1
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Maayah M, Grubman S, Allen S, Ye Z, Park DY, Vemmou E, Gokhan I, Sun WW, Possick S, Kwan JM, Gandhi PU, Hu JR. Clinical Interpretation of Serum Troponin in the Era of High-Sensitivity Testing. Diagnostics (Basel) 2024; 14:503. [PMID: 38472975 DOI: 10.3390/diagnostics14050503] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2024] [Revised: 02/03/2024] [Accepted: 02/05/2024] [Indexed: 03/14/2024] Open
Abstract
Cardiac troponin (Tn) plays a central role in the evaluation of patients with angina presenting with acute coronary syndrome. The advent of high-sensitivity assays has improved the analytic sensitivity and precision of serum Tn measurement, but this advancement has come at the cost of poorer specificity. The role of clinical judgment is of heightened importance because, more so than ever, the interpretation of serum Tn elevation hinges on the careful integration of findings from electrocardiographic, echocardiographic, physical exam, interview, and other imaging and laboratory data to formulate a weighted differential diagnosis. A thorough understanding of the epidemiology, mechanisms, and prognostic implications of Tn elevations in each cardiac and non-cardiac etiology allows the clinician to better distinguish between presentations of myocardial ischemia and myocardial injury-an important discernment to make, as the treatment of acute coronary syndrome is vastly different from the workup and management of myocardial injury and should be directed at the underlying cause.
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Affiliation(s)
- Marah Maayah
- Yale School of Medicine, Yale University, New Haven, CT 06520, USA
| | - Scott Grubman
- Yale School of Medicine, Yale University, New Haven, CT 06520, USA
| | - Stephanie Allen
- Department of Internal Medicine, Yale School of Medicine, Yale University, New Haven, CT 06520, USA
| | - Zachary Ye
- Department of Internal Medicine, Temple University Medical Center, Philadelphia, PA 19140, USA
| | - Dae Yong Park
- Department of Internal Medicine, Cook County Hospital, Chicago, IL 60612, USA
| | - Evangelia Vemmou
- Department of Internal Medicine, Yale School of Medicine, Yale University, New Haven, CT 06520, USA
| | - Ilhan Gokhan
- Yale School of Medicine, Yale University, New Haven, CT 06520, USA
| | - Wendy W Sun
- Department of Emergency Medicine, Yale School of Medicine, Yale University, New Haven, CT 06520, USA
| | - Stephen Possick
- Section of Cardiovascular Medicine, Yale School of Medicine, Yale University, New Haven, CT 06520, USA
| | - Jennifer M Kwan
- Section of Cardiovascular Medicine, Yale School of Medicine, Yale University, New Haven, CT 06520, USA
| | - Parul U Gandhi
- Section of Cardiovascular Medicine, Yale School of Medicine, Yale University, New Haven, CT 06520, USA
- Department of Cardiology, Veterans Affairs Connecticut Health Care System, West Haven, CT 06516, USA
| | - Jiun-Ruey Hu
- Section of Cardiovascular Medicine, Yale School of Medicine, Yale University, New Haven, CT 06520, USA
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2
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Banceu CM, Banceu DM, Kauvar DS, Popentiu A, Voth V, Liebrich M, Halic Neamtu M, Oprean M, Cristutiu D, Harpa M, Brinzaniuc K, Suciu H. Acute Aortic Syndromes from Diagnosis to Treatment-A Comprehensive Review. J Clin Med 2024; 13:1231. [PMID: 38592069 PMCID: PMC10932437 DOI: 10.3390/jcm13051231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2024] [Revised: 02/19/2024] [Accepted: 02/19/2024] [Indexed: 04/10/2024] Open
Abstract
This work aims to provide a comprehensive description of the characteristics of a group of acute aortic diseases that are all potentially life-threatening and are collectively referred to as acute aortic syndromes (AASs). There have been recent developments in the care and diagnostic plan for AAS. A substantial clinical index of suspicion is required to identify AASs before irreversible fatal consequences arise because of their indefinite symptoms and physical indicators. A methodical approach to the diagnosis of AAS is addressed. Timely and suitable therapy should be started immediately after diagnosis. Improving clinical outcomes requires centralising patients with AAS in high-volume centres with high-volume surgeons. Consequently, the management of these patients benefits from the increased use of aortic centres, multidisciplinary teams and an "aorta code". Each acute aortic entity requires a different patient treatment strategy; these are outlined below. Finally, numerous preventive strategies for AAS are discussed. The keys to good results are early diagnosis, understanding the natural history of these disorders and, where necessary, prompt surgical intervention. It is important to keep in mind that chest pain does not necessarily correspond with coronary heart disease and to be alert to the possible existence of aortic diseases because once antiplatelet drugs are administered, a blocked coagulation system can complicate aortic surgery and affect prognosis. The management of AAS in "aortic centres" improves long-term outcomes and decreases mortality rates.
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Affiliation(s)
- Cosmin M. Banceu
- I.O.S.U.D., George Emil Palade University of Medicine, Pharmacy, Science, and Technology of Targu Mures, 540139 Targu Mures, Romania; (C.M.B.)
- Department of Surgery M3, George Emil Palade University of Medicine, Pharmacy, Science, and Technology of Targu Mures, 540139 Targu Mures, Romania
- Emergency Institute for Cardiovascular Diseases and Transplantation Targu Mures, 540136 Targu Mures, Romania
| | - Diana M. Banceu
- Emergency Institute for Cardiovascular Diseases and Transplantation Targu Mures, 540136 Targu Mures, Romania
| | - David S. Kauvar
- Department of Surgery, Division of Vascular Surgery, Stanford University School of Medicine, Palo Alto, CA 94305, USA
| | - Adrian Popentiu
- Faculty of Medicine, University Lucian Blaga Sibiu, 550169 Sibiu, Romania
| | | | | | - Marius Halic Neamtu
- Swiss Federal Institute of Forest, Snow and Landscape Research WSL, 8903 Birmensdorf, Switzerland
- Institute of Environmental Engineering, ETH Zurich, 8039 Zurich, Switzerland
| | - Marvin Oprean
- Mathematics and Statistics Department, Amherst College, Amherst, MA 01002, USA
| | - Daiana Cristutiu
- Emergency Institute for Cardiovascular Diseases and Transplantation Targu Mures, 540136 Targu Mures, Romania
| | - Marius Harpa
- I.O.S.U.D., George Emil Palade University of Medicine, Pharmacy, Science, and Technology of Targu Mures, 540139 Targu Mures, Romania; (C.M.B.)
- Department of Surgery M3, George Emil Palade University of Medicine, Pharmacy, Science, and Technology of Targu Mures, 540139 Targu Mures, Romania
- Emergency Institute for Cardiovascular Diseases and Transplantation Targu Mures, 540136 Targu Mures, Romania
| | - Klara Brinzaniuc
- I.O.S.U.D., George Emil Palade University of Medicine, Pharmacy, Science, and Technology of Targu Mures, 540139 Targu Mures, Romania; (C.M.B.)
