Troponin Research Articles

Intra-operative anesthetic induced myocardial protection during cardiothoracic surgery: a literature review.

Myocardial protection involves limiting the metabolic activity and oxygen consumption of the heart, thus enabling surgery to proceed with minimal blood loss while reducing the level of ischemic injury. It was this concept that allowed for the development of the open-heart surgical technique. We know myocardial ischemia and reperfusion injury are both detrimental, thus developing strategies to mitigate this can help reduce peri-operative morbidity and mortality. In this review, we will mainly be addressing the anesthetic considerations for myocardial protection, along with discussing potential future research which can help expand the field. We searched the PubMed database for relevant studies dating from 2004-2022. In total, 18 studies were deemed suitable for this literature review. Studies have demonstrated cardioprotective effects with use of the volatile agents and propofol, mainly with respect to lower levels of inflammatory markers such as creatine kinase (CK)-MB and troponin I (TnI)/troponin T (TnT). The data is lacking regarding protective effects of dexmedetomidine and lidocaine, hence we cannot recommend either agent at present. Myocardial protection with respect to the anesthetic agents have been extensively studied over the past two decades, some routinely used drugs such as the volatile agents, propofol and opiates have demonstrated a cardioprotective role. The ideal dosing regimen and duration are areas of research that can be studied further. The data for the other anesthetic adjuncts such as lidocaine, dexmedetomidine along with use of regional anesthesia is still equivocal. Alongside advances in anesthesia, we believe surgical research looking into optimal cardioplegia solutions will also help improve myocardial protection in the future.

High-Sensitivity vs Conventional Troponin Cutoffs for Risk Stratification in Patients With Acute Pulmonary Embolism

High-sensitivity troponin tests can detect even milder cardiac troponin elevations in plasma, beyond the threshold of conventional troponin tests. Whether detection of low-grade cardiac troponin elevation is associated with outcomes of patients with hemodynamically stable pulmonary embolism (PE) and helps with risk stratification is unknown. To determine the association between high-sensitivity cardiac troponin I (hs-cTnI) compared with conventional cardiac troponin I (cTnI) and PE risk designations according to the European Society of Cardiology (ESC) 2019 classification scheme and clinical outcomes in patients with hemodynamically stable PE. This is a post hoc analysis of data from the prospective Prognostic Value of Computed Tomography (PROTECT) multicenter cohort study enrolling patients from 12 hospital emergency departments in Spain. In this analysis, cTnI and hs-cTnI were compared with respect to ESC risk designation, and the association between troponin values and a complicated course after PE diagnosis was evaluated. Of 848 patients enrolled in PROTECT, 834 (98.3%) had hsTnI and cTnI values available and were included in the present analysis. Data were analyzed from May to December 2022. Troponin blood testing with cTnI (threshold of >0.05 ng/mL) vs hs-cTnI (threshold of >0.029 ng/mL) assays at the time of PE diagnosis. Complicated course, defined as hemodynamic collapse, recurrent PE, or all-cause death, within 30 days after PE. Of 834 patients (mean [SEM] age, 67.5 [0.6] years; 424 [50.8%] female), 139 (16.7%) had elevated cTnI and 264 (31.7%) elevated hs-TnI, respectively. During follow-up, 62 patients (7.4%; 95% CI, 5.7-9.4) had a complicated course. Analyzing troponin elevation as a binary variable, elevated cTnI (odds ratio [OR], 2.84; 95% CI, 1.62-4.98) but not hs-cTnI (OR, 1.12; 95% CI, 0.65-1.93) was associated with increased odds of a complicated course. Of 125 patients who had elevated hs-cTnI but normal cTnI, none (0; 95% CI, 0.0-2.9) developed a complicated course. Using the 2019 ESC risk stratification scheme, hs-TnI classified fewer patients as low risk compared with cTnI. Among 78 patients designated as ESC low risk when using cTnI but not with hsTnI, none (0; 95% CI, 0.0-4.6) had a complicated course. In this study of patients with hemodynamically stable PE, hs-cTnI identified modest elevations in cardiac troponin levels. However, the results did not provide additive clinical value compared with cTnI. These findings suggest that use of hs-cTnI may result in overestimation of the risk in patients with stable PE.

Utility of preoperative troponin I to predict mortality in adult liver transplant recipients: Revisiting pretransplant cardiac risk in the current MELD-allocation era.

Preoperative risk assessment in liver transplant (LT) candidates, particularly related to cardiac risk, is an area of intense interest for transplant clinicians. Various cardiac testing methods are employed by transplant centers to characterize cardiac risk. Serum troponin is an established method for the detection of myocardial injury in a wide variety of clinical settings. Preoperative troponin screening has been reported to predict postoperative cardiac events and mortality in various surgical patient populations, however, the utility of preoperative troponin to predict posttransplant outcomes in current LT candidate populations requires further investigation. We performed a prospective blinded study in a cohort of 275 consecutive LT recipients at a single transplant center to determine if preoperative serum troponin I (TnI) was predictive for postoperative 1-year mortality. Abnormal preoperative TnI levels (>.1ng/mL) were found in 38 patients (14%). One-year mortality occurred in 19 patients (7%). There was no significant difference in mortality between patients with normal and abnormal troponin levels. Additionally, we found that there was no significant difference in early postoperative major adverse cardiac events between patient groups. Contrary to previous reports, elevated preoperative TnI was not significantly predictive of posttransplant mortality in LT recipients at our institution.

