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Bulescu NC, Mitchell J, Metton O, El Jonhy N, Amaz C, Perouse de Montclos T, Lilot M, Mewton N, Henaine R. Celsior® vs. St Thomas® cardioplegia: analysis of myocardial protection and clinical safety in neonates. Front Pediatr 2024; 12:1430832. [PMID: 39040670 PMCID: PMC11260699 DOI: 10.3389/fped.2024.1430832] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2024] [Accepted: 06/20/2024] [Indexed: 07/24/2024] Open
Abstract
Objective To compare the effectiveness and safety of Celsior® crystalloid solution to St Thomas® solution as cardioplegia in pediatric arterial switch surgery. Methods A retrospective study was conducted on 180 patients who underwent arterial switch operation (ASO) between 2005 and 2019. The patients were divided into two groups: the St Thomas group receiving St Thomas solution and the Celsior® group receiving Celsior® solution. The study aimed to assess myocardial protection while evaluating clinical outcomes of patients between groups. Results Baseline characteristics not different between groups. The postoperative troponin release trends and blood lactate levels were not different between groups. However, the Celsior® group had a significant lower incidence of delayed sternal closure (9.7% vs. 19.5%; p = 0.09) and mechanical circulatory support (ECMO) (4.9% vs. 24.7%; p < 0.001) compared to the St Thomas group. The length of stay in the intensive care unit (ICU) was significantly shorter in the Celsior® group (4.6 ± 3.36 days vs. 8.72 ± 5.08 days, respectively; p < 0.001). There was no significant difference in 30-day mortality between the two groups (2.9% vs. 2.6%; p = 0.147). Conclusion The study suggests that Celsior® solution is effective and safe for myocardial protection in pediatric arterial switch surgery. It may offer potential benefits such as reduced need for delayed sternal closure and ECMO support, as well as shorter ICU stay. However, the study has limitations including its retrospective design and the use of different cardioplegic solutions during different time periods. Further prospective randomized trials are needed for confirmation. Clinical Registration Number ClinicalTrials.gov, ID: NCT04616222.
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Affiliation(s)
| | - Julia Mitchell
- Congenital Cardiac Surgery, Louis Pradel Hospital, Lyon, France
| | - Olivier Metton
- Congenital Cardiac Surgery, Louis Pradel Hospital, Lyon, France
| | - Naoual El Jonhy
- Center for Clinical Investigation, Louis Pradel Hospital, Lyon, France
| | - Camille Amaz
- Center for Clinical Investigation, Louis Pradel Hospital, Lyon, France
| | | | - Marc Lilot
- Pediatric Cardiac, Thoracic and Vascular Anesthesia and Intensive Care Unit, Louis Pradel Hospital, Lyon, France
| | - Nathan Mewton
- Center for Clinical Investigation, Louis Pradel Hospital, Lyon, France
| | - Roland Henaine
- Congenital Cardiac Surgery, Louis Pradel Hospital, Lyon, France
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Seyfrydova M, Rokyta R, Rajdl D, Huml M. Arrhythmias and laboratory abnormalities after an electrical accident: a single-center, retrospective study of 333 cases. Clin Res Cardiol 2023; 112:1835-1847. [PMID: 37526697 DOI: 10.1007/s00392-023-02274-5] [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: 01/17/2023] [Accepted: 07/21/2023] [Indexed: 08/02/2023]
Abstract
BACKGROUND Even though electrical injuries are common in the emergency room, guidelines, consensus, and general recommendations for the management of these patients do not exist in Europe. Documented cases of delayed arrhythmias are rare and their connection with electrical injury has not been fully confirmed. We also use cardio-specific markers for the risk stratification of myocardial injury, but there is no significant study referring to their utility in this clinical situation. These reasons led us to retrospectively analyze all cases of electrical injuries over 23 years to determine the prevalence of cardiac arrhythmias (mainly malignant arrhythmias and delayed arrhythmias). METHODS We retrospectively searched all patients admitted to the University Hospital in Pilsen, CZ, with a diagnosis of electric injury (ICD diagnostic code T754) from 1997 to 2020. The hospital´s information system was used to research the injury; data were drawn from patient medical records. RESULTS We identified 333 cases of electrical injury in our hospital. Men accounted for about two-thirds, and women one-third. Children accounted for about one-third of cases. Most were low-voltage injuries (< 1000 V, 91.6%). All participants had an initial ECG, and 77.5% of patients had continuous ECG monitoring, usually lasting 24 h. Cardiac arrhythmias were noticed in 39 patients (11.7%). The most frequent arrhythmias were: ventricular fibrillation, sinus tachycardia, bradycardia and arrhythmia, atrial fibrillation, and supraventricular tachycardia. The ECG showed cardiac conduction abnormalities in 28 patients (8.1%), and ten patients (3%) had supraventricular or ventricular extrasystoles. In ten cases (3%), we found changes in ST segments and T waves on the initial ECG. Thirty-one patients (9.3%) suffered a loss of consciousness and 50 patients (15.02%) reported paresthesia. The most frequent ion disbalances were hypokalemia (18%) and hypocalcemia (3.3%). Patients with an ion disbalance had significantly more arrhythmias and newly diagnosed cardiac conduction abnormalities. Troponin levels (cTnI or hs-cTnT) were measured in 258 cases (77.48%) and found to be elevated above the 99th percentile in 19 cases (5.7%). Almost one-third of patients had burns of various degrees of seriousness, and 41 patients (12.3%) had concomitant traumatic injuries. Eleven patients underwent pre-hospital resuscitation, three died in the hospital, and another died as result of intracranial hemorrhage. CONCLUSION All malignant arrhythmias occurred immediately after the electrical injury, delayed life-threatening arrhythmias were not observed, and no predictive factors of malignant arrhythmias were found. While elevations of cardiac troponins were observed sporadically, they did not appear helpful for risk stratification. In patients with arrhythmias, ion disbalance may be more critical. We concluded that asymptomatic, uninjured adult and pediatric patients with normal initial ECG findings do not need continuous ECG monitoring and may be discharged home. Recommendations for high-risk patients and patients with mild ECG abnormalities at admission are less obvious.
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Affiliation(s)
- Miroslava Seyfrydova
- Department of Cardiology, University Hospital and Faculty of Medicine Pilsen, Charles University, Pilsen, Czech Republic.
| | - Richard Rokyta
- Department of Cardiology, University Hospital and Faculty of Medicine Pilsen, Charles University, Pilsen, Czech Republic
| | - Daniel Rajdl
- Institute of Clinical Biochemistry and Laboratory Diagnostics, University Hospital and Faculty of Medicine Pilsen, Charles University, Pilsen, Czech Republic
| | - Michal Huml
- Department of Pediatrics, University Hospital and Faculty of Medicine Pilsen, Charles University, Pilsen, Czech Republic
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Hill J, Yang EH, Lefebvre D, Doran S, Graham M, van Diepen S, Raizman JE, Tsui AK, Rowe BH. Effect of a High-Sensitivity Troponin I and Associated Diagnostic Protocol on Emergency Department Length of Stay: A Retrospective Cohort Study. CJC Open 2023; 5:925-933. [PMID: 38204856 PMCID: PMC10774082 DOI: 10.1016/j.cjco.2023.09.007] [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: 06/22/2023] [Accepted: 09/11/2023] [Indexed: 01/12/2024] Open
Abstract
Background The objective of this study was to assess the introduction of a high-sensitivity troponin I (hs-TnI) assay and its associated accelerated protocol on emergency department (ED) length of stay (LOS) for patients presenting with chest pain, compared to an accelerated diagnostic protocol using conventional troponin (TnI) testing. Methods We conducted a retrospective cohort study of all adults with a primary presenting complaint of chest pain of cardiac origin and a Canadian Triage and Acuity Scale score of 2 or 3, between November 8, 2019 and November 9, 2021, to a tertiary-care urban Canadian ED. The primary outcome was ED LOS. Secondary outcomes included consultation proportions and major adverse cardiac events within 30 days of the index ED visit. Results A total of 2640 patients presenting with chest pain were included, with 1333 in the TnI group and 1307 in the hs-TnI group. Median ED LOS decreased significantly, from 392 minutes for the TnI group, and 371 minutes for the hs-TnI group (median difference = 21 minutes; 95% confidence interval: 5.3, 36.7). The numbers of consultations and admissions were not statistically different between study periods. The major adverse cardiac events outcomes did not change following the implementation of the hs-TnI test (13.6% vs 13.1%; P = 0.71). Conclusions The implementation of an accelerated chest pain protocol using an hs-TnI assay in a tertiary-care Canadian ED was associated with a modest reduction of LOS for all patients, and a substantial reduction of LOS for patients undergoing serial troponin testing. This strategy was safe, with no increase in adverse outcomes.
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Affiliation(s)
- Jesse Hill
- Department of Emergency Medicine, Faculty of Medicine and Dentistry, College of Health Sciences, University of Alberta, Edmonton, Alberta, Canada
- School of Public Health, College of Health Sciences, University of Alberta, Edmonton, Alberta, Canada
| | - Esther H. Yang
- Department of Emergency Medicine, Faculty of Medicine and Dentistry, College of Health Sciences, University of Alberta, Edmonton, Alberta, Canada
- The Alberta Strategy for Patient-Oriented Research Support Unit, Alberta Health Services (AHS), Edmonton, Alberta, Canada
| | - Dennis Lefebvre
- Department of Emergency Medicine, Faculty of Medicine and Dentistry, College of Health Sciences, University of Alberta, Edmonton, Alberta, Canada
| | - Shandra Doran
- Department of Emergency Medicine, Faculty of Medicine and Dentistry, College of Health Sciences, University of Alberta, Edmonton, Alberta, Canada
| | - Michelle Graham
- Mazankowski Heart Institute, Division of Cardiology, Department of Medicine, Faculty of Medicine & Dentistry, College of Health Sciences, University of Alberta, Edmonton, Alberta, Canada
| | - Sean van Diepen
- Mazankowski Heart Institute, Division of Cardiology, Department of Medicine, Faculty of Medicine & Dentistry, College of Health Sciences, University of Alberta, Edmonton, Alberta, Canada
| | - Joshua E. Raizman
- Department of Laboratory Medicine and Pathology, Faculty of Medicine and Dentistry, College of Health Sciences, University of Alberta, Edmonton, Alberta, Canada
- Alberta Precision Laboratories (APL), Alberta Health Services (AHS), Edmonton, Alberta, Canada
| | - Albert K.Y. Tsui
- Department of Laboratory Medicine and Pathology, Faculty of Medicine and Dentistry, College of Health Sciences, University of Alberta, Edmonton, Alberta, Canada
- Alberta Precision Laboratories (APL), Alberta Health Services (AHS), Edmonton, Alberta, Canada
| | - Brian H. Rowe
- Department of Emergency Medicine, Faculty of Medicine and Dentistry, College of Health Sciences, University of Alberta, Edmonton, Alberta, Canada
- School of Public Health, College of Health Sciences, University of Alberta, Edmonton, Alberta, Canada
- Mazankowski Heart Institute, Division of Cardiology, Department of Medicine, Faculty of Medicine & Dentistry, College of Health Sciences, University of Alberta, Edmonton, Alberta, Canada
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Kulkarni SM, Roongta R, Sankar S. Clinical profile of patients and sensitivity of troponin I in patients with and without acute coronary syndrome: An observational study. THE NATIONAL MEDICAL JOURNAL OF INDIA 2023; 36:305-309. [PMID: 38759980 DOI: 10.25259/nmji_801_2021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/19/2024]
Abstract
Background Various clinical conditions can cause troponin elevation in the absence of myocardial ischaemia. Elevated troponin represents the likely occurrence of myocardial necrosis and does not itself provide any indication of the aetiology. Identifying the cause for troponin elevation and its sensitivity and specificity in predicting acute coronary syndrome (ACS) and cardiac mortality is an important step in determining the optimal management for these patients. Methods We retrospectively collected data of inpatients who had troponin I (TnI) testing as part of their clinical assessment, either in the emergency department, medical wards, coronary care unit (CCU) or intensive care unit (ICU) with their final diagnosis. TnI was used as the index test of sensitivity to diagnose ACS and either echocardiography or coronary angiogram in those available as the reference gold standard. They were classified into two groups of normal and elevated TnI, and further divided into those with ACS and no ACS. Data on clinical parameters and aetiology of elevated TnI in patients without ACS were analysed. Results Of the 254 patients studied, 114 patients (45%) had normal TnI and 140 (55%) had elevated TnI. Seventy-eight patients had ACS, 66 (84.6%) of whom had elevated TnI and 12 (15.38%) had normal TnI. Seventy-four (52.85%) of 140 patients with elevated TnI had alternate causes of TnI elevation; the most common being sepsis, acute kidney injury (AKI) and heart failure without ACS. All-cause mortality was significantly higher in patients with elevated TnI with or without ACS. There was no cardiac mortality among patients with ACS with normal TnI. Sensitivity and specificity of TnI for predicting ACS was 84.6% (95% CI 74.7%-91.8%) and 58% (95% CI 50.3%-65.3%), respectively. Conclusion A variety of conditions apart from myocardial infarction can lead to elevated TnI. Hence, caution should be exercised while diagnosing a patient with ACS based on TnI value in the absence of other supporting evidence given its low specificity. Elevated TnI portends a worse prognosis regardless of the aetiology and has a role in predicting all-cause and cardiac mortality.
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Affiliation(s)
- Shruthi M Kulkarni
- Department of General Medicine, St John's Medical College Hospital, Koramangala, Bengaluru 560034, Karnataka, India
| | - Rashmi Roongta
- Department of General Medicine, St John's Medical College Hospital, Koramangala, Bengaluru 560034, Karnataka, India
| | - Seena Sankar
- Department of General Medicine, St John's Medical College Hospital, Koramangala, Bengaluru 560034, Karnataka, India
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Hua G, Levin M, Zhang H, Xie M, McHugh T, Gupta M. Post-operative survival in head and neck cancer patients with elevated troponins. Clin Otolaryngol 2023; 48:200-205. [PMID: 36385741 DOI: 10.1111/coa.14009] [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: 04/19/2022] [Revised: 09/27/2022] [Accepted: 11/05/2022] [Indexed: 11/18/2022]
Abstract
OBJECTIVES The strenuous demands of head and neck cancer surgery (HNS) place patients at increased risk of myocardial injury. Troponin positivity (TP) post-operatively is a predictor of increased complications and mortality. The present study is the first to investigate the effects of TP on potential delays in adjuvant treatment and disease-specific survival. DESIGN, SETTING, PARTICIPANTS AND MAIN OUTCOME MEASURES All patients undergoing HNS from 2014 to 2016 had troponins measured at a single academic centre. Relevant patient data was extracted on retrospective chart review. The main outcome measures were the impact of TP on timing of adjuvant treatment and disease-specific survival. RESULTS Of 166 patients, 26 (15.6%) developed TP post-operatively. There was no significant difference between cohorts for baseline characteristics except for age. Overall and disease-specific survival for TP patients were respectively 45.9% and 57.4% at 3 years. There was no significant difference between cohorts for overall and disease-specific survival, and time to adjuvant therapy. CONCLUSION No significant association was found between TP and overall and disease-specific survival, and time to adjuvant therapy.
