BackgroundPatients with type 2 myocardial infarction (T2MI) and other mechanisms of nonthrombotic myocardial injury have an unmet therapeutic need. Eligibility for novel medical therapy is generally uncertain.MethodsWe predefined colchicine, eplerenone and ticagrelor as candidates for repurposing towards novel therapy for T2MI or myocardial injury. Considering eligibility for randomisation in a clinical trial, each drug was classified according to indications and contraindications for therapy and survival for at least 24 hours following admission. Eligibility criteria for prescription were evaluated against the Summary of Medical Product Characteristics. Consecutive hospital admissions were screened to identify patients with ≥1 high-sensitivity troponin-I value >99th percentile. Endotypes of myocardial injury were adjudicated according to the Fourth Universal Definition of MI. Patients’ characteristics and medication were prospectively evaluated.ResultsDuring 1 March to 15 April 2020, 390 patients had a troponin I>URL. Reasons for exclusion: type 1 MI n=115, indeterminate diagnosis n=42, lack of capacity n=14, death <24 hours n=7, duplicates n=2. Therefore, 210 patients with T2MI/myocardial injury and 174 (82.8%) who survived to discharge were adjudicated for treatment eligibility. Patients who fulfilled eligibility criteria initially on admission and then at discharge were colchicine 25/210 (11.9%) and 23/174 (13.2%); eplerenone 57/210 (27.1%) and 45/174 (25.9%); ticagrelor 122/210 (58.1%) and 98/174 (56.3%). Forty-six (21.9%) and 38 (21.8%) patients were potentially eligible for all three drugs on admission and discharge, respectively.ConclusionA reasonably high proportion of patients may be considered eligible for repurposing novel medical therapy in secondary prevention trials of type 2 MI/myocardial injury.
Introduction Invasive coronary angiography (ICA) is associated with higher complication rates in patients following coronary artery bypass surgery (CABG). CT coronary angiography (CTCA) has emerged as an attractive alternative. We assessed the impact of CTCA on subsequent ICA. Methods We identified 213 CABG patients undergoing CTCA between 2015 and 2018. In 151 the indication was suspected recurrence of angina. We then identified patients undergoing ICA within 1 year of CTCA. Results CTCA obviated the need for ICA in 115 cases (76%). CTCA was better at identifying targets for percutaneous coronary intervention (PCI) to saphenous vein grafts (SVG’s) than to native vessels (89% vs 47%). 7 out of 10 lesions of “probable” significance by CTCA proved flow-limiting, and 4 out of 13 “indeterminate” lesions. CTCA concordance was 97% for left internal mammary (LIMA) grafts. Conclusion CTCA directed management in a majority of patients without ICA. It identified a cohort of patients likely to be candidates for SVG PCI, but was less effective in identifying PCI targets in the native vessels. CTCA renders invasive LIMA cannulation redundant unless a target lesion is suspected.
Introduction: Unplanned hospitalizations are commonly associated with a circulating troponin concentration >99 th percentile upper reference limit (URL). In order to better understand the clinical significance of troponin elevation, we evaluated outcomes in hospitalized patients according to cardiac endotype. Methods: We prospectively screened consecutive hospitalized patients with elevated high-sensitivity troponin-I (hs-TnI) concentrations (Abbott ARCHITECT troponin-I assay; sex-specific URL, 99 th centile: male: >34ng/L; female: >16ng/L) within a regional cardiac care network (population 650,000). A cardiology clinical team adjudicated individual patient records and assigned endotypes by consensus agreement according to the Fourth Universal Definition of Myocardial Infarction (MI). Endotypes were sub-classified into etiological category by inciting event(s). Characteristics and comorbidity were compared and outcomes recorded on virtual follow-up until June 2 nd 2020. Results: A total of 390 consecutive patients with ≥1 hs-TnI value >URL between March 1-April 15, 2020, were evaluated; 44 patients were excluded ( Duplicates: 2; Missing data: 41; Research patient: 1 ). Of 346 who qualified for inclusion, an index diagnosis of Type 1 MI (T1MI), T2MI and myocardial injury were assigned in 115 (33.2%), 79 (22.8%) and 152 (43.9%) patients, respectively. Compared with T1MI, patients with T2MI and myocardial injury had lower peak hs-TnI values (median [IQR]: 86 [250-697] vs 5020 [853-7774]ng/L; p< 0.01), lower estimated 10-year survival (40.2% vs 53.4%; p=0.002), less frequently underwent coronary revascularization (1.4% vs 45.2%; p<0.0005) and had longer inpatient stay (13.0 vs 6.1 days). Inpatient and overall mortality rates from admission to follow-up (median [range]: 71 [0-151] days) were higher among patients with T2MI and myocardial injury (19.9% vs 7.8%; p=0.004; and 26.0% vs 11.3%; Log rank (Mantel-Cox) X 2 = 1.927; p=0.003) independent of similar cardiovascular risk profiles. Conclusions: Despite lower peak circulating troponin concentrations, patients with T2MI and myocardial injury had higher inpatient mortality, lower estimated 10-year survival and longer in-hospital stay compared to those with T1MI.
