Copeptin Improves Early Diagnosis of Acute Myocardial Infarction

Transcription

1 Journal of the American College of Cardiology Vol. 55, No. 19, by the American College of Cardiology Foundation ISSN /$36.00 Published by Elsevier Inc. doi: /j.jacc FOCUS ISSUE: BIOMARKERS IN CARDIOVASCULAR DISEASE Biomarkers in ACS Copeptin Improves Early Diagnosis of Acute Myocardial Infarction Till Keller, MD,* Stergios Tzikas, MD,* Tanja Zeller, PHD,* Ewa Czyz, MD,* Lars Lillpopp,* Francisco M. Ojeda, PHD,* Alexander Roth, PHD,* Christoph Bickel, MD, Stephan Baldus, MD, Christoph R. Sinning, MD,* Philipp S. Wild, MD,* Edith Lubos, MD,* Dirk Peetz, MD, Jan Kunde, PHD, Oliver Hartmann, MSC, Andreas Bergmann, PHD, Felix Post, MD,* Karl J. Lackner, MD, Sabine Genth-Zotz, MD,* Viviane Nicaud, MA,# Laurence Tiret, PHD,# Thomas F. Münzel, MD,* Stefan Blankenberg, MD* Mainz, Koblenz, Hamburg, and Henningsdorf, Germany; Boston, Massachusetts; and Paris, France Objectives Background Methods Results Conclusions Early identification of myocardial infarction in chest pain patients is crucial to identify patients at risk and to maintain a fast treatment initiation. The aim of the current investigation is to test whether determination of copeptin, an indirect marker for arginin-vasopressin, adds diagnostic information to cardiac troponin in early evaluation of patients with suspected myocardial infarction. Between January 2007 and July 2008, patients with suspected acute coronary syndrome were consecutively enrolled in this multicenter study. Copeptin, troponin T (TnT), myoglobin, and creatine kinase-myocardial band were determined at admission and after 3 and 6 h. Of 1,386 (66.4% male) enrolled patients, 299 (21.6%) had the discharge diagnosis of acute myocardial infarction, 184 (13.3%) presented with unstable angina, and in 903 (65.2%) an acute coronary syndrome could be excluded. Combined measurement of copeptin and TnT on admission improved the c-statistic from 0.84 for TnT alone to 0.93 in the overall population and from 0.77 to 0.9 in patients presenting within 3 h after chest pain onset (CPO) (p 0.001). In this group the combination of copeptin with a conventional TnT provided a negative predictive value of 92.4%. In triage of chest pain patients, determination of copeptin in addition to troponin improves diagnostic performance, especially early after CPO. Combined determination of troponin and copeptin provides a remarkable negative predictive value virtually independent of CPO time and therefore aids in early and safe rule-out of myocardial infarction. (J Am Coll Cardiol 2010;55: ) 2010 by the American College of Cardiology Foundation Early identification of myocardial infarction (MI) in chest pain patients is crucial to maintain a fast treatment initiation. Diagnosis of acute myocardial infarction (AMI) relies, besides clinical symptoms and electrocardiographic (ECG) From the *Department of Medicine II and Institute for Clinical Chemistry and Laboratory Medicine, University Medical Center of the Johannes Gutenberg- University, Mainz, Germany; Department of Internal Medicine, Federal Armed Hospital, Koblenz, Germany; Department of Cardiology, Heart Center, University Hospital Hamburg-Eppendorf, Hamburg, Germany; Department of Medicine, Brigham and Women=s Hospital and Harvard Medical School, Boston, Massachusetts; B.R.A.H.M.S. AG, Henningsdorf, Germany; and #INSERM, UMRS 937, Université Pierre et Marie Curie, Paris, France. The current study is funded through the research programs Wissen schafft Zukunft and Schwerpunkt Vaskuläre Prävention of the Johannes Gutenberg-University of Mainz and an unrestricted grant of the B.R.A.H.M.S. AG, Germany. Jan Kunde, Oliver Hartmann, and Andreas Bergmann are employed by B.R.A.H.M.S. AG, Germany. Manuscript received October 22, 2009; revised manuscript received December 17, 2009, accepted January 2, findings, primarily on biomarker levels. Markers of myocardial necrosis such as cardiac troponin and creatine kinasemyocardial band (CK-MB) are the gold standard in detection of AMI, and their use is recommended by current guidelines (1). In particular, cardiac troponin provides excellent specificity (2,3). The delayed release of necrosis markers after cell disintegration might explain the weakness in diagnostic performance of conventional troponin assays early after chest pain onset (CPO) (4). Therefore, markers with pathophysiologic background independent of cell necrosis might improve rapid diagnosis of AMI. The antidiuretic hormone arginin-vasopressin (AVP) is secreted neurohypophyseal and controls osmotic homeostasis (5). Release of AVP is regulated by hyperosmolality, hypovolemia (6), hypotension, hypothalamic osmoreceptors

2 JACC Vol. 55, No. 19, 2010 May 11, 2010: Keller et al. Copeptin in Diagnosis of Myocardial Infarction 2097 and angiotensin II, reflecting individual stress level (7). The AVP-induced vasoconstriction is mediated by the V 1a receptor on smooth muscle cells, the antidiuretic effect by the V 2 receptor on the distal kidney tubule, and the IP3 signal transduction pathway (8,9). Clinical relevance of AVP is given by its potential role in pathogenesis and its diagnostic value in congestive heart failure (10) and remodeling after AMI (11). As endocrine stress response, the AVP levels increase in shock and cardiac arrest (12 14). Routine measurement of AVP in clinical practice is prevented by various reasons, such as short half-life time (15), platelet binding (16), and assay variations. The glycosylated peptide copeptin is part of the uncleaved pro-avp and emerges equimolar to AVP, because both are derived from the precursor prepro-avp along with neurophysin II; therefore, it serves as an indirect marker for AVP. A recently developed assay for copeptin delivers the stability and reproducibility direct measurement of AVP is lacking (17). The release pattern of copeptin in patients with AMI