Cardiac troponin I in patients with severe exacerbation of chronic obstructive pulmonary disease

Mortality trends and disparities for coexisting chronic obstructive pulmonary disease and cardiovascular disease: A retrospective analysis of deaths in the United States from 1999-2020

BACKGROUND

Chronic obstructive pulmonary disease (COPD) and cardiovascular disease (CVD) greatly influence morbidity and mortality, with COPD patients frequently suffering from cardiovascular comorbidities like coronary heart disease and stroke. This study analyzes mortality trends and disparities among individuals in the United States (US) affected by both CVD and COPD.

METHODS

This study analyzed death certificates from the CDC WONDER database for individuals aged 25 and older who died between 1999 and 2020 with both CVD (ICD I00-I99) and COPD (ICD J41-J44). Age-adjusted mortality rates (AAMRs) and annual percent change (APC) were calculated by year, sex, age group, race/ethnicity, geographic region, and urbanization status.

RESULTS

Between 1999 and 2020, there were 3,590,124 reported deaths due to coexisting CVD and COPD, with overall AAMR slightly changing from 82.2 to 81.2 per 100,000 population, and a notable rise from 2018 to 2020 (APC: 5.28; 95% CI: 1.83 to 7.22) coinciding with the onset of COVID-19 pandemic. A similar surge in mortality was observed across multiple demographic subgroups, particularly among older adults. Disparities across age groups, sex, race, and geographic location were also observed in the mortality rates due to CVD and COPD. When analyzed by age group, older adults exhibited the highest AAMR at 824.1. Men had higher AAMRs than women (96.5 vs. 60.7). Ethnoracial analysis showed that non-Hispanic (NH) White individuals had the highest AAMRs (82.0), followed by NH American Indian or Alaska Native (74.5), NH Black (63.6), Hispanic (38.1), and NH Asian or Pacific Islander (25.1) individuals. Additionally, non-metropolitan areas had higher AAMRs compared to metropolitan areas (96.2 vs. 70.9).

CONCLUSIONS

The findings suggest that mortality rates for CVD and COPD have increased in recent years, coinciding with the onset of the COVID-19 pandemic, which may have exacerbated outcomes in vulnerable populations. The study highlights the need for targeted interventions to address the overlapping impacts of CVD and COPD, especially in high-risk groups.

Does a Raised Serum Troponin During a Severe Chronic Obstructive Pulmonary Disease Exacerbation Predict Future Cardiovascular Events?

Background Cardiovascular (CV) complications are common in chronic obstructive pulmonary disease (COPD), particularly after acute exacerbations (AECOPD). Elevated cardiac biomarkers, such as high-sensitivity troponin I (hsTnI), indicate myocardial injury and commonly rise during AECOPD. While elevated serum troponin during severe AECOPD predicts mortality, the relationship between admission hsTnI levels and future CV event risk has not been investigated. Aims and objectives This study evaluated the prognostic value of admission serum troponin during severe AECOPD for future CV events, including new atrial fibrillation (AF), myocardial infarction (MI), or decompensated congestive cardiac failure (CCF) requiring intravenous diuretics. Methods This retrospective cohort study analyzed all patients admitted to a single center in 2022 with severe AECOPD and an admission hsTnI measurement. Patients were stratified by hsTnI levels (0-20ng/L and >20ng/L). The primary outcome was CV event incidence at 12 months, with secondary endpoints including event timing, type, and overall mortality. Results Patients with elevated hsTnI (n=37) had higher CV event incidence at 12 months compared to those with normal hsTnI (n=44) (24.3% vs 13.6%; OR 2.04, 95% CI 0.65-6.38). The hazard ratio (HR) for events was elevated but not statistically significant (HR 1.992, 95% CI 0.709-5.601, p=0.191). Raised hsTnI was associated with the greatest event risk at one month (OR 3.79 95% CI 0.38-38.1) and remained elevated over 12 months. Time to first event was also shorter in the elevated hsTnI group (3.0 vs 3.7 months, p=0.529). CCF was the most frequent CV event (77% of all events), followed by MI and AF.​ Elevated hsTnI was associated with 12-month mortality (56.8% vs 36.3%; OR 1.83, 95% CI 0.75-4.48), although the HR did not reach statistical significance (HR 1.767, 95% CI 0.922-3.388, p=0.086). Discussion These findings indicate that elevated admission hsTnI during severe AECOPD is associated with increased CV event incidence, earlier time-to-event, and greater mortality over 12 months. Retrospective study design and opportunistic screening limited the ability to infer causality and statistical significance. Selection bias may have influenced the results from the clinical decision-making to measure hsTnI.​ Larger prospective studies with multivariate regression analysis are required to confirm these findings and address confounders.​ Conclusions Our findings suggest that raised admission troponin levels are associated with CV events following severe AECOPD.  These patients may benefit from early CV risk assessment and preventative strategies.

Elevated Troponins and Diagnosis of Non-ST-Elevation Myocardial Infarction in the Emergency Department

Background In the emergency department (ED), the diagnosis of non-ST-elevation myocardial infarction (NSTEMI) is primarily based on the presence or absence of elevated cardiac troponin levels, ECG changes, and clinical presentation. However, limited data exist regarding the incidence, clinical characteristics, and predictive value of different cardiac diagnostic tests and outcomes in patients with non-acute coronary syndrome (ACS)-related troponin elevation. Our study aimed to determine the percentage of patients with elevated troponin levels who had true ACS and identify various risk factors associated with true ACS in these patients. Methodology This was a single-center retrospective study. We performed a chart review of patients who presented to the ED from January 1, 2016, to December 31, 2017, and were admitted to the hospital with an elevated cardiac troponin I level in the first 12 hours after ED presentation with a diagnosis of NSTEMI. True ACS was defined as (a) patients with typical symptoms of ischemia and ECG ischemic changes and (b) patients with atypical symptoms of myocardial ischemia or without symptoms of ischemia and new segmental wall motion abnormalities on echocardiogram or evidence of culprit lesion on angiography. A logistic regression model was used to determine the association between risk factors and true ACS. Results A total of 204 patients were included in this study. The mean age of the study group was 67.4 ± 14.5 years; 53.4% (n = 109) were male, and 57.4% (n = 117) were Caucasian. In our study, 51% of patients were found to have true ACS, and the remaining 49% had a non-ACS-related elevation in troponins. Most patients without ACS had alternate explanations for elevated troponin levels. The presence of chest pain (odds ratio (OR) = 3.7, 95% confidence interval (CI) = 1.8-7.7, p = 0.001), tobacco smoking (OR = 4, 95% CI = 1.06-3.8, p = 0.032), and wall motion abnormalities on echocardiogram (OR = 3.8, 95% CI = 1.8-6.5, p = 001) were associated with increased risk of true ACS in patients with elevated troponins. Conclusions Cardiac troponin levels can be elevated in hospitalized patients with various medical conditions, in the absence of ACS. The diagnosis of ACS should not be solely based on elevated troponin levels, as it can lead to expensive workup and utilization of hospital resources.

Comorbidities in COPD: Current and Future Treatment Challenges

Chronic obstructive pulmonary disease (COPD) is a heterogeneous lung condition, primarily characterized by the presence of a limited airflow, due to abnormalities of the airways and/or alveoli, that often coexists with other chronic diseases such as lung cancer, cardiovascular diseases, and metabolic disorders. Comorbidities are known to pose a challenge in the assessment and effective management of COPD and are also acknowledged to have an important health and economic burden. Local and systemic inflammation have been proposed as having a potential role in explaining the association between COPD and these comorbidities. Considering that the number of patients with COPD is expected to rise, understanding the mechanisms linking COPD with its comorbidities may help to identify new targets for therapeutic purposes based on multi-dimensional assessments.

