Peak Troponin Levels Research Articles

Peak Troponin and CMR to Guide Management in Suspected ACS and Nonobstructive Coronary Arteries

BackgroundPatients presenting with acute coronary syndrome (ACS) and nonobstructive coronary arteries are a diagnostic dilemma. Cardiac magnetic resonance (CMR) has an overall diagnostic yield of ∼75%; however, in ∼25% of patients, CMR does not identify any myocardial injury. Identifying the underlying diagnosis has important clinical implications for patients’ management and outcome. ObjectivesThe authors sought to assess whether the combination of CMR and peak troponin levels in patients with ACS and nonobstructive coronary arteries would lead to increased diagnostic yield. MethodsConsecutive patients with ACS and nonobstructive coronary arteries without an obvious cause underwent CMR. The primary endpoint of the study was the diagnostic yield of CMR. The Youden index was used to find the optimal diagnostic cut point for peak troponin T to combine with CMR to improve diagnostic yield. Logistic or Cox regression models were used to estimate predictors of a diagnosis by CMR. ResultsA total of 719 patients met the inclusion criteria. The peak troponin T threshold for optimal diagnostic sensitivity and specificity was 211 ng/L. Overall, CMR has a diagnostic yield of 74%. CMR performed <14 days from presentation and with a peak troponin of ≥211 ng/L (n = 198) leads to an improved diagnostic yield (94% vs 72%) compared with CMR performed ≥14 days (n = 245). When CMR was performed <14 days and with a peak troponin of <211 ng/L, the diagnostic yield was 76% (n = 86) compared with 53% (n = 190) when performed ≥14 days. An increase in 1 peak troponin decile increases the odds of the CMR identifying a diagnosis by 20% (OR: 1.20; P = 0.008, 95% CI: 1.05-1.36). ConclusionsThe combination of CMR performed <14 days from presentation and peak troponin T ≥211 ng/L leads to a very high diagnostic yield (94%) on CMR. The diagnostic yield remains high (72%) even when CMR is performed ≥14 days from presentation, but reduces to 53% when peak troponin T was <211 ng/L.

Comparison between Non-obstructive versus obstructive coronary artery disease patients with acute coronary syndrome

Background and aim: Differences in prognosis and baseline clinical presentation have been documented among patient with acute coronary syndrome and coronary artery disease with obstructive (ObCAD) or nonobstructive arteries (NObCAD), but the rates of events largely varied across single studies, the present study aimed to compare the clinical profile, in-hospital and 3-month outcomes major adverse cardiovascular events (MACEs) of Acute Coronary Syndrome (ACS) patients with Non – Obstructive Coronary Diseases (NOCAD), versus Obstructive Coronary Diseases (OCAD). Patients and methods: This prospective observational study included 200 consecutive patients admitted with the diagnosis of ACS to Coronary Care Unit (CCU) at Al- Azhar University hospital Assiut and Sohag Specialized Cardiac and Digestive System Center. Results: There was statistically significant increase in patients suffered from common complication of ACS during 3 months follow up in group B (CAD) than group A (NOCAD).There was statistically significant between number of vessels in both groups with heart failure, and recurrent angina pain complications. Conclusion: Female sex, young age, less diabetic patients, less smoking, less ST segment changes, elevations in peak troponin levels were all associated with coronary angiography showing no significant stenosis.

Peak troponin T in STEMI: a predictor of all-cause mortality and left ventricular function

BackgroundThe clinical significance of peak troponin levels following ST-elevation myocardial infarction (STEMI) has not been definitively established. The purpose of this study was to examine the relationship between peak high-sensitivity cardiac troponin T (hs-cTnT) and all-cause mortality at 30 days and 1 year, and left ventricular ejection fraction (LVEF) in STEMI.MethodsA single-centre retrospective observational study was conducted of all patients with STEMI between January 2015 and December 2017. Demographics and clinical data were obtained through electronic patient records. Standard Bayesian statistics were employed for analysis.ResultsDuring the study period, 568 patients presented with STEMI. The mean age was 63.6±12 years and 76.4% were men. Of these, 535 (94.2%) underwent primary percutaneous coronary intervention, 12 (2.1%) underwent urgent coronary artery bypass and 21 (3.7%) were treated medically. Mean peak hs-cTnT levels were significantly higher in those who died within 30 days compared with those who survived (12 238 ng/L vs 4657 ng/L, respectively; p=0.004). Peak hs-cTnT levels were also significantly higher in those who died within 1 year compared with those who survived (10 319 ng/L vs 4622 ng/L, respectively; p=0.003). The left anterior descending artery was associated with the highest hs-cTnT and was the most common culprit in those who died at 1 year. An inverse relationship was demonstrated between peak hs-cTnT and LVEF (Pearson’s R=0.379; p<0.00001).ConclusionsIn STEMI, those who died at 30 days and 1 year had significantly higher peak troponin levels than those who survived. Peak troponin is also inversely proportional to LVEF with higher troponins associated with lower LVEF.

