Decreasing Troponin Redraws by Validating Tiered Hemolysis Thresholds

2019 ◽  
Vol 152 (Supplement_1) ◽  
pp. S11-S12
Author(s):  
Katherine Turner ◽  
Tanya Harnish ◽  
Zahra Madani ◽  
Erin Kaleta ◽  
Christine Snozek
Keyword(s):  
High Risk ◽  
Troponin T ◽  
Cardiac Injury ◽  
Significant Risk ◽  
Myocardial Infarctions ◽  
H Index ◽  
High Risk Patients ◽  
Risk Patients ◽  
The Mean ◽  
Serial Measurements

Abstract Cardiac troponin T (cTnT) assays are used for the diagnosis of acute myocardial infarctions and require serial measurements. Hemolysis is a common analytical interference for cTnT immunoassays, causing a false decrease in analyte concentration. Recollection of specimens that do not meet the recommended hemolysis threshold (H-index = 100) causes reporting delays and mistiming of serial measurements. This has been particularly disruptive to our emergency department and creates significant risk for patients whose diagnosis could be delayed by recollection due to hemolysis. Here we aimed to reevaluate the limits for acceptable hemolysis by determining the magnitude of cTnT concentration depression from hemolysis to evaluate whether more detailed thresholds could be established. To quantify the effects of hemolysis on cTnT, patient pools were prepared from residual serum with cTnT concentrations ranging from 10 to 100 ng/L and spiked with hemolysate prepared from lysed red blood cells to create H-indices ranging from 120 to 200. Samples were run in triplicate by the Elecsys Troponin T Gen. 5 STAT assay. Results demonstrated consistent percent decreases in cTnT across all concentrations tested for each level of hemolysis. The mean percent changes in cTnT concentrations in the presence of hemolysis for H-indices of 120, 140, 160, 180, and 200 were –3.4 ± 1.3%, –4.1 ± 1.2%, –6.3 ± 1.2%, –8.0 ± 1.7%, and –10.7 ± 1.22%, respectively. The observed decrease in cTnT was linearly related to the H index; predicted differences at higher H-indices (>200) agreed well with prior publications evaluating greater degrees of hemolysis. In our practice, a 2-hour delta ≥10 ng/L is considered significant for acute cardiac injury, <4 ng/L is a nonsignificant delta, and a delta of 4 to 9 ng/L is considered indeterminate. Baseline cTnT results of ≥100 ng/L result in immediate triage to cardiology. Approximately one-third of our patients with cTnT testing have baseline results within the reference range (≤15 ng/L males, ≤10 ng/L females). Based on the spiking data, H-index cutoffs were chosen to minimize recollections for low-risk and high-risk patients. Cutoffs for intermediate cTnT results were more restrictive to ensure delta interpretation would not change significantly. This resulted in a H-index of 300 for samples ≤8 ng/L, 200 for 9 to 40 ng/L, 160 for 41 to 70 ng/L, 140 for 71 to 99 ng/L, and 300 for ≥100 ng/L. These data quantify the percent change for cTnT in the presence of varying levels of hemolysis. At lower cTnT values, a larger degree of hemolysis can be tolerated because the percentage of depression results in a small absolute change, thus leading to less impact on the delta. The tiered H-index cutoffs allow minimal disruption to patient care for low- and high-risk patients, while maintaining the integrity of serial measurements for those with intermediate cTnT concentrations. Therefore, laboratories may consider releasing some hemolyzed cTnT specimens with a comment to decrease redraws and mistiming of serial measurements.

scholarly journals Evaluating Tiered Hemolysis Thresholds to Facilitate Rapid Reporting of High-Sensitivity Cardiac Troponin

2019 ◽  
Vol 4 (2) ◽  
pp. 193-200 ◽  
Author(s):  
Katherine A Turner ◽  
Erin J Kaleta ◽  
Tanya L Harnish ◽  
Zahra Madani ◽  
Christine L H Snozek
Keyword(s):  
High Risk ◽  
Cardiac Troponin ◽  
Troponin T ◽  
High Sensitivity ◽  
High Risk Patients ◽  
Percent Change ◽  
Risk Patients ◽  
The Mean ◽  
The Impact ◽  
Serial Measurements

