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Bilgeri V, Spitaler P, Puelacher C, Messner M, Adukauskaite A, Barbieri F, Bauer A, Senoner T, Dichtl W. Decongestion in Acute Heart Failure-Time to Rethink and Standardize Current Clinical Practice? J Clin Med 2024; 13:311. [PMID: 38256444 PMCID: PMC10816514 DOI: 10.3390/jcm13020311] [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: 11/30/2023] [Revised: 12/31/2023] [Accepted: 01/03/2024] [Indexed: 01/24/2024] Open
Abstract
Most episodes of acute heart failure (AHF) are characterized by increasing signs and symptoms of congestion, manifested by edema, pleura effusion and/or ascites. Immediately and repeatedly administered intravenous (IV) loop diuretics currently represent the mainstay of initial therapy aiming to achieve adequate diuresis/natriuresis and euvolemia. Despite these efforts, a significant proportion of patients have residual congestion at discharge, which is associated with a poor prognosis. Therefore, a standardized approach is needed. The door to diuretic time should not exceed 60 min. As a general rule, the starting IV dose is 20-40 mg furosemide equivalents in loop diuretic naïve patients or double the preexisting oral home dose to be administered via IV. Monitoring responses within the following first hours are key issues. (1) After 2 h, spot urinary sodium should be ≥50-70 mmol/L. (2) After 6 h, the urine output should be ≥100-150 mL/hour. If these target measures are not reached, the guidelines currently recommend a doubling of the original dose to a maximum of 400-600 mg furosemide per day and in patients with severely impaired kidney function up to 1000 mg per day. Continuous infusion of loop diuretics offers no benefit over intermittent boluses (DOSE trial). Emerging evidence by recent randomized trials (ADVOR, CLOROTIC) supports the concept of an early combination diuretic therapy, by adding either acetazolamide (500 mg IV once daily) or hydrochlorothiazide. Acetazolamide is particularly useful in the presence of a baseline bicarbonate level of ≥27 mmol/L and remains effective in the presence of preexisting/worsening renal dysfunction but should be used only in the first three days to prevent severe metabolic disturbances. Patients should not leave the hospital when they are still congested and/or before optimized long-term guideline-directed medical therapy has been initiated. Special attention should be paid to AHF patients during the vulnerable post-discharge period, with an early follow-up visit focusing on up-titrate treatments of recommended doses within 2 weeks (STRONG-HF).
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Affiliation(s)
- Valentin Bilgeri
- Department of Internal Medicine III, Medical University of Innsbruck, 6020 Innsbruck, Austria; (V.B.); (P.S.); (C.P.); (M.M.); (A.A.); (A.B.)
| | - Philipp Spitaler
- Department of Internal Medicine III, Medical University of Innsbruck, 6020 Innsbruck, Austria; (V.B.); (P.S.); (C.P.); (M.M.); (A.A.); (A.B.)
| | - Christian Puelacher
- Department of Internal Medicine III, Medical University of Innsbruck, 6020 Innsbruck, Austria; (V.B.); (P.S.); (C.P.); (M.M.); (A.A.); (A.B.)
| | - Moritz Messner
- Department of Internal Medicine III, Medical University of Innsbruck, 6020 Innsbruck, Austria; (V.B.); (P.S.); (C.P.); (M.M.); (A.A.); (A.B.)
| | - Agne Adukauskaite
- Department of Internal Medicine III, Medical University of Innsbruck, 6020 Innsbruck, Austria; (V.B.); (P.S.); (C.P.); (M.M.); (A.A.); (A.B.)
| | - Fabian Barbieri
- Deutsches Herzzentrum der Charité, Hindenburgdamm 30, 12203 Berlin, Germany;
| | - Axel Bauer
- Department of Internal Medicine III, Medical University of Innsbruck, 6020 Innsbruck, Austria; (V.B.); (P.S.); (C.P.); (M.M.); (A.A.); (A.B.)
| | - Thomas Senoner
- Department of Anesthesiology, Medical University of Innsbruck, 6020 Innsbruck, Austria;
| | - Wolfgang Dichtl
- Department of Internal Medicine III, Medical University of Innsbruck, 6020 Innsbruck, Austria; (V.B.); (P.S.); (C.P.); (M.M.); (A.A.); (A.B.)
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Lurati Buse G, Bollen Pinto B, Abelha F, Abbott TEF, Ackland G, Afshari A, De Hert S, Fellahi JL, Giossi L, Kavsak P, Longrois D, M'Pembele R, Nucaro A, Popova E, Puelacher C, Richards T, Roth S, Sheka M, Szczeklik W, van Waes J, Walder B, Chew MS. ESAIC focused guideline for the use of cardiac biomarkers in perioperative risk evaluation. Eur J Anaesthesiol 2023; 40:888-927. [PMID: 37265332 DOI: 10.1097/eja.0000000000001865] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
BACKGROUND In recent years, there has been increasing focus on the use of cardiac biomarkers in patients undergoing noncardiac surgery. AIMS The aim of this focused guideline was to provide updated guidance regarding the pre-, post- and combined pre-and postoperative use of cardiac troponin and B-type natriuretic peptides in adult patients undergoing noncardiac surgery. METHODS The guidelines were prepared using Grading of Recommendations Assessment Development and Evaluation (GRADE) methodology. This included the definition of critical outcomes, a systematic literature search, appraisal of certainty of evidence, evaluation of biomarker measurement in terms of the balance of desirable and undesirable effects including clinical outcomes, resource use, health inequality, stakeholder acceptance, and implementation. The panel differentiated between three different scopes of applications: cardiac biomarkers as prognostic factors, as tools for risk prediction, and for biomarker-enhanced management strategies. RESULTS In a modified Delphi process, the task force defined 12 critical outcomes. The systematic literature search resulted in over 25,000 hits, of which 115 full-text articles formed the body of evidence for recommendations. The evidence appraisal indicated heterogeneity in the certainty of evidence across critical outcomes. Further, there was relevant gradient in the certainty of evidence across the three scopes of application. Recommendations were issued and if this was not possible due to limited evidence, clinical practice statements were produced. CONCLUSION The ESAIC focused guidelines provide guidance on the perioperative use of cardiac troponin and B-type natriuretic peptides in patients undergoing noncardiac surgery, for three different scopes of application.
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Affiliation(s)
- Giovanna Lurati Buse
- From the Department of Anaesthesiology, University Hospital Dusseldorf, Dusseldorf, Germany (GLB, RMP, AN, SR), Division of Anaesthesiology, Geneva University Hospitals (HUG), Geneva, Switzerland (BBP, MS, BW), Department of Anesthesiology, Centro Hospitalar Universitário de São João, Porto, Portugal (FA), Cardiovascular Research and Development Center (UnIC@RISE), Department of Surgery and Physiology, Faculty of Medicine of the University of Porto, Porto, Portugal (FA), William Harvey Research Institute, Queen Mary University of London, London, UK (TEA, GA), Department of Anaesthesia and Perioperative Medicine, Royal London Hospital, Barts Health NHS Trust, London, UK (GA), Department of Paediatric and Obstetric Anaesthesia, Rigshospitalet & Department of Clinical Medicine, Copenhagen University, Denmark (AA), Department of Anaesthesiology and Perioperative Medicine, Ghent University Hospital, Ghent University, Ghent, Belgium (SDH), Service d'Anesthésie-Réanimation, Hôpital Universitaire Louis Pradel, Hospices Civils de Lyon, 59 boulevard Pinel, 69500 Lyon, France (J-LF), "Patients as Partners" program, Geneva University Hospitals (HUG), Geneva, Switzerland (LG), Department of Pathology and Molecular Medicine, McMaster University, Hamilton, Ontario, Canada (PK), Department of Anesthesiology and Intensive Care, Bichat Claude-Bernard Hospital, Assistance Publique-Hopitaux de Paris - Nord, University of Paris, INSERM U1148, Paris, France (DL), Institut d'Investigació Biomèdica Sant Pau (IIB SANT PAU), Barcelona, Spain (EP), Centro Cochrane Iberoamericano, Barcelona, Spain (EP), Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Basel-Stadt, Switzerland (CP), Department of Internal Medicine, University Hospital Basel, University of Basel, Petersgraben 4, 4031 Basel, Basel-Stadt, Switzerland (CP), Division of Surgery, University of Western Australia, Perkins South Building, Fiona Stanley Hospital, Murdoch, Perth, WA, Australia (TR), Institute of Clinical Trials and Methodology and Division of Surgery, University College London, UK (TR), Department of Intensive Care and Perioperative Medicine, Jagiellonian University Medical College, Krakow, Poland (WS), Department of Anesthesiology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands (JvW), Department of Anaesthesia and Intensive Care, Biomedical and Clinical Sciences, Linköping University Hospital, Sweden (MSC)
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Meister R, Puelacher C, Glarner N, Gualandro DM, Andersson HA, Pargger M, Huré G, Virant G, Bolliger D, Lampart A, Steiner L, Hidvegi R, Lurati Buse G, Kindler C, Gürke L, Mujagic E, Schaeren S, Clauss M, Lardinois D, Hammerer-Lercher A, Chew M, Mueller C. Prediction of perioperative myocardial infarction/injury in high-risk patients after noncardiac surgery. Eur Heart J Acute Cardiovasc Care 2023; 12:729-739. [PMID: 37548292 PMCID: PMC10655147 DOI: 10.1093/ehjacc/zuad090] [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] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Revised: 07/24/2023] [Accepted: 07/26/2023] [Indexed: 08/08/2023]
Abstract
AIMS Perioperative myocardial infarction/injury (PMI) is a surprisingly common yet difficult-to-predict cardiac complication in patients undergoing noncardiac surgery. We aimed to assess the incremental value of preoperative cardiac troponin (cTn) concentration in the prediction of PMI. METHODS AND RESULTS Among prospectively recruited patients at high cardiovascular risk (age ≥65 years or ≥45 years with preexisting cardiovascular disease), PMI was defined as an absolute increase in high-sensitivity cTnT (hs-cTnT) concentration of ≥14 ng/L (the 99th percentile) above the preoperative concentration. Perioperative myocardial infarction/injury was centrally adjudicated by two independent cardiologists using serial measurements of hs-cTnT. Using logistic regression, three models were derived: Model 1 including patient- and procedure-related information, Model 2 adding routinely available laboratory values, and Model 3 further adding preoperative hs-cTnT concentration. Models were also compared vs. preoperative hs-cTnT alone. The findings were validated in two independent cohorts. Among 6944 patients, PMI occurred in 1058 patients (15.2%). The predictive accuracy as quantified by the area under the receiver operating characteristic curve was 0.73 [95% confidence interval (CI) 0.71-0.74] for Model 1, 0.75 (95% CI 0.74-0.77) for Model 2, 0.79 (95% CI 0.77-0.80) for Model 3, and 0.74 for hs-cTnT alone. Model 3 included 10 preoperative variables: age, body mass index, known coronary artery disease, metabolic equivalent >4, risk of surgery, emergency surgery, planned duration of surgery, haemoglobin, platelet count, and hs-cTnT. These findings were confirmed in both independent validation cohorts (n = 722 and n = 966). CONCLUSION Preoperative cTn adds incremental value above patient- and procedure-related variables as well as routine laboratory variables in the prediction of PMI.
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Affiliation(s)
- Rebecca Meister
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Spitalstrasse 2, CH-4031 Basel, Basel-Stadt, Switzerland
| | - Christian Puelacher
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Spitalstrasse 2, CH-4031 Basel, Basel-Stadt, Switzerland
- Department of Internal Medicine, University Hospital Basel, University of Basel, Spitalstrasse 21, 4031 Basel, Basel-Stadt, Switzerland
| | - Noemi Glarner
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Spitalstrasse 2, CH-4031 Basel, Basel-Stadt, Switzerland
| | - Danielle Menosi Gualandro
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Spitalstrasse 2, CH-4031 Basel, Basel-Stadt, Switzerland
- Interdisciplinary Medicine in Cardiology Unit, Cardiology Department, Heart Institute (InCor), University of Sao Paulo Medical School, Av. Dr. Enéas Carvalho de Aguiar, 44, Cerqueira César, 05403-900 São Paulo, Brazil
| | - Henrik A Andersson
- Department of Anaesthesiology and Intensive Care Medicine, Linköping University Hospital, SE-581 83 Linköping, Sweden
| | - Mirjam Pargger
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Spitalstrasse 2, CH-4031 Basel, Basel-Stadt, Switzerland
| | - Gabrielle Huré
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Spitalstrasse 2, CH-4031 Basel, Basel-Stadt, Switzerland
| | - Georgiana Virant
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Spitalstrasse 2, CH-4031 Basel, Basel-Stadt, Switzerland
| | - Daniel Bolliger
- Department of Anaesthesiology, University Hospital Basel, University of Basel, Spitalstrasse 21, 4031 Basel, Basel-Stadt, Switzerland
| | - Andreas Lampart
- Department of Anaesthesiology, University Hospital Basel, University of Basel, Spitalstrasse 21, 4031 Basel, Basel-Stadt, Switzerland
| | - Luzius Steiner
- Department of Anaesthesiology, University Hospital Basel, University of Basel, Spitalstrasse 21, 4031 Basel, Basel-Stadt, Switzerland
- Department of Clinical Research, University Basel, Spitalstrasse 21, 4031 Basel, Basel-Stadt, Switzerland
| | - Reka Hidvegi
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Spitalstrasse 2, CH-4031 Basel, Basel-Stadt, Switzerland
- Department of Anaesthesiology, Cantonal Hospital St. Gallen, Rorschacher Str. 95/Haus 03, 9007 St. Gallen, Switzerland
| | - Giovanna Lurati Buse
- Department of Anaesthesiology, University Hospital Dusseldorf, Moorenstr. 5 40225 Düsseldorf, NRW, Germany
| | - Christoph Kindler
- Department of Anaesthesiology, Cantonal Hospital Aarau, Tellstrasse 25, 5001 Aarau, Aargau, Switzerland
| | - Lorenz Gürke
- Department of Vascular Surgery, University Hospital Basel, University Basel, Spitalstrasse 21, 4031 Basel, Basel-Stadt, Switzerland
| | - Edin Mujagic
- Department of Vascular Surgery, University Hospital Basel, University Basel, Spitalstrasse 21, 4031 Basel, Basel-Stadt, Switzerland
| | - Stefan Schaeren
- Department of Spinal Surgery, University Hospital Basel, University Basel, Spitalstrasse 21, 4031 Basel, Basel-Stadt, Switzerland
| | - Martin Clauss
- Department of Orthopedics and Center of Musculoskeletal Infections, University Hospital Basel, University Basel, Spitalstrasse 21, 4031 Basel, Basel-Stadt, Switzerland
| | - Didier Lardinois
- Department of Thoracic Surgery, University Hospital Basel, University of Basel, Spitalstrasse 21, 4031 Basel, Basel-Stadt, Switzerland
| | - Angelika Hammerer-Lercher
- Department of Laboratory Medicine, Cantonal Hospital Aarau, Tellstrasse 25, 5001 Aarau, Aargau, Switzerland
| | - Michelle Chew
- Department of Anaesthesiology and Intensive Care Medicine, Linköping University Hospital, SE-581 83 Linköping, Sweden
| | - Christian Mueller
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Spitalstrasse 2, CH-4031 Basel, Basel-Stadt, Switzerland
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Glarner N, Puelacher C, Gualandro DM, Lurati Buse G, Hidvegi R, Bolliger D, Lampart A, Burri K, Pargger M, Gerhard H, Weder S, Maiorano S, Meister R, Tschan C, Osswald S, Steiner LA, Guerke L, Kappos EA, Clauss M, Filipovic M, Arenja N, Mueller C. Guideline adherence to statin therapy and association with short-term and long-term cardiac complications following noncardiac surgery: A cohort study. Eur J Anaesthesiol 2023; 40:854-864. [PMID: 37747427 DOI: 10.1097/eja.0000000000001903] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/26/2023]
Abstract
BACKGROUND Peri-operative complications are common and associated with high morbidity and mortality. Optimising the use of statins might be of important benefit in peri-operative care and reduce morbidity and mortality. OBJECTIVE To evaluate adherence to current guideline recommendations regarding statin therapy and its association with peri-operative and long-term cardiac complications. DESIGN Prospective cohort study. SETTING Multicentre study with enrolment from October 2014 to February 2018. PATIENTS Eight thousand one hundred and sixteen high-risk inpatients undergoing major noncardiac surgery who were eligible for the institutional peri-operative myocardial injury/infarction (PMI) active surveillance and response program. MAIN OUTCOME MEASURES Class I indications for statin therapy were derived from the current ESC Clinical Practice Guidelines during the time of enrolment. PMI was prospectively defined as an absolute increase in cTn concentration of the 99th percentile in healthy individuals above the preoperative concentration within the first three postoperative days. Long-term cardiac complications included cardiovascular death and spontaneous myocardial infarction (MI) within 120 days. RESULTS The mean age was 73.7 years; 45.2% were women. Four thousand two hundred and twenty-seven of 8116 patients (52.1%) had a class I indication for statin therapy. Of these, 2440 of 4227 patients (57.7%) were on statins preoperatively. Adherence to statins was lower in women than in men (46.9 versus 63.9%, P < 0.001). PMI due to type 1 myocardial infarction/injury (T1MI; n = 42), or likely type 2 MI (lT2MI; n = 466) occurred in 508 of 4170 (12.2%) patients. The weighted odds ratio in patients on statin therapy was 1.15 [95% confidence interval (CI) 1.01 to 1.31, P = 0.036]. During the 120-day follow-up, 192 patients (4.6%) suffered cardiovascular death and spontaneous MI. After multivariable adjustment, preoperative use of statins was associated with reduced risk; weighted hazard ratio 0.59 (95% CI 0.41 to 0.86, P = 0.006). CONCLUSION Adherence to guideline-recommended statin therapy was suboptimal, particularly in women. Statin use was associated with an increased risk of PMI due to T1MI and lT2MI but reduced risk of cardiovascular death and spontaneous MI within 120 days. TRIAL REGISTRATION Clinicaltrials.gov identifier NCT02573532.
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Affiliation(s)
- Noemi Glarner
- From the Department of Cardiology, Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Switzerland (NG, CP, DMG, KB, MP, HG, SW, SM, RM, CT, SO, NA, CM), GREAT Network (NG, CP, DMG, KB, MP, HG, SW, SM, RM, NA, CM), Department of Anaesthesiology, University Hospital Dusseldorf, Germany (GLB), Department of Anaesthesiology, Cantonal Hospital St. Gallen, Switzerland (RH, MF), Department of Anaesthesiology, University Hospital Basel, University of Basel, Switzerland (DB, AL, KB, LAS), Department of Clinical Research, University Hospital Basel, University of Basel, Switzerland (LAS), Department of Vascular Surgery, University Hospital Basel, University of Basel, Switzerland (LG), Department of Plastic, Reconstructive, Aesthetic and Hand Surgery, University Hospital Basel, University of Basel, Switzerland (EAK), Department of Orthopaedics and Trauma Surgery, University Hospital Basel, University of Basel, Switzerland (MC), Centre for Musculoskeletal Infections, University Hospital Basel, University of Basel, Switzerland (MC), Department of Cardiology, Cantonal Hospital Olten, Switzerland (NA)
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Meier M, Boeddinghaus J, Nestelberger T, Koechlin L, Lopez-Ayala P, Wussler D, Walter JE, Zimmermann T, Badertscher P, Wildi K, Giménez MR, Puelacher C, Glarner N, Magni J, Miró Ò, Martin-Sanchez FJ, Kawecki D, Keller DI, Gualandro DM, Twerenbold R, Nickel CH, Bingisser R, Mueller C. Comparing the utility of clinical risk scores and integrated clinical judgement in patients with suspected acute coronary syndrome. Eur Heart J Acute Cardiovasc Care 2023; 12:693-702. [PMID: 37435949 PMCID: PMC10599640 DOI: 10.1093/ehjacc/zuad081] [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] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Revised: 06/05/2023] [Accepted: 07/10/2023] [Indexed: 07/13/2023]
Abstract
AIMS The utility of clinical risk scores regarding the prediction of major adverse cardiac events (MACE) is uncertain. We aimed to directly compare the prognostic performance of five established clinical risk scores as well as an unstructured integrated clinical judgement (ICJ) of the treating emergency department (ED) physician. METHODS AND RESULTS Thirty-day MACE including all-cause death, life-threatening arrhythmia, cardiogenic shock, acute myocardial infarction (including the index event), and unstable angina requiring urgent coronary revascularization were centrally adjudicated by two independent cardiologists in patients presenting to the ED with acute chest discomfort in an international multicentre study. We compared the prognostic performance of the HEART score, GRACE score, T-MACS, TIMI score, and EDACS, as well as the unstructured ICJ of the treating ED physician (visual analogue scale to estimate the probability of acute coronary syndrome, ranging from 0 to 100). Among 4551 eligible patients, 1110/4551 patients (24.4%) had at least one MACE within 30 days. Prognostic accuracy was high and comparable for the HEART score, GRACE score, T-MACS, and ICJ [area under the receiver operating characteristic curve (AUC) 0.85-0.87] but significantly lower and only moderate for the TIMI score (AUC 0.79, P < 0.001) and EDACS (AUC 0.74, P < 0.001), resulting in sensitivities for the rule-out of 30-day MACE of 93-96, 87 (P < 0.001), and 72% (P < 0.001), respectively. CONCLUSION The HEART score, GRACE score, T-MACS, and unstructured ICJ of the treating physician, not the TIMI score or EDACS, performed well for the prediction of 30-day MACE and may be considered for routine clinical use. TRIAL REGISTRATION ClinicalTrials.gov number NCT00470587.
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Affiliation(s)
- Mario Meier
- Cardiovascular Research Institute Basel (CRIB) and University Heart Center, University Hospital Basel, University of Basel, Petersgraben 4, Basel CH-4031, Switzerland
- GREAT Network, Via Antonio Serra 54, 00191 Rome, Italy
| | - Jasper Boeddinghaus
- Cardiovascular Research Institute Basel (CRIB) and University Heart Center, University Hospital Basel, University of Basel, Petersgraben 4, Basel CH-4031, Switzerland
- GREAT Network, Via Antonio Serra 54, 00191 Rome, Italy
| | - Thomas Nestelberger
- Cardiovascular Research Institute Basel (CRIB) and University Heart Center, University Hospital Basel, University of Basel, Petersgraben 4, Basel CH-4031, Switzerland
- GREAT Network, Via Antonio Serra 54, 00191 Rome, Italy
- Division of Cardiology, Vancouver General Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Luca Koechlin
- Cardiovascular Research Institute Basel (CRIB) and University Heart Center, University Hospital Basel, University of Basel, Petersgraben 4, Basel CH-4031, Switzerland
- GREAT Network, Via Antonio Serra 54, 00191 Rome, Italy
- Department of Cardiac Surgery, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Pedro Lopez-Ayala
- Cardiovascular Research Institute Basel (CRIB) and University Heart Center, University Hospital Basel, University of Basel, Petersgraben 4, Basel CH-4031, Switzerland
- GREAT Network, Via Antonio Serra 54, 00191 Rome, Italy
| | - Desiree Wussler
- Cardiovascular Research Institute Basel (CRIB) and University Heart Center, University Hospital Basel, University of Basel, Petersgraben 4, Basel CH-4031, Switzerland
- GREAT Network, Via Antonio Serra 54, 00191 Rome, Italy
- Department of Intensive Care Medicine, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Joan Elias Walter
- Cardiovascular Research Institute Basel (CRIB) and University Heart Center, University Hospital Basel, University of Basel, Petersgraben 4, Basel CH-4031, Switzerland
- GREAT Network, Via Antonio Serra 54, 00191 Rome, Italy
- Emergency Department, Triemli Hospital, Zurich, Switzerland
| | - Tobias Zimmermann
- Cardiovascular Research Institute Basel (CRIB) and University Heart Center, University Hospital Basel, University of Basel, Petersgraben 4, Basel CH-4031, Switzerland
- GREAT Network, Via Antonio Serra 54, 00191 Rome, Italy
- Department of Intensive Care Medicine, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Patrick Badertscher
- Cardiovascular Research Institute Basel (CRIB) and University Heart Center, University Hospital Basel, University of Basel, Petersgraben 4, Basel CH-4031, Switzerland
- GREAT Network, Via Antonio Serra 54, 00191 Rome, Italy
| | - Karin Wildi
- Cardiovascular Research Institute Basel (CRIB) and University Heart Center, University Hospital Basel, University of Basel, Petersgraben 4, Basel CH-4031, Switzerland
- GREAT Network, Via Antonio Serra 54, 00191 Rome, Italy
- Critical Care Research Group, The Prince Charles Hospital and The University of Queensland, Brisbane, Australia
| | - Maria Rubini Giménez
- Cardiovascular Research Institute Basel (CRIB) and University Heart Center, University Hospital Basel, University of Basel, Petersgraben 4, Basel CH-4031, Switzerland
- GREAT Network, Via Antonio Serra 54, 00191 Rome, Italy
- Department of Cardiology and internal Medicine, University Heart Center Leipzig, Leipzig, Germany
| | - Christian Puelacher
- Cardiovascular Research Institute Basel (CRIB) and University Heart Center, University Hospital Basel, University of Basel, Petersgraben 4, Basel CH-4031, Switzerland
- GREAT Network, Via Antonio Serra 54, 00191 Rome, Italy
| | - Noemi Glarner
- Cardiovascular Research Institute Basel (CRIB) and University Heart Center, University Hospital Basel, University of Basel, Petersgraben 4, Basel CH-4031, Switzerland
- GREAT Network, Via Antonio Serra 54, 00191 Rome, Italy
| | - Jan Magni
- Cardiovascular Research Institute Basel (CRIB) and University Heart Center, University Hospital Basel, University of Basel, Petersgraben 4, Basel CH-4031, Switzerland
- GREAT Network, Via Antonio Serra 54, 00191 Rome, Italy
| | - Òscar Miró
- GREAT Network, Via Antonio Serra 54, 00191 Rome, Italy
- Emergency Department, Hospital Clinic, Barcelona, Catalonia, Spain
| | | | - Damian Kawecki
- GREAT Network, Via Antonio Serra 54, 00191 Rome, Italy
- 2nd Department of Cardiology, School of Medicine with the Division of Dentistry in Zabrze, Medical University of Katowice, Zabrze, Poland
| | - Dagmar I Keller
- Emergency Department, University Hospital Zurich, Zurich, Switzerland
| | - Danielle M Gualandro
- Cardiovascular Research Institute Basel (CRIB) and University Heart Center, University Hospital Basel, University of Basel, Petersgraben 4, Basel CH-4031, Switzerland
- GREAT Network, Via Antonio Serra 54, 00191 Rome, Italy
- Heart Institute (InCor), University of Sao Paulo Medical School, Sao Paulo, Brazil
| | - Raphael Twerenbold
- Cardiovascular Research Institute Basel (CRIB) and University Heart Center, University Hospital Basel, University of Basel, Petersgraben 4, Basel CH-4031, Switzerland
- GREAT Network, Via Antonio Serra 54, 00191 Rome, Italy
- University Center of Cardiovascular Science & Department of Cardiology, University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Christian H Nickel
- GREAT Network, Via Antonio Serra 54, 00191 Rome, Italy
- Emergency Department, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Roland Bingisser
- GREAT Network, Via Antonio Serra 54, 00191 Rome, Italy
- Emergency Department, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Christian Mueller
- Cardiovascular Research Institute Basel (CRIB) and University Heart Center, University Hospital Basel, University of Basel, Petersgraben 4, Basel CH-4031, Switzerland
- GREAT Network, Via Antonio Serra 54, 00191 Rome, Italy
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Puelacher C, Mills NL, Mueller C. How to use cardiac troponin in non-cardiac surgery. Eur Heart J Acute Cardiovasc Care 2023; 12:464-466. [PMID: 37254820 PMCID: PMC10328434 DOI: 10.1093/ehjacc/zuad057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/28/2023] [Accepted: 05/30/2023] [Indexed: 06/01/2023]
Affiliation(s)
- Christian Puelacher
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Petersgraben 4, 4031 Basel, Switzerland
| | - Nicholas L Mills
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
- Usher Institute, University of Edinburgh, Edinburgh, UK
| | - Christian Mueller
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Petersgraben 4, 4031 Basel, Switzerland
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7
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Puelacher C, Gualandro DM, Glarner N, Lurati Buse G, Lampart A, Bolliger D, Steiner LA, Grossenbacher M, Burri-Winkler K, Gerhard H, Kappos EA, Clerc O, Biner L, Zivzivadze Z, Kindler C, Hammerer-Lercher A, Filipovic M, Clauss M, Gürke L, Wolff T, Mujagic E, Bilici M, Cardozo FA, Osswald S, Caramelli B, Mueller C. Long-term outcomes of perioperative myocardial infarction/injury after non-cardiac surgery. Eur Heart J 2023; 44:1690-1701. [PMID: 36705050 PMCID: PMC10263270 DOI: 10.1093/eurheartj/ehac798] [Citation(s) in RCA: 16] [Impact Index Per Article: 16.0] [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: 03/27/2022] [Revised: 11/21/2022] [Accepted: 12/19/2022] [Indexed: 01/28/2023] Open
Abstract
AIMS Perioperative myocardial infarction/injury (PMI) following non-cardiac surgery is a frequent cardiac complication. Better understanding of the underlying aetiologies and outcomes is urgently needed. METHODS AND RESULTS Aetiologies of PMIs detected within an active surveillance and response programme were centrally adjudicated by two independent physicians based on all information obtained during clinically indicated PMI work-up including cardiac imaging among consecutive high-risk patients undergoing major non-cardiac surgery in a prospective multicentre study. PMI aetiologies were hierarchically classified into 'extra-cardiac' if caused by a primarily extra-cardiac disease such as severe sepsis or pulmonary embolism; and 'cardiac', further subtyped into type 1 myocardial infarction (T1MI), tachyarrhythmia, acute heart failure (AHF), or likely type 2 myocardial infarction (lT2MI). Major adverse cardiac events (MACEs) including acute myocardial infarction, AHF (both only from day 3 to avoid inclusion bias), life-threatening arrhythmia, and cardiovascular death as well as all-cause death were assessed during 1-year follow-up. Among 7754 patients (age 45-98 years, 45% women), PMI occurred in 1016 (13.1%). At least one MACE occurred in 684/7754 patients (8.8%) and 818/7754 patients died (10.5%) within 1 year. Outcomes differed starkly according to aetiology: in patients with extra-cardiac PMI, T1MI, tachyarrhythmia, AHF, and lT2MI 51%, 41%, 57%, 64%, and 25% had MACE, and 38%, 27%, 40%, 49%, and 17% patients died within 1 year, respectively, compared to 7% and 9% in patients without PMI. These associations persisted in multivariable analysis. CONCLUSION At 1 year, most PMI aetiologies have unacceptably high rates of MACE and all-cause death, highlighting the urgent need for more intensive treatments. STUDY REGISTRATION https://clinicaltrials.gov/ct2/show/NCT02573532.
