High-sensitive cardiac troponin T

Cardiac troponin is the preferred biomarker for the diagnosis of acute myocardial infarction (AMI). The recent development of a high-sensitive cardiac troponin T (hs-cTnT) assay permits detection of very low levels of cTnT. Using the hs-cTnT assay improves the overall diagnostic accuracy in patients with suspected AMI, while a negative result also has a high negative predictive value. The gain in sensitivity may be particularly important in patients with a short duration from symptom onset to admission. Measurement of cardiac troponin T with the hs-cTnT assay may provide strong prognostic information in patients with acute coronary syndromes, stable coronary artery disease, heart failure and even in the general population; however, increased sensitivity comes at a cost of decreased specificity. Serial testing, as well as clinical context and co-existing diseases, are likely to become increasingly important for the interpretation of hs-cTnT assay results.     

Diagnostic sensitivity of high-sensitivity troponin T for acute myocardial infarction in patients with chest pain

IntroductionThe diagnosis of acute myocardial infarction (AMI) is based on an increase in plasma troponin levels above the 99th percentile of a healthy reference population values. On admission, over 30% of patients with AMI do not have specific symptoms and up to 70% of them may have normal or non-diagnostic ECG recordings. In these patient subgroups cardiac troponin assays may play a critical role in diagnosing AMI. Several diagnostic kits with enhanced analytic sensitivity (high-sensitivity kits) have been developed recently.Aim of studyTo compare diagnostic sensitivity of troponin I (cTnI) and high-sensitivity troponin T (hs-cTnT) in the diagnosis of acute myocardial infarction in patients with chest pain.Type of studyProspective, observational.Patients and methodsWe evaluated prospectively 107 consecutive patients [median (inter-quartile range) age: 64 (55–75) years; 29 women] admitted to intensive cardiac care unit for chest pain, with admission cTnI levels <0.1 μg/l. In all patients, the parameters determined on admission included their levels of cTnI (chemiluminiscence immunoassay with microparticles, Abbott, Architect i2000 analyzer), hs-cTnT (electrochemiluminiscence immunoassay; Roche Cobas e411 analyzer), and myoglobin (immunoturbidimetry). The diagnosis of AMI was established by the attending cardiologist (using the “universal” definition of acute myocardial infarction). The cTnI and hs-cTnT cut-off values for AMI were 0.033 μg/l and 14 ng/l, respectively. Troponin I levels were again determined at 6 and 12 h after admission.ResultsA total of 50 patients (46.7%) were diagnosed to have AMI with ST-segment elevation (STEMI), 35 patients (32.7%) developed AMI without STE (non-STEMI), 10 patients (9.3%) experienced a Type 2 AMI, four patients (3.7%) had unstable angina, and eight patients (7.5%) chest pain of non-coronary etiology (most often vertebrogenic pain). The diagnostic sensitivity of admission cTnI and hs-cTnT levels for AMI was 72% and 78%, respectively (p=0.1814). The correlation between cTnI and hs-cTnT was 0.67 (p<0.001; Spearman rank correlation coefficient). The diagnostic sensitivity of admission hs-cTnT and cTnI in STEMI patients was 82% vs. 70%, respectively (p=0.0771). In non-STEMI patients, similar baseline cTnI and hs-cTnT diagnostic sensitivity was found, 74.3% and 71.4%, respectively (p=0.91).ConclusionPatients with STEMI showed a trend toward a baseline diagnostic sensitivity of hs-cTnT superior to that of cTnI. In non-STEMI patients, the sensitivity of admission cTnI and hs-cTnT was similar.     

Early Diagnosis of Myocardial Infarction Using Absolute and Relative Changes in Cardiac Troponin Concentrations

Background

Absolute changes in high-sensitivity cardiac troponin T (hs-cTnT) seem to have higher diagnostic accuracy in the early diagnosis of acute myocardial infarction compared with relative changes. It is unknown whether the same applies to high-sensitivity cardiac troponin I (hs-cTnI) assays and whether the combination of absolute and relative change might further increase accuracy.

