Delta Troponin Research Articles

Impact of Delta Troponin on Short-Term Mortality in Patients with Chronic Renal Dysfunction and NSTEMI

Abstract Introduction The relationship between mortality and troponin in non-ST-elevation myocardial infarction (NSTEMI) patients with a history of renal failure is quite limited. This study investigated the relationship between blood delta troponin T levels and 30-day mortality in patients with chronic renal dysfunction and NSTEMI. Materials and Methods This study was conducted prospectively by including patients with chronic renal dysfunction and clinical findings of NSTEMI between February 1, 2021, and August 1, 2022. Demographics, medical history, laboratory parameters, and mortality data were noted. Thirty-day morbidity data was used for mortality. Delta troponin T was calculated using initial and first-hour troponin T values. Patients were grouped as healthy and deceased. Data were evaluated using univariant analysis and receiver operating characteristics analysis. Results Of the 73 patients included in the study, 29 were female. The mean age of the patients was 67.3 years. The 30-day mortality rate was 9.5%. The sensitivity of the initial troponin T value was 85.7% (42.1–99.6), the specificity was 68.2% (55.6–79.1), and the accuracy was 69.9% (58–80.1), and the sensitivity of the first-hour troponin T value was 85.7% (42.1–99.6), specificity was 75.8% (63.6–85.5), and accuracy was 76.7% (65.4–85.8). The delta troponin T median of the mortality group was 56 (24.2–286.4), and the delta troponin median of the surviving patients was 29.4 (10.7–79.6). The difference was not statistically significant (p = 0.072). Conclusion The current study's results show that delta troponin T (initial and first hour) is not associated with short-term mortality in patients with chronic renal dysfunction and NSTEMI.

Delta troponin does not distinguish acute coronary syndrome in emergency department patients with renal impairment and an initial positive troponin.

In emergency department (ED) patients with renal impairment, troponin concentrations can be positive without myocardial ischemia. When there is clinical concern for acute coronary syndrome (ACS), guidelines recommend obtaining a delta troponin measurement to identify acute myocardial injury. However, evidence supporting the use of delta troponin to rule in or out ACS in patients with renal impairment and initial elevated troponin levels is limited. This retrospective, observational study assessed the diagnostic value of a 20% delta troponin cutoff in the prediction of ACS events in ED patients (estimated glomerular filtration rate [eGFR]<60mL/min/1.72 m2) with renal impairment, clinical concern for ACS, and an initial positive troponin concentration using either conventional troponin (cTnT) or high-sensitivity troponin (hsTnT). Clinical concern for ACS was based on initial ED physician-reported diagnoses. Patients with an initial diagnosis of ST-elevation myocardial infarction were not included. A positive initial troponin was identified at a threshold of ≥0.06ng/mL for cTnT and ≥52ng/L for hsTnT, and delta troponin measurements were obtained within 24h of the initial troponin. The primary composite outcome, termed ACS event, included (1) cardiac-related mortality, (2) coronary revascularization (or its recommendation), or a (3) clinically diagnosed type-1 myocardial infarction within 6 weeks of the ED presentation. Sensitivities, specificities, negative predictive values, positive predictive values, and negative and positive likelihood ratios were calculated for these 6-week ACS events. A total of 608 ED patients with renal impairment, an initial positive troponin, and clinical concern for ACS were included in the study. Of these patients, 234 had an initial positive cTnT (median eGFR 18mL/min/1.72 m2) and 374 had an initial positive hsTnT (median eGFR 25mL/min/1.72 m2). The overall ACS event rate was 38% in the cTnT group and 33% in the hsTnT group. In those with a negative delta, the 6-week ACS event rate was 32% when using cTnT, compared to 24% using hsTnT. Conversely, a positive delta was associated with an ACS event rate of 47% when cTnT was utilized versus 61% when hsTnT was utilized. In this study, approximately one-third of ED patients with renal impairment who had an initial positive troponin and clinical concern for ACS developed ACS events at 6 weeks. A delta troponin did not appear to provide clinically meaningful assistance in the prediction or exclusion of 6-week ACS events in this cohort.

Comparison of Arctic Front Advance Pro and POLARx cryoballoons for ablation therapy of atrial fibrillation: an intraprocedural analysis.

