[Rhythm disorders and cardiac crypto-malformations]. / Troubles du rythme et crypto-malformations cardiaques.

Faced with a cardiac arrhythmia occuring in an apparently healthy heart, it is necessary to perform an anatomical investigation to detect any unsuspected anomalies. Congenital cardiopathy must certainly be excluded, as this is often responsible for rhythm disorders and/or cardiac conduction defects. Similarly, any acquired conditions, cardiomyopathy, or cardiac tumour must be sought. However, the possibility should always be considered of a minimal congenital malformation, which could be repsonsible for: any type of cardiac arrhythmia: rhythm disorder or conduction defect at the atrial, junctional or ventricular level, with a benign or serious prognosis. Unexpected therapeutic difficulties during radiofrequency ablation procedures or at implantation of pacemakers or defibrillators. Together with rhythm studies, the investigation of choice is high quality imaging, either the classic left or right angiography or the more modern cardiac CT or intracardiac mapping.

Relation of minor cardiac troponin I elevation to late cardiac events after uncomplicated elective successful percutaneous transluminal coronary angioplasty for angina pectoris.

There is little information about the relation between mild cardiac troponin I (cTn-I) increase after coronary interventions and late outcome. We therefore focused on the long-term outcome and the clinical, morphologic, and procedural correlates of elevation of cTn-I compared with cardiac troponin T, creatine kinase (CK), CK-MB activity and mass, and myoglobin in 105 patients with successful elective percutaneous transluminal coronary angioplasty (PTCA) for stable or unstable angina. Patients with myocardial infarction and those with unstable angina who had a detectable increase in serum markers before PTCA were excluded. Markers were measured before and after the procedure and for 2 days. Patients were followed up to record recurrent angina, myocardial infarction, cardiac death, repeat PTCA, or elective coronary artery bypass graft surgery. Procedure success was achieved in all cases. Elevation in cTn-I (> or =0.1 microg/L) was observed in 23 of 105 patients (22%) (median peak: 0.25 microg/L); 18% had cardiac troponin T (cTn-T) release (> or = 0.1 microg/L, median peak 0.21); 11.4% CK-MB mass (> or =5 microg/L), and 7.6% myoglobin (> or =90 microg/L) release. Five and 2 patients had elevated CK and CK-MB activity, respectively. Fourteen of 18 patients with cTn-T elevation had a corresponding elevation in cTn-I (kappa 0.68; p = 0.001). Patients positive for cTn-I had more unstable angina (p = 0.042) and heparin before PTCA (p = 0.046), and had longest total time (p = 0.004) and single inflation (p = 0.01). By multivariate logistic regression, predictors of postprocedure cTnI elevation were maximum time of each inflation (odds ratio 9.2; p = 0.0012), type B lesions (odds ratio 6.6; p = 0.013), unstable angina (p = 0.041), and age > or =60 years (p = 0.032). Clinical follow-up was available in 103 patients (98%) (mean 19+/-10 months). Kaplan-Meier survival analysis showed that cTn-I elevation was not an important correlate of cardiac events (p = 0.34, by log-rank analysis). The incidence of recurrent angina, myocardial infarction, cardiac death, and repeat revascularization after 12 months was not different in patients positive or negative for cTn-I. We conclude that cTn-I elevation after successful PTCA is not associated with significantly worse late clinical outcome. Levels of cTn-I allow a much higher diagnostic accuracy in detecting minor myocardial injury after PTCA compared with other markers, but there is no association with periprocedural myocardial cell injury and late outcome when cTn-I and other markers are considered.

[Mechanisms of action of antiarrhythmics in cardioversion of atrial fibrillation and atrial flutter]. / Mécanismes d'action des antiarythmiques dans la cardioversion de la fibrillation et du flutter auriculaires.

