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Kozhuharov N, Michou E, Wussler D, Belkin M, Heinisch C, Lassus J, Siirilä-Waris K, Veli-Pekka H, Arenja N, Socrates T, Nowak A, Shrestha S, Willi JV, Strebel I, Gualandro DM, Rentsch K, Maeder MT, Münzel T, Tavares de Oliveira Junior M, von Eckardstein A, Breidthardt T, Mueller C. Quantifying Hemodynamic Cardiac Stress and Cardiomyocyte Injury in Normotensive and Hypertensive Acute Heart Failure. Biomedicines 2024; 12:1099. [PMID: 38791061 PMCID: PMC11118007 DOI: 10.3390/biomedicines12051099] [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: 03/12/2024] [Revised: 04/23/2024] [Accepted: 05/08/2024] [Indexed: 05/26/2024] Open
Abstract
BACKGROUND The characterization of the different pathophysiological mechanisms involved in normotensive versus hypertensive acute heart failure (AHF) might help to develop individualized treatments. METHODS The extent of hemodynamic cardiac stress and cardiomyocyte injury was quantified by measuring the B-type natriuretic peptide (BNP), N-terminal proBNP (NT-proBNP), and high-sensitivity cardiac troponin T (hs-cTnT) concentrations in 1152 patients presenting with centrally adjudicated AHF to the emergency department (ED) (derivation cohort). AHF was classified as normotensive with a systolic blood pressure (SBP) of 90-140 mmHg and hypertensive with SBP > 140 mmHg at presentation to the ED. Findings were externally validated in an independent AHF cohort (n = 324). RESULTS In the derivation cohort, with a median age of 79 years, 43% being women, 667 (58%) patients had normotensive and 485 (42%) patients hypertensive AHF. Hemodynamic cardiac stress, as quantified by the BNP and NT-proBNP, was significantly higher in normotensive as compared to hypertensive AHF [1105 (611-1956) versus 827 (448-1419) pg/mL, and 5890 (2959-12,162) versus 4068 (1986-8118) pg/mL, both p < 0.001, respectively]. Similarly, the extent of cardiomyocyte injury, as quantified by hs-cTnT, was significantly higher in normotensive AHF as compared to hypertensive AHF [41 (24-71) versus 33 (19-59) ng/L, p < 0.001]. A total of 313 (28%) patients died during 360 days of follow-up. All-cause mortality was higher in patients with normotensive AHF vs. patients with hypertensive AHF (hazard ratio 1.66, 95%CI 1.31-2.10; p < 0.001). Normotensive patients with a high BNP, NT-proBNP, or hs-cTnT had the highest mortality. The findings were confirmed in the validation cohort. CONCLUSION Biomarker profiling revealed a higher extent of hemodynamic stress and cardiomyocyte injury in patients with normotensive versus hypertensive AHF.
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Affiliation(s)
- Nikola Kozhuharov
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Petersgraben 4, 4031 Basel, Switzerland
- Department of Cardiology, University Hospital Bern, University of Bern, Freiburgstrasse 20, 3010 Bern, Switzerland
| | - Eleni Michou
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Petersgraben 4, 4031 Basel, Switzerland
| | - Desiree Wussler
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Petersgraben 4, 4031 Basel, Switzerland
| | - Maria Belkin
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Petersgraben 4, 4031 Basel, Switzerland
- Department of Internal Medicine, University Hospital Basel, University of Basel, 4001 Basel, Switzerland
| | - Corinna Heinisch
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Petersgraben 4, 4031 Basel, Switzerland
| | - Johan Lassus
- Heart and Lung Center, Department of Cardiology, Helsinki University Central Hospital, 00280 Helsinki, Finland
| | - Krista Siirilä-Waris
- Heart and Lung Center, Department of Cardiology, Helsinki University Central Hospital, 00280 Helsinki, Finland
| | - Harjola Veli-Pekka
- Department of Emergency Care, Helsinki University Hospital, 00280 Helsinki, Finland
| | - Nisha Arenja
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Petersgraben 4, 4031 Basel, Switzerland
- Department of Cardiology, Solothurner Spitäler AG, 4500 Solothurn, Switzerland
| | - Thenral Socrates
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Petersgraben 4, 4031 Basel, Switzerland
