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Mital P, Forrester J, Abecassis S, Haverty J, Arata X, Gorlin M, Perera T. Delta troponin does not distinguish acute coronary syndrome in emergency department patients with renal impairment and an initial positive troponin. J Am Coll Emerg Physicians Open 2024; 5:e13228. [PMID: 38975017 PMCID: PMC11224499 DOI: 10.1002/emp2.13228] [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: 08/11/2023] [Revised: 05/01/2024] [Accepted: 06/06/2024] [Indexed: 07/09/2024] Open
Abstract
Background In emergency department (ED) patients with renal impairment, troponin concentrations can be positive without myocardial ischemia. When there is clinical concern for acute coronary syndrome (ACS), guidelines recommend obtaining a delta troponin measurement to identify acute myocardial injury. However, evidence supporting the use of delta troponin to rule in or out ACS in patients with renal impairment and initial elevated troponin levels is limited. Methods This retrospective, observational study assessed the diagnostic value of a 20% delta troponin cutoff in the prediction of ACS events in ED patients (estimated glomerular filtration rate [eGFR] <60 mL/min/1.72 m2) with renal impairment, clinical concern for ACS, and an initial positive troponin concentration using either conventional troponin (cTnT) or high-sensitivity troponin (hsTnT). Clinical concern for ACS was based on initial ED physician-reported diagnoses. Patients with an initial diagnosis of ST-elevation myocardial infarction were not included. A positive initial troponin was identified at a threshold of ≥0.06 ng/mL for cTnT and ≥52 ng/L for hsTnT, and delta troponin measurements were obtained within 24 h of the initial troponin. The primary composite outcome, termed ACS event, included (1) cardiac-related mortality, (2) coronary revascularization (or its recommendation), or a (3) clinically diagnosed type-1 myocardial infarction within 6 weeks of the ED presentation. Sensitivities, specificities, negative predictive values, positive predictive values, and negative and positive likelihood ratios were calculated for these 6-week ACS events. Results A total of 608 ED patients with renal impairment, an initial positive troponin, and clinical concern for ACS were included in the study. Of these patients, 234 had an initial positive cTnT (median eGFR 18 mL/min/1.72 m2) and 374 had an initial positive hsTnT (median eGFR 25 mL/min/1.72 m2). The overall ACS event rate was 38% in the cTnT group and 33% in the hsTnT group. In those with a negative delta, the 6-week ACS event rate was 32% when using cTnT, compared to 24% using hsTnT. Conversely, a positive delta was associated with an ACS event rate of 47% when cTnT was utilized versus 61% when hsTnT was utilized. Conclusion In this study, approximately one-third of ED patients with renal impairment who had an initial positive troponin and clinical concern for ACS developed ACS events at 6 weeks. A delta troponin did not appear to provide clinically meaningful assistance in the prediction or exclusion of 6-week ACS events in this cohort.
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Affiliation(s)
- Praveen Mital
- Department of Emergency MedicineNorth Shore University HospitalNorthwell HealthManhassetNew YorkUSA
| | - John Forrester
- Department of Emergency MedicineNorth Shore University HospitalNorthwell HealthManhassetNew YorkUSA
| | - Samuel Abecassis
- Department of Emergency MedicineNorth Shore University HospitalNorthwell HealthManhassetNew YorkUSA
| | - John Haverty
- Department of Emergency MedicineNorth Shore University HospitalNorthwell HealthManhassetNew YorkUSA
| | - Ximena Arata
- Department of Emergency MedicineNorth Shore University HospitalNorthwell HealthManhassetNew YorkUSA
| | - Margaret Gorlin
- Department of Emergency MedicineNorth Shore University HospitalNorthwell HealthManhassetNew YorkUSA
| | - Thomas Perera
- Department of Emergency MedicineNorth Shore University HospitalNorthwell HealthManhassetNew YorkUSA
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Knott JD, Ola O, De Michieli L, Akula A, Yang EH, Gharacholou SM, Slusser J, Lewis B, Mehta RA, Gulati R, Sandoval Y, Jaffe AS. High Baseline High-Sensitivity Cardiac Troponin T Concentrations and Risk of Index Acute Myocardial Infarction. Mayo Clin Proc 2024:S0025-6196(24)00026-0. [PMID: 38493402 DOI: 10.1016/j.mayocp.2023.12.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Revised: 12/15/2023] [Accepted: 12/26/2023] [Indexed: 03/18/2024]
Abstract
OBJECTIVE To evaluate the diagnostic performance of the previously recommended baseline high-sensitivity cardiac troponin T (hs-cTnT) thresholds of 52 and 100 ng/L in identifying patients at high risk of acute myocardial infarction (AMI). PATIENTS AND METHODS This study compared the positive predictive value (PPV) for index AMI of these high-risk hs-cTnT thresholds in adult patients in the emergency department undergoing hs-cTnT measurement. RESULTS The adjudicated MAyo Southwest Wisconsin 5th Gen Troponin T ImplementatiON cohort included 2053 patients, with 157 (7.6%) who received a diagnosis of AMI. The hs-cTnT concentrations of greater than 52 and greater than 100 ng/L resulted in PPVs of 41% (95% CI, 35%-48%) and 57% (95% CI, 48%-66%). In patients with chest discomfort, hs-cTnT concentrations greater than 52 ng/L resulted in a PPV of 66% (95% CI, 56%-76%) and hs-cTnT concentrations greater than 100 ng/L resulted in a PPV of 77% (95% CI, 65%-87%). The CV Data Mart Biomarker cohort included 143,709 patients, and 3003 (2.1%) received a diagnosis of AMI. Baseline hs-cTnT concentrations greater than 52 and greater than 100 ng/L resulted in PPVs of 12% (95% CI, 11%-12%) and 17% (95% CI, 17%-19%), respectively. In patients with chest pain and hs-cTnT concentrations greater than 52 ng/L, the PPV for MI was 17% (95% CI, 15%-18%) and in those with concentrations greater than 100 ng/L, only 22% (95% CI, 19%-25%). CONCLUSION In unselected patients undergoing hs-cTnT measurement, the hs-cTnT thresholds of greater than 52 and greater than 100 ng/L provide suboptimal performance for identifying high-risk patients. In patients with chest discomfort, an hs-cTnT concentration of greater than 100 ng/L, but not the European Society of Cardiology-recommended threshold of greater than 52 ng/L, provides an acceptable performance but should be used only with other clinical features.
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Affiliation(s)
- Jonathan D Knott
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN
| | - Olatunde Ola
- Department of Cardiovascular Diseases, Marshall University School of Medicine, Huntington, WV; Center for Clinical and Translational Science, Mayo Clinic Graduate School of Biomedical Sciences, Rochester, MN
| | - Laura De Michieli
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN; Department of Cardiac, Thoracic and Vascular Sciences and Public Health, University of Padova, Padova, Italy
| | - Ashok Akula
- Department of Cardiovascular Diseases, University of Arkansas for Medical Sciences, Little Rock, AK
| | - Eric H Yang
- Department of Cardiovascular Diseases, Mayo Clinic, Phoenix, AZ
| | | | - Josh Slusser
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN
| | - Bradley Lewis
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN
| | - Ramila A Mehta
- Department of Quantitative Health Sciences, Mayo College of Medicine, Rochester, MN
| | - Rajiv Gulati
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN
| | - Yader Sandoval
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN; Minneapolis Heart Institute, Abbott Northwestern Hospital, and Minneapolis Heart Institute Foundation, Minneapolis, MN
| | - Allan S Jaffe
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN; Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN.
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Hunderup MM, Kampmann JD, Kristensen FB, Hafsund M. The short-term effect of hemodialysis on the level of high-sensitive cardiac troponin T - A systematic review. Semin Dial 2024; 37:110-116. [PMID: 37779378 DOI: 10.1111/sdi.13178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Accepted: 09/10/2023] [Indexed: 10/03/2023]
Abstract
INTRODUCTION Patients with end-stage renal disease (ESRD) have an increased risk of cardiovascular disease, but interpreting cardiac troponin is difficult in this population. The effect of renal replacement therapy (RRT) is important to consider when interpreting serial cardiac troponin T (cTnT) results for patients with ESRD suspected of acute coronary syndrome (ACS). The aim of this systematic review is to answer how low-flux hemodialysis (LF-HD), high-flux hemodialysis (HF-HD), and hemodiafiltration (HDF) affect the blood concentration of high-sensitive cardiac troponin T (hs-cTnT). METHOD Several databases were searched and identified records were evaluated independently by two of the authors. Pre- and postdialysis hs-cTnT concentrations together with other relevant data were extracted from the included studies. The quality (potential bias and applicability issues) were assessed for each of the included studies. RESULTS The literature search identified 2,540 records and 15 studies were included. The relative pre- to postdialysis change of hs-cTnT varied from -41 to 29%. LF-HD increased the hs-cTnT concentration with relative changes between 2 and 17%. HDF decreased the concentration with relative changes from -41% to -9%. Both increases and decreases were seen for HF-HD (-16% to 12%). DISCUSSION/CONCLUSION In this systematic review, we found LF-HD to increase the hs-cTnT concentration and HDF to decrease the concentration. Results for HF-HD and unspecified HD are more heterogeneous. Because of the differences between the included studies, a meta-analysis was not meaningful. This systematic review can help with the assessment of patients with ESRD suspected of ACS in relation to hemodialysis/HDF treatment.
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Affiliation(s)
- Michael Mejer Hunderup
- Department of Clinical Biochemistry and Immunology, University Hospital of Southern Denmark, Aabenraa, Denmark
- Department of Clinical Biochemistry and Immunology, Lillebaelt Hospital, Vejle, Denmark
| | - Jan Dominik Kampmann
- Department of Internal Medicine, University Hospital of Southern Denmark, Sonderborg, Denmark
- Institute of Regional Health Research, University of Southern Denmark, Odense, Denmark
| | - Frans Brandt Kristensen
- Department of Internal Medicine, University Hospital of Southern Denmark, Sonderborg, Denmark
- Institute of Regional Health Research, University of Southern Denmark, Odense, Denmark
| | - Marius Hafsund
- Department of Internal Medicine, University Hospital of Southern Denmark, Sonderborg, Denmark
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Hti Lar Seng NS, Zeratsion G, Pena Zapata OY, Tufail MU, Jim B. Utility of Cardiac Troponins in Patients With Chronic Kidney Disease. Cardiol Rev 2024; 32:62-70. [PMID: 35617248 DOI: 10.1097/crd.0000000000000461] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Cardiovascular disease is a major cause of death worldwide especially in patients with chronic kidney disease (CKD). Troponin T and troponin I are cardiac biomarkers used not only to diagnose acute myocardial infarction (AMI) but also to prognosticate cardiovascular and all-cause mortality. The diagnosis of AMI in the CKD population is challenging because of their elevated troponins at baseline. The development of high-sensitivity cardiac troponins shortens the time needed to rule in and rule out AMI in patients with normal renal function. While the sensitivity of high-sensitivity cardiac troponins is preserved in the CKD population, the specificity of these tests is compromised. Hence, diagnosing AMI in CKD remains problematic even with the introduction of high-sensitivity assays. The prognostic significance of troponins did not differ whether it is detected with standard or high-sensitivity assays. The elevation of both troponin T and troponin I in CKD patients remains strongly correlated with adverse cardiovascular and all-cause mortality, and the prognosis becomes poorer with advanced CKD stages. Interestingly, the degree of troponin elevation appears to be predictive of the rate of renal decline via unclear mechanisms though activation of the renin-angiotensin and other hormonal/oxidative stress systems remain suspect. In this review, we present the latest evidence of the use of cardiac troponins in both the diagnosis of AMI and the prognosis of cardiovascular and all-cause mortality. We also suggest strategies to improve on the diagnostic capability of these troponins in the CKD/end-stage kidney disease population.