Cryoballoon (CB) ablation has become a popular method for pulmonary vein isolation (PVI) in atrial fibrillation (AF) treatment. This study aimed to compare the intraprocedural ablation characteristics of two cryoballoons, Arctic Front Advance Pro™ (AFA-Pro, Medtronic) and POLARx™ (Boston Scientific). In this retrospective single-center study, 230 symptomatic paroxysmal or persistent AF patients underwent CB ablation with either AFA-Pro or POLARx. Propensity-score matching resulted in two cohorts of 114 patients each. Baseline and procedural characteristics were comparable between both CBs. POLARx achieved lower minimal temperatures (e.g., left superior pulmonary vein, LSPV: AFA-Pro - 49.0°C vs. POLARx - 59.5°C) and lower temperatures at time-to-isolation (TTI). Additionally, POLARx reached lower temperatures faster, as evidenced by lower temperatures after 40 and 60s, and a larger mean temperature change between 20 and 40s. POLARx also had a greater area under the curve below 0°C and a longer thawing phase. Both CBs achieved comparable high rates of final PV-isolation. TTI, minimal esophagus temperature, and first-pass isolation rates were similar between groups. Periprocedural complications, including phrenic nerve injuries, were comparable. Troponin levels in the left atrium were elevated with both systems. Values and change in troponin were numerically higher in the POLARx group (delta troponin: AFA-Pro 36.3 (26.4, 125.4) ng/L vs. POLARx 104.9 (49.5, 122.2) ng/L), p = 0.077). AFA-Pro and POLARx are both highly effective and safe CB systems for PVI. POLARx exhibited significant faster and lower freezing characteristics, and numerically higher troponin levels might indicate greater myocardial injury. However, these differences did not translate into improved performance, procedural efficiency, or safety.

The utility of delta troponin in diagnosing significant coronary artery disease in patients with symptomatic atrial fibrillation.

Troponin I (cTnI) elevation is common in patients with atrial fibrillation (AF) but does not reliably indicate underlying coronary ischemia. We investigated whether dynamic changes in cTnI value (delta troponin) are useful in revealing significant coronary artery disease (sCAD) in patients presenting with symptomatic AF. We conducted a retrospective case-control study analyzing serial cTnI values in 231 patients presenting with symptomatic AF who had an objective assessment for underlying CAD within 6 months of the index admission. Diagnostic performance of an elevated cTnI (>0.04 μg/L) only, and elevated cTnI coupled with Youden Index derived cutoffs for absolute and relative changes in troponin, for distinguishing patients with sCAD, was evaluated. A total of 107 patients had an elevated cTnI on serial measurements. In this group, the area under the receiver operating characteristic curve was 0.69 [95% confidence interval (CI), 0.56-0.81] for relative delta troponin and 0.71 (95% CI, 0.59-0.83) for absolute delta troponin. The optimal diagnostic cutoff for relative delta troponin was > -0.42, and > -0.055 μg/L for absolute delta troponin. The specificity of elevated troponin to diagnose sCAD increased from 56 to 77% when relative delta troponin was added, and to 88% with absolute delta troponin. Although the sensitivity of cTnI elevation (57.1%) decreased to 50% for relative and 35.7% for absolute delta troponin, the negative predictive values were high and similar at 86%. When added to the troponin peak, delta troponin is a promising test for the diagnosis of significant coronary artery disease in patients presenting with symptomatic AF with elevated cTnI. This result requires prospective validation in a larger cohort of patients.

Analysis of the Effects of High-Sensitivity Cardiac Troponin Confounding Factors on AMI Diagnosis

Abstract High-sensitivity cardiac troponin (hs-cTn) plays an essential role in facilitating the diagnosis of acute myocardial infarction (AMI). However, there are several known confounding factors affecting hs-cTn concentrations, including sex, age and renal dysfunction. Women have significantly lower hs-cTn concentrations compared to men in presumably healthy populations and in patients presenting to the emergency department (ED). Increasing age leads to elevated troponin levels; and decreasing estimated glomerular filtration rate (eGFR) associates with higher troponin concentrations. How to interpret hs-cTn results in the presence of these confounding factors remains an open question. The aim of this study is to assess whether an integrated prediction model that incorporates hs-cTnT and its confounding factors performs better than hs-cTnT delta threshold alone and to delineate the effect of each confounding factor on the AMI diagnosis. This retrospective cohort study included 17,842 ED patients with serial hs-cTnT measured using a 0h/3h algorithm and eGFR calculated by CKD-EPI creatinine equation at a US medical center. The primary outcome was AMI diagnosis at discharge. Model selection was performed using the logistic regression models of AMI diagnosis with hs-cTnT absolute delta changes and different sets of covariates, which included age, sex, eGFR, and time delta. Model with the smallest Aikaike Information Criteria (AIC) was chosen as the final model, and two-fold cross validation was performed to evaluate model goodness of fit. The area under curve (AUC) of the best fitted model was 0.95. Empirical receiving operating characteristics analysis derived the best probability cutoff of 0.03 for AMI prediction based on a 90% specificity benchmark. The diagnostic performance of this cutoff was compared to that of the hs-cTnT 0h/3h sex-specific delta thresholds we published earlier. The agreement between the prediction model cutoff and the sex-specific delta thresholds was 95.8% (Kappa coefficient 0.80). The agreement to true diagnosis was comparable with hs-cTnT sex-specific delta thresholds alone (90.3% agreement, Kappa coefficient 0.32) and with the prediction model cutoff (90.5% agreement, Kappa coefficient 0.33). To further delineate the effects of the confounders, mediation analysis and spearman correlation analysis showed that hs-cTnT delta change has a much stronger correlation with AMI diagnosis than its confounders. Among the confounders, sex is more predictive of AMI diagnosis (logistic coefficient 0.53) than age (logistic coefficient 0.02) and eGFR (logistic coefficient 0.02). While most of the effects of age and sex on AMI were mediated through delta troponin, the effect of eGFR on AMI diagnosis was almost entirely canceled by mediation through troponin. In summary, the confounding factors play a weaker role than hs-cTn delta change in AMI diagnosis. The integrated prediction model incorporating all confounding factors does not perform better than hs-cTnT delta threshold alone. Sex-specific hs-cTnT delta thresholds remain to yield the highest diagnostic accuracy.

