Analytical and assay issues for use of cardiac troponin testing for risk stratification in primary care

Early detection of myocardial infarction with reference to baseline levels during health: impact on biological variation of high-sensitivity cardiac troponin

A 78-year-old male was seen in the emergency department (ED) with chest pain. Fifteen months earlier, he had presented to the ED with shoulder and elbow pain. High-sensitivity cardiac troponin I (hs-cTnI) testing was conducted at that time, which produced normal results of 10 and 13 ng/L (cutoff <48 ng/L). During the current admission, his electrocardiogram was unremarkable, with a borderline prolonged PR interval noted. The patient's hs-cTnI results were 25, 47, and 254 ng/L at 0, 1, and 7 hours, respectively. He was diagnosed with demand ischemia and admitted to the hospital. The detection of acute myocardial infarction in this case was made during the first sample collection (t = 0), despite the fact that this result was well within the normal range.

The current paradigm of cardiac troponin increase among athletes

Although it is known that exercise improves cardiovascular health and extends life expectancy, a significant number of people may also experience an elevation in cardiac troponin levels as a result of exercise. For many years, researchers have argued whether exercise-induced cardiac troponin rises are a consequence of a physiological or pathological reaction and whether they are clinically significant. Differences in cardiac troponin elevation and cardiac remodeling can be seen between athletes participating in different types of sports. When forecasting the exercise-induced cardiac troponin rise, there are many additional parameters to consider, as there is a large amount of interindividual heterogeneity in the degree of cardiac troponin elevation. Although it was previously believed that cardiac troponin increases in athletes represented a benign phenomenon, numerous recent studies disproved this notion by demonstrating that, in specific individuals, cardiac troponin increases may have clinical and prognostic repercussions. This review aims to examine the role of cardiac troponin in athletes and its role in various sporting contexts. This review also discusses potential prognostic and clinical implications, as well as future research methods, and provides a straightforward step-by-step algorithm to help clinicians interpret cardiac troponin rise in athletes in both ischemic and non-ischemic circumstances.

Antibody coated conductive polymer for the electrochemical immunosensing of Human Cardiac Troponin I in blood plasma

Cardiac troponin I (cTnI) is a sensitive biomarker for cardiovascular disease (CVD). Rapid determination of cTnI concentration in blood can greatly reduce the potential of significant heart damage and heart failure. Herein, we demonstrate a new electrochemical immunosensor for selective affinity binding and rapid detection of cTnI in blood plasma by an electrochemical method. A conductive film of "poly 2,5-bis(2-thienyl)3,4-diamine-terthiophene (PDATT)" was deposited onto an Indium Tin Oxide (ITO) electrode using chronoamperometry. Anti-cardiac troponin I antibody was then attached to the two amine (NH₂) groups substituted on the central thiophene of terthiophene repeating unit of the polymer chain via amide bond formation. The gaps on the surface of the antibody coated immunosensor were backfilled with bovine serum albumin (BSA) to prevent nonspecific binding of interfering molecules. Differential pulse voltammetry (DPV) was used to determine cTnI upon the formation of cTnI immunocomplex on the sensing surface, appearing a peak at 0.27 V. The response range was 0.01-100 ng mL^-1 with limit of quantification down to 0.01 ng mL^-1. The developed immunosensor was used to determine cTnI in spiked blood plasma without interference from cardiac troponin T (cTnT). Therefore, this new sensor can be utilised for the detection of cTnI biomarker in pathological laboratories and points of care in less than 15 min.

Supersensitive photon upconversion based immunoassay for detection of cardiac troponin I in human plasma

BACKGROUND AND AIMS

Upconverting nanoparticles (UCNPs) are attractive reporters for immunoassays due to their excellent detectability. Assays sensitive enough to measure baseline level of cardiac troponin I cTnI in healthy population could be used to identify patients at risk for cardiovascular disease. Aiming for a cTnI assay of such sensitivity, the surface chemistry of the nanoparticles as well as the assay reagents and the protocol were optimized for monodispersity of the UCNP antibody conjugates (Mab UCNPs) and to minimize their non-specific interactions with the solid support.

MATERIALS AND METHODS

UCNPs were coated with poly(acrylic acid) via two-step ligand exchange and conjugated with monoclonal antibodies. The conjugates were applied in a microplate-based sandwich immunoassay using a combination of two capture antibodies to detect cTnI. Assay was evaluated according to guidelines of Clinical & Laboratory Standards Institute.

RESULTS

The limit of detection and limit of blank of the assay were 0.13 ng/L and 0.01 ng/L cTnI, respectively. The recoveries were >90% in spiked plasma in the linear range. The within- and between-run imprecisions were <10%.