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Affiliation(s)
- Nang San Hti Lar Seng
- From the Division of Nephrology/Department of Medicine, Jacobi Medical Center at Albert Einstein College of Medicine, Bronx, NY
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Kumar S, Griffith N, Walter D, Swett M, Raman V, Vargas JD, Deb B, Chou J, Arafat A, Srichai MB. Characterization of Myocardial Injury With High-Sensitivity Troponin. Tex Heart Inst J 2023; 50:e238108. [PMID: 38115713 PMCID: PMC10751476 DOI: 10.14503/thij-23-8108] [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] [Indexed: 12/21/2023]
Abstract
BACKGROUND High-sensitivity troponin I, cardiac form (hs-cTnI) accelerates the assessment of acute coronary syndrome. Little has been documented about its performance, how it relates to different types of myocardial injury, and its impact on morbidity and mortality. This study sought to expand understanding of hs-cTnI by characterizing types of myocardial injury, the impact of comorbidities, and 30-day outcomes. METHODS The study retrospectively evaluated 1,975 patients with hs-cTnI levels obtained in the emergency department or inpatient setting from June to September 2020. Troponin was considered elevated if it was higher than the 99th percentile for either sex. Charts were reviewed to determine the presence of myocardial injury. Troponin elevation was adjusted for demographics, comorbidities, and kidney dysfunction. Thirty-day mortality and readmission rates were calculated. RESULTS Of 1,975 patients, 468 (24%) had elevated hs-cTnI, and 330 (17%) had at least 1 type of myocardial injury, type 2 myocardial infarction being the most frequent. Sensitivity and specificity using the 99th percentile as a cutoff were 99% and 92%, respectively. The average maximum hs-cTnI level was significantly higher for type 1 myocardial infarction (P < .001). Being male, Black, non-Hispanic, and a hospital inpatient were all associated with higher initial and peak hs-cTnI levels (P < .001). Elevated hs-cTnI level, age, heart disease, kidney dysfunction, and inpatient status were predictive of 30-day mortality on multivariate analysis. CONCLUSION Elevated hs-cTnI levels in emergency department and inpatient settings occurs most commonly because of type 2 myocardial infarction. Maximum hs-cTnI level is associated with the patient's particular type of myocardial injury, certain demographics, and cardiovascular comorbidities, and it may be a predictor of 30-day outcomes.
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Affiliation(s)
- Sant Kumar
- Department of Internal Medicine, MedStar Georgetown University Hospital, Washington, DC
| | - Nayrana Griffith
- Department of Internal Medicine, MedStar Georgetown University Hospital, Washington, DC
| | - Dylan Walter
- Department of Internal Medicine, MedStar Georgetown University Hospital, Washington, DC
| | - Michael Swett
- Department of Internal Medicine, MedStar Georgetown University Hospital, Washington, DC
| | - Venkatesh Raman
- Department of Cardiology, US Department of Veterans Affair Medical Center, Washington, DC
| | - Jose D. Vargas
- Department of Cardiology, US Department of Veterans Affair Medical Center, Washington, DC
| | - Brototo Deb
- Department of Internal Medicine, MedStar Washington Hospital Center, Washington, DC
| | - Jiling Chou
- MedStar Health Research Institute, Hyattsville, Maryland
| | - Ayah Arafat
- MedStar Health Research Institute, Hyattsville, Maryland
| | - Monvadi B. Srichai
- Department of Cardiology, MedStar Georgetown University Hospital, Washington, DC
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6
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O'Lone E, Apple FS, Burton JO, Caskey FJ, Craig JC, de Filippi CR, Forfang D, Hicks KA, Jha V, Mahaffey KW, Mark PB, Rossignol P, Scholes-Robertson N, Jaure A, Viecelli AK, Wang AY, Wheeler DC, White D, Winkelmayer WC, Herzog CA. Defining Myocardial Infarction in trials of people receiving hemodialysis: consensus report from the SONG-HD MI Expert Working group. Kidney Int 2023; 103:1028-1037. [PMID: 37023851 DOI: 10.1016/j.kint.2023.02.033] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Revised: 01/22/2023] [Accepted: 02/15/2023] [Indexed: 04/08/2023]
Abstract
Cardiovascular disease is the leading cause of death in patients receiving hemodialysis. Currently there is no standardized definition of myocardial infarction (MI) for patients receiving hemodialysis. Through an international consensus process MI was established as the core CVD measure for this population in clinical trials. The Standardised Outcomes in Nephrology Group - Hemodialysis (SONG-HD) initiative convened a multidisciplinary, international working group to address the definition of MI in this population.Based on current evidence, the working group recommends using the 4th Universal Definition of MI with specific caveats with regard to the interpretation of "ischemic symptoms" and performing a baseline 12-lead electrocardiogram to facilitate interpretation of acute changes on subsequent tracings. The working group does not recommend obtaining baseline cardiac troponin values, though does recommend obtaining serial cardiac biomarkers in settings where ischemia is suspected. Application of an evidence-based uniform definition should increase the reliability and accuracy of trial results.
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Affiliation(s)
- E O'Lone
- The University of Sydney, Camperdown, Sydney, Australia.
| | - F S Apple
- Departments of Laboratory Medicine and Pathology, Hennepin Healthcare/Hennepin County Medical Center and University of Minnesota, Minneapolis, Minnesota
| | - J O Burton
- Department of Cardiovascular Sciences, University of Leicester and NIHR Leicester Cardiovascular Biomedical Research Unit, Glenfield Hospital Leicester, Leicester, UK
| | - F J Caskey
- Population Health Sciences, University of Bristol, Southmead Hospital, Bristol, UK
| | - J C Craig
- College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia
| | - C R de Filippi
- Inova Heart and Vascular Institute, Falls Church, VA, USA
| | - D Forfang
- The National Forum of ESRD Networks, Kidney Patient Advisory Council (KPAC) WI USA
| | - K A Hicks
- Division of Cardiology and Nephrology, Office of Cardiology, Hematology, Endocrinology, and Nephrology, Center for Drug Evaluation and Research (CDER), United States Food and Drug Administration, Silver Spring, Maryland, USA
| | - V Jha
- George Institute of Global Health, UNSW, New Delhi, India; School of Public Health, Imperial College, London, UK; Prasanna School of Public Health, Manipal Academy of Higher Education, Manipal, India
| | - K W Mahaffey
- The Stanford Center for Clinical Research, Department of Medicine, Stanford University School of Medicine, Stanford, CA
| | - P B Mark
- University of Glasgow, Institute of Cardiovascular and Medical Sciences, Glasgow, UK
| | - P Rossignol
- Université de Lorraine, Centre d'Investigation Clinique Plurithématique 1433 -INSERM- CHRU de Nancy, Inserm U1116 & FCRIN INI-CRCT (Cardiovascular and RenalClinical Trialists), Vandoeuvre-les-Nancy, France; Medical specialties and nephrology -hemodialysis departments, Princess Grace Hospital, and Monaco Private Hemodialysis Centre, Monaco, Monaco
| | - N Scholes-Robertson
- College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia
| | - A Jaure
- The University of Sydney, Camperdown, Sydney, Australia; Centre for Kidney Research, Children's Hospital at Westmead, Westmead, NSW, Australia
| | - A K Viecelli
- Department of Nephrology, Princess Alexandra Hospital, Brisbane, Australia
| | - A Y Wang
- Queen Mary Hospital, The University of Hong Kong, Hong Kong, China
| | - D C Wheeler
- University College London, London, United Kingdom
| | - D White
- American Association of Kidney Patients, Tampa, Florida
| | - W C Winkelmayer
- Selzman Institute for Kidney Health, Section of Nephrology, Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - C A Herzog
- Chronic Disease Research Group, Hennepin Healthcare Research Institute,Minneapolis, Minnesota; Division of Cardiology, Department of Medicine, Hennepin Healthcare and University of Minnesota, Minneapolis, Minnesota
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Yuan L, Chen C, Feng Y, Yang X, Li Y, Wu Y, Hu F, Zhang M, Li X, Hu H, Zhang J, Li T, Liu Y, Sun X, Hu D, Zhao Y. High sensitivity cardiac troponin, a cardiac marker predicting death in patients with kidney disease: a dose-response Meta-analysis of cohort studies. QJM 2022; 116:335-343. [PMID: 35380710 DOI: 10.1093/qjmed/hcac091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Revised: 03/22/2022] [Accepted: 03/29/2022] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Patients with kidney disease are at increased risk of adverse mortality events. Numerous studies have demonstrated the positive association of high sensitivity cardiac troponin T (hs-cTnT) and I (hs-cTnI) with all-cause and cardiovascular (CV) mortality in patients with kidney disease; however, the dose-response meta-analysis have not been reported. We therefore performed this study to evaluate the dose-response associations of hs-cTn with risk of all-cause and CV mortality to improve risk stratification. METHODS We searched three databases (PubMed, Embase, and Web of Science) to identify relevant prospective cohort studies published up to January 12, 2021. Random-effects models were used to summarize relative risks (RRs) and 95% confidence intervals (CIs) of all-cause and CV mortality. Restricted cubic splines were used to fit the dose-response associations. RESULTS For each 10 ng/L increase in hs-cTnT and hs-cTnI, the risk increased by 14% (RR = 1.14, 95% CI, 1.10-1.18) and 19% (RR = 1.19, 95% CI, 1.09-1.31) for all-cause mortality, 25% (RR = 1.25, 95% CI, 1.13-1.38) and 19% (RR = 1.19, 95% CI, 1.10-1.29) for CV mortality. A linear trend was found between hs-cTnT and all-cause mortality, whereas a non-linear trend was found in hs-cTnI. Additionally, both hs-cTnT and hs-cTnI were shown to have linear trends with CV mortality. CONCLUSION Our meta-analysis suggests that hs-cTn had high sensitivity in predicting mortality events. All dose-response trends were rising rather than falling, conferring that any increase in the levels of hs-cTn may possibly predict a death prognosis among CKD patients.
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Affiliation(s)
- Lijun Yuan
- Department of Epidemiology and Biostatistics, College of Public Health, Zhengzhou University, Zhengzhou, Henan, People's Republic of China
| | - Chuanqi Chen
- Department of Endocrinology, Shenzhen Qianhai Shekou Free Trade Zone Hospital, Shenzhen, Guangdong, People's Republic of China
| | - Yifei Feng
- Department of Epidemiology and Biostatistics, College of Public Health, Zhengzhou University, Zhengzhou, Henan, People's Republic of China
| | - XingJin Yang
- Department of Epidemiology and Biostatistics, College of Public Health, Zhengzhou University, Zhengzhou, Henan, People's Republic of China
| | - Yang Li
- Department of Biostatistics and Epidemiology, School of Public Health, Shenzhen University Health Science Center, Shenzhen, Guangdong, People's Republic of China
| | - Yuying Wu
- Department of Biostatistics and Epidemiology, School of Public Health, Shenzhen University Health Science Center, Shenzhen, Guangdong, People's Republic of China
| | - Fulan Hu
- Department of Biostatistics and Epidemiology, School of Public Health, Shenzhen University Health Science Center, Shenzhen, Guangdong, People's Republic of China
| | - Ming Zhang
- Department of Biostatistics and Epidemiology, School of Public Health, Shenzhen University Health Science Center, Shenzhen, Guangdong, People's Republic of China
| | - Xi Li
- Department of Epidemiology and Biostatistics, College of Public Health, Zhengzhou University, Zhengzhou, Henan, People's Republic of China
| | - Huifang Hu
- Department of Epidemiology and Biostatistics, College of Public Health, Zhengzhou University, Zhengzhou, Henan, People's Republic of China
| | - Jinli Zhang
- Department of Epidemiology and Biostatistics, College of Public Health, Zhengzhou University, Zhengzhou, Henan, People's Republic of China
| | - Tianze Li
- Department of Epidemiology and Biostatistics, College of Public Health, Zhengzhou University, Zhengzhou, Henan, People's Republic of China
| | - Yu Liu
- Department of General Practice, The Affiliated Luohu Hospital of Shenzhen University Health Science Center, Shenzhen, Guangdong, People's Republic of China
| | - Xizhuo Sun
- Department of General Practice, The Affiliated Luohu Hospital of Shenzhen University Health Science Center, Shenzhen, Guangdong, People's Republic of China
| | - Dongsheng Hu
- Department of Epidemiology and Biostatistics, College of Public Health, Zhengzhou University, Zhengzhou, Henan, People's Republic of China
| | - Yang Zhao
- Department of Epidemiology and Biostatistics, College of Public Health, Zhengzhou University, Zhengzhou, Henan, People's Republic of China
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Kott KA, Bishop M, Yang CHJ, Plasto TM, Cheng DC, Kaplan AI, Cullen L, Celermajer DS, Meikle PJ, Vernon ST, Figtree GA. Biomarker Development in Cardiology: Reviewing the Past to Inform the Future. Cells 2022; 11:588. [PMID: 35159397 PMCID: PMC8834296 DOI: 10.3390/cells11030588] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Revised: 01/27/2022] [Accepted: 02/05/2022] [Indexed: 12/29/2022] Open
Abstract
Cardiac biomarkers have become pivotal to the clinical practice of cardiology, but there remains much to discover that could benefit cardiology patients. We review the discovery of key protein biomarkers in the fields of acute coronary syndrome, heart failure, and atherosclerosis, giving an overview of the populations they were studied in and the statistics that were used to validate them. We review statistical approaches that are currently in use to assess new biomarkers and overview a framework for biomarker discovery and evaluation that could be incorporated into clinical trials to evaluate cardiovascular outcomes in the future.
