101
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Giannitsis E, Biener M, Hund H, Mueller-Hennessen M, Vafaie M, Gandowitz J, Riedle C, Löhr J, Katus HA, Stoyanov KM. Management and outcomes of patients with unstable angina with undetectable, normal, or intermediate hsTnT levels. Clin Res Cardiol 2019; 109:476-487. [DOI: 10.1007/s00392-019-01529-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2019] [Accepted: 07/10/2019] [Indexed: 12/13/2022]
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102
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Christenson R, Peacock W, Apple F, Limkakeng A, Nowak R, McCord J, deFilippi C. Trial design for assessing analytical and clinical performance of high-sensitivity cardiac troponin I assays in the United States: The HIGH-US study. Contemp Clin Trials Commun 2019; 14:100337. [PMID: 30834354 PMCID: PMC6384326 DOI: 10.1016/j.conctc.2019.100337] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Revised: 01/22/2019] [Accepted: 02/13/2019] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND High-sensitivity cardiac troponin I (hs-cTnI) assays have been developed that quantify lower cTnI concentrations with better precision versus earlier generation assays. hs-cTnI assays allow improved clinical utility for diagnosis and risk stratification in patients presenting to the emergency department with suspected acute myocardial infarction. We describe the High-Sensitivity Cardiac Troponin I Assays in the United States (HIGH-US) study design used to conduct studies for characterizing the analytical and clinical performance of hs-cTnI assays, as required by the US Food and Drug Administration for a 510(k) clearance application. This study was non-interventional and therefore it was not registered at clinicaltrials.gov. METHODS We conducted analytic studies utilizing Clinical and Laboratory Standards Institute guidance that included limit of blank, limit of detection, limit of quantitation, linearity, within-run and between run imprecision and reproducibility as well as potential interferences and high dose hook effect. A sample set collected from healthy females and males was used to determine the overall and sex-specific cTnI 99th percentile upper reference limits (URL). The total coefficient of variation at the female 99th percentile URL and a universally available American Association for Clinical Chemistry sample set (AACC Universal Sample Bank) from healthy females and males was used to examine high-sensitivity (hs) performance of the cTnI assays. Clinical diagnosis of enrolled subjects was adjudicated by expert cardiologists and emergency medicine physicians. Assessment of temporal diagnostic accuracy including sensitivity, specificity, positive predictive value, and negative predictive value were determined at presentation and collection times thereafter. The prognostic performance at one-year after presentation to the emergency department was also performed. This design is appropriate to describe analytical characterization and clinical performance, and allows for acute myocardial infarction diagnosis and risk assessment.
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Key Words
- 99th percentile
- ACS, acute coronary syndrome
- AMI, acute myocardial infarction
- Analytical characteristics
- CLSI, Clinical and Laboratory Standards Institute
- Clinical performance
- High-sensitivity cardiac troponin
- IM, immunoassay
- Immunoassay
- Li-Hep, lithium heparin
- LoB, Limit of Blank
- LoD, Limit of Detection
- LoQ, Limit of Quantitation
- MDP, Medical Decision Pools
- NPV, negative predictive value
- PPV, positive predictive value
- Sex-specific 99th percentile cutoffs
- URL, upper reference limit
- cTn, cardiac troponin
- cTnI, cardiac troponin I
- hs-cTn, high-sensitivity cardiac troponin
- hs-cTnI, High-Sensitivity Troponin I
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Affiliation(s)
| | - W.F. Peacock
- Department of Emergency Medicine, Baylor College of Medicine, Houston, TX, USA
| | - F.S. Apple
- Department of Laboratory Medicine and Pathology, Hennepin County Medical Center of Hennepin Healthcare, University of Minnesota Minneapolis, Minneapolis, MN, USA
| | - A.T. Limkakeng
- Division of Emergency Medicine, Department of Surgery, Duke University, Durham, NC, USA
| | - R.M. Nowak
- Henry Ford Health System, Detroit, MI, USA
| | - J. McCord
- Henry Ford Hospital, Detroit, MI, USA
| | - C.R. deFilippi
- Inova Heart and Vascular Institute, Falls Church, VA, USA
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103
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Vafaie M, Stoyanov KM, Katus HA, Giannitsis E. Kardiales Troponin und mehr beim akuten Koronarsyndrom. Internist (Berl) 2019; 60:555-563. [DOI: 10.1007/s00108-019-0611-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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104
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Kavsak PA, Roy C, Malinowski P, Clark L, Lamers S, Bamford K, Hill S, Worster A, Jaffe AS. Sample matrix and high-sensitivity cardiac troponin I assays. ACTA ACUST UNITED AC 2019; 57:745-751. [DOI: 10.1515/cclm-2018-1100] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2018] [Accepted: 11/30/2018] [Indexed: 11/15/2022]
Abstract
Abstract
Background
Manufacturers of high-sensitivity cardiac troponin (hs-cTn) assays have restricted use of what sample types or matrices are acceptable to use for measurement. Our goal was to evaluate the comparability of the Siemens ADVIA Centaur hs-cTnI assay across different matrices and under different storage conditions.
Methods
Three different QC-plasma matrices were evaluated for imprecision <10 ng/L. Passing-Bablok regression and difference plots were determined for cTnI concentrations spanning the reference interval (limit of quantification to male 99th-percentile: 2.5 ng/L to <60 ng/L) between serum and lithium heparin plasma, lithium heparin and EDTA plasma and between the Siemens and Abbott hs-cTnI assays. Stability at room temperature (RT) and 2–8 °C was also assessed across the three matrices.
Results
Over 16-weeks the SDs were ≤1.0 ng/L for QCs ranging from 5.0 to 8.3 ng/L. Across the reference interval there was excellent agreement between lithium heparin plasma and serum for the Siemens hs-cTnI assay (slope=0.98/intercept=–0.1), however, cTnI concentrations were proportionally lower in EDTA as compared to lithium heparin plasma (slope=0.90, 95% CI: 0.88–0.92). In lithium heparin plasma the Siemens hs-cTnI concentrations were higher than the Abbott hs-cTnI concentrations (slope=1.26/intercept=–0.2). Stability of cTnI in lithium heparin plasma as compared in serum and EDTA plasma appeared more labile, with decreases ≥20% in concentrations evident as early as 1-day in storage at RT.
Conclusions
There is excellent agreement in concentrations between lithium heparin plasma and serum with the Siemens ADVIA Centaur hs-cTnI assay; however, cTnI concentrations in EDTA plasma are lower. Reference intervals and clinical studies in EDTA plasma for the Centaur hs-cTnI assay are required before clinical use.
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105
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Monneret D, Gellerstedt M, Bonnefont-Rousselot D. Determination of age- and sex-specific 99th percentiles for high-sensitive troponin T from patients: an analytical imprecision- and partitioning-based approach. Clin Chem Lab Med 2019; 56:818-829. [PMID: 29176015 DOI: 10.1515/cclm-2017-0256] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2017] [Accepted: 10/10/2017] [Indexed: 01/10/2023]
Abstract
BACKGROUND Detection of acute myocardial infarction (AMI) is mainly based on a rise of cardiac troponin with at least one value above the 99th percentile upper reference limit (99th URL). However, circulating high-sensitive cardiac troponin T (hs-cTnT) concentrations depend on age, sex and renal function. Using an analytical imprecision-based approach, we aimed to determine age- and sex-specific hs-cTnT 99th URLs for patients without chronic kidney disease (CKD). METHODS A 3.8-year retrospective analysis of a hospital laboratory database allowed the selection of adult patients with concomitant plasma hs-cTnT (<300 ng/L) and creatinine concentrations, both assayed twice within 72 h with at least 3 h between measurements. Absence of AMI was assumed when the variation between serial hs-cTnT values was below the adjusted-analytical change limit calculated according to the inverse polynomial regression of analytical imprecision. Specific URLs were determined using Clinical and Laboratory Standards Institute (CLSI) methods, and partitioning was tested using the proportion method, after adjustment for unequal prevalences. RESULTS After outlier removal (men: 8.7%; women: 6.6%), 1414 men and 1082 women with estimated glomerular filtration rate (eGFR) ≥60 mL/min/1.73 m2 were assumed as non-AMI. Partitioning into age groups of 18-50, 51-70 and 71-98 years, the hs-cTnT 99th URLs adjusted on French prevalence were 18, 33, 66 and 16, 30, 84 ng/L for men and women, respectively. Age-partitioning was clearly required. However, sex-partitioning was not justified for subjects aged 18-50 and 51-70 years for whom a common hs-cTnT 99th URLs of about 17 and 31 ng/L could be used. CONCLUSIONS Based on a laboratory approach, this study supports the need for age-specific hs-cTnT 99th URLs.
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Affiliation(s)
- Denis Monneret
- Department of Metabolic Biochemistry, La Pitié Salpêtrière-Charles Foix University Hospital (AP-HP), Paris, France
| | - Martin Gellerstedt
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, SSORG-Scandinavian Surgical Outcomes Research Group, Sahlgrenska University Hospital/Östra, Gothenburg, Sweden.,School of Business, Economics and IT, University West, Göteborg, Sweden
| | - Dominique Bonnefont-Rousselot
- Department of Metabolic Biochemistry, La Pitié Salpêtrière-Charles Foix University Hospital (AP-HP), Paris, France.,Faculty of Pharmacy, Department of Biochemistry, Paris Descartes University, Paris, France.,CNRS UMR8258 - INSERM U1022, Faculty of Pharmacy, Paris Descartes University, Paris, France
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106
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Bang C, Hansen C, Lauridsen KG, Frederiksen CA, Schmidt M, Jensen T, Hornung N, Løfgren B. Rapid use of high-sensitive cardiac troponin I for ruling-in and ruling-out of acute myocardial infarction (RACING-MI): study protocol. Open Heart 2019; 6:e000995. [PMID: 31168384 PMCID: PMC6519406 DOI: 10.1136/openhrt-2018-000995] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2018] [Revised: 02/18/2019] [Accepted: 03/04/2019] [Indexed: 12/27/2022] Open
Abstract
Introduction The European Society of Cardiology has suggested an accelerated algorithm for ruling-in and ruling-out myocardial infarction (MI) with high-sensitive cardiac troponin (hs-cTn) measured at admission (0 hour) and after 1 hour (1 hour) as an alternative to standard measurements at 0 hour and 3 hours. However, the 0 hour/1 hour algorithm has only been tested in a limited amount of patient cohorts and not for all hs-cTn assays. Moreover, it is unknown if MI can be ruled-out faster than 1 hour. In this single-centre, clinical trial, we will investigate whether MI safely can be ruled-in or ruled-out after 30 min and 1 hour. Methods and analysis Patients with chest pain suggestive of MI admitted to the emergency department will be subjected to hs-cTn measurements at the following time points: 0 hour, 30 min, 1 hour and 3 hours. Chest pain characteristics will be recorded. In total, 1000 patients with all four blood samples will be included. The diagnostic algorithms will be derived based on the first 500 patients and validated in the subsequent 500 patients. The primary endpoint is the negative predictive value of the 0 hour/30 min and the 0 hour/1 hour algorithms. Secondary endpoints include positive predictive value, sensitivity and specificity. Results will be compared with the standard 0 hour/3 hour algorithm. Ethics and dissemination Oral and written informed consent will be obtained from all patients. The trial is approved by The Regional Committee on Health Research Ethics and the Danish Data Protection Agency. Data will be disseminated and submitted to peer-reviewed scientific journals and meetings irrespective of study outcome. Trial registration number NCT03634384
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Affiliation(s)
- Camilla Bang
- Research Center for Emergency Medicine, Aarhus University Hospital, Aarhus, Denmark.,Department of Internal Medicine, Randers Regional Hospital, Randers, Denmark
| | - Camilla Hansen
- Research Center for Emergency Medicine, Aarhus University Hospital, Aarhus, Denmark.,Department of Internal Medicine, Randers Regional Hospital, Randers, Denmark
| | - Kasper Glerup Lauridsen
- Research Center for Emergency Medicine, Aarhus University Hospital, Aarhus, Denmark.,Department of Internal Medicine, Randers Regional Hospital, Randers, Denmark
| | | | - Morten Schmidt
- Department of Cardiology, Regional Hospital West Jutland, Herning, Denmark.,Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
| | - Tage Jensen
- Department of Internal Medicine, Randers Regional Hospital, Randers, Denmark
| | - Nete Hornung
- Department of Biochemistry, Regional Hospital West Jutland, Herning, Denmark
| | - Bo Løfgren
- Research Center for Emergency Medicine, Aarhus University Hospital, Aarhus, Denmark.,Department of Internal Medicine, Randers Regional Hospital, Randers, Denmark
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107
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Chapman AR, Fujisawa T, Lee KK, Andrews JP, Anand A, Sandeman D, Ferry AV, Stewart S, Marshall L, Strachan FE, Gray A, Newby DE, Shah ASV, Mills NL. Novel high-sensitivity cardiac troponin I assay in patients with suspected acute coronary syndrome. Heart 2019; 105:616-622. [PMID: 30442743 PMCID: PMC6580754 DOI: 10.1136/heartjnl-2018-314093] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2018] [Revised: 10/13/2018] [Accepted: 10/17/2018] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND High-sensitivity cardiac troponin assays enable the early risk stratification of patients with suspected acute coronary syndrome to identify those at low risk of myocardial infarction or cardiac death. We evaluated the performance of a novel high-sensitivity cardiac troponin I assay in early rule out pathways. METHODS In 1920 patients with suspected acute coronary syndrome, cardiac troponin was measured using the Siemens Atellica high-sensitivity cardiac troponin I assay (99th centile: 34 ng/L women, 53 ng/L men). We evaluated three pathways which use either low risk-stratification thresholds of cardiac troponin (High-SensitivityTroponin in the Evaluation of patients with Acute Coronary Syndrome (High-STEACS) and the European Society of Cardiology (ESC) 1 hour pathway) or the 99th centile diagnostic threshold (ESC 3 hour pathway) to rule out myocardial infarction. RESULTS The primary outcome of myocardial infarction or cardiac death at 30 days occurred in 14.4% (277/1920). The High-STEACS pathway ruled out 63% of patients (1218/1920), with five missed events for a negative predictive value (NPV) of 99.5% (95% CI (CI) 99.1% to 99.8%). Similar performance was observed for the ESC 1 hour pathway with an NPV of 99.0% (97.6% to 99.8%). In contrast, the ESC 3 hour pathway ruled out 65% of patients (1248/1920), but missed 25 events for an NPV of 98.0% (97.1% to 98.7%). CONCLUSIONS A novel high-sensitivity cardiac troponin I assay can safely identify patients at low risk of myocardial infarction or cardiac death. Diagnostic pathways that use low cardiac troponin concentrations for risk stratification miss fewer events than those that rely on the 99th centile to rule out myocardial infarction. TRIAL REGISTRATION NCT1852123.