CONCLUSION

The results demonstrate that UCNPs enable quantification of cTnI concentrations expected in plasma of healthy individuals and could be used to identify patients at risk for cardiovascular disease.

99th Percentile Upper-Reference Limit of Cardiac Troponin and the Diagnosis of Acute Myocardial Infarction

BACKGROUND

Concerns exist regarding how the 99th percentile upper reference limit (URL) of cardiac troponin (cTn) is determined and whether it should be derived from normal healthy individuals.

CONTENT

The 99th percentile URL of cTn is an important criterion to standardize the diagnosis of myocardial infarction (MI) for clinical, research, and regulatory purposes. Statistical heterogeneity in its calculation exists but recommendations have been proposed. Some negativity has resulted from the fact that with some high-sensitivity (hs) cTn assays, a greater number of increases above the 99th percentile are observed when transitioning from a contemporary assay. Increases reflect acute or chronic myocardial injury and provide valuable diagnostic and prognostic information. The etiology of increases can sometimes be difficult to determine, making a specific treatment approach challenging. For those reasons, some advocate higher cutoff concentrations. This approach can contribute to missed diagnoses. Contrary to claims, neither clinical or laboratory guidelines have shifted away from the 99th percentile. To support the diagnosis of acute MI, the 99th percentile URL remains the best-established approach given the absence of cTn assay standardization. Importantly, risk stratification algorithms using hs-cTn assays predict the possibility of MI diagnoses established using the 99th percentile.

SUMMARY

The 99th percentile of cTn remains the best-established criterion for the diagnosis of acute MI. While not perfect, it is analytically and clinically evidence-based. Until there are robust data to suggest some other approach, staying with the 99th percentile, a threshold that has served the field well for the past 20 years, appears prudent.

SERS-based immunoassay using gold-patterned array chips for rapid and sensitive detection of dual cardiac biomarkers

Cardiac troponin I (cTnI) and creatine kinase-MB (CK-MB) are important diagnostic biomarkers for acute myocardial infarction (AMI). Many efforts have been undertaken to develop highly sensitive detection methods for the quantitative analysis of these dual targets. However, current immunoassay methods are inadequate for accurate measurement of cTnI and CK-MB, due to their limited detection sensitivity. Thus, there is still an urgent demand for a new technique that will enable ultrahigh sensitive detection of these biomarkers. In this study, we developed a surface-enhanced Raman scattering (SERS)-based sandwich immunoassay platform for the ultrasensitive detection of cTnI and CK-MB. In this study, a monoclonal-antibody-immobilized gold-patterned chip was used as a SERS active template. Target samples and polyclonal-antibody-conjugated Au@Ag core-shell nanoparticles were then added. Using this SERS platform, the concentration of biomarkers could be quantified by monitoring the characteristic Raman peak intensity of Raman reporter molecules. Under optimized conditions, the limits of detection (LODs) were estimated to be 8.9 pg mL-1 and 9.7 pg mL-1 for cTnI and CK-MB, respectively. Thus, the proposed SERS-based immunoassay has great potential to be an effective diagnostic tool for the rapid and accurate detection of cTnI and CK-MB.

Point-of-Care Compatibility of Ultra-Sensitive Detection Techniques for the Cardiac Biomarker Troponin I-Challenges and Potential Value

Cardiac biomarkers are frequently measured to provide guidance on the well-being of a patient in relation to cardiac health with many assays having been developed and widely utilised in clinical assessment. Effectively treating and managing cardiovascular disease (CVD) relies on swiftly responding to signs of cardiac symptoms, thus providing a basis for enhanced patient management and an overall better health outcome. Ultra-sensitive cardiac biomarker detection techniques play a pivotal role in improving the diagnostic capacity of an assay and thus enabling a better-informed decision. However, currently, the typical approach taken within healthcare depends on centralised laboratories performing analysis of cardiac biomarkers, thus restricting the roll-out of rapid diagnostics. Point-of-care testing (POCT) involves conducting the diagnostic test in the presence of the patient, with a short turnaround time, requiring small sample volumes without compromising the sensitivity of the assay. This technology is ideal for combatting CVD, thus the formulation of ultra-sensitive assays and the design of biosensors will be critically evaluated, focusing on the feasibility of these techniques for point-of-care (POC) integration. Moreover, there are several key factors, which in combination, contribute to the development of ultra-sensitive techniques, namely the incorporation of nanomaterials for sensitivity enhancement and manipulation of labelling methods. This review will explore the latest developments in cardiac biomarker detection, primarily focusing on the detection of cardiac troponin I (cTnI). Highly sensitive detection of cTnI is of paramount importance regarding the rapid rule-in/rule-out of acute myocardial infarction (AMI). Thus the challenges encountered during cTnI measurements are outlined in detail to assist in demonstrating the drawbacks of current commercial assays and the obstructions to standardisation. Furthermore, the added benefits of introducing multi-biomarker panels are reviewed, several key biomarkers are evaluated and the analytical benefits provided by multimarkers-based methods are highlighted.

