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The ratio of N-terminal pro-B-type natriuretic peptide to troponin I for differentiating acute coronary syndrome

  • Dong Hoon Kim
    Affiliations
    Department of Emergency Medicine, Gyeongsang National University School of Medicine and Gyeongsang National University Hospital, Jinju, Gyeongsangnam-Do, Republic of Korea

    Gyeongsang Institute of Health Sciences, Gyeongsang National University School of Medicine, Jinju, Gyeongsangnam-Do, Republic of Korea
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  • Soo Hoon Lee
    Correspondence
    Corresponding author at: Department of Emergency Medicine, Gyeongsang National University School of Medicine and Gyeongsang National University Hospital, Gangnam-ro 79, Jinju, Gyeongsangnam-do 52727, Republic of Korea.
    Affiliations
    Department of Emergency Medicine, Gyeongsang National University School of Medicine and Gyeongsang National University Hospital, Jinju, Gyeongsangnam-Do, Republic of Korea

    Gyeongsang Institute of Health Sciences, Gyeongsang National University School of Medicine, Jinju, Gyeongsangnam-Do, Republic of Korea
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  • Seong Chun Kim
    Affiliations
    Department of Emergency Medicine, Gyeongsang National University School of Medicine and Gyeongsang National University Changwon Hospital, Changwon, Gyeongsangnam-Do, Republic of Korea
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  • Taeyun Kim
    Affiliations
    Department of Emergency Medicine, Gyeongsang National University School of Medicine and Gyeongsang National University Hospital, Jinju, Gyeongsangnam-Do, Republic of Korea
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  • Changwoo Kang
    Affiliations
    Department of Emergency Medicine, Gyeongsang National University School of Medicine and Gyeongsang National University Hospital, Jinju, Gyeongsangnam-Do, Republic of Korea

    Gyeongsang Institute of Health Sciences, Gyeongsang National University School of Medicine, Jinju, Gyeongsangnam-Do, Republic of Korea
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  • Jin Hee Jeong
    Affiliations
    Department of Emergency Medicine, Gyeongsang National University School of Medicine and Gyeongsang National University Hospital, Jinju, Gyeongsangnam-Do, Republic of Korea
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  • Yong Joo Park
    Affiliations
    Department of Emergency Medicine, Gyeongsang National University School of Medicine and Gyeongsang National University Changwon Hospital, Changwon, Gyeongsangnam-Do, Republic of Korea
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  • Daesung Lim
    Affiliations
    Department of Emergency Medicine, Gyeongsang National University School of Medicine and Gyeongsang National University Changwon Hospital, Changwon, Gyeongsangnam-Do, Republic of Korea
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  • Sang Bong Lee
    Affiliations
    Department of Emergency Medicine, Gyeongsang National University School of Medicine and Gyeongsang National University Hospital, Jinju, Gyeongsangnam-Do, Republic of Korea
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Published:August 14, 2018DOI:https://doi.org/10.1016/j.ajem.2018.08.035

      Abstract

      Introduction

      It is difficult to differentiate whether coronary or non-coronary causes in patients with elevated troponin I (TnI) in emergency department (ED). The aim of this study was to develop a clinical decision tool for differentiating a coronary cause in the patients with elevated TnI.

      Methods

      This was a retrospective observational study that enrolled consecutive ED patients. Patients were included in the study if they were ≥16 years of age, had admitted through ED with a medical illness, and TnI levels at initial evaluation in the ED were ≥0.2 ng/mL. Patients diagnosed with ST elevation myocardial infarction or congestive heart failure were excluded. Coronary angiography, electrocardiogram, laboratory results, echocardiography, and clinical characteristics were analyzed.

      Results

      Among the included 1441 patients, 603 and 838 patients were categorized into an acute coronary syndrome (ACS) group and non-acute coronary syndrome (non-ACS) group, respectively. The ratio of N-terminal pro-Btype natriuretic peptide (NT-proBNP) to TnI was significantly higher in the non-ACS group compared to the ACS group. The AUC of NT-proBNP/TnI (0.805, 95% CI, 0.784-0.826) was significantly superior to that of NT-proBNP/creatinine kinase-MB, TnI, and NT-proBNP. The patients of the non-ACS group with high levels of TnI and BNP showed more critically ill manifestation at the time of presentation and higher mortality.

      Conclusion

      NT-proBNP/TnI may help to distinguish medical patients with elevated TnI whether the elevated TnIs were caused from ACSs or from conditions other than ACS.

