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Yildirim M, Reich C, Salbach C, Pribe-Wolferts R, Milles BR, Täger T, Mueller-Hennessen M, Weiler M, Meder B, Frey N, Giannitsis E. Interpretation of elevated baseline concentrations and serial changes of high-sensitivity cardiac troponin T in confirmed muscular dystrophies. ESC Heart Fail 2024. [PMID: 38992971 DOI: 10.1002/ehf2.14864] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2024] [Revised: 04/18/2024] [Accepted: 05/03/2024] [Indexed: 07/13/2024] Open
Abstract
AIMS Concentrations of high-sensitivity cardiac troponin T (hs-cTnT) are frequently elevated in stable patients with confirmed muscle dystrophies. However, sparse information is available on the interpretation of serial concentration changes. METHODS Hs-cTnT was collected in 35 stable outpatients with confirmed skeletal muscle dystrophies at 0 and 1 h and after 6-12 months during scheduled outpatient visits. We simulated the effectiveness of the European Society of Cardiology (ESC) 0/1 h algorithm and assessed biological variation at 6-12 months using two established methods: reference change value (RCV) and minimal important difference (MID). RESULTS Median baseline hs-cTnT concentrations were 34.4 ng/L [inter-quartile range (IQR): 17.5-46.2], and values > 99th percentile upper limit of normal were present in 34 of 35 patients. All patients were stable without cardiovascular adverse events during a follow-up of 6.6 months (IQR: 6-7). Median concentration change was 1.9 ng/L (IQR: 0.7-3.2) and 0.8 ng/L (IQR: 0-7.0) at 60 min and 6-9 months, respectively. Applying the criteria of the ESC 0/1 h algorithm for triage of suspected acute coronary syndrome (ACS) showed poor overall effectiveness of baseline hs-cTnT values. No patient would qualify for rule-out based on hs-cTnT less than the limit of detection, whereas five cases would qualify for rule-in based on hs-cTnT ≥ 52 ng/L. Biological variabilities at 6-12 months per MID and RCV were 1.2 ng/L [95% confidence interval (CI): 0.7-2.1] and 28.6% (95% CI: 27.9-29.6), respectively. A total of 8 (22.9%) and 25 (71.4%) cases exceeded the biological variation range, suggesting some additional myocardial damage. CONCLUSIONS The high prevalence of elevated hs-cTnT could negatively impact the effectiveness of rule-out and rule-in strategies based on a single hs-cTnT value. Knowledge of the physiological and biological variation of hs-cTnT after 6-12 months is helpful to detect the progression of cardiac involvement or to search for cardiac complications including but not limited to arrhythmias that may trigger acute or chronic myocardial damage.
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Affiliation(s)
- Mustafa Yildirim
- Department of Internal Medicine III, Cardiology, University Hospital of Heidelberg, Heidelberg, Germany
| | - Christoph Reich
- Department of Internal Medicine III, Cardiology, University Hospital of Heidelberg, Heidelberg, Germany
- Institute for Cardiomyopathies & Center for Cardiogenetics, Department of Medicine III, Heidelberg University, Heidelberg, Germany
| | - Christian Salbach
- Department of Internal Medicine III, Cardiology, University Hospital of Heidelberg, Heidelberg, Germany
| | - Regina Pribe-Wolferts
- Department of Internal Medicine III, Cardiology, University Hospital of Heidelberg, Heidelberg, Germany
| | - Barbara Ruth Milles
- Department of Internal Medicine III, Cardiology, University Hospital of Heidelberg, Heidelberg, Germany
| | - Tobias Täger
- Department of Internal Medicine III, Cardiology, University Hospital of Heidelberg, Heidelberg, Germany
| | | | - Markus Weiler
- Department of Neurology, University Hospital of Heidelberg, Heidelberg, Germany
| | - Benjamin Meder
- Department of Internal Medicine III, Cardiology, University Hospital of Heidelberg, Heidelberg, Germany
- German Centre for Cardiovascular Research (DZHK), Heidelberg, Germany
- Institute for Cardiomyopathies & Center for Cardiogenetics, Department of Medicine III, Heidelberg University, Heidelberg, Germany
- Stanford Genome Technology Center, Stanford University School of Medicine, Palo Alto, California, USA
| | - Norbert Frey
- Department of Internal Medicine III, Cardiology, University Hospital of Heidelberg, Heidelberg, Germany
- German Centre for Cardiovascular Research (DZHK), Heidelberg, Germany
| | - Evangelos Giannitsis
- Department of Internal Medicine III, Cardiology, University Hospital of Heidelberg, Heidelberg, Germany
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Iwamura N, Kidoguchi S, Asahi N, Takeda I, Matsuta K, Miyagi K, Iwano M, Miyazaki R, Kimura H. Superiority of high sensitivity cardiac troponin I over NT-proBNP and adiponectin for 7-year mortality in stable patients receiving haemodialysis. Sci Rep 2024; 14:11488. [PMID: 38769120 PMCID: PMC11106234 DOI: 10.1038/s41598-024-62491-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2024] [Accepted: 05/17/2024] [Indexed: 05/22/2024] Open
Abstract
Patients on haemodialysis (HD) have high mortality risk, and prognostic values of the major cardiovascular biomarkers cardiac troponin I (cTnI), N-terminal pro-brain natriuretic peptide (NT-proBNP), and adiponectin should be ascertained over longer follow-up periods using higher-sensitivity assays, which we undertook. In 221 HD patients, levels of high-sensitivity (hs)-cTnI, NT-proBNP, and adiponectin, were measured using high-sensitivity assays, and their associations with all-cause mortality (ACM) and cardiovascular mortality (CVM) were prospectively investigated for 7 years. Higher hs-cTnI and NT-proBNP levels were significant risk factors for ACM and CVM in the Kaplan-Meier analysis. Multivariate Cox proportional hazards analyses in a model including hs-cTnI and NT-proBNP identified log hs-cTnI, but not log NT-proBNP, as an independent risk factor for ACM (HR 2.12, P < 0.02) and CVM (HR 4.48, P < 0.0005). Stepwise analyses identified a high hs-cTnI tertile as a risk factor for ACM (HR 2.31, P < 0.01) and CVM (HR 6.70, P < 0.001). The addition of hs-cTnI to a model including age, CRP, DM, and NT-proBNP significantly improved the discrimination of ACM and CVM each over 7 years. Conclusively, hs-cTnI was superior to NT-proBNP and adiponectin in predicting ACM and CVM over 7 years in HD patients, suggesting the significance of baseline hs-cTnI measurements in long-term management.
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Affiliation(s)
- Nanami Iwamura
- Department of Clinical Laboratory, University of Fukui Hospital, 23-3 Matsuoka-Shimoaizuki, Eiheiji, Yoshida, Fukui, 910-1193, Japan
| | - Shuhei Kidoguchi
- Department of Clinical Laboratory, University of Fukui Hospital, 23-3 Matsuoka-Shimoaizuki, Eiheiji, Yoshida, Fukui, 910-1193, Japan
| | - Nanae Asahi
- Department of Clinical Laboratory, University of Fukui Hospital, 23-3 Matsuoka-Shimoaizuki, Eiheiji, Yoshida, Fukui, 910-1193, Japan
| | - Izumi Takeda
- Department of Clinical Laboratory, University of Fukui Hospital, 23-3 Matsuoka-Shimoaizuki, Eiheiji, Yoshida, Fukui, 910-1193, Japan
| | - Kohei Matsuta
- Department of Clinical Laboratory, University of Fukui Hospital, 23-3 Matsuoka-Shimoaizuki, Eiheiji, Yoshida, Fukui, 910-1193, Japan
| | - Kyoko Miyagi
- Department of Internal Medicine, Fujita Memorial Hospital, Fukui, Japan
| | - Masayuki Iwano
- Division of Nephrology, Department of General Medicine, School of Medicine, University of Fukui, Fukui, Japan
| | - Ryoichi Miyazaki
- Department of Internal Medicine, Fujita Memorial Hospital, Fukui, Japan
| | - Hideki Kimura
- Department of Clinical Laboratory, University of Fukui Hospital, 23-3 Matsuoka-Shimoaizuki, Eiheiji, Yoshida, Fukui, 910-1193, Japan.
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Li Z, Wereski R, Anand A, Lowry MTH, Doudesis D, McDermott M, Ferry AV, Tuck C, Chapman AR, Lee KK, Shah ASV, Mills NL, Kimenai DM. Uniform or Sex-Specific Cardiac Troponin Thresholds to Rule Out Myocardial Infarction at Presentation. J Am Coll Cardiol 2024; 83:1855-1866. [PMID: 38537916 DOI: 10.1016/j.jacc.2024.03.365] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2024] [Revised: 03/05/2024] [Accepted: 03/06/2024] [Indexed: 07/18/2024]
Abstract
BACKGROUND Myocardial infarction can be ruled out in patients with a single cardiac troponin measurement. Whether use of a uniform rule-out threshold has resulted in sex differences in care remains unclear. OBJECTIVES The purpose of this study was to evaluate implementation of a uniform rule-out threshold in females and males with possible myocardial infarction, and to derive and validate sex-specific thresholds. METHODS The implementation of a uniform rule-out threshold (<5 ng/L) with a high-sensitivity cardiac troponin I assay was evaluated in consecutive patients presenting with possible myocardial infarction. The proportion of low-risk patients discharged from the emergency department and incidence of myocardial infarction or cardiac death at 30 days were determined. Sex-specific thresholds were derived and validated, and proportion of female and male patients were stratified as low-risk compared with uniform threshold. RESULTS In 16,792 patients (age 58 ± 17 years; 46% female) care was guided using a uniform threshold. This identified more female than male patients as low risk (73% vs 62%), but a similar proportion of low-risk patients were discharged from the emergency department (81% for both) with fewer than 5 (<0.1%) patients having a subsequent myocardial infarction or cardiac death at 30 days. Compared with a uniform threshold of <5 ng/L, use of sex-specific thresholds would increase the proportion of female (61.8% vs 65.9%) and reduce the proportion of male (54.8% vs 47.8%) patients identified as low risk. CONCLUSIONS Implementation of a uniform rule-out threshold for myocardial infarction was safe and effective in both sexes. Sex-specific rule-out thresholds should be considered, but their impact on effectiveness and safety may be limited.
