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Lehmacher J, Sörensen NA, Twerenbold R, Goßling A, Haller PM, Hartikainen TS, Schock A, Toprak B, Zeller T, Westermann D, Neumann JT. Diagnostic and prognostic value of the sex-specific 99th percentile of four high-sensitivity cardiac troponin assays in patients with suspected myocardial infarction. Eur Heart J Acute Cardiovasc Care 2024; 13:3-12. [PMID: 37890108 DOI: 10.1093/ehjacc/zuad131] [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: 01/27/2023] [Revised: 09/28/2023] [Accepted: 10/23/2023] [Indexed: 10/29/2023]
Abstract
AIMS High-sensitivity cardiac troponin (hs-cTn) assays are used for detection of myocardial infarction (MI). Ninety-ninth percentiles show wide inter-assay variation. The use of sex-specific cut-offs is recommended as definitory cut-off for MI. We compared diagnostic performance and prognostic value of sex-specific 99th percentiles of four hs-cTn assays in patients with suspected MI. METHODS AND RESULTS Concentrations of four hs-cTn assays were measured at presentation and after 3 h in patients with suspected MI. Final diagnoses were adjudicated according to the 4th Universal Definition of MI. Unisex and sex-specific 99th percentiles were evaluated as diagnostic cut-offs following the ESC 0/3 h algorithm. These cut-offs were used in Cox-regression analyses to investigate the association with a composite endpoint of MI, revascularization, cardiac rehospitalization, and death. Non-ST-elevation MI was diagnosed in 368 of 2718 patients. Applying the unisex 99th percentile, Elecsys hs-cTnT provided highest negative predictive value (NPV) of 99.7 and a positive predictive value (PPV) of 75.9. The analysed hs-cTnI assays showed slightly lower NPVs and comparable PPVs [Architect (NPV 98.0, PPV of 71.4); Atellica (NPV 97.7, PPV of 76.1); Pathfast (NPV 97.7, PPV of 66.6)]. Application of sex-specific 99th percentiles did not significantly affect diagnostic performance. Concentrations above 99th percentile were independent predictors for impaired long-term outcome (hazard ratios 1.2-1.5, P < 0.001). CONCLUSION We describe a good diagnostic accuracy of four hs-cTn assays using the assay-specific 99th percentile for detection of MI. Application of sex-specific 99th percentiles did neither affect diagnostic performance nor prognostic value significantly. Finally, values above the 99th percentile were associated with poor long-term outcome.
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Affiliation(s)
- Jonas Lehmacher
- Department of Cardiology, University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246 Hamburg, Germany
- Deutsches Zentrum für Herz-Kreislauf-Forschung (DZHK), site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - Nils Arne Sörensen
- Department of Cardiology, University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246 Hamburg, Germany
- Deutsches Zentrum für Herz-Kreislauf-Forschung (DZHK), site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - Raphael Twerenbold
- Department of Cardiology, University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246 Hamburg, Germany
- Deutsches Zentrum für Herz-Kreislauf-Forschung (DZHK), site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - Alina Goßling
- Department of Cardiology, University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246 Hamburg, Germany
| | - Paul Michael Haller
- Department of Cardiology, University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246 Hamburg, Germany
- Deutsches Zentrum für Herz-Kreislauf-Forschung (DZHK), site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - Tau Sarra Hartikainen
- Deutsches Zentrum für Herz-Kreislauf-Forschung (DZHK), site Hamburg/Kiel/Lübeck, Hamburg, Germany
- Department of Cardiology, University Heart Center Freiburg, Bad Krozingen, Germany
| | - Alina Schock
- Department of Cardiology, University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246 Hamburg, Germany
| | - Betül Toprak
- Department of Cardiology, University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246 Hamburg, Germany
- Deutsches Zentrum für Herz-Kreislauf-Forschung (DZHK), site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - Tanja Zeller
- Department of Cardiology, University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246 Hamburg, Germany
- Deutsches Zentrum für Herz-Kreislauf-Forschung (DZHK), site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - Dirk Westermann
- Deutsches Zentrum für Herz-Kreislauf-Forschung (DZHK), site Hamburg/Kiel/Lübeck, Hamburg, Germany
- Department of Cardiology, University Heart Center Freiburg, Bad Krozingen, Germany
| | - Johannes Tobias Neumann
- Department of Cardiology, University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246 Hamburg, Germany
- Deutsches Zentrum für Herz-Kreislauf-Forschung (DZHK), site Hamburg/Kiel/Lübeck, Hamburg, Germany
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, 553 St Kilda Road, Melbourne, VIC 3004, Australia
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Lehmacher J, Toprak B, Sörensen NA, Bei der Kellen R, Goßling A, Hartikainen TS, Haller PM, Schock A, Twerenbold R, Zeller T, Blankenberg S, Westermann D, Neumann JT. Validation of a 0/1 h Algorithm for Rapid Diagnosis of Myocardial Infarction Using a High-Sensitivity Troponin I Assay. Clin Chem 2023; 69:482-491. [PMID: 36935359 DOI: 10.1093/clinchem/hvad019] [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] [Received: 07/17/2022] [Accepted: 01/30/2023] [Indexed: 03/21/2023]
Abstract
BACKGROUND Current guidelines recommend 0/1 h algorithms using high-sensitivity cardiac troponin (hs-cTn) for fast diagnosis of myocardial infarction (MI). Yet, for some assays, existing data is limited. We aimed to evaluate the diagnostic performance and the prognostic value of a rapid 0/1 h algorithm for the Access hs-cTnI assay. METHODS In consecutive patients presenting with suspected MI, we measured concentrations of Access hs-cTnI at presentation and after 1 hour. Final diagnosis was adjudicated independently by 2 cardiologists. Parameters for diagnostic performance were calculated, applying the recently derived European Society of Cardiology (ESC) 0/1 h algorithm for Access hs-cTnI. Additionally, we assessed the prognostic utility of Access hs-cTnI for the composite end point of all-cause mortality and incident MI at 3 years. RESULTS In 1879 patients, 257 non-ST-elevation MIs occurred. Application of the 0/1 h algorithm classified 44.5% as rule-out, 20.3% as rule-in, and triaged 35.1% to the observe group. High rule-out safety was confirmed with a sensitivity of 97.7% (95% CI, 95.0%-99.1%) and a negative predictive value of 99.3% (95% CI, 98.4%-99.7%). Rule-in capacity was moderate with a specificity of 88.0% (95% CI, 86.3%-89.6%) and a positive predictive value of 50.8% (95% CI, 45.7%-55.9%). After exclusion of patients with ST-elevation MI the results showed strong prognostic value, even after adjustment for cardiovascular risk factors and comorbidities, with adjusted hazard ratios of 2.51 (95% CI, 1.56-4.04) in the observe and 3.55 (95% CI, 2.18-5.79) in the rule-in group for the composite end point of all-cause mortality and incident MI at 3 years, compared to ruled-out patients. CONCLUSION The ESC 0/1 h algorithm for Access hs-cTnI allows safe and efficient triage of patients with suspected MI and has strong prognostic utility up to 3 years after the initial evaluation.
