Elevated Troponin Concentrations Research Articles

Cardiovascular medications, high-sensitivity cardiac troponin T concentrations, and long-term outcome in non-ST segment elevation acute coronary syndrome.

Cardiac troponin plays an essential role in the management of non-ST segment elevation acute coronary syndrome (NSTE-ACS). However, it is not clear whether troponin concentrations provide guidance regarding the initiation of prognostically beneficial cardiovascular medications [i.e. betablockers, renin-angiotensin-aldosterone system (RAAS) inhibitors, and statins] in NSTE-ACS. Registry-based study investigating three NSTE-ACS cohorts (n = 43 075, 40 162, and 46 698) with elevated high-sensitivity cardiac troponin concentrations >14 ng/L. Cox proportional regression models with the addition of interaction terms were used to analyse the interrelations of high-sensitivity cardiac troponin T (hs-cTnT) concentrations, new initiated medications with the respective three drug classes, and long-term risk of all-cause mortality and major adverse events (MAE). Betablockers were associated with risk reductions of 8 and 5% regarding all-cause mortality and MAE, respectively. There was no evidence of an interaction with hs-cTnT concentrations. RAAS inhibitors were associated with 13 and 8% risk reductions, respectively, with a weak interaction between hs-cTnT and MAE (Pinteraction = 0.016). However, no increasing prognostic benefit was noted at hs-cTnT concentrations >100 ng/L. Statins were associated with 38 and 32% risk reductions, respectively, with prognostic benefit across the entire range of hs-cTnT concentrations, and with a weak interaction regarding MAE (Pinteraction = 0.011). Cardiovascular medications provide different prognostic benefit in patients with NSTE-ACS with elevated hs-cTnT, and there was some evidence of greater treatment effects regarding MAE along with higher hs-cTnT concentrations. However, hs-cTnT appears only to have limited value overall for customizing such treatments.

Myocardial Injury by COVID-19 Infection Assessed by Cardiovascular Magnetic Resonance Imaging - A Prospective Multicenter Study.

This prospective multicenter study assessed the prevalence of myocardial injury in patients with COVID-19 using cardiac magnetic resonance imaging (CMR).Methods and Results: We prospectively screened 505 patients with moderate to severe COVID-19 disease from 7 hospitals in Japan. Of these patients, 31 (mean [±SD] age 63.5±10.4 years, 23 [74%] male) suspected of myocardial injury, based on elevated serum troponin or B-type natriuretic peptide concentrations either upon admission or 3 months after discharge, underwent CMR 3 months after discharge. The primary endpoint was the presence of myocardial injury, defined by any of the following: (1) contrast enhancement in the left or right ventricle myocardium on late gadolinium enhancement CMR; (2) left or right ventricular dysfunction (defined as <50% and <45%, respectively); and (3) pericardial thickening on contrast enhancement. The mean (±SD) duration between diagnosis and CMR was 117±16 days. The primary endpoint was observed in 13 of 31 individuals (42%), with 8 (26%) satisfying the modified Lake Louise Criteria for the diagnosis of acute myocarditis. This study revealed a high incidence of myocardial injury identified by CMR in patients with moderate to severe COVID-19 and abnormal findings for cardiac biomarkers.

Diagnostic and prognostic value of cardiac troponins in emergency department patients presenting after a fall: A prospective, multicenter study.

Emergency department (ED) presentations after a ground-level fall (GLF) are common. Falls were suggested to be another possible presenting feature of a myocardial infarction (MI), as unrecognized MIs are common in older adults. Elevated high-sensitivity cardiac troponin (hs-cTn) concentrations could help determine the etiology of a GLF in ED. We investigated the prevalence of both MI and elevated high-sensitivity cardiac troponin T (hs-cTnT) and I (hs-cTnI), as well as the diagnostic accuracy of hs-cTnT and hs-cTnI regarding MI, and their prognostic value in older ED patients presenting after a GLF. This was a prospective, international, multicenter, cohort study with a follow-up of up to 1 year. Patients aged 65 years or older presenting to the ED after a GLF were prospectively enrolled. Two outcome assessors independently reviewed all discharge records to ascertain final gold standard diagnoses. Hs-cTnT and hs-cTnI levels were determined from thawed samples for every patient. In total, 558 patients were included. Median (IQR) age was 83 (77-89) years, and 67.7% were female. Elevated hs-cTnT levels were found in 384 (68.8%) patients, and elevated hs-cTnI levels in 86 (15.4%) patients. Three patients (0.5%) were ascertained the goldstandard diagnosis MI. Within 30 days, 18 (3.2%) patients had died. Nonsurvivors had higher hs-cTnT and hs-cTnI levels compared with survivors (hs-cTnT 40 [23-85] ng/L in nonsurvivors and 20 [13-33] ng/L in survivors; hs-cTnI 25 [14-54] ng/L in nonsurvivors and 8 [4-16] ng/L in survivors; p < 0.001 for both). A majority of patients (n = 364, 68.8%) presenting to the ED after a fall had elevated hs-cTnT levels and 86 (15.4%) elevated hs-cTnI levels. However, the incidence of MI in these patients was low (n = 3, 0.5%). Our data do not support the opinion that falls may be a common presenting feature of MI. We discourage routine troponin testing in this population. However, hs-cTnT and hs-cTnI were both found to have prognostic properties for mortality prediction up to 1 year.

