High-Sensitivity Cardiac Troponin-I Is Elevated in Patients with Rheumatoid Arthritis, Independent of Cardiovascular Risk Factors and Inflammation

Abstract

Objectives

We examined the hypothesis that cardiac-specific troponin-I (cTn-I), a biomarker of myocardial injury, is elevated in patients with rheumatoid arthritis (RA).

Background

RA patients have an increased incidence of heart failure (HF). Chronic myocardial injury in RA may be a mechanism for the development of HF.

Methods

We compared cTn-I concentrations measured by high-sensitivity immunoassay in 164 patients with RA and 90 controls, excluding prior or active heart failure. We examined the relationship between cTn-I concentrations and cardiovascular risk factors, inflammation, and coronary artery calcium score (CACS), a measure of coronary atherosclerosis.

Results

cTn-I concentrations were 49% higher in patients with RA (median 1.15 pg/mL [IQR 0.73–1.92] than controls (0.77 pg/mL [0.49–1.28](P<0.001). The difference remained statistically significant after adjustment for demographic characteristics (P = 0.002), further adjustment for cardiovascular (CV) risk factors (P = 0.004), inflammatory markers (P = 0.008), and in a comprehensive model of CV risk factors and inflammatory markers (P = 0.03). In patients with RA, cTn-I concentrations were positively correlated with age (rho = 0.359), Framingham risk score (FRS) (rho = 0.366), and systolic blood pressure (rho = 0.248 (all P values ≤0.001)), but not with measures of inflammation or RA drug therapies. cTn-I was significantly correlated with CACS in RA in univariate analysis, but not after adjustment for age, race, sex and FRS (P = 0.79). Further model adjustments for renal function and coronary artery disease confirmed the significance of the findings.

Conclusion

High-sensitivity cTn-I concentrations are elevated in patients with RA without heart failure, independent of cardiovascular risk profile and inflammatory markers. Elevated troponin concentrations in RA may indicate subclinical, indolent myocardial injury.

About the Authors:

William S. Bradham

* E-mail: [email protected]

Affiliation: Division of Cardiology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America

Aihua Bian

Affiliation: Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America

Annette Oeser

Affiliation: Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America

Tebeb Gebretsadik

Affiliation: Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America

Ayumi Shintani

Affiliation: Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America

Joseph Solus

Affiliation: Department of Molecular Physiology and Biophysics, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America

Joel Estis

Affiliation: Singulex Inc., Alameda, California, United States of America

Quynh Anh Lu

Affiliation: Singulex Inc., Alameda, California, United States of America

John Todd

Affiliation: Singulex Inc., Alameda, California, United States of America

Paolo Raggi

Affiliation: Division of Cardiology, Emory University, Atlanta, Georgia, United States of America

C. Michael Stein

Affiliation: Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America

Introduction

Patients with rheumatoid arthritis (RA) experience premature mortality that is largely due to cardiovascular disease [1], [2]. Cardiovascular mortality in RA is 50–60% higher compared to the general population, and there is increased prevalence of ischemic heart disease [3]–[6], There is a markedly higher prevalence of congestive heart failure (CHF) in RA patients. For example, in a longitudinal, population-based study, the 30-year cumulative incidence of CHF in RA was 37.1% compared to 27.7% in controls, and CHF, rather than ischemic heart disease, accounted for the majority of the increase in cardiovascular mortality in RA [7].

We have previously reported increased concentrations of N-terminal pro-brain natriuretic peptide (NT-proBNP) in patients with RA [8]. NT-proBNP is released by myocytes in response to myocardial stretch, and subtle increases may reflect subclinical myocardial dysfunction [9]. Cardiac magnetic resonance imaging has demonstrated decreased left ventricular mass in patients with RA [10]. Thus, RA may predispose to the development of heart failure through a pathophysiology distinct from that of ischemic heart disease; and chronic, indolent myocyte loss may be a central process.

Cardiac troponins (cTn) are components of the cardiomyocyte contractile apparatus, and circulating concentrations are elevated in the setting of myocardial injury, such as acute coronary syndromes (ACS) [11]. High-sensitivity (hs) cTn assays allow measurement of troponin concentrations below conventional levels of detection and have revealed a spectrum of circulating cTn concentrations spanning low and high levels in both healthy subjects and in patients with overt cardiovascular disease. Low levels of troponin elevation, below threshold levels used to diagnose ACS, are associated with increased CV mortality, both in patients with diagnosed ischemic heart disease and in the general population [12], [13].