with immediate rise after onset of chest pain and decrease toward physiologic levels within 5 days (18) as well as the potential use of copeptin in rule-out of AMI (19) was described recently. Thus, the role of copeptin as diagnostic marker in suspected acute coronary syndrome (ACS) needs to be evaluated in large prospective cohorts. The aim of the current investigation is to prospectively test whether copeptin adds diagnostic information to that provided by troponin and whether the combination of copeptin and troponin is superior to the combination of myoglobin and troponin in early evaluation of patients with suspected AMI. Methods Study population. All patients with suspected ACS presenting consecutively at the chest pain units of the University Medical Center of the Johannes Gutenberg-University Mainz, the Federal Armed Hospital Koblenz, or the University Hospital Hamburg-Eppendorf between January 2007 and July 2008 were enrolled in this study, to reflect an unbiased real world population. Patients older than 18 years and younger than 85 years of age with angina pectoris or equivalent symptoms were eligible to participate. Exclusion criteria were trauma or major surgery within the last 4 weeks, pregnancy, intravenous drug abuse, and anemia (hemoglobin 10 g/dl). Patients treated with antihypertensive drugs at enrollment or who had previous diagnosis of hypertension were classified as hypertensive. Patients were categorized as currently smoking, former smoking (if stopped 4 weeks to 40 years prior), and nonsmoker (if stopped smoking 40 years ago). Patients receiving dietary treatment or medication for diabetes were considered to have diabetes mellitus. We considered patients with previously diagnosed hyperlipidemia or with total cholesterol 200 mg/dl at admission as hyperlipidemic. Blood was drawn at admission and after 3 and 6 h. A 12-lead ECG was obtained at the same time points. Diagnosis of AMI was established according to the universal definition of MI (1). Patients with symptoms of myocardial ischemia together with ECG changes and/or elevated biomarkers of myocardial necrosis were categorized as having an AMI. Relevant ECG changes were defined as follows: ST-segment elevation 0.2 mv in at least 2 contiguous leads in V 2 to V 6 or ST-segment elevation 0.1 mv in other leads or with new left bundle branch block documented in ECG at admission or in outpatient clinic ECG were classified as AMI with ST-segment elevation; and ST-segment depression and T- or Q-wave changes were classified as ECG signs representative for acute ischemia. Necrosis of myocardium was noted if at least 1 determination of in-house troponin exceeded the predefined upper reference limit of the corresponding assay and if a typical kinetic with rise or fall 20% Abbreviations and Acronyms ACS acute coronary syndrome AMI acute myocardial infarction AUC area under the curve AVP arginin-vasopressin CK-MB creatine kinasemyocardial band CPO chest pain onset CV coefficient of variation ECG electrocardiogram/ electrocardiographic MI myocardial infarction NCCP noncoronary chest pain NPV negative predictive value NT-proBNP N-terminal pro-brain natriuretic peptide PPV positive predictive value ROC receiver operating characteristic TnI troponin I TnT troponin T UAP unstable angina pectoris within 6 h after admission could be observed. Unstable angina pectoris (UAP) was diagnosed if ECG was nondiagnostic; in-house troponin was negative, but coronary angiography revealed a culprit lesion; or ischemia was proven in stress test with subsequent need of coronary intervention. All patients with excluded ACS were categorized as having noncoronary chest pain (NCCP). Final diagnosis was made by an expert committee of 2 cardiologists, blinded to copeptin values, on the basis of all available clinical, laboratory, and imaging findings. The study was approved by the local ethics committees in Rheinland-Pfalz and Hamburg. Participation was voluntary; each patient gave written, informed consent. Blood sampling and laboratory methods. Routine laboratory parameters, including C-reactive protein, creatinine, myoglobin, N-terminal pro-brain natriuretic peptide (NTproBNP), and CK-MB, were measured immediately after blood withdrawal by standardized methods. Additionally, ethylenediaminetetraacetic acid plasma, citrate plasma, and serum samples were collected at each time point, centrifuged, and frozen at 80 C. Cardiac troponin T (TnT) (Roche Diagnostics, Mannheim, Germany) representing in-house troponin at 2 study

3 2098 Keller et al. JACC Vol. 55, No. 19, 2010 Copeptin in Diagnosis of Myocardial Infarction May 11, 2010: centers was measured at each time point in all patients with the electrochemiluminescence immunoassay (ECLIA) technology on an Elecsys 2010 system with detection limit of 0.01 ng/ml and measuring range of 0.01 to 25 ng/ml. Reference limit based on the 99th percentile for a healthy population was 0.01 ng/ml, and 10% coefficient of variation (CV) was 0.03 ng/ml, which was used as diagnostic cutoff. In-house cardiac troponin I (Dimension RxL TnI, Siemens Healthcare Diagnostics, Erlangen, Germany) was used at 1 study center for adjudication of final diagnosis. The assay had a detection limit of 0.04 ng/ml with a measuring range of 0.04 to 40 ng/ml. The 99th percentile was 0.07 ng/ml, and the 10% CV used as diagnostic cutoff was 0.14 ng/ml. Additionally, sensitive cardiac troponin I with the TnI- Ultra assay (Siemens Healthcare Diagnostics) was determined on an ADVIA Centaur XP system. The assay detection limit was ng/ml, measuring range was to 50 ng/ml, 99th percentile was 0.04 ng/ml, and 10% CV was 0.03 ng/ml. Copeptin was measured in ethylenediaminetetraacetic acid plasma by sandwich immunoluminometric assay (CTproAVP LIA B.R.A.H.M.S AG, Hennigsdorf, Germany) as described in detail elsewhere (17,20). The assay has an analytical detection limit of 0.4 pmol/l and a