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De Michieli L, Cipriani A, Iliceto S, Dispenzieri A, Jaffe AS. Cardiac Troponin in Patients With Light Chain and Transthyretin Cardiac Amyloidosis: JACC: CardioOncology State-of-the-Art Review. JACC CardioOncol 2024; 6:1-15. [PMID: 38510286 PMCID: PMC10950441 DOI: 10.1016/j.jaccao.2023.12.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Revised: 12/27/2023] [Accepted: 12/29/2023] [Indexed: 03/22/2024] Open
Abstract
Cardiac amyloidosis (CA) is an infiltrative disease caused by amyloid fibril deposition in the myocardium; the 2 forms that most frequently involve the heart are amyloid light chain (AL) and amyloid transthyretin (ATTR) amyloidosis. Cardiac troponin (cTn) is the biomarker of choice for the detection of myocardial injury and is frequently found to be elevated in patients with CA, particularly with high-sensitivity assays. Multiple mechanisms of myocardial injury in CA have been proposed, including cytotoxic effect of amyloid precursors, interstitial amyloid fibril infiltration, coronary microvascular dysfunction, amyloid- and non-amyloid-related coronary artery disease, diastolic dysfunction, and heart failure. Regardless of the mechanisms, cTn values have relevant prognostic (and potentially diagnostic) implications in both AL and ATTR amyloidosis. In this review, the authors discuss the significant aspects of cTn biology and measurement methods, potential mechanisms of myocardial injury in CA, and the clinical application of cTn in the management of both AL and ATTR amyloidosis.
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Affiliation(s)
- Laura De Michieli
- Department of Cardiac, Thoracic and Vascular Sciences and Public Health, University of Padua, Padua, Italy
- Cardiovascular Department, Mayo Clinic and Medical School, Rochester, Minnesota, USA
| | - Alberto Cipriani
- Department of Cardiac, Thoracic and Vascular Sciences and Public Health, University of Padua, Padua, Italy
- Cardiology Unit, University Hospital of Padua, Padua, Italy
| | - Sabino Iliceto
- Department of Cardiac, Thoracic and Vascular Sciences and Public Health, University of Padua, Padua, Italy
- Cardiology Unit, University Hospital of Padua, Padua, Italy
| | | | - Allan S. Jaffe
- Cardiovascular Department, Mayo Clinic and Medical School, Rochester, Minnesota, USA
- Department of Laboratory Medicine and Pathology, Mayo Clinic and Medical School, Rochester, Minnesota, USA
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2
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Liu L, Lewandrowski K. Establishing optimal cutoff values for high-sensitivity cardiac troponin algorithms in risk stratification of acute myocardial infarction. Crit Rev Clin Lab Sci 2024; 61:1-22. [PMID: 37466395 DOI: 10.1080/10408363.2023.2235426] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Revised: 06/11/2023] [Accepted: 07/07/2023] [Indexed: 07/20/2023]
Abstract
Acute myocardial infarction (AMI) is a leading cause of mortality globally, highlighting the need for timely and accurate diagnostic strategies. Cardiac troponin has been the biomarker of choice for detecting myocardial injury. A dynamic change in concentrations supports the diagnosis of AMI in the setting of evidence of acute myocardial ischemia. The new generation of high-sensitivity cardiac troponin (hs-cTn) assays has significantly improved analytical sensitivity but at the expense of decreased clinical specificity. As a result, sophisticated algorithms are required to differentiate AMI from non-AMI patients. Establishing optimal hs-cTn cutoffs for these algorithms to rule out and rule in AMI has been the subject of intensive investigations. These efforts have evolved from examining the utility of the hs-cTn 99th percentile upper reference limit, comparing the percentage versus absolute delta thresholds, and evaluating the performance of an early European Society of Cardiology-recommended 3 h algorithm, to the development of accelerated 1 h and 2 h algorithms that combine the admission hs-cTn concentrations and absolute delta cutoffs to rule out and rule in AMI. Specific cutoffs for individual confounding factors such as sex, age, and renal insufficiency have also been investigated. At the same time, concerns such as whether the small delta thresholds exceed the analytical and biological variations of hs-cTn assays and whether the algorithms developed in European study populations fit all other patient cohorts have been raised. In addition, the accelerated algorithms leave a substantial number of patients in a non-diagnostic observation zone. How to properly diagnose patients falling in this zone and those presenting with elevated baseline hs-cTn concentrations due to the presence of confounding factors or comorbidities remain open questions. Here we discuss the developments described above, focusing on criteria and underlying considerations for establishing optimal cutoffs. In-depth analyses are provided on the influence of biological variation, analytical imprecision, local AMI rate, and the timing of presentation on the performance metrics of the accelerated hs-cTn algorithms. Developing diagnostic strategies for patients who remain in the observation zone and those presenting with confounding factors are also reviewed.
