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Eggers, K. M., Jernberg, T. & Lindahl, B. (2019). Cardiac Troponin Elevation in Patients Without a Specific Diagnosis. Journal of the American College of Cardiology, 73(1), 1-9
Open this publication in new window or tab >>Cardiac Troponin Elevation in Patients Without a Specific Diagnosis
2019 (English)In: Journal of the American College of Cardiology, ISSN 0735-1097, E-ISSN 1558-3597, Vol. 73, no 1, p. 1-9Article in journal (Refereed) Published
Abstract [en]

BACKGROUND Cardiac troponin (cTn) elevation is a common finding in acutely admitted patients, even in the absence of acute coronary syndrome. In some of these patients, no etiology of cTn elevation can be identified. The term troponinemia is sometimes used to describe this scenario.

OBJECTIVES This study aimed to investigate the associations of cTn levels with clinical findings and long-term outcome in acutely admitted patients with suspected acute coronary syndrome who had been discharged without a specified diagnosis.

METHODS Retrospective registry-based cohort study investigating 48,872 patients (SWEDEHEART [Swedish Web-system for Enhancement and Development of Evidence-based care in Heart disease Evaluated According to Recommended Therapies] registry). Patients were stratified into cohorts with cTn levels less than or equal to the assay-specific 99th percentile and separated by assay-specific cTn tertiles in case of higher levels.

RESULTS A cTn level >99th percentile was noted in 9,800 (20.1%) patients. The prevalence of cardiovascular risk factors as well as cardiovascular and noncardiovascular comorbidities increased across higher cTn strata. In total, 7,529 (15.4%) patients had a major adverse event (MAE), defined as the composite of all-cause mortality, myocardial infarction, readmission for heart failure, or stroke (median follow-up 4.9 years). MAE risk was associated with higher cTn strata (hazard ratio for highest assay-specific cTn tertile: 2.59; 95% confidence interval: 2.39 to 2.80; hazard ratio in patients without cardiovascular comorbidities, renal dysfunction, left ventricular dysfunction, or significant coronary stenosis: 3.57; 95% confidence interval: 2.30 to 5.54).

CONCLUSIONS cTn elevation is associated with cardiovascular and noncardiovascular comorbidities and predicts major adverse events in acutely admitted patients, in whom no definite diagnosis could have been established. The term troponinemia is trivializing and should be avoided. Instead, careful work-up is required in these patients.

Keywords
cardiac troponin, chest pain, risk prediction, troponinemia
National Category
Cardiac and Cardiovascular Systems
Identifiers
urn:nbn:se:uu:diva-374424 (URN)10.1016/j.jacc.2018.09.082 (DOI)000455014900001 ()30621937 (PubMedID)
Funder
Swedish Foundation for Strategic Research
Available from: 2019-01-29 Created: 2019-01-29 Last updated: 2019-01-29Bibliographically approved
Mueller-Hennessen, M., Lindahl, B., Giannitsis, E., Vafaie, M., Biener, M., Haushofer, A. C., . . . Mueller, C. (2019). Combined testing of copeptin and high-sensitivity cardiac troponin T at presentation in comparison to other algorithms for rapid rule-out of acute myocardial infarction. International Journal of Cardiology, 276, 261-267
Open this publication in new window or tab >>Combined testing of copeptin and high-sensitivity cardiac troponin T at presentation in comparison to other algorithms for rapid rule-out of acute myocardial infarction
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2019 (English)In: International Journal of Cardiology, ISSN 0167-5273, E-ISSN 1874-1754, Vol. 276, p. 261-267Article in journal (Refereed) Published
Abstract [en]

BACKGROUND: We aimed to directly compare the diagnostic and prognostic performance of a dual maker strategy (DMS) with combined testing of copeptin and high-sensitivity (hs) cardiac troponin T (cTnT) at time of presentation with other algorithms for rapid rule-out of acute myocardial infarction (AMI).

