DE102006050497A1 - Risk stratification process for acute coronary syndrome involves finding levels of provasoppressin or its fragments and part-peptides by in-vitro diagnosis - Google Patents

Abstract

The risk stratification process for acute coronary syndrome, in particular an infarct of the myocardium or angina pectoris, involves finding the levels of provasoppressin or of fragments and part-peptides of it, in particular copeptin and neurophysin II, by means of in vitro diagnosis. It is applicable to symptomatic and/or asymptomatic patients, particularly emergency patients.

Description

The The invention relates to a method for risk stratification of the acute Coronary syndrome (ACS), especially of acute myocardial infarction (AMI) and angina pectoris (AP), with a provision of provasopressin (proAVP) or fragments and partial peptides thereof, especially copeptin or Neurophysin II by means of an in vitro diagnosis. Further For this purpose, the invention relates to suitable combinations of biomarkers for in vitro diagnostics.

The Risk stratification is becoming increasingly important in the area of Heart disease, be it symptomatic or asymptomatic Patients. Especially in the field of acute coronary syndrome there is a high need at an appropriate risk stratification.

The Risk stratification is used to find patients with the worse prognosis, for more intensive diagnostics and therapy / treatment with the aim of one as possible Great To allow progress. Appropriate risk stratification should therefore be effective treatment procedures which at acute coronary syndrome with percutaneous Coronary interventions and the newer drugs are given.

For the purpose of appropriate therapy requires early diagnosis and differentiation of acute coronary syndrome already in the emergency room with the need to make clinical decisions. by virtue of Non-specific symptoms (chest pain) in acute coronary syndrome is both the differentiation and differentiation of other diseases as well as the detection of acute coronary syndrome essential.

In the prior art, biochemical markers - in particular the classics such as cardiac troponins, myoglobin and CK-MB mass - have been used to predict myocardial infarction ( Katus, HA; Remppis, A .; Scheffold, T .; Diederich, KW and Kuebler, W. (1991): Intracellular compartmentation of cardiac troponin T and its release kinetics in patients with reperfused and nonreperfused myocardial infarction, Am J Cardiol 67 (16): 1360-1367 ). Another effective biochemical marker in myocardial diagnostics has been the B-type natriuretic peptide (BNP) together with pro-BNP (NT-ProBNP) ( EP1363128B1 . EP1666881A2 ).

Copeptin (also: C-terminal proAVP) is in WO 2006/018315 (BRAHMS AG) as a biomarker for the in-vitro diagnosis of AMI described. A corresponding copeptin assay is described in Morgenthaler et al. ( Nils G. Morgenthaler, Joachim Struck, Christine Alonso and Andreas Bergman, Assay for the Measurement of Copeptin, a Stable Peptide Derived from the Precursor of Vasopressin Clinical Chemistry 52: 112-119, 2006 ) disclosed.

adversely to known diagnostic methods using the previously known Markers, however, is that early and complete Incorporation of high-risk patients fails and therefore a risk stratification only insufficient he follows. An object of the invention is therefore based therein, a method for risk stratification of acute coronary syndrome to develop that improved detection of high-risk patients allows.

Further is disadvantageous that in the prior art usually no sufficient sensitivity and / or specificity the marker is reached.

A Another task is therefore a method for risk stratification acute coronary syndrome, wherein at least one Marker or combination of markers has sufficient sensitivity and specificity in one having in vitro diagnosis.

Therefore It is an object of the present invention, a method for risk stratification acute coronary syndrome.

The Task is performed by a method for risk stratification of the acute Coronary syndrome resolved, where a determination of provasopressin (proAVP) or fragments and Partial peptides thereof, in particular copeptin or neurophysin II by means of an in vitro diagnosis is carried out (hereinafter inventive method).

surprisingly Wise have provasopressin (proAVP) or fragments and partial peptides thereof, in particular copeptin or neurophysin II, a high sensitivity and specificity for the diagnosis acute coronary syndrome (see examples and figures).