The mechanisms of action of antiarrhythmic drugs at atrial level are multiple. Antiarrhythmics may act at three levels in the prevention of paroxysmal atrial fibrillation: on the arrhythmogenic atrial substrate, the initiating extrasystoles including those of the pulmonary veins, and in the modulation of the autonomic nervous system. However, there are many modes of initiation which are not well understood so that the preventive role of the antiarrhythmic drugs remains imprecise. Cardioversion of persistent atrial fibrillation has been better analysed in healthy hearts: Class I antiarrhythmics in particular, despite their depressive effects on the conduction which are potentially arrhythmogenic, are beneficial by decreasing the number of reentry circuits, prolonging the atrial refractory period on short cycles and, paradoxically, by increasing the period of excitability in AF. All have a preferential action on anisotropic conduction, especially at the pivotal point of reentry. On the other hand, their role in electrophysiological remodelling in the prevention of immediate recurrences and in pathological atria, remains poorly understood. As for atrial flutter, despite many clinical and experimental studies with antiarrhythmics, the current predominant role of radiofrequency ablation greatly limits the value of these pharmacological studies.

[Monophasic action potentials: considerations and limits]. / Potentiels d'action monophasiques: intérêts et limites.

Monophasic action potentials are currents recorded in vivo in the extracellular milieu which can reproduce the repolarisation signal of intracellular action potentials. For a long time unstable and complex to record, they now require simply a firm myocardial contact with a bipolar electrophysiological catheter and modification with recording filters, without a high-pass filter (DC). They have been widely used in recent years to study in vivo modifications of the action potential durations with frequency, epi-, endo-, or intramyocardial cellular topography, endocavity pressure modifications, or antiarrhythmic medication. They allow a unique means of continuous analysis in animals or in patients of the action potentials during polymorphic arrhythmias such as atrial fibrillation, ventricular fibrillation and torsades de pointes, although in these cases the refractory periods can not be measured precisely and continuously, beat after beat. In contrast, their clinical or experimental use in the study of arrhythmias dependent on premature post-depolarisations has without doubt been excessive and disputable, because it appears improbable that authentic premature post-depolarisations could ever be obtained on a monophasic action potential, which always represents the summation of the action potentials of dozens of cells.

[Electrocardiographic alternans]. / Alternance en électrocardiographie.

A simple ECG curiosity or a precursor of serious arrhythmia, associated with pericardial effusion or a sign of inotropic alteration, the phenomenon of electrical alternans has intrigued clinicians and research workers in its multiple facets, mechanical and electrical, consequences on PR interval, QRS complex or ventricular repolarisation. As a consequence, the causal mechanisms are very different, but these last few years, a predominant role of calcium flux, especially intracellular, has been demonstrated. Recently, clinical interest in this phenomenon has been revived with the demonstration of micro-alternans of repolarisation, apparently a new marker for the risk of sudden death.

[Electrocardiographic aspects of the pathology of the bundle of His]. / Aspects électrocardiographiques de la pathologie du faisceau de His.

The ECG appearances of His bundle pathology are very variable and endocavitory recordings are often required to confirm the diagnosis which may be suspected by close analysis of the surface ECG. Truncular AVB is a serious condition as the block is infranodal but with a supraventricular and therefore a narrow QRS complex: it may be median with a double His potential or proximal and distal, which are more difficult to diagnose. Hisian extrasystoles are particularly polymorphic, either overtly, suggesting successively atrial and ventricular extrasystoles, or masked with deceptive pseudo-1st or 2nd degree atrioventricular block. More rarely, hisian tachycardias complicating congenital heart disease in children are observed, particularly in the postoperative period.

[Vasovagal syndromes]. / Syndromes vasovagaux.

Most cases of dizziness or syncope referred to the emergency department or to services of internal medicine are caused by vasovagal syndromes. They comprise relative bradycardia with vasoplegia, the cardiovascular response to a neurological stimulus. It is possible to distinguish vagal or vasovagal syncope which is very common, the very stereotype reflex syncopes, carotid sinus hypersensitivity sometimes associated with sinus node dysfunction and borderline forms such as orthostatic sinus tachycardia and cerebrovascular syncope. The differential diagnosis is vast, from simple hysteria to severe cardiac disease. Tilt testing should be indicated for diagnosis of most cases of syncope with apparently normal hearts. Therapeutic abstention is the rule, providing certain preventive measures are taken, but, should treatment be necessary, cardiac pacing remains an exceptional modality in vasovagal syncope. Strict clinical and physiopathological studies are still required to determine the long-term prognosis and the underlying mechanisms of these syndromes.

[Arrhythmogenic effects of non cardiovascular drugs]. / Effets arythmogènes des médicaments non cardiovasculaires.

