculty of Medicine, Tanta University, Tanta, Egypt
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34
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du Fay de Lavallaz J, Prepoudis A, Wendebourg MJ, Kesenheimer E, Kyburz D, Daikeler T, Haaf P, Wanschitz J, Löscher WN, Schreiner B, Katan M, Jung HH, Maurer B, Hammerer-Lercher A, Mayr A, Gualandro DM, Acket A, Puelacher C, Boeddinghaus J, Nestelberger T, Lopez-Ayala P, Glarner N, Shrestha S, Manka R, Gawinecka J, Piscuoglio S, Gallon J, Wiedemann S, Sinnreich M, Mueller C. Skeletal Muscle Disorders: A Noncardiac Source of Cardiac Troponin T. Circulation 2022; 145:1764-1779. [PMID: 35389756 PMCID: PMC10069758 DOI: 10.1161/circulationaha.121.058489] [Citation(s) in RCA: 41] [Impact Index Per Article: 20.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
BACKGROUND Cardiac troponin (cTn) T and cTnI are considered cardiac specific and equivalent in the diagnosis of acute myocardial infarction. Previous studies suggested rare skeletal myopathies as a noncardiac source of cTnT. We aimed to confirm the reliability/cardiac specificity of cTnT in patients with various skeletal muscle disorders (SMDs). METHODS We prospectively enrolled patients presenting with muscular complaints (≥2 weeks) for elective evaluation in 4 hospitals in 2 countries. After a cardiac workup, patients were adjudicated into 3 predefined cardiac disease categories. Concentrations of cTnT/I and resulting cTnT/I mismatches were assessed with high-sensitivity (hs-) cTnT (hs-cTnT-Elecsys) and 3 hs-cTnI assays (hs-cTnI-Architect, hs-cTnI-Access, hs-cTnI-Vista) and compared with those of control subjects without SMD presenting with adjudicated noncardiac chest pain to the emergency department (n=3508; mean age, 55 years; 37% female). In patients with available skeletal muscle biopsies, TNNT/I1-3 mRNA differential gene expression was compared with biopsies obtained in control subjects without SMD. RESULTS Among 211 patients (mean age, 57 years; 42% female), 108 (51%) were adjudicated to having no cardiac disease, 44 (21%) to having mild disease, and 59 (28%) to having severe cardiac disease. hs-cTnT/I concentrations significantly increased from patients with no to those with mild and severe cardiac disease for all assays (all P<0.001). hs-cTnT-Elecsys concentrations were significantly higher in patients with SMD versus control subjects (median, 16 ng/L [interquartile range (IQR), 7-32.5 ng/L] versus 5 ng/L [IQR, 3-9 ng/L]; P<0.001), whereas hs-cTnI concentrations were mostly similar (hs-cTnI-Architect, 2.5 ng/L [IQR, 1.2-6.2 ng/L] versus 2.9 ng/L [IQR, 1.8-5.0 ng/L]; hs-cTnI-Access, 3.3 ng/L [IQR, 2.4-6.1 ng/L] versus 2.7 ng/L [IQR, 1.6-5.0 ng/L]; and hs-cTnI-Vista, 7.4 ng/L [IQR, 5.2-13.4 ng/L] versus 7.5 ng/L [IQR, 6-10 ng/L]). hs-cTnT-Elecsys concentrations were above the upper limit of normal in 55% of patients with SMD versus 13% of control subjects (P<0.01). mRNA analyses in skeletal muscle biopsies (n=33), mostly (n=24) from individuals with noninflammatory myopathy and myositis, showed 8-fold upregulation of TNNT2, encoding cTnT (but none for TNNI3, encoding cTnI) versus control subjects (n=16, PWald<0.001); the expression correlated with pathological disease activity (R=0.59, Pt-statistic<0.001) and circulating hs-cTnT concentrations (R=0.26, Pt-statistic=0.031). CONCLUSIONS In patients with active chronic SMD, elevations in cTnT concentrations are common and not attributable to cardiac disease in the majority. This was not observed for cTnI and may be explained in part by re-expression of cTnT in skeletal muscle. REGISTRATION URL: https://www. CLINICALTRIALS gov; Unique identifier: NCT03660969.
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Affiliation(s)
- Jeanne du Fay de Lavallaz
- Cardiovascular Research Institute Basel (J.d.F.d.L., A.P., P.H., D.M.G., A.A., C.P., J.B., T.N., P.L.-A., N.G., S.S., S.P., J. Gallon, S.W., C.M.), University Hospital of Basel, Switzerland.,Department of Cardiology (J.d.F.d.L., A.P., P.H., D.M.G., A.A., C.P., J.B., T.N., P.L.-A., N.G., S.S., S.P., J. Gallon, S.W., C.M.), University Hospital of Basel, Switzerland
| | - Alexandra Prepoudis
- Cardiovascular Research Institute Basel (J.d.F.d.L., A.P., P.H., D.M.G., A.A., C.P., J.B., T.N., P.L.-A., N.G., S.S., S.P., J. Gallon, S.W., C.M.), University Hospital of Basel, Switzerland.,Department of Cardiology (J.d.F.d.L., A.P., P.H., D.M.G., A.A., C.P., J.B., T.N., P.L.-A., N.G., S.S., S.P., J. Gallon, S.W., C.M.), University Hospital of Basel, Switzerland
| | - Maria Janina Wendebourg
- Neurology Clinic and Policlinic (M.J.W., E.K., M.S.), University Hospital of Basel, Switzerland
| | - Eva Kesenheimer
- Neurology Clinic and Policlinic (M.J.W., E.K., M.S.), University Hospital of Basel, Switzerland
| | - Diego Kyburz
- Department of Rheumatology (D.K., T.D.), University Hospital of Basel, Switzerland.,University of Basel, Switzerland (D.K., M.S., C.M.)
| | - Thomas Daikeler
- Department of Rheumatology (D.K., T.D.), University Hospital of Basel, Switzerland
| | - Philip Haaf
- Cardiovascular Research Institute Basel (J.d.F.d.L., A.P., P.H., D.M.G., A.A., C.P., J.B., T.N., P.L.-A., N.G., S.S., S.P., J. Gallon, S.W., C.M.), University Hospital of Basel, Switzerland
| | - Julia Wanschitz
- Departments of Neurology (J.W., W.N.L.), Medical University of Innsbruck, Austria
| | - Wolfgang N Löscher
- Departments of Neurology (J.W., W.N.L.), Medical University of Innsbruck, Austria
| | - Bettina Schreiner
- Departments of Neurology (B.S., M.K., H.H.J.), University Hospital of Zürich, Switzerland
| | - Mira Katan
- Departments of Neurology (B.S., M.K., H.H.J.), University Hospital of Zürich, Switzerland
| | - Hans H Jung
- Departments of Neurology (B.S., M.K., H.H.J.), University Hospital of Zürich, Switzerland
| | - Britta Maurer
- Rheumatology (B.M.), University Hospital of Zürich, Switzerland.,Department of Rheumatology and Immunology, Inselspital Bern, Switzerland (B.M.)