- Department of Anatomy, George Emil Palade University of Medicine, Pharmacy, Science, and Technology of Targu Mures, 540142 Targu Mures, Romania
| | - Horatiu Suciu
- I.O.S.U.D., George Emil Palade University of Medicine, Pharmacy, Science, and Technology of Targu Mures, 540139 Targu Mures, Romania; (C.M.B.)
- Department of Surgery M3, George Emil Palade University of Medicine, Pharmacy, Science, and Technology of Targu Mures, 540139 Targu Mures, Romania
- Emergency Institute for Cardiovascular Diseases and Transplantation Targu Mures, 540136 Targu Mures, Romania
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3
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Yamamoto K, Saito Y, Hashimoto O, Nakayama T, Okino S, Sakai Y, Nakamura Y, Fukuzawa S, Himi T, Kobayashi Y. Biomarkers for Risk Stratification in Patients With Type A Acute Aortic Dissection. Am J Cardiol 2024; 212:103-108. [PMID: 38040278 DOI: 10.1016/j.amjcard.2023.11.053] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2023] [Revised: 10/23/2023] [Accepted: 11/14/2023] [Indexed: 12/03/2023]
Abstract
Type A acute aortic dissection (AAD) is a fatal disease and thus, accurate and objective risk stratification is essential. In this study, we evaluated the prognostic value of readily available and assessable biomarkers in patients with type A AAD. This was a retrospective, multicenter, observational study. A total of 703 patients with type A AAD diagnosed using contrast-enhanced computed tomography were included. Therapeutic strategies were left to the physician's discretion in a real-world clinical setting. The prognostic value for in-hospital mortality was examined in 15 circulating biomarkers on admission, which are routinely available in clinical practice. Of the 703 patients, 126 (17.9%) died during the hospitalization. Of the 15 biomarkers, the multivariable analysis identified positive cardiac troponin, a low total bilirubin (T-Bil) level, and increased levels of brain natriuretic peptide (BNP) and lactate dehydrogenase (LDH) as significant predictors of in-hospital death. The receiver operating characteristics curve analysis showed that these 4 biomarkers had an independent additive prognostic value. With the cut-off values of T-Bil, BNP, and LDH, in combination with positive troponin, the increase in the number of positive biomarkers was progressively associated with higher in-hospital mortality from 1.3% to 9.8%, 20.5%, 36.4%, and 75.0% (p <0.001). In conclusion, in patients with type A AAD, positive cardiac troponin, a low T-Bil level, and increased levels of BNP and LDH on admission were related to higher in-hospital mortality, with an incremental prognostic value, suggesting that the readily available and assessable biomarkers can aid in decision-making in therapeutic strategies.
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Affiliation(s)
- Kayo Yamamoto
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Yuichi Saito
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, Chiba, Japan.
| | - Osamu Hashimoto
- Department of Cardiology, Chiba Emergency Medical Center, Chiba, Japan
| | - Takashi Nakayama
- Department of Cardiovascular Medicine, International University of Health and Welfare, Narita, Japan
| | - Shinichi Okino
- Department of Cardiology, Funabashi Municipal Medical Center, Funabashi, Japan
| | - Yoshiaki Sakai
- Department of Cardiology, Chiba Emergency Medical Center, Chiba, Japan
| | - Yoshitake Nakamura
- Division of Cardiology, Chiba Cerebral and Cardiovascular Center, Ichihara, Japan
| | - Shigeru Fukuzawa
- Department of Cardiology, Funabashi Municipal Medical Center, Funabashi, Japan
| | - Toshiharu Himi
- Division of Cardiology, Kimitsu Central Hospital, Kisarazu, Japan
| | - Yoshio Kobayashi
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, Chiba, Japan
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Kimura S, Sato H, Shimajiri S, Umehara T, Noguchi H, Niino D, Nakayama T. Association of troponin I and macrophages in cardiac tamponade with Stanford type A aortic dissection. Heliyon 2023; 9:e20791. [PMID: 37860537 PMCID: PMC10582508 DOI: 10.1016/j.heliyon.2023.e20791] [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: 11/20/2022] [Revised: 09/08/2023] [Accepted: 10/06/2023] [Indexed: 10/21/2023] Open
Abstract
Background Acute aortic dissection has a high mortality rate, especially for Stanford type A with a dissected ascending aorta. Cardiac tamponade is one of the most common complications of acute type A aortic dissection (ATAAD) and can cause death. However, the pathogenesis is often unclear. We aimed to examine laboratory findings at the onset of disease and macrophage involvement. Methods Hematological and biochemical parameters, and D-dimer, brain natriuretic peptide (BNP), and high-sensitivity troponin I (hs-cTnI) levels in 70 patients with ATAAD at our hospital were investigated. Additionally, the myocardium and aorta after autopsy of an ATAAD case with cardiac tamponade were pathologically examined. Results Forty-four ATAAD cases were complicated by cardiac tamponade. The mean age of patients with cardiac tamponade and proportion of patients over 70 years of age were both significantly higher than for those without cardiac tamponade. Evaluable D-dimer values were higher than 0.5 μg/mL in all patients. Significantly elevated laboratory parameters in patients with cardiac tamponade included: lactate dehydrogenase, aspartate aminotransferase, C-reactive protein, lactate, BNP, and hs-cTnI. However, multivariate analysis showed only hs-cTnI was significantly associated with cardiac tamponade. Histological examination revealed numerous M2-like macrophages infiltrating the myocardium and dissecting aorta, expressing CC chemokine ligand (CCL)2 together with vascular endothelial growth factor-C and matrix metalloproteinase-9. The peripheral monocyte-to-neutrophil ratio (MNR) was also significantly higher in cardiac tamponade. Conclusions In ATAAD patients with cardiac tamponade, hs-cTnI was significantly elevated and CCL2 expression was observed, which may be involved in the expression of M2-like macrophages via an increased MNR.
