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Maayah M, Grubman S, Allen S, Ye Z, Park DY, Vemmou E, Gokhan I, Sun WW, Possick S, Kwan JM, Gandhi PU, Hu JR. Clinical Interpretation of Serum Troponin in the Era of High-Sensitivity Testing. Diagnostics (Basel) 2024; 14:503. [PMID: 38472975 DOI: 10.3390/diagnostics14050503] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2024] [Revised: 02/03/2024] [Accepted: 02/05/2024] [Indexed: 03/14/2024] Open
Abstract
Cardiac troponin (Tn) plays a central role in the evaluation of patients with angina presenting with acute coronary syndrome. The advent of high-sensitivity assays has improved the analytic sensitivity and precision of serum Tn measurement, but this advancement has come at the cost of poorer specificity. The role of clinical judgment is of heightened importance because, more so than ever, the interpretation of serum Tn elevation hinges on the careful integration of findings from electrocardiographic, echocardiographic, physical exam, interview, and other imaging and laboratory data to formulate a weighted differential diagnosis. A thorough understanding of the epidemiology, mechanisms, and prognostic implications of Tn elevations in each cardiac and non-cardiac etiology allows the clinician to better distinguish between presentations of myocardial ischemia and myocardial injury-an important discernment to make, as the treatment of acute coronary syndrome is vastly different from the workup and management of myocardial injury and should be directed at the underlying cause.
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Affiliation(s)
- Marah Maayah
- Yale School of Medicine, Yale University, New Haven, CT 06520, USA
| | - Scott Grubman
- Yale School of Medicine, Yale University, New Haven, CT 06520, USA
| | - Stephanie Allen
- Department of Internal Medicine, Yale School of Medicine, Yale University, New Haven, CT 06520, USA
| | - Zachary Ye
- Department of Internal Medicine, Temple University Medical Center, Philadelphia, PA 19140, USA
| | - Dae Yong Park
- Department of Internal Medicine, Cook County Hospital, Chicago, IL 60612, USA
| | - Evangelia Vemmou
- Department of Internal Medicine, Yale School of Medicine, Yale University, New Haven, CT 06520, USA
| | - Ilhan Gokhan
- Yale School of Medicine, Yale University, New Haven, CT 06520, USA
| | - Wendy W Sun
- Department of Emergency Medicine, Yale School of Medicine, Yale University, New Haven, CT 06520, USA
| | - Stephen Possick
- Section of Cardiovascular Medicine, Yale School of Medicine, Yale University, New Haven, CT 06520, USA
| | - Jennifer M Kwan
- Section of Cardiovascular Medicine, Yale School of Medicine, Yale University, New Haven, CT 06520, USA
| | - Parul U Gandhi
- Section of Cardiovascular Medicine, Yale School of Medicine, Yale University, New Haven, CT 06520, USA
- Department of Cardiology, Veterans Affairs Connecticut Health Care System, West Haven, CT 06516, USA
| | - Jiun-Ruey Hu
- Section of Cardiovascular Medicine, Yale School of Medicine, Yale University, New Haven, CT 06520, USA
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2
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Budzianowski J, Faron W, Rzeźniczak J, Słomczyński M, Hiczkiewicz D, Olejniczak J, Hiczkiewicz J, Burchardt P. Predictors of Revascularization in Patients with Unstable Angina. J Clin Med 2024; 13:1096. [PMID: 38398410 PMCID: PMC10889168 DOI: 10.3390/jcm13041096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2024] [Revised: 02/06/2024] [Accepted: 02/12/2024] [Indexed: 02/25/2024] Open
Abstract
BACKGROUND The factors that determine the necessity of coronary artery revascularization in patients with unstable angina (UA) have been supported by limited data. Therefore, this study aimed to identify the predictors of revascularization in patients with UA. METHODS The study included the recorded data of 3668 patients with UA who underwent cardiac catheterization (age 66 ± 9.2, men 70%); 2615 of them (71%) underwent revascularization (percutaneous transluminal coronary angioplasty (PTCA), coronary artery bypass graft (CABG), or hybrid revascularization. The remaining 1053 patients (29%) had no significant coronary stenosis and were regarded as controls. Multivariable logistic regression analysis was performed to separate the predictors of revascularization. RESULTS It was found that severe angina (OR 2.7, 95%CI 1.9-3.7), male gender (OR 1.4, 95%CI 1.1-1.7), and hyperlipidemia were the predictors of revascularization. It was also noted that intraventricular conduction disorders including left and right bundle branch blocks and a history of previous revascularization and myocardial infarction were associated with lower odds of revascularization. CONCLUSION Overall, however, the predictive value of the studied factors proved to be poor and may still point to the multifactorial nature of significant coronary artery stenosis and the need for revascularization in patients with UA.
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Affiliation(s)
- Jan Budzianowski
- “Club 30”, Polish Cardiac Society, 93-338 Łódź, Poland;
- Department of Interventional Cardiology and Cardiac Surgery, Collegium Medicum, University of Zielona Góra, 65-046 Zielona Góra, Poland; (D.H.); (J.H.)
- Department of Cardiology, Nowa Sól Multidisciplinary Hospital, 67-100 Nowa Sól, Poland;
| | - Wojciech Faron
- Department of Cardiology, Nowa Sól Multidisciplinary Hospital, 67-100 Nowa Sól, Poland;
| | - Janusz Rzeźniczak
- Department of Cardiology, J. Strus Hospital, 61-285 Poznań, Poland; (J.R.); (M.S.)
| | - Marek Słomczyński
- Department of Cardiology, J. Strus Hospital, 61-285 Poznań, Poland; (J.R.); (M.S.)
| | - Dariusz Hiczkiewicz
- Department of Interventional Cardiology and Cardiac Surgery, Collegium Medicum, University of Zielona Góra, 65-046 Zielona Góra, Poland; (D.H.); (J.H.)
- Department of Cardiology, Nowa Sól Multidisciplinary Hospital, 67-100 Nowa Sól, Poland;
| | | | - Jarosław Hiczkiewicz
- Department of Interventional Cardiology and Cardiac Surgery, Collegium Medicum, University of Zielona Góra, 65-046 Zielona Góra, Poland; (D.H.); (J.H.)
- Department of Cardiology, Nowa Sól Multidisciplinary Hospital, 67-100 Nowa Sól, Poland;
| | - Paweł Burchardt
- “Club 30”, Polish Cardiac Society, 93-338 Łódź, Poland;
- Department of Cardiology, J. Strus Hospital, 61-285 Poznań, Poland; (J.R.); (M.S.)
- Department of Hypertension, Angiology, and Internal Medicine, Poznan University of Medical Sciences, 61-848 Poznań, Poland
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3
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Dakshi A, Salmon T, Collinson P, Ihsan J, Campbell M, Khand A. Unstable angina in the context of high-sensitive troponins: Still a marker of high risk? A comparison of outcomes with adjudicated type 1 myocardial infarction. Int J Cardiol 2023; 391:131226. [PMID: 37524123 DOI: 10.1016/j.ijcard.2023.131226] [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: 05/01/2023] [Revised: 07/05/2023] [Accepted: 07/28/2023] [Indexed: 08/02/2023]
Abstract
BACKGROUND Unstable angina (UA), considered historically a marker of high risk, has rarely been studied in the high sensitive troponin era. We sought to characterise this population and determine short- and medium-term outcomes for UA and compared this to both patients with musculoskeletal chest pain and adjudicated type 1 MI (NSTEMI). METHOD We conducted a post-hoc analysis of 2 prospective cohort studies of suspected acute coronary syndrome in 2 hospitals in the northwest of England. (n = 3018) We used a dedicated symptom score to diagnose unstable angina. Type 1 MI (NSTEMI) was diagnosed by independent physician adjudication according to 3rd universal definition of MI. Follow-up was 100% complete for all patients to 1 year. RESULTS 185 (6.1%) and 249 (8.3%) were adjudicated as suffering from UA and NSTEMI respectively. We restricted our analysis of UA to 158 (5.2%) patients with UA with high sensitive troponin T (Roche Elecsys) ≤14 ng/L (≤99th percentile). Compared to the NSTEMI population, the UA cohort were younger (59 vs 74, p < 0.002), had a lower incidence of hypertension (56.3% vs 69.1%, p = 0.009), had significantly lower composite risk scores and had fewer ECG abnormalities (ST depression >1 mm, 5.1% vs 15.6%, p = 0.001, T wave flattened, biphasic or inverted 24.1% vs 47.8%, p < 0.0001). Subsequent Type 1 MI to 30 days and 1 year in the UA cohort was 1.9% and 1.9% respectively compared to 0.8% and 2.4% in the index type 1 MI (NSTEMI cohort) respectively. However, compared to patients presenting with musculoskeletal chest pain (n = 468) there was a significantly greater incidence of subsequent MI and coronary revascularisation in patients with unstable angina. All cause death at 30 days and 1 year was 0.0% and 0.6% (n = 1) for UA patients and 2.8% (n = 7) and 16.1% (n = 40) for the NSTEMI cohort respectively. CONCLUSION UA, defined objectively by a symptom score and absence of myocyte necrosis, is still prevalent as an entity, with a risk of subsequent MI and urgent or emergency coronary revascularisation. However, mortality is >10-fold lower when compared to NSTEMI, indicating a less severe pathology in terms of atherosclerosis or plaque burden, and implying the need for a different management strategy to that of NSTEMI.
