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Wolter JS, Treiber JM, Fischer S, Fischer-Rasokat U, Kriechbaum SD, Rieth A, Weferling M, von Jeinsen B, Hain A, Hamm CW, Keller T, Rolf A. Native T2 Predicts Myocardial Inflammation Irrespective of a Patient's Volume Status. Diagnostics (Basel) 2023; 13:2240. [PMID: 37443634 DOI: 10.3390/diagnostics13132240] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2023] [Revised: 06/06/2023] [Accepted: 06/26/2023] [Indexed: 07/15/2023] Open
Abstract
Myocardial inflammation and edema are major pathological features in myocarditis. Myocardial tissue water content and myocardial edema can be quantified via T2 mapping. Thus, cardiac magnetic resonance (CMR) is the noninvasive gold standard for diagnosing myocarditis. Several studies showed an impact of short-term volume changes on T2 relaxation time. Plasma volume status (PVS) is a good surrogate parameter to quantify a patient's volume status, and it is simple to use. The aim of this study was to determine the effect of PVS on the diagnostic value of T2 relaxation time in myocardial inflammation. Between April 2017 and December 2022, patients who were indicated for cardiac CMR were included in our prospective clinical registry. Patients with myocardial inflammation and those with unremarkable findings were analyzed in the present study. A blood sample was drawn, and PVS was calculated. Patients were separated into PVS tertiles to explore a possible nonlinear dose-response relationship. Logistic regression analysis was used to determine whether T2 is an independent predictor of myocardial inflammation. A total of 700 patients (47.43% female) were eligible for analysis. Of these, 551 patients were healthy (78.7%), while 149 (21.3%) showed signs of myocardial inflammation. The T2 relaxation time was elevated in patients with myocardial inflammation (40 ms [IQR 37-42 ms] vs. 38.0 ms [IQR 36-39 ms], p < 0.001). PVS showed no difference between the groups (-12.94 [IQR -18.4--7.28] vs.-12.19 [IQR -18.93--5.87], p = 0.384). T2 showed a clear dose-response relationship with PVS, with increasing T2 values along the PVS tertiles. In spite of this, T2 was found to be an independent marker of myocardial inflammation in logistic regression (OR T2 1.3 [95% CI 1.21-1.39], p < 0.001), even after adjusting for PVS (OR T2 [adj. PVS] 1.31 [95% CI 1.22-1.40], p < 0.001). Despite a dose-response relationship between T2 and the volume status, T2 was found to be an independent indicator of myocardial inflammation.
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Affiliation(s)
- Jan Sebastian Wolter
- Kerckhoff Heart and Thorax Center, Department of Cardiology, Benekestrasse 2-8, 61231 Bad Nauheim, Germany
- German Center for Cardiovascular Research (DZHK), Rhine-Main Partner Site, 60590 Frankfurt am Main, Germany
| | - Julia M Treiber
- Kerckhoff Heart and Thorax Center, Department of Cardiology, Benekestrasse 2-8, 61231 Bad Nauheim, Germany
- German Center for Cardiovascular Research (DZHK), Rhine-Main Partner Site, 60590 Frankfurt am Main, Germany
| | - Selina Fischer
- Kerckhoff Heart and Thorax Center, Department of Cardiology, Benekestrasse 2-8, 61231 Bad Nauheim, Germany
| | - Ulrich Fischer-Rasokat
- Kerckhoff Heart and Thorax Center, Department of Cardiology, Benekestrasse 2-8, 61231 Bad Nauheim, Germany
- German Center for Cardiovascular Research (DZHK), Rhine-Main Partner Site, 60590 Frankfurt am Main, Germany
| | - Steffen D Kriechbaum
- Kerckhoff Heart and Thorax Center, Department of Cardiology, Benekestrasse 2-8, 61231 Bad Nauheim, Germany
- German Center for Cardiovascular Research (DZHK), Rhine-Main Partner Site, 60590 Frankfurt am Main, Germany
| | - Andreas Rieth
- Kerckhoff Heart and Thorax Center, Department of Cardiology, Benekestrasse 2-8, 61231 Bad Nauheim, Germany
- German Center for Cardiovascular Research (DZHK), Rhine-Main Partner Site, 60590 Frankfurt am Main, Germany
| | - Maren Weferling
- Kerckhoff Heart and Thorax Center, Department of Cardiology, Benekestrasse 2-8, 61231 Bad Nauheim, Germany
- German Center for Cardiovascular Research (DZHK), Rhine-Main Partner Site, 60590 Frankfurt am Main, Germany
| | - Beatrice von Jeinsen
- Kerckhoff Heart and Thorax Center, Department of Cardiology, Benekestrasse 2-8, 61231 Bad Nauheim, Germany
- German Center for Cardiovascular Research (DZHK), Rhine-Main Partner Site, 60590 Frankfurt am Main, Germany
| | - Andreas Hain
- Kerckhoff Heart and Thorax Center, Department of Cardiology, Benekestrasse 2-8, 61231 Bad Nauheim, Germany
| | - Christian W Hamm
- Kerckhoff Heart and Thorax Center, Department of Cardiology, Benekestrasse 2-8, 61231 Bad Nauheim, Germany
- German Center for Cardiovascular Research (DZHK), Rhine-Main Partner Site, 60590 Frankfurt am Main, Germany
- Justus-Liebig-Universität Gießen, Medicine, Medical Clinic 1, 35390 Giessen, Germany
| | - Till Keller
- Kerckhoff Heart and Thorax Center, Department of Cardiology, Benekestrasse 2-8, 61231 Bad Nauheim, Germany
- German Center for Cardiovascular Research (DZHK), Rhine-Main Partner Site, 60590 Frankfurt am Main, Germany
- Justus-Liebig-Universität Gießen, Medicine, Medical Clinic 1, 35390 Giessen, Germany
| | - Andreas Rolf
- Kerckhoff Heart and Thorax Center, Department of Cardiology, Benekestrasse 2-8, 61231 Bad Nauheim, Germany
- German Center for Cardiovascular Research (DZHK), Rhine-Main Partner Site, 60590 Frankfurt am Main, Germany
- Justus-Liebig-Universität Gießen, Medicine, Medical Clinic 1, 35390 Giessen, Germany
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Treiber J, Novak D, Fischer-Rasokat U, Wolter JS, Kriechbaum S, Weferling M, von Jeinsen B, Hain A, Rieth AJ, Siemons T, Keller T, Hamm CW, Rolf A. Regional extracellular volume within late gadolinium enhancement-positive myocardium to differentiate cardiac sarcoidosis from myocarditis of other etiology: a cardiovascular magnetic resonance study. J Cardiovasc Magn Reson 2023; 25:8. [PMID: 36755275 PMCID: PMC9909902 DOI: 10.1186/s12968-023-00918-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Accepted: 01/12/2023] [Indexed: 02/10/2023] Open
Abstract
BACKGROUND Cardiovascular magnetic resonance (CMR) plays a pivotal role in diagnosing myocardial inflammation. In addition to late gadolinium enhancement (LGE), native T1 and T2 mapping as well as extracellular volume (ECV) are essential tools for tissue characterization. However, the differentiation of cardiac sarcoidosis (CS) from myocarditis of other etiology can be challenging. Positron-emission tomography-computed tomography (PET-CT) regularly shows the highest Fluordesoxyglucose (FDG) uptake in LGE positive regions. It was therefore the aim of this study to investigate, whether native T1, T2, and ECV measurements within LGE regions can improve the differentiation of CS and myocarditis compared with using global native T1, T2, and ECV values alone. METHODS PET/CT confirmed CS patients and myocarditis patients (both acute and chronic) from a prospective registry were compared with respect to regional native T1, T2, and ECV. Acute and chronic myocarditis were defined based on the 2013 European Society of Cardiology position paper on myocarditis. All parametric measures and ECV were acquired in standard fashion on three short-axis slices according to the ConSept study for global values and within PET-CT positive regions of LGE. RESULTS Between 2017 and 2020, 33 patients with CS and 73 chronic and 35 acute myocarditis patients were identified. The mean ECV (± SD) in LGE regions of CS patients was higher than in myocarditis patients (CS vs. acute and chronic, respectively: 0.65 ± 0.12 vs. 0.45 ± 0.13 and 0.47 ± 0.1; p < 0.001). Acute and chronic myocarditis patients had higher global native T1 values (1157 ± 54 ms vs. 1196 ± 63 ms vs. 1215 ± 74 ms; p = 0.001). There was no difference in global T2 and ECV values between CS and acute or chronic myocarditis patients. CONCLUSION This is the first study to show that the calculation of regional ECV within LGE-positive regions may help to differentiate CS from myocarditis. Further studies are warranted to corroborate these findings.
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Affiliation(s)
- Julia Treiber
- Department of Cardiology, Kerckhoff Heart and Thorax Center, Benekestrasse 2-8, 61231, Bad Nauheim, Germany
- German Center for Cardiovascular Research (DZHK), Rhine-Main Partner Site, Frankfurt am Main, Germany
| | - Dijana Novak
- Department of Cardiology, Kerckhoff Heart and Thorax Center, Benekestrasse 2-8, 61231, Bad Nauheim, Germany
| | - Ulrich Fischer-Rasokat
- Department of Cardiology, Kerckhoff Heart and Thorax Center, Benekestrasse 2-8, 61231, Bad Nauheim, Germany
- German Center for Cardiovascular Research (DZHK), Rhine-Main Partner Site, Frankfurt am Main, Germany
| | - Jan Sebastian Wolter
- Department of Cardiology, Kerckhoff Heart and Thorax Center, Benekestrasse 2-8, 61231, Bad Nauheim, Germany
- German Center for Cardiovascular Research (DZHK), Rhine-Main Partner Site, Frankfurt am Main, Germany
| | - Steffen Kriechbaum
- Department of Cardiology, Kerckhoff Heart and Thorax Center, Benekestrasse 2-8, 61231, Bad Nauheim, Germany
- German Center for Cardiovascular Research (DZHK), Rhine-Main Partner Site, Frankfurt am Main, Germany
| | - Maren Weferling
- Department of Cardiology, Kerckhoff Heart and Thorax Center, Benekestrasse 2-8, 61231, Bad Nauheim, Germany
- German Center for Cardiovascular Research (DZHK), Rhine-Main Partner Site, Frankfurt am Main, Germany
| | - Beatrice von Jeinsen
- Department of Cardiology, Kerckhoff Heart and Thorax Center, Benekestrasse 2-8, 61231, Bad Nauheim, Germany
- German Center for Cardiovascular Research (DZHK), Rhine-Main Partner Site, Frankfurt am Main, Germany
| | - Andreas Hain
- Department of Cardiology, Kerckhoff Heart and Thorax Center, Benekestrasse 2-8, 61231, Bad Nauheim, Germany
| | - Andreas J Rieth
- Department of Cardiology, Kerckhoff Heart and Thorax Center, Benekestrasse 2-8, 61231, Bad Nauheim, Germany
- German Center for Cardiovascular Research (DZHK), Rhine-Main Partner Site, Frankfurt am Main, Germany
| | - Tamo Siemons
- Department of Cardiology, Kerckhoff Heart and Thorax Center, Benekestrasse 2-8, 61231, Bad Nauheim, Germany
| | - Till Keller
- Department of Cardiology, Kerckhoff Heart and Thorax Center, Benekestrasse 2-8, 61231, Bad Nauheim, Germany
- Medical Clinic 1, Justus-Liebig-Universität Giessen, Giessen, Germany
- German Center for Cardiovascular Research (DZHK), Rhine-Main Partner Site, Frankfurt am Main, Germany
| | - Christian W Hamm
- Department of Cardiology, Kerckhoff Heart and Thorax Center, Benekestrasse 2-8, 61231, Bad Nauheim, Germany
- Medical Clinic 1, Justus-Liebig-Universität Giessen, Giessen, Germany
- German Center for Cardiovascular Research (DZHK), Rhine-Main Partner Site, Frankfurt am Main, Germany
| | - Andreas Rolf
- Department of Cardiology, Kerckhoff Heart and Thorax Center, Benekestrasse 2-8, 61231, Bad Nauheim, Germany.