METHODS: 922 patients presenting to the emergency department with suspected AMI and available baseline copeptin measurements qualified for the present TRAPID-AMI substudy. Diagnostic measures using the DMS (copeptin <10, <14 or < 20 pmol/L and hs-cTnT≤14 ng/L), the 1 h-algorithm (hs-cTnT<12 ng/L and change <3 ng/L at 1 h), as well as the hs-cTnT limit-of-blank (LoB, <3 ng/L) and -detection (LoD, <5 ng/L) were compared. Outcomes were assessed as combined end-points of death and myocardial re-infarction.

RESULTS: True-negative rule-out using the DMS could be achieved in 50.9%-62.3% of all patients compared to 35.0%, 45.3% and 64.5% using LoB, LoD or the 1 h-algorithm, respectively. The DMS showed NPVs of 98.1%-98.3% compared to 99.2% for the 1 h-algorithm, 99.4% for the LoB and 99.3% for the LoD. Sensitivities were 93.5%-94.8%, as well as 96.8%, 98.7% and 98.1%, respectively. Addition of clinical low-risk criteria such as a HEART-score ≤ 3 to the DMS resulted in NPVs and sensitivities of 100% with a true-negative rule-out to 33.8%-41.6%. Rates of the combined end-point of death/MI within 30 days ranged between 0.2% and 0.3% for all fast-rule-out protocols.

CONCLUSION: Depending on the applied copeptin cut-off and addition of clinical low-risk criteria, the DMS might be an alternative to the hs-cTn-only-based algorithms for rapid AMI rule-out with comparable diagnostic measures and outcomes.

Keywords
Copeptin, Dual-marker strategy, High-sensitivity cardiac troponin T, Rapid AMI rule-out
National Category
Cardiac and Cardiovascular Systems
Identifiers
urn:nbn:se:uu:diva-374217 (URN)10.1016/j.ijcard.2018.10.084 (DOI)000454877900058 ()30404726 (PubMedID)
Available from: 2019-01-18 Created: 2019-01-18 Last updated: 2019-01-30Bibliographically approved
Boeckel, J.-N., Palapies, L., Klotsche, J., Zeller, T., von Jeinsen, B., Perret, M. F., . . . Keller, T. (2018). Adjusted Troponin I for Improved Evaluation of Patients with Chest Pain. Scientific Reports, 8, Article ID 8087.
Open this publication in new window or tab >>Adjusted Troponin I for Improved Evaluation of Patients with Chest Pain
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2018 (English)In: Scientific Reports, ISSN 2045-2322, E-ISSN 2045-2322, Vol. 8, article id 8087Article in journal (Refereed) Published
Abstract [en]

The use of cardiac troponins (cTn) is the gold standard for diagnosing myocardial infarction. Independent of myocardial infarction (MI), however, sex, age and kidney function affect cTn levels. Here we developed a method to adjust cTnI levels for age, sex, and renal function, maintaining a unified cut-off value such as the 99th percentile. A total of 4587 individuals enrolled in a prospective longitudinal study were used to develop a model for adjustment of cTn. cTnI levels correlated with age and estimated glomerular filtration rate (eGFR) in males/females with r(age) = 0.436/0.518 and with (r)(eGFR) = -0.142/-0.207. For adjustment, these variables served as covariates in a linear regression model with cTnl as dependent variable. This adjustment model was then applied to a real-world cohort of 1789 patients with suspected acute MI (AMI) (N = 407). Adjusting cTnI showed no relevant loss of diagnostic information, as evidenced by comparable areas under the receiver operator characteristic curves, to identify AMI in males and females for adjusted and unadjusted cTnI. In specific patients groups such as in elderly females, adjusting cTnI improved specificity for AMI compared with unadjusted cTnI. Specificity was also improved in patients with renal dysfunction by using the adjusted cTnI values. Thus, the adjustments improved the diagnostic ability of cTnI to identify AMI in elderly patients and in patients with renal dysfunction. Interpretation of cTnI values in complex emergency cases is facilitated by our method, which maintains a single diagnostic cut-off value in all patients.

