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Celeski M, Segreti A, Piscione M, Monticelli LM, Di Gioia G, Fossati C, Ussia GP, Pigozzi F, Grigioni F. The current paradigm of cardiac troponin increase among athletes. Monaldi Arch Chest Dis 2024. [PMID: 38700130 DOI: 10.4081/monaldi.2024.2878] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Accepted: 03/16/2024] [Indexed: 05/05/2024] Open
Abstract
Although it is known that exercise improves cardiovascular health and extends life expectancy, a significant number of people may also experience an elevation in cardiac troponin levels as a result of exercise. For many years, researchers have argued whether exercise-induced cardiac troponin rises are a consequence of a physiological or pathological reaction and whether they are clinically significant. Differences in cardiac troponin elevation and cardiac remodeling can be seen between athletes participating in different types of sports. When forecasting the exercise-induced cardiac troponin rise, there are many additional parameters to consider, as there is a large amount of interindividual heterogeneity in the degree of cardiac troponin elevation. Although it was previously believed that cardiac troponin increases in athletes represented a benign phenomenon, numerous recent studies disproved this notion by demonstrating that, in specific individuals, cardiac troponin increases may have clinical and prognostic repercussions. This review aims to examine the role of cardiac troponin in athletes and its role in various sporting contexts. This review also discusses potential prognostic and clinical implications, as well as future research methods, and provides a straightforward step-by-step algorithm to help clinicians interpret cardiac troponin rise in athletes in both ischemic and non-ischemic circumstances.
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Affiliation(s)
- Mihail Celeski
- Research Unit of Cardiovascular Science, Department of Medicine and Surgery, Università Campus Bio-Medico di Roma; Cardiology Unit, Fondazione Policlinico Universitario Campus Bio-Medico, Rome.
| | - Andrea Segreti
- Research Unit of Cardiovascular Science, Department of Medicine and Surgery, Università Campus Bio-Medico di Roma; Cardiology Unit, Fondazione Policlinico Universitario Campus Bio-Medico, Rome; Department of Movement, Human and Health Sciences, University of Rome "Foro Italico".
| | - Mariagrazia Piscione
- Research Unit of Cardiovascular Science, Department of Medicine and Surgery, Università Campus Bio-Medico di Roma; Cardiology Unit, Fondazione Policlinico Universitario Campus Bio-Medico, Rome.
| | - Luigi Maria Monticelli
- Research Unit of Cardiovascular Science, Department of Medicine and Surgery, Università Campus Bio-Medico di Roma; Cardiology Unit, Fondazione Policlinico Universitario Campus Bio-Medico, Rome.
| | - Giuseppe Di Gioia
- Research Unit of Cardiovascular Science, Department of Medicine and Surgery, Università Campus Bio-Medico di Roma; Cardiology Unit, Fondazione Policlinico Universitario Campus Bio-Medico, Rome; Department of Movement, Human and Health Sciences, University of Rome "Foro Italico"; Institute of Sport Medicine and Science, Italian National Olympic Committee, Rome.
| | - Chiara Fossati
- Department of Movement, Human and Health Sciences, University of Rome "Foro Italico".
| | - Gian Paolo Ussia
- Research Unit of Cardiovascular Science, Department of Medicine and Surgery, Università Campus Bio-Medico di Roma; Cardiology Unit, Fondazione Policlinico Universitario Campus Bio-Medico, Rome.
| | - Fabio Pigozzi
- Department of Movement, Human and Health Sciences, University of Rome "Foro Italico".
| | - Francesco Grigioni
- Research Unit of Cardiovascular Science, Department of Medicine and Surgery, Università Campus Bio-Medico di Roma; Cardiology Unit, Fondazione Policlinico Universitario Campus Bio-Medico, Rome.
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Valenzuela PL, Baggish A, Castillo-García A, Santos-Lozano A, Boraita A, Lucia A. Strenuous Endurance Exercise and the Heart: Physiological versus Pathological Adaptations. Compr Physiol 2022; 12:4067-4085. [PMID: 35950659 DOI: 10.1002/cphy.c210045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
Although the benefits of regular physical activity on cardiovascular health are well established, the effects of strenuous endurance exercise (SEE) have been a matter of debate since ancient times. In this article, we aim to provide a balanced overview of what is known about SEE and the heart-from epidemiological evidence to recent cardiac imaging findings. Lifelong SEE is overall cardioprotective, with endurance master athletes showing in fact a youthful heart. Yet, some lines of research remain open, such as the need to elucidate the time-course and potential relevance of transient declines in heart function (or increases in biomarkers of cardiac injury) with SEE. The underlying mechanisms and clinical relevance of SEE-associated atrial fibrillation, myocardial fibrosis, or high coronary artery calcium scores also remain to be elucidated. © 2022 American Physiological Society. Compr Physiol 12:1-19, 2022.