Immuno-analytical approach and its application for cardiac disease marker detection

Cardiac troponin-I is a promising diagnostic marker for cardiovascular diseases. Troponin-I immunoassays rely on monoclonal antibodies, while polyclonal antibodies, cheaper to manufacture, are uncommonly used. The current study established an immuno-analytical assay using a polyclonal antibody capable of mapping troponin-I antigenic determinant. Proteolytic digestion of troponin-I was performed. Antigenic determinant was assigned by separation of fragments using gel electrophoresis followed by Western blot and high-performance liquid chromatography followed by dot blot. The antigenic determinant region appeared within amino acid sequence 30-90. This robust procedure is suitable for early prognosis of diseases, stratification of patients, and possibly individualized therapy.

Circular noncoding RNAs as potential therapies and circulating biomarkers for cardiovascular diseases

Recent advancements in genome-wide analyses and RNA-sequencing technologies led to the discovery of small noncoding RNAs, such as microRNAs (miRs), as well as both linear long noncoding RNAs (lncRNAs) and circular long noncoding RNAs (circRNAs). The importance of miRs and lncRNAs in the treatment, prognosis and diagnosis of cardiovascular diseases (CVDs) has been extensively reported. We also previously reviewed their implications in therapies and as biomarkers for CVDs. More recently, circRNAs have also emerged as important regulators in CVDs. CircRNAs are circular genome products that are generated by back splicing of specific regions of pre-messenger RNAs (pre-mRNAs). Growing interest in circRNAs led to the discovery of a wide array of their pathophysiological functions. CircRNAs have been shown to be key regulators of CVDs such as myocardial infarction, atherosclerosis, cardiomyopathy and cardiac fibrosis. Accordingly, circRNAs have been recently proposed as potential therapeutic targets and biomarkers for CVDs. In this review, we summarize the current state of the literature on circRNAs, starting with their biogenesis and global mechanisms of actions. We then provide a synopsis of their involvement in various CVDs. Lastly, we emphasize the great potential of circRNAs as biomarkers for the early detection of CVDs, and discuss several patents and recent papers that highlight the utilization of circRNAs as promising biomarkers.

Quantification of cardiac troponin I in human plasma by immunoaffinity enrichment and targeted mass spectrometry

Quantification of cardiac troponin I (cTnI), a protein biomarker used for diagnosing myocardial infarction, has been achieved in native patient plasma based on an immunoaffinity enrichment strategy and isotope dilution (ID) liquid chromatography-tandem mass spectrometry (LC-MS/MS) method. The key steps in the workflow involved isolating cTnI from plasma using anti-cTnI antibody coupled to magnetic nanoparticles, followed by an enzymatic digestion with trypsin. Three tryptic peptides from cTnI were monitored and used for quantification by ID-LC-MS/MS via multiple reaction monitoring (MRM). Measurements were performed using a matrix-matched calibration system. NIST SRM 2921 Human Cardiac Troponin Complex acted as the calibrant and a full-length isotopically labeled protein analog of cTnI was used as an internal standard. The method was successfully demonstrated on five patient plasma samples, with cTnI concentrations measuring between 4.86 μg/L and 11.3 μg/L (signifying moderate myocardial infarctions). LC-MS/MS measurement precision was validated by three unique peptides from cTnI and two MRM transitions per peptide. Relative standard deviation (CV) from the five plasma samples was determined to be ≤14.3%. This study has demonstrated that quantification of cTnI in native plasma from myocardial infarction patients can be achieved based on an ID-LC-MS/MS method. The development of an ID-LC-MS/MS method for cTnI in plasma is a first step for future certification of matrix-based reference materials, which may be used to help harmonize discordant cTnI clinical assays. Graphical abstract A schematic of the workflow for measuring cardiac troponin I (cTnI), a low-abundant protein biomarker used for diagnosing myocardial infarction, in human plasma by isotope-dilution LC-MS/MS analysis.

Diagnostic Value of D-Dimer in Acute Myocardial Infarction Among Patients With Suspected Acute Coronary Syndrome

Background

The role of D-dimer as a diagnostic marker in myocardial infarction (MI) and acute coronary syndrome (ACS) is still a question. The aim of this study was to evaluate the diagnostic value of D-dimer in the diagnosis of AMI in patients suspected with ACS.

