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Westwood M, Armstrong N, Krijkamp E, Perry M, Noake C, Tsiachristas A, Corro-Ramos I. A cloud-based medical device for predicting cardiac risk in suspected coronary artery disease: a rapid review and conceptual economic model. Health Technol Assess 2024; 28:1-105. [PMID: 39023142 PMCID: PMC11299050 DOI: 10.3310/wygc4096] [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: 07/20/2024] Open
Abstract
Background The CaRi-Heart® device estimates risk of 8-year cardiac death, using a prognostic model, which includes perivascular fat attenuation index, atherosclerotic plaque burden and clinical risk factors. Objectives To provide an Early Value Assessment of the potential of CaRi-Heart Risk to be an effective and cost-effective adjunctive investigation for assessment of cardiac risk, in people with stable chest pain/suspected coronary artery disease, undergoing computed tomography coronary angiography. This assessment includes conceptual modelling which explores the structure and evidence about parameters required for model development, but not development of a full executable cost-effectiveness model. Data sources Twenty-four databases, including MEDLINE, MEDLINE In-Process and EMBASE, were searched from inception to October 2022. Methods Review methods followed published guidelines. Study quality was assessed using Prediction model Risk Of Bias ASsessment Tool. Results were summarised by research question: prognostic performance; prevalence of risk categories; clinical effects; costs of CaRi-Heart. Exploratory searches were conducted to inform conceptual cost-effectiveness modelling. Results The only included study indicated that CaRi-Heart Risk may be predictive of 8 years cardiac death. The hazard ratio, per unit increase in CaRi-Heart Risk, adjusted for smoking, hypercholesterolaemia, hypertension, diabetes mellitus, Duke index, presence of high-risk plaque features and epicardial adipose tissue volume, was 1.04 (95% confidence interval 1.03 to 1.06) in the model validation cohort. Based on Prediction model Risk Of Bias ASsessment Tool, this study was rated as having high risk of bias and high concerns regarding its applicability to the decision problem specified for this Early Value Assessment. We did not identify any studies that reported information about the clinical effects or costs of using CaRi-Heart to assess cardiac risk. Exploratory searches, conducted to inform the conceptual cost-effectiveness modelling, indicated that there is a deficiency with respect to evidence about the effects of changing existing treatments or introducing new treatments, based on assessment of cardiac risk (by any method), or on measures of vascular inflammation (e.g. fat attenuation index). A de novo conceptual decision-analytic model that could be used to inform an early assessment of the cost effectiveness of CaRi-Heart is described. A combination of a short-term diagnostic model component and a long-term model component that evaluates the downstream consequences is anticipated to capture the diagnosis and the progression of coronary artery disease. Limitations The rapid review methods and pragmatic additional searches used to inform this Early Value Assessment mean that, although areas of potential uncertainty have been described, we cannot definitively state where there are evidence gaps. Conclusions The evidence about the clinical utility of CaRi-Heart Risk is underdeveloped and has considerable limitations, both in terms of risk of bias and applicability to United Kingdom clinical practice. There is some evidence that CaRi-Heart Risk may be predictive of 8-year risk of cardiac death, for patients undergoing computed tomography coronary angiography for suspected coronary artery disease. However, whether and to what extent CaRi-Heart represents an improvement relative to current standard of care remains uncertain. The evaluation of the CaRi-Heart device is ongoing and currently available data are insufficient to fully inform the cost-effectiveness modelling. Future work A large (n = 15,000) ongoing study, NCT05169333, the Oxford risk factors and non-invasive imaging study, with an estimated completion date of February 2030, may address some of the uncertainties identified in this Early Value Assessment. Study registration This study is registered as PROSPERO CRD42022366496. Funding This award was funded by the National Institute for Health and Care Research (NIHR) Evidence Synthesis programme (NIHR award ref: NIHR135672) and is published in full in Health Technology Assessment; Vol. 28, No. 31. See the NIHR Funding and Awards website for further award information.
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Affiliation(s)
| | | | - Eline Krijkamp
- Erasmus School of Health Policy and Management, Department of Health Technology Assessment, Erasmus University, Rotterdam, the Netherlands
| | - Mark Perry
- Kleijnen Systematic Reviews (KSR) Ltd, York, UK
| | - Caro Noake
- Kleijnen Systematic Reviews (KSR) Ltd, York, UK
| | | | - Isaac Corro-Ramos
- Institute for Medical Technology Assessment (iMTA), Erasmus University, Rotterdam, the Netherlands
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Wu AHB, Graglia S. Early detection of myocardial infarction with reference to baseline levels during health: impact on biological variation of high-sensitivity cardiac troponin. Lab Med 2024:lmae043. [PMID: 38869173 DOI: 10.1093/labmed/lmae043] [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: 06/14/2024] Open
Abstract
A 78-year-old male was seen in the emergency department (ED) with chest pain. Fifteen months earlier, he had presented to the ED with shoulder and elbow pain. High-sensitivity cardiac troponin I (hs-cTnI) testing was conducted at that time, which produced normal results of 10 and 13 ng/L (cutoff <48 ng/L). During the current admission, his electrocardiogram was unremarkable, with a borderline prolonged PR interval noted. The patient's hs-cTnI results were 25, 47, and 254 ng/L at 0, 1, and 7 hours, respectively. He was diagnosed with demand ischemia and admitted to the hospital. The detection of acute myocardial infarction in this case was made during the first sample collection (t = 0), despite the fact that this result was well within the normal range.
