1
|
Vahedian-Azimi A, Sanjari MJ, Rahimi-Bashar F, Gohari-Mogadam K, Ouahrani A, Mustafa EMM, Ait Hssain A, Sahebkar A. Cardiac Rehabilitation Using the Family-Centered Empowerment Model is Effective in Improving Long-term Mortality in Patients with Myocardial Infarction: A 10-year Follow-Up Randomized Clinical Trial. High Blood Press Cardiovasc Prev 2024; 31:189-204. [PMID: 38564167 DOI: 10.1007/s40292-024-00636-2] [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: 01/09/2024] [Accepted: 03/21/2024] [Indexed: 04/04/2024] Open
Abstract
INTRODUCTION Cardiac rehabilitation (CR) play a critical role in reducing the risk of future cardiovascular events and enhancing the quality of life for individuals who have survived a heart attack. AIM To assess the mortality rates and stability of the effects in myocardial infarction (MI) survivors after implementing a Family-Centered Empowerment Model (FCEM)-focused hybrid cardiac rehabilitation program. METHODS This double-blind randomized controlled clinical trial, conducted at Shariati Hospital, an academic teaching hospital in Tehran, Iran (2012-2023), involved 70 MI patients and their families. Participants were randomly assigned to an FCEM intervention group or standard CR control group. The intervention commenced after the MI patient's safe discharge from the CCU and continued for the entire 10-year follow-up period. Various questionnaires were utilized to collect data on mortality rates and health-related quality of life (HRQoL). RESULTS The 10-year follow-up period revealed lower mortality rates in the intervention group (5.7%, 11.4%, and 17.1% at 5, 7, and 10 years, respectively) compared to the control group (20%, 37.1%, and 48.9%). After adjusting for age, gender, and BMI, the control group had a four times higher mortality risk (HR: 4.346, 95% CI 1.671-7.307, P = 0.003). The FCEM-focused program demonstrated a significant and sustained positive impact on participants' quality of life for 48 months, with greater improvement compared to the control group. CONCLUSION This study highlights the effectiveness of FCEM-based hybrid CR programs in enhancing long-term patient outcomes and reducing mortality rates among MI survivors. Further research is needed to explore the potential benefits in larger samples and diverse populations. TRIAL REGISTRATION This study (Identifier: NCT02402582) was registered in the ClinicalTrials.gov on 03/30/2015.
Collapse
Affiliation(s)
- Amir Vahedian-Azimi
- Trauma research center, Nursing Faculty, Baqiyatallah University of Medical Sciences, Tehran, Iran
| | - Mohammad Javad Sanjari
- Trauma research center, Nursing Faculty, Baqiyatallah University of Medical Sciences, Tehran, Iran
| | | | - Keivan Gohari-Mogadam
- Medical ICU and Pulmonary Unit, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Ayoub Ouahrani
- Department of Anesthesiology and Intensive Care, Dijon University Hospital, Dijon, France
| | | | - Ali Ait Hssain
- Medical Intensive Care Unit, Hamad General Hospital, Doha, Qatar.
- Department of Medicine, Weill Cornell Medical College, Doha, Qatar.
| | - Amirhossein Sahebkar
- Center for Global Health Research, Saveetha Medical College and Hospitals, Saveetha Institute of Medical and Technical Sciences, Saveetha University, Chennai, India.
- Applied Biomedical Research Center, Mashhad University of Medical Sciences, Mashhad, Iran.
- Biotechnology Research Center, Pharmaceutical Technology Institute, Mashhad University of Medical Sciences, Mashhad, Iran.