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Affiliation(s)
- Gordon Hua
- Division of Otolaryngology-Head and Neck Surgery, Department of Surgery, McMaster University, Hamilton, ON, Canada
| | - Marc Levin
- Department of Otolaryngology-Head and Neck Surgery, University of Toronto, Toronto, ON, Canada
| | - Han Zhang
- Division of Otolaryngology-Head and Neck Surgery, Department of Surgery, McMaster University, Hamilton, ON, Canada
| | - Michael Xie
- Division of Otolaryngology-Head and Neck Surgery, Department of Surgery, McMaster University, Hamilton, ON, Canada
| | - Tobial McHugh
- Division of Otolaryngology-Head and Neck Surgery, Department of Surgery, McMaster University, Hamilton, ON, Canada
| | - Michael Gupta
- Division of Otolaryngology-Head and Neck Surgery, Department of Surgery, McMaster University, Hamilton, ON, Canada
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El-Menyar A, Asim M, Bahey AAA, Chughtai T, Alyafai A, Abdelrahman H, Rizoli S, Peralta R, Al-Thani H. Beta blocker use in traumatic brain injury based on the high-sensitive troponin status (BBTBBT): methodology and protocol implementation of a double-blind randomized controlled clinical trial. Trials 2021; 22:890. [PMID: 34876207 PMCID: PMC8650244 DOI: 10.1186/s13063-021-05872-8] [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: 12/10/2020] [Accepted: 11/24/2021] [Indexed: 11/21/2022] Open
Abstract
Background Beta-adrenergic receptor blockers (BB) play an important role in the protection of organs that are susceptible for secondary injury due to stress-induced adrenergic surge. However, the use of BB in traumatic brain injury (TBI) patients is not yet the standard of care which necessitates clear scientific evidence to be used. The BBTBBT study aims to determine whether early administration of propranolol based on the high-sensitive troponin T(HsTnT) status will improve the outcome of TBI patients. We hypothesized that early propranolol use is effective in reducing 10- and 30-day mortality in TBI patients. Secondary outcomes will include correlation between serum biomarkers (troponin, epinephrine, cytokines, enolase, S100 calcium binding protein B) and the severity of injury and the impact of BB use on the duration of hospital stay and functional status at a 3-month period. Methods The BBTBBT study is a prospective, randomized, double-blinded, placebo-controlled three-arm trial of BB use in mild-to-severe TBI patients based on the HsTnT status. All enrolled patients will be tested for HsTnT at the first 4 and 6 h post-injury. Patients with positive HsTnT will receive BB if there is no contraindication (group 1). Patients with negative HsTnT will be randomized to receive either propranolol (group 2) or placebo (group 3). The time widow for receiving the study treatment is the first 24 h post-injury. Discussion Early BB use may reduce the catecholamine storm and subsequently the cascade of immune and inflammatory changes associated with TBI. HsTnT could be a useful fast diagnostic and prognostic tool in TBI patients. This study will be of great clinical interest to improve survival and functional outcomes of TBI patients. Trial registration ClinicalTrials.gov NCT04508244. Registered on 7 August 2020. Recruitment started on 29 December 2020 and is ongoing. Supplementary Information The online version contains supplementary material available at 10.1186/s13063-021-05872-8.
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Affiliation(s)
- Ayman El-Menyar
- Clinical Research, Trauma & Vascular Surgery Section, Hamad General Hospital (HGH), PO Box 3050, Doha, Qatar. .,Clinical Medicine, Weill Cornell Medical College, Doha, Qatar.
| | - Mohammad Asim
- Clinical Research, Trauma & Vascular Surgery Section, Hamad General Hospital (HGH), PO Box 3050, Doha, Qatar
| | | | - Talat Chughtai
- Department of Surgery, Trauma Surgery Section, HGH, Doha, Qatar.,Department of Surgery, Qatar University, Doha, Qatar
| | | | | | - Sandro Rizoli
- Department of Surgery, Trauma Surgery Section, HGH, Doha, Qatar
| | - Ruben Peralta
- Department of Surgery, Trauma Surgery Section, HGH, Doha, Qatar
| | - Hassan Al-Thani
- Department of Surgery, Trauma Surgery Section, HGH, Doha, Qatar
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Masseli F, Masseli M, Dolscheid-Pommerich R, Stoffel-Wagner B, Schiller W. Comparison of Perioperative High-Sensitive Troponin T and Troponin I Assays in Cardiac Surgery. Heart Lung Circ 2021; 31:407-414. [PMID: 34511360 DOI: 10.1016/j.hlc.2021.08.006] [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: 01/27/2019] [Revised: 03/22/2021] [Accepted: 08/01/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Troponin measurements are among the standard parameters for monitoring perioperative myocardial ischaemia after cardiosurgical procedures. As high-sensitive assays continue to replace older analytic parameters with lower sensitivity, this study aimed to compare perioperative profiles of a high-sensitive troponin T assay (hsTnT, Roche Diagnostics, Mannheim, Germany) with a troponin I assay (sTnI, Siemens Healthcare Diagnostics, Eschborn, Germany). METHODS A total of 287 consecutive patients undergoing a typical spectrum of cardiac procedures from August 2017 to March 2018 monitored with the hsTnT assay were compared with a propensity-matched collective analysed with the sTnI assay. For side-by side comparison, the peak troponin (Tmax) values were scaled to a z-score distribution before comparison. RESULTS Despite absolute postoperative hsTnT and sTnI values differing by an order of magnitude, parameters could be scaled to a common distribution with kernel density curves overlapping 92%. Both parameters showed equal behaviour in subgroup analyses regarding relevant perioperative factors, such as type of procedure, cross-clamping time, and type of cardioplegic solution. However, there were some differences regarding pre-existing renal impairment between both parameters. In both groups, renal failure patients with chronic kidney disease stages IV or V as well as patients on haemodialysis exhibited a marked Tmax increase of >100% compared with normal kidney function (hsTnT, +121%; 2,383.5 vs 1,078.8 ng/L; p=0.0006; and sTnI, +149%; 27.3 ng/mL vs 11.0 ng/mL; p=0.009). However, in patients with moderately impaired renal function, those in the hsTnT group, but not in the sTnI cohort, showed significantly increased Tmax values (CKD stages II or III, 1,233.5 ng/L [+14%] and 1,314.1 ng/L [+22%] vs 1,078.8 ng/L; p=0.01 and p=0.03). In these patients, the postoperative interval until Tmax was reached was also significantly increased (14.4 and 19.0 hrs vs 12.4 hrs for chronic kidney disease stages II and III; p=0.0038 and p<0.001), indicating a higher rate of accumulation in the hsTnT parameter. CONCLUSION In the context of cardiac surgery, this study found that both parameters behaved in a similar manner under most relevant circumstances. Despite significant difference in the absolute serum concentration, hsTnT and sTnI can be scaled to virtually identical distributions. However, renal impairment did affect both parameters differently with troponin T but not troponin I, showing evidence of accumulation in moderately impaired renal disease.
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Affiliation(s)
- Franz Masseli
- Department of Cardiovascular Surgery, University Clinic Mainz, Mainz, Germany.
| | - Marc Masseli
- Department of Cardiac Surgery, University Clinic Bonn, Bonn, Germany
| | | | - Birgit Stoffel-Wagner
- Institute for Clinical Chemistry and Biochemistry, University Clinic Bonn, Bonn, Germany
| | - Wolfgang Schiller
- Department of Cardiovascular Surgery, University Clinic Mainz, Mainz, Germany
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Westwood M, Ramaekers B, Grimm S, Worthy G, Fayter D, Armstrong N, Buksnys T, Ross J, Joore M, Kleijnen J. High-sensitivity troponin assays for early rule-out of acute myocardial infarction in people with acute chest pain: a systematic review and economic evaluation. Health Technol Assess 2021; 25:1-276. [PMID: 34061019 PMCID: PMC8200931 DOI: 10.3310/hta25330] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Early diagnosis of acute myocardial infarction is important, but only 20% of emergency admissions for chest pain will actually have an acute myocardial infarction. High-sensitivity cardiac troponin assays may allow rapid rule out of myocardial infarction and avoid unnecessary hospital admissions. OBJECTIVES To assess the clinical effectiveness and cost-effectiveness of high-sensitivity cardiac troponin assays for the management of adults presenting with acute chest pain, in particular for the early rule-out of acute myocardial infarction. METHODS Sixteen databases were searched up to September 2019. Review methods followed published guidelines. Studies were assessed for quality using appropriate risk-of-bias tools. The bivariate model was used to estimate summary sensitivity and specificity for meta-analyses involving four or more studies; otherwise, random-effects logistic regression was used. The health economic analysis considered the long-term costs and quality-adjusted life-years associated with different troponin testing methods. The de novo model consisted of a decision tree and a state-transition cohort model. A lifetime time horizon (of 60 years) was used. RESULTS Thirty-seven studies (123 publications) were included in the review. The high-sensitivity cardiac troponin test strategies evaluated are defined by the combination of four factors (i.e. assay, number and timing of tests, and threshold concentration), resulting in a large number of possible combinations. Clinical opinion indicated a minimum clinically acceptable sensitivity of 97%. When considering single test strategies, only those using a threshold at or near to the limit of detection for the assay, in a sample taken at presentation, met the minimum clinically acceptable sensitivity criterion. The majority of the multiple test strategies that met this criterion comprised an initial rule-out step, based on high-sensitivity cardiac troponin levels in a sample taken on presentation and a minimum symptom duration, and a second stage for patients not meeting the initial rule-out criteria, based on presentation levels of high-sensitivity cardiac troponin and absolute change after 1, 2 or 3 hours. Two large cluster randomised controlled trials found that implementation of an early rule-out pathway for myocardial infarction reduced length of stay and rate of hospital admission without increasing cardiac events. In the base-case analysis, standard troponin testing was both the most effective and the most costly. Other testing strategies with a sensitivity of 100% (subject to uncertainty) were almost equally effective, resulting in the same life-year and quality-adjusted life-year gain at up to four decimal places. Comparisons based on the next best alternative showed that for willingness-to-pay values below £8455 per quality-adjusted life-year, the Access High Sensitivity Troponin I (Beckman Coulter, Brea, CA, USA) [(symptoms > 3 hours AND < 4 ng/l at 0 hours) OR (< 5 ng/l AND Δ < 5 ng/l at 0 to 2 hours)] would be cost-effective. For thresholds between £8455 and £20,190 per quality-adjusted life-year, the Elecsys® Troponin-T high sensitive (Roche, Basel, Switzerland) (< 12 ng/l at 0 hours AND Δ < 3 ng/l at 0 to 1 hours) would be cost-effective. For a threshold > £20,190 per quality-adjusted life-year, the Dimension Vista® High-Sensitivity Troponin I (Siemens Healthcare, Erlangen, Germany) (< 5 ng/l at 0 hours AND Δ < 2 ng/l at 0 to 1 hours) would be cost-effective. CONCLUSIONS High-sensitivity cardiac troponin testing may be cost-effective compared with standard troponin testing. STUDY REGISTRATION This study is registered as PROSPERO CRD42019154716. FUNDING This project was funded by the National Institute for Health Research (NIHR) Evidence Synthesis programme and will be published in full in Health Technology Assessment; Vol. 25, No. 33. See the NIHR Journals Library website for further project information.
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Affiliation(s)
| | - Bram Ramaekers
- Department of Clinical Epidemiology and Medical Technology Assessment, Maastricht University, Maastricht, the Netherlands
| | - Sabine Grimm
- Department of Clinical Epidemiology and Medical Technology Assessment, Maastricht University, Maastricht, the Netherlands
| | | | | | | | | | | | - Manuela Joore
- Department of Clinical Epidemiology and Medical Technology Assessment, Maastricht University, Maastricht, the Netherlands
| | - Jos Kleijnen
- Kleijnen Systematic Reviews Ltd, York, UK
- School for Public Health and Primary Care, Care and Public Health Research Institute, Maastricht University, Maastricht, the Netherlands
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Prognostic value of soluble urokinase plasminogen activator receptor in patients presenting to the emergency department with chest pain suggestive of acute coronary syndrome. Clin Biochem 2021; 92:19-24. [PMID: 33662350 DOI: 10.1016/j.clinbiochem.2021.02.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Revised: 01/20/2021] [Accepted: 02/16/2021] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Soluble urokinase plasminogen activator receptor (suPAR) is a prognostic biomarker of cardiovascular disease. OBJECTIVES We aimed to evaluate the early prognostic value of suPAR in patients presenting to the emergency department (ED) with chest pain suggestive of acute coronary syndrome (ACS). PATIENTS AND METHODS In a post-hoc analysis from a multicenter study including patients with a chest pain < 6 h, suPAR concentrations at ED admission were studied according to the outcome at 30-days. RESULTS 198 patients (median age 56 years) in whom 16% had an ACS, were included. Fifteen (7.3%) patients presented a 30-day event. At ED admission, median (IQR) suPAR concentrations were higher in patients with a 30-day event in comparison to patients without event (4.54 (3.09-8.61) vs. 2.72 (2.10-3.43) ng/mL, p < 0.001). The ROC curve AUC of suPAR for the prediction of a 30-days event was 0.775 [95%CI: 0.710-0.831]. The optimal threshold was 3.3 ng/mL, with a sensitivity of 73 [45-92] % and a specificity of 72 [65-79] %. The association of a suPAR < 3.3 ng/mL AND a NT-proBNP < 160 ng/L AND a HEART score < 4 had a negative predictive value of 99 [91-100] %. A suPAR value at admission above 3.3 ng/mL was independently and significantly associated with a 30-day event in chest pain emergency patients (OR 4.87 [1.35-17.51], p = 0.015). CONCLUSION suPAR is a promising biomarker for early prediction of events in chest pain emergency patients.
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Wassie M, Lee MS, Sun BC, Wu YL, Baecker AS, Redberg RF, Ferencik M, Shen E, Musigdilok V, Sharp AL. Single vs Serial Measurements of Cardiac Troponin Level in the Evaluation of Patients in the Emergency Department With Suspected Acute Myocardial Infarction. JAMA Netw Open 2021; 4:e2037930. [PMID: 33620444 PMCID: PMC7903256 DOI: 10.1001/jamanetworkopen.2020.37930] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
IMPORTANCE Chest pain is among the most common reasons for emergency department (ED) presentations. However, most patients are at low risk for acute coronary syndrome (ACS), with low cardiac adverse outcomes rates. Biomarker testing with troponin levels is key in the initial assessment for ACS. Although serial troponin testing can improve the diagnosis of ACS in clinical practice, some patients deemed to be low risk are discharged after a single negative troponin test result. OBJECTIVE To report the clinical outcomes of patients discharged after a single negative troponin test result compared with patients discharged after serial troponin measurements. DESIGN, SETTING, AND PARTICIPANTS This is a retrospective cohort study of ED encounters from May 5, 2016, to December 1, 2017, across 15 community EDs within an integrated health care system in southern California. The study cohort includes 27 918 adult ED encounters in which patients were evaluated for suspected ACS with a HEART (history, electrocardiogram, age, risk factors, and troponin) score and an initial conventional troponin-I measurement below the level of detection (<0.02 ng/mL). Statistical analysis was performed from December 1, 2019, to December 1, 2020. EXPOSURE Single troponin test vs multiple troponin tests. MAIN OUTCOMES AND MEASURES The primary outcome was acute myocardial infarction or cardiac mortality; secondary outcomes included coronary artery bypass graft, percutaneous coronary intervention, invasive coronary angiography, and unstable angina within 30 days of discharge. A multivariable logistic regression model was performed to evaluate the association between testing strategies and clinical outcomes. RESULTS A total of 27 918 patient encounters (16 212 women [58.1%]; mean [SD] age, 58.7 [15.2] years) were included in the study. Of patients with an initial troponin measurement below the level of detection, 14 459 (51.8%) were discharged after a single troponin measurement, and 13 459 (48.2%) underwent serial troponin tests. After adjustment for cardiac risk factors and comorbidities, there was no statistically significant difference in the primary outcome of acute myocardial infarction or cardiac mortality within 30 days between the 2 groups (single troponin, 56 [0.4%] vs serial troponin, 52 [0.4%]; adjusted odds ratio, 1.41 [95% CI, 0.96-2.07]). Patients discharged after a single troponin test had lower rates of coronary artery bypass graft (adjusted odds ratio, 0.24 [95% CI, 0.11-0.48]) and invasive coronary angiography (adjusted odds ratio, 0.46 [95% CI, 0.38-0.56]). CONCLUSIONS AND RELEVANCE This study suggests that patients are routinely discharged from the ED after a single negative troponin test result, and when compared with serial troponin testing, a single troponin test appears safe based on current physician decision-making, with no difference in rates of 30-day cardiac mortality and acute myocardial infarction, which are low in both groups.
