natriuretic-peptide--brain and Chest-Pain

Cardiac biomarkers are an integral part of the diagnostic work-up and risk stratification of patients with chest pain. Cardiac troponins are highly sensitive diagnostic biomarkers in patients with acute coronary syndrome and have prognostic value in a multitude of acute and chronic diseases. In patients with suspected pulmonary embolism (PE) D‑dimer can be used together with the Wells score for exclusion of PE. In patients with confirmed PE, B‑type natriuretic peptide (BNP), N‑terminal pro-BNP (NT-proBNP) and heart-type fatty acid binding protein (h-FABP) can be used for risk stratification. Although normal D‑dimer levels largely decrease the possibility of acute aortic dissection, clinicians should not rely on D‑dimer alone to exclude the diagnosis of acute aortic syndrome. This continuing medical education article provides an overview of the most important biomarkers recommended in current guidelines for differential diagnoses of patients with chest pain with a focus on cardiac troponins in acute coronary syndrome.

Topics: Biomarkers; Chest Pain; Diagnosis, Differential; Fatty Acid-Binding Proteins; Heart Diseases; Humans; Natriuretic Peptide, Brain; Peptide Fragments; Prognosis

When patients present with chest pain, their levels of cardiac biomarkers are only one piece of the clinical picture, albeit an important one. Together with the history, physical examination, and electrocardiography (ECG), these levels help estimate the probability that the patient is experiencing an acute coronary syndrome and will have an adverse clinical outcome.

Topics: Biomarkers; Chest Pain; Cystatin C; Heart Diseases; Humans; Natriuretic Peptide, Brain; Sensitivity and Specificity; Serum Albumin; Troponin I; Troponin T

The role of cardiac biomarkers in the diagnosis, risk stratification, and treatment of patients with chest pain and suspected acute coronary syndromes (ACS) has continued to evolve. Although it is clear that troponin (Tn) measurement provides independent prognostic information in patients with suspected ACS, it is less well established that early B-type natriuretic peptide (BNP) measurement provides additional incremental prognostic information above and beyond electrocardiography and Tn measurement. It is useful to identify patients at high risk for adverse events through measurement of Tn and BNP levels so that timely treatment decisions can be made.

Topics: Acute Coronary Syndrome; Biomarkers; Chest Pain; Hospital Mortality; Humans; Natriuretic Peptide, Brain; Predictive Value of Tests; Risk Assessment; Risk Factors; Time Factors; Treatment Outcome; Troponin

Measurable B-type natriuretic peptides (BNPs), which are largely produced by the left ventricle, include BNP and N-terminal prohormone BNP (NT-proBNP). These proteins are released by cardiomyocytes in response to wall tension and neurohumoral signals, and are established tools in the diagnosis and prognosis of heart failure (HF). We identified 32 articles for entry into evidence tables that presented original data on BNP and/or NT-proBNP in more than 100 patients with acute coronary syndromes (ACS) presenting with chest discomfort with or without dyspnea. Natriuretic peptide (NP) elevation was associated with older age, female sex, hypertension, diabetes, prior HF, prior ischemic heart disease, and reduced renal function. Clinical correlates of elevated blood NP levels included left main or 3-vessel coronary disease, lipid-rich plaques with large necrotic cores in proximal locations, large zones of myocardial ischemia or infarction, no-reflow and impaired perfusion after percutaneous intervention, reduced left ventricular ejection fraction, higher Killip classification, and the development of cardiogenic shock. All studies indicated that after adjustment for baseline predictors and clinical risk scores, elevated NP concentrations were independently predictive of the development of HF and all-cause mortality. In contrast, studies did not consistently demonstrate that NPs were predictive of myocardial infarction and rehospitalization for ACS. In addition to baseline measurement, there is consensus that repeat testing at 4 to 12 weeks and 6 to 12 months in follow-up is helpful in the anticipation of late cardiac sequelae and may assist in assessing prognosis and guiding management.

Topics: Acute Coronary Syndrome; Algorithms; Biomarkers; Chest Pain; Critical Pathways; Dyspnea; Evidence-Based Medicine; Humans; Natriuretic Peptide, Brain; Peptide Fragments; Practice Guidelines as Topic; Predictive Value of Tests; Prognosis; Risk Assessment; Risk Factors; Up-Regulation

Acute coronary syndromes (ACS) are due to the rupture or erosion of atheromatous plaques. This produces, depending on plaque size, vascular anatomy and degree of collateral circulation, progressive tissue ischaemia which may progress to cardiomyocyte necrosis and subsequent cardiac remodelling. Cardiac biomarkers can be used for diagnosis and assessment of all of these stages. Markers to detect myocardial ischaemia at the pre-infarction stage are potentially the most interesting but also the most challenging. An ischaemia marker offers the opportunity to intervene to prevent progression to infarction. The challenges with potential ischaemia markers are specificity and the diagnostic reference standard for assessment. To date, only one, ischaemia modified albumin, has reached the point where clinical studies can be performed. The measurement of the cardiac troponins, cardiac troponin T and cardiac troponin I, has become the diagnostic standard as the biomarker of myocardial necrosis. The sensitive nature of troponin measurement has also revealed that myocardial necrosis is also found in a range of other clinical situations. This illustrates the need to use all clinical information for diagnosis of acute myocardial infarction. The measurement of B type natriuretic peptides can be shown to be diagnostic and prognostic for both acute ACS and detecting the sequelae of post infarction myocardial insufficiency. The role of the B type natriuretic peptides in detection of cardiac failure, acute and chronic, is well defined. Their role in ACS remains the subject of further studies.

Topics: Acute Coronary Syndrome; Acute Disease; Biomarkers; Cardiovascular Diseases; Chest Pain; Humans; Myocardial Infarction; Myocardial Ischemia; Natriuretic Peptide, Brain; Peptide Fragments; Prognosis; Risk Assessment; Troponin I; Troponin T

Chest pain is the most common clinical presentation of acute ischemic heart disease, but only one third of these patients are ultimately found to have an acute coronary syndrome. Initial assessment of the patient presenting with chest pain includes a careful history, physical examination, an initial electrocardiogram (ECG) and measurement of biochemical markers of myocardial injury. The natriuretic peptide system is activated in a broad spectrum of cardiovascular diseases, including acute coronary syndromes and stable coronary disease. A strong relation between plasma levels of B-type natriuretic peptide (BNP) and N-terminal proBNP (NT-proBNP) obtained in the subacute phase, and long-term, all-cause mortality, as well as the rate of re-admissions for heart failure after myocardial infarction, has been documented. Persistently elevated NT-proBNP levels during the first 72 hours following admission for an acute coronary syndrome have recently been associated with the presence of refractory ischemia and high risk of short-term recurrent ischemic events. Patients with signs of exercise-induced ischemia by dobutamine stress echocardiography have been reported to have higher baseline BNP values. Moreover, BNP and NT-proBNP levels are increased acutely in proportion to the magnitude of the inducible perfusion defect observed during stress testing, suggesting that BNP and NT-proBNP are markers of acute ischemia. Recently, a relationship between circulating levels of BNP and NT-proBNP and long-term all cause mortality in patients with stable coronary artery disease has been documented.

Topics: Cardiovascular Diseases; Chest Pain; Coronary Disease; Electrocardiography; Humans; Myocardial Ischemia; Natriuretic Peptide, Brain

In the emergency setting, acute chest pain and shortness of breath represent common patient presentations. Cardiac biomarkers including myoglobin, creatine kinase (CK)-MB, troponin, and b-type natriuretic peptide provide diagnostic and prognostic information for patients with chest pain and shortness of breath. This article reviews the use of cardiac biomarkers in the emergency department to evaluate acute coronary syndrome and congestive heart failure.

Topics: Acute Disease; Biomarkers; Chest Pain; Coronary Disease; Creatine Kinase; Creatine Kinase, MB Form; Emergency Medical Services; Heart Failure; Humans; Isoenzymes; Natriuretic Peptide, Brain; Syndrome; Troponin; United States

We explored whether hemodynamic cardiac stress leads to a differential release of cardiomyocyte injury biomarkers, used in the diagnosis of acute myocardial infarction (AMI).. In an observational international multicenter study, we enrolled 831 unselected patients presenting with symptoms suggestive of AMI to the emergency department. The final diagnosis was adjudicated by two independent cardiologists. Hemodynamic cardiac stress was quantified by levels of B-type natriuretic peptide (BNP). Spearman's rho correlation was used to analyze the correlations between BNP and high-sensitivity cardiac troponin T (hs-cTnT), Siemens cTnI-Ultra (cTnI-ultra), CK-MB and Myoglobin. Patients were categorized according to the extent of hemodynamic cardiac stress as quantified by BNP tertiles.. Among all patients, the positive pair-wise correlation with BNP was strongest with hs-cTnT and cTnI-ultra (r=0.58 and 0.50, respectively), moderate for Myoglobin (r=0.43), and weakest with CK-MB (r=0.25; p<0.001 for each). Similar pattern of correlations was also observed among AMI patients. Among patients diagnosed with non-cardiac cause of chest pain (n=385, 46%) and cardiac but non-coronary (n=109, 13%), BNP had significant positive correlations with hs-cTnT, cTnI-ultra and Myoglobin (p<0.05), but not with CK-MB (p=NS). A similar pattern of stronger correlation between BNP and hs-cTnT, cTnI-ultra and Myoglobin as compared to that with CK-MB was also observed within the higher BNP tertile range. There was no correlation between BNP and other biomarkers within the 1st BNP tertile group.. Hemodynamic cardiac stress, as quantified by BNP, as a likely cause of cardiomyocyte injury, is more closely reflected by concentrations of hs-cTnT, cTnI-ultra and Myoglobin than CK-MB.

Topics: Aged; Chest Pain; Creatine Kinase, MB Form; Diagnosis, Differential; Emergency Service, Hospital; Female; Hemodynamics; Humans; International Cooperation; Male; Middle Aged; Myocardial Infarction; Myocytes, Cardiac; Myoglobin; Natriuretic Peptide, Brain; Prospective Studies; Severity of Illness Index; Stress, Physiological; Troponin I; Troponin T

Copeptin, a quantitative marker of endogenous stress, seems to provide incremental value in addition to cardiac troponin in the early rule-out of acute myocardial infarction (AMI). Prevalence, characteristics and outcome of acute chest pain patients with causes other than AMI and elevated copeptin are poorly understood.. A total of 984 consecutive patients with non-cardiac chest pain were selected from a prospective multicentre study of acute chest pain patients presenting to the emergency department. Levels of copeptin were determined in a blinded fashion and considered elevated if above 13 pmol/L (the 97,5th centile of healthy individuals). The final diagnosis was adjudicated by two independent cardiologists. Median duration of follow-up was 756 days.. Elevated copeptin levels were seen in 215 patients (22%). In comparison to patients with normal copeptin levels, patients with elevated levels were older, had more pre-existing cardiac and non-cardiac disorders, more silent cardiomyocyte injury and increased haemodynamic stress as quantified by levels of high-sensitivity cardiac troponin T (9.6 ng/L (3.6-18.3) vs 5.8 ng/L (2.9-9.4)) and B-type natriuretic peptide (75 ng/L (37-187) vs 35 ng/L (15-77)) (both p<0.001), more electrocardiographic abnormalities, more often an adjudicated diagnosis of gastroesophageal reflux or bronchitis/pneumonia and higher 2- year mortality (HR 2.9, 95% CI 1.5  to 5.7). The increased mortality rate seemed to be largely explained by age and comorbidities.. Elevated levels of copeptin are present in about one in five patients with non-cardiac chest pain and are associated with aging, cardiac and non-cardiac comorbidities as well as mortality.

Topics: Acute Pain; Adult; Aged; Biomarkers; Chest Pain; Diagnosis, Differential; Electrocardiography; Female; Follow-Up Studies; Germany; Glycopeptides; Heart Diseases; Humans; Male; Middle Aged; Natriuretic Peptide, Brain; Predictive Value of Tests; Prevalence; Prospective Studies; Protein Precursors; Reproducibility of Results; Risk Assessment; ROC Curve; Spain; Survival Rate; Switzerland; Time Factors; Troponin T

Several studies have shown an association between vitamin D deficiency and cardiovascular risk. Vitamin D status is assessed by determination of 25-hydroxyvitamin D [25(OH)D] in serum.. We assessed the prognostic utility of 25(OH)D in 982 chest-pain patients with suspected acute coronary syndrome (ACS) from Salta, Northern Argentina. 2-year follow-up data including all-cause mortality, cardiac death and sudden cardiac death were analyzed in quartiles of 25(OH)D, applying univariate and multivariate analysis.. There were statistically significant changes in seasonal 25(OH)D levels. At follow-up, 119 patients had died. The mean 25(OH)D levels were significantly lower among patients dying than in long-term survivors, both in the total population and in patients with a troponin T (TnT) release (n = 388). When comparing 25(OH)D in the highest quartile to the lowest quartile in a multivariable Cox regression model for all-cause mortality, the hazard ratio (HR) for cardiac death and sudden cardiac death in the total population was 0.37 (95% CI, 0.19-0.73), p = 0.004, 0.23 (95% CI, 0.08-0.67), p = 0.007, and 0.32 (95% CI, 0.11-0.94), p = 0.038, respectively. In patients with TnT release, the respective HR was 0.24 (95% CI, 0.10-0.54), p = 0.001, 0.18 (95% CI, 0.05-0.60), p = 0.006 and 0.25 (95% CI, 0.07-0.89), p = 0.033. 25(OH)D had no prognostic value in patients with no TnT release.. Vitamin D was shown to be a useful biomarker for prediction of mortality when obtained at admission in chest pain patients with suspected ACS.. ClinicalTrials.gov NCT01377402.

Topics: Acute Coronary Syndrome; Aged; Argentina; Body Mass Index; C-Reactive Protein; Cause of Death; Chest Pain; Death, Sudden, Cardiac; Discriminant Analysis; Female; Humans; Kaplan-Meier Estimate; Male; Middle Aged; Natriuretic Peptide, Brain; Proportional Hazards Models; Risk Assessment; ROC Curve; Troponin T; Vitamin D

The evaluation of the patient with chest pain in the emergency department is one of the most common situations that the doctor has to face. The diagnostic procedure supposes an observation period of at least 6-12 hours, a well organized medical facilities and the identification of all SCA cases to reduce inappropriate admission.. In our study we have estimated the utility of the marker assay that is associated to the use of risk scores (TIMI and GRACE risk score) to obtain indication about the most appropriate assistance level. In particular, we used the assay of necrosis markers to highlight the damage along with the assay of natriuretic peptides for their role in the diagnosis and in the monitoring of the patients with cardiac damage.. Also PCR has an important role such as marker of plaque stability and of inflammation. These markers associated to the necrosis markers could give important clinical information of independent nature.. The sensibility of laboratory markers, without important necrosis, is low and it is not possible to exclude in a few time a SCA There is now an alternative strategy: a precocious risk stratification. Using clinical criteria it is possible to do a first evaluation of the probability of SCA and the complications.

