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1.
J Sports Sci ; 38(2): 187-191, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31783721

RESUMO

The popularity of pre-workout supplements is rising amongst professional athletes and fitness enthusiasts. Despite increased usage, the safety profile of pre-workout supplements is likely to be not well understood. Additionally, many different brands use various undisclosed proprietary blends of active ingredients creating safety regulation difficulties. This lack of oversight could prove unsafe for certain patients. This patient MK is a 33-year-old healthy housewife who presented with central chest tightness, pre-syncope and mild dyspnoea to the emergency department via ambulance. The presentation was in the context of recent strenuous exercise and ingestion of a pre-workout supplement (Alpha Lean-7). Most striking in her presentation was a troponin rise of 50 ng/L, while not very high it is unusual given her lack of cardiac risk factors. She had a 3-day uneventful admission with a downtrending troponin prior to discharge. This case highlights the possible dangers of pharmacologically active ingredients in pre-workout supplements.


Assuntos
Suplementos Nutricionais/efeitos adversos , Isquemia Miocárdica/etiologia , Corrida/fisiologia , Adulto , Cafeína/efeitos adversos , Estimulantes do Sistema Nervoso Central/efeitos adversos , Dispneia/etiologia , Serviço Hospitalar de Emergência , Feminino , Produtos de Degradação da Fibrina e do Fibrinogênio/metabolismo , Humanos , Isquemia Miocárdica/sangue , Síncope/etiologia , Troponina/sangue
2.
Forensic Sci Int ; 306: 110079, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31812084

RESUMO

The utility of biochemical marker analysis in forensic autopsy cases is still uncertain due to the postmortem changes which they undergo. Thus, research is required to elucidate alternative samples and biochemical markers which are less affected by postmortem changes. Levels of N-terminal pro-brain natriuretic peptide (NT-proBNP) are known to be elevated in congestive heart failure (CHF), acute myocardial infarction (AMI), and sepsis patients. Although NT-proBNP is reportedly excreted into the urine, no study has previously evaluated the diagnostic efficacy of urinary concentrations in a forensic setting. The aim of this study was to evaluate the diagnostic efficacy of NT-proBNP concentration in urine obtained postmortem in a series of forensic autopsy cases. METHODS: Urinary NT-proBNP was measured in 36 AMI, 10 CHF, and 19 sepsis cases, and in 124 control cases (all with postmortem interval [PMI]<72h). RESULTS: Urinary NT-proBNP was significantly higher in AMI, CHF, and sepsis cases than in control cases. Cut-off values for diagnosing AMI, CHF, and sepsis-related fatalities were 98 (sensitivity, 55.6 %; specificity, 73.4 %), 1050 (sensitivity, 80.0 %; specificity, 94.4 %), and 363pg/mL (sensitivity, 84.2 %; specificity, 85.5 %), respectively. Furthermore, we subdivided the control cases according to the death process as either acute death (87 cases) or prolonged death cases (37 cases). Although urine NT-proBNP of CHF and sepsis cases were significantly higher compared with both cases, the concentration in the AMI cases were significantly high only when compared with the acute death cases. CONCLUSION: This study is the first to elucidate the diagnostic utility of NT-proBNP measurement in urine obtained postmortem in a series of causes of death. This study suggests the diagnostic efficacy for AMI, CHF, and sepsis-related fatality in cases in which the PMI was within 72h.


Assuntos
Biomarcadores/urina , Medicina Legal , Peptídeo Natriurético Encefálico/urina , Fragmentos de Peptídeos/urina , Mudanças Depois da Morte , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Biomarcadores/metabolismo , Estudos de Casos e Controles , Causas de Morte , Criança , Creatina Quinase Forma MB/metabolismo , Feminino , Insuficiência Cardíaca/metabolismo , Humanos , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/metabolismo , Peptídeo Natriurético Encefálico/metabolismo , Fragmentos de Peptídeos/metabolismo , Líquido Pericárdico/metabolismo , Sensibilidade e Especificidade , Sepse/metabolismo , Troponina/sangue , Adulto Jovem
3.
BMJ ; 367: l6055, 2019 11 20.
Artigo em Inglês | MEDLINE | ID: mdl-31748235