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Affiliation(s)
- Andrew R Chapman
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Takeshi Fujisawa
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Kuan Ken Lee
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | | | - Atul Anand
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Dennis Sandeman
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Amy V Ferry
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Stacey Stewart
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Lucy Marshall
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Fiona E Strachan
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Alasdair Gray
- Department of Emergency Medicine, Royal Infirmary of Edinburgh, Edinburgh, UK
- EMERGE Research Group, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - David E Newby
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Anoop S V Shah
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Nicholas L Mills
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
- Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK
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108
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Narayanan MA, Garcia S. Role of High-sensitivity Cardiac Troponin in Acute Coronary Syndrome. US CARDIOLOGY REVIEW 2019. [DOI: 10.15420/usc.2018.16.1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Chest pain is one of the most common reasons for an emergency room (ER) visit in the US, with almost 6 million ER visits annually. High-sensitivity cardiac troponin (hscTn) assays have the ability to rapidly rule in or rule out acute coronary syndrome with improved sensitivity, and they are increasingly being used. Though hscTn assays have been approved for use in European, Australian, and Canadian guidelines since 2010, the FDA only approved their use in 2017. There is no consensus on how to compare the results from various hscTn assays. A literature review was performed to analyze the advantages and limitations of using hscTn as a standard biomarker to evaluate patients with suspected ACS in the emergency setting.
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Affiliation(s)
- Mahesh Anantha Narayanan
- Division of Cardiovascular Disease, Department of Medicine, University of Minnesota, Minneapolis, MN
| | - Santiago Garcia
- Minneapolis Heart Institute at Abbott Northwestern Hospital, Minneapolis, MN
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109
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Romiti GF, Cangemi R, Toriello F, Ruscio E, Sciomer S, Moscucci F, Vincenti M, Crescioli C, Proietti M, Basili S, Raparelli V. Sex-Specific Cut-Offs for High-Sensitivity Cardiac Troponin: Is Less More? Cardiovasc Ther 2019; 2019:9546931. [PMID: 31772621 PMCID: PMC6739766 DOI: 10.1155/2019/9546931] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2018] [Revised: 01/08/2019] [Accepted: 01/16/2019] [Indexed: 12/25/2022] Open
Abstract
Management of patients presenting to the Emergency Department with chest pain is continuously evolving. In the setting of acute coronary syndrome, the availability of high-sensitivity cardiac troponin assays (hs-cTn) has allowed for the development of algorithms aimed at rapidly assessing the risk of an ongoing myocardial infarction. However, concerns were raised about the massive application of such a simplified approach to heterogeneous real-world populations. As a result, there is a potential risk of underdiagnosis in several clusters of patients, including women, for whom a lower threshold for hs-cTn was suggested to be more appropriate. Implementation in clinical practice of sex-tailored cut-off values for hs-cTn represents a hot topic due to the need to reduce inequality and improve diagnostic performance in females. The aim of this review is to summarize current evidence on sex-specific cut-off values of hs-cTn and their application and usefulness in clinical practice. We also offer an extensive overview of thresholds reported in literature and of the mechanisms underlying such differences among sexes, suggesting possible explanations about debated issues.
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Affiliation(s)
- Giulio Francesco Romiti
- Department of Internal Medicine and Medical Specialties, Sapienza–University of Rome, Rome, Italy
| | - Roberto Cangemi
- Department of Internal Medicine and Medical Specialties, Sapienza–University of Rome, Rome, Italy
| | - Filippo Toriello
- Division of Cardiology, San Paolo Hospital, Department of Health Sciences, University of Milan, Milan, Italy
| | - Eleonora Ruscio
- Department of Cardiovascular and Thoracic Sciences, Catholic University of the Sacred Heart, Rome, Italy
| | - Susanna Sciomer
- Department of Cardiovascular, Respiratory, Nephrology, Anesthesiology and Geriatric Sciences, Sapienza–University of Rome, Rome, Italy
| | - Federica Moscucci
- Department of Cardiovascular, Respiratory, Nephrology, Anesthesiology and Geriatric Sciences, Sapienza–University of Rome, Rome, Italy
| | - Marianna Vincenti
- Department of Internal Medicine and Medical Specialties, Sapienza–University of Rome, Rome, Italy
| | - Clara Crescioli
- Department of Movement, Human and Health Sciences, University of Rome “Foro Italico”, Rome, Italy
| | - Marco Proietti
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milan, Italy
| | - Stefania Basili
- Department of Internal Medicine and Medical Specialties, Sapienza–University of Rome, Rome, Italy
| | - Valeria Raparelli
- Department of Experimental Medicine, Sapienza–University of Rome, Rome, Italy
- Center for Outcomes Research and Evaluation, Research Institute, McGill University Health Centre, Montreal, Quebec, Canada
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110
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Di Pietro M, Dipalo M, Rocchi MBL, Musa R, Avanzini P, Gnocchi C, Anelli MC, Aloe R. Assessment of Access hsTnI 99th percentiles upper reference limits following IFCC recommendations. Clin Chim Acta 2019; 492:26-28. [PMID: 30711523 DOI: 10.1016/j.cca.2019.01.028] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2018] [Revised: 01/30/2019] [Accepted: 01/30/2019] [Indexed: 11/28/2022]
Abstract
BACKGROUND The detection of an increase and/or decrease of cardiac troponin (cTnI) values, with at least one value above the 99th percentile of the upper reference limit (URL) have a central role in acute myocardial infarction (AMI) diagnosis. The employment of sex specific 99th percentile URLs and High-sensitivity (Hs) assays are recommended. We assessed sex specific 99th percentile URL for Access Hs-cTnI and AccuTnI3+ (Beckman Coulter) using European donor reference population following recent International Federation of Clinical Chemistry and Laboratory Medicine (IFCC) recommendations. METHODS 300 males and 300 females plasma samples were collected. Both chemiluminescent immunoenzymatic assays were performed on UniCel DxI 800 platform (Beckman Coulter). RESULTS For Access hsTnI, the observed sex-specific 99th percentile URLs were 5.5 (90% CI: 4.4-7.6) for females and 13.9 ng/L (90% CI: 7.4-17.4) for males. For AccuTnI+3 we could not establish them because the assay couldn't report detectable values of troponin for most of the analyzed samples. CONCLUSION The sex-specific 99th percentile URLs established for Access hsTnI assay were significantly lower than those declared by the manufacturer caused by the different choice of population selection, age groups and sample types: for those reasons, we maintain the 99th URLs provided by manufacturer.
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Affiliation(s)
- Martina Di Pietro
- SSD Biochimica ad Elevata Automazione, Azienda Ospedaliero-Universitaria di Parma, Via Gramsci 14, 43126 Parma, Italy.
| | - Mariella Dipalo
- SSD Biochimica ad Elevata Automazione, Azienda Ospedaliero-Universitaria di Parma, Via Gramsci 14, 43126 Parma, Italy
| | - Marco Bruno Luigi Rocchi
- Dipartimento di Scienze Biomolecolari, Università degli studi di Urbino "Carlo Bo", Via Ca' Le Suore, 2-4, 61029 Urbino, Italy
| | - Roberta Musa
- SSD Biochimica ad Elevata Automazione, Azienda Ospedaliero-Universitaria di Parma, Via Gramsci 14, 43126 Parma, Italy
| | - Paola Avanzini
- SSD Biochimica ad Elevata Automazione, Azienda Ospedaliero-Universitaria di Parma, Via Gramsci 14, 43126 Parma, Italy
| | - Cecilia Gnocchi
- SSD Biochimica ad Elevata Automazione, Azienda Ospedaliero-Universitaria di Parma, Via Gramsci 14, 43126 Parma, Italy
| | | | - Rosalia Aloe
- SSD Biochimica ad Elevata Automazione, Azienda Ospedaliero-Universitaria di Parma, Via Gramsci 14, 43126 Parma, Italy
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111
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Hof D, von Eckardstein A. High-Sensitivity Troponin Assays in Clinical Diagnostics of Acute Coronary Syndrome. Methods Mol Biol 2019; 1929:645-662. [PMID: 30710302 DOI: 10.1007/978-1-4939-9030-6_40] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Nowadays, measurement of cardiac troponins (cTn) in patient plasma is central for diagnosis of patients with acute coronary syndrome (ACS). High-sensitivity (hs) immunoassays have been developed that can very precisely record slightly elevated and rising plasma concentrations of cTn very early after onset of clinical symptoms. Algorithms integrate measurements of hs-cTn at onset of clinical symptoms of acute myocardial infarction (AMI), and 1 or 3 h after onset, to rule-in and rule-out AMI patients. More and more point-of-care (POC) cTn assays conquer the diagnostic market, but thorough clinical validation studies are required before potential implementation of such POC tests into hospital settings. This review provides an overview of the technical aspects, as well as diagnostic and prognostic use of cardiac troponins in AMI patients and in the healthy population.
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112
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High-sensitivity cardiac troponin T increases after stress echocardiography. Clin Biochem 2019; 63:18-23. [DOI: 10.1016/j.clinbiochem.2018.11.013] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2018] [Revised: 11/24/2018] [Accepted: 11/28/2018] [Indexed: 11/21/2022]
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113
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Howell SJ, Amsterdam EA, Mumma BE, López JE, Tran NK. Implementation of High-Sensitivity Cardiac Troponin: Challenges From the International Experience. Crit Pathw Cardiol 2018; 17:173-178. [PMID: 30418246 PMCID: PMC6234850 DOI: 10.1097/hpc.0000000000000156] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/10/2023]
Abstract
OBJECTIVE Implementation of the newly approved high-sensitivity cardiac troponin (hs-cTn) in the United States presents a challenge for clinical practice. Sex-specific cutoffs, clinical protocols, and workflows will likely require modifications before implementation. METHODS We conducted a cross-sectional survey of international physicians and laboratorians already utilizing hs-cTn for the evaluation of acute myocardial infarction. RESULTS Twenty-two of 54 (41%) eligible participants completed the survey, representing 9 countries and 18 hospitals. All reported successful hs-cTn implementation and diagnostic utility (mean 8.6 + 1.2 out of 10 for best implementation). The major perceived benefit was more rapid evaluation of acute myocardial infarction (14/19, 74%), and the most frequently cited limitation was an increase in the number of measurable hs-cTn values that required further evaluation (8/18, 44%). Institutions using the hs-cTnI assay favored sex-specific cutoffs (5/6, 83%), whereas institutions employing the hs-cTnT assay favored a combined cutoff (12/12, 100%). Timing of serial hs-cTn measurements varied, with 0-3 hours (8/17, 47%) most frequent, followed by 0-2 hours (4/17, 24%), 0-1 hour (3/17, 18%), and other (2/17, 12%). CONCLUSIONS Our survey of hs-cTn implementation at international institutions reveals satisfaction with new assays but reflects important variations in clinical practice. The use of sex-specific vs. combined cutoffs and timing of serial hs-cTn measurements varies across institutions and are subjects that United States centers must define without consensus from international practices.