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Affiliation(s)
- Jonas Lehmacher
- Department of Cardiology, University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.,University Center of Cardiovascular Science, University Heart and Vascular Center, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.,Deutsches Zentrum für Herz-Kreislauf-Forschung (DZHK), Standort Hamburg Kiel/Lübeck, Hamburg, Germany
| | - Betül Toprak
- Department of Cardiology, University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.,University Center of Cardiovascular Science, University Heart and Vascular Center, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.,Deutsches Zentrum für Herz-Kreislauf-Forschung (DZHK), Standort Hamburg Kiel/Lübeck, Hamburg, Germany
| | - Nils Arne Sörensen
- Department of Cardiology, University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.,University Center of Cardiovascular Science, University Heart and Vascular Center, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Ramona Bei der Kellen
- Department of Cardiology, University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Alina Goßling
- Department of Cardiology, University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Tau Sarra Hartikainen
- Department of Cardiology, University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.,Deutsches Zentrum für Herz-Kreislauf-Forschung (DZHK), Standort Hamburg Kiel/Lübeck, Hamburg, Germany.,Department of Cardiology, University Heart Center Freiburg, Bad Krozingen, Germany
| | - Paul Michael Haller
- Department of Cardiology, University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.,Deutsches Zentrum für Herz-Kreislauf-Forschung (DZHK), Standort Hamburg Kiel/Lübeck, Hamburg, Germany
| | - Alina Schock
- Department of Cardiology, University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Raphael Twerenbold
- Department of Cardiology, University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.,University Center of Cardiovascular Science, University Heart and Vascular Center, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.,Deutsches Zentrum für Herz-Kreislauf-Forschung (DZHK), Standort Hamburg Kiel/Lübeck, Hamburg, Germany.,Population Health Research Department, University Heart and Vascular Center, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Tanja Zeller
- Department of Cardiology, University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.,University Center of Cardiovascular Science, University Heart and Vascular Center, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.,Deutsches Zentrum für Herz-Kreislauf-Forschung (DZHK), Standort Hamburg Kiel/Lübeck, Hamburg, Germany
| | - Stefan Blankenberg
- Department of Cardiology, University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.,University Center of Cardiovascular Science, University Heart and Vascular Center, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.,Population Health Research Department, University Heart and Vascular Center, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Dirk Westermann
- Department of Cardiology, University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.,Deutsches Zentrum für Herz-Kreislauf-Forschung (DZHK), Standort Hamburg Kiel/Lübeck, Hamburg, Germany.,Department of Cardiology, University Heart Center Freiburg, Bad Krozingen, Germany
| | - Johannes Tobias Neumann
- Department of Cardiology, University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.,University Center of Cardiovascular Science, University Heart and Vascular Center, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.,Deutsches Zentrum für Herz-Kreislauf-Forschung (DZHK), Standort Hamburg Kiel/Lübeck, Hamburg, Germany.,Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
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Lehmacher J, Neumann JT, Sörensen NA, Goßling A, Schmidt SE, Zeller T, Blankenberg S, Westermann D, Clemmensen PM. Diagnostic performance of a device for acoustic heart sound analysis in patients with suspected myocardial infarction. Open Heart 2023; 10:openhrt-2022-002090. [PMID: 36858602 PMCID: PMC9980326 DOI: 10.1136/openhrt-2022-002090] [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] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Accepted: 02/10/2023] [Indexed: 03/03/2023] Open
Abstract
BACKGROUND As only a small proportion of patients with chest pain suffers from myocardial infarction (MI), safe rule-out of MI is of immense importance. Recently an ultrasensitive microphone performing diastolic heart sound analysis (CADScorSystem) for rule-out of coronary artery disease (CAD) has emerged. In this explorational study, we aimed to evaluate the feasibility of the CADScorSystem for diagnosis of MI in the setting of a large emergency department. METHODS Patients presenting to the emergency department with suspected MI were included. Acoustic heart sound analysis was performed in all patients and automated CAD-score values were calculated via a device-embedded algorithm, which also requires inclusion of three clinical variables: age, sex and presence of hypertension. Patients additionally received serial high-sensitive troponin T measurement measurements to assess the final diagnosis according to third Universal Definition of Myocardial Infarction applying the European Society of Cardiology 0 hour/3 hours algorithm. Diagnostic parameters for MI, considering different CAD-score cut-offs, were computed. RESULTS Of 167 patients, CAD-scores were available in 61.1%. A total of eight patients were diagnosed with MI. At a cut-off value of <20, CAD-score had a negative predictive value (NPV) of 90.7 (78.4-96.3). The corresponding positive predictive value (PPV) was 6.8 (2.7-16.2). For the adjusted CAD-score (age, sex, hypertension), at a cut-off value of <20, NPV was 90.0 (59.6-99.5) with a PPV of 10.8 (5.3-20.6). CONCLUSION In this explorative analysis, a transcutaneous ultrasensitive microphone for heart sound analysis resulted in a high NPV analogous to the findings in rule-out of stable CAD in elective patients yet inferior to serial high-sensitivity cardiac troponin measurements and does not seem feasible for application in an emergency setting for rule-out of MI. TRIAL REGISTRATION NUMBER NCT02355457.
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Affiliation(s)
- Jonas Lehmacher
- Department of Cardiology, University Medical Center Hamburg-Eppendorf University Heart & Vascular Center, Hamburg, Germany .,Deutsches Zentrum für Herz-Kreislauf-Forschung eV, Standort Hamburg/Kiel/Lübeck, Berlin, Germany
| | - Johannes T Neumann
- Department of Cardiology, University Medical Center Hamburg-Eppendorf University Heart & Vascular Center, Hamburg, Germany.,Deutsches Zentrum für Herz-Kreislauf-Forschung eV, Standort Hamburg/Kiel/Lübeck, Berlin, Germany.,Department of Epidemiology and Preventive Medicine, Monash University School of Public Health and Preventive Medicine, Melbourne, Victoria, Australia
| | - Nils Arne Sörensen
- Department of Cardiology, University Medical Center Hamburg-Eppendorf University Heart & Vascular Center, Hamburg, Germany.,Deutsches Zentrum für Herz-Kreislauf-Forschung eV, Standort Hamburg/Kiel/Lübeck, Berlin, Germany
| | - Alina Goßling
- Department of Cardiology, University Medical Center Hamburg-Eppendorf University Heart & Vascular Center, Hamburg, Germany
| | - Samuel Emil Schmidt
- Department of Health Science and Technology, Aalborg Universitet, Aalborg, Denmark
| | - Tanja Zeller
- Department of Cardiology, University Medical Center Hamburg-Eppendorf University Heart & Vascular Center, Hamburg, Germany.,Deutsches Zentrum für Herz-Kreislauf-Forschung eV, Standort Hamburg/Kiel/Lübeck, Berlin, Germany
| | - Stefan Blankenberg
- Department of Cardiology, University Medical Center Hamburg-Eppendorf University Heart & Vascular Center, Hamburg, Germany.,Deutsches Zentrum für Herz-Kreislauf-Forschung eV, Standort Hamburg/Kiel/Lübeck, Berlin, Germany
| | - Dirk Westermann
- Deutsches Zentrum für Herz-Kreislauf-Forschung eV, Standort Hamburg/Kiel/Lübeck, Berlin, Germany.,Klinik für Kardiologie und Angiologie, Universitats-Herzzentrum Freiburg Bad Krozingen Standort Freiburg, Freiburg, Germany
| | - Peter M Clemmensen
- Department of Cardiology, University Medical Center Hamburg-Eppendorf University Heart & Vascular Center, Hamburg, Germany.,Department of Regional Health Research, University of Southern Denmark Faculty of Health Sciences, Odense, Denmark
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4
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Hartikainen TS, Sörensen NA, Haller PM, Goßling A, Lehmacher J, Zeller T, Blankenberg S, Westermann D, Neumann JT. Clinical application of the 4th Universal Definition of Myocardial Infarction. Eur Heart J 2021; 41:2209-2216. [PMID: 32077925 DOI: 10.1093/eurheartj/ehaa035] [Citation(s) in RCA: 42] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2019] [Revised: 08/30/2019] [Accepted: 01/24/2020] [Indexed: 12/21/2022] Open
Abstract
AIMS The recently released 4th version of the Universal Definition of Myocardial Infarction (UDMI) introduces an increased emphasis on the entities of acute and chronic myocardial injury. We applied the 4th UDMI retrospectively in patients presenting to the emergency department with symptoms potentially indicating myocardial infarction (MI) to investigate its effect on diagnosis and prognosis. METHODS AND RESULTS We included 2302 patients presenting to the emergency department with symptoms suggestive of MI. The final diagnosis was adjudicated sequentially according to the 3rd and 4th UDMI. Reclassification after readjudication was assessed. Established diagnostic algorithms for patients with suspected MI were applied to compare diagnostic accuracy. All patients were followed to assess mortality, recurrent MI, revascularization, and rehospitalization to investigate the effect of the 4th UDMI on prognosis. After readjudication, 697 patients were reclassified. Most of these patients were reclassified as having acute (n = 78) and chronic myocardial injury (n = 585). Four hundred and thirty-four (18.9%) patients were diagnosed with MI, compared with 501 (21.8%) MIs when adjudication was based on the 3rd UDMI. In the non-MI population, patients with myocardial injury (n = 663) were older, more often female and had worse renal function compared with patients without myocardial injury (n = 1205). Application of diagnostic algorithms for patients with suspected MI revealed a high accuracy after readjudication. Reclassified patients had a substantially higher rate of cardiovascular events compared with not-reclassified patients, particularly patients reclassified to the category of myocardial injury. CONCLUSION By accentuating the categories of acute and chronic myocardial injury the 4th UDMI succeeds to identify patients with higher risk for cardiovascular events and poorer outcome and thus seems to improve risk assessment in patients with suspected MI. Application of established diagnostic algorithms remains safe when using the 4th UDMI.