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Affiliation(s)
- Ahmed Dakshi
- Liverpool University Hospital NHS Foundation Trust, UK
| | - Thomas Salmon
- Liverpool University Hospital NHS Foundation Trust, UK
| | | | - Jhanzeb Ihsan
- Liverpool University Hospital NHS Foundation Trust, UK
| | | | - Aleem Khand
- Liverpool University Hospital NHS Foundation Trust, UK; Liverpool Heart and Chest Hospital, Liverpool, UK; University of Liverpool, UK.
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4
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Duyan M, Vural N. Diagnostic value of end-tidal carbon dioxide in the differential diagnosis of unstable angina and non-cardiac chest pain. Am J Emerg Med 2023; 63:69-73. [PMID: 36327752 DOI: 10.1016/j.ajem.2022.10.026] [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: 08/16/2022] [Revised: 10/06/2022] [Accepted: 10/13/2022] [Indexed: 11/06/2022] Open
Abstract
OBJECTIVE This study aims to investigate the diagnostic value of End-tidal carbon dioxide (ETCO2) measured non-invasively at the bedside in order to distinguish between unstable angina pectoris (UAP) and non-cardiac chest pain among patients who present to the emergency department with chest pain without a history of cardiac pathology. MATERIAL AND METHODS This clinical study is a prospective case-control study among patients presenting to the emergency department of a tertiary hospital with chest pain. After evaluating the inclusion and exclusion criteria, the patients were divided into two groups: 62 patients with UAP and 62 patients with non-cardiac chest pain. Receiver Operating Characteristic (ROC) analysis was used to determine the cut-off in diagnostic value measurements. For UAP prediction, the odds ratio of ETCO2 (including 95% confidence intervals) was calculated using univariate with binary logistic regression analysis. RESULTS ETCO2 had an excellent diagnostic power in detecting UAP, with 35 cut-offs determined (AUC: 0.84, 95% Cl: 0.76-0.90, p < 0.001). When ETCO2, which affects both non-cardiac chest pain and UAP, is evaluated, an ETCO2 of <35 is statistically significant and 9.74 times more common among UAP patients than patients with non-cardiac chest pain. CONCLUSION ETCO2, a non-invasive parameter that can be measured immediately at the bedside, may be proposed as a potential biomarker for differentiating patients with UAP from those with non-cardiac chest pain.
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Affiliation(s)
- Murat Duyan
- Department of Emergency Medicine, Antalya Training and Research Hospital, Antalya, Turkey.
| | - Nafis Vural
- Department of Emergency Medicine, Ereğli State Hospital, Konya, Turkey
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5
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Recent advances in nanomedicines for imaging and therapy of myocardial ischemia-reperfusion injury. J Control Release 2023; 353:563-590. [PMID: 36496052 DOI: 10.1016/j.jconrel.2022.11.057] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Revised: 11/28/2022] [Accepted: 11/30/2022] [Indexed: 12/14/2022]
Abstract
Myocardial ischemia-reperfusion injury (IRI) is becoming a typical cardiovascular disease with increasing worldwide incidence. It is usually induced by the restoration of normal blood flow to the ischemic myocardium after a period of recanalization and directly leads to myocardial damage. Notably, the pathological mechanism of myocardial IRI is closely related to inflammation, oxidative stress, Ca2+ overload, and the opening of mitochondrial permeability transition pore channels. Therefore, monitoring of these changes and imaging lesions is a key to timely clinical diagnosis. Nanomedicines have shown great value in the diagnosis and treatment of myocardial IRI, with advantages including passive/active targeting, prolonged circulation, improved bioavailability, versatile carrier selection, and synergistic integration of different imaging and therapeutic agents in single particles with the same pharmaceutics. Because theranostic nanomedicines for myocardial IRI have advanced rapidly, we conduct an updated review on this topic. The special focus is on how to rationally design the nanomedicines to achieve optimal imaging and therapy. We hope this review would stimulate the interest of researchers with different backgrounds and expedite the development of nanomedicines for myocardial IRI.
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Clinical characteristics and in-hospital management strategies in patients with acute coronary syndrome: results from 2,096 accredited Chest Pain Centers in China from 2016 to 2021. CARDIOLOGY PLUS 2022. [DOI: 10.1097/cp9.0000000000000032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
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7
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Outcomes after coronary angiography for unstable angina compared to stable angina, myocardial infarction and an asymptomatic general population. IJC HEART & VASCULATURE 2022; 42:101099. [PMID: 35937948 PMCID: PMC9352908 DOI: 10.1016/j.ijcha.2022.101099] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Revised: 07/24/2022] [Accepted: 07/26/2022] [Indexed: 11/22/2022]
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Sandoval Y, Apple FS, Mahler SA, Body R, Collinson PO, Jaffe AS. High-Sensitivity Cardiac Troponin and the 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guidelines for the Evaluation and Diagnosis of Acute Chest Pain. Circulation 2022; 146:569-581. [PMID: 35775423 DOI: 10.1161/circulationaha.122.059678] [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: 12/14/2022]
Abstract
The 2021 American Heart Association/American College of Cardiology/American Society of Echocardiography/American College of Chest Physicians/Society for Academic Emergency Medicine/Society of Cardiovascular Computed Tomography/Society for Cardiovascular Magnetic Resonance guidelines for the evaluation and diagnosis of acute chest pain make important recommendations that include the recognition of high-sensitivity cardiac troponin (hs-cTn) as the preferred biomarker, endorsement of 99th percentile upper reference limits to define myocardial injury, and the use of clinical decision pathways, as well as acknowledgment of the uniqueness of women and other patient subsets. Details on how to integrate hs-cTn into clinical practice are less extensively addressed. Clinicians should be aware of some of the analytical aspects related to hs-cTn assays regarding the limit of detection and the limit of quantitation and how they are used clinically, especially for the single sample strategy to rule out acute myocardial infarction. Likewise, it is important for clinicians to understand issues related to the derivation of the 99th percentile upper reference limit; the value of sex-specific 99th percentile upper reference limits; how to use changing concentrations (deltas) to facilitate diagnosis and risk stratification of patients with suspected acute coronary syndrome, including the differentiation of acute from chronic myocardial injury; and how to best integrate the use of hs-cTn with clinical decision pathways. With the use of hs-cTn, conditions such as type 2 myocardial infarction become more common, whereas others such as unstable angina become less frequent but still occur. Sections relating to these issues are included.
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Affiliation(s)
- Yader Sandoval
- Departments of Cardiovascular Diseases (Y.S., A.S.J.), Mayo Clinic, Rochester, MN
| | - Fred S Apple
- Departments of Laboratory Medicine and Pathology, Hennepin Healthcare/Hennepin County Medical Center and University of Minnesota, Minneapolis (F.S.A.)
| | - Simon A Mahler
- Department of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, NC (S.A.M.)
| | - Richard Body
- Emergency Department, Manchester University NSH Foundation Trust, Manchester Academic Health Science Centre, UK (R.B.).,Division of Cardiovascular Sciences, The University of Manchester, UK (R.B.).,Healthcare Sciences Department, Manchester Metropolitan University, UK (R.B.)
| | - Paul O Collinson
- Department of Clinical Blood Sciences and Cardiology, St George's University Hospitals NHS Foundation Trust and St George's University of London, UK (P.O.C.)
| | - Allan S Jaffe
- Departments of Cardiovascular Diseases (Y.S., A.S.J.), Mayo Clinic, Rochester, MN.,Laboratory Medicine and Pathology (A.S.J.), Mayo Clinic, Rochester, MN
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9
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Gaba P, Bhatt DL. Has Unstable Angina Become a Vestigial of the Past in Clinical Trial Primary Endpoints? Cardiology 2022; 147:248-250. [PMID: 35468609 DOI: 10.1159/000524700] [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] [Received: 04/19/2022] [Accepted: 04/19/2022] [Indexed: 11/19/2022]
Affiliation(s)
- Prakriti Gaba
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Deepak L Bhatt
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
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10
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Roos A, Edgren G, Holzmann MJ. Unstable Angina Pectoris With Myocardial Injury Versus Myocardial Infarction in the Era of High-Sensitivity Cardiac Troponin. Am J Cardiol 2022; 169:32-41. [PMID: 35063271 DOI: 10.1016/j.amjcard.2021.12.044] [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] [Received: 10/22/2021] [Revised: 12/15/2021] [Accepted: 12/20/2021] [Indexed: 11/19/2022]
Abstract
It is unknown whether outcomes in patients with unstable angina pectoris (UAP) and myocardial injury are different from outcomes in patients with non-ST-segment myocardial infarction (NSTEMI) with low peak concentrations of high-sensitivity cardiac troponin T (hs-cTnT). This study aimed to compare the prognosis in patients with UAP and evidence of myocardial injury, with prognosis in patients with NSTEMI and different peak hs-cTnT concentrations. All visits to 7 different emergency departments in Sweden from December 9, 2009 to December 31, 2016 were identified (n = 5,225,075). We included all hospitalized patients with hs-cTnT >14 ng/L and a diagnosis of UAP or NSTEMI, with ≥2 hours-cTnT measurements. Hazard ratios (HRs) with 95% confidence intervals (CIs) were calculated for all-cause mortality and cardiovascular events, in patients with NSTEMI categorized according to peak hs-cTnT concentrations, compared with patients with UAP. Altogether, 11,944 patients were included, of whom 1,253 (10%) received a diagnosis of UAP. During a median follow-up of 3.0 years (interquartile [IQR] 1.6 to 4.7), 3,297 patients died. There was no difference comparing patients with NSTEMI with peak hs-cTnT of 15 to 49 ng/L to patients with UAP, with regards to long-term cardiovascular mortality (HR 1.15; 95% CI, 0.85 to 1.56), but the risk of recurrent myocardial infarction was higher in patients with NSTEMI (HR, 1.61; 95% CI, 1.29 to 2.00), and the risk of heart failure hospitalization slightly lower (HR 0.80, 95% CI, 0.64 to 0.99). In conclusion, patients with UAP and myocardial injury have a similar risk of death after discharge, but a lower risk of recurrent myocardial infarction and a marginally higher risk of heart failure, compared with patients with NSTEMI with moderately elevated hs-cTnT levels.
