Die aktuelle Leitlinie der europäischen Gesellschaft für Kardiologie (ESC) zur präoperativen Risikostratifizierung und zum perioperativem Management vor nicht kardiochirurgischen Eingriffen [10] wurde 2010 von der Deutschen Gesellschaft für Kardiologie (DGK) kommentiert und mit geringen Modifikationen übernommen [8). Diese ist auch Grundlage der aktuellen gemeinsamen Empfehlungen der Deutschen Gesellschaft für Anästhesiologie und Intensivmedizin, der Deutschen Gesellschaft für Innere Medizin und der Deutschen Gesellschaft für Chirurgie zur präoperativen Evaluation erwachsener Patienten vor elektiven, nicht kardiochirurgischen Eingriffen [3]. Im Kommentar der DGK [8] ist ein klarer, pragmatischer Algorithmus mit einer verlässlichen Risikostratifizierung des Patienten und der operativen Situation auf einer Seite zusammengefasst dargestellt (qAbb. 1). Wesentlich ist hierbei die Einteilung des patientenseitigen und des operativen Risikos jeweils in die Kategorien leicht-, mittelund hochgradig. Klare Handlungsanweisungen befassen sich mit der Akutund Notfallsituation bei dringendem chirurgischem Eingriff und/oder instabilen kardialen Patienten.

Kardiologische Aspekte der präoperativen Risikostratifizierung

Background—Current guidelines for the diagnosis of acute myocardial infarction (AMI), among other criteria, also require a rise and/or fall in cardiac troponin (cTn) levels. It is unknown whether absolute or relative changes in cTn have higher diagnostic accuracy and should therefore be preferred. Methods and Results—In a prospective, observational, multicenter study, we analyzed the diagnostic accuracy of absolute (Δ) and relative (Δ%) changes in cTn in 836 patients presenting to the emergency department with symptoms suggestive of AMI. Blood samples for the determination of high-sensitive cTn T and cTn I ultra were collected at presentation and after 1 and 2 hours in a blinded fashion. The final diagnosis was adjudicated by 2 independent cardiologists. The area under the receiver operating characteristic curve for diagnosing AMI was significantly higher for 2-hour absolute (Δ) versus 2-hour relative (Δ%) cTn changes (area under the receiver operating characteristic curve [95% confidence interval], high-...

Utility of Absolute and Relative Changes in Cardiac Troponin Concentrations in the Early Diagnosis of Acute Myocardial Infarction

Introduction: Structural changes in the heart, such as increased left atrial size and decreased ejection fraction, are known risk factors for atrial fibrillation (AF) An association between cardia

High-Sensitivity Cardiac Troponin T and the Risk of Incident Atrial Fibrillation: The Atherosclerosis Risk in Communities (ARIC) Study

Objectives The presence of coronary artery disease (CAD) in patients hospitalised with paroxysmal or first diagnosed atrial fibrillation (AF) has major implications for antithrombotic therapy and cardiovascular event rate. Coronary CT angiography (CCTA) is a feasible tool to identify patients with concealed CAD. We aimed to evaluate the diagnostic role of early CCTA in patients hospitalised with paroxysmal or first diagnosed AF. Methods In a 5-year single-centre retrospective analysis, 566 patients with paroxysmal or first diagnosed AF who underwent CCTA were enrolled to investigate the presence of CAD. Results In patients with paroxysmal or first diagnosed AF, CCTA revealed CAD (coronary artery stenosis ≥50%) in 39.2%. Cardiac catheterisation was performed in 31.6%, confirming CAD in 13.1% of all patients. In 8.0% percutaneous coronary intervention and in 0.5% coronary artery bypass grafting was performed. In patients with paroxysmal or first diagnosed AF: (1) angina pectoris per se does not predict CAD; (2) multivariable regression analysis revealed age, male sex and diabetes as risk factors for CAD in AF; (3) Framingham Risk Score for coronary heart disease and CHA2DS2-VASc-Score were relevant risk scores of CAD and (4) the classification of Coronary Artery Calcium score reference values according to the Multi-Ethnic Study of Atherosclerosis was a predictor of CAD. Conclusion Patients with paroxysmal or first diagnosed AF are at risk for CAD, while CCTA is a feasible diagnostic tool for CAD. We recommend to integrate CT calcium scoring and CCTA into the diagnostic workup of patients with new-onset or paroxysmal AF.

https://openheart.bmj.com/content/openhrt/8/1/e001638.full.pdf

Diagnostic role of coronary CT angiography in paroxysmal or first diagnosed atrial fibrillation.

Background
With multiple cholesterol guidelines, we evaluated the accuracy of recommended statin therapy on identifying coronary artery calcium (CAC) and cardiovascular disease (CVD) events by 2004 NCEP/ ATP III, 2016 ESC/EAS, and 2013 ACC/AHA guidelines.

Hypothesis
ACC/AHA guidelines are more accurate in identifying persons at risk for CVD.

Methods
5002/6814 participants age 0, ≥100, and ≥300) and 10 years of CVD outcomes were considered. Sensitivity (SN), specificity (SP), positive and negative predictive value (PPV and NPV), and likelihood ratios (LR) were calculated. Mean age was 59 years; 47% of subjects were males.

