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Ameh A, Brady JJ. Reference intervals for high sensitivity cardiac troponin I and N-terminal pro-B-type natriuretic peptide in children and adolescents on the Siemens Atellica. Clin Chem Lab Med 2024; 62:1636-1642. [PMID: 38373095 DOI: 10.1515/cclm-2023-0977] [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: 09/04/2023] [Accepted: 02/07/2024] [Indexed: 02/21/2024]
Abstract
OBJECTIVES The cardiac biomarkers high sensitivity cardiac troponin I (hs-cTnI) and N-terminal pro-B-type natriuretic peptide (NT-proBNP) are utilised in paediatric healthcare for the diagnosis and prognostic assessment of many conditions including myocarditis, congenital heart disease, multisystem inflammatory syndrome in children (MIS-C) and heart failure. However, the standardised age-related reference intervals, 99th percentile cut-offs and clinical guidelines are not available, making the interpretation of these biomarkers challenging. This study aimed to generate normative data in a paediatric cohort for the Siemens Atellica® IM 1300 analyser. METHODS Residual plasma samples were collected from children aged up to 17 years attending primary care and out-patient settings and with no apparent evidence of cardiac dysfunction, renal dysfunction or other confounders. Reference intervals were generated using the 2.5th-97.5th percentiles, and 99th percentile cut-offs determined according to CLSI EP28-A3c. RESULTS Statistical analysis revealed that partitioning was not required for gender for either biomarker. The reference interval for hs-cTnI for children aged one month to 16 years (n=292, 146 females and 146 males) was <14 ng/L with a 99th percentile cut-off of 19 ng/L. The reference interval for NT-proBNP for children aged one month up to one year was <714 ng/L (n=14) and for children aged 1-16 years (n=339) was <295 ng/L. CONCLUSIONS This is the first paediatric reference interval data generated on the Siemens Atellica® solution. These reference intervals and 99th percentiles will inform clinical decisions in the paediatric cardiology setting.
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Affiliation(s)
- Akoji Ameh
- Department of Biochemistry, Children's Health Ireland at Crumlin, Dublin, Republic of Ireland
| | - Jennifer J Brady
- Department of Biochemistry, Children's Health Ireland at Crumlin, Dublin, Republic of Ireland
- School of Medicine, University College Dublin, Dublin, Ireland
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2
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Cullen L, Greenslade J, Parsonage W, Stephensen L, Smith SW, Sandoval Y, Ranasinghe I, Gaikwad N, Khorramshahi Bayat M, Mahmoodi E, Schulz K, Than M, Apple FS. Point-of-care high-sensitivity cardiac troponin in suspected acute myocardial infarction assessed at baseline and 2 h. Eur Heart J 2024; 45:2508-2515. [PMID: 38842324 DOI: 10.1093/eurheartj/ehae343] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Revised: 04/15/2024] [Accepted: 05/16/2024] [Indexed: 06/07/2024] Open
Abstract
BACKGROUND AND AIMS Strategies to assess patients with suspected acute myocardial infarction (AMI) using a point-of-care (POC) high-sensitivity cardiac troponin I (hs-cTnI) assay may expedite emergency care. A 2-h POC hs-cTnI strategy for emergency patients with suspected AMI was derived and validated. METHODS In two international, multi-centre, prospective, observational studies of adult emergency patients (1486 derivation cohort and 1796 validation cohort) with suspected AMI, hs-cTnI (Siemens Atellica® VTLi) was measured at admission and 2 h later. Adjudicated final diagnoses utilized the hs-cTn assay in clinical use. A risk stratification algorithm was derived and validated. The primary diagnostic outcome was index AMI (Types 1 and 2). The primary safety outcome was 30-day major adverse cardiac events incorporating AMI and cardiac death. RESULTS Overall, 81 (5.5%) and 88 (4.9%) patients in the derivation and validation cohorts, respectively, had AMI. The 2-h algorithm defined 66.1% as low risk with a sensitivity of 98.8% [95% confidence interval (CI) 89.3%-99.9%] and a negative predictive value of 99.9 (95% CI 99.2%-100%) for index AMI in the derivation cohort. In the validation cohort, 53.3% were low risk with a sensitivity of 98.9% (95% CI 92.4%-99.8%) and a negative predictive value of 99.9% (95% CI 99.3%-100%) for index AMI. The high-risk metrics identified 5.4% of patients with a specificity of 98.5% (95% CI 96.6%-99.4%) and a positive predictive value of 74.5% (95% CI 62.7%-83.6%) for index AMI. CONCLUSIONS A 2-h algorithm using a POC hs-cTnI concentration enables safe and efficient risk assessment of patients with suspected AMI. The short turnaround time of POC testing may support significant efficiencies in the management of the large proportion of emergency patients with suspected AMI.
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Affiliation(s)
- Louise Cullen
- Emergency and Trauma Centre, Royal Brisbane and Women's Hospital, Butterfield Street, Herston, 4029 Queensland, Australia
- Australian Centre for Health Services Innovation, Centre for Healthcare Transformation, School of Public Health and Social Work, Faculty of Health, Queensland University of Technology, Musk Avenue, Kelvin Grove, 4059 Queensland, Australia
- Faculty of Medicine, The University of Queensland, Herston Road, Herston, 4006 Queensland, Australia
| | - Jaimi Greenslade
- Emergency and Trauma Centre, Royal Brisbane and Women's Hospital, Butterfield Street, Herston, 4029 Queensland, Australia
- Australian Centre for Health Services Innovation, Centre for Healthcare Transformation, School of Public Health and Social Work, Faculty of Health, Queensland University of Technology, Musk Avenue, Kelvin Grove, 4059 Queensland, Australia
- Faculty of Medicine, The University of Queensland, Herston Road, Herston, 4006 Queensland, Australia
| | - William Parsonage
- Australian Centre for Health Services Innovation, Centre for Healthcare Transformation, School of Public Health and Social Work, Faculty of Health, Queensland University of Technology, Musk Avenue, Kelvin Grove, 4059 Queensland, Australia
- Department of Cardiology, Royal Brisbane and Women's Hospital, Brisbane, Australia
| | - Laura Stephensen
- Emergency and Trauma Centre, Royal Brisbane and Women's Hospital, Butterfield Street, Herston, 4029 Queensland, Australia
| | - Stephen W Smith
- Department of Emergency Medicine at Hennepin Healthcare/Hennepin County Medical Center, University of Minnesota School of Medicine, Minneapolis, MN, USA
| | - Yader Sandoval
- Minneapolis Heart Institute, Abbott Northwestern Hospital and Center for Coronary Artery Disease, Minneapolis Heart Institute Foundation, Minneapolis, MN, USA
| | - Isuru Ranasinghe
- Faculty of Medicine, The University of Queensland, Herston Road, Herston, 4006 Queensland, Australia
- Department of Cardiology, The Prince Charles Hospital, Brisbane, Australia
| | - Niranjan Gaikwad
- Department of Cardiology, The Prince Charles Hospital, Brisbane, Australia
| | | | - Ehsan Mahmoodi
- Department of Cardiology, The Prince Charles Hospital, Brisbane, Australia
| | - Karen Schulz
- Department of Laboratory Medicine and Pathology, University of Minnesota, Minneapolis, MN, USA
| | - Martin Than
- Emergency Department, Christchurch Hospital, Christchurch, New Zealand
| | - Fred S Apple
- Department of Laboratory Medicine and Pathology, University of Minnesota, Minneapolis, MN, USA
- Clinical and Forensic Toxicology Laboratory, Hennepin Healthcare/Hennepin County Medical Center, Minneapolis, MN, USA
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Lehmacher J, Sörensen NA, Twerenbold R, Goßling A, Haller PM, Hartikainen TS, Schock A, Toprak B, Zeller T, Westermann D, Neumann JT. Diagnostic and prognostic value of the sex-specific 99th percentile of four high-sensitivity cardiac troponin assays in patients with suspected myocardial infarction. EUROPEAN HEART JOURNAL. ACUTE CARDIOVASCULAR CARE 2024; 13:3-12. [PMID: 37890108 DOI: 10.1093/ehjacc/zuad131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Revised: 09/28/2023] [Accepted: 10/23/2023] [Indexed: 10/29/2023]
Abstract
AIMS High-sensitivity cardiac troponin (hs-cTn) assays are used for detection of myocardial infarction (MI). Ninety-ninth percentiles show wide inter-assay variation. The use of sex-specific cut-offs is recommended as definitory cut-off for MI. We compared diagnostic performance and prognostic value of sex-specific 99th percentiles of four hs-cTn assays in patients with suspected MI. METHODS AND RESULTS Concentrations of four hs-cTn assays were measured at presentation and after 3 h in patients with suspected MI. Final diagnoses were adjudicated according to the 4th Universal Definition of MI. Unisex and sex-specific 99th percentiles were evaluated as diagnostic cut-offs following the ESC 0/3 h algorithm. These cut-offs were used in Cox-regression analyses to investigate the association with a composite endpoint of MI, revascularization, cardiac rehospitalization, and death. Non-ST-elevation MI was diagnosed in 368 of 2718 patients. Applying the unisex 99th percentile, Elecsys hs-cTnT provided highest negative predictive value (NPV) of 99.7 and a positive predictive value (PPV) of 75.9. The analysed hs-cTnI assays showed slightly lower NPVs and comparable PPVs [Architect (NPV 98.0, PPV of 71.4); Atellica (NPV 97.7, PPV of 76.1); Pathfast (NPV 97.7, PPV of 66.6)]. Application of sex-specific 99th percentiles did not significantly affect diagnostic performance. Concentrations above 99th percentile were independent predictors for impaired long-term outcome (hazard ratios 1.2-1.5, P < 0.001). CONCLUSION We describe a good diagnostic accuracy of four hs-cTn assays using the assay-specific 99th percentile for detection of MI. Application of sex-specific 99th percentiles did neither affect diagnostic performance nor prognostic value significantly. Finally, values above the 99th percentile were associated with poor long-term outcome.
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Affiliation(s)
- Jonas Lehmacher
- Department of Cardiology, University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246 Hamburg, Germany
- Deutsches Zentrum für Herz-Kreislauf-Forschung (DZHK), site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - Nils Arne Sörensen
- Department of Cardiology, University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246 Hamburg, Germany
- Deutsches Zentrum für Herz-Kreislauf-Forschung (DZHK), site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - Raphael Twerenbold
- Department of Cardiology, University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246 Hamburg, Germany
- Deutsches Zentrum für Herz-Kreislauf-Forschung (DZHK), site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - Alina Goßling
- Department of Cardiology, University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246 Hamburg, Germany
| | - Paul Michael Haller
- Department of Cardiology, University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246 Hamburg, Germany
- Deutsches Zentrum für Herz-Kreislauf-Forschung (DZHK), site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - Tau Sarra Hartikainen
- Deutsches Zentrum für Herz-Kreislauf-Forschung (DZHK), site Hamburg/Kiel/Lübeck, Hamburg, Germany
- Department of Cardiology, University Heart Center Freiburg, Bad Krozingen, Germany
| | - Alina Schock
- Department of Cardiology, University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246 Hamburg, Germany
| | - Betül Toprak
- Department of Cardiology, University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246 Hamburg, Germany
- Deutsches Zentrum für Herz-Kreislauf-Forschung (DZHK), site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - Tanja Zeller
- Department of Cardiology, University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246 Hamburg, Germany
- Deutsches Zentrum für Herz-Kreislauf-Forschung (DZHK), site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - Dirk Westermann
- Deutsches Zentrum für Herz-Kreislauf-Forschung (DZHK), site Hamburg/Kiel/Lübeck, Hamburg, Germany
- Department of Cardiology, University Heart Center Freiburg, Bad Krozingen, Germany
| | - Johannes Tobias Neumann
- Department of Cardiology, University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246 Hamburg, Germany
- Deutsches Zentrum für Herz-Kreislauf-Forschung (DZHK), site Hamburg/Kiel/Lübeck, Hamburg, Germany
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, 553 St Kilda Road, Melbourne, VIC 3004, Australia
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Byrne RA, Rossello X, Coughlan JJ, Barbato E, Berry C, Chieffo A, Claeys MJ, Dan GA, Dweck MR, Galbraith M, Gilard M, Hinterbuchner L, Jankowska EA, Jüni P, Kimura T, Kunadian V, Leosdottir M, Lorusso R, Pedretti RFE, Rigopoulos AG, Rubini Gimenez M, Thiele H, Vranckx P, Wassmann S, Wenger NK, Ibanez B. 2023 ESC Guidelines for the management of acute coronary syndromes. EUROPEAN HEART JOURNAL. ACUTE CARDIOVASCULAR CARE 2024; 13:55-161. [PMID: 37740496 DOI: 10.1093/ehjacc/zuad107] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/24/2023]
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Koechlin L, Boeddinghaus J, Lopez-Ayala P, Wildi K, Nestelberger T, Wussler D, Guzman Tacla CA, Holder T, Muench-Gerber T, Glaeser J, Sanchez AY, Miró Ò, Martin-Sanchez FJ, Kawecki D, Buergler F, Buser A, Huré G, Giménez MR, Keller DI, Christ M, Mueller C. External validation of the 0/1h-algorithm and derivation of a 0/2h-algorithm using a new point-of-care Hs-cTnI assay. Am Heart J 2024; 268:104-113. [PMID: 38042459 DOI: 10.1016/j.ahj.2023.11.014] [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: 07/05/2023] [Revised: 11/14/2023] [Accepted: 11/18/2023] [Indexed: 12/04/2023]
Abstract
BACKGROUND The high-sensitivity cardiac troponin (hs-cTn) I point-of-care (POC) hs-cTnI-PATHFAST assay has recently become clinically available. METHODS We aimed to externally validate the hs-cTnI-PATHFAST 0/1h-algorithm recently developed for the early diagnosis of non-ST-segment-elevation myocardial infarction (NSTEMI) and derive and validate a 0/2-algorithm in patients presenting to the emergency department with acute chest discomfort included in a multicenter diagnostic study. Two independent cardiologists centrally adjudicated the final diagnoses using all the clinical and study-specific information available including serial measurements of hs-cTnI-Architect. RESULTS Among 1,532 patients (median age 60 years, 33% [n = 501] women), NSTEMI was the final diagnosis in 13%. External validation of the hs-cTnI-PATHFAST 0/1h-algorithm showed very high negative predictive value (NPV; 100% [95%CI, 99.5%-100%]) and sensitivity 100% (95%CI, 98.2%-100%) for rule-out of NSTEMI. Positive predictive value (PPV) and specificity for rule-in of NSTEMI were high (74.9% [95%CI, 68.3%-80.5%] and 96.4% [95%CI, 95.2%-97.3%], respectively). Among 1,207 patients (median age 61 years, 32% [n = 391] women) available for the derivation (n = 848) and validation (n = 359) of the hs-cTnI-PATHFAST 0/2h-algorithm, a 0h-concentration <3 ng/L or a 0h-concentration <4 ng/L with a 2h-delta <4ng/L ruled-out NSTEMI in 52% of patients with a NPV of 100% (95%CI, 98-100) and sensitivity of 100% (95%CI, 92.9%-100%) in the validation cohort. A 0h-concentration ≥90ng/L or a 2h-delta ≥ 55ng/L ruled-in 38 patients (11%): PPV 81.6% (95%CI, 66.6-90.8), specificity 97.7% (95%CI, 95.4-98.9%). CONCLUSIONS The POC hs-cTnI-PATHFAST assay allows rapid and effective rule-out and rule-in of NSTEMI using both a 0/1h- and a 0/2h-algorithm with high NPV/sensitivity for rule-out and high PPV/specificity for rule-in. CLINICAL TRIAL REGISTRATION NCT00470587.
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Affiliation(s)
- Luca Koechlin
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland; Department of Cardiac Surgery, University Hospital Basel, University of Basel, Switzerland; GREAT network.
| | - Jasper Boeddinghaus
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland; GREAT network; BHF/University Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
| | - Pedro Lopez-Ayala
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland; GREAT network
| | - Karin Wildi
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland; GREAT network; Critical Care Research Group and the University of Queensland, Brisbane, Queensland, Australia
| | - Thomas Nestelberger
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland; GREAT network
| | - Desiree Wussler
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland; GREAT network
| | - Caroline A Guzman Tacla
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland; GREAT network
| | - Timothy Holder
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Tamar Muench-Gerber
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland; GREAT network
| | - Jonas Glaeser
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland; GREAT network
| | - Ana Yufera Sanchez
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland; GREAT network
| | - Òscar Miró
- GREAT network; Emergency Department, Hospital Clinic, Barcelona, Catalonia, Spain
| | | | - Damian Kawecki
- GREAT network; 2nd Department of Cardiology, School of Medicine with the Division of Dentistry in Zabrze, Medical University of Katowice, Zabrze, Poland
| | - Franz Buergler
- Emergency Department, Kantonsspital Liestal, LIestal, Switzerland
| | - Andreas Buser
- Department of hematology and Blood Bank, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Gabrielle Huré
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland; GREAT network
| | - Maria Rubini Giménez
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland; Department of Cardiology, Heart Center Leipzig, University of Leipzig, Leipzig, Germany
| | - Dagmar I Keller
- Emergency Department, University Hospital Zurich, Zurich, Switzerland
| | - Michael Christ
- Emergency Department, Kantonsspital Luzern, Luzern, Switzerland
| | - Christian Mueller
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland; GREAT network.
