Clinical significance of cardiac troponins I and T in acute heart failure

BACKGROUND: Elevated cardiac troponin (cTn) levels are relatively common in acute heart failure (AHF). AIMS: To evaluate the prevalence and prognostic significance of elevated cTnI and cTnT in AHF. METHODS: FINN-AKVA is a prospective, multicenter study in AHF. In this analysis, 364 non-ACS patients with measurements of cTnI and cTnT taken on admission and 48 h thereafter were analyzed. RESULTS: Of the 364 AHF patients, 51.1% had cTnI and 29.7% cTnT levels above the cut-off value. Six-month all-cause mortality was 18.7%. Both cTnI (OR 2.0, 95% CI 1.2-3.5, p=0.01) and cTnT (OR 2.6, 95% CI 1.5-4.4, p=0.0006) were associated with adverse outcome. The mortality risk was proportional to the magnitude of cTn release. On multivariable analysis, Cystatin C (OR 6.3, 95% CI 3.2-13, p<0.0001), logNT-proBNP (OR 1.4, 95% CI 1.0-1.8, p=0.03) and systolic blood pressure on admission (/10 mm Hg increase, OR 0.9, 95% CI 0.8-0.9, p=0.0004) were independent risk markers, whereas the troponins were not significantly associated with increased mortality. CONCLUSIONS: cTn elevations are frequent in AHF patients without ACS. cTnI is more often elevated than cTnT. Both cTnI and cTnT elevations are associated with increased mortality proportional to the degree elevation but they do not act as independent risk markers.     

Evaluation of B-type natriuretic peptide for risk assessment in unstable angina/non-ST-elevation myocardial infarction: B-type natriuretic peptide and prognosis in TACTICS-TIMI 18

OBJECTIVES: This study was designed to evaluate B-type natriuretic peptide (BNP) for risk assessment and clinical decision making over a range of cut points, alone and with cardiac troponin I (cTnI), in patients with non-ST-elevation acute coronary syndromes (ACS). BACKGROUND: B-type natriuretic peptide holds promise for risk stratification. Additional evidence regarding optimal decision limits, use in combination with troponin, and use in targeting therapy is needed before acceptance into clinical use for ACS. METHODS: We evaluated BNP at baseline in 1,676 patients with non-ST-elevation ACS randomized to early invasive versus conservative management. RESULTS: Patients with elevated BNP (>80 pg/ml; n = 320) were at higher risk of death at seven days (2.5% vs. 0.7%, p = 0.006) and six months (8.4% vs. 1.8%, p < 0.0001). The association between BNP and mortality at six months (adjusted odds ratio [OR] 3.3; 95% confidence interval [CI] 1.7 to 6.3) was independent of important clinical predictors, including cTnI and congestive heart failure (CHF). Patients with elevated BNP had a fivefold higher risk of developing new CHF by 30 days (5.9% vs. 1.0%, p < 0.0001). B-type natriuretic peptide added prognostic information to cTnI, discriminating patients at higher mortality risk among those with negative (OR 6.9; 95% CI 1.9 to 25.8) and positive (OR 4.1; 95% CI 1.9 to 9.0) baseline cTnI results. No difference was observed in the effect of invasive versus conservative management when stratified by baseline levels of BNP (p(interaction) > or = 0.6). CONCLUSIONS: Elevated BNP (>80 pg/ml) at presentation identifies patients with non-ST-elevation ACS who are at higher risk of death and CHF and adds incremental information to cTnI. Additional work is needed to identify therapies that may reduce the risk associated with increased BNP.     

Concurrent evaluation of novel cardiac biomarkers in acute coronary syndrome: myeloperoxidase and soluble CD40 ligand and the risk of recurrent ischaemic events in TACTICS-TIMI 18.

AIMS: We investigated the prognostic performance of myeloperoxidase (MPO), and soluble CD40 ligand (sCD40L) along with B-type natriuretic peptide (BNP), high-sensitivity C-reactive protein (hsCRP), and cardiac troponin I (cTnI) for non-fatal recurrent ischaemic events in non-ST elevation acute coronary syndrome (ACS). METHODS AND RESULTS: We measured plasma MPO and sCD40L in 1524 patients with ACS treated with tirofiban and randomized to early invasive vs. conservative management in the TACTICS-TIMI 18 trial who survived to 180 days. Patients with elevated baseline MPO (>884 pM) were at higher risk of non-fatal myocardial infarction or rehospitalization for ACS at 30 days (9.3 vs. 4.6%, P < 0.001). In contrast, no difference was observed with higher sCD40L (>989 pg/mL, 7.6 vs. 6.3%, P = 0.31). MPO remained associated with recurrent ischaemic events after adjustment for age, ST-deviation, diabetes, prior coronary artery disease, heart failure, cTnI, hsCRP, and sCD40L (OR 2.10; 95% CI 1.36-3.23, P = 0.001). This association was attenuated by 180 days (OR 1.26; 0.95-1.68). Stratification using baseline MPO, BNP, and cTnI identified a >3-fold gradient of risk. CONCLUSION: MPO adds to BNP and cTnI for short-term risk assessment for recurrent ischaemic events in non-ST elevation ACS. sCD40L was not associated with risk in this population treated with a platelet GPIIb/IIIa receptor antagonist.     