Abstract Background Cardiac troponin (cTn) assays are used for the diagnosis of acute myocardial infarction and frequently require serial measurements. Recollection of unacceptable specimens for hemolysis can delay results and disrupt timing of serial measurements. This study was designed to assess the influence of hemolysis on a high-sensitivity cTnT assay in granular detail at clinically important concentrations. These were used in consultation with the clinical practice to evaluate risk-based thresholds for acceptable amounts of hemolysis. Methods Plasma pools ranging from &lt;10 to &gt;100 ng/L cTnT were spiked with hemolysate to various degrees of hemolysis and measured using the Elecsys Troponin T Gen 5 STAT assay. The impact of accepting expanded hemolysis thresholds was completed using retrospective data of 12225 serial cTnT results and an additional 4651 baseline cTnT results. Results The mean percent change in cTnT was consistent for a given degree of hemolysis regardless of the initial nonhemolyzed cTnT concentration. Tiered hemolysis thresholds were evaluated for low-risk patients (apparent cTnT ≤8 ng/L), intermediate-risk patients (thresholds for 9–37 ng/L, 38–66 ng/L, and 67–99 ng/L cTnT), and high-risk patients (≥100 ng/L cTnT). The influence of tiered hemolysis thresholds was calculated for patients with serial (0 and 2 h) cTnT results, which demonstrated that the majority of 2-h delta interpretations were unchanged. Implementation of tiered thresholds dramatically decreased recollections for hemolyzed cTnT samples. Conclusion Tiered hemolysis cutoffs minimized disruption to patient care for low- and high-risk patients, while maintaining the integrity of serial measurements for those with intermediate cTnT concentrations.

Sutureless Aortic Valve Implantation through an Upper V-Type Ministernotomy: An Innovative Approach in High-Risk Patients

2013 ◽  
Vol 8 (1) ◽  
pp. 23-28 ◽  
Author(s):  
Giovanni Concistrè ◽  
Antonio Miceli ◽  
Francesca Chiaramonti ◽  
Pierandrea Farneti ◽  
Stefano Bevilacqua ◽  
...  
Keyword(s):  
High Risk ◽  
Aortic Valve ◽  
Minimally Invasive ◽  
Minimally Invasive Approach ◽  
Invasive Approach ◽  
High Risk Patients ◽  
Risk Patients ◽  
The Mean ◽  
Valve Implantation

Objective Aortic valve replacement in minimally invasive approach has shown to improve clinical outcomes even with a prolonged cardiopulmonary bypass and aortic cross-clamp (ACC) time. Sutureless aortic valve implantation may ideally shorten operative time. We describe our initial experience with the sutureless 3f Enable (Medtronic, Inc, ATS Medical, Minneapolis, MN USA) aortic bioprosthesis implanted in minimally invasive approach in high-risk patients. Methods Between May 2010 and May 2011, thirteen patients with severe aortic stenosis underwent aortic valve replacement with the 3f Enable bioprosthesis through an upper V-type ministernotomy interrupted at the second intercostal space. The mean ± SD age was 77 ± 3.9 years (range, 72–83 years), 10 patients were women, and the mean ± SD logistic EuroSCORE was 15% ± 13.5%. Echocardiography was performed preoperatively, at postoperative day 1, at discharge, and at follow-up. Clinical data, adverse events, and patient outcomes were recorded retrospectively. The median follow-up time was 4 months (interquartile range, 2–10 months). Results Most of the implanted valves were 21 mm in diameter (19–25 mm). The CPB and ACC times were 100.2 ± 25.3 and 66.4 ± 18.6 minutes. At short-term follow-up, the mean ± SD pressure gradient was 14 ± 4.9 mm Hg; one patient showed trivial paravalvular leakage. No patients died during hospital stay or at follow-up. Conclusions The 3f Enable sutureless bioprosthesis implanted in minimally invasive approach through an upper V-type ministernotomy is a feasible, safe, and reproducible procedure. Hemodynamic and clinical data are promising. This innovative approach might be considered as an alternative in high-risk patients. Reduction of CPB and ACC time is possible with increasing of experience and sutureless evolution of actual technology.