Topics: Acute Coronary Syndrome; Adult; Aged; Biomarkers; Chest Pain; Creatine Kinase, MB Form; Emergency Service, Hospital; Female; Fibrin Fibrinogen Degradation Products; Humans; Male; Middle Aged; Myoglobin; Natriuretic Peptide, Brain; Point-of-Care Systems; Predictive Value of Tests; Prognosis; Risk; Sensitivity and Specificity; Severity of Illness Index; Troponin I

The aim of this study is to assess the role of novel biomarkers for the diagnostic evaluation of acute coronary syndrome (ACS).. Among 318 patients presenting to an emergency department with acute chest discomfort, we evaluated the diagnostic value of 5 candidate biomarkers (amino terminal pro-B-type natriuretic peptide [NT-proBNP], ischemia modified albumin, heart fatty acid binding protein, high-sensitivity troponin I [hsTnI], and unbound free fatty acids [FFAu]) for detecting ACS, comparing their results with that of conventional troponin T (cTnT).. Sixty-two subjects (19.5%) had ACS. The sensitivity and negative predictive values of NT-proBNP (73%, 90%) and hsTnI (57%, 89%) were higher than that of cTnT (22%, 84%). Unbound free fatty acids had the highest overall combination of sensitivity (75%), specificity (72%), and negative predictive values (92%) of all the markers examined. A significant increase in the C-statistic for cTnT resulted from the addition of results for NT-proBNP (change 0.09, P = .001), hsTnI (change 0.13, P < .001), and FFAu (change 0.15, P < .001). In integrated discrimination improvement and net reclassification improvement analyses, NT-proBNP, hsTnI, and FFAu added significant diagnostic information to cTnT; when changing the diagnostic criterion standard for ACS to hsTnI, FFAu still added significant reclassification for both events and nonevents. In serial sampling (n = 180), FFAu added important reclassification information to hsTnI.. Among emergency department patients with symptoms suggestive of ACS, neither ischemia modified albumin nor heart fatty acid binding protein detected or excluded ACS, whereas NT-proBNP, hsTnI, or FFAu added diagnostic information to cTnT. In the context of hsTnI results, FFAu measurement significantly reclassified both false negatives and false positives at baseline and in serial samples.

Topics: Acute Coronary Syndrome; Albumins; Biomarkers; Chest Pain; Diagnosis, Differential; Emergency Service, Hospital; Fatty Acid-Binding Proteins; Fatty Acids, Nonesterified; Female; Humans; Male; Middle Aged; Natriuretic Peptide, Brain; Peptide Fragments; Predictive Value of Tests; Prognosis; Protein Precursors; Reproducibility of Results; Troponin T

The detection of postoperative myocardial infarction can be difficult in patients after lung surgery. The aim of this study was to verify the clinical significance of elevated Troponin I (cTnI), N-terminal pro-natriuretic peptide (NT-pro-BNP), lactate dehydrogenase (LDH), creatine kinase (CK), and CK-MB in the perioperative course.. Between 2007 and 2010, 64 patients (36 men, 28 women) were includeded in this prospective study and underwent thoracotomy and wedge lung resection (n = 20, group I), lobectomy/bilobectomy (n = 24, group II), and pneumonectomy (n = 20, group III). Peri-operative measurements were done for the serum markers: cTnI, NT-pro-BNP, LDH, CK, and CK-MB preoperatively and at 4 hours, 8 hours, and 24 hours postoperatively. Patients were followed over a 90-day period to evaluate postoperative cardiac mortality.. No basal troponin I elevation (or CK-MB) was found prior to surgery. Elevation in concentrations of troponin I (> 0.32 ng/mL) occurring after the procedure were seen in 9 patients. However, there was neither association with 90-day survival, postoperative ECG changes, nor with elevated levels of the other cardiac serum markers. cTnI correlated significantly with intrapericardial procedures in 7 out of 20 patients (Spearman's rank correlation coefficient: 0.406; p < 0.0001). Additionally, of the 20 patients within the pneumonectomy group, 8 patients had postoperative elevated serum cTnI. The grouping of patients into groups I through III was significantly associated with cTnI elevation (Spearman's rank correlation coefficient: 0.455; p < 0.0001).. Despite the excellent sensitivity of troponin I for detection of acute myocardial infarction the fact remains that troponin I elevations were common after intrapericardial procedures and pneumonectomies. Thus, to differentiate between cardiac ischemia provoked chest pain and wound pain related to thoracotomy remains most difficult. Patients with only marginally elevated cTnI concentrations after intrapericardial resections or pneumonectomy should remain in the intensive care unit and should be followed-up carefully by cardiologists.

Topics: Adult; Aged; Biomarkers; Chest Pain; Creatine Kinase; Creatine Kinase, MB Form; Electrocardiography; False Positive Reactions; Female; Humans; L-Lactate Dehydrogenase; Male; Middle Aged; Myocardial Infarction; Natriuretic Peptide, Brain; Pain, Postoperative; Peptide Fragments; Pneumonectomy; Postoperative Complications; Postoperative Period; Prospective Studies; Sensitivity and Specificity; Thoracotomy; Troponin I

Exercise testing constitutes the usual tool for decision making in chest pain units. This policy implies logistical constrains. Our aim was to evaluate a new strategy, combining a clinical risk score and N-terminal pro-B-type natriuretic peptide (NT-proBNP), in patients presenting to the emergency department with chest pain, without ischemic electrocardiogram changes or troponin elevation.. A total of 320 patients were randomized to either usual management, involving exercise testing, or a new strategy combining a clinical risk score and NT-proBNP without exercise testing. In the usual management, discharge decision was guided by the result of exercise test. In the new strategy, those patients with low clinical risk score and NT-proBNP were directly discharged. The primary outcome was hospitalization at the index episode. Secondary outcomes were cardiac events at 1 year.. A total of 110 patients (69%) were hospitalized using usual management in comparison with 90 (56%) in the new strategy (P = .03). There were no differences in death or myocardial infarction (n = 11, 6.9% vs n = 6, 3.8%, P = .3) or cardiac events (n = 38, 24% vs n = 28, 18%, P = .2). Revascularizations at the index episode were more frequent under usual management (18% vs 8%, P = .01), although the new strategy was associated with higher rate of planned postdischarge revascularizations (0.6% vs 5%, P = .04).. A strategy combining clinical history and NT-proBNP is simpler and reduced initial emergency hospitalizations in patients with chest pain, in comparison with the usual strategy involving exercise testing. Larger studies to assess its impact on long-term hard end points are needed.

Topics: Acute Disease; Chest Pain; Exercise Test; Female; Hospitalization; Humans; Male; Middle Aged; Natriuretic Peptide, Brain; Patient Discharge; Prospective Studies

The diagnosis of cardiac necrosis such as myocardial infarction can be difficult and relies on the use of circulating protein markers like troponin. However, there is a clear need to identify circulating, specific biomarkers that can detect cardiac ischemia without necrosis.. Using specific immunoassay and tandem mass spectrometry, we show that a fragment derived from the signal peptide of B-type natriuretic peptide (BNPsp) not only is detectable in cytosolic extracts of explant human heart tissue but also is secreted from the heart into the circulation of healthy individuals. Furthermore, plasma levels of BNPsp in patients with documented acute ST-elevation myocardial infarction (n=25) rise to peak values ( approximately 3 times higher than the 99th percentile of the normal range) significantly earlier than the currently used biomarkers myoglobin, creatine kinase-MB, and troponin. Preliminary receiver-operating characteristic curve analysis comparing BNPsp concentrations in ST-elevation myocardial infarction patients and other patient groups was positive (area under the curve=0.97; P<0.001), suggesting that further, more rigorous studies in heterogeneous chest pain patient cohorts are warranted.. Our results demonstrate for the first time that BNPsp exists as a distinct entity in the human circulation and could serve as a new class of circulating biomarker with the potential to accelerate the clinical diagnosis of cardiac ischemia and myocardial infarction. Clinical Trial Registration- URL: http://www.anzctr.org.au. Unique identifier: ACTRN12609000040268.

Topics: Acute Coronary Syndrome; Biomarkers; Chest Pain; Electrocardiography; Humans; Immunoassay; Myocardial Ischemia; Myocardium; Natriuretic Peptide, Brain; Tandem Mass Spectrometry

The emergency department (ED) evaluation of chest pain patients with potential acute coronary syndrome is limited by the initial sensitivity of cell injury markers. BNP is increased during myocardial ischemia and is associated with adverse outcomes. We determine whether the addition of B-type natriuretic peptide (BNP) to troponin I, creatine kinase-MB (CK-MB), and myoglobin increases the sensitivity and negative predictive value (NPV) for acute myocardial infarction, acute coronary syndrome, and 30-day adverse events among chest pain patients with potential acute coronary syndrome.. A convenience sample of patients aged 30 years or older and presenting to an urban academic ED with nontraumatic chest pain, thus prompting an ECG, was enrolled, and consent was obtained. Blood samples were drawn at 0 and 90 minutes. Thirty-day follow-up was performed for all enrolled patients. Main outcomes were acute myocardial infarction, acute coronary syndrome, and 30-day events (death, acute myocardial infarction, or revascularization). BNP cutoffs were derived from receiver operator characteristics curves. The sensitivity, specificity, positive predictive value (PPV), and NPV with 95% confidence intervals (CIs) were calculated with and without BNP. Differences in sensitivity and specificity with the addition of BNP were calculated with 95% CIs, and McNemar's test was performed to compare sensitivities and specificities.. Four hundred twenty-six patients were enrolled and analyzed. The cohort was 54.7+/-13.9 years old, 47.7% men, and 63.5% black. The outcomes were acute myocardial infarction, 39 (9.2%), acute coronary syndrome, 101 (23.7%), and 30-day adverse cardiovascular events 52 (12.2%). BNP cutoffs derived were 51, 31, and 31 pg/mL for acute myocardial infarction, acute coronary syndrome, and 30-day events, respectively. The addition of BNP showed increased sensitivity at the cost of decreased specificity for all 3 outcomes, as follows: (1) acute myocardial infarction: sensitivity: 87.2% (95% CI 72.6% to 95.7%) to 97.4% (95% CI 86.5% to 100%), difference 10.3% (95% CI-0.2% to 24.6%), P=.125; specificity: 62.3% (95% CI 57.2% to 67.1%) to 47.8% (95% CI 42.7% to 52.9%), difference 14.5% (95% CI 11.1% to %18.4), P<.0001; (2) acute coronary syndrome: sensitivity: 75.2% (95% CI 65.7% to 83.3%) to 88.1% (95% CI 80.2% to 93.7%), difference 12.9% (95% CI 7.0% to 21.0%), P=.0002; specificity: 68.0% (95% CI 62.6% to 73.0%) to 48.6% (95% CI 43.1% to 54.2%), difference 19.4% (95% CI 15.2% to 24.1%), P<.0001; (3) 30-day events: sensitivity: 71.2% (95% CI 56.9% to 82.9%) to 88.5% (95% CI 76.6% to 95.7%), difference 17.3% (95% CI 7.7% to 30.3%), P=.004; specificity: 61.8% (95% CI 56.6% to 66.7%) to 43.9% (95% CI 38.8% to 49.0%), difference 17.9% (95% CI 14.2% to 22.2%), P<.0001. There were trends toward increased NPV and decreased PPV for all outcomes, and the addition of BNP achieved a NPV of 99.5% (95% CI 97.0% to 100%) compared with 98.0% (95% CI 95.3% to 99.3%) for acute myocardial infarction.. The addition of BNP as a dichotomous test to troponin I, CK-MB, and myoglobin produces increased sensitivity at a cost of decreased specificity for acute myocardial infarction, acute coronary syndrome, and 30-day adverse events. Because of this tradeoff, BNP cannot be recommended for use among all ED chest pain patients. However, the improved sensitivity may make this test useful in selected cohorts when the decreased specificity is less important.

Topics: Angioplasty, Balloon, Coronary; Chest Pain; Coronary Artery Bypass; Coronary Disease; Creatine Kinase, MB Form; Emergency Service, Hospital; Female; Hospital Mortality; Humans; Male; Middle Aged; Myocardial Infarction; Natriuretic Peptide, Brain; Risk Factors; ROC Curve; Troponin I

Topics: Abdominal Pain; Acute Kidney Injury; Adolescent; Adult; Asthenia; Chest Pain; Conjunctivitis; Coronary Angiography; Coronary Care Units; COVID-19; Diarrhea; Dyspnea; Electrocardiography; Exanthema; Extracorporeal Membrane Oxygenation; Female; Fever; France; Headache; Humans; Hypotension; Intensive Care Units; Magnetic Resonance Imaging; Male; Mucocutaneous Lymph Node Syndrome; Myocarditis; Natriuretic Peptide, Brain; Peptide Fragments; Respiration, Artificial; SARS-CoV-2; Stroke Volume; Systemic Inflammatory Response Syndrome; Tachycardia; Troponin; Ventricular Dysfunction, Left; Young Adult

We report a case of cardiac injury in a 46-year-old man affected by COVID-19. The patient presented with shortness of breath and fever. ECG revealed sinus tachycardia with ventricular extrasystoles and T-wave inversion in anterior leads. Troponin T and N-terminal pro B-type natriuretic peptide were elevated. Transthoracic echocardiography showed severely reduced systolic function with an estimated left ventricle ejection fraction of 30%. A nasopharingeal swab was positive for SARS-CoV-2. On day 6, 11 days after onset of symptoms, the patient deteriorated clinically with new chest pain and type 1 respiratory failure. Treatment with colchicine 0.5 mg 8-hourly resulted in rapid clinical resolution. This case report highlights how cardiac injury can dominate the clinical picture in COVID-19 infection. The role of colchicine therapy should be further studied to determine its usefulness in reducing myocardial and possibly lung parenchymal inflammatory responses.