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Affiliation(s)
- Katharine A. Kott
- Cardiovascular Discovery Group, Kolling Institute of Medical Research, University of Sydney, St Leonards 2065, Australia; (K.A.K.); (S.T.V.)
- Department of Cardiology, Royal North Shore Hospital, St Leonards 2065, Australia
- Sydney Medical School, University of Sydney, Camperdown 2050, Australia; (C.H.J.Y.); (T.M.P.); (D.C.C.); (A.I.K.); (D.S.C.)
| | - Michael Bishop
- School of Medicine and Public Health, University of Newcastle, Kensington 2033, Australia;
| | - Christina H. J. Yang
- Sydney Medical School, University of Sydney, Camperdown 2050, Australia; (C.H.J.Y.); (T.M.P.); (D.C.C.); (A.I.K.); (D.S.C.)
| | - Toby M. Plasto
- Sydney Medical School, University of Sydney, Camperdown 2050, Australia; (C.H.J.Y.); (T.M.P.); (D.C.C.); (A.I.K.); (D.S.C.)
| | - Daniel C. Cheng
- Sydney Medical School, University of Sydney, Camperdown 2050, Australia; (C.H.J.Y.); (T.M.P.); (D.C.C.); (A.I.K.); (D.S.C.)
| | - Adam I. Kaplan
- Sydney Medical School, University of Sydney, Camperdown 2050, Australia; (C.H.J.Y.); (T.M.P.); (D.C.C.); (A.I.K.); (D.S.C.)
| | - Louise Cullen
- Emergency and Trauma Centre, Royal Brisbane and Women’s Hospital, Herston 4029, Australia;
| | - David S. Celermajer
- Sydney Medical School, University of Sydney, Camperdown 2050, Australia; (C.H.J.Y.); (T.M.P.); (D.C.C.); (A.I.K.); (D.S.C.)
- Department of Cardiology, Royal Prince Alfred Hospital, Camperdown 2050, Australia
- The Heart Research Institute, Newtown 2042, Australia
| | - Peter J. Meikle
- Baker Heart and Diabetes Institute, Melbourne 3004, Australia;
| | - Stephen T. Vernon
- Cardiovascular Discovery Group, Kolling Institute of Medical Research, University of Sydney, St Leonards 2065, Australia; (K.A.K.); (S.T.V.)
- Department of Cardiology, Royal North Shore Hospital, St Leonards 2065, Australia
- Sydney Medical School, University of Sydney, Camperdown 2050, Australia; (C.H.J.Y.); (T.M.P.); (D.C.C.); (A.I.K.); (D.S.C.)
| | - Gemma A. Figtree
- Cardiovascular Discovery Group, Kolling Institute of Medical Research, University of Sydney, St Leonards 2065, Australia; (K.A.K.); (S.T.V.)
- Department of Cardiology, Royal North Shore Hospital, St Leonards 2065, Australia
- Sydney Medical School, University of Sydney, Camperdown 2050, Australia; (C.H.J.Y.); (T.M.P.); (D.C.C.); (A.I.K.); (D.S.C.)
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Wan Nur Aimi WMZ, Noorazliyana S, Tuan Salwani TI, Adlin Zafrulan Z, Najib Majdi Y, Noor Azlin Azraini CS. Elevation of Highly Sensitive Cardiac Troponin T Among End-Stage Renal Disease Patients Without Acute Coronary Syndrome. Malays J Med Sci 2022; 28:64-71. [PMID: 35115888 PMCID: PMC8793973 DOI: 10.21315/mjms2021.28.5.6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Accepted: 06/26/2021] [Indexed: 02/08/2023] Open
Abstract
Background In end-stage renal disease (ESRD), troponin T concentrations can be elevated even without cardiac ischaemia, which hampers the diagnosis of acute myocardial infarction (AMI). The objectives of our study were to determine the proportion of dialysisdependent ESRD patients without acute coronary syndrome (ACS) but with highly sensitive cardiac troponin T (hs-cTnT) levels above the 99th percentile upper reference limit and to evaluate the range of hs-cTnT among this population. Methods A cross-sectional study was conducted at the haemodialysis (HD) unit of a tertiary hospital in Malaysia from January 2018 to February 2019. Dialysis-dependent ESRD patients were included and those with a recent history of ACS (within 30 days) were excluded. Pre-dialysed serum hs-cTnT levels were measured using Cobas e411. The upper limit of the 99th percentile value for troponin T was 14 ng/L. Results A total of 150 patients were recruited as study participants. The majority were female (62%) and of Malay ethnicity (94%), and the mean (SD) age was 45.19 (16.36) years old. The hs-cTnT range (min, max) was 11.39–738.30 ng/L and the median (interquartile range [IQR]) of hs-cTnT was 59.20 (83.41) ng/L. Elevated hs-cTnT levels were observed in 149/150 (99%) of the study participants (54/55 [98.2%] of the patients were on HD, and 95/95 [100.0%] of the patients were on continuous ambulatory peritoneal dialysis). Conclusion This study supports prior research showing that even without ACS, most ESRD patients have elevated concentrations of cardiac troponin. Furthermore, our study illustrates the need to revisit the use of absolute troponin values when making a diagnosis of ACS in ESRD patients.
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Affiliation(s)
| | - Shafii Noorazliyana
- Department of Chemical Pathology, School of Medical Sciences, Universiti Sains Malaysia, Kubang Kerian, Kelantan, Malaysia
| | - Tuan Ismail Tuan Salwani
- Department of Chemical Pathology, School of Medical Sciences, Universiti Sains Malaysia, Kubang Kerian, Kelantan, Malaysia
| | - Zakaria Adlin Zafrulan
- Department of Pathology, Hospital Raja Perempuan Zainab II, Kota Bharu, Kelantan, Malaysia
| | - Yaacob Najib Majdi
- Unit of Biostatistics and Research Methodology, School of Medical Sciences, Universiti Sains Malaysia, Kubang Kerian, Kelantan, Malaysia
| | - Che Soh Noor Azlin Azraini
- Department of Chemical Pathology, School of Medical Sciences, Universiti Sains Malaysia, Kubang Kerian, Kelantan, Malaysia
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10
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Emrich IE, Scheuer AL, Rogacev KS, Mahfoud F, Wagenpfeil S, Fliser D, Schirmer SH, Böhm M, Heine GH. Plasma biomarkers outperform echocardiographic measurements for cardiovascular risk prediction in kidney transplant recipients: results of the HOME ALONE study. Clin Kidney J 2021; 15:693-702. [PMID: 35371467 PMCID: PMC8967667 DOI: 10.1093/ckj/sfab216] [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: 06/03/2021] [Indexed: 11/24/2022] Open
Abstract
Background Since kidney transplant recipients (KTRs) have a high cardiovascular disease burden, adequate risk prediction is of importance. Whether echocardiographic parameters and plasma biomarkers, natriuretic peptides [N-terminal pro-B-type natriuretic peptide (NT-proBNP)] and troponin T provide complementary or overlapping prognostic information on cardiovascular events remains uncertain. Methods The prospective Heterogeneity of Monocytes and Echocardiography Among Allograft Recipients in Nephrology (HOME ALONE) study followed 177 KTRs for 5.4 ± 1.7 years. Predefined endpoints were hospitalization for acute decompensated heart failure or all-cause death (HF/D) and major atherosclerotic cardiovascular events or all-cause death (MACE/D). At baseline, plasma NT-proBNP, plasma troponin T and echocardiographic parameters [left atrial volume index, left ventricular (LV) mass index, LV ejection fraction, and LV filling pressure] were assessed. Results Among all echocardiographic and plasma biomarkers measured, only NT-proBNP was consistently associated with HF/D in univariate and multivariate {third versus first tertile: hazard ratio [HR] 4.20 [95% confidence interval (CI) 1.02–17.27]} analysis, and only troponin T was consistently associated with MACE/D in univariate and multivariate [third versus first tertile: HR 8.15 (95% CI 2.75–24.18)] analysis. Conclusion Our data suggest that plasma biomarkers are robust and independent predictors of heart failure and atherosclerotic cardiovascular events after kidney transplantation, whereas standard echocardiographic follow-up does not add to risk prediction.
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Affiliation(s)
- Insa E Emrich
- Saarland University Medical Center, Internal Medicine III, Cardiology, Angiology and Intensive Care Medicine, Homburg, Germany
| | - Anja L Scheuer
- Saarland University Medical Center, Internal Medicine IV, Nephrology and Hypertension, Homburg, Germany
- Agaplesion Markus Krankenhaus, Frankfurt am Main, Germany
| | - Kyrill S Rogacev
- Sana Hanse-Klinikum Wismar, Internal Medicine II, Cardiology, Wismar, Germany
| | - Felix Mahfoud
- Saarland University Medical Center, Internal Medicine III, Cardiology, Angiology and Intensive Care Medicine, Homburg, Germany
| | - Stefan Wagenpfeil
- Saarland University, Institute for Medical Biometry, Epidemiology and Medical Informatics, Campus Homburg, University Medical Center, Germany
| | - Danilo Fliser
- Saarland University Medical Center, Internal Medicine IV, Nephrology and Hypertension, Homburg, Germany
| | - Stephan H Schirmer
- Saarland University Medical Center, Internal Medicine III, Cardiology, Angiology and Intensive Care Medicine, Homburg, Germany
| | - Michael Böhm
- Saarland University Medical Center, Internal Medicine III, Cardiology, Angiology and Intensive Care Medicine, Homburg, Germany
| | - Gunnar H Heine
- Saarland University Medical Center, Internal Medicine IV, Nephrology and Hypertension, Homburg, Germany
- Agaplesion Markus Krankenhaus, Frankfurt am Main, Germany
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11
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Lan NSR, Nguyen LT, Vasikaran SD, Wilson C, Jonsson J, Rankin JM, Bell DA. Short- and long-term biological variation of cardiac troponin I in healthy individuals, and patients with end-stage renal failure requiring haemodialysis or cardiomyopathy. Clin Chem Lab Med 2021; 58:1941-1949. [PMID: 32598297 DOI: 10.1515/cclm-2020-0046] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Accepted: 05/20/2020] [Indexed: 11/15/2022]
Abstract
Objectives High-sensitivity (hs) cardiac troponin (cTn) assays can quantitate small fluctuations in cTn concentration. Determining biological variation allows calculation of reference change values (RCV), to define significant changes. We assessed the short- and long-term biological variation of cardiac troponin I (cTnI) in healthy individuals and patients with renal failure requiring haemodialysis or cardiomyopathy. Methods Plasma samples were collected hourly for 4 h and weekly for seven further weeks from 20 healthy individuals, 9 renal failure patients and 20 cardiomyopathy patients. Pre- and post-haemodialysis samples were collected weekly for 7 weeks. Samples were analysed using a hs-cTnI assay (Abbott Alinity ci-series). Within-subject biological variation (CVI), analytical variation (CVA) and between-subject biological variation (CVG) was used to calculate RCVs and index of individuality (II). Results For healthy individuals, CVI, CVA, CVG, RCV and II values were 8.8, 14.0, 43.1, 45.8% and 0.38 respectively for short-term, and 41.4, 14.0, 25.8, 121.0% and 1.69 for long-term. For renal failure patients, these were 2.6, 5.8, 50.5, 17.6% and 0.30 respectively for short-term, and 19.1, 5.8, 11.2, 55.2% and 1.78 for long-term. For cardiomyopathy patients, these were 4.2, 10.0, 65.9, 30.0% and 0.16 respectively for short-term, and 17.5, 10.0, 63.1, 55.8% and 0.32 for long-term. Mean cTnI concentration was lower post-haemodialysis (15.2 vs. 17.8 ng/L, p < 0.0001), with a 16.9% mean relative change. Conclusions The biological variation of cTnI is similar between end-stage renal failure and cardiomyopathy patients, but proportionately greater in well-selected healthy individuals with very low baseline cTnI concentrations.