There is no information about cardiac troponin concentrations in patients with RA. We hypothesized that concentrations high sensitivity cardiac troponin (hs-cTn), a marker of myocyte injury, may be elevated early in the disease process, before the development of clinical heart failure.

Methods

Ethics Statement

The study was approved by the Institutional Review Board (IRB) of Vanderbilt University Medical Center, and all subjects were provided written informed consent.

Patients and Control Subjects

Subjects were participants in an ongoing study of cardiovascular risk in RA, and detailed methods have been described previously [14], [15]. One hundred and sixty four eligible patients >18 years of age who met the American College of Rheumatology classification for RA and 90 control subjects without RA were studied. Individuals with heart failure, defined as current heart failure requiring treatment, or fulfillment of at least 2 of three following criteria; a previous history of heart failure, use of digoxin, or use of a diuretic, were excluded from the study.

Patients were recruited from an RA registry, by referral from area rheumatologists, and by local advertisement. Control subjects were recruited from among the patient’s acquaintances, by local advertisement, and from a database of volunteers maintained by the Vanderbilt Clinical Research Center.

Data Collection

Clinical and demographic information was acquired via structured interview, questionnaires, physical examination, laboratory tests, electron beam computed tomography (CT), and review of medical records. Current and historic medication use was determined from information provided by patients, and from review of medical records. Blood pressure was recorded as the average of 2 measurements obtained 5 minutes apart after the subject had rested in a supine position for at least 10 minutes. Subjects were considered hypertensive if they were taking antihypertensive agents, or if measured systolic blood pressure was greater than 140 mm Hg and/or diastolic pressure was greater than 90 mm Hg. RA disease activity was assessed using the Disease Activity Score based on evaluation of 28 joints (DAS28). The DAS28 is a validated composite index including a 28 joint count for tenderness and swelling, erythrocyte sedimentation rate (ESR), and the patient’s overall assessment of wellbeing [16]. The Framingham risk score (FRS), a composite score of traditional risk factors that includes blood pressure, smoking status, age, and sex, but not diabetes mellitus, was calculated.

Laboratory Tests

Blood was collected after an overnight fast for determination of complete blood count, serum creatinine, total cholesterol, high-density lipoprotein (HDL) cholesterol, triglycerides, homocysteine, and low-density (LDL) cholesterol at the Vanderbilt University Medical Center clinical laboratory. In patients with RA, CRP and Westergren ESR were measured by the hospital laboratory, and medical records reviewed to determine the presence or absence of rheumatoid factor (RF). Before 2003, the laboratory did not use a high-sensitivity CRP assay, and low concentrations were reported as <3 mg/L. Thus, in 40 patients with CRP reported as <3 mg/L, concentrations were re-measured by ELISA (Millipore), and the resulting data were used in the current study analysis. High sensitivity cardiac specific troponin-I (hs-cTn-I) was assayed using the ErennaR System (Singulex Corp, Alameda, CA) by technicians blinded to the clinical data. The limit of detection and the 10% coefficient of variation were 0.1 pg/mL and 0.7 pg/mL, respectively. TNFa, interleukin-6 (IL-6), and NT-pro-BNP concentrations were measured by multiplex enzyme-linked immunosorbent assay (Linco Research/Millipore, St. Louis, MO).

Coronary Artery Calcification

All subjects underwent tomographic imaging with a c-150 scanner (GE/Imatron, South San Francisco, CA) as described previously [14]. Scans were evaluated by a single investigator blinded to patient clinical status. The degree of calcified plaque was calculated as described previously; the sum of partial scores of all coronary artery lesions provided an overall coronary artery calcium score (CACS) for each patient [13].

Statistical Analysis

Descriptive statistics were calculated as the median with the interquartile range (median [IQR]) or mean ±SD) according to the distribution of the continuous variables. Wilcoxon rank-sum tests were used to compare continuous variables. Person Chi-square tests were used to compare categorical variables. We assessed the correlation between hs-cTn-I concentration and cardiovascular risk factors (body mass index (BMI), high density lipoprotein (HDL) and low density lipoprotein (LDL) cholesterol, triglycerides (TG), diabetic status, homocysteine, lipoprotein(a), inflammation markers (CRP, IL-6 and TNFα) with Spearman’s rank correlation test separately for patients with RA and control subjects. To assess the independent association between RA status and hs-cTn-I concentration, we used 4 multivariable linear regression models with a priori defined covariates. Those models adjusted for:

Model 1.

Age, race, and sex (base model)

Model 2.

