Troponin Levels In Patients Research Articles

High sensitive TROponin levels In Patients with Chest pain and kidney disease: A multicenter registry - The TROPIC study.

Accuracy of high sensitive troponin (hs-cTn) to detect coronary artery disease (CAD) in patients with renal insufficiency is not established. The aim of this study was to evaluate the prognostic role of hs-cTn T and I in patients with chronic kidney disease (CKD). All consecutive patients with chest pain, renal insufficiency (eGFR < 60 mL/min/1.73 m2) and high sensitive troponin level were included. The predictive value of baseline and interval troponin (hs-cTnT and hs-cTnI) for the presence of CAD was assessed. One hundred and thirteen patients with troponin I and 534 with troponin T were included, with 95 (84%) and 463 (87%) diagnosis of CAD respectively. There were no differences in clinical, procedural and outcomes between the two assays. For both, baseline hs-cTn values did not differ be-tween patients with/without CAD showing low area under the curve (AUC). For interval levels, hs-cTnI was significantly higher for patients with CAD (0.2 ± 0.8 vs. 8.9 ± 4.6 ng/mL; p = 0.04) and AUC was more accurate for troponin I than hs-cTnT (AUC 0.85 vs. 0.69). Peak level was greater for hs-cTnI in patients with CAD or thrombus (0.4 ± 0.6 vs. 15 ± 20 ng/mL; p = 0.02; AUC 0.87: 0.79-0.93); no differences were found for troponin T assays (0.8 ± 1.5 vs. 2.2 ± 3.6 ng/mL; p = 1.7), with lower AUC (0.73: 0.69-0.77). Peak troponin levels (both T and I) independently predicted all cause death at 30 days. Patients with CKD presenting with altered troponin are at high risk of coronary disease. Peak level of both troponin assays predicts events at 30 days, with troponin I being more accurate than troponin T. (Cardiol J 2017; 24, 2: 139-150).

Troponin levels in patients with stable CAD

IntroductionCardiac troponins are known as specific markers of myocardial damage. Their elevation in the serum is not always related to acute myocardial ischaemia. The increased sensitivity of diagnostic kits has resulted in an increase in the number of positive results in patients without acute coronary syndrome (ACS). Study objectivesTo determine the level of highly sensitive troponin T (hs TnT) in stable patients (without ACS) before selective coronarography (SCG) and to determine the correlation between hs TnT values and the extent of atherosclerotic damage to the coronary arteries. MethodologyWe studied a group of 251 consecutive patients with indications for SCG diagnosis. Indication criteria were stable angina pectoris, shortness of breath, newly diagnosed heart failure, syncope, and ventricular arrhythmia. Exclusion criteria were acute coronary syndrome, including unstable angina pectoris, prior cardiopulmonary resuscitation, cerebrovascular accident (CVA) within the last 6 months, and ongoing sepsis. The hs TnT value was determined before SCG (normal range, 0–0.013μg/l). Monitored parameters included coronary angiography (70% stenosis of coronary artery diameter was considered significant coronary disease), age, gender, heart rate, and serum creatinine levels. The study included 182 patients with normal renal function and 69 patients with renal insufficiency. The results were processed using STATISTICA (version 12), StatSoft©, Inc. (2013). ResultsThe average age of the studied population was 69.6±10.3 years (median, 70 years); 33% of patients were women. The serum level of hs TnT for the entire population was 0.031±0.091μg/l (0.014). A positive hs TnT was noted in 133 patients. The population study group consisted of 121 patients with normal coronary arteries or with insignificant atherosclerotic disease. Significant damage involving one or more arteries was present in 130 patients. In the subgroup with significant coronary disease, we found a significantly higher hs TnT level than in the group of patients without significant coronary disease: 0.043±0.125μg/l (0.018) vs. 0.019±0.018μg/l (0.013) (p=0.008) (Mann–Whitney test).Significantly higher troponin levels were found in the group of patients with renal insufficiency than in the subgroup with normal creatinine levels: 0.057±0.150μg/l (0.023) vs. 0.022±0.053μg/l (0.012), respectively (p<0.05) (Mann–Whitney test). ConclusionSlightly elevated serum troponin T levels are common in patients with stable coronary artery disease (CAD). We observed a significant correlation between the level of troponin and the presence of atherosclerotic damage to the coronary arteries. A significant correlation between the value of troponin and the extent of atherosclerotic damage (in terms of the number of damaged arteries) could not be demonstrated. On the basis of our findings, the absolute level of troponin T in patients with stable CAD must be interpreted with caution, especially in patients who also have renal insufficiency. Determination of basal troponin T levels in patients with stable CAD is reasonable as they may be used for comparison in case of change in a patient's clinical condition.

