Case Studies Using hsctn Assays. A Joint AACC ACC symposium Fred Apple Ph.D. Chris DeFlippi M.D. Allan S. Jaffe, M.D.
|
|
- Gillian Lynch
- 5 years ago
- Views:
Transcription
1 Case Studies Using hsctn Assays A Joint AACC ACC symposium Fred Apple Ph.D. Chris DeFlippi M.D. Allan S. Jaffe, M.D.
2 Case Study: Defining Gender Specific 99 th Percentiles for High Sensitivity Cardiac Troponin Assays: No Longer Analytically Challenging Fred Apple PhD Hennepin County Medical Center University of Minnesota School of Medicine Minneapolis, MN USA 2014 AACC Symposia Chicago July 31
3 hs-ctn Padua Italy
4 Biomarker (ctn) Guideline Efforts: ACS National Academy Clinical Biochemistry (Clin Chem 1999; Circ, Clin Chem 2007) Clinical, analytical, point of care International Federation Clinical Chemistry (CCLM 2001; Circ, Clin Chem 2007) Analytical - quality specifications Future biomarkers (Clin Chem 2005) Epidemiology Case Definition (Circ 2003) AHA collaboration Soc Chest Pain Centers (2005) Clinical: unstable angina/nstemi ACC/AHA 2007 Guidelines Management UA/NSTEMI (JACC 2002; Circ 2007) Clinical European Society of Cardiology on Acute Cardiac Care (Eur Heart J 2010) Analytical and clinical WHO Definition of MI: revision (Int J Epidemiol 2010) Joint ESC/ACC/AHA/WHF Task Force (JACC, EHJ 2000; Circ, JACC, EHJ 2007;2012) Clinical and analytical Third Universal Definition of Myocardial Infarction (Circ, JACC, EHJ Sept 2012) Clinical and analytical URL defined by 99 th percentile ACCF 2012 Expert Consensus Document Practical Clinical Considerations Interpretation Troponin Elevations (JACC 012)
5 Definition of Myocardial Infarction MI defined myocardial cell death due to prolonged ischemia Myocardial injury detected with increased (above 99 th percentile) blood ctn but does not indicate underlying mechanism 3 rd Universal Definition 2012
6 Case 56 year old female presents with clinical symptoms suggestive of ischemic chest pain Essentially normal EKG Contemporary ctni assay used in ER lab 99 th percentile (EDTA plasma): µg/l (30 ng/l) Patient 0h ctni result = 38 ng/l As presenting ctn above 99th percentile coupled with symptoms suggestive of ischemia, concern for an acute MI in ED for which Clopidogrel load given Patient transferred to RTU (Rapid Transit Unit) for assessment for possible ACS Apple 2014 Unpublished
7 Cardiac Troponin Order Set ctni, 99 th ng/l 0h 3h 6h 9h Contemporary Assay, Following the 3 rd Universal Definition of MI, this case was adjudicated as an acute MI Predicated on increased ctni above the 99 th percentile with a falling value over time with an suggestive presentation of ischemia Apple 2014 Unpublished
8 Cardiac Troponin Order Set Following Serial ctni Values ctni, 99 th ng/l 0h 3h 6h 9h Contemporary: High Sensitivity All normals: Using a hs-ctni assay based on an overall 99 th percentile, all serial ctn values were normal Independent adjudication rules out MI Apple 2014 Unpublished
9 Cardiac Troponin Order Set Following Serial ctni Values ctni, 99 th ng/l 0h 3h 6h 9h Contemporary: High Sensitivity All: 23 Male: 36 Female: Using an hs-ctni assay based on gender defined 99 th percentiles, all serial ctn values were increased However, no serial rising or falling pattern was observed Independent adjudication rules out MI, BUT determined to be non-acs myocardial injury Apple 2014 Unpublished
10 Common Questions/Concerns Emergency Medicine Need 30 min TAT 100% from time of blood draw POC testing Would like to rule out with 1 blood sample result Cardiology Do some cardiac troponin assays just measure MI? How to code a type 2 MI for reimbursement Would like use assay to avoid non-mi increases of ctn Worried that hs-ctn assays will force more consults/admissions Laboratory Don t understand that different assays by same manufacturer have different 99 th percentiles with different clinical sens & spec Assay in the lab does not have a 10%CV at the 99 th percentile, so we use the higher ROC curve / 10% CV cutoff concentration Should I use gender specific 99 th percentile when high sensitivity assays are cleared by FDA for clinical use
11 ACS Triage Process at HCMC Role of Cardiac Troponin Presentation To ED with Symptoms Suggestive of ACS Blood 0 h ED Lab ctni 45 min TAT (quant) Normal Increased 48h Rapid Transit Unit Monitored Beds 3,6,9 h (central lab) 3,6,9 h (central lab) Normal Out-Pt Discharge Become positive triage to monitored units 8,000/30,000 ctn tests (26%) ED, 2000 annual admissions for R/O Overall ACS rule in 8 to 12%; type 2 (non-acs) rule in 10 to 12%
12 3 2.5 ED LOS hrs 2.17 hrs Based on ctn Assay TAT Decreased ER LOS 40 Min Optimal TAT Storrow AB. Acad Emer Med. 2008;15 Storrow Acad Emer Med. 2008
13 Know Your Assay and Its Limitations 26/200 patients (13%) were negative by POC i-stat vs positive by central lab Architect ctni at ER Presentation Singh Clin Chim Acta 2009
14 POC ctni Assay Serial Kinetics & Diagnostics Clinical Diagnostics Based on 99 th Percentile Subject Prevalen ce of AMI Prevalence in of AMI in population populatio 19/169 = 11.2% n 19/169 = 11.2% Sens istat PATHFAST AQT90 Vitros 0h 32% 53% 26% 68% 3h 68% 89% 63% 95% 6h 68% 95% 63% 100% Palamalai Clin Biochem 2013
15 High Sensitivity Cardiac Troponin Assays Analytical Discussion Points Unlikely that ctni assays will ever be standardized There is no INR or harmonization factor for ctni assays Need uniform criteria for selecting reference group to determine 99 th percentile Role of surrogate biomarkers and imaging for defining normality Gender-dependent 99 th percentiles Likely age dependent over 60 years Criteria to define high-sensitivity assays Need to measure >50% of normals 10%CV at 99 th percentile Need appropriate quality control at 99 th percentile Biological variability now defined Need to report cardiac troponin in whole number: ng/l units Risk stratification cutoffs may vary depending on patient populations ACS patients Primary or secondary prevention in general population
16 Central Lab aa NH 2 І Stable Region І COOH Abbott Architect C:24-40 D:41-49 C:87-91 Beckman Access D:24-40 C:41-49 biomerieux Vidas C:22-29 C:41-49 D:87-91 Ortho Vitros ECi C:24-40 C:41-49 D:87-91 Siemens Centaur Ultra D:27-40 C:41-49 C:87-91 Siemens Dimension RxL C:27-32 D:41-56 Siemens Immulite 2000 D:27-40 C:87-91 Siemens VISTA C:27-32 D:41-56 Tosoh AIA II C:41-49 D:87-91 POC Assays 1. No Primary Standard Reference Material 2. No uniform capture or detection antibodies Abbott i-stat D:28-39 C:41-49 D:62-78 C:88-91 Alere Triage C:NA D:27-40 Alere Triage Cardio3* C:27-39 D:83-93 C: Mitsubishi Pathfast C:41-49 D: D: Radiometer AQT90* C:41-49 D: C: Response RAMP D:26-38 C: C: Siemens Stratus-CS Trinity Meritas C:24-40, C:27-32 C:41-49 D:41-56 C:88-90 D: D: High Sensitivity Abbott Architect C: D:41-49 Beckman Access D: C:41-49 Nanosphere MTP D:49-52 D:70-73 D:88 C: D:169 Singulex Errena D: C:41-49 Apple 2014
17 Contemporary Cardiac Troponin Assays Company/platform/assay LoD ng/l 99 th (%CV) 10%CV Risk Claim Epitopes recognized by antibodies Abbott AxSYM ADV (14%) 160 Yes C 87-91, 41-49; D Abbott Architect 9 28 (14%) 32 No C 87-91, 24-40: D: Beckman Access/DXi Accu (14%) 60 Yes C; 41-49; D: biomerieux Vidas Ultra (27.7%) 110 No C: 41-49, 22-29; D: 87-91,Mab 7B9 Ortho Vitros ECi ES (10%) 34 Yes C 24-40, 41-49; D Roche Elecsys ctnt gen 4 10 <10 30 Yes C: ; D: Elecsys ctni (10%) No C: 87-91, ; D: 23-29, Siemens Centaur Ultra 6 40 (8.8%) 30 Yes C; 41-49, 87-91; D: Siemens Dimension RxL (20%) 140 Yes C: 27-32; D: Siemens Immulite (NA) 420 No C: 87-91:D: Siemens VISTA (10%) 40 Yes C: 27-32; D: Tosoh AIA II 60 <60 (NA) 90 No C: 41-49; D: Imprecision in package insert very often NOT reproducible in real world clinical practice Apple Clin Chem 2012
