A More Appropriate Cardiac Troponin T Level That Can Predict Outcomes in End

7/31/2019 A More Appropriate Cardiac Troponin T Level That Can Predict Outcomes in End

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CK/CK-MB with at least one of the following: ischemic symptoms, development of pathologic Q waves or

changes in the ST segment on the ECG, or coronary artery intervention. 13

Follow-up data of the enrolled subjects were reviewed until death or June 2009. The date of death wasdefined as the end point. In the case of patients who did not have follow-up until December 2009, an inquiry

was made by phone call. Patients who underwent revascularization after enrollment were not treated ascensored in the analysis.

Laboratory measurements

The serum cTnT concentration by the third generation cTnT test and the serum CK-MB level were measured

on the Elecsys 2010 immunoassay analyzer (Roche Diagnostics, Mannheim, Germany). The third generationcTnT test uses the same monoclonal antibodies (M11.7 and M7) as the second generation test, but is

standardized with human recombinant cTnT instead of bovine cTnT. The detection limit and concentration

corresponding to the 10% total coefficient of variation of the assay are


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42.5%, p=0.441), beta-blockers (27.8% vs. 29.2%, p=0.780), HMG-CoA reductase inhibitors (13.4% vs.

16.5%, p=0.339), and renin angiotensin system blockers (35.9% vs. 37.5%, p=0.722) were compared before

and after event occurrence, there was no significant difference in the number of patients on thesemedications.

Table 1

Baseline Patient Characteristics

Determination of a more appropriate cTnT cut-off value for AMI

AMIs were diagnosed in 40 patients (14.1%), and coronary angiography was performed in 52 patients

(18.3%). Twenty-six patients (9.2%) underwent percutaneous coronary intervention; the remaining patientswere treated medically.

The ROC curve of cTnT for AMIs is shown in Fig. 1. The area under the curve (AUC) was 0.98 in the ROCcurve (p


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Fig. 1

Receiver operator characteristic (ROC) curve of cardiac troponin T (cTnT) for diagnosing acute myocardialinfarction. The area under the curve (AUC) was 0.98 (p


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Fig. 2

Kaplan-Meier survival curves according to initial cardiac troponin T (cTnT) levels. (A) The all-cause

mortality rate in the group with initial cTnT 0.35 ng/mL is significantly higher compared to the other

groups by log-rank test (p


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6.84; p=0.015), serum cTnT (RR: 1.12; 95% CI: 1.03-1.22; p=0.008), and hsCRP levels (RR: 1.09; 95% CI:

1.04-1.15; p=0.000) were independent predictors for all-cause mortality (Table 3).

Table 3

Results of the Cox Proportional Hazards Analysis Showing Hazard Ratios and 95% Confidence Intervals for

All-Cause Mortality

Factors correlated with cardiovascular mortality were also evaluated with univariate Cox regression

analysis. Age (RR: 1.07; 95% CI: 1.04-1.10; p=0.000), diabetes mellitus (RR: 2.11; 95% CI: 1.04-4.29;p=0.038), initial serum cTnT (RR: 1.16; 95% CI: 1.09-1.24; p=0.000), and STEMI (RR: 9.98; 95% CI: 3.48-

28.65; p=0.000) were significant. However, gender, history of hypertension or cardiovascular disease,dialysis modality, duration of dialysis, serum albumin, WBC count, and hsCRP levels were not significantlyrelated to cardiovascular mortality. In a multivariate Cox regression model, age (RR: 1.06; 95% CI: 1.03-

1.09; p=0.000), serum cTnT (RR: 1.14; 95% CI: 1.05-1.22; p=0.001), and STEMI (RR: 3.91; 95% CI: 1.30-

11.78; p=0.015) were independent predictors for cardiovascular mortality (Table 4).
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3104442/table/T3/http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3104442/table/T3/http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3104442/table/T4/http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3104442/table/T3/http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3104442/table/T3/http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3104442/table/T4/


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Table 4

Results of the Cox Proportional Hazards Analysis Showing Hazard Ratios and 95% Confidence Intervals for

Cardiovascular Mortality

DISCUSSION

In the present study, we demonstrated that an initial cTnT of 0.35 ng/mL was the best cut-off value for AMI

because it had the highest sensitivity and specificity in ESRD patients with ACS. In addition, all-cause and

cardiovascular mortalities of patients whose initial cTnT levels were 0.35 ng/mL were much higher thanthe other groups.

