Absence Of Acute Myocardial Infarction Research Articles

Kidney function-specific cut-off values of high-sensitivity cardiac troponin T for the diagnosis of acute myocardial infarction.

The diagnosis of acute myocardial infarction (AMI) using high-sensitivity cardiac troponin T (hs-cTnT) remains challenging in patients with kidney dysfunction. In this large, multicenter cohort study, a total of 20912 adults who underwent coronary angiography were included. Kidney function-specific cut-off values of hs-cTnT were determined to improve the specificity without sacrificing sensitivity, as compared with that using traditional cut-off value (14ng/L) in the normal kidney function group. The diagnostic accuracy of the novel cut-off values was validated in an independent validation cohort. In the derivation cohort (n=12900), 3247 patients had an estimated glomerular filtration rate (eGFR) <60mL/min/1.73 m2. Even in the absence of AMI, 50.2% of participants with eGFR <60mL/min/1.73 m2 had a hs-cTnT concentration ≥14ng/L. Using 14ng/L as the threshold of hs-cTnT for diagnosing AMI led to a significantly reduced specificity and positive predictive value in patients with kidney dysfunction, as compared with that in patients with normal kidney function. The kidney function-specific cut-off values were determined as 14, 18 and 48ng/L for patients with eGFR >60, 60-30 and <30mL/min/1.73 m2, respectively. Using the novel cut-off values, the specificities for diagnosing AMI in participants with different levels of kidney dysfunction were remarkably improved (from 9.1%-52.7% to 52.8-63.0%), without compromising sensitivity (96.6%-97.9%). Similar improvement of diagnostic accuracy was observed in the validation cohort (n=8012). The kidney function-specific cut-off values of hs-cTnT may help clinicians to accurately diagnose AMI in patients with kidney dysfunction and avoid the potential overtreatment in practice.

Limited Contribution of Creatine Kinase-Myocardial Band Alongside High-Sensitivity Cardiac Troponin in Diagnosing Acute Myocardial Infarction in an Emergency Department.

Cardiac biomarkers, especially high-sensitivity cardiac troponin C or I (hs-cTnC or hs-cTnI, respectively), are vital for diagnosing acute myocardial infarction (AMI). Despite the specificity of hs-cTn as a biomarker, the creatine kinase-myocardial band (CK-MB) is commonly used alongside hs-cTn in emergency departments (EDs). We analyzed 23,771 simultaneous hs-cTn (hs-cTnT or hs-cTnI) and CK-MB requests for 17,185 patients in tertiary hospital ED in 2022. The objective of this study was to assess their practical value in diagnosing AMI in real-world settings. Among all 17,185 patients tested, 98.0% underwent hs-cTnT and CK-MB tests, and substantially fewer underwent hs-cTnI testing. We observed concordance between the initial hs-cTn and CK-MB results in 71.3% of patients. Of 131 AMI cases, 57 were positive for both biomarkers, 63 for hs-cTn only, and none for CK-MB alone. CK-MB positivity was often found in the absence of AMI. Discrepancies between the hs-cTnT and hs-cTnI results occurred in 30.0% of patients. Indiscriminate CK-MB testing for diagnosing AMI in EDs should be reconsidered. Efficient use of CK-MB is important for reducing costs and ensuring optimal patient care.

High sensitivity cardiac troponin I in response to handgrip in women with signs and symptoms of ischemia with no obstructive coronary arteries

Abstract Background Women with signs and symptoms of ischemia and no obstructive coronary arteries (INOCA) are suspected to have myocardial ischemia, ∼10% have prior myocardial scar often in the absence of acute myocardial infarction (AMI) diagnosis and the development of heart failure with preserved ejection fraction (HFpEF) is relatively frequent. The mechanisms contributing to AMI and HFpEF progression are poorly understood in INOCA. Purpose To compare clinical, invasive, and high sensitivity cardiac troponin I (hsTnI) parameters in women with INOCA at rest and in response to isometric handgrip exercise. Methods Women with suspected INOCA underwent cannulation of the coronary sinus (CS), handgrip exercise testing and serial CS plasma sampling before, after 3 minutes of isometric handgrip stress at 30% of maximal voluntary contraction, and after 5 minutes of recovery. hsTnI was measured using a commercial immunoassay (R-PLEX, Meso Scale Discovery, Rockville, MD) and compared using t-tests. Results A total of 54 women with complete invasive data were included with a mean age of 53 ± 10 years, mean body mass index 28 ± 7 kg/m2. 20 women (37% of the cohort) had detectable CS hsTnI from baseline. Among these women, median values were elevated in response to handgrip (Figure) (baseline median 33.75 (IQR 18.12-67.75) pg/mL vs peak handgrip median 56.23 (IQR 32.84-97.83) pg/mL, signed rank p=0.0007, baseline vs recovery median 52.35 (IQR 32.59-106.27) pg/mL, signed rank p=0.0002). Conclusion Among women with INOCA, handgrip stress leads to an increase in hsTnI in more than a third, demonstrating objective evidence of myocardial injury. More work is needed to better understand contribution of coronary microvascular dysfunction to HFpEF progression.

