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Volume 11, Supplement 2  - 2010

Volume 11, Supplement 2 - 2010

Table of Contents

Capturing the Pathophysiology of Acute Coronary Syndromes With Circulating Biomarkers Proteomic Approaches to Acute Coronary Syndromes
There have been considerable advances in the evaluation of suspected acute coronary syndromes (ACS): sophistication of the clinical examination, electrocardiography, risk prediction scores, multiple blood biomarkers, and rapid cardiovascular imaging. Integration of information remains a formidable challenge for the physician in the setting of time-sensitive clinical decision making. In addition to conventional panels of biomarkers, there are novel entities that may be able to signal different stages of the acute event, including plaque disruption, atherothrombosis, ischemic damage, tissue hypoxia, and oxidative stress. The natriuretic peptides are normal myocyte products that reflect myocardial tissue response to neurohormonal and mechanical forces that rapidly change during an ACS event. This article summarizes major advancements in the integrative use of multiple blood biomarkers and cardiovascular imaging in the diagnosis, prognosis, and management of ACS. [Rev Cardiovasc Med. 2010;11(suppl 2):S3-S12 doi: 10.3909/ricm11S2S0005]
Differential Diagnosis and Overlap of Acute Chest Discomfort and Dyspnea in the Emergency Department Proteomic Approaches to Acute Coronary Syndromes
Acute chest discomfort and dyspnea are 2 of the most common nontraumatic symptoms that prompt emergency department evaluations in the United States. The overlap between these presenting symptoms is considerable. In addition, each symptom calls for a broad differential diagnosis that requires rapid refinement according to details in the history, physical examination, blood biomarkers, and radiographic evaluation. This article highlights the epidemiology and the evidence supporting critical decision making, which makes judicious use of the clinical laboratory and diagnostic radiology in the evaluation of the acutely ill patient with chest discomfort and dyspnea. [Rev Cardiovasc Med. 2010;11(suppl 2):S13-S23 doi: 10.3909/ricm11S2S0006]
Natriuretic Peptides in the Prognosis and Management of Acute Coronary Syndromes Proteomic Approaches to Acute Coronary Syndromes
Over the past decade, an evidence base has accumulated to support natriuretic peptide (NP) testing for diagnosis, risk assessment, and therapeutic monitoring and guidance of patients with heart failure. Investigators have also explored multiple other potential uses for these tests, including risk assessment of patients with suspected acute coronary syndromes (ACS). This article discusses the utility of NPs in the diagnosis and management of patients with ACS. [Rev Cardiovasc Med. 2010;11(suppl 2):S24-S34 doi: 10.3909/ricm11S2S0004]
Cardiac Computed Tomography in the Rapid Evaluation of Acute Cardiac Emergencies Proteomic Approaches to Acute Coronary Syndromes
Approximately 6 million patients are evaluated annually in US emergency departments for acute chest pain. The delineation of the presence or absence of acute coronary syndromes in these patients must be accurate and efficient in order to prevent missed diagnoses. Coronary computed tomography angiography has great promise as a tool to expedite the triage of patients with acute chest pain to early discharge or further inpatient diagnosis and treatment. [Rev Cardiovasc Med. 2010;11(suppl 2):S35-S44 doi: 10.3909/ricm11S2S0003]
Time to Treatment and Acute Coronary Syndromes: Bridging the Gap in Rapid Decision Making Proteomic Approaches to Acute Coronary Syndromes
The role of cardiac biomarkers in the diagnosis, risk stratification, and treatment of patients with chest pain and suspected acute coronary syndromes (ACS) has continued to evolve. Although it is clear that troponin (Tn) measurement provides independent prognostic information in patients with suspected ACS, it is less well established that early B-type natriuretic peptide (BNP) measurement provides additional incremental prognostic information above and beyond electrocardiography and Tn measurement. It is useful to identify patients at high risk for adverse events through measurement of Tn and BNP levels so that timely treatment decisions can be made. [Rev Cardiovasc Med. 2010;11(suppl 2):S45-S50 doi: 10.3909/ricm11S2S0001]
An Evidence-Based Algorithm for the Use of B-Type Natriuretic Testing in Acute Coronary Syndromes Proteomic Approaches to Acute Coronary Syndromes
Measurable B-type natriuretic peptides (BNPs), which are largely produced by the left ventricle, include BNP and N-terminal prohormone BNP (NT-proBNP). These proteins are released by cardiomyocytes in response to wall tension and neurohumoral signals, and are established tools in the diagnosis and prognosis of heart failure (HF). We identified 32 articles for entry into evidence tables that presented original data on BNP and/or NT-proBNP in more than 100 patients with acute coronary syndromes (ACS) presenting with chest discomfort with or without dyspnea. Natriuretic peptide (NP) elevation was associated with older age, female sex, hypertension, diabetes, prior HF, prior ischemic heart disease, and reduced renal function. Clinical correlates of elevated blood NP levels included left main or 3-vessel coronary disease, lipid-rich plaques with large necrotic cores in proximal locations, large zones of myocardial ischemia or infarction, no-reflow and impaired perfusion after percutaneous intervention, reduced left ventricular ejection fraction, higher Killip classification, and the development of cardiogenic shock. All studies indicated that after adjustment for baseline predictors and clinical risk scores, elevated NP concentrations were independently predictive of the development of HF and all-cause mortality. In contrast, studies did not consistently demonstrate that NPs were predictive of myocardial infarction and rehospitalization for ACS. In addition to baseline measurement, there is consensus that repeat testing at 4 to 12 weeks and 6 to 12 months in follow-up is helpful in the anticipation of late cardiac sequelae and may assist in assessing prognosis and guiding management. [Rev Cardiovasc Med. 2010;11(suppl 2):S51-S65 doi: 10.3909/ricm11S2S0002]