scholarly journals Mitral surgical redo versus transapical transcatheter mitral valve implantation

PLoS ONE ◽  
2021 ◽  
Vol 16 (8) ◽  
pp. e0256569
Author(s):  
Alina Zubarevich ◽  
Marcin Szczechowicz ◽  
Arian Arjomandi Rad ◽  
Robert Vardanyan ◽  
Philipp Marx ◽  
...  
Keyword(s):  
High Risk ◽  
Mitral Valve ◽  
Valve Replacement ◽  
Mitral Valve Replacement ◽  
Left Ventricular ◽  
High Risk Patients ◽  
Transcatheter Mitral Valve Replacement ◽  
Risk Patients ◽  
The Mean ◽  
Similar Survival

Background Transcatheter methods have been rapidly evolving to provide an alternative less invasive therapeutic option, mainly because redo patients often present with multiple comorbidities and high operative risk. We sought to evaluate and compare our experience with transapical transcatheter mitral valve replacement (TA-TMVR) to conventional redo mitral valve replacement in patients presenting with degenerated biological mitral valve prostheses or failed valve annuloplasty. Methods and material Between March 2012 and November 2020, 74 consecutive high-risk patients underwent surgical redo mitral valve replacement (n = 33) or TA-TMVR (n = 41) at our institution. All patients presented with a history of a surgical mitral valve procedure. All transcatheter procedures were performed using the SAPIEN XT/3™ prostheses. Data collection was prospectively according to MVARC criteria. Results The mean logistic EuroSCORE-II of the whole cohort was 19.9±16.7%, and the median STS-score was 11.1±12.5%. The mean age in the SMVR group was 63.7±12.8 years and in the TMVR group 73.6±9.7 years. Patients undergoing TA-TMVR presented with significantly higher risk scores. Echocardiography at follow up showed no obstruction of the left ventricular outflow tract, no paravalvular leakage and excellent transvalvular gradients in both groups (3.9±1.2 mmHg and 4.2±0.8 mmHg in the surgical and transcatheter arm respectively). There was no difference in postoperative major adverse events between the groups with no strokes in the whole cohort. Both methods showed similar survival rates at one year and a 30-day mortality of 15.2% and 9.8% in SAVR and TMVR group, respectively. Despite using contrast dye in the transcatheter group, the rate of postoperative acute kidney failure was similar between the groups. Conclusion Despite several contraindications for surgery, we showed the non-inferiority of TA-TMVR compared to conventional surgical redo procedures in high-risk patients. With its excellent hemodynamic and similar survival rate, TA-TMVR offers a feasible alternative to the conventional surgical redo procedure in selected patients.

scholarly journals The Coming Hip and Femur Fracture Bundle: A New Inpatient Risk Stratification Tool for Care Providers

2018 ◽  
Vol 9 ◽  
pp. 215145931879531 ◽  
Author(s):  
Sanjit R. Konda ◽  
Ariana Lott ◽  
Kenneth A. Egol
Keyword(s):  
High Risk ◽  
Femur Fracture ◽  
High Risk Patients ◽  
Femur Fractures ◽  
Risk Stratification Tool ◽  
Risk Patients ◽  
The Mean ◽  
Trauma Triage ◽  
Level 1 ◽  
Level 1 Trauma Center

