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Department of Cardiology, Aalborg Heart Center, Aarhus University Hospital, Aalborg, Denmark
Address correspondence to the author at: Department of Cardiology, Aalborg Heart Center, Aarhus University Hospital Aalborg, Hobrovej 18–22 DK-9000, Aalborg, Denmark, Fax +45-99-322164, E-mail j.ravkilde{at}rn.dk
This book should be highly welcomed by clinicians who deal with internal medicine and cardiology in their daily practice. It will also be useful to clinical chemists, who provide clinicians with the results of marker measurement. To aid in the understanding of the complex process of using biomarker results for patient care, this book provides a case-orientated approach to the interpretation of biomarker measurements in patients suffering cardiac disease. The focus is primarily on troponin and brain natriuretic peptide and secondarily on high-sensitivity C-reactive protein (hs-CRP).
Although troponin was identified nearly a quarter of century ago, the process of enabling its use as a biomarker for the diagnosis of acute myocardial infarction has been a struggle. Troponin’s potential as a diagnostic biomarker seemed too good to be true, but the high diagnostic sensitivity and specificity of troponin for detection of myocardial damage has been proven by numerous studies, as has the prognostic value of the marker. The impact of these findings led to the 2007 triple publication of "Universal Redefinition of Myocardial Infarction" (1). With the widespread implementation of troponin, however, several cases have been reported in which troponin measurement led to results judged to be false positive (2)(3), leading to terms such as "troponitis" or "troponism." Therefore, the thoroughness with which this book addresses the use of troponin as a cardiac biomarker is welcome and may make such expressions unnecessary.
In spite of the title of the book, the focus is not cardiology in general, but rather ischemic heart disease (i.e., acute coronary syndromes and congestive heart failure). The text is aimed primarily at cardiologists and internal medicine specialists, but laboratory staff will also find it useful for learning about the complex topic of the diagnostic role of cardiac biomarkers.
The book is divided into 3 parts, "Cardiac Troponins" (33 cases), "Brain Natriuretic Peptides" (39 cases), and "Contemporary Markers of Risk" (i.e., hs-CRP) (5 cases). The book provides several good cases with excellent follow-up discussion on how to interpret biomarker results for the case in question. Overall the cases are short and informative, with well-balanced discussions, but the first 3 chapters are characterized by long, reference-filled discussions. The key value of the book is the patient care discussion regarding false-positive troponin results, covered in chapters 1 and 4–11 (the last chapter is misplaced under part 2), including informative outlines by the authors (chapters 4–6, and 8).
The main emphasis of the book is on the clinical circumstances leading to laboratory results indicating increased troponin (including false positives). Another important focus is on analytical and technical problems associated with different immunoassays (chapters 1 and 11), issues that are of high importance, but of which the clinician often is unaware! Understanding of possible causes of increased troponin is even more important with the new universal redefinition of myocardial infarction, in which the discriminatory cutoff value of troponin is further decreased, thereby increasing the possibility of false-positive results.
Cardiac troponin and renal failure, especially end-stage renal disease, are discussed in a separate chapter. Other biomarkers useful for diagnosing acute coronary syndrome in this patient group are not mentioned, however, an omission that is puzzling. Similarly, the text advocates the use of troponin as a biomarker for reinfarction but does not address the ongoing need for the release kinetics of troponin I for the various commercial troponin I immunoassays. The kinetic release of troponin T illustrates the complexity of the use of troponin for diagnosing reinfarction (4)(5).
The section on natriuretic peptide and brain natriuretic peptide (N-terminal brain natriuretic peptide) covers the pros and cons of the use of these biomarkers for diagnosing acute and chronic congestive heart failure as well as for monitoring medical treatment. Clinical cases are also presented, including valuable questions and answers. A section on the use of brain natriuretic peptide in other clinical settings (e.g., asymptomatic heart disease, valve disease, renal failure) is concise, with short cases and mostly short discussions. The "Brain Natriuretic Peptides" section ends with a chapter containing refreshing, almost fictionally presented cases, but with a scientifically based discussion. The last chapter provides well-balanced comments on the value of multimarker strategies in acute and chronic congestive heart failure.
Part 3, "Contemporary Markers of Risk," introduces hs-CRP as risk biomarker of ischemic heart disease, together with well-known risk factors. Markers of inflammation with respect to risk factors are less discussed; however, repetitive measurement of hs-CRP after risk-factor adjustment (smoking cessation, lipid-lowering etc.) seems to be a promising strategy.
The authors of this book show elegantly that proper diagnosis, particularly in patients who may be suffering acute coronary syndromes and congestive heart failure, remains an "art" of medicine that is based on the doctor’s skillfulness. I highly recommend this book because its case-oriented approach demonstrates that diagnosing acute myocardial infarction and congestive heart failure still requires several diagnostic tools and not biomarkers alone.
Acknowledgments
Author Contributions: All authors confirmed they have contributed to the intellectual content of this paper and have met the following 3 requirements: (a) significant contributions to the conception and design, acquisition of data, or analysis and interpretation of data; (b) drafting or revising the article for intellectual content; and (c) final approval of the published article.
Author’s Disclosures of Potential Conflicts of Interest: Upon manuscript submission, all authors completed the Disclosures of Potential Conflict of Interest form. Potential conflicts of interest:
Employment or Leadership: None declared.
Consultant or Advisory Role: None declared.
Stock Ownership: None declared.
Honoraria: Abbott Diagnostics, Dade Behring Diagnostics, Radiometer, and Roche Diagnostics.
Research Funding: None declared.
Expert Testimony: None declared.
Role of Sponsor: The funding organizations played no role in the design of study, choice of enrolled patients, review and interpretation of data, preparation or approval of manuscript.
References
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