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Turino Miranda K, Greene DN, Collister D, Krasowski MD, Ahmed SB, Cirrincione LR, Rosas SE, Saad N, Pierre CC. A Holistic Framework for the Evaluation of Kidney Function in a Gender-Diverse Landscape. Am J Kidney Dis 2024; 84:232-240. [PMID: 38458377 DOI: 10.1053/j.ajkd.2024.01.522] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Revised: 01/08/2024] [Accepted: 01/12/2024] [Indexed: 03/10/2024]
Abstract
The most commonly used equations to estimate glomerular filtration rate incorporate a binary male-female sex coefficient, which has important implications for the care of transgender, gender-diverse, and nonbinary (TGD) people. Whether "sex assigned at birth" or a binary "gender identity" is most appropriate for the computation of estimated glomerular filtration rate (eGFR) is unknown. Furthermore, the use of gender-affirming hormone therapy (GAHT) for the development of physical changes to align TGD people with their affirmed gender is increasingly common, and may result in changes in serum creatinine and cystatin C, the biomarkers commonly used to estimate glomerular filtration rate. The paucity of current literature evaluating chronic kidney disease (CKD) prevalence and outcomes in TGD individuals on GAHT makes it difficult to assess any effects of GAHT on kidney function. Whether alterations in serum creatinine reflect changes in glomerular filtration rate or simply changes in muscle mass is unknown. Therefore, we propose a holistic framework to evaluate kidney function in TGD people. The framework focuses on kidney disease prevalence, risk factors, sex hormones, eGFR, other kidney function assessment tools, and the mitigation of health inequities in TGD people.
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Affiliation(s)
- Keila Turino Miranda
- Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada; Department of Medicine, University of Calgary, Calgary, Alberta, Canada; Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Dina N Greene
- Department of Laboratory Medicine and Pathology, University of Washington, Seattle, Washington; LetsGetChecked Laboratories, Monrovia, California
| | - David Collister
- Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Matthew D Krasowski
- Department of Pathology, University of Iowa Hospitals and Clinics, Iowa City, Iowa
| | - Sofia B Ahmed
- Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada; Alberta Kidney Disease Network, Calgary, Alberta, Canada; Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | | | - Sylvia E Rosas
- Kidney and Hypertension Unit, Joslin Diabetes Center, Boston, Massachusetts; Department of Nephrology, Beth Israel Deaconess Medical Centre, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts
| | - Nathalie Saad
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada; Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Christina C Pierre
- Department of Pathology and Laboratory Medicine, Penn Medicine Lancaster General Health, Lancaster, Pennsylvania; Department of Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.
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2
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Yener G, Kıyı İ, Düzenli-Öztürk S, Yerlikaya D. Age-Related Aspects of Sex Differences in Event-Related Brain Oscillatory Responses: A Turkish Study. Brain Sci 2024; 14:567. [PMID: 38928567 PMCID: PMC11202018 DOI: 10.3390/brainsci14060567] [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: 05/01/2024] [Revised: 05/28/2024] [Accepted: 05/30/2024] [Indexed: 06/28/2024] Open
Abstract
Earlier research has suggested gender differences in event-related potentials/oscillations (ERPs/EROs). Yet, the alteration in event-related oscillations (EROs) in the delta and theta frequency bands have not been explored between genders across the three age groups of adulthood, i.e., 18-50, 51-65, and >65 years. Data from 155 healthy elderly participants who underwent a neurological examination, comprehensive neuropsychological assessment (including attention, memory, executive function, language, and visuospatial skills), and magnetic resonance imaging (MRI) from past studies were used. The delta and theta ERO powers across the age groups and between genders were compared and correlational analyses among the ERO power, age, and neuropsychological tests were performed. The results indicated that females displayed higher theta ERO responses than males in the frontal, central, and parietal regions but not in the occipital location between 18 and 50 years of adulthood. The declining theta power of EROs in women reached that of men after the age of 50 while the theta ERO power was more stable across the age groups in men. Our results imply that the cohorts must be recruited at specified age ranges across genders, and clinical trials using neurophysiological biomarkers as an intervention endpoint should take gender into account in the future.
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Affiliation(s)
- Görsev Yener
- Faculty of Medicine, Izmir University of Economics, 35330 Balçova, Turkey
- Izmir Biomedicine and Genome Center, 35340 İzmir, Turkey
- Department of Neurosciences, Health Sciences Institute, Dokuz Eylül University, 35210 İzmir, Turkey; (İ.K.); (D.Y.)
| | - İlayda Kıyı
- Department of Neurosciences, Health Sciences Institute, Dokuz Eylül University, 35210 İzmir, Turkey; (İ.K.); (D.Y.)
| | - Seren Düzenli-Öztürk
- Department of Speech and Language Therapy, Faculty of Health Sciences, Izmir Bakırçay University, 35665 İzmir, Turkey;
| | - Deniz Yerlikaya
- Department of Neurosciences, Health Sciences Institute, Dokuz Eylül University, 35210 İzmir, Turkey; (İ.K.); (D.Y.)
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3
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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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Strandkjær N, Jørgensen N, Hasselbalch RB, Kristensen J, Knudsen MSS, Kock TO, Lange T, Lindholm MG, Bruun NE, Holmvang L, Terkelsen CJ, Pedersen CK, Christensen MK, Lassen JF, Hilsted L, Ladefoged S, Nybo M, Bor MV, Dahl M, Hansen AB, Kamstrup PR, Bundgaard H, Torp‐Pedersen C, Iversen KK. DANSPOT: A Multicenter Stepped-Wedge Cluster-Randomized Trial of the Reclassification of Acute Myocardial Infarction: Rationale and Study Design. J Am Heart Assoc 2024; 13:e033493. [PMID: 38639348 PMCID: PMC11179950 DOI: 10.1161/jaha.123.033493] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Accepted: 03/13/2024] [Indexed: 04/20/2024]
Abstract
BACKGROUND Cardiac troponins are the preferred biomarkers for the diagnosis of acute myocardial infarction. Although sex-specific 99th percentile thresholds of troponins are recommended in international guidelines, the clinical effect of their use is poorly investigated. The DANSPOT Study (The Danish Study of Sex- and Population-Specific 99th percentile upper reference limits of Troponin) aims to evaluate the clinical effect of a prospective implementation of population- and sex-specific diagnostic thresholds of troponins into clinical practice. METHODS This study is a nationwide, multicenter, stepped-wedge cluster-randomized trial of the implementation of population- and sex-specific thresholds of troponins in 22 of 23 clinical centers in Denmark. We established sex-specific thresholds for 5 different troponin assays based on troponin levels in a healthy Danish reference population. Centers will sequentially cross over from current uniform manufacturer-derived thresholds to the new population- and sex-specific thresholds. The primary cohort is defined as patients with symptoms suggestive of acute coronary syndrome having at least 1 troponin measurement performed within 24 hours of arrival with a peak troponin value between the current uniform threshold and the new sex-specific female and male thresholds. The study will compare the occurrence of the primary outcome, defined as a composite of nonfatal myocardial infarction, unplanned revascularization, and all-cause mortality within 1 year, separately for men and women before and after the implementation of the new sex-specific thresholds. CONCLUSIONS The DANSPOT Study is expected to show the clinical effects on diagnostics, treatment, and clinical outcomes in patients with myocardial infarction of implementing sex-specific diagnostic thresholds for troponin based on a national Danish reference population. REGISTRATION URL: https://www.clinicaltrials.gov; Unique identifier: NCT05336435.
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Affiliation(s)
- Nina Strandkjær
- Department of Emergency MedicineCopenhagen University Hospital—Herlev and GentofteHerlevDenmark
- Department of CardiologyCopenhagen University Hospital—Herlev and GentofteHerlevDenmark
- Department of Clinical MedicineUniversity of CopenhagenDenmark
| | - Nicoline Jørgensen
- Department of Emergency MedicineCopenhagen University Hospital—Herlev and GentofteHerlevDenmark
- Department of CardiologyCopenhagen University Hospital—Herlev and GentofteHerlevDenmark
| | - Rasmus Bo Hasselbalch
- Department of Emergency MedicineCopenhagen University Hospital—Herlev and GentofteHerlevDenmark
- Department of CardiologyCopenhagen University Hospital—Herlev and GentofteHerlevDenmark
- Department of Clinical MedicineUniversity of CopenhagenDenmark
| | - Jonas Kristensen
- Department of Emergency MedicineCopenhagen University Hospital—Herlev and GentofteHerlevDenmark
- Department of CardiologyCopenhagen University Hospital—Herlev and GentofteHerlevDenmark
- Department of Clinical MedicineUniversity of CopenhagenDenmark
| | - Marie Sophie Sander Knudsen
- Department of Emergency MedicineCopenhagen University Hospital—Herlev and GentofteHerlevDenmark
- Department of CardiologyCopenhagen University Hospital—Herlev and GentofteHerlevDenmark
| | - Thilde Olivia Kock
- Department of CardiologyCopenhagen University Hospital—Herlev and GentofteHerlevDenmark
| | - Theis Lange
- Department of Public HealthUniversity of CopenhagenDenmark
| | | | - Niels Eske Bruun
- Department of Clinical MedicineUniversity of CopenhagenDenmark
- Department of CardiologyZealand University HospitalRoskildeDenmark
| | - Lene Holmvang
- Department of CardiologyCopenhagen University Hospital—RigshospitaletCopenhagenDenmark
| | | | | | | | | | - Linda Hilsted
- Department of Clinical BiochemistryCopenhagen University Hospital—RigshospitaletCopenhagenDenmark
| | - Søren Ladefoged
- Department of Clinical BiochemistryAarhus University HospitalAarhusDenmark
| | - Mads Nybo
- Department of Clinical BiochemistryOdense University HospitalOdenseDenmark
| | - Mustafa Vakur Bor
- Department of Clinical BiochemistryUniversity of Hospital of South DenmarkEsbjergDenmark
| | - Morten Dahl
- Department of Clinical MedicineUniversity of CopenhagenDenmark
- Department of Clinical BiochemistryZealand University HospitalKøgeDenmark
| | | | - Pia Rørbæk Kamstrup
- Department of Clinical BiochemistryCopenhagen University Hospital—Herlev and GentofteHerlevDenmark
| | - Henning Bundgaard
- Department of Clinical MedicineUniversity of CopenhagenDenmark
- Department of CardiologyCopenhagen University Hospital—RigshospitaletCopenhagenDenmark
| | - Christian Torp‐Pedersen
- Department of Public HealthUniversity of CopenhagenDenmark
- Department of CardiologyCopenhagen University Hospital—North ZealandHillerødDenmark
| | - Kasper Karmark Iversen
- Department of Emergency MedicineCopenhagen University Hospital—Herlev and GentofteHerlevDenmark
- Department of CardiologyCopenhagen University Hospital—Herlev and GentofteHerlevDenmark
- Department of Clinical MedicineUniversity of CopenhagenDenmark
- Department of Internal MedicineCopenhagen University Hospital—Herlev and GentofteHerlevDenmark
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5
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Tiwari D, Aw TC. Optimizing the Clinical Use of High-Sensitivity Troponin Assays: A Review. Diagnostics (Basel) 2023; 14:87. [PMID: 38201396 PMCID: PMC10795745 DOI: 10.3390/diagnostics14010087] [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: 10/26/2023] [Revised: 12/14/2023] [Accepted: 12/29/2023] [Indexed: 01/12/2024] Open
Abstract
Ischemic heart diseases (IHDs) remain a global health concern. Many IHD cases go undiagnosed due to challenges in the initial diagnostic process, particularly in cases of acute myocardial infarction (AMI). High-sensitivity cardiac troponin (hs-cTn) assays have revolutionized myocardial injury assessment, but variations in diagnostic cut-off values and population differences have raised challenges. This review addresses essential laboratory and clinical considerations for hs-cTn assays. Laboratory guidelines discuss the importance of establishing standardized 99th-percentile upper reference limits (URLs) considering factors such as age, sex, health status, and analytical precision. The reference population should exclude individuals with comorbidities like diabetes and renal disease, and rigorous selection is crucial. Some clinical guidelines emphasize the significance of sex-specific URL limits while others do not. They highlight the use of serial troponin assays for AMI diagnosis. In addition, timely reporting of accurate hs-cTn results is essential for effective clinical use. This review aims to provide a clearer understanding among laboratory professionals and clinicians on how to optimize the use of hs-cTn assays in clinical settings in order to ensure accurate AMI diagnosis and thus improve patient care and outcomes.