Introduction: In response to increasing health-care costs, Centers for Medicare & Medicaid Services has initiated several programs to transition from a fee-for-service model to a value-based care model. One such voluntary program is Bundled Payments for Care Improvement Advanced (BPCI Advanced) which includes all hip and femur fractures that undergo operative fixation. The purpose of this study was to analyze the current cost and resource utilization of operatively fixed (nonarthroplasty) hip and femur fracture procedure bundle patients at a single level 1 trauma center within the framework of a risk stratification tool (Score for Trauma Triage in the Geriatric and Middle-Aged [STTGMA]) to identify areas of high utilization before our hospitals transition to bundle period. Materials and Methods: A cohort of Medicare-eligible patients discharged with the Diagnosis-Related Group (DRG) codes 480 to 482 (hip and femur fractures requiring surgical fixation) from a level 1 trauma center between October 2014 and September 2016 was evaluated and assigned a trauma triage risk score (STTGMA score). Patients were stratified into groups based on these scores to create a minimal-, low-, moderate-, and high-risk cohort. Length of stay (LOS), discharge location, need for Intensive Care Unit (ICU)/Step Down Unit (SDU) care, inpatient complications, readmission within 90 days, and inpatient admission costs were recorded. Results: One hundred seventy-three patients with a mean age of 81.5 (10.1) years met inclusion criteria. The mean LOS was 8.0 (4.2) days, with high-risk patients having 4 days greater LOS than lower risk patients. The mean number of total complications was 0.9 (0.8) with a significant difference between risk groups ( P = .029). The mean total cost of admission for the entire cohort of patients was US$25,446 (US$9725), with a nearly US$9000 greater cost for high-risk patients compared to the low-risk patients. High-cost areas of care included room/board, procedure, and radiology. Discussion: High-risk patients were more likely to have longer and more costly admissions with average index admission costs nearly US$9000 more than the lower risk patient cohorts. These high-risk patients were also more likely to develop inpatient complications and require higher levels of care. Conclusion: This analysis of a 2-year cohort of patients who would qualify for the BPCI Advanced hip and femur procedure bundle demonstrates that the STTGMA tool can be used to identify high-risk patients who fall outside the bundle.

Risk factors for symptomatic venous thromboembolism in Thai hospitalised medical patients

2011 ◽  
Vol 106 (12) ◽  
pp. 1103-1108 ◽  
Author(s):  
Noppacharn Uaprasert ◽  
Laddawan Vajragupta ◽  
Numphung Numkarunarunrote ◽  
Nathaporn Tanpowpong ◽  
Pranee Sutcharitchan ◽  
...  
Keyword(s):  
Risk Factors ◽  
Venous Thromboembolism ◽  
High Risk ◽  
Autoimmune Disease ◽  
Tertiary Care ◽  
Significant Risk ◽  
Solid Tumours ◽  
Medical Patients ◽  
High Risk Patients ◽  
Risk Patients

SummaryThromboprophylaxis for venous thromboembolism (VTE) failed to reduce overall mortality in hospitalised medical patients. As a VTE prediction model for Asians is still lacking, this study aimed to identify very high risk patients who would be the main target for prevention. In 2009, medical patients admitted to King Chulalongkorn Memorial hospital, a tertiary care centre, were prospectively evaluated for risk factors. The high-risk cohort was monitored for symptomatic VTE until six weeks after discharge. No heparin prophylaxis was given. Of 1,290 high-risk patients, 27 (2.1%, 95% confidence interval [CI] 1.3–2.9) developed proven VTE, 25.9% of which were diagnosed after discharge. Cases with VTE stayed longer in the hospital (median 18 vs. 11 days, p < 0.001). The significant risk factors in a multivariate analysis were autoimmune disease, solid tumours, family history of VTE, varicose vein and oestrogen with the relative risks of 11.8, 4.7, 120.3, 40.1 and 17.1 (p < 0.001, 0.001, 0.001, 0.002 and 0.038), respectively. Either autoimmune disease or solid tumours were found in 63% of VTE with the relative risk of 4.5 (95% CI 2.1–9.7, p < 0.001). In contrast, previously reported VTE scores in western patients could not stratify the VTE risks, but all the scores predicted higher mortality. In conclusion, VTE is common in Asian hospitalised medical patients. Patients with autoimmune disease and those with solid tumours are highly susceptible to VTE. A prophylactic strategy in these groups is required.

