RESUMEN
Cardiac biomarkers are an integral component of the diagnostic work-up of patients with suspected acute coronary syndrome (ACS). Cardiac troponin (cTn) is the most sensitive diagnostic biomarker for patients with ACS and enables the differentiation of acute non-ST-elevation myocardial infarction (NSTEMI) from unstable angina. All cardiac and non-cardiac differential diagnoses must be taken into consideration. The use of cTn has a prognostic value in a multitude of acute and chronic diseases apart from ACS. Highly sensitive cTn (hsTn) assays should be preferentially used. Point-of-care (POC) troponin assays can be used for rule-in of acute MI but are generally not useful for rule-out of MI due to their lack of sensitivity compared to hsTn assays. This, however, may change with recent developments of newer and improved POC troponin assays. For exclusion of MI using hsTn assays, there are various protocols available, such as the instant rule-out with undetectable hsTn levels at admission or normal hsTn/cTn levels combined with normal copeptin levels or rule-out with serial controls of hsTn after 1, 2 or 3â¯h. This article provides an overview of guideline-recommended rule-out protocols for patients with suspected ACS and discusses recent advances in POC troponin assays.
Asunto(s)
Síndrome Coronario Agudo/diagnóstico , Biomarcadores/sangre , Dolor en el Pecho/etiología , Infarto del Miocardio/diagnóstico , Troponina/sangre , Síndrome Coronario Agudo/sangre , Glicopéptidos/sangre , Humanos , Infarto del Miocardio/sangre , Pruebas en el Punto de Atención , PronósticoRESUMEN
Elevated cardiac troponin values are frequently observed in critically ill patients. These are often not due to myocardial infarction (MI) but caused by various other etiologies of myocardial injury. Understanding the etiology of any troponin elevation is of enormous importance for management and therapy. According to the fourth version of the Universal Definition of MI, myocardial injury is present if at least one troponin value is above the 99th percentile upper reference limit and considered acute, when a rise and/or fall occurs. Patients with acute MI are a subgroup of patients with acute myocardial injury, who present in an ischemic clinical context. Variables defining the clinical criteria of MI include symptoms of ischemia, presumably new electrocardiographic (ECG) changes or imaging evidence of new loss of viable myocardium or regional wall motion abnormalities, or detection of an intracoronary thrombus. In critically ill or mechanically ventilated patients, the diagnosis of MI is challenging due to limitations in history taking, co-existence of comorbidities, overlapping symptoms and equivocal or unspecific ECG changes. This article presents the diagnostic criteria of the Universal MI definition, discusses subtypes of MI and focuses on various differential diagnoses. Furthermore, implications of diagnosis of MI in critically ill patients, especially regarding the use of ECG and troponin assays, are discussed.
Asunto(s)
Enfermedad Crítica , Infarto del Miocardio , Biomarcadores , Electrocardiografía , Humanos , Infarto del Miocardio/diagnóstico , Respiración ArtificialRESUMEN
A hominid upper premolar was discovered in the Azmaka quarry, near Chirpan (Bulgaria). The associated fauna, especially the co-occurrence of Choerolophodon and Anancus among the proboscideans, and Cremohipparion matthewi and Hippotherium brachypus among the hipparions, constrains the age of the locality to the second half of the middle Turolian (ca. 7 Ma), making it the latest pre-human hominid of continental Europe and Asia Minor. The available morphological and metric data are more similar to those of Ouranopithecus from the Vallesian of Greece than to those of the early to middle Turolian hominids of Turkey and Georgia, but the time gap speaks against a direct phyletic link, and Turolian migration from the east cannot be rejected.
Asunto(s)
Diente Premolar/anatomía & histología , Hominidae/anatomía & histología , Animales , Evolución Biológica , Europa (Continente) , Fósiles , Hominidae/genéticaRESUMEN
BACKGROUND: The aim of this study is to establish an objective diagnostic method, through which the functional capacity of the upper extremity with chronic ischemia could be best assessed. METHODS: For a 9-year period (1986-1994) 74 patients suffering Arterial Occlusive Disease (AOD) of the upper extremity with chronic ischemia were treated. Fifty five of them (74.3%) were males (an average age of 52.4 years) and 19 females (25.6%), (an average age of 42.5 years). Forty nine of them (66.2%) were in second stage according to the adapted Fontain's classification. An original method and device have been established for the investigation of the abilities of the upper extremity to make repeated movements till they get an intermittent claudication. The apparatus consists of tree modules: a mechanical device, an interface adapter and a microcomputer. RESULTS: During the flexion of the fingers the patient overcomes the resistance of springs which is 1.82 Nm. An Ischemic Fatigue Index (IFI) is calculated--it gives the quantitative value of the functional capacity of the limb. IFI in patients in second stage of Chronic Arterial Ischemia (CAI) is from 0.14 to 0.76 during the diagnostic test and from 0.18 to 1.0 after the operative or drug treatment or Percutaneous Transluminal Angioplasty (PTA). A retrospective analysis shows that in patients who were operated on, the preoperative IFI was less than 0.50. The measurement of Arm-Arm Blood Pressure Index (AABPI) before treatment and after it in some cases shows normal values in spite of the presence of subclavian artery stenoses. The angiographies that were done could not help for the evaluation of the functional capacity of the upper extremities. The presence of pulse in 9 patients (18.4%) does not exclude a presence of occlusion. CONCLUSIONS: IFI is a quantitative indicator for the upper extremity capacity. It shows whether the symptoms are severe enough to justify the surgery. The periodical measurement of IFI is a monitoring of the development of AOD.