21 Dec Combined Biomarkers Copeptin and hsTroponin Help Exclude Severe Coronary Stenosis

Dr. Leclercq

MedicalResearch.com Interview with:
Florence Leclercq, MD, PhD
Department of Cardiology
Arnaud de Villeneuve Hospital
University hospital of Montpellier
Montpellier,France

Medical Research: What is the background for this study? What are the main findings?

Response: Patients with history of coronary artery disease (CAD) are considered as a population with high risk of further coronary events. However, frequent pre-existing ECG changes observed in these patients result in difficulty interpreting new ECG aspects in case of chest discomfort. Furthermore, anxiety frequently induced non-cardiac causes of chest pain in these patients, leading to unjustified admission to cardiology units.  Moreover, levels of troponin are usually higher in patients with previous CAD compared to patients without history of angina, resulting in difficulty interpreting baseline values in this population.  Conversely, copeptin may be influenced by the severity of myocardial ischemia and resulting endogenous stress, and could be a useful additional marker to exclude severe coronary stenosis in high-risk patients with recent chest pain.
This propective monocentric study evaluates the incremental value of copeptin associated with high-sensitivity cardiac T troponin (hs-cTnT) to exclude severe coronary stenosis in 96 patients with coronary artery disease  (CAD) and acute chest pain.  

Mean age of patients was 60 +/- 13.8 years and the mean time between chest pain onset and blood samples of copeptin was 4.2 +/-2.7 hours. According to clinical decision, coronary angiography was performed in 71 patients (73.9 %) and severe stenosis diagnosed in 14 of them (14.6%). No ischemia was detected on SPECT imaging (n=25). Among the 69 patients with a negative kinetic of hs-cTnT and a negative baseline copeptin, 5 (7.4%) had a severe stenosis (NPV 0.93; 95% CI: 0.87-0.99), 4 of them related to in-stent restenosis (NPV for exclusion of native coronary stenosis: 0.98; 95% CI: 0.93-1).

We can conclude that in patients with preexisting CAD, and once Acute Myocardial Infarction (AMI) is excluded, copeptin increases the NPV of  hs-cTnT  to rule out severe coronary stenosis or significant myocardial ischemia. Coronary stenosis not detected with this strategy concerned exclusively in-stent restenosis or stenosis related to infarcted -related  coronary artery without myocardial viability.

Medical Research: What should clinicians and patients take away from your report?

Response: While ruling out of  Acute Myocardial Infarction is crucial in patients with history of CAD and chest pain, exclusion of any severe cardiac conditions like unstable angina or critical coronary stenosis is also required in this population. While recent data showed the need to optimize ICU triage for patients who will truly benefit, identification of risk of immediate cardiac events in high-risk patients, like patients with history of coronary artery disease, is particularly relevant

Our study suggests that in patients with pre-existing CAD, acute chest pain and once ACS is excluded, copeptin provides a useful additional triage strategy to exclude severe coronary stenosis or stenosis inducing ischemia, particularly those not related to in-stent restenosis.

Subgroup analysis of our study showed that native severe stenosis could be excluded in many patients with the combined biomarkers hs-cTnT-copeptin strategy, whereas the only patients not detected had in-stent restenosis or stenosis concerning a myocardial area without  viability for 1 of them. In-stent restenosis is considered as associated with better prognosis than native stenosis and incidence of coronary thrombosis in these cases is uncommon. It is therefore probably more relevant to exclude in the ICU native tight stenosis vs in-stent tight restenosis.

Medical Research: What recommendations do you have for future research as a result of this study?

Response:  Due to the observational and monocentric design of the study, these results required need to be confirmed in a prospective interventional  study.

Citation:

Copeptin and high-sensitivity cardiac troponin to exclude severe coronary stenosis in patients with chest pain and coronary artery disease
Leclercq, Florence et al.
The American Journal of Emergency Medicine , Volume 0 , Issue 0
Published Online:December 14, 2015

DOI: http://dx.doi.org/10.1016/j.ajem.2015.12.017

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Florence Leclercq, MD, PhD (2015). Combined Biomarkers Copeptin and hsTroponin Help Exclude Severe Coronary Stenosis 

Last Updated on December 22, 2015 by Marie Benz MD FAAD