Prognostic implications of high-sensitivity cardiac troponin T assay in a real-world population with non-ST-elevation acute coronary syndrome

Background: High-sensitivity cardiac troponin T (hsTnT) was recently approved for clinical use by the Food and Drug Administration. The transition from contemporary to hsTnT assays requires a thorough understanding of the clinical differences between these assays. Hypothesis: HsTnT may provide a more accurate prognostic stratification than contemporary cardiac troponin I (cTnI) in patients with non-ST-segment elevation acute coronary syndromes (NSTE-ACS). Methods: HsTnT and cTnI were measured in 644 patients with CK-MB negative NSTE-ACS who were enrolled in the prospective multicenter SPAI (Stratificazione Prognostica dell'Angina Instabile) study. Patients were stratified at the 99th percentile reference limit for each assay. The primary endpoint was cardiovascular death (CVD) or non-fatal myocardial infarction (MI); the secondary endpoint was the occurrence of unstable angina (UA). Follow-up lasted 180 days. Results: Patients with hsTnT ≥99th percentile were at higher risk of CVD/MI (30-day: 5.9% vs 0.8%, p = 0.001; 180-day: 11.1% vs 4.7%, p = 0.004), also after adjusting for TIMI Risk Score. No significant difference in CVD/MI at 180-day was found between hsTnT-positive/cTnI-negative and hsTnT-negative/cTnI-negative patients (adjHR 1.61, 95% CI 0.74–3.49, p = 0.232). Occurrence of UA was not differently distributed between hsTnT groups dichotomized at the 99th percentile (12.4% vs 12.5% p = 0.54). Conclusions: Our investigation on a real-world NSTE-ACS population showed good prognostic performance of hsTnT in the risk stratification of the hard endpoint, but did not demonstrate the improved prognostic ability of hsTnT over contemporary cTn. Neither troponin assay predicted the recurrence of UA, suggesting the acute rise of cardiac troponin as a marker of severity, but not the occurrence of future coronary instability. Keywords: High-sensitivity cardiac troponin, Biomarkers, Acute coronary syndromes, Prognostic risk stratificatio

Fractal analysis of plaque border, a novel method for the quantification of atherosclerotic plaque contour irregularity, is associated with pro-atherogenic plasma lipid profile in subjects with non-obstructive carotid stenoses

<div><p>Background and aims</p><p>Plaque border irregularity is a known imaging characteristic of vulnerable plaques, but its evaluation heavily relies on subjective evaluation and operator expertise. Aim of the present work is to propose a novel fractal-analysis based method for the quantification of atherosclerotic plaque border irregularity and assess its relation with cardiovascular risk factors.</p><p>Methods and results</p><p>Forty-two asymptomatic subjects with carotid stenosis underwent ultrasound evaluation and assessment of cardiovascular risk factors. Total, low-density lipoprotein (LDL), high-density lipoprotein (HDL) plasma cholesterol and triglycerides concentrations were measured for each subject. Fractal analysis was performed in all the carotid segments affected by atherosclerosis, i.e. 147 segments. The resulting fractal dimension (FD) is a measure of irregularity of plaque profile on long axis view of the plaque. FD in the severest stenosis (main plaque FD,mFD) was 1.136±0.039. Average FD per patient (global FD,gFD) was 1.145±0.039. FD was independent of other plaque characteristics. mFD significantly correlated with plasma HDL (r = -0.367,p = 0.02) and triglycerides-to-HDL ratio (r = 0.480,p = 0.002).</p><p>Conclusions</p><p>Fractal analysis is a novel, readily available, reproducible and inexpensive technique for the quantitative measurement of plaque irregularity. The correlation between low HDL levels and plaque FD suggests a role for HDL in the acquisition of morphologic features of plaque instability. Further studies are needed to validate the prognostic value of fractal analysis in carotid plaques evaluation.</p></div

Bland Altman plot for fractal analysis.

<p>Panel A shows Bland-Altman plot for inter-operator reproducibility analysis, while Panel B shows results for intra-operator analysis.</p

Correlation between fractal dimension, plasma HDL cholesterol and triglycerides-to-HDL ratio.

<p>Panel A-B compare and contrast two representative patients. The subject in Panel A appear to have a higher plaque border complexity and lower HDL-C compared to the subject in panel B. Lower panels show a magnified image of plaque contour. Panel C displays the scatter plot of fractal dimension versus HDL-C, while Panel D shows the scatter plot of fractal dimension versus triglycerides-to-HDL ratio. HDL-C = high density lipoprotein cholesterol; FD = fractal dimension; Trig:HDL = triglycerides-to-HDL ratio.</p

Population characteristics.

<p>Population characteristics.</p

Fractal analysis of all segments involved by atherosclerosis in a representative subject.

<p>Panel A shows the image of the right carotid bifurcation, in which segments affected by atherosclerosis can be identified: the internal carotid artery (denoted with c) and the carotid bulb, the latter by a plaque extending in the external carotid artery (d). Panel B displays the left carotid bifurcation of the same patient. Again, two involved segments can be identified: the internal carotid artery (by a plaque extending from the carotid bulb, e) and the carotid bulb (f). Panels C-F display the magnified contour extracted from plaque c-f respectively. Fractal dimension (FD) for each contour is indicated in each panel. The total number of involved segments in this patient was 4. Average FD was 1.137.</p

Fractal analysis of a plaque located in the right carotid artery of a representative subject.

<p>Panel A shows the longitudinal view of a non-obstructive plaque located in the right common carotid artery. Panel B shows the same image after binarization using a modified IsoData algorithm, while Panel C displays contour extraction by computing edges in the areas of highest gradient magnitude using the Sobel operator. Panel D shows two grids of different scales generated as part of the evaluation of fractal dimension (FD) using a box counting algorithm. The FD of the plaque border corresponds to the opposite of the slope of logarithmic plot of the number of boxes containing the objects (Y, Ln Count) vs. the dimension of the boxes side (X, Ln<b>ε</b>). The higher is the FD, the higher is the irregularity of the plaque surface.</p

L'appendicectomia videolaparoscopica : tecnica ed esperienza di 250 casi

The videolaparoscopic approach for appendectomy was suggested many years ago and it has spread widely around the world due to its advantages over the traditional technique. Moreover, the technology reached with the instrumentation makes this operation simple, safe and rapid with adequate training. From October 1991 to December 1993, in the Department of General Surgery of the S. Giuseppe Hospital - Cattedra di Chirurgia Generale of the University of Milan, we performed 250 videolaparoscopic appendectomies. The operating technique is similar to the other authors', but with personal variations. Great number of interventions, 177, were elective and 73 were in emergency. The operation was converted to open procedure in 10 cases (4%) and we had postoperative complications that required a reintervention only in one case (0,4%). All patients had a short postoperative course and an excellent cosmetic result. The videolaparoscopic compared with the laparotomic approach offers a better exploration of the abdominal cavity, allows for easier location of the appendix, reduces the period of inactivity, and also in 'difficult' appendectomies gives an excellent cosmetic result. These advantages are appreciable both in elective and in emergency operations