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Affiliation(s)
- Alan H B Wu
- Laboratory Medicine, University of California San Francisco Medical Center at Parnassus, San Francisco, CA, US
| | - Sally Graglia
- Emergency Medicine, University of California San Francisco School of Medicine, San Francisco, CA, US
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Roshdi Dizaji S, Ahmadzadeh K, Zarei H, Miri R, Yousefifard M. Performance of Manchester Acute Coronary Syndromes decision rules in acute coronary syndrome: a systematic review and meta-analysis. Eur J Emerg Med 2024:00063110-990000000-00133. [PMID: 38864570 DOI: 10.1097/mej.0000000000001147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/13/2024]
Abstract
BACKGROUND AND IMPORTANCE Multiple decision-aiding models are available to help physicians identify acute coronary syndrome (ACS) and accelerate the decision-making process in emergency departments (EDs). OBJECTIVE This study evaluates the diagnostic performance of the Manchester Acute Coronary Syndrome (MACS) rule and its derivations, enhancing the evidence for their clinical use. DESIGN Systematic review and meta-analysis. SETTINGS AND PARTICIPANTS Medline, Embase, Scopus, and Web of Science were searched from inception until October 2023 for studies including adult ED patients with suspected cardiac chest pain and inconclusive findings requiring ACS risk-stratification. OUTCOME MEASURES AND ANALYSIS The predictive value of MACS, Troponin-only MACS (T-MACS), or History and Electrocardiogram-only MACS (HE-MACS) decision aids for diagnosing acute myocardial infarction (AMI) and 30-day major adverse cardiac outcomes (MACEs) among patients admitted to ED with chest pain suspected of ACS. Overall sensitivity and specificity were synthesized using the 'Diagma' package in STATA statistical software. Applicability and risk of bias assessment were performed using the QUADAS-2 tool. MAIN RESULTS For AMI detection, MACS has a sensitivity of 99% [confidence interval (CI): 97-100], specificity of 19% (CI: 10-32), and AUC of 0.816 (CI: 0.720-0.885). T-MACS shows a sensitivity of 98% (CI: 98-99), specificity of 35% (CI: 29-42), and AUC of 0.859 (CI: 0.824-0.887). HE-MACS exhibits a sensitivity of 99% (CI: 98-100), specificity of 9% (CI: 3-21), and AUC of 0.787 (CI: 0.647-0.882). For MACE detection, MACS demonstrates a sensitivity of 98% (CI: 94-100), specificity of 22% (CI: 10-42), and AUC of 0.804 (CI: 0.659-0.897). T-MACS displays a sensitivity of 96% (CI: 94-98), specificity of 36% (CI: 30-43), and AUC of 0.792 (CI: 0.748-0.830). HE-MACS maintains a sensitivity of 99% (CI: 97-99), specificity of 10% (CI 6-16), and AUC of 0.713 (CI: 0.625-0.787). CONCLUSION Of all the MACS models, T-MACS displayed the highest overall accuracy due to its high sensitivity and significantly superior specificity. T-MACS exhibits very good diagnostic performance in predicting both AMI and MACE. This makes it a highly promising tool for managing patients with acute chest pain.
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Affiliation(s)
| | | | - Hamed Zarei
- Physiology Research Center, Iran University of Medical Sciences
| | - Reza Miri
- Prevention of Cardiovascular Disease Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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Danagoulian S, Miller J, Cook B, Gunaga S, Fadel R, Gandolfo C, Mills NL, Modi S, Mahler SA, Levy PD, Parikh S, Krupp S, Abdul‐Nour K, Klausner H, Rockoff S, Gindi R, Lewandowski A, Hudson M, Perrotta G, Zweig B, Lanfear D, Kim H, Shaheen E, Darnell G, Nassereddine H, Hawatian K, Tang A, Keerie C, McCord J. Is rapid acute coronary syndrome evaluation with high-sensitivity cardiac troponin less costly? An economic evaluation. J Am Coll Emerg Physicians Open 2024; 5:e13140. [PMID: 38567033 PMCID: PMC10985545 DOI: 10.1002/emp2.13140] [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: 08/22/2023] [Revised: 02/04/2024] [Accepted: 02/22/2024] [Indexed: 04/04/2024] Open
Abstract
Objective Protocols to evaluate for myocardial infarction (MI) using high-sensitivity cardiac troponin (hs-cTn) have the potential to drive costs upward due to the added sensitivity. We performed an economic evaluation of an accelerated protocol (AP) to evaluate for MI using hs-cTn to identify changes in costs of treatment and length of stay compared with conventional testing. Methods We performed a planned secondary economic analysis of a large, cluster randomized trial across nine emergency departments (EDs) from July 2020 to April 2021. Patients were included if they were 18 years or older with clinical suspicion for MI. In the AP, patients could be discharged without further testing at 0 h if they had a hs-cTnI < 4 ng/L and at 1 h if the initial value were 4 ng/L and the 1-h value ≤7 ng/L. Patients in the standard of care (SC) protocol used conventional cTn testing at 0 and 3 h. The primary outcome was the total cost of treatment, and the secondary outcome was ED length of stay. Results Among 32,450 included patients, an AP had no significant differences in cost (+$89, CI: -$714, $893 hospital cost, +$362, CI: -$414, $1138 health system cost) or ED length of stay (+46, CI: -28, 120 min) compared with the SC protocol. In lower acuity, free-standing EDs, patients under the AP experienced shorter length of stay (-37 min, CI: -62, 12 min) and reduced health system cost (-$112, CI: -$250, $25). Conclusion Overall, the implementation of AP using hs-cTn does not result in higher costs.