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Affiliation(s)
- Christian Puelacher
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Petersgraben 4, 4031 Basel, Basel-Stadt, Switzerland
- Department of Internal Medicine, University Hospital Basel, University of Basel, Petersgraben 4, 4031 Basel, Basel-Stadt, Switzerland
| | - Danielle M Gualandro
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Petersgraben 4, 4031 Basel, Basel-Stadt, Switzerland
- Department of Cardiology, Unidade de Medicina Interdisciplinar em Cardiologia, Instituto do Coração (InCor), Universidade de Sao Paulo, Sao Paulo, Brazil
| | | | - Giovanna Lurati Buse
- Department of Anaesthesiology, University Hospital Dusseldorf, Dusseldorf, Germany
| | - Andreas Lampart
- Department of Anaesthesiology, University Hospital Basel, University Basel, Basel, Switzerland
| | - Daniel Bolliger
- Department of Anaesthesiology, University Hospital Basel, University Basel, Basel, Switzerland
| | - Luzius A Steiner
- Department of Anaesthesiology, University Hospital Basel, University Basel, Basel, Switzerland
| | - Mario Grossenbacher
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Petersgraben 4, 4031 Basel, Basel-Stadt, Switzerland
| | - Katrin Burri-Winkler
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Petersgraben 4, 4031 Basel, Basel-Stadt, Switzerland
- Department of Anaesthesiology, University Hospital Basel, University Basel, Basel, Switzerland
| | - Hatice Gerhard
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Petersgraben 4, 4031 Basel, Basel-Stadt, Switzerland
| | - Elisabeth A Kappos
- Department of Plastic, Reconstructive, Aesthetic and Hand Surgery, University Hospital Basel, Basel, Switzerland
| | - Olivier Clerc
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Petersgraben 4, 4031 Basel, Basel-Stadt, Switzerland
| | - Laura Biner
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Petersgraben 4, 4031 Basel, Basel-Stadt, Switzerland
| | - Zaza Zivzivadze
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Petersgraben 4, 4031 Basel, Basel-Stadt, Switzerland
| | - Christoph Kindler
- Department of Anaesthesiology, Cantonal Hospital Aarau, Aarau, Switzerland
| | | | - Miodrag Filipovic
- Department of Anaesthesiology, Cantonal Hospital St. Gallen, St. Gallen, Switzerland
| | - Martin Clauss
- Department of Orthopaedic and Trauma Surgery, University Hospital Basel, Basel, Switzerland
- Center for Musculoskeletal Infections, University Hospital Basel, Basel, Switzerland
| | - Lorenz Gürke
- Department of Vascular Surgery, University Hospital Basel, Basel, Switzerland
| | - Thomas Wolff
- Department of Vascular Surgery, University Hospital Basel, Basel, Switzerland
| | - Edin Mujagic
- Department of Vascular Surgery, University Hospital Basel, Basel, Switzerland
| | - Murat Bilici
- Department of Orthopaedic and Trauma Surgery, University Hospital Basel, Basel, Switzerland
| | - Francisco A Cardozo
- Department of Cardiology, Unidade de Medicina Interdisciplinar em Cardiologia, Instituto do Coração (InCor), Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Stefan Osswald
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Petersgraben 4, 4031 Basel, Basel-Stadt, Switzerland
| | - Bruno Caramelli
- Department of Cardiology, Unidade de Medicina Interdisciplinar em Cardiologia, Instituto do Coração (InCor), Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Christian Mueller
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Petersgraben 4, 4031 Basel, Basel-Stadt, Switzerland
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8
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Gualandro DM, Puelacher C, Mueller C. Reply to the letter regarding the article 'Acute heart failure after non-cardiac surgery: incidence, phenotypes, determinants and outcomes'. Eur J Heart Fail 2023; 25:771-772. [PMID: 37013342 DOI: 10.1002/ejhf.2850] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Accepted: 03/31/2023] [Indexed: 04/05/2023] Open
Affiliation(s)
- Danielle M Gualandro
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Basel, Switzerland
- Unidade de Medicina Interdisciplinar em Cardiologia, Instituto do Coração, Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Christian Puelacher
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Basel, Switzerland
| | - Christian Mueller
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Basel, Switzerland
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9
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Boeddinghaus J, Nestelberger T, Koechlin L, Lopez-Ayala P, Wussler D, Mais M, Zwimpfer L, Zimmermann T, Wildi K, Rubini Giménez M, Strebel I, Miró Ò, Martin-Sanchez FJ, Parenica J, Keller DI, Gualandro DM, Nickel CH, Bingisser R, Christ M, Mueller C, Twerenbold R, Puelacher C, Glarner N, Okamura B, Sanchez AY, de Lavallaz JDF, Potlukova E, Freese M, Rentsch K, Buser A, López B, Martinez-Nadal G, Adrada ER, von Eckardstein A, Morawiec B, Kawecki D, Muzyk P, Bürgler F, Geigy N. Association of accompanying dyspnea with diagnosis and outcome of patients presenting with acute chest discomfort. Eur Heart J Acute Cardiovasc Care 2023; 12:283-295. [PMID: 36917461 DOI: 10.1093/ehjacc/zuad026] [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] [Subscribe] [Scholar Register] [Received: 11/13/2022] [Revised: 02/27/2023] [Accepted: 03/10/2023] [Indexed: 03/15/2023]
Abstract
AIM The presence of accompanying dyspnea is routinely assessed and common in patients presenting with acute chest pain/discomfort to the emergency department (ED). We aimed to assess the association of accompanying dyspnea with differential diagnoses, diagnostic work-up and outcome. METHODS We enrolled patients presenting to the ED with chest pain/discomfort. Final diagnoses were adjudicated by independent cardiologists using all information including cardiac imaging. The primary diagnostic endpoint was the final diagnosis. The secondary diagnostic endpoint was the performance of high-sensitivity cardiac troponin (hs-cTn) and the European Society of Cardiology (ESC) 0/1h-algorithms for the diagnosis of myocardial infarction (MI). The prognostic endpoints were cardiovascular and all-cause mortality at two years. RESULTS Among 6045 patients, 2892/6045 (48%) had accompanying dyspnea. The prevalence of ACS in patients with versus without dyspnea was comparable (MI 22.4% vs. 21.9%, p = 0.60, unstable angina 8.7% vs. 7.9%, p = 0.29). In contrast, patients with dyspnea more often had cardiac, non-coronary disease (15.3% vs. 10.2%, p < 0.001). Diagnostic accuracy of hs-cTnT/I concentrations was not affected by the presence of dyspnea (area under the curve 0.89-0.91 in both groups) and the safety of the ESC 0/1h-algorithms was maintained with negative predictive values >99.4%. Accompanying dyspnea was an independent predictor for cardiovascular and all-cause death at two years (Hazard Ratio [HR] 1.813 [95%CI, 1.453-2.261, p < 0.01]). CONCLUSION Accompanying dyspnea was not associated with a higher prevalence of ACS but with cardiac, non-coronary disease. While the safety of the diagnostic work-up was not affected, accompanying dyspnea was an independent predictor for cardiovascular and all-cause death.
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Affiliation(s)
- Jasper Boeddinghaus
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Switzerland.,GREAT network, Rome, Italy.,BHF Centre for Cardiovascular Science, University of Edinburgh, Scotland, United Kingdom
| | - Thomas Nestelberger
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Switzerland.,GREAT network, Rome, Italy
| | - Luca Koechlin
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Switzerland.,GREAT network, Rome, Italy.,Department of Cardiac Surgery, University Hospital Basel, University of Basel, Switzerland
| | - Pedro Lopez-Ayala
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Switzerland.,GREAT network, Rome, Italy
| | - Desiree Wussler
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Switzerland.,GREAT network, Rome, Italy.,Division of Internal Medicine, University Hospital Basel, University of Basel, Switzerland
| | - Maximilian Mais
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Switzerland
| | - Luca Zwimpfer
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Switzerland
| | - Tobias Zimmermann
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Switzerland.,GREAT network, Rome, Italy.,Department of Intensive Care Medicine, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Karin Wildi
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Switzerland.,GREAT network, Rome, Italy.,Critical Care Research Group, the Prince Charles Hospital, Brisbane and the University of Queensland, Brisbane, Australia
| | - Maria Rubini Giménez
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Switzerland.,GREAT network, Rome, Italy.,Leipzig Heart Center, Leipzig, Germany
| | - Ivo Strebel
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Switzerland.,GREAT network, Rome, Italy
| | - Òscar Miró
- GREAT network, Rome, Italy.,Emergency Department, Hospital Clinic, Barcelona, Catalonia, Spain
| | - F Javier Martin-Sanchez
- GREAT network, Rome, Italy.,Servicio de Urgencias, Hospital Clínico San Carlos, Madrid, Spain
| | - Jiri Parenica
- Department of Cardiology, University Hospital Brno, Brno, Czech Republic and Medical Faculty, Masaryk University, Brno, Czech Republic
| | - Dagmar I Keller
- Emergency Department, University Hospital Zurich, Zurich, Switzerland
| | - Danielle M Gualandro
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Switzerland.,GREAT network, Rome, Italy
| | - Christian H Nickel
- Emergency Department, University Hospital Basel, University of Basel, Switzerland
| | - Roland Bingisser
- Emergency Department, University Hospital Basel, University of Basel, Switzerland
| | | | - Christian Mueller
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Switzerland.,GREAT network, Rome, Italy
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10
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Gualandro DM, Puelacher C, Chew MS, Andersson H, Lurati Buse G, Glarner N, Mueller D, Cardozo FAM, Burri-Winkler K, Mork C, Wussler D, Shrestha S, Heidelberger I, Fält M, Hidvegi R, Bolliger D, Lampart A, Steiner LA, Schären S, Kindler C, Gürke L, Rikli D, Lardinois D, Osswald S, Buser A, Caramelli B, Mueller C. Acute heart failure after non-cardiac surgery: incidence, phenotypes, determinants and outcomes. Eur J Heart Fail 2023; 25:347-357. [PMID: 36644890 DOI: 10.1002/ejhf.2773] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2022] [Revised: 11/27/2022] [Accepted: 01/08/2023] [Indexed: 01/17/2023] Open
Abstract
AIMS Primary acute heart failure (AHF) is a common cause of hospitalization. AHF may also develop postoperatively (pAHF). The aim of this study was to assess the incidence, phenotypes, determinants and outcomes of pAHF following non-cardiac surgery. METHODS AND RESULTS A total of 9164 consecutive high-risk patients undergoing 11 262 non-cardiac inpatient surgeries were prospectively included. The incidence, phenotypes, determinants and outcome of pAHF, centrally adjudicated by independent cardiologists, were determined. The incidence of pAHF was 2.5% (95% confidence interval [CI] 2.2-2.8%); 51% of pAHF occurred in patients without known heart failure (de novo pAHF), and 49% in patients with chronic heart failure. Among patients with chronic heart failure, 10% developed pAHF, and among patients without a history of heart failure, 1.5% developed pAHF. Chronic heart failure, diabetes, urgent/emergent surgery, atrial fibrillation, cardiac troponin elevations above the 99th percentile, chronic obstructive pulmonary disease, anaemia, peripheral artery disease, coronary artery disease, and age, were independent predictors of pAHF in the logistic regression model. Patients with pAHF had significantly higher all-cause mortality (44% vs. 11%, p < 0.001) and AHF readmission (15% vs. 2%, p < 0.001) within 1 year than patients without pAHF. After Cox regression analysis, pAHF was an independent predictor of all-cause mortality (adjusted hazard ratio [aHR] 1.7 [95% CI 1.3-2.2]; p < 0.001) and AHF readmission (aHR 2.3 [95% CI 1.5-3.7]; p < 0.001). Findings were confirmed in an external validation cohort using a prospective multicentre cohort of 1250 patients (incidence of pAHF 2.4% [95% CI 1.6-3.3%]). CONCLUSIONS Postoperative AHF frequently developed following non-cardiac surgery, being de novo in half of cases, and associated with a very high mortality.
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Affiliation(s)
- Danielle M Gualandro
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Basel, Switzerland
- Unidade de Medicina Interdisciplinar em Cardiologia, Instituto do Coração, Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Christian Puelacher
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Basel, Switzerland
| | - Michelle S Chew
- Departments of Anaesthesia and Intensive Care, Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Henrik Andersson
- Departments of Anaesthesia and Intensive Care, Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Giovanna Lurati Buse
- Department of Anesthesiology, University Hospital Düsseldorf, Düsseldorf, Germany
| | - Noemi Glarner
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Basel, Switzerland
| | - Daria Mueller
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Basel, Switzerland
| | - Francisco A M Cardozo
- Unidade de Medicina Interdisciplinar em Cardiologia, Instituto do Coração, Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Katrin Burri-Winkler
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Basel, Switzerland
| | - Constantin Mork
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Basel, Switzerland
| | - Desiree Wussler
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Basel, Switzerland
- Department of Internal Medicine, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Samyut Shrestha
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Basel, Switzerland
| | - Isabelle Heidelberger
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Basel, Switzerland
| | - Mikael Fält
- Departments of Anaesthesia and Intensive Care, Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Reka Hidvegi
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Basel, Switzerland
- Department of Anesthesiology, Cantonal Hospital St. Gallen, St. Gallen, Switzerland
| | - Daniel Bolliger
- Department of Anesthesiology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Andreas Lampart
- Department of Anesthesiology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Luzius A Steiner
- Department of Anesthesiology, University Hospital Basel, University of Basel, Basel, Switzerland
- Department of Clinical Research, University of Basel, Basel, Switzerland
| | - Stefan Schären
- Department of Spinal Surgery, University Hospital Basel, Basel, Switzerland
| | - Christoph Kindler
- Department of Anesthesiology, Kantonsspital Aarau, Aarau, Switzerland
| | - Lorenz Gürke
- Department of Vascular Surgery, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Daniel Rikli
- Clinic for Orthopedics and Trauma Surgery, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Didier Lardinois
- Department of Thoracic Surgery, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Stefan Osswald
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Basel, Switzerland
| | - Andreas Buser
- Department of Hematology and Blutspendezentrum, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Bruno Caramelli
- Unidade de Medicina Interdisciplinar em Cardiologia, Instituto do Coração, Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Christian Mueller
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Basel, Switzerland
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11
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Amrein M, Meier S, Schäfer I, Schaedelin S, Willemse E, Benkert P, Walter J, Puelacher C, Zimmermann T, Median D, Egli C, Leppert D, Twerenbold R, Zellweger M, Kuhle J, Mueller C. Serum neurofilament light chain in functionally relevant coronary artery disease and adverse cardiovascular outcomes. Biomarkers 2023; 28:341-351. [PMID: 36714921 DOI: 10.1080/1354750x.2023.2172211] [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: 01/31/2023]
Abstract
Background: Functionally relevant coronary artery disease (fCAD), causing symptoms of myocardial ischemia, can currently only be reliably detected with advanced cardiac imaging. Serum neurofilament light chain (sNfL) is a biomarker for neuro-axonal injury known to be elevated by cardiovascular (CV) risk factors and cerebrovascular small-vessel diseases. Due to their pathophysiological similarities with fCAD and the link to CV risk factors, we hypothesised that sNfL may have diagnostic and prognostic value for fCAD and adverse cardiovascular outcomes.Methods: Of the large prospective Basel VIII study (NCT01838148), 4'016 consecutive patients undergoing cardiac work-up for suspected fCAD were included (median age 68 years, 32.5% women, 46.9% with history of CAD). The presence of fCAD was adjudicated using myocardial perfusion imaging single-photon emission tomography (MPI-SPECT) and coronary angiography. sNfL was measured using a high-sensitive single-molecule array assay. All-cause and cardiovascular death, myocardial infarction (MI), and stroke/transient ischaemic attack (TIA) during 5-year follow-up were the prognostic endpoints.Results: The diagnostic accuracy of sNfL for fCAD as quantified by the area under the curve (AUC) was low (0.58, 95%CI 0.56-0.60). sNfL was strongly associated with age, renal dysfunction, and body mass index and was a strong and independent predictor of all-cause death, cardiovascular death, and stroke/TIA but not MI. Time-dependent AUC for cardiovascular-death at 1-year was 0.85, 95%CI 0.80-0.89, and 0.81, 95%CI 0.77-0.86 at 2-years.Conclusion: While sNfL concentrations did not show a diagnostic role for fCAD, in contrast, sNfL was a strong and independent predictor of cardiovascular outcomes, including all-cause death, cardiovascular death and stroke/TIA.
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Affiliation(s)
- Melissa Amrein
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Stephanie Meier
- Multiple Sclerosis Centre, Neurology, Departments of Head, Spine and Neuromedicine, Biomedicine and Clinical Research, University Hospital Basel and University of Basel, Basel, Switzerland.,Research Center for Clinical Neuroimmunology and Neuroscience (RC2NB), University Hospital and University of Basel, Basel, Switzerland
| | - Ibrahim Schäfer
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Sabine Schaedelin
- Research Center for Clinical Neuroimmunology and Neuroscience (RC2NB), University Hospital and University of Basel, Basel, Switzerland
| | - Eline Willemse
- Multiple Sclerosis Centre, Neurology, Departments of Head, Spine and Neuromedicine, Biomedicine and Clinical Research, University Hospital Basel and University of Basel, Basel, Switzerland.,Research Center for Clinical Neuroimmunology and Neuroscience (RC2NB), University Hospital and University of Basel, Basel, Switzerland
| | - Pascal Benkert
- Clinical Trial Unit, Department of Clinical Research, University Hospital Basel, Basel, Switzerland
| | - Joan Walter
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Christian Puelacher
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Tobias Zimmermann
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Daniela Median
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Caroline Egli
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - David Leppert
- Multiple Sclerosis Centre, Neurology, Departments of Head, Spine and Neuromedicine, Biomedicine and Clinical Research, University Hospital Basel and University of Basel, Basel, Switzerland.,Research Center for Clinical Neuroimmunology and Neuroscience (RC2NB), University Hospital and University of Basel, Basel, Switzerland
| | - Raphael Twerenbold
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland.,University Center of Cardiovascular Science & Department of Cardiology, University Heart and Vascular Center Hamburg, Hamburg, Germany
| | - Michael Zellweger
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Jens Kuhle
- Multiple Sclerosis Centre, Neurology, Departments of Head, Spine and Neuromedicine, Biomedicine and Clinical Research, University Hospital Basel and University of Basel, Basel, Switzerland.,Research Center for Clinical Neuroimmunology and Neuroscience (RC2NB), University Hospital and University of Basel, Basel, Switzerland
| | - Christian Mueller
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
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12
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Shrestha S, Lopez-Ayala P, Schaefer I, Nardiello SS, Papachristou A, Aliyeva F, Simmen C, Wussler D, Belkin M, Gualandro DM, Puelacher C, Michou E, Pfister O, Bingisser R, Nickel CH, Breidthardt T, Mueller C. Efficacy and safety of digoxin in acute heart failure triggered by tachyarrhythmia. J Intern Med 2022; 292:969-972. [PMID: 36065587 PMCID: PMC9826082 DOI: 10.1111/joim.13565] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Affiliation(s)
- Samyut Shrestha
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland.,GREAT Network, Rome, Italy
| | - Pedro Lopez-Ayala
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland.,GREAT Network, Rome, Italy
| | - Ibrahim Schaefer
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Svetlana S Nardiello
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Androniki Papachristou
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Fatima Aliyeva
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Cornelia Simmen
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Desiree Wussler
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland.,GREAT Network, Rome, Italy
| | - Maria Belkin
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland.,GREAT Network, Rome, Italy
| | - Danielle M Gualandro
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland.,GREAT Network, Rome, Italy
| | - Christian Puelacher
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland.,GREAT Network, Rome, Italy
| | - Eleni Michou
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland.,GREAT Network, Rome, Italy
| | - Otmar Pfister
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Roland Bingisser
- GREAT Network, Rome, Italy.,Department of Emergency Medicine, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Christian H Nickel
- GREAT Network, Rome, Italy.,Department of Emergency Medicine, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Tobias Breidthardt
- GREAT Network, Rome, Italy.,Department of Internal Medicine, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Christian Mueller
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland.,GREAT Network, Rome, Italy
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13
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Zimmermann T, Koechlin L, Walter J, Kimenai D, Nestelberger T, Boeddinghaus J, Lopez-Ayala P, Puelacher C, Gualandro D, Strebel I, Diebold M, Twerenbold R, Hammarsten O, Meex S, Mueller C. Differences in circulating cardiac troponin I and T in acute and chronic cardiac disease. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.1341] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
Background
Clinical practice and guidelines assume that cardiac troponin I (cTnI) and cTnT are interchangeable, reflecting identical pathophysiological processes. However, it is unknown if cTnI and cTnT really are equivalent measures in different pathophysiological settings.
Purpose
To highlight potential differences in the release of cTnI and cTnT.
Methods
Large pooled cohort analysis including extensively characterized individuals, stratified into three groups: no cardiac disease (normal aging), chronic cardiac disease, and acute cardiac disease. Circulating cTnI and cTnT concentrations were measured blinded to clinical data using high-sensitivity assays (hs-cTnI-Architect, hs-cTnT-Elecsys) and their ratio calculated. Findings were validated using a second hs-cTnI assay (hs-cTnI-Clarity).
Results
Among 8719 individuals, 29% female, 10% had no known cardiac disease, 71% chronic cardiac disease, and 20% acute cardiac disease. Baseline characteristics including renal function were comparable between individuals with chronic and acute cardiac disease. Normal aging (without cardiac disease) was associated with a disproportional increase in cTnT versus cTnI (low cTnI/cTnT ratio, median 0.50, IQR 0.38–0.68). Although older, patients with chronic cardiac disease had a slightly higher cTnI/cTnT ratio (median 0.53, IQR 0.37–0.79, p<0.05). In contrast, in patients with acute cardiac disease, cTnI concentrations were disproportionally elevated compared to cTnT concentrations, resulting in a cTnI/cTnT ratio of 1.96 (IQR 0.93–4.73, p<0.001). Internal validation using a second hs-cTnI assay confirmed these findings.
Conclusion
These findings suggest relevant differences in the release of cTnI and cTnT with a greater release of cTnT versus cTnI in normal aging and a disproportional increase in cTnI versus cTnT in acute cardiac disease.
Funding Acknowledgement
Type of funding sources: Foundation. Main funding source(s): Swiss National Science Foundation
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Affiliation(s)
| | - L Koechlin
- University Hospital Basel , Basel , Switzerland
| | - J Walter
- University Hospital Basel , Basel , Switzerland
| | - D Kimenai
- University of Edinburgh , Edinburgh , United Kingdom
| | | | | | | | - C Puelacher
- University Hospital Basel , Basel , Switzerland
| | - D Gualandro
- University Hospital Basel , Basel , Switzerland
| | - I Strebel
- University Hospital Basel , Basel , Switzerland
| | - M Diebold
- University Hospital Basel , Basel , Switzerland
| | - R Twerenbold
- University Heart & Vascular Center Hamburg , Hamburg , Germany
| | - O Hammarsten
- Sahlgrenska University Hospital , Gothenburg , Sweden
| | - S Meex
- Cardiovascular Research Institute Maastricht (CARIM) , Maastricht , The Netherlands
| | - C Mueller
- University Hospital Basel , Basel , Switzerland
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14
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Gualandro DM, Puelacher C, Chew MS, Andersson H, Lurati Buse G, Glarner N, Mueller D, Cardozo FAM, Burri K, Mork C, Wussler D, Bolliger D, Osswald S, Caramelli B, Mueller C. Acute heart failure after non-cardiac surgery: incidence, phenotypes, determinants and outcomes. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.2531] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Abstract
Background
Primary acute heart failure (AHF) is an established and common cause of hospitalization. AHF may also develop secondarily, e.g. postoperatively (pAHF). Little is known about pAHF.
Purpose
To assess the incidence, phenotypes, determinants and outcomes of pAHF following non-cardiac surgery.
Methods
We prospectively included 9,164 consecutive patients at high cardiovascular risk undergoing 11,262 non-cardiac surgeries. The incidence, phenotypes, determinants and outcome of pAHF, centrally adjudicated by independent cardiologists, was determined. Logistic regression models identified the risk factors for pAHF. Cox regression analysis compared mortality and AHF readmission within 1 year in patients with and without pAHF. External validation was performed using a prospective cohort multicenter study of 1250 patients.
Results
The incidence of pAHF was 2.5% (95% confidence interval [CI] 2.2–2.8%). pAHF most often occurred on postoperative day 2 (median day 4). About half of pAHF (51%) occurred in patients without known HF (de novo pAHF), and 49% in patients with chronic HF. Preserved left ventricular ejection fraction (LVEF) was the dominant phenotype among de novo pAHF (72%), while reduced LVEF was dominant among pAHF in chronic HF (43%). Age, coronary artery disease, peripheral artery disease, diabetes, urgent/emergent surgery, chronic HF, atrial fibrillation, chronic obstructive pulmonary disease, anemia, and chronic myocardial injury were independent predictors of pAHF. Patients with pAHF had significantly higher all-cause mortality (44% vs. 11%, p<0.001) and AHF readmission (15% vs. 2%, p<0.001) within 1 year than patients without pAHF. pAHF was an independent predictor of all-cause mortality (adjusted hazard ratio [aHR] 1.7 [95% CI 1.3–2.2]; P<0.001) and AHF readmission (aHR 2.7 [95% CI 1.7–4.2]; P<0.001) within 1 year. Findings were confirmed in an external validation cohort of 1250 patients, e.g. incidence of pAHF 2.4% (95% CI, 1.6–3.3%).
Conclusions
pAHF frequent developed following non-cardiac surgery, being de novo in about half of cases, and associated with an unacceptable high mortality. Strategies focusing on early detection and treatment of pAHF seem warranted.
Funding Acknowledgement
Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Swiss National Science FoundationSwiss Heart Foundation
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Affiliation(s)
| | - C Puelacher
- University Hospital Basel , Basel , Switzerland
| | - M S Chew
- Linköping University , Linköping , Sweden
| | | | - G Lurati Buse
- University Hospital Düsseldorf , Düsseldorf , Germany
| | - N Glarner
- University Hospital Basel , Basel , Switzerland
| | - D Mueller
- University Hospital Basel , Basel , Switzerland
| | - F A M Cardozo
- Heart Institute (InCor), University of São Paulo Medical School, Cardiology , São Paulo , Brazil
| | - K Burri
- University Hospital Basel , Basel , Switzerland
| | - C Mork
- University Hospital Basel , Basel , Switzerland
| | - D Wussler
- University Hospital Basel , Basel , Switzerland
| | - D Bolliger
- University Hospital Basel , Basel , Switzerland
| | - S Osswald
- University Hospital Basel , Basel , Switzerland
| | - B Caramelli
- Heart Institute (InCor), University of São Paulo Medical School, Cardiology , São Paulo , Brazil
| | - C Mueller
- University Hospital Basel , Basel , Switzerland
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15
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Puelacher C, Gualandro D, Glarner N, Lurati Buse G, Lampart A, Bolliger D, Steiner L, Gerhard H, Clerc O, Kindler C, Cardozo FA, Caramelli B, Osswald S, Mueller C. Risk stratification of perioperative myocardial infarction/injury following noncardiac surgery in high risk patients. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.2533] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
Perioperative myocardial infarction/injury (PMI) screening is increasingly recommended by current guidelines. PMI is often caused by type 2 myocardial infarction, and risk stratification tools for these patients are lacking.