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Affiliation(s)
- Pedro L Valenzuela
- Physical Activity and Health Research Group ('PaHerg'), Research Institute of the Hospital 12 de Octubre ('imas12'), Madrid, Spain
| | - Aaron Baggish
- Cardiovascular Performance Program, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Adrián Castillo-García
- Fissac - Physiology, Health and Physical Activity, Madrid, Spain.,Biology Systems Department, University of Alcalá, Madrid, Spain
| | - Alejandro Santos-Lozano
- Physical Activity and Health Research Group ('PaHerg'), Research Institute of the Hospital 12 de Octubre ('imas12'), Madrid, Spain.,i+HeALTH, European University Miguel de Cervantes, Valladolid, Spain
| | - Araceli Boraita
- Department of Cardiology, Sports Medicine Center, Spanish Agency for Health Protection in Sports, Madrid, Spain
| | - Alejandro Lucia
- Physical Activity and Health Research Group ('PaHerg'), Research Institute of the Hospital 12 de Octubre ('imas12'), Madrid, Spain.,Faculty of Sport Sciences, Universidad Europea de Madrid, Madrid, Spain
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3
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Wolff S, Picco JM, Díaz-González L, Valenzuela PL, Gonzalez-Dávila E, Santos-Lozano A, Matile P, Wolff D, Boraita A, Lucia A. Exercise-Induced Cardiac Fatigue in Recreational Ultramarathon Runners at Moderate Altitude: Insights From Myocardial Deformation Analysis. Front Cardiovasc Med 2022; 8:744393. [PMID: 35141287 PMCID: PMC8818846 DOI: 10.3389/fcvm.2021.744393] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Accepted: 12/31/2021] [Indexed: 11/13/2022] Open
Abstract
Background Controversy exists on the actual occurrence of exercise-induced cardiac fatigue (EICF) with ultraendurance exercise, as well as on whether factors such as age or training status might predispose to this condition. The present study aimed to assess the occurrence of EICF among recreational ultramarathon runners, as well as to determine potential predictive factors. Methods Nineteen male recreational runners (42 ± 12yrs) participated in a 55-km trial race at moderate altitude (1,800–2,500 m). Participants were evaluated before and after the race using Doppler echocardiography and myocardial deformation analysis. EICF was determined as a reduction >5% of either left ventricular global longitudinal strain (LVGLS) or right ventricular free wall strain (RVFWS). Demographical (age, body mass index), training (training experience, volume and intensity), competition (finishing time, relative intensity) and biochemical variables (blood lactate, creatine kinase [CK] and CK-MB) were assessed as predictors of EICF. Results A significant reduction in LVGLS (20.1 ± 2.1% at baseline vs. 18.8 ± 2.4% at post-race, p = 0.026), but not in RVFWS (27.4 ± 7.0 vs. 24.6 ± 5.3%, p = 0.187), was observed after the race. EICF was present in 47 and 71% of the participants attending to the decrease in LVGLS and RVFWS, respectively. No associations were found between any of the analyzed variables and EICF except for age, which was associated with the magnitude of decrement of RVFWS (r = 0.58, p = 0.030). Conclusions Ultramarathon running at moderate altitude seems to induce EICF in a considerable proportion of recreational athletes.
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Affiliation(s)
- Sebastián Wolff
- Wolff Cardiology and Sport Medicine Institute, Mendoza, Argentina
| | - José M. Picco
- Wolff Cardiology and Sport Medicine Institute, Mendoza, Argentina
| | - Leonel Díaz-González
- Cardiology Department, CEMTRO Clinic, Madrid, Spain
- Cardiology Department, La Paz Hospital, Madrid, Spain
| | - Pedro L. Valenzuela
- Faculty of Sport Sciences, Universidad Europea de Madrid, Madrid, Spain
- Physical Activity and Health Research Group (“PaHerg”), Research Institute of the Hospital 12 de Octubre (“Imas12”), Madrid, Spain
| | | | - Alejandro Santos-Lozano
- I+HeALTH, European University Miguel de Cervantes, Valladolid, Spain
- Physical Activity and Health Research Group (“PaHerg”), Research Institute of the Hospital 12 de Octubre (“Imas12”), Madrid, Spain
| | | | - David Wolff
- Wolff Cardiology and Sport Medicine Institute, Mendoza, Argentina
| | - Araceli Boraita
- Department of Cardiology, Sports Medicine Center, Spanish Sports Health Protection Agency, Consejo Superior de Deportes, Madrid, Spain
| | - Alejandro Lucia
- Faculty of Sport Sciences, Universidad Europea de Madrid, Madrid, Spain
- Physical Activity and Health Research Group (“PaHerg”), Research Institute of the Hospital 12 de Octubre (“Imas12”), Madrid, Spain
- *Correspondence: Alejandro Lucia
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4
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Chaulin A. Clinical and Diagnostic Value of Highly Sensitive Cardiac Troponins in Arterial Hypertension. Vasc Health Risk Manag 2021; 17:431-443. [PMID: 34366667 PMCID: PMC8336985 DOI: 10.2147/vhrm.s315376] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Accepted: 07/02/2021] [Indexed: 12/13/2022] Open
Abstract
In modern laboratory diagnostics of cardiovascular diseases (CVD), there is a clear tendency toward an increase in the sensitivity of methods for determining key CVD biomarkers, among which highly sensitive cardiac troponins (hs-Tn) deserve special attention. The introduction of the latter into clinical practice made it possible not only to improve the early diagnosis of acute myocardial infarction but also to open up a number of additional valuable opportunities for the use of hs-Tn, including the assessment of the risk of developing CVD in a healthy population, detection and monitoring of early myocardial injuries in the early stages of CVD development (for example, with ischemic heart disease and arterial hypertension), with noncardiac pathologies (for example, sepsis, chronic obstructive pulmonary disease, chronic renal failure, stroke, cancer, etc), and diagnostics of CVD by using biological fluids that can be obtained by noninvasive methods. This article discusses in detail the diagnostic value of hs-Tn in serum and urine in cases of arterial hypertension. Also, the paper pays considerable attention to the consideration of the mechanisms underlying the increase in hs-Tn in serum and urine in cases of arterial hypertension.
