Serially measured high-sensitivity cardiac troponin T, N-terminal-pro-B-type natriuretic peptide, high-sensitivity C-reactive protein, and growth differentiation factor 15 for risk assessment after acute coronary syndrome: the BIOMArCS cohort.

AIMS: Evidence regarding the role of serial measurements of biomarkers for risk assessment in post-acute coronary syndrome (ACS) patients is limited. The aim was to explore the prognostic value of four, serially measured biomarkers in a large, real-world cohort of post-ACS patients. METHODS AND RESULTS: BIOMArCS is a prospective, multi-centre, observational study in 844 post-ACS patients in whom 12 218 blood samples (median 17 per patient) were obtained during 1-year follow-up. The longitudinal patterns of high-sensitivity cardiac troponin T (hs-cTnT), N-terminal-pro-B-type natriuretic peptide (NT-proBNP), high-sensitivity C-reactive protein (hs-CRP), and growth differentiation factor 15 (GDF-15) were analysed in relation to the primary endpoint (PE) of cardiovascular mortality and recurrent ACS using multivariable joint models. Median age was 63 years, 78% were men and the PE was reached by 45 patients. The average biomarker levels were systematically higher in PE compared with PE-free patients. After adjustment for 6-month post-discharge Global Registry of Acute Coronary Events score, 1 standard deviation increase in log[hs-cTnT] was associated with a 61% increased risk of the PE [hazard ratio (HR) 1.61, 95% confidence interval (CI) 1.02-2.44, P = 0.045], while for log[GDF-15] this was 81% (HR 1.81, 95% CI 1.28-2.70, P = 0.001). These associations remained significant after multivariable adjustment, while NT-proBNP and hs-CRP were not. Furthermore, GDF-15 level showed an increasing trend prior to the PE (Structured Graphical Abstract). CONCLUSION: Longitudinally measured hs-cTnT and GDF-15 concentrations provide prognostic value in the risk assessment of clinically stabilized patients post-ACS. CLINICAL TRIAL REGISTRATION: The Netherlands Trial Register. Currently available at URL https://trialsearch.who.int/; Unique Identifiers: NTR1698 and NTR1106.

Prognostic significance of residual cumulative ST-segment deviation after mechanical reperfusion in patients with ST-segment elevation myocardial infarction.

BACKGROUND: The analysis of ST-segment resolution is a well established and easy method to assess myocardial perfusion after reperfusion therapy for ST-segment elevation myocardial infarction (STEMI). The aim of the current study was to identify an easy and practical instrument for patients' prognostic stratification after angioplasty for STEMI by the use of only postprocedural ST-segment analysis. METHODS: Our population is represented by a total of 1286 patients treated with primary angioplasty for STEMI. Residual ST-segment elevation and deviation were analyzed at 3 hours after revascularization. One-year follow-up data were collected prospectively in all patients. RESULTS: Patients with impaired ST-segment normalization were older, with larger prevalence of diabetes, anterior infarction, hypertension, signs of heart failure at presentation, lower rate of postprocedural thrombolysis in myocardial infarction 3 flow, myocardial blush grades 2 to 3, and successful reperfusion. A linear relationship was found between both residual cumulative ST-segment elevation and deviation with 1-year mortality. At multivariate analysis, postprocedural residual cumulative ST deviation (RR 1.31, 95% CI 1.06-1.63, P = .014), but not residual cumulative ST elevation (RR 0.95, 95% CI 0.55-1.67, P = .87), was an independent predictor of 1-year mortality. Furthermore, we found that residual cumulative ST-segment deviation provides better prognostic information (area receiver operating characteristic [ROC] = 0.733) than ST-segment elevation resolution (area ROC = 0.636) or ST-segment deviation resolution (area ROC = 0.660) in terms of 1-year mortality. These data were confirmed for both anterior and nonanterior infarct location. CONCLUSION: This study showed that postprocedural residual cumulative ST-segment deviation is an independent prognostic parameter in patients treated with primary angioplasty, providing even better prognostic information than ST-segment resolution.

Impact of ST-segment depression resolution on mortality after successful mechanical reperfusion in patients with ST-segment elevation acute myocardial infarction.

The aim of the present study was to evaluate the additional prognostic effect of ST-depression resolution in 610 patients who had ST-elevation myocardial infarction and underwent successful primary angioplasty (postprocedural Thrombolysis In Myocardial Infarction 3 flow and complete resolution of ST-segment elevation). Incomplete resolution of ST-segment depression (<70%) was observed in 50 patients (8.2%). These patients were older, had a higher Killip's class at presentation, had larger infarcts, and had an increased 1-year mortality (10% vs 2%, p = 0.0004). At multivariate analysis, incomplete resolution of ST-segment depression was an independent predictor of 1-year mortality (p = 0.028).

Combining baseline clinical descriptors and real-time response to therapy: the incremental prognostic value of continuous ST-segment monitoring in acute myocardial infarction.

BACKGROUND: Clinical descriptors and ST-segment recovery variables hold prognostic information for clinical outcome after thrombolysis for acute myocardial infarction (MI). We sought to define the incremental prognostic value of continuous 12-lead ST-segment monitoring variables to clinical risk descriptors identified by the Global Utilization of Streptokinase and TPA (alteplase) for Occluded Coronary Arteries (GUSTO-I) trial 30-day mortality analysis. METHODS: Of 1,777 patients enrolled in continuous ST-segment substudies from the Thrombolysis and Angioplasty in Myocardial Infarction (TAMI-9), GUSTO-I, Duke University Clinical Cardiology Study (DUCCS-II), Integrilin to manage Platelet Aggregation to Combat Thrombus in Acute Myocardial Infarction (IMPACT-AMI), Promotion of Reperfusion by Inhibition of Thrombin During Myocardial Infarction Evolution (PRIME), and Platelet Aggregation Receptor Antagonist Dose Investigation and Reperfusion Gain in Myocardial Infarction (PARADIGM) trials, 825 patients qualified for assessment of time to recovery. ST recovery variables analyzed were time to stable ST-recovery and late ST elevation. Patients who were at low clinical risk (n = 261) had no high-risk descriptors, and patients at high clinical risk (n = 564) had at least 1 of these high-risk descriptors: age >or=70 years, systolic blood pressure or=90 beats/min, anterior MI, or previous MI. High (n = 90), moderate (n = 318), and low (n =417) ST-risk groups were defined by the presence of both slow ST recovery and late ST elevation, one or the other, or neither, respectively. End points analyzed were inhospital death and combined death, reinfarction, or congestive heart failure. RESULTS: There was a trend toward increased mortality rate in the high-clinical/high-ST-risk group. For the composite end point, ST subgrouping resulted in significant event stratification in both patients at low and high clinical risk. In multivariable analysis, age and heart rate were independent predictors of both mortality and the composite end point. Late ST elevation added incremental prognostic information. CONCLUSION: Age, heart rate, and late ST elevation are powerful, independent predictors of adverse clinical outcome. Continuous monitoring allows noninvasive assessment of the response to therapy. Consequently, this technique will enhance the potential to risk-stratify individual patients in a real-time setting.