LO60: Diagnostic utility of creatine kinase in the diagnosis and management of non-ST elevation myocardial infarction

Introduction: Creatine kinase (CK) measurement, despite not being recommended for the diagnosis of a Non-ST Elevation Myocardial Infarction (NSTEMI) is still routinely performed in the emergency department (ED) for the workup of NSTEMI. The diagnostic utility of CK among ED patients with suspected NSTEMI is still not well understood. The objectives of this study were to assess: the additional value of CK in NSTEMI diagnosis and the correlation between the highest CK/TNI values and ejection fraction (EF) on follow-up echocardiography among patients with suspected NSTEMI. Methods: This was a prospective cohort study conducted at the Civic and General Campuses of The Ottawa Hospital from March 2014 to March 2016. We enrolled adults (18 years) for whom troponin (TNI) and CK were ordered for chest pain or non-chest pain symptoms within the past 24 hours concerning for NSTEMI and excluded those with suspected ST-Elevation Myocardial Infarction (STEMI). Primary outcome was a 30-day NSTEMI adjudicated by two blinded physicians. Demographics, medical history, and ED CK/TNI values were collected. We used descriptive statistics and report test diagnostic characteristics. Results: Of the 1,663 patients enrolled, 84 patients (5.1%) suffered NSTEMI. The sensitivity and specificity of CK was 30.9% (95%CI 21.1, 40.8) and 91.4% (95%CI 90.0, 92.8) respectively. The sensitivity and specificity of troponin was 96.4% (95%CI 92.4, 100) and 88.1% (95%CI 86.5, 89.7) respectively. Among 3 (0.2%) patients with missed NSTEMI diagnosis with TNI, CK measurements did not add value. The mean CK values were not significantly different between those with normal and abnormal EF on follow-up (132.4 U/L and 146.3 U/L respectively; p=0.44), whereas the mean TNI values were significantly different (0.5 µg/L and 1.3 µg/L respectively; p=0.046). Conclusion: CK measurements neither provide any additional value in the work-up of NSTEMI in the ED nor correlate with EF on follow-up. Discontinuing routine CK measurements would reduce overall costs and improve resource utilization in the ED, and streamline the management of patients in the ED with chest pain.

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Diagnostic Utility of Creatine Kinase in Patients Presenting to the Emergency Department with Chest Pain

University of Ottawa Journal of Medicine ◽

10.18192/uojm.v10i2.4826 ◽

2021 ◽

Vol 10 (2) ◽

Author(s):

Venkatesh Thiruganasambandamoorthy ◽

Brandon Lam ◽

Hina Chaudry ◽

Muhammad Mukarram ◽

Marie-Joe Nemnom ◽

...

Keyword(s):

Myocardial Infarction ◽

Creatine Kinase ◽

Troponin I ◽

Wilcoxon Test ◽

St Elevation Myocardial Infarction ◽

Diagnostic Utility ◽

Ottawa Hospital ◽

Diagnostic Characteristics ◽

St Elevation

Introduction: Creatine Kinase (CK) is routinely performed in some emergency departments (ED) for Non-ST-elevation myocardial infarction (NSTEMI) workup. Its diagnostic utility is not well understood. The objectives of this study were to assess the value of CK in NSTEMI diagnosis in the troponin era and the association between the highest CK/Troponin values and ejection fraction (EF) during NSTEMI follow-up. Methods: A prospective cohort study conducted at the two EDs of The Ottawa Hospital from March 2014 to March 2016 enrolled adults (≥18 years) for whom troponin I (TnI) and CK were ordered for NSTEMI symptoms. We excluded those with ST-Elevation Myocardial Infarction (STEMI). The primary outcome was a NSTEMI within 30 days. We used descriptive statistics and report test diagnostic characteristics with 95% confidence intervals (CI). We compared the highest median CK/Troponin values using Wilcoxon test. Results: Of the 2,153 patients enrolled, 99 (4.6%) suffered a NSTEMI. The sensitivity and specificity were: CK (cutoff >250U/L) 31.3% (95%CI 22.2, 40.5) and 91.1% (95%CI 89.9, 92.4) respectively; TnI (cutoff >0.045µg/L) 98.0% (95%CI 95.2, 100) and 86.2% (95%CI 84.7, 87.7) respectively. The median CK values were not significantly different between those with normal (n=267) and abnormal EF (n=55) on follow-up (107 U/L and 118 U/L respectively; p=0.31), whereas the median TnI values were significantly different (0.02 µg/L and 0.1 µg/L respectively; p<0.0001). Conclusions: CK measurements do not provide any value in the ED work-up of NSTEMI and is not associated with EF on follow-up. Discontinuing routine CK measurements would improve resource utilization.