Cardiac troponin I for risk stratification following percutaneous coronary artery intervention in acute coronary syndromes.

The cardiac troponins have been shown to provide prognostic information allowing risk stratification of patients with acute coronary syndromes (ACS). The benefit of early percutaneous coronary intervention (PCI) in this setting has been highlighted by the FRISC II study. We assessed the pattern of release of cardiac troponin I (cTnI) following PCI in patients with ACS and evaluated its prognostic value for major adverse cardiac events (MACE): death, Q-wave myocardial infarction (QWMI), and repeat revascularization at follow-up. cTnI was sampled at baseline and 6, 14, and 24 hr following PCI in 73 patients presenting with unstable and post-MI angina. Clinical follow-up was obtained in all 73 patients at a mean period of 43 +/- 19.9 weeks (range, 11-68 weeks). Patients were stratified into two groups according to whether cTnI remained unchanged or fell below baseline 24 hr post-PCI (group 1, n = 47) or increased above baseline 24 hr following PCI (group 2, n = 26). MACE occurred in 4 (8.5%) of patients in group 1 (QWMI = 1, CABG = 1, re-PCI = 2) and in 19 (73%) of patients in group 2 (death = 1, QWMI = 2, CABG = 2, re-PCI = 14; chi-square = 32.34, P < 0.0001). The positive predictive value of rising cTnI within 24 hr following PCI for MACE at follow-up was 0.73 and the negative predictive value was 0.92 (specificity = 83%, sensitivity = 86%; odds ratio = 29.18, 95% CI = 7.62-110.64, P < 0.0001). cTnI is an inexpensive and widely applicable tool that offers reliable prognostic information for the risk stratification of patients undergoing coronary revascularization in the setting of acute coronary syndromes and may identify a group of patients at particular risk of repeat PCI.     

The prognostic value of serum myoglobin in patients with non-ST-segment elevation acute coronary syndromes. Results from the TIMI 11B and TACTICS-TIMI 18 studies

OBJECTIVES: The goal of this study was to define the prognostic value of serum myoglobin in patients with non-ST-elevation acute coronary syndromes (ACS). BACKGROUND: While myoglobin is useful for the early diagnosis of myocardial infarction (MI), its role in the early risk-stratification of patients with ACS has not been established. METHODS: Myoglobin, creatine kinase-MB subfraction (CK-MB) and troponin I (cTnI) were measured at randomization in 616 patients from the Thrombolysis In Myocardial Ischemia/Infarction (TIMI) 11B study and 1,841 patients from the Treat Angina with Aggrastat and Determine Cost of Therapy with an Invasive or Conservative Therapy-Thrombolysis In Myocardial Ischemia/Infarction (TACTICS-TIMI) 18 study. The risks for death and nonfatal MI through six months of follow-up were compared between patients with and without myoglobin elevation (>110 microg/l) in each study and in a dataset combining all eligible patients from both studies (n = 2,457). RESULTS: In a multivariate model adjusting for baseline characteristics, ST changes and CK-MB and cTnI levels, an elevated baseline myoglobin was associated with increased six-month mortality in TIMI 11B (adjusted odds ratio [OR] 2.9 [95% confidence interval [CI] 1.2 to 7.1]), TACTICS-TIMI 18 (adjusted OR 3.0 [95% CI 1.5 to 5.9]) and the combined dataset (adjusted OR 3.0 [95% CI 1.8 to 5.0]). In contrast, there was no significant association between myoglobin elevation and nonfatal MI (combined dataset adjusted OR 1.55, 95% CI 0.9 to 2.6). In TACTICS-TIMI 18, patients with versus those without myoglobin elevation were more likely to have an occluded culprit artery (28% vs. 10%; p < 0.0001) and visible thrombus (49% vs. 34%; p = 0.006) and less likely to have TIMI 3 flow (53% vs. 68%; p = 0.009). CONCLUSIONS: A serum concentration of myoglobin above the MI detection threshold (>110 microg/l) is associated with an increased risk of six-month mortality, independent of baseline clinical characteristics, electrocardiographic changes and elevation in CK-MB and cTnI. These findings suggest that myoglobin may be a useful addition to cardiac biomarker panels for early risk-stratification in ACS.     