Donor heart preconditioning during orthotopic transplantation

Background. To date, there are about 500 patients in the heart transplant waiting list in Ukraine. The study included 20 donors for orthotopic heart transplantation. Their average age was 32.3 years. The study evaluated the preparation of the donor heart in terms of its protection against ischemia-reperfusion injury during transplantation and the effect of donor heart preconditioning in a recipient after orthotopic heart transplantation. Тhe purpose was to evaluate the effectiveness of donor heart preconditioning for increasing myocardial resistance to ischemia-reperfusion injury and its preparation for orthotopic transplantation. Materials and methods. The work is based on the results of 20 donors who were diagnosed with brain death and authorized for the use of transplantation of human anatomical materials. Then changes in the main biochemical parameters (lactate, troponin, acid-base balance, creatinine clearance, blood glucose) and the functional state of systemic hemodynamics (blood pressure, heart rate, central venous pressure, ejection fraction, cardiac index) were analyzed at the time of donor heart explantation. Results. It was found that in 100 % of donors, norepinephrine was used for inotropic support, in 40 % — dobutamine and in 25 % — dopamine. Lactate levels were higher than normal in 75 % of cases and troponin levels were increased in all donors, indicating a possible microcirculatory dysfunction that led to a deterioration in donor preconditioning and enhanced ischemia-reperfusion injury to the transplant. According to the correlation coefficient between time and cardiac index, there was a tendency to the deterioration in the donor’s condition depending on the time of making a decision about heart transplantation before heart explantation. Conclusions. The study showed that in 100 % of donors, norepinephrine was used for inotropic support — more often than dobutamine or dopamine. Lactate levels were higher than normal in 75 % of donors and troponin levels were increased in all donors, indicating a possible microcirculatory dysfunction that led to a deterioration in donor preconditioning and increased ischemia-reperfusion injury to the transplant. According to the correlation coefficient between time indicators and cardiac index, it is noted that the longer the time of authorization for orthotopic heart transplantation, the greater the deterioration in the donor’s condition, which is expressed in a decreased myocardial contractility. Based on the correlation coefficient between time indicators and troponin, it was concluded that the growth of troponin complexes was observed with an increase in the time of making a decision for obtaining permission to transplant human anatomical materials, which indicated the onset of ischemic changes in the myocardium.

Food insecurity is associated with a higher body mass index and lower albumin levels in patients with congestive heart failure in the All of Us research program

Abstract Introduction Congestive Heart Failure (CHF) is an extremely prevalent disorder worldwide with high morbidity and mortality rates. Estimates suggest that approximately 80% of cardiovascular diseases (CVD), including CHF, can be prevented by controlling risk factors and adopting a healthy lifestyle. However, there are substantial barriers to implementing this guidance for many patients, including food insecurity, which is a household-level economic and social condition of limited or uncertain access to adequate food. Food insecurity is also associated with a greater prevalence of overweight and obesity, which plays a role in the pathogenesis of CHF. Purpose Our goal is to examine the difference in body mass index (BMI), nutritional and cardiac-specific markers—specifically albumin, B-type natriuretic peptides (BNP), N-terminal pro-B-type natriuretic peptides (NT-proBNP), and troponin I (TnI)—between patients with CHF who are food secure and patients with CHF who are food insecure. To our knowledge, no prior studies have examined this important relationship in a large population-based sample. Methods We use the All of Us Research Program (AoURP) to analyze a large cohort of 372,380 participants representing the diversity of the US population in terms of ancestry, demographics, socioeconomic status, and other characteristics. Of the 372,380 participants, 12,529 had CHF, of which 1472 answered the two validated screening questions for food insecurity, also known as the "hunger vital sign". We split the CHF participants between a food-secure group (1297 participants) and a food-insecure group (175 participants), where food security is defined as responding "never" to both questions of the "hunger vital sign". Results Our findings indicate that the food insecure participants are younger (p<0.0001), less likely to drink alcohol (p<0.0001), less educated (p<0.0001), and more likely to be black (p<0.0001), female (p<0.0001), and Hispanic (p<0.001). The mean (+-SD) BMI for the food insecure group is 35.0 (+-8.8) kg m-2 compared to 31.3 (+-7.2) kg m-2 for the food secure group (p<0.00001) and the mean (+-SD) albumin level for the food insecure group is 34.2 (+- 2.9) g/L compared to 38.4 (+-4.2) g/L for the food secure group (p<0.0001). The differences in BNP, NT-proBNP, and TnI are not statistically significant. Conclusion Our findings–demographic differences, higher mean BMI, lower albumin levels in CHF patients who are food insecure–indicate the necessity to reevaluate our approach to care for historically underserved patients.