The term "acute coronary syndrome" encompasses various stages of coronary heart disease that are directly life-threatening, particularly in emergency medicine, such as acute myocardial infarction and / or angina pectoris and sudden cardiac death, in addition to acute myocardial infarction, which is classified according to WHO criteria. WHO (1979): Nomenclature and criteria for the diagnosis of ischemic heart disease. Standardization of clinical nomenclature, Circulation 59 (3): 607-609 ) is defined as an acute chest pain event lasting more than 20 minutes, associated with ST segment elevations and / or an increase of myocardial enzymes, the term unstable angina pectoris (AP) has been defined as "acute coronary syndrome" according to the invention ( Hamm CW: Guidelines: Acute coronary syndrome (ACS) - Part 1: ACS without persistent ST elevation. Z Kardiol (2004) 93: 72-90; see also: Pschyrembel, De Gruyter, Berlin 2004 ).

Of the The term "risk stratification" according to the invention includes finding of patients, especially emergency patients and high-risk patients, with the worse prognosis, for more intensive diagnostics and therapy / treatment of acute coronary syndrome, especially myocardial infarction, angina pectoris with the aim of one as possible Great To allow progress. A risk stratification according to the invention allows in consequence an effective treatment procedure, which in acute Coronary syndrome with percutaneous coronary interventions and the newer medicines are given.

Therefore The invention also relates to the identification of patients with elevated Risk or / and unfavorable Prognosis of acute coronary syndrome, especially myocardial infection, Angina pectoris in symptomatic and / or asymptomatic Patients, especially emergency patients.

Especially Advantageously, in particular in cases of emergency and / or intensive care by the method according to the invention a secure stratification take place. The inventive method allows Therefore, clinical decisions leading to rapid therapeutic success and to avoid deaths to lead. Such clinical decisions also include continuing treatment with medicines for the treatment or therapy of acute coronary syndrome, especially myocardial infarction (AMI) and angina pectoris (AP).

Therefore The invention also relates to a method for risk stratification of patients with acute coronary syndrome to carry out clinical decisions, such as further treatment and therapy by means of medicaments, preferably in the time critical intensive care medicine or emergency medicine.

In a further preferred embodiment relates to the method according to the invention hence the therapy control of the acute coronary syndrome, in particular Myocardial infarction (AMI) and angina (AP).

In a further preferred embodiment the method according to the invention the risk stratification takes place to the prognosis, to the differential diagnostic early detection and detection, to assess severity and companion therapy Assessment of the course.

In a further preferred embodiment The invention relates to a method for in vitro diagnostics for Early or Differential diagnosis or prognosis of myocardial infarction or angina Pectoris, whereby a determination of the marker provasopressin (proAVP) or fragments and partial peptides thereof, in particular copeptin or Neurophysin II, is performed on a patient to be examined. However, particularly preferred is copeptin or a fragment or a Partial sequence of it.

Further The invention relates to a method for risk stratification of acute coronary syndrome or a method for in-vitro diagnostics for early or differential diagnosis or prognosis of myocardial infarction or Angina pectoris according to any of the above embodiments, wherein after occurrence Symptoms have a cut-off (threshold) range of 6-20 pmol / L the marker provasopressin (proAVP) or fragments and partial peptides thereof, especially copeptin or neurophysin II significantly (specifically) for the Diagnosis and / or risk stratification is. Further preferred is a cut-off (threshold) of 6-10 pmol / L, especially 7.5 pmol / L, preferably until 2 hours after onset of symptoms.

The invention further relates to a method for risk stratification of acute coronary syndrome or a method for in-vitro diagnostics for the early or differential diagnosis or prognosis of myocardial infarction or angina pectoris according to any of the above embodiments, wherein after onset of symptoms, a cut-off (threshold) range from 10-30 pmol / L of the provasopressin (proAVP) markers or fragments and partial peptides thereof, in particular copeptin or neurophysin II, significantly (specifically) for the prognosis and / or risk stratification. Further preferred is a cut-off (threshold) of 10-20 pmol / L.

Out Based on this basis, these methods according to the invention are advantageously sensitive.