18 High-Sensitivity (hs) Cardiac Troponin Assays Company/platform LoD ng/l 99 th percentile ng/l (%CV) 10%CV ng/l Epitopes recognized by antibodies hs- ctni Abbott Architect* (5.6%) 3 C 24-40: D: Beckman Access (10%) 8.6 C; 41-49; D: Nanosphere MTP (9.5%) 0.5 C: ; D: Ab PA1010 Singulex Errena MTP (9.0%) 0.88 C: ; D: Siemens VISTA (5.0%) 3 C: 30-35; D: 41-56, hs-ctnt* Roche* E170/E (13%) 13 C: ; D: *Commercially available for use worldwide but not FDA cleared for use in US Apple Clin Chem 2012
19 Myocardial Infarction Do NOT use different assays within same medical center as ctn profiles will vary between assays even for hs-assays 2 hs-ctn assays 40-50% Difference Apple 2013
20
21 What Defines a Normal Subject? Need To Convene Expert Opinion Group Age; < 30y or 18 to 90y Ethnicity Caucasian, African and Native American, Hispanic, Asian Gender male/female (high sensitivity assay) Sample type Serum, plasma, whole blood Ideally, but not practical, negative exercise stress test and normal cardiac function by imaging Sample size = 300 min to account for 95% confidence interval Statistical analysis: 1-tailed nonparametric Consider surrogate biomarkers for disease Diabetes Hb A1C Renal egfr Myocardial dysfunction NT-proBNP Hypertension BP Health questionnaire for medications CLSI C28-A2
22 Male Caucasian 60 y.o. Normal?? ctni Vitros ES OCD hs-ctni Architect Abbott hs-ctnt Elecsys 2010 Roche ctni POC i-stat Abbott ctni AQT90 POC Radiometer 13 ng/l 5 ng/l 3 ng/l < 6ng/L < 9 ng/l Substantial Difference Between Assays. Apple 2013
23 Influence of Imprecision on 99 th Percentile: Assay Dependent Validation Is there an impact on adjudication for MI diagnosis? th Percentile: TnI = at 20% CV 99th Percentile: TnI = at 10%CV 0.07 Frequency TnI Apple et al Clin Chem 2006
24 Common Presumably Healthy Population 252 females, 273 males Apple Clin Chem 2012
25 Common Presumably Healthy Population Percent Detected ctni 98% ctnt 28% LoD ng/l Apple Clin Chem 2012
26 High Sensitivity Cardiac Troponin 99 th Percentiles By Gender 99% ctni values measureable above LoD Mills Unpublished 2013
27 Clin Chem 2010
28 Gore JACC 2014 ctnt
29 Evidence of Race/Ethnicity Differences Gore JACC 2014 ctnt
30 Age Related ctn Non-Cardiac Pathology Admissions 99 th percentile 14 ng/l Not clear why Roche does not endorse gender 99 th percentiles Bima, Clin Biochem 2012
31 Cardiac Troponin Assay Score Card Defining High Sensitivity Acceptance Designation Guideline Acceptable Total Precision at 99 th Percentile < 10% Clinically Usable >10 to < 20% Not Acceptable > 20% Assay Designation Level 4 3rd gen hs Level 3 2nd gen hs Measurable Normal Values below 99 th percentile > 95% 75 to < 95% Level 2 1st gen hs > 50% to < 75% Level 1 Contemporary < 50% Scorecard Apple Clin Chem 2009; IFCC Task Force 2012; web posted 2014
32 Apple CLN 2014
33 Biological Variation for High Sensitivity Cardiac Troponin Assays Analytical Variation Abbott Beckman Siemens Singulex Roche E170 and E2010 CV-A, % , 9.7 Biological Variation CV-I, % , 21.4 CV-G, % , 23.5 Index Individuality , 0.42 RCV increase % , +90 RCV decrease % , -47 Within Subject Mean ctn, pg/ml , 3.2 For contemporary (sensitive) assays in clinical practice today, biological variation cannot even be determined because assays are not able to reliably measure concentrations in normal subjects Apple Clin Chem 2012
34 Presenting (ER) with Normal ctn Concentration with High-Sensitivity ctn Assay and MI Normal hs-ctn levels at presentation should not be used as a single parameter to rule out AMI 2072 consecutive patients with hs-ctnt assay measurements, 21.4% had an adjudicated diagnosis of AMI 6%-23% of adjudicated AMI cases had normal levels of ctn (4 different hs-assays) at presentation Adjudicated by contemporary local assays Data highlight the lack of standardization among hs-ctni assays resulting in substantial differences in sensitivity and NPV at the 99th percentile If assays are going to be compared, absolutely necessary to determine 99 th percentiles from same reference population Hoeller, Mueller Heart 2013
35 Improved Diagnostic Accuracy For AMI With High Sensitivity ctni Assay Retrospective analysis 310 patients admitted through ER symptoms suggestive of ACS Adjudication independently predicated Contemporary ctni assay: 99 th 30 ng/l High-sensitivity ctni assay 99 th percentiles overall 26 ng/l male 34 ng/l female 16 ng/ml 24% fewer MIs adjudicated Apple Unpublished AACC 2014 Poster
36 Improved Diagnostic Accuracy For AMI With High Sensitivity ctni Assay 99 th Percentile Assay MI Number (%) hs Overall 33 (10.7).734 ROC AUC hs Gender 32 (10.3) Female.763 Male.705 Contemporary 43 (13.8).691 Apple Unpublished AACC 2014 Poster
37 ctni Utilization in CARE Monitored Unit Retrospectively reviewed EHR from 100 consecutive patients Moderate to high risk of ACS Adjudicated diagnosis of MI Universal Definition ctni order set: 0, 3, 6, 9h (OCD ctni) Clinicians not limited to number orders sets Excessive order sets /orders for ctni defined as beyond those necessary to rule in /rule out MI Apple Poster AACC 2014
38 ctni Utilization in CARE Monitored Unit MI Group 222 ctni values measured 107 (48%) determined to be excessive Measured after the diagnosis was made 52 additional order sets after initial order set 0,3,6,9h Average of 7.16 ctni values per MI patient 23% of all ctni measured were from 2 nd and 3 rd order set (not justified) Apple Poster AACC 2014
39 ctni Utilization in CARE Monitored Unit Non-MI Group 378 ctni values measured 150 (40%) determined to be excessive Measured after the diagnosis was excluded 63 additional order sets after initial order set 0,3,6,9h Average of 6.0 ctni values per no-mi patient 18% of all ctni measured were from 2 nd and 3 rd order sets (not justified) Apple Poster AACC 2014
40 ARCHITECT Quality Control Imprecision Data ARCHITECT Control Mean, ng/l %CV N CL1 i2000 *BioRad Low Dil (1/14) # CL2 (10x) (523) ED i (5/22) CL1 BioRad Low Dil CL2 (10x) ED * Initiated tightened control range # QC failure rate that required recal, etc hs-ctni Lot 10925JH00 Abbott JH JN Need QC at 99 th percentile values HCMC 2013 June/July: Mills Scotland 2013
41 Education, Education, Education Provide Peer-Reviewed Literature Quality of analytics critical in defining high sensitivity assays Imprecision and ability to measure normal subjects Normality needs to be defined by gender Age and ethnicity/race in future likely TAT/thruput important to meet clinical needs hs assays not available in POC Collaborative interdisciplinary efforts regarding ordering processes
42
43 Type 1 and Type 2 AMI Allan S. Jaffe, MD.* Consultant - Cardiology & Laboratory Medicine Professor of Medicine and Professor of Laboratory Medicine and Pathology Mayo Clinic and Medical School Rochester, Minnesota *Dr. Jaffe is or has been a consultant for most of the major diagnostic companies. He also presently is a consultant for Amgen.
