The clinical significance of cardiac troponins in medical practice

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Pleural fluid biomarkers: a narrative review

Background and Objective

Pleural fluid is a source from which various biomarkers can be obtained and measured to facilitate the management and prognostication of various conditions. This narrative review aims to summarise a few selected applications of pleural fluid biomarker analysis based on the latest literature.

Methods

A literature search for articles published in English regarding human subjects from the period January 2000 to December 2023 was performed through PubMed. Publications considered by the authors to be relevant were included in this review, with additional references added based on the authors' judgement. This review considered both prospective and retrospective cohort studies analysing the clinical value of a range of pleural fluid biomarkers.

Key Content and Findings

The biomarkers selected in this narrative review have either established clinical applicability or promising initial results which require further research. Pleural fluid adenosine deaminase, mesothelin and N-terminal pro-B-type natriuretic peptide can optimize the diagnosis of tuberculous pleuritis, malignant mesothelioma and heart failure-related pleural effusion respectively. The detection rate for epidermal growth factor receptor mutations for lung cancer is higher in the pleural fluid than in the pleural tissue or plasma. Suitable targeted therapy in patients with detectable mutations can offer survival benefits. The pleural fluid neutrophil-lymphocyte ratio, soluble urokinase plasminogen activator receptor and plasminogen activator inhibitor 1 carry prognostic implications and can potentially guide subsequent treatment decisions. These biomarkers used individually, or in conjunction with other clinical parameters, should only be utilised in pre-defined, appropriate clinical conditions to maximize their clinical value.

Conclusions

A great variety of different biomarkers are available for analysis in pleural fluid. Further research and development are necessary to widen the spectrum and enhance the clinical utility of pleural fluid biomarkers. Comparison with the diagnostic utilities of serum biomarkers and other investigation parameters, such as radiological findings, could be considered when evaluating the performance of pleural fluid biomarkers.

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.

Heat-related biomarkers: Focus on the correlation of troponin I and 70 kDa heat shock protein

Heat-related biomarkers: Focus on the correlation of troponin I and 70 kDa heat shock protein Abstract Introduction: There is intensive research related to the forensic importance of biomarkers that would be the standard for postmortem damage to cardiomyocytes and the mechanism of the resulting damage. The aim of the research was to examinate the forensic-medical significance of serum levels of biomarkers as detectors of terminal hyperthermic damage to the myocardium.

MATERIAL AND METHOD

40 laboratory animals were divided into groups: the first group was the control (n = 8) exposed to a physiological temperature of 37 °C, the second group was divided into two subgroups: antemortem (n = 8) and postmortem (n = 8), which included a exposure temperature of 41 °C and the third group was divided into two subgroups: antemortem (n = 8) and postmortem (n = 8), which included a exposure temperature of 44 °C. The concentration of cardiac TnI and Hsp70 was resoluted in serum by immunochemical enzyme-labeled immunoabsorption method.

RESULTS

A positive correlation was found between the temperature measured at the time of death and the serum values of cTnI (p = 0.02), in G41, and Hsp70 values did not significantly correlate with the core temperature in this group, p > 0.005. A positive correlation was significant between the concentration of Hsp 70 and the body temperature of rats in the group of rats with a fatal outcome was determined, p = 0.03.

CONCLUSION

Changes in the concentration of cTnI and Hsp70 in rat serum may indicate hyperthermic damage to the myocardium in the Wistar rat model of heat stroke.

Assessing the risk factors for myocardial infarction in diet-induced prediabetes: myocardial tissue changes

Background

Hyperglycaemia is known to result in oxidative stress tissue injury and dysfunction. Interestingly, studies have reported hepatic and renal oxidative stress injury during prediabetes; however, any injury to the myocardium during prediabetes has not been investigated. Hence this study aims to assess changes in the myocardial tissue in an HFHC diet-induced model of prediabetes.