Troponin I and T levels in renal failure patients without acute coronary syndrome: a systematic review of the literature

BACKGROUND: Debate surrounds the interpretation of troponin assays for the diagnosis and prognosis of cardiac disease in patients with renal failure. OBJECTIVES: To systematically review the diagnostic and prognostic test characteristics of quantitative serum cardiac troponin I (cTnI) and T (cTnT) in renal failure patients without acute coronary syndrome (ACS) symptoms. METHODS: English-language literature was identified through searching MEDLINE from 1966 to August 2003 and reviewing reference lists. Studies were excluded if they did not meet research objectives, had fewer than 10 patients or focused primarily on nonrenal patients. Of 119 potential studies, 39 articles with over 349 patients with chronic kidney disease (CKD) and 3899 hemodialysis patients were selected for abstraction. RESULTS: Among CKD and hemodialysis patients without ACS symptoms, cTnI had a mean specificity of 97% (95% CI 93% to 99%) and 96% (95% CI 94% to 98%), respectively, using the myocardial infarction cut-off threshold. The mean specificity of cTnT compared less favourably at 85% (95% CI 75% to 93%) and 71% (95% CI 64% to 77%) for CKD and hemodialysis patients, respectively. In hemodialysis patients without ACS symptoms, positive and negative likelihood ratios for all-cause mortality over 12 to 24 months for cTnT were 4.5 (95% CI 2.9 to 7.1) and 0.6 (95% CI 0.4 to 0.8), and for cTnI were 1.6 (95% CI 0.9 to 2.9) and 1.0 (95% CI 0.9 to 1.1), respectively. CONCLUSIONS: In CKD and hemodialysis patients without ACS symptoms, troponin I, at the myocardial infarction cut-off threshold, is unlikely to be falsely elevated. Among hemodialysis patients without ACS symptoms, a positive troponin T helps predict all-cause mortality.     

Admission glycemia: a predictor of death after acute coronary syndrome in non-diabetic patients?

BACKGROUND: Previous studies have demonstrated that acute phase hyperglycemia is associated with increased in-hospital mortality in diabetic patients admitted with acute coronary syndrome (ACS), but this has not been clearly demonstrated in non-diabetic patients. The present study was designed to determine whether admission hyperglycemia (AG) is an independent predictor of in-hospital and six-month mortality after ACS in non-diabetic patients. METHODS: This was a retrospective cohort study of 426 non-diabetic patients consecutively admitted with ACS. The patients were stratified into quartile groups according to AG, which was also analyzed as a continuous variable. Vital status was obtained at six-month follow-up in 96.8% of the patients surviving hospitalization. Logistic regression analysis was used to identify independent predictors of in-hospital and six-month death. RESULTS: Of the 426 patients included in the study (age 62.6 years+/-13.1, 77% male), 22 (5.4%) patients died during hospitalization and 20 (5.2% of the patients surviving hospitalization) within six months of ACS. Mean AG was 134.89 mg/dl+/-51.95. The higher the AG, the more probable was presentation with ST-segment elevation ACS (STEMI), anterior STEMI, higher heart rate, Killip class higher than one (KK >1), higher serum creatinine and greater risk of in-hospital and six-month death. In multivariate analysis, only age (OR=1.10; 95% CI 1.04-1.17), STEMI (OR=3.02; 95% CI 1.07-8.50), AG (OR=1.073; 95% CI 1.004-1.146), serum creatinine (OR=1.10; 95% CI 1.009-1.204) and KK >1 on admission (OR=4.65; 95% CI 1.59-13.52) were independently associated with in-hospital death. Age (OR=1.07; 95% CI 1.03-1.12), serum creatinine (OR=1.09; 95% CI 1.01-1.18) and in-hospital development of heart failure (OR=2.34; 95% CI 1.07-5.10) were independently associated with higher risk of death within six months of ACS. CONCLUSIONS: AG is an independent predictive factor of in-hospital death after ACS in non-diabetic patients. Although it did not show an independent association with higher risk of six-month death, AG appears to contribute to it, since the risk is greater the higher the AG. Its predictive value may have been blunted by the insufficient power of the sample and/or by the time interval between acquisition of AG and the evaluated endpoint.     

