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The concentration of troponin I is increased in patients with acute-onset atrial fibrillation
Letters to the Editor
579
http://dx.doi.org/10.1016/j.ijcard.2014.03.115 0167-5273/© 2014 Elsevier Ireland Ltd. All rights reserved.
The concentration of troponin I is increased in patients with acute-onset atrial fibrillation Giuseppe Lippi a,⁎, Alessandra Picanza a, Alessandro Formentini b, Laura Bonfanti c, Gianfranco Cervellin c a b c
Laboratory of Clinical Chemistry and Hematology, Academic Hospital of Parma, Parma, Italy Service of Transfusion Medicine and Immunohematology, Academic Hospital of Parma, Parma, Italy Emergency Department, Academic Hospital of Parma, Parma, Italy
a r t i c l e
i n f o
Article history: Received 29 January 2014 Accepted 14 March 2014 Available online 21 March 2014 Keyword: Atrial fibrillation Troponin I Cardiovascular disease Risk assessment
In a recent article, Parwani et al. showed that atrial fibrillation (AF) in patients admitted to the emergency department (ED) with clinical symptoms suggestive of myocardial ischemia is frequently associated with elevations of cardiospecific troponin I (TnI) [1]. Since definitive information about the frequency of troponin release during acute-onset AF (AAF) is lacking to the best our knowledge, we carried out a retrospective observational study by retrieving data from the electronic database of our hospital about all ED visits for AAF (defined as onset of symptoms within 48 h) recorded in the year 2013. According to currently available guidelines, the definition of AAF included both first-diagnosed AF and paroxysmal AF (PAF) [2]. The ED of the Academic Hospital of Parma is a large urban facility, with approximately 90,000 visits per year. The concentration of TnI was measured in all patients included in this study with the contemporary sensitive immunoassay Beckman Coulter AccuTnI, on Unicel DxI (Beckman Coulter, Brea, CA, USA) [3]. The concentration of cTnI was also assessed with the same method and during the same period in a population of 125 ostensibly healthy blood donors (77 males and 48 females, age range 21–54 years), who had this biomarker measured for definition of local 99th percentile of the upper reference limit (URL), as specified by the recommendations of the Clinical and Laboratory Standards Institute (CLSI) [4]. Results of TnI were finally expressed as median, interquartile range (IQR) and range (minimum and maximum values). The quality of TnI data was systematically validated throughout the study period by regular internal quality control (IQC) procedures and participation in an External Quality Assessment Scheme (EQAS). Differences between groups were assessed by Wilcoxon–Mann– Whitney test (for continuous variables) and χ2 test with Yates' correction (for categorical variables), using Analyse-it (Analyse-it Software Ltd, Leeds, UK). The investigation was performed in accord with the Declaration of Helsinki and under the terms of all relevant local legislation. The 99th percentile URL calculated from our local population of blood donors was 0.03 μg/L. Overall, 474 cases of AAF were diagnosed in the ED in the year 2013 (232 males and 242 females; age range 22–96 years).
⁎ Corresponding author at: U.O. Diagnostica Ematochimica, Azienda OspedalieroUniversitaria di Parma, Via Gramsci, 14, 43126 Parma, Italy. Tel.: +39 0521 703050; fax: +39 0521 703791. E-mail addresses: [email protected], [email protected] (G. Lippi).
The median concentration of TnI was found to be significantly higher in patients with AAF (0.01 μg/L; IQR, b0.01 to 0.02 μg/L; range, b0.01 to 0.54 μg/L) than in controls (b0.01 μg/L; IQR, b0.01 to b0.01 μg/L; range, b0.01 to 0.03 μg/L; p b 0.001) (Fig. 1). The frequency of values exceeding the 99th URL was also significantly greater in the group of patients with AAF (86/474, 18%) than in the control population (3/125, 2%; p b 0.001). The results of this study confirm the existence of an association between AAF and increased values of TnI, even when this biomarker is measured with a contemporary-sensitive immunoassay in a patient population with no symptoms of myocardial ischemia. Overall, the data observed in our investigation mirrors that reported by Parwani et al., who found that TnI measured with a point-of-care test was elevated in 15% of AF patients (18% in our case series), although the median concentration of TnI that we have found was approximately 30-fold lower than that reported by Parwani et al. (i.e., 0.01 versus 0.37 μg/L) [1]. This aspect is probably attributable to different analytical characteristics of the two TnI methods and, especially, to the different population of AF patients. Similar results have also been previously published by Anegawa et al. in a small population of AF patients (n = 12) [5], in whom the concentration of high-sensitivity troponin T (hs-TnT) was found to be nearly double than in non-AF subjects (0.012 ± 0.005 versus 0.006 ± 0.006 μg/L; p = 0.002). Due to a substantially increased risk of cardiovascular mortality and morbidity, AF requires an early and appropriate management. AAF represents a frequent reason for ED evaluation and the appropriate management strategy (e.g., rate-control versus rhythm control,
Fig. 1. Concentration of troponin I (TnI) in ostensibly healthy blood donors and patients admitted to the emergency department with acute-onset atrial fibrillation.