Topics: Chest Pain; Colchicine; COVID-19; COVID-19 Drug Treatment; Echocardiography; Heart Diseases; Humans; Male; Middle Aged; Myocardium; Natriuretic Peptide, Brain; Peptide Fragments; Systole; Troponin T

The objective of this study was to investigate the prognostic value of urinary N-terminal pro-brain natriuretic peptide (NT-proBNP) compared with plasma NT-proBNP in patients presenting with acute chest pain in the emergency department.. We measured simultaneously plasma and urinary NT-proBNP at admission in 301 patients with acute chest pain. In our cohort, 174 patients suffered from acute coronary syndrome (ACS). A follow-up (median of 55 months) was performed regarding the endpoints all-cause mortality and major adverse cardiac events (mortality, congestive heart failure, ACS with the necessity of a coronary intervention, and stroke). Fifty-four patients died during follow-up; 98 suffered from the combined endpoint. A significant and positive correlation of urinary and plasma NT-proBNP was found (r = 0.87, P < 0.05). Patients with troponin positive ACS had significantly elevated levels of plasma and urinary NT-proBNP compared with those with unstable angina pectoris or chest wall syndrome (each P < 0.05). The highest levels of both biomarkers were found in patients with congestive heart failure (each P < 0.05). According to Kaplan-Meier analysis, plasma and urinary NT-proBNP were significant predictors for mortality and the combined endpoint in the whole study cohort and in the subgroup of patients with ACS (each P < 0.05). Regarding Cox regression analysis, plasma and urinary NT-proBNP were independent predictors for mortality and the combined endpoint (each P < 0.05).. Urinary NT-proBNP seems to provide a significant predictive value regarding the endpoints all-cause mortality and major adverse cardiac events in patients with acute chest pain and those with ACS.

Topics: Chest Pain; Humans; Natriuretic Peptide, Brain; Peptide Fragments; Prognosis

BACKGROUND The main causes for takotsubo syndrome (TS) in oncological patients are stress related to cancer diagnosis and treatment, pain in the course of the disease, treatment complications, and paraneoplastic syndromes. CASE REPORT An obese 62-year-old female patient, with a 3-day history of chest pain, was admitted to the hospital with a suspected acute coronary event. She had been diagnosed with high-grade bladder cancer 6 months before. After the transurethral electroresection of the tumor 5 months before and subsequent chemotherapy (gemcitabine and cisplatin), the patient was qualified for the next cancer surgery. On admission, the patient remained without chest pain. The ECG record demonstrated inverted T waves in the leads from above the anterior and lateral wall. The coronarography demonstrated minor atherosclerotic changes in the coronary arteries. The left ventriculography presented akinesis of the apex and the apical and mid-segment of the anterior wall, and the ejection fraction (EF) was 38%. Takotsubo syndrome was diagnosed. Laboratory testing revealed elevated concentration of troponin and N-terminal pro-B-type natriuretic peptide. The subsequent ECG records demonstrated deeply inverted T waves and numerous ventricular premature beats and increased QTc (528 ms). A control echocardiography showed improved left ventricular contractive function (EF - 47%). On the 4th day of hospitalization, the patient was discharged and referred for further oncological treatment. CONCLUSIONS The diagnosis of TS in oncology patients is difficult, especially in the presence of atherosclerotic lesions in coronary arteries. Takotsubo syndrome in cancer patients delays the next stages of oncological treatment, which worsens the prognosis of these patients.

Topics: Chest Pain; Echocardiography; Female; Humans; Middle Aged; Natriuretic Peptide, Brain; Peptide Fragments; Takotsubo Cardiomyopathy; Troponin; Urinary Bladder Neoplasms

Topics: Adolescent; Adult; Asymptomatic Infections; Betacoronavirus; C-Reactive Protein; Chest Pain; Coronavirus Infections; COVID-19; Edema; Female; Ferritins; Fibrin Fibrinogen Degradation Products; Humans; Magnetic Resonance Imaging; Magnetic Resonance Imaging, Cine; Male; Myocarditis; Natriuretic Peptide, Brain; Pandemics; Pneumonia, Viral; Pregnancy; Pregnancy Complications, Infectious; Puerperal Disorders; SARS-CoV-2; Troponin I; Troponin T

Topics: Asthma; C-Reactive Protein; Chest Pain; Eosinophilia; Female; Granulomatosis with Polyangiitis; Humans; Leukocytosis; Lupus Erythematosus, Discoid; Magnetic Resonance Imaging, Cine; Middle Aged; Natriuretic Peptide, Brain; Pericarditis; Troponin T

Myocardial injury with systemic sclerosis (SSc) causes pericarditis and arrhythmia, and polymyositis-induced muscle inflammation causes myocarditis. We report a rare case of overlap syndrome (SSc and polymyositis) who presented with sudden chest pain secondary to myocardial fibrosis. Although the etiology of chest symptoms in collagen disease was difficult to identify, cardiac magnetic resonance imaging (MRI) revealed not myocarditis but myocardial fibrosis in our case. Synthetic judgement of serum brain natriuretic peptide/ troponin T levels and cardiac MRI is useful in the search for the cause of chest symptoms even in patients with collagen diseases.

Topics: Chest Pain; Fibrosis; Heart; Humans; Magnetic Resonance Imaging; Male; Myocardium; Natriuretic Peptide, Brain; Polymyositis; Scleroderma, Diffuse; Syndrome; Troponin T; Young Adult

Background Defects in human cognition commonly result in clinical reasoning failures that can lead to diagnostic errors. A metacognitive structured reflection on what clinical findings fit and/or do not fit with likely and "can't miss" diagnoses may reduce such errors. Case presentation A 57-year-old man was sent to the emergency department from clinic with chest pain, severe shortness of breath, weakness, and cold sweats. Further investigation revealed multiple risk factors for coronary artery disease, sudden onset of exertional dyspnea, and chest pain that incompletely resolved with rest, mild tachycardia and hypoxia, an abnormal electrocardiogram (ECG), elevated serum cardiac biomarkers, and elevated B-type natriuretic peptide (BNP) in the absence of left-sided heart failure. He was treated for acute coronary syndrome (ACS), discharged, and quickly returned with worsening symptoms that eventually led to a diagnosis of submassive pulmonary embolism (PE). Conclusions Through integrated commentary on the diagnostic reasoning process from clinical reasoning experts at two institutions, this case underscores the importance of frequent assessment of fit along with explicit explanation of dissonant features in order to avoid premature closure and diagnostic error. A fishbone diagram is provided to visually demonstrate the major factors that contributed to the diagnostic error. A case discussant describes the importance of diagnostic schema as an analytic reasoning strategy to assist in the creation of a differential diagnosis, problem representation to summarize updated findings, a Popperian analytic approach of attempting to falsify less-likely hypotheses, and matching pertinent positives and negatives to previously learned illness scripts. Finally, this case provides clinical teaching points in addition to a pitfall, myth, and pearl specific to premature closure.

Topics: Acute Coronary Syndrome; Chest Pain; Clinical Decision-Making; Cognitive Dissonance; Diagnostic Errors; Dyspnea; Emergency Service, Hospital; Humans; Male; Mental Processes; Middle Aged; Natriuretic Peptide, Brain; Pulmonary Embolism

We assessed the ability of B-type natriuretic peptide signal peptide (BNPsp) to assist with the identification of patients with myocardial infarction (MI) and unstable angina pectoris (UAP).. We studied 505 patients who presented to hospital within 4h of onset of chest pain suspicious of ACS. Blood samples were drawn at 0, 1, 2 and 24h from presentation and assayed for BNPsp, NT-proBNP, TnI and high sensitivity TnT. The ability of BNPsp and other markers to diagnose acute myocardial infarction (MI) and unstable angina pectoris (UAP) and predict subsequent events within one year was assessed. Statistical analysis was made using ROC AUC in SPSS, v.22.. Receiver operator area under the curve (AUC) data for the discrimination of MI was 0.69 for BNPsp and 0.97 for troponin, with BNPsp failing to add to troponin. However, in non-MI patients, BNPsp had discriminative power for UAP (p<0.05), and when combined with presentation values of NT-proBNP, white cell count and potassium into a unique parameter (UARatio), generated an AUC of 0.76 for UAP in patients with normal ECG results (p<0.001). In non-MI patients, the UARatio was significantly predictive of subsequent stroke (AUC=0.70, p<0.05) and heart failure (AUC=0.82, p<0.01) within one year.. In patients with chest pain, BNPsp is predictive of MI but is not a useful adjunct to troponin. However, the ability of BNPsp, in conjunction with NT-proBNP and key analytes, to diagnose UAP and other ischemic syndromes merits further investigation.

Topics: Aged; Aged, 80 and over; Biomarkers; Chest Pain; Female; Follow-Up Studies; Humans; Male; Middle Aged; Myocardial Infarction; Natriuretic Peptide, Brain; Peptide Fragments; Predictive Value of Tests; Prognosis; Prospective Studies; Risk Factors; ROC Curve

The endogenous amino acid homoarginine predicts mortality in cerebro- and cardiovascular disease. The objective was to explore whether homoarginine is associated with atrial fibrillation (AF) and outcome in patients with acute chest pain.. One thousand six hundred forty-nine patients with acute chest pain were consecutively enrolled in this study, of whom 589 were diagnosed acute coronary syndrome (ACS). On admission, plasma concentrations of homoarginine as well as brain natriuretic peptide (BNP), and high-sensitivity assayed troponin I (hsTnI) were determined along with electrocardiography (ECG) variables. During a median follow-up of 183 days, 60 major adverse cardiovascular events (MACEs; 3.8%), including all-cause death, myocardial infarction, or stroke, were registered in the overall study population and 43 MACEs (7.5%) in the ACS subgroup. Adjusted multivariable Cox regression analyses revealed that an increase of 1 SD of plasma log-transformed homoarginine (0.37) was associated with a hazard reduction of 26% (hazard ratio [HR], 0.74; 95% CI, 0.57-0.96) for incident MACE and likewise of 35% (HR, 0.65; 95% CI, 0.49-0.88) in ACS patients. In Kaplan-Meier survival curves, homoarginine was predictive for patients with high-sensitivity assayed troponin I (hsTnI) above 27 ng/L (P<0.05). Last, homoarginine was inversely associated with QTc duration (P<0.001) and prevalent AF (OR, 0.83; 95% CI, 0.71-0.95).. Low plasma homoarginine was identified as a risk marker for incident MACEs in patients with acute chest pain, in particular, in those with elevated hsTnI. Impaired homoarginine was associated with prevalent AF. Further studies are needed to investigate the link to AF and evaluate homoarginine as a therapeutic option for these patients.

Topics: Acute Coronary Syndrome; Acute Pain; Aged; Atrial Fibrillation; Biomarkers; Chest Pain; Female; Homoarginine; Humans; Kaplan-Meier Estimate; Male; Middle Aged; Myocardial Infarction; Natriuretic Peptide, Brain; Prognosis; Proportional Hazards Models; Stroke

Acute heart failure negatively affects short-term outcomes of patients with acute coronary syndrome (ACS). Therefore, reliable and non-invasive assessment of pulmonary congestion is needed to select patients requiring more intensive monitoring and therapy. Since plasma levels of natriuretic peptides are influenced by myocardial ischemia, they might not reliably reflect congestion in the context of ACS. The novel endothelial biomarker, soluble CD146 (sCD146), presents discriminative power for detecting the cardiac origin of acute dyspnea similar to that of natriuretic peptides and is associated with systemic congestion. We evaluated the performance of sCD146 for the assessment of pulmonary congestion in the early phase of ACS.. One thousand twenty-one consecutive patients with ACS were prospectively enrolled. Plasma levels of sCD146, brain natriuretic peptide (BNP), and high-sensitive troponin T were measured within 24 hr after the onset of chest pain. Pulmonary congestion on chest radiography was determined and classified in three groups according to the degree of congestion.. Nine hundred twenty-seven patients with ACS were analyzed. Ninety-two (10%) patients showed signs of pulmonary edema on chest radiography. Plasma levels of sCD146 reflected the radiological severity of pulmonary congestion. Higher plasma levels of sCD146 were associated with the worse degree of pulmonary congestion. In contrast to BNP, sCD146 levels were not affected by the level of troponin T.. The novel endothelial biomarker, sCD146, correlates with radiological severity of pulmonary congestion in the early phase of ACS and, in contrast to BNP, is not affected by the amount of myocardial cell necrosis.

Topics: Acute Coronary Syndrome; Aged; Biomarkers; CD146 Antigen; Chest Pain; Electrocardiography; Enzyme-Linked Immunosorbent Assay; Female; Humans; Male; Middle Aged; Myocardial Infarction; Natriuretic Peptide, Brain; Severity of Illness Index; Troponin T

Natriuretic peptides are the standard biomarker for risk stratification in cardiovascular disease. Novel biomarkers of cardiovascular stress might allow refinement in risk stratification for patients with acute coronary syndrome (ACS). We tested the performance of these novel biomarkers for cardiovascular risk stratification in patients who presented with ACS.. In the AtheroGene study, 873 patients presented with ACS in the emergency department. Biomarkers measured were: B-type natriuretic peptide (BNP), N-terminal pro BNP (NT-proBNP), midregional proatrial natriuretic peptide, midregional proadrenomedullin (MR-proADM), copeptin, and troponin I. The median follow-up time was 4 years and during this time 50 patients died from cardiac causes.. Cox regression analysis for the continuous variables NT-proBNP and BNP showed a hazard ratio (HR) of 1.9 and 1.8, respectively, for 1 SD increase (P < 0.001 and P = 0.003) in the fully adjusted model. Novel biomarkers with MR-proADM had an HR of 3.2, followed by midregional proatrial natriuretic peptide with an HR of 1.9 (both P < 0.001), and copeptin with an HR of 1.6 (P < 0.001). C-index revealed MR-proADM as the best discriminator for identifying patients with the outcome with a C-index = 0.8, and C-index was 0.72 for NT-proBNP (P for comparison = 0.017). Integrated discrimination improvement for MR-proADM was 0.059 compared with NT-proBNP (P = 0.016), thus providing background that MR-proADM was better to identify persons with the outcome. Troponin I levels at the time of admission were not significant for risk stratification.. In patients who present with ACS the novel biomarker, MR-proADM was the best predictor for outcome. MR-proADM adds modest information and is useful for risk prediction in ACS patients.

