Evidence Of Acute Coronary Syndrome Research Articles

578 LONG-TERM OUTCOME OF VENTRICULAR TACHYCARDIA CATHETER ABLATION IN PATIENTS WITH CHRONIC CORONARY TOTAL OCCLUSION

Abstract Background Chronic coronary total occlusions (CTO) are considered an emerging predictor of ventricular arrhythmias (VAs) but currently there are only few data on arrhythmic outcomes in patients affected by CTO undergoing radiofrequency catheter ablation of VAs. Objective This study sought to evaluate the impact of unrevascularized CTO on the recurrence of VAs after catheter ablation. Methods This was a single-center retrospective study that enrolled 120 patients, between 2015 and 2020. All patients were admitted for ventricular tachycardia (VT) or high premature ventricular contractions (PVCs) burden (>25% detected by Holter ECG), without evidence of acute coronary syndrome; they underwent coronary angiography, electrophysiology (EP) study and three-dimensional electroanatomic mapping (3D-EAM) followed by VAs ablation. Results Twenty-eight patients (23%) of 120 patients showed CTO at coronary angiography. At baseline, CTO group presented with higher prevalence of hypertension, chronic renal disease, systolic ventricular dysfunction, secondary prevention ICD implantation, higher rate of low abnormal activities by 3D-EAM compared to the non-CTO group. At a median follow-up of 15 months (range 1-96 months) after catheter ablation, the only independent predictor of VAs recurrence was the presence of moderate to severe left ventricular (LV) dysfunction (p=0.02). Conclusion The presence of CTO does not predict VAs recurrence after catheter ablation which is instead predicted by LV dysfunction.

Mid-Term Outcome of Ventricular Arrhythmias Catheter Ablation in Patients with Chronic Coronary Total Occlusion Compared to Ischemic and Non-Ischemic Patients.

Chronic coronary total occlusions (CTO) are considered an emerging predictor of ventricular arrhythmias (VAs), but currently there are few data on arrhythmic outcomes in patients affected by CTO undergoing radiofrequency catheter ablation of VAs. This study sought to evaluate the impact of unrevascularized CTO on the recurrence of VAs after catheter ablation. This was a single-center retrospective study enrolling 120 patients between 2015 and 2020. All patients were admitted for ventricular tachycardia (VT) or high premature ventricular contractions burden (>25% detected by Holter ECG), without evidence of acute coronary syndrome; they underwent coronary angiography, electrophysiology (EP) study, and three-dimensional electroanatomic mapping (3D-EAM) followed by VAs ablation. Twenty-eight patients (23%) of 120 patients showed CTO at coronary angiography. At baseline, the CTO group presented with higher prevalence of hypertension, chronic renal disease, systolic ventricular dysfunction, secondary prevention ICD implantation, and higher rate of LAVA by 3D-EAM compared with the non-CTO group. At a median follow-up of 15 months (range 1−96 months) after catheter ablation, the only independent predictor of VAs recurrence was the presence of moderate to severe left ventricular (LV) dysfunction. Therefore, the presence of CTO does not predict VAs recurrence after catheter ablation, which is instead predicted by LV dysfunction.

A FEBRILE CRISIS: MONOMORPHIC VENTRICULAR TACHYCARDIA IN A STRUCTURALLY INTACT HEART

A FEBRILE CRISIS: MONOMORPHIC VENTRICULAR TACHYCARDIA IN A STRUCTURALLY INTACT HEART

Prediction of acute-coronary-syndrome using newly-defined R2-CHA2DS2-VASc score among patients with chest pain