580
Letters to the Editor
antithrombotic therapy) should hence be based on timely risk stratification of stroke, bleeding and cardiovascular morbidity. Along with conventional risk assessment tools such as CHA2DS2-VASc and HAS-BLED scores, cardiospecific troponins may hence provide an important complementary information about the thromboembolic risk and the prognosis of patients with AF [6]. Interestingly, it is conceivable that an increased troponin value in these patients would not invariably mirror the presence of relevant coronary artery stenosis, but may be more commonly associated with tachycardia per se, thus reflecting a cardiac injury (e.g., myocyte necrosis and/or fibrosis) which may be directly attributed to AF [7]. References [1] Parwani AS, Boldt LH, Huemer M, et al. Atrial fibrillation-induced cardiac troponin I release. Int J Cardiol 2013;168:2734–7.
[2] Camm AJ, Lip GY, De Caterina R, et al, ESC Committee for Practice Guidelines (CPG). 2012 focused update of the ESC guidelines for the management of atrial fibrillation: an update of the 2010 ESC guidelines for the management of atrial fibrillation. Developed with the special contribution of the European Heart Rhythm Association. Eur Heart J 2012;33:2719–47. [3] Lippi G, Cervellin G. Assay characteristics and diagnostic improvement from contemporary to high-sensitivity troponin I immunoassays. Am J Med 2013;126: e9–e10. [4] Clinical. Defining, establishing, and verifying reference intervals in the clinical laboratory; approved guideline. CLSI document C28-A3. Third edition. Wayne, PA: Clinical and Laboratory Standards Institute; 2008. [5] Anegawa T, Kai H, Adachi H, et al. High-sensitive troponin T is associated with atrial fibrillation in a general population. Int J Cardiol 2012;156:98–100. [6] Providência R, Paiva L, Barra S, Faustino A. Troponin rise in patients with atrial fibrillation: a marker of adverse prognosis and increased thromboembolic risk. Int J Cardiol 2013;168:4889. [7] Parwani AS, Boldt LH. Atrial fibrillation-induced cardiac troponin I release. Int J Cardiol 2014;172:220.
http://dx.doi.org/10.1016/j.ijcard.2014.03.113 0167-5273/© 2014 Elsevier Ireland Ltd. All rights reserved.
Gait speed and comprehensive geriatric assessment: Two keys to improve the management of older persons with aortic stenosis M. Lilamand a,b,⁎, N. Dumonteil c, F. Nourhashémi a,d, O. Hanon e,f, B. Marcheix g, O. Toulza a, S. Elmalem a, G. Abellan van Kan a,d, A. Raynaud-Simon b, B. Vellas a,d, J. Afilalo h, M. Cesari a,d a
Department of Internal Medicine and Geriatrics, Gérontopôle, Toulouse, France Department of Geriatrics, Bichat–Claude Bernard University Hospital, Paris, France Department of Cardiology, University Hospital of Rangueil, Toulouse, France d INSERM, UMR 1027, Toulouse, France e Department of Geriatrics, Broca Hospital, Paris, France f University Paris Descartes, EA 4468, Paris, France g Department of Cardiac Surgery, University Hospital of Rangueil, Toulouse, France h Divisions of Cardiology and Clinical Epidemiology, Jewish General Hospital, McGill University, Montreal, Quebec, Canada b c
a r t i c l e
i n f o
Article history: Received 31 January 2014 Accepted 14 March 2014 Available online 21 March 2014 Keywords: Aortic stenosis Gait speed Frailty Geriatric cardiology
Key points • UGS is the gold standard screening assessment for estimating a global risk profile in older persons. • Individuals with UGS ≥ 0.83 m/s should be considered as “robust” and potentially eligible for standard treatment. • Individuals UGS b0.83 m/s may require a more in-depth evaluation (i.e. the CGA performed by the geriatrician). • According to the CGA results, tailored interventions may be collegially decided for preparing the frail patient to the TAVR or SAVR intervention or find the most suitable treatment for his/her management.