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Affiliation(s)
- Dipti Tiwari
- Independent Researcher, Singapore 069046, Singapore;
| | - Tar Choon Aw
- Department of Laboratory Medicine, Changi General Hospital, Singapore 529889, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore (NUS), Singapore 119228, Singapore
- Pathology Academic Clinical Program, Duke-NUS Graduate School of Medicine, Singapore 169857, Singapore
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6
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Zhao L, Hu Y, Li G, Zou S, Ling L. Chemical-Chemical Redox Cycle Signal Amplification Strategy Combined with Dual Ratiometric Immunoassay for Surface-Enhanced Raman Spectroscopic Detection of Cardiac Troponin I. Anal Chem 2023; 95:16677-16682. [PMID: 37916775 DOI: 10.1021/acs.analchem.3c03238] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2023]
Abstract
Improving the sensitivity and reproducibility of surface-enhanced Raman spectroscopy (SERS) methods for the detection of bioactive molecules is crucial in biological process research and clinical diagnosis. Herein, we designed a novel SERS platform for cardiac troponin I (cTnI) detection by a chemical-chemical redox cycle signal amplification strategy combined with a dual ratiometric immunoassay. First, ascorbic acid (AA) was generated by enzyme-assisted immunoreaction with a cTnI-anchored sandwich structure. Then, oxidized 4-mercaptophenol (ox4-MP) was reacted with AA to produce 4-mercaptophenol (4-MP). Quantitative analysis of cTnI was realized by a Raman signal switch between ox4-MP and 4-MP. Specifically, AA could be regenerated by reductant (tris(2-carboxyethyl) phosphine, TCEP), which in turn produced more signal indicator 4-MP, causing significant signal amplification for cTnI analysis by SERS immunosensing. Moreover, a dual ratiometric-type SERS method was established with the intensity ratio I1077/I822 and I633/I822, which improved the reproducibility of the cTnI assay. The excellent performance of the chemical-chemical redox cycle strategy and ratio-type SERS assay endows the method with high sensitivity and reproducibility. The linear ranges of cTnI were 0.001 to 50.0 ng mL-1 with detection limits of 0.33 pg mL-1 (upon I1077/I822) and 0.31 pg mL-1 (upon I635/I822), respectively. The amount of cTnI in human serum samples yielded recoveries from 89.0 to 114%. This SERS method has remarkable analytical performance, providing an effective approach for the early diagnosis of cardiovascular diseases, and has great latent capacity in the sensitive detection of bioactive molecules.
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Affiliation(s)
- Lizhen Zhao
- School of Chemistry, Sun Yat-sen University, Guangzhou 510006, China
| | - Yuling Hu
- School of Chemistry, Sun Yat-sen University, Guangzhou 510006, China
| | - Gongke Li
- School of Chemistry, Sun Yat-sen University, Guangzhou 510006, China
| | - Seyin Zou
- Department of Laboratory Medicine, Guangdong Second Provincial General Hospital, Guangzhou 510317, China
| | - Liansheng Ling
- School of Chemistry, Sun Yat-sen University, Guangzhou 510006, China
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7
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Aspromonte N, Zaninotto M, Aimo A, Fumarulo I, Plebani M, Clerico A. Measurement of Cardiac-Specific Biomarkers in the Emergency Department: New Insight in Risk Evaluation. Int J Mol Sci 2023; 24:15998. [PMID: 37958981 PMCID: PMC10648028 DOI: 10.3390/ijms242115998] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Revised: 11/02/2023] [Accepted: 11/04/2023] [Indexed: 11/15/2023] Open
Abstract
The aim of this article review is to analyze some models and clinical issues related to the implementation of accelerated diagnostic protocols based on specific cardiac biomarkers in patients admitted to the emergency department (ED) with symptoms compatible with acute cardiac disorders. Four specific clinical issues will be discussed in detail: (a) pathophysiological and clinical interpretations of circulating hs-cTnI and hs-cTnT levels; (b) the clinical relevance and estimation of the biological variation of biomarkers in patients admitted to the ED with acute and severe diseases; (c) the role and advantages of the point-of-care testing (POCT) methods for cardiac-specific biomarkers in pre-hospital and hospital clinical practice; and (d) the clinical role of specific cardiac biomarkers in patients with acute heart failure (AHF). In order to balance the risk between a hasty discharge versus the potential harms caused by a cardiac assessment in patients admitted to the ED with suspected acute cardiovascular disease, the measurement of specific cardiac biomarkers is essential for the early identification of the presence of myocardial dysfunction and/or injury and to significantly reduce the length and costs of hospitalization. Moreover, specific cardiac biomarkers (especially hs-cTnI and hs-cTnT) are useful predictors of mortality and major adverse cardiovascular events (MACE) in patients admitted to the ED with suspected acute cardiovascular disease. To guide the implementation of the most rapid algorithms for the diagnosis of Non-ST-Elevation Myocardial Infarction (NSTEMI) into routine clinical practice, clinical scientific societies and laboratory medicine societies should promote collaborative studies specifically designed for the evaluation of the analytical performance and, especially, the cost/benefit ratio resulting from the use of these clinical protocols and POCT methods in the ED clinical practice.
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Affiliation(s)
- Nadia Aspromonte
- Department of Cardiovascular and Thoracic Sciences, Catholic University of the Sacred Heart, 00168 Rome, Italy; (N.A.); (I.F.)
- Department of Cardiovascular and Thoracic Sciences, A. Gemelli University Policlinic Foundation IRCCS, 00168 Rome, Italy
| | - Martina Zaninotto
- Department of Laboratory Medicine, University-Hospital of Padova, 35129 Padova, Italy;
| | - Alberto Aimo
- CNR Foundation—Regione Toscana G. Monasterio, 56127 Pisa, Italy;
| | - Isabella Fumarulo
- Department of Cardiovascular and Thoracic Sciences, Catholic University of the Sacred Heart, 00168 Rome, Italy; (N.A.); (I.F.)
- Department of Cardiovascular and Thoracic Sciences, A. Gemelli University Policlinic Foundation IRCCS, 00168 Rome, Italy
| | - Mario Plebani
- Department of Medicine-DIMED, University of Padova, 35129 Padova, Italy;
| | - Aldo Clerico
- CNR Foundation—Regione Toscana G. Monasterio, 56127 Pisa, Italy;
- Coordinator of the Study Group on Cardiac Biomarkers of the Italian Societies of Laboratory Medicine, 56127 Pisa, Italy
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8
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Kim SJ, Mesquita FCP, Hochman-Mendez C. New Biomarkers for Cardiovascular Disease. Tex Heart Inst J 2023; 50:e238178. [PMID: 37846107 PMCID: PMC10658139 DOI: 10.14503/thij-23-8178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2023]
Abstract
Cardiovascular disease is the leading cause of death and disability worldwide. Early detection and treatment of cardiovascular disease are crucial for patient survival and long-term health. Despite advances in cardiovascular disease biomarkers, the prevalence of cardiovascular disease continues to increase worldwide as the global population ages. To address this problem, novel biomarkers that are more sensitive and specific to cardiovascular diseases must be developed and incorporated into clinical practice. Exosomes are promising biomarkers for cardiovascular disease. These small vesicles are produced and released into body fluids by all cells and carry specific information that can be correlated with disease progression. This article reviews the advantages and limitations of existing biomarkers for cardiovascular disease, such as cardiac troponin and cytokines, and discusses recent evidence suggesting the promise of exosomes as cardiovascular disease biomarkers.
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Affiliation(s)
- Stephanie J. Kim
- Department of Regenerative Medicine Research, The Texas Heart Institute, Houston, Texas
- Department of Biosciences, Rice University, Houston, Texas
| | | | - Camila Hochman-Mendez
- Department of Regenerative Medicine Research, The Texas Heart Institute, Houston, Texas
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9
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Wang J, Taur A, Chen A, Wu YL, Lee MS. Sex-Specific Cardiac Troponin Thresholds in Transgender Patients With Suspected Acute Coronary Syndrome. JAMA Netw Open 2023; 6:e2337345. [PMID: 37824147 PMCID: PMC10570872 DOI: 10.1001/jamanetworkopen.2023.37345] [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] [Received: 08/10/2023] [Accepted: 08/28/2023] [Indexed: 10/13/2023] Open
Abstract
This cohort study compares the use and outcomes of high-sensitivity cardiac troponin assay vs conventional troponin assay in transgender adults.
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Affiliation(s)
- Jiexi Wang
- Department of Cardiology, Kaiser Permanente Los Angeles Medical Center, Los Angeles, California
| | - Alison Taur
- Department of Clinical Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, California
- Department of Nuclear Medicine, Kaiser Permanente Ontario Medical Center, Ontario, California
| | - Aiyu Chen
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena
| | - Yi-lin Wu
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena
| | - Ming-Sum Lee
- Department of Cardiology, Kaiser Permanente Los Angeles Medical Center, Los Angeles, California
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10
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Zelco A, Wapeesittipan P, Joshi A. Insights into Sex and Gender Differences in Brain and Psychopathologies Using Big Data. Life (Basel) 2023; 13:1676. [PMID: 37629533 PMCID: PMC10455614 DOI: 10.3390/life13081676] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Revised: 06/30/2023] [Accepted: 07/15/2023] [Indexed: 08/27/2023] Open
Abstract
The societal implication of sex and gender (SG) differences in brain are profound, as they influence brain development, behavior, and importantly, the presentation, prevalence, and therapeutic response to diseases. Technological advances have enabled speed up identification and characterization of SG differences during development and in psychopathologies. The main aim of this review is to elaborate on new technological advancements, such as genomics, imaging, and emerging biobanks, coupled with bioinformatics analyses of data generated from these technologies have facilitated the identification and characterization of SG differences in the human brain through development and psychopathologies. First, a brief explanation of SG concepts is provided, along with a developmental and evolutionary context. We then describe physiological SG differences in brain activity and function, and in psychopathologies identified through imaging techniques. We further provide an overview of insights into SG differences using genomics, specifically taking advantage of large cohorts and biobanks. We finally emphasize how bioinformatics analyses of big data generated by emerging technologies provides new opportunities to reduce SG disparities in health outcomes, including major challenges.
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Affiliation(s)
| | | | - Anagha Joshi
- Department of Clinical Science, Computational Biology Unit, University of Bergen, 5020 Bergen, Norway; (A.Z.); (P.W.)
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11
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Aakre KM, Meex SJR, Mills NL. Cardiac Troponin Reporting in Children and Young Adults: Time to Change Clinical Practice. Circulation 2023; 148:17-19. [PMID: 37399263 DOI: 10.1161/circulationaha.123.065297] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/05/2023]
Affiliation(s)
- Kristin M Aakre
- Department of Medical Biochemistry and Pharmacology & Department of Heart Disease, Haukeland University Hospital, Bergen, Norway (K.M.A.)
- Department of Clinical Science, University of Bergen, Norway (K.M.A.)
| | - Steven J R Meex
- Central Diagnostic Laboratory, Maastricht University Medical Center, the Netherlands (S.J.R.M.)
- CARIM School for Cardiovascular Diseases, Maastricht University, the Netherlands (S.J.R.M.)
| | - Nicholas L Mills
- BHF Centre for Cardiovascular Science (N.L.M.), University of Edinburgh, UK
- Usher Institute (N.L.M.), University of Edinburgh, UK
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12
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Thomas YT, Jarman AF, Faynshtayn NG, Buehler GB, Andrabi S, McGregor AJ. Achieving Equity in Emergency Medicine Quality Measures Requires a Sex and Gender Lens. J Emerg Med 2023; 65:e60-e65. [PMID: 37331918 PMCID: PMC10505242 DOI: 10.1016/j.jemermed.2023.03.063] [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: 09/27/2022] [Revised: 03/07/2023] [Accepted: 03/11/2023] [Indexed: 03/19/2023]
Abstract
BACKGROUND Quality measures within Emergency Medicine (EM) were developed to standardize and improve care. Their development has been limited by lack of consideration of sex- and gender-based differences. Research has suggested that sex and gender can impact clinical care and treatment. Inclusion of sex and gender differences is needed to create EM quality measures that are equitable to all. OBJECTIVE The aim of the review is to provide a brief history of EM quality measures and the value of considering sex- and gender-based evidence in their development to ensure equity, using acute myocardial infarction (AMI) as an example. DISCUSSION Current quality measures related to AMI, such as time-to-electrocardiogram and door-to-balloon time in percutaneous coronary intervention, may have important and modifiable disparities when stratified by sex. Even when presenting with signs and symptoms of AMI, women experience delayed time to diagnosis and treatment. Few studies have considered interventions to mitigate these differences. However, the data available suggest that sex-based disparities can be minimized by implementation of strategies such as a quality control checklist. CONCLUSIONS Quality measures were created to deliver high-quality, evidence-based, and standardized care, but without the inclusion of sex and gender metrics, they may not advance care to an equitable level.