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Affiliation(s)
- Andreas Roos
- Department of Medicine; Department of Emergency and Reparative Medicine, Karolinska University Hospital, Stockholm, Sweden.
| | - Gustaf Edgren
- Department of Medicine, Clinical Epidemiology Division, Karolinska Institute, Stockholm, Sweden; Department of Cardiology, Södersjukhuset, Stockholm, Sweden
| | - Martin J Holzmann
- Department of Medicine; Department of Emergency and Reparative Medicine, Karolinska University Hospital, Stockholm, Sweden
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11
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Tjora HL, Steiro OT, Langørgen J, Bjørneklett RO, Skadberg Ø, Bonarjee VVS, Mjelva ØR, Collinson P, Omland T, Vikenes K, Aakre KM. Diagnostic Performance of Novel Troponin Algorithms for the Rule-Out of Non-ST-Elevation Acute Coronary Syndrome. Clin Chem 2021; 68:291-302. [PMID: 34897415 DOI: 10.1093/clinchem/hvab225] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Accepted: 09/17/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND The European Society of Cardiology (ESC) rule-out algorithms use cutoffs optimized for exclusion of non-ST elevation myocardial infarction (NSTEMI). We investigated these and several novel algorithms for the rule-out of non-ST elevation acute coronary syndrome (NSTE-ACS) including less urgent coronary ischemia. METHOD A total of 1504 unselected patients with suspected NSTE-ACS were included and divided into a derivation cohort (n = 988) and validation cohort (n = 516). The primary endpoint was the diagnostic performance to rule-out NSTEMI and unstable angina pectoris during index hospitalization. The secondary endpoint was combined MI, all-cause mortality (within 30 days) and urgent (24 h) revascularization. The ESC algorithms for high-sensitivity cardiac troponin T (hs-cTnT) and I (hs-cTnI) were compared to different novel low-baseline (limit of detection), low-delta (based on the assay analytical and biological variation), and 0-1-h and 0-3-h algorithms. RESULTS The prevalence of NSTE-ACS was 24.8%, 60.0% had noncardiac chest pain, and 15.2% other diseases. The 0-1/0-3-h algorithms had superior clinical sensitivity for the primary endpoint compared to the ESC algorithm (validation cohort); hs-cTnT: 95% vs 63%, and hs-cTnI: 87% vs 64%, respectively. Regarding the secondary endpoint, the algorithms had similar clinical sensitivity (100% vs 94%-96%) but lower clinical specificity (41%-19%) compared to the ESC algorithms (77%-74%). The rule-out rates decreased by a factor of 2-4. CONCLUSION Low concentration/low-delta troponin algorithms improve the clinical sensitivity for a combined endpoint of NSTEMI and unstable angina pectoris, with the cost of a substantial reduction in total rule-out rate. There was no clear benefit compared to ESC for diagnosing high-risk events.
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Affiliation(s)
- Hilde L Tjora
- Emergency Care Clinic, Haukeland University Hospital, Bergen, Norway
| | - Ole-Thomas Steiro
- Department of Heart Disease, Haukeland University Hospital, Bergen, Norway
| | - Jørund Langørgen
- Department of Heart Disease, Haukeland University Hospital, Bergen, Norway
| | - Rune O Bjørneklett
- Emergency Care Clinic, Haukeland University Hospital, Bergen, Norway.,Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Øyvind Skadberg
- Laboratory of Medical Biochemistry, Stavanger University Hospital, Stavanger, Norway
| | | | - Øistein R Mjelva
- Cardiology Department, Stavanger University Hospital, Stavanger, Norway
| | - Paul Collinson
- Cardiovascular Clinical Academic Group St Georges University Hospitals NHS Foundation Trust and St George's University of London, London, UK
| | - Torbjørn Omland
- Department of Cardiology, Akershus University Hospital, Oslo, Norway.,Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Kjell Vikenes
- Department of Heart Disease, Haukeland University Hospital, Bergen, Norway.,Department of Clinical Science, University of Bergen, Bergen, Norway
| | - Kristin M Aakre
- Department of Heart Disease, Haukeland University Hospital, Bergen, Norway.,Department of Clinical Science, University of Bergen, Bergen, Norway.,Department of Medical Biochemistry and Pharmacology, Haukeland University Hospital, Bergen, Norway
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12
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Davidson BP, Hodovan J, Layoun ME, Golwala H, Zahr F, Lindner JR. Echocardiographic Ischemic Memory Molecular Imaging for Point-of-Care Detection of Myocardial Ischemia. J Am Coll Cardiol 2021; 78:1990-2000. [PMID: 34763776 DOI: 10.1016/j.jacc.2021.08.068] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Revised: 08/18/2021] [Accepted: 08/24/2021] [Indexed: 12/19/2022]
Abstract
BACKGROUND Noninvasive molecular imaging of recent ischemia can potentially be used to diagnose acute coronary syndrome (ACS) with high accuracy. OBJECTIVES The authors hypothesized that bedside myocardial contrast echocardiography (MCE) ischemic memory imaging could be achieved with phosphatidylserine microbubbles (MBPS) that are retained in the microcirculation via ischemia-associated endothelial activation. METHODS A dose-finding study was performed in healthy volunteers (n = 17) to establish optimal MBPS dosing. Stable patients with ACS (n = 30) and confirmed antecedent but resolved myocardial ischemia were studied within 2 hours of coronary angiography and percutaneous coronary intervention (PCI) when indicated. MCE molecular imaging was performed 8 minutes after intravenous administration of MBPS. MCE perfusion imaging was used to assess the status of the postischemic microcirculation. RESULTS Based on dose-finding studies, 0.10 or 0.15 mL of MBPS based on body mass was selected. In patients with ACS, all but 2 underwent primary PCI. MCE molecular imaging signal intensity was greater in the postischemic risk area vs remote territory (median [95% CI]: 56 [33-66] vs 8 [2-17] IU; P < 0.001) with a receiver-operating characteristic curve C-statistic of 0.94 to differentiate post-ischemic from remote territory. Molecular imaging signal in the risk area was not related to type of ACS (unstable angina: 3; non-ST-segment elevation myocardial infarction: 14; ST-segment elevation myocardial infarction: 13), peak troponin, time to PCI, post-PCI myocardial perfusion, GRACE (Global Registry of Acute Coronary Events) score, or HEART score. CONCLUSIONS Molecular imaging with point-of-care echocardiography and MBPS can detect recent but resolved myocardial ischemia. This bedside technique requires only minutes to perform and appears independent of the degree of ischemia. (Ischemic Memory Imaging With Myocardial Contrast Echocardiography; NCT03009266).
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Affiliation(s)
- Brian P Davidson
- Knight Cardiovascular Institute, Oregon Health & Science University, Portland, Oregon, USA
| | - James Hodovan
- Knight Cardiovascular Institute, Oregon Health & Science University, Portland, Oregon, USA
| | - Michael E Layoun
- Oregon National Primate Research Center, Oregon Health & Science University, Portland, Oregon, USA
| | - Harsh Golwala
- Knight Cardiovascular Institute, Oregon Health & Science University, Portland, Oregon, USA
| | - Firas Zahr
- Knight Cardiovascular Institute, Oregon Health & Science University, Portland, Oregon, USA
| | - Jonathan R Lindner
- Knight Cardiovascular Institute, Oregon Health & Science University, Portland, Oregon, USA; Oregon National Primate Research Center, Oregon Health & Science University, Portland, Oregon, USA.
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13
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Li X, Qiu Q, Tong Q, Wang Y, Yu H, Li F, Xie X, Zhang J. Value of galectin-3 in the diagnosis of acute coronary syndrome and the assessment of coronary artery lesions. Biomark Med 2021; 15:647-657. [PMID: 34039037 DOI: 10.2217/bmm-2020-0610] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Aim: To investigate the value of galectin-3 in the diagnosis of acute coronary syndrome (ACS) and the assessment of coronary artery lesions. Methodology: This study recruited 157 patients with coronary artery disease where 102 and 55 of them were subsequently grouped as ACS and non-ACS, respectively. The severity of coronary artery lesions was evaluated by Gensini score and the number of vessels involved. Results: Receiver operator characteristics analyses of galectin-3 yielded an area under the curve of 0.679 in diagnosing ACS. The galectin-3 levels were correlated with Gensini score and the number of vessels involved. Conclusion: Our study demonstrated that galectin-3 is an effective auxiliary biomarker for the diagnosis of ACS and assessment of coronary artery lesions.
