cardiac bio markers are important diagnostic and prognostic tool in acute coronary syndrome. several new emerging bio markers are coming with more sensitivity and specificity.
cardiac bio markers are important diagnostic and prognostic tool in acute coronary syndrome. several new emerging bio markers are coming with more sensitivity and specificity.
Cardiac biomarkers have evolved over last 20 years. From enzymes like CPK,SGOT,LDH, the focus shifted to CPKMB mass & currently to high sensitive Troponins. Similarly the definition of AMI also evolved and included these markers in guidelines. Natriuretic peptides (BNP & Nt-proBNP) are good markers for heart failure. however, ACS in renal failure continues to have diagnostic challenges.
Cardiac troponin elevation in patients without a specific diagnosisNAJEEB ULLAH SOFI
Cardiac troponin (cTn) elevation is a common finding in acutely admitted patients, even in the absence of acute coronary syndrome. In some of these patients, no etiology of cTn elevation can be identified. The term troponinemia is sometimes used to describe this scenario.
The proportion of patients discharged from the emergency department without a specified diagnosis but with cTn levels above the 99th percentile has been reported as 31%.
Acute but subtle increases in cTn levels may also be difficult to distinguish from chronic cTn elevation which is a common finding in the elderly, patients with renal failure, or patients with chronic cardiac conditions
This often causes frustration among clinicians, and the term troponinemia has been coined to label this scenario.
Cardiac biomarkers have evolved over last 20 years. From enzymes like CPK,SGOT,LDH, the focus shifted to CPKMB mass & currently to high sensitive Troponins. Similarly the definition of AMI also evolved and included these markers in guidelines. Natriuretic peptides (BNP & Nt-proBNP) are good markers for heart failure. however, ACS in renal failure continues to have diagnostic challenges.
Cardiac troponin elevation in patients without a specific diagnosisNAJEEB ULLAH SOFI
Cardiac troponin (cTn) elevation is a common finding in acutely admitted patients, even in the absence of acute coronary syndrome. In some of these patients, no etiology of cTn elevation can be identified. The term troponinemia is sometimes used to describe this scenario.
The proportion of patients discharged from the emergency department without a specified diagnosis but with cTn levels above the 99th percentile has been reported as 31%.
Acute but subtle increases in cTn levels may also be difficult to distinguish from chronic cTn elevation which is a common finding in the elderly, patients with renal failure, or patients with chronic cardiac conditions
This often causes frustration among clinicians, and the term troponinemia has been coined to label this scenario.
Cardiac Troponin Elevation in Patients Without a Specific DiagnosisShadab Ahmad
Measurement of cardiac troponin (cTn) levels is a cornerstone in the assessment of patients with acute chest pain.
An elevation in the cTn level together with a significant change in the setting of coronary ischemia indicates myocardial infarction (MI).
However, even other cardiac and noncardiac conditions may result in acute cTn increases (e.g., arrhythmias, severe hyper- or hypotension, pulmonary embolism, neurologic events, or endurance efforts).
Acute but subtle increases in cTn levels may also be difficult to distinguish from chronic cTn elevation which is a common finding in the elderly, patients with renal failure, or patients with chronic cardiac conditions.
Bio-Markers of Heart Failure (Dr.LIKHIT T)Likhit T
A brief on bio-markers of Heart failure...First of all, I thank the Authors of all the books from which I picked the points to make this presentation.. This presentation includes classification of bio-markers and explanation according their importance.. Thank you
differentiating between supraventicular tachycardia and ventricular tachycardia in wide complex rhythm is always confusing and management is totally different. correct diagnosis will make dramatic difference in patient management.
Brugada Syndrome is a inherited sodium channel disorder leading to life threatening ventricular fibrillation in young population. diagnosis and ICD therapy could be life saving.
kawasaki disease is disease of pediatric age group leading to involvement of coronaries in 25% of case. some of presented as fetal complication. early diagnosis and treatment useful measure to prevent complications.
takayasu arteritis is inflammatory disorder of medium sized arteries of unknown etiology, prevent in young female. lead to life threatening complication and long lasting morbidity. early diagnosis and treatment prevent complication and improve quality of life
Trans catheter intervention is emerging field in cardiac intervention. due to complex anatomy of mitral valve understanding of anatomy and three dimensional imaging is most important aspect of successful intervention and could be life saving in high risk surgical candidate
RHD is prevalent in India, many patients requires valve replacement. understanding of prosthetic valve anatomy, morphology and early detection of valve related complication is very important for saving life. TTE and TEE are important tool for identifying these complications.