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Affiliation(s)
- Ynhi T Thomas
- Henry J.N. Taub Department of Emergency Medicine, Baylor College of Medicine, Houston, Texas.
| | - Angela F Jarman
- Department of Emergency Medicine, University of California-Davis, Sacramento, California
| | | | - Greg B Buehler
- Henry J.N. Taub Department of Emergency Medicine, Baylor College of Medicine, Houston, Texas
| | - Sara Andrabi
- Henry J.N. Taub Department of Emergency Medicine, Baylor College of Medicine, Houston, Texas
| | - Alyson J McGregor
- Department of Emergency Medicine, Prisma Health, University of South Carolina School of Medicine Greenville, Greenville, South Carolina
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13
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de Bakker M, Anand A, Shipley M, Fujisawa T, Shah AS, Kardys I, Boersma E, Brunner EJ, Mills NL, Kimenai DM. Sex Differences in Cardiac Troponin Trajectories Over the Life Course. Circulation 2023; 147:1798-1808. [PMID: 37114498 PMCID: PMC10249606 DOI: 10.1161/circulationaha.123.064386] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Accepted: 03/28/2023] [Indexed: 04/29/2023]
Abstract
BACKGROUND Cardiac troponin concentrations are lower in women than men. We examined whether age- and risk factor-related changes in cardiac troponin over the life course differ by sex and if the trajectory of cardiac troponin was informative in respect of cardiovascular outcomes in women and men in the general population. METHODS In the Whitehall II cohort, high-sensitivity cardiac troponin I concentrations were measured on 3 occasions over a 15-year period. Using linear mixed-effects models, the sex-specific trajectories of cardiac troponin were evaluated, and the relationship with conventional cardiovascular risk factors determined. Using multistate joint models, the association between sex-specific trajectories of cardiac troponin and a composite outcome of nonfatal myocardial infarction, nonfatal stroke, or cardiovascular death was evaluated. RESULTS In 2142 women and 5151 men (mean, 58±7 and 57±7 years of age, respectively), there were 177 (8.3%) and 520 (10.1%) outcome events, respectively, during a median follow-up of 20.9 (25th to 75th percentile, 15.8-21.3) years. Cardiac troponin concentrations were persistently lower in women than in men (median baseline concentration: 2.4 [25th to 75th percentile, 1.7-3.6] ng/L versus 3.7 [25th to 75th percentile, 2.6-5.8] ng/L, respectively, P<0.001), with women exhibiting a relatively larger increase with advancing age as compared with men (Pinteraction<0.001). Apart from age, a significant and divergent interaction with sex was found for the association between cardiac troponin and body mass index (BMI) (Pinteraction=0.008) and diabetes (Pinteraction=0.003). During follow-up, cardiac troponin concentrations were associated to the outcome in both women and men (adjusted hazard ratio per 2-fold difference [95% CI, 1.34 (1.17-1.52) and 1.30 (1.21-1.40), respectively], Pinteraction=0.752). The slope of cardiac troponin was significantly associated with the outcome in women, but not in men (adjusted hazard ratio [95% CI, 2.70 (1.01-7.33) and 1.31 (0.62-2.75), respectively], Pinteraction=0.250). CONCLUSIONS Trajectories of cardiac troponin differ between women and men in the general population, with differing associations to conventional risk factors and cardiovascular outcomes. Our findings highlight the importance of a sex-specific approach when serial cardiac troponin testing is applied for cardiovascular risk prediction.
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Affiliation(s)
- Marie de Bakker
- Department of Cardiology, Erasmus MC Cardiovascular Institute, University Medical Center Rotterdam, the Netherlands (M.d.B., I.K., E.B.)
| | - Atul Anand
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, United Kingdom (T.F., A.A., N.L.M., D.M.K.)
| | - Martin Shipley
- Department of Epidemiology and Public Health, University College London, United Kingdom (M.S., E.J.B.)
| | - Takeshi Fujisawa
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, United Kingdom (T.F., A.A., N.L.M., D.M.K.)
| | - Anoop S.V. Shah
- Department of Non-Communicable Disease, London School of Hygiene and Tropical Medicine, United Kingdom (A.S.V.S.)
| | - Isabella Kardys
- Department of Cardiology, Erasmus MC Cardiovascular Institute, University Medical Center Rotterdam, the Netherlands (M.d.B., I.K., E.B.)
| | - Eric Boersma
- Department of Cardiology, Erasmus MC Cardiovascular Institute, University Medical Center Rotterdam, the Netherlands (M.d.B., I.K., E.B.)
| | - Eric J. Brunner
- Department of Epidemiology and Public Health, University College London, United Kingdom (M.S., E.J.B.)
| | - Nicholas L. Mills
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, United Kingdom (T.F., A.A., N.L.M., D.M.K.)
- Usher Institute, University of Edinburgh, United Kingdom (N.L.M.)
| | - Dorien M. Kimenai
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, United Kingdom (T.F., A.A., N.L.M., D.M.K.)
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14
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Doudesis D, Lee KK, Boeddinghaus J, Bularga A, Ferry AV, Tuck C, Lowry MTH, Lopez-Ayala P, Nestelberger T, Koechlin L, Bernabeu MO, Neubeck L, Anand A, Schulz K, Apple FS, Parsonage W, Greenslade JH, Cullen L, Pickering JW, Than MP, Gray A, Mueller C, Mills NL. Machine learning for diagnosis of myocardial infarction using cardiac troponin concentrations. Nat Med 2023; 29:1201-1210. [PMID: 37169863 PMCID: PMC10202804 DOI: 10.1038/s41591-023-02325-4] [Citation(s) in RCA: 17] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Accepted: 03/28/2023] [Indexed: 05/13/2023]
Abstract
Although guidelines recommend fixed cardiac troponin thresholds for the diagnosis of myocardial infarction, troponin concentrations are influenced by age, sex, comorbidities and time from symptom onset. To improve diagnosis, we developed machine learning models that integrate cardiac troponin concentrations at presentation or on serial testing with clinical features and compute the Collaboration for the Diagnosis and Evaluation of Acute Coronary Syndrome (CoDE-ACS) score (0-100) that corresponds to an individual's probability of myocardial infarction. The models were trained on data from 10,038 patients (48% women), and their performance was externally validated using data from 10,286 patients (35% women) from seven cohorts. CoDE-ACS had excellent discrimination for myocardial infarction (area under curve, 0.953; 95% confidence interval, 0.947-0.958), performed well across subgroups and identified more patients at presentation as low probability of having myocardial infarction than fixed cardiac troponin thresholds (61 versus 27%) with a similar negative predictive value and fewer as high probability of having myocardial infarction (10 versus 16%) with a greater positive predictive value. Patients identified as having a low probability of myocardial infarction had a lower rate of cardiac death than those with intermediate or high probability 30 days (0.1 versus 0.5 and 1.8%) and 1 year (0.3 versus 2.8 and 4.2%; P < 0.001 for both) from patient presentation. CoDE-ACS used as a clinical decision support system has the potential to reduce hospital admissions and have major benefits for patients and health care providers.
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Grants
- FS/18/25/33454 British Heart Foundation
- MR/V007254/1 Medical Research Council
- CH/F/21/90010 British Heart Foundation
- RG/20/10/34966 British Heart Foundation
- MR/N013166/1 Medical Research Council
- RE/18/5/34216 British Heart Foundation
- MR/W000598/1 Medical Research Council
- British Heart Foundation (BHF)
- RCUK | Medical Research Council (MRC)
- The University of Basel, the University Hospital of Basel, the Swiss Academy of Medical Sciences, the Gottfried and Julia Bangerter-Rhyner Foundation, the Swiss National Science Foundation
- Swiss Heart Foundation, the University of Basel, the Swiss Academy of Medical Science, the Gottfried and Julia Bangerter-Rhyner Foundation, and the “Freiwillige Akademische Gesellschaft Basel.”
- Advance Queensland Fellowship
- the Swiss National Science Foundation, the Swiss Heart Foundation, the Commission for Technology and Innovation, and the University Hospital Basel.
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Affiliation(s)
- Dimitrios Doudesis
- British Heart Foundation/University Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
- Usher Institute, University of Edinburgh, Edinburgh, UK
| | - Kuan Ken Lee
- British Heart Foundation/University Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Jasper Boeddinghaus
- British Heart Foundation/University Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
- Cardiovascular Research Institute Basel and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Anda Bularga
- British Heart Foundation/University Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Amy V Ferry
- British Heart Foundation/University Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Chris Tuck
- British Heart Foundation/University Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Matthew T H Lowry
- British Heart Foundation/University Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Pedro Lopez-Ayala
- Cardiovascular Research Institute Basel and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Thomas Nestelberger
- Cardiovascular Research Institute Basel and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Luca Koechlin
- Cardiovascular Research Institute Basel and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- Department of Cardiac Surgery, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Miguel O Bernabeu
- Usher Institute, University of Edinburgh, Edinburgh, UK
- The Bayes Centre, The University of Edinburgh, Edinburgh, UK
| | - Lis Neubeck
- School of Health and Social Care, Edinburgh Napier University, Edinburgh, UK
| | - Atul Anand
- British Heart Foundation/University Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Karen Schulz
- Cardiac Biomarkers Trials Laboratory, Hennepin Healthcare Research Institute, Minneapolis, MN, USA
| | - Fred S Apple
- Departments of Laboratory Medicine and Pathology, Hennepin County Medical Center and University of Minnesota, Minneapolis, MN, USA
| | - William Parsonage
- Australian Centre for Health Service Innovation, Centre for Healthcare Transformation, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Jaimi H Greenslade
- Emergency and Trauma Centre, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
- School of Medicine, University of Queensland, Brisbane, Queensland, Australia
- Faculty of Health, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Louise Cullen
- Emergency and Trauma Centre, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
- School of Medicine, University of Queensland, Brisbane, Queensland, Australia
- Faculty of Health, Queensland University of Technology, Brisbane, Queensland, Australia
| | - John W Pickering
- Department of Medicine, University of Otago, Christchurch, New Zealand
- Emergency Department, Christchurch Hospital, Christchurch, New Zealand
| | - Martin P Than
- Department of Medicine, University of Otago, Christchurch, New Zealand
| | - Alasdair Gray
- Emergency Medicine Research Group Edinburgh, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Christian Mueller
- Cardiovascular Research Institute Basel and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Nicholas L Mills
- British Heart Foundation/University Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK.
- Usher Institute, University of Edinburgh, Edinburgh, UK.
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15
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Kimenai DM, Mills NL. Application of a sex-specific GRACE score in practice. Lancet 2023; 401:22-23. [PMID: 36610765 DOI: 10.1016/s0140-6736(22)02473-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Accepted: 11/25/2022] [Indexed: 01/07/2023]
Affiliation(s)
- Dorien M Kimenai
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh EH16 4SA, UK
| | - Nicholas L Mills
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh EH16 4SA, UK; Usher Institute, University of Edinburgh, Edinburgh EH16 4SA, UK.
