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Boeddinghaus J, Doudesis D, Lopez-Ayala P, Lee KK, Koechlin L, Wildi K, Nestelberger T, Borer R, Miró Ò, Martin-Sanchez FJ, Strebel I, Rubini Giménez M, Keller DI, Christ M, Bularga A, Li Z, Ferry AV, Tuck C, Anand A, Gray A, Mills NL, Mueller C. Machine Learning for Myocardial Infarction Compared With Guideline-Recommended Diagnostic Pathways. Circulation 2024; 149:1090-1101. [PMID: 38344871 DOI: 10.1161/circulationaha.123.066917] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Accepted: 01/16/2024] [Indexed: 02/29/2024]
Abstract
BACKGROUND Collaboration for the Diagnosis and Evaluation of Acute Coronary Syndrome (CoDE-ACS) is a validated clinical decision support tool that uses machine learning with or without serial cardiac troponin measurements at a flexible time point to calculate the probability of myocardial infarction (MI). How CoDE-ACS performs at different time points for serial measurement and compares with guideline-recommended diagnostic pathways that rely on fixed thresholds and time points is uncertain. METHODS Patients with possible MI without ST-segment-elevation were enrolled at 12 sites in 5 countries and underwent serial high-sensitivity cardiac troponin I concentration measurement at 0, 1, and 2 hours. Diagnostic performance of the CoDE-ACS model at each time point was determined for index type 1 MI and the effectiveness of previously validated low- and high-probability scores compared with guideline-recommended European Society of Cardiology (ESC) 0/1-hour, ESC 0/2-hour, and High-STEACS (High-Sensitivity Troponin in the Evaluation of Patients With Suspected Acute Coronary Syndrome) pathways. RESULTS In total, 4105 patients (mean age, 61 years [interquartile range, 50-74]; 32% women) were included, among whom 575 (14%) had type 1 MI. At presentation, CoDE-ACS identified 56% of patients as low probability, with a negative predictive value and sensitivity of 99.7% (95% CI, 99.5%-99.9%) and 99.0% (98.6%-99.2%), ruling out more patients than the ESC 0-hour and High-STEACS (25% and 35%) pathways. Incorporating a second cardiac troponin measurement, CoDE-ACS identified 65% or 68% of patients as low probability at 1 or 2 hours, for an identical negative predictive value of 99.7% (99.5%-99.9%); 19% or 18% as high probability, with a positive predictive value of 64.9% (63.5%-66.4%) and 68.8% (67.3%-70.1%); and 16% or 14% as intermediate probability. In comparison, after serial measurements, the ESC 0/1-hour, ESC 0/2-hour, and High-STEACS pathways identified 49%, 53%, and 71% of patients as low risk, with a negative predictive value of 100% (99.9%-100%), 100% (99.9%-100%), and 99.7% (99.5%-99.8%); and 20%, 19%, or 29% as high risk, with a positive predictive value of 61.5% (60.0%-63.0%), 65.8% (64.3%-67.2%), and 48.3% (46.8%-49.8%), resulting in 31%, 28%, or 0%, who require further observation in the emergency department, respectively. CONCLUSIONS CoDE-ACS performs consistently irrespective of the timing of serial cardiac troponin measurement, identifying more patients as low probability with comparable performance to guideline-recommended pathways for MI. Whether care guided by probabilities can improve the early diagnosis of MI requires prospective evaluation. REGISTRATION URL: https://www.clinicaltrials.gov; Unique identifier: NCT00470587.
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Affiliation(s)
- Jasper Boeddinghaus
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology (J.B., P.L.-A., L.K., K.W., T.N., R.B., I.S., M.R.G., C.M.), University Hospital Basel, University of Basel, Switzerland
- BHF/University Centre for Cardiovascular Science (J.B., D.D., K.K.L., A.B., Z.L., A.V.F., C.T., A.A., N.L.M.), University of Edinburgh, UK
| | - Dimitrios Doudesis
- BHF/University Centre for Cardiovascular Science (J.B., D.D., K.K.L., A.B., Z.L., A.V.F., C.T., A.A., N.L.M.), University of Edinburgh, UK
- Usher Institute (D.D., K.K.L., A.G., N.L.M.), University of Edinburgh, UK
| | - Pedro Lopez-Ayala
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology (J.B., P.L.-A., L.K., K.W., T.N., R.B., I.S., M.R.G., C.M.), University Hospital Basel, University of Basel, Switzerland
| | - Kuan Ken Lee
- BHF/University Centre for Cardiovascular Science (J.B., D.D., K.K.L., A.B., Z.L., A.V.F., C.T., A.A., N.L.M.), University of Edinburgh, UK
- Usher Institute (D.D., K.K.L., A.G., N.L.M.), University of Edinburgh, UK
| | - Luca Koechlin
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology (J.B., P.L.-A., L.K., K.W., T.N., R.B., I.S., M.R.G., C.M.), University Hospital Basel, University of Basel, Switzerland
- Departments of Cardiac Surgery (L.K.), University Hospital Basel, University of Basel, Switzerland
| | - Karin Wildi
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology (J.B., P.L.-A., L.K., K.W., T.N., R.B., I.S., M.R.G., C.M.), University Hospital Basel, University of Basel, Switzerland
- Intensive Care (K.W.), University Hospital Basel, University of Basel, Switzerland
| | - Thomas Nestelberger
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology (J.B., P.L.-A., L.K., K.W., T.N., R.B., I.S., M.R.G., C.M.), University Hospital Basel, University of Basel, Switzerland
| | - Raphael Borer
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology (J.B., P.L.-A., L.K., K.W., T.N., R.B., I.S., M.R.G., C.M.), University Hospital Basel, University of Basel, Switzerland
| | - Òscar Miró
- Emergency Department, Hospital Clinic, Barcelona, Catalonia, Spain (Ò.M.)
| | | | - Ivo Strebel
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology (J.B., P.L.-A., L.K., K.W., T.N., R.B., I.S., M.R.G., C.M.), University Hospital Basel, University of Basel, Switzerland
| | - Maria Rubini Giménez
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology (J.B., P.L.-A., L.K., K.W., T.N., R.B., I.S., M.R.G., C.M.), University Hospital Basel, University of Basel, Switzerland
| | - Dagmar I Keller
- Emergency Department, University Hospital Zurich, Switzerland (D.I.K.)
| | - Michael Christ
- Emergency Department, Kantonsspital Luzern, Switzerland (M.C.)
| | - Anda Bularga
- BHF/University Centre for Cardiovascular Science (J.B., D.D., K.K.L., A.B., Z.L., A.V.F., C.T., A.A., N.L.M.), University of Edinburgh, UK
| | - Ziwen Li
- BHF/University Centre for Cardiovascular Science (J.B., D.D., K.K.L., A.B., Z.L., A.V.F., C.T., A.A., N.L.M.), University of Edinburgh, UK
| | - Amy V Ferry
- BHF/University Centre for Cardiovascular Science (J.B., D.D., K.K.L., A.B., Z.L., A.V.F., C.T., A.A., N.L.M.), University of Edinburgh, UK
| | - Chris Tuck
- BHF/University Centre for Cardiovascular Science (J.B., D.D., K.K.L., A.B., Z.L., A.V.F., C.T., A.A., N.L.M.), University of Edinburgh, UK
| | - Atul Anand
- BHF/University Centre for Cardiovascular Science (J.B., D.D., K.K.L., A.B., Z.L., A.V.F., C.T., A.A., N.L.M.), University of Edinburgh, UK
| | - Alasdair Gray
- Usher Institute (D.D., K.K.L., A.G., N.L.M.), University of Edinburgh, UK
- Emergency Medicine Research Group Edinburgh, Royal Infirmary of Edinburgh, UK (A.G.)
| | - Nicholas L Mills
- BHF/University Centre for Cardiovascular Science (J.B., D.D., K.K.L., A.B., Z.L., A.V.F., C.T., A.A., N.L.M.), University of Edinburgh, UK
- Usher Institute (D.D., K.K.L., A.G., N.L.M.), University of Edinburgh, UK
| | - Christian Mueller
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology (J.B., P.L.-A., L.K., K.W., T.N., R.B., I.S., M.R.G., C.M.), University Hospital Basel, University of Basel, Switzerland
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2
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Jobs A, Boeddinghaus J, Neumann JT, Goßling A, Sörensen NA, Twerenbold R, Nestelberger T, Lopez-Ayala P, Gimenez MR, Miro O, Koechlin L, Buergin N, Feistritzer HJ, Collet JP, Bhatt DL, Granger CB, Blankenberg S, Desch S, Mueller C, Westermann D, Thiele H. GRACE scores or high-sensitivity troponin for timing of coronary angiography in non-ST-elevation acute coronary syndromes. Clin Res Cardiol 2024; 113:533-545. [PMID: 37421436 PMCID: PMC10954871 DOI: 10.1007/s00392-023-02258-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Accepted: 06/26/2023] [Indexed: 07/10/2023]
Abstract
BACKGROUND The GRACE risk score is generically recommended by guidelines for timing of invasive coronary angiography without stating which score should be used. The aim was to determine the diagnostic performance of different GRACE risk scores in comparison to the ESC 0/1 h-algorithm using high-sensitivity cardiac troponin (hs-cTn). METHODS Prospectively enrolled patients presenting with symptoms suggestive of myocardial infarction (MI) in two large studies testing biomarker diagnostic strategies were included. Five GRACE risk scores were calculated. The amount of risk reclassification and the theoretical impact on guideline-recommended timing of invasive coronary angiography was studied. RESULTS Overall, 8,618 patients were eligible for analyses. Comparing different GRACE risk scores, up to 63.8% of participants were reclassified into a different risk category. The proportion of MIs identified (i.e., sensitivity) dramatically differed between GRACE risk scores (range 23.8-66.5%) and was lower for any score than for the ESC 0/1 h-algorithm (78.1%). Supplementing the ESC 0/1 h-algorithm with a GRACE risk score slightly increased sensitivity (P < 0.001 for all scores). However, this increased the number of false positive results. CONCLUSION The substantial amount of risk reclassification causes clinically meaningful differences in the proportion of patients meeting the recommended threshold for pursuing early invasive strategy according to the different GRACE scores. The single best test to detect MIs is the ESC 0/1 h-algorithm. Combining GRACE risk scoring with hs-cTn testing slightly increases the detection of MIs but also increases the number of patients with false positive results who would undergo potential unnecessarily early invasive coronary angiography.
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Affiliation(s)
- Alexander Jobs
- Department of Internal Medicine/Cardiology and Leipzig Heart Institute, Heart Center Leipzig at University of Leipzig, Strümpellstr. 39, 04289, Leipzig, Germany.
- German Centre for Cardiovascular Research (DZHK), Partner Site Hamburg/Luebeck/Kiel, Hamburg, Germany.
| | - Jasper Boeddinghaus
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, Scotland, UK
| | - Johannes Tobias Neumann
- German Centre for Cardiovascular Research (DZHK), Partner Site Hamburg/Luebeck/Kiel, Hamburg, Germany
- Department of Cardiology, University Heart & Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Alina Goßling
- Department of Cardiology, University Heart & Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Nils A Sörensen
- German Centre for Cardiovascular Research (DZHK), Partner Site Hamburg/Luebeck/Kiel, Hamburg, Germany
- Department of Cardiology, University Heart & Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Raphael Twerenbold
- German Centre for Cardiovascular Research (DZHK), Partner Site Hamburg/Luebeck/Kiel, Hamburg, Germany
- Department of Cardiology, University Heart & Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Thomas Nestelberger
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Pedro Lopez-Ayala
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Maria Rubini Gimenez
- Department of Internal Medicine/Cardiology and Leipzig Heart Institute, Heart Center Leipzig at University of Leipzig, Strümpellstr. 39, 04289, Leipzig, Germany
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Oscar Miro
- Emergency Department, Hospital Clinic, Barcelona, Catalonia, Spain
| | - Luca Koechlin
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Natacha Buergin
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Hans-Josef Feistritzer
- Department of Internal Medicine/Cardiology and Leipzig Heart Institute, Heart Center Leipzig at University of Leipzig, Strümpellstr. 39, 04289, Leipzig, Germany
| | - Jean-Philippe Collet
- Sorbonne Université, ACTION Group, INSERM UMRS 1166, Hôpital Pitié-Salpêtrière (AP-HP), Institut de Cardiologie, Paris, France
| | - Deepak L Bhatt
- Brigham and Woman's Hospital, Harvard Medical School, Boston, USA
| | | | - Stefan Blankenberg
- German Centre for Cardiovascular Research (DZHK), Partner Site Hamburg/Luebeck/Kiel, Hamburg, Germany
- Department of Cardiology, University Heart & Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Steffen Desch
- Department of Internal Medicine/Cardiology and Leipzig Heart Institute, Heart Center Leipzig at University of Leipzig, Strümpellstr. 39, 04289, Leipzig, Germany
- German Centre for Cardiovascular Research (DZHK), Partner Site Hamburg/Luebeck/Kiel, Hamburg, Germany
| | - Christian Mueller
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Dirk Westermann
- Clinic for Cardiology and Angiology, University Heart Center Freiburg - Bad Krozingen, Freiburg and Bad Krozingen, Germany
| | - Holger Thiele
- Department of Internal Medicine/Cardiology and Leipzig Heart Institute, Heart Center Leipzig at University of Leipzig, Strümpellstr. 39, 04289, Leipzig, Germany
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Ohno M, Shiomi H, Baba O, Yano M, Aizawa T, Nakano-Matsumura Y, Yamagami S, Kato M, Ohya M, Chen PM, Nagao K, Ando K, Yokomatsu T, Kadota K, Kouchi I, Inada T, Valentine C, Kitagawa T, Kurokawa M, Ohtsuru S, Morimoto T, Kimura T, Nishi E. Auxiliary roles of nardilysin in the early diagnosis of acute coronary syndrome: a prospective cohort study, the Nardi-ACS study. Intern Emerg Med 2024; 19:649-659. [PMID: 38233578 PMCID: PMC11039555 DOI: 10.1007/s11739-023-03508-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Accepted: 12/06/2023] [Indexed: 01/19/2024]
Abstract
Acute coronary syndrome (ACS) includes myocardial infarction (MI) and unstable angina (UA). MI is defined by elevated necrosis markers, preferably high-sensitivity cardiac troponins (hs-cTn). However, it takes hours for cTn to become elevated after coronary occlusion; therefore, difficulties are associated with diagnosing early post-onset MI or UA. The aim of this prospective cohort study was to examine the diagnostic ability of serum nardilysin (NRDC) for the early detection of ACS. This study consisted of two sequential cohorts, the Phase I cohort, 435 patients presenting to the emergency room (ER) with chest pain, and the Phase II cohort, 486 patients with chest pain who underwent coronary angiography. The final diagnosis was ACS in 155 out of 435 patients (35.6%) in the phase I and 418 out of 486 (86.0%) in the phase II cohort. Among 680 patients who presented within 24 h of onset, 466 patients (68.5%) were diagnosed with ACS. Serum NRDC levels were significantly higher in patients with ACS than in those without ACS. The sensitivity of NRDC in patients who presented within 6 h after the onset was higher than that of hsTnI, and the AUC of NRDC within 1 h of the onset was higher than that of hsTnI (0.718 versus 0.633). Among hsTnI-negative patients (300 of 680 patients: 44.1%), 136 of whom (45.3%) were diagnosed with ACS, the sensitivity and the NPV of NRDC were 73.5 and 65.7%, respectively. When measured in combination with hsTnI, NRDC plays auxiliary roles in the early diagnosis of ACS.
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Affiliation(s)
- Mikiko Ohno
- Department of Pharmacology, Shiga University of Medical Science, Seta Tsukinowa-Cho, Otsu, Shiga, 520-2192, Japan.
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University, 54 Shogoin-Kawahara-Cho, Sakyo-Ku, Kyoto, 606-8507, Japan.
| | - Hiroki Shiomi
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University, 54 Shogoin-Kawahara-Cho, Sakyo-Ku, Kyoto, 606-8507, Japan
| | - Osamu Baba
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University, 54 Shogoin-Kawahara-Cho, Sakyo-Ku, Kyoto, 606-8507, Japan
- Preemptive Medicine and Lifestyle Disease Research Center, Kyoto University Hospital, 54 Shogoinkawahara-Cho, Sakyo-Ku, Kyoto, 606-8507, Japan
| | - Mariko Yano
- Kokura Memorial Hospital, 3-2-1 Asano, Kita-Ku, Kokura, Kitakyushu, Fukuoka, 802-8555, Japan
| | - Takanori Aizawa
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University, 54 Shogoin-Kawahara-Cho, Sakyo-Ku, Kyoto, 606-8507, Japan
| | - Yukiko Nakano-Matsumura
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University, 54 Shogoin-Kawahara-Cho, Sakyo-Ku, Kyoto, 606-8507, Japan
| | - Shintaro Yamagami
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University, 54 Shogoin-Kawahara-Cho, Sakyo-Ku, Kyoto, 606-8507, Japan
| | - Masashi Kato
- Mitsubishi Kyoto Hospital, 1, Katsuragoshomachi, Nishikyo-Ku, Kyoto, 615-8087, Japan
| | - Masanobu Ohya
- Kurashiki Central Hospital, 1-1-1 Miwa, Kurashiki, Okayama, 710-8602, Japan
| | - Po-Min Chen
- Saiseikai Noe Hospital, 1-3-25, Furuichi, Joto-Ku, Osaka, 536-0001, Japan
| | - Kazuya Nagao
- Osaka Red-Cross Hospital, 5-30 Fudegasakicho, Tennoji-Ku, Osaka, 543-8555, Japan
| | - Kenji Ando
- Kokura Memorial Hospital, 3-2-1 Asano, Kita-Ku, Kokura, Kitakyushu, Fukuoka, 802-8555, Japan
| | - Takafumi Yokomatsu
- Mitsubishi Kyoto Hospital, 1, Katsuragoshomachi, Nishikyo-Ku, Kyoto, 615-8087, Japan
| | - Kazushige Kadota
- Kurashiki Central Hospital, 1-1-1 Miwa, Kurashiki, Okayama, 710-8602, Japan
| | - Ichiro Kouchi
- Saiseikai Noe Hospital, 1-3-25, Furuichi, Joto-Ku, Osaka, 536-0001, Japan
| | - Tsukasa Inada
- Osaka Red-Cross Hospital, 5-30 Fudegasakicho, Tennoji-Ku, Osaka, 543-8555, Japan
| | - Cindy Valentine
- Sanyo Chemical Industries, 11-1 Hitotsubashi Nomoto, Higashiyama, Kyoto, 605-0995, Japan
| | - Takahiro Kitagawa
- Sanyo Chemical Industries, 11-1 Hitotsubashi Nomoto, Higashiyama, Kyoto, 605-0995, Japan
| | - Masato Kurokawa
- Sanyo Chemical Industries, 11-1 Hitotsubashi Nomoto, Higashiyama, Kyoto, 605-0995, Japan
| | - Shigeru Ohtsuru
- Department of Primary Care and Emergency Medicine, Graduate School of Medicine, Kyoto University, 54 Shogoinkawahara-Cho, Sakyo-Ku, Kyoto, 606-8507, Japan
| | - Takeshi Morimoto
- Hyogo College of Medicine, 1-1, Mukogawa-Cho, Nishinomiya, Hyogo, 663-8501, Japan
| | - Takeshi Kimura
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University, 54 Shogoin-Kawahara-Cho, Sakyo-Ku, Kyoto, 606-8507, Japan
- Hirakata Kosai Hospital, 1-2-1, Fujibanto-Cho, Hirakata, Osaka, 573-0153, Japan
| | - Eiichiro Nishi
- Department of Pharmacology, Shiga University of Medical Science, Seta Tsukinowa-Cho, Otsu, Shiga, 520-2192, Japan.
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University, 54 Shogoin-Kawahara-Cho, Sakyo-Ku, Kyoto, 606-8507, Japan.
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Rubini Gimenez M, Bergami M. Comment on: Diagnostic and prognostic value of the sex-specific 99th percentile of four high-sensitivity cardiac troponin assays in patients with suspected myocardial infarction. EUROPEAN HEART JOURNAL. ACUTE CARDIOVASCULAR CARE 2024; 13:13-14. [PMID: 38048386 DOI: 10.1093/ehjacc/zuad147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Accepted: 12/01/2023] [Indexed: 12/06/2023]
Affiliation(s)
- Maria Rubini Gimenez
- Department of Cardiology, University Heart Center Leipzig, Strümpellstr. 39, 04289 Leipzig, Germany
- Department of Cardiology, Imed Hospitales, Av. de la Ilustración, 1, 46100 Burjassot, Valencia, Spain
| | - Maria Bergami
- Laboratory of Epidemiological and Clinical Cardiology, Department of Medical and Surgical Sciences (DIMEC), Università di Bologna, Bologna, Italy
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Byrne RA, Rossello X, Coughlan JJ, Barbato E, Berry C, Chieffo A, Claeys MJ, Dan GA, Dweck MR, Galbraith M, Gilard M, Hinterbuchner L, Jankowska EA, Jüni P, Kimura T, Kunadian V, Leosdottir M, Lorusso R, Pedretti RFE, Rigopoulos AG, Rubini Gimenez M, Thiele H, Vranckx P, Wassmann S, Wenger NK, Ibanez B. 2023 ESC Guidelines for the management of acute coronary syndromes. EUROPEAN HEART JOURNAL. ACUTE CARDIOVASCULAR CARE 2024; 13:55-161. [PMID: 37740496 DOI: 10.1093/ehjacc/zuad107] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/24/2023]
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6
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Liu L, Lewandrowski K. Establishing optimal cutoff values for high-sensitivity cardiac troponin algorithms in risk stratification of acute myocardial infarction. Crit Rev Clin Lab Sci 2024; 61:1-22. [PMID: 37466395 DOI: 10.1080/10408363.2023.2235426] [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: 03/31/2023] [Revised: 06/11/2023] [Accepted: 07/07/2023] [Indexed: 07/20/2023]
Abstract
Acute myocardial infarction (AMI) is a leading cause of mortality globally, highlighting the need for timely and accurate diagnostic strategies. Cardiac troponin has been the biomarker of choice for detecting myocardial injury. A dynamic change in concentrations supports the diagnosis of AMI in the setting of evidence of acute myocardial ischemia. The new generation of high-sensitivity cardiac troponin (hs-cTn) assays has significantly improved analytical sensitivity but at the expense of decreased clinical specificity. As a result, sophisticated algorithms are required to differentiate AMI from non-AMI patients. Establishing optimal hs-cTn cutoffs for these algorithms to rule out and rule in AMI has been the subject of intensive investigations. These efforts have evolved from examining the utility of the hs-cTn 99th percentile upper reference limit, comparing the percentage versus absolute delta thresholds, and evaluating the performance of an early European Society of Cardiology-recommended 3 h algorithm, to the development of accelerated 1 h and 2 h algorithms that combine the admission hs-cTn concentrations and absolute delta cutoffs to rule out and rule in AMI. Specific cutoffs for individual confounding factors such as sex, age, and renal insufficiency have also been investigated. At the same time, concerns such as whether the small delta thresholds exceed the analytical and biological variations of hs-cTn assays and whether the algorithms developed in European study populations fit all other patient cohorts have been raised. In addition, the accelerated algorithms leave a substantial number of patients in a non-diagnostic observation zone. How to properly diagnose patients falling in this zone and those presenting with elevated baseline hs-cTn concentrations due to the presence of confounding factors or comorbidities remain open questions. Here we discuss the developments described above, focusing on criteria and underlying considerations for establishing optimal cutoffs. In-depth analyses are provided on the influence of biological variation, analytical imprecision, local AMI rate, and the timing of presentation on the performance metrics of the accelerated hs-cTn algorithms. Developing diagnostic strategies for patients who remain in the observation zone and those presenting with confounding factors are also reviewed.
