New definition of myocardial infarction: Impact on long-term mortality
ABSTRACT The use of cardiac troponin allows the identification of additional patients developing myocardial necrosis during an acute coronary syndrome. Novel guidelines of European and American cardiac societies recommend labeling these events as myocardial infarction. Our study evaluated the long-term mortality in the group of patients with non-ST segment elevation myocardial infarction not meeting the older World Health Organization (WHO) criteria (creatine phosphokinase) but additionally identified by the novel definition of myocardial infarction.
This cohort study included 1024 consecutive patients with non-ST segment elevation acute coronary syndrome classified into "unstable angina," myocardial infarction according to the WHO definition ("WHO criteria"), and myocardial infarction additionally identified by the novel definition ("additional criteria"). All patients were treated with an early invasive strategy. The primary end point was all-cause mortality during follow-up of up to 36 months.
During long-term follow-up (median 16 months, interquartile range 6-29 months), 67 deaths occurred. Kaplan-Meier analysis showed cumulative 3-year mortality rates of 5.6% in patients with "unstable angina," 9.1% in patients identified by "WHO criteria," and 17.5% in patients identified by "additional criteria" (P <.001). Cox regression analysis confirmed the "additional criteria" as a significant predictor of mortality (hazard ratio 3.1; 95% confidence interval, 1.9-5.0; P <.001).
The new definition of myocardial infarction based on cardiac troponin testing identifies a high-risk group of additional patients with acute coronary syndrome that is, therefore, appropriately classified as myocardial infarction. In fact, long-term mortality in "additional criteria" patients is higher than in "WHO criteria" patients.
[Show abstract] [Hide abstract]
ABSTRACT: REasons for Geographic and Racial Differences in Stroke (REGARDS) is a longitudinal study supported by the National Institutes of Health to determine the disparities in stroke-related mortality across USA. REGARDS has published a body of work designed to understand the disparities in prevalence, awareness, treatment, and control of coronary heart disease (CHD) and its risk factors in a biracial national cohort. REGARDS has focused on racial and geographical disparities in the quality and access to health care, the influence of lack of medical insurance, and has attempted to contrast current guidelines in lipid lowering for secondary prevention in a nationwide cohort. It has described CHD risk from nontraditional risk factors such as chronic kidney disease, atrial fibrillation, and inflammation (i.e., high-sensitivity C-reactive protein) and has also assessed the role of depression, psychosocial, environmental, and lifestyle factors in CHD risk with emphasis on risk factor modification and ideal lifestyle factors. REGARDS has examined the utility of various methodologies, e.g., the process of medical record adjudication, proxy-based cause of death, and use of claim-based algorithms to determine CHD risk. Some valuable insight into less well-studied concepts such as the reliability of current troponin assays to identify "microsize infarcts," caregiving stress, and CHD, heart failure, and cognitive decline have also emerged. In this review, we discuss some of the most important findings from REGARDS in the context of the existing literature in an effort to identify gaps and directions for further research.Current Hypertension Reports 04/2015; 17(4):541. DOI:10.1007/s11906-015-0541-5 · 3.90 Impact Factor
[Show abstract] [Hide abstract]
ABSTRACT: Prior studies indicate that an elevated creatinine kinase (CK)-MB imparts poor prognosis in patients with acute coronary syndrome despite a normal troponin. Its prognosis in the undifferentiated chest pain observation unit (CPU) population remains undefined. To compare rates and predictors of 30-day adverse cardiac events in 2 cohorts (CK±/MB+ vs. normal [CK±/MB-]) in low-moderate-risk CPU patients. Consecutive CPU patients were followed in a retrospective cohort study for primary outcome (acute coronary syndrome, percutaneous transluminal coronary angioplasty, coronary artery bypass graft, abnormal stress test, cardiac hospitalization, or death within 30 days) by using standardized chart reviews and national death registry. Exclusions were: those aged 30 years or younger, positive troponin, ischemic electrocardiogram, hemodynamic instability, heart failure, or dialysis. Between January 2006 and April 2009, 2979 patients were eligible, of which 350 excluded and 2629 analyzed. MB+ compared with normal patients were more likely to be: older (mean, 53.4 ± 14 vs. 51.5 ± 12 years; P = 0.04); male (71% vs. 40%; P = 0.01); renal insufficient (5% vs. 2%; P = 0.01); hypertensive (50% vs. 44%; P = 0.04); dyslipidemic (44% vs. 33%; P = 0.01) obese (55% vs. 43%; P = 0.01); and with known coronary artery disease (14% vs. 5%; P < 0.01). Composite adverse events were 213 (8%) and did not significantly differ for either initial MB+ vs. normal (9.1%, 8.0%; odds ratio, 1.1, 0.7-1.9) or serial MB+ vs. normal (7.5%, 7.4%; odds ratio, 1.0, 0.5-1.8). In a multiple logistic regression model, male sex, diabetes, and prior CAD predicted adverse events, whereas CK-MB along with race, hypertension, smoking, dyslipidemia, family history, and obesity did not. Elevated CK-MB does not add value to serial troponin testing in low-moderate-risk CPU patients.Critical pathways in cardiology 03/2014; 13(1):14-9. DOI:10.1097/HPC.0000000000000001
[Show abstract] [Hide abstract]
ABSTRACT: Purpose We examined the diagnostic and predictive value of cardiac troponin T high-sensitive (cTnThs) in syncope patients. Methods Analysis of consecutive syncope patients presenting to the emergency department. The primary endpoint is the accuracy to diagnose a cardiac syncope. In addition, the study explores the prognostic relevance of cTnThs in patients with cardiac and non-cardiac syncope. Results 360 patients were enrolled (median age: 70.5 years; male: 55.8%, 23.9% >80 years). Cardiac syncope was present in 22%, reflex syncope in 40%, syncope due to orthostatic hypotension in 20% and unexplained syncope in 17.5% of patients. 148 patients (41%) had cTnThs levels above the 99% confidence interval (cutoff point). The diagnostic accuracy for cTnThs levels to determine the diagnosis of cardiac syncope was quantified by the AUC (0.77, CI: 0.72 - 0.83; p<0.001). A comparable AUC (0.78, CI: 0.73-0.83; p<0.001) was obtained for the predictive value of cTnThs levels within 30 days: While patients with increased cTnThs levels had 52% likelihood for adverse events, patients with cTnThs levels below the cutoff point had a low risk (negative predictive value: 83.5%). Increased cTnThs levels indicate adverse prognosis in patients with non-cardiac causes of syncope, but not in patients with cardiac syncope being a risk factor for adverse outcome by itself. Conclusions Emergency department patients with syncope display a high proportion of life-threatening conditions. cTnThs levels display a limited diagnostic and predictive accuracy for the identification of syncope patients at high risk.The American Journal of Medicine 10/2014; 128(2). DOI:10.1016/j.amjmed.2014.09.021 · 5.30 Impact Factor