PROGNOSTIC VALUE OF H-FABP, A NEW MARKER IN ACUTE MYOCARDIAL INFARCTION Dr. GIAO THI THOA- Đ a Nang Hopital A/ Prof. NGUYEN LAN HIEU- Ha Noi Medical University Prof. HUYNH VAN MINH- Hue University of Medicine and Pharmacy
Deaths from Cardiovascular disease have been declining in developed nations but have increased in low- and middle-income countries. Over 80% of the world's CVD deaths now occur in developing nations.
Currently, heart disease is the biggest health threat to humans. Among them, AMI is one of the leading causes of death and disability.
Non ACS diagnosis? Stable Angina? Unstable Angina? NSTEMI? Despite the development of cardiac centers and theories of high sensitivity and specificity of biomarkers in myocardial necrosis. The evaluation of unexplained chest pain symptoms remains a huge challenge.
ACS Biomarker Development In order to improve the accuracy and effectiveness of diagnosis of MI, clinical researchers have discovered a new type of cardiac enzyme called H-FABP (Heart-type Fatty Acid Binding Protein).
Moriates C, Maisel A.( 2010), “The utility of biomarkers in sorting out the complex patient”, Am J Med, 123(5), pp.393 -9 Displays an array of biomarkers of different stages of cardiac disease. H-FABP was first shown to be released from injured myocardium in 1988, after which its application as a biochemical marker has been investigated.
H-FABP is the quickest marker for diagnosis of MI in the early stage when ECG is unclear.
• H-FABP is a small, cytoplasmic protein • Molecular weight of only 15 kDa • 20 times more cardiac specific than Myoglobin
H-FABP has demonstrated its outstanding capabilities of sensitivity and specificity, superior to troponin, particularly in the earliest stages of 0-6 hours.
Within only 30 minutes after onset of AMI, H-FABP became detectable in blood and increased very quickly.
The Prognostic Value
INTRODUCTION Viswanathan K, Kilcullen N, Morrell C, Thistlethwaite SJ, Sivananthan MU, Hassan TB, Barth JH, Hall AS. heart-type fatty-acid binding-protein (H-FABP) predicts long-term mortality and re-infarction in consecutive patients with suspected acute coronary syndrome who are troponin negative. J. Am. Coll. Cardiol. 2010;55(23): 2590-8 An increased concentration of H-FABP in the early stage after chest pain demonstrated a reliable prognostic value of death and cardiovascular events after AMI.
INTRODUCTION H-FABP contributed to providing valuable information for prognostic of AMI, independent of Troponin T, ECG and clinical tests.
Kilcullen N, Viswanathan K, Das R, Morrell C, Farrin A, Barth JH, Hall AS; Heart-type fatty acid-binding protein predicts long-term mortality after acute coronary syndrome and identifies high-risk patients across the range of troponin values. J. Am. Coll. Cardiol. 2007;50(21):2061-7..
To learn about the application of this cardiac enzyme, our selected research topic is "Prognostic value of H-FABP, a new marker in acute myocardial infarction".
AIMS 1/To evaluate variation of the level of H-FABP in patients with acute myocardial infarction before 6 hours and after 24 hours. 2/ To determine the relationship between the level of H- FABP and Killip class & early complications in acute myocardial infarction.
PATIENT SELECTION CRITERIA The target group included: - Patients with clinical manifestations and ECG for suspected AMI - Hospitalized before 24 hours after symptom onset - At Da Nang Hospital from June 2013 throughout June 2014.
EXCLUSION CRITERIA The following patients were excluded from the study group: - Patients with kidney disease. - Pulmonary embolism
EXCLUSION CRITERIA - Brain injury - Musculoskeletal injuries - Patients admitted to hospital late after 24 hours since symptom onset.
RESEARCH METHODOLOGY - The prospective, cross-sectional study was applied. - Each patient was surveyed in the following process: being asked about his medical history and having clinical examinations with an aim to selecting a target group in line with the study standards.
RESEARCH METHODOLOGY - Blood tests were taken in accordance with the regulations, diagnostic steps were conducted at a reliable specialist center. - All data were recorded on paper sheets.
Baseline Characteristics Characteristics n % X ± SD ≤ 60 26 41.9 65.74±14.5 Age > 60 36 58.1 Male 46 74.2 Sex Female 16 25.8 ≤ 6 hours 19 30.6 Onset of illness > 6 hours 69.4 43 Length of hospitalization (day) 9.65±5.1 Total 62 100.0 The average age of the target group was 65.74, among which over-60s made up a greater percent 58.1 %. Male patients accounted for 74.2%.
Baseline Characteristics Characteristics n % X ± SD ≤ 60 26 41.9 65.74±14.5 Age > 60 36 58.1 Male 46 74.2 Sex Female 16 25.8 ≤ 6 hours 19 30.6 Onset of illness > 6 hours 69.4 43 Length of hospitalization (day) 9.65±5.1 Total 62 100.0 The number of patients hospitalized prior to 6 hours since symptom onset made up 30.6%. The average length of stay at hospital was 9.65 days. Similar to the findings of some national and international studies.