Methods

In a prospective, international multicenter study, high-sensitivity cardiac troponin (hs-cTn) was measured with 3 novel assays (hs-cTnT, Roche Diagnostics Corp, Indianapolis, Ind; hs-cTnI, Beckman Coulter Inc, Brea, Calif; hs-cTnI, Siemens, Munich, Germany) in a blinded fashion at presentation and after 1 and 2 hours in a blinded fashion in 830 unselected patients with suspected acute myocardial infarction. The final diagnosis was adjudicated by 2 independent cardiologists.

Results

The area under the receiver operating characteristic curve for diagnosing acute myocardial infarction was significantly higher for 1- and 2-hour absolute versus relative hs-cTn changes for all 3 assays (P < .001). The area under the receiver operating characteristic curve of the combination of 2-hour absolute and relative change (hs-cTnT 0.98 [95% confidence interval {CI}, 0.97-0.99]; hs-cTnI, Beckman Coulter Inc, 0.97 [95% CI, 0.96-0.99]; hs-cTnI, Siemens, 0.96 [95% CI, 0.93-0.99]) were high and provided some benefit compared with the use of absolute change alone for hs-cTnT, but not for the hs-cTnI assays. Reclassification analysis confirmed the superiority of absolute changes versus relative changes.

Conclusions

Absolute changes seem to be the preferred metrics for both hs-cTnT and hs-cTnI in the early diagnosis of acute myocardial infarction. The combination of absolute and relative changes provides a small added value for hs-cTnT, but not for hs-cTnI.     

Diagnostic role of copeptin in patients presenting with chest pain in the emergency room

BackgroundChest pain is a frequent symptom leading patients to the Emergency Room. Copeptin, the C-terminal fragment of arginin-vasopressin, is a marker of stressful situations. Recent studies showed that normal levels of copeptin combined with normal troponin accurately rule out the diagnosis of acute coronary syndrome (ACS). In this observational, prospective, multicenter study we evaluated if negative levels of copeptin combined with negative troponin (Tn-T) can correctly rule out the diagnosis of ACS and also of other life-threatening causes of chest pain.ResultsOf 472 enrolled patients (64.6% males, mean age 60.1 yrs), 28 (5.9%) were diagnosed with ST‐elevation myocardial infarction (STEMI), 28 (5.9%) with non ST‐elevation myocardial infarction (NSTEMI), 43 (9.1%) with unstable angina (UA), 13 (2.8%) with potentially life‐threatening non‐ACS pathologies (aortic dissection, pulmonary embolism, pulmonary edema, sepsis), 360 (76.2%) with benign causes of chest pain. Copeptin levels were significantly higher in ACS patients with STEMI and NSTEMI than in those with other diagnoses, but not in those with UA. The combination of copeptin and troponin‐T attained a negative predictive value of 86.6% for ACS, of 97.9% for other potentially life‐threatening non‐ACS diseases and of 85% for all potentially lethal diseases (ACS plus others).ConclusionsThe combined use of troponin and copeptin significantly improved the diagnostic accuracy of troponin alone both in ACS (STEMI and NSTEMI) and in other life-threatening diseases. Measurement of this marker might be therefore considered not only for a rule-out strategy but also as a warning sign of a life-threatening disease.     

Structural Cardiac Abnormalities in Patients with Atrial Fibrillation/Flutter and Myocardial Injury

BackgroundHigh-sensitivity cardiac troponin (hs-cTnT) is often increased in patients with atrial fibrillation/flutter, portending a poor prognosis. The etiologies for these increases have not been systematically investigated. Our aim was to define prevalence/significance of structural cardiac abnormalities in patients with atrial fibrillation/flutter and high-sensitivity cardiac troponin T (hs-cTnT) increases.MethodsThis is a retrospective observational cohort study of patients with atrial fibrillation/flutter diagnosis with hs-cTnT measurements, echocardiograms, and coronary angiograms. Myocardial injury was defined as hs-cTnT >10 ng/L for women and >15 ng/L for men. Cases with myocardial injury were adjudicated according to the Fourth Universal Definition of Myocardial Infarction.ResultsPatients with definite causes for increased hs-cTnT (n = 875) were tabulated but not evaluated further; common diagnoses were type 1 myocardial infarction, critical illness, and known heart failure. Of the remaining 401, increased hs-cTnT was present in 336 (84%) patients. Of those, 78% had nonischemic myocardial injury, the remaining (n = 75, 22%) had type 2 myocardial infarction. Patients with elevated hs-cTnT had greater left ventricular mass index, left ventricular filling pressures, and right ventricular systolic pressure. They more frequently had significant coronary artery disease (47% vs 31%, P = .016), especially in type 2 myocardial infarction. With logistic regression, age, sex (F), diabetes, left ventricular mass index, e′ medial velocity, and right ventricular systolic pressure were independent determinants of myocardial injury. One-year mortality was higher in patients with myocardial injury.ConclusionsStructural heart abnormalities are common in patients with atrial fibrillation/flutter and increased hs-cTnT. Causes of myocardial injury should be elucidated in each patient to craft appropriate therapies.     