Base model and cardiovascular risk factors (body mass index (BMI), high density lipoprotein (HDL) and low density lipoprotein (LDL) cholesterol, triglycerides (TG), diabetic status, homocysteine, lipoprotein(a), current smoking status, and hypertension (HTN))

Model 3.

Base model and markers of inflammation (C reactive protein (CRP), interleukin-6 (IL-6), and tumor necrosis factor-alpha (TNFa) and

Model 4.

Base model, cardiovascular risk factors (as in Model 2), markers of inflammation (as in Model 3), and NT-proBNP.

[Figure omitted. See PDF.]

Table 1. Clinical Characteristics of Study Subjects.

https://doi.org/10.1371/journal.pone.0038930.t001

Among the RA group, the association between hs-cTn-I concentrations and CACS was examined using the proportional odds model with CACS as the dependent variable, and were adjusted for age, race, sex, and FRS. Concentrations of hs-cTn-I, triglycerides, homocysteine, CRP, TNF-α, and IL-6 were natural logarithm-transformed to improved normality. All calculations were performed using R version 2.10.0 (http://www.r-project.org) and two-sided P values less than 0.05 were considered statistically significant.

Sensitivity Analysis for Possible Confounders

Because cardiac troponin is renally cleared, the results of the study could be confounded in patients with poor renal function. To account for renal function, the statistical models were analyzed by including the estimated glomerular filtration rate (Modification of Diet in Renal Disease calculation) in the model. Further, to control for the presence of known cardiovascular disease in the study subjects, the statistical models were re-analyzed, excluding patients with a diagnosed cardiovascular disease (22 RA patients, 8 control patients excluded).

Results

Patient Characteristics

Patients with RA (n = 164) and control subjects (n = 90) were of similar age and had a similar sex distribution (Table 1). As reported previously in this cohort, NT-BNP, CRP, TNFa, IL-6, homocysteine, and CACS were significantly higher in RA than in control subjects [9], [14], [15]. A history of ischemic cardiovascular disease (stroke, myocardial infarction, angina) or a coronary procedure (coronary artery bypass graft or angioplasty) was present in 13% of patients with RA and 9% of controls (P = 0.29).

High Sensitivity cTn-I Concentrations and Clinical Variables in RA Patients and Controls

High sensitivity cTn-I concentrations were significantly higher in patients with RA (median 1.15 pg/mL [IQR 0.73–1.92] than controls (0.77 pg/mL [0.49–1.28](P<0.001) (Figure 1). Hs cTn-I remained significantly higher in RA patients after adjustment for age, race, and sex (p = 0.002)(Figure 2- Model 1); age, race, sex and cardiovascular risk factors (p = 0.004)(Figure 2- Model 2); age, race, sex, and markers of inflammation (p = 0.008)(Figure 2- Model 3); and age, race, sex, CV risk factors, markers of inflammation, and NT-proBNP (p = 0.029)(Figure 2- Model 4). Rheumatoid factor was measured in 157 patients, and hs-cTn-I concentrations were not significantly different among RA patients in whom rheumatoid factor was present (1.17 [0.73–1.99] pg/ml, n = 112 (71%)), or absent (1.09 [0.73–1.41] pg/ml, n = 45 (29%))(p = 0.28).

[Figure omitted. See PDF.]

Figure 1. Unadjusted Troponin Concentrations.

Boxplot of troponin concentrations (pg/mL) for RA subjects and controls, demonstrating elevated troponin concentrations in RA patients compared to controls (p = 0.0006). Presented as 25th quartile, median, 75th quartile. Fences drawn to nearest value not exceeding 1.5 interquartile range. Observations beyond fences are plotted.

https://doi.org/10.1371/journal.pone.0038930.g001

[Figure omitted. See PDF.]

Figure 2. Multivariable Linear Regression Troponin Models for RA Patients vs Controls.

Model 1: Adjusted for patient age, race, gender (p = 0.002); Model 2: Adjusted for age, race, gender, and cardiovascular risk factors (p = 0.004); Model 3: Adjusted for age, race, gender and markers of inflammation (p = 0.008); Model 4: Adjusted for age, race, gender, cardiovascular risk factors, markers of inflammation, and NT-proBNP (p = 0.03).

https://doi.org/10.1371/journal.pone.0038930.g002

Sensitivity Analysis

Sensitivity analyses were performed adjusting for renal function (MDRD) and excluding study subjects with previous CV disease. The finding that hs-cTn-I was higher in RA patients compared to controls remained statistically significant in models 1–4 (all P values <0.05).