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Affiliation(s)
- Li Liu
- Department of Pathology, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Kent Lewandrowski
- Department of Pathology, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
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7
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Zilinyi RS, Fertel BS, Chang BC, Abrukin L, Suh EH, Sayan OR, McCarty M, Stant JA, Chuich T, Smyth ET, Neuberg G, Collins MB, Kirtane AJ, Moses J, Rabbani L. Updating a Healthcare System-wide Clinical Pathway for Managing Chest Pain and Acute Coronary Syndromes. Crit Pathw Cardiol 2023; 22:103-109. [PMID: 37782621 DOI: 10.1097/hpc.0000000000000334] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/04/2023]
Abstract
Clinical pathways are useful tools for conveying and reinforcing best practices to standardize care and optimize patient outcomes across myriad conditions. The NewYork-Presbyterian Healthcare System has utilized a clinical chest pain pathway for more than 20 years to facilitate the timely recognition and management of patients presenting with chest pain syndromes and acute coronary syndromes. This chest pain pathway is regularly updated by an expanding group of key stakeholders, which has extended from the Columbia University Irving Medical Center to encompass the entire regional healthcare system, which includes 8 hospitals. In this 2023 update of the NewYork-Presbyterian clinical chest pain pathway, we present the key changes to the healthcare system-wide clinical chest pain pathway.
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Affiliation(s)
- Robert S Zilinyi
- From the Division of Cardiology, Department of Medicine, NewYork-Presbyterian Hospital/Columbia University Irving Medical Center, New York, NY
| | - Baruch S Fertel
- Quality and Patient Safety, NewYork-Presbyterian Hospital/Columbia University Irving Medical Center, New York, NY
- Department of Emergency Medicine, NewYork-Presbyterian Hospital/Columbia University Irving Medical Center, New York, NY
| | - Betty C Chang
- Department of Emergency Medicine, NewYork-Presbyterian Hospital/Columbia University Irving Medical Center, New York, NY
| | - Liliya Abrukin
- Department of Emergency Medicine, NewYork-Presbyterian Hospital/Columbia University Irving Medical Center, New York, NY
| | - Edward H Suh
- Department of Emergency Medicine, NewYork-Presbyterian Hospital/Columbia University Irving Medical Center, New York, NY
| | - Osman R Sayan
- Department of Emergency Medicine, NewYork-Presbyterian Hospital/Columbia University Irving Medical Center, New York, NY
| | - Matthew McCarty
- Department of Emergency Medicine, NewYork-Presbyterian Hospital/Weill Cornell Medical Center, New York, NY
| | - Jennifer A Stant
- From the Division of Cardiology, Department of Medicine, NewYork-Presbyterian Hospital/Columbia University Irving Medical Center, New York, NY
| | | | - Emily T Smyth
- Department of Emergency Medicine, NewYork-Presbyterian Hospital/Weill Cornell Medical Center, New York, NY
| | - Gerald Neuberg
- Division of Cardiology, Department of Medicine, NewYork-Presbyterian Hospital/Allen Hospital, New York, NY
| | - Michael B Collins
- From the Division of Cardiology, Department of Medicine, NewYork-Presbyterian Hospital/Columbia University Irving Medical Center, New York, NY
| | - Ajay J Kirtane
- From the Division of Cardiology, Department of Medicine, NewYork-Presbyterian Hospital/Columbia University Irving Medical Center, New York, NY
| | - Jeffrey Moses
- From the Division of Cardiology, Department of Medicine, NewYork-Presbyterian Hospital/Columbia University Irving Medical Center, New York, NY
| | - LeRoy Rabbani
- From the Division of Cardiology, Department of Medicine, NewYork-Presbyterian Hospital/Columbia University Irving Medical Center, New York, NY
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8
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Byrne RA, Rossello X, Coughlan JJ, Barbato E, Berry C, Chieffo A, Claeys MJ, Dan GA, Dweck MR, Galbraith M, Gilard M, Hinterbuchner L, Jankowska EA, Jüni P, Kimura T, Kunadian V, Leosdottir M, Lorusso R, Pedretti RFE, Rigopoulos AG, Rubini Gimenez M, Thiele H, Vranckx P, Wassmann S, Wenger NK, Ibanez B. 2023 ESC Guidelines for the management of acute coronary syndromes. Eur Heart J 2023; 44:3720-3826. [PMID: 37622654 DOI: 10.1093/eurheartj/ehad191] [Citation(s) in RCA: 368] [Impact Index Per Article: 368.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/26/2023] Open
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9
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Van Assche L, Peeters B, Vorlat A, Monsieurs K, Heidbuchel H, Claeys MJ. Safety and effectiveness of the short (0-1h) high sensitive troponin protocol in real-life practice. Acta Cardiol 2023; 78:937-944. [PMID: 37264905 DOI: 10.1080/00015385.2023.2218028] [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: 09/01/2022] [Accepted: 05/19/2023] [Indexed: 06/03/2023]
Abstract
AIM Recent guidelines recommend the use of a short 0-1h high sensitive cardiac troponin (hs-cTn) algorithm in patients presenting with chest pain at the emergency department (ED). This retrospective observational study evaluates the safety and effectiveness of the new 0-1h hs-cTn I protocol in comparison with the standard 0-3h cTn I protocol for the diagnosis of acute myocardial infarction (AMI). METHODS A total of two times 100 consecutive chest pain patients presenting at the ED in November/December 2018 (standard 0-3h cTn I group) and in November/December 2020 (short 0-1h hs-cTn I group) were enrolled. Decision making was based upon validated assay-specific cut-off values. RESULTS The new 0-1h hs-cTn I protocol had a sensitivity of 100% (95% CI 83.2-100) and a negative predictive value of 100% to rule out AMI. The accuracy of rule-in was slightly lower with a specificity of 92.5% (95% CI 84.4-97.2). The overall protocol accuracy was 94% (95% CI 87.4-97.8) in the short 0-1h hs-cTn I group compared to 88% (95% CI 80.0-93.6) in the standard 0-3h cTn I group (p-value 0.14). The 0-1h hs-cTn I protocol was associated with a numerically higher rate of early hospital discharge compared to the conventional 0-3h cTn I protocol (47% versus 59%; p-value 0.09) and with a shorter median length of stay for those patients (mean 316 min versus 289 min; p-value 0.09). CONCLUSION The abbreviated protocol based on the 0-1h hs-cTn I assays is effective and safe for the exclusion of AMI at the ED.
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Affiliation(s)
| | - Bart Peeters
- Department of Clinical Biology, Antwerp University Hospital, Antwerp, Belgium
| | - Anne Vorlat
- Department of Cardiology, Antwerp University Hospital, Antwerp, Belgium
| | - Koen Monsieurs
- Department of Emergency Medicine, Antwerp University Hospital, Antwerp, Belgium
| | - Hein Heidbuchel
- Department of Cardiology, Antwerp University Hospital, Antwerp, Belgium
| | - Marc J Claeys
- Department of Cardiology, Antwerp University Hospital, Antwerp, Belgium
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10
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Liu L, Cai X, Love T, Corsetti M, Mathias AM, Worster A, Ma J, Kavsak PA. Using logistic regression models to investigate the effects of high-sensitivity cardiac troponin T confounders on ruling in acute myocardial infarction. Clin Chem Lab Med 2023; 61:1335-1342. [PMID: 36698327 PMCID: PMC10585657 DOI: 10.1515/cclm-2022-1004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Accepted: 01/16/2023] [Indexed: 01/27/2023]
Abstract
OBJECTIVES Confounding factors, including sex, age, and renal dysfunction, affect high-sensitivity cardiac troponin T (hs-cTnT) concentrations and the acute myocardial infarction (AMI) diagnosis. This study assessed the effects of these confounders through logistic regression models and evaluated the diagnostic performance of an optimized, integrated prediction model. METHODS This retrospective study included a primary derivation cohort of 18,022 emergency department (ED) patients at a US medical center and a validation cohort of 890 ED patients at a Canadian medical center. Hs-cTnT was measured with 0/3 h sampling. The primary outcome was index AMI diagnosis. Logistic regression models were optimized to predict AMI using delta hs-cTnT and its confounders as covariates. The diagnostic performance of model cutoffs was compared to that of the hs-cTnT delta thresholds. Serial logistic regressions were carried out to evaluate the relationship between covariates. RESULTS The area under the curve of the best-fitted model was 0.95. The model achieved a 90.0% diagnostic accuracy in the validation cohort. The optimal model cutoff yielded comparable performance (90.5% accuracy) to the optimal sex-specific delta thresholds (90.3% accuracy), with 95.8% agreement between the two diagnostic methods. Serial logistic regressions revealed that delta hs-cTnT played a more predominant role in AMI prediction than its confounders, among which sex is more predictive of AMI (total effect coefficient 1.04) than age (total effect coefficient 0.05) and eGFR (total effect coefficient -0.008). CONCLUSIONS The integrated prediction model incorporating confounding factors does not outperform hs-cTnT delta thresholds. Sex-specific hs-cTnT delta thresholds remain to provide the highest diagnostic accuracy.
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Affiliation(s)
- Li Liu
- Department of Pathology, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
- Department of Pathology and Laboratory Medicine, University of Rochester Medical Center, Rochester, NY, USA
| | - Xueya Cai
- Department of Biostatistics and Computational Biology, University of Rochester, Rochester, NY, USA
| | - Tanzy Love
- Department of Biostatistics and Computational Biology, University of Rochester, Rochester, NY, USA
| | - Matthew Corsetti
- Department of Biostatistics and Computational Biology, University of Rochester, Rochester, NY, USA
| | - Andrew M Mathias
- Division of Cardiology, Department of Medicine, University of Rochester Medical Center, Rochester, NY, USA
| | - Andrew Worster
- Division of Emergency Medicine, Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Jinhui Ma
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Peter A Kavsak
- Department of Pathology and Molecular Medicine, McMaster University, Hamilton, ON, Canada
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11
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Clerico A, Zaninotto M, Aimo A, Cardinale DM, Dittadi R, Sandri MT, Perrone MA, Belloni L, Fortunato A, Trenti T, Plebani M. Variability of cardiac troponin levels in normal subjects and in patients with cardiovascular diseases: analytical considerations and clinical relevance. Clin Chem Lab Med 2023; 61:1209-1229. [PMID: 36695506 DOI: 10.1515/cclm-2022-1285] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Accepted: 01/09/2023] [Indexed: 01/26/2023]
Abstract
In accordance with all the most recent international guidelines, the variation of circulating levels of cardiac troponins I and T, measured with high-sensitivity methods (hs-cTnI and hs-cTnT), should be used for the detection of acute myocardial injury. Recent experimental and clinical evidences have demonstrated that the evaluation of hs-cTnI and hs-cTnT variations is particularly relevant: a) for the differential diagnosis of Acute Coronary Syndromes (ACS) in patients admitted to the Emergency Department (ED); b) for the evaluation of cardiovascular risk in patients undergoing major cardiac or non-cardiac surgery, and in asymptomatic subjects of the general population aged >55 years and with co-morbidities; c) for the evaluation of cardiotoxicity caused by administration of some chemotherapy drugs in patients with malignant tumors. The aim of this document is to discuss the fundamental statistical and biological considerations on the intraindividual variability of hs-cTnI and hs-cTnT over time in the same individual. Firstly, it will be discussed in detail as the variations of circulating levels strictly depend not only on the analytical error of the method used but also on the intra-individual variability of the biomarker. Afterwards, the pathophysiological interpretation and the clinical relevance of the determination of the variability of the hs-cTnI and hs-cTnT values in patients with specific clinical conditions are discussed. Finally, the evaluation over time of the variation in circulating levels of hs-cTnI and hs-cTnT is proposed for a more accurate estimation of cardiovascular risk in asymptomatic subjects from the general population.
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Affiliation(s)
- Aldo Clerico
- Scuola Superiore Sant'Anna e Fondazione CNR, Regione Toscana G. Monasterio, Pisa, Italy
| | - Martina Zaninotto
- Dipartimento di Medicina di Laboratorio, Università-Ospedale di Padova, Padova, Italy
- Azienda Ospedaliera Universitaria di Padova, e Facoltà di Medicina e Chirurgia, Università di Padova, Padova, Italy
| | - Alberto Aimo
- Scuola Superiore Sant'Anna e Fondazione CNR, Regione Toscana G. Monasterio, Pisa, Italy
| | | | - Ruggero Dittadi
- Unità di Medicina di Laboratorio, Ospedale dell'Angelo, e Centro Regionale dei Biomarcatori, Dipartimento di Patologia Clinica, Azienda ULSS 3, Mestre, Italy
| | - Maria T Sandri
- Laboratorio Bianalisi, Carate Brianza, Monza e Brianza, Italy
| | - Marco Alfonso Perrone
- Dipartimento di Biochimica Clinica e Divisione di Cardiologia, Università e Ospedale di Tor Vergata, Rome, Italy
| | - Lucia Belloni
- Unità di Immunologia Clinica, Allergia e Biotecnologie Avanzate, Arcispedale Santa Maria Nuova-IRCCS, Reggio Emilia, Italy
| | | | - Tommaso Trenti
- Dipartimento di Patologia Clinica e Laboratorio, Azienda USL of Modena, Modena, Italy
| | - Mario Plebani
- Dipartimento di Medicina di Laboratorio, Università-Ospedale di Padova, Padova, Italy
- Azienda Ospedaliera Universitaria di Padova, e Facoltà di Medicina e Chirurgia, Università di Padova, Padova, Italy
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12
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McEvoy JW, Tang O, Wang D, Ndumele CE, Coresh J, Christenson RH, Selvin E. Myocardial Injury Thresholds for 4 High-Sensitivity Troponin Assays in U.S. Adults. J Am Coll Cardiol 2023; 81:2028-2039. [PMID: 37197846 DOI: 10.1016/j.jacc.2023.03.403] [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: 01/11/2023] [Revised: 03/09/2023] [Accepted: 03/13/2023] [Indexed: 05/19/2023]
Abstract
BACKGROUND Myocardial injury is currently defined as a cardiac troponin above the sex-specific 99th percentile of a healthy reference population (upper reference limit [URL]). OBJECTIVES The purpose of this study was to estimate high-sensitivity (hs) troponin URLs in a representative sample of the U.S. adult population; overall and by sex, race/ethnicity, and age group. METHODS Among adults participating in the 1999-2004 National Health and Nutrition Examination Survey (NHANES), we measured hs-troponin T using 1 assay (Roche) and hs-troponin I using 3 assays (Abbott, Siemens, and Ortho). In a strictly defined healthy reference subgroup, we estimated 99th percentile URLs for each assay using the recommended nonparametric method. RESULTS Of 12,545 participants, 2,746 met criteria for the healthy subgroup (mean age 37 years, 50% men). The NHANES 99th percentile URL for hs-troponin T (19 ng/L) matched the manufacturer-reported URL (19 ng/L). NHANES URLs were 13 ng/L (95% CI: 10-15 ng/L) for Abbott hs-troponin I (manufacturer: 28 ng/L), 5 ng/L (95% CI: 4-7 ng/L) for Ortho hs-troponin I (manufacturer: 11 ng/L), and 37 ng/L (95% CI: 27-66 ng/L) for Siemens hs-troponin I (manufacturer: 46.5 ng/L). There were significant differences in URLs by sex, but none by race/ethnicity. Furthermore, the 99th percentile URLs for all 4 hs-troponin assays were statistically significantly lower in healthy adults aged <40 years compared with healthy adults ≥60 years (all P < 0.001 by rank sum testing). CONCLUSIONS We found URLs for hs-troponin I assays that were substantially lower than currently listed 99th percentile URLs. There were significant differences in hs-troponin T and I URLs by sex and by age group in healthy U.S. adults but none by race/ethnicity.
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Affiliation(s)
- John W McEvoy
- Division of Cardiology and National Institute for Prevention and Cardiovascular Health, University of Galway, Galway, Ireland; Johns Hopkins School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA; Department of Epidemiology and the Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA.
| | - Olive Tang
- Johns Hopkins School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Dan Wang
- Department of Epidemiology and the Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Chiadi E Ndumele
- Johns Hopkins School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA; Department of Epidemiology and the Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Josef Coresh
- Department of Epidemiology and the Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Robert H Christenson
- Department of Pathology, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Elizabeth Selvin
- Department of Epidemiology and the Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
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13
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Haller PM, Sörensen NA, Hartikainen TS, Goßling A, Lehmacher J, Toprak B, Twerenbold R, Richter J, Banko T, Korschid S, Schmidt J, Keller T, Zeller T, Blankenberg S, Westermann D, Neumann JT. Rising and Falling High-Sensitivity Cardiac Troponin in Diagnostic Algorithms for Patients With Suspected Myocardial Infarction. J Am Heart Assoc 2023; 12:e027166. [PMID: 37158171 DOI: 10.1161/jaha.122.027166] [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] [Indexed: 05/10/2023]
Abstract
Background High-sensitivity cardiac troponin (hs-cTn)-based diagnostic algorithms are recommended for the management of patients with suspected myocardial infarction (MI) without ST elevation. Although mirroring different phases of myocardial injury, falling and rising troponin patterns (FPs and RPs, respectively) are equally considered by most algorithms. We aimed to compare the performance of diagnostic protocols for RPs and FPs, separately. Methods and Results We pooled 2 prospective cohorts of patients with suspected MI and stratified patients to stable, FP, and RP during serial sampling separately for hs-cTnI and hs-cTnT and applied the European Society of Cardiology 0/1- and 0/3-hour algorithms comparing the positive predictive values to rule in MI. Overall, 3523 patients were included in the hs-cTnI study population. The positive predictive value for patients with an FP was significantly reduced compared with patients with an RP (0/1-hour: FP, 53.3% [95% CI, 45.0-61.4] versus RP, 76.9 [95% CI, 71.6-81.7]; 0/3-hour: FP, 56.9% [95% CI, 42.2-70.7] versus RP, 78.1% [95% CI, 74.0-81.8]). The proportion of patients in the observe zone was larger in the FP using 0/1-hour (31.3% versus 55.8%) and 0/3-hour (14.6% versus 38.6%) algorithms. Alternative cutoffs did not improve algorithm performances. Compared with stable hs-cTn, the risk for death or MI was highest in those with an FP (adjusted hazard ratio [HR], hs-cTnI 2.3 [95% CI, 1.7-3.2]; RP adjusted HR, hs-cTnI 1.8 [95% CI, 1.4-2.4]). Findings were similar for hs-cTnT tested in 3647 patients overall. Conclusions The positive predictive value to rule in MI by the European Society of Cardiology 0/1- and 0/3-hour algorithms is significantly lower in patients with FP than RP. These are at highest risk for incident death or MI. REGISTRATION: URL: https://www.clinicaltrials.gov; Unique identifiers: NCT02355457, NCT03227159.