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16
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Greene DN, Schmidt RL, Christenson RH, Rongitsch J, Imborek KL, Rebuck H, Lorey TS, Saenger AK, Krasowski MD. Distribution of High-Sensitivity Cardiac Troponin and N-Terminal Pro-Brain Natriuretic Peptide in Healthy Transgender People. JAMA Cardiol 2022; 7:1170-1174. [PMID: 36197689 PMCID: PMC9535541 DOI: 10.1001/jamacardio.2022.3299] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Accepted: 08/12/2022] [Indexed: 12/15/2022]
Abstract
Importance Sex-specific differences in the commonly used cardiac biomarkers high-sensitivity cardiac troponin (hs-cTn) and N-terminal pro-brain natriuretic peptide (NT-proBNP) are apparent. There is an absence of medical literature delineating the concentration differences for these biomarkers in transgender individuals without cardiac disease. Objective To determine the distribution of hs-cTn and NT-proBNP in healthy transgender people. Design, Setting, and Participants In this cross-sectional prospective study, healthy transgender individuals prescribed testosterone or estradiol for 12 months or more were recruited from internal medicine and primary care clinics that specialize in transgender medical care between November 1, 2017, and July 1, 2018. Exposures Testosterone or estradiol for 12 months. Main Outcomes and Measures Concentrations for hs-cTnI (troponin I), hs-cTnT (troponin T), and NT-proBNP were measured. Results Transgender people prescribed testosterone (n = 79; mean [SD] age, 28.8 [7.8] years) or estrogen (n = 93; mean [SD] age, 35.1 [11.7] years) were recruited. The concentration of hs-cTn was significantly higher in transgender men relative to transgender women. For Abbott hs-cTnI levels, the median (IQR) concentration observed in transgender men and women was 0.9 (0.6-1.7) ng/L and 0.6 (0.3-1.0) ng/L, respectively. Results were similar across 2 additional hs-cTn assays. In contrast, NT-proBNP level was higher in transgender women. The median (IQR) NT-proBNP concentration was significantly higher in transgender women ( 49 [32-86] ng/L) than in transgender men (17 [13-27] ng/L). Conclusions and Relevance Findings of this cross-sectional study suggest that the differences in concentration for hs-cTn and NT-proBNP between transgender men and women were similar to what is observed between cisgender men and women. Sex hormones, rather than sex assigned at birth, may be a stronger driver of the observed concentration differences between healthy men and women for biomarkers of cardiac disease.
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Affiliation(s)
- Dina N. Greene
- Department of Laboratory Medicine, University of Washington, Seattle
| | | | | | | | - Katherine L. Imborek
- Department of Family Medicine, University of Iowa Hospitals and Clinics, Iowa City
- Carver College of Medicine, University of Iowa Hospitals and Clinics, Iowa City
| | - Heather Rebuck
- Department of Pathology, University of Maryland, Baltimore
| | - Thomas S. Lorey
- Department of Laboratory Medicine, The Permanente Medical Group, Oakland, California
| | - Amy K. Saenger
- Departments of Laboratory Medicine and Pathology at Hennepin Healthcare/Hennepin County Medical Center and University of Minnesota, Minneapolis
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17
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Hanås S, Larsson A, Rydén J, Lilliehöök I, Häggström J, Tidholm A, Höglund K, Ljungvall I, Holst BS. Cardiac troponin I in healthy Norwegian Forest Cat, Birman and domestic shorthair cats, and in cats with hypertrophic cardiomyopathy. J Feline Med Surg 2022; 24:e370-e379. [PMID: 36073987 PMCID: PMC9511503 DOI: 10.1177/1098612x221117115] [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] [Indexed: 11/21/2022]
Abstract
Objectives The aims of this study were to assess the potential associations between the serum cardiac troponin I (cTnI) concentration in healthy cats and feline characteristics, systolic blood pressure, heart rate (HR), echocardiographic measurements and storage time; and to compare cTnI concentrations in healthy cats with concentrations in cats with hypertrophic cardiomyopathy (HCM), with or without left atrial enlargement (LAE) and in cats with HCM, to assess potential associations between cTnI concentration and echocardiographic variables. Methods Cardiac TnI was analysed using an Abbott ARCHITECT ci16200 analyser in serum from prospectively included healthy Norwegian Forest Cat (NF; n = 33), Birman (n = 33) and domestic shorthair (DSH; n = 30) cats, and from 39 cats with HCM, with or without LAE. Results In healthy cats, higher cTnI concentrations were found in Birman cats than in NF cats (P = 0.014) and in neutered male cats than in intact females (P = 0.032). Cardiac TnI was positively associated with HR (P <0.0001). In cats with HCM, cTnI concentration was positively associated with left ventricular wall thickness and with left atrial-to-aortic root ratio (all P ⩽0.010). Cats with HCM had higher cTnI concentrations than healthy cats, and cTnI concentrations were higher in cats with HCM and LAE than in those with HCM without LAE (all P = 0.0003). Conclusions and relevance Breed and sex may affect serum cTnI concentrations in healthy cats. The cTnI concentration increased with increasing severity of HCM.
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Affiliation(s)
- Sofia Hanås
- Department of Clinical Sciences, Swedish University of Agricultural Sciences, Uppsala, Sweden.,Evidensia Specialist Animal Hospital Strömsholm, Strömsholm, Sweden
| | - Anders Larsson
- Department of Medical Sciences, Clinical Chemistry, Uppsala University, Uppsala, Sweden
| | - Jesper Rydén
- Department of Energy and Technology, Swedish University of Agricultural Sciences, Uppsala, Sweden
| | - Inger Lilliehöök
- Department of Clinical Sciences, Swedish University of Agricultural Sciences, Uppsala, Sweden
| | - Jens Häggström
- Department of Clinical Sciences, Swedish University of Agricultural Sciences, Uppsala, Sweden
| | - Anna Tidholm
- Department of Clinical Sciences, Swedish University of Agricultural Sciences, Uppsala, Sweden.,Anicura Albano Animal Hospital, Stockholm, Sweden
| | - Katja Höglund
- Department of Anatomy, Physiology and Biochemistry, Swedish University of Agricultural Sciences, Uppsala, Sweden
| | - Ingrid Ljungvall
- Department of Clinical Sciences, Swedish University of Agricultural Sciences, Uppsala, Sweden
| | - Bodil S Holst
- Department of Clinical Sciences, Swedish University of Agricultural Sciences, Uppsala, Sweden
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18
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de Miguel-Balsa E. Risk stratification and health inequalities in women with acute coronary syndrome: time to move on. Lancet 2022; 400:710-711. [PMID: 36049492 DOI: 10.1016/s0140-6736(22)01607-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Accepted: 08/15/2022] [Indexed: 10/15/2022]
Affiliation(s)
- Eva de Miguel-Balsa
- Intensive and Coronary Care Unit, Intensive Care Medicine, Hospital General Universitario de Elche, Alicante, Spain; Department of Clinical Medicine, Universidad Miguel Hernández, Elche 03203, Spain.
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19
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Bergmark BA, Mathenge N, Merlini PA, Lawrence-Wright MB, Giugliano RP. Acute coronary syndromes. Lancet 2022; 399:1347-1358. [PMID: 35367005 PMCID: PMC8970581 DOI: 10.1016/s0140-6736(21)02391-6] [Citation(s) in RCA: 116] [Impact Index Per Article: 58.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Revised: 10/26/2021] [Accepted: 10/26/2021] [Indexed: 12/14/2022]
Abstract
Although substantial progress has been made in the diagnosis and treatment of acute coronary syndromes, cardiovascular disease remains the leading cause of death globally, with nearly half of these deaths due to ischaemic heart disease. The broadening availability of high-sensitivity troponin assays has allowed for rapid rule-out algorithms in patients with suspected non-ST-segment elevated myocardial infarction (NSTEMI). Dual antiplatelet therapy is recommended for 12 months following an acute coronary syndrome in most patients, and additional secondary prevention measures including intensive lipid-lowering therapy (LDL-C <1·4 mmol/L), neurohormonal agents, and lifestyle modification, are crucial. The scientific evidence for diagnosis and management of acute coronary syndromes continues to evolve rapidly, including adapting to the COVID-19 pandemic, which has impacted all aspects of care. This Seminar provides a clinically relevant overview of the pathobiology, diagnosis, and management of acute coronary syndromes, and describes key scientific advances.
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Affiliation(s)
- Brian A Bergmark
- TIMI Study Group, Cardiovascular Division, Brigham and Women's Hospital, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Njambi Mathenge
- Division of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Piera A Merlini
- 4th Division of Cardiology, Cardiocenter De Gasperis, ASST GOM Niguarda and Bicocca University, Milan, Italy
| | - Marilyn B Lawrence-Wright
- Division of Cardiology, Department of Medicine, The University of the West Indies at Mona, Kingston, Jamaica
| | - Robert P Giugliano
- TIMI Study Group, Cardiovascular Division, Brigham and Women's Hospital, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
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20
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Wereski R, Kimenai DM, Bularga A, Taggart C, Lowe DJ, Mills NL, Chapman AR. Risk factors for type 1 and type 2 myocardial infarction. Eur Heart J 2022; 43:127-135. [PMID: 34431993 PMCID: PMC8757580 DOI: 10.1093/eurheartj/ehab581] [Citation(s) in RCA: 32] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Revised: 06/25/2021] [Accepted: 08/10/2021] [Indexed: 11/13/2022] Open
Abstract
AIMS Whilst the risk factors for type 1 myocardial infarction due to atherosclerotic plaque rupture and thrombosis are established, our understanding of the factors that predispose to type 2 myocardial infarction during acute illness is still emerging. Our aim was to evaluate and compare the risk factors for type 1 and type 2 myocardial infarction. METHODS AND RESULTS We conducted a secondary analysis of a multi-centre randomized trial population of 48 282 consecutive patients attending hospital with suspected acute coronary syndrome. The diagnosis of myocardial infarction during the index presentation and all subsequent reattendances was adjudicated according to the Universal Definition of Myocardial Infarction. Cox regression was used to identify predictors of future type 1 and type 2 myocardial infarction during a 1-year follow-up period. Within 1 year, 1331 patients had a subsequent myocardial infarction, with 924 and 407 adjudicated as type 1 and type 2 myocardial infarction, respectively. Risk factors for type 1 and type 2 myocardial infarction were similar, with age, hyperlipidaemia, diabetes, abnormal renal function, and known coronary disease predictors for both (P < 0.05 for all). Whilst women accounted for a greater proportion of patients with type 2 as compared to type 1 myocardial infarction, after adjustment for other risk factors, sex was not a predictor of type 2 myocardial events [adjusted hazard ratio (aHR) 0.82, 95% confidence interval (CI) 0.66-1.01]. The strongest predictor of type 2 myocardial infarction was a prior history of type 2 events (aHR 6.18, 95% CI 4.70-8.12). CONCLUSIONS Risk factors for coronary disease that are associated with type 1 myocardial infarction are also important predictors of type 2 events during acute illness. Treatment of these risk factors may reduce future risk of both type 1 and type 2 myocardial infarction.