How vigilant were we in the diagnosis of peri-operative myocardial infarction before 2022 ESC guidelines?

Abstract Background The diagnosis of myocardial infarction (MI) after non-cardiac surgical intervention is complicated due to possible absence of symptoms as well as of objective ECG or echocardiography signs of ischemia. Aim This is a retrospective analysis of the prevalence of clinically diagnosed MI after non-cardiac surgery in two district hospitals with large-scale surgical services in the period of 2017 - 2022. Methods We retrospectively collected study data using electronic hospital records of all patients that underwent surgical operations for 6 years. Peri-operative MI was selected according to code I21 following any surgical procedure and verified by symptoms, elevated TnI, ECG and Echo changes. Results Total 103 028 patients underwent orthopedic, vascular, abdominal, neuro- surgery from 2017 to 2022. We found 45 patients diagnosed with MI, what makes the prevalence of 0,04%. Diagnostic criteria were: median TnI levels 4925 [1171; 13162] ng/L, symptoms [62% had typical anginal pain, 38% felt dyspnea, 22% had no symptoms], ECG changes {40% with ST elevation, 42% with ST depression, 16% bundle branch block}. Three patients (7%) were administered with troponin test before surgery. Patients with peri-operative MI were 81 [70; 86] years old, 49% females, with the history of CAD (42%), hypertension (71%), diabetes (33%), CKD (13%), anemia (38%), atrial fibrillation (33%), heart failure (47%). The duration of anesthesia was from 20 min to 3h 05 min and it was general in most cases. Bleeding requiring blood transfusion was observed in 27% of cases. It is known that 42% of patients used beta-blockers, 22% used statins before the operation, and 33% saw cardiologist in last 5 years. STEMI occurred in 44%, NSTEMI in 38% of patients, in 18% MI was unspecified, PCI was performed in 44%. Patients were transferred to ICU in 78% of cases and in 20% to cardiology ward. In-hospital deaths occurred in 49% of cases. Conclusions Little number of peri-operative myocardial infarctions are recognized in current practice, however, the mortality of these patients is very high. These findings highlights the importance of implementation of non-cardiac surgery guidelines, namely, routine troponin evaluation in high-risk patients.

The CRP Troponin Test (CTT) stratifies mortality risk in patients with Non-ST Elevation Myocardial Infarction (NSTEMI)

Abstract Introduction The CRP-Troponin test (CTT) comprises serial measurements of both CRP and cardiac troponin and might reflect the systemic inflammatory response in patients with acute coronary syndrome. Here, we sought to test the ability of the CTT to stratify the short and long-term mortality risk in patients with non-ST elevation myocardial infarction (NSTEMI). Materials and Methods We examined 1,675 patients who were diagnosed with NSTEMI on discharge and had at least two successive measurements of combined CRP and cardiac troponin (up to 6 h apart), all within the first 48 hours of admission. We used a tree classifier model to determine which measurements and cutoffs could be used to best predict mortality during a median follow-up period of 3 years [IQR 1.8–4.3] (Figure 1A). Results Patients with high CRP levels (above 90th percentile, >54 mg/L) had a higher 30-day mortality rate regardless of their troponin test status (Figure 1B). However, among patients with "normal" CRP levels (<54 mg/L), those who had high troponin levels (above the 80th percentile, 4,918 ng/L) had a higher 30-day mortality rate compared with patients with normal CRP and troponin concentrations; 7% vs. 2%, p<0.01 (Figure 1B). A multivariate cox regression analysis showed that the CTT test result was an independent predictor for overall mortality even after adjusting for age, sex, and existing co-morbidities (Figure 1C). Conclusion Early serial CTT results may stratify mortality risk in patients with NSTEMI, especially in those presenting with "normal" CRP levels. The CTT is a simple diagnostic tool that could potentially assess the impact of inflammation during myocardial necrosis on the outcomes of patients with NSTEMI. The CTT might be used to identify patients who could benefit from novel anti-inflammatory therapies following myocardial infarction.Figure 1

Assay of macrotroponin I not complexed with troponin T: effect on the performance of troponin T to predict myocardial infarction

