Major adverse cardiovascular events after diagnosis of myocardial injury and types 1 and 2 myocardial infarction

Aims Limited US outcome data exist among patients with myocardial injury and types 1 and 2 myocardial infarction (MI) evaluated with high-sensitivity cardiac troponin (hs-cTn). Methods and results This is an observational US cohort study of emergency department (ED) patients undergoing hs-cTnT measurement. Cases with >= 1 hs-cTnT increase >99th percentile were adjudicated following the Fourth Universal Definition of MI. Post-discharge major adverse cardiovascular events (MACE) included death, MI, heart failure (HF) hospitalization, stroke or transient ischaemic attack, and new-onset atrial fibrillation or flutter during 2 years follow-up. Among 2002 patients, 857 (43%) had >= 1 hs-cTnT >99th percentile. Among these, 702 (81.9%) had myocardial injury, 64 (7.5%) had type 1 MI, and 91 (10.6%) had type 2 MI. Compared with patients without myocardial injury, type 2 MI [8.4 vs. 50%; adjusted hazard ratio (HR) 2.31, 95% confidence interval (CI) 1.49-3.58] and myocardial injury (8.4 vs. 47%; adjusted HR 3.13, 95% CI 2.39-4.09) had a higher risk of MACE, in large part because of death and HF hospitalizations. Compared with patients with type 1 MI, type 2 MI (23 vs. 50%; adjusted HR 2.24; 95% CI 1.23-4.10) and myocardial injury (23 vs. 47%; adjusted HR 2.02; 95% CI 1.20-3.40) also have a higher risk of MACE. Conclusion Among unselected US ED patients undergoing hs-cTnT measurement, most increases are due to myocardial injury, and type 2 MI is more frequent than type 1 MI. Patients with myocardial injury and type 2 MI have morbid outcomes, in large part due to death and HF

Clinical Impact of High-Sensitivity Cardiac Troponin T Implementation in the Community

BACKGROUND Limited U.S. data exist regarding high-sensitivity cardiac troponin (cTn) implementation. OBJECTIVES This study sought to evaluate the impact of high-sensitivity cardiac troponin T (cTnT) implementation. METHODS Observational U.S. cohort study of emergency department (ED) patients undergoing measurement of cTnT during the transition from 4th (pre-implementation March 12, 2018, to September 11, 2018) to 5th generation (Gen) cTnT (post-implementation September 12, 2018, to March 11, 2019). Diagnoses were adjudicated following the Fourth Universal Definition of Myocardial Infarction (MI). Resources evaluated included length of stay, hospitalizations, and cardiac testing. RESULTS In this study, 3,536 unique patients were evaluated, including 2,069 and 2,491 ED encounters pre-and post implementation. Compared with 4th Gen cTnT, encounters with $1 cTnT >99th percentile increased using 5th Gen cTnT (15$1 cTnT 99th percentile increased using 5th Gen cTnT (15% vs. 47%; p < 0.0001). Acute MI (3.3% vs. 8.1%; p < 0.0001) and myocardial injury (11% vs. 38%; p < 0.0001) increased. Although type 1 MIs increased (1.7% vs. 2.9%; p = 0.0097), the overall MI increase was largely due to more type 2 MIs (1.6% vs. 5.2%; p < 0.0001). Women were less likely than men to have MI using 4th Gen cTnT (2.3% vs. 4.4%; p = 0.008) but not 5th Gen cTnT (7.7% vs. 8.5%; p = 0.46). Overall length of stay and stress testing were reduced, and angiography was increased (all p < 0.05). Among those without cTnT increases, there were more E

Rapid Exclusion of Acute Myocardial Injury and Infarction With a Single High-Sensitivity Cardiac Troponin T in the Emergency Department: A Multicenter United States Evaluation