44 Case 1
45 Clinical Presentation 43 year old woman who presented right after a 30 minute episode right sided heavy chest discomfort that made it hard to breath and dizziness. Family history in her father who had CABG at the age of 70. Mild obesity (BMI =31). Has had some lose stools of late
46 Physical Examination BP = 95/60 Pulse = 129 Examination of heart, lungs and vascular system= normal
47 Admission ECG
48 Admission Laboratory Results Hb/HCT 7.0/26.3 Glucose = 92 mg/dl hsctnt (Roche) = 5 ng/l 99 th % for women = 10 ng/l and for men 15 ng/l per Apple (Clin Chem 2012) Standard ctnt assay used locally undetectable (< 0.01 ng/ml) CKMB = 1.8 ng/ml
49 3 hour Laboratory Results hsctnt (Roche) = 10 ng/l 99 th % for women = 10 ng/l and for men 15 ng/l per Apple (Clin Chem 2012) Standard ctnt assay used locally undetectable (< 0.01 ng/ml) CKMB = 2.0 ng/ml
50 6 Hour Laboratory Results hsctnt (Roche) = 16 ng/l 99 th % for women = 10 ng/l and for men 15 ng/l per Apple (Clin Chem 2012) Standard ctnt assay used locally undetectable (< 0.01 ng/ml) CKMB = 1.5 ng/ml
51
52 Differentiation between MI Types according to the Condition of the Coronary Arteries Plaque rupture with clot MI Type 1 Vasospasm or endothelial dysfunction MI Type 2 Fixed Atherosclerosis and Supply-demand imbalance MI Type 2 Supply-demand imbalance alone MI Type 2
53 Patient Flow in Odense Study 220 missed ctni 4 hemolysis 216 only CKMB available 7,230 with first ctni sample 4,719 eligible for inclusion 4,499 included 2,511 excluded 2,277 residents outside local catchment area 43 age <18 years 191 ctni taken at GP or outpatient clinic 1,961 ctni >0.03 µg/l 2,538 ctni 0.03 µg/l 533 MI 1,408 myocardial necrosis without MI 44 unstable AP 397 Type 1 MI 144 Type 2 MI 2 Type 4a MI 7 Type 4b MI 221 cardiac; related to secondary ischemia 188 cardiac; not related to ischemia 425 extracardiac conditions 415 multifactorial conditions 491 prior IHD 2,003 no prior IHD 3 Type 5 MI 159 indeterminate origin Sabby et al: AJM 126(9):789, 2013
54 Cardiac procedure Non-cardiac major procedure MIM Tachy-/bradyarrhythmia Heart failure Myocardial Infarction Myocardial Injury Renal failure Myocardial injury with cell death marked by cardiac troponin elevation Clinical evidence of acute myocardial ischemia with rise and/or fall of cardiac troponin
55 Baseline Characteristics of With Type 1 and Type 2 Myocardial Infarction Characteristics Type 1 MI (n=397) Type 2 MI (n=144) P Laboratory data, median/total no., (IQR) First troponin I, µg/l 0.27 ( ) 0.20 ( ) 0.22 Peak troponin I value, µg/l 2.96 ( ) 1.09 ( ) <0.001 Hemoglobin, mmol/l 8.2/391 ( ) 7.7/138 ( ) <0.001 Leukocytes, 10E9/L 10.1/391 ( ) 11.6/142 ( ) <0.001 Creatinine (enzymatic)-p, µmol/ 84/394 (70-103) 102/143 (76-141) <0.001 C-reactive protein, mg/l 5/391 (2-18) 21/134 (4-63) <0.001 Clinical findings, median/total no., (IQR) Systolic blood pressure, mm Hg 146/395 ( ) 139/140 ( ) 0.01 Diastolic blood pressure, mm Hg 86/395 (73-101) 77/140 (62-96) <0.001 Heart rate, beats/min 80/393 (68-100) 113/142 (90-131) <0.001 Ejection fraction, median/total no., (IQR) 50/340 (40-55) 40/107 (30-55) <0.001 ST-elevation MI, no., (%) 130 (32.7) 5 (3.4) <0.001 Non-ST-elevation MI, no., (%) 267 (67.3) 139 (96.6) <0.001 Coronary angiography, no., (%) 281 (70.8) 31 (21.5) <0.001 Sabby et al: AJM 126(9):789, 2013
56 TACTICS (TIMI 18) Subgroups Cardiac troponin T Conservative Invasive No. treatment treatment Primary endpoint <0.1 ng/ml < < Favors invasive treatment Favors Conservative treatment Death or MI <0.1 ng/ml < < JAMA 286:2405, Odds ratio CP
57 Low-End Comparability.01 ng/ml.03 ng/m Difference with TnThs (%) 53 pg/ml 30 pg/ml Troponin T, Elecsys 4 th gen (pg/ml)
58 Baseline Characteristics of 397 Patients With Type 1 and Type 2 Myocardial Infarction Characteristics Type 1 MI (n=397) Type 2 MI (n=144) P Age (yr) (± SD) 71 (14) 75 (11) Male, no., (%) 249 (62.7) 76 (52.8) 0.04 Risk factors, no., (%) Diabetes 52 (13.1) 40 (27.9) <0.001 Hypercholesterolemia 158 (39.8) 60 (41.8) 0.69 Hypertension 215 (54.2) 81 (56.3) 0.67 Current smoker, no./total no., (%) 129/342 (37.7) 35/108 (32.4) 0.07 Family history, no./total no., (%) 103/305 (33.8) 14/74 (18.9) 0.01 Medical history, no., (%) Prior MI 96 (24.2) 39 (27.1) 0.49 Prior CABG 37 (9.3) 14 (9.7) 0.89 Prior PCI 57 (14.4) 25 (17.4) 0.39 Heart failure 45 (11.3) 34 (23.6) <0.001 Prior stroke 54 (13.6) 31 (21.5) 0.03 Peripheral arterial disease 21 (5.3) 18 (12.5) Renal failure 23 (5.8) 20 (13.9) Chronic obstructive pulmonary disease 46 (11.6) 36 (25.0) <0.001 Arrhythmia 50 (12.6) 34 (23.6) Sabby et al: AJM 126(9):789, 2013
59 Presence of Coronary Artery Disease by AMI Type (Odense) n=248 No significant CAD Significant CAD P<0.001 % n=14 n=17 n=33 Type 1 MI Type 2 MI Sabby et al: AJM 126(9):789, 2013
60 Extent of Coronary Artery Disease by AMI Type (Odense) P=0.008 n=12 4 P=0.38 n=12 3 n=11 Type 1 MI Type 2 MI % n=6 1 vessel disease 2-3 vessel disease Sabby et al: AJM 126(9):789, 2013 P=0.43 n=17 n=3 Left Main disease
61 Mechanisms Underlying Type 2 AMIs n=30 n=30 n=28 % n=15 n=14 n=13 n=9 n=4 n=1 n=0 n=0 Sabby et al: AJM 126(9):789, 2013
62 Survival by AMI Type Type 1 MI Survival Type 2 MI Years Sabby, AJM, 2014
63 Assocition of Triggers and Mortality Patients in Type 2 AMI Alive (n=61) Dead (n=58) Patients (no.) Sabby, AJM, 2014
64 Complications by AMI Type Type-I MI Type-II MI ** ** Patients (%) ** ** ** ** Stein et al: PLOS ONE Vol 9; Issue 1, 2014
65 Survival by AMI Type Type-I MI Survival (%) P< Type-II MI Time (days) Stein et al: PLOS ONE Vol 9; Issue 1, 2014
66 Changes in ctni (Abbott) Values in Patients with Type 1 and Typ 2 AMI Sandoval, in press, EHJ-ACA
67 Postop Survival by ctni Values Survival ctn-i 0.6 and ctn-t 0.03 ctn-i >3.1 and/or ctn-t > < ctn-i 1.5 and/or 0.03 <ctn-t 0.1 P= < ctn-i 3.1 and/ or 0.1 <ctn-t 0.2 P=0.007 P< J Am Coll Cardiol 42:1551, 2003 Years after surgery CP
68 Association of Longest Ischemia Duration with Biochemical Markers of MI Total Ischemia >15 min Ischemia >30 min Ischemia >60 min Symptoms attributable to MI No. % No. % No. % No. % No. % CK >170 IU and MB >5% CK >170 IU and MB >10% ctn-i >0.6 ng/ml and or ctn-t >0.03 ng/ml ctn-i >1.5 ng/ml and or ctn-t >0.1 ng/ml ctn-i >3.1 ng/ml and or ctn-t >0.2 ng/ml J Am Coll Cardiol 42:1549, 2003 CP
69 Comparative Incidence of Plaque Rupture Author Postop cases Cohen Dawood et al Combined Non-postop cases Constantanides Hori et al Quiao et al Burke et al Combined Point estimate with 95% CI 46% 36% 49% 50% 51% 55% 64% 83% % Cohen and Aretz: Cardiovasc Pathol 8(3):133, 1999
70 Mortality Analysis by Peak ctnt Value (VISION) Cumulative hazard Peak troponin T (ng/ml) Days after surgery No. at risk Peak troponin T (ng/ml) ,376 13,348 13,300 13,271 13,250 12,230 13,209 JAMA. 2012;307(21):
71 All-Cause Mortality Grouped by Preoperative hsctnt Quartiles All-cause mortality (%) Quartile (ng/l) 4 (>19.3) 3 ( ) 1 (<8.3) 2 ( ) Survival time (years) AHJ, 2013, (in press)
72 Probability of Death Based on ctnt Values on Admission in Patients with GI Bleeding* * Critical Care Medicine 37: ,
73 Probability of Death Based on ctnt Values on Admission in Patients with Acute Respiratory Failure* *The American Journal of Medicine, Volume 123, Issue 11, 2010,
74 Probability of Death Based on ctnt Values on Admission in Patients with Sepsis* *The American Journal of Medicine, Volume 126, Issue 12, 2013,
75 Relationship Between hsctnt and Diastolic and RV Echo Measures* Crit Care Med 42: ,
76 Hs-cTnl and hs-ctnt Concentrations Before and After Exercise Stress Testing No ischemia, no prev MI (n=146) No ischemia, but prev MI (n=33) Reversible ischemia (n=19) Troponin I (ng/l) Troponin T (ng/l) Baseline (n=112/ 30/19) Immediately after test (n=121/ 31/18) 1.5 h after test (n=154/ 32/17) 4.5 h after test (n=154/ 32/19) Baseline (n=106/ 24/15) Immediately after test (n=112/ 26/16) 1.5 h after test (n=113/ 27/17) 4.5 h after test (n=123/ 31/17) Clinical Chemistry 58:11, 2012
77 Out Patient Follow Up After Treatment Totally normal CTA without calcium or observed lesions at the patient s request.