BackgroundChest-pain patients with no evidence of acute coronary syndrome might still be at risk for adverse outcomes. Adding renal function to the classic scoring of CHADS and CHA2DS2 VASC may improve risk stratification of chest-pain patients discharged from internal medicine wards after acute coronary syndrome (ACS) rule-out. MethodsWe accessed medical records of patients admitted to internal medicine wards during 2010–2016 and discharged following ACS rule-out. A R2CHA2DS2-VASc score model that included higher scores as kidney function deteriorated was calculated and compared to CHADS and CHA2DS2 VASC scores. The primary endpoint was the composite of 30-day ACS and mortality. One-year ACS and 1-year mortality were the secondary endpoints. The study included 12,449 patients, stratified into three risk groups according to their R2CHA2DS2-VASc score. ResultsParticipants were stratified into 3 groups according to R2CHA2DS2-VASc score. R2CHA2DS2-VASc score predicted better the composite outcome of ACS and 30-day and 1-year mortality after discharge (OR: 4, 95%, CI 2.3–7, p < 0.01 and OR: 13.3, 95% CI 7.8–22.7, p < 0.01, respectively). Receiver operating characteristic curve analysis showed better risk stratification of the R2CHA2DS2-VASc compared with both CHADS and CHA2DS2 VASC score. ConclusionsThe R2CHA2DS2-VASc score is a better predictor of short- and long-term cardiovascular morbidity and mortality after hospital discharge.

The Impact of Cardiology Consultation on Medical Intensive Care Unit Patients with Elevated Troponin Levels

BackgroundCardiac troponin (cTn) is mainly used to diagnose acute coronary syndrome (ACS). However, cTn can also be elevated in critically ill patients secondary to demand ischemia or myocardial injury. The impact of cardiology consultation on the clinical outcomes of patients admitted to medical intensive care unit (ICU) with elevated cTn is unclear. MethodsA retrospective analysis of medical ICU patients with elevated cTn without evidence of ACS between January 2013 through December 2018. Patients were stratified based on documentation of cardiology consultation. The primary outcome was 1-year mortality. Secondary outcomes were in-hospital and 30-day mortality, the length of stay (LOS), further cardiac testing, 30-day readmission rate, new prescription of cardiac medications, and the predictors of a cardiology consultation. ResultsOf 846 patients screened, 766 patients were included, of whom 63.2% had cardiology consultation. Cardiology consultation group had longer median LOS (7 vs. 5 days, P = 0.007), additional cardiac testing (90.3% vs. 67.7%, P < 0.001), and more new cardiac medications (52.1% vs. 16.3%, P < 0.001). No difference was noted in-hospital mortality (adjusted odds ratio [aOR], 0.6, 95% CI, 0.4–1.1, P = .117), 30-day mortality (aOR = 0.8, 95% CI, 0.5–1.4, P = .425), 1- year mortality (aOR, 1.4, 95% CI, 0.9–2.2, P = .193), or cardiac-specific 30-day readmission rate (aOR, 7.0, 95% CI, 0.7–14.9, P = .137). History of coronary artery disease (CAD) was the most independent predictor for a cardiology consult (aOR, 2.2, 95% CI, 1.3–3.8, P < .001). ConclusionCardiology consultation for elevated cTn in medical ICU patients was associated with increased cardiac testing and LOS, without significant impact on mortality.

Clinical Features and Prognosis of Type 2 Myocardial Infarction in Acutely Decompensated Diabetic Patients

BackgroundAfter the introduction of the universal definition of myocardial infarction, the incidence and diagnosis of type 2 myocardial infarction have risen dramatically, yet there are no clear guidelines on clinical management. Diabetic patients are at high risk for developing type 2 myocardial infarction when admitted in a decompensated state, and they are also at high risk for future cardiovascular events. MethodsWe performed a retrospective analysis of 1058 patients admitted with diabetic ketoacidosis or hyperosmolar hyperglycemic state between 2011 and 2016. Patients were included if they had cardiac troponin I measured within 24 hours of admission, were older than 18 years of age, and had no evidence of acute coronary syndrome on admission. Baseline characteristics, admission laboratory test results, major adverse cardiovascular events, cardiac stress testing, and coronary angiography data up to 1 year after admission were reviewed. Patients were categorized into 2 groups: those with and those without type 2 myocardial infarction. The study had 2 endpoints: mortality and major adverse cardiac events (MACE) at 1 year and an abnormal result on stress test or coronary angiography at 1 year. ResultsOf the 845 patients who met the inclusion criteria, 133 patients (15%) had type 2 myocardial infarction on admission. Patients with type 2 myocardial infarction were at a significantly higher risk for mortality and MACE at 1 year than those without. Patients with type 2 myocardial infarction were also at higher risk for developing an abnormal result on stress test or coronary angiography within 1 year of admission as compared with those without type 2 myocardial infarction (40% vs 24%; odds ratio 2; P = .0699). ConclusionAcutely decompensated diabetic patients with type 2 myocardial infarction are at increased risk for death and MACE. These patients may also be at risk for undiagnosed coronary artery disease.