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Affiliation(s)
- Satoshi Kimura
- Department of Clinical Pathology, Kitakyushu City Yahata Hospital, Kitakyushu, Japan
- Department of Pathology, School of Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan
| | - Hiroaki Sato
- Department of Forensic Medicine, School of Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan
| | - Shohei Shimajiri
- Department of Pathology, School of Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan
| | - Takahiro Umehara
- Department of Forensic Medicine, School of Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan
| | - Hirotsugu Noguchi
- Department of Pathology, Field of Oncology, Graduate School of Medical and Dental Sciences, Kagoshima University, Kagoshima, Japan
| | - Daisuke Niino
- Pathology, Faculty of Medicine, Shimane University, Izumo, Japan
| | - Toshiyuki Nakayama
- Department of Pathology, School of Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan
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Lee M, Kim YW, Lee D, Kim TY, Lee S, Seo JS, Lee JH. The D-Dimer to Troponin Ratio Is a Novel Marker for the Differential Diagnosis of Thoracic Acute Aortic Syndrome from Non-ST Elevation Myocardial Infarction. J Clin Med 2023; 12:jcm12093054. [PMID: 37176495 PMCID: PMC10179683 DOI: 10.3390/jcm12093054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Revised: 04/15/2023] [Accepted: 04/21/2023] [Indexed: 05/15/2023] Open
Abstract
BACKGROUND Thoracic acute aortic syndrome (AAS) and non-ST elevation myocardial infarction (NSTEMI) have similar clinical presentations, making them difficult to differentiate. This study aimed to identify useful biomarkers for the differential diagnosis of thoracic AAS and NSTEMI. METHODS This was a retrospective observational study. PARTICIPANTS consecutive adult patients who visited the emergency department for acute chest pain between January 2015 and December 2021 diagnosed with thoracic AAS or NSTEMI. Clinical variables, including D-dimer (μg/mL) and high-sensitivity troponin T (ng/mL, hs-TnT) levels, were compared between the groups. RESULTS A total of 52 (30.1%) and 121 (69.9%) patients were enrolled in the thoracic AAS and NSTEMI groups, respectively. Logistic regression analysis revealed that the D-dimer to hs-TnT (D/T) ratio (odds ratio (OR), 1.038; 95% confidence interval (CI), 1.020-1.056; p < 0.001) and the thrombolysis in myocardial infarction (TIMI) score (OR, 0.184; 95% CI, 0.054-0.621; p = 0.006) were associated with thoracic AAS. The D/T ratio had an area under the receiver operating characteristic curve (AUC) of 0.973 (95% CI, 0.930-0.998), and the optimal cutoff value was 81.3 with 91.4% sensitivity and 96.2% specificity. The TIMI score had an AUC of 0.769 (95% CI, 0.644-0.812), and the optimal cutoff value was 1.5 with 96.7% sensitivity and 38.5% specificity. CONCLUSION the D/T ratio may be a simple and useful parameter for differentiating thoracic AAS from NSTEMI.
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Affiliation(s)
- Minsik Lee
- Department of Emergency Medicine, Dongguk University Ilsan Hospital, Dongguk University College of Medicine, Goyang 10326, Republic of Korea
- Department of Emergency Medicine, Kangwon National University College of Medicine, Chuncheon 24341, Republic of Korea
| | - Yong Won Kim
- Department of Emergency Medicine, Dongguk University Ilsan Hospital, Dongguk University College of Medicine, Goyang 10326, Republic of Korea
| | - Dayeon Lee
- Department of Emergency Medicine, Dongguk University Ilsan Hospital, Dongguk University College of Medicine, Goyang 10326, Republic of Korea
| | - Tae-Youn Kim
- Department of Emergency Medicine, Dongguk University Ilsan Hospital, Dongguk University College of Medicine, Goyang 10326, Republic of Korea
| | - Sanghun Lee
- Department of Emergency Medicine, Dongguk University Ilsan Hospital, Dongguk University College of Medicine, Goyang 10326, Republic of Korea
| | - Jun Seok Seo
- Department of Emergency Medicine, Dongguk University Ilsan Hospital, Dongguk University College of Medicine, Goyang 10326, Republic of Korea
| | - Jeong Hun Lee
- Department of Emergency Medicine, Dongguk University Ilsan Hospital, Dongguk University College of Medicine, Goyang 10326, Republic of Korea
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Tong F, Wang Y, Sun Z. Development and validation of nomogram models to discriminate between acute aortic syndromes and non-S T-elevation myocardial infarction during troponin-blind period. Front Cardiovasc Med 2023; 10:1077712. [PMID: 36742067 PMCID: PMC9895376 DOI: 10.3389/fcvm.2023.1077712] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2022] [Accepted: 01/03/2023] [Indexed: 01/22/2023] Open
Abstract
Background Blood-test-based methods of distinguishing between acute aortic syndromes (AASs) and non-ST-elevation myocardial infarction (NSTEMI) during the troponin-blind period of <2-3 h of symptom onset have not been studied previously. We aimed to explore whether routine biomarkers might facilitate differential diagnosis. Methods Data were retrospectively collected from 178 patients with AASs and 460 patients with NSTEMI within 3 h of onset. Differential risk factors related to AASs were identified by univariate and multivariate logistic regression analyses for patients with onset <2 h and onset ≥2 h, respectively, in the cardiac troponin (cTn) cohort. Nomograms were established in the cTn cohort as a training set and validated in the high-sensitivity cTn cohort. To assess the utility of the models in clinical practice, decision curve analyses were performed. Results D-dimer, fibrinogen, and age were identified as differential risk factors for AASs with the onset of <2 h. D-dimer at an optimal cutoff level of 281 ng/mL for AASs had a sensitivity of 86.4% and a specificity of 91.3%. A nomogram was developed and validated with areas under the curve (AUC) of 0.934 (95% CI: 0.880-0.988) and 0.952 (95% CI: 0.874-1.000), respectively. D-dimer, neutrophil, bilirubin, and platelet were the differential risk factors for AASs with the onset of ≥2 h. D-dimer at an optimal cutoff level of 385 ng/mL has a sensitivity of 91.8% and a specificity of 91.3%. The AUC of the second nomogram in the training set and the validation set were 0.965 (95% CI: 0.942-0.988) and 0.974 (95% CI: 0.944-1.000), respectively. Conclusion Time-dependent quality of D-dimer should be considered for discriminating AASs from NSTEMI. Both nomogram models may have a clinical utility for evaluating the probability of AASs.
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Affiliation(s)
- Fei Tong
- Department of Cardiology, Shengjing Hospital of China Medical University, Shenyang, China
| | - Yue Wang
- Department of Obstetrics and Gynaecology, Shengjing Hospital of China Medical University, Shenyang, China
| | - Zhijun Sun
- Department of Cardiology, Shengjing Hospital of China Medical University, Shenyang, China,*Correspondence: Zhijun Sun ✉
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Peng H, Liu W, Jian KT, Xia Y, Liu JS, Sun LZ, Mei YQ. Impact of unintentional coronary angiography on outcomes of emergency surgery in acute type A aortic dissection: a retrospective study. BMC Cardiovasc Disord 2022; 22:383. [PMID: 36002794 PMCID: PMC9400216 DOI: 10.1186/s12872-022-02821-4] [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: 03/29/2022] [Accepted: 08/16/2022] [Indexed: 12/02/2022] Open
Abstract
Background This study investigated the impact of coronary angiography on outcomes of emergency operation in acute type A aortic dissection (ATAAD) patients who were initially misdiagnosed as an acute coronary syndrome. Methods From October 2016 to April 2019, 129 patients underwent emergency operation for ATAAD in our institution, including 21 patients (16.3%, coronary angiography group) who received preoperative coronary angiography without knowledge of the ATAAD, and the rest 108 did not (Non-coronary angiography group). Preoperative clinical characteristics, 30-day mortality and postoperative complications were compared. Multivariable logistic regression was performed to confirm the independent prognostic factors for short-term and long-term outcomes. Results Patients undergoing coronary angiography had higher prevalence of preoperative hypotension or shock (61.9% vs 35.2%, P = 0.022), ischemic changes on electrocardiogram (66.7% vs 37.0%, P = 0.012), platelet inhibition (ADP-induced inhibition 92.0% vs 46.0%, P = 0.001), and coronary involvement (66.7% vs 30.6%, P = 0.002). 30-day mortality was 4.8% versus 9.3% (P = 0.84). Coronary angiography group had more intraoperative bleeding (1900 ml vs 1500 ml, P = 0.013) and chest-tube drainage on the first postoperative day (1040 ml vs 595 ml, P = 0.028). However, preoperative coronary angiography was not independent risk factors for 30-day mortality (OR 0.171, 95%CI 0.013–2.174, P = 0.173) and overall survival (HR 0.407; 95%CI 0.080–2.057; P = 0.277). Conclusion Patients undergoing coronary angiography carried a higher risk of preoperative hemodynamic instability, myocardial ischemia, and perioperative bleeding. However, unintentional coronary angiography did not have a significant impact on short-term and long-term outcomes of emergency surgery in ATAAD. Supplementary Information The online version contains supplementary material available at 10.1186/s12872-022-02821-4.
