European Society Of Cardiology Algorithm Research Articles

Cardiac biomarkers prior to noncardiac surgery

Cardiac biomarkers, such as high-sensitivity cardiac troponin (hs-cTn) and brain natriuretic peptide (BNP) or N‑terminal prohormone of brain natriuretic peptide (NT-proBNP) are measured perioperatively to improve the prognosis and risk prediction. The European Society of Cardiology (ESC), European Society of Anesthesiology and Intensive Care (ESAIC) and the German Society of Anesthesiology and Intensive Care Medicine (DGAI) have recently published guidelines on the use of cardiac biomarkers prior to surgery. This article provides an overview of the available evidence on perioperative troponin and BNP/NT-proBNP measurements. Current guideline recommendations are presented and discussed. MEDLINE, Cochrane and google.scholar were searched for relevant keywords. Titles and abstracts of identified papers were checked for relevance and published results were summarized. Guideline recommendations from the ESC, ESAIC and DGAI are presented, compared and evaluated based on the available literature. In addition, the significance of new perioperative cardiac biomarkers is discussed based on the existing evidence. The definitions, diagnosis and management of cardiovascular events in the perioperative context differ from those in the nonsurgical setting. The evidence for the measurement of hs-cTn and BNP/NT-proBNP is evaluated differently in the guidelines and the resulting recommendations are partly contradictory. In particular, recommendations for changes in perioperative management based on biomarker measurements diverge. The ESC guidelines propose an algorithm that uses preoperative biomarkers as the basis for additional cardiac investigations. In particular, invasive coronary angiography is recommended for patients with stable chronic coronary syndrome who have no preoperative cardiac symptoms but elevated biomarkers. In contrast, the ESAIC guidelines emphasize that the available evidence is not sufficient to use perioperative biomarker measurements as abasis for achange in perioperative management. Treating physicians should coordinate interdisciplinary (surgery, anesthesiology, cardiology) recommendations for clinical practice based on the aforementioned guidelines. If cardiac biomarkers are routinely determined in high-risk patients, this should be done in accordance with the ESC algorithm.

Diagnostic performance of the 0/2 hours ESC algorithm with high-sensitivity cardiac troponin T in an unselected community United States cohort

Abstract Background There are no robust data addressing the United States (US) experience with the 0/2 hours (h) European Society of Cardiology (ESC) algorithm using high-sensitivity cardiac troponin T (hs-cTnT). Purpose To evaluate the diagnostic performance of the 0/2h ESC-recommended absolute deltas in a US population. Methods Observational US cohort study of ED patients undergoing 0 and 2 h hs-cTnT measurements. The 99th percentiles upper reference limits (URL) used were 10 ng/L for women and 15 ng/L for men. Diagnostic outcomes were the adjudicated diagnoses of acute myocardial infarction (MI, type 1 or 2). Results A total of 1084 patients met inclusion criteria, amongst which 49% were women. Chest discomfort was reported in 521 (48%) patients. Among patients with a baseline hs-cTnT≤99th URL (n=434), 4 MIs occurred. To rule-out MI, an absolute 0-2h delta change <4 ng/L resulted in a sensitivity of 100% (95% CI: 39.8, 100) and a negative predictive value (NPV) of 100% (95% CI: 99.1, 100). To rule-in MI, an absolute 0-2h delta ≥10 ng/L had a specificity of 99.8 % (95% CI: 98.7, 99.9) and positive predictive value (PPV) of 75% (95% CI: 19.4, 99.4). Among patients with a baseline hs-cTnT >99th URL (n=650), 110 MIs occurred. In these patients, both rule-out (sensitivity 65%, NPV 91%) and rule-in (specificity 7.2%, PPV 11%) were poor using the ESC-recommended absolute deltas. Among patients with modest hs-cTnT increases (99th URL to 100 ng/L) neither the ESC-recommended absolute nor the Fourth Universal Definition of MI (UDMI)-recommended relative deltas provided acceptable performance. Among patients with marked hs-cTnT increases at presentation (>100 ng/L), a relative delta change >20% as recommended by the UDMI resulted in a superior rule-in performance, with a specificity of 92.0% (95% CI 74.0, 99.0) and PPV of 84.6% (57.4, 95.7). Conclusions In our unselected US-cohort of patients undergoing hs-cTnT, the 0/2h ESC algorithm had a good diagnostic performance in patients without myocardial injury at presentation. Conversely, in patients with myocardial injury at baseline, the ESC-recommended absolute deltas performed poorly to determine who had MI. In patients with marked hs-cTnT increases >100 ng/L at presentation, the UDMI recommended 20% relative change showed good rule-in performance.