Implications of elevated troponin on time-to-surgery in non-ST elevation myocardial infarction (NIHR Health Informatics Collaborative: TROP-CABG study)

Implications of elevated troponin on time-to-surgery in non-ST elevation myocardial infarction(NIHR Health Informatics Collaborative:TROP-CABG study). Benedetto et al. BackgroundThe optimal timing of coronary artery bypass grafting (CABG) in patients with non-ST elevation myocardial infarction (NSTEMI) and the utility of pre-operative troponin levels in decision-making remains unclear. We investigated (a) the association between peak pre-operative troponin and survival post-CABG in a large cohort of NSTEMI patients and (b) the interaction between troponin and time-to-surgery. Methods and resultsOur cohort consisted of 1746 patients (1684 NSTEMI; 62 unstable angina) (mean age 69 ± 11 years,21% female) with recorded troponins that had CABG at five United Kingdom centers between 2010 and 2017. Time-segmented Cox regression was used to investigate the interaction of peak troponin and time-to-surgery on early (within 30 days) and late (beyond 30 days) survival. Average interval from peak troponin to surgery was 9 ± 15 days, with 1466 (84.0%) patients having CABG during the same admission. Sixty patients died within 30-days and another 211 died after a mean follow-up of 4 ± 2 years (30-day survival 0.97 ± 0.004 and 5-year survival 0.83 ± 0.01). Peak troponin was a strong predictor of early survival (adjusted P = 0.002) with a significant interaction with time-to-surgery (P interaction = 0.007). For peak troponin levels <100 times the upper limit of normal, there was no improvement in early survival with longer time-to-surgery. However, in patients with higher troponins, early survival increased progressively with a longer time-to-surgery, till day 10. Peak troponin did not influence survival beyond 30 days (adjusted P = 0.64). ConclusionsPeak troponin in NSTEMI patients undergoing CABG was a significant predictor of early mortality, strongly influenced the time-to-surgery and may prove to be a clinically useful biomarker in the management of these patients.

Contemporary Outcomes of Pediatric Patients with Acute Fulminant Myocarditis Supported with Extracorporeal Membrane Oxygenation

<h3>Purpose</h3> Despite extracorporeal membrane oxygenation (ECMO) utilization in up to 20% of cases, there are limited outcome data in pediatric patients with acute fulminant myocarditis (AFM) requiring mechanical circulatory support. <h3>Methods</h3> Retrospective cohort of patients <18 years with AFM admitted to a single center cardiac ICU and supported with ECMO from 1997-2021. Patients had ≤14 days of symptoms, rapid cardiogenic shock, and normal LV size. We compared clinical variables in patients who survived to discharge without heart transplant (HT) to those who did not. In addition, we assessed long-term LV function in survivors. <h3>Results</h3> Among 29 patients (median age 9 years; IQR 3,14), 22 (76%) survived to discharge without HT. Patients were supported on ECMO for a median of 6 days (IQR 5,8). Three patients were bridged to HT with durable ventricular assist devices (VAD). Four patients died, 2 of whom were supported with VAD. At presentation, 7 patients (24%) had high grade or complete atrioventricular block and 8 (28%) had ventricular tachycardia. CPR prior to ECMO occurred in 22 (76%) including all patients in the death/HT group. The death/HT group had higher peak troponin levels (12.5 vs 0.9 ng/mL, p=0.01). All patients underwent cardiac catheterization. Initial LA pressure was higher in the death/HT group (27 vs 18 mmHg, p=0.02) and LA decompression was performed in 23 patients (79%). Twenty-two (76%) had biopsy findings consistent with AFM. Among transplant-free survivors, 19 (86%) had normalization in LV function (median 16 days from presentation, IQR 9,449); the remaining 3 patients had persistent mild LV dysfunction at last follow up. Nine patients underwent cardiac MRI (median 752 days post-diagnosis), among whom 4 exhibited late gadolinium enhancement. <h3>Conclusion</h3> Transplant-free survival of pediatric patients with AFM supported on ECMO was 76% and associated with lower initial LA pressure. Recovery of ventricular function among survivors was rapid and durable.

Untangling the relationship between hemoglobin, peak troponin level, and mortality in patients with myocardial infarction.

Patients with a history of myocardial infarction (MI) and lower admission hemoglobin (aHb) levels have a worse outcome than patients with higher aHb, but lower or similar peaks in enzymatic infarct size. Hemoglobin levels are positively correlated with body surface area (BSA), which is positively correlated with cardiac mass. We hypothesized that patients with lower aHb suffer comparatively greater myocardial injury. We examined the relationships between aHb, and troponin (Tn) normalized to BSA (Tn/BSA) and its association with 30-day mortality. Data from 6055 patients, who were divided into seven groups based on their aHb at 10g/L intervals, were analyzed, and the groups were compared. The relationships between aHb and Tn/BSA and between Tn/BSA and 30-day mortality were assessed. Patients with higher aHb levels had greater BSA (p<0.0001). A negative relationship between aHb and log10Tn/BSA was observed in the entire group, and in men and women separately (p<0.0001, p<0.0001, and p=0.013, respectively). The log10Tn/BSA value was associated with 30-day mortality in the entire group, and in men and women separately (p<0.0001, p=0.014, and p<0.0001, respectively). Our finding suggests that a similar peak Tn value in patients with lower aHb means comparatively greater myocardial injury relative to cardiac mass. This hypothesis helps to explain the worse outcomes in patients with lower aHb. According to our findings, Tn should be indexed to BSA to provide comparable information on cardiac injury relative to cardiac mass. Whether this relationship is causal remains to be clarified.