| | | | - Agnes Mayr
- Radiology (A.M.), Medical University of Innsbruck, Austria
| | - Danielle M Gualandro
- Cardiovascular Research Institute Basel (J.d.F.d.L., A.P., P.H., D.M.G., A.A., C.P., J.B., T.N., P.L.-A., N.G., S.S., S.P., J. Gallon, S.W., C.M.), University Hospital of Basel, Switzerland.,Department of Cardiology (J.d.F.d.L., A.P., P.H., D.M.G., A.A., C.P., J.B., T.N., P.L.-A., N.G., S.S., S.P., J. Gallon, S.W., C.M.), University Hospital of Basel, Switzerland
| | - Annemarie Acket
- Cardiovascular Research Institute Basel (J.d.F.d.L., A.P., P.H., D.M.G., A.A., C.P., J.B., T.N., P.L.-A., N.G., S.S., S.P., J. Gallon, S.W., C.M.), University Hospital of Basel, Switzerland.,Neurology Clinic and Policlinic (M.J.W., E.K., M.S.), University Hospital of Basel, Switzerland
| | - Christian Puelacher
- Cardiovascular Research Institute Basel (J.d.F.d.L., A.P., P.H., D.M.G., A.A., C.P., J.B., T.N., P.L.-A., N.G., S.S., S.P., J. Gallon, S.W., C.M.), University Hospital of Basel, Switzerland.,Department of Cardiology (J.d.F.d.L., A.P., P.H., D.M.G., A.A., C.P., J.B., T.N., P.L.-A., N.G., S.S., S.P., J. Gallon, S.W., C.M.), University Hospital of Basel, Switzerland
| | - Jasper Boeddinghaus
- Cardiovascular Research Institute Basel (J.d.F.d.L., A.P., P.H., D.M.G., A.A., C.P., J.B., T.N., P.L.-A., N.G., S.S., S.P., J. Gallon, S.W., C.M.), University Hospital of Basel, Switzerland.,Department of Cardiology (J.d.F.d.L., A.P., P.H., D.M.G., A.A., C.P., J.B., T.N., P.L.-A., N.G., S.S., S.P., J. Gallon, S.W., C.M.), University Hospital of Basel, Switzerland
| | - Thomas Nestelberger
- Cardiovascular Research Institute Basel (J.d.F.d.L., A.P., P.H., D.M.G., A.A., C.P., J.B., T.N., P.L.-A., N.G., S.S., S.P., J. Gallon, S.W., C.M.), University Hospital of Basel, Switzerland.,Department of Cardiology (J.d.F.d.L., A.P., P.H., D.M.G., A.A., C.P., J.B., T.N., P.L.-A., N.G., S.S., S.P., J. Gallon, S.W., C.M.), University Hospital of Basel, Switzerland.,Division of Cardiology, Vancouver General Hospital, University of British Columbia, Canada (T.N.)
| | - Pedro Lopez-Ayala
- Cardiovascular Research Institute Basel (J.d.F.d.L., A.P., P.H., D.M.G., A.A., C.P., J.B., T.N., P.L.-A., N.G., S.S., S.P., J. Gallon, S.W., C.M.), University Hospital of Basel, Switzerland.,Department of Cardiology (J.d.F.d.L., A.P., P.H., D.M.G., A.A., C.P., J.B., T.N., P.L.-A., N.G., S.S., S.P., J. Gallon, S.W., C.M.), University Hospital of Basel, Switzerland
| | - Noemi Glarner
- Cardiovascular Research Institute Basel (J.d.F.d.L., A.P., P.H., D.M.G., A.A., C.P., J.B., T.N., P.L.-A., N.G., S.S., S.P., J. Gallon, S.W., C.M.), University Hospital of Basel, Switzerland.,Department of Cardiology (J.d.F.d.L., A.P., P.H., D.M.G., A.A., C.P., J.B., T.N., P.L.-A., N.G., S.S., S.P., J. Gallon, S.W., C.M.), University Hospital of Basel, Switzerland
| | - Samyut Shrestha
- Cardiovascular Research Institute Basel (J.d.F.d.L., A.P., P.H., D.M.G., A.A., C.P., J.B., T.N., P.L.-A., N.G., S.S., S.P., J. Gallon, S.W., C.M.), University Hospital of Basel, Switzerland.,Department of Cardiology (J.d.F.d.L., A.P., P.H., D.M.G., A.A., C.P., J.B., T.N., P.L.-A., N.G., S.S., S.P., J. Gallon, S.W., C.M.), University Hospital of Basel, Switzerland
| | - Robert Manka
- Cardiology (R.M.), University Hospital of Zürich, Switzerland
| | - Joanna Gawinecka
- Institute of Clinical Chemistry (J. Gawinecka), University Hospital of Zürich, Switzerland
| | - Salvatore Piscuoglio
- Cardiovascular Research Institute Basel (J.d.F.d.L., A.P., P.H., D.M.G., A.A., C.P., J.B., T.N., P.L.-A., N.G., S.S., S.P., J. Gallon, S.W., C.M.), University Hospital of Basel, Switzerland.,Department of Cardiology (J.d.F.d.L., A.P., P.H., D.M.G., A.A., C.P., J.B., T.N., P.L.-A., N.G., S.S., S.P., J. Gallon, S.W., C.M.), University Hospital of Basel, Switzerland.,Department of Biomedicine (S.P., J. Gallon, S.W.), University Hospital of Basel, Switzerland
| | - John Gallon
- Cardiovascular Research Institute Basel (J.d.F.d.L., A.P., P.H., D.M.G., A.A., C.P., J.B., T.N., P.L.-A., N.G., S.S., S.P., J. Gallon, S.W., C.M.), University Hospital of Basel, Switzerland.,Department of Cardiology (J.d.F.d.L., A.P., P.H., D.M.G., A.A., C.P., J.B., T.N., P.L.-A., N.G., S.S., S.P., J. Gallon, S.W., C.M.), University Hospital of Basel, Switzerland.,Department of Biomedicine (S.P., J. Gallon, S.W.), University Hospital of Basel, Switzerland
| | - Sophia Wiedemann
- Cardiovascular Research Institute Basel (J.d.F.d.L., A.P., P.H., D.M.G., A.A., C.P., J.B., T.N., P.L.-A., N.G., S.S., S.P., J. Gallon, S.W., C.M.), University Hospital of Basel, Switzerland.,Department of Cardiology (J.d.F.d.L., A.P., P.H., D.M.G., A.A., C.P., J.B., T.N., P.L.-A., N.G., S.S., S.P., J. Gallon, S.W., C.M.), University Hospital of Basel, Switzerland.,Department of Biomedicine (S.P., J. Gallon, S.W.), University Hospital of Basel, Switzerland
| | - Michael Sinnreich
- Neurology Clinic and Policlinic (M.J.W., E.K., M.S.), University Hospital of Basel, Switzerland.,University of Basel, Switzerland (D.K., M.S., C.M.)
| | - Christian Mueller
- Cardiovascular Research Institute Basel (J.d.F.d.L., A.P., P.H., D.M.G., A.A., C.P., J.B., T.N., P.L.-A., N.G., S.S., S.P., J. Gallon, S.W., C.M.), University Hospital of Basel, Switzerland.,Department of Cardiology (J.d.F.d.L., A.P., P.H., D.M.G., A.A., C.P., J.B., T.N., P.L.-A., N.G., S.S., S.P., J. Gallon, S.W., C.M.), University Hospital of Basel, Switzerland.,University of Basel, Switzerland (D.K., M.S., C.M.)