Methods

Male Sprague Dawley rats were randomly grouped into non-prediabetes and prediabetes (n = 6 in each group) and consumed a standard rat chow or fed a high-fat-high-carbohydrate diet respectively for a 20-week prediabetes induction period. Post induction, prediabetes was confirmed using the ADA criteria. Aldose reductase, NADH oxidase 1, superoxide dismutase, glutathione peroxide, cardiac troponins were analysed in cardiac tissue homogenate using specific ELISA kits. Lipid peroxidation was estimated by determining the concentration of malondialdehyde in the heart tissue homogenate according to the previously described protocol. Myocardial tissue sections were stained with H&E stain and analysed using Leica microsystem. All data were expressed as means ± SEM. Statistical comparisons were performed with Graph Pad instat Software using the Student's two-sided t-test. Pearson correlation coefficient was calculated to assess the association. Value of p < 0.05 was considered statistically significant.

Results

The prediabetes group showed a markedly high oxidative stress as indicated by significantly increased NADH oxidase 1 and malondialdehyde while superoxide dismutase and glutathione peroxide were decreased compared to non-prediabetes group. There was no statistical difference between cardiac troponin I and T in the non-prediabetes and prediabetes groups. Cardiac troponins had a weak positive association with glycated haemoglobin.

Conclusion

The findings of this study demonstrate that prediabetes is associated with myocardial injury through oxidative stress. Future studies are to investigate cardiac contractile function and include more cardiac biomarkers.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12872-022-02758-8.

Effect of positive airway pressure on cardiac troponins in patients with sleep-disordered breathing: A meta-analysis

Background

Cardiac troponins are highly sensitive and specific biomarkers for cardiac injury. Previous studies evaluating the effect of positive airway pressure (PAP) on cardiac troponins in patients with sleep‐disordered breathing (SDB) have yielded conflicting results. The meta‐analysis was performed to examine the effect of PAP on cardiac troponins in SDB patients.

Methods

PubMed, Web of Science, and EMBASE before September 2021 on original English language studies were searched. The data on cardiac troponins in both baseline and post‐PAP treatment were extracted from all studies. The data on the change of cardiac troponins in both PAP and control group were extracted from randomized controlled trials. Standardized mean difference (SMD) was used to synthesize quantitative results.

Results

A total of 11 studies were included. PAP treatment was not associated with a significant change in cardiac troponin T between the baseline and post‐PAP treatment (SMD = −0.163, 95% confidence interval [CI] = −0.652 to 0.326, z = 0.65, p = .514). The pooled estimate of SMD of cardiac troponin I between the pre‐ and post‐PAP treatment was 0.287, and the 95% CI was −0.586 to 1.160 (z = 0.64, p = .519). The pooled SMD of change of cardiac troponin T between the PAP group and control group was −0.473 (95% CI = −1.198 to 0.252, z = 1.28, p = .201).

Conclusions

This meta‐analysis revealed that PAP treatment was not associated with any change of cardiac troponin in SDB patients.

The Impact of the Duration of Cardiac Troponin I Elevation on the Clinical Prognosis as Well as Incidence of New-Onset Atrial Fibrillation Respectively in Elderly Non-ST-Elevation Acute Myocardial Infarction Patients without PCI

Objective

This study aimed to investigate the impact of the duration of cardiac troponin I (TnI) elevation on the prognosis and incidence of new-onset atrial fibrillation (NOAF) in elderly patients with non-ST-elevation acute myocardial infarction (NSTE-AMI).

Methods

A total of 383 NSTE-AMI patients ≥75 years old were enrolled in this study and divided into two groups: in 194 cases, the duration of TnI elevation was ≥14 days (group 1), and in 189 cases, the duration of TnI elevation was <14 days (group 2). The patients were followed up for 60 months. The effect of TnI on prognosis was studied by cohort. The primary endpoint was a composite endpoint of cardiovascular death, reinfarction, ischemic stroke, and hospitalization for heart failure, and the secondary endpoint was all-cause death. A case–control study design was adopted to analyze the influencing factors of NOAF occurrence in Group 1 and Group 2.