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Affiliation(s)
- Ziwen Li
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom. https://twitter.com/ZiwenCassLi
| | - Ryan Wereski
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
| | - Atul Anand
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
| | - Matthew T H Lowry
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
| | - Dimitrios Doudesis
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
| | - Michael McDermott
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
| | - Amy V Ferry
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
| | - Chris Tuck
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
| | - Andrew R Chapman
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom; Department of Cardiology, Auckland City Hospital, Auckland, New Zealand
| | - Kuan Ken Lee
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
| | - Anoop S V Shah
- Department of Non-Communicable Disease, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Nicholas L Mills
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom; Usher Institute, University of Edinburgh, Edinburgh, United Kingdom
| | - Dorien M Kimenai
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom.
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4
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Kislikova M, Gaitán-Valdizán JJ, Parra Blanco JA, García Unzueta MT, Rodríguez Vidriales M, Escagedo Cagigas C, Piñera Haces VC, Valentín Muñoz MDLO, Benito Hernández A, Ruiz San Millan JC, Rodrigo Calabia E. Looking into the Eyes to See the Heart of Chronic Kidney Disease Patients. Life (Basel) 2024; 14:533. [PMID: 38672803 PMCID: PMC11051204 DOI: 10.3390/life14040533] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2024] [Revised: 04/03/2024] [Accepted: 04/17/2024] [Indexed: 04/28/2024] Open
Abstract
In patients with chronic kidney disease (CKD), the main cause of morbidity and mortality is cardiovascular disease (CVD). Both coronary artery calcium scoring by computed tomography (CT) and optical coherence tomography (OCT) are used to identify patients at increased risk for ischemic heart disease, thereby indicating a higher cardiovascular risk profile. Our study aimed to investigate the utility of these techniques in the CKD population. In patients with CKD, OCT was used to measure the choroidal thickness (CHT) and the thickness of the peripapillary retinal nerve fiber layer (pRNFL). A total of 127 patients were included, including 70 men (55%) with an estimated glomerular filtration rate (eGFR) of 39 ± 30 mL/min/1.73 m2. Lower pRNFL thickness was found to be related to high-sensitivity troponin I (r = -0.362, p < 0.001) and total coronary calcification (r = -0.194, p = 0.032). In a multivariate analysis, pRNFL measurements remained associated with age (β = -0.189; -0.739--0.027; p = 0.035) and high-sensitivity troponin I (β = -0.301; -0.259--0.071; p < 0.001). Severe coronary calcification (Agatston score ≥ 400 HU) was related to a worse eGFR (p = 0.008), a higher grade of CKD (p = 0.036), and a thinner pRNFL (p = 0.011). The ROC curve confirmed that the pRNFL measurement could determine the patients with an Agatston score of ≥400 HU (AUC 0.638; 95% CI 0.525-0.750; p = 0.015). Our study concludes that measurement of pRNFL thickness using OCT is related to the markers associated with ischemic heart disease, such as coronary calcification and high-sensitivity troponin I, in the CKD population.
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Affiliation(s)
- Maria Kislikova
- Immunopathology Group, Nephrology Department, Marqués de Valdecilla University Hospital—IDIVAL, 39008 Santander, Spain; (M.R.V.); (C.E.C.); (V.C.P.H.); (M.d.l.O.V.M.); (A.B.H.); (J.C.R.S.M.); (E.R.C.)
| | | | | | | | - María Rodríguez Vidriales
- Immunopathology Group, Nephrology Department, Marqués de Valdecilla University Hospital—IDIVAL, 39008 Santander, Spain; (M.R.V.); (C.E.C.); (V.C.P.H.); (M.d.l.O.V.M.); (A.B.H.); (J.C.R.S.M.); (E.R.C.)
| | - Clara Escagedo Cagigas
- Immunopathology Group, Nephrology Department, Marqués de Valdecilla University Hospital—IDIVAL, 39008 Santander, Spain; (M.R.V.); (C.E.C.); (V.C.P.H.); (M.d.l.O.V.M.); (A.B.H.); (J.C.R.S.M.); (E.R.C.)
| | - Vicente Celestino Piñera Haces
- Immunopathology Group, Nephrology Department, Marqués de Valdecilla University Hospital—IDIVAL, 39008 Santander, Spain; (M.R.V.); (C.E.C.); (V.C.P.H.); (M.d.l.O.V.M.); (A.B.H.); (J.C.R.S.M.); (E.R.C.)
| | - María de la Oliva Valentín Muñoz
- Immunopathology Group, Nephrology Department, Marqués de Valdecilla University Hospital—IDIVAL, 39008 Santander, Spain; (M.R.V.); (C.E.C.); (V.C.P.H.); (M.d.l.O.V.M.); (A.B.H.); (J.C.R.S.M.); (E.R.C.)
| | - Adalberto Benito Hernández
- Immunopathology Group, Nephrology Department, Marqués de Valdecilla University Hospital—IDIVAL, 39008 Santander, Spain; (M.R.V.); (C.E.C.); (V.C.P.H.); (M.d.l.O.V.M.); (A.B.H.); (J.C.R.S.M.); (E.R.C.)
| | - Juan Carlos Ruiz San Millan
- Immunopathology Group, Nephrology Department, Marqués de Valdecilla University Hospital—IDIVAL, 39008 Santander, Spain; (M.R.V.); (C.E.C.); (V.C.P.H.); (M.d.l.O.V.M.); (A.B.H.); (J.C.R.S.M.); (E.R.C.)
| | - Emilio Rodrigo Calabia
- Immunopathology Group, Nephrology Department, Marqués de Valdecilla University Hospital—IDIVAL, 39008 Santander, Spain; (M.R.V.); (C.E.C.); (V.C.P.H.); (M.d.l.O.V.M.); (A.B.H.); (J.C.R.S.M.); (E.R.C.)
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5
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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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Cepoi MR, Duca ST, Chetran A, Costache AD, Spiridon MR, Afrăsânie I, Leancă SA, Dmour BA, Matei IT, Miftode RS, Miftode L, Prepeliuc CS, Haba MȘC, Bădescu MC, Costache II. Chronic Kidney Disease Associated with Ischemic Heart Disease: To What Extent Do Biomarkers Help? Life (Basel) 2023; 14:34. [PMID: 38255650 PMCID: PMC10817293 DOI: 10.3390/life14010034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Revised: 12/17/2023] [Accepted: 12/20/2023] [Indexed: 01/24/2024] Open
Abstract
Chronic kidney disease represents a complex and multifaceted pathology characterized by the presence of structural or functional renal anomalies associated with a persistent reduction in renal function. As the disease progresses, complications arise due to the chronic inflammatory syndrome, hydro-electrolytic disorders, and toxicity secondary to the uremic environment. Cardiovascular complications are the leading cause of death for these patients. Ischemic cardiac pathology can be both a consequence and complication of chronic kidney disease, highlighting the need to identify specific cardiorenal dysfunction biomarkers targeting pathophysiological mechanisms common to both conditions. This identification is crucial for establishing accurate diagnoses, prognoses, and risk stratifications for patients. This work is intended to elucidate the intricate relationship between chronic kidney disease and ischemic heart disease and to investigate the roles of cardiorenal biomarkers, including cardiac troponin, natriuretic peptides, galectin-3, copeptin, fibroblast growth factor 23 and its co-receptor Klotho, soluble suppression of tumorigenicity 2, and plasma growth differentiation factor 15.
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Affiliation(s)
- Maria-Ruxandra Cepoi
- Department of Internal Medicine, Faculty of Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iași, Romania; (M.-R.C.); (S.T.D.); (A.C.); (I.A.); (S.A.L.); (B.-A.D.); (I.T.M.); (R.S.M.); (M.Ș.C.H.); (M.C.B.); (I.I.C.)
- Department of Cardiology, “St. Spiridon” County Clinical Emergency Hospital, 700111 Iași, Romania;
| | - Stefania Teodora Duca
- Department of Internal Medicine, Faculty of Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iași, Romania; (M.-R.C.); (S.T.D.); (A.C.); (I.A.); (S.A.L.); (B.-A.D.); (I.T.M.); (R.S.M.); (M.Ș.C.H.); (M.C.B.); (I.I.C.)
- Department of Cardiology, “St. Spiridon” County Clinical Emergency Hospital, 700111 Iași, Romania;
| | - Adriana Chetran
- Department of Internal Medicine, Faculty of Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iași, Romania; (M.-R.C.); (S.T.D.); (A.C.); (I.A.); (S.A.L.); (B.-A.D.); (I.T.M.); (R.S.M.); (M.Ș.C.H.); (M.C.B.); (I.I.C.)
- Department of Cardiology, “St. Spiridon” County Clinical Emergency Hospital, 700111 Iași, Romania;
| | - Alexandru Dan Costache
- Department of Internal Medicine, Faculty of Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iași, Romania; (M.-R.C.); (S.T.D.); (A.C.); (I.A.); (S.A.L.); (B.-A.D.); (I.T.M.); (R.S.M.); (M.Ș.C.H.); (M.C.B.); (I.I.C.)
- Department of Cardiovascular Rehabilitation, Clinical Rehabilitation Hospital, 700661 Iași, Romania
| | - Marilena Renata Spiridon
- Department of Cardiology, “St. Spiridon” County Clinical Emergency Hospital, 700111 Iași, Romania;
| | - Irina Afrăsânie
- Department of Internal Medicine, Faculty of Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iași, Romania; (M.-R.C.); (S.T.D.); (A.C.); (I.A.); (S.A.L.); (B.-A.D.); (I.T.M.); (R.S.M.); (M.Ș.C.H.); (M.C.B.); (I.I.C.)
- Department of Cardiology, “St. Spiridon” County Clinical Emergency Hospital, 700111 Iași, Romania;
| | - Sabina Andreea Leancă
- Department of Internal Medicine, Faculty of Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iași, Romania; (M.-R.C.); (S.T.D.); (A.C.); (I.A.); (S.A.L.); (B.-A.D.); (I.T.M.); (R.S.M.); (M.Ș.C.H.); (M.C.B.); (I.I.C.)
