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Kavsak PA, Sharif S, Globe I, Ainsworth C, Ma J, McQueen M, Mehta S, Ko DT, Worster A. The Clinical Validation of a Common Analytical Change Criteria for Cardiac Troponin for Ruling in an Acute Cardiovascular Outcome in Patients Presenting with Ischemic Chest Pain Symptoms. J Cardiovasc Dev Dis 2023; 10:335. [PMID: 37623348 PMCID: PMC10455380 DOI: 10.3390/jcdd10080335] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Revised: 07/20/2023] [Accepted: 08/01/2023] [Indexed: 08/26/2023] Open
Abstract
Serial cardiac troponin (cTn) testing on patients with symptoms suggestive of acute coronary syndrome (ACS) is primarily to identify those patients with evolving myocardial injury. With the improved analytical performance of the high-sensitivity cTn (hs-cTn) assays, different change criteria have been proposed that are mostly assay dependent. Here, we developed and compared a new Common Change Criteria (3C for the combined criteria of >3 ng/L, >30%, or >15% based on the initial cTn concentration of <10 ng/L, 10 to 100 ng/L, or >100 ng/L, respectively) method, versus the 2 h assay-dependent absolute change criteria endorsed by the European Society of Cardiology (ESC), versus the common relative >20% change criterion. These different analytical change criteria were evaluated in 855 emergency department (ED) patients with symptoms of ACS and who had two samples collected 3 h apart. The cTn concentrations were measured with four different assays (Abbott hs-cTnI, Roche hs-cTnT, Ortho cTnI-ES, and Ortho hs-cTnI). The outcomes evaluated were myocardial infarction (MI) and a composite outcome (MI, unstable angina, ventricular arrhythmia, heart failure, or cardiovascular death) within 7 days of ED presentation. The combined change criteria (3C) method yielded higher specificities (range: 93.9 to 97.2%) as compared to the >20% criterion (range: 42.3 to 88.1%) for all four assays for MI. The 3C method only yielded a higher specificity estimate for MI for the cTnI-ES assay (95.9%) versus the absolute change criteria (71.7%). Similar estimates were obtained for the composite outcome. There was also substantial agreement between hs-cTnT and the different cTnI assays for MI with the 3C method, with the percent agreement being ≥95%. The Common Change Criteria (3C) method combining both absolute and different percent changes may be used with cTnI, hs-cTnT, and different hs-cTnI assays to yield similar high-specificity (rule-in) estimates for adverse cardiovascular events for patients presenting to the ED with ACS symptoms.
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Affiliation(s)
- Peter A. Kavsak
- Department of Pathology and Molecular Medicine, McMaster University, Hamilton, ON L8S 4L8, Canada
| | - Sameer Sharif
- Department of Medicine, McMaster University, Hamilton, ON L8S 4L8, Canada
| | - Isabella Globe
- Faculty of Arts and Science, Queen’s University, Kingston, ON K7L 3N6, Canada
| | - Craig Ainsworth
- Department of Medicine, McMaster University, Hamilton, ON L8S 4L8, Canada
| | - Jinhui Ma
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON L8S 4L8, Canada
| | - Matthew McQueen
- Department of Pathology and Molecular Medicine, McMaster University, Hamilton, ON L8S 4L8, Canada
| | - Shamir Mehta
- Department of Medicine, McMaster University, Hamilton, ON L8S 4L8, Canada
| | - Dennis T. Ko
- Sunnybrook Hospital, Toronto, ON M4N 3M5, Canada
| | - Andrew Worster
- Department of Medicine, McMaster University, Hamilton, ON L8S 4L8, Canada
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Liu L, Cai X, Love T, Corsetti M, Mathias AM, Worster A, Ma J, Kavsak PA. Using logistic regression models to investigate the effects of high-sensitivity cardiac troponin T confounders on ruling in acute myocardial infarction. Clin Chem Lab Med 2023; 61:1335-1342. [PMID: 36698327 PMCID: PMC10585657 DOI: 10.1515/cclm-2022-1004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Accepted: 01/16/2023] [Indexed: 01/27/2023]
Abstract
OBJECTIVES Confounding factors, including sex, age, and renal dysfunction, affect high-sensitivity cardiac troponin T (hs-cTnT) concentrations and the acute myocardial infarction (AMI) diagnosis. This study assessed the effects of these confounders through logistic regression models and evaluated the diagnostic performance of an optimized, integrated prediction model. METHODS This retrospective study included a primary derivation cohort of 18,022 emergency department (ED) patients at a US medical center and a validation cohort of 890 ED patients at a Canadian medical center. Hs-cTnT was measured with 0/3 h sampling. The primary outcome was index AMI diagnosis. Logistic regression models were optimized to predict AMI using delta hs-cTnT and its confounders as covariates. The diagnostic performance of model cutoffs was compared to that of the hs-cTnT delta thresholds. Serial logistic regressions were carried out to evaluate the relationship between covariates. RESULTS The area under the curve of the best-fitted model was 0.95. The model achieved a 90.0% diagnostic accuracy in the validation cohort. The optimal model cutoff yielded comparable performance (90.5% accuracy) to the optimal sex-specific delta thresholds (90.3% accuracy), with 95.8% agreement between the two diagnostic methods. Serial logistic regressions revealed that delta hs-cTnT played a more predominant role in AMI prediction than its confounders, among which sex is more predictive of AMI (total effect coefficient 1.04) than age (total effect coefficient 0.05) and eGFR (total effect coefficient -0.008). CONCLUSIONS The integrated prediction model incorporating confounding factors does not outperform hs-cTnT delta thresholds. Sex-specific hs-cTnT delta thresholds remain to provide the highest diagnostic accuracy.
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Affiliation(s)
- Li Liu
- Department of Pathology, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
- Department of Pathology and Laboratory Medicine, University of Rochester Medical Center, Rochester, NY, USA
| | - Xueya Cai
- Department of Biostatistics and Computational Biology, University of Rochester, Rochester, NY, USA
| | - Tanzy Love
- Department of Biostatistics and Computational Biology, University of Rochester, Rochester, NY, USA
| | - Matthew Corsetti
- Department of Biostatistics and Computational Biology, University of Rochester, Rochester, NY, USA
| | - Andrew M Mathias
- Division of Cardiology, Department of Medicine, University of Rochester Medical Center, Rochester, NY, USA
| | - Andrew Worster
- Division of Emergency Medicine, Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Jinhui Ma
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Peter A Kavsak
- Department of Pathology and Molecular Medicine, McMaster University, Hamilton, ON, Canada
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Liu L, Consagra W, Cai X, Mathias A, Worster A, Ma J, Rock P, Kwong T, Kavsak PA. Sex-Specific Absolute Delta Thresholds for High-Sensitivity Cardiac Troponin T. Clin Chem 2021; 68:441-449. [PMID: 34871358 DOI: 10.1093/clinchem/hvab230] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Accepted: 09/27/2021] [Indexed: 11/13/2022]
Abstract
BACKGROUND Sex differences in high-sensitivity cardiac troponin (hs-cTn) concentrations from healthy populations have led to the establishment of sex-specific upper reference limits for hs-cTn assays. This study assessed the performance of sex-specific delta (i.e., changes in concentrations) thresholds for the hs-cTnT assay for ruling in acute myocardial infarction (AMI) in different emergency department (ED) populations. METHODS This retrospective study consisted of 2 cohorts (Cohort 1 derivation and Cohort 2 validation). Cohort 1 consisted of 18 056 ED patients who had serial hs-cTnT measured using a 0-h/3-h algorithm at a US medical center, with Cohort 2 consisting of 1137 ED patients with 0-h/3-h sampling at a Canadian medical center. The primary outcome was AMI diagnosis with sex-specific deltas derived based on the Youden index and specificity estimates (i.e., ≥90%) in Cohort 1 and validated in Cohort 2. RESULTS In Cohort 1, 42% of all patients had 0-h hs-cTnT above the sex-specific 99th percentile. Males had higher 0-h hs-cTnT (median 17 ng/L) and absolute deltas (median 2 ng/L) than females (0-h median 11 ng/L, P < 0.0001; deltas median 1 ng/L, P < 0.0001) in non-AMI patients but not in patients with AMI. For ruling in AMI, the sex-specific delta thresholds based on 90% specificity (14 ng/L for males, 11 ng/L for females) performed best and resulted in 91% diagnostic accuracy in both males and females. The sex-specific delta thresholds yielding high specificity estimates were confirmed in the validation data set. CONCLUSIONS Sex-specific absolute delta thresholds can be used to rule in AMI and are robust across different study populations.
