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Tapias AH, Oliveira GBDF, França JID, Ramos RF. Universal Definition of Myocardial Infarction 99th Percentile versus Diagnostic Cut-off Value of Troponin I for Acute Coronary Syndromes. Arq Bras Cardiol 2022; 118:S0066-782X2022005005201. [PMID: 35544848 PMCID: PMC9345147 DOI: 10.36660/abc.20210191] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Revised: 08/18/2021] [Accepted: 09/01/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Contemporary diagnosis of ACS and risk stratification are essential for appropriate management and reduction of mortality and recurrent ischemic events, in the acute phase of disease and after hospitalization. The Universal Definition of Myocardial Infarction recommends the detection of troponin levels above the 99th percentile. OBJECTIVES To evaluate the occurrence of early death and acute myocardial infarction (AMI) in patients without elevation of troponin (<0.034 ng/mL), patients with mild elevation (above the 99th percentile [>0.034 ng/mL and <0.12 ng/mL)], and patients with significant elevation of troponin (above the diagnostic cutoff for AMI defined by the troponin kit (≥0.12 ng/mL)]; and to analyze the impact of troponin on the indication for invasive strategy and myocardial revascularization. METHODS Cross-sectional cohort study of patients with ACS with assessment of peak troponin I, risk score, prospective analysis of 30-day clinical outcomes and two-sided statistical tests, with statistical significance set at p<0.05. RESULTS A total of 494 patients with ACS were evaluated. Troponin > 99th percentile and below the cutoff point, as well as values above the cutoff, were associated with higher incidence of composite endpoint (p<0.01) and higher rates of percutaneous or surgical revascularization procedures (p<0.01), without significative difference in 30-day mortality. CONCLUSIONS Troponin levels above the 99th percentile defined by the universal definition of AMI play a prognostic role and add useful information to the clinical diagnosis and risk scores by identifying those patients who would most benefit from invasive risk stratification and coronary revascularization procedures.
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Affiliation(s)
- Antonio Haddad Tapias
- Instituto Dante Pazzanese de CardiologiaSão PauloSPBrasilInstituto Dante Pazzanese de Cardiologia, São Paulo, SP – Brasil
| | | | - João Italo Dias França
- Instituto Dante Pazzanese de CardiologiaSão PauloSPBrasilInstituto Dante Pazzanese de Cardiologia, São Paulo, SP – Brasil
| | - Rui Fernando Ramos
- Instituto Dante Pazzanese de CardiologiaSão PauloSPBrasilInstituto Dante Pazzanese de Cardiologia, São Paulo, SP – Brasil
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3
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Westwood M, Ramaekers B, Grimm S, Worthy G, Fayter D, Armstrong N, Buksnys T, Ross J, Joore M, Kleijnen J. High-sensitivity troponin assays for early rule-out of acute myocardial infarction in people with acute chest pain: a systematic review and economic evaluation. Health Technol Assess 2021; 25:1-276. [PMID: 34061019 PMCID: PMC8200931 DOI: 10.3310/hta25330] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Early diagnosis of acute myocardial infarction is important, but only 20% of emergency admissions for chest pain will actually have an acute myocardial infarction. High-sensitivity cardiac troponin assays may allow rapid rule out of myocardial infarction and avoid unnecessary hospital admissions. OBJECTIVES To assess the clinical effectiveness and cost-effectiveness of high-sensitivity cardiac troponin assays for the management of adults presenting with acute chest pain, in particular for the early rule-out of acute myocardial infarction. METHODS Sixteen databases were searched up to September 2019. Review methods followed published guidelines. Studies were assessed for quality using appropriate risk-of-bias tools. The bivariate model was used to estimate summary sensitivity and specificity for meta-analyses involving four or more studies; otherwise, random-effects logistic regression was used. The health economic analysis considered the long-term costs and quality-adjusted life-years associated with different troponin testing methods. The de novo model consisted of a decision tree and a state-transition cohort model. A lifetime time horizon (of 60 years) was used. RESULTS Thirty-seven studies (123 publications) were included in the review. The high-sensitivity cardiac troponin test strategies evaluated are defined by the combination of four factors (i.e. assay, number and timing of tests, and threshold concentration), resulting in a large number of possible combinations. Clinical opinion indicated a minimum clinically acceptable sensitivity of 97%. When