Clinical profile of patients and sensitivity of troponin I in patients with and without acute coronary syndrome: An observational study

Background Various clinical conditions can cause troponin elevation in the absence of myocardial ischaemia. Elevated troponin represents the likely occurrence of myocardial necrosis and does not itself provide any indication of the aetiology. Identifying the cause for troponin elevation and its sensitivity and specificity in predicting acute coronary syndrome (ACS) and cardiac mortality is an important step in determining the optimal management for these patients. Methods We retrospectively collected data of inpatients who had troponin I (TnI) testing as part of their clinical assessment, either in the emergency department, medical wards, coronary care unit (CCU) or intensive care unit (ICU) with their final diagnosis. TnI was used as the index test of sensitivity to diagnose ACS and either echocardiography or coronary angiogram in those available as the reference gold standard. They were classified into two groups of normal and elevated TnI, and further divided into those with ACS and no ACS. Data on clinical parameters and aetiology of elevated TnI in patients without ACS were analysed. Results Of the 254 patients studied, 114 patients (45%) had normal TnI and 140 (55%) had elevated TnI. Seventy-eight patients had ACS, 66 (84.6%) of whom had elevated TnI and 12 (15.38%) had normal TnI. Seventy-four (52.85%) of 140 patients with elevated TnI had alternate causes of TnI elevation; the most common being sepsis, acute kidney injury (AKI) and heart failure without ACS. All-cause mortality was significantly higher in patients with elevated TnI with or without ACS. There was no cardiac mortality among patients with ACS with normal TnI. Sensitivity and specificity of TnI for predicting ACS was 84.6% (95% CI 74.7%-91.8%) and 58% (95% CI 50.3%-65.3%), respectively. Conclusion A variety of conditions apart from myocardial infarction can lead to elevated TnI. Hence, caution should be exercised while diagnosing a patient with ACS based on TnI value in the absence of other supporting evidence given its low specificity. Elevated TnI portends a worse prognosis regardless of the aetiology and has a role in predicting all-cause and cardiac mortality.

A review of cardiac troponin I detection by surface enhanced Raman spectroscopy: Under the spotlight of point-of-care testing

Cardiac troponin I (cTnI) is a biomarker widely related to acute myocardial infarction (AMI), one of the leading causes of death around the world. Point-of-care testing (POCT) of cTnI not only demands a short turnaround time for its detection but the highest accuracy levels to set expeditious and adequate clinical decisions. The analytical technique Surface-enhanced Raman spectroscopy (SERS) possesses several properties that tailor to the POCT format, such as its flexibility to couple with rapid assay platforms like microfluidics and paper-based immunoassays. Here, we analyze the strategies used for the detection of cTnI by SERS considering POCT requirements. From the detection ranges reported in the reviewed literature, we suggest the diseases other than AMI that could be diagnosed with this technique. For this, a section with information about cardiac and non-cardiac diseases with cTnI release, including their release kinetics or cut-off values are presented. Likewise, POCT features, the use of SERS as a POCT technique, and the biochemistry of cTnI are discussed. The information provided in this review allowed the identification of strengths and lacks of the available SERS-based point-of-care tests for cTnI and the disclosing of requirements for future assays design.

Association of Cardiac Troponin T Concentration on Admission with Prognosis in Critically Ill Patients without Myocardial Infarction: A Cohort Study

Purpose

To investigate the association of cardiac Troponin T (cTnT) with prognosis in critically ill patients without myocardial infarction.

Methods

Adult patients admitted to the intensive care units (ICUs) of the Beth Israel Deaconess Medical Center between 2008 and 2019 who were free of myocardial infarction with a length of ICU stay ≥24 hours and available cTnT records within 24 hours before and after ICU admission were included. The association between cTnT on ICU admission and hospital mortality was evaluated by multivariable logistic regression analysis. The discrimination capacity of cTnT on ICU admission for predicting hospital mortality was examined by receiver operating characteristic (ROC) analysis.

Results

A total of 2960 patients were included. Elevated cTnT (>0.01 ng/mL) was observed in 2730 (92.23%) patients with a higher hospital mortality compared to normal cTnT (11.21% versus 7.39%, P=0.075). There was no statistically significant association between elevated cTnT on ICU admission and hospital mortality (adjusted odds ratio 1.50, 95% confidence interval (CI) 0.88–2.57). Poor discrimination capacity was found for cTnT on ICU admission to predict hospital mortality (area under the ROC curve 0.48, 95% CI 0.44–0.53).

Conclusion

cTnT on ICU admission has limited prognostic value in critically ill patients without myocardial infarction.

Is there excessive troponin testing in clinical practice? Evidence from emergency medical admissions

AIM

To investigate whether excessive high-sensitivity cardiac troponin T (hscTnT) testing, in non-cardiac presentations, increases hospital length of stay (LOS) by driving down-stream investigations.

METHODS

We report on all hscTnT tests in emergency medical admissions, performed over a 9-year period between 2011-2019. Troponin testing frequency in different risk cohorts was determined and related to 30-day in-hospital mortality with a multivariable logistic regression model adjusted for other outcome predictors. Downstream utilization of procedures/services was related to LOS with zero truncated Poisson regression.

RESULTS

There were 66,475 admissions in 36,518 patients. hscTnT was tested in 24.4% of admissions, more frequently in the elderly (>70 years 33.4%, >80 years 35.9%), cardiovascular presentations (33.6%) and in those with high comorbidity (42.2%), and reduced in those with neurologic presentations (20%). A hscTnT request predicted increased 30-day in-hospital mortality OR 3.33 (95% CI: 3.06, 3.64). The univariate odds ratio (OR) of hscTnT test result was 1.45 (95% CI: 1.42, 1.49) and was semi-quantative with worsening outcomes as hscTnT increased. It remained predictive in the fully adjusted model OR 1.17 (95% CI: 1.09, 1.26). LOS was linearly related to the number of procedures/services performed. hscTnT testing did not increase LOS or number of procedures/services CONCLUSION: : A clinical request for hscTnT testing is prognostic and risk categorises. Subsequent resource utilization, if increased, appears an epiphenomenon related to risk categorisation, rather than being driven by inappropriate hscTnT testing.

Analysis of prevalence and prognosis of type 2 diabetes mellitus in patients with acute exacerbation of COPD

BACKGROUND

For patients with acute exacerbation of COPD (AECOPD), type 2 diabetes mellitus (T2DM) as comorbidity have poor outcomes. However, data on the impact of previously diagnosed and new- diagnosed T2DM in such a patient population is lacking.

METHODS

Inpatients diagnosed with AECOPD in the department of Pulmonary and Critical Care Medicine of The First Hospital of China Medical University during 2011-2017 were enrolled. Data on demography, prevalence of type 2 DM, other comorbidities, hospital stays and laboratory tests (including arterial partial pressure of oxygen [PaO2]) results were recorded. Results were compared with AECOPD patients having previously diagnosed and new-diagnosed type 2 diabetes. Markers associated with development of type 2 DM and the prognosis of AECOPD patients were identified.

