Copeptin is a marker for vasopressin, a hemodynamic stress indicator that shoots up immediately in an acute MI. In earlier studies, a negative result for both troponin and copeptin in an initial blood sample drawn at ED presentation had a 99% negative predictive value for MI.
The BiC-8 trial included 902 low- to intermediate-risk patients who presented with suspected ACS to EDs in university medical centers. All had a negative initial cardiac troponin test. They were randomized to standard care in the chest pain unit, including serial troponin testing and ECGs, or to the experimental strategy, in which physicians were informed of the copeptin results from the same initial blood sample as the troponin. If the copeptin test was positive as defined by a level of 10 pmol/L or more, the patient was hospitalized for standard care. If the copeptin result was negative, however, the patient was immediately discharged with a scheduled outpatient visit within72 hours.
Of the patients in the copeptin group, 66% were discharged directly from the ED, compared to 12% in the standard care group.
The 30-day incidence of major adverse cardiovascular events (MACE) was 5.5% in the standard care group and nearly identical at 5.46% in the copeptin group. MACE was defined in BiC-8 as all-cause mortality, MI, rehospitalization for ACS, acute unplanned PCI, coronary artery bypass surgery, life-threatening arrhythmia, or resuscitation from cardiac arrest.
MACE occurred in 14 copeptin-negative patients. However, 12 of the 14 were not discharged early because physicians overruled the negative biomarker results based on patient history and moved the patients into standard in-hospital management. Two patients, or 0.6% of those discharged from the ED on the basis of a negative copeptin test, had adverse events: one was rehospitalized on day 23 and underwent acute unplanned PCI on the next day, and the other was rehospitalized on day 4 and underwent coronary artery bypass graft surgery on day 12.
American Heart Association Immediate Past President Donna K. Arnett, PhD, said in an interview that she’d really like to see a second, confirmatory randomized trial before this early rule-out strategy is widely adopted. She considers the lost-to-followup rate uncomfortably high: 63 patients in the intention-to-treat analysis, and another 75 not accounted for in the per protocol analysis, noted Dr Arnett, professor and chair of the department of epidemiology at the University of Alabama, Birmingham.
"The most important message from BiC-8, I think, is that these were patients at low- to-intermediate risk; they’re not the high-risk patients. And it’s also important that the physician didn’t rely only on the test result, but also took a final look at the clinical situation before releasing the patient. There is some overruling when patients are biomarker-negative but have typical risk markers. No test is 100% accurate. Clinical judgment remains extremely important," emphasized co-investigator Dr Kurt Huber, professor and director of cardiology and emergency medicine at Wilhelminen Hospital, Vienna.
The BiC-8 trial was sponsored by ThermoFisher Scientic and six university medical centers in German-speaking Europe. Dr Moeckel reported receiving a research grant from ThermoFisher Scientific and serving as a consultant to Bayer, AstraZeneca, and The Medicines Company. Drs Arnett and Huber had no conflicts to declare.
Two studies document a rise in gun wounds, homicides
BY SHERRY BOSCHERT
At th AAST Annual Meeting
SAN FRANCISCO—Deaths from gunshot wounds doubled between 2000 and 2012 in the region served by one New Jersey trauma center and gun-related homicides as a proportion of violent crimes increased by 27% in southern Arizona after the state stopped requiring permits for concealed weapons, separate studies found.
In 2000, 8% of patients treated for gunshot wounds died. That rate increased to 15% in 2011, according to a retrospective study of 6,323 gunshot wounds seen at the New Jersey Trauma Center, a Level I trauma center in Newark.
The proportion of 15-minute time increments in which the hospital was treating two or more patients for gunshot wounds increased from approximately 10% in 2000 to nearly 30% by the end of 2011, and the proportion of 15-minute increments in which three or more gunshot wounds were being treated increased from 1% to 16%, reported Dr David H. Livingston and his associates.
Surgery on 71% of these patients plus other services incurred $115 million in costs, 75% of it unreimbursed. The mean cost per patient increased by 282% during the study period, reported Dr Livingston of University Hospital, Newark, NJ, and a professor of surgery at Rutgers University, also in Newark.
Half of the patients in his study needed ICU care, a third needed a ventilator, and just less than a third needed blood transfusions. All of these parameters increased by 50% to 180% during the study period, he said at the annual meeting of the American Association for the Surgery of Trauma.