| |
Collapse
|
2
|
Alazrag W, Idris H, Saad YM, Etaher A, Ren S, Ferguson I, Juergens C, Chew DP, Otton J, Middleton PM, French JK. Management and outcomes with 5-year mortality of patients with mildly elevated high-sensitivity troponin T levels not meeting criteria for myocardial infarction. Emerg Med Australas 2024; 36:62-70. [PMID: 37705175 DOI: 10.1111/1742-6723.14298] [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: 08/18/2022] [Revised: 05/12/2023] [Accepted: 08/08/2023] [Indexed: 09/15/2023]
Abstract
OBJECTIVES To examine management and outcomes of patients presenting to EDs with symptoms suggestive of acute coronary syndrome, who have mild non-dynamically elevated high-sensitivity troponin T (HsTnT) levels, not meeting the fourth universal definition of myocardial infarction (MI) criteria (observation group). METHODS Consecutive patients presenting to the ED with symptoms suggestive of acute coronary syndrome at Liverpool Hospital, Sydney, Australia, those having ≥2 HsTnT levels after initial assessment were adjudicated according to the fourth universal definition of MI, as MI ruled-in, MI ruled-out, or myocardial injury in whom MI is neither ruled-in nor ruled-out (>1 level ≥15 ng/L, called observation group); follow-up was 5 years. RESULTS Of 2738 patients, 547 were in the observation group, of whom 62% were admitted to hospital, 52% to cardiac services, whereas 97% of MI ruled-in patients and 21% of MI ruled-out patients were admitted; P < 0.001. Non-invasive testing occurred in 42% of observation group patients (36% had echo-cardiography), and 16% had coronary angiography. Of observation group patients, MI rates were 1.5% during hospitalisation and 4% during the following year, similar to that in those with MI ruled-in, among those with MI ruled-out, the MI rate was 0.2%. The 1-year death rate was 13% among observation group patients and 11% MI ruled-in patients (P = 0.624), whereas at 5 years among observation group patients, type 1 MI and type 2 MI were 48%, 26% and 58%, respectively (P = 0.001). CONCLUSION Very few unselected consecutive patients attending ED, with minor stable HsTnT elevation, had MI, although most had chronic myocardial injury. Late mortality rates among observation group patients were higher than those with confirmed type 1 MI but lower than those with type 2 MI.
Collapse
Affiliation(s)
- Weaam Alazrag
- Department of Cardiology, Liverpool Hospital, Sydney, New South Wales, Australia
- South Western Sydney Clinical School, The University of New South Wales, Sydney, New South Wales, Australia
| | - Hanan Idris
- Department of Cardiology, Liverpool Hospital, Sydney, New South Wales, Australia
- South Western Sydney Clinical School, The University of New South Wales, Sydney, New South Wales, Australia
| | - Yousef Me Saad
- Department of Cardiology, Liverpool Hospital, Sydney, New South Wales, Australia
- South Western Sydney Clinical School, The University of New South Wales, Sydney, New South Wales, Australia
| | - Aisha Etaher
- Department of Cardiology, Liverpool Hospital, Sydney, New South Wales, Australia
- South Western Sydney Clinical School, The University of New South Wales, Sydney, New South Wales, Australia
| | - Shiquan Ren
- South Western Sydney Clinical School, The University of New South Wales, Sydney, New South Wales, Australia
- Ingham Institute for Applied Medical Research, Sydney, New South Wales, Australia
| | - Ian Ferguson
- South Western Sydney Clinical School, The University of New South Wales, Sydney, New South Wales, Australia
- Department of Emergency Medicine, Liverpool Hospital, Sydney, New South Wales, Australia
| | - Craig Juergens
- Department of Cardiology, Liverpool Hospital, Sydney, New South Wales, Australia
- South Western Sydney Clinical School, The University of New South Wales, Sydney, New South Wales, Australia
| | - Derek P Chew
- College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia
- South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia
- South Australian Department of Health, Adelaide, South Australia, Australia
| | - James Otton
- Department of Cardiology, Liverpool Hospital, Sydney, New South Wales, Australia
- South Western Sydney Clinical School, The University of New South Wales, Sydney, New South Wales, Australia
| | - Paul M Middleton
- South Western Sydney Clinical School, The University of New South Wales, Sydney, New South Wales, Australia
- Ingham Institute for Applied Medical Research, Sydney, New South Wales, Australia
- Department of Emergency Medicine, Liverpool Hospital, Sydney, New South Wales, Australia
| | - John K French
- Department of Cardiology, Liverpool Hospital, Sydney, New South Wales, Australia
- South Western Sydney Clinical School, The University of New South Wales, Sydney, New South Wales, Australia
- Ingham Institute for Applied Medical Research, Sydney, New South Wales, Australia
| |
Collapse
|
3
|
Taggart C, Chapman AR. Historical cardiac troponin concentrations in patients with suspected acute coronary syndrome. Heart 2022; 109:86-87. [PMID: 36100358 DOI: 10.1136/heartjnl-2022-321481] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Affiliation(s)