- Medical Clinic 1, Justus-Liebig-Universität Giessen, Giessen, Germany.
- German Center for Cardiovascular Research (DZHK), Rhine-Main Partner Site, Frankfurt am Main, Germany.
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Vietheer J, Lehmann L, Unbehaun C, Fischer-Rasokat U, Wolter JS, Kriechbaum S, Weferling M, von Jeinsen B, Hain A, Liebetrau C, Hamm CW, Keller T, Rolf A. CMR-derived myocardial strain analysis differentiates ischemic and dilated cardiomyopathy-a propensity score-matched study. Int J Cardiovasc Imaging 2021; 38:10.1007/s10554-021-02469-9. [PMID: 34839396 DOI: 10.1007/s10554-021-02469-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Accepted: 11/05/2021] [Indexed: 01/31/2023]
Abstract
Left ventricular (LV) longitudinal, circumferential, and radial motion can be measured using feature tracking of cardiac magnetic resonance (CMR) images. The aim of our study was to detect differences in LV mechanics between patients with dilated cardiomyopathy (DCM) and ischemic cardiomyopathy (ICM) who were matched using a propensity score-based model. Between April 2017 and October 2019, 1224 patients were included in our CMR registry, among them 141 with ICM and 77 with DCM. Propensity score matching was used to pair patients based on their indexed end-diastolic volume (EDVi), ejection fraction (EF), and septal T1 relaxation time (psmatch2 module L Feature tracking provided six parameters for global longitudinal, circumferential, and radial strain with corresponding strain rates in each group. Strain parameters were compared between matched pairs of ICM and DCM patients using paired t tests. Propensity score matching yielded 72 patients in each group (DCM mean age 58.6 ± 11.6 years, 15 females; ICM mean age 62.6 ± 13.2 years, 11 females, p = 0.084 and 0.44 respectively; LV-EF 32.2 ± 13.5% vs. 33.8 ± 12.1%, p = 0.356; EDVi 127.2 ± 30.7 ml/m2 vs. 121.1 ± 41.8 ml/m2, p = 0.251; native T1 values 1165 ± 58 ms vs. 1167 ± 70 ms, p = 0.862). There was no difference in global longitudinal strain between DCM and ICM patients (- 10.9 ± 5.5% vs. - 11.2 ± 4.7%, p = 0.72), whereas in DCM patients there was a significant reduction in global circumferential strain (- 10.0 ± 4.5% vs. - 12.2 ± 4.7%, p = 0.002) and radial strain (17.1 ± 8.51 vs. 21.2 ± 9.7%, p = 0.039). Our data suggest that ICM and DCM patients have inherently different myocardial mechanics, even if phenotypes are similar. Our data show that GCS is significantly more impaired in DCM patients. This feature may help in more thoroughly characterizing cardiomyopathy patients.
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Affiliation(s)
- Julia Vietheer
- Department of Cardiology, Kerckhoff Heart and Thorax Center, Benekestrasse 2-8, 61231, Bad Nauheim, Germany
- DZHK (German Centre for Cardiovascular Research), partner site Rhine-Main, Frankfurt am Main, Germany
| | - Lena Lehmann
- Medical Clinic I, Justus-Liebig-University Giessen, Giessen, Germany
| | - Claudia Unbehaun
- Department of Cardiology, Kerckhoff Heart and Thorax Center, Benekestrasse 2-8, 61231, Bad Nauheim, Germany
- DZHK (German Centre for Cardiovascular Research), partner site Rhine-Main, Frankfurt am Main, Germany
| | - Ulrich Fischer-Rasokat
- Department of Cardiology, Kerckhoff Heart and Thorax Center, Benekestrasse 2-8, 61231, Bad Nauheim, Germany
- DZHK (German Centre for Cardiovascular Research), partner site Rhine-Main, Frankfurt am Main, Germany
| | - Jan Sebastian Wolter
- Department of Cardiology, Kerckhoff Heart and Thorax Center, Benekestrasse 2-8, 61231, Bad Nauheim, Germany
- DZHK (German Centre for Cardiovascular Research), partner site Rhine-Main, Frankfurt am Main, Germany
| | - Steffen Kriechbaum
- Department of Cardiology, Kerckhoff Heart and Thorax Center, Benekestrasse 2-8, 61231, Bad Nauheim, Germany
- DZHK (German Centre for Cardiovascular Research), partner site Rhine-Main, Frankfurt am Main, Germany
| | - Maren Weferling
- Department of Cardiology, Kerckhoff Heart and Thorax Center, Benekestrasse 2-8, 61231, Bad Nauheim, Germany
- DZHK (German Centre for Cardiovascular Research), partner site Rhine-Main, Frankfurt am Main, Germany
| | - Beatrice von Jeinsen
- Department of Cardiology, Kerckhoff Heart and Thorax Center, Benekestrasse 2-8, 61231, Bad Nauheim, Germany
- DZHK (German Centre for Cardiovascular Research), partner site Rhine-Main, Frankfurt am Main, Germany
| | - Andreas Hain
- Department of Cardiology, Kerckhoff Heart and Thorax Center, Benekestrasse 2-8, 61231, Bad Nauheim, Germany
- DZHK (German Centre for Cardiovascular Research), partner site Rhine-Main, Frankfurt am Main, Germany
| | - Christoph Liebetrau
- Department of Cardiology, Kerckhoff Heart and Thorax Center, Benekestrasse 2-8, 61231, Bad Nauheim, Germany
- DZHK (German Centre for Cardiovascular Research), partner site Rhine-Main, Frankfurt am Main, Germany
| | - Christian W Hamm
- Department of Cardiology, Kerckhoff Heart and Thorax Center, Benekestrasse 2-8, 61231, Bad Nauheim, Germany
- Medical Clinic I, Justus-Liebig-University Giessen, Giessen, Germany
- DZHK (German Centre for Cardiovascular Research), partner site Rhine-Main, Frankfurt am Main, Germany
| | - Till Keller
- Department of Cardiology, Kerckhoff Heart and Thorax Center, Benekestrasse 2-8, 61231, Bad Nauheim, Germany
- DZHK (German Centre for Cardiovascular Research), partner site Rhine-Main, Frankfurt am Main, Germany
| | - Andreas Rolf
- Department of Cardiology, Kerckhoff Heart and Thorax Center, Benekestrasse 2-8, 61231, Bad Nauheim, Germany.
- Medical Clinic I, Justus-Liebig-University Giessen, Giessen, Germany.
- DZHK (German Centre for Cardiovascular Research), partner site Rhine-Main, Frankfurt am Main, Germany.
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Askari N, Lipps C, Voss S, Staubach N, Grün D, Klingenberg R, von Jeinsen B, Wolter JS, Kriechbaum S, Dörr O, Nef H, Liebetrau C, Hamm CW, Keller T. Circulating Monocyte Subsets Are Associated With Extent of Myocardial Injury but Not With Type of Myocardial Infarction. Front Cardiovasc Med 2021; 8:741890. [PMID: 34796212 PMCID: PMC8592918 DOI: 10.3389/fcvm.2021.741890] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Accepted: 10/14/2021] [Indexed: 11/29/2022] Open
Abstract
Inflammation is a hallmark of the period after a myocardial infarction (MI) that is either promoted or resolved by distinct subtypes of circulating inflammatory cells. The three main monocyte subpopulations play different roles inflammation. This study examined whether the type of MI (type 1 or type 2) or the extent of myocardial injury is associated with differences in monocyte subpopulations. For this purpose, peripheral whole blood from patients with a suspected MI was used for flow cytometric measurements of the monocyte subpopulations, and myocardial injury was classified by cardiac troponin levels in serum. In patients with acute coronary syndrome (n = 82, 62.2% male) similar proportions of the monocyte subsets were associated with the two types of MI, whereas total monocyte counts were increased in patients with substantial myocardial injury vs. those with minor injury (p = 0.045). This was accompanied by a higher proportion of intermediate (p = 0.045) and classical monocytes (p = 0.059); no difference was found for non-classical monocytes (p = 0.772). In patients with chronic coronary syndrome (n = 144, 66.5% male), an independent association with myocardial injury was also observed for classical monocytes (p = 0.01) and intermediate monocytes (p = 0.08). In conclusion, changes in monocyte subpopulation counts, particularly for classical and intermediate monocytes, were related to the extent of myocardial injury in acute and stable coronary artery disease but not to the type of MI.
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Affiliation(s)
- Noushin Askari
- Department of Internal Medicine I, Cardiology, Justus-Liebig-University Gießen, Giessen, Germany
| | - Christoph Lipps
- Department of Internal Medicine I, Cardiology, Justus-Liebig-University Gießen, Giessen, Germany.,Department of Cardiology, Kerckhoff Heart and Thorax Center, Bad Nauheim, Germany.,German Center for Cardiovascular Research e.V. (DZHK), Partner Site RhineMain, Bad Nauheim, Germany
| | - Sandra Voss
- Department of Cardiology, Kerckhoff Heart and Thorax Center, Bad Nauheim, Germany.,German Center for Cardiovascular Research e.V. (DZHK), Partner Site RhineMain, Bad Nauheim, Germany
| | - Nora Staubach
- Department of Cardiology, Kerckhoff Heart and Thorax Center, Bad Nauheim, Germany.,German Center for Cardiovascular Research e.V. (DZHK), Partner Site RhineMain, Bad Nauheim, Germany
| | - Dimitri Grün
- Department of Internal Medicine I, Cardiology, Justus-Liebig-University Gießen, Giessen, Germany
| | - Roland Klingenberg
- Department of Cardiology, Kerckhoff Heart and Thorax Center, Bad Nauheim, Germany.,German Center for Cardiovascular Research e.V. (DZHK), Partner Site RhineMain, Bad Nauheim, Germany
| | - Beatrice von Jeinsen
- Department of Cardiology, Kerckhoff Heart and Thorax Center, Bad Nauheim, Germany
| | - Jan Sebastian Wolter
- Department of Cardiology, Kerckhoff Heart and Thorax Center, Bad Nauheim, Germany
| | - Steffen Kriechbaum
- Department of Cardiology, Kerckhoff Heart and Thorax Center, Bad Nauheim, Germany.,German Center for Cardiovascular Research e.V. (DZHK), Partner Site RhineMain, Bad Nauheim, Germany
| | - Oliver Dörr
- Department of Internal Medicine I, Cardiology, Justus-Liebig-University Gießen, Giessen, Germany
| | - Holger Nef
- Department of Internal Medicine I, Cardiology, Justus-Liebig-University Gießen, Giessen, Germany.,Department of Cardiology, Kerckhoff Heart and Thorax Center, Bad Nauheim, Germany.,German Center for Cardiovascular Research e.V. (DZHK), Partner Site RhineMain, Bad Nauheim, Germany
| | - Christoph Liebetrau
- Department of Internal Medicine I, Cardiology, Justus-Liebig-University Gießen, Giessen, Germany.,Department of Cardiology, Kerckhoff Heart and Thorax Center, Bad Nauheim, Germany.,German Center for Cardiovascular Research e.V. (DZHK), Partner Site RhineMain, Bad Nauheim, Germany.,Cardiovascular Center Bethanien (CCB), Frankfurt, Germany
| | - Christian W Hamm
- Department of Internal Medicine I, Cardiology, Justus-Liebig-University Gießen, Giessen, Germany.,Department of Cardiology, Kerckhoff Heart and Thorax Center, Bad Nauheim, Germany.,German Center for Cardiovascular Research e.V. (DZHK), Partner Site RhineMain, Bad Nauheim, Germany
| | - Till Keller
- Department of Internal Medicine I, Cardiology, Justus-Liebig-University Gießen, Giessen, Germany.,Department of Cardiology, Kerckhoff Heart and Thorax Center, Bad Nauheim, Germany.,German Center for Cardiovascular Research e.V. (DZHK), Partner Site RhineMain, Bad Nauheim, Germany
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5
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Grün D, Rudolph F, Gumpfer N, Hannig J, Elsner LK, von Jeinsen B, Hamm CW, Rieth A, Guckert M, Keller T. Identifying Heart Failure in ECG Data With Artificial Intelligence-A Meta-Analysis. Front Digit Health 2021; 2:584555. [PMID: 34713056 PMCID: PMC8521986 DOI: 10.3389/fdgth.2020.584555] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Accepted: 12/29/2020] [Indexed: 12/21/2022] Open
Abstract
Introduction: Electrocardiography (ECG) is a quick and easily accessible method for diagnosis and screening of cardiovascular diseases including heart failure (HF). Artificial intelligence (AI) can be used for semi-automated ECG analysis. The aim of this evaluation was to provide an overview of AI use in HF detection from ECG signals and to perform a meta-analysis of available studies. Methods and Results: An independent comprehensive search of the PubMed and Google Scholar database was conducted for articles dealing with the ability of AI to predict HF based on ECG signals. Only original articles published in peer-reviewed journals were considered. A total of five reports including 57,027 patients and 579,134 ECG datasets were identified including two sets of patient-level data and three with ECG-based datasets. The AI-processed ECG data yielded areas under the receiver operator characteristics curves between 0.92 and 0.99 to identify HF with higher values in ECG-based datasets. Applying a random-effects model, an sROC of 0.987 was calculated. Using the contingency tables led to diagnostic odds ratios ranging from 3.44 [95% confidence interval (CI) = 3.12–3.76] to 13.61 (95% CI = 13.14–14.08) also with lower values in patient-level datasets. The meta-analysis diagnostic odds ratio was 7.59 (95% CI = 5.85–9.34). Conclusions: The present meta-analysis confirms the ability of AI to predict HF from standard 12-lead ECG signals underlining the potential of such an approach. The observed overestimation of the diagnostic ability in artificial ECG databases compared to patient-level data stipulate the need for robust prospective studies.