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ECG of the month

British Journal of Cardiac Nursing ◽

10.12968/bjca.2021.0008 ◽

2021 ◽

Vol 16 (1) ◽

pp. 1-1

Author(s):

Charles Bloe

Keyword(s):

Myocardial Infarction ◽

Chest Pain ◽

Acute Chest Pain ◽

St Elevation Myocardial Infarction ◽

St Elevation ◽

Lost To Follow Up

In this issue's ECG of the month, Charles Bloe highlights a case of a 36-year-old woman presenting with severe acute chest pain after previously being lost to follow up post ST-elevation myocardial infarction.

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ECG of the month

British Journal of Cardiac Nursing ◽

10.12968/bjca.2021.0021 ◽

2021 ◽

pp. 1-2

Author(s):

Charles Bloe

Keyword(s):

Myocardial Infarction ◽

Chest Pain ◽

St Elevation Myocardial Infarction ◽

St Elevation ◽

Lost To Follow Up

In this issue's ECG of the month, Charles Bloe presents a case of a 36-year-old woman with severe central chest pain who had been lost to follow up after an ST-elevation myocardial infarction 4 years earlier.

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Early vascular responses to ultrathin biodegradable polymer sirolimus-eluting stent for the treatment of st-elevation myocardial infarction

European Heart Journal ◽

10.1093/ehjci/ehaa946.1781 ◽

2020 ◽

Vol 41 (Supplement_2) ◽

Author(s):

Y Oishi ◽

T Shinke ◽

H Tanaka ◽

K Ogura ◽

K Arai ◽

...

Keyword(s):

Myocardial Infarction ◽

Clinical Outcomes ◽

Antiplatelet Therapy ◽

St Elevation Myocardial Infarction ◽

Current Generation ◽

Vascular Responses ◽

Post Procedure ◽

St Elevation ◽

Sirolimus Eluting Stent

Abstract Background Recent clinical study suggests newer-generation drug-eluting stents (DES) that combine ultrathin strut and nano-coating with biodegradable polymers sirolimus-eluting stent (BP-SES) could improve long-term clinical outcomes in patients with ST-elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PCI) over current generation DES. However, safety profiles in very early phase have not been systematically addressed. Objective and method We exploratory investigate early vascular response following BP-SES implantation in patients with STEMI to reveal mechanism of the favorable clinical outcomes in recent studies using frequency domain-optical coherence tomography (FD-OCT). Consecutive twenty patients with STEMI who underwent FD-OCT immediately after primary PCI and were eligible for follow-up FD-OCT at 2 weeks after implantation were enrolled between June 2018 and November 2019. Results Twenty patients (age 62.7±11.3 years, male 85.0%) were enrolled with frequencies of hypertension (45.0%), diabetes mellitus (35.0%), dyslipidemia (55.0%) and smoking (80.0%). Aspiration catheter were used in all patients, and 1.13±0.34 stents were used. Only one patient (5.0%) received chronic antiplatelet therapy with aspirin prior to the onset of STEMI. All patients started to receive prasugrel as thienopyridine from this event and continued dual antiplatelet therapy for 2 weeks. The percentage of uncovered struts significantly decreased from post-procedure to 2W follow-up (69±18% post-procedure versus 30±11% at 2W follow up, p<0.0001). Malapposed struts also decreased (5.6±5.7% post-procedure versus0.9±1.2% at 2W follow up, p<0.0001).The average protrusion area of athero-thrombotic burden numerically decreased (0.37±0.19 at post-procedure versus 0.34±0.14 mm2 at 2W follow up, p=0.19) and its volume showed similar tendency (10.60±6.40 at post-procedure versus 9.36±5.14 mm3 at 2W follow up, p=0.19). Conclusion(s) This study firstly elucidated very early vascular responses following ultrathin strut BP-SES implantation in STEMI patients, showing early progression of strut coverage and resolution of athero-thrombotic materials. This technology may have a potential to overcome the current generation DESs in this clinical setting. Thrombus, uncovered and malapposed struts Funding Acknowledgement Type of funding source: None

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Short-term follow-up of tirofiban as alternative therapy for urgent surgery patients with an implanted coronary drug-eluting stent after ST-elevation myocardial infarction

Coronary Artery Disease ◽

10.1097/mca.0b013e3283645c79 ◽

2013 ◽

Vol 24 (6) ◽

pp. 522-526 ◽

Cited By ~ 8

Author(s):

Jing-Gang Xia ◽

Yang Qu ◽

Hong Shen ◽

Xiu-Hua Liu

Keyword(s):

Myocardial Infarction ◽

Alternative Therapy ◽

St Elevation Myocardial Infarction ◽

Drug Eluting Stent ◽

Short Term ◽

Urgent Surgery ◽

Drug Eluting ◽

St Elevation

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Abstract 5605: Real World Comparison of Long Term Mortality after Primary Percutanous Coronary Intervention (PPCI) versus Fibrinolysis for Acute St Elevation Myocardial Infarction: Initial Experience from the 24 Hour PPCI Program in Nova Scotia