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Affiliation(s)
- Li Liu
- Department of Pathology, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Kent Lewandrowski
- Department of Pathology, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
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3
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Kulkarni SM, Roongta R, Sankar S. Clinical profile of patients and sensitivity of troponin I in patients with and without acute coronary syndrome: An observational study. THE NATIONAL MEDICAL JOURNAL OF INDIA 2023; 36:305-309. [PMID: 38759980 DOI: 10.25259/nmji_801_2021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/19/2024]
Abstract
Background Various clinical conditions can cause troponin elevation in the absence of myocardial ischaemia. Elevated troponin represents the likely occurrence of myocardial necrosis and does not itself provide any indication of the aetiology. Identifying the cause for troponin elevation and its sensitivity and specificity in predicting acute coronary syndrome (ACS) and cardiac mortality is an important step in determining the optimal management for these patients. Methods We retrospectively collected data of inpatients who had troponin I (TnI) testing as part of their clinical assessment, either in the emergency department, medical wards, coronary care unit (CCU) or intensive care unit (ICU) with their final diagnosis. TnI was used as the index test of sensitivity to diagnose ACS and either echocardiography or coronary angiogram in those available as the reference gold standard. They were classified into two groups of normal and elevated TnI, and further divided into those with ACS and no ACS. Data on clinical parameters and aetiology of elevated TnI in patients without ACS were analysed. Results Of the 254 patients studied, 114 patients (45%) had normal TnI and 140 (55%) had elevated TnI. Seventy-eight patients had ACS, 66 (84.6%) of whom had elevated TnI and 12 (15.38%) had normal TnI. Seventy-four (52.85%) of 140 patients with elevated TnI had alternate causes of TnI elevation; the most common being sepsis, acute kidney injury (AKI) and heart failure without ACS. All-cause mortality was significantly higher in patients with elevated TnI with or without ACS. There was no cardiac mortality among patients with ACS with normal TnI. Sensitivity and specificity of TnI for predicting ACS was 84.6% (95% CI 74.7%-91.8%) and 58% (95% CI 50.3%-65.3%), respectively. Conclusion A variety of conditions apart from myocardial infarction can lead to elevated TnI. Hence, caution should be exercised while diagnosing a patient with ACS based on TnI value in the absence of other supporting evidence given its low specificity. Elevated TnI portends a worse prognosis regardless of the aetiology and has a role in predicting all-cause and cardiac mortality.
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Affiliation(s)
- Shruthi M Kulkarni
- Department of General Medicine, St John's Medical College Hospital, Koramangala, Bengaluru 560034, Karnataka, India
| | - Rashmi Roongta
- Department of General Medicine, St John's Medical College Hospital, Koramangala, Bengaluru 560034, Karnataka, India
| | - Seena Sankar
- Department of General Medicine, St John's Medical College Hospital, Koramangala, Bengaluru 560034, Karnataka, India
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Khan E, Lambrakis K, Nazir SA, Chuang A, Halabi A, Tiver K, Briffa T, Cullen LA, Horsfall M, French JK, Sun BC, Chew DP. Implementation of more sensitive cardiac troponin T assay in a state-wide health service. Int J Cardiol 2022; 347:66-72. [PMID: 34774641 DOI: 10.1016/j.ijcard.2021.11.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Revised: 10/30/2021] [Accepted: 11/07/2021] [Indexed: 11/29/2022]
Abstract
AIMS Explore the impact of deploying high-sensitivity (hs) cardiac troponin T (cTnT) assay across a state-wide health service. METHODS AND RESULTS Presentations to emergency departments of six tertiary hospitals between January 2008 and August 2019 were included; standard cTnT assay was superseded by hs-cTnT in June 2011 without changing the reference range (≥30 ng/L reported as elevated), despite cTnT level of 30 ng/L being equivalent to ∼44 ng/L with hs-cTnT. Clinical outcomes were captured using state-wide linked health records. Interrupted time series analyses were used adjusted for seasonality and multiple co-morbidities using propensity score matching allowing for correlation within hospitals. In total, 614,847 presentations had ≥1 troponin measurement. Clinical ordering of troponin decreased throughout the study with no increase in elevated measurements amongst those tested with hs-cTnT. Small but statistically significant changes in index myocardial infarction (MI) diagnosis (-0.36%/year, 95%CI [confidence interval]:-0.48, -0.24,p < 0.001) and invasive coronary angiography (0.12%/year,95%CI:0, 0.24,p = 0.02) were seen, with no impact on death/MI at 30 days or 3-year survival in episodes of care (EOCs) with elevated cTnT after hs-cTnT implementation. Length of stay (LOS) was shorter among those with an elevated hs-cTnT (-4.44 h/year, 95%CI:-5.27, -3.60, p < 0.001). Non-elevated cTnT EOCs demonstrated shorter total LOS and improved 3-year survival (adjusted hazard ratio:0.90, 95%CI:0.83, 0.97,p = 0.008) although death/MI at 30 days was unchanged using hs-cTnT. CONCLUSION Widespread implementation of hs-cTnT without altering clinical thresholds reported to clinicians provided significantly shorter LOS without a clinically significant impact on clinical outcomes. A safer cohort with non-elevated cTnT was identified by hs-cTnT compared to the standard cTnT assay.