| | - Albina Nowak
- Department of Endocrinology and Clinical Nutrition, University Hospital Zurich, 8091 Zürich, Switzerland
| | - Samyut Shrestha
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Petersgraben 4, 4031 Basel, Switzerland
| | - Julie Valerie Willi
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Petersgraben 4, 4031 Basel, Switzerland
- Department of Internal Medicine, University Hospital Basel, University of Basel, 4001 Basel, Switzerland
| | - Ivo Strebel
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Petersgraben 4, 4031 Basel, Switzerland
| | - Danielle M. Gualandro
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Petersgraben 4, 4031 Basel, Switzerland
- Heart Institute (INCOR), University of Sao Paulo Medical School, Sao Paulo 01246-000, Brazil
| | - Katharina Rentsch
- Department of Laboratory Medicine, University Hospital Basel, 4031 Basel, Switzerland
- Department of Laboratory Medicine, University Hospital Zurich, 8091 Zürich, Switzerland
| | - Micha T. Maeder
- Department of Cardiology, Kantonsspital St. Gallen, 9000 St. Gallen, Switzerland
| | - Thomas Münzel
- University Medical Center, Johannes Gutenberg University Mainz, 55122 Mainz, Germany
| | | | - Arnold von Eckardstein
- Institute for Emergency Medicine, University Hospital Zurich, University of Zurich, 8006 Zürich, Switzerland
| | - Tobias Breidthardt
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Petersgraben 4, 4031 Basel, Switzerland
- Department of Internal Medicine, University Hospital Basel, University of Basel, 4001 Basel, Switzerland
| | - Christian Mueller
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Petersgraben 4, 4031 Basel, Switzerland
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Singer AJ, Heslin S, Skopicki H, On C, Senzel LB, Tharakan M, Thode HC, Peacock F. Introduction of a high sensitivity troponin reduces ED length of stay. Am J Emerg Med 2024; 76:82-86. [PMID: 38006636 DOI: 10.1016/j.ajem.2023.11.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Revised: 11/08/2023] [Accepted: 11/16/2023] [Indexed: 11/27/2023] Open
Abstract
BACKGROUND High sensitivity cardiac troponins (hs-cTn) allow earlier identification and exclusion of acute myocardial infarction. We determined if transitioning from contemporary to high sensitivity troponin T (hs-cTnT) would reduce ED length of stay in chest pain (CP) patients. METHODS We conducted a pragmatic, prospective, before and after study of implementing a hs-cTnT by reviewing the electronic health records in all adult ED patients presenting to a large, suburban academic medical center during the 3 months before and after transitioning from a 4th generation troponin to a 5th generation hs-cTnT (Elecsys® Troponin T-high sensitive, Roche Diagnostics, Indianapolis, IN). RESULTS There were 1431 and 1437 CP patients before and after the intervention. Mean (SD) age was 51.5 (18) yrs. and 54.3% were female. The median (IQR) ED LOS for chest pain patients directly discharged to home was 6.2 (4.7-8.4) and 5.3 (4.0-7.2) hours before and after introducing hs-cTn respectively; difference 47 min (95%CI, 35-59); P < 0.001. The median (IQR) ED LOS for chest pain patients admitted to the hospital was 9.5 (6.6-13.8) and 8.1 (5.7-11.2) hours before and after introducing hs-cTn respectively; difference 77 min (95%CI, 35-121); P < 0.001. Overall admission rates (22 vs 21% both before and after) did not change during the study. The rates of computed tomography coronary angiography before and after the intervention were 21 and 20.4% respectively. The rates of invasive coronary angiography before and after the intervention were 5.8 and 5.6% respectively. CONCLUSIONS Transitioning to a hs-cTnT is associated with a clinically relevant and statistically significant reduction in ED LOS for both discharged and admitted patients with and without CP with no increase in admission or coronary angiography rates.
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Affiliation(s)
- Adam J Singer
- Department of Emergency Medicine, Renaissance School of Medicine at Stony Brook University, Stony Brook, NY, United States of America.