Abstract Background Cardiac troponin-immunoglobulin (Ig) complexes (macrotroponin) can interfere with cardiac troponin (cTn) test performance. However, the role of this interference has not been fully explored. We developed a specific, novel, 2-hour prototype immunoassay of monomer IgG-bound TnI (bTnI-IgG). Using this assay, our purpose was to examine the potential contribution of cTnT binding to macro-TnI, and report its effects on the clinical diagnostic and predictive performance of highly sensitive TnT (hs-TnT) and TnI (hs-TnI) assays. Methods Using the bTnI-IgG assay, we evaluated EDTA blood samples taken at presentation (t=0) from two ED acute chest pain studies; SPACE (n=1066) and FAST-TRAC (n=1440), with statistical analysis (logistic regression, ROC curves), to AMI and 1-year outcomes, alone and in combination, with hsTnT (Roche) and hsTnI (Abbott/Beckmann) tests. Pathway analysis was used to identify if single bTnI-IgG measurements improve risk stratification in low and high AMI risk. Results In individual and combined study datasets, bTnI-IgG concentrations in patients with adjudicated acute MI (n=336) were lower than all other diagnoses (p<0.001). Singularly, and in multivariable models containing hs-TnT or hs-TnI concentrations, bTnI-IgG was an independent predictor of MI. Amongst all patients with MI not ruled-out on presentation (hs-TnT >5ng/L) and not high-risk (hsTnT<14ng/L), the addition of bTnI-IgG to a model containing hs-TnT, HxMI and sex improved discrimination (AUC increase of 0.014 (95%CI: 0.004 to 0.025) from 0.788 to 0.802, p=0.009). Within a diagnostic pathway analyses of n=2126 matched patient data points, adding presentation bTnI-IgG measurement alone to an MI risk stratification model consisting of hs-TnT ≤URL, HxMI and sex yielded 14% more low risk patients identified (n=586 v 667 patients) through improved specificity (77% to 88%) whilst maintaining an overall sensitivity of >99%. bTnI-IgG also predicted 1-year mortality and new stroke in all patients (Odds Ratios 0.292 [95%CI 0.130 to 0.654] p=0.009) and 0.255 ([95%CI 0.078 to 0.834] p=0.024), respectively. Conclusions Measurement of bTnI-IgG that is free from cTnT could potentially improve ED presentation diagnostic test performance and risk stratification of MI patients using criteria that includes hs-TnT. No effects upon hs-TnI assays were observed. This data suggests current hs-TnT test design and measurements may be impacted by binding interactions between TnT and TnI. Finally, bTnI-IgG can independently predict mortality and stroke outcomes within 1 year of index presentation.

Sex differences in cardiac troponin trajectories over the life course

Abstract Background Cardiac troponin is a promising biomarker that may improve cardiovascular risk prediction. Previously, important differences have been demonstrated between cardiac troponin concentration in women and men. At this point, it is unknown whether changes in cardiac troponin concentration over the life course differ in women and men and whether this impacts cardiovascular risk prediction. Purpose Insights into sex-specific cardiac troponin trajectories and how these are influenced by risk factors are necessary to ensure approaches to the prevention of cardiovascular disease in women and men are equitable. Therefore, we examined whether age- and risk factor-related changes in cardiac troponin over the life course differ by sex and if the trajectory of cardiac troponin was informative in respect of cardiovascular outcomes in women and men in the general population. Methods In the Whitehall II cohort, high-sensitivity cardiac troponin I concentrations were measured on three occasions over a 15-year period. Using linear mixed-effects models, the sex-specific trajectories of cardiac troponin were evaluated, and the relationship with conventional cardiovascular risk factors determined. Using multistate joint models, the association between sex-specific trajectories of cardiac troponin and a composite outcome of non-fatal myocardial infarction, non-fatal stroke, or cardiovascular death was evaluated. Results In 2,142 women and 5,151 men (mean 58±7 and 57±7 years, respectively) there were 177 (8.3%) and 520 (10.1%) outcome events, respectively, during a median follow-up of 20.9 [25th to 75th percentile, 15.8 to 21.3] years. Cardiac troponin concentrations were persistently lower in women than in men (median baseline concentration: 2.4 [25th to 75th percentile, 1.7 to 3.6] ng/L versus 3.7 [25th to 75th percentile, 2.6 to 5.8] ng/L, respectively, P<0.001, Figure 1A), with women exhibiting a relatively larger increase with advancing age as compared with men (Pinteraction<0.001, Figure 1B). Apart from age, a significant and divergent interaction with sex was found for the association between cardiac troponin and body mass index (Pinteraction=0.008) and diabetes (Pinteraction=0.003). During follow-up, cardiac troponin concentrations were associated to the outcome in both women and men (adjusted HR per two-fold difference [95% CI], 1.34 [1.17-1.52] and 1.30 [1.21-1.40], respectively, Pinteraction=0.752). The slope of cardiac troponin was significantly associated with the outcome in women, but not in men (adjusted HR [95% CI], 2.70 [1.01-7.33] and 1.31 [0.62-2.75], respectively, Pinteraction=0.250). Conclusion Trajectories of cardiac troponin differ between women and men in the general population, with differing associations to conventional risk factors and cardiovascular outcomes. Our findings highlight the importance of a sex-specific approach when serial cardiac troponin testing is applied for cardiovascular risk prediction.