78 Case 2
79 Clinical Presentation 51 year old woman who presents with a 2 hour episode of chest discomfort that radiated to her arms and neck, associated with mild diaphoresis. Big time exerciser without symptoms in the past. PMHx treated for hyperlipidemia, borderline hypertension, untreated.
80 Physical Examination BP = 130/70 Pulse = 60 Examination of heart, lungs and vascular system normal save a soft S 4 sound
81 Admission ECG CP
82 Admission Laboratory Results Hb/HCT 14.0/41.5 Last cholesterol measurements (5 days prior) Total cholesterol = 161 mg/dl Triglycerides = 69 mg/dl HDL = 66 mg/dl Calculated LDL = 81 mg/dl TSH = 1.2mIU/L Glucose = 121 mg/dl hsctni (Abbott) = 16 ng/l 99 th % for women = 15 ng/l and for men 36 ng/l per Apple (Clin Chem 2012) Standard ctnt assay used locally undetectable (< 0.01 ng/ml) CKMB = 2.5 ng/ml
83 Clinical Course Rx - Oxygen Aspirin 81 mg qd IV nitroglycerin Metoprolol 50 mg BID IV Heparin IV Morphine IV Integrilin Urgent angiography
84 Subsequent Laboratory Results hsctni (Abbott) at 3 hours = 24 ng/l (above the overall 99 th % URL of 23ng/L for women) per Apple (Clin Chem 2012) Standard ctnt assy used locally = 0.02 ng/ml CKMB = 2.5 ng/ml
85 Use of Gender Specific Cut Offs fortype 1 Myocardial Infarction Contemporary Assay High-Sensitivity Assay % Men Women Single Single Sex-specific Sensitivity 77 (69-83) 87 (80-92) 47 (38-56) 68 (59-77) 86 (80-91) 95 (89-98) Mills, ESC 2013
86 Outcome of Women With Suspected Acute Coronary Syndrome Survival free from death or recurrent MI (%) Troponin I concentration <16 ng/l Troponin I concentration ng/l Troponin I concentration 50 mg/l P<0.001 Days Mills, ESC 2013
87
88 MRI Results
89 Cardiovascular Magnetic Resonance Findings CMR findings No. % Myocarditis Acute Non-acute Myocardial infarction Takotsubo cardiomyopathy Dilated cardiomyopathy Normal CMR findings EHJ 28:242, 2007
90 Representative Angiographic and Intravascular Ultrasound (IVUS) Images in Patients with Plaque Disruption Reynolds et al: Circulation 2011;124:
91 OCT Images of the Intimomedial Membrane in Different Patients Alfonso, F. et al. J Am Coll Cardiol 2012;59:
92 Clinical Presentation of Patients with Spontaneous Coronary Artery Dissection Subjects with SCAD n=87 STEMI (n=43) Single-vessel34 Multivessel 9 VFib/tach 9 NSTEMI (n=38) Single-vessel29 Multivessel 9 VFib/tach 3 UA (n=6) Single-vessel 3 Multivessel 2 Tweet et al: Circ, 2012
93 Treatment and Outcomes of Patients with SCAD Initial treatment strategy SCAD n=87 PCI n=39 CABG n=4 Fibrinolytics n=13 No revasc n=31 Hospital course Successful n=24 Unsuccessful n=15 (CABG n=5, death n=1) CABG n=3 PCI n=4 (Successful) Conservative n=6 Conservative n=31 Tweet et al: Circ, 2012
94 Circumflex Dissection and Evidence of Fibromuscular Dysplasia Tweet et al: Circ, 2012
95 Long Term Outcomes After SCAD Follow-Up Free of Recurrence % Years after index event No. at risk Tweet et al: Circ, 2012
96 Long Term Outcomes After SCAD Survival % Years after index event No. at risk Tweet et al: Circ, 2012
97 Long Term Outcomes After SCAD Survival Free of MACE % Years after index event No. at risk Tweet et al: Circ, 2012
98 Risk Assessment in the General Population Role of hs troponin assays in primary prevention Christopher defilippi, MD Division of Cardiovascular Medicine University of Maryland Baltimore, Maryland
99 Disclosures Receive grant support from: Roche Diagnostics, Critical diagnostics, BG Medicine, Alere Honorarium/consulting: Roche Diagnostics, Siemens Healthcare, Critical diagnostics, Radiometer, Singulex, HDL
100 Two cases: one patient Are the golden years going to be golden? The asymptomatic older adult Left ventricular hypertrophy, the other cardiac biomarker
101 The older adult Mr. M is a 73 year male who returns from Florida for his routine physical. He is has hypertension, but remains physically active. He asks about his long-term cardiovascular risk and you measure his ctnt level with a new high sensitive assay. It is 17 ng/l.
102 Possible responses to an elevated hs cardiac troponin result in an asymptomatic older adult No worries, we just learned that hs ctn results are age dependent and this patient is below the 99 th percentile for age. Repeat level in 2-3 years and follow the trajectory? Perhaps increased risk for symptomatic cardiovascular disease? Counsel on getting even more active? Get an echocardiogram and a basic metabolic panel
103 Evidence of Race/Ethnicity Differences Gore JACC 2014 ctnt
104 Our patient returns three years later He complains of progressive dyspnea with exertion and notes being short of breath at 2-3 blocks. The last several nights he has woken up with a cough and shortness of breath relived in part with sitting up hs ctnt = 28 ng/l
105 Discharges from Hospitalizations due to Heart Failure Circulation 2012;125:e12 30
106 Prevalence of Heart Failure A disease of older adults Circulation 2012;125:e12 30
107 Selected causes of troponin release in heart failure syndromes Januzzi J L et al. Eur Heart J 2012;33:
108 Stages of Heart Failure Prevalence of ctn elevation D ctn 6.2% hstni ~ 100% C Symptoms B Structural Abnormalities A Risk Factors ctnt 10% hstnt 92% ctn 0.7-8% hstnt 25-70% hstni 93%
109 High Sensitive ctnt in the General Population Study Designs Dallas Heart Study N=3546 Ages f/u 6.4 years ctnt measured by std and hs-ctnt assay Cardiac MRI (n=2501) EBCT (n=2770) Endpoints: Cardiac Phenotypes Mortality Cardiovascular Health Study N=4221 Age > 65 No prior heart failure Avg f/u 11.8 years ctnt by hs assay Repeat measurement of ctnt at 2-3 yrs (n=2918) Endpoints: CVD death New Heart Failure Atherosclerosis Risk in Communities N=9698 Ages Avg f/u 9.9 years ctnt measured by hs assay Endpoints: Coronary heart disease All-cause mortality HF Hospitalization
110 Proportion of Adults with Detectable ctnt (>3 ng/l) Dallas Heart Study Cardiovascular Health Study ARIC
111 Risk of New Onset Heart Failure Ambulatory Older Adults Stratified by ctnt level defilippi JAMA 2010;304:
112 Change in ctnt level from baseline to follow-up Association with new-onset heart failure 18 Rate of Incident HF (per 100 person-yrs) P<.001 P=.02 P<.001 P=.02 P< < >12.94 Baseline ctnt (pg/ml) >50% Decrease Change <=50% >50% Increase
113 Continuous Hazard Functions of ctnt with Several Endpoints The ARIC Study Adjusted for demographics and traditional cardiovascular risk factors Saunders, J. T. et al. Circulation 2011;123:
114 High sensitive ctni in Olmsted County New onset Heart Failure hs ctni: median = 3 ng/l, 80 th percentile (>7.8 ng/l males, >4.9 ng/l females) McKie P. Clin Chem 2014;July 1:epub
115 High sensitive ctni in Olmsted County Hazard for HF with multivariate adjustment McKie P. Clin Chem 2014;July 1:epub
116 Measuring hs-ctni or hs-ctnt is (and should be until proved otherwise) the standard to test all other biomarkers in patients from a community population with or without known coronary artery disease. The use of hs cardiac troponin assays, I think, will assume a spot as a biomarker in primary prevention and will eventually become a risk factor alongside the conventional Framingham risk factors Now what? Apple F. Clin Chem 2011;57:537-9
117 Association of moderate physical activity, rise in hs ctnt level and risk of new onset heart failure Composite score is a sum of walking pace and duration of moderate to intense leisure activities A higher score is a faster pace and longer duration of activity defilippi C. J Am Coll Cardiol 2012;60:2539-4