RESULTS

Of the 196 patients enrolled in this study, the overall prevalence of T2DM was 26%. The PaO2 in the newly diagnosed T2DM group was considerably lower versus non-diabetic group. The T2DM group had a longer hospital stay and higher troponin level versus the non-diabetic group. AECOPD patients with T2DM were found to be correlated with hypertension. Age, need for assisted ventilation, increased troponin, and elevated fasting blood glucose on admission were risk factors for death in hospitalized AECOPD patients.

CONCLUSIONS

AECOPD patients had a higher prevalence of T2DM than the general population; T2DM comorbidity caused lower PaO2, longer hospital stays, and increased troponin. Poor blood glucose control may increase the risk of death in AECOPD patients.

Establishment of risk prediction model and risk score for in-hospital mortality in patients with AECOPD

OBJECTIVE

Risk stratification for patients with acute exacerbation of chronic obstructive pulmonary disease (AECOPD) may help clinicians choose appropriate treatments and improve the quality of care.

METHODS

A total of 695 patients hospitalized with AECOPD from January 2015 to December 2017 were considered. They were assigned to a death and a survival cohort. The independent prognostic factors were determined by multivariate logistic regression analysis. Meanwhile, we also compared the new scale with three other scores and tested the new scale internally and externally.

RESULTS

A new risk score was created, made up of six independent variables: age, D-dimer, albumin, cardiac troponin I, partial pressure of carbon dioxide and oxygenation index. The area under the receiver operator characteristic curve (AUROC) for the model was 0.929, and the other three CURB-65, DECAF and BAP-65 models were 0.718, 0.922 and 0.708. The Cohen's kappa coefficient between the new scale and DECAF was calculated to be 0.648, suggesting that there is a substantial consistency between the two. In the internal and external validation cohorts, 490 and 500 patients were recruited with a total mortality rate of 5.15%. The AUROC for in-hospital mortality was 0.937 in the internal cohort and 0.914 in external cohort, which was significantly better than the scores for CURB-65 and BAP-65, but it was not significantly different from the DECAF.

CONCLUSIONS

The new scale may help to stratify the risk of in-hospital mortality of AECOPD. The DECAF performed as well as the new instrument, and it appears to be valid in Chinese patients.

Comparative outcome analysis of stable mildly elevated high sensitivity troponin T in patients presenting with chest pain. A single-center retrospective cohort study

Background

The ideal high-sensitivity troponin (hsTn) cutoff for identifying those at low risk of 30 days events is debated; however, the 99th percentile overall or gender-specific upper reference limit (URL) is most commonly used. The magnitude of risk and the best management strategy for those with low-level hsTn elevation hasn't been extensively studied.

Methods

We conducted a retrospective cohort analysis including 4396 chest pain patients (542 with low-level hsTn elevation) who ruled out for myocardial infarction (MI), had a stable high-sensitivity troponin T (hsTnT) levels (defined as < 5 ng/l inter-measurements increase in hsTnT levels), and were discharged from the emergency department without further ischemic testing. The aim of the study was to compare the 30-day incidence of adverse cardiac events (ACE) between patients with undetectable high-sensitivity troponin T (hsTnT) (group 1), patients with hsTnT within the 99th percentile sex-specific URL (group 2), and patients with low-level hsTnT elevation (between the 99th percentile URL and ≤ 50 ng/l) (group 3).

Results

30-day event rates were very low 0.1%, 0.6%, and 0.4% for hsTnT groups 1, 2, and 3 respectively (overall P = 0.041, for groups 2 & 3 interaction P = 0.74). 30-day all-cause mortality, as well as 1-year all-cause and cardiovascular mortalities, occurred more frequently in those with low-level hsTnT elevation as did 1-year composite ACE.

Conclusion

In conclusion, 30-day adverse event rates were very low in those with stable low-level hsTnT elevation who ruled out for MI and were discharged from the emergency department without further inpatient testing.

Aspects extrapulmonaires des exacerbations de bronchopneumopathie chronique obstructive

La bronchopneumopathie chronique obstructive (BPCO) est une maladie systémique aux multiples atteintes, émaillée d’exacerbations. L’inflammation, l’hypoxémie, les troubles de la coagulation et les perturbations des interactions coeur–poumon expliquent en partie les atteintes non pulmonaires observées notamment lors d’exacerbations aiguës. Les événements cardiovasculaires sont la première cause de mortalité des patients BPCO, et leur recrudescence est observée pendant plusieurs semaines après une exacerbation. Aux urgences, la prise en charge des patients en exacerbation de BPCO repose donc en plus du support ventilatoire sur une bonne évaluation des potentielles pathologies associées telles que l’insuffisance cardiaque, l’ischémie myocardique, l’insuffisance rénale ou encore la maladie thromboembolique. Cette évaluation globale permet d’adapter les thérapeutiques parfois délétères sur la fonction cardiaque ou l’équilibre acide−base et de prendre en compte le risque extrapulmonaire dans le choix du parcours de soins du patient. Dans cette mise au point, nous abordons quelques explications physiologiques des multiples perturbations observées au cours de l’exacerbation de BPCO, et proposons une vision globale de l’évaluation de ces patients admis pour une dyspnée ou un autre motif pouvant être en rapport avec la BPCO.

Perioperative myocardial infarction in elderly patients with hip fracture. Is there a role for early coronary angiography?

OBJECTIVES

To evaluate the effects of perioperative myocardial infarction in patients with hip fracture referred to multidisciplinary unit at a tertiary teaching hospital.

METHODS

1030 patients with hip fracture underwent troponin measurement, electrocardiogram and echocardiogram at admission, 24 and 48 h after surgery. Exclusion criteria were age < 70 years, severe aortic stenosis, myocardial infarction <30 days, stress cardiomyopathy, renal failure, sepsis, active neoplastic disease. End-points were 30-day and 1 year mortality.

RESULTS

Troponin I levels ≥0.5 μg/l were found in 129/1030. 37 of them were excluded according to reported criteria. In the 92 patients included in the study in hospital and 1 year mortality were significantly higher than in controls (12.5% vs 3.5%, p .0012 and respectively 44% vs 16.1% at 12 months, p < .001). 18 patients underwent coronary angiography within 1 week from hip surgery. All had multivessel coronary artery disease. One patient died after angiography. At multivariate logistic analysis age (OR 1.09, 95% CI = 1.01 to 1.19, p = .044) and creatinine values (OR = 7. 55, 95% CI = 1.26 to 45.3, p = .02) were independent predictive factors of 1 year mortality whereas coronary revascularization (OR = 0.15, 95% CI = 0.03 to 0.78, p = .024) was an independent factor associated with improved survival.

CONCLUSIONS

Perioperative TnI elevation is associated with a significantly increase in 30-day and 1-year mortality. Severe coronary disease may be suspected in patients with perioperative myocardial infarction after hip fracture surgery. Our study is one of the first providing data on the safety and feasibility of early (inhospital) coronary angiograpy and PCI after hip surgery. Further studies are needed to establish indication of coronary angiography in these patients.

COPD and Cardiovascular Disease

COPD is one of the major public health problems in people aged 40 years or above. It is currently the 4th leading cause of death in the world and projected to be the 3rd leading cause of death by 2020. COPD and cardiac comorbidities are frequently associated. They share common risk factors, pathophysiological processes, signs and symptoms, and act synergistically as negative prognostic factors. Cardiac disease includes a broad spectrum of entities with distinct pathophysiology, treatment and prognosis. From an epidemiological point of view, patients with COPD are particularly vulnerable to cardiac disease. Indeed, mortality due to cardiac disease in patients with moderate COPD is higher than mortality related to respiratory failure. Guidelines reinforce that the control of comorbidities in COPD has a clear benefit over the potential risk associated with the majority of the drugs utilized. On the other hand, the true survival benefits of aggressive treatment of cardiac disease and COPD in patients with both conditions have still not been clarified. Given their relevance in terms of prevalence and prognosis, we will focus in this paper on the management of COPD patients with ischemic coronary disease, heart failure and dysrhythmia.