Abstract 202: Liposome-Encapsulated Hemoglobin (HbV) Rescues Hemorrhagic Shock Heart Through Anti-Ischemic and Anti-Arrhythmogenic Effects on Myocardium in Repetitive 65% Bleeding Rat Model

Phase I clinical trial of Liposome-encapsulated hemoglobin vesicles (HbVs) was successfully accomplished. Since several ameliorating mechanisms are not fully understood on HbVs, to investigate its mechanisms of salutary effect on myocardium, optical mapping analysis (OMP) and electrophysiological study (EPS), immunostaining pathological examination for HIF1-alpha in heart and measurement of blood troponin I (TnI) were performed in 30% spontaneous arterial bleedings five times up to approximately total 65% hemorrhage in rats. Eighteen rats in each group were resuscitated by immediately after bleeding by same volume as bleedings each five times by transvenous infusion of 5%albumin solution (ALB-group), washed erythrocytes (wRBC-group) and HbVs (HbV-group). Survival effects over 24 hours were examined. After excising heart, OMP and EPS were performed. All rats died in ALB-group, whereas all survived in wRBC-group and HbV-group. OMP showed impaired (prolonged) action potential duration dispersion (APDd: which is arrhythmogenic index) in LV in ALB-group, whereas APDds were attenuated in HbV-group and wRBC-group (26±4 vs. 11±6, 14±5ms, P<0.05). Lethal arrhythmias (ventricular tachycardia [VT]/ventricular fibrillation [VF]; VT/VF) were provoked by EPS and/or spontaneously occurred in ALB-group whereas not in both wRBC-group and HbV-group. HIF1-alpha was positively stained and TnI levels were significantly elevated only in ALB-group (Peak TnI; 186±47 vs. 64±25, 91±24, 44±10pg/mL, P<0.05: Figure). Conclusions: HbVs rescue lethal hemorrhage through improving lethal arrhythmias and myocardial damages by reflected by inducing HIF1-alpha and elevated TnI. HbVs could be useful for resuscitation and saving life from gun-shot arterial bleeding on-site occurred in terrorisms.

Abstract 13848: Time to Coronary Angiography in Patients With NSTE-ACS is Longer in Women as Compared to Men

Introduction: Timely invasive coronary angiography (ICA) to restore myocardial blood flow in patients with non-ST-segment elevation acute coronary syndrome (NSTE-ACS) improves prognosis and reduces morbidity and mortality. NSTE-ACS practice guidelines recommend ICA <2 hours [hrs] (very high-risk) or <24 hrs (high-risk). Troponin is useful for guiding timing of ICA. However, there is little evidence comparing time to troponin and ICA in women vs. men, which could uncover important treatment differences. Therefore, the purpose of this study was to examine time to ICA and first troponin in women vs. men in a cohort of hospitalized NTSE-ACS patients. Methods: Secondary data analysis in 121 patients with NSTE-ACS; women ( n =41, 34%) vs. men ( n =80, 66%), who underwent ICA and had a troponin test. Variables of interest were obtained from the electronic health record. Results: Compared to men, women were older (67±12 vs. 62±11 years, p =0.039), had a higher proportion of diabetes (44% vs. 19%, p =0.006), and were non-smokers (61% vs. 31%, p =0.013). Time, in minutes , to first troponin did not differ between women vs. men (81.53±261.04 vs . 33.49±107.20, p =0.167), when including one outlier (one woman). Excluding this outlier, it remained non-significant (44.43±127.66 vs. 33.49±107.20, p =0.167). Overall, the time to ICA, in hours , was longer in women than men (24.01±27.64 vs. 13.83±12.89, p= 0.007). The first troponin was positive in 26 women (67%) and 53 men (69%), p =0.98; however, time to ICA, in hours , was longer in women vs. men (21.55±20.26 vs. 12.56±11.41, p= 0.014). Conclusions: In patients with confirmed NSTE-ACS, time from admission to ICA was nearly twice as long in women as compared to men. One explanation could be symptoms differences and should be explored further. Time from admission to first troponin was not statistically different (with and without oulier [one women]). Despite an equivalent rate of the first troponin being positive, time to ICA was on average 9 hours longer in women vs. men. Future studies in a larger cohort(s) using contemporary data are needed to explore possible reasons for ICA delay (symptoms and clinical characteristics) to confirm if similar trends persists and whether short- and long-term outcomes are different by sex.

Abstract 15468: Factor VII Induced Coronary Thrombosis

Case Description: 69-year-old male with a history of factor VII deficiency and coronary artery disease (CAD) with a stent in the distal left anterior descending (LAD) artery, underwent diagnostic laparoscopy for suspected appendiceal carcinoma. He is a non-smoker, has good exercise tolerance and takes aspirin only three times a week, due to epistaxis. Post-surgery, he complained of 10/10 substernal chest pain. Initial troponin (TnI) was 0.11 ng/dL, peaking at >80 ng/dL in 2 hours. EKG was compatible with an anterior wall STEMI. An emergent coronary angiogram showed a patent distal LAD stent and a 99% occlusive lesion in the mid-LAD, which was treated with a drug-eluting stent. With careful clinical judgment and hematology consultation, dual antiplatelet therapy was continued despite a history of coagulopathy. On probing, it was discovered that the patient received two doses of recombinant factor VII (rVII) prior to the surgery to reduce operative bleeding. Discussion: Recombinant factor VII is known to cause serious arterial and venous thromboembolic events. This risk increases to almost 10% in patients who are elderly with concomitant vascular disease. In our patient with prior history of CAD and in the setting of acute surgical stress, exogenous factor VII unbalanced the coagulation system leading to a STEMI. Surgical teams should be aware of the detrimental consequences of administration of rVII in high cardiovascular risk patients and seek alternative hemostatic strategies. Prothrombotic agents should be used with caution and close monitoring for acute coronary syndromes, especially in patients with a high risk of CAD.