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Affiliation(s)
- Maereg Wassie
- Division of Cardiology, Kaiser Permanente Southern California, Los Angeles Medical Center, Los Angeles
| | - Ming-Sum Lee
- Division of Cardiology, Kaiser Permanente Southern California, Los Angeles Medical Center, Los Angeles
| | - Benjamin C. Sun
- Department of Emergency Medicine, Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
| | - Yi-Lin Wu
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena
| | - Aileen S. Baecker
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena
| | - Rita F. Redberg
- Division of Cardiology, University of California, San Francisco, San Francisco
- Editor, JAMA Internal Medicine
| | - Maros Ferencik
- Knight Cardiovascular Institute, Oregon Health and Science University, Portland
| | - Ernest Shen
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena
| | - Visanee Musigdilok
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena
| | - Adam L. Sharp
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena
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11
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Sadighbayan D, Hasanzadeh M, Ghafar-Zadeh E. Biosensing based on field-effect transistors (FET): Recent progress and challenges. Trends Analyt Chem 2020; 133:116067. [PMID: 33052154 PMCID: PMC7545218 DOI: 10.1016/j.trac.2020.116067] [Citation(s) in RCA: 97] [Impact Index Per Article: 24.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
The use of field-Effect-Transistor (FET) type biosensing arrangements has been highlighted by researchers in the field of early biomarker detection and drug screening. Their non-metalized gate dielectrics that are exposed to an electrolyte solution cover the semiconductor material and actively transduce the biological changes on the surface. The efficiency of these novel devices in detecting different biomolecular analytes in a real-time, highly precise, specific, and label-free manner has been validated by numerous research studies. Considerable progress has been attained in designing FET devices, especially for biomedical diagnosis and cell-based assays in the past few decades. The exceptional electronic properties, compactness, and scalability of these novel tools are very desirable for designing rapid, label-free, and mass detection of biomolecules. With the incorporation of nanotechnology, the performance of biosensors based on FET boosts significantly, particularly, employment of nanomaterials such as graphene, metal nanoparticles, single and multi-walled carbon nanotubes, nanorods, and nanowires. Besides, their commercial availability, and high-quality production on a large-scale, turn them to be one of the most preferred sensing and screening platforms. This review presents the basic structural setup and working principle of different types of FET devices. We also focused on the latest progression regarding the use of FET biosensors for the recognition of viruses such as, recently emerged COVID-19, Influenza, Hepatitis B Virus, protein biomarkers, nucleic acids, bacteria, cells, and various ions. Additionally, an outline of the development of FET sensors for investigations related to drug development and the cellular investigation is also presented. Some technical strategies for enhancing the sensitivity and selectivity of detection in these devices are addressed as well. However, there are still certain challenges which are remained unaddressed concerning the performance and clinical use of transistor-based point-of-care (POC) instruments; accordingly, expectations about their future improvement for biosensing and cellular studies are argued at the end of this review.
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Affiliation(s)
- Deniz Sadighbayan
- Biologically Inspired Sensors and Actuators (BioSA), Faculty of Science, Dept. of Biology, York University, Toronto, Canada
- Pharmaceutical Analysis Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Mohammad Hasanzadeh
- Pharmaceutical Analysis Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Ebrahim Ghafar-Zadeh
- Biologically Inspired Sensors and Actuators (BioSA), Faculty of Science, Dept. of Biology, York University, Toronto, Canada
- Dept. of Elecrical Engineering and Computer Science, Lassonde School of Engineering, York University, Toronto, Canada
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12
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Berden J, Steblovnik K, Noc M. Mechanism and extent of myocardial injury associated with out-of-hospital cardiac arrest. Resuscitation 2019; 138:1-7. [DOI: 10.1016/j.resuscitation.2019.02.026] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2018] [Revised: 02/15/2019] [Accepted: 02/20/2019] [Indexed: 11/16/2022]
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13
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Fabbri A, Bachetti C, Ottani F, Morelli A, Benazzi B, Spiezia S, Cortigiani M, Dorizzi R, Jaffe AS, Galvani M. Rapid rule-out of suspected acute coronary syndrome in the Emergency Department by high-sensitivity cardiac troponin T levels at presentation. Intern Emerg Med 2019; 14:403-410. [PMID: 30499074 DOI: 10.1007/s11739-018-1996-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2018] [Accepted: 11/22/2018] [Indexed: 12/22/2022]
Abstract
The reliability of initial high-sensitivity cardiac troponin T (hs-cTnT) under limit-of-detection in ruling-out short- and long-term acute coronary events in subjects for suspected non-ST-segment elevation acute coronary syndrome (NSTE-ACS) is not definitely settled. In a retrospective chart review analysis, 1001 subjects with hs-cTnT ≤ 14 ng/L out of 4053 subjects with hs-cTnT measured at Emergency Department (ED) presentation were recruited. The main outcome measure is fatal or non-fatal myocardial infarction (MI) within 30 days; secondary outcomes are MI or major acute coronary events (MACE) as a combination of MI or re-hospitalization for unstable angina within 1 year. In subjects with hs-cTnT < 5 ng/L [32.6% of cases, mean age 63 years (interquartile range 23)], no cases (0%, NPV 100%) had MI within 30 days, 2 cases (0.6%, NPV 99.4%) MI at 1-year, and 11 cases (3.4%, NPV 96.6%) MACE at 1-year. Patients with hs-cTnT < 5 ng/L would have benefited from a shortened decision (9.30 h and 53% overnight ED stay saved). Hs-cTnT < 5 ng/L is confirmed as safe for patients and comfortable for physicians in ruling out MI or MACE both at short and long term, suggesting that a sizable number of patients can be rapidly discharged without unnecessary diagnostic tests and ED observation.
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Affiliation(s)
- Andrea Fabbri
- Dipartimento Emergenza, Presidio Ospedaliero Morgagni-Pierantoni, Azienda USL della Romagna, Via C Forlanini 34, 47121, Forlì, FC, Italy.
| | - Cristina Bachetti
- Dipartimento Cardio-vascolare, Presidio Ospedaliero Morgagni-Pierantoni, AUSL della Romagna, Via C Forlanini 34, 47121, Forlì, FC, Italy
| | - Filippo Ottani
- Dipartimento Cardio-vascolare, Presidio Ospedaliero Morgagni-Pierantoni, AUSL della Romagna, Via C Forlanini 34, 47121, Forlì, FC, Italy
- Cardiovascular Research Unit, Fondazione Cardiologica Sacco, 47121, Forlì, FC, Italy
| | - Alice Morelli
- Dipartimento Emergenza, Presidio Ospedaliero Morgagni-Pierantoni, Azienda USL della Romagna, Via C Forlanini 34, 47121, Forlì, FC, Italy
| | - Barbara Benazzi
- Dipartimento Emergenza, Presidio Ospedaliero Morgagni-Pierantoni, Azienda USL della Romagna, Via C Forlanini 34, 47121, Forlì, FC, Italy
| | - Sergio Spiezia
- Dipartimento Emergenza, Presidio Ospedaliero Morgagni-Pierantoni, Azienda USL della Romagna, Via C Forlanini 34, 47121, Forlì, FC, Italy
| | - Marco Cortigiani
- Dipartimento Emergenza, Presidio Ospedaliero Morgagni-Pierantoni, Azienda USL della Romagna, Via C Forlanini 34, 47121, Forlì, FC, Italy
| | - Romolo Dorizzi
- Laboratorio Unico AUSL della Romagna, Piazzale della Liberazione 60, Pievesestina di Cesena, FC, Italy
| | - Allan S Jaffe
- Cardiovascular Department and Department of Laboratory Medicine and Pathology, Mayo Clinic and Medical School, 200 First St. SW, Rochester, MN, 55905, USA
| | - Marcello Galvani
- Dipartimento Cardio-vascolare, Presidio Ospedaliero Morgagni-Pierantoni, AUSL della Romagna, Via C Forlanini 34, 47121, Forlì, FC, Italy
- Cardiovascular Research Unit, Fondazione Cardiologica Sacco, 47121, Forlì, FC, Italy
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14
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High-sensitivity troponin T in preterm infants with a hemodynamically significant patent ductus arteriosus. J Perinatol 2018; 38:1483-1489. [PMID: 30171214 DOI: 10.1038/s41372-018-0192-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2017] [Revised: 05/02/2018] [Accepted: 06/05/2018] [Indexed: 11/08/2022]
Abstract
OBJECTIVE To investigate if a hemodynamically significant patent ductus arteriosus (hsPDA) leads to elevated high-sensitivity troponin T (hsTnT) and NTproBNP levels in serum. STUDY DESIGN Infants <34 weeks and <1500 g were prospectively enrolled, except those with major congenital or chromosomal anomalies. An echocardiogram (ECHO) was performed and hsTnT and NTproBNP were measured within 5 days of life and repeated after treatment of hsPDA. Clinical, ECHO, and hsTnT data were analyzed using Student t-test, two proportion z-test, and regression analysis. RESULTS Seventy infants were enrolled. Infants in the hsPDA group had lower gestation and birth weight. Mean hsTnT and NTproBNP levels in the hsPDA group were higher compared to the group without an hsPDA, with levels being 251.54 vs 161.6 pg/ml, p < 0.01 for hsTnT and 18181.02 vs 3149.23 pg/ml, p < 0.001 for NTproBNP. CONCLUSION HsPDA leads to increased hsTnT and NTproBNP levels in preterm infants without affecting cardiac function.
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15
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Soeiro ADM, Gualandro DM, Bossa AS, Zullino CN, Biselli B, Soeiro MCFDA, Leal TDCAT, Serrano CV, Oliveira Junior MTD. Sensitive Troponin I Assay in Patients with Chest Pain - Association with Significant Coronary Lesions with or Without Renal Failure. Arq Bras Cardiol 2018. [PMID: 29538525 PMCID: PMC5831304 DOI: 10.5935/abc.20170182] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Introduction Despite having higher sensitivity as compared to conventional troponins,
sensitive troponins have lower specificity, mainly in patients with renal
failure. Objective Study aimed at assessing the sensitive troponin I levels in patients with
chest pain, and relating them to the existence of significant coronary
lesions. Methods Retrospective, single-center, observational. This study included 991 patients
divided into two groups: with (N = 681) and without (N = 310) significant
coronary lesion. For posterior analysis, the patients were divided into two
other groups: with (N = 184) and without (N = 807) chronic renal failure.
The commercial ADVIA Centaur® TnI-Ultra assay (Siemens
Healthcare Diagnostics) was used. The ROC curve analysis was performed to
identify the sensitivity and specificity of the best cutoff point of
troponin as a discriminator of the probability of significant coronary
lesion. The associations were considered significant when p < 0.05. Results The median age was 63 years, and 52% of the patients were of the male sex.
The area under the ROC curve between the troponin levels and significant
coronary lesions was 0.685 (95% CI: 0.65 - 0.72). In patients with or
without renal failure, the areas under the ROC curve were 0.703 (95% CI:
0.66 - 0.74) and 0.608 (95% CI: 0.52 - 0.70), respectively. The best cutoff
points to discriminate the presence of significant coronary lesion were: in
the general population, 0.605 ng/dL (sensitivity, 63.4%; specificity, 67%);
in patients without renal failure, 0.605 ng/dL (sensitivity, 62.7%;
specificity, 71%); and in patients with chronic renal failure, 0.515 ng/dL
(sensitivity, 80.6%; specificity, 42%). Conclusion In patients with chest pain, sensitive troponin I showed a good correlation
with significant coronary lesions when its level was greater than 0.605
ng/dL. In patients with chronic renal failure, a significant decrease in
specificity was observed in the correlation of troponin levels and severe
coronary lesions.
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Affiliation(s)
| | | | | | | | - Bruno Biselli
- Unidade Clínica de Emergência - InCor - HCFMUSP, São Paulo, SP - Brazil
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16
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Xue K, Gu JJ, Zhang Q, Liu X, Wang J, Li XQ, Luo J, Hernandez-Ilizaliturri FJ, Fernandez SF, Czuczman MS, Cao J, Hong X, Guo Y. Cardiotoxicity as indicated by LVEF and troponin T sensitivity following two anthracycline-based regimens in lymphoma: Results from a randomized prospective clinical trial. Oncotarget 2018; 7:32519-31. [PMID: 27081036 PMCID: PMC5078030 DOI: 10.18632/oncotarget.8685] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2015] [Accepted: 03/28/2016] [Indexed: 12/02/2022] Open
Abstract
Anthracycline-induced cardiotoxicity influences treatment selection and may negatively affect clinical outcomes in lymphoma patients. While epirubicin induced cardiotoxicity less often than the same dose of doxorubicin in breast cancer, higher doses of epirubicin are required in lymphoma regimens for equivalent efficacy. Whether a higher dosage of epirubicin also induces cardiotoxicity less often than doxorubicin in lymphoma remains unknown. We therefore administered 6-8 cycles of cyclophosphamide, vincristine and prednisone (CEpOP) +/− rituximab (R) with either epirubicin (CEpOP) or doxorubicin (CHOP) to patients (N=398) with untreated diffuse large B-cell lymphoma (DLBCL) or follicular lymphoma grade 3 (FLG3). Left ventricular ejection fraction (LVEF) and high-sensitivity serum cardiac troponin T (HsTnT) were assessed at baseline and after 4 cycles of treatment. Epirubicin (70 mg/m2/dose) was equivalent to doxorubicin (50 mg/m2/dose) in terms of 3-year progression-free survival. The risk of decreased LVEF was similar between the two regimens. CEpOP+/−R induced HsTnT elevation less often than CHOP+/−R. We conclude that CEpOP+/−R is a more acceptable regimen with short-term efficacy similar to CHOP+/−R in lymphoma patients. Longer follow-up is needed to monitor the risk of cardiac dysfunction and determine whether differences in the induction of elevated HsTnT between epirubicin and doxorubicin justify changes in clinical practice.
