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Síndrome Coronario Agudo , Cardiomiopatía de Takotsubo , Humanos , Cardiomiopatía de Takotsubo/complicaciones , Cardiomiopatía de Takotsubo/diagnóstico por imagen , Valor Predictivo de las Pruebas , Corazón , Electrocardiografía , Síndrome Coronario Agudo/diagnóstico por imagen , Síndrome Coronario Agudo/terapiaRESUMEN
BACKGROUND: Elevated D-dimer levels have been observed in COVID-19 and are of prognostic value, but have not been compared to an appropriate control group. METHODS: Observational cohort study including emergency patients with suspected or confirmed COVID-19. Logistic regression defined the association of D-dimer levels, COVID-19 positivity, age, and gender with 30-day-mortality. RESULTS: 953 consecutive patients (median age 58, 43% women) presented with suspected COVID-19: 12 (7.4%) patients with confirmed SARS-CoV-2-infection died, compared with 28 (3.5%) patients without SARS-CoV-2-infection. Overall, most (56%) patients had elevated D-dimer levels (≥0.5mg/l). Age (OR 1.07, CI 1.05-1.10), D-dimer levels ≥0.5mg/l (OR 2.44, CI 0.98-7.39), and COVID-19 (OR 2.79, CI 1.28-5.80) were associated with 30-day-mortality. CONCLUSION: D-dimer levels are effective prognosticators in both patient groups.
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COVID-19 , Femenino , Productos de Degradación de Fibrina-Fibrinógeno , Humanos , Masculino , Persona de Mediana Edad , Medición de Riesgo , SARS-CoV-2RESUMEN
BACKGROUND: microRNAs (miRNAs) have shown promise as potential new biomarkers for myocardial injury and myocardial ischemia. New digital polymerase chain reaction (PCR) techniques allow for highly precise and reliable absolute direct quantification. METHODS: In this pilot study we used droplet digital PCR (ddPCR) to assess if miRNAs might be released into circulation in patients with functionally relevant coronary artery disease (CAD). Blood samples for measurement of high-sensitivity cardiac troponin I (hs-cTnI) and miRNAs were obtained before, immediately after peak stress, and 2â¯h after stress testing in a blinded manner in consecutive patients referred for rest/stress myocardial perfusion single-photon emission tomography/computer tomography (MPI-SPECT/CT). ddPCR was used to directly quantify the serum concentrations of miR-21, miR-208a, and miR-499 as potential markers of myocardial injury/ischemia. Functionally relevant CAD was determined by expert interpretation of MPI-SPECT/CT, coronary angiography and fractional flow reserve, if performed. RESULTS: Overall, 200 patients were included and functionally relevant CAD was detected in 85 of them (42%). Neither miR-21, miR-208a, nor miR-499 concentrations differed at rest, stress, or 2-h after stress when comparing patients with versus without functionally relevant CAD, while hs-cTnI concentrations were significantly higher in patients with functionally relevant CAD (Pâ¯<â¯0.001). Exercise-induced changes in miRNA or hs-cTnI concentrations did not have diagnostic utility and were similar in patients with versus without functionally relevant CAD. CONCLUSION: miR-208a, miR-21 and miR-499 concentrations at rest, after exercise and exercise-induced changes do not provide additional clinical value regarding the detection of functionally relevant CAD.
