3296Clinical application of the fourth universal definition of myocardial infarction

2019 ◽  
Vol 40 (Supplement_1) ◽  
Author(s):  
T Hartikainen ◽  
N A Soerensen ◽  
P M Haller ◽  
A Gossling ◽  
S Blankenberg ◽  
...  
Keyword(s):  
Myocardial Infarction ◽  
Heart Failure ◽  
Cardiovascular Events ◽  
Myocardial Injury ◽  
Troponin T ◽  
Chronic Injury ◽  
All Cause Mortality ◽  
Acute Myocardial Injury ◽  
Universal Definition ◽  
Definition Of

Abstract Background The recently released fourth version of the Universal Definition of Myocardial Infarction (UDMI) introduced substantial changes such as the implementation of the categories acute and chronic myocardial injury. It further recommends the use of sex-specific troponin cut-offs and consideration of absolute rather than relative changes of troponin concentrations for diagnosis of myocardial infarction (MI). Our aim was to apply the updated UDMI in patients with suspected MI to investigate its effect on diagnosis and prognosis. Methods We included 2'304 patients presenting to the emergency department with suspected MI. The final diagnosis was first adjudicated according to the 3rd UDMI by two physicians in a blinded fashion using all available medical records, laboratory findings including high-sensitivity troponin T results as well as clinical and imaging findings. Thereafter all patients were re-adjudicated based on the 4th UDMI, again all available information was used. Included patients were followed up to 4 years to assess all-cause mortality, incident nonfatal MI, revascularization and rehospitalization. Hazard ratios (HR) were calculated to investigate the effect of the diagnoses based on the 4th UDMI on prognosis. Results Out of 2'304 included patients, 708 got reclassified by the 4th UDMI. 442 (19.2%) were diagnosed as having MI compared to 504 (21.9%) based on the 3rd UDMI. Out of 1'862 non-MI patients, 74 (3.97%) patients had acute and 583 (31.3%) chronic myocardial injury (Figure 1). Patients with acute or chronic injury were older, more often female and had worse renal function than other non-MI patients. The most common causes for acute myocardial injury were heart failure, pulmonary embolism and takotsubo cardiomyopathy. For chronic myocardial injury hypertension, heart failure and non-obstructive coronary artery disease were the most frequent reasons. In cox regression analyses unadjusted HR for all-cause mortality in patients with acute or chronic myocardial injury was considerably higher when compared to patients with non-cardiac chest pain (HR 13.2 (confidence interval (CI) 6.7–26.3) (p<0.001) for acute myocardial injury and 7.2 (CI 4.2–12.5) (p<0.001) for chronic myocardial injury). After adjustment for age and gender, acute and chronic myocardial injury still strongly predicted a poorer outcome and higher rate of cardiovascular events compared to other non-MI patients. Patients with acute or chronic myocardial injury showed equally poor outcome as patients with MI. Figure 1. Re-adjudication Conclusion By introducing the categories of acute and chronic myocardial injury the 4th UDMI succeeds to identify non-MI patients with higher risk for cardiovascular events and poorer outcome and thus seems to improve risk assessment in this heterogeneous population. Prevention strategies for this specific population are yet to be investigated.

scholarly journals Troponin elevation pattern and subsequent cardiac and non-cardiac outcomes: Implementing the Fourth Universal Definition of Myocardial Infarction and high-sensitivity troponin at a population level

PLoS ONE ◽  
2021 ◽  
Vol 16 (3) ◽  
pp. e0248289
Author(s):  
Anthony (Ming-yu) Chuang ◽  
Mau T. Nguyen ◽  
Ehsan Khan ◽  
Dylan Jones ◽  
Matthew Horsfall ◽  
...  
Keyword(s):  
Myocardial Infarction ◽  
Ventricular Arrhythmia ◽  
Myocardial Injury ◽  
High Sensitivity ◽  
Cardiac Outcomes ◽  
High Sensitivity Troponin ◽  
Acute Myocardial Injury ◽  
Acute Mi ◽  
Universal Definition ◽  
Definition Of