High-Sensitivity Cardiac Troponin T and Frailty Predict Short-Term Mortality in Patients ≥75 Years Undergoing Emergency Abdominal Surgery: A Prospective Observational Study.

An elevated cardiac troponin concentration is a prognostic factor for perioperative cardiac morbidity and mortality. In elderly patients undergoing emergency abdominal surgery, frailty is a recognized risk factor, but little is known about the prognostic value of cardiac troponin in these vulnerable patients. Therefore, we investigated the prognostic significance of elevated high-sensitivity cardiac troponin T (hs-cTnT) concentration and frailty in a cohort of elderly patients undergoing emergency abdominal surgery. We included consecutive patients ≥75 years of age who presented for emergency abdominal surgery, defined as abdominal pathology requiring surgery within 72 hours, in a university hospital in Norway. Patients who underwent vascular procedures or palliative surgery for inoperable malignancies were excluded. Preoperatively, frailty was assessed using the Clinical Frailty Scale (CFS), and blood samples were measured for hs-cTnT. We evaluated the predictive power of CFS and hs-cTnT concentrations using receiver operating characteristic (ROC) curves and Cox proportional hazard regression with 30-day mortality as the primary outcome. Secondary outcomes included (1) a composite of 30-day all-cause mortality and major adverse cardiac event (MACE), defined as myocardial infarction, nonfatal cardiac arrest, or coronary revascularization; and (2) 90-day mortality. Of the 210 screened and 156 eligible patients, blood samples were available in 146, who were included. Troponin concentration exceeded the 99th percentile upper reference limit (URL) in 83% and 89% of the patients pre- and postoperatively. Of the participants, 53% were classified as vulnerable or frail (CFS ≥4). The 30-day mortality rate was 12% (18 of 146). Preoperatively, a threshold of hs-cTnT ≥34 ng/L independently predicted 30-day mortality (hazard ratio [HR] 3.14, 95% confidence interval [CI], 1.13-9.45), and the composite outcome of 30-day mortality and MACE (HR 2.58, 95% CI, 1.07-6.49). In this model, frailty (continuous CFS score) also independently predicted 30-day mortality (HR 1.42, 95% CI, 1.01-2.00) and 30-day mortality or MACE (HR 1.37, 95% CI, 1.02-1.84). The combination of troponin and frailty, 0.14 × hs-cTnT +4.0 × CFS, yielded apparent superior predictive power (area under the receiver operating characteristics curve [AUC] 0.79, 95% CI, 0.68-0.88), compared to troponin concentration (AUC 0.69, 95% CI, 0.55-0.83) or frailty (AUC 0.69, 95% CI, 0.57-0.82) alone. After emergency abdominal surgery in elderly patients, increased preoperative troponin concentration and frailty were independent predictors of 30-day mortality. The combination of increased troponin concentration and frailty seemed to provide better prognostic information than troponin or frailty alone. These results must be validated in an independent sample.

A study of clinical and serological correlation of early myocardial injury in elderly patients infected with the Omicron variant.

Myocardial injury in elderly Omicron variant patients is a leading cause of severe disease and death. This study focuses on elucidating the clinical characteristics and potential risk factors associated with myocardial injury in elderly patients infected with the Omicron variant. Myocardial injury was defined based on elevated cardiac troponin concentrations exceeding the 99th percentile upper reference limit. Among 772 elderly Omicron-infected patients, categorized into myocardial injury (n = 263) and non-myocardial injury (n = 509) groups. The stratified log-rank statistic was used to compare the probability of patients developing intensive care. Receiver operating characteristic curves were used to determine the best cut-off values of clinical and laboratory data for predicting myocardial injury. Univariate and multivariate logistic regression was adopted to analyze the risk factors for myocardial injury. The occurrence of myocardial injury in Omicron variant-infected geriatric patients was up to 34.07% and these patients may have a higher rate of requiring intensive care (P < 0.05). By comparing myocardial injury patients with non-myocardial injury patients, notable differences were observed in age, pre-existing medical conditions (e.g., hypertension, coronary heart disease, cerebrovascular disease, arrhythmia, chronic kidney disease, and heart failure), and various laboratory biomarkers, including cycle threshold-ORF1ab gene (Ct-ORF1ab), cycle threshold-N gene (Ct-N), white blood cell count, neutrophil (NEUT) count, NEUT%, lymphocyte (LYM) count, LYM%, and D-dimer, interleukin-6, procalcitonin, C-reactive protein, serum amyloid A, total protein, lactate dehydrogenase, aspartate aminotransferase, glomerular filtration rate, blood urea nitrogen, and serum creatinine (sCr) levels (P < 0.05). Furthermore, in the multivariable logistic regression, we identified potential risk factors for myocardial injury in Omicron variant-infected elderly patients, including advanced age, pre-existing coronary artery disease, interleukin-6 > 22.69 pg/ml, procalcitonin > 0.0435 ng/ml, D-dimer > 0.615 mg/L, and sCr > 81.30 μmol/L. This study revealed the clinical characteristics and potential risk factors associated with myocardial injury that enable early diagnosis of myocardial injury in Omicron variant-infected elderly patients, providing important reference indicators for early diagnosis and timely clinical intervention.