Dexamethasone Improves Cardiovascular Outcomes in Critically Ill COVID-19, a Real World Scenario Multicenter Analysis.

BackgroundSevere COVID-19 pneumonia requiring intensive care treatment remains a clinical challenge to date. Dexamethasone was reported as a promising treatment option, leading to a reduction of mortality rates in severe COVID-19 disease. However, the effect of dexamethasone treatment on cardiac injury and pulmonary embolism remains largely elusive.MethodsIn total 178 critically ill COVID-19 patients requiring intensive care treatment and mechanical ventilation were recruited in three European medical centres and included in the present retrospective study. One hundred thirteen patients (63.5%) were treated with dexamethasone for a median duration of 10 days (IQR 9–10). Sixty five patients (36.5%) constituted the non-dexamethasone control group.ResultsWhile peak inflammatory markers were reduced by dexamethasone treatment, the therapy also led to a significant reduction in peak troponin levels (231 vs. 700% indicated as relative to cut off value, p = 0.001). Similar, dexamethasone resulted in significantly decreased peak D-Dimer levels (2.16 mg/l vs. 6.14 mg/l, p = 0.002) reflected by a significant reduction in pulmonary embolism rate (4.4 vs. 20.0%, p = 0.001). The antithrombotic effect of dexamethasone treatment was also evident in the presence of therapeutic anticoagulation (pulmonary embolism rate: 6 vs. 34.4%, p < 0.001). Of note, no significant changes in baseline characteristics were observed between the dexamethasone and non-dexamethasone group.ConclusionIn severe COVID-19, anti-inflammatory effects of dexamethasone treatment seem to be associated with a significant reduction in myocardial injury. Similar, a significant decrease in pulmonary embolism, independent of anticoagulation, was evident, emphasizing the beneficial effect of dexamethasone treatment in severe COVID-19.

Intracoronary epinephrine and verapamil in the refractory no-reflow phenomenon in patients with acute myocardial infarction

Despite modern advances in performing percutaneous coronary interventions, refractory no-reflow remains a serious problem that worsens in-hospital and long-term prognosis. Low-dose adrenaline may exhibit potent beta-receptor agonist properties that mediate coronary vasodilation.Aim. To evaluate the efficacy and safety of intracoronary administration of epinephrine and verapamil, as well as their combination, compared with standard treatment in patients with ST-segment elevation myocardial infarction (STEMI) and refractory no-reflow during percutaneous coronary interventions.Material and methods. Patients with STEMI and refractory no-reflow will be randomized into 4 groups: standard therapy, intracoronary adrenaline, intracoronary verapamil, intracoronary epinephrine + verapamil. All patients will be assessed for epicardial blood flow using the Thrombolysis in Myocardial Infarction (TIMI) and Myocardial Blush Grade (MBG) scales, peak troponin levels, ST segment changes, echocardiography, magnetic roesnance imaging, and dynamic single photon emission computed tomography.Results. Based on the pharmacodynamic effects of epinephrine and verapamil, their combination is expected to have a more potent vasodilating effect.Conclusion. If the Intracoronary administration of EPInephrine and VERapamil in the refractory no-reflow phenomenon (EPIVER) study will be successful, a novel, more effective method for managing refractory no-reflow phenomenon will appear. This will ensure better preservation of left ventricular systolic function, as well as improve the prognosis and clinical course of the disease.

Characteristics of patients presenting with acute myocardial injury with non-obstructive coronary arteries in Sfax, Tunisia

In approximately 4–10% of patients with acute myocardial infarction, coronary angiography does not reveal an obstructive coronary stenosis. This is known as myocardial infarction with non-obstructive coronary arteries (MINOCA). Therefore, mechanisms are not unequivocal and there are a variety of aetiologies grouping ischemic and non-ischemic causes, for this reason the generic term for MINOCA should be replaced with acute myocardial injury with non-obstructive coronary arteries (aMINOCA). Prospective study including all patients presenting aMINOCA, between 2019 and 2020. Other imaging tests such as echocardiography and CMR were used to better support the aetiological diagnosis. Among 1032 consecutive patients admitted for acute myocardial infarction, aMINOCA was identified in 31 (4%) patients and clinical presentation was more often STEMI than NSTEMI (52% vs. 48%). Median age was 47.3 years, male predominance (81%). Two patients presented with cardiogenic shock. Tobacco use was the most noted risk factor (67.7%). According to a clinical diagnostic algorithm using 2D STE and CMR imaging, diagnostic accuracy was 90% to identify causes of aMINOCA (38.7% myocarditis, 32.3% MI, and 19.4% Takotsubo cardiomyopathy). Peak troponin levels were significantly higher in the MI group (21.5 ± 29.24 vs. 10 ± 21.4, P = 0.035). However, CRP was significantly higher in myocarditis group (36 ± 45 vs. 4.7 ± 4, P = 0.007). There was no difference between MI and myocarditis groups in clinical presentation with or without ST elevation, in the mean left ventricular ejection fraction and in the LV Global longitudinal systolic strain. At follow-up, one death was noted in Takotsubo group. Non-obstructive coronary myocardial injury is a rare clinical entity that affects a particularly young population, with a predominance of men in our country. Clinical diagnosis algorithm with echocardiography and CMR imaging established a diagnosis in almost 9 of 10 cases.