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Affiliation(s)
- Dimitri Grün
- Department of Internal Medicine I, Cardiology, Justus-Liebig University Giessen, Giessen, Germany
| | - Felix Rudolph
- Department of Internal Medicine I, Cardiology, Justus-Liebig University Giessen, Giessen, Germany
| | - Nils Gumpfer
- Cognitive Information Systems, KITE - Kompetenzzentrum für Informationstechnologie, Technische Hochschule Mittelhessen - University of Applied Sciences, Friedberg, Germany
| | - Jennifer Hannig
- Cognitive Information Systems, KITE - Kompetenzzentrum für Informationstechnologie, Technische Hochschule Mittelhessen - University of Applied Sciences, Friedberg, Germany
| | - Laura K Elsner
- Department of Internal Medicine I, Cardiology, Justus-Liebig University Giessen, Giessen, Germany
| | - Beatrice von Jeinsen
- Department of Cardiology, Kerckhoff Heart and Thorax Center, Bad Nauheim, Germany
| | - Christian W Hamm
- Department of Internal Medicine I, Cardiology, Justus-Liebig University Giessen, Giessen, Germany.,Department of Cardiology, Kerckhoff Heart and Thorax Center, Bad Nauheim, Germany
| | - Andreas Rieth
- Department of Cardiology, Kerckhoff Heart and Thorax Center, Bad Nauheim, Germany
| | - Michael Guckert
- Cognitive Information Systems, KITE - Kompetenzzentrum für Informationstechnologie, Technische Hochschule Mittelhessen - University of Applied Sciences, Friedberg, Germany.,Department of MND - Mathematik, Naturwissenschaften und Datenverarbeitung, Technische Hochschule Mittelhessen - University of Applied Sciences, Friedberg, Germany
| | - Till Keller
- Department of Internal Medicine I, Cardiology, Justus-Liebig University Giessen, Giessen, Germany.,Department of Cardiology, Kerckhoff Heart and Thorax Center, Bad Nauheim, Germany
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6
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Weferling M, Liebetrau C, Kraus D, Zierentz P, von Jeinsen B, Dörr O, Weber M, Nef H, Hamm CW, Keller T. Definition of acute kidney injury impacts prevalence and prognosis in ACS patients undergoing coronary angiography. BMC Cardiovasc Disord 2021; 21:183. [PMID: 33858335 PMCID: PMC8051101 DOI: 10.1186/s12872-021-01985-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Accepted: 03/30/2021] [Indexed: 11/10/2022] Open
Abstract
Background Development of acute kidney injury (AKI) in invasively managed patients with acute coronary syndrome (ACS) is associated with a markedly increased mortality risk. Different definitions of AKI are in use, leading to varying prevalence and outcome measurements. The aim of the present study is to analyze an ACS population undergoing coronary angiography for differences in AKI prevalence and outcome using four established AKI definitions. Methods 944 patients (30% female) were enrolled in a prospective registry between 2003 and 2005 with 6-month all-cause mortality as outcome measure. Four established AKI definitions were used: an increase in serum creatinine (sCR) ≥ 1.5 fold, ≥ 0.3 mg/dl, and ≥ 0.5 mg/dl and a decrease in eGFR > 25% from baseline (AKIN 1, AKIN 2, CIN, and RIFLE definition groups, respectively). Results AKI rates varied widely between the different groups. Using the CIN definition, AKI frequency was lowest (4.4%), whereas it was highest if the RIFLE definition was applied (13.2%). AKIN 2 displayed a twofold higher AKI prevalence compared with AKIN 1 (10.2% vs. 5.3% (p < 0.001)). AKI was a strong risk factor for mid-term mortality, with distinctive variability between the definitions. The lowest mortality risk was found in the RIFLE group (HR 6.0; 95% CI 3.7–10.0; p < 0.001), whereas CIN revealed the highest risk (HR 16.7; 95% CI 9.9–28.1; p < 0.001). Conclusion Prevalence and outcome in ACS patients varied considerably depending on the AKI definition applied. To define patients with highest renal function-associated mortality risk, use of the CIN definition seems to have the highest prognostic relevance. Supplementary Information The online version contains supplementary material available at 10.1186/s12872-021-01985-9.
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Affiliation(s)
- Maren Weferling
- Department of Cardiology, Kerckhoff Heart and Thorax Center, Bad Nauheim, Germany.,German Centre for Cardiovascular Research (DZHK), Partner Site RheinMain, Bad Nauheim, Germany
| | - Christoph Liebetrau
- Department of Cardiology, Kerckhoff Heart and Thorax Center, Bad Nauheim, Germany.,German Centre for Cardiovascular Research (DZHK), Partner Site RheinMain, Bad Nauheim, Germany.,Medical Department I, Cardiology, University of Giessen, Giessen, Germany
| | - Daniel Kraus
- Medical Department I, Nephrology, University of Mainz, Mainz, Germany
| | - Philipp Zierentz
- Medical Department I, Cardiology, University of Giessen, Giessen, Germany
| | - Beatrice von Jeinsen
- Department of Cardiology, Kerckhoff Heart and Thorax Center, Bad Nauheim, Germany.,German Centre for Cardiovascular Research (DZHK), Partner Site RheinMain, Bad Nauheim, Germany
| | - Oliver Dörr
- Department of Cardiology, Kerckhoff Heart and Thorax Center, Bad Nauheim, Germany.,Medical Department I, Cardiology, University of Giessen, Giessen, Germany
| | - Michael Weber
- Department of Internal Medicine II, Hospital Darmstadt-Dieburg, Groß-Umstadt, Germany
| | - Holger Nef
- Department of Cardiology, Kerckhoff Heart and Thorax Center, Bad Nauheim, Germany.,German Centre for Cardiovascular Research (DZHK), Partner Site RheinMain, Bad Nauheim, Germany.,Medical Department I, Cardiology, University of Giessen, Giessen, Germany
| | - Christian W Hamm
- Department of Cardiology, Kerckhoff Heart and Thorax Center, Bad Nauheim, Germany.,German Centre for Cardiovascular Research (DZHK), Partner Site RheinMain, Bad Nauheim, Germany.,Medical Department I, Cardiology, University of Giessen, Giessen, Germany
| | - Till Keller
- Department of Cardiology, Kerckhoff Heart and Thorax Center, Bad Nauheim, Germany. .,German Centre for Cardiovascular Research (DZHK), Partner Site RheinMain, Bad Nauheim, Germany. .,Medical Department I, Cardiology, University of Giessen, Giessen, Germany. .,Department of Cardiology, Justus-Liebig-Universität Gießen, Campus Kerckhoff, Benekestr. 2-8, 61231, Bad Nauheim, Germany.
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7
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von Jeinsen B, Vasan RS, McManus DD, Mitchell GF, Cheng S, Xanthakis V. Joint influences of obesity, diabetes, and hypertension on indices of ventricular remodeling: Findings from the community-based Framingham Heart Study. PLoS One 2020; 15:e0243199. [PMID: 33301464 PMCID: PMC7728232 DOI: 10.1371/journal.pone.0243199] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Accepted: 11/17/2020] [Indexed: 01/20/2023] Open
Abstract
Introduction Obesity, hypertension, and diabetes are independently associated with cardiac remodeling and frequently co-cluster. The conjoint and separate influences of these conditions on cardiac remodeling have not been investigated. Materials and methods We evaluated 5,741 Framingham Study participants (mean age 50 years, 55% women) who underwent echocardiographic measurements of left ventricular (LV) mass (LVM), LV ejection fraction (LVEF), global longitudinal strain (GLS), mitral E/e’, left atrial end-systolic (peak) dimension (LASD) and emptying fraction (LAEF). We used multivariable generalized linear models to estimate the adjusted-least square means of these measures according to cross-classified categories of body mass index (BMI; normal, overweight and obese), hypertension (yes/no), and diabetes (yes/no). Results We observed statistically significant interactions of BMI category, hypertension, and diabetes with LVM, LVEF, GLS, and LAEF (p for all 3-way interactions <0.01). Overweight and obesity (compared to normal BMI), hypertension, and diabetes status were individually and conjointly associated with higher LVM and worse GLS (p<0.01 for all). We observed an increase of 34% for LVM and of 9% for GLS between individuals with a normal BMI and without hypertension or diabetes compared to obese individuals with hypertension and diabetes. Presence of hypertension was associated with higher LVEF, whereas people with diabetes had lower LVEF. Conclusions Obesity, hypertension, and diabetes interact synergistically to influence cardiac remodeling. These findings may explain the markedly heightened risk of heart failure and cardiovascular disease when these factors co-cluster.