Hemoglobin A1c control is an independent predictor of circulating troponin concentrations using machine learning

Abstract Diabetes mellitus (DM) is associated with multiple comorbidities that may precipitate cardiac damage and elevated cardiac troponin (cTn) concentrations including renal failure, hyperlipidemia (HLD), hypertension (HTN), coronary artery disease (CAD), and congestive heart failure (CHF). Diabetics &amp;gt;70 years old have a higher likelihood of adverse outcomes including major cardiovascular events and cardiac mortality. However, the risk to younger diabetic patients and the precipitating factor(s) that facilitate cardiac injury in those with DM are unknown. The objective of this study was to investigate factors predictive of cTn concentrations in young, relatively healthy diabetic patients. We collected 1,533 remnant plasma samples from outpatients between 06/22-09/22 with physician ordered hemoglobin A1c testing. cTn was measured using the Abbott ARCHITECT High Sensitivity Troponin-I assay (limit of detection = 1.7 ng/L, imprecision = 4.76% at 50 ng/L). Demographic information (sex, race, BMI) and pertinent medical history (diabetes, HTN, HLD, CAD, CHF) were collected from the electronic medical record, along with estimated glomerular filtration rate (eGFR) and hemoglobin A1c. Exclusion criteria included: patients with missing laboratory data, those undergoing cancer treatment, or a history of myocardial infarction/cardiomyopathy/ cardiac surgery. Troponin results were classified as normal- or high-risk using a cut-off of 10 ng/L for females and 12 ng/L for males, thresholds previously shown to correlate with incidence of cardiovascular disease risk within 15 years. Univariate statistics were calculated using bootstrap resampling. An XGBoost model was trained to predict high-risk troponinemia, and summary statistics were calculated on a held-out test set. Of the 1,135 patients that met inclusion criteria, 621 (54.7%) were female. The median age was 60 years (IQR: 49-69 years) and the median A1c was 6.2% (IQR: 5.8-7.0%). A total of 746 patients (65.7%) had a prior diabetes diagnosis, with 156 patients (13.7%) having prediabetes, 42 patients (3.7%) having Type 1, and 548 patients (48.3%) having Type 2. Median troponin concentration for patients with an A1c &amp;lt;5.7% was 1.6 ng/L (IQR: 0.8-3.4), 5.7-6.4% was 2.2 ng/L (IQR:1.3-4.8), and ≥6.5% was 2.9 ng/L (IQR: 1.6-6.7). Univariate analysis demonstrated significant differences in troponinemia by age (CI of difference: 4.4-8.9 years), A1c (0.2-0.7%), and eGFR (28-38mL/min/1.73m2). The machine learning model demonstrated strong predictive capacity (sensitivity: 0.74, specificity: 0.86, PPV: 0.5, NPV: 0.92, area under ROC curve: 0.91). The features with the greatest impact on area under the ROC curve when removed were eGFR, Age, A1c, and CHF, suggesting a combination of clinical and laboratory variables can be used to predict circulating troponin concentrations in outpatients. Results of both univariate and multivariate analyses suggest that A1c control is an independent contributor to cTn concentrations. Ultimately, this study provides evidence that glucose control may be associated with cardiac damage and future cardiovascular events, warranting longitudinal outcome studies.

FRI119 Cardiac Biomarkers In Fabry Disease Exhibit Distinct Associations With Cardiovascular Outcomes: A (Rare) Prism For Cardiovascular Endocrinology

