Combination of lymphocyte count and not the serological response with high-sensitivity cardiac troponin for risk stratification in patients with possible COVID-19

Background and Purpose: Optimal secondary prevention for patients with embolic stroke of undetermined source (ESUS) remains unknown. We aimed to assess whether high-sensitivity cardiac troponin T (hs-cTnT) levels are associated with major vascular events and whether hs-cTnT may identify patients who benefit from anticoagulation following ESUS. Methods: Data were obtained from the biomarker substudy of the NAVIGATE ESUS trial, a randomized controlled trial testing the efficacy of rivaroxaban versus aspirin for secondary stroke prevention in ESUS. Patients were dichotomized at the hs-cTnT upper reference limit (14 ng/L, Gen V, Roche Diagnostics). Cox proportional hazard models were computed to explore the association between hs-cTnT, the combined cardiovascular end point (recurrent stroke, myocardial infarction, systemic embolism, cardiovascular death), and recurrent ischemic stroke. Results: Among 1337 patients enrolled at 111 participating centers in 18 countries (mean age 67±9 years, 61% male), hs-cTnT was detectable in 95% and at/above the upper reference limit in 21%. During a median follow-up of 11 months, the combined cardiovascular end point occurred in 68 patients (5.0%/y, rivaroxaban 28 events, aspirin 40 events; hazard ratio, 0.67 [95% CI, 0.41–1.1]), and recurrent ischemic stroke occurred in 50 patients (4.0%/y, rivaroxaban 16 events, aspirin 34 events, hazard ratio 0.45 [95% CI, 0.25–0.81]). Annualized combined cardiovascular end point rates were 8.2% (9.5% rivaroxaban, 7.0% aspirin) for those above hs-cTnT upper reference limit and 4.8% (3.1% rivaroxaban, 6.6% aspirin) below with a significant treatment modification ( P =0.04). Annualized ischemic stroke rates were 4.7% above hs-cTnT upper reference limit and 3.9% below, with no suggestion of an interaction between hs-cTnT and treatment ( P =0.3). Conclusions: In patients with ESUS, hs-cTnT was associated with increased cardiovascular event rates. While fewer recurrent strokes occurred in patients receiving rivaroxaban, outcomes were not stratified by hs-cTn results. Our findings support using hs-cTnT for cardiovascular risk stratification but not for decision-making regarding anticoagulation therapy in patients with ESUS. Registration: URL: https://www.clinicaltrials.gov . Unique identifier: NCT02313909.

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P5673Combination of high-sensitivity cardiac troponin and B-Type natriuretic peptide (BNP) for diagnosis and risk-stratification of syncope

European Heart Journal ◽

10.1093/eurheartj/ehz746.0615 ◽

2019 ◽

Vol 40 (Supplement_1) ◽

Author(s):

T Zimmermann ◽

J Du Fay De Lavallaz ◽

P Badertscher ◽

C Puelacher ◽

T Nestelberger ◽

...

Keyword(s):

