Case Studies Using hsctn Assays. A Joint AACC ACC symposium Fred Apple Ph.D. Chris DeFlippi M.D. Allan S. Jaffe, M.D.

35105 - Case Studies Using hsctn Assays A Joint AACC ACC symposium Fred Apple Ph.D. Chris DeFlippi M.D. Allan S. Jaffe, M.D.

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

hs-ctn Padua Italy

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: 2008-2009 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)

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

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): 0.030 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which Clopidogrel load given Patient transferred to RTU (Rapid Transit Unit) for assessment for possible ACS Apple 2014 Unpublished

Cardiac Troponin Order Set ctni, 99 th ng/l 0h 3h 6h 9h Contemporary Assay, 30 38 29 25 26 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

Cardiac Troponin Order Set Following Serial ctni Values ctni, 99 th ng/l 0h 3h 6h 9h Contemporary: 30 38 22 25 29 High Sensitivity All normals: 23 20 19 19 20 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

Cardiac Troponin Order Set Following Serial ctni Values ctni, 99 th ng/l 0h 3h 6h 9h Contemporary: 30 38 22 25 29 High Sensitivity All: 23 Male: 36 Female: 15 20 19 19 20 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

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

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%

3 2.5 ED LOS 2 1.5 1 0.5 2.77 hrs 2.17 hrs Based on ctn Assay TAT Decreased ER LOS 40 Min Optimal 0 120 100 80 60 40 20 10 TAT Storrow AB. Acad Emer Med. 2008;15 Storrow Acad Emer Med. 2008

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

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

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

Central Lab aa1 30 110 209 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:190-196 Mitsubishi Pathfast C:41-49 D:71-116 D:163-209 Radiometer AQT90* C:41-49 D: 137-149 C:190-196 Response RAMP D:26-38 C:85-92.. C:190-196 Siemens Stratus-CS Trinity Meritas C:24-40, C:27-32 C:41-49 D:41-56 C:88-90 D: 137-148 D:190-196 High Sensitivity Abbott Architect C:24-40. D:41-49 Beckman Access D:24-40. C:41-49 Nanosphere MTP D:49-52 D:70-73 D:88 C: 136-147 D:169 Singulex Errena D:27-41. C:41-49 Apple 2014

Contemporary Cardiac Troponin Assays Company/platform/assay LoD ng/l 99 th (%CV) 10%CV Risk Claim Epitopes recognized by antibodies Abbott AxSYM ADV 20 40 (14%) 160 Yes C 87-91, 41-49; D 24-40 Abbott Architect 9 28 (14%) 32 No C 87-91, 24-40: D: 41-49 Beckman Access/DXi Accu 10 40 (14%) 60 Yes C; 41-49; D: 24-40. biomerieux Vidas Ultra 10 10 (27.7%) 110 No C: 41-49, 22-29; D: 87-91,Mab 7B9 Ortho Vitros ECi ES 12 34 (10%) 34 Yes C 24-40, 41-49; D 87-91 Roche Elecsys ctnt gen 4 10 <10 30 Yes C: 136-147; D: 125-131 Elecsys ctni 160 160 (10%) No C: 87-91, 190-196; D: 23-29, 27-43 Siemens Centaur Ultra 6 40 (8.8%) 30 Yes C; 41-49, 87-91; D: 27-40 Siemens Dimension RxL 40 70 (20%) 140 Yes C: 27-32; D: 41-56 Siemens Immulite 2500 100 0.2 (NA) 420 No C: 87-91:D: 27-40 Siemens VISTA 15 45 (10%) 40 Yes C: 27-32; D: 41-56 Tosoh AIA II 60 <60 (NA) 90 No C: 41-49; D: 87-91 Imprecision in package insert very often NOT reproducible in real world clinical practice Apple Clin Chem 2012

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* 1.2 16 (5.6%) 3 C 24-40: D: 41-49 Beckman Access 2-3 8.6 (10%) 8.6 C; 41-49; D: 24-40 Nanosphere MTP 0.2 2.8 (9.5%) 0.5 C: 136-147; D: Ab PA1010 Singulex Errena MTP 0.09 10.1 (9.0%) 0.88 C: 41-49 ; D: 27-41 Siemens VISTA 0.5 9 (5.0%) 3 C: 30-35; D: 41-56, 171-190 hs-ctnt* Roche* E170/E2010 5 14 (13%) 13 C: 136-147; D: 125-131 *Commercially available for use worldwide but not FDA cleared for use in US Apple Clin Chem 2012

