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Steiro OT, Langørgen J, Tjora HL, Bjørneklett RO, Skadberg Ø, Bonarjee VVS, Mjelva ØR, Steinsvik T, Lindahl B, Omland T, Aakre KM, Vikenes K. Prognostic significance of chronic myocardial injury diagnosed by three different cardiac troponin assays in patients admitted with suspected acute coronary syndrome. Clin Chem Lab Med 2024; 62:729-739. [PMID: 37937808 DOI: 10.1515/cclm-2023-0336] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2023] [Accepted: 10/17/2023] [Indexed: 11/09/2023]
Abstract
OBJECTIVES Chronic myocardial injury (CMI) is defined as stable concentrations of cardiac troponin T or I (cTnT or cTnI) above the assay-specific 99th percentile upper reference limit (URL) and signals poor outcome. The clinical implications of diagnosing CMI are unclear. We aimed to assess prevalence and association of CMI with long-term prognosis using three different high-sensitivity cTn (hs-cTn) assays. METHODS A total of 1,292 hospitalized patients without acute myocardial injury had cTn concentrations quantified by hs-cTn assays by Roche Diagnostics, Abbott Diagnostics and Siemens Healthineers. The median follow-up time was 4.1 years. The prevalence of CMI and hazard ratios for mortality and cardiovascular (CV) events were calculated based on the URL provided by the manufacturers and compared to the prognostic accuracy when lower percentiles of cTn (97.5, 95 or 90), limit of detection or the estimated bioequivalent concentrations between assays were used as cutoff values. RESULTS There was no major difference in prognostic accuracy between cTnT and cTnI analyzed as continuous variables. The correlation between cTnT and cTnI was high (r=0.724-0.785), but the cTnT assay diagnosed 3.9-4.5 times more patients with having CMI based on the sex-specific URLs (TnT, n=207; TnI Abbott, n=46, TnI Siemens, n=53) and had higher clinical sensitivity and AUC at the URL. CONCLUSIONS The prevalence of CMI is highly assay-dependent. cTnT and cTnI have similar prognostic accuracy for mortality or CV events when measured as continuous variables. However, a CMI diagnosis according to cTnT has higher prognostic accuracy compared to a CMI diagnosis according to cTnI.
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Affiliation(s)
- Ole-Thomas Steiro
- Department of Heart Disease, Haukeland University Hospital, Bergen, Norway
| | - Jørund Langørgen
- Department of Heart Disease, Haukeland University Hospital, Bergen, Norway
| | - Hilde L Tjora
- Emergency Care Clinic, Haukeland University Hospital, Bergen, Norway
| | - Rune O Bjørneklett
- Emergency Care Clinic, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Øyvind Skadberg
- Laboratory of Medical Biochemistry, Stavanger University Hospital, Stavanger, Norway
| | | | - Øistein R Mjelva
- Department of Internal Medicine, Stavanger University Hospital, Stavanger, Norway
| | - Trude Steinsvik
- Department of Laboratory Medicine, Vestre Viken Hospital Trust, Bærum, Norway
| | - Bertil Lindahl
- Department of Medical Sciences, Uppsala University Hospital, Uppsala, Sweden
- Uppsala Clinical Research Center, Uppsala, Sweden
| | - Torbjørn Omland
- Center for Heart Failure Research, Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Department of Cardiology, Akershus University Hospital, Oslo, Norway
| | - Kristin M Aakre
- Department of Heart Disease, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Science, University of Bergen, Bergen, Norway
- Department of Medical Biochemistry and Pharmacology, Haukeland University Hospital, Bergen, Norway
| | - Kjell Vikenes
- Department of Heart Disease, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Science, University of Bergen, Bergen, Norway
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2
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Myrmel GMS, Steiro OT, Tjora HL, Langørgen J, Bjørneklett RO, Skadberg Ø, Bonarjee VVS, Mjelva ØR, Pedersen ER, Vikenes K, Omland T, Aakre KM. Prognostic value of growth differentiation factor-15 3 months after an acute chest pain admission. Heart 2024; 110:508-516. [PMID: 38000899 DOI: 10.1136/heartjnl-2023-323260] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Accepted: 11/01/2023] [Indexed: 11/26/2023] Open
Abstract
