In this podcast, Robert P. Guigliano, MD, SM, discusses the findings from a secondary investigation from the IMPROVE-IT survey connected the relation of serial high-sensitivity cardiac troponin T with consequent cardiovascular events successful patients stabilized aft acute coronary syndrome, including if it is worthwhile to measurement troponin and however often.
Additional Resource:
- Patel SM, Qamar A, Giugliano RP, et al. Association of serial high-sensitivity cardiac troponin t with consequent cardiovascular events successful patients stabilized aft acute coronary syndrome: a secondary investigation from IMPROVE-IT. JAMA Cardiol. 2022;7(12):1199-1206. doi:10.1001/jamacardio.2022.3627
Robert P. Giugliano, MD, SM, is simply a elder researcher astatine the TIMI Study Group astatine the Brigham and Women’s Hospital, a unit doc successful the Cardiovascular Division astatine Harvard Medical School, and an subordinate prof of medicine astatine Harvard Medical School (Boston, Massachusetts).
TRANSCRIPTION:
Jessica Bard:
Hello, everyone. And invited to different installment of Podcast360, your go-to assets for aesculapian quality and objective updates. I'm your moderator, Jessica Bard, with Consultant360, a multidisciplinary aesculapian accusation network. Dr Robert Guigliano is present to talk with america contiguous astir the findings from a secondary investigation from the IMPROVE-IT survey connected the relation of serial high-sensitivity cardiac troponin T with consequent cardiovascular events successful patients stabilized aft acute coronary syndrome.
Dr Robert P. Guigliano:
Thank you for the invitation today. My sanction is Robert Guigliano. I'm a cardiologist astatine the Brigham and Women's Hospital and a elder researcher with the TIMI Study Group present successful Boston. And I not lone spot patients successful the CCU, but besides person an outpatient session astatine the Brigham and Women's Hospital and a prof astatine Harvard Medical School. So gladsome to beryllium present today.
Jessica Bard:
Thank you for joining america today, Dr. Guigliano. Could you delight supply america with an overview of your team's analysis?
Dr Robert P. Guigliano:
Right. Sure, no, I'm blessed to walk a fewer minutes talking astir this paper, which was published primitively online successful October of 2022 and came retired successful JAMA Cardiology successful people successful December 2022. This is 1 of galore secondary papers from the IMPROVE-IT Trial, which galore of the assemblage volition cognize well. IMPROVE-IT stands for improved simplification of outcomes Vytorin efficacy planetary trial. And it was a survey successful implicit 18,000 patients hospitalized for an acute coronary syndrome who were randomized to either simvastatin unsocial oregon ezetimibe positive simvastatin. And it was placebo-controlled, double-blinded, and showed that ezetimibe reduced LDL cholesterin and reduced cardiovascular events during a gathering successful a six years follow-up.
Now, arsenic portion of a ample objective trial, we collected humor samples, person been doing galore secondary analyses and papers. And truthful this peculiar insubstantial we're discussing contiguous was an investigation of implicit 6,000 patients who had their humor collected astatine 1 period and 4 months into the trial. And high-sensitivity troponin was measured. This was a troponin T assay. And we conscionable asked the question, bash the troponin T levels astatine 1 and 4 months aft a objective trial, are they important oregon adjuvant for prognostication? And we ended up focusing successful truly connected the alteration successful troponin, which was an important predictor of worse outcomes, worse cardiovascular outcomes. If your troponin was rising, peculiarly if determination was a ample rise, that was a atrocious motion for the patient.
Jessica Bard:
So of people we're talking about, is it worthwhile to measurement troponin? What would you say? Could you elaborate much connected the results of this analysis?
Dr Robert P. Guigliano:
Yeah, sure. So I would accidental archetypal successful modular practice, astatine slightest successful my area, it's not modular oregon regular successful outpatients to measurement troponin for prognostication. We usage it successful the exigency section to place myocardial infarction oregon myocardial injury. We evidently usage it successful the infirmary to recognize who's having an infarct oregon wherever they are successful the infarct, and are they recovering? But present we're talking astir measuring it successful unchangeable outpatients who person had a caller acute coronary syndrome. And successful fact, if you effort to bash that astatine our institution, you'll adjacent get a informing saying, "Do you truly privation to measurement the troponin successful an outpatient? It's not designed for that." So we're breaking caller crushed present by measuring it 1 and 4 months post-ACS. And noticed that, archetypal of all, precocious troponin adjacent successful stabilized patients is not a bully thing, higher rates of cardiovascular events.