- Department of Cardiology, “St. Spiridon” County Clinical Emergency Hospital, 700111 Iași, Romania;
| | - Bianca-Ana Dmour
- Department of Internal Medicine, Faculty of Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iași, Romania; (M.-R.C.); (S.T.D.); (A.C.); (I.A.); (S.A.L.); (B.-A.D.); (I.T.M.); (R.S.M.); (M.Ș.C.H.); (M.C.B.); (I.I.C.)
- Department of III Internal Medicine Clinic, “St. Spiridon” County Clinical Emergency Hospital, 700111 Iași, Romania
| | - Iulian Theodor Matei
- Department of Internal Medicine, Faculty of Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iași, Romania; (M.-R.C.); (S.T.D.); (A.C.); (I.A.); (S.A.L.); (B.-A.D.); (I.T.M.); (R.S.M.); (M.Ș.C.H.); (M.C.B.); (I.I.C.)
- Department of Cardiology, “St. Spiridon” County Clinical Emergency Hospital, 700111 Iași, Romania;
| | - Radu Stefan Miftode
- Department of Internal Medicine, Faculty of Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iași, Romania; (M.-R.C.); (S.T.D.); (A.C.); (I.A.); (S.A.L.); (B.-A.D.); (I.T.M.); (R.S.M.); (M.Ș.C.H.); (M.C.B.); (I.I.C.)
- Department of Cardiology, “St. Spiridon” County Clinical Emergency Hospital, 700111 Iași, Romania;
| | - Larisa Miftode
- Department of Infectious Diseases, Faculty of Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iași, Romania; (L.M.); (C.S.P.)
- “St. Parascheva” Clinical Hospital of Infectious Diseases, 700116 Iași, Romania
| | - Cristian Sorin Prepeliuc
- Department of Infectious Diseases, Faculty of Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iași, Romania; (L.M.); (C.S.P.)
- “St. Parascheva” Clinical Hospital of Infectious Diseases, 700116 Iași, Romania
| | - Mihai Ștefan Cristian Haba
- Department of Internal Medicine, Faculty of Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iași, Romania; (M.-R.C.); (S.T.D.); (A.C.); (I.A.); (S.A.L.); (B.-A.D.); (I.T.M.); (R.S.M.); (M.Ș.C.H.); (M.C.B.); (I.I.C.)
- Department of Cardiology, “St. Spiridon” County Clinical Emergency Hospital, 700111 Iași, Romania;
| | - Minerva Codruța Bădescu
- Department of Internal Medicine, Faculty of Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iași, Romania; (M.-R.C.); (S.T.D.); (A.C.); (I.A.); (S.A.L.); (B.-A.D.); (I.T.M.); (R.S.M.); (M.Ș.C.H.); (M.C.B.); (I.I.C.)
- Department of III Internal Medicine Clinic, “St. Spiridon” County Clinical Emergency Hospital, 700111 Iași, Romania
| | - Irina Iuliana Costache
- Department of Internal Medicine, Faculty of Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iași, Romania; (M.-R.C.); (S.T.D.); (A.C.); (I.A.); (S.A.L.); (B.-A.D.); (I.T.M.); (R.S.M.); (M.Ș.C.H.); (M.C.B.); (I.I.C.)
- Department of Cardiology, “St. Spiridon” County Clinical Emergency Hospital, 700111 Iași, Romania;
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7
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Su XF, Chen X, Zhang T, Song JM, Liu X, Xu XL, Fan N. A risk model for the early diagnosis of acute myocardial infarction in patients with chronic kidney disease. Front Cardiovasc Med 2023; 10:1253619. [PMID: 37881722 PMCID: PMC10597667 DOI: 10.3389/fcvm.2023.1253619] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Accepted: 09/22/2023] [Indexed: 10/27/2023] Open
Abstract
Introduction Acute myocardial infarction (AMI) remains a critical disease, characterized by a high fatality rate in several countries. In clinical practice, the incidence of AMI is increased in patients with chronic kidney disease (CKD). However, the early diagnosis of AMI in the above group of patients is still poor. Methods In the present study, a total of 829 patients with CKD, defined by an estimated glomerular filtration rate (eGFR) of <60 ml/min/1.73 m2 or 60-90 ml/min/1.73 m2 for patients with mildly reduced kidney function, who attended the Sichuan Provincial People's Hospital (SPPH) between January 2018 and November 2022 were enrolled. All patients underwent coronary angiography due to the presence of typical or atypical symptoms of AMI. Patients were divided into the following two groups: The training cohort, including 255 participants with AMI and 242 without AMI; and the testing cohort, including 165 and 167 subjects with and without AMI, respectively. Furthermore, a forward stepwise regression model and a multivariable logistic regression model, named SPPH-AMI-model, were constructed to select significant predictors and assist the diagnosis of AMI in patients with CKD, respectively. Results The following factors were evaluated in the model: Smoking status, high sensitivity cardiac troponin I, serum creatinine and uric acid levels, history of percutaneous coronary intervention and electrocardiogram. Additionally, the area under the curve (AUC) of the receiver operating characteristic curve were determined in the risk model in the training set [AUC, 0.78; 95% confidence interval (CI), 0.74-0.82] vs. the testing set (AUC, 0.74; 95% CI, 0.69-0.79) vs. the combined set (AUC, 0.76; 95% CI, 0.73-0.80). Finally, the sensitivity and specificity rates were 71.12 and 71.21%, respectively, the percentage of cases correctly classified was 71.14%, while positive and negative predictive values of 71.63 and 70.70%, respectively, were also recorded. Discussion The results of the current study suggested that the SPPH-AMI-model could be currently considered as the only risk scoring system for the early diagnosis of AMI in patients with CKD. This method could help clinicians and emergency physicians to quickly and accurately diagnose AMI in patients with CKD to promote the immediate and effective treatment of these patients.
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Affiliation(s)
- Xiao-Feng Su
- Ultrasound in Cardiac Electrophysiology and Biomechanics Key Laboratory of Sichuan Province, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, China
- Department of Cardiovascular Ultrasound & Noninvasive Cardiology, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, China
| | - Xu Chen
- Ultrasound in Cardiac Electrophysiology and Biomechanics Key Laboratory of Sichuan Province, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, China
- Department of Cardiovascular Ultrasound & Noninvasive Cardiology, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, China
| | - Tao Zhang
- Ultrasound in Cardiac Electrophysiology and Biomechanics Key Laboratory of Sichuan Province, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, China
- Department of Cardiovascular Ultrasound & Noninvasive Cardiology, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, China
| | - Jun-Mei Song
- Ultrasound in Cardiac Electrophysiology and Biomechanics Key Laboratory of Sichuan Province, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, China
- Department of Cardiovascular Ultrasound & Noninvasive Cardiology, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, China
| | - Xin Liu
- Ultrasound in Cardiac Electrophysiology and Biomechanics Key Laboratory of Sichuan Province, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, China
- Department of Cardiovascular Ultrasound & Noninvasive Cardiology, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, China
| | - Xing-Li Xu
- Ultrasound in Cardiac Electrophysiology and Biomechanics Key Laboratory of Sichuan Province, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, China
- Department of Cardiovascular Ultrasound & Noninvasive Cardiology, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, China
| | - Na Fan
- Ultrasound in Cardiac Electrophysiology and Biomechanics Key Laboratory of Sichuan Province, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, China
- Department of Cardiovascular Ultrasound & Noninvasive Cardiology, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, China
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8
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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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9
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Postoperative myocardial injury and platelet reactivity in patients undergoing vascular surgery: The platelet reactivity and postoperative myocardial injury after major vascular surgery (PROMISE) study. Thromb Res 2022; 218:177-185. [PMID: 36057168 DOI: 10.1016/j.thromres.2022.08.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Revised: 08/17/2022] [Accepted: 08/22/2022] [Indexed: 11/24/2022]
Abstract
BACKGROUND Postoperative myocardial injury (PMI) after major vascular surgery, detected by elevated cardiac troponin (cTn), has been associated with morbidity and mortality. It is unclear whether the pathophysiology of PMI is determined by increased platelet activity. OBJECTIVE To examine the relationship between platelet activation (P-selectin expression) and PMI in patients undergoing elective open abdominal aortic surgery. METHODS This prospective, single-centre, observational, cohort study included 33 patients undergoing elective open abdominal aortic surgery between March 2018 and April 2021. Patients were routinely treated with aspirin. Unstimulated platelet activation was measured by platelet bound P-selectin expression (range 0-100 %). Explorative coagulation measurements were: stimulated platelet aggregation measured with the VerifyNow® assay (aspirin cartridge), with the Multiplate® analyzer (ASPI, ADP and TRAP) and stimulated coagulation status evaluated by the TEG® Hemostasis Analyzer System (global hemostasis cartridge). The primary outcome was cTn release assessed by the fifth generation high-sensitive cTn assay. Multivariable generalized linear mixed models were used to evaluate the association between platelet function and cTn concentrations over time. RESULTS Ten patients (30.3 %) developed PMI. Increased P-selectin expression directly after surgery was associated with the cTn concentrations over 48 h (β = 1.39 (1.1-1.75), P = 0.0064). No association was found between P-selectin measured later after surgery (at 24 h or 48 h) and cTn concentrations. Furthermore, there was no association between the explorative coagulation parameters and cTn release. CONCLUSION Platelet reactivity, assessed by P-selectin expression measured directly after surgery is associated with PMI, assessed by elevated cTn concentrations in the early postoperative period in patients undergoing elective open abdominal aortic surgery.
