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Lowry MTH, Doudesis D, Boeddinghaus J, Kimenai DM, Bularga A, Taggart C, Wereski R, Ferry AV, Stewart SD, Tuck C, Koechlin L, Nestelberger T, Lopez-Ayala P, Huré G, Lee KK, Chapman AR, Newby DE, Anand A, Collinson PO, Mueller C, Mills NL. Troponin in early presenters to rule out myocardial infarction. Eur Heart J 2023; 44:2846-2858. [PMID: 37350492 PMCID: PMC10406338 DOI: 10.1093/eurheartj/ehad376] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Revised: 04/12/2023] [Accepted: 05/24/2023] [Indexed: 06/24/2023] Open
Abstract
AIMS Whether a single cardiac troponin measurement can safely rule out myocardial infarction in patients presenting within a few hours of symptom onset is uncertain. The study aim was to assess the performance of troponin in early presenters. METHODS AND RESULTS In patients with possible myocardial infarction, the diagnostic performance of a single measurement of high-sensitivity cardiac troponin I at presentation was evaluated and externally validated in those tested ≤3, 4-12, and >12 h from symptom onset. The limit-of-detection (2 ng/L), rule-out (5 ng/L), and sex-specific 99th centile (16 ng/L in women; 34 ng/L in men) thresholds were compared. In 41 103 consecutive patients [60 (17) years, 46% women], 12 595 (31%) presented within 3 h, and 3728 (9%) had myocardial infarction. In those presenting ≤3 h, a threshold of 2 ng/L had greater sensitivity and negative predictive value [99.4% (95% confidence interval 99.2%-99.5%) and 99.7% (99.6%-99.8%)] compared with 5 ng/L [96.5% (96.2%-96.8%) and 99.3% (99.1%-99.4%)]. In those presenting ≥3 h, the sensitivity and negative predictive value were similar for both thresholds. The sensitivity of the 99th centile was low in early and late presenters at 71.4% (70.6%-72.2%) and 92.5% (92.0%-93.0%), respectively. Findings were consistent in an external validation cohort of 7088 patients. CONCLUSION In early presenters, a single measurement of high-sensitivity cardiac troponin I below the limit of detection may facilitate the safe rule out of myocardial infarction. The 99th centile should not be used to rule out myocardial infarction at presentation even in those presenting later following symptom onset.
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Affiliation(s)
- Matthew T H Lowry
- BHF Centre for Cardiovascular Science, University of Edinburgh, Room SU.226, Chancellor’s Building, Edinburgh EH16 4SB, UK
| | - Dimitrios Doudesis
- BHF Centre for Cardiovascular Science, University of Edinburgh, Room SU.226, Chancellor’s Building, Edinburgh EH16 4SB, UK
- Usher Institute, 9 Little France Road, BioQuarter, Edinburgh, EH16 4UX, UK
| | - Jasper Boeddinghaus
- BHF Centre for Cardiovascular Science, University of Edinburgh, Room SU.226, Chancellor’s Building, Edinburgh EH16 4SB, UK
| | - Dorien M Kimenai
- BHF Centre for Cardiovascular Science, University of Edinburgh, Room SU.226, Chancellor’s Building, Edinburgh EH16 4SB, UK
| | - Anda Bularga
- BHF Centre for Cardiovascular Science, University of Edinburgh, Room SU.226, Chancellor’s Building, Edinburgh EH16 4SB, UK
| | - Caelan Taggart
- BHF Centre for Cardiovascular Science, University of Edinburgh, Room SU.226, Chancellor’s Building, Edinburgh EH16 4SB, UK
| | - Ryan Wereski
- BHF Centre for Cardiovascular Science, University of Edinburgh, Room SU.226, Chancellor’s Building, Edinburgh EH16 4SB, UK
| | - Amy V Ferry
- BHF Centre for Cardiovascular Science, University of Edinburgh, Room SU.226, Chancellor’s Building, Edinburgh EH16 4SB, UK
| | - Stacey D Stewart
- BHF Centre for Cardiovascular Science, University of Edinburgh, Room SU.226, Chancellor’s Building, Edinburgh EH16 4SB, UK
| | - Christopher Tuck
- BHF Centre for Cardiovascular Science, University of Edinburgh, Room SU.226, Chancellor’s Building, Edinburgh EH16 4SB, UK
| | - Luca Koechlin
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Switzerland
| | - Thomas Nestelberger
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Switzerland
| | - Pedro Lopez-Ayala
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Switzerland
| | - Gabrielle Huré
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Switzerland
| | - Kuan Ken Lee
- BHF Centre for Cardiovascular Science, University of Edinburgh, Room SU.226, Chancellor’s Building, Edinburgh EH16 4SB, UK
| | - Andrew R Chapman
