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Giubbini R, Paghera B, Dondi M, Estrada Lobato E, Peix A, Paez D. Critical Appraisal of the Current Role of Myocardial Perfusion Imaging in the Management of Acute Chest Pain. Semin Nucl Med 2023; 53:733-742. [PMID: 37722928 DOI: 10.1053/j.semnuclmed.2023.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Revised: 08/14/2023] [Accepted: 08/17/2023] [Indexed: 09/20/2023]
Abstract
This paper describes the evolution of nuclear cardiology techniques in the setting of acute coronary syndromes. Since the 1970s, the contribution of nuclear cardiology has been fundamental in delineating the physiopathology and diagnosis of acute myocardial infarction, when electrocardiogram (ECG) did not provide the diagnosis and when cardiac enzyme assessments were at a very early stage. In this clinical situation, at that time the role of pyrophosphate scintigraphy and antimyosin antibodies was important in ensuring diagnostic precision. However, these methods showed limitations and were abandoned in the late 80s and early 90s when therapeutic applications such as thrombolytic therapy, and primary-and rescue-percutaneous coronary intervention (PCI) were introduced. Beginning in the mid-80s, the introduction and widespread use of perfusion tracers such as 99mTc labelled compounds and technological advances such as SPECT, allowed to assess the efficacy of thrombolysis and early revascularization, as well as to assess in depth myocardial salvage. Currently, perfusion SPECT, especially using fast imaging techniques and dedicated cardiac SPECT with solid-state detectors, allows a quick confirmation or exclusion of acute coronary syndromes, particularly in low-to-intermediate likelihood of coronary artery disease (CAD), especially when there are absolute or relative contraindications to the use of coronary computed tomographic angiography (CCTA).
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Affiliation(s)
- Raffaele Giubbini
- Department of Nuclear Medicine, University of Brescia, Brescia, Italy
| | - Barbara Paghera
- Department of Nuclear Medicine, Nuclear Medicine Unit, University of Brescia, Brescia, Italy
| | - Maurizio Dondi
- Department of Nuclear Medicine, Nuclear Medicine and Diagnostic Imaging Section, Division of Human Health, Department of Nuclear Sciences and Applications, International Atomic Energy Agency, Vienna, Austria
| | - Enrique Estrada Lobato
- Department of Nuclear Medicine, Nuclear Medicine and Diagnostic Imaging Section, Division of Human Health, Department of Nuclear Sciences and Applications, International Atomic Energy Agency, Vienna, Austria
| | - Amalia Peix
- Department of Nuclear Medicine, Institute of Cardiology, Havana, Cuba
| | - Diana Paez
- Department of Nuclear Medicine, Nuclear Medicine and Diagnostic Imaging Section, Division of Human Health, Department of Nuclear Sciences and Applications, International Atomic Energy Agency, Vienna, Austria.
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Clinically Acquired High Sensitivity Cardiac Troponin T is a Poor Predictor of Reduced Left Ventricular Ejection Fraction After ST Elevation Myocardial Infarction: A National Cohort Study-ANZACS-QI 65. Heart Lung Circ 2022; 31:1513-1523. [PMID: 36041986 DOI: 10.1016/j.hlc.2022.07.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Revised: 06/27/2022] [Accepted: 07/18/2022] [Indexed: 11/20/2022]
Abstract
OBJECTIVE Cardiac troponins (cTn) have been used historically to estimate infarct size in ST elevation myocardial infarction (STEMI). Within a resource constrained health care environment, cTn could therefore be used for prioritisation of patients for cardiac imaging, in particular echocardiography. We aimed to determine how useful routinely collected cTn would be in predicting significant left ventricular (LV) impairment. METHODS All patients in the All New Zealand Acute Coronary Syndrome Quality Improvement (ANZACS-QI) registry with their first episode of STEMI between January 2013 and November 2018, who had high sensitivity troponin T measured, were included. We excluded patients with no left ventricular ejection fraction (LVEF) assessment, known LV dysfunction, or prior myocardial infarction. RESULTS In total, 3,698 patients were included in the analysis. A higher mean hsTnT (admission and peak) was seen in patients with more severely impaired LV function but there was significant overlap in the range of hsTnT between the different LVEF categories. Cardiac troponins demonstrated poor discriminative ability to either predict or exclude significant LV impairment (LVEF <40%). At an optimal cutpoint of 3,405 ng/L, peak hsTnT had a sensitivity of 56.5% (95% confidence interval [CI] 42-62%), a specificity of 65.3% (95% CI 62-79%) and an area under the receiver operating curve of 0.62 (95% CI 0.60-0.64). CONCLUSION This is the largest study comparing clinically measured troponin levels and LV function in patients presenting with STEMI. A definite, but weak, association was seen between peak troponin and the degree of LV dysfunction, with significant overlap in troponin levels between levels of myocardial dysfunction. Routinely acquired troponin is not suitable for clinical use as a method of prioritising patients for cardiac imaging.