Diagnostic evaluation of the MRP-8/14 for the emergency assessment of chest pain

Elevated levels of myeloid-related protein (MRP)-8/14 (S100A8/A9) are associated with first cardiovascular events in healthy individuals and worse prognosis in patients with acute coronary syndrome (ACS). The diagnostic utility of MRP-8/14 in patients presenting to the emergency room with symptoms concerning for ACS is uncertain. MRP-8/14 was measured in serial serum and plasma samples in a single center prospective cohort-study of patients presenting to the emergency room with non-traumatic chest pain concerning for ACS. Final diagnosis was adjudicated by an endpoint committee. Of patients with baseline MRP-8/14 results (n = 411), the median concentration in serum was 1.57 μg/ml (25th, 75th: 0.87, 2.68) and in plasma was 0.41 μg/ml (<0.4, 1.15) with only moderate correlation between serum and plasma (ρ = 0.40). A final diagnosis of MI was made in 106 (26%). Peak serum MRP-8/14 was higher in patients presenting with MI (p < 0.001). However, the overall diagnostic performance of MRP-8/14 was poor: sensitivity 28% (95% CI 20-38), specificity 82% (78-86), positive predictive value 36% (26-47), and negative predictive value 77% (72-81). The area under the ROC curve for diagnosis of MI with MRP-8/14 was 0.55 (95% CI 0.51-0.60) compared with 0.95 for cTnI. The diagnostic performance was not improved in early-presenters, patients with negative initial cTnI, or using later MRP-8/14 samples. Patients presenting with MI had elevated levels of serum MRP-8/14 compared to patients with non-cardiac chest pain. However, overall diagnostic performance of MRP-8/14 was poor and neither plasma nor serum MRP-8/14 offered diagnostic utility comparable to cardiac troponin.     

Troponin T and quantitative ST-segment depression offer complementary prognostic information in the risk stratification of acute coronary syndrome patients

OBJECTIVES: Our primary objective was to examine the prognostic relationship between baseline quantitative ST-segment depression (ST) and cardiac troponin T (cTnT) elevation. The secondary objectives were to: 1) examine whether ST provided additional insight into therapeutic efficacy of glycoprotein IIb/IIIa therapy similar to that demonstrated by cTnT; and 2) explore whether the time to evaluation impacted on each marker's relative prognostic utility. BACKGROUND: The relationship between the baseline electrocardiogram (ECG) and cTnT measurements in risk-stratifying patients presenting with acute coronary syndromes (ACS) has not been evaluated comprehensively. METHODS: The study population consisted of 959 patients enrolled in the cTnT substudy of the Platelet IIb/IIIa Antagonism for the Reduction of Acute coronary syndrome events in a Global Organization Network (PARAGON)-B trial. Patients were classified as having no ST (n = 387), 1 mm ST (n = 433), and ST > or =2 mm (n = 139). Forty-percent (n = 381) were classified as cTnT-positive based on a definition of > or =0.1 ng/ml. RESULTS: Six-month death/(re)myocardial infarction rates were 8.4% among cTnT-negative patients with no ST and 26.8% among cTnT-positive patients with ST > or =2 mm. On ECGs done after 6 h of symptom onset, ST > or =2 mm was associated with higher risk compared to its presence on ECGs done earlier (odds ratio [OR] 7.3 vs. 2.1). In contrast, the presence of elevated cTnT within 6 h of symptom was associated with a higher risk of adverse events compared with elevations after 6 h (OR 2.4 vs. 1.5). CONCLUSIONS: Quantitative ST and cTnT status are complementary in assessing risk among ACS patients and both should be employed to determine prognosis and assist in medical decision making.     

Alternative endocardial sites for artificial cardiac stimulation

Despite the association between high-sensitivity C-reactive protein (CRP) and recurrent events in non-ST elevation acute coronary syndromes (ACS), routine determination of this marker has not been recommended. In order to verify whether the current scientific evidence justifies the inclusion of CRP for risk stratification at hospital admission of patients with ACS, we carried out a systematic review and meta-analysis of the studies indexed in MEDLINE, SciELO or LILACS, with the following inclusion criteria: prospective cohort design and assessment of the prognostic value of CPR, as measured using a high-sensitivity method at the moment of hospital admission of patients with ACS. Nineteen studies met the inclusion criteria. In relation to the long-term follow-up, there was a consistent association between CRP and cardiovascular events, with an overall odds ratio (OR) of 4.6 (95% CI = 2.3 - 7.6) and overall multivariate OR of 2.5 (95% CI = 1.8-3.4). As for the short-term, nine studies were positive and six were negative, with an overall OR of 1.65 (95% CI = 1.2-2.3). The overall multivariate OR was not obtained for the short-term follow-up, because this measurement was described only in three heterogeneous studies. Only two short-term studies analyzed the incremental predictive value of CRP in relation to multivariate models, with contradicting results. In conclusion, the small number of assessments of the incremental value of CRP, in conjunction with controversial results regarding the independent predictive value of CRP for short-term events does not support the recommendation of the routine use of CRP for risk stratification at admission of patients with ACS.     