Results

The median duration of follow-up was 26 months. Multivariate Cox’s regression analysis revealed that the duration of TnI elevation ≥14 days and diuretic use were independent variables of the major composite endpoint (p < 0.01 for both), and the left ventricular ejection fraction and the duration of TnI elevation ≥14 days were independent related variables of all-cause death (p < 0.05). The duration of TnI elevation ≥14 days was correlated with the occurrence of NOAF, but, in the multivariate logistic regression model, only uric acid and high-sensitivity C-reactive protein were independently associated with NOAF (p < 0.05).

Conclusion

The duration of TnI elevation ≥14 days was the independent correlation factor of the major composite endpoint and all-cause death; high sensitivity C-reactive protein and uric acid are independent risk factors for NOAF.

Beta blocker use in traumatic brain injury based on the high-sensitive troponin status (BBTBBT): methodology and protocol implementation of a double-blind randomized controlled clinical trial

Background

Beta-adrenergic receptor blockers (BB) play an important role in the protection of organs that are susceptible for secondary injury due to stress-induced adrenergic surge. However, the use of BB in traumatic brain injury (TBI) patients is not yet the standard of care which necessitates clear scientific evidence to be used. The BBTBBT study aims to determine whether early administration of propranolol based on the high-sensitive troponin T(HsTnT) status will improve the outcome of TBI patients. We hypothesized that early propranolol use is effective in reducing 10- and 30-day mortality in TBI patients. Secondary outcomes will include correlation between serum biomarkers (troponin, epinephrine, cytokines, enolase, S100 calcium binding protein B) and the severity of injury and the impact of BB use on the duration of hospital stay and functional status at a 3-month period.

Methods

The BBTBBT study is a prospective, randomized, double-blinded, placebo-controlled three-arm trial of BB use in mild-to-severe TBI patients based on the HsTnT status. All enrolled patients will be tested for HsTnT at the first 4 and 6 h post-injury. Patients with positive HsTnT will receive BB if there is no contraindication (group 1). Patients with negative HsTnT will be randomized to receive either propranolol (group 2) or placebo (group 3). The time widow for receiving the study treatment is the first 24 h post-injury.

Discussion

Early BB use may reduce the catecholamine storm and subsequently the cascade of immune and inflammatory changes associated with TBI. HsTnT could be a useful fast diagnostic and prognostic tool in TBI patients. This study will be of great clinical interest to improve survival and functional outcomes of TBI patients.

Trial registration

ClinicalTrials.gov NCT04508244. Registered on 7 August 2020. Recruitment started on 29 December 2020 and is ongoing.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13063-021-05872-8.

Clinical and Angiographic Prophesy of Hemodynamic Status in Patients with Acute Anterior Wall ST-Segment-Elevation Myocardial Infarction and Totally Occluded Left Anterior Descending Artery

BACKGROUND

Left anterior descending artery (LAD) is the most common occluded vessel in a patient presenting with acute anterior wall ST-segment elevated myocardial infarction (STEMI). Acute occlusion of LAD usually results in hemodynamic compromise. However, some patients maintain hemodynamic stability despite its proximal occlusion. As the factors associated with hemodynamic status in such patients are poorly understood, our study sought to determine the clinical and angiographic parameters associated with hemodynamic stability in these patients.

METHODS

In this prospective observational study, 60 consecutive patients of acute anterior wall STEMI with completely occluded LAD on coronary angiography were included. Various clinical and angiographic parameters associated with hemodynamic status were evaluated.

RESULTS

Of the 60 patients, 30 patients each were included in the hemodynamically stable (group I) and hemodynamically unstable group (group II). The mean age of the patients in group I and group II was 51.07±13.78 years and 55.47±11.69 years, respectively. The hemodynamically unstable group had a significantly higher number of patients with diabetes mellitus, elevated Troponin T level, and lower left ventricular ejection fraction as compared to the stable group (p<0.05). In contrast, 11 (36.7%) patients in the hemodynamically stable group had rich collaterals compared to 4 (13.3%) patients in the hemodynamically unstable group. The difference was statistically significant (p=0.037).

CONCLUSION

The present study showed that the presence of diabetes, severe LV systolic dysfunction, elevated Troponin-T level, and poor collaterals were associated with hemodynamic instability, whereas the presence of better collaterals predicted hemodynamic stability in patients presenting with anterior wall STEMI and total LAD occlusion.

