scholarly journals Can the Addition of NT-proBNP and Glucose Measurements Improve the Prognostication of High-Sensitivity Cardiac Troponin Measurements for Patients with Suspected Acute Coronary Syndrome?

2021 ◽  
Vol 8 (9) ◽  
pp. 106
Author(s):  
Peter A. Kavsak ◽  
Shawn E. Mondoux ◽  
Mark K. Hewitt ◽  
Craig Ainsworth ◽  
Stephen Hill ◽  
...  
Keyword(s):  
Acute Coronary Syndrome ◽  
Cardiac Troponin ◽  
Primary Outcome ◽  
Secondary Analysis ◽  
Area Under The Curve ◽  
High Sensitivity ◽  
Ambulatory Setting ◽  
Emergency Setting ◽  
Cardiac Events ◽  
Coronary Syndrome

Guidelines published in 2021 have supported natriuretic peptide (NP) testing for the prognostication in patients with acute coronary syndrome (ACS) and for the diagnosis of chronic and acute heart failure (HF). Our objective was to determine if the addition of N-terminal pro B-type NP (NT-proBNP) and glucose to high-sensitivity cardiac troponin (hs-cTn) could better identify emergency department (ED) patients with potential ACS at low- and high-risk for a serious cardiovascular outcome over the next 72 h. The presentation sample in two different ED cohorts which enrolled patients with symptoms suggestive of ACS within six hours of pain onset (Cohort-1, n = 126 and Cohort-2, n = 143) that had Abbott hs-cTnI, Roche hs-cTnT, NT-proBNP and glucose were evaluated for NT-proBNP alone and combined with hs-cTn and glucose for the primary outcome (composite which included death, myocardial infarction, HF, serious arrhythmia and refractory angina) via receiver-operating characteristic (ROC) curve analyses with area under the curve (AUC) and diagnostic estimates derived. The AUC for NT-proBNP for the primary outcome was 0.68 (95% confidence interval (CI): 0.59–0.76) and 0.75 (95%CI: 0.67–0.82) in Cohort-1 and 2, respectively, with the 125 ng/L cutoff yielding a higher sensitivity (≥75%) as compared to the 300 ng/L cutoff (≥58%). Using the 125 ng/L cutoff for NT-proBNP with the published glucose and hs-cTn cutoffs for risk-stratification produced a new score (GuIDER score for Glucose, Injury and Dysfunction in the Emergency-setting for cardiovascular-Risk) and yielded higher AUCs as compared to NT-proBNP (p < 0.05). GuIDER scores of 0 and 5 using either hs-cTnI/T yielded sensitivity estimates of 100% and specificity estimates > 92% for the primary outcome. A secondary analysis assessing MI alone in the overall population (combined Cohorts 1 and 2) also achieved 100% sensitivity for MI with a GuIDER cutoff ≥ 2, ruling-out 48% (Roche) and 38% (Abbott) of the population at presentation for MI. Additional studies are needed for the GuIDER score in both the acute and ambulatory setting to further refine the utility, however, the preliminary findings reported here may present a pathway forward for inclusion of NP testing for ruling-out serious cardiac events and MI in the emergency setting.

scholarly journals Role of High-sensitivity Cardiac Troponin in Acute Coronary Syndrome

2019 ◽  
Vol 13 (1) ◽  
pp. 5-10 ◽  
Author(s):  
Mahesh Anantha Narayanan ◽  
Santiago Garcia
Keyword(s):  
Acute Coronary Syndrome ◽  
Chest Pain ◽  
Literature Review ◽  
Cardiac Troponin ◽  
High Sensitivity ◽  
Emergency Setting ◽  
Coronary Syndrome ◽  
The Us ◽  
Rule Out

Chest pain is one of the most common reasons for an emergency room (ER) visit in the US, with almost 6 million ER visits annually. High-sensitivity cardiac troponin (hscTn) assays have the ability to rapidly rule in or rule out acute coronary syndrome with improved sensitivity, and they are increasingly being used. Though hscTn assays have been approved for use in European, Australian, and Canadian guidelines since 2010, the FDA only approved their use in 2017. There is no consensus on how to compare the results from various hscTn assays. A literature review was performed to analyze the advantages and limitations of using hscTn as a standard biomarker to evaluate patients with suspected ACS in the emergency setting.

scholarly journals Biomarkers-in-Cardiology 8 RE-VISITED—Consistent Safety of Early Discharge with a Dual Marker Strategy Combining a Normal hs-cTnT with a Normal Copeptin in Low-to-Intermediate Risk Patients with Suspected Acute Coronary Syndrome—A Secondary Analysis of the Randomized Biomarkers-in-Cardiology 8 Trial