Utility of γ-Glutamyl Transferase in Predicting Troponin Elevation in Emergency Departments.

Serum γ-glutamyl transferase (GGT) activity is a risk predictor for the development of coronary artery disease and is related to cardiovascular morbidity and mortality. We evaluated the clinical utility of GGT activity in predicting high troponin levels in patients with acute coronary syndrome (ACS) admitted to the emergency department with chest pain. A total of 200 troponin-positive and 203 troponin-negative patients were classified into groups 1 and 2, respectively. γ-Glutamyl transferase activity was significantly higher in group 1 (44 ± 34 U/L) compared with group 2 (31 ± 26 U/L, P = .001). A GGT activity cutoff >25.5 showed 62% sensitivity and 61% specificity in predicting troponin positivity. Logistic regression analysis demonstrated a significant predictive value of GGT for troponin positivity. Spearman rank correlation analysis showed a moderately strong relationship between GGT activity and troponin positivity. Considering the predictive value of high GGT activity for troponin positivity, GGT activity may complement other diagnostic biomarkers for predicting troponin positivity in patients having ACS admitted with chest pain.

Strong diurnal rhythm of troponin T, but not troponin I, in a patient with renal dysfunction

Cardiac troponin T (cTnT) and I (cTnI), measured with high-sensitive assays, are the preferred biomarkers for the diagnosis of acute myocardial infarction [ 1 Roffi M. Patrono C. Collet J.P. Mueller C. Valgimigli M. Andreotti F. et al. 2015 ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation: Task Force for the Management of Acute Coronary Syndromes in Patients Presenting without Persistent ST-Segment Elevation of the European Society of Cardiology (ESC). Eur. Heart J. 2016; 37: 267-315 Crossref PubMed Scopus (4337) Google Scholar , 2 Mills N.L. Churchhouse A.M. Lee K.K. Anand A. Gamble D. Shah A.S. et al. Implementation of a sensitive troponin I assay and risk of recurrent myocardial infarction and death in patients with suspected acute coronary syndrome. JAMA. 2011; 305: 1210-1216 Crossref PubMed Scopus (271) Google Scholar ]. Serial cardiac troponin measurements, and the interpretation of a “troponin rise-or-fall” in patients with chest pain discriminate between acute and chronic troponin elevations [ [1] Roffi M. Patrono C. Collet J.P. Mueller C. Valgimigli M. Andreotti F. et al. 2015 ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation: Task Force for the Management of Acute Coronary Syndromes in Patients Presenting without Persistent ST-Segment Elevation of the European Society of Cardiology (ESC). Eur. Heart J. 2016; 37: 267-315 Crossref PubMed Scopus (4337) Google Scholar ]. This diagnostic concept assumes that troponin levels in patients without acute cardiac injury fluctuate randomly around an individual's homeostatic setpoint. However, it has recently been demonstrated that cTnT exhibits a diurnal rhythm [ 3 Klinkenberg L.J. van Dijk J.W. Tan F.E. van Loon L.J. van Dieijen-Visser M.P. Meex S.J. Circulating cardiac troponin T exhibits a diurnal rhythm. J. Am. Coll. Cardiol. 2014; 63: 1788-1795 Abstract Full Text Full Text PDF PubMed Scopus (65) Google Scholar , 4 Aakre K.M. Roraas T. Petersen P.H. Svarstad E. Sellevoll H. Skadberg O. et al. Weekly and 90-minute biological variations in cardiac troponin T and cardiac troponin I in hemodialysis patients and healthy controls. Clin. Chem. 2014; 60: 838-847 Crossref PubMed Scopus (75) Google Scholar ]. The amplitude of the diurnal cTnT rhythm and its diagnostic implication in patients with chronically elevated cTnT levels are unexplored. Also, whether cTnT and cTnI are equally affected by rhythmic diurnal oscillation is unknown.