RESUMO

OBJECTIVE: To determine the relation between age and troponin level and its prognostic implication. DESIGN: Retrospective cohort study. SETTING: Five cardiovascular centres in the UK National Institute for Health Research Health Informatics Collaborative (UK-NIHR HIC). PARTICIPANTS: 257 948 consecutive patients undergoing troponin testing for any clinical reason between 2010 and 2017. MAIN OUTCOME MEASURE: All cause mortality. RESULTS: 257 948 patients had troponin measured during the study period. Analyses on troponin were performed using the peak troponin level, which was the highest troponin level measured during the patient's hospital stay. Troponin levels were standardised as a multiple of each laboratory's 99th centile of the upper limit of normal (ULN). During a median follow-up of 1198 days (interquartile range 514-1866 days), 55 850 (21.7%) deaths occurred. A positive troponin result (that is, higher than the upper limit of normal) signified a 3.2 higher mortality hazard (95% confidence interval 3.1 to 3.2) over three years. Mortality varied noticeably with age, with a hazard ratio of 10.6 (8.5 to 13.3) in 18-29 year olds and 1.5 (1.4 to 1.6) in those older than 90. A positive troponin result was associated with an approximately 15 percentage points higher absolute three year mortality across all age groups. The excess mortality with a positive troponin result was heavily concentrated in the first few weeks. Results were analysed using multivariable adjusted restricted cubic spline Cox regression. A direct relation was seen between troponin level and mortality in patients without acute coronary syndrome (ACS, n=120 049), whereas an inverted U shaped relation was found in patients with ACS (n=14 468), with a paradoxical decline in mortality at peak troponin levels >70×ULN. In the group with ACS, the inverted U shaped relation persisted after multivariable adjustment in those who were managed invasively; however, a direct positive relation was found between troponin level and mortality in patients managed non-invasively. CONCLUSIONS: A positive troponin result was associated with a clinically important increased mortality, regardless of age, even if the level was only slightly above normal. The excess mortality with a raised troponin was heavily concentrated in the first few weeks. STUDY REGISTRATION: ClinicalTrials.gov NCT03507309.


Assuntos
Envelhecimento/sangue , Doenças Cardiovasculares , Troponina/sangue , Adulto , Idoso , Idoso de 80 Anos ou mais , Biomarcadores/sangue , Doenças Cardiovasculares/sangue , Doenças Cardiovasculares/mortalidade , Doenças Cardiovasculares/terapia , Estudos de Coortes , Tratamento Conservador/estatística & dados numéricos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Mortalidade , Valor Preditivo dos Testes , Prognóstico , Modelos de Riscos Proporcionais , Fatores de Risco , Reino Unido/epidemiologia
4.
Tex Heart Inst J ; 46(3): 161-166, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-31708695

RESUMO

In a time when cardiac troponin assays are widely used to detect myocardial injury, data remain scarce concerning the incidence and predictors of substantial obstructive coronary artery disease that causes unstable angina. This retrospective single-center study included consecutive patients hospitalized for unstable angina from January 2015 through January 2016. Patients with troponin I levels above the upper reference limit and those who did not undergo angiography were excluded. Multivariate logistic regression analysis was used to identify predictors of obstructive coronary artery disease that warranted revascularization and of major adverse cardiac events up to 6 months after discharge from the hospital. Of the 114 patients who met the inclusion criteria, 46 (40%) had obstructive coronary artery disease. In the univariate analysis, male sex, white race, history of coronary artery disease, prior revascularization, hyperlipidemia, chronic kidney disease, aspirin use, long-acting nitrate use, and Thrombolysis in Myocardial Infarction score ≥3 were associated with obstructive coronary artery disease. History of coronary artery disease, prior revascularization, hyperlipidemia, and long-acting nitrate use were associated with major adverse cardiac events. Male sex was an independent predictor of obstructive coronary artery disease (adjusted odds ratio=4.82; 95% CI, 1.79-13; P=0.002) in the multivariate analysis. Our results showed that coronary artery disease warranting revascularization is present in a considerable proportion of patients who have unstable angina. The association that we found between male sex and obstructive coronary artery disease suggests that the risk stratification of patients presenting with unstable angina may need to be refined to improve outcomes.


Assuntos
Angina Instável/sangue , Oclusão Coronária/epidemiologia , Medição de Risco/métodos , Troponina/sangue , Angina Instável/diagnóstico , Angina Instável/etiologia , Biomarcadores/sangue , Angiografia Coronária , Oclusão Coronária/sangue , Oclusão Coronária/complicações , Eletrocardiografia , Feminino , Seguimentos , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Prognóstico , Estudos Retrospectivos , Fatores de Risco , Estados Unidos/epidemiologia
5.
Cardiovasc Hematol Agents Med Chem ; 17(2): 144-151, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31629400

