PURPOSE: Cardiac troponin T (cTnT), a useful marker for diagnosing acute myocardial infarction (AMI) in the general population, is significantly higher than the usual cut-off value in many end-stage renal disease (ESRD) patients without clinically apparent evidence of AMI. The aim of this study was to evaluate the clinical usefulness of cTnT in ESRD patients with acute coronary syndrome (ACS). MATERIALS AND METHODS: Two hundred eighty-four ESRD patients with ACS were enrolled between March 2002 and February 2008. These patients were followed until death or June 2009. Medical records were reviewed retrospectively. The cut-off value of cTnT for AMI was evaluated using a receiver operating characteristic (ROC) curve. We calculated Kaplan-Meier survival curves, and potential outcome predictors were determined by Cox proportional hazard analysis. RESULTS: AMIs were diagnosed in 40 patients (14.1%). The area under the curve was 0.98 in the ROC curve (p<0.001; 95% CI, 0.95-1.00). The summation of sensitivity and specificity was highest at the initial cTnT value of 0.35 ng/mL (sensitivity, 0.95; specificity, 0.97). Survival analysis showed a statistically significant difference in all-cause and cardiovascular mortalities for the group with an initial cTnT > or =0.35 ng/mL compared to the other groups. Initial serum cTnT concentration was an independent predictor for mortality. CONCLUSION: Because ESRD patients with an initial cTnT concentration > or =0.35 ng/mL have a poor prognosis, it is suggested that urgent diagnosis and treatment be indicated in dialysis patients with ACS when the initial cTnT levels are > or =0.35 ng/mL.
Acute Coronary Syndrome/blood/complications/*diagnosis/mortality ; Aged ; Biological Markers/blood ; Female ; Humans ; Kidney Failure, Chronic/blood/complications/*diagnosis/mortality ; Male ; Middle Aged ; Prognosis ; Retrospective Studies ; Sensitivity and Specificity ; Troponin T/*blood

PURPOSE: Right heart failure (RHF) is not a infrequant disease entitiy, but it is difficult to diagnose and mortality rate increases with worsening right heart failure. The utility of Nterminal pro-brain natriuretic peptide (NT-proBNP) testing in the emergency department for differentiating right heart failure from left heart failure (LHF), and optimal cut-off points for its use, are not well established. METHODS: One hundred thirty-six consecutive patients with acute dyspnea, who visited our emergency medical center from August 2005 to August 2006 were recruited prospectively. Patients with acute coronary syndrome and chronic renal failure were excluded. The diagnosis of RHF was based on echocardiographic evidence of right ventricular dysfunction. The diagnostic accuracy of NT-proBNP was assessed by receiver operating characteristic curve analysis. RESULTS: The mean patient age was 68+/-13 years, and 64% were women. The median NT-proBNP level among 68 patients (50%) who had LHF and 29 patients (21%) who had RHF were 2524 1572 pg/ml, respectively, versus 520 pg/ml for 39 patients (29%) who did not have heart failure (HF) (p = 0.01). NT-proBNP levels correlated well with right ventricular systolic pressure. However, although patients with RHF exhibited significantly higher NT-proBNP levels than did patients without HF, NT-proBNP levels did not differentiate left from right heart failure. The area under the receiver operating characteristic curve was 0.71 (95% CI 0.63~0.85). At a cutoff of 700 pg/ml, NT-proBNP had a sensitivity of 68%, a specificity of 35%, an overall accuracy of 58%, a false negative rate of 32%, a false positive rate of 66% in differentiating between LHF from RHF (p = 0.03). CONCLUSION: NT-proBNP is elevated in majority of cases of right heart failure, but NT-proBNP could not differentiate RHF from LHF. Therefore, this underscores that NTproBNP is not a stand-alone test and that correct clinical evaluation and echocardiography is still of highest importance.
Acute Coronary Syndrome ; Blood Pressure ; Diagnosis ; Diagnosis, Differential* ; Dyspnea* ; Echocardiography ; Emergencies ; Emergency Service, Hospital ; Female ; Heart Failure* ; Heart* ; Humans ; Kidney Failure, Chronic ; Mortality ; Prospective Studies ; ROC Curve ; Sensitivity and Specificity ; Ventricular Dysfunction, Right

BACKGROUND: Amino-terminal pro-B type natriuretic peptide (NT-proBNP) is a well-established prognostic factor in heart failure (HF). However, numerous causes may lead to elevations in NT-proBNP, and thus, an increased NT-proBNP level alone is not sufficient to predict outcome. The aim of this study was to evaluate the utility of two acute response markers, high sensitivity C-reactive protein (hsCRP) and heart-type fatty acid binding protein (H-FABP), in patients with an increased NT-proBNP level. METHODS: The 278 patients were classified into three groups by etiology: 1) acute coronary syndrome (ACS) (n=62), 2) non-ACS cardiac disease (n=156), and 3) infectious disease (n=60). Survival was determined on day 1, 7, 14, 21, 28, 60, 90, 120, and 150 after enrollment. RESULTS: H-FABP (P<0.001), NT-proBNP (P=0.006), hsCRP (P<0.001) levels, and survival (P<0.001) were significantly different in the three disease groups. Patients were divided into three classes by using receiver operating characteristic curves for NT-proBNP, H-FABP, and hsCRP. Patients with elevated NT-proBNP (≥3,856 pg/mL) and H-FABP (≥8.8 ng/mL) levels were associated with higher hazard ratio for mortality (5.15 in NT-proBNP and 3.25 in H-FABP). Area under the receiver operating characteristic curve analysis showed H-FABP was a better predictor of 60-day mortality than NT-proBNP. CONCLUSIONS: The combined measurement of H-FABP with NT-proBNP provides a highly reliable means of short-term mortality prediction for patients hospitalized for ACS, non-ACS cardiac disease, or infectious disease.
Acute Coronary Syndrome/blood/*diagnosis/mortality ; Aged ; Area Under Curve ; Biomarkers/blood ; C-Reactive Protein/*analysis ; Fatty Acid-Binding Proteins/*blood ; Female ; Humans ; Kaplan-Meier Estimate ; Male ; Middle Aged ; Natriuretic Peptide, Brain/*blood ; Peptide Fragments/*blood ; Prognosis ; Proportional Hazards Models ; ROC Curve