Comparative analysis for the implication of serum cardiac troponin measurements by conventional versus high-sensitivity assays in patients with traumatic brain injury

BACKGROUND

Stress-induced myocardial injury is not well-studied in patients with head injury. We aimed to assess the prognostic implication of positive (+ve) Troponins (Tn) measurements by conventional (cTnT) versus High-Sensitivity (HsTnT) assay in patients with traumatic brain injury (TBI).

METHODS

A retrospective analysis was conducted for patients who were admitted with TBI. Patient demographics, clinical presentation, troponin assay results, TBI lesions, and hospital outcomes were analyzed and compared based on troponin assay (cTnT versus HsTnT).

RESULTS

Across the study period, 654 patients with TBI had troponin levels measured within 24 h postinjury (cTnT=252 and HsTnT=402). The mean age was 31 years and 46% had positive troponins. There were 147 deaths (22.5%); of them 54% had +ve HsTnT, 23% had +ve cTnT, 16% had -ve cTnT and 7% had -ve HsTnT). When the troponins were tested ≤4 h postinjury, the mortality was 10.2% in patients with -ve cTnT and 4% in patients with -ve HsTnT. There was no documented obvious direct trauma to the heart. Overall, patients with positive troponins had lower Glasgow Coma Scale (GCS), higher Injury Severity Scores and higher rates of brain edema (P=0.001), pneumonia and sepsis (P=0.001) than those with negative troponin results. In two different models, multivariate regression analysis showed that +ve cTnT and +ve HsTnT were independent predictors of mortality (OR 4.02, 95% CI: 1.72-9.39) and (OR 4.31; 95% CI: 1.76-10.57); respectively, after adjusting for age, injury severity scores, GCS at ED, head AIS, pneumonia, ARDS, surgical interventions, and chest injury.

CONCLUSIONS

Although the positivity of any troponin assay is associated with high mortality post-TBI, the use of HsTnT relatively outperforms the conventional troponin assay for early risk stratification and detection of stress-induced myocyte injury in patients with TBI.

Interventional cardiac catheterization predictors at Al-Arabi heart Center in Palestine in 2017

Background

Cardiac catheterization is performed for both therapeutic and diagnostic reasons, in which the outcome may vary from only medical treatment to the need of percutaneous coronary intervention and ending with coronary artery bypass graft. The primary goal of this study was to determine predictors of revascularization.

Methods

A retrospective cohort study was conducted on data collected from records of patients who underwent cardiac catheterization at Al-Arabi Heart Center in Palestine in 2017. Multivariate logistic regression analysis was carried out to assess the association of sociodemographic and pre-catheterization clinical predictors with revascularization.

Results

A total of 1550 patients were included in the study. The participants mean age was 58 with a SD of 11.7 years, 73.6% were males. 50.2% of patients who underwent an interventional cardiac catheterization tested negative for troponin on presentation. Multivariate logistic regression showed Troponin (RR = 4.5), Age (RR = 1.0), Female gender (RR = 0.4) previous catheterization (RR = 2.0), and existence of diabetes as significant predictors for revascularization. The correlation between ECG on presentation and the subsequent need for an interventional cardiac catheterization was significant only in case of ST-Elevation (RR = 1.5), and T wave inversion (RR = 1.6). CK-MB, Hypertension and ECG with ST-depression were not significant predictors.

Conclusion

This study assessed revascularization predictors in addition to characteristics and outcomes of patients who have undergone cardiac catheterization. The results showed the especially high predictive value of troponin in determining the need for revascularization which outweighed the importance of ECG findings on presentation in making clinical decision regarding catheterization.

Evolving Use of Biomarkers in the Management of Heart Failure

Objective, noninvasive, clinical assessment of patients with heart failure can be made using biomarker measurements, including natriuretic peptides, cardiac troponins, soluble suppression of tumorigenicity 2, and galectin-3. The aim of this review is to provide clinicians with guidance on the use of heart failure biomarkers in clinical practice. The authors provide a didactic narrative based on current literature, an exemplary case study, and their clinical experience.