118 LIFE-P Initiation of moderate physical activity reduces progression of cardiac injury Physical Activity N=156 Successful Aging N=154 p-value Age (years) 76.3± ± Male 51 (32.7%) 48 (31.2%) 0.7 BMI (kg/m 2 ) 29.7 [26.5, 34.8] 28.9 [26.1, 32.9] 0.1 Activity (min/wk) 30 [0, 135] 60 [0, 210] 0.2 Activity (kcal/week) 180 [0, 809] 324 [0, 920] 0.3 Baseline hs ctnt * (pg/ml) 10.8 [7.5, 14.8] 10.5 [6.4, 16.3] 0.7 After one-year of study intervention Physical Activity N=156 Successful Aging N=151 p-value Activity (min/wk) 135 [30, 330] 90 [0, 135] <0.001 Activity (Kcal/week) 756 [165, 1625] 377 [0, 846] <0.001 Δ hs ctnt (pg/ml) 0.19 [-1.1, 1.93] 0.73 [-0.64, 2.59] 0.02 Δ hs ctnt (%) 1.8 [-11.9, 20.0] 7.0 [-7.0, 24.7] 0.05 Increase in hs ctnt level > 8 (5.1%) 14 (9.3%) % from baseline 118 defilippi C. Circulation. 2013;128:A16937
119 Possible responses to an elevated hs cardiac troponin result in an asymptomatic older adult No worries, we just learned that hs ctn results are age dependent and this patient is below the 99 th percentile for age. Repeat level in 2-3 years and follow the trajectory? Perhaps increased risk for symptomatic cardiovascular disease? Counsel on getting even more active? Get an echocardiogram and a basic metabolic panel
120 The older at-risk adult Mr. M is a 73 year male who returns from Florida for his routine physical. He is has hypertension, but remains physically active. He asks about his long-term cardiovascular risk and you measure his ctnt level with a new high sensitive assay. It is 17 ng/l. You also get an ECG
121 Four-Year Age-Adjusted Incidence of Outcome Events, According to the Presence or Absence of Echocardiographic Evidence of Left Ventricular Hypertrophy (LVH). Levy D et al. N Engl J Med 1990;322:
122 Left Ventricular Hypertrophy Heterogeneous Progression to Heart Failure
123 Dose-dependent Association with LVH Dallas Heart Study Proportion with MRI-defined LVH Ptrend < ctnt Category <3 ng/l Tertiles >14 ng/l de Lemos et al. JAMA 2010;304:
124 Association with LV Systolic Dysfunction Proportion with LVEF<40% Ptrend < ctnt Category <0.003 μg/l Tertiles > μg/l
125 The malignant phenotype of LVH ctnt+ defined as > 3 ng/ml Neeland I. J Am Coll Cardiol 2013;61:187 95
126 Rate of incident HF by LVH and tertile of hs ctnt in older adults
127 hs ctn, imaging and risk of HFrEF in older adults The Cardiovascular Health Study 4.3? Tertile
128 LVH and hs ctn for the risk of HFrEF vs HFpEF in older adults The Cardiovascular Health Study HF with preserved LVEF risk (n=215) Hazard Ratios (95% CI) LVH by echo Tertile of hs Unadjusted Risk-factor adjusted * ctnt Table 3. Risk of Heart failure with reduced EF, by LVH and initial biomarker level None (0.93, 1.94) 1.15 (0.79, 1.67) (1.67, 3.31) 1.82 (1.29, 2.60) Yes (1.33, 4.54) 2.33 (1.25, 4.32) (0.68, 3.60) 1.21 (0.52, 2.81) (2.07, 6.63) 2.62 (1.44, 4.77) HF with reduced LVEF risk (n=150) LVH by echo Tertile of hs Unadjusted Risk-factor adjusted * ctnt None (1.42, 3.73) 1.77 (1.08, 2.89) (2.29, 5.80) 2.62 (1.62, 4.21) Yes (1.12, 6.51) 2.19 (0.90, 5.32) (1.40, 8.14) 2.65 (1.10, 6.46) (7.5, 22.23) 7.83 (4.43, 13.83)
129 Risk of Incident HF with reduced EF, by LVH and a >50% rise in hs ctnt levels
130 Risk of incident HF with preserved EF, by LVH and a >50% rise in hs ctnt level
131 Conclusions Troponin measured by a high sensitive assay is frequently elevated in high-risk asymptomatic cohorts and often detectable in the general population, particularly older adults Higher troponin levels are associated with cardiac hypertrophy and systolic dysfunction and predict progression to symptomatic heart failure Measures of high sensitive troponin levels may ultimately be used to guide efficacy of lifestyle or medical interventions
10 Ways to Make the Use of High Sensitivity Cardiac Troponin Values Easier and Better
10 Ways to Make the Use of High Sensitivity Cardiac Troponin Values Easier and Better Allan S. Jaffe, MD.* Consultant - Cardiology & Laboratory Medicine Professor of Medicine Chair, CCLS Division, Department
More informationTroponin Assessment. Does it Carry Clinical Message? Stefan Blankenberg. University Heart Center Hamburg
Biomarkers for Optimal Management of Heart Failure Troponin Assessment Does it Carry Clinical Message? Stefan Blankenberg University Heart Center Hamburg Congress of the European Society of Cardiology
More informationUse of Biomarkers for Detection of Acute Myocardial Infarction
Use of Biomarkers for Detection of Acute Myocardial Infarction Allan S. Jaffe, MD.* Consultant - Cardiology & Laboratory Medicine Professor of Medicine Chair, CCLS Division, Department of Laboratory Medicine
More informationWaiting for High-Sensitivity POCT Cardiac Troponin Assays: Clinical and Analytical Needs I Have a Pain in My Chest That Hurts Very Bad
Waiting for High-Sensitivity POCT Cardiac Troponin Assays: Clinical and Analytical Needs I Have a Pain in My Chest That Hurts Very Bad Fred Apple PhD Hennepin County Medical Center University of Minnesota
More informationDefining rise and fall of cardiac troponin values
Defining rise and fall of cardiac troponin values Doable but Not Simple Allan S. Jaffe, MD.* Consultant - Cardiology & Laboratory Medicine Professor of Medicine Chair, CCLS Division, Department of Laboratory
More informationHigh Sensitivity Troponin Improves Management. But Not Yet
High Sensitivity Troponin Improves Management But Not Yet Allan S. Jaffe, MD.* Consultant - Cardiology & Laboratory Medicine Professor of Medicine Chair, CCLS Division, Department of Laboratory Medicine
More informationTroponin when is an assay high sensitive?
Troponin when is an assay high sensitive? Professor P. O. Collinson MA MB BChir FRCPath FRCP edin MD FACB EurClin Chem Consultant Chemical Pathologist and Professor of Cardiovascular Biomarkers, Departments
More informationPeri-operative Troponin Measurements - Pathophysiology and Prognosis
Peri-operative Troponin Measurements - Pathophysiology and Prognosis Allan S. Jaffe, MD.* Consultant - Cardiology & Laboratory Medicine Professor of Medicine Chair, CCLS Division, Department of Laboratory
More informationDoes serial troponin measurement help identify acute ischemia/ischemic events?
Does serial troponin measurement help identify acute ischemia/ischemic events? Allan S. Jaffe, MD.* Consultant - Cardiology & Laboratory Medicine Professor of Medicine and Laboratory Medicine & Pathology
More informationImpact of Troponin Performance on Patient Care
Impact of Troponin Performance on Patient Care Linda C, Rogers PhD, DABCC, FACB Agenda Introduction Diagnosis of MI Guidelines Troponin Assay differences Classification of troponin assays Guideline acceptable
More informationWhat can we learn from EQAs and audits for cardiac marker testing?
What can we learn from EQAs and audits for cardiac marker testing? Dr P. O. Collinson MA MB BChir FRCPath MD FACB Consultant Chemical Pathologist and Director of Clinical Blood Sciences, Head of Vascular
More informationHow will new high sensitive troponins affect the criteria?
How will new high sensitive troponins affect the criteria? Hugo A Katus MD Abteilung Innere Medizin III Kardiologie, Angiologie, Pulmologie Universitätsklinikum Heidelberg Even more sensitive: The new
More informationBioRemarkable Symposium
BACC BioRemarkable Symposium Acute Myocardial infarction Stefan Blankenberg University Heart Center Hamburg London, September 7th, 2017 Universitätsklinikum Hamburg-Eppendorf Third Universal-Definition
More informationThe Clinical Laboratory Working with Physicians to Improve Patient Care
The Clinical Laboratory Working with Physicians to Improve Patient Care Michael A. Pesce, PhD Professor Emeritus Columbia University Medical Center Department of Pathology and Cell Biology Objectives Troponin
More informationTROPONINS HAVE THEY CHANGED YOUR
TROPONINS HAVE THEY CHANGED YOUR PRACTICE THIS WEEK? Harvey White John Neutze Scholar Green Lane Cardiovascular Service and Cardiovascular Research Unit Auckland City Hospital, Auckland, New Zealand Disclosure
More informationTable. Analytical characteristics of commercial and research cardiac troponin I and T assays declared by the manufacturer.