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Enfermedad de la Arteria Coronaria/diagnóstico , Reserva del Flujo Fraccional Miocárdico/fisiología , MicroARNs/sangre , Reacción en Cadena de la Polimerasa de Transcriptasa Inversa/métodos , Anciano , Biomarcadores/sangre , Angiografía Coronaria , Enfermedad de la Arteria Coronaria/sangre , Enfermedad de la Arteria Coronaria/genética , Prueba de Esfuerzo , Femenino , Humanos , Masculino , MicroARNs/genética , Proyectos Piloto , Tomografía Computarizada por Tomografía de Emisión de Positrones , Pronóstico , Estudios Prospectivos , Reproducibilidad de los Resultados , Troponina I/sangreRESUMEN
BACKGROUND: High-sensitivity cardiac troponin T (hs-cTnT) blood concentrations were shown to exhibit a diurnal rhythm, characterized by gradually decreasing concentrations throughout daytime, rising concentrations during nighttime and peak concentrations in the morning. We aimed to investigate whether this also applies to (h)s-cTnI assays and whether it would affect diagnostic accuracy for acute myocardial infarction (AMI). METHODS: Blood concentrations of cTnI were measured at presentation and after 1â¯h using four different cTnI assays: three commonly used sensitive (s-cTnI Architect, Ultra and Accu) and one experimental high-sensitivity assay (hs-cTnI Accu) in a prospective multicenter diagnostic study of patients presenting to the emergency department with suspected AMI. These concentrations and their diagnostic accuracy for AMI (quantified by the area under the curve (AUC)) were compared between morning (11â¯p.m. to 2â¯p.m.) and evening (2â¯p.m. to 11â¯p.m.) presenters. RESULTS: Among 2601 patients, AMI was the final diagnosis in 17.6% of patients. Concentrations of (h)s-cTnI as measured using all four assays were comparable in patients presenting in the morning versus patients presenting in the evening. Diagnostic accuracy for AMI of all four (h)s-cTnI assays were high and comparable between patients presenting in the morning versus presenting in the evening (AUC at presentation: 0.90 vs 0.93 for s-cTnI Architect; 0.91 vs 0.94 for s-cTnI Ultra; 0.89 vs 0.94 for s-cTnI Accu; 0.91 vs 0.94 for hs-cTnI Accu). CONCLUSIONS: Cardiac TnI does not seem to express a diurnal rhythm. Diagnostic accuracy for AMI is very high and does not differ with time of presentation. CLINICAL TRIAL REGISTRATION: NCT00470587, http://clinicaltrials.gov/show/NCT00470587.
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Ritmo Circadiano/fisiología , Infarto del Miocardio/sangre , Infarto del Miocardio/diagnóstico por imagen , Troponina I/sangre , Anciano , Biomarcadores/sangre , Femenino , Estudios de Seguimiento , Humanos , Masculino , Persona de Mediana Edad , Estudios ProspectivosRESUMEN
OBJECTIVE: To validate the National Institute for Health and Care Excellence (NICE) recommended algorithms for high-sensitivity troponin (hsTn) assays in adults presenting with chest pain. METHODS: International post hoc analysis of three prospective, observational studies from tertiary hospital emergency departments. The primary endpoint was cardiac death or acute myocardial infarction (AMI) within 24â hours of presentation, and the secondary endpoint was major adverse cardiac events (MACE) at 30â days. RESULTS: 15% of patients were diagnosed with non-ST elevation myocardial infarction (MI) on admission. The hsTnI algorithm classified 2506/3128 (80.1%) of patients as 'ruled out' with 50 (2.0%) missed MI. 943/3128 (30.1%) of patients had a troponin I level below the limit of detection on admission with 2 (0.2%) missed MI. For the hsTnT algorithm, 1794/3374 (53.1%) of patients were 'ruled out' with 7 (0.4%) missed MI. 490/3374 (14.5%) of patients had a troponin T below the limit of blank on admission with no MI. MACE at 30â days occurred in 10.7% and 8.5% of patients 'ruled out' defined by the hsTnI and hsTnT algorithms, respectively. CONCLUSIONS: The NICE algorithms could identify patients with low probability of AMI within 2â hours; however, neither strategy performed as predicted by the NICE diagnostic guidance model. Additionally, the rate of MACE at 30â days was sufficiently high that the algorithms should only be used as one component of a more extensive model of risk stratification. TRIAL REGISTRATION NUMBER: ACTRN12611001069943, NCT00470587; post-results.
