Cardiovascular Biomarkers in Early Discrimination of Type 2 MI
Quick Takes
- Novel cardiovascular biomarkers showed only modest promise for the early discrimination of type 2 myocardial infarction (T2MI).
- Clinical parameters remain the only means for reliable identification of patients with T2MI.
- At this time, most patients will require coronary angiography and/or noninvasive functional or anatomic testing to achieve a high level of diagnostic discrimination between T2MI and T1MI.
Study Questions:
Can novel cardiovascular biomarkers aid physicians in the early discrimination of type 2 myocardial infarction (T2MI) from type 1 myocardial infarction (T1MI)?
Methods:
The investigators conducted an international, multicenter, prospective diagnostic study in 12 emergency departments in five countries (Switzerland, Spain, Italy, Poland, and the Czech Republic) with patients presenting with acute chest discomfort to the emergency departments. The study quantified the discrimination of high-sensitivity cardiac troponin (hs-cTn) T, hs-cTn I, and 17 novel cardiovascular biomarkers measured in subsets of consecutively enrolled patients against a reference standard (final diagnosis), centrally adjudicated by two independent cardiologists according to the fourth universal definition of MI, using all information, including cardiac imaging and serial measurements of hs-cTnT or hs-cTnI. Receiver operating characteristic curves were constructed to assess the area under the curve (AUC) for the discrimination between T1MI and T2MI and between MI and no MI.
Results:
Among 5,887 patients, 1,106 (18.8%) had an adjudicated final diagnosis of MI; of these, 860 patients (77.8%) had T1MI, and 246 patients (22.2%) had T2MI. Patients with T2MI versus those with T1MI had lower concentrations of biomarkers quantifying cardiomyocyte injury hs-cTnT (median [interquartile range (IQR)], 30 (17-55) ng/L vs. 58 (28-150) ng/L), hs-cTnI (median [IQR], 23 [10-83] ng/L vs. 115 [28-576] ng/L; p < 0.001), and cardiac myosin-binding protein C (at presentation: median [IQR], 76 [38-189] ng/L vs. 257 [75-876] ng/L; p < 0.001), but higher concentrations of biomarkers quantifying endothelial dysfunction, microvascular dysfunction, and/or hemodynamic stress (median [IQR] values: C-terminal proendothelin-1 [ CT-proET-1], 97 [75-134] pmol/L vs. 68 [55-91] pmol/L; midregional proadrenomedullin, 0.97 [0.67-1.51] pmol/L vs. 0.72 [0.53-0.99] pmol/L; midregional pro–A-type natriuretic peptide [MR-proANP], 378 [207-491] pmol/L vs. 152 [90-247] pmol/L; and growth differentiation factor-15 [GDF-15], 2.26 [1.44-4.35] vs. 1.56 [1.02-2.19] ng/L; all p < 0.001). Discrimination for these biomarkers, as quantified by the area under the receiver operating characteristics curve, was modest (hs-cTnT, 0.67 [95% CI, 0.64-0.71]; hs-cTn I, 0.71 [95% CI, 0.67-0.74]; cardiac myosin-binding protein C, 0.67 [95% CI, 0.61-0.73]; CT-proET-1, 0.73 [95% CI, 0.63-0.83]; midregional proadrenomedullin, 0.66 [95% CI, 0.60-0.73]; MR-proANP, 0.77 [95% CI, 0.68-0.87]; and GDF-15, 0.68 [95% CI, 0.58-0.79]).
Conclusions:
The authors concluded that biomarkers quantifying myocardial injury, endothelial dysfunction, microvascular dysfunction, and/or hemodynamic stress provided modest discrimination in early, noninvasive diagnosis of T2MI.
Perspective:
This study reports that four novel cardiovascular biomarkers were higher in T2MI versus T1MI and showed modest promise for the early discrimination of T2MI. These include MR-proANP, considered to quantify hemodynamic stress; CT-proET-1, considered to quantify endothelial dysfunction; midregional proadrenomedullin, considered to quantify microvascular and endothelial dysfunction; and GDF-15, considered to quantify hemodynamic stress, inflammation, and vascular aging. Overall, these data suggest that clinical parameters remain the only means for reliable identification of patients with T2MI. At this time, most patients will require coronary angiography and/or noninvasive functional or anatomic testing to achieve a high level of diagnostic discrimination between T2MI and T1MI.
Clinical Topics: Acute Coronary Syndromes, Cardiovascular Care Team, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, ACS and Cardiac Biomarkers, Interventions and ACS, Interventions and Imaging, Angiography, Computed Tomography, Nuclear Imaging
Keywords: Acute Coronary Syndrome, Adrenomedullin, Biomarkers, Cardiac Myosins, Chest Pain, Coronary Angiography, Diagnostic Imaging, Diagnostic Tests, Routine, Emergency Service, Hospital, Endothelin-1, Growth Differentiation Factor 15, Hemodynamics, Inflammation, Myocardial Infarction, Myocytes, Cardiac, Natriuretic Peptides, Receptors, Adrenomedullin, Tomography, X-Ray Computed, Troponin I, Troponin T
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