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Metsu D, Mille D, Pailly C, Oancea VG, Essemilaire L, Coppin D. Analytical assays and bootstrap resampling method to validate performance of the Roche Elecsys STAT highly sensitive troponin T assay and its application for the 'rule-out' part of ESC guidelines for NTSTEMI. Ann Clin Biochem 2024; 61:63-69. [PMID: 37525403 DOI: 10.1177/00045632231194449] [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: 08/02/2023]
Abstract
BACKGROUND The European Society of Cardiology (ESC) guidelines recommend a dynamic (0-1h) cardiac troponin (cTn) determination for non-ST elevation myocardial infarction diagnosis. For patients with low cTn levels, a discharge from emergency can be considered. Nevertheless, cTn cutoffs for discharge are lower than the limits of quantification proposed by laboratory reagent suppliers. AIM Validate cTn assay on the Elecsys STAT kit. MATERIALS AND METHODS Precision, trueness, repeatability and within-laboratory variability were calculated from internal quality control and plasma pooled at 5.78 and 10.73 ng/L. Accuracy was calculated from external quality control. Uncertainty of measurement was calculated from (i) the uncertainty of the standard and control values and (ii) by precision from pooled plasma. Distribution of precision results from pooled plasma has been evaluated by bootstrap simulations. Dilution linearity tests with patient plasma were performed to evaluate the method for values near 5 ng/L. RESULTS Precision and trueness ranged from 1.35 to 4.45% and from 0.14 to -3.74%, respectively. Accuracy results ranged from 101.40 to 104.90%. Within laboratory variability was 2.91%. Uncertainty ranged from 3.66% to 19.90% for higher (2188) to lower values (5.78 ng/L). Bootstrap simulations allowed utilization of precision data from pooled plasma to evaluate cTn assay. The method was linear from 4.48 to 39.80 ng/L. A linear regression model best described the data. CONCLUSION Elecsys STAT method provides accurate cTn results, including patients with cTn results categorizing them as 'rule-out' in the ESC guidelines.
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Affiliation(s)
- David Metsu
- Department of Laboratory Medicine, Montauban Hospital, Montauban, France
| | - Daphné Mille
- Department of Emergency Medicine, Montauban Hospital, Montauban, France
| | - Carole Pailly
- Department of Emergency Medicine, Montauban Hospital, Montauban, France
| | - Valerica G Oancea
- Department of Laboratory Medicine, Montauban Hospital, Montauban, France
- Université Toulouse III, Toulouse University Hospital, Toulouse, France
| | - Luc Essemilaire
- Accredited Medical Laboratories Network (LABAC), Lyon, France
| | - Dominique Coppin
- Department of Emergency Medicine, Montauban Hospital, Montauban, France
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Liu L, Lewandrowski K. Establishing optimal cutoff values for high-sensitivity cardiac troponin algorithms in risk stratification of acute myocardial infarction. Crit Rev Clin Lab Sci 2024; 61:1-22. [PMID: 37466395 DOI: 10.1080/10408363.2023.2235426] [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: 03/31/2023] [Revised: 06/11/2023] [Accepted: 07/07/2023] [Indexed: 07/20/2023]
Abstract
Acute myocardial infarction (AMI) is a leading cause of mortality globally, highlighting the need for timely and accurate diagnostic strategies. Cardiac troponin has been the biomarker of choice for detecting myocardial injury. A dynamic change in concentrations supports the diagnosis of AMI in the setting of evidence of acute myocardial ischemia. The new generation of high-sensitivity cardiac troponin (hs-cTn) assays has significantly improved analytical sensitivity but at the expense of decreased clinical specificity. As a result, sophisticated algorithms are required to differentiate AMI from non-AMI patients. Establishing optimal hs-cTn cutoffs for these algorithms to rule out and rule in AMI has been the subject of intensive investigations. These efforts have evolved from examining the utility of the hs-cTn 99th percentile upper reference limit, comparing the percentage versus absolute delta thresholds, and evaluating the performance of an early European Society of Cardiology-recommended 3 h algorithm, to the development of accelerated 1 h and 2 h algorithms that combine the admission hs-cTn concentrations and absolute delta cutoffs to rule out and rule in AMI. Specific cutoffs for individual confounding factors such as sex, age, and renal insufficiency have also been investigated. At the same time, concerns such as whether the small delta thresholds exceed the analytical and biological variations of hs-cTn assays and whether the algorithms developed in European study populations fit all other patient cohorts have been raised. In addition, the accelerated algorithms leave a substantial number of patients in a non-diagnostic observation zone. How to properly diagnose patients falling in this zone and those presenting with elevated baseline hs-cTn concentrations due to the presence of confounding factors or comorbidities remain open questions. Here we discuss the developments described above, focusing on criteria and underlying considerations for establishing optimal cutoffs. In-depth analyses are provided on the influence of biological variation, analytical imprecision, local AMI rate, and the timing of presentation on the performance metrics of the accelerated hs-cTn algorithms. Developing diagnostic strategies for patients who remain in the observation zone and those presenting with confounding factors are also reviewed.
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Affiliation(s)
- Li Liu
- Department of Pathology, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Kent Lewandrowski
- Department of Pathology, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
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8
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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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Byrne RA, Rossello X, Coughlan JJ, Barbato E, Berry C, Chieffo A, Claeys MJ, Dan GA, Dweck MR, Galbraith M, Gilard M, Hinterbuchner L, Jankowska EA, Jüni P, Kimura T, Kunadian V, Leosdottir M, Lorusso R, Pedretti RFE, Rigopoulos AG, Rubini Gimenez M, Thiele H, Vranckx P, Wassmann S, Wenger NK, Ibanez B. 2023 ESC Guidelines for the management of acute coronary syndromes. Eur Heart J 2023; 44:3720-3826. [PMID: 37622654 DOI: 10.1093/eurheartj/ehad191] [Citation(s) in RCA: 498] [Impact Index Per Article: 498.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/26/2023] Open
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10
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Neumann JT, Twerenbold R, Ojeda F, Aldous SJ, Allen BR, Apple FS, Babel H, Christenson RH, Cullen L, Di Carluccio E, Doudesis D, Ekelund U, Giannitsis E, Greenslade J, Inoue K, Jernberg T, Kavsak P, Keller T, Lee KK, Lindahl B, Lorenz T, Mahler SA, Mills NL, Mokhtari A, Parsonage W, Pickering JW, Pemberton CJ, Reich C, Richards AM, Sandoval Y, Than MP, Toprak B, Troughton RW, Worster A, Zeller T, Ziegler A, Blankenberg S. Personalized diagnosis in suspected myocardial infarction. Clin Res Cardiol 2023; 112:1288-1301. [PMID: 37131096 PMCID: PMC10449973 DOI: 10.1007/s00392-023-02206-3] [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: 03/15/2023] [Accepted: 04/11/2023] [Indexed: 05/04/2023]
Abstract
BACKGROUND In suspected myocardial infarction (MI), guidelines recommend using high-sensitivity cardiac troponin (hs-cTn)-based approaches. These require fixed assay-specific thresholds and timepoints, without directly integrating clinical information. Using machine-learning techniques including hs-cTn and clinical routine variables, we aimed to build a digital tool to directly estimate the individual probability of MI, allowing for numerous hs-cTn assays. METHODS In 2,575 patients presenting to the emergency department with suspected MI, two ensembles of machine-learning models using single or serial concentrations of six different hs-cTn assays were derived to estimate the individual MI probability (ARTEMIS model). Discriminative performance of the models was assessed using area under the receiver operating characteristic curve (AUC) and logLoss. Model performance was validated in an external cohort with 1688 patients and tested for global generalizability in 13 international cohorts with 23,411 patients. RESULTS Eleven routinely available variables including age, sex, cardiovascular risk factors, electrocardiography, and hs-cTn were included in the ARTEMIS models. In the validation and generalization cohorts, excellent discriminative performance was confirmed, superior to hs-cTn only. For the serial hs-cTn measurement model, AUC ranged from 0.92 to 0.98. Good calibration was observed. Using a single hs-cTn measurement, the ARTEMIS model allowed direct rule-out of MI with very high and similar safety but up to tripled efficiency compared to the guideline-recommended strategy. CONCLUSION We developed and validated diagnostic models to accurately estimate the individual probability of MI, which allow for variable hs-cTn use and flexible timing of resampling. Their digital application may provide rapid, safe and efficient personalized patient care. TRIAL REGISTRATION NUMBERS Data of following cohorts were used for this project: BACC ( www. CLINICALTRIALS gov ; NCT02355457), stenoCardia ( www. CLINICALTRIALS gov ; NCT03227159), ADAPT-BSN ( www.australianclinicaltrials.gov.au ; ACTRN12611001069943), IMPACT ( www.australianclinicaltrials.gov.au , ACTRN12611000206921), ADAPT-RCT ( www.anzctr.org.au ; ANZCTR12610000766011), EDACS-RCT ( www.anzctr.org.au ; ANZCTR12613000745741); DROP-ACS ( https://www.umin.ac.jp , UMIN000030668); High-STEACS ( www. CLINICALTRIALS gov ; NCT01852123), LUND ( www. CLINICALTRIALS gov ; NCT05484544), RAPID-CPU ( www. CLINICALTRIALS gov ; NCT03111862), ROMI ( www. CLINICALTRIALS gov ; NCT01994577), SAMIE ( https://anzctr.org.au ; ACTRN12621000053820), SEIGE and SAFETY ( www. CLINICALTRIALS gov ; NCT04772157), STOP-CP ( www. CLINICALTRIALS gov ; NCT02984436), UTROPIA ( www. CLINICALTRIALS gov ; NCT02060760).
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Affiliation(s)
- Johannes Tobias Neumann
- Department of Cardiology, University Heart and Vascular Center, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
- German Center for Cardiovascular Research (DZHK), Partner SiteHamburg/Kiel/Lübeck, Hamburg, Germany
- Population Health Research Department, University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Raphael Twerenbold
- Department of Cardiology, University Heart and Vascular Center, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
- German Center for Cardiovascular Research (DZHK), Partner SiteHamburg/Kiel/Lübeck, Hamburg, Germany
- Population Health Research Department, University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- University Center of Cardiovascular Science, University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Francisco Ojeda
- Department of Cardiology, University Heart and Vascular Center, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
- Population Health Research Department, University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Sally J Aldous
- Department of Cardiology, Christchurch Hospital, Christchurch, New Zealand
| | - Brandon R Allen
- Department of Emergency Medicine, College of Medicine, University of Florida, Gainesville, FL, USA
| | - Fred S Apple
- Departments of Laboratory Medicine and Pathology, Hennepin Healthcare/HCMC and University of Minnesota, Minneapolis, MN, USA
| | - Hugo Babel
- Cardio-CARE, Medizincampus Davos, Davos, Switzerland
| | - Robert H Christenson
- Department of Pathology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Louise Cullen
- Department of Emergency Medicine, Royal Brisbane and Women's Hospital, Herston, QLD, Australia
| | | | - Dimitrios Doudesis
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Ulf Ekelund
- Department of Internal and Emergency Medicine, Lund University, Skåne University Hospital, Lund, Sweden
| | | | - Jaimi Greenslade
- Department of Emergency Medicine, Royal Brisbane and Women's Hospital, Herston, QLD, Australia
| | - Kenji Inoue
- Juntendo University Nerima Hospital, Tokyo, Japan
| | - Tomas Jernberg
- Department of Clinical Sciences, Danderyd University Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Peter Kavsak
- Department of Pathology and Molecular Medicine, McMaster University, Hamilton, ON, Canada
| | - Till Keller
- Department of Cardiology, Kerckhoff Heart and Thorax Center, Bad Nauheim, Germany
| | - Kuan Ken Lee
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Bertil Lindahl
- Department of Medical Sciences and Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - Thiess Lorenz
- Department of Cardiology, University Heart and Vascular Center, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
- German Center for Cardiovascular Research (DZHK), Partner SiteHamburg/Kiel/Lübeck, Hamburg, Germany
- Population Health Research Department, University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Simon A Mahler
- Department of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Nicholas L Mills
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Arash Mokhtari
- Department of Internal Medicine and Emergency Medicine and Department of Cardiology, Lund University, Skåne University Hospital, Lund, Sweden
| | - William Parsonage
- Australian Centre for Health Service Innovation, Queensland University of Technology, Kelvin Grove, Australia
| | - John W Pickering
- Department of Medicine, Christchurch and Emergency Department, University of Otago, Christchurch Hospital, Christchurch, New Zealand
| | - Christopher J Pemberton
- Department of Medicine, Christchurch Heart Institute, University of Otago, Christchurch, New Zealand
| | - Christoph Reich
- Department of Cardiology, Heidelberg University Hospital, Heidelberg, Germany
| | - A Mark Richards
- Department of Medicine, Christchurch and Emergency Department, University of Otago, Christchurch Hospital, Christchurch, New Zealand
| | - Yader Sandoval
- Minneapolis Heart Institute, Abbott Northwestern Hospital, and Minneapolis Heart Institute Foundation, Minneapolis, MN, USA
| | - Martin P Than
- Department of Medicine, Christchurch and Emergency Department, University of Otago, Christchurch Hospital, Christchurch, New Zealand
| | - Betül Toprak
- Department of Cardiology, University Heart and Vascular Center, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
- German Center for Cardiovascular Research (DZHK), Partner SiteHamburg/Kiel/Lübeck, Hamburg, Germany
- Population Health Research Department, University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- University Center of Cardiovascular Science, University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Richard W Troughton
- Department of Medicine, Christchurch Heart Institute, University of Otago, Christchurch, New Zealand
| | - Andrew Worster
- Division of Emergency Medicine, McMaster University, Hamilton, ON, Canada
| | - Tanja Zeller
- Department of Cardiology, University Heart and Vascular Center, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
- German Center for Cardiovascular Research (DZHK), Partner SiteHamburg/Kiel/Lübeck, Hamburg, Germany
- Population Health Research Department, University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- University Center of Cardiovascular Science, University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Andreas Ziegler
- Cardio-CARE, Medizincampus Davos, Davos, Switzerland
- School of Mathematics, Statistics and Computer Science, University of KwaZulu-Natal, Pietermaritzburg, South Africa
| | - Stefan Blankenberg
- Department of Cardiology, University Heart and Vascular Center, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany.
- German Center for Cardiovascular Research (DZHK), Partner SiteHamburg/Kiel/Lübeck, Hamburg, Germany.
- Population Health Research Department, University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
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11
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Lowry MTH, Doudesis D, Boeddinghaus J, Kimenai DM, Bularga A, Taggart C, Wereski R, Ferry AV, Stewart SD, Tuck C, Koechlin L, Nestelberger T, Lopez-Ayala P, Huré G, Lee KK, Chapman AR, Newby DE, Anand A, Collinson PO, Mueller C, Mills NL. Troponin in early presenters to rule out myocardial infarction. Eur Heart J 2023; 44:2846-2858. [PMID: 37350492 PMCID: PMC10406338 DOI: 10.1093/eurheartj/ehad376] [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: 11/15/2022] [Revised: 04/12/2023] [Accepted: 05/24/2023] [Indexed: 06/24/2023] Open
Abstract
AIMS Whether a single cardiac troponin measurement can safely rule out myocardial infarction in patients presenting within a few hours of symptom onset is uncertain. The study aim was to assess the performance of troponin in early presenters. METHODS AND RESULTS In patients with possible myocardial infarction, the diagnostic performance of a single measurement of high-sensitivity cardiac troponin I at presentation was evaluated and externally validated in those tested ≤3, 4-12, and >12 h from symptom onset. The limit-of-detection (2 ng/L), rule-out (5 ng/L), and sex-specific 99th centile (16 ng/L in women; 34 ng/L in men) thresholds were compared. In 41 103 consecutive patients [60 (17) years, 46% women], 12 595 (31%) presented within 3 h, and 3728 (9%) had myocardial infarction. In those presenting ≤3 h, a threshold of 2 ng/L had greater sensitivity and negative predictive value [99.4% (95% confidence interval 99.2%-99.5%) and 99.7% (99.6%-99.8%)] compared with 5 ng/L [96.5% (96.2%-96.8%) and 99.3% (99.1%-99.4%)]. In those presenting ≥3 h, the sensitivity and negative predictive value were similar for both thresholds. The sensitivity of the 99th centile was low in early and late presenters at 71.4% (70.6%-72.2%) and 92.5% (92.0%-93.0%), respectively. Findings were consistent in an external validation cohort of 7088 patients. CONCLUSION In early presenters, a single measurement of high-sensitivity cardiac troponin I below the limit of detection may facilitate the safe rule out of myocardial infarction. The 99th centile should not be used to rule out myocardial infarction at presentation even in those presenting later following symptom onset.