Topics: Acute Coronary Syndrome; Adrenomedullin; Aged; Biomarkers; Cardiovascular System; Chest Pain; Female; Germany; Glycopeptides; Humans; Male; Middle Aged; Natriuretic Peptide, Brain; Peptide Fragments; Proportional Hazards Models; Protein Precursors; Reproducibility of Results; Risk Assessment; Stress, Physiological; Troponin I

Recent studies have suggested that B-type Natriuretic Peptide (BNP) is an important predictor of ischemia and death in patients with suspected acute coronary syndrome. Increased levels of BNP are seen after episodes of myocardial ischemia and may be related to future adverse events.. To determine the prognostic value of BNP for major cardiac events and to evaluate its association with ischemic myocardial perfusion scintigraphy (MPS).. This study included retrospectively 125 patients admitted to the chest pain unit between 2002 and 2006, who had their BNP levels measured on admission and underwent CPM for risk stratification. BNP values were compared with the results of the MPS. The chi-square test was used for qualitative variables and the Student t test, for quantitative variables. Survival curves were adjusted using the Kaplan-Meier method and analyzed by using Cox regression. The significance level was 5%.. The mean age was 63.9 ± 13.8 years, and the male sex represented 51.2% of the sample. Ischemia was found in 44% of the MPS. The mean BNP level was higher in patients with ischemia compared to patients with non-ischemic MPS (188.3 ± 208.7 versus 131.8 ± 88.6; p = 0.003). A BNP level greater than 80 pg/mL was the strongest predictor of ischemia on MPS (sensitivity = 60%, specificity = 70%, accuracy = 66%, PPV = 61%, NPV = 70%), and could predict medium-term mortality (RR = 7.29, 95% CI: 0.90-58.6; p = 0.045) independently of the presence of ischemia.. BNP levels are associated with ischemic MPS findings and adverse prognosis in patients presenting with acute chest pain to the emergency room, thus, providing important prognostic information for an unfavorable clinical outcome.

Topics: Aged; Biomarkers; Chest Pain; Emergency Service, Hospital; Epidemiologic Methods; Female; Humans; Male; Middle Aged; Myocardial Ischemia; Myocardial Perfusion Imaging; Natriuretic Peptide, Brain; Prognosis; Time Factors

Non-invasive assessment using a pharmacological provocative test is an essential part of the workup of patients admitted to the emergency department with chest pain. Some doubts, however, remain about the safety of dipyridamole stress echocardiography in patients with non-diagnostic troponin and ECG.. Twenty-nine consecutive patients admitted to the emergency department with chest pain and no evidence of acute coronary syndrome were subjected to standard dipyridamole stress echocardiography. Blood samples for measurement of galectin-3, NT-proBNP and high-sensitivity troponin T (HS-TnT) were collected at the baseline and after provocative testing. The provocative test was positive in 7/29 patients. As compared with baseline measurements, no significant differences were observed in 1-h values of HS-TnT (10.7 versus 10.5 ng/L; P = 0.085) and galectin-3 (14.3 versus 13.7 ng/mL; P = 0.128), whereas values of NT-proBNP were slightly higher (126 versus 111 ng/L; P = 0.002). The 1-h delta variation of patients with a positive provocative test was significantly higher than that of patients with negative provocative testing for galectin-3 (1.12 versus 1.00; P < 0.001), but not for HS-TnT (0.98 versus 1.00; P = 0.184) and NT-proBNP (1.10 versus 1.04; P = 0.344). The 1-h delta variation of galectin-3 was > 1 in all patients with a positive provocative test as compared with 50% of patients with a negative provocative test (P = 0.018).. Dipyridamole stress testing did not trigger clinically meaningful injuries to the myocardium. Galectin-3 testing may hence be preliminarily regarded as a complementary means for enhancing the diagnostic value of provocative testing. It is also worthwhile investigating whether patients with abnormal response to a provocative test and increased galectin-3 values may be targeted with specific therapy.

Topics: Adult; Aged; Aged, 80 and over; Biomarkers; Chest Pain; Dipyridamole; Echocardiography, Stress; Emergency Service, Hospital; Female; Galectin 3; Humans; Male; Middle Aged; Myocardial Ischemia; Natriuretic Peptide, Brain; Peptide Fragments; Predictive Value of Tests; Prognosis; Risk Assessment; Risk Factors; Sensitivity and Specificity; Severity of Illness Index; Troponin T; Vasodilator Agents

The prognostic significance of chest pain is well established in patients with coronary artery disease, but still ill defined in primary prevention. Therefore, the aim of our analysis was to assess the prognostic value of different forms of chest pain in a large cohort of primary care subjects under the conditions of contemporary modalities of care in primary prevention, including measurement of serum levels of the biomarker NT-pro-BNP.. We carried out a post-hoc analysis of the prospective DETECT cohort study.. In a total of 5570 unselected subjects, free of coronary artery disease, within the 55,518 participants of the cross-sectional DETECT study, we assessed chest pain history by a comprehensive questionnaire and measured serum NT-pro-BNP levels. Three types of chest pain, which were any chest pain, exertional chest pain and classical angina, were defined. Major adverse cardiovascular events (MACEs = cardiovascular death, myocardial infarction, coronary revascularization procedures) were assessed during a 5-year follow-up period.. During follow-up, 109 subjects experienced a MACE. All types of reported chest pain were associated with an approximately three-fold increased risk for the occurrence of incident MACEs, even after adjusting for cardiovascular risk factors. Any form of reported chest pain had a similar predictive value for MACEs as a one-time measurement of NT-pro-BNP. However, adding a single measurement of NT-pro-BNP and the information on chest pain resulted in reclassification of approximately 40% of subjects, when compared with risk prediction based on established cardiovascular risk factors.. In primary prevention, self-reported chest pain and a single measurement of NT-pro-BNP substantially improve cardiovascular risk prediction and allow for risk reclassification of approximately 40% of the subjects compared with assessing classical cardiovascular risk factors alone.

Topics: Adult; Aged; Cardiovascular Diseases; Chest Pain; Female; Humans; Male; Middle Aged; Natriuretic Peptide, Brain; Peptide Fragments; Primary Health Care; Prognosis; Risk Assessment; Risk Factors

Topics: Chest Pain; Female; Humans; Male; Natriuretic Peptide, Brain; Troponin

High-sensitivity troponin assays have improved the diagnosis of acute coronary syndrome in patients presenting with chest pain and normal troponin levels as measured by conventional assays. Our aim was to investigate whether N-terminal pro-brain natriuretic peptide provides additional information to troponin determination in these patients.. A total of 398 patients, included in the PITAGORAS study, presenting to the emergency department with chest pain and normal troponin levels as measured by conventional assay in 2 serial samples (on arrival and 6 h to 8h later) were studied. The samples were also analyzed in a central laboratory for high-sensitivity troponin T (both samples) and for N-terminal pro-brain natriuretic peptide (second sample). The endpoints were diagnosis of acute coronary syndrome and the composite endpoint of in-hospital revascularization or a 30-day cardiac event.. Acute coronary syndrome was adjudicated to 79 patients (20%) and the composite endpoint to 59 (15%). When the N-terminal pro-brain natriuretic peptide quartile increased, the diagnosis of acute coronary syndrome also increased (12%, 16%, 23% and 29%; P=.01), as did the risk of the composite endpoint (6%, 13%, 16% and 24%; P=.004). N-terminal pro-brain natriuretic peptide elevation (>125ng/L) was associated with both endpoints (relative risk= 2.0; 95% confidence interval, 1.2-3.3; P=.02; relative risk=2.4; 95% confidence interval, 1.4-4.2; P=.004). However, in the multivariable models adjusted by clinical and electrocardiographic data, a predictive value was found for high-sensitivity T troponin but not for N-terminal pro-brain natriuretic peptide.. In low-risk patients with chest pain of uncertain etiology evaluated using high-sensitivity T troponin, N-terminal pro-brain natriuretic peptide does not contribute additional predictive value to diagnosis or the prediction of short-term outcomes.

Topics: Acute Coronary Syndrome; Aged; Biomarkers; Chest Pain; Endpoint Determination; Female; Humans; Male; Middle Aged; Natriuretic Peptide, Brain; Prospective Studies; Troponin

Current models incompletely risk-stratify patients with acute chest pain. In this study, N-terminal pro-B-type natriuretic peptide and cystatin C were incorporated into a contemporary chest pain triage algorithm in a clinically stratified population to improve acute coronary syndrome discrimination. Adult patients with chest pain presenting without myocardial infarction (n = 382) were prospectively enrolled from 2008 to 2009. After clinical risk stratification, N-terminal pro-B-type natriuretic peptide and cystatin C were measured and standard care was performed. The primary end point was the result of a clinical stress test. The secondary end point was any major adverse cardiac event at 6 months. Associations were determined through multivariate stratified analyses. In the low-risk group, 76 of 78 patients with normal levels of the 2 biomarkers had normal stress test results (negative predictive value 97%). Normal biomarkers predicted normal stress test results with an odds ratio of 10.56 (p = 0.006). In contrast, 26 of 33 intermediate-risk patients with normal levels of the 2 biomarkers had normal stress test results (negative predictive value 79%). Biomarkers and stress test results were not associated in the intermediate-risk group (odds ratio 2.48, p = 0.09). There were 42 major adverse cardiac events in the overall cohort. No major adverse cardiac events occurred at 6 months in the low-risk subgroup that underwent stress testing. In conclusion, N-terminal pro-B-type natriuretic peptide and cystatin C levels predict the results of stress tests in low-risk patients with chest pain but should not be substituted for stress testing in intermediate-risk patients. There is potential for their use in the early discharge of low-risk patients after clinical risk stratification.

Topics: Acute Pain; Biomarkers; Chest Pain; Cystatin C; Diagnosis, Differential; Emergency Service, Hospital; Female; Follow-Up Studies; Humans; Incidence; Male; Middle Aged; Myocardial Infarction; Natriuretic Peptide, Brain; Peptide Fragments; Prognosis; Protein Precursors; Retrospective Studies; Risk Assessment; Risk Factors; Triage; United States

To evaluate the prognostic value of high-sensitivity troponin T (hs-cTnT) in patients who present to General Practitioners (GPs) with non-acute chest pain.. A total of 625 patients who were referred by their GPs to a regional Rapid Access Chest Pain Clinic in Tayside, Scotland were consented and recruited. Diamond-Forrester pretest probability of coronary artery disease (CAD) was used to select patients with intermediate and high-pretest probability. Hs-cTnT and B-type Natriuretic Peptide (BNP) were measured and final diagnosis recorded. Twelve-month follow-up for cardiac events and hospital admission data was collected. Sensitivity, specificity, positive predictive value and negative predictive value (NPV), for both prognosis and diagnosis, were produced using various pre-specified cut-off values for hs-cTnT and BNP.. A total of 579 patients were included in the final analysis. Of these, 477 had intermediate/high-pretest probability of CAD. A total of 431 (90.4%) of patients had a hs-cTnT ≤14 ng/l. In this study, hs-cTnT of 14 ng/l was the best cut-off for ruling out if a patient would have an admission for cardiac chest pain in the following 12 months (specificity 90%, NPV 91.4%). It performed well as a predictor of a subsequent negative diagnosis of cardiac chest pain with a specificity of 92.4% and NPV of 83.5%.. Hs-cTnT, at the same level currently used in clinical practice as a diagnostic cut-off for myocardial infarction and acute coronary syndromes, is also a clinically-meaningful indicator for further 12-month cardiac chest pain hospital admissions in patients with non-acute chest pain referred to chest pain clinics by GPs.

Topics: Aged; Chest Pain; Coronary Artery Disease; Female; Follow-Up Studies; Humans; Male; Middle Aged; Natriuretic Peptide, Brain; Prognosis; Sensitivity and Specificity; Troponin T

Growth differentiation factor-15 (GDF-15) is a stress-responsive marker that might aid in the early diagnosis and risk stratification of patients with suspected acute myocardial infarction (AMI).. In a prospective, international multicenter study, GDF-15, high-sensitivity cardiac troponin T (hs-cTnT), and B-type natriuretic peptide (BNP) were measured in 646 unselected patients presenting to the emergency department with acute chest pain. The final diagnosis was adjudicated by 2 independent cardiologists. The primary prognostic end point was all-cause mortality during a median follow-up of 26 months.. AMI was the adjudicated final diagnosis in 115 patients (18%). GDF-15 concentrations at presentation were significantly higher in AMI patients compared to patients with other diagnoses. The diagnostic accuracy of GDF-15 at presentation for the diagnosis of AMI as quantified by the area under the ROC curve (AUC) was lower (AUC 0.69, 95% CI 0.64-0.74) compared to hs-cTnT (AUC 0.96, 95% CI 0.94-0.98, P < 0.001) and BNP (AUC 0.74, 95% CI 0.69-0.80, P = 0.02). A total of 55 deaths occurred during follow-up. GDF-15 predicted all-cause mortality independently of and more accurately than hs-cTnT [AUC 0.85 (95% CI 0.81-0.90) vs 0.77 (95% CI 0.72-0.83), P = 0.002] and BNP (AUC 0.75, 95% CI 0.68-0.82, P = 0.007). Net reclassification improvement was 0.15 (P = 0.01), and the absolute integrated discrimination improvement was 0.07, yielding a relative integrated discrimination improvement of 0.36 (P = 0.07).. GDF-15 predicts all-cause mortality in unselected patients with acute chest pain independently of and more accurately than hs-cTnT and BNP. However, GDF-15 does not seem to help in the early diagnosis of AMI.

Topics: Acute Disease; Aged; Aged, 80 and over; Angina, Unstable; Biomarkers; Chest Pain; Early Diagnosis; Female; Growth Differentiation Factor 15; Humans; Male; Middle Aged; Mortality; Myocardial Infarction; Natriuretic Peptide, Brain; Prognosis; Prospective Studies; Risk Assessment; Troponin T

The aim was to examine whether high sensitive troponin T (Hs-TnT) is better than conventional troponins to risk stratify chest pain patients, in particular when applying early serial measurements or combining with natriuretic peptides. Samples were obtained on admission and after 2 h in 231 chest pain patients who were followed for a median time of 22 months. Troponin levels were determined by Hs-TnT, conventional TnT (Roche Diagnostics) and troponin I (Beckman Coulter) assays. N-terminal pro B-type natriuretic peptide (NT-proBNP) was determined by the assay from Roche Diagnostics. The combined endpoint was death, MI or heart failure. When predefined decision limits were used, Hs-TnT (14 ng/L), TnT (0.04 μg/L), and TnI (0.06 μg/L) identified 63%, 46%, and 52% of the patients with positive troponin. In those with negative TnT, Hs-TnT identified 36 patients of whom 19% had subsequent events. In those with negative TnI, Hs-TnT identified 26 patients of whom 23% had subsequent events. After adjusting for differences in baseline characteristics, both Hs-TnT and NT-proBNP were independently associated with short-term (3 months) risk of combined endpoint and long-term risk of death or MI. By combining Hs-TnT and NT-proBNP patients could be divided into low-, intermediate- and high-risk groups.