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Affiliation(s)
- Kai Xue
- Department of Medical Oncology, Fudan University Shanghai Cancer Center, Shanghai, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - Juan J Gu
- Department of Medicine & Immunology, Roswell Park Cancer Institute, Buffalo, NY, USA
| | - Qunling Zhang
- Department of Medical Oncology, Fudan University Shanghai Cancer Center, Shanghai, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - Xiaojian Liu
- Department of Medical Oncology, Fudan University Shanghai Cancer Center, Shanghai, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - Jiachen Wang
- Department of Medical Oncology, Fudan University Shanghai Cancer Center, Shanghai, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - Xiao-Qiu Li
- Department of Pathology, Fudan University Shanghai Cancer Center, Shanghai, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - Jianfeng Luo
- Department of Biostatistics, School of Public Health, Fudan University, Shanghai, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | | | - Stanley F Fernandez
- Department of Medicine, University at Buffalo, The State University of New York, Buffalo, NY, USA
| | - Myron S Czuczman
- Department of Medicine & Immunology, Roswell Park Cancer Institute, Buffalo, NY, USA
| | - Junning Cao
- Department of Medical Oncology, Fudan University Shanghai Cancer Center, Shanghai, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - Xiaonan Hong
- Department of Medical Oncology, Fudan University Shanghai Cancer Center, Shanghai, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - Ye Guo
- Department of Medical Oncology, Fudan University Shanghai Cancer Center, Shanghai, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
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17
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Shah ASV, Sandoval Y, Noaman A, Sexter A, Vaswani A, Smith SW, Gibbins M, Griffiths M, Chapman AR, Strachan FE, Anand A, Denvir MA, Adamson PD, D'Souza MS, Gray AJ, McAllister DA, Newby DE, Apple FS, Mills NL. Patient selection for high sensitivity cardiac troponin testing and diagnosis of myocardial infarction: prospective cohort study. BMJ 2017; 359:j4788. [PMID: 29114078 PMCID: PMC5683043 DOI: 10.1136/bmj.j4788] [Citation(s) in RCA: 86] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/11/2017] [Indexed: 12/28/2022]
Abstract
Objective To evaluate how selection of patients for high sensitivity cardiac troponin testing affects the diagnosis of myocardial infarction across different healthcare settings.Design Prospective study of three independent consecutive patient populations presenting to emergency departments.Setting Secondary and tertiary care hospitals in the United Kingdom and United States.Participants High sensitivity cardiac troponin I concentrations were measured in 8500 consecutive patients presenting to emergency departments: unselected patients in the UK (n=1054) and two selected populations of patients in whom troponin testing was requested by the attending clinician in the UK (n=5815) and the US (n=1631). The final diagnosis of type 1 or type 2 myocardial infarction or myocardial injury was independently adjudicated.Main outcome measures Positive predictive value of an elevated cardiac troponin concentration for a diagnosis of type 1 myocardial infarction.Results Cardiac troponin concentrations were elevated in 13.7% (144/1054) of unselected patients, with a prevalence of 1.6% (17/1054) for type 1 myocardial infarction and a positive predictive value of 11.8% (95% confidence interval 7.0% to 18.2%). In selected patients, in whom troponin testing was guided by the attending clinician, the prevalence and positive predictive value were 14.5% (843/5815) and 59.7% (57.0% to 62.2%) in the UK and 4.2% (68/1631) and 16.4% (13.0% to 20.3%) in the US. Across both selected patient populations, the positive predictive value was highest in patients with chest pain, with ischaemia on the electrocardiogram, and with a history of ischaemic heart disease.Conclusions When high sensitivity cardiac troponin testing is performed widely or without previous clinical assessment, elevated troponin concentrations are common and predominantly reflect myocardial injury rather than myocardial infarction. These observations highlight how selection of patients for cardiac troponin testing varies across healthcare settings and markedly influences the positive predictive value for a diagnosis of myocardial infarction.
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Affiliation(s)
- Anoop S V Shah
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh EH16 4SB, UK
| | - Yader Sandoval
- Division of Cardiology, Hennepin County Medical Center and Minneapolis Heart Institute, Abbott Northwestern Hospital, Minneapolis, MN, USA
| | - Ala Noaman
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh EH16 4SB, UK
| | - Anne Sexter
- Chronic Disease Research Group of Minneapolis Medical Research Foundation, Hennepin County Medical Center and University of Minnesota, Minneapolis, MN, USA
| | - Amar Vaswani
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh EH16 4SB, UK
| | - Stephen W Smith
- Department of Emergency Medicine, Hennepin County Medical Center and University of Minnesota, Minneapolis, Minnesota, USA
| | - Mathew Gibbins
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh EH16 4SB, UK
| | - Megan Griffiths
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh EH16 4SB, UK
| | - Andrew R Chapman
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh EH16 4SB, UK
| | - Fiona E Strachan
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh EH16 4SB, UK
| | - Atul Anand
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh EH16 4SB, UK
| | - Martin A Denvir
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh EH16 4SB, UK
| | - Philip D Adamson
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh EH16 4SB, UK
| | - Michelle S D'Souza
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh EH16 4SB, UK
| | - Alasdair J Gray
- Emergency Medicine Research Group Edinburgh (EMeRGE) and Department of Emergency Medicine, Royal Infirmary of Edinburgh, Edinburgh, UK
| | | | - David E Newby
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh EH16 4SB, UK
| | - Fred S Apple
- Department of Laboratory Medicine and Pathology, Hennepin County Medical Center and University of Minnesota, Minneapolis, MN, USA
| | - Nicholas L Mills
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh EH16 4SB, UK
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18
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Wang Q, Ma J, Jiang Z, Wu F, Ping J, Ming L. Identification of microRNAs as diagnostic biomarkers for acute myocardial infarction in Asian populations: A systematic review and meta-analysis. Medicine (Baltimore) 2017; 96:e7173. [PMID: 28614255 PMCID: PMC5478340 DOI: 10.1097/md.0000000000007173] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Acute myocardial infarction (AMI) is one of the leading causes of mortality and morbidity worldwide. Recently, several studies have revealed the diagnostic value of circulating microRNAs (miRNAs) for AMI detection. However, the diagnostic capacity of miRNAs for AMI is still controversial due to the inconsistent results among studies. METHODS A systematic literature search was conducted to retrieve relevant articles in PubMed and other databases up to February 2017. The pooled sensitivity, specificity, positive likelihood ratio (PLR), negative likelihood ratio (NLR), diagnostic odds ratio (DOR), and area under the curve (AUC) were used to assess the overall test performance of miRNAs. Subgroup analysis was conducted to explore the potential sources of heterogeneity. We evaluated the publication bias by the Deeks' funnel plot asymmetry test and all statistical analyses were performed using Meta-disc 1.4 and Stata software. RESULTS A total of 26 articles comprising 1973 AMI patients and 1236 healthy controls were included in this meta-analysis. The overall pooled diagnostic data was as follows: the pooled sensitivity of 0.76 (95% confidence interval [CI]: 0.75-0.78), the pooled specificity of 0.82 (95% CI: 0.81-0.84), the pooled PLR of 4.68 (95% CI: 3.92-5.59), the pooled NLR of 0.28 (95% CI: 0.25-0.32), and the pooled DOR of 18.66 (95% CI: 14.11-24.68). The AUC value was 0.8661 in the overall summary receiver operator characteristic curve. Subgroup analysis indicated that miRNA-499 had better diagnostic accuracy over other miRNAs. CONCLUSION MiRNAs may serve as promising diagnostic biomarkers in the early diagnosis of AMI. Further studies were needed to evaluate the diagnostic value of miRNAs for AMI before clinical application.
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Affiliation(s)
- Qian Wang
- Department of Clinical Laboratory, The First Affiliated Hospital of Zhengzhou University
- Key Laboratory of Laboratory Medicine of Henan Province, Zhengzhou, Henan, China
| | - Junfen Ma
- Department of Clinical Laboratory, The First Affiliated Hospital of Zhengzhou University
- Key Laboratory of Laboratory Medicine of Henan Province, Zhengzhou, Henan, China
| | - Zhiyun Jiang
- Department of Clinical Laboratory, The First Affiliated Hospital of Zhengzhou University
- Key Laboratory of Laboratory Medicine of Henan Province, Zhengzhou, Henan, China
| | - Fan Wu
- Department of Clinical Laboratory, The First Affiliated Hospital of Zhengzhou University
- Key Laboratory of Laboratory Medicine of Henan Province, Zhengzhou, Henan, China
| | - Jiedan Ping
- Department of Clinical Laboratory, The First Affiliated Hospital of Zhengzhou University
- Key Laboratory of Laboratory Medicine of Henan Province, Zhengzhou, Henan, China
| | - Liang Ming
- Department of Clinical Laboratory, The First Affiliated Hospital of Zhengzhou University
- Key Laboratory of Laboratory Medicine of Henan Province, Zhengzhou, Henan, China
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19
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Song FY, Shi J, Guo Y, Zhang CJ, Xu YC, Zhang QL, Shu XH, Cheng LL. Assessment of biventricular systolic strain derived from the two-dimensional and three-dimensional speckle tracking echocardiography in lymphoma patients after anthracycline therapy. Int J Cardiovasc Imaging 2017; 33:857-868. [PMID: 28255826 DOI: 10.1007/s10554-017-1082-6] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2016] [Accepted: 01/24/2017] [Indexed: 12/25/2022]
Abstract
The aim of this study was to investigate the usefulness of three-dimensional (3D) speckle tracking echocardiography (STE) for assessment of both left and right ventricular systolic function in patients with lymphoma after anthracycline chemotherapy, compared with two-dimensional (2D) STE. Totally eighty-nine patients undergoing anthracycline containing chemotherapy were studied. Echocardiographic assessment included 2D and 3D left ventricular (LV) global longitudinal strain (GLS), global circumferential strain (GCS) and right ventricular (RV) GLS. All the parameters were analyzed at baseline, after the completion of four cycles and at the end of the regimen respectively. The area under the receiver operating characteristic curve was calculated to determine the capability of various echocardiographic parameters to discriminate between before and after chemotherapy. Compared with those at baseline, the 3D GLS and GCS of LV and GLS of RV decreased significantly after four cycles of the therapy (all p < 0.01). At the end of the treatment, 2D GLS and GCS of LV deteriorated markedly (both p < 0.05). The area under the curve for GLS, GCS of LV and GLS of RV derived by 3D were 0.81, 0.66 and 0.78, respectively. The cutoff value with -20.4% of LV GLS by 3D had sensitivity of 81% and specificity of 66% for differentiating patients after therapy from baselines. The cutoff value with -21.9% of RV GLS by 3D had sensitivity of 71% and specificity of 74% fordifferentiating patients after therapy from baselines. The data from this study demonstrated that both 2D and 3D STE can be conducted to evaluate the slight myocardial damage for lymphoma patients after anthracycline chemotherapy. 3D STE could examine subclinical biventricular dysfunction in earlier point than 2D STE.
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MESH Headings
- Adult
- Aged
- Anthracyclines/adverse effects
- Antibiotics, Antineoplastic/adverse effects
- Area Under Curve
- Biomarkers/blood
- Biomechanical Phenomena
- Cardiotoxicity
- Early Diagnosis
- Echocardiography, Doppler, Pulsed
- Echocardiography, Three-Dimensional
- Female
- Heart Diseases/blood
- Heart Diseases/chemically induced
- Heart Diseases/diagnostic imaging
- Heart Diseases/physiopathology
- Humans
- Image Interpretation, Computer-Assisted
- Lymphoma, Large B-Cell, Diffuse/drug therapy
- Male
- Middle Aged
- Observer Variation
- Predictive Value of Tests
- Prospective Studies
- ROC Curve
- Reproducibility of Results
- Risk Factors
- Stress, Mechanical
- Systole
- Time Factors
- Ventricular Function, Left/drug effects
- Ventricular Function, Right/drug effects
- Young Adult
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Affiliation(s)
- Fei-Yan Song
- Department of Echocardiography, Zhongshan Hospital, Shanghai Institute of Cardiovascular Diseases, Shanghai Institute of Medical Imaging, Fudan University, 180 Fenglin Road, Shanghai, 200032, China
| | - Jing Shi
- Department of Echocardiography, Zhongshan Hospital, Shanghai Institute of Cardiovascular Diseases, Shanghai Institute of Medical Imaging, Fudan University, 180 Fenglin Road, Shanghai, 200032, China
| | - Ye Guo
- Department of Medical Oncology, Fudan University Shanghai Cancer Center, 270 Dongan Road, Shanghai, 200032, China.
| | - Chu-Jie Zhang
- Department of Echocardiography, Zhongshan Hospital, Shanghai Institute of Cardiovascular Diseases, Shanghai Institute of Medical Imaging, Fudan University, 180 Fenglin Road, Shanghai, 200032, China
| | - Yu-Chen Xu
- Department of Echocardiography, Zhongshan Hospital, Shanghai Institute of Cardiovascular Diseases, Shanghai Institute of Medical Imaging, Fudan University, 180 Fenglin Road, Shanghai, 200032, China
| | - Qun-Ling Zhang
- Department of Medical Oncology, Fudan University Shanghai Cancer Center, 270 Dongan Road, Shanghai, 200032, China
| | - Xian-Hong Shu
- Department of Echocardiography, Zhongshan Hospital, Shanghai Institute of Cardiovascular Diseases, Shanghai Institute of Medical Imaging, Fudan University, 180 Fenglin Road, Shanghai, 200032, China
| | - Lei-Lei Cheng
- Department of Echocardiography, Zhongshan Hospital, Shanghai Institute of Cardiovascular Diseases, Shanghai Institute of Medical Imaging, Fudan University, 180 Fenglin Road, Shanghai, 200032, China.
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Omar AS, Mahmoud K, Hanoura S, Osman H, Sivadasan P, Sudarsanan S, Shouman Y, Singh R, AlKhulaifi A. Acute kidney injury induces high-sensitivity troponin measurement changes after cardiac surgery. BMC Anesthesiol 2017; 17:15. [PMID: 28143401 PMCID: PMC5282923 DOI: 10.1186/s12871-017-0307-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2016] [Accepted: 01/19/2017] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND The value of cardiac troponin as a risk assessment tool for cardiac disease in the setting of end-stage renal diseases (ESRD) is not equivalent to its value in those with normal renal function. This consideration had not been studied in settings of acute kidney injury (AKI). We aim to explore the diagnostic value of high sensitive troponin T (hsTnT) in the settings of cardiac surgery-induced AKI. METHODS Single center observational retrospective study. Based on the AKI Network, patients divided into 2 groups, group I without AKI (259 patients) and group II with AKI (100 patients) where serial testing of hsTnT and creatine kinase (CK)-MB were followed in both groups. Patients with (ESRD) were excluded. RESULTS The mean age in our study was 55.1 ± 10.2 years. High association of AKI (27.8%) was found in our patients. Both groups were matched regarding the age, gender, body mass index, the association of diabetes or hypertension, and Euro score. AKI group had significantly higher mortality 5% vs group I 1.1% (p = 0.03). The hsTnt showed a significant sustained rise in the AKI group as compared to the non-AKI group, however CK-MB changes were significant initially but not sustained. The AKI group was more associated with heart failure 17.9% vs 4.9% (p = 0.001); and post-operative atrial fibrillation, 12.4% vs 2.9% (p = 0.005). Lengths of ventilation, stays in ICU and in hospital were significantly higher in the AKI group. CONCLUSIONS Unlike the CK-MB profile, the hsTnT showed significant changes between both groups all over the course denoting possible delayed clearance in patients with AKI.
