Prognostic utility of a multibiomarker panel in patients with suspected myocardial infarction

Introduction

Rapid and accurate evaluation of patients presenting with suspected myocardial infarction (MI) to the emergency department (ED) is crucial due to strongly varying outcomes in these patients. Despite the routine use of circulating biomarkers, among which high-sensitivity cardiac troponin currently dictates diagnostic protocols in chest pain patients, it still remains unclear which biomarkers are of highest utility for prognostic purposes in this patient collective.

Purpose

We sought to investigate the prognostic utility of a multibiomarker panel with 29 different biomarkers in a contemporary cohort of patients with suspected MI by applying a dual analytical approach.

Methods

The multibiomarker panel was measured in stored blood samples that were collected directly at admission from 748 prospectively enrolled patients who presented with symptoms suggestive of MI to the ED of a German tertiary center between 2013 and 2017. The final diagnosis of all patients was adjudicated according to the 4th Universal Definition of MI. The investigated endpoint comprised incident major cardiovascular events (MACE) within 1 year after admission. MACE was defined as the composite of cardiovascular death, non-fatal MI (excluding index events), revascularization and cardiac rehospitalization. Log-transformed biomarkers were entered individually into an age-and sex-adjusted Cox regression model to explore the hazard ratio (HR) per one standard deviation increase (SD) for 1-year MACE in the overall cohort. The selection of optimal multimarker models, adjusted for age and sex, was performed using 1) stepwise backward selection via Akaike information criterion as the stopping rule, and 2) Least Absolute Shrinkage and Selection Operator (LASSO) with 5-fold cross-validation.

Results

Out of 748 patients with available multibiomarker panel, 138 (18.4%) were diagnosed with MI. Median age at admission was 64 (interquartile range [IQR] 50–75) years in the overall cohort, 63.1% were male. At 1 year of follow-up, 160 cases of incident MACE were documented. 16 of the investigated 29 biomarkers were significantly associated with 1-year MACE, amongst which NT-proBNP was the strongest predictor (HR per SD 1.74, 95% confidence interval [CI] 1.44–2.09, p<0.0001; Table 1). Using stepwise backward selection, three biomarkers including NT-proBNP, Apo A-I and Apo C-III remained in the final multivariable model (Figure 1). The LASSO approach confirmed NT-proBNP (HR per SD 1.24) and Apo A-I (HR per SD 0.98) as strong and independent predictors of 1-year MACE while Apo C-III was replaced with KIM-1 (HR per SD 1.06).

Conclusions

Among 29 biomarkers, numerous provide prognostic utility while NT-proBNP and Apo A-I emerged as the strongest independent predictors of 1-year MACE. Their routine assessment and integration into risk prediction models may improve personalized risk stratification in patients with symptoms suggestive of MI.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): The BACC study was supported by the German Center for Cardiovascular Research, an unrestricted grant by Abbott Diagnostics, and Prevencio, which also partly covered the biomarker measurements.

Validation of a rapid diagnostic algorithm for diagnosis of myocardial infarction using a high-sensitivity cardiac troponin assay

Background

As acute chest pain is one of the main reasons for presentation in emergency departments, early identification of patients with myocardial infarction (MI) is of crucial importance. Current guidelines recommend the application of rapid 0h/1h diagnostic algorithms using high-sensitivity cardiac troponin (hs-Tn) for the diagnosis of MI. Several hs-Tn assays have been evaluated and assay-specific algorithms have been developed, achieving great diagnostic performance. Yet, for some of these assays, existing data is limited.

Objective

We aimed to evaluate the diagnostic performance and prognostic value of a rapid 0/1h diagnostic algorithm for Access II hs-TnI as recommended by the European Society of Cardiology (ESC).

Methods

In the prospective Biomarkers in Acute Cardiac Care study enrolling patients presenting with suspected MI to the emergency department, we measured concentrations of Access II hs-TnI at presentation and after 1 hour. Final diagnoses were independently adjudicated by two cardiologists according to the 4th Universal Definition of MI using Elecsys hs-TnT. Parameters for diagnostic performance were calculated, when applying the ESC 0/1h algorithm. Additionally, to assess the prognostic utility of this ESC 0h/1h algorithm, we performed survival analyses for the composite of all-cause mortality and incident MI at three years, computing Kaplan-Meier-curves and Cox-regressions adjusted for common cardiovascular risk factors as well as pre-existing coronary artery disease and congestive heart failure.