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Association between Variation of Troponin and Prognosis of Acute Myocardial Infarction before and after Primary Percutaneous Coronary Intervention. J Interv Cardiol 2020; 2020:4793178. [PMID: 32774185 PMCID: PMC7399759 DOI: 10.1155/2020/4793178] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Accepted: 06/30/2020] [Indexed: 11/18/2022] Open
Abstract
Background Circulating levels of cardiac troponin I (cTnI) after ST-segment elevation myocardial infarction (STEMI) were considered as prognostic factors for predicting the incidence of major adverse cardiovascular events (MACE). △cTnI is the difference between peak cTnI after primary percutaneous coronary intervention (PPCI) and cTnI on initial admission. Purpose This study aimed to assess the relationship between △cTnI, the ratio of △cTnI to cTnI on initial admission, and the incidence of MACE during the follow-up period. Methods A total of 2596 patients with cTnI measured upon admission and one-time measurement of cTnI during hospitalization were enrolled. Results In the adjusted models of the survival receiver operating characteristic (ROC) curve, △cTnI and the ratio of △cTnI to cTnI on initial admission have stronger discrimination power of MACE (area under curve (AUC) 0.730 and 0.717) compared with peak cTnI after PPCI and cTnI at admission (AUC 0.590, 0.546). Multivariate Cox regression analysis identified △cTnI (hazard ratio (HR) 1.018, 95% confidence interval (CI) 1.001 to 1.035) as a relevant factor for MACE during follow-up. △cTnI was divided into quartiles, and maximum △ cTnI between 4.845 and 19.073 ng/ml comprised more patients with anterior wall myocardial infarction (p < 0.001), higher GRACE score (p = 0.038), CK-MB (p = 0.023), and Myoglobin (p < 0.001). On the K–M survival curves, the incidence of MACE, mortality, and angina pectoris were significantly higher in the group with maximum △cTnI (p = 0.035, 0.049, 0.026). Conclusion The △cTnI level and the ratio of △cTnI have stronger discrimination power of predicting the incidence of MACE. The group with maximum △cTnI has higher incidence of MACE, mortality, and angina pectoris during the follow-up period.
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Fillet M, Deroyer C, Cobraiville G, Le Goff C, Cavalier E, Chapelle JP, Marée R, Legrand V, Pierard L, Kolh P, Merville MP. Identification of protein biomarkers associated with cardiac ischemia by a proteomic approach. Biomarkers 2013; 18:614-24. [PMID: 24044526 DOI: 10.3109/1354750x.2013.838306] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Angina is chest pain induced by ischemia of the heart muscle, generally due to obstruction or spasm of the coronary arteries. People that suffer from average to severe cases of angina have an increased percentage of death before the age of 55, usually around 60%. Therefore, prevention of major complications, optimizing diagnosis, prognosis and therapeutics are of primary importance. The main objective of this study was to uncover biomarkers by comparing serum protein profiles of patients suffering from stable or unstable angina and controls. We identified by non-targeted proteomic approach and confirmed by the means of independent techniques, the differential expression of several proteins indicating significantly increased vascular inflammation response, disturbance in the lipid metabolism and in atherogenic plaques stability.
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Affiliation(s)
- M Fillet
- GIGA Proteomic Unit, Department of Clinical Chemistry, Clinical Chemistry Laboratory
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Abstract
Sensitive troponin assays have been developed to meet the diagnostic goals set by the universal definition of myocardial infarction (MI). The analytical advantages of sensitive troponin assays include improved analytical imprecision at concentrations below the 99th percentile and the ability to define a reference distribution fully. Clinically, the improved sensitivity translates into the ability to diagnosis MI earlier, possibly within 3 h from admission and the ability to use the rate of change of troponin (Δ troponin) for diagnosis. Very sensitive assays may, in appropriately selected populations (perhaps with the addition of Δ troponin), allow diagnosis on hospital admission or within 1–2 h of admission. An elevated troponin level occurring in patients without suspected acute coronary syndromes has, in all studies to date in which outcome has been examined, been shown to indicate an adverse prognosis whatever the underlying clinical diagnosis. Failure of elevation means a good prognosis allowing early, safe hospital discharge, whereas a raised value requires investigation and should help prevent clinically significant pathology being overlooked. Sensitive troponins do present a challenge to the laboratory and the clinician. For the laboratory, the diagnosis of MI requires a change in troponin value. For the clinician, the challenge is to shift from a simplistic yes/no diagnosis of MI based on a single troponin value to a diagnosis that utilises early troponin changes as part of the clinical picture, and to relate the new class of detectable troponin elevation in patients with ischaemic myocardial disease to existing clinical guidelines and trial evidence.