RESUMO

INTRODUCTION: Recent findings have shown that in Acute Ischemic Stroke (AIS) patients, elevated troponin is associated with increased mortality. However, due to concerns of cerebral hypoperfusion and hemorrhagic transformation, current practice has been slow to apply proven cardiac therapies to these patients. This study aims to determine this rate of utilization. MATERIALS AND METHODS: A single-center review of 83 patients with AIS and measured troponin was conducted. Patients were stratified based on elevated and non-elevated troponin. Between groups, we measured the utilization of evidence-based cardiac therapies and used a univariate logistic regression to compare outcomes of mortality, re-hospitalization, recurrent acute ischemic stroke, recurrent acute myocardial infarction, and a composite of these outcomes. RESULTS: Of 83 patients, 25 had elevated troponin and 58 had non-elevated troponin. There was no statistical difference in the use of cardiac therapies between the two groups. Adenosine diphosphate P2Y12 antagonists were infrequently used in both elevated and non-elevated troponin groups at 32% vs. 24% (p = 0.64), as were Angiotensin-Converting Enzyme Inhibitors (ACE-I) and angiotensin II receptor blockers (ARB) at 56% vs. 69% (p = 0.38). Those in the elevated troponin group encountered a statistically significant increase in composite endpoint 64% vs. 33% (Odds Ratio [OR] 7.28, 95% Confidence interval [CI] 2.19-28.88, p<0.01). CONCLUSION: Cardiac therapies are underutilized in patients with acute ischemic stroke and elevated troponin levels. In turn, this low usage may explain the increase in morbidity and mortality seen in these patients and the use of such therapies should be considered when treating this subset of patients as the cardio protective nature of these therapies may outweigh the risks associated with them in AIS patients.


Assuntos
Antagonistas de Receptores de Angiotensina/uso terapêutico , Inibidores da Enzima Conversora de Angiotensina/uso terapêutico , Infarto do Miocárdio/prevenção & controle , Antagonistas do Receptor Purinérgico P2Y/uso terapêutico , Acidente Vascular Cerebral/sangue , Troponina/sangue , Idoso , Isquemia Encefálica/sangue , Isquemia Encefálica/complicações , Feminino , Humanos , Masculino , Infarto do Miocárdio/sangue , Infarto do Miocárdio/etiologia , Estudos Retrospectivos , Acidente Vascular Cerebral/complicações
6.
Isr Med Assoc J ; 21(9): 603-606, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-31542905

RESUMO

BACKGROUND: With the recent introduction of high-sensitivity troponin (hsTn), the incremental benefit of stress myocardial perfusion imaging (MPI) in the evaluation of patients who present to the emergency department (ED) with acute coronary syndrome (ACS) is unclear. OBJECTIVES: To assess the added value of stress MPI in low-risk ACS patients with normal range hsTnI. METHODS: We analyzed all patients who were hospitalized at our medical center from February 2016 to November 2017, who presented with low-risk ACS and underwent stress MPI, and in whom hsTnI was in the normal range after the introduction of hsTnI. RESULTS: During the study period, 161 patients were admitted with a diagnosis of unstable angina (i.e., ACS with normal range hsTnI) and underwent stress MPI during index admission. The study population included 52/161 patients (31.7%) with low-risk ACS who had no indication for initial invasive strategy. No patients had positive MPI. One patient underwent coronary angiography due to suggestive history; however, he did not have a significant coronary artery disease and had no indication for percutaneous coronary intervention. CONCLUSIONS: In patients with low-risk ACS and normal range hsTnI without additional high-risk features, stress MPI has little additional value for the correct diagnosis and management. Prospective studies are warranted to confirm whether resting hsTnI could serve as a powerful triage tool in chest pain patients in the ED before diagnostic testing and thus, improve patient management.


Assuntos
Síndrome Coronariana Aguda/sangue , Síndrome Coronariana Aguda/diagnóstico por imagem , Imagem de Perfusão do Miocárdio/métodos , Troponina/sangue , Idoso , Estudos de Coortes , Feminino , Coração/diagnóstico por imagem , Humanos , Masculino , Estudos Retrospectivos , Medição de Risco
7.
Medicine (Baltimore) ; 98(32): e16370, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31393346

RESUMO

Validated risk scoring systems in African American (AA) population are under studied. We utilized history, electrocardiogram, age, risk factors, and initial troponin (HEART) and thrombolysis in myocardial infarction (TIMI) scores to predict major adverse cardiovascular events (MACE) in non-high cardiovascular (CV) risk predominantly AA patient population.A retrospective emergency department (ED) charts review of 1266 chest pain patients where HEART and TIMI scores were calculated for each patient. Logistic regression model was computed to predict 6-week and 1-year MACE and 90-day cardiac readmission. Decision curve analysis (DCA) was constructed to differentiate between clinical strategies in non-high CV risk patients.Of the 817 patients included, 500 patients had low HEART score vs. 317 patients who had moderate HEART score. Six hundred sixty-three patients had low TIMI score vs. 154 patients had high TIMI score. The univariate logistic regression model shows odds ratio of predicting 6-week MACE using HEART score was 3.11 (95% confidence interval [CI] 1.43-6.76, P = .004) with increase in risk category from low to moderate vs. 2.07 (95% CI 1.18-3.63, P = .011) using TIMI score with increase in risk category from low to high and c-statistic of 0.86 vs. 0.79, respectively. DCA showed net benefit of using HEART score is equally predictive of 6-week MACE when compared to TIMI.In non-high CV risk AA patients, HEART score is better predictive tool for 6-week MACE when compared to TIMI score. Furthermore, patients presenting to ED with chest pain, the optimal strategy for a 2% to 4% miss rate threshold probability should be to discharge these patients from the ED.