| | - Samita Heslin
- Department of Emergency Medicine, Renaissance School of Medicine at Stony Brook University, Stony Brook, NY, United States of America
| | - Hal Skopicki
- Division of Cardiology, Department of Medicine, Renaissance School of Medicine at Stony Brook University, Stony Brook, NY, United States of America
| | - Chen On
- Division of Cardiology, Department of Medicine, Renaissance School of Medicine at Stony Brook University, Stony Brook, NY, United States of America
| | - Lisa B Senzel
- Department of Clinical Pathology, Renaissance School of Medicine at Stony Brook University, Stony Brook, NY, United States of America
| | - Mathew Tharakan
- Division of Cardiology, Department of Medicine, Renaissance School of Medicine at Stony Brook University, Stony Brook, NY, United States of America
| | - Henry C Thode
- Department of Emergency Medicine, Renaissance School of Medicine at Stony Brook University, Stony Brook, NY, United States of America
| | - Frank Peacock
- Department of Emergency Medicine, Baylor College of Medicine, Houston, TX, United States of America
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Bhatnagar R, Berge K, Røysland R, Høiseth AD, Brynildsen J, Christensen G, Omland T, Røsjø H, Lyngbakken MN. Cardiac Troponin T and NT-proBNP for Prediction of 30-Day Readmission or Death in Patients with Acute Dyspnea: Data from the Akershus Cardiac Examination 2 Study. Cardiology 2023; 148:506-516. [PMID: 37544298 PMCID: PMC10733942 DOI: 10.1159/000533266] [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: 02/10/2023] [Accepted: 07/24/2023] [Indexed: 08/08/2023]
Abstract
INTRODUCTION N-terminal pro-B-type natriuretic peptide (NT-proBNP) and cardiac troponin T (cTnT) measurements are recommended in patients with acute dyspnea. We aimed to assess the prognostic merit of cTnT compared to NT-proBNP for 30-day readmission or death in patients hospitalized with acute dyspnea. METHODS We measured cTnT and NT-proBNP within 24 h in 314 patients hospitalized with acute dyspnea and adjudicated the cause of the index admission. Time to first event of readmission or death ≤30 days after hospital discharge was recorded, and cTnT and NT-proBNP measurements were compared head-to-head. RESULTS Patients who died (12/314) or were readmitted (71/314) within 30 days had higher cTnT concentrations (median: 32.6, Q1-Q3: 18.4-74.2 ng/L vs. median: 19.4, Q1-Q3: 8.4-36.1 ng/L; p for comparison <0.001) and NT-proBNP concentrations (median: 1,753.6, Q1-Q3: 464.2-6,862.0 ng/L vs. median 984, Q1-Q3 201-3,600 ng/L; for comparison p = 0.027) compared to patients who survived and were not readmitted. cTnT concentrations were associated with readmission or death within 30 days after discharge both in the total cohort (adjusted hazard ratio [aHR]: 1.64, 95% confidence interval [CI]: 1.30-2.05) and in patients with heart failure (HF) (aHR: 1.58, 95% CI: 1.14-2.18). In contrast, NT-proBNP concentrations were not associated with short-term events, neither in the total cohort (aHR: 1.10, 95% CI: 0.94-1.30) nor in patients with adjudicated HF (aHR: 1.06, 95% CI: 0.80-1.40). CONCLUSION cTnT concentrations are associated with 30-day readmission or death in patients hospitalized with acute dyspnea, as well as in patients adjudicated HF.
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Affiliation(s)
- Rahul Bhatnagar
- Department of Cardiology, Division of Medicine, Akershus University Hospital, Lørenskog, Norway,
- K.G. Jebsen Center for Cardiac Biomarkers, University of Oslo, Oslo, Norway,
| | - Kristian Berge
- Department of Cardiology, Division of Medicine, Akershus University Hospital, Lørenskog, Norway
- K.G. Jebsen Center for Cardiac Biomarkers, University of Oslo, Oslo, Norway
| | - Ragnhild Røysland
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Division for Diagnostics and Technology, Akershus University Hospital, Lørenskog, Norway
| | - Arne Didrik Høiseth
- Department of Cardiology, Division of Medicine, Akershus University Hospital, Lørenskog, Norway
| | - Jon Brynildsen
- Department of Cardiology, Division of Medicine, Akershus University Hospital, Lørenskog, Norway
| | - Geir Christensen
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Institute for Experimental Medical Research, Oslo University Hospital and University of Oslo, Oslo, Norway
| | - Torbjørn Omland
- Department of Cardiology, Division of Medicine, Akershus University Hospital, Lørenskog, Norway
- K.G. Jebsen Center for Cardiac Biomarkers, University of Oslo, Oslo, Norway
| | - Helge Røsjø
- K.G. Jebsen Center for Cardiac Biomarkers, University of Oslo, Oslo, Norway
- Division of Research and Innovation, Akershus University Hospital, Lørenskog, Norway
| | - Magnus Nakrem Lyngbakken
- Department of Cardiology, Division of Medicine, Akershus University Hospital, Lørenskog, Norway