Association between troponin-I levels and outcome in critically ill patients admitted to non-cardiac intensive care unit with high prevalence of cardiovascular risk factors

Background

The association of troponin-I levels and outcome in medical-surgical ICU patients has been studied before in populations with low to moderate prevalence of cardiovascular risk factors. The objective in this article is to examine the association of troponin-I levels with hospital mortality in patients with high prevalence of cardiovascular risk factors who were admitted with medical-surgical indications to a non-cardiac intensive care unit.

Methods

This was a retrospective study of adult patients admitted to a tertiary medical-surgical ICU between July 2001 and November 2011. Data were extracted from prospectively collected ICU and clinical laboratory databases. Patients were stratified based on the highest troponin-I level in the first 72 h of admission into four groups (Group I < 0.03, Group II = 0.03–0.3, Group III = 0.3–3 and Group IV > 3 ng/mL). Hospital mortality was the primary outcome. To study the association between elevated troponin-I and hospital mortality, we carried out multivariate logistic regression analyses with Group I as a reference group.

Results

During the study period, 3368 patients had troponin-I levels measured in the first 72 h, of whom 1293 (38.3%) were diabetic and 1356 (40.2%) were chronically hypertensive. Among the study population, 2719 (81%) had elevated troponin-I levels (0.03 ng/mL and higher). Hospital mortality increased steadily as the troponin-I levels increased. Hospital mortality was 23.4% for Group I, 33.2% for Group II (adjusted odds ratio (aOR) 1.08, 95% confidence interval (CI) 0.84, 1.38), 49.6% for Group III (aOR = 1.64, 95% CI 1.24, 2.17), and 57.4% for Group IV (aOR 1.80, 95% CI 1.30, 2.49). The association of increased mortality with increased troponin level was observed whether patients had underlying advanced heart failure or not. Subgroup analysis showed an increased mortality in patients aged < 50 years, non-diabetics and not on vasopressors.

Conclusion

In a population with high prevalence of diabetes and hypertension, elevated troponin-I was frequently observed in medical-surgical critically ill patients, and showed a level-dependent association with hospital mortality.

Electronic supplementary material

The online version of this article (10.1186/s12871-018-0515-7) contains supplementary material, which is available to authorized users.

Anemia, hypoalbuminemia, and elevated troponin levels as risk factors for respiratory failure in patients with severe exacerbations of chronic obstructive pulmonary disease requiring invasive mechanical ventilation

Aim

To determine in-hospital and post-discharge mortality, readmission rates, and predictors of invasive mechanical ventilation (IMV) in patients treated at intensive care unit (ICU) due to acute exacerbations of chronic obstructive pulmonary disease (AECOPD).

Methods

A retrospective observational cohort study included all patients treated at a respiratory ICU for AECOPD during one year. A total of 62 patients (41 men) with mean age 68.4 ± 10.4 years were analyzed for outcomes including in-hospital and post-discharge mortality, readmission rates, and IMV. Patients’ demographic, hematologic, biochemical data and arterial blood gas (ABG) values were recorded on admission to hospital. Mean duration of follow-up time was 2.4 years.

Results

Of 62 patients, 7 (11.3%) died during incident hospitalization and 21 (33.9%) died during the follow-up. The overall 2.4-year mortality was 45.2%. Twenty nine (46.8%) patients were readmitted due to AECOPD. The average number of readmissions was 1.2. Multivariate analysis showed that blood pH, bicarbonate levels, low albumin, low serum chloride, and low hemoglobin were significant predictors of IMV during incident hospitalization (P < 0.001 for the overall model fit).

Conclusion

High in-hospital and post-discharge mortality and high readmission rates in our patients treated due to AECOPD at ICU indicate that these patients represent a high risk group in need of close monitoring. Our results suggested that anemia, hypoalbuminemia, and elevated troponin levels were risk factors for the need of IMV in severe AECOPD. Identification of such high-risk patients could provide the opportunity for administration of an appropriate and timely treatment.

Causes of Troponin Elevation and Associated Mortality in Young Patients

BACKGROUND

While increased serum troponin levels are often due to myocardial infarction, increased levels may also be found in a variety of other clinical scenarios. Although these causes of troponin elevation have been characterized in several studies in older adults, they have not been well characterized in younger individuals.

METHODS

We conducted a retrospective review of patients 50 years of age or younger who presented with elevated serum troponin levels to 2 large tertiary care centers between January 2000 and April 2016. Patients with prior known coronary artery disease were excluded. The cause of troponin elevation was adjudicated via review of electronic medical records. All-cause death was determined using the Social Security Administration's death master file.

RESULTS

Of the 6081 cases meeting inclusion criteria, 3574 (58.8%) patients had a myocardial infarction, while 2507 (41.2%) had another cause of troponin elevation. Over a median follow-up of 8.7 years, all-cause mortality was higher in patients with nonmyocardial infarction causes of troponin elevation compared with those with myocardial infarction (adjusted hazard ratio [HR] 1.30; 95% confidence interval [CI], 1.15-1.46; P < .001). Specifically, mortality was higher in those with central nervous system pathologies (adjusted HR 2.21; 95% CI, 1.85-2.63; P < .001), nonischemic cardiomyopathies (adjusted HR 1.66; 95% CI, 1.37-2.02; P < .001), and end-stage renal disease (adjusted HR 1.36; 95% CI, 1.07-1.73; P = .013). However, mortality was lower in patients with myocarditis compared with those with an acute myocardial infarction (adjusted HR 0.43; 95% CI:, 0.31-0.59; P < .001).

CONCLUSION

There is a broad differential for troponin elevation in young patients, which differs based on demographic features. Most nonmyocardial infarction causes of troponin elevation are associated with higher all-cause mortality compared with acute myocardial infarction.

Cardiac Troponin Release is Associated with Biomarkers of Inflammation and Ventricular Dilatation During Critical Illness

Introduction:

Troponin release is common during critical illness. We hypothesized that there was an association between cardiac troponin T (cTnT) and biomarkers of systemic inflammation and ventricular dilatation.

Methods:

In an observational prospective cohort study, we enrolled consecutive adult patients admitted for noncardiac reasons to the intensive care unit (ICU) in two tertiary care centers. We measured cTnT, C-reactive protein (CRP), interleukin-6 (IL-6), procalcitonin (PCT), and N-terminal pro brain natriuretic peptide (NT-proBNP) daily in the first week, and on alternate days in the second week. Using a peak cTnT cutoff ≥15 ng/L and concomitant changes on electrocardiogram, patients were categorized as “definite myocardial infarction (MI),” “possible MI,” “cTnT rise only,” or “no cTnT rise.” Within each group, associations between CRP, IL-6, PCT, NT-proBNP, and cTnT were investigated using mixed effect models.

Results:

One hundred seventy-two patients were included in the analysis of whom 84% had a cTnT rise ≥15 ng/L. Twenty-one patients (12%) had a definite MI, 51 (30%) had a possible MI, and 73 (42%) had a cTnT rise only. At the time of peak cTnT, 71% of patients were septic and 67% were on vasopressors.