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Affiliation(s)
- Stacey J Howell
- From the Department of Internal Medicine, University of California Davis Health, Sacramento, CA
| | - Ezra A Amsterdam
- Division of Cardiovascular Medicine, University of California Davis Health, Sacramento, CA
| | - Bryn E Mumma
- Department of Emergency Medicine, University of California Davis Health, Sacramento, CA
| | - Javier E López
- Division of Cardiovascular Medicine, University of California Davis Health, Sacramento, CA
| | - Nam K Tran
- Department of Pathology and Laboratory Medicine, University of California Davis Health, Sacramento, CA
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Abstract
The definition of a high-sensitivity cardiac Troponin (cTn) assay describes the ability to quantify a cardiac biomarker level in at least 50% of healthy individuals. This advance in analytic sensitivity has come with a perceived loss of specificity in the most classic application - chest pain triage and the diagnosis of acute myocardial infarction (AMI). As cardiac Troponin can no longer be used as a dichotomous test, the medical field is increasingly moving towards a more granular interpretation. However, rapid rule-out/rule-in algorithms for AMI still rely on concrete thresholds for efficient triage, irrespective of the patient's comorbidities. Owing to a slightly elevated cTn value, evermore patients appear to fall into an indeterminate risk zone of diagnostic uncertainty. The reasons are manifold, spanning biological variation, analytical issues, increased plasma membrane permeability and the potential cytosolic release of cTn. This review provides a contemporary overview of the literature concerning the use of cardiac Troponin in chronic and acute cardiovascular care. Key messages High-sensitivity cardiac Troponin assays have transformed the assessment of cardiovascular disease. Rapid rule-out algorithms for chest pain triage have become increasingly complicated, but enable safe rule-out. Cardiac Troponin tracks mid- to long-term risk in patients with hyperlipidaemia, heart failure and renal dysfunction.
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Affiliation(s)
- Bashir Alaour
- a King's College London BHF Centre , The Rayne Institute, St Thomas' Hospital , London , UK
| | | | - Thomas E Kaier
- a King's College London BHF Centre , The Rayne Institute, St Thomas' Hospital , London , UK
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Saenger AK. Pick a Number, Any Number…Choosing Your Troponin Cutoff Wisely. J Appl Lab Med 2018; 3:753-755. [PMID: 31639749 DOI: 10.1373/jalm.2018.027714] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2018] [Accepted: 09/28/2018] [Indexed: 02/05/2023]
Affiliation(s)
- Amy K Saenger
- Hennepin County Medical Center, Department of Laboratory Medicine and Pathology, Minneapolis, MN; .,University of Minnesota, Department of Laboratory Medicine and Pathology, Minneapolis, MN
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116
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Sandoval Y, Sharain K, Saenger AK, Smith SW, Apple FS, Jaffe AS. Clinical use of cardiac troponin for acute cardiac care and emerging opportunities in the outpatient setting. Minerva Med 2018; 110:139-156. [PMID: 30484592 DOI: 10.23736/s0026-4806.18.05874-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Cardiac troponin (cTn) testing has evolved significantly in recent times. Because of increased sensitivity, its use has shifted from a marker used to help diagnose acute myocardial infarction (MI) to a marker than can be used in the outpatient setting, as well as for both detection of myocardial injury and risk-stratification. Its main role remains in the diagnosis of acute MI and the risk-stratification of patients presenting with suspected acute coronary syndrome. The analytical improvements in assays leading to precise high-sensitivity cTn assays have contributed to the development of numerous strategies to identify patients at both low- and high-risk for acute MI within a few hours. These approaches should reduce overcrowding in the emergency room and expedite triaging. The ability of measuring cTn in most patients using high-sensitivity (hs) assays has allowed for the opportunity to examine its use in the detection of cardiotoxicity in patients undergoing chemotherapy, as well as exploring the application in both primary and secondary prevention of coronary artery disease. This particular field of research has become increasingly complex, partly due to the numerous cTn assays available (I and T; point-of-care, contemporary, hs) and an array of approaches in which one can use the test. The purpose of this document is to summarize the analytical and clinical information relevant to cTn assays, in particular, hs-cTn assays, and describe present and future opportunities for use of cTn in acute cardiac care and in the outpatient setting.
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Affiliation(s)
- Yader Sandoval
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA -
| | - Korosh Sharain
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Amy K Saenger
- Department of Laboratory Medicine and Pathology, University of Minnesota, Minneapolis, MN, USA.,Department of Laboratory Medicine and Pathology, Hennepin County Medical Center, Minneapolis, MN, USA
| | - Stephen W Smith
- Department of Emergency Medicine, Hennepin County Medical Center and University of Minnesota, Minneapolis, MN, USA
| | - Fred S Apple
- Department of Laboratory Medicine and Pathology, University of Minnesota, Minneapolis, MN, USA.,Department of Laboratory Medicine and Pathology, Hennepin County Medical Center, Minneapolis, MN, USA
| | - Allan S Jaffe
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA.,Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
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Lippi G, Sanchis-Gomar F. "Ultra-sensitive" cardiac troponins: Requirements for effective implementation in clinical practice. Biochem Med (Zagreb) 2018; 28:030501. [PMID: 30429666 PMCID: PMC6214691 DOI: 10.11613/bm.2018.030501] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2018] [Accepted: 05/16/2018] [Indexed: 12/16/2022] Open
Abstract
The measurement of cardiac troponins, either cardiac troponin I or T, has become the culprit of clinical decision making in patients with suspected acute coronary syndrome (ACS), especially in those with non-ST elevation myocardial infarction (NSTEMI). The leading analytical mainstays of cardiac troponin immunoassays include the limit of blank (LoB), limit of detection (LoD), functional sensitivity, the 99th percentile of a healthy reference population, along with the percentage of "ostensibly healthy" subjects displaying measurable values < 99th percentile. The latest generation of cardiac troponin immunoassays, conventionally defined as "high-sensitive" (HS), is characterized by a LoD over 100-fold lower compared to the first commercialized techniques and a percentage of measurable values consistently > 50% in the general healthy population. The very recent commercialization of methods with further improved analytical sensitivity (i.e., "ultra-sensitive" assays), which allow to measure cardiac troponin values in the vast majority of healthy subjects, is now challenging the diagnostic paradigm based on early rule-out of subjects with cardiac troponin values comprised between the 99th percentile and LoD. New diagnostic strategies, entailing assay-specific cut-offs, must hence be developed and validated in large multicenter studies. The aim of this article is to provide an update on commercially available HS and "ultra"-sensitive techniques for measuring cardiac troponins, along with possible implications of increasingly enhanced analytical sensitivity on diagnostic algorithms for evaluating patients with suspected ACS.
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Affiliation(s)
- Giuseppe Lippi
- Section of Clinical Biochemistry, University of Verona, Verona, Italy
| | - Fabian Sanchis-Gomar
- Leon H. Charney Division of Cardiology, New York University School of Medicine, New York, USA
- Department of Physiology, Faculty of Medicine, University of Valencia, Valencia, Spain
- INCLIVA Biomedical Research Institute, Valencia, Spain
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Boeddinghaus J, Twerenbold R, Nestelberger T, Badertscher P, Wildi K, Puelacher C, du Fay de Lavallaz J, Keser E, Rubini Giménez M, Wussler D, Kozhuharov N, Rentsch K, Miró Ò, Martin-Sanchez FJ, Morawiec B, Stefanelli S, Geigy N, Keller DI, Reichlin T, Mueller C, Sanchez AY, Breidthardt T, Mueller D, Sazgary L, Marbot S, Sabti Z, Flores D, Mahfouz R, Osswald S, Schaerli N, Freese M, Stelzig C, Meissner K, Kulangara C, Shrestha S, Grimm K, Hartmann B, Ferel I, López B, Fuenzalida C, Adrada ER, Ganovská E, Lohrmann J, Kloos W, Buser A, von Eckardstein A, Muzyk P, Nowalany-Kozielska E, Kawecki D, Parenica J. Clinical Validation of a Novel High-Sensitivity Cardiac Troponin I Assay for Early Diagnosis of Acute Myocardial Infarction. Clin Chem 2018; 64:1347-1360. [DOI: 10.1373/clinchem.2018.286906] [Citation(s) in RCA: 79] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2018] [Accepted: 06/05/2018] [Indexed: 01/08/2023]
Abstract
Abstract
BACKGROUND
Clinical performance of the novel high-sensitivity cardiac troponin I (Siemens-hs-cTnI-Centaur) assay is unknown. We aimed to clinically validate the Siemens-hs-cTnI-Centaur assay and develop 0/1-h and 0/2-h algorithms.
METHODS
We enrolled patients presenting to the emergency department with symptoms suggestive of acute myocardial infarction (AMI). Final diagnoses were centrally adjudicated by 2 independent cardiologists including all clinical information twice: first, using serial hs-cTnT (Roche-Elecsys, primary analysis); second, using hs-cTnI (Abbott-Architect, secondary analysis) measurements in addition to the clinically applied (hs)-cTn. Siemens-hs-cTnI-Centaur was measured at presentation, 1 h, and 2 h. The primary objective was a direct comparison of diagnostic accuracy, quantified by the area under the ROC curve (AUC), of Siemens-hs-cTnI-Centaur vs the 2 established hs-cTn assays (Roche-hs-cTnT-Elecsys, Abbott-hs-cTnI-Architect). Secondary objectives included the development of Siemens-hs-cTnI-Centaur-specific 0/1-h and 0/2-h algorithms.
RESULTS
AMI was the final diagnosis in 318 of 1755 (18%) patients (using Roche-hs-cTnT-Elecsys for adjudication). The AUC at presentation for Siemens-hs-cTnI-Centaur was 0.94 (95% CI, 0.92–0.96) and comparable with 0.95 (95% CI, 0.93–0.97) for Roche-hs-cTnT-Elecsys and 0.93 (95% CI, 0.90–0.96) for Abbott-hs-cTnI-Architect. Applying the derived Siemens-hs-cTnI-Centaur 0/1-h algorithm to the validation cohort, 46% of patients were ruled out (sensitivity, 99.1%; 95% CI, 95.3–100), and 18% of patients were ruled in (specificity, 94.1%; 95% CI, 91.8–95.9). The Siemens-hs-cTnI-Centaur 0/2-h algorithm ruled out 55% of patients (sensitivity, 100%; 95% CI, 94.1–100), and ruled in 18% of patients (specificity, 96.0%; 95% CI, 93.1–97.9). Findings were confirmed in the secondary analyses using serial measurements of Abbott-hs-cTnI-Architect for adjudication.