Abbreviations: UGS, usual gait speed; CGA, comprehensive geriatric assessment; TAVR, transcatheter aortic valve replacement; SAVR, surgical aortic valve replacement. ⁎ Corresponding author at: Institut du Vieillissement, 37 Allées Jules Guesde, 31000 Toulouse, France. Tel.: + 33 5 61145657; fax: +33 5 61145640. E-mail address: [email protected] (M. Lilamand).
• The value of UGS should be considered only as support to the clinical judgment but should never redirect care and resources without the educated interpretation of the referent clinician. Aortic stenosis (AS) commonly affects older people. Surgical aortic valve replacement (SAVR), which is a generally safe procedure, associated with low morbi-mortality and good long term outcome established itself as the gold standard treatment [1]. The innovative transcatheter AVR (TAVR) offered an alternative treatment option for AS, which is superior to medical management in patients at prohibitive surgical risk, and non-inferior to SAVR in patients at very high risk [2,3]. Both procedures were associated with similar one-month and one-year mortality, and with comparable improvements of post-surgery cardiac symptoms and quality of life [4]. However, valvular interventions in older adults are still associated with high consumption of healthcare resources, and approximately half of patients do not have improvement in quality of life or are deceased within one year [5]. Unsurprisingly, older age is being reported as the main factor limiting the access of patients to AVR. Though, older persons (often defined according to different age thresholds) represent an extremely heterogeneous group. Thus, the “chronological age” criterion is often inappropriate for identifying the “geriatric patient”. The estimation of the general health status of older persons (taking into account the weight of their comorbidities, functional and cognitive performances) may provide more relevant information than the mere “chronological” age when assessing patient's suitability for a specific intervention. Frailty has been defined not only as a state of vulnerability and a multidimensional syndrome characterized by decreased reserve and diminished resistance to stressors, but also as a transition phase
579
http://dx.doi.org/10.1016/j.ijcard.2014.03.115 0167-5273/© 2014 Elsevier Ireland Ltd. All rights reserved.
The concentration of troponin I is increased in patients with acute-onset atrial fibrillation Giuseppe Lippi a,⁎, Alessandra Picanza a, Alessandro Formentini b, Laura Bonfanti c, Gianfranco Cervellin c a b c
Laboratory of Clinical Chemistry and Hematology, Academic Hospital of Parma, Parma, Italy Service of Transfusion Medicine and Immunohematology, Academic Hospital of Parma, Parma, Italy Emergency Department, Academic Hospital of Parma, Parma, Italy
a r t i c l e
i n f o
Article history: Received 29 January 2014 Accepted 14 March 2014 Available online 21 March 2014 Keyword: Atrial fibrillation Troponin I Cardiovascular disease Risk assessment
In a recent article, Parwani et al. showed that atrial fibrillation (AF) in patients admitted to the emergency department (ED) with clinical symptoms suggestive of myocardial ischemia is frequently associated with elevations of cardiospecific troponin I (TnI) [1]. Since definitive information about the frequency of troponin release during acute-onset AF (AAF) is lacking to the best our knowledge, we carried out a retrospective observational study by retrieving data from the electronic database of our hospital about all ED visits for AAF (defined as onset of symptoms within 48 h) recorded in the year 2013. According to currently available guidelines, the definition of AAF included both first-diagnosed AF and paroxysmal AF (PAF) [2]. The ED of the Academic Hospital of Parma is a large urban facility, with approximately 90,000 visits per year. The concentration of TnI was measured in all patients included in this study with the contemporary sensitive immunoassay Beckman Coulter AccuTnI, on Unicel DxI (Beckman Coulter, Brea, CA, USA) [3]. The concentration of cTnI was also assessed with the same method and during the same period in a population of 125 ostensibly healthy blood donors (77 males and 48 females, age range 21–54 years), who had this biomarker measured for definition of local 99th percentile of the upper reference limit (URL), as specified by the recommendations of the Clinical and Laboratory Standards Institute (CLSI) [4]. Results of TnI were finally expressed as median, interquartile range (IQR) and range (minimum and maximum values). The quality of TnI data was systematically validated throughout the study period by regular internal quality control (IQC) procedures and participation in an External Quality Assessment Scheme (EQAS). Differences between groups were assessed by Wilcoxon–Mann– Whitney test (for continuous variables) and χ2 test with Yates' correction (for categorical variables), using Analyse-it (Analyse-it Software Ltd, Leeds, UK). The investigation was performed in accord with the Declaration of Helsinki and under the terms of all relevant local legislation. The 99th percentile URL calculated from our local population of blood donors was 0.03 μg/L. Overall, 474 cases of AAF were diagnosed in the ED in the year 2013 (232 males and 242 females; age range 22–96 years).
