Outcomes with type 2 myocardial infarction compared with non-ischaemic myocardial injury

Cediel, Germán; González‐Del‐Hoyo, Maribel; Carrasquer, Anna; Sánchez, Rafael; Boqué, Carme; Bardajı́, Alfredo

doi:10.1136/heartjnl-2016-310243

Cited by 90 publications

(63 citation statements)

References 30 publications

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“…Firstly, raised cardiac troponin concentrations, particularly in patients not presenting with a typical history of cardiac pain, are often caused by myocardial injury or type 2 myocardial infarction 67. These conditions, which are secondary to ischaemia caused by increased oxygen demand or decreased supply rather than a plaque erosion,8910 are not well recognised when the troponin test is requested or the result interpreted.…”

Section: Introductionmentioning

confidence: 99%

True 99th centile of high sensitivity cardiac troponin for hospital patients: prospective, observational cohort study

Mariathas

Allan

Ramamoorthy

et al. 2019

BMJ

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ObjectiveTo determine the distribution, and specifically the true 99th centile, of high sensitivity cardiac troponin I (hs-cTnI) for a whole hospital population by applying the hs-cTnI assay currently used routinely at a large teaching hospital.DesignProspective, observational cohort study.SettingUniversity Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom, between 29 June 2017 and 24 August 2017.Participants20 000 consecutive inpatients and outpatients undergoing blood tests for any clinical reason. Hs-cTnI concentrations were measured in all study participants and nested for analysis except when the supervising doctor had requested hs-cTnI for clinical reasons.Main outcome measuresDistribution of hs-cTnI concentrations of all study participants and specifically the 99th centile.ResultsThe 99th centile of hs-cTnI for the whole population was 296 ng/L compared with the manufacturer’s quoted level of 40 ng/L (currently used clinically as the upper limit of normal; ULN). Hs-cTnI concentrations were greater than 40 ng/L in one in 20 (5.4%, n=1080) of the total population. After excluding participants diagnosed as having acute myocardial infarction (n=122) and those in whom hs-cTnI was requested for clinical reasons (n=1707), the 99th centile was 189 ng/L for the remainder (n=18 171). The 99th centile was 563 ng/L for inpatients (n=4759) and 65 ng/L for outpatients (n=9280). Patients from the emergency department (n=3706) had a 99th centile of 215 ng/L, with 6.07% (n=225) greater than the recommended ULN. 39.02% (n=48) of all patients from the critical care units (n=123) and 14.16% (n=67) of all medical inpatients had an hs-cTnI concentration greater than the recommended ULN.ConclusionsOf 20 000 consecutive patients undergoing a blood test for any clinical reason at our hospital, one in 20 had an hs-cTnI greater than the recommended ULN. These data highlight the need for clinical staff to interpret hs-cTnI concentrations carefully, particularly when applying the recommended ULN to diagnose acute myocardial infarction, in order to avoid misdiagnosis in the absence of an appropriate clinical presentation.Trial registrationClinicaltrials.govNCT03047785.

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Section: Introductionmentioning

confidence: 99%

True 99th centile of high sensitivity cardiac troponin for hospital patients: prospective, observational cohort study

Mariathas

Allan

Ramamoorthy

et al. 2019

BMJ

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“…Both type 1 and type 2 MI can present as NSTEMI or STEMI, although NSTEMI is more common for both types . Most NSTEMI pathophysiologically are consistent with type 1 MI, but the relative proportions of type 1 NSTEMI and type 2 NSTEMI vary between clinical settings …”

Section: Discussionmentioning

confidence: 99%

“…Underlying conditions that may predispose individuals to oxygen supply‐demand imbalances, and thus type 2 MI, include hypotension, sepsis, anemia, tachyarrhythmia, respiratory failure, and hypertension . In addition to CV differences, a number of studies have shown that patients who have a type 2 MI are usually older, more often women, and more likely to have a history of comorbidities such as heart failure, arrhythmias, chronic obstructive pulmonary disease, or renal impairment …”

Section: Epidemiologymentioning

confidence: 99%

“…18,22 In addition to CV differences, a number of studies have shown that patients who have a type 2 MI are usually older, more often women, and more likely to have a history of comorbidities such as heart failure, arrhythmias, chronic obstructive pulmonary disease, or renal impairment. 16,[18][19][20][27][28][29] F I G U R E 1 Classification of myocardial infarction based on the fourth universal definition. 5 CABG, coronary artery bypass grafting; CAD, coronary artery disease; ECG, electrocardiogram; MI, myocardial infarction; PCI, percutaneous coronary intervention 3.3 | Prognosis following type 1 and type 2 NSTEMI Among patients with NSTEMI of any type, in-hospital and 30-day mortality rates of between 5.2% and 13.1% and between 7.6% and 17.0%, respectively, have been reported.…”

