A prospective study of patients with refractory angina: outcomes and the role of high-sensitivity troponin T

A systematic review and meta-analysis evaluating the association of high sensitivity troponin levels with outcomes in patients with stable coronary artery disease

BACKGROUND

High-sensitivity cardiac troponins (Hs-cTns) are reliable indicators of myocardial injury, but their relationship with cardiovascular outcomes remains less understood. This study explores the association between adverse cardiac events and Hs-cTnT levels exceeding 14 ng/L in patients with stable CAD.

METHODS

Thirteen pertinent studies were identified using specific keywords from a pool of 208 articles retrieved from PubMed, Scopus, and Google Scholar, spanning 2013 to 2023. The primary outcomes included all-cause mortality (ACM), myocardial infarction (MI), cardiovascular death (CVD), rehospitalization due to decompensated heart failure (RDHF), need for revascularization, and stroke. Comprehensive meta-analysis (CMA) was employed to analyze the data for odds ratios (OR) and 95% confidence intervals (CI). Heterogeneity was assessed using I2 statistics, and both qualitative assessment (Newcastle-Ottawa Scale) and quantitative analysis (Egger's and Beggs test, funnel plots) were conducted.

RESULTS

The analysis included 29,115 participants (74.72% male) with a mean age of 68.34 years. It revealed a significantly elevated risk of ACM among stable CAD patients with Hs-cTnT levels >14 ng/L compared to those with levels <14 ng/L (11.2% vs. 3.3%; OR = 5.46; 95% CI = 1.53-19.54; p = 0.009). Similarly, higher risks were observed for MI (10.9% vs 3.6%; OR = 3.12; 95% CI = 0.98-9.95, p = 0.053), CVD (8.1% vs. 2.1%; OR = 3.37; 95% CI = 1.74-6.50; p < 0.0001), and RDHF (6.62% vs. 0.92%; OR = 9.46; 95% CI = 4.65-19.24; p < 0.0001). Notably, major adverse cardiovascular events (MACE) exhibited a stronger association with Hs-cTnT levels (18.2% vs 7.81%; OR = 1.89; 95% CI = 0.80-4.43; I2 = 97%; p = 0.14) compared to Hs-cTnI levels (20.1% vs 21.1%; OR = 1.30; 95% CI = 1.03-1.64; I2 <0.0001%; p = 0.03).

CONCLUSION

Elevated levels of Hs-cTnT (>14 ng/L) are significantly associated with increased risks of RDHF and ACM in patients with stable CAD. Further large-scale prospective studies are warranted to refine risk assessment strategies and mitigate cardiovascular mortality in this population.

Importance of so called "novel cardiovascular risk factors" in severity of coronary artery calcification; how serious they should be taken: a systematic review and metaanalysis

Cardiovascular diseases are among important causes of death. Atherosclerosis is an important etiology for coronary artery diseases in which coronary artery calcification plays a principal role. Recently novel cardiovascular risk factors in coronary calcification are under attention. In this study, we investigated possible association between novel cardiovascular risk factors and coronary calcification. This is a prospectively registered systematic review and meta-analysis in PROSPERO and was performed in accordance with PRISMA guidelines. Medical databases were searched. Primary papers were screened and studies reporting our outcomes of interest were selected for data extraction. Quantitative data syntheses were performed using Comprehensive Meta-analysis Ver.3. In this study, 5252 papers were screened and finally 28 papers including 31241 patients underwent data extraction. Based on our findings, neutrophil/lymphocyte ratio (8 out of 10), red cell distribution width (r = 0.250, p < 0.0001), and interleukin 6 (odds ratio [OR]: 1.101 [95% confidence interval (CI): 1.001-1.210], p = 0.047) were associated with severity of coronary calcification while C-reactive protein (one out of eight) was not associated with coronary calcification. Results of lymphocyte/monocyte ratio (r = -0.120, p < 0.001), platelet/lymphocyte ratio (OR: 1.47 [95% CI: 0.89-2.41, p = 0.124]), and MPV (r = 0.017, p = 0.814 vs. OR: 1.91 [95% CI: 1.28-2.85, p = 0.002]) remained controversial due to few number of included studies or contrary results. We can conclude that neutrophil/lymphocyte ratio, red cell distribution width, and interleukin-6 are significantly associated with coronary calcification and C-reactive protein is not significantly associated with severity of coronary calcification. Our results about mean platelet volume, platelet/lymphocyte ratio, and lymphocyte/monocyte ratio are not reliable and require further investigations.

Does Myocardial Injury Occur After an Acute Aerobic Exercise Session in Patients with Refractory Angina?

BACKGROUND

It is unclear whether exercise is safe in patients with more advanced forms of coronary artery disease, such as those with refractory angina (RA).

OBJECTIVE

We aimed to determine the effect of an acute aerobic exercise session (AAES) on high-sensitivity cardiac troponin T (hs-cTnT) levels in patients with RA.

METHODS

This was a longitudinal, non-randomized, and non-controlled clinical study. Participants were recruited from April 2015 to January 2019. On a visual pain scale from 0 to 10, pain rated up to 3 was considered as the top level allowed to continue exercising. We assessed hs-cTnT at baseline and 3 hours after the AAES. The protocol consisted of 5 minutes of warm-up, 30 minutes of continuous aerobic exercise at heart rate corresponding to the anaerobic threshold or angina threshold obtained in the cardiopulmonary exercise testing, and 5 minutes of cooling down. P values less than 0.05 were considered statistically significant.