Assuntos
Afro-Americanos , Doenças Cardiovasculares/etnologia , Dor no Peito/etnologia , Indicadores Básicos de Saúde , Hospitais Comunitários/estatística & dados numéricos , Adulto , Fatores Etários , Idoso , Doenças Cardiovasculares/mortalidade , Dor no Peito/etiologia , Dor no Peito/mortalidade , Eletrocardiografia , Serviço Hospitalar de Emergência/estatística & dados numéricos , Feminino , Humanos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/tratamento farmacológico , Readmissão do Paciente , Estudos Prospectivos , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Índice de Gravidade de Doença , Terapia Trombolítica/estatística & dados numéricos , Troponina/sangue
8.
Transplant Proc ; 51(6): 1673-1678, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31307770

RESUMO

BACKGROUND: Previously, we showed that B-type natriuretic peptide (BNP) measured in the donor was related to cardiac performance after cardiac transplantation. The present study assesses the value of 3 biomarkers in the selection of donor hearts in a larger cohort. METHODS: Blood samples were prospectively obtained in 105 brain-dead patients scheduled for heart donation. BNP, soluble suppressor of tumorigenicity 2 (ST2), and troponin of heart donors were correlated with hemodynamic parameters early after transplantation as well as with the mortality of the recipients. RESULTS: A significant inverse relationship was found between donor BNP measured at the time of donation and recipient cardiac index and cardiac output at day 13 post-transplantation (r = -0.31, P = .005, and r = -0.34, P = .0016, respectively). Logistic regression analysis-including BNP, ST2, and troponin-showed that donor BNP was a predictor of a poor cardiac index (< 2.2 L/min/m2) in the recipient (P = .04). A donor BNP > 132 pg/mL has a sensitivity of 56% (95% confidence interval 21-86) and a specificity of 86% (95% confidence interval 77-93) to predict poor cardiac performance in the recipient. When the donor BNP is ≤ 132 pg/mL, the risk of a poor cardiac function in the recipient is very low (negative predictive value 94%). Mortality at 30 days was also correlated to donor BNP (r = 0.29, P = .0029). Long-term survival of the recipient was not correlated to the biomarkers measured in the donor. CONCLUSION: Donor BNP, but not donor ST2 or high-sensitivity troponin, provides information on the donor heart and early post-transplant performance, including 1-month mortality.


Assuntos
Morte Encefálica/sangue , Seleção do Doador/métodos , Transplante de Coração , Proteína 1 Semelhante a Receptor de Interleucina-1/sangue , Peptídeo Natriurético Encefálico/sangue , Troponina/sangue , Adulto , Biomarcadores/sangue , Débito Cardíaco , Feminino , Coração/fisiopatologia , Hemodinâmica , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Sensibilidade e Especificidade , Doadores de Tecidos , Transplantes/fisiopatologia , Resultado do Tratamento
9.
Emerg Med Clin North Am ; 37(3): 493-509, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31262417

RESUMO

Although cardiogenic shock is uncommon in the emergency department, it is associated with high mortality. Most cardiogenic shock is caused by ischemia, but nonischemic etiologies are essential to recognize. Clinicians should optimize preload, contractility, and afterload. Volume-responsive patients should be resuscitated in small aliquots, although some patients may require diuresis to improve cardiac output. Vasopressors are important to restore end-organ perfusion, and inotropes improve contractility. Intubation and positive pressure ventilation impact hemodynamics, which, depending on volume status, may be beneficial or deleterious. Knowing indications for mechanical circulatory support is important for timely consultation or transfer as indicated.


Assuntos
Choque Cardiogênico/etiologia , Choque Cardiogênico/terapia , Algoritmos , Antiarrítmicos/uso terapêutico , Cardiotônicos/uso terapêutico , Cateterismo , Ecocardiografia , Eletrocardiografia , Medicina de Emergência , Cardiopatias/complicações , Cardiopatias/diagnóstico , Cardiopatias/terapia , Humanos , Ácido Láctico/sangue , Anamnese , Monitorização Fisiológica , Peptídeos Natriuréticos/sangue , Exame Físico , Sistemas Automatizados de Assistência Junto ao Leito , Troponina/sangue , Vasoconstritores/uso terapêutico
10.
J Cardiovasc Med (Hagerstown) ; 20(8): 504-509, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31259857

RESUMO

: Advances in technology have led to an improvement in the ability to detect and quantify acute cardiomyocyte injury with the measurement of high-sensitivity cardiac troponin as compared with conventional assays. The upper reference limit for the high-sensitivity cardiac troponin assays is defined as the 99th percentile cutoff value in a healthy reference population. Since sex-related threshold levels of high-sensitivity cardiac troponin assays have been proposed, this review will focus on the diagnostic and prognostic implications of adopting sex-specific threshold troponin values in patients with a suspected acute coronary syndrome.