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Affiliation(s)
- Nick S R Lan
- Department of Cardiology, Fiona Stanley Hospital, Perth, Western Australia, Australia.,Medical School, The University of Western Australia, Perth, Western Australia, Australia
| | - Lan T Nguyen
- Department of Clinical Biochemistry, PathWest Laboratory Medicine WA, Fiona Stanley Hospital, Perth, Western Australia, Australia
| | - Samuel D Vasikaran
- Department of Clinical Biochemistry, PathWest Laboratory Medicine WA, Fiona Stanley Hospital, Perth, Western Australia, Australia.,Department of Clinical Biochemistry, PathWest Laboratory Medicine WA, Royal Perth Hospital, Perth, Western Australia, Australia
| | - Catherine Wilson
- Department of Cardiology, Fiona Stanley Hospital, Perth, Western Australia, Australia
| | - Jacqueline Jonsson
- Department of Cardiology, Fiona Stanley Hospital, Perth, Western Australia, Australia
| | - James M Rankin
- Department of Cardiology, Fiona Stanley Hospital, Perth, Western Australia, Australia
| | - Damon A Bell
- Medical School, The University of Western Australia, Perth, Western Australia, Australia.,Department of Clinical Biochemistry, PathWest Laboratory Medicine WA, Fiona Stanley Hospital, Perth, Western Australia, Australia.,Department of Clinical Biochemistry, PathWest Laboratory Medicine WA, Royal Perth Hospital, Perth, Western Australia, Australia.,Department of Cardiology, Lipid Disorders Clinic, Royal Perth Hospital, Perth, Western Australia, Australia.,Department of Clinical Biochemistry, Clinipath Pathology, Perth, Western Australia, Australia
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12
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Monneret D, Fasiolo M, Bonnefont-Rousselot D. Relationships between renal function variations and relative changes in cardiac troponin T concentrations based on quantile generalized additive models (qgam). Clin Chem Lab Med 2021; 59:1115-1125. [PMID: 33915606 DOI: 10.1515/cclm-2020-0820] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Accepted: 01/22/2021] [Indexed: 12/31/2022]
Abstract
OBJECTIVES The relationship between high-sensitive cardiac troponin T concentration (hs-cTnT) and renal markers levels is known. However, the extent to which their variations are associated remains to be explored. Objective: model the relationship between relative changes in hs-cTnT (Δhs-cTnT) and variations in creatinine (Δcre) or estimated glomerular filtration rate (ΔeGFR), using a quantile generalized additive model (qgam). METHODS Concomitant plasma Δhs-cTnT and Δcre from patients aged 18-100 years, selected with a time variation (Δtime) of 3 h-7 days, were collected over a 5.8-year period. Relationships between Δhs-cTnT and covariates Δcre (A) or ΔeGFR (B), including age, Δtime, hour of blood sampling (HSB) and covariates interactions were fitted using qgam. RESULTS On the whole (n=106567), Δhs-cTnT was mainly associated with Δcre, in a positive and nonlinear way (-21, -6, +5, +20, +55% for -50, -20, +20, +50, +100%, respectively), but to a lesser extent with age (min -9%, max +2%), Δtime (min -4%, max +8%), and HSB (min -5%, max +7%). Δhs-cTnT was negatively associated with ΔeGFR (+46, +7, -5, -11, -20% for -50, -20, +20, +50, +100%, respectively). Classifying Δhs-cTnT as consistent or not with myocardial injury based on recommendations, an interpretation of Δhs-cTnT adjusted for model A or B led to statistically significant but small diagnostic discrepancies (<2%), as compared to an interpretation based on Δhs-cTnT only. CONCLUSIONS From a laboratory and statistical standpoint, considering renal function variations when interpreting relative changes in cardiac troponin T has a minor impact on the diagnosis rate of myocardial injury.
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Affiliation(s)
- Denis Monneret
- Service de Biochimie et Biologie Moléculaire, Laboratoire de Biologie Médicale Multisite (LBMMS), Hospices Civils de Lyon (HCL), Lyon, France
| | - Matteo Fasiolo
- School of Mathematics, University of Bristol, Bristol, UK
| | - Dominique Bonnefont-Rousselot
- CNRS, INSERM, UTCBS, Université de Paris, Paris, France.,Service de Biochimie Métabolique, AP-HP, Hôpital Pitié-Salpêtrière, Paris, France
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13
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Snaedal S, Bárány P, Lund SH, Qureshi AR, Heimbürger O, Stenvinkel P, Löwbeer C, Szummer K. High-sensitivity troponins in dialysis patients: variation and prognostic value. Clin Kidney J 2020; 14:1789-1797. [PMID: 34221386 PMCID: PMC8243265 DOI: 10.1093/ckj/sfaa215] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2019] [Revised: 09/08/2020] [Indexed: 11/23/2022] Open
Abstract
Background Dialysis patients have a high prevalence of cardiovascular mortality but also elevated cardiac troponins (cTns) even without signs of cardiac ischaemia. The study aims to assess variation and prognostic value of high-sensitivity cTnI and cTnT in prevalent dialysis patients. Methods In 198 prevalent haemodialysis (HD) and 78 peritoneal dialysis (PD) patients, 4-monthly serum troponin I and T measurements were obtained. Reference change values (RCVs) were used for variability assessment and competing-risk regression models for survival analyses; maximal follow-up was 50 months. Results HD and PD patients had similar troponin levels [median (interquartile range) troponin I: 25 ng/L (14–43) versus 21 ng/L (11–37), troponin T: 70 ng/L (44–129) versus 67 ng/L (43–123)]. Of troponin I and T levels, 42% versus 98% were above the decision level of myocardial infarction. RCVs were +68/−41% (troponin I) and +29/−23% (troponin T). Increased variability of troponins related to higher age, male sex, protein-energy wasting and congestive heart failure, but not ischaemic heart disease or dialysis form. Elevated troponin T, but not troponin I, predicted death after adjusting for confounders. Conclusions A large proportion of prevalent dialysis patients without current established or ongoing cardiac events have elevated levels of high-sensitivity cTns. Mortality risk was doubled in patients with persistently high troponin T levels. The large intraindividual variation of cTns suggests that serial measurements and reference change levels may be used to improve diagnostic utility. However, evidence-based recommendations require more data from large studies of dialysis patients with cardiac events.
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Affiliation(s)
- Sunna Snaedal
- Department of Clinical Science, Intervention and Technology, Division of Renal Medicine, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden.,Landspitali University Hospital, Reykjavik, Iceland
| | - Peter Bárány
- Department of Clinical Science, Intervention and Technology, Division of Renal Medicine, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Sigrún H Lund
- Faculty of Medicine, University of Iceland, Reykjavik, Iceland
| | - Abdul R Qureshi
- Department of Baxter Novum, Karolinska Institutet, Stockholm, Sweden
| | - Olof Heimbürger
- Department of Clinical Science, Intervention and Technology, Division of Renal Medicine, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Peter Stenvinkel
- Department of Clinical Science, Intervention and Technology, Division of Renal Medicine, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Christian Löwbeer
- Department of Laboratory Medicine, Division of Clinical Chemistry, Karolinska Institutet, Stockholm, Sweden.,Department of Clinical Chemistry, SYNLAB Medilab, Täby, Sweden
| | - Karolina Szummer
- Department of Medicine (Huddinge), Karolinska Institutet, Stockholm, Sweden.,Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden
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14
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Ideal high sensitivity troponin baseline cutoff for patients with renal dysfunction. Am J Emerg Med 2020; 46:170-175. [PMID: 33071083 DOI: 10.1016/j.ajem.2020.06.072] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Revised: 06/22/2020] [Accepted: 06/26/2020] [Indexed: 12/18/2022] Open
Abstract
OBJECTIVE High-sensitivity cardiac troponin assays (hs-cTn) aid in diagnosis of myocardial infarction (MI). These assays have lower specificity for non-ST Elevation MI (NSTEMI) in patients with renal disease. Our objective was to determine an optimized cutoff for patients with renal disease. METHODS We conducted an a priori secondary analysis of a prospective FDA study in adults with suspected MI presenting to 29 academic urban EDs between 4/2015 and 4/2016. Blood was drawn 0, 1, 2-3, and 6-9 h after ED arrival. We recorded cTn and estimated glomerular filtrate rate (eGFR) by Chronic Kidney Disease Epidemiology Collaboration equation. The primary endpoint was NSTEMI (Third Universal Definition of MI), adjudicated by physicians blinded to hs-cTn results. We generated an adjusted hscTn rule-in cutoff to increase specificity. RESULTS 2505 subjects were enrolled; 234 were excluded. Patients were mostly male (55.7%) and white (57.2%), median age was 56 years 472 patients [20.8%] had an eGFR <60 mL/min/1.73 m2. In patients with eGFR <15 mL/min/1.73 m2, a baseline rule-in cutoff of 120 ng/L led to a specificity of 85.0% and Positive Predictive Value (PPV) of 62.5% with 774 patients requiring further observation. Increasing the cutoff to 600 ng/L increased specificity and PPV overall and in every eGFR subgroup (specificity and PPV 93.3% and 78.9%, respectively for eGFR <15 mL/min/1.73m2), while increasing the number (79) of patients requiring observation. CONCLUSIONS An eGFR-adjusted baseline rule-in threshold for the Siemens Atellica hs-cTnI improves specificity with identical sensitivity. Further study in a prospective cohort with higher rates of renal disease is warranted.
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15
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Interpreting troponin in renal disease: A narrative review for emergency clinicians. Am J Emerg Med 2020; 38:990-997. [DOI: 10.1016/j.ajem.2019.11.041] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2019] [Revised: 11/16/2019] [Accepted: 11/26/2019] [Indexed: 01/11/2023] Open
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16
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Ross SJ, Shah NH, Noutong Njapo SA, Cordiner DJ, Winchester DE. Use of Cardiac Troponin Testing in the Outpatient Setting. South Med J 2019; 112:295-300. [PMID: 31050800 DOI: 10.14423/smj.0000000000000971] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVES Cardiac troponin (cTn) measurement is useful for diagnosing myocardial infarction (MI), particularly in the inpatient setting. A growing body of literature suggests that cTn may be useful for evaluating chronic conditions in the outpatient environment; however, little is known regarding cTn ordering patterns in this setting. We sought to investigate patterns of care and outcomes for patients evaluated with cTn in the outpatient setting. We hypothesized that a majority of outpatient cTn orders would be for the purpose of diagnosing possible MI. METHODS We analyzed 228 patients who had outpatient orders for standard-sensitivity troponin T assays placed at our institution between January 1, 2013 and December 18, 2015. Data were divided into two cohorts based on the intended utility of cTn measurement: orders placed to evaluate for possible MI versus orders placed for some other purpose. RESULTS Of the 228 patients, 161 were evaluated for possible MI and 67 for other reasons. Risk factors (hypertension P = 0.32, diabetes mellitus P = 0.41, coronary disease P = 0.38, heart failure P = 0.098, and chronic kidney disease P = 0.70) were similar between the cohorts. In the suspected MI cohort, an electrocardiogram was obtained in only 77% of patients, and only 13.1% were sent to the emergency department (ED) for further evaluation. Within the suspected MI cohort, 10.5% (n = 17) had elevated cTn and the majority of these patients (n = 10) were not sent to the ED. CONCLUSIONS The majority of outpatient cTn orders were intended to evaluate for MI, although electrocardiograms were frequently not ordered and few patients were sent for further ED evaluation. Providers should be encouraged to use cTn testing in a manner that minimizes the potential risk to patients with possible MI.
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Affiliation(s)
- Steven J Ross
- From the Department of Medicine, University of Florida College of Medicine, Gainesville, and the Division of Cardiovascular Medicine, University of Florida College of Medicine, Gainesville
| | - Nikhil H Shah
- From the Department of Medicine, University of Florida College of Medicine, Gainesville, and the Division of Cardiovascular Medicine, University of Florida College of Medicine, Gainesville
| | - Steve A Noutong Njapo
- From the Department of Medicine, University of Florida College of Medicine, Gainesville, and the Division of Cardiovascular Medicine, University of Florida College of Medicine, Gainesville
| | - Daniel J Cordiner
- From the Department of Medicine, University of Florida College of Medicine, Gainesville, and the Division of Cardiovascular Medicine, University of Florida College of Medicine, Gainesville
| | - David E Winchester
- From the Department of Medicine, University of Florida College of Medicine, Gainesville, and the Division of Cardiovascular Medicine, University of Florida College of Medicine, Gainesville
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17
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Klein EC, Kapoor R, Lewandowski D, Mason PJ. Revascularization Strategies in Patients with Chronic Kidney Disease and Acute Coronary Syndromes. Curr Cardiol Rep 2019; 21:113. [PMID: 31471758 DOI: 10.1007/s11886-019-1213-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
PURPOSE OF REVIEW Chronic kidney disease (CKD) is a highly prevalent condition that increases the incidence and complexity of acute coronary syndrome (ACS). The purpose of this review is to summarize current evidence, uncertainties, and opportunities in the management of patients with CKD and ACS, with a focus on revascularization. RECENT FINDINGS Patients with CKD have been systematically under-represented or excluded from clinical trials in ACS. Available data, however, demonstrates that although patients with CKD and ACS benefit from revascularization, they are also less likely to receive recommended medical and revascularization therapies when compared to patients with normal kidney function. Despite the increased short-term risk of major morbidity and mortality, patients with CKD and ACS should be considered for an early invasive strategy while also trying to mitigate the risks of procedural related complications. Until evidence emerges from randomized clinical trials, the decision about revascularization strategy should involve multi-disciplinary collaboration, heart team consensus, and patient shared decision-making.