Variability in High-Sensitivity Cardiac Troponin T Testing in Stable Patients With and Without Coronary Artery Disease

BackgroundHigh-sensitivity cardiac troponin T (hs-cTnT) is used to diagnosis acute myocardial infarction, often based on values exceeding the 99th percentile threshold (14 ng/L) of normal populations. The short- and long-term variability of hs-cTnT in stable patients with or without coronary artery disease (CAD) is unknown.MethodsProspective cohort study of 75 stable patients with CAD and 3 differing clinical profiles (stable angina [SA]; remote myocardial infarction [MI]; repetitive acute coronary syndrome [ACS]) and 25 controls without angiographic CAD, each with 15 hs-cTnT measurements over 1 year.ResultsIndividual results (1491 measurements) did not vary over within-day, daily, weekly, monthly, seasonal, or yearly time windows. The overall median was 2.8 ng/L (interquartile range [IQR] 5.2 ng/L) with the highest median (6.3 ng/L) and variability (IQR 6. 9 ng/L) in the repetitive ACS group. Diabetes, impaired renal function, and raised C-reactive protein were independent predictors of higher hs-cTnT values (average increase by 8.5 ng/L [95% CI, 5.0-11.9], 5.0 ng/L [95% CI, 2.0-8.1] and 4.0 ng/L (95% CI, 1.0-7.0), respectively). The 99th percentile value of all hs-cTnT measurements in the combined stable patients with CAD was 39 ng/L compared with 14 ng/L in the non-CAD patients.ConclusionsIndividual hs-cTnT readings in both patients with and without CAD were stable over hours, days, weeks, and months. Diabetes, poor renal function, and elevated C-reactive protein were independent predictors of higher median and IQR hs-cTnT values, often exceeding conventional thresholds. These findings highlight the need for caution and clinical contextualization in the interpretation of hs-cTnT results.     

High-sensitive cardiac troponin T is not always heart – Paraneoplastic systemic sclerosis simulated myocardial ischemia

BackgroundThe high-sensitive cardiac troponin T (hs-cTnT, Elecsys^®) is an excellent and worldwide used diagnostic marker for myocardial ischemia with high sensitivity. However, elevated hs-cTnT levels are found in different systemic diseases and can lead to misdiagnosis. The high-sensitive cardiac troponin I (hs-cTnI, ARCHITECT^®) shows comparable sensitivity. However, hs-cTnI is much more specific than hs-cTnT (92% vs. 80%, 99th percentile).Case summaryAn asymptomatic women with a cancer of unknown primary (CUP) presented constantly high hs-cTnT. Electrocardiogram, echocardiography as well as cardiac MRI and CT angiography of the coronary arteries showed no pathological findings. Accordingly, the measurement of the more specific hs-cTnI showed no significant increase. A repeated clinical examination revealed a localized scleroderma and autoimmune antibody pattern diagnosed a paraneoplastic systemic sclerosis (SSc). Therefore, a treatment with Rituximab — a CD20 antibody — was initiated, which reduced activity of SSc and also concentration of hs-cTnT.ConclusionIn the present case, a localized scleroderma due a paraneoplastic SSc was accompanied by elevated hs-cTnT levels in the absence of cardiovascular disease. A reduced inflammation of skeletal muscle tissue due to rituximab treatment decreased hs-cTnT levels. This is the first report of an occult hs-cTnT elevation due to paraneoplastic SSc.     