Assuntos
Síndrome Coronariana Aguda/diagnóstico , Troponina/sangue , Síndrome Coronariana Aguda/sangue , Síndrome Coronariana Aguda/terapia , Fatores Etários , Idoso , Biomarcadores/sangue , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Prognóstico , Fatores de Risco , Fatores Sexuais , Regulação para Cima
11.
J Cardiovasc Med (Hagerstown) ; 20(8): 495-499, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31169633

RESUMO

: Although the angiographic and procedural success of percutaneous coronary intervention (PCI) is now very high, some severe complications may still develop, including periprocedural myocardial infarction (MI). An accurate diagnosis of this condition is essential for guiding the clinical management, as these patients may need a tailored management. The current recommendations for diagnosing periprocedural myocardial infarction based on the fourth universal definition appear at first sight straightforward, but the clinical and prognostic significance of routine periprocedural cardiac troponin (cTn) assessment remains uncertain. The current scientific evidence suggests that the likelihood of observing increased periprocedural values of cTn is high, comprising between 30 and 90%. Moreover, cTn values after PCI do not straightforwardly predict major adverse cardiovascular events or all-cause mortality. Although it seems still premature to classify many cases as 'false positive' periprocedural MIs, it is now clear that an isolate 'biochemical diagnosis' of myocardial injury during or immediately after PCI does not translate into early unfavourable clinical consequences. At this point in time, it seems reasonable to suggest that serial cTn assessment should not be routinely performed, but should be reserved for a high-risk subset of PCI patients who have also developed new ECG changes or symptoms suggestive of myocardial ischemia.


Assuntos
Infarto do Miocárdio/diagnóstico , Intervenção Coronária Percutânea/efeitos adversos , Troponina/sangue , Biomarcadores/sangue , Medicina Baseada em Evidências , Humanos , Infarto do Miocárdio/sangue , Infarto do Miocárdio/etiologia , Valor Preditivo dos Testes , Reprodutibilidade dos Testes , Fatores de Risco , Resultado do Tratamento
12.
N Engl J Med ; 380(26): 2529-2540, 2019 06 27.
Artigo em Inglês | MEDLINE | ID: mdl-31242362

RESUMO

BACKGROUND: Data regarding high-sensitivity troponin concentrations in patients presenting to the emergency department with symptoms suggestive of myocardial infarction may be useful in determining the probability of myocardial infarction and subsequent 30-day outcomes. METHODS: In 15 international cohorts of patients presenting to the emergency department with symptoms suggestive of myocardial infarction, we determined the concentrations of high-sensitivity troponin I or high-sensitivity troponin T at presentation and after early or late serial sampling. The diagnostic and prognostic performance of multiple high-sensitivity troponin cutoff combinations was assessed with the use of a derivation-validation design. A risk-assessment tool that was based on these data was developed to estimate the risk of index myocardial infarction and of subsequent myocardial infarction or death at 30 days. RESULTS: Among 22,651 patients (9604 in the derivation data set and 13,047 in the validation data set), the prevalence of myocardial infarction was 15.3%. Lower high-sensitivity troponin concentrations at presentation and smaller absolute changes during serial sampling were associated with a lower likelihood of myocardial infarction and a lower short-term risk of cardiovascular events. For example, high-sensitivity troponin I concentrations of less than 6 ng per liter and an absolute change of less than 4 ng per liter after 45 to 120 minutes (early serial sampling) resulted in a negative predictive value of 99.5% for myocardial infarction, with an associated 30-day risk of subsequent myocardial infarction or death of 0.2%; a total of 56.5% of the patients would be classified as being at low risk. These findings were confirmed in an external validation data set. CONCLUSIONS: A risk-assessment tool, which we developed to integrate the high-sensitivity troponin I or troponin T concentration at emergency department presentation, its dynamic change during serial sampling, and the time between the obtaining of samples, was used to estimate the probability of myocardial infarction on emergency department presentation and 30-day outcomes. (Funded by the German Center for Cardiovascular Research [DZHK]; ClinicalTrials.gov numbers, NCT00470587, NCT02355457, NCT01852123, NCT01994577, and NCT03227159; and Australian New Zealand Clinical Trials Registry numbers, ACTRN12611001069943, ACTRN12610000766011, ACTRN12613000745741, and ACTRN12611000206921.).