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Affiliation(s)
- Amr S Omar
- Department of Cardiothoracic Surgery/Cardiac Anaesthesia and ICU, Heart Hospital, Hamad Medical Corporation, Doha, PO 3050, Qatar. .,Department of Critical Care Medicine, Beni Suef University, Beni Suef, Egypt. .,Weill Cornell Medical College-Qatar, Doha, Qatar.
| | - Khaled Mahmoud
- Weill Cornell Medical College-Qatar, Doha, Qatar.,Department of Nephrology, Hamad Medical Corporation, Doha, PO 3050, Qatar.,Department of Nephrology, Faculty of Medicine, Mansoura University, Mansoura, Egypt
| | - Samy Hanoura
- Department of Cardiothoracic Surgery/Cardiac Anaesthesia and ICU, Heart Hospital, Hamad Medical Corporation, Doha, PO 3050, Qatar.,Weill Cornell Medical College-Qatar, Doha, Qatar.,Department of Anesthesia, Al-Azhar University, Cairo, Egypt
| | - Hany Osman
- Department of Cardiothoracic Surgery/Cardiac Anaesthesia and ICU, Heart Hospital, Hamad Medical Corporation, Doha, PO 3050, Qatar.,Department of Anesthesia, Al-Azhar University, Cairo, Egypt
| | - Praveen Sivadasan
- Department of Cardiothoracic Surgery/Cardiac Anaesthesia and ICU, Heart Hospital, Hamad Medical Corporation, Doha, PO 3050, Qatar
| | - Suraj Sudarsanan
- Department of Cardiothoracic Surgery/Cardiac Anaesthesia and ICU, Heart Hospital, Hamad Medical Corporation, Doha, PO 3050, Qatar
| | - Yasser Shouman
- Department of Cardiothoracic Surgery/Cardiac Anaesthesia and ICU, Heart Hospital, Hamad Medical Corporation, Doha, PO 3050, Qatar
| | - Rajvir Singh
- Department of Cardiology Research Center, Hamad Medical Corporation, Doha, Qatar
| | - Abdulaziz AlKhulaifi
- Department of Cardiothoracic Surgery/Cardiac Anaesthesia and ICU, Heart Hospital, Hamad Medical Corporation, Doha, PO 3050, Qatar
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Markman PL, Tantiongco JP, Bennetts JS, Baker RA. High-Sensitivity Troponin Release Profile After Cardiac Surgery. Heart Lung Circ 2016; 26:833-839. [PMID: 28131774 DOI: 10.1016/j.hlc.2016.09.017] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2016] [Accepted: 09/06/2016] [Indexed: 01/11/2023]
Abstract
BACKGROUND Postoperative serum troponin levels and perioperative myocardial infarction (MI) rates correlate with mortality and morbidity following cardiac surgery. The objective of this study was to document the release profile of high sensitivity troponin T (hsTnT) following different cardiac operations. METHODS Patients undergoing one of five different isolated cardiac surgical procedures (eligible preoperative hsTnT <29ng/L, serum creatinine < 0.2mmol/L) were recruited prospectively. Serum hsTnT was measured at 0, 4, 6, 8, 10, 12, 24 and 72hours after the first surgical insult to myocardium, together with daily electrocardiographs. RESULTS There were 10 patients in the on-pump coronary artery bypass group and 5 each in the remaining groups (off-pump coronary artery bypass, open aortic valve replacement, transcutaneous aortic valve implantation and mitral valve replacement). Five additional patients were excluded due to perioperative MI or renal failure. Median [range] of peak hsTnT was 241[99-566], 64[50-136], 353[307-902], 115[112-275], and 918[604-1166] ng/L, respectively. Operations with the lowest peak hsTnT values peaked earliest (four hours) while those with highest values peaked latest (eight hours). CONCLUSION After cardiac surgery, the hsTnT profile peaks four to eight hours after the initial surgical insult. The magnitude and timing of the peak correlates to the expected degree of surgically-induced myocardial injury.
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Affiliation(s)
| | - John-Paul Tantiongco
- Flinders Medical Centre, Adelaide, SA, Australia; Flinders University, Adelaide, SA, Australia
| | - Jayme S Bennetts
- Flinders Medical Centre, Adelaide, SA, Australia; Flinders University, Adelaide, SA, Australia
| | - Robert A Baker
- Flinders Medical Centre, Adelaide, SA, Australia; Flinders University, Adelaide, SA, Australia.
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22
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Mokhtari A, Lindahl B, Smith JG, Holzmann MJ, Khoshnood A, Ekelund U. Diagnostic Accuracy of High-Sensitivity Cardiac Troponin T at Presentation Combined With History and ECG for Ruling Out Major Adverse Cardiac Events. Ann Emerg Med 2016; 68:649-658.e3. [DOI: 10.1016/j.annemergmed.2016.06.008] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2016] [Revised: 05/22/2016] [Accepted: 06/03/2016] [Indexed: 11/26/2022]
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23
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Chenevier-Gobeaux C, Meune C, Lefevre G, Doumenc B, Sorbets E, Peschanski N, Ray P. A single value of high-sensitive troponin T below the limit of detection is not enough for ruling out non ST elevation myocardial infarction in the emergency department. Clin Biochem 2016; 49:1113-1117. [PMID: 27234598 DOI: 10.1016/j.clinbiochem.2016.05.021] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2016] [Revised: 05/19/2016] [Accepted: 05/20/2016] [Indexed: 11/17/2022]
Abstract
BACKGROUND Recent 2015 ESC recommendations for the management of patients with suspected acute myocardial infarction (AMI) support that a single value of high-sensitivity cardiac troponin (HS-cTn) measured at presentation could rule out AMI if below the limit of blank (LoB) or detection (LoD). OBJECTIVES We aimed to evaluate whether an undetectable HS-cTnT at presentation safely rules out NSTEMI in unselected patients with chest pain. PATIENTS AND METHODS This is a post hoc analysis of two prospective cohorts with similar design that included patients suspected of AMI at three French university hospitals. Patients were followed-up during one month, before the adjudication of a final diagnosis. RESULTS 413 patients (mean age 58±17years) were analyzed; 45 (11%) had a final diagnosis of NSTEMI, and 26 (6%) had STEMI. The sensitivity of HS-cTnT value at 3ng/L (LoB) for NSTEMI was 97.8% [95% CI: 86.8-99.9], yielding a negative predictive value (NPV) of 99.3% [95% CI: 95.4-100.0]. Proportion of patients ruled out for NSTEMI was 32% when applying the LoB. The sensitivity of HS-cTnT value at 5ng/L (LoD) was 97.8% [95% CI: 86.8-99.9] yielding a NPV of 99.5% [95% CI: 96.5-100.0]. Proportion of patients ruled out for NSTEMI was 43% when applying the LoD. One patient (delay between onset of chest pain and presentation <3h) had NSTEMI and HS-cTnT <LoB at presentation. CONCLUSION The NPV of a single measurement of HS-cTnT below the LoD is high in unselected patients, but not enough to rule out safely NSTEMI for very early presenters.
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Affiliation(s)
- Camille Chenevier-Gobeaux
- Department of Automated Biological Diagnosis, Hôpital Cochin, Hôpitaux Universitaires Paris Centre (HUPC), Assistance Publique des Hôpitaux de Paris (AP-HP), 75014 Paris Cedex, France.
| | - Christophe Meune
- Department of Cardiology, Hôpital Avicenne, Hôpitaux Universitaires Paris Seine Saint Denis, Assistance Publique des Hôpitaux de Paris (AP-HP), Bobigny, Université Paris 13, UMR S-942, Paris, France
| | - Guillaume Lefevre
- Department of Biochemistry and Hormonology, Hôpital Tenon, Hôpitaux Universitaires est Parisiens (HUEP), Assistance Publique des Hôpitaux de Paris (AP-HP), 4 Rue de la Chine, 75020 Paris, France
| | - Benoit Doumenc
- Department of Emergency Medicine, Hôpital Cochin, Hôpitaux Universitaires Paris Centre (HUPC), Assistance Publique des Hôpitaux de Paris (AP-HP), 75014 Paris Cedex, France; Université Paris Descartes, France
| | - Emmanuel Sorbets
- Department of Cardiology, Hôpital Avicenne, Hôpitaux Universitaires Paris Seine Saint Denis, Assistance Publique des Hôpitaux de Paris (AP-HP), Bobigny, Université Paris 13, UMR S-942, Paris, France
| | - Nicolas Peschanski
- Department of Emergency Medicine, Hôpital Tenon, Hôpitaux Universitaires est Parisiens (HUEP), Assistance Publique des Hôpitaux de Paris (AP-HP), 4 Rue de la Chine, 75020 Paris, France
| | - Patrick Ray
- Department of Emergency Medicine, Hôpital Tenon, Hôpitaux Universitaires est Parisiens (HUEP), Assistance Publique des Hôpitaux de Paris (AP-HP), 4 Rue de la Chine, 75020 Paris, France; Sorbonne Universités UMPC Université Paris 06, Paris, DHU Fighting Aging and Stress (FAST) Université Pierre et Marie Curie Paris 6, France
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24
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Westwood M, van Asselt T, Ramaekers B, Whiting P, Thokala P, Joore M, Armstrong N, Ross J, Severens J, Kleijnen J. High-sensitivity troponin assays for the early rule-out or diagnosis of acute myocardial infarction in people with acute chest pain: a systematic review and cost-effectiveness analysis. Health Technol Assess 2016; 19:1-234. [PMID: 26118801 DOI: 10.3310/hta19440] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Early diagnosis of acute myocardial infarction (AMI) can ensure quick and effective treatment but only 20% of adults with emergency admissions for chest pain have an AMI. High-sensitivity cardiac troponin (hs-cTn) assays may allow rapid rule-out of AMI and avoidance of unnecessary hospital admissions and anxiety. OBJECTIVE To assess the clinical effectiveness and cost-effectiveness of hs-cTn assays for the early (within 4 hours of presentation) rule-out of AMI in adults with acute chest pain. METHODS Sixteen databases, including MEDLINE and EMBASE, research registers and conference proceedings, were searched to October 2013. Study quality was assessed using QUADAS-2. The bivariate model was used to estimate summary sensitivity and specificity for meta-analyses involving four or more studies, otherwise random-effects logistic regression was used. The health-economic analysis considered the long-term costs and quality-adjusted life-years (QALYs) associated with different troponin (Tn) testing methods. The de novo model consisted of a decision tree and Markov model. A lifetime time horizon (60 years) was used. RESULTS Eighteen studies were included in the clinical effectiveness review. The optimum strategy, based on the Roche assay, used a limit of blank (LoB) threshold in a presentation sample to rule out AMI [negative likelihood ratio (LR-) 0.10, 95% confidence interval (CI) 0.05 to 0.18]. Patients testing positive could then have a further test at 2 hours; a result above the 99th centile on either sample and a delta (Δ) of ≥ 20% has some potential for ruling in an AMI [positive likelihood ratio (LR+) 8.42, 95% CI 6.11 to 11.60], whereas a result below the 99th centile on both samples and a Δ of < 20% can be used to rule out an AMI (LR- 0.04, 95% CI 0.02 to 0.10). The optimum strategy, based on the Abbott assay, used a limit of detection (LoD) threshold in a presentation sample to rule out AMI (LR- 0.01, 95% CI 0.00 to 0.08). Patients testing positive could then have a further test at 3 hours; a result above the 99th centile on this sample has some potential for ruling in an AMI (LR+ 10.16, 95% CI 8.38 to 12.31), whereas a result below the 99th centile can be used to rule out an AMI (LR- 0.02, 95% CI 0.01 to 0.05). In the base-case analysis, standard Tn testing was both most effective and most costly. Strategies considered cost-effective depending upon incremental cost-effectiveness ratio thresholds were Abbott 99th centile (thresholds of < £6597), Beckman 99th centile (thresholds between £6597 and £30,042), Abbott optimal strategy (LoD threshold at presentation, followed by 99th centile threshold at 3 hours) (thresholds between £30,042 and £103,194) and the standard Tn test (thresholds over £103,194). The Roche 99th centile and the Roche optimal strategy [LoB threshold at presentation followed by 99th centile threshold and/or Δ20% (compared with presentation test) at 1-3 hours] were extendedly dominated in this analysis. CONCLUSIONS There is some evidence to suggest that hs-CTn testing may provide an effective and cost-effective approach to early rule-out of AMI. Further research is needed to clarify optimal diagnostic thresholds and testing strategies. STUDY REGISTRATION This study is registered as PROSPERO CRD42013005939. FUNDING The National Institute for Health Research Health Technology Assessment programme.
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Affiliation(s)
| | - Thea van Asselt
- Department of Clinical Epidemiology and Medical Technology Assessment, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Bram Ramaekers
- Department of Clinical Epidemiology and Medical Technology Assessment, Maastricht University Medical Centre, Maastricht, The Netherlands
| | | | - Praveen Thokala
- Health Economics and Decision Science Group, School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Manuela Joore
- Department of Clinical Epidemiology and Medical Technology Assessment, Maastricht University Medical Centre, Maastricht, The Netherlands
| | | | | | - Johan Severens
- Institute of Health Policy and Management, Erasmus University Rotterdam, Rotterdam, The Netherlands
| | - Jos Kleijnen
- School for Public Health and Primary Care (CAPHRI), Maastricht University, Maastricht, The Netherlands
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25
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The diagnostic utility of High-Sensitivity Cardiac Troponin T in acute coronary syndrome. Egypt Heart J 2016. [DOI: 10.1016/j.ehj.2014.12.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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26
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Ricci F, Di Scala R, Massacesi C, Di Nicola M, Cremonese G, De Pace D, Rossi S, Griffo I, Cataldo I, Martinotti S, Rotondo D, Jaffe AS, Zimarino M, De Caterina R. Ultra-Sensitive Copeptin and Cardiac Troponin in Diagnosing Non-ST-Segment Elevation Acute Coronary Syndromes--The COPACS Study. Am J Med 2016; 129:105-14. [PMID: 26169889 DOI: 10.1016/j.amjmed.2015.06.033] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2015] [Revised: 06/13/2015] [Accepted: 06/15/2015] [Indexed: 11/15/2022]
Abstract
OBJECTIVES We tested the noninferiority of a fast-track rule-out protocol for the diagnosis of non-ST-segment elevation myocardial infarction vs noncoronary chest pain based on the single-sampling combined assessment of medium-sensitivity cardiac troponin I and ultra-sensitive copeptin compared with the serial assessment of medium-sensitivity cardiac troponin I. METHODS Ultra-sensitive copeptin and medium-sensitivity cardiac troponin I levels were measured at presentation in 196 consecutive patients admitted to the emergency department for acute nontraumatic chest pain within 6 hours from symptoms onset and without ST-segment elevation on a 12-lead electrocardiogram. The diagnostic performance for non-ST-segment elevation myocardial infarction diagnosis of the dual-marker single-sampling strategy with medium-sensitivity cardiac troponin I and ultra-sensitive copeptin on admission was compared with that of the serial 0- and 3-hour medium-sensitivity cardiac troponin I sampling in reference to the adjudicated postdischarge diagnosis, using both the comparison of area under the curve (AUC) receiver operating characteristic and the McNemar chi-square test. RESULTS The diagnosis of non-ST-segment elevation myocardial infarction was adjudicated in 29 patients (14.8%). The combination of medium-sensitivity cardiac troponin I and ultra-sensitive copeptin generated an AUC of 0.87 (95% confidence interval, 0.82-0.91), which was noninferior with respect to the 3-hour interval medium-sensitivity cardiac troponin I serial sampling (P = .194 for AUC difference). The combination of medium-sensitivity cardiac troponin I and ultra-sensitive copeptin also yielded a numerically higher diagnostic sensitivity (100% vs 89.7%; P = not significant). CONCLUSIONS A single-sampling strategy of combined ultra-sensitive copeptin and medium-sensitivity cardiac troponin I is noninferior to a 0- and 3-hour serial medium-sensitivity cardiac troponin I sampling in ruling out non-ST-segment elevation myocardial infarction and thus may allow an earlier discharge of patients who are ruled out for non-ST-segment elevation myocardial infarction (ClinicalTrials.gov Identifier NCT01962506).