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Affiliation(s)
- Beatrice von Jeinsen
- Boston University’s and National Heart, Lung, and Blood Institute’s Framingham Heart Study, Framingham, Massachusetts, United States of America
| | - Ramachandran S. Vasan
- Boston University’s and National Heart, Lung, and Blood Institute’s Framingham Heart Study, Framingham, Massachusetts, United States of America
- Sections of Preventive Medicine and Epidemiology, and Cardiovascular Medicine, Department of Medicine, Boston University School of Medicine, Boston, Massachusetts, United States of America
- Department of Epidemiology, Boston University School of Public Health, Boston, Massachusetts, United States of America
| | - David D. McManus
- Division of Cardiovascular Medicine, Department of Medicine, University of Massachusetts Medical Center, Worcester, Massachusetts, United States of America
| | - Gary F. Mitchell
- Cardiovascular Engineering, Inc, Norwood, Massachusetts, United States of America
| | - Susan Cheng
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, United States of America
| | - Vanessa Xanthakis
- Boston University’s and National Heart, Lung, and Blood Institute’s Framingham Heart Study, Framingham, Massachusetts, United States of America
- Sections of Preventive Medicine and Epidemiology, and Cardiovascular Medicine, Department of Medicine, Boston University School of Medicine, Boston, Massachusetts, United States of America
- Department of Biostatistics, Boston University School of Public Health, Boston, Massachusetts, United States of America
- * E-mail:
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8
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von Jeinsen B, Ritzen L, Vietheer J, Unbehaun C, Weferling M, Liebetrau C, Hamm CW, Rolf A, Keller T. The adipokine fatty-acid binding protein 4 and cardiac remodeling. Cardiovasc Diabetol 2020; 19:117. [PMID: 32727561 PMCID: PMC7392717 DOI: 10.1186/s12933-020-01080-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Accepted: 07/02/2020] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Previous publications about the association between fatty-acid binding protein 4 (FABP4) and cardiac remodeling have reported different, both beneficial and harmful, associations. Aim of the present investigation was to evaluate the association of FABP4 with parameters of myocardial remodeling defined by cardiac magnetic resonance imaging (CMR). METHODS We investigated plasma FABP4 levels in 331 patients (71% men, mean age 63±13 years) with preserved left ventricular ejection fraction (LVEF ≥ 55%) who underwent a CMR examination. We used linear cox regression to investigate associations between FABP4 and left ventricular end-diastolic diameter (LVEDD), right ventricular end-diastolic diameter (RVEDD), relative wall thickness (RWT), left ventricular mass index (LVMI), and LVEF (unadjusted and adjusted for age, sex, body mass index, cardiac biomarkers, and comorbidities). RESULTS FABP4 levels were associated with lower LVMI and higher NT-proBNP levels in an adjusted model. The inverse association between FABP4 and LVMI was more pronounced in lower FABP4 levels, whereas the positive association between FABP4 and NT-proBNP was more pronounced in relatively high NT-proBNP levels. CONCLUSIONS Possible beneficial and harmful associations between FABP4 and left ventricular size have been reported. Our results suggest a beneficial association with LVMI (more pronounced in lower FABP4 levels) but a harmful association with NT-proBNP (more pronounced in higher FABP4 levels). Therefore, our results might indicate a potential dose-dependent association of FABP4, but this observation needs further investigation in larger study samples.
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Affiliation(s)
- Beatrice von Jeinsen
- Department of Cardiology, Kerckhoff Heart Center, Benekestrasse 2-8, 61231, Bad Nauheim, Germany.,German Centre for Cardiovascular Research (DZHK), Center Rhein-Main, Berlin, Germany
| | - Lisa Ritzen
- Department of Internal Medicine I, Cardiology, Justus-Liebig-University Giessen, Klinikstrasse 33, 35392, Giessen, Germany
| | - Julia Vietheer
- Department of Cardiology, Kerckhoff Heart Center, Benekestrasse 2-8, 61231, Bad Nauheim, Germany
| | - Claudia Unbehaun
- Department of Cardiology, Kerckhoff Heart Center, Benekestrasse 2-8, 61231, Bad Nauheim, Germany
| | - Maren Weferling
- Department of Cardiology, Kerckhoff Heart Center, Benekestrasse 2-8, 61231, Bad Nauheim, Germany
| | - Christoph Liebetrau
- Department of Cardiology, Kerckhoff Heart Center, Benekestrasse 2-8, 61231, Bad Nauheim, Germany.,Department of Internal Medicine I, Cardiology, Justus-Liebig-University Giessen, Klinikstrasse 33, 35392, Giessen, Germany.,German Centre for Cardiovascular Research (DZHK), Center Rhein-Main, Berlin, Germany
| | - Christian W Hamm
- Department of Cardiology, Kerckhoff Heart Center, Benekestrasse 2-8, 61231, Bad Nauheim, Germany.,Department of Internal Medicine I, Cardiology, Justus-Liebig-University Giessen, Klinikstrasse 33, 35392, Giessen, Germany.,German Centre for Cardiovascular Research (DZHK), Center Rhein-Main, Berlin, Germany
| | - Andreas Rolf
- Department of Cardiology, Kerckhoff Heart Center, Benekestrasse 2-8, 61231, Bad Nauheim, Germany.,Department of Internal Medicine I, Cardiology, Justus-Liebig-University Giessen, Klinikstrasse 33, 35392, Giessen, Germany.,German Centre for Cardiovascular Research (DZHK), Center Rhein-Main, Berlin, Germany
| | - Till Keller
- Department of Cardiology, Kerckhoff Heart Center, Benekestrasse 2-8, 61231, Bad Nauheim, Germany. .,Department of Internal Medicine I, Cardiology, Justus-Liebig-University Giessen, Klinikstrasse 33, 35392, Giessen, Germany. .,German Centre for Cardiovascular Research (DZHK), Center Rhein-Main, Berlin, Germany.
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9
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Bormann J, Psyrakis DA, von Jeinsen B, Grün D, Elsner LK, Wolter JS, Weferling M, Diouf K, Kriechbaum S, Troidl C, Dörr O, Nef H, Hamm CW, Liebetrau C, Keller T. Myeloid-related protein 8/14 and high-sensitivity cardiac troponin I to differentiate type 2 myocardial infarction. Int J Cardiol 2020; 304:144-147. [PMID: 32008845 DOI: 10.1016/j.ijcard.2020.01.043] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2019] [Revised: 01/10/2020] [Accepted: 01/20/2020] [Indexed: 12/31/2022]
Abstract
Myocardial infarction (MI) not only defines acute MI with obstructed coronary arteries (T1MI) but also myocardial necrosis caused by myocardial oxygen supply/demand mismatch as type 2 MI (T2MI); only T1MI patients benefit from an early invasive management. Myeloid-related protein(MRP)-8/14 is a biomarker described in various inflammatory diseases and in MI patients. Here we evaluate the potential of MRP-8/14 and high-sensitivity troponin I (hs-cTnI) to differentiate T2MI from T1MI. Patients with final diagnosis NSTEMI (n = 254; 33.1% female) enrolled in a prospective biomarker registry between 08/2011 and 10/2016 were analysed. Median baseline MRP-8/14 levels were higher in T2MI (n = 55; 3.37(1.88-6.48)μg/mL) than in T1MI (n = 199; 2.4 [1.4-3.79]μg/mL) (p = .013) patients, in contrast to hs-cTnI (T2MI:52[11.65-321.4]ng/L vs. T1MI:436.5 [61.25-1973.8]ng/L; p < .001). To detect the strength of this association odds ratios(OR) were calculated with MRP-8/14 yielding 2.13(1.16-3.92; p = .015) to predict T2MI and 0.47(0.26-0.87; p = .015) for T1MI. As expected, hs-cTnI yielded an OR of to predict T2MI 0.34(0.17-0.65; p = .001) and 2.98(1.53-5.81; p = .001) for T1MI. Both markers show comparable and independent results if adjust to hs-cTnI/MRP-8/14, TIMI risk score and CRP. T2MI is associated with higher MRP-8/14 and lower hs-cTnI concentrations than T1MI. Our data suggest that MRP-8/14 as a marker of inflammation might provide usable discriminatory information complementing hs-cTnI in a diagnostic procedure evaluating the type of MI directly upon hospital admission.
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Affiliation(s)
- Johanna Bormann
- Justus Liebig University Giessen, Department of Internal Medicine I, Cardiology, Giessen, Germany
| | - Dimitrios A Psyrakis
- Kerckhoff Heart and Thorax Center, Department of Cardiology, Bad Nauheim, Germany
| | - Beatrice von Jeinsen
- Kerckhoff Heart and Thorax Center, Department of Cardiology, Bad Nauheim, Germany
| | - Dimitri Grün
- Justus Liebig University Giessen, Department of Internal Medicine I, Cardiology, Giessen, Germany
| | - Laura K Elsner
- Justus Liebig University Giessen, Department of Internal Medicine I, Cardiology, Giessen, Germany
| | - Jan S Wolter
- Kerckhoff Heart and Thorax Center, Department of Cardiology, Bad Nauheim, Germany
| | - Maren Weferling
- Kerckhoff Heart and Thorax Center, Department of Cardiology, Bad Nauheim, Germany
| | - Katharina Diouf
- Kerckhoff Heart and Thorax Center, Department of Cardiology, Bad Nauheim, Germany
| | - Steffen Kriechbaum
- Kerckhoff Heart and Thorax Center, Department of Cardiology, Bad Nauheim, Germany; Justus Liebig University Giessen, Department of Internal Medicine I, Cardiology, Giessen, Germany
| | - Christian Troidl
- Justus Liebig University Giessen, Department of Internal Medicine I, Cardiology, Giessen, Germany
| | - Oliver Dörr
- Justus Liebig University Giessen, Department of Internal Medicine I, Cardiology, Giessen, Germany
| | - Holger Nef
- Kerckhoff Heart and Thorax Center, Department of Cardiology, Bad Nauheim, Germany; Justus Liebig University Giessen, Department of Internal Medicine I, Cardiology, Giessen, Germany; German Center for Cardiovascular Research (DZHK), Partnersite RhineMain, Bad Nauheim, Germany
| | - Christian W Hamm
- Kerckhoff Heart and Thorax Center, Department of Cardiology, Bad Nauheim, Germany; Justus Liebig University Giessen, Department of Internal Medicine I, Cardiology, Giessen, Germany; German Center for Cardiovascular Research (DZHK), Partnersite RhineMain, Bad Nauheim, Germany
| | - Christoph Liebetrau
- Kerckhoff Heart and Thorax Center, Department of Cardiology, Bad Nauheim, Germany; Justus Liebig University Giessen, Department of Internal Medicine I, Cardiology, Giessen, Germany; German Center for Cardiovascular Research (DZHK), Partnersite RhineMain, Bad Nauheim, Germany
| | - Till Keller
- Kerckhoff Heart and Thorax Center, Department of Cardiology, Bad Nauheim, Germany; Justus Liebig University Giessen, Department of Internal Medicine I, Cardiology, Giessen, Germany; German Center for Cardiovascular Research (DZHK), Partnersite RhineMain, Bad Nauheim, Germany.
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10
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von Jeinsen B, Short MI, Larson MG, Xanthakis V, McManus DD, Benjamin EJ, Mitchell GF, Aragam J, Cheng S, Vasan RS. Prognostic Significance of Echocardiographic Measures of Cardiac Remodeling. J Am Soc Echocardiogr 2020; 33:72-81.e6. [PMID: 31624026 PMCID: PMC6986561 DOI: 10.1016/j.echo.2019.08.001] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2019] [Revised: 07/29/2019] [Accepted: 08/01/2019] [Indexed: 12/18/2022]
Abstract
BACKGROUND In recent decades, novel echocardiographic measures have constantly emerged. It is still unclear which echocardiographic measures have the most significant prognostic value in the general population. Accordingly, the aim of this study was to compare the prognostic value of a large panel of echocardiographic measures to identify the most promising measures. METHODS A total of 1,497 Framingham study participants (mean age, 65 years; 55.4% women) who underwent echocardiographic measurements of left ventricular ejection fraction, left ventricular mass index, global longitudinal strain, global circumferential strain, mitral annular plane systolic excursion, mitral E/e' ratio, maximum and minimum left atrial (LA) volume index, LA emptying fraction, and left ventricular longitudinal synchrony were evaluated. These measures were related to the incidence of two composite outcomes: cardiovascular disease (CVD) or death and atrial fibrillation (AF) or congestive heart failure (CHF). RESULTS On follow-up (mean, 8.3 years), there were 241 CVD events or deaths and 139 AF or CHF events. In multivariate-adjusted Cox models, higher LA emptying fraction was associated with a lower risk (hazard ratios per SD, 0.80 and 0.70 for CVD or death and AF or CHF, respectively; P ≤ .001 for both) while higher minimum LA volume index (hazard ratios per SD, 1.32 and 1.70 for CVD or death and AF or CHF, respectively; P ≤ .001 for both) and maximum LA volume index (hazard ratios per SD, 1.26 and 1.54 for CVD or death and AF or CHF, respectively; P ≤ .002 for both) were associated with a higher risk for both composite outcomes. CONCLUSIONS In this community-based sample, LA volumes and function were the best echocardiographic predictors of clinical outcomes. Therefore, these values should be considered for inclusion in standard echocardiographic assessments for the purpose of risk stratification.