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Affiliation(s)
- Aleksey Chaulin
- Department of Cardiology and Cardiovascular Surgery, Samara State Medical University, Samara, 443099, Russia.,Department of Histology and Embryology, Samara State Medical University, Samara, 443099, Russia
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5
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Mahanty A, Xi L. Utility of cardiac biomarkers in sports medicine: Focusing on troponin, natriuretic peptides, and hypoxanthine. SPORTS MEDICINE AND HEALTH SCIENCE 2020; 2:65-71. [PMID: 35784176 PMCID: PMC9219314 DOI: 10.1016/j.smhs.2020.05.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Revised: 05/18/2020] [Accepted: 05/18/2020] [Indexed: 01/20/2023] Open
Abstract
Evidence-based consensus suggests that physical activity and regular exercise training can reduce modifiable risk factors as well as rate of mortality and morbidity in patients with chronic diseases, such as cardiovascular disease (CVD), diabetes, obesity and cancer. Conversely, long-term exercise training and drastic increase in vigorous physical activity may also cause acute cardiovascular events (e.g. acute myocardial infarction) and deleterious cardiac remodeling, particularly when exercise is performed by unfit or susceptible individuals. There is a reversed J-shaped hormesis-like curve between the duration and intensity of exercise and level of CVD risks. Therefore, it is important for an early detection of cardiac injuries in professional and amateur athletes. Under this context, this article focuses on the use of biomarker testing, an indispensable component in the current clinical practices especially in Cardiology and Oncology. We attempt to justify the importance of using circulating biomarkers in routine practices of Sports Medicine for an objective assessment of CVD events following exercise. Special attentions are dedicated to three established or emerging cardiac biomarkers (i.e. cardiac troponins, natriuretic peptides, hypoxanthine) for myocardial tissue hypoxia/ischemia events, muscle stress, and the consequent cellular necrotic injury. Based on these focused analyses, we propose use of circulating biomarker testing in both laboratory and point-of-care settings with an increasingly broader involvement or participation of team physicians, trainers, coaches, primary care doctors, as well as educated athlete community. This diagnostic approach may improve the quality of medical surveillance and preventive measures on exercise-related CVD risks/outcomes.
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Affiliation(s)
| | - Lei Xi
- Corresponding author. Division of Cardiology, Box 980204, Virginia Commonwealth University, 1101 East Marshall Street, Room 7-020C, Richmond, VA, 23298-0204, USA.
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6
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Gaze DC. Cardiac Troponin in Endurance Exercise-Fragments of the Imagination or Clinical Significance? J Appl Lab Med 2018; 3:760-763. [PMID: 31639751 DOI: 10.1373/jalm.2018.027870] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2018] [Accepted: 10/15/2018] [Indexed: 11/06/2022]
Affiliation(s)
- David C Gaze
- School of Life Sciences, College of Liberal Arts and Sciences, University of Westminster, London, UK.
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7
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Kosowski M, Młynarska K, Chmura J, Kustrzycka-Kratochwil D, Sukiennik-Kujawa M, Todd JA, Jankowska EA, Banasiak W, Reczuch K, Ponikowski P. Cardiovascular stress biomarker assessment of middle-aged non-athlete marathon runners. Eur J Prev Cardiol 2018; 26:318-327. [DOI: 10.1177/2047487318819198] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background Cardiovascular safety of marathon running in recreational runners remains unclear. We set up this study to comprehensively evaluate the effects of a marathon run on the profile of cardiovascular stress biomarkers in connection with transthoracic echocardiography. Design and methods Thirty-three healthy male amateur runners, aged ≥50 years (mean age 57 ± 7) were enrolled. Venous blood samples were obtained before the marathon, just after the race, 2–4 and seven days after the marathon. Using novel single molecule counting technology we measured: plasma concentrations of high-sensitivity cardiac troponin I (hs-cTnI) and endothelin-1. N-terminal pro B-type natriuretic peptide was measured using electrochemiluminescence. Each participant had transthoracic echocardiography before and immediately after the race. Results We observed a sharp rise in the levels of all biomarkers after the race (all p < 0.01), which subsequently normalized after 2–4 days and stayed within normal range after seven days. Runners with intensive training programmes (>169 km/month, a median for the studied group) had lower hs-cTnI leak after the race (median 15.11 ng/ml and 31.2 ng/ml, respectively; p < 0.05). Neither transthoracic echocardiography measures of ventricles nor strain rates changed after the run. We observed a decrease in the left atrial volume index and increase in the maximal right atrial volumes (all p < 0.05). Changes in Doppler indices of diastolic function suggestive of alteration in left ventricular relaxation were observed. Conclusions Marathon run is associated with sharp and significant rises in the biomarkers of cardiovascular stress. The profile of these changes, however, along with echocardiographic parameters, does not suggest irreversible myocardial damage.