Background: There are good data to support using a single high-sensitivity cardiac troponin T (hs-cTnT) below the limit of detection of 5 ng/L to exclude acute myocardial infarction. Per the US Food and Drug Administration, hs-cTnT can only report to the limit of quantitation of 6 ng/L, a threshold for which there are limited data. Our goal was to determine whether a single hs-cTnT below the limit of quantitation of 6 ng/L is a safe strategy to identify patients at low risk for acute myocardial injury and infarction. Methods: The efficacy (proportion identified as low risk based on baseline hs-cTnT99th percentile in those with an initial hs-cTnT<6 ng/L). The clinically intended rule-out strategy combining a nonischemic ECG with a baseline hs-cTnT<6 ng/L was subsequently tested in an adjudicated cohort in which the diagnostic performance for ruling out acute myocardial infarction and safety (myocardial infarction or death at 30 days) were evaluated. Results: A total of 85 610 patients were evaluated in the CV Data Mart Biomarker cohort, among which 24 646 (29%) had a baseline hs-cTnT<6 ng/L. Women were more likely than men to have hs-cTnT<6 ng/L (38% versus 20%, P<0.0001). Among 11 962 patients with baseline hs-cTnT<6 ng/L and serial measurements, only 1.2% developed acute myocardial injury, resulting in a negative predictive value of 98.8% (95% CI, 98.6-99.0) and sensitivity of 99.6% (95% CI, 99.5-99.6). In the adjudicated cohort, a nonischemic ECG with hs-cTnT<6 ng/L identified 33% of patients (610/1849) as low risk and resulted in a negative predictive value and sensitivity of 100% and a 30-day rate of 0.2% for myocardial infarction or death. Conclusions: A single hs-cTnT below the limit of quantitation of 6 ng/L is a safe and rapid method to identify a substantial number of patients at very low risk for acute myocardial injury and infarction

Precambrian geodynamics and ore formation: The Fennoscandian Shield

Compared with present-day global plate tectonics, Archaean and Palaeoproterozoic plate tectonics may have involved faster moving, hotter plates that accumulated less sediment and contained a thinner section of lithospheric mantle. This scenario also fits with the complex geodynamic evolution of the Fennoscandian Shield from 2.06 to 1.78 Ga when rapid accretion of island arcs and several microcontinent-continent collisions in a complex array of orogens was manifested in short-lived but intense orogenies involving voluminous magmatism. With a few exceptions, all major ore deposits formed in specific tectonic settings between 2.06 and 1.78 Ga and thus a strong geodynamic control oil ore deposit formation is suggested. All orogenic gold deposits formed syn- to post-peak metamorphism and their timing reflects the orogenic younging of the shield towards the SW and west. Most orogenic gold deposits formed during periods of crustal shortening with peaks at 2.72 to 2.67, 1.90 to 1.86 and 1.85 to 1.79 Ga. The ca. 2.5 to 2.4 Ga Ni-Cu PGE deposits formed both as part of layered igneous complexes and associated with mafic volcanism, in basins formed during rifling of the Archaean craton at ca. 2.5 to 2.4 Ga. Svecokarelian ca. 1.89 to 1.88 Ga Ni-Cu deposits are related to mafic-ultramafic rocks intruded along linear belts at the accretionary margins of microcratons. All major VMS deposits in the Fennoscandian Shield formed between 1.97 and 1.88 Ga, in extensional settings, prior to basin inversion and accretion. The oldest "Cyprus-type" deposits were obducted onto the Archaean continent during the onset of convergence. The Pyhasalmi VMS deposits formed at 1.93 to 1.91 Ga in primitive, bimodal arc complexes during extension of the arc. In contrast, the Skellefte VMS deposits are 20 to 30 million years younger and formed in a strongly extensional intra-arc region that developed on continental or mature arc crust. Deposits in the Bergslagen-Uusimaa belt are similar in age to the Skellefte deposits and formed in a microcraton that collided with the Karelian craton at ca. 1.88 to 1.87 Ga. The Bergslagen-Uusimaa belt is interpreted as an intra-continental, or continental margin back-arc, extensional region developed on older continental crust. Iron oxide-copper-gold (IOCG) deposits are diverse in style. At least the oldest mineralizing stages, at ca. 1.88 Ga, are coeval with calc-alkaline to monzonitic magmatism and coeval and possibly cogenetic subaerial volcanism more akin to continental arcs or to magmatic arcs inboard of the active subduction zone. Younger mineralization of similar style took place when S-type magmatism occurred at ca. 1.80 to 1.77 Ga during cratonization distal to the active N-S-trending subduction zone in the west. Possibly, interaction of magmatic fluids with evaporitic sequences in older rift sequences was important for ore formation. Finally, the large volumes of anorthositic magmas that characterize the Sveconorwegian Orogeny formed a major concentration of Ti in the SW part of the Sveconorwegian orogenic belt under granulite facies conditions, about 40 million years after the last regional deformation of the Sveconorwegian Orogeny, between ca. 930 and 920 Ma. (c) 2005 Elsevier B.V. All rights reserved