残余胆固醇与老年急性冠脉综合征患者的病变严重程度及预后的关联性研究

目的：探索残余胆固醇（RC）是否可成为老年冠脉综合征（ACS）患者的危险分层及预后评估指标。 方法：本研究为前瞻性队列观察研究。连续入组2020年3月—2021年3月于解放军总医院心血管内科住院的老年ACS患者,通过电子病历系统收集患者的基线临床资料、实验室检查等资料并计算RC水平,通过冠脉造影的分析进行Gensini评分。对所有患者进行随访,随访终点为发生主要不良心血管事件（MACEs）。采用多因素Logistic回归模型分析发生MACEs的危险因素,受试者工作特征（ROC）曲线评估不同危险因素对ACS患者预后的预测价值,并采用Spearman相关性检验评估RC与冠脉病变严重程度的关联。 结果：研究最终入选老年ACS患者740例,其中1年随访期内发生MACEs者84例（11.35%）。多因素Logistic回归分析结果显示,通过校正,LDL-c（OR=0.998,95%CI：0.997-1.000,P=0.015）与RC（OR=0.135,95%CI：0.069-0.265,P<0.001）为老年ACS发生MACEs的独立危险因素。ROC曲线分析结果显示LDL-c及RC对预后评估有良好的预测价值,AUC分别为0.754（95%CI:0.719-0.786）、0.774（95%CI:0.740-0.805）,二者联合评估预后的效能优于二者单独预测0.868(95%CI:0.840-0.893)（P<0.001）。RC与Gensini评分的相关系数R2为0.49,二者呈正相关。 结论：RC与老年ACS患者的冠脉病变狭窄程度正相关,并对患者MACEs的预后评估具有较好的应用价值。     

The J-shape effect of alcohol intake on the risk of developing acute coronary syndromes in diabetic subjects: the CARDIO2000 II Study.

AIMS: To identify the threshold of alcohol consumption above which the balance of risk and benefit becomes adverse in diabetic subjects. METHODS: We studied demographic, lifestyle, dietary and clinical information in 216 hospitalized diabetic patients (171 men, 63 +/- 9 years old, 45 women, 67 +/- 5 years old) with a first event of an acute coronary syndrome (ACS) and 196 frequency matched (age-sex) diabetic controls, without any clinical evidence of coronary heart disease. Alcohol consumption was quantified and a measure for the comparisons was predetermined to be a wine glass (100 ml of wine, 12 g of ethanol) and its alcohol equivalents. RESULTS: Alcohol consumption was associated with an age-adjusted J-shape relationship with total cholesterol, blood pressure and smoking (all P < 0.001). A J-shape association was also found between alcohol intake and the risk of ACS (OR = 2.54-2.43 x (alcohol intake) + 0.80 x (alcohol intake)2, R2 = 0.96, P < 0.001), adjusted for several risk factors and interactions between alcohol intake and smoking status, job and familial stress, and low income. In particular, low alcohol consumption (< 12 g/day) was associated with a 47% (OR = 0.53, 95% CI 0.28-0.97) reduction of the prevalence of ACS, while a higher intake (12-24 and > 24 g/day) increased the prevalence by 2.7-fold (OR = 2.72, 95% CI 1.39-5.38) and 5.4-fold (OR = 5.44, 95% CI 1.21-24.55), respectively. CONCLUSIONS: Alcohol intake is a significant predictor of coronary events. Low-to-moderate intake seems to be associated with a reduction in the prevalence of ACS in diabetes, whereas higher consumption is associated with an increase in lipids and blood pressure levels, and also the risk of developing ACS.     

Persistently increased serum concentrations of cardiac troponin in patients with acutely decompensated heart failure are predictive of adverse outcomes.