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Affiliation(s)
- Fabrizio Ricci
- Institute of Cardiology and Center of Excellence on Aging, "G. d'Annunzio" University, Chieti, Italy
| | - Rosa Di Scala
- Institute of Cardiology and Center of Excellence on Aging, "G. d'Annunzio" University, Chieti, Italy
| | - Cristiano Massacesi
- Institute of Cardiology and Center of Excellence on Aging, "G. d'Annunzio" University, Chieti, Italy
| | - Marta Di Nicola
- Laboratory of Biostatistics, Department of Experimental and Clinical Science, "G. d'Annunzio" University, Chieti, Italy
| | - Gianni Cremonese
- Institute of Cardiology and Center of Excellence on Aging, "G. d'Annunzio" University, Chieti, Italy
| | - Doranna De Pace
- Institute of Cardiology and Center of Excellence on Aging, "G. d'Annunzio" University, Chieti, Italy
| | - Serena Rossi
- Institute of Cardiology and Center of Excellence on Aging, "G. d'Annunzio" University, Chieti, Italy
| | - Irma Griffo
- Department of Biomedical Sciences, "G. d'Annunzio" University, Chieti, Italy
| | - Ivana Cataldo
- Department of Biomedical Sciences, "G. d'Annunzio" University, Chieti, Italy
| | - Stefano Martinotti
- Department of Biomedical Sciences, "G. d'Annunzio" University, Chieti, Italy
| | - Domenico Rotondo
- Emergency Department, Azienda Sanitaria Locale 2 Abruzzo Lanciano-Vasto-Chieti Hospitals, Chieti, Italy
| | | | - Marco Zimarino
- Institute of Cardiology and Center of Excellence on Aging, "G. d'Annunzio" University, Chieti, Italy
| | - Raffaele De Caterina
- Institute of Cardiology and Center of Excellence on Aging, "G. d'Annunzio" University, Chieti, Italy.
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27
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Huang HL, Zhu S, Wang WQ, Nie X, Shi YY, He Y, Song HL, Miao Q, Fu P, Wang LL, Li GX. Diagnosis of Acute Myocardial Infarction in Hemodialysis Patients With High-Sensitivity Cardiac Troponin T Assay. Arch Pathol Lab Med 2016; 140:75-80. [PMID: 26717058 DOI: 10.5858/arpa.2014-0580-oa] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Context
Cardiac troponins have become the gold standard for diagnosing acute myocardial infarction (AMI) in the general population; however, their diagnostic accuracy for hemodialysis (HD) patients presenting with chest pain or dyspnea is uncertain.
Objective
To examine the diagnostic accuracy of high-sensitivity cardiac troponin T (hs-cTnT) assay for AMI in HD patients.
Design
In this prospective study, we enrolled 670 consecutive stable HD patients presenting with chest pain or dyspnea on routine predialysis therapy in the nephrology department. Receiver operating characteristic (ROC) curves were used to examine the diagnostic accuracy of hs-cTnT levels at enrollment in HD patients presenting with chest pain or dyspnea, and the dynamic change in these levels after 3 hours.
Results
Acute myocardial infarction was the adjudicated final diagnosis in 12% of HD patients. Among patients with a final diagnosis other than AMI, 97% had a plasma hs-cTnT concentration above the 99th percentile. At the time of enrollment, the area under the ROC curve of hs-cTnT levels for diagnosis of AMI was 0.68 (95% confidence interval [CI], 0.62–0.74; P < .001) with a cutoff value of 107.7 ng/L; the relative change after 3 hours was 0.90 (95% CI, 0.82–0.96, P < .001) with a cutoff value of 24%, and the absolute change was 0.88 (95% CI, 0.82–0.94, P < .001) with a cutoff value of 32.6 ng/L. The prognostic value for 40-day mortality varied with the magnitude of elevation in hs-cTnT levels.
Conclusions
Tracking the dynamic change in hs-cTnT levels during the short term significantly increased this measure's diagnostic accuracy for AMI in HD patients.
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Affiliation(s)
- Hua-Lan Huang
- From the Departments of Laboratory Medicine (Drs Li and Wang L-L; Mss Huang, Wang W-Q, Nie, He, and Song; and Messrs Zhu and Miao) and Nephrology (Drs Shi and Fu), West China Hospital, Sichuan University, Chengdu, China
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Kinetics of Highly Sensitive Troponin T after Cardiac Surgery. BIOMED RESEARCH INTERNATIONAL 2015; 2015:574546. [PMID: 26539512 PMCID: PMC4619841 DOI: 10.1155/2015/574546] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/03/2015] [Revised: 07/18/2015] [Accepted: 08/17/2015] [Indexed: 12/11/2022]
Abstract
Perioperative myocardial infarction (PMI) confers a considerable risk in cardiac surgery settings; finding the ideal biomarker seems to be an ideal goal. Our aim was to assess the diagnostic accuracy of highly sensitive troponin T (hsTnT) in cardiac surgery settings and to define a diagnostic level for PMI diagnosis. This was a single-center prospective observational study analyzing data from all patients who underwent cardiac surgeries. The primary outcome was the diagnosis of PMI through a specific level. The secondary outcome measures were the lengths of mechanical ventilation (LOV), stay in the intensive care unit (LOSICU), and hospitalization. Based on the third universal definition of PMI, patients were divided into two groups: no PMI (Group I) and PMI (Group II). Data from 413 patients were analyzed. Nine patients fulfilled the diagnostic criteria of PMI, while 41 patients were identified with a 5-fold increase in their CK-MB (≥120 U/L). Using ROC analysis, a hsTnT level of 3,466 ng/L or above showed 90% sensitivity and 90% specificity for the diagnosis of PMI. Secondary outcome measures in patients with PMI were significantly prolonged. In conclusion, the hsTnT levels detected here paralleled those of CK-MB and a cut-off level of 3466 ng/L could be diagnostic of PMI.
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Li WJ, Chen XM, Nie XY, Lin XX, Cheng YJ, Hu CH, Du ZM, Dong YG, Ma H, Wu SH. Early diagnostic and prognostic utility of high-sensitive troponin assays in acute myocardial infarction: a meta-analysis. Intern Med J 2015; 45:748-56. [PMID: 25403852 DOI: 10.1111/imj.12642] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2014] [Accepted: 11/12/2014] [Indexed: 11/28/2022]
Affiliation(s)
- W.-J. Li
- Department of Cardiology; The First Affiliated Hospital, Sun Yat-Sen University; Guangzhou China
- Department of Cardiology; Guangzhou First Municipal People's Hospital; Guangzhou China
| | - X.-M. Chen
- Department of Cardiology; The First Affiliated Hospital, Sun Yat-Sen University; Guangzhou China
| | - X.-Y. Nie
- Outpatient Department; The First Affiliated Hospital, Sun Yat-Sen University; Guangzhou China
| | - X.-X. Lin
- Department of Cardiology; The First Affiliated Hospital, Sun Yat-Sen University; Guangzhou China
| | - Y.-J. Cheng
- Department of Cardiology; The First Affiliated Hospital, Sun Yat-Sen University; Guangzhou China
| | - C.-H. Hu
- Department of Cardiology; The First Affiliated Hospital, Sun Yat-Sen University; Guangzhou China
| | - Z.-M. Du
- Department of Cardiology; The First Affiliated Hospital, Sun Yat-Sen University; Guangzhou China
| | - Y.-G. Dong
- Department of Cardiology; The First Affiliated Hospital, Sun Yat-Sen University; Guangzhou China
| | - H. Ma
- Department of Cardiology; The First Affiliated Hospital, Sun Yat-Sen University; Guangzhou China
| | - S.-H. Wu
- Department of Cardiology; The First Affiliated Hospital, Sun Yat-Sen University; Guangzhou China
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Parikh RH, Seliger SL, deFilippi CR. Use and interpretation of high sensitivity cardiac troponins in patients with chronic kidney disease with and without acute myocardial infarction. Clin Biochem 2015; 48:247-53. [DOI: 10.1016/j.clinbiochem.2015.01.004] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2014] [Revised: 01/09/2015] [Accepted: 01/12/2015] [Indexed: 01/10/2023]
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Zhelev Z, Hyde C, Youngman E, Rogers M, Fleming S, Slade T, Coelho H, Jones-Hughes T, Nikolaou V. Diagnostic accuracy of single baseline measurement of Elecsys Troponin T high-sensitive assay for diagnosis of acute myocardial infarction in emergency department: systematic review and meta-analysis. BMJ 2015; 350:h15. [PMID: 25646632 PMCID: PMC4300724 DOI: 10.1136/bmj.h15] [Citation(s) in RCA: 139] [Impact Index Per Article: 15.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/10/2014] [Indexed: 12/29/2022]
Abstract
OBJECTIVE To obtain summary estimates of the accuracy of a single baseline measurement of the Elecsys Troponin T high-sensitive assay (Roche Diagnostics) for the diagnosis of acute myocardial infarction in patients presenting to the emergency department. DESIGN Systematic review and meta-analysis of diagnostic test accuracy studies. DATA SOURCES Medline, Embase, and other relevant electronic databases were searched for papers published between January 2006 and December 2013. STUDY SELECTION Studies were included if they evaluated the diagnostic accuracy of a single baseline measurement of Elecsys Troponin T high-sensitive assay for the diagnosis of acute myocardial infarction in patients presenting to the emergency department with suspected acute coronary syndrome. STUDY APPRAISAL AND DATA SYNTHESIS The first author screened all titles and abstracts identified through the searches and selected all potentially relevant papers. The screening of the full texts, the data extraction, and the methodological quality assessment, using the adapted QUADAS-2 tool, were conducted independently by two reviewers with disagreements being resolved through discussion or arbitration. If appropriate, meta-analysis was conducted using the hierarchical bivariate model. RESULTS Twenty three studies reported the performance of the evaluated assay at presentation. The results for 14 ng/L and 3-5 ng/L cut-off values were pooled separately. At 14 ng/L (20 papers), the summary sensitivity was 89.5% (95% confidence interval 86.3% to 92.1%) and the summary specificity was 77.1% (68.7% to 83.7%). At 3-5 ng/L (six papers), the summary sensitivity was 97.4% (94.9% to 98.7%) and the summary specificity was 42.4% (31.2% to 54.5%). This means that if 21 of 100 consecutive patients have the target condition (21%, the median prevalence across the studies), 2 (95% confidence interval 2 to 3) of 21 patients with acute myocardial infarction will be missed (false negatives) if 14 ng/L is used as a cut-off value and 18 (13 to 25) of 79 patients without acute myocardial infarction will test positive (false positives). If the 3-5 ng/L cut-off value is used, <1 (0 to 1) patient with acute myocardial infarction will be missed and 46 (36 to 54) patients without acute myocardial infarction will test positive. CONCLUSIONS The results indicate that a single baseline measurement of the Elecsys Troponin T high-sensitive assay could be used to rule out acute myocardial infarction if lower cut-off values such as 3 ng/L or 5 ng/L are used. However, this method should be part of a comprehensive triage strategy and may not be appropriate for patients who present less than three hours after symptom onset. Care must also be exercised because of the higher imprecision of the evaluated assay and the greater effect of lot-to-lot reagent variation at low troponin concentrations. SYSTEMATIC REVIEW REGISTRATION PROSPERO registration number CRD42013003926.
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Affiliation(s)
- Zhivko Zhelev
- Institute of Health Research, University of Exeter Medical School, Exeter EX2 4SG, UK
| | - Christopher Hyde
- Institute of Health Research, University of Exeter Medical School, Exeter EX2 4SG, UK
| | - Emily Youngman
- Institute of Health Research, University of Exeter Medical School, Exeter EX2 4SG, UK
| | - Morwenna Rogers
- Institute of Health Research, University of Exeter Medical School, Exeter EX2 4SG, UK
| | - Simon Fleming
- Clinical Chemistry, Royal Cornwall Hospital, Treliske, Truro TR1 3LQ, UK
| | - Toby Slade
- Emergency Department, Royal Cornwall Hospital, Truro TR1 3LJ, UK
| | - Helen Coelho
- Institute of Health Research, University of Exeter Medical School, Exeter EX2 4SG, UK
| | - Tracey Jones-Hughes
- Institute of Health Research, University of Exeter Medical School, Exeter EX2 4SG, UK
| | - Vasilis Nikolaou
- Institute of Health Research, University of Exeter Medical School, Exeter EX2 4SG, UK
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Huang H, Zhu S, Wang W, Yi H, Du X, Nie X, He Y, Song H, Miao Q, Wang L, Li G. Diagnosis of acute myocardial infarction in patients with renal insufficiency using high-sensitivity troponin T. ACTA ACUST UNITED AC 2015; 53:723-30. [DOI: 10.1515/cclm-2014-0715] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2014] [Accepted: 11/27/2014] [Indexed: 11/15/2022]
Abstract
AbstractThe objective of this study was to examine the diagnostic accuracy of high-sensitivity cardiac troponin T (hs-cTnT) for acute myocardial infarction (AMI) in patients with renal insufficiency, since this population has a high incidence of non-AMI elevations of hs-cTnT.In this prospective study, we enrolled 2249 consecutive patients presenting with chest pain in the emergency department (ED), of whom 19.5% had an estimated glomerular filtration rate (eGFR)Of the patients, 1108 (49.3%) were diagnosed as having AMI [321 with non-ST segment elevation myocardial infarction (NSTEMI)]. In patients whose final diagnosis was not AMI, there was a low but significant correlation between hs-cTnT and renal function [eGFRUsing a higher hs-cTnT cut-off value based on eGFR level is necessary for accurate diagnosis of AMI or NSTEMI in patients with renal insufficiency.