Multivariable analysis showed a significant association between cTnT and IL-6 in all patients with a cTnT rise independent of age, gender, renal function, and cardiovascular risk factors. In patients without a definite MI, cTnT levels were significantly associated with PCT and NT-proBNP values. In patients without elevated cTnT levels, there was no associated NT-proBNP rise.

Conclusions:

In ICU patients admitted for non-cardiac reasons, serial cTnT levels were independently associated with markers of systemic inflammation and NT-proBNP.

Isolated cardiac troponin rise does not modify the prognosis in elderly patients with hip fracture

Perioperative myocardial infarction remains a life-threatening complication in noncardiac surgery and even an isolated troponin rise (ITR) is associated with significant mortality. Our aim was to assess the prognostic value of ITR in elderly patients with hip fracture.In this cohort study, all patients admitted between 2009 and 2013 in our dedicated geriatric postoperative unit after hip fracture surgery with a cardiac troponin I determination were included and divided into Control, ITR, and acute coronary syndrome (ACS) groups. The primary end point was a composite criteria defined as 6-month mortality and/or re-hospitalization. Secondary end points included 30-day mortality, 6-month mortality, and 6-month functional outcome.Three hundred twelve patients were (age 85 ± 7 years) divided into Control (n = 217), ITR (n = 50), and ACS (n = 45) groups. There was no significant difference for any postoperative complications between ITR and Control groups. In contrast, atrial fibrillation, acute heart failure, hemorrhage, and ICU admission were significantly more frequent in the ACS group. Compared to the Control group, 6-month mortality and/or rehospitalization was not significantly modified in the ITR group (26% vs. 28%, P = 0.84, 95% confidence interval [CI] of the difference -13%-14%), whereas it was increased in the ACS group (44% vs. 28%, P = 0.02, 95% CI of the difference 2%-32%). ITR was not associated with a higher risk of new institutionalization or impaired walking ability at 6 months, in contrast to ACS group.In elderly patients with hip fracture, ITR was not associated with a significant increase in death and/or rehospitalization within 6 months.

Review: Systemic consequences of COPD

Chronic obstructive pulmonary disease (COPD) is a highly prevalent chronic lung condition, affecting ∼10% of adults over the age of 40 years in the western world. Research over the past 10 years has shown that COPD is more than just a lung disorder; it affects other end-organs including the cardiovascular and the musculoskeletal systems, making it a multi-component, multi-system disease. COPD increases the risk for ischemic heart disease, stroke, osteoporosis, cachexia, and muscle weakness by two to threefold, independent of other factors such as smoking and age. The mechanisms by which COPD affects these end-organs, however, are unclear. In this paper, we review some of the common and serious extra-pulmonary manifestations of COPD and the potential mechanisms by which they can be linked with COPD.

Prognostic value of cardiac troponin I during acute exacerbation of chronic obstructive pulmonary disease: A prospective study

BACKGROUND

Chronic obstructive pulmonary disease (COPD) is a major cause of mortality and morbidity. It is the fourth leading cause of death worldwide. Acute exacerbations of COPD are common and are associated with worsening lung function and mortality.

OBJECTIVES

To evaluate the prevalence of elevation of cTnI in patients admitted with acute exacerbation of COPD and to study its association with the need for ventilator support, duration of hospital stay, and in-hospital mortality.

METHODS

In a prospective design, 50 patients admitted to our hospital with acute exacerbation of COPD were included. cTnI was assayed in a blood sample obtained at admission and 24 h later. Levels above 0.017 µg/L were taken as positive. The following data were also recorded-demographic data, pattern of tobacco use, clinical symptoms and signs, comorbidities, Glasgow Coma Scale, arterial blood gas, electrocardiogram/two-dimensional echocardiography, chest X-ray, and peak expiratory flow rate.

RESULTS

Among the 50 patients, 4 were females, and 46 were males. cTnI was positive in 32% of patients with a mean value of 0.272. Patients with cTnI positive were taken as Group I and those with negative were included in Group II. Prevalence of comorbidities was higher in cTnI positive group, so was the duration of COPD. cTnI elevation correlated significantly with the need for ICU admission and ventilator support. No significant difference was found in the duration of ventilator support, hospital stay, and in-hospital mortality.

CONCLUSION

cTnI is elevated in a significant subset of patients with acute exacerbation of COPD. Duration of their illness was longer, higher incidence of ischemic heart disease was also found in these patients. Patients with cTnI elevation are more likely to require ICU care and ventilator support. However, it did not predict in-hospital mortality. Thus, it can be used as a marker to identify high-risk patients during acute exacerbation of COPD.

Chronic obstructive pulmonary disease and ischemic heart disease comorbidity: overview of mechanisms and clinical management

In the last few years, many studies focused their attention on the relationship between chronic obstructive pulmonary disease (COPD) and ischemic heart disease (IHD), showing that these diseases are mutually influenced. Many different biological processes such as hypoxia, systemic inflammation, endothelial dysfunction, heightened platelet reactivity, arterial stiffness and right ventricle modification interact in the development of the COPD-IHD comorbidity, which therefore deserves special attention in early diagnosis and treatment. Patients with COPD-IHD comorbidity have a worst outcome, when compared to patients with only COPD or only IHD. These patients showed a significant increase on risk of adverse events and of hospital readmissions for recurrent myocardial infarction, heart failure, coronary revascularization, and acute exacerbation of COPD. Taken together, these complications determine a significant increase in mortality. In most cases death occurs for cardiovascular cause, soon after an acute exacerbation of COPD or a cardiovascular adverse event. Recent data regarding incidence, mechanisms and prognosis of this comorbidity, along with the development of new drugs and interventional approaches may improve the management and long-term outcome of COPD-IHD patients. The aim of this review is to describe the current knowledge on COPD-IHD comorbidity. Particularly, we focused our attention on underlying pathological mechanisms and on all treatment and strategies that may improve and optimize the clinical management of COPD-IHD patients.

Pulmonary Artery Enlargement Is Associated With Cardiac Injury During Severe Exacerbations of COPD

BACKGROUND

Relative pulmonary arterial enlargement, defined by a pulmonary artery to aorta (PA/A) ratio > 1 on CT scanning, predicts hospitalization for acute exacerbations of COPD (AECOPD). However, it is unclear how AECOPD affect the PA/A ratio. We hypothesized that the PA/A ratio would increase at the time of AECOPD and that a ratio > 1 would be associated with worse clinical outcomes.

METHODS

Patients discharged with an International Classification of Diseases, Ninth Revision, diagnosis of AECOPD from a single center over a 5-year period were identified. Patients were included who had a CT scan performed during the stable period prior to the index AECOPD episode as well as a CT scan at the time of hospitalization. A subset of patients also underwent postexacerbation CT scans. The pulmonary arterial diameter, ascending aortic diameter, and the PA/A ratio were measured on CT scans. Demographic data, comorbidities, troponin level, and hospital outcome data were analyzed.

RESULTS

A total of 134 patients were included in the study. They had a mean age of 65 ± 10 years, 47% were male, and 69% were white; overall, patients had a mean FEV1 of 47% ± 19%. The PA/A ratio increased from baseline at the time of exacerbation (0.97 ± 0.15 from 0.91 ± 0.17; P < .001). Younger age and known pulmonary hypertension were independently associated with an exacerbation PA/A ratio > 1. Patients with PA/A ratio > 1 had higher troponin values. Those with a PA/A ratio > 1 and troponin levels > 0.01 ng/mL had increased acute respiratory failure, ICU admission, or inpatient mortality compared with those without both factors (P = .0028). The PA/A ratio returned to baseline values following AECOPD.