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Affiliation(s)
- Ryan Wereski
- BHF Centre for Cardiovascular Science, University of Edinburgh, Chancellors Building, 49 Little France Crescent, Edinburgh EH16 4SA, UK
| | - Dorien M Kimenai
- Usher Institute, University of Edinburgh, Edinburgh, NINE, 9 Little France Road, Edinburgh BioQuarter, Edinburgh EH16 4UX, UK
| | - Anda Bularga
- BHF Centre for Cardiovascular Science, University of Edinburgh, Chancellors Building, 49 Little France Crescent, Edinburgh EH16 4SA, UK
| | - Caelan Taggart
- BHF Centre for Cardiovascular Science, University of Edinburgh, Chancellors Building, 49 Little France Crescent, Edinburgh EH16 4SA, UK
| | - David J Lowe
- University of Glasgow, School of Medicine, Glasgow, UK
| | - Nicholas L Mills
- BHF Centre for Cardiovascular Science, University of Edinburgh, Chancellors Building, 49 Little France Crescent, Edinburgh EH16 4SA, UK
- Usher Institute, University of Edinburgh, Edinburgh, NINE, 9 Little France Road, Edinburgh BioQuarter, Edinburgh EH16 4UX, UK
| | - Andrew R Chapman
- BHF Centre for Cardiovascular Science, University of Edinburgh, Chancellors Building, 49 Little France Crescent, Edinburgh EH16 4SA, UK
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21
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Affiliation(s)
- Matthew T H Lowry
- BHF Centre for Cardiovascular Science, The University of Edinburgh, Edinburgh, UK
| | - Atul Anand
- BHF Centre for Cardiovascular Science, The University of Edinburgh, Edinburgh, UK
| | - Nicholas L Mills
- BHF Centre for Cardiovascular Science, The University of Edinburgh, Edinburgh, UK
- Usher Institute, The University of Edinburgh, Edinburgh, UK
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22
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Kimenai DM, Shah ASV, McAllister DA, Lee KK, Tsanas A, Meex SJR, Porteous DJ, Hayward C, Campbell A, Sattar N, Mills NL, Welsh P. Sex Differences in Cardiac Troponin I and T and the Prediction of Cardiovascular Events in the General Population. Clin Chem 2021; 67:1351-1360. [PMID: 34240125 PMCID: PMC8486023 DOI: 10.1093/clinchem/hvab109] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Accepted: 05/12/2021] [Indexed: 12/20/2022]
Abstract
BACKGROUND Cardiac troponin concentrations differ in women and men, but how this influences risk prediction and whether a sex-specific approach is required is unclear. We evaluated whether sex influences the predictive ability of cardiac troponin I and T for cardiovascular events in the general population. METHODS High-sensitivity cardiac troponin (hs-cTn) I and T were measured in the Generation Scotland Scottish Family Health Study of randomly selected volunteers drawn from the general population between 2006 and 2011. Cox-regression models evaluated associations between hs-cTnI and hs-cTnT and the primary outcome of cardiovascular death, myocardial infarction, or stroke. RESULTS In 19 501 (58% women, mean age 47 years) participants, the primary outcome occurred in 2.7% (306/11 375) of women and 5.1% (411/8126) of men during the median follow-up period of 7.9 (IQR, 7.1-9.2) years. Cardiac troponin I and T concentrations were lower in women than men (P < 0.001 for both), and both were more strongly associated with cardiovascular events in women than men. For example, at a hs-cTnI concentration of 10 ng/L, the hazard ratio relative to the limit of blank was 9.7 (95% CI 7.6-12.4) and 5.6 (95% CI 4.7-6.6) for women and men, respectively. The hazard ratio for hs-cTnT at a concentration of 10 ng/L relative to the limit of blank was 3.7 (95% CI 3.1-4.3) and 2.2 (95% CI 2.0-2.5) for women and men, respectively. CONCLUSIONS Cardiac troponin concentrations differ in women and men and are stronger predictors of cardiovascular events in women. Sex-specific approaches are required to provide equivalent risk prediction.
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Affiliation(s)
| | - Anoop S V Shah
- Usher Institute, University of Edinburgh, Edinburgh, UK
- BHF Centre for Cardiovascular Science, University of Edinburgh, UK
| | | | - Kuan Ken Lee
- BHF Centre for Cardiovascular Science, University of Edinburgh, UK
| | | | - Steven J R Meex
- Central Diagnostic Laboratory, Maastricht University Medical Center, Maastricht, the Netherlands
- CARIM School for Cardiovascular Diseases, Maastricht University, Maastricht, the Netherlands
| | - David J Porteous
- Institute of Genetics and Molecular Medicine, University of Edinburgh, Edinburgh, UK
| | - Caroline Hayward
- Institute of Genetics and Molecular Medicine, University of Edinburgh, Edinburgh, UK
| | - Archie Campbell
- Institute of Genetics and Molecular Medicine, University of Edinburgh, Edinburgh, UK
| | - Naveed Sattar
- Institute of Cardiovascular & Medical Sciences, University of Glasgow, Glasgow, UK
| | - Nicholas L Mills
- Usher Institute, University of Edinburgh, Edinburgh, UK
- BHF Centre for Cardiovascular Science, University of Edinburgh, UK
| | - Paul Welsh
- Institute of Cardiovascular & Medical Sciences, University of Glasgow, Glasgow, UK
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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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24
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Taranova NA, Slobodenuyk VD, Zherdev AV, Dzantiev BB. Network of gold conjugates for enhanced sensitive immunochromatographic assays of troponins. RSC Adv 2021; 11:16445-16452. [PMID: 35479181 PMCID: PMC9030257 DOI: 10.1039/d1ra02212a] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Accepted: 04/27/2021] [Indexed: 01/13/2023] Open
Abstract
Highly sensitive detection of cardiac troponins I and T (cTnI and cTnT) was completed by immunochromatography with double amplification, through the binding of functionalized gold nanoparticles (GNPs). The robust nature of the approach, based on the formation of nanoparticle networks through the biotin-streptavidin interaction, was confirmed; the choice of the best assay parameters for maximal increase in ICA sensitivity was demonstrated. A bifunctional conjugate of GNPs with biotinylated specific IgG and two auxiliary conjugates, GNP-biotin and GNP-streptavidin, form three-component aggregates in the analytical zone of the test strip. The inclusion of abundant gold labels in the resulting immune complex leads to an amplified colorimetric signal. The limits of detection (LoDs) of cTnI and cTnT were 0.9 and 0.4 ng mL-1, respectively, which is 3 times lower than the LoDs of more commonly used systems. Visual LoDs were 10-fold lower in concentration. The enhancement has been realized both in single and double assay formats; analysis of cTnI and cTnT presented the same characteristics.
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Affiliation(s)
- Nadezhda A Taranova
- A.N. Bach Institute of Biochemistry, Research Center of Biotechnology of the Russian Academy of Sciences Leninsky Prospect 33 119071 Moscow Russia
| | - Vladislav D Slobodenuyk
- A.N. Bach Institute of Biochemistry, Research Center of Biotechnology of the Russian Academy of Sciences Leninsky Prospect 33 119071 Moscow Russia
| | - Anatoly V Zherdev
- A.N. Bach Institute of Biochemistry, Research Center of Biotechnology of the Russian Academy of Sciences Leninsky Prospect 33 119071 Moscow Russia
| | - Boris B Dzantiev
- A.N. Bach Institute of Biochemistry, Research Center of Biotechnology of the Russian Academy of Sciences Leninsky Prospect 33 119071 Moscow Russia
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25
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Do age-adjusted sex-specific cut-off values improve the agreement between high sensitivity cardiac troponins I and T? A retrospective study. Clin Chim Acta 2021; 519:76-82. [PMID: 33865814 DOI: 10.1016/j.cca.2021.04.007] [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: 12/14/2020] [Revised: 04/07/2021] [Accepted: 04/11/2021] [Indexed: 11/19/2022]
Abstract
BACKGROUND Many reports noted a disagreement between High sensitivity cardiac Troponin (hs-cTn) assays on the diagnosis of Acute Coronary Syndrome (ACS). METHODS We conducted a retrospective study aiming to assess the agreement between hs-cTn T (Roche) and hs-cTn I (Abbott) in patients presenting with a suspected ACS to the emergency department at Hotel-Dieu hospital between September 2017 and October 2019 using overall, sex-specific, and age-adjusted sex-specific cut-off values. This was measured using Cohen's Kappa. We explored whether renal function, circadian rhythm, age and sex influenced the discordance. And we analyzed the trend of agreement between baseline and repeated measurements. RESULTS 4856 patients who had simultaneous hs-cTn I and T values were retained for the analysis. 53.5% had a hs-cTn T above the overall 99th percentile, compared to 19.9% for hs-cTn I. The numbers were significantly reduced when applying age-adjusted sex-specific 99th percentile. A disagreement was seen in 34% of cases using overall 99th percentile. Using sex-specific cut off values did not impact this discordance; however, age-adjusted sex-specific cut-off values reduced the percentage of discrepancies to 15.8%. The decreased renal function had a negative effect on the agreement while the circadian rhythm had minimal effect. This initial discordance was carried forward into repeated measurements. CONCLUSION The disagreement between hs-cTn T and I assays could be imputed to the choice of cut-off values. The use of age-adjusted sex specific 99th percentile reduced majorly these discordances. Further studies are needed in order to evaluate their clinical utility in patients presenting with ACS.
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26
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A feasibility study for CODE-MI: High-sensitivity cardiac troponin-Optimizing the diagnosis of acute myocardial infarction/injury in women. Am Heart J 2021; 234:60-70. [PMID: 33460579 DOI: 10.1016/j.ahj.2021.01.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Accepted: 01/11/2021] [Indexed: 01/22/2023]
Abstract
BACKGROUND CODE-MI is a pan-Canadian, multicentre, stepped-wedge, cluster randomized trial that evaluates the impact of using the female-specific 99th percentile threshold for high-sensitivity cardiac troponin (hs-cTn) on the diagnosis, treatment and outcomes of women presenting to the emergency department (ED) with symptoms suggestive for myocardial ischemia. A feasibility study was conducted to estimate the number of eligible patients, the rate of the study's primary outcome under control conditions, and the statistical power to detect a clinically important difference in the primary outcome. METHODS Using linked administrative data from 11 hospitals in Ontario, Canada, from October 2014 to September 2017, the following estimates were obtained: number of women presenting to the ED with symptoms suggestive of myocardial ischemia and a 24-hour peak hs-cTn value within the female-specific and overall thresholds (ie, primary cohort); the rate of the 1-year composite outcome of all-cause mortality, re-admission for nonfatal myocardial infarction, incident heart failure, or emergent/urgent coronary revascularization. Study power was evaluated via simulations. RESULTS Overall, 2,073,849 ED visits were assessed. Among women, chest pain (with or without cardiac features) and shortness of breath were the most common complaints associated with a diagnosis of acute coronary syndrome. An estimated 7.7% of women with these complaints are eligible for inclusion in the primary cohort. The rate of the 1-year outcome in the primary cohort varied significantly across hospitals with a median rate of 12.2% (95%CI: 7.9%-17.7%). With 30 hospitals, randomized at 5-month intervals in 5 steps, approximately 19,600 women are expected to be included in CODE-MI, resulting in >82% power to detect a 20% decrease in the odds of the primary outcome at a 0.05 significance level. CONCLUSIONS This feasibility study greatly enhanced the design of CODE-MI, allowed accurate evaluation of the study power, and demonstrated the strength of using linked administrative health data to guide the design of pragmatic clinical trials.
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27
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Kaier TE, Alaour B, Marber M. Cardiac troponin and defining myocardial infarction. Cardiovasc Res 2021; 117:2203-2215. [PMID: 33458742 PMCID: PMC8404461 DOI: 10.1093/cvr/cvaa331] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Revised: 09/12/2020] [Indexed: 12/19/2022] Open
Abstract
The 4th Universal Definition of Myocardial Infarction has stimulated considerable debate since its publication in 2018. The intention was to define the types of myocardial injury through the lens of their underpinning pathophysiology. In this review, we discuss how the 4th Universal Definition of Myocardial Infarction defines infarction and injury and the necessary pragmatic adjustments that appear in clinical guidelines to maximize triage of real-world patients.
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Affiliation(s)
- Thomas E Kaier
- King's College London BHF Centre, The Rayne Institute, 4th Floor, Lambeth Wing, St Thomas' Hospital, Westminster Bridge Road, London SE1 7EH, UK
| | - Bashir Alaour
- King's College London BHF Centre, The Rayne Institute, 4th Floor, Lambeth Wing, St Thomas' Hospital, Westminster Bridge Road, London SE1 7EH, UK
| | - Michael Marber
- King's College London BHF Centre, The Rayne Institute, 4th Floor, Lambeth Wing, St Thomas' Hospital, Westminster Bridge Road, London SE1 7EH, UK
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28
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Azar RR, Sarkis A, Giannitsis E. A Practical Approach for the Use of High-Sensitivity Cardiac Troponin Assays in the Evaluation of Patients With Chest Pain. Am J Cardiol 2021; 139:1-7. [PMID: 33164762 DOI: 10.1016/j.amjcard.2020.10.037] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Revised: 10/11/2020] [Accepted: 10/13/2020] [Indexed: 01/12/2023]
Abstract
Chest pain is a common clinical presentation, especially in the emergency department. Both rapid identification of patients with myocardial infarction as well as those with noncardiac chest pain is important in order to start therapy in the former and avoid unnecessary investigations and delay in discharge in the latter. Beside electrocardiogram, cardiac biomarkers are a key element in decision making. Conventional creatinine kinase and troponin assays are not sensitive enough and have to be repeated at least 6 to 12 hours after initial evaluation. New high-sensitivity cardiac troponin (hs-cTn) tests are currently available and if used appropriately can substantially improve management. Because of their high sensitivity and accuracy, these tests allow measurement of very low serum troponin levels, such as those present in healthy individuals and can detect small changes in troponin concentration within a short time frame. These tests are thus, very useful for the early diagnosis of myocardial infarction but can also be elevated in several other conditions that result in myocardial injury. A good understanding of the analytical characteristics of these assays is of uppermost importance for their appropriate use in clinical practice.