Assuntos
Infarto do Miocárdio/sangue , Infarto do Miocárdio/diagnóstico , Medição de Risco/métodos , Troponina/sangue , Adulto , Idoso , Biomarcadores/sangue , Estudos de Coortes , Serviço Hospitalar de Emergência , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Prognóstico , Sensibilidade e Especificidade , Troponina I/sangue
13.
Scand Cardiovasc J ; 53(5): 280-285, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31216908

RESUMO

Objectives. The main aim of the Aiming toWards Evidence baSed inTerpretation of Cardiac biOmarkers in patients pResenting with chest pain (WESTCOR-study) (Clinical Trials number NCT02620202) is to improve diagnostic pathways for patients presenting to the Emergency department (ED) with acute chest pain. Design. The WESTCOR-study is a two center, cross-sectional and prospective observational study recruiting unselected patients presenting to the ED with suspected non-ST elevation acute coronary syndrome (NSTE-ACS). Patient inclusion started September 2015 and we plan to include 2250 patients, finishing in 2019. The final diagnosis will be adjudicated by two independent cardiologists based on all available information including serial high sensitivity cardiac troponin measurements, coronary angiography, coronary CT angiography and echocardiography. The study includes one derivation cohort (N = 985) that will be used to develop rule out/rule in algorithms for NSTEMI and NSTE-ACS (if possible) using novel troponin assays, and to validate established NSTEMI algorithms, with and without clinical scoring systems. The study further includes one subcohort (n = 500) where all patients are examined with coronary CT angiography independent of biomarker status, aiming to assess the associations between biomarkers and the extent and severity of coronary atherosclerosis. Finally, an external validation cohort (N = 750) will be included at Stavanger University Hospital. Prospective studies will be based on the merged cohorts. Conclusion. The WESTCOR study will provide new diagnostic algorithms for early inclusion and exclusion of NSTE-ACS and insights in the associations between cardiovascular biomarkers, CT-angiographic findings and short and long-term clinical outcomes.


Assuntos
Síndrome Coronariana Aguda/diagnóstico , Angina Instável/diagnóstico , Infarto do Miocárdio sem Supradesnível do Segmento ST/diagnóstico , Projetos de Pesquisa , Troponina/sangue , Síndrome Coronariana Aguda/sangue , Síndrome Coronariana Aguda/mortalidade , Algoritmos , Angina Instável/sangue , Angina Instável/mortalidade , Biomarcadores/sangue , Angiografia por Tomografia Computadorizada , Angiografia Coronária/métodos , Estudos Transversais , Humanos , Estudos Multicêntricos como Assunto , Infarto do Miocárdio sem Supradesnível do Segmento ST/sangue , Infarto do Miocárdio sem Supradesnível do Segmento ST/mortalidade , Noruega , Estudos Observacionais como Assunto , Valor Preditivo dos Testes , Prognóstico , Estudos Prospectivos , Reprodutibilidade dos Testes
14.
Internist (Berl) ; 60(6): 555-563, 2019 Jun.
Artigo em Alemão | MEDLINE | ID: mdl-31076794

RESUMO

Cardiac biomarkers are an integral component of the diagnostic work-up of patients with suspected acute coronary syndrome (ACS). Cardiac troponin (cTn) is the most sensitive diagnostic biomarker for patients with ACS and enables the differentiation of acute non-ST-elevation myocardial infarction (NSTEMI) from unstable angina. All cardiac and non-cardiac differential diagnoses must be taken into consideration. The use of cTn has a prognostic value in a multitude of acute and chronic diseases apart from ACS. Highly sensitive cTn (hsTn) assays should be preferentially used. Point-of-care (POC) troponin assays can be used for rule-in of acute MI but are generally not useful for rule-out of MI due to their lack of sensitivity compared to hsTn assays. This, however, may change with recent developments of newer and improved POC troponin assays. For exclusion of MI using hsTn assays, there are various protocols available, such as the instant rule-out with undetectable hsTn levels at admission or normal hsTn/cTn levels combined with normal copeptin levels or rule-out with serial controls of hsTn after 1, 2 or 3 h. This article provides an overview of guideline-recommended rule-out protocols for patients with suspected ACS and discusses recent advances in POC troponin assays.


Assuntos
Síndrome Coronariana Aguda/diagnóstico , Biomarcadores/sangue , Dor no Peito/etiologia , Infarto do Miocárdio/diagnóstico , Troponina/sangue , Síndrome Coronariana Aguda/sangue , Glicopeptídeos/sangue , Humanos , Infarto do Miocárdio/sangue , Testes Imediatos , Prognóstico
15.
Internist (Berl) ; 60(6): 564-570, 2019 Jun.
Artigo em Alemão | MEDLINE | ID: mdl-31062038

RESUMO

In emergency situations, patients present with symptoms rather than diagnoses. Due to its high prevalence, the acute coronary syndrome (ACS) dominates acute diagnostics as a consequence of its chief complaint chest pain. The challenge for the attending physicians is that only a minor part of patients with chest pain are finally diagnosed with an acute myocardial infarction (AMI) and that other rare but dangerous differential diagnoses have to be kept in mind and-vice versa-severely ill patients with AMI may present with symptoms other than chest pain. Against this background, the initial evaluation of patients requires a process-orientated view beyond the key roles of clinical assessment and biomarkers. The use of cardiac troponin is mandatory for the diagnosis of ACS, but challenging in broader utilization due to the reduced clinical specificity. Further relevant biomarkers are copeptin in combination with cardiac troponin or natriuetic peptides, which help to diagnose relevant cardiac dysfunction in (acute) heart failure. In addition, patients who present with the symptom of a suspected cardiac syncope need the differential diagnosis of an underlying arrhythmia, which may be due to an ACS or reduced left ventricular (LV) function and other causes like pulmonary embolism or structural heart disease (e. g. aortic valve stenosis). This highlights that biomarker-based diagnostics are often crucial to decide after the initial clinical evaluation whether early imaging is needed or early discharge is possible.