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35
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Baigent C, Windecker S, Andreini D, Arbelo E, Barbato E, Bartorelli AL, Baumbach A, Behr ER, Berti S, Bueno H, Capodanno D, Cappato R, Chieffo A, Collet JP, Cuisset T, de Simone G, Delgado V, Dendale P, Dudek D, Edvardsen T, Elvan A, González-Juanatey JR, Gori M, Grobbee D, Guzik TJ, Halvorsen S, Haude M, Heidbuchel H, Hindricks G, Ibanez B, Karam N, Katus H, Klok FA, Konstantinides SV, Landmesser U, Leclercq C, Leonardi S, Lettino M, Marenzi G, Mauri J, Metra M, Morici N, Mueller C, Petronio AS, Polovina MM, Potpara T, Praz F, Prendergast B, Prescott E, Price S, Pruszczyk P, Rodríguez-Leor O, Roffi M, Romaguera R, Rosenkranz S, Sarkozy A, Scherrenberg M, Seferovic P, Senni M, Spera FR, Stefanini G, Thiele H, Tomasoni D, Torracca L, Touyz RM, Wilde AA, Williams B. European Society of Cardiology guidance for the diagnosis and management of cardiovascular disease during the COVID-19 pandemic: part 1-epidemiology, pathophysiology, and diagnosis. Cardiovasc Res 2022; 118:1385-1412. [PMID: 34864874 PMCID: PMC8690255 DOI: 10.1093/cvr/cvab342] [Citation(s) in RCA: 26] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
AIMS Since its emergence in early 2020, the novel severe acute respiratory syndrome coronavirus 2 causing coronavirus disease 2019 (COVID-19) has reached pandemic levels, and there have been repeated outbreaks across the globe. The aim of this two-part series is to provide practical knowledge and guidance to aid clinicians in the diagnosis and management of cardiovascular disease (CVD) in association with COVID-19. METHODS AND RESULTS A narrative literature review of the available evidence has been performed, and the resulting information has been organized into two parts. The first, reported here, focuses on the epidemiology, pathophysiology, and diagnosis of cardiovascular (CV) conditions that may be manifest in patients with COVID-19. The second part, which will follow in a later edition of the journal, addresses the topics of care pathways, treatment, and follow-up of CV conditions in patients with COVID-19. CONCLUSION This comprehensive review is not a formal guideline but rather a document that provides a summary of current knowledge and guidance to practicing clinicians managing patients with CVD and COVID-19. The recommendations are mainly the result of observations and personal experience from healthcare providers. Therefore, the information provided here may be subject to change with increasing knowledge, evidence from prospective studies, and changes in the pandemic. Likewise, the guidance provided in the document should not interfere with recommendations provided by local and national healthcare authorities.
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Affiliation(s)
- Colin Baigent
- MRC Population Health Research Unit, Nuffield Department of Population Health, Richard Doll Building, Old Road Campus, Roosevelt Drive, Oxford OX3 7LF, UK
| | - Stephan Windecker
- Department of Cardiology, Inselspital, Bern University Hospital, Freiburgstrasse 4, 3010 Bern, Switzerland
| | - Daniele Andreini
- Centro Cardiologico Monzino, IRCCS, Milan, Italy
- Department of Clinical Sciences and Community Health, Hospital Clínic
| | - Elena Arbelo
- Arrhythmia Section, Cardiology Department, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain
- Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
- ECGen, the Cardiogenetics Focus Group of EHRA
| | - Emanuele Barbato
- Department of Advanced Biomedical Sciences, Federico II University, Naples, Italy
- Cardiovascular Center Aalst, OLV Hospital, Aalst, Belgium
| | - Antonio L Bartorelli
- Centro Cardiologico Monzino, IRCCS, Milan, Italy
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
- Department of Biomedical and Clinical Sciences "Luigi Sacco", University of Milan, Milan, Italy
| | - Andreas Baumbach
- Centre for Cardiovascular Medicine and Devices, William Harvey Research Institute, Queen Mary University of London and Barts Heart Centre, London, UK
- Yale University School of Medicine, New Haven, CT, USA
| | - Elijah R Behr
- ECGen, the Cardiogenetics Focus Group of EHRA
- Cardiology Clinical Academic Group, Institute of Molecular and Clinical Sciences, St George's, University of London, London, UK
- St George's University Hospitals NHS Foundation Trust, London, UK
- European Reference Network for Rare and Low Prevalence Complex Diseases of the Heart (ERN GUARDHEART)
| | - Sergio Berti
- U.O.C. Cardiologia Diagnostica e Interventistica, Dipartimento Cardiotoracico, Fondazione Toscana G. Monasterio - Ospedale del Cuore G. Pasquinucci, Massa, Italy
| | - Héctor Bueno
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
- Cardiology Department, Hospital Universitario 12 de Octubre and Instituto de Investigación Sanitaria Hospital 12 de Octubre (imas12), Madrid, Spain
- Centro Nacional de Investigaciones Cardiovasculares (CNIC), Madrid, Spain
| | - Davide Capodanno
- Division of Cardiology, A.O.U. Policlinico "G. Rodolico-San Marco" University of Catania, Catania, Italy
| | - Riccardo Cappato
- Arrhythmia & Electrophysiology Center, IRCCS Gruppo MultiMedica, Sesto San Giovanni, Milan, Italy
| | | | - Jean-Philippe Collet
- Sorbonne Université, ACTION study group, Institut de Cardiologie, Pitié Salpêtrière Hospital (AP-HP), Paris, France
| | - Thomas Cuisset
- Département de Cardiologie, CHU Timone, Marseille, France
- INSERM, UMR1062, Nutrition, Obesity and Risk of Thrombosis, Marseille, France
- Faculté de Médecine, Aix-Marseille Université, Marseille, France
| | - Giovanni de Simone
- Department of Advanced Biomedical Sciences, Federico II University, Naples, Italy
- Hypertension Research Center, Federico II University Hospital, Naples, Italy
| | - Victoria Delgado
- Heart Lung Centrum, Leiden University Medical Center, Leiden, The Netherlands
| | - Paul Dendale
- Heart Centre Hasselt, Jessa Hospital, Hasselt, Belgium
- Faculty of Medicine and Life Sciences, Uhasselt, Diepenbeek, Belgium
| | - Dariusz Dudek
- Institute of Cardiology, Jagiellonian University Medical College, Kraków, Poland
- Maria Cecilia Hospital, GVM Care&Research, Cotignola (RA), Ravenna, Italy
| | - Thor Edvardsen
- Department of Cardiology, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | - Arif Elvan
- Isala Heart Center, Zwolle, The Netherlands
| | - José R González-Juanatey
- Cardiology Department, University Hospital, IDIS, CIBERCV, University of Santiago de Compostela, Santiago de Compostela, Spain
| | - Mauro Gori
- Cardiovascular Department and Cardiology Unit, Papa Giovanni XXIII Hospital-Bergamo, Bergamo, Italy
| | - Diederick Grobbee
- Julius Global Health, the Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Tomasz J Guzik
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
- Department of Medicine, Jagiellonian University College of Medicine, Kraków, Poland
| | - Sigrun Halvorsen
- Department of Cardiology, Oslo University Hospital Ulleval, Oslo, Norway
- University of Oslo, Oslo, Norway
| | - Michael Haude
- Medical Clinic I, Städtische Kliniken Neuss, Lukaskrankenhaus GmbH, Neuss, Germany
| | - Hein Heidbuchel
- Department of Cardiology, University Hospital Antwerp and University of Antwerp, Antwerp, Belgium
| | - Gerhard Hindricks
- Department of Internal Medicine/Cardiology/Electrophysiology, Heart Center Leipzig, University Hospital Leipzig, Leipzig, Germany
- Leipzig Heart Institute (LHI), Leipzig, Germany
| | - Borja Ibanez