- Caelan Taggart
- Centre for Cardiovascular Science, The University of Edinburgh, Edinburgh, UK
| | - Andrew R Chapman
- Centre for Cardiovascular Science, The University of Edinburgh, Edinburgh, UK
| |
Collapse
|
4
|
Wereski R, Kimenai DM, Bularga A, Taggart C, Lowe DJ, Mills NL, Chapman AR. Risk factors for type 1 and type 2 myocardial infarction. Eur Heart J 2022; 43:127-135. [PMID: 34431993 PMCID: PMC8757580 DOI: 10.1093/eurheartj/ehab581] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Revised: 06/25/2021] [Accepted: 08/10/2021] [Indexed: 11/13/2022] Open
Abstract
AIMS Whilst the risk factors for type 1 myocardial infarction due to atherosclerotic plaque rupture and thrombosis are established, our understanding of the factors that predispose to type 2 myocardial infarction during acute illness is still emerging. Our aim was to evaluate and compare the risk factors for type 1 and type 2 myocardial infarction. METHODS AND RESULTS We conducted a secondary analysis of a multi-centre randomized trial population of 48 282 consecutive patients attending hospital with suspected acute coronary syndrome. The diagnosis of myocardial infarction during the index presentation and all subsequent reattendances was adjudicated according to the Universal Definition of Myocardial Infarction. Cox regression was used to identify predictors of future type 1 and type 2 myocardial infarction during a 1-year follow-up period. Within 1 year, 1331 patients had a subsequent myocardial infarction, with 924 and 407 adjudicated as type 1 and type 2 myocardial infarction, respectively. Risk factors for type 1 and type 2 myocardial infarction were similar, with age, hyperlipidaemia, diabetes, abnormal renal function, and known coronary disease predictors for both (P < 0.05 for all). Whilst women accounted for a greater proportion of patients with type 2 as compared to type 1 myocardial infarction, after adjustment for other risk factors, sex was not a predictor of type 2 myocardial events [adjusted hazard ratio (aHR) 0.82, 95% confidence interval (CI) 0.66-1.01]. The strongest predictor of type 2 myocardial infarction was a prior history of type 2 events (aHR 6.18, 95% CI 4.70-8.12). CONCLUSIONS Risk factors for coronary disease that are associated with type 1 myocardial infarction are also important predictors of type 2 events during acute illness. Treatment of these risk factors may reduce future risk of both type 1 and type 2 myocardial infarction.
Collapse
Affiliation(s)
- Ryan Wereski
- BHF Centre for Cardiovascular Science, University of Edinburgh, Chancellors Building, 49 Little France Crescent, Edinburgh EH16 4SA, UK
| | - Dorien M Kimenai
- Usher Institute, University of Edinburgh, Edinburgh, NINE, 9 Little France Road, Edinburgh BioQuarter, Edinburgh EH16 4UX, UK
| | - Anda Bularga
- BHF Centre for Cardiovascular Science, University of Edinburgh, Chancellors Building, 49 Little France Crescent, Edinburgh EH16 4SA, UK
| | - Caelan Taggart
- BHF Centre for Cardiovascular Science, University of Edinburgh, Chancellors Building, 49 Little France Crescent, Edinburgh EH16 4SA, UK
| | - David J Lowe
- University of Glasgow, School of Medicine, Glasgow, UK
| | - Nicholas L Mills
- BHF Centre for Cardiovascular Science, University of Edinburgh, Chancellors Building, 49 Little France Crescent, Edinburgh EH16 4SA, UK
- Usher Institute, University of Edinburgh, Edinburgh, NINE, 9 Little France Road, Edinburgh BioQuarter, Edinburgh EH16 4UX, UK
| | - Andrew R Chapman
- BHF Centre for Cardiovascular Science, University of Edinburgh, Chancellors Building, 49 Little France Crescent, Edinburgh EH16 4SA, UK
| |
Collapse
|
5
|
Liu C, Bayado N, He D, Li J, Chen H, Li L, Li J, Long X, Du T, Tang J, Dang Y, Fan Z, Wang L, Yang PC. Therapeutic Applications of Extracellular Vesicles for Myocardial Repair. Front Cardiovasc Med 2021; 8:758050. [PMID: 34957249 PMCID: PMC8695616 DOI: 10.3389/fcvm.2021.758050] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Accepted: 11/10/2021] [Indexed: 12/12/2022] Open
Abstract
Cardiovascular disease is the leading cause of human death worldwide. Drug thrombolysis, percutaneous coronary intervention, coronary artery bypass grafting and other methods are used to restore blood perfusion for coronary artery stenosis and blockage. The treatments listed prolong lifespan, however, rate of mortality ultimately remains the same. This is due to the irreversible damage sustained by myocardium, in which millions of heart cells are lost during myocardial infarction. The lack of pragmatic methods of myocardial restoration remains the greatest challenge for effective treatment. Exosomes are small extracellular vesicles (EVs) actively secreted by all cell types that act as effective transmitters of biological signals which contribute to both reparative and pathological processes within the heart. Exosomes have become the focus of many researchers as a novel drug delivery system due to the advantages of low toxicity, little immunogenicity and good permeability. In this review, we discuss the progress and challenges of EVs in myocardial repair, and review the recent development of extracellular vesicle-loading systems based on their unique nanostructures and physiological functions, as well as the application of engineering modifications in the diagnosis and treatment of myocardial repair.