Results
1297 (26%), 1381 (28%), and 2538 (51%) had class I indications for statin/LLT by the NCEP ATP III, ESC/EAS, and AHA/ACC guidelines, respectively. SN, SP, NPV, and PPV for CAC ≥300 were: NCEP ATP III (41.1%, 75.5%, 93.3% and 13.4%), ESC/EAS (54.1%, 74.8%, 94.6% and16.6%), and ACC/AHA (87.2%, 52.6%, 97.8% and 14.5%). SN, SP, PPV, and NPV for corresponding CVD outcomes were: NCEP ATP III (45.8%, 75.1%, 96.3%, and 8.9%), ESC/EAS (50.5%, 72.9%, 98.7%, and 3.6%), and AHA/ACC (79.6%, 50.7%, 98%, and 7.7%). ESC/EAS had significantly higher positive LR 2.15 (95% CI, 1.95 – 2.38) and ACC/AHA had significantly lower negative LR [0.24, (95% CI 0.19 – 0.31)] for corresponding CVD.

Conclusions
Despite the increased in SN of statin eligibility by the ACC/AHA, it has similar NPV and PPV for CAC/future CVD events. The ACC/AHA class I indications for statin may be a superior screening tool for subclinical and clinical CVD.

https://onlinelibrary.wiley.com/doi/pdf/10.1002/clc.22642

Guideline-based statin/lipid-lowering therapy eligibility for primary prevention and accuracy of coronary artery calcium and clinical cardiovascular events: The Multi-Ethnic Study of Atherosclerosis (MESA).

Background
About 10% of patients admitted to a chest pain unit (CPU) exhibit atrial fibrillation (AF).

Hypothesis
To determine whether calcium scores (CS) are superior over common risk scores for coronary artery disease (CAD) in patients presenting with atypical chest pain, newly diagnosed AF, and intermediate pretest probability for CAD within the CPU.

Methods
In 73 subjects, CS was related to the following risk scores: Global Registry of Acute Coronary Events (GRACE) score, including a new model of a frequency-normalized approach; Thrombolysis In Myocardial Infarction score; European Society of Cardiology Systematic Coronary Risk Evaluation (SCORE); Framingham risk score; and Prospective Cardiovascular Munster Study score. Revascularization rates during index stay were assessed.

Results
Median CS was 77 (interquartile range, 1–270), with higher values in men and the left anterior descending artery. Only the modified GRACE (ρ = 0.27; P = 0.02) and the SCORE (ρ = 0.39; P < 0.005) were significantly correlated with CS, whereas the GRACE (τ = 0.21; P = 0.04) and modified GRACE (τ = 0.23; P = 0.02) scores were significantly correlated with percentile groups. Only the CS significantly discriminated between those with and without stenosis (P < 0.01).

Conclusions
Apart from modified GRACE score, overall correlations between risk scores and calcium burden, as well as revascularization rates during index stay, were low. By contrast, the determination of CS may be used as an additional surrogate marker in risk stratification in AF patients with intermediate pretest likelihood for CAD admitted to a CPU.

https://onlinelibrary.wiley.com/doi/pdf/10.1002/clc.22506

Coronary Artery Calcium as an Independent Surrogate Marker in the Risk Assessment of Patients With Atrial Fibrillation and an Intermediate Pretest Likelihood for Coronary Artery Disease Admitted to a German Chest Pain Unit.

To analyse the timing of cardiac troponin (cTn) measurements in high-risk and cTn-positive acute coronary syndromes without persistent ST-segment elevation (NSTE-ACS) in two structurally different German chest pain units (CPUs), contrasting an urban university maximum care and a rural regional primary care facility. All patients encoded as NSTEMI during the year 2013 were retrospectively enrolled in two centres: site (I)—centre of maximum care in an urban university setting and site (II)—centre of primary care in a rural regional care setting. Data acquisition included time intervals from admission to baseline cTn and first and second cTn control as well as type and timing of invasive management. The median times (site I vs. site II) from admission to cTn result announcement were 26.5 vs. 33.0 min (p = 0.02) for baseline, 4 vs. 4 h (p = 0.43) for the first and 11.0 vs. 16.5 h (p = 0.03) for the second control. Timely announcement, as recommended by guidelines, was available in 86.9 % at baseline, 59.4 % for the first or 41.1 % for the second cTn control. Rates and timing of invasive management were independent from the time point of positive cTn announcement (p = 0.51 and p = 0.68, respectively). German CPUs provide timely identification of cTn-positive patients in a narrow and guideline-adherent time frame using a rapid rule-out protocol. Especially, baseline and early cTn timing was comparable between the urban university maximum care and the rural regional primary care facility without relevant impact on guideline-conforming invasive management, underlining the high standard of care in those highly professional institutions.

/pdf/how-rapid-is-rapid-exemplary-results-of-real-life-rapid-rule-p7xnx0vdc9.pdf

How rapid is rapid? Exemplary results of real-life rapid rule-out troponin timing in troponin-positive acute coronary syndromes without persistent ST-segment elevation in two contrasting German chest pain unit facilities

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Coronary Artery Calcium as an Independent Surrogate Marker in the Risk Assessment of Patients With Atrial Fibrillation and an Intermediate Pretest Likelihood for Coronary Artery Disease Admitted to a German Chest Pain Unit.

How rapid is rapid? Exemplary results of real-life rapid rule-out troponin timing in troponin-positive acute coronary syndromes without persistent ST-segment elevation in two contrasting German chest pain unit facilities