OBJECTIVE Growth differentiation factor-15 (GDF-15) is a predictor of death and cardiovascular events when measured during index hospitalisation in patients with acute chest pain. This study investigated the prognostic utility of measuring GDF-15 3 months after an admission with suspected non-ST-elevation acute coronary syndrome (NSTE-ACS). METHODS GDF-15 was measured at baseline and 3 months after admission in 758 patients admitted with suspected NSTE-ACS. Patients were followed for a median of 1540 (IQR: 1087-1776) days after the 3-month visit. The primary endpoint was all-cause mortality, while the secondary composite endpoint included all-cause mortality, incident myocardial infarction and heart failure hospitalisation during follow-up. RESULTS In patients with GDF-15 ≥1200 pg/mL (n=248), 18% died and 25% met the composite endpoint. In patients with GDF-15 <1200 pg/mL (n=510), 1.7% died and 4% met the composite endpoint. The GDF-15 concentration (log2 transformed) at 3 months was significantly associated with all-cause mortality (adjusted HR: 2.2, 95% CI: 1.4 to 3.3, p<0.001) and the composite endpoint (adjusted HR: 1.9, 95% CI: 1.4 to 2.7, p<0.001), independently of traditional risk factors and baseline troponin T. A 10% change in GDF-15 concentration from baseline to the 3-month visit was associated with increased risk of all-cause mortality (HR: 1.06, 95% CI: 1.01 to 1.13, p=0.031), adjusting for baseline GDF-15 concentrations. CONCLUSIONS High GDF-15 concentrations 3 months after admission for suspected NSTE-ACS are associated with long-term mortality and cardiovascular events, independent of traditional risk factors and troponin T. A change in GDF-15 concentration can provide prognostic information.
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Affiliation(s)
| | - Ole-Thomas Steiro
- Department of Heart Disease, Haukeland University Hospital, Bergen, Norway
| | - Hilde Lunde Tjora
- Emergency Care Clinic, Haukeland University Hospital, Bergen, Norway
| | - Jørund Langørgen
- Department of Heart Disease, Haukeland University Hospital, Bergen, Norway
| | - Rune Oskar Bjørneklett
- Emergency Care Clinic, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Øyvind Skadberg
- Laboratory of Medical Biochemistry, Stavanger University Hospital, Stavanger, Norway
| | | | | | - Eva Ringdal Pedersen
- Department of Heart Disease, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Science, University of Bergen, Bergen, Norway
| | - Kjell Vikenes
- Department of Heart Disease, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Science, University of Bergen, Bergen, Norway
| | - Torbjorn Omland
- K.G. Jebsen Centre for Cardiac Biomarkers, Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Department of Cardiology, Akershus University Hospital, Oslo, Norway
| | - Kristin Moberg Aakre
- Department of Heart Disease, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Science, University of Bergen, Bergen, Norway
- Department of Medical Biochemistry and Pharmacology, Haukeland University Hospital, Bergen, Norway
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Saeed N, Norekvål TM, Steiro OT, Tjora HL, Langørgen J, Bjørneklett RO, Skadberg Ø, Bonarjee VVS, Mjelva ØR, Omland T, Vikenes K, Aakre KM. Predictors of long-term symptom burden and quality of life in patients hospitalised with chest pain: a prospective observational study. BMJ Open 2022; 12:e062302. [PMID: 35831040 PMCID: PMC9280876 DOI: 10.1136/bmjopen-2022-062302] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
OBJECTIVE To describe the magnitude and predictors of symptom burden (SB) and quality of life (QoL) 3 months after hospital admission for acute chest pain. DESIGN Prospective observational study. SETTING Single centre, outpatient follow-up. PARTICIPANTS 1506 patients. OUTCOMES Scores reported for general health (RAND-12), angina-related health (Seattle Angina Questionnaire 7 (SAQ-7)) and dyspnoea (Rose Dyspnea Scale) 3 months after hospital admission for chest pain. METHODS A total of 1506 patients received questionnaires assessing general health (RAND-12), angina-related health (SAQ-7) and dyspnoea (Rose Dyspnea Scale) 3 months after discharge. Univariable and multivariable regression models identified predictors of SB and QoL scores. A mediator analysis identified factors mediating the effect of an unstable angina pectoris (UAP) diagnosis. RESULTS 774 (52%) responded. Discharge diagnoses were non-ST elevation myocardial infarction (NSTEMI) (14.2%), UAP (17.1%), non-coronary cardiac disease (6.6%), non-cardiac disease (6.3%) and non-cardiac chest pain (NCCP) (55.6%). NSTEMI had the most favourable, and UAP patients the least favourable SAQ-7 scores (median SAQ7-summary; 88 vs 75, p<0.001). NCCP patients reported persisting chest pain in 50% and dyspnoea in 33% of cases. After adjusting for confounders, revascularisation predicted better QoL scores, while UAP, current smoking and hypertension predicted worse outcome. NSTEMI and UAP patients who were revascularised reported higher scores (p<0.05) in SAQ-7-QL, SAQ7-PL, SAQ7-summary (NSTEMI) and all SAQ-7 domains (UAP). Revascularisation altered the unstandardised beta value (>±10%) of an UAP diagnosis for all SAQ-7 and RAND-12 outcomes. CONCLUSIONS Patients with NSTEMI reported the most favourable outcome 3 months after hospitalisation for chest pain. Patients with other diseases, in particular UAP patients, reported lower scores. Revascularised NSTEMI and UAP patients reported higher QoL scores compared with patients receiving conservative treatment. Revascularisation mediated all outcomes in UAP patients. TRIAL REGISTRATION NUMBER NCT02620202.
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Affiliation(s)
- Nasir Saeed
- Department of Clinical Science, University of Bergen, Bergen, Norway
| | - Tone Merete Norekvål
- Department of Clinical Science, University of Bergen, Bergen, Norway
- Department of Heart Disease, Haukeland University Hospital, Bergen, Norway
| | - Ole-Thomas Steiro
- Department of Heart Disease, Haukeland University Hospital, Bergen, Norway
| | - Hilde Lunde Tjora
- Emergency Care Clinic, Haukeland University Hospital, Bergen, Norway
| | - Jørund Langørgen
- Department of Heart Disease, Haukeland University Hospital, Bergen, Norway
| | - Rune Oskar Bjørneklett
- Emergency Care Clinic, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Øyvind Skadberg
- Laboratory of Medical Biochemistry, Stavanger University Hospital, Stavanger, Norway
| | | | | | - Torbjørn Omland
- Institute for Clinical Medicine, University of Oslo, Oslo, Norway
- Department of Cardiology, Akershus University Hospital, Oslo, Norway
| | - Kjell Vikenes
- Department of Heart Disease, Haukeland University Hospital, Bergen, Norway
| | - Kristin Moberg Aakre
- Department of Clinical Science, University of Bergen, Bergen, Norway
- Department of Heart Disease, Haukeland University Hospital, Bergen, Norway
- Department of Medical Biochemistry and Pharmacology, Haukeland University Hospital, Bergen, Norway
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4
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Steiro OT, Aakre KM, Tjora HL, Bjørneklett RO, Skadberg Ø, Bonarjee VVS, Mjelva ØR, Omland T, Vikenes K, Langørgen J. Association between symptoms and risk of non-ST segment elevation myocardial infarction according to age and sex in patients admitted to the emergency department with suspected acute coronary syndrome: a single-centre retrospective cohort study. BMJ Open 2022; 12:e054185. [PMID: 35551077 PMCID: PMC9109031 DOI: 10.1136/bmjopen-2021-054185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVES Evaluate the association between symptoms and risk of non-ST segment elevation myocardial infarction (NSTEMI) in patients admitted to an emergency department with suspected acute coronary syndrome based on sex and age. DESIGN Post hoc analysis of a prospective observational study conducted between September 2015 and May 2019. SETTING University hospital in Norway. PARTICIPANTS 1506 participants >18 years of age (39.6% women and 31.0% 70 years of age or older). FINDINGS The OR for NSTEMI was 9.4 if pain radiated to both arms, 3.0 if exertional chest pain was present during the last week and 2.9 if pain occurred during activity. Men had significantly lower OR compared with women if pain was dependent of position, respiration or palpation (OR 0.17 vs 0.53, p value for interaction 0.047). Patients <70 years had higher predictive value than older patients if they reported exertional chest pain the last week (OR 4.08 vs 1.81, 95%, p value for interaction 0.025) and lower if pain radiated to the left arm (OR 0.73 vs 1.67, p value for interaction 0.045). CONCLUSIONS Chest pain with radiation to both arms, exertional chest pain during the last week and pain during activity had the strongest predictive value for NSTEMI. The differences in symptom presentation and risk of NSTEMI between sex and age groups were small. TRIAL REGISTRATION NUMBER WESTCOR study ClinicalTrials.gov (NCT02620202).
