It Was the Best of Times, It was The Worst of Times Cardiovascular Disease and Troponins

Transcription

1 It Was the Best of Times, It was The Worst of Times Cariovascular Disease an Troponins Copyright 2018 by.

2 Abstract There have been significant changes in the iagnosis an efinition of acute myocarial infarction over the years. From its first escription an efinition over 150 years ago to the high sensitivity cariac troponin assays of toay, we have come a long way in the iagnosis, management, an treatment of those with cariovascular isease. With the recent Foo an Drug Aministration s (FDA) clearance of the fifth generation high-sensitivity cariac troponin assays, a new history in iagnosing, treatment an managing those with heart isease is just beginning. The three articles associate with this focus series escribe avances in iagnosis an efinition of acute myocarial infarction (AMI) with the first article presenting an in-epth escription into the structure an function of troponin in health an isease, a secon article presenting a escription of AMI an how its iagnosis an efinition has change over the years culminating with a escription of the high sensitive troponin assays, an a thir article that presents clinical implications of the new high sensitivity troponin assays. Inex Terms Troponin, Acute Coronary Synrome, Myocarial Infarction, High-Sensitivity Troponins, Cariovascular Disease Abbreviations ACC/AHA - American College of Cariology/American Heart Association, AMI-Acute Myocarial Infarction, CVD-Cariovascular Disease, FDA-Foo an Drug Aministration, hsctn-high-sensitivity Cariac Troponins Downloae from on March

3 From the first escription of cariovascular isease (CVD) over 150 years ago, to the historic Framingham Heart Stuy of the 1950 s, to the high-sensitivity cariac troponins (hs-ctn) of toay, there is no oubt we have come a long way in the iagnosis, management, an treatment of those with CVD. Similar to the way Charles Dickens paire contrasting concepts to reflect the mirror images of goo an evil that recur in characters an situations throughout the novel A Tale of Two Cities, the iscovery an FDA clearance of the fifth generation hs-ctn assays presents a sweeping backrop of forces an events that will forever shape the way we iagnose, treat, an manage those with myocarial amage. It was the best of times in that never before have we been presente with such rapi avances in imaging stuies, meications, interventions, an laboratory testing that have enhance our ability to quickly an more accurately ientify, treat an manage those with CVD. It was the worst of times in that espite these avances heart isease remains as the number one cause of eath globally, accounting for more eaths annually than from any other cause. 1-2 One in every six health care ollars is spent on cariovascular isease an if things remain as they are toay, costs associate with heart isease are projecte to triple in 20 years from $555 billion in 2016 to a whopping $1.1 trillion in It was the season of light in January of 2017 when the Foo an Drug Aministration (FDA) announce the clearance of a fifth generation hs-ctn assay for use in the U.S. 4 With sex-specific 99 th percentile cutoffs, rule-out capability, new reporting units, an the potential to provie risk assessment in asymptomatic patients, this new assay is proving to be significantly ifferent from its fourth generation counterpart. While this new assay carries significant avantages over the fourth generation assays, it is also the season of arkness as there is much more potential for this assay to be clinically misunerstoo an results misinterprete, leaing to an increase in testing, inappropriate therapies, an increase resource utilization not ue to CVD. From the

4 Framingham Heart Stuy to the new ACC/AHA guielines to the expane efinition of acute myocarial infarction to the evelopment of acute coronary synrome algorithms, we have everything before us. With the avancement in troponin testing with its increase sensitivity an lack of specificity for acute myocarial infarction, we have nothing before us. This FOCUS series represents our effort to she some light on cariovascular isease from history to hs-ctn. We ecie to approach this topic in a more comprehensive fashion. The first article, Troponin Structure an Function in Health an Disease, provies the reaer with just that, an in-epth review of the troponin molecule from iscovery to its basic biology to its structure an function in health an isease. This article literally takes a back to the basics approach to a escription of the troponin molecule. The secon article, Acute Myocarial Infarction: Definition, Diagnosis, an the Evolution of Cariac Markers, takes you on a historical rie through the years as the iagnosis an efinition of AMI has change resulting in upates to the guielines for the management of those with AMI. The thir article, Clinical Consierations of High Sensitivity Troponins, takes you to the present ay escribing the impact of hs-ctn on the iagnosis, management, an treatment of those with CVD. Another aspect worthy of mentioning is the makeup of the authors inclue in eveloping this FOCUS series. Because this topic is so comprehensive, we felt it woul be best evelope from a comprehensive an multiisciplinary basis. As a result, we have engage authors across various isciplines to contribute their content expertise to the evelopment of these articles. This multiisciplinary team of authors was put together using faculty from various isciplines incluing clinical laboratory science, nuclear meicine technology, physician assistant stuies, an biomeical sciences.

5 Just as with A Tale of Two Cities where the ifferences between Lonon an Paris become more pronounce, I believe that the totality of ifferences between the fourth an fifth generation troponin assays an the impact on CVD is yet to be seen. A Tale of Two Cities was a novel publishe in weekly installments an, so too, I believe that the hs-ctn novel an its full impact on CVD is currently being evelope an will be release in regular installments over the next few years. We hope that you enjoy this FOCUS series. 1. Cause of Death on CDC WONDER Online Database [Internet]. Centers for Disease Control an Prevention, National Center for Health Statistics, Atlanta (GA): [cite 2018 june 28]. Available from: 2. Mozaffarian D, Benjamin EJ, Go AS, Arnett DK, Blaha MJ, Cushman M, et al. Heart isease an stroke statistics 2015 upate: a report from the American Heart Association. Circulation. 2015;131(4):e29-e Heienreich, PA, Trogon. JG, Khavjou, OA, Butler,J, Dracup, K, Ezekowitz, MD, et al. Forecasting the future of cariovascular isease in the Unite States: a policy statement from the american heart association. Circulation. 2011;123(8): Phen, C. Next-Generation Troponin test cleare by FDA. Mepage Toay [Internet] Jan [cite 2018 Aug 6]: [about 1 p.]. Available from