Role of Creatine Kinase in the Troponin Era: A Systematic Review

Introduction: The diagnosis of non-ST-elevated myocardial infarction (NSTEMI) depends on a combination of history, electrocardiogram, and cardiac biomarkers. The most sensitive and specific biomarkers for cardiac injury are the troponin assays. Many hospitals continue to automatically order less sensitive and less specific biomarkers such as creatine kinase (CK) alongside cardiac troponin (cTn) for workup of patients with chest pain. The objective of this systematic review was to identify whether CK testing is useful in the workup of patients with NSTEMI symptoms. Methods: We undertook a systematic review to ascertain whether CK ordered as part of the workup for NSTEMI was useful in screening patients with cardiac chest pain. The MEDLINE, Embase, and Cochrane databases were searched from January 1995–September 2020. Additional papers were added after consultation with experts. We screened a total of 2,865 papers, of which eight were included in the final analysis. These papers all compared CK and cTn for NSTEMI diagnosis. Results: In each of the eight papers included in the analysis, cTn showed a greater sensitivity and specificity than CK in the diagnosis of NSTEMI. Furthermore, none of the articles published reliable evidence that CK is useful in NSTEMI diagnosis when troponin was negative. Conclusion: There is no evidence to continue to use CK as part of the workup of NSTEMI acute coronary syndrome in undifferentiated chest pain patients. We conclude that CK should not be used to screen patients presenting to the emergency department with chest pain.

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PP23 Accuracy of emergency medical services (EMS) telephone triage in identifying acute coronary syndrome (ACS) for chest pain patients. A systematic review abstract

Emergency Medicine Journal ◽

10.1136/emermed-2021-999.23 ◽

2021 ◽

Vol 38 (9) ◽

pp. A10.2-A10

Author(s):

Ahmed Alotaibi ◽

Abdulrhman Alghamdi ◽

Charles Reynard ◽

Richard Body

Keyword(s):

Systematic Review ◽

Acute Coronary Syndrome ◽

Chest Pain ◽

Prediction Models ◽

Meta Analysis ◽

Final Diagnosis ◽

Telephone Triage ◽

Coronary Syndrome ◽

Life Threatening ◽

Pain Patients

IntroductionChest pain is one of the most common reasons for ambulance callouts and presentation to Emergency Departments (EDs). Differentiating patients with serious conditions (e.g. acute coronary syndrome [ACS]) from the majority, who have self-limiting, non-cardiac conditions is extremely challenging. This causes over-triage and over-use of healthcare resources. We aimed to systematically review existing evidence on the accuracy of emergency telephone triage to detect ACS or life-threatening conditions associated with chest pain.MethodsWe conducted a systematic review in accordance with PRISMA guidelines. Two independent investigators searched the Embase, Medline, and Cinahl databases for relevant papers. We included retrospective and prospective cohort studies written in English and investigating EMS telephone triage for chest pain patients linked with final diagnosis of ACS. Studies were summarised in a narrative format as the data were not suitable for meta-analysis.ResultIn total, 553 studies were identified from the literature search and cross-referencing. After excluding 550 studies, three were eligible for inclusion. Among those 3 studies, there are different prediction models developed by authors with variation in variables to detect ACS. The result showed that dispatch triage tools have good sensitivity to detect ACS and life-threatening conditions although they are used to triage sign and symptoms rather than diagnosing the patients. On the other hand, prediction models were built to detect ACS and life-threatening conditions and therefore it showed better sensitivity and NPV.ConclusionEMS dispatch systems accuracy for ACS and life-threatening conditions associated with chest pain is good. Since the dispatch tools were built to triage ambulance response priority based on sign and symptoms, this led to over triage among non-life-threatening chest pain patients. Over triage were slightly reduced by deriving prediction models and showed better sensitivity.

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MP46: Creatine kinase in the emergency department: antiquated relic or useful adjunct in diagnosis of NSTEMI: A systematic review

CJEM ◽

10.1017/cem.2019.181 ◽

2019 ◽

Vol 21 (S1) ◽

pp. S59

Author(s):

D. Beamish ◽

T. Maniuk ◽

M. Mukarram ◽

V. Thiruganasambandamoorthy

Keyword(s):