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Affiliation(s)
- Ehsan Khan
- College of Medicine & Public Health, Flinders University of South Australia, Adelaide, Australia; South Australian Department of Health, Adelaide, Australia
| | - Kristina Lambrakis
- College of Medicine & Public Health, Flinders University of South Australia, Adelaide, Australia; South Australian Department of Health, Adelaide, Australia
| | - Sheraz A Nazir
- Department of Cardiology, University Hospitals of Coventry & Warwickshire NHS Trust, Coventry, CV2 2DX, UK; Department of Cardiovascular Sciences, University of Leicester and the National Institute for Health for Research (NIHR) Leicester Cardiovascular Biomedical Research Centre, Glenfield Hospital, Leicester LE3 9QF, UK
| | - Anthony Chuang
- College of Medicine & Public Health, Flinders University of South Australia, Adelaide, Australia; South Australian Department of Health, Adelaide, Australia
| | - Amera Halabi
- College of Medicine & Public Health, Flinders University of South Australia, Adelaide, Australia; South Australian Department of Health, Adelaide, Australia
| | - Kathryn Tiver
- College of Medicine & Public Health, Flinders University of South Australia, Adelaide, Australia; South Australian Department of Health, Adelaide, Australia
| | - Tom Briffa
- School of Population and Global Health, University of Western Australia, Perth, Australia
| | - Louise A Cullen
- Emergency and Trauma Centre, Royal Brisbane and Women's Hospital, Brisbane, Australia; School of Public Health, Queensland University of Technology, Brisbane, Australia; School of Medicine, University of Queensland, Brisbane, Australia
| | - Matthew Horsfall
- College of Medicine & Public Health, Flinders University of South Australia, Adelaide, Australia; South Australian Department of Health, Adelaide, Australia
| | - John K French
- Department of Cardiology, Liverpool Hospital, University of New South Wales, Sydney, Australia
| | - Benjamin C Sun
- Center for Policy Research-Emergency Medicine, Department of Emergency Medicine, Oregon Health and Science University, Portland, OR, United States of America
| | - Derek P Chew
- College of Medicine & Public Health, Flinders University of South Australia, Adelaide, Australia; South Australian Health and Medical Research Institute, Adelaide, Australia; South Australian Department of Health, Adelaide, Australia.
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Gupta V, Paranzino M, Alnabelsi T, Ayoub K, Eason J, Mullis A, Kotter JR, Parks A, May L, Nerusu S, Dai C, Cleland D, Leung SW, Sorrell VL. 5th generation vs 4th generation troponin T in predicting major adverse cardiovascular events and all-cause mortality in patients hospitalized for non-cardiac indications: A cohort study. PLoS One 2021; 16:e0246332. [PMID: 33561174 PMCID: PMC7872231 DOI: 10.1371/journal.pone.0246332] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Accepted: 01/18/2021] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE The frequency and implications of an elevated cardiac troponin (4th or 5th generation TnT) in patients outside of the emergency department or presenting with non-cardiac conditions is unclear. METHODS Consecutive patients aged 18 years or older admitted for a primary non-cardiac condition who had the 4th generation TnT drawn had the 5th generation TnT run on the residual blood sample. Primary and secondary outcomes were all-cause mortality (ACM) and major adverse cardiovascular events (MACE) respectively at 1 year. RESULTS 918 patients were included (mean age 59.8 years, 55% male) in the cohort. 69% had elevated 5th generation TnT while 46% had elevated 4th generation TnT. 5th generation TnT was more sensitive and less specific than 4th generation TnT in predicting both ACM and MACE. The sensitivities for the 5th generation TnT assay were 85% for ACM and 90% for MACE rates, compared to 65% and 70% respectively for the 4th generation assay. 5th generation TnT positive patients that were missed by 4th generation TnT had a higher risk of ACM (27.5%) than patients with both assays negative (27.5% vs 11.1%, p<0.001), but lower than patients who had both assay positive (42.1%). MACE rates were not better stratified using the 5th generation TnT assay. CONCLUSIONS In patients admitted for a non-cardiac condition, 5th generation TnT is more sensitive although less specific in predicting MACE and ACM. 5th generation TnT identifies an intermediate risk group for ACM previously missed with the 4th generation assay.