Cells ◽  
2022 ◽  
Vol 11 (2) ◽  
pp. 211
Author(s):  
Evangelos Giannitsis ◽  
Tania Garfias-Veitl ◽  
Anna Slagman ◽  
Julia Searle ◽  
Christian Müller ◽  
...  
Keyword(s):  
Acute Coronary Syndrome ◽  
Cardiac Troponin ◽  
Troponin T ◽  
High Sensitivity ◽  
Early Discharge ◽  
Cardiac Troponin T ◽  
Cardiac Events ◽  
Coronary Syndrome ◽  
Adverse Cardiac Events ◽  
Risk Patients

Regarding the management of suspected Non-ST-segment-elevation acute coronary syndrome (ACS), the main Biomarker-in-Cardiology (BIC)-8 randomized controlled trial study had reported non-inferiority for the incidence of major adverse cardiac events at 30 days in the Copeptin group (dual marker strategy of copeptin and hs-cTnT at presentation) compared to the standard process (serial hs-cTnT testing). However, in 349 (38.7%) of the 902 patients, high-sensitivity cardiac troponin was not available for the treating physicians. High sensitivity cardiac troponin T was re-measured from thawed blood samples collected at baseline. This cohort qualified for a re-analysis of the 30-day incidence rate of MACE (death, survived cardiac death, acute myocardial infarction, re-hospitalization for acute coronary syndrome, acute unplanned percutaneous coronary intervention, coronary bypass grafting, or documented life-threatening arrhythmias), or components of the primary endpoint including death or death/MI. After re-measurement of troponin and exclusion of 9 patients with insufficient blood sample volume, 893 patients qualified for re-analysis. A total of 57 cases were detected with high sensitivity cardiac troponin T ≥ 14 ng/L who had been classified as “troponin negative” based on a conventional cardiac troponin T or I < 99th percentile upper limit of normal. Major adverse cardiac events rates after exclusion were non-inferior in the Copeptin group compared to the standard group (4.34% (95% confidence intervals 2.60–6.78%) vs. 4.27% (2.55–6.66%)). Rates were 53% lower in the per-protocol analysis (HR 0.47, 95% CI: 0.18–1.15, p = 0.09). No deaths occurred within 30 days in the discharged low risk patients of the Copeptin group. Copeptin combined with high sensitivity cardiac troponin is useful for risk stratification and allows early discharge of low-to-intermediate risk patients with suspected acute coronary syndrome is as safe as a re-testing strategy at 3 h or later.

scholarly journals Effect of Acute Coronary Syndrome Probability on Diagnostic and Prognostic Performance of High-Sensitivity Cardiac Troponin

2018 ◽  
Vol 64 (3) ◽  
pp. 515-525 ◽  
Author(s):  
Patrick Badertscher ◽  
Jasper Boeddinghaus ◽  
Thomas Nestelberger ◽  
Raphael Twerenbold ◽  
Karin Wildi ◽  
...  
Keyword(s):  
Acute Coronary Syndrome ◽  
Diagnostic Accuracy ◽  
Cardiac Troponin ◽  
Area Under The Curve ◽  
High Sensitivity ◽  
Final Diagnosis ◽  
Chest Discomfort ◽  
Bootstrap Analysis ◽  
St Segment Elevation ◽  
Coronary Syndrome

Abstract BACKGROUND There is concern that high-sensitivity cardiac troponin (hs-cTn) may have low diagnostic accuracy in patients with low acute coronary syndrome (ACS) probability. METHODS We prospectively stratified patients presenting with acute chest discomfort to the emergency department (ED) into 3 groups according to their probability for ACS as assessed by the treating ED physician using a visual analog scale: ≤10%, 11% to 79%, and ≥80%, reviewing all information available at 90 min. hs-cTnT and hs-cTnI concentrations were determined in a blinded fashion. Two independent cardiologists adjudicated the final diagnosis. RESULTS Among 3828 patients eligible for analysis, 1189 patients had low (≤10%) probability for ACS. The incidence of non-ST-segment elevation myocardial infarction (NSTEMI) increased from 1.3% to 12.2% and 54.8% in patients with low, intermediate, and high ACS probability, respectively. The positive predictive value of hs-cTnT and hs-cTnI was low in patients with low ACS probability and increased with the incidence of NSTEMI, whereas the diagnostic accuracy of hs-cTnT and hs-cTnI for NSTEMI as quantified by the area under the curve (AUC) was very high and comparable among all 3 strata, e.g., AUC hs-cTnI, 0.96 (95% CI, 0.94–0.97); 0.87 (95% CI, 0.85–0.89); and 0.89 (95% CI, 0.87–0.92), respectively. Findings were validated using bootstrap analysis as an alternative methodology to define ACS probability. Similarly, higher hs-cTnT/I concentrations independently predicted all-cause mortality within 2 years (e.g., hs-cTnT hazard ratio, 1.39; 95% CI, 1.27–1.52), irrespective of ACS probability. CONCLUSIONS Diagnostic and prognostic accuracy and utility of hs-cTnT and hs-cTnI remain high in patients with acute chest discomfort and low ACS probability. ClinicalTrials.gov Identifier: NCT00470587.