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Role of biomarkers in assessment of early infarct size after successful p-PCI for STEMI. Clin Res Cardiol 2011; 100:501-10. [DOI: 10.1007/s00392-010-0273-0] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2010] [Accepted: 12/17/2010] [Indexed: 10/18/2022]
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Hallén J, Buser P, Schwitter J, Petzelbauer P, Geudelin B, Fagerland MW, Jaffe AS, Atar D. Relation of cardiac troponin I measurements at 24 and 48 hours to magnetic resonance-determined infarct size in patients with ST-elevation myocardial infarction. Am J Cardiol 2009; 104:1472-7. [PMID: 19932777 DOI: 10.1016/j.amjcard.2009.07.019] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2009] [Revised: 07/10/2009] [Accepted: 07/10/2009] [Indexed: 12/25/2022]
Abstract
Levels of circulating cardiac troponin I (cTnI) or T are correlated to extent of myocardial destruction after an acute myocardial infarction. Few studies analyzing this relation have employed a second-generation cTnI assay or cardiac magnetic resonance (CMR) as the imaging end point. In this post hoc study of the Efficacy of FX06 in the Prevention of Mycoardial Reperfusion Injury (F.I.R.E.) trial, we aimed at determining the correlation between single-point cTnI measurements and CMR-estimated infarct size at 5 to 7 days and 4 months after a first-time ST-elevation myocardial infarction (STEMI) and investigating whether cTnI might provide independent prognostic information regarding infarct size at 4 months even taking into account early infarct size. Two hundred twenty-seven patients with a first-time STEMI were included in F.I.R.E. All patients received primary percutaneous coronary intervention within 6 hours from onset of symptoms. cTnI was measured at 24 and 48 hours after admission. CMR was conducted within 1 week of the index event (5 to 7 days) and at 4 months. Pearson correlations (r) for infarct size and cTnI at 24 hours were r = 0.66 (5 days) and r = 0.63 (4 months) and those for cTnI at 48 hours were r = 0.67 (5 days) and r = 0.65 (4 months). In a multiple regression analysis for predicting infarct size at 4 months (n = 141), cTnI and infarct location retained an independent prognostic role even taking into account early infarct size. In conclusion, a single-point cTnI measurement taken early after a first-time STEMI is a useful marker for infarct size and might also supplement early CMR evaluation in prediction of infarct size at 4 months.
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Affiliation(s)
- Jonas Hallén
- Division of Cardiology, Oslo University Hospital, Aker, Oslo, Norway.
