Accelerated -Rule-Out of acute Myocardial Infarction using prehospital copeptin and in-hospital troponin: The AROMI study

AIMS

The present acute myocardial infarction (AMI) rule-out strategies are challenged by the late temporal release of cardiac troponin. Copeptin is a non-specific biomarker of endogenous stress and rises early in AMI, covering the early period where troponin is still normal. An accelerated dual-marker rule-out strategy combining prehospital copeptin and in-hospital high-sensitivity troponin T could reduce length of hospital stay and thus the burden on the health care systems worldwide. The AROMI trial aimed to evaluate if the accelerated dual-marker rule-out strategy could safely reduce length of stay in patients discharged after early rule-out of AMI.

METHODS AND RESULTS

Patients with suspected AMI transported to hospital by ambulance were randomized 1:1 to either accelerated rule-out using copeptin measured in a prehospital blood sample and high-sensitivity troponin T measured at arrival to hospital or to standard rule-out using a 0 h/3 h rule-out strategy. The AROMI study included 4351 patients with suspected AMI. The accelerated dual-marker rule-out strategy reduced mean length of stay by 0.9 h (95% confidence interval 0.7-1.1 h) in patients discharged after rule-out of AMI and was non-inferior regarding 30-day major adverse cardiac events when compared to standard rule-out (absolute risk difference -0.4%, 95% confidence interval -2.5 to 1.7; P-value for non-inferiority = 0.013).

CONCLUSION

Accelerated dual marker rule-out of AMI, using a combination of prehospital copeptin and first in-hospital high-sensitivity troponin T, reduces length of hospital stay without increasing the rate of 30-day major adverse cardiac events as compared to using a 0 h/3 h rule-out strategy.

Direct comparison of very early AMI rule-out algorithms

Introduction

Early rule-out of AMI may have a considerable impact on healthcare spending.

Numerous algorithms for early rule-out of AMI has been suggested within the last year. However, most algorithms are limited by the need for consecutive, timely separated in-hospital blood samples, prolonging length of hospital stay. Very early rule-out algorithms, providing necessary biomarker results shortly after arrival to hospital or even before, could reduce the burden on EDs and cardiology departments.

Many algorithms have been evaluated, validated and compared in several studies; however, often in different subpopulations of larger studies. Reported differences in diagnostic performance of these algorithms may very likely have been caused by differences between the tested patient subgroups. Therefore, a direct comparison of very early rule-out algorithms in a single cohort with all necessary information available for all algorithms is needed.

Purpose

In this study we aimed to compare the ESC 0h/1h algorithm with ten rule-out algorithms, including the ESC 0h/3h algorithm, an in-hospital Dual-Marker strategy (DMS) (combining hs-cTnT with copeptin), and seven very early algorithms (potential rule-out at admission) for rule-out of AMI. Four algorithms are strictly prehospital and three combines prehospital and in-hospital blood samples, see table 1 for description of evaluated algorithms.

Methods

The diagnostic performance of the rule-out algorithms was compared in patients with suspected AMI from a randomized, controlled, multicenter trial. We only included patients who had all required information for each diagnostic algorithm available.

AMI was adjudicated by at least two cardiologists.

Results

We included 1.601 patients, see table 2. Of these 136 (8.5%) had type 1 AMI.

We found that 7 of 11 algorithms, including the present ECS-recommended 0h/1h algorithm, performed with acceptable sensitivities above 98% and specificities between 13.5 and 52.0%.

The ESC 0h/3h algorithm had a unacceptably low sensitivity of 87.5%.

Four of the very early rule-out algorithms (the HEART score, the Modified prehospital HEART score, the Modified prehospital DMS, and the Modified prehospital/in-hospital DMS) all performed with excellent sensitivity of 100% and thereby missing no AMIs. Of these, the HEART score derivates ruled out 13.5–16.2% of pts. without AMI, while the two DMS derivates ruled out 14.3–27.4% of pts without AMI.

Compared with the ESC 0h/1h algorithm the very early rule out algorithms provide the necessary biomarker results at least 1 hour earlier, and when well-performing POCT analyses becomes available for copeptin and troponin analysis, even before arrival to hospital.