considering single test strategies, only those using a threshold at or near to the limit of detection for the assay, in a sample taken at presentation, met the minimum clinically acceptable sensitivity criterion. The majority of the multiple test strategies that met this criterion comprised an initial rule-out step, based on high-sensitivity cardiac troponin levels in a sample taken on presentation and a minimum symptom duration, and a second stage for patients not meeting the initial rule-out criteria, based on presentation levels of high-sensitivity cardiac troponin and absolute change after 1, 2 or 3 hours. Two large cluster randomised controlled trials found that implementation of an early rule-out pathway for myocardial infarction reduced length of stay and rate of hospital admission without increasing cardiac events. In the base-case analysis, standard troponin testing was both the most effective and the most costly. Other testing strategies with a sensitivity of 100% (subject to uncertainty) were almost equally effective, resulting in the same life-year and quality-adjusted life-year gain at up to four decimal places. Comparisons based on the next best alternative showed that for willingness-to-pay values below £8455 per quality-adjusted life-year, the Access High Sensitivity Troponin I (Beckman Coulter, Brea, CA, USA) [(symptoms > 3 hours AND < 4 ng/l at 0 hours) OR (< 5 ng/l AND Δ < 5 ng/l at 0 to 2 hours)] would be cost-effective. For thresholds between £8455 and £20,190 per quality-adjusted life-year, the Elecsys® Troponin-T high sensitive (Roche, Basel, Switzerland) (< 12 ng/l at 0 hours AND Δ < 3 ng/l at 0 to 1 hours) would be cost-effective. For a threshold > £20,190 per quality-adjusted life-year, the Dimension Vista® High-Sensitivity Troponin I (Siemens Healthcare, Erlangen, Germany) (< 5 ng/l at 0 hours AND Δ < 2 ng/l at 0 to 1 hours) would be cost-effective. CONCLUSIONS High-sensitivity cardiac troponin testing may be cost-effective compared with standard troponin testing. STUDY REGISTRATION This study is registered as PROSPERO CRD42019154716. FUNDING This project was funded by the National Institute for Health Research (NIHR) Evidence Synthesis programme and will be published in full in Health Technology Assessment; Vol. 25, No. 33. See the NIHR Journals Library website for further project information.
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Affiliation(s)
| | - Bram Ramaekers
- Department of Clinical Epidemiology and Medical Technology Assessment, Maastricht University, Maastricht, the Netherlands
| | - Sabine Grimm
- Department of Clinical Epidemiology and Medical Technology Assessment, Maastricht University, Maastricht, the Netherlands
| | | | | | | | | | | | - Manuela Joore
- Department of Clinical Epidemiology and Medical Technology Assessment, Maastricht University, Maastricht, the Netherlands
| | - Jos Kleijnen
- Kleijnen Systematic Reviews Ltd, York, UK
- School for Public Health and Primary Care, Care and Public Health Research Institute, Maastricht University, Maastricht, the Netherlands
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4
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High sensitivity troponin, analytical advantages, clinical benefits and clinical challenges - An update. Clin Biochem 2021; 91:1-8. [PMID: 33610525 DOI: 10.1016/j.clinbiochem.2021.02.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2021] [Revised: 01/29/2021] [Accepted: 02/05/2021] [Indexed: 12/26/2022]
Abstract
The measurement of cardiac troponin (cTn) by a high sensitivity method now represents the standard method for cTn measurement in the laboratory. High sensitivity method are not measuring a novel form of troponin but have undergone methodological improvement in assay sensitivity to allow both very low level detection and repeat measurements at low levels with very low degrees of analytical imprecision. The methods identify additional patients with myocardial injury who would benefit from evidence-based interventions. Rapid predictive algorithms utilising measurement on admission as well as short sampling periods (1-2 h) allow much more rapid categorisation of patients to appropriate clinical pathways. The shift in the diagnosis from traditional "cardiac enzymes" to troponin based on the 99th percentile has accounted for the majority of the detection of myocardial injury in patients without acute coronary syndromes. These patients have a worse prognosis irrespective of the underlying cause of their hospital admission. The appropriate management strategy in this group, beyond managing the underlying problem, remains to be defined. Measurement of cTn in otherwise asymptomatic individuals may have a role for patient selection for preventive treatment or for patients monitoring. Clinical trials in this area are awaited.