Introduction: Coronavirus disease 2019 (COVID-19) is a novel cause of myocardial injury. We investigated the clinical significance of COVID-19 in a population of hospitalized patients with myocardial injury. Methods: This was a prospective, longitudinal cohort study of hospitalized patients admitted to an urban academic medical center (catchment population 650,000) from March 1 - April 15, 2020. Consecutive patients with myocardial injury were identified using laboratory records by occurrence of ≥1 high-sensitivity troponin-I (hsTnI) result (Abbott ARCHITECT assay) >99 th percentile sex-specific upper reference limit (URL; male: >34 ng/L; female: >16 ng/L). Cardiac endotypes were defined according to the Fourth Universal Definition of Myocardial Infarction (MI) and laboratory data used to determine presence of COVID-19 infection by PCR. Outcomes of patients with myocardial injury with and without COVID-19 were assessed. Results: Of 390 hospitalized patients with elevated hsTnI, 346 were eligible for inclusion; 44 were excluded ( Duplicate: 2; Missing data: 41; Research patient: 1 ). 35 (10.1%) had laboratory-confirmed COVID-19 (COVID-19, yes vs no: median age [IQR]; 65 [59-74] vs 74 [63-83] years); 64.8% vs 43.7% male). Distribution of cardiac endotypes by COVID-19 status (yes vs no) were: Type 1 MI (0 [0%] vs 115 [100%]; p<0.0005), Type 2 MI (13 [16.5%] vs 66 [83.5%]; p=0.045), and non-ischemic myocardial injury (cardiac: 4 [5.8%] vs 65 [94.2%]; p=0.191, non-cardiac:19 [22.9%] vs 64 [77.%]; p<0.0005). Among all patients, those with COVID-19 had lower comorbidity burden (Charlson Comorbidity Index: 3.6 vs 5.1; p=0.002), similar average hsTnI concentrations (initial: 282 vs 316; p=0.853, peak: 560 vs 527ng/L; p=0.911), longer hospital stay (median [IQR]: 16 [20] vs 4 [9] days; p<0.0005) and higher inpatient mortality (66.7% vs 10.3%; OR=17.5; 95% CI: 8.00, 38.3). Respiratory failure requiring invasive ventilation occurred in 24 (68.6%) patients with COVID-19, whilst 18 (51.4%) and 21 (60%) required renal and/or circulatory support, respectively. Conclusion: Presence of both myocardial injury and COVID-19 is associated with high in-hospital mortality. Systemic consequences may be associated with higher mortality risk in this patient group.
High-sensitivity cardiac troponin assays have emerged as a powerful tool in the management of patients presenting acutely to hospital with suspected cardiac chest pain. Recent guidelines emphasize the reassurance offered by low troponin concentrations early after admission. We describe a patient with known coronary artery disease, who presented with a classical history of recurrent myocardial ischaemia. High-sensitivity cardiac Troponin-I concentrations remained in the low-normal sex-specific reference range, despite serial testing on the day of admission, and despite recurrent pain with dynamic ECG changes. Urgent coronary angiography confirmed severe multi-vessel disease. He required an intra-aortic balloon pump within 24 h due to clinical instability, and had urgent coronary artery bypass surgery a few days later. This case confirms that "unstable angina" remains a genuine entity. It highlights the hazards of over-reliance on any single test and serves as a reminder of the importance of integrating tests with clinical assessment.
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