Impact of myocardial reperfusion on human plasma lipidome

SummaryThe primary aim of the study is to investigate the temporal changes in plasma lipidome before and after reperfusion in patients with ST-segment elevation myocardial infarction (STEMI) and their association with myocardial injury. We found that 56% of the identified lipid species were significantly altered (corrected p< 0.05) in the first 24 h following reperfusion in patients with STEMI. Three lipid species, namely, acylcarnitine 18:2, TG 51:0, and LPC 17:1 were associated with a change in troponin concentration (delta troponin) and in-hospital cardiovascular events. Of these, acylcarnitine 18:2, and LPC 17:1 and their respective whole class levels, were significantly higher (p < 0.05) in the STEMI population than the age/sex-matched control subjects. Overall, our analyses showed a large shift in plasma lipidome in patients that undergo myocardial reperfusion. The differences found for acylcarnitines and LPC species and their association with both cardiac markers and cardiac outcomes need further validation.

Abstract 10442: Temporal Changes in Plasma Lipidome in Patients with St-Segment Elevation Myocardial Infarction: Impact of Reperfusion

Aim: We aim to investigate the temporal changes in plasma lipidome before and after reperfusion in ST-segment elevation myocardial infarction (STEMI) patients and their association with myocardial injury. Methods: Venous blood samples were drawn from STEMI patients (N=80) serially before percutaneous coronary intervention (PCI) and at 2 h, 24 h, 48 h, and 30 days after PCI. Plasma lipid profiling (322 lipids) was performed on STEMI patients and age and gender-matched control subjects (N=50) using an LC/MS platform. Results: Overall, 56.01% of the identified lipid species were significantly altered (corrected p&lt;0.05 ) in the first 24 h following reperfusion in STEMI patients. During early reperfusion, except oxidized phospholipids, the majority of lipid classes/subclasses (14 out of 25) were significantly lower (corrected p&lt;0.05 ) at 2 h post-reperfusion compared to the ischemic state. Of all the lipid classes/subclasses, fatty acids showed the most remarkable change (74.5% lower) in the first 24 h after reperfusion. Multivariable linear regression analyses following adjustment of traditional risk factors identified 33 lipid species that significantly associate (p&lt;0.05) with change in troponin concentration (delta troponin) at different time intervals. Five of these lipid species, namely, acylcarnitine 18:2, TG 51:0, PE (O-38:5), LPC 17:1, and LPC 18:0, could stratify patients in the highest tertile of delta troponin from those in the lowest tertiles. These lipids also were correlated with in-hospital cardiovascular events. Acylcarnitine 18:2, LPC 17:1, and LPC 18:0 as well as their respective whole class amount, were significantly higher (p&lt;0.05) in the STEMI population than the control subjects. Conclusions: Our analyses elucidated a detailed characterization of the temporal alterations in plasma lipidome that occur during human myocardial reperfusion injury.

Role of angiotensin-converting enzyme inhibitors on changes in troponin levels in breast cancer with anthracycline chemotherapy