Association between hs-cTn-I Concentrations and Clinical Variables

In RA, hs-cTn-I concentrations were positively correlated with age, systolic BP, CACS and NT-proBNP; and in control subjects with systolic BP, serum creatinine, and CACS, but not with age or NT-proBNP (Table 2). There was no significant difference in hs-cTn-I concentrations among RA patients who were or were not currently receiving methotrexate, anti-TNF drugs, hydroxychloroquine, and corticosteroids (Table 3).

[Figure omitted. See PDF.]

Table 2. Correlation between hs-cTn-I and clinical variables in patients with RA and controls.

https://doi.org/10.1371/journal.pone.0038930.t002

[Figure omitted. See PDF.]

Table 3. Concentrations of hs-cTn-I in patients with RA receiving different drugs (n = 164).

https://doi.org/10.1371/journal.pone.0038930.t003

High Sensitivity cTn-I and Coronary Artery Calcification Score (CACS)

Although CACS was significantly correlated with hs-cTn-I concentrations in both patients with RA (rho = 0.33, P<0.001) and control subjects (rho = 0.24, P = 0.005), there were no statistically significant associations after multivariable model adjustment for age, race, sex and FRS in both RA (P = 0.79) and control subjects (P = 0.43).

Discussion

The major finding of this study was that concentrations of high sensitivity cardiac troponin-I, a biomarker of cardiac injury, were higher in patients with RA compared to controls. This difference in troponin-I concentrations between patients with RA and controls remained statistically significant after adjustment for demographic variables, inflammation, renal function, coronary artery disease, and cardiovascular risk factors.

As the preferred biomarkers of myocardial necrosis in patients suspected of having acute coronary syndrome (ACS), elevated cTn concentrations have almost complete specificity for myocardial tissue. Consensus guidelines recommend that cardiac troponin concentrations corresponding to the 99th percentile of a healthy population (commonly 0.03 µg/L or 30 pg/mL) be used as the threshold for defining an abnormal elevation [17]–[20]. More recently, high-sensitivity troponin assays allow measurement of troponin with detection limits 10-fold lower than conventional assays, and are thus capable of identifying subclinical myocardial injury and CV risk [12]. Low level hs-cTn elevation, is associated with increased risk of heart failure and cardiovascular death in patients with stable coronary artery disease [13]. Similarly, in several community-based studies, the troponin concentration detected was predictive of long-term cardiovascular outcomes [21], [22]. For example, in the Atherosclerosis Risk in Communities (ARIC) cohort, cTn concentrations of 6–8 pg/mL were associated with significantly increased risk for coronary heart disease, heart failure, and mortality [22].

Patients with RA have shorter life expectancy, more ischemic heart disease and heart failure, and higher cardiovascular mortality compared to the general population [23], [24], [25]. The increased risk of heart failure in patients with RA is not explained by traditional cardiovascular risk factors, or solely by the presence of ischemic heart disease [8], [26], [27]. Interestingly, a recent cardiac MRI study reported lower myocardial mass in patients with RA compared to age matched controls [10], suggesting chronic myocardial injury or myocyte loss as an underlying problem in RA. Our finding of increased circulating hs-cTn would be concordant with that hypothesis.

The mechanistic explanation for elevated troponin concentrations in RA is not known. There are several proposed myocardial mechanisms for cTn release, including subendocardial ischemia leading to myocyte necrosis, cardiomyocyte injury from inflammatory cytokines, hibernating myocardium, and apoptosis [28]–[32]. We found no significant association between hs-cTn-I levels and inflammatory cytokines, acute phase reactants, or a disease activity score (Table 2). This suggests that active inflammation may not be the primary driver of troponin elevation in RA.

Viable cardiomyocytes, without necrosis, can release cTn as an intact protein by a stretch-related mechanism mediated by integrins [33]. Thus, underlying hemodynamic stress leading to increased myocardial stretch may play a role in the elevated troponin concentrations in RA. The mechanism for BNP release from myocytes is also hypothesized to be stretch related. Indeed, we previously reported that NT-proBNP concentrations are elevated in patients with RA [9], and in the present study, hs-cTn-I and NT-proBNP concentrations were significantly correlated. However, the concentrations of hs-cTn-I remained significantly higher in patients with RA than controls, even when NT-proBNP was included in the statistical model. This suggests that there may be additional mechanisms underlying elevated hs-cTn-I in RA, compared to those that drive NT-proBNP.