A cTnT level of 0.1 ng/mL is currently used as the cut-off value for AMIs in the general population. In

ESRD patients, however, a number of studies have reported that false positive elevations in cTnT level, even

without evidence of myocardial injury, are not uncommon.16-19 Several studies have suggested the followingpossible reasons for elevated cTnT without myocardial damage: left ventricular hypertrophy, endothelial

dysfunction, leakage of free cytosolic troponin pool, stretch-mediated troponin release, and impaired renalexcretion.17-19

In this study, the summation of sensitivity and specificity of cTnT for AMI in ESRD patients with ACSpeaked at 0.35 ng/mL. At a value of 0.1 ng/mL, the sensitivity was 98%, yet the specificity was only 65%.

Although AMI is such a serious complication that it is important for the screening test to have high

sensitivity, a 35% false positive rate cannot be ignored. Therefore, we suggest that an initial cTnTconcentration of 0.35 ng/mL in ESRD patients with ACS is a more appropriate cut-off value for AMI, even

though patients with lower levels of cTnT should also be carefully monitored.

Plasma concentrations of total CK are also elevated in 42% of ESRD patients without myocardial damage, 20

and 30-50% of asymptomatic HD patients exhibit an elevation in the CK-MB fraction.21,22 Moreover, 18-31% of patients with an ACS have elevated cTnT levels without an increase in the CK-MB fraction.23,24

Therefore, we performed survival analyses to confirm the validity of the ROC results. An elevation in serum

cTnT levels is a well-known predictive factor for all-cause and cardiovascular mortality in asymptomaticESRD patients.16,25-28 Although the reasons for the association between elevated levels of cTnT and a poor

prognosis are not clear, the possibility has been suggested that patients with increased cTnT have diffuse

coronary artery disease.27,29

Increased serum troponin levels are highly prognostic for cardiac and all-cause mortality among patientswith chronic kidney disease with ACS.12,30 In the GUSTO-IV trial, elevated cTnT independently predicted

the 30-day prognosis in all patients, and patients with creatinine clearance in the lowest quartile (


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diabetes, serum cTnT, and hsCRP levels still had statistical significance. When the patients were divided

into four groups according to the initial serum concentration of cTnT, all-cause mortality rate in patients

with a moderate increase in cTnT (0.1cTnT


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Reduced performance of Troponin T for acute coronary syndromes diagnosis in the

elderly and very elderly patients: a retrospective study of 2688 patients.

Covino M, Simeoni B, Montalto M,Burzotta F,Buccelletti F,Carbone L,Gallo A, Gentiloni Silveri N.

Source

Department of Emergency Medicine, School of Medicine, Catholic University of the Sacred Heart, Rome,Italy. [email protected]

Abstract

STUDY OBJECTIVE:

We evaluated the performance of Troponin T (cTnT) for acute coronary syndrome (ACS) diagnosis in elder

compared to younger patients.

MATERIALS AND METHODS:

We retrospectively evaluated 2688 patients admitted to our Emergency Department for suspected ACS. All

patients received ECG, serum creatinine determination, and serial cTnT samplings. Patients were consideredpositive for cTnT if they had a cTnT above our reference standard (>0.03 microg/L) in any determination

obtained within 6 hours from admission. ACS diagnosis, either acute myocardial infarction or unstable

angina, was based on reviewed data and discharge diagnosis hospital. Patients were divided in three groupsaccording to age: or =65 and or =80 years. CTnT