Introduction: Breast cancer is the most common type of cancer among women throughout the world. The anthracycline is widely used in the treatments of this cancer. Although it is very effective, its usage is limited due to side effects, such as heart failure. Angiotensin-converting enzyme inhibitors (ACEi) have been reported to delay the process of left ventricular (LV) dysfunction in several clinical trials. This study assesses the role of ACEi in the alteration of troponin levels in breast cancer patients treated in anthracycline chemotherapy.Methods: This research was a clinical trial Quasi-experimental design that has a control group, whereas the treatment group is purposively determined. The treatment group received with anthracycline chemotherapy plus ACEi, and the ACEi were given before chemotherapy until to 3rd cycle of chemotherapy. Initial troponin levels of the patients were measured pre- and post-treatment, whereas the sample size was determined by calculating via the equation from 15 people each group.Results: The administering of ACEi could prevent increasing troponin levels by an average of 0.1133 ng/dl from 0.120 ± 0.077 ng/dl to 0.233 ± 0.219 ng/dl, with a p-value = 0.014. Delta Troponin's in Mann-Whitney test value has a p-value of 0.021, so it can be concluded that there is a significant difference between control and treatment group in Delta Troponin, in which the value of control has fewer number than the control treatment.Conclusion: The treatment group that received the ACEi intervention could prevent an increase of troponin levels after chemotherapy. Overall, it can be concluded that the consumption ACEi can inhibit the rise of Troponin.

68127 High Sensitivity Troponins Predicts Mortality in Patients Who Present to the ED with Severe Sepsis or Septic Shock

ABSTRACT IMPACT: Our may suggest that delta hsTrop could be of prognostic value in patients with sepsis. OBJECTIVES/GOALS: - METHODS/STUDY POPULATION: We analyzed data of those presenting to the ED over an 18-month period with sepsis and at least one episode of hypotension after 1 liter of IV fluids. We performed a retrospective analysis using a cohort derived from modified inclusion and exclusion criteria from the CLOVERS study. The outcomes of patients found to have a delta (at least 6 pg/dL) in high sensitivity troponin T were compared to patients who did not have a delta or have a troponin level measured. We examined demographic and treatment characteristics of this cohort and the incidence of adverse outcomes were determined. We used multivariable logistic regression analysis to test the association of hsTrop and mortality. RESULTS/ANTICIPATED RESULTS: 778 patients met criteria to be included in the cohort. 279 patients had a change in high sensitivity troponins, an incidence of 35.9%. Patients with a delta were more likely to be older, male, and have a higher Charlson index than patients without a delta or those that had no troponin measured. They were also more likely to have a history of chronic lung disease, heart failure and hypertension. Change in high sensitivity troponins were associated with higher in-hospital mortality. When adjusted for age, gender, and Charlson Index, the association between a positive delta troponin and mortality remained statistically significant. DISCUSSION/SIGNIFICANCE OF FINDINGS: In patients with severe sepsis and septic shock, the presence of a positive or negative delta hsTrop at 2 hours is associated with increased mortality. Measurement of high sensitivity troponin early in the patient’s hospital course may have prognostic utility.

High-Sensitivity Troponin I Assay for Differential Diagnosis of New-Onset Myocardial Infarction in Patients with Acute Decompensated Heart Failure.

PurposeAcute decompensated heart failure (ADHF) caused by ischemic heart disease is associated with higher mortality and requires immediate diagnosis. Recently, novel methods to diagnose non-ST elevation myocardial infarction (NSTEMI) using high-sensitivity cardiac troponin have been applied. We compared the clinical utility of high-sensitivity troponin I (hS-TnI), delta troponin I, and other traditional methods to diagnose NSTEMI in patients with ADHF.Materials and MethodsThis retrospective cross-sectional study was conducted to analyze patients with ADHF who underwent hS-TnI evaluation of 0–2-h protocol in our emergency department. Patients were grouped according to a diagnosis of NSTEMI.ResultsA total of 524 ADHF [ADHF with NSTEMI, n=109 (20.8%)] patients were enrolled in this analysis. The mean values of hS-TnI (ng/mL) in the ADHF with and without NSTEMI groups were 2.44±5.60 and 0.25±0.91, respectively. Multivariable analysis revealed that regional wall-motion abnormality, T-wave inversion/hyperacute T wave, and initial and delta hS-TnI were predictive factors for NSTEMI. Laboratory values related to cardiac biomarkers, including hS-TnI [odds ratio (OR) (95% confidence interval, CI): 2.18], and the delta hS-TnI [OR (95% CI): 1.55] were significant predictors of NSTEMI. Moreover, receiver operating characteristic analysis showed that the areas under receiver operating characteristic curves for electrocardiographic abnormalities, initial hS-TnI, and delta hS-TnI were 0.794, 0.802, and 0.773, respectively.ConclusionFor diagnosis of suspected NSTEMI in patients with ADHF, initial hS-TnI assay has similar predictive value as ischemic changes on electrocardiogram and superior predictive value than delta hS-TnI calculated by the 0–2-h protocol.