Incremental Value of Cardiac MRI in Patients Suspected to Have Myocarditis Following COVID-19 mRNA Vaccination

Myocarditis post MRNA based COVID-19 vaccination remains a community concern. This usually occurs in young males within 7 days post. We aimed to review local data for presentations of this including investigations and clinical outcomes. We performed a search of the cardiac MRI database for studies including the words “vaccine”, “Pfizer”, “Moderna” and “mRNA” alone and in combination. All cardiac MRIs were reviewed, and those with no evidence of myocardial or pericardial inflammation were excluded. The cases were then reviewed. Between February 2020 to February 2022, 14 cases were identified with MRI confirmed myocarditis post COVID-19 vaccination. 3 cases were deemed unlikely to be attributable to the vaccination. Of the remaining 11 patients, 7/11 (64%) were male, with a mean age of 20 years. Most had no significant medical history. 8/11 (73%) occurred after the second dose with a median onset of 3 days post vaccination. Chest pain (100%), dyspnoea (18%) and fevers (18%) were the most common presenting complaints. The mean peak troponin level was 7869 ng/L, mean CRP was 22.57 mg/L. 6/11 (54%) of had ECG abnormalities, widespread ST elevation was most common (37%). Transthoracic echocardiography was normal for most 9/11 (81.8%). Lateral wall subepicardial late gadolinium enhancement was the most common MRI finding. Mean LOS was 2.64 days. There were no readmissions. In keeping with international data, most cases were young, male, and after dose two. Most cases had normal TTE. Lateral wall LGE was the most common MRI finding. Most cases were clinically mild, with short LOS.

773 Correlation between high troponin levels and left atrial strain as biomarker of incremented atrial fibrillation rate in patients with acute myocardial infarction

Abstract Aims Heart rhythm disorders, both bradyarrhythmias and tachyarrhythmias, are the most frequently observed complication in the acute phase and after primary angioplasty in patients with acute myocardial infarction (AMI). New onset atrial fibrillation (Afib) represents the most frequent arrhythmia found between 6% and 21% in patients with AMI and its onset increases the thromboembolic and mortality risk of all causes of those patients. Troponin levels measured with modern assays represent today the most specific cardiac biomarker of myocardial injury and its measurement represents the cornerstone for the diagnosis of AMI in accordance with the ESC Guidelines 2018; however, also Afib itself causes an increase in troponin values (troponinopathy). Therefore, the single biohumoral value cannot assume prognostic value in helping the clinician to recognize patients with AMI who are more predisposed to encounter Afib. So, the object of our evaluation was to support the elevated troponin values with echocardiographic biomarkers, such as the evaluation of the left atrial strain (LAS), to perform a more accurate stratification of the arrhythmic risk in patients with AMI. Methods and results A prospective multiparametric study was carried out at our Interventional Cardiology Hub Center. 240 patients with ACS-STEMI diagnosed were recruited over one year from March 2020 to March 2021. Patients included were all ≥18 (55 ± 23 y), predominantly male (88% male, 12% female). Exclusion criteria were: permanent atrial fibrillation; valvular heart disease (moderate or severe heart valve stenosis or valve replacement); implantation of a pacemaker or defibrillator; (4) poor image quality. Emergency coronary angiography (CAG) was carried out to execute primary percutaneous intervention (primary PCI with DES) on the culprit vessel. All patients underwent echocardiography by GE Vivid 80 (GE Ultrasound, Horten, Norway) in order to evaluate changes in segmental kinetics, left ventricular ejection fraction (LVEF). The ratio of peak early filling velocity of mitral inflow to early diastolic annulus velocity (E′) of the medial annulus (E/E′) was calculated. Left atrial volumes (LAVi, ml/m2) and diameter were obtained through standard apical 4 and 2 chamber views with a frame-rate range of 40–71 frames/s; then, offline analysis of images was performed using EchoPAC version 201 (GE Vingmed Ultrasound) (VSSLV) software in order to calculate LAS for each one. Patients were subjected to serial sampling to evaluate temporally troponin values and the possible Afib appearance was recognized by telemetry monitoring. Statistical analysis was performed using SPSS version 20 (IBM, Armonk, New York), continuous variables were expressed as mean ± standard deviation (SD). Pearson’s correlation coefficient was used to assess the correlation between strain value, baseline characteristics and troponin levels. All statistical tests are two-sided, and a P-value &amp;lt; 0.05 is considered statistically significant. Two groups were recognized: high troponin levels with pathological LAS and new Afib (N = 47); medium-high troponin levels with normal LAS and no Afib (N = 143). Respectively, LAS were 8.4 ± 4.0% vs. 16 ± 4.5%, P &amp;lt; 0.001, LAVi 44 ± 5 ml/m2 vs. 30 ± 3.2, P = 0.001, and peak of troponin levels (3.45 ± 0.46 ng/ml vs. 2.34 ± 0.22 ng/ml, P = 0.002). Multivariate analysis identified that peak troponin levels alone wasn’t a prognostic index of increased arrhythmic burden, while the correlation between high peak levels and altered LAS were independent predictors of new AFib in AMI. Conclusions The evaluation of atrial dysfunction by new echo-derived parameters and its correlation with troponin values allows a more accurate stratification of arrhythmic risk in patients with ACS. The applicability of the obtained data would allow a more careful evaluation of the clinical trend and the prognostic outcome in the subcategory analysed. Therefore, the association between biohumoral and instrumental parameters could become new biomarkers capable of predicting an increase in thromboembolic risk in AMI patients. The creation of an app that takes into account the parameters listed could be a possible future support that can help the clinician calculate the increased risk rate of new Afib in patients with ACS.