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Affiliation(s)
- Michał Kosowski
- Department of Heart Diseases, Wroclaw Medical University, Poland
- Centre for Heart Diseases, 4th Military Hospital, Wroclaw, Poland
| | | | - Jan Chmura
- Department of Motor Ability and Sport Performance, University School of Physical Education, Wroclaw, Poland
| | | | | | | | - Ewa A Jankowska
- Department of Heart Diseases, Wroclaw Medical University, Poland
- Centre for Heart Diseases, 4th Military Hospital, Wroclaw, Poland
| | | | - Krzysztof Reczuch
- Department of Heart Diseases, Wroclaw Medical University, Poland
- Centre for Heart Diseases, 4th Military Hospital, Wroclaw, Poland
| | - Piotr Ponikowski
- Department of Heart Diseases, Wroclaw Medical University, Poland
- Centre for Heart Diseases, 4th Military Hospital, Wroclaw, Poland
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8
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Manjunath L, Yeluru A, Rodriguez F. 27-Year-Old Man with a Positive Troponin: A Case Report. Cardiol Ther 2018; 7:197-204. [PMID: 30367446 PMCID: PMC6251827 DOI: 10.1007/s40119-018-0120-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2018] [Indexed: 11/24/2022] Open
Abstract
In this case report, we describe a young athletic male with a family history of early sudden cardiac death who presented with atypical chest pain and was found to have a positive serum troponin. Although his symptoms resolved without intervention, workup revealed hypertension, hyperlipidemia, mild left ventricular hypertrophy, non-obstructive coronary artery disease, and the presence of serum heterophile antibodies. Ultimately, it was concluded that his rigorous exercise regimen as well as the presence of heterophile antibodies may have contributed to his positive serum troponin. This case serves as a reminder of the nonspecific diagnostic value of modern troponin assays, and that the results of these tests should always be incorporated into the clinical context.
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Affiliation(s)
| | - Apurva Yeluru
- Department of Medicine, Stanford University, Stanford, CA, USA
| | - Fatima Rodriguez
- Department of Medicine, Stanford University, Stanford, CA, USA.,Division of Cardiovascular Medicine, Department of Medicine, Stanford University, Stanford, CA, USA
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9
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Abstract
Cardiac troponins are the preferred biomarkers in diagnostic of myocardial infarction, but these markers also can rise in response to exercise. Multiple studies have assessed troponins post-exercise, but the results have varied and there have been disagreements about the mechanism of troponin release. The aim of this paper was to review the literature, and to consider factors and mechanisms regarding exercise-induced increase of troponin. 145 studies were found after a search in pubmed and inclusion of additional articles found in the reference list of the first articles. Results showed that troponin rises in 0-100% of subjects after prolonged heavy exercise like marathon, but also after short-term and intermittent exercise like 30min of running and basketball. The variation can be due to factors like intensity, age, training experience, variation in sample size, blood sample timing and troponin assay. The pattern of troponin level post-exercise corresponds to release from the cytosolic compartment of cardiomyocytes. Increased membrane permeability might be caused by production of reactive oxygen species or alterations in calcium, pH, glucose/fat metabolism or in communication between integrins. Other suggested mechanisms are increased cardiovascular stress, inflammation, vasculitis, release of troponin degradation products in "blebs", dehydration, impaired renal clearance and expression of cardiac troponin in skeletal muscle. It can be concluded that both heavy and light exercise may cause elevated troponin, which have to be considered when patient are suspected to have a myocardial infarction. Several factors probably influence post-exercise levels of troponin, but the mechanism of release is most likely physiologic.
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Affiliation(s)
- T Gresslien
- Department of Cardiology, Oslo University Hospital Ullevål and Institute of Clinical Sciences, University of Oslo, Oslo, Norway
| | - S Agewall
- Department of Cardiology, Oslo University Hospital Ullevål and Institute of Clinical Sciences, University of Oslo, Oslo, Norway.
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10
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Wedin JO, Henriksson AE. Postgame elevation of cardiac markers among elite floorball players. Scand J Med Sci Sports 2014; 25:495-500. [PMID: 25109452 DOI: 10.1111/sms.12304] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/10/2014] [Indexed: 12/20/2022]
Abstract
Cardiac biomarker release after exercise is well documented in endurance sports, but neither the impact of intermittent high-intensity exercise nor the reproducibility has yet been established. Floorball, a popular sport in Scandinavia, involves intermittent periods of high-intensity exercise. This study aimed to determine the prevalence and reproducibility of elevated cardiac marker levels among elite floorball players after two games. Twenty-three healthy male elite floorball players of median age 19 years (range 16-34 years) participated in two standard games. Blood was drawn at three time points: pregame, immediately after, and 2 h after the game. Creatine kinase MB (CK-MB), myoglobin, and high-sensitivity cardiac troponin T (hs-cTnT) were measured. The results showed significantly elevated median postgame values in all markers. In both games, hs-cTnT exceeded the cutoff for myocardial damage (≥ 14 ng/L) 2 h postgame in the same six players. The major findings were that postgame cardiac hs-cTnT values among elite floorball players were significantly elevated and reproducible. The findings imply that extended investigations should incorporate evaluation of myocardial function and myocardial perfusion during exercise to seek the clinical significance and underlying mechanisms of elevated cardiac troponin after high-intensity exercise.