Purpose
To derive and internally validate a risk prognostication model for PMI of likely type 2 infarction (lT2MI)
Methods
We included consecutive high-risk patients undergoing noncardiac surgery into this prospective multicenter study. Patients received a systematic routine PMI screening with pre- and postoperative measurement of cardiac troponin (cTn). PMI was prospectively defined as an absolute increase of cTn above the preoperative value. PMI etiology was centrally adjudicated and hierarchically classified by 2 independent physicians based on all clinical information obtained during index hospitalization and selected those with lT2MI for further analyses. To identify risk factors and allow risk stratification in lT2MI, we prespecified that only perioperative variables should be included into the model. We constructed a logistic binary regression model for major adverse cardiac events (MACE) within 120 days, including variables available at time of clinical evaluation: additional symptoms or ECG-criteria required according to the Universal Definition of Myocardial Infarction, absolute increase in cTn (categorized according to level of absolute increase 1–<2 times the 99th percentile, ≥2 to <4 times, and ≥4 times), urgency of procedure, perioperative bleeding (drop in haemoglobin >30g/L or deemed relevant for PMI by adjudicator), and ESC/ESA surgery risk (low, medium, high risk of cardiac events). Variables were omitted from the final model if the p-value was >0.05. Variable levels with similar odds ratios were grouped for simplification of the prognostic model. We constructed a calibration plot and calculated the area under the receiver-operating characteristics curve (AUC) and Brier Score. For internal validation we calculated the predicted probabilities and classified patients into low-risk (predicted event rate <10%), intermediate range (10–20%), and high-risk (>20%), and compared the predicted with the observed event rate.
Results
PMI occurred in 1016/7754 patients (13.1%) of which 750/1016 (73.8%) were adjudicated as lT2MI. MACE within 120 days occurred in 118/750 (15.7%) patients. The initial and final logistic prognostic model for 120-day MACE or death is shown in the table. Internal validation found a good fit of predicted and observed event rate following bootstrapping of 1000 iterations (Figure 1), a good AUC of 0.71 and a Brier score of 0.12.
Conclusion
The derived risk prognostication model for PMI of lT2MI can aid in the stratification of patients and support clinical decision making following noncardiac surgery.
Funding Acknowledgement
Type of funding sources: Foundation. Main funding source(s): Swiss National Science FoundationSwiss Heart Foundation
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Affiliation(s)
- C Puelacher
- University Hospital Basel, Cardiology , Basel , Switzerland
| | - D Gualandro
- University Hospital Basel, Cardiology , Basel , Switzerland
| | - N Glarner
- University Hospital Basel, Cardiology , Basel , Switzerland
| | - G Lurati Buse
- University Hospital Dusseldorf, Anaesthesiology , Dusseldorf , Germany
| | - A Lampart
- University Hospital Basel, Department of Anaesthesiology , Basel , Switzerland
| | - D Bolliger
- University Hospital Basel, Department of Anaesthesiology , Basel , Switzerland
| | - L Steiner
- University Hospital Basel, Department of Anaesthesiology , Basel , Switzerland
| | - H Gerhard
- University Hospital Basel, Cardiology , Basel , Switzerland
| | - O Clerc
- University Hospital Basel, Cardiology , Basel , Switzerland
| | - C Kindler
- Cantonal Hospital Aarau, Department of Anaesthesiology , Aarau , Switzerland
| | - F A Cardozo
- Heart Institute of the University of Sao Paulo (InCor) , Sao Paulo , Brazil
| | - B Caramelli
- Heart Institute of the University of Sao Paulo (InCor) , Sao Paulo , Brazil
| | - S Osswald
- University Hospital Basel, Cardiology , Basel , Switzerland
| | - C Mueller
- University Hospital Basel, Cardiology , Basel , Switzerland
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16
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Papachristou A, Puelacher C, Glarner N, Strebel I, Steiger J, Diebold M, Lurati Buse G, Bolliger D, Steiner LA, Gurke L, Wolff T, Mujagic E, Gualandro DM, Mueller C, Breidthardt T. Renal failure: a non-cardiac source of high sensitivity cardiac troponin T. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.2611] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Background
Circulating high sensitivity cardiac troponin T (hs-cTnT) levels are frequently elevated in patients with end-stage renal disease (ESRD). The underlying pathophysiology is largely unknown. Currently, accumulation of hs-cTnT due to impaired renal clearance, as well as increased production caused by chronic cardiomyocyte injury is being discussed.
Purpose
The aim of this study was to assess the relative contribution of impaired renal clearance as a non-cardiac source of elevated hs-cTnT concentrations, using renal transplantation as an in vivo model of rapidly improved renal function and on a short-term basis rather unchanged cardiac pathology.
Methods
This single-centre study was a secondary analysis within a prospective active surveillance study program for perioperative myocardial infarction/injury (PMI). 42 consecutive high-risk patients undergoing renal transplantation without evidence of PMI were included. Serial creatinine and hs-cTnT (Elecsys, Roche) measurements were performed pre-transplant (baseline) and post-transplant on day (d) 1, between d2 and d5, and between d14 and d180. The effect of time and creatinine on hs-cTnT was estimated with a log-level non-linear mixed-effects model, where time and creatinine were treated as the fixed effects and subject as the random effect. Natural cubic splines were used to account for nonlinearity in the fixed effects.
Results
Baseline median serum creatinine concentration was 616 umol/L [interquartile range (IQR) 477–825], and significantly fell to 425 umol/L (IQR 313–619) on d1, 285 umol/L (IQR 194–509) on day2–5, and 116 umol/L (IQR 100–166) on d14–180 (p<0.001, p<0.001, and p=0.043, respectively; Figure 1A).
Pre-transplant hs-cTnT concentrations were above the 99th percentile (14ng/L) in all patients, median hs-cTnT concentration was 50 ng/L (IQR 35–70). In parallel to the fall in serum creatinine from baseline to d1, hs-cTnT concentrations significantly fell to 28 ng/L (IQR 15–40) on d1 (p<0.001), and then remained constant on d2–5 (27 ng/L (IQR 18–35)), and on d14–180 (24 ng/L (IQR 19–28); Figure 1B).
The mixed-effect model showed a significant decrease of hs-cTnT between baseline and d1 (p<0.001), whereas no significant change between d1 and d2 (p=0.82) occurred (Figure 2).
Conclusion
In contrast to the continuously falling serum creatinine levels, hs-cTnT concentrations reduced by about 50% only within the first 24 hours with a functional graft and then remained elevated above the 99th percentile. This suggests, that ESRD is a non-cardiac source of elevated circulating hs-cTnT concentrations, which contributes about 50%, while the other 50% seem related to chronic cardiomyocyte injury. Further studies assessing the long-term effect of renal transplantation on hs-cTnT levels and cardiac function are needed.
Funding Acknowledgement
Type of funding sources: Public Institution(s). Main funding source(s): Swiss National Science FoundationSwiss Heart Foundation
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Affiliation(s)
- A Papachristou
- University Hospital Basel, Cradiovascular Research Institute Basel and Department of Cardiology, Division of Internal Medicine , Basel , Switzerland
| | - C Puelacher
- University Hospital Basel, Cardiovascular Reasearch Institute Basel and Department of Cardiology , Basel , Switzerland
| | - N Glarner
- University Hospital Basel, Cardiovascular Reasearch Institute Basel and Department of Cardiology , Basel , Switzerland
| | - I Strebel
- University Hospital Basel, Cardiovascular Reasearch Institute Basel and Department of Cardiology , Basel , Switzerland
| | - J Steiger
- University Hospital Basel, Clinic for Transplantation Immunology and Nephrology , Basel , Switzerland
| | - M Diebold
- University Hospital Basel, Clinic for Transplantation Immunology and Nephrology , Basel , Switzerland
| | - G Lurati Buse
- University Hospital Duesseldorf, Department of Anaesthesiology , Duesseldorf , Germany
| | - D Bolliger
- University Hospital Basel, Clinic for Anaesthesia, Intermediate Care, Prehospital Emergency Medicine, and Pain Therapy , Basel , Switzerland
| | - L A Steiner
- University Hospital Basel, Clinic for Anaesthesia, Intermediate Care, Prehospital Emergency Medicine, and Pain Therapy , Basel , Switzerland
| | - L Gurke
- University Hospital Basel, Department of Vascular Surgery and Renal Transplantation , Basel , Switzerland
| | - T Wolff
- University Hospital Basel, Department of Vascular Surgery and Renal Transplantation , Basel , Switzerland
| | - E Mujagic
- University Hospital Basel, Department of Vascular Surgery and Renal Transplantation , Basel , Switzerland
| | - D M Gualandro
- University Hospital Basel, Cardiovascular Reasearch Institute Basel and Department of Cardiology , Basel , Switzerland
| | - C Mueller
- University Hospital Basel, Cardiovascular Reasearch Institute Basel and Department of Cardiology , Basel , Switzerland
| | - T Breidthardt
- University Hospital Basel, Cradiovascular Research Institute Basel and Department of Cardiology, Division of Internal Medicine , Basel , Switzerland
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17
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Schaefer I, Lopez-Ayala P, Walter J, Rumora K, Amrein M, Zimmermann T, Boeddinghaus J, Koechlin L, Strebel I, Nestelberger T, Wussler D, Puelacher C, Kaiser C, Zellweger M, Mueller C. Using high-sensitivity cardiac troponin for the exclusion of inducible myocardial ischemia in patients without previously known coronary artery disease. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.1191] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Background
The rapid and safe exclusion of functionally relevant coronary artery disease (CAD) is a crucial, yet unmet clinical need. High-sensitivity cardiac troponin (hs-cTn) may be an attractive strategy, particularly in patients without previously known CAD.
Purpose
To derive and internally validate optimal rule-out cutoffs for an early and safe exclusion of functionally relevant CAD in symptomatic patients without previously known CAD.
Methods
In an ongoing single-center, prospective, cohort study, we enrolled consecutive patients without previously known CAD that were referred with symptoms possibly related to functionally relevant CAD. Cardiac troponin concentrations were measured at presentation using two high-sensitivity assays (Elecsys hs-cTnT and Architect hs-cTnI). Presence of functionally relevant CAD was adjudicated by 2 independent cardiologists, blinded to hs-cTn measurements, using MPI-SPECT/CT in all patients, as well as coronary angiography and fractional flow reserve measurements, whenever available. The primary diagnostic outcome was safety for early rule-out of functionally relevant CAD, quantified by sensitivity and the negative predictive value (NPV). The co-primary prognostic outcomes were cumulative incidences of cardiovascular death and all-cause death after 5 years. A NPV ≥90% and sensitivity ≥90% were predefined as acceptable performance criteria. The derived cutoffs were further evaluated in pre-specified subgroups. Internal validity was assessed with a bootstrapping procedure for a realistic estimate in similar future patients. Cumulative incidence curves stratified by the presence of functionally relevant CAD and hs-cTn concentrations below and above the derived cutoffs were constructed.
Results
Among 2111 eligible patients, 498 (23.6%) had a final diagnosis of functionally relevant CAD. Median age was 68 years and 938 (44.4%) were female. For ruling out functionally relevant CAD, a hs-cTnT concentration <5 ng/L resulted in a sensitivity of 90.8% (95% CI: 87.9–93.0%) and a NPV of 90.2% (95% CI: 87.1–92.5), triaging 468 (22.2%) patients towards rule-out. Similarly, a hs-cTnI concentration <2 ng/L resulted in a sensitivity of 91.6% (95% CI: 88.8–93.7%) and a NPV of 90.0% (95% CI: 86.8–92.6), triaging 422 (20.0%) patients. Internal validation showed robustness of these findings. The diagnostic performance of the derived cutoffs did not significantly vary across the subgroups. Hs-cTn concentrations above the derived cutoffs were associated with a substantially higher cumulative event rate of cardiovascular death (hs-cTnT: 7.0% vs. 0.8%; hs-cTnI: 6.6% vs. 1.2%) and all-cause death (hs-cTnT: 14.3% vs. 2.4%; hs-cTnI: 13.1% vs. 4.4%) during 5-years follow-up (log rank p<0.001 for all).
Conclusion
In symptomatic patients without previously known CAD, very low hs-cTn concentrations may generally allow to safely and effectively exclude functionally relevant CAD.
Funding Acknowledgement
Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Swiss National Science FoundationSwiss Heart Foundation
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Affiliation(s)
- I Schaefer
- University Hospital Basel, Cardiovascular Research Institute Basel , Basel , Switzerland
| | - P Lopez-Ayala
- University Hospital Basel, Cardiovascular Research Institute Basel , Basel , Switzerland
| | - J Walter
- University Hospital Basel, Cardiovascular Research Institute Basel , Basel , Switzerland
| | - K Rumora
- University Hospital Basel, Cardiovascular Research Institute Basel , Basel , Switzerland
| | - M Amrein
- University Hospital Basel, Cardiovascular Research Institute Basel , Basel , Switzerland
| | - T Zimmermann
- University Hospital Basel, Cardiovascular Research Institute Basel , Basel , Switzerland
| | - J Boeddinghaus
- University Hospital Basel, Cardiovascular Research Institute Basel , Basel , Switzerland
| | - L Koechlin
- University Hospital Basel, Cardiovascular Research Institute Basel , Basel , Switzerland
| | - I Strebel
- University Hospital Basel, Cardiovascular Research Institute Basel , Basel , Switzerland
| | - T Nestelberger
- University Hospital Basel, Cardiovascular Research Institute Basel , Basel , Switzerland
| | - D Wussler
- University Hospital Basel, Cardiovascular Research Institute Basel , Basel , Switzerland
| | - C Puelacher
- University Hospital Basel, Cardiovascular Research Institute Basel , Basel , Switzerland
| | - C Kaiser
- University Hospital Basel, Cardiovascular Research Institute Basel , Basel , Switzerland
| | - M Zellweger
- University Hospital Basel, Cardiovascular Research Institute Basel , Basel , Switzerland
| | - C Mueller
- University Hospital Basel, Cardiovascular Research Institute Basel , Basel , Switzerland
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18
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Puelacher C, Gualandro D, Glarner N, Lurati Buse G, Lampart A, Bolliger D, Grossenbacher M, Steiner L, Burri K, Biner L, Caramelli B, Cardozo FA, Osswald S, Mueller C. Long term outcomes in different aetiologies of perioperative myocardial infarction/injury after noncardiac surgery. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.2532] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Background
Perioperative myocardial infarction/injury (PMI) occurring in the first 48h following noncardiac surgery is a frequent cardiac complication. Better understanding of the underlying aetiologies is urgently needed.
Aim
To explore the association of different aetiologies of PMI with long term outcomes.
Methods
In this prospective multicenter observational study, PMI aetiology was centrally adjudicated and hierarchically classified by two independent physicians based on all information obtained during clinically-indicated PMI work-up including cardiac imaging among consecutive high-risk patients undergoing major noncardiac surgery. PMI aetiology was classified into “extracardiac” if caused by a primarily extracardiac disease such as severe sepsis or pulmonary embolism; and “cardiac”, further subtyped into type 1 myocardial infarction (T1MI), tachyarrhythmia, acute heart failure (AHF), or likely type 2 myocardial infarction (lT2MI). Major adverse cardiac events (MACE) including T1MI, AHF (both only from day 3 to avoid inclusion bias), life-threatening arrhythmia, and cardiovascular death as well as all-cause death were assessed during 365-days follow-up.
Results
PMI occurred in 1016/7754 patients (13.1%). At least one MACE occurred in 684/7754 patients (8.8%) and 818/7754 patients died (10.5%) within 365 days. MACE and all-cause death occurred in 51% (95% CI 31–60) and 38% (95% CI 29–47), 41% (95% CI 28–51) and 27% (95% CI 16–34), 57% (95% CI 41–69) and 40% (95% CI 25–53), 64% (95% CI 45–76) and 49% (95% CI 30–62), as well as 25% (95% CI 22–28%) and 17% (95% CI 14–20) of patients with extracardiac PMI, T1MI, tachyarrhythmia, AHF, and lT2MI, respectively. These associations were confirmed in multivariable analysis.
Conclusion
At 365 days, most PMI aetiologies have unacceptably high rates of MACE and all-cause death, highlighting the urgent need for more intensive treatments.
Funding Acknowledgement
Type of funding sources: Other. Main funding source(s): Swiss National Science FoundationRoche Diagnostics
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Affiliation(s)
- C Puelacher
- University Hospital Basel, Cardiology , Basel , Switzerland
| | - D Gualandro
- University Hospital Basel, Cardiology , Basel , Switzerland
| | - N Glarner
- University Hospital Basel, Cardiology , Basel , Switzerland
| | - G Lurati Buse
- University Hospital Dusseldorf, Anaesthesiology , Dusseldorf , Germany
| | - A Lampart
- University Hospital Basel, Department of Anaesthesiology , Basel , Switzerland
| | - D Bolliger
- University Hospital Basel, Department of Anaesthesiology , Basel , Switzerland
| | | | - L Steiner
- University Hospital Basel, Department of Anaesthesiology , Basel , Switzerland
| | - K Burri
- University Hospital Basel, Cardiology , Basel , Switzerland
| | - L Biner
- University Hospital Basel, Cardiology , Basel , Switzerland
| | - B Caramelli
- Heart Institute of the University of Sao Paulo (InCor) , Sao Paulo , Brazil
| | - F A Cardozo
- Heart Institute of the University of Sao Paulo (InCor) , Sao Paulo , Brazil
| | - S Osswald
- University Hospital Basel, Cardiology , Basel , Switzerland
| | - C Mueller
- University Hospital Basel, Cardiology , Basel , Switzerland
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19
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du Fay de Lavallaz J, Prepoudis A, Wendebourg MJ, Kesenheimer E, Kyburz D, Daikeler T, Haaf P, Wanschitz J, Löscher WN, Schreiner B, Katan M, Jung HH, Maurer B, Hammerer-Lercher A, Mayr A, Gualandro DM, Acket A, Puelacher C, Boeddinghaus J, Nestelberger T, Lopez-Ayala P, Glarner N, Shrestha S, Manka R, Gawinecka J, Piscuoglio S, Gallon J, Wiedemann S, Sinnreich M, Mueller C. Skeletal Muscle Disorders: A Noncardiac Source of Cardiac Troponin T. Circulation 2022; 145:1764-1779. [PMID: 35389756 PMCID: PMC10069758 DOI: 10.1161/circulationaha.121.058489] [Citation(s) in RCA: 31] [Impact Index Per Article: 15.5] [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] [Indexed: 01/24/2023]
Abstract
BACKGROUND Cardiac troponin (cTn) T and cTnI are considered cardiac specific and equivalent in the diagnosis of acute myocardial infarction. Previous studies suggested rare skeletal myopathies as a noncardiac source of cTnT. We aimed to confirm the reliability/cardiac specificity of cTnT in patients with various skeletal muscle disorders (SMDs). METHODS We prospectively enrolled patients presenting with muscular complaints (≥2 weeks) for elective evaluation in 4 hospitals in 2 countries. After a cardiac workup, patients were adjudicated into 3 predefined cardiac disease categories. Concentrations of cTnT/I and resulting cTnT/I mismatches were assessed with high-sensitivity (hs-) cTnT (hs-cTnT-Elecsys) and 3 hs-cTnI assays (hs-cTnI-Architect, hs-cTnI-Access, hs-cTnI-Vista) and compared with those of control subjects without SMD presenting with adjudicated noncardiac chest pain to the emergency department (n=3508; mean age, 55 years; 37% female). In patients with available skeletal muscle biopsies, TNNT/I1-3 mRNA differential gene expression was compared with biopsies obtained in control subjects without SMD. RESULTS Among 211 patients (mean age, 57 years; 42% female), 108 (51%) were adjudicated to having no cardiac disease, 44 (21%) to having mild disease, and 59 (28%) to having severe cardiac disease. hs-cTnT/I concentrations significantly increased from patients with no to those with mild and severe cardiac disease for all assays (all P<0.001). hs-cTnT-Elecsys concentrations were significantly higher in patients with SMD versus control subjects (median, 16 ng/L [interquartile range (IQR), 7-32.5 ng/L] versus 5 ng/L [IQR, 3-9 ng/L]; P<0.001), whereas hs-cTnI concentrations were mostly similar (hs-cTnI-Architect, 2.5 ng/L [IQR, 1.2-6.2 ng/L] versus 2.9 ng/L [IQR, 1.8-5.0 ng/L]; hs-cTnI-Access, 3.3 ng/L [IQR, 2.4-6.1 ng/L] versus 2.7 ng/L [IQR, 1.6-5.0 ng/L]; and hs-cTnI-Vista, 7.4 ng/L [IQR, 5.2-13.4 ng/L] versus 7.5 ng/L [IQR, 6-10 ng/L]). hs-cTnT-Elecsys concentrations were above the upper limit of normal in 55% of patients with SMD versus 13% of control subjects (P<0.01). mRNA analyses in skeletal muscle biopsies (n=33), mostly (n=24) from individuals with noninflammatory myopathy and myositis, showed 8-fold upregulation of TNNT2, encoding cTnT (but none for TNNI3, encoding cTnI) versus control subjects (n=16, PWald<0.001); the expression correlated with pathological disease activity (R=0.59, Pt-statistic<0.001) and circulating hs-cTnT concentrations (R=0.26, Pt-statistic=0.031). CONCLUSIONS In patients with active chronic SMD, elevations in cTnT concentrations are common and not attributable to cardiac disease in the majority. This was not observed for cTnI and may be explained in part by re-expression of cTnT in skeletal muscle. REGISTRATION URL: https://www. CLINICALTRIALS gov; Unique identifier: NCT03660969.
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Affiliation(s)
- Jeanne du Fay de Lavallaz
- Cardiovascular Research Institute Basel (J.d.F.d.L., A.P., P.H., D.M.G., A.A., C.P., J.B., T.N., P.L.-A., N.G., S.S., S.P., J. Gallon, S.W., C.M.), University Hospital of Basel, Switzerland.,Department of Cardiology (J.d.F.d.L., A.P., P.H., D.M.G., A.A., C.P., J.B., T.N., P.L.-A., N.G., S.S., S.P., J. Gallon, S.W., C.M.), University Hospital of Basel, Switzerland
| | - Alexandra Prepoudis
- Cardiovascular Research Institute Basel (J.d.F.d.L., A.P., P.H., D.M.G., A.A., C.P., J.B., T.N., P.L.-A., N.G., S.S., S.P., J. Gallon, S.W., C.M.), University Hospital of Basel, Switzerland.,Department of Cardiology (J.d.F.d.L., A.P., P.H., D.M.G., A.A., C.P., J.B., T.N., P.L.-A., N.G., S.S., S.P., J. Gallon, S.W., C.M.), University Hospital of Basel, Switzerland
| | - Maria Janina Wendebourg
- Neurology Clinic and Policlinic (M.J.W., E.K., M.S.), University Hospital of Basel, Switzerland
| | - Eva Kesenheimer
- Neurology Clinic and Policlinic (M.J.W., E.K., M.S.), University Hospital of Basel, Switzerland
| | - Diego Kyburz
- Department of Rheumatology (D.K., T.D.), University Hospital of Basel, Switzerland.,University of Basel, Switzerland (D.K., M.S., C.M.)
| | - Thomas Daikeler
- Department of Rheumatology (D.K., T.D.), University Hospital of Basel, Switzerland
| | - Philip Haaf
- Cardiovascular Research Institute Basel (J.d.F.d.L., A.P., P.H., D.M.G., A.A., C.P., J.B., T.N., P.L.-A., N.G., S.S., S.P., J. Gallon, S.W., C.M.), University Hospital of Basel, Switzerland
| | - Julia Wanschitz
- Departments of Neurology (J.W., W.N.L.), Medical University of Innsbruck, Austria
| | - Wolfgang N Löscher
- Departments of Neurology (J.W., W.N.L.), Medical University of Innsbruck, Austria
| | - Bettina Schreiner
- Departments of Neurology (B.S., M.K., H.H.J.), University Hospital of Zürich, Switzerland
| | - Mira Katan
- Departments of Neurology (B.S., M.K., H.H.J.), University Hospital of Zürich, Switzerland
| | - Hans H Jung
- Departments of Neurology (B.S., M.K., H.H.J.), University Hospital of Zürich, Switzerland
| | - Britta Maurer
- Rheumatology (B.M.), University Hospital of Zürich, Switzerland.,Department of Rheumatology and Immunology, Inselspital Bern, Switzerland (B.M.)
| | | | - Agnes Mayr
- Radiology (A.M.), Medical University of Innsbruck, Austria
| | - Danielle M Gualandro
- Cardiovascular Research Institute Basel (J.d.F.d.L., A.P., P.H., D.M.G., A.A., C.P., J.B., T.N., P.L.-A., N.G., S.S., S.P., J. Gallon, S.W., C.M.), University Hospital of Basel, Switzerland.,Department of Cardiology (J.d.F.d.L., A.P., P.H., D.M.G., A.A., C.P., J.B., T.N., P.L.-A., N.G., S.S., S.P., J. Gallon, S.W., C.M.), University Hospital of Basel, Switzerland
| | - Annemarie Acket
- Cardiovascular Research Institute Basel (J.d.F.d.L., A.P., P.H., D.M.G., A.A., C.P., J.B., T.N., P.L.-A., N.G., S.S., S.P., J. Gallon, S.W., C.M.), University Hospital of Basel, Switzerland.,Neurology Clinic and Policlinic (M.J.W., E.K., M.S.), University Hospital of Basel, Switzerland
| | - Christian Puelacher
- Cardiovascular Research Institute Basel (J.d.F.d.L., A.P., P.H., D.M.G., A.A., C.P., J.B., T.N., P.L.-A., N.G., S.S., S.P., J. Gallon, S.W., C.M.), University Hospital of Basel, Switzerland.,Department of Cardiology (J.d.F.d.L., A.P., P.H., D.M.G., A.A., C.P., J.B., T.N., P.L.-A., N.G., S.S., S.P., J. Gallon, S.W., C.M.), University Hospital of Basel, Switzerland
| | - Jasper Boeddinghaus
- Cardiovascular Research Institute Basel (J.d.F.d.L., A.P., P.H., D.M.G., A.A., C.P., J.B., T.N., P.L.-A., N.G., S.S., S.P., J. Gallon, S.W., C.M.), University Hospital of Basel, Switzerland.,Department of Cardiology (J.d.F.d.L., A.P., P.H., D.M.G., A.A., C.P., J.B., T.N., P.L.-A., N.G., S.S., S.P., J. Gallon, S.W., C.M.), University Hospital of Basel, Switzerland
| | - Thomas Nestelberger
- Cardiovascular Research Institute Basel (J.d.F.d.L., A.P., P.H., D.M.G., A.A., C.P., J.B., T.N., P.L.-A., N.G., S.S., S.P., J. Gallon, S.W., C.M.), University Hospital of Basel, Switzerland.,Department of Cardiology (J.d.F.d.L., A.P., P.H., D.M.G., A.A., C.P., J.B., T.N., P.L.-A., N.G., S.S., S.P., J. Gallon, S.W., C.M.), University Hospital of Basel, Switzerland.,Division of Cardiology, Vancouver General Hospital, University of British Columbia, Canada (T.N.)
| | - Pedro Lopez-Ayala
- Cardiovascular Research Institute Basel (J.d.F.d.L., A.P., P.H., D.M.G., A.A., C.P., J.B., T.N., P.L.-A., N.G., S.S., S.P., J. Gallon, S.W., C.M.), University Hospital of Basel, Switzerland.,Department of Cardiology (J.d.F.d.L., A.P., P.H., D.M.G., A.A., C.P., J.B., T.N., P.L.-A., N.G., S.S., S.P., J. Gallon, S.W., C.M.), University Hospital of Basel, Switzerland
| | - Noemi Glarner
- Cardiovascular Research Institute Basel (J.d.F.d.L., A.P., P.H., D.M.G., A.A., C.P., J.B., T.N., P.L.-A., N.G., S.S., S.P., J. Gallon, S.W., C.M.), University Hospital of Basel, Switzerland.,Department of Cardiology (J.d.F.d.L., A.P., P.H., D.M.G., A.A., C.P., J.B., T.N., P.L.-A., N.G., S.S., S.P., J. Gallon, S.W., C.M.), University Hospital of Basel, Switzerland
| | - Samyut Shrestha
- Cardiovascular Research Institute Basel (J.d.F.d.L., A.P., P.H., D.M.G., A.A., C.P., J.B., T.N., P.L.-A., N.G., S.S., S.P., J. Gallon, S.W., C.M.), University Hospital of Basel, Switzerland.,Department of Cardiology (J.d.F.d.L., A.P., P.H., D.M.G., A.A., C.P., J.B., T.N., P.L.-A., N.G., S.S., S.P., J. Gallon, S.W., C.M.), University Hospital of Basel, Switzerland
| | - Robert Manka
- Cardiology (R.M.), University Hospital of Zürich, Switzerland
| | - Joanna Gawinecka
- Institute of Clinical Chemistry (J. Gawinecka), University Hospital of Zürich, Switzerland
| | - Salvatore Piscuoglio
- Cardiovascular Research Institute Basel (J.d.F.d.L., A.P., P.H., D.M.G., A.A., C.P., J.B., T.N., P.L.-A., N.G., S.S., S.P., J. Gallon, S.W., C.M.), University Hospital of Basel, Switzerland.,Department of Cardiology (J.d.F.d.L., A.P., P.H., D.M.G., A.A., C.P., J.B., T.N., P.L.-A., N.G., S.S., S.P., J. Gallon, S.W., C.M.), University Hospital of Basel, Switzerland.,Department of Biomedicine (S.P., J. Gallon, S.W.), University Hospital of Basel, Switzerland
| | - John Gallon
- Cardiovascular Research Institute Basel (J.d.F.d.L., A.P., P.H., D.M.G., A.A., C.P., J.B., T.N., P.L.-A., N.G., S.S., S.P., J. Gallon, S.W., C.M.), University Hospital of Basel, Switzerland.,Department of Cardiology (J.d.F.d.L., A.P., P.H., D.M.G., A.A., C.P., J.B., T.N., P.L.-A., N.G., S.S., S.P., J. Gallon, S.W., C.M.), University Hospital of Basel, Switzerland.,Department of Biomedicine (S.P., J. Gallon, S.W.), University Hospital of Basel, Switzerland
| | - Sophia Wiedemann
- Cardiovascular Research Institute Basel (J.d.F.d.L., A.P., P.H., D.M.G., A.A., C.P., J.B., T.N., P.L.-A., N.G., S.S., S.P., J. Gallon, S.W., C.M.), University Hospital of Basel, Switzerland.,Department of Cardiology (J.d.F.d.L., A.P., P.H., D.M.G., A.A., C.P., J.B., T.N., P.L.-A., N.G., S.S., S.P., J. Gallon, S.W., C.M.), University Hospital of Basel, Switzerland.,Department of Biomedicine (S.P., J. Gallon, S.W.), University Hospital of Basel, Switzerland
| | - Michael Sinnreich
- Neurology Clinic and Policlinic (M.J.W., E.K., M.S.), University Hospital of Basel, Switzerland.,University of Basel, Switzerland (D.K., M.S., C.M.)
| | - Christian Mueller
- Cardiovascular Research Institute Basel (J.d.F.d.L., A.P., P.H., D.M.G., A.A., C.P., J.B., T.N., P.L.-A., N.G., S.S., S.P., J. Gallon, S.W., C.M.), University Hospital of Basel, Switzerland.,Department of Cardiology (J.d.F.d.L., A.P., P.H., D.M.G., A.A., C.P., J.B., T.N., P.L.-A., N.G., S.S., S.P., J. Gallon, S.W., C.M.), University Hospital of Basel, Switzerland.,University of Basel, Switzerland (D.K., M.S., C.M.)