there are several limitation in VKA,to over come these problem NOACs came in picture but still limited indication for NOACs currently,required further study inter and intra comparison between anticoagulants.
rotablation is procedure used in complex pci with heavily calcified lesion for adequate expansion of stent.if used in indicated case and well aware of contraindication is necessary for achieving good results.
ebstein anomaly is rare congenital disorder,with variable presentation in neonate to adults,early diagnosis and timely take decision make remarkable difference in patients life.
diabetes is most prevalent disease in asia, incidence of heart failure is also increasing in diabetic population, understanding the pathophysiology is very important to deal with these cases.
preop TEE assessment of atrial septal defect is very important for making decision for device closure, properly assessed adequate rims of ASD will reduce risk of device embolization to almost nil.
atherosclerosis is one of most common cause of aortic ds,screening of abdominal aorta in vulnerable population is very useful for prevention and early detection of future omplication.
ARVD is one of important coardiomyopathy in our clinical practice,early diagnosis, risk stratification and early diagnosis of CHF, management of VT will make big difference in patient life
Anti ulcer drugs and their Advance pharmacology ||
Anti-ulcer drugs are medications used to prevent and treat ulcers in the stomach and upper part of the small intestine (duodenal ulcers). These ulcers are often caused by an imbalance between stomach acid and the mucosal lining, which protects the stomach lining.
||Scope: Overview of various classes of anti-ulcer drugs, their mechanisms of action, indications, side effects, and clinical considerations.
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
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micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
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ARTIFICIAL INTELLIGENCE IN HEALTHCARE.pdfAnujkumaranit
Artificial intelligence (AI) refers to the simulation of human intelligence processes by machines, especially computer systems. It encompasses tasks such as learning, reasoning, problem-solving, perception, and language understanding. AI technologies are revolutionizing various fields, from healthcare to finance, by enabling machines to perform tasks that typically require human intelligence.
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
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2. INTRODUCTION
• A rapid and accurate diagnosis is critical in patients with presumed ACS
• Clinical assessment, 12-lead ECG and cardiac troponin (cTn) I or T form the
diagnostic cornerstones
• Early rule-in of AMI
• An early rule-out of AMI
7. ROLE OF CARDIAC BIOMARKERS IN PATIENTS WITH NON DIAGNOSTIC ECGS
• A diagnosis of AMI is based on the detection of a rise and/or fall of cTn along with the
presence of characteristic symptoms, and/or ECG or imaging evidence of acute
myocardial ischemia.
• The cut-off value of cTn to diagnose MI is defined as a concentration exceeding the
99th percentile of a normal reference population (i.e. upper reference limit [URL])
using an assay with an imprecision (coefficient of variation, CV) ≤10% at the URL
8. NEED FOR HIGH-SENSITIVITY CARDIAC TROPONIN
The contemporary cTn assays cannot measure cTn levels at low concentrations
corresponding to the 99th percentile value of a normal reference population.
Thus, they lack the precision criteria to diagnose AMI
The high-sensitivity cardiac troponin (hs-cTn) assays were developed to meet
the requirements of analytical precision and overcome the short- comings
associated with contemporary cTn assays.
9. HIGH-SENSITIVITY CARDIAC TROPONIN
5th generation hs-cTn T and I assays which can detect troponin at
concentrations 10- to 100-fold lower than conventional assays
Hs-cTn assays detect troponin with higher sensitivity and precision at
an earlier point of time
12. Characteristics of Hs Troponin
• Reported as nanograms per litre
• Cardiac troponin values below the lower limit of detection should not be
reported as numbers.
• High-sensitivity cardiac troponin assays have high precision at lower
concentration ranges
• High-sensitivity cardiac troponin assays enable detection of cTn in a significant
proportion of the reference population.
17. ACUTE VERSUS CHRONIC ELEVATION OF TROPONIN RISE
• To maintain a high specificity, it is important to distinguish acute from chronic hs-
cTn elevation
• Acute cardiomyocyte injury causes a steep release of troponins, such as in AMI,
shock, myocarditis, pulmonary embolus, Tako-tsubo (stress-induced)
cardiomyopathy
• Chronic, stable elevations of hs- cTn at or above the 99th percentile without a
significant rise or fall are common in patients with structural heart disease
18. HIGH-SENSITIVITY CARDIAC TROPONIN KINETICS WITH SERIAL TESTING
• To differentiate acute from chronic troponin elevation and to maintain a high
specificity,
• Various rule-in and rule-out algorithms have been proposed using different
time points and cutoff values, including the question whether absolute or
relative hs-cTn changes
• Optimal cutoffs for (absolute and relative) changes and the earliest time
points of the second hs-cTn measurement will have to be determined for each
assay and clinical background
21. Non AMI conditions
• Acute heart failure: Using a high-sensitivity assay, troponin was detectable in nearly all patients with
acute decompensation in the large RELAX-HF study.
