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Wildi K, Gimenez MR, Twerenbold R, Reichlin T, Jaeger C, Heinzelmann A, Arnold C, Nelles B, Druey S, Haaf P, Hillinger P, Schaerli N, Kreutzinger P, Tanglay Y, Herrmann T, Moreno Weidmann Z, Krivoshei L, Freese M, Stelzig C, Puelacher C, Rentsch K, Osswald S, Mueller C. Misdiagnosis of Myocardial Infarction Related to Limitations of the Current Regulatory Approach to Define Clinical Decision Values for Cardiac Troponin. Circulation 2015; 131:2032-40. [PMID: 25948541 PMCID: PMC4456170 DOI: 10.1161/circulationaha.114.014129] [Citation(s) in RCA: 102] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2014] [Accepted: 04/02/2015] [Indexed: 11/16/2022]
Abstract
BACKGROUND Misdiagnosis of acute myocardial infarction (AMI) may significantly harm patients and may result from inappropriate clinical decision values (CDVs) for cardiac troponin (cTn) owing to limitations in the current regulatory process. METHODS AND RESULTS In an international, prospective, multicenter study, we quantified the incidence of inconsistencies in the diagnosis of AMI using fully characterized and clinically available high-sensitivity (hs) cTn assays (hs-cTnI, Abbott; hs-cTnT, Roche) among 2300 consecutive patients with suspected AMI. We hypothesized that the approved CDVs for the 2 assays are not biologically equivalent and might therefore contribute to inconsistencies in the diagnosis of AMI. Findings were validated by use of sex-specific CDVs and parallel measurements of other hs-cTnI assays. AMI was the adjudicated diagnosis in 473 patients (21%). Among these, 86 patients (18.2%) had inconsistent diagnoses when the approved uniform CDV was used. When sex-specific CDVs were used, 14.1% of female and 22.7% of male AMI patients had inconsistent diagnoses. Using biologically equivalent CDV reduced inconsistencies to 10% (P<0.001). These findings were confirmed with parallel measurements of other hs-cTn assays. The incidence of inconsistencies was only 7.0% for assays with CDVs that were nearly biologically equivalent. Patients with inconsistent AMI had long-term mortality comparable to that of patients with consistent diagnoses (P=NS) and a trend toward higher long-term mortality than patients diagnosed with unstable angina (P=0.05). CONCLUSIONS Currently approved CDVs are not biologically equivalent and contribute to major inconsistencies in the diagnosis of AMI. One of 5 AMI patients will receive a diagnosis other than AMI if managed with the alternative hs-cTn assay. CLINICAL TRIAL REGISTRATION URL: http://www.clinicaltrials.gov. Unique identifier: NCT00470587.
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Affiliation(s)
- Karin Wildi
- From Department of Cardiology and Cardiovascular Research Institute Basel (K.W., M.R.G., R.T., T.R., C.J., A.H., S.D., P.H., P.H., N.S., P.K., Y.T., T.H., Z.M.W., L.K., M.F., C.S., C.P., S.O., C.M.) and Laboratory Medicine (K.R.), University Hospital Basel, Switzerland; Servicio de Urgencias y Pneumologia, CIBERES ISC III, Hospital del Mar-Institut Municipal d'Investigació Mèdica, Barcelona, Spain (M.R.G.); and Department of Internal Medicine, Kantonsspital Olten, Switzerland (C.A.)
| | - Maria Rubini Gimenez
- From Department of Cardiology and Cardiovascular Research Institute Basel (K.W., M.R.G., R.T., T.R., C.J., A.H., S.D., P.H., P.H., N.S., P.K., Y.T., T.H., Z.M.W., L.K., M.F., C.S., C.P., S.O., C.M.) and Laboratory Medicine (K.R.), University Hospital Basel, Switzerland; Servicio de Urgencias y Pneumologia, CIBERES ISC III, Hospital del Mar-Institut Municipal d'Investigació Mèdica, Barcelona, Spain (M.R.G.); and Department of Internal Medicine, Kantonsspital Olten, Switzerland (C.A.)
| | - Raphael Twerenbold
- From Department of Cardiology and Cardiovascular Research Institute Basel (K.W., M.R.G., R.T., T.R., C.J., A.H., S.D., P.H., P.H., N.S., P.K., Y.T., T.H., Z.M.W., L.K., M.F., C.S., C.P., S.O., C.M.) and Laboratory Medicine (K.R.), University Hospital Basel, Switzerland; Servicio de Urgencias y Pneumologia, CIBERES ISC III, Hospital del Mar-Institut Municipal d'Investigació Mèdica, Barcelona, Spain (M.R.G.); and Department of Internal Medicine, Kantonsspital Olten, Switzerland (C.A.)