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20
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Kvarda P, Puelacher C, Clauss M, Kuehl R, Gerhard H, Mueller C, Morgenstern M. Perioperative myocardial injury and mortality after revision surgery for orthopaedic device-related infection. Bone Joint J 2022; 104-B:696-702. [PMID: 35638215 DOI: 10.1302/0301-620x.104b6.bjj-2021-1486.r1] [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] [Indexed: 11/05/2022]
Abstract
AIMS Periprosthetic joint infections (PJIs) and fracture-related infections (FRIs) are associated with a significant risk of adverse events. However, there is a paucity of data on cardiac complications following revision surgery for PJI and FRI and how they impact overall mortality. Therefore, this study aimed to investigate the risk of perioperative myocardial injury (PMI) and mortality in this patient cohort. METHODS We prospectively included consecutive patients at high cardiovascular risk (defined as age ≥ 45 years with pre-existing coronary, peripheral, or cerebrovascular artery disease, or any patient aged ≥ 65 years, plus a postoperative hospital stay of > 24 hours) undergoing septic or aseptic major orthopaedic surgery between July 2014 and October 2016. All patients received a systematic screening to reliably detect PMI, using serial measurements of high-sensitivity cardiac troponin T. All-cause mortality was assessed at one year. Multivariable logistic regression models were applied to compare incidence of PMI and mortality between patients undergoing septic revision surgery for PJI or FRI, and patients receiving aseptic major bone and joint surgery. RESULTS In total, 911 consecutive patients were included. The overall perioperative myocardial injury (PMI) rate was 15.4% (n = 140). Septic revision surgery for PJI was associated with a significantly higher PMI rate (43.8% (14/32) vs 14.5% (57/393); p = 0.001) and one-year mortality rate (18.6% (6/32) vs 7.4% (29/393); p = 0.038) compared to aseptic revision or primary arthroplasty. The association with PMI persisted in multivariable analysis with an adjusted odds ratio (aOR) of 4.7 (95% confidence interval (CI) 2.1 to 10.7; p < 0.001), but was not statistically significant for one-year mortality (aOR 1.9 (95% CI 0.7 to 5.4; p = 0.240). PMI rate (15.2% (5/33) vs 14.1% (64/453)) and one-year mortality (15.2% (5/33) vs 9.1% (41/453)) after FRI revision surgery were comparable to aseptic long-bone fracture surgery. CONCLUSION Patients undergoing revision surgery for PJI were at a risk of PMI and death compared to those undergoing aseptic arthroplasty surgery. Screening for PMI and treatment in specialized multidisciplinary units should be considered in major bone and joint infections. Cite this article: Bone Joint J 2022;104-B(6):696-702.
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Affiliation(s)
- Peter Kvarda
- Center for Musculoskeletal Infections, University Hospital Basel, Basel, Switzerland.,Department of Orthopaedic and Trauma Surgery, University Hospital Basel, Basel, Switzerland.,University of Basel, Basel, Switzerland
| | - Christian Puelacher
- University of Basel, Basel, Switzerland.,Cardiovascular Research Institute Basel and Department of Cardiology, University Hospital Basel, Basel, Switzerland
| | - Martin Clauss
- Center for Musculoskeletal Infections, University Hospital Basel, Basel, Switzerland.,Department of Orthopaedic and Trauma Surgery, University Hospital Basel, Basel, Switzerland.,University of Basel, Basel, Switzerland
| | - Richard Kuehl
- University of Basel, Basel, Switzerland.,Department of Infectious Diseases and Hospital Epidemiology, University Hospital Basel, Basel, Switzerland
| | - Hatice Gerhard
- University of Basel, Basel, Switzerland.,Cardiovascular Research Institute Basel and Department of Cardiology, University Hospital Basel, Basel, Switzerland
| | - Christian Mueller
- University of Basel, Basel, Switzerland.,Cardiovascular Research Institute Basel and Department of Cardiology, University Hospital Basel, Basel, Switzerland
| | - Mario Morgenstern
- Center for Musculoskeletal Infections, University Hospital Basel, Basel, Switzerland.,Department of Orthopaedic and Trauma Surgery, University Hospital Basel, Basel, Switzerland.,University of Basel, Basel, Switzerland
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21
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Zimmermann T, du Fay de Lavallaz J, Nestelberger T, Gualandro DM, Lopez-Ayala P, Badertscher P, Widmer V, Shrestha S, Strebel I, Glarner N, Diebold M, Miró Ò, Christ M, Cullen L, Than M, Martin-Sanchez FJ, Di Somma S, Peacock WF, Keller DI, Bilici M, Costabel JP, Kühne M, Breidthardt T, Thiruganasambandamoorthy V, Mueller C, Belkin M, Leu K, Lohrmann J, Boeddinghaus J, Twerenbold R, Koechlin L, Walter JE, Amrein M, Wussler D, Freese M, Puelacher C, Kawecki D, Morawiec B, Salgado E, Martinez-Nadal G, Inostroza CIF, Mandrión JB, Poepping I, Rentsch K, von Eckardstein A, Buser A, Greenslade J, Reichlin T, Bürgler F. International Validation of the Canadian Syncope Risk Score : A Cohort Study. Ann Intern Med 2022; 175:783-794. [PMID: 35467933 DOI: 10.7326/m21-2313] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND The Canadian Syncope Risk Score (CSRS) was developed to predict 30-day serious outcomes not evident during emergency department (ED) evaluation. OBJECTIVE To externally validate the CSRS and compare it with another validated score, the Osservatorio Epidemiologico della Sincope nel Lazio (OESIL) score. DESIGN Prospective cohort study. SETTING Large, international, multicenter study recruiting patients in EDs in 8 countries on 3 continents. PARTICIPANTS Patients with syncope aged 40 years or older presenting to the ED within 12 hours of syncope. MEASUREMENTS Composite outcome of serious clinical plus procedural events (primary outcome) and the primary composite outcome excluding procedural interventions (secondary outcome). RESULTS Among 2283 patients with a mean age of 68 years, the primary composite outcome occurred in 7.2%, and the composite outcome excluding procedural interventions occurred in 3.1% at 30 days. Prognostic performance of the CSRS was good for both 30-day composite outcomes and better compared with the OESIL score (area under the receiver-operating characteristic curve [AUC], 0.85 [95% CI, 0.83 to 0.88] vs. 0.74 [CI, 0.71 to 0.78] and 0.80 [CI, 0.75 to 0.84] vs. 0.69 [CI, 0.64 to 0.75], respectively). Safety of triage, as measured by the frequency of the primary composite outcome in the low-risk group, was higher using the CSRS (19 of 1388 [0.6%]) versus the OESIL score (17 of 1104 [1.5%]). A simplified model including only the clinician classification of syncope (cardiac syncope, vasovagal syncope, or other) variable at ED discharge-a component of the CSRS-achieved similar discrimination as the CSRS (AUC, 0.83 [CI, 0.80 to 0.87] for the primary composite outcome). LIMITATION Unable to disentangle the influence of other CSRS components on clinician classification of syncope at ED discharge. CONCLUSION This international external validation of the CSRS showed good performance in identifying patients at low risk for serious outcomes outside of Canada and superior performance compared with the OESIL score. However, clinician classification of syncope at ED discharge seems to explain much of the performance of the CSRS in this study. The clinical utility of the CSRS remains uncertain. PRIMARY FUNDING SOURCE Swiss National Science Foundation & Swiss Heart Foundation.
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Affiliation(s)
- Tobias Zimmermann
- Cardiovascular Research Institute Basel (CRIB), Department of Cardiology, and Department of Intensive Care Medicine, University Hospital Basel, University of Basel, Basel, Switzerland, and GREAT Network, Rome, Italy (T.Z.)
| | - Jeanne du Fay de Lavallaz
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland, and GREAT Network, Rome, Italy (J.F.L., P.L., P.B., S.S., I.S., M.D., M.K., C.M.)
| | - Thomas Nestelberger
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland, GREAT Network, Rome, Italy, and Division of Cardiology, Vancouver General Hospital, University of British Columbia, Vancouver, British Columbia, Canada (T.N.)
| | - Danielle M Gualandro
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland, GREAT Network, Rome, Italy, and Heart Institute (InCor), University of São Paulo Medical School, São Paulo, Brazil (D.M.G.)
| | - Pedro Lopez-Ayala
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland, and GREAT Network, Rome, Italy (J.F.L., P.L., P.B., S.S., I.S., M.D., M.K., C.M.)
| | - Patrick Badertscher
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland, and GREAT Network, Rome, Italy (J.F.L., P.L., P.B., S.S., I.S., M.D., M.K., C.M.)
| | - Velina Widmer
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland (V.W., N.G.)
| | - Samyut Shrestha
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland, and GREAT Network, Rome, Italy (J.F.L., P.L., P.B., S.S., I.S., M.D., M.K., C.M.)
| | - Ivo Strebel
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland, and GREAT Network, Rome, Italy (J.F.L., P.L., P.B., S.S., I.S., M.D., M.K., C.M.)
| | - Noemi Glarner
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland (V.W., N.G.)
| | - Matthias Diebold
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland, and GREAT Network, Rome, Italy (J.F.L., P.L., P.B., S.S., I.S., M.D., M.K., C.M.)
| | - Òscar Miró
- GREAT Network, Rome, Italy, and Hospital Clinic, Barcelona, Catalonia, Spain (Ò.M.)
| | - Michael Christ
- GREAT Network, Rome, Italy, and Kantonsspital Luzern, Luzern, Switzerland (M.C.)
| | - Louise Cullen
- GREAT Network, Rome, Italy, and Royal Brisbane & Women's Hospital, Herston, Australia (L.C.)
| | - Martin Than
- GREAT Network, Rome, Italy, and Christchurch Hospital, Christchurch, New Zealand (M.T.)
| | - F Javier Martin-Sanchez
- GREAT Network, Rome, Italy, and Servicio de Urgencias, Hospital Clínico San Carlos, Madrid, Spain (F.J.M.)
| | - Salvatore Di Somma
- GREAT Network, Rome, Italy, and Emergency Medicine, Department of Medical-Surgery Sciences and Translational Medicine, University Sapienza Rome, Sant'Andrea Hospital, Italy (S.D.S.)
| | - W Frank Peacock
- GREAT Network, Rome, Italy, and Baylor College of Medicine, Department of Emergency Medicine, Houston, Texas (W.F.P.)
| | - Dagmar I Keller
- Emergency Department, University Hospital Zürich, Zürich, Switzerland (D.I.K.)
| | - Murat Bilici
- Department of Orthopedics and Traumatology, University Hospital Basel, University of Basel, Basel, Switzerland (M.B.)
| | | | - Michael Kühne
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland, and GREAT Network, Rome, Italy (J.F.L., P.L., P.B., S.S., I.S., M.D., M.K., C.M.)
| | - Tobias Breidthardt
- Cardiovascular Research Institute Basel (CRIB), Department of Cardiology, and Department of Internal Medicine, University Hospital Basel, University of Basel, Basel, Switzerland, and GREAT Network, Rome, Italy (T.B.)
| | | | - Christian Mueller
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland, and GREAT Network, Rome, Italy (J.F.L., P.L., P.B., S.S., I.S., M.D., M.K., C.M.)
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22
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du Fay de Lavallaz J, Zimmermann T, Badertscher P, Lopez-Ayala P, Nestelberger T, Miró Ò, Salgado E, Zaytseva X, Gafner MS, Christ M, Cullen L, Than M, Martin-Sanchez FJ, Di Somma S, Peacock WF, Keller DI, Costabel JP, Sigal A, Puelacher C, Wussler D, Koechlin L, Strebel I, Schuler S, Manka R, Bilici M, Lohrmann J, Kühne M, Breidthardt T, Clark CL, Probst M, Gibson TA, Weiss RE, Sun BC, Mueller C. Performance of the American Heart Association/American College of Cardiology/Heart Rhythm Society versus European Society of Cardiology guideline criteria for hospital admission of patients with syncope. Heart Rhythm 2022; 19:1712-1722. [PMID: 35644354 DOI: 10.1016/j.hrthm.2022.05.024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [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: 12/17/2021] [Revised: 04/28/2022] [Accepted: 05/23/2022] [Indexed: 11/26/2022]
Abstract
BACKGROUND Current American College of Cardiology/American Heart Association/Heart Rhythm Society (ACC/AHA/HRS) and European Society of Cardiology (ESC) guidelines recommend different strategies to avoid low-yield admissions in patients with syncope. OBJECTIVE The purpose of this study was to directly compare the safety and efficacy of applying admission criteria of both guidelines to patients presenting with syncope to the emergency department in 2 multicenter studies. METHODS The international BASEL IX (BAsel Syncope EvaLuation) study (median age 71 years) and the U.S. SRS (Improving Syncope Risk Stratification in Older Adults) study (median age 72 years) were investigated. Primary endpoints were sensitivity/specificity for the adjudicated diagnosis of cardiac syncope (BASEL IX only) and 30-day major adverse cardiovascular events (30d-MACE). RESULTS Among 2560 patients in the BASEL IX and 2085 in SRS studies, ACC/AHA/HRS and ESC criteria recommended admission for a comparable number of patients in BASEL IX (27% vs 28%), but ACC/AHA/HRS criteria less often in SRS (19% vs 32%; P <.01). Recommendations were discordant in ∼25% of patients. In BASEL IX, sensitivity for cardiac syncope and 30d-MACE among patients without admission criteria was comparable for ACC/AHA/HRS and ESC criteria (64% vs 65%, P = .86; and 67% vs 71%, P = .15, respectively). In SRS, sensitivity for 30d-MACE was lower with ACC/AHA/HRS (54%) vs ESC criteria (88%; P <.001). Similarly, specificity for cardiac syncope and 30d-MACE in BASEL IX was comparable for both guidelines, but in SRS the ACC/AHA/HRS guidelines showed a higher specificity for 30d-MACE than the ESC guidelines. CONCLUSION ACC/AHA/HRS and ESC guidelines showed disagreement regarding admission for 1 in 4 patients and had only modest sensitivity, all indicating possible opportunities for improvements.
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Affiliation(s)
- Jeanne du Fay de Lavallaz
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland; GREAT Network.
| | - Tobias Zimmermann
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland; GREAT Network
| | - Patrick Badertscher
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland; GREAT Network
| | - Pedro Lopez-Ayala
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland; GREAT Network
| | - Thomas Nestelberger
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland; GREAT Network; Division of Cardiology, Vancouver General Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Òscar Miró
- GREAT Network; Hospital Clinic, Barcelona, Catalonia, Spain
| | - Emilio Salgado
- GREAT Network; Hospital Clinic, Barcelona, Catalonia, Spain
| | - Xenia Zaytseva
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland; University Hospital Zürich, Zürich, Switzerland
| | - Michele Sara Gafner
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland; GREAT Network
| | - Michael Christ
- Department of Emergency Medicine, Kantonsspital Luzern, Lucerne, Switzerland
| | - Louise Cullen
- GREAT Network; Royal Brisbane & Women's Hospital, Herston, Australia
| | - Martin Than
- GREAT Network; Christchurch Hospital, Christchurch, New Zealand
| | | | - Salvatore Di Somma
- GREAT Network; Emergency Medicine, Department of Medical-Surgery Sciences and Translational Medicine, University Sapienza Rome, Sant'Andrea Hospital, Rome, Italy
| | - W Frank Peacock
- GREAT Network; Department of Emergency Medicine, Baylor College of Medicine, Houston, Texas
| | | | | | - Alan Sigal
- Instituto Cardiovascular de Buenos Aires, Buenos Aires, Argentina
| | - Christian Puelacher
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland; GREAT Network
| | - Desiree Wussler
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland; GREAT Network
| | - Luca Koechlin
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland; GREAT Network; Department of Cardiac Surgery, University Hospital Basel, Basel, Switzerland
| | - Ivo Strebel
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland; GREAT Network
| | - Sereina Schuler
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland; University Hospital Zürich, Zürich, Switzerland
| | | | - Murat Bilici
- Department of Orthopedics and Traumatology, Basel University Hospital, Basel, Switzerland
| | - Jens Lohrmann
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Michael Kühne
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Tobias Breidthardt
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland; GREAT Network
| | - Carol L Clark
- Beaumont Health System-Royal Oak, Royal Oak, Michigan
| | - Marc Probst
- Department of Emergency Medicine, Mount Sinai School of Medicine, New York, New York
| | - Thomas A Gibson
- Department of Biostatistics, University of California Fielding School of Public Health, Los Angeles, California
| | - Robert E Weiss
- Department of Biostatistics, University of California Fielding School of Public Health, Los Angeles, California
| | - Benjamin C Sun
- Department of Emergency Medicine, Leonard David Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Christian Mueller
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland; GREAT Network
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23
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Arslani K, Gualandro DM, Puelacher C, Lurati Buse G, Lampart A, Bolliger D, Schulthess D, Glarner N, Hidvegi R, Kindler C, Blum S, Cardozo FAM, Caramelli B, Gürke L, Wolff T, Mujagic E, Schaeren S, Rikli D, Campos CA, Fahrni G, Kaufmann BA, Haaf P, Zellweger MJ, Kaiser C, Osswald S, Steiner LA, Mueller C. Cardiovascular imaging following perioperative myocardial infarction/injury. Sci Rep 2022; 12:4447. [PMID: 35292719 PMCID: PMC8924205 DOI: 10.1038/s41598-022-08261-6] [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: 09/20/2021] [Accepted: 03/01/2022] [Indexed: 11/09/2022] Open
Abstract
Patients developing perioperative myocardial infarction/injury (PMI) have a high mortality. PMI work-up and therapy remain poorly defined. This prospective multicenter study included high-risk patients undergoing major non-cardiac surgery within a systematic PMI screening and clinical response program. The frequency of cardiovascular imaging during PMI work-up and its yield for possible type 1 myocardial infarction (T1MI) was assessed. Automated PMI detection triggered evaluation by the treating physician/cardiologist, who determined selection/timing of cardiovascular imaging. T1M1 was considered with the presence of a new wall motion abnormality within 30 days in transthoracic echocardiography (TTE), a new scar or ischemia within 90 days in myocardial perfusion imaging (MPI), and Ambrose-Type II or complex lesions within 7 days of PMI in coronary angiography (CA). In patients with PMI, 21% (268/1269) underwent at least one cardiac imaging modality. TTE was used in 13% (163/1269), MPI in 3% (37/1269), and CA in 5% (68/1269). Cardiology consultation was associated with higher use of cardiovascular imaging (27% versus 13%). Signs indicative of T1MI were found in 8% of TTE, 46% of MPI, and 63% of CA. Most patients with PMI did not undergo any cardiovascular imaging within their PMI work-up. If performed, MPI and CA showed high yield for signs indicative of T1MI.Trial registration: https://clinicaltrials.gov/ct2/show/NCT02573532 .
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Affiliation(s)
- Ketina Arslani
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Basel, Switzerland
| | - Danielle M Gualandro
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Basel, Switzerland. .,Unidade de Medicina Interdisciplinar em Cardiologia, Instituto do Coração, Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil.
| | - Christian Puelacher
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Basel, Switzerland.,Department of Internal Medicine, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Giovanna Lurati Buse
- Department of Anaesthesiology, University Hospital Düsseldorf, Düsseldorf, Germany.,Department of Anaesthesiology, University Hospital Basel, University Basel, Basel, Switzerland
| | - Andreas Lampart
- Department of Anaesthesiology, University Hospital Basel, University Basel, Basel, Switzerland
| | - Daniel Bolliger
- Department of Anaesthesiology, University Hospital Basel, University Basel, Basel, Switzerland
| | - David Schulthess
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Basel, Switzerland
| | - Noemi Glarner
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Basel, Switzerland
| | - Reka Hidvegi
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Basel, Switzerland.,Department of Anaesthesiology, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - Christoph Kindler
- Department of Anaesthesiology, Kantonsspital Aarau, Aarau, Switzerland
| | - Steffen Blum
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Basel, Switzerland
| | - Francisco A M Cardozo
- Unidade de Medicina Interdisciplinar em Cardiologia, Instituto do Coração, Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Bruno Caramelli
- Unidade de Medicina Interdisciplinar em Cardiologia, Instituto do Coração, Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Lorenz Gürke
- Department of Vascular Surgery, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Thomas Wolff
- Department of Vascular Surgery, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Edin Mujagic
- Department of Vascular Surgery, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Stefan Schaeren
- Department of Spinal Surgery, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Daniel Rikli
- Department Orthopedic Surgery, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Carlos A Campos
- Unidade de Medicina Interdisciplinar em Cardiologia, Instituto do Coração, Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Gregor Fahrni
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Basel, Switzerland
| | - Beat A Kaufmann
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Basel, Switzerland
| | - Philip Haaf
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Basel, Switzerland
| | - Michael J Zellweger
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Basel, Switzerland
| | - Christoph Kaiser
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Basel, Switzerland
| | - Stefan Osswald
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Basel, Switzerland
| | - Luzius A Steiner
- Department of Anaesthesiology, University Hospital Basel, University Basel, Basel, Switzerland
| | - Christian Mueller
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Basel, Switzerland
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24
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Prepoudis A, Koechlin L, Nestelberger T, Boeddinghaus J, Lopez-Ayala P, Wussler D, Zimmermann T, Rubini Giménez M, Strebel I, Puelacher C, Shrestha S, Keller DI, Christ M, Gualandro DM, Twerenbold R, Martinez-Nadal G, Lopez-Barbeito B, Miro O, Mueller C. Incidence, clinical presentation, management, and outcome of acute pericarditis and myopericarditis. Eur Heart J Acute Cardiovasc Care 2022; 11:137-147. [PMID: 34849666 DOI: 10.1093/ehjacc/zuab108] [Citation(s) in RCA: 5] [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] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Revised: 10/16/2021] [Accepted: 11/03/2021] [Indexed: 06/13/2023]
Abstract
AIMS Little is known about the epidemiology, clinical presentation, management, and outcome of acute pericarditis and myopericarditis. METHODS AND RESULTS The final diagnoses of acute pericarditis, myopericarditis, and non-ST-segment elevation myocardial infarction (NSTEMI) of patients presenting to seven emergency departments in Switzerland with acute chest pain were centrally adjudicated by two independent cardiologists using all information including serial measurements of high-sensitivity cardiac troponin T. The overall incidence of pericarditis and myopericarditis was estimated relative to the established incidence of NSTEMI. Current management and long-term outcome of both conditions were also assessed. Among 2533 chest pain patients, the incidence of pericarditis, myopericarditis, and NSTEMI were 1.9% (n = 48), 1.1% (n = 29), and 21.6% (n = 548), respectively. Accordingly, the estimated incidence of pericarditis and myopericarditis in Switzerland was 10.1 [95% confidence interval (95% CI) 9.3-10.9] and 6.1 (95% CI 5.6-6.7) cases per 100 000 population per year, respectively, vs. 115.0 (95% CI 112.3-117.6) cases per 100 000 population per year for NSTEMI. Pericarditis (85% male, median age 46 years) and myopericarditis (62% male, median age 56 years) had male predominance, and commonly (50% and 97%, respectively) resulted in hospitalization. No patient with pericarditis or myopericarditis died or had life-threatening arrhythmias within 30 days [incidence 0% (95% CI 0.0-4.8%)]. Compared with NSTEMI, the 2-year all-cause mortality adjusted hazard ratio of pericarditis and myopericarditis was 0.40 (95% CI 0.05-2.96), being 0.59 (95% CI 0.40-0.88) for non-cardiac causes of chest pain. CONCLUSION Pericarditis and myopericarditis are substantially less common than NSTEMI and have an excellent short- and long-term outcome. CLINICAL TRIAL REGISTRATION ClinicalTrial.gov, number NCT00470587, https://clinicaltrials.gov/ct2/show/NCT00470587.