First randomised controlled trial comparing the sirolimus-eluting bioadaptor with the zotarolimus-eluting drug-eluting stent in patients with de novo coronary artery lesions: 12-month clinical and imaging data from the multi-centre, international, BIODAPTOR-RCT

The DynamX™ bioadaptor is the first coronary implant technology with a unique mechanism of unlocking the bioadaptor frame after polymer resorption over 6 months, uncaging the vessel while maintaining a dynamic support to the vessel. It aims to achieve the acute performance of drug-eluting stents (DES) with the advantages of restoration of vessel function. This international, single blinded, randomised controlled (1:1) trial compared a sirolimus-eluting bioadaptor with a contemporary zotarolimus-eluting stent (DES) in 34 hospitals in Europe, Japan and New Zealand. Patients with de novo coronary lesions and absence of acute myocardial infarction were enrolled from January 2021 to Feburary 2022. The implantation of the bioadaptor followed the standards of DES. An imaging subset of 100 patients had angiographic and intravascular ultrasound assessments, and 20 patients additionally optical coherence tomography. Data collection will continue through 5 years, we herein report 12-month data based on an intention-to-treat population. This trial is registered at ClinicalTrials.gov (NCT04192747). 445 patients were randomised between January 2021 and February 2022. Device, lesion and procedural success rates, and acute gain were similar amongst the groups. The primary endpoint, 12-month target lesion failure, was 1.8% [95% CI: 0.5; 4.6] (n=4) versus 2.8% [95% CI: 1.0; 6.0] (n=6), pnon-inferiority < 0.001 for the bioadaptor and the DES, respectively (Δ-1.0% [95% CI:-3.3; 1.4]). One definite or probable device thrombosis occurred in each group. The 12-month imaging endpoints showed superior effectiveness of the bioadaptor such as in-device late lumen loss (0.09mm [SD 0.34] versus 0.25mm [SD 0.39], p=0.04), and restored compliance and cyclic pulsatility (%mid in-device lumen area change of 7.5% versus 2.7%, p<0.001). This is the first randomised controlled trial comparing the novel bioadaptor technology against a contemporary DES. The bioadaptor demonstrated similar acute performance and 12-month clinical outcomes, and superior imaging endpoints including restoration of vessel function. The study was funded by Elixir Medical.

D-Dimer Levels and the Risk of 30-Day All-Cause Mortality in Cardiogenic Shock Stratified by Etiology.

The study investigates the prognostic impact of D-dimer levels in patients with cardiogenic shock (CS). Although D-dimer levels were found to be associated with prognosis in various clinical settings such as heart failure or acute myocardial infarction (AMI), the prognostic role of D-dimer levels in CS patients has not yet been clarified. Consecutive CS patients with and without concomitant AMI were prospectively included from 2019 to 2021. The prognostic impact of D-dimer levels was tested for 30-day all-cause mortality within the entire study cohort and stratified by the presence or absence of AMI. Statistical analyses included C-statistics, Kaplan-Meier, and multivariate Cox regression analyses. One hundred and twenty-three consecutive CS patients were included with an overall all-cause mortality at 30 days of 55%. The median D-dimer level on admission was 8.44 mg/L, whereas D-dimer levels were higher in 30-day non-survivors compared to survivors (median 13.0 vs. 5.2 mg/L; p = 0.011). D-dimer levels above the median were associated with an increased risk of 30-day all-cause mortality compared to patients with lower D-dimer levels (66% vs. 54%, log rank p = 0.050; HR = 1.594; 95% CI 0.979 - 2.594; p = 0.061), especially in patients with non-AMI-related CS (65% vs. 30%, log rank p = 0.010). The prognostic value of D-dimer levels was still demonstrated after multivariate adjustment (HR = 1.024; 95% CI 1.004 - 1.045; p = 0.020). D-dimer measurement may be a reliable biomarker to predict the risk of 30-day mortality in CS patients, especially in patients with non-AMI related CS.

Effect of Admission and Onset Time on the Prognosis of Patients With Cardiogenic Shock

