972-104 Diagnostic Ability of a Single Admission Value of Serum Myoglobin, Troponin-T and CK-MB in Acute Myocardial Infarction Patients

Admission serum myoglobin 1Mb) and troponin-T(TNT) levels were evaluated vs admission CK-MB (mass assay) levels and the admission ECG ST elevation (ST↑)>2 m V. for their diagnostic values in patients with suspected acute myocardial infarction (AMI) before thrombolytic treatment.Consecutive patients (n=153), presenting with chest pain at rest>30 min but<12 hrs, unresponsive to nitroglycerin, were included. The ultimate diagnosis of AMI was based on a rise and fall pattern of CK-MB (catalytic assay) and a peak value>15 U/I, and/or the development of Q-waves on the ECG.AMI (n = 81) (median (95% C))No-AMI(n = 72) (median (95% C))pminutes to admission179,6 (100-210)179.7 (105-240)NSadmission Mb (μg/|)123,0 (79-1540)46.2(40.0-506)<0.00001admission TNT (μg/|)0,082(0.03-l.15)0.003 (0.00-0,01)<0.00005admission CK-MB(μg/|)54 (36-7.6)1.85(1.4-2.6)<0.00001admission ECG (ST↑)n = 50n = 9<0.00005The admission Mb, TNT and CK-MB concentrations were significantly higher in the AMI patients compared to the No-AMI patients, and there was no overlap of the 95% CI of the medians between the two groups. For AMI diagnosis, the predictive values of positive and negative tests were 0.84 and 0.62 for Mb>110μg/l; 0.70 and 0.62 for TNT>0,02 μg/l; 1.00 and 0,53 for CK-MB>9.5 μg/l, and 0.85 and 0.67 for the ECG STt,ConclusionA rise in serum Mb and TNT at admission, even below the usual diagnostic cut-off values for AMI diagnosis, has an acceptable diagnostic accuracy. For more prompt and widespread use of fibrinolytic therapy we propose a lowering of the diagnostic cut-off values for serum Mb, TNT and CK-MB for admission diagnosis of MI

CT or invasive coronary angiography in stable chest pain

Background: In the diagnosis of obstructive coronary artery disease (CAD), computed tomography (CT) is an accurate, noninvasive alternative to invasive coronary angiography (ICA). However, the comparative effectiveness of CT and ICA in the management of CAD to reduce the frequency of major adverse cardiovascular events is uncertain. Methods: We conducted a pragmatic, randomized trial comparing CT with ICA as initial diagnostic imaging strategies for guiding the treatment of patients with stable chest pain who had an intermediate pretest probability of obstructive CAD and were referred for ICA at one of 26 European centers. The primary outcome was major adverse cardiovascular events (cardiovascular death, nonfatal myocardial infarction, or nonfatal stroke) over 3.5 years. Key secondary outcomes were procedure-related complications and angina pectoris. Results: Among 3561 patients (56.2% of whom were women), follow-up was complete for 3523 (98.9%). Major adverse cardiovascular events occurred in 38 of 1808 patients (2.1%) in the CT group and in 52 of 1753 (3.0%) in the ICA group (hazard ratio, 0.70; 95% confidence interval [CI], 0.46 to 1.07; P=0.10). Major procedure-related complications occurred in 9 patients (0.5%) in the CT group and in 33 (1.9%) in the ICA group (hazard ratio, 0.26; 95% CI, 0.13 to 0.55). Angina during the final 4 weeks of follow-up was reported in 8.8% of the patients in the CT group and in 7.5% of those in the ICA group (odds ratio, 1.17; 95% CI, 0.92 to 1.48). Conclusions: Among patients referred for ICA because of stable chest pain and intermediate pretest probability of CAD, the risk of major adverse cardiovascular events was similar in the CT group and the ICA group. The frequency of major procedure-related complications was lower with an initial CT strategy. (Funded by the European Union Seventh Framework Program and others; DISCHARGE ClinicalTrials.gov number, NCT02400229

Effect of body mass index on effectiveness of CT versus invasive coronary angiography in stable chest pain: The DISCHARGE trial

Background Recent trials support the role of cardiac CT in the evaluation of symptomatic patients suspected of having coronary artery disease (CAD); however, body mass index (BMI) has been reported to negatively impact CT image quality. Purpose To compare initial use of CT versus invasive coronary angiography (ICA) on clinical outcomes in patients with stable chest pain stratified by BMI category. Materials and Methods This prospective study represents a prespecified BMI subgroup analysis of the multicenter Diagnostic Imaging Strategies for Patients with Stable Chest Pain and Intermediate Risk of Coronary Artery Disease (DISCHARGE) trial conducted between October 2015 and April 2019. Adult patients with stable chest pain and a CAD pretest probability of 10%–60% were randomly assigned to undergo initial CT or ICA. The primary end point was major adverse cardiovascular events (MACE), including cardiovascular death, nonfatal myocardial infarction, or stroke. The secondary end point was an expanded MACE composite, including transient ischemic attack, and major procedure-related complications. Competing risk analyses were performed using the Fine and Gray subdistribution Cox proportional hazard model to assess the impact of the relationship between BMI and initial management with CT or ICA on the study outcomes, whereas noncardiovascular death and unknown causes of death were considered competing risk events. Results Among the 3457 participants included, 831 (24.0%), 1358 (39.3%), and 1268 (36.7%) had a BMI of less than 25, between 25 and 30, and greater than 30 kg/m2, respectively. No interaction was found between CT or ICA and BMI for MACE (P = .29), the expanded MACE composite (P = .38), or major procedure-related complications (P = .49). Across all BMI subgroups, expanded MACE composite events (CT, 10 of 409 [2.4%] to 23 of 697 [3.3%]; ICA, 26 of 661 [3.9%] to 21 of 422 [5.1%]) and major procedure-related complications during initial management (CT, one of 638 [0.2%] to five of 697 [0.7%]; ICA, nine of 630 [1.4%] to 12 of 422 [2.9%]) were less frequent in the CT versus ICA group. Participants with a BMI exceeding 30 kg/m² exhibited a higher nondiagnostic CT rate (7.1%, P = .044) compared to participants with lower BMI. Conclusion There was no evidence of a difference in outcomes between CT and ICA across the three BMI subgroups