Topics: Aged; Aged, 80 and over; Biomarkers; Chest Pain; Female; Follow-Up Studies; Heart Failure; Humans; Male; Middle Aged; Myocardial Infarction; Natriuretic Peptide, Brain; Peptide Fragments; Prognosis; Prospective Studies; Risk Factors; Troponin T

Elevated ST2 predicts future heart failure and/or death in patients with pulmonary diseases, heart failure, acute dyspnea, and acute coronary syndromes. This study assesses both diagnostic and prognostic utility of ST2 in patients with chest pain.. From November 2007 to April 2010, 995 patients attending the Emergency Department with chest pain were prospectively recruited. Troponin I (TnI), B-type natriuretic peptide (BNP), creatine kinase-myocardial band (CKMB), myoglobin, and ST2 were measured at 0 and 2 hours. The diagnostic utility of ST2 for heart failure and prognostic utility for primary outcome of death and/or heart failure by 18 months was assessed. Elevated ST2 had sensitivity 73.5% (55.8%-86.4%) and specificity 79.6% (79.0%-80.1%) for acute heart failure (n = 34) [compared with BNP sensitivity 88.2% (73.6%-95.3%), specificity 66.2% (65.7%-66.4%)]. Elevated ST2 conveyed risk of 18-month primary outcome (n = 110), with an adjusted hazard ratio (HR) of 1.9 (1.2-3.2), compared with BNP HR 2.8 (1.4-5.7), myoglobin HR 1.9 (1.1-3.3), TnI HR 1.7 (1.0-2.7), and CKMB HR 0.9 (0.5-1.7). When ST2 and BNP were both elevated, risk was greater than if either marker was elevated in isolation (P < .001).. ST2 was more specific for acute heart failure than BNP. ST2 is independently predictive of future death and/or heart failure and has incremental utility in combination with BNP.

Topics: Acute Coronary Syndrome; Chest Pain; Creatine Kinase, MB Form; Emergency Service, Hospital; Female; Heart Failure; Humans; Interleukin-1 Receptor-Like 1 Protein; Kaplan-Meier Estimate; Male; Middle Aged; Myoglobin; Natriuretic Peptide, Brain; Peptide Fragments; Prognosis; Prospective Studies; Receptors, Cell Surface; Receptors, Interleukin-1; Sensitivity and Specificity; Troponin I

Recent studies have demonstrated the association between increased concentrations of high-sensitivity cardiac troponin T (hs-cTnT) and the incidence of myocardial infarction, heart failure, and mortality. However, most prognostic studies to date focus on the value of hs-cTnT in the elderly or general population. The value of hs-cTnT in symptomatic patients visiting the outpatient department remains unclear. The aim of this study was to investigate the prognostic value of hs-cTnT as a biomarker in patients with symptoms of chest discomfort suspected for coronary artery disease and to assess its additional value in combination with other risk stratification tools in predicting cardiac events.. We studied 1,088 patients (follow-up 2.2 ± 0.8 years) with chest discomfort who underwent coronary calcium scoring and coronary CT-angiography. Traditional cardiovascular risk factors and concentrations of hs-cTnT, N-terminal pro-brain-type natriuretic peptide (NT-proBNP) and high-sensitivity C-reactive protein (hsCRP) were assessed. Study endpoint was the occurrence of late coronary revascularization (>90 days), acute coronary syndrome, and cardiac mortality.. Hs-cTnT was a significant predictor for the composite endpoint (highest quartile [Q4]>6.7 ng/L, HR 3.55; 95%CI 1.88-6.70; P<0.001). Survival analysis showed that hs-cTnT had significant predictive value on top of current risk stratification tools (Chi-square change P<0.01). In patients with hs-cTnT in Q4 versus

Topics: Biomarkers; C-Reactive Protein; Calcium; Chest Pain; Coronary Angiography; Coronary Artery Disease; Echocardiography; Endpoint Determination; Humans; Kaplan-Meier Estimate; Natriuretic Peptide, Brain; Peptide Fragments; Risk Assessment; Risk Factors; Troponin T

Compared to troponin alone, a dual-marker strategy with natriuretic peptides may improve acute coronary syndrome (ACS) diagnosis with a single blood draw and provide physiologic information regarding underlying heart disease. We evaluate the value of adding natriuretic peptides (myocyte stress markers) to troponins (myocardial injury markers) for diagnosing ACS in emergency department patients with chest pain.. In 328 patients (53 ± 12 years, 63% men) with an initially negative conventional troponin and nonischemic electrocardiogram who underwent 64-slice cardiac computed tomography (CT), we measured conventional troponin-T (cTnT), high-sensitivity troponin-T (hsTnT), N-terminal pro-B type natriuretic peptide, and mid-regional pro-atrial natriuretic peptide. ACS was defined as myocardial infarction or unstable angina. CT was evaluated for coronary plaque, stenosis, and regional wall motion abnormality.. Patients with ACS (n = 29, 9%) had higher concentrations of each biomarker compared to those without (all P < .01). Adding natriuretic peptides, especially N-terminal pro-B type natriuretic peptide, to both cTnT or hsTnT improved the C-statistics and net reclassification index for ACS, largely driven by correctly reclassifying events. Dual-negative marker results improved sensitivity (cTnT 38% to 83%-86%, hsTnT 59% to 86%-90%; all P < .01) and negative predictive value (cTnT 94% to 97%-98%, hsTnT 96% to 97%-98%) for ACS. Patients with dual-negative markers had the lowest percentage of CT coronary plaque, stenosis, and regional wall motion abnormality (all P-trend <.001).. Among emergency department patients with low-intermediate likelihood of ACS, combining natriuretic peptides with either conventional or highly-sensitive troponin improved discriminatory capacity and allowed for better reclassification of ACS, findings supported by structural and functional CT results.

Topics: Acute Coronary Syndrome; Adult; Atrial Natriuretic Factor; Biomarkers; Chest Pain; Emergency Service, Hospital; Female; Humans; Male; Middle Aged; Myocardial Infarction; Natriuretic Peptide, Brain; Natriuretic Peptides; Peptide Fragments; Sensitivity and Specificity; Tomography, X-Ray Computed; Troponin T

Early and adequate risk stratification is essential in patients with suspected acute coronary syndrome (ACS). The aim of the present study was to investigate whether glycogen phosphorylase BB (GPBB) could add prognostic information in the context of contemporary sensitive troponin I determination and B-type natriuretic peptide (BNP). Patients with suspected ACS were consecutively enrolled at 3 German study centers from January 2007 through December 2008. Troponin I, GPBB, and BNP were determined at admission. Follow-up information on the combined end point of death, myocardial infarction, revascularization, and hospitalization owing to a cardiovascular cause was obtained 6 months after enrollment. In total 1,818 patients (66% men) were enrolled of whom 413 (23%) were diagnosed as having acute myocardial infarction and 240 (13%) as having unstable angina pectoris, whereas in 1,165 patients (64%) an ACS could be excluded. Follow-up information was available in 98% of patients; 203 events were registered. GPBB measured on admission predicted an unfavorable outcome with a hazard ratio of 1.24 (p <0.05) in an unadjusted Cox regression model and showed a tendency with a hazard ratio of 1.13 (p = 0.07) in a fully adjusted model. Kaplan-Meier analysis revealed a poorer outcome in patients with increased GPBB levels amendatory to the information provided by troponin I or BNP. In conclusion, GPBB measurement provides predictive information on midterm prognosis in patients with chest pain in addition to BNP and troponin I.

Topics: Acute Coronary Syndrome; Aged; Angina, Unstable; Biomarkers; Case-Control Studies; Chest Pain; Cohort Studies; Female; Glycogen Phosphorylase, Brain Form; Humans; Kaplan-Meier Estimate; Male; Middle Aged; Myocardial Infarction; Natriuretic Peptide, Brain; Predictive Value of Tests; Prognosis; Risk Assessment; Sensitivity and Specificity; Severity of Illness Index; Survival Analysis; Troponin T

Activation of leukocytes with release of myeloperoxidase (MPO) has been linked to acute coronary disease. To date, studies investigating the diagnostic and prognostic performance of circulating MPO in patients with chest pain (CP) are mainly retrospective, of low size, and lack a cut-off value for MPO. Herein, we prospectively assess the diagnostic and prognostic properties of MPO compared with sensitive troponin I (sTNI) in patients admitted to the emergency room with CP.. One thousand, eight hundred and eighteen consecutive patients (mean age, 61.4±13.5 years; 33.6% female) admitted for CP underwent determination of MPO, sTnI, and B-natriuretic peptide plasma levels at admission and 3 hours and 6 hours thereafter. A cut-off for MPO was defined in 5000 population-based subjects. Baseline MPO levels were elevated in patients with acute myocardial infarction compared with patients with noncoronary CP. For all time-points accuracy of MPO was inferior to sTNI for predicting AMI. The sensitivity of MPO to diagnose AMI at presentation was 73.5% compared with 90.7% for sTNI, and the specificity of MPO was 45.5% as opposed to 90.2%. B-natriuretic peptide levels also failed to demonstrate independent diagnostic information. Both MPO and B-natriuretic peptide were predictive for increased risk of adverse events at 30 days and 6 months, whereas their predictive value was weakened after covariate adjustment.. The data demonstrate that MPO and B-natriuretic peptide fail to provide incremental information for patients with acute onset CP when added to sensitive troponin. However, there is a potential value for both biomarkers as prognostic markers.

Topics: Acute Disease; Adult; Aged; Biomarkers; Chest Pain; Female; Humans; Male; Middle Aged; Myocardial Infarction; Natriuretic Peptide, Brain; Peroxidase; Prognosis; Retrospective Studies; ROC Curve; Troponin I

Tako-tsubo cardiomyopathy (TTC) is typically triggered by an acute emotional or physical stress event. The aim of this study was to investigate the impact of stressor patterns on clinical features, laboratory parameters, and electrocardiographic and echocardiographic findings in patients with TTC.. Clinical features are different according to stressor patterns.. Of 137 patients enrolled from the TTC registry database, 14 patients had emotional triggers (E group), 96 had physical triggers (P group), and 27 had no triggers (N group).. Most clinical presentations and in-hospital courses were similar among the groups. However, the E group had a higher prevalence of chest pain (P = 0.006) and palpitation (P = 0.006), whereas the P group had a higher prevalence of cardiogenic shock (P = 0.040), than other groups. The P group had a significantly higher heart rate (P = 0.001); higher high-sensitivity C-reactive protein (P = 0.006), creatine kinase MB fraction (P = 0.045), and N terminal-probrain natriuretic peptide (P = 0.036) levels; higher left ventricular end-diastolic pressure (P = 0.019) and left ventricular end-systolic diameter (P = 0.002); but lower left ventricular ejection fraction (P = 0.018). The E group had lesser prevalence of apical ballooning pattern (P = 0.038) than other groups. The P group required more frequent use of inotropics (P = 0.041) and diuretics (P = 0.047) and had significantly longer intensive care unit (P = 0.014) and in-hospital stays (P = 0.001).. The clinical features of TTC are different according to preceding stressor patterns. The TTC group with preceding physical stressors was less likely to have preserved cardiovascular reserve and more likely to require hemodynamic support than other groups. The overall prognosis of TTC is excellent, regardless of triggering stressors.

Topics: Aged; Analysis of Variance; Arrhythmias, Cardiac; Biomarkers; C-Reactive Protein; Cardiotonic Agents; Chest Pain; Chi-Square Distribution; Coronary Angiography; Creatine Kinase, MB Form; Critical Care; Diuretics; Echocardiography; Electrocardiography; Emotions; Female; Heart Rate; Humans; Length of Stay; Male; Middle Aged; Natriuretic Peptide, Brain; Peptide Fragments; Predictive Value of Tests; Registries; Republic of Korea; Retrospective Studies; Risk Factors; Shock, Cardiogenic; Stress, Physiological; Stress, Psychological; Stroke Volume; Takotsubo Cardiomyopathy; Tertiary Care Centers; Ventricular Function, Left; Ventricular Pressure

Topics: Acute Coronary Syndrome; Biomarkers; Chest Pain; Humans; Immunoassay; Myocardial Ischemia; Natriuretic Peptide, Brain; Protein Sorting Signals; Sensitivity and Specificity

Myocardial ischemia is a strong trigger of B-type natriuretic peptide (BNP) release. As ischemia precedes necrosis in acute myocardial infarction, we hypothesized that BNP might be useful in the early diagnosis and risk stratification of patients with acute chest pain.. In a prospective, international multicenter study, BNP was measured in 1075 unselected patients with acute chest pain. The final diagnosis was adjudicated by 2 independent cardiologists. Patients were followed long term regarding mortality.. Acute myocardial infarction was the adjudicated final diagnosis in 168 patients (16%). BNP levels at presentation were significantly higher in acute myocardial infarction as compared with patients with other diagnoses (median 224 pg/mL vs. 56 pg/mL, P <.001). The diagnostic accuracy of BNP for the diagnosis of acute myocardial infarction as quantified by the area under the receiver operating characteristic curve (AUC) (0.74; 95% confidence interval [CI], 0.70-0.78) was lower compared with cardiac troponin T at presentation (AUC 0.88; 95% CI, 0.84-0.92; P <.001). Cumulative 24-month mortality rates were 0.5% in the first, 2.1% in the second, 7.0% in the third, and 22.9% in the fourth quartile of BNP (P <.001). BNP predicted all-cause mortality independently of and more accurately than cardiac troponin T: AUC 0.81 (95% CI, 0.76-0.86) versus AUC 0.70 (95% CI, 0.62-0.77; P <.001). Net reclassification improvement for BNP was 0.10 (P=.04), and integrated discrimination improvement 0.068 (P=.01).. BNP accurately predicts mortality in unselected patients with acute chest pain independently of and more accurately than cardiac troponin T, but does not seem to help in the early diagnosis of acute myocardial infarction.

Topics: Acute Coronary Syndrome; Aged; Aged, 80 and over; Analysis of Variance; Angina Pectoris; Biomarkers; Chest Pain; Disease-Free Survival; Early Diagnosis; Female; Humans; Kaplan-Meier Estimate; Male; Middle Aged; Myocardial Infarction; Natriuretic Peptide, Brain; Odds Ratio; Predictive Value of Tests; Risk Factors; Troponin T

Several mechanisms are involved in the pathophysiology of the Acute Coronary Syndrome (ACS). We have addressed whether B-type natriuretic peptide (BNP) and high-sensitive C-reactive protein (hsCRP) in admission samples may improve risk stratification in chest pain patients with suspected ACS.. We included 982 patients consecutively admitted with chest pain and suspected ACS at nine hospitals in Salta, Northern Argentina. Total and cardiac mortality were recorded during a 2-year follow up period. Patients were divided into quartiles according to BNP and hsCRP levels, respectively, and inter quartile differences in mortality were statistically evaluated applying univariate and multivariate analyses.. 119 patients died, and the BNP and hsCRP levels were significantly higher among these patients than in survivors. In a multivariable Cox regression model for total death and cardiac death in all patients, the hazard ratio (HR) in the highest quartile (Q4) as compared to the lowest quartile (Q1) of BNP was 2.32 (95% confidence interval (CI), 1.24-4.35), p = 0.009 and 3.34 (95% CI, 1.26-8.85), p = 0.015, respectively. In the TnT positive patients (TnT > 0.01 ng/mL), the HR for total death and cardiac death in Q4 as compared to Q1 was 2.12 (95% CI, 1.07-4.18), p = 0.031 and 3.42 (95% CI, 1.13-10.32), p = 0.029, respectively.The HR for total death for hsCRP in Q4 as compared to Q1 was 1.97 (95% CI, 1.17-3.32), p = 0.011, but this biomarker did not predict cardiac death (p = 0.21). No prognostic impact of these two biomarkers was found in the TnT negative patients.. BNP and hsCRP may act as clinically useful biomarkers when obtained at admission in a population with suspected ACS.