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Affiliation(s)
- Tau S Hartikainen
- Department of Cardiology, University Heart & Vascular Center Hamburg Eppendorf, Martinistr. 52, 20246 Hamburg, Germany
| | - Nils Arne Sörensen
- Department of Cardiology, University Heart & Vascular Center Hamburg Eppendorf, Martinistr. 52, 20246 Hamburg, Germany.,German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - Paul Michael Haller
- Department of Cardiology, University Heart & Vascular Center Hamburg Eppendorf, Martinistr. 52, 20246 Hamburg, Germany.,German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - Alina Goßling
- Department of Cardiology, University Heart & Vascular Center Hamburg Eppendorf, Martinistr. 52, 20246 Hamburg, Germany
| | - Jonas Lehmacher
- Department of Cardiology, University Heart & Vascular Center Hamburg Eppendorf, Martinistr. 52, 20246 Hamburg, Germany
| | - Tanja Zeller
- Department of Cardiology, University Heart & Vascular Center Hamburg Eppendorf, Martinistr. 52, 20246 Hamburg, Germany.,German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - Stefan Blankenberg
- Department of Cardiology, University Heart & Vascular Center Hamburg Eppendorf, Martinistr. 52, 20246 Hamburg, Germany.,German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - Dirk Westermann
- Department of Cardiology, University Heart & Vascular Center Hamburg Eppendorf, Martinistr. 52, 20246 Hamburg, Germany.,German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - Johannes Tobias Neumann
- Department of Cardiology, University Heart & Vascular Center Hamburg Eppendorf, Martinistr. 52, 20246 Hamburg, Germany.,German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany
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Sörensen NA, Neumann JT, Ojeda F, Renné T, Karakas M, Blankenberg S, Westermann D, Zeller T. Differences in measurement of high-sensitivity troponin in an on-demand and batch-wise setting. Eur Heart J Acute Cardiovasc Care 2020; 10:2048872620924198. [PMID: 32700543 DOI: 10.1177/2048872620924198] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Accepted: 04/16/2020] [Indexed: 11/17/2022]
Abstract
BACKGROUND Most studies assessing the diagnostic value of high-sensitivity troponin in the diagnosis of myocardial infarction used batch-wise analyses of frozen samples for high-sensitivity troponin measurements. Whether the accuracy of these batch-wise high-sensitivity troponin measurements described in diagnostic studies is comparable to clinical routine is unknown. METHODS We enrolled 937 patients presenting with suspected myocardial infarction in this prospective cohort study. Measurements of high-sensitivity troponin I (Abbott Architect) and high-sensitivity troponin T (Roche) were performed in two settings: (a) on-demand in clinical routine using fresh blood samples; and (b) in batches using frozen blood samples from the same individuals at three timepoints (0 hours, 1 hour and 3 hours after presentation). RESULTS Median troponin levels were not different between on-demand and batch-wise measurements. Troponin levels in the range of 0 to 40 ng/L showed a very high correlation between the on-demand and batch setting (Pearson correlation coefficient (r) was 0.92-0.95 for high-sensitivity troponin I and 0.96 for high-sensitivity troponin T). However, at very low troponin levels (0 to 10 ng/L) correlation between the two settings was moderate (r for high-sensitivity troponin I 0.59-0.66 and 0.65-0.69 for high-sensitivity troponin T). Application of guideline-recommended rapid diagnostic algorithms showed similar diagnostic performance with both methods. CONCLUSIONS Overall on-demand and batch-wise measurements of high-sensitivity troponin provided similar results, but their correlation was moderate, when focusing on very low troponin levels. The application of rapid diagnostic algorithms was safe in both settings.Trial Registration: www.clinicaltrials.gov (NCT02355457).