Table. Analytical characteristics of commercial and research cardiac troponin I and T assays declared by the manufacturer. Commercially available assays - Company/ platform(s)/ assay LoB a LoD b 99 th
More informationHigh-Sensitivity Cardiac Troponin in Suspected ACS
15 th Annual Biomarkers in Heart Failure and Acute Coronary Syndromes STATE-OF-THE-ART High-Sensitivity Cardiac Troponin in Suspected ACS David A. Morrow, MD, MPH Director, Levine Cardiac Intensive Care
More informationHigh Sensitivity Troponins. IT S TIME TO SAVE LIVES. Updates from the ESC 2015 Guidelines November 17th 2016 OPL CONGRESS Dr.
High Sensitivity Troponins. IT S TIME TO SAVE LIVES. Updates from the ESC 2015 Guidelines November 17th 2016 OPL CONGRESS Dr. Marcel El Achkar Chairperson of Laboratory department Nini Hospital Lecturer
More informationCardiac Troponin Testing and Chest Pain Patients: Exploring the Shades of Gray
Cardiac Troponin Testing and Chest Pain Patients: Exploring the Shades of Gray Nichole Korpi-Steiner, PhD, DABCC, FACB University of North Carolina Chapel Hill, NC Learning Objectives Describe the acute
More informationMario Plebani University-Hospital of Padova, Italy
Mario Plebani University-Hospital of Padova, Italy CK-MB mass assay CHF guidelines use BNP for rule out AST in AMI CK in AMI INH for CK-MB electrophoresis for CK and LD isoenzymes RIA for myoglobin WHO
More information7/31/2018. Overview of Next Generation Cardiac Troponin T High Sensitivity. Disclosures. Course Objectives: high sensitive Troponin T assay
Overview of Next Generation Cardiac Troponin T High Sensitivity Arleen Francis Medical & Scientific Liaison Roche Diagnostics 1 Disclosures Arleen Francis is an employee of Roche Diagnostics and a member
More informationMeasuring Natriuretic Peptides in Acute Coronary Syndromes
Measuring Natriuretic Peptides in Acute Coronary Syndromes Peter A. McCullough, MD, MPH, FACC, FACP, FAHA, FCCP Consultant Cardiologist Chief Academic and Scientific Officer St. John Providence Health
More informationClinical Application of Cardiac Biomarkers in an Accredited Chest Pain Center Laboratory s Best Practices
Clinical Application of Cardiac Biomarkers in an Accredited Chest Pain Center Laboratory s Best Practices Noemi Melendres-Wozny, BSN., RN Accreditation Review Specialist National Client Relations Manager
More informationÄr dagens troponinmetoder tillräckligt känsliga?
Är dagens troponinmetoder tillräckligt känsliga? Per Venge, MD PhD Professor Department of Medical Sciences Uppsala University and Department of Clinical Chemistry and Pharmacology University Hospital
More informationCurrent and Future Imaging Trends in Risk Stratification for CAD
Current and Future Imaging Trends in Risk Stratification for CAD Brian P. Griffin, MD FACC Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic Disclosures: None Introduction
More informationCurrent Utilities of Cardiac Biomarker Testing at POC. June 24, 2010 Joe Pezzuto, MT (ASCP) Carolyn Kite, RN
Current Utilities of Cardiac Biomarker Testing at POC June 24, 2010 Joe Pezzuto, MT (ASCP) Carolyn Kite, RN 1. Discuss challenges associated with diagnosing Acute Coronary Syndromes (ACS) and Heart Failure
More informationNatriuretic Peptides The Cardiologists View. Christopher defilippi, MD University of Maryland Baltimore, MD, USA
Natriuretic Peptides The Cardiologists View Christopher defilippi, MD University of Maryland Baltimore, MD, USA Disclosures Research support: Alere, BG Medicine, Critical Diagnostics, Roche Diagnostics,
More informationAssays Pros and Cons AACB 2013 GOLD COAST QUEENSLAND AUSTRALIA
Highly Sensitive Versus Sensitive Troponin Assays Pros and Cons AACB 2013 GOLD COAST QUEENSLAND AUSTRALIA Robert H. Christenson, Ph.D., DABCC, FACB 2013 AACC President Professor of Pathology Professor
More informationSupplementary Online Content
Supplementary Online Content McEvoy JW, Chen Y, Ndumele CE, et al. Six-year change in high-sensitivity cardiac troponin T and risk of subsequent coronary heart disease, heart failure, and death. JAMA Cardiol.
More informationCardiac Troponin: Current Status and Future Promise
Cardiac Troponin: Current Status and Future Promise Robert H. Christenson, Ph.D., ABCC, FACB Professor of Pathology Professor of Medical and Research Technology University of Maryland School of Medicine
More informationAcute Coronary Syndrome. Sonny Achtchi, DO
Acute Coronary Syndrome Sonny Achtchi, DO Objectives Understand evidence based and practice based treatments for stabilization and initial management of ACS Become familiar with ACS risk stratification
More informationCongreso Nacional del Laboratorio Clínico 2016
Can biomarkers help us make a better use of cardiac imaging for myocardial ischaemia rule-out in the Emergency Department? Alessandro Sionis Director Acute and Intensive Cardiac Care Unit Hospital de la
More informationFifty shades of Troponin. Dr Liam Penny The Queens Hotel, Cheltenham 4 th October 2012
Fifty shades of Troponin Dr Liam Penny The Queens Hotel, Cheltenham 4 th October 2012 Plaque-fissure and intracoronary thrombus Courtesy Prof. MJ Davies Acute Coronary Syndromes Plaque-fissure and intracoronary
More informationACCESS hstni SCIENTIFIC LITERATURE
ACCESS hstni SCIENTIFIC LITERATURE 2017 2018 Table of contents Performance Evaluation of Access hstni A critical evaluation of the Beckman Coulter Access hstni: Analytical performance, reference interval
More informationLearning Objectives. Predicting and Preventing Cardiovascular Disease. ACC/AHA Cholesterol Guidelines Key differences vs ATP III
Presenter Disclosure Information 10:30 11:15am Predicting and Preventing Cardiovascular Disease: Can we put the Cardiologist out of business? The following relationships exist related to this presentation:
More informationHit the road Jack! W. FRANK PEACOCK, MD, FACEP, FACC
Hit the road Jack! W. FRANK PEACOCK, MD, FACEP, FACC Visits 130,000,000 annually 10.4 M chest pain (8.0%) 4.1 M sent home non-cardiac 6.24 M suspected or actual cardiac 50,000 MIs 3.1 M non-cardiac (50%)
More informationBiomarkers in Heart Disease. Felix J. Rogers, DO, FACOI April 29, 2018
Biomarkers in Heart Disease Felix J. Rogers, DO, FACOI April 29, 2018 Biomarkers NIH: A biomarker is a characteristic that is objectively measured and evaluated as an indicator of normal biological processes,
More informationImproving the detection of myocardial infarction in women
Improving the detection of myocardial infarction in women British Cardiac Society Listening to the Female Voice 4 th June 2014 anoopsshah@gmail.com Dr Anoop Shah BHF Centre for Cardiovascular Sciences
More informationBeta-blockers in Patients with Mid-range Left Ventricular Ejection Fraction after AMI Improved Clinical Outcomes
Beta-blockers in Patients with Mid-range Left Ventricular Ejection Fraction after AMI Improved Clinical Outcomes Seung-Jae Joo and other KAMIR-NIH investigators Department of Cardiology, Jeju National
More informationMultimodality Imaging in Spontaneous Coronary Artery Dissection in the Peripartum Period
Multimodality Imaging in Spontaneous Coronary Artery Dissection in the Peripartum Period Marysia Tweet, MD NASCI Annual Meeting October 18 th, 2016 2016 MFMER slide-1 DISCLOSURE No relevant financial relationship(s)
More informationWhat oral antiplatelet therapy would you choose? a) ASA alone b) ASA + Clopidogrel c) ASA + Prasugrel d) ASA + Ticagrelor
76 year old female Prior Hypertension, Hyperlipidemia, Smoking On Hydrochlorothiazide, Atorvastatin New onset chest discomfort; 2 episodes in past 24 hours Heart rate 122/min; BP 170/92 mm Hg, Killip Class
More informationPost Operative Troponin Leak: David Smyth Christchurch New Zealand
Post Operative Troponin Leak: Does It Really Matter? David Smyth Christchurch New Zealand Life Was Simple Once Transmural Infarction Subendocardial Infarction But the Blood Tests Were n t Perfect Creatine
More informationWomen and Ischemic Heart Disease Lessons Learned
Women and Ischemic Heart Disease 2017- Lessons Learned Bina Ahmed MD Interventional Cardiology Dartmouth-Hitchcock Medical Center Assistant Professor of Medicine Geisel School of Medicine Lebanon, NH ba@hitchcock.org
More informationPost-Procedural Myocardial Injury or Infarction
Post-Procedural Myocardial Injury or Infarction Hugo A Katus MD & Evangelos Giannitsis MD Abteilung Innere Medizin III Kardiologie, Angiologie, Pulmologie Universitätsklinikum Heidelberg Conflict of Interest:
More informationThe Universal Definition of Myocardial Infarction 3 rd revision, 2012
The Universal Definition of Myocardial Infarction 3 rd revision, 2012 Joseph S. Alpert, MD Professor of Medicine, University of Arizona College of Medicine, Tucson, AZ; Editor-in-Chief, American Journal
More informationEDUCATIONAL COMMENTARY CARDIAC FUNCTION: BIOCHEMICAL MARKERS UPDATE
EDUCATIONAL COMMENTARY CARDIAC FUNCTION: BIOCHEMICAL MARKERS UPDATE Educational commentary is provided through our affiliation with the American Society for Clinical Pathology (ASCP). To obtain FREE CME/CMLE
More informationhs-c Tn I high sensitivity troponin I <17 min
hs-c Tn I high sensitivity troponin I IFCC & ESC compliant 0/ h NSTEMI rule-out / rule-in algorithm POCT whole blood/plasma Results in < 7 minutes
More informationHigh-sensitivity Troponin T Predicts Recurrent Cardiovascular Events in Patients with Stable Coronary Heart Disease: KAROLA Study 8 Year FU
ESC Congress 2011 Paris, France, August 27-31 KAROLA Session: Prevention: Are biomarkers worth their money? Abstract # 84698 High-sensitivity Troponin T Predicts Recurrent Cardiovascular Events in Patients
More informationMedical History Form. Part 1. Administrative Information
Medical History Form ID NUMBER: FORM CODE: MHX VERSION:A 02/10/10 Contact Occasion 0 1 SEQ # Administrative Information 0a. Completion Date: / / 0b. Staff ID: Part 1 Instructions: Part 1 of this form is
More informationSupplementary Online Content
Supplementary Online Content Rubini Giménez M, Twerenbold R, Boeddinghaus J, et al. Clinical effect of sex-specific cutoff values of high-sensitivity cardiac troponin T in suspected myocardial infarction.
