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Serial sampling of copeptin levels improves diagnosis and risk stratification in patients presenting with chest pain: results from the CHOPIN trial
  1. Nicholas A Marston1,
  2. Kevin S Shah1,
  3. Christian Mueller2,
  4. Sean-Xavier Neath1,
  5. Robert H Christenson3,
  6. James McCord4,
  7. Richard M Nowak4,
  8. Lori B Daniels1,
  9. Judd E Hollander5,
  10. Fred Apple6,
  11. John Nagurney7,
  12. Donald Schreiber8,
  13. Christopher deFilippi3,
  14. Deborah Diercks9,
  15. Alexander Limkakeng10,
  16. Inder S Anand11,
  17. Alan HB Wu12,
  18. Allan S Jaffe13,
  19. W Frank Peacock14,
  20. Alan S Maisel1,15
    1. 1University of California, San Diego, California, USA
    2. 2University Hospital Basel, Basel, Switzerland
    3. 3University of Maryland, Baltimore, Maryland, USA
    4. 4Henry Ford Health System, Detroit, Michigan, USA
    5. 5Thomas Jefferson University, Philadelphia, Pennsylvania, USA
    6. 6Hennepin County Medical Center, Minneapolis, Minnesota, USA
    7. 7Massachusetts General Hospital, Boston, Massachusetts, USA
    8. 8Stanford University School of Medicine, Palo Alto, California, USA
    9. 9University of California, Davis Medical Center, Sacramento, California, USA
    10. 10Duke University Medical Center, Durham, North Carolina, USA
    11. 11Veterans Affairs Medical Center, Minneapolis, Minnesota, USA
    12. 12University of California, San Francisco, California, USA
    13. 13Mayo Clinic, Rochester, Minnesota, USA
    14. 14Baylor College of Medicine, Houston, Texas, USA
    15. 15Veterans Affairs Medical Center, San Diego, California, USA
    1. Correspondence to Professor Alan S Maisel, Coronary Care Unit, VA San Diego Healthcare System, 3350 La Jolla Village Drive, Cardiology Section, mc 9111A, San Diego, CA 92161, USA; amaisel{at}ucsd.edu

    Abstract

    Background Copeptin has demonstrated a role in early rule out for acute myocardial infarction (AMI) in combination with a negative troponin. However, management of patients with chest pain with a positive copeptin in the setting of a negative troponin is unclear.

    Methods The multicentre CHOPIN trial enrolled 2071 patients with acute chest pain. Of these, 476 subjects with an initial negative troponin but an elevated copeptin (>14 pmol/L) were included in this study. Copeptin and troponin levels were rechecked at 2 h and the final diagnosis of AMI was made by two independent, blinded cardiologists. Follow-up at 30 days was obtained for major adverse cardiac events (MACEs), including death, AMI and urgent revascularisation.

    Results Of the 476 patients analysed, 365 (76.7%) had a persistently elevated copeptin at 2 h and 111 patients (23.3%) had a copeptin that fell below the cut-off of 14 pmol/L. When the second copeptin was elevated there were 18 AMIs (4.9%) compared with 0 (0%) when the second copeptin was negative (p=0.017), yielding a negative predictive value of 100% (95% CI 96.7% to 100%). On 30-day follow-up there were 36 MACEs (9.9%) in the positive second copeptin group and 2 (1.8%) MACEs in the negative second copeptin group (p=0.006).

    Conclusions Patients with chest pain with an initial negative troponin but positive copeptin are common and carry an intermediate risk of AMI. A second copeptin drawn 2 h after presentation may help risk stratify and potentially rule out AMI in this cohort.

    • diagnosis
    • acute myocardial infarct
    • chest - non trauma

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