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Affiliation(s)
- Nils Arne Sörensen
- Department of Cardiology, University Heart and Vascular Center Hamburg Eppendorf, Hamburg, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - Johannes Tobias Neumann
- Department of Cardiology, University Heart and Vascular Center Hamburg Eppendorf, Hamburg, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - Francisco Ojeda
- Department of Cardiology, University Heart and Vascular Center Hamburg Eppendorf, Hamburg, Germany
| | - Thomas Renné
- Institute of Clinical Chemistry and Laboratory Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany and Clinical Chemistry, Department of Molecular Medicine and Surgery, Karolinska Institute, Stockholm, Sweden
| | - Mahir Karakas
- Department of Cardiology, University Heart and Vascular Center Hamburg Eppendorf, Hamburg, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - Stefan Blankenberg
- Department of Cardiology, University Heart and Vascular Center Hamburg Eppendorf, Hamburg, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - Dirk Westermann
- Department of Cardiology, University Heart and Vascular Center Hamburg Eppendorf, Hamburg, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - Tanja Zeller
- Department of Cardiology, University Heart and Vascular Center Hamburg Eppendorf, Hamburg, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany
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Neumann JT, Sörensen NA, Rübsamen N, Ojeda F, Schock A, Seddighizadeh P, Zeller T, Westermann D, Blankenberg S. Evaluation of a new ultra-sensitivity troponin I assay in patients with suspected myocardial infarction. Int J Cardiol 2019; 283:35-40. [DOI: 10.1016/j.ijcard.2018.12.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2018] [Revised: 11/05/2018] [Accepted: 12/03/2018] [Indexed: 12/25/2022]
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Neumann JT, Sörensen NA, Rübsamen N, Ojeda F, Schäfer S, Keller T, Blankenberg S, Clemmensen P, Westermann D. Right bundle branch block in patients with suspected myocardial infarction. European Heart Journal: Acute Cardiovascular Care 2018; 8:161-166. [DOI: 10.1177/2048872618809700] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Aims: The new European Society of Cardiology guideline for ST-segment elevation myocardial infarction recommends that left and right bundle branch block should be considered equal for recommending urgent angiography in patients with suspected myocardial infarction. We aimed to evaluate this novel recommendation in two prospective studies of patients with suspected myocardial infarction. Methods and results: We included 4067 patients presenting to the emergency department with suspected myocardial infarction. All patients had an ECG recorded immediately upon admission. Patients were classified as having right bundle branch block (RBBB), left bundle branch block (LBBB), bifascicular block (BFB) or no bundle branch block. All patients were followed for up to two years to assess mortality. In the overall population 125 (3.1%) patients had RBBB, 281 (6.9%) LBBB and 60 (1.5%) BFB. The final diagnosis of myocardial infarction was adjudicated in 20.8% (RBBB), 28.5% (LBBB), 23.3% (BFB) and 21.6% (no complete block) of patients. The mortality rate after one year was 10.7% (RBBB), 7% (LBBB), 17.5% (BFB) and 3.2% (no complete block). The adjusted hazard ratios were 1.29 (95% confidence interval (CI) 0.71–2.34; P=0.40) for RBBB, 1.71 (95% CI 1.17–2.50; P=0.006) for LBBB and 2.27 (95% CI 1.28–4.05; P=0.005) for BFB. Conclusion: Our results support the new European Society of Cardiology ST-segment elevation myocardial infarction guideline describing RBBB as a high risk for mortality in patients with suspected myocardial infarction. However, the data challenge the concept of RBBB as a trigger of acute angiography because the likelihood of myocardial infarction in a chest pain unit setting is equally frequent in patients without bundle branch block.
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Affiliation(s)
- Johannes Tobias Neumann
- University Heart Center Hamburg, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Germany
| | | | | | | | | | - Till Keller
- Kerckhoff Herzforschungsinstitut, University Giessen, Germany
| | - Stefan Blankenberg
- University Heart Center Hamburg, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Germany
| | | | - Dirk Westermann
- University Heart Center Hamburg, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Germany
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Boeddinghaus J, Nestelberger T, Twerenbold R, Neumann JT, Lindahl B, Giannitsis E, Sörensen NA, Badertscher P, Jann JE, Wussler D, Puelacher C, Rubini Giménez M, Wildi K, Strebel I, Du Fay de Lavallaz J, Selman F, Sabti Z, Kozhuharov N, Potlukova E, Rentsch K, Miró Ò, Martin-Sanchez FJ, Morawiec B, Parenica J, Lohrmann J, Kloos W, Buser A, Geigy N, Keller DI, Osswald S, Reichlin T, Westermann D, Blankenberg S, Mueller C, Klimmeck I, Chiaverio F, Garrido E, Gea J, Cruz HM, Inostroza CIF, Briñón MAG, Shrestha S, Flores D, Freese M, Stelzig C, Kulangara C, Meissner K, Schaerli N, Mueller D, Sazgary L, Marbot S, López B, Calderón S, Adrada ER, Kawecki D, Nowalany-Kozielska E, Ganovská E, von Eckardstein A, Campodarve I, Christ M, Ordóñez-Llanos J, de Filippi CR, McCord J, Body R, Panteghini M, Jernberg T, Plebani M, Verschuren F, French JK, Christenson R, Weiser S, Bendig G, Dilba P. Impact of age on the performance of the ESC 0/1h-algorithms for early diagnosis of myocardial infarction. Eur Heart J 2018; 39:3780-3794. [DOI: 10.1093/eurheartj/ehy514] [Citation(s) in RCA: 51] [Impact Index Per Article: 8.5] [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: 10/04/2017] [Accepted: 08/05/2018] [Indexed: 11/14/2022] Open
Affiliation(s)
- Jasper Boeddinghaus
- Department of Cardiology, Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Petersgraben 4, Basel, Switzerland
- Division of Internal Medicine, University Hospital Basel, University of Basel, Petersgraben 4, Basel, Switzerland
- GREAT Network, Via Antonio Serra 54, Rome, Italy
| | - Thomas Nestelberger
- Department of Cardiology, Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Petersgraben 4, Basel, Switzerland
- GREAT Network, Via Antonio Serra 54, Rome, Italy
| | - Raphael Twerenbold
- Department of Cardiology, Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Petersgraben 4, Basel, Switzerland
- GREAT Network, Via Antonio Serra 54, Rome, Italy
- Department of General and Interventional Cardiology, Hamburg University Heart Center, Martinistraße 52, Hamburg, Germany
| | - Johannes Tobias Neumann
- Department of General and Interventional Cardiology, Hamburg University Heart Center, Martinistraße 52, Hamburg, Germany
| | - Bertil Lindahl
- Department of Medical Sciences, Uppsala University and Uppsala Clinical Research Centre, Uppsala University, Akademiska sjukhuset, Ing. 40, 5 tr, Uppsala, Sweden
| | - Evangelos Giannitsis
- Medizinische Klinik III, University Heidelberg, Im Neuenheimer Feld 410, Heidelberg, Germany
| | - Nils Arne Sörensen
- Department of General and Interventional Cardiology, Hamburg University Heart Center, Martinistraße 52, Hamburg, Germany
| | - Patrick Badertscher
- Department of Cardiology, Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Petersgraben 4, Basel, Switzerland
- GREAT Network, Via Antonio Serra 54, Rome, Italy
| | - Janina E Jann
- Department of Cardiology, Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Petersgraben 4, Basel, Switzerland
- GREAT Network, Via Antonio Serra 54, Rome, Italy
| | - Desiree Wussler
- Department of Cardiology, Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Petersgraben 4, Basel, Switzerland
- GREAT Network, Via Antonio Serra 54, Rome, Italy
| | - Christian Puelacher
- Department of Cardiology, Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Petersgraben 4, Basel, Switzerland
- GREAT Network, Via Antonio Serra 54, Rome, Italy