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Affiliation(s)
| | - Joseph Miller
- Department of Emergency MedicineHenry Ford Health SystemDetroitMichiganUSA
| | - Bernard Cook
- Department of ChemistryHenry Ford Health SystemDetroitMichiganUSA
| | - Satheesh Gunaga
- Department of Emergency MedicineHenry Ford Wyandotte HospitalWyandotteMichiganUSA
| | - Raef Fadel
- Department of CardiologyHenry Ford Health SystemDetroitMichiganUSA
| | - Chaun Gandolfo
- Department of CardiologyHenry Ford Health SystemDetroitMichiganUSA
| | - Nicholas L. Mills
- Department of CardiologyThe University of Edinburgh Usher Institute of Population Health Sciences and InformaticsUnited Kingdom of Great Britain and Northern IrelandEdinburghUK
| | - Shalini Modi
- Department of CardiologyHenry Ford West Bloomfield HospitalWest Bloomfield TownshipMichiganUSA
| | - Simon A. Mahler
- Department of Emergency MedicineWake Forest School of MedicineWinston‐SalemNorth CarolinaUSA
| | - Phillip D. Levy
- Department of Emergency Medicine and Integrative Biosciences CenterWayne State University School of MedicineDetroitMichiganUSA
| | - Sachin Parikh
- Department of CardiologyHenry Ford Health SystemDetroitMichiganUSA
| | - Seth Krupp
- Department of Emergency MedicineHenry Ford Health SystemDetroitMichiganUSA
| | | | - Howard Klausner
- Department of Emergency MedicineHenry Ford Health SystemDetroitMichiganUSA
| | - Steven Rockoff
- Department of Emergency MedicineHenry Ford Health SystemDetroitMichiganUSA
| | - Ryan Gindi
- Department of CardiologyHenry Ford Health SystemDetroitMichiganUSA
| | - Aaron Lewandowski
- Department of CardiologyHenry Ford West Bloomfield HospitalWest Bloomfield TownshipMichiganUSA
| | - Michael Hudson
- Department of CardiologyHenry Ford Health SystemDetroitMichiganUSA
| | - Giuseppe Perrotta
- Department of Emergency MedicineHenry Ford Health SystemDetroitMichiganUSA
| | - Bryan Zweig
- Department of CardiologyHenry Ford Health SystemDetroitMichiganUSA
| | - David Lanfear
- Department of CardiologyHenry Ford Health SystemDetroitMichiganUSA
| | - Henry Kim
- Department of CardiologyHenry Ford Health SystemDetroitMichiganUSA
| | - Elizabeth Shaheen
- Department of Emergency MedicineHenry Ford Wyandotte HospitalWyandotteMichiganUSA
| | - Gale Darnell
- Department of Emergency MedicineHenry Ford Wyandotte HospitalWyandotteMichiganUSA
| | | | - Kegham Hawatian
- Department of Emergency MedicineHenry Ford Health SystemDetroitMichiganUSA
| | - Amy Tang
- Department of ResearchHenry Ford Health SystemDetroitMichiganUSA
| | - Catriona Keerie
- Department of CardiologyThe University of Edinburgh Usher Institute of Population Health Sciences and InformaticsUnited Kingdom of Great Britain and Northern IrelandEdinburghUK
| | - James McCord
- Department of CardiologyHenry Ford Health SystemDetroitMichiganUSA
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Shinkins B, Allen AJ, Karichu J, Garrison LP, Monz BU. Evidence Synthesis and Linkage for Modelling the Cost-Effectiveness of Diagnostic Tests: Preliminary Good Practice Recommendations. APPLIED HEALTH ECONOMICS AND HEALTH POLICY 2024; 22:131-144. [PMID: 38316713 PMCID: PMC10864520 DOI: 10.1007/s40258-023-00855-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 11/05/2023] [Indexed: 02/07/2024]
Abstract
OBJECTIVES To develop preliminary good practice recommendations for synthesising and linking evidence of treatment effectiveness when modelling the cost-effectiveness of diagnostic tests. METHODS We conducted a targeted review of guidance from key Health Technology Assessment (HTA) bodies to summarise current recommendations on synthesis and linkage of treatment effectiveness evidence within economic evaluations of diagnostic tests. We then focused on a specific case study, the cost-effectiveness of troponin for the diagnosis of myocardial infarction, and reviewed the approach taken to synthesise and link treatment effectiveness evidence in different modelling studies. RESULTS The Australian and UK HTA bodies provided advice for synthesising and linking treatment effectiveness in diagnostic models, acknowledging that linking test results to treatment options and their outcomes is common. Across all reviewed models for the case study, uniform test-directed treatment decision making was assumed, i.e., all those who tested positive were treated. Treatment outcome data from a variety of sources, including expert opinion, were utilised for linked clinical outcomes. Preliminary good practice recommendations for data identification, integration and description are proposed. CONCLUSION Modelling the cost-effectiveness of diagnostic tests poses unique challenges in linking evidence on test accuracy to treatment effectiveness data to understand how a test impacts patient outcomes and costs. Upfront consideration of how a test and its results will likely be incorporated into patient diagnostic pathways is key to exploring the optimal design of such models. We propose some preliminary good practice recommendations to improve the quality of cost-effectiveness evaluations of diagnostics tests going forward.