| | - Tobias Reichlin
- From Department of Cardiology and Cardiovascular Research Institute Basel (K.W., M.R.G., R.T., T.R., C.J., A.H., S.D., P.H., P.H., N.S., P.K., Y.T., T.H., Z.M.W., L.K., M.F., C.S., C.P., S.O., C.M.) and Laboratory Medicine (K.R.), University Hospital Basel, Switzerland; Servicio de Urgencias y Pneumologia, CIBERES ISC III, Hospital del Mar-Institut Municipal d'Investigació Mèdica, Barcelona, Spain (M.R.G.); and Department of Internal Medicine, Kantonsspital Olten, Switzerland (C.A.)
| | - Cedric Jaeger
- From Department of Cardiology and Cardiovascular Research Institute Basel (K.W., M.R.G., R.T., T.R., C.J., A.H., S.D., P.H., P.H., N.S., P.K., Y.T., T.H., Z.M.W., L.K., M.F., C.S., C.P., S.O., C.M.) and Laboratory Medicine (K.R.), University Hospital Basel, Switzerland; Servicio de Urgencias y Pneumologia, CIBERES ISC III, Hospital del Mar-Institut Municipal d'Investigació Mèdica, Barcelona, Spain (M.R.G.); and Department of Internal Medicine, Kantonsspital Olten, Switzerland (C.A.)
| | - Amely Heinzelmann
- From Department of Cardiology and Cardiovascular Research Institute Basel (K.W., M.R.G., R.T., T.R., C.J., A.H., S.D., P.H., P.H., N.S., P.K., Y.T., T.H., Z.M.W., L.K., M.F., C.S., C.P., S.O., C.M.) and Laboratory Medicine (K.R.), University Hospital Basel, Switzerland; Servicio de Urgencias y Pneumologia, CIBERES ISC III, Hospital del Mar-Institut Municipal d'Investigació Mèdica, Barcelona, Spain (M.R.G.); and Department of Internal Medicine, Kantonsspital Olten, Switzerland (C.A.)
| | - Christiane Arnold
- From Department of Cardiology and Cardiovascular Research Institute Basel (K.W., M.R.G., R.T., T.R., C.J., A.H., S.D., P.H., P.H., N.S., P.K., Y.T., T.H., Z.M.W., L.K., M.F., C.S., C.P., S.O., C.M.) and Laboratory Medicine (K.R.), University Hospital Basel, Switzerland; Servicio de Urgencias y Pneumologia, CIBERES ISC III, Hospital del Mar-Institut Municipal d'Investigació Mèdica, Barcelona, Spain (M.R.G.); and Department of Internal Medicine, Kantonsspital Olten, Switzerland (C.A.)
| | - Berit Nelles
- From Department of Cardiology and Cardiovascular Research Institute Basel (K.W., M.R.G., R.T., T.R., C.J., A.H., S.D., P.H., P.H., N.S., P.K., Y.T., T.H., Z.M.W., L.K., M.F., C.S., C.P., S.O., C.M.) and Laboratory Medicine (K.R.), University Hospital Basel, Switzerland; Servicio de Urgencias y Pneumologia, CIBERES ISC III, Hospital del Mar-Institut Municipal d'Investigació Mèdica, Barcelona, Spain (M.R.G.); and Department of Internal Medicine, Kantonsspital Olten, Switzerland (C.A.)
| | - Sophie Druey
- From Department of Cardiology and Cardiovascular Research Institute Basel (K.W., M.R.G., R.T., T.R., C.J., A.H., S.D., P.H., P.H., N.S., P.K., Y.T., T.H., Z.M.W., L.K., M.F., C.S., C.P., S.O., C.M.) and Laboratory Medicine (K.R.), University Hospital Basel, Switzerland; Servicio de Urgencias y Pneumologia, CIBERES ISC III, Hospital del Mar-Institut Municipal d'Investigació Mèdica, Barcelona, Spain (M.R.G.); and Department of Internal Medicine, Kantonsspital Olten, Switzerland (C.A.)