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10
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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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11
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Chesnaye NC, Al-Sodany E, Szummer K, Barany P, Heimbürger O, Almquist T, Melander S, Uhlin F, Dekker F, Wanner C, Jager KJ, Evans M. Association of Longitudinal High-Sensitivity Troponin T With Mortality in Patients With Chronic Kidney Disease. J Am Coll Cardiol 2022; 79:327-336. [DOI: 10.1016/j.jacc.2021.11.023] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Revised: 11/01/2021] [Accepted: 11/03/2021] [Indexed: 11/28/2022]
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12
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Advanced CKD, Delta Troponins, Mortality. J Am Coll Cardiol 2022; 79:337-340. [DOI: 10.1016/j.jacc.2021.11.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Accepted: 11/22/2021] [Indexed: 11/18/2022]
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13
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Prognostic value of changes in high-sensitivity cardiac troponin T beyond biological variation in stable outpatients with cardiovascular disease: a validation study. Clin Res Cardiol 2021; 111:333-342. [PMID: 34694435 PMCID: PMC8873128 DOI: 10.1007/s00392-021-01952-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2021] [Accepted: 10/13/2021] [Indexed: 12/03/2022]
Abstract
Objective To evaluate the prognostic implications of longitudinal long-term changes beyond the biological variation of high-sensitivity cardiac troponin T (hs-cTnT) in outpatients with stable or asymptomatic cardiovascular disease (CV) and to assess possible differences in the prognostic value while using reference change value (RCV) and minimal important differences (MID) as metric for biological variation. Methods Hs-cTnT was measured at index visit and after 12 months in outpatients presenting for routine follow-up. The prognostic relevance of a concentration change of hs-cTnT values exceeding the biological variation defined by RCV and MID of a healthy population within the next 12 months following the stable initial period was determined regarding three endpoints: all-cause mortality (EP1), a composite of all-cause mortality, non-fatal myocardial infarction and stroke (EP2), and a composite of all-cause mortality, non-fatal myocardial infarction, stroke, hospitalization for acute coronary syndrome (ACS) or decompensated heart failure, and planned and unplanned percutaneous coronary interventions (PCI, EP3). Results Change in hs-cTnT values exceeding the biovariability defined by MID but not by RCV discriminated a group with a higher cardiovascular risk profile. Changes within MID were associated with uneventful course (NPV 91.6–99.7%) while changes exceeding MID were associated with a higher occurrence of all endpoints within the next 365 days indicating a 5.5-fold increased risk for EP 1 (p = 0.041) a 2.4-fold increased risk for EP 2 (p = 0.049) and a 1.9-fold increased risk for EP 3 (p < 0.0001). Conclusions In stable outpatients MID calculated from hs-cTnT changes measured 365 ± 120 days apart are helpful to predict an uneventful clinical course. Clinical trials identifier NCT01954303. Graphic abstract ![]()
Supplementary Information The online version contains supplementary material available at 10.1007/s00392-021-01952-6.
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14
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Bansal N, Zelnick LR, Soliman EZ, Anderson A, Christenson R, DeFilippi C, Deo R, Feldman HI, He J, Ky B, Kusek J, Lash J, Seliger S, Shafi T, Wolf M, Go AS, Shlipak MG, Appel LJ, Rao PS, Rahman M, Townsend RR. Change in Cardiac Biomarkers and Risk of Incident Heart Failure and Atrial Fibrillation in CKD: The Chronic Renal Insufficiency Cohort (CRIC) Study. Am J Kidney Dis 2021; 77:907-919. [DOI: 10.1053/j.ajkd.2020.09.021] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Accepted: 09/26/2020] [Indexed: 12/16/2022]
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15
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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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16
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Rossignol P, Agarwal R, Canaud B, Charney A, Chatellier G, Craig JC, Cushman WC, Gansevoort RT, Fellström B, Garza D, Guzman N, Holtkamp FA, London GM, Massy ZA, Mebazaa A, Mol PGM, Pfeffer MA, Rosenberg Y, Ruilope LM, Seltzer J, Shah AM, Shah S, Singh B, Stefánsson BV, Stockbridge N, Stough WG, Thygesen K, Walsh M, Wanner C, Warnock DG, Wilcox CS, Wittes J, Pitt B, Thompson A, Zannad F. Cardiovascular outcome trials in patients with chronic kidney disease: challenges associated with selection of patients and endpoints. Eur Heart J 2020; 40:880-886. [PMID: 28431138 DOI: 10.1093/eurheartj/ehx209] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2017] [Revised: 03/17/2017] [Accepted: 03/30/2017] [Indexed: 12/11/2022] Open
Abstract
Although cardiovascular disease is a major health burden for patients with chronic kidney disease, most cardiovascular outcome trials have excluded patients with advanced chronic kidney disease. Moreover, the major cardiovascular outcome trials that have been conducted in patients with end-stage renal disease have not demonstrated a treatment benefit. Thus, clinicians have limited evidence to guide the management of cardiovascular disease in patients with chronic kidney disease, particularly those on dialysis. Several factors contribute to both the paucity of trials and the apparent lack of observed treatment effect in completed studies. Challenges associated with conducting trials in this population include patient heterogeneity, complexity of renal pathophysiology and its interaction with cardiovascular disease, and competing risks for death. The Investigator Network Initiative Cardiovascular and Renal Clinical Trialists (INI-CRCT), an international organization of academic cardiovascular and renal clinical trialists, held a meeting of regulators and experts in nephrology, cardiology, and clinical trial methodology. The group identified several research priorities, summarized in this paper, that should be pursued to advance the field towards achieving improved cardiovascular outcomes for these patients. Cardiovascular and renal clinical trialists must partner to address the uncertainties in the field through collaborative research and design clinical trials that reflect the specific needs of the chronic and end-stage kidney disease populations, with the shared goal of generating robust evidence to guide the management of cardiovascular disease in patients with kidney disease.
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Affiliation(s)
- Patrick Rossignol
- Inserm, Centre d'Investigations Cliniques- 1433, and Inserm U1116; CHRU Nancy; Université de Lorraine; Association Lorraine pour le Traitement de l'Insuffisance Rénale, Institut lorrain du Cœur et des Vaisseaux Louis Mathieu, 4 rue du Morvan, Nancy, France.,F-CRIN INI-CRCT, Nancy, France
| | - Rajiv Agarwal
- Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA.,Richard L. Roudebush Veterans Administration Medical Center, Indianapolis, IN, USA
| | - Bernard Canaud
- Fresenius Medical Care Deutschland and University of Montpellier, UFR Medicine, France
| | - Alan Charney
- Novartis Pharmaceuticals Corporation, East Hanover, NJ, USA
| | - Gilles Chatellier
- AP-HP, Hôpital Européen Georges Pompidou, Unité de Recherche Clinique and INSERM CIC 1418, Paris, France
| | - Jonathan C Craig
- School of Public Health, The University of Sydney, New South Wales, Australia.,Centre for Kidney Research, The Children's Hospital at Westmead, New South Wales, Australia
| | - William C Cushman
- Preventive Medicine Section, Veterans Affairs Medical Center, Memphis, Tennessee, USA
| | - Ronald T Gansevoort
- Department of Nephrology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Bengt Fellström
- Inserm U1018, Université Paris-Saclay, UVSQ, Université. Paris-Sud, Villejuif, France
| | | | | | - Frank A Holtkamp
- Dutch Medicines Evaluation Board, Utrecht, The Netherlands.,Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Gerard M London
- F-CRIN INI-CRCT, Nancy, France.,France Centre Hospitalier F.H. Manhès, Fleury-Merogis, France
| | - Ziad A Massy
- F-CRIN INI-CRCT, Nancy, France.,Ambroise Pare University Hospital, APHP, Paris-Ile-de France-Ouest University (UVSQ), and INSERM U1018, Team 5 Boulogne Billancourt, France
| | - Alexandre Mebazaa
- F-CRIN INI-CRCT, Nancy, France.,U942 Inserm, Paris, France.,University Paris Diderot, Sorbonne Paris Cité, Paris, France.,APHP, Department of Anesthesia and Critical Care, Hôpitaux Universitaires Saint Louis-Lariboisière, Paris, France
| | - Peter G M Mol
- Dutch Medicines Evaluation Board, Utrecht, The Netherlands.,Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Marc A Pfeffer
- Cardiovascular Division, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Yves Rosenberg
- National Heart, Lung, and Blood Institute, Bethesda, MD, USA
| | - Luis M Ruilope
- Institute of Investigation and Hypertension Unit, Hospital 12 de Octubre, Department of Preventive Medicine and Public Health, Universidad Autonoma and School of Doctoral Studies and Research, Universidad Europea de Madrid, Madrid, Spain
| | | | - Amil M Shah
- Cardiovascular Division, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Salim Shah
- Sarfez Pharmaceuticals, Inc., McLean, VA, USA
| | | | | | - Norman Stockbridge
- Division of Cardiovascular and Renal Products, Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, MD, USA
| | | | - Kristian Thygesen
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
| | - Michael Walsh
- McMaster University and Population Health Research Institute, Hamilton, Canada
| | - Christoph Wanner
- Division of Nephrology, Department of Internal Medicine 1, University Hospital Würzburg and Comprehensive Heart Failure Center, Würzburg, Germany
| | - David G Warnock
- Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Christopher S Wilcox
- Hypertension, Kidney and Vascular Research Center and Division of Nephrology and Hypertension, Department of Medicine, Georgetown University, Washington, DC, USA
| | - Janet Wittes
- Statistics Collaborative, Inc., Washington, District of Columbia, USA
| | - Bertram Pitt
- University of Michigan School of Medicine, Ann Arbor, MI, USA
| | - Aliza Thompson
- Division of Cardiovascular and Renal Products, Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, MD, USA
| | - Faiez Zannad
- Inserm, Centre d'Investigations Cliniques- 1433, and Inserm U1116; CHRU Nancy; Université de Lorraine; Association Lorraine pour le Traitement de l'Insuffisance Rénale, Institut lorrain du Cœur et des Vaisseaux Louis Mathieu, 4 rue du Morvan, Nancy, France.,F-CRIN INI-CRCT, Nancy, France
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17
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McCarthy CP, Raber I, Chapman AR, Sandoval Y, Apple FS, Mills NL, Januzzi JL. Myocardial Injury in the Era of High-Sensitivity Cardiac Troponin Assays: A Practical Approach for Clinicians. JAMA Cardiol 2020; 4:1034-1042. [PMID: 31389986 DOI: 10.1001/jamacardio.2019.2724] [Citation(s) in RCA: 77] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Importance Traditionally, elevated troponin concentrations were synonymous with myocardial infarction. But with improvements in troponin assays, elevated concentrations without overt myocardial ischemia are now more common; this is referred to as myocardial injury. Physicians may be falsely reassured by the absence of myocardial ischemia; however, recent evidence suggests that myocardial injury is associated with even more detrimental outcomes. Accordingly, this article reviews the definition, epidemiology, differential diagnosis, diagnostic evaluation, and management of myocardial injury. Observations Current epidemiological evidence suggests that myocardial injury without overt ischemia represents about 60% of cases of abnormal troponin concentrations when obtained for clinical indications, and 1 in 8 patients presenting to the hospital will have evidence of myocardial injury. Myocardial injury is a concerning prognosis; the 5-year mortality rate is approximately 70%, with a major adverse cardiovascular event rate of 30% in the same period. The differential diagnosis is broad and can be divided into acute and chronic precipitants. The initial workup involves an assessment for myocardial ischemia. If infarction is ruled out, further evaluation includes a detailed history, physical examination, laboratory testing, a 12-lead electrocardiogram, and (if there is no known history of structural or valvular heart disease) an echocardiogram. Unfortunately, no consensus exists on routine management of patients with myocardial injury. Identifying and treating the underlying precipitant is the most practical approach. Conclusion and Relevance Myocardial injury is the most common cause of abnormal troponin results, and its incidence will likely increase with an aging population, increasing prevalence of cardiovascular comorbidities, and greater sensitivity of troponin assays. Myocardial injury represents a challenge to clinicians; however, given its serious prognosis, it warrants a thorough evaluation of its underlying precipitant. Future strategies to prevent and/or manage myocardial injury are needed.
