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Published on: July 2, 2018
Quantifying cardiac hemodynamic stress and cardiomyocyte damage in ischemic and nonischemic acute heart failure
Beatrice Drexler1, Corinna Heinisch, Cathrin Balmelli
1Department of Internal Medicine, University Hospital Basel, Basel, Switzerland.
Insights
Biomarkers like BNP and troponin show higher levels in ischemic acute heart failure (AHF) patients. However, these markers have poor diagnostic accuracy for differentiating ischemic from nonischemic AHF in the emergency department.
Area of Science:
- Cardiology
- Emergency Medicine
- Biomarker Research
Background:
- Differentiating ischemic from nonischemic acute heart failure (AHF) in the emergency department (ED) is clinically challenging.
- Current diagnostic methods lack noninvasive and early differentiation capabilities.
Purpose of the Study:
- To evaluate the utility of B-type natriuretic peptide (BNP) and cardiac troponin assays in distinguishing ischemic AHF from nonischemic AHF.
- To assess the diagnostic accuracy of these biomarkers in an emergency department setting.
Main Methods:
- Quantified cardiac hemodynamic stress using BNP and cardiomyocyte damage using cardiac troponin T (cTnT) and sensitive cardiac troponin I (s-cTnI).
- Analyzed data from 718 consecutive AHF patients in a derivation cohort and validated findings in 326 AHF patients in an independent multicenter cohort.
- Adjudicated ischemic AHF diagnoses using all available clinical information, including coronary angiography.
Main Results:
- Patients with ischemic AHF showed significantly higher BNP, cTnT, and s-cTnI levels compared to nonischemic AHF patients.
- The diagnostic accuracy, measured by the area under the receiver-operating characteristic curve, was low for BNP (0.58), cTnT (0.61), and s-cTnI (0.59).
- These results were consistent across both the derivation and validation cohorts.
Conclusions:
- Ischemic AHF is associated with greater hemodynamic stress and cardiomyocyte damage than nonischemic AHF at ED presentation.
- Despite observed differences, substantial overlap in biomarker levels leads to poor diagnostic accuracy for differentiating the two conditions.
- Novel biomarkers or diagnostic strategies are needed for accurate early differentiation of ischemic AHF.
Background:
The early and noninvasive differentiation of ischemic and nonischemic acute heart failure (AHF) in the emergency department (ED) is an unmet clinical need.
Methods And Results:
We quantified cardiac hemodynamic stress using B-type natriuretic peptide (BNP) and cardiomyocyte damage using 2 different cardiac troponin assays in 718 consecutive patients presenting to the ED with AHF (derivation cohort). The diagnosis of ischemic AHF was adjudicated using all information, including coronary angiography. Findings were validated in a second independent multicenter cohort (326 AHF patients). Among the 718 patients, 400 (56%) were adjudicated to have ischemic AHF. BNP levels were significantly higher in ischemic compared with nonischemic AHF (1097 [604-1525] pg/mL versus 800 [427-1317] pg/mL; P<0.001). Cardiac troponin T (cTnT) and sensitive cardiac troponin I (s-cTnI) were also significantly higher in ischemic compared with nonischemic AHF patients (0.040 [0.010-0.306] μg/L versus 0.018 [0.010-0.060] μg/L [P<0.001]; 0.024 [0.008-0.106] μg/L versus 0.016 [0.004-0.044 ] μg/L [P=0.002]). The diagnostic accuracy of BNP, cTnT, and s-cTnI for the diagnosis of ischemic AHF, as quantified by the area under the receiver-operating characteristic curve, was low (0.58 [95% CI, 0.54-0.63], 0.61 [95% CI, 0.57-0.66], and 0.59 [95% CI,0.54-0.65], respectively). These findings were confirmed in the validation cohort.
Conclusions:
At presentation to the ED, patients with ischemic AHF exhibit more extensive hemodynamic cardiac stress and cardiomyocyte damage than patients with nonischemic AHF. However, the overlap is substantial, resulting in poor diagnostic accuracy.
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