Topics: Acute Coronary Syndrome; Aged; Argentina; C-Reactive Protein; Chest Pain; Emergency Medical Services; Female; Follow-Up Studies; Humans; Male; Middle Aged; Natriuretic Peptide, Brain; Predictive Value of Tests; Prognosis; Prospective Studies; Risk Adjustment; Survival Analysis; Troponin

Little is known about the long-term prognostic value of N-terminal pro B-type natriuretic peptide (NT-proBNP) and C-reactive protein (CRP) in low-risk patients with chest pain.. Between June 1997 and January 2000, a standard rule-out protocol was performed in patients presenting to the emergency department within 6 hours of onset of chest pain with a normal or nondiagnostic electrocardiogram (ECG) on admission at the Academic Medical Center Amsterdam, VU University Medical Center Amsterdam and Medical Center Alkmaar, The Netherlands. Patients with acute coronary syndrome were identified by troponin T, recurrent angina, and serial ECGs. CRP and NT-proBNP on admission were measured using standardized methods.. A total of 524 patients were included (145 with acute coronary syndrome and 379 with rule-out acute coronary syndrome). Long-term follow-up was successfully carried out in 96% of the study population. Death occurred in 78 patients (15%), 43 (11%) in the rule-out acute coronary syndrome group and 35 (24%) in the acute coronary syndrome group (P<.001). In the rule-out acute coronary syndrome group, 21 patients (42%) died of a cardiovascular cause compared with 24 patients (69%) in the acute coronary syndrome group (P<.001). In multivariate Cox regression analysis, age more than 65 years, previous myocardial infarction, known chronic heart failure, a nondiagnostic ECG on admission, and elevated NT-proBNP levels (>87 pg/mL, as derived from the receiver operating characteristic curve) were independent predictors of long-term cardiovascular mortality in the rule-out acute coronary syndrome group. In the acute coronary syndrome group, these predictors were age more than 65 years, documented coronary artery disease, and elevated NT-proBNP levels. Elevated levels of CRP were an independent predictor for cardiovascular mortality in patients with rule-out acute coronary syndrome at 3-year follow-up only. In patients with rule-out acute coronary syndrome with normal CRP and NT-proBNP levels, the cardiovascular mortality incidence rate was 4.7 per 1000 person-years, compared with a death rate of 20 in patients with both biomarkers elevated, which was comparable to the 17.9 per 1000 person-years incidence rate in patients with acute coronary syndrome.. A positive biomarker panel discriminates patients with rule-out acute coronary syndrome chest pain with a normal or nondiagnostic ECG who have a high risk for long-term cardiovascular mortality.

Topics: Adult; Aged; Biomarkers; C-Reactive Protein; Cardiovascular Diseases; Chest Pain; Female; Humans; Male; Middle Aged; Natriuretic Peptide, Brain; Peptide Fragments; Predictive Value of Tests; Prognosis; Time Factors

Elevated levels of high-sensitivity C-reactive protein (hs-CRP), B-type natriuretic peptide (BNP), and D-dimer each are associated with higher rates of death and recurrent ischemic events in patients with acute myocardial infarction (AMI). The aim of this study was to examine the dynamic course of D-dimer, hs-CRP, and pro-BNP in patients with Non-ST-Elevation Myocardial Infarction (NSTEMI).. The study group consisted of 82 patients presenting with symptoms suggestive of acute coronary syndrome (ACS). 40 of the patients were diagnosed as NSTEMI and for the rest AMI was ruled out. Blood was drawn at the time of admission, 6 and 12 hours after that. The samples were tested for hs-CRP, pro-BNP and fibrin D-dimer by a quantitative, point-of-care instrument system (Stratus CS).. D-dimer and pro-BNP did not change between admission and 6 and 12 hours after admission in patients with acute NSTEMI, whereas hs-CRP went down 12 hours after admission compared to the admission value (14.9 +/- 19.4 (mg/mL) v 10.1 +/- 13.5 (mg/mL), p = 0.04).. There was no dynamic change of D-dimer or pro-BNP during the first 12 hours after admission in patients with acute NSTEMI, whereas hs-CRP decreased 12 hours after admission in these patients.

Topics: Aged; Aged, 80 and over; C-Reactive Protein; Chest Pain; Female; Fibrin Fibrinogen Degradation Products; Humans; Male; Middle Aged; Myocardial Infarction; Natriuretic Peptide, Brain; Troponin I

Topics: Acute Coronary Syndrome; Chest Pain; Female; Humans; Male; Myocardial Infarction; Natriuretic Peptide, Brain

We examined the effect of renal dysfunction on B-natriuretic peptide (BNP), N-terminal (NT)-proBNP, and their molar ratio at varying severities of cardiac function in 94 Thai patients with chest pain (52 men; 32 women), also measuring creatinine and left ventricular ejection fraction (LVEF). Renal function was classified into 5 stages by estimated glomerular filtration rate. The molar NT-proBNP/BNP ratio was calculated. Cardiac status was classified by LVEF (normal, >50%; moderate, 35%-50%; severe, <35%). BNP, NT-proBNP, and their ratio corresponded to renal disease stage exponential (0.51, 1.05, and 0.54, respectively; correlation coefficients, >or=0.95). BNP and the ratio are affected less than NT-proBNP by renal dysfunction, starting in stage III; NT-proBNP expresses effects starting in stage II. NT-proBNP is more sensitive than BNP to renal disease stage. For log of geometric means vs stage of renal disease, the BNP slopes and correlation coefficients vary considerably (slopes, 0.036-0.531; r(2), 0.017-0.99). The NT-proBNP slopes and regression coefficients vary considerably (slopes, 0.18-0.71; r(2), 0.33-0.99). For the ratio, the slopes show low variation (0.148-0.337), r(2) greater than 0.96, women differing from men (P = .012). The effect of renal disease differs by gender. BNP and NT-proBNP increase by stage III for women but not for men. One must consider renal function, gender, and LVEF when using BNP or NT-proBNP as cardiac biomarkers. The ratio of the 2 peptides is the most consistent marker across LVEFs.

Topics: Aged; Aged, 80 and over; Biomarkers; Cardiovascular Diseases; Chest Pain; Creatinine; Female; Glomerular Filtration Rate; Humans; Kidney Diseases; Kidney Function Tests; Male; Middle Aged; Natriuretic Peptide, Brain; Peptide Fragments; Protein Precursors; Stroke Volume

The expanding role of cardiac markers - cytosolic [heart-type fatty acid-binding protein (H-FABP) and creatine kinase MB (CK-MB)], myofibril [troponin T (TnT)], and cardio-endocrine [N-terminal pro-B-type natriuretic peptide (NT-proBNP)] - has been clarified in patients with acute coronary syndrome and those with heart failure. However, these applications for early risk stratification in the cardiac emergency, and the influence of renal function on these evaluations have not been fully investigated.. We investigated the prognostic value of these representative cardiac markers and influence of renal function on these evaluations in 165 consecutive patients who were admitted for cardiac emergency because of chest pain or dyspnea.. There were significant correlations between TnT and CK-MB (r=0.512, p<0.001), and between H-FABP and TnT (r=0.409, p<0.001) and CK-MB (r=0.254, p<0.01); however, NT-proBNP levels did not show significant correlations with other cardiac markers. There were significant correlations between estimated glomerular filtration rate and NT-proBNP (r=-0.466, p<0.001) and H-FABP (r=-0.235, p<0.001) levels, and between left ventricular ejection fraction (LVEF) and NT-proBNP (r=-0.407, p<0.001) and H-FABP (r=-0.253, p<0.01) levels. Kaplan-Meier analysis showed that median of NT-proBNP, H-FABP, and CK-MB significantly discriminated in-hospital cardiovascular death, and multivariate analysis revealed NT-proBNP and LVEF as independent prognostic predictors.. NT-proBNP is a novel biomarker for integrated cardio-renal burden, and extremely useful for early risk stratification in the situation of cardiac emergency.

Topics: Biomarkers; Chest Pain; Creatine Kinase, MB Form; Cytosol; Dyspnea; Emergencies; Fatty Acid Binding Protein 3; Fatty Acid-Binding Proteins; Female; Glomerular Filtration Rate; Heart Diseases; Humans; Kidney Diseases; Male; Middle Aged; Natriuretic Peptide, Brain; Peptide Fragments; Prognosis; Stroke Volume; Troponin T

We hypothesized that pro-B-type natriuretic peptide (proBNP) levels in venous blood increase in patients with acute out-of-hospital heart failure because of stress during emergency ambulance transportation, and furthermore, we wanted to show if there is an effect of increasing proBNP levels on hemodynamic parameters.. Venous proBNP levels, visual analog scale (VAS) for pain and anxiety before and after transportation, heart rate, blood pressure, and transcutaneous Spo(2) were measured every 3 minutes in 32 patients with defined clinical signs of heart failure.. ProBNP levels increased significantly (P < .01) during transportation (278.13 +/- 113.20 vs 984.67 +/- 627.33 pg/mL), whereas heart rate and mean blood pressure remained almost stable. There was no significant change in VAS for pain and anxiety (3.79 +/- 3.70 and 2.89 +/- 3.01 vs 2.13 +/- 3.30 and 1.57 +/- 2.78).. A rapid increase in proBNP levels was shown in patients with acute out-of-hospital heart failure during emergency ambulance transportation but no significant changes in hemodynamic parameters.

Topics: Aged; Ambulances; Anxiety; Blood Pressure; Chest Pain; Heart Failure; Heart Rate; Humans; Natriuretic Peptide, Brain; Oxygen; Pain Measurement; Prospective Studies

The Global Registry of Acute Coronary Events (GRACE) risk score is widely recommended for risk assessment in patients with acute coronary syndrome. However, there is limited knowledge regarding the utility of this score for long-term risk prediction in unselected patients with acute chest pain and whether it might be improved by the integration of nonnecrosis biomarkers.. We calculated the GRACE risk score in 453 chest pain patients and assessed its value for risk assessment together with the additive prognostic information obtained from N-terminal pro-B-type natriuretic peptide, C-reactive protein, growth differentiation factor-15 (GDF-15), and cystatin C.. After a median follow-up of 5.8 years, 92 patients (20.7%) had died. The GRACE risk score was significantly higher in patients who died (median 146 vs 93, P < .001) and provided a c-statistic regarding mortality of 0.78. A significant increase of the c-statistic was achieved only after addition of GDF-15 (c-statistic 0.81, P = .003) and, to a minor extent, after addition of cystatin C (c-statistic 0.81, P = .035). Assessment of the integrated discriminative improvement yielded similar results. N-terminal pro-B-type natriuretic peptide had only limited incremental prognostic value, and C-reactive protein was not predictive for outcome.. The GRACE risk score allows for the prediction of mortality in chest pain patients even after almost 6 years of follow-up. However, its predictive value could be further enhanced by the addition of selected nonnecrosis biomarkers, in particular GDF-15 or cystatin C.

Topics: Acute Coronary Syndrome; Aged; Aged, 80 and over; Biomarkers; C-Reactive Protein; Chest Pain; Coronary Care Units; Disease Progression; Electrocardiography; Female; Follow-Up Studies; Growth Differentiation Factor 15; Humans; Male; Middle Aged; Natriuretic Peptide, Brain; Necrosis; Peptide Fragments; Prevalence; Prognosis; Protein Precursors; Registries; Retrospective Studies; Risk Assessment; Risk Factors; Salivary Cystatins; Severity of Illness Index; Sweden; Time Factors; Troponin I

To evaluate the prognostic role of novel biomarkers for the risk stratification of patients admitted with ischemic-type chest pain, a prospective study of 664 patients presenting to 2 coronary care units with ischemic-type chest pain was conducted over 3 years beginning in 2003. Patients were assessed on admission for clinical characteristics, electrocardiographic findings, renal function, cardiac troponin T (cTnT), markers of myocyte injury (heart fatty acid-binding protein [H-FABP] and glycogen phosphorylase BB), neurohormonal activation (N-terminal-pro-brain natriuretic peptide [NT-pro-BNP]), hemostatic activity (fibrinogen and D-dimer), and vascular inflammation (high-sensitivity C-reactive protein, myeloperoxidase, matrix metalloproteinase-9, pregnancy-associated plasma protein-A, and soluble CD40 ligand). A >or=12-hour cTnT sample was also obtained. Myocardial infarction (MI) was defined as peak cTnT >or=0.03 microg/L. Patients were followed for 1 year from the time of admission. The primary end point was death or MI. Elevated fibrinogen, D-dimer, H-FABP, NT-pro-BNP, and peak cTnT were predictive of death or MI within 1 year (unadjusted odds ratios 2.5, 3.1, 5.4, 5.4, and 6.9, respectively). On multivariate analysis, H-FABP and NT-pro-BNP were selected, in addition to age, peak cTnT, and left ventricular hypertrophy on initial electrocardiography, as significant independent predictors of death or MI within 1 year. Patients without elevations of H-FABP, NT-pro-BNP, or peak cTnT formed a very low risk group in terms of death or MI within 1 year. A very high risk group had elevations of all 3 biomarkers. In conclusion, the measurement of H-FABP and NT-pro-BNP at the time of hospital admission for patients with ischemic-type chest pain adds useful prognostic information to that provided by the measurement of baseline and 12-hour cTnT.