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

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

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

Influence of Imprecision on 99 th Percentile: Assay Dependent Validation Is there an impact on adjudication for MI diagnosis? 0.1 0.09 0.08 99th Percentile: TnI = 0.070 at 20% CV 99th Percentile: TnI = 0.063 at 10%CV 0.07 Frequency 0.06 0.05 0.04 0.03 0.02 0.01 0 0 0.02 0.04 0.06 0.08 0.1 0.12 0.14 0.16 TnI Apple et al Clin Chem 2006

Common Presumably Healthy Population 252 females, 273 males Apple Clin Chem 2012

Common Presumably Healthy Population Percent Detected ctni 98% ctnt 28% LoD ng/l Apple Clin Chem 2012

High Sensitivity Cardiac Troponin 99 th Percentiles By Gender 99% ctni values measureable above LoD Mills Unpublished 2013

Clin Chem 2010

Gore JACC 2014 ctnt

Evidence of Race/Ethnicity Differences Gore JACC 2014 ctnt

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

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

Apple CLN 2014

Biological Variation for High Sensitivity Cardiac Troponin Assays Analytical Variation Abbott Beckman Siemens Singulex Roche E170 and E2010 CV-A, % 13.8 14.5 13.0 8.3 9.7, 9.7 Biological Variation CV-I, % 15.2 6.1 12.9 9.7 15.1, 21.4 CV-G, % 70.5 34.8 12.3 57 17.9, 23.5 Index Individuality 0.22 0.46 0.11 0.21 0.30, 0.42 RCV increase % +69.3 +63.8 +57.5 +46 +64, +90 RCV decrease % -40.9-38.9-36.5-32 -39, -47 Within Subject Mean ctn, pg/ml 3.5 4.9 4.9 2.2 2.5, 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

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

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

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

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

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

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

ARCHITECT Quality Control Imprecision Data ARCHITECT Control Mean, ng/l %CV N CL1 i2000 *BioRad Low Dil 22 12.8 13 (1/14) # CL2 (10x) 20 18.0 18 (523) ED i1000 25 20.8 17 (5/22) CL1 BioRad Low Dil 23 24.9 45 CL2 (10x) 25 23.7 45 ED 26 50.3 45 * Initiated tightened control range # QC failure rate that required recal, etc hs-ctni Lot 10925JH00 Abbott 19.6 5.3 118 18930JH00 19.9 5.7 263 23911JN00 20.8 4.7 176 Need QC at 99 th percentile values HCMC 2013 June/July: Mills Scotland 2013

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

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.

Case 1

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

Physical Examination BP = 95/60 Pulse = 129 Examination of heart, lungs and vascular system= normal

Admission ECG

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

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

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

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

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

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

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 (0.06-1.48) 0.20 (0.07-0.78) 0.22 Peak troponin I value, µg/l 2.96 (0.44-15.85) 1.09 (0.43-3.24) <0.001 Hemoglobin, mmol/l 8.2/391 (7.4-8.9) 7.7/138 (6.2-8.9) <0.001 Leukocytes, 10E9/L 10.1/391 (7.7-12.8) 11.6/142 (8.9-17.6) <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 (122-168) 139/140 (106-167) 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

TACTICS (TIMI 18) Subgroups Cardiac troponin T Conservative Invasive No. treatment treatment Primary endpoint <0.1 ng/ml 840 5.6 6.0 0.1 - <0.4 137 16.2 8.7 0.4 - <1.5 101 12.2 3.9 1.5 748 16.8 8.3 Favors invasive treatment Favors Conservative treatment Death or MI <0.1 ng/ml 810 3.1 2.9 0.1 - <0.4 137 13.2 7.3 0.4 - <1.5 101 4.1 1.9 1.5 748 11.0 5.5 JAMA 286:2405, 2001 0.0 1 0.1 1.0 10 Odds ratio CP1036852-10

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)

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) 0.010 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) 0.004 Renal failure 23 (5.8) 20 (13.9) 0.002 Chronic obstructive pulmonary disease 46 (11.6) 36 (25.0) <0.001 Arrhythmia 50 (12.6) 34 (23.6) 0.002 Sabby et al: AJM 126(9):789, 2013

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

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

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

Survival by AMI Type Type 1 MI Survival Type 2 MI Years Sabby, AJM, 2014

Assocition of Triggers and Mortality Patients in Type 2 AMI Alive (n=61) Dead (n=58) Patients (no.) Sabby, AJM, 2014