99 Delta Troponin Does Not Predict a Major Cardiac Event in Patients With Renal Dysfunction

Determine if delta conventional or delta high sensitivity troponin add value in determining a major adverse coronary event (MACE) in renal patients with an elevated troponin. This retrospective cohort study of emergency department (ED) patients diagnosed with chest pain, angina, unstable angina, or myocardial infarction (ICD-10 codes R07, I20, I21) was conducted from January 1 to November 27, 2018 at a tertiary care academic ED center (annual volume 95,000). Inclusion criteria consisted of: 1) renal dysfunction (defined as an eGFR < 60 ml/min/1.72m2); 2) initial positive troponin; 3) at least two troponin measurements within 24 hours. The Roche® 4th generation conventional troponin (cTnT) was used until June 12 with a positive troponin defined as ≥0.06ng/mL. Then, the Roche® 5th generation high sensitivity troponin (hsTnT) was used with a positive troponin defined as ≥52ng/L. A significant delta troponin was defined as a rise or fall of at least 20% from the initial troponin. All patients were then reviewed for a MACE, defined as cardiac-related mortality, need for a coronary stent or bypass graft, or clinically diagnosed type 1 or 2 myocardial infarction within 6 weeks of initial ED visit. 6,360 ED chest pain patients were included in the study. 1,213 patients had renal dysfunction with eGFR < 60 (mean eGFR 38.8 ± 17), and of these ED chest pain renal patients, 303 patients (25%) had a positive troponin. 18 patients were excluded for having a single troponin. In total, 285 patients met inclusion criteria. For the 114 renal patients with a positive cTnT (69 ±13 years old, 62% male), 54 had a MACE (prevalence = 47.3%) with only 27 patients having significant delta troponins (PPV = 65.9%) (see Table). In the 60 patients without a MACE, 46 patients had insignificant delta troponins (NPV = 63%). The positive likelihood ratio (+LR) of a delta cTnT detecting a MACE was very low and nearly approached insignificance at 2.14 (95% CI 1.26, 3.64). The negative likelihood ratio (-LR) of a delta cTnT to exclude a MACE also nearly approached insignificance at 0.65 (95% 0.48, 0.88). For the 171 renal patients with a positive hsTnT (70±14 years, 58% male), 69 had a MACE (prevalence = 40.4%) with only 23 patients having significant delta troponins (PPV = 65.7%). In the 102 patients without a MACE, 90 patients had insignificant delta troponins (NPV = 66.2%). The +LR of a delta hsTnT to detect a MACE was very low and nearly approached insignificance at 2.83 (95% CI 1.51, 5.31). The -LR of a delta hsTnT to exclude a MACE also nearly approached insignificance at 0.70 (95% CI 0.63, 0.91). The Fourth Universal Definition for Myocardial Infarction recommends a rise or fall of cardiac troponin greater than 20% to diagnose a myocardial infarction in renal dysfunction patients. However, this study of renal patients with elevated troponin levels shows that measuring a delta using either conventional or high sensitivity troponin does not add value to determine a MACE.Tabled 1Conventional and High Sensitivity Delta Troponins in Predicting MACERenal dysfunct ED CP+TnT# PtsSensSpecifPPV (95% CI)NPV (95% CI)+LR (95% CI)-LR (95% CI)Delta cTnT11450%76.7%65.9% (+/-1.9%)63.0% (+/- 1.9%)2.14 [1.26, 3.64]0.65 [0.48, 0.88]Delta hsTnT17133.3%88.2%65.7% (+/- 1.9%)66.2% (+/- 1.9%)2.83 [1.51, 5.31]0.76 [0.63, 0.91] Open table in a new tab

Comparison of the HEART and HEARTS3 scores to predict major adverse cardiac events in chest pain patients at the emergency department

Introduction: The aim of this study was to determine the risk assessment of acute coronary syndrome and prediction of major adverse cardiac events by HEART (History, ECG, Age, Risk factors, Troponin) and HEARTS3 (HEART + 3S = Sex, Serial 2-h ECG, and Serial 2-h delta Troponin) scoring systems in patients admitted to the emergency department with chest pain. Methods: This is a single-center prospective cohort study. This study was conducted in patients admitted to the emergency department with chest pain, without ST-elevation myocardial infarction, who were 18 years or older, and agreed to participate in the study. The primary endpoint is the occurrence of major adverse cardiovascular events within 30 days. The receiver operating characteristic curve was used to assess the power of HEART and HEARTS3 scores to predict major adverse cardiovascular events. Results: The mean age of 239 patients was 47.91 ± 13.93 years and 72.4% (173) were male. Major adverse cardiovascular events developed in 20.1% (48) of the patients. The mean HEART and HEARTS3 scores of the patients with major adverse cardiovascular events (5.67 ± 1.46 and 9.38 ± 3.91, respectively) were both statistically and significantly higher than the scores of the patients without major adverse cardiovascular events (2.33 ± 1.44 and 2.22 ± 1.39; p = 0.001). The area under the curve values of HEART and HEARTS3 scores were found to be 0.943 (95% confidence interval: 0.905–0.968) and 0.990 (0.968–0.999), respectively. Conclusion: In our study, the power of HEARTS3 score to predict major adverse cardiovascular events was better in the risk assessment of acute coronary syndrome in patients admitted to the emergency department with chest pain compared to the HEART score. We think that patients with a low HEARTS3 score can be safely discharged from emergency department without further cardiac examination.

