HEARTBEAT-TROP. Polyethylene Glycol Precipitation to Unmask Macrotroponin

Official title

HEARTBEAT-TROP. Testing of Polyethylene Glycol Precipitation to Unmask Macrotroponin in Acute Coronary Syndrome and Marathon Runners.

Overview

Troponin elevation can, among others, be due to myocardial infarction, acute inflammation or structural heart disease. Formation of macrocomplexes against troponin is an underestimated cause for persistent troponin elevation. Polyethlylene glycol precipitation (PEG) can differentiate macrotroponin from real troponin elevation, but cut-off values for PEG have not been established. PEG is analyzed in patients with acute coronary syndrome undergoing invasive coronary angiography and compared to healthy marathon runners who have undergone cardiological pre-participation screening and have rested for 24 hours.

Detailed description

Troponin elevation can be caused by acute coronary syndrome, myocarditis or structural heart disease. In most cases, troponin levels drop back to normal after the acute phase of the disease. In some cases, troponin elevation may persist despite clinical recovery due to macrocomplex formation. In athletes, this may cause unnecessary exclusion from competitive sport. Polypethylene glycol precipitation (PEG) has emerged as a cost-effective and feasible laboratory method to reveal macrotroponin. However, cut-off values have not been established for macrotroponin. PEG will be assessed in patients presenting with acute coronary syndrome (ACS) and undergoing invasive coronary angiography and compared to healthy controls, marathon runners who have undergone cardiological pre-participation screening and have been cleared for competition. 24 hours of rest are required before troponin levels are assessed in these athletes. In the control group of marathon runners, PEG will also be analyzed within one hour after crossing the finishing line. In both groups, blood lipids (LDL-cholesterol, lipoprotein a), blood glucose and hemoglobin 1Ac will be assessed at baseline. Transthoracic echocardiography will be performed in both groups at baseline. Also, in the marathon group echocardiography will be performed within one hour after completion of the race. PEG and echocardiography will also be repeated in the group of ACS within 24 hours before hospital discharge. The primary outcome is PEG recovery in both groups at presentation (upon emergency presentation in ACS and baseline examination in athletes). Secondary outcomes are PEG recovery values in the second exam (before discharge in ACS and within one hour after marathon completion in athletes), left and right ventricular ejection fraction in both groups during both exams. Athletes are defined as marathon participants older than 18 years without overt cardiovascular disease.

Interventions

• Diagnostic test Polyethylene glycol precipitation
  PEG will be assessed in patients with acute coronary syndrome upon presentation and before hospital discharge. Athletes will receive this intervention at baseline and within one hour after completion of the marathon
• Diagnostic test Transthoracic echocardiography
  Patients with acute coronary syndrome will receive echocardiography upon presentation and before hospital discharge. Athletes will receive echocardiography at baseline and within one after marathon completion.

Primary outcome measures

• Recovery of troponin after polyethylene glycole precipitation in health and disease [Time frame: Day 1]

Secondary outcome measures (6)

• Recovery of troponin after polyethylene glycol precipitation after marathon running [Time frame: Day 2]
• Recovery of troponin after polyethylene glycole precipitation in patients with acute coronary syndrome upon hospital discharge [Time frame: Day 2]
• Left and right ventricular ejection fraction in athletes at baseline [Time frame: Day 1]
• Left and right ventricular ejection fraction after marathon running [Time frame: Day 2]
• Left and right ventricular ejection fraction during acute coronary syndrome [Time frame: Day 1]
• Left and right ventricular ejection fraction after acute coronary syndrome [Time frame: Day 2]

Eligibility criteria

Inclusion criteria

• Age above 18 years
• Group with acute coronary syndrome (ACS): Diagnosis of ACS (ST-segment elevation or non-ST-segment elevation myocardial infarction according to the European Society of Cardiology Guidelines 2023 with at least one measurement of high sensitive troponin I or T above the 99th percentile of reference).
• Marathon runners: Participation in a marathon following cardiological pre-participation screening and medical clearance for competition. No clinical signs of cardiovascular or structural heart disease

Exclusion criteria

• Patients with acute coronary syndrome: Known macrotroponin, terminal renal disease (glomerular filtration rate below 10ml per minute), diagnosis of cancer, pregnancy
• Marathon runners: Coronary artery disease, structural heart disease, diagnosis of cancer, pregnancy

Criteria are shown verbatim from the registry (in English). Final eligibility is always assessed by the study center.

Healthy volunteers: Yes

Study design

Allocation

Non-randomized

Model

Parallel assignment

Masking

Open label

Primary purpose

Diagnostic

Study locations

Germany · 1 center

• Technical University Munich — Munich

Publications

• Byrne RA, Rossello X, Coughlan JJ, Barbato E, Berry C, Chieffo A, Claeys MJ, Dan GA, Dweck MR, Galbraith M, Gilard M, Hinterbuchner L, Jankowska EA, Juni P, Kimura T, Kunadian V, Leosdottir M, Lorusso R, Pedretti RFE, Rigopoulos AG, Rubini Gimenez M, Thiele H, Vranckx P, Wassmann S, Wenger NK, Ibanez B; ESC Scientific Document Group. 2023 ESC Guidelines for the management of acute coronary syndrom PMID 37622654
• Stekelenburg JO, Berge K, Janssen SLJE, Omland T, Myhre PL, Thompson PD, Aengevaeren VL, Eijsvogels TMH. Prevalence and Predictors of Cardiac Troponin Elevations Following Exercise: a Systematic Review, Meta-analysis, and Meta-regression. Eur J Prev Cardiol. 2026 Apr 15:zwag218. doi: 10.1093/eurjpc/zwag218. Online ahead of print. PMID 41985028
• Salaun E, Drory S, Cote MA, Tremblay V, Bedard E, Steinberg C, Pare D, O'Connor K, Cieza T, Cote N, Poirier P, Douville P, Blais J, Desmeules P, Kalavrouziotis D, Mohammadi S, Voisine P, Bernier M, Pibarot P, Theriault S. Role of Antitroponin Antibodies and Macrotroponin in the Clinical Interpretation of Cardiac Troponin. J Am Heart Assoc. 2024 Jun 18;13(12):e035128. doi: 10.1161/JAHA.123.035128. PMID 38879450
• Hammarsten O, Warner JV, Lam L, Kavsak P, Lindahl B, Aakre KM, Collinson P, Jaffe AS, Saenger AK, Body R, Mills NL, Omland T, Ordonez-Llanos J, Apple FS. Antibody-mediated interferences affecting cardiac troponin assays: recommendations from the IFCC Committee on Clinical Applications of Cardiac Biomarkers. Clin Chem Lab Med. 2023 Mar 24;61(8):1411-1419. doi: 10.1515/cclm-2023-0028. Print 2023 Jul PMID 36952681
• Hammarsten O, Becker C, Engberg AE. Methods for analyzing positive cardiac troponin assay interference. Clin Biochem. 2023 Jun;116:24-30. doi: 10.1016/j.clinbiochem.2023.03.004. Epub 2023 Mar 6. PMID 36889375
• Wernhart S, Halle M, Zenk S. Handling persistent cardiac troponin elevation in asymptomatic athletes: The role of macrocomplexes. Am Heart J Plus. 2026 May 25;67:100804. doi: 10.1016/j.ahjo.2026.100804. eCollection 2026 Jul. PMID 42253289

Identifiers

NCT: NCT07726420 · 2026-319-S-CT

Primary sources (government registries)

• ClinicalTrials.gov (US NIH)

View this study on ClinicalTrials.gov ↗