The spectrum of patients with cardiogenic shock (CS) has changed significantly over time. CS has become especially more common in the absence of acute myocardial infarction (AMI), while this subset of patients was typically excluded from recent studies. Furthermore the prognostic impact of onset time and onset place due to CS has rarely been investigated. Do the place of CS onset (out-of-hospital, ie, primary CS vs in-hospital, ie, secondary CS) and the onset time of out-of-hospital CS (ie, on-hours vs off-hours admission) affect the risk of all-cause mortality at 30 days? This prospective monocentric registry included consecutive patients with CS of any cause from 2019 until 2021. First, the prognostic impact of the place of CS onset (out-of-hospital, ie, primary CS vs during hospitalization, ie, secondary CS) was investigated. Thereafter, the prognostic impact of the onset time of out-of-hospital CS was investigated. Furthermore, the prognostic impact of causative AMI vs non-AMI was investigated. Statistical analyses included Kaplan-Meier analyses, and univariable and multivariable Cox regression analyses. Two hundred seventy-three patients with CS were included prospectively (64% with primary out-of-hospital CS). The place of CS onset was not associated with increased risk of all-cause mortality within the entire study cohort (secondary in-hospital CS: hazard ratio [HR], 1.532; 95% CI, 0.990-2.371; P = .06). However, increased risk of 30-day all-cause mortality was seen in patients with AMI related secondary in-hospital CS (HR, 2.087; 95% CI, 1.126-3.868; P = .02). Furthermore, primary out-of-hospital CS admitted during off-hours was associated with lower risk of all-cause mortality compared to primary CS admitted during on-hours (HR, 0.497; 95% CI, 0.302-0.817; P = .01), irrespective of the presence or absence of AMI. Primary and secondary CS were associated with comparable, whereas primary out-of-hospital CS admitted during off-hours was associated with lower risk of all-cause mortality at 30 days. ClinicalTrials.gov; No.: NCT05575856; URL: www. gov.

Prognosis of cardiogenic shock with and without acute myocardial infarction: results from a prospective, monocentric registry.

The study investigates the prognostic impact of cardiogenic shock (CS) stratified by the presence or absence of acute myocardial infarction (AMI). Intensive care unit (ICU) related mortality in CS patients remains unacceptably high despite improvement concerning the treatment of CS patients. Consecutive patients with CS from 2019 to 2021 were included monocentrically. The prognostic impact of CS related to AMI was compared to patients without AMI-related CS. The primary endpoint was 30-day all-cause mortality. Statistical analyses included Kaplan-Meier analyses, multivariable Cox proportional regression analyses and propensity score matching. 273 CS patients were included (AMI-related CS: 49%; non-AMI-related CS: 51%). The risk of 30-day all-cause mortality was increased in patients with AMI-related CS (64% vs. 47%; HR = 1.653; 95% CI 1.199-2.281; p = 0.002), which was still observed after multivariable adjustment (HR = 1.696; 95% CI 1.153-2.494; p = 0.007). Even after propensity score matching (i.e., 87 matched pairs), AMI was still an independent predictor of 30-day mortality (HR = 1.524; 95% CI 1.020-2.276; p = 0.040). In contrast, non-ST-segment AMI (NSTEMI) and STEMI were associated with comparable prognosis (log-rank p = 0.528). AMI-related CS was associated with increased 30-day all-cause mortality compared to patients with CS not related to AMI. In contrast, the prognosis of STEMI- and NSTEMI-CS patients was comparable.

Acetylsalicylic acid use is associated with reduced risk of out-of-hospital cardiac arrest in the general population: Real-world data from a population-based study.

AimActivated blood platelet products facilitate myocardial intracellular Ca2+ overload, thereby provoking afterdepolarizations and increasing susceptibility of ischemic myocardium to ventricular fibrillation (VF). These effects are counteracted in vitro by acetylsalicylic acid (ASA), but no prior study investigated whether ASA is associated with decreased out-of-hospital cardiac arrest (OHCA) risk on a population level. Therefore, we studied whether ASA and other antiplatelet drugs (carbasalate calcium, clopidogrel) are associated with decreased risk of OHCA.MethodsWe conducted a population-based case-control study among individuals (772 OHCA-cases with documented VT/VF, 2444 non-OHCA-controls) who had used antiplatelet drugs in the year before index-date (OHCA-date), and studied the association between current antiplatelet drug use and OHCA-risk with multivariable logistic regression analysis.ResultsASA use was associated with reduced OHCA-risk (adjusted odds ratio (ORadj) 0.6 [0.5–0.8]), and more so in women (ORadj 0.3 [0.2–0.6]) than in men (ORadj 0.7 [0.5–0.95], Pinteraction 0.021). Carbasalate calcium was associated with decreased OHCA-risk in women (ORadj 0.5 [0.3–0.9]), but not in men (ORadj 1.3 [0.96–1.7], Pinteraction 0.005). Clopidogrel was not associated with reduction in OHCA-risk. Risk reduction associated with ASA in patients with OHCA was similar in the presence of acute myocardial infarction (AMI) (ORadj 0.6 [0.4–0.9]) and in the absence of AMI (ORadj 0.7 [0.4–1.2]).ConclusionASA use was associated with reduced OHCA-risk in both sexes, and more so in women, while carbasalate calcium only protected women. Clopidogrel was not associated with reduced OHCA-risk.

Cardiogenic Shock Among Patients with and without Acute Myocardial Infarction in a Latin American Country: A Single-Institution Study.