Topics: Acute Disease; Aged; Biomarkers; Chest Pain; Electrocardiography; Fatty Acid Binding Protein 3; Fatty Acid-Binding Proteins; Female; Follow-Up Studies; Hospitalization; Humans; Male; Middle Aged; Myocardial Ischemia; Natriuretic Peptide, Brain; Peptide Fragments; Prognosis; Prospective Studies; Protein Precursors; Risk Factors

Early identification of acute coronary syndrome (ACS) is important to guide therapy at a time when it is most likely to be of value. In addition, predicting future risk helps identify those most likely to benefit from ongoing therapy. Cardiac troponin T (cTnT) is useful for both purposes although cannot reliably rule out ACS until 12 hours after pain onset and does not fully define future risk. In this review article we summarize our previously published research, which assessed the value of myocyte injury, vascular inflammation, hemostatic, and neurohormonal markers in the early diagnosis of ACS and risk stratification of patients with ACS. In addition to cTnT, we measured heart fatty acid binding protein (H-FABP), glycogen phosphorylase-BB, high-sensitivity C-reactive protein, myeloperoxidase, matrix metalloproteinase 9, pregnancy-associated plasma protein-A, D-dimer, soluble CD40 ligand, and N-terminal pro-brain natriuretic peptide (NT-proBNP). Of the 664 patients enrolled, 415 met inclusion criteria for the early diagnosis of acute myocardial infarction (MI) analysis; 555 were included in the risk stratification analysis and were followed for 1 year from admission. In patients presenting <4 hours from pain onset, initial H-FABP had higher sensitivity for acute MI than cTnT (73% vs. 55%; P=0.043) but was of no benefit beyond 4 hours when compared to cTnT. On multivariate analysis, H-FABP, NT-proBNP, and peak cTnT were independent predictors of 1-year death/MI. Our research demonstrated that, in patients presenting within 4 hours from pain onset, H-FABP may improve detection of ACS. Measuring H-FABP and proBNP may help improve long-term risk stratification.

Topics: Acute Coronary Syndrome; Biomarkers; C-Reactive Protein; CD40 Ligand; Chest Pain; Early Diagnosis; Fatty Acid Binding Protein 3; Fatty Acid-Binding Proteins; Fibrin Fibrinogen Degradation Products; Glycogen Phosphorylase, Brain Form; Humans; Matrix Metalloproteinase 9; Multivariate Analysis; Myocardial Infarction; Natriuretic Peptide, Brain; Peptide Fragments; Peroxidase; Predictive Value of Tests; Pregnancy-Associated Plasma Protein-A; Reproducibility of Results; Risk Assessment; Troponin T

To determine the reference value of plasma N-terminal pro-B-type natriuretic peptide (NT-proBNP) in subjects without heart diseases.. The plasma concentration of NT-proBNP was measured with ELISA method in 300 adults excluded heart disease through various examinations including electrocardiography, echocardiography, X-ray and coronary artery angiography. The plasma NT-proBNP concentration was compared between age-groups 30-39, 40-49, 50-59, 60-69 and > or = 70 years old, between male and female in the same age-group and between subjects with and without hypertension, diabetes and obesity. A multiple linear regression analysis was used to detect factors influencing NT-proBNP among age, sex, body mass index, blood pressure, heart rate, serum creatinine, hypertension, diabetes mellitus, use of angiotensin-converting-enzyme inhibitors, Ca(2+)-antagonist, and beta-blocker.. The plasma NT-proBNP concentration increased in proportion to aging in male subjects more than 60 years old (P < 0.05), remained unchanged in males less than 60 years old and females (P > 0.05). Plasma NT-proBNP concentration was significantly higher in female (170-660 pmol/L) than in male (160-470 pmol/L) in subjects less than 60 years old (P < 0.05) and significantly lower in female (180-560 pmol/L) than in male (180-760 pmol/L) in subjects more than 60 years old (P < 0.05). Multiple linear regression analysis demonstrated that age was the only independent predictor for plasma NT-proBNP in these subjects (P < 0.01).. The plasma concentration of NT-proBNP in subjects without heart diseases was different between male and female, and was increasing with age in male subjects more than 60 years old.

Topics: Adult; Age Factors; Aged; Chest Pain; Female; Humans; Linear Models; Male; Middle Aged; Natriuretic Peptide, Brain; Peptide Fragments; Reference Values

Growth-differentiation factor-15 (GDF-15) has emerged as a biomarker of increased mortality and recurrent myocardial infarction (MI) in patients diagnosed with non-ST-elevation acute coronary syndrome. We explored the usefulness of GDF-15 for early risk stratification in 479 unselected patients with acute chest pain.. Sixty-nine per cent of the patients presented with GDF-15 levels above the previously defined upper reference limit (1200 ng/L). The risks of the composite endpoint of death or (recurrent) MI after 6 months were 1.3, 5.1, and 12.6% in patients with normal (<1200 ng/L), moderately elevated (1200-1800 ng/L), or markedly elevated (>1800 ng/L) levels of GDF-15 on admission, respectively (P < 0.001). By multivariable analysis that included clinical characteristics, ECG findings, peak cardiac troponin I levels within 2 h (cTnI(0-2 h)), N-terminal pro-B-type natriuretic peptide, C-reactive protein, and cystatin C, GDF-15 remained an independent predictor of the composite endpoint. The ability of the ECG combined with peak cTnI(0-2 h) to predict the composite endpoint was markedly improved by addition of GDF-15 (c-statistic, 0.74 vs. 0.83; P < 0.001).. GDF-15 improves risk stratification in unselected patients with acute chest pain and provides prognostic information beyond clinical characteristics, the ECG, and cTnI.

Topics: Aged; Biomarkers; C-Reactive Protein; Chest Pain; Cohort Studies; Electrocardiography; Female; Growth Differentiation Factor 15; Humans; Male; Middle Aged; Myocardial Ischemia; Natriuretic Peptide, Brain; Predictive Value of Tests; Prognosis; Risk Assessment; Statistics, Nonparametric; Triage; Troponin I

To evaluate the role of novel biomarkers in early detection of acute myocardial infarction (MI) in patients admitted with acute chest pain.. A prospective study of 664 patients presenting to two coronary care units with chest pain was conducted over 3 years from 2003. Patients were assessed on admission: clinical characteristics, ECG (electrocardiogram), renal function, cardiac troponin T (cTnT), heart fatty acid binding protein (H-FABP), glycogen phosphorylase-BB, NT-pro-brain natriuretic peptide, D-dimer, hsCRP (high sensitivity C-reactive protein), myeloperoxidase, matrix metalloproteinase-9, pregnancy associated plasma protein-A, soluble CD40 ligand. A > or = 12 h cTnT sample was also obtained. MI was defined as cTnT > or = 0.03 microg/L. In patients presenting <4 h of symptom onset, sensitivity of H-FABP for MI was significantly higher than admission cTnT (73 vs. 55%; P = 0.043). Specificity of H-FABP was 71%. None of the other biomarkers challenged cTnT. Combined use of H-FABP and cTnT (either one elevated initially) significantly improved the sensitivities of H-FABP or cTnT (85%; P < or = 0.004). This combined approach also improved the negative predictive value, negative likelihood ratio, and the risk ratio.. Assessment of H-FABP within the first 4 h of symptoms is superior to cTnT for detection of MI, and is a useful additional biomarker for patients with acute chest pain.

Topics: Angina, Unstable; Biomarkers; Chest Pain; Electrocardiography; Epidemiologic Methods; Fatty Acid Binding Protein 3; Fatty Acid-Binding Proteins; Female; Humans; Male; Middle Aged; Myocardial Infarction; Natriuretic Peptide, Brain; Prognosis; Troponin T

Few studies have addressed whether the combined use of B-type natriuretic peptide (BNP) and high-sensitive C-reactive protein (hsCRP) improves risk stratification for mortality and cardiovascular events in a population with chest pain and suspected acute coronary syndromes (ACS). Therefore, we wanted to assess the incremental prognostic value of these biomarkers with respect to long-term all-cause mortality and recurrent troponin T (TnT) positive cardiac events in 871 patients admitted to the emergency department.. Blood samples were obtained immediately following admission.. After a follow-up period of 24 months, 129 patients had died. The BNP levels were significantly higher among patients dying than in long-term survivors (401 (145-736) versus 75 (29-235) pq/mL [median, 25 and 75% percentiles], p = 0.000). In a multivariable Cox regression model for death within 2 years, the hazard ratio (HR) for BNP in the highest quartile (Q4) was 5.13 (95% confidence interval (CI), 1.97-13.38) compared to the lowest quartile (Q1) and was associated with all-cause mortality above and beyond age, congestive heart failure and the index diagnosis ST-segment elevation myocardial infarction. HsCRP rendered no prognostic information for all-cause mortality. However, within 30 days, the adjusted HR for patients with recurrent TnT cardiac positive events hsCRP in Q4 was 14.79 (95% CI, 1.89-115.63) compared with Q1 and was associated with recurrent ischemic events above and beyond age, hypercholesterolemia and TnT values at admission.. BNP may act as a clinically useful biomarker when obtained at admission in an unselected patient population following hospitalization with chest pain and potential ACS, and may provide complementary prognostic information to established risk determinants at long-term follow-up. Our data do not support the hypothesis that the additional assessment of hsCRP will lead to better risk stratification for survival than BNP alone.

Topics: Acute Coronary Syndrome; Adult; Aged; Aged, 80 and over; Biomarkers; C-Reactive Protein; Chest Pain; Female; Follow-Up Studies; Humans; Male; Middle Aged; Natriuretic Peptide, Brain; Predictive Value of Tests; Prognosis; Risk Factors; Secondary Prevention; Survival Analysis; Time Factors; Troponin T

Topics: Aged; Biomarkers; Chest Pain; Coronary Angiography; Echocardiography, Transesophageal; Electrocardiography; Female; Humans; Natriuretic Peptide, Brain; Peptide Fragments; Prognosis; Remission, Spontaneous; Risk Assessment; Sensitivity and Specificity; Takotsubo Cardiomyopathy

To investigate the combination of clinical data, exercise testing and biomarkers for the evaluation of patients with chest pain without ST-segment deviation or troponin elevation.. Prospective cohort design. SETTTING: Two teaching hospitals in Spain.. 422 patients presenting to the emergency department were studied. Leukocyte count, C-reactive protein (CRP), pregnancy-associated plasma protein A (PAPP-A) and N-terminal pro-brain natriuretic peptide (NT-proBNP) were determined. A validated clinical risk score (number of points according to pain characteristics and risk factors) was used for clinical evaluation and early exercise testing was performed.. Adverse events (death, myocardial infarction or revascularisation) during a median 60 weeks follow-up.. By receiver operating characteristic curve analysis, the association between death or myocardial infarction and adverse events was not significant with leukocyte count (p = 0.3, p = 0.3) or CRP (p = 0.5, p = 0.8), was borderline significant with PAPP-A (p = 0.07, p = 0.04) and strongly significant with NT-pro-BNP (p = 0.0001, p = 0.0001). By Cox regression including clinical risk score, exercise testing result and biomarkers, exercise testing was the independent predictor of revascularisation (p = 0.0001), whereas risk score (p = 0.03) and NT-proBNP (p = 0.0004) predicted death or myocardial infarction. The inclusion of NT-proBNP improved the accuracy of the model for death or myocardial infarction (C-statistic 0.84 versus 0.76, p = 0.01). The combination of clinical score and NT-proBNP afforded the stratification in high (17.2%, p = 0.0001), intermediate (5.3%) and low (1.1%) risk categories of death or myocardial infarction.. NT-proBNP provides incremental prognostic information above that given by clinical history and exercise testing in patients with chest pain without ST-segment deviation and negative troponin.

Topics: Biomarkers; Chest Pain; Epidemiologic Methods; Exercise Test; Humans; Middle Aged; Myocardial Infarction; Natriuretic Peptide, Brain; Peptide Fragments; Troponin

Early risk stratification of patients with chest pain may be improved by combining cardiac Troponin I (cTnI) results and ECG findings with markers of left-ventricular dysfunction, inflammation or renal function.. Serial measurements of cTnI were prospectively performed in 452 chest pain patients with a non-diagnostic ECG for AMI and admitted to the coronary care unit. NT-pro BNP, CRP, cystatin C and creatinine-clearance were retrospectively analyzed in admission samples. The prognostic value of these markers alone and in different combinations together with ECG findings was evaluated by multivariate logistic regression models.. During follow-up, 14 deaths and 21 myocardial (re)-infarctions occurred. Independent predictors for the combined endpoint of death or (re)-infarction were peak cTnI >or=0.1 microg/L within 24 h (OR 3.9; 95% confidence interval [CI]1.5-10.4), cystatin C >or=1.28 mg/L (OR 5.6; 95% CI 1.9-16.3) and NT-pro BNP >or=550 ng/L (OR 2.7; 95% CI 1.0-7.3). At 2 h from admission, a combination of cTnI >or=0.1 microg/L, an abnormal ECG and NT-pro BNP or cystatin C as a third variable resulted in a similar stratification of patients to different risk groups.. cTnI, NT-pro BNP and cystatin C are strong risk predictors in patients with chest pain. For pragmatic reasons, a combination of cTnI >or=0.1 microg/L, ECG findings and a marker of renal function, preferably cystatin C, appears to be most appropriate for early risk stratification of these patients.

Topics: Aged; Biomarkers; C-Reactive Protein; Chest Pain; Creatinine; Cystatin C; Cystatins; Female; Heart Function Tests; Humans; Kidney Function Tests; Logistic Models; Male; Middle Aged; Multivariate Analysis; Myocardial Infarction; Natriuretic Peptide, Brain; Peptide Fragments; Recurrence; Retrospective Studies; Risk Assessment; ROC Curve; Troponin I

Risk stratification of patients with ischaemic type chest pain assessed in the emergency department utilizing a point of care (POC) protocol.. Patient demographics, cardiac biomarkers, management and follow-up at 6 months were reviewed for patients seen over 20 months.. Out of 546 patients, 351 (64%) were admitted. The diagnoses after admission were confirmed as acute myocardial infarction in 59 patients and unstable angina, (cTroponin T<0.09 ng/ml) in 92 patients. The c-statistic of the receiver operating curves for myocardial infarction (myocardial infarction, cTroponinT at 12 h >0.09 ng/ml) as determined by the POC assay was cTroponin I=0.884, CK-MB=0.883, myoglobin=0.845 and beta-type natriuretic peptide (BNP)=0.755. The c-statistic for the same sample assessed by the hospital laboratory was cTroponin T=0.893: for CK-MB within 12 h of admission it was 0.918; the 12 h cTroponin T was 0.982 and within 24 h of admission NT pro-BNP was 0.789. POC BNP in patients admitted was 68 ng/l (median) vs. 24 ng/l (median) for those not admitted, (P<0.001). POC BNP for patients admitted with unstable angina (12 h cTroponin T <0.09 ng/ml) was 47 ng/l (median, P<0.001). At 6 months, 14 patients had died; five during admission, two within 30 days and seven up to 6 months. During admission two died from heart failure, two with respiratory tract infection and one from carcinoma. Of those not admitted one had died from asbestosis.. Risk stratification by a specialist nurse utilizing a POC protocol is an appropriate means of assessing patients with chest pain.

