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Indian Heart Journal 2021Coronavirus disease 2019 (COVID-19) has been reported to cause worse outcomes in patients with underlying cardiovascular disease, especially in patients with acute... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Coronavirus disease 2019 (COVID-19) has been reported to cause worse outcomes in patients with underlying cardiovascular disease, especially in patients with acute cardiac injury, which is determined by elevated levels of high-sensitivity troponin. There is a paucity of data on the impact of congestive heart failure (CHF) on outcomes in COVID-19 patients.
METHODS
We conducted a literature search of PubMed/Medline, EMBASE, and Google Scholar databases from 11/1/2019 till 06/07/2020, and identified all relevant studies reporting cardiovascular comorbidities, cardiac biomarkers, disease severity, and survival. Pooled data from the selected studies was used for metanalysis to identify the impact of risk factors and cardiac biomarker elevation on disease severity and/or mortality.
RESULTS
We collected pooled data on 5967 COVID-19 patients from 20 individual studies. We found that both non-survivors and those with severe disease had an increased risk of acute cardiac injury and cardiac arrhythmias, our pooled relative risk (RR) was - 8.52 (95% CI 3.63-19.98) (p < 0.001); and 3.61 (95% CI 2.03-6.43) (p = 0.001), respectively. Mean difference in the levels of Troponin-I, CK-MB, and NT-proBNP was higher in deceased and severely infected patients. The RR of in-hospital mortality was 2.35 (95% CI 1.18-4.70) (p = 0.022) and 1.52 (95% CI 1.12-2.05) (p = 0.008) among patients who had pre-existing CHF and hypertension, respectively.
CONCLUSION
Cardiac involvement in COVID-19 infection appears to significantly adversely impact patient prognosis and survival. Pre-existence of CHF, and high cardiac biomarkers like NT-pro BNP and CK-MB levels in COVID-19 patients correlates with worse outcomes.
Topics: Biomarkers; COVID-19; Creatine Kinase, MB Form; Heart Failure; Humans; Natriuretic Peptide, Brain; Pandemics; Peptide Fragments; Prognosis; SARS-CoV-2; Severity of Illness Index; Survival Rate; Troponin
PubMed: 33714416
DOI: 10.1016/j.ihj.2020.12.002 -
Sports Medicine (Auckland, N.Z.) Aug 2019We performed a systematic review, meta-analysis and meta-regression of exercise studies that sought to determine the relationship between cardiac troponin (cTn) and left... (Meta-Analysis)
Meta-Analysis
OBJECTIVE
We performed a systematic review, meta-analysis and meta-regression of exercise studies that sought to determine the relationship between cardiac troponin (cTn) and left ventricular (LV) function. The second objective was to determine how study-level and exercise factors influenced the variation in the body of literature.
DATA SOURCES
A systematic search of Pubmed Central, Science Direct, SPORTDISCUS and MEDLINE databases.
ELIGIBILITY CRITERIA
Original research articles published between 1997 and 2018 involving > 30 mins of continuous exercise, measuring cardiac troponin event rates and either LV ejection fraction (LVEF) or the ratio of the peak early (E) to peak late (A) filling velocity (E/A ratio).
DESIGN
Random-effects meta-analyses and meta-regressions with four a priori determined covariates (age, exercise heart rate [HR], duration, mass).
REGISTRATION
The systematic search strategy was registered on the PROSPERO database (CRD42018102176).
RESULTS
Pooled cTn event rates were evident in 45.6% of participants (95% confidence interval (CI) 33.6-58.2); however, the overall effect was non-significant (P > 0.05). There were significant (P < 0.05) reductions in E/A ratio of - 0.38 (SMD = - 1.2, 95% CI - 1.4 to - 1.0), and LVEF of - 2.02% (SMD = - 0.38, 95% CI - 0.7 to - 0.1) pre- to post-exercise. Increased exercise HR was a significant predictor of troponin release and E/A ratio. Participant age was negatively associated with cTn release. There was a significant negative association between E/A ratio with increased rates of cTn release (P < 0.05).