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Lipinski MJ, Baker NC, Escárcega RO, Torguson R, Chen F, Aldous SJ, Christ M, Collinson PO, Goodacre SW, Mair J, Inoue K, Lotze U, Sebbane M, Cristol JP, Freund Y, Chenevier-Gobeaux C, Meune C, Eggers KM, Pracoń R, Schreiber DH, Wu AHB, Ordoñez-Llanos J, Jaffe AS, Twerenbold R, Mueller C, Waksman R. Comparison of conventional and high-sensitivity troponin in patients with chest pain: a collaborative meta-analysis. Am Heart J 2015; 169:6-16.e6. [PMID: 25497242 DOI: 10.1016/j.ahj.2014.10.007] [Citation(s) in RCA: 73] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2014] [Accepted: 10/10/2014] [Indexed: 02/07/2023]
Abstract
BACKGROUND Multiple studies have evaluated the diagnostic and prognostic performance of conventional troponin (cTn) and high-sensitivity troponin (hs-cTn). We performed a collaborative meta-analysis comparing cTn and hs-cTn for diagnosis of acute myocardial infarction (AMI) and assessment of prognosis in patients with chest pain. METHODS MEDLINE/PubMed, Cochrane CENTRAL, and EMBASE were searched for studies assessing both cTn and hs-cTn in patients with chest pain. Study authors were contacted and many provided previously unpublished data. RESULTS From 17 included studies, there were 8,644 patients. Compared with baseline cTn, baseline hs-cTn had significantly greater sensitivity (0.884 vs 0.749, P < .001) and negative predictive value (NPV; 0.964 vs 0.935, P < .001), whereas specificity (0.816 vs 0.938, P < .001) and positive predictive value (0.558 vs 0.759, P < .001) were significantly reduced. Based on summary receiver operating characteristic curves, test performance for the diagnosis of AMI was not significantly different between baseline cTn and hs-cTn (0.90 [95% CI 0.85-0.95] vs 0.92 [95% CI 0.90-0.94]). In a subanalysis of 6 studies that alternatively defined AMI based on hs-cTn, cTn had lower sensitivity (0.666, P < .001) and NPV (0.906, P < .001). Elevation of baseline hs-cTn, but negative baseline cTn, was associated with increased risk of death or nonfatal myocardial infarction during follow-up (P < .001) compared with both negative. CONCLUSION High-sensitivity troponin has significantly greater early sensitivity and NPV for the diagnosis of AMI at the cost of specificity and positive predictive value, which may enable early rule in/out of AMI in patients with chest pain. Baseline hs-cTn elevation in the setting of negative cTn is also associated with increased nonfatal myocardial infarction or death during follow-up.
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Affiliation(s)
- Michael J Lipinski
- MedStar Cardiovascular Research Network, MedStar Heart Institute, Medstar Washington Hospital Center, Washington, DC
| | - Nevin C Baker
- MedStar Cardiovascular Research Network, MedStar Heart Institute, Medstar Washington Hospital Center, Washington, DC
| | - Ricardo O Escárcega
- MedStar Cardiovascular Research Network, MedStar Heart Institute, Medstar Washington Hospital Center, Washington, DC
| | - Rebecca Torguson
- MedStar Cardiovascular Research Network, MedStar Heart Institute, Medstar Washington Hospital Center, Washington, DC
| | - Fang Chen
- MedStar Cardiovascular Research Network, MedStar Heart Institute, Medstar Washington Hospital Center, Washington, DC
| | - Sally J Aldous
- Department of Cardiology, Christchurch Hospital, Christchurch, New Zealand
| | - Michael Christ
- Department of Emergency and Critical Care Medicine, Paracelsus Medical University, Nuremberg, Germany
| | - Paul O Collinson
- Clinical Blood Sciences Laboratory, St George's Hospital, London, United Kingdom
| | - Steve W Goodacre
- School of Health and Related Research, University of Sheffield, Sheffield, United Kingdom
| | - Johannes Mair
- Department of Internal Medicine, Innsbruck Medical University, Innsbruck, Austria
| | - Kenji Inoue
- Department of Cardiology, Juntendo University Nerima Hospital, Tokyo, Japan
| | - Ulrich Lotze
- Department of Internal Medicine, DRK-Manniske-Krankenhaus Bad Frankenhausen, Frankenhausen, Germany
| | - Mustapha Sebbane
- Départment des urgences, Centre Hospitalier Régional Universitaire Lapeyronie, Montpellier, France
| | - Jean-Paul Cristol
- Département de Biochimie, Centre Hospitalier Régional Universitaire Lapeyronie, Montpellier, France
| | - Yonathan Freund
- Department of Emergency Medicine and Surgery, Hôspital Pitié-Salpétrière, APHP, Université Pierre et Marie Curie-Paris 6 (UPMC), Paris, France
| | - Camille Chenevier-Gobeaux
- Clinical Chemistry Laboratory, Groupe Hospitalier Cochin-Broca-Hôtel Dieu, Université Paris Descartes, Assistance Publique des Hôpitaux de Paris, Paris, France
| | - Christophe Meune
- Cardiology Department, Groupe Hospitalier Cochin-Broca-Hôtel Dieu, Université Paris Descartes, Assistance Publique des Hôpitaux de Paris, Paris, France; Cardiology Department, Paris XIII University, Avicenne Hospital, Bobigny, France
| | - Kai M Eggers
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - Radosław Pracoń
- Department of Coronary and Structural Heart Diseases, National Insititute of Cardiology, Warsaw, Poland
| | - Donald H Schreiber
- Division of Emergency Medicine, Stanford University School of Medicine, Stanford, CA
| | - Alan H B Wu
- Department of Laboratory Medicine, University of California, San Francisco, CA
| | - Jordi Ordoñez-Llanos
- Servei de Bioquímica Clínica, Hospital de Sant Pau, Barcelona, Spain; Biochemistry and Molecular Biology Department, Universitat Autònoma, Barcelona, Spain
| | - Allan S Jaffe
- Division of Cardiology, Mayo Clinic College of Medicine, Rochester, MN; Department of Laboratory Medicine and Pathology, Mayo Clinic College of Medicine, Rochester, MN
| | - Raphael Twerenbold
- Department of Cardiology, University Hospital Basel, Basel, Switzerland; Universitäres Herz-Zentrum Bad Krozingen, Bad Krozingen, Germany
| | - Christian Mueller
- Department of Cardiology, University Hospital Basel, Basel, Switzerland
| | - Ron Waksman
- MedStar Cardiovascular Research Network, MedStar Heart Institute, Medstar Washington Hospital Center, Washington, DC.
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Lian J, Li J, Dai D, Fang P, Zhou J, Duan S. A lack of association between the CRP rs2794520 polymorphism and coronary artery disease. Biomed Rep 2014; 3:110-114. [PMID: 25469258 DOI: 10.3892/br.2014.384] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2014] [Accepted: 10/29/2014] [Indexed: 11/05/2022] Open
Abstract
Coronary artery disease (CAD) is mainly caused by atherosclerosis, which is closely associated with the C-reactive protein (CRP), a systemic inflammatory mediator. The aim of the present study was to examine whether the CRP rs2794520 polymorphism played a role in the risk of CAD. A total of 459 CAD patients and 432 non-CAD controls were recruited in the case-control study. Genotyping was performed on the SEQUENOM® Mass-ARRAY iPLEX® platform according to the manufacturer's instructions. The results showed that CRP rs2794520 was not associated with CAD. A further breakdown analysis by age or gender also indicated a lack of association between rs2794520 and CAD. In addition, the CRP rs2794520 polymorphism was not associated with the severity of CAD, which was represented by the number of coronary arteries with stenosis. In conclusion, there was no contribution of the CRP rs2794520 polymorphism to the risk of CAD.
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Affiliation(s)
- Jiangfang Lian
- Ningbo Medical Center, Lihuili Hospital, School of Medicine, Ningbo University, Ningbo, Zhejiang 315000, P.R. China
| | - Junxing Li
- Ningbo Medical Center, Lihuili Hospital, School of Medicine, Ningbo University, Ningbo, Zhejiang 315000, P.R. China ; Zhejiang Provincial Key Laboratory of Pathophysiology, School of Medicine, Ningbo University, Ningbo, Zhejiang 315000, P.R. China
| | - Dongjun Dai
- Zhejiang Provincial Key Laboratory of Pathophysiology, School of Medicine, Ningbo University, Ningbo, Zhejiang 315000, P.R. China
| | - Peiliang Fang
- Ningbo Medical Center, Lihuili Hospital, School of Medicine, Ningbo University, Ningbo, Zhejiang 315000, P.R. China ; Zhejiang Provincial Key Laboratory of Pathophysiology, School of Medicine, Ningbo University, Ningbo, Zhejiang 315000, P.R. China
| | - Jianqing Zhou
- Ningbo Medical Center, Lihuili Hospital, School of Medicine, Ningbo University, Ningbo, Zhejiang 315000, P.R. China
| | - Shiwei Duan
- Zhejiang Provincial Key Laboratory of Pathophysiology, School of Medicine, Ningbo University, Ningbo, Zhejiang 315000, P.R. China
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Wolf S, Kaur R, McKeown WP, Chan H, Dang A, Kuston T, Leung W, Purakal J, O'Neil BJ, Levy P. Noise versus signal: the clinical implications of an increasingly sensitive troponin assay for patients with suspected acute coronary syndrome. Crit Pathw Cardiol 2014; 13:89-95. [PMID: 25062391 DOI: 10.1097/hpc.0000000000000020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
OBJECTIVES To evaluate the clinical impact of a troponin assay switch in suspected acute coronary syndromes (ACS). METHODS Retrospective analysis of ACS cases in the 3 months before and after changing to a contemporary, higher sensitivity troponin assay. Admitting diagnosis, proportion with a positive result, initial treatment and testing, coronary artery intervention, inhospital events, and final discharge diagnosis were compared by assay group. RESULTS Seven hundred seventy patients were included: 319 (41.4%) preassay and 451 (58.6%) postassay. Preassay change, non-ST segment elevation myocardial infarction at admission (43.0% vs. 70.5%; diff [95% confidence interval (CI)] = -27.5 [-34.2, -20.6]) was diagnosed less often, and a positive troponin was less common (33.2% vs. 72.3%; diff [95% CI] = -39.1 [-45.4, -32.2]). However, anticoagulation (53.3% vs. 42.4%; diff [95% CI] = 10.9 [3.8, 18.0]) and cardiac catheterization use were more frequent (53.9% vs. 41.9%; diff [95% CI] = 12.0 [19.0, 48.5]). There was no difference in coronary intervention (41.9% vs. 40.7%; diff [95% CI] = 1.2 [-9.0, 11.2]) by assay period. Inhospital event were rare (unstable ventricular arrhythmia = 1.2%, cardiac arrest = 3.4%, death = 4.4%) with no difference between groups. A non-ACS diagnosis at discharge was more common in the postassay group (31.6% vs. 46.5%; diff [95% CI] = 14.9 [7.9, 21.6]). CONCLUSIONS Although non-ST segment elevation myocardial infarction diagnosis at admission and a positive troponin were more frequent postassay change, rates of anticoagulation and cardiac catheterization were lower and a non-ACS diagnosis at discharge was more common. These data suggest an evolving understanding and clinical impact of contemporary troponin assays when used in real-world settings.
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Affiliation(s)
- Sarah Wolf
- From the *Department of Emergency Medicine, Emory University, Atlanta GA; †Department of Internal Medicine, Wayne State University, Detroit, MI; ‡Department of Emergency Medicine, Metro Health Hospital-Statewide Campus System, Michigan State University College of Osteopathic Medicine, Wyoming, MI; §Oakwood Heritage Transitional Year Residency Program/Oakwood Healthcare, Taylor, MI; ¶Department of Internal Medicine, Loma Linda University, Loma Linda, CA; ‖Department of Emergency Medicine, St. John Hospital and Medical Center, Detroit, MI; **Department of Internal Medicine, California Pacific Medical Center, San Francisco, CA; ††Wayne State University School of Medicine, Detroit, MI; ‡‡Department of Emergency Medicine, Wayne State University School of Medicine, Detroit, MI; and §§Cardiovascular Research Institute, Wayne State University School of Medicine, Detroit, MI
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Sethi A, Bajaj A, Malhotra G, Arora RR, Khosla S. Diagnostic accuracy of sensitive or high-sensitive troponin on presentation for myocardial infarction: a meta-analysis and systematic review. Vasc Health Risk Manag 2014; 10:435-50. [PMID: 25092986 PMCID: PMC4115590 DOI: 10.2147/vhrm.s63416] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
Background Recently, high-sensitive troponin (hsTrop) assays consistent with professional societies’ recommendations became available. We aimed to summarize the evidence on the diagnostic accuracy of hsTrop on presentation. Methods We searched electronic databases for studies evaluating the diagnostic accuracy of hsTrop in suspected acute coronary syndrome (ACS) patients. Random effect meta-analyses and meta-regression were performed. Primary and secondary analyses were restricted to studies using conventional Trop and hsTrop in the reference standard, respectively. Results Fifteen studies with a total of 8,628 patients met the inclusion criteria for the primary analysis. hsTrop T (Hoffman-La Roche Ltd) and hsTrop I (Siemens) had sensitivities of 0.89 (95% confidence interval [CI]: 0.86–0.91) and 0.90 (95% CI: 0.87–0.92) and specificities of 0.79 (95% CI: 0.77–0.80) and 0.89 (95% CI: 0.87–0.90), respectively. There was no statistically significant difference in the area under the curve between hsTrop (95% CI: 0.920) and conventional Trop (95% CI: 0.929) at the 99th percentile (P=0.62). hsTrop at the level of detection had a sensitivity of 0.97 (95% CI: 0.96–0.98) and a specificity of 0.41 (95% CI: 0.40–0.42). The studies using a cut-off at coefficient of variance <10% as opposed to the 99th percentile for the conventional assay used for diagnosis reported higher diagnostic accuracy (relative diagnostic odds ratio =2.13, P=0.02). Five studies were included in the secondary analysis; hsTrop T (Hoffman-La Roche Ltd) had a sensitivity of 0.91 (95% CI: 0.89–0.93) and a specificity of 0.67 (95% CI: 0.63–0.70). There was significant heterogeneity among the studies. Conclusion hsTrop have excellent diagnostic accuracy for myocardial infarction on presentation, but may not outperform conventional Trop assays. The variation among the studies can be explained, in part, by the cut-off used for conventional Trop assays.
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Affiliation(s)
- Ankur Sethi
- Department of Medicine, Division of Cardiology, Rosalind Franklin University of Medicine and Science, North Chicago, IL, USA
| | - Anurag Bajaj
- Department of Medicine, Wright Center of Graduate Medical Education, Scranton, PA, USA
| | - Gurveen Malhotra
- Department of Medicine, Division of Cardiology, Rosalind Franklin University of Medicine and Science, North Chicago, IL, USA
| | - Rohit R Arora
- Department of Medicine, Division of Cardiology, Rosalind Franklin University of Medicine and Science, North Chicago, IL, USA
| | - Sandeep Khosla
- Department of Medicine, Division of Cardiology, Rosalind Franklin University of Medicine and Science, North Chicago, IL, USA
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Al-Saleh A, Alazzoni A, Al Shalash S, Ye C, Mbuagbaw L, Thabane L, Jolly SS. Performance of the high-sensitivity troponin assay in diagnosing acute myocardial infarction: systematic review and meta-analysis. CMAJ Open 2014; 2:E199-207. [PMID: 25295240 PMCID: PMC4183183 DOI: 10.9778/cmajo.20130074] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND High-sensitivity cardiac troponin assays have been adopted by many clinical centres worldwide; however, clinicians are uncertain how to interpret the results. We sought to assess the utility of these assays in diagnosing acute myocardial infarction (MI). METHODS We carried out a systematic review and meta-analysis of studies comparing high-sensitivity with conventional assays of cardiac troponin levels among adults with suspected acute MI in the emergency department. We searched MEDLINE, EMBASE and Cochrane databases up to April 2013 and used bivariable random-effects modelling to obtain summary parameters for diagnostic accuracy. RESULTS We identified 9 studies that assessed the use of high-sensitivity troponin T assays (n = 9186 patients). The summary sensitivity of these tests in diagnosing acute MI at presentation to the emergency department was estimated to be 0.94 (95% confidence interval [CI] 0.89-0.97); for conventional tests, it was 0.72 (95% CI 0.63-0.79). The summary specificity was 0.73 (95% CI 0.64-0.81) for the high-sensitivity assay compared with 0.95 (95% CI 0.93-0.97) for the conventional assay. The differences in estimates of the summary sensitivity and specificity between the high-sensitivity and conventional assays were statistically significant (p < 0.01). The area under the curve was similar for both tests carried out 3-6 hours after presentation. Three studies assessed the use of high-sensitivity troponin I assays and showed similar results. INTERPRETATION Used at presentation to the emergency department, the high-sensitivity cardiac troponin assay has improved sensitivity, but reduced specificity, compared with the conventional troponin assay. With repeated measurements over 6 hours, the area under the curve is similar for both tests, indicating that the major advantage of the high-sensitivity test is early diagnosis.