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Affiliation(s)
- Paul M Haller
- Department of Cardiology University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf Hamburg Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck Hamburg Germany
| | - Nils A Sörensen
- Department of Cardiology University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf Hamburg Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck Hamburg Germany
| | - Tau S Hartikainen
- Department of Cardiology University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf Hamburg Germany
| | - Alina Goßling
- Department of Cardiology University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf Hamburg Germany
| | - Jonas Lehmacher
- Department of Cardiology University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf Hamburg Germany
| | - Betül Toprak
- Department of Cardiology University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf Hamburg Germany
| | - Raphael Twerenbold
- Department of Cardiology University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf Hamburg Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck Hamburg Germany
- University Center of Cardiovascular Science University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf Hamburg Germany
| | - Janine Richter
- Department of Cardiology University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf Hamburg Germany
| | - Thorben Banko
- Department of Cardiology University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf Hamburg Germany
| | - Solaf Korschid
- Department of Cardiology University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf Hamburg Germany
| | - Jakob Schmidt
- Department of Cardiology University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf Hamburg Germany
| | - Till Keller
- Department of Internal Medicine I, Cardiology Justus-Liebig-University Gießen Gießen Germany
| | - Tanja Zeller
- Department of Cardiology University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf Hamburg Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck Hamburg Germany
- University Center of Cardiovascular Science University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf Hamburg Germany
| | - Stefan Blankenberg
- Department of Cardiology University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf Hamburg Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck Hamburg Germany
| | - Dirk Westermann
- Department of Cardiology University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf Hamburg Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck Hamburg Germany
- Department of Cardiology University Heart Center Freiburg Bad Krotzingen Bad Krotzingen Germany
| | - Johannes T Neumann
- Department of Cardiology University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf Hamburg Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck Hamburg Germany
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine Monash University Melbourne Australia
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14
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Doudesis D, Lee KK, Boeddinghaus J, Bularga A, Ferry AV, Tuck C, Lowry MTH, Lopez-Ayala P, Nestelberger T, Koechlin L, Bernabeu MO, Neubeck L, Anand A, Schulz K, Apple FS, Parsonage W, Greenslade JH, Cullen L, Pickering JW, Than MP, Gray A, Mueller C, Mills NL. Machine learning for diagnosis of myocardial infarction using cardiac troponin concentrations. Nat Med 2023; 29:1201-1210. [PMID: 37169863 PMCID: PMC10202804 DOI: 10.1038/s41591-023-02325-4] [Citation(s) in RCA: 17] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Accepted: 03/28/2023] [Indexed: 05/13/2023]
Abstract
Although guidelines recommend fixed cardiac troponin thresholds for the diagnosis of myocardial infarction, troponin concentrations are influenced by age, sex, comorbidities and time from symptom onset. To improve diagnosis, we developed machine learning models that integrate cardiac troponin concentrations at presentation or on serial testing with clinical features and compute the Collaboration for the Diagnosis and Evaluation of Acute Coronary Syndrome (CoDE-ACS) score (0-100) that corresponds to an individual's probability of myocardial infarction. The models were trained on data from 10,038 patients (48% women), and their performance was externally validated using data from 10,286 patients (35% women) from seven cohorts. CoDE-ACS had excellent discrimination for myocardial infarction (area under curve, 0.953; 95% confidence interval, 0.947-0.958), performed well across subgroups and identified more patients at presentation as low probability of having myocardial infarction than fixed cardiac troponin thresholds (61 versus 27%) with a similar negative predictive value and fewer as high probability of having myocardial infarction (10 versus 16%) with a greater positive predictive value. Patients identified as having a low probability of myocardial infarction had a lower rate of cardiac death than those with intermediate or high probability 30 days (0.1 versus 0.5 and 1.8%) and 1 year (0.3 versus 2.8 and 4.2%; P < 0.001 for both) from patient presentation. CoDE-ACS used as a clinical decision support system has the potential to reduce hospital admissions and have major benefits for patients and health care providers.
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Grants
- FS/18/25/33454 British Heart Foundation
- MR/V007254/1 Medical Research Council
- CH/F/21/90010 British Heart Foundation
- RG/20/10/34966 British Heart Foundation
- MR/N013166/1 Medical Research Council
- RE/18/5/34216 British Heart Foundation
- MR/W000598/1 Medical Research Council
- British Heart Foundation (BHF)
- RCUK | Medical Research Council (MRC)
- The University of Basel, the University Hospital of Basel, the Swiss Academy of Medical Sciences, the Gottfried and Julia Bangerter-Rhyner Foundation, the Swiss National Science Foundation
- Swiss Heart Foundation, the University of Basel, the Swiss Academy of Medical Science, the Gottfried and Julia Bangerter-Rhyner Foundation, and the “Freiwillige Akademische Gesellschaft Basel.”
- Advance Queensland Fellowship
- the Swiss National Science Foundation, the Swiss Heart Foundation, the Commission for Technology and Innovation, and the University Hospital Basel.
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Affiliation(s)
- Dimitrios Doudesis
- British Heart Foundation/University Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
- Usher Institute, University of Edinburgh, Edinburgh, UK
| | - Kuan Ken Lee
- British Heart Foundation/University Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Jasper Boeddinghaus
- British Heart Foundation/University Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
- Cardiovascular Research Institute Basel and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Anda Bularga
- British Heart Foundation/University Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Amy V Ferry
- British Heart Foundation/University Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Chris Tuck
- British Heart Foundation/University Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Matthew T H Lowry
- British Heart Foundation/University Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Pedro Lopez-Ayala
- Cardiovascular Research Institute Basel and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Thomas Nestelberger
- Cardiovascular Research Institute Basel and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Luca Koechlin
- Cardiovascular Research Institute Basel and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- Department of Cardiac Surgery, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Miguel O Bernabeu
- Usher Institute, University of Edinburgh, Edinburgh, UK
- The Bayes Centre, The University of Edinburgh, Edinburgh, UK
| | - Lis Neubeck
- School of Health and Social Care, Edinburgh Napier University, Edinburgh, UK
| | - Atul Anand
- British Heart Foundation/University Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Karen Schulz
- Cardiac Biomarkers Trials Laboratory, Hennepin Healthcare Research Institute, Minneapolis, MN, USA
| | - Fred S Apple
- Departments of Laboratory Medicine and Pathology, Hennepin County Medical Center and University of Minnesota, Minneapolis, MN, USA
| | - William Parsonage
- Australian Centre for Health Service Innovation, Centre for Healthcare Transformation, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Jaimi H Greenslade
- Emergency and Trauma Centre, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
- School of Medicine, University of Queensland, Brisbane, Queensland, Australia
- Faculty of Health, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Louise Cullen
- Emergency and Trauma Centre, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
- School of Medicine, University of Queensland, Brisbane, Queensland, Australia
- Faculty of Health, Queensland University of Technology, Brisbane, Queensland, Australia
| | - John W Pickering
- Department of Medicine, University of Otago, Christchurch, New Zealand
- Emergency Department, Christchurch Hospital, Christchurch, New Zealand
| | - Martin P Than
- Department of Medicine, University of Otago, Christchurch, New Zealand
| | - Alasdair Gray
- Emergency Medicine Research Group Edinburgh, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Christian Mueller
- Cardiovascular Research Institute Basel and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Nicholas L Mills
- British Heart Foundation/University Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK.
- Usher Institute, University of Edinburgh, Edinburgh, UK.
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15
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Ho YJ, Chen CH, Sung CW, Fan CY, Lin SY, Chen JW, Edward Pei-Chang Huang S. Risk stratification of patients with chest pain who have an unscheduled revisit to the emergency department. Int J Cardiol 2023:S0167-5273(23)00596-X. [PMID: 37116755 DOI: 10.1016/j.ijcard.2023.04.043] [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: 11/26/2022] [Revised: 03/11/2023] [Accepted: 04/23/2023] [Indexed: 04/30/2023]
Abstract
AIMS Acute cardiovascular (CV) emergencies are critical conditions that require urgent attention in the emergency department (ED). Failure to make a timely diagnosis may result in unscheduled ED revisits and severe outcomes. Therefore, this study aimed to investigate the risk factors associated with potentially missed acute CV emergencies. METHODS AND RESULTS This retrospective study enrolled adult patients who presented with chest pain and returned to the ED within 72 h. Demographic information, pre-existing medical conditions, chief complaints, triage level and vital signs, electrocardiography (ECG) reports, and laboratory data were collected from medical charts by independent physicians. The primary outcome was the diagnosis of acute CV diseases, including ACS, pulmonary embolism, unstable arrhythmia, acute decompensated heart failure, and aortic dissection. Multivariable logistic regression was used to analyze the association between variables and acute CV emergencies. A total of 453 eligible patients were included, with 60 (13.2%) patients diagnosed as acute CV emergencies at the ED revisit. Risk factors for acute CV emergencies included male gender (adjusted odds ratio [aOR] = 2.71, 95% confidence interval [CI] = 1.17-6.25), abnormal ECG rhythm (aOR = 10.33, 95% CI = 4.68-22.83), and abnormal changes in high sensitivity Troponin-T (hs-cTnT) during sequential follow-up (aOR = 6.52, 95% CI = 2.19-19.45). CONCLUSIONS Male gender, abnormal ECG rhythm, and a significant increase in sequential follow-up hs-cTnT levels were identified as significant risk factors for acute CV emergencies. ED physicians should recognize these high-risk patients with chest pain to prevent misdiagnosis and potential severe complications.
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Affiliation(s)
- Yi-Ju Ho
- Department of Emergency Medicine, National Taiwan University Hospital, No.7, Chung-Shan S. Road, Taipei 100, Taiwan
| | - Chi-Hsin Chen
- Department of Emergency Medicine, National Taiwan University Hospital Hsin-Chu Branch, No. 25, Ln. 442, Sec. 1, Jing-guo Rd., North Dist., Hsinchu 310, Taiwan
| | - Chih-Wei Sung
- Department of Emergency Medicine, National Taiwan University Hospital Hsin-Chu Branch, No. 25, Ln. 442, Sec. 1, Jing-guo Rd., North Dist., Hsinchu 310, Taiwan
| | - Cheng-Yi Fan
- Department of Emergency Medicine, National Taiwan University Hospital Hsin-Chu Branch, No. 25, Ln. 442, Sec. 1, Jing-guo Rd., North Dist., Hsinchu 310, Taiwan
| | - Shao-Yung Lin
- Department of Emergency Medicine, National Taiwan University Hospital, No.7, Chung-Shan S. Road, Taipei 100, Taiwan
| | - Jiun-Wei Chen
- Department of Emergency Medicine, National Taiwan University Hospital Hsin-Chu Branch, No. 25, Ln. 442, Sec. 1, Jing-guo Rd., North Dist., Hsinchu 310, Taiwan
| | - S Edward Pei-Chang Huang
- Department of Emergency Medicine, National Taiwan University Hospital, No.7, Chung-Shan S. Road, Taipei 100, Taiwan; Department of Emergency Medicine, National Taiwan University Hospital Hsin-Chu Branch, No. 25, Ln. 442, Sec. 1, Jing-guo Rd., North Dist., Hsinchu 310, Taiwan.
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16
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Rubini Gimenez M, Boeddinghaus J, Nestelberger T, Koechlin L, López-Ayala P, Müller C. Implementation of the ESC 0 h/1 h high-sensitivity troponin algorithm for decision-making in the emergency department. REVISTA ESPANOLA DE CARDIOLOGIA (ENGLISH ED.) 2023; 76:468-472. [PMID: 36669731 DOI: 10.1016/j.rec.2023.01.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/10/2022] [Accepted: 12/12/2022] [Indexed: 01/19/2023]
Abstract
Diagnosis of non-ST-segment elevation acute coronary syndromes (NSTEACS) is based on 3 cornerstones: clinical presentation, 12-lead electrocardiogram, and cardiac troponin measurement. Advances in the development of high-sensitivity cardiac troponin (hs-cTn) assays have substantially improved the detection of cardiomyocyte injury in a shorter time period, and hs-cTn has consequently been established as the gold-standard biomarker for the assessment of patients with suspected NSTEACS. The implementation of these assays in clinical practice allows a faster "rule-out", especially among low-risk patients, as well as a safer and more rapid "rule-in", with its therapeutic consequences. Current guidelines for the diagnosis of NSTEACS recommend the use of hs-cTn applied in rapid diagnostic algorithms based on serial hs-cTn sampling within the first few hours. The current work provides an overview of the use of hs-cTn for the early detection of NSTEACS.
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Affiliation(s)
- Maria Rubini Gimenez
- Department of Cardiology and internal Medicine, University Heart Center Leipzig, Leipzig, Germany; Cardiovascular Research Institute of Basel, University Hospital Basel, Basel, Switzerland.
| | - Jasper Boeddinghaus
- Cardiovascular Research Institute of Basel, University Hospital Basel, Basel, Switzerland; BHF/University Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
| | - Thomas Nestelberger
- Cardiovascular Research Institute of Basel, University Hospital Basel, Basel, Switzerland
| | - Luca Koechlin
- Cardiovascular Research Institute of Basel, University Hospital Basel, Basel, Switzerland
| | - Pedro López-Ayala
- Cardiovascular Research Institute of Basel, University Hospital Basel, Basel, Switzerland
| | - Christian Müller
- Cardiovascular Research Institute of Basel, University Hospital Basel, Basel, Switzerland
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17
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Roos A, Edgren G. Using historical cardiac troponins to identify patients at a high risk of myocardial infarction. HEART (BRITISH CARDIAC SOCIETY) 2023; 109:127-133. [PMID: 35948410 PMCID: PMC9811078 DOI: 10.1136/heartjnl-2022-321198] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Accepted: 07/18/2022] [Indexed: 02/04/2023]
Abstract
OBJECTIVE Many patients who present with chest pain have previous measurements of high-sensitivity cardiac troponin T (hs-cTnT). The clinical usefulness of incorporating these measurements in identifying patients who are at a high risk of myocardial infarction (MI) is unknown. We investigated if the relative change between a historical hs-cTnT and the admission hs-cTnT could improve early identification of patients with a high risk of MI. METHODS We included all patients presenting with chest pain to seven different emergency departments (EDs) in Sweden from December 2009 to December 2016, who had at least one hs-cTnT measurement at the presentation and at least one available prior measurement. We used logistic regression to investigate the diagnostic performance of using various combinations of current and historical hs-cTnT measurements in diagnosing MI within 30 days. RESULTS A total of 27 809 visits were included, among whom 2686 (9.7%) had an MI within 30 days. A cut-off value for historical hs-cTnT-adjusted admission hs-cTnT with similar specificity (91.2%) as an admission hs-cTnT of ≥52 ng/L identified 4% more MIs (43% vs 39%) and had a higher positive predictive value, 42.6% (95% CI, 41.0% to 44.3%) vs 38.9% (95% CI 37.4% to 40.4%), as well as a higher positive likelihood ratio, 6.95 (95% CI 6.69 to 7.22) vs 5.95 (95% CI 5.73 to 6.18). Among patients with an admission hs-cTnT of <52 ng/L who were classified as high-risk patients when incorporating past hs-cTnT measurements, 28% suffered an MI. CONCLUSIONS Historical hs-cTnT levels can be used with admission hs-cTnT to improve early risk stratification of MI in the ED.
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Affiliation(s)
- Andreas Roos
- Department of Emergency and Reparative Medicine, Karolinska University Hospital, Huddinge Stockholm, Sweden,Department of Medicine Clinical Epidemiology Division, Karolinska Institutet, Solna Stockholm, Sweden
| | - Gustaf Edgren
- Department of Medicine Clinical Epidemiology Division, Karolinska Institutet, Solna Stockholm, Sweden
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18
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Ohtake H, Terasawa T, Zhelev Z, Iwata M, Rogers M, Peters JL, Hyde C. Serial high-sensitivity cardiac troponin testing for the diagnosis of myocardial infarction: a scoping review. BMJ Open 2022; 12:e066429. [PMID: 36414302 PMCID: PMC9685223 DOI: 10.1136/bmjopen-2022-066429] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVES We aimed to assess the diversity and practices of existing studies on several assays and algorithms for serial measurements of high-sensitivity cardiac troponin (hs-cTn) for risk stratification and the diagnosis of myocardial infarction (MI) and 30-day outcomes in patients suspected of having non-ST-segment elevation MI (NSTEMI). METHODS We searched multiple databases including MEDLINE, EMBASE, Science Citation Index, the Cochrane Database of Systematic Reviews and the CENTRAL databases for studies published between January 2006 and November 2021. Studies that assessed the diagnostic accuracy of serial hs-cTn testing in patients suspected of having NSTEMI in the emergency department (ED) were eligible. Data were analysed using the scoping review method. RESULTS We included 86 publications, mainly from research centres in Europe, North America and Australasia. Two hs-cTn assays, manufactured by Abbott (43/86) and Roche (53/86), dominated the evaluations. The studies most commonly measured the concentrations of hs-cTn at two time points, at presentation and a few hours thereafter, to assess the two-strata or three-strata algorithm for diagnosing or ruling out MI. Although data from 83 studies (97%) were prospectively collected, 0%-90% of the eligible patients were excluded from the analysis due to missing blood samples or the lack of a final diagnosis in 53 studies (62%) that reported relevant data. Only 19 studies (22%) reported on head-to-head comparisons of alternative assays. CONCLUSION Evidence on the accuracy of serial hs-cTn testing was largely derived from selected research institutions and relied on two specific assays. The proportions of the eligible patients excluded from the study raise concerns about directly applying the study findings to clinical practice in frontline EDs. PROSPERO REGISTRATION NUMBER CRD42018106379.
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Affiliation(s)
- Hirotaka Ohtake
- Department of Emergency and General Internal Medicine, Fujita Health University, Toyoake, Aichi, Japan
| | - Teruhiko Terasawa
- Department of Emergency and General Internal Medicine, Fujita Health University, Toyoake, Aichi, Japan
| | - Zhivko Zhelev
- University of Exeter Medical School, University of Exeter, Exeter, UK
| | - Mitsunaga Iwata
- Department of Emergency and General Internal Medicine, Fujita Health University, Toyoake, Aichi, Japan
| | - Morwenna Rogers
- NIHR CLAHRC South West Peninsula, University of Exeter, Exeter, UK
| | - Jaime L Peters
- Peninsula Technology Assessment Group (PenTAG), University of Exeter, Exeter, UK
- Peninsula Technology Assessment Group (PenTAG), University of Exeter, Exeter, UK
| | - Chris Hyde
- Exeter Test Group, University of Exeter, Exeter, UK
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19
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Kontos MC, de Lemos JA, Deitelzweig SB, Diercks DB, Gore MO, Hess EP, McCarthy CP, McCord JK, Musey PI, Villines TC, Wright LJ. 2022 ACC Expert Consensus Decision Pathway on the Evaluation and Disposition of Acute Chest Pain in the Emergency Department: A Report of the American College of Cardiology Solution Set Oversight Committee. J Am Coll Cardiol 2022; 80:1925-1960. [PMID: 36241466 PMCID: PMC10691881 DOI: 10.1016/j.jacc.2022.08.750] [Citation(s) in RCA: 40] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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20
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Lowry MT, Doudesis D, Wereski R, Kimenai DM, Tuck C, Ferry AV, Bularga A, Taggart C, Lee KK, Chapman AR, Shah AS, Newby DE, Mills NL, Anand A. Influence of Age on the Diagnosis of Myocardial Infarction. Circulation 2022; 146:1135-1148. [PMID: 36106552 PMCID: PMC9555758 DOI: 10.1161/circulationaha.122.059994] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Accepted: 08/04/2022] [Indexed: 01/24/2023]
Abstract
BACKGROUND The 99th centile of cardiac troponin, derived from a healthy reference population, is recommended as the diagnostic threshold for myocardial infarction, but troponin concentrations are strongly influenced by age. Our aim was to assess the diagnostic performance of cardiac troponin in older patients presenting with suspected myocardial infarction. METHODS In a secondary analysis of a multicenter trial of consecutive patients with suspected myocardial infarction, we assessed the diagnostic accuracy of high-sensitivity cardiac troponin I at presentation for the diagnosis of type 1, type 2, or type 4b myocardial infarction across 3 age groups (<50, 50-74, and ≥75 years) using guideline-recommended sex-specific and age-adjusted 99th centile thresholds. RESULTS In 46 435 consecutive patients aged 18 to 108 years (mean, 61±17 years), 5216 (11%) had a diagnosis of myocardial infarction. In patients <50 (n=12 379), 50 to 74 (n=22 380), and ≥75 (n=11 676) years, the sensitivity of the guideline-recommended threshold was similar at 79.2% (95% CI, 75.5-82.9), 80.6% (95% CI, 79.2-82.1), and 81.6% (95% CI, 79.8-83.2), respectively. The specificity decreased with advancing age from 98.3% (95% CI, 98.1-98.5) to 95.5% (95% CI, 95.2-95.8), and 82.6% (95% CI, 81.9-83.4). The use of age-adjusted 99th centile thresholds improved the specificity (91.3% [90.8%-91.9%] versus 82.6% [95% CI, 81.9%-83.4%]) and positive predictive value (59.3% [57.0%-61.5%] versus 51.5% [49.9%-53.3%]) for myocardial infarction in patients ≥75 years but failed to prevent the decrease in either parameter with increasing age and resulted in a marked reduction in sensitivity compared with the use of the guideline-recommended threshold (55.9% [53.6%-57.9%] versus 81.6% [79.8%-83.3%]. CONCLUSIONS Age alters the diagnostic performance of cardiac troponin, with reduced specificity and positive predictive value in older patients when applying the guideline-recommended or age-adjusted 99th centiles. Individualized diagnostic approaches rather than the adjustment of binary thresholds are needed in an aging population.