CONCLUSIONS
High levels of statistical heterogeneity and methodological variability exist in the majority of EICF studies. Our findings show that exercise intensity and age are the most powerful determinants of cTn release. Diastolic function is influenced by exercise HR and cTn release, which implies that exercise bouts at high intensities are enough to elicit cTn release and reduce LV diastolic function. Future EICF studies should (1) utilise specific echocardiographic techniques such as myocardial speckle tracking, (2) ensure participants are euhydrated during post-exercise measurements, and (3) repeat measures in the hours following exercise to assess symptom progression or recovery. It is also recommended to further explore the relationship between aging, training history, and exercise intensity on cTn release and functional changes.
Topics: Age Factors; Biomarkers; Exercise; Humans; Troponin; Ventricular Function, Left
PubMed: 31214979
DOI: 10.1007/s40279-019-01142-5 -
European Heart Journal. Acute... Mar 2014This systematic review aimed to investigate the diagnostic accuracy of combined cardiac troponin (cTn) and copeptin assessment in comparison to cTn alone for early... (Meta-Analysis)
Meta-Analysis Review
AIMS
This systematic review aimed to investigate the diagnostic accuracy of combined cardiac troponin (cTn) and copeptin assessment in comparison to cTn alone for early rule-out of acute myocardial infarction (AMI).
METHODS
Primary studies were eligible if they evaluated diagnostic accuracy for cTn with and without copeptin in patients with symptoms suggestive of AMI. AMI was defined according to the universal definition, using detection of cTn as a marker for myocardial necrosis. Eligible studies were identified by searching electronic databases (Medline, EMBASE, Science Citation Index Expanded, CINAHL, Pascal, and Cochrane) from inception to March 2013, reviewing conference proceedings and contacting field experts and the copeptin manufacturer.
RESULTS
In 15 studies totalling 8740 patients (prevalence of AMI 16%), adding copeptin improved the sensitivity of cTn assays (from 0.87 to 0.96, p=0.003) at the expense of lower specificity (from 0.84 to 0.56, p<0.001). In 12 studies providing data for 6988 patients without ST-segment elevation, the summary sensitivity and specificity estimates were 0.95 (95% CI 0.89 to 0.98) and 0.57 (95% CI 0.49 to 0.65) for the combined assessment of cTn and copeptin. When a high-sensitivity cTnT assay was used in combination with copeptin, the summary sensitivity and specificity estimates were 0.98 (95% CI 0.96 to 1.00) and 0.50 (95% CI 0.42 to 0.58).
CONCLUSION
Despite substantial between-study heterogeneity, this meta-analysis demonstrates that copeptin significantly improves baseline cTn sensitivity. Management studies are needed to establish the effectiveness and safety of measuring copeptin in combination with high-sensitivity cTnT for early rule-out of AMI without serial testing.
Topics: Biomarkers; Diagnosis, Differential; Glycopeptides; Humans; Myocardial Infarction; Predictive Value of Tests; Protein Precursors; ROC Curve; Troponin I; Troponin T
PubMed: 24562800
DOI: 10.1177/2048872613514015 -
Forensic Science, Medicine, and... Sep 2018Conducted Electrical Weapons (CEWs) are being used as the preferred non-lethal force option for police and special forces worldwide. This new technology challenges an... (Review)
Review
Conducted Electrical Weapons (CEWs) are being used as the preferred non-lethal force option for police and special forces worldwide. This new technology challenges an exposed opponent similarly to the way they would be challenged by physical exercise combined with emotional stress. While adrenergic and metabolic effects have been meta-analyzed and reviewed, there has been no systematic review of the effects of CEWs on skeletal and cardiac muscle. A systematic and careful search of the MedLine database was performed to find publications describing pathophysiological cardiac and skeletal muscle effects of CEWs. For skeletal muscle effects, we analyzed all publications providing changes in creatine kinase, myoglobin and potassium. For cardiac effects, we analyzed reported troponin changes and arrhythmias related to short dart-to-heart-distances. Conducted electrical weapons satisfy all relevant electrical safety standards and there are, to date, no proven electrocution incidents caused by CEWs. A potential cardiovascular risk has been recognized by some of the experimental animal data. The effects on the heart appear to be limited to instances when there is a short dart-to-heart-distance. The effect on the skeletal muscle system appears to be negligible. A responsible use of a CEW on a healthy adult, within the guidelines proposed by the manufacturer, does not imply a significant health risk for that healthy adult.