| | - Maria Rubini Giménez
- Department of Cardiology, Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Petersgraben 4, Basel, Switzerland
- GREAT Network, Via Antonio Serra 54, Rome, Italy
| | - Karin Wildi
- Department of Cardiology, Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Petersgraben 4, Basel, Switzerland
- GREAT Network, Via Antonio Serra 54, Rome, Italy
| | - Ivo Strebel
- Department of Cardiology, Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Petersgraben 4, Basel, Switzerland
- GREAT Network, Via Antonio Serra 54, Rome, Italy
| | - Jeanne Du Fay de Lavallaz
- Department of Cardiology, Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Petersgraben 4, Basel, Switzerland
- GREAT Network, Via Antonio Serra 54, Rome, Italy
| | - Farah Selman
- Department of Cardiology, Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Petersgraben 4, Basel, Switzerland
| | - Zaid Sabti
- Department of Cardiology, Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Petersgraben 4, Basel, Switzerland
- GREAT Network, Via Antonio Serra 54, Rome, Italy
| | - Nikola Kozhuharov
- Department of Cardiology, Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Petersgraben 4, Basel, Switzerland
- GREAT Network, Via Antonio Serra 54, Rome, Italy
| | - Eliska Potlukova
- Department of Cardiology, Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Petersgraben 4, Basel, Switzerland
- Division of Internal Medicine, University Hospital Basel, University of Basel, Petersgraben 4, Basel, Switzerland
| | - Katharina Rentsch
- Laboratory Medicine, University Hospital Basel, University of Basel, Petersgraben 4, Basel, Switzerland
| | - Òscar Miró
- GREAT Network, Via Antonio Serra 54, Rome, Italy
- Emergency Department, Hospital Clinic, Calle Villarroel, Barcelona, Catalonia, Spain
| | - F Javier Martin-Sanchez
- GREAT Network, Via Antonio Serra 54, Rome, Italy
- Servicio de Urgencias, Hospital Clínico San Carlos, Profesor Martín Lagos, S/N, Madrid, Spain
| | - Beata Morawiec
- GREAT Network, Via Antonio Serra 54, Rome, Italy
- 2nd Department of Cardiology, School of Medicine with the Division of Dentistry in Zabrze, Medical University of Katowice, ul. M. Curie-Sklodowskiej 9, Zabrze, Poland
| | - Jiri Parenica
- GREAT Network, Via Antonio Serra 54, Rome, Italy
- Department of Cardiology, University Hospital Brno, Jihlavská 20, CZ, Brno, Czech Republic
- Medical Faculty, Masaryk University, Kamenice 5, Brno-Bohunice, Czech Republic
| | - Jens Lohrmann
- Department of Cardiology, Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Petersgraben 4, Basel, Switzerland
| | - Wanda Kloos
- Department of Cardiology, Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Petersgraben 4, Basel, Switzerland
| | - Andreas Buser
- Blood Transfusion Centre, Swiss Red Cross, Hebelstrasse 10, Basel, Switzerland
- Department of Hematology, University Hospital Basel, University of Basel, Petersgraben 4, Basel, Switzerland
| | - Nicolas Geigy
- Emergency Department, Kantonsspital Liestal, Rheinstrasse 26, Liestal, Switzerland
| | - Dagmar I Keller
- Emergency Department, University Hospital Zurich, Rämistrasse 100, Zürich, Switzerland
| | - Stefan Osswald
- Department of Cardiology, Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Petersgraben 4, Basel, Switzerland
| | - Tobias Reichlin
- Department of Cardiology, Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Petersgraben 4, Basel, Switzerland
- GREAT Network, Via Antonio Serra 54, Rome, Italy
| | - Dirk Westermann
- Department of General and Interventional Cardiology, Hamburg University Heart Center, Martinistraße 52, Hamburg, Germany
| | - Stefan Blankenberg
- Department of General and Interventional Cardiology, Hamburg University Heart Center, Martinistraße 52, Hamburg, Germany
| | - Christian Mueller
- Department of Cardiology, Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Petersgraben 4, Basel, Switzerland
- GREAT Network, Via Antonio Serra 54, Rome, Italy
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Sörensen NA, Neumann JT, Ojeda F, Schäfer S, Magnussen C, Keller T, Lackner KJ, Zeller T, Karakas M, Münzel T, Blankenberg S, Westermann D, Schnabel RB. Relations of Sex to Diagnosis and Outcomes in Acute Coronary Syndrome. J Am Heart Assoc 2018; 7:e007297. [PMID: 29525782 PMCID: PMC5907542 DOI: 10.1161/jaha.117.007297] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2017] [Accepted: 01/24/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND The atypical presentation of women with acute coronary syndrome (ACS) has been related to delayed diagnosis and treatment, which may explain worse outcome compared with men. METHODS AND RESULTS We analyzed pooled data of 2520 patients of 2 prospective cohorts in terms of differences in presentation and management of women and men suggestive of ACS. Using logistic regression, we established 2 diagnostic models and tested their diagnostic performance in both sexes separately. Sex-specific differences in management of patients with ACS were ascertained and a 2-year follow-up was performed. Women were older than men (median 67 versus 61 years, P=0.001), had more often dyspnea (22% versus 18%, P=0.024), nausea or vomiting (26% versus 16%, P=0.001) and radiating chest pain (47% versus 40%, P=0.001). Classical risk factors (smoking, diabetes mellitus, dyslipidemia or known coronary artery disease) were less frequent in women. Diagnostic models showed no significant sex-related differences in diagnostic performance in a "first contact" setting (medical history and symptoms) or after "complete triage" (including ECG and biomarkers). Women with ACS underwent coronary angiography (73.8% versus 84.3%, P<0.001) and revascularization (53.8% versus 70.1%, P<0.001) less frequently. Two-year incidence of myocardial infarction and death was similar in both sexes, but revascularization and cardiac rehospitalization were more frequent in men. CONCLUSIONS In a large cohort of patients with suspected ACS, sex differences in clinical presentation did not impair diagnostic accuracy. Two-year outcomes were comparable. Our findings suggest a benefit of chest pain units to minimize sex differences in ACS management and prognosis. CLINICAL TRIAL REGISTRATION URL: https://www.clinicaltrials.gov. Unique identifiers: NCT02355457 (BACC), NCT03227159 (stenoCardia).
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Affiliation(s)
- Nils Arne Sörensen
- Department of General and Interventional Cardiology, University Heart Center Hamburg, Germany
- German Center for Cardiovascular Research, Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - Johannes Tobias Neumann
- Department of General and Interventional Cardiology, University Heart Center Hamburg, Germany
- German Center for Cardiovascular Research, Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - Francisco Ojeda
- Department of General and Interventional Cardiology, University Heart Center Hamburg, Germany
| | - Sarina Schäfer
- Department of General and Interventional Cardiology, University Heart Center Hamburg, Germany
- German Center for Cardiovascular Research, Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - Christina Magnussen
- Department of General and Interventional Cardiology, University Heart Center Hamburg, Germany
- German Center for Cardiovascular Research, Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - Till Keller
- Department of Cardiology, Kerckhoff Heart and Thorax Center, Bad Nauheim, Germany
- German Center for Cardiovascular Research, Partner Site RheinMain, Hamburg, Germany
| | - Karl J Lackner
- German Center for Cardiovascular Research, Partner Site RheinMain, Hamburg, Germany
- Department of Clinical Chemistry and Laboratory Medicine, University Medical Center of the Johannes Gutenberg-University Mainz, Germany
| | - Tanja Zeller
- Department of General and Interventional Cardiology, University Heart Center Hamburg, Germany
- German Center for Cardiovascular Research, Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - Mahir Karakas