Among the unwanted effects of drugs, arrhythmogenic effects are particularly fearsome. Although rare they are serious, and responsible for syncope or sudden death, often linked with torsades de pointe on established long QT. For non cardiovascular drugs, detection is difficult because patients do not undergo systematic cardiological surveillance. Nevertheless understanding the risk, identification of predisposing factors, and consideration of the contra-indications are the rules of prescription, which are even more indispensable when the pathology being treated is benign. In effect, the implicated drugs are mainly anti-histamines, antibiotics, neuroleptics and antidepressants. The pharmaceutical companies, regulatory agencies, and pharmacological surveillance services must recognise the greatest possible risk of a drug, thanks to pre-clinical data, experimental electrophysiology both in vivo (measurement of the QT interval) and in vitro (action potential duration) or even in the elementary channel (essentially analysis of the iKr current). Correlated with clinical data (QT changes, pharmacokinetic interactions), a risk/benefit profile can therefore be established, which is even more demanding when the pathology is benign or when alternative drugs are available.

[Continuous nodal reciprocal rhythm and Steinert's disease: treatment by double chamber stimulation. A case report]. / Rythme réciproque nodal incessant et maladie de Steinert: traitement par stimulation double chambre. A propos d'un cas.

We report a case of continuous supraventricular tachycardia in a patient affected by Steinert's myotonic dystrophy. The investigation of this tachycardia showed that there was a "slow-fast" common nodal re-entry, rendered continuous by the existence of significant conduction defects in the fast pathway and the slow anterograde pathway. Implantation of a double chamber cardiac stimulator, necessary for conduction defects present in the basal state in this patient allowed, with the evolution of the conduction defects, the complete eradication of reciprocal rhythm entry, without resorting to ablation.

[Prognostic significance of early raised cardiac troponine I in unstable angina. Contribution to the identification of a high-risk sub-group]. / Signification pronostique de l'élévation précoce de la troponine I cardiaque chez les patients en angor instable. Contribution à l'identification d'un sous-groupe à haut-risque.

The authors compared the clinical and angiographic characteristics of 44 patients with unstable angina according to cardiac Troponine I concentrations (TnIc) during early blood sampling and then tried to determine a threshold value to predic the occurrence of cardiac events during the hospital period and after 12 months. Tnlc, creatinine-kinase (CK), CK-MB activity and CK-MB mass were sampled over 48 hours. Forty-five per cent of patients had TnIc > or = 0.1 microgram/L; CK-MB activity and CK-MB mass were detected in 16 and 32% of patients. Age, gender, classification and recurrence of angina, previous cardiac history, risk factors, coronary angiographic appearances were comparable in patients with and without raised TnIc. No major cardiac events occurred during the hospital period in either group. The number of angioplasties and coronary bypass procedures was also comparable. At one year, the incidence of myocardial infarction (N = 4) and death (N = 5) was significantly different in patients with raised Tnlc (33% versus 0% in patients without increased TnIc). However, betablocker therapy was less prescribed in the group with the poorest outcomes and left ventricular dysfunction was also significantly more common in this group. Early elevation of Tnlc could contribute to the identification of a high risk subgroup of patients with unstable angina.

[Hypertensive encephalopathy as revealing symptom of Takayasu's arteritis]. / Encéphalopathie hypertensive révélatrice d'une maladie de Takayasu.

A 29-year-old patient presented with Takayasu's arteritis which was revealed by heart failure, epilepsy, right hemiparesis and fever. Transient abnormalities of MRI and CSF (raised protein and cell content) were initially observed. The hypothesis of a hypertensive encephalopathy is suggested.

Prevalence, characteristics, and prognosis role of type 1 ST elevation in the peripheral ECG leads in patients with Brugada syndrome.