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Affiliation(s)
- Ole-Thomas Steiro
- Department of Heart Disease, Haukeland University Hospital, Bergen, Norway
| | - Kristin Moberg Aakre
- Department of Heart Disease, Haukeland University Hospital, Bergen, Norway
- Department of Medical Biochemistry and Pharmacology, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Science, Haukeland University Hospital, Bergen, Norway
| | - Hilde Lunde Tjora
- Emergency Care Clinic, Haukeland University Hospital, Bergen, Norway
| | - Rune Oskar Bjørneklett
- Emergency Care Clinic, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Medicine, Haukeland University Hospital, Bergen, Norway
| | - Øyvind Skadberg
- Laboratory of Medical Biochemistry, Stavanger University Hospital, Stavanger, Norway
| | | | - Øistein Rønneberg Mjelva
- Department of Clinical Science, Haukeland University Hospital, Bergen, Norway
- Department of Medicine, Stavanger University Hospital, Stavanger, Norway
| | - Torbjorn Omland
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Department of Cardiology, Akershus University Hospital, Lørenskog, Norway
| | - Kjell Vikenes
- Department of Heart Disease, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Science, Haukeland University Hospital, Bergen, Norway
| | - Jørund Langørgen
- Department of Heart Disease, Haukeland University Hospital, Bergen, Norway
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5
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Restan IZ, Sanchez AY, Steiro OT, Lopez-Ayala P, Tjora HL, Langørgen J, Omland T, Boeddinghaus J, Nestelberger T, Koechlin L, Collinson P, Bjørneklett R, Vikenes K, Strand H, Skadberg Ø, Mjelva ØR, Larsen AI, Bonarjee VVS, Mueller C, Aakre KM. Adding stress biomarkers to high-sensitivity cardiac troponin for rapid non-ST-elevation myocardial infarction rule-out protocols. EUROPEAN HEART JOURNAL. ACUTE CARDIOVASCULAR CARE 2022; 11:201-212. [PMID: 35024819 PMCID: PMC8929978 DOI: 10.1093/ehjacc/zuab124] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Revised: 07/30/2021] [Accepted: 12/14/2021] [Indexed: 11/13/2022]
Abstract
AIMS This study tested the hypothesis that combining stress-induced biomarkers (copeptin or glucose) with high-sensitivity cardiac troponin (hs-cTn) increases diagnostic accuracy for non-ST-elevation myocardial infarction (NSTEMI) in patients presenting to the emergency department. METHODS AND RESULTS The ability to rule-out NSTEMI for combinations of baseline hs-cTnT or hs-cTnI with copeptin or glucose was compared with the European Society of Cardiology (ESC) hs-cTnT/I-only rule-out algorithms in two independent (one Norwegian and one international multicentre) diagnostic studies. Among 959 patients (median age 64 years, 60.5% male) with suspected NSTEMI in the Norwegian cohort, 13% had NSTEMI. Adding copeptin or glucose to hs-cTnT/I as a continuous variable did not improve discrimination as quantified by the area under the curve {e.g. hs-cTnT/copeptin 0.91 [95% confidence interval (CI) 0.89-0.93] vs. hs-cTnT alone 0.91 (95% CI 0.89-0.93); hs-cTnI/copeptin 0.85 (95% CI 0.82-0.87) vs. hs-cTnI alone 0.93 (95% CI 0.91-0.95)}, nor did adding copeptin <9 mmol/L or glucose <5.6 mmol/L increase the sensitivity of the rule-out provided by hs-cTnT <5 ng/L or hs-cTnI <4 ng/L in patients presenting more than 3 h after chest pain onset (target population in the ESC-0 h-algorithm). The combination decreased rule-out efficacy significantly (both P < 0.01). These findings were confirmed among 1272 patients (median age 62 years, 69.3% male) with suspected NSTEMI in the international validation cohort, of which 20.7% had NSTEMI. A trend towards increased sensitivity for the hs-cTnT/I/copeptin combinations (97-100% vs. 91-97% for the ESC-0 h-rule-out cut-offs) was observed in the Norwegian cohort. CONCLUSION Adding copeptin or glucose to hs-cTnT/I did not increase diagnostic performance when compared with current ESC guideline hs-cTnT/I-only 0 h-algorithms.