Machine learning for early prediction of acute myocardial infarction or death in acute chest pain patients using electrocardiogram and blood tests at presentation

AimsIn the present study, we aimed to evaluate the performance of machine learning (ML) models for identification of acute myocardial infarction (AMI) or death within 30 days among emergency department (ED) chest pain patients.Methods and resultsUsing data from 9519 consecutive ED chest pain patients, we created ML models based on logistic regression or artificial neural networks. Model inputs included sex, age, ECG and the first blood tests at patient presentation: High sensitivity TnT (hs-cTnT), glucose, creatinine, and hemoglobin. For a safe rule-out, the models were adapted to achieve a sensitivity > 99% and a negative predictive value (NPV) > 99.5% for 30-day AMI/death. For rule-in, we set the models to achieve a specificity > 90% and a positive predictive value (PPV) of > 70%. The models were also compared with the 0 h arm of the European Society of Cardiology algorithm (ESC 0 h); An initial hs-cTnT < 5 ng/L for rule-out and ≥ 52 ng/L for rule-in. A convolutional neural network was the best model and identified 55% of the patients for rule-out and 5.3% for rule-in, while maintaining the required sensitivity, specificity, NPV and PPV levels. ESC 0 h failed to reach these performance levels.DiscussionAn ML model based on age, sex, ECG and blood tests at ED arrival can identify six out of ten chest pain patients for safe early rule-out or rule-in with no need for serial blood tests. Future studies should attempt to improve these ML models further, e.g. by including additional input data.

Influence of novel risk markers on defibrillator implantation in hypertrophic cardiomyopathy

Abstract Background/Introduction To guide implantable defibrillator (ICD) use in hypertrophic cardiomyopathy (HCM), European Society of Cardiology (ESC) guidelines recommend using individualised sudden death (SCD) risk scores based on quantitative clinical data. Newly published American guidelines are based on the accumulation of binary risk markers, which include imaging-based novel risk markers (NRMs) that were absent from the development of the ESC's algorithm. These NRMs are ejection fraction &amp;lt;50%, apical aneurysm, and extensive late gadolinium enhancement on cardiac magnetic resonance (CMR) imaging. Purpose To assess how NRMs may have altered ICD prescription across ESC-based SCD risk status prior to publication of current American guidance. Methods We examined electronic records (2013–2020) of a subset of HCM patients with contemporaneous (within 12 months) CMR and echocardiography data for NRMs, ESC risk status, and ICD prescription. Differences in categorical data were assessed by Fisher's exact test. Results We studied 334 HCM patients (74% male; age: 58±14 years), of whom 83 (25%) were referred for ICD. ESC risk status was considered low, medium (4–6% 5-year SCD risk), or high in 264, 26, and 20 patients, for whom ICDs were recommended in 40 (15%), 20 (77%), and 18 (90%) patients, respectively. In patients with low SCD risk status, rate of ICD recommendation was significantly higher when ≥1 NRMs were present (34/126 – 27% vs. 0 NRMs: 6/138 – 4%; p&amp;lt;0.0001). NRMs did not appear to influence ICD recommendation in patients with medium (≥1 NRMs: 14/17 – 82% vs. 0 NRMs: 6/9 – 67%; p=0.6) or high (≥1 NRMs: 14/15 – 93% vs. 0 NRMs: 4/5 – 80%; p=0.4) SCD risk status (Figure 1). NRMs were less frequent in low risk patients than in high risk patients (126/264 – 48% vs. 15/20 – 75%; p&amp;lt;0.05), suggesting interaction between ESC status and NRMs (Figure 2). Conclusion NRMs have disproportionate influence on ICD prescription in low ESC risk HCM patients. However, NRMs are not independent of ESC risk status, suggesting iterative development of the ESC's algorithmic approach will be the most effective way of predicting SCD. Funding Acknowledgement Type of funding sources: None.

Diagnostic Performance of Novel Troponin Algorithms for the Rule-Out of Non-ST-Elevation Acute Coronary Syndrome.

The European Society of Cardiology (ESC) rule-out algorithms use cutoffs optimized for exclusion of non-ST elevation myocardial infarction (NSTEMI). We investigated these and several novel algorithms for the rule-out of non-ST elevation acute coronary syndrome (NSTE-ACS) including less urgent coronary ischemia. A total of 1504 unselected patients with suspected NSTE-ACS were included and divided into a derivation cohort (n = 988) and validation cohort (n = 516). The primary endpoint was the diagnostic performance to rule-out NSTEMI and unstable angina pectoris during index hospitalization. The secondary endpoint was combined MI, all-cause mortality (within 30 days) and urgent (24 h) revascularization. The ESC algorithms for high-sensitivity cardiac troponin T (hs-cTnT) and I (hs-cTnI) were compared to different novel low-baseline (limit of detection), low-delta (based on the assay analytical and biological variation), and 0-1-h and 0-3-h algorithms. The prevalence of NSTE-ACS was 24.8%, 60.0% had noncardiac chest pain, and 15.2% other diseases. The 0-1/0-3-h algorithms had superior clinical sensitivity for the primary endpoint compared to the ESC algorithm (validation cohort); hs-cTnT: 95% vs 63%, and hs-cTnI: 87% vs 64%, respectively. Regarding the secondary endpoint, the algorithms had similar clinical sensitivity (100% vs 94%-96%) but lower clinical specificity (41%-19%) compared to the ESC algorithms (77%-74%). The rule-out rates decreased by a factor of 2-4. Low concentration/low-delta troponin algorithms improve the clinical sensitivity for a combined endpoint of NSTEMI and unstable angina pectoris, with the cost of a substantial reduction in total rule-out rate. There was no clear benefit compared to ESC for diagnosing high-risk events.