Systematic Review ◽

Emergency Department ◽

Creatine Kinase ◽

Final Analysis ◽

Outcome Data ◽

Definitive Diagnosis ◽

Cardiac Biomarkers ◽

Reference List ◽

Published Evidence ◽

Work Up

Introduction: The diagnosis of non-ST elevated myocardial infarction (NSTEMI) depends on a combination of history, ECG and cardiac biomarkers. Many hospitals continue to automatically order less sensitive and specific biomarkers such as Creatine Kinase (CK) alongside cardiac Troponin (cTn) as part of an extended panel of bloodwork for work-up of patients with suspected NSTEMI. Methods: We undertook a systematic review to assess the usefulness of CK measurements in addition to cTnI in NSTEMI diagnosis. Medline, EMBASE and Cochrane databases were searched from 1995 until May 31, 2018. We added additional articles after reviewing the reference list of pertinent articles and consulting experts. A total of 1123 papers were screened, of which 8 were included in the final analysis. These papers all compared CK and troponin (TnI) testing in the diagnosis of NSTEMI. Results: Of the 8 papers included in the analysis none showed CK having a greater sensitivity or specificity than the TnI assays. Furthermore, no paper originally published evidence of CK diagnosing NSTEMI when Troponin was negative. One author, when contacted, described 10% of patients diagnosed with NSTEMI as having discordant data (eg. +CK, -Troponin). However, the outcome data such as angiography and echocardiography were not available for these patients, making definitive diagnosis unclear. Conclusion: Troponin has consistently shown to have greater sensitivity and specificity than CK in the diagnosis of NSTEMI with CK adding no improvements in diagnosis. We believe CK should not be used in the emergency department work-up for NSTEMI diagnosis.

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The Impact of B-Type Natriuretic Peptide in Addition to Troponin I, Creatine Kinase-MB, and Myoglobin on the Risk Stratification of Emergency Department Chest Pain Patients With Potential Acute Coronary Syndrome

Annals of Emergency Medicine ◽

10.1016/j.annemergmed.2006.08.024 ◽

2007 ◽

Vol 49 (2) ◽

pp. 153-163 ◽

Cited By ~ 16

Author(s):

Aaron M. Brown ◽

Keara L. Sease ◽

Jennifer L. Robey ◽

Frances S. Shofer ◽

Judd E. Hollander

Keyword(s):

Emergency Department ◽

Acute Coronary Syndrome ◽

Creatine Kinase ◽

Chest Pain ◽

Risk Stratification ◽

Troponin I ◽

Coronary Syndrome ◽

Creatine Kinase Mb ◽

The Impact ◽

Pain Patients

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Role of Cardio-Specific Micro-Ribonucleic Acids and Correlation with Cardiac Biomarkers in Acute Coronary Syndrome: A Comprehensive Systematic Review

Cureus ◽

10.7759/cureus.5878 ◽

2019 ◽

Author(s):

Raja S Mushtaque ◽

Sajid Hameed ◽

Rabia Mushtaque ◽

Muhammad Idrees ◽

Farah Siraj

Keyword(s):

Systematic Review ◽

Acute Coronary Syndrome ◽

Cardiac Biomarkers ◽

Ribonucleic Acids ◽

Coronary Syndrome

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The feasibility and diagnostic accuracy by multiple cardiac biomarkers in emergency chest pain patients: a clinical analysis to compare 290 suspected acute coronary syndrome cases stratified by age and gender in Taiwan

BMC Cardiovascular Disorders ◽

10.1186/s12872-016-0374-4 ◽

2016 ◽

Vol 16 (1) ◽

Cited By ~ 4

Author(s):

Chung-Lieh Hung ◽

Ding-Kuo Chien ◽

Shou-Chuan Shih ◽

Wen-Han Chang

Keyword(s):

Acute Coronary Syndrome ◽

Chest Pain ◽

Diagnostic Accuracy ◽

Clinical Analysis ◽

Cardiac Biomarkers ◽

Age And Gender ◽

Coronary Syndrome ◽

And Gender ◽

Pain Patients

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Cardiac biomarkers in acute respiratory distress syndrome: a systematic review and meta-analysis

Journal of Intensive Care ◽

10.1186/s40560-021-00548-6 ◽

2021 ◽

Vol 9 (1) ◽

Author(s):

Dilip Jayasimhan ◽

Simon Foster ◽

Catherina L. Chang ◽

Robert J. Hancox

Keyword(s):