Results

Of 1879 enrolled patients, 257 (14%) were diagnosed with NSTEMI. Median age was 63 years, 64.3% were males. When applying the ESC 0/1h algorithm using Access II hs-TnI, 44.5% of patients were ruled-out with a sensitivity of 97.7% (95% CI; 95.0, 99.1) and a negative predictive value (NPV) of 99.3% (95% CI; 98.4, 99.7). Similarly, 20.3% of patients were ruled-in with a specificity of 88.0% (95% CI; 86.3%, 89.6%) and a positive predictive value (PPV) of 50.8% (95% CI; 45.7, 55.9) whereas 35.1% remained in the observe group (Table 1). Three-year event rates differed substantially between patients triaged towards the rule-out (2.9%), observe (16.1%) and rule-in group (18.4%, log-rank p<0.001; Figure 1). Adjusted hazard ratios confirmed a significantly worse prognosis for patients in the observe group (HR 2.51 [95% CI; 1.56, 4.04], p=0.001) and rule-in group (HR 3.55 [95% CI; 2.18, 5.79], p<0.001), when compared to the rule-out group.

Conclusion

The ESC 0/1h algorithm for Access II hs-TnI allows a save and efficient rapid triage of patients with suspected MI and harbours prognostic utility for incident MI and all-cause mortality.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): German Center of Cardiovascular Research (DZHK)Abbott Diagnostics

Louping ill virus: an endemic tick-borne disease of Great Britain

In Europe and Asia, Ixodid ticks transmit tick-borne encephalitis virus (TBEV), a flavivirus that causes severe encephalitis in humans but appears to show no virulence for livestock and wildlife. In the British Isles, where TBEV is absent, a closely related tick-borne flavivirus, named louping ill virus (LIV), is present. However, unlike TBEV, LIV causes a febrile illness in sheep, cattle, grouse and some other species, that can progress to fatal encephalitis. The disease is detected predominantly in animals from upland areas of the UK and Ireland. This distribution is closely associated with the presence of its arthropod vector, the hard tick Ixodes ricinus. The virus is a positive-strand RNA virus belonging to the genus Flavivirus, exhibiting a high degree of genetic homology to TBEV and other mammalian tick-borne viruses. In addition to causing acute encephalomyelitis in sheep, other mammals and some avian species, the virus is recognized as a zoonotic agent with occasional reports of seropositive individuals, particularly those whose occupation involves contact with sheep. Preventative vaccination in sheep is effective although there is no treatment for disease. Surveillance for LIV in Great Britain is limited despite an increased awareness of emerging arthropod-borne diseases and potential changes in distribution and epidemiology. This review provides an overview of LIV and highlights areas where further effort is needed to control this disease.

Laminin 332 deposition is diminished in irradiated skin in an animal model of combined radiation and wound skin injury

Skin exposure to ionizing radiation affects the normal wound healing process and greatly impacts the prognosis of affected individuals. We investigated the effect of ionizing radiation on wound healing in a rat model of combined radiation and wound skin injury. Using a soft X-ray beam, a single dose of ionizing radiation (10-40 Gy) was delivered to the skin without significant exposure to internal organs. At 1 h postirradiation, two skin wounds were made on the back of each rat. Control and experimental animals were euthanized at 3, 7, 14, 21 and 30 days postirradiation. The wound areas were measured, and tissue samples were evaluated for laminin 332 and matrix metalloproteinase (MMP) 2 expression. Our results clearly demonstrate that radiation exposure significantly delayed wound healing in a dose-related manner. Evaluation of irradiated and wounded skin showed decreased deposition of laminin 332 protein in the epidermal basement membrane together with an elevated expression of all three laminin 332 genes within 3 days postirradiation. The elevated laminin 332 gene expression was paralleled by an elevated gene and protein expression of MMP2, suggesting that the reduced amount of laminin 332 in irradiated skin is due to an imbalance between laminin 332 secretion and its accelerated processing by elevated tissue metalloproteinases. Western blot analysis of cultured rat keratinocytes showed decreased laminin 332 deposition by irradiated cells, and incubation of irradiated keratinocytes with MMP inhibitor significantly increased the amount of deposited laminin 332. Furthermore, irradiated keratinocytes exhibited a longer time to close an artificial wound, and this delay was partially corrected by seeding keratinocytes on laminin 332-coated plates. These data strongly suggest that laminin 332 deposition is inhibited by ionizing radiation and, in combination with slower keratinocyte migration, can contribute to the delayed wound healing of irradiated skin.