Conclusions

Four very early rule out algorithms performed excellent in the rule out of AMI, with 100% sensitivities and specificities of up to 27.4%. This enables safe rule out of AMI shortly after arrival to hospital, and in future, potentially already in the ambulance.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): National budget only - Danish Heart Foundation and Independent Research Fund Denmark

Anterior-Lateral Versus Anterior-Posterior Electrode Position for Cardioverting Atrial Fibrillation

BACKGROUND

Smaller randomized studies have reported conflicting results regarding the optimal electrode position for cardioverting atrial fibrillation. However, anterior-posterior electrode positioning is widely used as a standard and believed to be superior to anterior-lateral electrode positioning. Therefore, we aimed to compare anterior-lateral and anterior-posterior electrode positioning for cardioverting atrial fibrillation in a multicenter randomized trial.

METHODS

In this multicenter, investigator-initiated, open-label trial, we randomly assigned patients with atrial fibrillation scheduled for elective cardioversion to either anterior-lateral or anterior-posterior electrode positioning. The primary outcome was the proportion of patients in sinus rhythm after the first shock. The secondary outcome was the proportion of patients in sinus rhythm after up to 4 shocks escalating to maximum energy. Safety outcomes were any cases of arrhythmia during or after cardioversion, skin redness, and patient-reported periprocedural pain.

RESULTS

We randomized 468 patients. The primary outcome occurred in 126 patients (54%) assigned to the anterior-lateral electrode position and in 77 patients (33%) assigned to the anterior-posterior electrode position (risk difference, 22 percentage points [95% CI, 13-30]; P<0.001). The number of patients in sinus rhythm after the final cardioversion shock was 216 (93%) assigned to anterior-lateral electrode positioning and 200 (85%) assigned to anterior-posterior electrode positioning (risk difference, 7 percentage points [95% CI, 2-12]). There were no significant differences between groups in any safety outcomes.

CONCLUSIONS

Anterior-lateral electrode positioning was more effective than anterior-posterior electrode positioning for biphasic cardioversion of atrial fibrillation. There were no significant differences in any safety outcome. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT03817372.

Pulmonary vasodilation by sildenafil in acute intermediate-high risk pulmonary embolism: a randomized explorative trial

BACKGROUND

To investigate if acute pulmonary vasodilation by sildenafil improves right ventricular function in patients with acute intermediate-high risk pulmonary embolism (PE).

METHODS

Single center, explorative trial. Patients with PE were randomized to a single oral dose of sildenafil 50 mg (n = 10) or placebo (n = 10) as add-on to conventional therapy. The time from hospital admission to study inclusion was 2.3 ± 0.7 days. Right ventricular function was evaluated immediately before and shortly after (0.5-1.5 h) randomization by right heart catheterization (RHC), trans-thoracic echocardiography (TTE), and cardiac magnetic resonance (CMR). The primary efficacy endpoint was cardiac index measured by CMR.

RESULTS

Patients had acute intermediate-high risk PE verified by computed tomography pulmonary angiography, systolic blood pressure of 135 ± 18 (mean ± SD) mmHg, increased right ventricular/left ventricular ratio 1.1 ± 0.09 and increased troponin T 167 ± 144 ng/L. Sildenafil treatment did not improve cardiac index compared to baseline (0.02 ± 0.36 l/min/m2, p = 0.89) and neither did placebo (0.00 ± 0.34 l/min/m2, p = 0.97). Sildenafil lowered mean arterial blood pressure (- 19 ± 10 mmHg, p < 0.001) which was not observed in the placebo group (0 ± 9 mmHg, p = 0.97).

CONCLUSION

A single oral dose of sildenafil 50 mg did not improve cardiac index but lowered systemic blood pressure in patients with acute intermediate-high risk PE. The time from PE to intervention, a small patient sample size and low pulmonary vascular resistance are limitations of this study that should be considered when interpreting the results.

TRIAL REGISTRATION

The trial was retrospectively registered at www.clinicaltrials.gov (NCT04283240) February 2nd 2020, https://clinicaltrials.gov/ct2/show/NCT04283240?term=NCT04283240&draw=2&rank=1 .