- BHF Centre for Cardiovascular Science, University of Edinburgh, Room SU.226, Chancellor’s Building, Edinburgh EH16 4SB, UK
| | - David E Newby
- BHF Centre for Cardiovascular Science, University of Edinburgh, Room SU.226, Chancellor’s Building, Edinburgh EH16 4SB, UK
| | - Atul Anand
- BHF Centre for Cardiovascular Science, University of Edinburgh, Room SU.226, Chancellor’s Building, Edinburgh EH16 4SB, UK
| | - Paul O Collinson
- Department of Clinical Blood Sciences, St George’s, University Hospitals NHS Trust and St George’s University of London, London, UK
- Department Cardiology, St George’s, University Hospitals NHS Trust and St George’s University of London, London, UK
| | - Christian Mueller
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Switzerland
| | - Nicholas L Mills
- BHF Centre for Cardiovascular Science, University of Edinburgh, Room SU.226, Chancellor’s Building, Edinburgh EH16 4SB, UK
- Usher Institute, 9 Little France Road, BioQuarter, Edinburgh, EH16 4UX, UK
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Torabi F, Harris DE, Bodger O, Akbari A, Lyons RA, Gravenor M, Halcox JP. Identifying unmet antithrombotic therapeutic need, and implications for stroke and systemic embolism in atrial fibrillation patients: a population-scale longitudinal study. Eur Heart J Open 2022; 2:oeac066. [PMID: 36415305 PMCID: PMC9678205 DOI: 10.1093/ehjopen/oeac066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Revised: 09/15/2022] [Indexed: 11/23/2022]
Abstract
Aims Guidelines recommend anticoagulation (AC) in atrial fibrillation (AF) to reduce stroke and systemic embolism (SSE) risk; however, implementation has been slow across many populations. This study aimed to quantify the potential impact of changing prevalence of AF, associated risk, and AC prescribing on SSE hospitalizations and death. Methods and results We evaluated temporal trends of AF, CHA2DS2-VASc, antithrombotic prescriptions, SSE hospitalizations, death, and their associations between 2012 and 2018 in a longitudinal cohort of AF patients in Wales UK. Multi-state Markov models were used to estimate expected SSE rates given the AC coverage, adjusting for CHA2DS2-VASc scores. SSE rates were modelled for various past and future AC scenarios. A total of 107 137 AF patients were evaluated (mean age = 74 years, 45% female). AF prevalence increased from 1.75 to 2.22% (P-value <0.001). SSE hospitalizations decreased by 18% (2.34-1.92%, P-value <0.001). Increased AC coverage from 50 to 70% was associated with a 37% lower SSE rate, after adjustment for individual time-dependent CHA2DS2VASc scores. The observed AC increase accounted for approximately 80 fewer SSE hospitalizations per 100 000/year. If 90% AC coverage had been achieved since 2012, an estimated 279 SSE per 100 000/year may have been prevented. Our model also predicts that improving AC coverage to 90% over the next 9 years could reduce annual SSE rates by 9%. Conclusion We quantified the relationship between observed AC coverage, estimating the potential impact of variation in the timing of large-scale implementation. These data emphasize the importance of timely implementation and the considerable opportunity to improve clinical outcomes in the Wales-AF population.
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Affiliation(s)
- Fatemeh Torabi
- Population Data Science, Swansea University, Swansea SA2 8PP, UK
| | - Daniel E Harris
- Population Data Science, Swansea University, Swansea SA2 8PP, UK
| | - Owen Bodger
- Population Data Science, Swansea University, Swansea SA2 8PP, UK
| | - Ashley Akbari
- Population Data Science, Swansea University, Swansea SA2 8PP, UK
| | - Ronan A Lyons
- Population Data Science, Swansea University, Swansea SA2 8PP, UK
| | - Michael Gravenor
- Population Data Science, Swansea University, Swansea SA2 8PP, UK
| | - Julian P Halcox
- Population Data Science, Swansea University, Swansea SA2 8PP, UK
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Hung J, Roos A, Kadesjö E, McAllister DA, Kimenai DM, Shah ASV, Anand A, Strachan FE, Fox KAA, Mills NL, Chapman AR, Holzmann MJ. Performance of the GRACE 2.0 score in patients with type 1 and type 2 myocardial infarction. Eur Heart J 2021; 42:2552-2561. [PMID: 32516805 PMCID: PMC8266602 DOI: 10.1093/eurheartj/ehaa375] [Citation(s) in RCA: 38] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2020] [Revised: 03/17/2020] [Accepted: 04/22/2020] [Indexed: 12/22/2022] Open