CONCLUSIONS
Diagnostic accuracy and clinical utility of the novel Siemens-hs-cTnI-Centaur assay are high and comparable with the established hs-cTn assays. ClinicalTrials.gov Identifier: NCT00470587
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Affiliation(s)
- Jasper Boeddinghaus
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- Division of Internal Medicine, University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT network, Rome, Italy
| | - Raphael Twerenbold
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT network, Rome, Italy
- Department of General and Interventional Cardiology, Hamburg University Heart Center, Hamburg, Germany
| | - Thomas Nestelberger
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT network, Rome, Italy
| | - Patrick Badertscher
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT network, Rome, Italy
| | - Karin Wildi
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT network, Rome, Italy
| | - Christian Puelacher
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT network, Rome, Italy
| | - Jeanne du Fay de Lavallaz
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- Division of Internal Medicine, University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT network, Rome, Italy
| | - Elif Keser
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT network, Rome, Italy
| | - Maria Rubini Giménez
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT network, Rome, Italy
| | - Desiree Wussler
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- Division of Internal Medicine, University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT network, Rome, Italy
| | - Nikola Kozhuharov
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT network, Rome, Italy
| | | | - Òscar Miró
- GREAT network, Rome, Italy
- Emergency Department, Hospital Clinic, Barcelona, Catalonia, Spain
| | | | - Beata Morawiec
- GREAT network, Rome, Italy
- 2nd Department of Cardiology, School of Medicine with the Division of Dentistry in Zabrze, Medical University of Katowice, Katowice, Poland
| | - Sabrina Stefanelli
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Nicolas Geigy
- Emergency Department, Kantonsspital Liestal, Switzerland
| | - Dagmar I Keller
- Emergency Department, University Hospital Zurich, Zurich, Switzerland
| | - Tobias Reichlin
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT network, Rome, Italy
| | - Christian Mueller
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT network, Rome, Italy
| | - Ana Yufera Sanchez
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- Department of Internal Medicine, University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT network, Rome, Italy
| | - Tobias Breidthardt
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- Department of Internal Medicine, University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT network, Rome, Italy
| | - Deborah Mueller
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Lorraine Sazgary
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Stella Marbot
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Zaid Sabti
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT network, Rome, Italy
| | - Dayana Flores
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT network, Rome, Italy
| | - Riham Mahfouz
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT network, Rome, Italy
| | - Stefan Osswald
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Nicolas Schaerli
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- Department of Internal Medicine, University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT network, Rome, Italy
| | - Michael Freese
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT network, Rome, Italy
| | - Claudia Stelzig
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT network, Rome, Italy
| | - Kathrin Meissner
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT network, Rome, Italy
| | - Caroline Kulangara
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT network, Rome, Italy
| | - Samyut Shrestha
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT network, Rome, Italy
| | - Karin Grimm
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- Department of Internal Medicine, University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT network, Rome, Italy
| | - Beate Hartmann
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT network, Rome, Italy
| | - Ina Ferel
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT network, Rome, Italy
| | - Beatriz López
- GREAT network, Rome, Italy
- Emergency Department, Hospital Clinic, Barcelona, Catalonia, Spain
| | - Carolina Fuenzalida
- GREAT network, Rome, Italy
- Emergency Department, Hospital Clinic, Barcelona, Catalonia, Spain
| | | | - Eva Ganovská
- GREAT network, Rome, Italy
- Department of Cardiology, University Hospital Brno, Brno, Czech Republic and Medical Faculty, Masaryk University, Brno, Czech Republic
| | - Jens Lohrmann
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Wanda Kloos
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Andreas Buser
- Blood Transfusion Centre, Swiss Red Cross, Basel, Switzerland and Department of Hematology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Arnold von Eckardstein
- Emergency Department of Laboratory Medicine, University Hospital Zurich, Zurich, Switzerland
| | - Piotr Muzyk
- GREAT network, Rome, Italy
- Second Department of Cardiology, School of Medicine with the Division of Dentistry in Zabrze, Medical University of Katowice, Katowice, Poland
| | - Ewa Nowalany-Kozielska
- Second Department of Cardiology, School of Medicine with the Division of Dentistry in Zabrze, Medical University of Katowice, Katowice, Poland
| | - Damian Kawecki
- GREAT network, Rome, Italy
- Second Department of Cardiology, School of Medicine with the Division of Dentistry in Zabrze, Medical University of Katowice, Katowice, Poland
| | - Jiri Parenica
- GREAT network, Rome, Italy
- Department of Cardiology, University Hospital Brno, Brno, Czech Republic and Medical Faculty, Masaryk University, Brno, Czech Republic
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Thygesen K, Alpert JS, Jaffe AS, Chaitman BR, Bax JJ, Morrow DA, White HD. Fourth Universal Definition of Myocardial Infarction (2018). J Am Coll Cardiol 2018; 72:2231-2264. [PMID: 30153967 DOI: 10.1016/j.jacc.2018.08.1038] [Citation(s) in RCA: 2038] [Impact Index Per Article: 339.7] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Thygesen K, Alpert JS, Jaffe AS, Chaitman BR, Bax JJ, Morrow DA, White HD, Thygesen K, Alpert JS, Jaffe AS, Chaitman BR, Bax JJ, Morrow DA, White HD, Mickley H, Crea F, Van de Werf F, Bucciarelli-Ducci C, Katus HA, Pinto FJ, Antman EM, Hamm CW, De Caterina R, Januzzi JL, Apple FS, Alonso Garcia MA, Underwood SR, Canty JM, Lyon AR, Devereaux PJ, Zamorano JL, Lindahl B, Weintraub WS, Newby LK, Virmani R, Vranckx P, Cutlip D, Gibbons RJ, Smith SC, Atar D, Luepker RV, Robertson RM, Bonow RO, Steg PG, O’Gara PT, Fox KAA, Hasdai D, Aboyans V, Achenbach S, Agewall S, Alexander T, Avezum A, Barbato E, Bassand JP, Bates E, Bittl JA, Breithardt G, Bueno H, Bugiardini R, Cohen MG, Dangas G, de Lemos JA, Delgado V, Filippatos G, Fry E, Granger CB, Halvorsen S, Hlatky MA, Ibanez B, James S, Kastrati A, Leclercq C, Mahaffey KW, Mehta L, Müller C, Patrono C, Piepoli MF, Piñeiro D, Roffi M, Rubboli A, Sharma S, Simpson IA, Tendera M, Valgimigli M, van der Wal AC, Windecker S, Chettibi M, Hayrapetyan H, Roithinger FX, Aliyev F, Sujayeva V, Claeys MJ, Smajić E, Kala P, Iversen KK, El Hefny E, Marandi T, Porela P, Antov S, Gilard M, Blankenberg S, Davlouros P, Gudnason T, Alcalai R, Colivicchi F, Elezi S, Baitova G, Zakke I, Gustiene O, Beissel J, Dingli P, Grosu A, Damman P, Juliebø V, Legutko J, Morais J, Tatu-Chitoiu G, Yakovlev A, Zavatta M, Nedeljkovic M, Radsel P, Sionis A, Jemberg T, Müller C, Abid L, Abaci A, Parkhomenko A, Corbett S. Fourth universal definition of myocardial infarction (2018). Eur Heart J 2018; 40:237-269. [DOI: 10.1093/eurheartj/ehy462] [Citation(s) in RCA: 1047] [Impact Index Per Article: 174.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
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Thygesen K, Alpert JS, Jaffe AS, Chaitman BR, Bax JJ, Morrow DA, White HD. Fourth Universal Definition of Myocardial Infarction (2018). Glob Heart 2018; 13:305-338. [PMID: 30154043 DOI: 10.1016/j.gheart.2018.08.004] [Citation(s) in RCA: 173] [Impact Index Per Article: 28.8] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
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Kaier TE, Alaour B, Marber M. Cardiac myosin-binding protein C: how a novel biomarker could transform chest pain triage. Biomark Med 2018; 12:823-826. [PMID: 30019910 DOI: 10.2217/bmm-2018-0176] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Affiliation(s)
- Thomas E Kaier
- King's College London BHF Centre, The Rayne Institute, St Thomas' Hospital, London, UK
| | - Bashir Alaour
- King's College London BHF Centre, The Rayne Institute, St Thomas' Hospital, London, UK
| | - Michael Marber
- King's College London BHF Centre, The Rayne Institute, St Thomas' Hospital, London, UK
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Rossi TM, Kavsak PA, Maxie MG, Pearl DL, Pyle WG, Physick-Sheard PW. Post-exercise cardiac troponin I release and clearance in normal Standardbred racehorses. Equine Vet J 2018. [DOI: 10.1111/evj.12967] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- T. M. Rossi
- Department of Population Medicine; Ontario Veterinary College; University of Guelph; Guelph Ontario Canada
| | - P. A. Kavsak
- Department of Pathology and Molecular Medicine; McMaster University; Hamilton Ontario Canada
| | - M. G. Maxie
- Animal Health Laboratory; Laboratory Services Division; University of Guelph; Guelph Ontario Canada
| | - D. L. Pearl
- Department of Population Medicine; Ontario Veterinary College; University of Guelph; Guelph Ontario Canada
| | - W. G. Pyle
- Centre for Cardiovascular Research; Department of Biomedical Sciences; Ontario Veterinary College; University of Guelph; Guelph Ontario Canada
| | - P. W. Physick-Sheard
- Department of Population Medicine; Ontario Veterinary College; University of Guelph; Guelph Ontario Canada
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Kavsak PA. Should detectable cardiac troponin concentrations in a healthy population be the only criterion for classifying high-sensitivity cardiac troponin assays? Clin Biochem 2018; 56:1-3. [DOI: 10.1016/j.clinbiochem.2018.05.015] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2018] [Accepted: 05/22/2018] [Indexed: 11/26/2022]
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Kavsak PA, Andruchow JE, McRae AD, Worster A. Profile of Roche’s Elecsys Troponin T Gen 5 STAT blood test (a high-sensitivity cardiac troponin assay) for diagnosing myocardial infarction in the emergency department. Expert Rev Mol Diagn 2018; 18:481-489. [DOI: 10.1080/14737159.2018.1476141] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Affiliation(s)
- Peter A. Kavsak
- Department of Pathology and Molecular Medicine, McMaster University, Hamilton, Ontario, Canada
| | - James E. Andruchow
- Department of Emergency Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Andrew D. McRae
- Department of Emergency Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Andrew Worster
- Division of Emergency Medicine, McMaster University, Hamilton, Ontario, Canada
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Christenson RH, Mullins K, Duh SH. Validation of high-sensitivity performance for a United States Food and Drug Administration cleared cardiac troponin I assay. Clin Biochem 2018; 56:4-10. [PMID: 29750939 DOI: 10.1016/j.clinbiochem.2018.05.004] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2018] [Revised: 04/30/2018] [Accepted: 05/06/2018] [Indexed: 01/01/2023]
Abstract
BACKGROUND High-Sensitivity (hs) cardiac troponin (cTn) assays are categorized by two criteria: (i) cTn values above the limit of detection (LoD) for >50% of male and female healthy cohorts of ≥300 individuals; (ii) imprecision ≤10% total %CV for sex-specific 99th-percentile clinical decision values (CDVs). No documented hs-Tn assay has yet been FDA-cleared. METHODS The PATHFAST cTnI-II assay's LoD was 2.3 ng/L using CLSI EP-17. The AACC Universal Sample Bank of 847 healthy men (50.6%) and women (49.4%) was used to determine 99th-percentile CDVs with Nonparametric, Harrell-Davis and Robust modeling. Health/Medication questionnaires and Amino-terminal proBNP, Hemoglobin A1c and estimated Glomerular Filtration Rate surrogates excluded underlying health conditions. RESULTS The cTnI-II test's total CV was 6.1% at 29 ng/L and 7.1% at 22 ng/L; the LoD was 2.3 ng/L. Of the full 847-member healthy cohort, 113 (13.3%) were excluded by abnormal surrogate biomarkers. The final 734-member healthy population had the following (% > LoD): overall, 487 (66.3%); women, 186 (52.8%); and men, 301 (78.8%). 99th-percentile CDVs by Nonparametric modeling were: 28 ng/L (90% CI: 20-30), overall final 732-member healthy population; 20 ng/L (90% CI: 13-30), 352 women; and 30 ng/L (90% CI: 21-37), 382 men. Differences between sex-specific CDVs were not significantly different (p > .05) with Nonparametric or Harrell-Davis modeling; however, Robust Modeling did show significance (<0.05), with lower CDVs at 11 ng/L (90% CI: 9-12) and 16 ng/L (90% CI: 15-18) for the female and male cohorts, respectively. CONCLUSIONS cTnI-II is the only FDA-cleared assay that has demonstrated high-sensitivity cTn assay. Use of recommended modeling in >300 healthy subjects for determining sex-specific 99th-percentile CDVs did not show statistically significant differences except with the Robust modeling.