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Affiliation(s)
- Matthew T H Lowry
- BHF Centre for Cardiovascular Science, University of Edinburgh, Room SU.226, Chancellor’s Building, Edinburgh EH16 4SB, UK
| | - Dimitrios Doudesis
- BHF Centre for Cardiovascular Science, University of Edinburgh, Room SU.226, Chancellor’s Building, Edinburgh EH16 4SB, UK
- Usher Institute, 9 Little France Road, BioQuarter, Edinburgh, EH16 4UX, UK
| | - Jasper Boeddinghaus
- BHF Centre for Cardiovascular Science, University of Edinburgh, Room SU.226, Chancellor’s Building, Edinburgh EH16 4SB, UK
| | - Dorien M Kimenai
- BHF Centre for Cardiovascular Science, University of Edinburgh, Room SU.226, Chancellor’s Building, Edinburgh EH16 4SB, UK
| | - Anda Bularga
- BHF Centre for Cardiovascular Science, University of Edinburgh, Room SU.226, Chancellor’s Building, Edinburgh EH16 4SB, UK
| | - Caelan Taggart
- BHF Centre for Cardiovascular Science, University of Edinburgh, Room SU.226, Chancellor’s Building, Edinburgh EH16 4SB, UK
| | - Ryan Wereski
- BHF Centre for Cardiovascular Science, University of Edinburgh, Room SU.226, Chancellor’s Building, Edinburgh EH16 4SB, UK
| | - Amy V Ferry
- BHF Centre for Cardiovascular Science, University of Edinburgh, Room SU.226, Chancellor’s Building, Edinburgh EH16 4SB, UK
| | - Stacey D Stewart
- BHF Centre for Cardiovascular Science, University of Edinburgh, Room SU.226, Chancellor’s Building, Edinburgh EH16 4SB, UK
| | - Christopher Tuck
- BHF Centre for Cardiovascular Science, University of Edinburgh, Room SU.226, Chancellor’s Building, Edinburgh EH16 4SB, UK
| | - Luca Koechlin
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Switzerland
| | - Thomas Nestelberger
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Switzerland
| | - Pedro Lopez-Ayala
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Switzerland
| | - Gabrielle Huré
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Switzerland
| | - Kuan Ken Lee
- BHF Centre for Cardiovascular Science, University of Edinburgh, Room SU.226, Chancellor’s Building, Edinburgh EH16 4SB, UK
| | - Andrew R Chapman
- BHF Centre for Cardiovascular Science, University of Edinburgh, Room SU.226, Chancellor’s Building, Edinburgh EH16 4SB, UK
| | - David E Newby
- BHF Centre for Cardiovascular Science, University of Edinburgh, Room SU.226, Chancellor’s Building, Edinburgh EH16 4SB, UK
| | - Atul Anand
- BHF Centre for Cardiovascular Science, University of Edinburgh, Room SU.226, Chancellor’s Building, Edinburgh EH16 4SB, UK
| | - Paul O Collinson
- Department of Clinical Blood Sciences, St George’s, University Hospitals NHS Trust and St George’s University of London, London, UK
- Department Cardiology, St George’s, University Hospitals NHS Trust and St George’s University of London, London, UK
| | - Christian Mueller
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Switzerland
| | - Nicholas L Mills
- BHF Centre for Cardiovascular Science, University of Edinburgh, Room SU.226, Chancellor’s Building, Edinburgh EH16 4SB, UK
- Usher Institute, 9 Little France Road, BioQuarter, Edinburgh, EH16 4UX, UK
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12
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Westreich R, Tsaban G, Neumann Y, Abu Salman A, Braver O, Braiman D, Zamed T, Neuhaus ZF, Deutsch O, Palmon A, Maimon N, Zahger D, Abramowitz Y. Development of saliva-based cardiac troponin I point-of-care test using alpha-amylase depletion: a feasibility study. Coron Artery Dis 2023; 34:351-355. [PMID: 37335230 DOI: 10.1097/mca.0000000000001257] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/21/2023]
Abstract
INTRODUCTION Cardiac troponin (cTn) is the biomarker of choice for detection of myocardial injury. There is a great need for simple point-of-care (POC) troponin testing among patients with chest pain, mainly in the prehospital setting. The purpose of this study was to evaluate the presence of cardiac troponin I (cTnI) in saliva of patients with myocardial injury using alpha-amylase depletion technique. METHODS Saliva samples were collected from 40 patients with myocardial injury who were tested positive for conventional high-sensitivity cardiac troponin T (cTnT) blood tests, and from 66 healthy volunteers. Saliva samples were treated for the removal of salivary alpha-amylase. Treated and untreated samples were tested with blood cTnI Rapid Diagnostic Test. Salivary cTnI levels were compared to blood cTnT levels. RESULTS Thirty-six of 40 patients with positive blood cTnT had positive salivary samples for cTnI following alpha-amylase depletion treatment (90.00% sensitivity). Moreover, three of the four negative saliva samples were obtained from patients with relatively low blood cTnT levels of 100 ng/L or less (96.88% sensitivity for 100 ng/L and above). The negative predictive value was 93.65% and rose up to 98.33% considering the 100 ng/L cutoff. Positive predictive values were 83.72% and 81.58%, respectively. Among 66 healthy volunteers and 7 samples yielded positive results (89.39% specificity). CONCLUSION In this preliminary work, the presence of cTnI in saliva was demonstrated for the first time to be feasibly identified by a POC oriented assay. The specific salivary alpha-amylase depletion technique was shown to be crucial for the suggested assay.
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Affiliation(s)
- Roi Westreich
- Department of Cardiology, Soroka University Medical Center, Faculty of Health Sciences, Ben Gurion University of the Negev, Beer-Sheva
| | - Gal Tsaban
- Department of Cardiology, Soroka University Medical Center, Faculty of Health Sciences, Ben Gurion University of the Negev, Beer-Sheva
| | - Yoav Neumann
- Department of D&R, Faculty of Dental Medicine, Hebrew University, Jerusalem, Israel
| | - Amjad Abu Salman
- Department of Cardiology, Soroka University Medical Center, Faculty of Health Sciences, Ben Gurion University of the Negev, Beer-Sheva
| | - Omri Braver
- Department of Cardiology, Soroka University Medical Center, Faculty of Health Sciences, Ben Gurion University of the Negev, Beer-Sheva
| | - Dana Braiman
- Department of Cardiology, Soroka University Medical Center, Faculty of Health Sciences, Ben Gurion University of the Negev, Beer-Sheva
| | - Tali Zamed
- Department of Cardiology, Soroka University Medical Center, Faculty of Health Sciences, Ben Gurion University of the Negev, Beer-Sheva
| | - Zipora Feiga Neuhaus
- Department of Cardiology, Soroka University Medical Center, Faculty of Health Sciences, Ben Gurion University of the Negev, Beer-Sheva
| | - Omer Deutsch
- Department of D&R, Faculty of Dental Medicine, Hebrew University, Jerusalem, Israel
| | - Aaron Palmon
- Department of D&R, Faculty of Dental Medicine, Hebrew University, Jerusalem, Israel
| | - Nimrod Maimon
- Department of Cardiology, Soroka University Medical Center, Faculty of Health Sciences, Ben Gurion University of the Negev, Beer-Sheva
| | - Doron Zahger
- Department of Cardiology, Soroka University Medical Center, Faculty of Health Sciences, Ben Gurion University of the Negev, Beer-Sheva
| | - Yigal Abramowitz
- Department of Cardiology, Soroka University Medical Center, Faculty of Health Sciences, Ben Gurion University of the Negev, Beer-Sheva
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13
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Jaffe AS, Body R, Mills NL, Aakre KM, Collinson PO, Saenger A, Hammarsten O, Wereski R, Omland T, Sandoval Y, Ordonez-Llanos J, Apple FS. Single Troponin Measurement to Rule Out Myocardial Infarction: JACC Review Topic of the Week. J Am Coll Cardiol 2023; 82:60-69. [PMID: 37380305 DOI: 10.1016/j.jacc.2023.04.040] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Revised: 04/05/2023] [Accepted: 04/10/2023] [Indexed: 06/30/2023]
Abstract
The term "single-sample rule-out" refers to the ability of very low concentrations of high-sensitivity cardiac troponin (hs-cTn) on presentation to exclude acute myocardial infarction with high clinical sensitivity and negative predictive value. Observational and randomized studies have confirmed this ability. Some guidelines endorse use of a concentration of hs-cTn at the assay's limit of detection, while other studies have validated the use of higher concentrations, allowing this approach to identify a greater proportion of patients at low risk. In most studies, at least 30% of patients can be triaged with this approach. The concentration of hs-cTn varies according to the assay used and sometimes how regulations permit reporting. It is clear that patients need to be at least 2 hours from the onset of symptoms being evaluated. Caution is warranted, particularly with older patients, women, and patients with underlying cardiac comorbidities.
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Affiliation(s)
- Allan S Jaffe
- Department of Cardiology, Mayo Clinic, Rochester, Minnesota, USA; Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA.
| | - Richard Body
- Emergency Department, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, United Kingdom; Division of Cardiovascular Sciences, University of Manchester, Manchester, United Kingdom; Healthcare Sciences Department, Manchester Metropolitan University, Manchester, United Kingdom
| | - Nicholas L Mills
- Usher Institute, University of Edinburgh, Edinburgh, United Kingdom; British Heart Foundation/University Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
| | - Kristin M Aakre
- Department of Medical Biochemistry and Pharmacology, Haukeland University Hospital, Bergen, Norway; Department of Heart Disease, Haukeland University Hospital, Bergen, Norway; Department of Clinical Science, University of Bergen, Bergen, Norway
| | - Paul O Collinson
- Department of Clinical Blood Sciences, St George's University Hospitals NHS Foundation Trust, London, United Kingdom; Department of Cardiology, St George's University Hospitals NHS Foundation Trust, London, United Kingdom; St George's University of London, London, United Kingdom
| | - Amy Saenger
- Department of Laboratory Medicine and Pathology, Hennepin Healthcare/Hennepin County Medical Center, Minneapolis, Minnesota, USA; Department of Laboratory Medicine and Pathology, University of Minnesota, Minneapolis, Minnesota, USA
| | - Ole Hammarsten
- Department of Clinical Chemistry and Transfusion Medicine, University of Gothenburg, Gothenburg, Sweden
| | - Ryan Wereski
- Usher Institute, University of Edinburgh, Edinburgh, United Kingdom
| | - Torbjørn Omland
- Department of Cardiology, Akershus University Hospital, Lørenskog, Norway; Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Yader Sandoval
- Minneapolis Heart Institute, Abbott Northwestern Hospital, and Minneapolis Heart Institute Foundation, Minneapolis, Minnesota, USA
| | - Jordi Ordonez-Llanos
- Clinical Biochemistry Department, Hospital de Sant Pau, Barcelona, Spain; Foundation for Biochemistry and Molecular Pathology, Barcelona, Spain
| | - Fred S Apple
- Department of Laboratory Medicine and Pathology, Hennepin Healthcare/Hennepin County Medical Center, Minneapolis, Minnesota, USA; Department of Laboratory Medicine and Pathology, University of Minnesota, Minneapolis, Minnesota, USA
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14
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Clerico A, Zaninotto M, Aimo A, Cardinale DM, Dittadi R, Sandri MT, Perrone MA, Belloni L, Fortunato A, Trenti T, Plebani M. Variability of cardiac troponin levels in normal subjects and in patients with cardiovascular diseases: analytical considerations and clinical relevance. Clin Chem Lab Med 2023; 61:1209-1229. [PMID: 36695506 DOI: 10.1515/cclm-2022-1285] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Accepted: 01/09/2023] [Indexed: 01/26/2023]
Abstract
In accordance with all the most recent international guidelines, the variation of circulating levels of cardiac troponins I and T, measured with high-sensitivity methods (hs-cTnI and hs-cTnT), should be used for the detection of acute myocardial injury. Recent experimental and clinical evidences have demonstrated that the evaluation of hs-cTnI and hs-cTnT variations is particularly relevant: a) for the differential diagnosis of Acute Coronary Syndromes (ACS) in patients admitted to the Emergency Department (ED); b) for the evaluation of cardiovascular risk in patients undergoing major cardiac or non-cardiac surgery, and in asymptomatic subjects of the general population aged >55 years and with co-morbidities; c) for the evaluation of cardiotoxicity caused by administration of some chemotherapy drugs in patients with malignant tumors. The aim of this document is to discuss the fundamental statistical and biological considerations on the intraindividual variability of hs-cTnI and hs-cTnT over time in the same individual. Firstly, it will be discussed in detail as the variations of circulating levels strictly depend not only on the analytical error of the method used but also on the intra-individual variability of the biomarker. Afterwards, the pathophysiological interpretation and the clinical relevance of the determination of the variability of the hs-cTnI and hs-cTnT values in patients with specific clinical conditions are discussed. Finally, the evaluation over time of the variation in circulating levels of hs-cTnI and hs-cTnT is proposed for a more accurate estimation of cardiovascular risk in asymptomatic subjects from the general population.
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Affiliation(s)
- Aldo Clerico
- Scuola Superiore Sant'Anna e Fondazione CNR, Regione Toscana G. Monasterio, Pisa, Italy
| | - Martina Zaninotto
- Dipartimento di Medicina di Laboratorio, Università-Ospedale di Padova, Padova, Italy
- Azienda Ospedaliera Universitaria di Padova, e Facoltà di Medicina e Chirurgia, Università di Padova, Padova, Italy
| | - Alberto Aimo
- Scuola Superiore Sant'Anna e Fondazione CNR, Regione Toscana G. Monasterio, Pisa, Italy
| | | | - Ruggero Dittadi
- Unità di Medicina di Laboratorio, Ospedale dell'Angelo, e Centro Regionale dei Biomarcatori, Dipartimento di Patologia Clinica, Azienda ULSS 3, Mestre, Italy
| | - Maria T Sandri
- Laboratorio Bianalisi, Carate Brianza, Monza e Brianza, Italy
| | - Marco Alfonso Perrone
- Dipartimento di Biochimica Clinica e Divisione di Cardiologia, Università e Ospedale di Tor Vergata, Rome, Italy
| | - Lucia Belloni
- Unità di Immunologia Clinica, Allergia e Biotecnologie Avanzate, Arcispedale Santa Maria Nuova-IRCCS, Reggio Emilia, Italy
| | | | - Tommaso Trenti
- Dipartimento di Patologia Clinica e Laboratorio, Azienda USL of Modena, Modena, Italy
| | - Mario Plebani
- Dipartimento di Medicina di Laboratorio, Università-Ospedale di Padova, Padova, Italy
- Azienda Ospedaliera Universitaria di Padova, e Facoltà di Medicina e Chirurgia, Università di Padova, Padova, Italy
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15
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Haller PM, Sörensen NA, Hartikainen TS, Goßling A, Lehmacher J, Toprak B, Twerenbold R, Richter J, Banko T, Korschid S, Schmidt J, Keller T, Zeller T, Blankenberg S, Westermann D, Neumann JT. Rising and Falling High-Sensitivity Cardiac Troponin in Diagnostic Algorithms for Patients With Suspected Myocardial Infarction. J Am Heart Assoc 2023; 12:e027166. [PMID: 37158171 DOI: 10.1161/jaha.122.027166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/10/2023]
Abstract
Background High-sensitivity cardiac troponin (hs-cTn)-based diagnostic algorithms are recommended for the management of patients with suspected myocardial infarction (MI) without ST elevation. Although mirroring different phases of myocardial injury, falling and rising troponin patterns (FPs and RPs, respectively) are equally considered by most algorithms. We aimed to compare the performance of diagnostic protocols for RPs and FPs, separately. Methods and Results We pooled 2 prospective cohorts of patients with suspected MI and stratified patients to stable, FP, and RP during serial sampling separately for hs-cTnI and hs-cTnT and applied the European Society of Cardiology 0/1- and 0/3-hour algorithms comparing the positive predictive values to rule in MI. Overall, 3523 patients were included in the hs-cTnI study population. The positive predictive value for patients with an FP was significantly reduced compared with patients with an RP (0/1-hour: FP, 53.3% [95% CI, 45.0-61.4] versus RP, 76.9 [95% CI, 71.6-81.7]; 0/3-hour: FP, 56.9% [95% CI, 42.2-70.7] versus RP, 78.1% [95% CI, 74.0-81.8]). The proportion of patients in the observe zone was larger in the FP using 0/1-hour (31.3% versus 55.8%) and 0/3-hour (14.6% versus 38.6%) algorithms. Alternative cutoffs did not improve algorithm performances. Compared with stable hs-cTn, the risk for death or MI was highest in those with an FP (adjusted hazard ratio [HR], hs-cTnI 2.3 [95% CI, 1.7-3.2]; RP adjusted HR, hs-cTnI 1.8 [95% CI, 1.4-2.4]). Findings were similar for hs-cTnT tested in 3647 patients overall. Conclusions The positive predictive value to rule in MI by the European Society of Cardiology 0/1- and 0/3-hour algorithms is significantly lower in patients with FP than RP. These are at highest risk for incident death or MI. REGISTRATION: URL: https://www.clinicaltrials.gov; Unique identifiers: NCT02355457, NCT03227159.