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Affiliation(s)
- J O Wedin
- Department of Clinical Chemistry, Sundsvall County Hospital, Sundsvall, Sweden
| | - A E Henriksson
- Department of Clinical Chemistry, Sundsvall County Hospital, Sundsvall, Sweden.,Department of Natural Sciences, Mid Sweden University, Sundsvall, Sweden
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11
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Cohen SI, Ellis ER. Death and near death from cardiac arrest during the Boston Marathon. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2011; 35:241-4. [PMID: 22040232 DOI: 10.1111/j.1540-8159.2011.03248.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
The Boston Marathon has been run for 115 years during which there were three sudden cardiac arrests. The most recent was a near death avoided by rapid cardiopulmonary resuscitation (CPR) and defibrillation. Awareness of the dangers of participating in a marathon, the risk factors associated with sudden death during competition, and the life-saving importance of rapid CPR and defibrillation are essential for participants and event organizers. Available records and reports of the three known cases of cardiac arrest during the Boston Marathon were examined. These cases were identified by representatives of the Boston Athletic Association, which has organized each marathon since its inception. Pertinent literature was reviewed and new information was obtained during interviews of witnesses and rescuers. The data were analyzed in search of shared risk factors for cardiac arrest, death, and the optimal requirements for survival. In 115 years, there were two cardiac deaths and one near death from cardiac arrest. A history of coronary artery disease, advanced age, and prolonged race time are risk factors for sudden cardiac arrest. Rapid application of CPR and defibrillation are essential for survival. Prevention or reduction of life-threatening cardiac incidents during marathon races might be achieved if participants of advanced age or with a history of coronary artery disease seek medical clearance prior to entering an event. Those with coronary risk factors should have a discussion with their physician. Availability of trained personnel and defibrillators are important considerations in marathon planning.
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Affiliation(s)
- Stafford I Cohen
- Division of Cardiology, Beth Israel Deaconess Medical Center, Boston, Massachusetts 02215, USA
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12
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Regwan S, Hulten EA, Martinho S, Slim J, Villines TC, Mitchell J, Slim AM. Marathon running as a cause of troponin elevation: a systematic review and meta-analysis. J Interv Cardiol 2011; 23:443-50. [PMID: 20663014 DOI: 10.1111/j.1540-8183.2010.00575.x] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Cardiac troponin (cTn) has high sensitivity and specificity for myocardial injury in acute coronary syndrome. Our objective was to review the published literature regarding the incidence of cTn elevations in marathon runners. METHODS Systematic review and meta-analysis of observational studies published before September 2009. We included studies of patients who had completed a marathon and had serum cTn levels within 24 hours. The primary outcome was the odds ratio for conversion of a normal pre-marathon cTn to an elevated post-marathon cTn. Secondary outcomes included the pooled prevalence of cTn elevation and comparison of the odds ratio for post-marathon elevation of cTnI versus cTnT. RESULTS Sixteen studies of 939 participants met criteria for inclusion. The mean age was 39 ± 4 years and patients were 74 ± 14% male. There were 6 pre-marathon cTn elevations and 579 post-race elevations. The pooled odds ratio for converting from a normal pre-race to an elevated post-race cTn was 51.84 (95% CI 16-168, I² = 66%, P < 0.001). The pooled incidence of a post-marathon cTn elevation was 51% (95% CI 33-69, I² = 98%, P < 0.001) of all runners. For the primary outcome there was no significant publication bias. Age and gender were not associated, but publication date and assay sensitivity was associated with cTn elevation. cTnI was less commonly elevated versus cTnT. CONCLUSIONS The available data demonstrate that cTn levels are frequently elevated after a marathon with unclear cardiovascular significance. This elevation of cTn appears to be consistent among a diverse patient population.
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Affiliation(s)
- Steven Regwan
- Cardiology Service, San Antonio Military Medical Center, San Antonio, Texas, USA
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13
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Thompson PD, Venero CV. A history of medical reports on the Boston Marathon: 112 years and still running. Med Sci Sports Exerc 2010; 41:1341-8. [PMID: 19461529 DOI: 10.1249/01.mss.0000350977.65985.cf] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
INTRODUCTION/METHODS We performed a systematic search for medical reports on the Boston Marathon, run annually since April 19, 1897 and studied medically since 1899. RESULTS We identified 66 articles: 25 were related to cardiology; 10, exercise physiology; 8, metabolism; 5, neurology; 4, gastroenterology; 3, hematology; 3, several disciplines; and 8, nephrology, orthopedics, and general topics. The predominance of cardiology articles reflects concerns about the cardiac risks of exercise present in the early 20th century and persistent to this day. The authors and contributors included luminaries from the medical and exercise community including Drs. Paul Dudley White, Samuel Levine, Kenneth Cooper, Paul Zoll, Ellsworth Buskirk, and David Costill. The articles identified or confirmed many of the presently accepted principles of marathon medicine. CONCLUSIONS Medical studies on the Boston Marathon not only provide lessons applicable to managing modern athletes but also demonstrate the interests and concerns of researchers who have used the event to study the physiology of prolonged exercise for more than a century.