Background:Latin America has limited information about the full spectrum cardiogenic shock (CS) and its hospital outcome. This study sought to examine the temporal trends, clinical features and outcomes of patients with CS in a coronary care unit of single Mexican institution.Methods:This was a retrospective study of consecutive patients hospitalized with CS in a Mexican teaching hospital between 2006–2019. Patients were classified according to the presence or absence of acute myocardial infarction (AMI).Results:Of 22,747 admissions, 833 (3.7%) exhibited CS. Among patients with AMI (n = 12,438), 5% had AMI–CS, and in patients without AMI (n = 10,309), 2.3% developed CS (non-AMI–CS). Their median age was 63 years and 70.5% were men. Cardiovascular risk factors were more frequent among the AMI–CS group, whereas a history of heart failure was greater in non-AMI–CS patients (70.1%). In AMI-CS patients, the median delay time was 17.2 hours from the onset of AMI symptoms to hospital admission. Overall, the median left ventricular ejection fraction (LVEF) was 30%. Patients with CS at admission showed end-organ dysfunction, evidenced by lactic acidosis, renal impairment, and elevated liver transaminases. Of the 620 AMI–CS patients, the main cause was left ventricular dysfunction in 71.3%, mechanical complications in 15.2% and right ventricular infarction in 13.5%. Among the 213 non-AMI–CS patients, valvular heart disease (49.3%) and cardiomyopathies (42.3%) were the most frequent etiologies. In-hospital all-cause mortality rates were 69.7% and 72.3% in the AMI–CS and non-AMI–CS groups, respectively. Among AMI–CS patients, renal dysfunction, diabetes, older age, depressed LVEF, absence of revascularization and the use of mechanical ventilation were independent predictors of in-hospital mortality. However, in the non-AMI–CS group, only low LVEF and high lactate levels proved significant.Conclusions:This study demonstrates differences in the epidemiology of CS compared to high-income countries; the high mortality reflects critically ill patients and the lack of contemporary effective therapies in the population studied.

Abstract 11566: Use of Temporary Mechanical Circulatory Support Devices in Heart Failure Patients with Cardiogenic Shock

Objective: Contemporary use of temporary mechanical circulatory support devices (tMCS) for heart failure (HF) without acute myocardial infarction (AMI) is not well described. Accordingly, we evaluated use patterns for tMCS in HF patients. Methods: This was a retrospective study of a large administrative claims dataset between 01/01/06 and 12/31/19. We included patients with HF or cardiogenic shock who received tMCS i.e. Impella, intra-aortic balloon pump (IABP) or extra-corporeal membrane oxygenator (ECMO) in the absence of AMI or coronary revascularization. Multinomial logistic regression model was used to identify predictors for type of tMCS device. Temporal trends in use of tMCS was also evaluated. Results: We included 2722 HF patients receiving tMCS: 1836 (68%) with ischemic cardiomyopathy (ICM) and 886 (32%) with non-ischemic cardiomyopathy (NICM). There were no gender or racial differences in device use. Table shows adjusted odds ratio for predictors associated with receipt of ECMO or Impella compared to IABP. After multivariable adjustment, patients with ICM or NICM placed on ECMO compared to IABP, had a higher comorbidity burden. For both groups, patients with valvular disease were more likely to receive IABP and patients with peripheral vascular disease an Impella. Over time, there was an increase in Impella and ECMO use with a decrease in IABP use (p &lt;0.05; Figure). Conclusions: In a real world cohort of HF patients with cardiogenic shock without AMI, use of Impella and ECMO has increased over the last decade and IABP has decreased. Patients receiving ECMO have a higher co-morbidity burden, whereas patients receiving IABP are more likely to have valvular heart disease.

The role of cardiac magnetic resonance in MINOCA diagnosis

Abstract Introduction Absence of obstructive coronary disease does not imply absence of acute myocardial infarction (AMI). Hence, it can be designated as Myocardial Infarction with Non-obstructive Coronary Arteries (MINOCA). Performing Cardiac Magnetic Resonance (CMR) can be essential for establishing a final diagnosis, according to the presence and pattern of late gadolinium enhancement (LGE). Purpose The aim of this study is to evaluate the diagnostic and prognostic impact of CMR in patients with a possible diagnosis of MINOCA. Methods A 7-year prospective study, which included all patients proposed to CMR with a presumptive diagnosis of MINOCA due to acute chest pain, troponin raise and absence of angiographically significant coronary disease (luminal stenosis of &amp;lt;50%). All patients performed functional, anatomical evaluation and LGE assessment. We analysed clinical characteristics, electrocardiographic presentation, echocardiographic and invasive coronary angiography results. A presumptive diagnosis was elaborated after invasive coronary angiography and comparison was made with the definitive one after CMR. Results A total of 96 patients were included, 50% were male, with a mean age of 48±20 years old. Clinical history of hypertension was observed in 51.0% patients, 35.4% had dyslipidaemia, 7.3% with diabetes, obesity was present in 22.9% of patients and smoking habits in 30.2%. At admission, 44.8% had ST segment elevation, so emergent invasive coronary angiography was performed. The mean highest troponin I was 7.34±9.18 ng/mL. Late gadolinium enhancement was observed in 53 (55.2%) of patients. After CMR realization a final diagnosis of MINOCA was made in only 8 patients (8.4%) and in 51 patients (53.1%) CMR evaluation allowed a diagnosis modification, with impact on patients' management and prognosis. A definitive diagnosis of myocarditis was seen in 46.9% (n=45) of cases, of Takotsubo's myocardiopathy in 13.5% (n=13), and hypertrophic cardiomyopathy in 3.1% (n=3). In 27 (28.1%) of patients, late gadolinium enhancement was not found. This diagnosis adjustment had an impact on treatment in 34.4% (n=33). Conclusion CMR is a pivotal technique on MINOCA patients' management. Our study portrayed the importance of performing CMR, allowing initial diagnosis modification in half of the cases, with important therapeutic in one third of patients and prognostic implications, related to diagnosis and target treatment adverse effects. Funding Acknowledgement Type of funding sources: None.

