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SICU Journal Meeting

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... cardiac ischemia and the absence of noncardiac causes of biomarker elevation ... Diagnosis of Perioperative Myocardial Infarction ... – PowerPoint PPT presentation

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Title: SICU Journal Meeting


1
SICU Journal Meeting
  • Troponin I vs CK-MB
  • Is It Time for A Change?
  • Ri ???

2
Why do we measure it?
  • To detect new ACS(UA/MI)
  • To monitor post op course
  • Prognosis
  • Risk stratification
  • Choice of further treatment
  • Clinical study

3
ACS Concept
4
  • ACC/AHA 2002 Guideline Update for the Management
    of Patients With Unstable Angina and
    NonST-Segment Elevation Myocardial Infarction

5
  • ACC/AHA 2002 Guideline Update for the Management
    of Patients With Unstable Angina and
    NonST-Segment Elevation Myocardial Infarction

6
  • National Academy of Clinical Biochemistry,
    November 5, 1999.

7
CKMB
8
Troponin
9
Mortality Rates at 42 Days According to the Level
of Cardiac Troponin I Measured at Enrollment
Antman, E. M. et. al. N Engl J Med
19963351342-1349
10
Mortality Rates at 42 Days According to the Time
from the Onset of Pain to Study Enrollment and
the Base-Line Cardiac Troponin I Levels
Antman, E. M. et. al. N Engl J Med
19963351342-1349
11
  • Am J Cardiol 1998811405-10.

12
Why is it sensitive specific?
  • cardiac troponin I not normally circulate in the
    blood and is 13 times more abundant in the
    myocardium than CK-MB
  • ?low signal-to-noise ratio
  • elevated CK-MB levels confounded by injury of
    skeletal muscles
  • Clin Chem 1994401291-1295.

13
Odds Ratios for Cardiac Events Associated with
Treatment with Abciximab at the Six-Month
Follow-up, in Subgroups of Patients Defined
According to Serum Troponin T (TnT) Level, Serum
Creatine Kinase MB Fraction (CK-MB), ST-Segment
Depression, and T-Wave Inversion
Hamm, C. W. et. al. N Engl J Med
19993401623-1629
14
Ability of Minor Elevations of Troponins I and T
to Predict Benefit From an Early Invasive
Strategy in Patients With Unstable Angina and
Non-ST Elevation Myocardial Infarction
  • JAMA. 20012862405-2412.

15
(No Transcript)
16
ACS Risk Stratification
  • Circulation. 2000102118-122.

17
ESC ACC Panel on Biochemistry
  • Its Time for a Change to a Troponin Standard
  • Cardiac troponins (I or T) the preferred markers
    for the diagnosis of myocardial injury
  • The diagnostic and prognostic value of
    elevations irrespective of the mechanism of
    cellular injury
  • The term myocardial infarction evidence of
    cardiac damage, as detected by marker proteins in
    a clinical setting consistent with myocardial
    ischemia
  • Circulation. 20001021216-1220.

18
ESC ACC Panel on Biochemistry
  • Patients who undergo interventional procedures
    and cardiac surgery have elevations because of
    the procedures.
  • Classification of elevations, their significance,
    and the care of patients that results should be
    individualized to these groups.
  • Circulation. 20001021216-1220.

19
AHA Scientific StatementDefinitions for Acute
Coronary Heart Disease in Epidemiology and
Clinical Research Studies
  • The order of diagnostic value cTngtCK-MBmgtCK-MBgtCK
    .
  • Adequate set of biomarkers At least 2
    measurements of the same marker taken at least 6
    hours apart
  • Diagnostic biomarkers At least 1 positive
    biomarker in an adequate set of biomarkers
    showing a rising or falling pattern in clinical
    cardiac ischemia and the absence of noncardiac
    causes of biomarker elevation
  • Circulation. 20031082543.

20
Diagnosis of Perioperative Myocardial Infarction
21
Peak Cardiac Troponin I Mass in Patients with and
without Perioperative Myocardial Infarction
Adams, J. E. et. al. N Engl J Med 1994330670-674
22
Peak MB Creatine Kinase Mass in Patients with and
without Perioperative Myocardial Infarction
Adams, J. E. et. al. N Engl J Med 1994330670-674
23
Cardiac Troponin I Predicts Short-Term Mortality
in Vascular Surgery Patients
  • Circulation. 20021062366

24
  • Circulation. 20021062366.

25
For CABG
  • Eur J Cardiothorac Surg. 19981357-65.

26
  • Eur J Cardiothorac Surg. 19981357-65.

27
cTnI qualifies as a useful tool
  • (1)a quick diagnostic test with high specificity
    for myocardial tissue
  • (2)high diagnostic efficiency of 94 at 12 h and
    98 at 24 h( cut-off value 9.8, 11.6 ng/ml)
  • sensitivity100, specificity 97
  • (3)sufficient by a single determination 24 h post
    op for diagnosis of PMI and quantitation of the
    amount of myocardial damage
  • Eur J Cardiothorac Surg. 19981357-65.

28
Shall we measure it?
  • To detect new ACS(UA/MI)
  • To monitor post op course
  • Prognosis
  • Risk stratification
  • Choice of further treatment
  • Clinical study

29
Cost in NTUH
  • CKMB 150 NT
  • Troponin I 450 NT

30
Thanks for Your Attention
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