In an embodiment the method according to the invention Blood is taken from the patient to be examined, optionally whole blood or serum or available Plasma and diagnosis are in vitro / ex vivo, i. outside of the human or animal body. Due to the provision of the marker provasopressin (proAVP) or fragments and partial peptides of it, in particular Copeptin or Neurophysin II becomes a high sensitivity and specificity for the Achieved acute coronary syndrome, myocardial infarction and angina pectoris and based on the amount present in at least one patient sample the diagnosis or risk stratification can take place. Most notably however, the marker is preferably copeptin (stable fragment from proAVP or preprovasopressin) or a fragment or a partial sequence from that.

In the context of this invention, "provasopressin" is understood to mean a human protein or polypeptide which can be obtained from the preprovasopressin and which comprises amino acids 29-164 in the context of the preproasopeptic (see also FIG WO2006 / 018315 and 3 and fragments or partial peptides obtainable therefrom, in particular copeptin (fragment: AS 126-164 (39AS: SEQ: NASDRSNATNL DGPAGALLLR LVQLAGAPEP FEPAQPDAY) or neurophysin II (fragment: AS 32-124 of preprovasopressin (93AS: SEQ: AMSDLELRQC LPCGPGGKGR CFGPSICCAD ELGCFVGTAE ALRCQEENYL PSPCQSGQKA CGSGGRCAAF GVCCNDESCV TEPECREGFH RRA) Furthermore, these polypeptides according to the invention may have posttranslational modifications, such as glycosylation, lipid (o) idization or derivatizations.

In a further embodiment may be the determination of provasopressin (proAVP) or fragments and partial peptides thereof, especially copeptin or neurophysin II additionally with other markers and preferably those that already on an acute coronary syndrome, especially myocardial infarction or angina pectoris.

Therefore the invention relates to such an embodiment of the method according to the invention, the provision in addition with at least one further marker selected from the group of inflammatory Marker, cardiovascular Marker, neurohormonal marker or ischemic marker on one examining patient.

According to the invention of inflammatory markers from at least one marker from the group C-reactive Protein (CRP), cytokines, such as TNF-alpha, interleukins, such as such as IL-6, procalcitonin (1-116, 3-116) and adhesion molecules such as VCAM or ICAM as well as the cardiovascular Marker, in particular a necrosis of cardiac muscle tissue indicating Markers and blood pressure affecting markers from at least one Markers from the group creatine kinase, myoglobin, myeloperoxidase, natriuretic protein, in particular ANP (or ANF), proANP (NT-proANP), BNP, proBNP (NT-proBNP) or a partial sequence thereof, cardiac Troponin, CRP selected be. Also included here are circulatory (pro) hormones understood, in particular as pro-gastrin-releasing peptide (proGRP), pro-endothelin-1, pro-leptin, pro-neuropeptide-Y, pro-somatostatin, pro-neuropeptide-YY, pro-opio-melanocortin or pro-adrenomedullin (proADM) or one subsequence of each. The ischemic marker can consist of at least one marker from the group troponin I and T, CK-MB selected be. About that In addition, the neurohormonal marker may be at least one natriuretic Be protein, especially AN? (or ANF), proANP (NT-proANP), BNP, proBNP (NT-proBNP) or each a partial sequence thereof.

In a particularly preferred embodiment the invention relates to a particularly advantageous combination of Biomarker namely provasopressin (proANP) or fragments and Partial peptides thereof, in particular copeptin or neurophysin II with natriuretic proteins, in particular ANP (or ANF), proANP (NT-proANP), BNP, proBNP (NT-proBNP) or each a partial sequence thereof.

Therefore The invention relates to a method for the in-vitro diagnosis of the acute Coronary syndrome, myocardial infarction or angina pectoris, where one Determination of the marker provasopressin (proAVP) or fragments and Partial peptides thereof, in particular copeptin or neurophysin II in Combination with natriuretic proteins, in particular ANP (resp. ANF), proANP (NT-proANP), BNP, proBNP (NT-proBNP) or one each Partial sequence thereof is performed on a patient to be examined. Again, a combination of neurophysin is particularly preferred II, copeptin and BNP, proBNP (NT-proBNP), especially copeptin and proBNP. These mentioned biomarker combinations are particularly advantageous Synergies leading to improved specificity and sensitivity to diagnosis of the lead (see examples).