Del Nido versus warm blood cardioplegia in adult patients with a low ejection fraction

BackgroundDel Nido cardioplegia was recently introduced to adult cardiac surgery with encouraging results. The effect of Del Nido cardioplegia in patients with low ejection fraction (EF) has not been thoroughly evaluated. The objective of this study was to assess the safety of Del Nido cardioplegia in adult patients with low EF compared to intermittent warm blood cardioplegia.ResultsDuring 2018 and 2019, 73 adult patients with an EF of ≤ 40% underwent cardiac surgery using Del Nido cardioplegia. The patients were compared to a historical cohort of consecutive patients with low EF who had intermitted warm blood cardioplegia (n = 81). Patients who had Del Nido cardioplegia had significantly lower EuroSCORE II (2.73 (1.7–4.1) vs. 4.5 (2.4–7.4), P = 0.004). There were no differences in creatinine clearance and preoperative echocardiographic data between the groups. Cardiopulmonary bypass and cross-clamp times were non-significantly lower with Del Nido cardioplegia. There were no differences in stroke and postoperative echocardiographic data between the groups. No hospital mortality was reported in both groups. Peak troponin levels were significantly higher in patients who had Del Nido cardioplegia (0.88 (0.58–1.47) vs. 0.7 (0.44–1.01) ng/dL; P = 0.01); however, after multivariable regression analysis, cardiopulmonary bypass time was the only predictor of postoperative troponin level (coefficient 0.005 (95% CI: 0.003–0.008); P < 0.001). ICU stay was significantly longer in patients who had Del Nido cardioplegia (4 (3–6) vs. 2(1–4) days, P < 0.001), while postoperative hospital stay did not differ between the groups. After multivariable regression, the use of intermittent warm blood cardioplegia was significantly associated with shorter ICU stay (coefficient − 1.80 (95% CI − 3.06 – -0.55); P = 0.01).ConclusionsProlonged ICU was reported with Del Nido cardioplegia; however, there were no differences in the duration of hospital stay and the clinical outcomes between the groups. Despite the proven efficacy of intermittent warm blood cardioplegia, the use of Del Nido cardioplegia might be safe in patients with low EF.

Frequency, Etiology, and Impact of Unplanned Repeat Coronary Angiography After ST-Elevation Myocardial Infarction

Unplanned repeat coronary angiography (CAG) after balloon angioplasty for ST-elevation myocardial infarction (STEMI) was common before the advent of coronary stenting. Limited data are available regarding the role of unplanned repeat CAG in contemporary percutaneous coronary intervention (PCI) for STEMI. Therefore, we analyzed a large, 2-center prospective STEMI registry (January 2011 to June 2020) stratified by the presence or absence of unplanned repeat CAG during index hospitalization. Patients with planned CAG for staged PCI or experimental drug administration were excluded. Among 3,637 patients with STEMI, 130 underwent unplanned repeat CAG (3.6%) during index hospitalization. These patients were more likely to have cardiogenic shock (16% vs 9.8%, p=0.021), left anterior descending culprit (44% vs 31%, p <0.001), lower left ventricular ejection fraction (45% vs 52%, p <0.001), and higher peak troponin levels (22 vs 8ng/ml, p <0.001) than those without repeat CAG. At repeat CAG, 80 patients had a patent stent (62%) including 65 requiring no further intervention (50%) and 15 who underwent intervention on a nonculprit lesion (12%). Only 32 patients had stent thrombosis (25%). Repeat CAG was associated with a higher incidence of recurrent MI (19% vs 0%, p <0.001) and major bleeding (12% vs 4.5%, p <0.001), yet similar in-hospital mortality (7% vs 6.4%, p=0.93) than those without repeat CAG. In conclusion, in the era of contemporary PCI for STEMI, unplanned repeat CAG during index hospitalization was infrequent and more commonly observed in patients with left anterior descending culprit in the presence of significant left ventricular dysfunction or shock and was associated with higher in-hospital recurrent myocardial infarction and major bleeding complications.