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Affiliation(s)
- Xihong Li
- Department of Clinical Laboratory, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Qing Qiu
- Department of Clinical Laboratory, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Qingchao Tong
- Department of Clinical Laboratory, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Yanzhong Wang
- Department of Clinical Laboratory, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Haitao Yu
- Department of Clinical Laboratory, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Fengying Li
- Department of Clinical Laboratory, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Xinyou Xie
- Department of Clinical Laboratory, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Jun Zhang
- Department of Clinical Laboratory, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
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Baber U, Dangas G, Angiolillo DJ, Cohen DJ, Sharma SK, Nicolas J, Briguori C, Cha JY, Collier T, Dudek D, Džavik V, Escaned J, Gil R, Gurbel P, Hamm CW, Henry T, Huber K, Kastrati A, Kaul U, Kornowski R, Krucoff M, Kunadian V, Marx SO, Mehta S, Moliterno D, Ohman EM, Oldroyd K, Sardella G, Sartori S, Shlofmitz R, Steg PG, Weisz G, Witzenbichler B, Han YL, Pocock S, Gibson CM, Mehran R. Ticagrelor alone vs. ticagrelor plus aspirin following percutaneous coronary intervention in patients with non-ST-segment elevation acute coronary syndromes: TWILIGHT-ACS. Eur Heart J 2020; 41:3533-3545. [DOI: 10.1093/eurheartj/ehaa670] [Citation(s) in RCA: 51] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2020] [Revised: 04/08/2020] [Accepted: 07/29/2020] [Indexed: 01/09/2023] Open
Abstract
AbstractAims The aim of this study was to determine the effect of ticagrelor monotherapy on clinically relevant bleeding and major ischaemic events in relation to clinical presentation with and without non-ST elevation acute coronary syndromes (NSTE-ACS) among patients undergoing percutaneous coronary intervention (PCI) with drug-eluting stents (DES).Methods and results We conducted a pre-specified subgroup analysis of The Ticagrelor With Aspirin or Alone in High Risk Patients After Coronary Intervention (TWILIGHT) trial, which enrolled 9006 patients with high-risk features undergoing PCI with DES. After 3 months of dual antiplatelet therapy (DAPT) with ticagrelor plus aspirin, 7119 adherent and event-free patients were randomized in a double-blind manner to ticagrelor plus placebo versus ticagrelor plus aspirin for 12 months. The primary outcome was Bleeding Academic Research Consortium (BARC) type 2, 3, or 5 bleeding while the composite of all-cause death, myocardial infarction (MI), or stroke was the key secondary outcome. Among patients with NSTE-ACS (n = 4614), ticagrelor monotherapy reduced BARC 2, 3, or 5 bleeding by 53% [3.6% vs. 7.6%; hazard ratio (HR) 0.47; 95% confidence interval (CI) 0.36–0.61; P < 0.001) and in stable patients (n = 2503) by 24% (4.8% vs. 6.2%; HR 0.76; 95% CI 0.54–1.06; P = 0.11; nominal Pint = 0.03). Rates of all-cause death, MI, or stroke among those with (4.3% vs. 4.4%; HR 0.97; 95% CI 0.74–1.28; P = 0.84) and without (3.1% vs. 3.2%; HR 0.96; 95% CI 0.61–1.49; P = 0.85) NSTE-ACS were similar between treatment arms irrespective of clinical presentation (Pint = 0.96).Conclusion Among patients with or without NSTE-ACS who have completed an initial 3-month course of DAPT following PCI with DES, ticagrelor monotherapy reduced clinically meaningful bleeding events without increasing ischaemic risk as compared with ticagrelor plus aspirin. The benefits of ticagrelor monotherapy with respect to bleeding events were more pronounced in patients with NSTE-ACS.Trial registrationClinicaltrials.gov identifier: NCT02270242.
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Affiliation(s)
- Usman Baber
- Department of Cardiology, The University of Oklahoma Health Sciences Center, Oklahoma City, OK 73104, USA
- Department of Cardiology, The Zena and Michael A. Wiener Cardiovascular Institute, Mount Sinai Hospital, One Gustave L. Levy Place, Box 1030, New York, NY 10029-6574, USA
| | - George Dangas
- Department of Cardiology, The Zena and Michael A. Wiener Cardiovascular Institute, Mount Sinai Hospital, One Gustave L. Levy Place, Box 1030, New York, NY 10029-6574, USA
| | | | - David Joel Cohen
- Department of Cardiology, University of Missouri-Kansas CIty, Kansas City, MO 64110, USA
| | - Samin Kumar Sharma
- Department of Cardiology, The Zena and Michael A. Wiener Cardiovascular Institute, Mount Sinai Hospital, One Gustave L. Levy Place, Box 1030, New York, NY 10029-6574, USA
| | - Johny Nicolas
- Department of Cardiology, The Zena and Michael A. Wiener Cardiovascular Institute, Mount Sinai Hospital, One Gustave L. Levy Place, Box 1030, New York, NY 10029-6574, USA
| | - Carlo Briguori
- Department of Cardiology, Clinica Mediterranea, 80122 Napoli NA, Italy
| | - Jin Yu Cha
- Department of Cardiology, The Zena and Michael A. Wiener Cardiovascular Institute, Mount Sinai Hospital, One Gustave L. Levy Place, Box 1030, New York, NY 10029-6574, USA
| | - Timothy Collier
- Department of Cardiology, London School of Hygiene and Tropical Medicine, Keppel St, Bloomsbury, London WC1E 7HT, UK
| | - Dariusz Dudek
- The 2nd Department of Cardiology Jagiellonian University Medical College, Swietej Anny 12, 31-008 Krakow, Poland
| | - Vladimir Džavik
- Department of Interventional Cardiology, Research and Innovation in Interventional Cardiology and Cardiac Intensive Care, Peter Munk Cardiac Centre, University Health Network, 200 Elizabeth St, Toronto, ON M5G 2CA, Canada
| | - Javier Escaned
- Department of Cardiology, Instituto de Investigacion Sanitaria del Hospital Clinico San Carlos and Complutense University, Calle del Prof Martin Lagos, s/n, 28040 Madrid, Spain
| | - Robert Gil
- Department of Invasive Cardiology, Center of Postgraduate Medical Education, Central Clinical Hospital of the Ministry of Interior and Administration, 137 Woloska Str, 02-507 Warsaw, Poland
| | - Paul Gurbel
- Department of Cardiology, Sinai Hospital of Baltimore System, Baltimore, MD 21215, USA
| | - Christian W Hamm
- Department of Cardiology, Kerckhoff Clinic, Benekestrabe 2-8, 61231 Bad Nauheim, Germany
| | - Timothy Henry
- Department of Cardiology, The Carl and Edyth Lindner Center for Research and Education at the Christ Hospital, Cincinnati, OH 45219, USA
| | - Kurt Huber
- Department of Cardiology, Wilhelminenhospital, Montleartstrabe 37, 1160 Wien, Austria
| | - Adnan Kastrati
- Department of Cardiology, Deutsches Herzzentrum Munchen, Lazarettstrabe 36, 80636 Munchen, Germany
| | - Upendra Kaul
- Department of Cardiology, Batra Hospital and Medical Research Centre, New Delhi 110062, India
| | - Ran Kornowski
- Department of Cardiology, Rabin Medical Center, Zeev Jabutinsky Rd 39, Petach Tikva 49100, Israel
| | - Mitchell Krucoff
- Department of Cardiology, Duke University Medical Center–Duke Clinical Research Institute, Durham, NC 27710, USA
| | - Vijay Kunadian
- Department of Cardiology, Institute of Cellular Medicine, Faculty of Medical Sciences, Newcastle University, Freeman Road, High Heaton, NE7 7DN Newcastle upon Tyne, UK
- Department of Cardiology, Cardiothoracic Centre, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Freeman Road, High Heaton, NE7 7DN Newcastle upon Tyne, UK
| | - Steven Owen Marx
- Department of Cardiology, Columbia University Medical Center, New York, NY 10027, USA
| | - Shamir Mehta
- Department of Cardiology, Hamilton Health Sciences, Hamilton, ON L8N 3Z5, Canada
| | - David Moliterno
- Department of Cardiology, University of Kentucky, Lexington, KY 40506, USA
| | - Erik Magnus Ohman
- Department of Cardiology, Duke University Medical Center–Duke Clinical Research Institute, Durham, NC 27710, USA
| | - Keith Oldroyd
- Department of Cardiology, The West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Agamemnon St, Clydebank G81 4DY, UK
| | - Gennaro Sardella
- Department of Cardiology, Policlinico Umberto I University, 00161 Roma, Italy
| | - Samantha Sartori
- Department of Cardiology, The Zena and Michael A. Wiener Cardiovascular Institute, Mount Sinai Hospital, One Gustave L. Levy Place, Box 1030, New York, NY 10029-6574, USA
| | - Richard Shlofmitz
- Department of Cardiology, St. Francis Hospital, Roslyn, 100 Port Washington Blvd, Roslyn, NY 11576, USA
| | - Philippe Gabriel Steg
- Department of Cardiology, Groupe Hospitalier Bichat–Claude-Bernard, 46 Rue Henri Huchard, 75018 Paris, France
| | - Giora Weisz
- Department of Cardiology, Montefiore Medical Center, The Bronx, NY 10467, USA
| | - Bernhard Witzenbichler
- Department of Cardiology, Helios Amper-Klinikum, Krankenhausstrabe 15, 85221 Dachau, Germany
| | - Ya-Ling Han
- Department of Cardiology, Shenyang North Hospital, Huanggu Qu, Shenyang Shi, Liaoning Sheng, China
| | - Stuart Pocock
- Department of Cardiology, London School of Hygiene and Tropical Medicine, Keppel St, Bloomsbury, London WC1E 7HT, UK
| | | | - Roxana Mehran
- Department of Cardiology, The Zena and Michael A. Wiener Cardiovascular Institute, Mount Sinai Hospital, One Gustave L. Levy Place, Box 1030, New York, NY 10029-6574, USA
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Dekker M, Waissi F, van Bennekom J, Silvis MJM, Timmerman N, Schoneveld AH, Grobbee DE, de Winter RJ, Mosterd A, Timmers L, de Kleijn DPV. Extracellular Vesicle cystatin c is associated with unstable angina in troponin negative patients with acute chest pain. PLoS One 2020; 15:e0237036. [PMID: 32756583 PMCID: PMC7406038 DOI: 10.1371/journal.pone.0237036] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Accepted: 07/17/2020] [Indexed: 01/12/2023] Open
Abstract
Background Despite the use of high-sensitive cardiac troponin there remains a group of high-sensitive cardiac troponin negative patients with unstable angina with a non-neglectable risk for future adverse cardiovascular events, emphasising the need for additional risk stratification. Plasma extracellular vesicles are small bilayer membrane vesicles known for their potential role as biomarker source. Their role in unstable angina remains unexplored. We investigate if extracellular vesicle proteins are associated with unstable angina in patients with chest pain and low high-sensitive cardiac troponin. Methods The MINERVA study included patients presenting with acute chest pain but no acute coronary syndrome. We performed an exploratory retrospective case-control analysis among 269 patients. Cases were defined as patients with low high-sensitive cardiac troponin and proven ischemia. Patients without ischemia were selected as controls. Blood samples were fractionated to analyse the EV proteins in three plasma-subfractions: TEX, HDL and LDL. Protein levels were quantified using electrochemiluminescence immunoassay. Results Lower levels of (adjusted) EV cystatin c in the TEX subfraction were associated with having unstable angina (OR 0.93 95% CI 0.88–0.99). Conclusion In patients with acute chest pain but low high-sensitive cardiac troponin, lower levels of plasma extracellular vesicle cystatin c are associated with having unstable angina. This finding is hypothesis generating only considering the small sample size and needs to be confirmed in larger cohort studies, but still identifies extracellular vesicle proteins as source for additional risk stratification.
