The development and assessment of newer markers of inflammation, ischemia, thrombosis, and hemodynamic stress have been described in detail in other chapters of this volume. Notably, biomarkers of inflammation and hemodynamic stress have emerged as robust, independent predictors ofoutcome in patients with chronic and acute atherothrom-bosis (see Chapters 16, 17, 24). Specifically, high-sensitivity testing for C-reactive protein (high-sensitivity CRP [hsCRP]) is a convenient tool for detecting low-level systemic inflammation that portends a higher risk of developing atherothrombotic vascular disease (9), as well as poor short- and long-term prognosis in patients post-ACS (10,11). In addition, growing evidence implicates CRP as a mediator, in addition to a marker, of atherothrombosis (12). Similarly, the natriuretic peptides have been shown to provide important insight with respect to complications and outcomes among patients with ischemic heart disease. The concentration of B-type natriuretic peptide (BNP) and the N-ter-minal fragment of proBNP (NT-proBNP) correlates with left ventricular (LV) dilatation, remodeling, and dysfunction, as well as the risk of congestive heart failure (CHF) and death in patients presenting with acute myocardial infarction (AMI) (13,14). Moreover, at least 12 studies have demonstrated a robust association between BNP or NT-proBNP and the short and long-term risk of death across the spectrum of patients with ACS (15-19), including those without myocardial necrosis or clinical evidence of heart failure (18). More importantly, CRP and BNP/NT-proBNP, as well as other novel markers ofinflamma-tion and thrombosis, such as soluble CD40 ligand (CD40L) and myeloperoxidase (MPO)
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Fig. 2. Proportion of patients with positive marker strategy at time of presentation (A) and risk of death or MI at 30 d (B) stratified by marker status in Chest Pain Evaluation by Creatine Kinase-MB, Myoglobin, and Troponin I study. Myo, myoglobin; Freq, frequency. (Data are from ref. 20.)
(see Chapter 18), are associated with outcome independently ofthe results oftesting for cardiac troponin and, thus, set the stage for a combined assessment in multimarker strategies.
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