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Algoritmos , Biomarcadores/sangre , Técnicas de Apoyo para la Decisión , Infarto del Miocardio/diagnóstico , Guías de Práctica Clínica como Asunto/normas , Troponina I/sangre , Troponina T/sangre , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Angina de Pecho/diagnóstico , Angina de Pecho/etiología , Servicio de Cardiología en Hospital/normas , Servicio de Urgencia en Hospital/normas , Femenino , Humanos , Masculino , Persona de Mediana Edad , Infarto del Miocardio/sangre , Infarto del Miocardio/complicaciones , Nueva Zelanda , Valor Predictivo de las Pruebas , Pronóstico , Estudios Prospectivos , Queensland , Reproducibilidad de los Resultados , Suiza , Centros de Atención Terciaria , Factores de Tiempo , Regulación hacia Arriba , Adulto JovenRESUMEN
BACKGROUND: Diabetes is a major risk factor for acute myocardial infarction (AMI). Assessment of diabetic patients is challenging due to an often atypical presentation of symptoms. We aimed to evaluate the two novel biomarkers copeptin and high-sensitive cardiac troponin (hs-TnT) for the improvement of early diagnosis and risk-stratification in patients with diabetes and suspected AMI. METHODS: In this prospective international multicenter study we evaluated 379 patients with diabetes in a cohort of 1991 patients presenting with symptoms suggestive of AMI. The measurement of biomarkers was performed at presentation. RESULTS: Among the 379 diabetic patients, 32.7% had AMI, and in the 1621 patients without diabetes, 18.8% had AMI. The additional use of copeptin improved the diagnostic accuracy provided by conventional troponin alone (AUC 0.86 vs. 0.79, p=0.004). During a median follow-up of 814 days, 49 (13.1%) diabetic patients died. Cumulative 2-year survival rate for patients with copeptin levels below 9 pmol/l was 96.6% compared to 82.8% in patients above that level (p<0.001). The same was observed for hs-TnT with a cutoff level of 14 ng/l (97.7% vs. 82.0%, p<0.001) respective of cTnT with a cutoff level of 10 ng/l (93.5% vs. 75.6%, p<0.001). In multivariate Cox analysis, copeptin, hs-TnT and cTnT were strong and independent predictors of 24-month-mortality. Using the dual marker strategy (copeptin and troponin) identified two groups of high-risk patients where 22.5% of the group with hs-cTnT and copeptin above the cutoff and 28.6% with cTnT and copeptin above the cutoff died. CONCLUSION: In diabetic patients, copeptin only slightly improves the early diagnosis of AMI provided by hs-cTnT. However, both markers (copeptin and troponin) predict long-term mortality accurately and independently of each other.
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Diabetes Mellitus/sangre , Diabetes Mellitus/diagnóstico , Glicopéptidos/sangre , Infarto del Miocardio/sangre , Infarto del Miocardio/diagnóstico , Troponina T/sangre , Anciano , Anciano de 80 o más Años , Biomarcadores/sangre , Estudios de Cohortes , Diabetes Mellitus/mortalidad , Diagnóstico Precoz , Femenino , Estudios de Seguimiento , Humanos , Internacionalidad , Masculino , Persona de Mediana Edad , Mortalidad/tendencias , Infarto del Miocardio/mortalidad , Pronóstico , Estudios ProspectivosRESUMEN
OBJECTIVES: To address the diagnostic value of circulating microRNAs (miRNAs) in patients presenting with acute chest pain. DESIGN: In a prospective, international, multicentre study, six miRNAs (miR-133a, miR-208b, miR-223, miR-320a, miR-451 and miR-499) were simultaneously measured in a blinded fashion in 1155 unselected patients presenting with acute chest pain to the emergency department. The final diagnosis was adjudicated by two independent cardiologists. The clinical follow-up period was 2 years. RESULTS: Acute myocardial infarction (AMI) was the adjudicated final diagnosis in 224 patients (19%). Levels of miR-208b, miR-499 and miR-320a were significantly higher in patients with AMI compared to those with other final diagnoses. MiR-208b provided the highest diagnostic accuracy for AMI (area under the receiver operating characteristic curve 0.76, 95% confidence interval 0.72-0.80). This diagnostic value was lower than that of the fourth-generation cardiac troponin T (cTnT; 0.84) or the high-sensitivity cTnT (hs-cTnT; 0.94; both P < 0.001 for comparison). None of the six miRNAs provided added diagnostic value when combined with cTnT or hs-cTnT (ns for the comparison of combinations vs. cTnT or hs-cTnT alone). During follow-up, 102 (9%) patients died. Levels of MiR-208b were higher in patients who died within 30 days, but the prognostic accuracy was low to moderate. None of the miRNAs predicted long-term mortality. CONCLUSION: The miRNAs investigated in this study do not seem to provide incremental diagnostic or prognostic value in patients presenting with suspected AMI.