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Affiliation(s)
- Mirthe Dekker
- Department of Vascular Surgery, University Medical Centre Utrecht, Utrecht, the Netherlands
- Department of Cardiology, Amsterdam University Medical Centre, Amsterdam, the Netherlands
| | - Farahnaz Waissi
- Department of Vascular Surgery, University Medical Centre Utrecht, Utrecht, the Netherlands
- Department of Cardiology, Amsterdam University Medical Centre, Amsterdam, the Netherlands
| | - Joelle van Bennekom
- Department of Vascular Surgery, University Medical Centre Utrecht, Utrecht, the Netherlands
| | - Max J. M. Silvis
- Department of Cardiology, University Medical Centre Utrecht, Utrecht, the Netherlands
| | - Nathalie Timmerman
- Department of Vascular Surgery, University Medical Centre Utrecht, Utrecht, the Netherlands
| | - Arjan H. Schoneveld
- Department of Clinical Chemistry and Haematology, University Medical Centre Utrecht, Utrecht, the Netherlands
| | - Diederick E. Grobbee
- Julius Center for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht, the Netherlands
| | - Robbert J. de Winter
- Department of Cardiology, Amsterdam University Medical Centre, Amsterdam, the Netherlands
| | - Arend Mosterd
- Department of Cardiology, Meander Medical Centre Amersfoort, Amersfoort, the Netherlands
| | - Leo Timmers
- Department of Cardiology, St. Antonius Hospital Nieuwegein, Nieuwegein, the Netherlands
| | - Dominique P. V. de Kleijn
- Department of Vascular Surgery, University Medical Centre Utrecht, Utrecht, the Netherlands
- Netherlands Heart Institute, Utrecht, the Netherlands
- * E-mail:
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Implementing the European Society of Cardiology 0-h/1-h algorithm in patients presenting very early after chest pain. Int J Cardiol 2020; 320:1-6. [PMID: 32730826 DOI: 10.1016/j.ijcard.2020.07.037] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Revised: 05/29/2020] [Accepted: 07/20/2020] [Indexed: 12/22/2022]
Abstract
BACKGROUND The European Society of Cardiology (ESC) recommends a 0-h/1-h (0/1-h) algorithm to classify patients with suspected non-ST-segment elevation myocardial infarction (NSTEMI). However, reliable evidence about patients who present early after the onset of symptoms is limited, likely because high-sensitivity cardiac troponin (hs-cTn) values cannot increase sufficiently within that time. This study aimed to evaluate the outcomes in real-world situations that utilized the 0/1-h algorithm. METHODS In a prospective, international, multicenter cohort study that enrolled 1638 patients presenting with acute chest pain to the emergency department, we assessed the performance of the 0/1-h algorithm using hs-cTnT and the associated 30-day rates of major adverse cardiac events: death and acute myocardial infarction (AMI). RESULTS Among 1074 patients, the prevalence of AMI was 16.0%. An approximately 60.1% (n = 645) of patients visited the hospital within 3 h after onset of chest pain (less than 1 h; 18.2% [n = 196], less than 2 h; 27.5% [n = 295], and less than 3 h; 14.3% [n = 154]). Moreover, the prevalence rates of AMI were similar at all times (1 h, 16.8%; 1-2 h, 20.7%; 2-3 h, 18.2%; p = .5). According to the ESC 0/1-h algorithm, the distribution patterns of rule-out, observe, and rule-in groups were similar; however, none of the patients was diagnosed with AMI or cardiac death in the rule-out group. CONCLUSION This study revealed the applicability of the 0/1-h algorithm for the management of early presenters.
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17
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Biomarkers for infarct diagnosis and rapid rule-out/rule-in of acute myocardial infarction. Herz 2020; 45:509-519. [DOI: 10.1007/s00059-020-04943-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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Short-term prognosis of unstable angina in the era of high-sensitivity cardiac troponin: insights for early rule-out strategies. Coron Artery Dis 2020; 31:687-693. [PMID: 32398574 DOI: 10.1097/mca.0000000000000906] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND It is unclear if strategies to rule-out myocardial infarction (MI) based on a single high-sensitivity troponin T (hsTnT) measurement at the emergency department (ED) presentation may also exclude unstable angina. METHODS We measured hsTnT ex-post on the admission frozen blood sample of 644 subjects with Braunwald IIIB CK-MB-negative unstable angina. This analysis included the 240 patients with hsTnT value ≤99th percentile reference limit (UA). We evaluated the clinical outcome of UA patients and the applicability of two rule-out strategies based on the combination of a non-ischemic ECG with (1) a single hsTnT value below the Limit-of-Detection (LoD), (2) a TIMI risk score ≤1. RESULTS UA patients with hsTnT ≤99th percentile reference limit had a favorable 30-day outcome [0.8% MI, 0% cardiovascular death (CVD)], but the rate of CVD/MI at 180-day was 4.7%. Sensitivities for UA were 94.6% according to the 'TIMI ≤1-strategy' and 75.4% according to 'hsTnT-below-LoD-strategy', accounting for 5.4 and 24.6% missed diagnoses, respectively. A prognostic risk stratification to guide appropriate outpatient assessment in potential discharged unrecognized UA patients was developed: a risk score based on the combination of age >60 years and C-reactive protein >4.5 mg/L effectively stratified the 180-day CVD/MI occurrence: 0, 2.5 and 12.7% for score 0, 1 and 2 (log-rank = 0.001, C-statistic = 0.776). CONCLUSION Single measurement hsTnT strategies, successfully tested to rule-out MI, may allow safe ED discharge of patients with a suspected acute coronary syndrome: even if UA may not be excluded, its short-term prognosis is favorable. UA patients with a C-reactive protein >4.5 mg/L and older than 60 years have a substantial medium-term cardiovascular risk and may benefit from a timely outpatient diagnostic assessment.