- Department of General and Interventional Cardiology, University Heart Center Hamburg, Germany
- German Center for Cardiovascular Research, Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - Thomas Münzel
- German Center for Cardiovascular Research, Partner Site RheinMain, Hamburg, Germany
- Center for Cardiology, University Medical Center of the Johannes Gutenberg-University Mainz, Germany
| | - Stefan Blankenberg
- Department of General and Interventional Cardiology, University Heart Center Hamburg, Germany
- German Center for Cardiovascular Research, Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - Dirk Westermann
- Department of General and Interventional Cardiology, University Heart Center Hamburg, Germany
- German Center for Cardiovascular Research, Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - Renate B Schnabel
- Department of General and Interventional Cardiology, University Heart Center Hamburg, Germany
- German Center for Cardiovascular Research, Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany
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10
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Jagodzinski A, Neumann JT, Ojeda F, Sörensen NA, Wild P, Münzel T, Zeller T, Westermann D, Blankenberg S. Cardiovascular Biomarkers in Hypertensive Patients with Medical Treatment-Results from the Randomized TEAMSTA Protect I Trial. Clin Chem 2017; 63:1877-1885. [PMID: 28904053 DOI: 10.1373/clinchem.2017.275289] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2017] [Accepted: 08/03/2017] [Indexed: 01/06/2023]
Abstract
BACKGROUND High blood pressure (BP) is associated with an increased rate of cardiovascular events and mortality. Cardiovascular biomarkers are able to predict long-term risk in the general population, particularly in diseased cohorts. We undertook an investigation of the effect of 2 different antihypertensive treatments on cardiovascular biomarkers in a randomized trial. METHODS The TEAMSTA study included 481 hypertensive patients. They were randomized to either 80-mg telmisartan + 5-mg amlodipine (TA) or 40-mg olmesartan + 12.5-mg hydrochlorothiazide (OH). The trial was performed as a prospective, randomized, double-blinded, controlled, single-center study. We measured BP, high-sensitivity cardiac troponin I (hs-cTnI), high-sensitivity cardiac troponin T (hs-cTnT), B-type natriuretic peptide (BNP), and N-terminal-pro-BNP (NT-proBNP) before randomization and after 6 months. RESULTS Individuals were randomized into 2 groups: 230 individuals to the OH-group and 251 to the TA-group. After 6 months of treatment, a reduction in BP (systolic/diastolic) was seen, from 135.2/85.2 mmHg to 122.5/75.7 mmHg with similar effects in both groups. hs-cTnT concentrations were measureable in 26.2% of the study population, while hs-cTnI was detected in 98.3%. hs-cTnI concentrations were significantly reduced from 4.6 to 4.2 ng/L in the overall population, from 4.7 to 4.4 ng/L in the OH-group, and from 4.6 to 4.0 ng/L in the TA-group (all P < 0.001). No significant changes of hs-cTnT were observed. BNP and NT-proBNP concentrations decreased from 15.0 to 12.4 ng/L (P < 0.001) and from 64.8 to 53.3 ng/L (P < 0.001), respectively, after 6 months. CONCLUSIONS The reduction in BP was associated with a decrease of high-sensitivity troponin I, BNP, and NT-proBNP concentrations, which might represent a cardiovascular risk reduction. CLINICAL TRIAL REGISTRATION EudraCT 2009-017010-68.
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Affiliation(s)
- Annika Jagodzinski
- Department of General and Interventional Cardiology, University Heart Center Hamburg, Hamburg, Germany.,German Center for Cardiovascular Research, Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - Johannes Tobias Neumann
- Department of General and Interventional Cardiology, University Heart Center Hamburg, Hamburg, Germany; .,German Center for Cardiovascular Research, Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - Francisco Ojeda
- Department of General and Interventional Cardiology, University Heart Center Hamburg, Hamburg, Germany
| | - Nils Arne Sörensen
- Department of General and Interventional Cardiology, University Heart Center Hamburg, Hamburg, Germany
| | - Philipp Wild
- Department of Preventive Cardiology and Preventive Medicine, Center for Cardiology, University Medical Center Mainz, Germany.,Center for Thrombosis and Hemostasis, University Medical Center Mainz, Germany.,German Center for Cardiovascular Research, Partner Site RheinMain, Mainz, Germany.,Center for Translational Vascular Biology, University Medical Center Mainz, Germany
| | - Thomas Münzel
- German Center for Cardiovascular Research, Partner Site RheinMain, Mainz, Germany.,Center for Translational Vascular Biology, University Medical Center Mainz, Germany.,Center for Cardiology-Cardiology I, University Medical Center Mainz, Germany
| | - Tanja Zeller
- Department of General and Interventional Cardiology, University Heart Center Hamburg, Hamburg, Germany.,German Center for Cardiovascular Research, Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - Dirk Westermann
- Department of General and Interventional Cardiology, University Heart Center Hamburg, Hamburg, Germany.,German Center for Cardiovascular Research, Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - Stefan Blankenberg
- Department of General and Interventional Cardiology, University Heart Center Hamburg, Hamburg, Germany.,German Center for Cardiovascular Research, Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany
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Neumann JT, Sörensen NA, Rübsamen N, Ojeda F, Renné T, Qaderi V, Teltrop E, Kramer S, Quantius L, Zeller T, Karakas M, Blankenberg S, Westermann D. Discrimination of patients with type 2 myocardial infarction. Eur Heart J 2017; 38:3514-3520. [DOI: 10.1093/eurheartj/ehx457] [Citation(s) in RCA: 74] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2017] [Accepted: 07/19/2017] [Indexed: 01/02/2023] Open
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Neumann JT, Sörensen NA, Ojeda F, Renné T, Schnabel RB, Zeller T, Karakas M, Blankenberg S, Westermann D. Early diagnosis of acute myocardial infarction using high-sensitivity troponin I. PLoS One 2017; 12:e0174288. [PMID: 28333976 PMCID: PMC5363912 DOI: 10.1371/journal.pone.0174288] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2017] [Accepted: 03/06/2017] [Indexed: 01/11/2023] Open
Abstract
Objective There is a clinical need for early and accurate diagnosis of acute myocardial infarction (AMI). Current European Society of Cardiology (ESC) guidelines recommend diagnosis of non-ST-elevation AMI based on serial troponin measurements. We aimed to challenge the ESC guidelines using 1) a high-sensitivity troponin I (hs-TnI) baseline cutoff, 2) an absolute hs-TnI change after 1 hour and 3) additional application of an ischemic ECG. Methods 1,516 patients with suspected AMI presenting to the emergency department were included. Hs-TnI was measured directly at admission, after 1 and 3 hours. We investigated baseline concentrations, absolute changes of hs-TnI and additional application of an ischemic ECG to diagnose AMI. A positive predictive value (PPV) of more than 85% was targeted. Results The median age of the study population was 65 years; 291 patients were diagnosed with AMI. The PPV of the 3-hours ESC algorithm was 85.5% (CI 79.7, 90.1) and 65.8% (CI 60.5,70.8) for the 1-hour algorithm. Using a high baseline hs-TnI concentration of 150 ng/L resulted in a PPV of 87.8% (CI 80.9,92.9). Alternatively, a hs-TnI change of 20 ng/L after 1 hour, resulted in a PPV of 86.5% (80.9,91.0), respectively for the diagnosis of AMI. Additional use of an ischemic ECG increased the PPV to 90.5% (CI 83.2,95.3), while reducing the efficacy. Conclusion The diagnosis of AMI based on hs-TnI is challenging. The application of absolute hs-TnI changes after 1 hour may facilitate rapid rule-in of patients. Trial registration www.clinicaltrials.gov (NCT02355457).