Assuntos
Síndrome Coronariana Aguda/diagnóstico , Biomarcadores/sangue , Dor no Peito/etiologia , Emergências , Glicopeptídeos/sangue , Peptídeos Natriuréticos/sangue , Troponina/sangue , Síndrome Coronariana Aguda/sangue , Dor no Peito/diagnóstico , Diagnóstico Diferencial , Serviço Hospitalar de Emergência , Insuficiência Cardíaca/sangue , Insuficiência Cardíaca/diagnóstico , Humanos , Embolia Pulmonar
17.
Ann Vasc Surg ; 60: 156-164, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31075460

RESUMO

BACKGROUND: Postopertive troponin elevation may occur without typical or atypical cardiac symptoms and is associated with an increased 30-day morbidity and mortality. The objective of the study was to implement a quality improvement initiative of postoperative troponin surveillance algorithm aimed at intensifying medical management after vascular surgery. METHODS: We conducted a single-center study of postoperative troponin surveillance after vascular surgery (n = 201) at a tertiary care, academic medical center from January to December 2016. Troponin surveillance was performed on postoperative days 1-3 after carotid endarterectomy, endovascular aortic repair, infrainguinal bypass, open abdominal aortic aneurysm repair, peripheral vascular intervention, and suprainguinal bypass, regardless of cardiac symptoms. Patients with troponin I elevation (>0.034 ng/mL) were managed with a treatment algorithm which included single or dual antiplatelet (AP) agent, high-intensity statin therapy, smoking cessation consultation, and outpatient cardiology consultation and stress testing. Patients with troponin elevation ≥1.0 ng/mL received inpatient cardiology consultation. We assessed adherence to the protocol for intensification of best medical therapy defined as high-dose statin therapy, increase in AP therapy, and smoking cessation consultation according to the established algorithm. RESULTS: Troponin elevation was recorded in 17% (34/201) of patients and was associated with cardiac symptoms in 8 patients (24%), while 26 (76%) patients had an asymptomatic abnormal troponin on postoperative surveillance. One patient was excluded due to death immediately after SUPRA, resulting in 200 patients. Troponin elevation ≥1.0 ng/mL occurred in 11 asymptomatic patients (5.5%). Any intensification of medical therapy was instituted in 76% of patients with elevated troponin and included high-intensity statin therapy (58%), increase in AP therapy (18%), and smoking cessation consultation (66%). Once an elevated troponin level was recognized, 52% of our patients received cardiology consultation with an increased likelihood (100%) in patients with troponin ≥1 ng/mL (P < 0.001). Adherence to outpatient stress testing was 66%. Intensification of medical therapy was not significantly different between patients with abnormal troponin values, >0.034-1.0 (n = 23) versus ≥1.0 ng/mL (n = 10); statin therapy (P = 1.0), AP (P = 0.34), and smoking cessation (P = 1.0). One-year mortality was higher in patients with postoperative troponin elevation than those with normal postoperative troponin levels (12% vs. 2.4%; P = 0.03). CONCLUSIONS: Routine postoperative troponin surveillance results in intensification of statin therapy in patients with asymptomatic troponin elevation. Further study is needed to determine if this approach reduces long-term cardiovascular morbidity and mortality.


Assuntos
Cardiopatias/diagnóstico , Melhoria de Qualidade , Indicadores de Qualidade em Assistência à Saúde , Troponina/sangue , Procedimentos Cirúrgicos Vasculares/efeitos adversos , Idoso , Idoso de 80 Anos ou mais , Biomarcadores/sangue , Feminino , Cardiopatias/sangue , Cardiopatias/etiologia , Cardiopatias/terapia , Humanos , Inibidores de Hidroximetilglutaril-CoA Redutases/uso terapêutico , Masculino , Pessoa de Meia-Idade , Inibidores da Agregação de Plaquetas/uso terapêutico , Valor Preditivo dos Testes , Estudos Prospectivos , Fatores de Risco , Abandono do Hábito de Fumar , Fatores de Tempo , Resultado do Tratamento , Regulação para Cima
18.
Rev Med Chil ; 147(2): 145-152, 2019 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-31095161