Do circulating blood cell types correlate with modifiable risk factors and outcomes in patients with acute coronary syndrome (ACS)?

AimsAtherosclerosis is an inflammatory process with different cardiovascular risk factors (CVRFs) contributing to its pathogenesis. We aimed to evaluate the specific relationship between circulating blood leukocytes, troponin I and CVRFs. MethodsWe prospectively enrolled 959 patients with evidence of acute coronary syndrome either in form of unstable angina or STEMI or NSTEMI. Details demographic characteristics, CVRF and biochemical parameters such as total white blood cells (WBC), neutrophil, lymphocytes, platelet, neutrophil/lymphocyte ratio (NLR), platelet/lymphocyte ratio (PLR), and troponin I were collected. ResultsThe results indicated that patients having either hypertension, diabetes or smoking habit had significantly higher levels of total WBC (p=0.013), neutrophil (p=0.029), NLR (p=0.029) and PLR (p=0.009). The level of troponin I was unaffected by these risk factors. Significant association of hypertension was found with total WBC (p=0.0392), lymphocytes (p=0.0384) and PLR (p=0.0027), whereas in diabetes and females all other leukocyte subtypes were significantly altered except for platelet and troponin I. Smokers had higher level of total WBC count (p=0.0033) and PLR (p=0.0464). No relationship between CVRFs and leukocytes was observed in males. The age independent effect was observed with PLR, whereas association with total WBC, lymphocytes, NLR, platelet was specific in older population. In younger patients NLR (p=0.0453) is more likely to be elevated. Mortality was significantly associated with changes in the leukocytes but not with the CVRF presence. ConclusionWe demonstrate that the neutrophils, lymphocytes and total WBC along with its ratios predict mortality and are more likely to be elevated in presence of CVRFs.

10 Current Utilisation of High-Sensitivity Troponin; Does it Improve Our Accuracy in Diagnosing Acute Myocardial Infarction?

Introduction High sensitivity troponin assays (Hs-Tn) are part of the diagnostic criteria for identifying myocardial infarction, in the presence of ischaemic chest pain, with or without ECG changes. However, the increased sensitivity of the new generation HS-Tn assays has come at the expense of a marked reduction in specificity, which is further confounded when sampled inappropriately in the absence of clinical features suggestive of an acute coronary syndrome (ACS). We audited the utilisation of HS-Tn in both the emergency and acute medical departments at our institution. Methods A retrospective observational audit was performed before and after formal education was delivered to the hospital regarding use of HS-TnI, between October 2013 and July 2014. The audit was assessed against current European Society of Cardiology guidelines in the use of HS-Tn in diagnosing ACS. The main parameters assessed were presence of symptoms or ECG findings in keeping with an ischaemic-episode and the concordance of the initial diagnosis with the subsequent cardiologist-guided diagnosis. Results Ninety-six consecutive patients were sampled in the two audit cycles (50 in the initial cohort and 46 in the re-audit. All patients had HS-TnI assayed on admission and initial treatment with anti-platelet and anti-thrombotic therapy commenced. 46% (n = 23/50) (Figure 1) vs. 67% (n = 31/46) sampled in the presence of chest pain +/- ECG changes. 8% (n = 4/50) vs. 11% (n = 5/46) were treated for an ACS following cardiology review, with 92% (n = 46/50) vs. 89% (n = 41/46), having no evidence of ACS. 52% (n = 26/46) (Figure 2) vs. 34% (14/41) of the cohorts had an elevated HS-TnI (>0.04 mcg/L), attributable to concurrent sepsis, renal dysfunction or tachy-arrhythmias. Conclusion HS-Tn is frequently performed in the absence of clinical features or clinical suspicion of an ACS, reducing the specificity of the test. There are important clinical and financial implications with the inappropriate use of Troponin assays outside of the context of a clinical suspicion of an ACS. Improved education and adherence to guidelines is paramount in improving clinical and diagnostic accuracy of this cardiac biomarker in identifying ACS.