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Affiliation(s)
- Johannes Tobias Neumann
- Department of General and Interventional Cardiology, University Heart Center, Hamburg, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Germany
- * E-mail:
| | - Nils Arne Sörensen
- Department of General and Interventional Cardiology, University Heart Center, Hamburg, Germany
| | - Francisco Ojeda
- Department of General and Interventional Cardiology, University Heart Center, Hamburg, Germany
| | - Thomas Renné
- Institute of Clinical Chemistry and Laboratory Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Clinical Chemistry, Department of Molecular Medicine and Surgery, Karolinska Institute, Stockholm, Sweden
| | - Renate B. Schnabel
- Department of General and Interventional Cardiology, University Heart Center, Hamburg, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Germany
| | - Tanja Zeller
- Department of General and Interventional Cardiology, University Heart Center, Hamburg, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Germany
| | - Mahir Karakas
- Department of General and Interventional Cardiology, University Heart Center, Hamburg, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Germany
| | - Stefan Blankenberg
- Department of General and Interventional Cardiology, University Heart Center, Hamburg, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Germany
| | - Dirk Westermann
- Department of General and Interventional Cardiology, University Heart Center, Hamburg, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Germany
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14
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Sörensen NA, Neumann JT, Ojeda F, Schwemer T, Renné T, Schnabel RB, Zeller T, Karakas M, Blankenberg S, Westermann D. Challenging the 99th percentile: A lower troponin cutoff leads to low mortality of chest pain patients. Int J Cardiol 2016; 232:289-293. [PMID: 28087181 DOI: 10.1016/j.ijcard.2016.12.167] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [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: 07/29/2016] [Revised: 12/19/2016] [Accepted: 12/25/2016] [Indexed: 11/17/2022]
Abstract
BACKGROUND Rule-out of non-ST-elevation myocardial infarction is based on consecutive measurements of cardiac troponins using the 99th percentile of the respective assay as cutoff. The new ESC guidelines alternatively offer rapid 1h algorithms with lower cutoffs than the 99th percentile for rule-out of non-ST-elevation myocardial infarction. We aimed to compare a recently introduced 1h algorithm based on a high-sensitivity cardiac troponin I (hs-TnI) cutoff of 6ng/L at 0h and 1h to the current standard of care using the 99th percentile (27ng/L) as cutoff with reference to follow-up events in a large chest pain cohort. METHODS Hs-TnI was measured at three time points (0h, 1h and 3h) in 1625 patients presenting with suspected myocardial infarction to the emergency department of the University-Medical Center Hamburg-Eppendorf. Seventy-five patients with ST-elevation myocardial infarction were excluded from the analysis. All-cause mortality, cardiac death, acute myocardial infarction, revascularization and cardiac rehospitalization after 12months were assessed. RESULTS Patients ruled out by the 1h algorithm showed significantly less cardiac rehospitalizations (12.84% vs. 17.66%; p<0.001), and overall mortality (1.30% vs 3.46%, p<0.001) compared to using the 99th percentile as cutoff. The majority of deaths were caused by non-cardiac reasons. Cardiac deaths were rare using the 1h algorithm (0.21%). CONCLUSION The commonly used 99th percentile as cutoff neglects patients with a high risk in the setting of acute chest pain. TRIAL REGISTRATION www.clinicaltrials.gov (NCT02355457).
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Affiliation(s)
- Nils Arne Sörensen
- Department of General and Interventional Cardiology, University Heart Center Hamburg, Martinistrasse 52, 20246 Hamburg, Germany.
| | - Johannes Tobias Neumann
- Department of General and Interventional Cardiology, University Heart Center Hamburg, Martinistrasse 52, 20246 Hamburg, Germany; German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Martinistrasse 52, 20246 Hamburg, Germany
| | - Francisco Ojeda
- Department of General and Interventional Cardiology, University Heart Center Hamburg, Martinistrasse 52, 20246 Hamburg, Germany; German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Martinistrasse 52, 20246 Hamburg, Germany
| | - Tjark Schwemer
- Department of General and Interventional Cardiology, University Heart Center Hamburg, Martinistrasse 52, 20246 Hamburg, Germany
| | - Thomas Renné
- Institute of Clinical Chemistry and Laboratory Medicine, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246 Hamburg, Germany; Clinical Chemistry and Blood Coagulation Research, Department of Molecular Medicine and Surgery, Karolinska University Hospital, Solna (L1:00), SE-171 76, Stockholm, Sweden
| | - Renate B Schnabel
- Department of General and Interventional Cardiology, University Heart Center Hamburg, Martinistrasse 52, 20246 Hamburg, Germany; German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Martinistrasse 52, 20246 Hamburg, Germany
| | - Tanja Zeller
- Department of General and Interventional Cardiology, University Heart Center Hamburg, Martinistrasse 52, 20246 Hamburg, Germany; German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Martinistrasse 52, 20246 Hamburg, Germany
| | - Mahir Karakas
- Department of General and Interventional Cardiology, University Heart Center Hamburg, Martinistrasse 52, 20246 Hamburg, Germany; German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Martinistrasse 52, 20246 Hamburg, Germany
| | - Stefan Blankenberg
- Department of General and Interventional Cardiology, University Heart Center Hamburg, Martinistrasse 52, 20246 Hamburg, Germany; German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Martinistrasse 52, 20246 Hamburg, Germany
| | - Dirk Westermann
- Department of General and Interventional Cardiology, University Heart Center Hamburg, Martinistrasse 52, 20246 Hamburg, Germany; German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Martinistrasse 52, 20246 Hamburg, Germany
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15
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Neumann JT, Sörensen NA, Ojeda F, Schwemer T, Lehmacher J, Gönner S, Jarsetz N, Keller T, Schaefer S, Renné T, Landmesser U, Clemmensen P, Makarova N, Schnabel RB, Zeller T, Karakas M, Pickering JW, Than M, Parsonage W, Greenslade J, Cullen L, Westermann D, Blankenberg S. Immediate Rule-Out of Acute Myocardial Infarction Using Electrocardiogram and Baseline High-Sensitivity Troponin I. Clin Chem 2016; 63:394-402. [PMID: 27903616 DOI: 10.1373/clinchem.2016.262659] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2016] [Accepted: 09/01/2016] [Indexed: 11/06/2022]
Abstract
AIMS Serial measurements of high-sensitivity troponin are used to rule out acute myocardial infarction (AMI) with an assay specific cutoff at the 99th percentile. Here, we evaluated the performance of a single admission troponin with a lower cutoff combined with a low risk electrocardiogram (ECG) to rule out AMI. METHODS Troponin I measured with a high-sensitivity assay (hs-TnI) was determined at admission in 1040 patients presenting with suspected AMI (BACC study). To rule out AMI we calculated the negative predictive value (NPV) utilizing the optimal hs-TnI cutoff combined with a low risk ECG. The results were validated in 3566 patients with suspected AMI [2-h Accelerated Diagnostic Protocol to Assess Patients With Chest Pain Symptoms Using Contemporary Troponins as the Only Biomarker (ADAPT) studies]. Patients were followed for 6 or 12 months. RESULTS 184 of all patients were diagnosed with AMI. An hs-TnI cutoff of 3 ng/L resulted in a NPV of 99.3% (CI 97.3-100.0), ruling out 35% of all non-AMI patients. Adding the information of a low risk ECG resulted in a 100% (CI 97.5-100.0) NPV (28% ruled out). The 2 validation cohorts replicated the high NPV of this approach. The follow-up mortality in the ruled out population was low (0 deaths in BACC and Stenocardia, 1 death in ADAPT). CONCLUSIONS A single hs-TnI measurement on admission combined with a low risk ECG appears to rule out AMI safely without need for serial troponin testing. TRIAL REGISTRATION www.clinicaltrials.gov (NCT02355457).