Abstract Disclosure: E. Shemesh: None. R. Rusk: None. P. Feigin: None. P. Deegan: None. Background: Fabry disease (FD) (OMIM 301500) is a rare x-linked metabolic disorder. Cardiovascular involvement in this rare metabolic disorder is common, including hypertrophy, fibrosis, heart failure and arrythmias. Troponin concentrations are often continuously elevated in FD patients, which at times may lead to false assumptions and unnecessary invasive investigations. Furthermore, while nt-proBNP, another cardiac biomarker, is regarded by some as a valuable biomarker in FD, its concentrations might be falsely high due to renal involvement in the disease. We sought to explore the associations between these cardiac biomarkers with myocardial architecture and clinical outcomes in patients with FD. Hypothesis: Biomarkers in FD associate similarly with myocardial architecture and clinical outcomes. Results: 107 patients from a tertiary referral center in the United Kingdom were included in this study. Mean age at first visit was 44.5±17 years. Study population was composed of 40 males and 67 females. Twenty males and 43 females carried a classic mutation. At baseline, 27% had elevated troponin concentrations and 30% of patients had elevated nt-proBNP concentrations. Throughout follow-up, 17 cardiac-related hospitalizations were recorded, and 12 cardiac-related deaths occurred. While troponin and nt-proBNP concentrations at baseline were closely related (r= 0.5, p &amp;lt; 0.05), distinct associations with future occurrence of cardiac architecture pathologies were noted: elevated troponin concentrations associated with presence of late gadolinium enhancement and left ventricular hypertrophy in a statistically significant manner (late gadolinium enhancement: r=0.54, p&amp;lt;0.05; hypertrophy: r-0.45, p&amp;lt;0.05), but nt-proBNP did not. However, both biomarkers associated with adverse clinical outcomes, and nt-proBNP displayed stronger correlation with future heart failure events than troponin (r= 0.52, p&amp;lt;0.05 vs r=0.3, p&amp;lt;0.05). Neither troponin nor nt-proBNP baseline concentrations associated with the implantation of cardiac device (defibrillator or pacemaker). Conclusions: Cardiac biomarkers associate differently with myocardial architecture pathologies, but similarly with clinical outcomes in FD. Our results imply distinct roles for troponin and nt-proBNP in adverse cardiac events in FD. Presentation: Friday, June 16, 2023

A-015 Hemoglobin A1c Control is An Independent Predictor of Circulating Troponin Concentrations Using Machine Learning

Abstract Background Diabetes mellitus (DM) is associated with multiple comorbidities that may precipitate cardiac damage and elevated cardiac troponin (cTn) concentrations including renal failure, hyperlipidemia (HLD), hypertension (HTN), coronary artery disease (CAD), and congestive heart failure (CHF). Diabetics &amp;gt;70 years old have a higher likelihood of adverse outcomes including major cardiovascular events and cardiac mortality. However, the risk to younger diabetic patients and the precipitating factor(s) that facilitate cardiac injury in those with DM are unknown. The objective of this study was to investigate factors predictive of cTn concentrations in young, relatively healthy diabetic patients. Methods We collected 1533 remnant plasma samples from outpatients between 06/22–09/22 with physician ordered hemoglobin A1c testing. cTn was measured using the Abbott ARCHITECT High Sensitivity Troponin-I assay (limit of detection = 1.7 ng/L, imprecision = 4.76% at 50 ng/L). Demographic information (sex, race, BMI) and pertinent medical history (diabetes, HTN, HLD, CAD, CHF) were collected from the electronic medical record, along with estimated glomerular filtration rate (eGFR) and hemoglobin A1c. Exclusion criteria included: patients with missing laboratory data, those undergoing cancer treatment, or a history of myocardial infarction/cardiomyopathy/cardiac surgery. Troponin results were classified as normal- or high-risk using a cut-off of 10 ng/L for females and 12 ng/L for males, thresholds previously shown to correlate with incidence of cardiovascular disease risk within 15 years. Univariate statistics were calculated using Wilcoxon rank sum tests. An XGBoost model was trained to predict high-risk troponinemia, and summary statistics were calculated on a held-out test set. Results Of the 1135 patients that met inclusion criteria, 621 (54.7%) were female. The median age was 60 years (IQR: 49–69 years) and the median A1c was 6.2% (IQR: 5.8%–7.0%). A total of 746 patients (65.7%) had a prior diabetes diagnosis, with 156 patients (13.7%) having prediabetes, 42 patients (3.7%) having Type 1, and 548 patients (48.3%) having Type 2. Median troponin concentration for patients with an A1c &amp;lt;5.7% was 1.6 ng/L (IQR: 0.8–3.4), 5.7%–6.4% was 2.2 ng/L (IQR: 1.3–4.8), and ≥6.5% was 2.9 ng/L (IQR: 1.6–6.7). Univariate analysis demonstrated significant differences in troponinemia by age (CI of difference: 4.4–8.9 years), A1c (0.2%–0.7%), and eGFR (28–38 mL/min/1.73 m2). The machine learning model demonstrated strong predictive capacity (sensitivity: 0.74, specificity: 0.86, PPV: 0.5, NPV: 0.92, area under ROC curve: 0.91). The features with the greatest impact on area under the ROC curve when removed were eGFR, Age, A1c, and CHF. Conclusion A combination of clinical and laboratory variables can be used to predict circulating troponin concentrations in outpatients. A1c control was an independent contributor to cTn concentrations, both in univariate and multivariate analyses. This study provides evidence that glucose control may be associated with cardiac damage and future cardiovascular events, warranting longitudinal outcome studies.

