Biomarkers in Acute Coronary Syndromes
Biomarkers in Acute Coronary Syndromes
Biomarkers in Acute Coronary Syndromes
Latest update
DOI: 10.1093/med/9780199687039.003.0036_update_002
Update:
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Biomarkers in acute coronary syndromes
Summary
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Contents
Summary [link]
Introduction: pathophysiology and classification of acute coronary
syndromes—the role of biomarkers [link]
Cardiac troponins [link]
High-sensitivity cardiac troponin assays [link]
Risk stratification and selection of invasive vs medical
treatment [link]
Point-of-care testing [link]
Cardiac troponin testing on point-of-care systems [link]
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Figure 36.1
Representative biomarkers involved in the process of atherosclerosis at
different stages of the disease
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Cardiac troponins
• Symptoms of ischaemia
• ECG changes indicative of new ischaemia(new ST-T changes
or new left bundle branch block [LBBB])
• Development of pathological Q waves in the
electrocardiogram (ECG)
• Imaging evidence of new loss of viable myocardium or new
regional wall motion abnormality
• Identification of an intracoronary thrombus on coronary
angiography or autopsy
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Figure 36.2
Putative mechanisms related to the development of type 1 or type 2 MI
The diagnosis of an AMI requires a relevant rise and/or fall of cTn, with at
least one cTn value exceeding the 99th percentile [9]. Therefore, cTn has
to be measured serially to distinguish an acute from a chronic cTn
elevation. According to current ESC guideline recommendations [4], cTn
must be measured on presentation and at 6–9 hours after admission,
unless a hscTn assay is being used [4, 21]. In patients with an
intermediate or high clinical index of suspicion, who remain troponin-
normal, and after recurrence of typical symptoms, a later measurement at
12–24 hours should be considered, in order not to miss a late rise in cTn.
Clinical indicators, other than cTn, also provide an estimate of the acute
thrombotic risk such as dynamic ST-segment deviations, refractory
angina, diabetes mellitus, renal failure, older age, and an intermediate or
high GRACE or TIMI risk score [4]. Current ESC guidelines therefore
advocate that the decision and timing of an early invasive treatment
strategy should be based on individual risk stratification. Patients at
higher risk were found to benefit from an early invasive strategy within
72 hours. Patients with a high GRACE score exceeding 140 points,
dynamic ST-segment changes, or a relevant rise and/or fall of cTn qualify
for an invasive strategy within 24 hours (see Table 36.3). An
immediate invasive strategy within 2 hours is recommended in patients
with very high-risk features.
Hemodynamic instability or
cardiogenic shock
Recurrent or ongoing chest pain
refractory to medical therapy
Life-threatening arrhythmias or
cardiac arrest
Mechanical complications of MI
Acute heart Failzre
Recurrent dynamic ST-T wave
changes, particularly with intermittent
ST elevation
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Diabetes
Renal insufficiency (eGFR <60 ml/min/
1.73m2
LVEF < 40% or congestive heart
failure
Early postinfarct angina
Prior PCI
Prior CABG
GRACE score > 109 and < 140
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Figure 36.3
Increasing numbers of differential diagnoses with the use of more
sensitive and highly sensitive cardiac troponin assays.
Patients with a rising pattern of hscTn to high peak values most likely
have an acute aetiology such as NSTEMI, acute heart failure (AHF),
stress cardiomyopathy, myocarditis, or PE [44]. On the other hand, if the
pattern of the hscTn values is not changing, chronic structural heart
disease should be suspected. Irrespective of the cause of myocardial
injury, elevations of hscTn are associated with an adverse clinical
outcome in most clinical conditions [45]. The higher the cTn
concentrations on admission, the less likely a differential diagnosis other
than an AMI is [46], particularly among those who present with AHF [47].
Point-of-care testing
Thus, for most point-of-care systems, the potential for reduced times to
decision making needs to be weighed against a loss of sensitivity, when
compared to hscTn assays in central laboratories.
Other biomarkers
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Prognostic biomarkers
Copeptin
The LAMP study (Leicester AMI Peptide study) reported that, post-MI,
MR-proANP added prognostic information, independently of established
conventional risk factors [73]. As a shortcoming, STEMI was over-
represented, and results of MR-proANP were not evaluated against a
hscTn assay.
MR-proadrenomedullin
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Personal perspective
cTn are anticipated to remain the preferred biomarker for ACS
diagnosis and classification, due to its cardiospecificity and superior
sensitivity to other cardiac constituents. In addition, it appears that
an elevated cTn accurately indicates myocardial injury and thus
predicts a higher risk for cardiovascular events, regardless of the
underlying aetiology. Thus, elevated hscTn should be viewed as an
important tool for risk stratification in ACS and non-ACS conditions,
and not as a confounder of ACS diagnosis. Moreover, it is tempting to
speculate that cTn levels may be influenced by various forms of
intervention (physical activity, lifestyle modification, statin therapy,
potent antiplatelet therapies) and thus may be used for the
monitoring of disease progression or therapeutic effects.
Further reading
1. Apple FS. A new season for cardiac troponin assays: it’s time to keep a
scorecard. Clin Chem 2009;55:1303–6.
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3. Hamm CW, Bassand JP, Agewall S, et al. ESC Guidelines for the
management of acute coronary syndromes in patients presenting without
persistent ST-segment elevation: the Task Force for the management of
acute coronary syndromes (ACS) in patients presenting without persistent
ST-segment elevation of the European Society of Cardiology (ESC). Eur
Heart J 2011;32:2999–3054.
8. Thygesen K, Alpert JS, Jaffe AS, Simoons ML, Chaitman BR, White HD;
Joint ESC/ACCF/AHA/WHF Task Force for the Universal Definition of
Myocardial Infarction, Katus HA, Lindahl B, Morrow DA, et al. Third
universal definition of myocardial infarction. Circulation 2012;126:
2020-35.
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