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Affiliation(s)
- Ingar Ziad Restan
- Department of Cardiology, Stavanger University Hospital, Pb. 8100, 4068 Stavanger, Norway
| | - Ana Yufera Sanchez
- Department of Cardiology, Cardiovascular Research Institute Basel, University Hospital Basel, University of Basel, Basel, Switzerland.,Global research on acute conditions team, Rome, Italy
| | - Ole-Thomas Steiro
- Department of Heart Disease, Haukeland University Hospital, Bergen, Norway
| | - Pedro Lopez-Ayala
- Department of Cardiology, Cardiovascular Research Institute Basel, University Hospital Basel, University of Basel, Basel, Switzerland.,Global research on acute conditions team, Rome, Italy
| | - Hilde L Tjora
- Emergency Care Clinic, Haukeland University Hospital, Bergen, Norway
| | - Jørund Langørgen
- Department of Heart Disease, Haukeland University Hospital, Bergen, Norway
| | - Torbjørn Omland
- Department of Cardiology, Akershus University Hospital, Oslo, Norway.,Center for Heart Failure Research, Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Jasper Boeddinghaus
- Department of Cardiology, Cardiovascular Research Institute Basel, University Hospital Basel, University of Basel, Basel, Switzerland.,Global research on acute conditions team, Rome, Italy
| | - Thomas Nestelberger
- Department of Cardiology, Cardiovascular Research Institute Basel, University Hospital Basel, University of Basel, Basel, Switzerland.,Global research on acute conditions team, Rome, Italy.,Division of Cardiology, Department of Medicine, Vancouver General Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Luca Koechlin
- Department of Cardiology, Cardiovascular Research Institute Basel, University Hospital Basel, University of Basel, Basel, Switzerland.,Global research on acute conditions team, Rome, Italy.,Department of Cardiac Surgery, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Paul Collinson
- Cardiovascular Clinical Academic Group, Molecular and Clinical Sciences Research Institute, St. George's, University of London, London, UK.,Clinical Blood Science, St George's University Hospitals NHS Foundation Trust, London, UK
| | - Rune Bjørneklett
- Emergency Care Clinic, Haukeland University Hospital, Bergen, Norway.,Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Kjell Vikenes
- Department of Heart Disease, Haukeland University Hospital, Bergen, Norway.,Department of Clinical Science, University of Bergen, Bergen, Norway
| | - Heidi Strand
- Multidisciplinary Laboratory Medicine and Medical Biochemistry, Akershus University Hospital, Lørenskog, Norway
| | - Øyvind Skadberg
- Laboratory of Clinical Biochemistry, Stavanger University Hospital, Stavanger, Norway
| | - Øistein R Mjelva
- Department of Cardiology, Stavanger University Hospital, Pb. 8100, 4068 Stavanger, Norway
| | - Alf Inge Larsen
- Department of Cardiology, Stavanger University Hospital, Pb. 8100, 4068 Stavanger, Norway.,Department of Clinical Science, University of Bergen, Bergen, Norway