Patients with RA have an increased risk of ischemic heart disease. Thus, pre-existing heart disease could account for differences between RA patients and controls. Indeed, we found a significant correlation between hs-cTn-I concentrations and CACS, a measure of coronary artery atherosclerosis. However, the association between hs-cTn-I concentrations and CACS was not significant after adjustment for age, sex, race, and Framingham risk score. Furthermore, when we adjusted for cardiovascular risk factors, hs-cTn-I concentrations remained significantly higher in patients with RA than controls.

These observations suggest that the clinical and subclinical measures of heart disease we studied do not fully account for the increased concentrations of hs-cTn-I concentrations in RA patients. The most plausible explanation is that elevated hs-cTn-I concentrations in RA patients reflect subclinical myocardial damage, perhaps reflected by small vessel disease or fibrosis, in addition to that accrued from hypertension, age, and other cardiovascular risk factors.

Another consideration is whether the increased concentrations of hs-cTn-I in RA could be artifactual since rheumatoid factor and other heterophilic antibodies can potentially interfere with antibody-based immunoassays by nonspecific binding with detection agents. Rheumatoid factor, present in 71% of patients in this study, however, was not associated with higher circulating hs-cTn-I. Furthermore, in developing the assay, we designed the assay buffers to contain blockers to suppress interference from heterophile antibodies, including RF and human anti-mouse antibodies. The assay was tested experimentally with samples known to contain high concentrations of such interfering substances and no interference was observed.

A limitation of the study was that we did not have measures of myocardial structure or function. Furthermore, the study was cross-sectional, and thus provided no information about long-term outcomes. We could not evaluate the temporal relationship between inflammatory markers and troponin. We cannot, for example, exclude the possibility that waxing and waning concentrations of inflammatory mediators during exacerbations of RA may affect hs-cTn-I concentrations. The patients in this study had relatively well-controlled disease and it is possible that high levels of inflammation, as occurs in poorly controlled disease, may affect hs-cTn-I concentrations.

In conclusion, high-sensitivity cTn-I concentrations are elevated in patients with RA without heart failure, independent of cardiovascular risk profile and inflammatory markers. Elevated troponin concentrations in RA may indicate subclinical, indolent myocardial injury.

Author Contributions

Conceived and designed the experiments: WSB CMS. Performed the experiments: WSB AO JS JE QAL JT. Analyzed the data: WSB CMS AB TG AS JS PR. Contributed reagents/materials/analysis tools: JE QAL JT. Wrote the paper: WSB CMS.

Citation: Bradham WS, Bian A, Oeser A, Gebretsadik T, Shintani A, Solus J, et al. (2012) High-Sensitivity Cardiac Troponin-I Is Elevated in Patients with Rheumatoid Arthritis, Independent of Cardiovascular Risk Factors and Inflammation. PLoS ONE7(6): e38930. https://doi.org/10.1371/journal.pone.0038930

References

1. Wolfe F, Mitchell DM, Sibley JT, Fries JF, Bloch DA, et al. (1994) The mortality of rheumatoid arthritis. Arthritis Rheum 37(4): 481–494.F. WolfeDM MitchellJT SibleyJF FriesDA Bloch1994The mortality of rheumatoid arthritis.Arthritis Rheum37(4)481494

2. Pincus T, Callahan LF, Sale WG, Brooks AL, Payne LE, et al. (1984) Severe functional declines, work disability, and increased mortality in seventy-five rheumatoid arthritis patients studied over nine years. Arthritis Rheum 27(8): 864–872.T. PincusLF CallahanWG SaleAL BrooksLE Payne1984Severe functional declines, work disability, and increased mortality in seventy-five rheumatoid arthritis patients studied over nine years.Arthritis Rheum27(8)864872

3. Solomon DH, Karlson EW, Rimm EB, Cannuscio CC, Mandl LA, et al. (2003) Cardiovascular morbidity and mortality in women diagnosed with rheumatoid arthritis. Circulation 107(9): 1303–1307.DH SolomonEW KarlsonEB RimmCC CannuscioLA Mandl2003Cardiovascular morbidity and mortality in women diagnosed with rheumatoid arthritis.Circulation107(9)13031307

4. Meune C, Touze E, Trinquart L, Allanore Y (2009) Trends in cardiovascular mortality in patients with rheumatoid arthritis over 50 years: a systematic review and meta-analysis of cohort studies. Rheumatology (Oxford) 48(10): 1309–1313.C. MeuneE. TouzeL. TrinquartY. Allanore2009Trends in cardiovascular mortality in patients with rheumatoid arthritis over 50 years: a systematic review and meta-analysis of cohort studies.Rheumatology (Oxford)48(10)13091313