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Affiliation(s)
- Robert H Christenson
- University of Maryland School of Medicine, Department of Pathology, 685 West Baltimore Street, MSTF Room 2-54, Baltimore, MD 21201, USA.
| | - Kristin Mullins
- University of Maryland School of Medicine, Department of Pathology, 685 West Baltimore Street, MSTF Room 2-54, Baltimore, MD 21201, USA
| | - Show-Hong Duh
- University of Maryland School of Medicine, Department of Pathology, 685 West Baltimore Street, MSTF Room 2-54, Baltimore, MD 21201, USA
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Giannitsis E, Katus HA. Troponins: established and novel indications in the management of cardiovascular disease. Heart 2018; 104:1714-1722. [PMID: 29724751 DOI: 10.1136/heartjnl-2017-311387] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Affiliation(s)
| | - Hugo A Katus
- Medizinische Klinik III, University of Heidelberg, Heidelberg, Germany
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128
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Wu AHB, Christenson RH, Greene DN, Jaffe AS, Kavsak PA, Ordonez-Llanos J, Apple FS. Clinical Laboratory Practice Recommendations for the Use of Cardiac Troponin in Acute Coronary Syndrome: Expert Opinion from the Academy of the American Association for Clinical Chemistry and the Task Force on Clinical Applications of Cardiac Bio-Markers of the International Federation of Clinical Chemistry and Laboratory Medicine. Clin Chem 2018; 64:645-655. [DOI: 10.1373/clinchem.2017.277186] [Citation(s) in RCA: 251] [Impact Index Per Article: 41.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2017] [Accepted: 12/12/2017] [Indexed: 12/16/2022]
Abstract
Abstract
This document is an essential companion to the third iteration of the National Academy of Clinical Biochemistry [NACB,8 now the American Association for Clinical Chemistry (AACC) Academy] Laboratory Medicine Practice Guidelines (LMPG) on cardiac markers. The expert consensus recommendations were drafted in collaboration with the International Federation of Clinical Chemistry and Laboratory Medicine Task Force on Clinical Applications of Bio-Markers (IFCC TF-CB). We determined that there is sufficient clinical guidance on the use of cardiac troponin (cTn) testing from clinical practice groups. Thus, in this expert consensus document, we focused on clinical laboratory practice recommendations for high-sensitivity (hs)-cTn assays. This document utilized the expert opinion class of evidence to focus on the following 10 topics: (a) quality control (QC) utilization, (b) validation of the lower reportable analytical limits, (c) units to be used in reporting measurable concentrations for patients and QC materials, (d) 99th percentile sex-specific upper reference limits to define the reference interval; (e) criteria required to define hs-cTn assays, (f) communication with clinicians and the laboratory's role in educating clinicians regarding the influence of preanalytic and analytic problems that can confound assay results, (g) studies on hs-cTn assays and how authors need to document preanalytical and analytical variables, (h) harmonizing and standardizing assay results and the role of commutable materials, (i) time to reporting of results from sample receipt and sample collection, and (j) changes in hs-cTn concentrations over time and the role of both analytical and biological variabilities in interpreting results of serial blood collections.
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Affiliation(s)
- Alan H B Wu
- Department of Laboratory Medicine, University of California, San Francisco, San Francisco, CA
| | | | - Dina N Greene
- Department of Laboratory Medicine, University of Washington, Seattle, WA
| | - Allan S Jaffe
- Departments of Cardiology and Laboratory Medicine, Mayo Clinic, Rochester, MN
| | - Peter A Kavsak
- Department of Pathology and Molecular Medicine, McMaster University, Hamilton, Ontario, Canada
| | | | - Fred S Apple
- Department of Laboratory Medicine and Pathology, Hennepin County Medical Center and University of Minnesota, Minneapolis, MN
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Badertscher P, Boeddinghaus J, Nestelberger T, Twerenbold R, Wildi K, Sabti Z, Puelacher C, Rubini Giménez M, Pfäffli J, Flores D, du Fay de Lavallaz J, Miró Ò, Martin-Sanchez FJ, Morawiec B, Lohrmann J, Buser A, Keller DI, Geigy N, Reichlin T, Mueller C, Cupa J, Schumacher L, Grimm K, Kozhuharov N, Shrestha S, Rentsch K, López B, Yañez-Palma MC, Iglesias S, Kawecki D, Ganovská E, Osswald S. Effect of Acute Coronary Syndrome Probability on Diagnostic and Prognostic Performance of High-Sensitivity Cardiac Troponin. Clin Chem 2018; 64:515-525. [DOI: 10.1373/clinchem.2017.279513] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2017] [Accepted: 12/20/2017] [Indexed: 11/06/2022]
Abstract
Abstract
BACKGROUND
There is concern that high-sensitivity cardiac troponin (hs-cTn) may have low diagnostic accuracy in patients with low acute coronary syndrome (ACS) probability.
METHODS
We prospectively stratified patients presenting with acute chest discomfort to the emergency department (ED) into 3 groups according to their probability for ACS as assessed by the treating ED physician using a visual analog scale: ≤10%, 11% to 79%, and ≥80%, reviewing all information available at 90 min. hs-cTnT and hs-cTnI concentrations were determined in a blinded fashion. Two independent cardiologists adjudicated the final diagnosis.
RESULTS
Among 3828 patients eligible for analysis, 1189 patients had low (≤10%) probability for ACS. The incidence of non-ST-segment elevation myocardial infarction (NSTEMI) increased from 1.3% to 12.2% and 54.8% in patients with low, intermediate, and high ACS probability, respectively. The positive predictive value of hs-cTnT and hs-cTnI was low in patients with low ACS probability and increased with the incidence of NSTEMI, whereas the diagnostic accuracy of hs-cTnT and hs-cTnI for NSTEMI as quantified by the area under the curve (AUC) was very high and comparable among all 3 strata, e.g., AUC hs-cTnI, 0.96 (95% CI, 0.94–0.97); 0.87 (95% CI, 0.85–0.89); and 0.89 (95% CI, 0.87–0.92), respectively. Findings were validated using bootstrap analysis as an alternative methodology to define ACS probability. Similarly, higher hs-cTnT/I concentrations independently predicted all-cause mortality within 2 years (e.g., hs-cTnT hazard ratio, 1.39; 95% CI, 1.27–1.52), irrespective of ACS probability.
CONCLUSIONS
Diagnostic and prognostic accuracy and utility of hs-cTnT and hs-cTnI remain high in patients with acute chest discomfort and low ACS probability.
ClinicalTrials.gov Identifier: NCT00470587.
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Affiliation(s)
- Patrick Badertscher
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT network, Sao Paulo, Brazil
| | - Jasper Boeddinghaus
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- Department of Internal Medicine, University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT network, Sao Paulo, Brazil
| | - Thomas Nestelberger
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- Department of Internal Medicine, University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT network, Sao Paulo, Brazil
| | - Raphael Twerenbold
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT network, Sao Paulo, Brazil
- Department of General and Interventional Cardiology, Hamburg University Heart Center, Hamburg, Germany
| | - Karin Wildi
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT network, Sao Paulo, Brazil
| | - Zaid Sabti
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT network, Sao Paulo, Brazil
| | - Christian Puelacher
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT network, Sao Paulo, Brazil
| | - Maria Rubini Giménez
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT network, Sao Paulo, Brazil
| | - Julian Pfäffli
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Dayana Flores
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT network, Sao Paulo, Brazil
| | - Jeanne du Fay de Lavallaz
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT network, Sao Paulo, Brazil
| | - Òscar Miró
- GREAT network, Sao Paulo, Brazil
- Emergency Department, Hospital Clinic, University of Barcelona, Barcelona, Spain
| | | | - Beata Morawiec
- GREAT network, Sao Paulo, Brazil
- 2nd Department of Cardiology, School of Medicine with the Division of Dentistry in Zabrze, Medical University of Katowice, Katowice, Poland
| | - Jens Lohrmann
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Andreas Buser
- Blood Transfusion Centre, Swiss Red Cross, and Department of Hematology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Dagmar I Keller
- Emergency Department, University Hospital Zurich, Zurich, Switzerland
| | - Nicolas Geigy
- Emergency Department, Kantonsspital, Liestal, Switzerland
| | - Tobias Reichlin
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT network, Sao Paulo, Brazil
| | - Christian Mueller
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT network, Sao Paulo, Brazil
| | - Janosch Cupa
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT network
| | - Lukas Schumacher
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT network
| | - Karin Grimm
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- Department of Internal Medicine, University Hospital Basel, University Basel, Basel, Switzerland
- GREAT network
| | - Nikola Kozhuharov
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- Department of Internal Medicine, University Hospital Basel, University Basel, Basel, Switzerland
| | - Samyut Shrestha
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT network
| | - Katharina Rentsch
- Laboratory Medicine, University Hospital Basel, University Basel, Basel, Switzerland
| | - Beatriz López
- GREAT network
- Emergency Department, Hospital Clinic, University of Barcelona, Catalonia, Spain
| | - M C Yañez-Palma
- Servicio de Urgencias, Hospital Clínico San Carlos, Madrid, Spain
| | - Sergio Iglesias
- Department of Cardiology, University Hospital Brno, Brno, Czech Republic and Medical Faculty, Masaryk University, Brno, Czech Republic
| | - Damian Kawecki
- GREAT network
- 2nd Department of Cardiology, School of Medicine with the Division of Dentistry in Zabrze, Medical University of Katowice, Katowice, Poland
| | - Eva Ganovská
- GREAT network
- Department of Cardiology, University Hospital Brno, Brno, Czech Republic and Medical Faculty, Masaryk University, Brno, Czech Republic
| | - Stefan Osswald
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
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Comparing analytical outliers and the percent of emergency department patients with results above the 99th percentile upper reference limit for 2 conventional and one high sensitivity troponin assay. Clin Biochem 2018; 53:104-109. [DOI: 10.1016/j.clinbiochem.2018.01.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2017] [Revised: 12/08/2017] [Accepted: 01/02/2018] [Indexed: 11/21/2022]
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131
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Gunsolus I, Sandoval Y, Smith SW, Sexter A, Schulz K, Herzog CA, Apple FS. Renal Dysfunction Influences the Diagnostic and Prognostic Performance of High-Sensitivity Cardiac Troponin I. J Am Soc Nephrol 2018; 29:636-643. [PMID: 29079658 PMCID: PMC5791068 DOI: 10.1681/asn.2017030341] [Citation(s) in RCA: 48] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2017] [Accepted: 09/25/2017] [Indexed: 01/09/2023] Open
Abstract
Measures of cardiac troponin (cTn) may have lower specificity for myocardial infarction in patients with CKD. We examined the diagnostic accuracy of baseline and serial high-sensitivity cTnI (hs-cTnI) measurements for myocardial infarction and 30- and 180-day mortality according to renal function. hs-cTnI was measured (Abbott assay) using sex-specific 99th percentiles (women, 16 ng/L; men, 34 ng/L) in 1555 adults presenting to the emergency department with symptoms suggesting ischemia (NCT02060760). Myocardial infarction was adjudicated along universal definition classification. Renal function did not significantly affect sensitivity or negative predictive values. Specificity decreased with impaired renal function from 93%-95% with normal function (eGFR≥90 ml/min per 1.73 m2; n=722) to 57%-61% with severely impaired renal function (eGFR<30 ml/min per 1.73 m2; n=81) and 40%-41% on dialysis (n=78). Positive predictive values decreased with decreasing renal function from 51%-57% with normal function to 27%-42% with severely impaired function and 15%-32% on dialysis. Receiver operating characteristic curve areas trended lower at baseline and 3 hours with renal impairment. Mortality increased significantly with increasing hs-cTnI tertile (1.3%, 6.0%, and 10.4%, respectively). Patients with hs-cTnI concentration exceeding concentrations in the 99th percentiles had a mortality rate (11.7%) significantly higher than that of patients with concentrations between 99th percentile concentrations and limit of detection (6.2%) or below limit of detection (1.1%). Renal dysfunction and dialysis reduced the rule-in performance but not the rule-out performance of hs-cTnI for myocardial infarction, and mortality increased in patients with higher hs-cTnI concentrations and any level of renal dysfunction.