Abstract 9546: Cancer Therapeutics-Related Cardiac Dysfunction is Associated With High Risk of Cancer-Related Mortality in Patients Treated With Anthracycline-Containing Chemotherapy

Background: Cancer therapeutics-related cardiac dysfunction (CTRCD) is a concerning problem in anthracycline-containing chemotherapy. However, the impact of CTRCD on cancer-related mortality is remained to be elucidated. Methods: Consecutive 174 patients planned for anthracycline-containing chemotherapy were enrolled. Echocardiography and blood test were performed at baseline, 3 months, 6 months, 12 months after starting chemotherapy, and after that every 3 months until cardiotoxic chemotherapy was completed. Results: Of 174 patients, CTRCD was developed in 16 patients (CTRCD group, median onset was 8 months), and the other patients (no-CTRCD group) showed normal left ventricular ejection fraction (LVEF). CTRCD group showed higher levels of peak troponin I (0.05 [0.04-0.16] ng/ml vs. 0.02 [0.02-0.04] ng/ml, P&lt;0.001), peak B-type natriuretic peptide (59 [26-161] pg/ml vs. 25 [15-41] pg/ml, P=0.001), and lower LVEF at 12-month (54.1±7.5% vs. 64.6±4.8%, P&lt;0.001) compared to no-CTRCD group. When we set the cut-off value of troponin I at 0.03 ng/ml, sensitivity, specificity, and area under the curve to predict CTRCD were 88%, 72%, and 0.792, respectively. In CTRCD group, 4 patients (25%) discontinued cardiotoxic chemotherapy due to CTRCD, and 12 patients (75%) showed recovered LVEF to more than 53%. In total study subjects, no patients presented cardiac death in follow up period (median 1056 days), but 22 patients (13%) died due to cancer progression. Kaplan-Meier analysis revealed that CTRCD group showed higher cancer-related mortality compared to no-CTRCD group (figure, P&lt;0.001). Multivariate Cox-proportional hazard analysis showed that CTRCD was an independent risk factor for cancer death (HR 4.639, 95%CI [1.691-12.730], P=0.003). Conclusion: The development of CTRCD was associated with high risk of cancer death, but not with cardiac death. Cardioprotective treatment and careful cancer monitoring are required to the patients with CTRCD.

Abstract 14169: Implications of Elevated Troponin on Time-to-Surgery in Non-ST Elevation Myocardial Infarction (NIHR Health Informatics Collaborative: Trop-CABG Study)

Background: The optimal timing of coronary artery bypass grafting(CABG) in patients with non-ST elevation myocardial infarction (NSTEMI) and the utility of pre-operative troponin levels in decision-making remains unclear. We investigated (a)the association between peak pre-operative troponin and survival post-CABG in a large cohort of NSTEMI patients and (b)the interaction between troponin and time-to-surgery. Methods: Our cohort consisted of 1746 NSTEMI patients(mean age 69±11 years, 21% female) with recorded troponins that had CABG at five United Kingdom centers between 2010 and 2017. Time-segmented Cox regression was used to investigate the interaction of peak troponin and time-to-surgery on early(within 30 days) and late(beyond 30 days) survival. Results: Average interval from peak troponin to surgery was 9±15 days, with 1466(84.0%) patients having CABG during the same admission. Sixty patients died within 30-days and another 211 died after a mean follow-up of 4±2years(30-day survival 0.97±0.004 and 5-year survival 0.83±0.01). Peak troponin was a strong predictor of early survival(adjusted P=0.002) with a significant interaction with time-to-surgery(P interaction=0.007). For peak troponin levels &lt;100 times the upper limit of normal, there was no improvement in early survival with longer time-to-surgery. However, in patients with higher troponins, early survival increased progressively with a longer time-to-surgery, till day 10. Peak troponin did not influence survival beyond 30 days(adjusted P=0.64). Conclusions: Peak troponin in NSTEMI patients undergoing CABG was a significant predictor of early mortality, strongly influenced the time-to-surgery and may prove to be a clinically useful biomarker in the management of these patients.

Abstract 11345: Incidence, Characteristics, and Outcomes of Patients Presenting to an Urban Academic Institution with ST-Segment Elevation Myocardial Infarction During the COVID-19 Pandemic