5. Avina-Zubieta JA, Choi HK, Sadatsafavi M, Etminan M, Esdaile JM, et al. (2008) Risk of cardiovascular mortality in patients with rheumatoid arthritis: a meta-analysis of observational studies. Arthritis Rheum 59(12): 1690–1697.JA Avina-ZubietaHK ChoiM. SadatsafaviM. EtminanJM Esdaile2008Risk of cardiovascular mortality in patients with rheumatoid arthritis: a meta-analysis of observational studies.Arthritis Rheum59(12)16901697

6. Levy L, Fautrel B, Barnetche T, Schaeverbeke T (2008) Incidence and risk of fatal myocardial infarction and stroke events in rheumatoid arthritis patients. A systematic review of the literature. Clin Exp Rheumatol 26(4): 673–679.L. LevyB. FautrelT. BarnetcheT. Schaeverbeke2008Incidence and risk of fatal myocardial infarction and stroke events in rheumatoid arthritis patients. A systematic review of the literature.Clin Exp Rheumatol26(4)673679

7. Nicola PJ, Crowson CS, Maradit-Kremers H, Ballman KV, Roger VL, et al. (2006) Contribution of congestive heart failure and ischemic heart disease to excess mortality in rheumatoid arthritis. Arthritis Rheum 54(1): 60–67.PJ NicolaCS CrowsonH. Maradit-KremersKV BallmanVL Roger2006Contribution of congestive heart failure and ischemic heart disease to excess mortality in rheumatoid arthritis.Arthritis Rheum54(1)6067

8. Solus J, Chung CP, Oeser A, Avalos I, Gebretsadik T, et al. (2008) Amino-terminal fragment of the prohormone brain-type natriuretic peptide in rheumatoid arthritis. Arthritis Rheum 58(9): 2662–9.J. SolusCP ChungA. OeserI. AvalosT. Gebretsadik2008Amino-terminal fragment of the prohormone brain-type natriuretic peptide in rheumatoid arthritis.Arthritis Rheum58(9)26629

9. D’Errico MP, Grimaldi L, Petruzelli MF, Gianicolo EA, Tramacere F, et al. (2012) N-terminal pro-B-type natriuretic peptide plasma levels as a potential biomarker for cardiac damage after radiotherapy in patients with left-sided breast cancer. Int J Radiat Biol Phys 82(2):e239–46. Epub 2011 Jun 2. MP D’ErricoL. GrimaldiMF PetruzelliEA GianicoloF. Tramacere2012N-terminal pro-B-type natriuretic peptide plasma levels as a potential biomarker for cardiac damage after radiotherapy in patients with left-sided breast cancer. Int J Radiat Biol Phys 82(2):e239–46.Epub 2011 Jun 2

10. Giles JT, Malayeri AA, Fernandes V, Post W, Blumenthal RS, et al. (2010) Left ventricular structure and function in patients with rheumatoid arthritis, as assessed by cardiac magnetic resonance imaging. Arthritis Rheum 62(4): 940–51.JT GilesAA MalayeriV. FernandesW. PostRS Blumenthal2010Left ventricular structure and function in patients with rheumatoid arthritis, as assessed by cardiac magnetic resonance imaging.Arthritis Rheum62(4)94051

11. Gupta S, de Lemos JA (2007) Use and misuse of cardiac troponins in clinical practice. Prog Cardiovasc Dis 50(2): 151–65.S. GuptaJA de Lemos2007Use and misuse of cardiac troponins in clinical practice.Prog Cardiovasc Dis50(2)15165

12. Januzzi JL, Bamberg F, Lee H, Truong QA, Nichols JH, et al. (2010) High-sensitivity troponin T concentrations in acute chest pain patients evaluated with cardiac computed tomography. Circulation 121(10): 1227–34.JL JanuzziF. BambergH. LeeQA TruongJH Nichols2010High-sensitivity troponin T concentrations in acute chest pain patients evaluated with cardiac computed tomography.Circulation121(10)122734

13. Omland T, de Lemos JA, Sabatine MS, Christophi CA, Rice MM, et al. (2009) A sensitive cardiac troponin T assay in stable coronary artery disease. N Engl J Med 361(26): 2538–47.T. OmlandJA de LemosMS SabatineCA ChristophiMM Rice2009A sensitive cardiac troponin T assay in stable coronary artery disease.N Engl J Med361(26)253847