Baseline Characteristics Risk factors Frequency (n =62) Percent (%) X ± SD Dyslipidemia 32 51.6 70.23±134.8 Hypertension 36 58.1 101.25±142.5 Diabetes 12 19.4 97.37±95.9 Obesity 12 19.4 105.74±117.5 Smoking 34 54.8 124.92±244.3 The number of patients with hypertension was the highest at 58.1%, followed by patients with smoking at 54.8%. However, the average levels of H-FABP in the smoking group was higher than the hypertension group.
Levels of CK, CK MB, Troponin T, myoglobin, NT pro BNP, H-FABP measured for the first time Onset of AMI 1-6h (n = 27) 7-12h (n = 9) 13-24h (n = 26) Level 232 ± 41,7 1409,50 ± 697,9 2805 ± 775,78 CK 41,26 ± 7,2 135,34 ± 57,6 210 ± 48,5 CK-MB 0,74 ± 0,6 1,03 ± 0,4 18,12 ± 14,2 Troponin T * 1956,89 ± 653,5 1861,42 ± 1200,6 4975,79 ± 1942,7 NT-proBNP* 35,30 ± 147,7 1604,25 ± 227,5 506,83 ± 164,9 Myoglobin 157,75 ± 55,64 384,82 ± 98,4 93,11 ± 25,3 H-FABP * The level of biomarkers such as Troponin, NT-proBNP, and H-FABP changed over time and was accepted as statistically significant.
Levels of CK, CK MB, Troponin T, myoglobin, NT pro BNP, H-FABP measured for the second time Onset of AMI 25-36h (n=40) >36h (n=22) Levels 2544,9 ± 562,4 4788,86 ± 2951,8 CK 229,43 ± 53,0 138,78 ± 56,2 CK-MB 6,23 ± 1,2 5,43 ± 1,7 Troponin T 5324,80 ± 3358,1 2119,48 ± 761,8 NT-proBNP 1010,83 ± 554,5 373,15 ± 174,1 Myoglobin 13,93 ± 4,8 4,75 ± 0,9 H-FABP The levels of biomarkers such as Troponin, NT-proBNP, and H-FABP changed over time, especially the level of H-FABP decreased at 25-36 hours.
Variation of H-FABP level in patients with AMI H-FABP became detectable very soon in serum (less than one hour) and increased rapidly in most cases. The median levels of H-FABP peaked at 7-12 hours and returned to normal after 36 hours.
Relationship between H-FABP level and Killip class Level H-FABP (X ± SD) n % p Class 51,46 ± 15,7 Class I 30 48,4 136,70 ± 43,9 Class II 18 29,0 < 0,05 138,10 ± 30,4 Class III 4 6,5 818,65 ± 422,2 Class IV 10 16,1 Total 62 100,0 The patients with Killip class I was the highest at 48.4%. The correlation between the level of H-FABP and Killip class in patients with MI was accepted statistically significant.
Correlation of H-FABP and early complications in patients with myocardial infarction n % H-FABP (X ± SD) Complications Arrhythmias * 15 24,2 161,09±31,3 Heart failure* 24 38,7 143,11±25,4 Cardiogenic shock 14 22,6 175,63±39,4 Sudden death* 11 17,7 180,77±68,4 3 4,8 Recurrent MI 84,61±25,6 2 3,2 79,95±53,6 Acute mechanical complications The patient with heart failure group was the highest at 38.7%. The average level of H-FABP in the group with sudden death was the highest.
Correlation of H-FABP and early complications in patients with myocardial infarction n % H-FABP (X ± SD) Complications Arrhythmias * 15 24,2 161,09±31,3 Heart failure* 24 38,7 143,11±25,4 Cardiogenic shock 14 22,6 175,63±39,4 Sudden death* 11 17,7 180,77±68,4 3 4,8 Recurrent MI 84,61±25,6 2 3,2 79,95±53,6 Acute mechanical complications There was a correlation between the level of H-FABP and complications such as arrhythmias, heart failure, sudden death and this finding was accepted as statistically significant.
Correlation of H-FABP and the number of complications in one patient No. of complications Frequency (n =62) Ratio % H-FABP (X ± SD) 0 24 38,7 28,78±45,3 1 12 19,4 112,48±74,3 2 10 16,1 147,29±201,9 3 8 12,9 173,74±120,1 4 8 12,9 238,06±382,5 Total 62 100,0 The percentage of patients without complications accounted for 38.7% and the average level of H-FABP in this group was also the lowest. The percentage of patients having four complications accounted for 12.9% and the average level of H-FABP in this group was the highest.
Correlation of the level of H-FABP between fatal and non-fatal groups Non-mortality Concentration Mortality (n=12) p (n=50) 180,77 ± 68,4 103,91 ± 29,69 H-FABP <0,05 The level of H-FABP of the fatal group after the treatment was higher than the group with non-fatal AMI. There was a correlation between level of H-FABP and treatment results, which was accepted as statistically significant.
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