diagnostic accuracy for ACS was compared in these three groups in patients or =65and or =80 years.
http://www.ncbi.nlm.nih.gov/pubmed?term=Covino%20M%5BAuthor%5D&cauthor=true&cauthor_uid=22582477http://www.ncbi.nlm.nih.gov/pubmed?term=Simeoni%20B%5BAuthor%5D&cauthor=true&cauthor_uid=22582477http://www.ncbi.nlm.nih.gov/pubmed?term=Montalto%20M%5BAuthor%5D&cauthor=true&cauthor_uid=22582477http://www.ncbi.nlm.nih.gov/pubmed?term=Burzotta%20F%5BAuthor%5D&cauthor=true&cauthor_uid=22582477http://www.ncbi.nlm.nih.gov/pubmed?term=Burzotta%20F%5BAuthor%5D&cauthor=true&cauthor_uid=22582477http://www.ncbi.nlm.nih.gov/pubmed?term=Burzotta%20F%5BAuthor%5D&cauthor=true&cauthor_uid=22582477http://www.ncbi.nlm.nih.gov/pubmed?term=Buccelletti%20F%5BAuthor%5D&cauthor=true&cauthor_uid=22582477http://www.ncbi.nlm.nih.gov/pubmed?term=Carbone%20L%5BAuthor%5D&cauthor=true&cauthor_uid=22582477http://www.ncbi.nlm.nih.gov/pubmed?term=Carbone%20L%5BAuthor%5D&cauthor=true&cauthor_uid=22582477http://www.ncbi.nlm.nih.gov/pubmed?term=Gallo%20A%5BAuthor%5D&cauthor=true&cauthor_uid=22582477http://www.ncbi.nlm.nih.gov/pubmed?term=Gallo%20A%5BAuthor%5D&cauthor=true&cauthor_uid=22582477http://www.ncbi.nlm.nih.gov/pubmed?term=Gentiloni%20Silveri%20N%5BAuthor%5D&cauthor=true&cauthor_uid=22582477http://www.ncbi.nlm.nih.gov/pubmed?term=Covino%20M%5BAuthor%5D&cauthor=true&cauthor_uid=22582477http://www.ncbi.nlm.nih.gov/pubmed?term=Simeoni%20B%5BAuthor%5D&cauthor=true&cauthor_uid=22582477http://www.ncbi.nlm.nih.gov/pubmed?term=Montalto%20M%5BAuthor%5D&cauthor=true&cauthor_uid=22582477http://www.ncbi.nlm.nih.gov/pubmed?term=Burzotta%20F%5BAuthor%5D&cauthor=true&cauthor_uid=22582477http://www.ncbi.nlm.nih.gov/pubmed?term=Buccelletti%20F%5BAuthor%5D&cauthor=true&cauthor_uid=22582477http://www.ncbi.nlm.nih.gov/pubmed?term=Carbone%20L%5BAuthor%5D&cauthor=true&cauthor_uid=22582477http://www.ncbi.nlm.nih.gov/pubmed?term=Gallo%20A%5BAuthor%5D&cauthor=true&cauthor_uid=22582477http://www.ncbi.nlm.nih.gov/pubmed?term=Gentiloni%20Silveri%20N%5BAuthor%5D&cauthor=true&cauthor_uid=22582477


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Comparison of diagnostic accuracy between three different rules ofinterpreting high sensitivity troponin T results.

Buccelletti F,Galiuto L,Marsiliani D,Iacomini P,Mattogno P,Carroccia A,Cordischi C, Antonini S,

Fedele E,Sabbatini M,Silveri NG, Franceschi F.

Source

Department of Emergency Medicine, Catholic University of the Sacred Heart, Largo Francesco Vito 1,

00168, Rome, Italy.