Complications by AMI Type Type-I MI Type-II MI ** ** Patients (%) ** ** ** ** Stein et al: PLOS ONE Vol 9; Issue 1, 2014

Survival by AMI Type Type-I MI Survival (%) P<0.0001 Type-II MI Time (days) Stein et al: PLOS ONE Vol 9; Issue 1, 2014

Changes in ctni (Abbott) Values in Patients with Type 1 and Typ 2 AMI Sandoval, in press, EHJ-ACA

Postop Survival by ctni Values Survival 1.0 0.9 0.8 0.7 0.6 0.5 0.4 ctn-i 0.6 and ctn-t 0.03 ctn-i >3.1 and/or ctn-t >0.2 0.6< ctn-i 1.5 and/or 0.03 <ctn-t 0.1 P=0.047 1.5< ctn-i 3.1 and/ or 0.1 <ctn-t 0.2 P=0.007 P<0.001 0.3 0 1 2 3 4 5 J Am Coll Cardiol 42:1551, 2003 Years after surgery CP1133453-8

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 34 6.7 17 50.0 14 41.2 12 35.3 7 20.5 MB >5% CK >170 IU and 14 2.9 8 57.1 7 50.0 7 50.0 5 35.7 MB >10% ctn-i >0.6 ng/ml 107 23.9 34 31.8 29 27.1 21 19.6 19 17.7 and or ctn-t >0.03 ng/ml ctn-i >1.5 ng/ml 41 8.7 38 87.8 24 58.3 19 46.3 18 43.9 and or ctn-t >0.1 ng/ml ctn-i >3.1 ng/ml 21 4.2 19 90.5 17 81.0 17 81.0 13 61.9 and or ctn-t >0.2 ng/ml J Am Coll Cardiol 42:1549, 2003 CP1133453-7

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

Mortality Analysis by Peak ctnt Value (VISION) Cumulative hazard Peak troponin T (ng/ml) 0.3 0 0.03-0.29 0.02 0.01 Days after surgery No. at risk Peak troponin T (ng/ml) 0.30 142 136 129 127 121 118 117 0.03-0.29 1121 1103 1075 1058 1036 1030 1018 0.02 494 492 489 485 480 477 473 0.01 13,376 13,348 13,300 13,271 13,250 12,230 13,209 JAMA. 2012;307(21):2295-2304

All-Cause Mortality Grouped by Preoperative hsctnt Quartiles All-cause mortality (%) Quartile (ng/l) 4 (>19.3) 3 (12.0-19.3) 1 (<8.3) 2 (8.3-12.0) Survival time (years) AHJ, 2013, (in press)

Probability of Death Based on ctnt Values on Admission in Patients with GI Bleeding* * Critical Care Medicine 37:140-147, 2009 5

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, 1049-1058

Probability of Death Based on ctnt Values on Admission in Patients with Sepsis* *The American Journal of Medicine, Volume 126, Issue 12, 2013, 1114-1121

Relationship Between hsctnt and Diastolic and RV Echo Measures* Crit Care Med 42:790-800, 2014 6

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

Out Patient Follow Up After Treatment Totally normal CTA without calcium or observed lesions at the patient s request.

Case 2

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.

Physical Examination BP = 130/70 Pulse = 60 Examination of heart, lungs and vascular system normal save a soft S 4 sound

Admission ECG CP1126367-1

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

Clinical Course Rx - Oxygen Aspirin 81 mg qd IV nitroglycerin Metoprolol 50 mg BID IV Heparin IV Morphine IV Integrilin Urgent angiography

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

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

Outcome of Women With Suspected Acute Coronary Syndrome Survival free from death or recurrent MI (%) Troponin I concentration <16 ng/l Troponin I concentration 17-49 ng/l Troponin I concentration 50 mg/l P<0.001 Days Mills, ESC 2013

MRI Results

Cardiovascular Magnetic Resonance Findings CMR findings No. % Myocarditis 30 50.0 Acute 19 31.7 Non-acute 11 18.3 Myocardial infarction 7 11.6 Takotsubo cardiomyopathy 1 1.7 Dilated cardiomyopathy 1 1.7 Normal CMR findings 21 35.0 EHJ 28:242, 2007

Representative Angiographic and Intravascular Ultrasound (IVUS) Images in Patients with Plaque Disruption Reynolds et al: Circulation 2011;124:1414-1425

OCT Images of the Intimomedial Membrane in Different Patients Alfonso, F. et al. J Am Coll Cardiol 2012;59:1073-1079

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

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

Circumflex Dissection and Evidence of Fibromuscular Dysplasia Tweet et al: Circ, 2012