⁎ Corresponding author at: U.O. Diagnostica Ematochimica, Azienda OspedalieroUniversitaria di Parma, Via Gramsci, 14, 43126 Parma, Italy. Tel.: +39 0521 703050; fax: +39 0521 703791. E-mail addresses: [email protected], [email protected] (G. Lippi).
The median concentration of TnI was found to be significantly higher in patients with AAF (0.01 μg/L; IQR, b0.01 to 0.02 μg/L; range, b0.01 to 0.54 μg/L) than in controls (b0.01 μg/L; IQR, b0.01 to b0.01 μg/L; range, b0.01 to 0.03 μg/L; p b 0.001) (Fig. 1). The frequency of values exceeding the 99th URL was also significantly greater in the group of patients with AAF (86/474, 18%) than in the control population (3/125, 2%; p b 0.001). The results of this study confirm the existence of an association between AAF and increased values of TnI, even when this biomarker is measured with a contemporary-sensitive immunoassay in a patient population with no symptoms of myocardial ischemia. Overall, the data observed in our investigation mirrors that reported by Parwani et al., who found that TnI measured with a point-of-care test was elevated in 15% of AF patients (18% in our case series), although the median concentration of TnI that we have found was approximately 30-fold lower than that reported by Parwani et al. (i.e., 0.01 versus 0.37 μg/L) [1]. This aspect is probably attributable to different analytical characteristics of the two TnI methods and, especially, to the different population of AF patients. Similar results have also been previously published by Anegawa et al. in a small population of AF patients (n = 12) [5], in whom the concentration of high-sensitivity troponin T (hs-TnT) was found to be nearly double than in non-AF subjects (0.012 ± 0.005 versus 0.006 ± 0.006 μg/L; p = 0.002). Due to a substantially increased risk of cardiovascular mortality and morbidity, AF requires an early and appropriate management. AAF represents a frequent reason for ED evaluation and the appropriate management strategy (e.g., rate-control versus rhythm control,
Fig. 1. Concentration of troponin I (TnI) in ostensibly healthy blood donors and patients admitted to the emergency department with acute-onset atrial fibrillation.
580
Letters to the Editor
antithrombotic therapy) should hence be based on timely risk stratification of stroke, bleeding and cardiovascular morbidity. Along with conventional risk assessment tools such as CHA2DS2-VASc and HAS-BLED scores, cardiospecific troponins may hence provide an important complementary information about the thromboembolic risk and the prognosis of patients with AF [6]. Interestingly, it is conceivable that an increased troponin value in these patients would not invariably mirror the presence of relevant coronary artery stenosis, but may be more commonly associated with tachycardia per se, thus reflecting a cardiac injury (e.g., myocyte necrosis and/or fibrosis) which may be directly attributed to AF [7]. References [1] Parwani AS, Boldt LH, Huemer M, et al. Atrial fibrillation-induced cardiac troponin I release. Int J Cardiol 2013;168:2734–7.