Comparison of Acute Versus Subacute Coronary Angiography in Patients With NON-ST-Elevation Myocardial Infarction (from the NONSTEMI Trial)

The optimal timing of coronary angiography (CAG) in high-risk patients with acute coronary syndrome without persisting ST-segment elevation (NST-ACS) remains undetermined. The NON-ST-Elevation Myocardial Infarction trial aimed to compare outcomes in NSTE-ACS patients randomized to acute CAG (STEMI-like approach) with patients randomized to medical therapy and subacute CAG. We randomized 496 patients with suspected NST-ACS based on symptoms and significant regional ST depressions and/or elevated point-of-care troponin T (POC-cTnT) (≥50 ng/l) to either acute CAG (<2 hours, n = 245) or subacute CAG (<72 hours, n = 251). The primary end point was a composite of all-cause death, reinfarction, and readmission with congestive heart failure within 1 year from randomization. A final acute coronary syndrome (ACS) diagnosis was assigned to 429 (86.5%) patients. The median time from randomization to revascularization was 1.3 hours in the acute CAG group versus 51.1 hours in the subacute CAG group (p <0.001). The composite end point occurred in 25 patients (10.2%) in the acute CAG group and 29 (11.6%) in the subacute CAG group, p = 0.62. The acute CAG group had a 1-year all-cause mortality of 5.7% compared with 5.6% in the subacute CAG group, p = 0.96. In conclusion, neither the composite end point of all-cause death, reinfarction, and readmission with congestive heart failure nor mortality differed between an acute and subacute CAG approach in NSTE-ACS patients. However, identification of NSTE-ACS patients in the prehospital phase and direct triage to an invasive center is feasible, safe and may facilitate early diagnosis and revascularization.

Chest pain in the ambulance; prevalence, causes and outcome - a retrospective cohort study

BACKGROUND

Chest pain is common in acute ambulance transports. This study aims to characterize and compare ambulance-transported chest pain patients to non-chest pain patients and evaluate if patient characteristics and accompanying symptoms accessible at the time of emergency call can predict cause and outcome in chest pain patients.

METHODS

Retrospective, observational population-based study, including acute ambulance transports. Patient characteristics and symptoms are included in a multivariable risk model to identify characteristics, associated with being discharged without an acute cardiac diagnosis and surviving 30 days after chest pain event.

RESULTS

In total, 10,033 of 61,088 (16.4%) acute ambulance transports were due to chest pain. In chest pain patients, 30-day mortality was 2.1% (95%CI 1.8-2.4) compared to 6.0% (95%CI 5.7-6.2) in non-chest pain patients. Of chest pain patients, 1054 (10.5%) were diagnosed with acute myocardial infarction, and 5068 (50.5%) were discharged without any diagnosis of disease. This no-diagnosis group had very low 30-day mortality, 0.4% (95%CI 0.2-0.9). Female gender, younger age, chronic pulmonary disease, absence of accompanying symptoms of dyspnoea, radiation, severe pain for > 5 min, clammy skin, uncomfortable, and nausea were associated with being discharged without an acute cardiac diagnosis and surviving 30 days after a chest pain event.

CONCLUSION

Chest pain is a common reason for ambulance transport, but the majority of patients are discharged without a diagnosis and with a high survival rate. Early risk prediction seems to hold a potential for resource downgrading and thus cost-saving in selected chest pain patients.

Myocardial Oxygen Consumption and Efficiency in Aortic Valve Stenosis Patients With and Without Heart Failure

Background

Myocardial oxygen consumption (MVO₂) and its coupling to contractile work are fundamentals of cardiac function and may be involved causally in the transition from compensated left ventricular hypertrophy to failure. Nevertheless, these processes have not been studied previously in patients with aortic valve stenosis (AS).

Methods and Results

Participants underwent ¹¹C‐acetate positron emission tomography, cardiovascular magnetic resonance, and echocardiography to measure MVO₂ and myocardial external efficiency (MEE) defined as the ratio of left ventricular stroke work and the energy equivalent of MVO₂. We studied 10 healthy controls (group A), 37 asymptomatic AS patients with left ventricular ejection fraction ≥50% (group B), 12 symptomatic AS patients with left ventricular ejection fraction ≥50% (group C), and 9 symptomatic AS patients with left ventricular ejection fraction <50% (group D). MVO₂ did not differ among groups A, B, C, and D (0.105±0.02, 0.117±0.024, 0.129±0.032, and 0.104±0.026 mL/min per gram, respectively; P=0.07), whereas MEE was reduced in group D (21.0±1.6%, 22.3±3.3%, 22.1±4.2%, and 17.3±4.7%, respectively; P<0.05). Similarly, patients with global longitudinal strain greater than −12% and paradoxical low‐flow, low‐gradient AS had impaired MEE (P<0.05 versus controls). The ability to discriminate between symptomatic and asymptomatic patients was superior for global longitudinal strain compared with MVO₂ and MEE (area under the curve 0.98, 0.48, and 0.61, respectively; P<0.05).