Background The Fourth Universal Definition of Myocardial Infarction (MI) differentiates MI from myocardial injury. We characterised the temporal course of cardiac and non-cardiac outcomes associated with MI, acute and chronic myocardial injury. Methods We included all patients presenting to public emergency departments in South Australia between June 2011–Sept 2019. Episodes of care (EOCs) were classified into 5 groups based on high-sensitivity troponin-T (hs-cTnT) and diagnostic codes: 1) Acute MI [rise/fall in hs-cTnT and primary diagnosis of acute coronary syndrome], 2) Acute myocardial injury with coronary artery disease (CAD) [rise/fall in hs-cTnT and diagnosis of CAD], 3) Acute myocardial injury without CAD [rise/fall in hs-cTnT without diagnosis of CAD], 4) Chronic myocardial injury [elevated hs-cTnT without rise/fall], and 5) No myocardial injury. Multivariable flexible parametric models were used to characterize the temporal hazard of death, MI, heart failure (HF), and ventricular arrhythmia. Results 372,310 EOCs (218,878 individuals) were included: acute MI (19,052 [5.12%]), acute myocardial injury with CAD (6,928 [1.86%]), acute myocardial injury without CAD (32,231 [8.66%]), chronic myocardial injury (55,056 [14.79%]), and no myocardial injury (259,043 [69.58%]). We observed an early hazard of MI and HF after acute MI and acute myocardial injury with CAD. In contrast, subsequent MI risk was lower and more constant in patients with acute injury without CAD or chronic injury. All patterns of myocardial injury were associated with significantly higher risk of all-cause mortality and ventricular arrhythmia. Conclusions Different patterns of myocardial injury were associated with divergent profiles of subsequent cardiac and non-cardiac risk. The therapeutic approach and modifiability of such excess risks require further research.

scholarly journals Incidence and outcomes of perioperative myocardial infarction/injury diagnosed by high-sensitivity cardiac troponin I

2021 ◽  
Author(s):  
Danielle M. Gualandro ◽  
◽  
Christian Puelacher ◽  
Giovanna Lurati Buse ◽  
Noemi Glarner ◽  
...  
Keyword(s):  
Myocardial Infarction ◽  
Myocardial Injury ◽  
Troponin I ◽  
High Sensitivity ◽  
Prognostic Impact ◽  
Perioperative Myocardial Infarction ◽  
Important Complication ◽  
All Cause Mortality ◽  
Universal Definition ◽  
Definition Of

Abstract Background  Perioperative myocardial infarction/injury (PMI) diagnosed by high-sensitivity troponin (hs-cTn) T is frequent and a prognostically important complication of non-cardiac surgery. We aimed to evaluate the incidence and outcome of PMI diagnosed using hs-cTnI, and compare it to PMI diagnosed using hs-cTnT. Methods We prospectively included 2455 patients at high cardiovascular risk undergoing 3111 non-cardiac surgeries, for whom hs-cTnI and hs-cTnT concentrations were measured before surgery and on postoperative days 1 and 2. PMI was defined as a composite of perioperative myocardial infarction (PMIInfarct) and perioperative myocardial injury (PMIInjury), according to the Fourth Universal Definition of Myocardial Infarction. All-cause mortality was the primary endpoint. Results Using hs-cTnI, the incidence of overall PMI was 9% (95% confidence interval [CI] 8–10%), including PMIInfarct 2.6% (95% CI 2.0–3.2) and PMIInjury 6.1% (95% CI 5.3–6.9%), which was lower versus using hs-cTnT: overall PMI 15% (95% CI 14–16%), PMIInfarct 3.7% (95% CI 3.0–4.4) and PMIInjury 11.3% (95% CI 10.2–12.4%). All-cause mortality occurred in 52 (2%) patients within 30 days and 217 (9%) within 1 year. Using hs-cTnI, both PMIInfarct and PMIInjury were independent predictors of 30-day all-cause mortality (adjusted hazard ratio [aHR] 2.5 [95% CI 1.1–6.0], and aHR 2.8 [95% CI 1.4–5.5], respectively) and, 1-year all-cause mortality (aHR 2.0 [95% CI 1.2–3.3], and aHR 1.8 [95% CI 1.2–2.7], respectively). Overall, the prognostic impact of PMI diagnosed by hs-cTnI was comparable to the prognostic impact of PMI using hs-cTnT. Conclusions Using hs-cTnI, PMI is less common versus using hs-cTnT. Using hs-cTnI, both PMIInfarct and PMIInjury remain independent predictors of 30-day and 1-year mortality. Graphic abstract