Outbreak of tuberculosis caused by Mycobacterium bovis in golden Guernsey goats in Great Britain

An outbreak of caprine tuberculosis caused by Mycobacterium bovis was disclosed in June 2008, affecting goats of the golden Guernsey breed kept on 10 separate smallholdings in south-west Wales and the west of England. Following the initial diagnosis at postmortem examination, 30 goats that reacted positively to the single intradermal comparative cervical tuberculin (SICCT) test, together with five in-contact animals, were euthanased and subjected to postmortem examination and mycobacterial culture. Spoligotyping and variable number tandem repeat analysis of isolates showed that they were all of the same genotype, endemic to south-west Wales. Retrospective movement tracings identified a goat herd in south-west Wales, by then completely dispersed, as the probable common source of infection. There was a perfect correlation between the SICCT test and culture results in all slaughtered goats. Grossly visible tubercular lesions were observed at postmortem examination in all but one reactor.

Maternal and fetal immune responses of cattle inoculated with Neospora caninum at mid-gestation

The humoral and cell-mediated immune responses of pregnant cattle and their fetuses were examined at intervals after infection with Neospora caninum tachyzoites at mid-gestation (day 140). All cattle seroconverted and interferon gamma was detected in supernatants of peripheral blood mononuclear cells stimulated with specific antigen. At day 14 post-inoculation (pi), specific cell proliferation responses were detected in the lymph node draining the site of inoculation and in the uterine lymph node. The peak response was recorded in the majority of maternal lymph nodes by day 28 pi and cells from the maternal retropharyngeal lymph node, which in part drains the central nervous system, showed no specific activity to N. caninum until day 42 pi. This changing pattern of immune responsiveness may reflect parasite invasion and development within different host tissues. Fetal lymph node cells showed mitogen responsiveness from day 14 pi (day 154 of gestation) and also showed N. caninum-specific cell proliferation and interferon-gamma responses by day 28 pi (day 168 of gestation). At day 42 pi, specific cell-mediated immune responses were not apparent; however, N. caninum-specific fetal IgG and IgM antibodies were detected.

The pathogenesis of neosporosis in pregnant cattle: inoculation at mid-gestation

To investigate the pathogenesis of bovine neosporosis, 14 pregnant cattle were each inoculated subcutaneously with either 10(7) or 5 x 10(8) Neospora caninum (strain NC1) tachyzoites at 140 days' gestation. Serial necropsies were then carried out over an 8-week period. In the placenta, Neospora DNA and histopathological changes were observed in samples taken 14 days post-inoculation (dpi), with focal necrosis of maternal caruncular septa and fetal placental villi, serum leakage, and a maternal and fetal inflammatory response. At subsequent samplings, pathological changes in the placenta showed signs of resolution. No parasitaemia was detected in the dams in the two weeks following inoculation. In the fetus, Neospora DNA was detected at 14 dpi, and histopathological changes in the fetal central nervous system at 28 and 42 dpi consisted of small foci of necrosis and inflammation. Resolution of placental lesions during the experiment indicated that the disease was being controlled, and fetal infection, although established, did not appear to be progressing to a fatal outcome. The two doses of tachyzoites produced similar results, but the higher dose elicited earlier and more extensive lesions in the placenta and fetus. Control animals remained negative for all parameters recorded. It is concluded that in bovine neosporosis the placenta plays a central role in the pathogenesis and epidemiology of the infection, and that while primary tissue destruction by the parasite may endanger the fetus, the maternal and fetal inflammatory responses may also be damaging.

Experimental induction of pneumonic pasteurellosis in calves by intratracheal infection with Pasteurella multocida biotype A:3

The study aimed to establish an experimental model to investigate the pathogenesis of lung infection by Pasteurella multocida, an important cause of bovine respiratory disease. An experimental model is required to assist the development of an effective vaccine. Sixteen 8-week-old calves were challenged intratracheally with 10(9) or 10(10) colony forming units of P. multocida in either 60 or 300 ml saline in a 2 x 2 factorial experiment. All animals became dull within 2-6h post-infection (p.i.) and two calves were killed humanely because of suspected endotoxic shock. Remaining animals showed increased respiratory rates by 15-20 h p.i. and, at 23 h p.i., calves given the high dose, high volume challenge showed higher (P < 0.05) rectal temperatures. From 24 to 36 h p.i., clinical signs decreased in a majority of animals. Plasma haptoglobin concentrations increased (P < 0.05) in calves given the high volume challenge irrespective of the number of bacteria. At post-mortem examination (4d p.i.), lung lesions, mainly in the apical lobes, were found in all calves. Histopathological examination showed areas of purulent pneumonia with a tendency to abscessation and inflamed interlobular septa characterised by accumulation of neutrophils and oedema. The clinical and pathological responses described were typical of bovine pneumonic pasteurellosis.