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Affiliation(s)
- Rabih R Azar
- Hotel Dieu de France Hospital and the St. Joseph University Faculty of Medicine, Beirut, Lebanon.
| | - Antoine Sarkis
- Hotel Dieu de France Hospital and the St. Joseph University Faculty of Medicine, Beirut, Lebanon
| | - Evangelos Giannitsis
- Medizinische Klinik III, Department of Cardiology, Angiology and Pneumology, University Hospital of Heidelberg, Heidelberg, Germany
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29
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Westwood ME, Armstrong N, Worthy G, Fayter D, Ramaekers BLT, Grimm S, Buksnys T, Ross J, Mills NL, Body R, Collinson PO, Timmis A, Kleijnen J. Optimizing the Use of High-Sensitivity Troponin Assays for the Early Rule-out of Myocardial Infarction in Patients Presenting with Chest Pain: A Systematic Review. Clin Chem 2021; 67:237-244. [PMID: 33418577 DOI: 10.1093/clinchem/hvaa280] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Accepted: 10/21/2020] [Indexed: 01/22/2023]
Abstract
BACKGROUND We assessed the accuracy and clinical effectiveness of high-sensitivity cardiac troponin (hs-cTn) assays for early rule-out of non-ST-segment elevation myocardial infarction (NSTEMI) in adults presenting with acute chest pain. METHODS Sixteen databases were searched to September 2019. Review methods followed published guidelines. The bivariate model was used to estimate summary sensitivity and specificity with 95% confidence intervals for meta-analyses involving 4 or more studies, otherwise random-effects logistic regression was used. RESULTS Thirty-seven studies (124 publications) were included in the review. The hs-cTn test strategies evaluated in the included studies were defined by the combination of 4 factors (assay, number of tests, timing of tests, and threshold concentration or change in concentration between tests). Clinical opinion indicated a minimum acceptable sensitivity of 97%. A single test at presentation using a threshold at or near the assay limit of detection could reliably rule-out NSTEMI for a range of hs-cTn assays. Serial testing strategies, which include an immediate rule-out step, increased the proportion ruled out without loss of sensitivity. Finally, serial testing strategies without an immediate rule-out step had excellent sensitivity and specificity, but at the expense of the option for immediate patient discharge. CONCLUSION Test strategies that comprise an initial rule-out step, based on low hs-cTn concentrations at presentation and a minimum symptom duration, and a second step for those not ruled-out that incorporates a small absolute change in hs-cTn at 1, 2, or 3 hours, produce the highest rule-out rates with a very low risk of missed NSTEMI. PROSPERO REGISTRATION CRD42019154716.
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Affiliation(s)
| | | | - Gill Worthy
- Kleijnen Systematic Reviews Ltd, Escrick, York, UK
| | - Debra Fayter
- Kleijnen Systematic Reviews Ltd, Escrick, York, UK
| | - Bram L T Ramaekers
- Department of Clinical Epidemiology and Medical Technology Assessment, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Sabine Grimm
- Department of Clinical Epidemiology and Medical Technology Assessment, Maastricht University Medical Centre, Maastricht, the Netherlands
| | | | - Janine Ross
- Kleijnen Systematic Reviews Ltd, Escrick, York, UK
| | - Nicholas L Mills
- BHF/University Centre for Cardiovascular Science and Usher Institute, The University of Edinburgh, Edinburgh, UK
| | - Richard Body
- Division of Cardiovascular Sciences, The University of Manchester, Manchester, UK
- Emergency Department, Manchester Royal Infirmary, Manchester University NHS Foundation Trust, Manchester, UK
| | - Paul O Collinson
- Departments of Clinical Blood Sciences and Cardiology, St George's University Hospitals NHS Foundation Trust and St George's University of London, UK
| | - Adam Timmis
- Barts Heart Centre, Queen Mary University, London, UK
| | - Jos Kleijnen
- Kleijnen Systematic Reviews Ltd, Escrick, York, UK
- School for Public Health and Primary Care (CAPHRI), Maastricht University, Maastricht, the Netherlands
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30
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Reference limits of high-sensitive cardiac troponin T indirectly estimated by a new approach applying data mining. A special example for measurands with a relatively high percentage of values at or below the detection limit. J LAB MED 2020. [DOI: 10.1515/labmed-2020-0063] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
Abstract
A new model for the indirect estimation of reference limits (RLs) has been proposed recently and was coined TMC approach (truncated minimum chi-square estimation) which can be performed with R statistic. A spline function is applied to the RLs to get a continuous function if age is graphically presented vs. the RLs avoiding artificial “jumps” between different age groups. Most indirect models assume a power normal distribution and fail if this assumption is not fulfilled as e.g. if a relatively high percentage of measured values is below the detection limit and the data are distributed extremely skewed. This problem is handled by the TMC model. High-sensitive cardiac troponin T (hs cTnT) was chosen as an example. The hs cTnT concentration in serum or plasma is well accepted as a valuable marker in the diagnosis of acute myocardial infarction. Currently, the 99th percentile derived from a “healthy” subpopulation is the decision limit recommended by consensus groups. However, this decision limit is questioned by several authors for many reasons. In the present report, the 97.5th and the 99th percentile limits were reinvestigated by the TMC model with different subpopulations stratified according to age and sex and were finally compared to presently recommended decision limits. In summary, the generally recommended 99th percentile as a fixed decision limit should be reconsidered. It is suggested to apply more specific reference limits stratified for age and sex instead of a fixed decision limit.
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31
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Zhao Y, Izadnegahdar M, Lee MK, Kavsak PA, Singer J, Scheuermeyer F, Udell JA, Robinson S, Norris CM, Lyon AW, Pilote L, Cox J, Hassan A, Rychtera A, Johnson D, Mills NL, Christenson J, Humphries KH. High-Sensitivity Cardiac Troponin-Optimizing the Diagnosis of Acute Myocardial Infarction/Injury in Women (CODE-MI): Rationale and design for a multicenter, stepped-wedge, cluster-randomized trial. Am Heart J 2020; 229:18-28. [PMID: 32916606 DOI: 10.1016/j.ahj.2020.06.013] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Accepted: 06/17/2020] [Indexed: 10/24/2022]
Abstract
Despite evidence that high-sensitivity cardiac troponin (hs-cTn) levels in women are lower than in men, a single threshold based on the 99th percentile upper reference limit of the overall reference population is commonly used to diagnose myocardial infarction in clinical practice. This trial aims to determine whether the use of a lower female-specific hs-cTn threshold would improve the diagnosis, treatment, and outcomes of women presenting to the emergency department with symptoms suggestive of myocardial ischemia. METHODS/DESIGN: CODE-MI (hs-cTn-Optimizing the Diagnosis of Acute Myocardial Infarction/Injury in Women) is a multicenter, stepped-wedge, cluster-randomized trial of 30 secondary and tertiary care hospitals across 8 Canadian provinces, with the unit of randomization being the hospital. All adults (≥20 years of age) presenting to the emergency department with symptoms suggestive of myocardial ischemia and at least 1 hs-cTn test are eligible for inclusion. Over five, 5-month intervals, hospitals will be randomized to implement lower female hs-cTn thresholds according to the assay being used at each site. Men will continue to be assessed using the overall thresholds throughout. Women with a peak hs-cTn value between the female-specific and the overall thresholds will form our primary cohort. The primary outcome, a 1-year composite of all-cause mortality or readmission for nonfatal myocardial infarction, incident heart failure, or emergent/urgent coronary revascularization, will be compared before and after the implementation of female thresholds using mixed-effects logistic regression models. The cohort and outcomes will be obtained from routinely collected administrative data. The trial is designed to detect a 20% relative risk difference in the primary outcome, or a 2.2% absolute difference, with 82% power. CONCLUSIONS: This pragmatic trial will assess whether adopting lower female hs-cTn thresholds leads to appropriate assessment of women with symptoms suggestive of myocardial infarction, thereby improving treatment and outcomes.
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32
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Abstract
PURPOSE OF REVIEW To summarize gender- and sex-specific differences in the presentation, diagnosis, management, and pathophysiology of women presenting with acute coronary syndrome (ACS). RECENT FINDINGS Sex differences exist in many aspects of ACS that impact the identification, treatment, and outcomes in women. There are delays in the initiation of care, under recognized diagnostic differences based on sex, and inconsistencies in the management of ACS in women compared with men, that ultimately impact outcomes. Additionally, women with ACS are more likely than men to present with non-obstructive coronary artery disease (CAD), which appears to be due to diverse underlying pathophysiology. Women with ACS face diagnostic and treatment dilemmas from time of symptom onset to hospital discharge. Under-recognition, under-diagnosis, and under-treatment ultimately result in poorer outcomes in women. Underlying pathophysiologic differences in women require additional testing to elucidate underlying etiologies.
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33
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Kimenai DM, Lindahl B, Jernberg T, Bekers O, Meex SJR, Eggers KM. Sex-specific effects of implementing a high-sensitivity troponin I assay in patients with suspected acute coronary syndrome: results from SWEDEHEART registry. Sci Rep 2020; 10:15227. [PMID: 32943674 PMCID: PMC7499170 DOI: 10.1038/s41598-020-72204-2] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Accepted: 08/14/2020] [Indexed: 01/06/2023] Open
Abstract
Using high-sensitivity cardiac troponin (hs-cTn) assays with sex-specific 99th percentiles may improve management of patients with suspected acute myocardial infarction (AMI). We investigated the impact of transitioning from a conventional troponin I assay to a high-sensitivity assay with sex-specific thresholds, in patients with suspected acute coronary syndrome admitted to Swedish coronary care units. Based on data from SWEDEHEART registry (females, n = 4,819/males, n = 7,670), we compared periods before and after implementation of hs-cTnI assay (Abbott) using sex-specific 99th percentiles. We investigated differences on discharge diagnosis, in-hospital examinations, treatments, and clinical outcome. Upon implementation of the hs-cTnI assay, proportion of patients with troponin levels above diagnostic AMI threshold increased in women and men by 24.3% versus 14.8%, respectively. Similarly, incidence of AMI increased by 11.5% and 9.8%. Diagnostic interventions and treatments increased regardless of sex. However, these associations did not persist following multivariable adjustment, probably due to the effect of temporal management trends during the observation period. Overall, no risk reduction on major adverse cardiovascular events was observed (HR: 0.91 [95% CI 0.80-1.03], P = 0.126). The implementation of hs-cTnI assay together with sex-specific 99th percentiles was associated with an increase in incidence of AMI regardless of sex, but had no major impact on clinical management and prognosis.
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Affiliation(s)
- Dorien M Kimenai
- Central Diagnostic Laboratory, Maastricht University Medical Center, Post Office Box 5800, 6202 AZ, Maastricht, The Netherlands.