Routine Troponin Measurements Are Unnecessary to Exclude Asymptomatic Coronary Events in Acute Ischemic Stroke Patients

Obtaining serum troponin levels in every patient with acute stroke is recommended in recent stroke guidelines, but there is no evidence that these contribute positively to clinical care. We sought to determine the clinical significance of measuring troponin levels in acute ischemic stroke patients. We reviewed 398 consecutive patients with acute ischemic stroke at a large academic institution from 2010 to 2012. Troponin levels were measured as a result of protocol in place during part of the study period. The mean age was 70 years (standard deviation ±16 years) and 197 (49.5%) were men. Chronic kidney disease was present in 78 (19.6%), coronary artery disease in 107 (26.9%), and atrial fibrillation in 107 (26.9%). Serum troponin T was measured in 246 of 398 patients (61.8%). Troponin was elevated (>.01 ng/mL) at any point in 38 of 246 patients (15.5%) and was elevated in 28 patients at all 3 measurements (11.3% of those with troponin measured). Only 4 of 246 patients (1.6%) had a significant uptrend. Two were iatrogenic in the setting of hemodynamic augmentation using vasopressors to maintain cerebral perfusion. One case was attributed to stroke and chronic kidney disease and another case to heart failure from inflammatory fibrocalcific mitral valvular heart disease. Serum troponin elevation in patients with ischemic stroke is not usually caused by clinically significant acute myocardial ischemia unless iatrogenic in the setting of vasopressor administration. Serum troponin levels should be measured judicially, based on clinical context, rather than routinely in all stroke patients.

High-sensitivity Troponin T in relation to coronary plaque characteristics in patients with stable coronary artery disease; results of the ATHEROREMO-IVUS study

Background and aimsTo assess the relationship between the extent and phenotype of coronary atherosclerosis, as assessed by in-vivo grayscale and radiofrequency intravascular ultrasound (IVUS), and circulating Troponin levels in patients with established stable coronary artery disease (CAD). MethodsIn this single-center, cross-sectional analysis, high-sensitivity Troponin T (hsTnT) was measured and IVUS was performed in a predefined non-stenotic segment of a non-culprit coronary artery in 231 patients with stable CAD undergoing elective angiography. ResultsHsTnT was detectable (>3 pg/mL) in 212 patients (92%) and a concentration above 14 pg/mL was observed in 19.5%. Normalised segmental plaque volumes were positively associated with hsTnT levels (25.0 mm3 increase in segmental plaque volume per SD increase in ln-transformed hsTnT, 95% CI: 6.0–44.0, p = 0.010). Higher hsTnT levels were measured in patients with a virtual histology derived thin-cap fibroatheroma (VH-TCFA, adj. odds ratio for presence of VH-TCFA = 1.52 per SD increase in ln-transformed hsTnT, 95% CI: 1.10–2.11, p = 0.011). Patients with a VH-TCFA had a 2-fold increased prevalence of hsTnT concentration ≥14 pg/mL (adj. OR 2.35, 95% CI: 1.12–4.91, p = 0.024). In addition, a 3-fold increased prevalence of hsTnT concentration ≥14 pg/mL was observed in patients with a VH-TCFA with a lesional plaque volume higher than the median (adj. OR 3.36, 95% CI: 1.44–7.84, p = 0.005). ConclusionsSegmental plaque volume and presence of VH-TCFA lesions are associated with higher circulating hsTnT concentrations in stable CAD patients. Subclinical plaque rupture or erosion and distal embolisation may be hypothesized as a potential pathophysiological mechanism with respect to Troponin elevation and its relation with adverse outcome in this patient population.

Two-dimensional speckle-tracking-derived segmental peak systolic longitudinal strain identifies regional myocardial involvement in patients with myocarditis and normal global left ventricular systolic function.