Risk Stratification ◽

Natriuretic Peptide ◽

Cardiac Troponin ◽

Area Under The Curve ◽

High Sensitivity ◽

Risk Groups ◽

Patient Specific ◽

Cardiovascular Research ◽

Cardiac Syncope

Abstract Background While high-sensitivity cardiac troponin (hs-cTn) and B-Type natriuretic peptide (BNP) have been assessed separately for the diagnosis and risk-stratification of patients with syncope, their combined accuracy is unknown. Methods We assessed the diagnostic and prognostic accuracy of the combination of hs-cTnI and BNP in a prospective international multicenter study enrolling patients 40 years and older presenting with syncope to the emergency department (ED). Hs-cTnI (Architect) and BNP (Architect) concentrations were measured in a blinded fashion. Cardiac syncope, as adjudicated by two independent physicians using all available clinical information including one year follow-up, was the diagnostic endpoint. MACE were defined as death, resuscitation, life-threatening arrhythmia, implantation of a pacemaker or implantable cardioverter defibrillator (ICD), acute myocardial infarction, pulmonary embolism, stroke/transient ischemic attack (TIA), intracranial bleeding or valvular intervention. Patients were classified in three risk groups (low (<10%), medium (10–30%), high (>30%)) for cardiac syncope based on hs-cTnI and BNP levels. Results Among 1533 patients, cardiac syncope was the adjudicated final diagnosis in 233 (15.2%). Hs-cTnI and BNP concentrations both remained independent predictors of cardiac syncope in multivariable models. The diagnostic accuracy of the combination hs-cTnI/BNP for cardiac syncope was good with an area under the curve (AUC) of 0.81 (95%-CI 0.78–0.84) and significantly better than each biomarker separately or a set of clinical variables (each p<0.001). The classification of patients in three risk groups, depending on the probability for cardiac syncope based on their hs-cTnI and BNP values, translated well in predictions for MACE (AUC 0.79, 95%-CI 0.77–0.82) and death (AUC 0.78, 95%-CI 0.74–0.82) at 2 years follow-up. Based on these results, we designed a visual tool allowing convenient patient-specific diagnostic and prognostic risk evaluation based solely on hs-cTnI and BNP concentrations (Figure). Risk stratification based on hs-cTnI/BNP Conclusion The combination hs-cTnI/BNP may have clinical utility in patients presenting to the ED with syncope as it allows good diagnostic as well as prognostic discrimination. Acknowledgement/Funding Swiss National Science Foundation, Swiss Heart Foundation, Cardiovascular Research Foundation Basel, University Basel

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Measurement of High-Sensitivity Cardiac Troponin in Pulmonary Embolism: Useful Test or a Clinical Distraction

Seminars in Thrombosis and Hemostasis ◽

10.1055/s-0039-1698762 ◽

2019 ◽

Vol 45 (08) ◽

pp. 784-792

Author(s):

Giuseppe Lippi ◽

Emmanuel J. Favaloro ◽

Peter Kavsak

Keyword(s):

Pulmonary Embolism ◽

Risk Stratification ◽

Cardiac Troponin ◽

Laboratory Tests ◽

High Sensitivity ◽

Severity Index ◽

Adverse Outcomes ◽

Incremental Value ◽

Risk Patients ◽

Acute Pe

AbstractThe ability to predict death or other unfavorable outcomes after an acute pulmonary embolism (PE) is challenging, with current available risk score models having relatively unsatisfactory prognostic performance in this area. For example, the simplified pulmonary embolism severity index (sPESI), the most frequently used stratification tool, misclassifies a significant percentage of low- and high-risk patients. This gap in care, along with the increasing clinical availability of high-sensitivity cardiac troponin (hs-cTn) laboratory tests and the recent emphasis on detecting myocardial injury, may foster further evaluation of hs-cTn testing in patients with acute PE. Our analysis of the current scientific literature on hs-cTn in patients with acute PE identified that hs-cTn testing may provide valuable information for predicting future adverse outcomes and mortality, independently from baseline clinical risk assessment. Although the risk of an adverse event is indeed higher in patients with higher sPESI scores, cTns retain their prognostic value also in those at low risk, suggesting that a combination of hs-cTn with sPESI may provide an incremental value over assessment of either variable alone. Accordingly, the future development of updated risk stratification models, with the inclusion of laboratory tests such as hs-cTn, may represent an enhanced approach for risk stratification in patients with acute PE. Additional research, however, is needed to verify whether the combination of cTns, specifically as measured with hs-cTn assays, with other biomarkers may further improve the current capacity to efficiently manage patients with acute PE.

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Letter in response to the article entitled “High-sensitivity cardiac troponin T: A biomarker for the early risk stratification of type-A acute aortic dissection?” by Li et al.