RESULTS

Thirty-two patients with RA were included (61 ± 9 years, 59.4% male). The baseline hs-cTnT concentration was 10.9 ng/L (95% confidence interval: 9.1 to 13.0 ng/L). The hs-cTnT collected 3 hours after the AAES was 11.1 ng/L (95% confidence interval: 9.1 to 13.5 ng/L). No difference occurred in hs-cTnT before and after AAES (p = 0.657).

CONCLUSIONS

A single AAES performed at the angina threshold with corresponding visual pain scale did not alter hs-cTnT in patients with RA, suggesting that no significant myocardial injury was elicited by exercising and that this exercise protocol can be considered safe.

An evidence-based review of neuromodulation for the treatment and management of refractory angina

Angina pectoris is defined as substernal chest pain that is typically exacerbated by exertion, stress, or other exposures. There are various methods of treatment for angina. Lifestyle modification and pharmacological management are considered as conservative treatments. If these medications do not result in the resolution of pain, more invasive approaches are an option, like coronary revascularization. Refractory angina (RA) is differentiated from acute or chronic angina based on the persistence of symptoms despite conventional therapies. Overall, the prevalence of RA is estimated to be 5%-15% in patients with coronary artery disease, which can account for up to 1,500,000 current cases and 100,000 new cases in the United States per year. Spinal cord stimulation treatment is a viable option for patients who are suffering from RA pain and are either not candidates for revascularization surgery or are currently not being well managed on more traditional treatments. Many studies show a positive result.

Use of Cardiac Troponin Testing in the Outpatient Setting

OBJECTIVES

Cardiac troponin (cTn) measurement is useful for diagnosing myocardial infarction (MI), particularly in the inpatient setting. A growing body of literature suggests that cTn may be useful for evaluating chronic conditions in the outpatient environment; however, little is known regarding cTn ordering patterns in this setting. We sought to investigate patterns of care and outcomes for patients evaluated with cTn in the outpatient setting. We hypothesized that a majority of outpatient cTn orders would be for the purpose of diagnosing possible MI.

METHODS

We analyzed 228 patients who had outpatient orders for standard-sensitivity troponin T assays placed at our institution between January 1, 2013 and December 18, 2015. Data were divided into two cohorts based on the intended utility of cTn measurement: orders placed to evaluate for possible MI versus orders placed for some other purpose.

RESULTS

Of the 228 patients, 161 were evaluated for possible MI and 67 for other reasons. Risk factors (hypertension P = 0.32, diabetes mellitus P = 0.41, coronary disease P = 0.38, heart failure P = 0.098, and chronic kidney disease P = 0.70) were similar between the cohorts. In the suspected MI cohort, an electrocardiogram was obtained in only 77% of patients, and only 13.1% were sent to the emergency department (ED) for further evaluation. Within the suspected MI cohort, 10.5% (n = 17) had elevated cTn and the majority of these patients (n = 10) were not sent to the ED.

CONCLUSIONS

The majority of outpatient cTn orders were intended to evaluate for MI, although electrocardiograms were frequently not ordered and few patients were sent for further ED evaluation. Providers should be encouraged to use cTn testing in a manner that minimizes the potential risk to patients with possible MI.

A prospective study of patients with refractory angina: outcomes and the role of high-sensitivity troponin T

BACKGROUND

The predictors of cardiovascular events in patients with chronic refractory angina are limited. High-sensitivity cardiac troponin T (hs-cTnT) assays are biomarkers that may be used to determine the prognosis of patients with stable coronary artery disease.

HYPOTHESIS

Hs-cTnT is a predictor of death and nonfatal myocardial infarction (MI) in patients with refractory angina.

METHODS

We prospectively enrolled 117 consecutive patients in this study. A heart team ruled out myocardial revascularization feasibility after assessing recent coronary angiograms; evidence of myocardial ischemia served as an inclusion criterion. Optimal medical therapy was encouraged via outpatient visits every 6 months; plasma hs-cTnT levels were determined at baseline. The primary endpoint was the composite incidence of death and nonfatal MI.

RESULTS

During a median follow-up period of 28.0 months (interquartile range, 18.0-47.5 months), an estimated 28.0-month cumulative event rate of 13.4% was determined via the Kaplan-Meier method. Univariate predictors of the composite endpoint were hs-cTnT levels and LV dysfunction. Following a multivariate analysis, only hs-cTnT was independently associated with the events in question, either as a continuous variable (hazard ratio per unit increase in the natural logarithm: 2.83, 95% confidence interval: 1.62-4.92, P < 0.001) or as a categorical variable (hazard ratio for concentrations above the 99th percentile: 5.14, 95% confidence interval: 2.05-12.91, P < 0.001).

CONCLUSIONS

In patients with chronic refractory angina, plasma concentration of hs-cTnT is the strongest predictor of death and nonfatal MI. Notably, none of the outcomes in question occurred in patients with baseline plasma levels <5.0 ng/L.