More informationIFCC Task Force on Clinical Applications of Cardiac Biomarkers (TF-CB) Report to the General Conference 2016 Madrid
IFCC Task Force on Clinical Applications of Cardiac Biomarkers (TF-CB) Report to the General Conference 2016 Madrid 1 CREATED By the EB in 2011, following to the Committee on Standardization of Cardiac
More informationChest pain and troponins on the acute take. J N Townend Queen Elizabeth Hospital Birmingham
Chest pain and troponins on the acute take J N Townend Queen Elizabeth Hospital Birmingham 3 rd Universal Definition of Myocardial Infarction Type 1: Spontaneous MI related to atherosclerotic plaque rupture
More informationCARDIOLOGY GRAND ROUNDS
CARDIOLOGY GRAND ROUNDS Presentation: Speaker: Date: Location: Troponin State of the Art: Past, Present and Future Yader Sandoval, MD Cardiovascular Disease Fellow Minneapolis Heart Institute at Abbott
More informationOvercoming the Risk-Treatment Paradox in Non-STE ACS: It s Time! Christopher Granger, MD
Overcoming the Risk-Treatment Paradox in Non-STE ACS: It s Time! Christopher Granger, MD Disclosures Research contracts: AstraZeneca, Bayer, Novartis, GSK, Sanofi-Aventis, BMS, Pfizer, The Medicines Company,
More informationJUPITER NEJM Poll. Panel Discussion: Literature that Should Have an Impact on our Practice: The JUPITER Study
Panel Discussion: Literature that Should Have an Impact on our Practice: The Study Kaiser COAST 11 th Annual Conference Maui, August 2009 Robert Blumberg, MD, FACC Ralph Brindis, MD, MPH, FACC Primary
More informationTyp 2 Myokardinfarkt. Thomas Nestelberger. Kardiolunch USB
Typ 2 Myokardinfarkt Thomas Nestelberger Kardiolunch USB 08.02.2018 Content I. Patient case presentation II. III. IV. Universal Definition of Myocardial Infarction Impact of Coronary Artery Disease on
More informationEssam Mahfouz, MD. Professor of Cardiology, Mansoura University
By Essam Mahfouz, MD. Professor of Cardiology, Mansoura University Agenda Definitions Classifications Epidemiology Risk stratification What is new? What is MI? Myocardial infarction is the death of part
More informationREVISED MI DEFINITIONS IMPLICATIONS FOR CLINICAL TRIALS. Maarten L Simoons Thoraxcenter - Erasmus MC Rotterdam - The Netherlands
REVISED MI DEFINITIONS IMPLICATIONS FOR CLINICAL TRIALS Maarten L Simoons Thoraxcenter - Erasmus MC Rotterdam - The Netherlands TRITON Prasugrel ACS + PCI n = 13,608 moderate / high risk ACS, all PCI p
More information(ClinicalTrials.gov ID: NCT ) Title: The Italian Elderly ACS Study Author: Stefano Savonitto. Date: 29 August 2011 Meeting: ESC congress, Paris
Early aggressive versus initially conservative strategy in elderly patients with non-st- elevation acute coronary syndrome: the Italian randomised trial (ClinicalTrials.gov ID: NCT00510185) Stefano Savonitto,
More informationBio-Rad Laboratories. Cardiac Assessment Controls. Value Assigned for Clinical Laboratory and Point of Care Test Systems
Bio-Rad Laboratories Cardiac Assessment Controls Cardiac Assessment Controls Value Assigned for Clinical Laboratory and Point of Care Test Systems Solving the Challenges of Troponin I Testing for the Central
More informationRapid Disposition of Chest Pain Patients February 2019
UCSF High Risk Emergency Medicine Rapid Disposition of Chest Pain Patients February 2019 Corey M. Slovis, M.D. Vanderbilt University Medical Center Metro Nashville Fire Department Nashville International
More informationSpeaker: Richard Heitsman, MICT, C-POC-AACC. Title: National Account Manager/Clinical Cardiac Specialist-Radiometer America.
Speaker: Richard Heitsman, MICT, C-POC-AACC Title: National Account Manager/Clinical Cardiac Specialist-Radiometer America. Upon completion the participant will be able to o Review current and evolving
More informationCVD risk assessment using risk scores in primary and secondary prevention
CVD risk assessment using risk scores in primary and secondary prevention Raul D. Santos MD, PhD Heart Institute-InCor University of Sao Paulo Brazil Disclosure Honoraria for consulting and speaker activities
More informationImproving Diagnostic, Prognostic & Therapeutic Biomarkers in Heart Disease. Professor Mark Richards Medicine, University of Otago, Christchurch
Improving Diagnostic, Prognostic & Therapeutic Biomarkers in Heart Disease Professor Mark Richards Medicine, University of Otago, Christchurch BNP / NT-ProBNP H 2 N 1 Pro-BNP Cardiomyocyte 76 77 108 COOH
More informationAn update on the management of UA / NSTEMI. Michael H. Crawford, MD
An update on the management of UA / NSTEMI Michael H. Crawford, MD New ACC/AHA Guidelines 2007 What s s new in the last 5 years CT imaging advances Ascendancy of troponin and BNP Clarification of ACEI/ARB
More informationBelinda Green, Cardiologist, SDHB, 2016
Acute Coronary syndromes All STEMI ALL Non STEMI Unstable angina Belinda Green, Cardiologist, SDHB, 2016 Thrombus in proximal LAD Underlying pathophysiology Be very afraid for your patient Wellens
More informationEDUCATIONAL COMMENTARY UNDERSTANDING THE BENEFITS AND CHALLENGES OF HIGH- SENSITIVITY TROPONIN TESTING IN CLINICAL AND PATHOLOGY SETTINGS
SENSITIVITY TROPONIN TESTING IN CLINICAL AND PATHOLOGY SETTINGS Educational commentary is provided through our affiliation with the American Society for Clinical Pathology (ASCP). To obtain FREE CME/CMLE
More informationDIAGNOSTICS ASSESSMENT PROGRAMME
DIAGNOSTICS ASSESSMENT PROGRAMME Evidence overview Early rule out or diagnosis of acute myocardial infarction: High-sensitivity troponin tests (Elecsys troponin T high-sensitive, ARCHITECT STAT highsensitivity
More informationThe use of Cardiac CT and MRI in Clinical Practice
The use of Cardiac CT and MRI in Clinical Practice Matthew W. Martinez, MD Assistant Professor of Medicine LVPG - Lehigh Valley Heart Specialists Lehigh Valley Health Network Oct. 3, 2009 DISCLOSURE Relevant
More informationIn-Ho Chae. Seoul National University College of Medicine
The Earlier, The Better: Quantum Progress in ACS In-Ho Chae Seoul National University College of Medicine Quantum Leap in Statin Landmark Trials in ACS patients Randomized Controlled Studies of Lipid-Lowering
More informationBertil Lindahl Akademiska sjukhuset Uppsala
Bertil Lindahl Akademiska sjukhuset Uppsala Kriterier för akut hjärtinfarkt Bevis på myokardskada/nekros: Konstaterad höjning och/eller sänkning av biomarkörer (företrädesvis troponin) med minst ett värde
More information6/6/17. Heart Failure and Natriuretic Peptides. Learning objectives
Heart Failure and Natriuretic Peptides Maria-Magdalena Patru, MD, PhD Director, Medical and Scientific Affairs This promotional educational activity is brought to you by Ortho-Clinical Diagnostics, Inc.