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
- Centro Nacional de Investigaciones Cardiovasculares (CNIC), Madrid, Spain
- IIS-Fundación Jiménez Díaz Hospital, Madrid, Spain
| | - Nicole Karam
- Université de Paris, PARCC, INSERM, Paris, France
- European Hospital Georges Pompidou, Paris, France
| | - Hugo Katus
- Department of Internal Medicine, University Hospital of Heidelberg, Heidelberg, Germany
| | - Fredrikus A Klok
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Stavros V Konstantinides
- Center for Thrombosis and Hemostasis, Johannes Gutenberg University Mainz, Mainz, Germany
- Department of Cardiology, Democritus University of Thrace, Alexandroupolis, Greece
| | - Ulf Landmesser
- Department of Cardiology, Charite University Medicine Berlin, Berlin, Germany
- Berlin Institute of Health (BIH), German Center of Cardiovascular Research (DZHK), Partner Site Berlin, Berlin, Germany
| | | | - Sergio Leonardi
- University of Pavia, Pavia, Italy
- Fondazione IRCCS Policlinico S.Matteo, Pavia, Italy
| | - Maddalena Lettino
- Cardio-Thoracic and Vascular Department, San Gerardo Hospital, ASST-Monza, Monza, Italy
| | | | - Josepa Mauri
- Institut del Cor, Hospital Universitari Germans Trias i Pujol, Badalona, Spain
- Health Department of the Government of Catalonia, Barcelona, Spain
| | - Marco Metra
- Institute of Cardiology, ASST Spedali Civili di Brescia, Brescia, Italy
- Department of Medical and Surgical Specialities, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Nuccia Morici
- Unità di Cure Intensive Cardiologiche e De Gasperis Cardio Center, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
- Dipartimento di Scienze Cliniche e di Comunità, Università degli Studi, Milan, Italy
| | - Christian Mueller
- Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Basel, Switzerland
- University of Basel, Basel, Switzerland
| | - Anna Sonia Petronio
- Cardiothoracic and Vascular Department, University of Pisa, Ospedale Cisanello, Pisa, Italy
| | - Marija M Polovina
- Faculty of Medicine, Belgrade University, Belgrade, Serbia
- Department of Cardiology, Clinical Centre of Serbia, Belgrade, Serbia
| | - Tatjana Potpara
- School of Medicine, University of Belgrade, Belgrade, Serbia
- Department for Intensive Arrhythmia Care, Cardiology Clinic, Clinical Centre of Serbia, Belgrade, Serbia
| | - Fabien Praz
- Department of Cardiology, University Hospital Bern, Bern, Switzerland
| | | | - Eva Prescott
- Department of Cardiology, Bispebjerg University Hospital, Copenhagen, Denmark
| | - Susanna Price
- Royal Brompton Hospital, London, UK
- National Heart & Lung Institute, Imperial College, London, UK
| | - Piotr Pruszczyk
- Department of Internal Medicine and Cardiology, Medical University of Warsaw, Warsaw, Poland
| | - Oriol Rodríguez-Leor
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
- Health Department of the Government of Catalonia, Barcelona, Spain
| | - Marco Roffi
- Department of Cardiology, Geneva University Hospitals, Geneva, Switzerland
| | - Rafael Romaguera
- Servicio de Cardiología, Hospital Universitario de Bellvitge-IDIBELL, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Stephan Rosenkranz
- Clinic III for Internal Medicine (Cardiology) and Cologne Cardiovascular Research Center (CCRC), Heart Center at the University of Cologne, Cologne, Germany
- Center for Molecular Medicine Cologne (CMMC), University of Cologne, Cologne, Germany
| | - Andrea Sarkozy
- Department of Cardiology, University Hospital Antwerp and University of Antwerp, Antwerp, Belgium
| | - Martijn Scherrenberg
- Heart Centre Hasselt, Jessa Hospital, Hasselt, Belgium
- Faculty of Medicine and Life Sciences, Uhasselt, Diepenbeek, Belgium
| | - Petar Seferovic
- Faculty of Medicine, Belgrade University, Belgrade, Serbia
- Serbian Academy of Sciences and Arts, Belgrade, Serbia
| | - Michele Senni
- Cardiovascular Department and Cardiology Unit, Papa Giovanni XXIII Hospital-Bergamo, Bergamo, Italy
| | - Francesco R Spera
- Department of Cardiology, University Hospital Antwerp and University of Antwerp, Antwerp, Belgium
| | - Giulio Stefanini
- Department of Biomedical Sciences, Humanitas Clinical and Research Center, Humanitas University, Pieve Emanuele - Milan, Italy
- Humanitas Research Hospital IRCCS, Rozzano - Milan, Italy
| | - Holger Thiele
- Department of Internal Medicine/Cardiology, Heart Center Leipzig at University of Leipzig, Leipzig, Germany
- Leipzig Heart Institute (LHI), Leipzig, Germany
| | - Daniela Tomasoni
- Institute of Cardiology, ASST Spedali Civili di Brescia, Brescia, Italy
- Department of Medical and Surgical Specialities, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Luccia Torracca
- Department of Biomedical Sciences, Humanitas Clinical and Research Center, Humanitas University, Pieve Emanuele - Milan, Italy
- Humanitas Research Hospital IRCCS, Rozzano - Milan, Italy
| | - Rhian M Touyz
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Arthur A Wilde
- ECGen, the Cardiogenetics Focus Group of EHRA
- European Reference Network for Rare and Low Prevalence Complex Diseases of the Heart (ERN GUARDHEART)
- Amsterdam UMC, University of Amsterdam, Heart Center, Amsterdam, The Netherlands
- Department of Clinical Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - Bryan Williams
- Institute of Cardiovascular Sciences, University College London, London, UK
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Nomura O, Hashiba K, Kikuchi M, Kojima S, Hanada H, Mano T, Yamamoto T, Nakashima T, Tanaka A, Nakayama N, Yamaguchi J, Matsuo K, Matoba T, Tahara Y, Nonogi H. Performance of the 0-Hour/1-Hour Algorithm for Diagnosing Myocardial Infarction in Patients With Chest Pain in the Emergency Department ― A Systematic Review and Meta-Analysis ―. Circ Rep 2022; 4:241-247. [PMID: 35774074 PMCID: PMC9168511 DOI: 10.1253/circrep.cr-22-0001] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Revised: 03/20/2022] [Accepted: 03/28/2022] [Indexed: 11/24/2022] Open
Abstract
Background: This study assessed the diagnostic performance of the 0-hour/1-hour (0/1-h) algorithm to rule in and rule out acute myocardial infarction (MI) in patients presenting to the emergency department (ED) for suspected acute coronary syndrome without ST-segment elevation, as recommended in the 2015 European Society of Cardiology (ESC) guideline. Methods and Results: Following the Preferred Reporting Items for a Systematic Review and Meta-analysis of Diagnostic Test Accuracy (PRISMA-DTA) guidelines, a systematic review was conducted using the PubMed database from inception to March 31, 2020. We included any article published in English investigating the diagnostic performance of the ESC 0/1-h algorithm for diagnosing MI in patients with chest pain visiting the ED. Of 651 studies identified as potentially available for the study, 7 studies including 16 databases were analyzed. A meta-analysis of the diagnostic accuracy of the 0/1-h algorithm using high-sensitivity cardiac troponin I (hs-cTn) with 6 observational databases showed a pooled sensitivity of 99.3% (95% confidence interval [CI] 98.5–99.7%) and a pooled specificity of 90.1% (95% CI 80.7–95.2%). A meta-analysis of the diagnostic accuracy of 10 observational databases of the ESC 0/1-h algorithm using hs-cTn revealed a pooled sensitivity of 99.3% (95% CI 96.9–99.9%) and a pooled specificity of 91.7% (95% CI 83.5–96.1%). Conclusions: Our results demonstrate that the ESC 0/1-h algorithm can effectively rule in and rule out patients with non-ST-segment elevation MI.