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Affiliation(s)
- Matthew T.H. Lowry
- BHF Centre for Cardiovascular Science (M.T.H.L., D.D., R.W., D.M.K., C.T., A.V.F., A.B., C.T., K.K.L., A.R.C., D.E.N., N.L.M., A.A.), University of Edinburgh, UK
| | - Dimitrios Doudesis
- BHF Centre for Cardiovascular Science (M.T.H.L., D.D., R.W., D.M.K., C.T., A.V.F., A.B., C.T., K.K.L., A.R.C., D.E.N., N.L.M., A.A.), University of Edinburgh, UK
- Usher Institute (D.D., N.L.M.), University of Edinburgh, UK
| | - Ryan Wereski
- BHF Centre for Cardiovascular Science (M.T.H.L., D.D., R.W., D.M.K., C.T., A.V.F., A.B., C.T., K.K.L., A.R.C., D.E.N., N.L.M., A.A.), University of Edinburgh, UK
| | - Dorien M. Kimenai
- BHF Centre for Cardiovascular Science (M.T.H.L., D.D., R.W., D.M.K., C.T., A.V.F., A.B., C.T., K.K.L., A.R.C., D.E.N., N.L.M., A.A.), University of Edinburgh, UK
| | - Christopher Tuck
- BHF Centre for Cardiovascular Science (M.T.H.L., D.D., R.W., D.M.K., C.T., A.V.F., A.B., C.T., K.K.L., A.R.C., D.E.N., N.L.M., A.A.), University of Edinburgh, UK
| | - Amy V. Ferry
- BHF Centre for Cardiovascular Science (M.T.H.L., D.D., R.W., D.M.K., C.T., A.V.F., A.B., C.T., K.K.L., A.R.C., D.E.N., N.L.M., A.A.), University of Edinburgh, UK
| | - Anda Bularga
- BHF Centre for Cardiovascular Science (M.T.H.L., D.D., R.W., D.M.K., C.T., A.V.F., A.B., C.T., K.K.L., A.R.C., D.E.N., N.L.M., A.A.), University of Edinburgh, UK
| | - Caelan Taggart
- BHF Centre for Cardiovascular Science (M.T.H.L., D.D., R.W., D.M.K., C.T., A.V.F., A.B., C.T., K.K.L., A.R.C., D.E.N., N.L.M., A.A.), University of Edinburgh, UK
| | - Kuan K. Lee
- BHF Centre for Cardiovascular Science (M.T.H.L., D.D., R.W., D.M.K., C.T., A.V.F., A.B., C.T., K.K.L., A.R.C., D.E.N., N.L.M., A.A.), University of Edinburgh, UK
| | - Andrew R. Chapman
- BHF Centre for Cardiovascular Science (M.T.H.L., D.D., R.W., D.M.K., C.T., A.V.F., A.B., C.T., K.K.L., A.R.C., D.E.N., N.L.M., A.A.), University of Edinburgh, UK
| | - Anoop S.V. Shah
- Department of Non-communicable Disease, London School of Hygiene and Tropical Medicine, UK (A.S.V.S.)
- Department of Cardiology, Imperial College Healthcare NHS Trust, London, UK (A.S.V.S.)
| | - David E. Newby
- BHF Centre for Cardiovascular Science (M.T.H.L., D.D., R.W., D.M.K., C.T., A.V.F., A.B., C.T., K.K.L., A.R.C., D.E.N., N.L.M., A.A.), University of Edinburgh, UK
| | - Nicholas L. Mills
- BHF Centre for Cardiovascular Science (M.T.H.L., D.D., R.W., D.M.K., C.T., A.V.F., A.B., C.T., K.K.L., A.R.C., D.E.N., N.L.M., A.A.), University of Edinburgh, UK
| | - Atul Anand
- BHF Centre for Cardiovascular Science (M.T.H.L., D.D., R.W., D.M.K., C.T., A.V.F., A.B., C.T., K.K.L., A.R.C., D.E.N., N.L.M., A.A.), University of Edinburgh, UK
- Usher Institute (D.D., N.L.M.), University of Edinburgh, UK
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21
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du Fay de Lavallaz J, Prepoudis A, Wendebourg MJ, Kesenheimer E, Kyburz D, Daikeler T, Haaf P, Wanschitz J, Löscher WN, Schreiner B, Katan M, Jung HH, Maurer B, Hammerer-Lercher A, Mayr A, Gualandro DM, Acket A, Puelacher C, Boeddinghaus J, Nestelberger T, Lopez-Ayala P, Glarner N, Shrestha S, Manka R, Gawinecka J, Piscuoglio S, Gallon J, Wiedemann S, Sinnreich M, Mueller C. Skeletal Muscle Disorders: A Noncardiac Source of Cardiac Troponin T. Circulation 2022; 145:1764-1779. [PMID: 35389756 PMCID: PMC10069758 DOI: 10.1161/circulationaha.121.058489] [Citation(s) in RCA: 31] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
BACKGROUND Cardiac troponin (cTn) T and cTnI are considered cardiac specific and equivalent in the diagnosis of acute myocardial infarction. Previous studies suggested rare skeletal myopathies as a noncardiac source of cTnT. We aimed to confirm the reliability/cardiac specificity of cTnT in patients with various skeletal muscle disorders (SMDs). METHODS We prospectively enrolled patients presenting with muscular complaints (≥2 weeks) for elective evaluation in 4 hospitals in 2 countries. After a cardiac workup, patients were adjudicated into 3 predefined cardiac disease categories. Concentrations of cTnT/I and resulting cTnT/I mismatches were assessed with high-sensitivity (hs-) cTnT (hs-cTnT-Elecsys) and 3 hs-cTnI assays (hs-cTnI-Architect, hs-cTnI-Access, hs-cTnI-Vista) and compared with those of control subjects without SMD presenting with adjudicated noncardiac chest pain to the emergency department (n=3508; mean age, 55 years; 37% female). In patients with available skeletal muscle biopsies, TNNT/I1-3 mRNA differential gene expression was compared with biopsies obtained in control subjects without SMD. RESULTS Among 211 patients (mean age, 57 years; 42% female), 108 (51%) were adjudicated to having no cardiac disease, 44 (21%) to having mild disease, and 59 (28%) to having severe cardiac disease. hs-cTnT/I concentrations significantly increased from patients with no to those with mild and severe cardiac disease for all assays (all P<0.001). hs-cTnT-Elecsys concentrations were significantly higher in patients with SMD versus control subjects (median, 16 ng/L [interquartile range (IQR), 7-32.5 ng/L] versus 5 ng/L [IQR, 3-9 ng/L]; P<0.001), whereas hs-cTnI concentrations were mostly similar (hs-cTnI-Architect, 2.5 ng/L [IQR, 1.2-6.2 ng/L] versus 2.9 ng/L [IQR, 1.8-5.0 ng/L]; hs-cTnI-Access, 3.3 ng/L [IQR, 2.4-6.1 ng/L] versus 2.7 ng/L [IQR, 1.6-5.0 ng/L]; and hs-cTnI-Vista, 7.4 ng/L [IQR, 5.2-13.4 ng/L] versus 7.5 ng/L [IQR, 6-10 ng/L]). hs-cTnT-Elecsys concentrations were above the upper limit of normal in 55% of patients with SMD versus 13% of control subjects (P<0.01). mRNA analyses in skeletal muscle biopsies (n=33), mostly (n=24) from individuals with noninflammatory myopathy and myositis, showed 8-fold upregulation of TNNT2, encoding cTnT (but none for TNNI3, encoding cTnI) versus control subjects (n=16, PWald<0.001); the expression correlated with pathological disease activity (R=0.59, Pt-statistic<0.001) and circulating hs-cTnT concentrations (R=0.26, Pt-statistic=0.031). CONCLUSIONS In patients with active chronic SMD, elevations in cTnT concentrations are common and not attributable to cardiac disease in the majority. This was not observed for cTnI and may be explained in part by re-expression of cTnT in skeletal muscle. REGISTRATION URL: https://www. CLINICALTRIALS gov; Unique identifier: NCT03660969.
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Affiliation(s)
- Jeanne du Fay de Lavallaz
- Cardiovascular Research Institute Basel (J.d.F.d.L., A.P., P.H., D.M.G., A.A., C.P., J.B., T.N., P.L.-A., N.G., S.S., S.P., J. Gallon, S.W., C.M.), University Hospital of Basel, Switzerland.,Department of Cardiology (J.d.F.d.L., A.P., P.H., D.M.G., A.A., C.P., J.B., T.N., P.L.-A., N.G., S.S., S.P., J. Gallon, S.W., C.M.), University Hospital of Basel, Switzerland
| | - Alexandra Prepoudis
- Cardiovascular Research Institute Basel (J.d.F.d.L., A.P., P.H., D.M.G., A.A., C.P., J.B., T.N., P.L.-A., N.G., S.S., S.P., J. Gallon, S.W., C.M.), University Hospital of Basel, Switzerland.,Department of Cardiology (J.d.F.d.L., A.P., P.H., D.M.G., A.A., C.P., J.B., T.N., P.L.-A., N.G., S.S., S.P., J. Gallon, S.W., C.M.), University Hospital of Basel, Switzerland
| | - Maria Janina Wendebourg
- Neurology Clinic and Policlinic (M.J.W., E.K., M.S.), University Hospital of Basel, Switzerland
| | - Eva Kesenheimer
- Neurology Clinic and Policlinic (M.J.W., E.K., M.S.), University Hospital of Basel, Switzerland
| | - Diego Kyburz
- Department of Rheumatology (D.K., T.D.), University Hospital of Basel, Switzerland.,University of Basel, Switzerland (D.K., M.S., C.M.)
| | - Thomas Daikeler
- Department of Rheumatology (D.K., T.D.), University Hospital of Basel, Switzerland
| | - Philip Haaf
- Cardiovascular Research Institute Basel (J.d.F.d.L., A.P., P.H., D.M.G., A.A., C.P., J.B., T.N., P.L.-A., N.G., S.S., S.P., J. Gallon, S.W., C.M.), University Hospital of Basel, Switzerland
| | - Julia Wanschitz
- Departments of Neurology (J.W., W.N.L.), Medical University of Innsbruck, Austria
| | - Wolfgang N Löscher
- Departments of Neurology (J.W., W.N.L.), Medical University of Innsbruck, Austria
| | - Bettina Schreiner
- Departments of Neurology (B.S., M.K., H.H.J.), University Hospital of Zürich, Switzerland
| | - Mira Katan
- Departments of Neurology (B.S., M.K., H.H.J.), University Hospital of Zürich, Switzerland
| | - Hans H Jung
- Departments of Neurology (B.S., M.K., H.H.J.), University Hospital of Zürich, Switzerland
| | - Britta Maurer
- Rheumatology (B.M.), University Hospital of Zürich, Switzerland.,Department of Rheumatology and Immunology, Inselspital Bern, Switzerland (B.M.)
| | | | - Agnes Mayr
- Radiology (A.M.), Medical University of Innsbruck, Austria
| | - Danielle M Gualandro
- Cardiovascular Research Institute Basel (J.d.F.d.L., A.P., P.H., D.M.G., A.A., C.P., J.B., T.N., P.L.-A., N.G., S.S., S.P., J. Gallon, S.W., C.M.), University Hospital of Basel, Switzerland.,Department of Cardiology (J.d.F.d.L., A.P., P.H., D.M.G., A.A., C.P., J.B., T.N., P.L.-A., N.G., S.S., S.P., J. Gallon, S.W., C.M.), University Hospital of Basel, Switzerland
| | - Annemarie Acket
- Cardiovascular Research Institute Basel (J.d.F.d.L., A.P., P.H., D.M.G., A.A., C.P., J.B., T.N., P.L.-A., N.G., S.S., S.P., J. Gallon, S.W., C.M.), University Hospital of Basel, Switzerland.,Neurology Clinic and Policlinic (M.J.W., E.K., M.S.), University Hospital of Basel, Switzerland
| | - Christian Puelacher
- Cardiovascular Research Institute Basel (J.d.F.d.L., A.P., P.H., D.M.G., A.A., C.P., J.B., T.N., P.L.-A., N.G., S.S., S.P., J. Gallon, S.W., C.M.), University Hospital of Basel, Switzerland.,Department of Cardiology (J.d.F.d.L., A.P., P.H., D.M.G., A.A., C.P., J.B., T.N., P.L.-A., N.G., S.S., S.P., J. Gallon, S.W., C.M.), University Hospital of Basel, Switzerland
| | - Jasper Boeddinghaus
- Cardiovascular Research Institute Basel (J.d.F.d.L., A.P., P.H., D.M.G., A.A., C.P., J.B., T.N., P.L.-A., N.G., S.S., S.P., J. Gallon, S.W., C.M.), University Hospital of Basel, Switzerland.,Department of Cardiology (J.d.F.d.L., A.P., P.H., D.M.G., A.A., C.P., J.B., T.N., P.L.-A., N.G., S.S., S.P., J. Gallon, S.W., C.M.), University Hospital of Basel, Switzerland
| | - Thomas Nestelberger
- Cardiovascular Research Institute Basel (J.d.F.d.L., A.P., P.H., D.M.G., A.A., C.P., J.B., T.N., P.L.-A., N.G., S.S., S.P., J. Gallon, S.W., C.M.), University Hospital of Basel, Switzerland.,Department of Cardiology (J.d.F.d.L., A.P., P.H., D.M.G., A.A., C.P., J.B., T.N., P.L.-A., N.G., S.S., S.P., J. Gallon, S.W., C.M.), University Hospital of Basel, Switzerland.,Division of Cardiology, Vancouver General Hospital, University of British Columbia, Canada (T.N.)
| | - Pedro Lopez-Ayala
- Cardiovascular Research Institute Basel (J.d.F.d.L., A.P., P.H., D.M.G., A.A., C.P., J.B., T.N., P.L.-A., N.G., S.S., S.P., J. Gallon, S.W., C.M.), University Hospital of Basel, Switzerland.,Department of Cardiology (J.d.F.d.L., A.P., P.H., D.M.G., A.A., C.P., J.B., T.N., P.L.-A., N.G., S.S., S.P., J. Gallon, S.W., C.M.), University Hospital of Basel, Switzerland
| | - Noemi Glarner
- Cardiovascular Research Institute Basel (J.d.F.d.L., A.P., P.H., D.M.G., A.A., C.P., J.B., T.N., P.L.-A., N.G., S.S., S.P., J. Gallon, S.W., C.M.), University Hospital of Basel, Switzerland.,Department of Cardiology (J.d.F.d.L., A.P., P.H., D.M.G., A.A., C.P., J.B., T.N., P.L.-A., N.G., S.S., S.P., J. Gallon, S.W., C.M.), University Hospital of Basel, Switzerland
| | - Samyut Shrestha
- Cardiovascular Research Institute Basel (J.d.F.d.L., A.P., P.H., D.M.G., A.A., C.P., J.B., T.N., P.L.-A., N.G., S.S., S.P., J. Gallon, S.W., C.M.), University Hospital of Basel, Switzerland.,Department of Cardiology (J.d.F.d.L., A.P., P.H., D.M.G., A.A., C.P., J.B., T.N., P.L.-A., N.G., S.S., S.P., J. Gallon, S.W., C.M.), University Hospital of Basel, Switzerland
| | - Robert Manka
- Cardiology (R.M.), University Hospital of Zürich, Switzerland
| | - Joanna Gawinecka
- Institute of Clinical Chemistry (J. Gawinecka), University Hospital of Zürich, Switzerland
| | - Salvatore Piscuoglio
- Cardiovascular Research Institute Basel (J.d.F.d.L., A.P., P.H., D.M.G., A.A., C.P., J.B., T.N., P.L.-A., N.G., S.S., S.P., J. Gallon, S.W., C.M.), University Hospital of Basel, Switzerland.,Department of Cardiology (J.d.F.d.L., A.P., P.H., D.M.G., A.A., C.P., J.B., T.N., P.L.-A., N.G., S.S., S.P., J. Gallon, S.W., C.M.), University Hospital of Basel, Switzerland.,Department of Biomedicine (S.P., J. Gallon, S.W.), University Hospital of Basel, Switzerland
| | - John Gallon
- Cardiovascular Research Institute Basel (J.d.F.d.L., A.P., P.H., D.M.G., A.A., C.P., J.B., T.N., P.L.-A., N.G., S.S., S.P., J. Gallon, S.W., C.M.), University Hospital of Basel, Switzerland.,Department of Cardiology (J.d.F.d.L., A.P., P.H., D.M.G., A.A., C.P., J.B., T.N., P.L.-A., N.G., S.S., S.P., J. Gallon, S.W., C.M.), University Hospital of Basel, Switzerland.,Department of Biomedicine (S.P., J. Gallon, S.W.), University Hospital of Basel, Switzerland
| | - Sophia Wiedemann
- Cardiovascular Research Institute Basel (J.d.F.d.L., A.P., P.H., D.M.G., A.A., C.P., J.B., T.N., P.L.-A., N.G., S.S., S.P., J. Gallon, S.W., C.M.), University Hospital of Basel, Switzerland.,Department of Cardiology (J.d.F.d.L., A.P., P.H., D.M.G., A.A., C.P., J.B., T.N., P.L.-A., N.G., S.S., S.P., J. Gallon, S.W., C.M.), University Hospital of Basel, Switzerland.,Department of Biomedicine (S.P., J. Gallon, S.W.), University Hospital of Basel, Switzerland
| | - Michael Sinnreich
- Neurology Clinic and Policlinic (M.J.W., E.K., M.S.), University Hospital of Basel, Switzerland.,University of Basel, Switzerland (D.K., M.S., C.M.)
| | - Christian Mueller
- Cardiovascular Research Institute Basel (J.d.F.d.L., A.P., P.H., D.M.G., A.A., C.P., J.B., T.N., P.L.-A., N.G., S.S., S.P., J. Gallon, S.W., C.M.), University Hospital of Basel, Switzerland.,Department of Cardiology (J.d.F.d.L., A.P., P.H., D.M.G., A.A., C.P., J.B., T.N., P.L.-A., N.G., S.S., S.P., J. Gallon, S.W., C.M.), University Hospital of Basel, Switzerland.,University of Basel, Switzerland (D.K., M.S., C.M.)
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22
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McCord J, Gibbs J, Hudson M, Moyer M, Jacobsen G, Murtagh G, Nowak R. Machine Learning to Assess for Acute Myocardial Infarction Within 30 Minutes. Crit Pathw Cardiol 2022; 21:67-72. [PMID: 35190507 DOI: 10.1097/hpc.0000000000000281] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Variations in high-sensitivity cardiac troponin I by age and sex along with various sampling times can make the evaluation for acute myocardial infarction (AMI) challenging. Machine learning integrates these variables to allow a more accurate evaluation for possible AMI. The goal was to test the diagnostic and prognostic utility of a machine learning algorithm in the evaluation of possible AMI. We applied a machine learning algorithm (myocardial-ischemic-injury-index [MI3]) that incorporates age, sex, and high-sensitivity cardiac troponin I levels at time 0 and 30 minutes in 529 patients evaluated for possible AMI in a single urban emergency department. MI3 generates an index value from 0 to 100 reflecting the likelihood of AMI. Patients were followed at 30-45 days for major adverse cardiac events (MACEs). There were 42 (7.9%) patients that had an AMI. Patients were divided into 3 groups by the MI3 score: low-risk (≤ 3.13), intermediate-risk (> 3.13-51.0), and high-risk (> 51.0). The sensitivity for AMI was 100% with a MI3 value ≤ 3.13 and 353 (67%) ruled-out for AMI at 30 minutes. At 30-45 days, there were 2 (0.6%) MACEs (2 noncardiac deaths) in the low-risk group, in the intermediate-risk group 4 (3.0%) MACEs (3 AMIs, 1 cardiac death), and in the high-risk group 4 (9.1%) MACEs (4 AMIs, 2 cardiac deaths). The MI3 algorithm had 100% sensitivity for AMI at 30 minutes and identified a low-risk cohort who may be considered for early discharge.
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Affiliation(s)
- James McCord
- From the Heart and Vascular Institute, Henry Ford Hospital, Detroit, MI
| | - Joseph Gibbs
- From the Heart and Vascular Institute, Henry Ford Hospital, Detroit, MI
| | - Michael Hudson
- From the Heart and Vascular Institute, Henry Ford Hospital, Detroit, MI
| | - Michele Moyer
- Department of Emergency Medicine, Henry Ford Hospital, Detroit, MI
| | - Gordon Jacobsen
- Biostatistics, Department of Public Health Sciences, Henry Ford Health System, Detroit, MI
| | | | - Richard Nowak
- Department of Emergency Medicine, Henry Ford Hospital, Detroit, MI
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23
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Chaulin AM. Metabolic Pathway of Cardiospecific Troponins: From Fundamental Aspects to Diagnostic Role (Comprehensive Review). Front Mol Biosci 2022; 9:841277. [PMID: 35517866 PMCID: PMC9062030 DOI: 10.3389/fmolb.2022.841277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Accepted: 03/28/2022] [Indexed: 11/28/2022] Open
Abstract
Many molecules of the human body perform key regulatory functions and are widely used as targets for the development of therapeutic drugs or as specific diagnostic markers. These molecules undergo a significant metabolic pathway, during which they are influenced by a number of factors (biological characteristics, hormones, enzymes, etc.) that can affect molecular metabolism and, as a consequence, the serum concentration or activity of these molecules. Among the most important molecules in the field of cardiology are the molecules of cardiospecific troponins (Tns), which regulate the processes of myocardial contraction/relaxation and are used as markers for the early diagnosis of ischemic necrosis of cardiomyocytes (CMC) in myocardial infarction (MI). The diagnostic value and diagnostic capabilities of cardiospecific Tns have changed significantly after the advent of new (highly sensitive (HS)) detection methods. Thus, early diagnostic algorithms of MI were approved for clinical practice, thanks to which the possibility of rapid diagnosis and determination of optimal tactics for managing patients with MI was opened. Relatively recently, promising directions have also been opened for the use of cardiospecific Tns as prognostic markers both at the early stages of the development of cardiovascular diseases (CVD) (arterial hypertension (AH), heart failure (HF), coronary heart disease (CHD), etc.), and in non-ischemic extra-cardiac pathologies that can negatively affect CMC (for example, sepsis, chronic kidney disease (CKD), chronic obstructive pulmonary disease (COPD), etc.). Recent studies have also shown that cardiospecific Tns are present not only in blood serum, but also in other biological fluids (urine, oral fluid, pericardial fluid, amniotic fluid). Thus, cardiospecific Tns have additional diagnostic capabilities. However, the fundamental aspects of the metabolic pathway of cardiospecific Tns are definitively unknown, in particular, specific mechanisms of release of Tns from CMC in non-ischemic extra-cardiac pathologies, mechanisms of circulation and elimination of Tns from the human body, mechanisms of transport of Tns to other biological fluids and factors that may affect these processes have not been established. In this comprehensive manuscript, all stages of the metabolic pathway are consistently and in detail considered, starting from release from CMC and ending with excretion (removal) from the human body. In addition, the possible diagnostic role of individual stages and mechanisms, influencing factors is analyzed and directions for further research in this area are noted.