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Affiliation(s)
- Alexandra Prepoudis
- Department of Cardiology, Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Petersgraben 4, CH-4031 Basel, Switzerland
- Deparment of Internal Medicine, University Hospital Basel, University of Basel, Petersgraben 4, CH-4031 Basel, Switzerland
- GREAT Network, Via Antonio Serra 54, 00191 Rome, Italy
| | - Luca Koechlin
- Department of Cardiology, Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Petersgraben 4, CH-4031 Basel, Switzerland
- GREAT Network, Via Antonio Serra 54, 00191 Rome, Italy
- Department of Cardiac Surgery, University Hospital Basel, University of Basel, Petersgraben 4, CH-4031 Basel, Switzerland
| | - Thomas Nestelberger
- Department of Cardiology, Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Petersgraben 4, CH-4031 Basel, Switzerland
- GREAT Network, Via Antonio Serra 54, 00191 Rome, Italy
- Deparment of Cardiology, Vancouver General Hospital, University of British Columbia, Vancouver, BC, Canada
| | - Jasper Boeddinghaus
- Department of Cardiology, Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Petersgraben 4, CH-4031 Basel, Switzerland
- GREAT Network, Via Antonio Serra 54, 00191 Rome, Italy
| | - Pedro Lopez-Ayala
- Department of Cardiology, Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Petersgraben 4, CH-4031 Basel, Switzerland
- GREAT Network, Via Antonio Serra 54, 00191 Rome, Italy
| | - Desiree Wussler
- Department of Cardiology, Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Petersgraben 4, CH-4031 Basel, Switzerland
- Deparment of Internal Medicine, University Hospital Basel, University of Basel, Petersgraben 4, CH-4031 Basel, Switzerland
- GREAT Network, Via Antonio Serra 54, 00191 Rome, Italy
| | - Tobias Zimmermann
- Department of Cardiology, Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Petersgraben 4, CH-4031 Basel, Switzerland
- GREAT Network, Via Antonio Serra 54, 00191 Rome, Italy
- Department of Intensive Care Medicine, University Hospital Basel, University of Basel, Petersgraben 4, CH-4031 Basel, Switzerland
| | - Maria Rubini Giménez
- Department of Cardiology, Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Petersgraben 4, CH-4031 Basel, Switzerland
- GREAT Network, Via Antonio Serra 54, 00191 Rome, Italy
- Deparment of Cardiology, Leipzig Heart Center, Strümpellstraße 39, 04289 Leipzig, Germany
| | - Ivo Strebel
- Department of Cardiology, Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Petersgraben 4, CH-4031 Basel, Switzerland
- GREAT Network, Via Antonio Serra 54, 00191 Rome, Italy
| | - Christian Puelacher
- Department of Cardiology, Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Petersgraben 4, CH-4031 Basel, Switzerland
- Deparment of Internal Medicine, University Hospital Basel, University of Basel, Petersgraben 4, CH-4031 Basel, Switzerland
- GREAT Network, Via Antonio Serra 54, 00191 Rome, Italy
| | - Samyut Shrestha
- Department of Cardiology, Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Petersgraben 4, CH-4031 Basel, Switzerland
- GREAT Network, Via Antonio Serra 54, 00191 Rome, Italy
| | - Dagmar I Keller
- Emergency Department, University Hospital Zurich, Schmelzbergstrasse 8, 8091 Zurich, Switzerland
| | - Michael Christ
- Emergency Department, Luzerner Kantonsspital, Spitalstrasse, 6004 Luzern, Switzerland
| | - Danielle M Gualandro
- Department of Cardiology, Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Petersgraben 4, CH-4031 Basel, Switzerland
- GREAT Network, Via Antonio Serra 54, 00191 Rome, Italy
| | - Raphael Twerenbold
- Department of Cardiology, Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Petersgraben 4, CH-4031 Basel, Switzerland
- GREAT Network, Via Antonio Serra 54, 00191 Rome, Italy
| | - Gemma Martinez-Nadal
- GREAT Network, Via Antonio Serra 54, 00191 Rome, Italy
- Emergency Department, Hospital Clinic, C. de Villarroel, 170, 08036 Barcelona, Spain
| | - Beatriz Lopez-Barbeito
- GREAT Network, Via Antonio Serra 54, 00191 Rome, Italy
- Emergency Department, Hospital Clinic, C. de Villarroel, 170, 08036 Barcelona, Spain
| | - Oscar Miro
- GREAT Network, Via Antonio Serra 54, 00191 Rome, Italy
- Emergency Department, Hospital Clinic, C. de Villarroel, 170, 08036 Barcelona, Spain
| | - Christian Mueller
- Department of Cardiology, Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Petersgraben 4, CH-4031 Basel, Switzerland
- GREAT Network, Via Antonio Serra 54, 00191 Rome, Italy
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25
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Walter JE, Amrein MLF, Schäfer I, Zimmermann T, Lopez-Ayala P, Boeddinghaus J, Twerenbold R, Puelacher C, Nestelberger T, Wussler D, Honegger U, Badertscher P, Eugen-Olsen J, Koechlin L, Fahrni G, Jeger R, Kaiser C, Zellweger M, Mueller C. Soluble urokinase plasminogen activator receptor and functionally relevant coronary artery disease: a prospective cohort study. Biomarkers 2022; 27:278-285. [PMID: 35112976 DOI: 10.1080/1354750x.2022.2038269] [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: 11/02/2022]
Abstract
BACKGROUND Soluble urokinase plasminogen activator receptor (suPAR) is an emerging biomarker associated with anatomical CAD burden and cardiovascular outcomes including myocardial infarction (MI) and death. We aimed at validating previous findings of the prognostic value of suPAR and evaluated its diagnostic potential for functional relevant CAD (fCAD). METHODS Consecutive patients with suspected fCAD were enrolled. Adjudication of fCAD was performed blinded to suPAR concentrations by myocardial perfusion single photon emission tomography (MPI-SPECT) and coronary angiography. Prognostic outcome measures included all-cause, cardiovascular death, and incident MI during 2-year follow-up. RESULTS Among consecutive 968 patients, SuPAR concentrations were higher in patients with fCAD compared to those without (3.45ng/mL versus 3.20ng/mL, p = 0.007), without acceptable diagnostic accuracy (area under the curve [AUC]: 0.56, 95%CI 0.52-0.60). SuPAR correlated with high-sensitivity cardiac-troponin (hs-cTn) T (Spearman's rho (ρ) 0.393, p < 0.001), NT-proBNP (ρ = 0.327, p < 0.001), age (ρ = 0.364, p < 0.001) and very weakly with coronary atherosclerosis (ρ = 0.123, p < 0.001). Prognostic discrimination of suPAR was moderate for cardiovascular death (AUC =0.72, 95%CI 0.62-0.81) and all-cause death (AUC =0.72, 95%CI 0.65-0.79) at 2-years. SuPAR remained a significant predictor for all-cause death in the full model (HR =1.96, p = 0.001). CONCLUSIONS SuPAR was an independent predictor of all-cause death, without diagnostic utility for fCAD.
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Affiliation(s)
- Joan Elias Walter
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Switzerland.,Department of Radiology, University Hospital Zurich, University of Zurich, Switzerland
| | - Melissa Lee Fen Amrein
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Switzerland
| | - Ibrahim Schäfer
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Switzerland
| | - Tobias Zimmermann
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Switzerland
| | - Pedro Lopez-Ayala
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Switzerland
| | - Jasper Boeddinghaus
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Switzerland
| | - Raphael Twerenbold
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Switzerland.,University Heart & Vascular Center Hamburg, Germany
| | - Christian Puelacher
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Switzerland.,Department of Radiology, University Hospital Zurich, University of Zurich, Switzerland
| | - Thomas Nestelberger
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Switzerland.,Vancouver General Hospital, University of British Columbia, Canada
| | - Desiree Wussler
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Switzerland.,Universitäts-Herzzentrum Bad Krozingen, Germany
| | - Ursina Honegger
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Switzerland
| | - Patrick Badertscher
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Switzerland
| | - Jesper Eugen-Olsen
- Clinical Research Centre, Copenhagen University Hospital Hvidovre, Denmark
| | - Luca Koechlin
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Switzerland.,Department of Cardiac Surgery, University Hospital Basel, University of Basel, Switzerland
| | - Gregor Fahrni
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Switzerland
| | - Raban Jeger
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Switzerland
| | - Christoph Kaiser
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Switzerland
| | - Michael Zellweger
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Switzerland
| | - Christian Mueller
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Switzerland
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26
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Amrein M, Li XS, Walter J, Wang Z, Zimmermann T, Strebel I, Honegger U, Leu K, Schäfer I, Twerenbold R, Puelacher C, Glarner N, Nestelberger T, Koechlin L, Ceresa B, Haaf P, Bakula A, Zellweger M, Hazen SL, Mueller C. Gut microbiota-dependent metabolite trimethylamine N-oxide (TMAO) and cardiovascular risk in patients with suspected functionally relevant coronary artery disease (fCAD). Clin Res Cardiol 2022; 111:692-704. [PMID: 35220448 PMCID: PMC9151506 DOI: 10.1007/s00392-022-01992-6] [Citation(s) in RCA: 5] [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: 05/12/2021] [Accepted: 02/10/2022] [Indexed: 12/29/2022]
Abstract
BACKGROUND Trimethylamine N-oxide (TMAO) has been associated with cardiovascular outcomes. However, the diagnostic value of TMAO and its precursors have not been assessed for functionally relevant coronary artery disease (fCAD) and its prognostic potential in this setting needs to be evaluated. METHODS Among 1726 patients with suspected fCAD serum TMAO, and its precursors betaine, choline and carnitine, were quantified using liquid chromatography tandem mass spectrometry. Diagnosis of fCAD was performed by myocardial perfusion single photon emission tomography (MPI-SPECT) and coronary angiography blinded to marker concentrations. Incident all-cause death, cardiovascular death (CVD) and myocardial infarction (MI) were assessed during 5-years follow-up. RESULTS Concentrations of TMAO, betaine, choline and carnitine were significantly higher in patients with fCAD versus those without (TMAO 5.33 μM vs 4.66 μM, p < 0.001); however, diagnostic accuracy was low (TMAO area under the receiver operating curve [AUC]: 0.56, 95% CI [0.53-0.59], p < 0.001). In prognostic analyses, TMAO, choline and carnitine above the median were associated with significantly (p < 0.001 for all) higher cumulative events for death and CVD during 5-years follow-up. TMAO remained a significant predictor for death and CVD even in full models adjusted for renal function (HR = 1.58 (1.16, 2.14), p = 0.003; HR = 1.66 [1.07, 2.59], p = 0.025). Prognostic discriminative accuracy for TMAO was good and robust for death and CVD (2-years AUC for CVD 0.73, 95% CI [0.65-0.80]). CONCLUSION TMAO and its precursors, betaine, choline and carnitine were significantly associated with fCAD, but with limited diagnostic value. TMAO was a strong predictor for incident death and CVD in patients with suspected fCAD. CLINICAL TRIAL REGISTRATION NCT01838148.
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Affiliation(s)
- Melissa Amrein
- Department of Cardiology, Cardiovascular Research Institute Basel (CRIB, University Hospital Basel, University of Basel, Petersgraben 4, CH-4031 Basel, Switzerland
| | - Xinmin S. Li
- Department of Cardiovascular and Metabolic Sciences, Lerner Research Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195 USA
| | - Joan Walter
- Department of Cardiology, Cardiovascular Research Institute Basel (CRIB, University Hospital Basel, University of Basel, Petersgraben 4, CH-4031 Basel, Switzerland ,Department of Radiology, University Hospital Zürich, University of Zürich, Zürich, Switzerland
| | - Zeneng Wang
- Department of Cardiovascular and Metabolic Sciences, Lerner Research Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195 USA
| | - Tobias Zimmermann
- Department of Cardiology, Cardiovascular Research Institute Basel (CRIB, University Hospital Basel, University of Basel, Petersgraben 4, CH-4031 Basel, Switzerland ,Department of Internal Medicine, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Ivo Strebel
- Department of Cardiology, Cardiovascular Research Institute Basel (CRIB, University Hospital Basel, University of Basel, Petersgraben 4, CH-4031 Basel, Switzerland
| | - Ursina Honegger
- Department of Cardiology, Cardiovascular Research Institute Basel (CRIB, University Hospital Basel, University of Basel, Petersgraben 4, CH-4031 Basel, Switzerland
| | - Kathrin Leu
- Department of Cardiology, Cardiovascular Research Institute Basel (CRIB, University Hospital Basel, University of Basel, Petersgraben 4, CH-4031 Basel, Switzerland
| | - Ibrahim Schäfer
- Department of Cardiology, Cardiovascular Research Institute Basel (CRIB, University Hospital Basel, University of Basel, Petersgraben 4, CH-4031 Basel, Switzerland ,Department of Internal Medicine, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Raphael Twerenbold
- Department of Cardiology, Cardiovascular Research Institute Basel (CRIB, University Hospital Basel, University of Basel, Petersgraben 4, CH-4031 Basel, Switzerland
| | - Christian Puelacher
- Department of Cardiology, Cardiovascular Research Institute Basel (CRIB, University Hospital Basel, University of Basel, Petersgraben 4, CH-4031 Basel, Switzerland ,Department of Internal Medicine, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Noemi Glarner
- Department of Cardiology, Cardiovascular Research Institute Basel (CRIB, University Hospital Basel, University of Basel, Petersgraben 4, CH-4031 Basel, Switzerland
| | - Thomas Nestelberger
- Department of Cardiology, Cardiovascular Research Institute Basel (CRIB, University Hospital Basel, University of Basel, Petersgraben 4, CH-4031 Basel, Switzerland ,Departement of Cardiology, University of British Columbia, Vancouver, Canada
| | - Luca Koechlin
- Department of Cardiology, Cardiovascular Research Institute Basel (CRIB, University Hospital Basel, University of Basel, Petersgraben 4, CH-4031 Basel, Switzerland ,Department of Cardiac Surgery, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Benjamin Ceresa
- Department of Cardiology, Cardiovascular Research Institute Basel (CRIB, University Hospital Basel, University of Basel, Petersgraben 4, CH-4031 Basel, Switzerland
| | - Philip Haaf
- Department of Cardiology, Cardiovascular Research Institute Basel (CRIB, University Hospital Basel, University of Basel, Petersgraben 4, CH-4031 Basel, Switzerland
| | - Adam Bakula
- Department of Cardiology, Cardiovascular Research Institute Basel (CRIB, University Hospital Basel, University of Basel, Petersgraben 4, CH-4031 Basel, Switzerland
| | - Michael Zellweger
- Department of Cardiology, Cardiovascular Research Institute Basel (CRIB, University Hospital Basel, University of Basel, Petersgraben 4, CH-4031 Basel, Switzerland
| | - Stanley L. Hazen
- Department of Cardiovascular and Metabolic Sciences, Lerner Research Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195 USA ,Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195 USA
| | - Christian Mueller
- Department of Cardiology, Cardiovascular Research Institute Basel (CRIB, University Hospital Basel, University of Basel, Petersgraben 4, CH-4031, Basel, Switzerland.
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Chew MS, Puelacher C, Patel A, Hammarskjöld F, Lyckner S, Kollind M, Jawad M, Andersson U, Fredrikson M, Sperber J, Johnsson P, Elander L, Zeuchner J, Linhardt M, De Geer L, Rolander WG, Gagnö G, Didriksson H, Pearse R, Mueller C, Andersson H. Identification of myocardial injury using perioperative troponin surveillance in major noncardiac surgery and net benefit over the Revised Cardiac Risk Index. Br J Anaesth 2021; 128:26-36. [PMID: 34857357 DOI: 10.1016/j.bja.2021.10.006] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2021] [Revised: 09/12/2021] [Accepted: 10/05/2021] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Patients with perioperative myocardial injury are at risk of death and major adverse cardiovascular and cerebrovascular events (MACCE). The primary aim of this study was to determine optimal thresholds of preoperative and perioperative changes in high-sensitivity cardiac troponin T (hs-cTnT) to predict MACCE and mortality. METHODS Prospective, observational, cohort study in patients ≥50 yr of age undergoing elective major noncardiac surgery at seven hospitals in Sweden. The exposures were hs-cTnT measured before and days 0-3 after surgery. Two previously published thresholds for myocardial injury and two thresholds identified using receiver operating characteristic analyses were evaluated using multivariable logistic regression models and externally validated. The weighted comparison net benefit method was applied to determine the additional value of hs-cTnT thresholds when compared with the Revised Cardiac Risk Index (RCRI). The primary outcome was a composite of 30-day all-cause mortality and MACCE. RESULTS We included 1291 patients between April 2017 and December 2020. The primary outcome occurred in 124 patients (9.6%). Perioperative increase in hs-cTnT ≥14 ng L-1 above preoperative values provided statistically optimal model performance and was associated with the highest risk for the primary outcome (adjusted odds ratio 2.9, 95% confidence interval 1.8-4.7). Validation in an independent, external cohort confirmed these findings. A net benefit over RCRI was demonstrated across a range of clinical thresholds. CONCLUSIONS Perioperative increases in hsTnT ≥14 ng L-1 above baseline values identifies acute perioperative myocardial injury and provides a net prognostic benefit when added to RCRI for the identification of patients at high risk of death and MACCE. CLINICAL TRIAL REGISTRATION NCT03436238.
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Affiliation(s)
- Michelle S Chew
- Departments of Anaesthesia and Intensive Care, Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden.
| | - Christian Puelacher
- Cardiovascular Research Institute Basel and Department of Cardiology, University Hospital Basel, University Basel, Basel, Switzerland
| | - Akshaykumar Patel
- William Harvey Research Institute, Queen Mary University of London, London, UK
| | - Fredrik Hammarskjöld
- Department of Anesthesiology and Intensive Care, Ryhov County Hospital, Jönköping, Sweden
| | - Sara Lyckner
- Department of Anesthesiology, Mälarsjukhuset, Centre for Clinical Research Sörmland, Eskilstuna, Sweden
| | - Malin Kollind
- Department of Anaesthesia and Intensive Care, Centralsjukhuset Kristianstad, Kristianstad, Sweden
| | - Monir Jawad
- Department of Anaesthesia and Intensive Care, Centralsjukhuset Kristianstad, Kristianstad, Sweden; Department of Clinical Sciences Malmö, Lund University, Malmö, Sweden
| | - Ulrika Andersson
- Department of Clinical Sciences Lund, Anaesthesiology and Intensive Care, Skåne University Hospital Lund, Lund University, Sweden
| | - Mats Fredrikson
- Department of Clinical and Experimental Medicine, Faculty of Medicine and Health, Linköping University, Linköping, Sweden
| | - Jesper Sperber
- Department of Anesthesiology, Mälarsjukhuset, Centre for Clinical Research Sörmland, Eskilstuna, Sweden
| | - Patrik Johnsson
- Department of Clinical Sciences, Anaesthesiology and Intensive Care, Skåne University Hospital Malmö, Lund University, Sweden
| | - Louise Elander
- Department of Anaesthesia and Intensive Care, Biomedical and Clinical Sciences, Vrinnevi Hospital, Norrköping, Sweden
| | - Jakob Zeuchner
- Department of Anaesthesia and Intensive Care, Biomedical and Clinical Sciences, Vrinnevi Hospital, Norrköping, Sweden
| | - Michael Linhardt
- Departments of Anaesthesia and Intensive Care, Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Lina De Geer
- Departments of Anaesthesia and Intensive Care, Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Wictor Gääw Rolander
- Departments of Anaesthesia and Intensive Care, Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Gunilla Gagnö
- Departments of Anaesthesia and Intensive Care, Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Helén Didriksson
- Departments of Anaesthesia and Intensive Care, Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Rupert Pearse
- William Harvey Research Institute, Queen Mary University of London, London, UK
| | - Christian Mueller
- Cardiovascular Research Institute Basel and Department of Cardiology, University Hospital Basel, University Basel, Basel, Switzerland
| | - Henrik Andersson
- Departments of Anaesthesia and Intensive Care, Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
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28
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Koechlin L, Boeddinghaus J, Nestelberger T, Lopez-Ayala P, Wussler D, Shrestha S, Resa T, Wildi K, Bakula A, Frey S, Miró Ò, Martin-Sanchez FJ, Strebel I, Gualandro DM, Eckstein FS, Reuthebuch O, Keller DI, Twerenbold R, Giménez MR, Mueller C, Zimmermann T, Reichlin T, Christ M, Puelacher C, de Lavallaz JDF, Potlukova E, Diebold M, Kawecki D, Geigy N, Rentsch K, Mitrovic S, Fuenzalida C, Glarner N, Morawiec B, Munzk P, Breidthardt T, Freese M, López B, Calderón S, Adrada ER, Ganovská E, Parenica J, von Eckardstein A, Campodarve I, Gea J. Performance of the ESC 0/2h-algorithm using high-sensitivity cardiac troponin I in the early diagnosis of myocardial infarction. Am Heart J 2021; 242:132-137. [PMID: 34508692 DOI: 10.1016/j.ahj.2021.08.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2021] [Accepted: 08/10/2021] [Indexed: 10/20/2022]
Abstract
The 2020 guidelines of the European Society of Cardiology (ESC) recommend a novel ESC 0/2h-algorithm as the preferred alternative to the ESC 0/1h-algorithm in the early triage for rule-out and/or rule-in of Non-ST-segment-elevation myocardial infarction (NSTEMI). The aim was to prospectively validate the performance of the ESC 0/2h-algorithm using the high-sensitivity cardiac troponin I (hs-cTnI) assay (ARCHITECT) in an international, multicenter diagnostic study enrolling patients presenting with acute chest discomfort to the emergency department.
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29
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Müller D, Glarner N, Lopez-Ayala P, Puelacher C, Müller C. Correspondence on "Association between cardiologist evaluation and mortality in myocardial injury after non-cardiac surgery" by Park et al. Heart 2021; 108:154. [PMID: 34836892 DOI: 10.1136/heartjnl-2021-320436] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Affiliation(s)
- Daria Müller
- Cardiovascular Research Institute, University Hospital Basel, Basel, Switzerland .,Cardiology, University Hospital Basel, Basel, Switzerland
| | - Noemi Glarner
- Cardiovascular Research Institute, University Hospital Basel, Basel, Switzerland.,Cardiology, University Hospital Basel, Basel, Switzerland
| | - Pedro Lopez-Ayala
- Cardiovascular Research Institute, University Hospital Basel, Basel, Switzerland.,Cardiology, University Hospital Basel, Basel, Switzerland
| | - Christian Puelacher
- Cardiovascular Research Institute, University Hospital Basel, Basel, Switzerland.,Cardiology, University Hospital Basel, Basel, Switzerland
| | - Christian Müller
- Cardiovascular Research Institute, University Hospital Basel, Basel, Switzerland.,Cardiology, University Hospital Basel, Basel, Switzerland
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30
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Gualandro DM, Puelacher C, Lurati Buse G, Glarner N, Cardozo FA, Vogt R, Hidvegi R, Strunz C, Bolliger D, Gueckel J, Yu PC, Liffert M, Arslani K, Prepoudis A, Calderaro D, Hammerer-Lercher A, Lampart A, Steiner LA, Schären S, Kindler C, Guerke L, Osswald S, Devereaux PJ, Caramelli B, Mueller C. Incidence and outcomes of perioperative myocardial infarction/injury diagnosed by high-sensitivity cardiac troponin I. Clin Res Cardiol 2021; 110:1450-1463. [PMID: 33768367 PMCID: PMC8405484 DOI: 10.1007/s00392-021-01827-w] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [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] [Received: 11/05/2020] [Accepted: 02/21/2021] [Indexed: 01/04/2023]
Abstract
BACKGROUND Perioperative myocardial infarction/injury (PMI) diagnosed by high-sensitivity troponin (hs-cTn) T is frequent and a prognostically important complication of non-cardiac surgery. We aimed to evaluate the incidence and outcome of PMI diagnosed using hs-cTnI, and compare it to PMI diagnosed using hs-cTnT. METHODS We prospectively included 2455 patients at high cardiovascular risk undergoing 3111 non-cardiac surgeries, for whom hs-cTnI and hs-cTnT concentrations were measured before surgery and on postoperative days 1 and 2. PMI was defined as a composite of perioperative myocardial infarction (PMIInfarct) and perioperative myocardial injury (PMIInjury), according to the Fourth Universal Definition of Myocardial Infarction. All-cause mortality was the primary endpoint. RESULTS Using hs-cTnI, the incidence of overall PMI was 9% (95% confidence interval [CI] 8-10%), including PMIInfarct 2.6% (95% CI 2.0-3.2) and PMIInjury 6.1% (95% CI 5.3-6.9%), which was lower versus using hs-cTnT: overall PMI 15% (95% CI 14-16%), PMIInfarct 3.7% (95% CI 3.0-4.4) and PMIInjury 11.3% (95% CI 10.2-12.4%). All-cause mortality occurred in 52 (2%) patients within 30 days and 217 (9%) within 1 year. Using hs-cTnI, both PMIInfarct and PMIInjury were independent predictors of 30-day all-cause mortality (adjusted hazard ratio [aHR] 2.5 [95% CI 1.1-6.0], and aHR 2.8 [95% CI 1.4-5.5], respectively) and, 1-year all-cause mortality (aHR 2.0 [95% CI 1.2-3.3], and aHR 1.8 [95% CI 1.2-2.7], respectively). Overall, the prognostic impact of PMI diagnosed by hs-cTnI was comparable to the prognostic impact of PMI using hs-cTnT. CONCLUSIONS Using hs-cTnI, PMI is less common versus using hs-cTnT. Using hs-cTnI, both PMIInfarct and PMIInjury remain independent predictors of 30-day and 1-year mortality.
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Affiliation(s)
- Danielle M Gualandro
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Spitalstrasse 2, CH-4056, Basel, Switzerland.
- Interdisciplinary Medicine in Cardiology Unit, Cardiology Department, Heart Institute (InCor), University of Sao Paulo Medical School, São Paulo, Brazil.
| | - Christian Puelacher
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Spitalstrasse 2, CH-4056, Basel, Switzerland
| | - Giovanna Lurati Buse
- Department of Anesthesiology, University Hospital Düsseldorf, Düsseldorf, Germany
| | - Noemi Glarner
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Spitalstrasse 2, CH-4056, Basel, Switzerland
| | - Francisco A Cardozo
- Interdisciplinary Medicine in Cardiology Unit, Cardiology Department, Heart Institute (InCor), University of Sao Paulo Medical School, São Paulo, Brazil
| | - Ronja Vogt
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Spitalstrasse 2, CH-4056, Basel, Switzerland
| | - Reka Hidvegi
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Spitalstrasse 2, CH-4056, Basel, Switzerland
- Department of Anesthesiology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Celia Strunz
- Laboratory Medicine, Heart Institute (InCor), University of Sao Paulo Medical School, São Paulo, Brazil
| | - Daniel Bolliger
- Department of Anesthesiology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Johanna Gueckel
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Spitalstrasse 2, CH-4056, Basel, Switzerland
| | - Pai C Yu
- Interdisciplinary Medicine in Cardiology Unit, Cardiology Department, Heart Institute (InCor), University of Sao Paulo Medical School, São Paulo, Brazil
| | - Marcel Liffert
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Spitalstrasse 2, CH-4056, Basel, Switzerland
- Department of Anesthesiology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Ketina Arslani
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Spitalstrasse 2, CH-4056, Basel, Switzerland
| | - Alexandra Prepoudis
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Spitalstrasse 2, CH-4056, Basel, Switzerland
| | - Daniela Calderaro
- Interdisciplinary Medicine in Cardiology Unit, Cardiology Department, Heart Institute (InCor), University of Sao Paulo Medical School, São Paulo, Brazil
| | | | - Andreas Lampart
- Department of Anesthesiology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Luzius A Steiner
- Department of Laboratory Medicine, University of Basel, Basel, Switzerland
- Department of Clinical Research, University of Basel, Basel, Switzerland
| | - Stefan Schären
- Department of Spinal Surgery, University Hospital Basel, Basel, Switzerland
| | - Christoph Kindler
- Department of Anesthesiology, Cantonal Hospital Aarau, Aarau, Switzerland
| | - Lorenz Guerke
- Department of Vascular Surgery, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Stefan Osswald
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Spitalstrasse 2, CH-4056, Basel, Switzerland
| | - P J Devereaux
- Population Health Research Institute, David Braley Cardiac, Vascular and Stroke Research Institute, Anesthesiology, Perioperative Medicine, and Surgical Research Unit C/o Hamilton General Hospital, McMaster University, Hamilton, Canada
| | - Bruno Caramelli
- Interdisciplinary Medicine in Cardiology Unit, Cardiology Department, Heart Institute (InCor), University of Sao Paulo Medical School, São Paulo, Brazil
| | - Christian Mueller
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Spitalstrasse 2, CH-4056, Basel, Switzerland
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31
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Lurati Buse GAL, Puelacher C, Gualandro DM, Kilinc D, Glarner N, Hidvegi R, Bolliger D, Arslani K, Lampart A, Steiner LA, Kindler C, Wolff T, Mujagic E, Guerke L, Mueller C. Adherence to the European Society of Cardiology/European Society of Anaesthesiology recommendations on preoperative cardiac testing and association with positive results and cardiac events: a cohort study. Br J Anaesth 2021; 127:376-385. [PMID: 34330416 DOI: 10.1016/j.bja.2021.06.027] [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] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Revised: 05/19/2021] [Accepted: 06/08/2021] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND European Society of Cardiology/European Society of Anaesthesiology (ESC/ESA) guidelines inform cardiac workup before noncardiac surgery based on an algorithm. Our primary hypotheses were that there would be associations between (i) the groups stratified according to the algorithms and major adverse cardiac events (MACE), and (ii) over- and underuse of cardiac testing and MACE. METHODS This is a secondary analysis of a multicentre prospective cohort. Major adverse cardiac events were a composite of cardiac death, myocardial infarction, acute heart failure, and life-threatening arrhythmia at 30 days. For each cardiac test, pathological findings were defined a priori. We used multivariable logistic regression to measure associations. RESULTS We registered 359 MACE at 30 days amongst 6976 patients; classification in a higher-risk group using the ESC/ESA algorithm was associated with 30-day MACE; however, discrimination of the ESC/ESA algorithms for 30-day MACE was modest; area under the curve 0.64 (95% confidence interval: 0.61-0.67). After adjustment for sex, age, and ASA physical status, discrimination was 0.72 (0.70-0.75). Overuse or underuse of cardiac tests were not consistently associated with MACE. There was no independent association between test recommendation class and pathological findings (P=0.14 for stress imaging; P=0.35 for transthoracic echocardiography; P=0.52 for coronary angiography). CONCLUSIONS Discrimination for MACE using the ESC/ESA guidelines algorithms was limited. Overuse or underuse of cardiac tests was not consistently associated with cardiovascular events. The recommendation class of preoperative cardiac tests did not influence their yield. CLINICAL TRIAL REGISTRATION NCT02573532.