Topics: Animals; Conducted Energy Weapon Injuries; Creatine Kinase; Defibrillators, Implantable; Humans; Muscle Contraction; Myoglobin; Pacemaker, Artificial; Troponin; Ventricular Fibrillation
PubMed: 29956100
DOI: 10.1007/s12024-018-9997-3 -
Health Technology Assessment... 2013Current practice for suspected acute coronary syndrome (ACS) involves troponin testing 10-12 hours after symptom onset to diagnose myocardial infarction (MI). Patients... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Current practice for suspected acute coronary syndrome (ACS) involves troponin testing 10-12 hours after symptom onset to diagnose myocardial infarction (MI). Patients with a negative troponin can be investigated further with computed tomographic coronary angiography (CTCA) or exercise electrocardiography (ECG).
OBJECTIVES
We aimed to estimate the diagnostic accuracy of early biomarkers for MI, the prognostic accuracy of biomarkers for major adverse cardiac adverse events (MACEs) in troponin-negative patients, the diagnostic accuracy of CTCA and exercise ECG for coronary artery disease (CAD) and the prognostic accuracy of CTCA and exercise ECG for MACEs in patients with suspected ACS. We then aimed to estimate the cost-effectiveness of using alternative biomarker strategies to diagnose MI, and using biomarkers, CTCA and exercise ECG to risk-stratify troponin-negative patients.
DATA SOURCES
We searched MEDLINE, MEDLINE In-Process & Other Non-Indexed Citations; Cumulative Index of Nursing and Allied Health Literature (CINAHL), EMBASE, Web of Science, Cochrane Central Database of Controlled Trials (CENTRAL), Cochrane Database of Systematic Reviews (CDSR), NHS Database of Abstracts of Reviews of Effects (DARE) and the Health Technology Assessment database from 1985 (CTCA review) or 1995 (biomarkers review) to November 2010, reviewed citation lists and contacted experts to identify relevant studies.
REVIEW METHODS
Diagnostic studies were assessed using the Quality Assessment of Diagnostic Accuracy Studies (QUADAS) tool and prognostic studies using a framework adapted for the project. Meta-analysis was conducted using bayesian Markov chain Monte Carlo simulation. We developed a decision-analysis model to evaluate the cost-effectiveness of alternative biomarker strategies to diagnose MI, and the cost-effectiveness of biomarkers, CTCA or exercise ECG to risk-stratify patients with a negative troponin. Strategies were applied to a theoretical cohort of patients with suspected ACS. Cost-effectiveness was estimated as the incremental cost per quality-adjusted life-year (QALY) of each strategy compared with the next most effective, taking a health-service perspective and a lifetime horizon.
RESULTS
Sensitivity and specificity (95% predictive interval) were 77% (29-96%) and 93% (46-100%) for troponin I, 80% (33-97%) and 91% (53-99%) for troponin T (99th percentile threshold), 81% (50-95%) and 80% (26-98%) for quantitative heart-type fatty acid-binding protein (H-FABP), 68% (11-97%) and 92% (20-100%) for qualitative H-FABP, 77% (19-98%) and 39% (2-95%) for ischaemia-modified albumin and 62% (35-83%) and 83% (35-98%) for myoglobin. CTCA had 94% (61-99%) sensitivity and 87% (16-100%) specificity for CAD. Positive CTCA and positive-exercise ECG had relative risks of 5.8 (0.6-24.5) and 8.0 (2.3-22.7) for MACEs. In most scenarios in the economic analysis presentation, high-sensitivity troponin measurement was the most effective strategy with an incremental cost-effectiveness ratio (ICER) of less than the £20,000-30,000/QALY threshold (ICER £7487-17,191/QALY). CTCA appeared to be the most cost-effective strategy for patients with a negative troponin, with an ICER of £11,041/QALY. However, when a lower MACE rate was assumed, CTCA had a high ICER (£262,061/QALY) and the no-testing strategy was optimal.
LIMITATIONS
There was substantial variation between the primary studies and heterogeneity in their results. Findings of the economic model were dependent on assumptions regarding the value of detecting and treating positive cases.