Chronic meningoencephalitis associated with Brucella sp. infection in live-stranded striped dolphins (Stenella coeruleoalba)

A chronic, non-suppurative meningoencephalitis was found in three young striped dolphins (Stenella coeruleoalba) during routine neuropathological examination of marine mammals live-stranded on the Scottish coast. In all three dolphins the lesions were associated with the isolation of a Brucella sp. from the brain and with the immunohistochemical detection of brucella antigen. Moreover, antibodies to Brucella spp. were detected in the two dolphins that were subjected to serological examination. Immunohistochemical and serological examinations for morbillivirus antigen and antibodies, respectively, were negative in all cases. Although brucella infection of marine mammals has been extensively documented in recent years, its association with lesions and disease is less well recognized. The present report provides the first description of an association between Brucella sp. infection and neuropathological changes in a cetacean species.

Protection against vertical transmission in bovine neosporosis

In this study we were interested to determine whether infection of cattle prior to pregnancy would afford any protection to the foetus if the dams were challenged with Neospora caninum at mid-gestation. The experiment comprised four groups of cattle: group 1, uninfected controls; group 2, inoculated with N. caninum tachyzoites 6 weeks prior to mating and then challenged with N. caninum at mid-gestation; group 3, naive cattle challenged with N. caninum at mid-gestation and group 4 were infected with N. caninum prior to mating and left unchallenged throughout pregnancy. Positive cell-mediated and humoral immune responses to N. caninum were recorded in groups 2 and 4 prior to pregnancy and in groups 2, 3 and 4 following challenge at mid-gestation. However there was a marked down regulation of the cell-mediated immune response in all groups around mid-gestation. There was a significant increase in rectal temperature response in animals in group 3 compared to group 2 following challenge but no other clinical symptoms of disease were recorded and all cattle proceeded to calving. At calving, pre-colostral blood samples were negative for antibodies to N. caninum in all the calves born to dams in groups 1, 2 and 4. In contrast, all the calves born to dams in group 3 had high levels of specific antibody to N. caninum indicating that they had been exposed to the parasite in utero. At post-mortem N. caninum DNA was detected in CNS, thymus and placental cotyledon samples in calves from group 3. All tissue samples from calves in the other 3 groups were negative for N. caninum DNA with the exception of one calf from group 2 where specific DNA was detected in a sample of spinal cord. These results suggest that the immune response generated in the dams in group 2 prior to pregnancy had protected against vertical transmission of the parasite following challenge at mid-gestation.

Genetic and biological diversity among isolates of Neospora caninum

Neospora caninum is a protozoan parasite that causes bovine abortion. The epidemiology of N. caninum is poorly understood and little is known about the genetic diversity of the parasite, or whether individual isolates differ in virulence. Such diversity may, among other factors, underlie the range of pathologies seen in cattle. In this study we analysed biological and genetic variation in 6 isolates of N. caninum originating from canine and bovine hosts by measurement of growth rate in vitro, Western blotting and random amplification of polymorphic DNA (RAPD). This comparative analysis of intra-species diversity demonstrated that heterogeneity exists within the species. The relative growth rate in vitro, as assessed by 3[H]uracil uptake, showed significant variation between isolates. However, no significant differences were detected between the antigenic profiles of each isolate by Western blotting. RAPD-PCR was performed on DNA from the 6 Neospora isolates; 3 strains of Toxoplasma gondii, Sarcocystis sp. and Cryptosporidium parvum were also analysed. Twenty-six RAPD primers gave rise to 434 markers of which 222 were conserved between all the Neospora isolates and distinguished them from the other Apicomplexa. An additional 54 markers were unique for Neospora but were polymorphic within the species and able to differentiate between the individual isolates. The RAPD data were subjected to pair-wise similarity and cluster analysis and showed that the Neospora isolates clustered together as a group, with T. gondii as their nearest neighbour. N. caninum isolates showed no clustering with respect either to host or geographical origin. The genetic similarity between Neospora isolates from cattle and dogs suggests that these hosts may be epidemiologically related, although further analysis of bovine and canine field samples are required. The genetic and biological diversity observed in this study may have important implications for our understanding of the pathology and epidemiology of neosporosis.