In a further embodiment of the invention, the inventive method in the context of in vitro diagnosis using parallel or simultaneous determinations the marker performed (e.g., multi-well plates with 96 or more wells), where the determinations are made on at least one patient sample.

Furthermore, the method according to the invention and its determinations in a diagnostic device can be carried out using an automatic analyzer, in particular by means of a cryptor ( http://www.kryptor.net/ ) be performed.

In a further embodiment can the inventive method and its determinations are carried out by means of a rapid test (e.g., lateral flow test), whether in single or multiparameter determination. In a particularly preferred embodiment, it is to a self-test or to a device used in emergency diagnostics suitable is.

Further the invention relates to the use of provasopressin (proAVP) or fragments and partial peptides thereof, in particular copeptin or Neurophysin II for the risk stratification of acute coronary syndrome, Myocardial infarction or angina pectoris and / or for in-vitro diagnostics for early or differential diagnosis or prognosis of myocardial infarction or Angina pectoris.

In a particular embodiment the invention relates to the use of provasopressin (proAVP) or fragments and partial peptides thereof, in particular copeptin or Neurophysin II in combination with natriuretic proteins, in particular ANP (or ANF), proANP (NT-proAVP), BNP, proBNP (NT-proBNP) or each a subsequence thereof, for diagnosis and / or risk stratification of acute coronary syndrome, myocardial infarction or angina pectoris.

A Another task is to provide a corresponding diagnostic Apparatus for carrying out the inventive method.

in the This invention is under such a diagnostic Device, in particular an array or assay understood (e.g. Immunoassay, ELISA etc.), in the broadest sense a device for execution the inventive method.

The The invention also relates to a kit for the risk stratification of the acute Coronary syndrome, myocardial infarction and / or angina pectoris, containing Detection reagents for the determination of provasopressin (proAVP) or Fragments and partial peptides thereof, in particular copeptin or neurophysin II if necessary, the above-mentioned further markers. Such detection reagents include e.g. antibody Etc.

In a particular embodiment The invention relates to a kit for diagnosis and / or risk stratification acute coronary syndrome, myocardial infarction and / or angina pectoris, containing detection reagents for the determination of provasopressin (proAVP) or fragments and partial peptides thereof, especially copeptin or Neurophysin II in combination with natriuretic proteins, in particular ANP (or ANF), proANP (NT-proANP), BNP, proBNP (NT-proBNP) or in each case a subsequence thereof, if necessary Marker. Such detection reagents include e.g. Antibodies, etc.

subsequent Examples and figures serve to illustrate the invention, however without limiting the invention to these examples and figures.

Examples and figures:

example 1

patients dealing with the main symptom of chest pain in the emergency room a hospital was presented during the initial examination taken a blood sample.

131 Patients with myocardial infarction (MI) (median age: 64.0 years) were in a total period of 180 days after the onset of acute MI symptoms observed: Within the first 6 hours after symptom appearance (Chest pain) and hospital admission, 3 blood samples were taken each within the time periods 0-2 hours, 2-4 hours, and 4-6 hours after onset of MI symptoms. In each case, the determination of copeptin and NT-ProBNP was carried out.

To Hospitalization took place within the first 4 days after therapeutic Interventions (standard, see Braunwald et al, 2002) (day 2-5) each 1 blood sample with trailing copeptin determination).

To Discharge (median of the hospital stay: 7.2 days) took place the observation of patients in a period of 180 days. When Events (events) have been the development of severe heart failure and / or death of the patient. From the observed patients were 115 without events (o.E.) and 16 with events (+ E.). The Age medians of the groups were 63.8 and 64.5 years.

To assess the diagnostic performance of early MI biomarkers and to assess risk stratification, the results of individual blood tests were compared in patients with those of 200 (median age 65.2 years) who showed no evidence of MI (controls). Results are in Table 1 and in 1 and 2 shown.

In Table 1 shows the sensitivities (values> cut off) in MI patients against the corresponding specificities (values <Cut Off (Threshold)) in the Check at the indicated times after onset of symptoms specified.