Usefulness of Positive Troponin-T and Negative Creatine Kinase Levels in Identifying High-Risk Patients With Unstable Angina Pectoris

1997 ◽  
Vol 80 (4) ◽  
pp. 510-511 ◽  
Author(s):  
Trent L Pettijohn ◽  
Thomas Doyle ◽  
A. Michael Spiekerman ◽  
Linley E Watson ◽  
Mark W Riggs ◽  
...  
Keyword(s):  
Creatine Kinase ◽  
High Risk ◽  
Angina Pectoris ◽  
Unstable Angina ◽  
Troponin T ◽  
Unstable Angina Pectoris ◽  
High Risk Patients ◽  
Risk Patients

scholarly journals Moderate and Severe Postendoscopic Retrograde Cholangiopancreatography Pancreatitis Despite Prophylactic Pancreatic Stent Placement: The Effect of Early Prophylactic Pancreatic Stent Dislodgement

2011 ◽  
Vol 25 (4) ◽  
pp. 215-219 ◽  
Author(s):  
Dana C Moffatt ◽  
Pradermchai Kongkam ◽  
Haritha Avula ◽  
Stuart Sherman ◽  
Evan L Fogel ◽  
...  
Keyword(s):  
Risk Factors ◽  
High Risk ◽  
Stent Placement ◽  
Pancreatic Stent ◽  
High Risk Patients ◽  
Before And After ◽  
Risk Patients ◽  
The Mean ◽  
Length Of Hospitalization

BACKGROUND: Placement of prophylactic pancreatic stents (PPS) is a method proven to reduce the rate and severity of postendoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) in high-risk patients; however, PPS do not eliminate the risk completely. Early PPS dislodgement may occur prematurely and contribute to more frequent or severe PEP.OBJECTIVE: To determine the effect of early dislodgement of PPS in patients with moderate or severe PEP.METHOD: A total of 27,176 ERCP procedures from January 1994 to September 2007 for PPS placement in high-risk patients were analyzed. Patient and procedure data were analyzed to assess risk factors for PEP, and to evaluate the severity of pancreatitis, length of hospitalization and subsequent complications. Timing of stent dislodgment was assessed radiographically.RESULTS: PPS were placed in 7661 patients. Of these, 580 patients (7.5%) developed PEP, which was graded as mild in 460 (6.0%), moderate in 87 (1.1%) and severe in 33 (0.4%). Risk factors for developing PEP were not different in patients who developed moderate PEP compared with those with severe PEP. PPS dislodged before 72 h in seven of 59 (11.9%) patients with moderate PEP and five of 27 (18.5%) patients with severe PEP (P=0.505). The mean (± SD) length of hospitalization in patients with moderate PEP with stent dislodgement before and after 72 h were 7.43±1.46 days and 8.37±1.16 days, respectively (P=0.20). The mean length of hospitalization in patients with severe PEP whose stent dislodged before and after 72 h were 21.6±6.11 and 22.23±3.13 days, respectively (P=0.96).CONCLUSION: Early PPS dislodgement was associated with moderate and severe PEP in less than 20% of cases and was not associated with a more severe course. Factors other than ductal obstruction contribute to PEP in high-risk patients undergoing ERCP and PPS placement.

scholarly journals Sonic Estimation of Elasticity Via Resonance Sonorheometry to Predict Thrombotic Risk in Patients with Cancer

Blood ◽  
2016 ◽  
Vol 128 (22) ◽  
pp. 4996-4996 ◽  
Author(s):  
Erin McLoughlin ◽  
Elisa Ferrante ◽  
Francesco Viola ◽  
Hillary S. Maitland
Keyword(s):  
Lung Cancer ◽  
High Risk ◽  
Thrombin Time ◽  
Thrombotic Risk ◽  
Time Points ◽  
High Risk Patients ◽  
Upper Limit ◽  
Risk Patients ◽  
The Mean ◽  
D Dimer