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Affiliation(s)
- Aleksey M Chaulin
- Department of Cardiology and Cardiovascular Surgery, Department of Clinical Chemistry, Samara State Medical University, Samara, Russia.,Samara Regional Clinical Cardiological Dispensary, Samara, Russia
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24
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Baigent C, Windecker S, Andreini D, Arbelo E, Barbato E, Bartorelli AL, Baumbach A, Behr ER, Berti S, Bueno H, Capodanno D, Cappato R, Chieffo A, Collet JP, Cuisset T, de Simone G, Delgado V, Dendale P, Dudek D, Edvardsen T, Elvan A, González-Juanatey JR, Gori M, Grobbee D, Guzik TJ, Halvorsen S, Haude M, Heidbuchel H, Hindricks G, Ibanez B, Karam N, Katus H, Klok FA, Konstantinides SV, Landmesser U, Leclercq C, Leonardi S, Lettino M, Marenzi G, Mauri J, Metra M, Morici N, Mueller C, Petronio AS, Polovina MM, Potpara T, Praz F, Prendergast B, Prescott E, Price S, Pruszczyk P, Rodríguez-Leor O, Roffi M, Romaguera R, Rosenkranz S, Sarkozy A, Scherrenberg M, Seferovic P, Senni M, Spera FR, Stefanini G, Thiele H, Tomasoni D, Torracca L, Touyz RM, Wilde AA, Williams B. European Society of Cardiology guidance for the diagnosis and management of cardiovascular disease during the COVID-19 pandemic: part 1-epidemiology, pathophysiology, and diagnosis. Cardiovasc Res 2022; 118:1385-1412. [PMID: 34864874 PMCID: PMC8690255 DOI: 10.1093/cvr/cvab342] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
AIMS Since its emergence in early 2020, the novel severe acute respiratory syndrome coronavirus 2 causing coronavirus disease 2019 (COVID-19) has reached pandemic levels, and there have been repeated outbreaks across the globe. The aim of this two-part series is to provide practical knowledge and guidance to aid clinicians in the diagnosis and management of cardiovascular disease (CVD) in association with COVID-19. METHODS AND RESULTS A narrative literature review of the available evidence has been performed, and the resulting information has been organized into two parts. The first, reported here, focuses on the epidemiology, pathophysiology, and diagnosis of cardiovascular (CV) conditions that may be manifest in patients with COVID-19. The second part, which will follow in a later edition of the journal, addresses the topics of care pathways, treatment, and follow-up of CV conditions in patients with COVID-19. CONCLUSION This comprehensive review is not a formal guideline but rather a document that provides a summary of current knowledge and guidance to practicing clinicians managing patients with CVD and COVID-19. The recommendations are mainly the result of observations and personal experience from healthcare providers. Therefore, the information provided here may be subject to change with increasing knowledge, evidence from prospective studies, and changes in the pandemic. Likewise, the guidance provided in the document should not interfere with recommendations provided by local and national healthcare authorities.
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Affiliation(s)
- Colin Baigent
- MRC Population Health Research Unit, Nuffield Department of Population Health, Richard Doll Building, Old Road Campus, Roosevelt Drive, Oxford OX3 7LF, UK
| | - Stephan Windecker
- Department of Cardiology, Inselspital, Bern University Hospital, Freiburgstrasse 4, 3010 Bern, Switzerland
| | - Daniele Andreini
- Centro Cardiologico Monzino, IRCCS, Milan, Italy
- Department of Clinical Sciences and Community Health, Hospital Clínic
| | - Elena Arbelo
- Arrhythmia Section, Cardiology Department, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain
- Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
- ECGen, the Cardiogenetics Focus Group of EHRA
| | - Emanuele Barbato
- Department of Advanced Biomedical Sciences, Federico II University, Naples, Italy
- Cardiovascular Center Aalst, OLV Hospital, Aalst, Belgium
| | - Antonio L Bartorelli
- Centro Cardiologico Monzino, IRCCS, Milan, Italy
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
- Department of Biomedical and Clinical Sciences "Luigi Sacco", University of Milan, Milan, Italy
| | - Andreas Baumbach
- Centre for Cardiovascular Medicine and Devices, William Harvey Research Institute, Queen Mary University of London and Barts Heart Centre, London, UK
- Yale University School of Medicine, New Haven, CT, USA
| | - Elijah R Behr
- ECGen, the Cardiogenetics Focus Group of EHRA
- Cardiology Clinical Academic Group, Institute of Molecular and Clinical Sciences, St George's, University of London, London, UK
- St George's University Hospitals NHS Foundation Trust, London, UK
- European Reference Network for Rare and Low Prevalence Complex Diseases of the Heart (ERN GUARDHEART)
| | - Sergio Berti
- U.O.C. Cardiologia Diagnostica e Interventistica, Dipartimento Cardiotoracico, Fondazione Toscana G. Monasterio - Ospedale del Cuore G. Pasquinucci, Massa, Italy
| | - Héctor Bueno
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
- Cardiology Department, Hospital Universitario 12 de Octubre and Instituto de Investigación Sanitaria Hospital 12 de Octubre (imas12), Madrid, Spain
- Centro Nacional de Investigaciones Cardiovasculares (CNIC), Madrid, Spain
| | - Davide Capodanno
- Division of Cardiology, A.O.U. Policlinico "G. Rodolico-San Marco" University of Catania, Catania, Italy
| | - Riccardo Cappato
- Arrhythmia & Electrophysiology Center, IRCCS Gruppo MultiMedica, Sesto San Giovanni, Milan, Italy
| | | | - Jean-Philippe Collet
- Sorbonne Université, ACTION study group, Institut de Cardiologie, Pitié Salpêtrière Hospital (AP-HP), Paris, France
| | - Thomas Cuisset
- Département de Cardiologie, CHU Timone, Marseille, France
- INSERM, UMR1062, Nutrition, Obesity and Risk of Thrombosis, Marseille, France
- Faculté de Médecine, Aix-Marseille Université, Marseille, France
| | - Giovanni de Simone
- Department of Advanced Biomedical Sciences, Federico II University, Naples, Italy
- Hypertension Research Center, Federico II University Hospital, Naples, Italy
| | - Victoria Delgado
- Heart Lung Centrum, Leiden University Medical Center, Leiden, The Netherlands
| | - Paul Dendale
- Heart Centre Hasselt, Jessa Hospital, Hasselt, Belgium
- Faculty of Medicine and Life Sciences, Uhasselt, Diepenbeek, Belgium
| | - Dariusz Dudek
- Institute of Cardiology, Jagiellonian University Medical College, Kraków, Poland
- Maria Cecilia Hospital, GVM Care&Research, Cotignola (RA), Ravenna, Italy
| | - Thor Edvardsen
- Department of Cardiology, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | - Arif Elvan
- Isala Heart Center, Zwolle, The Netherlands
| | - José R González-Juanatey
- Cardiology Department, University Hospital, IDIS, CIBERCV, University of Santiago de Compostela, Santiago de Compostela, Spain
| | - Mauro Gori
- Cardiovascular Department and Cardiology Unit, Papa Giovanni XXIII Hospital-Bergamo, Bergamo, Italy
| | - Diederick Grobbee
- Julius Global Health, the Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Tomasz J Guzik
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
- Department of Medicine, Jagiellonian University College of Medicine, Kraków, Poland
| | - Sigrun Halvorsen
- Department of Cardiology, Oslo University Hospital Ulleval, Oslo, Norway
- University of Oslo, Oslo, Norway
| | - Michael Haude
- Medical Clinic I, Städtische Kliniken Neuss, Lukaskrankenhaus GmbH, Neuss, Germany
| | - Hein Heidbuchel
- Department of Cardiology, University Hospital Antwerp and University of Antwerp, Antwerp, Belgium
| | - Gerhard Hindricks
- Department of Internal Medicine/Cardiology/Electrophysiology, Heart Center Leipzig, University Hospital Leipzig, Leipzig, Germany
- Leipzig Heart Institute (LHI), Leipzig, Germany
| | - Borja Ibanez
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
- Centro Nacional de Investigaciones Cardiovasculares (CNIC), Madrid, Spain
- IIS-Fundación Jiménez Díaz Hospital, Madrid, Spain
| | - Nicole Karam
- Université de Paris, PARCC, INSERM, Paris, France
- European Hospital Georges Pompidou, Paris, France
| | - Hugo Katus
- Department of Internal Medicine, University Hospital of Heidelberg, Heidelberg, Germany
| | - Fredrikus A Klok
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Stavros V Konstantinides
- Center for Thrombosis and Hemostasis, Johannes Gutenberg University Mainz, Mainz, Germany
- Department of Cardiology, Democritus University of Thrace, Alexandroupolis, Greece
| | - Ulf Landmesser
- Department of Cardiology, Charite University Medicine Berlin, Berlin, Germany
- Berlin Institute of Health (BIH), German Center of Cardiovascular Research (DZHK), Partner Site Berlin, Berlin, Germany
| | | | - Sergio Leonardi
- University of Pavia, Pavia, Italy
- Fondazione IRCCS Policlinico S.Matteo, Pavia, Italy
| | - Maddalena Lettino
- Cardio-Thoracic and Vascular Department, San Gerardo Hospital, ASST-Monza, Monza, Italy
| | | | - Josepa Mauri
- Institut del Cor, Hospital Universitari Germans Trias i Pujol, Badalona, Spain
- Health Department of the Government of Catalonia, Barcelona, Spain
| | - Marco Metra
- Institute of Cardiology, ASST Spedali Civili di Brescia, Brescia, Italy
- Department of Medical and Surgical Specialities, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Nuccia Morici
- Unità di Cure Intensive Cardiologiche e De Gasperis Cardio Center, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
- Dipartimento di Scienze Cliniche e di Comunità, Università degli Studi, Milan, Italy
| | - Christian Mueller
- Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Basel, Switzerland
- University of Basel, Basel, Switzerland
| | - Anna Sonia Petronio
- Cardiothoracic and Vascular Department, University of Pisa, Ospedale Cisanello, Pisa, Italy
| | - Marija M Polovina
- Faculty of Medicine, Belgrade University, Belgrade, Serbia
- Department of Cardiology, Clinical Centre of Serbia, Belgrade, Serbia
| | - Tatjana Potpara
- School of Medicine, University of Belgrade, Belgrade, Serbia
- Department for Intensive Arrhythmia Care, Cardiology Clinic, Clinical Centre of Serbia, Belgrade, Serbia
| | - Fabien Praz
- Department of Cardiology, University Hospital Bern, Bern, Switzerland
| | | | - Eva Prescott
- Department of Cardiology, Bispebjerg University Hospital, Copenhagen, Denmark
| | - Susanna Price
- Royal Brompton Hospital, London, UK
- National Heart & Lung Institute, Imperial College, London, UK
| | - Piotr Pruszczyk
- Department of Internal Medicine and Cardiology, Medical University of Warsaw, Warsaw, Poland
| | - Oriol Rodríguez-Leor
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
- Health Department of the Government of Catalonia, Barcelona, Spain
| | - Marco Roffi
- Department of Cardiology, Geneva University Hospitals, Geneva, Switzerland
| | - Rafael Romaguera
- Servicio de Cardiología, Hospital Universitario de Bellvitge-IDIBELL, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Stephan Rosenkranz
- Clinic III for Internal Medicine (Cardiology) and Cologne Cardiovascular Research Center (CCRC), Heart Center at the University of Cologne, Cologne, Germany
- Center for Molecular Medicine Cologne (CMMC), University of Cologne, Cologne, Germany
| | - Andrea Sarkozy
- Department of Cardiology, University Hospital Antwerp and University of Antwerp, Antwerp, Belgium
| | - Martijn Scherrenberg
- Heart Centre Hasselt, Jessa Hospital, Hasselt, Belgium
- Faculty of Medicine and Life Sciences, Uhasselt, Diepenbeek, Belgium
| | - Petar Seferovic
- Faculty of Medicine, Belgrade University, Belgrade, Serbia
- Serbian Academy of Sciences and Arts, Belgrade, Serbia
| | - Michele Senni
- Cardiovascular Department and Cardiology Unit, Papa Giovanni XXIII Hospital-Bergamo, Bergamo, Italy
| | - Francesco R Spera
- Department of Cardiology, University Hospital Antwerp and University of Antwerp, Antwerp, Belgium
| | - Giulio Stefanini
- Department of Biomedical Sciences, Humanitas Clinical and Research Center, Humanitas University, Pieve Emanuele - Milan, Italy
- Humanitas Research Hospital IRCCS, Rozzano - Milan, Italy
| | - Holger Thiele
- Department of Internal Medicine/Cardiology, Heart Center Leipzig at University of Leipzig, Leipzig, Germany
- Leipzig Heart Institute (LHI), Leipzig, Germany
| | - Daniela Tomasoni
- Institute of Cardiology, ASST Spedali Civili di Brescia, Brescia, Italy
- Department of Medical and Surgical Specialities, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Luccia Torracca
- Department of Biomedical Sciences, Humanitas Clinical and Research Center, Humanitas University, Pieve Emanuele - Milan, Italy
- Humanitas Research Hospital IRCCS, Rozzano - Milan, Italy
| | - Rhian M Touyz
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Arthur A Wilde
- ECGen, the Cardiogenetics Focus Group of EHRA
- European Reference Network for Rare and Low Prevalence Complex Diseases of the Heart (ERN GUARDHEART)
- Amsterdam UMC, University of Amsterdam, Heart Center, Amsterdam, The Netherlands
- Department of Clinical Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - Bryan Williams
- Institute of Cardiovascular Sciences, University College London, London, UK
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25
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The Importance of Cardiac Troponin Metabolism in the Laboratory Diagnosis of Myocardial Infarction (Comprehensive Review). BIOMED RESEARCH INTERNATIONAL 2022; 2022:6454467. [PMID: 35402607 PMCID: PMC8986381 DOI: 10.1155/2022/6454467] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/25/2021] [Revised: 03/14/2022] [Accepted: 03/15/2022] [Indexed: 01/02/2023]
Abstract
The study of the metabolism of endogenous molecules is not only of great fundamental significance but also of high practical importance, since many molecules serve as drug targets and/or biomarkers for laboratory diagnostics of diseases. Thus, cardiac troponin molecules have long been used as the main biomarkers for confirmation of diagnosis of myocardial infarction, and with the introduction of high-sensitivity test methods, many of our ideas about metabolism of these cardiac markers have changed significantly. In clinical practice, there are opening new promising diagnostic capabilities of cardiac troponins, the understanding and justification of which are closely connected with the fundamental principles of the metabolism of these molecules. Our current knowledge about the metabolism of cardiac troponins is insufficient and extremely disconnected from various literary sources. Thus, many researchers do not sufficiently understand the potential importance of cardiac troponin metabolism in the laboratory diagnosis of myocardial infarction. The purpose of this comprehensive review is to systematize information about the metabolism of cardiac troponins and during the discussion to focus on the potential impact of cTns metabolism on the laboratory diagnosis of myocardial infarction. The format of this comprehensive review includes a sequential consideration and analysis of the stages of the metabolic pathway, starting from possible release mechanisms and ending with elimination mechanisms. This will allow doctors and researchers to understand the significant importance of cTns metabolism and its impact on the laboratory diagnosis of myocardial infarction.
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Baigent C, Windecker S, Andreini D, Arbelo E, Barbato E, Bartorelli AL, Baumbach A, Behr ER, Berti S, Bueno H, Capodanno D, Cappato R, Chieffo A, Collet JP, Cuisset T, de Simone G, Delgado V, Dendale P, Dudek D, Edvardsen T, Elvan A, González-Juanatey JR, Gori M, Grobbee D, Guzik TJ, Halvorsen S, Haude M, Heidbuchel H, Hindricks G, Ibanez B, Karam N, Katus H, Klok FA, Konstantinides SV, Landmesser U, Leclercq C, Leonardi S, Lettino M, Marenzi G, Mauri J, Metra M, Morici N, Mueller C, Petronio AS, Polovina MM, Potpara T, Praz F, Prendergast B, Prescott E, Price S, Pruszczyk P, Rodríguez-Leor O, Roffi M, Romaguera R, Rosenkranz S, Sarkozy A, Scherrenberg M, Seferovic P, Senni M, Spera FR, Stefanini G, Thiele H, Tomasoni D, Torracca L, Touyz RM, Wilde AA, Williams B. European Society of Cardiology guidance for the diagnosis and management of cardiovascular disease during the COVID-19 pandemic: part 1-epidemiology, pathophysiology, and diagnosis. Eur Heart J 2022; 43:1033-1058. [PMID: 34791157 PMCID: PMC8690026 DOI: 10.1093/eurheartj/ehab696] [Citation(s) in RCA: 60] [Impact Index Per Article: 30.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Revised: 07/08/2021] [Accepted: 09/13/2021] [Indexed: 01/08/2023] Open
Abstract
AIMS Since its emergence in early 2020, the novel severe acute respiratory syndrome coronavirus 2 causing coronavirus disease 2019 (COVID-19) has reached pandemic levels, and there have been repeated outbreaks across the globe. The aim of this two-part series is to provide practical knowledge and guidance to aid clinicians in the diagnosis and management of cardiovascular disease (CVD) in association with COVID-19. METHODS AND RESULTS A narrative literature review of the available evidence has been performed, and the resulting information has been organized into two parts. The first, reported here, focuses on the epidemiology, pathophysiology, and diagnosis of cardiovascular (CV) conditions that may be manifest in patients with COVID-19. The second part, which will follow in a later edition of the journal, addresses the topics of care pathways, treatment, and follow-up of CV conditions in patients with COVID-19. CONCLUSION This comprehensive review is not a formal guideline but rather a document that provides a summary of current knowledge and guidance to practicing clinicians managing patients with CVD and COVID-19. The recommendations are mainly the result of observations and personal experience from healthcare providers. Therefore, the information provided here may be subject to change with increasing knowledge, evidence from prospective studies, and changes in the pandemic. Likewise, the guidance provided in the document should not interfere with recommendations provided by local and national healthcare authorities.
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Chaulin AM. Biology of Cardiac Troponins: Emphasis on Metabolism. BIOLOGY 2022; 11:biology11030429. [PMID: 35336802 PMCID: PMC8945489 DOI: 10.3390/biology11030429] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Revised: 02/28/2022] [Accepted: 03/07/2022] [Indexed: 02/07/2023]
Abstract
Simple Summary Cardiovascular diseases, including myocardial infarction, are among the most common diseases worldwide. Markers associated with the diagnosis of myocardial infarction have been in the spotlight for many years. The most commonly used markers of myocardial infarction are cardiac troponins. However, insufficient understanding of the biology and metabolism of cardiac troponins does not allow us to fully unlock the full diagnostic potential of these cardiomarkers. In this article, I summarized and discussed in detail the features of the metabolism of cardiac troponins. I conducted a comprehensive review of current literary sources and presented my point of view. The format of the manuscript includes a consistent description of the biology and stages of the metabolism of cardiac troponins, starting from the release and circulation, and ending with the features of elimination of cardiac troponins. The possible influence of the biology of cardiac troponins on the diagnostic value of cardiac troponins is analyzed. Based on the analysis of the literature, I found a close relationship between the diagnostic value of cardiac troponins and their biology/metabolism. Further research is needed to increase the diagnostic value of cardiac troponins, and to fully unlock their diagnostic potential. Abstract Understanding of the biology of endo- and exogenous molecules, in particular their metabolism, is not only of great theoretical importance, but also of high practical significance, since many molecules serve as drug targets or markers for the laboratory diagnostics of many human diseases. Thus, cardiac troponin (cTns) molecules have long been used as key markers for the confirmation of diagnosis of myocardial infarction (MI), and with the introduction of contemporary (high sensitivity) test methods, many of our concepts related to the biology of these cardiac markers have changed significantly. In current clinical practice, there are opening new promising diagnostic capabilities of cTns, the understanding and justification of which is closely connected with the theoretical principles of the metabolism of these molecules. However, today, the biology and metabolism of cTns have not been properly investigated; in particular, we do not know the precise mechanisms of release of these molecules from the myocardial cells (MCs) of healthy people and the mechanisms of circulation, and the elimination of cTns from the bloodstream. The main purpose of this manuscript is to systematize information about the biology of cTns, with an emphasis on the metabolism of cTns. The format of this paper, starting with the release of cTns in the blood and concluding with the metabolism/filtration of troponins, provides a comprehensive yet logically easy way for the readers to approach our current knowledge in the framework of understanding the basic mechanisms by which cTns are produced and processed. Conclusions. Based on the analysis of the current literature, the important role of biology and all stages of metabolism (release, circulation, removal) of cTns in laboratory diagnostics should be noted. It is necessary to continue studying the biology and metabolism of cTns, because this will improve the differential diagnosis of MI and i a new application of cTns immunoassays in current clinical practice.
