Article, Cardiology

Lack of copeptin elevation during induced myocardial infarction

Unlabelled image

Case Report

Contents lists available at ScienceDirect

American Journal of Emergency Medicine

journal homepage: locate/ ajem

American Journal of Emergency Medicine 32 (2014) 1557.e5-1557.e6

Lack of copeptin elevation during induced myocardial infarction

Abstract

The specific kinetic of copeptin secretion during the course of an acute coronary syndrome (ACS) had poorly been studied, with most studies assessing copeptin levels in the very first hours of chest pain onset and not ACS itself. To overcome this issue, we took advantage of septal embolization technique for hypertrophic obstructive cardiomyopathy (HOCM) treatment, a unique situation during which myocardial infarction (MI) is provoked, to measure plasmatic copeptin levels variation.

In the past few years, several biomarkers have been suggested for early management of acute coronary syndrome. Antidiuretic hormone also called arginin vasopressin (AVP) is playing a pivotal role in the regulation of the hypothalamo-pituitary-adrenal axis and as such reflects individual stress response [1,2]. Accordingly, copeptin, the C- terminal portion of AVP prohormone, is currently being evaluated in the diagnostic of ST-segment elevation myocardial infarction and non-STEMI [3].

However, the specific kinetic of copeptin secretion during the course of an acute coronary syndrome (ACS) had poorly been studied, with most studies assessing copeptin levels in the very first hours of chest pain onset and not ACS itself. To overcome this issue, we took advantage of septal embolization technique for hypertrophic obstruc- tive cardiomyopathy (HOCM) treatment, a unique situation during which myocardial infarction (MI) is provoked, to measure plasmatic copeptin level variation.

A 42-year-old patient, having HOCM, underwent septal trans- catheter embolization. During the procedure, the patient presented typical chest pain radiating to left arm associated with anteroseptal ST- segment elevation and requiring morphine infusions for several hours. To seek for copeptin elevation, we performed several blood samples. Plasmatic levels of copeptin (BRAHMS (Hennigsdorf, Germany) kit according to the manufacturer’s instructions with an Upper limit of normal of 12 pg/mL), total creatine kinase (CK), CK-MB, troponin I (BECKMAN (Villepinte, France) kit), and myoglobin were evaluated before and after embolization every 30 minutes during 4 hours, then every 2 hours during the following 8 hours, and every 4 hours up to the 24th hour. To evaluate the hypothalamo-pituitary-adrenal axis re- sponse, cortisol and antidiuretic hormone (ADH) were also measured in the same time.

As expected, TnI levels rose from the first hour to a peak at the 14th hour (51.44 ng/mL) (Table). Similarly, myoglobin became positive during first hour with a maximum obtained after 2 hours (704 UI/mL). Maximum total CK level was 1112 UI/mL. Surprisingly, copeptin was measured at 3 pmol/L before the procedure and did not change at all until the 20th hour. The same profile was observed for ADH, which remained at 0.5 pmol/L. Cortisol values did not follow the type of pattern expected in such stress situation but rather a weave profile with peaks occurring every 2.5 hours.

In this case report, we use septal embolization of an HOCM as a unique opportunity to induce an MI. We evaluate copeptin secretion kinetic, starting before the beginning of the ACS.

Although an ST-segment elevation myocardial infarction was clearly induced, as expected, by our procedure, we failed to observe any copeptin elevation. In agreement with this absence of copeptin increase, ADH remained unchanged, thus confirming the hypotha- lamo-pituitary-adrenal axis not stimulated during the ACS.

The negative predictive value (NPV) of copeptin levels has been studied in recent trials. Maisel et al [4], in a study involving 1967 patients with chest pain presenting in an emergency department within 6 hours of pain onset, found that adding copeptin (BRAHMS kit) to TnI evaluation allowed safe rule out of MI with an NPV more than 99%.

Liebetrau [5] analysed 21 consecutive patients who underwent a septal embolization measuring the copeptin serum levels (BRAHMS kit). In this study, copeptin increased in all patients, at the 30th minute significantly and returned to baseline concentrations after 24 hours.

Our case report highlights the situation during which an authentic induced MI does not induce copeptin elevation. To our knowledge, the absence of ADH hormone elevation has never been sought previously and together with the nonelevation of cortisol could mean that hypothalamo-pituitary-adrenal axis is not always stimulated in all ACS.

Table

Kinetics of copeptin, troponin, and cortisol during septal embolization. Abbreviations:

PO, procedure onset; SE, septal embolization

0735-6757/(C) 2014

1557.e6 E.D. Schouver et al. / American Journal of Emergency Medicine 32 (2014) 1557.e51557.e6

Elie Dan Schouver, MD?

Department of Cardiology, CHU Pasteur, Nice, France

?Corresponding author. 30 Ave Valombrose Chu Pasteur Nice France

Batiment I Department of Cardiology

E-mail address: [email protected]

Patricia Panaia Ferrari, MD

Department of Biochimy, CHU Pasteur, Nice, France

Olivier Chiche, MD Pamela Moceri, MD Emile Ferrari, MD, PhD

Department of Cardiology, Chu Pasteur, Nice, France

http://dx.doi.org/10.1016/j.ajem.2014.05.018

References

  1. Reichlin T, et al. Incremental value of copeptin for rapid rule out of acute myocardial infarction. J Am Coll Cardiol 2009;54(1):60-8.
  2. Maisel A, et al. Increased 90-day mortality in patients with acute heart failure with elevated copeptin: secondary results from the Biomarkers in Acute Heart Failure (BACH) study. Circ Heart Fail 2011;4(5):613-20.
  3. Raskovalova T, et al. Diagnostic accuracy of combined cardiac troponin and copeptin assessment for early rule-out of myocardial infarction: a systematic review and meta-analysis. Eur Heart J Acute Cardiovasc Care 2014;3 (1):18-27.
  4. Maisel A, et al. Copeptin helps in the early detection of patients with acute myocardial infarction: primary results of the CHOPIN trial (Copeptin Helps in the early detection Of Patients with acute myocardial INfarction). J Am Coll Cardiol 2013;62(2):150-60.
  5. Liebetrau C, et al. Release kinetics of copeptin in patients undergoing transcoronary ablation of septal hypertrophy. Clin Chem 2013;59(3):566-9.

Leave a Reply

Your email address will not be published. Required fields are marked *