Methods

This cross-sectional study was conducted on patients suspected with ACS. Serial standard 12-lead electrocardiogram (ECG), D-dimer, and troponin tests were done for all the patients. According to the examinations, ECG changes, and troponin, patients were allocated into two groups of MI and unstable angina (UA). Chi-square, independent t-test, and Pearson correlation test were used by SPSS ver, 17. Cut-off point of D-dimer for MI diagnosis was evaluated by receiver operating characteristic (ROC) curve analysis.

Results

Seventy-five patients with a mean age of 63.1 ± 9.75 years were studied in two groups of MI (n = 34) and UA (n = 41). Patients were homogeneous based on age, gender, and risk factors for diabetes and dyslipidemia. D-dimer in patients with MI patients was higher than in patients with UA (P = 0.001). The optimal cut-off point of D-dimer for diagnosis of MI was 548 mEq/L with sensitivity and specifity of 63.4% and 91.2%, respectively.

Conclusions

Based on the results of this study, it seems that the measurement of D-dimer serum level can be appropriate as a marker with high sensitivity and relatively high specificity for differentiating MI from UA in patients with suspected ACS.

Adropin as a potential marker of enzyme-positive acute coronary syndrome

Aim

Enzyme-positive acute coronary syndrome (EPACS) can cause injury to or death of the heart muscle owing to prolonged ischaemia. Recent research has indicated that in addition to liver and brain cells, cardiomyocytes also produce adropin. We hypothesised that adropin is released into the bloodstream during myocardial injury caused by acute coronary syndrome (ACS), so serum and saliva levels rise as the myocytes die. Therefore, it could be useful to investigate how ACS affects the timing and significance of adropin release in human subjects

Methods

Samples were taken over three days after admission, from 22 EPACS patients and 24 age- and gendermatched controls. The three major salivary glands (submandibular, sublingual and parotid) were immunohistochemically screened for adropin production, and serum and saliva adropin levels were measured by an enzyme-linked immunosorbent assay (ELISA). Salivary gland cells produce and secrete adropin locally.

Results

Serum adropin, troponin I, CK and CK-MB concentrations in the EPACS group became gradually higher than those in the control group up to six hours (p < 0.05), and troponin I continued to rise up to 12 hours after EPACS. The same relative increase in adropin level was observed in the saliva. Troponin I, CK and CK-MB levels started to decrease after 12 hours, while saliva and serum adropin levels started to decrease at six hours after EPACS. In samples taken four hours after EPACS, when the serum adropin value averaged 4.43 ng/ml, the receiver operating characteristic curve showed that the serum adropin concentration indicated EPACS with 91.7% sensitivity and 50% specificity, while when the cut-off adropin value in saliva was 4.12 ng/ml, the saliva adropin concentration indicated EPACS with 91.7% sensitivity and 57% specificity.

Conclusion

In addition to cardiac troponin and CK-MB assays, measurement of adropin level in saliva and serum samples is a potential marker for diagnosing EPACS.

Clinical impact of a high-sensitivity troponin assay introduction on patients presenting to the emergency department

OBJECTIVE

Biomarkers are a critical component in the investigation of patients with potential ischaemic heart disease. The proposed benefits of a high-sensitivity troponin (hs-Tn) assay include earlier diagnosis of myocardial infarction. However, the decreased specificity may adversely affect clinical practice. The present study aims to investigate the impact that the introduction of a hs-Tn assay had on patients presenting to the ED.

METHODS

A pre- and post-interventional analysis was performed on all patients presenting to the Royal Melbourne Hospital ED, and had a troponin, in the 12 months before and after the introduction of the hs-Tn assay. The main outcome measures were ED length of stay, admission rates, proportion of patients undergoing interventional cardiac procedures and proportion diagnosed with myocardial infarction.

RESULTS

There were 6557 patients who had a conventional assay and 7335 patients who had a hs-Tn assay. The introduction of a hs-Tn assay was associated with an increased abnormal troponin rate (23.4% vs 28.1%, P < 0.001). The median length of ED stay decreased by 9.1% (P < 0.001). The proportion admitted to hospital increased (60.9% vs 65.9%, P < 0.001); however, there was no difference in the proportion undergoing revascularisation or the proportion diagnosed with myocardial infarction.

CONCLUSIONS

Although the introduction of a hs-Tn assay led to an increase in hospital admissions, the unchanged rate of cardiac procedures or final diagnoses of acute myocardial infarction and ischaemic heart disease suggests that the hs-Tn did not improve the detection of these conditions. It remains unclear whether there was a benefit admitting the additional cohort of patients.