The presence of myocardial late gadolinium enhancement (LGE) by cardiac magnetic resonance (CMR) imaging in concert with electrocardiography and elevated biomarkers helps support the diagnosis of acute myocarditis. Two-dimensional echocardiography is limited to global and qualitative regional function assessment and may not contribute to the diagnosis, especially in the presence of normal LV systolic function. Two-dimensional speckle-tracking (2D-STE)-derived segmental peak systolic (pkS) longitudinal strain (LS) may identify segmental myocardial involvement in myocarditis. We sought to identify an association between segmental pkS, LGE, and troponin levels in patients with myocarditis. Retrospective analysis of myocardial segmental function by 2D-STE segmental strain was compared to the presence of LGE and admission peak troponin levels in patients with acute myocarditis and preserved global LV systolic function. American Heart Association 17-segment model was used for comparison between imaging modalities. Global function was assessed by m-mode-derived shortening fraction (SF). Descriptive statistics and regression analysis were utilized. Forty-four CMRs performed to evaluate for myocarditis were identified. Of the 44, 10 patients, median age 17.5 years (14-18.5 years) and median SF 35 % (28-44 %), had paired CMR and 2D-STE data for analysis, and 161/170 segments could be analyzed by both methods for comparison. PkS LS was decreased in 51 % of segments that were positive for LGE with average pkS of -14.7 %. Segmental pkS LS abnormalities were present in all but one patient who had abnormal pkS circumferential strain. Global pkS LS was decreased in patients with myocarditis. There is a moderate correlation between decreased pkS LS and the presence of LGE by CMR, 2D-STE for myocardial involvement in acute myocarditis can serve as an useful noninvasive adjunct to the existing tests used for the diagnosis of acute myocarditis and might have a role in prognostication.

The Prognostic Significance of Elevated Troponin Levels in Patients with Normal Coronaries Undergoing Surgery for Aortic Valve Stenosis

The Prognostic Significance of Elevated Troponin Levels in Patients with Normal Coronaries Undergoing Surgery for Aortic Valve Steno Objective: The outcome of aortic valve replacement (AVR) in patients without occlusive coronary artery disease who present with raised pre-operative troponin is not clear. We therefore, investigated the operative mortality and morbidity in this subset of patients undergoing urgent surgery for aortic stenosis. Methods: From a pool of 595 AVR patients in our institution’s database from July 2007 to July 2013, we reviewed the notes of all patients who underwent urgent surgery for aortic stenosis (n=57) and identified those with raised pre-operative troponin (n=16). We compared the observed operative mortality and major morbidity rates between patients with raised preoperative troponin levels (group I) and those with normal troponin levels (group II), and also with their predicted outcomes. Results: The baseline and operative characteristics for the two groups were comparable. There was a trend towards higher operative mortality for group I patients (18.8% versus 7.3% for group II, P=.07). Whereas, the observed operative mortality for group I far exceeded the predicted (18.8% vs 12.5%, p=.05), for group II the observed was slightly lower than the predicted operative mortality (7.3% vs 9.3%, p=.63). On the other hand, the observed mortality was well below the predicted for the elective patients. Conclusion: Patients with aortic stenosis and raised preoperative troponin undergoing urgent AVR may be at risk of higher operative mortality than predicted by the EuroScore. Further studies in this high risk group are warranted.

Abstract 16133: High Density Lipoprotein Cholesterol is an Alternative Marker to Troponin for Acute Coronary Syndrome in High Risk Patients

Introduction: It is well known that high density lipoprotein cholesterol is inversely correlated with the risk of coronary artery disease. However, data is limited regarding the relationship of high density lipoprotein cholesterol in the acute setting of coronary artery disease and particularly how it compares to the most well-known biomarker, cardiac troponin I. Hypothesis: We assessed the hypothesis that high density lipoprotein cholesterol could be used as an alternative marker to troponin for acute coronary syndrome (ACS) in high risk patients. Methods: We analysed 740 patients of the BRAVEHEART cohort presenting for coronary angiography at our institution between October 2009 and March 2014. Of these, 153 patients presented with ACS, including 44 with ST elevation myocardial infarction and 109 with non-ST elevation myocardial infarction, and 587 patients presented without ACS. Binary logistic regression was used to compare high density lipoprotein cholesterol and cardiac troponin I levels as predictors of ACS, independent of age, sex, cardiac risk factors and statin use. Results: Patients presenting with ACS had higher median cardiac troponin I levels (0.34 vs. 0.02 μg/L; p&lt;0.001), higher median serum triglyceride levels (1.5 vs. 1.3 mmol/L, p&lt;0.001) and lower median high density lipoprotein cholesterol levels (0.97 vs. 1.09 mmol/L, p&lt;0.001) than patients without ACS. There was no difference in total cholesterol and low density lipoprotein cholesterol between the two groups. After adjusting for differences in patient variables, the strongest independent predictors of ACS were cardiac troponin I (odds ratio (OR), 1.50; 95% confidence interval (CI), 1.24-1.82; p&lt;0.001) and high density lipoprotein cholesterol (OR, 0.12; 95% CI, 0.04-0.36; p&lt;0.001). Conclusion: In conclusion, high density lipoprotein cholesterol was found to be an independent marker of ACS in high risk patients at our institution. Further studies on high density lipoprotein cholesterol could determine its clinical use in conjunction with troponin levels in patients presenting with ACS.