Abstract
AIMS The Global Registry of Acute Coronary Events (GRACE) score was developed to evaluate risk in patients with myocardial infarction. However, its performance in type 2 myocardial infarction is uncertain. METHODS AND RESULTS In two cohorts of consecutive patients with suspected acute coronary syndrome from 10 hospitals in Scotland (n = 48 282) and a tertiary care hospital in Sweden (n = 22 589), we calculated the GRACE 2.0 score to estimate death at 1 year. Discrimination was evaluated by the area under the receiver operating curve (AUC), and compared for those with an adjudicated diagnosis of type 1 and type 2 myocardial infarction using DeLong's test. Type 1 myocardial infarction was diagnosed in 4981 (10%) and 1080 (5%) patients in Scotland and Sweden, respectively. At 1 year, 720 (15%) and 112 (10%) patients died with an AUC for the GRACE 2.0 score of 0.83 [95% confidence interval (CI) 0.82-0.85] and 0.85 (95% CI 0.81-0.89). Type 2 myocardial infarction occurred in 1121 (2%) and 247 (1%) patients in Scotland and Sweden, respectively, with 258 (23%) and 57 (23%) deaths at 1 year. The AUC was 0.73 (95% CI 0.70-0.77) and 0.73 (95% CI 0.66-0.81) in type 2 myocardial infarction, which was lower than for type 1 myocardial infarction in both cohorts (P < 0.001 and P = 0.008, respectively). CONCLUSION The GRACE 2.0 score provided good discrimination for all-cause death at 1 year in patients with type 1 myocardial infarction, and moderate discrimination for those with type 2 myocardial infarction. TRIAL REGISTRATION ClinicalTrials.gov number, NCT01852123.
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Affiliation(s)
- John Hung
- BHF Centre for Cardiovascular Science, University of Edinburgh, 49 Little France Crescent, EH16 4SB Edinburgh, UK
| | - Andreas Roos
- Department of Medicine, Karolinska Institute, 171 77 Solna, Stockholm, Sweden
- Functional Area of Emergency Medicine, Karolinska University Hospital, 141 57 Huddinge, Stockholm, Sweden
| | - Erik Kadesjö
- Department of Medicine, Karolinska Institute, 171 77 Solna, Stockholm, Sweden
- Functional Area of Emergency Medicine, Karolinska University Hospital, 141 57 Huddinge, Stockholm, Sweden
| | - David A McAllister
- Institute of Health and Wellbeing, University of Glasgow, G12 8QQ Glasgow, UK
| | - Dorien M Kimenai
- BHF Centre for Cardiovascular Science, University of Edinburgh, 49 Little France Crescent, EH16 4SB Edinburgh, UK
- Usher Institute, University of Edinburgh, EH8 9AG Edinburgh, UK
- CARIM School for Cardiovascular Diseases, Maastricht University, 6229 ER Maastricht, the Netherlands
- Central Diagnostic Laboratory, Maastricht University Medical Center, 6229 ER Maastricht, the Netherlands
| | - Anoop S V Shah
- BHF Centre for Cardiovascular Science, University of Edinburgh, 49 Little France Crescent, EH16 4SB Edinburgh, UK
- Usher Institute, University of Edinburgh, EH8 9AG Edinburgh, UK
| | - Atul Anand
- BHF Centre for Cardiovascular Science, University of Edinburgh, 49 Little France Crescent, EH16 4SB Edinburgh, UK
| | - Fiona E Strachan
- BHF Centre for Cardiovascular Science, University of Edinburgh, 49 Little France Crescent, EH16 4SB Edinburgh, UK
| | - Keith A A Fox
- BHF Centre for Cardiovascular Science, University of Edinburgh, 49 Little France Crescent, EH16 4SB Edinburgh, UK
| | - Nicholas L Mills
- BHF Centre for Cardiovascular Science, University of Edinburgh, 49 Little France Crescent, EH16 4SB Edinburgh, UK
- Usher Institute, University of Edinburgh, EH8 9AG Edinburgh, UK
| | - Andrew R Chapman
- BHF Centre for Cardiovascular Science, University of Edinburgh, 49 Little France Crescent, EH16 4SB Edinburgh, UK
| | - Martin J Holzmann
- Department of Medicine, Karolinska Institute, 171 77 Solna, Stockholm, Sweden
- Functional Area of Emergency Medicine, Karolinska University Hospital, 141 57 Huddinge, Stockholm, Sweden
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Williams MC, Massera D, Moss AJ, Bing R, Bularga A, Adamson PD, Hunter A, Alam S, Shah ASV, Pawade T, Roditi G, van Beek EJR, Nicol ED, Newby DE, Dweck MR. Prevalence and clinical implications of valvular calcification on coronary computed tomography angiography. Eur Heart J Cardiovasc Imaging 2021; 22:262-270. [PMID: 33306104 PMCID: PMC7899264 DOI: 10.1093/ehjci/jeaa263] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Accepted: 09/07/2020] [Indexed: 12/11/2022] Open
Abstract