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Affiliation(s)
- Hao Peng
- Department of Cardiovascular and Thoracic Surgery, Tongji Hospital, Tongji University School of Medicine, 389 Xincun Road, Shanghai, 200065, People's Republic of China.,Department of Cardiovascular Surgery, Shanghai DeltaHealth Hospital, 109 Xule Rd, Shanghai, 201702, People's Republic of China
| | - Wei Liu
- Department of Cardiovascular Surgery, Shanghai DeltaHealth Hospital, 109 Xule Rd, Shanghai, 201702, People's Republic of China
| | - Kai-Tao Jian
- Department of Cardiovascular Surgery, Shanghai DeltaHealth Hospital, 109 Xule Rd, Shanghai, 201702, People's Republic of China
| | - Yu Xia
- Department of Cardiovascular Surgery, Shanghai DeltaHealth Hospital, 109 Xule Rd, Shanghai, 201702, People's Republic of China
| | - Jian-Shi Liu
- Department of Cardiovascular Surgery, Shanghai DeltaHealth Hospital, 109 Xule Rd, Shanghai, 201702, People's Republic of China
| | - Li-Zhong Sun
- Department of Cardiovascular Surgery, Shanghai DeltaHealth Hospital, 109 Xule Rd, Shanghai, 201702, People's Republic of China.
| | - Yun-Qing Mei
- Department of Cardiovascular and Thoracic Surgery, Tongji Hospital, Tongji University School of Medicine, 389 Xincun Road, Shanghai, 200065, People's Republic of China.
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Taggart C, Wereski R, Mills NL, Chapman AR. Diagnosis, Investigation and Management of Patients with Acute and Chronic Myocardial Injury. J Clin Med 2021; 10:2331. [PMID: 34073539 PMCID: PMC8199345 DOI: 10.3390/jcm10112331] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Revised: 05/14/2021] [Accepted: 05/20/2021] [Indexed: 12/16/2022] Open
Abstract
The application of high-sensitivity cardiac troponins in clinical practice has led to an increase in the recognition of elevated concentrations in patients without myocardial ischaemia. The Fourth Universal Definition of Myocardial Infarction encourages clinicians to classify such patients as having an acute or chronic myocardial injury based on the presence or absence of a rise or a fall in cardiac troponin concentrations. Both conditions may be caused by a variety of cardiac and non-cardiac conditions, and evidence suggests that clinical outcomes are worse than patients with myocardial infarction due to atherosclerotic plaque rupture, with as few as one-third of patients alive at 5 years. Major adverse cardiovascular events are comparable between populations, and up to three-fold higher than healthy individuals. Despite this, no evidence-based strategies exist to guide clinicians in the investigation of non-ischaemic myocardial injury. This review explores the aetiology of myocardial injury and proposes a simple framework to guide clinicians in early assessment to identify those who may benefit from further investigation and treatment for those with cardiovascular disease.
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Affiliation(s)
- Caelan Taggart
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh EH16 4SA, UK; (C.T.); (R.W.); (N.L.M.)
| | - Ryan Wereski
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh EH16 4SA, UK; (C.T.); (R.W.); (N.L.M.)
| | - Nicholas L. Mills
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh EH16 4SA, UK; (C.T.); (R.W.); (N.L.M.)
- Usher Institute, University of Edinburgh, Edinburgh EH16 4UX, UK
| | - Andrew R. Chapman
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh EH16 4SA, UK; (C.T.); (R.W.); (N.L.M.)
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9
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Pitts L, Montagner M, Kofler M, Van Praet KM, Heck R, Buz S, Kurz SD, Sündermann S, Hommel M, Falk V, Kempfert J. State of the Art Review: Surgical Treatment of Acute Type A Aortic Dissection. Surg Technol Int 2021; 38:279-288. [PMID: 33823055 DOI: 10.52198/21.sti.38.cv1413] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
Acute type A aortic dissection (ATAAD) is a life-threatening event that requires immediate surgical treatment. Improvements in surgical treatment, graft technology, organ protection and imaging techniques have led to improved clinical outcomes. Individualized treatment concepts have emerged based on more advanced planning tools that allow for a tailored approach even in complex situations such as multi-level malperfusion. This review provides an overview of the current surgical treatment of ATAAD, focusing on new disease classifications, preoperative computed tomography angiography (CTA) assessment, new prosthesis and stent technologies, and organ-protection strategies.
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Affiliation(s)
- Leonard Pitts
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Germany
| | - Matteo Montagner
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Germany
| | - Markus Kofler
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Germany
| | - Karel M Van Praet
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Germany
- DZHK (German Center for Cardiovascular Research), Partner Site Berlin, Germany
| | - Roland Heck
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Germany
| | - Semih Buz
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Germany
- DZHK (German Center for Cardiovascular Research), Partner Site Berlin, Germany
| | - Stephan D Kurz
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Germany
- Charité - Universitätsmedizin Berlin, Department of Cardiovascular Surgery, Berlin, Germany
| | - Simon Sündermann
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Germany
- DZHK (German Center for Cardiovascular Research), Partner Site Berlin, Germany
- Charité - Universitätsmedizin Berlin, Department of Cardiovascular Surgery, Berlin, Germany
| | - Matthias Hommel
- Department of Anesthesiology, German Heart Center Berlin, Germany
| | - Volkmar Falk
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Germany
- DZHK (German Center for Cardiovascular Research), Partner Site Berlin, Germany
- Charité - Universitätsmedizin Berlin, Department of Cardiovascular Surgery, Berlin, Germany
- Translational Cardiovascular Technologies, Institute of Translational Medicine, Department of Health Sciences and Technology, Swiss Federal Institute of Technology (ETH), Zurich, Switzerland
| | - Jörg Kempfert
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Germany
- DZHK (German Center for Cardiovascular Research), Partner Site Berlin, Germany
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Vrsalović M, Vrsalović Presečki A. ADMISSION CARDIAC TROPONINS PREDICT HOSPITAL MORTALITY IN TYPE A ACUTE AORTIC DISSECTION: A META-ANALYSIS OF ADJUSTED RISK ESTIMATES. Acta Clin Croat 2021; 60:115-119. [PMID: 34588730 PMCID: PMC8305354 DOI: 10.20471/acc.2021.60.01.16] [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: 12/16/2020] [Accepted: 02/02/2021] [Indexed: 11/24/2022] Open
Abstract
Acute aortic dissection (AAD) is a serious medical emergency that requires early diagnosis and rapid treatment. Whether cardiac troponin could be an independent prognostic marker in patients with type A AAD is still unknown. We systematically searched Medline and Scopus to identify all observational cohort studies published before January 2020 that compared outcome (in-hospital mortality) in patients with type A AAD with and without troponin elevation on admission. Four studies with 412 patients were included in final analysis (median age 59 years, 65% of males). A total of 124 (30%) patients died during in-hospital stay, and 73% underwent surgery. Elevated troponins (39.6% of patients) were associated with an increased risk of short-term mortality (adjusted odds ratio 1.26; 95% confidence interval 1.08-1.47), with low heterogeneity among studies (I2=29.81%). Elevated troponins on admission are independently associated with increased in-hospital mortality in type A AAD.