Neosporosis. Aspects of epidemiology and host immune response

Neospora caninum is a recently recognized protozoan parasite which has been described as causing a neuromuscular paralysis in dogs and is emerging as a major cause of bovine infertility and abortion worldwide. The parasite is known to infect a range of warm blooded animals but the disease predominates in dogs and cattle. It is not yet known if N. caninum can infect and cause disease in people. The dog has recently been identified as the definitive host and the parasite may be transmitted through the ingestion of oocysts or congenitally from mother to fetus. N. caninum is known to infect red foxes (Vulpes vulpes) and coyotes (Canis latrans) and the role of wildlife species as reservoirs of infection requires further investigation. Little is known about the range of parasite genotypes within the environment or the variation in virulence between different strains. RAPD-PCR analysis of geographically distinct bovine and canine isolates has revealed little genetic variation. Epidemiological studies from different areas of the world have investigated the importance of N. caninum as an abortifacient agent and longitudinal studies have shown the high rate (approximately 80%) of congenital transmission within infected herds. Information on the rates of repeat abortion due to neosporosis are less well defined however current estimates put this at 5% suggesting that cattle may develop some form of protective immunity against N. caninum-induced abortion. Diagnosis of the disease is based upon detection of the parasite in the tissues, most commonly using immunohistochemistry with additional information provided by serology. However, although positive fetal serology is a strong indicator of exposure to the parasite, care should be taken in the interpretation of maternal serology. As we understand more about the epidemiology of neosporosis we are also better able to interpret the results of diagnostic tests. The mere presence of the parasite does not necessarily infer that this was the primary cause of abortion. CD4+ T-cells, interferon gamma and macrophages have all been found to significantly inhibit multiplication of N. caninum tachyzoites. The nature of a protective immune response and its modulation in the pregnant animal is discussed.

Clinical, pathological and epidemiological findings in three outbreaks of ovine protozoan myeloencephalitis

Ovine protozoan myeloencephalitis is a disease of sheep associated with the apicomplexan protozoan Sarcocystis tenella. This paper describes the clinical, pathological and epidemiological findings in three affected flocks from a well-defined geographical area. Clinical signs were restricted to sheep under one year old in their first winter and were first observed at least 42 days after they had been moved off the hill grazing areas to low ground pasture, or after they were given conserved forage. The findings are discussed in relation to the timescale of the life cycle of S. tenella and it is suggested that clinical disease was precipitated by the change from a low level of exposure to infection on the hill to a high level of exposure through contaminated pasture or forage. Possible preventive strategies are discussed.

Phenotype, growth regulation and cytokine transcription in Ovine Herpesvirus-2 (OHV-2)-infected bovine T-cell lines

The causal agent of sheep-associated malignant catarrhal fever (MCF), Ovine Herpesvirus-2 (OHV-2), can be propagated in IL-2-dependent lymphoblastoid cell lines derived from diseased cattle and deer providing a useful model for the investigation of the pathogenesis of MCF. In this study, five interleukin-2 (IL-2)-dependent cell lines were established from affected cattle to examine their growth regulation and cytokine transcription. All cell lines expressed CD2, CD5 and CD25. Three of the cell lines were CD4+ and one CD8+, whereas one cell was of mixed CD4 and CD8 phenotye. The growth of these cell lines was reduced when cultured with antibody against CD25, the IL-2 receptor alpha subunit. All cell lines showed a lack of response to Con A and their cell growth was inhibited by Cyclosporin A which is known to inhibit cytokine promoters. It was decided therefore, to examine the cell lines for the presence of mRNA of different cytokines. The results showed that the cell lines transcribed message for IFNgamma, TNFalpha, IL-4 and IL-10 whereas no mRNA for IL-2 or IL-1beta was detected. In conclusion, the OHV-2-immortalised cell lines resemble anergic T-cells which may be activated giving rise to the characteristic lesions of MCF.

Characterisation of the lymphoproliferation in rabbits experimentally affected with malignant catarrhal fever

Malignant catarrhal fever (MCF) in rabbits caused by the three Herpesviruses: alcelaphine herpesvirus-1 (AHV-1), ovine herpesvirus-2 (OHV-2) and hippotragine herpesvirus-1 (HipHV-1) induced hyperplasia of lymphoid tissues and accumulations of mononuclear lymphoid cells in non-lymphoid tissues. However, certain lymph nodes were affected preferentially. The lymphoid cells in non-lymphoid tissues were CD43+ T-cells which showed evidence of in situ multiplication. A more detailed phenotypic analysis of splenocytes and lymph node cells in AHV-1 infected rabbits suggested that the hyperplasia was probably due to the expansion of CD8+ T-cells. On the basis of these data and the observations of other authors, that no or very little viral expression can be detected in lesions of MCF affected animals, we propose that the pathogenesis of MCF results from a dysregulation of a secretory T-cell activator. The variable pathology induced by the three viruses may reflect a quantitative or qualitative differences in this proposed activator.