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Affiliation(s)
- Li Liu
- Department of Pathology and Laboratory Medicine, University of Rochester Medical Center, Rochester, NY, USA
| | - William Consagra
- Department of Biostatistics and Computational Biology, University of Rochester, Rochester, NY, USA
| | - Xueya Cai
- Department of Biostatistics and Computational Biology, University of Rochester, Rochester, NY, USA
| | - Andrew Mathias
- Division of Cardiology, Department of Medicine, University of Rochester Medical Center, Rochester, NY, USA
| | - Andrew Worster
- Division of Emergency Medicine, Department of Medicine, McMaster University, Hamilton, ON, Canada.,Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Jinhui Ma
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Philip Rock
- Department of Pathology and Laboratory Medicine, University of Rochester Medical Center, Rochester, NY, USA
| | - Tai Kwong
- Department of Pathology and Laboratory Medicine, University of Rochester Medical Center, Rochester, NY, USA
| | - Peter A Kavsak
- Department of Pathology and Molecular Medicine, McMaster University, Hamilton, ON, Canada
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Diagnostic Performance of Serial High-Sensitivity Cardiac Troponin Measurements in the Emergency Setting. J Cardiovasc Dev Dis 2021; 8:jcdd8080097. [PMID: 34436239 PMCID: PMC8397128 DOI: 10.3390/jcdd8080097] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Revised: 08/05/2021] [Accepted: 08/09/2021] [Indexed: 12/13/2022] Open
Abstract
Serial high-sensitivity cardiac troponin (hsTn) testing in the emergency department (ED) and the intensive cardiac care unit may assist physicians in ruling out or ruling in acute myocardial infarction (MI). There are three major algorithms proposed for high-sensitivity cardiac troponin I (hsTnI) using serial measurements while incorporating absolute concentration changes for MI or death following ED presentation. We sought to determine the diagnostic estimates of these three algorithms and if one was superior in two different Canadian ED patient cohorts with serial hsTnI measurements. An undifferentiated ED population (Cohort-1) and an ED population with symptoms suggestive of acute coronary syndrome (ACS; Cohort-2) were clinically managed with non-hsTn testing with the hsTnI testing performed in real-time with physicians blinded to these results (i.e., hsTnI not reported). The three algorithms evaluated were the European Society of Cardiology (ESC), the High-STEACS pathway, and the COMPASS-MI algorithm. The diagnostic estimates were derived for each algorithm for the 30-day MI/death outcome for the rule-out and rule-in arm in each cohort and compared to proposed diagnostic benchmarks (i.e., sensitivity ≥ 99.0% and specificity ≥ 90.0%) with 95% confidence intervals (CI). In Cohort-1 (n = 2966 patients, 15.3% had outcome) and Cohort-2 (n = 935 patients, 15.6% had outcome), the algorithm that obtained the highest sensitivity (97.8%; 95% CI: 96.0-98.9 and 98.6%; 95% CI: 95.1-99.8, respectively) in both cohorts was COMPASS-MI. Only Cohort-2 with both the ESC and COMPASS-MI algorithms exceeded the specificity benchmark (97.0%; 95% CI: 95.5-98.0 and 96.7%; 95% CI: 95.2-97.8, respectively). Patient selection for serial hsTnI testing will affect specificity estimates, with no algorithm achieving a sensitivity ≥ 99% for 30-day MI or death.
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Kavsak PA, Clark L, Martin J, Mark CT, Paré G, Mondoux S, Chetty VT, Ainsworth C, Worster A. Acute Phase Response and Non-Reproducible Elevated Concentrations with a High-Sensitivity Cardiac Troponin I Assay. J Clin Med 2021; 10:1014. [PMID: 33801415 PMCID: PMC7958626 DOI: 10.3390/jcm10051014] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Revised: 02/20/2021] [Accepted: 02/22/2021] [Indexed: 02/06/2023] Open
Abstract
High-sensitivity cardiac troponin (hs-cTn) testing has enabled physicians to make earlier diagnostic and prognostic decisions in the hospital setting than previous cardiac troponin assays. Analytical improvements have permitted one to measure cardiac troponin precisely in the nanogram per litre (ng/L) range with hs-cTn assays which has resulted in fast 0/1-h and 0/2-h algorithms for ruling-in and ruling-out myocardial infarction. Although analytical interferences that affect the reporting of hs-cTn are uncommon, not all hs-cTn assays are designed the same nor have undergone the same clinical and analytical validations. Here, after investigating an initial case of discrepant hs-cTnI results, we report that patients with an acute phase response (e.g., patients with inflammatory or infectious illnesses) can yield high and non-reproducible results with the Ortho Clinical Diagnostics hs-cTnI assay. Compared to Abbott Diagnostics hs-cTnI, Ortho Clinical Diagnostics hs-cTnI assay misclassifies biochemical injury in approximately 10% of the population being assessed for myocardial injury with imprecise results in approximately half of this population (i.e., 5%). In conclusion, caution is warranted in interpreting Ortho Clinical Diagnostics hs-cTnI alone in patients being evaluated for myocardial injury, especially in patients whose primary presentation is related to an acute phase response and not an acute coronary syndrome symptom.
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Affiliation(s)
- Peter A. Kavsak
- Department of Pathology and Molecular Medicine, McMaster University, Hamilton, ON L8S 4L8, Canada; (J.M.); (G.P.); (V.T.C.)
- Core Laboratory, Juravinski Hospital and Cancer Centre, Hamilton Health Sciences, Hamilton, ON L8V 1C3, Canada; (L.C.); (C.-T.M.)
| | - Lorna Clark
- Core Laboratory, Juravinski Hospital and Cancer Centre, Hamilton Health Sciences, Hamilton, ON L8V 1C3, Canada; (L.C.); (C.-T.M.)
| | - Janet Martin
- Department of Pathology and Molecular Medicine, McMaster University, Hamilton, ON L8S 4L8, Canada; (J.M.); (G.P.); (V.T.C.)
| | - Ching-Tong Mark
- Core Laboratory, Juravinski Hospital and Cancer Centre, Hamilton Health Sciences, Hamilton, ON L8V 1C3, Canada; (L.C.); (C.-T.M.)
| | - Guillaume Paré
- Department of Pathology and Molecular Medicine, McMaster University, Hamilton, ON L8S 4L8, Canada; (J.M.); (G.P.); (V.T.C.)
| | - Shawn Mondoux
- Division of Emergency Medicine, Department of Medicine, McMaster University, Hamilton, ON L8S 4L8, Canada; (S.M.); (A.W.)
| | - V. Tony Chetty
- Department of Pathology and Molecular Medicine, McMaster University, Hamilton, ON L8S 4L8, Canada; (J.M.); (G.P.); (V.T.C.)
| | - Craig Ainsworth
- Division of Cardiology, Department of Medicine, McMaster University, Hamilton, ON L8S 4L8, Canada;
| | - Andrew Worster
- Division of Emergency Medicine, Department of Medicine, McMaster University, Hamilton, ON L8S 4L8, Canada; (S.M.); (A.W.)
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Kavsak PA, Cerasuolo JO, Ko DT, Ma J, Sherbino J, Mondoux SE, Clayton N, Hill SA, McQueen M, Griffith LE, Mehta SR, Perez R, Seow H, Devereaux PJ, Worster A. Using the clinical chemistry score in the emergency department to detect adverse cardiac events: a diagnostic accuracy study. CMAJ Open 2020; 8:E676-E684. [PMID: 33139388 PMCID: PMC7608943 DOI: 10.9778/cmajo.20200047] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND The ability to rule out or in a major adverse cardiac event (MACE) in patients with suspected acute coronary syndrome at emergency department (ED) presentation would be beneficial to patient care and the health care system. The clinical chemistry score (CCS) was evaluated in this context. METHODS This diagnostic accuracy study evaluated 2 different ED cohorts with suspected acute coronary syndrome. For patients in cohort 1, who presented to the ED of 3 hospitals in Hamilton, Ontario, between May and August 2013, retrospective measurements were taken using the Ortho Clinical Diagnostics high-sensitivity cardiac troponin I (hs-cTnI) assay; for patients in cohort 2, who presented to the ED of the same 3 hospitals in Hamilton between November 2012 and February 2013, an ED cardiac presentation blood test panel was performed with the Abbott Diagnostics hs-cTnI assay. The sensitivity and specificity of the CCS (cut-offs of ≥ 1 and 5) and hs-cTnI alone (published cut-offs) were compared for MACE (composite of death, myocardial infarction, unstable angina, revascularization) at 30 days for both cohorts and at 90 days for cohort 2. RESULTS The incidence of MACE at 30 days was higher in cohort 1 (n = 1058) (19.4%, 95% confidence interval [CI] 16.8%-22.2%) than in cohort 2 (n = 5974) (14.6%, 95% CI 13.6%-15.6%). In cohort 1, a CCS of 1 or above yielded a sensitivity of 99.5% (95% CI 97.3%-99.9%). The sensitivity with an Ortho hs-cTnI cut-off of 1 ng/L or above was 91.2% (95% CI 86.5%-95.7%). The specificity of a CCS of 5 (97.8%, 95% CI 96.5%-98.7%) was higher than when the overall 99th-percentile cut-off for the Ortho hs-cTnI assay (> 11 ng/L; 90.1%, 95% CI 87.9%-92.0%) was used. A similar pattern was observed in cohort 2 at 30 days and persisted at 90 days with the Abbott hs-cTnI assay. INTERPRETATION The CCS derived with 2 different hs-cTnI assays and ED populations yielded higher sensitivity and specificity estimates for MACE than hs-cTnI alone. An intervention study is needed to evaluate the impact of the CCS at both the patient and hospital levels. TRIAL REGISTRATION ClinicalTrials.gov, no. NCT01994577.
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Affiliation(s)
- Peter A Kavsak
- Department of Pathology and Molecular Medicine (Kavsak, Hill, McQueen), McMaster University; ICES McMaster (Cerasuolo, Perez, Seow), Faculty of Health Sciences, McMaster University, Hamilton, Ont.; ICES (Ko), Toronto, Ont.; Department of Health Research Methods, Evidence, and Impact (Ma, Griffith); Division of Emergency Medicine (Sherbino, Mondoux, Worster); Department of Medicine (Clayton); Division of Cardiology, and Population Health Research Institute (Mehta, Devereaux), McMaster University, Hamilton, Ont.