Nice within the earliest Observation period (0-2 hours) compared to controls the copeptin greatly increased. For example, Only 4.5% of all controls showed a copeptin value higher than 7.5 pmol / l (exemplary cut-off threshold) (specificity = 95.5%), whereas 78.3% of patients without later events and even 87.5% of patients with events copeptin concentrations above 7.5 pmol / l (sensitivity). Compared to markers previously used in routine diagnostics (Troponine, myoglobin, CK-MB) are surprising increases in the Sensitivities At times, now the use of these biomarkers for Early or early Differential diagnosis of MI and risk stratification of the acute Coronary syndrome allowed. (Troponins; CK-MB usually appear only after 6 hours post-event, myoglobin appears with less sensitivity though early, but falls after about 2 hours, i. it results in an uncertain diagnostic window.) Advantageously, the increase in copeptin, i. the time of blood collection for early diagnosis of subordinate Meaning (at Cut Off 7.5 pmol / L, for example, 78.3 / 80.0 / 73% sensitivity at 0-2 / 2-4 / 4-6 Hours, respectively.

Combination with proBNP or NT-ProBNP

Surprisingly, it was shown that the combination of copeptin with proBNP (NT-ProBNP) allows a significant increase in the sensitivity of the early diagnosis of MI (see Table 1). The proBNP (NT-ProBNP) is inferior to the diagnostic performance of copeptin, but allows for example in the assessment copeptin> 7.5 pmol / l and / or proBNP (NT-ProBNP)> 200 pmol / ml in a comparable single marker markers Specificity of approximately 95% an increase in sensitivities at all time points in the non-event group by 3-6% and in the event group by 6-9.5% compared to the sensitivities of copeptin as a single marker. Table 1: 0-2 h oe 0-2 h + E. 2-4 h oe 2-4 h + E. 4-6 h oe 4-6 h + E Controls (specificity) Copeptin (pmol / l) Sens / Spef for cut-off 6 88.7% 93.8% 89.6% 93.8% 80.0% 87.5% 93.0% Sens / Spef for cut-off 7.5 78.3% 87.5% 80.0% 87.5% 73.0% 75.0% 95.5% Sens / Spef for cut-off 10 67.0% 68.8% 68.7% 68.8% 56.5% 68.8% 97.5% Sens / Spef for cut-off 20 44.3% 68.8% 43.5% 68.8% 40.0% 62.5% 100.0% NT-ProBNP (pmol / ml), cut off 200 58.5% 62.0% 61.5% 65.0% 66.5% 70.0% 94.5% Combination: Copeptin> 7.5 pmol / L and / or NT-ProBNP> 200 pmol / ml 81.2% 93.5% 83.5% 96.0% 79.5% 84.5% 93.8%

Sample collection, biomarker analysis:

Blood samples were taken using standard serum monotypes. After a clotting time of 20-40 min, centrifugation was carried out for 15 min at 2000 g, followed by serum separation by decantation. Until further use, the serum samples were stored at -20 ° C. NT-ProBNP was prepared according to Omland et al ( Omland T, Persson A, Ng L, et al. N-terminal pro-B-type natriuretic peptide and long-term mortality in acute coronary syndromes. Circulation. 2002; 106: 2913-2918 ) determined with a luminescence immunoassay. Copeptin was determined by means of the Copeptin-Lumineszenzimmunoassays Brahms AG. The copeptin determination method is detailed in Morgenthaler NG et al Clin. Chem. 2006 Jan, 52 (1), 112-9 described. In summary, 50 μl of sample are pipetted into a copeptin-antibody (Ak1) -coated tube and mixed with 200 μl of a solution of acridinium ester-labeled anti-copeptin antibody (AK2) and incubated for 2 hours at room temperature. After removal of unbound (free) labeled antibody by washing with washing solution 4 times (Lumitest wash solution, Brahms AG), the determination of bound acridinium ester-labeled antibody was carried out in a luminometer from Berthold.

Forecast (event occurrence prediction):

It was surprisingly that MI patients with events within the following 180 days post-hospitalization even higher Copeptin concentrations, as such without events. Already within 6 hours of onset of MI symptoms shows Copeptin at the exemplary cut off (threshold) of 30 pmol / l a relative risk of about 1: 2 (patients with a copeptin> 30 have a twice the risk for later events, as a patient <30 pmol / l.