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Affiliation(s)
- Paul D Thompson
- Henry Low Heart Center, Hartford Hospital, Hartford, CT 06102, USA.
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14
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Sahlén A, Shahgaldi K, Aminoff A, Aagaard P, Manouras A, Winter R, Ehrenborg E, Braunschweig F. Effects of Prolonged Exercise on Left Ventricular Mechanical Synchrony in Long-Distance Runners: Importance of Previous Exposure to Endurance Races. J Am Soc Echocardiogr 2010; 23:977-84. [DOI: 10.1016/j.echo.2010.06.030] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2010] [Indexed: 11/26/2022]
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15
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Shave R, Baggish A, George K, Wood M, Scharhag J, Whyte G, Gaze D, Thompson PD. Exercise-induced cardiac troponin elevation: evidence, mechanisms, and implications. J Am Coll Cardiol 2010; 56:169-76. [PMID: 20620736 DOI: 10.1016/j.jacc.2010.03.037] [Citation(s) in RCA: 278] [Impact Index Per Article: 19.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2009] [Revised: 02/19/2010] [Accepted: 03/09/2010] [Indexed: 12/20/2022]
Abstract
Regular physical exercise is recommended for the primary prevention of cardiovascular disease. Although the high prevalence of physical inactivity remains a formidable public health issue, participation in exercise programs and recreational sporting events, such as marathons and triathlons, is on the rise. Although regular exercise training reduces cardiovascular disease risk, recent studies have documented elevations in cardiac troponin (cTn) consistent with cardiac damage after bouts of exercise in apparently healthy individuals. At present, the prevalence, mechanism(s), and clinical significance of exercise-induced cTn release remains incompletely understood. This paper will review the biochemistry, prevalence, potential mechanisms, and management of patients with exercise-induced cTn elevations.
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Affiliation(s)
- Rob Shave
- Brunel University, Uxbridge, Middlesex, United Kingdom.
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Sahlén A, Gustafsson TP, Svensson JE, Marklund T, Winter R, Linde C, Braunschweig F. Predisposing factors and consequences of elevated biomarker levels in long-distance runners aged >or=55 years. Am J Cardiol 2009; 104:1434-40. [PMID: 19892064 DOI: 10.1016/j.amjcard.2009.06.067] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2009] [Revised: 06/28/2009] [Accepted: 06/28/2009] [Indexed: 11/26/2022]
Abstract
Cardiac biomarkers play an important role in the diagnosis of cardiovascular disease. Elevated levels can be seen in the context of strenuous exercise. We studied this phenomenon in senior endurance runners. We included 185 participants (61.1 +/- 5 years; 29% women) at a 30-km cross-country race who were self-reportedly in excellent health. Before and after the race, the creatinine, N-terminal pro-brain natriuretic peptide (NT-proBNP), and troponin T were analyzed, and participation in the number of previous races and the race duration were recorded. NT-proBNP increased from 53 ng/L (interquartile range 31 to 89) to 121 ng/L (interquartile range 79 to 184) and troponin T from undetectable to 0.01 microg/L (interquartile range 0.01 to 0.04). The independent predictors of a large NT-proBNP increase were (1) greater levels present at baseline, (2) a greater increase in creatinine (both p <0.001), (3) older age (p = 0.01), and (4) a longer race duration (p <0.05). Troponin T elevation was independently predicted by (1) older age (p = 0.01), (2) a greater increase in creatinine, and (3) participation in fewer previous races (both p <0.05). Of the 15 runners with an elevated (>194 ng/L) baseline NT-proBNP level (8.1% of 185), 4 were found to have serious cardiovascular disease (2.2% of whole sample). Of these 4 patients, 1 died from sudden cardiac death within months after the race. In conclusion, biomarker elevation occurs commonly in senior runners. A high baseline NT-proBNP is predictive of a large release during exercise, suggesting that the factors that control the at rest levels also determine its release with exertion. Troponin T elevation was seen in less-experienced participants. A small group of very ill runners were identified by NT-proBNP analysis.