BACKGROUND: Persistently increased serum concentrations of cardiac troponin (cTn) are a prognostic marker in patients suffering from chronic congestive heart failure (CHF), but the significance in acute cardiac decompensation is unclear. METHODS AND RESULTS: Serial blood samples were collected from 52 patients presenting with acute cardiac decompensation in the absence of an acute coronary event. Serial serum concentrations of cTnI, creatine kinase (CK)-MB, and brain natriuretic peptide (BNP) were measured by rapid assay. BNP and CK-MB steadily decreased from 902+/-529 pg/ml and 2.3+/-1.6 ng/ml at baseline to 453+/-427 pg/ml and 1.2+/-1.6 ng/ml on day 7, respectively, (p<0.0001 for both comparisons). In contrast, cTnI did not decrease significantly and, in 17 patients (35%), increased from 0.063+/-0.047 ng/ml at baseline to 0.167+/-0.181 ng/ml on day 1 (p<0.05). By single variable regression analysis, systolic blood pressure (SBP), use of inotropes or inodilators, vasodilators, and an initially elevated cTnI were predictors of elevated cTnI on day 1. By multiple variable analysis, an elevated SBP (as a mitigating factor) (odds ratios (OR) 0.12; 95% confidence intervals (CI): 0.02-0.76; p=0.0248), and high baseline cTnI (OR 13.85; 95%CI: 1.97-97.54; p=0.0083) were significant predictors of an elevated cTnI on day 1. Patients with elevated cTnI on day 1 had higher rates of worsening CHF and death from CHF than patients without such an increase (p<0.05). CONCLUSIONS: Persistently increased serum concentrations of cTn in patients with acutely decompensated heart failure are predictive of adverse outcomes.     

The incidence of adverse clinical outcome in acute coronary syndrome patients with subclinical hypothyroidism

Background Subclinical hypothyroidism is associated with adverse cardiovascular outcomes.But less is known about its prognostic role in patients with acute coronary syndrome(ACS).Methods 538 ACS patients with normal serum concentrations of T3 and T4 underwent coronary angiography in our hospital from January 2015 to January 2019 were retrospectively enrolled.They were divided into normal thyroid stimulating hormone(TSH) group(0.27-4.2 uIU/mL)(n=385) and high TSH group(4.2 uIU/mL)(n=135).The study endpoints were the major adverse cardiovascular events(MACEs).The univariate and multivariate regression analysis including significant covariables were performed to test for the association between subclinical hypothyroidism and MACEs.Results The mean concentration of TSH were 8.72(6.37-11.02) uIU/mL in the high TSH group and 1.94(1.34-2.45) uIU/mL in the normal TSH group.Multivariate logistic regression analysis found that subclinical hypothyroidism [Odds ratio(OR): 1.94, 95% confidence interval(CI): 1.23-2.65, P=0.030] was associated independently with MACE rate in ACS patients.The area under the receiver operating characteristic curve showed that the subclinical hypothyroidism had good predictable value for MACEs in patients with ACS(area under the curve:0.713, 95% CI: 0.668-0.802, P0.001).Conclusions Subclinical hypothyroidism is associated with worse clinical prognosis in ACS patients.Clinicians need to pay more attention to subclinical hypothyroidism in ACS patients.[S Chin J Cardiol 2021;22(1):1-6]     

Prognostic value of preoperative cardiac troponin I in patients with non-ST-segment elevation acute coronary syndromes undergoing coronary artery bypass surgery

STUDY OBJECTIVES: Elevated levels of cardiac troponin I (cTnI) have been associated with adverse short-term and long-term outcomes in acute coronary syndrome (ACS) patients and in patients who underwent coronary artery bypass grafting (CABG); however, the prognostic implications of preoperative cTnI determination have not been investigated so far. DESIGN AND SETTING: Retrospective study in a department of cardiothoracic surgery of a university hospital. PATIENTS AND METHODS: A possible correlation between preoperative cTnI levels and major adverse cardiac events (MACE) and in-hospital mortality in CABG patients with non-ST-segment elevation ACS (NSTE-ACS) was investigated. cTnI was determined in 1,978 of 3,124 consecutive CABG patients. Among these, 1,592 patients had preoperative cTnI levels < 0.1 ng/mL and therefore served as control subjects (group 1), 265 patients had NSTE-ACS with cTnI levels from 0.11 to 1.5 ng/mL (group 2), and 121 patients had NSTE-ACS with cTnI levels > 1.5 ng/mL (group 3). cTnI levels, clinical data, MACE, and in-hospital mortality were recorded prospectively. Logistic regression and receiver operating characteristic analyses were applied to determine prognostic cutoff values of cTnI. RESULTS: Perioperative myocardial infarction was found in 5.8% of the patients in group 1, 8.3% of the patients in group 2 (odds ratio [OR], 1.5; 95% confidence interval [CI], 0.9 to 2.5), and 18.2% patients in group 3 (OR, 3.6; 95% CI, 2.1 to 6.2; p < 0.0001, Cochran-Armitage trend test). Low cardiac output syndrome occurred in 1.5% of patients in group 1, 4.2% of patients in group 2 (OR, 2.8; 95% CI, 1.3 to 6.1), and 10.9% patients in group 3 (OR, 6.5; 95% CI, 2.9 to 14.4; p < 0.0001). In-hospital mortality was 1.5% in group 1, 3.0% in group 2 (OR, 2.0; 95% CI, 0.8 to 4.8), but 6.6% in group 3 (OR, 4.6; 95% CI, 1.9 to 11.1; p < 0.0001). Univariate and multivariate logistic regression analyses identified cTnI as the strongest preoperative predictor for MACE and in-hospital mortality, respectively. CONCLUSIONS: Preoperative cTnI measurement before CABG appears as a powerful and independent determinant of short-term surgical risk in patients with NSTE-ACS.     