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Dolor en el Pecho/etiología , MicroARNs/sangre , Infarto del Miocardio/diagnóstico , Troponina T/sangre , Enfermedad Aguda , Anciano , Biomarcadores/sangre , Índice de Masa Corporal , Diagnóstico Diferencial , Diagnóstico Precoz , Electrocardiografía , Servicio de Urgencia en Hospital , Femenino , Estudios de Seguimiento , Humanos , Estimación de Kaplan-Meier , Luxemburgo , Masculino , Persona de Mediana Edad , Infarto del Miocardio/sangre , Infarto del Miocardio/complicaciones , Infarto del Miocardio/mortalidad , Valor Predictivo de las Pruebas , Pronóstico , Estudios Prospectivos , Medición de Riesgo , Factores de Riesgo , Sensibilidad y Especificidad , SuizaAsunto(s)
Infarto del Miocardio , Troponina I , Biomarcadores , Humanos , Estudios Prospectivos , Troponina TRESUMEN
OBJECTIVES: The rapid and accurate diagnosis of heart failure in primary care is a major unmet clinical need. We evaluated the additional use of B-type natriuretic peptide (BNP) levels. DESIGN: A randomized controlled trial. SETTING: Twenty-nine primary care physicians in Switzerland and Germany coordinated by the University Hospital Basel, Switzerland. SUBJECTS: A total of 323 consecutive patients presenting with dyspnoea. INTERVENTIONS: Assignment in a 1 : 1 ratio to a diagnostic strategy including point-of-care measurement of BNP (n = 163) or standard assessment without BNP (n = 160). The total medical cost at 3 months was the primary end-point. Secondary end-points were diagnostic certainty, time to appropriate therapy, functional capacity, hospitalization and mortality. The final diagnosis was adjudicated by a physician blinded to the BNP levels. RESULTS: Heart failure was the final diagnosis in 34% of patients. The number of hospitalizations, functional status and total medical cost at 3 months [median $1655, interquartile range (IQR), 850-3331 vs. $1541, IQR 859-2827; P = 0.68] were similar in both groups. BNP increased diagnostic certainty as defined by the need for further diagnostic work-up (33% vs. 45%; P = 0.02) and accelerated the initiation of the appropriate treatment (13 days vs. 25 days; P = 0.01). The area under the receiver-operating characteristics curve for BNP to identify heart failure was 0.87 (95% confidence interval, 0.81-0.93). CONCLUSIONS: The use of BNP levels in primary care did not reduce total medical cost, but improved some of the secondary end-points including diagnostic certainty and time to initiation of appropriate treatment.