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Affiliation(s)
- Vedant Gupta
- Gill Heart and Vascular Institute, University of Kentucky, Lexington, Kentucky, United States of America
| | - Marc Paranzino
- Gill Heart and Vascular Institute, University of Kentucky, Lexington, Kentucky, United States of America
| | - Talal Alnabelsi
- Gill Heart and Vascular Institute, University of Kentucky, Lexington, Kentucky, United States of America
| | - Karam Ayoub
- Gill Heart and Vascular Institute, University of Kentucky, Lexington, Kentucky, United States of America
| | - Joshua Eason
- Gill Heart and Vascular Institute, University of Kentucky, Lexington, Kentucky, United States of America
| | - Andin Mullis
- Gill Heart and Vascular Institute, University of Kentucky, Lexington, Kentucky, United States of America
| | - John R. Kotter
- Gill Heart and Vascular Institute, University of Kentucky, Lexington, Kentucky, United States of America
| | - Andrew Parks
- Department of Internal Medicine, University of Kentucky, Lexington, Kentucky, United States of America
| | - Levi May
- Department of Internal Medicine, University of Kentucky, Lexington, Kentucky, United States of America
| | - Sethabhisha Nerusu
- Performance Analytics Center of Excellence, University of Kentucky, Lexington, Kentucky, United States of America
| | - Chen Dai
- Performance Analytics Center of Excellence, University of Kentucky, Lexington, Kentucky, United States of America
| | - Daniel Cleland
- Performance Analytics Center of Excellence, University of Kentucky, Lexington, Kentucky, United States of America
| | - Steve Wah Leung
- Gill Heart and Vascular Institute, University of Kentucky, Lexington, Kentucky, United States of America
| | - Vincent Leigh Sorrell
- Gill Heart and Vascular Institute, University of Kentucky, Lexington, Kentucky, United States of America
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Savonnet M, Rolland T, Cubizolles M, Roupioz Y, Buhot A. Recent advances in cardiac biomarkers detection: From commercial devices to emerging technologies. J Pharm Biomed Anal 2020; 194:113777. [PMID: 33293175 DOI: 10.1016/j.jpba.2020.113777] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Revised: 11/13/2020] [Accepted: 11/16/2020] [Indexed: 01/09/2023]
Abstract
Although cardiac pathologies are the major cause of death in the world, it remains difficult to provide a reliable diagnosis to prevent heart attacks. Rapid patient care and management in emergencies are critical to prevent dramatic consequences. Thus, relevant biomarkers such as cardiac troponin and natriuretic peptides are currently targeted by commercialized Point-Of-Care immunoassays. Key points still to be addressed concern cost, lack of standardization, and poor specificity, which could limit the reliability of the assays. Consequently, alternatives are emerging to address these issues. New probe molecules such as aptamers or molecularly imprinted polymers should allow a reduction in cost of the assays and an increase in reproducibility. In addition, the assay specificity and reliability could be improved by enabling multiplexing through the detection of several molecular targets in a single device.
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Affiliation(s)
- Maud Savonnet
- Univ. Grenoble Alpes, CEA, CNRS, IRIG, SyMMES, F-38000, Grenoble, France; Univ. Grenoble Alpes, CEA, LETI, Technologies for Healthcare and Biology Division, Microfluidic Systems and Bioengineering Lab, F-38000, Grenoble, France
| | - Tristan Rolland
- Univ. Grenoble Alpes, CEA, LETI, Technologies for Healthcare and Biology Division, Microfluidic Systems and Bioengineering Lab, F-38000, Grenoble, France
| | - Myriam Cubizolles
- Univ. Grenoble Alpes, CEA, LETI, Technologies for Healthcare and Biology Division, Microfluidic Systems and Bioengineering Lab, F-38000, Grenoble, France
| | - Yoann Roupioz
- Univ. Grenoble Alpes, CEA, CNRS, IRIG, SyMMES, F-38000, Grenoble, France
| | - Arnaud Buhot
- Univ. Grenoble Alpes, CEA, CNRS, IRIG, SyMMES, F-38000, Grenoble, France.