Abstract 9789: Transient Elevation of Highly Sensitive Troponin T Levels in Patients With Documented Coronary Artery Disease Following Stress Myocardial Perfusion Imaging

Introduction: Cardiac troponins are the preferred biomarkers of myocardial injury. More sensitive assays led to the detection of circulating troponins not only in myocardial infarction, but also in apparently healthy subjects after prolonged exercise. Hypothesis: In the era of highly sensitive troponin T (hs-TnT) tests we assesed the hypothesis that brief but intense exercise during diagnostic tests might cause elevated troponin levels in patients with stable coronary artery disease (CAD). Methods: Seventy-two patients (71% male, age 64±10 years) with documented CAD, LVEF &gt;45%, normal renal function and normal baseline hs-TnT levels (&lt;14 ng/l) underwent myocardial perfusion imaging (MPI, Tc-99m sestamibi) using bicycle stress test (n=19) or adenosine stimulation (n=55). Hs-TnT levels were detected immediately before and immediately after stress, and again after 4 hours and 24 hours. The extent of stress-induced myocardial ischemia was estimated from perfusion scores derived from single-photon emission computed tomography (SPECT) post stress and rest images. Significant reversible myocardial ischemia was prospectively defined as regional perfusion abnormality ≥10% of the left ventricular myocardium. Results: Transient elevations of hs-TnT levels above the normal limit occurred in 5/72 patients (7%) after diagnostic stress testing with a peak level at 4 hours after stress. Hs-TnT elevations were more common in patients with stress-induced myocardial ischemia (3/12, 25%) compared to patients without ischemia (2/60, 3%; p=0.038). However, no relation between peak hs-TnT levels and the extent of reversible myocardial ischemia was found (r=-0.16, n=72, p=NS). Furthermore, peak hs-TnT levels were similar with both types of stress (bicycle 6.6 [4.0 – 10.5] pg/l versus adenosine 5.1 [3.1 – 8.6] pg/l, median [IQR]). Conclusions: Transient hs-TnT elevations are quite common after diagnostic stress testing and occur more frequently in patients with documented reversible ischemia. No relation between peak hs-TnT levels and the extent of reversible myocardial ischemia at MPI was obtained. In conclusion this suggests that hs-TNT elevation during stress testing depends on other factors then those leading to SPECT-detected myocardial ischemia.

Significance of troponin levels in patients with stable coronary artery disease

Significance of troponin levels in patients with stable coronary artery disease

Prognostic value of cardiac troponin in patients with chronic kidney disease without suspected acute coronary syndrome: a systematic review and meta-analysis.

Clinicians face uncertainty about the prognostic value of troponin testing in patients with chronic kidney disease (CKD) without suspected acute coronary syndrome (ACS). To systematically review the literature on troponin testing in patients with CKD without ACS. MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials through May 2014. Studies examining elevated versus normal troponin levels in patients with CKD without ACS. Paired reviewers selected articles for inclusion, extracted data, and graded strength of evidence (SOE). Meta-analyses were conducted when studies had sufficient homogeneity of key variables. Ninety-eight studies met inclusion criteria. Elevated troponin levels were associated with all-cause and cardiovascular mortality among patients receiving dialysis (moderate SOE). Pooled hazard ratios (HRs) for all-cause mortality from studies that adjusted for age and coronary artery disease or a risk equivalent were 3.0 (95% CI, 2.4 to 4.3) for troponin T and 2.7 (CI, 1.9 to 4.6) for troponin I. The pooled adjusted HRs for cardiovascular mortality were 3.3 (CI, 1.8 to 5.4) for troponin T and 4.2 (CI, 2.0 to 9.2) for troponin I. Findings were similar for patients with CKD who were not receiving dialysis, but there were fewer studies. No study tested treatment strategies by troponin cut points. Studies were heterogeneous regarding assays, troponin cut points, covariate adjustment, and follow-up. In patients with CKD without suspected ACS, elevated troponin levels were associated with worse prognosis. Future studies should focus on whether this biomarker is more appropriate than clinical models for reclassifying risk of patients with CKD and whether such classification can help guide treatment in those at highest risk for death. Agency for Healthcare Research and Quality.