[2] Camm AJ, Lip GY, De Caterina R, et al, ESC Committee for Practice Guidelines (CPG). 2012 focused update of the ESC guidelines for the management of atrial fibrillation: an update of the 2010 ESC guidelines for the management of atrial fibrillation. Developed with the special contribution of the European Heart Rhythm Association. Eur Heart J 2012;33:2719–47. [3] Lippi G, Cervellin G. Assay characteristics and diagnostic improvement from contemporary to high-sensitivity troponin I immunoassays. Am J Med 2013;126: e9–e10. [4] Clinical. Defining, establishing, and verifying reference intervals in the clinical laboratory; approved guideline. CLSI document C28-A3. Third edition. Wayne, PA: Clinical and Laboratory Standards Institute; 2008. [5] Anegawa T, Kai H, Adachi H, et al. High-sensitive troponin T is associated with atrial fibrillation in a general population. Int J Cardiol 2012;156:98–100. [6] Providência R, Paiva L, Barra S, Faustino A. Troponin rise in patients with atrial fibrillation: a marker of adverse prognosis and increased thromboembolic risk. Int J Cardiol 2013;168:4889. [7] Parwani AS, Boldt LH. Atrial fibrillation-induced cardiac troponin I release. Int J Cardiol 2014;172:220.
http://dx.doi.org/10.1016/j.ijcard.2014.03.113 0167-5273/© 2014 Elsevier Ireland Ltd. All rights reserved.
Gait speed and comprehensive geriatric assessment: Two keys to improve the management of older persons with aortic stenosis M. Lilamand a,b,⁎, N. Dumonteil c, F. Nourhashémi a,d, O. Hanon e,f, B. Marcheix g, O. Toulza a, S. Elmalem a, G. Abellan van Kan a,d, A. Raynaud-Simon b, B. Vellas a,d, J. Afilalo h, M. Cesari a,d a
Department of Internal Medicine and Geriatrics, Gérontopôle, Toulouse, France Department of Geriatrics, Bichat–Claude Bernard University Hospital, Paris, France Department of Cardiology, University Hospital of Rangueil, Toulouse, France d INSERM, UMR 1027, Toulouse, France e Department of Geriatrics, Broca Hospital, Paris, France f University Paris Descartes, EA 4468, Paris, France g Department of Cardiac Surgery, University Hospital of Rangueil, Toulouse, France h Divisions of Cardiology and Clinical Epidemiology, Jewish General Hospital, McGill University, Montreal, Quebec, Canada b c
a r t i c l e
i n f o
Article history: Received 31 January 2014 Accepted 14 March 2014 Available online 21 March 2014 Keywords: Aortic stenosis Gait speed Frailty Geriatric cardiology
Key points • UGS is the gold standard screening assessment for estimating a global risk profile in older persons. • Individuals with UGS ≥ 0.83 m/s should be considered as “robust” and potentially eligible for standard treatment. • Individuals UGS b0.83 m/s may require a more in-depth evaluation (i.e. the CGA performed by the geriatrician). • According to the CGA results, tailored interventions may be collegially decided for preparing the frail patient to the TAVR or SAVR intervention or find the most suitable treatment for his/her management.
Abbreviations: UGS, usual gait speed; CGA, comprehensive geriatric assessment; TAVR, transcatheter aortic valve replacement; SAVR, surgical aortic valve replacement. ⁎ Corresponding author at: Institut du Vieillissement, 37 Allées Jules Guesde, 31000 Toulouse, France. Tel.: + 33 5 61145657; fax: +33 5 61145640. E-mail address: [email protected] (M. Lilamand).
• The value of UGS should be considered only as support to the clinical judgment but should never redirect care and resources without the educated interpretation of the referent clinician. Aortic stenosis (AS) commonly affects older people. Surgical aortic valve replacement (SAVR), which is a generally safe procedure, associated with low morbi-mortality and good long term outcome established itself as the gold standard treatment [1]. The innovative transcatheter AVR (TAVR) offered an alternative treatment option for AS, which is superior to medical management in patients at prohibitive surgical risk, and non-inferior to SAVR in patients at very high risk [2,3]. Both procedures were associated with similar one-month and one-year mortality, and with comparable improvements of post-surgery cardiac symptoms and quality of life [4]. However, valvular interventions in older adults are still associated with high consumption of healthcare resources, and approximately half of patients do not have improvement in quality of life or are deceased within one year [5]. Unsurprisingly, older age is being reported as the main factor limiting the access of patients to AVR. Though, older persons (often defined according to different age thresholds) represent an extremely heterogeneous group. Thus, the “chronological age” criterion is often inappropriate for identifying the “geriatric patient”. The estimation of the general health status of older persons (taking into account the weight of their comorbidities, functional and cognitive performances) may provide more relevant information than the mere “chronological” age when assessing patient's suitability for a specific intervention. Frailty has been defined not only as a state of vulnerability and a multidimensional syndrome characterized by decreased reserve and diminished resistance to stressors, but also as a transition phase