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Affiliation(s)
- Cian P McCarthy
- Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston
| | - Inbar Raber
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Andrew R Chapman
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
| | - Yader Sandoval
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Fred S Apple
- Department of Laboratory Medicine and Pathology, Hennepin Healthcare/Hennepin County Medical Center and University of Minnesota, Minneapolis
| | - Nicholas L Mills
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom.,Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, United Kingdom
| | - James L Januzzi
- Division of Cardiology, Massachusetts General Hospital, Boston.,Baim Institute for Clinical Research, Boston, Massachusetts
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18
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Corte Z, Venta R. Biological variation of metabolic cardiovascular risk factors in haemodialysis patients and healthy individuals. ANNALS OF TRANSLATIONAL MEDICINE 2020; 8:281. [PMID: 32355725 PMCID: PMC7186598 DOI: 10.21037/atm.2020.03.26] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Background Maintenance haemodialysis (HD) is associated with a very high cardiovascular risk and the assessment of metabolic cardiovascular risk factors is essential for an adequate diagnosis and management. The aim of the study has been to estimate the biological variation (BV) of serum lipids, calcium, inorganic phosphorus, 25-OH vitamin D, C-reactive protein and plasma intact parathyroid hormone (PTHi) and total homocysteine, to evaluate whether HD alter the homeostatic set-point of these magnitudes. Methods Blood samples were collected from 18 HD patients in steady-state conditions, one per month during 6 months, and from 11 healthy volunteers at weekly intervals over 5 weeks. BV data were derived using CV-ANOVA. Results Within-subject coefficients of variation (CVI) and derived reference change values (RCV) estimated in HD patients were significantly higher than in healthy individuals for calcium (CVI =3.8% vs. 2.3%) (RCV =12.6% vs. 7.6%), inorganic phosphorus (13.1% vs. 8.0%) (RCV =38.7% vs. 30.1%) and PTHi (20.3% vs. 11.3%) (RCV =57.5% vs. 34.0%). Conclusions For calcium, inorganic phosphorus and PTHi, RCV derived from advanced disease-specific BV data is recommended for the management of bone-mineral disturbances in HD patients. For the rest of cardiovascular risk factors, the use of RCV derived from healthy individuals could be appropriate.
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Affiliation(s)
- Zoraida Corte
- Clinical Biochemistry Service, San Agustín University Hospital, Avilés, Asturias, Spain
| | - Rafael Venta
- Clinical Biochemistry Service, San Agustín University Hospital, Avilés, Asturias, Spain.,Biochemistry and Molecular Biology Department, Oviedo University, Asturias, Spain
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19
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Evaluation of the Relationship between Early Troponin Clearance and Short-Term Mortality in Patients with Chronic Renal Failure. Emerg Med Int 2020; 2020:6328037. [PMID: 32089888 PMCID: PMC7013312 DOI: 10.1155/2020/6328037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2019] [Revised: 12/05/2019] [Accepted: 12/27/2019] [Indexed: 11/17/2022] Open
Abstract
Objective In patients with CKD, cTn concentrations may be elevated in the absence of AMI, which is a predicted finding caused by chronic structural heart disease rather than acute injury. The increase in troponin level observed in noncardiac conditions provides conflicting results when predicting mortality. Low lactate clearance was associated with increased mortality. Lactate clearance is calculated as follows: (early lactate - late lactate/early lactate) ∗ 100. We aimed to investigate whether troponin clearance calculated according to this formula had an effect on short-term mortality. Methods The study included 300 patients with chronic renal failure who had a sepsis-related organ failure assessment (SOFA) score ≥3. By taking the baseline troponin at the time of emergency presentation as reference and comparing them with the fourth-hour troponin values, troponin clearance was investigated in the evaluation of mortality among hospitalized patients with CKD within the first month after discharge. The data obtained were analyzed using the SPSS data analysis software version 20.0. Student's t-test was used for the parametric data, and the Chi-squared test for the nonparametric data. Results Of the 300 patients evaluated, 189 patients survived (mean age 66.20 ± 14.597 years), and 111 died (mean age 74.81 ± 12.916 years). Troponin clearance was detected in 40 of the 111 patients in the mortality group and 119 of the 189 patients in the survival group. Troponin clearance was significantly more frequent in surviving patients (P=0.0000083). Conclusion Troponin clearance can be considered as a valuable leading indicator of survival, but higher levels of troponin clearance did not lead to higher survival rates.
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20
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Fitzgerald G, Kerley RN, Kiernan TJ. High-sensitivity troponin assays: development and utility in a modern health-care system. Expert Rev Cardiovasc Ther 2019; 17:763-770. [PMID: 31574239 DOI: 10.1080/14779072.2019.1675514] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Introduction: The introduction of cardiac troponin (cTn) assays have revolutionized the diagnosis and management of acute myocardial infarction in Emergency Departments worldwide. Its success has led to significant research and development investment in this area culminating in the development of newer high-sensitivity cardiac troponin assays (hs-cTn). While these newer assays allow for more rapid diagnosis by decreasing the time interval between serial data points, there is an inevitable trade off between increasing sensitivity and specificity. This review examines in detail the introduction and implementation of hs-cTN and its implications for clinical practice.Areas covered: This article reviews the history and development of high-sensitivity troponin assays and their application to clinical practice and current evidence base. It also discusses both the positive and negative aspects of the continuing increasing sensitivity of biochemical assays and the translation of this into clinical practice. Potential future developments are also discussed.Expert commentary: It is clear that there are many benefits to detecting extremely low concentration of cardiac troponin including the development of rapid rule out algorithms and the cost and time-saving advantages associated with the quicker movement of patients through the health-care system. It is important to note however that detecting troponin at very low concentrations also dramatically increases the false-positive rates and leads to a potentially large increase in invasive testing and diagnosis of myocardial infarction.
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Affiliation(s)
- Gerald Fitzgerald
- Department of Cardiology, University Hospital Limerick, Limerick, Ireland
| | - R N Kerley
- Department of Cardiology, University Hospital Limerick, Limerick, Ireland
| | - Thomas J Kiernan
- Department of Cardiology, University Hospital Limerick, Limerick, Ireland
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21
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Thygesen K, Alpert JS, Jaffe AS, Chaitman BR, Bax JJ, Morrow DA, White HD. Fourth Universal Definition of Myocardial Infarction (2018). Circulation 2019; 138:e618-e651. [PMID: 30571511 DOI: 10.1161/cir.0000000000000617] [Citation(s) in RCA: 1707] [Impact Index Per Article: 341.4] [Reference Citation Analysis] [Key Words] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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22
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Niizuma S, Iwanaga Y, Washio T, Ashida T, Harasawa S, Miyazaki S, Matsumoto N. Clinical Significance of Increased Cardiac Troponin T in Patients with Chronic Hemodialysis and Cardiovascular Disease: Comparison to B-Type Natriuretic Peptide and A-Type Natriuretic Peptide Increase. Kidney Blood Press Res 2019; 44:1050-1062. [PMID: 31487705 DOI: 10.1159/000502232] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2019] [Accepted: 07/18/2019] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND An increased cardiac troponin T (cTnT) level identifies a high-risk group in patients with end-stage renal disease; however, the mechanism of cTnT elevation remains unclear in such patients without acute coronary syndrome (ACS). Therefore, we explored the relationship between cTnT levels and the hemodynamic parameters and the prognostic potential of cTnT in stable patients with chronic hemodialysis (HD). METHODS We included consecutive 174 patients with HD who were referred for coronary angiography due to stable coronary artery disease (CAD), peripheral artery disease (PAD), or heart failure (HF). Hemodynamic measurement was performed, and plasma cTnT, B-type natriuretic peptide (BNP), and A-type natriuretic peptide (ANP) were measured at the same time. The potential of 3 biomarkers to predict all-cause mortality, cardiac death or hospitalized HF, and vascular event was assessed. RESULTS Increased log cTnT levels were correlated with increased log BNP and log ANP levels (r = 0.531, p < 0.001 and r = 0.411, p < 0.001, respectively). Not increased log cTnT, but increased log BNP and log ANP were associated with the presence of CAD and the extent of CAD. In contrast, they were all associated with the New York Heart Association functional classification and the presence of PAD and significantly correlated with left ventricular end-diastolic pressure (LVEDP) in an independent manner. Increased cTnT and BNP levels were associated with the mortality and hospitalized HF. However, increased cTnT was not associated with vascular events, unlike increased BNP. CONCLUSIONS In patients with chronic HD without ACS, increased cTnT reflected increased LVEDP and the presence of HF or PAD independently, and it did not reflect the presence of CAD in contrast to increased BNP. cTnT and BNP were significant prognostic predictors; however, increased cTnT was associated with HF-related events, not with arteriosclerotic events.