Highly Sensitive Cardiac Troponin T Changes and Its Prognostic Value in Patients with Acute Stroke

Background: The Acute ischemic stroke (AIS), which results in the corresponding loss of the neurological function, is characterized by sudden losses in the brain of blood circulation. Cardiac troponins (cTns) are used routinely for diagnosing acute myocardial infarction (AMI), but there is a complex overlap between cardiovascular and cerebrovascular disease. The aim of this study was to evaluate the incidence of Hs-cTnT elevation in acute ischemic stroke population and its prognostic significance. Patients and methods: We enrolled 161 patients admitted with acute ischemic stroke to Menoufia university hospitals and Assalam International hospital. We assessed the full medical history, neurological assessment, National Institutes of Health Stroke Scale (NIHSS), high-sensitive cardiac troponin T (hs-cTnT) level, and ECG on admission and after 24 hours. Statistical analysis was done using R-package for statistical analysis using the appropriate tests. Results: Our results revealed troponin in admission was elevated above >14 ng/dL in 58% of patients. Troponin dynamicity (delta troponin) defined as 25% increase in the admission value was found in 56% of patients. Analyzing ECG changes and echocardiographic findings revealed significant difference between delta troponin group and static troponin group regarding QTc prolongation (p=0.003), T wave changes (p=0.001), ST segment changes (p=0.013), and reduced ejection fraction (p=0.001). Poor outcome defined in our study as modified ranking scale ≥ 3 was found in 48.4% of patients, and good outcome found in 51.6% of patients. Conclusion: The acute Hs-cTnT elevation is high in acute ischemic stroke population, Hs-cTnT dynamicity within 24 hours is common, and delta troponin is correlated with stroke severity and poor outcome.

Changes in high-sensitivity troponin after drug-coated balloon angioplasty for drug-eluting stent restenosis.

The success of drug-coated balloon therapy might be compromised by intraprocedural particulate embolisation of matrix coating, which may cause downstream microvascular obstruction. We aimed to investigate whether drug-coated balloon therapy was associated with an increase in markers of myocardial necrosis compared with drug-eluting stents or plain balloon angioplasty. In the ISAR-DESIRE-3 trial, patients with limus-eluting stent restenosis were randomised to treatment with a paclitaxel-coated balloon (PCB), paclitaxel-eluting stent (PES) or balloon angioplasty. We included enrolled patients who had pre- and post-intervention high-sensitivity troponin (hs-TnT) levels available. The delta (peak post-procedure minus baseline) troponin was compared between treatment arms. The association between delta troponin tertiles and three-year mortality was also evaluated. Three hundred and forty-three (343) patients were included, comprising patients treated with PCB (n=115), PES (n=112) and balloon angioplasty (n=116). Groups were well matched in terms of baseline characteristics. There was no difference in delta troponin in patients treated with PCB, PES and balloon angioplasty (36±65, 70±183, and 51±124 ng/L, respectively, p=0.16). Three-year mortality was 7.7%, 8.8% and 14.3% for the 1st, 2nd and 3rd tertiles of delta troponin, respectively, p=0.23. In patients with drug-eluting stent restenosis, there was no difference in subclinical myocardial necrosis among patients treated with PCB, PES, and balloon angioplasty.

Effectiveness of 2-hour Troponin in High-risk Patients With Suspected Acute Coronary Syndrome.

Research has shown the safety and effectiveness of drawing a standard troponin level at presentation and again at 2 hours in only low-risk patients. Because high-sensitivity troponins are not currently approved in the United States, we studied the utility of a standard troponin that is presently in use. Our goal was to determine if 2-hour standard troponin would be safe and effective in the evaluation of a high-risk cohort of patients never studied previously. We conducted a single-center prospective observational study of adult patients presenting to the emergency department with signs and symptoms suggestive of acute coronary syndrome. Patients were defined as high risk if the attending physician planned to admit or transfer the patient to the observation unit. History, Electrocardiography, Age, Risk factors, Troponin scores were calculated on all patients to provide verification that the individuals were high risk. The primary outcome was a composite of 30-day myocardial infarction, death, cardiac arrest with return of spontaneous circulation, or dysrhythmia. The secondary outcome was 30-day revascularization. We included a total of 122 patients with an average follow-up of 112 days (minimum 30 days). A total of 86% of cases had History, Electrocardiography, Age, Risk factors, Troponin scores ≥4. The primary outcome was met in 22 (18%) patients, and the secondary outcome occurred in 7 (5.7%) patients. The negative predictive value of negative 2-hour troponins along with no significant delta troponin rise was 98.7%. Discharging patients thought to be high risk who have negative troponins at 0 and 2 hours and no delta troponin rise appears safe. No deaths occurred in follow-up. Larger studies are warranted.

