Using High-Sensitivity Cardiac Troponin for the Exclusion of Inducible Myocardial Ischemia in Symptomatic Patients: A Cohort Study.
- 作者列表："Walter J","du Fay de Lavallaz J","Koechlin L","Zimmermann T","Boeddinghaus J","Honegger U","Strebel I","Twerenbold R","Amrein M","Nestelberger T","Wussler D","Puelacher C","Badertscher P","Zellweger M","Fahrni G","Jeger R","Kaiser C","Reichlin T","Mueller C
Background:The optimal noninvasive method for surveillance in symptomatic patients with stable coronary artery disease (CAD) is unknown. Objective:To apply a novel approach using very low concentrations of high-sensitivity cardiac troponin I (hs-cTnI) for exclusion of inducible myocardial ischemia in symptomatic patients with CAD. Design:Prospective diagnostic cohort study. (ClinicalTrials.gov: NCT01838148). Setting:University hospital. Patients:1896 consecutive patients with CAD referred with symptoms possibly related to inducible myocardial ischemia. Measurements:Presence of inducible myocardial ischemia was adjudicated using myocardial perfusion imaging with single-photon emission computed tomography, as well as coronary angiography and fractional flow reserve measurements where available. Staff blinded to adjudication measured circulating hs-cTn concentrations. An hs-cTnI cutoff of 2.5 ng/L, derived previously in mostly asymptomatic patients with CAD, was assessed. Predefined target performance criteria were at least 90% negative predictive value (NPV) and at least 90% sensitivity for exclusion of inducible myocardial ischemia. Sensitivity analyses were based on measurements with an hs-cTnT assay and an alternative hs-cTnI assay with even higher analytic sensitivity (limit of detection, 0.1 ng/L). Results:Overall, 865 patients (46%) had inducible myocardial ischemia. The hs-cTnI cutoff of 2.5 ng/L provided an NPV of 70% (95% CI, 64% to 75%) and a sensitivity of 90% (CI, 88% to 92%) for exclusion of inducible myocardial ischemia. No hs-cTnI cutoff reached both performance characteristics predefined as targets. Similarly, using the alternative assays for hs-cTnI or hs-cTnT, no cutoff achieved the target performance: hs-cTnT concentrations less than 5 ng/L yielded an NPV of 66% (CI, 59% to 72%), and hs-cTnI concentrations less than 2 ng/L yielded an NPV of 68% (CI, 62% to 74%). Limitation:Data were generated in a large single-center diagnostic study using central adjudication. Conclusion:In symptomatic patients with CAD, very low hs-cTn concentrations, including hs-cTnI concentrations less than 2.5 ng/L, do not generally allow users to safely exclude inducible myocardial ischemia. Primary Funding Source:European Union, Swiss National Science Foundation, Kommission für Technologie und Innovation (Innosuisse), Swiss Heart Foundation, Cardiovascular Research Foundation Basel, University of Basel, University Hospital Basel, Roche, Abbott, and Singulex.
背景: 有症状的稳定性冠心病患者的最佳无创监测方法尚不清楚。 目的: 应用极低浓度高敏心肌肌钙蛋白I (hs-cTnI) 排除有症状的冠心病患者的可诱导心肌缺血的新方法。 设计: 前瞻性诊断队列研究。(ClinicalTrials.gov: NCT01838148)。 单位: 大学医院。 患者: 1896例连续的CAD患者涉及可能与诱导型心肌缺血相关的症状。 测量: 使用具有单光子发射计算机断层扫描的心肌灌注成像以及可用的冠状动脉血管造影和血流储备分数测量来判断诱导型心肌缺血的存在。对裁定不知情的工作人员测量了循环hs-cTn浓度。我们评估了先前在大多数无症状的CAD患者中获得的2.5 ng/L的hs-cTnI截止值。预定的目标性能标准是至少90% 的阴性预测值 (NPV) 和至少90% 的排除诱导型心肌缺血的灵敏度。灵敏度分析基于使用hs-ctnt测定和具有更高分析灵敏度 (检测限，0.1 ng/L) 的替代hs-ctni测定的测量。 结果: 总体上，865例 (46%) 患者存在可诱导的心肌缺血。2.5 ng/L的hs-cTnI截止值提供了70% 的NPV (95% CI，64% 至75%) 和排除诱导型心肌缺血的90% (CI，88% 至92%) 的灵敏度。没有hs-cTnI截止值达到预定义的两种性能特征作为目标。类似地，使用hs-cTnI或hs-cTnT的替代测定，没有达到目标性能的截止值: 小于5 ng/L的hs-cTnT浓度产生66% 的NPV (CI，59% 至72%)，并且hs-cTnI浓度小于2 ng/L产生68% 的NPV (CI，62% 至74%)。 局限性: 数据是在使用中心裁定的大型单中心诊断研究中产生的。 结论: 在有症状的CAD患者中，非常低的hs-cTn浓度，包括小于2.5 ng/L的hs-cTnI浓度，通常不允许使用者安全地排除可诱导的心肌缺血。 主要资金来源: 欧盟、瑞士国家科学基金会、Kommission f ü r技术创新 (Innosuisse) 、瑞士心脏基金会、巴塞尔心血管研究基金会、巴塞尔大学医院、罗氏公司、雅培公司和Singulex公司。
METHODS::We present the case of a 61-year-old woman with a large tumoral infiltration extending from the pelvis throughout the inferior vena cava inferior to the right atrium, protruding into the right ventricle and right ventricular outflow tract. She had been treated 10 years before for low-grade endometrial stromal sarcoma by hysterectomy and adnexectomy followed by hormone- and radio-therapy. Due to cancer recurrence, she underwent peritonectomy, appendectomy, and resection of terminal ileum.
METHODS:AIMS:Significant platelet activation after long stented coronary segments has been associated with periprocedural microvascular impairment and myonecrosis. In long lesions treated either with an everolimus-eluting bioresorbable vascular scaffold (BVS) or an everolimus-eluting stent (EES), we aimed to investigate (a) procedure-related microvascular impairment, and (b) the relationship of platelet activation with microvascular function and related myonecrosis. METHODS AND RESULTS:Patients (n=66) undergoing elective percutaneous coronary intervention (PCI) in long lesions were randomised 1:1 to either BVS or EES. The primary endpoint was the difference between groups in changes of pressure-derived corrected index of microvascular resistance (cIMR) after PCI. Periprocedural myonecrosis was assessed by high-sensitivity cardiac troponin T (hs-cTnT), platelet reactivity by high-sensitivity adenosine diphosphate (hs-ADP)-induced platelet reactivity with the Multiplate Analyzer. Post-dilatation was more frequent in the BVS group, with consequent longer procedure time. A significant difference was observed between the two groups in the primary endpoint of ΔcIMR (p=0.04). hs-ADP was not different between the groups at different time points. hs-cTnT significantly increased after PCI, without difference between the groups. CONCLUSIONS:In long lesions, BVS implantation is associated with significant acute reduction in IMR as compared with EES, with no significant interaction with platelet reactivity or periprocedural myonecrosis.
METHODS:BACKGROUND:Aortopulmonary window is an uncommon congenital heart disease, with untreated cases not surviving beyond childhood. However, very rarely it can present in adult patients with features of pulmonary hypertension. Clinically these patients cannot be differentiated from other more common conditions with left to right shunt. Transthoracic echocardiography if performed meticulously, can depict the defect in aortopulmonary septum. RESULTS:We report a case of large unrepaired aortopulmonary window in a 23 years old patient, diagnosed on transthoracic echocardiography.