Introduction: ST-segment elevation myocardial infarction (STEMI) is an emergency presentation of an acutely occluded coronary artery. Following the announcement of the COVID-19 pandemic (March 11, 2020), a global decrease in STEMI incidence has been observed. Incidence, characteristics, and outcomes for STEMI activation patients were investigated in the 5 years prior (“reference period”) to and 1 year into the pandemic (“pandemic period”). We assessed the hypothesis that pandemic period STEMI activations will have more severe infarction (elevated troponin I), a higher percentage of true STEMI, and worse outcomes (higher case fatality rate). Methods: STEMI activation incidence was obtained from an institutional database (reference period n = 430; pandemic period n = 31). Patient characteristics and outcomes were obtained retrospectively from electronic health records (EHRs). True STEMI was adjudicated based on chest pain, EKG, troponins, and angiogram. Results: Monthly STEMI activations declined significantly in the first year of the pandemic (2.50 ± .68 vs. 7.17 ± .41, P = &lt;.001). No significant difference in demographic characteristics (age, BMI, and male-to-female ratio) were observed. True STEMI percentage was higher during the pandemic (80.65% vs. 70.93%), but not statistically significant. Peak troponin levels for true STEMI were significantly higher during the pandemic (98.83 ± 25.82 vs. 51.44 ± 4.11, P = .003). There was no significant difference in 30-day and 90-day case fatality rates. Conclusions: STEMI activation incidence declined significantly during the pandemic; interestingly, the proportion of these which were true STEMIs remained consistent. True STEMIs during the pandemic had higher troponin levels suggesting larger infarct, but there was no significant difference in case fatality. In conclusion, fewer patients presented with STEMI while case fatality remained unchanged despite more severe infarct occurrence during the pandemic.

Reperfusion After Fibrinolytic Therapy (RAFT): An open-label, multi-centre, randomised controlled trial of bivalirudin versus heparin in rescue percutaneous coronary intervention.

BackgroundThe safety and efficacy profile of bivalirudin has not been examined in a randomised controlled trial of patients undergoing rescue PCI.ObjectivesWe conducted an open-label, multi-centre, randomised controlled trial to compare bivalirudin with heparin ± glycoprotein IIb/IIIa inhibitors (GPIs) in patients undergoing rescue PCI.MethodsBetween 2010–2015, we randomly assigned 83 patients undergoing rescue PCI to bivalirudin (n = 42) or heparin ± GPIs (n = 41). The primary safety endpoint was any ACUITY (Acute Catheterization and Urgent Intervention Triage Strategy) bleeding at 90 days. The primary efficacy endpoint was infarct size measured by peak troponin levels as a multiple of the local upper reference limit (Tn/URL). Secondary endpoints included periprocedural change in haemoglobin adjusted for red cells transfused, TIMI (Thrombolysis in Myocardial Infarction) bleeding, ST-segment recovery and infarct size determined by the Selvester QRS score.ResultsThe trial was terminated due to slow recruitment and futility after an interim analysis of 83 patients. The primary safety endpoint occurred in 6 (14%) patients in the bivalirudin group (4.8% GPIs) and 3 (7.3%) in the heparin ± GPIs group (54% GPIs) (risk ratio, 1.95, 95% confidence interval [CI], 0.52–7.3, P = 0.48). Infarct size was similar between the two groups (mean Tn/URL, 730 [±675] for bivalirudin, versus 984 [±1585] for heparin ± GPIs, difference, 254, 95% CI, -283-794, P = 0.86). There was a smaller decrease in the periprocedural haemoglobin level with bivalirudin than heparin ± GPIs (-7.5% [±15] versus -14% [±17], difference, -6.5%, 95% CI, -0.83–14, P = 0.0067). The rate of complete (≥70%) ST-segment recovery post-PCI was higher in patients randomised to heparin ± GPIs compared with bivalirudin.ConclusionsWhether bivalirudin compared with heparin ± GPI reduces bleeding in rescue PCI could not be determined. Slow recruitment and futility in the context of lower-than-expected bleeding event rates led to the termination of this trial (ANZCTR.org.au, ACTRN12610000152022).

Superiority of cardiac magnetic resonance derived left-ventricular ejection fraction in the identification of true acute myocardial infarction among MINOCA patients

Abstract Background/Introduction MINOCA constitutes a clinical entity characterized by heterogeneous and poorly understood pathophysiological substrate, whereas current knowledge leaves significant gaps regarding the identification, risk stratification and therapeutical approach of these patients. Purpose The aim of our study is to investigate the potential role of clinical, hemodynamic, laboratory and imaging parameters in the early identification of true acute myocardial infarction (AMI) among patients with a working diagnosis of MINOCA. Methods Our study population included 62 patients admitted with acute coronary syndrome (ACS) fulfilling the diagnostic criteria of MINOCA. A subsequent cardiac magnetic resonance (CMR) performed at 54 patients demonstrated an ischemic pattern of late gadolinium enhancement (LGE) confirming the diagnosis of true AMI in 15 cases (27.8%). Other findings included Takotsubo syndrome (n=19; 35.2%) and myocarditis (n=4; 7.4%), whereas CMR failed to reveal abnormal findings at 16 cases (29.8%). Results Focusing on the combined population of true AMI and clear CMR groups (n=31; 51.6% male; mean age: 58±12 years old; 42% hypertensives (HTN), 16% with history of diabetes mellitus (DM), 28.6% smokers) no significant difference was observed regarding classic cardiovascular risk factors (HTN, DM, smoking, age, dyslipidemia) except for a tendency of overrepresentation of female sex (r=0.354; p=0.051) in the true AMI group. Coronary angiographic (CA) findings did not differ between the two groups: clear vessels: 16/31 (51.6%); lesions causing ≤50% stenosis: 7/31 (22.6%); bridges: 4/31 (12.9%); spontaneous coronary artery dissection (SCAD): 2/31 (6.5%); slow flow phenomenon or spontaneous epicardial spasm: 2/31 (6.5%). No difference was observed in treatment approach with beta-blockers, renin-angiotensin system blockers, statins or the selection of no, single or dual antiplatelet strategy. Univariate regression analysis demonstrated that CMR derived left-ventricular ejection fraction (CMR-LVEF) (OR, 0.846; CI 95%: 0.742–0.965; p=0.012), as well as admission ECG abnormalities (OR, 0.154; CI 95%: 0.026–0.914; p=0.04), admission (OR, 5.689; CI 95%: 1.374–23.553; p=0.016) and peak troponin levels (OR, 15.874; CI 95%: 2.486–101.367; p=0.003) were the only parameters significantly related to a true AMI. Statistical significance was retained in multivariate models adjusted for age, gender, history of HTN and DM. On the contrary echocardiography derived LVEF failed to predict true AMI. Conclusions These preliminary results further highlight the need of an early CMR evaluation of MINOCA patients. A timely identification of true AMI is expected to improve patient outcomes by guiding the treatment approach. Funding Acknowledgement Type of funding sources: None.