BACKGROUND: Despite isolated reports of Brugada syndrome (BrS) in the inferior or lateral leads, the prevalence and prognostic value of ST elevation in the peripheral electrocardiographic (ECG) leads in patients with BrS remain poorly known. OBJECTIVE: To study the prevalence, characteristics, and prognostic value of type 1 ST elevation and ST depression in the peripheral ECG leads in a large cohort of patients with BrS. METHODS: ECGs from 323 patients with BrS (age 47 ± 13 years; 257 men) with spontaneous (n = 141) or drug-induced (n = 182) type 1 ECG were retrospectively reviewed. Two hundred twenty-five (70%) patients were asymptomatic, 72 (22%) patients presented with unexplained syncope, and 26 (8%) patients presented with sudden death (12 patients) or appropriated implantable cardioverter-defibrillator therapies (14 patients) at diagnosis or over a mean follow-up of 48 ± 34 months. RESULTS: Thirty (9%) patients presented with type 1 ST elevation in at least 1 peripheral lead (22 patients in the aVR leads, 2 in the inferior leads, 5 in both aVR and inferior leads, and 1 in the aVR and VL leads). Patients with type 1 ST elevation in the peripheral leads more often had mutations in the SCN5A gene, were more often inducible, had slower heart rate, and higher J-wave amplitude in the right precordial leads. Twenty-seven percent (8 of 30) of the patients with type 1 ST elevation in the peripheral leads experimented sudden death/appropriate implantable cardioverter-defibrillator therapy, whereas it occurred in only 6% (18 of 293) of other patients (P < .0001). In multivariate analysis, type 1 ECG in the peripheral leads was independently associated with malignant arrhythmic events (odds ratio 4.58; 95% confidence interval 1.7-12.32; P = .0025). CONCLUSIONS: Type 1 ST elevation in the peripheral ECG leads can be seen in 10% of the patients with BrS and is an independent predictor for a malignant arrhythmic event.

[Are patients undergoing coronary angiography well-informed? Prospective evaluation of the effectiveness of written information]. / Les patients bénéficiant d'une coronarographie sont-ils bien informés ? Évaluation de l'efficacité de l'information écrite. Étude prospective unicentrique.

INTRODUCTION: Prior information in the realization of an invasive intervention is crucial. Indeed, the patient has to know theoretically his disease, diagnostic and therapeutic means, but also the risks of the used technique. The habits of information vary many from one center to another, in spite of the proposition of an information leaflet written by the French Society of Cardiology. Our aim was to evaluate the effectiveness of written information for patients hospitalized for coronary arteriography. METHODS: Among patients hospitalized for realization of a programmed coronarography, a questionnaire was delivered before the information leaflet. The knowledge of the patients was so tested (27 items) before and after the reading of the information sheet (not limited time). The knowledge of the patients concerning coronarography indication, modalities, benefits, possible complications or still later possibilities was informed. RESULTS: Thirty-four patients were included: all knew hospitalization reason, 86% were men, middle-aged 65 (IC 95% 60-70). Thirty-four percent (15-54) had studied in higher education. Ninety-seven percent had had information before. Only 56% (38-74) were informed about the mode of anesthesia, 36% (19-53) duration, 69% (53-86) the injection of iodine, 44% the risk of allergy, 53% the risk of bruise, 15% of the cardiac risks, 21% the renal risks. Seventy-one percent knew the diagnostic benefits, 44% the possible coronary angioplasty, 17% the eventuality of a bypass surgery. The delivery of the information leaflet did not modify the knowledge on most of these items, in particular the modalities and the profits. The risks were known significantly better for the allergy (P=0.019), the bruise (P=0.018), the cardiac risks (0.001). CONCLUSIONS: The population benefiting from a coronarography considers to be enough informed. However, knowledge of the modalities, profits and risks is very low. The delivery of the consensual leaflet does not allow improving the situation, except as far as concerned the complications. Better information is so indispensable, not only to obtain a better support of the patient in the treatment, but also to prevent the forensic implications. The improvement of the information must be multifactorial, but usually used means could be not sufficient.

[Atrial fibrillation in 2010: an increasing morbidity and mortality burden]. / La fibrillation atriale en 2010: un poids croissant sur la morbidité et la mortalité cardiovasculaires.

AF, a frequent and banal arrhythmia, is a debilitating and costly disease. The majority of patients with AF are aged 60 to 80 years, but the prevalence is as high as 10% after 80 years and the incidence increases in recent years in an "epidemic" way. AF is responsible for an excess of mortality with an relative risk between 2 and 4 depending of age and sex, especially as cardiovascular risk factors are associated. The morbidity is also important, with cerebral systemic embolism (2-3% per year), heart failure (1 patient for 3), and a total risk of hospitalization from 20 to 30% per year for AF patients with high cardiovascular risks. Whatever be the reasons for hospitalization, cardiovascular or not, in connection with AF or not, these reasons must be well analyzed, so that the risk of occurrence of hospitalization should reflect the efficacy of anti-arrhythmic drugs, or of their complications, or of the comorbidities associated with AF, so common in these older subjects. This morbidity-mortality composite endpoint should now be used in AF randomized trials, as occurring more frequently than mortality (4% per year) or embolic or hemorrhagic usual endpoints. Medico-economic consequences are significant and AF cost is almost 1% of total health spending, with 20% to 30% of the cost for anti-arrhythmic or anti-thrombotic drugs, and 50 to 60% for hospitalizations. Prevention of hospitalizations related to atrial fibrillation may represent a therapeutic target priority on the medico-economic ground.