More informationAcute Coronary Syndrome. Cindy Baker, MD FACC Director Peripheral Vascular Interventions Division of Cardiovascular Medicine
Acute Coronary Syndrome Cindy Baker, MD FACC Director Peripheral Vascular Interventions Division of Cardiovascular Medicine Topics Timing is everything So many drugs to choose from What s a MINOCA? 2 Acute
More informationBiomarkers in Acute Cardiac Disease Samir Arnaout, M.D.FESC Associate Professor of Medicine Internal Medicine i & Cardiology American University of Beirut Time course of the appearance of various markers
More informationSpontaneous Coronary Artery Dissection
Spontaneous Coronary Artery Dissection Malissa J. Wood, MD FACC FAHA Co-Director MGH Heart Center Corrigan Women s Heart Health Program Massachusetts General Hospital 40 y/o female transferred from OSH
More informationObjectives. Identify early signs and symptoms of Acute Coronary Syndrome Initiate proper protocol for ACS patient 10/2013 2
10/2013 1 Objectives Identify early signs and symptoms of Acute Coronary Syndrome Initiate proper protocol for ACS patient 10/2013 2 Purpose of this Education Module: Chest Pain Center Accreditation involves
More informationCardiovascular Disorders Lecture 3 Coronar Artery Diseases
Cardiovascular Disorders Lecture 3 Coronar Artery Diseases By Prof. El Sayed Abdel Fattah Eid Lecturer of Internal Medicine Delta University Coronary Heart Diseases It is the leading cause of death in
More informationM/39 CC D. => peak CKMB (12 hr later) ng/ml T.chol/TG/HDL/LDL 180/150/48/102 mg/dl #
Acute Coronary Syndrome - Case Review - Young-Guk Ko, MD Yonsei Cardiovascular Center Yonsei University College of Medicine Case 1 M/39 #4306212 CC D : Severe squeezing chest pain : 4 hours, aggravated
More informationChest pain management. Ruvin Gabriel and Niels van Pelt August 2011
Chest pain management Ruvin Gabriel and Niels van Pelt August 2011 Introduction Initial assessment Case 1 Case 2 and 3 Comparison of various diagnostic techniques Summary 1-2 % of GP consultations are
More informationHeFSSA Practitioners Program 2017 Theme The Patient Journey: Feel Good and Live Long. Case Study 2
HeFSSA Practitioners Program 2017 Theme The Patient Journey: Feel Good and Live Long Case Study 2 HEART FAILURE WITH MID-RANGE EJECTION FRACTION TREATMENT OPTIONS CLINICAL CASE MEDICAL HISTORY 59-year-old
More informationJohn J.P. Kastelein MD PhD Professor of Medicine Dept. of Vascular Medicine Academic Medial Center / University of Amsterdam
Latest Insights from the JUPITER Study John J.P. Kastelein MD PhD Professor of Medicine Dept. of Vascular Medicine Academic Medial Center / University of Amsterdam Inflammation, hscrp, and Vascular Prevention
More informationAcute Myocardial Infarction
Acute Myocardial Infarction Hafeza Shaikh, DO, FACC, RPVI Lourdes Cardiology Services Asst.Program Director, Cardiology Fellowship Associate Professor, ROWAN-SOM Acute Myocardial Infarction Definition:
More informationDisclosures. Inpatient Management of Non-ST Elevation Acute Coronary Syndromes. Edward McNulty MD, FACC. None
Inpatient Management of Non-ST Elevation Acute Coronary Syndromes Edward McNulty MD, FACC Assistant Clinical Professor UCSF Director, SF VAMC Cardiac Catheterization Laboratory Disclosures None New Guidelines
More informationTroponin = 35. Objectives. Low Risk Chest Pain. Does this patient have ACS? Does this patient have ACS? Objectives
Objectives Low Risk Chest Pain Jeffrey Tabas, MD Professor of Emergency Medicine Office of CME UCSF School of Medicine Improve speed and accuracy in assessing patients with possible ACS! Avoid pitfalls
More information8:30-10:30 WS #4: Cardiology :00-13:00 WS #11: Cardiology 101 (Repeated)
Professor Ralph Stewart Cardiologist Auckland City Hospital Green Lane Cardiovascular Research Unit Auckland Heart Group Fiona Stewart Cardiologist Green Lane Hospital National Women's Hospital Professor
More informationContinuing Medical Education Post-Test
Continuing Medical Education Post-Test Based on the information presented in this monograph, please choose one correct response for each of the following questions or statements. Record your answers on
More informationRecognizing the High Risk NSTEMI Patient for Early Appropriate Therapy
Recognizing the High Risk NSTEMI Patient for Early Appropriate Therapy Learning Objectives Learn to recognize the high risk patient Discuss effective management of a high risk NSTEMI patient Review CCS
More informationPerioperative Myocardial Infarction
Perioperative Myocardial Infarction Which patient should UNDERGO CORONARY ANGIOGRAPHY? The Cardiologists view Hans Rickli, St.Gallen 1 Experience Standards Risk stratification Team approach.. Tightrope
More informationFasting or non fasting?
Vascular harmony Robert Chilton Professor of Medicine University of Texas Health Science Center Director of Cardiac Catheterization labs Director of clinical proteomics Which is best to measure Lower continues
More informationDIFFERENTIATING THE PATIENT WITH UNDIFFERENTIATED CHEST PAIN
DIFFERENTIATING THE PATIENT WITH UNDIFFERENTIATED CHEST PAIN Objectives Gain competence in evaluating chest pain Recognize features of moderate risk unstable angina Review initial management of UA and
More informationTopic. Updates on Definition of Myocardial Infarction
Topic Updates on Definition of Myocardial Infarction In the past, general consensus for MI? Definition of MI by WHO - Combination of 2 of 3 characteristics - 1. Typical Symptoms 2. Enzyme Rise 3. Typical
More informationQuality Payment Program: Cardiology Specialty Measure Set
Quality Payment Program: Cardiology Specialty Set Title Number CMS Reporting Method(s) Heart Failure (HF): Angiotensin- Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy for
More informationAcute Coronary Syndromes. January 9, 2013 Chris Chiles M.D. FACC
Acute Coronary Syndromes January 9, 2013 Chris Chiles M.D. FACC Disclosures None- not even a breakfast burrito from a drug company Hospitalizations in the U.S. Due to ACS Acute Coronary Syndromes* 1.57
More informationAdvanced Imaging MRI and CTA
Advanced Imaging MRI and CTA Who and why may benefit. Matthew W. Martinez, M.D. FACC Lehigh Valley Health Network Director, Cardiovascular Imaging Learning Objectives Review basics of CMR and CTA Review
More informationImaging ischemic heart disease: role of SPECT and PET. Focus on Patients with Known CAD
Imaging ischemic heart disease: role of SPECT and PET. Focus on Patients with Known CAD Hein J. Verberne Academic Medical Center, University of Amsterdam, Amsterdam, Netherlands International Conference
More informationTrial to Reduce. Aranesp* Therapy. Cardiovascular Events with
Trial to Reduce Cardiovascular Events with Aranesp* Therapy John J.V. McMurray, Hajime Uno, Petr Jarolim, Akshay S. Desai, Dick de Zeeuw, Kai-Uwe Eckardt, Peter Ivanovich, Andrew S. Levey, Eldrin F. Lewis,
More informationTHE PROPER APPROACH TO DIAGNOSING HEART FAILURE WITH PRESERVED EJECTION FRACTION
THE PROPER APPROACH TO DIAGNOSING HEART FAILURE WITH PRESERVED EJECTION FRACTION James C. Fang, MD, FACC Professor and Chief Cardiovascular Division University of Utah School of Medicine Disclosures Data
More informationRikshospitalet, University of Oslo
Rikshospitalet, University of Oslo Preventing heart failure by preventing coronary artery disease progression European Society of Cardiology Dyslipidemia 29.08.2010 Objectives The trends in cardiovascular
More information10 Steps to Managing Non-ST Elevation ACS
Pathophysiology of Acute Coronary Syndromes and Potential Pharmacologic Interventions Acute Coronary Syndrome 4. Downstream from thrombus myocardial ischemia/necrosis (Beta-blockers, Nitrates etc) 3. Activation
More informationNon ST Elevation-ACS. Michael W. Cammarata, MD
Non ST Elevation-ACS Michael W. Cammarata, MD Case Presentation 65 year old man PMH: CAD s/p stent in 2008 HTN HLD Presents with chest pressure, substernally and radiating to the left arm and jaw, similar
More information