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Affiliation(s)
- Osamu Nomura
- Department of Emergency and Disaster Medicine, Hirosaki University
| | | | - Migaku Kikuchi
- Department of Cardiovascular Medicine, Emergency and Critical Care Center, Dokkyo Medical University
| | - Sunao Kojima
- Department of Internal Medicine, Sakurajyuji Yatsushiro Rehabilitation Hospital
| | - Hiroyuki Hanada
- Department of Emergency and Disaster Medicine, Hirosaki University
| | | | - Takeshi Yamamoto
- Division of Cardiovascular Intensive Care, Nippon Medical School Hospital
| | - Takahiro Nakashima
- Department of Emergency Medicine and Michigan Center for Integrative Research in Critical Care, University of Michigan
| | - Akihito Tanaka
- Department of Cardiology, Nagoya University Graduate School of Medicine
| | - Naoki Nakayama
- Department of Cardiology, Kanagawa Cardiovascular and Respiratory Center
| | | | - Kunihiro Matsuo
- Department of Acute Care Medicine, Fukuoka University Chikushi Hospital
| | - Tetsuya Matoba
- Department of Cardiovascular Medicine, Kyushu University Faculty of Medical Sciences
| | - Yoshio Tahara
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
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Aarts GW, Camaro C, Vermaas N, Kamps J, van Herwaarden AE, Cramer GE, van Kimmenade RR, van Royen N, van Geuns R, Damman P. Implementation of the ESC 0 h/1h algorithm and the HEART score in the emergency department: A prospective cohort study. IJC HEART & VASCULATURE 2022; 39:100988. [PMID: 35257026 PMCID: PMC8897680 DOI: 10.1016/j.ijcha.2022.100988] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Revised: 02/21/2022] [Accepted: 02/27/2022] [Indexed: 11/25/2022]
Abstract
Background The European Society of Cardiology (ESC) 0 h/1h algorithm is the preferred diagnostic strategy for chest pain patients in the emergency department (ED). It is suggested that adding clinical information to the algorithm improves its diagnostic performance. This study evaluates implementation of the ESC 0 h/1h algorithm in the ED and investigates the potential advantages of combining it with a clinical decision rule, which might be especially relevant in the heterogenous observation category. Methods In this prospective cohort study, chest pain patients in whom the ESC 0 h/1h algorithm was applied were enrolled. HEART score components were collected. Diagnostic characteristics were determined for the algorithm with and without addition of the HEART score. Primary endpoint was a composite endpoint at 30-day follow-up, consisting of myocardial infarction and death. Results A total of 668 patients were enrolled. The rule-in and rule-out categories consisted of 8.2% and 54.9% of the patients, respectively. Positive predictive value and specificity of the rule-in category were 67.3% and 97.1%, respectively. Negative predictive value (NPV) and sensitivity of the rule-out category were both 100%. In the observation category, a HEART score ≤ 3 yielded a NPV and sensitivity of 97.1% and 93.8%, respectively. Conclusion The ESC 0 h/1h algorithm yielded a NPV and sensitivity of 100% for myocardial infarction and death at 30-day follow-up. Addition of the HEART score did not provide clinically relevant advantages. Although the HEART score can be used to guide diagnostic testing in the observation category, a low HEART score did not yield an NPV of > 99%.
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Will M, Weiss TW. Rise and fall of troponin in the emergency department: do we overlook an important group at risk? Intern Emerg Med 2022; 17:635-637. [PMID: 35305215 DOI: 10.1007/s11739-022-02942-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2021] [Accepted: 02/01/2022] [Indexed: 11/05/2022]
Affiliation(s)
- Maximillian Will
- Department of Internal Medicine 3, Karl Landsteiner University of Health Sciences, University Hospital St. Pölten, Krems, Austria
- Karl Landsteiner Institute for Cardiometabolics, Karl Landsteiner Society, St Poelten, Austria
| | - Thomas Werner Weiss
- Department of Internal Medicine 3, Karl Landsteiner University of Health Sciences, University Hospital St. Pölten, Krems, Austria.
- Karl Landsteiner Institute for Cardiometabolics, Karl Landsteiner Society, St Poelten, Austria.
- Department of Cardiology, Sigmund Freud University Medical School, Vienna, Austria.
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Baigent C, Windecker S, Andreini D, Arbelo E, Barbato E, Bartorelli AL, Baumbach A, Behr ER, Berti S, Bueno H, Capodanno D, Cappato R, Chieffo A, Collet JP, Cuisset T, de Simone G, Delgado V, Dendale P, Dudek D, Edvardsen T, Elvan A, González-Juanatey JR, Gori M, Grobbee D, Guzik TJ, Halvorsen S, Haude M, Heidbuchel H, Hindricks G, Ibanez B, Karam N, Katus H, Klok FA, Konstantinides SV, Landmesser U, Leclercq C, Leonardi S, Lettino M, Marenzi G, Mauri J, Metra M, Morici N, Mueller C, Petronio AS, Polovina MM, Potpara T, Praz F, Prendergast B, Prescott E, Price S, Pruszczyk P, Rodríguez-Leor O, Roffi M, Romaguera R, Rosenkranz S, Sarkozy A, Scherrenberg M, Seferovic P, Senni M, Spera FR, Stefanini G, Thiele H, Tomasoni D, Torracca L, Touyz RM, Wilde AA, Williams B. European Society of Cardiology guidance for the diagnosis and management of cardiovascular disease during the COVID-19 pandemic: part 1-epidemiology, pathophysiology, and diagnosis. Eur Heart J 2022; 43:1033-1058. [PMID: 34791157 PMCID: PMC8690026 DOI: 10.1093/eurheartj/ehab696] [Citation(s) in RCA: 65] [Impact Index Per Article: 32.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Revised: 07/08/2021] [Accepted: 09/13/2021] [Indexed: 01/08/2023] Open
Abstract
AIMS Since its emergence in early 2020, the novel severe acute respiratory syndrome coronavirus 2 causing coronavirus disease 2019 (COVID-19) has reached pandemic levels, and there have been repeated outbreaks across the globe. The aim of this two-part series is to provide practical knowledge and guidance to aid clinicians in the diagnosis and management of cardiovascular disease (CVD) in association with COVID-19. METHODS AND RESULTS A narrative literature review of the available evidence has been performed, and the resulting information has been organized into two parts. The first, reported here, focuses on the epidemiology, pathophysiology, and diagnosis of cardiovascular (CV) conditions that may be manifest in patients with COVID-19. The second part, which will follow in a later edition of the journal, addresses the topics of care pathways, treatment, and follow-up of CV conditions in patients with COVID-19. CONCLUSION This comprehensive review is not a formal guideline but rather a document that provides a summary of current knowledge and guidance to practicing clinicians managing patients with CVD and COVID-19. The recommendations are mainly the result of observations and personal experience from healthcare providers. Therefore, the information provided here may be subject to change with increasing knowledge, evidence from prospective studies, and changes in the pandemic. Likewise, the guidance provided in the document should not interfere with recommendations provided by local and national healthcare authorities.