Conclusions

AS patients display a persistent ability to maintain normal MVO₂ and MEE (ie, the ability to convert energy into stroke work); however, patients with left ventricular ejection fraction <50%; global longitudinal strain greater than −12%; or paradoxical low‐flow, low‐gradient AS demonstrate reduced MEE. These findings suggest that mitochondrial uncoupling contributes to the dismal prognosis in patients with reduced contractile function or paradoxical low‐flow, low‐gradient AS.

Dyspnea, a high-risk symptom in patients suspected of myocardial infarction in the ambulance? A population-based follow-up study

BACKGROUND

Systematic management of patients suffering high-risk symptoms is essential in emergency medical services. Patients with chest pain receive algorithm-based work-up and treatment. Though dyspnea is recognized as an independent predictor of mortality, no generally accepted prehospital treatment algorithm exists and this may affect outcome. The objective of this study was to compare mortality in patients suspected of myocardial infarction (MI) presenting with dyspnea versus chest pain in the ambulance.

METHODS

Follow-up study in patients undergoing electrocardiogram-based telemedical triage because of suspected MI in an ambulance in the Central Denmark Region from 1 June 2008 to 1 January 2013. Primary outcome was 30-day mortality. Secondary outcomes were 4-year mortality and mortality rates in subgroups of patients with and without a confirmed MI. Absolute risk differences adjusted for comorbidity, age, systolic blood pressure and heart rate were calculated by a generalized linear regression model.

RESULTS

Of 17,398 patients, 12,230 (70%) suffered from chest pain, 1464 (8%) from dyspnea, 3540 (20%) from other symptoms and 164 (1%) from cardiac arrest. Among patients with dyspnea, 30-day mortality was 13% (CI 12-15) and 4-year mortality was 50% (CI 47-54) compared to 2.9% (CI 2.6-3.2) and 20% (CI 19-21) in patients with chest pain. MI was confirmed in 121 (8.3%) patients with dyspnea and in 2319 (19%) with chest pain. Patients with dyspnea and confirmed MI had a 30-day and 4-year mortality of 21 % (CI 15-30) and 60% (CI 50-70) compared to 5.0% (CI 4.2-5.8) and 23% (CI 21-25) in patients with chest pain and confirmed MI. Adjusting for age, comorbidity, systolic blood pressure and heart rate did not change these patterns.

CONCLUSION

Patients suspected of MI presenting with dyspnea have significantly higher short- and long-term mortality than patients with chest pain irrespective of a confirmed MI diagnosis. Future studies should examine if supplementary prehospital diagnostics can improve triage, facilitate early therapy and improve outcome in patients presenting with dyspnea.

Statin use prior to first myocardial infarction in contemporary patients: Inefficient and not gender equitable

OBJECTIVES

Guidelines recommend initiating primary prevention with statins to those at highest cardiovascular risk. We assessed the gender-specific implementation and effectiveness of this risk-guided approach.

METHODS

We identified 1399 consecutive patients without known cardiovascular disease or diabetes hospitalized with a first myocardial infarction (MI) in Denmark. Statin use before MI was assessed, and cardiovascular risk was calculated using SCORE (Systematic COronary Risk Evaluation).

RESULTS

Among patients with first MI, 36% were women. Compared with men, they were older (mean 72 vs. 65years) but had a lower estimated risk (median 3.4% vs. 6.7%, SCORE high-risk model in the statin-naïve patients). Statin therapy had been initiated in 12% of women and 10% of men prior to MI. After adding 1.5mmol/L to the total cholesterol concentration of those already on statins, the estimated pre-treatment risk was much lower in women than men (median 3.8% vs. 9.2%, SCORE high-risk model), and only 29% of women would have passed the risk-based treatment threshold defined by the European guidelines (SCORE ≥5%). Estimated risk and statin use correlated directly in men but not in women. Only ~5% of first MI are prevented by the current use of statins in people without diabetes.