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Affiliation(s)
| | - Ana Vrsalović Presečki
- 1University of Zagreb, School of Medicine, Zagreb, Croatia; 2Department of Cardiology, Sestre milosrdnice University Hospital Centre, Zagreb, Croatia; 3Faculty of Chemical Engineering and Technology, University of Zagreb, Zagreb, Croatia
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Ma C, Zhao H, Shi F, Li M, Liu X, Ji C, Han Y. Serum Ceruloplasmin Is the Candidate Predictive Biomarker for Acute Aortic Dissection and Is Related to Thrombosed False Lumen: a Propensity Score-Matched Observational Case-Control Study. Biol Trace Elem Res 2021; 199:895-911. [PMID: 32504399 DOI: 10.1007/s12011-020-02219-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Accepted: 05/22/2020] [Indexed: 12/19/2022]
Abstract
Acute aortic dissection (AAD), one of the fatal diseases observed at the department of vascular surgery, is associated with a great mortality rate at the early stage. Ceruloplasmin (CP) is the plasma protein that functions as a copper transporter. The current retrospective research was carried out to assess CP contents and to examine the possible part in diagnosing patients with AAD. In addition, propensity score matching (PSM) was also utilized for reducing the bias in case screening as well as the clinical confounders. Using PSM, this study included 85 pairs of AAD cases (Stanford A and B dissection) and matched controls, and their CP levels were also detected through enzyme-linked immunosorbent assay (ELISA). Additionally, the relative clinical data were extracted from participants included in this study. After PSM adjustment for clinical variables, including gender, age, body mass index (BMI), heart ratio (HR), smoking, hypertension, diabetes mellitus, coronary heart disease (CHD), and stroke, the serum CP contents among AAD cases were remarkably increased compared with those among the normal subjects. Besides, the CP contents showed independent association with the AAD risk. Typically, the CP level was significantly positively correlated with platelet (R = 0.329) or C-reactive protein (R = 0.340) level. Meanwhile, the area under the receiver operating characteristic (ROC) curve (AUC) was 0.929 when CP was used to diagnose AAD, and the best threshold value was 36.82mg/dL. Serum CP content significantly increased in cases with thrombosed false lumen (FL) relative to those in patent FL cases. Results of logistic regression analysis suggested that a greater CP content indicated an increased thrombosed FL risk (OR = 1.11; 95% CI: 1.01-1.23; P = 0.040). Findings in this study suggest that serum ceruloplasmin contents evidently increased among acute aortic dissection cases. CP shows close correlation with the inflammatory factors among AAD cases. Further, CP may serve as the candidate biomarker to diagnose AAD and to identify an increased risk of thrombosed false lumen.
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Affiliation(s)
- Changcheng Ma
- Department of Laboratory Medicine, Shengjing Hospital of China Medical University, Shenyang, China
| | - Haibin Zhao
- Department of Emergency Medicine, Shengjing Hospital of China Medical University, Shenyang, China
| | - Feng Shi
- Department of Health Management, Shengjing Hospital of China Medical University, Shenyang, China
| | - Mu Li
- Department of General Surgery, Shengjing Hospital of China Medical University, Shenyang, China
| | - Xun Liu
- Department of General Surgery, Shengjing Hospital of China Medical University, Shenyang, China
| | - Chao Ji
- Department of Clinical Epidemiology, Shengjing Hospital of China Medical University, Shenyang, China
| | - Yanshuo Han
- School of Life and Pharmaceutical Sciences, Dalian University of Technology, No. 2 Dagong Road, Liaodongwan New District, Panjin, 124221, China.
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12
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Feistritzer HJ, Jobs A, de Waha-Thiele S, Eitel I, Freund A, Abdel-Wahab M, Desch S, Thiele H. Multivessel versus culprit-only PCI in STEMI patients with multivessel disease: meta-analysis of randomized controlled trials. Clin Res Cardiol 2020; 109:1381-1391. [PMID: 32239284 PMCID: PMC7588388 DOI: 10.1007/s00392-020-01637-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Accepted: 03/17/2020] [Indexed: 11/30/2022]
Abstract
AIMS To perform a pairwise meta-analysis of randomized controlled trials (RCTs) comparing multivessel percutaneous coronary intervention (PCI) and culprit vessel-only PCI in ST-elevation myocardial infarction (STEMI) patients without cardiogenic shock. METHODS We searched MEDLINE, Cochrane Central Register of Controlled Trials, and Embase for RCTs comparing multivessel PCI with culprit vessel-only PCI in STEMI patients without cardiogenic shock and multivessel coronary artery disease. Only RCTs reporting mortality or myocardial reinfarction after at least 6 months following randomization were included. Hazard ratios (HRs) were pooled using random-effect models. RESULTS Nine RCTs were included in the final analysis. In total, 523 (8.3%) of 6314 patients suffered the combined primary endpoint of death or non-fatal reinfarction. This primary endpoint was significantly reduced with multivessel PCI compared to culprit vessel-only PCI (HR 0.63, 95% confidence interval [CI] 0.43-0.93; p = 0.03). This finding was driven by a reduction of non-fatal reinfarction (HR 0.64, 95% CI 0.52-0.79; p = 0.001), whereas no significant reduction of all-cause death (HR 0.77, 95% CI 0.44-1.35; p = 0.28) or cardiovascular death (HR 0.64, 95% CI 0.37-1.11; p = 0.09) was observed. CONCLUSIONS In STEMI patients without cardiogenic shock multivessel PCI reduced the risk of death or non-fatal reinfarction compared to culprit vessel-only PCI.