functional assay sensitivity (lowest value with an interassay CV 20%) 1.0 pmol/l and allows precise measurement of copeptin in a range of 0.4 to 1,250 pmol/l. To determine a diagnostic cutoff based on a reference population, copeptin was measured with the same assay as described in the preceding text in 5,000 individuals of the Gutenberg Heart Study. Characteristics of the participants are given in Online Table 1. On the basis of the distribution of copeptin, different potential cutoff values were considered (Fig. 1): the 99th percentile with 18.9 pmol/l as suggested Baseline Table 1Characteristics Baseline Characteristics of 1,386 Patients of 1,386 With Patients Chest Pain With Chest Pain NCCP UAP AMI All n 903 (65.2) 184 (13.3) 299 (21.6) 1,386 (100) Age (yrs) Male sex 569 (63) 122 (66.3) 229 (76.6) 920 (66.4) Traditional risk factors Body mass index (kg/m 2 ) Waist/hip ratio 0.98 (0.93/1.03) 0.98 (0.94/1.04) 1.02 (0.96/1.05) 0.99 (0.94/1.04) Hypertension 640 (70.9) 161 (87.5) 224 (74.9) 1,025 (74) Diabetes mellitus 135 (15.1) 48 (26.2) 67 (22.6) 250 (18.2) Smoking status Current smoker 192 (21.4) 31 (17.1) 99 (33.7) 322 (23.5) Former smoker 263 (31.1) 64 (37.9) 93 (35.4) 420 (32.9) Never smoked 437 (49.3) 83 (47.2) 96 (33.3) 616 (45.6) Hyperlipidemia 624 (69.1) 151 (82.1) 225 (75.3) 1,000 (72.2) Lipid status Total cholesterol (mg/dl) HDL cholesterol (mg/dl) LDL cholesterol (mg/dl) LDL/HDL ratio 2.2 (1.6/2.8) 2.2 (1.5/3.1) 2.7 (2/3.5) 2.3 (1.6/3) Parental CAD 302 (34.5) 59 (35.1) 95 (33.5) 456 (34.3) Known CAD 285 (32.6) 111 (62) 103 (35.4) 499 (37.2) Laboratory parameters at admission TnT 0.03 ng/ml 27 (3.01) 4 (2.19) 184 (61.95) 215 (15.6) Copeptin (pmol/l) 5.4 (2.9/11.9) 5.1 (3/11.9) 18.5 (7/50.1) 6.7 (3.3/16.5) Myoglobin (ng/ml) 58.8 (43.13/82.85) 65.9 (46.5/82.6) (83.89/238.92) (46.88/102.58) CK-MB (U/l) 14 (11/18) 14 (11/18) 21 (15/32) 15 (12/20) NT-proBNP (pg/ml) 119 (47.2/345) (83.2/566.6) (141.5/1,277.1) 161 (64.3/572.5) C-reactive protein (mg/l) 2.3 (1.1/5.5) 2.3 (1.3/4.5) 3.7 (1.8/10) 2.5 (1.3/6) Creatinine (mg/dl) 0.93 (0.8/1.07) 0.92 (0.81/1.04) 0.98 (0.88/1.16) 0.94 (0.82/1.08) egfr (ml/min for 1.73 m 2 ) Time of chest pain onset, h (36.8) 64 (34.8) 121 (40.5) 517 (37.3) (57.6) 111 (60.3) 175 (58.5) 806 (58.2) (73.8) 139 (75.5) 212 (70.9) 1,017 (73.4) (26.2) 45 (24.5) 87 (29.1) 369 (26.6) Data presented as n (%) of patients, mean SD for even variables, or median and 25th/75th interquartile range for skewed variables. Number of patients for which data were available for: body mass index: 1,297; waist-hip ratio: 879; hypertension: 1,385; diabetes mellitus: 1,372; smoking status: 1,273; hyperlipidemia: 1,386; high-density lipoprotein (HDL) cholesterol: 1,223; low-density lipoprotein (LDL) cholesterol: 1,223; parental coronary artery disease (CAD): 1,328; troponin T (TnT): 1,378; copeptin: 1,382; C-reactive protein: 1,377; myoglobin: 1,216; creatine kinase-myocardial band (CK-MB): 1,350; N-terminal pro-brain natriuretic peptide (NT-proBNP): 543; estimated glomerular filtration rate (egfr): 1,383; creatinine: 1,383; and time of chest pain onset: 1,386. AMI acute myocardial infarction; NCCP noncoronary chest pain; UAP unstable angina pectoris.

4 JACC Vol. 55, No. 19, 2010 May 11, 2010: Keller et al. Copeptin in Diagnosis of Myocardial Infarction 2099 Figure 1 Histogram of Copeptin in the General Population Distribution of copeptin values in 5,000 representative individuals of the Gutenberg Heart Study with corresponding 95th, 97.5th, and 99th percentiles. for a biomarker in diagnosis of an AMI by the universal definition, the 97.5th percentile with 13 pmol/l as 95% of the measured values define the reference range of a biomarker, and the 95th percentile with 9.8 pmol/l as copeptin showed a skewed distribution and as only the upper reference limit is of interest in this context. Technical assistants measuring copeptin were blinded to the patients characteristics. To estimate glomerular filtration rate, the abbreviated Modification of Diet in Renal Disease equation was used (21). Statistical analysis. Skewed variables were described by median and interquartile range. Symmetric variables were characterized by arithmetic mean and SD. Association between copeptin and different continuous variables was assessed with Spearman rank correlation coefficient. The Mann-Whitney test was used to compare the median levels of copeptin among different groups defined by binary risk factors. To describe changes over time, the Page L test for ordered alternatives was used in markers with continuous increase or decrease, and the Friedman 2-way analysis of variance by ranks test was used in markers without an obvious trend (22). Receiver-operating characteristic (ROC) curves based on continuously measured biomarker levels dependent on time since chest-pain onset were calculated and graphed by using logistic regression according to diagnosis; all biomarkers entered these analyses after being log-transformed, due to their skewness. A nonparametric approach according to DeLong et al. (23) was used to test for difference between the areas under the curve (AUCs). Confidence intervals for the AUCs were constructed with the covariance matrix estimated by the DeLong et al. method. Additionally, positive predictive values (PPVs), negative predictive values (NPVs), sensitivity, and specificity for the target markers were assessed by first applying a markerspecific cutoff value and consecutively calculating the corresponding values from a 2 2 table in the usual way that these quantities are defined. Because these numbers represent proportions, 95% confidence limits for binomial distributed variables are given additionally. All analyses were done with R (R Foundation for Statistical Computing, Vienna, Austria). Results Baseline characteristics. Table 1 provides the baseline characteristics of the overall study population at admission. Mean age was 