Abstract 14091: Subclinical Cardiac Dysfunction in the Patients Treated With Anthracycline-Containing Chemotherapy in the Chronic Phase

Background: Anthracycline-induced cardiotoxicity is a concerning problem in the treatment of a variety of cancers. The highest incidence of anthracycline-induced cardiotoxicity was observed during the first year after the completion of chemotherapy, but the changes in cardiac function and biomarkers after the first year have not been adequately investigated. Methods: We analyzed 105 consecutive patients who were followed up for 24 months after starting anthracycline-containing chemotherapy in our hospital from June 2018 to April 2021. Echocardiography and blood test for troponin I and B-type natriuretic peptide (BNP) were performed at baseline, 3 months, 6 months, 12 months, and 24 months after starting the chemotherapy. Results: The cancer types included 71 breast cancers, 18 hematologic cancers, 11 gynecologic cancers, and 5 soft tissue tumors. Compared to baseline, troponin I levels were increased at 3 months (0.011±0.007 ng/ml vs. 0.021±0.021 ng/ml, P<0.05) and 6 months (0.023±0.047 ng/ml, P<0.001), then, recovered to baseline levels. In contrast, BNP levels remained unchanged for 12 months but increased at 24 months compared to baseline (31.9 [5.8-625.7] pg/ml vs. 15.5 [5.8-89.2] pg/ml, P<0.01). In addition, the left ventricular ejection fraction was decreased from baseline to 6 months (65.4±4.8% vs. 63.6±4.5%, P<0.05) and 24 months (63.6±4.7%, P<0.05). Multivariate logistic analysis revealed that age (OR 1.049, 95% CI [1.006-1.097], P=0.029) and total anthracycline dose (OR 1.011, 95% CI [1.002-1.022], P=0.026) were predicting factors for elevated BNP levels above the normal range (>18.2 pg/ml) at 24 months. Conclusion: Subclinical cardiac dysfunction was developed after more than one year. Long-term follow-up is desirable to detect cardiac dysfunction in patients treated with anthracycline-containing chemotherapy.

Cardiovascular effects of COVID-19 in children

Introduction: Although severe acute respiratory failure is the primary cause of morbidity and mortality in severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, this viral infection leads to cardiovascular disease in some individuals. Cardiac effects of the virus include myocarditis, pericarditis, arrhythmias, coronary aneurysms and cardiomyopathy, and can result in cardiogenic shock and multisystem organ failure. Method: This review summarises cardiac manifestations of SARS-CoV-2 in the paediatric population. We performed a scoping review of cardiovascular disease associated with acute coronavirus disease 2019 (COVID-19) infection, multisystem inflammatory syndrome in children (MIS-C), and mRNA COVID-19 vaccines. Also examined are special considerations for paediatric athletes and return to play following COVID-19 infection. Results: Children presenting with acute COVID-19 should be screened for cardiac dysfunction and a thorough history should be obtained. Further cardiovascular evaluation should be considered following any signs/symptoms of arrhythmias, low cardiac output, and/or myopericarditis. Patients admitted with severe acute COVID-19 should be monitored with continuous cardiac monitoring. Laboratory testing, as clinically indicated, includes tests for troponin and B-type natriuretic peptide or N-terminal pro-brain natriuretic peptide. Echocardiography with strain evaluation and/or cardiac magnetic resonance imaging should be considered to evaluate diastolic and systolic dysfunction, coronary anatomy, the pericardium and the myocardium. For patients with MIS-C, combination therapy with intravenous immunoglobulin and glucocorticoid therapy is safe and potentially disease altering. Treatment of MIS-C targets the hyperimmune response. Supportive care, including mechanical support, is needed in some cases. Conclusion: Cardiovascular disease is a striking feature of SARS-CoV-2 infection. Most infants, children and adolescents with COVID-19 cardiac disease fully recover with no lasting cardiac dysfunction. However, long-term studies and further research are needed to assess cardiovascular risk with variants of SARS-CoV-2 and to understand the pathophysiology of cardiac dysfunction with COVID-19.

Cardiovascular effects of COVID-19 in children.