- K.G. Jebsen Center for Cardiac Biomarkers, University of Oslo, Oslo, Norway
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Gulati M, Levy PD, Mukherjee D, Amsterdam E, Bhatt DL, Birtcher KK, Blankstein R, Boyd J, Bullock-Palmer RP, Conejo T, Diercks DB, Gentile F, Greenwood JP, Hess EP, Hollenberg SM, Jaber WA, Jneid H, Joglar JA, Morrow DA, O'Connor RE, Ross MA, Shaw LJ. 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Cardiovasc Comput Tomogr 2022; 16:54-122. [PMID: 34955448 DOI: 10.1016/j.jcct.2021.11.009] [Citation(s) in RCA: 60] [Impact Index Per Article: 30.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
AIM This clinical practice guideline for the evaluation and diagnosis of chest pain provides recommendations and algorithms for clinicians to assess and diagnose chest pain in adult patients. METHODS A comprehensive literature search was conducted from November 11, 2017, to May 1, 2020, encompassing randomized and nonrandomized trials, observational studies, registries, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Collaboration, Agency for Healthcare Research and Quality reports, and other relevant databases. Additional relevant studies, published through April 2021, were also considered. STRUCTURE Chest pain is a frequent cause for emergency department visits in the United States. The "2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain" provides recommendations based on contemporary evidence on the assessment and evaluation of chest pain. This guideline presents an evidence-based approach to risk stratification and the diagnostic workup for the evaluation of chest pain. Cost-value considerations in diagnostic testing have been incorporated, and shared decision-making with patients is recommended.
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Gulati M, Levy PD, Mukherjee D, Amsterdam E, Bhatt DL, Birtcher KK, Blankstein R, Boyd J, Bullock-Palmer RP, Conejo T, Diercks DB, Gentile F, Greenwood JP, Hess EP, Hollenberg SM, Jaber WA, Jneid H, Joglar JA, Morrow DA, O'Connor RE, Ross MA, Shaw LJ. 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol 2021; 78:e187-e285. [PMID: 34756653 DOI: 10.1016/j.jacc.2021.07.053] [Citation(s) in RCA: 319] [Impact Index Per Article: 106.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
AIM This clinical practice guideline for the evaluation and diagnosis of chest pain provides recommendations and algorithms for clinicians to assess and diagnose chest pain in adult patients. METHODS A comprehensive literature search was conducted from November 11, 2017, to May 1, 2020, encompassing randomized and nonrandomized trials, observational studies, registries, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Collaboration, Agency for Healthcare Research and Quality reports, and other relevant databases. Additional relevant studies, published through April 2021, were also considered. STRUCTURE Chest pain is a frequent cause for emergency department visits in the United States. The "2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain" provides recommendations based on contemporary evidence on the assessment and evaluation of chest pain. This guideline presents an evidence-based approach to risk stratification and the diagnostic workup for the evaluation of chest pain. Cost-value considerations in diagnostic testing have been incorporated, and shared decision-making with patients is recommended.
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2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol 2021; 78:2218-2261. [PMID: 34756652 DOI: 10.1016/j.jacc.2021.07.052] [Citation(s) in RCA: 48] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
AIM This executive summary of the clinical practice guideline for the evaluation and diagnosis of chest pain provides recommendations and algorithms for clinicians to assess and diagnose chest pain in adult patients. METHODS A comprehensive literature search was conducted from November 11, 2017, to May 1, 2020, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Collaboration, Agency for Healthcare Research and Quality reports, and other relevant databases. Additional relevant studies, published through April 2021, were also considered. STRUCTURE Chest pain is a frequent cause for emergency department visits in the United States. The "2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain" provides recommendations based on contemporary evidence on the assessment and evaluation of chest pain. These guidelines present an evidence-based approach to risk stratification and the diagnostic workup for the evaluation of chest pain. Cost-value considerations in diagnostic testing have been incorporated and shared decision-making with patients is recommended.