Archives of Cardiovascular Diseases ◽

10.1016/j.acvd.2016.05.003 ◽

2016 ◽

Vol 109 (10) ◽

pp. 562

Author(s):

Levent Cerit

Keyword(s):

Aortic Dissection ◽

Risk Stratification ◽

Cardiac Troponin ◽

Acute Aortic Dissection ◽

Troponin T ◽

High Sensitivity ◽

Type A ◽

Cardiac Troponin T ◽

Early Risk

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B-Type Natriuretic Peptide and High-Sensitivity Cardiac Troponin for Risk Stratification in Low-Flow, Low-Gradient Aortic Stenosis

JACC Cardiovascular Imaging ◽

10.1016/j.jcmg.2017.06.018 ◽

2018 ◽

Vol 11 (7) ◽

pp. 939-947 ◽

Cited By ~ 12

Author(s):

Abdellaziz Dahou ◽

Marie-Annick Clavel ◽

Romain Capoulade ◽

Kim O’Connor ◽

Henrique B. Ribeiro ◽

...

Keyword(s):

Aortic Stenosis ◽

Risk Stratification ◽

Natriuretic Peptide ◽

Cardiac Troponin ◽

High Sensitivity ◽

Low Flow

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247Safety and efficacy of high-sensitivity cardiac troponin for risk stratification in patients with suspected acute coronary syndrome

European Heart Journal ◽

10.1093/eurheartj/ehz747.0064 ◽

2019 ◽

Vol 40 (Supplement_1) ◽

Author(s):

A Bularga ◽

A Anand ◽

F E Strachan ◽

K K Lee ◽

S Stewart ◽

...

Keyword(s):

Myocardial Infarction ◽

Acute Coronary Syndrome ◽

Risk Stratification ◽

Cardiac Troponin ◽

Cardiac Death ◽

Controlled Trial ◽

High Sensitivity ◽

Composite Outcome ◽

Coronary Syndrome

Abstract Background Guidelines acknowledge the emerging role of high-sensitivity cardiac troponin (hs-cTn) assays for the risk stratification and rapid rule-out of myocardial infarction, but multiple approaches have been described. We previously demonstrated the utility of a single hs-cTnI concentration <5 ng/L at presentation to risk stratify patients with suspected acute coronary syndrome (ACS). Purpose To assess the safety and efficacy of a hs-cTnI concentration <5 ng/L at presentation in consecutive patients included in the High-STEACS (High-SensitivityTroponin in the Evaluation of patients with Acute Coronary Syndrome) randomised controlled trial. Methods The High-STEACS trial was a stepped wedge cluster randomised controlled trial in ten hospitals across Scotland that included 48,282 patients in whom high-sensitivity cardiac troponin was requested by the attending clinician for evaluation of suspected ACS. Patients with ST-segment elevation myocardial infarction (STEMI) were excluded. We evaluated the negative predictive value (NPV) and sensitivity of a presentation hs-cTnI <5 ng/L for a composite outcome of type 1 myocardial infarction, or subsequent type 1 myocardial infarction or cardiac death at 30 days. To assess safety, we report the one-year risk of type 1 myocardial infarction or cardiac death. To assess efficacy, we report the proportion of patients with cardiac troponin <5 ng/L at presentation. Results We included 47,101 consecutive patients in the analysis (mean 61±17 years old, 47% female). Of these patients, 27,500 (58%) had a cardiac troponin <5 ng/L at presentation. Overall, 4,313/47,101 (9%) patients had a composite outcome at 30 days, but the event rate was only 0.4% in those with troponin <5 ng/L (98/27,500). The NPV for the composite outcome in those <5 ng/L was 99.7% (95% confidence intervals [CI] 99.6–99.7) and the sensitivity was 98.0% (95% CI 97.6–98.4). In those without evidence of myocardial injury at presentation (hs-cTnI <99thcentile), type 1 myocardial infarction or cardiac death at one year occurred in 197 (0.7%) patients with cardiac troponin <5 ng/L, compared to 647 (5.5%) of those ≥5 ng/L. The NPV was unchanged across all age groups, although efficacy fell as fewer older patients had hs-cTnI concentrations below the risk stratification threshold (see Figure). Conclusion A hs-cTnI concentration <5 ng/L at presentation identifies the majority of patients with suspected ACS as low-risk of early or late cardiac events. Although the proportion identified as low risk is reduced in older populations, the safety of this risk stratification approach is maintained across patients of all ages. Acknowledgement/Funding British Heart Foundation

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