Place, publisher, year, edition, pages
NATURE PUBLISHING GROUP, 2018
National Category
Cardiac and Cardiovascular Systems
Identifiers
urn:nbn:se:uu:diva-357270 (URN)10.1038/s41598-018-26120-l (DOI)000432928200012 ()29799020 (PubMedID)
Available from: 2018-08-17 Created: 2018-08-17 Last updated: 2018-08-17Bibliographically approved
Mohammad, M. A., Karlsson, S., Haddad, J., Cederberg, B., Jernberg, T., Lindahl, B., . . . Erlinge, D. (2018). Christmas, national holidays, sport events, and time factors as triggers of acute myocardial infarction: SWEDEHEART observational study 1998-2013. BMJ. British Medical Journal, 363, Article ID k4811.
Open this publication in new window or tab >>Christmas, national holidays, sport events, and time factors as triggers of acute myocardial infarction: SWEDEHEART observational study 1998-2013
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2018 (English)In: BMJ. British Medical Journal, E-ISSN 1756-1833, Vol. 363, article id k4811Article in journal (Refereed) Published
Abstract [en]

OBJECTIVES To study circadian rhythm aspects, national holidays, and major sports events as triggers of myocardial infarction.

DESIGN Retrospective observational study using the nationwide coronary care unit registry, SWEDEHEART.

SETTING Sweden.

PARTICIPANTS 283 014 cases of myocardial infarction reported to SWEDEHEART between 1998 and 2013. Symptom onset date was documented for all cases, and time to the nearest minute for 88%.

INTERVENTIONS Myocardial infarctions with symptom onset on Christmas/New Year, Easter, and Midsummer holiday were identified. Similarly, myocardial infarctions that occurred during a FIFA World Cup, UEFA European Championship, and winter and summer Olympic Games were identified. The two weeks before and after a holiday were set as a control period, and for sports events the control period was set to the same time one year before and after the tournament. Circadian and circaseptan analyses were performed with Sunday and 24:00 as the reference day and hour with which all other days and hours were compared. Incidence rate ratios were calculated using a count regression model.

MAIN OUTCOME MEASURES Daily count of myocardial infarction.

RESULTS Christmas and Midsummer holidays were associated with a higher risk of myocardial infarction (incidence rate ratio 1.15, 95% confidence interval 1.12 to 1.19, P<0.001, and 1.12, 1.07 to 1.18, P<0.001, respectively). The highest associated risk was observed for Christmas Eve (1.37, 1.29 to 1.46, P<0.001). No increased risk was observed during Easter holiday or sports events. A circaseptan and circadian variation in the risk of myocardial infarction was observed, with higher risk during early mornings and on Mondays. Results were more pronounced in patients aged over 75 and those with diabetes and a history of coronary artery disease.

CONCLUSIONS In this nationwide real world study covering 16 years of hospital admissions for myocardial infarction with symptom onset documented to the nearest minute, Christmas, and Midsummer holidays were associated with higher risk of myocardial infarction, particularly in older and sicker patients, suggesting a role of external triggers in vulnerable individuals.

National Category
Cardiac and Cardiovascular Systems
Identifiers
urn:nbn:se:uu:diva-372933 (URN)10.1136/bmj.k4811 (DOI)000453691400001 ()30541902 (PubMedID)
Funder
Swedish Research CouncilSwedish Foundation for Strategic Research Knut and Alice Wallenberg FoundationSwedish Heart Lung Foundation
Available from: 2019-01-10 Created: 2019-01-10 Last updated: 2019-01-10Bibliographically approved
Mair, J., Lindahl, B., Müller, C., Giannitsis, E., Huber, K., Möckel, M., . . . Jaffe, A. S. (2018). Editor's Choice-What to do when you question cardiac troponin values. European heart journal. Acute cardiovascular care., 7(6), 577-586
Open this publication in new window or tab >>Editor's Choice-What to do when you question cardiac troponin values
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2018 (English)In: European heart journal. Acute cardiovascular care., ISSN 2048-8726, Vol. 7, no 6, p. 577-586Article in journal (Refereed) Published
Abstract [en]