CONCLUSIONS

The PA/A ratio increased at the time of severe AECOPD and a ratio > 1 predicted cardiac injury and a more severe hospital course.

Post-ICU discharge and outcome: rationale and methods of the The French and euRopean Outcome reGistry in Intensive Care Units (FROG-ICU) observational study

BACKGROUND

Previous studies have demonstrated that ICU (intensive care unit) survivors have decreased long-term survival rates compared to the general population. However, knowledge about how to identify ICU survivors with higher risk of death and the adjustable factors associated with mortality is still lacking.

METHODS AND DESIGN

The FROG-ICU (the French and European Outcome Registry in Intensive Care Units) study is a prospective, observational, multicenter cohort study where ICU survivors are followed up to one year after ICU discharge. Beside one year survival, the study is designed to assess incidence and identifying risk factors for mortality over the year following discharge from the ICU. All consecutive patients admitted in ICU to the 28 participating centers during the study period will be included. Every subject will undergo an evaluation at admission, throughout the ICU stay and at ICU discharge. The global, especially cardiovascular, assessment of each subject will be performed through a complete clinical exam, instrumental tests (electrocardiogram, echocardiogram) and biological parameters. Blood and urine samples will be collected at admission and at discharge with the primary goal to assess effectiveness of routine and novel cardiovascular, inflammatory and renal biomarkers, with potential interest in risk stratification for patients who survive an ICU stay. The follow up will include a careful tracking of patients through telephone calls and questionnaires at 3, 6 and 12 months after ICU discharge. FROG-ICU aims to identify the clinical and biological phenotype of patients with different levels of probability of death in the year after ICU discharge.

DISCUSSION

FROG-ICU has been designed to better understand long term outcome after ICU discharge as well as risk factors for all-cause and cardiovascular morbidity and associated mortality. It is a large prospective multicenter cohort with a biological (on plasma and urine) collection and one-year follow-up of ICU patients. FROG ICU will allow performing a risk stratification of ICU survivors as to recognize the subset of patients who may benefit from an early intervention to allow decreased cardiovascular morbidity and related mortality.

TRIAL REGISTRATION

ClinicalTrials.gov NCT01367093 .

Cardiac troponin elevation predicts all-cause mortality in patients with acute exacerbation of chronic obstructive pulmonary disease: Systematic review and meta-analysis

BACKGROUND

Cardiovascular disease, especially ischemic heart disease, is a major comorbidity in chronic obstructive pulmonary disease (COPD) patients. Several studies suggested that after acute exacerbation of COPD (AECOPD), there is a significant increase of mortality (cardiac and all-cause) and of myocardial infarction. Whether cardiac troponin (Tn) elevation during AECOPD could be considered a prognostic marker of all-cause mortality is still debated.

METHODS

To assess the prognostic role of cardiac Tn elevation during AECOPD, we performed a systematic review and meta-analysis. We included studies with patients admitted to the hospital for AECOPD, with at least one Tn assessment and reporting the relationship (after multivariable analysis) between Tn elevation and all-cause mortality. Secondarily, studies were stratified according to: i) type of troponin (Tn I or Tn T), and ii) follow-up length (≤6 months vs. >6 months).

RESULTS

Ten studies were included in the systematic review and 8 in the meta-analysis. Cardiac Tn elevation ranges from 18% to 73%. We found that cardiac Tn elevation was significantly related to an increased risk for all-cause mortality (OR 1.69; 95% CI 1.25-2.29; I(2) 40%). This finding was independent to the follow-up length of studies (≤6 months: OR 3.22; 95% CI 1.31-7.91; >6 months: OR 1.38; 95% CI 1.02-1.86). Finally, Tn T seems to be more helpful in predicting all-cause mortality as compared to Tn I (OR 1.54; 95% CI 1.2-1.96 vs. OR 3.39, 95% CI 0.86-13.36, respectively).

CONCLUSIONS

In patients admitted to the hospital for AECOPD, cardiac Tn elevation emerged as an independent predictor of increased risk of all-cause mortality.

The role of cardiac biomarkers for predicting left ventricular dysfunction and cardiovascular mortality in acute exacerbations of COPD

The presence of cardiovascular comorbidities is frequently associated with poor outcomes in chronic obstructive pulmonary disease (COPD). No clear role has been defined for cardiac biomarkers in acute exacerbations of COPD (AECOPD). The aim of this systematic review was to examine the prognostic value of brain natriuretic peptide (BNP) and troponins in patients with AECOPD. Two independent authors searched the PubMed and Cochrane Library to collect clinical trials, observational studies and meta-analyses studying the prognostic value of cardiac biomarkers in AECOPD. The reference lists of all the included studies were also reviewed. A total of 14 studies were included in the review, of which 10 measured troponins, 7 measured BNP or NT-proBNP, and 3 measured both. Of the studies that used mortality in AECOPD as an end point, some but not all found that elevated BNP and/or troponins were associated with increased mortality. Of the studies that used left ventricular (LV) dysfunction in AECOPD as an end point, all found a significant association between elevated BNP and troponins in the diagnosis of LV dysfunction. In summary, it appears that there may be a link between an elevated level of BNP or NT-proBNP and increased cardiovascular mortality in AECOPD, although the data currently available are not conclusive. The inconsistencies in biomarkers measured, time points of measurements and the variability in outcome measured preclude more robust analysis.

Relationship between Troponin Elevation, Cardiovascular History and Adverse Events in Patients with acute exacerbation of COPD

Evidence suggests that troponin (Tn) elevation during acute exacerbation of chronic obstructive pulmonary disease (AECOPD) may predict an increase in mortality risk. We performed an observational study of 935 patients admitted to hospital for AECOPD from January 2010 to December 2012. Principal clinical and laboratory data were recorded, especially ischemic heart disease (IHD) history, Tn T values and cardiovascular drug prescription. The occurrence of all-cause death, cardiac death (CD), nonfatal myocardial infarction (MI), heart failure and cerebrovascular accident (CVA) was assessed on December 2013. Overall, 694 patients respected inclusion and exclusion criteria. We identified 210 (30%) patients without Tn elevation (negative Tn T group) and 484 (70%) patients with Tn elevation (positive Tn T group). With the exception of CVA, all adverse events were significantly higher in positive Tn T group as compared to negative Tn T group. At multivariable analysis, positive Tn T failed to predict all-cause death. Contrarily, positive Tn T emerged as independent predictors of CD (HR 1.61, 95%CI 1.2-2.2, p = 0.04), nonfatal MI (HR 3.12, 95%CI 1.4-8.1, p = 0.03) and composite endpoint including CD and nonfatal MI (HR 1.73, 95%CI 1.2-2.7, p = 0.03). Of note, positive Tn T stratified prognosis in patients without IHD history, but not in those with IHD history. In conclusion, after hospital admission for AECOPD, we observed a significant increase in the risk of cardiac adverse events in patients with Tn T elevation, especially in those without IHD history.

Prognostic value of serum growth differentiation factor-15 in patients with chronic obstructive pulmonary disease exacerbation

BACKGROUND

Information regarding prognostic value of growth differentiation factor 15 (GDF-15) and heart-type fatty acid-binding protein (H-FABP) in patients with chronic obstructive pulmonary disease (COPD) exacerbation is limited. The aim of this study was to investigate whether serum levels of GDF-15 and H-FABP predict an adverse outcome for COPD exacerbation.