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7
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Han X, Zhang S, Chen Z, Adhikari BK, Zhang Y, Zhang J, Sun J, Wang Y. Cardiac biomarkers of heart failure in chronic kidney disease. Clin Chim Acta 2020; 510:298-310. [PMID: 32710942 DOI: 10.1016/j.cca.2020.07.040] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2020] [Revised: 07/18/2020] [Accepted: 07/20/2020] [Indexed: 12/15/2022]
Abstract
Heart failure remains a continuing threat to patients with chronic kidney disease (CKD). Although various heart failure biomarkers have been applied for early detection, diagnosis and prognosis in CKD, these are easily affected by renal insufficiency thus limiting use in these patients. In this review, the major four groups of heart failure biomarkers are explored. These include those associated with: myocardial stretch, ie, brain natriuretic peptide (BNP), N-terminal pro-BNP (NT-proBNP) and mid-regional proatrial natriuretic peptide (MR-proANP); myocyte injury, ie, high-sensitivity troponin T (hsTnT), heart-type fatty acid-binding protein (H-FABP); fibrosis, matrix remodelling and inflammation, ie, soluble growth stimulating gene 2 (sST2), galectin-3 (Gal-3), growth differentiation factor-15 (GDF-15); and renal function, ie, neutrophil gelatinase-associated lipocalin (NGAL) kidney injury molecule-1 (KIM-1), cystatin C (CysC), urinary sodium and urinary albumin. This review highlights classic heart failure biomarkers with critical values adjusted to glomerular filtration rate, summarizes research progress of new heart failure biomarkers and future research directions. Because diagnostic and prognostic usefulness of a single time point biomarker is limited, biomarkers should be combined and monitored at multiple times for optimal clinical impact.
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Affiliation(s)
- Xiaorong Han
- Department of Cardiovascular Centre, The First Hospital of Jilin University, Changchun, Jilin 130021, China
| | - Shuai Zhang
- Department of Cardiovascular Centre, The First Hospital of Jilin University, Changchun, Jilin 130021, China
| | - Zhongbo Chen
- Department of Cardiovascular Centre, The First Hospital of Jilin University, Changchun, Jilin 130021, China
| | | | - Ying Zhang
- Department of Cardiovascular Centre, The First Hospital of Jilin University, Changchun, Jilin 130021, China
| | - Jin Zhang
- Department of Cardiovascular Centre, The First Hospital of Jilin University, Changchun, Jilin 130021, China
| | - Jian Sun
- Department of Cardiovascular Centre, The First Hospital of Jilin University, Changchun, Jilin 130021, China.
| | - Yonggang Wang
- Department of Cardiovascular Centre, The First Hospital of Jilin University, Changchun, Jilin 130021, China.
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Chew DP, Lambrakis K, Blyth A, Seshadri A, Edmonds MJR, Briffa T, Cullen LA, Quinn S, Karnon J, Chuang A, Nelson AJ, Wright D, Horsfall M, Morton E, French JK, Papendick C. A Randomized Trial of a 1-Hour Troponin T Protocol in Suspected Acute Coronary Syndromes: The Rapid Assessment of Possible Acute Coronary Syndrome in the Emergency Department With High-Sensitivity Troponin T Study (RAPID-TnT). Circulation 2019; 140:1543-1556. [PMID: 31478763 DOI: 10.1161/circulationaha.119.042891] [Citation(s) in RCA: 142] [Impact Index Per Article: 28.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND High-sensitivity troponin assays promise earlier discrimination of myocardial infarction. Yet, the benefits and harms of this improved discriminatory performance when incorporated within rapid testing protocols, with respect to subsequent testing and clinical events, has not been evaluated in an in-practice patient-level randomized study. This multicenter study evaluated the noninferiority of a 0/1-hour high-sensitivity cardiac troponin T (hs-cTnT) protocol in comparison with a 0/3-hour masked hs-cTnT protocol in patients with suspected acute coronary syndrome presenting to the emergency department (ED). METHODS Patients were randomly assigned to either a 0/1-hour hs-cTnT protocol (reported to the limit of detection [<5 ng/L]) or masked hs-cTnT reported to ≤29 ng/L evaluated at 0/3-hours (standard arm). The 30-day primary end point was all-cause death and myocardial infarction. Noninferiority was defined as an absolute margin of 0.5% determined by Poisson regression. RESULTS In total, 3378 participants with an emergency presentation were randomly assigned between August 2015 and April 2019. Ninety participants