Can troponin elevation predict worse prognosis in patients with acute pericarditis?

INTRODUCTION: Myopericarditis are common in clinical practice: up to 15% of acute pericarditis have a significant myocardial involvement as assessed by biological markers. This prospective, bicentric study is aimed at describing a myopericarditis population, the clinical and MRI follow-up, and search for prognosis markers. PATIENTS AND METHODS: Between May 2005 and September 2007, 103 patients hospitalised for acute pericarditis were prospectively enrolled. Physical examination, ECG, echocardiography, biological screening and cardiac MRI, in case of myopericarditis defined as acute pericarditis with troponin I elevation, were performed. Between December 2007 and July 2008, patients were contacted for new clinical and MRI evaluation. RESULTS: Among the initial population of 103 patients admitted for acute pericarditis, 14 myopericarditis and 38 pericarditis were included. Compared with pericarditis, the myopericarditis group was associated with the following features: younger age (34.9 years [95% CI 28.3-41.2]; p=0.01), ST-segment elevation (nine patients between 14; p=0.03), higher troponin I (7.3 microg/L [95% CI 4.4-10.2]; p<10(-4)) and lower systemic inflammation (CRP peak 38.1mg/L [95% CI 7-69.2]; p=0.01). In the case of myopericarditis, infectious etiologies were predominant (12 patients among 14; p=0.002) and patients stayed longer in hospital (5.8 days [95% CI 4.7-6.8]; p=0.01). Follow-up showed no difference in terms of functional status (p=0.3) and global complications (p=0.9) between paired myopericarditis and pericarditis. Nevertheless, cardiac mortality was higher for myopericarditis (p=0.04). MRI follow-up showed myocardial sequelae without clinical impact. CONCLUSION: Myopericarditis significantly distinguished from pericarditis. Three years follow-up showed no difference in terms of global complications but a higher cardiac mortality for myopericarditis. MRI myocardial lesions did not develop into symptomatic sequelae.

Routinely-feasible multiple biomarkers score to predict prognosis after revascularized STEMI.

INTRODUCTION: We assessed the long-term prognostic value of an easy-to-do multiple cardiac biomarkers score after a revascularized acute myocardial infarction (MI) in order to evaluate a multimarker approach to risk stratification, based on routine biomarkers. MATERIAL AND METHODS: Blood samples from 138 patients hospitalized with acute myocardial infarction and successfully treated by primary coronary intervention (with TIMI 3 flow) were subsequently tested for creatinin level at admittance and then BNP, hsCRP, troponin I from Day 0 to day 7. The primary endpoint was a clinical evaluation comprising: new hospitalization for cardiac reasons, acute coronary events (acute coronary syndrome), and death. RESULTS: During the median follow-up period of 11.01 months [9.44-12.59], 47 events were recorded. All the following markers were able to predict events: creatinemia on admission (p=0.0057), CRP on day 3 (p, troponin I on day 1 (p<0.001), BNP (p<0.0001) and biological multimarker score (p<0.0001). Clinical events were predicted with a hazard ratio (HR) of respectively 3.30 [2.88-12.30] in BNP Q4 as compared to the three lower quartiles (Q1-3), and 3.15 [2.75-21.00] for the Multimarker approach. The multimarker score was not significantly better than BNP on day 1 alone (p=0.77), troponin on day 1 alone (p=0.43), creatininemia on admission (p=0.19) or CRPhs on day 3 alone (p=0.054). Nevertheless, the Multimarker approach leads to the selection of a smaller, hence more manageable, high-risk population (13% versus 25%). CONCLUSION: Among 138 subjects admitted for acute MI, and all successfully revascularized, a routinely multimarker approach with BNP, hsCRP, creatininemia, troponin I, is feasible. BNP is the most powerful marker, and this multimarker approach renders additional prognostic information helping to identify patients with high-risk to clinical events.