Функциональное состояние миокарда правого желудочка у пациентов с острой тромбоэмболией легочной артерии до и после тромболитической терапии

We present in this paper results of assessment of functional state of right ventricular (RV) myocardium in 38 patients with acute pulmonary embolism (PE) before and after endovascular recanalization of pulmonary arteries supplemented with thrombolytic therapy. According to echocardiography data RV dysfunction was detected in 60.5% of cases, while an elevated concentration of brain natriuretic peptide (BNP) in blood plasma was observed in all patients. None of the patients had elevated level of troponin I. An increased concentration of BNP in blood plasma with normal troponin level in patients with acute PE was indicative of a hidden RV dysfunction due to its dilatation, acute volume or pressure overload without evidence of myocardial damage. Implications. All patients with acute pulmonary embolism who are hemodynamically stable, but have elevated levels of plasma BNP should undergo thrombolytic therapy (TLT) with the aim of early recanalization of pulmonary arteries and elimination of RV dysfunction. Early thrombolytic recanalization of the pulmonary arteries not only provides restoration of impaired RV function, but also prevents formation of post embolic chronic pulmonary hypertension and improves clinical prognosis.

Effect of CPAP treatment on plasma high sensitivity troponin levels in patients with obstructive sleep apnea

Obstructive sleep apnea (OSA) is associated with an increased prevalence of cardiovascular diseases. New generations of highly sensitive assays for cardiac troponin (hs-cTnT) have been introduced recently, and a number of clinical observations have challenged the notion that troponins are only increased in blood following irreversible necrosis. The aims of this study were to compare the levels of hs-cTnT between a group of healthy controls and a group of patients with OSA without co-existent coronary artery disease, and to assess the possible influence of the treatment with Continuous positive airway pressure (CPAP) on these levels. The study population included 200 male participants. The case (n=133) or control (n=67) status was defined by an apnea-hypopnea index of 10 or greater. The hs-cTnT assay was validated as reported previously, with a limit of detection of 3ng/L and an upper reference limit (99th percentile) of 14ng/L. The proportion of subjects with detectable plasma hs-cTnT was higher in patients with OSA than in controls (61 vs 75%, p=0.04). In patients, a significant increase in hs-cTnT levels was observed after an effective treatment with CPAP (7.3±3.4 vs 10.1±4.9ng/L; p<0.01). This study shows that the percentage of subjects with detectable hs-cTnT is associated with the presence of OSA. It also evidences that treatment with CPAP is followed by a rise in hs-cTnT concentrations. It is reasonable to suggest that CPAP therapy might induce a potential degree of cardiac stress, resulting in deleterious consequences for the heart.

The Impact of Non-Cardiac Surgery on Electrocardiograph Changes, Troponin Levels in patients with Intermediate and High Risk According to Framingham General Cardiovascular Disease Risk Score

The Impact of Non-Cardiac Surgery on Electrocardiograph Changes, Troponin Levels in patients with Intermediate and High Risk According to Framingham General Cardiovascular Disease Risk Score

A clinical scoring system in undifferentiated chest pain predicting undetectable troponin concentration

BackgroundChest pain is the most common reason for emergency admission to hospital, but the majority of these are due to non-cardiac pain. We sought to determine which combination of clinical features is more likely to predict an undetectable troponin level in patients presenting with chest pain. MethodsWe collected data over a two-month period on consecutive patients presenting acutely to hospital with chest pain and who had a troponin I measured. We recorded basic demographics, risk factors, pain distribution, associated symptoms, physical findings and ECG changes. The parameters significantly associated with troponin positivity were entered into a stepwise logistic regression analysis and the resulting model's coefficients were used to construct a simple clinical score to categorise patients into low, medium or high probability of having a positive troponin. Results26 of 157 (16.6%) patients had a positive troponin. The variables retained in the regression model were: age >65, heart rate >80, previous myocardial infarction, diabetes and pain radiating to either arm. The model showed good discrimination (area under ROC curve 0.869, 95% CI 0.806 – 0.917). Using the regression model's coefficients, patients were grouped into low, intermediate or high probability groups. Being in the low probability group had a negative predictive value of 97.8% and being in the high probability group had a positive predictive value of 65.2%. The majority (73.9%) of patients could be categorised as either low or high probability. DiscussionThis simple scoring system, if prospectively validated, may be useful in identifying low risk patients with chest pain who are unlikely to have elevation of serum troponin concentration.