were deemed ineligible or withdrew consent. The remaining participants received care guided either by the 0/1-hour hs-cTnT protocol (n=1646) or the 0/3-hour standard masked hs-cTnT protocol (n=1642) and were followed for 30 days. Median age was 59 (49-70) years, and 47% were female. Participants in the 0/1-hour arm were more likely to be discharged from the ED (0/1-hour arm: 45.1% versus standard arm: 32.3%, P<0.001) and median ED length of stay was shorter (0/1-hour arm: 4.6 [interquartile range, 3.4-6.4] hours versus standard arm: 5.6 (interquartile range, 4.0-7.1) hours, P<0.001). Those randomly assigned to the 0/1-hour protocol were less likely to undergo functional cardiac testing (0/1-hour arm: 7.5% versus standard arm: 11.0%, P<0.001). The 0/1-hour hs-cTnT protocol was not inferior to standard care (0/1-hour arm: 17/1646 [1.0%] versus 16/1642 [1.0%]; incidence rate ratio, 1.06 [ 0.53-2.11], noninferiority P value=0.006, superiority P value=0.867), although an increase in myocardial injury was observed. Among patients discharged from ED, the 0/1-hour protocol had a negative predictive value of 99.6% (95% CI, 99.0-99.9%) for 30-day death or myocardial infarction. CONCLUSIONS This in-practice evaluation of a 0/1-hour hs-cTnT protocol embedded in ED care enabled more rapid discharge of patients with suspected acute coronary syndrome. Improving short-term outcomes among patients with newly recognized troponin T elevation will require an evolution in management strategies for these patients. CLINICAL TRIAL REGISTRATION URL: https://www.anzctr.org.au. Unique identifier: ACTRN12615001379505.
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Affiliation(s)
- Derek P Chew
- College of Medicine & Public Health, Flinders University of South Australia, Adelaide (D.P.C., A.B., A.S., J.K., A.C., E.M.).,South Australian Health and Medical Research Institute, Adelaide (D.P.C., A.J.C.).,South Australian Department of Health, Adelaide (D.P.C., K.L., A.B., A.S., M.J.R.E., A.C., D.W., M.H., C.P.)
| | - Kristina Lambrakis
- South Australian Department of Health, Adelaide (D.P.C., K.L., A.B., A.S., M.J.R.E., A.C., D.W., M.H., C.P.)
| | - Andrew Blyth
- College of Medicine & Public Health, Flinders University of South Australia, Adelaide (D.P.C., A.B., A.S., J.K., A.C., E.M.).,South Australian Department of Health, Adelaide (D.P.C., K.L., A.B., A.S., M.J.R.E., A.C., D.W., M.H., C.P.)
| | - Anil Seshadri
- College of Medicine & Public Health, Flinders University of South Australia, Adelaide (D.P.C., A.B., A.S., J.K., A.C., E.M.).,South Australian Department of Health, Adelaide (D.P.C., K.L., A.B., A.S., M.J.R.E., A.C., D.W., M.H., C.P.)
| | - Michael J R Edmonds
- South Australian Department of Health, Adelaide (D.P.C., K.L., A.B., A.S., M.J.R.E., A.C., D.W., M.H., C.P.)
| | - Tom Briffa
- School of Population and Global Health, University of Western Australia, Perth (T.B.)
| | - Louise A Cullen
- Department of Emergency Medicine, Royal Brisbane and Women's Hospital, Australia (L.A.C.).,School of Public Health, Queensland University of Technology, Brisbane, Australia (L.A.C.).,School of Medicine, University of Queensland, Brisbane, Australia (L.A.C.)
| | - Stephen Quinn
- Department of Statistics, Data Science and Epidemiology, Swinburne University of Technology, Melbourne, Australia (S.Q.)
| | - Jonathan Karnon
- College of Medicine & Public Health, Flinders University of South Australia, Adelaide (D.P.C., A.B., A.S., J.K., A.C., E.M.)
| | - Anthony Chuang
- College of Medicine & Public Health, Flinders University of South Australia, Adelaide (D.P.C., A.B., A.S., J.K., A.C., E.M.).,South Australian Department of Health, Adelaide (D.P.C., K.L., A.B., A.S., M.J.R.E., A.C., D.W., M.H., C.P.)
| | - Adam J Nelson
- South Australian Health and Medical Research Institute, Adelaide (D.P.C., A.J.C.).,School of Medicine, University of Adelaide, Australia (A.J.C.)
| | - Deborah Wright
- South Australian Department of Health, Adelaide (D.P.C., K.L., A.B., A.S., M.J.R.E., A.C., D.W., M.H., C.P.)
| | - Matthew Horsfall
- South Australian Department of Health, Adelaide (D.P.C., K.L., A.B., A.S., M.J.R.E., A.C., D.W., M.H., C.P.)
| | - Erin Morton
- College of Medicine & Public Health, Flinders University of South Australia, Adelaide (D.P.C., A.B., A.S., J.K., A.C., E.M.)
| | - John K French
- Department of Cardiology, University of New South Wales, Sydney, Australia (J.K.F.)
| | - Cynthia Papendick
- South Australian Department of Health, Adelaide (D.P.C., K.L., A.B., A.S., M.J.R.E., A.C., D.W., M.H., C.P.)