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Affiliation(s)
- Bethany Shinkins
- Health Sciences, Warwick Medical School, University of Warwick, Coventry, CV4 7AL, UK.
- Leeds Institute for Health Sciences, University of Leeds, Clarendon Way, Leeds, UK.
- NIHR Leeds In Vitro Diagnostics Co-operative (MIC), Leeds, UK.
| | - A Joy Allen
- Access and Innovation, Roche Diagnostics UK and Ireland, Burgess Hill, UK
| | - James Karichu
- Global Access & Policy, Roche Diagnostics Solutions, Pleasanton, California, USA
| | - Louis P Garrison
- The Comparative Health Outcomes, Policy, and Economics (CHOICE) Institute, University of Washington, Seattle, USA
| | - Brigitta U Monz
- Global Access & Policy, Roche Diagnostics International AG, Forrenstrasse 2, 6343, Rotkreuz, Switzerland
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Sasaki S, Inoue K, Shiozaki M, Hanada K, Watanabe R, Minamino T. Diagnostic and Cost Efficiency of the 0-h/1-h Rule-out and Rule-in Algorithm for Patients With Chest Pain in the Emergency Department. Circ J 2023; 87:1362-1368. [PMID: 37394574 DOI: 10.1253/circj.cj-23-0064] [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] [Indexed: 07/04/2023]
Abstract
BACKGROUND This study investigated the economic impact of the European Society of Cardiology (ESC) clinical practice guideline recommendation of using the 0-h/1-h rule-out and rule-in algorithm with high-sensitivity cardiac troponin assays (0/1-h algorithm) to triage patients presenting with chest pain.Methods and Results: This post hoc cost-effectiveness evaluation (DROP-ACS; UMIN000030668) used deidentified electronic medical records from health insurance claims from 2 diagnostic centers in Japan. A cost-effectiveness analysis was conducted with 472 patients with care provided following the 0/1-h algorithm (Hospital A) and 427 patients following point-of-care testing (Hospital B). The clinical outcome of interest was all-cause mortality or subsequent myocardial infarction within 30 days of the index presentation. The sensitivity and specificity for the clinical outcome were 100% (95% confidence interval [CI] 91.1-100%) and 95.0% (95% CI 94.3-95.0%), respectively, in Hospital A and 92.9% (95% CI 69.6-98.7%) and 89.8% (95% CI 89.0-90.0%), respectively, in Hospital B. If the diagnostic accuracy of the 0/1-h algorithm was implemented in Hospital B, it is expected that the number of urgent (<24-h) coronary angiograms would decrease by 50%. Incorporating this assumption, implementing the 0/1-h algorithm could potentially reduce medical costs by JPY4,033,874 (95% CI JPY3,440,346-4,627,402) in Hospital B (JPY9,447 per patient; 95% CI JPY 8,057-10,837 per patient). CONCLUSIONS The ESC 0/1-h algorithm was efficient for risk stratification and for reducing medical costs.
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Affiliation(s)
- Shun Sasaki
- Department of Cardiovascular Biology and Medicine, Juntendo University Nerima Hospital
| | - Kenji Inoue
- Department of Cardiovascular Biology and Medicine, Juntendo University Nerima Hospital
| | | | | | - Ryo Watanabe
- Graduate School of Health Innovation, Kanagawa University of Human Service
| | - Tohru Minamino
- Department of Cardiovascular Biology and Medicine, Juntendo University School of Medicine
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Tolsma RT, Fokkert MJ, Ottervanger JP, van Dongen DN, Badings EA, der Sluis AV, Van't Hof AW, Slingerland RJ. Consequences of different cut-off values for high-sensitivity cardiac troponin for risk stratification of patients suspected for NSTE-ACS with a modified HEART score. Future Cardiol 2023; 19:497-504. [PMID: 37702223 DOI: 10.2217/fca-2023-0038] [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: 09/14/2023] Open
Abstract
Aim: This study aims to enhance prehospital risk assessment for suspected non-ST-elevation acute coronary syndrome (NSTE-ACS) patients using the HEART-score. By incorporating novel point-of-care high-sensitivity cardiac troponin devices, a modified HEART-score was developed and compared with the conventional approach. Patients & methods: Troponin points within the modified HEART-score are based on values below the limit of quantitation (LoQ), between the LoQ and 99th percentile and above the 99th percentile of the used device. A total HEART-score of three or lower is considered low-risk for major adverse cardiac events. Results & conclusion: The number of low-risk patients decreased based on the modified HEART-score. The sensitivity and negative predictive value increased which suggests increasing safety in ruling out patients with suspected NSTE-ACS.
