(O-L3) Multimarkers Approach in Acute Chest Pain in Emergency Department

Objectives: The study sought to investigate the utility of a multimarker approach in which the use of sST2, IL-6 and suPAR was combined with hsTnI in the diagnostic workup and early risk stratification of patients with chest pain in the ED.

Background: Chest pain is one of the most common causes of access to the Emergency Room, and it can be a clinical manifestation of a broad spectrum of diseases including 'time dependent' conditions such as acute coronary syndrome. Diagnosis or exclusion of acute myocardial infarction with classic clinical criteria and ECG are insufficient to make a diagnosis. Recently, the importance of inflammatory processes and endothelial damage in cardiovascular disease has been highlighted; consequently, the focus has shifted on new markers, in a "multimarker" approach in which the strengths of each are combined to provide an optimal solution to a clinical problem

Methods: The study is a pilot, single-center observational, prospective study. Twenty-five hundred and eighty-eight patients were consecutively enrolled subsequently to their access to the ED with typical chest pain, after acquisition of informed consent. Biochemical marker assays (0-1h) such as sST2, IL-6, suPAR were performed for each patient in addition to routine tests that are performed in the emergency department, including hsTnI (0-1h) (TNIH kit Siemens). Each patient's data (history, home therapy, blood test results, ECG, etc.) were collected in an Excel® database and analysed with IBM SPSS Statistics 25® software. In addition, a 6-month follow-up was performed to observe the outcome and any adverse events.

Results: The group of patients with hsTnI levels above the cardiac ischemic cut-off and/or with hsTnI excursion greater than 20% deserve in-depth diagnostic and therapeutic investigations in a timely manner, as their conditions are likely cardio-ischemic in nature. In the group with intermediate hsTnI (>6ng/mL < 47/57 ng/mL), also called the 'GREY ZONE,' with suPAR < 3 ng/mL, if sST2’s and IL-6’s values are normal, no difference is shown with a control group of healthy patients. The latter group is represented by patients who can be discharged from the ER safely. Follow-up confirms the absence of adverse events at 6 months. Patients with hsTnI < 6ng/L and suPAR < 3 ng/mL do not require continuation of the diagnostic procedure in the ER. The group of patients with intermediate hsTnI values, suPAR> 3ng/ml and sST2 > 28ng/mL, deserves hospitalization and further investigations, agreeing with the follow up where sST2 takes on a particular prognostic function, as all patients with sST2 values>110 ng/mL died. An additional group is represented by intermediate hsTnI and IL-6 >4.4 ng/L, where IL-6 increase suggests the presence of acute inflammation that may also involve an extra-cardiac cause.

Conclusions: Our data suggest that hsTnI remains the biomarker of choice for the heart, considering its peculiar cardio-specificity; on the other hand, it is known that numerous different pathophysiological elements can influence each other and associate, determining multiple clinical pictures in patients. sST2 may play a complementary role to troponin in the prognostic stratification of ischemic patients. When troponin is not indicative for diagnosis of ACS suPAR, as a marker of endothelial damage and involvement of different pathophysiological pathways, can guide the clinician where further diagnostic investigation is needed. IL-6, is quintessentially a marker of inflammation.

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Funding (Optional): no funding