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7
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Gulati M, Levy PD, Mukherjee D, Amsterdam E, Bhatt DL, Birtcher KK, Blankstein R, Boyd J, Bullock-Palmer RP, Conejo T, Diercks DB, Gentile F, Greenwood JP, Hess EP, Hollenberg SM, Jaber WA, Jneid H, Joglar JA, Morrow DA, O'Connor RE, Ross MA, Shaw LJ. 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation 2021; 144:e368-e454. [PMID: 34709879 DOI: 10.1161/cir.0000000000001029] [Citation(s) in RCA: 152] [Impact Index Per Article: 50.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
AIM This clinical practice guideline for the evaluation and diagnosis of chest pain provides recommendations and algorithms for clinicians to assess and diagnose chest pain in adult patients. METHODS A comprehensive literature search was conducted from November 11, 2017, to May 1, 2020, encompassing randomized and nonrandomized trials, observational studies, registries, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Collaboration, Agency for Healthcare Research and Quality reports, and other relevant databases. Additional relevant studies, published through April 2021, were also considered. Structure: Chest pain is a frequent cause for emergency department visits in the United States. The "2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain" provides recommendations based on contemporary evidence on the assessment and evaluation of chest pain. This guideline presents an evidence-based approach to risk stratification and the diagnostic workup for the evaluation of chest pain. Cost-value considerations in diagnostic testing have been incorporated, and shared decision-making with patients is recommended.
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Gulati M, Levy PD, Mukherjee D, Amsterdam E, Bhatt DL, Birtcher KK, Blankstein R, Boyd J, Bullock-Palmer RP, Conejo T, Diercks DB, Gentile F, Greenwood JP, Hess EP, Hollenberg SM, Jaber WA, Jneid H, Joglar JA, Morrow DA, O'Connor RE, Ross MA, Shaw LJ. 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation 2021; 144:e368-e454. [PMID: 34709928 DOI: 10.1161/cir.0000000000001030] [Citation(s) in RCA: 87] [Impact Index Per Article: 29.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
AIM This executive summary of the clinical practice guideline for the evaluation and diagnosis of chest pain provides recommendations and algorithms for clinicians to assess and diagnose chest pain in adult patients. METHODS A comprehensive literature search was conducted from November 11, 2017, to May 1, 2020, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Collaboration, Agency for Healthcare Research and Quality reports, and other relevant databases. Additional relevant studies, published through April 2021, were also considered. Structure: Chest pain is a frequent cause for emergency department visits in the United States. The "2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain" provides recommendations based on contemporary evidence on the assessment and evaluation of chest pain. These guidelines present an evidence-based approach to risk stratification and the diagnostic workup for the evaluation of chest pain. Cost-value considerations in diagnostic testing have been incorporated and shared decision-making with patients is recommended.
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10
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Bardají A, Bonet G, Carrasquer A, González-del Hoyo M, Domínguez F, Sánchez R, Boqué C, Cediel G. Prognostic implications of detectable cardiac troponin I below the 99th percentile in patients admitted to an emergency department without acute coronary syndrome. ACTA ACUST UNITED AC 2018; 56:1954-1961. [DOI: 10.1515/cclm-2017-1140] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2017] [Accepted: 04/03/2018] [Indexed: 11/15/2022]
Abstract
Abstract
Background:
Detectable troponin below the 99th percentile may reflect an underlying cardiac abnormality which might entail prognostic consequences. This study aimed to investigate the prognosis of patients admitted to an emergency department (ED) with detectable troponin below the 99th percentile reference limit who did not present with an acute coronary syndrome (ACS).
Methods:
We analysed the clinical data of all consecutive patients admitted to the ED during the years 2012 and 2013 in whom cardiac troponin was requested by the attending clinician (cTnI Ultra Siemens, Advia Centaur). Patients with troponin below the 99th percentile of the reference population (40 ng/L) and who did not have a diagnosis of ACS were selected, and their mortality was evaluated in a 2-year follow-up.
Results:
A total of 2501 patients had a troponin level below the reference limit, with 43.9% of those showing detectable levels (>6 ng/L and <40 ng/L). Patients with detectable levels were elderly and had a higher prevalence of cardiovascular history and more comorbidities. The total mortality in the 2-year follow-up was 12.4% in patients with detectable troponin and 4.5% in patients with undetectable troponin (p<0.001). In the Cox multivariate regression analysis, the detectable troponin was an independent marker of mortality at 2 years (HR 1.62, 95% CI 1.07–2.45, p=0.021).
Conclusions:
Detectable troponin I below the 99th percentile is associated with higher mortality risk at 2-year follow-up in patients admitted to the ED who did not present with ACS.