Epigenetic regulation of cardiac myofibril gene expression during heart development

Cardiac gene expression regulation is controlled not only by genetic factors but also by environmental, i.e., epigenetic factors. Several environmental toxic effects such as oxidative stress and ischemia can result in abnormal myofibril gene expression during heart development. Troponin, one of the regulatory myofibril proteins in the heart, is a well-known model in study of cardiac gene regulation during the development. In our previous studies, we have demonstrated that fetal form troponin I (ssTnI) expression in the heart is partially regulated by hormones, such as thyroid hormone. In the present study, we have explored the epigenetic role of histone modification in the regulation of ssTnI expression. Mouse hearts were collected at different time of heart development, i.e., embryonic day 15.5, postnatal day 1, day 7, day 14 and day 21. Levels of histone H3 acetylation (acH3) and histone H3 lysine 9 trimethylation (H3K9me(3)) were detected using chromatin immunoprecipitation assays in slow upstream regulatory element (SURE) domain (TnI slow upstream regulatory element), 300-bp proximal upstream domain and the first intron of ssTnI gene, which are recognized as critical regions for ssTnI regulation. We found that the levels of acH3 on the SURE region were gradually decreased, corresponding to a similar decrease of ssTnI expression in the heart, whereas the levels of H3K9me(3) in the first intron of ssTnI gene were gradually increased. Our results indicate that both histone acetylation and methylation are involved in the epigenetic regulation of ssTnI expression in the heart during the development, which are the targets for environmental factors.

Effect of Coronary Atherosclerosis and Myocardial Ischemia on Plasma Levels of High-Sensitivity Troponin T and NT-proBNP in Patients With Stable Angina

OBJECTIVE

Circulating levels of high-sensitivity cardiac troponin T (hs-cTnT) and N terminal pro brain natriuretic peptide (NT-proBNP) are predictors of prognosis in patients with coronary artery disease (CAD). We aimed at evaluating the effect of coronary atherosclerosis and myocardial ischemia on cardiac release of hs-cTnT and NT-proBNP in patients with suspected CAD.

APPROACH AND RESULTS

Hs-cTnT and NT-proBNP were measured in 378 patients (60.1±0.5 years, 229 males) with stable angina and unknown CAD enrolled in the Evaluation of Integrated Cardiac Imaging (EVINCI) study. All patients underwent stress imaging to detect myocardial ischemia and coronary computed tomographic angiography to assess the presence and characteristics of CAD. An individual computed tomographic angiography score was calculated combining extent, severity, composition, and location of plaques. In the whole population, the median (25-75 percentiles) value of plasma hs-cTnT was 6.17 (4.2-9.1) ng/L and of NT-proBNP was 61.66 (31.2-132.6) ng/L. In a multivariate model, computed tomographic angiography score was an independent predictor of the plasma hs-cTnT (coefficient 0.06, SE 0.02; P=0.0089), whereas ischemia was a predictor of NT-proBNP (coefficient 0.38, SE 0.12; P=0.0015). Hs-cTnT concentrations were significantly increased in patients with CAD with or without myocardial ischemia (P<0.005), whereas only patients with CAD and ischemia showed significantly higher levels of NT-proBNP (P<0.001).

CONCLUSIONS

In patients with stable angina, the presence and extent of coronary atherosclerosis is related with circulating levels of hs-cTnT, also in the absence of ischemia, suggesting an ischemia-independent mechanism of hs-cTnT release. Obstructive CAD causing myocardial ischemia is associated with increased levels of NT-proBNP.

Estimation of age- and comorbidities-adjusted percentiles of high-sensitivity cardiac troponin T levels in the elderly

BACKGROUND

Cardiac troponin level measured by high-sensitivity assays (hs-cTn) in the elderly is frequently found higher than the 99th percentile upper reference limit, making the diagnosis of acute coronary syndromes (ACS) difficult. This study aimed at: 1) identifying determinants of hs-cTnT levels in an unselected population of elderly subjects; and 2) assessing the prognosis value of increased hs-cTnT in elderly people free of ACS.

METHODS

Hs-cTnT was measured in 591 individuals aged over 65 years without suspicion of ACS. Comorbidities were assessed using the Cumulative Illness Rating Scale for Geriatrics (CIRS-G). C-reactive protein, α1-acid glycoprotein, albumin and creatinine were measured. Factors influencing hs-cTnT levels were assessed through linear regression and quantile regression was used to model percentiles of hs-cTnT. Risk of mortality was assessed through Cox regression.

RESULTS

Age, gender, cardiac CIRS-G, estimated glomerular filtration rate (p<0.001 for all), albumin (p<0.028) and α1-acid glycoprotein (p=0.002) were independent predictors of hs-cTnT. After exclusion of outliers, the median was 15 ng/L and 99th percentile was 64 ng/L. After controlling for comorbidities, the 99th percentile increased from 24 ng/L at age 65 to 53 ng/L at age 90 in females and from 33 ng/L to 75 ng/L in males. In multivariate analysis, hs-cTnT level was significantly related to mortality.