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Affiliation(s)
- Johannes Tobias Neumann
- Department of General and Interventional Cardiology, University Heart Center Hamburg Eppendorf, Hamburg, Germany; .,German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - Nils Arne Sörensen
- Department of General and Interventional Cardiology, University Heart Center Hamburg Eppendorf, Hamburg, Germany
| | - Francisco Ojeda
- Department of General and Interventional Cardiology, University Heart Center Hamburg Eppendorf, Hamburg, Germany
| | - Tjark Schwemer
- Department of General and Interventional Cardiology, University Heart Center Hamburg Eppendorf, Hamburg, Germany
| | - Jonas Lehmacher
- Department of General and Interventional Cardiology, University Heart Center Hamburg Eppendorf, Hamburg, Germany
| | - Saskia Gönner
- Department of General and Interventional Cardiology, University Heart Center Hamburg Eppendorf, Hamburg, Germany
| | - Nikolas Jarsetz
- Department of General and Interventional Cardiology, University Heart Center Hamburg Eppendorf, Hamburg, Germany
| | - Till Keller
- Department of Cardiology, Johann Wolfgang Goethe University Hospital, Frankfurt/Main, Germany
| | - Sarina Schaefer
- Department of General and Interventional Cardiology, University Heart Center Hamburg Eppendorf, Hamburg, Germany.,German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - Thomas Renné
- Institute of Clinical Chemistry and Laboratory Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany and Clinical Chemistry, Department of Molecular Medicine and Surgery, Karolinska Institute, Stockholm, Sweden
| | - Ulf Landmesser
- Department of Cardiology, Charite Universitätsmedizin Berlin, Campus Benjamin Franklin, Berlin, Germany
| | - Peter Clemmensen
- Department of General and Interventional Cardiology, University Heart Center Hamburg Eppendorf, Hamburg, Germany.,Department of Medicine, Nykoebing F Hospital, University of Southern Denmark, Odense, Denmark
| | - Nataliya Makarova
- Department of General and Interventional Cardiology, University Heart Center Hamburg Eppendorf, Hamburg, Germany.,German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - Renate B Schnabel
- Department of General and Interventional Cardiology, University Heart Center Hamburg Eppendorf, Hamburg, Germany.,German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - Tanja Zeller
- Department of General and Interventional Cardiology, University Heart Center Hamburg Eppendorf, Hamburg, Germany.,German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - Mahir Karakas
- Department of General and Interventional Cardiology, University Heart Center Hamburg Eppendorf, Hamburg, Germany.,German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - John W Pickering
- Emergency Department, Christchurch Hospital, Christchurch, New Zealand
| | - Martin Than
- Emergency Department, Christchurch Hospital, Christchurch, New Zealand
| | - William Parsonage
- Department of Emergency Medicine, Royal Brisbane and Women's Hospital, Brisbane, Australia
| | - Jaimi Greenslade
- Department of Emergency Medicine, Royal Brisbane and Women's Hospital, Brisbane, Australia
| | - Louise Cullen
- Department of Emergency Medicine, Royal Brisbane and Women's Hospital, Brisbane, Australia
| | - Dirk Westermann
- Department of General and Interventional Cardiology, University Heart Center Hamburg Eppendorf, Hamburg, Germany.,German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - Stefan Blankenberg
- Department of General and Interventional Cardiology, University Heart Center Hamburg Eppendorf, Hamburg, Germany.,German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany
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Neumann JT, Sörensen NA, Schwemer T, Ojeda F, Bourry R, Sciacca V, Schaefer S, Waldeyer C, Sinning C, Renné T, Than M, Parsonage W, Wildi K, Makarova N, Schnabel RB, Landmesser U, Mueller C, Cullen L, Greenslade J, Zeller T, Blankenberg S, Karakas M, Westermann D. Diagnosis of Myocardial Infarction Using a High-Sensitivity Troponin I 1-Hour Algorithm. JAMA Cardiol 2016; 1:397-404. [DOI: 10.1001/jamacardio.2016.0695] [Citation(s) in RCA: 147] [Impact Index Per Article: 18.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Johannes Tobias Neumann
- Department of General and Interventional Cardiology, University Heart Center Hamburg, University Hospital Hamburg-Eppendorf, Hamburg, Germany2German Center for Cardiovascular Research, Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - Nils Arne Sörensen
- Department of General and Interventional Cardiology, University Heart Center Hamburg, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Tjark Schwemer
- Department of General and Interventional Cardiology, University Heart Center Hamburg, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Francisco Ojeda
- Department of General and Interventional Cardiology, University Heart Center Hamburg, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Rafael Bourry
- Department of General and Interventional Cardiology, University Heart Center Hamburg, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Vanessa Sciacca
- Department of General and Interventional Cardiology, University Heart Center Hamburg, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Sarina Schaefer
- Department of General and Interventional Cardiology, University Heart Center Hamburg, University Hospital Hamburg-Eppendorf, Hamburg, Germany2German Center for Cardiovascular Research, Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - Christoph Waldeyer
- Department of General and Interventional Cardiology, University Heart Center Hamburg, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Christoph Sinning
- Department of General and Interventional Cardiology, University Heart Center Hamburg, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Thomas Renné
- Institute of Clinical Chemistry and Laboratory Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany4Unit of Clinical Chemistry, Department of Molecular Medicine and Surgery, Karolinska Institute, Stockholm, Sweden
| | - Martin Than
- Emergency Department, Christchurch Hospital, Christchurch, New Zealand
| | - William Parsonage
- Department of Emergency Medicine, Royal Brisbane and Women’s Hospital, Brisbane, Australia
| | - Karin Wildi
- Department of Cardiology, Cardiovascular Research Institute Basel, University Hospital Basel, Basel, Switzerland
| | - Nataliya Makarova
- Department of General and Interventional Cardiology, University Heart Center Hamburg, University Hospital Hamburg-Eppendorf, Hamburg, Germany2German Center for Cardiovascular Research, Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - Renate B. Schnabel
- Department of General and Interventional Cardiology, University Heart Center Hamburg, University Hospital Hamburg-Eppendorf, Hamburg, Germany2German Center for Cardiovascular Research, Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - Ulf Landmesser
- Department of Cardiology, Charité Universitätsmedizin Berlin, Campus Benjamin Franklin, Berlin, Germany
| | - Christian Mueller
- Department of Cardiology, Cardiovascular Research Institute Basel, University Hospital Basel, Basel, Switzerland
| | - Louise Cullen
- Department of Emergency Medicine, Royal Brisbane and Women’s Hospital, Brisbane, Australia
| | - Jaimi Greenslade
- Department of Emergency Medicine, Royal Brisbane and Women’s Hospital, Brisbane, Australia
| | - Tanja Zeller
- Department of General and Interventional Cardiology, University Heart Center Hamburg, University Hospital Hamburg-Eppendorf, Hamburg, Germany2German Center for Cardiovascular Research, Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - Stefan Blankenberg
- Department of General and Interventional Cardiology, University Heart Center Hamburg, University Hospital Hamburg-Eppendorf, Hamburg, Germany2German Center for Cardiovascular Research, Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - Mahir Karakas
- Department of General and Interventional Cardiology, University Heart Center Hamburg, University Hospital Hamburg-Eppendorf, Hamburg, Germany2German Center for Cardiovascular Research, Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - Dirk Westermann
- Department of General and Interventional Cardiology, University Heart Center Hamburg, University Hospital Hamburg-Eppendorf, Hamburg, Germany2German Center for Cardiovascular Research, Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany
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Affiliation(s)
| | - Nils Arne Sörensen
- General & Interventional Cardiology, University Heart Center Hamburg, Hamburg, Germany
| | - Dirk Westermann
- General & Interventional Cardiology, University Heart Center Hamburg, Hamburg, Germany
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