Cinética temprana de troponina en pacientes con sospecha de infarto agudo de miocardio

Introduction and objectivesRelease kinetics of high-sensitivity cardiac troponin (hs-cTn) T and I in patients with acute myocardial infarction (AMI) are incompletely understood. We aimed to assess whether hs-cTnT/I release in early AMI is near linear.MethodsIn a prospective diagnostic multicenter study the acute release of hs-cTnT and hs-cTnI within 1 and 2 hours from presentation to the emergency department was quantified using 3 hs-cTnT/I assays in patients with suspected AMI. The primary endpoint was correlation between hs-cTn changes from presentation to 1 hour vs changes from presentation to 2 hours, among all AMI patients and different prespecified subgroups. The final diagnosis was adjudicated by 2 independent cardiologists, based on serial hs-cTnT from the serial study blood samples and additional locally measured hs-cTn values.ResultsAmong 2437 patients with complete hs-cTnT data, AMI was the adjudicated diagnosis in 376 patients (15%). For hs-cTnT, the correlation coefficient between 0- to 1-hour change and 0- to 2 hour change was 0.931 (95%CI, 0.916-0.944), P < .001. Similar findings were obtained with hs-cTnI (Architect) with correlation coefficients between 0- to 1-hour change and 0- to 2 hour change of 0.969 and hs-cTnI (Centaur) of 0.934 (P < .001 for both). Findings were consistent among type 1 and type 2 AMI and in the subgroup of patients presenting very early after chest pain onset.ConclusionsPatients presenting with early AMI showed a near linear release of hs-cTnT and hs-cTnI. This near linearity provides the pathophysiological basis for rapid diagnostic algorithms using 0- to 1-hour changes as surrogates for 0- to 2 hour or 0- to 3 hour changes.Registered at ClinicalTrials.gov (Identifier: NCT00470587).     

Prognostic value of copeptin in patients with acute myocardial infarction treated with percutaneous coronary intervention: a prospective cohort study

BackgroundIschemic myocardial injury leads to neurohormonal system activation and increased release of copeptin. Although diagnostic value of copeptin has been widely described, data on its prognostic performance in patients with myocardial infarction is inconclusive. The aim of this study was to asses if elevated copeptin concentration provides prognostic information for long-term adverse cardiac events in a cohort of first acute myocardial infarction patients treated with percutaneous coronary intervention.MethodsCopeptin concentration was assessed in a cohort of 100 consecutive patients (39% women; mean age 63±7 years) presenting with first acute myocardial infarction and subjected to percutaneous coronary intervention. Samples were collected at the time of admission and on the 4^th/5^th day of hospitalisation. All patients were followed-up prospectively for 12 months for the occurrence of major adverse cardiovascular events defined as reinfarction, unscheduled coronary revascularisation and all-cause death.ResultsElevated copeptin concentration on the 4^th/5^th day of hospitalisation was identified as a predictor of major adverse cardiovascular events (P=0.0445). The increase between copeptin level on admission and on day 4^th/5^th was associated with the requirement for unscheduled coronary revascularisation in receiver operating characteristics (ROC) analysis (AUC =0.639; 95% CI: 0.504–0.773; P=0.0430). In a multivariate analysis, copeptin concentration on the 4^th/5^th day of hospitalisation and left ventricular ejection fraction assessed by transthoracic echocardiography, were the only predictors for major adverse cardiac events during follow-up (P=0.024 and P=0.001, respectively).ConclusionsCopeptin seems to be a prognostic marker in patients with first myocardial infarction treated with percutaneous coronary intervention.     

TUSARC: Prognostic Value of High-Sensitivity Cardiac Troponin T Assay in Asymptomatic Patients with High Cardiovascular Risk