血清Serpin B1水平对终末期肾病新入血液透析患者发生心血管事件有预测价值

摘要 目的：探讨血清丝氨酸蛋白酶抑制剂B1（Serpin B1）水平与终末期肾病新入血液透析患者发生心血管事件关联性。方法：回顾性分析160例终末期肾病患者的临床资料,根据患者治疗期间是否发生心血管事件将患者分为发生组（94例）与未发生组（66例）。比较2组患者一般资料（性别、年龄、合并症等）、血生化指标（总胆固醇、血红蛋白、甘油三酯等）。采用单因素分析终末期肾病新入血液透析患者发生心血管事件发生的影响因素,并将有统计学意义的项目纳入多因素Logistic回归,分析终末期肾病血液透析患者发生心血管事件的危险因素。采用受试者工作特征（ROC）曲线分析血清Serpin B1水平对终末期肾病新入血液透析患者发生心血管事件的预测价值。结果：2组患者年龄、甘油三酯、肌钙蛋白、C反应蛋白、血肌酐、甲状旁腺激素及Serpin B1比较,差异有统计学意义（P均＜0.05）。进一步进行Logistic回归分析,结果显示年龄（OR=2.34,95%CI：1.11~4.93）、C反应蛋白（OR=3.57,95%CI：2.22~5.76）、肌钙蛋白（OR=7.19,95%CI：3.15~16.37）及血清Serpin B1（OR=14.94,95%CI：2.69~82.85）是终末期肾病新入血液透析患者发生心血管事件的危险因素（P均＜0.05）。ROC曲线分析表明血清Serpin B1具有较高的预测价值,其最佳截断值为70.34ng/mL,曲线下面积（AUC）为0.879（95%CI：0.84~0.92）,其敏感度与特异性分别为79.89%与76.65%。结论：终末期肾病新入血液透析发生心血管事件患者血清Serpin B1水平较高,血清Serpin B1水平对于预测此类患者发生心血管事件提供一定参考价值。     

Vascular surgery patients: perioperative and long-term risk according to the ACC/AHA guidelines, the additive role of post-operative troponin elevation.

AIMS: The objectives of this study are to evaluate the prognostic role of pre-operative stratification in patients undergoing elective major vascular surgery, the timing of adverse outcomes, and the predictive role of troponin (cTn). METHODS AND RESULTS: Consecutive vascular surgery candidates (n=391) were prospectively stratified and treated according to the ACC/AHA guidelines. The patients were categorized into three groups: (1) with coronary revascularization in the past 5 years, (2) with intermediate clinical risk predictors, and (3) with minor or no clinical risk predictors. cTnI was measured post-operatively. By 18 months, 18.7% of subjects had experienced death or acute myocardial infarction (MI) (by the ACC/ESC criteria). The hazard ratio (HR) was 5.21 (95% CI=2.60-10.43; P<0.0001) in group 1 and 2.58 (95% CI=1.27-4.38; P=0.004) in group 2 when compared with group 3. Most events occurred within 30 days. Elevations of cTnI were associated with adverse outcomes even after multivariable adjustment at long-term (adjusted overall HR=4.73, 95% CI=2.92-7.65; P<0.0001) and at 30 days (adjusted HR=5.52, 95% CI=3.23-9.42; P<0.0001). CONCLUSION: After pre-operative stratification, patients undergoing elective major vascular surgery remain at high risk of MI and death. Events occur mainly early after surgery. cTnI elevations are frequent and independently associated with increased risk. These findings suggest the need for a major re-evaluation of our approach to these patients.     