Routine measurements of left and right ventricular output by gated blood pool emission tomography in comparison with thermodilution measurements: a preliminary study.

The aim of this preliminary study was to evaluate the accuracy of left and right ventricular output computed from a semi-automatic processing of tomographic radionuclide ventriculography data (TRVG) in comparison with the conventional thermodilution method. Twenty patients with various heart diseases were prospectively included in the study. Thermodilution and TRVG acquisitions were carried out on the same day for all patients. Analysis of gated blood pool slices was performed using a watershed-based segmentation algorithm. Right and left ventricular output measured by TRVG correlated well with the measurements obtained with thermodilution (r = 0.94 and 0.91 with SEE = 0.38 and 0.46 l/min, respectively, P < 0.001). The limits of agreement for TRVG and thermodilution measurements were -0.78-1.20 l/min for the left ventricle and -0.34-1.16 l/min for the right ventricle. No significant difference was found between the results of TRVG and thermodilution with respect to left ventricular output (P = 0.09). A small but significant difference was found between right ventricular output measured by TRVG and both left ventricular output measured by TRVG (mean difference = 0.17 l/min, P = 0.04) and thermodilution-derived cardiac output (mean difference = 0.41 l/min, P = 0.0001). It is concluded that the watershed-based semi-automatic segmentation of TRVG slices provides non-invasive measurements of right and left ventricular output and stroke volumes at equilibrium, in routine clinical settings. Further studies are necessary to check whether the accuracy of these measurements is good enough to permit correct assessment of intracardiac shunts.

Evaluation of incidence, clinical significance, and prognostic value of circulating cardiac troponin I and T elevation in hemodynamically stable patients with suspected myocardial contusion after blunt chest trauma.

BACKGROUND: The frequency and prognostic influence of myocardial injury in patients with blunt chest trauma is controversial. We investigated the value of cardiac troponin I (cTn-I) and cardiac troponin T (cTn-T), highly specific markers of myocardial injury, to determine whether their measurement would improve the ability to detect myocardial contusion in stable patients with blunt chest trauma in comparison with conventional markers and whether they were associated with significantly worse late clinical outcome. METHODS AND RESULTS: Over an 18-month period, myocardial contusion was diagnosed in 26 of 94 patients (27.6%) with acute blunt chest trauma (motor vehicle crash; 81%), because of echocardiographic abnormalities (n = 12), electrocardiographic abnormalities (n = 29), or both. Patients with myocardial contusion had a significantly higher Injury Severity Score at the time of admission (p = 0.001) and a significantly longer hospital stay (p = 0.0008). All patients survived admission to hospital and were hemodynamically stable. None of the patients died or had severe in-hospital cardiac complications. The percentage of patients with elevated CK, (CK-MB/total CK) ratio, or CK-MB mass concentration was not significantly different between patients with or without myocardial contusion. However, there were significant differences between the two groups when we applied the commonly used threshold levels of CK-MB activity and myoglobin. The percentage of patients with elevated circulating cTn-I and cTn-T (> or = 0.1 microg/L) was significantly higher in patients with myocardial contusion (23% vs. 3%; p = 0.01 and 12% vs. 0%; p = 0.03, respectively). Complete changes in cTn-I and cTn-T correlated well (r = 0.91, p = 0.0001). Sensitivity, specificity, and negative and positive predictive values of cTn-I and cTn-T in predicting a myocardial contusion in blunt trauma patients were 23%, 97%, and 77%, 75%, and 12%, 100%, and 74%, 100%, respectively. Clinical follow-up was available in 83 patients (88%) (mean, 16 +/- 7.5 months). There were no deaths in either group directly attributed to cardiac complications. None of the patients had any long-term cardiac complications or myocardial failure related to blunt chest trauma. CONCLUSION: Although improved specificity of cTn-I and cTn-T compared with conventional markers, it should be emphasized that the main problem with cTn-I and cTn-T is low sensitivity as well as low predictive values in diagnosing myocardial contusion. cTn-I and cTn-T measurement is currently not an improved method in diagnosing blunt cardiac injury in hemodynamically stable patients. Moreover, there was no association of postmyocardial contusion cell injury and late outcome in these patients when cTn-I and cTn-T and other conventional markers were considered.