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9
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Andruchow JE, Boyne T, Innes G, Vatanpour S, Seiden-Long I, Wang D, Lang E, McRae AD. Low High-Sensitivity Troponin Thresholds Identify Low-Risk Patients With Chest Pain Unlikely to Benefit From Further Risk Stratification. CJC Open 2019; 1:289-296. [PMID: 32159123 PMCID: PMC7063640 DOI: 10.1016/j.cjco.2019.08.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2019] [Accepted: 08/20/2019] [Indexed: 01/20/2023] Open
Abstract
Background Very low high-sensitivity cardiac troponin T (hs-cTnT) thresholds on presentation can rule out acute myocardial infarction (AMI), but the ability to identify patients at low risk of 30-day major adverse cardiac events (MACE) is less clear. This study examines the sensitivity of low concentrations of hs-cTnT on presentation to rule out 30-day MACE. Methods This prospective cohort study enrolled patients with chest pain presenting to the emergency department with nonischemic electrocardiograms who underwent AMI rule-out with an hs-cTnT assay. The primary outcome was 30-day MACE; secondary outcomes were individual MACE components. Because guidelines recommend using a single hs-cTnT strategy only for patients with more than 3 hours since symptom onset, a subgroup analysis was performed for this population. Outcomes were adjudicated on the basis of review of medical records and telephone follow-up. Results Of 1167 patients enrolled, 125 (10.7%) experienced 30-day MACE and 97 (8.3%) had AMI on the index visit. More than one-third of patients (35.6%) had presenting hs-cTnT concentrations below the limit of detection (5 ng/L), which was 94.4% (95% confidence interval [CI], 88.8-97.7) sensitive for 30-day MACE and 99.0% (95% CI, 94.5-100) sensitive for index AMI. Of 292 patients (25.0%) with hs-cTnT < 5 ng/L and at least 3 hours since symptom onset, only 3 experienced 30-day MACE (sensitivity 97.6%; 95% CI, 93.2-100) and none had AMI within 30 days (sensitivity 100%; 95% CI, 96.3-100). Conclusions Among patients with nonischemic electrocardiograms and > 3 hours since symptom onset, low hs-cTnT thresholds on presentation confer a very low risk of 30-day MACE. In the absence of a high-risk clinical presentation, further risk stratification is likely to be low yield.
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Affiliation(s)
- James E Andruchow
- Department of Emergency Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Timothy Boyne
- Department of Cardiac Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Grant Innes
- Department of Emergency Medicine, University of Calgary, Calgary, Alberta, Canada.,Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Shabnam Vatanpour
- Department of Emergency Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Isolde Seiden-Long
- Department of Pathology and Laboratory Medicine, University of Calgary and Alberta Public Laboratories, Calgary, Alberta, Canada
| | - Dongmei Wang
- Department of Emergency Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Eddy Lang
- Department of Emergency Medicine, University of Calgary, Calgary, Alberta, Canada.,Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Andrew D McRae
- Department of Emergency Medicine, University of Calgary, Calgary, Alberta, Canada.,Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
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10
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Narayanan MA, Garcia S. Role of High-sensitivity Cardiac Troponin in Acute Coronary Syndrome. US CARDIOLOGY REVIEW 2019. [DOI: 10.15420/usc.2018.16.1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Chest pain is one of the most common reasons for an emergency room (ER) visit in the US, with almost 6 million ER visits annually. High-sensitivity cardiac troponin (hscTn) assays have the ability to rapidly rule in or rule out acute coronary syndrome with improved sensitivity, and they are increasingly being used. Though hscTn assays have been approved for use in European, Australian, and Canadian guidelines since 2010, the FDA only approved their use in 2017. There is no consensus on how to compare the results from various hscTn assays. A literature review was performed to analyze the advantages and limitations of using hscTn as a standard biomarker to evaluate patients with suspected ACS in the emergency setting.