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Affiliation(s)
- Hans-Josef Feistritzer
- Department of Internal Medicine/Cardiology, Heart Center Leipzig at University of Leipzig, Strümpellstr. 39, 04289, Leipzig, Germany
- Leipzig Heart Institute, Leipzig, Germany
| | - Alexander Jobs
- Department of Internal Medicine/Cardiology, Heart Center Leipzig at University of Leipzig, Strümpellstr. 39, 04289, Leipzig, Germany
- Leipzig Heart Institute, Leipzig, Germany
- Department of Cardiology, Angiology and Intensive Care Medicine, University Heart Center Lübeck, University Hospital Schleswig-Holstein, Lübeck, Germany
| | - Suzanne de Waha-Thiele
- Department of Cardiology, Angiology and Intensive Care Medicine, University Heart Center Lübeck, University Hospital Schleswig-Holstein, Lübeck, Germany
| | - Ingo Eitel
- Department of Cardiology, Angiology and Intensive Care Medicine, University Heart Center Lübeck, University Hospital Schleswig-Holstein, Lübeck, Germany
| | - Anne Freund
- Department of Internal Medicine/Cardiology, Heart Center Leipzig at University of Leipzig, Strümpellstr. 39, 04289, Leipzig, Germany
- Leipzig Heart Institute, Leipzig, Germany
| | - Mohamed Abdel-Wahab
- Department of Internal Medicine/Cardiology, Heart Center Leipzig at University of Leipzig, Strümpellstr. 39, 04289, Leipzig, Germany
- Leipzig Heart Institute, Leipzig, Germany
| | - Steffen Desch
- Department of Internal Medicine/Cardiology, Heart Center Leipzig at University of Leipzig, Strümpellstr. 39, 04289, Leipzig, Germany
- Leipzig Heart Institute, Leipzig, Germany
| | - Holger Thiele
- Department of Internal Medicine/Cardiology, Heart Center Leipzig at University of Leipzig, Strümpellstr. 39, 04289, Leipzig, Germany.
- Leipzig Heart Institute, Leipzig, Germany.
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13
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Ghersin I, Zahran M, Azzam ZS, Suleiman M, Bahouth F. Prognostic value of cardiac troponin levels in patients presenting with supraventricular tachycardias. J Electrocardiol 2020; 62:200-203. [PMID: 32980810 DOI: 10.1016/j.jelectrocard.2020.09.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Revised: 08/06/2020] [Accepted: 09/01/2020] [Indexed: 12/24/2022]
Abstract
BACKGROUND An association between paroxysmal supraventricular tachycardias (PSVT) and elevated cardiac troponin I (cTnI) has been reported in small studies, even in the absence of significant coronary artery or structural heart disease. We sought to explore the prognostic significance of elevated cTnI among patients presenting with PSVT. METHODS This is a retrospective single-center observational study conducted between January 2014 and Decemebr 2016. 165 patients (60% men, mean age 55 ± 17 year-old) with an acute episode of regular supraventricular tachyarrhythmia were admitted to the emergency department at Rambam Medical Center. 131 patients had at least one serum cTnI value measured. Of those, 57 had a positive result, defined as serum cTnI of more than 0.028 ng/dL. RESULTS Multivariate analysis showed that heart rate > 150 beats per minute (bpm) on admission (OR = 3.9; 95% CI 1.1.6-9.5; p < 0.003) and history of coronary artery disease (CAD) (OR = 3.4; 95% CI 1.2-10.1; p = 0.026) were the only independent predictors of cTnI elevation. After mean follow-up period of 23 ± 7 months, the combined primary outcome of death, coronary intervention (PCI) or myocardial infarction (MI) occurred in 7 patients (12.3%) out of 57 patients with positive cTnI and in zero patients with negative cTn (p = 0.002). Cox proportional hazard model showed that elevated cTnI on admission was an independent predictor of adverse outcomes only in patients with known coronary artery disease (CAD) (HR = 3.3, p = 0.05). CONCLUSION Elevated cTnI among patients presenting with PSVT appears to have prognostic significance only in patients with history of CAD. In this patient group elevated cTnI is associated with increased risk of adverse cardiac outcomes. We therefore believe serum cTnI should be measured selectively, such as in patients with symptoms of ischemic chest pain and a high pretest likelihood of having CAD.
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Affiliation(s)
- Itai Ghersin
- Department of Internal Medicine B, Rambam Health Care Campus, Haifa, Israel.
| | - Maria Zahran
- Rappaport Faculty of Medicine, Technion - Israel Institute of Technology, Haifa, Israel
| | - Zaher S Azzam
- Department of Internal Medicine B, Rambam Health Care Campus, Haifa, Israel; Rappaport Faculty of Medicine, Technion - Israel Institute of Technology, Haifa, Israel
| | - Mahmoud Suleiman
- Rappaport Faculty of Medicine, Technion - Israel Institute of Technology, Haifa, Israel; Department of Cardiology, Rambam Health Care Campus, Haifa, Israel
| | - Fadel Bahouth
- Department of Cardiology, Rambam Health Care Campus, Haifa, Israel; Department of Internal Medicine H, Rambam Health Care Campus, Haifa, Israel
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14
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McCarthy CP, Raber I, Chapman AR, Sandoval Y, Apple FS, Mills NL, Januzzi JL. Myocardial Injury in the Era of High-Sensitivity Cardiac Troponin Assays: A Practical Approach for Clinicians. JAMA Cardiol 2020; 4:1034-1042. [PMID: 31389986 DOI: 10.1001/jamacardio.2019.2724] [Citation(s) in RCA: 76] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Importance Traditionally, elevated troponin concentrations were synonymous with myocardial infarction. But with improvements in troponin assays, elevated concentrations without overt myocardial ischemia are now more common; this is referred to as myocardial injury. Physicians may be falsely reassured by the absence of myocardial ischemia; however, recent evidence suggests that myocardial injury is associated with even more detrimental outcomes. Accordingly, this article reviews the definition, epidemiology, differential diagnosis, diagnostic evaluation, and management of myocardial injury. Observations Current epidemiological evidence suggests that myocardial injury without overt ischemia represents about 60% of cases of abnormal troponin concentrations when obtained for clinical indications, and 1 in 8 patients presenting to the hospital will have evidence of myocardial injury. Myocardial injury is a concerning prognosis; the 5-year mortality rate is approximately 70%, with a major adverse cardiovascular event rate of 30% in the same period. The differential diagnosis is broad and can be divided into acute and chronic precipitants. The initial workup involves an assessment for myocardial ischemia. If infarction is ruled out, further evaluation includes a detailed history, physical examination, laboratory testing, a 12-lead electrocardiogram, and (if there is no known history of structural or valvular heart disease) an echocardiogram. Unfortunately, no consensus exists on routine management of patients with myocardial injury. Identifying and treating the underlying precipitant is the most practical approach. Conclusion and Relevance Myocardial injury is the most common cause of abnormal troponin results, and its incidence will likely increase with an aging population, increasing prevalence of cardiovascular comorbidities, and greater sensitivity of troponin assays. Myocardial injury represents a challenge to clinicians; however, given its serious prognosis, it warrants a thorough evaluation of its underlying precipitant. Future strategies to prevent and/or manage myocardial injury are needed.