Collapse
Affiliation(s)
- Chunping Liu
- State Key Laboratory of Dampness Syndrome of Chinese Medicine, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China.,State Key Laboratory of Quality Research in Chinese Medicine, Institute of Chinese Medical Sciences, University of Macau, Macau, China
| | - Nathan Bayado
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, CA, United States
| | - Dongyue He
- State Key Laboratory of Dampness Syndrome of Chinese Medicine, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Jie Li
- State Key Laboratory of Dampness Syndrome of Chinese Medicine, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Huiqi Chen
- State Key Laboratory of Dampness Syndrome of Chinese Medicine, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Longmei Li
- State Key Laboratory of Dampness Syndrome of Chinese Medicine, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Jinhua Li
- State Key Laboratory of Dampness Syndrome of Chinese Medicine, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Xinyao Long
- State Key Laboratory of Dampness Syndrome of Chinese Medicine, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Tingting Du
- State Key Laboratory of Dampness Syndrome of Chinese Medicine, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Jing Tang
- State Key Laboratory of Dampness Syndrome of Chinese Medicine, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Yue Dang
- State Key Laboratory of Dampness Syndrome of Chinese Medicine, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Zhijin Fan
- School of Medicine, South China University of Technology, Guangzhou, China
| | - Lei Wang
- State Key Laboratory of Dampness Syndrome of Chinese Medicine, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Phillip C Yang
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, CA, United States
| |
Collapse
|
6
|
Role of Cardiac Biomarkers in Cancer Patients. Cancers (Basel) 2021; 13:cancers13215426. [PMID: 34771589 PMCID: PMC8582425 DOI: 10.3390/cancers13215426] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Revised: 10/22/2021] [Accepted: 10/26/2021] [Indexed: 02/02/2023] Open
Abstract
Simple Summary Cardiac biomarkers have proved increasingly useful in the various branches of cardiology, not sparing the field of cardio-oncology. With specific reference to the latter subject, they have been investigated as predictors and/or diagnostic and monitoring tools, as well as prognostic factors, with the purpose of allowing the early prevention of many cardiovascular complications related to the direct action of some cancer types or related to the toxicity of its treatments. However, despite this great potential and excellent cost-effectiveness, their usefulness in some areas still seems to be limited due to lack of sufficient specificity or sensitivity. In fact, in clinical practice, while their use is nowadays standard in some circumstances, evidence does not yet support their routine use in other cases. Abstract In patients with cancer—and especially some specific subtypes—the heart can be pathologically affected due to the direct action of the tumor or its secretion products or due to the toxicity of some oncological treatments. Cardiac biomarkers have been investigated as inexpensive and easily accessible tools for prediction, early diagnosis, monitoring, or prognosis of various forms of cancer-related cardiac diseases. However, their clinical usefulness was not always clearly demonstrated in every area of cardioncology. For the identification of anthracycline related cardiotoxicity in the very early stages troponins proved to be more efficient detectors than imaging methods. Nevertheless, the lack of a standardized dosage methodology and of cardiotoxicity specific thresholds, do not yet allow to outline the precise way to employ them in clinical routine and to incorporate them into appropriate diagnostic or managing algorithms. Cardiac biomarkers proved also effective in patients with primary cardiac amyloidosis, in which both troponins and natriuretic peptides were able to predict adverse outcome, and carcinoid heart disease, where a precise diagnostic cut-off for N-terminal prohormone of brain natriuretic peptide (NT-proBNP) was identified to screen patients with valvular involvement. Likewise, NT-proBNP proved to be an excellent predictor of postoperative atrial fibrillation (POAF). On the contrary, evidence is still not sufficient to promote the routine use of cardiac biomarkers to early diagnose myocarditis due to immune check points inhibitors (ICIs), radiotherapy induced cardiotoxicity and cardiac complications related to androgenetic deprivation. In this review we present all the evidence gathered so far regarding the usefulness and limitations of these relatively inexpensive diagnostic tools in the field of cardio-oncology.