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11
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Mingels AMA, Cardinaels EPM, Broers NJH, van Sleeuwen A, Streng AS, van Dieijen-Visser MP, Kooman JP, Bekers O. Cardiac Troponin T: Smaller Molecules in Patients with End-Stage Renal Disease than after Onset of Acute Myocardial Infarction. Clin Chem 2017; 63:683-690. [DOI: 10.1373/clinchem.2016.261644] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2016] [Accepted: 08/23/2016] [Indexed: 11/06/2022]
Abstract
Abstract
BACKGROUND
We have found previously that in acute myocardial infarction (AMI), cardiac troponin T (cTnT) is degraded in a time-dependent pattern. We investigated whether cTnT forms differed in patients with chronic cTnT increases, as seen with renal dysfunction, from those in the acute phase of myocardial infarction.
METHODS
We separated cTnT forms by gel filtration chromatography (GFC) in end-stage renal disease (ESRD) patients: prehemodialysis (pre-HD) and post-HD (n = 10) and 2 months follow-up (n = 6). Purified (cTnT) standards, quality control materials of the clinical cTnT immunoassay (Roche), and AMI patients' sera also were analyzed. Immunoprecipitation and Western blotting were performed with the original cTnT antibodies from the clinical assay and antibodies against the N- and C-terminal end of cTnT.
RESULTS
GFC analysis revealed the retention of purified cTnT at 27.5 mL, identical to that for cTnT in quality controls. For all ESRD patients, one cTnT peak was found at 45 mL, pre- and post-HD, and stable over time. Western blotting illustrated that this peak corresponded to cTnT fragments <18 kDa missing the N- and C-terminal ends. AMI patients' sera revealed cTnT peaks at 27.5 and 45 mL, respectively, corresponding to N-terminal truncated cTnT of 29 kDa and N- and C-terminal truncated fragments of <18 kDa, respectively.
CONCLUSIONS
We found that cTnT forms in ESRD patients are small (<18 kDa) and different from forms seen in AMI patients. These insights may prove useful for development of a more specific cTnT immunoassay, especially for the acute and diagnostic phase of myocardial infarction.
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Affiliation(s)
- Alma M A Mingels
- Department of Clinical Chemistry, Central Diagnostic Laboratory, Maastricht University Medical Center
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University
| | - Eline P M Cardinaels
- Department of Clinical Chemistry, Central Diagnostic Laboratory, Maastricht University Medical Center
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University
| | - Natascha J H Broers
- Department of Internal Medicine, Division of Nephrology, Maastricht University Medical Center; and
- School of Nutrition and Translational Research in Metabolism (NUTRIM), Maastricht University, Maastricht, the Netherlands
| | - Anneke van Sleeuwen
- Department of Clinical Chemistry, Central Diagnostic Laboratory, Maastricht University Medical Center
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University
| | - Alexander S Streng
- Department of Clinical Chemistry, Central Diagnostic Laboratory, Maastricht University Medical Center
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University
| | - Marja P van Dieijen-Visser
- Department of Clinical Chemistry, Central Diagnostic Laboratory, Maastricht University Medical Center
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University
| | - Jeroen P Kooman
- Department of Internal Medicine, Division of Nephrology, Maastricht University Medical Center; and
- School of Nutrition and Translational Research in Metabolism (NUTRIM), Maastricht University, Maastricht, the Netherlands
| | - Otto Bekers
- Department of Clinical Chemistry, Central Diagnostic Laboratory, Maastricht University Medical Center
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University
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Jacob J, Roset A, Miró Ò, Alquézar A, Herrero P, Martín-Sanchez FJ, Möckel M, Müller C, Llorens P. EAHFE – TROPICA2 study. Prognostic value of troponin in patients with acute heart failure treated in Spanish hospital emergency departments. Biomarkers 2017; 22:337-344. [DOI: 10.1080/1354750x.2016.1265006] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Affiliation(s)
- Javier Jacob
- Emergency Department, Hospital Universitari de Bellvitge, IDIBELL, L’Hospitalet de Llobregat, Barcelona, Catalonia, Spain
| | - Alex Roset
- Emergency Department, Hospital Universitari de Bellvitge, IDIBELL, L’Hospitalet de Llobregat, Barcelona, Catalonia, Spain
| | - Òscar Miró
- Emergency Department, Hospital Clínic, Research Group “Emergencies: processes and diseases”, IDIBAPS, Barcelona, Catalonia, Spain
| | - Aitor Alquézar
- Emergency Department, Hospital de la Santa Creu i Sant Pau, Barcelona, Catalonia, Spain
| | - Pablo Herrero
- Emergency Department, Hospital Universitario Central de Asturias, Oviedo, Spain