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Affiliation(s)
- Beatrice von Jeinsen
- Boston University's and National Heart, Lung, and Blood Institute's Framingham Heart Study, Framingham, Massachusetts; Department of Cardiology, Kerckhoff Heart and Thorax Center, Bad Nauheim, Germany
| | - Meghan I Short
- Department of Biostatistics, Boston University School of Public Health, Boston, Massachusetts
| | - Martin G Larson
- Boston University's and National Heart, Lung, and Blood Institute's Framingham Heart Study, Framingham, Massachusetts; Department of Biostatistics, Boston University School of Public Health, Boston, Massachusetts
| | - Vanessa Xanthakis
- Boston University's and National Heart, Lung, and Blood Institute's Framingham Heart Study, Framingham, Massachusetts; Department of Biostatistics, Boston University School of Public Health, Boston, Massachusetts; Sections of Preventive Medicine and Epidemiology and Cardiovascular Medicine, Department of Medicine, Boston University School of Medicine, Boston, Massachusetts
| | - David D McManus
- Division of Cardiovascular Medicine, Department of Medicine, University of Massachusetts Medical Center, Worcester, Massachusetts
| | - Emelia J Benjamin
- Boston University's and National Heart, Lung, and Blood Institute's Framingham Heart Study, Framingham, Massachusetts; Sections of Preventive Medicine and Epidemiology and Cardiovascular Medicine, Department of Medicine, Boston University School of Medicine, Boston, Massachusetts; Department of Epidemiology, Boston University School of Public Health, Boston, Massachusetts
| | | | - Jayashri Aragam
- Harvard Medical School, Boston, Massachusetts; Cardiovascular Division, Veterans Administration Hospital, West Roxbury, Massachusetts
| | - Susan Cheng
- Boston University's and National Heart, Lung, and Blood Institute's Framingham Heart Study, Framingham, Massachusetts; Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Ramachandran S Vasan
- Boston University's and National Heart, Lung, and Blood Institute's Framingham Heart Study, Framingham, Massachusetts; Sections of Preventive Medicine and Epidemiology and Cardiovascular Medicine, Department of Medicine, Boston University School of Medicine, Boston, Massachusetts; Department of Epidemiology, Boston University School of Public Health, Boston, Massachusetts.
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11
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Kraus D, von Jeinsen B, Tzikas S, Palapies L, Zeller T, Bickel C, Fette G, Lackner KJ, Drechsler C, Neumann JT, Baldus S, Blankenberg S, Münzel T, Wanner C, Zeiher AM, Keller T. Cardiac Troponins for the Diagnosis of Acute Myocardial Infarction in Chronic Kidney Disease. J Am Heart Assoc 2019; 7:e008032. [PMID: 30371308 PMCID: PMC6404905 DOI: 10.1161/jaha.117.008032] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Patients with chronic kidney disease ( CKD ) are at high risk of myocardial infarction. Cardiac troponins are the biomarkers of choice for the diagnosis of acute myocardial infarction ( AMI ) without ST -segment elevation ( NSTE ). In patients with CKD , troponin levels are often chronically elevated, which reduces their diagnostic utility when NSTE - AMI is suspected. The aim of this study was to derive a diagnostic algorithm for serial troponin measurements in patients with CKD and suspected NSTE - AMI . Methods and Results Two cohorts, 1494 patients from a prospective cohort study with high-sensitivity troponin I (hs- cTnI ) measurements and 7059 cases from a clinical registry with high-sensitivity troponin T (hs- cTnT ) measurements, were analyzed. The prospective cohort comprised 280 CKD patients (estimated glomerular filtration rate <60 mL/min/1.73 m2). The registry data set contained 1581 CKD patients. In both cohorts, CKD patients were more likely to have adjudicated NSTE - AMI than non- CKD patients. The specificities of hs- cTnI and hs- cTnT to detect NSTE - AMI were reduced with CKD (0.82 versus 0.91 for hs- cTnI and 0.26 versus 0.73 for hs- cTnT ) but could be restored by applying optimized cutoffs to either the first or a second measurement after 3 hours. The best diagnostic performance was achieved with an algorithm that incorporates serial measurements and rules in or out AMI in 69% (hs- cTnI ) and 55% (hs- cTnT ) of CKD patients. Conclusions The diagnostic performance of high-sensitivity cardiac troponins in patients with CKD with suspected NSTE - AMI is improved by use of an algorithm based on admission troponin and dynamic changes in troponin concentration.
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Affiliation(s)
- Daniel Kraus
- 1 Division of Nephrology 1st Department of Medicine University of Würzburg Germany
| | - Beatrice von Jeinsen
- 2 Division of Cardiology Department of Internal Medicine III Goethe University Frankfurt Frankfurt Germany.,10 German Centre for Cardiovascular Research (DZHK), partner site RheinMain Frankfurt Germany
| | - Stergios Tzikas
- 3 3rd Department of Cardiology Ιppokrateio Hospital Aristotle University of Thessaloniki Greece
| | - Lars Palapies
- 2 Division of Cardiology Department of Internal Medicine III Goethe University Frankfurt Frankfurt Germany
| | - Tanja Zeller
- 4 Clinic for General and Interventional Cardiology University Heart Center Hamburg Hamburg Germany.,11 German Centre for Cardiovascular Research (DZHK), partner site Hamburg/Lübeck/Kiel Hamburg Germany
| | - Christoph Bickel
- 5 Department of Internal Medicine Federal Armed Forces Hospital Koblenz Germany
| | - Georg Fette
- 6 Department for Artificial Intelligence and Applied Computer Science University of Würzburg Germany
| | - Karl J Lackner
- 7 Department of Laboratory Medicine University Medical Center Johannes Gutenberg University Mainz Germany
| | - Christiane Drechsler
- 1 Division of Nephrology 1st Department of Medicine University of Würzburg Germany
| | - Johannes T Neumann
- 4 Clinic for General and Interventional Cardiology University Heart Center Hamburg Hamburg Germany.,11 German Centre for Cardiovascular Research (DZHK), partner site Hamburg/Lübeck/Kiel Hamburg Germany
| | - Stephan Baldus
- 8 Department of Internal Medicine III University of Cologne Germany
| | - Stefan Blankenberg
- 4 Clinic for General and Interventional Cardiology University Heart Center Hamburg Hamburg Germany.,11 German Centre for Cardiovascular Research (DZHK), partner site Hamburg/Lübeck/Kiel Hamburg Germany
| | - Thomas Münzel
- 9 Department of Internal Medicine II University Medical Center Johannes Gutenberg University Mainz Germany
| | - Christoph Wanner
- 1 Division of Nephrology 1st Department of Medicine University of Würzburg Germany.,12 Comprehensive Heart Failure Center (CHFC) University Hospital Würzburg Germany
| | - Andreas M Zeiher
- 2 Division of Cardiology Department of Internal Medicine III Goethe University Frankfurt Frankfurt Germany.,10 German Centre for Cardiovascular Research (DZHK), partner site RheinMain Frankfurt Germany
| | - Till Keller
- 2 Division of Cardiology Department of Internal Medicine III Goethe University Frankfurt Frankfurt Germany.,10 German Centre for Cardiovascular Research (DZHK), partner site RheinMain Frankfurt Germany.,13 Department of Cardiology Kerckhoff Heart and Thorax Center Bad Nauheim Germany
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12
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Henglin M, Niiranen T, Watrous JD, Lagerborg KA, Antonelli J, Claggett BL, Demosthenes EJ, von Jeinsen B, Demler O, Vasan RS, Larson MG, Jain M, Cheng S. A Single Visualization Technique for Displaying Multiple Metabolite-Phenotype Associations. Metabolites 2019; 9:metabo9070128. [PMID: 31269707 PMCID: PMC6680673 DOI: 10.3390/metabo9070128] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2019] [Revised: 06/28/2019] [Accepted: 06/28/2019] [Indexed: 12/20/2022] Open
Abstract
To assist with management and interpretation of human metabolomics data, which are rapidly increasing in quantity and complexity, we need better visualization tools. Using a dataset of several hundred metabolite measures profiled in a cohort of ~1500 individuals sampled from a population-based community study, we performed association analyses with eight demographic and clinical traits and outcomes. We compared frequently used existing graphical approaches with a novel ‘rain plot’ approach to display the results of these analyses. The ‘rain plot’ combines features of a raindrop plot and a conventional heatmap to convey results of multiple association analyses. A rain plot can simultaneously indicate effect size, directionality, and statistical significance of associations between metabolites and several traits. This approach enables visual comparison features of all metabolites examined with a given trait. The rain plot extends prior approaches and offers complementary information for data interpretation. Additional work is needed in data visualizations for metabolomics to assist investigators in the process of understanding and convey large-scale analysis results effectively, feasibly, and practically.
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Affiliation(s)
- Mir Henglin
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Teemu Niiranen
- National Institute for Health and Welfare, FI 00271 Helsinki, Finland
- Department of Medicine, Turku University Hospital and University of Turku, FI 20521 Turku, Finland
| | - Jeramie D Watrous
- Departments of Medicine & Pharmacology, University of California San Diego, La Jolla, CA 92093, USA
| | - Kim A Lagerborg
- Departments of Medicine & Pharmacology, University of California San Diego, La Jolla, CA 92093, USA
| | - Joseph Antonelli
- Department of Statistics, University of Florida, Gainesville, FL 32611, USA
| | - Brian L Claggett
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Emmanuella J Demosthenes
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA
| | | | - Olga Demler
- Preventive Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, MA 02115, USA
| | - Ramachandran S Vasan
- Framingham Heart Study, Framingham, MA 01701, USA
- Preventive Medicine, Department of Medicine, Boston University Medical Center, Boston, MA 02215, USA
| | - Martin G Larson
- Framingham Heart Study, Framingham, MA 01701, USA
- Preventive Medicine, Department of Medicine, Boston University Medical Center, Boston, MA 02215, USA
- Biostatistics Department, School of Public Health, Boston University, Boston, MA 02215, USA
| | - Mohit Jain
- Departments of Medicine & Pharmacology, University of California San Diego, La Jolla, CA 92093, USA.
| | - Susan Cheng
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA.
- Framingham Heart Study, Framingham, MA 01701, USA.
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA.
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13
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von Jeinsen B, Liebetrau C, Palapies L, Tzikas S, Zeller T, Bickel C, Schmidt A, Tubaro M, Lackner KJ, Sar F, Baldus S, Zeiher AM, Blankenberg S, Gori T, Münzel T, Hamm CW, Wild PS, Keller T. Identification of acute myocardial infarction in elderly patients using optimized highly sensitive troponin I thresholds. Biomarkers 2019; 24:549-555. [PMID: 31159594 DOI: 10.1080/1354750x.2019.1606276] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Purpose: Established diagnostic thresholds for high-sensitivity cardiac troponins (hs-cTn) might not apply for elderly patients as they are elevated irrespective of the presence of an acute myocardial infarction (AMI). Aim of the present study was to investigate hs-cTnI in elderly patients with suspected AMI and to calculate optimized diagnostic cutoffs. Material and methods: Data from a prospective multi-centre study and from a second independent prospective single-centre cohort study were analysed. A number of 2903 patients were eligible for further analysis. Patients > 70 years were classified as elderly. hs-cTnI was measured upon admission. Results: Around 34.7% of 2903 patients were classified as elderly. Around 22.5% of elderly patients were finally diagnosed with AMI. Elderly patients had higher hs-cTnI levels at admission irrespective of the final diagnosis (p < 0.001). According to the AUROC, hs-cTnI was a strong marker for detection of AMI in elderly patients. Application of the 99th percentile cutoffs showed a substantially lower specificity in elderly. By using optimized thresholds, specificity was improved to levels as in younger patients in both cohorts but accompanied with a decrease in sensitivity. Conclusions: hs-cTnI levels have a lower specificity for detecting AMI in elderly patients. This lower specificity can be improved by using hs-cTnI thresholds optimized for elderly patients.