Predictive value of positive high-sensitivity troponin T in intubated traumatic brain injury patients

OBJECTIVEThe clinical relevance of high-sensitivity troponin T (HsTnT) in trauma patients is not well explored. In this study, the authors aimed to study the predictive value of serum HsTnT in intubated patients who had sustained traumatic brain injury (TBI).METHODSA retrospective analysis was conducted for all intubated TBI patients between 2010 and 2014 at a national level 1 trauma center. Data were analyzed and compared based on the HsTnT status on admission (group 1, negative results; and group 2, positive results). Receiver operating characteristic curves were used to determine sensitivity, specificity, and cutoff level of HsTnT to predict mortality. Time to earlier discharge from hospital or death was modeled using Cox proportional hazard models to describe the relationship between HsTnT and in-hospital mortality.RESULTSOf the 826 intubated TBI patients, 490 underwent HsTnT testing; 65.7% had positive HsTnT results. Patients in group 2 had a higher Injury Severity Score (p = 0.001) and head Abbreviated Injury Scale (AIS) score (p = 0.004) than those in group 1. In addition, group 2 patients were more likely to have lower Glasgow Coma Scale scores (p = 0.001) and more likely to experience intraventricular hemorrhage, brain edema, pneumonia, and sepsis (p = 0.001). HsTnT values positively correlated with head AIS score (r = 0.19, p = 0.001) and varied by the type of lesion and time to death. Ventilator days and length of hospital stay were more prolonged in group 2 patients (p = 0.001). Area under the curve (AUC) analysis showed that HsTnT ≥ 26.5 ng/L predicted all-cause mortality (AUC 0.75, 95% CI 0.699-0.801) with 80% sensitivity. Positive HsTnT was an independent predictor of mortality in multivariate models (adjusted OR 3.10, 95% CI 1.308-7.351) even after excluding chest injury (adjusted OR 4.18, 95% CI 1.320-13.231).CONCLUSIONSPositive HsTnT results are associated with poor outcomes in intubated patients with TBI. In this subset of patients, measuring serum HsTnT on admission is a useful tool for early risk stratification and expedited care; however, further prospective studies are warranted.

Serum cardiac troponins as prognostic markers in patients with traumatic and non-traumatic brain injuries: A meta-analysis

OBJECTIVE

The association between brain injury and elevated serum cardiac troponin (cTn) remains poorly understood. We conducted a systematic review and meta-analysis to evaluate whether elevated cTn increases the risk of mortality in patients with traumatic (TBI) or non-traumatic brain injury (NT-BI).

METHODS

Cochrane Library, MEDLINE, PubMed, Scopus, Cochrane Central Register of Controlled Trials (CENTRAL), WHO International Clinical Trials Registry Platform, and Google scholar databases, and clinicaltrials.gov were searched for a retrospective, prospective and randomized clinical trials (RCT) or quasi-RCT studies that assessed the effect of elevated cTn (conventional or high sensitive assay) on the outcomes of brain injury patients. The main outcome of interest was mortality. Two authors independently abstracted the data using a data collection form. Results from different studies were pooled for analysis, whenever appropriate. The total number of patients pooled was 2435, of which 916 had elevated cTn and 1519 were in control group.

RESULTS

Out of 691 references identified through the search, 8 analytical studies met inclusion criteria. Among both types of brain injuries, an elevated cTn was associated with a higher mortality with an overall pooled odd ratio (OR) of 3.37 (95% CI 2.13-5.36). The pooled OR for mortality was 3.31 (95% CI 1.99-5.53) among patients with TBI and 3.36 (95% CI 1.32-8.6) among patients with NT-BI.

CONCLUSIONS

Pooled analysis indicates that elevated cTn is significantly associated with a high mortality in patients with TBI and NT-BI. Prospective clinical trials are needed to support these findings and to inform a biomarker risk stratification regardless of the mechanism of injury.