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Affiliation(s)
- Aleksey M. Chaulin
- Department of Histology and Embryology, Samara State Medical University, 89 Chapaevskaya Street, Samara Region, 443099 Samara, Russia; ; Tel.: +7-(927)-770-25-87
- Department of Cardiology and Cardiovascular Surgery, Samara State Medical University, 89 Chapaevskaya Street, Samara Region, 443099 Samara, Russia
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Chaulin A. Metabolic Pathway of Cardiac Troponins and Its Diagnostic Value. Vasc Health Risk Manag 2022. [DOI: 10.2147/vhrm.s335851] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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Guaricci AI, Chiarello G, Gherbesi E, Fusini L, Soldato N, Siena P, Ursi R, Ruggieri R, Guglielmo M, Muscogiuri G, Baggiano A, Rabbat MG, Memeo R, Lepera M, Favale S, Pontone G. Coronary-specific quantification of myocardial deformation by strain echocardiography may disclose the culprit vessel in patients with non-ST-segment elevation acute coronary syndrome. EUROPEAN HEART JOURNAL OPEN 2022; 2:oeac010. [PMID: 35919124 PMCID: PMC9242069 DOI: 10.1093/ehjopen/oeac010] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Revised: 12/06/2021] [Indexed: 12/22/2022]
Abstract
Aims To compare the diagnostic accuracy of speckle tracking echocardiography technique using territorial longitudinal strain (TLS) for the detection of culprit vessel vs. vessel-specific wall motion score index (WMSI) in non-ST-segment elevation–acute coronary syndrome (NSTE-ACS) patients scheduled for invasive coronary angiography (ICA). Methods and results One hundred and eighty-three patients (mean age: 66 ± 12 years, male: 71%) diagnosed with NSTE-ACS underwent echocardiography evaluation at hospital admission and ICA within 24 h. Culprit vessels were left anterior descending (LAD), left circumflex (CX), and right coronary arteries (RCAs) in 38.5%, 39.6%, and 21.4%, respectively. An increase of affected vessels [1-, 2-, and 3-vessel coronary artery disease (CAD)] was associated with increased WMSI and TLS values. There was a statistically significant difference of both WMSI-LAD, WMSI-CX, WMSI-RCA and TLS-LAD, TLS-CX, TLS-RCA of myocardial segments with underlying severe CAD compared to no CAD (P = 0.001 and P < 0.001, respectively). Moreover, a significant difference of TLS-LAD, TLS-CX, TLS-RCA, and WMSI-CX of myocardial segments with an underlying culprit vessel compared to non-culprit vessels (P < 0.001, P < 0.001, P = 0.022, and P < 0.001, respectively) was identified. WMSI-LAD and WMSI-RCA did not show statistical significant differences. A regression model revealed that the combination of WMSI + TLS was more accurate compared to WMSI alone in detecting the culprit vessel (LAD, P = 0.001; CX, P < 0.001; and RCA, P = 0.019). Conclusion Territorial longitudinal strain allows an accurate identification of the culprit vessel in NSTE-ACS patients. In addition to WMSI, TLS may be considered as part of routine echocardiography for better clinical assessment in this subset of patients.
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Affiliation(s)
- Andrea Igoren Guaricci
- Department of Emergency and Organ Transplantation, University Cardiology Unit, Policlinic University Hospital, Piazza Giulio Cesare 11, Bari 70124, Italy
| | - Giuseppina Chiarello
- Department of Emergency and Organ Transplantation, University Cardiology Unit, Policlinic University Hospital, Piazza Giulio Cesare 11, Bari 70124, Italy
| | - Elisa Gherbesi
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Laura Fusini
- Perioperative Cardiology and Cardiovascular Imaging Department, Centro Cardiologico Monzino, IRCCS, Milan, Italy
| | - Nicolo' Soldato
- Department of Emergency and Organ Transplantation, University Cardiology Unit, Policlinic University Hospital, Piazza Giulio Cesare 11, Bari 70124, Italy
| | - Paola Siena
- Department of Emergency and Organ Transplantation, University Cardiology Unit, Policlinic University Hospital, Piazza Giulio Cesare 11, Bari 70124, Italy
| | - Raffaella Ursi
- Department of Emergency and Organ Transplantation, University Cardiology Unit, Policlinic University Hospital, Piazza Giulio Cesare 11, Bari 70124, Italy
| | - Roberta Ruggieri
- Department of Emergency and Organ Transplantation, University Cardiology Unit, Policlinic University Hospital, Piazza Giulio Cesare 11, Bari 70124, Italy
| | - Marco Guglielmo
- Perioperative Cardiology and Cardiovascular Imaging Department, Centro Cardiologico Monzino, IRCCS, Milan, Italy
| | - Giuseppe Muscogiuri
- Perioperative Cardiology and Cardiovascular Imaging Department, Centro Cardiologico Monzino, IRCCS, Milan, Italy
| | - Andrea Baggiano
- Perioperative Cardiology and Cardiovascular Imaging Department, Centro Cardiologico Monzino, IRCCS, Milan, Italy
| | | | - Riccardo Memeo
- Department of Emergency and Organ Transplantation, University Cardiology Unit, Policlinic University Hospital, Piazza Giulio Cesare 11, Bari 70124, Italy
| | - Mario Lepera
- Department of Emergency and Organ Transplantation, University Cardiology Unit, Policlinic University Hospital, Piazza Giulio Cesare 11, Bari 70124, Italy
| | - Stefano Favale
- Department of Emergency and Organ Transplantation, University Cardiology Unit, Policlinic University Hospital, Piazza Giulio Cesare 11, Bari 70124, Italy
| | - Gianluca Pontone
- Perioperative Cardiology and Cardiovascular Imaging Department, Centro Cardiologico Monzino, IRCCS, Milan, Italy
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Tangpaisarn T, Srimakam N, Senthong V, Phungoen P, Kotruchin P. Differential Association Between Significant Coronary Stenosis and Cardiac Troponin T Serial Algorithms in Chronic Kidney Disease Patients Diagnosed with Non-ST-Segment Elevation Acute Coronary Syndromes. Open Access Emerg Med 2022; 14:41-49. [PMID: 35140532 PMCID: PMC8818962 DOI: 10.2147/oaem.s348378] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Accepted: 01/17/2022] [Indexed: 11/23/2022] Open
Abstract
Background Methods Results Conclusion
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Affiliation(s)
- Thanat Tangpaisarn
- Department of Emergency Medicine, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
| | - Nirut Srimakam
- Department of Emergency Medicine, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
| | - Vichai Senthong
- Department of Internal Medicine, Faculty of Medicine Srinagarind Hospital, Khon Kaen University, Khon Kaen, Thailand
| | - Pariwat Phungoen
- Department of Emergency Medicine, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
| | - Praew Kotruchin
- Department of Emergency Medicine, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
- Correspondence: Praew Kotruchin, Department of Emergency Medicine, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand, Tel +66 65 5269 422, Email
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Current and Future Applications of Artificial Intelligence in Coronary Artery Disease. Healthcare (Basel) 2022; 10:healthcare10020232. [PMID: 35206847 PMCID: PMC8872080 DOI: 10.3390/healthcare10020232] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Revised: 01/19/2022] [Accepted: 01/24/2022] [Indexed: 02/07/2023] Open
Abstract
Cardiovascular diseases (CVDs) carry significant morbidity and mortality and are associated with substantial economic burden on healthcare systems around the world. Coronary artery disease, as one disease entity under the CVDs umbrella, had a prevalence of 7.2% among adults in the United States and incurred a financial burden of 360 billion US dollars in the years 2016–2017. The introduction of artificial intelligence (AI) and machine learning over the last two decades has unlocked new dimensions in the field of cardiovascular medicine. From automatic interpretations of heart rhythm disorders via smartwatches, to assisting in complex decision-making, AI has quickly expanded its realms in medicine and has demonstrated itself as a promising tool in helping clinicians guide treatment decisions. Understanding complex genetic interactions and developing clinical risk prediction models, advanced cardiac imaging, and improving mortality outcomes are just a few areas where AI has been applied in the domain of coronary artery disease. Through this review, we sought to summarize the advances in AI relating to coronary artery disease, current limitations, and future perspectives.
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Bang C, Andersen CF, Lauridsen KG, Frederiksen CA, Schmidt M, Jensen T, Hornung N, Løfgren B. Rapid Rule-Out of Myocardial Infarction After 30 Minutes as an Alternative to 1 Hour: The RACING-MI Cohort Study. Ann Emerg Med 2021; 79:102-112. [PMID: 34969529 DOI: 10.1016/j.annemergmed.2021.08.024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2021] [Revised: 08/10/2021] [Accepted: 08/30/2021] [Indexed: 12/15/2022]
Abstract
STUDY OBJECTIVE The aim of this study was to investigate whether myocardial infarction can be safely ruled in or out after 30 minutes as an alternative to 1 hour. METHODS This was a prospective, single-center clinical study enrolling patients admitted to the emergency department. Patients with chest pain suggestive of myocardial infarction were eligible for inclusion. There was no walk-in to the emergency department, and patients with highly elevated out-of-hospital troponin were transferred directly to an invasive heart center. High-sensitivity troponin I was measured at admission (0 hour), 30 minutes, 1 hour, and 3 hours. Diagnostic performance was assessed using the sensitivity and negative predictive value (primary endpoints) as measures of ability to rule out myocardial infarction. Specificity and positive predictive value of myocardial infarction were used as measures for the ability to rule in myocardial infarction (secondary endpoints). RESULTS In total, 1,003 patients qualified for analysis. Median age was 64 (interquartile range 52 to 74) years, and 42% were women. Myocardial infarction was confirmed in 9% of patients. In the validation cohort (n=503), the 0-h/30-min algorithm assigned 242 (48%) patients to rule out, 54 (11%) to rule in, and 207 (41%) to the observational zone. This resulted in a sensitivity of 100% (92.0% to 100%), negative predictive value of 100% (95% confidence interval 98.5% to 100%), specificity of 96.7% (94.7% to 98.2%), and positive predictive value of 72.2% (58.4% to 83.5%). In comparison, the 0-h/1-h algorithm performed with a sensitivity of 100% (92.0% to 100%), negative predictive value of 100% (98.5% to 100%), specificity of 97.2% (95.2% to 98.5%), and positive predictive value of 75.5% (61.7% to 86.2%). CONCLUSION The accelerated 0-h/30-min algorithm allowed for safe rule-out of myocardial infarction 30 minutes after admission. The rule-in ability of the 0-h/30-min algorithm was comparable to that of the 0-h/1h algorithm.
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Affiliation(s)
- Camilla Bang
- Research Center for Emergency Medicine, Aarhus University Hospital, Denmark; Clinical Research Unit, Randers Regional Hospital, Denmark; Department of Internal Medicine, Randers Regional Hospital, Denmark
| | - Camilla F Andersen
- Research Center for Emergency Medicine, Aarhus University Hospital, Denmark; Clinical Research Unit, Randers Regional Hospital, Denmark; Department of Internal Medicine, Randers Regional Hospital, Denmark; Department of Cardiology, Herlev and Gentofte University Hospital, Denmark
| | - Kasper G Lauridsen
- Research Center for Emergency Medicine, Aarhus University Hospital, Denmark; Clinical Research Unit, Randers Regional Hospital, Denmark; Department of Internal Medicine, Randers Regional Hospital, Denmark
| | | | - Morten Schmidt
- Department of Cardiology, Aarhus University Hospital, Denmark; Department of Clinical Epidemiology, Aarhus University Hospital, Denmark
| | - Tage Jensen
- Department of Internal Medicine, Randers Regional Hospital, Denmark
| | - Nete Hornung
- Department of Clinical Biochemistry, Regional Hospital West Jutland, Denmark
| | - Bo Løfgren
- Research Center for Emergency Medicine, Aarhus University Hospital, Denmark; Department of Clinical Medicine, Aarhus University Hospital, Denmark; Clinical Research Unit, Randers Regional Hospital, Denmark; Department of Internal Medicine, Randers Regional Hospital, Denmark.
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Wildi K, Boeddinghaus J, Nestelberger T, Lopez-Ayala P, Yufera Sanchez A, Okamura B, Shrestha S, Rohner J, Miró Ò, Martinez-Nadal G, Martin-Sanchez FJ, Koechlin L, Twerenbold R, Christ M, Kawecki D, Rubini Giménez M, Keller DI, Mueller C, Wussler DI, Strebel A, Bakula S, Frey DM, Gualandro T, Zimmermann C, Puelacher J, du Fay de Lavallaz E, Potlukova M, Diebold N, Geigy K, Rentsch S, Mitrovic C, Fuenzalida N, Glarner BMP, Munzk T, Breidthardt M, Freese B, López S, Calderón ER, Adrada E, Ganovská J, Parenica A, von Eckardstein I, Campodarve J, Gea . 0/2 h-Algorithm for Rapid Triage of Suspected Myocardial Infarction Using a Novel High-Sensitivity Cardiac Troponin I Assay. Clin Chem 2021. [DOI: 10.1093/clinchem/hvab203] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Abstract
Background
We aimed to derive and validate a 0/2 h-algorithm using the new high-sensitivity cardiac troponin I (hs-cTnI)-VITROS assay (VITROS® Immunodiagnostic Products hs-Troponin I Reagent Pack, Ortho Clinical Diagnostics) for rapid rule-out/in of non-ST-segment elevation myocardial infarction (NSTEMI).
Methods
The final diagnosis was centrally adjudicated by 2 independent cardiologists according to the fourth universal definition of myocardial infarction (MI) among 1888 patients presenting to the emergency department with acute chest pain. hs-cTnI-VITROS concentrations were measured at presentation and at 2 h in a blinded fashion. The optimal assay-specific thresholds for the hs-cTnI-VITROS 0/2 h-algorithm were derived in a randomly selected 70% of the cohort and validated in the remaining 30%.
Results
NSTEMI was the final diagnosis in 216/1322 (16.3%) patients of the derivation cohort. Rule-out was defined as baseline hs-cTnI concentrations of <1 ng/L in patients presenting with chest pain onset >3 h or a baseline hs-cTnI concentration of <2 ng/L and an absolute change of <3 ng/L within 2 h. Thresholds for rule-in were either ≥40 ng/L at presentation or an absolute change within 2 h of ≥ 5ng/L. In the derivation cohort, these thresholds ruled-out 50.8% of patients with a negative predictive value (NPV) and sensitivity of 99.7% (95% Confidence Interval (CI), 98.8–99.9%) and 99.1% (95% CI, 96.7–99.9%), and ruled-in 17.9% with a positive predictive value (PPV) of 79.2% (95% CI, 74.3–83.5%). In the validation cohort, NSTEMI was the final diagnosis in 91/566 (16.1%) patients. The derived 0/2 h-algorithm ruled-out 46.3% of patients with a NPV and sensitivity of 100% (95% CI, 95.6–100%) and 100% (95% CI, 96.0–100%), and ruled-in 18.9% with a PPV of 73.8% (95% CI, 66.1–80.3%) in the validation cohort.
Conclusion
hs-cTnI-VITROS concentrations at presentation combined with absolute changes within the first 2 h allowed safe rule-out and accurate rule-in of NSTEMI in two-thirds of unselected patients presenting with acute chest pain to the emergency department.
Trial registration
www.clinicaltrials.gov: NCT0047058
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Affiliation(s)
- Karin Wildi
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT Network
- Critical Care Research Group, The Prince Charles Hospital, Brisbane and University of Queensland, Brisbane, Australia
| | - Jasper Boeddinghaus
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT Network
- Division of Internal Medicine, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Thomas Nestelberger
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT Network
- Division of Cardiology, Vancouver General Hospital, University of British Columbia, Vancouver, BC, Canada
| | - Pedro Lopez-Ayala
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT Network
| | - Ana Yufera Sanchez
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT Network
| | - Bernhard Okamura
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT Network
| | - Samyut Shrestha
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT Network
| | - Jennifer Rohner
- GREAT Network
- Emergency Department, University Hospital Zurich, Zurich, Switzerland
| | - Òscar Miró
- GREAT Network
- Emergency Department, Hospital Clinic, Barcelona, Catalonia, Spain
| | | | | | - Luca Koechlin
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT Network
- Department of Cardiac Surgery, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Raphael Twerenbold
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT Network
- Department of Cardiology and University Center of Cardiovascular Science, University Heart and Vascular Center Hamburg, Hamburg, Germany
| | | | - Damian Kawecki
- 2nd Department of Cardiology, School of Medicine with the Division of Dentistry in Zabrze, Medical University of Katowice, Katowice, Poland
| | - Maria Rubini Giménez
- GREAT Network
- Department of Internal Medicine/Cardiology, Heart Center Leipzig at University of Leipzig, Leipzig, Germany
| | - Dagmar I Keller
- Emergency Department, University Hospital Zurich, Zurich, Switzerland
| | - Christian Mueller
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT Network
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Dietl A, Zimmermann ME, Brandl C, Wallner S, Burkhardt R, Maier LS, Luchner A, Heid IM, Stark KJ. Distribution and specificity of high-sensitivity cardiac troponin T in older adults without acute cardiac conditions: cross-sectional results from the population-based AugUR study. BMJ Open 2021; 11:e052004. [PMID: 34728452 PMCID: PMC8565570 DOI: 10.1136/bmjopen-2021-052004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
OBJECTIVE European guidelines recommended a uniform upper reference limit of high-sensitivity cardiac troponin T (hsTnT) to rule out non-ST segment elevation myocardial infarction. Our study aimed to provide a hsTnT reference distribution and to assess the specificity of the 14 ng/L cut-off value in the mobile population ≥70 years of age. DESIGN A cross-sectional analysis was performed in the German AugUR study (Altersbezogene Untersuchungen zur Gesundheit der University of Regensburg). SETTING Study population was the mobile population aged 70+ years living in the city and county of Regensburg, Germany. PARTICIPANTS A random sample was derived from the local population registries of residence. Of the 5644 individuals invited, 1133 participated (response ratio=20.1%). All participants came to the study centre and were mentally and physically mobile to conduct the protocol (face-to-face interview, blood draw and standardised transthoracic echocardiography). None of the participants was in an acute state of myocardial infarction. RESULTS Among the 1129 individuals with hsTnT measurements (overall median=10.0 ng/L(25th, 75th percentile)=(7.0, 15.0 ng/L)), hsTnT was higher among the older individuals and higher among men (men 70-74 years median=9.6 ng/L (7.2, 13.1 ng/L); men 90-95 years median=21.2 ng/L (14.6, 26.0 ng/L); women 70-74 years median=6.3 ng/L (4.7, 8.7 ng/L); and women 90-95 years median=18.0 ng/L (11.0, 21.0 ng/L)). In participants with impaired kidney function (eGFRcrea <60 mL/min/1.73 m2), hsTnT was elevated (median=13.6 ng/L (9.4, 20.6 ng/L)).Specificity of recommended upper reference limit, 14 ng/L, is 68%. Most false positives were among men aged >79 years (specificity=34%). In a healthy subgroup (n=96, none of the following: overt heart disease, impaired renal function, blood pressure >160/100 mm Hg, left ventricular hypertrophy and diastolic/systolic dysfunction), specificity was 90%. CONCLUSION In the elderly population without acute myocardial infarction, hsTnT further increases with age showing different levels for men and women. The specificity of the 14 ng/L cut-off is considerably lower than 99%, even in healthy subjects.
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Affiliation(s)
- Alexander Dietl
- Department of Internal Medicine II, University Hospital Regensburg, Regensburg, Germany
| | - Martina E Zimmermann
- Department of Genetic Epidemiology, University of Regensburg, Regensburg, Germany
| | - Caroline Brandl
- Department of Genetic Epidemiology, University of Regensburg, Regensburg, Germany
- Department of Ophthalmology, University Hospital Regensburg, Regensburg, Germany
| | - Stefan Wallner
- Institute of Clinical Chemistry and Laboratory Medicine, University Hospital Regensburg, Regensburg, Germany
| | - Ralph Burkhardt
- Institute of Clinical Chemistry and Laboratory Medicine, University Hospital Regensburg, Regensburg, Germany
| | - Lars S Maier
- Department of Internal Medicine II, University Hospital Regensburg, Regensburg, Germany
| | - Andreas Luchner
- Department of Cardiology, Krankenhaus Barmherzige Brueder Regensburg, Regensburg, Germany
| | - Iris M Heid
- Department of Genetic Epidemiology, University of Regensburg, Regensburg, Germany
| | - Klaus J Stark
- Department of Genetic Epidemiology, University of Regensburg, Regensburg, Germany
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García-Blas S, Cordero A, Diez-Villanueva P, Martinez-Avial M, Ayesta A, Ariza-Solé A, Mateus-Porta G, Martínez-Sellés M, Escribano D, Gabaldon-Perez A, Bodi V, Bonanad C. Acute Coronary Syndrome in the Older Patient. J Clin Med 2021; 10:jcm10184132. [PMID: 34575243 PMCID: PMC8467899 DOI: 10.3390/jcm10184132] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Revised: 09/06/2021] [Accepted: 09/07/2021] [Indexed: 01/21/2023] Open
Abstract
Coronary artery disease is one of the leading causes of morbidity and mortality, and its prevalence increases with age. The growing number of older patients and their differential characteristics make its management a challenge in clinical practice. The aim of this review is to summarize the state-of-the-art in diagnosis and treatment of acute coronary syndromes in this subgroup of patients. This comprises peculiarities of ST-segment elevation myocardial infarction (STEMI) management, updated evidence of non-STEMI therapeutic strategies, individualization of antiplatelet treatment (weighting ischemic and hemorrhagic risks), as well as assessment of geriatric conditions and ethical issues in decision making.
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Affiliation(s)
- Sergio García-Blas
- Cardiology Department, Hospital Clínico Universitario de Valencia, INCLIVA Biomedical Research Institute, University of Valencia, 46010 Valencia, Spain; (S.G.-B.); (A.G.-P.); (V.B.)
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), 28029 Madrid, Spain; (A.C.); (M.M.-S.); (D.E.)
| | - Alberto Cordero
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), 28029 Madrid, Spain; (A.C.); (M.M.-S.); (D.E.)
- Cardiology Department, Hospital Universitario de San Juan, 03550 Alicante, Spain
| | - Pablo Diez-Villanueva
- Cardiology Department, Hospital Universitario de La Princesa, 28006 Madrid, Spain; (P.D.-V.); (M.M.-A.)
| | - Maria Martinez-Avial
- Cardiology Department, Hospital Universitario de La Princesa, 28006 Madrid, Spain; (P.D.-V.); (M.M.-A.)
| | - Ana Ayesta
- Cardiology Department, Hospital Central de Asturias, 33011 Oviedo, Spain;
| | - Albert Ariza-Solé
- Cardiology Department, Hospital Universitari de Bellvitge, L’Hospitalet de Llobregat, 08907 Barcelona, Spain; (A.A.-S.); (G.M.-P.)
| | - Gemma Mateus-Porta
- Cardiology Department, Hospital Universitari de Bellvitge, L’Hospitalet de Llobregat, 08907 Barcelona, Spain; (A.A.-S.); (G.M.-P.)
| | - Manuel Martínez-Sellés
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), 28029 Madrid, Spain; (A.C.); (M.M.-S.); (D.E.)