61.5 years; 33.6% of the patients presented were women. In 903 of the 1,386 enrolled patients, an ACS could be excluded; these patients were classified as having NCCP, including patients with diagnosis of decompensated aortic valve stenosis (n 2), aortic dissection (n 5), myocarditis (n 13), decompensated heart failure (n 16), and pulmonary embolism (n 17). Discharge diagnosis of AMI was made in 299 patients (21.6%), including 93 patients (6.7%) having an STsegment elevation MI. The diagnosis of UAP was made in 184 (13.3%) patients. The observed distribution of approximately 22% AMI and 35% ACS is in line with other European studies (24). Traditional risk factors were more common in ACS patients. As anticipated, biomarkers of myocardial necrosis as well as copeptin levels were highest in patients suffering AMI. The distribution of CPO time was comparable amongst all groups categorized according to diagnosis. Analyses of serial blood sampling. In addition to blood sampling at admission, serial samples were obtained after 3 and 6 h. To prospectively assess the time course of the

5 2100 Keller et al. JACC Vol. 55, No. 19, 2010 Copeptin in Diagnosis of Myocardial Infarction May 11, 2010: evaluated potential early biomarkers, patients with discharge diagnosis of AMI (n 75) or NCCP (n 213) presenting with CPO 2 h were selected. Figure 2 illustrates the representative time courses of TnT, copeptin, myoglobin, and CK-MB in those patients during the first 6 h after admission. Median troponin T levels strongly increased within 6 h after admission (p 0.001). By contrast, copeptin levels decreased during the first 6 h from its peak at admission (p 0.001). Levels of myoglobin seemed to increase during the first 3 h and decline afterward (p 0.397), whereas CK-MB concentration continuously increased within the observed 6h(p 0.001). Biomarker concentration according to CPO. Table 2 outlines the course of biomarker concentration at admission according to CPO time in the overall study population. The concentration of TnT continuously increased with CPO time in AMI patients, reaching a maximum later than 12 h after CPO. In AMI patients with CPO of 3 h, mean TnT was at the concentration of 10% CV with 0.03 ng/ml. In contrast, median copeptin levels were highest in AMI patients with CPO below 3 h. In this time interval, patients with AMI had 5-fold higher copeptin levels (29.6 pmol/l) compared with NCCP (5.7 pmol/l) and UAP (5.45 pmol/l) patients. Median copeptin levels decreased over time, reaching values comparable to NCCP and UAP in patients presenting later than 12 h after CPO. In patients with CPO below 3 h, NT-proBNP levels were elevated 2.5-fold in AMI patients compared with NCCP, increasing within 12 h after CPO. As expected, in AMI patients, myoglobin was already elevated 2-fold in patients presenting earlier than 3 h, peaking within 12 h after CPO. The time course of CK-MB showed a slower increase and later peak. Correlates of copeptin. Association between classical risk factors and median copeptin levels according to diagnosis is displayed in Table 3. Men, obese patients, smokers, and patients with diabetes in the NCCP group and patients with diabetes in the UAP group had significantly higher copeptin levels. Female patients presenting with AMI had lower copeptin levels compared with male patients (13.55 pmol/l vs pmol/l; p 0.25); this might be explained by the longer time interval between CPO and admission of female patients. Furthermore, prevalence of hypertension and hyperlipidemia tended to be related to copeptin levels. Table 3 also shows the correlation of continuous risk variables and of serum biomarkers and copeptin. Myoglobin Figure 2 Representative Time Course of Copeptin, Troponin T, Myoglobin, and CK-MB Levels in Patients Suffering AMI on the Basis of Serial Sampling During First 6 h After Admission Data selected for patients with final diagnosis of acute myocardial infarction (AMI) or noncoronary chest pain (NCCP) with time of chest pain onset 2 h (AMI n 75, NCCP n 213). Levels of copeptin, troponin T, myoglobin, and creatine kinase-myocardial band (CK-MB) were measured in blood samples drawn at admission (0 h) and 3 and 6 h after admission. Data represent median concentrations with 95% bootstrap confidence interval.

6 JACC Vol. 55, No. 19, 2010 May 11, 2010: Keller et al. Copeptin in Diagnosis of Myocardial Infarction 2101 Levels According of Copeptin, tolevels Time of TnT, Chest Copeptin, Myoglobin, PainTnT, Onset CK-MB, Myoglobin, and Final and CK-MB, NT-proBNP Diagnosis and NT-proBNP Table 2 According to Time of Chest Pain Onset and Final Diagnosis 0 3 h 3 6 h 6 12 h >12 h TnT (ng/ml) NCCP 0.01 (0.01/0.01) 0.01 (0.01/0.01) 0.01 (0.01/0.01) 0.01 (0.01/0.01) UAP 0.01 (0.01/0.01) 0.01 (0.01/0.01) 0.01 (0.01/0.01) 0.01 (0.01/0.01) AMI 0.03 (0.01/0.1) 0.06 (0.02/0.2) 0.06 (0.01/0.32) 0.28 (0.08/0.8) Copeptin (pmol/l) NCCP 5.7 (3.1/13.07) 5.1 (2.62/13.1) 5.15 (2.8/11.31) 5.4 (2.97/10) UAP 5.45 (3.54/14.56) 3.9 (2.7/9.67) 4.65 (2.23/15.17) 6.4 (3.57/10.77) AMI 29.6 (9.83/69.37) 25.5 (9.17/61.89) 18.6 (7.77/33.17) 8.4 (4.13/17.3) Myoglobin (ng/ml) NCCP 55.9 (41.38/80.96) 59.1 (44.57/88.77) 62 (46.92/82.23) 60.7 (44.12/81.48) UAP 65.7 (43.12/81.56) 66.2 (49.8/77.47) 69 (37.13/106.25) 61.7 (49.82/83.95) AMI 144 (84.66/241.33) 131 (79.93/378.5) 117 (84.35/320.5) 125 (82.13/181.67) CK-MB (U/l) NCCP 14 (11/18) 14 (11.92/18.08) 14 (11/17) 15 (11/19.08) UAP 12 (10/17.08) 17 (12/23.08) 15 (11.17/18) 14 (12/17.33) AMI 18 (14/24) 22 (16/29) 24 (16/44.67) 28 (16/66.17) NT-proBNP (pg/ml) NCCP 84.5 (40.92/222.33) 131 (55.67/574.33) 135 (54.67/673.67) 139 (66/489.83) UAP 140 (57.42/372.58) 201 (122.5/354.33) 166 (70.67/540.25) 281 (136.33/1,006.67) AMI 211 (89.83/721.83) 506 (122.33/1,879.58) (212.42/960.58) 604 (341.17/2,032) Data presented as median and 25th/75th interquartile range of concentrations of TnT, copeptin, myoglobin, CK-MB, and