High-Sensitivity Cardiac Troponin T and the Diagnosis of Cardiovascular Disease in the Emergency Room: The Importance of Combining Cardiovascular Biomarkers with Clinical Data

Sex-related differences in non-ischemic myocardial injury in the emergency department: A real-world perspective

BACKGROUND

Myocardial injury is associated with adverse outcomes. No data are reported about sex differences in incidence and factors associated with myocardial injury in an emergency department (ED) setting from a real-world perspective. We aimed to assess whether sex plays a major role in the diagnosis of myocardial injury in the ED.

METHODS

In this subanalysis of a retrospective study, patients presenting at the ED with at least one high-sensitivity cardiac troponin T (hs-cTnT) value and without acute coronary syndromes diagnosis were compared.

RESULTS

31,383 patients were admitted to the ED, 4660 had one hs-cTnT value, and 3937 were enrolled: 1943 females (49.4%) and 1994 males (50.6%). The diagnosis of myocardial injury was higher among men (36.8% vs. 32.9%, p < 0.01). Male sex was independently associated with myocardial injury. An older age, an elevated NT-proB-type Natriuretic Peptide and a lower estimated glomerular filtrate rate were independently associated with myocardial injury in both sexes.

CONCLUSIONS

In the ED, from a real-world perspective, myocardial injury occurred more frequently in males, and it was associated with older age and the presence of cardiac, lung, and kidney disease but not higher hs-cTnT values.

Diagnostic value of high sensitivity cardiac troponin T (hs-cTnT) in dialysis patients with myocardial infarction

Background

As a sensitive diagnostic marker for myocardial infarction (MI) in people with normal renal function, elevated high sensitivity cardiac troponin T (hs-cTnT) was often found in chronic kidney disease (CKD) patients requiring dialysis. However, the accuracy of baseline hs-cTnT in the diagnosis of MI (including Type 1 MI (T1MI) and Type 2 MI (T2MI)) in dialysis patients is still controversial. The aim of this study was to retrospectively explore whether there were any clinical indices that could increase the predictive value of hs-cTnT on admission for MI occurrence in dialysis patients.

Methods

Here, 136 patients with uremia who underwent regular dialysis with coronary angiography in the First Affiliated Hospital of Nanjing Medical University from August 2017 to October 2021 were enrolled. According to the coronary angiography results and the presence of clinical symptoms, the patients were divided into: (1). AMI group (n = 69; angiography positive) and Control group (n = 67; angiography negative); (2). T1MI group (n = 69; angiography positive), T2MI group (n = 7; angiography negative & symptomatic), and Control group (n = 60; angiography negative & asymptomatic).

Results

Here, we found the mean hs-cTnT on admission in the Control group was much lower than that in the AMI group. Hs-cTnT alone had a mediocre predictive performance, with an AUROC of 0.7958 (95% CI: 0.7220, 0.8696). Moreover, the ROC curve of hs-cTnT combined with the Triglyceride (TG), Time of dialysis, and Albumin (Alb) showed a higher sensitivity area [0.9343 (95% CI: 0.8901, 0.9786)] than that of single hs-cTnT. Next, hs-cTnT combined with the TG, Time of dialysis, and Alb also presented a better performance in predicting T1MI [0.9150 (95% CI: 0.8678, 0.9621)] or T2MI (0.9167 [0.9167 (95% CI: 0.8427, 0.9906)] occurrences. Last, these combined variables could better distinguish patient between T1MI and T2MI group than hs-cTnT alone.

Conclusions

On admission, a combination of hs-cTnT, TG, Time of dialysis, and Alb presented a higher sensitivity than hs-cTnT alone in predicting MI occurrence in dialysis patients, suggesting a better diagnostic approach for future clinical applications.

Risk stratification of patients with chest pain who have an unscheduled revisit to the emergency department

AIMS

Acute cardiovascular (CV) emergencies are critical conditions that require urgent attention in the emergency department (ED). Failure to make a timely diagnosis may result in unscheduled ED revisits and severe outcomes. Therefore, this study aimed to investigate the risk factors associated with potentially missed acute CV emergencies.

METHODS AND RESULTS

This retrospective study enrolled adult patients who presented with chest pain and returned to the ED within 72 h. Demographic information, pre-existing medical conditions, chief complaints, triage level and vital signs, electrocardiography (ECG) reports, and laboratory data were collected from medical charts by independent physicians. The primary outcome was the diagnosis of acute CV diseases, including ACS, pulmonary embolism, unstable arrhythmia, acute decompensated heart failure, and aortic dissection. Multivariable logistic regression was used to analyze the association between variables and acute CV emergencies. A total of 453 eligible patients were included, with 60 (13.2%) patients diagnosed as acute CV emergencies at the ED revisit. Risk factors for acute CV emergencies included male gender (adjusted odds ratio [aOR] = 2.71, 95% confidence interval [CI] = 1.17-6.25), abnormal ECG rhythm (aOR = 10.33, 95% CI = 4.68-22.83), and abnormal changes in high sensitivity Troponin-T (hs-cTnT) during sequential follow-up (aOR = 6.52, 95% CI = 2.19-19.45).

CONCLUSIONS

Male gender, abnormal ECG rhythm, and a significant increase in sequential follow-up hs-cTnT levels were identified as significant risk factors for acute CV emergencies. ED physicians should recognize these high-risk patients with chest pain to prevent misdiagnosis and potential severe complications.

Outcome of patients admitted with oxygen mismatch and myocardial injury or infarction in emergency departments

AIMS

To describe the outcomes and associated factors in a population of patients admitted to emergency departments with at least one condition of oxygen supply/demand imbalance, regardless of the troponin result or restrictive criteria for type 2 myocardial infarction.

METHODS

We constituted a retrospective cohort of 824 patients. Medical records of patients having undergone a troponin assay were reviewed for selection and classification, and data including in-hospital stay and readmissions were collected. The reported outcomes are in-hospital mortality, 3-year mortality, and major adverse cardiovascular events.

RESULTS

Patients with myocardial infarction or injury, either chronic or acute, were older, with more history of hypertension and chronic heart or renal failure but not for other cardiovascular risk factors and medical history. Acute myocardial injury and type 2 myocardial infarction were significantly associated with in-hospital mortality [odds ratio (OR) 3.71 95% confidence interval (CI) 1.90-7.33 and OR 3.15 95% CI 1.59-6.28, respectively]. However, the long-term mortality does not differ in comparison with patients presenting chronic myocardial injury or nonelevated troponin, ranging from 26.9 to 34.3%. Patients with chronic myocardial injury and type 2 myocardial infarction had more long-term major cardiovascular events (39.3 and 38.8%), but only for acute heart failure, and none was associated with this outcome after adjustment.

CONCLUSION

Among patients admitted to emergency departments with an oxygen supply/demand imbalance, acute myocardial injury and type 2 myocardial infarction are strongly associated with in-hospital mortality. However, they are not associated with higher long-term mortality or major cardiovascular events after discharge, which tend to occur in elderly people with comorbidities.