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Pudil R, Mueller C, Čelutkienė J, Henriksen PA, Lenihan D, Dent S, Barac A, Stanway S, Moslehi J, Suter TM, Ky B, Štěrba M, Cardinale D, Cohen‐Solal A, Tocchetti CG, Farmakis D, Bergler‐Klein J, Anker MS, Von Haehling S, Belenkov Y, Iakobishvili Z, Maack C, Ciardiello F, Ruschitzka F, Coats AJ, Seferovic P, Lainscak M, Piepoli MF, Chioncel O, Bax J, Hulot J, Skouri H, Hägler‐Laube ES, Asteggiano R, Fernandez TL, Boer RA, Lyon AR. Role of serum biomarkers in cancer patients receiving cardiotoxic cancer therapies: a position statement from the
Cardio‐Oncology Study Group
of the
Heart Failure Association
and the
Cardio‐Oncology Council of the European Society of Cardiology. Eur J Heart Fail 2020; 22:1966-1983. [DOI: 10.1002/ejhf.2017] [Citation(s) in RCA: 89] [Impact Index Per Article: 22.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2020] [Revised: 06/14/2020] [Accepted: 09/25/2020] [Indexed: 12/19/2022] Open
Affiliation(s)
- Radek Pudil
- 1st Department Medicine – Cardioangiology Charles University Prague, Medical Faculty and University Hospital Hradec Kralove Prague Czech Republic
| | - Christian Mueller
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology University Hospital Basel, University of Basel Basel Switzerland
| | - Jelena Čelutkienė
- Clinic of Cardiac and Vascular Diseases Institute of Clinical Medicine, Faculty of Medicine, Vilnius University Vilnius Lithuania
- State Research Institute Centre For Innovative Medicine Vilnius Lithuania
| | | | - Dan Lenihan
- Cardio‐Oncology Center of Excellence Washington University in St Louis St Louis MO USA
| | - Susan Dent
- Duke Cancer Institute Duke University Durham NC USA
| | - Ana Barac
- MedStar Heart and Vascular Institute Georgetown University Washington DC USA
| | | | - Javid Moslehi
- Cardio‐Oncology Program, Department of Medicine Vanderbilt University Medical Center Nashville TN USA
| | - Thomas M. Suter
- Department of Cardiology Bern University Hospital, Inselspital, University of Bern Bern Switzerland
| | - Bonnie Ky
- University of Pennsylvania Philadelphia PA USA
| | - Martin Štěrba
- Department of Pharmacology Faculty of Medicine in Hradec Kralove, Charles University Hradec Kralove Czech Republic
| | - Daniela Cardinale
- Cardioncology Unit European Institute of Oncology, IRCCS Milan Italy
| | - Alain Cohen‐Solal
- UMR‐S 942, Paris University, Cardiology Department, Lariboisiere Hospital, AP‐HP Paris France
| | - Carlo Gabriele Tocchetti
- Department of Translational Medical Sciences and Interdepartmental Center for Clinical and Translational Research (CIRCET) ‘Federico II’ University Naples Italy
| | - Dimitrios Farmakis
- University of Cyprus Medical School Nicosia Cyprus
- Cardio‐Oncology Clinic, Heart Failure Unit, ‘Attikon’ University Hospital Athens Greece
- National and Kapodistrian University of Athens Medical School Athens Greece
| | | | - Markus S. Anker
- Division of Cardiology and Metabolism, Department of Cardiology Charité and Berlin Institute of Health Center for Regenerative Therapies (BCRT) and DZHK (German Centre for Cardiovascular Research), partner site Berlin and Department of Cardiology, Charité Campus Benjamin Franklin Berlin Germany
| | - Stephan Von Haehling
- Department of Cardiology and Pneumology University of Goettingen Medical Center Goettingen Germany
- German Center for Cardiovascular Research (DZHK), partner site Goettingen Goettingen Germany
| | | | - Zaza Iakobishvili
- Department of Community Cardiology Tel Aviv Jaffa District, Clalit Health Fund and Sackler Faculty of Medicine, Tel Aviv University Tel Aviv Israel
| | - Christoph Maack
- Comprehensive Heart Failure Center University Clinic Würzburg Würzburg Germany
| | - Fortunato Ciardiello
- Department of Precision Medicine ‘Luigi Vanvitelli’ University of Campania Naples Italy
| | - Frank Ruschitzka
- University Heart Center, Department of Cardiology University Hospital Zurich Zurich Switzerland
| | - Andrew J.S. Coats
- University of Warwick Warwick UK
- Pharmacology Centre of Clinical and Experimental Medicine, IRCCS San Raffaele Pisana Rome Italy
| | - Petar Seferovic
- Faculty of Medicine and Serbian Academy of Sciences and Arts University of Belgrade Belgrade Serbia
| | | | - Massimo F. Piepoli
- Cardiac Department ‘Guglielmo da Saliceto’ Polichirurgico Hospital AUSL Piacenza Piacenza Italy
| | - Ovidiu Chioncel
- Emergency Institute for Cardiovascular Diseases ‘Prof. C.C. Iliescu’ Bucharest Romania
- University of Medicine Carol Davila Bucharest Romania
| | - Jereon Bax
- Department of Cardiology Leiden University Medical Centre Leiden The Netherlands
| | - Jean‐Sebastien Hulot
- Université de Paris CIC1418, Paris Cardiovascular Research Center, INSERM Paris France