Although severe acute respiratory failure is the primary cause of morbidity and mortality in severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, this viral infection leads to cardiovascular disease in some individuals. Cardiac effects of the virus include myocarditis, pericarditis, arrhythmias, coronary aneurysms and cardiomyopathy, and can result in cardiogenic shock and multisystem organ failure. This review summarises cardiac manifesta-tions of SARS-CoV-2 in the paediatric population. We performed a scoping review of cardiovascular disease associated with acute coronavirus disease 2019 (COVID-19) infection, multisystem inflammatory syndrome in children (MIS-C), and mRNA COVID-19 vaccines. Also examined are special considerations for paediatric athletes and return to play following COVID-19 infection. Children presenting with acute COVID-19 should be screened for cardiac dysfunction and a thorough history should be obtained. Further cardiovascular evaluation should be considered following any signs/symptoms of arrhythmias, low cardiac output, and/or myopericarditis. Patients admitted with severe acute COVID-19 should be monitored with continuous cardiac monitoring. Laboratory testing, as clinically indicated, includes tests for troponin and B-type natriuretic peptide or N-terminal pro-brain natriuretic peptide. Echocardiography with strain evaluation and/or cardiac magnetic resonance imaging should be considered to evaluate diastolic and systolic dysfunction, coronary anatomy, the pericardium and the myocardium. For patients with MIS-C, combination therapy with intravenous immunoglobulin and glucocorticoid therapy is safe and potentially disease altering. Treatment of MIS-C targets the hyperimmune response. Supportive care, including mechanical support, is needed in some cases. Cardiovascular disease is a striking feature of SARS-CoV-2 infection. Most infants, children and adolescents with COVID-19 cardiac disease fully recover with no lasting cardiac dysfunction. However, long-term studies and further research are needed to assess cardiovascular risk with variants of SARS-CoV-2 and to understand the pathophysiology of cardiac dysfunction with COVID-19.

Emergency department presentations for chest complaints after mRNA COVID-19 vaccinations in children and adolescents.

To investigate characteristics and management of children presenting with chest complaints to a tertiary paediatric ED post-mRNA COVID-19 vaccine. This was a retrospective medical record review with data linkage to the Australian Immunisation Register. The study setting was the Royal Children's Hospital, Melbourne, Australia. Children <18 years who had a troponin blood test performed in hospital within 14 days of receiving mRNA COVID-19 vaccination were included. Elevated troponin and myocarditis or pericarditis as per Brighton criteria was the primary outcome. Vaccination status, length of stay, investigations and clinical management were secondary outcomes. Six hundred and ten patients had a troponin test in 13 months. After exclusion of trauma-related tests (n = 31), known cardiac patients (n = 75) and others (n = 145), 359 troponins were obtained due to chest complaints and related symptoms, with 283 troponins assessed to be mRNA vaccination-related. There was a temporal peak in presentations with a 30-fold monthly increase in troponin post-commencement of mRNA COVID-19 vaccines. In those with chest complaints following mRNA vaccination, mean age was 14 years and 50.4% were female. Fourteen out of 283 (5%) vaccine-related troponins were abnormal with 14 patients assessed to have vaccine-associated myocarditis. No patients had pericarditis. There was a large number of possible mRNA COVID-19 vaccine-related chest complaints presenting to the ED. Few patients had abnormal troponins or myocarditis.

A case of Brugada phenocopy alteration induced by immune checkpoint inhibitors

Immunotherapy has shown remarkable efficacy in various cancer treatments. However, enhanced T-cell immune surveillance can lead to aberrant immune responses, resulting in severe immune checkpoint inhibitor-related adverse events. This is a case report of a patient previously treated with immune checkpoint inhibitors who presented with ST-segment elevation without abnormal troponin and cardiac enzyme spectrum test results. Cardiac toxicity of immune checkpoint inhibitors mainly manifests as acute immune-mediated myocarditis. While Brugada phenocopy is commonly caused by fever, electrolyte abnormalities, tricyclic/tetracyclic antidepressants, and marijuana use, we suspect that it was induced by immune checkpoint inhibitors in the current case.

Role of serum biomarkers in predicting management strategies for acute pulmonary embolism

BackgroundAcute pulmonary embolism (APE) is a condition that can be fatal. The severity of the disease influences therapeutic decisions, and mortality varies significantly depending on the condition's severity. Identification of patients with a high mortality risk is crucial. Since inflammation, hemostatic, and coagulation abnormalities are linked to APE, serum biomarkers may be helpful for prognostication. AimTo evaluate the significance of serum biomarkers in APE risk assessment and the suitability of these biomarkers for management and decision-making. MethodsThis study involved 60 adult patients with APE who were divided according to risk categorization. It was conducted in Chest, Cardiology and Internal Medicine department, Zagazig University Hospitals from December 2022 to May 2023. Several hematological biomarkers and their significance in APE risk assessment were measured with a comparison with the latest risk stratification methods which include haemodynamic measures and right ventricular (RV) dysfunction echocardiographic markers. ResultsEach risk group involved 20 patients (high, intermediate (10 were intermediate-high and 10 were intermediate-low) and low risk group). They were 34 females and 26 males with the mean ± SD of their age was 59.25 ± 13.06 years. Regarding hematological biomarkers, there were statistically significant differences as regards; lymphocytes, platelet to lymphocyte ratio (PLR), albumin, blood urea nitrogen (BUN), C-reactive protein (CRP) and D-dimer with highly statistically significant differences as regards; neutrophil to lymphocyte ratio (NLR), BUN to albumin (B/A) ratio, troponin I (TnI), and brain natriuretic peptide (BNP). TnI had the highest specificity and predictive value positive (PVP) and BNP had the highest sensitivity and predictive value negative (PVN) in predicting high risk groups. The Lymphocyte and NLR showed the lowest sensitivity and the albumin and B/A ratio had the lowest specificity. Regarding transthoracic echocardiography (TEE); there was a statistically significant increase regarding pulmonary artery systolic pressure (PASP) and a highly statistically significant increase regarding the right ventricle/left ventricle (RV/LV) ratio. There were statistically significant decreases regarding tricuspid annular plane systolic excursion (TAPSE) and peak systolic velocity of tricuspid annulus (S′) among risk groups. ConclusionAPE prognosis can be judged accurately by simultaneously measuring a few biomarkers along with haemodynamic variables and echocardiographic parameters of RV dysfunction.