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Affiliation(s)
| | - Yoshitaka Iwanaga
- Division of Cardiology, Kindai University Faculty of Medicine, Osakasayama, Japan
| | - Takehiko Washio
- Department of Cardiology, Nihon University Hospital, Tokyo, Japan
| | - Tadashi Ashida
- Department of Cardiology, Nihon University Hospital, Tokyo, Japan
| | | | - Shunichi Miyazaki
- Division of Cardiology, Kindai University Faculty of Medicine, Osakasayama, Japan
| | - Naoya Matsumoto
- Department of Cardiology, Nihon University Hospital, Tokyo, Japan
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23
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Martín Raymondi D, Garcia H, Álvarez I, Hernández L, Molinero JP, Villamandos V. TUSARC: Prognostic Value of High-Sensitivity Cardiac Troponin T Assay in Asymptomatic Patients with High Cardiovascular Risk. Am J Med 2019; 132:631-638. [PMID: 30557532 DOI: 10.1016/j.amjmed.2018.11.035] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2018] [Revised: 11/28/2018] [Accepted: 11/29/2018] [Indexed: 02/05/2023]
Abstract
BACKGROUND Prognostic value of high-sensitivity cardiac troponin T (hs-cTnT) assays have been assessed in selected populations in different studies and in registries of members of the general population with low cardiovascular risk. The aim of this study was to determine the prognostic value of hs-cTnT in an asymptomatic very-high cardiovascular risk Spanish population. METHODS From a previous prospective cohort of the TUSARC (troponina T UltraSensible en pacientes Asintomáticos de alto Riesgo Cardiovascular) registry, follow-up was conducted in 602 patients (93.18%). The association of high hs-cTnT (≥99th percentile value) and incidence of primary event was studied. A primary event was defined as a combined major cardiovascular event (incidence of cardiovascular death, decompensated heart failure, non-fatal cerebrovascular event, non-fatal myocardial infarction, or coronary revascularization). The association between high hs-cTnT and incidence of secondary events was studied as well. RESULTS In patients with high hs-cTnT, the incidence of primary event during follow-up was significantly higher (18.30% vs 3.67% P < .001): heart failure (6.25% vs 0.73% P < .001), cardiovascular death (7.29% vs 0.00% P < .001), and death from any cause (7.81% vs 0.98% P < .001). CONCLUSIONS In an asymptomatic very-high cardiovascular risk Spanish population, elevated hs-cTnT was significantly associated with incident major cardiovascular combined end point and incidence of heart failure, cardiovascular death, and death from any cause.
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Affiliation(s)
| | - Héctor Garcia
- Department of Cardiology, Hospital Santos Reyes Aranda de Duero Burgos, Spain
| | - Isabel Álvarez
- Family and Community Medicine, Hospital Santos Reyes Aranda de Duero Burgos, Spain
| | - Luis Hernández
- Department of Internal Medicine, Hospital Santos Reyes Aranda de Duero Burgos, Spain
| | | | - Vicente Villamandos
- Clinical testing laboratory, Hospital Santos Reyes Aranda de Duero Burgos, Spain
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24
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Long-term biological variation of high-sensitivity cardiac troponin T using minimal important differences and reference change values in stable outpatients with cardiovascular disease. Clin Biochem 2019; 67:7-11. [DOI: 10.1016/j.clinbiochem.2019.03.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Revised: 02/14/2019] [Accepted: 03/08/2019] [Indexed: 11/17/2022]
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25
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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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26
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Rangaswami J, McCullough PA. Heart Failure in End-Stage Kidney Disease: Pathophysiology, Diagnosis, and Therapeutic Strategies. Semin Nephrol 2018; 38:600-617. [DOI: 10.1016/j.semnephrol.2018.08.005] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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27
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Thygesen K, Alpert JS, Jaffe AS, Chaitman BR, Bax JJ, Morrow DA, White HD. Fourth Universal Definition of Myocardial Infarction (2018). J Am Coll Cardiol 2018; 72:2231-2264. [PMID: 30153967 DOI: 10.1016/j.jacc.2018.08.1038] [Citation(s) in RCA: 2086] [Impact Index Per Article: 347.7] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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28
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Thygesen K, Alpert JS, Jaffe AS, Chaitman BR, Bax JJ, Morrow DA, White HD, Thygesen K, Alpert JS, Jaffe AS, Chaitman BR, Bax JJ, Morrow DA, White HD, Mickley H, Crea F, Van de Werf F, Bucciarelli-Ducci C, Katus HA, Pinto FJ, Antman EM, Hamm CW, De Caterina R, Januzzi JL, Apple FS, Alonso Garcia MA, Underwood SR, Canty JM, Lyon AR, Devereaux PJ, Zamorano JL, Lindahl B, Weintraub WS, Newby LK, Virmani R, Vranckx P, Cutlip D, Gibbons RJ, Smith SC, Atar D, Luepker RV, Robertson RM, Bonow RO, Steg PG, O’Gara PT, Fox KAA, Hasdai D, Aboyans V, Achenbach S, Agewall S, Alexander T, Avezum A, Barbato E, Bassand JP, Bates E, Bittl JA, Breithardt G, Bueno H, Bugiardini R, Cohen MG, Dangas G, de Lemos JA, Delgado V, Filippatos G, Fry E, Granger CB, Halvorsen S, Hlatky MA, Ibanez B, James S, Kastrati A, Leclercq C, Mahaffey KW, Mehta L, Müller C, Patrono C, Piepoli MF, Piñeiro D, Roffi M, Rubboli A, Sharma S, Simpson IA, Tendera M, Valgimigli M, van der Wal AC, Windecker S, Chettibi M, Hayrapetyan H, Roithinger FX, Aliyev F, Sujayeva V, Claeys MJ, Smajić E, Kala P, Iversen KK, El Hefny E, Marandi T, Porela P, Antov S, Gilard M, Blankenberg S, Davlouros P, Gudnason T, Alcalai R, Colivicchi F, Elezi S, Baitova G, Zakke I, Gustiene O, Beissel J, Dingli P, Grosu A, Damman P, Juliebø V, Legutko J, Morais J, Tatu-Chitoiu G, Yakovlev A, Zavatta M, Nedeljkovic M, Radsel P, Sionis A, Jemberg T, Müller C, Abid L, Abaci A, Parkhomenko A, Corbett S. Fourth universal definition of myocardial infarction (2018). Eur Heart J 2018; 40:237-269. [DOI: 10.1093/eurheartj/ehy462] [Citation(s) in RCA: 1047] [Impact Index Per Article: 174.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
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29
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Thygesen K, Alpert JS, Jaffe AS, Chaitman BR, Bax JJ, Morrow DA, White HD. Fourth Universal Definition of Myocardial Infarction (2018). Glob Heart 2018; 13:305-338. [PMID: 30154043 DOI: 10.1016/j.gheart.2018.08.004] [Citation(s) in RCA: 175] [Impact Index Per Article: 29.2] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
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30
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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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Burlacu A, Genovesi S, Ortiz A, Kanbay M, Rossignol P, Banach M, Malyszko J, Goldsmith D, Covic A. The quest for equilibrium: exploring the thin red line between bleeding and ischaemic risks in the management of acute coronary syndromes in chronic kidney disease patients. Nephrol Dial Transplant 2018; 32:1967-1976. [PMID: 28371905 DOI: 10.1093/ndt/gfx041] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2016] [Accepted: 02/16/2017] [Indexed: 11/13/2022] Open
Abstract
Coronary artery disease and acute coronary syndrome (ACS) are both common in patients with chronic kidney disease (CKD). CKD patients have higher risks of bleeding and thrombosis. However, they remain under-represented in major randomized clinical trials (RCTs), and there is no medical evidence-based foundation on which to issue specific recommendations about the management of ACS in CKD. CKD patients with ACS frequently are diagnosed later, receive fewer acute interventions and are at increased risk of over-dosage of medications and under-prescription/under-performance of interventional treatments than CKD patients without ACS. The lack of RCTs should not discourage reliance on clinical common sense, while clearer decisional algorithms with better outcomes are a priority for urgent development. Future guidelines should further refine the assessment of CKD with ACS while placing much greater emphasis on the correct dosing of medications based on contemporaneous renal function. Until a strategy is designed with specific measures translated into the actual decrease of bleeding risk, providers will be forced to balance the equilibrium on a thin red line that is not clearly established.