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Biomarcadores/sangre , Disnea/diagnóstico , Insuficiencia Cardíaca/diagnóstico , Natriuréticos/sangre , Péptido Natriurético Encefálico/sangre , Anciano , Anciano de 80 o más Años , Disnea/economía , Disnea/terapia , Electrocardiografía , Femenino , Insuficiencia Cardíaca/economía , Insuficiencia Cardíaca/terapia , Humanos , Masculino , Persona de Mediana Edad , Péptido Natriurético Encefálico/economía , Atención Primaria de Salud , Curva ROC , Radiografía Torácica , Método Simple CiegoRESUMEN
BACKGROUND: The aim of our study was to investigate the diagnostic and prognostic value of a sensitive cardiac troponin I (s-cTnI) assay in patients with acute heart failure (AHF). METHODS: Sensitive cardiac troponin I was measured in 667 consecutive patients at presentation to the emergency department with acute dyspnoea. Three s-cTnI strata were predefined: below the limit of detection (<0.01 µg L(-1) , undetectable), detectable but still within the normal range (0.01-0.027 µg L(-1) ) and increased (≥0.028 µg L(-1) , ≥99th percentile). The final diagnosis was adjudicated by two independent cardiologists blinded to the s-cTnI levels. Median follow-up in patients with AHF was 371 days. RESULTS: Levels of s-cTnI were higher in patients with AHF (n = 377, 57%) compared to patients with noncardiac causes of acute dyspnoea (median 0.02 vs. <0.01 µg L(-1) , P < 0.001). In patients with AHF, in-hospital mortality increased with increasing s-cTnI in the three strata (2%, 5% and 14%, P < 0.001). One-year mortality also increased with increasing s-cTnI (21%, 33% and 47%, P < 0.001). s-cTnI remained an independent predictor of 1-year mortality [adjusted odds ratio 1.03 for each increase of 0.1 µg L(-1) , 95% confidence interval (CI) 1.02-1.05, P < 0.001] after adjustment for other risk factors including B-type natriuretic peptide. The net reclassification improvement was 68% (P < 0.001), and absolute integrated discrimination improvement was 0.18 (P < 0.001). The diagnostic accuracy of s-cTnI for the diagnosis of AHF as quantified by the area under the receiver operating characteristic curve was 0.78 (95% CI, 0.75-0.82). CONCLUSIONS: Sensitive cardiac troponin I is a strong predictor of short- and long-term prognosis in AHF that helps to reclassify patients in terms of mortality risk. Detectable levels of s-cTnI, even within the normal range, are independently associated with mortality.
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Insuficiencia Cardíaca/diagnóstico , Troponina I/sangre , Enfermedad Aguda , Anciano , Anciano de 80 o más Años , Algoritmos , Biomarcadores/sangre , Intervalos de Confianza , Servicio de Urgencia en Hospital , Femenino , Estudios de Seguimiento , Insuficiencia Cardíaca/sangre , Insuficiencia Cardíaca/mortalidad , Humanos , Masculino , Oportunidad Relativa , Valor Predictivo de las Pruebas , Pronóstico , Estudios Prospectivos , Medición de Riesgo , Sensibilidad y Especificidad , Índice de Severidad de la Enfermedad , Análisis de SupervivenciaRESUMEN
OBJECTIVES: The study objective was to investigate the prognostic utility and patient-specific characteristics of ST2 (suppression of tumorigenicity 2), assessed with a novel sensitive assay. BACKGROUND: Suppression of tumorigenicity 2 signalling has been shown to be associated with death in cardiac and pulmonary diseases. DESIGN/SUBJECTS: In an international multicentre cohort design, we prospectively enrolled 1091 patients presenting with acute dyspnoea to the emergency department (ED). ST2 was measured in a blinded fashion using a novel assay and compared to B-type natriuretic peptide (BNP) and NT-proBNP. The primary end-point was mortality within 30 days and 1 year. The prognostic value of ST2 was evaluated in comparison and in addition to BNP and NT-proBNP. RESULTS: Suppression of tumorigenicity 2 concentrations was higher amongst decedents than among survivors (median 85 vs. 43 U mL⻹, P < 0.001) and also higher in patients with impaired left ventricular ejection fraction (LVEF) when compared with preserved LVEF (P < 0.001). In receiver operator characteristics analysis, the area under the curve (AUC) for ST2, BNP and NT-proBNP to predict 30-day and 1-year mortality were 0.76, 0.63 and 0.71, and 0.72, 0.71 and 0.73, respectively. The combinations of ST2 with BNP or NT-proBNP improved prediction of mortality provided by BNP or NT-proBNP alone. After multivariable adjustment, ST2 values above the median (50 U mL⻹) significantly predicted 1-year mortality (HR 2.3, P < 0.001). CONCLUSION: In patients presenting to the ED with acute dyspnoea, ST2 is a strong and independent predictor of 30-day and 1-year mortality and might improve risk stratification already provided by BNP or NT-proBNP.