Abstract

With the introduction of high sensitivity troponin-T (hs-TnT) assay, clinicians face more patients with

'positive' results but without myocardial infarction. Repeated hs-TnT determinations are warranted to

improve specificity. The aim of this study was to compare diagnostic accuracy of three differentinterpretation rules for two hs-TnT results taken 6 h apart. After adjusting for clinical differences, hs-TnT

results were recoded according to the three rules. Rule1: hs-TnT >13 ng/L in at least one determination.Rule2: change of >20 % between the two measures. Rule3: change >50 % if baseline hs-TnT 14-53 ng/L

and >20 % if baseline >54 ng/L. The sensitivity, specificity and ROC curves were compared. The sensitivity

analysis was used to generate post-test probability for any test result. Primary outcome was the evidence of

coronary critical stenosis (CCS) on coronary angiography in patients with high-risk chest pain. 183 patientswere analyzed (38.3 %) among all patients presenting with chest pain during the study period. CCS was

found in 80 (43.7 %) cases. The specificity was 0.62 (0.52-0.71), 0.76 (0.66-0.84) and 0.83 (0.74-0.89) for

rules 1, 2 and 3, respectively (P < 0.01). Sensitivity decreased with increasing specificity (P < 0.01). Overalldiagnostic accuracy did not differ among the three rules (AUC curves difference P = 0.12). Sensitivity

analysis showed a 25 % relative gain in predicting CCS using rule 3 compared to rule 1. Changes betweentwo determinations of hs-TnT 6 h apart effectively improved specificity for CCS presence in high-risk chestpain patients. There was a parallel loss in sensitivity that discouraged any use of such changes as a unique

way to interpret the new hs-TnT results.
http://www.ncbi.nlm.nih.gov/pubmed?term=Buccelletti%20F%5BAuthor%5D&cauthor=true&cauthor_uid=22618889http://www.ncbi.nlm.nih.gov/pubmed?term=Galiuto%20L%5BAuthor%5D&cauthor=true&cauthor_uid=22618889http://www.ncbi.nlm.nih.gov/pubmed?term=Galiuto%20L%5BAuthor%5D&cauthor=true&cauthor_uid=22618889http://www.ncbi.nlm.nih.gov/pubmed?term=Marsiliani%20D%5BAuthor%5D&cauthor=true&cauthor_uid=22618889http://www.ncbi.nlm.nih.gov/pubmed?term=Marsiliani%20D%5BAuthor%5D&cauthor=true&cauthor_uid=22618889http://www.ncbi.nlm.nih.gov/pubmed?term=Iacomini%20P%5BAuthor%5D&cauthor=true&cauthor_uid=22618889http://www.ncbi.nlm.nih.gov/pubmed?term=Iacomini%20P%5BAuthor%5D&cauthor=true&cauthor_uid=22618889http://www.ncbi.nlm.nih.gov/pubmed?term=Mattogno%20P%5BAuthor%5D&cauthor=true&cauthor_uid=22618889http://www.ncbi.nlm.nih.gov/pubmed?term=Mattogno%20P%5BAuthor%5D&cauthor=true&cauthor_uid=22618889http://www.ncbi.nlm.nih.gov/pubmed?term=Carroccia%20A%5BAuthor%5D&cauthor=true&cauthor_uid=22618889http://www.ncbi.nlm.nih.gov/pubmed?term=Carroccia%20A%5BAuthor%5D&cauthor=true&cauthor_uid=22618889http://www.ncbi.nlm.nih.gov/pubmed?term=Cordischi%20C%5BAuthor%5D&cauthor=true&cauthor_uid=22618889http://www.ncbi.nlm.nih.gov/pubmed?term=Cordischi%20C%5BAuthor%5D&cauthor=true&cauthor_uid=22618889http://www.ncbi.nlm.nih.gov/pubmed?term=Antonini%20S%5BAuthor%5D&cauthor=true&cauthor_uid=22618889http://www.ncbi.nlm.nih.gov/pubmed?term=Fedele%20E%5BAuthor%5D&cauthor=true&cauthor_uid=22618889http://www.ncbi.nlm.nih.gov/pubmed?term=Sabbatini%20M%5BAuthor%5D&cauthor=true&cauthor_uid=22618889http://www.ncbi.nlm.nih.gov/pubmed?term=Sabbatini%20M%5BAuthor%5D&cauthor=true&cauthor_uid=22618889http://www.ncbi.nlm.nih.gov/pubmed?term=Sabbatini%20M%5BAuthor%5D&cauthor=true&cauthor_uid=22618889http://www.ncbi.nlm.nih.gov/pubmed?term=Silveri%20NG%5BAuthor%5D&cauthor=true&cauthor_uid=22618889http://www.ncbi.nlm.nih.gov/pubmed?term=Franceschi%20F%5BAuthor%5D&cauthor=true&cauthor_uid=22618889http://www.ncbi.nlm.nih.gov/pubmed?term=Buccelletti%20F%5BAuthor%5D&cauthor=true&cauthor_uid=22618889http://www.ncbi.nlm.nih.gov/pubmed?term=Galiuto%20L%5BAuthor%5D&cauthor=true&cauthor_uid=22618889http://www.ncbi.nlm.nih.gov/pubmed?term=Marsiliani%20D%5BAuthor%5D&cauthor=true&cauthor_uid=22618889http://www.ncbi.nlm.nih.gov/pubmed?term=Iacomini%20P%5BAuthor%5D&cauthor=true&cauthor_uid=22618889http://www.ncbi.nlm.nih.gov/pubmed?term=Mattogno%20P%5BAuthor%5D&cauthor=true&cauthor_uid=22618889http://www.ncbi.nlm.nih.gov/pubmed?term=Carroccia%20A%5BAuthor%5D&cauthor=true&cauthor_uid=22618889http://www.ncbi.nlm.nih.gov/pubmed?term=Cordischi%20C%5BAuthor%5D&cauthor=true&cauthor_uid=22618889http://www.ncbi.nlm.nih.gov/pubmed?term=Antonini%20S%5BAuthor%5D&cauthor=true&cauthor_uid=22618889http://www.ncbi.nlm.nih.gov/pubmed?term=Fedele%20E%5BAuthor%5D&cauthor=true&cauthor_uid=22618889http://www.ncbi.nlm.nih.gov/pubmed?term=Sabbatini%20M%5BAuthor%5D&cauthor=true&cauthor_uid=22618889http://www.ncbi.nlm.nih.gov/pubmed?term=Silveri%20NG%5BAuthor%5D&cauthor=true&cauthor_uid=22618889http://www.ncbi.nlm.nih.gov/pubmed?term=Franceschi%20F%5BAuthor%5D&cauthor=true&cauthor_uid=22618889