Association between glycosylated hemoglobin and acute coronary syndrome in type 2 diabetes mellitus

Background and objective: Chronic hyperglycemia in type 2 diabetes increases the risk of microvascular events. However, the prognostic value of hemoglobin A1c (HbA1c) level in patients with coronary atherosclerotic disease has not been well characterized and remains controversial. This study was an attempt to know the association between HbA1c and acute coronary syndrome (ACS) in Indian type 2 diabetic patients. Materials and Methods: This study is a case-control study done at a tertiary care hospital. Cases were diabetic patients with ACS and controls were diabetic patients without any evidence of ACS. To eliminate confounding bias, matching was done between two groups for age, sex, duration of diabetes, presence of hypertension, smoking, and dyslipidemia. Patients belonging to either gender in age group of 40-80 years, with diagnosis of diabetes mellitus (as per American diabetic association (ADA) criteria) on treatment were selected. HbA1c was measured by immunological assay. Results: A total of 60 cases (Group A, diabetic patients with ACS) and 60 controls (Group B, diabetic patients without the evidence of ACS) were included in the study. Mean age of patients in group A is 64.22 ± 6.39 years and in group B is 64.48 ± 6.57 years. Duration of diabetes group in A is 9 ± 5.75 years and in group B is 9.2 ± 5.45 years. The association of HbA1c level with ACS was highly significant when analyzed by multiple regression analysis after adjusting for confounders (adjusted odds ratio (OR): 4.92, confidence interval (CI): 2.16-11.17, P = 0.0001).The difference in HbA1c level between the groups was highly significant in the whole groups (P < 0.0001) and when analyzed by categorizing the patients based on gender, presence of hypertension, dyslipidemia, and smoking. Conclusion: HbA1c level is strongly associated with risk of ACS. Occurrence of ACS was significantly more in patients with HbA1c level more than 7% when compared with patients with HbA1c level less than 7%.

Cardiac troponin I as a prognostic factor in critically ill pneumonia patients in the absence of acute coronary syndrome

PurposeElevated cardiac troponin (cTn) has been associated with worse outcomes in critically ill patients, but few studies have focused on whether these markers are related to outcomes in patients with severe pneumonia. We investigated the levels of cTnI in critically ill patients hospitalized for severe pneumonia and whether elevated levels of cTnI correlated with the clinical outcome of this patient group. Materials and methodsWe conducted a retrospective study of patients admitted to the medical intensive care unit (ICU) with severe pneumonia with levels of cTnI obtained within 24 hours of admittance. Patients with evidence of acute coronary syndrome were excluded. A cTnI level greater than 0.034 ng/mL was considered positive. P value < .05 was considered significant. ResultsA total of 152 patients (community-acquired pneumonia [39.5%], health care–associated pneumonia [40.8%], and hospital-acquired pneumonia [19.7%]) were included in the study. Eighty-eight (58%) patients had detectable cTnI levels (median, 0.049 ng/mL). Patients with increased cTnI levels showed higher in-ICU mortality (38.6% vs 21.9%, P = .028). The association between elevated cTnI levels and mortality remained significant after adjustment using a multivariate model (adjusted hazard ratio = 1.398; 95% confidence interval, 1.005-1.945; P = .047). ConclusionsIncreased levels of cTnI are an independent predictor of ICU mortality in patients hospitalized with severe pneumonia without evidence of acute coronary syndrome.

A study of ECG pattern, cardiac structural abnormalities and familial tendency in patients with early repolarisation syndrome in South India

BackgroundEarly repolarisation (ER) on ECG, which was initially believed to be benign, has of late been considered otherwise. Brugada syndrome has recently been thought to be an extension of the...

Troponin I Elevation Due to Alcoholism in Absence of Acute Coronary Syndrome: A Case Report

Cardiac troponin I (cTnI), a sensitive and specific marker for myocardial injury, has been utilized for the diagnosis of an acute myocardial infarction. However, a variety of clinical scenarios without evidence of acute coronary syndrome (ACS), such as pulmonary embolism, sepsis, renal failure or stress-induced cardiomyopathy may also cause the elevation of cTnI. We described a 55-year-old Hispanic male with abnormal elevations of cTnI without objective evidence of myocardial infarction damage. We hypothesized that his long-term chronic alcoholic intoxication is causing the myocardial injury, responsive for cTnI elevation. We proposed that alcohol-induced early myocardial damage, independent of alcoholic cardiomyopathy, might be related to alcohol-induced cTnI elevation in this patient. This is the first report suggesting that the abnormal elevations of cTnI can be seen in patients with chronic alcoholism without objective evidence of myocardial infarction. J Med Cases. 2014;5(10):545-548 doi: http://dx.doi.org/10.14740/jmc1895w