BackgroundPrognostic value of high-sensitivity cardiac troponin T (hs-cTnT) assays have been assessed in selected populations in different studies and in registries of members of the general population with low cardiovascular risk. The aim of this study was to determine the prognostic value of hs-cTnT in an asymptomatic very-high cardiovascular risk Spanish population.MethodsFrom a previous prospective cohort of the TUSARC (troponina T UltraSensible en pacientes Asintomáticos de alto Riesgo Cardiovascular) registry, follow-up was conducted in 602 patients (93.18%). The association of high hs-cTnT (≥99th percentile value) and incidence of primary event was studied. A primary event was defined as a combined major cardiovascular event (incidence of cardiovascular death, decompensated heart failure, non-fatal cerebrovascular event, non-fatal myocardial infarction, or coronary revascularization). The association between high hs-cTnT and incidence of secondary events was studied as well.ResultsIn patients with high hs-cTnT, the incidence of primary event during follow-up was significantly higher (18.30% vs 3.67% P < .001): heart failure (6.25% vs 0.73% P < .001), cardiovascular death (7.29% vs 0.00% P < .001), and death from any cause (7.81% vs 0.98% P < .001).ConclusionsIn an asymptomatic very-high cardiovascular risk Spanish population, elevated hs-cTnT was significantly associated with incident major cardiovascular combined end point and incidence of heart failure, cardiovascular death, and death from any cause.     

Biomarker assessment for early infarct size estimation in ST-elevation myocardial infarction

BackgroundHigh-sensitivity cardiac troponin T (hs-cTnT) represents the biomarker of choice for infarct size (IS) estimation in patients with acute ST-elevation myocardial infarction (STEMI). However, admission values of hs-cTnT are only weakly associated with IS. The aim of this study was to investigate the incremental value of different biomarkers measured on admission for IS estimation in STEMI patients.MethodsIn this prospective observational study, we included 161 consecutive STEMI patients treated with primary percutaneous coronary intervention (pPCI). The following biomarkers were assessed on admission: hs-cTnT, N-terminal pro-B-type natriuretic peptide (NT-pro-BNP) and neutrophil/lymphocyte ratio (NLR). IS was determined by cardiac magnetic resonance (CMR) imaging 3 (Interquartile range [IQR] 2 to 4) days after the index event.ResultsPatients with large IS (>19% of left ventricular myocardium) showed significantly higher levels of admission hs-cTnT (399.6 vs. 53.4 ng/L, p < .001), NT-pro-BNP (140 vs. 86 ng/L, p = .008) and NLR (6.4 vs. 4.1, p < .001). The combination of hs-cTnT, NT-pro-BNP and NLR on admission resulted in a significantly higher area under the curve (0.78; 95% CI 0.704 to 0.838, (p = .01)) for the prediction of large IS than admission hs-cTnT alone (0.69; 95% CI 0.619 to 0.767).ConclusionsIn STEMI patients undergoing pPCI, a comprehensive biomarker approach on admission including hs-cTnT, NT-pro-BNP and NLR was significantly better for immediate infarct severity estimation as compared to hs-cTnT alone.     

Use of neutrophil count in early diagnosis and risk stratification of AMI

Background

Neutrophils are rapidly released into the circulation upon acute stress such as trauma or acute myocardial infarction (AMI). We hypothesized that neutrophil count might provide incremental value in the early diagnosis and risk stratification of AMI.

Methods

We conducted a prospective observational multicenter study to examine the diagnostic accuracy of the combination of neutrophil count and cardiac troponin T from 1125 consecutive patients who presented to the Emergency Department with symptoms suggestive of acute myocardial infarction. The final diagnosis was adjudicated by 2 independent cardiologists.

Results

Neutrophil count was higher in patients with acute myocardial infarction compared with other diagnoses (median 6.7 vs. 5.0 × 10⁹/L, respectively, P <.001). The accuracy of the neutrophil count for diagnosing acute myocardial infarction, quantified by the area under the receiver operating characteristic curve (AUC) was 0.69, which was significantly lower than that of cardiac troponin T (AUC 0.89, P <.001). The combination of the neutrophil count and cardiac troponin T did not improve the early diagnosis of acute myocardial infarction versus cardiac troponin T alone (P = .79). The prognostic accuracy of neutrophil count for death and AMI was significantly lower than that of cardiac troponin T. However, patients in the highest tertile of neutrophil count had a significantly increased risk of death and AMI at 90 and 360 days compared with patients in the lowest tertile (hazard ratios 2.47 [95% confidence interval, 1.63–3.72] and 2.28 [95% confidence interval, 1.55–3.36], respectively).

Conclusion

The neutrophil count does not improve the early diagnosis of AMI in patients presenting with chest pain but identifies patients at increased risk of death.     