De Novo vs Acute-on-Chronic Presentations of Heart Failure-Related Cardiogenic Shock: Insights from the Critical Care Cardiology Trials Network Registry

Heart failure-related cardiogenic shock (HF-CS) accounts for an increasing proportion of cases of CS in contemporary cardiac intensive care units. Whether the chronicity of HF identifies distinct clinical profiles of HF-CS is unknown. We evaluated admissions to cardiac intensive care units for HF-CS in 28 centers using data from the Critical Care Cardiology Trials Network registry (2017-2020). HF-CS was defined as CS due to ventricular failure in the absence of acute myocardial infarction and was classified as de novo vs acute-on-chronic based on the absence or presence of a prior diagnosis of HF, respectively. Clinical features, resource use, and outcomes were compared among groups. Of 1405 admissions with HF-CS, 370 had de novo HF-CS (26.3%), and 1035 had acute-on-chronic HF-CS (73.7%). Patients with de novo HF-CS had a lower prevalence of hypertension, diabetes, coronary artery disease, atrial fibrillation, and chronic kidney disease (all P < 0.01). Median Sequential Organ Failure Assessment (SOFA) scores were higher in those with de novo HF-CS (8; 25th-75th: 5-11) vs acute-on-chronic HF-CS (6; 25th-75th: 4-9, P < 0.01), as was the proportion of Society of Cardiovascular Angiography and Intervention (SCAI) shock stage E (46.1% vs 26.1%, P < 0.01). After adjustment for clinical covariates and preceding cardiac arrest, the risk of in-hospital mortality was higher in patients with de novo HF-CS than in those with acute-on-chronic HF-CS (adjusted hazard ratio 1.36, 95% confidence interval 1.05-1.75, P = 0.02). Despite having fewer comorbidities, patients with de novo HF-CS had more severe shock presentations and worse in-hospital outcomes. Whether HF disease chronicity is associated with time-dependent compensatory adaptations, unique pathobiological features and responses to treatment in patients presenting with HF-CS warrants further investigation.

Informative significance of serum cytokines and their importance for development of metabolic syndrome with arterial hypertension in elderly persons

Metabolic syndrome (MS) is among the main public health challenges worldwide, leading to significant labor losses, increased costs for treatment and rehabilitation of the patients. The aim of the present study was to identify the informative serum interleukins, by determining the odds ratio in elderly patients with MS and hypertension. The main group of 86 patients with MS and arterial hypertension (AH) aged 60-75 years was examined under clinical conditions. The inclusion criteria were as follows: age of 60-75 years, presence of MS, primary hypertension (grade II-III), absence of acute myocardial infarction, malignant neoplasms, disorders of cerebral circulation, kidney failure over last 6 months. Diagnostics of MS and hypertension was carried out in accordance with Expert Guidelines from the Russian Research Society of Cardiology on the MS Diagnosis and Treatment. Our first study of a large range of serum interleukins in elderly patients with MS and hypertension allowed us to reveal the inversely directed changes in pro- and anti-inflammatory cytokine contents. Combined AH/MS in elderly persons is accomplished by sufficient increase of the most proinflammatory cytokines, and vice versa, by significant decrease in anti-inflammatory cytokines in blood serum. This finding clearly points to importance of immunological regulatory systems for initiation of AH with MS at older age. Pro- and anti-inflammatory serum interleukins are actively involved into the AH/MS development in elderly accompanied by their pronounced imbalance. The mentioned immune reactions could underlie the MS/AH condition. High risk of this disorder is connected with changed production of proinflammatory cytokines (IL-8, IL-1β), like as anti-inflammatory serum interleukins (IL-4, IL-10), with predominance of the former. The above interleukins should be considered dominant diagnostic markers of AH/MS in elderly persons. Measurement of serum interleukins and discriminant-based approach allows highly reliable differentiation of elderly patients with AH/MS from similar individuals without this disorder.