scholarly journals Myocardial injury after aortoiliac revascularization for extensive disease: A survival analysis

2020 ◽  
Vol 28 (3) ◽  
pp. 426-434
Author(s):  
Juliana Pereira-Macedo
Keyword(s):  
Myocardial Infarction ◽  
Heart Failure ◽  
Cardiac Surgery ◽  
Chronic Heart Failure ◽  
Cardiovascular Events ◽  
Myocardial Injury ◽  
Major Adverse Cardiovascular Events ◽  
Extensive Disease ◽  
Type D ◽  
All Cause Mortality

Background: This study aims to evaluate the incidence of myocardial injury after non-cardiac surgery for an extensive disease pattern (TASC II type D) and to examine its prognostic value. Methods: This prospective study included a total of 66 consecutive patients (62 males, 4 females; mean age 62.5±8.2 years) who underwent elective revascularization for aortoiliac TASC II type D lesions in the tertiary setting between January 2013 and March 2019. The patients were scheduled for revascularization either by open surgery or endovascular approach. Cardiac troponins were routinely measured in the postoperative period. Myocardial injury after non-cardiac surgery was defined as the elevation of cardiac troponin for at least one value above the 99th percentile upper reference limit. Myocardial infarction, acute heart failure, stroke, major adverse cardiovascular events, major adverse limb events, and all-cause mortality were assessed both postoperatively and during follow-up. Results: The incidence of myocardial injury after non-cardiac surgery was 25.8%. In the multivariate analysis, chronic heart failure was found to be a significant risk factor for myocardial injury after non-cardiac surgery (odds ratio: 10.3; 95% confidence interval 1.00-106.8, p=0.018). At 12 months after revascularization, the diagnosis of myocardial injury after non-cardiac surgery was significantly associated with myocardial infarction, stroke, major adverse cardiovascular events, major adverse limb events, and all-cause mortality. At 12 months after revascularization, the diagnosis of myocardial injury after non-cardiac surgery was significantly associated with myocardial infarction (log-rank p=0.002), stroke (log-rank p=0.007), major adverse cardiovascular events (log-rank p=0.000), major adverse limb events (log-rank p=0.007), and all-causemortality (log-rank p=0.000). Conclusion: Our study results suggest that myocardial injury after non-cardiac surgery plays a role as a predictor of significant cardiovascular comorbidities and mortality after complex aortoiliac revascularization. The presence of chronic heart failure is also associated with a higher incidence of myocardial injury after aortoiliac TASC II type D revascularization. Therefore, preemptive strategies should be adopted to identify and treat these patients.

Acute versus chronic myocardial injury and long-term outcomes

Heart ◽  
2019 ◽  
Vol 105 (24) ◽  
pp. 1905-1912 ◽  
Author(s):  
Erik Kadesjö ◽  
Andreas Roos ◽  
Anwar Siddiqui ◽  
Liyew Desta ◽  
Magnus Lundbäck ◽  
...  
Keyword(s):  
Myocardial Infarction ◽  
Heart Failure ◽  
Myocardial Injury ◽  
Troponin T ◽  
Long Term Outcomes ◽  
Adjusted Risk ◽  
Risk Of Death ◽  
Acute Myocardial Injury ◽  
Similar Risk