• Pulmonary embolism: In patients with confirmed pulmonary embolism, elevated troponin
concentrations were reported in up to 50% of patients
• Sepsis: Elevated levels of hs-TnT were associated with adverse outcome, and changes (either
increase or decrease) in hs-TnT levels during the hospital stay were predictive of in-hospital mortality
• Stroke: In patients with stroke, elevated troponin concentrations have been reported and were
associated with mortality
22.
23. • Stable coronary artery disease In BARI 2D study patients with
diabetes mellitus and stable coronary artery disease,elevated hs-TnT
level above the 99th percentile was reported in 39% of patients,
which was associated with increased rates of cardiovascular events
and death
• Chronic kidney disease. In the CRIC study, hs-TnT was detectable in
81% of patients with impaired renal function, but without previous
cardiovascular disease.
• Concentrations of hs-TnT were associated with incident heart failure
24. High-sensitivity cardiac troponin elevation in CKD
• Maintain high diagnostic accuracy in patients with renal dysfunction
when assay- specific higher optimal cutoff levels are used
• The high prevalence of persistently elevated more sensitive cTn levels
in patients with chronic kidney disease (CKD) cannot primarily be
explained by reduced renal clearance alone
25. • Chronic heart failure: Patients with chronic heart failure from the Val-
HeFT and the GISSI-HF studies, hs-TnT was measured at baseline and
after 3 or 4 months.
• Baseline hs-TnT level was a strong predictor of all-cause mortality, but
serial measurement had only a minor influence on risk discrimination.
26. CONCLUSIONS
• The introduction of the hs-cTnT assay with lower cut-off levels for diagnosing AMI
in patients with acute chest pain is associated with enhanced overall diagnostic
accuracy
• A negative hs-cTnT test has a high negative predictive value, and may thus serve
as an exclusionary test early in the diagnostic process.
• Risk stratification for ACS
• The levels of hs-TnT can serve as a risk stratification in patients with stable CAD,
HF, and non-cardiac disease conditions
syndrome for the initiation of effective evidence-based medical management and revascularization
prevents the mistaken discharge of patients with AMI with normal findings on initial ECG and also helps in early initiation of effective evidence- based therapy.
prevents inadver- tent admission of patients without ACS and facilitates early discharge of patients and thereby decreases the unwarranted healthcare burden.10
.
Patients with ST-segment elevation AMI can easily be diagnosed using an electrocardiogram (ECG) on admission, whereas the differential diagnosis of non-ST- segment elevation AMI (NSTEMI) and unstable angina pectoris is on the basis of cardiac troponin testing with serial sampling7
Timeline of the development of cardiac biomarkers for the diagnosis of acute myocardial infarction
troponin T attaches the troponin complex to the actin filament; troponin C acts as the calcium binding site; troponin I inhibits interaction with myosin heads in the absence of sufficient calcium ions.
Troponin T and I isoforms are highly specific and sensitive to cardiac myocytes and, therefore, are known as cardiac troponins (cTn).
92–95% of troponin is attached to the actin thin filaments in the cardiac sarcomere, and the remaining 5–8% is free in the myocyte cytoplasm
However, in patients with chronic renal failure, cTnI has greater specificity for myocar- dial injury than cTnT.
Current guidelines recommend serial measurements of troponin with a cut-off concentration at the 99th percentile to triage patients in the emergency department. Newer, high-sensitivity assays for troponin enable the detection of distinctly lower concentrations. Using these assays and very low cut-off concentrations, several rapid diagnostic strategies have been reported to improve diagnosis in acute cardiac care
5th generation hs-cTn T and I assays which can detect troponin at concentrations 10- to 100-fold lower than con- ventional assays
hs-cTn assays detect troponin with higher sensi- tivity and precision at an earlier point of time [22], and allow detection and quantification in 50% to ideally 95% of healthy individuals
In 2009, the first high-sensitivity assay for TnT (hs-TnT) was introduced (fifth-generation assays). The limit of detection was 2 ng/l and the 99th percentile was 14 ng/l2
The hs-TnT assay is a modification of the fourth- generation assay. It uses a mouse–human chimeric detection antibody, with an increased sample size, and decreased background noise owing to buffer opti- mization22
To label an assay as ‘high-sensitivity’, it should report troponin concentrations in a large proportion of the general population.