Diagnoses and mortality in a population without acute myocardial infarction, but with elevated highsensitive troponin I – a retrospective register-based single center study

Aim: To explore, which differential diagnoses to consider in individuals with elevated troponins without acute myocardial infarction (AMI), and the mortality for those individuals. Methods: Retrospective, register-based study on a representative sample of the Danish population with the following inclusion criteria: High-sensitive troponin I (hs-TnI) ≥25 ng/L, age ≥18 years, and exclusion of AMI. Results: 3067 individuals without AMI but increased hs-TnI were included. Most frequent discharge diagnoses: Pneumonia (12.8%), Aortic valve disorder (11.3%), Medical observation (10.9%) and Heart failure (8.9%). The 30-days and one-year mortality was 15.8% and 32.0%, respectively. Conclusions: A selected number of alternative diagnoses must be considered in individuals with increased hs-TnI. Due to high mortality it is crucial to carefully evaluate these individuals despite the absence of AMI.

Value of troponin T in assessment of the cardiopulmonary relationships in the patients with underlying chronic obstructive pulmonary disease hospitalized with acute coronary syndrome

The analysis of troponin T (TnT) blood levels in the patients with acute coronary syndrome (ACS) and the underlying chronic obstructive pulmonary disease (COPD) is relevant to assessment of the cardiovascular prognosis and the risk of respiratory complications. The aim of the study was to investigate TnT levels in the patients hospitalized with ACS and underlying COPD in order to analyze the cardiopulmonary relationships. Methods. 52 patients (29 men and 23 women) were divided into 2 groups depending on outcomes of ACS: the 1st group - 30 patients (57.7%) with acute myocardial infarction (AMI); the 2nd group - 22 patients (42.3%) without AMI. The acute exacerbation of COPD (AECOPD) was found in 33 patients (63.5%) upon admission to the hospital, and 19 patients (36.5%) did not have AECOPD. All patients underwent spirometry, the assessment of symptoms severity by COPD Assessment Test (CAT test) and the analyses for the level of TnT and oxygen saturation. Results. AECOPD was found upon admission in the 1st group more often than in the 2nd group: 76.7% vs 45.5% (p = 0.022). The patients with AECOPD had significantly higher levels of TnT than patients without AECOPD in both groups: 0.78 ± 0.17 and 0.59 ± 0.14 ng/mL respectively (p = 0.014) in the 1st group vs 0.19 ± 0.08 and 0.11 ± 0.04 ng/mL respectively (p = 0.002) in the 2nd group. In the 2nd group, 8 patients (80.0%) with AECOPD and 4 patients (33.3%) without AECOPD had levels of TnT in the range of «a myocardial necrosis» (p = 0.029) in the absence of AMI. The inverse correlation between levels of TnT and forced expiratory volume in 1 second (FEV1) was also found (R = 0.376; p = 0.009). Conclusion. Thus, the significantly increased levels of TnT in patients with ACS are associated with AECOPD upon admission, development of AMI and deterioration of the indexes of spirometry. It was shown that blood levels of TnT were significantly higher in the patients with AECOPD than in the patients with stable COPD in absence of AMI.

Evaluation of the effect of older age on the diagnostic specificity of high-sensitivity troponin I and high-sensitivity troponin T in patients with suspected acute myocardial infarction

Abstract Background Cardiac troponins have become the gold standard for appropriate and rapid diagnosis of an acute myocardial infarction (AMI). However, elevated cardiac troponins levels can be observed in the absence of AMI in elderly patients and therefore a loss of specificity is seen in the diagnosis of AMI in elderly patients. Purpose This study aims to define old age in suspected AMI and to evaluate the effect of older age on the diagnostic specificity of a high sensitivity troponin I (hs-cTnI) and high sensitivity troponin T (hs-cTnT) assay in elderly women and men. Methods This study used data from patients with suspected AMI who were enrolled between 08–2011 and 10–2016 to a multicentre biomarker registry and an University Hospital and with available hs-cTnI and hs-cTnT upon admission (n=564 patients). First, we investigated the effect of age on the specificity of both hs-cTnI and hs-cTnT to detect AMI continuously. We then classified over seventy-year-olds as elderly (n=281; 49,8%) and compared the specificity of hs-cTnI and hs-cTnT between elderly and younger patients. Results In the group of older patients, 62.6% (n=176) were diagnosed with AMI compared with 50.9% (n=144) in younger age patients (p&amp;lt;0.01). Elderly patients had higher median levels of hs-cTnI and hs-cTnT than younger patients: 45.4 ng/L vs. 13.1 ng/L hs-cTnI (p&amp;lt;0.001) and 36.8 ng/L vs. 12.8 ng/L hs-cTnT (p&amp;lt;0.001) irrespective of the final diagnosis. Figure1 shows a shift in diagnostic specificity for the whole troponin concentration range in elderly patients compared to younger patients starting at the age of 60 years with clear impact in patients older than 70 years used as threshold for old age in further analyses. Applying the 99th percentile cut-off led to a specificity of 93.5% (95% CI: 88.1–97.0%) in younger patients vs. 88.6% (95% CI: 80.9–94.0%) in elderly patients for hs-cTnI and of 91.4% (95% CI: 85.4–95.5%) vs. 65.7% (95% CI: 55.8–74.7%) for hs-cTnT. To achieve the same specificity in elderly patients as in younger patients, optimized rule-in cut-offs were calculated with 2.6-fold of the 99th percentile for hs-cTnI (68.9 ng/L) and 3.1-fold of the 99th percentile for hs-TnT (43.9 ng/L). Conclusions The specificity of both, hs-cTnI and hs-cTnT is significantly reduced in elderly patients due to higher hs-cTnT and hs-cTnI levels in elderly patients at admission irrespective of the final diagnosis. A relevant loss in diagnostic specificity is observed at 70 years of age starting already at 60 years. Use of assay-specific adjusted cut-offs for hs-cTnI and hs-cTnT for elderly patients regains diagnostic specificity that leads to a more accurate decision-making concerning “rule-in” for older patients with suspected AMI. Funding Acknowledgement Type of funding source: None