NT-proBNP assessed at admission according to chest pain onset time. Abbreviations as in Table 1. as a marker of necrosis showed a mild correlation to copeptin in all diagnosis groups, TnT in NCCP and AMI patients, whereas CK-MB had no correlation with copeptin. Furthermore, creatinine and egfr, showed a significant correlation with copeptin in all diagnostic groups. Diagnostic value of copeptin. To compare the discriminatory ability of the continuous biomarkers troponin T, copeptin, myoglobin, and CK-MB in detecting MI, ROC curve analysis with AUC determination was performed according to different times after CPO (Table 4, upper section). The AUC for TnT increased over time, with highest value in the overall population (0.84) compared with patients presenting as early as 12, 6, and 3 h after CPO. CK-MB showed dynamics similar to troponin T with lower AUCs in all groups. In contrast, copeptin as well as myoglobin provided the highest discriminatory power in patients with CPO 3 h. Adding the markers copeptin, myoglobin, and CK-MB individually to TnT improved the AUC significantly in all groups in comparison with troponin T alone. In patients presenting within 3 h after CPO, addition of copeptin to TnT revealed highest diagnostic power with AUC of 0.9 compared with addition of myoglobin to TnT. Combination of copeptin and TnT stayed superior with AUCs of 0.91, 0.92, and 0.93 in patients with CPO of 6 h and 12 h, and the overall population, respectively. Considering all patients at baseline, the combination of copeptin and TnT was superior to all single marker determinations or other marker combinations. Using NT-proBNP as a diagnostic biomarker resulted in an AUC of 0.7 in the overall population; the combination of NT-proBNP and TnT was not significantly superior to troponin alone (AUC 0.87 vs. 0.84; p 0.145). The ROC curves of the single markers and their combination in serial samples at admission and after 3 and 6hin the overall study population are graphed in Figure 3. The lower section of Table 4 shows sensitivities and specificities as well as PPV and NPV for TnT, copeptin, and myoglobin and combinations of these biomarkers for measured values above the respective cutoff. TnT showed a high specificity, independent of CPO (97.9%, 97.7%, and 97.7% with CPO 3 h, 6 h,and 12 h, respectively), as well as the highest PPV (88.1%, 87.9%, and 88.2%) compared with copeptin and myoglobin. The combination of TnT and myoglobin showed higher sensitivity (75.9%, 77.6%, and 77.6%) and higher NPV (89.9%, 91.1%, and 91.6%) than TnT alone with downside of lower specificity and PPV. Combining copeptin and TnT resulted in even higher sensitivity, and NPV with all 3 used cutoff values representing the 95th, 97.5th, and 99th percentiles of a general population. Highest sensitivity (85.1%, 87.4%, and 88.2%) and NPV (92.4%, 93.9%, and 94.6%) were achieved with 9.8 pmol/l as the cutoff representing the 95th percentile. If patients with ST-segment elevation (n 93) were excluded from the AMI group, single TnT determination at admission in the overall population showed an AUC of 0.87, which improved to 0.93 (p 0.001) by adding copeptin. In patients with CPO 3 h, the AUC for TnT

7 2102 Keller et al. JACC Vol. 55, No. 19, 2010 Copeptin in Diagnosis of Myocardial Infarction May 11, 2010: Median and Correlation Concentration Median WithConcentration Continuous of CopeptinVariables According of Copeptin toaccording Categorical Diagnosis to Risk Categorical FactorsRisk Factors Table 3 and Correlation With Continuous Variables According to Diagnosis NCCP (n 899) UAP (n 184) AMI (n 299) Copeptin p Value Copeptin p Value Copeptin p Value Male Female Body mass index (kg/m 2 ) Hypertension Yes No Diabetes mellitus Yes No Current smoking Yes No Hyperlipidemia Yes No Known CAD Yes No NCCP UAP AMI r p Value r p Value r p Value Age LDL/HDL ratio Waist/hip ratio Creatinine egfr C-reactive protein TnT Myoglobin CK-MB NT-proBNP Correlations with continuous variables are given as Spearman correlation coefficients. Abbreviations as in Table 1. alone was 0.79; for the combination of troponin and copeptin, the AUC improved to 0.9 (p 0.001). Sensitivity and NPV of TnT alone with 10% CV as cutoff was 64.7% and 92.4%, respectively, in the overall population and 46.7% and 89.0% in patients with CPO 3 h. Applying the 95th percentile cutoff of 9.8 pmol/l for copeptin in combination with TnT improved sensitivity and NPV to 89.3% and 96.5%, respectively, in the overall population and to 81.3% and 94.0% in patients with CPO 3 h. Regarding rule-out of ACS including AMI and UAP, determination of TnT at admission with 10% CV as cutoff provided an NPV of 74.9%; in combination with copeptin with the 95th percentile as cutoff, an NPV of 80% was achieved. In patients with CPO 3 h, the NPV increased from 70.8% for TnT alone to 77.8% in combination with copeptin. Early evaluation of AMI with a more sensitive troponin. Additional to conventional TnT, data are given in Table 5 on a more sensitive troponin I representative for a new generation of commercially available troponin assays with 10% CV below the 99th percentile as recommended by the universal definition of MI. In identification of AMI patients presenting within 3 h after CPO, troponin I delivered an AUC of 0.96 (0.95 to 0.98); the combination with copeptin improved the AUC slightly to 0.97 (0.96 to 0.98) (p ). Application of the 99th percentile cutoff of 0.04 ng/ml showed a high sensitivity of 86.7% and NPV of 95%; the combination with copeptin with the 95th percentile of 9.8 pmol/l was able to improve the sensitivity to 98.3% and NPV to 99%. The combination had a sensitivity of 79.3% and an NPV of 84.6%, in exclusion of an ACS. Discussion Early identification of patients at risk in a population with undifferentiated chest pain is essential, because these patients benefit the most from an aggressive therapeutic regimen.