| | - Francisco Javier Martín-Sanchez
- Emergency Department, Hospital Clínico San Carlos, Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Madrid, Spain
| | - Martin Möckel
- Department of Cardiology Division of Emergency Medicine, Charité-University Medicine Berlin, Berlin, Germany
| | - Christian Müller
- Department of Cardiology & Cardiovascular Research Institute Basel, University Hospital Basel, Basel, Switzerland
| | - Pere Llorens
- Department of Emergency Medicine, Short-Stay Unit and Hospital at-home, Hospital General Universitario de Alicante, Alicante, Spain
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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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Salvatici M, Cardinale D, Botteri E, Bagnardi V, Mauro C, Cassatella MC, Lentati P, Bottari F, Zorzino L, Passerini R, Cipolla CM, Sandri MT. TnI-Ultra assay measurements in cancer patients: Comparison with the conventional assay and clinical implication. Scandinavian Journal of Clinical and Laboratory Investigation 2014; 74:385-91. [DOI: 10.3109/00365513.2014.898325] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
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15
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Effect of antioxidant supplementation on exercise-induced cardiac troponin release in cyclists: a randomized trial. PLoS One 2013; 8:e79280. [PMID: 24260184 PMCID: PMC3834092 DOI: 10.1371/journal.pone.0079280] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2013] [Accepted: 09/20/2013] [Indexed: 12/02/2022] Open
Abstract
Background Cardiac troponin is the biochemical gold standard to diagnose acute myocardial infarction. Interestingly however, elevated cardiac troponin concentrations are also frequently observed during and after endurance-type exercise. Oxidative stress associated with prolonged exercise has been proposed to contribute to cardiac troponin release. Therefore, the aim of this study was to assess the effect of 4 week astaxanthin supplementation (a potent cartenoid antioxidant) on antioxidant capacity and exercise-induced cardiac troponin release in cyclists. Methods Thirty-two well-trained male cyclists (age 25±5, weight 73±7 kg, maximum O2 uptake 60±5 mL·kg−1·min−1, Wmax 5.4±0.5 W·kg−1; mean ± SD) were repeatedly subjected to a laboratory based standardized exercise protocol before and after 4 weeks of astaxanthin (20 mg/day), or placebo supplementation in a double-blind randomized manner. Blood samples were obtained at baseline, at 60 min of cycling and immediately post-exercise (≈ 120 min). Results The pre-supplementation cycling trial induced a significant rise of median cardiac troponin T concentrations from 3.2 (IQR 3.0–4.2) to 4.7 ng/L (IQR 3.7–6.7), immediately post-exercise (p<0.001). Four weeks of astaxanthin supplementation significantly increased mean basal plasma astaxanthin concentrations from non-detectable values to 175±86 µg·kg−1. However, daily astaxanthin supplementation had no effect on exercise-induced cardiac troponin T release (p = 0.24), as measured by the incremental area under the curve. Furthermore, the elevation in basal plasma astaxanthin concentrations was not reflected in changes in antioxidant capacity markers (trolox equivalent antioxidant capacity, uric acid, and malondialdehyde). Markers of inflammation (high-sensitivity C-reactive protein) and exercise-induced skeletal muscle damage (creatine kinase) were equally unaffected by astaxanthin supplementation. Conclusion Despite substantial increases in plasma astaxanthin concentrations, astaxanthin supplementation did not improve antioxidant capacity in well-trained cyclists. Accordingly, exercise-induced cardiac troponin T concentrations were not affected by astaxanthin supplementation. Trial registration ClinicalTrials.gov NCT01241877
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16
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Gamble JHP, Carlton EW, Orr WP, Greaves K. High-sensitivity cardiac troponins: no more 'negatives'. Expert Rev Cardiovasc Ther 2013; 11:1129-39. [PMID: 23977868 DOI: 10.1586/14779072.2013.828978] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
According to recently published expert guidelines, cardiac troponins are the only accepted biomarkers to define acute myocardial infarction. New high sensitivity cardiac troponin assays provide exciting opportunities for early rule-out and rule-in strategies and for identifying high-risk patients early in their presentation to guide early treatment and intervention. This review briefly discusses the history of troponin testing, before going on to cover clinical uses of the new highly sensitive assays in the early assessment of acute myocardial infection. Common clinical pitfalls with the use of these assays are discussed, as is the use of highly sensitive troponins more widely as prognostic markers. Likely future developments in this area are discussed.