RESUMO

BACKGROUND: Mean platelet volume (MPV) is a risk factor for cardiovascular and inflammatory diseases. AIM: To evaluate the association between high MPV and 90-day mortality after an episode of venous thromboembolism (VTE). MATERIAL AND METHODS: Retrospective cohort of 594 patients with a median age of 73 years (58% women) with a first episode VTE, included in an institutional Thromboembolic Disease registry between 2014 and 2015. MPV values were obtained from the automated blood cell count measured at the moment of VTE diagnosis. Volumes ≥ 11 fL were classified as high. All patients were followed for 90 days to assess survival. RESULTS: The main comorbidities were cancer in 221 patients (37%), sepsis in 172 (29%) and coronary artery disease in 107 (18%). Median MPV was 8 fl (8-9), brain natriuretic peptide 2,000 pg/ml (1,025-3,900) and troponin 40 pg/ml (19.5-75). Overall mortality was 20% (121/594) during the 90 days of follow-up. Thirty three deaths occurred within 7 days and 43 within the first month. The loss of patients from follow-up was 5% (28/594) at 90 days. Mortality among patients with high MP was 36% (23/63). The crude mortality hazard ratio (HR) for high MPV was 2.2 (95% confidence intervals (CI) 1.4-3.5). When adjusted for sepsis, oncological disease, heart disease, kidney failure and surgery, the mortality HR of high MPV was 2.4 (CI95% 1.5-3.9) in the VTE group, 2.3 (CI95% 1.5-4.4) in the deep venous thrombosis group, and 2.9 (CI95% 1.6 -5.6) in the pulmonary embolism group. CONCLUSIONS: High MPV is an independent risk factor for mortality following an episode of VTE.


Assuntos
Volume Plaquetário Médio , Tromboembolia Venosa/mortalidade , Doença Aguda , Idoso , Idoso de 80 Anos ou mais , Plaquetas , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Peptídeo Natriurético Encefálico/sangue , Neoplasias/complicações , Fragmentos de Peptídeos/sangue , Prognóstico , Embolia Pulmonar/sangue , Embolia Pulmonar/mortalidade , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Sepse/complicações , Análise de Sobrevida , Troponina/sangue , Tromboembolia Venosa/sangue , Tromboembolia Venosa/complicações , Trombose Venosa/sangue , Trombose Venosa/mortalidade
19.
Rev Med Suisse ; 15(652): 1087-1090, 2019 May 22.
Artigo em Francês | MEDLINE | ID: mdl-31116524

RESUMO

The interpretation of troponin elevation whitout a typical myocardial infarction symptomatology is a daily challenge in the acute care setting. Using current investigative techniques, doctors navigate between the five types of myocardial infarction established by the Fourth Universal Definition. However, due to the development of ultrasensitive troponin assays, the myocardial injury without ischemia, acute or chronic, is became a more common entity. The purpose of this article is to describe the situations without typical symptoms of myocardial ischemia and their mechanisms to better differentiate them.


Assuntos
Infarto do Miocárdio , Isquemia Miocárdica , Troponina , Biomarcadores , Eletrocardiografia , Humanos , Infarto do Miocárdio/sangue , Infarto do Miocárdio/diagnóstico , Isquemia Miocárdica/sangue , Isquemia Miocárdica/diagnóstico , Troponina/sangue
20.
N Z Med J ; 132(1493): 25-37, 2019 04 12.
Artigo em Inglês | MEDLINE | ID: mdl-30973857

RESUMO

AIMS: Accelerated diagnostic chest pain pathways (ADP) have become standard of care in urban emergency departments. It is, however, unknown how widely they are used in New Zealand's rural hospitals because ADP require immediate access to contemporary or high-sensitivity troponin (hs-Tn). We aimed to determine for rural hospitals the troponin assay being used, if they were using an ADP and if they had access to on-site exercise tolerance testing (ETT). METHODS: An online survey was sent to 27 rural hospitals providing acute care in New Zealand. RESULTS: Most rural hospitals (23/27, 85%) responded to the survey. Most (17/23, 74%) used point-of-care cardiac troponin (POC-cTn) and the majority of these hospitals (15/17, 88%) were reliant on this assay 24-hours per day. All hospitals that had timely access to hs-Tn (8/23, 35%) used an ADP but only a minority (4/17, 24%) of hospitals using POC-cTn used an ADP. Only a minority of the larger rural hospitals (7/23, 30%) had access to on-site ETT. CONCLUSIONS: Most New Zealand rural hospitals rely on POC-cTn to assess chest pain and are not using an ADP. There are limited data available to support this approach in rural settings especially with patients who are not low-risk.


Assuntos
Síndrome Coronariana Aguda/sangue , Infarto do Miocárdio/sangue , Sistemas Automatizados de Assistência Junto ao Leito/organização & administração , Troponina/sangue , Síndrome Coronariana Aguda/diagnóstico , Dor no Peito/etiologia , Feminino , Hospitais Rurais/organização & administração , Humanos , Masculino , Infarto do Miocárdio/diagnóstico , Nova Zelândia , Saúde da População Rural/normas
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