      Keywords

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      References

        • Thygesen K.
        • Alpert J.S.
        • Jaffe A.S.
        • Simoons M.L.
        • Chaitman B.R.
        • White H.D.
        • et al.
        Third universal definition of myocardial infarction.
        J Am Coll Cardiol. 2012; 60: 1581-1598
        • Anderson J.L.
        • Adams C.D.
        • Antman E.M.
        • Bridges C.R.
        • Califf R.M.
        • Casey Jr., D.E.
        • et al.
        2012 ACCF/AHA focused update incorporated into the ACCF/AHA 2007 guidelines for the management of patients with unstable angina/non-ST-elevation myocardial infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines.
        Circulation. 2013; 127: e663-e828
        • Tsuchihashi K.
        • Ueshima K.
        • Uchida T.
        • Oh-Mura N.
        • Kimura K.
        • Owa M.
        • et al.
        Transient left ventricular apical ballooning without coronary artery stenosis: a novel heart syndrome mimicking acute myocardial infarction. Angina pectoris-myocardial infarction investigations in Japan.
        J Am Coll Cardiol. 2001; 38: 11-18
        • Apple F.S.
        • Murakami M.M.
        • Pearce L.A.
        • Herzog C.A.
        Predictive value of cardiac troponin I and T for subsequent death in end-stage renal disease.
        Circulation. 2002; 106: 2941-2945
        • Jeremias A.
        • Gibson C.M.
        Narrative review: alternative causes for elevated cardiac troponin levels when acute coronary syndromes are excluded.
        Ann Intern Med. 2005; 142: 786-791
        • Roongsritong C.
        • Warraich I.
        • Bradley C.
        Common causes of troponin elevations in the absence of acute myocardial infarction: incidence and clinical significance.
        Chest. 2004; 125: 1877-1884
        • Ammann P.
        • Maggiorini M.
        • Bertel O.
        • Haenseler E.
        • Joller-Jemelka H.I.
        • Oechslin E.
        • et al.
        Troponin as a risk factor for mortality in critically ill patients without acute coronary syndromes.
        J Am Coll Cardiol. 2003; 41: 2004-2009
        • Pruszczyk P.
        • Bochowicz A.
        • Torbicki A.
        • Szulc M.
        • Kurzyna M.
        • Fijalkowska A.
        • et al.
        Cardiac troponin T monitoring identifies high-risk group of normotensive patients with acute pulmonary embolism.
        Chest. 2003; 123: 1947-1952
        • Smith S.C.
        • Ladenson J.H.
        • Mason J.W.
        • Jaffe A.S.
        Elevations of cardiac troponin I associated with myocarditis. Experimental and clinical correlates.
        Circulation. 1997; 95: 163-168
        • Perna E.R.
        • Macin S.M.
        • Parras J.I.
        • Pantich R.
        • Farias E.F.
        • Badaracco J.R.
        • et al.
        Cardiac troponin T levels are associated with poor short- and long-term prognosis in patients with acute cardiogenic pulmonary edema.
        Am Heart J. 2002; 143: 814-820
        • Ammann P.
        • Fehr T.
        • Minder E.I.
        • Gunter C.
        • Bertel O.
        Elevation of troponin I in sepsis and septic shock.
        Intensive Care Med. 2001; 27: 965-969
        • Urhausen A.
        • Scharhag J.
        • Herrmann M.
        • Kindermann W.
        Clinical significance of increased cardiac troponins T and I in participants of ultra-endurance events.
        Am J Cardiol. 2004; 94: 696-698
        • Aldous S.
        • Elliott J.
        • McClean D.
        • Puri A.
        • Richards A.M.
        Outcomes in patients presenting with symptoms suggestive of acute coronary syndrome with elevated cardiac troponin but non-obstructive coronary disease on angiography.
        Heart Lung Circ. 2015; 24: 869-878
        • Randhawa M.S.
        • Dhillon A.S.
        • Taylor H.C.
        • Sun Z.
        • Desai M.Y.
        Diagnostic utility of cardiac biomarkers in discriminating Takotsubo cardiomyopathy from acute myocardial infarction.
        J Card Fail. 2014; 20 (377 e25–31)
        • Jo S.
        • Jeong T.
        • Lee J.B.
        • Jin Y.
        • Yoon J.
        • Park B.
        Validation of modified early warning score using serum lactate level in community-acquired pneumonia patients. The National Early Warning Score-Lactate score.
        Am J Emerg Med. 2016; 34: 536-541
        • Xu M.
        • Tam B.
        • Thabane L.
        • Fox-Robichaud A.