Long-term Prognostic Value of Dysglycemia and Ischemic Vascular Disease Beyond Abnormal Troponin Levels in Patients Presenting Acute Atrial Fibrillation

Prognostication beyond troponin levels in patients with acute atrial fibrillation (AF) is still unclear. One-month and 1-year outcomes in 1091 patients with acute AF were analyzed. Primary endpoints were stroke or the composite of acute coronary syndrome, revascularization, and death. In the short term, troponin (odds ratio (OR) 15, 95% confidence interval (CI), 3.4-67.9, P < 0.001) and known ischemic heart disease (OR 5.83, 95% CI, 1.3-26.2, P = 0.021) were predictors of the composite endpoint, with multivariate analysis. No variables linked with stroke. In the long term, metabolic syndrome (OR 4.7, 95% CI, 1.2-18.3, P = 0.024) and age (OR 1.1, 95% CI, 1.0-1.1, P = 0.009) were predictors of stroke; metabolic syndrome (OR 4.3, 95% CI, 1.6-11.0, P = 0.003), known ischemic heart disease (OR 3.3, 95% CI, 1.7-6.4, P = 0.001), persistence of AF after the first-line approach (OR 2.2, 95% CI, 1.2-4.3, P = 0.018), and age (OR 1.0, 95% CI, 1.0-1.1, P = 0.025), but not troponin so were of the composite endpoint. In the short term, increased discriminative values in prognostication of the composite endpoint were observed with C-statistic when troponin was compared with dysglycemia (P = 0.032). No variables did better than others in the prognostication of stroke. In the long term, increased discriminative values in the prognostication of stroke were observed with C-statistic when age was compared with troponin (P = 0.020), ischemic heart disease (P = 0.025), and persistence of AF after the first-line approach (P = 0.049); so was for CHADS2 score ≥1 versus vascular disease (P = 0.038). In patients with acute AF, abnormal troponin levels add prognostic value to clinical parameters in the short term; dysglycemia and known vascular disease in the long term.

Elevated high-sensitivity cardiac troponin is associated with hypertrophy and fibrosis assessed with CMR in patients with hypertrophic cardiomyopathy

Background High-sensitivity (hs) cardiac troponin is a valuable biomarker of myocardial injury and frequently elevated in patients with hypertrophic cardiomyopathy (HCM). Using cardiovascular magnetic resonance (CMR) the HCM phenotype can be characterized in great detail with fibrosis as a key finding with prognostic impact. Therefore, our aim was to investigate whether elevated troponin levels in patients with clinical HCM were associated with LV hypertrophy and fibrosis as assessed with CMR. Methods In 62 clinical HCM patients (58% males, mean age 51 ± 15 years) hs-troponin T was determined with a highsensitivity assay (Roche Diagnostics). The lower detection limit is 0.003 pg/l and an elevated hs-troponin is defined as a concentration ≥ the 99 th percentile reference limit (≥ 0.014 pg/l). CMR with late gadolinium enhancement (LGE) was performed (Philips Achieva 1.5T) to assess LV mass indexed to body surface area, maximal wall thickness (MWT) and fibrosis. LV mass, MWT and the presence and extent of LGE were assessed (QMass 7.0, Medis) and compared between HCM patients with and without an elevated hs-troponin using Mann Whitney U or Fisher exact testing. Results Hs-troponin was detectable in 46 HCM patients (74%), of whom 16 patients had an elevated hs-troponin level. The median LV mass and MWT were higher in HCM patients with an elevated hs-troponin (p<0.001). The difference in the presence of fibrosis was almost statistically significant between groups. Notably, if present, the extent of fibrosis was higher in patients with an elevated hs-troponin (p= 0.04) (Table 1).