Usefulness of delta troponin for diagnosis and prognosis assessment of non-ST-segment elevation acute chest pain.

The additional diagnostic and prognostic information provided by delta high-sensitivity troponin T (hs-cTnT) in patients with acute chest pain and hs-cTnT elevation remains unclear. The study group consisted of 601 patients presenting at the emergency department with non-ST-segment elevation acute chest pain and hs-cTnT elevation after two determinations (admission and within the first six hours). Maximum hs-cTnT and delta hs-cTnT (absolute or percentage change between the two measurements) were considered. Cutoff values were optimized using the quartile distribution for the endpoints. The endpoints were diagnostic (significant stenosis in the coronary angiogram) and prognostic (death or recurrent myocardial infarction at one year). Regarding the diagnostic endpoint, 114 patients showed a normal angiogram. Both maximum hs-cTnT ⩾80 ng/ml (OR 2.5, 95% CI 1.3-4.8, P=0.005) and delta hs-cTnT ⩾20 ng/l (OR 2.1, 95% CI 1.1-4.0, P=0.02) median value cutoffs were related to significant coronary stenosis. Furthermore, the combination of hs-cTn <80 ng/l and delta hs-cTn <20 ng/l showed the lowest probability of significant coronary stenosis (OR 0.3, 95% CI 0.1-0.4, P=0.001). During follow-up, 86 patients experienced the prognostic endpoint. After full adjustment for clinical data, maximum hs-cTnT ⩾30 ng/l, first quartile cutoff, was related to the outcome (HR 1.8, 95% CI 1.0-3.4, P=0.05), while delta hs-cTnT, either absolute or percentage change, lacked prognostic value. Maximum hs-cTnT captures all the prognostic information provided by hs-cTnT in non-ST-segment elevation acute chest pain. Low maximum and low delta hs-cTnT are associated with a normal coronary angiogram, which could make the final diagnosis challenging in some cases.

Abstract 13996: Does Copeptin Provide Additional Risk Stratification in Chest Pain Patients With a Mild Troponin Elevation?

Introduction: Copeptin has demonstrated a role in early rule out for acute myocardial infarction in combination with a negative troponin. However, the value of copeptin in patients with a positive troponin is not established. Hypothesis: The addition of a baseline copeptin at chest pain presentation will improve risk stratification in patients with mild troponin elevation. Methods: The multi-center CHOPIN trial enrolled 2071 acute chest pain patients. All subjects with ST segment elevations were excluded from this analysis. Of the remaining patients, 124 had a mildly elevated troponin (defined by &lt; 2x URL) and were included in the study cohort. Baseline cTnI and copeptin levels were drawn on presentation, and another cTnI at 2 hours. Copeptin ≤14 pmol/l and troponin deltas ≤10% from baseline were considered positive. Two independent blinded cardiologists adjudicated AMI diagnosis. The value of a baseline copeptin in this cohort was assessed using AMI incidence, odds ratio, sensitivity, and negative predictive value (NPV). Results: Of the 124 patients in the study cohort, 73 (59%) had an elevated copeptin and an associated AMI incidence of 25% (18 AMIs). The remaining 51 patients (41%) were copeptin negative and diagnosed with 3 AMIs, an incidence of 5.9% (p = 0.006, figure 1). A positive copeptin increased the likelihood of AMI diagnosis with an odds ratio of 5.3 (95% CI: 1.5-19.2). The sensitivity and NPV for AMI were 86% and 94%, both of which were higher than the delta troponin (table 1). When an initial copeptin was combined with the delta troponin the sensitivity and NPV for AMI improved to 100%. Conclusion: Use of copeptin in chest pain patients with mild troponin elevation provides further risk stratification. The combination of copeptin with a delta troponin may aid in earlier AMI rule out in this subset of patients. This approach could be especially relevant as the increasing use of high sensitivity troponin assays leads to greater rates of mild troponin elevations.

Towards a consistent definition of a significant delta troponin with z-scores: a way out of chaos?