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Affiliation(s)
- Rudolf T Tolsma
- Emergency Medical Service, Ambulance IJsselland, 8013 PM, Zwolle, The Netherlands
| | - Marion J Fokkert
- Department of Innovation & Science, Isala, 8025 AB, Zwolle, The Netherlands
- Department of Clinical Chemistry, Isala, 8025 AB, Zwolle, The Netherlands
| | | | | | - Erik A Badings
- Department of Cardiology, Deventer Hospital, 7416 SE, Deventer, The Netherlands
| | - Aize van der Sluis
- Department of Cardiology, Deventer Hospital, 7416 SE, Deventer, The Netherlands
| | - Arnoud Wj Van't Hof
- Department of Cardiology, MUMC, 6229 HX, Maastricht, The Netherlands
- Department of Cardiology, Zuyderland MC, 6419 PC, Heerlen, The Netherlands
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Wessman T, Zorlak A, Wändell P, Melander O, Carlsson AC, Ruge T. Myocardial injury defined as elevated high-sensitivity cardiac troponin T is associated with higher mortality in patients seeking care at emergency departments with acute dyspnea. BMC Emerg Med 2023; 23:40. [PMID: 37016316 PMCID: PMC10074855 DOI: 10.1186/s12873-023-00787-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Accepted: 02/02/2023] [Indexed: 04/06/2023] Open
Abstract
BACKGROUND Elevated levels of cardiac troponin T has been observed in patients seeking care at the emergency department (ED) presenting with chest pain but without myocardial infarction (MI). The clinical importance of this observation remains, however, still unclear. Our main aim was to study the role of cardiac troponin T in patients admitted to the emergency department with acute dyspnea, a group of patients with a high cardiovascular comorbidity, but no primary acute MI. POPULATION AND METHODS Patients from the age of 18 seeking care at the ED for dyspnea, without an acute cardiac syndrome, and with a recorded assessment of high-sensitivity cardiac troponin T (hs-cTnT), were included (n = 1001). Patients were categorized into 3 groups by hs-cTnT level, i.e. <15, 15-100 and > 100 µg/l. Cox regression with Hazard Ratios (HRs) and 95% Confidence Intervals (CI) for 3-months mortality was performed, with adjustment for sex, age, respiratory frequency, saturation, CHF, renal disease, and BMI. RESULTS Fully adjusted HRs (95% CI) for 3-month mortality, with hs-cTnT < 15 µg/l as reference level, showed for hs-cTnT 15-100 a HR of 3.682 (1.729-7.844), and for hs-cTnT > 100 a HR of 10.523 (4.465-24.803). CONCLUSION Elevated hs-cTnT seems to be a relevant marker of poor prognosis in patients with acute dyspnea without MI and warrants further validation and clinical testing.
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Affiliation(s)
- T Wessman
- Department of Emergency and Internal Medicine, Skåne University Hospital, Malmö, Sweden
- Department of Clinical Sciences Malmö, Department of Internal Medicine, Lund University, Skåne University Hospital, Malmö, Sweden
| | - A Zorlak
- Department of Emergency and Internal Medicine, Skåne University Hospital, Malmö, Sweden
| | - Per Wändell
- Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Huddinge, Sweden.
| | - O Melander
- Department of Emergency and Internal Medicine, Skåne University Hospital, Malmö, Sweden
- Department of Clinical Sciences Malmö, Department of Internal Medicine, Lund University, Skåne University Hospital, Malmö, Sweden
| | - A C Carlsson
- Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Huddinge, Sweden
- Academic Primary Care Center, Region Stockholm, Sweden
| | - T Ruge
- Department of Emergency and Internal Medicine, Skåne University Hospital, Malmö, Sweden
- Department of Clinical Sciences Malmö, Department of Internal Medicine, Lund University, Skåne University Hospital, Malmö, Sweden
- Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Huddinge, Sweden
- Academic Primary Care Center, Region Stockholm, Sweden
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Qasum M, Massalha S, Marcusohn E, Elias A, Darawshi S, Zukermann R. Coronary computed tomography angiography in the evaluation of acute chest pain in patients with elevated high sensitive cardiac troponin I (hs-cTn) level. AMERICAN HEART JOURNAL PLUS : CARDIOLOGY RESEARCH AND PRACTICE 2023; 27:100276. [PMID: 38511099 PMCID: PMC10945961 DOI: 10.1016/j.ahjo.2023.100276] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/28/2023] [Revised: 02/13/2023] [Accepted: 02/13/2023] [Indexed: 03/22/2024]
Abstract
Aims CCTA is a well-established and safe imaging modality for the diagnosis of CAD and is gate keeping for invasive coronary angiography (ICA). We aimed to examine CCTA performance in patients presenting with ACP and dynamic hs-cTn elevation compatible with MI but not exceeding 7 folds of the URL. We also examined the performance of GRACE and PTP consortium scores in this population of patients.