ObjectiveThere is a paucity of data regarding prognosis in patients with acute versus chronic myocardial injury for long-term outcomes. We hypothesised that patients with chronic myocardial injury have a similar long-term prognosis as patients with acute myocardial injury.MethodsIn an observational cohort study of 22 589 patients who had high-sensitivity cardiac troponin T (hs-cTnT) measured in the emergency department during 2011–2014, we identified all patients with level >14 ng/L and categorised them as acute myocardial injury, type 1 myocardial infarction (T1MI), type 2 myocardial infarction (T2MI) or chronic myocardial injury through adjudication. We estimated adjusted HRs with 95% CIs for the primary outcome all-cause mortality and secondary outcomes MI, and heart failure in patients with acute myocardial injury, T1MI and T2MI compared with chronic myocardial injury.ResultsIn total, 3853 patients were included. During 3.9 (±2) years of follow-up, 48%, 24%, 44% and 49% of patients with acute myocardial injury, T1MI, T2MI and chronic myocardial injury died, respectively. Patients with acute myocardial injury had higher adjusted risks of death (1.21, 95% CI 1.08 to 1.36) and heart failure (1.24, 95% CI 1.07 to 1.43), but a similar risk for myocardial infarction (MI) compared with the reference group. Patients with T1MI had a lower adjusted risk of death (0.86, 95% CI 0.74 to 1.00) and higher risk of MI (2.09, 95% CI 1.62 to 2.68), but a similar risk of heart failure. Patients with T2MI had a higher adjusted risk of death (1.46, 95% CI 1.18 to 1.80) and heart failure (1.30, 95% CI 1.00 to 1.69) compared with patients with chronic myocardial injury.ConclusionsAbsolute long-term risks for death are similar, and adjusted risks are slightly higher, among patients with acute myocardial injury and T2MI, respectively, compared with chronic myocardial injury. The lowest risk of long-term mortality was found in patients with T1MI. Both acute and chronic myocardial injury are associated with very high risks of adverse outcomes.

Clinical application of the 4th Universal Definition of Myocardial Infarction

2020 ◽  
Vol 41 (23) ◽  
pp. 2209-2216 ◽  
Author(s):  
Tau S Hartikainen ◽  
Nils Arne Sörensen ◽  
Paul Michael Haller ◽  
Alina Goßling ◽  
Jonas Lehmacher ◽  
...  
Keyword(s):  
Myocardial Infarction ◽  
Emergency Department ◽  
Cardiovascular Events ◽  
Myocardial Injury ◽  
Final Diagnosis ◽  
High Accuracy ◽  
Diagnostic Algorithms ◽  
Diagnosis And Prognosis ◽  
Universal Definition ◽  
Definition Of

Abstract Aims The recently released 4th version of the Universal Definition of Myocardial Infarction (UDMI) introduces an increased emphasis on the entities of acute and chronic myocardial injury. We applied the 4th UDMI retrospectively in patients presenting to the emergency department with symptoms potentially indicating myocardial infarction (MI) to investigate its effect on diagnosis and prognosis. Methods and results We included 2302 patients presenting to the emergency department with symptoms suggestive of MI. The final diagnosis was adjudicated sequentially according to the 3rd and 4th UDMI. Reclassification after readjudication was assessed. Established diagnostic algorithms for patients with suspected MI were applied to compare diagnostic accuracy. All patients were followed to assess mortality, recurrent MI, revascularization, and rehospitalization to investigate the effect of the 4th UDMI on prognosis. After readjudication, 697 patients were reclassified. Most of these patients were reclassified as having acute (n = 78) and chronic myocardial injury (n = 585). Four hundred and thirty-four (18.9%) patients were diagnosed with MI, compared with 501 (21.8%) MIs when adjudication was based on the 3rd UDMI. In the non-MI population, patients with myocardial injury (n = 663) were older, more often female and had worse renal function compared with patients without myocardial injury (n = 1205). Application of diagnostic algorithms for patients with suspected MI revealed a high accuracy after readjudication. Reclassified patients had a substantially higher rate of cardiovascular events compared with not-reclassified patients, particularly patients reclassified to the category of myocardial injury. Conclusion By accentuating the categories of acute and chronic myocardial injury the 4th UDMI succeeds to identify patients with higher risk for cardiovascular events and poorer outcome and thus seems to improve risk assessment in patients with suspected MI. Application of established diagnostic algorithms remains safe when using the 4th UDMI.