| | - Philip Haaf
- From Department of Cardiology and Cardiovascular Research Institute Basel (K.W., M.R.G., R.T., T.R., C.J., A.H., S.D., P.H., P.H., N.S., P.K., Y.T., T.H., Z.M.W., L.K., M.F., C.S., C.P., S.O., C.M.) and Laboratory Medicine (K.R.), University Hospital Basel, Switzerland; Servicio de Urgencias y Pneumologia, CIBERES ISC III, Hospital del Mar-Institut Municipal d'Investigació Mèdica, Barcelona, Spain (M.R.G.); and Department of Internal Medicine, Kantonsspital Olten, Switzerland (C.A.)
| | - Petra Hillinger
- From Department of Cardiology and Cardiovascular Research Institute Basel (K.W., M.R.G., R.T., T.R., C.J., A.H., S.D., P.H., P.H., N.S., P.K., Y.T., T.H., Z.M.W., L.K., M.F., C.S., C.P., S.O., C.M.) and Laboratory Medicine (K.R.), University Hospital Basel, Switzerland; Servicio de Urgencias y Pneumologia, CIBERES ISC III, Hospital del Mar-Institut Municipal d'Investigació Mèdica, Barcelona, Spain (M.R.G.); and Department of Internal Medicine, Kantonsspital Olten, Switzerland (C.A.)
| | - Nicolas Schaerli
- From Department of Cardiology and Cardiovascular Research Institute Basel (K.W., M.R.G., R.T., T.R., C.J., A.H., S.D., P.H., P.H., N.S., P.K., Y.T., T.H., Z.M.W., L.K., M.F., C.S., C.P., S.O., C.M.) and Laboratory Medicine (K.R.), University Hospital Basel, Switzerland; Servicio de Urgencias y Pneumologia, CIBERES ISC III, Hospital del Mar-Institut Municipal d'Investigació Mèdica, Barcelona, Spain (M.R.G.); and Department of Internal Medicine, Kantonsspital Olten, Switzerland (C.A.)
| | - Philipp Kreutzinger
- From Department of Cardiology and Cardiovascular Research Institute Basel (K.W., M.R.G., R.T., T.R., C.J., A.H., S.D., P.H., P.H., N.S., P.K., Y.T., T.H., Z.M.W., L.K., M.F., C.S., C.P., S.O., C.M.) and Laboratory Medicine (K.R.), University Hospital Basel, Switzerland; Servicio de Urgencias y Pneumologia, CIBERES ISC III, Hospital del Mar-Institut Municipal d'Investigació Mèdica, Barcelona, Spain (M.R.G.); and Department of Internal Medicine, Kantonsspital Olten, Switzerland (C.A.)
| | - Yunus Tanglay
- From Department of Cardiology and Cardiovascular Research Institute Basel (K.W., M.R.G., R.T., T.R., C.J., A.H., S.D., P.H., P.H., N.S., P.K., Y.T., T.H., Z.M.W., L.K., M.F., C.S., C.P., S.O., C.M.) and Laboratory Medicine (K.R.), University Hospital Basel, Switzerland; Servicio de Urgencias y Pneumologia, CIBERES ISC III, Hospital del Mar-Institut Municipal d'Investigació Mèdica, Barcelona, Spain (M.R.G.); and Department of Internal Medicine, Kantonsspital Olten, Switzerland (C.A.)
| | - Thomas Herrmann
- From Department of Cardiology and Cardiovascular Research Institute Basel (K.W., M.R.G., R.T., T.R., C.J., A.H., S.D., P.H., P.H., N.S., P.K., Y.T., T.H., Z.M.W., L.K., M.F., C.S., C.P., S.O., C.M.) and Laboratory Medicine (K.R.), University Hospital Basel, Switzerland; Servicio de Urgencias y Pneumologia, CIBERES ISC III, Hospital del Mar-Institut Municipal d'Investigació Mèdica, Barcelona, Spain (M.R.G.); and Department of Internal Medicine, Kantonsspital Olten, Switzerland (C.A.)
| | - Zoraida Moreno Weidmann
- From Department of Cardiology and Cardiovascular Research Institute Basel (K.W., M.R.G., R.T., T.R., C.J., A.H., S.D., P.H., P.H., N.S., P.K., Y.T., T.H., Z.M.W., L.K., M.F., C.S., C.P., S.O., C.M.) and Laboratory Medicine (K.R.), University Hospital Basel, Switzerland; Servicio de Urgencias y Pneumologia, CIBERES ISC III, Hospital del Mar-Institut Municipal d'Investigació Mèdica, Barcelona, Spain (M.R.G.); and Department of Internal Medicine, Kantonsspital Olten, Switzerland (C.A.)
