Introduction Heart-type Fatty Acid-Binding Protein (H-FABP) may be useful for early diagnosis of ACS1,2 and has been associated with increased cardiovascular events. Type 4a procedural myocardial infarction (MI) may occur after percutaneous coronary intervention (PCI).3 Little is known about the use of early biomarkers as predictors of cardiovascular events following elective PCI.
Methods We prospectively evaluated highly sensitive troponin T (hsTnT), H-FABP, troponin I (TnI), creatine kinase MB type (CKMB), myoglobin, glycogen phosphorylase BB (GPBB) and carbonic anhydrase III (CAIII) at 0, 4, 6 and 24 h following elective PCI. Baseline demographic and cardiac risk factors were recorded. The primary endpoint was type 4a MI, diagnosed as a rise of >5 × 99th upper reference limit (URL) of 14 ng/L (i.e. rise of >70 ng/L) at 6 h if hsTnT was normal at baseline or > 20% from 0 to 6 hrs if hsTnT was >14 ng/L at baseline.3 Patients were followed up at 1 year to assess for major adverse clinical events (MACE); MI, target vessel revascularisation, heart failure, stroke and death.
Results We enrolled 241 patients of whom 32 were excluded due to withdrawal of consent or PCI being cancelled after angiography. A cohort of 209 patients was included in analysis, of whom 144 (68.9%) were male, mean age was 68.8 years, 28 (13.4%) were smokers, 31 (14.8%) were diabetic, 199 (95.2%) had hypercholesterolaemia and 138 (66.0%) had hypertension. Type 4a MI was observed in 37 (17.7%) patients. Comparing those with and without type 4a MI, there was no statistical difference in risk factors (p > 0.05) except for age, (p = 0.015). Median troponin at 6 h was 90.24 ng/L (95% CI 76.56 â€” 186.41) versus 14.43 ng/L (95% CI 16.37 â€” 21.26) in the type 4a / non type 4a groups respectively, p=<0.001, Figure 1. Median H-FABP at 4 h was most predictive of type 4a MI (followed by CKMB and myoglobin) with levels of 6.23 mg/L (95% CI 4.38–18.96), versus 2.05mg/L (95% CI 2.23–2.74), p=<0.001, AUC 0.91, Table 1, Figure 2. Results for TnI, CKMB, myoglobin, GBPP and CAIII are shown in Table 1. Multivariate logistic regression (stepwise elimination) showed H-FABP to be most predictive of type 4a MI, p < 0.001. Sensitivity of 4 h H-FABP (>6.32 mg/L) for type 4a MI was 51.5%, specificity 96.1%, positive predictive value (PPV) 73.9%, negative predictive value (NPV) 90.3%, odds ratio (OR) 26.39, relative risk (RR) 7.62. MACE was noted in 6 (2.9%) patients (three MI, two death and one stroke), 3 of which had type 4a MI at index PCI, p = 0.036. Table 2 compares median change in H-FABP and hsTnT from 0 â€” 6 h in patients who developed MACE at 1 year with CAIII performing best, p = 0.02.
Conclusions/implications Median 4 h H-FABP was most predictive of a 6 h hsTnT rise as a consequence of type 4a MI in elective PCI, followed by CKMB and myoglobin. H-FABP and CAIII were independently predictive of MACE at 1 year and MACE was associated with type 4a MI at index PCI.
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