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Affiliation(s)
- Evan C Klein
- Medical College of Wisconsin, Milwaukee, WI, USA
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18
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Antukh DE, Shchekochikhin DY, Nesterov AP, Gilarov MY. Diagnosis and treatment of myocardial infarction in patient with end - stage renal disease on chronic hemodialysis. TERAPEVT ARKH 2019; 91:137-144. [DOI: 10.26442/00403660.2019.06.000203] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Indexed: 11/22/2022]
Abstract
This review represents different aspects of myocardial infarction in patient with end - stage renal disease on chronic hemodialysis. We discuss difficulties in diagnosis, optimal method of coronary revascularization, timing of hemodialysis session, medical therapy, as well as epidemiology and prognosis. There are no unambiguous answers to these problems because patients with end - stage renal disease were excluded from most of the studies.
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19
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Maresca B, Manzione A, Moioli A, Salerno G, Cardelli P, Punzo G, Barberi S, Menè P. Prognostic value of high-sensitive cardiac troponin I in asymptomatic chronic hemodialysis patients. J Nephrol 2019; 33:129-136. [PMID: 31020624 DOI: 10.1007/s40620-019-00610-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Accepted: 04/13/2019] [Indexed: 12/30/2022]
Abstract
INTRODUCTION Increased levels of cardiac troponins (cTn) are a hallmark of acute myocardial infarction (AMI), along with symptoms and electrocardiographic (ECG) changes. Stably elevated cTn concentrations are frequently observed in asymptomatic patients with chronic kidney disease (CKD) and/or on hemodialysis (HD); the meaning of this elevation, as assessed by conventional techniques, remains unclear. Aim of our study was to evaluate the clinical significance of cTnI levels in asymptomatic HD patients by employing a newer high-sensitive cTnI (hs-cTnI) assay. METHODS We enrolled 49 patients undergoing regular HD treatment for more than 3 months; all patients were asymptomatic for chest pain and had no history of acute coronary syndrome in the past 2 months. For every patient we measured hs-cTnI, cTnI and brain natriuretic peptide (BNP) before initiation of one HD session at baseline (T0), after 3 (T1) and 9 months (T2). Demographic, anamnestic, dialytic and echocardiographic characteristics of the examined population were evaluated. We also recorded the number of cardiovascular events from T0 to 12 months after T2. RESULTS Fifteen patients were lost to follow-up: 6 died, 2 underwent kidney transplantation, 7 did not match the inclusion criteria later during observation. At T0 (49 patients) we observed 14 hs-cTnI positive patients vs. 4 standard c-TnI positive patients (28,5% vs 8,1%); at T1 (40 patients) 16 vs 3 (26.4% vs 7.5%); at T2 (34 pz) 9 vs 0 (26.4% vs 0%). During the study we recorded 10 cardiovascular events, 8 of which in patients that were hs-cTNI positive, leading to death in 3. Hs-cTnI levels were predictive of cardiovascular events at all times and predictive of cardiovascular mortality at T0 and T1 (p < 0.001). In a multivariate analysis, a history of coronary artery disease (CAD) was an independent variable of high hs-cTnI levels at T0 (p < 0.04) and T1 (p < 0.03). CONCLUSIONS Our study shows that a novel sensitive assay detects more asymptomatic HD patients compared to previously used methods, being at the same time predictive of cardiovascular mortality and morbidity. The only independent variable of high hs-cTnI concentrations was a positive history of cardiovascular disease, suggesting a possible role of hs-cTnI in identifying a high-risk subset of patients.
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Affiliation(s)
- Barbara Maresca
- Division of Nephrology, Department of Clinical and Molecular Medicine, Sant'Andrea University Hospital, "Sapienza" University of Rome, Via di Grottarossa, 1035-1039, 00189, Rome, Italy
| | - Andrea Manzione
- Division of Nephrology, Department of Clinical and Molecular Medicine, Sant'Andrea University Hospital, "Sapienza" University of Rome, Via di Grottarossa, 1035-1039, 00189, Rome, Italy
| | - Alessandra Moioli
- Division of Nephrology, Department of Clinical and Molecular Medicine, Sant'Andrea University Hospital, "Sapienza" University of Rome, Via di Grottarossa, 1035-1039, 00189, Rome, Italy
| | - Gerardo Salerno
- Division of Laboratory Medicine, Sant'Andrea University Hospital, "Sapienza" University of Rome, Rome, Italy
| | - Patrizia Cardelli
- Division of Laboratory Medicine, Sant'Andrea University Hospital, "Sapienza" University of Rome, Rome, Italy
| | - Giorgio Punzo
- Division of Nephrology, Department of Clinical and Molecular Medicine, Sant'Andrea University Hospital, "Sapienza" University of Rome, Via di Grottarossa, 1035-1039, 00189, Rome, Italy
| | - Simona Barberi
- Division of Nephrology, Department of Clinical and Molecular Medicine, Sant'Andrea University Hospital, "Sapienza" University of Rome, Via di Grottarossa, 1035-1039, 00189, Rome, Italy
| | - Paolo Menè
- Division of Nephrology, Department of Clinical and Molecular Medicine, Sant'Andrea University Hospital, "Sapienza" University of Rome, Via di Grottarossa, 1035-1039, 00189, Rome, Italy.
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20
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Monneret D, Gellerstedt M, Bonnefont-Rousselot D. Determination of age- and sex-specific 99th percentiles for high-sensitive troponin T from patients: an analytical imprecision- and partitioning-based approach. Clin Chem Lab Med 2019; 56:818-829. [PMID: 29176015 DOI: 10.1515/cclm-2017-0256] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2017] [Accepted: 10/10/2017] [Indexed: 01/10/2023]
Abstract
BACKGROUND Detection of acute myocardial infarction (AMI) is mainly based on a rise of cardiac troponin with at least one value above the 99th percentile upper reference limit (99th URL). However, circulating high-sensitive cardiac troponin T (hs-cTnT) concentrations depend on age, sex and renal function. Using an analytical imprecision-based approach, we aimed to determine age- and sex-specific hs-cTnT 99th URLs for patients without chronic kidney disease (CKD). METHODS A 3.8-year retrospective analysis of a hospital laboratory database allowed the selection of adult patients with concomitant plasma hs-cTnT (<300 ng/L) and creatinine concentrations, both assayed twice within 72 h with at least 3 h between measurements. Absence of AMI was assumed when the variation between serial hs-cTnT values was below the adjusted-analytical change limit calculated according to the inverse polynomial regression of analytical imprecision. Specific URLs were determined using Clinical and Laboratory Standards Institute (CLSI) methods, and partitioning was tested using the proportion method, after adjustment for unequal prevalences. RESULTS After outlier removal (men: 8.7%; women: 6.6%), 1414 men and 1082 women with estimated glomerular filtration rate (eGFR) ≥60 mL/min/1.73 m2 were assumed as non-AMI. Partitioning into age groups of 18-50, 51-70 and 71-98 years, the hs-cTnT 99th URLs adjusted on French prevalence were 18, 33, 66 and 16, 30, 84 ng/L for men and women, respectively. Age-partitioning was clearly required. However, sex-partitioning was not justified for subjects aged 18-50 and 51-70 years for whom a common hs-cTnT 99th URLs of about 17 and 31 ng/L could be used. CONCLUSIONS Based on a laboratory approach, this study supports the need for age-specific hs-cTnT 99th URLs.
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Affiliation(s)
- Denis Monneret
- Department of Metabolic Biochemistry, La Pitié Salpêtrière-Charles Foix University Hospital (AP-HP), Paris, France
| | - Martin Gellerstedt
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, SSORG-Scandinavian Surgical Outcomes Research Group, Sahlgrenska University Hospital/Östra, Gothenburg, Sweden.,School of Business, Economics and IT, University West, Göteborg, Sweden
| | - Dominique Bonnefont-Rousselot
- Department of Metabolic Biochemistry, La Pitié Salpêtrière-Charles Foix University Hospital (AP-HP), Paris, France.,Faculty of Pharmacy, Department of Biochemistry, Paris Descartes University, Paris, France.,CNRS UMR8258 - INSERM U1022, Faculty of Pharmacy, Paris Descartes University, Paris, France
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21
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Wu C, Chen X, Ying Wang A, Chen J, Gao H, Li G, Wang L, Hong D. Peritoneal dialysis in Sichuan province of China - report from the Chinese National Renal Data System. Ren Fail 2018; 40:577-582. [PMID: 30343613 PMCID: PMC6201772 DOI: 10.1080/0886022x.2018.1496933] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
Background: Peritoneal dialysis (PD) is one of the important treatment strategies for end stage renal disease (ESRD). In this study, we aimed to study the patients on PD of Sichuan province in the registry system and to explore the risk factors. Methods: This was a retrospective study based on data from the Chinese National Renal Data System (CNRDS). The outcomes were prevalence and incidence of patients receiving PD, all-cause mortality, technical failure, end events and peritonitis. Results: This study included 2654 patients between 1 January 2010 and 31 December 2016. From 2010 to 2016, despite there were increasing numbers of patients requiring PD. Primary and secondary glomerular diseases were the main causes of ESRD. Erythropoietin, iron and antihypertensive agents were the most commonly used medications in this cohort. 12.43% of patients died and the most important cause of death was cardiac events (30.30%). The incidences of peritonitis were 0.09, 0.16, 0.11, 0.09, 0.08, 0.12 and 0.06 per patient-year, respectively. The most common etiological agent of peritonitis was staphylococcus. We divided the patients into four groups according to the incident months of peritonitis. Compared with <20 months group, the level of calcium and platelet in >60 months group were higher, and the level of ferritin in >60 months group was lower. Conclusion: Our results, representing the first largest report of peritoneal dialysis in the Southwest of China, indicated increasing numbers of patients receiving peritoneal dialysis, which will require need for medical resource.
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Affiliation(s)
- Changwei Wu
- a Renal Department and Nephrology Institute , Sichuan Provincial People's Hospital, School of Medicine, University of Electronic Science and Technology of China , Chengdu , China
| | - Xiuling Chen
- a Renal Department and Nephrology Institute , Sichuan Provincial People's Hospital, School of Medicine, University of Electronic Science and Technology of China , Chengdu , China
| | - Amanda Ying Wang
- b The George Institute for Global Health, University of Sydney , Sydney , Australia
| | - Jin Chen
- a Renal Department and Nephrology Institute , Sichuan Provincial People's Hospital, School of Medicine, University of Electronic Science and Technology of China , Chengdu , China
| | - Hui Gao
- a Renal Department and Nephrology Institute , Sichuan Provincial People's Hospital, School of Medicine, University of Electronic Science and Technology of China , Chengdu , China
| | - Guisen Li
- a Renal Department and Nephrology Institute , Sichuan Provincial People's Hospital, School of Medicine, University of Electronic Science and Technology of China , Chengdu , China
| | - Li Wang
- a Renal Department and Nephrology Institute , Sichuan Provincial People's Hospital, School of Medicine, University of Electronic Science and Technology of China , Chengdu , China
| | - Daqing Hong
- a Renal Department and Nephrology Institute , Sichuan Provincial People's Hospital, School of Medicine, University of Electronic Science and Technology of China , Chengdu , China
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22
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Manjunath L, Yeluru A, Rodriguez F. 27-Year-Old Man with a Positive Troponin: A Case Report. Cardiol Ther 2018; 7:197-204. [PMID: 30367446 PMCID: PMC6251827 DOI: 10.1007/s40119-018-0120-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2018] [Indexed: 11/24/2022] Open
Abstract
In this case report, we describe a young athletic male with a family history of early sudden cardiac death who presented with atypical chest pain and was found to have a positive serum troponin. Although his symptoms resolved without intervention, workup revealed hypertension, hyperlipidemia, mild left ventricular hypertrophy, non-obstructive coronary artery disease, and the presence of serum heterophile antibodies. Ultimately, it was concluded that his rigorous exercise regimen as well as the presence of heterophile antibodies may have contributed to his positive serum troponin. This case serves as a reminder of the nonspecific diagnostic value of modern troponin assays, and that the results of these tests should always be incorporated into the clinical context.