CONCLUSION

In people destined for a first MI, statin therapy is uncommon and prevents few events. Lower-risk women receive as much statins as higher risk men. This gender disparity and inefficient targeting of statins to those at highest risk indicate that risk scoring is not widely used in routine clinical practice in Denmark.

Increased levels of soluble tumour necrosis factor receptor-I (P55) and decreased IgG1 reactivities in HIV-1 patients with cytomegalovirus disease

The purpose of the study was to investigate potential associations between tumour necrosis factor (TNF), soluble TNF receptors (sTNF-Rs), immunoglobulin (Ig)G subclasses and development of cytomegalovirus (CMV) disease amongst human immunodeficiency virus (HIV)-1 patients. We enrolled HIV-1 patients with CD4 counts less than 100/microl in a prospective study and followed them over 1 year for development of CMV disease. Concentrations of TNF, sTNF-RI, sTNF-RII and IgG subclass reactivities were measured by ELISA; levels of CMV pp65 antigenaemia were determined as numbers of pp65 expressing cells/100,000 cells and were measured by staining of leucocytes; and HIV-1 RNA loads were measured by polymerase chain reaction (PCR). Eighteen patients studied with CMV disease had higher levels of sTNF-RI than 18 similar patients without CMV disease. Concentrations of sTNF-RI correlated with levels of CMV antigenaemia in blood samples collected before the development of CMV disease. Patients with CMV disease had lower levels of IgG1 reactivities to CMV than patients without CMV disease. We conclude that increased levels of sTNF-RI and decreased IgG1 reactivities are associated with an increased risk of development of CMV disease among HIV-1 patients.

Development of cytomegalovirus (CMV) disease may be predicted in HIV-infected patients by CMV polymerase chain reaction and the antigenemia test

OBJECTIVE

Cytomegalovirus (CMV) is a frequent opportunistic viral pathogen in patients with AIDS leading to retinitis and other serious manifestations. CMV disease may be successfully treated. Prophylactic antiviral therapy has been shown to reduce the risk of CMV disease if initiated early. We evaluated PCR and the antigenemia tests as methods for early detection of CMV disease.

METHODS

Two-hundred HIV-seropositive subjects with CD4 T-cell counts below 100 x 10(6)/l were monitored with CMV polymerase chain reaction (PCR), the antigenemia test, blood cultures and CMV immunoglobulin (Ig) G and IgM titres every second month for 1 year.

RESULTS

Thirty-eight patients (19%) developed CMV disease. The PCR test detected CMV DNA a median of 46 days before onset of disease. This was earlier than the median of 34 for the antigenemia test and a median of 1 day for CMV blood cultures. Univariate analysis showed that the CMV PCR, the antigenemia test and blood cultures all had significant predictive values for subsequent development of CMV disease with odds ratios (OR) of 30, 22 and 20. CMV serology had no predictive value. Multivariate analysis showed that the PCR method was superior to the other tests; OR: CMV PCR 10.0, antigenemia test 4.4 and CMV cultures 4.3. No clinical parameters had any significant predictive value in the stepwise multivariate model.

CONCLUSIONS

The CMV PCR and the CMV antigenemia tests are both sensitive methods that may predict development of CMV disease up to several months prior to clinical disease. These methods make it possible to select patients at high risk for CMV disease and suitable for prophylactic therapy against CMV.

Human herpes virus-8 DNA in bronchoalveolar lavage samples from patients with AIDS-associated pulmonary Kaposi's sarcoma

Kaposi's sarcoma (KS) is the most frequent AIDS-associated neoplasm, and often disseminates to visceral organs, including the lungs. An ante-mortem diagnosis of pulmonary KS is difficult. Recently, DNA sequences resembling a new human herpes virus (HHV-8), have been identified in various forms of KS. We hypothesized that these sequences are present in samples obtained by bronchoalveolar lavage (BAL) in patients with pulmonary KS. Utilizing a nested polymerase chain reaction (PCR), 7/12 BAL cell samples from HIV-infected patients with endobronchial KS were positive for HHV-8 DNA. In contrast, only 2/39 samples from HIV-infected patients without evidence of KS were positive (p = 0.007). Detection of HHV-8 in BAL cells of patients with pulmonary KS was highly specific (95%), with a sensitivity of 58% and a positive predictive value of 78%. In conclusion, HHV-8 is associated with pulmonary KS, and PCR amplification of HHV-8 in BAL cells provides a non-invasive method with a high positive predictive value.