Brain-Heart Interactions in Traumatic Brain Injury

The cardiovascular manifestations associated with nontraumatic head disorders are commonly known. Similar manifestations have been reported in patients with traumatic brain injury (TBI); however, the underlying mechanisms and impact on the patient's clinical outcomes are not well explored. The neurocardiac axis theory and neurogenic stunned myocardium phenomenon could partly explain the brain-heart link and interactions and can thus pave the way to a better understanding and management of TBI. Several observational retrospective studies have shown a promising role for beta-adrenergic blockers in patients with TBI in reducing the overall TBI-related mortality. However, several questions remain to be answered in clinical randomized-controlled trials, including population selection, beta blocker type, dosage, timing, and duration of therapy, while maintaining the optimal mean arterial pressure and cerebral perfusion pressure in patients with TBI.

Interrelationship of rotavirus infection and Creatine Kinase-MB isoenzyme levels in children hospitalized with acute gastroenteritis in Guangzhou, China, 2012-2015

Elevated levels of Creatine Kinase-MB (CK-MB) Isoenzyme are a common phenomenon among rotavirus (RV) diarrhea. However, few studies have addressed this issue using large sample size. In current study, 1,118 children (age <5 years) hospitalized with diarrhea in Guangzhou Women and Children’s Medical Center from 2012 to 2015 were finally included. Changing pattern of CK-MB and its relationship with RV-infection were analyzed and characterized. Multivariate linear regression models showed that RV-positive cases had a 28% rise in CK-MB compared to RV-negative cases (OR = 1.28, 95% CI: 1.15 to 1.41, P < 0.01) after controlling for age, gender, season of admission, and weight. The pattern of change showed that CK-MB level of RV-positive group started to rise immediately at the 1^st day of diarrhea, reached the peak on days 2 to 4, declined during 4–9 days, and then reached a relatively stable level when compared to the RV-negative group. Mediation analyses showed that indirect effect of RV infection on the increase of CK-MB via Vesikari score was significant (β = 8.01, P < 0.01), but direct effect was not (β = 9.96, P = 0.12). Thus, elevated CK-MB value is a common finding in RV-infection and completely mediated by the severity of diarrhea. CK-MB monitoring may help to identify children with more severe viral infection.

The relationship between smoking intensity and subclinical cardiovascular injury: The Multi-Ethnic Study of Atherosclerosis (MESA)

BACKGROUND AND AIMS

Modern tobacco regulatory science requires an understanding of which biomarkers of cardiovascular injury are most sensitive to cigarette smoking exposure.

METHODS

We studied self-reported current smokers from the Multi-Ethnic Study of Atherosclerosis. Smoking intensity was defined by number of cigarettes/day and urinary cotinine levels. Subclinical cardiovascular injury was assessed using markers of inflammation [high-sensitivity C-reactive protein (hsCRP), interleukin 6 & 2 (IL-2 & IL-6), tumor necrosis factor alpha (TNF-α)], thrombosis (fibrinogen, D-dimer, homocysteine), myocardial injury (troponin T; TnT), endothelial damage (albumin: creatinine ratio), and vascular function [aortic & carotid distensibility, flow-mediated dilation (FMD)]. Biomarkers were modeled as absolute and percent change using multivariable-adjusted linear regression models adjusted for cardiovascular risk factors and smoking duration.

RESULTS

Among 843 current smokers, mean age was 58 (9) years, 53% were men, 39% were African American, mean number of cigarettes per day was 13 (10), and median smoking duration was 39 (15) years. Cigarette count was significantly associated with higher hsCRP, IL-6 and fibrinogen (β coefficients: 0.013, 0.011, 0.60 respectively), while ln-transformed cotinine was associated with the same biomarkers (β coefficients: 0.12, 0.04, 5.3 respectively) and inversely associated with aortic distensibility (β coefficient: -0.13). There was a limited association between smoking intensity and homocysteine, D-dimer, and albumin:creatinine ratio in partially adjusted models only, while there was no association with IL-2, TNF-α, carotid distensibility, FMD, or TnT in any model. In percent change analyses, relationships were strongest with hsCRP.

CONCLUSIONS

Smoking intensity was associated with early biomarkers of CVD, particularly, markers of systemic inflammation. Of these, hsCRP may be the most sensitive.