| | - Hadi Skouri
- Cardiology Division, Internal Medicine Department at American University of Beirut Medical Center Beirut Lebanon
| | | | | | - Teresa Lopez Fernandez
- Cardiology Service Cardio‐Oncology Unit, La Paz University Hospital and IdiPAz Research Institute, Ciber CV Madrid Spain
| | - Rudolf A. Boer
- Department of Cardiology University of Groningen, University Medical Center Groningen Groningen The Netherlands
| | - Alexander R. Lyon
- Cardio‐Oncology Service Royal Brompton Hospital and Imperial College London London UK
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6
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Xu W, Wang L, Zhang R, Sun X, Huang L, Su H, Wei X, Chen CC, Lou J, Dai H, Qian K. Diagnosis and prognosis of myocardial infarction on a plasmonic chip. Nat Commun 2020; 11:1654. [PMID: 32245966 PMCID: PMC7125217 DOI: 10.1038/s41467-020-15487-3] [Citation(s) in RCA: 74] [Impact Index Per Article: 18.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2018] [Accepted: 03/13/2020] [Indexed: 01/06/2023] Open
Abstract
Cardiovascular diseases lead to 31.5% of deaths globally, and particularly myocardial infarction (MI) results in 7.4 million deaths per year. Diagnosis of MI and monitoring for prognostic use are critical for clinical management and biomedical research, which require advanced tools with accuracy and speed. Herein, we developed a plasmonic gold nano-island (pGold) chip assay for diagnosis and monitoring of MI. On-chip microarray analysis of serum biomarkers (e.g., cardiac troponin I) afforded up to 130-fold enhancement of near-infrared fluorescence for ultra-sensitive and quantitative detection within controlled periods, using 10 μL of serum only. The pGold chip assay achieved MI diagnostic sensitivity of 100% and specificity of 95.54%, superior to the standard chemiluminescence immunoassay in cardiovascular clinics. Further, we monitored biomarker concentrations regarding percutaneous coronary intervention for prognostic purpose. Our work demonstrated a designed approach using plasmonic materials for enhanced diagnosis and monitoring for prognostic use towards point-of-care testing.
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Affiliation(s)
- Wei Xu
- School of Biomedical Engineering and Med-X Research Institute, Shanghai Jiao Tong University, Shanghai, 200030, China.,State Key Laboratory for Oncogenes and Related Genes, Division of Cardiology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, 160 Pujian Road, Shanghai, 200127, China
| | - Lin Wang
- Department of Laboratory Medicine, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, 200030, China
| | - Ru Zhang
- School of Biomedical Engineering and Med-X Research Institute, Shanghai Jiao Tong University, Shanghai, 200030, China.,State Key Laboratory for Oncogenes and Related Genes, Division of Cardiology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, 160 Pujian Road, Shanghai, 200127, China
| | - Xuming Sun
- School of Biomedical Engineering and Med-X Research Institute, Shanghai Jiao Tong University, Shanghai, 200030, China.,State Key Laboratory for Oncogenes and Related Genes, Division of Cardiology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, 160 Pujian Road, Shanghai, 200127, China
| | - Lin Huang
- School of Biomedical Engineering and Med-X Research Institute, Shanghai Jiao Tong University, Shanghai, 200030, China.,State Key Laboratory for Oncogenes and Related Genes, Division of Cardiology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, 160 Pujian Road, Shanghai, 200127, China
| | - Haiyang Su
- School of Biomedical Engineering and Med-X Research Institute, Shanghai Jiao Tong University, Shanghai, 200030, China.,State Key Laboratory for Oncogenes and Related Genes, Division of Cardiology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, 160 Pujian Road, Shanghai, 200127, China
| | - Xunbin Wei
- School of Biomedical Engineering and Med-X Research Institute, Shanghai Jiao Tong University, Shanghai, 200030, China
| | - Chia-Chun Chen
- Department of Chemistry, National Taiwan Normal University, Taipei, 11677, Taiwan
| | - Jiatao Lou
- Department of Laboratory Medicine, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, 200030, China.
| | - Hongjie Dai
- Department of Chemistry, Stanford University, Stanford, CA, 94305, USA
| | - Kun Qian
- School of Biomedical Engineering and Med-X Research Institute, Shanghai Jiao Tong University, Shanghai, 200030, China. .,State Key Laboratory for Oncogenes and Related Genes, Division of Cardiology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, 160 Pujian Road, Shanghai, 200127, China.
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