CONCLUSIONS
Although presentation troponin has suboptimal sensitivity, measurement of a 10-hour troponin level is unlikely to be cost-effective in most scenarios compared with a high-sensitivity presentation troponin. CTCA may be a cost-effective strategy for troponin-negative patients, but further research is required to estimate the effect of CTCA on event rates and health-care costs.
FUNDING
The National Institute for Health Research Health Technology Assessment programme.
Topics: Acute Coronary Syndrome; Bayes Theorem; Biomarkers; Cost-Benefit Analysis; Decision Support Techniques; Electrocardiography; Exercise Test; Fatty Acid Binding Protein 3; Fatty Acid-Binding Proteins; Humans; Models, Econometric; Myocardial Infarction; Myoglobin; Prognosis; Quality-Adjusted Life Years; Sensitivity and Specificity; Serum Albumin; Serum Albumin, Human; Troponin T
PubMed: 23331845
DOI: 10.3310/hta17010 -
Sports Medicine (Auckland, N.Z.) May 2015'Natural selection' has been shown to have enriched the genomes of high-altitude native populations with genetic variants of advantage in this hostile hypoxic... (Review)
Review
BACKGROUND AND OBJECTIVE
'Natural selection' has been shown to have enriched the genomes of high-altitude native populations with genetic variants of advantage in this hostile hypoxic environment. In lowlanders who ascend to altitude, genetic factors may also contribute to the substantial interindividual variation in exercise performance noted at altitude. We performed a systematic literature review to identify genetic variants of possible influence on human hypoxic exercise performance, commenting on the strength of any identified associations.
CRITERIA FOR CONSIDERING STUDIES FOR THIS REVIEW
All studies of the association of genetic factors with human hypoxic exercise performance, whether at sea level using 'nitrogen dilution of oxygen' (normobaric hypoxia), or at altitude or in low-pressure chambers (field or chamber hypobaric hypoxia, respectively) were sought for review.
SEARCH STRATEGY FOR IDENTIFICATION OF STUDIES
Two electronic databases were searched (Ovid MEDLINE, Embase) up to 31 January 2014. We also searched the reference lists of relevant articles for eligible studies. All studies published in English were included, as were studies in any language for which the abstract was available in English.
DATA COLLECTION AND ANALYSIS
Studies were selected and data extracted independently by two reviewers. Differences regarding study inclusion were resolved through discussion. The quality of each study was assessed using a scoring system based on published guidelines for conducting and reporting genetic association studies.
RESULTS
A total of 11 studies met all inclusion criteria and were included in the review. Subject numbers ranged from 20 to 1,931 and consisted of healthy individuals in all cases. The maximum altitude of exposure ranged from 2,690 to 8,848 m. The exercise performance phenotypes assessed were mountaineering performance (n = 5), running performance (n = 2), and maximum oxygen consumption ([Formula: see text]O2max) (n = 4). In total, 13 genetic polymorphisms were studied, four of which were associated with hypoxic exercise performance. The adenosine monophosphate deaminase (AMPD1) C34T (rs17602729), beta2-adrenergic receptor (ADRB2) Gly16Arg single nucleotide polymorphism (SNP) (rs1042713), and androgen receptor CAG repeat polymorphisms were associated with altitude performance in one study, and the angiotensin I-converting enzyme (ACE) insertion/deletion (I/D) (rs4646994) polymorphism was associated with performance in three studies. The median score achieved in the study quality analysis was 6 out of 10 for case-control studies, 8 out of 10 for cohort studies with a discrete outcome, 6 out of 9 for cohort studies with a continuous outcome, and 4.5 out of 8 for genetic admixture studies.
CONCLUSION
The small number of articles identified in the current review and the limited number of polymorphisms studied in total highlights that the influence of genetic factors on exercise performance in hypoxia has not been studied in depth, which precludes firm conclusions being drawn. Support for the association between the ACE-I allele and improved high-altitude performance was the strongest, with three studies identifying a relationship. Analysis of study quality highlights the need for future studies in this field to improve the conduct and reporting of genetic association studies.