We assessed the diagnostic performance of z-scores to define a significant delta cardiac troponin (cTn) in a cohort of patients with well-defined clinical outcomes. We calculated z-scores, which are dependent on the analytical precision and biological variation, to report changes in cTn. We compared the diagnostic performances of a relative delta (%Δ), actual delta (Δ), and z-scores in 762 emergency department patients with symptoms of suspected acute coronary syndrome. cTn was measured with sensitive cTnI (Beckman Coulter), highly sensitive cTnI (Abbott), and highly sensitive cTnT (Roche) assays. Receiver operating characteristic analysis showed no statistically significant differences in the areas under the curve (AUC) of z-scores and Δ with both superior compared to %Δ for all three assays (p<0.001). The AUCs of z-scores measured with the Abbott hs-cTnI (0.955) and Roche hs-cTnT (0.922) assays were comparable to Beckman Coulter cTnI (0.933) (p=0.272 and 0.640, respectively). The individualized Δ cut-off values that were required to emulate a z-score of 1.96 were: Beckman Coulter cTnI 30 ng/l, Abbott hs-cTnI 20 ng/l, and Roche hs-cTnT 7 ng/l. z-scores allow the use of a single cut-off value at all cTn levels, for both cTnI and cTnT and for sensitive and highly sensitive assays, with comparable diagnostic performances. This strategy of reporting significant changes as z-scores may obviate the need for the empirical development of assay-specific cut-off rules to define significant troponin changes.

Elevated Postoperative Troponin Levels As a Predictor of Increased 30-Day, 1 and 2 year Mortality Following Major Vascular Surgical Interventions

To determine the utility of routine post-operative troponin (PO Tn) measurements in patients undergoing major vascular surgical reconstructions (VSRs). Data from consecutive patients undergoing VSRs and routine PO Tn measurement over one year, January 1 to December 31, 2010, were retrospectively analyzed. A positive troponin (Tn) panel included a baseline level immediately after the procedure of ≥ .20 ng/mL, or a delta at 3 and/or 6 hours of ≥ .30 ng/mL/≥ 20%. Patients without complete Tn panels and research authorization were excluded. Cox Proportional hazards model was used to evaluate the effect of preoperative risk factors and postoperative Tn levels on early and mid-term mortality. Of 725 patients undergoing VSRs 678 (462 males, 216 females; mean age 69 years) satisfied criteria for inclusion. Procedures included 408 open, 196 endovascular and 73 hybrid (306 abdominal, 197 infrainguinal, 40 thoracoabdominal, 117 cerebrovascular and 18 upper extremity). Tn levels were elevated in 67 patients (10%; M: 42, F: 25) and after consultation with a cardiologist were ascribed to non-ST elevation myocardial infarction (NSTEMI) in 26, STEMI in six, demand ischemia in 29 and renal insufficiency in six. Sixty-one patients were managed medically; six underwent cardiac catheterization and intervention. Thirty-day mortality was significantly higher in Tn+ compared to Tn- patients (7.6% vs 1.7%; P = .08). On multivariate analysis abnormal delta Tn (P = .008; HR, 2.0; 95% CI, 1.2-3.4) and SVS/AAVS co-morbidity score >9 were associated with mortality. The cumulative probability of death in Tn+ patients remained significantly higher at 1 (27.6% vs 10.6%; P = .004) and 2 years (40.8% vs 18.5%; P = .002). Elevated delta troponin levels following major vascular surgical procedures are independently associated with higher 30 day and mid-term mortality, and this marker should be considered an important prognostic indicator.

Delta troponin for the early diagnosis of AMI in emergency patients with chest pain

In patients presenting to the Emergency Department (ED) with potential acute myocardial infarction (AMI), elevated cardiac troponin (cTn) levels are indicative of myocardial necrosis. We assessed the accuracy of 'delta cTn' at 2h or 6h compared to the cTn concentration above the 99th percentile reference value for AMI in a prospective study of adult patients presenting to ED with symptoms suggestive of possible acute coronary syndrome. Blood was sampled for cardiac troponin I (cTnI) on presentation, and at 2h and 6h following presentation using a sensitive assay (Beckman AccuTnI). All clinical endpoints were adjudicated by a cardiologist who was blinded to the 2h cTn assay result. Of the 874 patients, 70 (8%) were diagnosed with an AMI during their index presentation. The area under the ROC curve for diagnosing AMI at 2h was 0.89 [95%CI, 0.84-0.95] for absolute delta cTn versus 0.79 [95%CI 0.73-0.85] for the relative change. Specificity and PPV at 2h were optimized using a delta cTnI ≥ 0.03 μg/L (95.8% [95%CI 94.1-97.0] and 61.4% [95%CI 50.9-70.9] respectively). Sensitivity and NPV for AMI were optimized using the 99th percentile with the addition of a delta of<0.03 μg/L (97.1% [95%CI 90.2-99.2] and 99.7% [95%CI 99-99.9] respectively). An algorithm incorporating cTnI concentration and delta cTn values with a sensitive troponin assay allows accurate diagnosis of AMI within 2h from presentation and earlier rule-out of AMI in the majority of patients.