| | - Vernon V S Bonarjee
- Department of Cardiology, Stavanger University Hospital, Pb. 8100, 4068 Stavanger, Norway
| | - Christian Mueller
- Department of Cardiology, Cardiovascular Research Institute Basel, University Hospital Basel, University of Basel, Basel, Switzerland.,Global research on acute conditions team, Rome, Italy
| | - Kristin M Aakre
- Department of Heart Disease, Haukeland University Hospital, Bergen, Norway.,Department of Clinical Science, University of Bergen, Bergen, Norway.,Department of Medical Biochemistry and Pharmacology, Haukeland University Hospital, Bergen, Norway
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6
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Tjora HL, Steiro OT, Langørgen J, Bjørneklett RO, Skadberg Ø, Bonarjee VVS, Mjelva ØR, Collinson P, Omland T, Vikenes K, Aakre KM. Diagnostic Performance of Novel Troponin Algorithms for the Rule-Out of Non-ST-Elevation Acute Coronary Syndrome. Clin Chem 2021; 68:291-302. [PMID: 34897415 DOI: 10.1093/clinchem/hvab225] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Accepted: 09/17/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND The European Society of Cardiology (ESC) rule-out algorithms use cutoffs optimized for exclusion of non-ST elevation myocardial infarction (NSTEMI). We investigated these and several novel algorithms for the rule-out of non-ST elevation acute coronary syndrome (NSTE-ACS) including less urgent coronary ischemia. METHOD A total of 1504 unselected patients with suspected NSTE-ACS were included and divided into a derivation cohort (n = 988) and validation cohort (n = 516). The primary endpoint was the diagnostic performance to rule-out NSTEMI and unstable angina pectoris during index hospitalization. The secondary endpoint was combined MI, all-cause mortality (within 30 days) and urgent (24 h) revascularization. The ESC algorithms for high-sensitivity cardiac troponin T (hs-cTnT) and I (hs-cTnI) were compared to different novel low-baseline (limit of detection), low-delta (based on the assay analytical and biological variation), and 0-1-h and 0-3-h algorithms. RESULTS The prevalence of NSTE-ACS was 24.8%, 60.0% had noncardiac chest pain, and 15.2% other diseases. The 0-1/0-3-h algorithms had superior clinical sensitivity for the primary endpoint compared to the ESC algorithm (validation cohort); hs-cTnT: 95% vs 63%, and hs-cTnI: 87% vs 64%, respectively. Regarding the secondary endpoint, the algorithms had similar clinical sensitivity (100% vs 94%-96%) but lower clinical specificity (41%-19%) compared to the ESC algorithms (77%-74%). The rule-out rates decreased by a factor of 2-4. CONCLUSION Low concentration/low-delta troponin algorithms improve the clinical sensitivity for a combined endpoint of NSTEMI and unstable angina pectoris, with the cost of a substantial reduction in total rule-out rate. There was no clear benefit compared to ESC for diagnosing high-risk events.