Long Term Outcomes After SCAD Follow-Up Free of Recurrence % Years after index event No. at risk87 67 59 50 41 34 29 28 20 16 12 Tweet et al: Circ, 2012

Long Term Outcomes After SCAD Survival % Years after index event No. at risk87 71 64 54 44 38 35 32 25 21 17 Tweet et al: Circ, 2012

Long Term Outcomes After SCAD Survival Free of MACE % Years after index event No. at risk87 64 56 48 39 32 27 26 18 14 11 Tweet et al: Circ, 2012

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

Disclosures Receive grant support from: Roche Diagnostics, Critical diagnostics, BG Medicine, Alere Honorarium/consulting: Roche Diagnostics, Siemens Healthcare, Critical diagnostics, Radiometer, Singulex, HDL

Two cases: one patient Are the golden years going to be golden? The asymptomatic older adult Left ventricular hypertrophy, the other cardiac biomarker

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.

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

Evidence of Race/Ethnicity Differences Gore JACC 2014 ctnt

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

Discharges from Hospitalizations due to Heart Failure Circulation 2012;125:e12 30

Prevalence of Heart Failure A disease of older adults Circulation 2012;125:e12 30

Selected causes of troponin release in heart failure syndromes Januzzi J L et al. Eur Heart J 2012;33:2265-2271

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%

High Sensitive ctnt in the General Population Study Designs Dallas Heart Study N=3546 Ages 30-65 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 54-74 Avg f/u 9.9 years ctnt measured by hs assay Endpoints: Coronary heart disease All-cause mortality HF Hospitalization

Proportion of Adults with Detectable ctnt (>3 ng/l) Dallas Heart Study Cardiovascular Health Study 33.5 66.5 ARIC

Risk of New Onset Heart Failure Ambulatory Older Adults Stratified by ctnt level defilippi JAMA 2010;304:2494-2502

Change in ctnt level from baseline to follow-up Association with new-onset heart failure 18 Rate of Incident HF (per 100 person-yrs) 16 14 12 10 8 6 4 2 P<.001 P=.02 P<.001 P=.02 P<.001 0 <3 3.00-5.44 5.45-8.16 8.17-12.94 >12.94 Baseline ctnt (pg/ml) >50% Decrease Change <=50% >50% Increase

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;123:1367-1376

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

High sensitive ctni in Olmsted County Hazard for HF with multivariate adjustment McKie P. Clin Chem 2014;July 1:epub

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

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

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±4.1 77.0±4.3 0.1 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%) 0.16 50% from baseline 118 defilippi C. Circulation. 2013;128:A16937

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

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

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;322:1561-1566.

Left Ventricular Hypertrophy Heterogeneous Progression to Heart Failure

Dose-dependent Association with LVH Dallas Heart Study Proportion with MRI-defined LVH Ptrend <0.0001 ctnt Category 1 2 3 4 5 <3 ng/l Tertiles >14 ng/l de Lemos et al. JAMA 2010;304:2503-12

Association with LV Systolic Dysfunction Proportion with LVEF<40% Ptrend <0.0001 0 0 ctnt Category 1 2 3 4 5 <0.003 μg/l Tertiles > 0.014 μg/l

The malignant phenotype of LVH ctnt+ defined as > 3 ng/ml Neeland I. J Am Coll Cardiol 2013;61:187 95

Rate of incident HF by LVH and tertile of hs ctnt in older adults

hs ctn, imaging and risk of HFrEF in older adults The Cardiovascular Health Study 4.3? Tertile

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 1 1.0 1.0 2 1.35 (0.93, 1.94) 1.15 (0.79, 1.67) 3 2.35 (1.67, 3.31) 1.82 (1.29, 2.60) Yes 1 2.46 (1.33, 4.54) 2.33 (1.25, 4.32) 2 1.56 (0.68, 3.60) 1.21 (0.52, 2.81) 3 3.71 (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 1.0 1.0 2 2.30 (1.42, 3.73) 1.77 (1.08, 2.89) 3 3.64 (2.29, 5.80) 2.62 (1.62, 4.21) Yes 1 2.70 (1.12, 6.51) 2.19 (0.90, 5.32) 2 3.38 (1.40, 8.14) 2.65 (1.10, 6.46) 3 12.94 (7.5, 22.23) 7.83 (4.43, 13.83)

Risk of Incident HF with reduced EF, by LVH and a >50% rise in hs ctnt levels

Risk of incident HF with preserved EF, by LVH and a >50% rise in hs ctnt level

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