As expected fall the concentrations after therapeutic interventions (day 2ff, Table 2b). Here, surprisingly, that patients with later Event have a significantly lower reduction of the biomarker.

• Legende in Tabellen und Figuren: surv. = Überleben, E. = Event (Ereignis): Tod, Entwicklung einer schweren Herzinsuffizienz, cut-off = Schwellenwert in pmol/L, Sens = Sensitivität, Spef = Spezifität, o. = ohne.

This results in a strong increase in risk to levels of up to 1: 7.14 in patients with a higher copeptin value than 30 pmol / l. Table 2a 0-2 h 0-2 h 2-4 h 2-4 h 4-6 h 4-6 h + E. oE + E. oE + E. oE copeptin Patients> 30 pmol / l 62.5% 36.5% 62.5% 35.7% 62.5% 27.8% Relative risk of heart failure or death up to 180 days after discharge from the hospital 1.7 1.75 2.25 Table 2b day 2 day 2 Day 3 Day 3 Day 4 Day 4 Day 5 Day 5 + E. oE + E. oE + E. oE + E. oE copeptin Patients> 30 pmol / l 50.0% 7.0% 43.8% 7.0% 39.2% 6.1% 31.3% 6.1% Relative risk of heart failure or death up to 180 days after discharge from the hospital 7.14 6.26 6.42 5.13

• Legend in tables and figures: surv. = Survival, E. = event (event): death, development of severe heart failure, cut-off = threshold in pmol / L, Sens = sensitivity, Spef = specificity, n = no.

Characters:

1 :

copeptin Values of patients after myocardial infarction. Plasma samples were taken from 131 patients, as indicated, at various times after myocardial infarction won. additionally Copeptin values of healthy persons are shown ("controls", 200 values) Copeptin values of the groups are shown as box whiskers plots.

2 :

copeptin Values of patients after myocardial infarction. Plasma samples were, as indicated, gained at various times after myocardial infarction. The patients were grouped afterwards, whether later Death or re-hospitalization due to heart failure ("event", 16 patients) or not ("surv", 115 patients) Copeptin values of healthy people ("controls", 200 values) Copeptin values of the groups are shown as box whiskers plots.

3 :

presentation the amino acid sequence of preprovasopressin (164 AS) and the partial peptides and fragments from proAVP (AS: 29-164), Neurophysin II (AS: 32-124) and copeptin (AS: 126-164)

Claims (24)