| | - Joshua O Cerasuolo
- Department of Pathology and Molecular Medicine (Kavsak, Hill, McQueen), McMaster University; ICES McMaster (Cerasuolo, Perez, Seow), Faculty of Health Sciences, McMaster University, Hamilton, Ont.; ICES (Ko), Toronto, Ont.; Department of Health Research Methods, Evidence, and Impact (Ma, Griffith); Division of Emergency Medicine (Sherbino, Mondoux, Worster); Department of Medicine (Clayton); Division of Cardiology, and Population Health Research Institute (Mehta, Devereaux), McMaster University, Hamilton, Ont
| | - Dennis T Ko
- Department of Pathology and Molecular Medicine (Kavsak, Hill, McQueen), McMaster University; ICES McMaster (Cerasuolo, Perez, Seow), Faculty of Health Sciences, McMaster University, Hamilton, Ont.; ICES (Ko), Toronto, Ont.; Department of Health Research Methods, Evidence, and Impact (Ma, Griffith); Division of Emergency Medicine (Sherbino, Mondoux, Worster); Department of Medicine (Clayton); Division of Cardiology, and Population Health Research Institute (Mehta, Devereaux), McMaster University, Hamilton, Ont
| | - Jinhui Ma
- Department of Pathology and Molecular Medicine (Kavsak, Hill, McQueen), McMaster University; ICES McMaster (Cerasuolo, Perez, Seow), Faculty of Health Sciences, McMaster University, Hamilton, Ont.; ICES (Ko), Toronto, Ont.; Department of Health Research Methods, Evidence, and Impact (Ma, Griffith); Division of Emergency Medicine (Sherbino, Mondoux, Worster); Department of Medicine (Clayton); Division of Cardiology, and Population Health Research Institute (Mehta, Devereaux), McMaster University, Hamilton, Ont
| | - Jonathan Sherbino
- Department of Pathology and Molecular Medicine (Kavsak, Hill, McQueen), McMaster University; ICES McMaster (Cerasuolo, Perez, Seow), Faculty of Health Sciences, McMaster University, Hamilton, Ont.; ICES (Ko), Toronto, Ont.; Department of Health Research Methods, Evidence, and Impact (Ma, Griffith); Division of Emergency Medicine (Sherbino, Mondoux, Worster); Department of Medicine (Clayton); Division of Cardiology, and Population Health Research Institute (Mehta, Devereaux), McMaster University, Hamilton, Ont
| | - Shawn E Mondoux
- Department of Pathology and Molecular Medicine (Kavsak, Hill, McQueen), McMaster University; ICES McMaster (Cerasuolo, Perez, Seow), Faculty of Health Sciences, McMaster University, Hamilton, Ont.; ICES (Ko), Toronto, Ont.; Department of Health Research Methods, Evidence, and Impact (Ma, Griffith); Division of Emergency Medicine (Sherbino, Mondoux, Worster); Department of Medicine (Clayton); Division of Cardiology, and Population Health Research Institute (Mehta, Devereaux), McMaster University, Hamilton, Ont
| | - Natasha Clayton
- Department of Pathology and Molecular Medicine (Kavsak, Hill, McQueen), McMaster University; ICES McMaster (Cerasuolo, Perez, Seow), Faculty of Health Sciences, McMaster University, Hamilton, Ont.; ICES (Ko), Toronto, Ont.; Department of Health Research Methods, Evidence, and Impact (Ma, Griffith); Division of Emergency Medicine (Sherbino, Mondoux, Worster); Department of Medicine (Clayton); Division of Cardiology, and Population Health Research Institute (Mehta, Devereaux), McMaster University, Hamilton, Ont
| | - Stephen A Hill
- Department of Pathology and Molecular Medicine (Kavsak, Hill, McQueen), McMaster University; ICES McMaster (Cerasuolo, Perez, Seow), Faculty of Health Sciences, McMaster University, Hamilton, Ont.; ICES (Ko), Toronto, Ont.; Department of Health Research Methods, Evidence, and Impact (Ma, Griffith); Division of Emergency Medicine (Sherbino, Mondoux, Worster); Department of Medicine (Clayton); Division of Cardiology, and Population Health Research Institute (Mehta, Devereaux), McMaster University, Hamilton, Ont
| | - Matthew McQueen
- Department of Pathology and Molecular Medicine (Kavsak, Hill, McQueen), McMaster University; ICES McMaster (Cerasuolo, Perez, Seow), Faculty of Health Sciences, McMaster University, Hamilton, Ont.; ICES (Ko), Toronto, Ont.; Department of Health Research Methods, Evidence, and Impact (Ma, Griffith); Division of Emergency Medicine (Sherbino, Mondoux, Worster); Department of Medicine (Clayton); Division of Cardiology, and Population Health Research Institute (Mehta, Devereaux), McMaster University, Hamilton, Ont
| | - Lauren E Griffith
- Department of Pathology and Molecular Medicine (Kavsak, Hill, McQueen), McMaster University; ICES McMaster (Cerasuolo, Perez, Seow), Faculty of Health Sciences, McMaster University, Hamilton, Ont.; ICES (Ko), Toronto, Ont.; Department of Health Research Methods, Evidence, and Impact (Ma, Griffith); Division of Emergency Medicine (Sherbino, Mondoux, Worster); Department of Medicine (Clayton); Division of Cardiology, and Population Health Research Institute (Mehta, Devereaux), McMaster University, Hamilton, Ont
| | - Shamir R Mehta
- Department of Pathology and Molecular Medicine (Kavsak, Hill, McQueen), McMaster University; ICES McMaster (Cerasuolo, Perez, Seow), Faculty of Health Sciences, McMaster University, Hamilton, Ont.; ICES (Ko), Toronto, Ont.; Department of Health Research Methods, Evidence, and Impact (Ma, Griffith); Division of Emergency Medicine (Sherbino, Mondoux, Worster); Department of Medicine (Clayton); Division of Cardiology, and Population Health Research Institute (Mehta, Devereaux), McMaster University, Hamilton, Ont
| | - Richard Perez
- Department of Pathology and Molecular Medicine (Kavsak, Hill, McQueen), McMaster University; ICES McMaster (Cerasuolo, Perez, Seow), Faculty of Health Sciences, McMaster University, Hamilton, Ont.; ICES (Ko), Toronto, Ont.; Department of Health Research Methods, Evidence, and Impact (Ma, Griffith); Division of Emergency Medicine (Sherbino, Mondoux, Worster); Department of Medicine (Clayton); Division of Cardiology, and Population Health Research Institute (Mehta, Devereaux), McMaster University, Hamilton, Ont
| | - Hsien Seow
- Department of Pathology and Molecular Medicine (Kavsak, Hill, McQueen), McMaster University; ICES McMaster (Cerasuolo, Perez, Seow), Faculty of Health Sciences, McMaster University, Hamilton, Ont.; ICES (Ko), Toronto, Ont.; Department of Health Research Methods, Evidence, and Impact (Ma, Griffith); Division of Emergency Medicine (Sherbino, Mondoux, Worster); Department of Medicine (Clayton); Division of Cardiology, and Population Health Research Institute (Mehta, Devereaux), McMaster University, Hamilton, Ont
| | - P J Devereaux
- Department of Pathology and Molecular Medicine (Kavsak, Hill, McQueen), McMaster University; ICES McMaster (Cerasuolo, Perez, Seow), Faculty of Health Sciences, McMaster University, Hamilton, Ont.; ICES (Ko), Toronto, Ont.; Department of Health Research Methods, Evidence, and Impact (Ma, Griffith); Division of Emergency Medicine (Sherbino, Mondoux, Worster); Department of Medicine (Clayton); Division of Cardiology, and Population Health Research Institute (Mehta, Devereaux), McMaster University, Hamilton, Ont
| | - Andrew Worster
- Department of Pathology and Molecular Medicine (Kavsak, Hill, McQueen), McMaster University; ICES McMaster (Cerasuolo, Perez, Seow), Faculty of Health Sciences, McMaster University, Hamilton, Ont.; ICES (Ko), Toronto, Ont.; Department of Health Research Methods, Evidence, and Impact (Ma, Griffith); Division of Emergency Medicine (Sherbino, Mondoux, Worster); Department of Medicine (Clayton); Division of Cardiology, and Population Health Research Institute (Mehta, Devereaux), McMaster University, Hamilton, Ont
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Kavsak PA, Mondoux SE, Ma J, Sherbino J, Hill SA, Clayton N, Mehta SR, Griffith LE, McQueen M, Devereaux PJ, Worster A. Comparison of two biomarker only algorithms for early risk stratification in patients with suspected acute coronary syndrome. Int J Cardiol 2020; 319:140-143. [PMID: 32634494 DOI: 10.1016/j.ijcard.2020.06.066] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Revised: 06/12/2020] [Accepted: 06/29/2020] [Indexed: 11/25/2022]
Abstract
BACKGROUND We developed a biomarker algorithm encompassing the clinical chemistry score (CCS; which includes the combination of a random glucose concentration, an estimated glomerular filtration rate and high-sensitivity cardiac troponin; hs-cTn) with the Ortho Clinical Diagnostics hs-cTnI assay (CCS-serial) and compared it to the cutoffs derived from Ortho Clinical Diagnostics 0/1 h (h) algorithm for 7-day myocardial infarction (MI) or cardiovascular (CV)-death. METHODS The study cohort was an emergency department (ED) population (n = 906) with symptoms suggestive of acute coronary syndrome (ACS) who had two Ortho hs-cTnI results approximately 3 h apart. Diagnostic parameters (sensitivity/specificity/negative predictive value; NPV/positive predictive value; PPV) were derived for the CCS-serial and the 0/1 h algorithm for 7-day MI/CV-death. A safety analysis was performed for patients in the rule-out arms of the algorithms for 30-day MI/death. RESULTS The CCS-serial algorithm yielded 100% sensitivity/NPV (32% low-risk) and 95.7% specificity/65% PPV (11% high-risk). The 0/1 h algorithm-cutoffs yielded sensitivity/NPV/specificity/PPV of 97.8%/99.4%/91.3%/50%, which classified 38% of patients as low-risk and 16% of patients as high-risk. Four patients (1.2%) in the 0/1 h algorithm-cutoff rule-out arm had a 30-day MI/death outcome as compared to zero patients in the CCS-serial rule-out arm (p = 0.06). CONCLUSION Both the CCS-serial and 0/1 h algorithm cutoffs yield high NPVs with a similar proportion of patients identified as low-risk. These data may be useful for sites who are unable to collect samples at 0/1 h in the emergency department.