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Affiliation(s)
- Majd Qasum
- Departments of Cardiology, Rambam Health Care Campus, Haifa, Israel
- Department of Nuclear Medicine, Rambam Health Care Campus, Haifa, Israel
| | - Samia Massalha
- Departments of Cardiology, Rambam Health Care Campus, Haifa, Israel
- Department of Nuclear Medicine, Rambam Health Care Campus, Haifa, Israel
| | - Erez Marcusohn
- Departments of Cardiology, Rambam Health Care Campus, Haifa, Israel
| | - Adi Elias
- Departments of Cardiology, Rambam Health Care Campus, Haifa, Israel
| | - Said Darawshi
- Department of Medicine D, Ruth & Bruce Rappaport Faculty of Medicine, Rambam Health Care Campus, Technion-IIT, Haifa, Israel
| | - Robert Zukermann
- Departments of Cardiology, Rambam Health Care Campus, Haifa, Israel
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Garlant HN, Ellappan K, Hewitt M, Perumal P, Pekeleke S, Wand N, Southern J, Kumar SV, Belgode H, Abubakar I, Sinha S, Vasan S, Joseph NM, Kempsell KE. Evaluation of Host Protein Biomarkers by ELISA From Whole Lysed Peripheral Blood for Development of Diagnostic Tests for Active Tuberculosis. Front Immunol 2022; 13:854327. [PMID: 35720382 PMCID: PMC9205408 DOI: 10.3389/fimmu.2022.854327] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Accepted: 02/28/2022] [Indexed: 11/23/2022] Open
Abstract
Tuberculosis (TB) remains a significant global health crisis and the number one cause of death for an infectious disease. The health consequences in high-burden countries are significant. Barriers to TB control and eradication are in part caused by difficulties in diagnosis. Improvements in diagnosis are required for organisations like the World Health Organisation (WHO) to meet their ambitious target of reducing the incidence of TB by 50% by the year 2025, which has become hard to reach due to the COVID-19 pandemic. Development of new tests for TB are key priorities of the WHO, as defined in their 2014 report for target product profiles (TPPs). Rapid triage and biomarker-based confirmatory tests would greatly enhance the diagnostic capability for identifying and diagnosing TB-infected individuals. Protein-based test methods e.g. lateral flow devices (LFDs) have a significant advantage over other technologies with regard to assay turnaround time (minutes as opposed to hours) field-ability, ease of use by relatively untrained staff and without the need for supporting laboratory infrastructure. Here we evaluate the diagnostic performance of nine biomarkers from our previously published biomarker qPCR validation study; CALCOCO2, CD274, CD52, GBP1, IFIT3, IFITM3, SAMD9L, SNX10 and TMEM49, as protein targets assayed by ELISA. This preliminary evaluation study was conducted to quantify the level of biomarker protein expression across latent, extra-pulmonary or pulmonary TB groups and negative controls, collected across the UK and India, in whole lysed blood samples (WLB). We also investigated associative correlations between the biomarkers and assessed their suitability for ongoing diagnostic test development, using receiver operating characteristic/area under the curve (ROC) analyses, singly and in panel combinations. The top performing single biomarkers for pulmonary TB versus controls were CALCOCO2, SAMD9L, GBP1, IFITM3, IFIT3 and SNX10. TMEM49 was also significantly differentially expressed but downregulated in TB groups. CD52 expression was not highly differentially expressed across most of the groups but may provide additional patient stratification information and some limited use for incipient latent TB infection. These show therefore great potential for diagnostic test development either in minimal configuration panels for rapid triage or more complex formulations to capture the diversity of disease presentations.
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Affiliation(s)
- Harriet N. Garlant
- Science Group: Research and Evaluation, UK Health Security Agency, Salisbury, United Kingdom
| | - Kalaiarasan Ellappan
- Department of Microbiology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
| | - Matthew Hewitt
- Science Group: Research and Evaluation, UK Health Security Agency, Salisbury, United Kingdom
| | - Prem Perumal
- Science Group: Research and Evaluation, UK Health Security Agency, Salisbury, United Kingdom
| | - Simon Pekeleke
- Science Group: Research and Evaluation, UK Health Security Agency, Salisbury, United Kingdom
| | - Nadina Wand
- Science Group: Research and Evaluation, UK Health Security Agency, Salisbury, United Kingdom
| | - Jo Southern
- School of Life & Medical Sciences, Mortimer Market Centre, University College London, London, United Kingdom
| | - Saka Vinod Kumar
- Department of Microbiology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
| | - Harish Belgode
- Department of Microbiology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
| | - Ibrahim Abubakar
- School of Life & Medical Sciences, Mortimer Market Centre, University College London, London, United Kingdom
| | - Sanjeev Sinha
- Department of Medicine, All India Institute for Medical Sciences, New Delhi, India
| | - Seshadri Vasan
- Department of Health Sciences, University of York, York, United Kingdom
| | - Noyal Mariya Joseph
- Department of Microbiology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
| | - Karen E. Kempsell
- Science Group: Research and Evaluation, UK Health Security Agency, Salisbury, United Kingdom
- *Correspondence: Karen E. Kempsell,
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11
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Ferraro S, Biganzoli EM, Castaldi S, Plebani M. Health Technology Assessment to assess value of biomarkers in the decision-making process. Clin Chem Lab Med 2022; 60:647-654. [PMID: 35245972 DOI: 10.1515/cclm-2021-1291] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Accepted: 02/08/2022] [Indexed: 12/20/2022]
Abstract
Clinical practice guidelines (CPGs) on screening, surveillance, and treatment of several diseases recommend the selective use of biomarkers with central role in clinical decision-making and move towards including patients in this process. To this aim we will clarify the multidisciplinary interactions required to properly measure the cost-effectiveness of biomarkers with regard to the risk-benefit of the patients and how Health Technology Assessment (HTA) approach may assess value of biomarkers integrated within the decision-making process. HTA through the interaction of different skills provides high-quality research information on the effectiveness, costs, and impact of health technologies, including biomarkers. The biostatistical methodology is relevant to HTA but only meta-analysis is covered in depth, whereas proper approaches are needed to estimate the benefit-risk balance ratio. Several biomarkers underwent HTA evaluation and the final reports have pragmatically addressed: 1) a redesign of the screening based on biomarker; 2) a de-implementation/replacement of the test in clinical practice; 3) a selection of biomarkers with potential predictive ability and prognostic value; and 4) a stronger monitoring of the appropriateness of test request. The COVID-19 pandemic has disclosed the need to create a robust and sustainable system to urgently deal with global health concerns and the HTA methodology enables rapid cost-effective implementation of diagnostic tests allowing healthcare providers to make critical patient-management decisions.