387 Dispositions for Patients Ruled Out for Acute Myocardial Infarction Using a 1-Hour High Sensitivity Troponin I Algorithm: Home or Hospital?

The multicenter High Sensitivity Cardiac Troponin I (hs-cTnI) in the United States (HIGH-US) study has reported a baseline/1-hour emergency department (ED) hs-cTnI algorithm with an acute myocardial infarction (AMI) rule-out rate of 50.4% (negative predictive value 99.7%, sensitivity 98.7%). In the ruled-out patients the 30-day AMI/death rate was 0.2%. Our objective was to describe any differential clinical characteristics of the AMI ruled-out patients placed in observation/inpatient beds (OBS/ADM) compared to those with an ED discharge (EDD). 2113 consenting adults with any symptoms suspicious for AMI were enrolled from 2015-2016 in 29 US medical centers. There were no exclusion criteria for enrollment. Baseline and 1-hour plasma samples were analyzed using the Siemens Atellica hs-cTnI assay (99th % = 47.0 ng/L). AMI diagnosis was independently adjudicated by cardiologists and ED physicians using local contemporary troponin assays and all following 30-day clinical information available. Patients were placed in OBS/ADM or EDD according to local practice during the study period. Step logistic regression modeling was used to determine which of 25 clinical patient characteristics were associated with OBS/ADM disposition decisions. 1020 (48.3%) individuals were ruled out for AMI at 1 hour. Of these, 584 (57.3%) were EDD and 436 (42.7%) were placed in OBS/ADM. No AMI/deaths occurred in the latter group while they were in the hospital. The frequency of patients having an EDD rather than being placed in OBS/ADM varied significantly (0.0% - 94.1%) amongst the participating sites. 30-day AMI/death rates in these 2 groups were not significantly different (0.0% v 0.5% {2 patients, days 7 and 28}, p=0.185). The highest Hs-cTnI values were very low in both groups (mean 3.1 and 2.3 ng/L in the OBSD/ADM compared to the EDD patients). The clinical variables significantly associated with a decision to place a patient in OBS/ADM (table) were generally risk factors for the development of coronary artery disease. Of the many potential factors that could influence the decision for an extended length of stay for patients at very low risk for AMI/death, those with a personal and/or family history of coronary artery disease, stroke, no prior heart failure hospitalizations, hypertension, or having an abnormal ECG were likely to be placed in OBS/ADM for further cardiac evaluations. Considering their excellent prognosis and recent evidence (ISCHEMIA Trial) showing revascularization in the absence of AMI does not reduce AMI/death compared to medical therapy, reliance on clinical variables should be judiciously considered and systems developed to reduce the frequent decisions for extended stay for rapidly ruled-out for AMI patients.Tabled 1Variables associated with OBS/ADM placementOBS/ADM versus EDD variablesp-valueOdds ratio estimate95% CI lower limit95% CI upper limitHistory of CAD<0.0012.9401.9994.325Previous stroke0.0022.7421.4605.148No prior HF hospitalization0.0192.20221.11213.647History of hypertension<0.0011.8951.3612.638Abnormal ECG<0.0011.7661.2922.413Family history of CAD0.0351.3991.0241.912 Open table in a new tab

Abstract 20: Are We Ready for High(er) Sensitivity Troponin Assays? The Positive Predictive Value of a Contemporary Troponin Assay for Acute Myocardial Infarction