- CARIM School for Cardiovascular Diseases, Maastricht University, Maastricht, The Netherlands.
| | - Bertil Lindahl
- Department of Medical Sciences, Cardiology, Uppsala University, Uppsala, Sweden
- Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - Tomas Jernberg
- Department of Clinical Sciences, Danderyd University Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Otto Bekers
- Central Diagnostic Laboratory, Maastricht University Medical Center, Post Office Box 5800, 6202 AZ, Maastricht, The Netherlands
- CARIM School for Cardiovascular Diseases, Maastricht University, Maastricht, The Netherlands
| | - Steven J R Meex
- Central Diagnostic Laboratory, Maastricht University Medical Center, Post Office Box 5800, 6202 AZ, Maastricht, The Netherlands
- CARIM School for Cardiovascular Diseases, Maastricht University, Maastricht, The Netherlands
| | - Kai M Eggers
- Department of Medical Sciences, Cardiology, Uppsala University, Uppsala, Sweden
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Lee KK, Ferry AV, Anand A, Strachan FE, Chapman AR, Kimenai DM, Meex SJR, Berry C, Findlay I, Reid A, Cruickshank A, Gray A, Collinson PO, Apple FS, McAllister DA, Maguire D, Fox KAA, Newby DE, Tuck C, Keerie C, Weir CJ, Shah ASV, Mills NL. Sex-Specific Thresholds of High-Sensitivity Troponin in Patients With Suspected Acute Coronary Syndrome. J Am Coll Cardiol 2020; 74:2032-2043. [PMID: 31623760 PMCID: PMC6876271 DOI: 10.1016/j.jacc.2019.07.082] [Citation(s) in RCA: 80] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2019] [Revised: 07/25/2019] [Accepted: 07/28/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND Major disparities between women and men in the diagnosis, management, and outcomes of acute coronary syndrome are well recognized. OBJECTIVES The aim of this study was to evaluate the impact of implementing a high-sensitivity cardiac troponin I assay with sex-specific diagnostic thresholds for myocardial infarction in women and men with suspected acute coronary syndrome. METHODS Consecutive patients with suspected acute coronary syndrome were enrolled in a stepped-wedge, cluster-randomized controlled trial across 10 hospitals. Myocardial injury was defined as high-sensitivity cardiac troponin I concentration >99th centile of 16 ng/l in women and 34 ng/l in men. The primary outcome was recurrent myocardial infarction or cardiovascular death at 1 year. RESULTS A total of 48,282 patients (47% women) were included. Use of the high-sensitivity cardiac troponin I assay with sex-specific thresholds increased myocardial injury in women by 42% and in men by 6%. Following implementation, women with myocardial injury remained less likely than men to undergo coronary revascularization (15% vs. 34%) and to receive dual antiplatelet (26% vs. 43%), statin (16% vs. 26%), or other preventive therapies (p < 0.001 for all). The primary outcome occurred in 18% (369 of 2,072) and 17% (488 of 2,919) of women with myocardial injury before and after implementation, respectively (adjusted hazard ratio: 1.11; 95% confidence interval: 0.92 to 1.33), compared with 18% (370 of 2,044) and 15% (513 of 3,325) of men (adjusted hazard ratio: 0.85; 95% confidence interval: 0.71 to 1.01). CONCLUSIONS Use of sex-specific thresholds identified 5 times more additional women than men with myocardial injury. Despite this increase, women received approximately one-half the number of treatments for coronary artery disease as men, and outcomes were not improved. (High-Sensitivity Troponin in the Evaluation of Patients With Acute Coronary Syndrome [High-STEACS]; NCT01852123).
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Affiliation(s)
- Kuan Ken Lee
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
| | - Amy V Ferry
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
| | - Atul Anand
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
| | - Fiona E Strachan
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
| | - Andrew R Chapman
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
| | - Dorien M Kimenai
- CARIM School for Cardiovascular Diseases, Maastricht University, Maastricht, the Netherlands; Central Diagnostic Laboratory, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Steven J R Meex
- CARIM School for Cardiovascular Diseases, Maastricht University, Maastricht, the Netherlands; Central Diagnostic Laboratory, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Colin Berry
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, United Kingdom
| | - Iain Findlay
- Department of Cardiology, Royal Alexandra Hospital, Paisley, United Kingdom
| | - Alan Reid
- Department of Biochemistry, Queen Elizabeth University Hospital, Glasgow, United Kingdom
| | - Anne Cruickshank
- Department of Biochemistry, Queen Elizabeth University Hospital, Glasgow, United Kingdom
| | - Alasdair Gray
- Emergency Medicine Research Group Edinburgh, Royal Infirmary of Edinburgh, Edinburgh, United Kingdom
| | - Paul O Collinson
- Departments of Clinical Blood Sciences and Cardiology, St. George's, University Hospitals NHS Trust and St. George's University of London, London, United Kingdom
| | - Fred S Apple
- Department of Laboratory Medicine and Pathology, Hennepin County Medical Center & University of Minnesota, Minneapolis, Minnesota
| | - David A McAllister
- Institute of Health and Wellbeing, University of Glasgow, Glasgow, United Kingdom
| | - Donogh Maguire
- Emergency Medicine Department, Glasgow Royal Infirmary, Glasgow, United Kingdom
| | - Keith A A Fox
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
| | - David E Newby
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
| | - Chris Tuck
- Edinburgh Clinical Trials Unit, University of Edinburgh, Edinburgh, United Kingdom
| | - Catriona Keerie
- Edinburgh Clinical Trials Unit, University of Edinburgh, Edinburgh, United Kingdom
| | - Christopher J Weir
- Edinburgh Clinical Trials Unit, University of Edinburgh, Edinburgh, United Kingdom
| | - Anoop S V Shah
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom; Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, United Kingdom
| | - 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, Edinburgh, United Kingdom.
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The European Biological Variation Study (EuBIVAS): weekly biological variation of cardiac troponin I estimated by the use of two different high-sensitivity cardiac troponin I assays. ACTA ACUST UNITED AC 2020; 58:1741-1747. [DOI: 10.1515/cclm-2019-1182] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2019] [Accepted: 03/10/2020] [Indexed: 01/26/2023]
Abstract
Abstract
Background
Cardiac troponins (cTn) are specific markers for cardiac damage and acute coronary syndromes. The availability of new high-sensitivity assays allows cTn detection in healthy people, thus permitting the estimation of biological variation (BV) of cTn. The knowledge of BV is important to define analytical performance specifications (APS) and reference change values (RCVs). The aim of this study was to estimate the within- and between-subject weekly BV (CVI, CVG) of cTnI applying two high-sensitivity cTnI assays, using European Biological Variation Study (EuBIVAS) specimens.
Methods
Thirty-eight men and 53 women underwent weekly fasting blood drawings for 10 consecutive weeks. Duplicate measurements were performed with Singulex Clarity (Singulex, USA) and Siemens Atellica (Siemens Healthineers, Germany).
Results
cTnI was measurable in 99.4% and 74.3% of the samples with Singulex and Atellica assays, respectively. Concentrations were significantly higher in men than in women with both methods. The CVI estimates with 95% confidence interval (CI) were for Singulex 16.6% (15.6–17.7) and for Atellica 13.8% (12.7–15.0), with the observed difference likely being caused by the different number of measurable samples. No significant CVI differences were observed between men and women. The CVG estimates for women were 40.3% and 36.3%, and for men 65.3% and 36.5% for Singulex and Atellica, respectively. The resulting APS and RCVs were similar for the two methods.
Conclusions
This is the first study able to estimate cTnI BV for such a large cohort of well-characterized healthy individuals deriving objective APS and RCV values for detecting significant variations in cTnI serial measurements, even within the 99th percentile.
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Wang XY, Zhang F, Zhang C, Zheng LR, Yang J. The Biomarkers for Acute Myocardial Infarction and Heart Failure. BIOMED RESEARCH INTERNATIONAL 2020; 2020:2018035. [PMID: 32016113 PMCID: PMC6988690 DOI: 10.1155/2020/2018035] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/01/2019] [Revised: 11/05/2019] [Accepted: 12/04/2019] [Indexed: 01/06/2023]
Abstract
The use of a large number of cardiovascular biomarkers, meant to complement the use of the electrocardiogram, echocardiography cardiac imaging, and clinical symptom assessment, has become a routine in clinical diagnosis, differential diagnosis, risk stratification, and prognosis and guides the management of patients with suspected cardiovascular diseases. There is a broad consensus that cardiac troponin and natriuretic peptides are the preferred biomarkers in clinical practice for the diagnosis of the acute coronary syndrome and heart failure, respectively, while the roles and possible clinical applications of several other potential biomarkers are still under study. This review mainly focuses on the recent studies of the roles and clinical applications of troponin and natriuretic peptides, which seem to be the best-validated markers in distinguishing and predicting the future cardiac events of patients with suspected cardiovascular diseases. Additionally, the review briefly discusses some of the large number of potential markers that may play a more prominent role in the future.
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Affiliation(s)
- Xi-Ying Wang
- Department of Cardiology, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Fen Zhang
- Department of Cardiology, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Chi Zhang
- Department of Cardiology, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Liang-Rong Zheng
- Department of Cardiology, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Jian Yang
- Department of Cardiology, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
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Lee KK, Shah ASV. High-sensitivity cardiac troponin: a double-edged sword. EUROPEAN HEART JOURNAL. QUALITY OF CARE & CLINICAL OUTCOMES 2020; 6:3-4. [PMID: 31263882 DOI: 10.1093/ehjqcco/qcz033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Affiliation(s)
- Kuan Ken Lee
- BHF Centre for Cardiovascular Science, University of Edinburgh, SU.305 Chancellor's Building, 49 Little France Crescent, Edinburgh EH16 4SB, UK
| | - Anoop S V Shah
- BHF Centre for Cardiovascular Science, University of Edinburgh, SU.305 Chancellor's Building, 49 Little France Crescent, Edinburgh EH16 4SB, UK
- Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK
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Performance of a novel high sensitivity cardiac troponin I assay in asymptomatic hemodialysis patients – evidence for sex-specific differences. ACTA ACUST UNITED AC 2019; 57:1261-1270. [DOI: 10.1515/cclm-2018-1176] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2018] [Accepted: 02/14/2019] [Indexed: 11/15/2022]
Abstract
Abstract
Background
High sensitivity assays for the determination of cardiac troponin I (cTnI) are able to reliably measure cTnI far below the 99th percentile of healthy persons (hs-cTnI) and display sex-specific differences. There is uncertainty regarding the clinical utility of hs-cTnI in asymptomatic hemodialysis (HD) patients and if sex-specific differences also apply in this cohort.
Methods
In this multicenter study we measured hs-cTnI and sensitive cTnI (s-TnI) concentrations (both on Siemens Centaur) in 215 HD patients from a predialytic sample to determine the prevalence of elevated concentrations above the 99th percentile, the association with baseline characteristics, prognostic accuracy for death, and sex-specific differences.
Results
Hs-cTnI and s-cTnI concentrations were below the 99th percentile in 93% and 85% of patients with a median concentration of 12 ng/L (interquartile range 7–66) and 19 ng/L (12; 31, p < 0.0001). Hs-cTnI and s-cTnI concentrations were independently associated with age (p < 0.05) and ischemic cardiac disease (p < 0.05), but not with residual renal function. Both hs-cTnI and s-cTnI were predictors of death after median follow-up of 2.6 years with an AUC of 0.733 and 0.744, respectively (both p < 0.0001). Important sex-differences emerged for hs-cTnI, but not for s-cTnI: first, women had significantly lower hs-cTnI concentrations than men (p = 0.03); second, hs-cTnI had significantly higher prognostic accuracy for death in women than for men (AUC 0.824 vs. 0.674, p = 0.04).
Conclusions
The majority of HD patients have (h)s-cTnI concentrations below the 99th percentile. High normal values are predictive of death. Hs-cTnI allows to elucidate important sex-differences in HD patients with lower concentrations and higher prognostic accuracy in women.
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Raparelli V, Romiti GF, Basili S. Editorial commentary: Marital status and cardiovascular disease: Can a soulmate prevent a "broken heart"? Trends Cardiovasc Med 2019; 30:221-222. [PMID: 31300253 DOI: 10.1016/j.tcm.2019.06.007] [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: 06/19/2019] [Accepted: 06/19/2019] [Indexed: 11/29/2022]
Affiliation(s)
- Valeria Raparelli
- Department of Experimental Medicine, Sapienza - University of Rome, Rome, Italy; Center for Outcomes Research and Evaluation, Research Institute-McGill University Health Centre, Montreal, Quebec, Canada
| | - Giulio Francesco Romiti
- Department of Internal Medicine and Medical Specialties, Sapienza - University of Rome, Rome, Italy
| | - Stefania Basili
- Department of Translational and Precision Medicine, Sapienza - University of Rome, Rome, Italy.