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Affiliation(s)
- Ian Gunsolus
- Department of Laboratory Medicine and Pathology and
| | - Yader Sandoval
- Division of Cardiology, Hennepin County Medical Center, Minneapolis, Minnesota
- Minneapolis Heart Institute, Abbott Northwestern Hospital, Minneapolis, Minnesota
- Cardiac Biomarkers Trials Laboratory and
| | | | - Anne Sexter
- Chronic Disease Research Group, Minneapolis Medical Research Foundation, Minneapolis, Minnesota; and
| | | | - Charles A Herzog
- Chronic Disease Research Group, Minneapolis Medical Research Foundation, Minneapolis, Minnesota; and
- Medicine, and
| | - Fred S Apple
- Cardiac Biomarkers Trials Laboratory and
- Laboratory Medicine and Pathology, Hennepin County Medical Center and University of Minnesota, Minneapolis, Minnesota
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132
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Jaffe AS, Miller WL. Meta-Analyses and Interpretation of Troponin Values in Heart Failure. JACC-HEART FAILURE 2018; 6:198-200. [PMID: 29331273 DOI: 10.1016/j.jchf.2017.12.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/04/2017] [Accepted: 12/05/2017] [Indexed: 11/26/2022]
Affiliation(s)
- Allan S Jaffe
- Department of Laboratory Medicine and Pathology, Mayo Clinic and Foundation, Rochester, Minnesota.
| | - Wayne L Miller
- Department of Cardiovascular Medicine, Mayo Clinic and Foundation, Rochester, Minnesota
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133
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Prognostic value of postoperative high-sensitivity troponin T in patients with different stages of kidney disease undergoing noncardiac surgery. Br J Anaesth 2018; 120:84-93. [DOI: 10.1016/j.bja.2017.09.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2016] [Revised: 08/02/2017] [Accepted: 09/18/2017] [Indexed: 11/24/2022] Open
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Mariathas M, Olechowski B, Mahmoudi M, Curzen N. High sensitivity troponins in contemporary cardiology practice: are we turning a corner? Expert Rev Cardiovasc Ther 2017; 16:49-57. [PMID: 29260921 DOI: 10.1080/14779072.2018.1419063] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Troponin is considered to be the gold standard biomarker for ruling out MI. There has been a drive to improve the diagnostic speed, and as such the high sensitivity cardiac troponin (hs-cTn) assays have been introduced into clinical practice and are now part of international guidelines. Their novel value in clinical practice more generally is becoming apparent. Areas covered: In this review we will evaluate the evidence for the use of hs-cTn assays in clinical practice, the issues with the assay and how the hs-cTn can be utilized in the future as a biomarker of cardiovascular risk. Expert commentary: The use of the hs-cTn assays as a 'rule out' test for MI is compelling, as a 'rule in' there are significant issues relating the specificity of the assay for MI. The future of the assay may lie in population screening and risk modeling.
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Affiliation(s)
- Mark Mariathas
- a Coronary Research Group , University Hospital Southampton NHS Foundation Trust , Southampton , UK.,b Faculty of Medicine , University of Southampton , Southampton , UK
| | - Bartosz Olechowski
- a Coronary Research Group , University Hospital Southampton NHS Foundation Trust , Southampton , UK.,b Faculty of Medicine , University of Southampton , Southampton , UK
| | - Michael Mahmoudi
- a Coronary Research Group , University Hospital Southampton NHS Foundation Trust , Southampton , UK.,b Faculty of Medicine , University of Southampton , Southampton , UK
| | - Nick Curzen
- a Coronary Research Group , University Hospital Southampton NHS Foundation Trust , Southampton , UK.,b Faculty of Medicine , University of Southampton , Southampton , UK
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135
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Alquézar-Arbé A, Sionis A, Ordoñez-Llanos J. Cardiac troponins: 25 years on the stage and still improving their clinical value. Crit Rev Clin Lab Sci 2017; 54:551-571. [PMID: 29226754 DOI: 10.1080/10408363.2017.1410777] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Twenty-five years ago, non-isotopic immunoassays for measuring the cardiac specific isoforms of troponin I (cTnI) and T (cTnT) were developed. Both biomarkers radically changed the diagnosis, prognosis, and therapy indication of acute coronary syndromes (ACS) and, particularly, of myocardial infarction (MI). However, cardiac troponins (cTn) rapidly demonstrated their usefulness in other cardiac and non-cardiac conditions, a part of the ischemic coronary diseases. Consequently, the number of patients to be tested for cTn and the number of tests requested to clinical laboratories sharply increased. Though the manufacturers continuously improved the analytical characteristics of the first cTn assays and produced different cTn assay "generations", the universal definition of myocardial infarction required less-than-available analytical imprecision at the cTn concentration used to assess MI (i.e. the 99th reference percentile). To address the clinical requirements, manufacturers developed the high-sensitivity cTn (hs-cTn) assays that allow to measure the 99th reference percentile with adequate precision, to detect cTn in many healthy subjects and, hence, to calculate the hs-cTn biological variation and especially to observe in very short time intervals serial differences in hs-cTn attributable to cardiac ischemia. Since the number of patients attending the emergency departments (ED) for a suspected ACS or MI is increasing, the improved properties of hs-cTn assays, allowing faster and safer patient assessment, will help to alleviate the sometimes overcrowded EDs. However, there are many biological, analytical, and clinical factors that can influence the true hs-cTn values of a patient. Clinicians and laboratory professionals should know about them for the best interpretation of the otherwise largely useful hs-cTn measurements. In conclusion, 25 years after their introduction for clinical use, "cTn are still on the stage and improving their clinical value".
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Affiliation(s)
| | - Alessandro Sionis
- b Cardiology Department, Acute and Intensive Cardiac Care Unit, IIB-Sant Pau, CIBER-CV , Hospital de la Santa Creu i Sant Pau , Barcelona , Spain.,c Faculty of Medicine , Universitat de Barcelona , Barcelona , Spain
| | - Jorge Ordoñez-Llanos
- d Clinical Biochemistry Department , Hospital de la Santa Creu i Sant Pau, IIB-Sant Pau , Barcelona , Spain.,e Biochemistry and Molecular Biology Department , Universitat Autònoma , Barcelona , Spain.,f Task Force on Clinical Application of Cardiac Biomarkers , International Federation of Clinical Chemistry , Milan , Italy
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Andruchow JE, Kavsak PA, McRae AD. Contemporary Emergency Department Management of Patients with Chest Pain: A Concise Review and Guide for the High-Sensitivity Troponin Era. Can J Cardiol 2017; 34:98-108. [PMID: 29407013 DOI: 10.1016/j.cjca.2017.11.012] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2017] [Revised: 11/23/2017] [Accepted: 11/23/2017] [Indexed: 11/17/2022] Open
Abstract
This article synthesizes current best evidence for the evaluation of patients with suspected acute coronary syndrome (ACS) using high-sensitivity troponin assays, enabling physicians to effectively incorporate them into practice. Unlike conventional assays, high-sensitivity assays can precisely measure blood cardiac troponin concentrations in the vast majority of healthy individuals, facilitating the creation of rapid diagnostic algorithms. Very low troponin concentrations on presentation accurately rule out acute myocardial infarction (AMI) and enable the discharge of approximately 20% of patients after a single test, whereas an additional 30%-40% of patients can be safely discharged after short-interval serial sampling in as little as 1 or 2 hours. In contrast, highly abnormal troponin concentrations on presentation (more than 5 times the upper reference limit) or rapidly rising levels on serial testing can rapidly rule in AMI with high specificity. However, approximately one-third of patients remain in a biomarker-indeterminate "observation zone" even after serial sampling. These patients pose a disposition challenge to clinicians because although the differential diagnosis of elevated troponin concentrations is broad, these patients have an increased risk for short-term major adverse cardiac events. Use of repeated serial troponin sampling and structured clinical prediction tools may assist disposition for these patients, because no validated pathways currently exist to guide clinicians. Ongoing research to tailor diagnostic thresholds to individual patient characteristics may enable improved diagnostic accuracy and usher in a new era of personalized medicine in the evaluation of suspected ACS.
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Affiliation(s)
- James E Andruchow
- Department of Emergency Medicine, University of Calgary, Calgary, Alberta, Canada; Alberta Health Services, Calgary, Alberta, Canada.
| | - Peter A Kavsak
- Department of Pathology and Molecular Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Andrew D McRae
- Department of Emergency Medicine, University of Calgary, Calgary, Alberta, Canada; Alberta Health Services, Calgary, Alberta, Canada
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137
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Sandoval Y, Jaffe AS. Using High-Sensitivity Cardiac Troponin T for Acute Cardiac Care. Am J Med 2017; 130:1358-1365.e1. [PMID: 28843652 DOI: 10.1016/j.amjmed.2017.07.033] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2017] [Revised: 07/27/2017] [Accepted: 07/28/2017] [Indexed: 12/21/2022]
Abstract
The recent approval of the fifth-generation cardiac troponin T assay, which has characteristics clinically of a high-sensitivity assay, has led to concern that the problems of increased sensitivity will be greater than the benefits. This will not be the case if cardiology, emergency medicine, and laboratory medicine combine to develop procedures for use of the assay. We advocate sex-specific 99th percentile upper reference limit values of 15 ng/L for men and 10 ng/L for women. We suggest a 2-hour rule-out strategy, including a value less than the 99th percentile upper reference limit and the lack of a change in values of <4 ng/L. Those with values >100 ng/L and or a changing pattern of values ≥10 ng/L are a population much more likely to have acute myocardial infarction. Most of the increment in elevated values will occur not in those with acute coronary problems but in those with primary cardiac disease like heart failure and those with primary noncardiac problems. The former belong on a cardiac service because they are at high risk. The latter should have therapy on the service most apt to provide optimal care for their primary diagnosis, with cardiac consultation as needed.
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Affiliation(s)
- Yader Sandoval
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minn
| | - Allan S Jaffe
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minn; Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minn.
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Gunsolus IL, Jaffe AS, Sexter A, Schulz K, Ler R, Lindgren B, Saenger AK, Love SA, Apple FS. Sex-specific 99th percentiles derived from the AACC Universal Sample Bank for the Roche Gen 5 cTnT assay: Comorbidities and statistical methods influence derivation of reference limits. Clin Biochem 2017; 50:1073-1077. [DOI: 10.1016/j.clinbiochem.2017.09.009] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2017] [Revised: 09/09/2017] [Accepted: 09/11/2017] [Indexed: 11/28/2022]
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Natale M, Behnes M, Kim SH, Hoffmann J, Reckord N, Hoffmann U, Budjan J, Lang S, Borggrefe M, Papavassiliu T, Bertsch T, Akin I. High sensitivity troponin T and I reflect left atrial function being assessed by cardiac magnetic resonance imaging. Ann Clin Biochem 2017; 55:264-275. [DOI: 10.1177/0004563217714004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Background Left atrial function (LAF) plays an interactive role between pulmonary and systemic circulation. Cardiac biomarkers, such as amino-terminal pro-brain natriuretic peptide (NT-proBNP) and troponins, might reflect cardiac function. This study aims to evaluate the association between high sensitivity troponins (hsTn) and left atrial function in patients undergoing cardiac magnetic resonance imaging (cMRI). Methods Patients undergoing cardiac magnetic resonance imaging (cMRI) were enrolled prospectively. Patients with right ventricular dysfunction (<50%) were excluded. Blood samples for measurements of hsTn and NT-proBNP were collected at the time of cMRI. Results Eighty-four patients were included. Median LVEF was 59% (IQR 51–64%). HsTn correlated inversely with LAF within multivariable linear regression models (hsTnI: Beta −0.46; T −4.44; P = 0.0001; hsTnT: Beta −0.29; T −3.06; P = 0.003). High sensitivity troponins increased significantly according to decreasing stages of impaired LAF ( P = 0.0001). High sensitivity troponins discriminated patients with impaired LAF < 55% (hsTnT: AUC = 0.80; P = 0.0001; hsTnI: AUC = 0.74; P = 0.0001) and <45% (hsTnT: AUC = 0.75; P = 0.0001; hsTnI: AUC = 0.73; P = 0.001) and were still significantly associated in multivariable logistic regression models (LAF < 55%: hsTnT: OR = 21.78; P = 0.0001; hsTnI: OR = 5.96; P = 0.009; LAF < 45%: hsTnT: OR = 10.27; P = 0.0001; hsTnI: OR = 12.56; P = 0.001). Conclusions This study demonstrates that hsTn are able to reflect LAF being assessed by cardiac magnetic resonance imaging.