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THOMPSON PAULD, VENERO CARMELOV. A History of Medical Reports on the Boston Marathon. Med Sci Sports Exerc 2009; 41:257-64. [DOI: 10.1249/mss.0b013e3181878067] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Michielsen ECHJ, Wodzig WKWH, Van Dieijen-Visser MP. Cardiac Troponin T Release after Prolonged Strenuous Exercise. Sports Med 2008; 38:425-35. [DOI: 10.2165/00007256-200838050-00005] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
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Makowski GS, Ramsby ML, Ramsby GR. An indium:calcium phosphate colloid that specifically targets fibrin. J Biomed Sci 2005; 12:421-9. [PMID: 15918002 DOI: 10.1007/s11373-004-0226-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2004] [Accepted: 12/20/2004] [Indexed: 10/25/2022] Open
Abstract
The ability of indium to target fibrin in vitro was evaluated. The radionuclide (114m)Indium (114mIn) was prepared as a soluble and colloidal (In:In) form, as well as, a mixed indium:calcium phosphate (In:CaP) colloid. Soluble 114mIn was prepared by maintaining acid pH (50 mM HCl). Colloidal 114mIn (In:In) was prepared under slightly basic conditions (50 mM Tris-Cl, pH 7.6). The mixed In:CaP colloid was prepared by incubation of 114mIn with calcium (10 mM) and phosphate (250 microM) under slightly basic conditions (50 mM Tris-Cl, pH 7.6). To assess fibrin binding, the three 114mIn preparations were mixed with diluted human plasma (source of fibrinogen). Fibrin polymerization was initiated by addition of calcium (5 mM) and thrombin (0.5 U/ml). Following incubation (15 min, 37 degrees C), the fibrin matrix was condensed, removed from the reaction mixture, and washed briefly. Fibrin uptake of 114mIn (soluble, colloidal, or In:CaP) was determined by gamma counting. Results demonstrated that soluble 114mIn exclusively bound a plasma protein electrophoretically and immunologically identified as transferrin. Although both colloidal 114mIn and 114mIn:CaP bound fibrin, the mixed 114mIn:CaP colloid demonstrated substantially higher fibrin binding activity (about 2-fold). The target of indium binding was confirmed as fibrin due to the presence of characteristic cross-linked gamma-gamma dimers (100 kDa) and beta-monomers (58 kDa) by SDS-PAGE. 114mIn colloid and the mixed 114mIn:CaP colloid demonstrated no ability to bind fibrin's precursor, fibrinogen. 114mIn:CaP fibrin binding was associated with formation of CaP, as evidenced by its dependence on phosphate concentration. The biocompatibility of CaP including its ability to bind 114mIn and specifically target fibrin may be of potential value for diagnostic imaging studies to identify regions of occult vascular stenosis (i.e., atherosclerotic plaques, deep vein thrombosis, pulmonary embolus).
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Affiliation(s)
- Gregory S Makowski
- Department of Laboratory Medicine, School of Medicine, University of Connecticut Health Center, Farmington, CT, USA.
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Rivera ML, Nadel ES, Brown DFM. Exertional chest pain. J Emerg Med 2005; 28:69-73. [PMID: 15657008 DOI: 10.1016/j.jemermed.2004.10.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/01/2023]
Affiliation(s)
- Morris L Rivera
- Division of Emergency Medicine, Harvard Medical School, Boston, MA, USA
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Apple FS, Quist HE, Otto AP, Mathews WE, Murakami MM. Release Characteristics of Cardiac Biomarkers and Ischemia-modified Albumin as Measured by the Albumin Cobalt-binding Test after a Marathon Race. Clin Chem 2002. [DOI: 10.1093/clinchem/48.7.1097] [Citation(s) in RCA: 107] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Fred S Apple
- Department of Laboratory Medicine and Pathology, Hennepin County Medical Center, University of Minnesota School of Medicine, Minneapolis, MN 55415
| | - Heidi E Quist
- Department of Laboratory Medicine and Pathology, Hennepin County Medical Center, University of Minnesota School of Medicine, Minneapolis, MN 55415
| | - Angela P Otto
- Department of Laboratory Medicine and Pathology, Hennepin County Medical Center, University of Minnesota School of Medicine, Minneapolis, MN 55415
| | - Wendy E Mathews
- Department of Laboratory Medicine and Pathology, Hennepin County Medical Center, University of Minnesota School of Medicine, Minneapolis, MN 55415
| | - MaryAnn M Murakami
- Department of Laboratory Medicine and Pathology, Hennepin County Medical Center, University of Minnesota School of Medicine, Minneapolis, MN 55415
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Siegel AJ, Lewandrowski EL, Chun KY, Sholar MB, Fischman AJ, Lewandrowski KB. Changes in cardiac markers including B-natriuretic peptide in runners after the Boston marathon. Am J Cardiol 2001; 88:920-3. [PMID: 11676966 DOI: 10.1016/s0002-9149(01)01910-5] [Citation(s) in RCA: 57] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Affiliation(s)
- A J Siegel
- Department of Medicine, McLean Hospital, Belmont, Massachusetts, USA
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23
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Cleave P, Boswell TD, Speedy DB, Boswell DR. Plasma Cardiac Troponin Concentrations after Extreme Exercise. Clin Chem 2001. [DOI: 10.1093/clinchem/47.3.608] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
| | | | - Dale B Speedy
- Department of General Practice, and Primary Care, University of Auckland, Auckland, NZ
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Chiang VW, Burns JP, Rifai N, Lipshultz SE, Adams MJ, Weiner DL. Cardiac toxicity of intravenous terbutaline for the treatment of severe asthma in children: a prospective assessment. J Pediatr 2000; 137:73-7. [PMID: 10891825 DOI: 10.1067/mpd.2000.106567] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To examine the cardiac toxicity as measured by elevations in serum cardiac troponin T (cTnT) and to compare creatine kinase (CK) and creatine kinase MB (CK-MB) and findings on electrocardiography (ECG) as markers of cardiac toxicity with cTnT during the infusion of intravenous terbutaline for the treatment of severe asthma in children. STUDY DESIGN Prospective cohort study of patients receiving intravenous terbutaline for severe asthma. RESULTS Only 3 (10%) of the 29 patients had elevations in cTnT. Each underwent mechanical ventilation for >72 hours, which was the earliest point at which cTnT elevations were identified. Eighteen (62%) patients had an elevation in CK, and 3 had an elevation in CK-MB fraction without an elevated cTnT. Twenty (69%) patients had ECG findings consistent with ischemia, and 19 of these patients had the ischemic findings on their preterbutaline ECG. Elevations in CK and CK-MB and ischemic changes on ECG did not correlate with elevations in cTnT. Both mechanical ventilation (P =.02) and prolonged administration (>72 hours) of intravenous terbutaline (P =. 02) were significantly associated with elevations in cTnT. CONCLUSIONS We found no clinically significant cardiac toxicity from the use of intravenous terbutaline for severe asthma as measured by serum cTnT elevations.