scholarly journals Outcomes of non–acute coronary syndrome patients discharged from the emergency department with troponin positivity

CJEM ◽  
2014 ◽  
Vol 16 (01) ◽  
pp. 41-52 ◽  
Author(s):  
Nathan W. Brunner ◽  
Frank X. Scheuermeyer ◽  
Eric Grafstein ◽  
Krishnan Ramanathan
Keyword(s):  
Acute Coronary Syndrome ◽  
Cardiac Troponin ◽  
Primary Outcome ◽  
Univariate Analysis ◽  
Left Ventricular ◽  
Inpatient Admission ◽  
Do Not Resuscitate ◽  
Troponin Elevation ◽  
Coronary Syndrome ◽  
Significant Difference

ABSTRACT Background: Cardiac troponin elevation portends a worse prognosis in diverse patient populations. The significance of troponin elevation in patients discharged from emergency departments (EDs)without inpatient admission is notwell known. Methods: Patients without a diagnosis of acute coronary syndrome discharged fromtwo EDs between April 1, 2006, and December 31, 2007, with an abnormal cardiac troponin (troponin positive [TP]) were compared to a troponin-negative (TN) cohort matched for age, sex, and primary discharge diagnosis. Outcomes were obtained by linking with a regional ED and a provincial vital statistics database and adjusted for the following: estimated glomerular filtration rate, do-not-resuscitate status, history of coronary artery disease, Canadian Triage and Acuity Scale, and left ventricular hypertrophy on electrocardiography. The primary outcome was a composite of death or admission to hospital within 1 year. Results: Our total cohort (n 5 344) consisted of 172 TP and 172 TN patients. In the univariate analysis, TP patients had a higher rate of the primary outcome (OR 3.2, 95% CI 2.1–5.0, p &lt; 0.001) and both of its components (p &lt; 0.001). After adjusting for covariates, positive troponin remained an independent predictor of the primary outcome (OR 2.1, 95% CI 1.3–3.4, p 5 0.005) and inpatient admission (OR 2.0, 95% CI 1.2–3.4, p 5 0.006). There was no significant difference in death (OR 1.3, 95% CI 0.6–2.9, p 5 0.5) after adjustment. Conclusions: A positive troponin assay during ED stay in discharged patients is an independent marker for risk of subsequent admission. Our findings suggest that the prognostic power of an abnormal troponin extends to patients discharged from the ED.

A comparison of cardiac troponin T delta change methods and the importance of the clinical context in the assessment of acute coronary syndrome

2019 ◽  
Vol 56 (6) ◽  
pp. 701-707
Author(s):  
Paul Simpson ◽  
Rosy Tirimacco ◽  
Penelope Cowley ◽  
May Siew ◽  
Narelle Berry ◽  
...  
Keyword(s):  
Myocardial Infarction ◽  
Acute Myocardial Infarction ◽  
Acute Coronary Syndrome ◽  
Cardiac Troponin ◽  
Troponin T ◽  
High Sensitivity ◽  
Z Score ◽  
Clinical Context ◽  
Coronary Syndrome ◽  
Delta Change

Background The management of patients presenting with symptoms suggestive of acute coronary syndrome is a significant challenge for clinicians. Guidelines for the diagnosis of acute myocardial infarction require a rise and/or fall of cardiac troponin, along with other criteria. Knowing what constitutes a significant delta change from baseline is still unclear and the literature is varied. Methods We compared three methods for determining cardiac troponin delta changes (relative, absolute and z-scores) for detecting acute myocardial infarction in 806 patients presenting to an emergency department with symptoms suggestive of acute coronary syndrome. Blood specimens were collected at admission and 2, 3, 4 and 6 h postadmission and tested on the Roche Elecsys high-sensitivity troponin T assay. Results A positive diagnosis for acute myocardial infarction was found in 39 (4.8%) patients. ROC AUC showed better performance for the absolute and z-score delta change (0.959–0.988 and 0.956–0.988, respectively) compared with relative delta change (0.921–0.960) at all time points in the diagnosis of acute myocardial infarction. Optimal timing for the second sample was at 4–6 h postadmission. Conclusions Although not statistically significant, the results show a trend of absolute and z-score delta change performing better than relative delta change for the diagnosis of acute myocardial infarction. The z-score approach allows for a single cut-off value across multiple high-sensitivity assays which could be useful in the clinical setting. Our study also highlighted the importance of interpreting cardiac troponin changes in the clinical context with a combination of the patient’s clinical history and electrocardiogram.

High-sensitivity cardiac troponin assays and acute coronary syndrome

2019 ◽  
Vol 20 (8) ◽  
pp. 504-509 ◽  
Author(s):  
Erica Rocco ◽  
Giulio La Rosa ◽  
Giovanna Liuzzo ◽  
Luigi M. Biasucci
Keyword(s):  
Acute Coronary Syndrome ◽  
Cardiac Troponin ◽  
High Sensitivity ◽  
Coronary Syndrome
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