Combining high-sensitivity cardiac troponin and B-type natriuretic peptide in the detection of inducible myocardial ischemia
Institution:
1. Cardiovascular Research Institute Basel (CRIB), Department of Cardiology, University Hospital Basel, University Basel, Switzerland;2. Department of Internal Medicine, University Hospital Basel, University Basel, Switzerland;3. Department of General and Interventional Cardiology, University Heart Center Hamburg, Hamburg, Germany;4. Division of Nuclear Medicine, University Hospital Basel, University Basel, Switzerland;1. Interventional Cardiology, Clinica Mediterranea, Naples, Italy;2. Department of Molecular Medicine and Medical Biotechnologies, “Federico II” University of Naples, IEOS, CNR, Naples, Italy;3. CEINGE Biotecnologie Avanzate, Naples, Italy;4. Department of Mental Health and Preventive Medicine, Second University of Naples, Italy;5. University Cardiology Division, “G. d''Annunzio”, Chieti, Italy;1. Department of Cardiology, Bern University Hospital, Bern, Switzerland;2. Department of Advanced Biomedical Sciences, University Federico II of Naples, Italy;3. Cardiology Department, Crete Naval Hospital, Crete, Greece;4. Department of Cardiology, University of Szeged, Hungary;5. Interventional cardiology, San Giovanni Bosco Hospital, Torino, Italy;6. Cardiology Unit, Azienda Ospedaliera Universitaria di Ferrara, Ferrara, Italy;7. Maria Cecilia Hospital, GVM Care and Research, Cotignola, RA, Italy;8. Azienda Ospedaliero-Universitaria di Modena, Ospedale Civile di Baggiovara, Italy;9. Division of Cardiology, University Hospital, Geneva, Switzerland;10. Interventional Cardiology Unit, Azienda Ospedaliero-Universitaria di Parma, Italy;11. Policlinico S. Marco, IOB, Zingonia-Osio Sotto (BG), Italy;12. Azienda Ospedaliera Ordine Mauriziano Torino, Italy;13. Department of Cardiology, IRCCS Policlinico San Donato, San Donato Milanese, Milan, Italy;14. Hospital de Santa Cruz, Carnaxide, Lisbon, Portugal;15. Fondazione IRCCS Policlinico San Matteo, Pavia, Italy;p. Cardiovascular Departments of San Donato Hospital, Arezzo, Italy;q. Ospedale SS. Annunziata – Savigliano, Italy;r. Department of Cardiology and Critical Care Medicine, Hartcentrum Hasselt, Jessa Ziekenhuis, Faculty of Medicine and Life Sciences University of Hasselt, Hasselt, Belgium;s. Clinica Mediterranea, Napoli, Italy
Abstract:
BackgroundSingle biomarker approaches provide only moderate accuracy in the non-invasive detection of exercise-induced myocardial ischemia. We therefore assessed the combination of the two most promising single biomarkers: high-sensitivity cardiac troponin I (hs-cTnI) and B-type natriuretic peptide (BNP).MethodsConsecutive patients with suspected myocardial ischemia referred to stress myocardial perfusion single-photon emission tomography imaging (MPI) were enrolled. Clinical judgment (CJ) of the treating cardiologist regarding myocardial ischemia, quantified using a visual analogue scale, and blood concentrations of hs-cTnI and BNP were determined before and after stress. The presence of myocardial ischemia was adjudicated by independent cardiologists using MPI, blinded to biomarker measurements. Death and acute myocardial infarction (AMI) during follow-up were the prognostic endpoints.ResultsAmong 1142 consecutive patients inducible myocardial ischemia was found in 456 (40%) of all patients. For the detection of inducible myocardial ischemia, CJ before exercise stress testing (CJb) showed an area under the receiver-operating-characteristics curve (AUC) of 0.66 (95%CI 0.63–0.69), hs-cTnI 0.70 (95%CI 0.67–0.73, p = 0.07 vs CJb), and BNP 0.66 (95%CI 0.62–0.69, p = 0.98). The use of a dual-biomarker strategy combining hs-cTnI and BNP with CJb did not provide a significant advantage over the combination of hs-cTnI alone and CJb (AUC 0.74, 95%CI 0.72–0.77 vs AUC 0.74, 95%CI 0.71–0.77, p = 0.16). Hs-cTnI showed good prognostic value for AMI (HR 1.6, 95%CI 1.3–1.9), and BNP for death (HR 1.6, 95%CI 1.3–2.1).ConclusionA dual-biomarker strategy combing BNP and hs-cTnI does not further increase diagnostic accuracy on top of clinical judgment and hs-cTnI alone.Summary and highlightsWe included 1142 consecutive patients with suspected inducible ischemia, and evaluated the added value of the biomarkers high-sensitivity cardiac troponin (hs-cTn) and B-type natriuretic peptide (BNP), alone and in combination, on top of clinical judgment.Clinical trial registrationBiochemical and Electrocardiographic Signatures in the Detection of Exercise-induced Myocardial Ischemia (BASEL VIII), NCT01838148, https://clinicaltrials.gov/ct2/show/NCT01838148