Role of Cardiac Troponins in Predicting Adverse Outcomes in Acute Coronary Syndrome With Renal Dysfunction.

A substantial global cause of mortality as well as disability is acute myocardial infarction (AMI). It is alsowidespread knowledge that patients with chronic kidney disease (CKD) possess greater mortality and cardiovascular disease risks than the rest of the population. A vital biomarker for the diagnosis of AMI is high-sensitive cardiac troponin T (hs-cTnT). Individuals afflicted with severe CKDfrequently exhibit increased hs-cTnTlevels, which can pose a significant diagnostic challenge in cases of non-ST elevation acute coronary syndrome (NSTE-ACS) necessitating revascularization. Alteration in kidney function exerts an impact on troponin levels, making a single value less useful. As the renal population has an increased risk of non-ST-segment elevation myocardial infarction (NSTEMI), serial tracking of cardiac biomarkers is essential to detect ACS in this population. Numerous studies using algorithmic remedies based on admission troponin and spontaneous variations in troponin concentration have been put forth by researchers to address these issues. A considerable majority of CKD patients can be accurately diagnosed or excluded from having AMI using the approach, which involves serial measures. Patients who suffer from kidney impairment exhibit lesser chances of undergoing angiography or revascularizationand receiving preventative therapies. Furthermore, their outcomes are comparatively poorer when compared to patients who possess normal kidney function. Despite studies indicating a higher risk of poor outcomes after AMI in this population, these patients are less likely to receive guideline-indicated care. In this study, we employed a systematic literature review (SLR) methodology to provide an account of the available studies and to draw attention to the importance of cardiac troponins in predicting unfavorable outcomes and algorithms in the prediction, diagnosis, and prognosis of patients with ACS and renal impairment. Eight papers were chosen for in-depth analysis after reviewing 86 articles from trusted publications between 2013 and August 3, 2023. The analysis considered factors such as sensitivity, severity of renal damage, algorithms used, the benefits of algorithms, and the challenges. One must examine the change in cardiac troponin (cTn) and take higher cut-off values into consideration in order to increase the sensitivity and specificity for the diagnosis of AMI. Higher levels of cTn have also been correlated prognostically to unfavorable outcomes like incident heart failure and death from cardiovascular causes. Also, raised troponin levels have been linked to all-cause and cardiovascular death in both dialysis patients and patients with CKD who did not receive dialysis. Future studies should concentrate on whether troponin testing can reclassify risk and provide treatment in people with CKD who are at the greatest threat of death. The clinical practice benefits of routinely measuring cardiac troponin concentrations are largely unknown. Future research should also concentrate on figuring out how troponin testing can influence clinical management and how to address the root reasons for chronic hs-cTnT elevation in patients with CKD, which may include elements like uremic toxicity, macrovascular or microvascular ischemia, anemia, as well as reduced renal clearance.

Derivation of a HEAR Pathway for Emergency Department Chest Pain Patients to Safely Avoid a Second Troponin Test.

The study aims to develop a decision pathway based on HEAR score and 0 h high-sensitivity cardiac troponin T (hs-cTnT) to safely avoid a second troponin test for suspected non-ST elevation myocardial infarction (NSTEMI) in emergency departments. A HEAR score consists of history, electrocardiogram, age, and risk factors. A HEAR pathway is established using a Bayesian approach based on a predefined safety threshold of NSTEMI prevalence in the rule-out group. In total, 7131 patients were retrospectively enrolled, 582 (8.2%) with index visit NSTEMI and 940 (13.2%) with 180-day major adverse cardiovascular events (MACE). For patients with a low-risk HEAR score (0 to 2) and low 0 h hs-cTnT (<14 ng/L), the HEAR pathway recommends early discharge without further testing. After the HEAR pathway had been applied to rule out NSTEMI, the negative predictive value of index visit NSTEMI was 100.0% (95% CI, 99.8% to 100.0%) and false-negative rate of 180-day MACE was 0.40% (95% CI, 0.18% to 0.87%). Compared with the 0 h hs-cTnT < limit of detection (LoD) strategy (<5 ng/L), the HEAR pathway could correctly reclassify 1298 patients without MACE as low risk and lead to a 18.2% decrease (95% CI, 17.4-19.1%) in the need for a second troponin test. The HEAR pathway may lead to a substantial and safe reduction in repeated troponin test for emergency department patients with suspected NSTEMI.