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Skalsky K, Shiyovich A, Steinmetz T, Kornowski R. Chronic Renal Failure and Cardiovascular Disease: A Comprehensive Appraisal. J Clin Med 2022; 11:jcm11051335. [PMID: 35268426 PMCID: PMC8911484 DOI: 10.3390/jcm11051335] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2021] [Revised: 02/23/2022] [Accepted: 02/24/2022] [Indexed: 02/01/2023] Open
Abstract
Coronary artery disease is highly prevalent in patients with chronic kidney disease. The concomitant renal disease often poses a major challenge in decision making as symptoms, cardiac biomarkers and noninvasive studies for evaluation of myocardial ischemia have different sensitivity and specificity thresholds in this specific population. Moreover, the effectiveness and safety of intervention and medical treatment in those patients is of great doubt as most clinical studies exclude patients with advance CKD. In the present paper, we discuss and review the literature in the diagnosis, treatment and prevention of CAD in the acute and chronic setting, in patients with CKD.
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Affiliation(s)
- Keren Skalsky
- Department of Cardiology, Rabin Medical Center, Petah Tikva 4941492, Israel; (A.S.); (R.K.)
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel;
- Correspondence: or ; Tel.: +972-39372251; Fax: +972-39372460
| | - Arthur Shiyovich
- Department of Cardiology, Rabin Medical Center, Petah Tikva 4941492, Israel; (A.S.); (R.K.)
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel;
| | - Tali Steinmetz
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel;
- Department of Nephrology, Rabin Medical Center, Petah Tikva 4941492, Israel
| | - Ran Kornowski
- Department of Cardiology, Rabin Medical Center, Petah Tikva 4941492, Israel; (A.S.); (R.K.)
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel;
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Wang Y, Gao L. Inflammation and Cardiovascular Disease Associated With Hemodialysis for End-Stage Renal Disease. Front Pharmacol 2022; 13:800950. [PMID: 35222026 PMCID: PMC8867697 DOI: 10.3389/fphar.2022.800950] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2021] [Accepted: 01/10/2022] [Indexed: 12/24/2022] Open
Abstract
Chronic kidney disease (CKD) and cardiac insufficiency often co-exist, particularly in uremic patients on hemodialysis (HD). The occurrence of abnormal renal function in patients with cardiac insufficiency is often indicative of a poor prognosis. It has long been established that in patients with cardiac insufficiency, poorer renal function tends to indicate poorer cardiac mechanics, including left atrial reserve strain, left ventricular longitudinal strain, and right ventricular free wall strain (Unger et al., Eur J Heart Fail, 2016, 18(1), 103–12). Similarly, patients with chronic kidney disease, particularly uremic patients on HD, often have cardiovascular complications in addition to abnormal endothelial function with volume overload, persistent inflammatory states, calcium overload, and imbalances in redox responses. Cardiac insufficiency due to uremia is therefore mainly due to multifaceted non-specific pathological changes rather than pure renal insufficiency. Several studies have shown that the risk of adverse cardiovascular events is greatly increased and persistent in all patients treated with HD, especially in those who have just started HD treatment. Inflammation, as an important intersection between CKD and cardiovascular disease, is involved in the development of cardiovascular complications in patients with CKD and is indicative of prognosis (Chan et al., Eur Heart J, 2021, 42(13), 1244–1253). Therefore, only by understanding the mechanisms underlying the sequential development of inflammation in CKD patients and breaking the vicious circle between inflammation-mediated renal and cardiac insufficiency is it possible to improve the prognosis of patients with end-stage renal disease (ESRD). This review highlights the mechanisms of inflammation and the oxidative stress that co-exists with inflammation in uremic patients on dialysis, as well as the mechanisms of cardiovascular complications in the inflammatory state, and provides clinical recommendations for the anti-inflammatory treatment of cardiovascular complications in such patients.
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Tangpaisarn T, Srimakam N, Senthong V, Phungoen P, Kotruchin P. Differential Association Between Significant Coronary Stenosis and Cardiac Troponin T Serial Algorithms in Chronic Kidney Disease Patients Diagnosed with Non-ST-Segment Elevation Acute Coronary Syndromes. Open Access Emerg Med 2022; 14:41-49. [PMID: 35140532 PMCID: PMC8818962 DOI: 10.2147/oaem.s348378] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Accepted: 01/17/2022] [Indexed: 11/23/2022] Open
Abstract
Background Methods Results Conclusion
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Affiliation(s)
- Thanat Tangpaisarn
- Department of Emergency Medicine, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
| | - Nirut Srimakam
- Department of Emergency Medicine, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
| | - Vichai Senthong
- Department of Internal Medicine, Faculty of Medicine Srinagarind Hospital, Khon Kaen University, Khon Kaen, Thailand
| | - Pariwat Phungoen
- Department of Emergency Medicine, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
| | - Praew Kotruchin
- Department of Emergency Medicine, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
- Correspondence: Praew Kotruchin, Department of Emergency Medicine, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand, Tel +66 65 5269 422, Email
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Current and Future Applications of Artificial Intelligence in Coronary Artery Disease. Healthcare (Basel) 2022; 10:healthcare10020232. [PMID: 35206847 PMCID: PMC8872080 DOI: 10.3390/healthcare10020232] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Revised: 01/19/2022] [Accepted: 01/24/2022] [Indexed: 02/07/2023] Open
Abstract
Cardiovascular diseases (CVDs) carry significant morbidity and mortality and are associated with substantial economic burden on healthcare systems around the world. Coronary artery disease, as one disease entity under the CVDs umbrella, had a prevalence of 7.2% among adults in the United States and incurred a financial burden of 360 billion US dollars in the years 2016–2017. The introduction of artificial intelligence (AI) and machine learning over the last two decades has unlocked new dimensions in the field of cardiovascular medicine. From automatic interpretations of heart rhythm disorders via smartwatches, to assisting in complex decision-making, AI has quickly expanded its realms in medicine and has demonstrated itself as a promising tool in helping clinicians guide treatment decisions. Understanding complex genetic interactions and developing clinical risk prediction models, advanced cardiac imaging, and improving mortality outcomes are just a few areas where AI has been applied in the domain of coronary artery disease. Through this review, we sought to summarize the advances in AI relating to coronary artery disease, current limitations, and future perspectives.