A proportion of 50% has been dis- cussed, whereas an even higher proportion of up to 80% might be reasonable2
with analytical CV -10% at the 99th percentile concentration of the reference population (URL).
thereby allowing for a more accurate calculation of the 99th percentile URL with its 99% confidence interval.
The lower the level of hs-cTn, the higher the negative predictive value (NPV) for the presence of AMI. The higher the level of hs-cTn, the higher the positive predictive value (PPV) for the presence of AMI. Levels just above the 99th percentile have a low PPV for AM
Cohorts of patients, including those with suspected AMI, were used to investigate the diagnostic performance of various troponin assays and shorter time intervals (TABLE 2). These cohorts were heterogeneous in terms of prevalence of AMI (8–22%) and cardiovascular risk factors (for example, 9–25% had a history of AMI).
The ADAPT study45 was the first cohort, and serial troponin measurement after only 2 h was investigated. The researchers used a hs-Tn cut-off level at the 99th percentile in combination with a nonischaemic ECG and a low risk score, based on history and symptoms. This approach resulted in a high NPV of 99.7% for the primary outcome (major adverse cardiac events (MACE) after 30 days;
n the TRAPID-AMI study48, a hs-TnT assay with two different strategies was used To rule out AMI, a baseline cut-off concentration of 12 ng/l, which is close to the 99th percentile, and an absolute change of only 3 ng/l were used, which resulted in a high NPV of 99.1%. The rule-in of AMI was based on a high cut-off value of 52 ng/l, or a change of >5 ng/l, and had a high positive predictive value (PPV) of 77%.
In the High-STEACS study53, this approach was prospectively tested using a hs-TnI assay. A hs-TnI cut-off value of 5 ng/l resulted in the ruling out of AMI in 61% of the study population, and a NPV of 99.6%.
The first US testing of the use of a baseline hs-TnI measurement to rule out AMI involved the UTROPIA cohort; a cut-off value of 1.9 ng/l (the limit of detection) was associated with a NPV of 99.6%56.
In these cases, increased ventricular wall tension is thought to cause direct myofibrillar filament damage and an increase in programmed cell death, both of which contribute to hs-cTn release
This has been observed in patients with left ventricular hypertrophy, valvular heart disease, stable congestive heart failure, pulmonary hypertension, stable angina or other forms of clinically stable cardiomyopathy.
clinical evaluation (pre-test probability) and serial testing of hs-cTn are warranted.
It is generally recommended to use the 3-h algorithm.
In cases of high pre-test probability for NSTEMI and if chest pain onset [3 h, a 1-h algorithm has now been proposed with assay-specific hs-cTn cutoff levels
Additional blood sampling after 3 h in patients with strong clinical suspicion of AMI but no significant rise or fall of hs-cTn may nevertheless still be warranted:
In a large study using an insensitive assay for troponin, 6% of patients with acute decompensated heart failure had elevated concentrations of troponin . Furthermore, troponin detection was associated with adverse outcomes in this popula- tion, and improved risk prediction when added to the established biomarker B-type natriuretic peptide. s well as increased wall stress, oxidative stress, inflammatory processes, and several other causes more related to the heart failure pathophysiology itself.
Pulmonary embolism is one of the most important differential diagnoses in patients presenting with suspected AMI, and is often associated with chest pain or dyspnoea.
An elevated level of TnT or TnI was an independent predictor of heart failure and death.
In patients with chronic kidney disease, troponin con- centrations are often elevated, which is mostly explained by an increased prevalence of cardiovascular disease, but also by reduced renal elimination of troponin from the blood . In patients receiv- ing haemodialysis, hs-TnT level was a powerful predictor of all-cause mortality, whereas all patients with a hs-TnT level <24 ng/l survived follow-up (median 46 months)1
The etiology of persistent troponin elevation in CKD remains incompletely explained and controversial. The underlying process appears to be multifactorial related to both increased subclinical cardiac damage (uremic toxicity, ischemic heart disease, heart failure or hypertensive heart disease) and decreased renal clear- ance in this population
In patients with stable heart fail- ure, troponin concentrations increased with worsening NYHA class and were associated with a worse outcome in these patients1
The gain in sensitivity may be particularly important in patients with a short dura- tion from symptom onset to admission.
even at levels below the LoD of the previous generation of assays.