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Affiliation(s)
| | - Apurva Yeluru
- Department of Medicine, Stanford University, Stanford, CA, USA
| | - Fatima Rodriguez
- Department of Medicine, Stanford University, Stanford, CA, USA.,Division of Cardiovascular Medicine, Department of Medicine, Stanford University, Stanford, CA, USA
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23
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Ünlü S, Şahinarslan A, Sezenöz B, Uludağ OM, Gökalp G, Seçkin Ö, Arınsoy ST, Gülbahar Ö, Boyacı NB. High-sensitive troponin T increase after hemodialysis is associated with left ventricular global longitudinal strain and ultrafiltration rate. Cardiol J 2018; 27:376-383. [PMID: 30338843 DOI: 10.5603/cj.a2018.0118] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2018] [Revised: 09/02/2018] [Accepted: 09/24/2018] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Circulating troponin levels are both stable and higher in patients with end-stage renal disease, even in the absence of acute coronary syndrome. These patients commonly have underlying cardiac problems that frequently cause troponin elevation. The effect of hemodialysis (HD) on troponin levels has not been well elucidated. Thus, investigated herein is the relationship between the changes in troponin levels along with left ventricular deformation and volume depletion in patients with end-stage renal disease. METHODS Patients included were between 18 and 85 years of age and were receiving hemodialysis for at least 6 months. High sensitive cardiac troponin T (hs-cTnT) levels were studied in blood samples taken at the beginning and end of HD. Two-dimensional speckle tracking strain imaging was used to evaluate myocardial contractility. RESULTS Seventy patients (50.7 ± 16.9 years of age, 27 women) were included in study. The mean volume of ultrafiltration was 3260 ± 990 mL. A significant increase in circulating hs-cTnT levels was observed, as well as a prominent decrease in left ventricular global longitudinal strain (GLS) after HD (52.4 ± 40.2 ng/L vs. 66.8 ± 48.5 ng/L, p < 0.001 and 20.1 ± 3.6% vs. 16.8 ± 3.8% p < 0.001, respectively). Moreover, ultrafiltration rate and GLS were found as the strongest independent variables in relation to the relative increase in hs-cTnT. CONCLUSIONS Hemodialysis can cause a significant increase in hsTnT. This can jeopardize the accuracy of clinical diagnoses based on hs-TnT measurements. GLS may be used as a determinant of this hs-TnT increase. The influence of HD on the cardiovascular system should be kept in mind to prevent unnecessary interventions.
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24
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Mavrakanas TA, Sniderman AD, Barré PE, Alam A. Serial versus single troponin measurements for the prediction of cardiovascular events and mortality in stable chronic haemodialysis patients. Nephrology (Carlton) 2018; 23:69-74. [PMID: 27718506 DOI: 10.1111/nep.12945] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2016] [Revised: 10/04/2016] [Accepted: 10/06/2016] [Indexed: 11/30/2022]
Abstract
AIM This study aims to describe the variability of pre-dialysis troponin values in stable haemodialysis patients and compare the performance of single versus fluctuating or persistently elevated troponins in predicting a composite of mortality and cardiac arrest, myocardial infarction or stroke. METHODS A total of 128 stable ambulatory chronic haemodialysis patients were enrolled. Pre-dialysis troponin I was measured for three consecutive months. The patients were followed for 1 year. A troponin elevation (>0.06 μg/L) was considered high risk, and patients were classified into three risk groups: (i) patients who had normal troponin levels on all three measurements; (ii) patients with at least one elevated and one normal troponin value; and (iii) patients with elevated troponin values on all measurements. RESULTS A total of 81 patients had all three troponin values in the normal range; 29 had fluctuating values; 18 had all three values elevated. Twenty-seven deaths or composite events were observed: eight in the first risk group, 10 in the second and nine in the third. Persistently elevated and fluctuating troponin values were associated with higher mortality and cardiovascular event rate. Serial troponin measurement had a higher sensitivity for the composite outcome than single troponin measurement when either fluctuating or persistently elevated values were considered to confer high risk. CONCLUSION Most haemodialysis patients do not have elevated troponin levels at baseline. Troponin levels that remain elevated or fluctuate are associated with worse outcomes. A serial troponin measurement strategy is associated with better sensitivity and higher negative predictive value compared with single troponin measurement.
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Affiliation(s)
- Thomas A Mavrakanas
- Division of Nephrology, McGill University Health Center, Montreal, Canada.,Division of General Internal Medicine, Geneva University Hospitals, Geneva, Switzerland
| | - Allan D Sniderman
- Division of Cardiology, McGill University Health Center, Montreal, Canada
| | - Paul E Barré
- Division of Nephrology, McGill University Health Center, Montreal, Canada
| | - Ahsan Alam
- Division of Nephrology, McGill University Health Center, Montreal, Canada
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25
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Affiliation(s)
- Germán Cediel
- Department of Medicine, Heart Institute, Hospital Universitari Germans Trias i Pujol, CIBERCV, Autonomous University of Barcelona, Carretera de Canyet s/n, Barcelona, Spain
| | - Evelyn Santiago-Vacas
- Department of Medicine, Heart Institute, Hospital Universitari Germans Trias i Pujol, CIBERCV, Autonomous University of Barcelona, Carretera de Canyet s/n, Barcelona, Spain
| | - Antoni Bayes-Genis
- Department of Medicine, Heart Institute, Hospital Universitari Germans Trias i Pujol, CIBERCV, Autonomous University of Barcelona, Carretera de Canyet s/n, Barcelona, Spain
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26
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Alpert JS, Jaffe AS. 1-h High-Sensitivity Troponin Rule-Out and Rule-In Approach. J Am Coll Cardiol 2018; 72:633-635. [DOI: 10.1016/j.jacc.2018.05.041] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2018] [Accepted: 05/16/2018] [Indexed: 10/28/2022]
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27
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Chen T, Hassan HC, Qian P, Vu M, Makris A. High-Sensitivity Troponin T and C-Reactive Protein Have Different Prognostic Values in Hemo- and Peritoneal Dialysis Populations: A Cohort Study. J Am Heart Assoc 2018; 7:JAHA.117.007876. [PMID: 29478023 PMCID: PMC5866329 DOI: 10.1161/jaha.117.007876] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Background Dialysis patients have an exceedingly high mortality rate. Biomarkers may be useful tools in risk stratification of this population. We evaluated the prognostic value of high‐sensitivity cardiac troponin T (hs‐cTnT) and CRP (C‐reactive protein) in predicting adverse outcomes in stable hemodialysis and peritoneal dialysis (PD) patients. Variability in hs‐cTnT was also examined. Methods and Results A retrospective cohort study included 574 dialysis patients (hemodialysis 347, PD 227). Outcomes examined included mortality and major adverse cardiovascular events, with median follow‐up of 3.5 years. hs‐cTnT was an independent predictor of both outcomes in hemodialysis and PD patients. Increased risk only became significant when hs‐cTnT reached quintile 3 (>49 ng/L). Area under the receiver operating curve analysis showed that the addition of hs‐cTnT to clinical parameters significantly improved its prognostic performance for mortality in PD patients (P=0.002). CRP was an independent predictor of both outcomes in PD patients only. Only CRP in the highest quintile (>16.8 mg/L) was associated with increased risk. hs‐cTnT remained relatively stable for the whole follow‐up period for hemodialysis patients, whereas for PD patients, hs‐cTnT increased by 23.63% in year 2 and 29.13% in year 3 compared with baseline (P<0.001). Conclusions hs‐cTnT and CRP are useful tools in predicting mortality and major adverse cardiovascular events in hemodialysis and PD patients. Given that hs‐cTnT levels increase over time in PD patients, interval monitoring may be valuable for risk assessment. In contrast, hs‐cTnT in hemodialysis patients has little interval change and progress monitoring is not indicated.
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Affiliation(s)
- Titi Chen
- The University of Sydney, Camperdown, New South Wales, Australia .,Department of Renal Medicine, Westmead Hospital, Westmead, New South Wales, Australia.,The Westmead Institute for Medical Research, Westmead, New South Wales, Australia
| | - Hicham C Hassan
- Department of Nephrology, Wollongong Hospital, Wollongong, New South Wales, Australia.,University of Wollongong, New South Wales, Australia
| | - Pierre Qian
- The University of Sydney, Camperdown, New South Wales, Australia.,Department of Cardiology, Westmead Hospital, Westmead, New South Wales, Australia
| | - Monica Vu
- The University of Sydney, Camperdown, New South Wales, Australia.,Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
| | - Angela Makris
- Department of Renal Medicine, Liverpool Hospital, Liverpool, New South Wales, Australia.,University of New South Wales, Kensington, New South Wales, Australia
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28
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Chen M, Gerson H, Eintracht S, Nessim SJ, MacNamara E. Effect of Hemodialysis on Levels of High-Sensitivity Cardiac Troponin T. Am J Cardiol 2017; 120:2061-2064. [PMID: 29033047 DOI: 10.1016/j.amjcard.2017.08.026] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2017] [Revised: 07/25/2017] [Accepted: 08/08/2017] [Indexed: 10/18/2022]
Abstract
Cardiac troponin (cTn) is essential for the diagnosis of an acute coronary syndrome (ACS). However, in end-stage renal disease (ESRD) baseline cTn levels are often elevated, and it is unknown whether the hemodialysis (HD) procedure affects cTn levels. This leaves clinicians unsure of how to interpret cTn in HD patients with cardiac ischemia. We therefore sought to determine if plasma levels of high-sensitivity cardiac troponin T (hs-cTnT) vary during or after HD treatment. We prospectively enrolled 10 chronic HD patients who were admitted to our institution. All participants were receiving thrice weekly HD before admission and were medically stable. Those admitted for ACS or to critical care units were excluded. Baseline hs-cTnT was measured immediately before HD. For the subsequent 6 hours, hs-cTnT was measured every 2 hours and every 3 hours thereafter for a total collection period of 24 hours. A significant decline in mean hs-cTnT was noted with HD. During HD (2 hours after HD initiation), hs-cTnT decreased by 10.7% (confidence interval 5% to 17%). Immediately after HD (4 hours after HD initiation), a decline of 12% (confidence interval 5% to 19%) was observed. Thereafter hs-cTnT began to rise. Hs-cTnT levels returned to baseline by 11 hours after HD completion and remained stable for the reminder of the study. In conclusion, HD induces a short-lived negative bias in hs-cTnT. When measured for investigation of ACS, hs-cTnT concentration should be interpreted with respect to time of dialysis and specimen collection.
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29
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Sandoval Y, Jaffe AS. Using High-Sensitivity Cardiac Troponin T for Acute Cardiac Care. Am J Med 2017; 130:1358-1365.e1. [PMID: 28843652 DOI: 10.1016/j.amjmed.2017.07.033] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2017] [Revised: 07/27/2017] [Accepted: 07/28/2017] [Indexed: 12/21/2022]
Abstract
The recent approval of the fifth-generation cardiac troponin T assay, which has characteristics clinically of a high-sensitivity assay, has led to concern that the problems of increased sensitivity will be greater than the benefits. This will not be the case if cardiology, emergency medicine, and laboratory medicine combine to develop procedures for use of the assay. We advocate sex-specific 99th percentile upper reference limit values of 15 ng/L for men and 10 ng/L for women. We suggest a 2-hour rule-out strategy, including a value less than the 99th percentile upper reference limit and the lack of a change in values of <4 ng/L. Those with values >100 ng/L and or a changing pattern of values ≥10 ng/L are a population much more likely to have acute myocardial infarction. Most of the increment in elevated values will occur not in those with acute coronary problems but in those with primary cardiac disease like heart failure and those with primary noncardiac problems. The former belong on a cardiac service because they are at high risk. The latter should have therapy on the service most apt to provide optimal care for their primary diagnosis, with cardiac consultation as needed.
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Affiliation(s)
- Yader Sandoval
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minn
| | - Allan S Jaffe
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minn; Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minn.
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30
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B-Type Natriuretic Peptide and Cardiac Troponin I Are Associated With Adverse Outcomes in Stable Kidney Transplant Recipients. Transplantation 2017; 101:182-190. [PMID: 26910333 DOI: 10.1097/tp.0000000000001080] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Approximately 200 000 kidney transplant recipients are living in the United States; they are at increased risk for cardiovascular and other adverse outcomes. Biomarkers predicting these outcomes are needed. Using specimens collected during the Folic Acid for Vascular Outcome Reduction in Transplantation trial, we determined whether plasma levels of B-type natriuretic peptide (BNP) and cardiac troponin I are associated with adverse outcomes in stable kidney transplant recipients. METHODS Five hundred ten subjects were selected randomly from the 4110 Folic Acid for Vascular Outcome Reduction in Transplantation participants. This cohort was then enriched for all additional subjects with adverse outcomes (death, dialysis-dependent kidney failure (DDKF), and cardiovascular outcomes) for a total of 1131 participants studied. Quartiles of BNP and high-sensitivity cardiac troponin I (hs-cTnI) were included in adjusted models. Combinations of normal and elevated hs-cTnI (>26.2 ng/L) and BNP (>100 pg/mL) were also studied. RESULTS Median concentrations (interquartile ranges) were 5.6 (3.3-10.5) ng/L for hs-cTnI and 39 (15, 94) pg/mL for BNP. Hazard ratios for each adverse outcome were higher with higher quartiles of BNP after adjustment and remained statistically significant after adding hs-cTnI to the model. The highest quartile hazard ratio for DDKF was 2.47 (95% confidence interval [95% CI], 1.21-5.05). Simultaneous elevations of BNP and hs-cTnI over clinical cutoffs were strongly associated with adverse outcomes with hazard ratios 8.8 (95% CI, 3.4-23.1) for DDKF and 6.3 (95% CI, 2.7-15.0) for cardiovascular outcomes. CONCLUSIONS Higher BNP is associated with mortality and cardiovascular and kidney outcomes in stable kidney transplant recipients. Elevated BNP and hs-cTnI identify candidates for targeted risk reduction.