Background: Patients with elevated troponin (cTn) in the absence of Acute Myocardial Infarction (AMI) present a diagnostic dilemma: they at high risk of adverse cardiac events, yet there is little evidence on how they should be managed clinically. In recent years, greater sensitivity of cTn assays and less selective use of cTn in clinical practice have led to a greater number of non-AMI patients with elevated troponin. The exact scope of the problem in routine clinical practice is not known, as published estimates of troponin’s positive predictive value (PPV) for AMI range from 15% to 70%. We sought to define troponin’s PPV for AMI at our institution and examine both process and outcome measures for AMI and non-AMI patients. Methods: In a retrospective cohort analysis of patients evaluated at the University of Colorado Hospital, we identified 5,903 hospital encounters between January 1, 2017 and October 6, 2018 in which patients were found to have an elevated serum troponin level (&gt;0.04 ng/mL, Siemens Advia Centaur Tnl-Ultra). We used ICD-10 codes, billing diagnosis related groups (DRGs), or inclusion in the NCDR® ACTION Registry® to identify patients with a diagnosis of AMI. Patients not captured by one of these diagnoses were categorized as non-AMI. We then compared AMI and non-AMI patients according to the primary outcome of 100-day mortality. Secondary outcomes and process measures were also examined. Results: Out of 5,903 hospital encounters in which elevated cTn was detected, 730 were associated with any diagnosis of AMI (PPV 12.4%). The PPV was lower for individual AMI diagnosis groups. The primary outcome of 100-day mortality was observed in 10.3% of AMI patients versus 20.5% of non-AMI patients (p &lt; 0.001). AMI patients also had significantly shorter hospitalizations, higher rates of inpatient echocardiography and higher rates of P2Y12 inhibitor therapy (Table 1). Conclusion: The PPV of a contemporary troponin assay for AMI was 12.4% in routine clinical practice at a tertiary care academic hospital. Concordant with prior studies, non-AMI patients had worse outcomes. With high-sensitivity troponin (hsTn) assays poised to increase the prevalence of non-AMI troponin elevation, guidance is needed regarding the appropriate use of hsTn as well as the evaluation and treatment of non-ACS patients.

Hospital mortality and thirty day readmission among patients with non-acute myocardial infarction related cardiogenic shock

BackgroundCardiogenic shock (CS) in absence of acute myocardial infarction (AMI) has significant morbidity and mortality. This population of patients has been excluded from prior major randomized trials and observational studies. MethodsWe included patients with CS in absence of AMI from the 2013–14 HCUP's National Readmission Database. 30-day readmissions were studied and etiology for readmission was identified by using ICD-9CM codes in primary diagnosis field. Multivariable mixed effect logistic regression models were created to identify predictors of 30-day readmission and in-hospital mortality, respectively. ResultsWe studied 38,198 index admissions with non-AMI CS, with an in-hospital mortality of 35.4%. Mean age, length and cost of stay were 63.6 years, 16.9 days and 69,947$, respectively among survivors of index admission. Among those discharged, 22.6% were readmitted within 30 days with >50% readmissions occurring within 11-days. Cardiovascular etiologies (42.3%), especially heart failure (24.0%) comprised the commonest reason for readmission. Among non-cardiac causes were infectious (11.7%) and respiratory (9.2%) etiologies. Older age (50–64 years odds ratio:1.29, 65–79 years, OR:1.59, ≥80 years OR:2.69), ventilator use (OR:4.25), sepsis (OR:1.12), use of short term devices (intra-aortic balloon pump OR:2.67, Impella/TandemHeart OR:4.84, extracorporeal membrane oxygenation OR:3.68) and non-ischemic cardiomyopathy(OR:0.65) were among the predictors of in-hospital mortality. Older age (65–79 years, OR:1.25, ≥80 years OR:1.41), male sex (OR:1.08), and ventilator use (OR:1.21) predicted higher 30-day readmission. ConclusionBoth, in-hospital mortality and 30-day readmission among those admitted for non-AMI CS were significantly elevated. The majority of readmissions were due to non-cardiovascular causes. Identifying high-risk factors may help devise strategies to improve quality of care and reduce adverse outcome rates.

Improving the diagnostic accuracy of acute myocardial infarction with the use of high-sensitive cardiac troponin T in different chronic kidney disease stages

High-sensitive cardiac troponin T (hs-TnT) is a critical biomarker in diagnosis of acute myocardial infarction (AMI). However, CKD individuals usually have elevated hs-TnT even in the absence of AMI. Our study aimed to explore the optimal cutoff-value of hs-TnT and further to improve diagnostic accuracy of AMI in CKD patients. Clinical data of 489 patients were collected from the maintained database between September 2010 and June 2014. CKD patients with AMI were assigned to CKD+AMI group and CKD patients without AMI were assigned to CKD group. Receiver operating characteristic curves were utilized to derive the optimal cutoff-value. In CKD+STEMI and CKD group, hs-TnT was increased with descending eGFR. In CKD+NSTEMI group, hs-TnT showed an upward trend with increasing SYNTAX Score. In patients with CKD+STEMI, hs-TnT was significantly correlated with SYNTAX Score in CKD stage 2, stage 4 and in total. In CKD patients, the optimal cutoff-value of hs-TnT for diagnosis of AMI was 129.45 ng/l with 75.2% sensitivity and 83.2% specificity. The cutoff-value appeared to be hs-TnT level of 99.55ng/l in CKD stage 3, 129.45 ng/l in CKD stage 4, 105.50 ng/l in CKD stage 5 and 149.35 ng/l in dialysis patients, respectively. In different stages of CKD, eGFR-range-specific optimal cutoff-values should be considered.