Systematic Review ◽

Acute Respiratory Distress Syndrome ◽

Intensive Care ◽

Cardiac Dysfunction ◽

Distress Syndrome ◽

Troponin I ◽

Meta Analysis ◽

Cardiac Injury ◽

Cardiac Biomarkers ◽

Risk Of Death

Abstract Background Acute respiratory distress syndrome (ARDS) is a leading cause of morbidity and mortality in the intensive care unit. Biochemical markers of cardiac dysfunction are associated with high mortality in many respiratory conditions. The aim of this systematic review is to examine the link between elevated biomarkers of cardiac dysfunction in ARDS and mortality. Methods A systematic review of MEDLINE, EMBASE, Web of Science and CENTRAL databases was performed. We included studies of adult intensive care patients with ARDS that reported the risk of death in relation to a measured biomarker of cardiac dysfunction. The primary outcome of interest was mortality up to 60 days. A random-effects model was used for pooled estimates. Funnel-plot inspection was done to evaluate publication bias; Cochrane chi-square tests and I2 tests were used to assess heterogeneity. Results Twenty-two studies were included in the systematic review and 18 in the meta-analysis. Biomarkers of cardiac stretch included NT-ProBNP (nine studies) and BNP (six studies). Biomarkers of cardiac injury included Troponin-T (two studies), Troponin-I (one study) and High-Sensitivity-Troponin-I (three studies). Three studies assessed multiple cardiac biomarkers. High levels of NT-proBNP and BNP were associated with a higher risk of death up to 60 days (unadjusted OR 8.98; CI 4.15-19.43; p<0.00001). This association persisted after adjustment for age and illness severity. Biomarkers of cardiac injury were also associated with higher mortality, but this association was not statistically significant (unadjusted OR 2.21; CI 0.94-5.16; p= 0.07). Conclusion Biomarkers of cardiac stretch are associated with increased mortality in ARDS.

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Assessing the Performance of a Novel Point-of-Care Qualitative Assay for Early Diagnosis of Acute Coronary Syndrome

Cardiology ◽

10.1159/000511435 ◽

2020 ◽

pp. 1-8

Author(s):

Ronny Alcalai ◽

Boris Varshisky ◽

Ahmad Marhig ◽

David Leibowitz ◽

Larissa Kogan-Boguslavsky ◽

...

Keyword(s):

Acute Coronary Syndrome ◽

Chest Pain ◽

Diagnostic Accuracy ◽

Diagnostic Performance ◽

Troponin I ◽

Point Of Care ◽

Final Diagnosis ◽

Cardiac Biomarkers ◽

Fatty Acid Binding ◽

Coronary Syndrome

Background: Early and accurate diagnosis of acute coronary syndrome (ACS) is essential for initiating lifesaving interventions. In this article, the diagnostic performance of a novel point-of-care rapid assay (SensAheart©) is analyzed. This assay qualitatively determines the presence of 2 cardiac biomarkers troponin I and heart-type fatty acid-binding protein that are present soon after onset of myocardial injury. Methods: We conducted a prospective observational study of consecutive patients who presented to the emergency department with typical chest pain. Simultaneous high-sensitive cardiac troponin T (hs-cTnT) and SensAheart testing was performed upon hospital admission. Diagnostic accuracy was computed using SensAheart or hs-cTnT levels versus the final diagnosis defined as positive/negative. Results: Of 225 patients analyzed, a final diagnosis of ACS was established in 138 patients, 87 individuals diagnosed with nonischemic chest pain. In the overall population, as compared to hs-cTnT, the sensitivity of the initial SensAheart assay was significantly higher (80.4 vs. 63.8%, p = 0.002) whereas specificity was lower (78.6 vs. 95.4%, p = 0.036). The overall diagnostic accuracy of SensAheart assay was similar to the hs-cTnT (82.7% compared to 76.0%, p = 0.08). Conclusions: Upon first medical contact, the novel point-of-care rapid SensAheart assay shows a diagnostic performance similar to hs-cTnT. The combination of 2 cardiac biomarkers in the same kit allows for very early detection of myocardial damage. The SensAheart assay is a reliable and practical tool for ruling-in the diagnosis of ACS.