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Affiliation(s)
| | - Christian Puelacher
- Department of Cardiology and Cardiovascular Research Institute Basel, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Danielle Menosi Gualandro
- Department of Cardiology and Cardiovascular Research Institute Basel, University Hospital Basel, University of Basel, Basel, Switzerland; Interdisciplinary Medicine in Cardiology Unit, Cardiology Department, Heart Institute (InCor), University of São Paulo Medical School, São Paulo, Brazil
| | - Derya Kilinc
- Department of Cardiology and Cardiovascular Research Institute Basel, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Noemi Glarner
- Department of Cardiology and Cardiovascular Research Institute Basel, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Reka Hidvegi
- Department of Cardiology and Cardiovascular Research Institute Basel, University Hospital Basel, University of Basel, Basel, Switzerland; Department of Anaesthesiology, University Hospital Basel, Basel, Switzerland
| | - Daniel Bolliger
- Department of Anaesthesiology, University Hospital Basel, Basel, Switzerland
| | - Ketina Arslani
- Department of Cardiology and Cardiovascular Research Institute Basel, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Andreas Lampart
- Department of Anaesthesiology, University Hospital Basel, Basel, Switzerland
| | - Luzius A Steiner
- Department of Anaesthesiology, University Hospital Basel, Basel, Switzerland
| | - Christoph Kindler
- Department of Anaesthesiology, Cantonal Hospital Aarau, Aarau, Switzerland
| | - Thomas Wolff
- Department of Vascular Surgery, University Hospital Basel, Basel, Switzerland
| | - Edin Mujagic
- Department of Vascular Surgery, University Hospital Basel, Basel, Switzerland
| | - Lorenz Guerke
- Department of Vascular Surgery, University Hospital Basel, Basel, Switzerland
| | - Christian Mueller
- Department of Cardiology and Cardiovascular Research Institute Basel, University Hospital Basel, University of Basel, Basel, Switzerland
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32
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Rubini Giménez M, Wildi K, Wussler D, Koechlin L, Boeddinghaus J, Nestelberger T, Badertscher P, Sedlmayer R, Puelacher C, Zimmermann T, du Fay de Lavallaz J, Lopez-Ayala P, Leu K, Rentsch K, Miró Ò, López B, Martín-Sánchez FJ, Bustamante J, Kawecki D, Parenica J, Lohrmann J, Kloos W, Buser A, Keller DI, Reichlin T, Twerenbold R, Mueller C. Cinética temprana de troponina en pacientes con sospecha de infarto agudo de miocardio. Rev Esp Cardiol (Engl Ed) 2021. [DOI: 10.1016/j.recesp.2020.04.004] [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: 11/17/2022]
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33
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Puelacher C, Bollen Pinto B, Mills NL, Duceppe E, Popova E, Duma A, Nagele P, Omland T, Hammerer-Lercher A, Lurati Buse G. Expert consensus on peri-operative myocardial injury screening in noncardiac surgery: A literature review. Eur J Anaesthesiol 2021; 38:600-608. [PMID: 33653981 DOI: 10.1097/eja.0000000000001486] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Peri-operative myocardial injury, detected by dynamic and elevated cardiac troponin (cTn) concentrations, is a common complication of noncardiac surgery that is strongly associated with 30-day mortality. Although active screening for peri-operative myocardial injury has been suggested in recent guidelines, clinical implementation remains tentative due to a lack of examples on how to tackle such an interdisciplinary project at a local level. Moreover, consensus on which assay and cTn cut-off values should be used has not yet been reached, and guidance on whom to screen is lacking. In this article, we aim to summarise local examples of successfully implemented cTn screening practices and review the current literature in order to provide information and suggestions for patient selection, organisation of a screening programme, caveats and a potential management pathway.
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Affiliation(s)
- Christian Puelacher
- From the Department of Cardiology and Cardiovascular Research Institute Basel, University Hospital of Basel, University of Basel; Department of Internal Medicine, University Hospital Basel, University Basel, Basel (CP), Division of Anaesthesiology, Department of Anaesthesiology, Pharmacology, Intensive Care and Emergency Medicine, University Hospitals of Geneva, Geneva, Switzerland (CP, BBP), Geneva Perioperative Basic, Translational and Clinical Research Group (BB-P), BHF Centre for Cardiovascular Science and Usher Institute, University of Edinburgh, Edinburgh, UK (NLM), Department of Medicine, Centre Hospitalier de l'Universite de Montreal, Montreal, Quebec, Canada (ED), Iberoamerican Cochrane Centre, Biomedical Research Institute (IIB Sant Pau), Barcelona, Spain (EP), Department of Anaesthesiology and Intensive Care, Medical University of Vienna, Vienna, Austria (AD), Departments of Anesthesia and Critical Care, University of Chicago, Chicago, Illinois, USA (PN), Department of Cardiology, Division of Medicine, Akershus University Hospital and University of Oslo, Oslo, Norway (TO), Institute of Laboratory Medicine, County Hospital Aarau, Aarau, Switzerland (A-HL), Department of Anaesthesiology, University Hospital Düsseldorf, Düsseldorf, Germany (GLB)
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Nestelberger T, Lopez-Ayala P, Boeddinghaus J, Strebel I, Rubini Gimenez M, Huber I, Wildi K, Wussler D, Koechlin L, Prepoudis A, Gualandro DM, Puelacher C, Glarner N, Haaf P, Frey S, Bakula A, Wick R, Miró Ò, Martin-Sanchez FJ, Kawecki D, Keller D, Twerenbold R, Mueller C. External Validation and Extension of a Clinical Score for the Discrimination of Type 2 Myocardial Infarction. J Clin Med 2021; 10:1264. [PMID: 33803801 PMCID: PMC8003225 DOI: 10.3390/jcm10061264] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [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: 03/03/2021] [Revised: 03/12/2021] [Accepted: 03/14/2021] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND The early non-invasive discrimination of Type 2 versus Type 1 Myocardial Infarction (T2MI, T1MI) is a major unmet clinical need. We aimed to externally validate a recently derived clinical score (Neumann) combing female sex, no radiating chest pain, and high-sensitivity cardiac troponin I (hs-cTnI) concentration ≤40.8 ng/L. METHODS Patients presenting with acute chest discomfort to the emergency department were prospectively enrolled into an international multicenter diagnostic study. The final diagnoses of T2MI and T1MI were centrally adjudicated by two independent cardiologists using all information including cardiac imaging and serial measurements of hs-cTnT/I according to the fourth universal definition of MI. Model performance for T2MI diagnosis was assessed by formal tests and graphical means of discrimination and calibration. RESULTS Among 6684 enrolled patients, MI was the adjudicated final diagnosis in 1079 (19%) patients, of which 242 (22%) had T2MI. External validation of the Neumann Score showed a moderate discrimination (C-statistic 0.67 (95%CI 0.64-0.71)). Model calibration showed underestimation of the predicted probabilities of having T2MI for low point scores. Model extension by adding the binary variable heart rate >120/min significantly improved model performance (C-statistic 0.73 (95% CI 0.70-0.76, p < 0.001) and had good calibration. Patients with the highest score values of 3 (Neumann Score, 9.9%) and 5 (Extended Neumann Score, 3.3%) had a 53% and 91% predicted probability of T2MI, respectively. CONCLUSION The Neumann Score provided moderate discrimination and suboptimal calibration. Extending the Neumann Score by adding heart rate >120/min improved the model's performance.
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Affiliation(s)
- Thomas Nestelberger
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, 4031 Basel, Switzerland; (T.N.); (P.L.-A.); (J.B.); (I.S.); (M.R.G.); (I.H.); (K.W.); (D.W.); (L.K.); (A.P.); (D.M.G.); (C.P.); (N.G.); (P.H.); (S.F.); (A.B.); (R.W.); (R.T.)
- GREAT Network, 00191 Rome, Italy; (Ò.M.); (F.J.M.-S.); (D.K.)
- Division of Cardiology, Vancouver General Hospital, University of British Columbia, Vancouver, BC V5Z 1M9, Canada
| | - Pedro Lopez-Ayala
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, 4031 Basel, Switzerland; (T.N.); (P.L.-A.); (J.B.); (I.S.); (M.R.G.); (I.H.); (K.W.); (D.W.); (L.K.); (A.P.); (D.M.G.); (C.P.); (N.G.); (P.H.); (S.F.); (A.B.); (R.W.); (R.T.)
- GREAT Network, 00191 Rome, Italy; (Ò.M.); (F.J.M.-S.); (D.K.)
| | - Jasper Boeddinghaus
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, 4031 Basel, Switzerland; (T.N.); (P.L.-A.); (J.B.); (I.S.); (M.R.G.); (I.H.); (K.W.); (D.W.); (L.K.); (A.P.); (D.M.G.); (C.P.); (N.G.); (P.H.); (S.F.); (A.B.); (R.W.); (R.T.)
- GREAT Network, 00191 Rome, Italy; (Ò.M.); (F.J.M.-S.); (D.K.)
| | - Ivo Strebel
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, 4031 Basel, Switzerland; (T.N.); (P.L.-A.); (J.B.); (I.S.); (M.R.G.); (I.H.); (K.W.); (D.W.); (L.K.); (A.P.); (D.M.G.); (C.P.); (N.G.); (P.H.); (S.F.); (A.B.); (R.W.); (R.T.)
- GREAT Network, 00191 Rome, Italy; (Ò.M.); (F.J.M.-S.); (D.K.)
| | - Maria Rubini Gimenez
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, 4031 Basel, Switzerland; (T.N.); (P.L.-A.); (J.B.); (I.S.); (M.R.G.); (I.H.); (K.W.); (D.W.); (L.K.); (A.P.); (D.M.G.); (C.P.); (N.G.); (P.H.); (S.F.); (A.B.); (R.W.); (R.T.)
- GREAT Network, 00191 Rome, Italy; (Ò.M.); (F.J.M.-S.); (D.K.)
- Department of Internal Medicine/Cardiology, Heart Center Leipzig at University Leipzig, 04109 Leipzig, Germany
| | - Iris Huber
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, 4031 Basel, Switzerland; (T.N.); (P.L.-A.); (J.B.); (I.S.); (M.R.G.); (I.H.); (K.W.); (D.W.); (L.K.); (A.P.); (D.M.G.); (C.P.); (N.G.); (P.H.); (S.F.); (A.B.); (R.W.); (R.T.)
- GREAT Network, 00191 Rome, Italy; (Ò.M.); (F.J.M.-S.); (D.K.)
| | - Karin Wildi
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, 4031 Basel, Switzerland; (T.N.); (P.L.-A.); (J.B.); (I.S.); (M.R.G.); (I.H.); (K.W.); (D.W.); (L.K.); (A.P.); (D.M.G.); (C.P.); (N.G.); (P.H.); (S.F.); (A.B.); (R.W.); (R.T.)
- GREAT Network, 00191 Rome, Italy; (Ò.M.); (F.J.M.-S.); (D.K.)
- Critical Care Research Institute, the Prince Charles Hospital, Brisbane and University of Queensland, 4072 Brisbane, Australia
| | - Desiree Wussler
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, 4031 Basel, Switzerland; (T.N.); (P.L.-A.); (J.B.); (I.S.); (M.R.G.); (I.H.); (K.W.); (D.W.); (L.K.); (A.P.); (D.M.G.); (C.P.); (N.G.); (P.H.); (S.F.); (A.B.); (R.W.); (R.T.)
- GREAT Network, 00191 Rome, Italy; (Ò.M.); (F.J.M.-S.); (D.K.)
| | - Luca Koechlin
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, 4031 Basel, Switzerland; (T.N.); (P.L.-A.); (J.B.); (I.S.); (M.R.G.); (I.H.); (K.W.); (D.W.); (L.K.); (A.P.); (D.M.G.); (C.P.); (N.G.); (P.H.); (S.F.); (A.B.); (R.W.); (R.T.)
- GREAT Network, 00191 Rome, Italy; (Ò.M.); (F.J.M.-S.); (D.K.)
- Department of Cardiac Surgery, University Hospital Basel, 3010 Basel, Switzerland
| | - Alexandra Prepoudis
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, 4031 Basel, Switzerland; (T.N.); (P.L.-A.); (J.B.); (I.S.); (M.R.G.); (I.H.); (K.W.); (D.W.); (L.K.); (A.P.); (D.M.G.); (C.P.); (N.G.); (P.H.); (S.F.); (A.B.); (R.W.); (R.T.)
- GREAT Network, 00191 Rome, Italy; (Ò.M.); (F.J.M.-S.); (D.K.)
| | - Danielle M. Gualandro
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, 4031 Basel, Switzerland; (T.N.); (P.L.-A.); (J.B.); (I.S.); (M.R.G.); (I.H.); (K.W.); (D.W.); (L.K.); (A.P.); (D.M.G.); (C.P.); (N.G.); (P.H.); (S.F.); (A.B.); (R.W.); (R.T.)
- GREAT Network, 00191 Rome, Italy; (Ò.M.); (F.J.M.-S.); (D.K.)
| | - Christian Puelacher
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, 4031 Basel, Switzerland; (T.N.); (P.L.-A.); (J.B.); (I.S.); (M.R.G.); (I.H.); (K.W.); (D.W.); (L.K.); (A.P.); (D.M.G.); (C.P.); (N.G.); (P.H.); (S.F.); (A.B.); (R.W.); (R.T.)
- GREAT Network, 00191 Rome, Italy; (Ò.M.); (F.J.M.-S.); (D.K.)
| | - Noemi Glarner
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, 4031 Basel, Switzerland; (T.N.); (P.L.-A.); (J.B.); (I.S.); (M.R.G.); (I.H.); (K.W.); (D.W.); (L.K.); (A.P.); (D.M.G.); (C.P.); (N.G.); (P.H.); (S.F.); (A.B.); (R.W.); (R.T.)
- GREAT Network, 00191 Rome, Italy; (Ò.M.); (F.J.M.-S.); (D.K.)
| | - Philip Haaf
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, 4031 Basel, Switzerland; (T.N.); (P.L.-A.); (J.B.); (I.S.); (M.R.G.); (I.H.); (K.W.); (D.W.); (L.K.); (A.P.); (D.M.G.); (C.P.); (N.G.); (P.H.); (S.F.); (A.B.); (R.W.); (R.T.)
| | - Simon Frey
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, 4031 Basel, Switzerland; (T.N.); (P.L.-A.); (J.B.); (I.S.); (M.R.G.); (I.H.); (K.W.); (D.W.); (L.K.); (A.P.); (D.M.G.); (C.P.); (N.G.); (P.H.); (S.F.); (A.B.); (R.W.); (R.T.)
| | - Adam Bakula
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, 4031 Basel, Switzerland; (T.N.); (P.L.-A.); (J.B.); (I.S.); (M.R.G.); (I.H.); (K.W.); (D.W.); (L.K.); (A.P.); (D.M.G.); (C.P.); (N.G.); (P.H.); (S.F.); (A.B.); (R.W.); (R.T.)
| | - Rupprecht Wick
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, 4031 Basel, Switzerland; (T.N.); (P.L.-A.); (J.B.); (I.S.); (M.R.G.); (I.H.); (K.W.); (D.W.); (L.K.); (A.P.); (D.M.G.); (C.P.); (N.G.); (P.H.); (S.F.); (A.B.); (R.W.); (R.T.)
| | - Òscar Miró
- GREAT Network, 00191 Rome, Italy; (Ò.M.); (F.J.M.-S.); (D.K.)
- Emergency Department, Hospital Clinic, 08036 Barcelona, Spain
| | - F. Javier Martin-Sanchez
- GREAT Network, 00191 Rome, Italy; (Ò.M.); (F.J.M.-S.); (D.K.)
- Servicio de Urgencias, Hospital Clínico San Carlos, 28040 Madrid, Spain
| | - Damian Kawecki
- GREAT Network, 00191 Rome, Italy; (Ò.M.); (F.J.M.-S.); (D.K.)
- 2nd Department of Cardiology, School of Medicine with the Division of Dentistry in Zabrze, Medical University of Silesia, 40-055 Katowice, Poland
| | - Dagmar Keller
- Emergency Department, University Hospital Zurich, 8006 Zurich, Switzerland;
| | - Raphael Twerenbold
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, 4031 Basel, Switzerland; (T.N.); (P.L.-A.); (J.B.); (I.S.); (M.R.G.); (I.H.); (K.W.); (D.W.); (L.K.); (A.P.); (D.M.G.); (C.P.); (N.G.); (P.H.); (S.F.); (A.B.); (R.W.); (R.T.)
- GREAT Network, 00191 Rome, Italy; (Ò.M.); (F.J.M.-S.); (D.K.)
| | - Christian Mueller
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, 4031 Basel, Switzerland; (T.N.); (P.L.-A.); (J.B.); (I.S.); (M.R.G.); (I.H.); (K.W.); (D.W.); (L.K.); (A.P.); (D.M.G.); (C.P.); (N.G.); (P.H.); (S.F.); (A.B.); (R.W.); (R.T.)
- GREAT Network, 00191 Rome, Italy; (Ò.M.); (F.J.M.-S.); (D.K.)
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Giger RD, du Fay de Lavallaz J, Prepoudis A, Stoll T, Lopez-Ayala P, Glarner N, Boeddinghaus J, Puelacher C, Nestelberger T, Mueller C. Rhabdomyolysis: A Noncardiac Source of Increased Circulating Concentrations of Cardiac Troponin T? J Am Coll Cardiol 2021; 76:2685-2687. [PMID: 33243386 DOI: 10.1016/j.jacc.2020.08.088] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Revised: 07/30/2020] [Accepted: 08/18/2020] [Indexed: 12/22/2022]
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Schaerli N, Abächerli R, Walter J, Honegger U, Puelacher C, Rinderknecht T, Müller D, Boeddinghaus J, Nestelberger T, Strebel I, Badertscher P, du Fay de Lavallaz J, Twerenbold R, Wussler D, Hofer J, Leber R, Kaiser C, Osswald S, Wild D, Zellweger MJ, Mueller C, Reichlin T. Incremental value of high-frequency QRS analysis for diagnosis and prognosis in suspected exercise-induced myocardial ischaemia. European Heart Journal. Acute Cardiovascular Care 2020; 9:836-847. [DOI: 10.1177/2048872619842988] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Aim:
Exercise stress testing is used to detect myocardial ischaemia, but is limited by low sensitivity and specificity. The authors investigated the value of the analysis of high-frequency QRS components as a marker of abnormal depolarization in addition to standard ST-deviations as a marker of abnormal repolarization to improve the diagnostic accuracy.
Methods and results:
Consecutive patients undergoing bicycle exercise stress nuclear myocardial perfusion imaging were prospectively enrolled. Presence of myocardial ischaemia, the primary diagnostic endpoint, was adjudicated using MPI and coronary angiography. Automated high-frequency QRS analysis was performed in a blinded fashion. The prognostic endpoint was major adverse cardiac events (MACEs) during two years of follow-up. Exercise-induced ischaemia was detected in 147/662 patients (22%). The sensitivity of high-frequency QRS was similar to ST-deviations (46% vs. 43%, p=0.59), while the specificity was lower (75% vs. 87%, p<0.001). The combined use of high-frequency QRS and ST-deviations classified 59% of patients as ‘rule-out’ (both negative), 9% as ‘rule-in’ (both positive) and 32% in an intermediate zone (one test positive). The sensitivity for ‘rule-out’ and the specificity for ‘rule-in’ improved to 63% and 97% compared with ST-deviation analysis alone (both p<0.001). MACE-free survival was 90%, 80% and 42% in patients in the ‘rule-out’, intermediate and ‘rule-in’ groups (p<0.001). After adjustment for age, gender, ST-deviations and clinical post-test probability of ischaemia, high-frequency QRS remained an independent predictor for the occurrence of MACEs.
Conclusion:
The use of high-frequency QRS analysis in addition to ST-deviation analysis improves the diagnostic accuracy during exercise stress testing and adds independent prognostic information.
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Affiliation(s)
- Nicolas Schaerli
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Switzerland
- Department of Internal Medicine, University Hospital Basel, Switzerland
| | - Roger Abächerli
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Switzerland
- Institute for Medical Engineering, Lucerne University of Applied Sciences and Arts, Horw, Switzerland
| | - Joan Walter
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Switzerland
| | - Ursina Honegger
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Switzerland
| | - Christian Puelacher
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Switzerland
- Department of Internal Medicine, University Hospital Basel, Switzerland
| | - Therese Rinderknecht
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Switzerland
| | - Deborah Müller
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Switzerland
| | - Jasper Boeddinghaus
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Switzerland
- Department of Internal Medicine, University Hospital Basel, Switzerland
| | - Thomas Nestelberger
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Switzerland
- Department of Internal Medicine, University Hospital Basel, Switzerland
| | - Ivo Strebel
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Switzerland
| | - Patrick Badertscher
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Switzerland
| | - Jeanne du Fay de Lavallaz
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Switzerland
| | - Raphael Twerenbold
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Switzerland
- Department of General and Interventional Cardiology, University Heart Centre Hamburg, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Desiree Wussler
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Switzerland
| | - Johanna Hofer
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Switzerland
| | - Remo Leber
- Research, Schiller AG, Baar, Switzerland
| | - Christoph Kaiser
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Switzerland
| | - Stefan Osswald
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Switzerland
| | - Damian Wild
- Division of Nuclear Medicine, University Hospital Basel, Switzerland
| | - Michael J Zellweger
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Switzerland
| | - Christian Mueller
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Switzerland
| | - Tobias Reichlin
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Switzerland
- Department of Cardiology, Inselspital, University Hospital Bern, University of Bern, Switzerland
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Gualandro D, Puelacher C, Liffert M, Arslani K, Meister R, Glarner N, Luratibuse G, Cardozo F, Bolliger D, Steiner L, Caramelli B, Osswald S, Mueller C. Direct comparison of the accuracy of preoperative high-sensitivity cardiac troponin T to predict mortality, acute heart failure and perioperative myocardial infarction/injury after non-cardiac surgery. Eur Heart J 2020. [DOI: 10.1093/ehjci/ehaa946.3216] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
Background
Death, acute heart failure (AHF) and perioperative myocardial infarction/injury (PMI) are the most relevant cardiovascular complications following non-cardiac surgery. Unfortunately, the incidence of these complications are higher than expected. Currently available tools to predict these complications have only modest accuracy.
Purpose
To determine the accuracy of preoperative high-sensitivity cardiac troponin T (hs-cTnT) concentrations for prediction of mortality, AHF and PMI after non-cardiac surgery.
Methods
We prospectively included 4,709 patients at high cardiovascular risk undergoing non-cardiac surgery. Hs-cTnT concentrations were measured before surgery and, daily after surgery, for two days. PMI was defined as an absolute increase of 14ng/L (the 99th percentile of the assay used) from hs-cTnT baseline values. The primary endpoint was the diagnostic accuracy of preoperative hs-cTnT concentration to predict death, AHF and PMI within 30 days, as quantified by the area under the receiving-operating curve (AUC). Multivariate logistic regression analysis was performed to test the association between preoperative hs-cTnT and each endpoint.
Results
All-cause mortality occurred in 133 (3%), AHF in 84 (2%) and PMI in 742 (16%) patients. Preoperative hs-cTnT concentrations had good accuracy for prediction of death, AHF and PMI (AUC = 0.75 [95% CI, 0.71–0.79], 0.72 [95% CI, 0.67–0.77] and 0.73 [95% CI, 0.71–0.75], respectively). After adjusting for confounders, hs-cTnT remained an independent predictor for death with an adjusted odds ratio (aOR) of 2.1 (95% CI, 1.7–2.7, P<0.001) and for PMI (aOR 2.2, 95% CI, 1.9–2.4, P<0.001), but not for AHF (aOR 1.0, 95% CI, 0.7–1.4, P=0.99). An hs-cTnT concentration below 5ng/L was found in 526 (11%) patients, and this cut-off yielded a negative predictive value of 99.6% for the occurrence of death, 99.2% for AHF and 95.6% for PMI.
Conclusion
The preoperative hs-cTnT concentration has a good accuracy to predict mortality, AHF and PMI after non-cardiac surgery, but is an independent predictor only for mortality and PMI. A cut-off value of 5ng/L identifies a subgroup of patients at low risk for these complications.
Funding Acknowledgement
Type of funding source: Foundation. Main funding source(s): Swiss National Foundation, Swiss Herat Foundation
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Affiliation(s)
- D Gualandro
- University Hospital Basel, Basel, Switzerland
| | - C Puelacher
- University Hospital Basel, Basel, Switzerland
| | - M Liffert
- University Hospital Basel, Basel, Switzerland
| | - K Arslani
- University Hospital Basel, Basel, Switzerland
| | - R Meister
- University Hospital Basel, Basel, Switzerland
| | - N Glarner
- University Hospital Basel, Basel, Switzerland
| | - G Luratibuse
- University Hospital Düsseldorf, Düsseldorf, Germany
| | - F.A Cardozo
- Heart Institute (InCor), University of São Paulo Medical School, Cardiology, São Paulo, Brazil
| | - D Bolliger
- University Hospital Basel, Basel, Switzerland
| | - L Steiner
- University Hospital Basel, Basel, Switzerland
| | - B Caramelli
- Heart Institute (InCor), University of São Paulo Medical School, Cardiology, São Paulo, Brazil
| | - S Osswald
- University Hospital Basel, Basel, Switzerland
| | - C Mueller
- University Hospital Basel, Basel, Switzerland
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Lurati Buse GAL, Puelacher C, Gualandro DM, Genini AS, Hidvegi R, Bolliger D, Arslani K, Steiner LA, Kindler C, Mueller C. Association between self-reported functional capacity and major adverse cardiac events in patients at elevated risk undergoing noncardiac surgery: a prospective diagnostic cohort study. Br J Anaesth 2020; 126:102-110. [PMID: 33081973 DOI: 10.1016/j.bja.2020.08.041] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Revised: 08/18/2020] [Accepted: 08/27/2020] [Indexed: 10/23/2022] Open
Abstract
BACKGROUND Perioperative cardiovascular guidelines endorse functional capacity estimation, based on 'cut-off' daily activities for risk assessment and climbing two flights of stairs to approximate 4 metabolic equivalents. We assessed the association between self-reported functional capacity and postoperative cardiac events. METHODS Consecutive patients at elevated cardiovascular risk undergoing in-patient noncardiac surgery were included in this predefined secondary analysis. Self-reported ability to walk up two flights of stairs was extracted from electronic charts. The primary endpoint was a composite of cardiac death and cardiac events at 30 days. Secondary endpoints included the same composite at 1 yr, all-cause mortality, and myocardial injury. RESULTS Among the 4560 patients, mean (standard deviation) age 73 (SD 8 yr) yr, classified as American Society of Anesthesiologists physical status ≥3 in 61% (n=2786/4560), the 30-day and 1-yr incidences of major adverse cardiac events were 5.7% (258/4560) and 11.2% (509/4560), respectively. Functional capacity less than two flights of stairs was associated with the 30-day composite endpoint (adjusted hazard ratio 1.63, 95% confidence interval [CI] 1.23-2.15) and all other endpoints. The addition of functional capacity information to the revised cardiac risk index (RCRI) significantly improved risk classification (functional capacity plus RCRI vs RCRI: net reclassification improvement [NRI]Events 6.2 [95% CI 3.6-9.9], NRINonevents19.2 [95% CI 18.1-20.0]). CONCLUSIONS In patients at high cardiovascular risk undergoing noncardiac surgery, self-reported functional capacity less than two flights of stairs was independently associated with major adverse cardiac events and all-cause mortality at 30 days and 1 yr. The addition of self-reported functional capacity to surgical and clinical risk improved risk classification. CLINICAL TRIAL REGISTRATION INCT 02573532.