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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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Abstract
Acute coronary syndrome (ACS) encompasses a pathophysiological spectrum of cardiovascular diseases, all of which have significant morbidity and mortality. ACS was once considered an acute condition; however, new treatment strategies and improvements in biomarker assays have led to ACS being an acute and chronic disease. Cardiac troponin is the preferred biomarker for the diagnosis of myocardial infarction, and there is considerable interest and efforts toward development and implementation of high-sensitivity cardiac troponin (hs-cTn) assays worldwide. Analytical and clinical performance characteristics of hs-cTn assays as well as testing limitations are important for laboratorians and clinicians to understand in order to utilize testing appropriately. Furthermore, expanding the clinical utility of hs-cTn into other cohorts such as asymptomatic community dwelling populations, heart failure, and chronic kidney disease populations supports novel opportunities for improved short- and long-term prognosis.
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Siriopol D, Onofriescu M, Voroneanu L, Apetrii M, Nistor I, Hogas S, Kanbay M, Sascau R, Scripcariu D, Covic A. Dry weight assessment by combined ultrasound and bioimpedance monitoring in low cardiovascular risk hemodialysis patients: a randomized controlled trial. Int Urol Nephrol 2016; 49:143-153. [DOI: 10.1007/s11255-016-1471-0] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2016] [Accepted: 11/29/2016] [Indexed: 01/17/2023]
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Skadberg Ø, Sandberg S, Røraas T, Petersen PH, Sellevoll H, Svarstad E, Sæle K, Aakre KM. The variation in high sensitive cardiac troponin concentration during haemodialysis treatment is not similar to the biological variation observed in stable end stage renal disease patients. Scandinavian Journal of Clinical and Laboratory Investigation 2016; 76:645-652. [DOI: 10.1080/00365513.2016.1230886] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Øyvind Skadberg
- Laboratory of Clinical Biochemistry, Stavanger University Hospital, Stavanger, Norway
| | - Sverre Sandberg
- Laboratory of Clinical Biochemistry, Haukeland University Hospital, Bergen, Norway
- The Norwegian Quality Improvement of Primary Care Laboratories (NOKLUS), Department of Public Health and Primary Health Care, University of Bergen, Bergen, Norway
| | - Thomas Røraas
- The Norwegian Quality Improvement of Primary Care Laboratories (NOKLUS), Department of Public Health and Primary Health Care, University of Bergen, Bergen, Norway
| | - Per Hyltoft Petersen
- The Norwegian Quality Improvement of Primary Care Laboratories (NOKLUS), Department of Public Health and Primary Health Care, University of Bergen, Bergen, Norway
| | - Hilde Sellevoll
- Department of Gynaecology, Haukeland University Hospital, Bergen, Norway
| | - Einar Svarstad
- Department of Medicine, Haukeland University Hospital, Bergen, Norway
| | - Kristin Sæle
- Department of Medicine, Haukeland University Hospital, Bergen, Norway
| | - Kristin Moberg Aakre
- Laboratory of Clinical Biochemistry, Haukeland University Hospital, Bergen, Norway
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Cardinaels EPM, Altintas S, Versteylen MO, Joosen IA, Jellema LJC, Wildberger JE, Das M, Crijns HJ, Bekers O, van Dieijen-Visser MP, Kietselaer BL, Mingels AMA. High-Sensitivity Cardiac Troponin Concentrations in Patients with Chest Discomfort: Is It the Heart or the Kidneys As Well? PLoS One 2016; 11:e0153300. [PMID: 27096420 PMCID: PMC4838230 DOI: 10.1371/journal.pone.0153300] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2015] [Accepted: 03/11/2016] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND High-sensitivity cardiac troponins (hs-cTn) are the preferred biomarkers to detect myocardial injury, making them promising risk-stratifying tools for patients with symptoms of chest pain. However, circulating hs-cTn are also elevated in other conditions like renal dysfunction, complicating appropriate interpretation of low-level hs-cTn concentrations. METHODS A cross-sectional analysis was performed in 1864 patients with symptoms of chest discomfort from the cardiology outpatient department who underwent cardiac computed tomographic angiography (CCTA). Serum samples were analyzed using hs-cTnT and hs-cTnI assays. Renal function was measured by the estimated glomerular filtration rate (eGFR), established from serum creatinine and cystatin C. On follow-up, the incidence of adverse events was assessed. RESULTS Median hs-cTnT and hs-cTnI concentrations were 7.2(5.8-9.2) ng/L and 2.6(1.8-4.1) ng/L, respectively. Multivariable regression analysis revealed that both assay results were more strongly associated with eGFR (hs-cTnT:stβ:-0.290;hs-cTnI:stβ:-0.222) than with cardiac imaging parameters, such as coronary calcium score, CCTA plaque severity score and left ventricular mass (all p<0.01). Furthermore, survival analysis indicated lower relative risks in patients with normal compared to reduced renal function for hs-cTnT [HR(95%CI), 1.02(1.00-1.03) compared to 1.07(1.05-1.09)] and hs-cTnI [1.01(1.00-1.01) compared to 1.02(1.01-1.02)] (all p<0.001). CONCLUSION In patients with chest discomfort, we identified an independent influence of renal function on hs-cTn concentrations besides CAD, that affected the association of hs-cTn concentrations with adverse events. Estimating renal function is therefore warranted when interpreting baseline hs-cTn concentrations.
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Affiliation(s)
- Eline P. M. Cardinaels
- Central Diagnostic Laboratory, Department of Clinical Chemistry, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center (MUMC+), Maastricht, the Netherlands
| | - Sibel Altintas
- Department of Cardiology, CARIM, MUMC+, Maastricht, the Netherlands
| | | | - Ivo A. Joosen
- Department of Cardiology, CARIM, MUMC+, Maastricht, the Netherlands
| | - Laurens-Jan C. Jellema
- Department of Clinical Chemistry and Hematology, Gelre Hospitals, Apeldoorn, the Netherlands
| | | | - Marco Das
- Department of Radiology, CARIM, MUMC+, Maastricht, the Netherlands
| | - Harry J. Crijns
- Department of Cardiology, CARIM, MUMC+, Maastricht, the Netherlands
| | - Otto Bekers
- Central Diagnostic Laboratory, Department of Clinical Chemistry, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center (MUMC+), Maastricht, the Netherlands
| | - Marja P. van Dieijen-Visser
- Central Diagnostic Laboratory, Department of Clinical Chemistry, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center (MUMC+), Maastricht, the Netherlands
| | - Bastiaan L. Kietselaer
- Department of Cardiology, CARIM, MUMC+, Maastricht, the Netherlands
- Department of Radiology, CARIM, MUMC+, Maastricht, the Netherlands
| | - Alma M. A. Mingels
- Central Diagnostic Laboratory, Department of Clinical Chemistry, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center (MUMC+), Maastricht, the Netherlands
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Sandoval Y, Herzog CA, Love SA, Cao J, Hu Y, Wu AHB, Gilbertson D, Brunelli SM, Young A, Ler R, Apple FS. Prognostic Value of Serial Changes in High-Sensitivity Cardiac Troponin I and T over 3 Months Using Reference Change Values in Hemodialysis Patients. Clin Chem 2016; 62:631-8. [DOI: 10.1373/clinchem.2015.251835] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2015] [Accepted: 01/07/2016] [Indexed: 11/06/2022]
Abstract
Abstract
INTRODUCTION
Serial changes in cardiac troponin in hemodialysis (HD) patients have uncertain clinical implications. We evaluated associations of adverse outcomes in HD patients with reference change value (RCV) data and tertile concentrations for cardiac troponin I (cTnI) and cTnT measured by high-sensitivity (hs) assays.
METHODS
RCV data and tertiles for hs-cTnI and hs-cTnT were determined from plasma samples collected 3 months apart in 677 stable outpatient HD patients and assessed for their associations with adverse outcomes using adjusted Cox models. Primary outcomes were all-cause mortality and sudden cardiac death (SCD).
RESULTS
During a median follow-up of 23 months, 18.6% of patients died. RCVs were: hs-cTnI +37% and −30%; hs-cTnT +25% and −20%. Patients with serial hs-cTnI and hs-cTnT changes >RCV (increase or decrease) had all-cause mortality of 25.2% and 23.8% respectively, compared to 15.0% and 16.5% with changes ≤RCV [adjusted hazard ratios (aHRs): 1.9, P = 0.0003 and 1.7, P = 0.0066), respectively]. Only hs-cTnI changes >RCV were predictive of SCD (aHR 2.6, P = 0.005). hs–Cardiac troponin changes >RCV improved all-cause mortality prognostication compared to changes ≤RCV in tertile 2: hs-cTnI aHR, 2.70 (P = 0.003); hs-cTnT aHR, 1.98 (P = 0.043). The aHR of changes in hs-cTnI in tertile 2 >RCV for SCD was 5.62 (P = 0.039).
CONCLUSIONS
Changes over 3 months in hs-cTnI and hs-cTnT of >RCV identified patients at greater risk of all-cause mortality, and for hs-cTnI were also predictive of SCD. Among patients with middle tertile cardiac troponin concentrations, hs-cTnI changes >RCV provided additive prognostic value for both SCD and all-cause mortality, whereas those for hs-cTnT provided additive prognostic value only for all-cause mortality.
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Affiliation(s)
- Yader Sandoval
- Division of Cardiology, Department of Medicine, Hennepin County Medical Center, Minneapolis, MN
| | - Charles A Herzog
- Division of Cardiology, Department of Medicine, Hennepin County Medical Center and University of Minnesota, Minneapolis, MN
- Chronic Disease Research Group (CDRG), Minneapolis Medical Research Foundation, Minneapolis, MN
| | - Sara A Love
- Cardiac Biomarkers Trials Laboratory (CBTL), Minneapolis Medical Research Foundation, Minneapolis, MN
- Department of Laboratory Medicine and Pathology, Hennepin County Medical Center and University of Minnesota, Minneapolis, MN
| | - Jing Cao
- Cardiac Biomarkers Trials Laboratory (CBTL), Minneapolis Medical Research Foundation, Minneapolis, MN
| | - Yan Hu
- Chronic Disease Research Group (CDRG), Minneapolis Medical Research Foundation, Minneapolis, MN
| | - Alan H B Wu
- Department of Laboratory Medicine, University of California, San Francisco, CA
| | - David Gilbertson
- Chronic Disease Research Group (CDRG), Minneapolis Medical Research Foundation, Minneapolis, MN
| | | | - Amy Young
- DaVita Clinical Research, Minneapolis, MN
| | - Ranka Ler
- Cardiac Biomarkers Trials Laboratory (CBTL), Minneapolis Medical Research Foundation, Minneapolis, MN
| | - Fred S Apple
- Cardiac Biomarkers Trials Laboratory (CBTL), Minneapolis Medical Research Foundation, Minneapolis, MN
- Department of Laboratory Medicine and Pathology, Hennepin County Medical Center and University of Minnesota, Minneapolis, MN
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Bargnoux AS, Kuster N, Patrier L, Dupuy AM, Tachon G, Maurice F, Badaoui B, Chalabi L, Badiou S, Deleuze S, Leray-Moragues H, Morena M, Canaud B, Cristol JP. Cardiovascular risk stratification in hemodialysis patients in the era of highly sensitive troponins: should we choose between hs-troponin I and hs-troponin T? ACTA ACUST UNITED AC 2016; 54:673-82. [DOI: 10.1515/cclm-2015-0071] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2015] [Accepted: 09/08/2015] [Indexed: 11/15/2022]
Abstract
AbstractNew highly sensitive (hs) assays have challenged the interpretation of cardiac troponins (cTn). The present study was designed to evaluate simultaneously conventional cTnT and cTnI together with their corresponding highly sensitive determinations in stable hemodialysis (HD) patients. Ability of cTn to stratify HD patient risk was assessed.A total of 224 stable HD patients was included in this observational study. cTnT and hs-cTnT were measured using Roche cTnT/hs-cTnT assays based on a Cobas e601The median cTnT and cTnI concentrations were 38.5 ng/L (IQR, 18.8–76) and 10 ng/L (IQR, 10–20), respectively. The median hs-cTnT and hs-cTnI concentrations were 62.5 ng/L (IQR, 38.8–96.3) and 13.9 ng/L (IQR, 8.4–23.6), respectively. The prevalence of values above the 99th percentile was significantly more marked with cTnT (85.3 and 97.8% for conventional and hs cTnT, respectively) than with cTnI (7.6 and 67.4% for conventional and hs cTnI, respectively). During the follow-up, 167 patients died, mainly from cardiac cause (n=77). The optimized cut-off values, determined by bootstrap method, predicting mortality were 38, 69, 20 and 11 ng/L for cTnT, hs-cTnT, cTnI and hs-cTnI, respectively. After full adjustment, elevated plasma concentrations of all troponin were significant predictors of mortality.A large proportion of patients free of acute coronary syndrome (ACS) has hs-cTn I or T higher than the 99th percentile which could be seen as a limiting factor for ACS screening. However, all generation and type of troponin assays could be reliable indicators of prognosis risk in HD patients.