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Affiliation(s)
- Hilde L Tjora
- Emergency Care Clinic, Haukeland University Hospital, Bergen, Norway
| | - Ole-Thomas Steiro
- Department of Heart Disease, Haukeland University Hospital, Bergen, Norway
| | - Jørund Langørgen
- Department of Heart Disease, Haukeland University Hospital, Bergen, Norway
| | - Rune O Bjørneklett
- Emergency Care Clinic, Haukeland University Hospital, Bergen, Norway.,Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Øyvind Skadberg
- Laboratory of Medical Biochemistry, Stavanger University Hospital, Stavanger, Norway
| | | | - Øistein R Mjelva
- Cardiology Department, Stavanger University Hospital, Stavanger, Norway
| | - Paul Collinson
- Cardiovascular Clinical Academic Group St Georges University Hospitals NHS Foundation Trust and St George's University of London, London, UK
| | - Torbjørn Omland
- Department of Cardiology, Akershus University Hospital, Oslo, Norway.,Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Kjell Vikenes
- Department of Heart Disease, Haukeland University Hospital, Bergen, Norway.,Department of Clinical Science, University of Bergen, Bergen, Norway
| | - Kristin M Aakre
- Department of Heart Disease, Haukeland University Hospital, Bergen, Norway.,Department of Clinical Science, University of Bergen, Bergen, Norway.,Department of Medical Biochemistry and Pharmacology, Haukeland University Hospital, Bergen, Norway
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7
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Tjora HL, Steiro OT, Langørgen J, Bjørneklett R, Nygård OK, Skadberg Ø, Bonarjee VVS, Collinson P, Omland T, Vikenes K, Aakre KM. Cardiac Troponin Assays With Improved Analytical Quality: A Trade-Off Between Enhanced Diagnostic Performance and Reduced Long-Term Prognostic Value. J Am Heart Assoc 2020; 9:e017465. [PMID: 33238783 PMCID: PMC7763786 DOI: 10.1161/jaha.120.017465] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Background Cardiac troponin (cTn) permits early rule‐out/rule‐in of patients admitted with possible non–ST‐segment–elevation myocardial infarction. In this study, we developed an admission and a 0/1 hour rule‐out/rule‐in algorithm for a troponin assay with measurable results in >99% of healthy individuals. We then compared its diagnostic and long‐term prognostic properties with other protocols. Methods and Results Blood samples were collected at 0, 1, 3, and 8 to 12 hours from patients admitted with possible non–ST‐segment–elevation myocardial infarction. cTnT (Roche Diagnostics), cTnI(Abbott) (Abbott Diagnostics), and cTnI(sgx) (Singulex Clarity System) were measured in 971 admission and 465 1‐hour samples. An admission and a 0/1 hour rule‐out/rule‐in algorithm were developed for the cTnI(sgx) assay and its diagnostic properties were compared with cTnTESC (European Society of Cardiology), cTnI(Abbott)ESC, and 2 earlier cTnI(sgx) algorithms. The prognostic composite end point was all‐cause mortality and future nonfatal myocardial infarction during a median follow‐up of 723 days. non–ST‐segment–elevation myocardial infarction prevalence was 13%. The novel cTnI(sgx) algorithms showed similar performance regardless of time from symptom onset, and area under the curve was significantly better than comparators. The cTnI(sgx)0/1 hour algorithm classified 92% of patients to rule‐in or rule‐out compared with ≤78% of comparators. Patients allocated to rule‐out by the prior published 0/1 hour algorithms had significantly fewer long‐term events compared with the rule‐in and observation groups. The novel cTnI(sgx)0/1 hour algorithm used a higher troponin baseline concentration for rule‐out and did not allow for prognostication. Conclusions Increasingly sensitive troponin assays may improve identification of non–ST‐segment–elevation myocardial infarction but could rule‐out patients with subclinical chronic myocardial injury. Separate protocols for diagnosis and risk prediction seem appropriate.
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Affiliation(s)
- Hilde L Tjora
- Emergency Care Clinic Haukeland University Hospital Bergen Norway
| | - Ole-Thomas Steiro
- Department of Heart Disease Haukeland University Hospital Bergen Norway
| | - Jørund Langørgen
- Department of Heart Disease Haukeland University Hospital Bergen Norway
| | - Rune Bjørneklett
- Emergency Care Clinic Haukeland University Hospital Bergen Norway.,Department of Clinical Medicine University of Bergen Norway
| | - Ottar K Nygård
- Department of Heart Disease Haukeland University Hospital Bergen Norway.,Department of Clinical Science University of Bergen Norway
| | - Øyvind Skadberg
