P. Haaf

One-hour Rule-in and Rule-out of Acute Myocardial Infarction Using High-sensitivity Cardiac Troponin I

OBJECTIVEnWe aimed to prospectively derive and validate a novel 1h-algorithm using high-sensitivity cardiac troponin I (hs-cTnI) for early rule-out and rule-in of acute myocardial infarction.nnnMETHODSnWe performed a prospective multicenter diagnostic study enrolling 1811 patients with suspected acute myocardial infarction. The final diagnosis was centrally adjudicated by 2 independent cardiologists using all available information, including coronary angiography, echocardiography, follow-up data, and serial measurements of hs-cTnT (but not hs-cTnI). The hs-cTnI 1h-algorithm, incorporating measurements performed at baseline and absolute changes within 1 hour, was derived in a randomly selected sample of 906 patients (derivation cohort), and then validated in the remaining 905 patients (validation cohort).nnnRESULTSnAcute myocardial infarction was the final diagnosis in 18% of patients. After applying the hs-cTnI 1h-algorithm developed in the derivation cohort to the validation cohort, 50.5% of patients could be classified as rule-out, 19% as rule-in, 30.5% as observe. In the validation cohort, the negative predictive value for acute myocardial infarction in the rule-out zone was 99.6% (95% confidence interval, 98.4%-100%), and the positive predictive value for acute myocardial infarction in the rule-in zone was 73.9% (95% confidence interval, 66.7%-80.2%). Negative predictive value of the 1h-algorithm was higher compared with the classical dichotomous interpretation of hs-cTnI and to the standard of care combining hs-cTnI with the electrocardiogram (both P < .001). Positive predictive value also was higher compared with the standard of care (P < .001).nnnCONCLUSIONnUsing a simple algorithm incorporating baseline hs-cTnI values and the absolute change within the first hour allows safe rule-out as well as accurate rule-in of acute myocardial infarction in 70% of patients presenting with suspected acute myocardial infarction.

Use of copeptin and high-sensitive cardiac troponin T for diagnosis and prognosis in patients with diabetes mellitus and suspected acute myocardial infarction

BACKGROUNDnDiabetes 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.nnnMETHODSnIn 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.nnnRESULTSnAmong 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.nnnCONCLUSIONnIn 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.

Quality of life as predictor for the development of cardiac ischemia in high-risk asymptomatic diabetic patients