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Affiliation(s)
- V W Chiang
- Division of Emergency Medicine and the Departments of Anesthesia and Laboratory Medicine, Children's Hospital, Harvard Medical School, Boston, MA 02115, USA
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Chen Y, Serfass RC, Mackey-Bojack SM, Kelly KL, Titus JL, Apple FS. Cardiac troponin T alterations in myocardium and serum of rats after stressful, prolonged intense exercise. J Appl Physiol (1985) 2000; 88:1749-55. [PMID: 10797139 DOI: 10.1152/jappl.2000.88.5.1749] [Citation(s) in RCA: 94] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
The goal of this study was to determine whether the stress of forced exercise would result in injury to the myocardium. Male rats with 8% of body weight attached to the tail were forced to swim 3.5 h (3.5S), forced to swim 5 h (5S), or pretrained for 8 days and then forced to swim 5 h (T5S). Rats were killed immediately after they swam (0 h PS) and at 3 h (3 h PS), 24 h (24 h PS), and 48 h after they swam (48 h PS). Tissue homogenates of the left ventricle were analyzed by Western blot analysis for cardiac troponin T (cTnT). Serum cTnT was quantified by immunoassay. Results indicated that, in the 3.5S, 5S, and T5S groups, serum cTnT was significantly (P < 0.01) increased at 0 and 3 h PS. The 5S group demonstrated a greater increase in serum cTnT than the 3.5S group (P < 0.01) and the T5S group (P < 0.01) at 0 h PS. Western blot analysis indicated significant decreases (P < 0. 01) in myocardial cTnT in the 5S group only at 0 h PS (P < 0.01) and 3 h PS (P < 0.05). Histological evidence of localized myocyte damage demonstrated by interstitial inflammatory infiltrates consisting of neutrophils, lymphocytes, and histiocytes, as well as vesicular nuclei-enlarged chromatin patterns, was observed in left ventricle specimens from the 5S group at 24 and 48 h PS. Our findings demonstrate that stressful, forced exercise induces alterations in myocardial cTnT and that training before exercise attenuates the exercise-induced heart damage.
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Affiliation(s)
- Y Chen
- Division of Kinesiology, School of Kinesiology and Leisure Studies, University of Minnesota, Minneapolis 55455, Minnesota, USA
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Musha H, Nagashima J, Awaya T, Oomiya K, Takada H, Murayama M. Myocardial injury in a 100-km ultramarathon. Curr Ther Res Clin Exp 1997. [DOI: 10.1016/s0011-393x(97)80085-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Abstract
A number of techniques are available to assess the clinical value of enzyme methodologies including regression and discriminant analyses, expert systems, neural networks, and probabilistic. Each has its adherents but the probabilistic approach appears to be the most commonly used technique. This approach uses the fourfold contingency table that categorises subjects by both the presence or absence of the target disease-as defined by a gold standard test- and by a test result being above or below a chosen decision threshold. From this classification can be defined the test's sensitivity and specificity. By altering the decision threshold across the entire range of test values a series of sensitivity:specificity pairs can be tabulated. These may be plotted as 1-specificity (or false positive rate or fraction) versus sensitivity (or true positive rate or fraction) to create a receiver operator characteristic (ROC) curve. ROC curves can provide the accuracy of the test (the area under the curve with associated confidence intervals), the rule-in and rule-out decision thresholds, and the clinical power of the test (likelihood ratio). However, a review of three years' publications in a peer-reviewed journal indicated that much of this essential data is usually absent. It is argued that such publications should include the decision thresholds used, the area under the curve and its standard error, a statistical assessment of the difference between two or more ROC plots, the rule-in and rule-out decision thresholds (indicating if these change with time after the onset of disease), and the relevant likelihood ratios.
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Affiliation(s)
- A R Henderson
- Department of Biochemistry, University of Western Ontario, London, Canada.
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