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Superiority of high sensitivity cardiac troponin T vs. I for long-term prognostic value in patients with chest pain; data from the Akershus cardiac Examination (ACE) 3 study. Clin Biochem 2020; 78:10-17. [DOI: 10.1016/j.clinbiochem.2019.12.016] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2019] [Revised: 12/05/2019] [Accepted: 12/27/2019] [Indexed: 12/18/2022]
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20
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Guo S, Wu J, Zhou W, Liu X, Zhang J, Jia S, Meng Z, Liu S, Ni M, Liu Y. Investigating the multi-target pharmacological mechanism of danhong injection acting on unstable angina by combined network pharmacology and molecular docking. BMC Complement Med Ther 2020; 20:66. [PMID: 32122353 PMCID: PMC7076845 DOI: 10.1186/s12906-020-2853-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2019] [Accepted: 02/11/2020] [Indexed: 02/06/2023] Open
Abstract
Background Danhong injection (DHI), which is one of the most well-known Traditional Chinese Medicine (TCM) injections, widely used to treat unstable angina (UA). However, its underlying pharmacological mechanisms need to be further clarified. Methods In the present study, network pharmacology was adopted. Firstly, the relative compounds were obtained by a wide-scaled literatures-mining and potential targets of these compounds by target fishing were collected. Then, we built the UA target database by DisGeNET, DigSee, TTD, OMIM. Based on data, protein-protein interaction (PPI) analysis, GO and KEGG pathway enrichment analysis were performed and screen the hub targets by topology. Furthermore, evaluation of the binding potential of key targets and compounds through molecular docking. Results The results showed that 12 ingredients of DHI and 27 putative known therapeutic targets were picked out. By systematic analysis, identified 4 hub targets (TNF, TLR4, NFKB1 and SERPINE1) mainly involved in the complex treating effects associated with coagulation and hemostasis, cell membrane region, platelet alpha granule, NF-kappa B signaling pathway and TNF signaling pathway. Conclusion The results of this study preliminarily explained the potential targets and signaling pathways of DHI in the treatment of UA, which may help to laid a good foundation for experimental research and further clinical application.
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Affiliation(s)
- Siyu Guo
- Department of Clinical Chinese Pharmacy, School of Chinese Materia Medica, Beijing University of Chinese Medicine, No. 11 of North Three-ring East Road, Chao Yang District, Beijing, China
| | - Jiarui Wu
- Department of Clinical Chinese Pharmacy, School of Chinese Materia Medica, Beijing University of Chinese Medicine, No. 11 of North Three-ring East Road, Chao Yang District, Beijing, China.
| | - Wei Zhou
- Department of Clinical Chinese Pharmacy, School of Chinese Materia Medica, Beijing University of Chinese Medicine, No. 11 of North Three-ring East Road, Chao Yang District, Beijing, China
| | - Xinkui Liu
- Department of Clinical Chinese Pharmacy, School of Chinese Materia Medica, Beijing University of Chinese Medicine, No. 11 of North Three-ring East Road, Chao Yang District, Beijing, China
| | - Jingyuan Zhang
- Department of Clinical Chinese Pharmacy, School of Chinese Materia Medica, Beijing University of Chinese Medicine, No. 11 of North Three-ring East Road, Chao Yang District, Beijing, China
| | - Shanshan Jia
- Department of Clinical Chinese Pharmacy, School of Chinese Materia Medica, Beijing University of Chinese Medicine, No. 11 of North Three-ring East Road, Chao Yang District, Beijing, China
| | - Ziqi Meng
- Department of Clinical Chinese Pharmacy, School of Chinese Materia Medica, Beijing University of Chinese Medicine, No. 11 of North Three-ring East Road, Chao Yang District, Beijing, China
| | - Shuyu Liu
- Department of Clinical Chinese Pharmacy, School of Chinese Materia Medica, Beijing University of Chinese Medicine, No. 11 of North Three-ring East Road, Chao Yang District, Beijing, China
| | - Mengwei Ni
- Department of Clinical Chinese Pharmacy, School of Chinese Materia Medica, Beijing University of Chinese Medicine, No. 11 of North Three-ring East Road, Chao Yang District, Beijing, China
| | - Yingying Liu
- Department of Clinical Chinese Pharmacy, School of Chinese Materia Medica, Beijing University of Chinese Medicine, No. 11 of North Three-ring East Road, Chao Yang District, Beijing, China
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Evaluation of the Relationship between Early Troponin Clearance and Short-Term Mortality in Patients with Chronic Renal Failure. Emerg Med Int 2020; 2020:6328037. [PMID: 32089888 PMCID: PMC7013312 DOI: 10.1155/2020/6328037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2019] [Revised: 12/05/2019] [Accepted: 12/27/2019] [Indexed: 11/17/2022] Open
Abstract
Objective In patients with CKD, cTn concentrations may be elevated in the absence of AMI, which is a predicted finding caused by chronic structural heart disease rather than acute injury. The increase in troponin level observed in noncardiac conditions provides conflicting results when predicting mortality. Low lactate clearance was associated with increased mortality. Lactate clearance is calculated as follows: (early lactate - late lactate/early lactate) ∗ 100. We aimed to investigate whether troponin clearance calculated according to this formula had an effect on short-term mortality. Methods The study included 300 patients with chronic renal failure who had a sepsis-related organ failure assessment (SOFA) score ≥3. By taking the baseline troponin at the time of emergency presentation as reference and comparing them with the fourth-hour troponin values, troponin clearance was investigated in the evaluation of mortality among hospitalized patients with CKD within the first month after discharge. The data obtained were analyzed using the SPSS data analysis software version 20.0. Student's t-test was used for the parametric data, and the Chi-squared test for the nonparametric data. Results Of the 300 patients evaluated, 189 patients survived (mean age 66.20 ± 14.597 years), and 111 died (mean age 74.81 ± 12.916 years). Troponin clearance was detected in 40 of the 111 patients in the mortality group and 119 of the 189 patients in the survival group. Troponin clearance was significantly more frequent in surviving patients (P=0.0000083). Conclusion Troponin clearance can be considered as a valuable leading indicator of survival, but higher levels of troponin clearance did not lead to higher survival rates.
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Thygesen K, Alpert JS, Jaffe AS, Chaitman BR, Bax JJ, Morrow DA, White HD. Fourth Universal Definition of Myocardial Infarction (2018). Circulation 2019; 138:e618-e651. [PMID: 30571511 DOI: 10.1161/cir.0000000000000617] [Citation(s) in RCA: 1661] [Impact Index Per Article: 332.2] [Reference Citation Analysis] [Key Words] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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Giannitsis E, Biener M, Hund H, Mueller-Hennessen M, Vafaie M, Gandowitz J, Riedle C, Löhr J, Katus HA, Stoyanov KM. Management and outcomes of patients with unstable angina with undetectable, normal, or intermediate hsTnT levels. Clin Res Cardiol 2019; 109:476-487. [DOI: 10.1007/s00392-019-01529-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2019] [Accepted: 07/10/2019] [Indexed: 12/13/2022]
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Ramos HR, López LE, Castro WQ, Serra CMJ. High-sensitivity cardiac troponins: sex-specific values in clinical practice. Precision or confusion? Hellenic J Cardiol 2019; 60:171-177. [DOI: 10.1016/j.hjc.2019.02.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2018] [Revised: 02/04/2019] [Accepted: 02/27/2019] [Indexed: 02/06/2023] Open
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Wang G, Wang J, Wu S, Zheng W, Zhang H, Ma J, Zheng J, Xu F, Chen Y. Clinical impact of using a more sensitive troponin assay in patients with acute chest pain. Clin Cardiol 2019; 42:561-567. [PMID: 30887538 PMCID: PMC6522991 DOI: 10.1002/clc.23177] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2019] [Revised: 03/13/2019] [Accepted: 03/15/2019] [Indexed: 12/27/2022] Open
Abstract
Background More sensitive troponin assays have the potential to better evaluate patients with suspected acute coronary syndrome (ACS). Meanwhile, they may result in avoidable diagnostic testing. Hypothesis Our aim was to determine the clinical impact of implementing a more sensitive cardiac troponin I (cTnI) assay in patients with acute non‐traumatic chest pain presenting to the emergency department (ED). Methods This is a pre‐post cohort study. A total of 1201 consecutive patients with acute non‐traumatic chest pain or equivalent ischemic symptoms suggestive of ACS were allocated to two groups according to the cTnI assay used. The outcomes included the ED length of stay (LOS), hospital admission rate, the use of procedures and the incidence of major adverse cardiac events (MACE) at 30 days. Results The introduction of the more sensitive troponin assay shortened ED LOS (odds ratio [OR] 0.39, 95% confidence interval [CI] 0.28‐0.54) regarding patients discharged home directly, increased the hospital admission rate (OR 1.43, 95% CI 1.12‐1.84), the use of echocardiography (OR 1.58, 95% CI 1.22‐2.06), coronary computed tomography angiography (OR 1.78, 95% CI 1.04‐3.06), coronary angiography (OR 1.53, 95% CI 1.10‐2.12) and percutaneous coronary intervention (OR 2.42, 95% CI 1.58‐3.70) regarding patients discharged or admitted. The incidence of MACE did not decrease significantly (OR 0.61, 95% CI 0.27‐1.37). Conclusions The introduction of the more sensitive troponin assay appeared to result in less time spent in the ED regarding patients discharged home directly, but prompted more hospitalizations and procedures without impacting the incidence of MACE.