Collapse
|
7
|
Lind L, Araujo JA, Barchowsky A, Belcher S, Berridge BR, Chiamvimonvat N, Chiu WA, Cogliano VJ, Elmore S, Farraj AK, Gomes AV, McHale CM, Meyer-Tamaki KB, Posnack NG, Vargas HM, Yang X, Zeise L, Zhou C, Smith MT. Key Characteristics of Cardiovascular Toxicants. ENVIRONMENTAL HEALTH PERSPECTIVES 2021; 129:95001. [PMID: 34558968 PMCID: PMC8462506 DOI: 10.1289/ehp9321] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/03/2023]
Abstract
BACKGROUND The concept of chemical agents having properties that confer potential hazard called key characteristics (KCs) was first developed to identify carcinogenic hazards. Identification of KCs of cardiovascular (CV) toxicants could facilitate the systematic assessment of CV hazards and understanding of assay and data gaps associated with current approaches. OBJECTIVES We sought to develop a consensus-based synthesis of scientific evidence on the KCs of chemical and nonchemical agents known to cause CV toxicity along with methods to measure them. METHODS An expert working group was convened to discuss mechanisms associated with CV toxicity. RESULTS The group identified 12 KCs of CV toxicants, defined as exogenous agents that adversely interfere with function of the CV system. The KCs were organized into those primarily affecting cardiac tissue (numbers 1-4 below), the vascular system (5-7), or both (8-12), as follows: 1) impairs regulation of cardiac excitability, 2) impairs cardiac contractility and relaxation, 3) induces cardiomyocyte injury and death, 4) induces proliferation of valve stroma, 5) impacts endothelial and vascular function, 6) alters hemostasis, 7) causes dyslipidemia, 8) impairs mitochondrial function, 9) modifies autonomic nervous system activity, 10) induces oxidative stress, 11) causes inflammation, and 12) alters hormone signaling. DISCUSSION These 12 KCs can be used to help identify pharmaceuticals and environmental pollutants as CV toxicants, as well as to better understand the mechanistic underpinnings of their toxicity. For example, evidence exists that fine particulate matter [PM ≤2.5μm in aerodynamic diameter (PM2.5)] air pollution, arsenic, anthracycline drugs, and other exogenous chemicals possess one or more of the described KCs. In conclusion, the KCs could be used to identify potential CV toxicants and to define a set of test methods to evaluate CV toxicity in a more comprehensive and standardized manner than current approaches. https://doi.org/10.1289/EHP9321.