METHODS

Clinical variables, including serum GDF-15 and H-FABP levels were compared in prospectively enrolled patients with COPD exacerbation that did or did not experience an adverse outcome. An adverse outcome included 30-day mortality and need for endotracheal intubation or inotropic support.

RESULTS

Ninety-seven patients were included and allocated into an adverse outcome (n=10) or a control (n=87) group. Frequencies of mental change and PaCO2>37 mm Hg were significantly higher in the adverse outcome group (mental change: 30% vs. 6%, p=0.034 and PaCO2>37 mm Hg: 80% vs. 22%, p<0.001, respectively). Serum GDF-15 elevation (>1,600 pg/mL) was more common in the adverse outcome group (80% vs. 43%, p=0.041). However, serum H-FABP level and frequency of serum H-FABP elevation (>755 pg/mL) did not differ between the two groups. Multivariate analysis showed that an elevated serum GDF-15 and PaCO2>37 mm Hg were significant predictors of an adverse outcome (odds ratio [OR], 25.8; 95% confidence interval [CI], 2.7-243.8; p=0.005 and OR, 11.8; 95% CI, 1.2-115.3; p=0.034, respectively).

CONCLUSION

Elevated serum GDF-15 level and PaCO2>37 mm Hg were found to predict an adverse outcome independently in patients with COPD exacerbation, suggesting the possibility that serum GDF-15 could be used as a prognostic biomarker of COPD exacerbation.

Prognostic significance of elevated troponin in non-cardiac hospitalized patients: a systematic review and meta-analysis

Cardiac biomarker troponin can be elevated in patients without a primary cardiac diagnosis and may have prognostic value. We conducted a systematic review to estimate the prevalence and prognostic significance of elevated troponin levels in patients admitted to hospital without a primary cardiac diagnosis. Literature search was done using MEDLINE (1946 to November 2012), EMBASE (1974 to Week 45, 2012), and Cochrane Central Register of Controlled Trials (November 2012). Two independent investigators reviewed full-text studies for final inclusion. We included studies of patients admitted without a primary cardiac diagnosis. Eligible studies compared adverse outcomes in patients with normal versus elevated troponin levels. Twenty-seven studies were included in the meta-analysis. Elevated troponin was associated with increased in-hospital and 30-day mortality (25 studies, 7255 patients, OR 3.88, 95% CI 2.90-5.19, P < 0.0001). Elevated troponin was also associated with increased risk of long-term mortality at 6 months (9 studies, 5368 patients, OR 4.21, 95% CI 1.84-9.64, P < 0.00001). Troponin is an independent predictor of short-term mortality with a pooled adjusted OR of 2.36, 95% CI 1.47-3.76, P < 0.0003. In conclusion, elevated troponin in non-cardiac patients is independently associated with increased mortality.

High-sensitivity troponin as an outcome predictor in acute medical admissions

BACKGROUND

Troponin estimation is increasingly performed on emergency medical admissions. We report on a high-sensitivity troponin (hscTn) assay, introduced in January 2011, and its relevance to in-hospital mortality in such patients.

AIM

To evaluate the impact of hscTn results on in-hospital mortality and the value of incorporating troponin into a predictive score of in-hospital mortality.

METHODS

All patients admitted as general medical emergencies between January 2011 and October 2012 were studied. Patients admitted under other admitting services including cardiology were excluded. We examined outcomes using generalised estimating equations, an extension of generalised linear models that permitted adjustment for correlated observations (readmissions). Margins statistics used adjusted predictions to test for interactions of key predictors while controlling for other variables using computations of the average marginal effect.

RESULTS

A total of 11 132 admission episodes were recorded. The in-hospital mortality for patients with predefined cut-offs was 1.9% when no troponin assay was requested, 5.1% when the troponin result was below the 25 ng/L 'normal' cut-off, 9.7% for a troponin result ≥25 and <50 ng/L, 14.5% for a troponin result ≥50 and <100 ng/L, 34.4% for a troponin result ≥100 and <1000 ng/L, and 58.3% for a troponin result >1000 ng/L. The OR for an in-hospital death for troponin-positive patients was 2.02 (95% CI 1.84 to 2.21); when adjusted for other mortality predictors including illness severity, the OR remained significant at 2.83 (95% CI 2.20 to 3.64). The incorporation of troponin into a multivariate logistic predictive algorithm resulted in an area under the receiver operating characteristic curve to predict an in-hospital death of 0.87 (95% CI 0.85 to 0.88).

CONCLUSIONS

An increase in troponin carries prognostic information in acutely ill medical patients; the extent of the risk conferred justifies incorporation of this information into predictive algorithms for hospital mortality.

Acute exacerbation of chronic obstructive pulmonary disease: cardiovascular links

Chronic obstructive pulmonary disease (COPD) is a chronic, progressive lung disease resulting from exposure to cigarette smoke, noxious gases, particulate matter, and air pollutants. COPD is exacerbated by acute inflammatory insults such as lung infections (viral and bacterial) and air pollutants which further accelerate the steady decline in lung function. The chronic inflammatory process in the lung contributes to the extrapulmonary manifestations of COPD which are predominantly cardiovascular in nature. Here we review the significant burden of cardiovascular disease in COPD and discuss the clinical and pathological links between acute exacerbations of COPD and cardiovascular disease.

The clinical value of serial measurement of high-sensitivity cardiac troponin T in acute exacerbations ofchronic obstructive pulmonary disease

Objective

To assess the prevalence and long-term prognostic value of a dynamic (rise/fall) pattern of cardiac troponin T (hs-cTnT) elevation during acute exacerbation of chronic obstructive pulmonary disease (AECOPD) compared with a stable hs-cTnT elevation.

Methods

Prospective cohort study of unselected patients admitted with AECOPD to the emergency room of a university hospital. Serial hs-cTnT measurements were made during admission. Survival after a median of 1.8 years was recorded.

Results

83 patients with a mean age of 72 years and a mean forced expiratory volume in 1 s (FEV₁) of 0.9 L. The mortality rate was 62%. The median hs-cTnT at admission was 27 ng/L (IQR 13.4–51)). 65 patients (78%) had at least one hs-cTnT measurement ≥14 ng/L, and among these the median change in hs-cTnT was 50.7% (IQR 25.2–89.4). Of the patients with serial hs-cTnT measurements, 53 (82%) had a dynamic pattern (ie, ΔTnT ≥20%). In multivariate analysis, stable hs-cTnT elevation was associated with increasing age (OR per 5 years with 95% CI 1.9 (1.01 to 3.7), p=0.045) and low Hb (OR 7.3 (1.1 to 49), p=0.039). Stable hs-cTnT elevation was associated with increased mortality with an HR of 2.4 (95%CI 1.1 to 5.3, p=0.027) in the multivariate Cox regression analysis.

Conclusions

Among the patients with at least one hs-cTnT above the 99th centile, 82% had a rise/fall pattern, as requested to make a diagnosis of myocardial infarction. Compared to a dynamic rise/fall pattern of hs-cTnT, a stable and moderately elevated hs-cTnT during AECOPD is associated with poor long-term prognosis.

Predictors of mortality in hospitalized adults with acute exacerbation of chronic obstructive pulmonary disease

RATIONALE

There is a need to identify clinically meaningful predictors of mortality following hospitalized COPD exacerbation.