Abstract Venous thromboembolic (VTE) disease is associated with significant morbidity and mortality and is one of the leading causes of death in patients diagnosed with a malignancy. The actual reported incidence of VTE in patients with malignancy varies greatly and depends on the type and stage of cancer, type of treatment, and patient-specific factors. This study is designed to assess the efficacy of a novel ultrasound-based technology, Sonic Estimation of Elasticity via Resonance (SEER) Sonorheometry, in predicting thrombosis and identifying high-risk patients. Treatment naïve patients with a new diagnosis of a solid tumor malignancy were eligible for inclusion in the study. Baseline conventional measures of hemostasis (D-Dimer, fibrinogen, thrombin time, PT/INR, PTT, and platelet count) were measured within the first cycle of chemotherapy and at 6 months for all patients. The HemoSonics' Quantra Hemostasis Analyzer (Quantra) is a point of care device that uses SEER Sonorheometry to measure key parameters of clot formation including clotting time, clot stiffness, and platelet and fibrinogen contributions to clot stiffness. A research use only (RUO) version of the Quantra was utilized to collect data within the first cycle of chemotherapy and at 6 months. Patients were monitored for the development of a venous thromboembolism. In order to determine the feasibility of using this technology/device on a larger scale, our ongoing enrollment goal for this pilot study is 20 patients. Seven patients with lung cancer (non-small cell lung cancer n=5, small cell lung cancer n=2), 4 patients with squamous cell carcinoma of the head and neck, and 1 patient with gastric adenocarcinoma have been enrolled to date. At the initial and 6-month time points, the mean values for INR, PT, PTT, thrombin time, and platelet count were normal. The mean D-dimer and mean fibrinogen were elevated at both time points. The D-dimer decreased by 7.1 percent over the 6 months while the mean fibrinogen increased by 7.7 percent over the same time period. The mean clotting time increased by 19.2% from 2.6 minutes to 3.1 minutes (95% CI, 2.1-4.1), however it remained within the normal limits of the assay. The mean values for the remaining Quantra parameters increased above the upper limit of normal for the assays over the 6-month time frame. Clot stiffness, fibrinogen and platelet contribution increased by 79.2, 83.3, and 84.0% respectively. Specifically, the mean fibrinogen contribution increased from 5.4 to 9.9 hecto-Pascals (hPa) (95% CI, 3.3-16.5) at 6 months, exceeding the upper limit of normal of 7.0 hPa. The mean platelet contribution to the clot increased from 18.2 to 33.5 hPa (95% CI, 20.6-46.5), exceeding the upper limit of normal of 30 hPa. The mean clot stiffness increased from 24 to 43 hPa over the 6-month interval; the upper limit of normal for the assay is 37 hPa. To date, there have been no documented occurrences of venous thromboembolism in our patient population. Thromboprophylaxis can be considered for certain high risk patients, however it is not currently recommended as a part of therapy for solid tumors. Additionally, identifying patients at high risk for thrombosis is difficult as no specific biomarkers have been shown to reliably predict VTE risk. SEER Sonorheometry and the Quantra will potentially allow for the ability to identify high risk patients based on parameters that more closely mimic in vivo hemostasis. The number of patients enrolled to date only allows for the observation of potential trends but there is a consistent increase in the clot stiffness as well as platelet and fibrinogen contributions in the patients' hemostatic balance as time progresses. Compared to using D-Dimer for predicting thrombotic risk, which is elevated at both time points, the Quantra parameters tended to be normal at the initial time point and increase over the 6 months to levels that exceeded the upper limit of normal for the assays. While this data suggests a trend toward increasing hypercoagulability with progressive chemotherapy cycles, more data is needed to confirm and understand the significance of these trends and to determine if SEER Sonorheometry and the Quantra can be used to identify those patients at highest risk for thrombosis. Disclosures Ferrante: Hemosonics: Employment. Viola:Hemosonics: Employment, Other: Shareholder.

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