Influence of dipyridamole stress echocardiography on galectin-3, amino-terminal B-type natriuretic peptide (NT-proBNP) and high-sensitivity troponin T

Objective Non-invasive assessment using a pharmacological provocative test is an essential part of the workup of patients admitted to the emergency department with chest pain. Some doubts, however, remain about the safety of dipyridamole stress echocardiography in patients with non-diagnostic troponin and ECG.Methods and results Twenty-nine consecutive patients admitted to the emergency department with chest pain and no evidence of acute coronary syndrome were subjected to standard dipyridamole stress echocardiography. Blood samples for measurement of galectin-3, NT-proBNP and high-sensitivity troponin T (HS-TnT) were collected at the baseline and after provocative testing. The provocative test was positive in 7/29 patients. As compared with baseline measurements, no signifi cant diff erences were observed in 1-h values of HS-TnT (10.7 versus 10.5 ng/L; P= 0.085) and galectin-3 (14.3 versus 13.7 ng/mL; P= 0.128), whereas values of NT-proBNP were slightly higher (126 versus 111 ng/L; P= 0.002). The 1-h delta variation of patients with a positive provocative test was signifi cantly higher than that of patients with negative provocative testing for galectin-3 (1.12 versus 1.00; P< 0.001), but not for HS-TnT (0.98 versus 1.00; P= 0.184) and NT-proBNP (1.10 versus 1.04; P= 0.344). The 1-h delta variation of galectin-3 was > 1 in all patients with a positive provocative test as compared with 50% of patients with a negative provocative test (P = 0.018).Conclusions Dipyridamole stress testing did not trigger clinically meaningful injuries to the myocardium. Galectin-3 testing may hence be preliminarily regarded as a complementary means for enhancing the diagnostic value of provocative testing. It is also worthwhile investigating whether patients with abnormal response to a provocative test and increased galectin-3 values may be targeted with specifi c therapy.

High Grade Atrioventricular Block Presenting with Cardiac Arrest

Introduction: Atrioventricular block usually does not cause cardiac arrest because of the development of an escape rhythm which maintains cardiac output. We report a case of high grade AV block presenting with cardiac arrest. Case Description: A 74-year-old man with past medical history of hypertension, dyslipidemia and a recent stroke was brought to the emergency room after a cardiac arrest, with pulseless electrical activity as the initial rhythm. Cardiopulmonary resuscitation was performed with return of spontaneous circulation after five minutes. On examination, he was unresponsive, with heart rate of 33 beats per minute, blood pressure of 108/51mmHg, normal heart sounds and clear lungs. He was given a total of 2mg of atropine, following which he was started on dopamine infusion, with no significant increase in heart rate. His electrocardiogram showed high grade AV block with ventricular rate of 30 beats per minute. An assessment of cardiac arrest due to severe conduction disease, with no evidence of acute coronary syndrome was made. A trans-venous pacemaker was inserted with improvement in the patient’s blood pressure and mental status. EKG revealed demand ventricular pacing with 100% ventricular capture. By the third day of admission, he was fully awake and following simple commands, but he remained pacemaker-dependent with no subsidiary rhythm. He had a dual chamber permanent pacemaker inserted without complication. Discussion: In advanced (high grade) second degree AV block, there is failure of conduction of two or more consecutive P waves. High grade AV block may be asymptomatic, or it may present with symptoms of hypoperfusion due to reduced cardiac output. Conclusion: This case describes a not previously reported presentation of high grade AV block with cardiac arrest and is in agreement with the 2008 American College of Cardiology/American Heart Association/Heart Rhythm Society (ACC/AHA/HRS) device guidelines recommendations for permanent pacemaker insertion.

Elevated Cardiac Troponin in Acute Stroke without Acute Coronary Syndrome Predicts Long-Term Adverse Cardiovascular Outcomes.