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Affiliation(s)
- Beatrice von Jeinsen
- a Department of Cardiology, Kerckhoff Heart Center , Bad Nauheim , Germany.,b Department of Internal Medicine III, Division of Cardiology, Goethe University Frankfurt , Frankfurt , Germany.,c German Centre for Cardiovascular Research (DZHK), Partner Site Center Rhein-Main , Germany
| | - Christoph Liebetrau
- a Department of Cardiology, Kerckhoff Heart Center , Bad Nauheim , Germany.,c German Centre for Cardiovascular Research (DZHK), Partner Site Center Rhein-Main , Germany
| | - Lars Palapies
- b Department of Internal Medicine III, Division of Cardiology, Goethe University Frankfurt , Frankfurt , Germany
| | - Stergios Tzikas
- d 3rd Department of Cardiology, ιppokrateio Hospital of Thessaloniki, Aristotle University of Thessaloniki , Thessaloniki , Greece
| | - Tanja Zeller
- e Clinic for General and Interventional Cardiology, University Heart Center Hamburg , Hamburg , Germany.,f German Centre for Cardiovascular Research (DZHK), German Partner Site Hamburg/Kiel/Lübeck partner , Hamburg , Germany
| | - Christoph Bickel
- g Department of Internal Medicine, Federal Armed Forces Hospital , Koblenz , Germany
| | - Alexander Schmidt
- h Preventive Cardiology, Center for Cardiology, University Medical Center , Johannes Gutenberg University , Mainz , Germany
| | - Marco Tubaro
- i Ospedale San Filippo Neri Hospital , Rome , Italy
| | - Karl J Lackner
- j Department of Laboratory Medicine, University Medical Center, Johannes Gutenberg University , Mainz , Germany
| | - Fachrie Sar
- h Preventive Cardiology, Center for Cardiology, University Medical Center , Johannes Gutenberg University , Mainz , Germany
| | - Stephan Baldus
- k Department of Internal Medicine III, University of Cologne , Cologne , Germany
| | - Andreas M Zeiher
- b Department of Internal Medicine III, Division of Cardiology, Goethe University Frankfurt , Frankfurt , Germany.,c German Centre for Cardiovascular Research (DZHK), Partner Site Center Rhein-Main , Germany
| | - Stefan Blankenberg
- e Clinic for General and Interventional Cardiology, University Heart Center Hamburg , Hamburg , Germany.,f German Centre for Cardiovascular Research (DZHK), German Partner Site Hamburg/Kiel/Lübeck partner , Hamburg , Germany
| | - Tommaso Gori
- c German Centre for Cardiovascular Research (DZHK), Partner Site Center Rhein-Main , Germany.,l Cardiology I, Center for Cardiology , University Medical Center, Johannes Gutenberg University , Mainz , Germany
| | - Thomas Münzel
- c German Centre for Cardiovascular Research (DZHK), Partner Site Center Rhein-Main , Germany.,l Cardiology I, Center for Cardiology , University Medical Center, Johannes Gutenberg University , Mainz , Germany
| | - Christian W Hamm
- b Department of Internal Medicine III, Division of Cardiology, Goethe University Frankfurt , Frankfurt , Germany.,c German Centre for Cardiovascular Research (DZHK), Partner Site Center Rhein-Main , Germany
| | - Philipp S Wild
- c German Centre for Cardiovascular Research (DZHK), Partner Site Center Rhein-Main , Germany.,h Preventive Cardiology, Center for Cardiology, University Medical Center , Johannes Gutenberg University , Mainz , Germany.,m Center for Thrombosis and Hemostasis, University Medical Center, Johannes Gutenberg University , Mainz , Germany
| | - Till Keller
- a Department of Cardiology, Kerckhoff Heart Center , Bad Nauheim , Germany.,b Department of Internal Medicine III, Division of Cardiology, Goethe University Frankfurt , Frankfurt , Germany.,c German Centre for Cardiovascular Research (DZHK), Partner Site Center Rhein-Main , Germany
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von Jeinsen B, Sopova K, Palapies L, Leistner DM, Fichtlscherer S, Seeger FH, Honold J, Dimmeler S, Aßmus B, Zeiher AM, Keller T. Bone marrow and plasma FGF-23 in heart failure patients: novel insights into the heart-bone axis. ESC Heart Fail 2019; 6:536-544. [PMID: 30912310 PMCID: PMC6487718 DOI: 10.1002/ehf2.12416] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2018] [Accepted: 01/17/2019] [Indexed: 01/13/2023] Open
Abstract
Aims Fibroblast growth factor 23 (FGF‐23) is known to be elevated in patients with congestive heart failure (CHF). As FGF‐23 is expressed in the bone but can also be expressed in the myocardium, the origin of serum FGF‐23 in CHF remains unclear. It is also unclear if FGF‐23 expressed in the bone is associated with outcome in CHF. The aim of the present study was to investigate FGF‐23 levels measured in bone marrow plasma (FGF‐23‐BM) and in peripheral blood (FGF‐23‐P) in CHF patients to gain further insights into the heart–bone axis of FGF‐23 expression. We also investigated possible associations between FGF‐23‐BM as well as FGF‐23‐P and outcome in CHF patients. Methods and results We determined FGF‐23‐P and FGF‐23‐BM levels in 203 CHF patients (85% male, mean age 61.3 years) with a left ventricular ejection fraction (LVEF) ≤45% and compared them with those of 48 healthy controls (48% male, mean age 39.2 years). We investigated the association between FGF‐23‐BM and FGF‐23‐P with all‐cause mortality in CHF patients, 32 events, median follow‐up 1673 days, interquartile range [923, 1828]. FGF‐23‐P (median 60.3 vs. 22.0 RU/mL, P < 0.001) and FGF‐23‐BM (median 130.7 vs. 93.1 RU/mL, P < 0.001) levels were higher in CHF patients compared with healthy controls. FGF‐23‐BM levels were significantly higher than FGF‐23‐P levels in both CHF patients and in healthy controls (P < 0.001). FGF‐23‐P and FGF‐23‐BM correlated significantly with LVEF (r = −0.37 and r = −0.33, respectively), N terminal pro brain natriuretic peptide levels (r = 0.57 and r = 0.6, respectively), New York Heart Association status (r = 0.28 and r = 0.25, respectively), and estimated glomerular filtration rate (r = −0.43 and r = −0.41, respectively) (P for all <0.001) and were independently associated with all‐cause mortality in CHF patients after adjustment for LVEF, estimated glomerular filtration rate, New York Heart Association status, and N terminal pro brain natriuretic peptide, hazard ratio 2.71 [confidence interval: 1.18–6.20], P = 0.018, and hazard ratio 2.80 [confidence interval: 1.19–6.57], P = 0.018, respectively. Conclusions In CHF patients, FGF‐23 is elevated in bone marrow plasma and is independently associated with heart failure severity and all‐cause mortality. The failing heart seems to interact via FGF‐23 within a heart–bone axis.
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Affiliation(s)
- Beatrice von Jeinsen
- Division of Cardiology, Department of Internal Medicine III, Goethe University Frankfurt, Frankfurt, Germany.,Department of Cardiology, Kerckhoff Heart and Thorax Center, Benekestr. 2-8, 61231, Bad Nauheim, Germany.,German Centre for Cardiovascular Research (DZHK), partner site RheinMain, Frankfurt, Germany
| | - Kateryna Sopova
- Division of Cardiology, Department of Internal Medicine III, Goethe University Frankfurt, Frankfurt, Germany.,German Centre for Cardiovascular Research (DZHK), partner site RheinMain, Frankfurt, Germany
| | - Lars Palapies
- Division of Cardiology, Department of Internal Medicine III, Goethe University Frankfurt, Frankfurt, Germany
| | - David M Leistner
- Division of Cardiology, Department of Internal Medicine III, Goethe University Frankfurt, Frankfurt, Germany.,Campus Benjamin Franklin, Department of Cardiology, Charité - Universitaetsmedizin Berlin, Berlin, Germany.,German Centre for Cardiovascular Research (DZHK), partner site Berlin, Berlin, Germany
| | - Stephan Fichtlscherer
- Division of Cardiology, Department of Internal Medicine III, Goethe University Frankfurt, Frankfurt, Germany.,German Centre for Cardiovascular Research (DZHK), partner site RheinMain, Frankfurt, Germany
| | - Florian H Seeger
- Division of Cardiology, Department of Internal Medicine III, Goethe University Frankfurt, Frankfurt, Germany.,German Centre for Cardiovascular Research (DZHK), partner site RheinMain, Frankfurt, Germany
| | - Jörg Honold
- Division of Cardiology, Department of Internal Medicine III, Goethe University Frankfurt, Frankfurt, Germany.,German Centre for Cardiovascular Research (DZHK), partner site RheinMain, Frankfurt, Germany
| | - Stefanie Dimmeler
- Institute for Cardiovascular Regeneration, Goethe University Frankfurt, Frankfurt, Germany.,German Centre for Cardiovascular Research (DZHK), partner site RheinMain, Frankfurt, Germany
| | - Birgit Aßmus
- Division of Cardiology, Department of Internal Medicine III, Goethe University Frankfurt, Frankfurt, Germany.,German Centre for Cardiovascular Research (DZHK), partner site RheinMain, Frankfurt, Germany
| | - Andreas M Zeiher
- Division of Cardiology, Department of Internal Medicine III, Goethe University Frankfurt, Frankfurt, Germany.,German Centre for Cardiovascular Research (DZHK), partner site RheinMain, Frankfurt, Germany
| | - Till Keller
- Division of Cardiology, Department of Internal Medicine III, Goethe University Frankfurt, Frankfurt, Germany.,Department of Cardiology, Kerckhoff Heart and Thorax Center, Benekestr. 2-8, 61231, Bad Nauheim, Germany.,German Centre for Cardiovascular Research (DZHK), partner site RheinMain, Frankfurt, Germany
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von Jeinsen B, Short MI, Xanthakis V, Carneiro H, Cheng S, Mitchell GF, Vasan RS. Association of Circulating Adipokines With Echocardiographic Measures of Cardiac Structure and Function in a Community-Based Cohort. J Am Heart Assoc 2018; 7:JAHA.118.008997. [PMID: 29929991 PMCID: PMC6064918 DOI: 10.1161/jaha.118.008997] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Adipokines mediate cardiometabolic risk associated with obesity but their role in the pathogenesis of obesity-associated heart failure remains uncertain. We investigated the associations between circulating adipokine concentrations and echocardiographic measures in a community-based sample. METHODS AND RESULTS We evaluated 3514 Framingham Heart Study participants (mean age 40 years, 53.8% women) who underwent routine echocardiography and had select circulating adipokines measured, ie, leptin, soluble leptin receptor, fatty acid-binding protein 4, retinol-binding protein 4, fetuin-A, and adiponectin. We used multivariable linear regression, adjusting for known correlates (including weight), to relate adipokine concentrations (independent variables) to the following echocardiographic measures (dependent variables): left ventricular mass index, left atrial diameter in end systole, fractional shortening, and E/e'. In multivariable-adjusted analysis, left ventricular mass index was inversely related to circulating leptin and fatty acid-binding protein 4 concentrations but positively related to retinol-binding protein 4 and leptin receptor levels (P≤0.002 for all). Left atrial end-systolic dimension was inversely related to leptin but positively related to retinol-binding protein 4 concentrations (P≤0.0001). E/e' was inversely related to leptin receptor levels (P=0.0002). We observed effect modification by body weight for select associations (leptin receptor and fatty acid-binding protein 4 with left ventricular mass index, and leptin with left atrial diameter in end systole; P<0.05 for interactions). Fractional shortening was not associated with any of the adipokines. No echocardiographic trait was associated with fetuin-A or adiponectin concentrations. CONCLUSIONS In our cross-sectional study of a large, young to middle-aged, relatively healthy community-based sample, key indices of subclinical cardiac remodeling were associated with higher or lower circulating concentrations of prohypertrophic and antihypertrophic adipokines in a context-specific manner. These observations may offer insights into the pathogenesis of the cardiomyopathy of obesity.