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Affiliation(s)
- Paul M Haller
- Department of Cardiology University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf Hamburg Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck Hamburg Germany
| | - Nils A Sörensen
- Department of Cardiology University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf Hamburg Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck Hamburg Germany
| | - Tau S Hartikainen
- Department of Cardiology University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf Hamburg Germany
| | - Alina Goßling
- Department of Cardiology University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf Hamburg Germany
| | - Jonas Lehmacher
- Department of Cardiology University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf Hamburg Germany
| | - Betül Toprak
- Department of Cardiology University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf Hamburg Germany
| | - Raphael Twerenbold
- Department of Cardiology University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf Hamburg Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck Hamburg Germany
- University Center of Cardiovascular Science University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf Hamburg Germany
| | - Janine Richter
- Department of Cardiology University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf Hamburg Germany
| | - Thorben Banko
- Department of Cardiology University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf Hamburg Germany
| | - Solaf Korschid
- Department of Cardiology University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf Hamburg Germany
| | - Jakob Schmidt
- Department of Cardiology University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf Hamburg Germany
| | - Till Keller
- Department of Internal Medicine I, Cardiology Justus-Liebig-University Gießen Gießen Germany
| | - Tanja Zeller
- Department of Cardiology University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf Hamburg Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck Hamburg Germany
- University Center of Cardiovascular Science University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf Hamburg Germany
| | - Stefan Blankenberg
- Department of Cardiology University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf Hamburg Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck Hamburg Germany
| | - Dirk Westermann
- Department of Cardiology University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf Hamburg Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck Hamburg Germany
- Department of Cardiology University Heart Center Freiburg Bad Krotzingen Bad Krotzingen Germany
| | - Johannes T Neumann
- Department of Cardiology University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf Hamburg Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck Hamburg Germany
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine Monash University Melbourne Australia
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16
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Ho YJ, Chen CH, Sung CW, Fan CY, Lin SY, Chen JW, Edward Pei-Chang Huang S. Risk stratification of patients with chest pain who have an unscheduled revisit to the emergency department. Int J Cardiol 2023:S0167-5273(23)00596-X. [PMID: 37116755 DOI: 10.1016/j.ijcard.2023.04.043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2022] [Revised: 03/11/2023] [Accepted: 04/23/2023] [Indexed: 04/30/2023]
Abstract
AIMS Acute cardiovascular (CV) emergencies are critical conditions that require urgent attention in the emergency department (ED). Failure to make a timely diagnosis may result in unscheduled ED revisits and severe outcomes. Therefore, this study aimed to investigate the risk factors associated with potentially missed acute CV emergencies. METHODS AND RESULTS This retrospective study enrolled adult patients who presented with chest pain and returned to the ED within 72 h. Demographic information, pre-existing medical conditions, chief complaints, triage level and vital signs, electrocardiography (ECG) reports, and laboratory data were collected from medical charts by independent physicians. The primary outcome was the diagnosis of acute CV diseases, including ACS, pulmonary embolism, unstable arrhythmia, acute decompensated heart failure, and aortic dissection. Multivariable logistic regression was used to analyze the association between variables and acute CV emergencies. A total of 453 eligible patients were included, with 60 (13.2%) patients diagnosed as acute CV emergencies at the ED revisit. Risk factors for acute CV emergencies included male gender (adjusted odds ratio [aOR] = 2.71, 95% confidence interval [CI] = 1.17-6.25), abnormal ECG rhythm (aOR = 10.33, 95% CI = 4.68-22.83), and abnormal changes in high sensitivity Troponin-T (hs-cTnT) during sequential follow-up (aOR = 6.52, 95% CI = 2.19-19.45). CONCLUSIONS Male gender, abnormal ECG rhythm, and a significant increase in sequential follow-up hs-cTnT levels were identified as significant risk factors for acute CV emergencies. ED physicians should recognize these high-risk patients with chest pain to prevent misdiagnosis and potential severe complications.
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Affiliation(s)
- Yi-Ju Ho
- Department of Emergency Medicine, National Taiwan University Hospital, No.7, Chung-Shan S. Road, Taipei 100, Taiwan
| | - Chi-Hsin Chen
- Department of Emergency Medicine, National Taiwan University Hospital Hsin-Chu Branch, No. 25, Ln. 442, Sec. 1, Jing-guo Rd., North Dist., Hsinchu 310, Taiwan
| | - Chih-Wei Sung
- Department of Emergency Medicine, National Taiwan University Hospital Hsin-Chu Branch, No. 25, Ln. 442, Sec. 1, Jing-guo Rd., North Dist., Hsinchu 310, Taiwan
| | - Cheng-Yi Fan
- Department of Emergency Medicine, National Taiwan University Hospital Hsin-Chu Branch, No. 25, Ln. 442, Sec. 1, Jing-guo Rd., North Dist., Hsinchu 310, Taiwan
| | - Shao-Yung Lin
- Department of Emergency Medicine, National Taiwan University Hospital, No.7, Chung-Shan S. Road, Taipei 100, Taiwan
| | - Jiun-Wei Chen
- Department of Emergency Medicine, National Taiwan University Hospital Hsin-Chu Branch, No. 25, Ln. 442, Sec. 1, Jing-guo Rd., North Dist., Hsinchu 310, Taiwan
| | - S Edward Pei-Chang Huang
- Department of Emergency Medicine, National Taiwan University Hospital, No.7, Chung-Shan S. Road, Taipei 100, Taiwan; Department of Emergency Medicine, National Taiwan University Hospital Hsin-Chu Branch, No. 25, Ln. 442, Sec. 1, Jing-guo Rd., North Dist., Hsinchu 310, Taiwan.
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17
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Rubini Gimenez M, Boeddinghaus J, Nestelberger T, Koechlin L, López-Ayala P, Müller C. Implementation of the ESC 0 h/1 h high-sensitivity troponin algorithm for decision-making in the emergency department. REVISTA ESPANOLA DE CARDIOLOGIA (ENGLISH ED.) 2023; 76:468-472. [PMID: 36669731 DOI: 10.1016/j.rec.2023.01.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/10/2022] [Accepted: 12/12/2022] [Indexed: 01/19/2023]
Abstract
Diagnosis of non-ST-segment elevation acute coronary syndromes (NSTEACS) is based on 3 cornerstones: clinical presentation, 12-lead electrocardiogram, and cardiac troponin measurement. Advances in the development of high-sensitivity cardiac troponin (hs-cTn) assays have substantially improved the detection of cardiomyocyte injury in a shorter time period, and hs-cTn has consequently been established as the gold-standard biomarker for the assessment of patients with suspected NSTEACS. The implementation of these assays in clinical practice allows a faster "rule-out", especially among low-risk patients, as well as a safer and more rapid "rule-in", with its therapeutic consequences. Current guidelines for the diagnosis of NSTEACS recommend the use of hs-cTn applied in rapid diagnostic algorithms based on serial hs-cTn sampling within the first few hours. The current work provides an overview of the use of hs-cTn for the early detection of NSTEACS.
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Affiliation(s)
- Maria Rubini Gimenez
- Department of Cardiology and internal Medicine, University Heart Center Leipzig, Leipzig, Germany; Cardiovascular Research Institute of Basel, University Hospital Basel, Basel, Switzerland.
| | - Jasper Boeddinghaus
- Cardiovascular Research Institute of Basel, University Hospital Basel, Basel, Switzerland; BHF/University Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
| | - Thomas Nestelberger
- Cardiovascular Research Institute of Basel, University Hospital Basel, Basel, Switzerland
| | - Luca Koechlin
- Cardiovascular Research Institute of Basel, University Hospital Basel, Basel, Switzerland
| | - Pedro López-Ayala
- Cardiovascular Research Institute of Basel, University Hospital Basel, Basel, Switzerland
| | - Christian Müller
- Cardiovascular Research Institute of Basel, University Hospital Basel, Basel, Switzerland
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18
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Collinson P, Aakre KM, Saenger A, Body R, Hammarsten O, Jaffe AS, Kavsak P, Omland T, Ordonez-Lianos J, Karon B, Apple FS. Cardiac troponin measurement at the point of care: educational recommendations on analytical and clinical aspects by the IFCC Committee on Clinical Applications of Cardiac Bio-Markers (IFCC C-CB). Clin Chem Lab Med 2023; 61:989-998. [PMID: 36637984 DOI: 10.1515/cclm-2022-1270] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Accepted: 12/16/2022] [Indexed: 01/14/2023]
Abstract
The International Federation of Clinical Chemistry and Laboarator Medicine (IFCC) Committee on Clinical Applications of Cardiac Bio-Markers (C-CB) has provided evidence-based educational resources to aid and improve the understanding of important analytical and clinical aspects of cardiac biomarkers. The present IFCC C-CB educational report focuses on recommendations for appropriate use, analytical performance, and gaps in clinical studies related to the use of cardiac troponin (cTn) by point of care (POC) measurement, often referred to as a point of care testing (POCT). The use of high-sensitivity (hs)-cTn POC devices in accelerated diagnostic protocols used in emergency departments or outpatient clinics investigating acute coronary syndrome has the potential for improved efficacy, reduction of length of stay and reduced costs in the health care system. POCT workflow integration includes location of the instrument, assignment of collection and testing responsibility to (non-lab) staff, instrument maintenance, in-service and recurrent training, quality control, proficiency assessments, discrepant result trapping, and troubleshooting and inventory management.
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Affiliation(s)
- Paul Collinson
- Departments of Clinical Blood Sciences and Cardiology, St George's University Hospitals NHS Foundation Trust, London, UK.,St George's University of London, London, UK
| | - Kristin M Aakre
- Department of Medical Biochemistry and Pharmacology and Department of Heart Disease, Haukeland University Hospital, Bergen, Norway.,Department of Clinical Science, University of Bergen, Bergen, Norway
| | - Amy Saenger
- Department of Laboratory Medicine and Pathology, Hennepin Healthcare/HCMC, Minneapolis, MN, USA.,Department of Laboratory Medicine and Pathology, University of Minnesota, Minneapolis, MN, USA
| | - Rick Body
- Emergency Department, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK.,Division of Cardiovascular Sciences, The University of Manchester, Manchester, UK.,Healthcare Sciences Department, Manchester Metropolitan University, Manchester, UK
| | - Ole Hammarsten
- Department of Clinical Chemistry and Transfusion Medicine, University of Gothenburg, Gothenburg, Sweden
| | - Allan S Jaffe
- Departments of Laboratory Medicine and Pathology and Cardiology, Mayo Clinic, Rochester, MN, USA
| | - Pete Kavsak
- Department of Pathology and Molecular Medicine, McMaster University, Hamilton, ON, Canada
| | - Torbjørn Omland
- Department of Cardiology, Akershus University Hospital, Lørenskog, Norway.,Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Jordi Ordonez-Lianos
- Servicio de Bioquímica Clínica, Institut d'Investigacions Biomèdiques Sant Pau, Barcelona, Spain.,Departamento de Bioquímica y Biología Molecular, Universidad Autònoma de Barcelona, Barcelona, Spain
| | - Brad Karon
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | - Fred S Apple
- Department of Laboratory Medicine and Pathology, Hennepin Healthcare/HCMC, Minneapolis, MN, USA.,Department of Laboratory Medicine and Pathology, University of Minnesota, Minneapolis, MN, USA
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19
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Apple FS, Smith SW, Greenslade JH, Sandoval Y, Parsonage W, Ranasinghe I, Gaikwad N, Schulz K, Stephensen L, Schmidt CW, Okeson B, Cullen L. Single High-Sensitivity Point-of-Care Whole-Blood Cardiac Troponin I Measurement to Rule Out Acute Myocardial Infarction at Low Risk. Circulation 2022; 146:1918-1929. [PMID: 36314160 DOI: 10.1161/circulationaha.122.061148] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
BACKGROUND High-sensitivity cardiac troponin (hs-cTn) laboratory assays are used to rule out myocardial infarction (MI) on presentation, but prolonged result turnaround times can delay patient management. Our primary aim was to identify patients at low risk of index MI using a rapid point-of-care (POC) whole-blood hs-cTnI assay at presentation with potential early patient discharge. METHODS Consecutive patients presenting to the emergency department from 2 prospective observational studies with suspected acute coronary syndrome were enrolled. A POC hs-cTnI assay (Atellica VTLi) threshold using whole blood at presentation, which resulted in a negative predictive value of ≥99.5% and sensitivity of >99% for index MI, was derived (SEIGE [Safe Emergency Department Discharge Rate]) and validated with plasma (SAMIE [Suspected Acute Myocardial Infarction in Emergency]). Event adjudications were established with hs-cTnI assay results from routine clinical care. The primary outcome was MI at 30 days. RESULTS A total of 1086 patients (8.1% with MI) were enrolled in a US derivation cohort (SEIGE) and 1486 (5.5% MI) in an Australian validation cohort (SAMIE). A derivation whole-blood POC hs-cTnI concentration of <4 ng/L provided a sensitivity of 98.9% (95% CI, 93.8%-100%) and negative predictive value of 99.5% (95% CI, 97.2%-100%) for ruling out MI. In the validation cohort, the sensitivity was 98.8% (95% CI, 93.3%-100%), and negative predictive value was 99.8% (95% CI, 99.1%-100%); 17.8% and 41.8%, respectively, were defined as low risk for discharge. The 30-day adverse cardiac events were 0.1% (n=1) for SEIGE and 0.8% (n=5) for SAMIE. CONCLUSIONS A POC whole-blood hs-cTnI assay permits accessible, rapid, and safe exclusion of MI and may expedite discharge from the emergency department. REGISTRATION URL: https://www. CLINICALTRIALS gov; Unique identifier: NCT04772157. URL: https://www.australianclinicaltrials.gov.au/anzctr_feed/form; Unique identifier: 12621000053820.
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Affiliation(s)
- Fred S Apple
- Departments of Laboratory Medicine (F.S.A., K.S.), Hennepin Healthcare/Hennepin County Medical Center and University of Minnesota School of Medicine, Minneapolis, MN.,Pathology (F.S.A., K.S.), Hennepin Healthcare/Hennepin County Medical Center and University of Minnesota School of Medicine, Minneapolis, MN
| | - Stephen W Smith
- Emergency Medicine (S.W.S.), Hennepin Healthcare/Hennepin County Medical Center and University of Minnesota School of Medicine, Minneapolis, MN
| | - Jaimi H Greenslade
- Emergency and Trauma Centre (J.H.G., L.S., L.C.), Royal Brisbane and Women's Hospital, Brisbane, Australia.,Australian Centre for Health Services Innovation, Centre for Healthcare Transformation, School of Public Health and Social Work, Faculty of Health, Queensland University of Technology, Brisbane, Australia (J.H.G., L.C.).,Faculty of Medicine, University of Queensland, Brisbane, Australia (J.H.G., I.R., L.C.)
| | - Yader Sandoval
- Minneapolis Heart Institute, Abbott Northwestern Hospital, and Minneapolis Heart Institute Foundation, Minneapolis, MN (Y.S., C.W.S., B.O.)
| | - William Parsonage
- Department of Cardiology (W.P., I.R.), Royal Brisbane and Women's Hospital, Brisbane, Australia.,Department of Cardiology, Prince Charles Hospital, Brisbane, Australia (W.P., I.R., N.G.)
| | - Isuru Ranasinghe
- Department of Cardiology (W.P., I.R.), Royal Brisbane and Women's Hospital, Brisbane, Australia.,Faculty of Medicine, University of Queensland, Brisbane, Australia (J.H.G., I.R., L.C.).,Department of Cardiology, Prince Charles Hospital, Brisbane, Australia (W.P., I.R., N.G.)
| | - Niranjan Gaikwad
- Department of Cardiology, Prince Charles Hospital, Brisbane, Australia (W.P., I.R., N.G.)
| | - Karen Schulz
- Departments of Laboratory Medicine (F.S.A., K.S.), Hennepin Healthcare/Hennepin County Medical Center and University of Minnesota School of Medicine, Minneapolis, MN.,Pathology (F.S.A., K.S.), Hennepin Healthcare/Hennepin County Medical Center and University of Minnesota School of Medicine, Minneapolis, MN.,Hennepin Healthcare Research Institute, Minneapolis, MN (K.S.)
| | - Laura Stephensen
- Emergency and Trauma Centre (J.H.G., L.S., L.C.), Royal Brisbane and Women's Hospital, Brisbane, Australia.,Australian Centre for Health Services Innovation, Centre for Healthcare Transformation, School of Public Health and Social Work, Faculty of Health, Queensland University of Technology, Brisbane, Australia (J.H.G., L.C.)
| | - Christian W Schmidt
- Minneapolis Heart Institute, Abbott Northwestern Hospital, and Minneapolis Heart Institute Foundation, Minneapolis, MN (Y.S., C.W.S., B.O.)
| | - Brynn Okeson
- Minneapolis Heart Institute, Abbott Northwestern Hospital, and Minneapolis Heart Institute Foundation, Minneapolis, MN (Y.S., C.W.S., B.O.)
| | - Louise Cullen
- Emergency and Trauma Centre (J.H.G., L.S., L.C.), Royal Brisbane and Women's Hospital, Brisbane, Australia.,Faculty of Medicine, University of Queensland, Brisbane, Australia (J.H.G., I.R., L.C.)
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20
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Ohtake H, Terasawa T, Zhelev Z, Iwata M, Rogers M, Peters JL, Hyde C. Serial high-sensitivity cardiac troponin testing for the diagnosis of myocardial infarction: a scoping review. BMJ Open 2022; 12:e066429. [PMID: 36414302 PMCID: PMC9685223 DOI: 10.1136/bmjopen-2022-066429] [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] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVES We aimed to assess the diversity and practices of existing studies on several assays and algorithms for serial measurements of high-sensitivity cardiac troponin (hs-cTn) for risk stratification and the diagnosis of myocardial infarction (MI) and 30-day outcomes in patients suspected of having non-ST-segment elevation MI (NSTEMI). METHODS We searched multiple databases including MEDLINE, EMBASE, Science Citation Index, the Cochrane Database of Systematic Reviews and the CENTRAL databases for studies published between January 2006 and November 2021. Studies that assessed the diagnostic accuracy of serial hs-cTn testing in patients suspected of having NSTEMI in the emergency department (ED) were eligible. Data were analysed using the scoping review method. RESULTS We included 86 publications, mainly from research centres in Europe, North America and Australasia. Two hs-cTn assays, manufactured by Abbott (43/86) and Roche (53/86), dominated the evaluations. The studies most commonly measured the concentrations of hs-cTn at two time points, at presentation and a few hours thereafter, to assess the two-strata or three-strata algorithm for diagnosing or ruling out MI. Although data from 83 studies (97%) were prospectively collected, 0%-90% of the eligible patients were excluded from the analysis due to missing blood samples or the lack of a final diagnosis in 53 studies (62%) that reported relevant data. Only 19 studies (22%) reported on head-to-head comparisons of alternative assays. CONCLUSION Evidence on the accuracy of serial hs-cTn testing was largely derived from selected research institutions and relied on two specific assays. The proportions of the eligible patients excluded from the study raise concerns about directly applying the study findings to clinical practice in frontline EDs. PROSPERO REGISTRATION NUMBER CRD42018106379.