14. Chung CP, Oeser A, Raggi P, Gebretsadik T, Shintani AK, et al. (2005) Increased coronary-artery atherosclerosis in rheumatoid arthritis: relationship to disease duration and cardiovascular risk factors. Arthritis Rheum 52(10): 3045–53.CP ChungA. OeserP. RaggiT. GebretsadikAK Shintani2005Increased coronary-artery atherosclerosis in rheumatoid arthritis: relationship to disease duration and cardiovascular risk factors.Arthritis Rheum52(10)304553

15. Chung CP, Oeser A, Avalos I, Gebretsadik T, Shintani A, et al. (2006) Utility of the Framingham risk score to predict the presence of coronary atherosclerosis in patients with rheumatoid arthritis. Arthritis Res Ther 8(6): R186.CP ChungA. OeserI. AvalosT. GebretsadikA. Shintani2006Utility of the Framingham risk score to predict the presence of coronary atherosclerosis in patients with rheumatoid arthritis.Arthritis Res Ther8(6)R186

16. van der Heijde DM, van’t Hof MA, van Riel PL, Theunisse LA, Lubberts EW, et al. (1990) Judging disease activity in clinical practice in rheumatoid arthritis: first step in the development of a disease activity score. Ann Rheum Dis 49(11): 916–20.DM van der HeijdeMA van’t HofPL van RielLA TheunisseEW Lubberts1990Judging disease activity in clinical practice in rheumatoid arthritis: first step in the development of a disease activity score.Ann Rheum Dis49(11)91620

17. Hamm CW, Ravkilde J, Gerhardt W, Jorgensen P, Peheim E, et al. (1992) The prognostic value of serum troponin T in unstable angina. N Engl J Med 327(3): 146–50.CW HammJ. RavkildeW. GerhardtP. JorgensenE. Peheim1992The prognostic value of serum troponin T in unstable angina.N Engl J Med327(3)14650

18. Alpert JS, Thygesen K, Antman E, Bassand JP (2000) Myocardial infarction redefined–a consensus document of The Joint European Society of Cardiology/American College of Cardiology Committee for the redefinition of myocardial infarction. J Am Coll Cardiol 36(3): 959–69.JS AlpertK. ThygesenE. AntmanJP Bassand2000Myocardial infarction redefined–a consensus document of The Joint European Society of Cardiology/American College of Cardiology Committee for the redefinition of myocardial infarction.J Am Coll Cardiol36(3)95969

19. Braunwald E, Antman EM, Beasley JW, Califf RM, Cheitllin MD, et al. (2000) ACC/AHA guidelines for the management of patients with unstable angina and non-ST-segment elevation myocardial infarction. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on the Management of Patients With Unstable Angina). J Am Coll Cardiol 36(3): 970–1062.E. BraunwaldEM AntmanJW BeasleyRM CaliffMD Cheitllin2000ACC/AHA guidelines for the management of patients with unstable angina and non-ST-segment elevation myocardial infarction. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on the Management of Patients With Unstable Angina).J Am Coll Cardiol36(3)9701062

20. Thygesen K, Alpert JS, White HD, Jaffe AS, Apple FS, et al. (2007) Universal definition of myocardial infarction. Circulation 116(22): 2634–53.K. ThygesenJS AlpertHD WhiteAS JaffeFS Apple2007Universal definition of myocardial infarction.Circulation116(22)263453

21. Saunders JT, Nambi V, de Lemos JA, Chambless LE, Virani SS, et al. (2011) Cardiac troponin T measured by a highly sensitive assay predicts coronary heart disease, heart failure, and mortality in the Atherosclerosis Risk in Communities Study. Circulation 123(13): 1367–76.JT SaundersV. NambiJA de LemosLE ChamblessSS Virani2011Cardiac troponin T measured by a highly sensitive assay predicts coronary heart disease, heart failure, and mortality in the Atherosclerosis Risk in Communities Study.Circulation123(13)136776

22. Blankenberg S, Zeller T, Saarela O, Havaulinna AS, Kee F, et al. (2010) Contribution of 30 biomarkers to 10-year cardiovascular risk estimation in 2 population cohorts: the MONICA, risk, genetics, archiving, and monograph (MORGAM) biomarker project. Circulation 121(22): 2388–97.S. BlankenbergT. ZellerO. SaarelaAS HavaulinnaF. Kee2010Contribution of 30 biomarkers to 10-year cardiovascular risk estimation in 2 population cohorts: the MONICA, risk, genetics, archiving, and monograph (MORGAM) biomarker project.Circulation121(22)238897