Topics: AMP Deaminase; Actinin; Altitude Sickness; Athletic Performance; Exercise; Genetic Variation; Genotype; Humans; INDEL Mutation; Oxygen Consumption; Peptidyl-Dipeptidase A
PubMed: 25682119
DOI: 10.1007/s40279-015-0309-8 -
Journal of Interventional Cardiology Oct 2010Cardiac troponin (cTn) has high sensitivity and specificity for myocardial injury in acute coronary syndrome. Our objective was to review the published literature... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Cardiac troponin (cTn) has high sensitivity and specificity for myocardial injury in acute coronary syndrome. Our objective was to review the published literature regarding the incidence of cTn elevations in marathon runners.
METHODS
Systematic review and meta-analysis of observational studies published before September 2009. We included studies of patients who had completed a marathon and had serum cTn levels within 24 hours. The primary outcome was the odds ratio for conversion of a normal pre-marathon cTn to an elevated post-marathon cTn. Secondary outcomes included the pooled prevalence of cTn elevation and comparison of the odds ratio for post-marathon elevation of cTnI versus cTnT.
RESULTS
Sixteen studies of 939 participants met criteria for inclusion. The mean age was 39 ± 4 years and patients were 74 ± 14% male. There were 6 pre-marathon cTn elevations and 579 post-race elevations. The pooled odds ratio for converting from a normal pre-race to an elevated post-race cTn was 51.84 (95% CI 16-168, I² = 66%, P < 0.001). The pooled incidence of a post-marathon cTn elevation was 51% (95% CI 33-69, I² = 98%, P < 0.001) of all runners. For the primary outcome there was no significant publication bias. Age and gender were not associated, but publication date and assay sensitivity was associated with cTn elevation. cTnI was less commonly elevated versus cTnT.
CONCLUSIONS
The available data demonstrate that cTn levels are frequently elevated after a marathon with unclear cardiovascular significance. This elevation of cTn appears to be consistent among a diverse patient population.
Topics: Adaptation, Physiological; Adult; Confidence Intervals; Exercise Tolerance; Female; Humans; Incidence; Inflammation; Male; Myocardial Infarction; Myocardium; Odds Ratio; Prevalence; Regression Analysis; Running; Stress, Physiological; Troponin
PubMed: 20663014
DOI: 10.1111/j.1540-8183.2010.00575.x -
Journal of Hospital Medicine Jun 2016Elevated cardiac troponin (cTn) is often observed in patients with acute decompensated heart failure (ADHF). We assessed the magnitude of association and quality of... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Elevated cardiac troponin (cTn) is often observed in patients with acute decompensated heart failure (ADHF). We assessed the magnitude of association and quality of supporting evidence between cTn and clinically important outcomes in persons hospitalized for ADHF.
METHODS
We searched MEDLINE In-Process & Other Non-Indexed Citations, MEDLINE, Embase, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and Scopus from inception through February 28, 2015. The outcomes analyzed included hospital length of stay (LOS), readmissions, and mortality. Random effects meta-analysis was used to combine outcomes across studies.
RESULTS
We included 26 clinical studies. A detectable or elevated cTn was associated with increased LOS (odds ratio [OR]: 1.05; 95% confidence interval [CI]: 1.01-1.10), increased in-hospital mortality (OR: 2.57; 95% CI: 2.27-2.91), and a composite of mortality and major adverse events (OR: 1.33; 95% CI: 1.03-1.71) during hospitalization. ADHF patients with a detectable or elevated cTn were at increased risk for mortality and composite of mortality and readmission over the short term (mortality OR: 2.11; 95% CI: 1.43-3.12; composite OR: 2.81; 95% CI: 1.60-4.92), intermediate term (mortality OR: 2.21; 95% CI: 1.46-3.35; composite OR: 2.30; 95% CI: 1.78-2.99), and long term (mortality OR: 3.69; 95% CI: 2.64-5.18; composite OR: 3.49; 95% CI: 2.08-5.84). The overall confidence in estimates was moderate.
CONCLUSIONS
Among ADHF patients, a detectable or elevated cTn identifies subjects at increased risk for adverse clinical outcomes during acute hospitalization and those at higher risk for postdischarge mortality and composite of readmission and mortality. Journal of Hospital Medicine 2016;11:446-454. 2016 Society of Hospital Medicine.