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Affiliation(s)
- Peter A Kavsak
- Department of Pathology and Molecular Medicine, McMaster University, Hamilton, ON, Canada.
| | - Shawn E Mondoux
- Division of Emergency Medicine, McMaster University, Hamilton, ON, Canada
| | - Jinhui Ma
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada McMaster University, Canada
| | - Jonathan Sherbino
- Division of Emergency Medicine, McMaster University, Hamilton, ON, Canada
| | - Stephen A Hill
- Department of Pathology and Molecular Medicine, McMaster University, Hamilton, ON, Canada
| | - Natasha Clayton
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Shamir R Mehta
- Division of Cardiology, Population Health Research Institute, McMaster University, Hamilton, ON, Canada
| | - Lauren E Griffith
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada McMaster University, Canada
| | - Matthew McQueen
- Department of Pathology and Molecular Medicine, McMaster University, Hamilton, ON, Canada
| | - P J Devereaux
- Division of Cardiology, Population Health Research Institute, McMaster University, Hamilton, ON, Canada
| | - Andrew Worster
- Division of Emergency Medicine, McMaster University, Hamilton, ON, Canada
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Lee CC, Huang SS, Yeo YH, Hou YT, Park JY, Inoue K, Hsu WT. High-sensitivity-cardiac troponin for accelerated diagnosis of acute myocardial infarction: A systematic review and meta-analysis. Am J Emerg Med 2019; 38:1402-1407. [PMID: 31932131 DOI: 10.1016/j.ajem.2019.11.035] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2019] [Revised: 10/28/2019] [Accepted: 11/19/2019] [Indexed: 02/01/2023] Open
Abstract
OBJECTIVES Cardiovascular disease is the leading cause of mortality and morbidity. Serial troponin tests have been endorsed as essential diagnostic steps to rule out/-in acute myocardial infarction (AMI), and hs-cTn assays have shown promise in enhancing the accuracy and efficiency of AMI diagnosis in the emergency department (ED). METHODS A systematic review and meta-analysis of diagnostic test accuracy studies were conducted to compare the diagnostic performance of various accelerated diagnostic algorithms of hs-cTn assays for patients with symptoms of AMI. Random-effects bivariate meta-analysis was conducted to estimate the summary sensitivity, specificity, likelihood ratios, and area under receiver operating characteristic curve. RESULTS In the systematic review consisting of 56 studies and 67,945 patients, both hs-cTnT and hs-cTnI-based 0-, 1-, 2- and 0-1 h algorithms showed a pooled sensitivity >90%. The hs-cTnI-based algorithm showed a pooled specificity >80%. The hs-cTnT-based algorithms had a specificity of 68% for the 0-h algorithm and of around 80% for the 1-, 2-, and 0-1 h algorithms. The heterogeneities of all diagnostic algorithms were mild (I2 < 50%). CONCLUSION Both hs-cTnI- and hs-cTnT-based accelerated diagnostic algorithms have high sensitivities but moderate specificities for early diagnosis of AMI. Overall, hs-cTnI-based algorithms have slightly higher specificities in early diagnosis of AMI. For patients presenting ED with typical symptoms, the use of hs-cTnT or hs-cTnI assays at the 99th percentile may help identify patients with low risk for AMI and promote early discharge from the ED.
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Affiliation(s)
- Chien-Chang Lee
- Department of Emergency Medicine, National Taiwan University Hospital, Taipei, Taiwan; Health Data Science Research Group, National Taiwan University Hospital, Taipei, Taiwan.
| | - Sih-Shiang Huang
- Department of Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan; Health Data Science Research Group, National Taiwan University Hospital, Taipei, Taiwan
| | - Yee Hui Yeo
- Division of General Internal Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Yi-Ting Hou
- Department of Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan; Health Data Science Research Group, National Taiwan University Hospital, Taipei, Taiwan
| | - James Yeongjun Park
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Kenji Inoue
- Department of Cardiology, Juntendo University Nerima Hospital, Tokyo, Japan
| | - Wan-Ting Hsu
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA; Health Data Science Research Group, National Taiwan University Hospital, Taipei, Taiwan
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Kavsak PA, Neumann JT, Cullen L, Than M, Shortt C, Greenslade JH, Pickering JW, Ojeda F, Ma J, Clayton N, Sherbino J, Hill SA, McQueen M, Westermann D, Sörensen NA, Parsonage WA, Griffith L, Mehta SR, Devereaux PJ, Richards M, Troughton R, Pemberton C, Aldous S, Blankenberg S, Worster A. Clinical chemistry score versus high-sensitivity cardiac troponin I and T tests alone to identify patients at low or high risk for myocardial infarction or death at presentation to the emergency department. CMAJ 2019; 190:E974-E984. [PMID: 30127037 DOI: 10.1503/cmaj.180144] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/09/2018] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND Testing for high-sensitivity cardiac troponin (hs-cTn) may assist triage and clinical decision-making in patients presenting to the emergency department with symptoms of acute coronary syndrome; however, this could result in the misclassification of risk because of analytical variation or laboratory error. We sought to evaluate a new laboratory-based risk-stratification tool that incorporates tests for hs-cTn, glucose level and estimated glomerular filtration rate to identify patients at risk of myocardial infarction or death when presenting to the emergency department. METHODS We constructed the clinical chemistry score (CCS) (range 0-5 points) and validated it as a predictor of 30-day myocardial infarction (MI) or death using data from 4 cohort studies involving patients who presented to the emergency department with symptoms suggestive of acute coronary syndrome. We calculated diagnostic parameters for the CCS score separately using high-sensitivity cardiac troponin I (hs-cTnI) and high-sensitivity cardiac troponin T (hs-cTnT). RESULTS For the combined cohorts (n = 4245), 17.1% of participants had an MI or died within 30 days. A CCS score of 0 points best identified low-risk participants: the hs-cTnI CCS had a sensitivity of 100% (95% confidence interval [CI] 99.5%-100%), with 8.9% (95% CI 8.1%-9.8%) of the population classified as being at low risk of MI or death within 30 days; the hs-cTnT CCS had a sensitivity of 99.9% (95% CI 99.2%-100%), with 10.5% (95% CI 9.6%-11.4%) of the population classified as being at low risk. The CCS had better sensitivity than hs-cTn alone (hs-cTnI < 5 ng/L: 96.6%, 95% CI 95.0%-97.8%; hs-cTnT < 6 ng/L: 98.2%, 95% CI 97.0%-99.0%). A CCS score of 5 points best identified patients at high risk (hs-cTnI CCS: specificity 96.6%, 95% CI 96.0%-97.2%; 11.2% [95% CI 10.3%-12.2%] of the population classified as being at high risk; hs-cTnT CCS: specificity 94.0%, 95% CI 93.1%-94.7%; 13.1% [95% CI 12.1%-14.1%] of the population classified as being at high risk) compared with using the overall 99th percentiles for the hs-cTn assays (specificity of hs-cTnI 93.2%, 95% CI 92.3-94.0; specificity of hs-cTnT 73.8%, 95% CI 72.3-75.2). INTERPRETATION The CCS score at the chosen cut-offs was more sensitive and specific than hs-cTn alone for risk stratification of patients presenting to the emergency department with suspected acute coronary syndrome. Study registration: ClinicalTrials.gov, nos. NCT01994577; NCT02355457.
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Affiliation(s)
- Peter A Kavsak
- Departments of Pathology and Molecular Medicine (Kavsak, Hill, McQueen), Health Research Methods, Evidence and Impact (Ma, Griffith); and Medicine (Clayton); Division of Emergency Medicine (Shortt, Sherbino, Worster); Division of Cardiology (Mehta, Devereaux); Population Health Research Institute (Devereaux), McMaster University, Hamilton, Ont.; Department of General and Interventional Cardiology (Neumann, Ojeda, Westermann, Sörensen, Blankenberg), University Heart Center Hamburg Eppendorf, Hamburg, Germany; Royal Brisbane and Women's Hospital (Cullen, Greenslade, Parsonage), Brisbane, Australia; Christchurch Hospital (Than, Pickering, Troughton, Aldous), Christchurch, New Zealand; Department of Medicine and Christchurch Heart Institute, University of Otago (Richards, Pickering, Troughton, Pemberton), Christchurch, New Zealand; Cardiovascular Research Institute (Richards), National University of Singapore
| | - Johannes T Neumann
- Departments of Pathology and Molecular Medicine (Kavsak, Hill, McQueen), Health Research Methods, Evidence and Impact (Ma, Griffith); and Medicine (Clayton); Division of Emergency Medicine (Shortt, Sherbino, Worster); Division of Cardiology (Mehta, Devereaux); Population Health Research Institute (Devereaux), McMaster University, Hamilton, Ont.; Department of General and Interventional Cardiology (Neumann, Ojeda, Westermann, Sörensen, Blankenberg), University Heart Center Hamburg Eppendorf, Hamburg, Germany; Royal Brisbane and Women's Hospital (Cullen, Greenslade, Parsonage), Brisbane, Australia; Christchurch Hospital (Than, Pickering, Troughton, Aldous), Christchurch, New Zealand; Department of Medicine and Christchurch Heart Institute, University of Otago (Richards, Pickering, Troughton, Pemberton), Christchurch, New Zealand; Cardiovascular Research Institute (Richards), National University of Singapore
| | - Louise Cullen
- Departments of Pathology and Molecular Medicine (Kavsak, Hill, McQueen), Health Research Methods, Evidence and Impact (Ma, Griffith); and Medicine (Clayton); Division of Emergency Medicine (Shortt, Sherbino, Worster); Division of Cardiology (Mehta, Devereaux); Population Health Research Institute (Devereaux), McMaster University, Hamilton, Ont.; Department of General and Interventional Cardiology (Neumann, Ojeda, Westermann, Sörensen, Blankenberg), University Heart Center Hamburg Eppendorf, Hamburg, Germany; Royal Brisbane and Women's Hospital (Cullen, Greenslade, Parsonage), Brisbane, Australia; Christchurch Hospital (Than, Pickering, Troughton, Aldous), Christchurch, New Zealand; Department of Medicine and Christchurch Heart Institute, University of Otago (Richards, Pickering, Troughton, Pemberton), Christchurch, New Zealand; Cardiovascular Research Institute (Richards), National University of Singapore
| | - Martin Than
