Early Australian Experience With AbsorbTM Bioresorbable Scaffold Technology in “Real-World” Coronary Disease (original) (raw)
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Patients with Acute Coronary Syndrome and Normal High-sensitivity Troponin
The American Journal of Medicine, 2011
BACKGROUND: Failure to identify patients with acute coronary syndrome (ACS) is a serious clinical problem. The incidence, characteristics, and outcome of ACS patients with normal high-sensitivity cardiac troponin T (hs-cTnT) levels at presentation are unknown. METHODS: In a prospective multicenter study, hs-cTnT was determined in a blinded fashion in 1181 consecutive patients presenting with acute chest pain to the emergency department. The final diagnosis of ACS was adjudicated by 2 independent cardiologists. Patients were followed for 12 months. RESULTS: ACS was the adjudicated diagnosis in 351 patients (30%), including 187 patients with acute myocardial infarction (AMI) and 164 patients with unstable angina (UA). At presentation, hs-cTnT was normal (Ͻ.014 ug/L) in 112 ACS patients (32%), including 11 patients (6%) with AMI and 101 patients (62%) with UA (P Ͻ.001). Multivariable analysis revealed previous statin treatment, younger age, preserved renal function, and the absence of ST deviation on the electrocardiogram as independently associated with normal hs-cTnT levels. Mortality rates in ACS patients with normal hs-cTnT level were 0.0% at 30 days, 0.0% at 90 days, and 2.0% (95% confidence interval, 0.5-7.9) at 360 days, which was significantly lower than in ACS patients with elevated hs-cTnT level at presentation (17.5% at 360 days, P Ͻ.001). Conversely, AMI rates at 360 days was higher in ACS patients with normal versus elevated hs-cTnT levels (P ϭ .004). CONCLUSION: Almost one third of ACS patients have normal hs-cTnT levels at presentation, mostly patients with UA. ACS patients with normal hs-cTnT have a very low mortality, but an increased rate of AMI during the subsequent 360 days.
Annals of Translational Medicine, 2016
Background: Cardiac troponin (cTn) testing has reduced the likelihood of erroneous discharge of patients with acute coronary syndrome (ACS) from the emergency department (ED), but doubts remain about optimal clinical use. This study was planned for evaluating the predictive significance of cTn values between the limit of detection of the method and the 99th percentile in ED patients evaluated for suspected ACS. Methods: In this retrospective study all hospital records of patients admitted over a 6-month period to the ED and with at least one cTnI value comprised between the limit of detection (0.01 ng/mL) and the 99th percentile of the assay (0.05 ng/mL) were analyzed. Results: A total of 4,749 patients with cTnI value between 0.01-0.05 ng/mL were identified among 57,879 ED visits throughout the study period. Overall, 2,189 patients (46.1%) were discharged from the ED, 2,529 (53.25%) were admitted to the hospital and 31 (0.65%) died during ED stay. A total number of 289 patients out of 2,189 who were discharged (i.e., 13.2%) had additional ED visits within 30 days. Among these, 6 were diagnosed with ACS, representing 0.27% of patients discharged [negative predictive value (NPV) 0.997; 95% CI, 0.994-0.999] and 2.1% of those with second admission (NPV 0.979; 95% CI, 0.955-0.992). Only one of the 2,529 patients admitted to the hospital (i.e., 0.04%) developed an ACS during hospital stay. Conclusions: The results of our retrospective study suggest that the suitability of using a contemporary-sensitive cTnI immunoassay assay in the context of an appropriate protocol represents a safe and effective strategy for ruling in and ruling out ACS in patients presenting to the ED.
Clinical Considerations of High Sensitivity Troponins and CVD
American Society for Clinical Laboratory Science, 2018
Cardiovascular disease (CVD) remains the number one cause of death in the United States (US). According to the American Heart Association, it causes roughly 2300 deaths per day, and one death about every 38 seconds. The introduction and generalized use of high sensitivity cardiac troponins (hs-cTn) has the potential to improve diagnosis, which would allow for shorter times to reperfusion and better patient outcomes. Emergency departments in the US have established evidence-based protocols that aide providers to rule out acute coronary syndrome or acute myocardial infarction. These protocols currently utilize traditional troponin assay but are being validated using high-sensitivity troponin assays. With the advent of high-sensitivity troponin assays, however, clinicians must have care in their interpretation. The myonecrosis that leads to elevations in serum troponins is not a disease specific phenomena, but rather organ specific. As such, several diseases exist other than acute myocardial infarction (AMI) that can lead to troponin elevations. It is important for providers to use these biomarkers as an adjunct to the clinical picture to determine diagnosis, management, and treatment. High sensitivity troponin assays are also being studied to evaluate risk stratification and prognosis for CVD diseases such as procedural outcomes, transplant recipients, and chronic stable angina. The data shows mixed results in terms of applicability for risk stratification and prognosis but likely will evolve over time. Finally, the 2015 European Society of Cardiology (ESC) guidelines include an algorithm for managing acute coronary syndrome (ACS) using a-0/-1 hour hs-cTn testing based on studies that demonstrating a 97% sensitivity for a one hour testing protocol. The guidelines included two methods of ruling out AMI, a) a single sample with hs-cTn levels that were undetectable and b) a change of 6ng/L between zero and one hour or absolute threshold concentration >52ng/L. In 2017, the FDA cleared high sensitivity assays for use in the US. Continued studies are needed in the US to determine if protocols using hs-cTn lead to early diagnosis and, subsequently, improved patient outcomes. Studies are needed to incorporate the use of hs-cTn as a better prognostic indicator for various cardiac diseases and interventions.
American Heart Journal, 2010
Background Cardiac troponins are currently the markers of choice for diagnosis of acute myocardial infarction and risk assessment in acute coronary syndrome (ACS). With the introduction of the new high-sensitivity cardiac troponin T (hs-cTnT) assay, it has become possible to measure cTnT even in healthy subjects. However, how the hs-cTnT assay compares with the old cTnT assay for risk assessment in ACS is still unknown. Methods Cardiac troponin T levels were measured with the new hs-cTnT assay and the old third-generation cTnT assay in serum samples collected 48 hours after randomization in 1,452 randomly selected ACS patients enrolled in the GUSTO-IV trial. During 30 days of follow-up, deaths and myocardial infarctions were recorded. At 12 months, only all-cause mortality was collected. Results The 16% of the patients that had levels higher than the 99th percentile cutoff for hs-cTnT but less than for cTnT had a similar 1-year mortality as the 60% that were positive for both assays (9.2% vs 10.7%, P = .52) and a higher 1-year mortality compared with the 24% that were negative for both assays (9.2% vs 2.6%, P = .001). For death or acute myocardial infarction at 30 days, the group that was positive only for hs-cTnT had an intermediate risk compared with the groups negative or positive for both assays (2.4%, 5.2%, and 8.7%; P b .001). Conclusion The new hs-cTnT assay, compared with the old cTnT assay, identified more patients with myocardial damage and who were at an increased risk for new cardiac events.