8 AUC, Copeptin, Sensitivity, Myoglobin, AUC, Specificity, Sensitivity, CK-MB, PPVs, Specificity, and Combination and NPVs PPVs, for According and NCCP NPVs Versus to fortime NCCP AMI offor Versus Chest TnT, Pain AMI for Onset TnT, Table 4 Copeptin, Myoglobin, CK-MB, and Combination According to Time of Chest Pain Onset <3 h <6 h <12 h All AUC (CI) p Value vs. TnT AUC (CI) p Value vs. TnT AUC (CI) p Value vs. TnT AUC (CI) p Value vs. TnT Troponin T 0.77 ( ) 0.8 ( ) 0.81 ( ) 0.84 ( ) Copeptin 0.79 ( ) ( ) ( ) ( ) Myoglobin 0.83 ( ) ( ) ( ) ( ) CK-MB 0.68 ( ) ( ) ( ) ( ) Combination TnT/Cop 0.9 ( ) ( ) ( ) ( ) Combination TnT/Myo 0.89 ( ) ( ) ( ) ( ) Combination TnT/CK-MB 0.83 ( ) ( ) ( ) ( ) h TnT* Myoglobin* Copeptin* Copeptin* Copeptin* TnT* or Myoglobin* TnT* or Copeptin* TnT* or Copeptin* TnT* or Copeptin* Sensitivity 43 ( ) 62.3 ( ) 75.2 ( ) 70.2 ( ) 63.6 ( ) 75.9 ( ) 85.1 ( ) 82.6 ( ) 80.2 ( ) Specificity 97.9 ( ) 87.5 ( ) 68.1 ( ) 75.1 ( ) 83.3 ( ) 85.9 ( ) 66.7 ( ) 73.4 ( ) 81.7 ( ) PPV 88.1 ( ) 64.7 ( ) 46.4 ( ) 50.9 ( ) 58.3 ( ) 68.2 ( ) 48.6 ( ) 53.5 ( ) 61.8 ( ) NPV 82.4 ( ) 86.3 ( ) 88.2 ( ) 87.3 ( ) 86.2 ( ) 89.9 ( ) 92.4 ( ) 92 (88 95) 91.8 ( ) 6 h Sensitivity 50 ( ) 61.4 ( ) 74.9 ( ) 69.1 ( ) 63.4 ( ) 77.6 ( ) 87.4 ( ) 84 ( ) 81.1 ( ) Specificity 97.7 ( ) 85.8 ( ) 67.6 ( ) 74.8 ( ) 82 ( ) 83.9 ( ) 66.2 ( ) 73.2 ( ) 80.3 ( ) PPV 87.9 ( ) 59.1 ( ) 44 ( ) 48.2 ( ) 54.4 ( ) 64.1 ( ) 46.9 ( ) 51.8 ( ) 58.4 ( ) NPV 85.3 ( ) 86.9 ( ) 88.8 ( ) 87.7 ( ) 86.9 ( ) 91.1 ( ) 93.9 ( ) 93.1 ( ) 92.6 ( ) 12 h Sensitivity 53.1 ( ) 60.1 ( ) 74.1 ( ) 67.5 ( ) 60.8 ( ) 77.6 ( ) 88.2 ( ) 84.9 ( ) 82.1 ( ) Specificity 97.7 ( ) 86.2 ( ) 68 ( ) 75.8 ( ) 82.5 ( ) 84.5 ( ) 66.9 ( ) 74.6 ( ) 81.2 ( ) PPV 88.2 ( ) 57.6 ( ) 42.5 ( ) 47.2 ( ) 52.7 ( ) 63.3 ( ) 46.2 ( ) 51.9 ( ) 58.4 ( ) NPV 86.7 ( ) 87.4 ( ) 89.1 ( ) 87.9 ( ) 86.8 ( ) 91.6 ( ) 94.6 ( ) 93.9 ( ) 93.4 ( ) All Sensitivity 62 ( ) 61 ( ) 65.6 ( ) 57.5 ( ) 49.2 ( ) 81 ( ) 90.9 ( ) 87.6 ( ) 84.6 ( ) Specificity 97 ( ) 86.6 ( ) 69.7 ( ) 77.9 ( ) 84.4 ( ) 84.5 ( ) 68.3 ( ) 76.2 ( ) 82.4 ( ) PPV 87.2 ( ) 60.1 ( ) 41.9 ( ) 46.4 ( ) 51.2 ( ) 65.3 ( ) 48.8 ( ) 55.1 ( ) 61.6 ( ) NPV 88.5 ( ) 87 ( ) 85.9 ( ) 84.6 (82 87) 83.3 ( ) 92.5 ( ) 95.8 ( ) 94.8 ( ) 94.1 ( ) AUC, sensitivity, specificity, PPVs, and NPVs for NCCP versus AMI for troponin T, copeptin, myoglobin, CK-MB, and the combination of troponin T with each other marker according to time of chest pain onset. The AUC, sensitivity, specificity, and negative (NPV) and positive predictive value (PPV) are given with corresponding 95% confidence interval (CI). Chest pain onset was 3 h in 517 patients, 6 h in 806 patients, 12 h in 1,017 patients, and 12 h in 369 patients. *Concentrations greater than cutoff. Cutoffs: troponin T 0.03 ng/ml; myoglobin 107 ng/ml; copeptin (95th percentile) 9.8 pmol/l; copeptin (97.5th percentile) 13 pmol/l; copeptin (99th percentile) 18.9 pmol/l. Cop copeptin; Myo myoglobin; TnT troponin T; other abbreviations as in Table 1. JACC Vol. 55, No. 19, 2010 Keller et al. May 11, 2010: Copeptin in Diagnosis of Myocardial Infarction 2103

9 2104 Keller et al. JACC Vol. 55, No. 19, 2010 Copeptin in Diagnosis of Myocardial Infarction May 11, 2010: Figure 3 Diagnostic Power of Copeptin, Troponin, and Classical Necrosis Markers Receiver operating characteristic curves and corresponding area under the curve for troponin T (TnT), copeptin (Cop), myoglobin (Myo), creatine kinase-myocardial band (CK-MB), and their combination for serial samples at admission and after 3 and 6 h for the overall study population. Cardiac TnT, the basis of the diagnostic work-up, had a low sensitivity of 43% in detecting AMI in patients presenting within 3 h. In this important group, copeptin had a sensitivity of 75.2%, being more sensitive than TnT as well as myoglobin (62.3%). The overall diagnostic performance of a single copeptin measurement reflected by ROC analysis could only challenge TnT within the first 6 h, due to lower specificity. Therefore, copeptin is not able to replace troponin in final rule-in of AMI but allows earlier decisionmaking in clinical practice. Combination of cardiac troponin with markers of different origin or variant release kinetics should, in theory, add diagnostic information. Indeed, we showed that combining TnT and copeptin, which reflects a physiologic hemodynamic stress response to myocardial ischemia, significantly improved the ROC performance within 3 h after CPO. Myoglobin as a marker of myocardial necrosis added less to TnT compared with copeptin. The approach of adding copeptin to TnT provided stable diagnostic performance albeit time of presentation after CPO, which reflects both the early peak of copeptin with the following decrease and the slow increase of TnT levels over time. The observed high sensitivity in the first hours after CPO makes copeptin an ideal candidate to complement troponin with its high specificity to accurately rule out AMI at admission. Our study supports this assumption, with an NPV of copeptin using the 95th percentile as cutoff combined with TnT using the 10% CV as cutoff of nearly 96% in the overall population and of already 92.4% in patients presenting within 3 h after CPO. Regarding myoglobin, an established early marker of myocyte necrosis, our results are in line with previous studies (25). In the overall picture, we could