Maximal Wall Thickness Measurement in Hypertrophic Cardiomyopathy: Biomarker Variability and its Impact on Clinical Care

ObjectivesThe aim of this study was to define the variability of maximal wall thickness (MWT) measurements across modalities and predict its impact on care in patients with hypertrophic cardiomyopathy (HCM). BackgroundLeft ventricular MWT measured by echocardiography or cardiovascular magnetic resonance (CMR) contributes to the diagnosis of HCM, stratifies risk, and guides key decisions, including whether to place an implantable cardioverter-defibrillator (ICD). MethodsA 20-center global network provided paired echocardiographic and CMR data sets from patients with HCM, from which 17 paired data sets of the highest quality were selected. These were presented as 7 randomly ordered pairs (at 6 cardiac conferences) to experienced readers who report HCM imaging in their daily practice, and their MWT caliper measurements were captured. The impact of measurement variability on ICD insertion decisions was estimated in 769 separately recruited multicenter patients with HCM using the European Society of Cardiology algorithm for 5-year risk for sudden cardiac death. ResultsMWT analysis was completed by 70 readers (from 6 continents; 91% with >5 years’ experience). Seventy-nine percent and 68% scored echocardiographic and CMR image quality as excellent. For both modalities (echocardiographic and then CMR results), intramodality inter-reader MWT percentage variability was large (range –59% to 117% [SD ±20%] and –61% to 52% [SD ±11%], respectively). Agreement between modalities was low (SE of measurement 4.8 mm; 95% CI 4.3 mm-5.2 mm; r = 0.56 [modest correlation]). In the multicenter HCM cohort, this estimated echocardiographic MWT percentage variability (±20%) applied to the European Society of Cardiology algorithm reclassified risk in 19.5% of patients, which would have led to inappropriate ICD decision making in 1 in 7 patients with HCM (8.7% would have had ICD placement recommended despite potential low risk, and 6.8% would not have had ICD placement recommended despite intermediate or high risk). ConclusionsUsing the best available images and experienced readers, MWT as a biomarker in HCM has a high degree of inter-reader variability and should be applied with caution as part of decision making for ICD insertion. Better standardization efforts in HCM recommendations by current governing societies are needed to improve clinical decision making in patients with HCM.

Use of historical high-sensitivity cardiac troponin T levels to rule out myocardial infarction

ObjectiveSeveral high-sensitivity cardiac troponin (hs-cTn)-based strategies exist for rule-out of myocardial infarction (MI). It is unknown whether historical hs-cTnT concentrations can be used. This study aim to evaluate the performance...

Venous lactate improves the prediction of in-hospital adverse outcomes in normotensive pulmonary embolism

BackgroundArterial lactate is an established risk marker in patients with pulmonary embolism (PE). However, its clinical applicability is limited by the need of an arterial puncture. In contrast, venous lactate can easily be measured from blood samples obtained via routine peripheral venepuncture. MethodsWe investigated the prognostic value of venous lactate with regard to in-hospital adverse outcomes and mortality in 419 consecutive PE patients enrolled in a single-center registry between 09/2008 and 09/2017. ResultsAn optimised venous lactate cut-off value of 3.3 mmol/l predicted both, in-hospital adverse outcome (OR 11.0 [95% CI 4.6–26.3]) and all-cause mortality (OR 3.8 [95%CI 1.3–11.3]). The established cut-off value for arterial lactate (2.0 mmol/l) and the upper limit of normal for venous lactate (2.3 mmol/l) had lower prognostic value for adverse outcomes (OR 3.6 [95% CI 1.5–8.7] and 5.7 [95% CI 2.4–13.6], respectively) and did not predict mortality. If added to the 2019 European Society of Cardiology (ESC) algorithm, venous lactate <2.3 mmol/l was associated with a high negative predictive value (0.99 [95% CI 0.97–1.00]) for adverse outcomes in intermediate-low-risk patients, whereas levels ≥3.3 mmol/l predicted adverse outcomes in the intermediate-high-risk group (OR 5.2 [95% CI 1.8–15.0]). ConclusionVenous lactate above the upper limit of normal was associated with increased risk for adverse outcomes and an optimised cut-off value of 3.3 mmol/l predicted adverse outcome and mortality. Adding venous lactate to the 2019 ESC algorithm may improve risk stratification. Importantly, the established cut-off value for arterial lactate has limited specificity in venous samples and should not be used.