Abstract 14746: Pulse Pressure More Strongly Associates With Subclinical Myocardial Injury Than Do Systolic and Diastolic Blood Pressures

Introduction: Long-standing hypertension is associated with subclinical myocardial injury expressed as chronically elevated cardiac troponin concentrations. Subclinical myocardial injury and subsequent diffuse myocardial fibrosis may represent important intermediaries between hypertension and risk of heart failure and cardiovascular (CV) death. The relative strength of the associations between systolic blood pressure (BP), diastolic BP and pulse pressure and subclinical myocardial injury is unknown. Aim: To assess the relative impact of systolic BP, diastolic BP and pulse pressure on subclinical myocardial injury. Methods: Cardiac troponin I (cTnI) was measured by a high-sensitivity assay (Abbott Diagnostics) in 32,968 participants of the fourth wave of the Trøndelag Health Study (HUNT4) from 2017 to 2019. The longitudinal substudy included participants from HUNT4 who also had BP measurements from the third wave of HUNT (HUNT3) from 2006 to 2008. This included 18,681 study participants. All study participants with a history of CV disease were excluded prior to analysis. We defined subclinical myocardial injury as cTnI ≥4ng/L for women and ≥6ng/L for men, and used logistic regression models adjusted for established CV risk factors. Results: The mean age was 52 (SD±17) years, and 56.9% were female. Cross-sectionally, pulse pressure was more strongly associated with subclinical myocardial injury (adjusted odds ratio [aOR] 1.08, 95% confidence interval [CI] 1.06-1.10) compared to systolic BP (aOR 1.05, 95% CI 1.04-1.06) and diastolic BP (aOR 1.02, 95% CI 0.99-1.04). Longitudinally, change in diastolic BP was the only BP variable associated with subclinical myocardial injury (aOR 1.03, 95% CI 1.01-1.06), compared to change in systolic BP (aOR 1.01, 95% CI 0.99-1.02) and change in pulse pressure (aOR 0.99, 95% 0.97-1.01, p for all comparisons &lt; 0.05). Conclusions: At a given time, pulse pressure is the superior BP variable in predicting subclinical myocardial injury. Over time, only change in diastolic BP is associated with subclinical myocardial injury. High pulse pressure and longitudinal changes in diastolic BP could represent hypertension phenotypes at high risk for subclinical myocardial injury and subsequent increased CV risk.

Heart disease in the course of systemic sclerosis - an observational study.

Cardiac involvement is one of the major mortality factors in systemic sclerosis (SSc). This observational study aimed to compare patients with and without heart involvement in the course of SSc. Electronic medical records of patients treated between January 2021 and August 2022 in the Department of Rheumatology were searched for the diagnosis of SSc (ICD-10 code M47). The clinical characteristics of patients with and without heart involvement in the course of SSc were compared. Out of 36 patients with SSc, 7 patients were diagnosed with heart disease in the course of SSc. The major type of cardiac involvement was myocarditis (71%). The majority of patients with heart involvement had elevated troponin (86%) and NT-proBNP (71%) concentrations. The most common finding observed in echocardiography was diastolic failure (71%). The most frequent abnormality found in 24-hour Holter ECG was isolated supraventricular extrasystoles (100%). Risk factors for developing heart disease in the course of SSc were male gender (p = 0.018), diffuse type of SSc (p = 0.03), higher values of modified Rodnan skin score (p < 0.001), gastrointestinal tract involvement (p = 0.027) and myositis (p = 0.018). Optimal screening for heart disease is needed in this group of patients.

Outcomes following acute myocardial injury and type 2 myocardial infarction in patients with and without coronary artery disease

Abstract Background Acute myocardial injury and type 2 myocardial infarction typically occur in the setting of a concurrent illness. Differentiating acute myocardial injury from type 2 myocardial infarction is challenging as it relies on the assessment of myocardial ischaemia. Indeed, some have questioned whether this distinction is important, as patients with both conditions are at increased risk of future cardiovascular events. Whether this risk is similar and the role of identifying those with coronary artery disease is uncertain. Purpose To determine whether future risk of cardiovascular events and death differs in patients with type 2 myocardial infarction and acute myocardial injury according to the presence or absence of prior coronary artery disease. Methods We conducted a secondary analysis of a multi-centre randomised controlled trial of 48,282 consecutive patients with suspected acute coronary syndrome. Patients with an adjudicated index diagnosis of acute myocardial injury and type 2 myocardial infarction were stratified according to whether they were known previously to have coronary artery disease defined as prior coronary revascularisation, myocardial infarction, or angina. Cardiovascular death or myocardial infarction adjusted for the competing risk of non-cardiovascular death and all-cause death at one year was compared. Results In 9,115 patients with elevated cardiac troponin concentrations, 1,676 (18%) and 1,121 (12%) had acute myocardial injury and type 2 myocardial infarction, respectively. Patients with either condition known to have coronary artery disease were older (mean [standard deviation] age 78 [11] versus 73 [16] years) and more likely to be female (55% versus 45%) than those with no prior history. Coronary artery disease was previously identified in 40% (454/1,121) and 30% (509/1,167) of those with type 2 myocardial infarction and acute myocardial injury, respectively. Cardiovascular death or myocardial infarction at one year was more common in patients known to have coronary artery disease than those without for both acute myocardial injury (23% [115/509]) versus 14% [158/1,167]; P&amp;lt;0.001) and type 2 myocardial infarction (20% [91/454] versus 10% [69/667]; log-rank P&amp;lt;0.001) (Figure 1). Similarly all-cause death at one year was higher in patients with known coronary artery disease for both acute myocardial injury (31% [357/1,167] versus 18% [123/667]; P&amp;lt;0.001) and type 2 myocardial infarction (40% [115/509] versus 30% [135/454]; P&amp;lt;0.001) (Figure 2). Conclusion Coronary artery disease is recognised in around one third of patients with acute myocardial injury and type 2 myocardial infarction and is associated with higher rates of cardiovascular events and all-cause death. Risk doubled in those with coronary artery disease and was similar whether the index diagnosis was myocardial injury or infarction, suggesting that coronary investigation and secondary prevention may have a role in both conditions. Funding Acknowledgement Type of funding sources: Foundation. Main funding source(s): The University of Edinburgh and British Heart Foundation