Safety of β-blockers in the acute management of cocaine-associated chest pain

BackgroundCocaine is the most commonly abused illegal drug in patients presenting to emergency departments (EDs) because of chest pain and accounts for almost 40% of all drug-related visits. It is not known whether all β-blockers (BB) and β1-selective agents or mixed α1/β-adrenergic antagonists (α1/β-BB) are safe in the acute management of cocaine-associated chest pain, due to concerns of unopposed α-receptor activity resulting in coronary artery spasm and hypertensive urgency. MethodsPatients who presented to the EDs of 2 large inner city hospitals because of chest pain and who tested positive for cocaine were identified by retrospective chart review. Demographic characteristics, symptoms, vital signs, electrocardiographic abnormalities, medication use, comorbidities, and troponin values were documented. The presence and type of BB used were studied in relation to peak elevation in troponin T and troponin I. Troponin elevation was defined as a troponin I greater than 0.6 ng/mL and troponin T greater than 0.1 ng/mL if serum creatinine was less than 2 mg/dL. ResultsA total of 378 patients were included in the study; of these, 78% (n = 296) were black; 12% (n = 44), white; and 10% (n = 38), of other race. Twelve percent (n = 46) of the patients had typical chest pain, 22% (n = 84) had coronary artery disease, 56% (n = 213) had hypertension, and 21% (n = 79) had diabetes mellitus. The admission electrocardiogram showed changes (ST elevation, ST depression, or T-wave inversion) in 43% (n = 163) of the patients. β-Blockers were used in 43% (n = 162) of the encounters. Troponin elevation occurred in 11% (n = 42) of patients. There was no difference in the number of patients with troponin rise in the BB and non-BB groups, 22 of 162 vs 20 of 213 (P = .2). There was no difference in mean peak troponin levels in patients with troponin rise who were treated with BB vs no BB, 6.7 vs 5.7 ng/mL (P = .6). There was no difference in mean peak troponin levels in patients with troponin rise who were treated with a β1-selective agents vs a α1/β-BB, 7.5 vs 4.1 ng/mL (P = .4). No cases of hypertensive urgency were identified after taking any BB. ConclusionTroponin rise is not uncommon in patients with cocaine-associated chest pain and occurred in 11% of the patients. In patients with cocaine-associated chest pain, BBs did not appear to change the incidence of troponin rise. β1-Selective BBs did not appear to worsen troponin levels compared with mixed α1/β-BB.

403 Comparison of Peak Troponin (cTnI) Levels Based on Patient Characteristics

Background: Troponin I (CnTi) is the biomarker of choice for diagnosis of acute myocardial infarction (AMI). It is preferred due to sensitivity and specificity of heart cell necrosis although it has a slow rise and fall requires multiple testing (0, 4, and 8 hours) before rule out. Currently, all patients have same threshold troponin level. No variation for different patient populations. Rule in defined as any level >99% of normal population (0.10 ng/μL) Study Objectives: Determine whether there are identifiable patient characteristics (age, sex, race) that are associated with differences in peak troponin level. Methods: Study was conducted at large urban, teaching hospital in Washington, DC. All patients presenting to ED from 11/2009-12/31/11 and admitted with final ICD-9 diagnosis of sub-endocardial infarction (410.71) Key variables (age, sex, race, length of stay) automatically extracted. Peak cTnI measured in ED and/or inpatient floors were manually extracted to the database. Exploratory data analysis, simple linear, and multivariable regression were performed using Stata v. 12. Results: 460 total patients. Five patients excluded due to death in emergency department and no troponin measurements. 13 patient were included twice due to second visit to ED. Peak cTnI showed log-normal distribution. Required natural logarithm transformation for further analysis. Multivariate analysis comparing peak troponin to sex are shown in table 2, figure one. There was no-statistical difference between male and female peak troponin levels. The same analysis was completed for race and age. From the initial statistical analysis only race influenced peak cTnI with African-Americans having a lower measured value then other races.Tabled 1 Conclusion: Our study is the first known to look at differences in troponin levels in patients with known NSTEMI. Race was the only characteristic to show statistically significant differences in peak cTnI level with African-Americans having a lower peak than other races. Diagnostically treated levels of cTnI may need to be modified to include differences between race.