- Cardiology Department, Hospital Universitario Gregorio Marañón, Universidad Europea, Universidad Complutense, 28007 Madrid, Spain
| | - David Escribano
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), 28029 Madrid, Spain; (A.C.); (M.M.-S.); (D.E.)
- Cardiology Department, Hospital Universitario de San Juan, 03550 Alicante, Spain
| | - Ana Gabaldon-Perez
- Cardiology Department, Hospital Clínico Universitario de Valencia, INCLIVA Biomedical Research Institute, University of Valencia, 46010 Valencia, Spain; (S.G.-B.); (A.G.-P.); (V.B.)
| | - Vicente Bodi
- Cardiology Department, Hospital Clínico Universitario de Valencia, INCLIVA Biomedical Research Institute, University of Valencia, 46010 Valencia, Spain; (S.G.-B.); (A.G.-P.); (V.B.)
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), 28029 Madrid, Spain; (A.C.); (M.M.-S.); (D.E.)
| | - Clara Bonanad
- Cardiology Department, Hospital Clínico Universitario de Valencia, INCLIVA Biomedical Research Institute, University of Valencia, 46010 Valencia, Spain; (S.G.-B.); (A.G.-P.); (V.B.)
- Correspondence:
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Trajković N, Đorđević D, Stanković M, Petrušič T, Bogataj Š, Peršič V. Exercise-Based Interventions in Middle-Aged and Older Adults after Myocardial Infarction: A Systematic Review. Life (Basel) 2021; 11:life11090928. [PMID: 34575077 PMCID: PMC8466422 DOI: 10.3390/life11090928] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Revised: 08/30/2021] [Accepted: 09/04/2021] [Indexed: 11/16/2022] Open
Abstract
This study summarized the relevant literature and aimed to determine the effect of exercise-based interventions after myocardial infarction in middle-aged and older adults. Studies were identified and analyzed according to the PRISMA guidelines. The following electronic databases were used: Google Scholar, PubMed, Mendeley, Science Direct, and Scopus. The identified studies had to be longitudinal, be published in English, have taken place between 2010 and 2020, involve participants who had suffered myocardial infarction, and address different types of exercise-based interventions to be included. Of the 592 relevant studies identified, 20 were included in the qualitative analysis. After analyzing the results obtained, it could be concluded that different types of exercise-based interventions or their combination have a positive effect after myocardial infarction in middle-aged and elderly adults. It can also be suggested that the combination of a cycle ergometer and a treadmill may be the most effective exercise-based intervention. An adequate choice of intensity and volume is crucial, with the optimal duration of the experimental program and the type(s) of exercises adapted to participants after myocardial infarction.
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Affiliation(s)
- Nebojša Trajković
- Faculty of Sport and Physical Education, University of Niš, 18000 Niš, Serbia; (N.T.); (D.Đ.); (M.S.)
| | - Dušan Đorđević
- Faculty of Sport and Physical Education, University of Niš, 18000 Niš, Serbia; (N.T.); (D.Đ.); (M.S.)
| | - Mima Stanković
- Faculty of Sport and Physical Education, University of Niš, 18000 Niš, Serbia; (N.T.); (D.Đ.); (M.S.)
| | - Tanja Petrušič
- Faculty of Education, University of Ljubljana, 1000 Ljubljana, Slovenia;
| | - Špela Bogataj
- Department of Nephrology, University Medical Centre, 1000 Ljubljana, Slovenia;
- Faculty of Sport, University of Ljubljana, 1000 Ljubljana, Slovenia
| | - Vanja Peršič
- Department of Nephrology, University Medical Centre, 1000 Ljubljana, Slovenia;
- Correspondence:
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37
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Andersen CF, Bang C, Lauridsen KG, Frederiksen CA, Schmidt M, Jensen T, Hornung N, Løfgren B. External validation of a high-sensitive troponin I algorithm for rapid evaluation of acute myocardial infarction in a Danish cohort. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2021; 10:1056-1064. [PMID: 34423355 DOI: 10.1093/ehjacc/zuab062] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Revised: 05/19/2021] [Accepted: 07/14/2021] [Indexed: 11/14/2022]
Abstract
AIMS An accelerated diagnostic algorithm for ruling-in or ruling-out myocardial infarction (MI) after 1 hour (1 h) has recently been derived and internally validated for the Siemens ADVIA Centaur TNIH assay. We aimed to validate the diagnostic performance of the TNIH 0 h/1 h algorithm ad modum Boeddinghaus in a Danish cohort. METHODS AND RESULTS Patients with chest pain suggestive of MI were prospectively enrolled. High-sensitive troponin I (TNIH) was measured at admission (0 h) and after 30 minutes (30 m), 1 h, and 3 hours (3 h). We externally validated the TNIH 0 h/1 h algorithm ad modum Boeddinghaus in Danish patients. Moreover, we applied the algorithm using the second TNIH measurement at 30 m instead of 1 h. We enrolled 1003 patients: median (Q1-Q3) age 64 (52-74) years, 42% female, and 23% with previous MI. Myocardial infarction was the final diagnosis in 9% of patients. Median (Q1-Q3) times from admission to 30 m and 1 h blood draw were 35 min (30-37 min) and 67 min (62-75 min), respectively. Using the 0 h and 1 h results, 468 (47%) patients were assigned to rule-out, 104 (10%) to rule-in, and 431 (43%) to the observational zone. This resulted in a negative predictive value of 100% (95% confidence interval: 99.2-100%), sensitivity of 100% (95.9-100%), positive predictive value of 79.8 (70.8-87.0%), and specificity of 97.7% (96.5-98.6%). The diagnostic performance after 30 m was similar. CONCLUSIONS The TNIH 0 h/1 h algorithm ad modum Boeddinghaus performed excellently for rule-out of MI in a Danish cohort. The Boeddinghaus algorithm also performed excellently after only 30 m. TRIAL REGISTRATION NUMBER NCT03634384. TRIAL REGISTRY NAME AND URL Rapid Use of High-Sensitive Cardiac Troponin I for Ruling-in and Ruling-out Acute Myocardial Infarction (RACING-MI), https://clinicaltrials.gov/ct2/show/NCT03634384.
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Affiliation(s)
- Camilla Fuchs Andersen
- Research Center for Emergency Medicine, Aarhus University, Palle Juul-Jensens Boulevard 99, J103, Aarhus N 8200, Denmark.,Clinical Research Unit, Randers Regional Hospital, Skovlyvej 15, Randers 8930, Denmark.,Department of Internal Medicine, Randers Regional Hospital, Skovlyvej 15, 8930 Randers, Denmark.,Department of Cardiology, Herlev and Gentofte University Hospital, Borgmester Ib Juuls Vej, 1, Herlev, Hellerup 2730, Denmark
| | - Camilla Bang
- Research Center for Emergency Medicine, Aarhus University, Palle Juul-Jensens Boulevard 99, J103, Aarhus N 8200, Denmark.,Clinical Research Unit, Randers Regional Hospital, Skovlyvej 15, Randers 8930, Denmark.,Department of Internal Medicine, Randers Regional Hospital, Skovlyvej 15, 8930 Randers, Denmark
| | - Kasper Glerup Lauridsen
- Research Center for Emergency Medicine, Aarhus University, Palle Juul-Jensens Boulevard 99, J103, Aarhus N 8200, Denmark.,Clinical Research Unit, Randers Regional Hospital, Skovlyvej 15, Randers 8930, Denmark.,Department of Internal Medicine, Randers Regional Hospital, Skovlyvej 15, 8930 Randers, Denmark
| | | | - Morten Schmidt
- Department of Cardiology, Regional Hospital West Jutland, Gl Landevej 61, Herning 7400, Denmark.,Department of Clinical Epidemiology, Aarhus University Hospital, Olof Palmes Allé 43-45, Aarhus N 8200, Denmark
| | - Tage Jensen
- Department of Internal Medicine, Randers Regional Hospital, Skovlyvej 15, 8930 Randers, Denmark
| | - Nete Hornung
- Department of Clinical Biochemistry, Regional Hospital West Jutland, Gl Landevej 61, Herning 7400, Denmark
| | - Bo Løfgren
- Research Center for Emergency Medicine, Aarhus University, Palle Juul-Jensens Boulevard 99, J103, Aarhus N 8200, Denmark.,Department of Internal Medicine, Randers Regional Hospital, Skovlyvej 15, 8930 Randers, Denmark.,Department of Clinical Medicine, Aarhus University Hospital, Incuba Skejby, building 2, Palle Juul-Jensens Boulevard 82, Aarhus N 8200, Denmark
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38
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Wereski R, Kimenai DM, Taggart C, Doudesis D, Lee KK, Lowry MT, Bularga A, Lowe DJ, Fujisawa T, Apple FS, Collinson PO, Anand A, Chapman AR, Mills NL. Cardiac Troponin Thresholds and Kinetics to Differentiate Myocardial Injury and Myocardial Infarction. Circulation 2021; 144:528-538. [PMID: 34167318 PMCID: PMC8360674 DOI: 10.1161/circulationaha.121.054302] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Accepted: 07/07/2021] [Indexed: 11/16/2022]
Abstract
BACKGROUND Although the 99th percentile is the recommended diagnostic threshold for myocardial infarction, some guidelines also advocate the use of higher troponin thresholds to rule in myocardial infarction at presentation. It is unclear whether the magnitude or change in troponin concentration can differentiate causes of myocardial injury and infarction in practice. METHODS In a secondary analysis of a multicenter randomized controlled trial, we identified 46 092 consecutive patients presenting with suspected acute coronary syndrome without ST-segment-elevation myocardial infarction. High-sensitivity cardiac troponin I concentrations at presentation and on serial testing were compared between patients with myocardial injury and infarction. The positive predictive value and specificity were determined at the sex-specific 99th percentile upper reference limit and rule-in thresholds of 64 ng/L and 5-fold of the upper reference limit for a diagnosis of type 1 myocardial infarction. RESULTS Troponin was above the 99th percentile in 8188 patients (18%). The diagnosis was type 1 or type 2 myocardial infarction in 50% and 14% and acute or chronic myocardial injury in 20% and 16%, respectively. Troponin concentrations were similar at presentation in type 1 (median [25th-75th percentile] 91 [30-493] ng/L) and type 2 (50 [22-147] ng/L) myocardial infarction and in acute (50 [26-134] ng/L) and chronic (51 [31-130] ng/L) myocardial injury. The 99th percentile and rule-in thresholds of 64 ng/L and 5-fold upper reference limit gave a positive predictive value of 57% (95% CI, 56%-58%), 59% (58%-61%), and 62% (60%-64%) and a specificity of 96% (96%-96%), 96% (96%-96%), and 98% (97%-98%), respectively. The absolute, relative, and rate of change in troponin concentration were highest in patients with type 1 myocardial infarction (P<0.001 for all). Discrimination improved when troponin concentration and change in troponin were combined compared with troponin concentration at presentation alone (area under the curve, 0.661 [0.642-0.680] versus 0.613 [0.594-0.633]). CONCLUSIONS Although we observed important differences in the kinetics, cardiac troponin concentrations at presentation are insufficient to distinguish type 1 myocardial infarction from other causes of myocardial injury or infarction in practice and should not guide management decisions in isolation. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT01852123.
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Affiliation(s)
- Ryan Wereski
- British Heart Foundation Centre for Cardiovascular Science (R.W., C.T., D.D., K.K.L., M.T.H.L., A.B., T.F., A.A., A.R.C., N.L.M.), University of Edinburgh, UK
| | | | - Caelan Taggart
- British Heart Foundation Centre for Cardiovascular Science (R.W., C.T., D.D., K.K.L., M.T.H.L., A.B., T.F., A.A., A.R.C., N.L.M.), University of Edinburgh, UK
| | - Dimitrios Doudesis
- British Heart Foundation Centre for Cardiovascular Science (R.W., C.T., D.D., K.K.L., M.T.H.L., A.B., T.F., A.A., A.R.C., N.L.M.), University of Edinburgh, UK
- Usher Institute (D.M.K., D.D., N.L.M.), University of Edinburgh, UK
| | - Kuan Ken Lee
- British Heart Foundation Centre for Cardiovascular Science (R.W., C.T., D.D., K.K.L., M.T.H.L., A.B., T.F., A.A., A.R.C., N.L.M.), University of Edinburgh, UK
| | - Matthew T.H. Lowry
- British Heart Foundation Centre for Cardiovascular Science (R.W., C.T., D.D., K.K.L., M.T.H.L., A.B., T.F., A.A., A.R.C., N.L.M.), University of Edinburgh, UK
| | - Anda Bularga
- British Heart Foundation Centre for Cardiovascular Science (R.W., C.T., D.D., K.K.L., M.T.H.L., A.B., T.F., A.A., A.R.C., N.L.M.), University of Edinburgh, UK
| | - David J. Lowe
- University of Glasgow, School of Medicine, UK (D.J.L.)
| | - Takeshi Fujisawa
- British Heart Foundation Centre for Cardiovascular Science (R.W., C.T., D.D., K.K.L., M.T.H.L., A.B., T.F., A.A., A.R.C., N.L.M.), University of Edinburgh, UK
| | - Fred S. Apple
- Department of Laboratory Medicine and Pathology, Hennepin Healthcare/Hennepin County Medical Center and University of Minnesota, Minneapolis (F.S.A.)
| | - Paul O. Collinson
- Department of Clinical Blood Sciences and Cardiology, St. George’s University of London, UK (P.O.C.)
| | - Atul Anand
- British Heart Foundation Centre for Cardiovascular Science (R.W., C.T., D.D., K.K.L., M.T.H.L., A.B., T.F., A.A., A.R.C., N.L.M.), University of Edinburgh, UK
| | - Andrew R. Chapman
- British Heart Foundation Centre for Cardiovascular Science (R.W., C.T., D.D., K.K.L., M.T.H.L., A.B., T.F., A.A., A.R.C., N.L.M.), University of Edinburgh, UK
| | - Nicholas L. Mills
- British Heart Foundation Centre for Cardiovascular Science (R.W., C.T., D.D., K.K.L., M.T.H.L., A.B., T.F., A.A., A.R.C., N.L.M.), University of Edinburgh, UK
- Usher Institute (D.M.K., D.D., N.L.M.), University of Edinburgh, UK
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Haller PM, Neumann JT, Sörensen NA, Hartikainen TS, Goßling A, Lehmacher J, Keller T, Zeller T, Blankenberg S, Westermann D. The association of anaemia and high-sensitivity cardiac troponin and its effect on diagnosing myocardial infarction. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2021; 10:1187-1196. [PMID: 34350455 DOI: 10.1093/ehjacc/zuab066] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Revised: 05/13/2021] [Accepted: 07/20/2021] [Indexed: 11/14/2022]
Abstract
AIMS Anaemia is common in patients with acute myocardial infarction (MI). We investigated the association of high-sensitivity cardiac troponin (hs-cTn) and haemoglobin (Hb) and the influence of anaemia on the performance of diagnostic protocols for suspected MI. METHODS AND RESULTS Patients with suspected MI were consecutively enrolled at a tertiary centre. Final diagnoses were independently adjudicated by two cardiologists. Performance measures of hs-cTn-based algorithms were compared for anaemic and non-anaemic patients (Hb <12 g/dL in women and <13 g/dL in men). The influence of anaemia on survival (median follow-up 1.7 years) was investigated using multivariable cox-regression analysis and the association of Hb and hs-cTn by multivariable linear regression analysis. Overall, 2223 patients were included, of whom 415 (18.7%) had anaemia. In anaemic patients, the incidence of MI was similar; however, chronic myocardial injury was significantly more prevalent (20.1% vs. 48.2%). The negative predictive value to rule-out MI was similar for both algorithms and all assays in patients with anaemia, although the positive predictive value to rule-in MI was partly reduced for the 0/3-h algorithm. Fewer anaemic patients were triaged after 1 h. Anaemia was an independent predictor of death. Adjusted for patient characteristics, Hb was significantly associated with hs-cTn. By providing a point-based tool, the Hb-associated hs-cTn concentration and thus chronic myocardial injury may be predicted. CONCLUSION Anaemia partly affects the rule-in, but not the rule-out of MI in hs-cTn-based diagnostic protocols. Hs-cTn concentrations and thus chronic myocardial injury may be predicted by clinical variables and Hb. TRIAL REGISTRATION clinicaltrials.gov (NCT02355457 and NCT03227159).
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Affiliation(s)
- Paul Michael Haller
- Department of Cardiology, University Heart & Vascular Center Hamburg, Martinistrasse 52, 20246 Hamburg, Germany.,German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - Johannes T Neumann
- Department of Cardiology, University Heart & Vascular Center Hamburg, Martinistrasse 52, 20246 Hamburg, Germany.,German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany.,Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Nils A Sörensen
- Department of Cardiology, University Heart & Vascular Center Hamburg, Martinistrasse 52, 20246 Hamburg, Germany.,German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - Tau S Hartikainen
- Department of Cardiology, University Heart & Vascular Center Hamburg, Martinistrasse 52, 20246 Hamburg, Germany
| | - Alina Goßling
- Department of Cardiology, University Heart & Vascular Center Hamburg, Martinistrasse 52, 20246 Hamburg, Germany
| | - Jonas Lehmacher
- Department of Cardiology, University Heart & Vascular Center Hamburg, Martinistrasse 52, 20246 Hamburg, Germany
| | - Till Keller
- Department of Internal Medicine I, Cardiology, Justus-Liebig-University Gießen, Gießen, Germany
| | - Tanja Zeller
- Department of Cardiology, University Heart & Vascular Center Hamburg, Martinistrasse 52, 20246 Hamburg, Germany.,German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - Stefan Blankenberg
- Department of Cardiology, University Heart & Vascular Center Hamburg, Martinistrasse 52, 20246 Hamburg, Germany.,German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - Dirk Westermann
- Department of Cardiology, University Heart & Vascular Center Hamburg, Martinistrasse 52, 20246 Hamburg, Germany.,German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany
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40
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Kite TA, Ladwiniec A, Arnold JR, McCann GP, Moss AJ. Early invasive versus non-invasive assessment in patients with suspected non-ST-elevation acute coronary syndrome. Heart 2021; 108:500-506. [PMID: 34234006 DOI: 10.1136/heartjnl-2020-318778] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Accepted: 06/22/2021] [Indexed: 11/04/2022] Open
Abstract
Non-ST-elevation acute coronary syndrome (NSTE-ACS) comprises a broad spectrum of disease ranging from unstable angina to myocardial infarction. International guidelines recommend a routine invasive strategy for managing patients with NSTE-ACS at high to very high-risk, supported by evidence of improved composite ischaemic outcomes as compared with a selective invasive strategy. However, accurate diagnosis of NSTE-ACS in the acute setting is challenging due to the spectrum of non-coronary disease that can manifest with similar symptoms. Heterogeneous clinical presentations and limited uptake of risk prediction tools can confound physician decision-making regarding the use and timing of invasive coronary angiography (ICA). Large proportions of patients with suspected NSTE-ACS do not require revascularisation but may unnecessarily undergo ICA with its attendant risks and associated costs. Advances in coronary CT angiography and cardiac MRI have prompted evaluation of whether non-invasive strategies may improve patient selection, or whether tailored approaches are better suited to specific subgroups. Future directions include (1) better understanding of risk stratification as a guide to investigation and therapy in suspected NSTE-ACS, (2) randomised clinical trials of non-invasive imaging versus standard of care approaches prior to ICA and (3) defining the optimal timing of very early ICA in high-risk NSTE-ACS.
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Affiliation(s)
- Thomas A Kite
- Department of Cardiovascular Sciences and the NIHR Leicester Biomedical Research Centre, Glenfield Hospital, University of Leicester and University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Andrew Ladwiniec
- Department of Cardiovascular Sciences and the NIHR Leicester Biomedical Research Centre, Glenfield Hospital, University of Leicester and University Hospitals of Leicester NHS Trust, Leicester, UK
| | - J Ranjit Arnold
- Department of Cardiovascular Sciences and the NIHR Leicester Biomedical Research Centre, Glenfield Hospital, University of Leicester and University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Gerry P McCann
- Department of Cardiovascular Sciences and the NIHR Leicester Biomedical Research Centre, Glenfield Hospital, University of Leicester and University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Alastair J Moss
- Department of Cardiovascular Sciences and the NIHR Leicester Biomedical Research Centre, Glenfield Hospital, University of Leicester and University Hospitals of Leicester NHS Trust, Leicester, UK
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41
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Lopez-Ayala P, Boeddinghaus J, Koechlin L, Nestelberger T, Mueller C. Early Rule-Out Strategies in the Emergency Department Utilizing High-Sensitivity Cardiac Troponin Assays. Clin Chem 2021; 67:114-123. [PMID: 33279982 DOI: 10.1093/clinchem/hvaa226] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Accepted: 09/09/2020] [Indexed: 11/14/2022]
Abstract
BACKGROUND Over the past decade, intense collaboration between academic investigators and the diagnostic industry have allowed the integration of high-sensitivity cardiac troponin (hs-cTn) assays into clinical practice worldwide. The hs-cTn assays, with their increased diagnostic accuracy for acute myocardial infarction (AMI), have facilitated the maturation of early rule-out strategies. The first iteration was complex and required the combination of a biomarker panel, the electrocardiogram, and a clinical risk score and allowed the safe rule-out of AMI in only 10% of patients with acute chest pain. In contrast, the latest iterations, including the European Society of Cardiology (ESC) 0/1-h algorithm, are simple. They are based on hs-cTn concentrations only and allow the safe rule-out or rule-in of AMI in up to 75% of patients. CONTENT The purposes of this minireview are (a) to describe the best validated hs-cTn-based strategies for early rule-out of AMI, (b) to discuss the advantages and limitations of the different strategies, (c) to identify patient subgroups requiring particular attention, (d) to recognize challenges for widespread clinical implementation, and (e) to provide guidance on strategies for their safe and effective clinical implementation. SUMMARY Physicians and institutions may choose among several well-validated rule-out algorithms. The ESC 0/1-h algorithm for hs-cTnT or hs-cTnI seems to be the most attractive option today. It best balances safety and efficacy, and it has been derived and validated for all currently available hs-cTnT/I assays, facilitating widespread clinical implementation.