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Affiliation(s)
- Beatrice von Jeinsen
- Boston University's and National Heart, Lung, and Blood Institute's Framingham Heart Study, Framingham, MA
| | - Meghan I Short
- Boston University's and National Heart, Lung, and Blood Institute's Framingham Heart Study, Framingham, MA
- Section of Preventive Medicine and Epidemiology, Departments of Medicine, Biostatistics and Epidemiology, Boston University Schools of Medicine and Public Health, Boston, MA
| | - Vanessa Xanthakis
- Boston University's and National Heart, Lung, and Blood Institute's Framingham Heart Study, Framingham, MA
- Section of Preventive Medicine and Epidemiology, Departments of Medicine, Biostatistics and Epidemiology, Boston University Schools of Medicine and Public Health, Boston, MA
| | - Herman Carneiro
- Boston University's and National Heart, Lung, and Blood Institute's Framingham Heart Study, Framingham, MA
- Section of Preventive Medicine and Epidemiology, Departments of Medicine, Biostatistics and Epidemiology, Boston University Schools of Medicine and Public Health, Boston, MA
| | - Susan Cheng
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, MA
| | | | - Ramachandran S Vasan
- Boston University's and National Heart, Lung, and Blood Institute's Framingham Heart Study, Framingham, MA
- Section of Preventive Medicine and Epidemiology, Departments of Medicine, Biostatistics and Epidemiology, Boston University Schools of Medicine and Public Health, Boston, MA
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16
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Boeckel JN, Palapies L, Klotsche J, Zeller T, von Jeinsen B, Perret MF, Kleinhaus SL, Pieper L, Tzikas S, Leistner D, Bickel C, Stalla GK, Lehnert H, Lindahl B, Wittchen HU, Silber S, Baldus S, Maerz W, Dimmeler S, Blankenberg S, Münzel T, Zeiher AM, Keller T. Adjusted Troponin I for Improved Evaluation of Patients with Chest Pain. Sci Rep 2018; 8:8087. [PMID: 29799020 PMCID: PMC5967336 DOI: 10.1038/s41598-018-26120-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2018] [Accepted: 05/03/2018] [Indexed: 11/29/2022] Open
Abstract
The use of cardiac troponins (cTn) is the gold standard for diagnosing myocardial infarction. Independent of myocardial infarction (MI), however, sex, age and kidney function affect cTn levels. Here we developed a method to adjust cTnI levels for age, sex, and renal function, maintaining a unified cut-off value such as the 99th percentile. A total of 4587 individuals enrolled in a prospective longitudinal study were used to develop a model for adjustment of cTn. cTnI levels correlated with age and estimated glomerular filtration rate (eGFR) in males/females with rage = 0.436/0.518 and with reGFR = -0.142/-0.207. For adjustment, these variables served as covariates in a linear regression model with cTnI as dependent variable. This adjustment model was then applied to a real-world cohort of 1789 patients with suspected acute MI (AMI) (N = 407). Adjusting cTnI showed no relevant loss of diagnostic information, as evidenced by comparable areas under the receiver operator characteristic curves, to identify AMI in males and females for adjusted and unadjusted cTnI. In specific patients groups such as in elderly females, adjusting cTnI improved specificity for AMI compared with unadjusted cTnI. Specificity was also improved in patients with renal dysfunction by using the adjusted cTnI values. Thus, the adjustments improved the diagnostic ability of cTnI to identify AMI in elderly patients and in patients with renal dysfunction. Interpretation of cTnI values in complex emergency cases is facilitated by our method, which maintains a single diagnostic cut-off value in all patients.
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Affiliation(s)
- Jes-Niels Boeckel
- Department of Internal Medicine III, Cardiology, University Hospital, Goethe University Frankfurt, Frankfurt, Germany
- German Center for Cardiovascular Disease (DZHK), Berlin, Germany
- Institute of Cardiovascular Regeneration, Centre for Molecular Medicine, Goethe University Frankfurt, Frankfurt, Germany
- Department of Internal Medicine, Cardiology, University Hospital Leipzig, Leipzig, Germany
| | - Lars Palapies
- Department of Internal Medicine III, Cardiology, University Hospital, Goethe University Frankfurt, Frankfurt, Germany
| | - Jens Klotsche
- Clinical Psychology und Psychotherapy, Technical University Dresden, Dresden, Germany
| | - Tanja Zeller
- German Center for Cardiovascular Disease (DZHK), Berlin, Germany
- Clinic for General and Interventional Cardiology, University Heart Centre Hamburg, Hamburg, Germany
| | - Beatrice von Jeinsen
- Department of Internal Medicine III, Cardiology, University Hospital, Goethe University Frankfurt, Frankfurt, Germany
- German Center for Cardiovascular Disease (DZHK), Berlin, Germany
| | - Maya F Perret
- Department of Internal Medicine III, Cardiology, University Hospital, Goethe University Frankfurt, Frankfurt, Germany
| | - Soeren L Kleinhaus
- Institute of Cardiovascular Regeneration, Centre for Molecular Medicine, Goethe University Frankfurt, Frankfurt, Germany
| | - Lars Pieper
- Clinical Psychology und Psychotherapy, Technical University Dresden, Dresden, Germany
| | - Stergios Tzikas
- 3rd Department of Cardiology, Ippokrateio Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
- Department of Medicine II, University Medical Center, Johannes Gutenberg University, Mainz, Germany
| | - David Leistner
- Department of Internal Medicine III, Cardiology, University Hospital, Goethe University Frankfurt, Frankfurt, Germany
- German Center for Cardiovascular Disease (DZHK), Berlin, Germany
| | - Christoph Bickel
- Department of Internal Medicine, Federal Armed Forces Hospital, Koblenz, Germany
| | - Günter K Stalla
- Max Plank Institute for Psychiatry, Neuroendocrinology, Munich, Munich, Germany
| | - Hendrik Lehnert
- Department of Internal Medicine I, University Hospital Schleswig-Holstein, Lübeck, Germany
| | - Bertil Lindahl
- Department of Medical Sciences and Uppsala Clinical Research Center, Uppsala, Sweden
| | - Hans-Ulrich Wittchen
- Clinical Psychology und Psychotherapy, Technical University Dresden, Dresden, Germany
| | - Sigmund Silber
- Praxisklinik, Kardiologische Gemeinschaftspraxis, Munich, Germany
| | - Stephan Baldus
- Clinic for General and Interventional Cardiology, University Heart Centre Hamburg, Hamburg, Germany
- Heart Center, University of Cologne, Cologne, Germany
| | - Winfried Maerz
- Synlab Akademie für ärztliche Fortbildung, Synlab Services GmbH, Mannheim, Germany
| | - Stefanie Dimmeler
- German Center for Cardiovascular Disease (DZHK), Berlin, Germany
- Institute of Cardiovascular Regeneration, Centre for Molecular Medicine, Goethe University Frankfurt, Frankfurt, Germany
| | - Stefan Blankenberg
- German Center for Cardiovascular Disease (DZHK), Berlin, Germany
- Clinic for General and Interventional Cardiology, University Heart Centre Hamburg, Hamburg, Germany
| | - Thomas Münzel
- German Center for Cardiovascular Disease (DZHK), Berlin, Germany
- Department of Medicine II, University Medical Center, Johannes Gutenberg University, Mainz, Germany
| | - Andreas M Zeiher
- Department of Internal Medicine III, Cardiology, University Hospital, Goethe University Frankfurt, Frankfurt, Germany
- German Center for Cardiovascular Disease (DZHK), Berlin, Germany
| | - Till Keller
- Department of Internal Medicine III, Cardiology, University Hospital, Goethe University Frankfurt, Frankfurt, Germany.
- German Center for Cardiovascular Disease (DZHK), Berlin, Germany.
- Kerckhoff Heart and Thorax Center, Bad Nauheim, Germany.
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von Jeinsen B, Kraus D, Palapies L, Tzikas S, Zeller T, Schauer A, Drechsler C, Bickel C, Baldus S, Lackner KJ, Münzel T, Blankenberg S, Zeiher AM, Keller T. Urinary neutrophil gelatinase-associated lipocalin and cystatin C compared to the estimated glomerular filtration rate to predict risk in patients with suspected acute myocardial infarction. Int J Cardiol 2017; 245:6-12. [PMID: 28778467 DOI: 10.1016/j.ijcard.2017.07.086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2016] [Revised: 06/02/2017] [Accepted: 07/21/2017] [Indexed: 10/19/2022]
Abstract
INTRODUCTION Impaired renal function, reflected by estimated glomerular filtration rate (eGFR) or cystatin C, is a strong risk predictor in the presence of acute myocardial infarction (AMI). Urinary neutrophil gelatinase-associated lipocalin (uNGAL) is an early marker of acute kidney injury. uNGAL might also be a good predictor of outcome in patients with cardiovascular disease. Aim of the present study was to evaluate the prognostic value of uNGAL compared to eGFR and cystatin C in patients with suspected AMI. METHODS 1818 patients were enrolled with suspected AMI. Follow-up information on the combined endpoint of death or non-fatal myocardial infarction was obtained 6months after enrolment and was available in 1804 patients. 63 events (3.5%) were registered. RESULTS While cystatin C and eGFR were strong risk predictors for the primary endpoint even adjusted for several variables, uNGAL was not independently associated with outcome: When applied continuously uNGAL was associated with outcome but did not remain a statistically significant predictor after several adjustments (i.e. eGFR). By adding cystatin C or uNGAL to GRACE risk score variables, only cystatin C could improve the predictive value while uNGAL showed no improvement. CONCLUSION We could show that cystatin C is an independent risk predictor in patients with suspected AMI and cystatin C can add improvement to the commonly used GRACE risk score. In contrast uNGAL is not independently associated with outcome and seems not to add further prognostic information to GRACE risk score.
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Affiliation(s)
- Beatrice von Jeinsen
- Division of Cardiology, Department of Internal Medicine III, Goethe University Frankfurt, Germany; German Centre for Cardiovascular Research (DZHK), partner site RheinMain, Frankfurt, Germany
| | - Daniel Kraus
- Division of Nephrology, Department of Medicine, University of Würzburg, Germany
| | - Lars Palapies
- Division of Cardiology, Department of Internal Medicine III, Goethe University Frankfurt, Germany
| | - Stergios Tzikas
- 3rd Department of Cardiology, Aristotle University of Thessaloniki, Ιppokrateio Hospital, Thessaloniki, Greece; Department of Internal Medicine II, University Medical Center, Johannes Gutenberg University, Mainz, Germany
| | - Tanja Zeller
- Clinic for General and Interventional Cardiology, University Heart Center Hamburg, Germany; German Centre for Cardiovascular Research (DZHK), partner site Hamburg/Lübeck/Kiel, Hamburg, Germany
| | - Anne Schauer
- Department of Internal Medicine II, University Medical Center, Johannes Gutenberg University, Mainz, Germany
| | | | - Christoph Bickel
- Department of Internal Medicine, Federal Armed Forces Hospital, Koblenz, Germany
| | - Stephan Baldus
- Department of Internal Medicine III, University of Cologne, Germany
| | - Karl J Lackner
- Department of Laboratory Medicine, University Medical Center, Johannes Gutenberg University, Mainz, Germany
| | - Thomas Münzel
- Department of Internal Medicine II, University Medical Center, Johannes Gutenberg University, Mainz, Germany
| | - Stefan Blankenberg
- Clinic for General and Interventional Cardiology, University Heart Center Hamburg, Germany; German Centre for Cardiovascular Research (DZHK), partner site Hamburg/Lübeck/Kiel, Hamburg, Germany
| | - Andreas M Zeiher
- Division of Cardiology, Department of Internal Medicine III, Goethe University Frankfurt, Germany; German Centre for Cardiovascular Research (DZHK), partner site RheinMain, Frankfurt, Germany
| | - Till Keller
- Division of Cardiology, Department of Internal Medicine III, Goethe University Frankfurt, Germany; German Centre for Cardiovascular Research (DZHK), partner site RheinMain, Frankfurt, Germany; Kerckhoff Heart and Thorax Center, Department of Cardiology, Bad Nauheim, Germany.