Background. Elevated cardiac troponin in acute stroke in absence of acute coronary syndrome (ACS) has unclear long-term outcomes. Methods. Retrospective analysis of 566 patients admitted to Temple University Hospital from 2008 to 2010 for acute stroke was performed. Patients were included if cardiac troponin I was measured and had no evidence of ACS and an echocardiogram was performed. Of 200 patients who met the criteria, baseline characteristics, electrocardiograms, and major adverse cardiovascular events (MACE) were reviewed. Patients were characterized into two groups with normal and elevated troponins. Primary end point was nonfatal myocardial infarction during follow-up period after discharge. The secondary end points were MACE and death from any cause. Results. For 200 patients, 17 patients had positive troponins. Baseline characteristics were as follows: age 63.1 ± 13.8, 64% African Americans, 78% with hypertension, and 22% with previous CVA. During mean follow-up of 20.1 months, 7 patients (41.2%) in elevated troponin and 6 (3.3%) patients in normal troponin group had nonfatal myocardial infarction (P = 0.0001). MACE (41.2% versus 14.2%, P = 0.01) and death from any cause (41.2% versus 14.5%, P = 0.017) were significant in the positive troponin group. Conclusions. Elevated cardiac troponin in patients with acute stroke and no evidence of ACS is strong predictor of long-term cardiac outcomes.

A Case of Superior Mesenteric Vein Thrombosis Associated with Left Ventricular Thrombus Formation

A 55-year-old man with atopic dermatitis came to emergency department at our hospital due to acute abdominal pain. Abdominal enhanced CT revealed superior mesenteric vein thrombosis，small intestine necrosis and peritonitis. He underwent emergency surgery(jejunectomy). ECG demonstrated abnormal Q waves in I and aVL. The result for hematologic laboratory values on admission revealed no evidence of acute coronary syndrome. After surgery, non-sustained VT was recorded on ECG monitoring. Echocardiography was performed and there was an asynergy in the postero-lateral region of the left ventricular(LV). LV thrombus was also detected. LV ejection fraction was 40%. Left ventricular ejection fraction was 40%. Echocardiography also revealed thrombosis in left ventricular with asynergy of posterior-lateral. Intravenous heparin was begun and the size of LV thrombus was gradually reduced. Thrombosis was gradually reduced. Although acute cerebral infarction, splenic and renal infarction were detected, no apparent organic disorders were found. 11 days after admission, LV thrombus disappeared. We continued the anticoagulant therapy with warfarin, and there was no evidence of the recurrence of thrombus. The case of mesenteric venous thrombosis in this case is thought to be prothrombotic state due to inflammatory conditions. We report a rare case of superior mesenteric vein thrombosis associate with LV asynergy and thrombus formation.

Clinical significance of troponin elevations in acute decompensated diabetes without clinical acute coronary syndrome

BackgroundElevation of cardiac troponin has been documented in multiple settings without acute coronary syndrome. However, its impact on long-term cardiac outcomes in the context of acute decompensated diabetes remains to be explored.MethodsWe performed a retrospective analysis of 872 patients admitted to Temple University Hospital from 2004–2009 with DKA or HHS. Patients were included if they had cardiac troponin I (cTnI) measured within 24 hours of hospital admission, had no evidence of acute coronary syndrome and had a follow up period of at least 18 months. Of the 264 patients who met the criteria, we reviewed the baseline patient characteristics, admission labs, EKGs and major adverse cardiovascular events during the follow up period. Patients were categorized into two groups with normal and elevated levels of cardiac enzymes. The composite end point of the study was the occurrence of a major cardiovascular event (MACE) during the follow up period and was compared between the two groups.ResultsOf 264 patients, 24 patients were found to have elevated cTnI. Compared to patients with normal cardiac enzymes, there was a significant increase in incidence of MACE in patients with elevated cTnI. In a regression analysis, which included prior history of CAD, HTN and ESRD, the only variable that independently predicted MACE was an elevation in cTnI (p = 0.044). Patients with elevated CK-MB had increased lengths of hospitalization compared to the other group (p < 0.001).ConclusionsElevated cardiac troponin I in patients admitted with decompensated diabetes and without evidence of acute coronary syndrome, strongly correlate with a later major cardiovascular event. Thus, elevated troponin I during metabolic abnormalities identify a group of patients at an increased risk for poor long-term outcomes. Whether these patients may benefit from early detection, risk stratification and preventive interventions remains to be investigated.