CONCLUSIONS

Hs-cTnT level is associated with inflammation and renal function in the elderly. Independently of comorbidities, hs-cTnT concentration increases exponentially with age after 65 years. Decision limits adapted to age and sex may be useful to patient management.

DNA methylation regulates mouse cardiac myofibril gene expression during heart development

Background

It is well known that epigenetic modifications play an important role in controlling the regulation of gene expression during the development. Our previous studies have demonstrated that the expression of fetal troponin I gene (also called slow skeletal troponin I, ssTnI) is predominated in the fetal stage, reduced after birth and disappeared in the adulthood. The mechanism underlying the developmentally related ssTnI gene regulation is not clear. In this study, we have explored the epigenetic role of DNA methylation in the regulation of ssTnI expression in the heart during the development.

Results

The DNA methylation levels of CpG island and CpG dinucleotides region were detected using methylation specific PCR (MSP) and bisulfite sequence PCR (BSP) in 2000 bp upstream and 100 bp upstream of ssTnI gene promoter. Real time RT-PCR and Western blot were used to detect ssTnI mRNA and protein expression levels. We found that DNA methylation levels of the CpG dinucleotides region in ssTnI gene promoter were increased with the development, corresponding to a decreased expression of ssTnI gene in mouse heart. However the DNA methylation levels of CpG islands in this gene were not changed during the development. Application of a methylation inhibitor, 5-Azacytidine, in cultured myocardial cells partially prevented the decline of ssTnI expression.

Conclusion

Our results indicate that DNA methylation, as an epigenetic intervention, plays a role in the regulation of the fetal TnI gene expression in the heat during the development.

Fully automated ultrasensitive digital immunoassay for cardiac troponin I based on single molecule array technology

BACKGROUND

The association between increases in cardiac troponin and adverse cardiac outcomes is well established. There is a growing interest in exploring routine cardiac troponin monitoring as a potential early indicator of adverse heart health trends. Prognostic use of cardiac troponin measurements requires an assay with very high sensitivity and outstanding analytical performance. We report development and preliminary validation of an investigational assay meeting these requirements and demonstrate its applicability to cohorts of healthy individuals and patients with heart failure.

METHODS

On the basis of single molecule array technology, we developed a 45-min immunoassay for cardiac troponin I (cTnI) for use on a novel, fully automated digital analyzer. We characterized its analytical performance and measured cTnI in healthy individuals and heart failure patients in a preliminary study of assay analytical efficacy.

RESULTS

The assay exhibited a limit of detection of 0.01 ng/L, a limit of quantification of 0.08 ng/L, and a total CV of 10% at 2.0 ng/L. cTnI concentrations were well above the assay limit of detection for all samples tested, including samples from healthy individuals. cTnI was significantly higher in heart failure patients, and exhibited increasing median and interquartile concentrations with increasing New York Heart Association classification of heart failure severity.

CONCLUSIONS

The robust 2-log increase in sensitivity relative to contemporary high-sensitivity cardiac troponin immunoassays, combined with full automation, make this assay suitable for exploring cTnI concentrations in cohorts of healthy individuals and for the potential prognostic application of serial cardiac troponin measurements in both apparently healthy and diseased individuals.

Incidence and Expression of Circulating Cell Free p53-Related Genes in Acute Myocardial Infarction Patients

AIM

The circulating RNA levels are predictive markers in several diseases. We determined the levels of circulating p53-related genes in patients with acute ST-segment elevation myocardial infarction (STEMI), indicating major heart muscle damage.

METHODS

Plasma RNA was extracted from the patients (n=45) upon their arrival to the hospital (STEMI 0h) and at four hours post-catheterization (STEMI 4h) as well as from controls (n=34).

RESULTS

Of 18 circulating p53-related genes, nine genes were detectable. A significantly lower incidence of circulating p21 (p ＜ 0.0001), Notch1 (p=0.042) and BTG2 (p ＜ 0.0001) was observed in the STEMI 0h samples in comparison to the STEMI 4h and control samples. Lower expression levels (2.1-fold) of circulating BNIP3L (p=0.011), p21 (3.4-fold, p=0.005) and BTG2 (6.3-fold, p=0.0001) were observed in the STEMI 0h samples in comparison to the STEMI 4h samples, with a 7.4-fold lower BTG2 expression (p ＜ 0.001) and 2.6-fold lower p21 expression (p=0.034) compared to the control samples. Moreover, the BNIP3L expression (borderline significance, p=0.0655) predicted the level of peak troponin, a marker of myocardial infarction. In addition, the BNIP3L levels on admission (p=0.0025), at post-catheterization (p=0.020) and the change between the groups (p=0.0079) were inversely associated with troponin. The BNIP3L (p=0.0139) and p21 levels (p=0.0447) were also associated with a longer time to catheterization.