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18
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Kraus D, von Jeinsen B, Tzikas S, Palapies L, Zeller T, Bickel C, Fette G, Lackner K, Drechsler C, Neumann J, Baldus S, Blankenberg S, Münzel T, Wanner C, Zeiher A, Keller T. SP308INTRA-INDIVIDUAL CHANGES IN HIGH-SENSITIVE TROPONIN I AND T LEVELS IMPROVE DIAGNOSTIC PERFORMANCE FOR ACUTE MYOCARDIAL INFARCTION IN PATIENTS WITH CHRONIC KIDNEY DISEASE. Nephrol Dial Transplant 2017. [DOI: 10.1093/ndt/gfx146.sp308] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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von Jeinsen B, Keller T. Strategies to overcome misdiagnosis of type 1 myocardial infarction using high sensitive cardiac troponin assays. Diagnosis (Berl) 2016. [DOI: 10.1515/dx-2016-0022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Abstract
High sensitive cardiac troponin assays have become the gold standard in the diagnosis of an acute type 1 myocardial infarction (MI) in the absence of ST-segment elevation. Several acute or chronic conditions that impact cardiac troponin levels in the absence of a MI might lead to a misdiagnosis of MI. For example, patients with impaired renal function as well as elderly patients often present with chronically increased cardiac troponin levels. Therefore, the diagnosis of MI type 1 based on the 99th percentile upper limit of normal threshold is more difficult in these patients. Different diagnostic approaches might help to overcome this limitation of reduced MI specificity of sensitive troponin assays. First, serial troponin measurement helps to differentiate chronic from acute troponin elevations. Second, specific diagnostic cut-offs, optimized for a particular patient group, like elderly patients, are able to regain specificity. Such an individualized use and interpretation of sensitive cardiac troponin measurements improves diagnostic accuracy and reduces the amount of misdiagnosed MI type 1.
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Affiliation(s)
- Beatrice von Jeinsen
- Department of Internal Medicine III, Division of Cardiology, Goethe University Frankfurt, Frankfurt, Germany
- German Centre for Cardiovascular Research (DZHK), Partnersite RheinMain, Frankfurt, Germany
| | - Till Keller
- Department of Internal Medicine III, Division of Cardiology, Goethe University Frankfurt, Frankfurt, Germany
- German Centre for Cardiovascular Research (DZHK), Partnersite RheinMain, Frankfurt, Germany
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von Jeinsen B, Tzikas S, Pioro G, Palapies L, Zeller T, Bickel C, Lackner KJ, Baldus S, Blankenberg S, Muenzel T, Zeiher AM, Keller T. Troponin I Assay for Identification of a Significant Coronary Stenosis in Patients with Suspected Acute Myocardial Infarction and Wide QRS Complex. PLoS One 2016; 11:e0154724. [PMID: 27148734 PMCID: PMC4858235 DOI: 10.1371/journal.pone.0154724] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2016] [Accepted: 04/18/2016] [Indexed: 12/02/2022] Open
Abstract
Background Common ECG criteria such as ST-segment changes are of limited value in patients with suspected acute myocardial infarction (AMI) and bundle branch block or wide QRS complex. A large proportion of these patients do not suffer from an AMI, whereas those with ST-elevation myocardial infarction (STEMI) equivalent AMI benefit from an aggressive treatment. Aim of the present study was to evaluate the diagnostic information of cardiac troponin I (cTnI) in hemodynamically stable patients with wide QRS complex and suspected AMI. Methods In 417 out of 1818 patients presenting consecutively between 01/2007 and 12/2008 in a prospective multicenter observational study with suspected AMI a prolonged QRS duration was observed. Of these, n = 117 showed significant obstructive coronary artery disease (CAD) used as diagnostic outcome variable. cTnI was determined at admission. Results Patients with significant CAD had higher cTnI levels compared to individuals without (median 250ng/L vs. 11ng/L; p<0.01). To identify patients needing a coronary intervention, cTnI yielded an area under the receiver operator characteristics curve of 0.849. Optimized cut-offs with respect to a sensitivity driven rule-out and specificity driven rule-in strategy were established (40ng/L/96ng/L). Application of the specificity optimized cut-off value led to a positive predictive value of 71% compared to 59% if using the 99th percentile cut-off. The sensitivity optimized cut-off value was associated with a negative predictive value of 93% compared to 89% provided by application of the 99th percentile threshold. Conclusion cTnI determined in hemodynamically stable patients with suspected AMI and wide QRS complex using optimized diagnostic thresholds improves rule-in and rule-out with respect to presence of a significant obstructive CAD.
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Affiliation(s)
- Beatrice von Jeinsen
- Division of Cardiology, Department of Internal Medicine III, Goethe University Frankfurt, Frankfurt, Germany
- * E-mail: (TK); (BJ)
| | - Stergios Tzikas
- 3rd Department of Cardiology, Aristotle University of Thessaloniki, Ippokrateio Hospital, Thessaloniki, Greece
- Department of Internal Medicine II, University Medical Center, Johannes Gutenberg University, Mainz, Germany
| | - Gerhard Pioro
- Department of Internal Medicine II, University Medical Center, Johannes Gutenberg University, Mainz, Germany
| | - Lars Palapies
- Division of Cardiology, Department of Internal Medicine III, Goethe University Frankfurt, Frankfurt, Germany
| | - Tanja Zeller
- Department of General and Interventional Cardiology, University Heart Center, Hamburg, Germany
- German Centre for Cardiovascular Research (DZHK), Berlin, Germany
| | - Christoph Bickel
- Department of Internal Medicine, Federal Armed Forces Hospital, Koblenz, Germany
| | - Karl J. Lackner
- Department of Laboratory Medicine, University Medical Center, Johannes Gutenberg University, Mainz, Germany
| | - Stephan Baldus
- Department of Internal Medicine III, University of Cologne, Köln, Germany
| | - Stefan Blankenberg
- Department of General and Interventional Cardiology, University Heart Center, Hamburg, Germany
- German Centre for Cardiovascular Research (DZHK), Berlin, Germany
| | - Thomas Muenzel
- Department of Internal Medicine II, University Medical Center, Johannes Gutenberg University, Mainz, Germany
- German Centre for Cardiovascular Research (DZHK), Berlin, Germany
| | - Andreas M. Zeiher
- Division of Cardiology, Department of Internal Medicine III, Goethe University Frankfurt, Frankfurt, Germany
- German Centre for Cardiovascular Research (DZHK), Berlin, Germany
| | - Till Keller
- Division of Cardiology, Department of Internal Medicine III, Goethe University Frankfurt, Frankfurt, Germany
- German Centre for Cardiovascular Research (DZHK), Berlin, Germany
- * E-mail: (TK); (BJ)
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Boeckel JN, Palapies L, Zeller T, Reis SM, von Jeinsen B, Tzikas S, Bickel C, Baldus S, Blankenberg S, Münzel T, Zeiher AM, Lackner KJ, Keller T. Estimation of Values below the Limit of Detection of a Contemporary Sensitive Troponin I Assay Improves Diagnosis of Acute Myocardial Infarction. Clin Chem 2015. [DOI: 10.1373/clinchem.2015.238949] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Abstract
BACKGROUND
The limit of detection (LoD) is the minimal amount of a substance that can be consistently detected. In the diagnosis of acute myocardial infarction (AMI) many patients present with troponin concentrations below the LoD of contemporary sensitive cardiac troponin I (cs-cTnI) assays. These censored values below the LoD influence the diagnostic performance of these assays compared to highly sensitive cTnI (hs-cTnI) assays. Therefore we assessed the impact of a new approach for interpolation of the left-censored data of a cs-cTnI assay in the evaluation of patients with suspected AMI.
METHODS
Our posthoc analysis used a real world cohort of 1818 patients with suspected MI. Data on cs-cTnI was available in 1786 patients. As a comparator the hs-cTnI version of the assay was used. To reconstruct quantities below the LoD of the cs-cTnI assay, a gamma regression approach incorporating the GRACE (Global Registry of Acute Coronary Events) score variables was used.
RESULTS
Censoring of cs-cTnI data below the LoD yielded weaker diagnostic information [area under the curve (AUC), 0.781; 95% CI, 0.731–0.831] regarding AMI compared to the hs-cTnI assay (AUC, 0.949; CI, 0.936–0.961). Use of our model to estimate cs-cTnI values below the LoD showed an AUC improvement to 0.921 (CI, 0.902–0.940). The cs-cTnI LoD concentration had a negative predictive value (NPV) of 0.950. An estimated concentration that was to be undercut by 25% of patients presenting with suspected AMI was associated with an improvement of the NPV to 0.979.
CONCLUSIONS
Estimation of values below the LoD of a cs-cTnI assay with this new approach improves the diagnostic performance in evaluation of patients with suspected AMI.
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Affiliation(s)
- Jes-Niels Boeckel
- Institute for Cardiovascular Regeneration, Center of Molecular Medicine and
- DZHK (German Centre for Cardiovascular Research), partner site Rhein-Main, Germany
| | - Lars Palapies
- Division of Cardiology, Department of Medicine III, Goethe University Frankfurt, Frankfurt, Germany
| | - Tanja Zeller
- Clinic for General and Interventional Cardiology, University Heart Centre Hamburg, Hamburg, Germany
- DZHK (German Centre for Cardiovascular Research), partner site Hamburg/Kiel/Lübeck, Germany
| | - Sophia M Reis
- Division of Cardiology, Department of Medicine III, Goethe University Frankfurt, Frankfurt, Germany
| | - Beatrice von Jeinsen
- Division of Cardiology, Department of Medicine III, Goethe University Frankfurt, Frankfurt, Germany
| | - Stergios Tzikas
- Department of Medicine II, University Medical Center, Johannes Gutenberg University, Mainz, Germany
- 3rd Department of Cardiology, Aristotle University of Thessaloniki, Ippokrateio Hospital, Thessaloniki, Greece
| | - Christoph Bickel
- Department of Internal Medicine, Federal Armed Forces Hospital, Koblenz, Germany
| | | | - Stefan Blankenberg
- Clinic for General and Interventional Cardiology, University Heart Centre Hamburg, Hamburg, Germany
- DZHK (German Centre for Cardiovascular Research), partner site Hamburg/Kiel/Lübeck, Germany
| | - Thomas Münzel
- Department of Medicine II, University Medical Center, Johannes Gutenberg University, Mainz, Germany
- DZHK (German Centre for Cardiovascular Research), partner site Rhein-Main, Germany
| | - Andreas M Zeiher
- Division of Cardiology, Department of Medicine III, Goethe University Frankfurt, Frankfurt, Germany
- DZHK (German Centre for Cardiovascular Research), partner site Rhein-Main, Germany
| | - Karl J Lackner
- Institute for Clinical Chemistry and Laboratory Medicine, University Medical Center, Johannes Gutenberg University, Mainz, Germany
| | - Till Keller
- Division of Cardiology, Department of Medicine III, Goethe University Frankfurt, Frankfurt, Germany
- DZHK (German Centre for Cardiovascular Research), partner site Rhein-Main, Germany
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