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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleDisplayedQuote" id="dsq0005"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">&#8220;When I pronounce the word Future&#44; the first syllable already belongs to the past&#46;&#8221;</p><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">&#8211; Wis&#322;awa Szymborska&#44; Poems New and Collected</p></span></p><p id="par0010" class="elsevierStylePara elsevierViewall">In recent decades&#44; cardiovascular medicine has been actively looking for biomarkers that could be used as additional tools to predict therapeutic failure or morbidity and mortality in patients with heart disease&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">The measurement of biomarkers such as troponin and natriuretic peptides has consistently been shown to improve risk prediction in addition to clinical risk stratification models&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Recently&#44; a study investigated the relationship between troponin level&#44; coronary angiography&#44; and all-cause mortality in patients presenting with atrial fibrillation &#40;AF&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">1</span></a> In this study the presence of elevated troponin levels in patients presenting to the hospital with AF was associated with a high risk of mortality&#44; with higher levels associated with worse prognosis&#46; Importantly&#44; the risk of mortality associated with troponin increase was lower in patients who underwent coronary angiography than in those who did not&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">The exact pathophysiology of circulating troponin in AF is still the subject of research&#44; and there are no clear answers&#46; One hypothesis is that myocardial necrosis is caused by rapidly conducted AF in the context of pre-existing coronary artery disease &#40;causing oxygen supply-demand mismatch&#41;&#46; But several other pathophysiological mechanisms may be involved&#44; including volume and pressure overload&#44; changes in microvascular blood flow&#44; atrial calcium overload&#44; oxidative stress&#44; and changes in tissue structure&#46;<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">2&#44;3</span></a> Oxygen supply-demand mismatch is probably a credible explanation&#44; as it has been observed that rate control can reduce troponin leak&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">4</span></a> Nonetheless&#44; there are also circumstances in which troponin release also occurs at normal ventricular rates&#44; and furthermore in several patients with stroke and AF there is evidence of troponin increase in the acute phase&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">5</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">The role of coronary revascularization is not obvious&#44; as the identified coronary artery disease is not always severe or functionally significant&#44; which makes clear treatment decisions difficult&#44; but this debate is beyond the scope of the present discussion&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">In the area of electrical activity analysis&#44; research has shown that the presence of P-wave disturbance is a predictive factor not only of arrhythmia morbidity&#44; but also of overall mortality&#44; stroke and dementia&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">6</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">Prolonged P-wave duration is a marker of left atrial abnormality&#44; and in a sub-analysis of the Atherosclerosis Risk in Communities study&#44; an association was also found between the presence of P-wave prolongation and the increased risk of sudden cardiac death in the general population&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">7</span></a> This association was independent of cardiovascular risk factors and conditions including AF&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Recently&#44; a deep convolutional neural network using digital electrocardiogram &#40;ECG&#41; traces&#44; trained on &#62;1 million 12-lead resting ECGs&#44; predicted new-onset AF within one year&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">8</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">Electrocardiographic analysis during sinus rhythm could thus be an additional tool to predict the development of cardiovascular disease&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">In the context set out above&#44; it seems extremely attractive to include the combined assessment of different biomarkers and electrical parameters&#44; so that together they add predictive value to clinical data&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">Ocak et al&#46;&#44; <a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">9</span></a> in their study published in this issue of the <span class="elsevierStyleItalic">Journal</span>&#44; analyzed the clinical usefulness of combining P-wave dispersion and cardiac troponin I to predict AF recurrence in patients presenting to the emergency department with paroxysmal AF&#46; P-wave dispersion &#40;PWD&#41; is defined as the difference between maximum and minimum P-wave duration recorded by 12-lead surface ECG&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">In this analysis&#44; 65 patients with paroxysmal AF were included&#44; divided into three groups according to baseline troponin I and PWD values&#46; The novelty of this approach is the combination of a serum biomarker with an electrocardiographic parameter&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">The multivariate logistic regression analysis&#44; in which age&#44; C-reactive protein&#44; white blood cell count&#44; erythrocyte sedimentation rate&#44; glucose&#44; platelets and gender were analyzed&#44; revealed that higher values of troponin and PWD were independent predictors of AF recurrence&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">Troponin I values &#8805;0&#46;11 ng&#47;ml predicted AF recurrence with a specificity of 61&#46;9&#37; and sensitivity of 72&#46;7&#37;&#44; and PWD&#8805;44&#46;5 ms predicted AF recurrence with a specificity of 79&#46;5&#37; and sensitivity of 71&#46;4&#37;&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">The combined use of PWD and baseline troponin I values had higher predictive value than PWD or troponin alone&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">As the authors report&#44; the study is limited by its small sample size and the inclusion only of patients with the paroxysmal phenotype of AF&#44; and this should be taken into consideration when analyzing the results&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">Even with the above limitations&#44; this study is a further step in the inclusion of relatively accessible markers in the risk stratification of patients with AF&#46; Its findings suggest that it will soon be possible to integrate these data routinely into clinical decision-making&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">The combination of these two parameters could add significant information on the likelihood of AF recurrence&#44; ultimately resulting in the therapeutic approach being decided based on this prediction&#44; particularly with regard to the maintenance of oral anticoagulation&#46; However&#44; in order for its use as a prediction tool to become routine&#44; it will be necessary to demonstrate its validity in larger numbers of patients&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of interest</span><p id="par0100" class="elsevierStylePara elsevierViewall">The author has no conflicts of interest to declare&#46;</p></span></span>"
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Serum biomarkers and the electrocardiogram: Best friends forever?
Biomarcadores séricos e ECG: melhores amigos para sempre?