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Affiliation(s)
- Ayman Al-Saleh
- Department of Cardiology, Hamilton Health Sciences, McMaster University, Hamilton, Ont
| | - Ashraf Alazzoni
- Department of Cardiology, Hamilton Health Sciences, McMaster University, Hamilton, Ont
| | - Saleh Al Shalash
- Department of Internal Medicine, McMaster University, Hamilton, Ont
| | - Chenglin Ye
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ont. ; Biostatistics Unit, St Joseph's Healthcare, Hamilton, Ont
| | - Lawrence Mbuagbaw
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ont. ; Biostatistics Unit, St Joseph's Healthcare, Hamilton, Ont. ; Centre for Development of Best Practices in Health, Yaoundé Central Hospital, Yaoundé, Cameroon
| | - Lehana Thabane
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ont. ; Departments of Anesthesia and Pediatrics, McMaster University, Hamilton, Ont. ; Population Health Research Institute, Hamilton Health Sciences, Hamilton, Ont
| | - Sanjit S Jolly
- Department of Cardiology, Hamilton Health Sciences, McMaster University, Hamilton, Ont. ; Population Health Research Institute, Hamilton Health Sciences, Hamilton, Ont
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Aboukhoudir F, Rekik S, Latil Plat F, Aboukhoudir I, Kadem M, Benamo E, Pansieri M. [Uselessness of high-sensitivity cardiac troponins to improve diagnostic accuracy of dobutamine stress echocardiography in high-risk diabetic patients]. Ann Cardiol Angeiol (Paris) 2014; 63:307-11. [PMID: 24972986 DOI: 10.1016/j.ancard.2014.05.015] [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: 05/01/2014] [Accepted: 05/25/2014] [Indexed: 10/25/2022]
Abstract
BACKGROUND AND AIM Dobutamine stress echocardiography (DSE) is a well-established noninvasive stress modality for the detection and evaluation of coronary artery disease in diabetic patients. High-sensitivity cardiac troponin T recently emerged as a highly sensitive dosage for the detection of ischemia. The aim of the study was to examine whether high-sensitivity cardiac troponin T may improve the diagnostic accuracy of silent ischemia by DSE in high-risk diabetic patients. METHODS AND RESULTS Twenty-one patients with long-standing (>10years) and/or complicated type II DM but no established CAD were included. In addition to DSE, venous blood samples for measurement of hs-cTnT were collected prior to DSE, 6hours and 24hours after the test. Troponins were deemed positive if>1.5 upper limit for normality. Patients with positive troponins underwent coronary angiography or CT scan regardless of the result of DSE. Among the 21 patients, 7 had positive troponins measured 6hours after stress, (mean peak troponin=44.5). DSE were negative in all of them. Mean age was 64years significantly higher than patients with negative troponins. No differences were noted between the groups in terms of epidemiological, clinical or echocardiographic characteristics. Patients with positive cardiac troponins were evaluated for the presence of coronary lesions but none of them had significant disease. After an 18-month mean follow-up, no adverse cardiac events were noted in either group. CONCLUSION In high-risk diabetic patients, the measurement of hs-cTnT during DSE does not improve the sensitivity at least in those with negative DSE tests.
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Affiliation(s)
- F Aboukhoudir
- Service de cardiologie, centre hospitalier d'Avignon, 305, rue Raoul-Follereau, 84000 Avignon, France; Laboratoire de Pharm écologie cardiovasculaire, université d'Avignon, EA4278, 84000 Avignon, France
| | - S Rekik
- Service de cardiologie, centre hospitalier d'Antibes, 107, route de Nice, 06600 Antibes, France.
| | - F Latil Plat
- Service endocrinologie, centre hospitalier d'Avignon, 305, rue Raoul Follereau, 84000 Avignon, France
| | - I Aboukhoudir
- Service de cardiologie, centre hospitalier d'Avignon, 305, rue Raoul-Follereau, 84000 Avignon, France
| | - M Kadem
- Service endocrinologie, centre hospitalier d'Avignon, 305, rue Raoul Follereau, 84000 Avignon, France
| | - E Benamo
- Service endocrinologie, centre hospitalier d'Avignon, 305, rue Raoul Follereau, 84000 Avignon, France
| | - M Pansieri
- Service de cardiologie, centre hospitalier d'Avignon, 305, rue Raoul-Follereau, 84000 Avignon, France
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39
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Geri G, Mongardon N, Dumas F, Chenevier-Gobeaux C, Varenne O, Jouven X, Vivien B, Mira JP, Empana JP, Spaulding C, Cariou A. Diagnosis performance of high sensitivity troponin assay in out-of-hospital cardiac arrest patients. Int J Cardiol 2013; 169:449-54. [DOI: 10.1016/j.ijcard.2013.10.011] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2013] [Revised: 08/19/2013] [Accepted: 10/05/2013] [Indexed: 10/26/2022]
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40
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Recchioni R, Marcheselli F, Olivieri F, Ricci S, Procopio AD, Antonicelli R. Conventional and novel diagnostic biomarkers of acute myocardial infarction: a promising role for circulating microRNAs. Biomarkers 2013; 18:547-58. [PMID: 24025051 DOI: 10.3109/1354750x.2013.833294] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Biomarkers play a critical role in the diagnosis of acute myocardial infarction (AMI), especially in patients with atypical clinical and/or electrocardiographic presentation or co-morbidities, like the elderly. High-sensitivity assays based on specific biomarkers (e.g. cardiac troponins) enabling earlier AMI diagnosis have recently become available in clinical practice. Although no single biomarker of myocardial necrosis is ever likely to afford AMI diagnosis, a combination including different biomarkers for necrosis and ischemia, like new circulating molecules (microRNAs), could enhance diagnostic specificity. We review the recent literature on conventional and novel AMI biomarkers, with special emphasis on circulating microRNAs.
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Affiliation(s)
- Rina Recchioni
- Center of Clinical Pathology and Innovative Therapy, Italian National Research Center on Aging (I.N.R.C.A-IRCCS) , Ancona , Italy
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41
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Early rule out of acute myocardial infarction in ED patients: value of combined high-sensitivity cardiac troponin T and ultrasensitive copeptin assays at admission. Am J Emerg Med 2013; 31:1302-8. [DOI: 10.1016/j.ajem.2013.04.033] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2013] [Accepted: 04/30/2013] [Indexed: 11/19/2022] Open
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42
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Retracted article: Concomitant measurement of copeptin and high-sensitivity troponin for fast and reliable rule out of acute myocardial infarction. Intensive Care Med 2013; 38:732. [PMID: 22302027 DOI: 10.1007/s00134-012-2481-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2011] [Accepted: 12/19/2011] [Indexed: 12/24/2022]
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43
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Chenevier-Gobeaux C, Meune C, Freund Y, Wahbi K, Claessens YE, Doumenc B, Zuily S, Riou B, Ray P. Influence of age and renal function on high-sensitivity cardiac troponin T diagnostic accuracy for the diagnosis of acute myocardial infarction. Am J Cardiol 2013; 111:1701-7. [PMID: 23540652 DOI: 10.1016/j.amjcard.2013.02.024] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2013] [Revised: 02/07/2013] [Accepted: 02/07/2013] [Indexed: 11/25/2022]
Abstract
Concerns have been raised about the performance of highly sensitive cardiac troponin assays to accurately detect acute myocardial infarction (AMI), particularly in non-ST segment elevation (NSTEMI), in elderly patients, and in patients with renal failure. We evaluated whether increased age and low estimated glomerular filtration rate (eGFR) alter diagnostic performance of high-sensitivity cardiac troponin T (HScTnT). In a prospective multicentric study, HScTnT levels were measured blindly at presentation in patients with acute chest pain. Three hundred and sixty-seven patients were enrolled, including 84 patients ≥70 years. Final diagnosis was AMI for 57 patients (16%) and NSTEMI for 43 patients (12%). NSTEMI was more frequent in elderly patients (p = 0.008). Sensitivity and specificity of HScTnT >14 ng/L at admission for AMI were 96% and 51% in patients ≥70 years versus 91% (NS) and 88% (p <0.0001) in younger patients; the same observations were done for the diagnosis of NSTEMI. Given an HScTnT >53.5 ng/L for the diagnosis of AMI and NSTEMI, respective sensitivities were 87% and 84% and respective specificities were 87% and 87% in elderly patients. Using a cutoff at 35.8 ng/L (for AMI) or 43.2 ng/L (for NSTEMI), sensitivities were 94% and 92%, and specificities were 86% and 88% in patients with low eGFR. Older age, but not low eGFR, was an independent predictive factor of an elevated HScTnT at admission (odds ratio 2.2 [1.2-3.9], p = 0.007). In conclusion, adapted thresholds of HScTnT are required for an accurate diagnosis of AMI/NSTEMI in patients aged ≥70 and in those with low eGFR.
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44
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Hammerer-Lercher A, Ploner T, Neururer S, Schratzberger P, Griesmacher A, Pachinger O, Mair J. High-sensitivity cardiac troponin T compared with standard troponin T testing on emergency department admission: how much does it add in everyday clinical practice? J Am Heart Assoc 2013; 2:e000204. [PMID: 23735897 PMCID: PMC3698787 DOI: 10.1161/jaha.113.000204] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Background We compared high‐sensitivity cardiac troponin T (hs‐cTnT) and standard cTnT for acute myocardial infarction (AMI) diagnosis in everyday clinical practice of an emergency department (ED). Methods and Results cTnT was measured in 2384 consecutive patients (60±21 years, 52% female) on ED admission. Readmissions to the ED (n=720) and mortality (n=101) were followed for an average period of 239±49 days. There were 53 AMIs (delay, 1 to 96 hours; median, 3 hours), 440 chest pain patients, 286 dyspnea patients, 785 acute or chronic cardiac diseases, and 540 neurological diseases, with the remaining having various internal diseases. The diagnostic performances of hs‐ and standard cTnT were comparable for AMI diagnosis (area under receiver operating characteristics curves [ROC AUC], 0.91±0.02 versus 0.90±0.03; P=0.31). Using the 99th‐percentile cutoff, the sensitivities and specificities for AMI in the whole population were 91% and 74% for hs‐cTnT and 89% and 80% for standard cTnT. hs‐cTnT detected significantly more patients with cardiac diseases (ROC AUC, 0.77±0.01 versus 0.67±0.01; P<0.001). hs‐cTnT and standard cTnT were significant predictors of ED readmissions but not of mortality, but both were not independent predictors of ED readmissions or the combined end point of readmission or mortality in binary logistic regression analysis. Conclusions In unselected ED patients the diagnostic performances of hs‐cTnT and standard cTnT for AMI diagnosis did not differ significantly. hs‐cTnT detected significantly more cardiac diseases. hs‐cTnT and standard cTnT were not independent predictors of ED readmissions and mortality from all causes.
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Affiliation(s)
- Angelika Hammerer-Lercher
- Central Institute for Medical and Chemical Laboratory Diagnostics, Innsbruck Medical University, Innsbruck, Austria
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45
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Markman PL, Tantiongco JP, Bennetts JS, Baker RA. High-Sensitivity Troponin Release Profile After Cardiac Surgery. Heart Lung Circ 2013. [DOI: 10.1016/j.hlc.2013.03.045] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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46
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Fortin P, Mintzes B, Innes M. A systematic review of intravitreal bevacizumab for the treatment of diabetic macular edema. CADTH TECHNOLOGY OVERVIEWS 2013; 3:e3203. [PMID: 23463845 PMCID: PMC3711526] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
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47
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De Backer D, Cortés DO. Year in review 2011: Critical Care--Cardiology. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2012; 16:246. [PMID: 23256884 PMCID: PMC3672576 DOI: 10.1186/cc11826] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
We review key research papers in cardiology and intensive care published during 2011 in Critical Care and quote related studies published in other journals whenever appropriate. Papers are grouped into the following categories: cardiovascular therapies, mechanical therapies, biomarkers, prognostic markers, hemodynamic monitoring, cardiovascular diseases, microcirculation, hypertension in critically ill patients, and miscellaneous.
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48
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Olivieri F, Galeazzi R, Giavarina D, Testa R, Abbatecola AM, Çeka A, Tamburrini P, Busco F, Lazzarini R, Monti D, Franceschi C, Procopio AD, Antonicelli R. Aged-related increase of high sensitive Troponin T and its implication in acute myocardial infarction diagnosis of elderly patients. Mech Ageing Dev 2012; 133:300-5. [PMID: 22446505 DOI: 10.1016/j.mad.2012.03.005] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2011] [Revised: 02/12/2012] [Accepted: 03/06/2012] [Indexed: 10/28/2022]
Abstract
High sensitive cardiac Troponin T (hs-cTnT) represents an important tool in acute myocardial infarction (AMI) diagnosis. Even though the hs-cTnT evaluation is relevant for AMI diagnosis in elderly patients characterized by clinical and instrumental atypical presentation, the overall reliability in elderly patients is unknown. We aimed at: (1) defining the hs-cTnT 99th percentile value in an aged healthy reference population and (2) testing hs-cTnT diagnostic accuracy in elderly patients with a suspected AMI. 294 healthy subjects (50-105 years old) and 299 elderly patients (75-96 years old) with suspected AMI at presentation, were enrolled. Conventional cTnT, hs-cTnT, NT-proBNP and creatinine levels were determined in all participants. Our main results are: (1) a significant hs-cTnT age-related increase was observed in an healthy reference population ranging 50-105 years old; (2) hs-cTnT levels showed an age-related multimodal distribution in the healthy reference population: 16 ng/L corresponds to the 99th percentile in subjects ranging 50-75 years old, whereas 70.6 ng/L corresponds to the 99th percentile in subjects ≥75 years old; (3) 86.8 ng/L resulted the hs-cTnT cut-off value with the highest efficiency in AMI diagnosis of geriatric patients. Our data suggest that the hs-cTnT cut-off value must be age-tailored to improve the AMI diagnostic accuracy.
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Affiliation(s)
- Fabiola Olivieri
- Department of Clinical and Molecular Sciences, Università Politecnica delle Marche, Ancona, Italy.
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Retraction of “Concomitant measurement of copeptin and high-sensitivity troponin for fast and reliable rule out of acute myocardial infarction”. Intensive Care Med 2012; 38:733-4. [DOI: 10.1007/s00134-012-2520-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/15/2012] [Indexed: 10/28/2022]
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50
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Combined copeptin and troponin to rule out myocardial infarction in patients with chest pain and a history of coronary artery disease. Am J Emerg Med 2012; 30:440-8. [DOI: 10.1016/j.ajem.2011.12.008] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2011] [Revised: 11/29/2011] [Accepted: 12/09/2011] [Indexed: 11/22/2022] Open
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