Collapse
Affiliation(s)
- Lars Lind
- Department of Medical Sciences, Clinical Epidemiology, University of Uppsala, Sweden
| | - Jesus A. Araujo
- Division of Cardiology, David Geffen School of Medicine at University of California Los Angeles (UCLA), UCLA, Los Angeles, California, USA
- Department of Environmental Health Sciences, Fielding School of Public Health and Molecular Biology Institute, UCLA, Los Angeles, California, USA
| | - Aaron Barchowsky
- Department of Environmental and Occupational Health, Graduate School of Public Health, University of Pittsburgh, Pennsylvania, USA
| | - Scott Belcher
- Department of Biological Sciences, North Carolina State University, North Carolina, USA
| | - Brian R. Berridge
- Division of the National Toxicology Program, National Institute of Environmental Health Sciences, National Institutes of Health, Department of Health and Human Services, Research Triangle Park, North Carolina, USA
| | - Nipavan Chiamvimonvat
- Department of Internal Medicine, University of California, Davis, Davis, California, USA
| | - Weihsueh A. Chiu
- College of Veterinary Medicine and Biomedical Sciences, Texas A&M University, College Station, Texas, USA
| | - Vincent J. Cogliano
- Office of Environmental Health Hazard Assessment, California Environmental Protection Agency (EPA), Oakland, California, USA
| | - Sarah Elmore
- Office of Environmental Health Hazard Assessment, California Environmental Protection Agency (EPA), Oakland, California, USA
| | - Aimen K. Farraj
- Public Health and Integrated Toxicology Division, Center for Public Health and Environmental Assessment, U.S. EPA, Research Triangle Park, North Carolina, USA
| | - Aldrin V. Gomes
- Department of Neurobiology, Physiology and Behavior, College of Biological Sciences, University of California, Davis, Davis, California, USA
| | - Cliona M. McHale
- Division of Environmental Health Sciences, School of Public Health, University of California, Berkeley, Berkeley, California, USA
| | | | - Nikki Gillum Posnack
- Children’s National Heart Institute and the Sheikh Zayed Institute for Pediatric Surgical Innovation, Children’s National Hospital, Washington, DC, USA
| | - Hugo M. Vargas
- Translational Safety & Bioanalytical Sciences, Amgen, Inc., Thousand Oaks, California, USA
| | - Xi Yang
- Division of Pharmacology and Toxicology, Office of Cardiology, Hematology, Endocrinology, and Nephrology, Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, Maryland, USA
| | - Lauren Zeise
- Office of Environmental Health Hazard Assessment, California Environmental Protection Agency (EPA), Oakland, California, USA
| | - Changcheng Zhou
- Division of Biomedical Sciences, School of Medicine, University of California, Riverside, Riverside, California, USA
| | - Martyn T. Smith
- Division of Environmental Health Sciences, School of Public Health, University of California, Berkeley, Berkeley, California, USA
| |
Collapse
|
8
|
Wereski R, Kimenai DM, Taggart C, Doudesis D, Lee KK, Lowry MT, Bularga A, Lowe DJ, Fujisawa T, Apple FS, Collinson PO, Anand A, Chapman AR, Mills NL. Cardiac Troponin Thresholds and Kinetics to Differentiate Myocardial Injury and Myocardial Infarction. Circulation 2021; 144:528-538. [PMID: 34167318 PMCID: PMC8360674 DOI: 10.1161/circulationaha.121.054302] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Accepted: 07/07/2021] [Indexed: 11/16/2022]
Abstract
BACKGROUND Although the 99th percentile is the recommended diagnostic threshold for myocardial infarction, some guidelines also advocate the use of higher troponin thresholds to rule in myocardial infarction at presentation. It is unclear whether the magnitude or change in troponin concentration can differentiate causes of myocardial injury and infarction in practice. METHODS In a secondary analysis of a multicenter randomized controlled trial, we identified 46 092 consecutive patients presenting with suspected acute coronary syndrome without ST-segment-elevation myocardial infarction. High-sensitivity cardiac troponin I concentrations at presentation and on serial testing were compared between patients with myocardial injury and infarction. The positive predictive value and specificity were determined at the sex-specific 99th percentile upper reference limit and rule-in thresholds of 64 ng/L and 5-fold of the upper reference limit for a diagnosis of type 1 myocardial infarction. RESULTS Troponin was above the 99th percentile in 8188 patients (18%). The diagnosis was type 1 or type 2 myocardial infarction in 50% and 14% and acute or chronic myocardial injury in 20% and 16%, respectively. Troponin concentrations were similar at presentation in type 1 (median [25th-75th percentile] 91 [30-493] ng/L) and type 2 (50 [22-147] ng/L) myocardial infarction and in acute (50 [26-134] ng/L) and chronic (51 [31-130] ng/L) myocardial injury. The 99th percentile and rule-in thresholds of 64 ng/L and 5-fold upper reference limit gave a positive predictive value of 57% (95% CI, 56%-58%), 59% (58%-61%), and 62% (60%-64%) and a specificity of 96% (96%-96%), 96% (96%-96%), and 98% (97%-98%), respectively. The absolute, relative, and rate of change in troponin concentration were highest in patients with type 1 myocardial infarction (P<0.001 for all). Discrimination improved when troponin concentration and change in troponin were combined compared with troponin concentration at presentation alone (area under the curve, 0.661 [0.642-0.680] versus 0.613 [0.594-0.633]). CONCLUSIONS Although we observed important differences in the kinetics, cardiac troponin concentrations at presentation are insufficient to distinguish type 1 myocardial infarction from other causes of myocardial injury or infarction in practice and should not guide management decisions in isolation. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT01852123.