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Affiliation(s)
- Alexandru Burlacu
- Department of Interventional Cardiology, Cardiovascular Diseases Institute, Iasi, Romania.,'Grigore T. Popa' University of Medicine, Iasi, Romania
| | - Simonetta Genovesi
- Department of Medicine and Surgery, University of Milan Bicocca and Nephrology Unit, San Gerardo Hospital, Monza, Italy
| | - Alberto Ortiz
- IIS-Fundacion Jimenez Diaz UAM, FRIAT and REDINREN, Madrid, Spain
| | - Mehmet Kanbay
- Department of Medicine, Division of Nephrology, Koc University School of Medicine, Istanbul, Turkey
| | - Patrick Rossignol
- Inserm, Centre d'Investigations Cliniques, Plurithématique 14-33, Inserm U1116, CHRU Nancy, France.,Université de Lorraine, Association Lorraine de Traitement de l'Insuffisance Rénale (ALTIR) and F-CRIN INI-CRCT (Cardiovascular and Renal Clinical Trialists), Nancy, France
| | - Maciej Banach
- Department of Hypertension, Chair of Nephrology and Hypertension, Medical University of Lodz, Lodz, Poland
| | - Jolanta Malyszko
- 2nd Department of Nephrology, Medical University, Bialystok, Poland
| | - David Goldsmith
- Renal, Dialysis and Transplantation Unit, Guy's and St Thomas' Hospital, London, UK
| | - Adrian Covic
- 'Grigore T. Popa' University of Medicine, Iasi, Romania.,Nephrology Clinic, Dialysis and Renal Transplant Center, 'C.I. Parhon' University Hospital, Iasi, Romania
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32
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Turakhia MP, Blankestijn PJ, Carrero JJ, Clase CM, Deo R, Herzog CA, Kasner SE, Passman RS, Pecoits-Filho R, Reinecke H, Shroff GR, Zareba W, Cheung M, Wheeler DC, Winkelmayer WC, Wanner C. Chronic kidney disease and arrhythmias: conclusions from a Kidney Disease: Improving Global Outcomes (KDIGO) Controversies Conference. Eur Heart J 2018; 39:2314-2325. [PMID: 29522134 PMCID: PMC6012907 DOI: 10.1093/eurheartj/ehy060] [Citation(s) in RCA: 166] [Impact Index Per Article: 27.7] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2017] [Revised: 12/18/2017] [Accepted: 01/27/2018] [Indexed: 12/15/2022] Open
MESH Headings
- Arrhythmias, Cardiac/epidemiology
- Arrhythmias, Cardiac/therapy
- Atrial Fibrillation/complications
- Atrial Fibrillation/drug therapy
- Atrial Fibrillation/epidemiology
- Death, Sudden, Cardiac/prevention & control
- Defibrillators, Implantable
- Humans
- Hyperkalemia/epidemiology
- Hyperkalemia/metabolism
- Hypokalemia/epidemiology
- Hypokalemia/metabolism
- Inflammation
- Kidney Failure, Chronic/epidemiology
- Kidney Failure, Chronic/metabolism
- Kidney Failure, Chronic/therapy
- Oxidative Stress
- Potassium/metabolism
- Renal Dialysis
- Renal Insufficiency, Chronic/epidemiology
- Renal Insufficiency, Chronic/metabolism
- Renal Insufficiency, Chronic/therapy
- Risk Factors
- Stroke/etiology
- Stroke/prevention & control
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Affiliation(s)
- Mintu P Turakhia
- Stanford University School of Medicine, Veterans Affairs Palo Alto Health Care System, Miranda Ave, Palo Alto, CA, USA
| | - Peter J Blankestijn
- Department of Nephrology, room F03.220, University Medical Center, Utrecht, The Netherlands
| | - Juan-Jesus Carrero
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Nobels väg 12A, Stockholm, Sweden
| | - Catherine M Clase
- Department of Medicine and Department of Health Research Methods, Evidence, and Impact, McMaster University, St. Joseph’s Healthcare, Marian Wing, 3rd Floor, M333, 50 Charlton Ave. E, Hamilton, Ontario, Canada
| | - Rajat Deo
- Section of Electrophysiology, Division of Cardiovascular Medicine, Perelman School of Medicine at the University of Pennsylvania, 3400 Spruce Street, 9 Founders Cardiology, Philadelphia, PA, USA
| | - Charles A Herzog
- Division of Cardiology, Department of Medicine, Hennepin County Medical Center and University of Minnesota, Minneapolis, Minnesota and Chronic Disease Research Group, Minneapolis Medical Research Foundation, 914 S. 8th Street, S4.100, Minneapolis, MN, USA
| | - Scott E Kasner
- Department of Neurology, 3W Gates Bldg. Hospital of the University of Pennsylvania, 3400 Spruce St., Philadelphia, PA, USA
| | - Rod S Passman
- Northwestern University Feinberg School of Medicine and the Bluhm Cardiovascular Institute, 201 E. Huron St. Chicago, IL, USA
| | - Roberto Pecoits-Filho
- School of Medicine, Pontificia Universidade Catolica do Paraná, Rua Imaculada Conceição Curitiba PR, Brazil
| | - Holger Reinecke
- Department für Kardiologie und Angiologie Universitätsklinikum Münster, Albert-Schweitzer-Campus 1, Gebäude A1, Muenster, Germany
| | - Gautam R Shroff
- Division of Cardiology, Hennepin County Medical Center, 701 Park Avenue, Minneapolis, MN, USA
| | - Wojciech Zareba
- Heart Research Follow-up Program, Cardiology Division, University of Rochester Medical Center, Saunders Research Building, 265 Crittenden Blvd. CU, Rochester, NY, USA
| | | | - David C Wheeler
- Centre for Nephrology, University College London, Rowland Hill Street, London, UK
| | - Wolfgang C Winkelmayer
- Selzman Institute for Kidney Health, Section of Nephrology, Department of Medicine, Baylor College of Medicine, One Baylor Plaza, ABBR R705, MS: 395, Houston, TX, USA
| | - Christoph Wanner
- Division of Nephrology, Department of Medicine, University Hospital of Würzburg, Oberduerrbacherstr. 6 Würzburg, Germany
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33
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Árnadóttir Á, Vestergaard KR, Pallisgaard J, Sölétormos G, Steffensen R, Goetze JP, Iversen K. High-sensitivity cardiac troponin T is superior to troponin I in the prediction of mortality in patients without acute coronary syndrome. Int J Cardiol 2018; 259:186-191. [DOI: 10.1016/j.ijcard.2018.01.131] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2017] [Revised: 11/08/2017] [Accepted: 01/30/2018] [Indexed: 01/30/2023]
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34
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Gunsolus I, Sandoval Y, Smith SW, Sexter A, Schulz K, Herzog CA, Apple FS. Renal Dysfunction Influences the Diagnostic and Prognostic Performance of High-Sensitivity Cardiac Troponin I. J Am Soc Nephrol 2018; 29:636-643. [PMID: 29079658 PMCID: PMC5791068 DOI: 10.1681/asn.2017030341] [Citation(s) in RCA: 48] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2017] [Accepted: 09/25/2017] [Indexed: 01/09/2023] Open
Abstract
Measures of cardiac troponin (cTn) may have lower specificity for myocardial infarction in patients with CKD. We examined the diagnostic accuracy of baseline and serial high-sensitivity cTnI (hs-cTnI) measurements for myocardial infarction and 30- and 180-day mortality according to renal function. hs-cTnI was measured (Abbott assay) using sex-specific 99th percentiles (women, 16 ng/L; men, 34 ng/L) in 1555 adults presenting to the emergency department with symptoms suggesting ischemia (NCT02060760). Myocardial infarction was adjudicated along universal definition classification. Renal function did not significantly affect sensitivity or negative predictive values. Specificity decreased with impaired renal function from 93%-95% with normal function (eGFR≥90 ml/min per 1.73 m2; n=722) to 57%-61% with severely impaired renal function (eGFR<30 ml/min per 1.73 m2; n=81) and 40%-41% on dialysis (n=78). Positive predictive values decreased with decreasing renal function from 51%-57% with normal function to 27%-42% with severely impaired function and 15%-32% on dialysis. Receiver operating characteristic curve areas trended lower at baseline and 3 hours with renal impairment. Mortality increased significantly with increasing hs-cTnI tertile (1.3%, 6.0%, and 10.4%, respectively). Patients with hs-cTnI concentration exceeding concentrations in the 99th percentiles had a mortality rate (11.7%) significantly higher than that of patients with concentrations between 99th percentile concentrations and limit of detection (6.2%) or below limit of detection (1.1%). Renal dysfunction and dialysis reduced the rule-in performance but not the rule-out performance of hs-cTnI for myocardial infarction, and mortality increased in patients with higher hs-cTnI concentrations and any level of renal dysfunction.
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Affiliation(s)
- Ian Gunsolus
- Department of Laboratory Medicine and Pathology and
| | - Yader Sandoval
- Division of Cardiology, Hennepin County Medical Center, Minneapolis, Minnesota
- Minneapolis Heart Institute, Abbott Northwestern Hospital, Minneapolis, Minnesota
- Cardiac Biomarkers Trials Laboratory and
| | | | - Anne Sexter
- Chronic Disease Research Group, Minneapolis Medical Research Foundation, Minneapolis, Minnesota; and
| | | | - Charles A Herzog
- Chronic Disease Research Group, Minneapolis Medical Research Foundation, Minneapolis, Minnesota; and
- Medicine, and
| | - Fred S Apple
- Cardiac Biomarkers Trials Laboratory and
- Laboratory Medicine and Pathology, Hennepin County Medical Center and University of Minnesota, Minneapolis, Minnesota
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35
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Park KC, Gaze DC, Collinson PO, Marber MS. Cardiac troponins: from myocardial infarction to chronic disease. Cardiovasc Res 2017; 113:1708-1718. [PMID: 29016754 PMCID: PMC5852618 DOI: 10.1093/cvr/cvx183] [Citation(s) in RCA: 283] [Impact Index Per Article: 40.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2017] [Revised: 06/05/2017] [Accepted: 09/12/2017] [Indexed: 12/18/2022] Open
Abstract
Elucidation of the physiologically distinct subunits of troponin in 1973 greatly facilitated our understanding of cardiac contraction. Although troponins are expressed in both skeletal and cardiac muscle, there are isoforms of troponin I/T expressed selectively in the heart. By exploiting cardiac-restricted epitopes within these proteins, one of the most successful diagnostic tests to date has been developed: cardiac troponin (cTn) assays. For the past decade, cTn has been regarded as the gold-standard marker for acute myocardial necrosis: the pathological hallmark of acute myocardial infarction (AMI). Whilst cTn is the cornerstone for ruling-out AMI in patients presenting with a suspected acute coronary syndrome (ACS), elevated cTn is frequently observed in those without clinical signs indicative of AMI, often reflecting myocardial injury of 'unknown origin'. cTn is commonly elevated in acute non-ACS conditions, as well as in chronic diseases. It is unclear why these elevations occur; yet they cannot be ignored as cTn levels in chronically unwell patients are directly correlated to prognosis. Paradoxically, improvements in assay sensitivity have meant more differential diagnoses have to be considered due to decreased specificity, since cTn is now more easily detected in these non-ACS conditions. It is important to be aware cTn is highly specific for myocardial injury, which could be attributable to a myriad of underlying causes, emphasizing the notion that cTn is an organ-specific, not disease-specific biomarker. Furthermore, the ability to detect increased cTn using high-sensitivity assays following extreme exercise is disconcerting. It has been suggested troponin release can occur without cardiomyocyte necrosis, contradicting conventional dogma, emphasizing a need to understand the mechanisms of such release. This review discusses basic troponin biology, the physiology behind its detection in serum, its use in the diagnosis of AMI, and some key concepts and experimental evidence as to why cTn can be elevated in chronic diseases.
