In One-Hour: A Diagnosis of Heart Attack made possible by one Blood Test
Reporter: Larry H Bernstein, MD, FCAP
Voice of Dr. Larry:
This presents a dilemma for medicine with the pressure to discharge patients, and to save money for the system. The practice of decision-making is still quite elemental.
TRAPID-AMI is a prospective observational study supported by Roche and investigated more than 1,200 patients with acute chest pain during 2011-2014. The study was conducted in twelve institutions from nine countries and three continents, led by Professors Christian Mueller, University of Basel (Switzerland), and Bertil Lindahl, University of Uppsala (Sweden).
I have great respect for Mueller and Lindahl. This is a prospective observational study and does not carry the same weight as a randomized study. Moreover, there is nothing new in this, as you must know.
I think that the Roche hsTNT is the best method out there, but the study will not spur laboratories to switch from hsTnI. The only condition for such a decision would be performing the test in the ED, which might be the case here. POCT is not without problems.
Only in the last 5 years we have seen much confusion about interpreting the hsTnT and hsTnI. There is a sensitivity not achieved in earlier methods of the same proteins. However, there was a tradeoff in specificity and accuracy of diagnosis. It was great for cardiologists, and the measurement of a second assay in 3 hours was warranted. However, it was certainly reasonable to carry out the one hour study because patients arrive at the ED perhaps 6 hrs after onset. There was a time that while the CK-MB was increased and the second assay was in decline, The LD1 assay was needed for a late arrival because of placement on the curve. LD1 is no longer done, and patient awareness is much better than 15-20 years ago. I had a patent on an LD1 assay that could be done on a centrifugal fast analyzer using the forward reaction PYR–LAC, with NADH oxdation rather than LAC–PYR.
This study indicates that a validation of the suspect diagnosis can be done in 1 hour based on the increase in a shorter time span. It resolves some of the problem of hsTn’s. I’m not at all convinced that it is sufficient. I would have to see something more definitive.
There is consensus on the reclassification of Acute Coronary Syndrome into plaque rupture and not plaque rupture.
This creates a problem for relying on a so called “magic bullet” approach. It would certainly indicate that in order to classify correctly there has to be a minimum of two tests. All patients with CKD would fall into the not plaque rupture category. There are other patients who might have 50-60% narrowing and experience precordial symptoms, pressure, but without elevation. Are they very early AMI presentation, as my grandfather some 48 years ago?
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This is very insightful. There is no doubt that there is the bias you refer to. 42 years ago, when I was postdocing in biochemistry/enzymology before completing my residency in pathology, I knew that there were very influential mambers of the faculty, who also had large programs, and attracted exceptional students. My mentor, it was said (although he was a great writer), could draft a project on toilet paper and call the NIH. It can’t be true, but it was a time in our history preceding a great explosion. It is bizarre for me to read now about eNOS and iNOS, and about CaMKII-á, â, ã, ä – isoenzymes. They were overlooked during the search for the genome, so intermediary metabolism took a back seat. But the work on protein conformation, and on the mechanism of action of enzymes and ligand and coenzyme was just out there, and became more important with the research on signaling pathways. The work on the mechanism of pyridine nucleotide isoenzymes preceded the work by Burton Sobel on the MB isoenzyme in heart. The Vietnam War cut into the funding, and it has actually declined linearly since.
A few years later, I was an Associate Professor at a new Medical School and I submitted a proposal that was reviewed by the Chairman of Pharmacology, who was a former Director of NSF. He thought it was good enough. I was a pathologist and it went to a Biochemistry Review Committee. It was approved, but not funded. The verdict was that I would not be able to carry out the studies needed, and they would have approached it differently. A thousand young investigators are out there now with similar letters. I was told that the Department Chairmen have to build up their faculty. It’s harder now than then. So I filed for and received 3 patents based on my work at the suggestion of my brother-in-law. When I took it to Boehringer-Mannheim, they were actually clueless.