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Affiliation(s)
- Hirotaka Ohtake
- Department of Emergency and General Internal Medicine, Fujita Health University, Toyoake, Aichi, Japan
| | - Teruhiko Terasawa
- Department of Emergency and General Internal Medicine, Fujita Health University, Toyoake, Aichi, Japan
| | - Zhivko Zhelev
- University of Exeter Medical School, University of Exeter, Exeter, UK
| | - Mitsunaga Iwata
- Department of Emergency and General Internal Medicine, Fujita Health University, Toyoake, Aichi, Japan
| | - Morwenna Rogers
- NIHR CLAHRC South West Peninsula, University of Exeter, Exeter, UK
| | - Jaime L Peters
- Peninsula Technology Assessment Group (PenTAG), University of Exeter, Exeter, UK
- Peninsula Technology Assessment Group (PenTAG), University of Exeter, Exeter, UK
| | - Chris Hyde
- Exeter Test Group, University of Exeter, Exeter, UK
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21
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Christenson RH, Frenk LDS, de Graaf HJ, van Domburg TSY, Wijnands FPG, Foolen HWJ, Kemper DWM, Bruinen AL, Meijering BDM, Fonville JM, de Theije FK. Point-of-Care: Roadmap for Analytical Characterization and Validation of a High-Sensitivity Cardiac Troponin I Assay in Plasma and Whole Blood Matrices. J Appl Lab Med 2022; 7:971-988. [PMID: 35660917 DOI: 10.1093/jalm/jfac028] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Accepted: 03/18/2022] [Indexed: 11/14/2022]
Abstract
BACKGROUND High-sensitivity cardiac troponin (hs-cTn) assays enable more precise use of traditional diagnostic strategies and earlier rule-out/rule-in at 0/1 h or 0/2 h after presentation of acute myocardial infarction (AMI). Availability of hs-cTn measurements at point-of-care (POC) can improve timely management of AMI patients. A roadmap for regulatory and analytical validation is exemplified with studies with the Atellica VTLi hs-cTnI at POC. METHODS High-sensitivity performance was assessed with AACC/IFCC expert recommendations. Clinical Laboratory Standards Institute protocols were used for characterizing limit of blank, limit of detection (LoD), limit of quantitation (LoQ), 10% CV, precision, linearity, and analytic specificity with several reagent lots. Bland-Altman, Passing-Bablok, and hematocrit bias plots compared hs-cTnI measurement in lithium-heparin plasma (PL) and whole blood (WB) matrices. RESULTS LoB was 0.55 ng/L; LoD and LoQ were 1.24 ng/L and 2.1 ng/Lm for PL and 1.60 ng/L and 3.7 ng/L for WB, respectively. The male 99th percentile is 27 ng/L, and female 99th percentile upper reference limit is 18 ng/L; 10% CVs were 6.7 ng/L for PL and 8.9 ng/L for WB. Also ≥50% of hs-cTnI values for healthy cohorts exceeded the LoD, confirming high-sensitivity performance. Linearity spanned from LoQ to 1250 ng/L. Specificity was >90% for 40 potential interferences; no hook effect was detected. WB and PL correlation was WB = 1.02*plasma + 0.3 ng/L (r = 0.996, n = 152). No hs-cTnI association with hematocrit was detected (R2 = 0.003). CONCLUSION This analytical roadmap showed high-sensitivity performance, good analytic characteristics, and excellent PL and WB agreement for the Atellica VTLi hs-cTnI POC system. Essential clinical performance studies in patients by intended POC users may now commence.
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Affiliation(s)
- Robert H Christenson
- Department of Pathology, University of Maryland School of Medicine, Baltimore, MD, USA
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22
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Miller R, Nixon G, Pickering JW, Stokes T, Turner RM, Young J, Gutenstein M, Smith M, Norman T, Watson A, George P, Devlin G, Du Toit S, Than M. A prospective multi-centre study assessing the safety and effectiveness following the implementation of an accelerated chest pain pathway using point-of-care troponin for use in New Zealand rural hospital and primary care settings. EUROPEAN HEART JOURNAL. ACUTE CARDIOVASCULAR CARE 2022; 11:418-427. [PMID: 35373255 PMCID: PMC9197428 DOI: 10.1093/ehjacc/zuac037] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Accepted: 03/15/2022] [Indexed: 11/30/2022]
Abstract
Aims Most rural hospitals and general practices in New Zealand (NZ) are reliant on point-of-care troponin. A rural accelerated chest pain pathway (RACPP), combining an electrocardiogram (ECG), a structured risk score (Emergency Department Assessment of Chest Pain Score), and serial point-of-care troponin, was designed for use in rural hospital and primary care settings across NZ. The aim of this study was to evaluate the safety and effectiveness of the RACPP. Methods and results A prospective multi-centre evaluation following implementation of the RACPP was undertaken from 1 July 2018 to 31 December 2020 in rural hospitals, rural and urban general practices, and urgent care clinics. The primary outcome measure was the presence of 30-day major adverse cardiac events (MACEs) in low-risk patients. The secondary outcome was the percentage of patients classified as low-risk that avoided transfer or were eligible for early discharge. There were 1205 patients enrolled in the study. 132 patients were excluded. Of the 1073 patients included in the primary analysis, 474 (44.0%) patients were identified as low-risk. There were no [95% confidence interval (CI): 0–0.3%] MACE within 30 days of the presentation among low-risk patients. Most of these patients (91.8%) were discharged without admission to hospital. Almost all patients who presented to general practice (99%) and urgent care clinics (97.6%) were discharged to home directly. Conclusion The RACPP is safe and effective at excluding MACEs in NZ rural hospital and primary care settings, where it can identify a group of low-risk patients who can be safely discharged home without transfer to hospital.
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Affiliation(s)
- Rory Miller
- Department of General Practice and Rural Health, University of Otago, Dunedin School of Medicine , Dunedin , New Zealand
| | - Garry Nixon
- Department of General Practice and Rural Health, University of Otago, Dunedin School of Medicine , Dunedin , New Zealand
| | - John W Pickering
- Emergency Department, University of Otago – Christchurch , Christchurch , New Zealand
| | - Tim Stokes
- Department of General Practice and Rural Health, University of Otago, Dunedin School of Medicine , Dunedin , New Zealand
| | - Robin M Turner
- Centre for Biostatistics, Division of Health Sciences, University of Otago , Dunedin , New Zealand
| | - Joanna Young
- Canterbury DHB, Christchurch Hospital , Christchurch , New Zealand
| | - Marc Gutenstein
- Rural Health Academic Centre Ashburton, University of Otago – Christchurch , Christchurch , New Zealand
| | - Michelle Smith
- Department of General Practice and Rural Health, University of Otago, Dunedin School of Medicine , Dunedin , New Zealand
| | - Tim Norman
- Project Office, Midlands Regional Health Network Charitable Trust , Hamilton , New Zealand
| | - Antony Watson
- Canterbury DHB, Christchurch Hospital , Christchurch , New Zealand
| | - Peter George
- Chemical Pathology, PathoGene, Merivale , Christchurch , New Zealand
| | | | | | - Martin Than
- Emergency Department, Canterbury DHB, Christchurch Hospital , Christchurch , New Zealand
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23
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Clerico A, Aimo A, Zaninotto M, Plebani M. Transdermal measurement of cardiac troponins: the future is now. Clin Chem Lab Med 2022; 60:1133-1135. [PMID: 35506635 DOI: 10.1515/cclm-2022-0382] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Aldo Clerico
- Scuola Superiore Sant'Anna and Fondazione CNR, Regione Toscana G. Monasterio, Pisa, Italy
| | - Alberto Aimo
- Scuola Superiore Sant'Anna and Fondazione CNR, Regione Toscana G. Monasterio, Pisa, Italy
| | - Martina Zaninotto
- Department of Laboratory Medicine, University Hospital of Padova, Padova, Italy.,Department of Medicine DIMED, University of Padova, Padova, Italy
| | - Mario Plebani
- Department of Laboratory Medicine, University Hospital of Padova, Padova, Italy.,Department of Medicine DIMED, University of Padova, Padova, Italy
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24
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Orlov AV, Malkerov JA, Novichikhin DO, Znoyko SL, Nikitin PI. Multiplex Label-Free Kinetic Characterization of Antibodies for Rapid Sensitive Cardiac Troponin I Detection Based on Functionalized Magnetic Nanotags. Int J Mol Sci 2022; 23:ijms23094474. [PMID: 35562865 PMCID: PMC9102693 DOI: 10.3390/ijms23094474] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Revised: 04/12/2022] [Accepted: 04/15/2022] [Indexed: 02/04/2023] Open
Abstract
Express and highly sensitive immunoassays for the quantitative registration of cardiac troponin I (cTnI) are in high demand for early point-of-care differential diagnosis of acute myocardial infarction. The selection of antibodies that feature rapid and tight binding with antigens is crucial for immunoassay rate and sensitivity. A method is presented for the selection of the most promising clones for advanced immunoassays via simultaneous characterization of interaction kinetics of different monoclonal antibodies (mAb) using a direct label-free method of multiplex spectral correlation interferometry. mAb-cTnI interactions were real-time registered on an epoxy-modified microarray glass sensor chip that did not require activation. The covalent immobilization of mAb microdots on its surface provided versatility, convenience, and virtually unlimited multiplexing potential. The kinetics of tracer antibody interaction with the “cTnI—capture antibody” complex was characterized. Algorithms are shown for excluding mutual competition of the tracer/capture antibodies and selecting the optimal pairs for different assay formats. Using the selected mAbs, a lateral flow assay was developed for rapid quantitative cTnI determination based on electronic detection of functionalized magnetic nanoparticles applied as labels (detection limit—0.08 ng/mL, dynamic range > 3 orders). The method can be extended to other molecular biomarkers for high-throughput screening of mAbs and rational development of immunoassays.
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Affiliation(s)
- Alexey V. Orlov
- Prokhorov General Physics Institute of the Russian Academy of Sciences, 38 Vavilov St, 119991 Moscow, Russia; (J.A.M.); (D.O.N.); (S.L.Z.)
- Correspondence: (A.V.O.); (P.I.N.)
| | - Juri A. Malkerov
- Prokhorov General Physics Institute of the Russian Academy of Sciences, 38 Vavilov St, 119991 Moscow, Russia; (J.A.M.); (D.O.N.); (S.L.Z.)
- National Research Nuclear University MEPhI (Moscow Engineering Physics Institute), 31 Kashirskoe Shosse, 115409 Moscow, Russia
| | - Denis O. Novichikhin
- Prokhorov General Physics Institute of the Russian Academy of Sciences, 38 Vavilov St, 119991 Moscow, Russia; (J.A.M.); (D.O.N.); (S.L.Z.)
- National Research Nuclear University MEPhI (Moscow Engineering Physics Institute), 31 Kashirskoe Shosse, 115409 Moscow, Russia
| | - Sergey L. Znoyko
- Prokhorov General Physics Institute of the Russian Academy of Sciences, 38 Vavilov St, 119991 Moscow, Russia; (J.A.M.); (D.O.N.); (S.L.Z.)
| | - Petr I. Nikitin
- Prokhorov General Physics Institute of the Russian Academy of Sciences, 38 Vavilov St, 119991 Moscow, Russia; (J.A.M.); (D.O.N.); (S.L.Z.)
- National Research Nuclear University MEPhI (Moscow Engineering Physics Institute), 31 Kashirskoe Shosse, 115409 Moscow, Russia
- Correspondence: (A.V.O.); (P.I.N.)
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25
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Gunsolus IL, Schulz K, Sandoval Y, Smith SW, Lindgren B, Okeson B, Apple FS. Diagnostic performance of a rapid, novel, whole blood, point of care high-sensitivity cardiac troponin I assay for myocardial infarction. Clin Biochem 2022; 105-106:70-74. [PMID: 35447148 DOI: 10.1016/j.clinbiochem.2022.04.008] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2022] [Revised: 04/08/2022] [Accepted: 04/14/2022] [Indexed: 11/03/2022]
Abstract
BACKGROUND We evaluated the diagnostic performance of a whole blood, point of care (POC) high-sensitivity cardiac troponin I (hs-cTnI) assay for myocardial infarction (MI) compared to central laboratory assays. METHODS Consecutive patients presenting to the emergency department with symptoms of ischemia were studied. Serial hs-cTnI testing was based on clinical indication at presentation. Parallel measurements were made using fresh whole blood on Siemens Atellica VTLi POC assay, EDTA plasma on Abbott ARCHITECT i2000 used in practice, and heparin plasma on Siemens Atellica. MI was determined according to the Fourth Universal Definition of MI using 99th percentiles. Sensitivities and negative predictive values (NPV) were calculated using 99th percentile URLs. RESULTS 1089 Patients, 418 females and 671 males, were enrolled. There were 91 (8.4%) MIs. At baseline (0 h), POC hs-cTnI assay had a sensitivity of 65.7% (95% CI 47.8-80.9) for females and 67.9% (54.0-79.7) for males and NPV of 96.4% (93.9-98.1) for females and 96.7% (94.9-98.0) for males. At 2 h, sensitivity improved to 82.9% (66.4-93.4) for females and 80.4% (67.6-89.8) for males, while NPV improved to 98.2% (96.1-99.3) and 97.9% (96.3-99.0), respectively. For central laboratory assays, comparable diagnostics were observed at 2 h: females - sensitivity 94.3% (80.8-99.3) for ARCHITECT and 79.4% (62.1-91.3) for Atellica, and NPV 99.3% (97.6-99.9) and 98.0% (95.8-99.2), respectively; males - sensitivity 87.5% (75.9-94.8) for ARCHITECT and 80.4% (67.6-89.8) for Atellica, NPVs of 98.7% (97.3-99.5) and 97.9% (96.3-99.0), respectively. CONCLUSIONS The POC, whole blood Atellica VTLi hs-cTnI assay demonstrated comparable diagnostic accuracy for MI to central laboratory assays using 99th percentiles.
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Affiliation(s)
- Ian L Gunsolus
- Department of Laboratory Medicine and Pathology, HealthPartners, Minneapolis, MN, USA
| | - Karen Schulz
- Cardiac Biomarkers Trials Laboratory, Hennepin Healthcare Research Institute, Minneapolis, MN, USA
| | - Yader Sandoval
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Stephen W Smith
- Department of Emergency Medicine, Hennepin Healthcare/HCMC, Minneapolis, MN, USA; Department of Emergency Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Brittany Lindgren
- Department of Laboratory Medicine and Pathology, Hennepin Healthcare/HCMC, Minneapolis, MN, USA
| | - Brynn Okeson
- Minneapolis Heart Institute Foundation, Minneapolis, MN, USA
| | - Fred S Apple
- Department of Laboratory Medicine and Pathology, Hennepin Healthcare/HCMC, Minneapolis, MN, USA; Department of Laboratory Medicine and Pathology, University of Minnesota, Minneapolis, MN, USA; Cardiac Biomarkers Trials Laboratory, Hennepin Healthcare Research Institute, Minneapolis, MN, USA.
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26
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Clerico A, Aimo A, Cantinotti M. High-sensitivity cardiac troponins in pediatric population. Clin Chem Lab Med 2022; 60:18-32. [PMID: 34679265 DOI: 10.1515/cclm-2021-0976] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2021] [Accepted: 10/11/2021] [Indexed: 12/15/2022]
Abstract
Apparently healthy children often complain of chest pain, especially after physical exercise. Cardiac biomarker levels are often measured, but the clinical relevance of these assays in children is still debated, even when a cardiac disease is present. Coronary artery disease is exceedingly rare in children, but elevated circulating levels of cardiac troponin I (cTnI) and T (cTnT) in an acute setting may help detect heart failure due to an unknown cardiac disorder, or worsening heart failure, particularly in combination with other biomarkers such as B-type natriuretic peptides. However, the interpretation of biomarkers is often challenging, especially when institutions transition from conventional cTn assays to high-sensitivity (hs-cTn) methods, as well demonstrated in the emergency setting for adult patients. From a clinical perspective, the lack of established reference values in the pediatric age is the main problem limiting the use of hs-cTn methods for the diagnosis and managements of cardiac diseases in infants, children and adolescents. This review aims to discuss the possibility to use hs-cTnI and hs-cTnT to detect cardiac disease and to explore age-related differences in biomarker levels in the pediatric age. We start from some analytical and pathophysiological considerations related to hs-cTn assays. Then, after a systematic literature search, we discuss the current evidence and possible limitations of hs-cTn assay as indicators of cardiac disease in the most frequently cardiac disease in pediatric setting.
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Affiliation(s)
- Aldo Clerico
- Fondazione CNR-Regione Toscana G. Monasterio and Scuola Superiore Sant'Anna, Pisa, Italy
| | - Alberto Aimo
- Fondazione CNR-Regione Toscana G. Monasterio and Scuola Superiore Sant'Anna, Pisa, Italy
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27
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Cullen L, Collinson PO, Giannitsis E. Point-of-care testing with high-sensitivity cardiac troponin assays: the challenges and opportunities. Emerg Med J 2022; 39:861-866. [PMID: 35017187 DOI: 10.1136/emermed-2021-211907] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Accepted: 12/29/2021] [Indexed: 12/12/2022]
Abstract
Methods to improve the safety, accuracy and efficiency of assessment of patients with suspected acute coronary symptoms have occupied decades of study and have supported significant changes in clinical practice. Much of the progress is reliant on results of laboratory-based high-sensitivity cardiac troponin assays that can detect low concentrations with high precision. Until recently, point-of-care (POC) platforms were unable to perform with similar analytical precision as laboratory-based assays, and recommendations for their use in accelerated assessment strategies for patients with suspected acute coronary syndrome has been limited. As POC assays can provide troponin results within 20 min, and can be used proximate to patient care, improvements in the efficiency of assessment of patients with suspected acute coronary syndrome is possible, particularly with new high-sensitivity assays.