Comparison of Cardiac Troponin I versus T and Creatine Kinase MB after Coronary Artery Bypass Grafting in Patients with and without Perioperative Myocardial Infarction

BACKGROUND AND PURPOSE: Cardiac troponins have shown to be specific markers of myocardial injury. The aim of this prospective study was to compare patterns and kinetics of troponin I and T after coronary artery bypass grafting (CABG) with or without perioperative myocardial infarction (PMI). PATIENTS AND METHODS: 119 patients (male/female: 96/23, age 64 +/- 10 years) underwent first time elective CABG. Preoperative mean ejection fraction was 55.8% +/- 15.6%. The mean number of grafts was 3.1 +/- 1.1/patient, in 85.7% the internal mammary artery was used. Cardiac troponin I (cTnI) and T (cTnT) levels, total serum activities of creatine kinase (CK) and creatine kinase isoenzyme MB (CK-MB) were measured before operation, at arrival on the intensive care unit (ICU), and 6, 12, 24, 48, and 120 h after unclamping of the aorta. Twelve lead electrocardiograms (ECGs) were recorded preoperatively and at days 1, 2, and 5. Perioperative data and postoperative cTnI and cTnT levels were correlated statistically. RESULTS: Two patients died due to refractory myocardial failure in the early postoperative period. For further evaluation, patients were divided in two groups according to postoperative ECG changes (group I: patients without PMI, n = 107; group II: patients with PMI, n = 10: six of them with Q-wave and four of them with non-Q-wave PMI). Calculated best cutoff values for cTnI and cTnT were 8.35 microg/l and 0.768 microg/l in ROC (receiver-operator characteristic) analysis. Serum concentrations of cTnI, and cTnT were in the normal range preoperatively and increased significantly after surgery in both groups. In both groups, cTnI reached its medium peak level after 24 h (group I: 2.7 microg/l, 95% confidence interval [CI]: [2.1,3.2]); group II: 70.5 microg/l). CTnT reached its medium peak level in group I without PMI after 48 h (0.298 microg/l, 95% CI: [0.254,0.354]), in group II with PMI not until 120 h (3.0 microg/l) postoperatively. In group II serum level of both troponins remained considerably high at 120 h (cTnI median = 10.75 microg/l, cTnT median = 3 microg/l). CONCLUSION: Release patterns of cTnI and cTnT after CABG are different: cTnI reaches its postoperative peak value earlier and declines more quickly than cTnT. After uncomplicated CABG, serum levels of both cardiac troponins remain continuously low. Elevated concentrations reflect perioperative myocardial ischemia or infarction. CTnT shows a different release pattern in patients with or without myocardial infarction.     

Pregnancy-associated plasma protein-A levels in patients with acute coronary syndromes: comparison with markers of systemic inflammation, platelet activation, and myocardial necrosis

OBJECTIVES: The goal of this study was to determine the predictive value of pregnancy-associated plasma protein-A (PAPP-A) in patients with acute coronary syndromes (ACS). BACKGROUND: Pregnancy-associated plasma protein-A is a zinc-binding matrix metalloproteinase abundantly expressed in eroded and ruptured plaques and may serve as a marker of plaque destabilization. METHODS: In 547 patients with angiographically validated ACS and in a heterogeneous emergency room population of 644 patients with acute chest pain, respectively, PAPP-A as well as markers of myocardial necrosis (troponin T [TnT]), ischemia (vascular endothelial growth factor [VEGF]), inflammation (high-sensitivity C-reactive protein [hsCRP]), anti-inflammatory activity (interleukin [IL]-10), and platelet activation (soluble CD40 ligand [sCD40L]) were determined. Patients were followed for the occurrence of death or myocardial infarction. RESULTS: In patients with ACS, elevated PAPP-A levels (>12.6 mIU/l) indicated an increased risk (odds ratio 2.44 [95% confidence interval (CI) 1.43 to 4.15]; p = 0.001). When the analysis was restricted to TnT-negative patients, PAPP-A still identified a subgroup of high-risk patients (odds ratio [OR] 2.72 [95% confidence interval (CI) 1.25 to 5.89]; p = 0.009). In a multivariable model, PAPP-A (OR 2.01; p = 0.015), sCD40L (OR 2.37; p = 0.003), IL-10 (OR 0.43; p = 0.003), and VEGF (OR 2.19; p = 0.018) were independent predictors. Prospective validation in patients with chest pain confirmed that PAPP-A levels reliably identify high-risk patients (adjusted OR 2.32 [95% CI 1.32 to 4.26]; p = 0.008). Patients negative for all three markers (TnT, sCD40L, and PAPP-A) were at very low cardiac risk (30 days: 3.0% event rate; no death). CONCLUSIONS: The PAPP-A level as a marker of plaque instability is a strong independent predictor of cardiovascular events in patients with ACS. Simultaneous determination of biomarkers with distinct pathophysiological profiles appears to remarkably improve risk stratification in patients with ACS.