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Affiliation(s)
| | - Christian Puelacher
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Basel, Switzerland
| | - Danielle Menosi Gualandro
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Basel, Switzerland; Interdisciplinary Medicine in Cardiology Unit, Cardiology Department, Heart Institute (InCor), University of Sao Paulo Medical School, Sao Paulo, Brazil
| | - Alessandro S Genini
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Basel, Switzerland; Department of Anaesthesiology, University Hospital Basel, Basel, Switzerland
| | - Reka Hidvegi
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Basel, Switzerland; Department of Anaesthesiology, University Hospital Basel, Basel, Switzerland
| | - Daniel Bolliger
- Department of Anaesthesiology, University Hospital Basel, Basel, Switzerland
| | - Ketina Arslani
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Basel, Switzerland
| | - Luzius A Steiner
- Department of Anaesthesiology, University Hospital Basel, Basel, Switzerland
| | - Christoph Kindler
- Department of Anaesthesiology, Cantonal Hospital Aarau, Aarau, Switzerland
| | - Christian Mueller
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Basel, Switzerland
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Sazgary L, Puelacher C, Lurati Buse G, Glarner N, Lampart A, Bolliger D, Steiner L, Gürke L, Wolff T, Mujagic E, Schaeren S, Lardinois D, Espinola J, Kindler C, Hammerer-Lercher A, Strebel I, Wildi K, Hidvegi R, Gueckel J, Hollenstein C, Breidthardt T, Rentsch K, Buser A, Gualandro DM, Mueller C. Incidence of major adverse cardiac events following non-cardiac surgery. Eur Heart J Acute Cardiovasc Care 2020; 10:zuaa008. [PMID: 33620378 PMCID: PMC8245139 DOI: 10.1093/ehjacc/zuaa008] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Revised: 07/19/2020] [Accepted: 07/31/2020] [Indexed: 12/16/2022]
Abstract
AIMS Major adverse cardiac events (MACE) triggered by non-cardiac surgery are prognostically important perioperative complications. However, due to often asymptomatic presentation, the incidence and timing of postoperative MACE are incompletely understood. METHODS AND RESULTS We conducted a prospective observational study implementing a perioperative screening for postoperative MACE [cardiovascular death (CVD), acute heart failure (AHF), haemodynamically relevant arrhythmias, spontaneous myocardial infarction (MI), and perioperative myocardial infarction/injury (PMI)] in patients at increased cardiovascular risk (≥65 years OR ≥45 years with history of cardiovascular disease) undergoing non-cardiac surgery at a tertiary hospital. All patients received serial measurements of cardiac troponin to detect asymptomatic MACE. Among 2265 patients (mean age 73 years, 43.4% women), the incidence of MACE was 15.2% within 30 days, and 20.6% within 365 days. CVD occurred in 1.2% [95% confidence interval (CI) 0.9-1.8] and in 3.7% (95% CI 3.0-4.5), haemodynamically relevant arrhythmias in 1.2% (95% CI 0.9-1.8) and in 2.1% (95% CI 1.6-2.8), AHF in 1.6% (95% CI 1.2-2.2) and in 4.2% (95% CI 3.4-5.1), spontaneous MI in 0.5% (95% CI 0.3-0.9) and in 1.6% (95% CI 1.2-2.2), and PMI in 13.2% (95% CI 11.9-14.7) and in 14.8% (95% CI 13.4-16.4) within 30 days and within 365 days, respectively. The MACE-incidence was increased above presumed baseline rate until Day 135 (95% CI 104-163), indicating a vulnerable period of 3-5 months. CONCLUSION One out of five high-risk patients undergoing non-cardiac surgery will develop one or more MACE within 365 days. The risk for MACE remains increased for about 5 months after non-cardiac surgery. TRIAL REGISTRATION https://www.clinicaltrials.gov. Unique identifier: NCT02573532.
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Affiliation(s)
- Lorraine Sazgary
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University Basel, Basel, Switzerland
| | - Christian Puelacher
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University Basel, Basel, Switzerland
| | - Giovanna Lurati Buse
- Department of Anesthesiology, University Hospital Dusseldorf, Moorenstraße 5, 40225 Düsseldorf, Germany
- Department of Anesthesiology, University Hospital Basel, Spitalstrasse 21 4031 Basel, University of Basel, Basel, Switzerland
| | - Noemi Glarner
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University Basel, Basel, Switzerland
| | - Andreas Lampart
- Department of Anesthesiology, University Hospital Basel, Spitalstrasse 21 4031 Basel, University of Basel, Basel, Switzerland
| | - Daniel Bolliger
- Department of Anesthesiology, University Hospital Basel, Spitalstrasse 21 4031 Basel, University of Basel, Basel, Switzerland
| | - Luzius Steiner
- Department of Anesthesiology, University Hospital Basel, Spitalstrasse 21 4031 Basel, University of Basel, Basel, Switzerland
| | - Lorenz Gürke
- Department of Vascular Surgery, University Hospital Basel, Spitalstrasse 21 4031 Basel, University of Basel, Basel, Switzerland
| | - Thomas Wolff
- Department of Vascular Surgery, University Hospital Basel, Spitalstrasse 21 4031 Basel, University of Basel, Basel, Switzerland
| | - Edin Mujagic
- Department of Vascular Surgery, University Hospital Basel, Spitalstrasse 21 4031 Basel, University of Basel, Basel, Switzerland
| | - Stefan Schaeren
- Department of Traumatology & Orthopedics, Spitalstrasse 21 4031 Basel, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Didier Lardinois
- Department of Thoracic Surgery, University Hospital Basel, Spitalstrasse 21 4031 Basel, University of Basel, Basel, Switzerland
| | - Jacqueline Espinola
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University Basel, Basel, Switzerland
- Department of Anesthesiology, Cantonal Hospital Aarau, Tellstrasse 25 5001 Aarau, Switzerland
| | - Christoph Kindler
- Department of Anesthesiology, Cantonal Hospital Aarau, Tellstrasse 25 5001 Aarau, Switzerland
| | | | - Ivo Strebel
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University Basel, Basel, Switzerland
| | - Karin Wildi
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University Basel, Basel, Switzerland
- Department of Anesthesiology, University Hospital Basel, Spitalstrasse 21 4031 Basel, University of Basel, Basel, Switzerland
| | - Reka Hidvegi
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University Basel, Basel, Switzerland
| | - Johanna Gueckel
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University Basel, Basel, Switzerland
| | - Christina Hollenstein
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University Basel, Basel, Switzerland
| | - Tobias Breidthardt
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University Basel, Basel, Switzerland
- Department of Internal Medicine, University Hospital Basel, University of Basel, Petersgraben 4 4031 Basel, Switzerland
| | - Katharina Rentsch
- Department of Laboratory Medicine, University Hospital Basel, University of Basel, Petersgraben 4 4031 Basel, Switzerland
| | - Andreas Buser
- Blood Bank and Department of Hematology, University Hospital Basel, University of Basel, Petersgraben 4 4031 Basel, Switzerland
| | - Danielle M Gualandro
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University Basel, Basel, Switzerland
- Department of Cardiology, Incor, University of Sao Paulo, Av. Dr. Enéas Carvalho de Aguiar, 44 - Cerqueira César, São Paulo - SP, 05403-900 Sao Paulo, Brazil
| | - Christian Mueller
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University Basel, Basel, Switzerland
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Puelacher C, Gualandro DM, Lurati Buse G, Bolliger D, Marbot S, Kindler C, Hammerer-Lercher A, Gürke L, Steiner L, Mueller C. Etiology of Peri-Operative Myocardial Infarction/Injury After Noncardiac Surgery and Associated Outcome. J Am Coll Cardiol 2020; 76:1910-1912. [DOI: 10.1016/j.jacc.2020.08.043] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Revised: 07/31/2020] [Accepted: 08/03/2020] [Indexed: 02/01/2023]
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Arslani K, Puelacher C, Gualandro DM, Mueller C. Re: Myocardial Injury After Noncardiac Surgery: Incidence, Predictive Factors, and Outcome in High-Risk Patients Undergoing Thoracic Surgery: An Observational Study. J Cardiothorac Vasc Anesth 2020; 34:2549-2550. [PMID: 32553414 DOI: 10.1053/j.jvca.2020.05.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Revised: 04/28/2020] [Accepted: 05/08/2020] [Indexed: 11/11/2022]
Affiliation(s)
- Ketina Arslani
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Basel, Switzerland
| | - Christian Puelacher
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Basel, Switzerland
| | - Danielle Menosi Gualandro
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Basel, Switzerland
| | - Christian Mueller
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Basel, Switzerland
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Rubini Giménez M, Wildi K, Wussler D, Koechlin L, Boeddinghaus J, Nestelberger T, Badertscher P, Sedlmayer R, Puelacher C, Zimmermann T, du Fay de Lavallaz J, Lopez-Ayala P, Leu K, Rentsch K, Miró Ò, López B, Martín-Sánchez FJ, Bustamante J, Kawecki D, Parenica J, Lohrmann J, Kloos W, Buser A, Keller DI, Reichlin T, Twerenbold R, Mueller C. Early kinetics of cardiac troponin in suspected acute myocardial infarction. ACTA ACUST UNITED AC 2020; 74:502-509. [PMID: 32451223 DOI: 10.1016/j.rec.2020.04.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [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: 09/23/2019] [Accepted: 04/02/2020] [Indexed: 01/22/2023]
Abstract
INTRODUCTION AND OBJECTIVES Release kinetics of high-sensitivity cardiac troponin (hs-cTn) T and I in patients with acute myocardial infarction (AMI) are incompletely understood. We aimed to assess whether hs-cTnT/I release in early AMI is near linear. METHODS In a prospective diagnostic multicenter study the acute release of hs-cTnT and hs-cTnI within 1 and 2hours from presentation to the emergency department was quantified using 3 hs-cTnT/I assays in patients with suspected AMI. The primary endpoint was correlation between hs-cTn changes from presentation to 1 hour vs changes from presentation to 2hours, among all AMI patients and different prespecified subgroups. The final diagnosis was adjudicated by 2 independent cardiologists, based on serial hs-cTnT from the serial study blood samples and additional locally measured hs-cTn values. RESULTS Among 2437 patients with complete hs-cTnT data, AMI was the adjudicated diagnosis in 376 patients (15%). For hs-cTnT, the correlation coefficient between 0- to 1-hour change and 0- to 2 hour change was 0.931 (95%CI, 0.916-0.944), P <.001. Similar findings were obtained with hs-cTnI (Architect) with correlation coefficients between 0- to 1-hour change and 0- to 2 hour change of 0.969 and hs-cTnI (Centaur) of 0.934 (P <.001 for both). Findings were consistent among type 1 and type 2 AMI and in the subgroup of patients presenting very early after chest pain onset. CONCLUSIONS Patients presenting with early AMI showed a near linear release of hs-cTnT and hs-cTnI. This near linearity provides the pathophysiological basis for rapid diagnostic algorithms using 0- to 1-hour changes as surrogates for 0- to 2 hour or 0- to 3 hour changes. Registered at ClinicalTrials.gov (Identifier: NCT00470587).
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Affiliation(s)
- María Rubini Giménez
- Department of Cardiology and Cardiovascular Research, Institute Basel (CRIB), University Hospital Basel, Basel, Switzerland; Department of Cardiology, Heart Center Leipzig, Leipzig, Germany
| | - Karin Wildi
- Department of Cardiology and Cardiovascular Research, Institute Basel (CRIB), University Hospital Basel, Basel, Switzerland; Critical Care Research Institute, the Prince Charles Hospital, Brisbane and University of Queensland, Brisbane, Australia
| | - Desiree Wussler
- Department of Cardiology and Cardiovascular Research, Institute Basel (CRIB), University Hospital Basel, Basel, Switzerland; Department of Internal Medicine, University Hospital Basel, Basel, Switzerland
| | - Luca Koechlin
- Department of Cardiology and Cardiovascular Research, Institute Basel (CRIB), University Hospital Basel, Basel, Switzerland; Department of Heart Surgery, University Hospital Basel, Basel, Switzerland
| | - Jasper Boeddinghaus
- Department of Cardiology and Cardiovascular Research, Institute Basel (CRIB), University Hospital Basel, Basel, Switzerland; Department of Internal Medicine, University Hospital Basel, Basel, Switzerland
| | - Thomas Nestelberger
- Department of Cardiology and Cardiovascular Research, Institute Basel (CRIB), University Hospital Basel, Basel, Switzerland
| | - Patrick Badertscher
- Department of Cardiology and Cardiovascular Research, Institute Basel (CRIB), University Hospital Basel, Basel, Switzerland; Department of Cardiology, University of Illinois at Chicago, Chicago, United States
| | - Raphael Sedlmayer
- Department of Cardiology and Cardiovascular Research, Institute Basel (CRIB), University Hospital Basel, Basel, Switzerland
| | - Christian Puelacher
- Department of Cardiology and Cardiovascular Research, Institute Basel (CRIB), University Hospital Basel, Basel, Switzerland; Department of Internal Medicine, University Hospital Basel, Basel, Switzerland
| | - Tobias Zimmermann
- Department of Cardiology and Cardiovascular Research, Institute Basel (CRIB), University Hospital Basel, Basel, Switzerland
| | - Jeanne du Fay de Lavallaz
- Department of Cardiology and Cardiovascular Research, Institute Basel (CRIB), University Hospital Basel, Basel, Switzerland; Department of Internal Medicine, University Hospital Basel, Basel, Switzerland
| | - Pedro Lopez-Ayala
- Department of Cardiology and Cardiovascular Research, Institute Basel (CRIB), University Hospital Basel, Basel, Switzerland; Department of Internal Medicine, University Hospital Basel, Basel, Switzerland
| | - Kathrin Leu
- Department of Cardiology and Cardiovascular Research, Institute Basel (CRIB), University Hospital Basel, Basel, Switzerland
| | | | - Òscar Miró
- Servicio de Urgencias, Hospital Clínic, Barcelona, Spain
| | - Beatriz López
- Servicio de Urgencias, Hospital Clínic, Barcelona, Spain
| | | | - José Bustamante
- Servicio de Urgencias, Hospital Clínico San Carlos, Madrid, Spain
| | - Damian Kawecki
- 2nd Department of Cardiology, Medical University of Silesia, Zabrze, Poland
| | - Jiri Parenica
- Department of Cardiology, University Hospital Brno, Brno, Czech Republic and Medical Faculty, Masaryk University, Brno, Czech Republic
| | - Jens Lohrmann
- Department of Cardiology and Cardiovascular Research, Institute Basel (CRIB), University Hospital Basel, Basel, Switzerland; Emergency Department, University Hospital Basel, Basel, Switzerland
| | - Wanda Kloos
- Department of Cardiology and Cardiovascular Research, Institute Basel (CRIB), University Hospital Basel, Basel, Switzerland; Emergency Department, University Hospital Basel, Basel, Switzerland
| | - Andreas Buser
- Blood Transfusion Centre, Swiss Red Cross, Basel, Switzerland and Department of Hematology, University Hospital Basel, Basel, Switzerland
| | - Dagmar I Keller
- Emergency Department, University Hospital Zurich, Zurich, Switzerland
| | - Tobias Reichlin
- Department of Cardiology and Cardiovascular Research, Institute Basel (CRIB), University Hospital Basel, Basel, Switzerland; Department of Department, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Raphael Twerenbold
- Department of Cardiology and Cardiovascular Research, Institute Basel (CRIB), University Hospital Basel, Basel, Switzerland
| | - Christian Mueller
- Department of Cardiology and Cardiovascular Research, Institute Basel (CRIB), University Hospital Basel, Basel, Switzerland.
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Flick H, Arns BM, Bolitschek J, Bucher B, Cima K, Gingrich E, Handzhiev S, Hochmair M, Horak F, Idzko M, Jaksch P, Kovacs G, Kropfmüller R, Lamprecht B, Löffler-Ragg J, Meilinger M, Olschewski H, Pfleger A, Puchner B, Puelacher C, Prior C, Rodriguez P, Salzer H, Schenk P, Schindler O, Stelzmüller I, Strenger V, Täubl H, Urban M, Wagner M, Wimberger F, Zacharasiewicz A, Zwick RH, Eber E. [Statement of the Austrian Society of Pneumology (ASP)]. Wien Klin Mag 2020; 23:92-115. [PMID: 32427192 PMCID: PMC7232599 DOI: 10.1007/s00740-020-00350-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
The COVID-19 pandemic is currently a challenge worldwide. In Austria, a crisis within the health care system has so far been avoided. The treatment of patients with community-acquired pneumonia (CAP), including SARS-CoV‑2 infections, should continue to be based on evidence-based CAP guidelines during the pandemic. However, COVID-19-specific adjustments are useful. The treatment of patients with chronic lung diseases must be adapted during the pandemic, but must still be guaranteed.
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Affiliation(s)
- H. Flick
- Klinische Abteilung für Pulmonologie, Univ. Klinik für Innere Medizin, Medizinische Universität Graz/LKH Graz Ost, Graz, Österreich
| | - B. M. Arns
- 1. Medizinische Abteilung, Hanusch Krankenhaus, Wien, Österreich
| | | | - B. Bucher
- Abteilung für Pneumologie, Tirol Kliniken, Landeskrankenhaus Hochzirl-Natters, Natters, Österreich
| | - K. Cima
- Abteilung für Pneumologie, Tirol Kliniken, Landeskrankenhaus Hochzirl-Natters, Natters, Österreich
| | - E. Gingrich
- Lungenfachärztliche Ordination, Wien, Österreich
| | - S. Handzhiev
- Klinische Abteilung für Pneumologie, Universitätsklinikum Krems, Krems, Österreich
| | - M. Hochmair
- Karl Landsteiner Institut für Lungenforschung und pneumologische Onkologie, Krankenhaus Nord – Klinik Floridsdorf, Wien, Österreich
| | - F. Horak
- Allergiezentrum Wien West, Wien, Österreich
| | - M. Idzko
- Klinische Abteilung für Pulmologie, Univ. Klinik für Innere Medizin II, Medizinische Universität Wien/AKH Wien, Wien, Österreich
| | - P. Jaksch
- Klinische Abteilung für Thoraxchirurgie, Univ. Klinik für Chirurgie, Medizinische Universität Wien/AKH Wien, Wien, Österreich
| | - G. Kovacs
- Klinische Abteilung für Pulmonologie, Univ. Klinik für Innere Medizin, Medizinische Universität Graz/LKH Graz Ost, Graz, Österreich
- Ludwig Boltzmann Institut für Lungengefäßforschung Graz, Graz, Österreich
| | - R. Kropfmüller
- Klinik für Lungenheilkunde/Pneumologie, Medizinische Fakultät, Johannes Kepler Universität, Linz, Österreich
| | - B. Lamprecht
- Klinik für Lungenheilkunde/Pneumologie, Medizinische Fakultät, Johannes Kepler Universität, Linz, Österreich
| | - J. Löffler-Ragg
- Pneumologische Ambulanz, Univ. Klinik für Innere Medizin II, Medizinische Universität Innsbruck, Innsbruck, Österreich
| | - M. Meilinger
- Abteilung für Innere Medizin und Pneumologie, Krankenhaus Nord – Klinik Floridsdorf, Wien, Österreich
| | - H. Olschewski
- Klinische Abteilung für Pulmonologie, Univ. Klinik für Innere Medizin, Medizinische Universität Graz/LKH Graz Ost, Graz, Österreich
- Ludwig Boltzmann Institut für Lungengefäßforschung Graz, Graz, Österreich
| | - A. Pfleger
- Klinische Abteilung für pädiatrische Pulmonologie und Allergologie, Univ. Klinik für Kinder- und Jugendheilkunde, Medizinische Universität Graz, Auenbruggerplatz 34/2, 8036 Graz, Österreich
| | - B. Puchner
- Department für Pneumologie, Reha Zentrum Münster, Münster, Österreich
| | - C. Puelacher
- Interdisziplinäres Schlaflabor, Telfs, Österreich
| | - C. Prior
- Lungenfachärztliche Ordination, Innsbruck, Österreich
| | - P. Rodriguez
- Klinische Abteilung für pädiatrische Pulmonologie und Allergologie, Univ. Klinik für Kinder- und Jugendheilkunde, Medizinische Universität Graz, Auenbruggerplatz 34/2, 8036 Graz, Österreich
| | - H. Salzer
- Klinik für Lungenheilkunde/Pneumologie, Medizinische Fakultät, Johannes Kepler Universität, Linz, Österreich
| | - P. Schenk
- Abteilung Pulmologie, Landesklinikum Hochegg, Grimmenstein, Österreich
| | - O. Schindler
- Abteilung für Innere Medizin und Pneumologie, LKH Graz II, Standort Enzenbach, Gratwein, Österreich
| | | | - V. Strenger
- Klinische Abteilung für pädiatrische Pulmonologie und Allergologie, Univ. Klinik für Kinder- und Jugendheilkunde, Medizinische Universität Graz, Auenbruggerplatz 34/2, 8036 Graz, Österreich
| | - H. Täubl
- Abteilung für Pneumologie, Tirol Kliniken, Landeskrankenhaus Hochzirl-Natters, Natters, Österreich
| | - M. Urban
- Abteilung für Innere Medizin und Pneumologie, Krankenhaus Nord – Klinik Floridsdorf, Wien, Österreich
| | - M. Wagner
- Klinische Abteilung für pädiatrische Pulmonologie und Allergologie, Univ. Klinik für Kinder- und Jugendheilkunde, Medizinische Universität Graz, Auenbruggerplatz 34/2, 8036 Graz, Österreich
| | - F. Wimberger
- Ordensklinikum Elisabethinen Linz, Linz, Österreich
| | - A. Zacharasiewicz
- Abteilung für Kinder- und Jugendheilkunde, Wilhelminenspital der Stadt Wien, Lehrkrankenhaus der Medizinischen Universität Wien, Wien, Österreich
| | - R. H. Zwick
- Ambulante Pneumologische Rehabilitation, Therme Wien Med, Wien, Österreich
| | - E. Eber
- Klinische Abteilung für pädiatrische Pulmonologie und Allergologie, Univ. Klinik für Kinder- und Jugendheilkunde, Medizinische Universität Graz, Auenbruggerplatz 34/2, 8036 Graz, Österreich
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Nestelberger T, Boeddinghaus J, Wussler D, Twerenbold R, Badertscher P, Wildi K, Miró Ò, López B, Martin-Sanchez FJ, Muzyk P, Koechlin L, Baumgartner B, Meier M, Troester V, Rubini Giménez M, Puelacher C, du Fay de Lavallaz J, Walter J, Kozhuharov N, Zimmermann T, Gualandro DM, Michou E, Potlukova E, Geigy N, Keller DI, Reichlin T, Mueller C. Predicting Major Adverse Events in Patients With Acute Myocardial Infarction. J Am Coll Cardiol 2020; 74:842-854. [PMID: 31416527 DOI: 10.1016/j.jacc.2019.06.025] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Revised: 05/06/2019] [Accepted: 06/03/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND Early and accurate detection of short-term major adverse cardiac events (MACE) in patients with suspected acute myocardial infarction (AMI) is an unmet clinical need. OBJECTIVES The goal of this study was to test the hypothesis that adding clinical judgment and electrocardiogram findings to the European Society of Cardiology (ESC) high-sensitivity cardiac troponin (hs-cTn) measurement at presentation and after 1 h (ESC hs-cTn 0/1 h algorithm) would further improve its performance to predict MACE. METHODS Patients presenting to an emergency department with suspected AMI were enrolled in a prospective, multicenter diagnostic study. The primary endpoint was MACE, including all-cause death, cardiac arrest, AMI, cardiogenic shock, sustained ventricular arrhythmia, and high-grade atrioventricular block within 30 days including index events. The secondary endpoint was MACE + unstable angina (UA) receiving early (≤24 h) revascularization. RESULTS Among 3,123 patients, the ESC hs-cTnT 0/1 h algorithm triaged significantly more patients toward rule-out compared with the extended algorithm (60%; 95% CI: 59% to 62% vs. 45%; 95% CI: 43% to 46%; p < 0.001), while maintaining similar 30-day MACE rates (0.6%; 95% CI: 0.3% to 1.1% vs. 0.4%; 95% CI: 0.1% to 0.9%; p = 0.429), resulting in a similar negative predictive value (99.4%; 95% CI: 98.9% to 99.6% vs. 99.6%; 95% CI: 99.2% to 99.8%; p = 0.097). The ESC hs-cTnT 0/1 h algorithm ruled-in fewer patients (16%; 95% CI: 14.9% to 17.5% vs. 26%; 95% CI: 24.2% to 27.2%; p < 0.001) compared with the extended algorithm, albeit with a higher positive predictive value (76.6%; 95% CI: 72.8% to 80.1% vs. 59%; 95% CI: 55.5% to 62.3%; p < 0.001). For 30-day MACE + UA, the ESC hs-cTnT 0/1 h algorithm had a higher positive predictive value for rule-in, whereas the extended algorithm had a higher negative predictive value for the rule-out. Similar findings emerged when using hs-cTnI. CONCLUSIONS The ESC hs-cTn 0/1 h algorithm better balanced efficacy and safety in the prediction of MACE, whereas the extended algorithm is the preferred option for the rule-out of 30-day MACE + UA. (Advantageous Predictors of Acute Coronary Syndromes Evaluation [APACE]; NCT00470587).
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Affiliation(s)
- Thomas Nestelberger
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland; GREAT Network. https://twitter.com/thomas_nest
| | - Jasper Boeddinghaus
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland; GREAT Network; Department of Internal Medicine, University Hospital Basel, University of Basel, Basel, Switzerland. https://twitter.com/J_Boeddinghaus
| | - Desiree Wussler
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland; GREAT Network; Department of Internal Medicine, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Raphael Twerenbold
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland; GREAT Network
| | - Patrick Badertscher
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland; GREAT Network; Division of Cardiology, University of Illinois at Chicago, Chicago, Illinois
| | - Karin Wildi
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland; GREAT Network; Critical Care Research Institute, The Prince Charles Hospital, Brisbane and University of Queensland, Brisbane, Queensland, Australia
| | - Òscar Miró
- GREAT Network; Emergency Department, Hospital Clinic, Barcelona, Spain
| | - Beatriz López
- Emergency Department, Hospital Clinic, Barcelona, Spain
| | | | - Piotr Muzyk
- GREAT Network; 2(nd) Department of Cardiology, School of Medicine with the Division of Dentistry, Zabrze, Medical University of Katowice, Katowice, Poland
| | - Luca Koechlin
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland; GREAT Network; Department of Cardiac Surgery, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Benjamin Baumgartner
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland; GREAT Network
| | - Mario Meier
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland; GREAT Network
| | - Valentina Troester
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland; GREAT Network
| | - Maria Rubini Giménez
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland; GREAT Network
| | - Christian Puelacher
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland; GREAT Network; Department of Internal Medicine, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Jeanne du Fay de Lavallaz
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland; GREAT Network
| | - Joan Walter
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland; GREAT Network
| | - Nikola Kozhuharov
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland; GREAT Network
| | - Tobias Zimmermann
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland; GREAT Network
| | - Danielle M Gualandro
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland; GREAT Network
| | - Eleni Michou
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland; GREAT Network
| | - Eliska Potlukova
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland; Department of Internal Medicine, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Nicolas Geigy
- Emergency Department, Kantonsspital Baselland, Liestal, Switzerland
| | - Dagmar I Keller
- Emergency Department, University Hospital Zürich, Zürich, Switzerland
| | - Tobias Reichlin
- GREAT Network; Department of Cardiology, University Hospital Bern, University of Bern, Bern, Switzerland
| | - Christian Mueller
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland; GREAT Network.
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Siciliano RF, Gualandro DM, Bittencourt MS, Paixão M, Marcondes-Braga F, Soeiro ADM, Strunz C, Pacanaro AP, Puelacher C, Tarasoutchi F, Di Somma S, Caramelli B, de Oliveira Junior MT, Mansur AJ, Mueller C, Barretto ACP, Strabelli TMV. Biomarkers for prediction of mortality in left-sided infective endocarditis. Int J Infect Dis 2020; 96:25-30. [PMID: 32169690 DOI: 10.1016/j.ijid.2020.03.009] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [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: 12/02/2019] [Revised: 03/03/2020] [Accepted: 03/04/2020] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND Evidence regarding biomarkers for risk prediction in patients with infective endocarditis (IE) is limited. We aimed to investigate the value of a panel of biomarkers for the prediction of in-hospital mortality in patients with IE. METHODS Between 2016 and 2018, consecutive IE patients admitted to the emergency department were prospectively included. Blood concentrations of nine biomarkers were measured at admission (D0) and on the seventh day (D7) of antibiotic therapy: C-reactive protein (CRP), sensitive troponin I (s-cTnI), procalcitonin, B-type natriuretic peptide (BNP), neutrophil gelatinase-associated lipocalin (NGAL), interleukin 6 (IL6), tumor necrosis factor α (TNF-α), proadrenomedullin, alpha-1-acid glycoprotein, and galectin 3. The primary endpoint was in-hospital mortality. RESULTS Among 97 patients, 56% underwent cardiac surgery, and in-hospital mortality was 27%. At admission, six biomarkers were independent predictors of in-hospital mortality: s-cTnI (OR 3.4; 95%CI 1.8-6.4; P<0.001), BNP (OR 2.7; 95%CI 1.4-5.1; P=0.002), IL-6 (OR 2.06; 95%CI 1.3-3.7; P=0.019), procalcitonin (OR 1.9; 95%CI 1.1-3.2; P=0.018), TNF-α (OR 1.8; 95%CI 1.1-2.9; P=0.019), and CRP (OR 1.8; 95%CI 1.0-3.3; P=0.037). At admission, S-cTnI provided the highest accuracy for predicting mortality (area under the ROC curve: s-cTnI 0.812, BNP 0.727, IL-6 0.734, procalcitonin 0.684, TNF-α 0.675, CRP 0.670). After 7 days of antibiotic therapy, BNP and inflammatory biomarkers improved their performance (s-cTnI 0.814, BNP 0.823, IL-6 0.695, procalcitonin 0.802, TNF-α 0.554, CRP 0.759). CONCLUSION S-cTnI concentration measured at admission had the highest accuracy for mortality prediction in patients with IE.