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Affiliation(s)
- James H P Gamble
- Cardiovascular Clinical Research Facility, John Radcliffe Hospital, Oxford OX3 9DU, UK
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Eurlings LW, Sanders-van Wijk S, van Kimmenade R, Osinski A, van Helmond L, Vallinga M, Crijns HJ, van Dieijen-Visser MP, Brunner-La Rocca HP, Pinto YM. Multimarker strategy for short-term risk assessment in patients with dyspnea in the emergency department: the MARKED (Multi mARKer Emergency Dyspnea)-risk score. J Am Coll Cardiol 2012; 60:1668-77. [PMID: 23021334 DOI: 10.1016/j.jacc.2012.06.040] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2012] [Revised: 05/28/2012] [Accepted: 06/26/2012] [Indexed: 11/15/2022]
Abstract
OBJECTIVES The study aim was to determine the prognostic value of a multimarker strategy for risk-assessment in patients presenting to the emergency department (ED) with dyspnea. BACKGROUND Combining biomarkers with different pathophysiological backgrounds may improve risk stratification in dyspneic patients in the ED. METHODS The study prospectively investigated the prognostic value of the biomarkers N-terminal pro-B-type natriuretic peptide (NT-proBNP), high-sensitivity cardiac troponin T (hs-cTnT), Cystatin-C (Cys-C), high-sensitivity C-reactive protein (hs-CRP), and Galectin-3 (Gal-3) for 90-day mortality in 603 patients presenting to the ED with dyspnea as primary complaint. RESULTS hs-CRP, hs-cTnT, Cyst-C, and NT-proBNP were independent predictors of 90-day mortality. The number of elevated biomarkers was highly associated with outcome (odds ratio: 2.94 per biomarker, 95% confidence interval [CI]: 2.29 to 3.78, p < 0.001). A multimarker approach had incremental value beyond a single-marker approach. Our multimarker emergency dyspnea-risk score (MARKED-risk score) incorporating age ≥75 years, systolic blood pressure <110 mm Hg, history of heart failure, dyspnea New York Heart Association functional class IV, hs-cTnT ≥0.04 μg/l, hs-CRP ≥25 mg/l, and Cys-C ≥1.125 mg/l had excellent prognostic performance (area under the curve: 0.85, 95% CI: 0.81 to 0.89), was robust in internal validation analyses and could identify patients with very low (<3 points), intermediate (≥3, <5 points), and high risk (≥5 points) of 90-day mortality (2%, 14%, and 44% respectively; p < 0.001). CONCLUSIONS A multimarker strategy provided superior risk stratification beyond any single-marker approach. The MARKED-risk score that incorporates hs-cTnT, hs-CRP, and Cys-C along with clinical risk factors accurately identifies patients with very low, intermediate, and high risk.
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Affiliation(s)
- Luc W Eurlings
- Department of Cardiology, Maastricht University Medical Center, CARIM, Maastricht, the Netherlands.
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Yap CYF, Phua SK, Aw TC. Clinical Use and Measurement of Cardiac Troponin (cTn). PROCEEDINGS OF SINGAPORE HEALTHCARE 2012. [DOI: 10.1177/201010581202100211] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Cardiac troponins are cardio-specific and are widely used for the early diagnosis and triage of patients with acute coronary syndromes in conjunction with clinical history, electrocardiographic changes and imaging. Troponin is also useful for the prediction of outcomes in acute coronary syndromes, renal failure, sepsis, and critically ill patients. New developments in assay technology, designated as high sensitivity troponins, permit detection of lower levels of troponin in most healthy individuals, earlier diagnosis of myocardial infarction, and prognosis of stable coronary disease in the community.
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Affiliation(s)
- Clementine YF Yap
- Department of Laboratory Medicine, Changi General Hospital, Singapore
| | - Soon Kieng Phua
- Department of Laboratory Medicine, Changi General Hospital, Singapore
| | - Tar Choon Aw
- Department of Laboratory Medicine, Changi General Hospital, Singapore
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Apple FS, Blankenberg S, Morrow DA. Impact of Biomarkers, Proteomics, and Genomics in Cardiovascular Disease. Clin Chem 2012; 58:1-2. [DOI: 10.1373/clinchem.2011.175919] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Affiliation(s)
- Fred S Apple
- Hennepin County Medical Center, Minneapolis, MN
- Department of Laboratory Medicine and Pathology, University of Minnesota, Minneapolis, MN
| | - Stefan Blankenberg
- Department of General and Interventional Cardiology, The University Heart Center at the University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - David A Morrow
- TIMI Study Group, and
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Boston, MA
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