Venous lactate predicts adverse outcomes in normotensive pulmonary embolism

Abstract Background/Introduction Arterial lactate is an established risk marker in patients with acute pulmonary embolism (PE). However, its clinical application is limited by the need for an arterial puncture, a procedure not routinely performed in haemodynamically stable PE patients. In contrast, information on venous lactate can be easily obtained via peripheral venepuncture and might thus be more suitable for risk assessment in normotensive PE. Purpose To investigate the prognostic value of peripheral venous lactate for outcome prediction in normotensive patients with acute PE. Methods Consecutive normotensive PE patients enrolled in a prospective single-centre registry between 09/2008 and 03/2018 were studied. Study outcomes included in-hospital adverse outcome (PE-related death, cardiopulmonary resuscitation or vasopressor treatment) and all-cause mortality. An optimised venous lactate cut-off concentration was identified using receiver operating curve analysis and its prognostic value compared to the established cut-off value for arterial lactate (2.0 mmol/l) and the upper limit of normal for venous lactate (2.3 mmol/l). Furthermore, we tested if addition of venous lactate to the 2019 European Society of Cardiology (ESC) risk stratification algorithm improves risk prediction. Results We analysed data from 419 (age 70 [interquartile range (IQR) 57–79] years; 53% female) patients. Patients with an in-hospital adverse outcome had higher venous lactate concentrations than those with a favourable clinical course (3.1 [IQR 1.3–4.9] vs. 1.6 [IQR 1.2–2.3] mmol/l, p=0.001). An optimized cut-off value of 3.3 mmol/l predicted both, adverse outcome (OR 11.0 [95% CI 4.6–26.3]) and all-cause mortality (OR 3.8 [95% CI 1.3–11.3]). Venous lactate ≥2.0 mmol/l and ≥2.3 mmol/l had lower predictive value for an adverse outcome (OR 3.6 [95% CI 1.5–8.7] and OR 5.7 [95% CI 2.4–13.6], respectively) and did not predict all-cause mortality. If venous lactate was added to the 2019 ESC algorithm (Figure), a cut-off concentration of 2.3 mmol/l had high negative predictive value (0.99 [95% CI 0.97–1.00]) for an adverse outcome in intermediate-low-risk patients, whereas levels ≥3.3 mmol/l predicted adverse outcomes in the intermediate-high-risk group (OR 5.2 (95% CI 1.8–15.0). Conclusions Even modest venous lactate elevations above the upper limit of normal (2.3 mmol/l) were associated with increased risk for an in-hospital adverse outcome and a cut-off value of 3.3 mmol/l provided optimal prognostic performance predicting both, an adverse outcome and all-cause mortality. Adding venous lactate to the 2019 ESC algorithm seems to further improve risk stratification. Importantly, the established cut-off value for arterial lactate (2.0 mmol/l) has limited specificity in venous samples and should not be used. Venous lactate for risk stratification Funding Acknowledgement Type of funding source: Public grant(s) – National budget only. Main funding source(s): This study was supported by the German Federal Ministry of Education and Research (BMBF 01EO1503). The authors are responsible for the contents of this publication. BRAHMS GmbH, part of Thermo Fisher Scientific, Hennigsdorf/Berlin, Germany provided financial support for biomarker measurements. The sponsor was neither involved in biomarker measurements, statistical analyses, writing of the abstract nor had any influence on the scientific contents.

High-sensitivity troponin I for risk stratification in normotensive pulmonary embolism.

While numerous studies have confirmed the prognostic role of high-sensitivity troponin T (hsTnT) in pulmonary embolism (PE), high-sensitivity troponin I (hsTnI) is inappropriately studied. This study aimed to investigate the prognostic relevance of hsTnI in normotensive PE, establish the optimal cut-off value for risk stratification and to compare the prognostic performances of hsTnI and hsTnT.Based on data from 459 consecutive PE patients enrolled in a single-centre registry, receiver operating characteristic analysis was used to identify an optimal hsTnI cut-off value for prediction of in-hospital adverse outcomes (PE-related death, cardiopulmonary resuscitation or vasopressor treatment) and all-cause mortality.Patients who suffered an in-hospital adverse outcome (4.8%) had higher hsTnI concentrations compared with those with a favourable clinical course (57 (interquartile range (IQR) 22–197) versus 15 (IQR 10–86) pg·mL−1, p=0.03). A hsTnI cut-off value of 16 ng·mL−1 provided optimal prognostic performance and predicted in-hospital adverse outcomes (OR 6.5, 95% CI 1.9–22.4) and all-cause mortality (OR 3.7, 95% CI 1.0–13.3). Between female and male patients, no relevant differences in hsTnI concentrations (17 (IQR 10–97) versus 17 (IQR 10–92) pg·mL−1, p=0.79) or optimised cut-off values were observed. Risk stratification according to the 2019 European Society of Cardiology algorithm revealed no differences if calculated based on either hsTnI or hsTnT (p=0.68).Our findings confirm the prognostic role of hsTnI in normotensive PE. HsTnI concentrations >16 pg·mL−1 predicted in-hospital adverse outcome and all-cause mortality; sex-specific cut-off values do not seem necessary. Importantly, our results suggest that hsTnI and hsTnT can be used interchangeably for risk stratification.

Performance of the European Society of Cardiology 0/1-hour algorithm in the diagnosis of myocardial infarction with high-sensitivity cardiac troponin: Systematic review and meta-analysis.