BackgroundIschemia induced by psychological stress and depression is a common phenomenon in stable coronary artery disease (CAD). We evaluated the quality of life (QoL) of diabetic patients screened for CAD and assessed the prognostic value of mental and physical QoL scores to predict the development of new cardiac ischemia.MethodsProspective multicentre outcome study. The study comprised 400 asymptomatic diabetic patients without history or symptoms of CAD. They underwent myocardial perfusion single-photon emission computed tomography (MPS) and assessment of QoL by two questionnaires: Hospital Depression and Anxiety Scale (HADS-D and HADS-A) and Medical Outcomes Study Short Form 36 (SF-36) at baseline and after 2xa0years. Patients with normal MPS received usual care; those with abnormal MPS received medical or combined invasive and medical management.ResultsOnly mental QoL scores but not physical QoL scores or traditional cardiovascular risk factors were predictive of new ischemia (nxa0=xa011/306) during follow-up. The prognostic value for new ischemia as quantified by the area under the receiver operating characteristics curve (AUC) amounted to 0.784 (95% confidence interval (CI) 0.654-0.914, Pxa0=xa00.002) for HADS-D and to 0.737 (95% CI 0.580-0.893, Pxa0=xa00.011) for HADS-A. This finding was confirmed by SF-36 mental sum score (AUC 0.688, 95% CI 0.539-0.836, Pxa0=xa00.036), but not SF-36 physical sum score. QoL scores did not change after 2xa0years in patients with ischemia at baseline.ConclusionsQoL scores assessing mental health, particularly depression and anxiety, predicted the development of new cardiac ischemia in asymptomatic diabetic patients. The study is limited by a small number of events (new ischemia) and so the results should be considered hypothesis generating rather than conclusive.Spanish AbstractAntecedentesLa isquemia inducida por el estrés psicosocial y la depresión es un fenómeno común en la enfermedad arterial coronaria estable (EAC). Evaluamos la calidad de vida (CV) de pacientes diabéticos seleccionados para EAC y valoramos el valor pronóstico de las puntuaciones de la calidad de vida mental y física para predecir el desarrollo isquemia cardíaca de novo.MétodosEstudio prospectivo y multicéntrico. En el estudio participaron 400 pacientes diabéticos asintomáticos sin historia o síntomas de EAC. Se les realizó un estudio de perfusión miocárdica (EPM) con tomografía computarizada por emisión de fotón único y una evaluación de la calidad de vida mediante dos cuestionarios: Hospital Depression and Anxiety Scale (HADS-D and HADS-A) y Medical Outcomes Study Short-Form 36 (SF-36) al inicio del estudio y después de 2 años. Los pacientes con EPM normales recibieron tratamiento habitual; aquellos con EPM anormales recibieron el tratamiento médico o la combinación de tratamiento medico e invasivo.ResultadosDurante el seguimiento sólo la puntuación de calidad de vida mental fue predictiva de isquemia de novo, no así la puntuación de calidad de vida física o los factores de riesgo cardiovascular tradicionales (n = 11/306). El valor pronóstico para isquemia de novo cuantificada por el área bajo la curva (AUC) fue de 0.784 (IC del 95%, 0.654-0.914, Pxa0=xa00,002) para HADS-D y 0.737 (IC del 95%, 0.580-0.893, Pxa0=xa00.011) para el HADS-A. Este hallazgo fue confirmado por el puntaje de suma SF-36 mental (AUC 0.688; IC del 95%: 0.539-0.836, Pxa0=xa00,036), no así por el puntaje de suma SF-36 físico. Los puntajes de CV no cambiaron después de 2 años en los pacientes que presentaban isquemia al inicio del estudio.Conclusioneslos puntajes de CV que evalúan la salud mental, especialmente depresión y ansiedad, predijeron el desarrollo de isquemia cardíaca de novo en pacientes diabéticos asintomáticos. El estudio está limitado por un pequeño número de eventos (isquemia dexa0novo) por lo que los resultados deben ser considerados como una generación de hipótesis y no concluyentes.Chinese Abstract背景在稳定性心绞痛患者中, 神压抑和抑郁常会引起局部的心肌缺血。本研究拟通过精神与活动量表对糖尿病患者进行生活质量评分, 从而预测新发的心肌缺血。方法本研究是前瞻性、多中心研究。入选400例无冠心病及相关症状的糖尿病患者,xa0对其进行单光子发射断层心肌灌注扫描 (MPS) 和生活质量评估。后者采用调查问卷的方式对基线水平与随访2年后的生活质量情况进行评估,xa0包括医院抑郁和焦虑评分量表 (HADS-D and HADS-A) 和健康状况调查问卷简表-36 (SF-36)。MPS正常的患者接受常规处理,xa0MPSxa0异常的患者接受药物和/或再血管化治疗。结果只有精神量表评分能够预测新发生的心肌缺血 (n=11/306), 活动量表评分与传统心血管危险因素均无效。对新发心肌缺血的预测可以被量化为受试者的特征曲线下面积(AUC), 其中xa0HADS-Dxa0为0.7 84 (95%可信区间0.654-0.914, Pxa0=xa00.002), HADS-A为0.737 (95%可信区间0.580-0.893, Pxa0=xa00.011)。该结果与SF-36精神评分相符 (AUC 0.688, 95% 可信区间 0.539-0.836, p=0.036), 而与SF-36活动量评分不一致。对于基线有心肌缺血的患者, 其两年后各项评分均无明显变化。结论精神评分量表,xa0尤其是针对压抑和焦虑的评分,xa0能够预测无症状性的糖尿病患者的新发心肌缺血。受限于较少的事件数 (新发心肌缺血), 本研究更倾向于假说而非定论。

Predictors and prognostic impact of silent coronary artery disease in asymptomatic high-risk patients with diabetes mellitus