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Chest pain in general practice: a systematic review of prediction rules

BMJ Open ◽

10.1136/bmjopen-2018-027081 ◽

2019 ◽

Vol 9 (2) ◽

pp. e027081 ◽

Cited By ~ 2

Author(s):

Ralf E Harskamp ◽

Simone C Laeven ◽

Jelle CL Himmelreich ◽

Wim A M Lucassen ◽

Henk C P M van Weert

Keyword(s):

Systematic Review ◽

General Practice ◽

Chest Pain ◽

Coronary Disease ◽

Clinical Decision ◽

Clinical Judgement ◽

Predictive Values ◽

Heart Score ◽

Coronary Syndrome ◽

Rule Out

ObjectiveTo identify and assess the performance of clinical decision rules (CDR) for chest pain in general practice.DesignSystematic review of diagnostic studies.Data sourcesMedline/Pubmed, Embase/Ovid, CINAHL/EBSCO and Google Scholar up to October 2018.Study selectionStudies that assessed CDRs for intermittent-type chest pain and for rule out of acute coronary syndrome (ACS) applicable in general practice, thus not relying on advanced laboratory, computer or diagnostic testing.Review methodsReviewers identified studies, extracted data and assessed the quality of the evidence (using Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2)), independently and in duplicate.ResultsEight studies comprising five CDRs met the inclusion criteria. Three CDRs are designed for rule out of coronary disease in intermittent-type chest pain (Gencer rule, Marburg Heart Score, INTERCHEST), and two for rule out of ACS (Grijseels rule, Bruins Slot rule). Studies that examined the Marburg Heart Score had the highest methodological quality with consistent sensitivity (86%–91%), specificity (61%–81%) and positive (23%–35%) and negative (97%–98%) predictive values (PPV and NPV). The diagnostic performance of Gencer (PPV: 20%–34%, NPV: 95%–99%) and INTERCHEST (PPV: 35%–43%, NPV: 96%–98%) appear comparable, but requires further validation. The Marburg Heart Score was more sensitive in detecting coronary disease than the clinical judgement of the general practitioner. The performance of CDRs that focused on rule out of ACS were: Grijseels rule (sensitivity: 91%, specificity: 37%, PPV: 57%, NPV: 82%) and Bruins Slot (sensitivity: 97%, specificity: 10%, PPV: 23%, NPV: 92%). Compared with clinical judgement, the Bruins Slot rule appeared to be safer than clinical judgement alone, but the study was limited in sample size.ConclusionsIn general practice, there is currently no clinical decision aid that can safely rule out ACS. For intermittent chest pain, several rules exist, of which the Marburg Heart Score has been most extensively tested and appears to outperform clinical judgement alone.

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Impact of non-menthol flavours in e-cigarettes on perceptions and use: an updated systematic review

BMJ Open ◽

10.1136/bmjopen-2019-031598 ◽

2019 ◽

Vol 9 (10) ◽

pp. e031598 ◽

Cited By ~ 14

Author(s):

Clare Meernik ◽

Hannah M Baker ◽

Sarah D Kowitt ◽

Leah M Ranney ◽

Adam O Goldstein

Keyword(s):

Systematic Review ◽

Risk Perceptions ◽

Longitudinal Research ◽

Age Groups ◽

Experimental Studies ◽

Final Analysis ◽

Eligibility Criteria ◽

Product Appeal ◽

The Impact

ObjectivesGiven the exponential increase in the use of e-cigarettes among younger age groups and in the growth in research on e-cigarette flavours, we conducted a systematic review examining the impact of non-menthol flavoured e-cigarettes on e-cigarette perceptions and use among youth and adults.DesignPubMed, Embase, PyscINFO and CINAHL were systematically searched for studies published and indexed through March 2018.Eligibility criteriaQuantitative observational and experimental studies that assessed the effect of non-menthol flavours in e-cigarettes on perceptions and use behaviours were included. Specific outcome measures assessed are appeal, reasons for use, risk perceptions, susceptibility, intention to try, initiation, preference, current use, quit intentions and cessation.Data extraction and synthesisThree authors independently extracted data related to the impact of flavours in tobacco products. Data from a previous review were then combined with those from the updated review for final analysis. Results were then grouped and analysed by outcome measure.ResultsThe review included 51 articles for synthesis, including 17 published up to 2016 and an additional 34 published between 2016 and 2018. Results indicate that non-menthol flavours in e-cigarettes decrease harm perceptions (five studies) and increase willingness to try and initiation of e-cigarettes (six studies). Among adults, e-cigarette flavours increase product appeal (seven studies) and are a primary reason many adults use the product (five studies). The role of flavoured e-cigarettes on smoking cessation remains unclear (six studies).ConclusionThis review provides summary data on the role of non-menthol flavours in e-cigarette perceptions and use. Consistent evidence shows that flavours attract both youth and adults to use e-cigarettes. Given the clear findings that such flavours increase product appeal, willingness to try and initiation among youth, banning non-menthol flavours in e-cigarettes may reduce youth e-cigarette use. Longitudinal research is needed to examine any role flavours may play in quit behaviours among adults.

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