Abstract 350: Assessment of Clinicians’ Attitudes and Knowledge About Cardiac Troponin Testing

2020 ◽  
Vol 13 (Suppl_1) ◽  
Author(s):  
Sandeep Jain ◽  
Andrew Hammes ◽  
Eric Rudofker ◽  
Karen Ream ◽  
Andrew E Levy
Keyword(s):  
Myocardial Infarction ◽  
Cardiac Troponin ◽  
Myocardial Injury ◽  
The United States ◽  
Advanced Practice ◽  
Attitudes And Knowledge ◽  
Universal Definition ◽  
Definition Of ◽  
Attending Physicians

In the United States, the positive predictive value (PPV) of cardiac troponin for type 1 myocardial infarction is substantially lower than in Europe (15% vs. 50%). Further, even with publication of the 4 th Universal Definition of Myocardial Infarction, recent studies have shown that inaccurate classification of myocardial injury is common among clinicians in the United States. These findings are at least partly attributable to clinicians’ knowledge and attitudes about cardiac troponin testing; a survey of these parameters has never been conducted. Clinicians at the University of Colorado completed a brief 8-question multiple-choice survey related to troponin use, definitions of myocardial infarction and clinical assessment of elevated troponin levels. The survey was distributed via secure email and administered electronically using the Qualtrics™ platform. Responses were anonymous, completion was estimated to take 3 minutes and a lottery award system was used as an incentive for participation. Respondents included trainees, advanced practice providers and attending physicians from internal medicine, emergency medicine and medical subspecialties. We plan to obtain a total of 300 responses with descriptive findings of preliminary results included below. The survey was completed by 114 clinicians: 37 interns (32%), 45 residents (39%), 9 advanced practice providers (8%), 11 fellows (10%), and 12 attending physicians (11%). Regarding indications for troponin testing, 93% (106/114) indicated that they “usually” or “always” check troponin levels in patients with chest pain. More interestingly, 46% (52/112) reported checking troponin on “undifferentiated patients” at least half the time. For troponin interpretation, 97% (110/114) of participants identified that troponin levels alone cannot rule in or rule out coronary artery disease. In contrast, only 36% (41/114) and 55% (63/114), respectively, identified the NPV and PPV of a contemporary troponin assay for type 1 MI. Further, only 50% (57/114) of respondents identified that the likelihood of type 1 MI increases as troponin levels increase. Three brief clinical vignettes revealed that, while 78% (89/114) and 74% (45/61) of participants, respectively, identified type 1 MI and type 2 MI presentations, only 40% (21/53) of respondents correctly identified a vignette for non-ischemic myocardial injury. Concordant with this finding, 54% (61/114) of clinicians correctly identified the 4 th Universal Definition of Myocardial Infarction. These preliminary findings highlight important facets of clinician attitudes and knowledge about troponin testing that help explain the poor PPV for troponin and diagnostic misclassification observed among U.S. clinicians. These results could help guide curricular and clinical decision support interventions designed to improve the use and interpretation of cardiac troponin testing.

scholarly journals Concordance, Variance, and Outliers in 4 Contemporary Cardiac Troponin Assays: Implications for Harmonization

2012 ◽  
Vol 58 (1) ◽  
pp. 274-283 ◽  
Author(s):  
Jacobus P J Ungerer ◽  
Louise Marquart ◽  
Peter K O'Rourke ◽  
Urs Wilgen ◽  
Carel J Pretorius
Keyword(s):  
Myocardial Infarction ◽  
Cardiac Troponin ◽  
Troponin I ◽  
Troponin T ◽  
Analytical Imprecision ◽  
Universal Definition ◽  
Definition Of ◽  
Abbott Architect ◽  
Roche Cobas