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Affiliation(s)
- Guangmei Wang
- Department of Emergency, Qilu Hospital, Shandong University, Jinan, China.,Chest Pain Center, Qilu Hospital, Shandong University, Jinan, China.,Key Laboratory of Emergency and Critical Care Medicine of Shandong Province, Qilu Hospital, Shandong University, Jinan, China.,Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education and Chinese Ministry of Public Health, Qilu Hospital, Shandong University, Jinan, China
| | - Jiali Wang
- Department of Emergency, Qilu Hospital, Shandong University, Jinan, China.,Chest Pain Center, Qilu Hospital, Shandong University, Jinan, China.,Key Laboratory of Emergency and Critical Care Medicine of Shandong Province, Qilu Hospital, Shandong University, Jinan, China.,Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education and Chinese Ministry of Public Health, Qilu Hospital, Shandong University, Jinan, China
| | - Shuo Wu
- Department of Emergency, Qilu Hospital, Shandong University, Jinan, China.,Chest Pain Center, Qilu Hospital, Shandong University, Jinan, China.,Key Laboratory of Emergency and Critical Care Medicine of Shandong Province, Qilu Hospital, Shandong University, Jinan, China.,Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education and Chinese Ministry of Public Health, Qilu Hospital, Shandong University, Jinan, China
| | - Wen Zheng
- Department of Emergency, Qilu Hospital, Shandong University, Jinan, China.,Chest Pain Center, Qilu Hospital, Shandong University, Jinan, China.,Key Laboratory of Emergency and Critical Care Medicine of Shandong Province, Qilu Hospital, Shandong University, Jinan, China.,Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education and Chinese Ministry of Public Health, Qilu Hospital, Shandong University, Jinan, China
| | - He Zhang
- Department of Emergency, Qilu Hospital, Shandong University, Jinan, China.,Chest Pain Center, Qilu Hospital, Shandong University, Jinan, China.,Key Laboratory of Emergency and Critical Care Medicine of Shandong Province, Qilu Hospital, Shandong University, Jinan, China.,Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education and Chinese Ministry of Public Health, Qilu Hospital, Shandong University, Jinan, China
| | - Jingjing Ma
- Department of Emergency, Qilu Hospital, Shandong University, Jinan, China.,Chest Pain Center, Qilu Hospital, Shandong University, Jinan, China.,Key Laboratory of Emergency and Critical Care Medicine of Shandong Province, Qilu Hospital, Shandong University, Jinan, China.,Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education and Chinese Ministry of Public Health, Qilu Hospital, Shandong University, Jinan, China
| | - Jiaqi Zheng
- Department of Emergency, Qilu Hospital, Shandong University, Jinan, China.,Chest Pain Center, Qilu Hospital, Shandong University, Jinan, China.,Key Laboratory of Emergency and Critical Care Medicine of Shandong Province, Qilu Hospital, Shandong University, Jinan, China.,Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education and Chinese Ministry of Public Health, Qilu Hospital, Shandong University, Jinan, China
| | - Feng Xu
- Department of Emergency, Qilu Hospital, Shandong University, Jinan, China.,Chest Pain Center, Qilu Hospital, Shandong University, Jinan, China.,Key Laboratory of Emergency and Critical Care Medicine of Shandong Province, Qilu Hospital, Shandong University, Jinan, China.,Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education and Chinese Ministry of Public Health, Qilu Hospital, Shandong University, Jinan, China
| | - Yuguo Chen
- Department of Emergency, Qilu Hospital, Shandong University, Jinan, China.,Chest Pain Center, Qilu Hospital, Shandong University, Jinan, China.,Key Laboratory of Emergency and Critical Care Medicine of Shandong Province, Qilu Hospital, Shandong University, Jinan, China.,Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education and Chinese Ministry of Public Health, Qilu Hospital, Shandong University, Jinan, China
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Abstract
PURPOSE OF REVIEW Non-invasive molecular imaging is currently used as a research technique to better understand disease pathophysiology. There are also many potential clinical applications where molecular imaging may provide unique information that allows either earlier or more definitive diagnosis, or can guide precision medicine-based decisions on therapy. Contrast-enhanced ultrasound (CEU) with targeted microbubble contrast agents is one such technique that has been developed that has the unique properties of providing rapid information and revealing information only on events that occur within the vascular space. RECENT FINDINGS CEU molecular probes have been developed for a wide variety of disease states including atherosclerosis, vascular inflammation, thrombosis, tumor neovascularization, and ischemic injury. While the technique has not yet been adapted to clinical use, it has been used to reveal pathological processes, to identify new therapeutic targets, and to test the efficacy of novel treatments. This review will explore the physical basis for CEU molecular imaging, its strengths and limitations compared to other molecular imaging modalities, and the pre-clinical translational research experience.
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Affiliation(s)
- Eran Brown
- Department of Biomedical Engineering, Oregon Health & Science University, Portland, OR, USA.,Knight Cardiovascular Institute, UHN-62, Oregon Health & Science University, 3181 SW Sam Jackson Park Rd., Portland, OR, 97239, USA
| | - Jonathan R Lindner
- Knight Cardiovascular Institute, UHN-62, Oregon Health & Science University, 3181 SW Sam Jackson Park Rd., Portland, OR, 97239, USA. .,Oregon National Primate Research Center (J.R.L.), Oregon Health & Science University, Portland, OR, USA.
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27
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For Low-Risk Patients With Suspected Acute Coronary Syndrome, Should Urgent (72-hours) Non-Invasive Cardiac Testing Be Performed After Biomarker Exclusion of Acute Myocardial Infarction. Ann Emerg Med 2018; 71:464-465. [PMID: 29566886 DOI: 10.1016/j.annemergmed.2017.08.048] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2017] [Indexed: 11/23/2022]
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Thygesen K, Alpert JS, Jaffe AS, Chaitman BR, Bax JJ, Morrow DA, White HD. Fourth Universal Definition of Myocardial Infarction (2018). J Am Coll Cardiol 2018; 72:2231-2264. [PMID: 30153967 DOI: 10.1016/j.jacc.2018.08.1038] [Citation(s) in RCA: 2033] [Impact Index Per Article: 338.8] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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29
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Thygesen K, Alpert JS, Jaffe AS, Chaitman BR, Bax JJ, Morrow DA, White HD, Thygesen K, Alpert JS, Jaffe AS, Chaitman BR, Bax JJ, Morrow DA, White HD, Mickley H, Crea F, Van de Werf F, Bucciarelli-Ducci C, Katus HA, Pinto FJ, Antman EM, Hamm CW, De Caterina R, Januzzi JL, Apple FS, Alonso Garcia MA, Underwood SR, Canty JM, Lyon AR, Devereaux PJ, Zamorano JL, Lindahl B, Weintraub WS, Newby LK, Virmani R, Vranckx P, Cutlip D, Gibbons RJ, Smith SC, Atar D, Luepker RV, Robertson RM, Bonow RO, Steg PG, O’Gara PT, Fox KAA, Hasdai D, Aboyans V, Achenbach S, Agewall S, Alexander T, Avezum A, Barbato E, Bassand JP, Bates E, Bittl JA, Breithardt G, Bueno H, Bugiardini R, Cohen MG, Dangas G, de Lemos JA, Delgado V, Filippatos G, Fry E, Granger CB, Halvorsen S, Hlatky MA, Ibanez B, James S, Kastrati A, Leclercq C, Mahaffey KW, Mehta L, Müller C, Patrono C, Piepoli MF, Piñeiro D, Roffi M, Rubboli A, Sharma S, Simpson IA, Tendera M, Valgimigli M, van der Wal AC, Windecker S, Chettibi M, Hayrapetyan H, Roithinger FX, Aliyev F, Sujayeva V, Claeys MJ, Smajić E, Kala P, Iversen KK, El Hefny E, Marandi T, Porela P, Antov S, Gilard M, Blankenberg S, Davlouros P, Gudnason T, Alcalai R, Colivicchi F, Elezi S, Baitova G, Zakke I, Gustiene O, Beissel J, Dingli P, Grosu A, Damman P, Juliebø V, Legutko J, Morais J, Tatu-Chitoiu G, Yakovlev A, Zavatta M, Nedeljkovic M, Radsel P, Sionis A, Jemberg T, Müller C, Abid L, Abaci A, Parkhomenko A, Corbett S. Fourth universal definition of myocardial infarction (2018). Eur Heart J 2018; 40:237-269. [DOI: 10.1093/eurheartj/ehy462] [Citation(s) in RCA: 1047] [Impact Index Per Article: 174.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
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30
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Thygesen K, Alpert JS, Jaffe AS, Chaitman BR, Bax JJ, Morrow DA, White HD. Fourth Universal Definition of Myocardial Infarction (2018). Glob Heart 2018; 13:305-338. [PMID: 30154043 DOI: 10.1016/j.gheart.2018.08.004] [Citation(s) in RCA: 173] [Impact Index Per Article: 28.8] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
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31
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Abstract
Cardiac troponin assays have become more sensitive over the years leading to the clinical introduction of high-sensitivity cardiac troponin assays in 2010. Their use has revolutionized the assessment of patients with chest pain in the emergency department by allowing earlier rule-in and rule-out of myocardial infarction leading to shorter stays in the emergency department and reduced admissions for chest pain. The incidence of myocardial infarction has increased slightly, and patients with myocardial infarction diagnosed with high-sensitivity cardiac troponins have been found to have a reduced risk of reinfarction, though without an impact on survival. High-sensitivity cardiac troponins are powerful predictors of long-term mortality and cardiovascular disease in the general population as well as in patients with chest pain with or without cardiovascular disease. The increase in risk for death and cardiovascular disease associated with high-sensitivity cardiac troponins is graded and starts already at detectable levels, well below the upper normal level. The aim of this review was to describe the clinical use and consequences of the introduction of high-sensitivity cardiac troponins. In addition, the importance of persistently elevated troponin levels for prognosis and what investigations may be appropriate to perform in patients with stable troponin elevations are discussed.