AIMS Valvular heart disease can be identified by calcification on coronary computed tomography angiography (CCTA) and has been associated with adverse clinical outcomes. We assessed aortic and mitral valve calcification in patients presenting with stable chest pain and their association with cardiovascular risk factors, coronary artery disease, and cardiovascular outcomes. METHODS AND RESULTS In 1769 patients (58 ± 9 years, 56% male) undergoing CCTA for stable chest pain, aortic and mitral valve calcification were quantified using Agatston score. Aortic valve calcification was present in 241 (14%) and mitral calcification in 64 (4%). Independent predictors of aortic valve calcification were age, male sex, hypertension, diabetes mellitus, and cerebrovascular disease, whereas the only predictor of mitral valve calcification was age. Patients with aortic and mitral valve calcification had higher coronary artery calcium scores and more obstructive coronary artery disease. The composite endpoint of cardiovascular mortality, non-fatal myocardial infarction, or non-fatal stroke was higher in those with aortic [hazard ratio (HR) 2.87; 95% confidence interval (CI) 1.60-5.17; P < 0.001] or mitral (HR 3.50; 95% CI 1.47-8.07; P = 0.004) valve calcification, but this was not independent of coronary artery calcification or obstructive coronary artery disease. CONCLUSION Aortic and mitral valve calcification occurs in one in six patients with stable chest pain undergoing CCTA and is associated with concomitant coronary atherosclerosis. Whilst valvular calcification is associated with a higher risk of cardiovascular events, this was not independent of the burden of coronary artery disease.
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Affiliation(s)
- Michelle C Williams
- University of Edinburgh/British Heart Foundation Centre for Cardiovascular Science, Chancellor’s Building, 49 Little France Crescent, Edinburgh EH164SB, UK
- Edinburgh Imaging Facility QMRI, University of Edinburgh, Edinburgh EH164TJ, UK
| | - Daniele Massera
- Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, NY 10461, USA
| | - Alastair J Moss
- University of Edinburgh/British Heart Foundation Centre for Cardiovascular Science, Chancellor’s Building, 49 Little France Crescent, Edinburgh EH164SB, UK
| | - Rong Bing
- University of Edinburgh/British Heart Foundation Centre for Cardiovascular Science, Chancellor’s Building, 49 Little France Crescent, Edinburgh EH164SB, UK
| | - Anda Bularga
- University of Edinburgh/British Heart Foundation Centre for Cardiovascular Science, Chancellor’s Building, 49 Little France Crescent, Edinburgh EH164SB, UK
| | - Philip D Adamson
- University of Edinburgh/British Heart Foundation Centre for Cardiovascular Science, Chancellor’s Building, 49 Little France Crescent, Edinburgh EH164SB, UK
- Christchurch Heart Institute, University of Otago, Christchurch 8140, New Zealand
| | - Amanda Hunter
- University of Edinburgh/British Heart Foundation Centre for Cardiovascular Science, Chancellor’s Building, 49 Little France Crescent, Edinburgh EH164SB, UK
| | - Shirjel Alam
- University of Edinburgh/British Heart Foundation Centre for Cardiovascular Science, Chancellor’s Building, 49 Little France Crescent, Edinburgh EH164SB, UK
| | - Anoop S V Shah
- University of Edinburgh/British Heart Foundation Centre for Cardiovascular Science, Chancellor’s Building, 49 Little France Crescent, Edinburgh EH164SB, UK
| | - Tania Pawade
- University of Edinburgh/British Heart Foundation Centre for Cardiovascular Science, Chancellor’s Building, 49 Little France Crescent, Edinburgh EH164SB, UK
| | - Giles Roditi
- Glasgow Clinical Research Imaging Facility, Queen Elizabeth University Hospital, Glasgow G514LB, UK
| | - Edwin J R van Beek
- Edinburgh Imaging Facility QMRI, University of Edinburgh, Edinburgh EH164TJ, UK
| | | | - David E Newby
- University of Edinburgh/British Heart Foundation Centre for Cardiovascular Science, Chancellor’s Building, 49 Little France Crescent, Edinburgh EH164SB, UK
- Edinburgh Imaging Facility QMRI, University of Edinburgh, Edinburgh EH164TJ, UK
| | - Marc R Dweck
- University of Edinburgh/British Heart Foundation Centre for Cardiovascular Science, Chancellor’s Building, 49 Little France Crescent, Edinburgh EH164SB, UK
- Edinburgh Imaging Facility QMRI, University of Edinburgh, Edinburgh EH164TJ, UK
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