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Affiliation(s)
- Kyung Chan Park
- 1 BHF Centre of Research Excellence, The Rayne Institute, Cardiovascular Division, King’s College London, London, UK
- 2 Burdon Sanderson Cardiac Science Centre, Department of Physiology, Anatomy and Genetics, University of Oxford, Oxford, UK
| | - David C Gaze
- 3 Clinical Blood Sciences and Cardiology, St George’s University Hospitals NHS Trust and St George’s University of London, London, UK
- 4 Department of Biomedical Science, University of Westminster, London, UK
| | - Paul O Collinson
- 3 Clinical Blood Sciences and Cardiology, St George’s University Hospitals NHS Trust and St George’s University of London, London, UK
| | - Michael S Marber
- 1 BHF Centre of Research Excellence, The Rayne Institute, Cardiovascular Division, King’s College London, London, UK
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36
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Árnadóttir Á, Falk Klein C, Iversen K. Head-to-head comparison of cardiac troponin T and troponin I in patients without acute coronary syndrome: a systematic review. Biomarkers 2017; 22:701-708. [DOI: 10.1080/1354750x.2017.1335779] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Affiliation(s)
| | | | - Kasper Iversen
- Department of Cardiology, Herlev-Gentofte Hospital, Copenhagen, Denmark
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37
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Mair J, Lindahl B, Müller C, Giannitsis E, Huber K, Möckel M, Plebani M, Thygesen K, Jaffe AS. What to do when you question cardiac troponin values. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2017; 7:577-586. [DOI: 10.1177/2048872617708973] [Citation(s) in RCA: 53] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
High-sensitivity cardiac troponin assays enable cardiac troponin measurement with a high degree of analytical sensitivity and a low level of analytical imprecision at the low measuring range. One of the most important advantages of these new assays is that they allow novel, more rapid approaches for ruling in or ruling out acute myocardial infarctions. The increase in the early diagnostic sensitivity of high-sensitivity cardiac troponin assays comes at the cost of a reduced acute myocardial infarction specificity of the biomarker, because more patients with other causes of acute or chronic myocardial injury without overt myocardial ischaemia are detected than with previous cardiac troponin assays. Increased troponin concentrations that do not fit with the clinical presentation are seen in the daily routine, mainly as a result of a variety of pathologies, and if tested in the same sample, even discrepancies between high-sensitivity cardiac troponin I and troponin T test results may sometimes be found as well. In addition, analytically false-positive test results occasionally may occur since no assay is perfect. In this review, we summarise the biochemical, pathophysiological and analytical background of the work-up for such a clinical setting.
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Affiliation(s)
- Johannes Mair
- Department of Internal Medicine III – Cardiology and Angiology, Heart Center, Medical University of Innsbruck, Innsbruck, Austria
| | - Bertil Lindahl
- Department of Medical Sciences, Uppsala University, Uppsala Sweden
- Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - Christian Müller
- Department of Cardiology and Cardiovascular Research Institute Basel, University Hospital Basel, Basel, Switzerland
| | - Evangelos Giannitsis
- Medizinische Klinik III, Department of Cardiology, University of Heidelberg, Heidelberg, Germany
| | - Kurt Huber
- Department of Medicine, Cardiology and Intensive Care Medicine, Wilhelminen Hospital, Vienna, Austria
| | - Martin Möckel
- Division of Emergency Medicine and Department of Cardiology, Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Mario Plebani
- Department of Laboratory Medicine, University Hospital Padova, Padova, Italy
| | - Kristian Thygesen
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
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38
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Mahmood U, Johnson DW, Fahim MA. Cardiac biomarkers in dialysis. AIMS GENETICS 2016; 4:1-20. [PMID: 31435501 PMCID: PMC6690238 DOI: 10.3934/genet.2017.1.1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/12/2016] [Accepted: 12/19/2016] [Indexed: 01/06/2023]
Abstract
Cardiovascular disease is the major cause of death, accounting for approximately 40 percent of all-cause mortality in patients receiving either hemodialysis or peritoneal dialysis. Cardiovascular risk stratification is an important aspect of managing dialysis patients as it enables early identification of high-risk patients, so therapeutic interventions can be optimized to lower cardiovascular morbidity and mortality. Biomarkers can detect early stages of cardiac injury so timely intervention can be provided. The B-type natriuretic peptides (Brain Natriuretic peptide [BNP] and N-terminal pro-B-type natriuretic peptide [NT-proBNP]) and troponins have been shown to predict mortality in dialysis patients. Suppression of tumorigenicity 2 (ST2) and galectin-3 are new emerging biomarkers in the field of heart failure in both the general and dialysis populations. This article aims to discuss the current evidence regarding cardiac biomarker use to diagnose myocardial injury and monitor the risk of major adverse cardiovascular events in patients undergoing dialysis.
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Affiliation(s)
- Usman Mahmood
- Department of Nephrology, Princess Alexandra Hospital, Australia
| | - David W Johnson
- Department of Nephrology, Princess Alexandra Hospital, Australia.,Australasian Kidney Trials Network, School of Medicine, University of Queensland, Brisbane, Australia.,Translational Research Institute, Brisbane, Australia
| | - Magid A Fahim
- Department of Nephrology, Princess Alexandra Hospital, Australia.,Australasian Kidney Trials Network, School of Medicine, University of Queensland, Brisbane, Australia.,Translational Research Institute, Brisbane, Australia
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39
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deFilippi CR, Herzog CA. Interpreting Cardiac Biomarkers in the Setting of Chronic Kidney Disease. Clin Chem 2016; 63:59-65. [PMID: 27811207 DOI: 10.1373/clinchem.2016.254748] [Citation(s) in RCA: 56] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2016] [Accepted: 08/23/2016] [Indexed: 02/06/2023]
Abstract
BACKGROUND Chronic kidney disease (CKD) is common, particularly in those of advanced age. Because patients with CKD frequently have cardiac comorbidities and acute or chronic symptoms that may represent heart failure or an acute myocardial infarction (AMI), testing for concentrations of cardiac troponins and natriuretic peptides is frequent. Interpretation of these biomarkers can be challenging when differentiating acute from chronic processes, potentially resulting in missed opportunities to direct appropriate treatment. CONTENT This review is designed to provide clinicians and laboratorians a platform to understand cardiac specific biomarker interpretation in patients with CKD by summarizing the extensive literature base that has developed specific to this population. First we review the epidemiology and unique contributions of CKD to cardiac pathophysiology. Next we consider the interpretation of cardiac troponin tests for the diagnosis AMI and the prognostic significance of chronic increases across the spectrum of CKD including those requiring renal replacement therapy. Last, we consider the caveats of interpreting natriuretic peptide results for the diagnosis of acute decompensated heart failure in addition to the short- and long-term prognostic implications of increased natriuretic peptide concentrations and CKD in a patient with heart failure. SUMMARY CKD is common and associated with acceleration of cardiovascular disease. Cardiac biomarker concentrations are often increased even in an absence of symptoms; typically reflecting the extent of underlying cardiovascular disease rather than impairment of renal clearance. Thoughtful interpretation of cardiac biomarkers in those with CKD can continue to provide important diagnostic and prognostic information.
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40
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Rossignol P, Pitt B, Thompson A, Zannad F. Roadmap for cardiovascular prevention trials in chronic kidney disease. Lancet 2016; 388:1964-1966. [PMID: 27789005 DOI: 10.1016/s0140-6736(16)31331-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2016] [Accepted: 08/02/2016] [Indexed: 01/14/2023]
Affiliation(s)
- Patrick Rossignol
- Inserm 1433, Centre d'Investigations Cliniques-Plurithématique, Université de Lorraine, CHU Nancy, 54500 France; F-CRIN INI-CRCT (Cardiovascular and Renal Clinical Trialists), Nancy, France; Association Lorraine de Traitement de l'Insuffisance Rénale, Nancy, France.
| | - Bertram Pitt
- University of Michigan School of Medicine, Ann Arbor, MI, USA
| | - Aliza Thompson
- Division of Cardiovascular and Renal Products, Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, MD, USA
| | - Faiez Zannad
- Inserm 1433, Centre d'Investigations Cliniques-Plurithématique, Université de Lorraine, CHU Nancy, 54500 France; F-CRIN INI-CRCT (Cardiovascular and Renal Clinical Trialists), Nancy, France
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41
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Sandoval Y, Apple FS, Smith SW. High-sensitivity cardiac troponin assays and unstable angina. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2016; 7:120-128. [DOI: 10.1177/2048872616658591] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
The term unstable angina has been conventionally applied to patients with myocardial ischemia without myocardial necrosis. However, while the clinical context has remained constant over time, the biomarkers of myocardial injury and acute myocardial infarction have evolved. High-sensitivity cardiac troponin assays have several key analytical differences from prior cardiac troponin assay generations, which may alter the diagnosis and frequency of unstable angina, as well as affect our understanding of previously developed risk stratification strategies. This document reviews the current challenges in regards to unstable angina when using high-sensitivity cardiac troponin I and T assays.
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Affiliation(s)
- Yader Sandoval
- Division of Cardiology, Department of Medicine, Hennepin County Medical Center, Minneapolis, MN, USA
- Minneapolis Heart Institute, Abbott-Northwestern Hospital, Minneapolis, MN, USA
| | - Fred S Apple
- Department of Laboratory Medicine and Pathology, Hennepin County Medical Center and University of Minnesota, Minneapolis, MN, USA
| | - Stephen W Smith
- Department of Emergency Medicine, Hennepin County Medical Center and University of Minnesota, Minneapolis, MN, USA
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