- Departments of Pathology and Molecular Medicine (Kavsak, Hill, McQueen), Health Research Methods, Evidence and Impact (Ma, Griffith); and Medicine (Clayton); Division of Emergency Medicine (Shortt, Sherbino, Worster); Division of Cardiology (Mehta, Devereaux); Population Health Research Institute (Devereaux), McMaster University, Hamilton, Ont.; Department of General and Interventional Cardiology (Neumann, Ojeda, Westermann, Sörensen, Blankenberg), University Heart Center Hamburg Eppendorf, Hamburg, Germany; Royal Brisbane and Women's Hospital (Cullen, Greenslade, Parsonage), Brisbane, Australia; Christchurch Hospital (Than, Pickering, Troughton, Aldous), Christchurch, New Zealand; Department of Medicine and Christchurch Heart Institute, University of Otago (Richards, Pickering, Troughton, Pemberton), Christchurch, New Zealand; Cardiovascular Research Institute (Richards), National University of Singapore
| | - Colleen Shortt
- Departments of Pathology and Molecular Medicine (Kavsak, Hill, McQueen), Health Research Methods, Evidence and Impact (Ma, Griffith); and Medicine (Clayton); Division of Emergency Medicine (Shortt, Sherbino, Worster); Division of Cardiology (Mehta, Devereaux); Population Health Research Institute (Devereaux), McMaster University, Hamilton, Ont.; Department of General and Interventional Cardiology (Neumann, Ojeda, Westermann, Sörensen, Blankenberg), University Heart Center Hamburg Eppendorf, Hamburg, Germany; Royal Brisbane and Women's Hospital (Cullen, Greenslade, Parsonage), Brisbane, Australia; Christchurch Hospital (Than, Pickering, Troughton, Aldous), Christchurch, New Zealand; Department of Medicine and Christchurch Heart Institute, University of Otago (Richards, Pickering, Troughton, Pemberton), Christchurch, New Zealand; Cardiovascular Research Institute (Richards), National University of Singapore
| | - Jaimi H Greenslade
- Departments of Pathology and Molecular Medicine (Kavsak, Hill, McQueen), Health Research Methods, Evidence and Impact (Ma, Griffith); and Medicine (Clayton); Division of Emergency Medicine (Shortt, Sherbino, Worster); Division of Cardiology (Mehta, Devereaux); Population Health Research Institute (Devereaux), McMaster University, Hamilton, Ont.; Department of General and Interventional Cardiology (Neumann, Ojeda, Westermann, Sörensen, Blankenberg), University Heart Center Hamburg Eppendorf, Hamburg, Germany; Royal Brisbane and Women's Hospital (Cullen, Greenslade, Parsonage), Brisbane, Australia; Christchurch Hospital (Than, Pickering, Troughton, Aldous), Christchurch, New Zealand; Department of Medicine and Christchurch Heart Institute, University of Otago (Richards, Pickering, Troughton, Pemberton), Christchurch, New Zealand; Cardiovascular Research Institute (Richards), National University of Singapore
| | - John W Pickering
- Departments of Pathology and Molecular Medicine (Kavsak, Hill, McQueen), Health Research Methods, Evidence and Impact (Ma, Griffith); and Medicine (Clayton); Division of Emergency Medicine (Shortt, Sherbino, Worster); Division of Cardiology (Mehta, Devereaux); Population Health Research Institute (Devereaux), McMaster University, Hamilton, Ont.; Department of General and Interventional Cardiology (Neumann, Ojeda, Westermann, Sörensen, Blankenberg), University Heart Center Hamburg Eppendorf, Hamburg, Germany; Royal Brisbane and Women's Hospital (Cullen, Greenslade, Parsonage), Brisbane, Australia; Christchurch Hospital (Than, Pickering, Troughton, Aldous), Christchurch, New Zealand; Department of Medicine and Christchurch Heart Institute, University of Otago (Richards, Pickering, Troughton, Pemberton), Christchurch, New Zealand; Cardiovascular Research Institute (Richards), National University of Singapore
| | - Francisco Ojeda
- Departments of Pathology and Molecular Medicine (Kavsak, Hill, McQueen), Health Research Methods, Evidence and Impact (Ma, Griffith); and Medicine (Clayton); Division of Emergency Medicine (Shortt, Sherbino, Worster); Division of Cardiology (Mehta, Devereaux); Population Health Research Institute (Devereaux), McMaster University, Hamilton, Ont.; Department of General and Interventional Cardiology (Neumann, Ojeda, Westermann, Sörensen, Blankenberg), University Heart Center Hamburg Eppendorf, Hamburg, Germany; Royal Brisbane and Women's Hospital (Cullen, Greenslade, Parsonage), Brisbane, Australia; Christchurch Hospital (Than, Pickering, Troughton, Aldous), Christchurch, New Zealand; Department of Medicine and Christchurch Heart Institute, University of Otago (Richards, Pickering, Troughton, Pemberton), Christchurch, New Zealand; Cardiovascular Research Institute (Richards), National University of Singapore
| | - Jinhui Ma
- Departments of Pathology and Molecular Medicine (Kavsak, Hill, McQueen), Health Research Methods, Evidence and Impact (Ma, Griffith); and Medicine (Clayton); Division of Emergency Medicine (Shortt, Sherbino, Worster); Division of Cardiology (Mehta, Devereaux); Population Health Research Institute (Devereaux), McMaster University, Hamilton, Ont.; Department of General and Interventional Cardiology (Neumann, Ojeda, Westermann, Sörensen, Blankenberg), University Heart Center Hamburg Eppendorf, Hamburg, Germany; Royal Brisbane and Women's Hospital (Cullen, Greenslade, Parsonage), Brisbane, Australia; Christchurch Hospital (Than, Pickering, Troughton, Aldous), Christchurch, New Zealand; Department of Medicine and Christchurch Heart Institute, University of Otago (Richards, Pickering, Troughton, Pemberton), Christchurch, New Zealand; Cardiovascular Research Institute (Richards), National University of Singapore
| | - Natasha Clayton
- Departments of Pathology and Molecular Medicine (Kavsak, Hill, McQueen), Health Research Methods, Evidence and Impact (Ma, Griffith); and Medicine (Clayton); Division of Emergency Medicine (Shortt, Sherbino, Worster); Division of Cardiology (Mehta, Devereaux); Population Health Research Institute (Devereaux), McMaster University, Hamilton, Ont.; Department of General and Interventional Cardiology (Neumann, Ojeda, Westermann, Sörensen, Blankenberg), University Heart Center Hamburg Eppendorf, Hamburg, Germany; Royal Brisbane and Women's Hospital (Cullen, Greenslade, Parsonage), Brisbane, Australia; Christchurch Hospital (Than, Pickering, Troughton, Aldous), Christchurch, New Zealand; Department of Medicine and Christchurch Heart Institute, University of Otago (Richards, Pickering, Troughton, Pemberton), Christchurch, New Zealand; Cardiovascular Research Institute (Richards), National University of Singapore
| | - Jonathan Sherbino
- Departments of Pathology and Molecular Medicine (Kavsak, Hill, McQueen), Health Research Methods, Evidence and Impact (Ma, Griffith); and Medicine (Clayton); Division of Emergency Medicine (Shortt, Sherbino, Worster); Division of Cardiology (Mehta, Devereaux); Population Health Research Institute (Devereaux), McMaster University, Hamilton, Ont.; Department of General and Interventional Cardiology (Neumann, Ojeda, Westermann, Sörensen, Blankenberg), University Heart Center Hamburg Eppendorf, Hamburg, Germany; Royal Brisbane and Women's Hospital (Cullen, Greenslade, Parsonage), Brisbane, Australia; Christchurch Hospital (Than, Pickering, Troughton, Aldous), Christchurch, New Zealand; Department of Medicine and Christchurch Heart Institute, University of Otago (Richards, Pickering, Troughton, Pemberton), Christchurch, New Zealand; Cardiovascular Research Institute (Richards), National University of Singapore
| | - Stephen A Hill
- Departments of Pathology and Molecular Medicine (Kavsak, Hill, McQueen), Health Research Methods, Evidence and Impact (Ma, Griffith); and Medicine (Clayton); Division of Emergency Medicine (Shortt, Sherbino, Worster); Division of Cardiology (Mehta, Devereaux); Population Health Research Institute (Devereaux), McMaster University, Hamilton, Ont.; Department of General and Interventional Cardiology (Neumann, Ojeda, Westermann, Sörensen, Blankenberg), University Heart Center Hamburg Eppendorf, Hamburg, Germany; Royal Brisbane and Women's Hospital (Cullen, Greenslade, Parsonage), Brisbane, Australia; Christchurch Hospital (Than, Pickering, Troughton, Aldous), Christchurch, New Zealand; Department of Medicine and Christchurch Heart Institute, University of Otago (Richards, Pickering, Troughton, Pemberton), Christchurch, New Zealand; Cardiovascular Research Institute (Richards), National University of Singapore
| | - Matthew McQueen
- Departments of Pathology and Molecular Medicine (Kavsak, Hill, McQueen), Health Research Methods, Evidence and Impact (Ma, Griffith); and Medicine (Clayton); Division of Emergency Medicine (Shortt, Sherbino, Worster); Division of Cardiology (Mehta, Devereaux); Population Health Research Institute (Devereaux), McMaster University, Hamilton, Ont.; Department of General and Interventional Cardiology (Neumann, Ojeda, Westermann, Sörensen, Blankenberg), University Heart Center Hamburg Eppendorf, Hamburg, Germany; Royal Brisbane and Women's Hospital (Cullen, Greenslade, Parsonage), Brisbane, Australia; Christchurch Hospital (Than, Pickering, Troughton, Aldous), Christchurch, New Zealand; Department of Medicine and Christchurch Heart Institute, University of Otago (Richards, Pickering, Troughton, Pemberton), Christchurch, New Zealand; Cardiovascular Research Institute (Richards), National University of Singapore
| | - Dirk Westermann
- Departments of Pathology and Molecular Medicine (Kavsak, Hill, McQueen), Health Research Methods, Evidence and Impact (Ma, Griffith); and Medicine (Clayton); Division of Emergency Medicine (Shortt, Sherbino, Worster); Division of Cardiology (Mehta, Devereaux); Population Health Research Institute (Devereaux), McMaster University, Hamilton, Ont.; Department of General and Interventional Cardiology (Neumann, Ojeda, Westermann, Sörensen, Blankenberg), University Heart Center Hamburg Eppendorf, Hamburg, Germany; Royal Brisbane and Women's Hospital (Cullen, Greenslade, Parsonage), Brisbane, Australia; Christchurch Hospital (Than, Pickering, Troughton, Aldous), Christchurch, New Zealand; Department of Medicine and Christchurch Heart Institute, University of Otago (Richards, Pickering, Troughton, Pemberton), Christchurch, New Zealand; Cardiovascular Research Institute (Richards), National University of Singapore
| | - Nils A Sörensen