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Affiliation(s)
- Michèle Natale
- First Department of Medicine, University Medical Center Mannheim (UMM), Faculty of Medicine Mannheim, University of Heidelberg, Mannheim, Germany
| | - Michael Behnes
- First Department of Medicine, University Medical Center Mannheim (UMM), Faculty of Medicine Mannheim, University of Heidelberg, Mannheim, Germany
| | - Seung-Hyun Kim
- First Department of Medicine, University Medical Center Mannheim (UMM), Faculty of Medicine Mannheim, University of Heidelberg, Mannheim, Germany
| | - Julia Hoffmann
- First Department of Medicine, University Medical Center Mannheim (UMM), Faculty of Medicine Mannheim, University of Heidelberg, Mannheim, Germany
| | - Nadine Reckord
- First Department of Medicine, University Medical Center Mannheim (UMM), Faculty of Medicine Mannheim, University of Heidelberg, Mannheim, Germany
| | - Ursula Hoffmann
- First Department of Medicine, University Medical Center Mannheim (UMM), Faculty of Medicine Mannheim, University of Heidelberg, Mannheim, Germany
| | - Johannes Budjan
- Institute of Clinical Radiology and Nuclear Medicine, University Medical Center Mannheim (UMM), Faculty of Medicine Mannheim, University of Heidelberg, Mannheim, Germany
| | - Siegfried Lang
- First Department of Medicine, University Medical Center Mannheim (UMM), Faculty of Medicine Mannheim, University of Heidelberg, Mannheim, Germany
| | - Martin Borggrefe
- First Department of Medicine, University Medical Center Mannheim (UMM), Faculty of Medicine Mannheim, University of Heidelberg, Mannheim, Germany
| | - Theano Papavassiliu
- First Department of Medicine, University Medical Center Mannheim (UMM), Faculty of Medicine Mannheim, University of Heidelberg, Mannheim, Germany
| | - Thomas Bertsch
- Institute of Clinical Chemistry, Laboratory Medicine and Transfusion Medicine, General Hospital Nuremberg, Paracelsus Medical University, Nuremberg, Germany
| | - Ibrahim Akin
- First Department of Medicine, University Medical Center Mannheim (UMM), Faculty of Medicine Mannheim, University of Heidelberg, Mannheim, Germany
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Trupp RJ, Albert G, Ziegler A. Sex-specific 99th percentiles derived from the AACC Universal Sample Bank for the Roche Gen 5 cTnT assay: Comorbidities and statistical methods influence derivation of reference limits. Clin Biochem 2017; 52:173. [PMID: 29113784 DOI: 10.1016/j.clinbiochem.2017.11.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2017] [Accepted: 11/04/2017] [Indexed: 11/26/2022]
Affiliation(s)
- Robin J Trupp
- Roche Diagnostics Corporation, Scientific Affairs - Cardiac, United States.
| | - Gesa Albert
- Roche Diagnostics Corporation, Cardiac & Critical Care, Switzerland
| | - Andre Ziegler
- Roche Diagnostics Corporation, Cardiovascular Disease, Switzerland
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Katus H, Ziegler A, Ekinci O, Giannitsis E, Stough WG, Achenbach S, Blankenberg S, Brueckmann M, Collinson P, Comaniciu D, Crea F, Dinh W, Ducrocq G, Flachskampf FA, Fox KAA, Friedrich MG, Hebert KA, Himmelmann A, Hlatky M, Lautsch D, Lindahl B, Lindholm D, Mills NL, Minotti G, Möckel M, Omland T, Semjonow V. Early diagnosis of acute coronary syndrome. Eur Heart J 2017; 38:3049-3055. [PMID: 29029109 DOI: 10.1093/eurheartj/ehx492] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2017] [Accepted: 08/21/2017] [Indexed: 01/01/2023] Open
Abstract
The diagnostic evaluation of acute chest pain has been augmented in recent years by advances in the sensitivity and precision of cardiac troponin assays, new biomarkers, improvements in imaging modalities, and release of new clinical decision algorithms. This progress has enabled physicians to diagnose or rule-out acute myocardial infarction earlier after the initial patient presentation, usually in emergency department settings, which may facilitate prompt initiation of evidence-based treatments, investigation of alternative diagnoses for chest pain, or discharge, and permit better utilization of healthcare resources. A non-trivial proportion of patients fall in an indeterminate category according to rule-out algorithms, and minimal evidence-based guidance exists for the optimal evaluation, monitoring, and treatment of these patients. The Cardiovascular Round Table of the ESC proposes approaches for the optimal application of early strategies in clinical practice to improve patient care following the review of recent advances in the early diagnosis of acute coronary syndrome. The following specific 'indeterminate' patient categories were considered: (i) patients with symptoms and high-sensitivity cardiac troponin <99th percentile; (ii) patients with symptoms and high-sensitivity troponin <99th percentile but above the limit of detection; (iii) patients with symptoms and high-sensitivity troponin >99th percentile but without dynamic change; and (iv) patients with symptoms and high-sensitivity troponin >99th percentile and dynamic change but without coronary plaque rupture/erosion/dissection. Definitive evidence is currently lacking to manage these patients whose early diagnosis is 'indeterminate' and these areas of uncertainty should be assigned a high priority for research.
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Affiliation(s)
- Hugo Katus
- Medizinische Klinik III, University of Heidelberg, Im Neuenheimer Feld 410, 69120 Heidelberg, Germany
| | | | - Okan Ekinci
- Siemens Healthineers, Erlangen, Germany
- University College Dublin, Dublin, Ireland
| | - Evangelos Giannitsis
- Medizinische Klinik III, University of Heidelberg, Im Neuenheimer Feld 410, 69120 Heidelberg, Germany
| | | | - Stephan Achenbach
- Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | | | - Martina Brueckmann
- Boehringer-Ingelheim GmbH & Co. KG, Ingelheim am Rhein, Germany
- Faculty of Medicine Mannheim, University of Heidelberg, Mannheim, Germany
| | - Paul Collinson
- St. George's University Hospitals NHS Foundation Trust, London, UK
- St. Georges, University of London, London, UK
| | | | - Filippo Crea
- Universita Cattolica del Sacro Cuore, Rome, Italy
| | - Wilfried Dinh
- Bayer AG Pharmaceuticals, Drug Discovery, Wuppertal, Germany
- Department of Cardiology, HELIOS Clinic Wuppertal, University Hospital Witten/Herdecke, Wuppertal, Germany
| | | | - Frank A Flachskampf
- Department of Medical Sciences, Clinical Physiology/Cardiology, Uppsala University, Uppsala, Sweden
| | - Keith A A Fox
- Centre for Cardiovascular Science, University and Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Matthias G Friedrich
- Departments of Medicine and Diagnostic Radiology, McGill University Health Centre, Montreal, Canada
- Heidelberg University, Heidelberg, Germany
| | | | | | - Mark Hlatky
- Stanford University School of Medicine, Stanford, CA, USA
| | | | - Bertil Lindahl
- Department of Medical Sciences, Clinical Physiology/Cardiology, Uppsala University, Uppsala, Sweden
| | - Daniel Lindholm
- Department of Medical Sciences, Cardiology, Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - Nicholas L Mills
- BHF Center for Cardiovascular Sciences, University of Edinburgh, Edinburgh, UK
| | | | | | - Torbjørn Omland
- Akershus University Hospital and University of Oslo, Oslo, Norway
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Soetkamp D, Raedschelders K, Mastali M, Sobhani K, Bairey Merz CN, Van Eyk J. The continuing evolution of cardiac troponin I biomarker analysis: from protein to proteoform. Expert Rev Proteomics 2017; 14:973-986. [PMID: 28984473 DOI: 10.1080/14789450.2017.1387054] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
INTRODUCTION The troponin complex consists of three proteins that fundamentally couple excitation with contraction. Circulating cardiac-specific Troponin I (cTnI) serves as diagnostic biomarker tools for risk stratification of acute coronary syndromes and acute myocardial infarction (MI). Within the heart, cTnI oscillates between inactive and active conformations to either block or disinhibit actinomyosin formation. This molecular mechanism is fine-tuned through extensive protein modifications whose profiles are maladaptively altered with co-morbidities including hypertrophic cardiomyopathy, diabetes, and heart failure. Technological advances in analytical platforms over the last decade enable routine baseline cTnI analysis in patients without cardiovascular complications, and hold potential to expand cTnI readouts that include modified cTnI proteoforms. Areas covered: This review covers the current state, advances, and prospects of analytical platforms that now enable routine baseline cTnI analysis in patients. In parallel, improved mass spectrometry instrumentation and workflows already reveal an array of modified cTnI proteoforms with promising diagnostic implications. Expert commentary: New analytical capabilities provide clinicians and researchers with an opportunity to address important questions surrounding circulating cTnI in the improved diagnosis of specific patient cohorts. These techniques also hold considerable promise for new predictive and prescriptive applications for individualized profiling and improve patient care.
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Affiliation(s)
- Daniel Soetkamp
- a Heart Institute , Cedars-Sinai Medical Center , Los Angeles , CA , USA
| | - Koen Raedschelders
- a Heart Institute , Cedars-Sinai Medical Center , Los Angeles , CA , USA
| | - Mitra Mastali
- a Heart Institute , Cedars-Sinai Medical Center , Los Angeles , CA , USA
| | - Kimia Sobhani
- b Pathology and Laboratory Medicine , Cedars-Sinai Medical Center , Los Angeles , CA , USA
| | - C Noel Bairey Merz
- c Women's Heart Center , Cedars-Sinai Medical Center , Los Angeles , CA , USA
| | - Jennifer Van Eyk
- a Heart Institute , Cedars-Sinai Medical Center , Los Angeles , CA , USA
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High sensitivity troponin T and I reflect mitral annular plane systolic excursion being assessed by cardiac magnetic resonance imaging. Eur J Med Res 2017; 22:38. [PMID: 28978339 PMCID: PMC5628434 DOI: 10.1186/s40001-017-0281-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2017] [Accepted: 09/22/2017] [Indexed: 01/13/2023] Open
Abstract
Purpose This study aims to evaluate the association between high sensitivity troponins (hsTn) and mitral annular plane systolic excursion (MAPSE) in patients undergoing cardiac magnetic resonance imaging (cMRI). Methods Patients undergoing cMRI were prospectively enrolled. Patients with right ventricular dysfunction (< 50%) were excluded. Blood samples for measurements of hsTn and amino-terminal pro-brain natriuretic peptide (NT-proBNP) were collected at the time of cMRI. Results 84 patients were included. Median left ventricular ejection fraction was 59% (IQR 51–64%). HsTn were correlated inversely with MAPSE within multivariable linear regression models (hsTnI: Beta − 0.19; T − 1.96; p = 0.05; hsTnT: Beta − 0.26; T − 3.26; p = 0.002). HsTn increased significantly according to decreasing stages of impaired MAPSE (p < 0.003). HsTn discriminated patients with impaired MAPSE < 11 mm (hsTnT: AUC = 0.67; p = 0.008; hsTnI: AUC = 0.64; p = 0.03) and < 8 mm (hsTnT: AUC = 0.79; p = 0.0001; hsTnI: AUC = 0.75; p = 0.001) and were still significantly associated in multivariable logistic regression models with impaired MAPSE < 11 mm (hsTnT: OR = 4.71; p = 0.002; hsTnI: OR = 4.22; p = 0.009). Conclusions This study demonstrates that hsTn are able to reflect MAPSE being assessed by cMRI. Electronic supplementary material The online version of this article (doi:10.1186/s40001-017-0281-x) contains supplementary material, which is available to authorized users.
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Herman DS, Kavsak PA, Greene DN. Variability and Error in Cardiac Troponin Testing: An ACLPS Critical Review. Am J Clin Pathol 2017; 148:281-295. [PMID: 28967956 DOI: 10.1093/ajcp/aqx066] [Citation(s) in RCA: 52] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES To provide a comprehensive overview of the complexities associated with cardiac troponin (cTn) testing. An emphasis is placed on the sources of error, organized into the preanalytical, analytical, and postanalytical phases of the testing pathway. Controversial areas are also explored. METHODS A case scenario and review of the relevant literature describing laboratory considerations involving cTn testing are described. RESULTS Advanced comprehension of the specific assay used in a given laboratory is necessary for optimal reporting, utilization, and quality monitoring of cTn. CONCLUSIONS cTn assays are reliable diagnostic tests for acute myocardial infarction, but understanding their limitations is required for appropriate result interpretation.