And furthermore, if you look astatine the alteration betwixt period 1 and period four, those who had nary alteration had beauteous debased lawsuit rates, those who had a mean alteration connected this peculiar assay betwixt 3 and 7 nanograms per liter had worse cardiovascular outcomes. And the radical that truly had the highest lawsuit rates were those who had an summation of much than 7 nanograms per liter. And we analyzed it successful each antithetic ways, antithetic chopped points, and truthful forth, and recovered beauteous accordant results that the larger the implicit increase, the worst the prognosis. And past determination were immoderate patients who had a decrease, and those patients tended to bash amended with little lawsuit rates than those that increased. So benignant of an absorbing caller exertion of a troponin assay successful outpatients aft acute coronary syndromes.
Jessica Bard:
Now, you mentioned that it's not ever communal to measurement troponin. What would you accidental are the gaps successful the probe of troponin and consequent cardiovascular events? And what would you accidental is adjacent for probe connected this topic?
Dr Robert P. Guigliano:
Yeah. Well, troponin was designed to assistance america place patients who are having a myocardial infarction, and past has been proven utile successful different cardiovascular diagnoses similar a pulmonary embolism to place high-risk PE, to place patients who person different causes of myocardial wounded oregon necrosis, similar myopericarditis, acute cardiomyopathies, takotsubo syndrome. So it's precise utile successful the ED and successful the inpatient setting. This is 1 of the archetypal applications successful an outpatient mounting and with the usage of serial troponins. And truthful we person successful this insubstantial a small implicit 6,000 patients with values astatine period 1 and period four. But is this thing we ought to beryllium measuring astatine period 12, yearly thereafter? Is it a marker you privation to proceed to follow? And successful which patients? And however bash you construe that? All that remains to beryllium determined. But this is benignant of conscionable the archetypal section successful the outpacing usage of serial troponins to say, "Hey, this biomarker could beryllium utile to travel successful patients with chronic coronary disease."
Jessica Bard:
What would you accidental are the wide take-home messages from this investigation and from our speech today?
Dr Robert P. Guigliano:
Yeah. I would accidental the take-home connection would beryllium these cardiac biomarkers, similar troponin, and we didn't sermon BNP due to the fact that that wasn't successful this paper, but there's BNP, and determination are different caller markers. Keep an oculus connected this abstraction due to the fact that we're opening to spot that the biomarkers we usage and probe and successful the infirmary whitethorn besides play an important relation successful the outpatient setting. And specifically, the take-home connection from this insubstantial is, if you person a unchangeable diligent pursuing acute coronary syndrome, measuring serial troponin, and present we did it astatine period 1 and four, but I deliberation apt you could grow that out, that changes successful troponin are associated with a gradient of risk. And if you commencement debased and stay low, past that's a low-risk situation. If you're debased to precocious oregon you commencement precocious and you stay high, peculiarly if you're increasing, that indicates a diligent who is astatine precocious hazard for further cardiovascular events successful the future. And successful the aboriginal means, successful this trial, a six-year mean follow-up.
Jessica Bard:
Now, we cognize determination are respective secondary analyses from IMPROVE-IT. Is determination thing that you'd similar to speech astir that's adjacent successful the investigation of the information oregon different important papers that you'd similar to mention?
Dr Robert P. Guigliano:
Yes. Well, IMPROVE-IT was 1 of the galore ample TIMI trials that we person run, this 1 successful concern with Duke Clinical Research Institute. And similar galore of the trials, ample cardiovascular result trials, there's a wealthiness of data. You person tons of patients successful bid to maximize the experience. And being successful a objective trial, we'll often measurement humor samples including genetics and look astatine assorted biomarkers oregon look astatine different types of imaging studies, what person you. This signifier of IMPROVE-IT, which is simply a proceedings that started, geez, present we're talking astir 17 years ago, enrolled and past followed for six years and reported retired astir a decennary ago. We've surely published galore papers and we're present focusing connected caller biomarkers, truthful the humor samples we have. And successful particular, the genetics due to the fact that that's a tract that's precise breathtaking and novel. And we're continuing to larn from analyzing genetics and tying those into the objective outcomes.
Jessica Bard:
Well, convey you truthful overmuch for each of your enactment connected this and for joining america successful the podcast. Is determination thing other that you'd similar to adhd that you deliberation we missed?
Dr Robert P. Guigliano:
I mean, I would conscionable accidental that, for the listeners, this is simply a two-way street. That we're precise blessed to enactment successful these types of discussions and stock with you the caller data. But a batch of the listeners volition person absorbing ideas. And a batch of the advances successful subject hap erstwhile you're successful objective signifier and you person a question that's related to a patient. And certainly, consciousness escaped to stock those either with maine oregon different members of our group. And who knows, we whitethorn enactment unneurotic connected 1 of your ideas 1 day.
Jessica Bard:
Well, convey you Dr. Guigliano. It was a pleasance speaking with you.
Dr Robert P. Guigliano:
All right, convey you
English (US)