Topics: Acute Disease; Heart Failure; Hospital Mortality; Hospitalization; Humans; Length of Stay; Patient Readmission; Risk Factors; Troponin
PubMed: 26889916
DOI: 10.1002/jhm.2558 -
European Journal of Anaesthesiology Jun 2016Reports from animal studies indicate that volatile anaesthetics protect the myocardium against the effects of acute ischaemia-reperfusion injury by reducing infarct... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Reports from animal studies indicate that volatile anaesthetics protect the myocardium against the effects of acute ischaemia-reperfusion injury by reducing infarct size. This cardioprotective effect in the clinical setting of coronary artery bypass graft (CABG) surgery, where the heart is subjected to global ischaemia-reperfusion injury, remains controversial.
OBJECTIVE
The objective was to demonstrate that clinical studies investigating the cardioprotective effect of volatile anaesthetics on cardiac troponins in CABG are no longer warranted. We also investigated the effect of volatile anaesthetics on cardiac enzymes in off-pump cardiac surgery.
DESIGN
Systematic review of randomised clinical trials, meta-analyses and trial sequential analysis (TSA).
DATA SOURCES
Trials between January 1985 and March 2015 were obtained from electronic databases (Medline, Excerpta Medica Database (EMBASE), Cochrane Controlled Trial Register, abstracts from major anaesthesiology and cardiology journals and reference lists of relevant randomised trials and review articles.
ELIGIBILITY CRITERIA
Relevant randomised clinical trials were included. We investigated the effect of volatile anaesthetics in both off-pump and on-pump CABG surgery with respect to troponin release [peak postoperative cardiac troponin I (cTnI) and cardiac troponin T (cTnT), cTnI/cTnT] and performed two separate meta-analyses. TSA was used to overcome the weakness of a type-1 error associated with repeated meta-analyses.
RESULTS
From 30 studies, 2578 patients were pooled for the meta-analysis. The outcome significantly favours the use of peroperative volatile over non-volatile anaesthetics during on-pump CABG surgery with regard to peak postoperative cTnI (0.995 mg l; standard mean difference, 95% confidence interval, -1.316 to -0.673; P < 0.001). Meta-analysis of 11 off-pump studies showed no difference in peak postoperative cTnI (0.385 mg l; standard mean difference, 95% confidence interval, -0.857 to 0.087; P = 0.11). TSA indicated that the required information size for on-pump surgery was 1072 patients, and for off-pump surgery it was 1442; this latter figure has not yet been reached.
CONCLUSION
Studies investigating the cardioprotective effect of volatile anaesthetics on cardiac troponins in on-pump CABG surgery are no longer warranted. This is not yet the case for off-pump surgery.
Topics: Anesthesia, Inhalation; Anesthetics, Inhalation; Coronary Artery Bypass; Humans; Myocardium; Postoperative Complications; Randomized Controlled Trials as Topic; Troponin
PubMed: 26901389
DOI: 10.1097/EJA.0000000000000397 -
Cerebrovascular Diseases (Basel,... 2009Troponin levels are elevated in some acute stroke patients, but the clinical significance of this is unclear. (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Troponin levels are elevated in some acute stroke patients, but the clinical significance of this is unclear.
METHODS
We conducted a systematic review of studies measuring troponin within 7 days of symptom onset in acute stroke patients.
RESULTS
We identified 15 studies (2,901 patients). Overall 18.1% (95% CI 13.6-22.6) had a positive troponin level. These patients were more likely to have electrocardiogram (ECG) changes suggestive of myocardial ischemia (OR 3.0; 95% CI 1.5-6.2), and there was an independent association with death (OR 2.9; 95% CI 1.7-4.8).
CONCLUSION
Elevated troponin level after acute stroke is common and is associated with ECG changes suggestive of myocardial ischemia and increased risk of death.
Topics: Acute Disease; Death; Electrocardiography; Humans; Myocardial Ischemia; Odds Ratio; Risk; Stroke; Treatment Outcome; Troponin; Troponin I; Troponin T
PubMed: 19571535
DOI: 10.1159/000226773