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Affiliation(s)
- Louise Cullen
- Emergency and Trauma Centre, Royal Brisbane and Women's Hospital, Herston, Queensland, Australia
| | - Paul O Collinson
- Departments of Clinical Blood Sciences and Cardiology, St George's University of London, London, UK
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28
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Kapur A, Boutin S, Lyster K, Irvine J, Sawchuk K. Retrospective application of the HEAR score on patients evacuated for chest pain: Assessing the utility of point-of-care troponin. CANADIAN JOURNAL OF RURAL MEDICINE 2022; 27:16-21. [PMID: 34975112 DOI: 10.4103/cjrm.cjrm_23_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Introduction The HEART scoring system codifies the clinical gestalt used by physicians with 0-2 points assigned to 5 criteria (history, electrocardiography, age, risk factors and troponin). This scoring provides a prognostic tool that assists in disposition planning. The use of a truncated HEART score, minus the troponin data (HEAR score), was used for patients presenting with chest pain at one of four outpost nursing stations served by La Ronge Health Centre in northern Saskatchewan. These nursing stations have no onsite physician and no ability to obtain any troponin data. This study set out to determine if there was any utility in conducting point-of-care (PoC) troponins in these nursing outposts. Materials and Methods A retrospective analysis was conducted using the La Ronge regional electronic medical record by searching for all patients for whom an outpost nurse had called a physician regarding chest pain symptoms between 01 January 2011 and 31 December 2016. The HEAR and HEART score were then calculated for each individual presentation of patients with chest pain that met inclusion and exclusion criteria. Results By calculating both the patient's HEART score before evacuation from the outposts and after (i.e. with the troponin data), we were able to determine that, in 89.4% of cases (110/123 events), patients would require evacuation regardless of the troponin values due to a HEART score ≥4. In 10.6% (13/124 events) of cases, the patients who were evacuated had a HEART score ≤3, and in only one case did the troponin data increase this score. Conclusions The majority of patients would continue to be evacuated regardless of the result of their PoC troponin due to an already elevated HEAR score. PoC troponin is unlikely to reduce the rate of evacuation of patients with chest pain from the nursing stations served by the La Ronge Health Centre.
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Affiliation(s)
- A Kapur
- Emergency Medicine, University of Saskatchewan, Regina, SK, Canada
| | - S Boutin
- Emergency Medicine, University of Saskatchewan, Saskatoon, SK, Canada
| | - K Lyster
- Family Medicine, University of Saskatchewan, Regina, SK, Canada
| | - J Irvine
- Internal Medicine, Regina Qu'appelle Health Region, Regina, SK, Canada
| | - K Sawchuk
- Academic Family Medicine, University of Saskatchewan, LaRonge, SK, Canada
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29
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Clerico A, Zaninotto M, Aimo A, Dittadi R, Cosseddu D, Perrone M, Padoan A, Masotti S, Belloni L, Migliardi M, Fortunato A, Trenti T, Malloggi L, Cappelletti P, Galli GA, Bernardini S, Sciacovelli L, Plebani M. Use of high-sensitivity cardiac troponins in the emergency department for the early rule-in and rule-out of acute myocardial infarction without persistent ST-segment elevation (NSTEMI) in Italy. Clin Chem Lab Med 2021; 60:169-182. [PMID: 34927403 DOI: 10.1515/cclm-2021-1085] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Accepted: 11/26/2021] [Indexed: 12/15/2022]
Abstract
Serial measurements of cardiac troponin are recommended by international guidelines to diagnose myocardial infarction (MI) since 2000. However, some relevant differences exist between the three different international guidelines published between 2020 and 2021 for the management of patients with chest pain and no ST-segment elevation. In particular, there is no agreement on the cut-offs or absolute change values to diagnose non-ST-segment elevation MI (NSTEMI). Other controversial issues concern the diagnostic accuracy and cost-effectiveness of cut-off values for the most rapid algorithms (0 h/1 h or 0 h/2 h) to rule-in and rule-out NSTEMI. Finally, another important point is the possible differences between demographic and clinical characteristics of patients enrolled in multicenter trials compared to those routinely admitted to the Emergency Department in Italy. The Study Group of Cardiac Biomarkers, supported by the Italian Scientific Societies Società Italiana di Biochimica Clinica, Italian Society of the European Ligand Assay Society, and Società Italiana di Patolgia Clinica e Medicina di Laboratorio decided to revise the document previously published in 2013 about the management of patients with suspected NSTEMI, and to provide some suggestions for the use of these biomarkers in clinical practice, with a particular focus on the Italian setting.
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Affiliation(s)
- Aldo Clerico
- Fondazione CNR Regione Toscana G. Monasterio e Scuola Superiore Sant'Anna, Pisa, Italy
| | - Martina Zaninotto
- Department of Laboratory Medicine, University Hospital of Padova, Padova, Italy.,Department of Medicine-DIMED, University of Padova, Padova, Italy
| | - Alberto Aimo
- Fondazione CNR Regione Toscana G. Monasterio e Scuola Superiore Sant'Anna, Pisa, Italy
| | - Ruggero Dittadi
- Ospedale dell'Angelo ULSS 3 Serenissima, Laboratorio di Analisi Cliniche, Mestre, Italy
| | - Domenico Cosseddu
- S.C. Laboratorio Analisi, A.O. Ordine Mauriziano di Torino, Torino, Italy
| | - Marco Perrone
- Division of Cardiology and Clinical Biochemistry, University of Rome Tor Vergata, Rome, Italy
| | - Andrea Padoan
- Department of Laboratory Medicine, University Hospital of Padova, Padova, Italy
| | - Silvia Masotti
- Fondazione CNR Regione Toscana G. Monasterio e Scuola Superiore Sant'Anna, Pisa, Italy
| | - Lucia Belloni
- Dipartimento di Medicina di laboratorio, Arcispedale Santa Maria Nuova - IRCCS, Reggio Emilia, Italy
| | - Marco Migliardi
- S.C. Laboratorio Analisi, A.O. Ordine Mauriziano di Torino, Torino, Italy
| | | | - Tommaso Trenti
- Azienda Ospedaliero - Universitaria Policlinico di Modena c/o Ospedale Civile di Baggiovara, Modena, Italy
| | - Lucia Malloggi
- Laboratorio Analisi, Azienda Ospedaliera-Universitaria di Pisa, Pisa, Italy
| | | | | | - Sergio Bernardini
- Division of Cardiology and Clinical Biochemistry, University of Rome Tor Vergata, Rome, Italy
| | - Laura Sciacovelli
- Department of Laboratory Medicine, University Hospital of Padova, Padova, Italy
| | - Mario Plebani
- Department of Laboratory Medicine, University Hospital of Padova, Padova, Italy
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30
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Martín-Rodríguez F, Sanz-García A, Castro-Portillo E, Delgado-Benito JF, Del Pozo Vegas C, Ortega Rabbione G, Martín-Herrero F, Martín-Conty JL, López-Izquierdo R. Prehospital troponin as a predictor of early clinical deterioration. Eur J Clin Invest 2021; 51:e13591. [PMID: 34002363 DOI: 10.1111/eci.13591] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Revised: 02/01/2021] [Accepted: 04/09/2021] [Indexed: 12/19/2022]
Abstract
BACKGROUND AND OBJECTIVES Elevated troponin T (cTnT) values are associated with comorbidities and early mortality, in both cardiovascular and noncardiovascular diseases. The objective of this study is to evaluate the prognostic accuracy of the sole utilization of prehospital point-of-care cardiac troponin T to identify the risk of early in-hospital deterioration, including mortality within 28 days. METHODS We conducted a prospective, multicentric, controlled, ambulance-based, observational study in adults with acute diseases transferred with high priority by ambulance to emergency departments, between 1 January and 30 September 2020. Patients with hospital diagnosis of acute coronary syndrome were excluded. The discriminative power of the predictive cTnT was assessed through a discrimination model trained using a derivation cohort and evaluated by the area under the curve of the receiver operating characteristic on a validation cohort. RESULTS A total of 848 patients were included in our study. The median age was 68 years (25th-75th percentiles: 50-81 years), and 385 (45.4%) were women. The mortality rate within 28 days was 12.4% (156 cases). The predictive ability of cTnT to predict mortality presented an area under the curve of 0.903 (95% CI: 0.85-0.954; P < .001). Risk stratification was performed, resulting in three categories with the following optimal cTnT cut-off points: high risk greater than or equal to 100, intermediate risk 40-100 and low risk less than 40 ng/L. In the high-risk group, the mortality rate was 61.7%, and on the contrary, the low-risk group presented a mortality of 2.3%. CONCLUSIONS The implementation of a routine determination of cTnT on the ambulance in patients transferred with high priority to the emergency department can help to stratify the risk of these patients and to detect unknown early clinical deterioration.
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Affiliation(s)
- Francisco Martín-Rodríguez
- Advanced Life Support Unit, Gerencia de Emergencias Sanitarias, Gerencia Regional de Salud de Castilla y León (SACYL), Valladolid, Spain.,Advanced Clinical Simulation Center, Medicine Faculty, Valladolid University, Valladolid, Spain
| | - Ancor Sanz-García
- Data Analysis Unit, Health Research Institute, Hospital de la Princesa, Madrid (IIS-IP), Spain
| | - Enrique Castro-Portillo
- Emergency Department, Hospital Universitario Rio Hortega de Valladolid, Gerencia Regional de Salud de Castilla y León (SACYL), Salamanca, Spain
| | - Juan F Delgado-Benito
- Advanced Life Support Unit, Gerencia de Emergencias Sanitarias, Gerencia Regional de Salud de Castilla y León (SACYL), Valladolid, Spain
| | - Carlos Del Pozo Vegas
- Emergency Department, Hospital Clínico Universitario de Valladolid, Gerencia Regional de Salud de Castilla y León (SACYL), Salamanca, Spain
| | - Guillermo Ortega Rabbione
- Data Analysis Unit, Health Research Institute, Hospital de la Princesa, Madrid (IIS-IP), Spain.,National Scientific and Technical Research Council (CONICET), Buenos Aires, Argentina
| | - Francisco Martín-Herrero
- Department of Cardiology, Complejo Asistencial de Salamanca, Gerencia Regional de Salud de Castilla y León (SACYL), Salamanca, Spain
| | - José Luis Martín-Conty
- Faculty of Health Sciences, Universidad de Castilla la Mancha, Talavera de la Reina, Spain
| | - Raúl López-Izquierdo
- Emergency Department, Hospital Universitario Rio Hortega de Valladolid, Gerencia Regional de Salud de Castilla y León (SACYL), Salamanca, Spain
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31
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Osredkar J, Krivic K, Fabjan T, Kumer K, Tršan J, Poljančič L, Finderle P, Možina H. Point-of-care high-sensitivity assay on PATHFAST as the backup in the emergency room. MEDICINE ACCESS @ POINT OF CARE 2021; 5:23992026211055095. [PMID: 36204501 PMCID: PMC9413655 DOI: 10.1177/23992026211055095] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Accepted: 10/06/2021] [Indexed: 12/05/2022] Open
Abstract
Aim: Although the levels of cardiac troponin I (cTnI) have proved to be a useful
diagnostic biomarker of acute myocardial infarction, there are a wide
variety of point-of-care (POC) analysers, which provide measurements of
cTnI. The aim of this study was to compare the results obtained by the ADVIA
Centaur ultra-assay cTnI assay (us-cTnI), ADVIA Centaur high-sensitive cTnI
assay (hs-cTnI) and a POC high-sensitivity assay using PATHFAST. We also
aimed to explore total turnaround time (TAT) for laboratory results using
the POC PATHFAST analyser. Methods: Samples from 161 patients were taken. Of these samples, 129 were tested with
all three assays (us-cTnI, hs-cTnI and PATHFAST), and 32 samples were tested
on PATHFAST for the comparison of whole blood, serum and plasma. Results: Comparison of the POC testing methods in this study demonstrated that there
are strong linear relationships between all three cTnI assays (us-cTnI,
hs-cTnI and POC on PATHFAST). Furthermore, we also show there are strong
linear relationships between the two high-sensitive cTnI assays (hs-cTnI and
PATHFAST) for blood serum samples, as determined by Passing–Bablok
regression analyses. In our comparison of our new data with our older study,
the TAT went down. Conclusion: The timeliness of laboratory results is, in addition to accuracy and
precision, one of the key indicators of laboratory performance, and at the
same time has a significant impact on the course of the patient’s condition.
It is therefore important that the laboratory strives to meet the
expectations of clinicians regarding the time from the order to the result
of the analysis.
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Affiliation(s)
- Joško Osredkar
- Institute of Clinical Chemistry and Biochemistry, University Medical Centre Ljubljana, Ljubljana, Slovenia
- Faculty of Pharmacy, University of Ljubljana, Ljubljana, Slovenia
| | - Katja Krivic
- Faculty of Pharmacy, University of Ljubljana, Ljubljana, Slovenia
| | - Teja Fabjan
- Institute of Clinical Chemistry and Biochemistry, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Kristina Kumer
- Institute of Clinical Chemistry and Biochemistry, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Jure Tršan
- Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Laura Poljančič
- Department of Anaesthesiology and Surgical Intensive Care, Division of Surgery, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Petra Finderle
- Institute of Clinical Chemistry and Biochemistry, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Hugon Možina
- Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
- Medical Emergency Unit, Division of Internal Medicine, University Medical Centre Ljubljana, Ljubljana, Slovenia
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32
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Modeling Hypoxic Stress In Vitro Using Human Embryonic Stem Cells Derived Cardiomyocytes Matured by FGF4 and Ascorbic Acid Treatment. Cells 2021; 10:cells10102741. [PMID: 34685725 PMCID: PMC8534799 DOI: 10.3390/cells10102741] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Revised: 10/08/2021] [Accepted: 10/11/2021] [Indexed: 11/23/2022] Open
Abstract
Mature cardiomyocytes (CMs) obtained from human pluripotent stem cells (hPSCs) have been required for more accurate in vitro modeling of adult-onset cardiac disease and drug discovery. Here, we found that FGF4 and ascorbic acid (AA) induce differentiation of BG01 human embryonic stem cell–cardiogenic mesoderm cells (hESC-CMCs) into mature and ventricular CMs. Co-treatment of BG01 hESC-CMCs with FGF4+AA synergistically induced differentiation into mature and ventricular CMs. FGF4+AA-treated BG01 hESC-CMs robustly released acute myocardial infarction (AMI) biomarkers (cTnI, CK-MB, and myoglobin) into culture medium in response to hypoxic injury. Hypoxia-responsive genes and potential cardiac biomarkers proved in the diagnosis and prognosis of coronary artery diseases were induced in FGF4+AA-treated BG01 hESC-CMs in response to hypoxia based on transcriptome analyses. This study demonstrates that it is feasible to model hypoxic stress in vitro using hESC-CMs matured by soluble factors.
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33
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Regan B, O'Kennedy R, Collins D. Advances in point-of-care testing for cardiovascular diseases. Adv Clin Chem 2021; 104:1-70. [PMID: 34462053 DOI: 10.1016/bs.acc.2020.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Point-of-care testing (POCT) is a specific format of diagnostic testing that is conducted without accompanying infrastructure or sophisticated instrumentation. Traditionally, such rapid sample-to-answer assays provide inferior analytical performances to their laboratory counterparts when measuring cardiac biomarkers. Hence, their potentially broad applicability is somewhat bound by their inability to detect clinically relevant concentrations of cardiac troponin (cTn) in the early stages of myocardial injury. However, the continuous refinement of biorecognition elements, the optimization of detection techniques, and the fabrication of tailored fluid handling systems to manage the sensing process has stimulated the production of commercial assays that can support accelerated diagnostic pathways. This review will present the latest commercial POC assays and examine their impact on clinical decision-making. The individual elements that constitute POC assays will be explored, with an emphasis on aspects that contribute to economically feasible and highly sensitive assays. Furthermore, the prospect of POCT imparting a greater influence on early interventions for medium to high-risk individuals and the potential to re-shape the paradigm of cardiovascular risk assessments will be discussed.
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Affiliation(s)
- Brian Regan
- School of Biotechnology, Dublin City University, Dublin, Ireland.
| | - Richard O'Kennedy
- School of Biotechnology, Dublin City University, Dublin, Ireland; Research Complex, Hamad Bin Khalifa University, Qatar Foundation, Doha, Qatar
| | - David Collins
- School of Biotechnology, Dublin City University, Dublin, Ireland
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Delombaerde D, Vervloet D, Franssen C, Croes L, Gremonprez F, Prenen H, Peeters M, Vulsteke C. Clinical implications of isolated troponinemia following immune checkpoint inhibitor therapy. ESMO Open 2021; 6:100216. [PMID: 34271309 PMCID: PMC8287144 DOI: 10.1016/j.esmoop.2021.100216] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Revised: 06/18/2021] [Accepted: 06/28/2021] [Indexed: 01/27/2023] Open
Abstract
Cardiovascular adverse events induced by immune checkpoint inhibitors (ICIs) have gained significant interest over the past decade due to their impact on short- and long-term outcomes. They were initially thought to be rare, but the increasing use of ICIs in the treatment of both advanced and early stages of various malignancies has resulted in a substantial increase in their incidence. Different guidelines have proposed screening measures for ICI-induced myocarditis by incorporating troponin measurements at baseline and during the first few weeks of treatment. However, no specific guidelines have been developed yet regarding the interpretation of an asymptomatic rise in troponins. This state-of-the art review aims to provide an overview of the clinical relevance of elevated troponins during checkpoint inhibition and recommendations on how to manage elevated troponin levels during ICI therapy.