- Departments of Pathology and Molecular Medicine (Kavsak, Hill, McQueen), Health Research Methods, Evidence and Impact (Ma, Griffith); and Medicine (Clayton); Division of Emergency Medicine (Shortt, Sherbino, Worster); Division of Cardiology (Mehta, Devereaux); Population Health Research Institute (Devereaux), McMaster University, Hamilton, Ont.; Department of General and Interventional Cardiology (Neumann, Ojeda, Westermann, Sörensen, Blankenberg), University Heart Center Hamburg Eppendorf, Hamburg, Germany; Royal Brisbane and Women's Hospital (Cullen, Greenslade, Parsonage), Brisbane, Australia; Christchurch Hospital (Than, Pickering, Troughton, Aldous), Christchurch, New Zealand; Department of Medicine and Christchurch Heart Institute, University of Otago (Richards, Pickering, Troughton, Pemberton), Christchurch, New Zealand; Cardiovascular Research Institute (Richards), National University of Singapore
| | - William A Parsonage
- Departments of Pathology and Molecular Medicine (Kavsak, Hill, McQueen), Health Research Methods, Evidence and Impact (Ma, Griffith); and Medicine (Clayton); Division of Emergency Medicine (Shortt, Sherbino, Worster); Division of Cardiology (Mehta, Devereaux); Population Health Research Institute (Devereaux), McMaster University, Hamilton, Ont.; Department of General and Interventional Cardiology (Neumann, Ojeda, Westermann, Sörensen, Blankenberg), University Heart Center Hamburg Eppendorf, Hamburg, Germany; Royal Brisbane and Women's Hospital (Cullen, Greenslade, Parsonage), Brisbane, Australia; Christchurch Hospital (Than, Pickering, Troughton, Aldous), Christchurch, New Zealand; Department of Medicine and Christchurch Heart Institute, University of Otago (Richards, Pickering, Troughton, Pemberton), Christchurch, New Zealand; Cardiovascular Research Institute (Richards), National University of Singapore
| | - Lauren Griffith
- Departments of Pathology and Molecular Medicine (Kavsak, Hill, McQueen), Health Research Methods, Evidence and Impact (Ma, Griffith); and Medicine (Clayton); Division of Emergency Medicine (Shortt, Sherbino, Worster); Division of Cardiology (Mehta, Devereaux); Population Health Research Institute (Devereaux), McMaster University, Hamilton, Ont.; Department of General and Interventional Cardiology (Neumann, Ojeda, Westermann, Sörensen, Blankenberg), University Heart Center Hamburg Eppendorf, Hamburg, Germany; Royal Brisbane and Women's Hospital (Cullen, Greenslade, Parsonage), Brisbane, Australia; Christchurch Hospital (Than, Pickering, Troughton, Aldous), Christchurch, New Zealand; Department of Medicine and Christchurch Heart Institute, University of Otago (Richards, Pickering, Troughton, Pemberton), Christchurch, New Zealand; Cardiovascular Research Institute (Richards), National University of Singapore
| | - Shamir R Mehta
- Departments of Pathology and Molecular Medicine (Kavsak, Hill, McQueen), Health Research Methods, Evidence and Impact (Ma, Griffith); and Medicine (Clayton); Division of Emergency Medicine (Shortt, Sherbino, Worster); Division of Cardiology (Mehta, Devereaux); Population Health Research Institute (Devereaux), McMaster University, Hamilton, Ont.; Department of General and Interventional Cardiology (Neumann, Ojeda, Westermann, Sörensen, Blankenberg), University Heart Center Hamburg Eppendorf, Hamburg, Germany; Royal Brisbane and Women's Hospital (Cullen, Greenslade, Parsonage), Brisbane, Australia; Christchurch Hospital (Than, Pickering, Troughton, Aldous), Christchurch, New Zealand; Department of Medicine and Christchurch Heart Institute, University of Otago (Richards, Pickering, Troughton, Pemberton), Christchurch, New Zealand; Cardiovascular Research Institute (Richards), National University of Singapore
| | - P J Devereaux
- Departments of Pathology and Molecular Medicine (Kavsak, Hill, McQueen), Health Research Methods, Evidence and Impact (Ma, Griffith); and Medicine (Clayton); Division of Emergency Medicine (Shortt, Sherbino, Worster); Division of Cardiology (Mehta, Devereaux); Population Health Research Institute (Devereaux), McMaster University, Hamilton, Ont.; Department of General and Interventional Cardiology (Neumann, Ojeda, Westermann, Sörensen, Blankenberg), University Heart Center Hamburg Eppendorf, Hamburg, Germany; Royal Brisbane and Women's Hospital (Cullen, Greenslade, Parsonage), Brisbane, Australia; Christchurch Hospital (Than, Pickering, Troughton, Aldous), Christchurch, New Zealand; Department of Medicine and Christchurch Heart Institute, University of Otago (Richards, Pickering, Troughton, Pemberton), Christchurch, New Zealand; Cardiovascular Research Institute (Richards), National University of Singapore
| | - Mark Richards
- Departments of Pathology and Molecular Medicine (Kavsak, Hill, McQueen), Health Research Methods, Evidence and Impact (Ma, Griffith); and Medicine (Clayton); Division of Emergency Medicine (Shortt, Sherbino, Worster); Division of Cardiology (Mehta, Devereaux); Population Health Research Institute (Devereaux), McMaster University, Hamilton, Ont.; Department of General and Interventional Cardiology (Neumann, Ojeda, Westermann, Sörensen, Blankenberg), University Heart Center Hamburg Eppendorf, Hamburg, Germany; Royal Brisbane and Women's Hospital (Cullen, Greenslade, Parsonage), Brisbane, Australia; Christchurch Hospital (Than, Pickering, Troughton, Aldous), Christchurch, New Zealand; Department of Medicine and Christchurch Heart Institute, University of Otago (Richards, Pickering, Troughton, Pemberton), Christchurch, New Zealand; Cardiovascular Research Institute (Richards), National University of Singapore
| | - Richard Troughton
- Departments of Pathology and Molecular Medicine (Kavsak, Hill, McQueen), Health Research Methods, Evidence and Impact (Ma, Griffith); and Medicine (Clayton); Division of Emergency Medicine (Shortt, Sherbino, Worster); Division of Cardiology (Mehta, Devereaux); Population Health Research Institute (Devereaux), McMaster University, Hamilton, Ont.; Department of General and Interventional Cardiology (Neumann, Ojeda, Westermann, Sörensen, Blankenberg), University Heart Center Hamburg Eppendorf, Hamburg, Germany; Royal Brisbane and Women's Hospital (Cullen, Greenslade, Parsonage), Brisbane, Australia; Christchurch Hospital (Than, Pickering, Troughton, Aldous), Christchurch, New Zealand; Department of Medicine and Christchurch Heart Institute, University of Otago (Richards, Pickering, Troughton, Pemberton), Christchurch, New Zealand; Cardiovascular Research Institute (Richards), National University of Singapore
| | - Chris Pemberton
- Departments of Pathology and Molecular Medicine (Kavsak, Hill, McQueen), Health Research Methods, Evidence and Impact (Ma, Griffith); and Medicine (Clayton); Division of Emergency Medicine (Shortt, Sherbino, Worster); Division of Cardiology (Mehta, Devereaux); Population Health Research Institute (Devereaux), McMaster University, Hamilton, Ont.; Department of General and Interventional Cardiology (Neumann, Ojeda, Westermann, Sörensen, Blankenberg), University Heart Center Hamburg Eppendorf, Hamburg, Germany; Royal Brisbane and Women's Hospital (Cullen, Greenslade, Parsonage), Brisbane, Australia; Christchurch Hospital (Than, Pickering, Troughton, Aldous), Christchurch, New Zealand; Department of Medicine and Christchurch Heart Institute, University of Otago (Richards, Pickering, Troughton, Pemberton), Christchurch, New Zealand; Cardiovascular Research Institute (Richards), National University of Singapore
| | - Sally Aldous
- Departments of Pathology and Molecular Medicine (Kavsak, Hill, McQueen), Health Research Methods, Evidence and Impact (Ma, Griffith); and Medicine (Clayton); Division of Emergency Medicine (Shortt, Sherbino, Worster); Division of Cardiology (Mehta, Devereaux); Population Health Research Institute (Devereaux), McMaster University, Hamilton, Ont.; Department of General and Interventional Cardiology (Neumann, Ojeda, Westermann, Sörensen, Blankenberg), University Heart Center Hamburg Eppendorf, Hamburg, Germany; Royal Brisbane and Women's Hospital (Cullen, Greenslade, Parsonage), Brisbane, Australia; Christchurch Hospital (Than, Pickering, Troughton, Aldous), Christchurch, New Zealand; Department of Medicine and Christchurch Heart Institute, University of Otago (Richards, Pickering, Troughton, Pemberton), Christchurch, New Zealand; Cardiovascular Research Institute (Richards), National University of Singapore
| | - Stefan Blankenberg
- Departments of Pathology and Molecular Medicine (Kavsak, Hill, McQueen), Health Research Methods, Evidence and Impact (Ma, Griffith); and Medicine (Clayton); Division of Emergency Medicine (Shortt, Sherbino, Worster); Division of Cardiology (Mehta, Devereaux); Population Health Research Institute (Devereaux), McMaster University, Hamilton, Ont.; Department of General and Interventional Cardiology (Neumann, Ojeda, Westermann, Sörensen, Blankenberg), University Heart Center Hamburg Eppendorf, Hamburg, Germany; Royal Brisbane and Women's Hospital (Cullen, Greenslade, Parsonage), Brisbane, Australia; Christchurch Hospital (Than, Pickering, Troughton, Aldous), Christchurch, New Zealand; Department of Medicine and Christchurch Heart Institute, University of Otago (Richards, Pickering, Troughton, Pemberton), Christchurch, New Zealand; Cardiovascular Research Institute (Richards), National University of Singapore
| | - Andrew Worster
- Departments of Pathology and Molecular Medicine (Kavsak, Hill, McQueen), Health Research Methods, Evidence and Impact (Ma, Griffith); and Medicine (Clayton); Division of Emergency Medicine (Shortt, Sherbino, Worster); Division of Cardiology (Mehta, Devereaux); Population Health Research Institute (Devereaux), McMaster University, Hamilton, Ont.; Department of General and Interventional Cardiology (Neumann, Ojeda, Westermann, Sörensen, Blankenberg), University Heart Center Hamburg Eppendorf, Hamburg, Germany; Royal Brisbane and Women's Hospital (Cullen, Greenslade, Parsonage), Brisbane, Australia; Christchurch Hospital (Than, Pickering, Troughton, Aldous), Christchurch, New Zealand; Department of Medicine and Christchurch Heart Institute, University of Otago (Richards, Pickering, Troughton, Pemberton), Christchurch, New Zealand; Cardiovascular Research Institute (Richards), National University of Singapore
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Is It Time to Recalibrate Cardiac Prediction Tools to Accommodate Chronic Kidney Disease? Can J Cardiol 2019; 35:1082-1084. [PMID: 31472806 DOI: 10.1016/j.cjca.2019.06.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2019] [Accepted: 06/30/2019] [Indexed: 10/26/2022] Open
