Utilization of Cardiac Serum Marker Measurements to Identify and Exclude Acute Myocardial Infarction Francis M. Fesmire, MD, FACEP Assistant Professor,

Slides:



Advertisements
Similar presentations
Patient Oriented Therapy Non STE ACS
Advertisements

Prognostic significance of atrial fibrillation/flutter following acute myocardial infarction in patients with diabetes mellitus M.Gashi,E.Pllana,D.Kocinaj,S.Rexhepi.
ASSENCE Assessment of cost-effectiveness of Several Strategies of Early diagnosis in patients with acute chest pain and Non Conclusive Electrocardiogram.
AST in AMI CK in AMI electrophoresis for CK and LD isoenzymes INH for CK-MB RIA for myoglobin WHO criteria for AMI CK-MB mass.
NAPLES II Novel Approaches for Preventing or Limiting Event Study Impact of a Single High Loading Dose of Atorvastatin on Periprocedural Myocardial Infarction.
TRIAGE OF THE ED PATIENT COMPLAINING OF CHEST PAIN David Plaut Snow, 2004.
© 2010, American Heart Association. All rights Association of Hospital Primary Angioplasty Volume in ST-Segment Elevation Myocardial Infarction With Quality.
Biochemical Markers for Diagnosis of Myocardial Infarction.
Likelihood ratios Why these are the most thrilling statistics in Emergency Medicine.
Lecture 3 Validity of screening and diagnostic tests
Acute Coronary Syndromes Jason Ryan, M.D.. Acute Coronary Syndromes Unstable Angina + Non-ST-Elevation MI + ST-Elevation MI Acute Coronary Syndromes (ACS)
1 Lecture | Dr. Usman Ghani
1. What is the acute coronary syndrome? How big a health problem is the acute coronary syndrome? 1.
Early assessment of myocardial injury by joint measurement of TnT-hs and Copeptin (1) J. Teixeira, (2) P. Wotquenne, (2) V. D’Orio, (3) D. Gruson, (1)
Listening to the Data: Why There’s Room for Improvement in MI Care Heartscape® Consultants Meeting Charles V. Pollack, Jr, MA, MD, FACEP, FAAEM, FAHA Chairman,
Tobias Reichlin, W. Hochholzer, C. Stelzig, K. Laule, M. Potocki, K
Journal Club Mohammed AlShamsi R4
Copeptin and high sensitive Troponins Discussion of NEJM publications on sensitive Troponins BRAHMS GmbH, August 2010.
High Sensitivity Troponin
Overly concerning and falsely reassuring?? FRAMINGHAM RISK FACTORS IN THE ED.
OnSite Troponin I Rapid Test. Cardiac markers are biomarkers measured to evaluate heart function.biomarkers They are often discussed in the context of.
Myocardial infarction biomarkers Lecture 5. Cases 1 Middle aged man referred by family doctor to a dermatologist because of extensive yellow papules with.
Statistics in Screening/Diagnosis
Biochemical Markers of Myocardial Infarction
Myocardial Ischemia Redefined: Optimal Care in CAD.
Cardiac memory distinguishes between new and old left bundle branch block Alexei Shvilkin, MD, PhD.
Sex-Specific Chest Pain Characteristics in AMI Jay Mansfield, Pgy-3 July 22, 2014 LSU Journal Club Gimenez, M, et. Al. Jama Int Med. 2014;174(2):
Please press F5 on your keyboard to enter presentation mode Welcome to the Eastern Health Pathology guide to hsTnT. The information in this presentation.
Evidence-Based Medicine Diagnosis Component 2 / Unit 5 1 Health IT Workforce Curriculum Version 1.0 /Fall 2010.
Biochemical Markers for Diagnosis of Myocardial Infarction Cardiovascular Block Medical Biochemistry Course Dr. Reem M. Sallam, MD, PhD.
ACUTE CORONARY SYNDROMES Part I. Definition Acute coronary syndrome (ACS) describes a spectrum of clinical conditions ranging from ST segment elevation.
Absolute and Relative Kinetic Changes of High-Sensitivity Cardiac Troponin T in Acute Coronary Syndrome and in Patients with Increased Troponin in the.
Introduction Left bundle branch block (LBBB) is notorious for obscuring the ECG diagnosis of acute myocardial infarction (AMI) and, therefore, the decision.
Biochemical Investigations In Heart Disaeses
Ischaemic Heart Disease CASE A. CASE A: Mr HA, aged 60 years, was brought in to A&E complaining of chest pain, nausea and a suspected AMI.
Journal Club Optimizing Early Rule-Out Strategies for Acute Myocardial Infarction: Utility of 1-Hour Copeptin P. Hillinger, R. Twerenbold, C. Jaeger, K.
Implementation of a Sensitive Troponin I Assay and Risk of Recurrent Myocardial Infarction and Death in Patients With Suspected Acute Coronary Syndrome.
Biochemical Markers of Myocardial Infarction
Spectrum of Acute Coronary Syndromes: Laboratory Findings in Q-Wave AMI Creatine kinase evidence of necrosis NonePositive ECG early ST-segment depression.
The percentage of values for cardiac troponin (cTn)T associated with elevated values for a point-of-care assay with less sensitivity and precision: the.
Biochemical Markers for Diagnosis of Myocardial Infarction
Cost Conscious Project: How Many Troponins Does It Take? Rola Khedraki.
RESEARCH POSTER PRESENTATION DESIGN © Cardiac Troponin Assay Cardiac troponin I is the diagnostic marker used for myocardial.
Which troponin assay to choose? Clinical performances of troponin T and troponin I assays Per Venge, MD PhD Professor Department of Medical Sciences Uppsala.
Troponin By Julie Moore C Dt204/2.
Date of download: 6/22/2016 Copyright © The American College of Cardiology. All rights reserved. From: Pregnancy-associated plasma protein-A levels in.
Date of download: 7/5/2016 Copyright © 2016 American Medical Association. All rights reserved. From: One-Hour Rule-out and Rule-in of Acute Myocardial.
Date of download: 11/12/2016 Copyright © The American College of Cardiology. All rights reserved. From: N-terminal pro brain natriuretic peptide on admission.
Risk Stratification of Chest Pain: Best Practices
Biochemical Investigations In Heart Disaeses
Cardiac enzymes. 2 – Non enzyme proteins The Troponins
The European Society of Cardiology Presented by Dr. Bo Lagerqvist
Tobias Reichlin, M. D. , Willibald Hochholzer, M. D
Biochemical Markers of Myocardial Infarction
Cardiac Troponin.
Diagnostic Algorithms for ACS and High-Sensitivity Troponin
Identifying Patients Suitable for Discharge After a Single-Presentation High-Sensitivity Troponin Result: A Comparison of Five Established Risk Scores.
Cardiac enzymes and cardiac proteins
Section A: Introduction
European Heart Association Journal 2007 April
Part I: A Sensible Approach to Sensitive Troponin
Nat. Rev. Cardiol. doi: /nrcardio
Advancing Acute Coronary Syndrome Assessment:
Cardiac enzymes. 2 – Non enzyme proteins The Troponins
Clinical Policy: Critical Issues in the Evaluation and Management of Adult Patients with Non–ST-Segment Elevation Acute Coronary Syndromes  Francis M.
Undetectable High Sensitivity Cardiac Troponin T Level in the Emergency Department and Risk of Myocardial Infarction Nadia Bandstein, MD; Rickard Ljung,
Undetectable High Sensitivity Cardiac Troponin T Level in the Emergency Department and Risk of Myocardial Infarction Nadia Bandstein, MD; Rickard Ljung,
Update on better disease diagnosis
Biochemical Markers of Myocardial Infarction
Performance of the Manchester Acute Coronary Syndromes decision rule with high-sensitivity cardiac troponin T (hs-cTnT) as the reference standard for the.
Presentation transcript:

Utilization of Cardiac Serum Marker Measurements to Identify and Exclude Acute Myocardial Infarction Francis M. Fesmire, MD, FACEP Assistant Professor, UT College of Medicine Director, Heart-Stroke Center Erlanger Medical Center, Chattanooga, Tn

Do You Want A Piece of Me?

Ready, Aim…..

Fire!!!!

Overview Which is the best marker of AMI? – CK-MB activity – CK-MB mass – CK-MB subform ratio – Myoglobin – cTnT – cTnI – Newer assays?????

2000 Clinical Policy of the American College of Emergency Physicians reviewed 50 articles comparing serum markers: – CK-MB activity: 7 cutoff values (5-23 IU/L) – CK-MB mass: 14 (4-20 ng/ml) – CK-MB subform ratio: 2 (1.5 & 2.3) – Myoglogin: 9 ( ng/ml) – cTnT: 5 ( ng/ml) – cTnI: 5 ( ng/ml)

Bias Multitude of Experimental Bias – Positive value of assay also defines AMI – Use the ROC curve optimum value of newer assay to compare against “gold standard” for older assay – Differing patient populations ICU vs general ED Early symptom onset versus late symptom onset

Valid Comparison? Conditions for a valid study: – The diagnosis of AMI needs to be independent of positive value of marker under investigation – Statistical Analysis of ROC curve area – Sensitivity and specificity comparison should be performed at a point on the individual ROC curves where likelihood ratio’s are equivalent and clinically meaningful

Likelihood Ratios Bayes’ Theorem – Pretest odds of the disease X likelihood ratio = Posttest odds of the disease – Positive LR = sensitivity/(1-specificity) – Negative LR = (1-sensitivity)/specificity In general, a +LR > 10 or < 0.1 should influence clinical decision making The ideal marker of AMI should both identify and exclude AMI

Definition Reliably Identifies: – sensitivity > 90% with +LR > 10 Reliably Excludes: – specificity > 90% with -LR < 0.1 ACEP Clinical Policy: Suspected AMI or Unstable Angina; Annals of Emergency Medicine 2000; Ann Emerg Med 2000;35:

Diagnostic Marker Cooperative Study Prospective double-blind study comparing CK-MB activity, CK-MB mass, CK-MB subforms, myoglobin, cTnT, and cTnI 955 patients, 119 with AMI Conclude that CK-MB subforms and myoglobin are the most sensitive for early diagnosis of AMI Zimmerman et al: Circulation; 1999;99:

AMI Definition “The diagnostic standard for myocardial infarction was a CK-MB mass > 7 ng/ml and CK-MB index > 2.5% in greater than 2 samples or in one sample if only one sample was available for analysis” – CK-MB mass > 7 ng/ml both defines AMI and a positive value of CK-MB – No WHO criteria for AMI utilized

ROC Curve Area Data 6 Hours: CK-MB subform (0.95) = cTnT (0.95) > CK-MB activity (0.94) > myoglobin (0.92) > cTnI (0.89) 14 Hours: CK-MB activity (0.99) > cTnI (0.97) > CK-MB subform (0.94) > cTnT (0.91) > myoglobin (0.84) – Area of CK-MB mass not given??? – No statistical analysis of ROC curves – No comparison at equal likelihood ratio’s

6 Hour Data

14 Hour Data

*Reliably identifies and reliably excludes

Ideal Marker ?? The ideal marker should reliably identify (sensitivity >90%; +LR > 10) and reliably exclude (specificity > 90% and -LR < 0.1): – No marker fulfills this criteria at 2, 4, 6 hours – CK-MB activity: 10, 14, 18 hours – CK-MB mass: 10, 14, 18, 22 hours – cTnI:10, 18 hours – CK-MB subform, myoglobin, cTnT: never

ACEP Evidence-Based Standards “No single determination of one serum biochemical marker of myocardial necrosis reliably identifies or reliably excludes AMI less than 6 hours of symptom onset.” “No serum biochemical marker identifies or excludes unstable angina at any time after symptom onset.” ACEP Clinical Policy: Suspected AMI or Unstable Angina; Annals of Emergency Medicine 2000; 35:

ACEP Guidelines “In patients presenting with acute chest pain and a negative baseline serum marker level, consider repeat testing at the following time intervals from symptom onset prior to making an exclusionary diagnosis of AMI:” ACEP Clinical Policy: Suspected AMI or Unstable Angina; Annals of Emergency Medicine 2000; In Press

ACEP Guidelines

“The exact timing of the repeat serum marker should take into account the sensitivity, precision, and institutional norms of the assay being utilized, as well as the release kinetics of the marker being measured.” “cTnT and cTnI are the preferred serum markers in patients presenting greater than 24 hours after symptom onset.” “Myoglobin does not reliably identify or exclude AMI at any time after symptom onset.”

Footnote “If time of symptom onset is unknown, unreliable, or more consistent with preinfarctional angina, then time of symptom onset should be referenced to the time of ED presentation.” ACEP Clinical Policy: Suspected AMI or Unstable Angina; Annals of Emergency Medicine 2000; 35:

WHO Diagnostic Criteria for AMI WHO Criteria: Two of three characteristics: – Typical symptoms – Typical rise and fall in cardiac markers – New Q waves on ECG

ESC/ACC Diagnostic Criteria Typical rise and fall of cardiac markers accompanied by one of the following: – Ischemic symptoms – New Q waves – Ischemic ECG changes – Coronary intervention J Am Col Cardiol 2000;36;

ESC/ACC Diagnostic Criteria “An increased value for cardiac troponin should be defined as a measurement exceeding the 99 th percentile of a reference control group…. Acceptable imprecision at the 99 th percentile for each assay should be defined as < 10%” J Am Col Cardiol 2000;36;

ESC/ACC Cutoff Values 99% (ng/ml)10% CV (ng/ml) Abbott Axsym Bayer Immuno Beckman-Coulter Biosite Dade RXL Dade Stratus CS Ortho Vitros Roche Elecys Am Heart J 2002;144:

Implications Estimated that number of patients with diagnosis of AMI utilizing new definition will increase by??? Ferguson et al (Heart 2002; 88: ) – 80 admitted chest pain patients 29% fulfilled WHO criteria 40% fulfilled ESC/AHA criteria

Implications Global Registry of Acute Coronary Events (GRACE Registry) – 3420 patients Redefining AMI based on new troponin cutoff recommendations: – 25% increase in number of patients classified as AMI Gooman et al: J Am Coll Cardiol 2001;37:358A

The Future !!! Utilization of Second Generation cTnI Assays for the Early Identification of Acute Coronary Syndromes

Stratus CS: 2-Hour cTnI

Stratus CS: Delta cTnI

What is the best marker of AMI? Troponins by default become best marker of AMI (incorporation bias) Multiple causes of troponin elevations confusing physicians and researchers New definitions on AMI need to focus on measuring changes in troponin values as opposed to absolute values

Proud Card Member Since 1981

Breakfast of Champions !!

No Excuses!

Utilization of Cardiac Serum Marker Measurements to Identify and Exclude Acute Myocardial Infarction Francis M. Fesmire, MD, FACEP Director Heart-Stroke Center, Erlanger Medical Center Associate Professor, UT College of Medicine Just Do It!!!