A rapid rule-out or rule-in protocol based on the 0-hour/1-hour algorithm using high-sensitivity cardiac troponin (hs-cTn) is recommended by the European Society of Cardiology (ESC); recently multiple studies have validated it in their settings. We aimed to assess the diagnostic accuracy of the 2015 ESC guidelines for management of acute coronary syndrome in patients without ST-segment elevation 0-hour/1-hour algorithm using hs-cTn for the early rule-out and rule-in of acute myocardial infarction (AMI) on presentation. Systematic searches were conducted using PubMed, the Cochrane Library and the International Clinical Trials Registry Platform to identify prospective studies from 2015 to October 2019 involving adults presenting to the emergency department with possible acute coronary syndrome in which hs-cTn measurements were obtained according to the ESC algorithm and AMI outcomes were adjudicated during the initial hospitalization. Eleven studies, involving 19,213 patients, were identified. Pooled prevalence of AMI during the index hospitalization was 11.3% (95% confidence interval (CI) 3.9-18.8%). Summary sensitivity and specificity in diagnosing AMI were 99% (95% CI 98-99%; I2 63%) and 91% (95% CI 91-92%; I2 96%) respectively. The summary positive likelihood ratio was 11.6 (95% CI 8.5-15.8; I2 97%) and the pooled likelihood ratio negative 0.02 (0.01-0.03; I2 52%). Cumulative all-cause mortality at 30 days in the rule-out group was 0.11%, and 2.8% in the rule-in group, and 30 days AMI in the rule-out group was 0.08%. The ESC 0-hour/1-hour algorithm using high-sensitivity cardiac troponin has high diagnostic accuracy; it allows safe rule-out as well as accurate rule-in of AMI, with low cumulative 30-day mortality and AMI in patients assigned the rule-out zone.

Validation of a fast prognostic score for risk stratification of normotensive patients with acute pulmonary embolism

BackgroundRecent studies demonstrate an improved prognostic performance of the 2014 European Society of Cardiology (ESC) algorithm for risk stratification of patients with pulmonary embolism (PE) compared to the 2008 ESC algorithm. The modified FAST and Bova scores appear especially helpful to identify PE patients at intermediate-high risk.MethodsWe validated the prognostic performance of the modified FAST score compared to other scores for risk stratification in a post-hoc analysis of 868 normotensive PE patients included in the prospective Italian Pulmonary Embolism Registry. In-hospital adverse outcome was defined as PE-related death, mechanical ventilation, cardiopulmonary resuscitation or administration of catecholamines.ResultsOverall, 27 patients (3.1%) had an adverse outcome and 32 patients (3.7%) died. The rate of an adverse outcome was highest in the intermediate-high risk classes of the 2019 ESC algorithm (7.5%) and the modified FAST score (5.3%) while the Bova score failed to discriminate between intermediate-low and intermediate-high-risk patients. Patients classified as intermediate-high risk by the 2019 ESC algorithm (Odds Ratio [OR], 4.2 [95% CI, 1.9–9.0]) and modified FAST score (OR, 2.8 [1.3–6.2]) had a higher risk of an adverse outcome compared to patients classified by the Bova score (OR, 1.6 [0.7–3.7]). The c-index was higher for the 2019 ESC algorithm and the modified FAST score (AUC, 0.69 [0.58–0.79] and 0.67 [0.59–0.76]) compared to the Bova score (AUC, 0.64 [0.55–0.73]).ConclusionsThe 2019 ESC algorithm provided the best prognostic performance, but also the modified FAST score accurately stratified normotensive PE patients in different risk classes while the Bova score failed to identify patients at highest risk.Graphic abstract

P2678Performance of the European society cardiology 0/1-hour algorithm in the diagnosis of myocardial infarction with high-sensitivity cardiac troponin T: meta-analysis

Abstract Introduction A rapid rule-out or rule-in protocol based on the 0-hour/1-hour algorithm using high-sensitivity cardiac troponin T (hs-cTnT) is recommended by the European Society of Cardiology (ESC), and recently multiple studies have validated it in their settings. We conducted a systematic review and meta-analysis with the aim of assess the diagnostic accuracy of the 2015 ESC guidelines for management of acute coronary syndrome (ACS) in patients without ST-segment elevation's 0-/1-hour algorithm using hs-cTnT for the early rule-out and rule-in of acute myocardial infarction (AMI) on presentation. For the secondary analysis we evaluate cumulative mortality at 30 days. Methods We carried out a systematic review and meta-analysis of prospective studies involving adults presenting to the emergency department with possible ACS in which hs-cTnT measurements were obtained according to the ESC algorithm and AMI outcomes were adjudicated during the initial hospitalization. We searched MEDLINE, EMBASE, Cochrane database and LILACS, and unpublished abstracts presented in international congresses from 2015 to November 2018.To obtain estimates of sensitivity and specificity, with corresponding 95% confidence intervals (CI), we used a bivariable random-effects model. Summary receiver operating characteristic curves were drawn, plotting individual studies as well as the summary estimate. Results Seven studies involving 9251 patients were identified. The summary sensitivity of these tests in diagnosing acute MI at presentation to the emergency department was estimated to be 99.1% (95% CI 97.2–99.7%) and the summary specificity was 92.5% (95% CI 86.6–95.9%). With a false positive rate of 0.075 (95% CI 0.041–0.134), diagnostic odds ratio (DOR) of 1293.1 (95% CI −52.48 to 2638.5), and Likelihood Ratio (LR) +13.193 (95% CI 5.3–21, and LR −0.010 (95% CI −0.001 to 0.021). Cumulative mortality at 30 days in the rule-out group was 0,08% (4 studies; n=3715). Conclusion The European Society Cardiology 0-Hour/1-Hour Algorithm using High-Sensitivity Cardiac Troponin T has high diagnostic accuracy, it allows safe rule-out as well as accurate rule-in of acute myocardial infarction. With low cumulative 30-day mortality in patients assigned the rule-out zone.