Presentation cardiac troponin and early computed tomography coronary angiography in patients with suspected acute coronary syndrome: a pre-specified secondary analysis of the RAPID-CTCA trial.

AimsTo evaluate the potential associations between presentation cardiac troponin and the clinical impact of early computed tomography coronary angiography (CTCA) in intermediate-risk patients with suspected acute coronary syndrome.Methods and resultsIn a large multicentre randomized controlled trial of patients with intermediate-risk chest pain due to suspected acute coronary syndrome, early CTCA had no effect on the primary outcome—death or subsequent Type 1 or 4b myocardial infarction—but reduced the rate of invasive coronary angiography. In this pre-specified secondary analysis, cardiovascular testing and clinical outcomes were compared between those with or without cardiac troponin elevation at presentation. Of 1748 patients, 1004 (57%) had an elevated cardiac troponin concentration and 744 (43%) had a normal concentration. Patients with cardiac troponin elevation had a higher Global Registry of Acute Coronary Events score (132 vs. 91; P < 0.001) and were more likely to have obstructive coronary artery disease (59 vs. 33%; P < 0.001), non-invasive (72 vs. 52%; P < 0.001) and invasive (72 vs. 38%; P < 0.001) testing, coronary revascularization (47 vs. 15%; P < 0.001), and the primary outcome (8 vs. 3%; P = 0.007) at 1 year. However, there was no evidence that presentation cardiac troponin was associated with the relative effects of early CTCA on rates of non-invasive (Pinteraction = 0.33) and invasive (Pinteraction = 0.99) testing, coronary revascularization (Pinteraction = 0.57), or the primary outcome (Pinteraction = 0.41).ConclusionPresentation cardiac troponin had no demonstrable associations between the effects of early CTCA on reductions in non-invasive and invasive testing, or the lack of effect on coronary revascularization or the primary outcome in intermediate-risk patients with suspected acute coronary syndrome.

Transfusion in Older Anemic Patients: Should the Troponin Value Be Taken into Account?

BackgroundAnemia is common in older individuals, but it is not known whether the prognostic impact of transfusion differs according to cardiac troponin concentration. MethodsDuring this 2-year retrospective study in an acute geriatric unit, 514 patients with hemoglobin <10 g/dL and troponin sampling were included. Thirty-day and 1-year mortality were compared according to transfusion status and troponin and hemoglobin levels. ResultsOf the 514 anemic patients included (median age 88 years), 157 (31%) had elevated troponin concentrations. These patients were more likely to die at 30 days (49% vs 27%, P < .001) and 1 year (65% vs 51%, P = .004) than patients with normal values. Among patients with elevated troponin concentrations, 30-day mortality tended to be lower in transfused than in not-transfused patients (hazard ratio 0.48; 95% confidence interval, 0.21-1.08; P = .07). This association was not found in patients without troponin elevation (hazard ratio 1.09; 95% CI, 0.61-1.93; P = .8). Transfusion was associated with 30-day survival in patients with hemoglobin ≤8 g/dL. It was also associated with excess 1-year mortality in patients with hemoglobin >8 g/dL. ConclusionsThis pilot study suggests that transfusion could be associated with better 30-day outcomes in older anemic patients with anemia-related myocardial injury. Thus, troponin levels could be involved in decision-making relative to transfusion in anemic older patients. Clinical trials are needed to establish the benefit of transfusion in patients with elevated troponins.

Ficus sur methanol leaf extract ameliorated doxorubicin-induced cardio-renal damage in Wistar albino rats