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Affiliation(s)
- D Delombaerde
- Integrated Cancer Center Ghent, Department of Medical Oncology, AZ Maria Middelares, Ghent, Belgium; Center for Oncological Research (CORE), Integrated Personalized and Precision Oncology Network (IPPON), University of Antwerp, Wilrijk, Belgium.
| | - D Vervloet
- Department of Cardiology, AZ Maria Middelares, Ghent, Belgium
| | - C Franssen
- Department of Cardiology, Antwerp University Hospital, Edegem, Belgium
| | - L Croes
- Integrated Cancer Center Ghent, Department of Medical Oncology, AZ Maria Middelares, Ghent, Belgium; Center for Oncological Research (CORE), Integrated Personalized and Precision Oncology Network (IPPON), University of Antwerp, Wilrijk, Belgium
| | - F Gremonprez
- Integrated Cancer Center Ghent, Department of Medical Oncology, AZ Maria Middelares, Ghent, Belgium
| | - H Prenen
- Center for Oncological Research (CORE), Integrated Personalized and Precision Oncology Network (IPPON), University of Antwerp, Wilrijk, Belgium; Multidisciplinary Oncologic Center Antwerp (MOCA), Antwerp University Hospital, Edegem, Belgium
| | - M Peeters
- Center for Oncological Research (CORE), Integrated Personalized and Precision Oncology Network (IPPON), University of Antwerp, Wilrijk, Belgium; Multidisciplinary Oncologic Center Antwerp (MOCA), Antwerp University Hospital, Edegem, Belgium
| | - C Vulsteke
- Integrated Cancer Center Ghent, Department of Medical Oncology, AZ Maria Middelares, Ghent, Belgium; Center for Oncological Research (CORE), Integrated Personalized and Precision Oncology Network (IPPON), University of Antwerp, Wilrijk, Belgium
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Sörensen NA, Goßling A, Neumann JT, Hartikainen TS, Haller PM, Scharlemann L, Lehmacher J, Ziegler A, Blankenberg S, Zeller T, Nordholt G, Renné T, Westermann D. Diagnostic Validation of a High-Sensitivity Cardiac Troponin I Assay. Clin Chem 2021; 67:1230-1239. [PMID: 34254126 DOI: 10.1093/clinchem/hvab070] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Accepted: 04/30/2021] [Indexed: 01/29/2023]
Abstract
BACKGROUND Emergency departments worldwide are increasingly adopting rapid diagnosis of patients with suspected myocardial infarction (MI) based on high-sensitivity troponin. We set out to assess the diagnostic accuracy of a high-sensitivity cardiac troponin I (hs-cTnI) assay in a prospective study. METHODS In a cohort study including 1800 patients presenting with suspected acute MI, we developed and temporally validated a 0/1 h diagnostic algorithm using the Siemens Atellica IM hs-cTnI assay. The algorithm was established in the first 928 patients and validated in the following 872 patients. RESULTS The derived algorithm consisted of a baseline rule-out of non-ST-segment elevation MI using a cutoff <3 ng/L in patients with symptom onset ≥3 h or an admission troponin I level <6 ng/L with a Δ change of <3 ng/L from 0 h to 1 h. For rule-in, an admission troponin I level ≥120 ng/L or an increase within the first hour ≥12 ng/L was required. Application of the algorithm to the validation cohort showed a negative predictive value of 99.8% (95% CI, 98.7%-100.0%), sensitivity of 99.1% (95% CI, 95.1%-100.0%), and 48.3% of patients ruled out, whereas 15.1% were ruled in with a positive predictive value of 68.0% (95% CI, 59.1%-75.9%) and specificity of 94.4% (95% CI, 92.5%-96.0%). The diagnostic performance was comparable to guideline-recommended application of an established hs-cTnI assay in a rapid 0/1 h strategy. CONCLUSIONS The Siemens hs-cTnI assay is well suited for application in rapid diagnostic stratification of patients with suspected MI. STUDY REGISTRATION www.clinicaltrials.gov (NCT02355457).
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Affiliation(s)
- Nils A Sörensen
- Department of Cardiology, University Heart and Vascular Center Hamburg, Hamburg, Germany.,German Center for Cardiovascular Research (DZHK), Hamburg, Germany
| | - Alina Goßling
- Department of Cardiology, University Heart and Vascular Center Hamburg, Hamburg, Germany
| | - Johannes T Neumann
- Department of Cardiology, University Heart and Vascular Center Hamburg, Hamburg, Germany.,German Center for Cardiovascular Research (DZHK), Hamburg, Germany.,Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Tau S Hartikainen
- Department of Cardiology, University Heart and Vascular Center Hamburg, Hamburg, Germany.,German Center for Cardiovascular Research (DZHK), Hamburg, Germany
| | - Paul M Haller
- Department of Cardiology, University Heart and Vascular Center Hamburg, Hamburg, Germany.,German Center for Cardiovascular Research (DZHK), Hamburg, Germany
| | - Lea Scharlemann
- Department of Cardiology, University Heart and Vascular Center Hamburg, Hamburg, Germany
| | - Jonas Lehmacher
- Department of Cardiology, University Heart and Vascular Center Hamburg, Hamburg, Germany
| | - Andreas Ziegler
- Department of Cardiology, University Heart and Vascular Center Hamburg, Hamburg, Germany.,School of Mathematics, Statistics and Computer Science, University of KwaZulu-Natal, Pietermaritzburg, South Africa.,Cardio-Care AG, Medizincampus Davos, Davos, Switzerland
| | - Stefan Blankenberg
- Department of Cardiology, University Heart and Vascular Center Hamburg, Hamburg, Germany.,German Center for Cardiovascular Research (DZHK), Hamburg, Germany
| | - Tanja Zeller
- Department of Cardiology, University Heart and Vascular Center Hamburg, Hamburg, Germany.,German Center for Cardiovascular Research (DZHK), Hamburg, Germany
| | - Gerhard Nordholt
- Institute of Clinical Chemistry and Laboratory Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Thomas Renné
- Institute of Clinical Chemistry and Laboratory Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Dirk Westermann
- Department of Cardiology, University Heart and Vascular Center Hamburg, Hamburg, Germany.,German Center for Cardiovascular Research (DZHK), Hamburg, Germany
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Clerico A, Zaninotto M, Plebani M. High-sensitivity assay for cardiac troponins with POCT methods. The future is soon. Clin Chem Lab Med 2021; 59:1477-1478. [PMID: 34090315 DOI: 10.1515/cclm-2021-0620] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Affiliation(s)
- Aldo Clerico
- Department of Laboratory Medicine, Cardiovascular Endocrinology and Cell Biology, Scuola Superiore Sant'Anna e Fondazione CNR - Regione Toscana G. Monasterio, Pisa, Italy
| | - Martina Zaninotto
- Department of Laboratory Medicine, University Hospital of Padova, Padova, Italy
| | - Mario Plebani
- Department of Laboratory Medicine, University Hospital of Padova, Padova, Italy.,Department of Medicine-DIMED, University of Padova, Padova, Italy
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Gopi V, Milles B, Spanuth E, Müller-Hennessen M, Biener M, Stoyanov K, Frey N, Giannitsis E. Comparison of the analytical performance of the PATHFAST high sensitivity cardiac troponin I using fresh whole blood vs. fresh plasma samples. Clin Chem Lab Med 2021; 59:1579-1584. [PMID: 34087961 DOI: 10.1515/cclm-2021-0354] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Accepted: 05/25/2021] [Indexed: 01/19/2023]
Abstract
OBJECTIVES The PATHFAST hs-cTnI (high-sensitivity cardiac troponin) assay is the first point-of-care assay with a high-sensitivity designation that received FDA approval for diagnosis of myocardial infarction (MI). Testing from whole blood does not need centrifugation and therefore is faster and more convenient in the emergency room instead of plasma. However, there is sparse evidence whether point-of-care testing of Tn from whole blood is as reliable as from plasma samples. METHODS We investigated the agreement between plasma and whole blood hs-cTnI by using the PATHFAST hs-cTnI assay. Hs-cTnT measured on Cobas 602 in the central laboratory and compared to a final diagnosis of NSTEMI using serial hs-cTnT served as reference. We assessed biases, limits of agreement (±1.96 SD) and coefficients of correlation, and tested the discriminatory ability of the baseline sample of plasma and whole blood hs-cTnI and plasma hs-cTnT to discriminate non-ST-segment elevation myocardial infarction (NSTEMI). RESULTS A total of 224 paired fresh samples were collected simultaneously from 191 patients presenting with suspected acute coronary syndrome. There was an excellent correlation between plasma and whole blood hs-cTnI (r=0.99), and a very good inter-rater agreement (k=0.93) between elevated and normal plasma and whole blood results. Precision evaluation according to CLSI ep 15 revealed comparable coefficients of variation (CV) in whole blood and plasma. The discriminatory ability of baseline hs-cTnT, plasma and whole blood hs-cTnI was excellent (AUC 0.967, AUC 0.954 and AUC 0.953) without significant difference. CONCLUSIONS Whole blood can be used interchangeably with plasma for more convenient and less time and labor-consuming testing of hs-cTnI on the PATHFAST instrument.
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Affiliation(s)
- Vinajak Gopi
- Department of Cardiology, Angiology and Pulmonology, Heidelberg University Hospital, Heidelberg, Germany
| | - Barbara Milles
- Department of Cardiology, Angiology and Pulmonology, Heidelberg University Hospital, Heidelberg, Germany
| | | | - Matthias Müller-Hennessen
- Department of Cardiology, Angiology and Pulmonology, Heidelberg University Hospital, Heidelberg, Germany
| | - Moritz Biener
- Department of Cardiology, Angiology and Pulmonology, Heidelberg University Hospital, Heidelberg, Germany
| | - Kiril Stoyanov
- Department of Cardiology, Angiology and Pulmonology, Heidelberg University Hospital, Heidelberg, Germany
| | - Norbert Frey
- Department of Cardiology, Angiology and Pulmonology, Heidelberg University Hospital, Heidelberg, Germany
| | - Evangelos Giannitsis
- Department of Cardiology, Angiology and Pulmonology, Heidelberg University Hospital, Heidelberg, Germany
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38
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Collet JP, Thiele H, Barbato E, Barthélémy O, Bauersachs J, Bhatt DL, Dendale P, Dorobantu M, Edvardsen T, Folliguet T, Gale CP, Gilard M, Jobs A, Jüni P, Lambrinou E, Lewis BS, Mehilli J, Meliga E, Merkely B, Mueller C, Roffi M, Rutten FH, Sibbing D, Siontis GC. Guía ESC 2020 sobre el diagnóstico y tratamiento del síndrome coronario agudo sin elevación del segmento ST. Rev Esp Cardiol (Engl Ed) 2021. [DOI: 10.1016/j.recesp.2020.12.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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39
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Cooper JG, Ferguson J, Donaldson LA, Black KMM, Livock KJ, Horrill JL, Davidson EM, Scott NW, Lee AJ, Fujisawa T, Lee KK, Anand A, Shah ASV, Mills NL. The Ambulance Cardiac Chest Pain Evaluation in Scotland Study (ACCESS): A Prospective Cohort Study. Ann Emerg Med 2021; 77:575-588. [PMID: 33926756 DOI: 10.1016/j.annemergmed.2021.01.012] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Revised: 01/11/2021] [Accepted: 01/12/2021] [Indexed: 11/22/2022]
Abstract
STUDY OBJECTIVE To determine whether risk stratification in the out-of-hospital setting could identify patients with chest pain who are at low and high risk to avoid admission or aid direct transfer to cardiac centers. METHODS Paramedics prospectively enrolled patients with suspected acute coronary syndrome without diagnostic ST-segment elevation on the ECG. The History, ECG, Age and Risk Factors (HEAR) score was recorded contemporaneously, and out-of-hospital samples were obtained to measure cardiac Troponin I (cTnI) level on a point-of-care device, to allow calculation of the History, ECG, Age, Risk Factors, and Troponin (HEART) score. HEAR and HEART scores less than or equal to 3 and greater than or equal to 7 were defined as low and high risk for major adverse cardiac events at 30 days. RESULTS Of 1,054 patients (64 years [SD 15 years]; 42% women), 284 (27%) experienced a major adverse cardiac event at 30 days. The HEAR score was calculated in all patients, with point-of-care cTnI testing available in 357 (34%). A HEAR score less than or equal to 3 identified 32% of patients (334/1,054) as low risk, with a sensitivity of 84.9% (95% confidence interval [CI] 80.7% to 89%), whereas a score greater than or equal to 7 identified just 3% of patients (30/1,054) as high risk, with a specificity of 98.7% (95% CI 97.9% to 99.5%). A point-of-care HEART score less than or equal to 3 identified a similar proportion as low risk (30%), with a sensitivity of 87.0% (95% CI 80.7% to 93.4%), whereas a score greater than or equal to 7 identified 14% as high risk, with a specificity of 94.8% (95% CI 92.0% to 97.5%). CONCLUSION Paramedics can use the HEAR score to discriminate risk, but even when used in combination with out-of-hospital point-of-care cTnI testing, the HEART score does not safely rule out major adverse cardiac events, and only a small proportion of patients are identified as high risk.
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Affiliation(s)
- Jamie G Cooper
- Emergency Department, Aberdeen Royal Infirmary, Aberdeen, United Kingdom; Department of Applied Medicine, University of Aberdeen, Aberdeen, United Kingdom.
| | - James Ferguson
- Emergency Department, Aberdeen Royal Infirmary, Aberdeen, United Kingdom; Department of Applied Medicine, University of Aberdeen, Aberdeen, United Kingdom
| | | | - Kim M M Black
- Emergency Department, Aberdeen Royal Infirmary, Aberdeen, United Kingdom
| | - Kate J Livock
- Emergency Department, Aberdeen Royal Infirmary, Aberdeen, United Kingdom
| | - Judith L Horrill
- Emergency Department, Aberdeen Royal Infirmary, Aberdeen, United Kingdom
| | - Elaine M Davidson
- Department of Clinical Biochemistry, Aberdeen Royal Infirmary, Aberdeen, United Kingdom
| | - Neil W Scott
- Medical Statistics Team, University of Aberdeen, Aberdeen, United Kingdom
| | - Amanda J Lee
- Medical Statistics Team, University of Aberdeen, Aberdeen, United Kingdom
| | - Takeshi Fujisawa
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom; BHF Cardiovascular Biomarker Laboratory, University of Edinburgh, Edinburgh, United Kingdom
| | - Kuan Ken Lee
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
| | - Atul Anand
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
| | - Anoop S V Shah
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom; Usher Institute, University of Edinburgh, Edinburgh, United Kingdom
| | - Nicholas L Mills
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom; BHF Cardiovascular Biomarker Laboratory, University of Edinburgh, Edinburgh, United Kingdom; Usher Institute, University of Edinburgh, Edinburgh, United Kingdom
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40
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Collet JP, Thiele H, Barbato E, Barthélémy O, Bauersachs J, Bhatt DL, Dendale P, Dorobantu M, Edvardsen T, Folliguet T, Gale CP, Gilard M, Jobs A, Jüni P, Lambrinou E, Lewis BS, Mehilli J, Meliga E, Merkely B, Mueller C, Roffi M, Rutten FH, Sibbing D, Siontis GCM. 2020 ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation. Eur Heart J 2021; 42:1289-1367. [PMID: 32860058 DOI: 10.1093/eurheartj/ehaa575] [Citation(s) in RCA: 2628] [Impact Index Per Article: 876.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
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41
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Giannitsis E, Blankenberg S, Christenson RH, Frey N, von Haehling S, Hamm CW, Inoue K, Katus HA, Lee CC, McCord J, Möckel M, Chieh JTW, Tubaro M, Wollert KC, Huber K. Critical appraisal of the 2020 ESC guideline recommendations on diagnosis and risk assessment in patients with suspected non-ST-segment elevation acute coronary syndrome. Clin Res Cardiol 2021; 110:1353-1368. [PMID: 33635437 PMCID: PMC8405476 DOI: 10.1007/s00392-021-01821-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Accepted: 02/08/2021] [Indexed: 10/27/2022]
Abstract
Multiple new recommendations have been introduced in the 2020 ESC guidelines for the management of acute coronary syndromes with a focus on diagnosis, prognosis, and management of patients presenting without persistent ST-segment elevation. Most recommendations are supported by high-quality scientific evidence. The guidelines provide solutions to overcome obstacles presumed to complicate a convenient interpretation of troponin results such as age-, or sex-specific cutoffs, and to give practical advice to overcome delays of laboratory reporting. However, in some areas, scientific support is less well documented or even missing, and other areas are covered rather by expert opinion or subjective recommendations. We aim to provide a critical appraisal on several recommendations, mainly related to the diagnostic and prognostic assessment, highlighting the discrepancies between Guideline recommendations and the existing scientific evidence.