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Ramos HR, López LE, Castro WQ, Serra CMJ. High-sensitivity cardiac troponins: sex-specific values in clinical practice. Precision or confusion? Hellenic J Cardiol 2019; 60:171-177. [DOI: 10.1016/j.hjc.2019.02.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2018] [Revised: 02/04/2019] [Accepted: 02/27/2019] [Indexed: 02/06/2023] Open
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Ognissanti D, Bjurman C, Holzmann MJ, Theodorsson E, Petzold M, Cvijovic M, Hammarsten O. Cardiac troponin T concentrations and patient-specific risk of myocardial infarction using the novel PALfx parameter. Clin Biochem 2019; 66:21-28. [DOI: 10.1016/j.clinbiochem.2019.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2018] [Revised: 01/23/2019] [Accepted: 02/03/2019] [Indexed: 11/16/2022]
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Aw TC, Huang WT, Le TT, Pua CJ, Ang B, Phua SK, Yeo KK, Cook SA, Chin CWL. High-Sensitivitycardiac Troponinsin Cardio-Healthy Subjects: A Cardiovascular Magnetic Resonance Imaging Study. Sci Rep 2018; 8:15409. [PMID: 30337631 PMCID: PMC6194119 DOI: 10.1038/s41598-018-33850-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2018] [Accepted: 10/07/2018] [Indexed: 12/22/2022] Open
Abstract
The 99th percentile upper reference limits (URL) of high-sensitivity cardiac troponin (hs-cTn) in healthy subjects are essential for diagnosis and management of cardiovascular diseases. Unless screened stringently, subclinical disease affects the derived URL. In 779 healthy subjects(49% males; 17-88 years) screened by cardiovascular magnetic resonance (CMR), the gold standard for assessing cardiac volumes and myocardial mass; and estimated glomerular filtration rate (eGFR), the 99th percentile URL of hsTnT (Roche) and hs-cTnI (Abbott) were similar to the published URL. The overall 99th percentile URL of hsTnT and hsTnI were 15.2 and 21.2 ng/L, respectively; males had higher values than females (hsTnT: 16.8 versus 11.9 ng/L and hsTnI: 38.8 versus 14.4 ng/L). Correlation between hsTnT and hsTnI was modest (r = 0.45; p < 0.001). A larger proportion of healthy volunteers <60 years had detectable hsTnI compared to hsTnT (n = 534; 30.0% versus 18.3%, p < 0.001). Lower eGFR was an independent clinical determinant of hsTnT, but not hsTnI. Both hs-cTn concentrations were independently associated with myocardial mass and cardiac volumes (p < 0.01 for all), but only hsTnI was independently associated with CMR multi-directional strain measures and extent of LV trabeculations (p < 0.05 for all). Differences exist between hs-cTn assays and may influence their selection depending on cardiac conditions, patient population and local factors.
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Affiliation(s)
- Tar-Choon Aw
- Department of Laboratory Medicine, Changi General Hospital, 2 Simei Street 3, Singapore, 529889, Singapore.
| | - Wei-Ting Huang
- Department of Cardiology, National Heart Center Singapore, 5 Hospital Drive, Singapore, 169609, Singapore
| | - Thu-Thao Le
- Department of Cardiology, National Heart Center Singapore, 5 Hospital Drive, Singapore, 169609, Singapore
| | - Chee-Jian Pua
- Department of Cardiology, National Heart Center Singapore, 5 Hospital Drive, Singapore, 169609, Singapore
| | - Briana Ang
- Department of Cardiology, National Heart Center Singapore, 5 Hospital Drive, Singapore, 169609, Singapore
| | - Soon-Kieng Phua
- Department of Laboratory Medicine, Changi General Hospital, 2 Simei Street 3, Singapore, 529889, Singapore
| | - Khung-Keong Yeo
- Department of Cardiology, National Heart Center Singapore, 5 Hospital Drive, Singapore, 169609, Singapore
| | - Stuart A Cook
- Department of Cardiology, National Heart Center Singapore, 5 Hospital Drive, Singapore, 169609, Singapore.,Duke-NUS Medical School, Singapore, Singapore
| | - Calvin W L Chin
- Department of Cardiology, National Heart Center Singapore, 5 Hospital Drive, Singapore, 169609, Singapore.,Duke-NUS Medical School, Singapore, Singapore
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Mueller T, Egger M, Peer E, Jani E, Dieplinger B. Evaluation of sex-specific cut-off values of high-sensitivity cardiac troponin I and T assays in an emergency department setting - Results from the Linz Troponin (LITROP) study. Clin Chim Acta 2018; 487:66-74. [PMID: 30227114 DOI: 10.1016/j.cca.2018.09.026] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2018] [Revised: 08/24/2018] [Accepted: 09/13/2018] [Indexed: 11/18/2022]
Abstract
BACKGROUND The aim of the present analysis was to evaluate sex-specific cut-off values of a high-sensitivity cardiac troponin T (hs-cTnT) assay and a high-sensitivity cardiac troponin I (hs-cTnI) assay in an emergency department setting. METHODS We retrospectively studied 1945 male and 1643 female emergency department patients in whom we had measured both Roche hs-cTnT and Abbott hs-cTnI routinely upon every troponin measurement request. We performed reclassification analyses of sex-specific thresholds versus sex-neutral thresholds of both assays. In addition, we performed sensitivity analyses to find those sex-specific cut-off values for the Roche hs-cTnT and the Abbott hs-cTnI assays with the lowest possible rate of discordant classifications by both assays. RESULTS Compared with the classification by the sex-neutral thresholds (i.e., 14 ng/L for hs-cTnT and 26 ng/L for hs-cTnI), using sex-specific thresholds (i.e., 16 ng/L in males and 9 ng/L in females for hs-cTnT; and in 34 ng/L males and 16 ng/L in females for hs-cTnI) resulted in a total reclassification rate of 4% for hs-cTnT and 3% for hs-cTnI in male individuals, and of 11% and 6%, respectively, in female individuals. In our cohort, the sex-specific hs-cTnT cut-off values currently in use (i.e., 16 ng/L in males and 9 ng/L in females) were best matched to a hs-cTnI cut-off value of 11 ng/L in male and 5 ng/L in female individuals. Conversely, the sex-specific hs-cTnI cut-off values currently in use (i.e., 34 ng/L in males and 16 ng/L in females) were best matched to a hs-cTnT cut-off value of 49 ng/L in male and 24 ng/L in female individuals. These "harmonised" cut-off values reduced discordant classifications between both assays by 43-68% compared to using cut-off values currently in use. CONCLUSION Especially in women, reclassification rates were high, when using sex specific versus sex-neutral thresholds. Best matching cut-off values for hs-cTnT and hs-cTnI were markedly different to those currently in use. These "harmonised" cut-off values minimised discordant classifications between both assays.
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Affiliation(s)
- Thomas Mueller
- Department of Clinical Pathology, Hospital of Bolzano, Bolzano, Italy.
| | - Margot Egger
- Department of Laboratory Medicine, Konventhospital Barmherzige Brueder Linz, Linz, Austria
| | - Evi Peer
- Department of Clinical Pathology, Hospital of Bolzano, Bolzano, Italy
| | - Erika Jani
- Department of Clinical Pathology, Hospital of Bolzano, Bolzano, Italy
| | - Benjamin Dieplinger
- Department of Laboratory Medicine, Konventhospital Barmherzige Brueder Linz, Linz, Austria
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Shah ASV, Anand A, Strachan FE, Ferry AV, Lee KK, Chapman AR, Sandeman D, Stables CL, Adamson PD, Andrews JPM, Anwar MS, Hung J, Moss AJ, O'Brien R, Berry C, Findlay I, Walker S, Cruickshank A, Reid A, Gray A, Collinson PO, Apple FS, McAllister DA, Maguire D, Fox KAA, Newby DE, Tuck C, Harkess R, Parker RA, Keerie C, Weir CJ, Mills NL. High-sensitivity troponin in the evaluation of patients with suspected acute coronary syndrome: a stepped-wedge, cluster-randomised controlled trial. Lancet 2018; 392:919-928. [PMID: 30170853 PMCID: PMC6137538 DOI: 10.1016/s0140-6736(18)31923-8] [Citation(s) in RCA: 233] [Impact Index Per Article: 38.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2018] [Revised: 08/08/2018] [Accepted: 08/10/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND High-sensitivity cardiac troponin assays permit use of lower thresholds for the diagnosis of myocardial infarction, but whether this improves clinical outcomes is unknown. We aimed to determine whether the introduction of a high-sensitivity cardiac troponin I (hs-cTnI) assay with a sex-specific 99th centile diagnostic threshold would reduce subsequent myocardial infarction or cardiovascular death in patients with suspected acute coronary syndrome. METHODS In this stepped-wedge, cluster-randomised controlled trial across ten secondary or tertiary care hospitals in Scotland, we evaluated the implementation of an hs-cTnI assay in consecutive patients who had been admitted to the hospitals' emergency departments with suspected acute coronary syndrome. Patients were eligible for inclusion if they presented with suspected acute coronary syndrome and had paired cardiac troponin measurements from the standard care and trial assays. During a validation phase of 6-12 months, results from the hs-cTnI assay were concealed from the attending clinician, and a contemporary cardiac troponin I (cTnI) assay was used to guide care. Hospitals were randomly allocated to early (n=5 hospitals) or late (n=5 hospitals) implementation, in which the high-sensitivity assay and sex-specific 99th centile diagnostic threshold was introduced immediately after the 6-month validation phase or was deferred for a further 6 months. Patients reclassified by the high-sensitivity assay were defined as those with an increased hs-cTnI concentration in whom cTnI concentrations were below the diagnostic threshold on the contemporary assay. The primary outcome was subsequent myocardial infarction or death from cardiovascular causes at 1 year after initial presentation. Outcomes were compared in patients reclassified by the high-sensitivity assay before and after its implementation by use of an adjusted generalised linear mixed model. This trial is registered with ClinicalTrials.gov, number NCT01852123. FINDINGS Between June 10, 2013, and March 3, 2016, we enrolled 48 282 consecutive patients (61 [SD 17] years, 47% women) of whom 10 360 (21%) patients had cTnI concentrations greater than those of the 99th centile of the normal range of values, who were identified by the contemporary assay or the high-sensitivity assay. The high-sensitivity assay reclassified 1771 (17%) of 10 360 patients with myocardial injury or infarction who were not identified by the contemporary assay. In those reclassified, subsequent myocardial infarction or cardiovascular death within 1 year occurred in 105 (15%) of 720 patients in the validation phase and 131 (12%) of 1051 patients in the implementation phase (adjusted odds ratio for implementation vs validation phase 1·10, 95% CI 0·75 to 1·61; p=0·620). INTERPRETATION Use of a high-sensitivity assay prompted reclassification of 1771 (17%) of 10 360 patients with myocardial injury or infarction, but was not associated with a lower subsequent incidence of myocardial infarction or cardiovascular death at 1 year. Our findings question whether the diagnostic threshold for myocardial infarction should be based on the 99th centile derived from a normal reference population. FUNDING The British Heart Foundation.
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Affiliation(s)
- Anoop S V Shah
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK; Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK
| | - Atul Anand
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Fiona E Strachan
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Amy V Ferry
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Kuan Ken Lee
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Andrew R Chapman
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | | | - Catherine L Stables
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Philip D Adamson
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Jack P M Andrews
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Mohamed S Anwar
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - John Hung
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Alistair J Moss
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Rachel O'Brien
- Emergency Medicine Research Group of Edinburgh, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Colin Berry
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Iain Findlay
- Department of Cardiology, Royal Alexandra Hospital, Paisley, UK
| | - Simon Walker
- Department of Clinical Biochemistry, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Anne Cruickshank
- Department of Biochemistry, Queen Elizabeth University Hospital, Glasgow, UK
| | - Alan Reid
- Department of Biochemistry, Queen Elizabeth University Hospital, Glasgow, UK
| | - Alasdair Gray
- Emergency Medicine Research Group of Edinburgh, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Paul O Collinson
- Department of Clinical Blood Sciences and Department of Cardiology, St George's University Hospitals NHS Trust and St George's University of London, London, UK
| | - Fred S Apple
- Department of Laboratory Medicine and Pathology, Hennepin County Medical Center and University of Minnesota, Minneapolis, MN, USA
| | | | - Donogh Maguire
- Emergency Medicine Department, Glasgow Royal Infirmary, Glasgow, UK
| | - Keith A A Fox
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - David E Newby
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Christopher Tuck
- Edinburgh Clinical Trials Unit, University of Edinburgh, Edinburgh, UK
| | - Ronald Harkess
- Edinburgh Clinical Trials Unit, University of Edinburgh, Edinburgh, UK
| | - Richard A Parker
- Edinburgh Clinical Trials Unit, University of Edinburgh, Edinburgh, UK
| | - Catriona Keerie
- Edinburgh Clinical Trials Unit, University of Edinburgh, Edinburgh, UK
| | | | - Nicholas L Mills
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK; Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK.
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