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Prognostic Value of Biomarkers During and After Non–ST-Segment Elevation Acute Coronary Syndrome. J Am Coll Cardiol 2009; 54:357-64. [DOI: 10.1016/j.jacc.2009.03.056] [Citation(s) in RCA: 69] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2008] [Revised: 01/30/2009] [Accepted: 03/10/2009] [Indexed: 11/23/2022]
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Hallén J, Atar D. In ST-Elevation myocardial infarction patients receiving primary percutaneous coronary intervention, admission cardiac troponin T and peak cardiac troponin T values differ in their prognostic properties. Am J Cardiol 2009; 103:1331. [PMID: 19406285 DOI: 10.1016/j.amjcard.2009.02.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2009] [Accepted: 02/23/2009] [Indexed: 10/20/2022]
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Measurement of activin A in acute myocardial infarction: Is there a clinical role? Clin Chim Acta 2009; 401:1-2. [DOI: 10.1016/j.cca.2008.10.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2008] [Accepted: 10/28/2008] [Indexed: 11/22/2022]
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Roubille F, Cayla G, Picot MC, Pradet V, Massin F, Gervasoni R, Pasquie JL, Macia JC, Piot C, Leclercq F. Intérêt de la C-reactive protein (CRP) dans l’évaluation pronostique de l’infarctus du myocarde revascularisé. Rev Med Interne 2008; 29:868-74. [DOI: 10.1016/j.revmed.2008.01.026] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2007] [Revised: 01/23/2008] [Accepted: 01/23/2008] [Indexed: 10/22/2022]
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Peronnet E, Becquart L, Martinez J, Charrier JP, Jolivet-Reynaud C. Isoelectric point determination of cardiac troponin I forms present in plasma from patients with myocardial infarction. Clin Chim Acta 2007; 377:243-7. [PMID: 17113062 DOI: 10.1016/j.cca.2006.10.006] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2006] [Revised: 10/03/2006] [Accepted: 10/04/2006] [Indexed: 11/24/2022]
Abstract
BACKGROUND Cardiac troponin I (cTnI) is a specific marker of myocardial injury. In blood of patients with cardiovascular diseases, cTnI is released as a mixture of free, complexed and post-translationally modified forms. METHODS The cTnI forms present in the plasma from 8 patients with acute myocardial infarction (AMI) have been analysed by two-dimensional gel electrophoresis (2-DE) and Western Blot using anti-cTnI mAb 19C7 and anti-phosphorylated cTnI (Serines 22-23) mAb 5E6. RESULTS After immunoextraction of cTnI in plasma samples by 19C7 and 2-DE separation, 4 different forms were detected by 19C7 in 7 out the 8 AMI plasma samples. Two 29 kDa spots corresponding to intact free cTnI forms were detected at pIs 5.2 and 5.4. However, spot with pI 5.4 was also recognized by mAb 5E6, and should be bis-phosphorylated cTnI. Two 55 kDa spots with pIs 6.6 and 6.7 could be IC complexes. CTnI forms with pIs lower than the theoretical pI were also found in free cTnI and phosphorylated cTnI purified materials. CONCLUSIONS 2-DE analysis of AMI plasma showed the presence of acidic cTnI forms, one of them being phosphorylated. The clinical significance of these forms has to be further investigated.
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Affiliation(s)
- Estelle Peronnet
- Unité Mixte de Recherche UMR 2714 CNRS-bioMérieux, IFR 128 BioSciences Lyon-Gerland, CERVI 21 avenue Tony Garnier, 69365 Lyon Cedex 07, France
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Collinson PO, Gaze DC. Biomarkers of cardiovascular damage. Med Princ Pract 2007; 16:247-61. [PMID: 17541289 DOI: 10.1159/000102146] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2006] [Accepted: 02/17/2007] [Indexed: 01/12/2023] Open
Abstract
Acute coronary syndromes (ACS) are due to the rupture or erosion of atheromatous plaques. This produces, depending on plaque size, vascular anatomy and degree of collateral circulation, progressive tissue ischaemia which may progress to cardiomyocyte necrosis. This may then result in cardiac remodelling. Serum biomarkers are available which can be used for diagnosis of all of these stages. Markers to detect myocardial ischaemia at the pre-infarction stage are potentially the most interesting but also the most challenging. An ischaemia marker offers the opportunity to intervene to prevent progression to infarction. The problems with potential ischaemia markers are specificity and the reference diagnostic standard against which they can be judged. To date, only one, ischaemia-modified albumin(R), has reached the point where clinical studies can be performed. The measurement of the cardiac troponins, cardiac troponin T and cardiac troponin I, have become recognised as the diagnostic reference standard for myocardial necrosis. The sensitive nature of these tests has also revealed that myocardial necrosis is also found in a range of other clinical situations, highlighting the need to use all clinical information for diagnosis of acute myocardial infarction. The measurement of B-type natriuretic peptides can be shown to be diagnostic and prognostic in both ACS and detecting the sequelae of post-infarction myocardial insufficiency. The role of the B-type natriuretic peptides in detection of cardiac failure, both acute and chronic, is well defined but remains the subject of further studies, in ACS.
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Affiliation(s)
- Paul O Collinson
- Departments of Chemical Pathology, Cardiac Research and Cardiology, St George's Hospital and Medical School, London, UK.
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Collinson P. Cardiac troponins T and I: Biochemical markers in diagnosing myocardial infarction. ACTA ACUST UNITED AC 2006. [DOI: 10.12968/bjca.2006.1.9.21776] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Paul Collinson
- Department of Chemical Pathology, 2nd Floor Jenner Wing, St George’s Hospital, Blackshaw Road, London SW17 0QT
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