AIMSnEvaluation of predictors of silent coronary artery disease (SCAD) in high-risk asymptomatic diabetic patients and to evaluate their two-year outcome.nnnMETHODS AND RESULTSnFour hundred diabetic patients without prior CAD but at high CAD risk underwent myocardial perfusion scintigraphy (MPS) in this prospective multicentre outcome trial. MPS were abnormal in 22% of patients. Male sex (OR 2.223, 1.152-4.290; p=0.017), diabetes duration (OR 1.049,1.015-1.085; p=0·005), peripheral artery disease (OR 2.134, 1·150-3.961; p=0.016), smoking (OR 2.064, 1.109-3.839; p=0·022), systolic blood pressure (OR 1.014, 1.00-1.03, p=0·056), brain natriuretic peptide (OR 1.002, 1.001-1.004, p=0·005) independently predicted an abnormal MPS: if <2 and >3 predictors were present, 3.2% and 47% patients had an abnormal MPS, respectively (p<0·001). Two-year major adverse cardiac event rates increased from 2·9% to 14·6%, cardiac death rates from 0·6% to 4·1% in patients with summed stress scores ≤10 and >10%, respectively (each p<0.045).nnnCONCLUSIONSnMale sex, diabetes duration, peripheral artery disease, smoking, elevated systolic blood pressure and increased brain-natriuretic peptides independently predicted SCAD. In presence of >3 predictors, almost 50% of patients had an abnormal MPS. They may benefit from screening by MPS since the extent of the MPS abnormality discriminated clearly between a favourable compared to a bad 2-year outcome. However, even highest risk patients without objective evidence of CAD had a benign prognosis without need for specific evaluation or therapy.nnnTRIAL REGISTRATION NUMBERnISRCTN87953632.

Cavopulmonary window: case report of an unusual variant of a sinus venosus defect

Abstract Introduction Isolated partial anomalous pulmonary venous return (PAPVR) with intact atrial septum is a rare finding. A cavopulmonary window is a side-to-side veno-venous communication of the right upper pulmonary vein with the superior vena cava which in its course retains connection to the left atrium. Case presentation We present a case of this unusual variant of a sinus venosus defect far from the atrial roof. Haemodynamic significance of the shunt was confirmed by enlargement of right heart cavities, elevation of pulmonary artery pressure, and significant left-to-right shunting using multimodality cardiac imaging (transoesophageal echocardiography, cardiac magnetic resonance imaging, and right heart catheterization). The defect has been successfully repaired using minimally invasive axillary thoracotomy. Discussion Partial anomalous pulmonary venous return prevalence is low and about 0.4–0.7% in autopsy series of patients with congenital heart disease. This patient’s unusual variant of a sinus venosus defect with a window between a pulmonary vein and the superior vena cava far from the atrial roof shows that a sinus venosus defect is not a true atrial septum defect. Left-to-right shunting generally increases with age. Usually, surgical treatment is considered in cases of significant left-to-right shunt (Qp:Qsu2009>u20091.5–2.0) and right heart dilatation.

Gender-specific chest pain characteristics in the early diagnosis of acute myocardial infarction

Purpose: We aimed to contribute to an improvement in the management of women with suspected acute myocardial infarction (AMI) by exploring gender-specific chest pain characteristics (CPC).nnMethods: We enrolled 2475 consecutive patients (796 women and 1679 men) presenting with acute chest pain to the emergency department (ED) in a prospective multicenter study. The gender-specific diagnostic performance of 34 predefined CPC was evaluated in the early diagnosis of AMI.nnResults: AMI was the adjudicated final diagnosis in 18% of women and in 22% of men. Overall, the symptoms reported by women with suspected AMI differed from those reported by men. The capability of most CPC to diagnose AMI was low in women as well as in men with positive likelihood ratios (LR) close to 1 (ranging from 0.25 to 2.27, mean value 1.03, SD of ± 0.35) and rather large 95% confidence intervals. However some CPC significantly increased the likelihood for the diagnosis of AMI (pain aggravated by exertion or relieved by nitrates, pain location on the mid-chest and/or right chest, pain area over 3 cm, radiation to the left and/or right shoulder/arm, and more severe pain as quantified on the VAS) and others significantly decreased the likelihood for the diagnosis of AMI (stabbing pain, aggravation of the pain by breathing, movement or palpation, pain location on the left chest and inframamilar, pain without radiation and pain duration less than 2 minutes). But comparing male and female patients, most of the predefined chest pain criteria tended to increase or decrease the likelihood for AMI similarly showing no significant differences between genders. (p>0.05)nnConclusion: CPC reported by women with suspected AMI differ from those reported by men; nevertheless the diagnostic performance was similar in women and men and did therefore not allow to establish a women-specific strategy which would help physicians to differentiate between women with AMI from women without AMI at the ED