Method for risk stratification of the acute Coronary syndrome, with a provision of provasopressin (proAVP) or fragments and partial peptides thereof, in particular copeptin or Neurophysin II by means of an in-vitro diagnosis. Method for risk stratification of acute coronary syndrome according to claim 1, for the identification of patients at increased risk or / and an unfavorable one Prognosis of acute coronary syndrome, especially myocardial infarction, Angina pectoris. Method for risk stratification of acute coronary syndrome according to claim 1 or 2, wherein the patient has a symptomatic and / or asymptomatic patient, especially an emergency patient. Method for risk stratification of acute coronary syndrome according to one of the claims 1 to 3 for therapy control of acute coronary syndrome, in particular Myocardial infarction (AMI) and angina (AP), in particular in intensive care or emergency medicine. Method for risk stratification of acute coronary syndrome according to one of the claims 1 to 4 for implementation of clinical decisions, in particular further treatment and therapy by drugs, especially in intensive care or emergency medicine. Method for in-vitro diagnostics for early or Differential diagnosis or prognosis of myocardial infarction or angina Pectoris, whereby a determination of the marker provasopressin (proAVP) or fragments and partial peptides thereof, in particular copeptin or Neurophysin II, is performed on a patient to be examined. Method for in-vitro diagnosis of acute coronary syndrome Myocardial infarction or angina pectoris, with a determination of the marker Provasopressin (proAVP) or fragments and partial peptides thereof, especially copeptin or neurophysin II in combination with natriuretic Proteins, in particular ANP (or ANF), proANP (NT-proAVP), BNP, proBNP (NT-proBNP) or one subsequence of each, on one to be examined. A method for the in-vitro diagnosis of acute coronary syndrome, myocardial infarction or angina pectoris according to claim 7, characterized in that the diagnosis for prophylaxis, prognosis, for differential diagnosis and detection, for the assessment of severity and therapiebeglei assessment is carried out. Method according to one of the preceding claims, characterized characterized in that the cut-off (threshold) for diagnosis 6-20 pmol / L, in particular 6-10 pmol / L or the cut-off (threshold) for prognosis 10-30 pmol / L, in particular 10-20 pmol / L of markers Provasopressin (proAVP) or fragments and partial peptides thereof, especially copeptin or neurophysin II significant (specific) is. Method according to one of the preceding claims, characterized marked that in addition a determination of at least one further marker selected from the group of inflammatory markers, cardiovascular markers, neurohormonal marker or ischemic Marker is performed in an in vitro diagnosis. Method according to one of the preceding claims, characterized characterized in that the inflammatory marker consists of at least a marker from the group C-reactive protein (CRP), cytokines, such as TNF-alpha, interleukins such as IL-6, procalcitonin (1-116, 3-116) and Adhesion molecules, such as VCAM or ICAM selected is. Method according to one of the preceding claims, characterized in that the cardiovascular marker comprises at least one Markers from the group creatine kinase, myoglobin, myeloperoxidase, natriuretic protein, in particular ANP (or ANF), proANP (NT-proANP), BNP, proBNP (NT-proBNP) or a partial sequence thereof, cardiac Troponin, CRP and circulatory (pro) hormones, such as pro-gastrin releasing Peptide (proGRP), pro-endothelin-1, pro-leptin, pro-neuropeptide-Y, pro-somatostatin, pro- neuropeptide YY, pro-opio mandelanocortin or pro-adrenomedullin (proADM) or one subsequence of each is selected. Method according to one of the preceding claims, characterized characterized in that the ischemic marker from at least one marker from the group Troponin I and T, CK-MB selected is. Method according to one of the preceding claims, characterized in that the neurohormonal marker is at least one natriuretic marker Protein is, in particular ANP (or ANF), proANP (NT-proANP), BNP, proBNP (NT-proBNP) or a subsequence of it is. Method according to one of the preceding claims, characterized characterized in that parallel or simultaneous determinations of the markers carried out become. Method according to one of the preceding claims, characterized characterized in that the determinations on at least one patient sample carried out become. Method according to one of the preceding claims, characterized characterized in that the provisions on an automated analyzer, in particular by means of a cryptor. Method according to one of the preceding claims, characterized characterized in that the determinations are made by means of a rapid test, especially in single or multiparameter determinations. Method according to one of the preceding claims, characterized characterized in that the risk stratification to the prognosis, Differential diagnostic early detection and detection, to assess severity and companion therapy Assessment of acute coronary syndrome. Use of provasopressin (proAVP) or fragments and partial peptides thereof, especially copeptin or neurophysin II for risk stratification of acute coronary syndrome, myocardial infarction or angina pectoris and / or for in-vitro diagnostics for early or Differential diagnosis or prognosis of myocardial infarction or angina Pectoris. Use of provasopressin (proAVP) or fragments and partial peptides thereof, especially copeptin or neurophysin II in combination with natriuretic proteins, in particular ANP (resp. ANF), proANP (NT-proANP), BNP, proBNP (NT-proBNP) or in each case a partial sequence thereof to Diagnosis of acute coronary syndrome, myocardial infarction and / or angina Pectoris. Kit for risk stratification of acute coronary syndrome, myocardial infarction and / or angina pectoris containing detection reagents for the determination of provasopressin (proAVP) or fragments and part peptides thereof, in particular copeptin or neurophysin II and optionally further markers according to any one of claims 10 to 14 and adjuvants. Diagnostic device for performing a Method according to one of the claims 6 to 14. Kit for diagnosis of acute coronary syndrome, myocardial infarction and / or angina pectoris containing detection reagents for determination of provasopressin (proAVP) or fragments and partial peptides thereof, especially copeptin or neurophysin II in combination with natriuretic Proteins, in particular ANP (or ANF), proANP (NT-proAVP), BNP, proBNP (NT-proBNP) or in each case a partial sequence thereof and, if necessary. further markers according to any one of claims 10 to 14 and adjuvants.