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Affiliation(s)
- Cian P McCarthy
- Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston
| | - Inbar Raber
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Andrew R Chapman
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
| | - Yader Sandoval
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Fred S Apple
- Department of Laboratory Medicine and Pathology, Hennepin Healthcare/Hennepin County Medical Center and University of Minnesota, Minneapolis
| | - Nicholas L Mills
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom.,Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, United Kingdom
| | - James L Januzzi
- Division of Cardiology, Massachusetts General Hospital, Boston.,Baim Institute for Clinical Research, Boston, Massachusetts
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15
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Salmasi MY, Al-Saadi N, Hartley P, Jarral OA, Raja S, Hussein M, Redhead J, Rosendahl U, Nienaber CA, Pepper JR, Oo AY, Athanasiou T. The risk of misdiagnosis in acute thoracic aortic dissection: a review of current guidelines. Heart 2020; 106:885-891. [PMID: 32170039 DOI: 10.1136/heartjnl-2019-316322] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2019] [Revised: 02/21/2020] [Accepted: 02/24/2020] [Indexed: 12/24/2022] Open
Abstract
Acute aortic syndrome and in particular aortic dissection (AAD) persists as a cause of significant morbidity and mortality despite improvements in surgical management. This clinical review aims to explore the risks of misdiagnosis, outcomes associated with misdiagnosis and evaluate current diagnostic methods for reducing its incidence.Due to the nature of the pathology, misdiagnosing the condition and delaying management can dramatically worsen patient outcomes. Several diagnostic challenges exist, including low prevalence, rapidly propagating pathology, non-discrete symptomatology, non-specific signs, analogy with other acute conditions and lack of management infrastructure. A similarity to acute coronary syndromes is a specific concern and risks patient maltreatment. AAD with malperfusion syndromes are both a cause of misdiagnosis and marker of disease complication, requiring specifically tailored management plans from the emergency setting.Despite improvements in diagnostic measures, including imaging modalities and biomarkers, misdiagnosis of AAD remains commonplace and current guidelines are relatively limited in preventing its occurrence. This paper recommends the early use of AAD risk scoring, focused echocardiography and most importantly, fast-tracking patients to cross-sectional imaging where the suspicion of AAD is high. This has the potential to improve the diagnostic process for AAD and limit the risk of misdiagnosis. However, our understanding remains limited by the lack of large patient datasets and an adequately audited processes of emergency department practice.
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Affiliation(s)
- M Yousuf Salmasi
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - Nina Al-Saadi
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - Philip Hartley
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - Omar A Jarral
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - Shahzad Raja
- Cardiac Surgery, Royal Brompton and Harefield NHS Foundation Trust, Harefield, UK
| | - Muthana Hussein
- Emergency Medicine, Kingston Hospital NHS Foundation Trust, Kingston upon Thames, London, UK
| | - Julian Redhead
- Emergency Medicine, Imperial College Healthcare NHS Trust, London, UK
| | - Ulrich Rosendahl
- Cardiac Surgery, Royal Brompton and Harefield NHS Foundation Trust, Harefield, UK
| | - Christoph A Nienaber
- Department of Cardiology, Royal Brompton and Harefield NHS Foundation Trust, London, UK
| | - John R Pepper
- Cardiac Surgery, Royal Brompton and Harefield NHS Foundation Trust, Harefield, UK
| | - Aung Y Oo
- Cardiac Surgery, Barts Health NHS Trust, London, UK
| | - Thanos Athanasiou
- Department of Surgery and Cancer, Imperial College London, London, UK
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16
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Salmasi MY, Hartley P, Hussein M, Jarral O, Pepper J, Nienaber C, Athanasiou T. Diagnosis and management of acute Type-A aortic dissection in emergency departments: Results of a UK national survey. Int J Cardiol 2020; 300:50-59. [DOI: 10.1016/j.ijcard.2019.09.074] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2019] [Revised: 09/05/2019] [Accepted: 09/30/2019] [Indexed: 01/16/2023]
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17
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Gong M, Wu Z, Guan X, Jiang W, Zhang H. Comparison of prognostic ability of perioperative myocardial biomarkers in acute type A aortic dissection. Medicine (Baltimore) 2019; 98:e17023. [PMID: 31651834 PMCID: PMC6824686 DOI: 10.1097/md.0000000000017023] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
Stanford type A aortic dissection (AD) is a lethal disease requiring surgery. Evidence regarding the prognostic ability of perioperative myocardiac markers on long-term outcome is limited.In this cohort study, we measured perioperative myocardiac markers level in 583 surgical patients with type A AD in our hospital between 2015 and 2017. All patients were followed up after surgery for a median period of 864 days to determine short- and long-term mortality.About one-fifth of patients has a positive preoperative myocardial markers, which was increased significantly after operation. Increase log10 post-creatine kinase MB isoenzyme (CK-MB) (hazard ratio [HR], 4.64; 95% confidence interval [CI] 1.89-11.43; P = .0008), log10 post-TnI (HR, 3.11; 95% CI 1.56-6.21; P = .0013), log10 post-Mb (HR, 3.00; 95% CI 1.40-6.43; P = .0048), log10 pre-CK-MB (HR,1.82; 95% CI 1.03-3.21; P = .0377), and upper tertile of post-CK-MB (HR,1.52; 95% CI 1.05-2.20; P = .0261) were the independent risk factor for 30 days mortality adjusted for potential confounders. None of cardiac markers was significantly associated with long-term outcome independent of other factors.Perioperative myocardiac predicts early outcome in type A AD patients undergoing surgery. Increasing perioperative myocardial markers do not appear to be a predictor for long-term all-cause mortality.