Prognostic assessment following acute myocarditis requires convalescent scanning: neither peak troponin nor index scan T2 signal predicts convalescent late gadolinium enhancement

Abstract Funding Acknowledgements Type of funding sources: None. Background Cardiovascular magnetic resonance (CMR) is a key diagnostic investigation in acute myocarditis (1) and permits quantification of late gadolinium enhancement (LGE) and myocardial oedema. Follow-up CMR imaging is recommended to check for persistence of scar and oedema (2). Persistent late gadolinium enhancement is associated with a worse prognosis (3). It is not known whether all patients require follow-up scanning or whether the initial scan can provide useful information to identify which patients need convalescent assessment. Purpose In this study we considered whether extent of troponin elevation, extent of T2 elevation and initial late gadolinium enhancement burden predicted long-term late gadolinium enhancement at follow-up. Methods Index and follow-up CMR scans of consecutive patients presenting with a diagnosis of acute myocarditis between 2019 and 2020 across three hospitals were included. Inclusion criteria were: follow-up scan within 9 months of the index scan, CMR with LGE imaging and T2 mapping, and acute myocarditis being the primary diagnosis of the index scan. Myocardial T2 values in the area affected by myocarditis and percentage of LV myocardium showing late enhancement (using a threshold-based full height half width or manual region of interest strategy) were extracted. Results 20 patients were included in the study (80% male; mean age 37 years). Mean interval between the index and follow-up scan was 4.1 months. Peak troponin level during the acute illness was not associated with the proportion of LV myocardium affected by LGE in the index scan (R^2 &amp;lt;0.01) (Figure 1A). Myocardial T2 values in the first scan were not associated with the proportional resolution in LGE between the index and follow-up scans (R^2 0.02) (Figure 1B). The mean change in LGE was -61.7% (+/-22.8%) but the initial LGE burden did not predict the proportional degree of improvement in LGE between scans (R^2 &amp;lt;0.01)(Figure 1C). Conclusions The extent of troponin elevation and initial CMR phenotype was not a good predictor of the burden of long-term late gadolinium enhancement. Although most cases showed improvement in LGE scar burden between index and follow-up imaging, neither peak troponin level during the acute episode, nor T2 values at the first CMR scan were predictive of initial or change in scar burden. Serial CMR assessment is required to identify those patients who have residual long-term scarring.

Evaluation of Myocardial Damage in Relation to HbA1c in Patients with Previously Unrecognized Diabetes Presenting with STEMI

Objective: The mechanisms underlying worse clinical outcomes in previously unrecognized diabetic (DM) patients in ST-elevation myocardial infarction (STEMI) are unclear. It was hypothesized that poor chronic glucose control might be related to greater myocardial damage.&#x0D; Material and Method: 51 newly diagnosed DM patients with glycated hemoglobin A1c (HbA1c) &gt; 6.5 comprised the DM group, 54 sex- and age-matched individuals with normal glucose metabolism served as the non-DM group. Each patient underwent primary angioplasty for STEMI. The levels of cardiac specific markers before angioplasty, during angioplasty, at 6, 12, and 18 h after angioplasty were recorded. SPSS 10 package program was used to analyse data.&#x0D; Results: In both DM and non-DM groups troponin peaked at 6 h. Peak troponin levels were similar in both groups (diabetics, 22.89 ± 18.19 vs. non-diabetics, 32.67 ± 17.68 ng/ml, p=0.168).&#x0D; Conclusions: HbA1c &gt; 6.5 is not related to extent of infarction in previously unrecognized DM patients presenting with STEMI. Future studies assessing the effects of other factors unrelated to chronic glucose control on myocardial damage and cardiovascular event rates in these patients would be of great interest.