23. Wolfe F, Mitchell DM, Silbey JT, Fries JF, Bloch DA, et al. (1994) The mortality of rheumatoid arthritis. Arthritis Rheum 37(4): 481–94.F. WolfeDM MitchellJT SilbeyJF FriesDA Bloch1994The mortality of rheumatoid arthritis.Arthritis Rheum37(4)48194

24. Solomon DH, Karlson EW, Rimm EB, Cannuscio CC, Mandl LA, et al. (2003) Cardiovascular morbidity and mortality in women diagnosed with rheumatoid arthritis. Circulation 107(9): 1303–7.DH SolomonEW KarlsonEB RimmCC CannuscioLA Mandl2003Cardiovascular morbidity and mortality in women diagnosed with rheumatoid arthritis.Circulation107(9)13037

25. Meune C, Touze E, Trinquart L, Allanore Y (2009) Trends in cardiovascular mortality in patients with rheumatoid arthritis over 50 years: a systematic review and meta-analysis of cohort studies. Rheumatology (Oxford) 48(10): 1309–13.C. MeuneE. TouzeL. TrinquartY. Allanore2009Trends in cardiovascular mortality in patients with rheumatoid arthritis over 50 years: a systematic review and meta-analysis of cohort studies.Rheumatology (Oxford)48(10)130913

26. Aviña-Zubieta JA, Choi HK, Sadatsafavi M, Etminan M, Esdaile JM, et al. (2008) Risk of cardiovascular mortality in patients with rheumatoid arthritis: a meta-analysis of observational studies. Arthritis Rheum 2008 59(12): 1690–7.JA Aviña-ZubietaHK ChoiM. SadatsafaviM. EtminanJM Esdaile2008Risk of cardiovascular mortality in patients with rheumatoid arthritis: a meta-analysis of observational studies.Arthritis Rheum 200859(12)16907

27. Semb AG, Kvien TK, Aastveit AH, Jungner I, Pedersen TR, et al. (2010) Lipids, myocardial infarction and ischaemic stroke in patients with rheumatoid arthritis in the Apolipoprotein-related Mortality RISk (AMORIS) Study. Ann Rheum Dis 269(11): 1996–2001.AG SembTK KvienAH AastveitI. JungnerTR Pedersen2010Lipids, myocardial infarction and ischaemic stroke in patients with rheumatoid arthritis in the Apolipoprotein-related Mortality RISk (AMORIS) Study.Ann Rheum Dis269(11)19962001

28. Levine B, Kalman J, Mayer L, Fillit HM, Packer M (1990) Elevated circulating levels of tumor necrosis factor in severe chronic heart failure. N Engl J Med 323(4): 236–41.B. LevineJ. KalmanL. MayerHM FillitM. Packer1990Elevated circulating levels of tumor necrosis factor in severe chronic heart failure.N Engl J Med323(4)23641

29. Narula J, Haider N, Virmani R, Disalvo TG, Kolodgie FD, et al. (1996) Apoptosis in myocytes in end-stage heart failure. N Engl J Med 335(16): 1182–9.J. NarulaN. HaiderR. VirmaniTG DisalvoFD Kolodgie1996Apoptosis in myocytes in end-stage heart failure.N Engl J Med335(16)11829

30. Olivetti G, Abbi R, Quaini F, Kajstura J, Cheng W, et al. (1997) Apoptosis in the failing human heart. N Engl J Med 336(16): 1131–41.G. OlivettiR. AbbiF. QuainiJ. KajsturaW. Cheng1997Apoptosis in the failing human heart.N Engl J Med336(16)113141

31. Logeart D, Beyne P, Cusson C, Tokmakova M, Leban M, et al. (2001) Evidence of cardiac myolysis in severe nonischemic heart failure and the potential role of increased wall strain. Am Heart J 141(2): 247–53.D. LogeartP. BeyneC. CussonM. TokmakovaM. Leban2001Evidence of cardiac myolysis in severe nonischemic heart failure and the potential role of increased wall strain.Am Heart J141(2)24753

32. Braunwald E (2008) Biomarkers in heart failure. N Engl J Med 358(20): 2148–59.E. Braunwald2008Biomarkers in heart failure.N Engl J Med358(20)214859

33. Hessel MH, Atsma DE, van der Valk EJ, Bax WH, Schalij MJ, et al. (2008) Release of cardiac troponin I from viable cardiomyocytes is mediated by integrin stimulation. Pflugers Arch 455(6): 979–86.MH HesselDE AtsmaEJ van der ValkWH BaxMJ Schalij2008Release of cardiac troponin I from viable cardiomyocytes is mediated by integrin stimulation.Pflugers Arch455(6)97986