Heterogeneity of patients with arterial hypertension and heart failure with preserved left ventricular ejection fraction according to the clinical and structural-functional profile of the heart and arteries depending on the available diagnostic criteria o

The aim — to determine the frequency of different combinations of criteria of heart failure (HF) with preserved ventricular ejection fraction (EF), established by the European Society of Cardiology (ESC) in 2016, in symptomatic patients with arterial hypertension (AH) in clinical practice and to assess their relationship to the clinical profile and the structural and functional state of the heart and arteries.Materials and methods. The study included 103 patients aged 43 to 85 years, with symptoms and signs of HF, AH and LVEF ³ 50 %, which had signs of diastolic dysfunction (DD) according to Doppler EchoCG data. The level of N­terminal fragment of the brain natriuretic peptide (NT­proBNP) was assessed by an enzyme immunoassay. The pulse wave velocity (carotid­femoral) (PWVcf) was assessed using applanation tonometry. Using ECG, the back wall thickness (BWT) of the left ventricle (LV) and interventricular septal thickness (IST), end­diastolic index (EDI) and end­systolic index (ESI) of the LV, left ventricular myocardial index (LVMI), left atrium volume index (LAVI) and left ventricular ejection fraction (LVEF). Early (E) and late diastolic left ventricular filling velocity (A), E/A ratio, diastolic speed of septal and lateral motion of fibrous mitral valve ring, the mean value e¢, the relation Е/e¢, tricuspidal regurgitation velocity (TRV), the deceleration time of early diastolic filling (DT) and left ventricular isovolumic relaxation time (IVRT), and systolic pulmonary artery pressure (SPAP) — with the use of Doppler EchoCG were evaluated. Patients with ratio E/e¢ 9 — 13 at rest underwent diastolic stress test.Results and discussion. According to the ESC algorithm, HF was absent in 11 (10.6 %) patients (group 1); 28 (30.4 %) patients had structural criteria and no functional criteria (group 2); 64 (69.5 %) patients had three structural and functional criteria of HF according to ESC algorithm (group 3). High left ventricular filling pressure (LVFP) was found in all 35 (54.6 %) patients of group 3 without atrial fibrillation (AF) and in 7 (26.9 %) patients of group 3. Normal left ventricular filling pressure was found in all patients of group 1 and 7 (26.9 %) patients of group 2. Left ventricular filling pressure could not be identified in 4 (36.3 %) patients of group 1 and 12 (46.1 %) patients of group 2 (all p < 0.01). AF was present in 29 (45.3 %) patients of group 3 and in 2 patients (7.1 %) of group 2 (p < 0.01). Increase in SPAP was noted in 52 (81.2 %) patients of group 3 and 4 (14.2 %) patients of group 2 (p < 0.01). The dilatation of the right ventricle (RV) was more pronounced in group 3 than in groups 2 and 1 (p < 0.01 and p < 0.05). Patients of groups 1 and 2 were comparable according to PWVcf, patients of group 3 had higher values of this indicator than those of groups 2 and 1 (all p < 0.01). E/e¢ while exercise stress was more than 13 in 78.5 % patients of group 2 and in 18.2 % of group 1 (p < 0.01). Groups 2 and 3 had high levels of NT­proBNP — 438.4 ± 97.2 and 1057.3 ± 157.0 pg/ml, accordingly, in group 1 its level was 199.7 ± 17.2 pg/ml (all p < 0.01).Conclusions. In 70 % of patients with hypertension and clinical signs of HF, both structural and functional criteria of diagnosis of HF with preserved LV EF were defined according to the recommendations of the ESC (2016), which was associated with an increase in LV feeling pressure, AF — in 45 %, pulmonary hypertension — in 52 (81.2 %), with right ventricle dilatation — in 81 % and 27 % increase in PWVcf in compared with age and sex matched patients with AH without HF. AH patients with only two structural criteria of heart failure with a preserved LVEF in the absence of functional criteria (30 % of cases) differ from patients with AH without HF in terms of the level of NT­proBNP, an increase in E/e’ while exercise (85 % of cases) and comparable severity of clinical signs of heart failure.