| | - Lian Krivoshei
- From Department of Cardiology and Cardiovascular Research Institute Basel (K.W., M.R.G., R.T., T.R., C.J., A.H., S.D., P.H., P.H., N.S., P.K., Y.T., T.H., Z.M.W., L.K., M.F., C.S., C.P., S.O., C.M.) and Laboratory Medicine (K.R.), University Hospital Basel, Switzerland; Servicio de Urgencias y Pneumologia, CIBERES ISC III, Hospital del Mar-Institut Municipal d'Investigació Mèdica, Barcelona, Spain (M.R.G.); and Department of Internal Medicine, Kantonsspital Olten, Switzerland (C.A.)
| | - Michael Freese
- From Department of Cardiology and Cardiovascular Research Institute Basel (K.W., M.R.G., R.T., T.R., C.J., A.H., S.D., P.H., P.H., N.S., P.K., Y.T., T.H., Z.M.W., L.K., M.F., C.S., C.P., S.O., C.M.) and Laboratory Medicine (K.R.), University Hospital Basel, Switzerland; Servicio de Urgencias y Pneumologia, CIBERES ISC III, Hospital del Mar-Institut Municipal d'Investigació Mèdica, Barcelona, Spain (M.R.G.); and Department of Internal Medicine, Kantonsspital Olten, Switzerland (C.A.)
| | - Claudia Stelzig
- From Department of Cardiology and Cardiovascular Research Institute Basel (K.W., M.R.G., R.T., T.R., C.J., A.H., S.D., P.H., P.H., N.S., P.K., Y.T., T.H., Z.M.W., L.K., M.F., C.S., C.P., S.O., C.M.) and Laboratory Medicine (K.R.), University Hospital Basel, Switzerland; Servicio de Urgencias y Pneumologia, CIBERES ISC III, Hospital del Mar-Institut Municipal d'Investigació Mèdica, Barcelona, Spain (M.R.G.); and Department of Internal Medicine, Kantonsspital Olten, Switzerland (C.A.)
| | - Christian Puelacher
- From Department of Cardiology and Cardiovascular Research Institute Basel (K.W., M.R.G., R.T., T.R., C.J., A.H., S.D., P.H., P.H., N.S., P.K., Y.T., T.H., Z.M.W., L.K., M.F., C.S., C.P., S.O., C.M.) and Laboratory Medicine (K.R.), University Hospital Basel, Switzerland; Servicio de Urgencias y Pneumologia, CIBERES ISC III, Hospital del Mar-Institut Municipal d'Investigació Mèdica, Barcelona, Spain (M.R.G.); and Department of Internal Medicine, Kantonsspital Olten, Switzerland (C.A.)
| | - Katharina Rentsch
- From Department of Cardiology and Cardiovascular Research Institute Basel (K.W., M.R.G., R.T., T.R., C.J., A.H., S.D., P.H., P.H., N.S., P.K., Y.T., T.H., Z.M.W., L.K., M.F., C.S., C.P., S.O., C.M.) and Laboratory Medicine (K.R.), University Hospital Basel, Switzerland; Servicio de Urgencias y Pneumologia, CIBERES ISC III, Hospital del Mar-Institut Municipal d'Investigació Mèdica, Barcelona, Spain (M.R.G.); and Department of Internal Medicine, Kantonsspital Olten, Switzerland (C.A.)
| | - Stefan Osswald
- From Department of Cardiology and Cardiovascular Research Institute Basel (K.W., M.R.G., R.T., T.R., C.J., A.H., S.D., P.H., P.H., N.S., P.K., Y.T., T.H., Z.M.W., L.K., M.F., C.S., C.P., S.O., C.M.) and Laboratory Medicine (K.R.), University Hospital Basel, Switzerland; Servicio de Urgencias y Pneumologia, CIBERES ISC III, Hospital del Mar-Institut Municipal d'Investigació Mèdica, Barcelona, Spain (M.R.G.); and Department of Internal Medicine, Kantonsspital Olten, Switzerland (C.A.)
| | - Christian Mueller
- From Department of Cardiology and Cardiovascular Research Institute Basel (K.W., M.R.G., R.T., T.R., C.J., A.H., S.D., P.H., P.H., N.S., P.K., Y.T., T.H., Z.M.W., L.K., M.F., C.S., C.P., S.O., C.M.) and Laboratory Medicine (K.R.), University Hospital Basel, Switzerland; Servicio de Urgencias y Pneumologia, CIBERES ISC III, Hospital del Mar-Institut Municipal d'Investigació Mèdica, Barcelona, Spain (M.R.G.); and Department of Internal Medicine, Kantonsspital Olten, Switzerland (C.A.).
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