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Affiliation(s)
- Ming Gong
- Department of Cardiac Surgery, Beijing Anzhen Hospital, Capital Medical University
- Beijing Institute of Heart, Lung and Blood Vessel Diseases
- Beijing Lab for Cardiovascular Precision Medicine
- Beijing Aortic Disease Center, Cardiovascular Surgery Center
- Beijing Engineering Research Center for Vascular Prostheses, Beijing, China
| | - Zining Wu
- Department of Cardiac Surgery, Beijing Anzhen Hospital, Capital Medical University
- Beijing Institute of Heart, Lung and Blood Vessel Diseases
- Beijing Lab for Cardiovascular Precision Medicine
- Beijing Aortic Disease Center, Cardiovascular Surgery Center
- Beijing Engineering Research Center for Vascular Prostheses, Beijing, China
| | - Xinliang Guan
- Department of Cardiac Surgery, Beijing Anzhen Hospital, Capital Medical University
- Beijing Institute of Heart, Lung and Blood Vessel Diseases
- Beijing Lab for Cardiovascular Precision Medicine
- Beijing Aortic Disease Center, Cardiovascular Surgery Center
- Beijing Engineering Research Center for Vascular Prostheses, Beijing, China
| | - Wenjian Jiang
- Department of Cardiac Surgery, Beijing Anzhen Hospital, Capital Medical University
- Beijing Institute of Heart, Lung and Blood Vessel Diseases
- Beijing Lab for Cardiovascular Precision Medicine
- Beijing Aortic Disease Center, Cardiovascular Surgery Center
- Beijing Engineering Research Center for Vascular Prostheses, Beijing, China
| | - Hongjia Zhang
- Department of Cardiac Surgery, Beijing Anzhen Hospital, Capital Medical University
- Beijing Institute of Heart, Lung and Blood Vessel Diseases
- Beijing Lab for Cardiovascular Precision Medicine
- Beijing Aortic Disease Center, Cardiovascular Surgery Center
- Beijing Engineering Research Center for Vascular Prostheses, Beijing, China
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18
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Turkish Society of Cardiology consensus paper on the rational use of cardiac troponins in daily practice. Anatol J Cardiol 2019; 21:331-344. [PMID: 31073114 PMCID: PMC6683230 DOI: 10.14744/anatoljcardiol.2019.42247] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
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Barrabés JA, Bardají A, Jiménez-Candil J, Bodí V, Freixa R, Vázquez R, Sánchez-Ramos JG, May A, Rollán MJ, Fernández-Ortiz A. Characteristics and Outcomes of Patients Hospitalized With Suspected Acute Coronary Syndrome in Whom the Diagnosis is not Confirmed. Am J Cardiol 2018; 122:1604-1609. [PMID: 30213384 DOI: 10.1016/j.amjcard.2018.07.036] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2018] [Revised: 07/23/2018] [Accepted: 07/31/2018] [Indexed: 01/16/2023]
Abstract
Patients admitted with suspected acute coronary syndrome (ACS) in whom the diagnosis is not confirmed are poorly characterized. In a contemporary registry of consecutive patients hospitalized with suspected ACS as the primary diagnosis, we assessed characteristics on admission and in-hospital and 6-month mortality of patients discharged with other diagnoses and compared this subgroup with true ACS patients. Of 2557 patients included, 9.0% were discharged with a non-ACS diagnosis such as nonspecific chest pain, myopericarditis, stress cardiomyopathy, hemodynamic disturbances, heart failure, myocardial, pulmonary or valvular disease, or others. Compared with true ACS patients, those with other diagnoses were younger, more often female, and had less cardiovascular risk factors. Both groups had comparable rates of nonchest pain presentation and similar hemodynamic characteristics on admission. Non-ACS patients presented less often with Q waves or with ST-segment or T-wave changes and had a lower Global Registry of Acute Coronary Events score than true ACS patients. In-hospital (4.3 vs 4.0%, respectively, p = 0.834) and 6-month (5.4 vs 8.0%, respectively, p = 0.163) mortality rates were comparable in both groups. However, if patients in the non-ACS group were divided into subgroups with nonspecific chest pain (6.2% of total) or other diagnoses (2.8% of total), major differences in in-hospital (0.0 vs 13.9%, respectively, p < 0.001) and 6-month (0.7 vs 15.7%, respectively, p < 0.001) mortality rates would become apparent and remain after multivariable adjustment. In conclusion, in a non-negligible proportion of patients hospitalized with suspected ACS, this diagnosis is not confirmed. Prognosis of these patients follows a bimodal pattern, being excellent in those with nonspecific chest pain but worse than that of true ACS patients in the rest. Efforts are necessary to ensure prompt identification and early risk stratification of these patients allowing appropriate management decisions.
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20
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Pourafkari L, Tajlil A, Ghaffari S, Parvizi R, Chavoshi M, Kolahdouzan K, Khaki N, Parizad R, Hobika GG, Nader ND. The frequency of initial misdiagnosis of acute aortic dissection in the emergency department and its impact on outcome. Intern Emerg Med 2017; 12:1185-1195. [PMID: 27592236 DOI: 10.1007/s11739-016-1530-7] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2016] [Accepted: 08/27/2016] [Indexed: 11/26/2022]
Abstract
We determine the frequency of initial misdiagnosis and inappropriate treatment with antiplatelets/anticoagulants in the emergency department (ED) and the resultant clinical outcomes in patients with acute type A aortic dissection (AAOD). Medical records of patients with a final diagnosis of AAOD admitted from March 2004 through October 2015 to our tertiary-level heart hospital were evaluated. Patients with suspected dissection in ED were compared to those with initial misdiagnosis regarding demographics and clinical presentation, laboratory and echocardiographic findings. Our primary outcome was hospital mortality in two groups. Long-term mortality after discharge was our secondary outcome. Among 189 patients, 47 (24.8 %) were initially misdiagnosed and received antiplatelets/anticoagulants in ED (Group F), and 142 (75.1 %) were appropriately diagnosed in ED (Group T). The mean age in group F was 60.4 ± 15.0 vs. 57.4 ± 16.0 years in group T (p = 0.260). In group F, 70.2 % were male vs. 60.6 % in group T (p = 0.311). Hospital mortality was 48.9 % in group F vs. 43.7 % in group T (p = 0.645). Long-term mortality was significantly higher in group F (55.6 vs. 21.2 %, p = 0.007). Univariate hazard ratio (HR) of initial misdiagnosis for long-term mortality was 2.56 (95 % CI 1.08-6.06, p = 0.031). In multivariate Cox regression analysis with adjustment for age and type of management (surgical/medical), initial misdiagnosis lost its significance for predicting long-term mortality (HR 2.14, 95 % CI 0.89-5.13, p = 0.086). Initial misdiagnosis of AAOD is a common problem. Hospital mortality is not significantly affected by receiving antiplatelets/anticoagulants. Although long-term mortality is higher in patients with initial misdiagnosis, it is not an independent predictor for long-term mortality.
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Affiliation(s)
- Leili Pourafkari
- Cardiovascular Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
- Department of Anesthesiology, School of Medicine and Biomedical Sciences, University at Buffalo, 77 Goodell Street Suite #550, Buffalo, NY, 14203, USA
| | - Arezou Tajlil
- Cardiovascular Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Samad Ghaffari
- Cardiovascular Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Rezayat Parvizi
- Cardiovascular Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | | | - Kasra Kolahdouzan
- Cardiovascular Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Nasrin Khaki
- Cardiovascular Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Raziyeh Parizad
- Cardiovascular Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Geoffery G Hobika
- Department of Anesthesiology, School of Medicine and Biomedical Sciences, University at Buffalo, 77 Goodell Street Suite #550, Buffalo, NY, 14203, USA
| | - Nader D Nader
- Department of Anesthesiology, School of Medicine and Biomedical Sciences, University at Buffalo, 77 Goodell Street Suite #550, Buffalo, NY, 14203, USA.
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21
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Westermann D, Neumann JT, Sörensen NA, Blankenberg S. High-sensitivity assays for troponin in patients with cardiac disease. Nat Rev Cardiol 2017; 14:472-483. [DOI: 10.1038/nrcardio.2017.48] [Citation(s) in RCA: 106] [Impact Index Per Article: 15.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Prognostic effect of cardiac troponin elevation in acute aortic dissection: A meta-analysis. Int J Cardiol 2016; 214:277-8. [DOI: 10.1016/j.ijcard.2016.03.230] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2016] [Accepted: 03/27/2016] [Indexed: 11/30/2022]
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