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Affiliation(s)
- Daniel S Herman
- Department of Pathology and Laboratory Medicine, University of Pennsylvania,Philadelphia
| | - Peter A Kavsak
- Department of Pathology and Molecular Medicine, McMaster University,Hamilton, Canada
| | - Dina N Greene
- Department of Laboratory Medicine, University of Washington, Seattle
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Sandoval Y, Smith SW, Thordsen SE, Bruen CA, Carlson MD, Dodd KW, Driver BE, Jacoby K, Johnson BK, Love SA, Moore JC, Sexter A, Schulz K, Scott NL, Nicholson J, Apple FS. Diagnostic Performance of High Sensitivity Compared with Contemporary Cardiac Troponin I for the Diagnosis of Acute Myocardial Infarction. Clin Chem 2017; 63:1594-1604. [DOI: 10.1373/clinchem.2017.272930] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2017] [Accepted: 06/09/2017] [Indexed: 12/13/2022]
Abstract
Abstract
BACKGROUND
We examined the diagnostic performance of high-sensitivity cardiac troponin I (hs-cTnI) vs contemporary cTnI with use of the 99th percentile alone and with a normal electrocardiogram (ECG) to rule out acute myocardial infarction (MI) and serial changes (deltas) to rule in MI.
METHODS
We included consecutive patients presenting to a US emergency department with serial cTnI onclinical indication. Diagnostic performance for acute MI, including MI subtypes, and 30-day outcomes were examined.
RESULTS
Among 1631 patients, MI was diagnosed in 12.9% using the contemporary cTnI assay and in 10.4% using the hs-cTnI assay. For ruling out MI, contemporary cTnI ≤99th percentile at 0, 3, and 6 h and a normal ECG had a negative predictive value (NPV) of 99.5% (95% CI, 98.6–100) and a sensitivity of 99.1% (95% CI, 97.4–100) for diagnostic and safety outcomes. Serial hs-cTnI measurements ≤99th percentile at 0 and 3 h and a normal ECG had an NPV and sensitivity of 100% (95% CI, 100–100) for diagnostic and safety outcomes. For ruling in MI, contemporary cTnI measurements had specificities of 84.4% (95% CI, 82.5–86.3) at presentation and 78.7% (95% CI, 75.4–82.0) with serial testing at 0, 3, and 6 h, improving to 89.2% (95% CI, 87.1–91.3) by using serial cTnI changes (delta, 0 and 6 h) >150%. hs-cTnI had specificities of 86.9% (95% CI, 85.1–88.6) at presentation and 85.7% (95% CI, 83.5–87.9) with serial testing at 0 and 3 h, improving to 89.3% (95% CI, 87.3–91.2) using a delta hs-cTnI (0 and 3 h) >5 ng/L.
CONCLUSIONS
hs-cTnI and contemporary cTnI assays are excellent in ruling out MI following recommendations predicated on serial testing and the 99th percentile with a normal ECG. For ruling in MI, deltas improve the specificity. ClinicalTrials.gov Identifier: NCT02060760
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Affiliation(s)
- Yader Sandoval
- Division of Cardiology, Hennepin County Medical Center and Minneapolis Heart Institute, Abbott Northwestern Hospital, Minneapolis, MN
| | - Stephen W Smith
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, MN
- Department of Emergency Medicine, University of Minnesota, Minneapolis, MN
| | - Sarah E Thordsen
- Division of Cardiology, Hennepin County Medical Center and Minneapolis Heart Institute, Abbott Northwestern Hospital, Minneapolis, MN
| | - Charles A Bruen
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, MN
- Department of Medicine, Hennepin County Medical Center, Minneapolis, MN
| | - Michelle D Carlson
- Division of Cardiology, Hennepin County Medical Center and Minneapolis Heart Institute, Abbott Northwestern Hospital, Minneapolis, MN
| | - Kenneth W Dodd
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, MN
- Department of Medicine, Hennepin County Medical Center, Minneapolis, MN
| | - Brian E Driver
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, MN
| | - Katherine Jacoby
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, MN
- Department of Medicine, Hennepin County Medical Center, Minneapolis, MN
| | - Benjamin K Johnson
- Division of Cardiology, Hennepin County Medical Center and Minneapolis Heart Institute, Abbott Northwestern Hospital, Minneapolis, MN
| | - Sara A Love
- Department of Laboratory Medicine and Pathology, Hennepin County Medical, Minneapolis, MN
- Department of Laboratory Medicine and Pathology, University of Minnesota, Minneapolis, MN
| | - Johanna C Moore
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, MN
| | - Anne Sexter
- Minneapolis Medical Research Foundation, Minneapolis, MN
| | - Karen Schulz
- Minneapolis Medical Research Foundation, Minneapolis, MN
| | - Nathaniel L Scott
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, MN
- Department of Medicine, Hennepin County Medical Center, Minneapolis, MN
| | - Jennifer Nicholson
- Department of Laboratory Medicine and Pathology, Hennepin County Medical, Minneapolis, MN
| | - Fred S Apple
- Department of Laboratory Medicine and Pathology, Hennepin County Medical, Minneapolis, MN
- Department of Laboratory Medicine and Pathology, University of Minnesota, Minneapolis, MN
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Shiozaki M, Inoue K, Suwa S, Lee CC, Chikata Y, Ishiura J, Kimura Y, Fukuda K, Tamura H, Fujiwara Y, Sumiyoshi M, Daida H. Utility of the 0-hour/1-hour high-sensitivity cardiac troponin T algorithm in Asian patients with suspected non-ST elevation myocardial infarction. Int J Cardiol 2017; 249:32-35. [PMID: 28986063 DOI: 10.1016/j.ijcard.2017.09.009] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2017] [Revised: 08/02/2017] [Accepted: 09/07/2017] [Indexed: 10/18/2022]
Abstract
BACKGROUND A rapid rule-out or rule-in protocol based on the 0-hour/1-hour algorithm using high-sensitivity cardiac troponin T is recommended by the European Society of Cardiology. However, Asian data are not available. METHODS This prospective cohort study included 413 patients with suspected non-ST elevation myocardial infarction in 3 hospitals in Japan and Taiwan from November 2014 to April 2017. Patients were divided into 3groups-rule-out, observe, and rule-in-according to the algorithm. Major adverse cardiovascular events were evaluated at the 30-dayfollow-up. RESULTS The algorithm ruled out acute myocardial infarction (AMI) in 171 patients with a negative predictive value and sensitivity of 100% (95% confidential interval [CI], 96.8%-100%) and 100% (95% CI, 88.0%-100%), respectively, in the rule-out group. None of the patients were diagnosed with AMI. Among the 127 patients classified into the rule-in group, 47 were diagnosed as having AMI. The positive predictive value and specificity were 33.1% (95% CI, 25.1%-41.9%) and 66.3% (95% CI, 60.2%-72.0%), respectively. Elective catheter intervention was required in 13 patients (5 in the rule-out group, 8 in the observe group) by the 30-dayfollow-up. The Framingham Risk Score (FRS) identified moderate risk in 5 patients and high risk in 8, while the Global Registry of Acute Coronary Events (GRACE) 2.0 risk score identified low risk in 6 patients and moderate risk in 7. CONCLUSION The ESC0-hour/1-hour algorithm could be sufficient in Asian patients. The combination with FRS may be more precise than that with the GRACE 2.0 risk score.
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Affiliation(s)
- Masayuki Shiozaki
- Department of Cardiology, Juntendo University Nerima Hospital, Tokyo, Japan
| | - Kenji Inoue
- Department of Cardiology, Juntendo University Nerima Hospital, Tokyo, Japan.
| | - Satoru Suwa
- Department of Cardiology, Juntendo University Shizuoka Hospital, Shizuoka, Japan
| | - Chien-Chang Lee
- Department of Emergency Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Yuichi Chikata
- Department of Cardiology, Juntendo University School of Medicine, Tokyo, Japan
| | - Junko Ishiura
- Department of Cardiology, Juntendo University Nerima Hospital, Tokyo, Japan
| | - Yuki Kimura
- Department of Cardiology, Juntendo University Nerima Hospital, Tokyo, Japan
| | - Kentaro Fukuda
- Department of Cardiology, Juntendo University Nerima Hospital, Tokyo, Japan
| | - Hiroshi Tamura
- Department of Cardiology, Juntendo University Nerima Hospital, Tokyo, Japan
| | - Yasumasa Fujiwara
- Department of Cardiology, Juntendo University Nerima Hospital, Tokyo, Japan
| | - Masataka Sumiyoshi
- Department of Cardiology, Juntendo University Nerima Hospital, Tokyo, Japan
| | - Hiroyuki Daida
- Department of Cardiology, Juntendo University School of Medicine, Tokyo, Japan
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Collinson P. Troponin measurement in patients with suspected acute coronary syndromes: walking beyond the wall. EUROPEAN HEART JOURNAL. QUALITY OF CARE & CLINICAL OUTCOMES 2017; 4:8-9. [DOI: 10.1093/ehjqcco/qcx034] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
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Sandoval Y, Smith SW, Love SA, Sexter A, Schulz K, Apple FS. Single High-Sensitivity Cardiac Troponin I to Rule Out Acute Myocardial Infarction. Am J Med 2017; 130:1076-1083.e1. [PMID: 28344141 DOI: 10.1016/j.amjmed.2017.02.032] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2017] [Revised: 02/10/2017] [Accepted: 02/13/2017] [Indexed: 01/09/2023]
Abstract
BACKGROUND This study examined the performance of single high-sensitivity cardiac troponin I (hs-cTnI) measurement strategies to rule out acute myocardial infarction. METHODS This was a prospective, observational study of consecutive patients presenting to the emergency department (n = 1631) in whom cTnI measurements were obtained using an investigational hs-cTnI assay. The goals of the study were to determine 1) negative predictive value (NPV) and sensitivity for the diagnosis of acute myocardial infarction, type 1 myocardial infarction, and type 2 myocardial infarction; and 2) safety outcome of acute myocardial infarction or cardiac death at 30 days using hs-cTnI less than the limit of detection (LoD) (<1.9 ng/L) or the High-STEACS threshold (<5 ng/L) alone and in combination with normal electrocardiogram (ECG). RESULTS Acute myocardial infarction occurred in 170 patients (10.4%), including 68 (4.2%) type 1 myocardial infarction and 102 (6.3%) type 2 myocardial infarction. For hs-cTnI<LoD (27%), the NPV and sensitivity for acute myocardial infarction were 99.6% (95% confidence interval 98.9%-100%) and 98.8 (97.2%-100%). For hs-cTnI<5 ng/L (50%), the NPV and sensitivity for acute myocardial infarction were 98.9% (98.2%-99.6%) and 94.7% (91.3%-98.1%). In combination with a normal ECG, 1) hs-cTnI<LoD had an NPV of 99.6% (98.9%-100%) and sensitivity of 99.4% (98.3%-100%); and 2) hs-cTnI<5 ng/L had an NPV of 99.5% (98.8%-100%) and sensitivity of 98.8% (97.2%-100%). The NPV and sensitivity for the safety outcome were excellent for hs-cTnI<LoD alone or in combination with a normal ECG, and for hs-cTnI<5 ng/L in combination with a normal ECG. CONCLUSION Strategies using a single hs-cTnI alone or in combination with a normal ECG allow the immediate identification of patients unlikely to have acute myocardial infarction and who are at very low risk for adverse events at 30 days.
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Affiliation(s)
- Yader Sandoval
- Division of Cardiology, Hennepin County Medical Center and Minneapolis Heart Institute, Abbott Northwestern Hospital, Minn
| | - Stephen W Smith
- Department of Emergency Medicine, Hennepin County Medical Center and University of Minnesota, Minneapolis
| | - Sara A Love
- Minneapolis Medical Research Foundation, Minn; Department of Laboratory Medicine and Pathology, Hennepin County Medical Center and University of Minnesota, Minneapolis
| | - Anne Sexter
- Minneapolis Medical Research Foundation, Minn
| | | | - Fred S Apple
- Minneapolis Medical Research Foundation, Minn; Department of Laboratory Medicine and Pathology, Hennepin County Medical Center and University of Minnesota, Minneapolis.
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Abstract
INTRODUCTION Biobehavioral research requires the ability to objectively measure the presence and/or severity of disease, symptoms and their burden, or to determine the effect of treatment on outcomes. Biomarker research has advanced care for patients across the lifespan. There have been significant advancements in biological marker use for nursing research in recent years. The purposes of this article are to define the characteristics of a valid biomarker; review common biological sources of genetic, hormonal, and proteomic biomarkers with attention to practical strengths, weaknesses, and challenges for specimen selection and quality; and discuss potential use of biomarkers in clinical and research settings. METHODS Authors draw on the literature and research experiences to address the issues relevant to incorporating biomarkers into nursing research. RESULTS AND DISCUSSION An overview of the practical aspects of incorporating biomarkers into nursing research, and the resultant actual and potential clinical applications, are discussed.
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