Proceedings of an international symposium forum on platelet transfusion. Evolving Alternative Therapeutic Products 10 April 1997, Edinburgh,Scotland

Abstract

The aim of this study was to determine the associations of the mean platelet volume (MPV) high-sensitivity cardiac troponin T (hs-cTnT) and N-terminal pro-B type natriuretic peptide (NT-proBNP) with the development of adverse outcomes after percutaneous coronary intervention (PCI). MPV hs-cTnT and NT-proBNP were analyzed in 372 patients who underwent PCI. The primary endpoint was cardiac death. The secondary endpoint analyzed was cardiovascular events (CVE): the composite of cardiac death, myocardial infarction (MI), target vessel revascularization (TVR), ischemic stroke and stent thrombosis (ST). The median MPV hs-cTnT and NT-proBNP levels were 8.20 (IQR 7.70–8.70) fL, 0.291 (IQR 0.015–3.785) ng/mL, and 105.25 (IQR 50.84–1128.5) pg/mL, respectively. There were 21 events of cardiac death, 10 MI (including 4 events of ST), 7 ischemic strokes and 29 TVR during a mean of 25.8 months of follow-up. The Kaplan–Meier analysis revealed that the higher MPV group (>8.20?fL, median) had a significantly higher cardiac death rate than the lower MPV group (≤8.20?fL; 9.4% vs. 2.1%, log-rank: p?=?0.0026). When the MPV cut-off level was set to 8.20?fL using the receiver operating characteristic curve, the sensitivity was 81% and the specificity was 53.3% for differentiating between the group with cardiac death and the group without cardiac death. This value was more useful in patients with myocardial injury (hs-cTnT?≥?0.1?ng/mL) or heart failure (NT-proBNP?≥?450?pg/mL). The results of this study show that MPV is a predictive marker for cardiac death after PCI; its predictive power for cardiac death is more useful in patients with myocardial injury or heart failure.     

Biochemical markers in the diagnosis of myocardial infarction

The diagnosis of myocardial necrosis due to acute myocardial infarction (AMI) and other causes has long been based on the plasma levels of cardiac troponins. Other markers of myocardial injury such as myoglobin, heart-type fatty acid binding protein, glycogen phosphorylase isoenzyme BB, or the early and sensitive total stress marker copeptin remain to be just attractive options used primarily to early rule out AMI and in risk stratification. Recent years have seen the introduction of a routine practice of the high-sensitivity cardiac troponin assays capable of detecting diagnostic elevations in plasma troponin levels as early as the first hours of myocardial injury. However, this assay tends to identify very often low plasma troponin levels in primarily noncardiac conditions and also in healthy or apparently healthy individuals. Hence, this novel technology warrants further study.     

New features of troponin testing in different clinical settings

Abstract. Omland T. (Institute of Clinical Medicine, University of Oslo, Oslo and Division of Medicine, Akershus University Hospital, Lørenskog, Norway) New features of troponin testing in different clinical settings (Review). J Intern Med 2010; 268 : 207–217. Cardiac troponin levels are routinely measured for diagnosing acute myocardial infarction. Cardiac troponin measurements also provide information concerning prognosis and the effect of early intervention in patients with acute coronary syndromes. The recent development of highly sensitive cardiac troponin assays permits detection of very low circulating levels. Use of sensitive troponin assays improves overall diagnostic accuracy in patients with suspected acute coronary syndromes, and these assays provide strong prognostic information in stable coronary artery disease and chronic heart failure. However, increased sensitivity comes with a cost of decreased specificity, and serial testing, as well as clinical context and judgment, is likely to become increasingly important in the interpretation of troponin assay results.     