OBJECTIVES

The aim of this study was to systematically review the literature to identify clinically important factors that predict mortality after hospitalization for acute exacerbation of chronic obstructive pulmonary disease (COPD).

METHODS

Eligible studies considered adults admitted to hospital with COPD exacerbation. Two authors independently abstracted data. Odds ratios were then calculated by comparing the prevalence of each predictor in survivors versus nonsurvivors. For continuous variables, mean differences were pooled by the inverse of their variance, using a random effects model.

MEASUREMENTS AND MAIN RESULTS

There were 37 studies included (189,772 study subjects) with risk of death ranging from 3.6% for studies considering short-term mortality, 31.0% for long-term mortality (up to 2 yr after hospitalization), and 29.0% for studies that considered solely intensive care unit (ICU)-admitted study subjects. Twelve prognostic factors (age, male sex, low body mass index, cardiac failure, chronic renal failure, confusion, long-term oxygen therapy, lower limb edema, Global Initiative for Chronic Lung Disease criteria stage 4, cor pulmonale, acidemia, and elevated plasma troponin level) were significantly associated with increased short-term mortality. Nine prognostic factors (age, low body mass index, cardiac failure, diabetes mellitus, ischemic heart disease, malignancy, FEV1, long-term oxygen therapy, and PaO2 on admission) were significantly associated with long-term mortality. Three factors (age, low Glasgow Coma Scale score, and pH) were significantly associated with increased risk of mortality in ICU-admitted study subjects.

CONCLUSION

Different factors correlate with mortality from COPD exacerbation in the short term, long term, and after ICU admission. These parameters may be useful to develop tools for prediction of outcome in clinical practice.

Acute liver failure and elevated troponin-I: controversial results and significance?

Acute liver failure in ICU patients is an often fatal condition in which many patients may die of multiple organ failure in the absence of liver transplantation. In this setting, cardiac injury may be associated with or precipitate a fatal outcome. Troponin-I is a well-established, specific, and sensitive surrogate of acute coronaropathy, with both diagnostic and prognostic value. Troponin-I elevation in acute liver failure patients is common, ranging from 60 to 75%, and probably multifactorial. Despite a previous well-conducted US study showing that elevated troponin-I is associated with an independent risk of poor outcome and mortality, a recent UK study did not confirm these data and reported contradictory results. Troponin-I elevation observed in acute liver failure may therefore not represent true myocardial injury and may be better viewed as a marker of metabolic stress. The debate on the significance of elevated troponin-I in acute liver failure patients is revived.

The prognostic variables predictive of mortality in patients with an exacerbation of COPD admitted to the ICU: an integrative review

INTRODUCTION

Chronic Obstructive Pulmonary Disease (COPD) frequently presents with an acute exacerbation (AECOPD). Debate exists as to whether these patients should be admitted to intensive care units (ICUs). An integrative review was performed to determine whether clinical variables available at the time of ICU admission are predictive of the intermediate-term mortality of patients with an AECOPD.

METHODS

An integrative review was structured to incorporate a five-stage review framework to facilitate data extraction, analysis and presentation. The quality of the studies contributing to the integrative review was assessed with a novel scoring system developed from previously published data and adapted to this setting.

RESULTS

The integrative review search strategy identified 28 studies assessing prognostic variables in this setting. Prognostic variables associated with intermediate-term mortality were low Glasgow Coma Scale (GCS) on admission to ICU, cardio-respiratory arrest prior to ICU admission, cardiac dysrhythmia prior to ICU admission, length of hospital stay prior to ICU admission and higher values of acute physiology scoring systems. Premorbid variables such as age, functional capacity, pulmonary function tests, prior hospital or ICU admissions, body mass index and long-term oxygen therapy were not found to be associated with intermediate-term mortality nor was the diagnosis attributed to the cause of the AECOPD.

DISCUSSION

Variables associated with intermediate-term mortality after AECOPD requiring ICU admission are those variables, which reflect underlying severity of acute illness. Premorbid and diagnostic data have not been shown to be predictive of outcome. A scoring system is proposed to assess studies of prognosis in AECOPD.

Elevated Cardiac Biomarkers With Normal Right Ventricular Size Indicate an Unlikely Diagnosis of Acute Pulmonary Embolism in Stable Patients

The purpose of this investigation is to assess the prevalence of elevated cardiac biomarkers, with or without estimates of right ventricular (RV) size, in stable patients with acute pulmonary embolism (PE). Our hypothesis is that the combination of high levels of cardiac troponin I (cTnI), high creatine kinase isoenzyme MB (CK-MB), and normal size RV are sufficiently uncommon in stable patients with PE to make the diagnosis of PE unlikely. Retrospective review showed a high cTnI plus high CK-MB in 20 (3.4%) of 585 stable patients with acute PE. A high cTnI plus high CK-MB with normal RV size was shown in 5 (1.9%) of 264 patients. In stable patients with such findings, therefore, PE is unlikely and other diagnoses, particularly acute coronary syndrome, should be considered before pursuing a diagnosis of PE.

Troponin elevation in conditions other than acute coronary syndromes

Acute coronary syndromes comprise a large spectrum of clinical conditions ranging from unstable angina pectoris to acute ST-elevation myocardial infarction. Chest pain is usually the major symptom of atherosclerotic heart disease; however, it may be challenging to diagnose correctly, especially in the emergency department, because of the ambiguous way that pain is characterized by some patients. Cardiac troponins are sensitive and specific biomarkers used in the diagnosis of myocardial infarction that are released into the bloodstream when cardiac myocytes are damaged by acute ischemia or any other mechanism. They are the cornerstone for the diagnosis, risk assessment, prognosis, and determination of antithrombotic and revascularization strategies. However, troponin elevation indicates the presence, not the mechanism, of myocardial injury. There are many clinical conditions other than myocardial infarction that cause troponin elevation; thus, the physician should be aware of the wide spectrum of disease states that may result in troponin elevation and have a clear understanding of the related pathophysiology to effectively make a differential diagnosis. This review focuses on causes of troponin elevation other than acute coronary syndromes.

Systemic biomarkers in exacerbations of COPD: the evolving clinical challenge

BACKGROUND

Exacerbations of COPD (ECOPD) remain a major cause of mortality and morbidity. Despite advances in the understanding of their pathophysiology, their assessment relies primarily on clinical presentation, which can be variable and difficult to predict. A large number of biomarkers already have been assessed in this context, and some appear to be promising.

METHODS

An online search for articles published until December 2010 was conducted using three terms for ECOPD, five terms for biomarkers, and five terms for the sampling method. Biomarkers were evaluated for their potential role in the establishment and confirmation of the diagnosis of ECOPD, the evaluation of etiology and severity, the prediction of prognosis, and the guidance of treatment decisions.

RESULTS

Several systemic biomarkers have been measured in the context of ECOPD, and most have been found to increase at ECOPD onset and to subside during the course of exacerbations. Correlations have been reported among these biomarkers, but direct associations with clinical variables have been more difficult to establish. Although there are several limitations yet to be addressed, some of the biomarkers, most notably C-reactive protein for the identification of an ECOPD and procalcitonin for antibiotic guidance, may provide clinically relevant information.

CONCLUSIONS

So far, no single biomarker has been able to gain wide acceptance, but some provide clinically useful information. The evaluation of such biomarkers in large decision-making studies is expected to become an area of intense investigation in the near future.