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Affiliation(s)
- Pedro Lopez-Ayala
- Department of Cardiology, Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Switzerland.,GREAT Network, Rome, Italy
| | - Jasper Boeddinghaus
- Department of Cardiology, Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Switzerland.,GREAT Network, Rome, Italy
| | - Luca Koechlin
- Department of Cardiology, Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Switzerland.,GREAT Network, Rome, Italy.,Department of Cardiac Surgery, University Hospital Basel, Switzerland
| | - Thomas Nestelberger
- Department of Cardiology, Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Switzerland.,GREAT Network, Rome, Italy.,Division of Cardiology, Vancouver General Hospital, University of British Columbia, Vancouver, BC, Canada
| | - Christian Mueller
- Department of Cardiology, Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Switzerland.,GREAT Network, Rome, Italy
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42
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Nestelberger T, Boeddinghaus J, Giménez MR, Lopez-Ayala P, Ratmann PD, Badertscher P, Wildi K, Wussler D, Koechlin L, Arslani K, Zimmermann T, Freese M, Rinderknecht T, Miró Ò, Martin-Sanchez FJ, Kawecki D, Geigy N, Keller D, Twerenbold R, Müller C. Direct comparison of high-sensitivity cardiac troponin T and I in the early differentiation of type 1 vs. type 2 myocardial infarction. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2021; 11:62-74. [PMID: 34195803 DOI: 10.1093/ehjacc/zuab039] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Revised: 05/01/2021] [Accepted: 05/19/2021] [Indexed: 11/14/2022]
Abstract
AIMS To directly compare the diagnostic accuracy of high-sensitivity cardiac troponin (hs-cTn) T vs. hs-cTnI in the early non-invasive differentiation of Type 1 myocardial infarction (T1MI) due to plaque rupture and atherothrombosis from Type 2 myocardial infarction (T2MI) due to supply-demand mismatch. METHODS AND RESULTS In a prospective multicentre diagnostic study, two independent cardiologists centrally adjudicated the final diagnosis of T1MI vs. T2MI according to the fourth universal definition of myocardial infarction (MI), using all available clinical information including cardiac imaging in patients presenting with acute chest pain. Diagnostic accuracy was quantified by the area under the receiver operating characteristics curve (AUC). The most extensively validated hs-cTnT-Elecsys and hs-cTnI-Architect assays were measured at presentation, 1 h, and 2 h. Among 5887 patients, 1106 (19%) had a final diagnosis of MI, including 860 (78%) T1MI and 246 (22%) T2MI. The AUC of hs-cTnT-Elecsys to differentiate T1MI from T2MI was moderate and comparable to that provided by hs-cTnI-Architect: hs-cTnT-Elecsys AUC-presentation 0.67 [95% confidence interval (CI) 0.64-0.71], AUC-1 h 0.70 (95% CI 0.66-0.74), and AUC-2 h 0.71 (95% CI 0.66-0.75) vs. hs-cTnI-Architect AUC-presentation 0.71 (95% CI 0.67-0.74), AUC-1 h 0.72 (95% CI 0.68-0.76), and AUC-2 h 0.74 (95% CI 0.69-0.78), all P = not significant (NS). Similarly, the AUC of absolute changes was moderate and comparable for hs-cTnT-Elecsys and hs-cTnI-Architect (all P = NS). Cut-off concentrations achieving at least 90% specificity for the differentiation of T1MI vs. T2MI were >114 ng/L for hs-cTnT-Elecsys [odds ratio (OR) 4.2, 95% CI 2.7-6.6] and >371 ng/L for hs-cTnI-Architect (OR 4.0, 95% CI 2.6-6.2). CONCLUSION hs-cTnT-Elecsys and hs-cTnI-Architect provided comparable, albeit only moderate, diagnostic accuracy for the early differentiation of T1MI vs. T2MI. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov number, NCT00470587, https://clinicaltrials.gov/ct2/show/NCT00470587.
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Affiliation(s)
- Thomas Nestelberger
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Petersgraben 4, CH-4031 Basel, Switzerland
- GREAT Network, Via Antonio Serra 54, 00191 Rome, Italy
- Division of Cardiology, Vancouver General Hospital, University of British Columbia, 899 12th Avenue West, V5Z 1M9 Vancouver BC, Canada
| | - Jasper Boeddinghaus
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Petersgraben 4, CH-4031 Basel, Switzerland
- GREAT Network, Via Antonio Serra 54, 00191 Rome, Italy
| | - Maria Rubini Giménez
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Petersgraben 4, CH-4031 Basel, Switzerland
- GREAT Network, Via Antonio Serra 54, 00191 Rome, Italy
- Department of Internal Medicine and Cardiology, Heart Center Leipzig-University Hospital, Strümpellstrasse 39, 04289 Leipzig, Germany
| | - Pedro Lopez-Ayala
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Petersgraben 4, CH-4031 Basel, Switzerland
- GREAT Network, Via Antonio Serra 54, 00191 Rome, Italy
| | - Paul David Ratmann
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Petersgraben 4, CH-4031 Basel, Switzerland
- GREAT Network, Via Antonio Serra 54, 00191 Rome, Italy
| | - Patrick Badertscher
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Petersgraben 4, CH-4031 Basel, Switzerland
- GREAT Network, Via Antonio Serra 54, 00191 Rome, Italy
- Department of Cardiology, Medical University of South Carolina, 179 Ashley Avenue, Charleston, SC, USA
| | - Karin Wildi
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Petersgraben 4, CH-4031 Basel, Switzerland
- GREAT Network, Via Antonio Serra 54, 00191 Rome, Italy
- Critical Care Research Institute, The Prince Charles Hospital, Brisbane and University of Queensland, 627 Rode Road, Chemside Queensland 4032, Brisbane, Australia
| | - Desiree Wussler
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Petersgraben 4, CH-4031 Basel, Switzerland
- GREAT Network, Via Antonio Serra 54, 00191 Rome, Italy
| | - Luca Koechlin
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Petersgraben 4, CH-4031 Basel, Switzerland
- GREAT Network, Via Antonio Serra 54, 00191 Rome, Italy
- Department of Cardiac Surgery, University Hospital Basel, Petersgraben 4, 4031 Basel, Switzerland
| | - Ketina Arslani
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Petersgraben 4, CH-4031 Basel, Switzerland
- GREAT Network, Via Antonio Serra 54, 00191 Rome, Italy
| | - Tobias Zimmermann
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Petersgraben 4, CH-4031 Basel, Switzerland
- GREAT Network, Via Antonio Serra 54, 00191 Rome, Italy
| | - Michael Freese
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Petersgraben 4, CH-4031 Basel, Switzerland
- GREAT Network, Via Antonio Serra 54, 00191 Rome, Italy
| | - Therese Rinderknecht
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Petersgraben 4, CH-4031 Basel, Switzerland
- GREAT Network, Via Antonio Serra 54, 00191 Rome, Italy
| | - Òscar Miró
- GREAT Network, Via Antonio Serra 54, 00191 Rome, Italy
- Emergency Department, Hospital Clinic, Barcelona, Villarroel 170, 08036 Barcelona, Spain
| | - F Javier Martin-Sanchez
- GREAT Network, Via Antonio Serra 54, 00191 Rome, Italy
- Servicio de Urgencias, Hospital Clínico San Carlos, Profesor Martin Lagos, 28040, Madrid, Spain
| | - Damian Kawecki
- GREAT Network, Via Antonio Serra 54, 00191 Rome, Italy
- 2nd Department of Cardiology, School of Medicine with the Division of Dentistry in Zabrze, Medical University of Silesia, Poniatowskiego 15, 40-055 Katowice, Poland
| | - Nicolas Geigy
- Emergency Department, Kantonsspital Liestal, Rheinstrasse 26, 4410 Liestal, Switzerland
| | - Dagmar Keller
- Emergency Department, University Hospital Zurich, Rämistrasse 100, 8091 Zurich, Switzerland
| | - Raphael Twerenbold
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Petersgraben 4, CH-4031 Basel, Switzerland
- GREAT Network, Via Antonio Serra 54, 00191 Rome, Italy
| | - Christian Müller
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Petersgraben 4, CH-4031 Basel, Switzerland
- GREAT Network, Via Antonio Serra 54, 00191 Rome, Italy
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Collet JP, Thiele H, Barbato E, Barthélémy O, Bauersachs J, Bhatt DL, Dendale P, Dorobantu M, Edvardsen T, Folliguet T, Gale CP, Gilard M, Jobs A, Jüni P, Lambrinou E, Lewis BS, Mehilli J, Meliga E, Merkely B, Mueller C, Roffi M, Rutten FH, Sibbing D, Siontis GC. Guía ESC 2020 sobre el diagnóstico y tratamiento del síndrome coronario agudo sin elevación del segmento ST. Rev Esp Cardiol (Engl Ed) 2021. [DOI: 10.1016/j.recesp.2020.12.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Mueller C, Giannitsis E, Jaffe AS, Huber K, Mair J, Cullen L, Hammarsten O, Mills NL, Möckel M, Krychtiuk K, Thygesen K, Lindahl B. Cardiovascular biomarkers in patients with COVID-19. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2021; 10:310-319. [PMID: 33655301 PMCID: PMC7989520 DOI: 10.1093/ehjacc/zuab009] [Citation(s) in RCA: 36] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Accepted: 02/12/2021] [Indexed: 01/08/2023]
Abstract
The coronavirus disease 2019 (COVID-19) pandemic has increased awareness that severe acute respiratory distress syndrome coronavirus-2 (SARS-CoV-2) may have profound effects on the cardiovascular system. COVID-19 often affects patients with pre-existing cardiac disease, and may trigger acute respiratory distress syndrome (ARDS), venous thromboembolism (VTE), acute myocardial infarction (AMI), and acute heart failure (AHF). However, as COVID-19 is primarily a respiratory infectious disease, there remain substantial uncertainty and controversy whether and how cardiovascular biomarkers should be used in patients with suspected COVID-19. To help clinicians understand the possible value as well as the most appropriate interpretation of cardiovascular biomarkers in COVID-19, it is important to highlight that recent findings regarding the prognostic role of cardiovascular biomarkers in patients hospitalized with COVID-19 are similar to those obtained in studies for pneumonia and ARDS in general. Cardiovascular biomarkers reflecting pathophysiological processes involved in COVID-19/pneumonia and its complications have a role evaluating disease severity, cardiac involvement, and risk of death in COVID-19 as well as in pneumonias caused by other pathogens. First, cardiomyocyte injury, as quantified by cardiac troponin concentrations, and haemodynamic cardiac stress, as quantified by natriuretic peptide concentrations, may occur in COVID-19 as in other pneumonias. The level of those biomarkers correlates with disease severity and mortality. Interpretation of cardiac troponin and natriuretic peptide concentrations as quantitative variables may aid in risk stratification in COVID-19/pneumonia and also will ensure that these biomarkers maintain high diagnostic accuracy for AMI and AHF. Second, activated coagulation as quantified by D-dimers seems more prominent in COVID-19 as in other pneumonias. Due to the central role of endothelitis and VTE in COVID-19, serial measurements of D-dimers may help physicians in the selection of patients for VTE imaging and the intensification of the level of anticoagulation from prophylactic to slightly higher or even therapeutic doses.
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Affiliation(s)
- Christian Mueller
- Department of Cardiology and Cardiovascular Research Institute Basel, University Hospital Basel, University of Basel, Petersgraben 4, CH-4031 Basel, Switzerland
| | | | | | - Kurt Huber
- Department of Medicine, Cardiology and Intensive Care Medicine, Wilhelminenhospital, and Sigmund Freud University, Medical School, Vienna, Austria
| | - Johannes Mair
- Department of Internal Medicine III-Cardiology and Angiology, Medical University Innsbruck, Innsbruck, Austria
| | - Louise Cullen
- Emergency and Trauma Centre, Royal Brisbane and Women`s Hospital, University of Queensland, St Lucia, QLD, Australia
| | - Ola Hammarsten
- Department of Clinical Chemistry and Transfusion Medicine, University of Gothenburg, Gothenburg, Sweden
| | - Nicholas L Mills
- University/BHF Centre for Cardiovascular Science and Usher Institute, University of Edinburgh, Edinburgh, UK
| | - Martin Möckel
- Division of Emergency Medicine, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Konstantin Krychtiuk
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, Vienna, Austria
| | - Kristian Thygesen
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
| | - Bertil Lindahl
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden
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45
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Banning AP, Crea F, Lüscher TF. The year in cardiology: acute coronary syndromes. Eur Heart J 2021; 41:821-832. [PMID: 31901933 DOI: 10.1093/eurheartj/ehz942] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2019] [Revised: 11/25/2019] [Accepted: 12/18/2019] [Indexed: 11/12/2022] Open
Abstract
Abstract
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Affiliation(s)
- Adrian P Banning
- Department of Cardiology, John Radcliffe Hospital and University of Oxford, Oxford, UK
| | - Filippo Crea
- Fondazione Policlinico Univeristario A. Gemelli, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Thomas F Lüscher
- Royal Brompton & Harefield Hospital, Imperial College, London, UK
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46
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Collet JP, Thiele H, Barbato E, Barthélémy O, Bauersachs J, Bhatt DL, Dendale P, Dorobantu M, Edvardsen T, Folliguet T, Gale CP, Gilard M, Jobs A, Jüni P, Lambrinou E, Lewis BS, Mehilli J, Meliga E, Merkely B, Mueller C, Roffi M, Rutten FH, Sibbing D, Siontis GCM. 2020 ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation. Eur Heart J 2021; 42:1289-1367. [PMID: 32860058 DOI: 10.1093/eurheartj/ehaa575] [Citation(s) in RCA: 2554] [Impact Index Per Article: 851.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
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47
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Wildi K, Boeddinghaus J, Nestelberger T, Haaf P, Koechlin L, Ayala Lopez P, Walter J, Badertscher P, Ratmann PD, Miró Ò, Martin-Sanchez FJ, Muzyk P, Kaeslin M, RubiniGiménez M, M Gualandro D, Buergler F, Keller DI, Christ M, Twerenbold R, Mueller C. External validation of the clinical chemistry score. Clin Biochem 2021; 91:16-25. [PMID: 33636187 DOI: 10.1016/j.clinbiochem.2021.02.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Revised: 02/02/2021] [Accepted: 02/11/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Combining high-sensitivity cardiac troponin (hs-cTn) with estimated glomerular filtration rate and glucose within the Clinical Chemistry Score (CCS) could help in the assessment of patients with suspected acute myocardial infarction (AMI). METHODS In patients presenting with suspected AMI to the emergency department, we aimed to externally validate the performance of the CCS in a prospective international multicenter study and to directly compare the diagnostic and prognostic performance of the CCS with hs-cTnT and hs-cTnI baseline levels alone using a single cut-off approach. The diagnostic endpoint was diagnostic accuracy for AMI as centrally adjudicated by two independent cardiologists including cardiac imaging and serial hs-cTnT/I measurements. The prognostic endpoint was 30-day AMI or death. RESULTS AMI was the final diagnosis in 620/3827 patients (16.2%) adjudicated with hs-cTnT and 599 patients (15.7%) adjudicated with hs-cTnI. The CCS resulted in high diagnostic accuracy for AMI and prognostic accuracy for 30-days AMI/death as quantified by the area under the receiver-operating characteristic curve (AUC), using hs-cTnT 0.90 (95%CI 0.89-0.91) and 0.89 (95%CI 0.88-0.90), using hs-cTnI 0.91 (95%Cl 0.90-0.92) and 0.90 (95%CI 0.89-0.91) respectively. E.g. a CCS of 0 points resulted in a sensitivity of 99.8% (95%CI 99.1-100%) for rule-out of index AMI and 99.5% (95%CI 98.5-100%) for AMI/death at 30 days for hs-cTnT and 99.8% (95%CI 98.9-100%) and 99.6% (95%CI 98.6-100%) using hs-cTnI. Overall, the single hs-cTnT/I measurement approach provided comparable diagnostic (sensitivity 99.5-99.7%) and prognostic (sensitivity 98.9-99.5%) performance versus the CCS. INTERPRETATION The CCS provided high diagnostic and prognostic performance also in this independent large validation cohort. A single hs-cTnT/I measurement approach for rule-out MI yielded similar estimates.
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Affiliation(s)
- Karin Wildi
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Switzerland; GREAT Network; Critical Care Research Group, The Prince Charles Hospital, Brisbane, and the University of Queensland, Brisbane, Australia
| | - Jasper Boeddinghaus
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Switzerland; GREAT Network
| | - Thomas Nestelberger
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Switzerland; GREAT Network
| | - Philip Haaf
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Switzerland; GREAT Network
| | - Luca Koechlin
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Switzerland; GREAT Network; Department of Cardiac Surgery, University Hospital Basel, University of Basel, Switzerland
| | - Pedro Ayala Lopez
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Switzerland; GREAT Network
| | - Joan Walter
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Switzerland; GREAT Network; Division of Internal Medicine, University Hospital Basel, University of Basel, Switzerland
| | - Patrick Badertscher
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Switzerland; GREAT Network; Division of Cardiology, Medical University of South Carolina, Charleston, SC, United States
| | - Paul David Ratmann
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Switzerland; GREAT Network
| | - Òscar Miró
- GREAT Network; Emergency Department, Hospital Clinic, Barcelona, Catalonia, Spain
| | | | - Piotr Muzyk
- GREAT Network; 2(nd) Department of Cardiology, School of Medicine with the Division of Dentistry, Zabrze, Medical University of Katowice, Poland
| | - Marina Kaeslin
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Switzerland; GREAT Network
| | - Maria RubiniGiménez
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Switzerland; GREAT Network
| | - Danielle M Gualandro
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Switzerland; GREAT Network
| | - Franz Buergler
- Emergency Department, Kantonsspital Liestal, Switzerland
| | - Dagmar I Keller
- Emergency Department, University Hospital Zurich, Zurich, Switzerland
| | | | - Raphael Twerenbold
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Switzerland; GREAT Network
| | - Christian Mueller
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Switzerland; GREAT Network.
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[Cardiac biomarkers in noncardiac surgery patients : Review of cardiac biomarkers for risk stratification and detection of postoperative adverse cardiac events]. Med Klin Intensivmed Notfmed 2021; 117:381-388. [PMID: 33564901 DOI: 10.1007/s00063-021-00788-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Revised: 12/18/2020] [Accepted: 01/10/2021] [Indexed: 10/22/2022]
Abstract
BACKGROUND Yearly, more than 200 million people worldwide undergo noncardiac surgery of whom about 5% will suffer adverse cardiac events. Therefore, risk stratification and early detection of these events is crucial. OBJECTIVES The goal of this review is to summarize the currently available evidence on the role of biomarkers in perioperative cardiac risk assessment. It presents current data of the established biomarkers troponin and brain natriuretic peptide (BNP), and it also reports on new biomarkers that are still under evaluation, e.g. copeptin (a marker of neurohumoral activation) and presepsin (an inflammation marker). MATERIALS AND METHODS Narrative review. RESULTS AND CONCLUSION According to currently available data, there is a strong association between preoperative troponin or BNP values and postoperative adverse cardiac events and mortality. However, to date, there is only a weak recommendation for routine measurement of these biomarkers even in high-risk patients because the evidence on outcome improvement is still very limited. The evidence on treatment options in case of increased postoperative troponin values is also scarce so that international guidelines come to different conclusions regarding postoperative measurement of toponin. Meanwhile, several new biomarkers are under evaluation.
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49
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Cardiovascular Biomarkers and Imaging in Older Adults: JACC Council Perspectives. J Am Coll Cardiol 2021; 76:1577-1594. [PMID: 32972536 DOI: 10.1016/j.jacc.2020.07.055] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Revised: 07/09/2020] [Accepted: 07/13/2020] [Indexed: 01/13/2023]
Abstract
Whereas the burgeoning population of older adults is intrinsically vulnerable to cardiovascular disease, the utility of many management precepts that were validated in younger adults is often unclear. Whereas biomarker- and imaging-based tests are a major part of cardiovascular disease care, basic assumptions about their use and efficacy cannot be simply extrapolated to many older adults. Biology, physiology, and body composition change with aging, with important influences on cardiovascular disease testing procedures and their interpretation. Furthermore, clinical priorities of older adults are more heterogeneous, potentially undercutting the utility of testing data that are collected. The American College of Cardiology and the National Institutes on Aging, in collaboration with the American Geriatrics Society, convened, at the American College of Cardiology Heart House, a 2-day multidisciplinary workshop, "Diagnostic Testing in Older Adults with Cardiovascular Disease," to address these issues. This review summarizes key concepts, clinical limitations, and important opportunities for research.
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50
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Aarts GWA, Mol JQ, Camaro C, Lemkes J, van Royen N, Damman P. Recent developments in diagnosis and risk stratification of non-ST-elevation acute coronary syndrome. Neth Heart J 2020; 28:88-92. [PMID: 32780337 PMCID: PMC7419413 DOI: 10.1007/s12471-020-01457-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
In the past year, a number of important papers have been published on non-ST-elevation acute coronary syndrome, highlighting progress in clinical care. The current review focuses on early diagnosis and risk stratification using biomarkers and advances in intracoronary imaging.
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Affiliation(s)
- G W A Aarts
- Department of Cardiology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - J Q Mol
- Department of Cardiology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - C Camaro
- Department of Cardiology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - J Lemkes
- Department of Cardiology, Amsterdam UMC, location VUMC, University of Amsterdam, Amsterdam, The Netherlands
| | - N van Royen
- Department of Cardiology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - P Damman
- Department of Cardiology, Radboud University Medical Centre, Nijmegen, The Netherlands.
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