Recommandations ESC 2015 : exclure ou confirmer le diagnostic d’infarctus du myocarde en 1 heure avec la troponine T hypersensible

High-sensitivity-cardiac troponin for accelerated diagnosis of acute myocardial infarction: A systematic review and meta-analysis

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.

High-sensitive cardiac troponin hs-TnT levels in sudden deaths related to atherosclerotic coronary artery disease

INTRODUCTION

Ischemic heart disease (IHD) related to atherosclerotic coronary artery disease (CAD) is one of the most prevalent causes of death in Europe. Postmortem evaluation of IHD remains a challenge because of possible non-specific autopsy finding in some autopsy cases, especially in early myocardial ischemia. High-sensitive cardiac troponin T (hs-TnT) is used today in clinical practice as the "gold standard" to diagnose the myocardial ischemia, and might also be applied as an ancillary tool for post-mortem evaluation.

PURPOSE

The goal of this study is to evaluate the diagnostic value of post-mortem serum hs-TnT assay in cases of sudden death related to IHD. We will also investigate the influence of cardiopulmonary resuscitation (CPR) attempts on post-mortem hs-TnT levels.

METHODS

The hs-TnT values in serum were retrospectively analysed in 85 autopsy data. 52 cases with clinical history and morphological results suggesting cardiac ischemia were included in the study group (mean age 53.5; age range 34-75) and 33 cases in the control group (mean age 40.4; age range 15-69). The group's statistical comparison was performed using logistic regression model.

RESULTS

Our study showed a significant non-linear association between hs-TnT serum values and post-mortem diagnosis of sudden deaths related to IHD (p-value 0.005). The shape of the relationship is showing that the probability of death due to IHD increases quickly with a light level of hs-TnT (maximum around 90ng/L) then decreases slightly while remaining at high in values. No significant difference in the hs-TnT serum values was found between the CPR and the non-CPR cases (p-value 0.304).

CONCLUSION

The measurement of hs-TnT serum values might be considered as an ancillary tool for the evaluation of death related to IHD, while taking necessary precautions in the interpretation of the results.