Pedro Silva Cunha
Arrhythmology, Pacing and Electrophysiology Unit, Cardiology Service, Central Lisbon Hospital and University Center, Lisbon, Portugal
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleDisplayedQuote" id="dsq0005"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">&#8220;When I pronounce the word Future&#44; the first syllable already belongs to the past&#46;&#8221;</p><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">&#8211; Wis&#322;awa Szymborska&#44; Poems New and Collected</p></span></p><p id="par0010" class="elsevierStylePara elsevierViewall">In recent decades&#44; cardiovascular medicine has been actively looking for biomarkers that could be used as additional tools to predict therapeutic failure or morbidity and mortality in patients with heart disease&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">The measurement of biomarkers such as troponin and natriuretic peptides has consistently been shown to improve risk prediction in addition to clinical risk stratification models&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Recently&#44; a study investigated the relationship between troponin level&#44; coronary angiography&#44; and all-cause mortality in patients presenting with atrial fibrillation &#40;AF&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">1</span></a> In this study the presence of elevated troponin levels in patients presenting to the hospital with AF was associated with a high risk of mortality&#44; with higher levels associated with worse prognosis&#46; Importantly&#44; the risk of mortality associated with troponin increase was lower in patients who underwent coronary angiography than in those who did not&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">The exact pathophysiology of circulating troponin in AF is still the subject of research&#44; and there are no clear answers&#46; One hypothesis is that myocardial necrosis is caused by rapidly conducted AF in the context of pre-existing coronary artery disease &#40;causing oxygen supply-demand mismatch&#41;&#46; But several other pathophysiological mechanisms may be involved&#44; including volume and pressure overload&#44; changes in microvascular blood flow&#44; atrial calcium overload&#44; oxidative stress&#44; and changes in tissue structure&#46;<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">2&#44;3</span></a> Oxygen supply-demand mismatch is probably a credible explanation&#44; as it has been observed that rate control can reduce troponin leak&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">4</span></a> Nonetheless&#44; there are also circumstances in which troponin release also occurs at normal ventricular rates&#44; and furthermore in several patients with stroke and AF there is evidence of troponin increase in the acute phase&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">5</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">The role of coronary revascularization is not obvious&#44; as the identified coronary artery disease is not always severe or functionally significant&#44; which makes clear treatment decisions difficult&#44; but this debate is beyond the scope of the present discussion&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">In the area of electrical activity analysis&#44; research has shown that the presence of P-wave disturbance is a predictive factor not only of arrhythmia morbidity&#44; but also of overall mortality&#44; stroke and dementia&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">6</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">Prolonged P-wave duration is a marker of left atrial abnormality&#44; and in a sub-analysis of the Atherosclerosis Risk in Communities study&#44; an association was also found between the presence of P-wave prolongation and the increased risk of sudden cardiac death in the general population&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">7</span></a> This association was independent of cardiovascular risk factors and conditions including AF&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Recently&#44; a deep convolutional neural network using digital electrocardiogram &#40;ECG&#41; traces&#44; trained on &#62;1 million 12-lead resting ECGs&#44; predicted new-onset AF within one year&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">8</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">Electrocardiographic analysis during sinus rhythm could thus be an additional tool to predict the development of cardiovascular disease&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">In the context set out above&#44; it seems extremely attractive to include the combined assessment of different biomarkers and electrical parameters&#44; so that together they add predictive value to clinical data&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">Ocak et al&#46;&#44; <a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">9</span></a> in their study published in this issue of the <span class="elsevierStyleItalic">Journal</span>&#44; analyzed the clinical usefulness of combining P-wave dispersion and cardiac troponin I to predict AF recurrence in patients presenting to the emergency department with paroxysmal AF&#46; P-wave dispersion &#40;PWD&#41; is defined as the difference between maximum and minimum P-wave duration recorded by 12-lead surface ECG&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">In this analysis&#44; 65 patients with paroxysmal AF were included&#44; divided into three groups according to baseline troponin I and PWD values&#46; The novelty of this approach is the combination of a serum biomarker with an electrocardiographic parameter&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">The multivariate logistic regression analysis&#44; in which age&#44; C-reactive protein&#44; white blood cell count&#44; erythrocyte sedimentation rate&#44; glucose&#44; platelets and gender were analyzed&#44; revealed that higher values of troponin and PWD were independent predictors of AF recurrence&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">Troponin I values &#8805;0&#46;11 ng&#47;ml predicted AF recurrence with a specificity of 61&#46;9&#37; and sensitivity of 72&#46;7&#37;&#44; and PWD&#8805;44&#46;5 ms predicted AF recurrence with a specificity of 79&#46;5&#37; and sensitivity of 71&#46;4&#37;&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">The combined use of PWD and baseline troponin I values had higher predictive value than PWD or troponin alone&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">As the authors report&#44; the study is limited by its small sample size and the inclusion only of patients with the paroxysmal phenotype of AF&#44; and this should be taken into consideration when analyzing the results&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">Even with the above limitations&#44; this study is a further step in the inclusion of relatively accessible markers in the risk stratification of patients with AF&#46; Its findings suggest that it will soon be possible to integrate these data routinely into clinical decision-making&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">The combination of these two parameters could add significant information on the likelihood of AF recurrence&#44; ultimately resulting in the therapeutic approach being decided based on this prediction&#44; particularly with regard to the maintenance of oral anticoagulation&#46; However&#44; in order for its use as a prediction tool to become routine&#44; it will be necessary to demonstrate its validity in larger numbers of patients&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of interest</span><p id="par0100" class="elsevierStylePara elsevierViewall">The author has no conflicts of interest to declare&#46;</p></span></span>"
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