Section: Prevalence Of Type 1 and Type 2 MI In Nstemimentioning

confidence: 99%

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Defining and managing patients with non‐ST‐elevation myocardial infarction: Sorting through type 1 vs other types

Cohen

Visveswaran

2020

Clinical Cardiology

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Advances in cardiovascular (CV) imaging, redefined electrocardiogram criteria, and high‐sensitivity CV biomarker assays have enabled more differentiated etiological classification of myocardial infarction (MI). Type 1 MI has a different underlying pathophysiology than type 2 through type 5 MI; type 1 MI is characterized primarily by intracoronary atherothrombosis and the other types by a variety of mechanisms, which can occur with or without an atherosclerotic component. In type 2 MI, there is evidence of myocardial oxygen supply‐demand imbalance unrelated to acute coronary atherothrombosis. Types 1 and 2 MI are spontaneous events, while type 4 and type 5 are procedure‐related; type 3 MI is identified only after death. Most type 1 and type 2 MI present as non‐ST‐elevation MI (NSTEMI), although both types can also present as ST‐elevation MI. Because of their different underlying etiologies, type 1 and type 2 NSTEMI have different presentation and prognosis and should be managed differently. In this article, we discuss the epidemiology, prognosis, and management of NSTEMI occurring in the setting of underlying type 1 or type 2 pathophysiology. Most NSTEMI (65%–90%) are type 1 MI. Patients with type 2 MI have multiple comorbidities and causes of in‐hospital mortality among these patients are not always CV‐related. It is important to distinguish between type 1 and type 2 NSTEMI early in the clinical course to allow for the use of the most appropriate treatments that will provide the greatest benefit for these patients.

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“…hs-cTn assays are less specific than contemporary assays for MI, as more patients with non-ACS conditions have hs-cTn elevations that are missed with the contemporary assay [22]. While patients with hs-cTn elevations have increased downstream mortality, regardless of cause [23, 24], the optimal testing and management strategies for non-ACS patients with hs-cTn elevations are unclear. Therefore, some have been concerned about the impact of integrating hs-cTn assays into an ADP, such as the HEART Pathway, which has previously demonstrated a sensitivity >99% for 30-day MACE using serial contemporary cTn measures.…”

Section: Discussionmentioning

confidence: 99%

Use of the HEART Pathway with high sensitivity cardiac troponins: A secondary analysis

Mahler

Stopyra

Apple

et al. 2017

Clinical Biochemistry

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Objectives The HEART Pathway combines a decision aid and serial contemporary cardiac troponin I (cTnI) measures to achieve >99% sensitivity for major adverse cardiac events (MACE) at 30 days and early discharge rates >20%. However, the impact of integrating high-sensitivity troponin (hs-cTn) measures into the HEART Pathway has yet to be determined. In this analysis we compare test characteristics of the HEART Pathway using hs-cTnI, hs-cTnT, or cTnI. Design & Methods A secondary analysis of participants enrolled in the HEART Pathway RCT was conducted. Each patient was risk stratified by the cTn-HEART Pathway (Siemens TnI-Ultra at 0- and 3-hours) and a hs-cTn-HEART Pathway using hs-cTnI (Abbott) or hs-cTnT (Roche) at 3-hours. The early discharge rate, sensitivity, specificity, and negative predictive value (NPV) for MACE (death, myocardial infarction, or coronary revascularization) at 30 days were calculated. Results hs-cTnI measures were available on 133 patients. MACE occurred in 11/133 (8%) of these patients. Test characteristics for the HEART Pathway using serial cTnI vs 3 hour hs-cTnI were the same: sensitivity (100%, 95%CI: 72–100%), specificity (49%, 95%CI: 40–58%), NPV (100%, 95%CI: 94–100%), and early discharge rate (45%, 95%CI: 37–54%). The HEART Pathway using hs-cTnT missed one MACE event (myocardial infarction): sensitivity (91%, 95%CI: 59–100%), specificity (48%, 95%CI: 39–57%), NPV (98%, 95%CI: 91–100%), and early discharge rate (45%, 95%CI: 37–54%). Conclusions There was no difference in the test characteristics of the HEART Pathway whether using cTnI or hs-cTnI, with both achieving 100% sensitivity and NPV. Use of hs-cTnT with the HEART Pathway was associated with one missed MACE.

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Outcomes with type 2 myocardial infarction compared with non-ischaemic myocardial injury

Cited by 90 publications

References 30 publications

True 99th centile of high sensitivity cardiac troponin for hospital patients: prospective, observational cohort study

True 99th centile of high sensitivity cardiac troponin for hospital patients: prospective, observational cohort study

Defining and managing patients with non‐ST‐elevation myocardial infarction: Sorting through type 1 vs other types

Use of the HEART Pathway with high sensitivity cardiac troponins: A secondary analysis

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