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On-demand therapy for Los Angeles grade A and B reflux esophagitis:

esomeprazole versus omeprazole.

Kao AW, Sheu BS, Sheu MJ,Chang YM, Huang SF, Chuang CH, Lai YL, Kao YH.

Source

Department of Internal Medicine, National Cheng Kung University, Medical College, Tainan, Taiwan.

Abstract

BACKGROUND AND PURPOSE:

Reflux esophagitis of Los Angeles grade A or B is more common than grades C and D disease amongTaiwanese. This study compared the efficacy of esomeprazole 40 mg and omeprazole 20 mg for starting on-

demand therapy for grade A and B reflux esophagitis.

METHODS:

100 patients with grade A and B reflux esophagitis were randomized to receive either esomeprazole 40 mgonce daily (n = 50) or omeprazole 20 mg once daily (n = 50) for the first 4 weeks. Sustained symptomatic

response (SSR) was defined as freedom from symptoms for the last 7 days of the 4-week treatment duration.

On-demand therapy was used for the next 4 weeks in patients with SSR; patients without SSR continued

with the same proton pump inhibitor regimen. Patients were asked to record their daily severity of acidregurgitation (AR) and heartburn (HB). Medication usage during on-demand therapy was recorded.

RESULTS:

Forty six patients in the esomeprazole group and 45 patients in the omeprazole group completed the study

protocol. The rate of SSR was higher in the esomeprazole group than in the omeprazole group (per-protocol:73.9% vs 51.1%, p < 0.05; intent-to-treat: 68% vs 46%, p < 0.05). The symptomatic scores for AR and HB

were similar between patients taking medication continuously and those taking medication on-demand with

both esomeprazole and omeprazole. For patients starting on-demand therapy, the total number of tabletsused during 4 weeks was lower in the esomeprazole group than in the omeprazole group (13.5 vs 18.5, p

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A More Appropriate Cardiac Troponin T Level That Can Predict Outcomes in End