- Laboratory of Medical Biochemistry Stavanger University Hospital Stavanger Norway
| | | | - Paul Collinson
- Departments of Clinical Blood Sciences and Cardiology St Georges University Hospitals NHS Foundation Trust and St George's University of London London United Kingdom
| | - Torbjørn Omland
- Division of Medicine Akershus University Hospital Oslo Norway.,Center for Heart Failure Research Institute of Clinical Medicine University of Oslo Norway
| | - Kjell Vikenes
- Department of Heart Disease Haukeland University Hospital Bergen Norway.,Department of Clinical Science University of Bergen Norway
| | - Kristin M Aakre
- Department of Heart Disease Haukeland University Hospital Bergen Norway.,Department of Clinical Science University of Bergen Norway.,Department of Medical Biochemistry and Pharmacology Haukeland University Hospital Bergen Norway
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Steiro OT, Tjora HL, Langørgen J, Bjørneklett R, Nygård OK, Skadberg Ø, Bonarjee VVS, Lindahl B, Omland T, Vikenes K, Aakre KM. Clinical risk scores identify more patients at risk for cardiovascular events within 30 days as compared to standard ACS risk criteria: the WESTCOR study. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2020; 10:287-301. [PMID: 33620429 DOI: 10.1093/ehjacc/zuaa016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/25/2020] [Revised: 07/26/2020] [Accepted: 08/26/2020] [Indexed: 02/07/2023]
Abstract
AIMS Troponin-based algorithms are made to identify myocardial infarctions (MIs) but adding either standard acute coronary syndrome (ACS) risk criteria or a clinical risk score may identify more patients eligible for early discharge and patients in need of urgent revascularization. METHODS AND RESULTS Post-hoc analysis of the WESTCOR study including 932 patients (mean 63 years, 61% male) with suspected NSTE-ACS. Serum samples were collected at 0, 3, and 8-12 h and high-sensitivity cTnT (Roche Diagnostics) and cTnI (Abbott Diagnostics) were analysed. The primary endpoint was MI, all-cause mortality, and unplanned revascularizations within 30 days. Secondary endpoint was non-ST-elevation myocardial infarction (NSTEMI) during index hospitalization. Two combinations were compared: troponin-based algorithms (ESC 0/3 h and the High-STEACS algorithm) and either ACS risk criteria recommended in the ESC guidelines, or one of eleven clinical risk scores, HEART, mHEART, CARE, GRACE, T-MACS, sT-MACS, TIMI, EDACS, sEDACS, Goldman, and Geleijnse-Sanchis. The prevalence of primary events was 21%. Patients ruled out for NSTEMI and regarded low risk of ACS according to ESC guidelines had 3.8-4.9% risk of an event, primarily unplanned revascularizations. Using HEART score instead of ACS risk criteria reduced the number of events to 2.2-2.7%, with maintained efficacy. The secondary endpoint was met by 13%. The troponin-based algorithms without evaluation of ACS risk missed three-index NSTEMIs with a negative predictive value (NPV) of 99.5% and 99.6%. CONCLUSION Combining ESC 0/3 h or the High-STEACS algorithm with standardized clinical risk scores instead of ACS risk criteria halved the prevalence of rule-out patients in need of revascularization, with maintained efficacy.
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Affiliation(s)
- Ole-Thomas Steiro
- Department of Heart Disease, Haukeland University Hospital, Bergen, Norway
| | - Hilde L Tjora
- Emergency Care Clinic, Haukeland University Hospital, Bergen, Norway
| | - Jørund Langørgen
- Department of Heart Disease, Haukeland University Hospital, Bergen, Norway
| | - Rune Bjørneklett
- Emergency Care Clinic, Haukeland University Hospital, Bergen, Norway.,Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Ottar K Nygård
- Department of Heart Disease, Haukeland University Hospital, Bergen, Norway.,Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Øyvind Skadberg
- Laboratory of Medical Biochemistry, Stavanger University Hospital, Stavanger, Norway
| | | | - Bertil Lindahl
- Department of Medical Sciences, Uppsala University Hospital, Uppsala, Sweden.,Uppsala Clinical Research Center, Uppsala, Sweden
| | - Torbjørn Omland
- Division of Medicine, Akershus University Hospital, Oslo, Norway.,Faculty of Medicine, Center for Heart Failure Research, Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Kjell Vikenes
- Department of Heart Disease, Haukeland University Hospital, Bergen, Norway.,Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Kristin M Aakre
- Department of Clinical Medicine, University of Bergen, Bergen, Norway.,Department of Medical Biochemistry and Pharmacology, Haukeland University Hospital, Jonas Lies vei 65, 5021 Bergen, Norway
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