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Troponin Cut-Offs for Acute Myocardial Infarction in Patients with Impaired Renal Function—A Systematic Review and Meta-Analysis. Diagnostics (Basel) 2022; 12:diagnostics12020276. [PMID: 35204367 PMCID: PMC8871519 DOI: 10.3390/diagnostics12020276] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Revised: 01/14/2022] [Accepted: 01/19/2022] [Indexed: 11/27/2022] Open
Abstract
Identifying acute myocardial infarction in patients with renal disease is notoriously difficult, due to atypical presentation and chronically elevated troponin. The aim of this study was to identify a specific troponin T/troponin I cut-off value for diagnosis of acute myocardial infarction in patients with renal impairment via meta-analysis. Two investigators screened 2590 publications from MEDLINE, Embase, PubMed, Web of Science, and the Cochrane library. Only studies that investigated alternative cut-offs according to renal impairment were included. Fifteen articles fulfilled the inclusion criteria. Six studies were combined for meta-analysis. The manufacturer’s upper reference level for troponin T is 14 ng/L. Based on the meta-analyses, cut-off values for troponin in patients with renal impairment with myocardial infarction was 42 ng/L for troponin I and 48 ng/L for troponin T. For patients on dialysis the troponin T cut-off is even higher at 239 ng/L. A troponin I cut-off value for dialysis patients could not be established due to lack of data. The 15 studies analyzed showed considerable diversity in study design, study population, and the definition of myocardial infarction. Further studies are needed to define a reliable troponin cut-off value for patients with kidney disease, especially in dialysis patients, and to allow necessary subanalysis.
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ÖZBIÇER S, KALKAN G, URGUN ÖD, NEŞELİOĞLU S, EREL Ö. Ischemia modified albumin levels in distinguishing NSTEMI patients from non-ischemic controls and correlation with disease severity. CUKUROVA MEDICAL JOURNAL 2021. [DOI: 10.17826/cumj.976875] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
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Clerico A, Zaninotto M, Aimo A, Dittadi R, Cosseddu D, Perrone M, Padoan A, Masotti S, Belloni L, Migliardi M, Fortunato A, Trenti T, Malloggi L, Cappelletti P, Galli GA, Bernardini S, Sciacovelli L, Plebani M. Use of high-sensitivity cardiac troponins in the emergency department for the early rule-in and rule-out of acute myocardial infarction without persistent ST-segment elevation (NSTEMI) in Italy. Clin Chem Lab Med 2021; 60:169-182. [PMID: 34927403 DOI: 10.1515/cclm-2021-1085] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Accepted: 11/26/2021] [Indexed: 12/15/2022]
Abstract
Serial measurements of cardiac troponin are recommended by international guidelines to diagnose myocardial infarction (MI) since 2000. However, some relevant differences exist between the three different international guidelines published between 2020 and 2021 for the management of patients with chest pain and no ST-segment elevation. In particular, there is no agreement on the cut-offs or absolute change values to diagnose non-ST-segment elevation MI (NSTEMI). Other controversial issues concern the diagnostic accuracy and cost-effectiveness of cut-off values for the most rapid algorithms (0 h/1 h or 0 h/2 h) to rule-in and rule-out NSTEMI. Finally, another important point is the possible differences between demographic and clinical characteristics of patients enrolled in multicenter trials compared to those routinely admitted to the Emergency Department in Italy. The Study Group of Cardiac Biomarkers, supported by the Italian Scientific Societies Società Italiana di Biochimica Clinica, Italian Society of the European Ligand Assay Society, and Società Italiana di Patolgia Clinica e Medicina di Laboratorio decided to revise the document previously published in 2013 about the management of patients with suspected NSTEMI, and to provide some suggestions for the use of these biomarkers in clinical practice, with a particular focus on the Italian setting.
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Affiliation(s)
- Aldo Clerico
- Fondazione CNR Regione Toscana G. Monasterio e Scuola Superiore Sant'Anna, Pisa, Italy
| | - Martina Zaninotto
- Department of Laboratory Medicine, University Hospital of Padova, Padova, Italy.,Department of Medicine-DIMED, University of Padova, Padova, Italy
| | - Alberto Aimo
- Fondazione CNR Regione Toscana G. Monasterio e Scuola Superiore Sant'Anna, Pisa, Italy
| | - Ruggero Dittadi
- Ospedale dell'Angelo ULSS 3 Serenissima, Laboratorio di Analisi Cliniche, Mestre, Italy
| | - Domenico Cosseddu
- S.C. Laboratorio Analisi, A.O. Ordine Mauriziano di Torino, Torino, Italy
| | - Marco Perrone
- Division of Cardiology and Clinical Biochemistry, University of Rome Tor Vergata, Rome, Italy
| | - Andrea Padoan
- Department of Laboratory Medicine, University Hospital of Padova, Padova, Italy
| | - Silvia Masotti
- Fondazione CNR Regione Toscana G. Monasterio e Scuola Superiore Sant'Anna, Pisa, Italy
| | - Lucia Belloni
- Dipartimento di Medicina di laboratorio, Arcispedale Santa Maria Nuova - IRCCS, Reggio Emilia, Italy
| | - Marco Migliardi
- S.C. Laboratorio Analisi, A.O. Ordine Mauriziano di Torino, Torino, Italy
| | | | - Tommaso Trenti
- Azienda Ospedaliero - Universitaria Policlinico di Modena c/o Ospedale Civile di Baggiovara, Modena, Italy
| | - Lucia Malloggi
- Laboratorio Analisi, Azienda Ospedaliera-Universitaria di Pisa, Pisa, Italy
| | | | | | - Sergio Bernardini
- Division of Cardiology and Clinical Biochemistry, University of Rome Tor Vergata, Rome, Italy
| | - Laura Sciacovelli
- Department of Laboratory Medicine, University Hospital of Padova, Padova, Italy
| | - Mario Plebani
- Department of Laboratory Medicine, University Hospital of Padova, Padova, Italy
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(Overview and application of validated algorithms using high-sensitivity cardiac troponin assays for early diagnosis of acute myocardial infarction). COR ET VASA 2021. [DOI: 10.33678/cor.2021.064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Affiliation(s)
- Matthew T H Lowry
- BHF Centre for Cardiovascular Science, The University of Edinburgh, Edinburgh, UK
| | - Atul Anand
- BHF Centre for Cardiovascular Science, The University of Edinburgh, Edinburgh, UK
| | - Nicholas L Mills
- BHF Centre for Cardiovascular Science, The University of Edinburgh, Edinburgh, UK
- Usher Institute, The University of Edinburgh, Edinburgh, UK
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Gärtner C, Langhammer R, Schmidt M, Federbusch M, Wirkner K, Löffler M, Isermann B, Laufs U, Wachter R, Kaiser T. Revisited Upper Reference Limits for Highly Sensitive Cardiac Troponin T in Relation to Age, Sex, and Renal Function. J Clin Med 2021; 10:5508. [PMID: 34884210 PMCID: PMC8658212 DOI: 10.3390/jcm10235508] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Revised: 10/15/2021] [Accepted: 11/13/2021] [Indexed: 12/03/2022] Open
Abstract
(1) Background: Highly sensitive cardiac troponin T (hs-cTnT) plays an essential role in the diagnosis of myocardial injury. The upper reference limit of the respective assay is generally applied, irrespective of age, renal function, or sex. We aimed to identify age-adjusted and sex-adjusted upper reference limits in relation to renal function in a large population-based cohort without cardiac diseases. (2) Methods: We included 5428 subjects of the population-based LIFE-Adult cohort, free of diagnosed cardiac diseases. Sex-adjusted and age-adjusted 99th percentiles for hs-cTnT in subjects with preserved renal function were obtained. (3) Results: The hs-cTnT values were higher in men of all age groups. In both sexes, an increasing age positively correlated with higher hs-cTnT values. Hs-cTnT weakly correlated with serum creatinine. The three-dimensional analysis of age, creatinine, and hs-cTnT showed no relevant additional effect of creatinine on hs-cTnT. In men aged above 60 and women above 70, the calculated 99th percentiles clearly exceeded the commonly applied thresholds. (4) Conclusion: Age and sex have a major impact on the serum concentration of hs-cTnT, while renal function does not. We propose to consider age-adjusted and sex-adjusted reference values.
