Advertisement

Differentiating type 1 and 2 acute myocardial infarctions using the N-terminal pro B-type natriuretic peptide/cardiac troponin T ratio

      Abstract

      Purpose

      Differentiation of type 1 (T1MI) from type 2 myocardial infarction (T2MI) is important as recommended treatments for each differ. Patients with T2MI may have more/earlier cardiac wall stress resulting in an increased N-terminal pro B-type natriuretic peptide (NT-proBNP)/cTnT generation 5 ratio (cTnT Gen 5).

      Methods

      Emergency Department (ED) patients presenting with symptoms suspicious for acute coronary syndrome (ACS) were enrolled from 2013 to 2015. Baseline blood samples were collected within 60 min of a triage ECG, with additional draws at 30, 60 and 180 min. NT-proBNP and cTnT Gen 5 levels were measured later in an independent laboratory. Acute myocardial infarction (AMI) was adjudicated using the Third Universal Definition of Myocardial Infarction.

      Results

      575 patients were enrolled with 44 (7.7%) having AMI [25 T1MI (59.1%) and 18 T2MI (40.9%)]. Patient characteristics showed very few AMI type differences so accurate clinical differentiation was difficult. The median NT-proBNP/cTnT Gen 5 ratios were significantly higher in T2MI when compared to T2MI at baseline and 30, 60 and 180 min later [7.3 v 53.0 (p = 0.003), 5.8 v 49.5 (p = 0.002), 6.3 v 47.5 (p = 0.003) and 4.3 v 33.7 (p = 0.016) respectively].

      Conclusions

      The clinical determination of whether an AMI is type 1 or 2 is difficult as the ED patient characteristics of each are similar. The NT-proBNP/cTnT Gen 5 ratio can aid in making this differentiation. Additional multicenter trials are needed to validate our results.

      Keywords

      To read this article in full you will need to make a payment
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to The American Journal of Emergency Medicine
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Thygesen K.
        • Alpert J.S.
        • Jaffe A.S.
        • Simoons M.L.
        • Chaitman B.R.
        White HD: the writing group on behalf of the joint WSC/ACCF/AHA/WHF task force for the universal definition of myocardial infarction.
        Circulation. 2012; https://doi.org/10.1161/CIR.0b013e31826e1058
        • Sandoval Y.
        • Smith S.W.
        • Thordsen S.A.
        • Apple F.S.
        Supply/demand type 2 myocardial infarction: Should we be paying more attention.
        J Am Coll Cardiol. 2014; 63: 2079-2097
        • Nagele P.
        The case for a revised definition of myocardial infarction-resolving the ambiguity of type 2 myocardial infarction.
        JAMA Cardiol. 2016; 1: 247-248
        • Lopez-Cuenca A.
        • Gomez-Molina M.
        • Flores-Blanco P.J.
        • et al.
        Comparison between type 2 and type 1 myocardial infarction: clinical features, treatment strategies and outcomes.
        J Geriatr Cardiol. 2016; 13: 15-22
        • Greenslade J.H.
        • Adikari T.
        • Mueller C.
        • et al.
        Characteristics and occurrence of type 2 myocardial infarction in emergency department patients: a prospective study.
        Emerg Med J. 2017; 0: 1-8
        • Saaby L.
        • Poulsen T.S.
        • Hosbond S.
        • et al.
        Classification of myocardial infarction: frequency and features of type 2 myocardial infarction.
        Am J Med. 2013; 126: 789-797
        • Alpert J.S.
        • Thygesen K.A.
        • White H.D.
        • Jaffe A.S.
        Diagnostic and therapeutic implications of type 2 myocardial infarction: review and commentary.
        Am J Med. 2014; 127: 105-108
        • Saaby L.
        • Poulsen T.V.
        • Diederichsen A.C.P.
        • Hosbond S.
        • et al.
        Mortality rate in type 2 myocardial infarction: observations from an unselected hospital cohort.
        Am J Med. 2014; 127: 295-302
        • Januzzi Jr., J.L.
        • Chen-Tournoux A.A.C.
        • Christenson R.H.
        • on behalf of the ICON-RELOADED investigators
        • et al.
        N-terminal pro-B type natriuretic peptide in the emergency department.
        J Am Coll Cardiol. 2018; 71: 1191-1200
        • Chen A.A.
        • Wood M.J.
        • Krauser D.G.
        • et al.
        NT-proBNP levels, echocardiographic findings and outcomes in breathless patients: results from the ProBNP Investigation of Dyspnea in the Emergency Department (PRIDE) echocardiographic substudy.
        Eur Heart J. 2006; 27: 839-845
        • Maisel A.S.
        • Krishnaswamy P.
        • Nowak R.M.
        • et al.
        For the breathing not properly multinational study investigators. Rapid measurements of B-type natriuretic peptide in the emergency department.
        N Engl J Med. 2002; 347: 161-167
        • CW Yancy
        • Jessup M.
        • Bozkurt B.
        • et al.
        ACCF/AHA guideline for the management of heart failure: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines.
        Circulation. 2013; 128 (2013): e240-e327