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Affiliation(s)
- Evangelos Giannitsis
- Medizinische Klinik III, Department of Cardiology, Angiology and Pulmology, University Hospital of Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany.
| | - Stefan Blankenberg
- Department of Cardiology, University Heart and Vascular Centre Hamburg, Hamburg, Germany
| | | | - Norbert Frey
- Medizinische Klinik III, Department of Cardiology, Angiology and Pulmology, University Hospital of Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
| | - Stephan von Haehling
- Department of Cardiology and Pneumology, University of Göttingen Medical Center, Göttingen, Germany.,German Center for Cardiovascular Research (DZHK), Partner Site Göttingen, Göttingen, Germany
| | - Christian W Hamm
- Department of Cardiology, Kerckhoff Heart and Thorax Centre, Bad Nauheim, Germany
| | - Kenji Inoue
- Department of Cardiovascular Biology and Medicine, Juntendo University Nerima Hospital, Tokyo, Japan
| | - Hugo A Katus
- Medizinische Klinik III, Department of Cardiology, Angiology and Pulmology, University Hospital of Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
| | - Chien-Chang Lee
- Department of Emergency Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - James McCord
- Henry Ford Heart and Vascular Institute Detroit, Detroit, MI, USA
| | - Martin Möckel
- Department of Emergency Medicine, Charité-Universitätsmedizin Berlin, Campus Mitte and Virchow, Berlin, Germany
| | - Jack Tan Wei Chieh
- Department of Cardiology, National Heart Centre and Sengkang General Hospital, Singapore, Singapore
| | | | - Kai C Wollert
- Division of Molecular and Translational Cardiology, Department of Cardiology and Angiology, Hannover Medical School, Hannover, Germany
| | - Kurt Huber
- 3rd Department of Internal Medicine, Cardiology and Intensive Care Medicine, Wilhelminenhospital, Vienna, Austria.,Medical School, Sigmund Freud University, Vienna, Austria
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Johannessen TR, Atar D, Vallersnes OM, Larstorp ACK, Mdala I, Halvorsen S. Comparison of a single high-sensitivity cardiac troponin T measurement with the HEART score for rapid rule-out of acute myocardial infarction in a primary care emergency setting: a cohort study. BMJ Open 2021; 11:e046024. [PMID: 33627355 PMCID: PMC7908281 DOI: 10.1136/bmjopen-2020-046024] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE This study aims to compare the rule-out safety of a single high-sensitivity cardiac troponin T (hs-cTnT) with the History, ECG, Age, Risk factors and Troponin (HEART) score in a low-prevalence primary care setting of acute myocardial infarction (AMI). PARTICIPANTS Patients with non-specific symptoms suggestive of AMI were consecutively enroled at a primary care emergency clinic in Oslo, Norway from November 2016 to October 2018. METHODS After initial assessment by a general practitioner, hs-cTnT samples were drawn. AMI was ruled-out by a single hs-cTnT <5 ng/L measured ≥3 hours after symptom onset. The HEART score was calculated retrospectively; a score ≤3 of 10 points was considered low risk. We also calculated a modified HEART score using more sensitive hs-cTnT thresholds. The primary outcome was the diagnostic performance for the rule-out of AMI at the index event; the secondary the composite of AMI or all-cause death at 90 days. RESULTS Among 1711 patients, 61 (3.6%) were diagnosed with AMI, and 569 (33.3%) patients were assigned to single rule-out (<5 ng/L). With no AMIs in this group, the negative predictive value (NPV) and sensitivity were both 100.0% (95% CI 99.4% to 100.0% and 94.1% to 100.0%, respectively), and the specificity 34.5% (32.2% to 36.8%). The original HEART score triaged more patients as low risk (n=871), but missed five AMIs (NPV 99.4% (98.7% to 99.8%); sensitivity 91.8% (81.9% to 97.3%) and specificity 52.5% (50.0% to 54.9%)). The modified HEART score increased the low-risk sensitivity to 98.4% (91.2% to 100.0%), with specificity 38.7% (36.3% to 41.1%). The 90-day incidence of AMI or death in the single rule-out and the original and modified low-risk HEART groups were 0.0%, 0.7%, and 0.2%, respectively. CONCLUSION In a primary care emergency setting, a single hs-cTnT strategy was superior to the HEART score in ruling out AMI. This rapid and safe approach may enhance the assessment of patients with chest pain outside of hospitals. TRIAL REGISTRATION NUMBER NCT02983123.
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Affiliation(s)
- Tonje R Johannessen
- Department of General Practice, University of Oslo, Oslo, Norway
- Department of Emergency General Practice, Oslo Accident and Emergency Outpatient Clinic, Oslo, Norway
| | - Dan Atar
- Department of Cardiolgy, Oslo University Hospital, Ullevaal, Oslo, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Odd Martin Vallersnes
- Department of General Practice, University of Oslo, Oslo, Norway
- Department of Emergency General Practice, Oslo Accident and Emergency Outpatient Clinic, Oslo, Norway
| | - Anne Cecilie K Larstorp
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Section of Cardiovascular and Renal Research, Oslo University Hospital, Ullevaal, Oslo, Norway
| | - Ibrahimu Mdala
- Department of General Practice, University of Oslo, Oslo, Norway
| | - Sigrun Halvorsen
- Department of Cardiolgy, Oslo University Hospital, Ullevaal, Oslo, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
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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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44
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Bahbah EI, Noehammer C, Pulverer W, Jung M, Weinhaeusel A. Salivary biomarkers in cardiovascular disease: An insight into the current evidence. FEBS J 2020; 288:6392-6405. [PMID: 33370493 DOI: 10.1111/febs.15689] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Revised: 11/28/2020] [Accepted: 12/23/2020] [Indexed: 01/08/2023]
Abstract
Cardiovascular diseases (CVDs) are the most common cause of mortality worldwide. In acute cardiovascular conditions, time is a crucial player in the outcomes of disease management. Given the ease and noninvasiveness of obtaining saliva, salivary biomarkers may provide a rapid and efficient diagnosis of CVD. Here, we reviewed the published data on the value of salivary molecules for diagnosis of CVD, especially in acute care settings. In this review, we show that some biomarkers such as salivary creatinine kinase myocardial band, C-reactive protein, troponin-1, and myoglobin exhibited promising diagnostic values that were comparable to their serum counterparts. Other molecules were also investigated and showed controversial results, including myeloperoxidase, brain natriuretic peptide, and some oxidative stress markers. Based on our review, we concluded that the clinical use of salivary biomarkers to diagnose CVD is promising; however, it is still in the early stage of development. Further studies are needed to validate these findings, determine cutoff values for diagnosis, and compare them to other established biomarkers currently in clinical use.
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Affiliation(s)
- Eshak I Bahbah
- AIT Molecular Diagnostics, Center for Health & Bioresources, AIT Austrian Institute of Technology GmbH, Vienna, Austria.,Faculty of Medicine, Al-Azhar University, Damietta, Egypt
| | - Christa Noehammer
- AIT Molecular Diagnostics, Center for Health & Bioresources, AIT Austrian Institute of Technology GmbH, Vienna, Austria
| | - Walter Pulverer
- AIT Molecular Diagnostics, Center for Health & Bioresources, AIT Austrian Institute of Technology GmbH, Vienna, Austria
| | - Martin Jung
- AIT Molecular Diagnostics, Center for Health & Bioresources, AIT Austrian Institute of Technology GmbH, Vienna, Austria
| | - Andreas Weinhaeusel
- AIT Molecular Diagnostics, Center for Health & Bioresources, AIT Austrian Institute of Technology GmbH, Vienna, Austria
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Pudil R, Mueller C, Čelutkienė J, Henriksen PA, Lenihan D, Dent S, Barac A, Stanway S, Moslehi J, Suter TM, Ky B, Štěrba M, Cardinale D, Cohen‐Solal A, Tocchetti CG, Farmakis D, Bergler‐Klein J, Anker MS, Von Haehling S, Belenkov Y, Iakobishvili Z, Maack C, Ciardiello F, Ruschitzka F, Coats AJ, Seferovic P, Lainscak M, Piepoli MF, Chioncel O, Bax J, Hulot J, Skouri H, Hägler‐Laube ES, Asteggiano R, Fernandez TL, Boer RA, Lyon AR. Role of serum biomarkers in cancer patients receiving cardiotoxic cancer therapies: a position statement from the
Cardio‐Oncology Study Group
of the
Heart Failure Association
and the
Cardio‐Oncology Council of the European Society of Cardiology. Eur J Heart Fail 2020; 22:1966-1983. [DOI: 10.1002/ejhf.2017] [Citation(s) in RCA: 89] [Impact Index Per Article: 22.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2020] [Revised: 06/14/2020] [Accepted: 09/25/2020] [Indexed: 12/19/2022] Open
Affiliation(s)
- Radek Pudil
- 1st Department Medicine – Cardioangiology Charles University Prague, Medical Faculty and University Hospital Hradec Kralove Prague Czech Republic
| | - Christian Mueller
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology University Hospital Basel, University of Basel Basel Switzerland
| | - Jelena Čelutkienė
- Clinic of Cardiac and Vascular Diseases Institute of Clinical Medicine, Faculty of Medicine, Vilnius University Vilnius Lithuania
- State Research Institute Centre For Innovative Medicine Vilnius Lithuania
| | | | - Dan Lenihan
- Cardio‐Oncology Center of Excellence Washington University in St Louis St Louis MO USA
| | - Susan Dent
- Duke Cancer Institute Duke University Durham NC USA
| | - Ana Barac
- MedStar Heart and Vascular Institute Georgetown University Washington DC USA
| | | | - Javid Moslehi
- Cardio‐Oncology Program, Department of Medicine Vanderbilt University Medical Center Nashville TN USA
| | - Thomas M. Suter
- Department of Cardiology Bern University Hospital, Inselspital, University of Bern Bern Switzerland
| | - Bonnie Ky
- University of Pennsylvania Philadelphia PA USA
| | - Martin Štěrba
- Department of Pharmacology Faculty of Medicine in Hradec Kralove, Charles University Hradec Kralove Czech Republic
| | - Daniela Cardinale
- Cardioncology Unit European Institute of Oncology, IRCCS Milan Italy
| | - Alain Cohen‐Solal
- UMR‐S 942, Paris University, Cardiology Department, Lariboisiere Hospital, AP‐HP Paris France
| | - Carlo Gabriele Tocchetti
- Department of Translational Medical Sciences and Interdepartmental Center for Clinical and Translational Research (CIRCET) ‘Federico II’ University Naples Italy
| | - Dimitrios Farmakis
- University of Cyprus Medical School Nicosia Cyprus
- Cardio‐Oncology Clinic, Heart Failure Unit, ‘Attikon’ University Hospital Athens Greece
- National and Kapodistrian University of Athens Medical School Athens Greece
| | | | - Markus S. Anker
- Division of Cardiology and Metabolism, Department of Cardiology Charité and Berlin Institute of Health Center for Regenerative Therapies (BCRT) and DZHK (German Centre for Cardiovascular Research), partner site Berlin and Department of Cardiology, Charité Campus Benjamin Franklin Berlin Germany
| | - Stephan Von Haehling
- Department of Cardiology and Pneumology University of Goettingen Medical Center Goettingen Germany
- German Center for Cardiovascular Research (DZHK), partner site Goettingen Goettingen Germany
| | | | - Zaza Iakobishvili
- Department of Community Cardiology Tel Aviv Jaffa District, Clalit Health Fund and Sackler Faculty of Medicine, Tel Aviv University Tel Aviv Israel
| | - Christoph Maack
- Comprehensive Heart Failure Center University Clinic Würzburg Würzburg Germany
| | - Fortunato Ciardiello
- Department of Precision Medicine ‘Luigi Vanvitelli’ University of Campania Naples Italy
| | - Frank Ruschitzka
- University Heart Center, Department of Cardiology University Hospital Zurich Zurich Switzerland
| | - Andrew J.S. Coats
- University of Warwick Warwick UK
- Pharmacology Centre of Clinical and Experimental Medicine, IRCCS San Raffaele Pisana Rome Italy
| | - Petar Seferovic
- Faculty of Medicine and Serbian Academy of Sciences and Arts University of Belgrade Belgrade Serbia
| | | | - Massimo F. Piepoli
- Cardiac Department ‘Guglielmo da Saliceto’ Polichirurgico Hospital AUSL Piacenza Piacenza Italy
| | - Ovidiu Chioncel
- Emergency Institute for Cardiovascular Diseases ‘Prof. C.C. Iliescu’ Bucharest Romania
- University of Medicine Carol Davila Bucharest Romania
| | - Jereon Bax
- Department of Cardiology Leiden University Medical Centre Leiden The Netherlands
| | - Jean‐Sebastien Hulot
- Université de Paris CIC1418, Paris Cardiovascular Research Center, INSERM Paris France
| | - Hadi Skouri
- Cardiology Division, Internal Medicine Department at American University of Beirut Medical Center Beirut Lebanon
| | | | | | - Teresa Lopez Fernandez
- Cardiology Service Cardio‐Oncology Unit, La Paz University Hospital and IdiPAz Research Institute, Ciber CV Madrid Spain
| | - Rudolf A. Boer
- Department of Cardiology University of Groningen, University Medical Center Groningen Groningen The Netherlands
| | - Alexander R. Lyon
- Cardio‐Oncology Service Royal Brompton Hospital and Imperial College London London UK
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46
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Optimal Detection of Acute Myocardial Injury and Infarction with Cardiac Troponin: Beyond the 99th Percentile, into the High-Sensitivity Era. Curr Cardiol Rep 2020; 22:101. [PMID: 32748286 DOI: 10.1007/s11886-020-01350-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
PURPOSE OF REVIEW Cardiac troponin (cTn) is the biomarker of choice for the diagnosis of acute myocardial infarction (MI); use of this biomarker has centered around the 99th percentile upper reference limit (URL) for healthy populations. Recent development and regulatory approval of high-sensitivity cardiac troponin (hs-cTn) assays have required a fresh look at utilization of the 99th percentile URL. This review covers issues regarding the 99th percentile URL and approaches for use of cTn as biomarker for detecting cardiac injury and diagnosis of acute myocardial infarction. RECENT FINDINGS Development of hs-cTn assays has allowed determination and use of sex-specific 99th percentile URLs for assessing cardiac injury and increased the utility of cTn values below the 99th percentile URL. This improved analytical performance for hs-cTn assays has allowed for development of accelerated diagnostic protocols (ADPs) for rapid assessment and disposition of patients based on serial sampling of cTn for use in acute MI diagnosis as soon as 0-1 h after clinical presentation. The 99th percentile URLs of cTn is essential for detecting cardiac injury; however, use of the 99th percentile URLs in the era of hs-cTn results may be modified. ADPs have the potential to substantially decrease the time many patients spend under evaluation for acute MI, thereby potentiating improvement in patient satisfaction, decreased healthcare costs, and reducing the burden on emergency departments.
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47
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Collinson P. Cardiac biomarker measurement by point of care testing - Development, rationale, current state and future developments. Clin Chim Acta 2020; 508:234-239. [PMID: 32464138 DOI: 10.1016/j.cca.2020.05.018] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Revised: 05/08/2020] [Accepted: 05/08/2020] [Indexed: 11/28/2022]
Abstract
Cardiac biomarker measurements are integral to the diagnosis and management of patients presenting with breathlessness and chest pain. Measurement of B type natriuretic peptide either directly or of the N-terminal portion of the prohormone although possible by point of care testing (POCT) has largely become a laboratory test. Measurement of the cardiac troponins cardiac troponin T (cTnT) and cardiac troponin I (cTnI) can easily and accurately be performed by POCT. The situation has been complicated by the development of high sensitivity assays for cTnT and cTnI and the subsequent development of rapid rule out algorithms allowing patient categorisation and discharge on admission and 1 to 2 h following admission. This article reviews the development of POCT for cardiac biomarkers, the evidence base comparing POCT with central laboratory testing, its strengths and limitations, and how POCT fits into the world of high sensitivity troponin assays. It also discusses what evidence there is that POCT can form part of rapid decision-making strategies and how this applies in an era of algorithms based on and is derived from measurement of high sensitivity troponin in the central laboratory.
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Affiliation(s)
- Paul Collinson
- Departments of Clinical Blood Sciences and Cardiology, St George's University Hospitals NHS Foundation Trust and St George's University of London, Cranmer Terrace, London SW17 0QT, UK.
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48
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Biomarkers for infarct diagnosis and rapid rule-out/rule-in of acute myocardial infarction. Herz 2020; 45:509-519. [DOI: 10.1007/s00059-020-04943-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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49
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Boeddinghaus J, Nestelberger T, Koechlin L, Wussler D, Lopez-Ayala P, Walter JE, Troester V, Ratmann PD, Seidel F, Zimmermann T, Badertscher P, Wildi K, Rubini Giménez M, Potlukova E, Strebel I, Freese M, Miró Ò, Martin-Sanchez FJ, Kawecki D, Keller DI, Gualandro DM, Christ M, Twerenbold R, Mueller C, Meier M, Puelacher C, du Fay de Lavallaz J, Kozhuharov N, Rentsch K, Stelzig C, Meissner K, Kulangara C, Hillinger P, Michou E, Flores D, Reichlin T, López B, Fuenzalida C, Adrada ER, Ganovská E, Lohrmann J, Huber J, Steude J, Buser A, von Eckardstein A, Morawiec B, Nowalany-Kozielska E, Muzyk P, Bürgler F, Geigy N. Early Diagnosis of Myocardial Infarction With Point-of-Care High-Sensitivity Cardiac Troponin I. J Am Coll Cardiol 2020; 75:1111-1124. [DOI: 10.1016/j.jacc.2019.12.065] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2019] [Revised: 12/16/2019] [Accepted: 12/17/2019] [Indexed: 10/24/2022]
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