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Affiliation(s)
- Simona Ferraro
- Endocrinology Laboratory Unit, "Luigi Sacco" University Hospital, Milan, Italy
| | - Elia Mario Biganzoli
- Medical Statistics Unit, Department of Biomedical and Clinical Sciences L. Sacco, "Luigi Sacco" University Hospital, Università degli Studi di Milano, Milan, Italy
| | - Silvana Castaldi
- Fondazione Ca' Granda Ospedale Maggiore Policlinico Research Institute of Milano, Milan, Italy
- Department of Biomedical Sciences for Health, Università degli Studi di Milano, Milan, Italy
| | - Mario Plebani
- Department of Medicine-DIMED, University of Padova, Padua, Italy
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12
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Douglas KO, Payne K, Sabino-Santos G, Agard J. Influence of Climatic Factors on Human Hantavirus Infections in Latin America and the Caribbean: A Systematic Review. Pathogens 2021; 11:pathogens11010015. [PMID: 35055965 PMCID: PMC8778283 DOI: 10.3390/pathogens11010015] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Revised: 12/16/2021] [Accepted: 12/17/2021] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND With the current climate change crisis and its influence on infectious disease transmission there is an increased desire to understand its impact on infectious diseases globally. Hantaviruses are found worldwide, causing infectious diseases such as haemorrhagic fever with renal syndrome (HFRS) and hantavirus cardiopulmonary syndrome (HCPS)/hantavirus pulmonary syndrome (HPS) in tropical regions such as Latin America and the Caribbean (LAC). These regions are inherently vulnerable to climate change impacts, infectious disease outbreaks and natural disasters. Hantaviruses are zoonotic viruses present in multiple rodent hosts resident in Neotropical ecosystems within LAC and are involved in hantavirus transmission. METHODS We conducted a systematic review to assess the association of climatic factors with human hantavirus infections in the LAC region. Literature searches were conducted on MEDLINE and Web of Science databases for published studies according to Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) criteria. The inclusion criteria included at least eight human hantavirus cases, at least one climatic factor and study from > 1 LAC geographical location. RESULTS In total, 383 papers were identified within the search criteria, but 13 studies met the inclusion criteria ranging from Brazil, Chile, Argentina, Bolivia and Panama in Latin America and a single study from Barbados in the Caribbean. Multiple mathematical models were utilized in the selected studies with varying power to generate robust risk and case estimates of human hantavirus infections linked to climatic factors. Strong evidence of hantavirus disease association with precipitation and habitat type factors were observed, but mixed evidence was observed for temperature and humidity. CONCLUSIONS The interaction of climate and hantavirus diseases in LAC is likely complex due to the unknown identity of all vertebrate host reservoirs, circulation of multiple hantavirus strains, agricultural practices, climatic changes and challenged public health systems. There is an increasing need for more detailed systematic research on the influence of climate and other co-related social, abiotic, and biotic factors on infectious diseases in LAC to understand the complexity of vector-borne disease transmission in the Neotropics.
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Affiliation(s)
- Kirk Osmond Douglas
- Centre for Biosecurity Studies, Cave Hill Campus, The University of the West Indies, Cave Hill, St. Michael BB11000, Barbados
- Correspondence:
| | - Karl Payne
- Centre for Resource Management and Environmental Studies, Cave Hill Campus, The University of the West Indies, Cave Hill, St. Michael BB11000, Barbados;
| | - Gilberto Sabino-Santos
- School of Public Health and Tropical Medicine, Tulane University, 1324 Tulane Ave Suite 517, New Orleans, LA 70112, USA;
- Centre for Virology Research, Ribeirao Preto Medical School, University of Sao Paulo, 3900 Av. Bandeirantes, Ribeirao Preto 14049-900, SP, Brazil
| | - John Agard
- Department of Life Sciences, The University of the West Indies, St. Augustine 999183, Trinidad and Tobago;
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13
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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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14
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Du X, Su X, Zhang W, Yi S, Zhang G, Jiang S, Li H, Li S, Xia F. Progress, Opportunities, and Challenges of Troponin Analysis in the Early Diagnosis of Cardiovascular Diseases. Anal Chem 2021; 94:442-463. [PMID: 34843218 DOI: 10.1021/acs.analchem.1c04476] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Xuewei Du
- State Key Laboratory of Biogeology Environmental Geology, Engineering Research Center of Nano-Geomaterials of Ministry of Education, Faculty of Materials Science and Chemistry, China University of Geosciences, Wuhan 430074, China
| | - Xujie Su
- State Key Laboratory of Biogeology Environmental Geology, Engineering Research Center of Nano-Geomaterials of Ministry of Education, Faculty of Materials Science and Chemistry, China University of Geosciences, Wuhan 430074, China
| | - Wanxue Zhang
- State Key Laboratory of Biogeology Environmental Geology, Engineering Research Center of Nano-Geomaterials of Ministry of Education, Faculty of Materials Science and Chemistry, China University of Geosciences, Wuhan 430074, China
| | - Suyan Yi