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Maznyczka A, Kaier T, Marber M. Troponins and other biomarkers in the early diagnosis of acute myocardial infarction. Postgrad Med J 2015; 91:322-30. [DOI: 10.1136/postgradmedj-2014-133129] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2014] [Accepted: 05/08/2015] [Indexed: 12/24/2022]
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Yang Y, Wang C, Jin L, Chen G, Li C, Qi K, Kong D, Wang Y, Song M, Ma L. Effectiveness of and risk associated with aspirin therapy in hemodialysis patients with a background of antiplatelet factor 4/heparin complex antibody detection. Thromb Res 2015; 136:61-8. [PMID: 25936230 DOI: 10.1016/j.thromres.2015.04.023] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2014] [Revised: 04/10/2015] [Accepted: 04/18/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND The optimal prevention measures against hemodialysis (HD)-associated complications, including all-cause thrombotic events and death, are unclear. METHODS This prospective study was designed to assess the effect of aspirin on prevention of HD-associated complications. Patients were divided into four groups according to platelet factor-4/heparin-complex (PF4/H) antibody detection and aspirin prescription: Group 1, antibody(-)/aspirin(+); Group 2, antibody(-)/aspirin(-); Group 3, antibody(+)/aspirin(+); and Group 4, antibody(+)/aspirin(-). Adverse events were compared among all four groups. Cox hazard regression was performed to analyze the effects of anti-PF4/H antibody and aspirin on thrombosis and death. RESULTS This study included 648 patients undergoing HD; 142 were positive for anti-PF4/H antibodies, and 229 had received aspirin before enrollment. During the 4-year follow-up period, 138 patients developed thrombosis, and 63 of these events were anti-PF4/H antibody-associated. A total of 112 patients died; 75 died of coronary heart disease (CHD). Group 4 had a significantly higher incidence of total and anti-PF4/H antibody-associated thrombosis events as well as total and CHD-associated death than did the other three groups. Aspirin had a preventive effect against all adverse events in anti-PF4/H antibody-positive patients, but not in antibody-negative patients. Group 1 patients with baseline D-dimer levels of <0.6μg/mL developed more hemorrhagic events than did patients in the other groups. CONCLUSIONS Aspirin prevention of thrombosis and death in patients undergoing HD might require consideration of the anti-PF4/H antibody status. In antibody-positive individuals, taking aspirin could improve the prognosis and therefore might be recommended. In antibody-negative individuals, prevention was minimal and the bleeding risk was obviously increased; thus, aspirin should be avoided or at least require careful evaluation prior to aspirin treatment.
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Affiliation(s)
- Yang Yang
- Kidney Therapeutic Center of Traditional Chinese and Western Medicine, Beidaihe Sanatorium of Beijing Military Region, Qinhuangdao, China
| | - Chao Wang
- Kidney Therapeutic Center of Traditional Chinese and Western Medicine, Beidaihe Sanatorium of Beijing Military Region, Qinhuangdao, China
| | - Liping Jin
- Kidney Therapeutic Center of Traditional Chinese and Western Medicine, Beidaihe Sanatorium of Beijing Military Region, Qinhuangdao, China
| | - Guanglei Chen
- Kidney Therapeutic Center of Traditional Chinese and Western Medicine, Beidaihe Sanatorium of Beijing Military Region, Qinhuangdao, China
| | - Changchun Li
- Kidney Therapeutic Center of Traditional Chinese and Western Medicine, Beidaihe Sanatorium of Beijing Military Region, Qinhuangdao, China
| | - Ka Qi
- Hemodialysis Centre, Beidaihe Sanatorium of Beijing Military Region, Qinhuangdao, China
| | - Deyang Kong
- Hemodialysis Centre, First Affiliated Hospital of Haerbin Medical University, Haerbin, China
| | - Yaping Wang
- Hemodialysis Centre, General Hospital of Beijing Military Region, Beijing, China
| | - Minghui Song
- Kidney Therapeutic Center of Traditional Chinese and Western Medicine, Beidaihe Sanatorium of Beijing Military Region, Qinhuangdao, China
| | - Lu Ma
- Kidney Therapeutic Center of Traditional Chinese and Western Medicine, Beidaihe Sanatorium of Beijing Military Region, Qinhuangdao, 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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Cardinaels EP, Cornelis T, van der Sande FM, Leunissen KM, van Dieijen-Visser MP, Mingels AM, Kooman JP, Bekers O. Acute effects of conventional and extended hemodialysis and hemodiafiltration on high-sensitivity cardiac troponins. ACTA ACUST UNITED AC 2015; 53:e289-92. [DOI: 10.1515/cclm-2015-0201] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2015] [Accepted: 04/23/2015] [Indexed: 11/15/2022]
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Jarolim P. High sensitivity cardiac troponin assays in the clinical laboratories. ACTA ACUST UNITED AC 2015; 53:635-52. [DOI: 10.1515/cclm-2014-0565] [Citation(s) in RCA: 74] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2014] [Accepted: 07/24/2014] [Indexed: 01/01/2023]
Abstract
AbstractImmunoassays measuring cardiac troponins I or T have become firmly established as critical tools for diagnosing acute myocardial infarction. While most contemporary assays provide adequate diagnostic performance, the increased sensitivity and precision of the new, high sensitivity assays that have already been introduced into clinical practice, provide the potential to further shorten intervals between blood draws or the time needed to detect the first significant troponin elevation. In addition to the relatively modest benefits at the diagnostic end, the high sensitivity assays and the investigational ultrasensitive cardiac troponin assays offer improvements for predicting major adverse cardiovascular events, development of heart failure or transition to end-stage kidney disease. These novel high sensitivity assays can measure troponin concentrations in 50%–100% of healthy individuals and therefore allow for the distribution of troponin values within a healthy cohort to be measured, patient’s baseline troponin levels to be monitored, and clinicians to be alerted of deteriorating cardiorenal conditions. We envisage that the high sensitivity assays will become important tools for predicting each patient’s risk of future adverse events and for guiding and monitoring corresponding adjustments of preventative therapeutic interventions.
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Voroneanu L, Siriopol D, Nistor I, Apetrii M, Hogas S, Onofriescu M, Covic A. Superior predictive value for NTproBNP compared with high sensitivity cTnT in dialysis patients: a pilot prospective observational study. Kidney Blood Press Res 2014; 39:636-47. [PMID: 25571877 DOI: 10.1159/000368452] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/13/2014] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND/AIMS The clinical utility of the new biomarker, high sensitivity cardiac T troponin (hs-cTnT) is still unclear in dialysis patients. Furthermore, the prognostic value of combining N-terminal pro-B-type natriuretic peptide (NT-pro-BNP) and hs-cTnT has not been explored so far. The objective of this pilot study was to determine the utility of hs-cTnT alone versus hs-cTnT in combination with NT-proBNP for predicting death in a stable hemodialysis cohort. METHODS A prospective observational pilot study including 98 chronic asymptomatic hemodialysis patients with a follow up period of 24 months was designed. The cut-off values for NT-proBNP and hs-cTnT were calculated using receiver operating characteristic (ROC) analysis, using mortality as an end-point. Based on the cut-off values, the cohort was divided into four groups. Group 1--NT-proBNP < 14275 pg/ml and hs-cTnT < 69.48 ng/l; group 2--NT-proBNP < 14275 pg/ml and hs-cTnT > 69.48 ng/l; group 3--NT-proBNP > 14275 pg/ml and hs-cTnT < 69.48 ng/l; group 4--NT-proBNP > 14275 pg/ml and hs-cTnT > 69.48 ng/l. Survival for each group was determined using the Kaplan-Meier method and Cox regression analysis. RESULTS During the follow-up period 16 patients died. According to the ROC curves analysis, the cut-off point for hs-cTnT and for NT-proBNP were 69.43 ng/l (AUC = 0.618; p = 0.04) and 14275 pg/ml (AUC = 0.722; p = 0.003), respectively. In univariate Cox analysis, both hs-cTnT (HR = 3.34; p = 0.016) and NT-proBNP (HR = 5.94; p = 0.01) were predictors of death. In the multivariable Cox proportional hazards model, only NT-pro-BNP levels above the cut-off value remained an independent predictor of all-cause mortality. The combined elevation of both biomarkers did not improve significantly the prognostic value compared with NT-proBNP alone (HR = 6.15 versus HR =4 .78; p = 0.338). CONCLUSION NT-pro-BNP is a strong predictor of overall mortality in asymptomatic hemodialysis patients. The addition of hs-cTnT did not improve the prognostic accuracy compared with NT proBNP alone.
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Affiliation(s)
- Luminita Voroneanu
- Nephrology Clinic, Dialysis and Renal Transplant Center, C.I. Parhon University Hospital, Gr. T. Popa University of Medicine and Pharmacy, Iasi, Romania
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Bostick B, Whaley-Connell A. The Use and Interpretation of Troponin in ESRD Patients. Semin Dial 2014; 27:545-7. [DOI: 10.1111/sdi.12263] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Brian Bostick
- Division of Cardiovascular Medicine; Department of Medicine; University of Missouri; Columbia Missouri
- Research Service; Harry S. Truman Memorial Veterans Hospital; Columbia Missouri
| | - Adam Whaley-Connell
- Research Service; Harry S. Truman Memorial Veterans Hospital; Columbia Missouri
- Division of Nephrology and Hypertension; Department of Medicine; University of Missouri; Columbia Missouri
- Division of Endocrinology and Metabolism; Department of Medicine; University of Missouri; Columbia Missouri
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Mácsai E, Németh I, Benke A, Dávid G. [Effect of diabetes on the relation between troponin T and inflammatory markers in patients on hemodialysis]. Orv Hetil 2014; 155:627-33. [PMID: 24733105 DOI: 10.1556/oh.2014.29872] [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] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Cardiac troponin T in renal failure is used for the assessment of cardiovascular risk and mortality. Elevated cardiac troponin T levels correlate with subclinical myocardial necrosis, coronary heart disease, several echocardiographic parameters, metastatic calcification, as well as the presence of diabetes and uremic toxins. AIM The aim of the authors was to examine the impact of factors, mainly the independent effects of inflammatory laboratory parameters, which may influence hypersensitive troponin T levels in hemodialysed patient groups with and without diabetes. METHOD Hemodialysed patient groups with (n = 44) and without diabetes (n = 76) were studied. Difference in serum hypersensitive troponin T values before and after dialysis were analysed by paired Wilcoxon test. Factors possibly affecting the level of hypersensitive troponin T (especially inflammatory markers) were evaluated by multiregression analysis. RESULTS Hypersensitive troponin T levels in patients without diabetes (p = 0.0003) and those with diabetes (p = 0.0032) significantly increased during hemodialysis. In patients without diabetes several factors had significant effect on hypersensitive troponin T including age (p = 0.025), duration of hemodialysis (p = 0.0002), presence of cardiovascular complications (p = 0.0002), high sensitivity C-reactive protein (p = 0.0021), white blood cell count (p = 0.038), and the monocyte ratio (p = 0.0202). However, in patients with diabetes only high sensitivity C-reactive protein (p = 0.0024) showed association with hypersensitive troponin T levels. CONCLUSIONS In hemodyalised patients with and without diabetes the hypersensitive troponin T levels are differently influenced by clinical and inflammatory laboratory parameters, which should be taken into consideration during clinical judgement.
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Affiliation(s)
- Emília Mácsai
- Csolnoky Ferenc Oktatókórház Veszprém Kórház u. 1. 8200 BBRAUN 3 Dialíziscentrum Veszprém
| | - Ilona Németh
- Csolnoky Ferenc Oktatókórház Veszprém Kórház u. 1. 8200
| | | | - Gyula Dávid
- Csolnoky Ferenc Oktatókórház Veszprém Kórház u. 1. 8200
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