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Affiliation(s)
- Rinaldo F Siciliano
- Heart Institute (InCor), University of São Paulo Medical School, Brazil; GREAT (Global Research on Acute Conditions Team) Network.
| | - Danielle M Gualandro
- Heart Institute (InCor), University of São Paulo Medical School, Brazil; GREAT (Global Research on Acute Conditions Team) Network; Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Switzerland
| | - Marcio Sommer Bittencourt
- Center for Clinical and Epidemiological Research, University Hospital, University of Sao Paulo, Sao Paulo, Brazil; Hospital Israelita Albert Einstein, Sao Paulo, Brazil
| | - Milena Paixão
- Heart Institute (InCor), University of São Paulo Medical School, Brazil
| | | | | | - Célia Strunz
- Heart Institute (InCor), University of São Paulo Medical School, Brazil
| | | | - Christian Puelacher
- GREAT (Global Research on Acute Conditions Team) Network; Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Switzerland
| | | | - Salvatore Di Somma
- Department of Medical-Surgery Sciences and Translational Medicine University of Rome Sapienza, Italy; GREAT (Global Research on Acute Conditions Team) Network
| | - Bruno Caramelli
- Heart Institute (InCor), University of São Paulo Medical School, Brazil
| | - Mucio Tavares de Oliveira Junior
- Heart Institute (InCor), University of São Paulo Medical School, Brazil; Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Switzerland
| | | | - Christian Mueller
- Heart Institute (InCor), University of São Paulo Medical School, Brazil; Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Switzerland
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46
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Boeddinghaus J, Nestelberger T, Koechlin L, Wussler D, Lopez-Ayala P, Walter JE, Troester V, Ratmann PD, Seidel F, Zimmermann T, Badertscher P, Wildi K, Rubini Giménez M, Potlukova E, Strebel I, Freese M, Miró Ò, Martin-Sanchez FJ, Kawecki D, Keller DI, Gualandro DM, Christ M, Twerenbold R, Mueller C, Meier M, Puelacher C, du Fay de Lavallaz J, Kozhuharov N, Rentsch K, Stelzig C, Meissner K, Kulangara C, Hillinger P, Michou E, Flores D, Reichlin T, López B, Fuenzalida C, Adrada ER, Ganovská E, Lohrmann J, Huber J, Steude J, Buser A, von Eckardstein A, Morawiec B, Nowalany-Kozielska E, Muzyk P, Bürgler F, Geigy N. Early Diagnosis of Myocardial Infarction With Point-of-Care High-Sensitivity Cardiac Troponin I. J Am Coll Cardiol 2020; 75:1111-1124. [DOI: 10.1016/j.jacc.2019.12.065] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2019] [Revised: 12/16/2019] [Accepted: 12/17/2019] [Indexed: 10/24/2022]
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Walter J, du Fay de Lavallaz J, Koechlin L, Zimmermann T, Boeddinghaus J, Honegger U, Strebel I, Twerenbold R, Amrein M, Nestelberger T, Wussler D, Puelacher C, Badertscher P, Zellweger M, Fahrni G, Jeger R, Kaiser C, Reichlin T, Mueller C. Using High-Sensitivity Cardiac Troponin for the Exclusion of Inducible Myocardial Ischemia in Symptomatic Patients: A Cohort Study. Ann Intern Med 2020; 172:175-185. [PMID: 31905377 DOI: 10.7326/m19-0080] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND The optimal noninvasive method for surveillance in symptomatic patients with stable coronary artery disease (CAD) is unknown. OBJECTIVE To apply a novel approach using very low concentrations of high-sensitivity cardiac troponin I (hs-cTnI) for exclusion of inducible myocardial ischemia in symptomatic patients with CAD. DESIGN Prospective diagnostic cohort study. (ClinicalTrials.gov: NCT01838148). SETTING University hospital. PATIENTS 1896 consecutive patients with CAD referred with symptoms possibly related to inducible myocardial ischemia. MEASUREMENTS Presence of inducible myocardial ischemia was adjudicated using myocardial perfusion imaging with single-photon emission computed tomography, as well as coronary angiography and fractional flow reserve measurements where available. Staff blinded to adjudication measured circulating hs-cTn concentrations. An hs-cTnI cutoff of 2.5 ng/L, derived previously in mostly asymptomatic patients with CAD, was assessed. Predefined target performance criteria were at least 90% negative predictive value (NPV) and at least 90% sensitivity for exclusion of inducible myocardial ischemia. Sensitivity analyses were based on measurements with an hs-cTnT assay and an alternative hs-cTnI assay with even higher analytic sensitivity (limit of detection, 0.1 ng/L). RESULTS Overall, 865 patients (46%) had inducible myocardial ischemia. The hs-cTnI cutoff of 2.5 ng/L provided an NPV of 70% (95% CI, 64% to 75%) and a sensitivity of 90% (CI, 88% to 92%) for exclusion of inducible myocardial ischemia. No hs-cTnI cutoff reached both performance characteristics predefined as targets. Similarly, using the alternative assays for hs-cTnI or hs-cTnT, no cutoff achieved the target performance: hs-cTnT concentrations less than 5 ng/L yielded an NPV of 66% (CI, 59% to 72%), and hs-cTnI concentrations less than 2 ng/L yielded an NPV of 68% (CI, 62% to 74%). LIMITATION Data were generated in a large single-center diagnostic study using central adjudication. CONCLUSION In symptomatic patients with CAD, very low hs-cTn concentrations, including hs-cTnI concentrations less than 2.5 ng/L, do not generally allow users to safely exclude inducible myocardial ischemia. PRIMARY FUNDING SOURCE European Union, Swiss National Science Foundation, Kommission für Technologie und Innovation (Innosuisse), Swiss Heart Foundation, Cardiovascular Research Foundation Basel, University of Basel, University Hospital Basel, Roche, Abbott, and Singulex.
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Affiliation(s)
- Joan Walter
- Cardiovascular Research Institute Basel, University Hospital Basel, and University of Basel, Basel, Switzerland (J.W., J.D., L.K., T.Z., J.B., U.H., I.S., R.T., M.A., T.N., D.W., C.P., M.Z., G.F., R.J., C.K., C.M.)
| | - Jeanne du Fay de Lavallaz
- Cardiovascular Research Institute Basel, University Hospital Basel, and University of Basel, Basel, Switzerland (J.W., J.D., L.K., T.Z., J.B., U.H., I.S., R.T., M.A., T.N., D.W., C.P., M.Z., G.F., R.J., C.K., C.M.)
| | - Luca Koechlin
- Cardiovascular Research Institute Basel, University Hospital Basel, and University of Basel, Basel, Switzerland (J.W., J.D., L.K., T.Z., J.B., U.H., I.S., R.T., M.A., T.N., D.W., C.P., M.Z., G.F., R.J., C.K., C.M.)
| | - Tobias Zimmermann
- Cardiovascular Research Institute Basel, University Hospital Basel, and University of Basel, Basel, Switzerland (J.W., J.D., L.K., T.Z., J.B., U.H., I.S., R.T., M.A., T.N., D.W., C.P., M.Z., G.F., R.J., C.K., C.M.)
| | - Jasper Boeddinghaus
- Cardiovascular Research Institute Basel, University Hospital Basel, and University of Basel, Basel, Switzerland (J.W., J.D., L.K., T.Z., J.B., U.H., I.S., R.T., M.A., T.N., D.W., C.P., M.Z., G.F., R.J., C.K., C.M.)
| | - Ursina Honegger
- Cardiovascular Research Institute Basel, University Hospital Basel, and University of Basel, Basel, Switzerland (J.W., J.D., L.K., T.Z., J.B., U.H., I.S., R.T., M.A., T.N., D.W., C.P., M.Z., G.F., R.J., C.K., C.M.)
| | - Ivo Strebel
- Cardiovascular Research Institute Basel, University Hospital Basel, and University of Basel, Basel, Switzerland (J.W., J.D., L.K., T.Z., J.B., U.H., I.S., R.T., M.A., T.N., D.W., C.P., M.Z., G.F., R.J., C.K., C.M.)
| | - Raphael Twerenbold
- Cardiovascular Research Institute Basel, University Hospital Basel, and University of Basel, Basel, Switzerland (J.W., J.D., L.K., T.Z., J.B., U.H., I.S., R.T., M.A., T.N., D.W., C.P., M.Z., G.F., R.J., C.K., C.M.)
| | - Melissa Amrein
- Cardiovascular Research Institute Basel, University Hospital Basel, and University of Basel, Basel, Switzerland (J.W., J.D., L.K., T.Z., J.B., U.H., I.S., R.T., M.A., T.N., D.W., C.P., M.Z., G.F., R.J., C.K., C.M.)
| | - Thomas Nestelberger
- Cardiovascular Research Institute Basel, University Hospital Basel, and University of Basel, Basel, Switzerland (J.W., J.D., L.K., T.Z., J.B., U.H., I.S., R.T., M.A., T.N., D.W., C.P., M.Z., G.F., R.J., C.K., C.M.)
| | - Desiree Wussler
- Cardiovascular Research Institute Basel, University Hospital Basel, and University of Basel, Basel, Switzerland (J.W., J.D., L.K., T.Z., J.B., U.H., I.S., R.T., M.A., T.N., D.W., C.P., M.Z., G.F., R.J., C.K., C.M.)
| | - Christian Puelacher
- Cardiovascular Research Institute Basel, University Hospital Basel, and University of Basel, Basel, Switzerland (J.W., J.D., L.K., T.Z., J.B., U.H., I.S., R.T., M.A., T.N., D.W., C.P., M.Z., G.F., R.J., C.K., C.M.)
| | - Patrick Badertscher
- Cardiovascular Research Institute Basel, University Hospital Basel, and University of Basel, Basel, Switzerland, and University of Illinois at Chicago, Chicago, Illinois (P.B.)
| | - Michael Zellweger
- Cardiovascular Research Institute Basel, University Hospital Basel, and University of Basel, Basel, Switzerland (J.W., J.D., L.K., T.Z., J.B., U.H., I.S., R.T., M.A., T.N., D.W., C.P., M.Z., G.F., R.J., C.K., C.M.)
| | - Gregor Fahrni
- Cardiovascular Research Institute Basel, University Hospital Basel, and University of Basel, Basel, Switzerland (J.W., J.D., L.K., T.Z., J.B., U.H., I.S., R.T., M.A., T.N., D.W., C.P., M.Z., G.F., R.J., C.K., C.M.)
| | - Raban Jeger
- Cardiovascular Research Institute Basel, University Hospital Basel, and University of Basel, Basel, Switzerland (J.W., J.D., L.K., T.Z., J.B., U.H., I.S., R.T., M.A., T.N., D.W., C.P., M.Z., G.F., R.J., C.K., C.M.)
| | - Christoph Kaiser
- Cardiovascular Research Institute Basel, University Hospital Basel, and University of Basel, Basel, Switzerland (J.W., J.D., L.K., T.Z., J.B., U.H., I.S., R.T., M.A., T.N., D.W., C.P., M.Z., G.F., R.J., C.K., C.M.)
| | - Tobias Reichlin
- Cardiovascular Research Institute Basel, University Hospital Basel, and University of Basel, Basel, and University Hospital Bern, University of Bern, Bern, Switzerland (T.R.)
| | - Christian Mueller
- Cardiovascular Research Institute Basel, University Hospital Basel, and University of Basel, Basel, Switzerland (J.W., J.D., L.K., T.Z., J.B., U.H., I.S., R.T., M.A., T.N., D.W., C.P., M.Z., G.F., R.J., C.K., C.M.)
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Grimm K, Twerenbold R, Abaecherli R, Boeddinghaus J, Nestelberger T, Koechlin L, Troester V, Bourtzou A, Keller DI, Geigy N, Kozhuharov N, Wussler D, Wildi K, Hillinger P, Rubini Giménez M, Strebel I, Badertscher P, Puelacher C, du Fay de Lavallaz J, Osswald L, Morawiec B, Kawecki D, Miró Ò, Kühne M, Reichlin T, Mueller C. Diagnostic and prognostic value of ST-segment deviation scores in suspected acute myocardial infarction. Eur Heart J Acute Cardiovasc Care 2020; 9:857-868. [PMID: 31976746 DOI: 10.1177/2048872619853579] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Recent advances in digital electrocardiography technology allow evaluating ST-segment deviations in all 12 leads as quantitative variables and calculating summed ST-segment deviation scores. The diagnostic and prognostic utility of summed ST-segment deviation scores is largely unknown. METHODS We aimed to explore the diagnostic and prognostic utility of the conventional and the modified ST-segment deviation score (Better Analysis of ST-segment Elevations and Depressions in a 12- Lead-ECG-Score (BASEL-Score): sum of elevations in the augmented voltage right - lead (aVR) plus absolute, unsigned ST-segment depressions in the remaining leads) in patients presenting with suspected non-ST-segment elevation myocardial infarction. The diagnostic endpoint was non-ST-segment elevation myocardial infarction, adjudicated by two independent cardiologists. Prognostic endpoint was mortality during two-year follow up. RESULTS Among 1330 patients, non-ST-segment elevation myocardial infarction was present in 200 (15%) patients. Diagnostic accuracy for non-ST-segment elevation myocardial infarction as quantified by the area under the receiver-operating-characteristics curve was significantly higher for the BASEL-Score (0.73; 95% confidence interval 0.69-0.77) as compared to the conventional ST-segment deviation score (0.53; 95% confidence interval 0.49-0.57, p<0.001). The BASEL-Score provided additional independent diagnostic value to dichotomous electrocardiogram variables (ST-segment depression, T-inversion, both p<0.001) and to high-sensitivity cardiac troponin (p<0.001) as well as clinical judgment at 90 min (p<0.001). Similarly, only the BASEL-Score proved to be an independent predictor of two year mortality. CONCLUSIONS The modified ST-segment deviation score BASEL-Score focusing on ST-segment elevation in aVR and ST-segment depressions in the remaining leads provides incremental diagnostic and prognostic information.
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Affiliation(s)
- Karin Grimm
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Switzerland.,Global Research on acute conditions Team (GREAT Network), Italy.,Department of Internal Medicine, University Hospital Basel, Switzerland
| | - Raphael Twerenbold
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Switzerland.,Global Research on acute conditions Team (GREAT Network), Italy
| | - Roger Abaecherli
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Switzerland.,Global Research on acute conditions Team (GREAT Network), Italy.,Institute for Medical Engineering, Lucerne University of Applied Sciences and Arts, Switzerland
| | - Jasper Boeddinghaus
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Switzerland.,Global Research on acute conditions Team (GREAT Network), Italy.,Department of Internal Medicine, University Hospital Basel, Switzerland
| | - Thomas Nestelberger
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Switzerland.,Global Research on acute conditions Team (GREAT Network), Italy
| | - Luca Koechlin
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Switzerland.,Global Research on acute conditions Team (GREAT Network), Italy
| | - Valentina Troester
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Switzerland.,Global Research on acute conditions Team (GREAT Network), Italy.,Department of Internal Medicine, University Hospital Basel, Switzerland
| | - Anna Bourtzou
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Switzerland.,Global Research on acute conditions Team (GREAT Network), Italy
| | - Dagmar I Keller
- Emergency Department, University Hospital Zurich, Switzerland
| | - Nicolas Geigy
- Emergency Department, Kantonsspital Baselland, Switzerland
| | - Nikola Kozhuharov
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Switzerland
| | - Desiree Wussler
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Switzerland.,Department of Internal Medicine, University Hospital Basel, Switzerland
| | - Karin Wildi
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Switzerland.,Global Research on acute conditions Team (GREAT Network), Italy
| | - Petra Hillinger
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Switzerland
| | - Maria Rubini Giménez
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Switzerland.,Global Research on acute conditions Team (GREAT Network), Italy.,Servicio de Urgencias y Pneumologia, Hospital del Mar - Institut Municipal d'Investigació Mèdica, Spain.,Leipzig Heart Center, Leipzig, Germany
| | - Ivo Strebel
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Switzerland
| | - Patrick Badertscher
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Switzerland.,Global Research on acute conditions Team (GREAT Network), Italy
| | - Christian Puelacher
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Switzerland.,Global Research on acute conditions Team (GREAT Network), Italy.,Department of Internal Medicine, University Hospital Basel, Switzerland
| | - Jeanne du Fay de Lavallaz
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Switzerland.,Global Research on acute conditions Team (GREAT Network), Italy
| | - Luca Osswald
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Switzerland
| | - Beata Morawiec
- 2nd Department of Cardiology, Zabrze, Medical University of Silesia in Katowice, Poland
| | - Damian Kawecki
- 2nd Department of Cardiology, Zabrze, Medical University of Silesia in Katowice, Poland
| | - Òscar Miró
- Emergency Department, Hospital Clinic, IDIBAPS, University of Barcelona, Barcelona, Catalonia, Spain
| | - Michael Kühne
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Switzerland
| | - Tobias Reichlin
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Switzerland.,Global Research on acute conditions Team (GREAT Network), Italy.,Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Christian Mueller
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Switzerland.,Global Research on acute conditions Team (GREAT Network), Italy
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49
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Nestelberger T, Boeddinghaus J, Greenslade J, Parsonage WA, Than M, Wussler D, Lopez-Ayala P, Zimmermann T, Meier M, Troester V, Badertscher P, Koechlin L, Wildi K, Anwar M, Freese M, Keller DI, Reichlin T, Twerenbold R, Cullen L, Mueller C, Puelacher C, du Fay de Lavallaz J, Rubini Giménez M, Strebel I, Walter J, Huber J, Christ M, Kozhuharov N, Gualandro DM, Potlukova E, Baumgartner B, Hafner B, Rentsch K, Miró Ò, Fuenzalida C, Gil B, Martin-Sanchez FJ, Kawecki D, Geigy N, Meissner K, Kulangara C, López B, Rodriguez Adrada E, Ganovská E, Lohrmann J, Kloos W, Steude J, Buser A, von Eckardstein A, Nowalany-Kozielska E, Muzyk P. Two-Hour Algorithm for Rapid Triage of Suspected Acute Myocardial Infarction Using a High-Sensitivity Cardiac Troponin I Assay. Clin Chem 2019; 65:1437-1447. [DOI: 10.1373/clinchem.2019.305193] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2019] [Accepted: 08/07/2019] [Indexed: 11/06/2022]
Abstract
Abstract
BACKGROUND
We aimed to derive and externally validate a 0/2-h algorithm using the high-sensitivity cardiac troponin I (hs-cTnI)-Access assay.
METHODS
We enrolled patients presenting to the emergency department with symptoms suggestive of acute myocardial infarction (AMI) in 2 prospective diagnostic studies using central adjudication. Two independent cardiologists adjudicated the final diagnosis, including all available medical information including cardiac imaging. hs-cTnI-Access concentrations were measured at presentation and after 2 h in a blinded fashion.
RESULTS
AMI was the adjudicated final diagnosis in 164 of 1131 (14.5%) patients in the derivation cohort. Rule-out by the hs-cTnI-Access 0/2-h algorithm was defined as 0-h hs-cTnI-Access concentration <4 ng/L in patients with an onset of chest pain >3 h (direct rule-out) or a 0-h hs-cTnI-Access concentration <5 ng/L and an absolute change within 2 h <5 ng/L in all other patients. Derived thresholds for rule-in were a 0-h hs-cTnI-Access concentration ≥50 ng/L (direct rule-in) or an absolute change within 2 h ≥20 ng/L. In the derivation cohort, these cutoffs ruled out 55% of patients with a negative predictive value (NPV) of 99.8% (95% CI, 99.3–100) and sensitivity of 99.4% (95% CI, 96.5–99.9), and ruled in 30% of patients with a positive predictive value (PPV) of 73% (95% CI, 66.1–79). In the validation cohort, AMI was the adjudicated final diagnosis in 88 of 1280 (6.9%) patients. These cutoffs ruled out 77.9% of patients with an NPV of 99.8% (95% CI, 99.3–100) and sensitivity of 97.7% (95% CI, 92.0–99.7), and ruled in 5.8% of patients with a PPV of 77% (95% CI, 65.8–86) in the validation cohort.
CONCLUSIONS
Safety and efficacy of the l hs-cTnI-Access 0/2-h algorithm for triage toward rule-out or rule-in of AMI are very high.
TRIAL REGISTRATION
APACE, NCT00470587; ADAPT, ACTRN1261100106994; IMPACT, ACTRN12611000206921.
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Affiliation(s)
- Thomas Nestelberger
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT network
| | - Jasper Boeddinghaus
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT network
- Division of Internal Medicine, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Jaimi Greenslade
- Royal Brisbane and Women's Hospital, Brisbane, Australia
- Queensland University of Technology, Brisbane, Australia
- University of Queensland, Brisbane, Australia
| | - William A Parsonage
- Royal Brisbane and Women's Hospital, Brisbane, Australia
- Queensland University of Technology, Brisbane, Australia
- University of Queensland, Brisbane, Australia
| | - Martin Than
- Emergency Department, Christchurch Hospital, Christchurch, New Zealand
| | - Desiree Wussler
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT network
- Division of Internal Medicine, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Pedro Lopez-Ayala
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT network
| | - Tobias Zimmermann
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT network
| | - Mario Meier
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT network
| | - Valentina Troester
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT network
| | - Patrick Badertscher
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT network
- Division of Cardiology, University of Illinois at Chicago, Chicago, IL
| | - Luca Koechlin
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT network
- Department of Cardiac Surgery, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Karin Wildi
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- Division of Internal Medicine, University Hospital Basel, University of Basel, Basel, Switzerland
- Critical Care Research Institute, The Prince Charles Hospital, Brisbane and University of Queensland, Brisbane, Australia
| | - Mahnoor Anwar
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT network
| | - Michael Freese
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT network
| | - Dagmar I Keller
- Emergency Department, University Hospital Zurich, Zurich, Switzerland
| | - Tobias Reichlin
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT network
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Raphael Twerenbold
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT network
| | - Louise Cullen
- GREAT network
- Royal Brisbane and Women's Hospital, Brisbane, Australia
- Queensland University of Technology, Brisbane, Australia
- University of Queensland, Brisbane, Australia
| | - Christian Mueller
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT network
| | - Christian Puelacher
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- Department of Internal Medicine, University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT network
| | - Jeanne du Fay de Lavallaz
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT network
| | - Maria Rubini Giménez
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT network
- Heart Centre Leipzig, University Hospital of Cardiology, Leipzig, Germany
| | - Ivo Strebel
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT network
| | - Joan Walter
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- Department of Internal Medicine, University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT network
| | - Jeffrey Huber
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT network
| | - Michael Christ
- Department of Emergency Medicine Lucerne Hospital, Lucerne, Switzerland
| | - Nikola Kozhuharov
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT network
| | - Danielle M Gualandro
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT network
| | - Eliska Potlukova
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- Department of Internal Medicine, University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT network
| | - Benjamin Baumgartner
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT network
| | - Benjamin Hafner
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT network
| | - Katharina Rentsch
- Department of Laboratory Medicine, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Òscar Miró
- GREAT network
- Emergency Department, Hospital Clinic, Barcelona, Catalonia, Spain
| | - Carolina Fuenzalida
- GREAT network
- Emergency Department, Hospital Clinic, Barcelona, Catalonia, Spain
| | - Beatriz Gil
- Emergency Department, Hospital Clinic, Barcelona, Catalonia, Spain
| | | | - Damian Kawecki
- GREAT network
- Department of Cardiology, University Hospital Brno, Brno, Czech Republic and Medical Faculty, Masaryk University, Brno, Czech Republic
| | - Nicolas Geigy
- Department of Emergency Medicine, Hospital Baselland, Liestal, Switzerland
| | - Kathrin Meissner
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT network
| | - Caroline Kulangara
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT network
| | - Beatriz López
- GREAT network
- Emergency Department, Hospital Clinic, Barcelona, Catalonia, Spain
| | | | - Eva Ganovská
- GREAT network
- Emergency Department, Hospital Clinic, Barcelona, Catalonia, Spain
| | - Jens Lohrmann
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Wanda Kloos
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Jana Steude
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Andreas Buser
- Blood Transfusion Centre, Swiss Red Cross, Basel, Switzerland and Department of Hematology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Arnold von Eckardstein
- Emergency Department of Laboratory Medicine, University Hospital Zurich, Zurich, Switzerland
| | - Ewa Nowalany-Kozielska
- 2nd Department of Cardiology, School of Medicine with the Division of Dentistry in Zabrze, Medical University of Katowice, Katowice, Poland
| | - Piotr Muzyk
- GREAT network
- 2nd Department of Cardiology, School of Medicine with the Division of Dentistry in Zabrze, Medical University of Katowice, Katowice, Poland
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50
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Boeddinghaus J, Nestelberger T, Twerenbold R, Koechlin L, Wussler D, Badertscher P, Puelacher C, Du Fay De Lavallaz J, Rubini Gimenez M, Zimmermann T, Miro O, Martin-Sanchez FJ, Keller DI, Reichlin T, Mueller C. 3301A novel high-sensitivity cardiac troponin i assay for early diagnosis of acute myocardial infarction. Eur Heart J 2019. [DOI: 10.1093/eurheartj/ehz745.0065] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Background
Lately, the novel high-sensitivity cardiac troponin I (hs-cTnI) Access assay was developed. Its clinical performance in patients presenting with chest pain to the emergency department (ED) is unknown.
Purpose
To clinically validate the novel hs-cTnI-Access assay and to derive and validate an assay specific 0/1h-algorithm accordingly to the European Society of Cardiology (ESC) recommendations.
Methods
In a prospective international multicentre study we enrolled patients presenting to the emergency department with symptoms suggestive of acute myocardial infarction (AMI). Final diagnoses were centrally adjudicated by two independent cardiologists including all clinical information including cardiac imaging twice: first, using serial hs-cTnT (Elecsys, primary analysis) and second, using hs-cTnI (Architect, secondary analysis) measurements in addition to the clinically used (hs)-cTn. Hs-cTnI-Access was measured at presentation and at 1h. Primary objective was a direct comparison of diagnostic accuracy as quantified by the area under the receiver-operating-characteristic curve (AUC) of hs-cTnI-Access versus the two established hs-cTn assays (hs-cTnT-Elecsys, hs-cTnI-Architect). Secondary objectives included the derivation and internal validation of an hs-cTnI-Access specific 0/1h-algorithm.
Results
AMI was the adjudicated final diagnosis in 243/1579 (15.4%) patients. The AUC at presentation for hs-cTnI-Access was 0.95 (95% CI, 0.94–0.96), significantly higher as hs-cTnI-Architect (0.92 [95% CI, 0.91–0.94; p<0.001]), and comparable to hs-cTnT-Elecsys (0.94 [95% CI, 0.93–0.95; p=0.12]) Applying the derived hs-cTnI-Access 0/1h-algorithm (derivation cohort n=686) to the internal validation cohort (n=680), 60% of patients were ruled-out (sensitivity 98.9% [95% CI, 94.3–99.8]), and 15% of patients were ruled-in (specificity 95.9% [95% CI, 94.0–97.2]). Patients ruled-out by the 0/1h-algorithm had a survival rate of of 100% after 30-days and 98.4% after two years of follow up. Findings were confirmed in the secondary analyses using the adjudication including serial measurements of hs-cTnI (Architect).
Performance of the 0/1h-algorithm
Conclusions
Diagnostic accuracy of the novel hs-cTnI-Access assay is excellent and at least comparable to the two established hs-cTn assays. The assay-specific 0/1h-algorithm allows a safe rule-out and accurate rule-in of MI in about 75% of patients within 1-hour after presentation to the ED. Survival of patients ruled-out by the 0/1h-algorithm was very high.
Acknowledgement/Funding
Swiss National Science Foundation, the Swiss Heart Foundation, the KTI, the European Union, the Stiftung für kardiovaskuläre Forschung Basel
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Affiliation(s)
- J Boeddinghaus
- University Hospital Basel, Cardiovascular Research Institute Basel (CRIB), Basel, Switzerland
| | - T Nestelberger
- University Hospital Basel, Cardiovascular Research Institute Basel (CRIB), Basel, Switzerland
| | - R Twerenbold
- University Hospital Basel, Cardiovascular Research Institute Basel (CRIB), Basel, Switzerland
| | - L Koechlin
- University Hospital Basel, Cardiovascular Research Institute Basel (CRIB), Basel, Switzerland
| | - D Wussler
- University Hospital Basel, Cardiovascular Research Institute Basel (CRIB), Basel, Switzerland
| | - P Badertscher
- University Hospital Basel, Cardiovascular Research Institute Basel (CRIB), Basel, Switzerland
| | - C Puelacher
- University Hospital Basel, Cardiovascular Research Institute Basel (CRIB), Basel, Switzerland
| | - J Du Fay De Lavallaz
- University Hospital Basel, Cardiovascular Research Institute Basel (CRIB), Basel, Switzerland
| | - M Rubini Gimenez
- University Hospital Basel, Cardiovascular Research Institute Basel (CRIB), Basel, Switzerland
| | - T Zimmermann
- University Hospital Basel, Cardiovascular Research Institute Basel (CRIB), Basel, Switzerland
| | - O Miro
- Hospital Clinic de Barcelona, Emergency Department, Barcelona, Spain
| | | | - D I Keller
- University Hospital Zurich, Emergency Department, Zurich, Switzerland
| | - T Reichlin
- Bern University Hospital, Department of Cardiology, Bern, Switzerland
| | - C Mueller
- University Hospital Basel, Cardiovascular Research Institute Basel (CRIB), Basel, Switzerland
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