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Disnea/sangre , Disnea/mortalidad , Receptores de Superficie Celular/sangre , Enfermedad Aguda , Biomarcadores/sangre , Estudios de Cohortes , Humanos , Proteína 1 Similar al Receptor de Interleucina-1 , Pronóstico , Estudios Prospectivos , Tasa de SupervivenciaRESUMEN
OBJECTIVES: The purpose of this study was to evaluate the utility of B-type natriuretic peptide (BNP) to predict blood pressure (BP) response in patients with renal artery stenosis (RAS) after renal angioplasty and stenting (PTRA). METHODS: In 120 patients with RAS and hypertension referred for PTRA, 24-h ambulatory BP recordings were obtained before and 6 months after intervention. BNP was measured before, 1 day and 6 months after PTRA. RESULTS: BP improved in 54% of patients. Median BNP levels pre-intervention were 97 pg ml(-1) (interquartile range (IQR) 35-250) and decreased significantly within 1 day of PTRA to 62 pg ml(-1) (IQR 24-182) (p < 0.001), remaining at 75 pg ml(-1) (IQR 31-190) at 6 months. The area under the receiver operating curve for pre-intervention BNP to predict BP improvement was 0.57 (95% confidence interval (CI) 0.46-0.67). Pre-intervention BNP >50 pg ml(-1) was seen in 79% of patients with BP improvement compared with 56% in patients without improvement (p = 0.01). In a multivariate logistic regression analysis, BNP >50 pg ml(-1) was significantly associated with BP improvement (odds ratio (OR) 4.0, 95% CI 1.2-13.2). CONCLUSIONS: BNP levels are elevated in patients with RAS and decrease after revascularisation. Although BNP does not seem useful as a continuous variable, pre-interventional BNP >50 pg ml(-1) may be helpful to identify patients in whom PTRA will improve BP.
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Péptido Natriurético Encefálico/sangre , Obstrucción de la Arteria Renal/cirugía , Anciano , Angioplastia , Monitoreo Ambulatorio de la Presión Arterial , Femenino , Humanos , Hipertensión/sangre , Hipertensión/diagnóstico , Hipertensión/etiología , Hipertensión/fisiopatología , Masculino , Persona de Mediana Edad , Valor Predictivo de las Pruebas , Estudios Prospectivos , Obstrucción de la Arteria Renal/complicaciones , StentsRESUMEN
OBJECTIVE: To investigate the effect of different sodium concentrations in replacement fluids on haematological variables and endurance performance during prolonged exercise. METHODS: Thirteen female endurance athletes completed three four hour runs on a 400 m track. Environmental conditions differed between the three trials: 5.3 degrees C and snow (trial 1), 19.0 degrees C and sunny weather (trial 2), 13.9 degrees C and precipitation (trial 3). They consumed 1 litre of fluid an hour during the trials with randomised intake of fluids: one trial (H) with high sodium concentration (680 mg/l), one trial (L) with low sodium concentration (410 mg/l), and one trial with only water (W). Before and after the trials, subjects were weighed and blood samples were taken for analysis of [Na(+)](plasma), packed cell volume, and mean corpuscular volume. RESULTS: The mean (SD) decrease in [Na(+)](plasma) over the whole trial was significantly (p<0.001) less in trial H (2.5 (2.5) mmol/l) than in trial W (6.2 (2.1) mmol/l). Mild hyponatraemia ([Na(+)](plasma) = 130-135 mmol/l) was observed in only six women (46%) in trial H compared with nine (69%) in trial L, and 12 (92%) in trial W. Two subjects (17%) in trial W developed severe hyponatraemia ([Na(+)](plasma)<130 mmol/l). No significant differences were found in performance or haematological variables with the three different fluids. There was no significant correlation between[Na(+)](plasma) after the run and performance. There was a significant correlation between changes in [Na(+)](plasma) and changes in body weight. CONCLUSIONS: Exercise induced hyponatraemia in women is likely to develop from fluid overload during prolonged exercise. This can be minimised by the use of replacement fluids of high sodium concentration. Sodium replacement of at least 680 mg/h is recommended for women in a state of fluid overload during endurance exercise of four hours. However, higher [Na(+)](plasma) after the run and smaller decreases in [Na(+)](plasma) during the trials were no indication of better performance over four hours.