show a clear superiority of copeptin over myoglobin in our setting. Disease entities of nonischemic etiology like myocarditis also might lead to elevated troponin levels and, therefore, Sensitivity, More ChestSensitive Pain Onset Specificity, Sensitivity, TnI and PPVs, Copeptin Specificity, andinnpvs PPVs, Patients forand NCCP Presenting NPVs Versus for NCCP Within AMI and Versus 3 hacs After AMI for and a ACS for a Table 5 More Sensitive TnI and Copeptin in Patients Presenting Within 3 h After Chest Pain Onset Sensitive TnI or Copeptin* Sensitive TnI or Copeptin* Sensitive TnI or Copeptin* Sensitive TnI* AMI Sensitivity 86.7 ( ) 98.3 ( ) 96.7 ( ) 96.7 ( ) Specificity 92.4 ( ) 63.2 ( ) 69.3 ( ) 76.9 ( ) PPV 80.6 ( ) 49.4 ( ) 53.5 ( ) 60.4 ( ) NPV 95.0 ( ) 99.0 ( ) 98.3 ( ) 98.4 ( ) ACS Sensitivity 62.5 ( ) 79.3 ( ) 77.2 ( ) 73.4 ( ) Specificity 92.4 ( ) 63.2 ( ) 69.3 ( ) 76.9 ( ) PPV 82.1 ( ) 54.7 ( ) 58.4 ( ) 64 ( ) NPV 81.6 ( ) 84.6 ( ) 84.4 ( ) 83.8 ( ) Sensitivity, specificity, NPV, and PPV are given with corresponding 95% confidence interval. A total of 517 patients with chest pain onset 3hwere included. *Concentrations greater than cutoff. Cutoffs: troponin I (TnI) 0.04 ng/ml; copeptin (95th percentile) 9.8 pmol/l; copeptin (97.5th percentile) 13 pmol/l; copeptin (99th percentile) 18.9 pmol/l. Abbreviations as in Tables 1 and 4.

10 JACC Vol. 55, No. 19, 2010 May 11, 2010: Keller et al. Copeptin in Diagnosis of Myocardial Infarction 2105 result in lower specificity and PPV of troponin in evaluation of chest pain patients. Serial troponin determination can possibly exclude chronic diseases like renal impairment accompanied by troponin elevation (26). To distinguish other entities with acute onset and troponin rise like aortic dissection (27), early biomarkers of different origin than troponin like copeptin are amendatory, particularly in a real world population of patients with new-onset chest pain. Such biomarkers could also be helpful, due to the slow decrease of troponin, in detection of re-infarction with prolonged troponin elevation caused by initial necrosis. In summary, we can state 3 major findings. First, determination of copeptin as a single marker has diagnostic value comparable to that of myoglobin, being superior to a conventional TnT within the first 3 h after CPO. Neither single copeptin nor myoglobin determination is able, with regard to the overall population independent of CPO and need for high specificity, to displace or challenge a serial troponin T measurement to detect myocardial necrosis within a rule-in approach. Second, combination of copeptin and TnT improves diagnostic performance for detection of AMI compared with single TnT measurement on admission, being clearly superior in patients presenting within 3 h after CPO. In contrast, combination of myoglobin and TnT adds less diagnostic information. Third, combination of copeptin and conventional troponin T aids in early rule-out of AMI virtually independent of CPO with high NPV in patients presenting as early as 0 to 3 h after CPO. The current universal definition of MI (1) asks for use of the 99th percentile as the troponin cutoff with CV of 10% at this concentration. This demand stimulated development of new troponin assays with high sensitivity in identification of AMI within the first hours after CPO where established troponins have shortcomings (2). Recently, we demonstrated that a more sensitive troponin I representative for this new troponin generation (28) provides a sensitivity of 84% in identification of AMI in patients presenting within 3 h after onset of chest pain (29). The present analysis shows comparable sensitivity of 85.1% for the combination of copeptin and conventional TnT in patients presenting as early as 3 h after CPO, compensating for the weakness of established troponins in the early phase. Combination of copeptin and more sensitive TnI could further improve sensitivity to 98.3% in patients presenting within 3 h, providing an excellent NPV of 99% with the downside of reduced specificity and PPV. Therefore, combination of copeptin and troponin is useful in rapid evaluation of chest pain patients in many settings. Furthermore, in a point-of-care environment with inherent lower test sensitivity of troponin, copeptin could facilitate fast diagnosis and treatment initiation. Study limitations. Using conventional cardiac troponin as a diagnostic criterion might favor the tested troponin compared with copeptin and myoglobin. The percentage of patients with AMI was rather high in this all-comers study. This distribution is in line with other European studies but might limit the use in populations with lower risk. Conclusions In triage of patients with suspected ACS, combined assessment of conventional troponin and copeptin improves diagnostic performance, specifically in the first hours after CPO, and thus might accelerate therapeutic decisionmaking. The addition of the classical early marker myoglobin to conventional troponin had, compared with copeptin, a less ameliorative effect. Combined determination of troponin and copeptin on admission in patients early after onset of chest pain provides a high NPV. This combination might aid in early and safe rule-out of AMI and makes copeptin an ideal candidate to complement troponin in point-of-care testing. Reprint requests and