Efficacy and safety of Shexiang Baoxin Pill combined with Western medicine in the treatment of acute myocardial infarction: A single-center,double-blind,randomized controlled trial

Background:The morbidity and mortality of acute myocardial infarction are on the rise, and the efficacy of conventional treatment is limited. Shexiang Baoxin Pill is a kind of proprietary Chinese medicine, which has been widely used in the treatment of acute myocardial infarction in China, and has certain advantages. At present, there is a lack of strict randomized controlled trials to verify the efficacy and safety of Shexiang Baoxin Pill combined with Western medicine in the treatment of acute myocardial infarction. Therefore, the purpose of this randomized controlled trial is to evaluate the clinical efficacy of Shexiang Baoxin Pill combined with Western medicine in the treatment of acute myocardial infarction.Methods:This is a prospective randomized controlled trial to study the efficacy and safety of Shexiang Baoxin Pill combined with Western medicine in the treatment of acute myocardial infarction. It is approved by the Clinical Research Society of our hospital. According to 1:1, the patients will be randomly divided into observation group (Shexiang Baoxin Pill combined with Western medicine group) and control group (routine Western medicine group). The patients in the 2 groups will be treated continuously for 4 weeks and followed up for 3 months. Pay attention to its curative effect index and safety index. The observation indexes included total effective rate of improvement of cardiac function, left ventricular ejection fraction (LVEF), endothelin (ET), nitric oxide (NO) level, interleukin-6 (IL--6), adverse reactions, and so on. We will analyze the structure by SPSS version 19.0.Discussion:This study will evaluate the efficacy and safety of Shexiang Baoxin Pill combined with Western medicine in the treatment of acute myocardial infarction. The results of this experiment will provide clinical basis for Shexiang Baoxin Pill combined with Western medicine in the treatment of acute myocardial infarction.Trial registration:OSF Registration number: DOI 10.17605/OSF.IO/PYJTK.     

Implementation of high sensitivity cardiac troponin T measurement in the emergency department

BackgroundWe examined the diagnostic performance of high sensitivity cardiac troponin T (cTnThs) measurement and its ability to predict risk in unselected patients presenting to the emergency department with acute chest pain.MethodsWe conducted a retrospective analysis of 137 consecutive patients with chest pain (age range, 66 ± 16 years; 64% male). A final diagnosis of acute myocardial infarction was made using the “old” (cTnT fourth-generation assay, ≥0.04 μg/L) or the “new” cutpoint (cTnThs ≥0.014 μg/L).ResultsThe adjudicated final diagnosis of acute myocardial infarction significantly increased from 20 to 35 patients (a 75% increase) and troponin-positive nonvascular cardiac chest pain from 10 to 30 (a 200% increase) using cTnThs. The number of patients with unstable angina or troponin-negative nonvascular cardiac chest pain significantly decreased (P <.05). Diagnostic performance of cTnThs levels at admission was significantly higher compared to cTnT levels (area under the curve [AUC] 0.85 vs AUC 0.70; P <.05). cTnThs levels below the detection limit (<0.003 μg/L) had a negative predictive value of 100% to exclude acute myocardial infarction. The event rate during 6 months of follow-up was low in patients with cTnThs levels <0.014 μg/L, while patients with cTnT levels ≥0.04 μg/L were at increased, and patients with cTnThs ≥0.014 μg/L and cTnT <0.04 μg/L at intermediate risk of death or recurrent myocardial infarction (P = .002). Risk was highest in chest pain patients with dynamic changes of cTnThs levels >30%.ConclusionThe introduction of cTnThs assay displays an excellent diagnostic performance for the workup of patients with chest pain at the time of their initial presentation. Even small increases of cTnThs indicate increased risk for death or myocardial infarction during follow-up.     

One-Hour Rule-out and Rule-in of Acute Myocardial Infarction Using High-Sensitivity Cardiac Troponin T