Risk stratification of acute pulmonary embolism based on clinical parameters, H-FABP and multidetector CT

IntroductionRisk stratification of normotensive patients with acute pulmonary embolism (PE) includes the assessment of right ventricular dysfunction (RVD), biomarker levels, and a clinical score as suggested by the 2014 guidelines of the European Society of Cardiology (ESC). We performed an external validation of the prognostic performance of Heart-type Fatty Acid Binding Protein (H-FABP) and incorporated it into the new ESC algorithm. Material and methodsH-FABP was measured by fully-automated immunoturbidimetry in 716 patients from the PROTECT study (PROgnosTic valuE of CT scan in haemodynamically stable patients with acute symptomatic PE). ResultsH-FABP ranged from 0.7 to 123.6 ng/ml (median 4.13; IQR, 2.53–6.61) and was above the cut-off of 6 ng/ml in 209 patients (29.2%). A complicated course within 30 days (death, catecholamine administration, mechanical ventilation, resuscitation) occurred in 1.1% (n = 3) of the 271 low risk patients with a simplified Pulmonary Embolism Severity Index (sPESI) of 0 and was particular low (0.4%), if H-FABP levels were normal. In the case of elevated H-FABP, 4.3% of patients suffered complications despite sPESI of 0. The risk for an adverse 30-day outcome increased for patients of the intermediate-low and intermediate-high risk group and was highest for the combination of sPESI ≥1 with RVD on MDCT and elevated H-FABP (odds ratio 12.3, 95% confidence interval, 3.49–43.32; P < 0.001). ConclusionsH-FABP is suitable for risk stratification of normotensive PE patients if integrated in the new ESC algorithm and may help to identify patients with higher risk for adverse clinical events.

Prognostic impact of copeptin in pulmonary embolism: a multicentre validation study.

To externally validate the prognostic impact of copeptin, either alone or integrated in risk stratification models, in pulmonary embolism (PE), we performed a post hoc analysis of 843 normotensive PE patients prospectively included in three European cohorts.Within the first 30 days, 21 patients (2.5%, 95% CI 1.5-3.8) had an adverse outcome and 12 (1.4%, 95% CI 0.7-2.5) died due to PE. Patients with copeptin ≥24 pmol·L-1 had a 6.3-fold increased risk for an adverse outcome (95% CI 2.6-15.5, p<0.001) and a 7.6-fold increased risk for PE-related death (95% CI 2.3-25.6, p=0.001). Risk classification according to the 2014 European Society of Cardiology (ESC) guideline algorithm identified 248 intermediate-high-risk patients (29.4%) with 5.6% (95% CI 3.1-9.3) at risk of adverse outcomes. A stepwise biomarker-based risk assessment strategy (based on high-sensitivity troponin T, N-terminal pro-brain natriuretic peptide and copeptin) identified 123 intermediate-high-risk patients (14.6%) with 8.9% (95% CI 4.5-15.4) at risk of adverse outcomes. The identification of patients at higher risk was even better when copeptin was measured on top of the 2014 ESC algorithm in intermediate-high-risk patients (adverse outcome OR 11.1, 95% CI 4.6-27.1, p<0.001; and PE-related death OR 13.5, 95% CI 4.2-43.6, p<0.001; highest risk group versus all other risk groups). This identified 85 patients (10.1%) with 12.9% (95% CI 6.6-22.0) at risk of adverse outcomes and 8.2% (95% CI 3.4-16.2) at risk of PE-related deaths.Copeptin improves risk stratification of normotensive PE patients, especially when identifying patients with an increased risk of an adverse outcome.

European Society of Cardiology-Proposed Diagnostic Echocardiographic Algorithm in Elective Patients with Clinical Suspicion of Infective Endocarditis: Diagnostic Yield and Prognostic Implications in Clinical Practice.

Background:Echocardiography plays a central role in diagnosing infective endocarditis (IE). Accordingly, the European Society of Cardiology (ESC) has proposed a diagnostic echocardiographic algorithm. However, new studies are still needed to evaluate the degree of implementation of these guidelines in clinical practice and their consequences on incidence and prognosis of IE.Aim:This study aims to investigate the diagnostic yield of the ESC proposed echocardiographic algorithm in patients with suspected IE. We also examined the association among IE diagnosis and clinical outcomes.Methods:Retrospective analysis of a series of patients undergoing the ESC algorithm for clinical suspicion of IE at our institution.Results:Between 2009 and 2013, 323 cases were managed by a multidisciplinary team for clinical suspicion of IE. Following ESC algorithm, 26 (8%) patients were diagnosed with IE and 297 (92%) had IE excluded. In 92% of patients with a good-quality negative transthoracic echocardiography (TTE) and low level of clinical suspicion, the first TTE was considered sufficient to rule out IE. During a mean follow-up of 2.3 ± 1.4 years, patients who had a final diagnosis of IE showed similar mortality (P = 0.2) and rates of combined endpoint (all-cause death, stroke/transient ischemic attack, advanced atrioventricular block, and heart failure) compared to patients without echocardiographic diagnosis of IE (P = 0.5). Only 1% of the patients who had IE excluded experienced IE in the following 3 months, none of them in the subgroup of patients, in which a first negative TTE was considered sufficient to rule out IE.Conclusions:In spite of the current ESC recommendation TTE is used as part of a routine fever screen. Consequently, only a minority of patients had a final echocardiographic diagnosis of IE. Although in patients with low clinical suspicion a first negative TTE is sufficient to rule out IE, the incidence of clinical events is similar regardless the final diagnosis of IE.