Biomarkers for monitoring chemotherapy-induced cardiotoxicity

Cardiotoxicity, including acute and late-onset cardiotoxicity, is a well-known adverse effect of many types of antitumor agents. Early identification of patients with cardiotoxicity is important to ensure prompt treatment and minimize toxic effects. The etiology of chemotherapy-induced cardiotoxicity is multifactorial. Traditional methods for assessment of chemotherapy-induced cardiotoxicity typically involve serial measurements of cardiac function via multi-modality imaging techniques. Typically, however, significant left ventricular dysfunction has already occurred when cardiotoxicity is detected by imaging techniques. Biomarkers, most importantly cardiac natriuretic peptides and troponins, are promising markers for identifying patients potentially at risk for clinical heart failure symptoms. This review summarizes the recent progress in clinical utilization of biomarkers for early diagnosis of acute cardiotoxicity and for prediction of late-onset cardiotoxicity. We also discuss the conflicting results of different studies and the association of results with study design.

Unstable cardiac injury complicated with septic shock-a challenge

Background

Road traffic accident accounts for 70 % to 80 % of the blunt cardiac injury. The true incidence varies in the literature due to non-uniform criteria for diagnosis.

Case Presentation

Here, we describe the case of a young male presenting after blunt chest injury and hemodynamic instability. Initially, the patient had frequent episodes of arrhythmias and hypotension due to cardiac injury per se. However, he was stabilized by day 2. Subsequently, patient developed cellulitis followed by septic shock and succumbed to cellulitis on day 5 of injury.

Conclusion

Sepsis is difficult to be diagnosed and treated in the presence of cardiac injury. Myocardial depression has been found in sepsis, which contributes as an added comorbidity in an already compromised heart function. Sepsis also interferes with the diagnosis and follow-up of progress of blunt cardiac injury.

Prognosis of Troponin-Positive Patients with Non-Obstructive Coronary Artery Disease

Introduction

Troponin elevation is an independent risk factor for mortality, but the prognosis of patients with troponin elevation and non-obstructive coronary artery disease (CAD) is unknown. Recent data have suggested an increased risk of mortality. This study was performed to further investigate the outcomes of troponin-positive patients with obstructive and non-obstructive CAD.

Methods

A retrospective cohort analysis was performed of all patients with raised troponin presenting to Kettering General Hospital (January 2010 to December 2011, n = 1,351). The patients who had angiograms were stratified anatomically into obstructive CAD and non-obstructive CAD (≤50% stenosis). The obstructive CAD group (O-CAD) was sub-analyzed by management strategy: emergency re-vascularization (<12 h), urgent, delayed, and medically managed. Patients with non-obstructive CAD were grouped by the cause of the raised troponin if this could be identified (NO-CAD-I) or cause remained unidentified (NO-CAD-U). The major adverse cardiac and cerebrovascular event (MACCE) and mortality rates were calculated at 30 days and 1-year follow-up.

Results

There was a preponderance of hypertension and severe renal impairment in the non-obstructive CAD group. The patients with NO-CAD-U were a low-risk group (MACCE at 1-year follow-up = 0). The remaining NO-CAD-I group had a similar risk to the O-CAD group for MACCE and mortality at 30 days and 1-year follow-up. In fact, at 1-year follow-up, the NO-CAD-I patients when compared with the subgroups of O-CAD, had higher MACCE rates and mortality compared with the emergency re-vascularized group [MACCE: relative risk (RR) (95% CI) = 2.27 (1.29–3.40), P = 0.0047; mortality: RR (95% CI) = 2.08 (1.10–3.93), P = 0.024]. This was driven by higher risk non-cardiac death [RR (95% CI) = 4.10 (1.53–10.99), P = 0.005].

Conclusion

Patients with identified cause for raised troponin and non-obstructive CAD are at equivalent risk of MACCE and mortality at 30 days and 1-year follow-up compared to those with obstructive CAD.

Electronic supplementary material

The online version of this article (doi:10.1007/s40119-014-0027-6) contains supplementary material, which is available to authorized users.