CONCLUSIONS

Our results suggest that circulating downstream targets of p53 are inhibited during severe AMI and subsequently re-expressed after catheterization, uncovering possible novel death-or-survival decisions regarding the fate of p53 in the heart and the potential use of its target genes as prognostic biomarkers for oxygenation normalization.

High sensitivity cardiac troponin assays in the clinical laboratories

Immunoassays measuring cardiac troponins I or T have become firmly established as critical tools for diagnosing acute myocardial infarction. While most contemporary assays provide adequate diagnostic performance, the increased sensitivity and precision of the new, high sensitivity assays that have already been introduced into clinical practice, provide the potential to further shorten intervals between blood draws or the time needed to detect the first significant troponin elevation. In addition to the relatively modest benefits at the diagnostic end, the high sensitivity assays and the investigational ultrasensitive cardiac troponin assays offer improvements for predicting major adverse cardiovascular events, development of heart failure or transition to end-stage kidney disease. These novel high sensitivity assays can measure troponin concentrations in 50%–100% of healthy individuals and therefore allow for the distribution of troponin values within a healthy cohort to be measured, patient’s baseline troponin levels to be monitored, and clinicians to be alerted of deteriorating cardiorenal conditions. We envisage that the high sensitivity assays will become important tools for predicting each patient’s risk of future adverse events and for guiding and monitoring corresponding adjustments of preventative therapeutic interventions.

Cardiac troponin assays in the management of heart failure

Cardiac troponins I and T are established biomarkers of cardiac injury. Testing for either of these two cardiac troponins has long been an essential component of the diagnosis of acute myocardial infarction. In addition, cardiac troponin concentrations after acute myocardial infarction predict future adverse events including development of ischemic heart failure and chronic elevations of cardiac troponin correlate with heart failure severity. These predictions and correlations are particularly obvious when cardiac troponin concentrations are measured using the new high sensitivity cardiac troponin assays. Thus, a growing body of literature suggests that cardiac troponin testing may have important clinical implications for heart failure patients with reduced or preserved ejection fraction. In this review, we explore the prognostic utility of measuring cardiac troponin concentrations in patients with acute or chronic heart failure and in populations at risk of developing heart failure and the relationship between cardiac troponin levels and disease severity. We also summarize the ongoing debates and research on whether serial monitoring of cardiac troponin levels may become a useful tool for guiding therapeutic interventions in patients with heart failure.

Making sense of high sensitivity troponin assays and their role in clinical care

Cardiac troponin assays have an established and undisputed role in the diagnosis and risk stratification of patients with acute myocardial infarction. As troponin assays gets more sensitive and more precise, the number of potential uses has rapidly expanded, but the use of this test has also become more complicated and controversial. Highly sensitive troponin assays can now detect troponin levels in most individuals, but accurate interpretation of these levels requires a clear understanding of the assay in the context of the clinical scenario. This paper provides a practical and up-to-date overview of the uses of highly sensitive troponin assays for diagnosis, prognosis, and risk stratification in clinical practice.

Biomarkers in cardiorenal syndromes

Cardiac and renal diseases often coexist and patients with cardiac and renal failure have high morbidity and mortality. Cardiorenal syndromes (CRSs) are disorders of the heart and kidneys whereby dysfunction in one organ may induce dysfunction in the other organ. Five subtypes of CRSs have been defined by the Acute Dialysis Quality Initiative Consensus Group. There is a need for early detection and monitoring of patients with CRSs. Biomarkers play a key role in the diagnosis and monitoring of acute myocardial infarction, chronic heart failure, and chronic kidney disease. In recent years, new biomarkers have been identified that may play a role in the early diagnosis of acute kidney injury. Herein, we review the use of serum and urine biomarkers in the diagnosis and management of CRSs. The established cardiac and renal biomarkers such as the cardiac troponins, natriuretic peptides, urine albumin, and creatinine, as well as the new renal biomarkers cystatin C and neutrophil gelatinase-associated lipocalin are reviewed in detail. The recent advances in assay methods, clinical studies, and recommendations in clinical guidelines are discussed. With advances in biomarker research, in future, perhaps a multimarker approach will become feasible to stratify the diagnosis of CRS for individualized treatment and prognosis.

The need to address poor numeracy skills in the emergency department environment

Substantial evidence exists for lack of numerical skills among many health professionals. Although poor numeracy has long been recognised as a contributor to medication error, other activities for which numerical literacy are required, such as interpretation of diagnostic results, have been largely ignored. Poor self-awareness of lack of numerical literacy increases the risk, especially in the busy and hurried emergency environment. System changes, such as standardising units and improving number presentation, reduce the potential for misinterpretation; however system changes do not address the underlying deficiencies in mathematical skills. The training of doctors in numeracy has been largely ignored. In contrast, education for nurses frequently occurs during both pre- and post-registration programmes. Interventions have had mixed success, although additional emphasis in increasing conceptual understanding of numbers is encouraging. The consequences of poor numerical literacy should be addressed in all clinical staff, not only by practice change to remove the potential for errors to be made, but also complemented by self-awareness and education.