High-sensitivity cardiac troponin assays enable cardiac troponin measurement with a high degree of analytical sensitivity and a low level of analytical imprecision at the low measuring range. One of the most important advantages of these new assays is that they allow novel, more rapid approaches for ruling in or ruling out acute myocardial infarctions. The increase in the early diagnostic sensitivity of high-sensitivity cardiac troponin assays comes at the cost of a reduced acute myocardial infarction specificity of the biomarker, because more patients with other causes of acute or chronic myocardial injury without overt myocardial ischaemia are detected than with previous cardiac troponin assays. Increased troponin concentrations that do not fit with the clinical presentation are seen in the daily routine, mainly as a result of a variety of pathologies, and if tested in the same sample, even discrepancies between high-sensitivity cardiac troponin I and troponin T test results may sometimes be found as well. In addition, analytically false-positive test results occasionally may occur since no assay is perfect. In this review, we summarise the biochemical, pathophysiological and analytical background of the work-up for such a clinical setting.

Place, publisher, year, edition, pages
SAGE PUBLICATIONS LTD, 2018
Keywords
Cardiac troponin I, cardiac troponin T, high sensitivity, discrepancy, interference, mismatch
National Category
Cardiac and Cardiovascular Systems
Identifiers
urn:nbn:se:uu:diva-366277 (URN)10.1177/2048872617708973 (DOI)000444973300011 ()28485179 (PubMedID)
Available from: 2018-11-26 Created: 2018-11-26 Last updated: 2018-11-26Bibliographically approved
Pettersson, A., Ljung, L., Johansson, C., Heilborn, U., Jernberg, T., Frick, M., . . . Svensson, P. (2018). Experiences of a One-hour Algorithm in Chest Pain Patients With a Nonelevated Troponin T at Presentation.. Critical Pathways in Cardiology, 17(1), 6-12
Open this publication in new window or tab >>Experiences of a One-hour Algorithm in Chest Pain Patients With a Nonelevated Troponin T at Presentation.
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2018 (English)In: Critical Pathways in Cardiology, ISSN 1535-282X, E-ISSN 1535-2811, Vol. 17, no 1, p. 6-12Article in journal (Refereed) Published
Abstract [en]

Background: We aimed to evaluate the use of a 1-hour measurement of high-sensitivity cardiac troponin T (hs-cTnT) in an emergency department (ED) population of chest pain patients with a nonelevated baseline hs-cTnT and to examine the prevalence of early dynamic changes in hs-cTnT and the association with admission rate, diagnosis, and outcome.

Methods: All patients with a chief complaint of chest pain presenting to the ED of Karolinska University Hospital, Solna, Sweden, from December 2014 to September 2015 who had a baseline hs-cTnT of ≤14 ng/L and a second value obtained within >30 to ≤90 minutes were followed for 30 days regarding admission, readmission, myocardial infarction (MI), and death.

Results: A total of 1091 patients were included. Dynamic 1-hour changes in hs-cTnT defined as an increase or decrease of ≥3 ng/L occurred in 23 patients (2.1%). Fifteen patients (65.2%) in the dynamic group were admitted, compared with 148 patients (13.9%) in the nondynamic group (P < 0.001). Four of the admitted patients (26.7%) in the dynamic and 1 (0.7%) in the nondynamic group were diagnosed with an MI (P < 0.001). No death or MI occurred within 30 days among those discharged from the ED.

Conclusions: Dynamic 1-hour changes in hs-cTnT were uncommon but associated with a higher rate of admission and of MI in an unselected population of chest pain patients with a nonelevated hs-cTnT at presentation. Lack of dynamic changes makes MI highly unlikely, and a 1-hour measurement may facilitate an early rule out of MI but should be used together with clinical assessment.

National Category
Cardiac and Cardiovascular Systems
Identifiers
urn:nbn:se:uu:diva-369663 (URN)10.1097/HPC.0000000000000138 (DOI)
Available from: 2018-12-15 Created: 2018-12-15 Last updated: 2019-01-30Bibliographically approved
Eggers, K. M., Jernberg, T. & Lindahl, B. (2018). High-sensitivity cardiac troponin T, left ventricular function, and outcome in non-ST elevation acute coronary syndrome. American Heart Journal, 197, 70-76
Open this publication in new window or tab >>High-sensitivity cardiac troponin T, left ventricular function, and outcome in non-ST elevation acute coronary syndrome
2018 (English)In: American Heart Journal, ISSN 0002-8703, E-ISSN 1097-6744, Vol. 197, p. 70-76Article in journal (Refereed) Published
Abstract [en]