BACKGROUND High-sensitivity cardiac troponin (hs-cTn) assays seem to improve the early diagnosis of acute myocardial infarction (AMI), but it is unknown how to best use them in clinical practice. Our objective was to develop and validate an algorithm for rapid rule-out and rule-in of AMI. METHODS A prospective multicenter study enrolling 872 unselected patients with acute chest pain presenting to the emergency department. High-sensitivity cardiac troponin T (hs-cTnT) was measured in a blinded fashion at presentation and after 1 hour. The final diagnosis was adjudicated by 2 independent cardiologists. An hs-cTnT algorithm incorporating baseline values as well as absolute changes within the first hour was derived from 436 randomly selected patients and validated in the remaining 436 patients. The primary prognostic end point was death during 30 days of follow-up. RESULTS Acute myocardial infarction was the final diagnosis in 17% of patients. After applying the hs-cTnT algorithm developed in the derivation cohort to the validation cohort, 259 patients (60%) could be classified as "rule-out," 76 patients (17%) as "rule-in," and 101 patients (23%) as in the "observational zone" within 1 hour. Overall, this resulted in a sensitivity and negative predictive value of 100% for rule-out, a specificity and positive predictive value of 97% and 84%, respectively, for rule-in, and a prevalence of AMI of 8% in the observational zone group. Cumulative 30-day survival was 99.8%, 98.6%, and 95.3% (P?<?.001) in patients classified as rule-out, observational zone, and rule-in, respectively. CONCLUSIONS Using a simple algorithm incorporating hs-cTnT baseline values and absolute changes within the first hour allowed a safe rule-out as well as an accurate rule-in of AMI within 1 hour in 77% of unselected patients with acute chest pain. This novel strategy may obviate the need for prolonged monitoring and serial blood sampling in 3 of 4 patients.     

Novel biomarkers in cardiovascular disease: update 2010

The rapid evaluation of patients presenting with symptoms suggestive of an acute coronary syndrome is of great clinical relevance. Biomarkers have become increasingly important in this setting to supplement electrocardiographic findings and patient history because one or both can be misleading. Today, cardiac troponin is still the only marker used routinely in this setting due to its myocardial tissue specificity and sensitivity, as well as its established usefulness for therapeutic decision making. However, even current generation troponin assays have certain limitations such as insufficient sensitivity for diagnosing unstable angina. Novel high-sensitivity assays for cardiac troponin have the potential to overcome these limitations. Further studies are needed to answer some critical questions regarding the best cutoffs for diagnosis and risk assessment and the optimal work-up for rule-out of acute myocardial infarction. Other nonmyocardial tissue-specific markers might help in this setting. Myeloperoxidase, copeptin, and growth differentiation factor 15 reflect different aspects of the development of atherosclerosis or acute ischemia. Each has demonstrated impact in risk stratification of acute coronary syndromes. Limited data also show that copeptin may, when used together with cardiac troponin, improve the sensitivity for diagnosing acute myocardial infarction, and growth differentiation factor 15 may help in selection of patients that benefit from invasive therapy. Further evaluation is needed before these markers can be adopted routinely in clinical practice.     

First Sampled High-Sensitive Cardiac Troponin T is Associated With One-Year Mortality in Sepsis Patients and 30- to 365-Day Mortality in Sepsis Survivors

BackgroundPrevious studies using cardiac troponin levels to investigate the relationship between myocardial injury and mortality in sepsis patients have been conflicting. Our aim was to investigate the relationship between plasma high-sensitive cardiac troponin T (hs-cTnT) level and 30-day and 1-year mortality in sepsis patients and 30- to 365-day mortality in sepsis survivors.MethodsSepsis patients requiring vasopressor support and admitted to our institution between 2012 and 2021 (n = 586) were included in this retrospective cohort study. Elevated hs-cTnT values (≥15 ng/L) were divided into quartiles (Q): Q1 15-35 ng/L; Q2 36-61 ng/L; Q3 62-125 ng/L; Q4 126-8630 ng/L. Stratified Kaplan-Meier curves and multivariable Cox regression were used for survival analyses.ResultsFirst sampled hs-cTnT was elevated in 529 (90%) patients. One-year mortality was 45% (n = 264). Increasing level of hs-cTnT was independently associated with higher adjusted hazard ratios (HR) for 1-year mortality compared with normal levels: Q1 HR 2.9 (95% confidence interval [CI], 1.03-8.1); Q2 HR 3.5 (95% CI, 1.2-9.8); Q3 HR 4.8 (95% CI, 1.7-13.4); Q4 HR 5.7 (95% CI, 2.1-16). In acute phase survivors, first sampled hs-cTnT was an independent predictor of 30- to 365-day mortality (HR 1.3; 95% CI, 1.1-1.6 per log_e hs-cTnT).ConclusionsFirst sampled plasma hs-cTnT in critically ill sepsis patients was independently associated with 30-day and 1-year mortality. Importantly, first sampled hs-cTnT was associated with mortality during the convalescence phase (30- to 365-day) and could be a feasible marker to identify acute phase survivors at high risk of death.