Calprotectin and cardiovascular events. A narrative review

OBJECTIVES

Calprotectin, also known as S100A8/A9 complex, is currently considered as a valid biomarker for diagnosis, follow-up and therapeutic monitoring of inflammatory bowel diseases. The attractive evidence that this protein may be actively produced and released by leukocytes (especially neutrophils) and by nonmyeloid cardiovascular cell types has paved the way to a series of studies that have assessed its biology in the setting of cardiovascular disease. The aim of this review was thus to investigate the diagnostic and prognostic utility of this biomarker in cardiovascular disease and in particular in myocardial infarction.

DESIGN AND METHODS

We performed a systematic, electronic search on Medline, Scosus and Web of Science, using the keywords "calprotectin" or "S100A8/A9" or "MRP-8/14" and "myocardial infarction" or "acute coronary syndrome" or "cardiovascular disease", from inception to June 2013. The bibliographic references of articles published in English, French and Italian were reviewed for additional relevant studies.

RESULTS

The data of the current scientific literature seems to confirm that calprotectin is actively secreted in the setting of cardiac ischemia and its concentration is significantly associated with the prognosis. Nevertheless, the evidence provided by recent articles that have assessed its performance for diagnosing acute myocardial infarction, either alone or in combination with troponin, supports the hypothesis that this biomarker may be of limited value for enabling a better or faster diagnosis of cardiac ischemia. Even its putative role as an independent prognostic biomarker of cardiovascular morbidity and death is still largely uncertain.

CONCLUSIONS

It can hence be concluded that calprotectin does not currently meet the requirements for efficient diagnosis and prognostication of patients with cardiovascular disease.

Methodologies for measurement of cardiac markers

Antibody-based tests are the primary technology used for clinical measurement of cardiac biomarkers in peripheral circulation. This article focuses on the principles of immunometric methods that have been applied to cardiac biomarkers of widespread clinical utility (CKMB, Troponins, and B-type natriuretic proteins) and of more recent clinical testing (ST2, Galectin-2, and myosin binding protein C). How these principles are applied in the design of immunometric assays and how they influence assay performance in quantifying cardiac biomarkers in biologic fluids (serum or plasma) is discussed.

Decimal numbers and safe interpretation of clinical pathology results

OBJECTIVE

To determine the understanding of decimal numbers by medical laboratory scientists, doctors and nurses.

METHODS

A Decimal Comparison Test determined the comprehension of decimals numbers. Additional questions sought the participants' understanding of concentrations and reference ranges, and their preferences for the presentation of clinical pathology results.

RESULTS

Of the 108 participants, 40% exhibited poor comprehension of decimal numbers. One-third of the medical laboratory scientists, a quarter of doctors, and half the nurses were characterised as lacking numeracy skills. The majority of participants (60%) thought it would be safer for results to be presented as whole numbers rather than as decimals with leading zeros.

CONCLUSIONS

The number of laboratory and clinical staff who show numeracy issues that could lead to misinterpretation of clinical pathology results and contribute to medical error strongly supports recommendations that pathology results should be presented as whole numbers.

The role of cardiac biomarkers in the diagnosis and management of patients presenting with suspected acute coronary syndrome

Myocardial infarction (MI) is the leading cause of death in the developed world. Biomarkers have an essential role in diagnosis, risk stratification, guiding management and clinical decision making in the setting of patients presenting with signs and symptoms of MI. Cardiac troponin (cTn) rose to prominence during the 1990s and has evolved to be the cornerstone for diagnosis of MI. The current criteria for MI diagnosis include a rise and/or fall in cTn with at least one value above the 99th percentile of the upper reference limit. Along with cTn, the natriuretic peptides B-type natriuretic peptide (BNP) and amino-terminal proBNP (NT-proBNP) have an important role in determining prognosis and guiding management. As assays for cTn have been evolved that are capable of reliably detecting smaller and smaller quantities in the blood, a dilemma has emerged as to how to use this new information. Several studies have attempted to answer this question and have shown that these lower concentrations of cTn have important prognostic significance and, more importantly, that intervention in these patients leads to improved clinical outcomes. New algorithms incorporating BNP, NT-proBNP, and more sensitive cTn assays hold promise for more rapid diagnosis or rule-out of MI, allowing for appropriate management steps to be initiated and more efficient and effective utilization of healthcare resources.