Troponin I in acute decompensated heart failure: insights from the ASCEND‐HF study

We examined the prognostic importance of cardiac troponin I (cTnI) in a cohort of patients enrolled in the ASCEND-HF study of nesiritide in acute decompensated heart failure (ADHF). Circulating troponins are a prognostic marker in patients with ADHF. Contemporary assays with greater sensitivity require reassessment of the significance of troponin elevation in HF. Cardiac troponin I was measured in a core laboratory in 808 ADHF patients enrolled in the ASCEND-HF biomarkers substudy using a sensitive assay (VITROS Trop I ES, Ortho Clinical Diagnostics) with a lower limit of detection of 0.012 ng/mL and a 99th percentile upper reference limit (URL) of 0.034 ng/mL. Patients with clinical evidence of acute coronary syndrome or troponin >5× the URL were excluded. Multivariable modelling was used to assess the relationship between log(cTnI) and in-hospital and post-discharge outcomes. Baseline cTnI was undetectable in 22% and elevated above the 99th percentile URL in 50% of subjects. cTnI levels did not differ based on HF aetiology. After multivariable adjustment, higher cTnI was associated with worsened in-hospital outcomes such as length of stay (P = 0.01) and worsening HF during the index hospitalization (P = 0.01), but was not associated with worsened post-discharge outcomes at 30 or 180 days. The relationship between cTnI and outcomes was generally linear and there was no evidence of a threshold effect at any particular level of cTnI. cTnI is elevated above the 99th percentile URL in 50% of ADHF patients and predicts in-hospital outcome, but is not an independent predictor of long-term outcomes.

Incremental Prognostic Value of Different Components of Coronary Atherosclerotic Plaque at Cardiac CT Angiography beyond Coronary Calcification in Patients with Acute Chest Pain

To systematically evaluate the incremental predictive value of cardiac computed tomographic (CT) angiography beyond the assessment of coronary artery calcium (CAC) in patients who present with acute chest pain but without evidence of acute coronary syndrome (ACS). The human research committee approved this study and waived the need for individual written informed consent. The study was HIPAA compliant. A total of 458 patients (36% male; mean age, 55 years ± 11) with acute chest pain at low to intermediate risk for coronary artery disease underwent coronary calcification assessment with cardiac CT angiography. All patients who did not experience ACS at index hospitalization were followed for instances of a major adverse cardiac event (MACE), such as a myocardial infarct, revascularization, cardiac death, or angina requiring hospitalization. CAC score and cardiac CT angiography were used to derive the presence and extent of atherosclerotic plaque (calcified, noncalcified, or mixed), and obstructive lesions (>50% luminal narrowing) were related to outcomes by using univariate and adjusted Cox proportional hazards models. Of the 458 patients, 70 (15%) experienced MACE (median follow-up, 13 months). Patients with no plaque at cardiac CT angiography remained free of events during the follow-up period, while 11 (5%) of 215 patients with no CAC had MACE. The extent of plaque was the strongest predictor of MACE independent of traditional risk factors (hazard ratio [HR], 151.77 for four or more segments containing plaque as compared with those containing no plaque; P < .001). Patients with mixed plaque were more likely to experience MACE (HR, 86.96; P = .002) than those with exclusively noncalcified plaque (HR, 58.06; P = .005) or exclusively calcified plaque (HR, 32.94; P = .02). The strong prognostic value of cardiac CT angiography is incremental to its known diagnostic value in patients with acute chest pain without ACS and is independent of traditional risk factors and CAC.

TROPONINS PREDICT LONG TERM OUTCOMES IN DKA PATIENTS WITHOUT ACUTE CORONARY SYNDROME

Methods: A Retrospective analysis of all patients admitted to Temple University Hospital with DKA between 2003-2008. Patient were included if they had their cardiac troponin I measured, did not have an evidence of acute coronary syndrome (ACS) and had a follow up at Temple for at least 18 months. Patients were divided into 1elevated troponin group (above the normal reference interval 0.05-0.40 ng/ml), 2normal troponin group. The composite end point of the study was the occurrence of MI, PCI, CABG or death during the follow up period and not at the time of the initial admission.