Circulation ◽

10.1161/circ.118.suppl_18.s_972-d ◽

2008 ◽

Vol 118 (suppl_18) ◽

Author(s):

Boniface Chan ◽

Helen Curran ◽

Michael P Love ◽

Stephen Fort

Keyword(s):

Myocardial Infarction ◽

Nova Scotia ◽

Real World ◽

Cox Regression ◽

Coronary Intervention ◽

St Elevation Myocardial Infarction ◽

Coronary Artery Patency ◽

St Elevation ◽

Door To Balloon

Background Randomized controlled trials indicate that acute ST elevation myocardial infarction (STEMI) patients have better clinical outcomes if rapid, complete and stable coronary artery patency can be achieved. The Queen Elizabeth II Health Sciences Center in Halifax, Nova Scotia (QEIIHSC) commenced a 24 hour PPCI program in November 2005. This real world study compares 2 year mortality in STEMI patients treated by PPCI versus patients treated by fibrinolysis with provisional rescue PCI within Nova Scotia, Canada. Methods This was a single center retrospective cohort study. All consecutive Nova Scotia, fibrinolytic and PPCI eligible STEMI patients presenting within 12 hours of symptom onset between July 1 st 2005 and June 30 th 2006 treated by PPCI at the QEIIHSC or fibrinolyis outside the QEIIHSC were included. The outcome measure was all cause mortality censored on June 30 th 2007. The crude and independent association between PPCI versus fibrinolysis on mortality was estimated using a Cox regression model. Results Data for 423 eligible patients (100% of cohort) comprised of 359/423 (85%) patients treated with fibrinolytics and 64/359 (18%) treated by PPCI were analyzed. The median follow-up was 1.4 years. The median (Q25 to Q75) door to needle times in the fibrinolytic group and corresponding door to balloon times in the PPCI group were: 0.5 (.3 to .9) and 1.5 (1.1 to 1.9) hours respectively. PPCI was associated with a consistent trend toward lower mortality versus fibrinolysis during hospitalization: 2/64 (3.1%) vs. 29/359 (8.1%), P=0.16 and at 30 days 2/64 (3.1%) vs. 32/359 (15%), P=0.12. This association was significant at 1 and 2 year follow-up: 2/64 (3.1%) vs. 41/359 (11%), P=0.043 and 2/64 (3.1%) vs. 45/359 (12%), P=0.027 respectively. This corresponded with an independent HR for 2 year mortality of: 0.1 (.01 to 0.8), p=0.03. Conclusion Initial data from the PPCI program at the QEIIHSC in Halifax, Nova Scotia indicates that PPCI was associated significant reductions in mortality versus fibrinolysis for real world patients presenting with STEMI. This mortality reduction was achieved in the early pilot phase of a PPCI program with evolving door to balloon timelines versus an established fibrinolytic program with acceptable door to needle timelines.

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Novel biomarker of Cysteine-rich angiogenic inducer 61 (Cyr61) predicts long-term outcome of ST-elevation myocardial infarction

10.21203/rs.2.14310/v1 ◽

2019 ◽

Author(s):

Rui Xiang ◽

Min Mao ◽

Ping Tang ◽

Jun Gu ◽

Kanghua Ma

Keyword(s):

Myocardial Infarction ◽

St Elevation Myocardial Infarction ◽

Cardiac Complications ◽

Term Outcome ◽

Long Term Outcome ◽

Risk Of Death ◽

Secondary Endpoints ◽

St Elevation

Abstract Background: Cysteine-rich angiogenic inducer 61 (Cyr61) is a matricellular protein participating in the angiogenesis, inflammation, and fibrotic tissue repair. Previous study has proven its value in diagnosing and risk stratification of ST-elevation myocardial infarction (STEMI). However, there is no study focusing on Cyr61 and the long-term outcome of STEMI. Methods: A total of 426 patients diagnosed with STEMI were enrolled in this study. Blood sample was acquired 24 hours after the admission. The patients were required long-term follow-up after the discharge, when primary endpoint of all-cause death and secondary endpoint of cardiac complications were observed. Cox hazard ratio model and survival analysis were used to compare the risk of patients with higher level and lower level of Cyr61. Results: We conducted an average of (48.4 ± 17.8) months of follow-up, during which a total of 28 deaths happened (6.6%), while 106 episodes of secondary endpoints occurred (24.9%). Patients with higher quartile (Q4) Cyr61 were at higher risk of death [HR 3.404 95%CI (1.574-7.360), P<0.001] when compared with lower three quartiles (Q1-Q3) Cyr61. In terms of secondary endpoints, patients with Q4 Cyr61 were subject to 4.718 [95%CI (3.189-6.978) , P<0.001] times of risk compared with Q1-Q3 Cyr61. Conclusions: For STEMI Patients, those with increased Cyr61 have higher risk of all-cause death and cardiac complications. Therefore, Cyr61 may be a useful tool in predicting the long-term prognosis of STEMI.

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