Topics: Adult; Aged; Angina, Unstable; Biomarkers; Chest Pain; Emergency Nursing; Emergency Service, Hospital; Female; Humans; Male; Middle Aged; Myocardial Infarction; Natriuretic Peptide, Brain; Nurses; Point-of-Care Systems; Retrospective Studies; ROC Curve; Triage; Troponin I; Troponin T

Blood pro-B-type natriuretic peptide (pro-BNP) level increases in case of myocardial ischemia and myocardial volume or pressure overload. The aim of this study is to measure changes in blood pro-BNP level during the course of panic attack with symptoms of chest pain and/or dyspnea.. Patients who were admitted to the emergency room with panic attack have been regarded as the study group. Blood pro-BNP level has been measured during follow-up of the patients upon admission and 2h later.. Systolic and diastolic blood pressure and pulse rate were significantly decreased (p<0.0001) during follow-up of the patients (ages between 18 and 43 years; mean 26+/-6.13 years). Paradoxically, blood pro-BNP level of patients was significantly increased during the same period (52.86+/-59.73 versus 50.97+/-57.42 U/L; p<0.0001).. Blood pro-BNP level has increased among patients who have complained chest pain and/or dyspnea as symptoms of panic attack. It is thought that chest pain and dyspnea in the course of panic attack may not be purely psychological.

Topics: Adolescent; Adult; Chest Pain; Dyspnea; Humans; Natriuretic Peptide, Brain; Panic Disorder

The purpose of this study was to characterize the diagnostic and prognostic utility of short-term dynamic changes in natriuretic peptides in patients presenting with chest pain.. Although single levels of natriuretic peptides in patients admitted for acute coronary syndromes (ACS) have important prognostic value, it is unclear whether serial sampling of natriuretic peptides might have both diagnostic and prognostic value in the setting of chest pain.. We followed 276 patients for 90 days who presented to the emergency department with chest pain. We sampled brain natriuretic peptide (BNP) and amino-terminal (NT)-proBNP up to 5 times within 24 h of presentation and again at discharge. Follow-up data was collected at 30 and 90 days after admission. Adverse events included emergency department visits for chest pain, cardiac readmission, and death. We assessed the prognostic and diagnostic value of baseline natriuretic peptide measurements with receiver-operating characteristic analyses.. Natriuretic peptides were diagnostic for congestive heart failure (CHF) and new-onset CHF but less so for ACS. The prognostic utility of serial sampling was evaluated through testing the statistical contribution of each future time point (as well as variability over time) over and above the baseline values in logistic regression models.. Baseline elevated BNP and NT-proBNP concentrations were predictive of adverse events at 30 and 90 days. Serial sampling did not improve the prognostic value of BNP or NT-proBNP.

Topics: Acute Disease; Angina, Unstable; Biomarkers; Chest Pain; Cohort Studies; Emergency Service, Hospital; Female; Follow-Up Studies; Humans; Male; Myocardial Infarction; Natriuretic Peptide, Brain; Natriuretic Peptides; Peptide Fragments; Predictive Value of Tests; Retrospective Studies; Risk Assessment; ROC Curve; Sensitivity and Specificity; Severity of Illness Index; Statistics, Nonparametric; Time Factors

Patients complaining of chest pain are frequently referred to secondary care, although the majority have pain of non-cardiac origin.. To investigate whether B-type natriuretic peptide (BNP) levels are predictive of a diagnosis of non-cardiac pain.. Cross-sectional study.. Consecutive patients (n = 296) presenting to a rapid-access chest pain clinic (RACPC) received the usual clinical assessment plus near-patient BNP testing, with the assessor blinded to the result. After clinical assessment (including exercise stress testing if clinically indicated), pain was diagnosed likely/definitely cardiac or non-cardiac.. Median BNP was higher in those diagnosed with likely/definite cardiac chest pain (26.5 vs. 8 pg/ml) (p < 0.0001, Wilcoxon rank sum test). The odds ratio for cardiac pain in those with BNP <20 pg/ml was 0.25 (95%CI 0.14-0.47) (p < 0.0005); adjusting for age and sex reduced this to 0.41 (95%CI 0.20-0.83) (p = 0.01). The area under the curve (AUC) for the model including BNP, age and sex was 0.70. With BNP as a continuous variable, the AUC for the same model was 0.72.. In typical patients presenting to a RACPC, those with a BNP < or =20 pg/ml were significantly less likely to be diagnosed with cardiac pain. Near-patient BNP testing may have a role as a 'rule out test' for angina in patients presenting to a RACPC.

Topics: Adult; Aged; Angina Pectoris; Area Under Curve; Biomarkers; Chest Pain; Cross-Sectional Studies; Female; Humans; Male; Middle Aged; Natriuretic Peptide, Brain; Pain Clinics; Predictive Value of Tests; Sensitivity and Specificity

The assessment of chest pain relies on clinical assessment and markers of cell necrosis such as Troponin T (TnT). B-type natriuretic peptide (BNP) is also raised in myocardial ischaemia and therefore may be useful in deciding if acute chest pain is of cardiac origin or not.. To investigate the role of BNP in the assessment of unselected patients presenting with acute chest pain.. A prospective observational study of 100 patients presenting with chest pain to the Acute Medical Admissions Unit was carried out. All patients had BNP and TnT levels measured. The primary outcome was categorization of chest pain as cardiac or non-cardiac. This was determined by the discharge diagnosis. BNP cutoffs were derived from a receiver operated characteristic (ROC) curve. The sensitivity, specificity, positive predictive accuracy (PPA) and negative predictive accuracy (NPA) were all calculated for BNP, TnT and for the composite of BNP and TnT.. Mean BNP in patients with cardiac chest pain was significantly greater than mean BNP for patients with non-cardiac chest pain (P

Topics: Adult; Aged; Biomarkers; Chest Pain; Coronary Disease; Female; Humans; Male; Middle Aged; Natriuretic Peptide, Brain; Patient Discharge; Pilot Projects; Predictive Value of Tests; Prospective Studies; ROC Curve; Sensitivity and Specificity; Troponin T

B-type natriuretic peptide (BNP) testing is a useful tool for diagnosis of congestive heart failure (CHF). In our institution only physicians in the lung disease, cardiology, and intensive care departments were authorized to order BNP testing. Our study sought to determine the validity of this strategy.. In this one-year prospective study, BNP testing was performed only in the lung disease and cardiology departments. The following details were recorded for each patient with a BNP assay: demographic information, clinical symptoms, physical examination, laboratory reports, chest radiography and ECG findings, and initial diagnosis (including in particular suspicion of CHF). The criterion for inclusion in this study was acute dyspnea on admission from the emergency department (ED), and the exclusion criterion was chest pain. We collected information about each patient's final diagnosis and outcome from the medical file.. Overall, the study included 236 patients (100 admitted into the pneumology department and 136 into cardiology). Their mean age was 77.3+/-12.4 years and the sex ratio 1.29 (133 M/103 F). CHR was the final diagnosis for 170 patients (72%: 56% in pneumology and 84% in cardiology). Initial misdiagnosis led to erroneous orientation of 66 patients, 13 (5.5%) of whom were among the 39 (17%) patients who died. The diagnostic accuracy of the specialists' clinical judgment was 74%, compared with 87% and 91% for BNP cut-off levels of 100 and 250 pg/mL, respectively.. Without BNP testing in the ED, more than a quarter of the patients with acute dyspnea were incorrectly oriented. Our study found BNP testing to be more effective than clinical judgment. In this series of patients, the cut-off value providing the best sensitivity and specificity was 250 pg/mL.

Topics: Aged; Aged, 80 and over; Biomarkers; Chest Pain; Diagnosis, Differential; Emergency Service, Hospital; Female; Heart Failure; Humans; Male; Natriuretic Peptide, Brain; Reproducibility of Results

Apical ballooning after sudden emotional stress is a new syndrome characterised by abrupt onset of angina-like chest pain, ST-segment elevation, wall motion abnormalities involving the lower anterior wall and apex without significant coronary artery stenosis. We present a case of a 57-year-old woman with apical ballooning syndrome which occurred during premedication the general anaesthesia. We also found an increased B-type natriuretic peptide level in this patent--the finding not reported previously in the literature.

Topics: Anesthesia, General; Chest Pain; Echocardiography; Electrocardiography; Female; Gated Blood-Pool Imaging; Humans; Middle Aged; Myocardial Contraction; Natriuretic Peptide, Brain; Premedication; Stress, Psychological; Syndrome; Ventricular Dysfunction, Left

Topics: Biomarkers; Chest Pain; Humans; Myocardial Infarction; Natriuretic Peptide, Brain; Risk Assessment; Sensitivity and Specificity

This study was undertaken to determine the diagnostic value of admission B-type natriuretic peptide (BNP) for acute myocardial infarction (AMI) in patients with acute chest pain and no ST-segment elevation.. A prospective study with 631 consecutive patients was conducted in the emergency department. Non-ST elevation AMI was present in 72 patients and their median admission BNP level was significantly higher than in unstable angina and non-acute coronary syndrome patients. Sensitivity of admission BNP for AMI (cut-off value of 100 pg/mL) was significantly higher than creatine kinase-MB (CKMB) and troponin-I on admission (70.8 vs. 45.8 vs. 50.7%, respectively, P<0.0001) and specificity was 68.9%. Simultaneous use of these markers significantly improved sensitivity to 87.3% and the negative predictive value to 97.3%. In multiple logistic regression analysis, admission BNP was a significant independent predictor of AMI, even when CKMB and troponin-I were present in the model.. BNP is a useful adjunct to standard cardiac markers in patients presenting to the emergency department with chest pain and no ST-segment elevation, particularly if initial CKMB and/or troponin-I are non-diagnostic.

Topics: Aged; Angina, Unstable; Biomarkers; Chest Pain; Female; Humans; Male; Myocardial Ischemia; Natriuretic Peptide, Brain; Prospective Studies; Sensitivity and Specificity; Troponin I

This study was sought to investigate whether plasma N-terminal pro-brain natriuretic peptide (proBNP) can help identify patients with an elevated left ventricular end-diastolic pressure (LVEDP) or filling pressures in patients with a normal systolic function.. The proBNP is a good predictor of an elevated LVEDP in patients with a systolic dysfunction. However, whether proBNP can predict an elevated LVEDP in patients with a normal systolic function remains to be determined.. The LV pressures were measured by fluid-filled catheters in 216 patients (125 men, mean age 60 +/- 10 years) with a normal systolic function (ejection fraction 66% +/- 8%, range 50%-81%) who were undergoing diagnostic cardiac catheterization. The proBNP was sampled at the time of cardiac catheterization and was measured using a quantitative electrochemiluminescence immunoassay.. The log-transformed proBNP levels correlated significantly with the LVEDP (r = 0.33, P = .001) and LV pre-A-wave pressure (pre-A pressure) (r = 0.31, P = .001). An elevated proBNP, defined as >315 pg/mL, predicted an LVEDP > or = 15 mm Hg with a sensitivity of 16% and a specificity of 95% as well as a pre-A pressure > or = 15 mm Hg with a sensitivity of 36% and a specificity of 95%. However, among the 93 patients with an LVEDP > or = 15 mm Hg, 77 (83%) patients had a normal proBNP concentration (< 315 pg/mL).. The proBNP level showed weak correlations with the LVEDP and LV pre-A pressure in patients with a normal systolic function. Although high proBNP levels can predict an elevated LV diastolic pressure with high specificity, the sensitivity was quite low. Because the majority of patients with an elevated LVEDP had a normal proBNP, the proBNP level may not be suitable as a screening test for assessing LV filling pressures in the presence of normal systolic function.

Topics: Adult; Aged; Aged, 80 and over; Angina Pectoris; Angina, Unstable; Angioplasty, Balloon, Coronary; Biomarkers; Cardiac Catheterization; Chest Pain; Female; Humans; Male; Middle Aged; Natriuretic Peptide, Brain; Peptide Fragments; Reference Values; Regression Analysis; Systole; Ventricular Dysfunction, Left; Ventricular Function, Left

Unstable angina is a serious condition, difficult to diagnose in the emergency room. Clinical, electrocardiographic and biological signs (increased troponine) are not sensitive. The authors set out to assess whether measuring B natiuretic peptide in the emergency room was more sensitive for identifying symptomatic coronary lesions. One hundred and twenty patients admitted to the emergency room for chest pain compatible with the diagnosis of unstable angina and a normal ECG were included in this prospective study. All patients underwent coronary angiography during their hospital admission. The sensitivities of troponine at a threshold of 0.4 ng/ml and of brain natiuretic peptide (BNP) at a threshold of 10 pg/ml in this population were 66% and 92% respectively. The use of troponine and BNP together provided better results than troponine and BNP alone for the identification of patients with chest pain with significant coronary lesions.

Topics: Angina, Unstable; Biomarkers; Chest Pain; Coronary Angiography; Electrocardiography; Emergency Service, Hospital; France; Humans; Middle Aged; Natriuretic Peptide, Brain; Predictive Value of Tests; Prospective Studies; ROC Curve; Sensitivity and Specificity; Statistics, Nonparametric; Troponin I

The diagnosis of unstable angina (troponine undetectable) is often difficult in the absence of electrocardiographic changes after suggestive chest pains. The object of this study was to analyse the kinetics of Brain Natiuretic Peptide (BNP) during acute coronary syndromes (ACS) without ST elevation. Plasma BNP was measured every 6 hours for 48 hours in 65 patients admitted for suspicion of ACS without ST elevation and without clinical, radiological or echocardiographic signs of left ventricular dysfunction. The results of BNP measurements were masked until the final diagnosis was established on the usual investigations (ECG changes, troponine I values, myocardial scintigraphy, coronary angiography). These investigations identified 3 groups of patients: non-Q wave infarction (group A: 19 patients), unstable angina (group B: 21 patients) and non-coronary chest pain (group C: 25 patients). The peak BNP was significantly higher in groups A (210 +/- 172 pg/ml) and B (152 +/- 159 pg/ml) than in group C (16 +/- 14 pg/ml). However, the BNP was normal or only slightly increased (< 50 pg/ml) in 25% of cases of ACS. Analysis of the kinetics of BNP was much more discriminating: early increase after the pain, peak between the 14th and 24th hours (19th hour on average), followed by a progressive decrease. The kinetics were identical in Groups A and B, contrasting with the flat profile of the curve in group C. A change of > 20 pg/ml in BNP was a better criterion of ACS with a diagnostic accuracy > 90% than increased troponine (group A) or undetectable troponine (group B). The authors conclude that BNP kinetics is a new and reliable diagnostic marker of unstable angina when the usual criteria of ACS are not present (notably a normal ECG and undetectable troponine).

Topics: Aged; Angina, Unstable; Biomarkers; Chest Pain; Coronary Disease; Female; Humans; Kinetics; Male; Middle Aged; Natriuretic Peptide, Brain; Reference Values; Reproducibility of Results; Time Factors