- State Key Laboratory of Biogeology Environmental Geology, Engineering Research Center of Nano-Geomaterials of Ministry of Education, Faculty of Materials Science and Chemistry, China University of Geosciences, Wuhan 430074, China
| | - Ge Zhang
- State Key Laboratory of Biogeology Environmental Geology, Engineering Research Center of Nano-Geomaterials of Ministry of Education, Faculty of Materials Science and Chemistry, China University of Geosciences, Wuhan 430074, China
| | - Shan Jiang
- State Key Laboratory of Biogeology Environmental Geology, Engineering Research Center of Nano-Geomaterials of Ministry of Education, Faculty of Materials Science and Chemistry, China University of Geosciences, Wuhan 430074, China
| | - Hui Li
- State Key Laboratory of Biogeology Environmental Geology, Engineering Research Center of Nano-Geomaterials of Ministry of Education, Faculty of Materials Science and Chemistry, China University of Geosciences, Wuhan 430074, China
| | - Shaoguang Li
- State Key Laboratory of Biogeology Environmental Geology, Engineering Research Center of Nano-Geomaterials of Ministry of Education, Faculty of Materials Science and Chemistry, China University of Geosciences, Wuhan 430074, China
| | - Fan Xia
- State Key Laboratory of Biogeology Environmental Geology, Engineering Research Center of Nano-Geomaterials of Ministry of Education, Faculty of Materials Science and Chemistry, China University of Geosciences, Wuhan 430074, China
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15
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Tanase DM, Gosav EM, Ouatu A, Badescu MC, Dima N, Ganceanu-Rusu AR, Popescu D, Floria M, Rezus E, Rezus C. Current Knowledge of MicroRNAs (miRNAs) in Acute Coronary Syndrome (ACS): ST-Elevation Myocardial Infarction (STEMI). Life (Basel) 2021; 11:life11101057. [PMID: 34685428 PMCID: PMC8541211 DOI: 10.3390/life11101057] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Revised: 10/02/2021] [Accepted: 10/06/2021] [Indexed: 02/06/2023] Open
Abstract
Regardless of the newly diagnostic and therapeutic advances, coronary artery disease (CAD) and more explicitly, ST-elevation myocardial infarction (STEMI), remains one of the leading causes of morbidity and mortality worldwide. Thus, early and prompt diagnosis of cardiac dysfunction is pivotal in STEMI patients for a better prognosis and outcome. In recent years, microRNAs (miRNAs) gained attention as potential biomarkers in myocardial infarction (MI) and acute coronary syndromes (ACS), as they have key roles in heart development, various cardiac processes, and act as indicators of cardiac damage. In this review, we describe the current available knowledge about cardiac miRNAs and their functions, and focus mainly on their potential use as novel circulating diagnostic and prognostic biomarkers in STEMI.
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Affiliation(s)
- Daniela Maria Tanase
- Department of Internal Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania; (D.M.T.); (A.O.); (M.C.B.); (N.D.); (A.R.G.-R.); (D.P.); (C.R.)
- Internal Medicine Clinic, “Sf. Spiridon” County Clinical Emergency Hospital Iasi, 700111 Iasi, Romania
| | - Evelina Maria Gosav
- Department of Internal Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania; (D.M.T.); (A.O.); (M.C.B.); (N.D.); (A.R.G.-R.); (D.P.); (C.R.)
- Internal Medicine Clinic, “Sf. Spiridon” County Clinical Emergency Hospital Iasi, 700111 Iasi, Romania
- Correspondence: (E.M.G.); (M.F.); (E.R.)
| | - Anca Ouatu
- Department of Internal Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania; (D.M.T.); (A.O.); (M.C.B.); (N.D.); (A.R.G.-R.); (D.P.); (C.R.)
- Internal Medicine Clinic, “Sf. Spiridon” County Clinical Emergency Hospital Iasi, 700111 Iasi, Romania
| | - Minerva Codruta Badescu
- Department of Internal Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania; (D.M.T.); (A.O.); (M.C.B.); (N.D.); (A.R.G.-R.); (D.P.); (C.R.)
- Internal Medicine Clinic, “Sf. Spiridon” County Clinical Emergency Hospital Iasi, 700111 Iasi, Romania
| | - Nicoleta Dima
- Department of Internal Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania; (D.M.T.); (A.O.); (M.C.B.); (N.D.); (A.R.G.-R.); (D.P.); (C.R.)
- Internal Medicine Clinic, “Sf. Spiridon” County Clinical Emergency Hospital Iasi, 700111 Iasi, Romania
| | - Ana Roxana Ganceanu-Rusu
- Department of Internal Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania; (D.M.T.); (A.O.); (M.C.B.); (N.D.); (A.R.G.-R.); (D.P.); (C.R.)
- Internal Medicine Clinic, “Sf. Spiridon” County Clinical Emergency Hospital Iasi, 700111 Iasi, Romania
| | - Diana Popescu
- Department of Internal Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania; (D.M.T.); (A.O.); (M.C.B.); (N.D.); (A.R.G.-R.); (D.P.); (C.R.)
- Internal Medicine Clinic, “Sf. Spiridon” County Clinical Emergency Hospital Iasi, 700111 Iasi, Romania
| | - Mariana Floria
- Department of Internal Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania; (D.M.T.); (A.O.); (M.C.B.); (N.D.); (A.R.G.-R.); (D.P.); (C.R.)
- Internal Medicine Clinic, Emergency Military Clinical Hospital Iasi, 700483 Iasi, Romania
- Correspondence: (E.M.G.); (M.F.); (E.R.)
| | - Elena Rezus
- Department of Rheumatology and Physiotherapy, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania
- I Rheumatology Clinic, Clinical Rehabilitation Hospital, 700661 Iasi, Romania
- Correspondence: (E.M.G.); (M.F.); (E.R.)
| | - Ciprian Rezus
- Department of Internal Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania; (D.M.T.); (A.O.); (M.C.B.); (N.D.); (A.R.G.-R.); (D.P.); (C.R.)
- Internal Medicine Clinic, “Sf. Spiridon” County Clinical Emergency Hospital Iasi, 700111 Iasi, Romania
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