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Kavsak PA, Petryayeva E, Clark L. Analytical Variation and Abbott Diagnostics High-Sensitivity Cardiac Troponin I Risk Categories in Asymptomatic Individuals. Can J Cardiol 2019; 35:1605.e7-1605.e8. [PMID: 31590986 DOI: 10.1016/j.cjca.2019.08.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2019] [Revised: 08/12/2019] [Accepted: 08/13/2019] [Indexed: 01/26/2023] Open
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Belley-Cote EP, Whitlock RP, Ulic DV, Honarmand K, Khalifa A, McClure GR, Gibson A, Alshamsi F, D'Aragon F, Rochwerg B, Duan E, Savija N, Karachi T, Lamontagne F, Kavsak P, Cook DJ. The PROTROPIC feasibility study: prognostic value of elevated troponins in critical illness. Can J Anaesth 2019; 66:648-657. [PMID: 31037586 DOI: 10.1007/s12630-019-01375-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2018] [Revised: 11/22/2018] [Accepted: 11/26/2018] [Indexed: 10/26/2022] Open
Abstract
PURPOSE Elevated cardiac troponin concentrations in people with critical illness are associated with an increased risk of death. We aimed to assess the feasibility of a larger study to ascertain the utility of cardiac troponin as a prognostic tool for mortality in critically ill patients. METHODS Patients admitted to participating intensive care units during the one-month enrolment period were eligible. We excluded cardiac surgical patients and patients who were admitted and either died or were discharged within 12 hr. In enrolled patients, we measured high-sensitivity cardiac troponin I (hs-cTnI) and obtained electrocardiograms to ascertain the incidence of myocardial infarction (MI) and isolated troponin elevation. Our feasibility objectives were to measure recruitment rate, the proportion of patients who consented under a deferred consent model, and time required for data collection and study procedures. RESULTS Over a four-week enrolment period, 280 patients were enrolled using a deferred consent model. We obtained subsequent consent from 81% of patients. Study procedures and data collection required 1.7 hr per participant. Overall, 86 (38%) suffered a MI, 23 (10%) had an isolated hs-cTnI elevation, and 117 (52%) had no hs-cTnI elevation. The crude hospital mortality rate was 10% without an hs-cTnI elevation, 29% with an isolated hs-cTnl elevation (relative risk [RR]) 2.2; 95% confidence interval [CI], 1.0 to 6.0) and 29% with an MI (RR, 2.6; 95% CI, 1.4 to 5.1). CONCLUSION Myocardial injury with elevated hs-cTnI concentrations and MIs occur frequently during critical illness. This pilot study has established the feasibility of conducting a large-scale investigation addressing this issue.
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Affiliation(s)
- Emilie P Belley-Cote
- Department of Medicine, McMaster University, Hamilton, ON, Canada. .,Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada. .,Population Health Research Institute, Hamilton, ON, Canada. .,David Braley Cardiac, Vascular and Stroke Research Institute, 237 Barton St. E., Hamilton, ON, L8L 2X2, Canada.
| | - Richard P Whitlock
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada.,Population Health Research Institute, Hamilton, ON, Canada.,Department of Surgery, McMaster University, Hamilton, ON, Canada
| | - Diana V Ulic
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Kimia Honarmand
- Department of Medicine, Western University, London, ON, Canada
| | - Abubaker Khalifa
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Graham R McClure
- Department of Surgery, McMaster University, Hamilton, ON, Canada
| | - Andrew Gibson
- Department of Medicine, William Osler Health System, Brampton, ON, Canada
| | - Fayez Alshamsi
- Department of Internal Medicine, College of Medicine and Health Sciences, UAE University, Ain, UAE
| | | | - Bram Rochwerg
- Department of Medicine, McMaster University, Hamilton, ON, Canada.,Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - Erick Duan
- Department of Medicine, McMaster University, Hamilton, ON, Canada.,Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - Nevena Savija
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada.,Population Health Research Institute, Hamilton, ON, Canada
| | - Tim Karachi
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | | | - Peter Kavsak
- Department of Pathology and Molecular Medicine, McMaster University, Hamilton, ON, Canada
| | - Deborah J Cook
- Department of Medicine, McMaster University, Hamilton, ON, Canada.,Population Health Research Institute, Hamilton, ON, Canada
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13
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Kavsak PA, Worster A, Hill SA, Jaffe AS. Evaluation of the Siemens ADVIA Centaur high-sensitivity cardiac troponin I assay in serum. Clin Chim Acta 2018; 487:216-221. [PMID: 30296440 DOI: 10.1016/j.cca.2018.10.012] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2018] [Revised: 10/03/2018] [Accepted: 10/04/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND International recommendations on high-sensitivity cardiac troponin (hs-cTn) testing recommend that laboratories select only one sample type for testing. We evaluated the Siemens ADVIA Centaur hs-cTnI assay in serum and thereby provide information on imprecision, long-term storage stability, freeze-thaw stability, method comparison to other hs-cTnI assays, and clinical performance. METHODS Patients with chest pain onset <6 h who already had Roche hs-cTnT, Beckman hs-cTnI and Abbott hs-cTnI results recorded and had non-thawed and frozen serum aliquots formed the study population (n = 134 patients with 305 serum aliquots obtained at either 0, 3 or 6 h stored below -70 °C since 2003) for measurement with the Siemens hs-cTnI assay in 2018. Receiver-operating characteristic curve analyses for myocardial infarction (MI) using the highest obtained hs-cTn concentration was performed. Additional comparison testing on serum samples stored frozen (at -70 °C for <1 month in 2018) for the Siemens and Abbott hs-cTnI assays were performed, as well as precision testing in serum pools and freeze-thaw stability testing. RESULTS The Siemens hs-cTnI assay had an area under the curve (AUC) of 0.978 (95%CI: 0.937-0.996) for MI in the study cohort (Roche hs-cTnT AUC = 0.965 and Abbott AUC = 0.973). The Siemens hs-cTnI assay yielded higher cTnI concentrations than the other hs-cTn assays, with the same proportional bias (slope = 1.4) between the Siemens and Abbott hs-cTnI assays obtained from serum samples collected in 2003 and 2018. Over 3 months, a low serum pool of 3.5 ng/l achieved a CV of 20% (SD = 0.7, n = 42) and a high serum pool of 820 ng/l achieved a CV of 2.3% (SD = 20, n = 42). Three different serum pools recovered within 10% from baseline concentration after 5 freeze-thaw cycles for the Siemens hs-cTnI assay. CONCLUSIONS In serum, the Siemens ADVIA Centaur hs-cTnI assay had excellent clinical performance for MI in an early chest pain onset population, acceptable precision at normal and highly elevated cTnI concentrations, long-term storage stability (15 y storage below -70 °C) and acceptable freeze-thaw stability, all of which supports serum as an acceptable sample type to use in clinical studies and in clinical practice.
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Affiliation(s)
- Peter A Kavsak
- Department of Pathology and Molecular Medicine, McMaster University, Hamilton, ON, Canada; Hamilton Health Sciences, Hamilton, ON, Canada.
| | - Andrew Worster
- Division of Emergency Medicine, McMaster University, Hamilton, ON, Canada
| | - Stephen A Hill
- Department of Pathology and Molecular Medicine, McMaster University, Hamilton, ON, Canada
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14
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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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15
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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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16
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Kavsak PA, Worster A, Shortt C, Ma J, Clayton N, Sherbino J, Hill SA, McQueen M, Griffith LE, Mehta SR, McRae AD, Devereaux PJ. Performance of high-sensitivity cardiac troponin in the emergency department for myocardial infarction and a composite cardiac outcome across different estimated glomerular filtration rates. Clin Chim Acta 2018; 479:166-170. [PMID: 29366835 DOI: 10.1016/j.cca.2018.01.034] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2017] [Revised: 01/11/2018] [Accepted: 01/19/2018] [Indexed: 10/18/2022]
Abstract
BACKGROUND Clinicians regularly observe increased high-sensitivity cardiac troponin (hs-cTn) concentrations in patients with low estimated glomerular filtration rate (eGFR). The challenge is to differentiate acute coronary syndrome (ACS) from increased hs-cTn results across a range of eGFR. The objective of this study was to determined the optimal hs-cTn concentrations for acute myocardial infarction (MI) and a composite cardiovascular outcome across different eGFR ranges and to assess the utility of a low hs-cTn cutoff to rule-out events. METHODS We undertook an observational study in the emergency department of patients (n = 1212) with symptoms suggestive of ACS who had an eGFR and at least one Roche hs-cTnT and one Abbott hs-cTnI result. The 7-day outcomes were MI or a composite of MI, unstable angina, congestive heart failure, serious ventricular cardiac arrhythmia, or death. The maximum hs-cTn concentration was assessed across different eGFR ranges (<30,30-59,60-89,≥90 ml/min/1.73m2) by spearman correlation, ROC-curve analyses, and sensitivity and negative predictive value (NPV) for the proposed rule-out hs-cTn cutoffs (hs-cTnI<5 ng/l and hs-cTnT<6 ng/l) for the outcomes. RESULTS Both hs-cTnI and hs-cTnT concentrations were negatively correlated with eGFR. The lower the eGFR, the lower the AUC and the higher the optimal hs-cTn cutoffs for both MI and the composite outcome. The highest combined sensitivity (100%), NPV (100%) and proportion of low-risk for MI (45% of group) was observed for patients with hs-cTnT<6 ng/l with an eGFR≥90. CONCLUSION The test performance for hs-cTn for diagnosing or ruling-out an acute cardiac event varies per the eGFR. Accurate risk stratification requires knowledge of the eGFR.