Early diagnosis of acute myocardial infarction using high-sensitivity troponin I

ObjectiveThere is a clinical need for early and accurate diagnosis of acute myocardial infarction (AMI). Current European Society of Cardiology (ESC) guidelines recommend diagnosis of non-ST-elevation AMI based on serial troponin measurements. We aimed to challenge the ESC guidelines using 1) a high-sensitivity troponin I (hs-TnI) baseline cutoff, 2) an absolute hs-TnI change after 1 hour and 3) additional application of an ischemic ECG.Methods1,516 patients with suspected AMI presenting to the emergency department were included. Hs-TnI was measured directly at admission, after 1 and 3 hours. We investigated baseline concentrations, absolute changes of hs-TnI and additional application of an ischemic ECG to diagnose AMI. A positive predictive value (PPV) of more than 85% was targeted.ResultsThe median age of the study population was 65 years; 291 patients were diagnosed with AMI. The PPV of the 3-hours ESC algorithm was 85.5% (CI 79.7, 90.1) and 65.8% (CI 60.5,70.8) for the 1-hour algorithm. Using a high baseline hs-TnI concentration of 150 ng/L resulted in a PPV of 87.8% (CI 80.9,92.9). Alternatively, a hs-TnI change of 20 ng/L after 1 hour, resulted in a PPV of 86.5% (80.9,91.0), respectively for the diagnosis of AMI. Additional use of an ischemic ECG increased the PPV to 90.5% (CI 83.2,95.3), while reducing the efficacy.ConclusionThe diagnosis of AMI based on hs-TnI is challenging. The application of absolute hs-TnI changes after 1 hour may facilitate rapid rule-in of patients.Trial registrationwww.clinicaltrials.gov (NCT02355457).

Effectiveness of prognosticating pulmonary embolism using the ESC algorithm and the Bova score.

The prognostic value of the European Society of Cardiology (ESC) 2014 algorithm and the Bova score has lacked adequate validation. According to the ESC 2014 guidelines and the Bova score, we retrospectively risk stratified normotensive patients with PE who were enrolled in the PROTECT study. This study used a complicated course (which consisted of death from any cause, haemodynamic collapse, or recurrent PE) as the primary endpoint, and follow-up occurred through 30 days after the PE diagnosis. Of 848 patients, 37 % had a sPESI of 0 and 5 (1.6 %; 95 % confidence interval [CI], 0.5-3.7 %) experienced a complicated course. Of 143 patients with a sPESI of 0 points and negative computed tomographic pulmonary angiography (CTPA) for right ventricle (RV) dysfunction, three (2.1 %; 95 % CI, 0.4-6.0 %) experienced a complicated course. Four hundred seventy-eight (56 %) patients with a sPESI ≥ 1 had echocardiographic evidence of RV dysfunction or elevated troponin level or none, and 48 (10 %, 95 % CI, 7.5-13.1 %) experienced a complicated course. Fifty-seven (6.7 %) patients with a sPESI ≥ 1 had echocardiographic RV dysfunction and elevated troponin level, and 10 (17.5 %; 95 % CI, 8.8-29.9 %) experienced a complicated course, compared to 21.6 % (8 of 37 patients, 21.6 %; 95 % CI, 9.8-38.2 %) in Bova risk class III. In conclusion, the ESC 2014 prognostic algorithm is effective in the risk stratification of normotensive patients with PE. Use of CTPA did not improve the ability for identification of low-risk PE. Bova risk scoring did not significantly improve identification of intermediate-high risk PE.

Performance of the “CCS Algorithm” in real world patients

BackgroundWith the publication of the 2014 Focused Update of the Canadian Cardiovascular Society Guidelines for the Management of Atrial Fibrillation, the Canadian Cardiovascular Society Atrial Fibrillation Guidelines Committee has introduced a new triage and management algorithm; the so-called “CCS Algorithm”. The CCS Algorithm is based upon expert opinion of the best available evidence; however, the CCS Algorithm has not yet been validated. Accordingly, the purpose of this study is to evaluate the performance of the CCS Algorithm in a cohort of real world patients. MethodsWe compared the CCS Algorithm with the European Society of Cardiology (ESC) Algorithm in 172 hospital inpatients who are at risk of stroke due to non-valvular atrial fibrillation in whom anticoagulant therapy was being considered. ResultsThe CCS Algorithm and the ESC Algorithm were concordant in 170/172 patients (99% of the time). There were two patients (1%) with vascular disease, but no other thromboembolic risk factors, which were classified as requiring oral anticoagulant therapy using the ESC Algorithm, but for whom ASA was recommended by the CCS Algorithm. ConclusionsThe CCS Algorithm appears to be unnecessarily complicated in so far as it does not appear to provide any additional discriminatory value above and beyond the use of the ESC Algorithm, and its use could result in under treatment of patients, specifically female patients with vascular disease, whose real risk of stroke has been understated by the Guidelines.