Background Cardiac troponin (cTn) levels reflect infarct size and depressed left ventricular ejection fraction (LVEF) in patients with non-ST elevation acute coronary syndrome (NSTE-ACS). However, there is very limited information on whether cTn measured with a high-sensitivity (hs) assay would provide incremental prognostic information to the LVEF in NSTE-ACS patients. Methods This was a registry-based study (SWEDEHEART registry) investigating 20,652 NSTE-ACS patients with available information on hs-cTnT (highest level recorded during the hospitalization) and the LVEF estimated using echocardiography. All patients had been followed for 1 year. Results Hs-cTnT levels independently predicted major cardiovascular events (MACE) in cohorts with normal, slightly depressed, moderately depressed, and severely depressed LVEF. The adjusted hazard ratios in these cohorts were 1.18 (95% CI 1.13-1.23), 1.12 (95% CI 1.06-1.18), 1.12 (95% CI 1.06-1.19), and 1.21 (95% CI 1.13-1.30), respectively. Hs-cTnT levels were particularly predictive for cardiovascular mortality and readmission for heart failure. Excluding patients with previous cardiac disease did not affect the overall interrelations of hs-cTnT and LVEF with MACE. Conclusions Hs-cTnT levels provide incremental prognostic value independent of the LVEF in patients with NSTE-ACS. Hs-cTnT is particularly predictive for MACE in patients with severely depressed LVEF but also in those with a normal LVEF. Accordingly, a normal LVEF should not be used as an argument not to target patients to thorough workup.

Place, publisher, year, edition, pages
MOSBY-ELSEVIER, 2018
National Category
Cardiac and Cardiovascular Systems
Identifiers
urn:nbn:se:uu:diva-348973 (URN)10.1016/j.ahj.2017.11.012 (DOI)000425723700009 ()29447786 (PubMedID)
Available from: 2018-05-03 Created: 2018-05-03 Last updated: 2018-05-03Bibliographically approved
Eggers, K. M., Jernberg, T., Lindhagen, L. & Lindahl, B. (2018). High-Sensitivity Cardiac Troponin T Levels Identify Patients With Non-ST-Segment Elevation Acute Coronary Syndrome Who Benefit From Invasive Assessment [Letter to the editor]. JACC: Cardiovascular Interventions, 11(16), 1665-1667
Open this publication in new window or tab >>High-Sensitivity Cardiac Troponin T Levels Identify Patients With Non-ST-Segment Elevation Acute Coronary Syndrome Who Benefit From Invasive Assessment
2018 (English)In: JACC: Cardiovascular Interventions, ISSN 1936-8798, E-ISSN 1876-7605, Vol. 11, no 16, p. 1665-1667Article in journal, Letter (Other academic) Published
Place, publisher, year, edition, pages
ELSEVIER SCIENCE INC, 2018
National Category
Cardiac and Cardiovascular Systems
Identifiers
urn:nbn:se:uu:diva-363868 (URN)10.1016/j.jcin.2018.03.027 (DOI)000442425900029 ()30139480 (PubMedID)
Funder
Swedish Foundation for Strategic Research
Available from: 2018-11-14 Created: 2018-11-14 Last updated: 2019-01-24Bibliographically approved
Eggers, K. M., Jernberg, T., Ljung, L. & Lindahl, B. (2018). High-Sensitivity Cardiac Troponin-Based Strategies for the Assessment of Chest Pain Patients: A Review of Validation and Clinical Implementation Studies. Clinical Chemistry, 64(11), 1572-1585
Open this publication in new window or tab >>High-Sensitivity Cardiac Troponin-Based Strategies for the Assessment of Chest Pain Patients: A Review of Validation and Clinical Implementation Studies
2018 (English)In: Clinical Chemistry, ISSN 0009-9147, E-ISSN 1530-8561, Vol. 64, no 11, p. 1572-1585Article, review/survey (Refereed) Published
Abstract [en]