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Affiliation(s)
- Peter A Kavsak
- Department of Pathology and Molecular Medicine, McMaster University, Hamilton, ON, Canada.
| | - Andrew Worster
- Division of Emergency Medicine, McMaster University, Hamilton, ON, Canada
| | - Colleen Shortt
- Division of Emergency Medicine, McMaster University, Hamilton, ON, Canada
| | - Jinhui Ma
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Natasha Clayton
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Jonathan Sherbino
- Division of Emergency Medicine, McMaster University, Hamilton, ON, Canada
| | - Stephen A Hill
- Department of Pathology and Molecular Medicine, McMaster University, Hamilton, ON, Canada
| | - Matthew McQueen
- Department of Pathology and Molecular Medicine, McMaster University, Hamilton, ON, Canada
| | - Lauren E Griffith
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Shamir R Mehta
- Division of Cardiology, and Population Health Research Institute, McMaster University, Hamilton, ON, Canada
| | - Andrew D McRae
- Department of Emergency Medicine, University of Calgary, Calgary, Alberta, Canada
| | - P J Devereaux
- Division of Cardiology, and Population Health Research Institute, McMaster University, Hamilton, ON, Canada
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Zhang Y, Zheng L, Xu BM, Tang WH, Ye ZD, Huang C, Ma X, Zhao JJ, Guo FX, Kang CM, Lu JB, Xiu JC, Li P, Xu YJ, Xiao L, Wu Q, Hu YW, Wang Q. LncRNA-RP11-714G18.1 suppresses vascular cell migration via directly targeting LRP2BP. Immunol Cell Biol 2017; 96:175-189. [PMID: 29363163 DOI: 10.1111/imcb.1028] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2017] [Revised: 10/13/2017] [Accepted: 10/28/2017] [Indexed: 12/26/2022]
Affiliation(s)
- Yuan Zhang
- Laboratory Medicine Center; Nanfang Hospital; Southern Medical University; Guangzhou Guangdong 510515 China
- Clinical laboratory department; Guangzhou Women and Children's Medical Center; Guangzhou Medical University; Guangzhou Guangdong 510623 China
| | - Lei Zheng
- Laboratory Medicine Center; Nanfang Hospital; Southern Medical University; Guangzhou Guangdong 510515 China
| | - Bang-Ming Xu
- Laboratory Medicine Center; Nanfang Hospital; Southern Medical University; Guangzhou Guangdong 510515 China
| | - Wai-Ho Tang
- Clinical laboratory department; Guangzhou Women and Children's Medical Center; Guangzhou Medical University; Guangzhou Guangdong 510623 China
| | - Zhi-Dong Ye
- Department of Cardiovascular Surgery; China- Japan Friendship Hospital; Beijing 100029 China
| | - Chuan Huang
- Laboratory Medicine Center; Nanfang Hospital; Southern Medical University; Guangzhou Guangdong 510515 China
| | - Xin Ma
- Department of Anesthesiology; Nanfang Hospital; Southern Medical University; Guangzhou Guangdong 510515 China
| | - Jing-Jing Zhao
- Laboratory Medicine Center; Nanfang Hospital; Southern Medical University; Guangzhou Guangdong 510515 China
| | - Feng-Xia Guo
- Laboratory Medicine Center; Nanfang Hospital; Southern Medical University; Guangzhou Guangdong 510515 China
| | - Chun-Min Kang
- Laboratory Medicine Center; Nanfang Hospital; Southern Medical University; Guangzhou Guangdong 510515 China
| | - Jing-Bo Lu
- Department of Vascular Surgery; Nanfang Hospital; Southern Medical University; Guangzhou Guangdong 510515 China
| | - Jian-Cheng Xiu
- Department of Cardiology; Nanfang Hospital; Southern medical University; Guangzhou 510515 China
| | - Pan Li
- Laboratory Medicine Center; Nanfang Hospital; Southern Medical University; Guangzhou Guangdong 510515 China
| | - Yuan-Jun Xu
- Laboratory Medicine Center; Nanfang Hospital; Southern Medical University; Guangzhou Guangdong 510515 China
| | - Lei Xiao
- Laboratory Medicine Center; Nanfang Hospital; Southern Medical University; Guangzhou Guangdong 510515 China
| | - Qian Wu
- Laboratory Medicine Center; Nanfang Hospital; Southern Medical University; Guangzhou Guangdong 510515 China
| | - Yan-Wei Hu
- Laboratory Medicine Center; Nanfang Hospital; Southern Medical University; Guangzhou Guangdong 510515 China
| | - Qian Wang
- Laboratory Medicine Center; Nanfang Hospital; Southern Medical University; Guangzhou Guangdong 510515 China
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18
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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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19
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Kavsak PA, Worster A, Shortt C, Ma J, Clayton N, Sherbino J, Hill SA, McQueen M, Griffith L, Mehta SR, Devereaux PJ. High-sensitivity cardiac troponin concentrations at emergency department presentation in females and males with an acute cardiac outcome. Ann Clin Biochem 2017; 55:604-607. [PMID: 29169258 DOI: 10.1177/0004563217743997] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background There is interest in utilizing different cut-offs per sex for high-sensitivity cardiac troponin I (hs-cTnI) but less so for high-sensitivity cardiac troponin T (hs-cTnT) for patient management in the acute setting. Our objective was to assess if differences in hs-cTn concentrations exist between males and females for an acute cardiac outcome following the presentation measurement in the emergency department. Methods An observational emergency department population with hs-cTn measurements (Roche Diagnostics and Abbott Diagnostics) at presentation with seven-day outcomes for a composite acute cardiac outcome (i.e. myocardial infarction, unstable angina, ventricular arrhythmia, heart failure or cardiovascular death) (ClinicalTrials.gov: NCT01994577). Receiver operating characteristic curve analyses were performed for each sex with both hs-cTn assays. Results In those patients who had a composite acute cardiac outcome ( n = 128 females; n = 145 males), there was no difference in hs-cTn concentrations between the sexes (median [IQR] female hs-cTnT = 35 ng/L [21-69] vs. male hs-cTnT = 38 ng/L [19-77], P = 0.95; and median [IQR] female hs-cTnI = 27 ng/L [12-75] vs. male hs-cTnI = 26 ng/L [12-85], P = 0.97]. There was also no difference in the area under the curve between the hs-cTn assays and between the sexes ( P > 0.10). Comparing hs-cTn concentrations in those patients with the composite outcome between the sexes <60 years and ≥60 years of age also did not yield significant differences ( P > 0.70). Conclusions The concentrations and area under the curves of hs-cTnT and hs-cTnI at patient presentation in the emergency department for an acute composite cardiac outcome were similar between the sexes in this exploratory study.
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Affiliation(s)
- Peter A Kavsak
- 1 Department of Pathology and Molecular Medicine, McMaster University, Hamilton, ON, Canada
| | - Andrew Worster
- 2 Division of Emergency Medicine, McMaster University, Hamilton, ON, Canada
| | - Colleen Shortt
- 1 Department of Pathology and Molecular Medicine, McMaster University, Hamilton, ON, Canada
| | - Jinhui Ma
- 3 Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Natasha Clayton
- 4 Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Jonathan Sherbino
- 2 Division of Emergency Medicine, McMaster University, Hamilton, ON, Canada
| | - Stephen A Hill
- 1 Department of Pathology and Molecular Medicine, McMaster University, Hamilton, ON, Canada
| | - Matthew McQueen
- 1 Department of Pathology and Molecular Medicine, McMaster University, Hamilton, ON, Canada
| | - Lauren Griffith
- 3 Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Shamir R Mehta
- 5 Division of Cardiology, and Population Health Research Institute, McMaster University, Hamilton, ON, Canada
| | - P J Devereaux
- 5 Division of Cardiology, and Population Health Research Institute, McMaster University, Hamilton, ON, Canada
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Richardson A, Neeman T, Yoon HJ, Haslett S. Statistical response to issues with the determination of the troponin 99th percentile. Clin Biochem 2017; 50:1332-1333. [PMID: 28818529 DOI: 10.1016/j.clinbiochem.2017.08.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2017] [Revised: 08/08/2017] [Accepted: 08/13/2017] [Indexed: 10/19/2022]
Affiliation(s)
- Alice Richardson
- National Centre for Epidemiology & Population Health, Australian National University, Canberra, Australia.
| | - Teresa Neeman
- Statistical Consulting Unit, Australian National University, Canberra, Australia
| | - Hwan-Jin Yoon
- Statistical Consulting Unit, Australian National University, Canberra, Australia
| | - Stephen Haslett
- Statistical Consulting Unit, Australian National University, Canberra, Australia; Centre for Public Health Research, Massey University, Wellington, New Zealand
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