        A protocol for developing early warning score models from vital signs data in hospitals using ensembles of decision trees.
        BMJ Open. 2015; 5e008699
        • Lee J.W.
        • Kim J.Y.
        Stress-induced cardiomyopathy: the role of echocardiography.
        J Cardiovasc Ultrasound. 2011; 19: 7-12
        • Hamm C.W.
        • Giannitsis E.
        • Katus H.A.
        Cardiac troponin elevations in patients without acute coronary syndrome.
        Circulation. 2002; 106: 2871-2872
        • Mukoyama M.
        • Nakao K.
        • Saito Y.
        • Ogawa Y.
        • Hosoda K.
        • Suga S.
        • et al.
        Increased human brain natriuretic peptide in congestive heart failure.
        N Engl J Med. 1990; 323: 757-758
        • Hall C.
        NT-ProBNP: the mechanism behind the marker.
        J Card Fail. 2005; 11: S81-S83
        • Madhavan M.
        • Borlaug B.A.
        • Lerman A.
        • Rihal C.S.
        • Prasad A.
        Stress hormone and circulating biomarker profile of apical ballooning syndrome (Takotsubo cardiomyopathy): insights into the clinical significance of B-type natriuretic peptide and troponin levels.
        Heart. 2009; 95: 1436-1441
        • Akashi Y.J.
        • Nakazawa K.
        • Sakakibara M.
        • Miyake F.
        • Koike H.
        • Sasaka K.
        The clinical features of takotsubo cardiomyopathy.
        QJM. 2003; 96: 563-573
        • Bonaca M.P.
        • Morrow D.A.
        Defining a role for novel biomarkers in acute coronary syndromes.
        Clin Chem. 2008; 54: 1424-1431
        • Akashi Y.J.
        • Nef H.M.
        • Mollmann H.
        • Ueyama T.
        Stress cardiomyopathy.
        Annu Rev Med. 2010; 61: 271-286
        • Bielecka-Dabrowa A.
        • Mikhailidis D.P.
        • Hannam S.
        • Rysz J.
        • Michalska M.
        • Akashi Y.J.
        • et al.
        Takotsubo cardiomyopathy--the current state of knowledge.
        Int J Cardiol. 2010; 142: 120-125
        • Frohlich G.M.
        • Schoch B.
        • Schmid F.
        • Keller P.
        • Sudano I.
        • Luscher T.F.
        • et al.
        Takotsubo cardiomyopathy has a unique cardiac biomarker profile: NT-proBNP/myoglobin and NT-proBNP/troponin T ratios for the differential diagnosis of acute coronary syndromes and stress induced cardiomyopathy.
        Int J Cardiol. 2012; 154: 328-332
        • Tanabe Y.
        • Obayashi T.
        • Yamamoto T.
        • Takayama M.
        • Nagao K.
        Predictive value of biomarkers for the prognosis of acute pulmonary embolism in Japanese patients: results of the Tokyo CCU network registry.
        J Cardiol. 2015; 66: 460-465
        • Satyan S.
        • Light R.P.
        • Agarwal R.
        Relationships of N-terminal pro-B-natriuretic peptide and cardiac troponin T to left ventricular mass and function and mortality in asymptomatic hemodialysis patients.
        Am J Kidney Dis. 2007; 50: 1009-1019
        • Moammar M.Q.
        • Ali M.I.
        • Mahmood N.A.
        • Debari V.A.
        • Khan M.A.
        Cardiac troponin I levels and alveolar-arterial oxygen gradient in patients with community-acquired pneumonia.
        Heart Lung Circ. 2010; 19: 90-92
        • Pavo N.
        • Raderer M.
        • Hulsmann M.
        • Neuhold S.
        • Adlbrecht C.
        • Strunk G.
        • et al.
        Cardiovascular biomarkers in patients with cancer and their association with all-cause mortality.
        Heart. 2015; 101: 1874-1880
        • Nigro N.
        • Wildi K.
        • Mueller C.
        • Schuetz P.
        • Mueller B.
        • Fluri F.
        • et al.
        BNP but Not s-cTnln is associated with cardioembolic aetiology and predicts short and long term prognosis after cerebrovascular events.
        PLoS One. 2014; 9e102704
        • Charpentier J.
        • Luyt C.E.
        • Fulla Y.
        • Vinsonneau C.
        • Cariou A.
        • Grabar S.
        • et al.
        Brain natriuretic peptide: a marker of myocardial dysfunction and prognosis during severe sepsis.
        Crit Care Med. 2004; 32: 660-665
        • Klouche K.
        • Pommet S.
        • Amigues L.
        • Bargnoux A.S.
        • Dupuy A.M.
        • Machado S.
        • et al.
        Plasma brain natriuretic peptide and troponin levels in severe sepsis and septic shock: relationships with systolic myocardial dysfunction and intensive care unit mortality.
        J Intensive Care Med. 2014; 29: 229-237