Article

Coronary Artery Disease

Ischaemic heart disease is the single most common cause of death worldwide and its frequency is increasing.1

What is Acute Coronary Syndrome?

Acute Coronary Syndrome (ACS) is a situation of medical emergency that refers to a group of clinical conditions compatible with acute myocardial ischemia (AMI) and/or infarction. ACS occurs when the blood supply to the heart is blocked due to destabilization of a previously stable atherosclerotic plaque.2,3

There are three classifications according to the presence of Electrocardiography (ECG) abnormalities and Myocardial Infarction (MI):2,3

  • Unstable angina;
  • NSTEMI (non ST-segment-elevation MI);
  • STEMI (ST-segment-elevation MI).2,3

How is AMI diagnosed?

 

Myocardial infarction (MI), commonly known as a heart attack, is defined pathologically as the irreversible death of myocardial cells caused by ischemia. Clinically, MI is a syndrome that can be recognized by a set of symptoms, chest pain being the hallmark of these symptoms in most cases, supported by biochemical laboratory changes, electrocardiographic (ECG) changes, or findings on imaging modalities able to detect myocardial injury and necrosis.


The Fourth Universal Definition of Myocardial infarction proposes that the term acute myocardial infarction(AMI) should be used only when there is acute myocardial damage with clinical evidence of acute myocardial ischemia.4


The diagnosis of AMI requires elevation or drop in troponin values and the presence of at least one of the following criteria:
 

  1. Symptoms of acute myocardial ischemia;
  2. New ischemic electrocardiographic (EKG) findings;
  3. Development of new abnormal Q waves;
  4. Imaging evidence of loss of viable myocardium or abnormal motion of any of the walls due to ischemic cause; or
  5. Identification of a coronary thrombus on angiography.

     

Should this not be the case, then the proposal is to refer only to myocardial damage.4 High-sensitivity (hs)–cTn assays are recommended for routine clinical use.5 Myocardial injury is defined as being present when blood levels of cTn are increased above the 99th percentile upper reference limit (URL).5,6 The injury may be acute, as evidenced by a newly detected dynamic rising and/or falling pattern of cTn values above the 99th percentile URL, or chronic, in the setting of persistently elevated cTn levels.

Unmet needs in CAD patient management

Sepsis - Patient journey

1. Screening

Risk prediction in asymptomatic individuals1

2. Rule-out ACS

Only 25% of patients presenting at EDwith chest pain have AMI but 80% will have a prolonged stay in ED: Need to facilitate earlier dischange2

3. Cornerstone to accelerate the diagnosis of AMI
 

High-sensitivity Troponin testings with clinical assessments are the cornerstone for the diagnosis of Acute Myocardial Infarction(AMI)3

4. Patient management

22-25% of patients suspected of AMI remain undiagnosed within 1- hour: Need to improve triaging4

5. Risk stratification

Perioperative myocardial injury(PMI) is an often undetected complication of noncardiac surgery in patients at high-CV risk, and is strongly associated with mortality5

6. Therapy selection

High risk (diabetes & chemotherapy) and medium risk patients (elderly & chronic kidney diseases)6

References
 

  1. Devereaux PJ, Sessler DI. N Engl J Med 2015;373:2258-2269, 2. Devereaux PJ, et al. JAMA 2017;317:1642-1651; 3. Puelacher C, et al. Circulation 2018;137:1221-1232
  2. Cervellin et al “The clinics of acute coronary syndrome.”
  3. Twerenbold et al “Clinical Use of High-Sensitivity Cardiac Troponin in Patients With Suspected Myocardial Infarction”
  4. Reichlin et al “APACE ” One-Hour Rule-out and Rule-in
  5. Deveraux PJ et al "Association of postoperative high sensitivity troponin levels with myocardial injury and 30-day mortality among patients undergoing cardiac surgery, 2017.
  6. Tavares et al Endocrinol. Metab. 2016; 60 (2)


*ED: Emergency Department

Partner with the pioneer to improve AMI diagnosis


Through a combination of technical improvements and supporting the right clinical studies Roche has improved the way AMI is diagnosed around the world. This has led to the ability to triage over 75% of ED chest pain patients in as little as 1 hour.

A rapid and accurate diagnosis is critical when patients arrive with acute chest pain and suspected heart attack are in the emergency department. The TRAPID-AMI study7 results show that the cardiac Troponin T-high sensitive test from Roche provides a reliable and rapid diagnosis within a 1-hour, and much faster than the 3 to 6 hours observation time using the conventional diagnostic approach.


There are significant benefits to this approach, including:

  • Improved care

  • Shorter length of stay in ED

  • Substantial cost savings

  • ESC Guidelines compliance

     

Troponin is the preferred biomarker in defining AMI according to the European Society of Cardiology (ESC) guidelines.8 In addition, it is the gold standard to distinguish between AMI and non-AMI patients.8,9

Elecsys® Troponin T-high sensitive (TnT-hs) can reduce the time needed to rule-in or rule-out NSTEMI to as little as just 1 hour.10-12

References

 

  1. ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation, Ibanez et al 2017
  2. Roffi M, et al. Eur Heart J 2016; 37:267-315
  3. Amsterdam E A, et al. Circulation 2014; 130:e344-e426
  4. Thygesen K, Alpert JS, Jaffe AS, et al. Fourth universal definition of myocardial infarction. J Am College Cardiol 2018;72:2231–2264.
  5. Thygesen K, Mair J, Giannitsis E, Mueller C, Lindahl B, Blankenberg S, Huber K, Plebani M, Biasucci LM. Tubaro M, Collinson P, Venge P, Hasin Y, Galvani M, Koenig W, Hamm C, Alpert JS, Katus H, Jaffe AS; Study Group on Biomarkers in Cardiology of the ESC Working Group on Acute Cardiac Care. How to use high-sensitivity cardiac troponins in acute cardiac care.Eur Heart J. 2012
  6. Apple FS, Jaffe AS, Collinson P, Mockel M, Ordonez-Llanos J, Lindahl B, Hollander J, Plebani M, Than M, Chan MH; on behalf of the International Federation of Clinical Chemistry (IFCC) Task Force on Clinical Applications of Cardiac Bio-Markers. IFCC educational materials on selected analytical and clinical applications of high sensitivity cardiac troponin assays. Clin Biochem. 2015; 48:201–203
  7. Mueller C, Giannitsis E, Christ M, et al; TRAPID-AMI Investigators. Multicenter evaluation of a 0-hour/1-hour algorithm in the diagnosis of myocardial infarction with high-sensitivity cardiac troponin T. Ann Emerg Med. 2016;68:76–87.e4. 
  8. A Maziar Zafari, MD, PhD, FACC, FAHA; Medscape 2019
  9. De Luca, et al. Circulation 2004; 109:1223-1225
  10. Roffi, et al. Eur Heart J. 2016; 37:267-315
  11. Thygesen K, et al. Eur Heart J. 2019; 40:237–269
  12. Twerenbold R, et al. JACC 2019; 74:483 – 94