Rapid rule out of myocardial infarction with the use of copeptin as a biomarker for cardiac injury

A meta-analysis and trial sequential analysis of serum copeptin level in adult patients with Obstructive Sleep Apnoea Syndrome

OBJECTIVE

Copeptin can act as a stable biomarker in inflammation and stress response that obstructive sleep apnoea syndrome (OSAS), can induce oxidative stress and consequently promotes systemic inflammation. The purpose of the study is to appraise serum copeptin level in adult patients with OSAS compared to the controls.

MATERIAL AND METHODS

Electronic search was done in the databases of PubMed/Medline, Web of Science, Scopus, and Cochrane Library until June 2021, without any restrictions. For comparison of the serum copeptin level between groups, the mean difference (MD) and 95% confidence interval (CI) were calculated by the Review Manager 5.3 software. Trial sequential analysis (TSA) was used by applying TSA software.

RESULTS

Among the databases, five articles (involving 495 OSAS patients and 135 controls) were included. To report the serum copeptin level in OSAS patients compared to controls, the pooled OR became 12.21pg/mL (95%CI: 2.31 to 22.11; P=0.02) and also the pooled OR for comparison of serum copeptin level in severe versus moderate/mild OSAS patients was 5.96pg/mL (95%CI: 1.46 to 10.47; P=0.009). The results of TSA illustrated that the Z-curve has not crossed the monitoring boundary curves and did not reach the required information size.

CONCLUSIONS

The main findings recommended that copeptin had a significantly higher serum level in OSAS patients compared to controls, as well as a significantly higher level in severe patients compared to mild/moderate OSAS patients for the serum level of copeptin.

Copeptin to rule out myocardial infarction in Blacks versus Caucasians

Background:

Copeptin in combination with troponin has been shown to have incremental value for the early rule-out of myocardial infarction, but its performance in Black patients specifically has never been examined. In light of a potential for wider use, data on copeptin in different relevant cohorts are needed. This is the first study to determine whether copeptin is equally effective at ruling out myocardial infarction in Black and Caucasian races.

Methods:

This analysis of the CHOPIN trial included 792 Black and 1075 Caucasian patients who presented to the emergency department with chest pain and had troponin-I and copeptin levels drawn.

Results:

One hundred and forty-nine patients were diagnosed with myocardial infarction (54 Black and 95 Caucasian). The negative predictive value of copeptin at a cut-off of 14 pmol/l (as in the CHOPIN study) for myocardial infarction was higher in Blacks (98.0%, 95% confidence interval (CI) 96.2–99.1%) than Caucasians (94.1%, 95% CI 92.1–95.7%). The sensitivity at 14 pmol/l was higher in Blacks (83.3%, 95% CI 70.7–92.1%) than Caucasians (53.7%, 95% CI 43.2–64.0%). After controlling for age, hypertension, heart failure, chronic kidney disease and body mass index in a logistic regression model, the interaction term had a P value of 0.03. A cut-off of 6 pmol/l showed similar sensitivity in Caucasians as 14 pmol/l in Blacks.

Conclusions:

This is the first study to identify a difference in the performance of copeptin to rule out myocardial infarction between Blacks and Caucasians, with increased negative predictive value and sensitivity in the Black population at a cut-off of 14 pmol/l. This also holds true for non-ST-segment elevation myocardial infarction and, although numbers were small, similar trends exist in the normal troponin population. This may have significant implications for early rule-out strategies using copeptin.

Necessity of hospitalization and stress testing in low risk chest pain patients

BACKGROUND

Copeptin is a marker of endogenous stress including early myocardial infarction(MI) and has value in early rule out of MI when used with cardiac troponin I(cTnI).

OBJECTIVES

The goal of this study was to demonstrate that patients with a normal electrocardiogram and cTnI<0.040μg/l and copeptin<14pmol/l at presentation and after 2 h may be candidates for early discharge with outpatient follow-up potentially including stress testing.

METHODS

This study uses data from the CHOPIN trial which enrolled 2071 patients with acute chest pain. Of those, 475 patients with normal electrocardiogram and normal cTnI(<0.040μg/l) and copeptin<14pmol/l at presentation and after 2 h were considered "low risk" and selected for further analysis.

RESULTS

None of the 475 "low risk" patients were diagnosed with MI during the 180day follow-up period (including presentation). The negative predictive value of this strategy was 100% (95% confidence interval(CI):99.2%-100.0%). Furthermore no one died during follow up. 287 (60.4%) patients in the low risk group were hospitalized. In the "low risk" group, the only difference in outcomes (MI, death, revascularization, cardiac rehospitalization) was those hospitalized underwent revascularization more often (6.3%[95%CI:3.8%-9.7%] versus 0.5%[95%CI:0.0%-2.9%], p=.002). The hospitalized patients were tested significantly more via stress testing or angiogram (68.6%[95%CI:62.9%-74.0%] vs 22.9%[95%CI:17.1%-29.6%], p<.001). Those tested had less cardiac rehospitalizations during follow-up (1.7% vs 5.1%, p=.040).

CONCLUSIONS

In conclusion, patients with a normal electrocardiogram, troponin and copeptin at presentation and after 2 h are at low risk for MI and death over 180days. These low risk patients may be candidates for early outpatient testing and cardiology follow-up thereby reducing hospitalization.

[Usefulness of copeptin in the diagnosis of acute coronary syndrome in the emergency department of a tertiary hospital]

OBJECTIVES

This study was conducted in order to evaluate the usefulness of copeptin (a stable fragment of the precursor of arginine vasopressin) in the differential diagnosis of acute chest pain of probable coronary origin.

MATERIAL AND METHODS

The study includes 82 patients who were initially evaluated according to the protocol of a patient with suspected acute coronary syndrome (ACS) in our Emergency Department, including the determination of troponin and copeptin with specimens taken on admission (time 0) and at 6h.

RESULTS

Statistically significant differences were observed in copeptin concentrations at time 0 among patients diagnosed with non-ST-segment elevation (NTEACS): 42.1±38.7pmol/L and non-NSTEACS patients: 15.6±21.2pmol/L (P<. 01). However, the differences did not reach statistical significance at 6h (P=.093). The analysis of the area under the ROC curve for Copeptin in NSTEACS patients at time 0 was 0.713, with a confidence interval of 95% from 0.592 to 0.834 and a significance level of P=.001.

CONCLUSIONS

The concentration of copeptin represents an additional value in the differentiation between NSTEACS patients and non-NSTEACS patients, as well as between ACS patients and patients with stable angina. The cut-off point of 10pmol/L provides the best values for sensitivity, negative predictive value (NPV), positive likelihood ratio (LR+), and negative likelihood ratio (LR-) in the diagnosis of NSTEACS patients.