correspondence: Dr. Stefan Blankenberg, Department of Medicine II, Johannes Gutenberg- University, Langenbeckstrasse 1, Mainz, Germany. stefan.blankenberg@unimedizin-mainz.de. REFERENCES 1. Thygesen K, Alpert JS, White HD, et al. Universal definition of myocardial infarction. Circulation 2007;116: Apple FS, Smith SW, Pearce LA, Ler R, Murakami MM. Use of the Centaur TnI-Ultra assay for detection of myocardial infarction and adverse events in patients presenting with symptoms suggestive of acute coronary syndrome. Clin Chem 2008;54: Melanson SE, Morrow DA, Jarolim P. Earlier detection of myocardial injury in a preliminary evaluation using a new troponin I assay with improved sensitivity. Am J Clin Pathol 2007;128: Eggers KM, Oldgren J, Nordenskjold A, Lindahl B. Diagnostic value of serial measurement of cardiac markers in patients with chest pain: limited value of adding myoglobin to troponin I for exclusion of myocardial infarction. Am Heart J 2004;148: Robertson GL. Antidiuretic hormone. Normal and disordered function. Endocrinol Metab Clin North Am 2001;30:671 94, vii. 6. Robertson GL, Athar S. The interaction of blood osmolality and blood volume in regulating plasma vasopressin in man. J Clin Endocrinol Metab 1976;42: Katan M, Morgenthaler N, Widmer I, et al. Copeptin, a stable peptide derived from the vasopressin precursor, correlates with the individual stress level. Neuro Endocrinol Lett 2008;29: Goldsmith SR. Vasopressin as vasopressor. Am J Med 1987;82: Fukuzawa J, Haneda T, Kikuchi K. Arginine vasopressin increases the rate of protein synthesis in isolated perfused adult rat heart via the V1 receptor. Mol Cell Biochem 1999;195: Goldsmith SR, Gheorghiade M. Vasopressin antagonism in heart failure. J Am Coll Cardiol 2005;46: Kelly D, Squire IB, Khan SQ, et al. C-terminal provasopressin (copeptin) is associated with left ventricular dysfunction, remodeling, and clinical heart failure in survivors of myocardial infarction. J Card Fail 2008;14: Lindner KH, Strohmenger HU, Ensinger H, Hetzel WD, Ahnefeld FW, Georgieff M. Stress hormone response during and after cardiopulmonary resuscitation. Anesthesiology 1992;77: Krismer AC, Wenzel V, Stadlbauer KH, et al. Vasopressin during cardiopulmonary resuscitation: a progress report. Crit Care Med 2004;32:S Mutlu GM, Factor P. Role of vasopressin in the management of septic shock. Intensive Care Med 2004;30:

11 2106 Keller et al. JACC Vol. 55, No. 19, 2010 Copeptin in Diagnosis of Myocardial Infarction May 11, 2010: Kluge M, Riedl S, Erhart-Hofmann B, Hartmann J, Waldhauser F. Improved extraction procedure and RIA for determination of arginine8-vasopressin in plasma: role of premeasurement sample treatment and reference values in children. Clin Chem 1999;45: Preibisz JJ, Sealey JE, Laragh JH, Cody RJ, Weksler BB. Plasma and platelet vasopressin in essential hypertension and congestive heart failure. Hypertension 1983;5:I Morgenthaler NG, Struck J, Alonso C, Bergmann A. Assay for the measurement of copeptin, a stable peptide derived from the precursor of vasopressin. Clin Chem 2006;52: Khan SQ, Dhillon OS, O Brien RJ, et al. C-terminal provasopressin (copeptin) as a novel and prognostic marker in acute myocardial infarction: Leicester Acute Myocardial Infarction Peptide (LAMP) study. Circulation 2007;115: Reichlin T, Hochholzer W, Stelzig C, et al. Incremental value of copeptin for rapid rule out of acute myocardial infarction. J Am Coll Cardiol 2009;54: Staub D, Morgenthaler NG, Buser C, et al. Use of copeptin in the detection of myocardial ischemia. Clin Chim Acta 2009;399: Levey AS, Coresh J, Greene T, et al. Expressing the Modification of Diet in Renal Disease Study equation for estimating glomerular filtration rate with standardized serum creatinine values. Clin Chem 2007;53: Hollander M, Wolfe DA. Nonparametric Statistical Methods. 2nd edition. New York, NY: John Wiley & Sons, Inc., DeLong ER, DeLong DM, Clarke-Pearson DL. Comparing the areas under two or more correlated receiver operating characteristic curves: a nonparametric approach. Biometrics 1988:44: Bjork J, Forberg JL, Ohlsson M, Edenbrandt L, Ohlin H, Ekelund U. A simple statistical model for prediction of acute coronary syndrome in chest pain patients in the emergency department. BMC Med Inform Decis Mak 2006;6: Stork TV, Wu AH, Muller-Bardorff M, et al., North-Wurttemberg Infarction Study (NOWIS) Group. Diagnostic and prognostic role of myoglobin in patients with suspected acute coronary syndrome. Am J Cardiol 2000;86: Wu AH, Jaffe AS. The clinical need for high-sensitivity cardiac troponin assays for acute coronary syndromes and the role for serial testing. Am Heart J 2008;155: Bonnefoy E, Godon P, Kirkorian G, Chabaud S, Touboul P. Significance of serum troponin I elevation in patients with acute aortic dissection of the ascending aorta. Acta Cardiol 2005;60: Reichlin T, Hochholzer W, Bassetti S, et al. Early diagnosis of myocardial infarction with sensitive cardiac troponin assays. N Engl J Med 2009;361: Keller T, Zeller T, Peetz D, et al. Sensitive troponin I assay in early diagnosis of acute myocardial infarction. N Engl J Med 2009;361: Key Words: chest pain y copeptin y diagnosis y myocardial infarction y troponin. APPENDIX For a supplementary table on the characteristics of 5,000 individuals of the Gutenberg Heart Study, please see the online version of this article.