Abstract BACKGROUND Data to standardize and harmonize the differences between cardiac troponin assays are needed to support their universal status in diagnosis of myocardial infarction. We characterized the variation between methods, the comparability of the 99th-percentile cutoff thresholds, and the occurrence of outliers in 4 cardiac troponin assays. METHODS Cardiac troponin was measured in duplicate in 2358 patient samples on 4 platforms: Abbott Architect i2000SR, Beckman Coulter Access2, Roche Cobas e601, and Siemens ADVIA Centaur XP. RESULTS The observed total variances between the 3 cardiac troponin I (cTnI) methods and between the cTnI and cardiac troponin T (cTnT) methods were larger than expected from the analytical imprecision (3.0%–3.7%). The between-method variations of 26% between cTnI assays and 127% between cTnI and cTnT assays were the dominant contributors to total variances. The misclassification of results according to the 99th percentile was 3%–4% between cTnI assays and 15%–17% between cTnI and cTnT. The Roche cTnT assay identified 49% more samples as positive than the Abbott cTnI. Outliers between methods were detected in 1 patient (0.06%) with Abbott, 8 (0.45%) with Beckman Coulter, 10 (0.56%) with Roche, and 3 (0.17%) with Siemens. CONCLUSIONS The universal definition of myocardial infarction should not depend on the choice of analyte or analyzer, and the between- and within-method differences described here need to be considered in the application of cardiac troponin in this respect. The variation between methods that cannot be explained by analytical imprecision and the discordant classification of results according to the respective 99th percentiles should be addressed.

scholarly journals Myocardial Injury after Noncardiac Surgery

2014 ◽  
Vol 120 (3) ◽  
pp. 564-578 ◽  
Keyword(s):  
Diagnostic Criteria ◽  
Myocardial Injury ◽  
Cox Regression ◽  
Troponin T ◽  
Perioperative Complications ◽  
Population Attributable Risk ◽  
Noncardiac Surgery ◽  
Universal Definition ◽  
Definition Of ◽  
Diagnostic Criterion

Abstract Background: Myocardial injury after noncardiac surgery (MINS) was defined as prognostically relevant myocardial injury due to ischemia that occurs during or within 30 days after noncardiac surgery. The study’s four objectives were to determine the diagnostic criteria, characteristics, predictors, and 30-day outcomes of MINS. Methods: In this international, prospective cohort study of 15,065 patients aged 45 yr or older who underwent in-patient noncardiac surgery, troponin T was measured during the first 3 postoperative days. Patients with a troponin T level of 0.04 ng/ml or greater (elevated “abnormal” laboratory threshold) were assessed for ischemic features (i.e., ischemic symptoms and electrocardiography findings). Patients adjudicated as having a nonischemic troponin elevation (e.g., sepsis) were excluded. To establish diagnostic criteria for MINS, the authors used Cox regression analyses in which the dependent variable was 30-day mortality (260 deaths) and independent variables included preoperative variables, perioperative complications, and potential MINS diagnostic criteria. Results: An elevated troponin after noncardiac surgery, irrespective of the presence of an ischemic feature, independently predicted 30-day mortality. Therefore, the authors’ diagnostic criterion for MINS was a peak troponin T level of 0.03 ng/ml or greater judged due to myocardial ischemia. MINS was an independent predictor of 30-day mortality (adjusted hazard ratio, 3.87; 95% CI, 2.96–5.08) and had the highest population-attributable risk (34.0%, 95% CI, 26.6–41.5) of the perioperative complications. Twelve hundred patients (8.0%) suffered MINS, and 58.2% of these patients would not have fulfilled the universal definition of myocardial infarction. Only 15.8% of patients with MINS experienced an ischemic symptom. Conclusion: Among adults undergoing noncardiac surgery, MINS is common and associated with substantial mortality.

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