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Affiliation(s)
- M J Holzmann
- Department of Medicine, Karolinska Institutet, Solna, Sweden.,Functional area of Emergency Medicine, Karolinska University Hospital, Huddinge, Sweden
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32
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Vrints CJ. Improving outcomes of acute coronary syndromes through better risk stratification, earlier and more accurate diagnosis of acute myocardial infarction and assessment of frailty. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2018; 7:99-101. [DOI: 10.1177/2048872618767743] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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33
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Gunsolus I, Sandoval Y, Smith SW, Sexter A, Schulz K, Herzog CA, Apple FS. Renal Dysfunction Influences the Diagnostic and Prognostic Performance of High-Sensitivity Cardiac Troponin I. J Am Soc Nephrol 2018; 29:636-643. [PMID: 29079658 PMCID: PMC5791068 DOI: 10.1681/asn.2017030341] [Citation(s) in RCA: 48] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2017] [Accepted: 09/25/2017] [Indexed: 01/09/2023] Open
Abstract
Measures of cardiac troponin (cTn) may have lower specificity for myocardial infarction in patients with CKD. We examined the diagnostic accuracy of baseline and serial high-sensitivity cTnI (hs-cTnI) measurements for myocardial infarction and 30- and 180-day mortality according to renal function. hs-cTnI was measured (Abbott assay) using sex-specific 99th percentiles (women, 16 ng/L; men, 34 ng/L) in 1555 adults presenting to the emergency department with symptoms suggesting ischemia (NCT02060760). Myocardial infarction was adjudicated along universal definition classification. Renal function did not significantly affect sensitivity or negative predictive values. Specificity decreased with impaired renal function from 93%-95% with normal function (eGFR≥90 ml/min per 1.73 m2; n=722) to 57%-61% with severely impaired renal function (eGFR<30 ml/min per 1.73 m2; n=81) and 40%-41% on dialysis (n=78). Positive predictive values decreased with decreasing renal function from 51%-57% with normal function to 27%-42% with severely impaired function and 15%-32% on dialysis. Receiver operating characteristic curve areas trended lower at baseline and 3 hours with renal impairment. Mortality increased significantly with increasing hs-cTnI tertile (1.3%, 6.0%, and 10.4%, respectively). Patients with hs-cTnI concentration exceeding concentrations in the 99th percentiles had a mortality rate (11.7%) significantly higher than that of patients with concentrations between 99th percentile concentrations and limit of detection (6.2%) or below limit of detection (1.1%). Renal dysfunction and dialysis reduced the rule-in performance but not the rule-out performance of hs-cTnI for myocardial infarction, and mortality increased in patients with higher hs-cTnI concentrations and any level of renal dysfunction.
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Affiliation(s)
- Ian Gunsolus
- Department of Laboratory Medicine and Pathology and
| | - Yader Sandoval
- Division of Cardiology, Hennepin County Medical Center, Minneapolis, Minnesota
- Minneapolis Heart Institute, Abbott Northwestern Hospital, Minneapolis, Minnesota
- Cardiac Biomarkers Trials Laboratory and
| | | | - Anne Sexter
- Chronic Disease Research Group, Minneapolis Medical Research Foundation, Minneapolis, Minnesota; and
| | | | - Charles A Herzog
- Chronic Disease Research Group, Minneapolis Medical Research Foundation, Minneapolis, Minnesota; and
- Medicine, and
| | - Fred S Apple
- Cardiac Biomarkers Trials Laboratory and
- Laboratory Medicine and Pathology, Hennepin County Medical Center and University of Minnesota, Minneapolis, Minnesota
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Andruchow JE, Kavsak PA, McRae AD. Contemporary Emergency Department Management of Patients with Chest Pain: A Concise Review and Guide for the High-Sensitivity Troponin Era. Can J Cardiol 2017; 34:98-108. [PMID: 29407013 DOI: 10.1016/j.cjca.2017.11.012] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2017] [Revised: 11/23/2017] [Accepted: 11/23/2017] [Indexed: 11/17/2022] Open
Abstract
This article synthesizes current best evidence for the evaluation of patients with suspected acute coronary syndrome (ACS) using high-sensitivity troponin assays, enabling physicians to effectively incorporate them into practice. Unlike conventional assays, high-sensitivity assays can precisely measure blood cardiac troponin concentrations in the vast majority of healthy individuals, facilitating the creation of rapid diagnostic algorithms. Very low troponin concentrations on presentation accurately rule out acute myocardial infarction (AMI) and enable the discharge of approximately 20% of patients after a single test, whereas an additional 30%-40% of patients can be safely discharged after short-interval serial sampling in as little as 1 or 2 hours. In contrast, highly abnormal troponin concentrations on presentation (more than 5 times the upper reference limit) or rapidly rising levels on serial testing can rapidly rule in AMI with high specificity. However, approximately one-third of patients remain in a biomarker-indeterminate "observation zone" even after serial sampling. These patients pose a disposition challenge to clinicians because although the differential diagnosis of elevated troponin concentrations is broad, these patients have an increased risk for short-term major adverse cardiac events. Use of repeated serial troponin sampling and structured clinical prediction tools may assist disposition for these patients, because no validated pathways currently exist to guide clinicians. Ongoing research to tailor diagnostic thresholds to individual patient characteristics may enable improved diagnostic accuracy and usher in a new era of personalized medicine in the evaluation of suspected ACS.
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Affiliation(s)
- James E Andruchow
- Department of Emergency Medicine, University of Calgary, Calgary, Alberta, Canada; Alberta Health Services, Calgary, Alberta, Canada.
| | - Peter A Kavsak
- Department of Pathology and Molecular Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Andrew D McRae
- Department of Emergency Medicine, University of Calgary, Calgary, Alberta, Canada; Alberta Health Services, Calgary, Alberta, Canada
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35
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Sandoval Y, Jaffe AS. Using High-Sensitivity Cardiac Troponin T for Acute Cardiac Care. Am J Med 2017; 130:1358-1365.e1. [PMID: 28843652 DOI: 10.1016/j.amjmed.2017.07.033] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2017] [Revised: 07/27/2017] [Accepted: 07/28/2017] [Indexed: 12/21/2022]
Abstract
The recent approval of the fifth-generation cardiac troponin T assay, which has characteristics clinically of a high-sensitivity assay, has led to concern that the problems of increased sensitivity will be greater than the benefits. This will not be the case if cardiology, emergency medicine, and laboratory medicine combine to develop procedures for use of the assay. We advocate sex-specific 99th percentile upper reference limit values of 15 ng/L for men and 10 ng/L for women. We suggest a 2-hour rule-out strategy, including a value less than the 99th percentile upper reference limit and the lack of a change in values of <4 ng/L. Those with values >100 ng/L and or a changing pattern of values ≥10 ng/L are a population much more likely to have acute myocardial infarction. Most of the increment in elevated values will occur not in those with acute coronary problems but in those with primary cardiac disease like heart failure and those with primary noncardiac problems. The former belong on a cardiac service because they are at high risk. The latter should have therapy on the service most apt to provide optimal care for their primary diagnosis, with cardiac consultation as needed.
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Affiliation(s)
- Yader Sandoval
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minn
| | - Allan S Jaffe
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minn; Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minn.
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36
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Two-dimensional speckle-tracking global longitudinal strain in high-sensitivity troponin-negative low-risk patients with unstable angina: a “resting ischemia test”? Int J Cardiovasc Imaging 2017; 34:561-568. [DOI: 10.1007/s10554-017-1269-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2017] [Accepted: 11/04/2017] [Indexed: 01/05/2023]
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37
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Reply. Am J Cardiol 2017; 120:e73-e74. [PMID: 27846981 DOI: 10.1016/j.amjcard.2016.10.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2016] [Accepted: 10/18/2016] [Indexed: 11/24/2022]
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38
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Biomarkers of vascular inflammation. Cell stress offers new clues. Int J Cardiol 2017; 246:18-19. [PMID: 28733073 DOI: 10.1016/j.ijcard.2017.05.115] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2017] [Accepted: 05/31/2017] [Indexed: 01/11/2023]
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39
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Kozinski M, Krintus M, Kubica J, Sypniewska G. High-sensitivity cardiac troponin assays: From improved analytical performance to enhanced risk stratification. Crit Rev Clin Lab Sci 2017; 54:143-172. [DOI: 10.1080/10408363.2017.1285268] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Affiliation(s)
- Marek Kozinski
- Department of Principles of Clinical Medicine, Nicolaus Copernicus University, Collegium Medicum, Bydgoszcz, Poland
| | - Magdalena Krintus
- Department of Laboratory Medicine, Nicolaus Copernicus University, Collegium Medicum, Bydgoszcz, Poland
| | - Jacek Kubica
- Department of Cardiology and Internal Medicine, Nicolaus Copernicus University, Collegium Medicum, Bydgoszcz, Poland
| | - Grazyna Sypniewska
- Department of Laboratory Medicine, Nicolaus Copernicus University, Collegium Medicum, Bydgoszcz, Poland
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40
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Seki K, Mizuno Y, Sakashita T, Nakano S, Tanno J, Okazaki Y, Muramatsu T, Nishimura S, Senbonmatsu T. Demeanor of rivaroxaban in activated/inactivated FXa. J Pharmacol Sci 2017; 133:156-161. [DOI: 10.1016/j.jphs.2017.02.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2016] [Revised: 01/24/2017] [Accepted: 02/17/2017] [Indexed: 01/30/2023] Open
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