Doxorubicin is an effective and still-used antineoplastic agent. However, the clinical use of doxorubicin is marred by life-threatening cardiotoxicity and nephrotoxicity. Free radicals have been implicated in the toxicity of doxorubicin. The aim of this study was to determine the phytochemical contents and protective effects of methanol extract of Ficus sur (MEFS) in doxorubicin-induced oxidative damage in Wistar albino rats, using biomarkers of cardiac, renal functions and oxidative stress as indicators. Phytochemical analyses revealed that MEFS is rich in tannins, alkaloid, saponins, flavonoids, but low in steroids. Acute toxicity studies show that MEFS was non-toxic up to 5000mg/kg b.w of Wistar rats. Administration of doxorubicin led to a significant (P&lt; 0.05) increase in Creatine kinase (CK-MB), troponin, creatinine, urea and MDA concentrations. Sodium and potassium concentrations were not significantly (P&gt;0.05) affected. Cardiac and renal superoxide dismutase (SOD), catalase and glutathione (GSH) were also significantly reduced. Results also show that pre-administration of MEFS was cardio- and nephroprotective in doxorubicin oxidative damage as evidenced by significant (P&lt;0.05) reduction of elevated troponin, CK-MB, creatinine and urea concentrations. Concentrations of renal and cardiac SOD, catalase and GSH were also significantly (p&lt;0.05) increased by MEFS compared to doxorubicin-treated group. Cardiac and renal MDA concentrations were significantly reduced. It may be concluded that protective effects of MEFS on doxorubicin toxicity may be due to the antioxidant properties of MEFS.

Diagnosis and Management of Patients With Myocardial Injury After Noncardiac Surgery: A Scientific Statement From the American Heart Association.

Myocardial injury after noncardiac surgery is defined by elevated postoperative cardiac troponin concentrations that exceed the 99th percentile of the upper reference limit of the assay and are attributable to a presumed ischemic mechanism, with or without concomitant symptoms or signs. Myocardial injury after noncardiac surgery occurs in ≈20% of patients who have major inpatient surgery, and most are asymptomatic. Myocardial injury after noncardiac surgery is independently and strongly associated with both short-term and long-term mortality, even in the absence of clinical symptoms, electrocardiographic changes, or imaging evidence of myocardial ischemia consistent with myocardial infarction. Consequently, surveillance of myocardial injury after noncardiac surgery is warranted in patients at high risk for perioperative cardiovascular complications. This scientific statement provides diagnostic criteria and reviews the epidemiology, pathophysiology, and prognosis of myocardial injury after noncardiac surgery. This scientific statement also presents surveillance strategies and treatment approaches.

Myopericarditis after messenger RNA Coronavirus Disease 2019 Vaccination in Adolescents 12 to 18 Years of Age

ObjectivesTo characterize the clinical course and outcomes of children 12-18 years of age who developed probable myopericarditis after vaccination with the Pfizer-BioNTech (BNT162b2) coronavirus disease 2019 (COVID-19) messenger RNA (mRNA) vaccine.Study designA cross-sectional study of 25 children, aged 12-18 years, diagnosed with probable myopericarditis after COVID-19 mRNA vaccination as per the Centers for Disease Control and Prevention criteria for myopericarditis at 8 US centers between May 10, 2021, and June 20, 2021. We retrospectively collected the following data: demographics, severe acute respiratory syndrome coronavirus 2 virus detection or serologic testing, clinical manifestations, laboratory test results, imaging study results, treatment, and time to resolutions of symptoms.ResultsMost (88%) cases followed the second dose of vaccine, and chest pain (100%) was the most common presenting symptom. Patients came to medical attention a median of 2 days (range, <1-20 days) after receipt of Pfizer mRNA COVID-19 vaccination. All adolescents had an elevated plasma troponin concentration. Echocardiographic abnormalities were infrequent, and 92% showed normal cardiac function at presentation. However, cardiac magnetic resonance imaging, obtained in 16 patients (64%), revealed that 15 (94%) had late gadolinium enhancement consistent with myopericarditis. Most were treated with ibuprofen or an equivalent nonsteroidal anti-inflammatory drug for symptomatic relief. One patient was given a corticosteroid orally after the initial administration of ibuprofen or an nonsteroidal anti-inflammatory drug; 2 patients also received intravenous immune globulin. Symptom resolution was observed within 7 days in all patients.ConclusionsOur data suggest that symptoms owing to myopericarditis after the mRNA COVID-19 vaccination tend to be mild and transient. Approximately two-thirds of patients underwent cardiac magnetic resonance imaging, which revealed evidence of myocardial inflammation despite a lack of echocardiographic abnormalities.

Myocardial injury in coronavirus disease 19 (Covid-19): main pathophysiological mechanisms and clinical utility of cardiac biomarkers

Covid-19 is responsible for myocardial injury in many infected patients, which is associated with severe disease and critical illness. The mechanisms by which SARS-CoV-2 may cause myocardial damage involve direct effect of the virus in cardiac cells and indirect effect due to the clinical consequences of Covid-19. Cardiomyocytes are well known to express Angiotensin-Converting Enzyme-2 receptors (ACE-2) to facilitate the virus cell entry, which could explain the occurrence of myocarditis, functional alterations in the myocardium, and more rarely, myocardial infarction. Myocardial injury may also be secondary to systemic inflammation or coagulopathy due to complicated Covid-19. The existence of a cardio-intestinal axis with alteration of tryptophan metabolism in the small bowel leading first to colitis and then to systemic inflammation has also been evoked to explain the myocardial injury. Morphological and metabolic disturbances of the heart during the Covid-19 are associated with elevated concentrations of cardiac blood biomarkers, mainly troponins and natriuretic peptides. The determination of these biomarkers has proven to be very useful for diagnosis, prognosis, and risk stratification. Indeed, recent data demonstrated that about 20% of infected patients admitted to the hospital have elevated troponin or BNP levels, and Covid-19 patients with elevated troponin concentrations beyond the diagnostic threshold (99th percentile) were associated with a higher risk of in-hospital mortality. In conclusion, after more than a year of a unique global pandemic, it is now clearly established that myocardial injury during Covid-19 is frequent and strongly contributes to the severity of the disease. Cardiac alterations secondary to direct infection of cardiac cells by SARS-CoV-2 or to the clinical consequences of Covid-19 are associated with elevated levels of cardiac biomarkers in blood, whose measurement is crucial in clinical decision making.