BACKGROUND: The introduction of high-sensitivity cardiac troponin (hs-cTn) assays has improved the early assessment of chest pain patients. A number of hs-cTn-based algorithms and accelerated diagnostic protocols (ADPs) have been developed and tested subsequently. In this review, we summarize the data on the performance and clinical utility of these strategies. CONTENT: We reviewed studies investigating the diagnostic and prognostic performance of hs-cTn algorithms [level of detection (LoD) strategy, 0/1-h, 0/2-h, and 0/3-h algorithms) and of hs-cTn-based ADPs, together with the implications of these strategies when implemented as clinical routine. The LoD strategy, when combined with a nonischemic electrocardiogram, is best suited for safe rule-out of myocardial infarction and the identification of patients eligible for early discharge from the emergency department. The 0/1-h algorithms appear to identify most patients as being eligible for rule-out. The hs-cTn-based ADPs mainly focus on prognostic assessment, which is in contrast with the hs-cTn algorithms. They identify smaller proportions of rule-out patients, but there is increasing evidence from prospective studies on their successful clinical implementation. Such information is currently lacking for hs-cTn algorithms. CONCLUSIONS: There is a trade-off between safety and efficacy for different hs-cTn-based strategies. This trade-off should be considered for the intended strategy, along with its user-friendliness and evidence from clinical implementation studies. However, several gaps in knowledge remain. At present, we suggest the use of an ADP in conjunction with serial hs-cTn results to optimize the early assessment of chest pain patients. (C) 2018 American Association for Clinical Chemistry

Place, publisher, year, edition, pages
American Association for Clinical Chemistry, 2018
National Category
Cardiac and Cardiovascular Systems
Research subject
Cardiology
Identifiers
urn:nbn:se:uu:diva-369662 (URN)10.1373/clinchem.2018.287342. (DOI)000448660500007 ()29941466 (PubMedID)
Available from: 2018-12-15 Created: 2018-12-15 Last updated: 2019-01-24Bibliographically approved
Mair, J., Lindahl, B., Hammarsten, O., Mueller, C., Giannitsis, E., Huber, K., . . . Jaffe, A. S. (2018). How is cardiac troponin released from injured myocardium?. European heart journal. Acute cardiovascular care., 7(6), 553-560
Open this publication in new window or tab >>How is cardiac troponin released from injured myocardium?
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2018 (English)In: European heart journal. Acute cardiovascular care., ISSN 2048-8726, Vol. 7, no 6, p. 553-560Article in journal (Refereed) Published
Abstract [en]

Cardiac troponin I and cardiac troponin T are nowadays the criterion biomarkers for the laboratory diagnosis of acute myocardial infarction due to their very high sensitivities and specificities for myocardial injury. However, still many aspects of their degradation, tissue release and elimination from the human circulation are incompletely understood. Myocardial injury may be caused by a variety of different mechanisms, for example, myocardial ischaemia, inflammatory and immunological processes, trauma, drugs and toxins, and myocardial necrosis is preceded by a substantial reversible prelethal phase. Recent experimental data in a pig model of myocardial ischaemia demonstrated cardiac troponin release into the circulation from apoptotic cardiomyocytes as an alternative explanation for clinical situations with increased cardiac troponin without any other evidence for myocardial necrosis. However, the comparably lower sensitivities of all currently available imaging modalities, including cardiac magnetic resonance imaging for the detection of particularly non-focal myocardial necrosis in patients, has to be considered for cardiac troponin test result interpretation in clinical settings without any other evidence for myocardial necrosis apart from increased cardiac troponin concentrations as well.

Place, publisher, year, edition, pages
SAGE PUBLICATIONS LTD, 2018
Keywords
Cardiac troponin I, cardiac troponin T, myocardial injury, release, reversible, necrosis, apoptosis
National Category
Cardiac and Cardiovascular Systems
Identifiers
urn:nbn:se:uu:diva-366275 (URN)10.1177/2048872617748553 (DOI)000444973300008 ()29278915 (PubMedID)
Available from: 2018-11-26 Created: 2018-11-26 Last updated: 2018-11-26Bibliographically approved
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ORCID iD: ORCID iD iconorcid.org/0000-0002-5795-0061

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