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Affiliation(s)
- Christiane Gärtner
- Institute for Laboratory Medicine, Clinical Chemistry and Molecular Diagnostics, University of Leipzig Medical Center and Medical Faculty, 04109 Leipzig, Germany; (C.G.); (M.S.); (M.F.); (B.I.)
| | - Romy Langhammer
- Clinic and Polyclinic for Cardiology, University of Leipzig Medical Center, 04103 Leipzig, Germany; (R.L.); (U.L.); (R.W.)
| | - Maria Schmidt
- Institute for Laboratory Medicine, Clinical Chemistry and Molecular Diagnostics, University of Leipzig Medical Center and Medical Faculty, 04109 Leipzig, Germany; (C.G.); (M.S.); (M.F.); (B.I.)
| | - Martin Federbusch
- Institute for Laboratory Medicine, Clinical Chemistry and Molecular Diagnostics, University of Leipzig Medical Center and Medical Faculty, 04109 Leipzig, Germany; (C.G.); (M.S.); (M.F.); (B.I.)
| | - Kerstin Wirkner
- LIFE—Leipzig Research Center for Civilization Diseases, University of Leipzig, 04109 Leipzig, Germany; (K.W.); (M.L.)
- Institute for Medical Informatics, Statistics, and Epidemiology (IMISE), University of Leipzig, 04109 Leipzig, Germany
| | - Markus Löffler
- LIFE—Leipzig Research Center for Civilization Diseases, University of Leipzig, 04109 Leipzig, Germany; (K.W.); (M.L.)
- Institute for Medical Informatics, Statistics, and Epidemiology (IMISE), University of Leipzig, 04109 Leipzig, Germany
| | - Berend Isermann
- Institute for Laboratory Medicine, Clinical Chemistry and Molecular Diagnostics, University of Leipzig Medical Center and Medical Faculty, 04109 Leipzig, Germany; (C.G.); (M.S.); (M.F.); (B.I.)
| | - Ulrich Laufs
- Clinic and Polyclinic for Cardiology, University of Leipzig Medical Center, 04103 Leipzig, Germany; (R.L.); (U.L.); (R.W.)
| | - Rolf Wachter
- Clinic and Polyclinic for Cardiology, University of Leipzig Medical Center, 04103 Leipzig, Germany; (R.L.); (U.L.); (R.W.)
| | - Thorsten Kaiser
- Institute for Laboratory Medicine, Clinical Chemistry and Molecular Diagnostics, University of Leipzig Medical Center and Medical Faculty, 04109 Leipzig, Germany; (C.G.); (M.S.); (M.F.); (B.I.)
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Dietl A, Zimmermann ME, Brandl C, Wallner S, Burkhardt R, Maier LS, Luchner A, Heid IM, Stark KJ. Distribution and specificity of high-sensitivity cardiac troponin T in older adults without acute cardiac conditions: cross-sectional results from the population-based AugUR study. BMJ Open 2021; 11:e052004. [PMID: 34728452 PMCID: PMC8565570 DOI: 10.1136/bmjopen-2021-052004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
OBJECTIVE European guidelines recommended a uniform upper reference limit of high-sensitivity cardiac troponin T (hsTnT) to rule out non-ST segment elevation myocardial infarction. Our study aimed to provide a hsTnT reference distribution and to assess the specificity of the 14 ng/L cut-off value in the mobile population ≥70 years of age. DESIGN A cross-sectional analysis was performed in the German AugUR study (Altersbezogene Untersuchungen zur Gesundheit der University of Regensburg). SETTING Study population was the mobile population aged 70+ years living in the city and county of Regensburg, Germany. PARTICIPANTS A random sample was derived from the local population registries of residence. Of the 5644 individuals invited, 1133 participated (response ratio=20.1%). All participants came to the study centre and were mentally and physically mobile to conduct the protocol (face-to-face interview, blood draw and standardised transthoracic echocardiography). None of the participants was in an acute state of myocardial infarction. RESULTS Among the 1129 individuals with hsTnT measurements (overall median=10.0 ng/L(25th, 75th percentile)=(7.0, 15.0 ng/L)), hsTnT was higher among the older individuals and higher among men (men 70-74 years median=9.6 ng/L (7.2, 13.1 ng/L); men 90-95 years median=21.2 ng/L (14.6, 26.0 ng/L); women 70-74 years median=6.3 ng/L (4.7, 8.7 ng/L); and women 90-95 years median=18.0 ng/L (11.0, 21.0 ng/L)). In participants with impaired kidney function (eGFRcrea <60 mL/min/1.73 m2), hsTnT was elevated (median=13.6 ng/L (9.4, 20.6 ng/L)).Specificity of recommended upper reference limit, 14 ng/L, is 68%. Most false positives were among men aged >79 years (specificity=34%). In a healthy subgroup (n=96, none of the following: overt heart disease, impaired renal function, blood pressure >160/100 mm Hg, left ventricular hypertrophy and diastolic/systolic dysfunction), specificity was 90%. CONCLUSION In the elderly population without acute myocardial infarction, hsTnT further increases with age showing different levels for men and women. The specificity of the 14 ng/L cut-off is considerably lower than 99%, even in healthy subjects.
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Affiliation(s)
- Alexander Dietl
- Department of Internal Medicine II, University Hospital Regensburg, Regensburg, Germany
| | - Martina E Zimmermann
- Department of Genetic Epidemiology, University of Regensburg, Regensburg, Germany
| | - Caroline Brandl
- Department of Genetic Epidemiology, University of Regensburg, Regensburg, Germany
- Department of Ophthalmology, University Hospital Regensburg, Regensburg, Germany
| | - Stefan Wallner
- Institute of Clinical Chemistry and Laboratory Medicine, University Hospital Regensburg, Regensburg, Germany
| | - Ralph Burkhardt
- Institute of Clinical Chemistry and Laboratory Medicine, University Hospital Regensburg, Regensburg, Germany
| | - Lars S Maier
- Department of Internal Medicine II, University Hospital Regensburg, Regensburg, Germany
| | - Andreas Luchner
- Department of Cardiology, Krankenhaus Barmherzige Brueder Regensburg, Regensburg, Germany
| | - Iris M Heid
- Department of Genetic Epidemiology, University of Regensburg, Regensburg, Germany
| | - Klaus J Stark
- Department of Genetic Epidemiology, University of Regensburg, Regensburg, Germany
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