The c- reactive protein to troponin ratio enhances the differentiation of perimyocarditis from acute myocardial infarction

Abstract Funding Acknowledgements Type of funding sources: None. Differentiating perimyocarditis from acute myocardial infarction (AMI) is frequently difficult . Perimyocarditis is primarily an inflammatory disease associated with high C-reactive protein (CRP) and relatively low elevated troponin concentrations, while AMI is characterized by the opposite. We surmised that the CRP/troponin ratio on presentation could improve the differentiation between these two clinical entities. We evaluated the CRP/troponin ratio on presentation among patients consecutively included in a large hospital registry that included 1898 consecutive patients comprising 1025 ST-elevation myocardial infarction (STEMI) patients, 518 Non-STEMI (NSTEMI) patients, and 355 patients diagnosed as perimyocarditis. CRP and troponin were sampled on admission and their ratio was assessed against discharge diagnosis. ROC analysis of the CRP/troponin ratios evaluated the diagnostic accuracy of perimyocarditis against STEMI with or without NSTEMI. Median admission CRP/troponin ratios were 84, 65, and 436 mg × ml/liter × ng in STEMI, NSTEMI and perimyocarditis groups, respectively (p &amp;lt; 0.001) demonstrating good differentiating capability. The ROC of admission CRP/troponin ratio for diagnosis of perimyocarditis against STEMI with or without NSTEMI yielded a similar AUC of 0.74 and 0.73, respectively. CRP/troponin ratio &amp;gt; 500 resulted in specificity exceeding 85%. The CRP/troponin ratio is an effective tool that enhances the differentiation between perimyocarditis and AMI.

Differentiation between myopericarditis and acute myocardial infarction on presentation in the emergency department using the admission C-reactive protein to troponin ratio.

The treatment of myopericarditis is different than that of acute myocardial infarction (AMI). However, since their clinical presentation is frequently similar it may be difficult to distinguish between these entities despite a disparate underlying pathogenesis. Myopericarditis is primarily an inflammatory disease associated with high C-reactive protein (CRP) and relatively low elevated troponin concentrations, while AMI is characterized by the opposite. We hypothesized that evaluation of the CRP/troponin ratio on presentation to the emergency department could improve the differentiation between these two related clinical entities whose therapy is different. Such differentiation should facilitate triage to appropriate and expeditious therapy. We evaluated the CRP/troponin ratio on presentation among patients consecutively included in a large single center registry that included 1898 consecutive patients comprising 1025 ST-elevation myocardial infarction (STEMI) patients, 518 Non-STEMI (NSTEMI) patients, and 355 patients diagnosed on discharge as myopericarditis. CRP and troponin were sampled on admission in all patients and their ratio was assessed against discharge diagnosis. ROC analysis of the CRP/troponin ratios evaluated the diagnostic accuracy of myopericarditis against all AMI, STEMI, and NSTEMI patients. Median admission CRP/troponin ratios were 84, 65, and 436 mg×ml/liter×ng in STEMI, NSTEMI and myopericarditis groups, respectively (p<0.001) demonstrating good differentiating capability. The Receiver-operator-curve of admission CRP/troponin ratio for diagnosis of myopericarditis against all AMI, STEMI, and NSTEMI patients yielded an area-under-the curve of 0.74, 0.73, and 0.765, respectively. CRP/troponin ratio>500 resulted in specificity exceeding 85%, and for a ratio>1000, specificity>92%. The CRP/troponin ratio can serve as an effective tool to differentiate between myopericarditis and AMI. In the appropriate clinical context, the CRP/troponin ratio may preclude further evaluation.

Expert consensus on peri-operative myocardial injury screening in noncardiac surgery: A literature review.

Peri-operative myocardial injury, detected by dynamic and elevated cardiac troponin (cTn) concentrations, is a common complication of noncardiac surgery that is strongly associated with 30-day mortality. Although active screening for peri-operative myocardial injury has been suggested in recent guidelines, clinical implementation remains tentative due to a lack of examples on how to tackle such an interdisciplinary project at a local level. Moreover, consensus on which assay and cTn cut-off values should be used has not yet been reached, and guidance on whom to screen is lacking. In this article, we aim to summarise local examples of successfully implemented cTn screening practices and review the current literature in order to provide information and suggestions for patient selection, organisation of a screening programme, caveats and a potential management pathway.