Collapse
Affiliation(s)
- Ryan Wereski
- British Heart Foundation Centre for Cardiovascular Science (R.W., C.T., D.D., K.K.L., M.T.H.L., A.B., T.F., A.A., A.R.C., N.L.M.), University of Edinburgh, UK
| | | | - Caelan Taggart
- British Heart Foundation Centre for Cardiovascular Science (R.W., C.T., D.D., K.K.L., M.T.H.L., A.B., T.F., A.A., A.R.C., N.L.M.), University of Edinburgh, UK
| | - Dimitrios Doudesis
- British Heart Foundation Centre for Cardiovascular Science (R.W., C.T., D.D., K.K.L., M.T.H.L., A.B., T.F., A.A., A.R.C., N.L.M.), University of Edinburgh, UK
- Usher Institute (D.M.K., D.D., N.L.M.), University of Edinburgh, UK
| | - Kuan Ken Lee
- British Heart Foundation Centre for Cardiovascular Science (R.W., C.T., D.D., K.K.L., M.T.H.L., A.B., T.F., A.A., A.R.C., N.L.M.), University of Edinburgh, UK
| | - Matthew T.H. Lowry
- British Heart Foundation Centre for Cardiovascular Science (R.W., C.T., D.D., K.K.L., M.T.H.L., A.B., T.F., A.A., A.R.C., N.L.M.), University of Edinburgh, UK
| | - Anda Bularga
- British Heart Foundation Centre for Cardiovascular Science (R.W., C.T., D.D., K.K.L., M.T.H.L., A.B., T.F., A.A., A.R.C., N.L.M.), University of Edinburgh, UK
| | - David J. Lowe
- University of Glasgow, School of Medicine, UK (D.J.L.)
| | - Takeshi Fujisawa
- British Heart Foundation Centre for Cardiovascular Science (R.W., C.T., D.D., K.K.L., M.T.H.L., A.B., T.F., A.A., A.R.C., N.L.M.), University of Edinburgh, UK
| | - Fred S. Apple
- Department of Laboratory Medicine and Pathology, Hennepin Healthcare/Hennepin County Medical Center and University of Minnesota, Minneapolis (F.S.A.)
| | - Paul O. Collinson
- Department of Clinical Blood Sciences and Cardiology, St. George’s University of London, UK (P.O.C.)
| | - Atul Anand
- British Heart Foundation Centre for Cardiovascular Science (R.W., C.T., D.D., K.K.L., M.T.H.L., A.B., T.F., A.A., A.R.C., N.L.M.), University of Edinburgh, UK
| | - Andrew R. Chapman
- British Heart Foundation Centre for Cardiovascular Science (R.W., C.T., D.D., K.K.L., M.T.H.L., A.B., T.F., A.A., A.R.C., N.L.M.), University of Edinburgh, UK
| | - Nicholas L. Mills
- British Heart Foundation Centre for Cardiovascular Science (R.W., C.T., D.D., K.K.L., M.T.H.L., A.B., T.F., A.A., A.R.C., N.L.M.), University of Edinburgh, UK
- Usher Institute (D.M.K., D.D., N.L.M.), University of Edinburgh, UK
| |
Collapse
|