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Affiliation(s)
- Mahesh Anantha Narayanan
- Division of Cardiovascular Disease, Department of Medicine, University of Minnesota, Minneapolis, MN
| | - Santiago Garcia
- Minneapolis Heart Institute at Abbott Northwestern Hospital, Minneapolis, MN
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11
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Staging systems use for risk stratification of systemic amyloidosis in the era of high-sensitivity troponin T assay. Blood 2019; 133:763-766. [DOI: 10.1182/blood-2018-10-875252] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
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12
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Eggers KM, Jernberg T, Ljung L, Lindahl B. High-Sensitivity Cardiac Troponin-Based Strategies for the Assessment of Chest Pain Patients-A Review of Validation and Clinical Implementation Studies. Clin Chem 2018; 64:1572-1585. [PMID: 29941466 DOI: 10.1373/clinchem.2018.287342] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2018] [Accepted: 05/14/2018] [Indexed: 12/26/2022]
Abstract
BACKGROUND The introduction of high-sensitivity cardiac troponin (hs-cTn) assays has improved the early assessment of chest pain patients. A number of hs-cTn-based algorithms and accelerated diagnostic protocols (ADPs) have been developed and tested subsequently. In this review, we summarize the data on the performance and clinical utility of these strategies. CONTENT We reviewed studies investigating the diagnostic and prognostic performance of hs-cTn algorithms [level of detection (LoD) strategy, 0/1-h, 0/2-h, and 0/3-h algorithms) and of hs-cTn-based ADPs, together with the implications of these strategies when implemented as clinical routine. The LoD strategy, when combined with a nonischemic electrocardiogram, is best suited for safe rule-out of myocardial infarction and the identification of patients eligible for early discharge from the emergency department. The 0/1-h algorithms appear to identify most patients as being eligible for rule-out. The hs-cTn-based ADPs mainly focus on prognostic assessment, which is in contrast with the hs-cTn algorithms. They identify smaller proportions of rule-out patients, but there is increasing evidence from prospective studies on their successful clinical implementation. Such information is currently lacking for hs-cTn algorithms. CONCLUSIONS There is a trade-off between safety and efficacy for different hs-cTn-based strategies. This trade-off should be considered for the intended strategy, along with its user-friendliness and evidence from clinical implementation studies. However, several gaps in knowledge remain. At present, we suggest the use of an ADP in conjunction with serial hs-cTn results to optimize the early assessment of chest pain patients.
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Affiliation(s)
- Kai M Eggers
- Department of Medical Sciences and Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden;
| | - Tomas Jernberg
- Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Lina Ljung
- Department of Cardiology, Södersjukhuset and Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden
| | - Bertil Lindahl
- Department of Medical Sciences and Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
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13
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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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14
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Shah ASV, Sandoval Y, Noaman A, Sexter A, Vaswani A, Smith SW, Gibbins M, Griffiths M, Chapman AR, Strachan FE, Anand A, Denvir MA, Adamson PD, D'Souza MS, Gray AJ, McAllister DA, Newby DE, Apple FS, Mills NL. Patient selection for high sensitivity cardiac troponin testing and diagnosis of myocardial infarction: prospective cohort study. BMJ 2017; 359:j4788. [PMID: 29114078 PMCID: PMC5683043 DOI: 10.1136/bmj.j4788] [Citation(s) in RCA: 86] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/11/2017] [Indexed: 12/28/2022]
Abstract
Objective To evaluate how selection of patients for high sensitivity cardiac troponin testing affects the diagnosis of myocardial infarction across different healthcare settings.Design Prospective study of three independent consecutive patient populations presenting to emergency departments.Setting Secondary and tertiary care hospitals in the United Kingdom and United States.Participants High sensitivity cardiac troponin I concentrations were measured in 8500 consecutive patients presenting to emergency departments: unselected patients in the UK (n=1054) and two selected populations of patients in whom troponin testing was requested by the attending clinician in the UK (n=5815) and the US (n=1631). The final diagnosis of type 1 or type 2 myocardial infarction or myocardial injury was independently adjudicated.Main outcome measures Positive predictive value of an elevated cardiac troponin concentration for a diagnosis of type 1 myocardial infarction.Results Cardiac troponin concentrations were elevated in 13.7% (144/1054) of unselected patients, with a prevalence of 1.6% (17/1054) for type 1 myocardial infarction and a positive predictive value of 11.8% (95% confidence interval 7.0% to 18.2%). In selected patients, in whom troponin testing was guided by the attending clinician, the prevalence and positive predictive value were 14.5% (843/5815) and 59.7% (57.0% to 62.2%) in the UK and 4.2% (68/1631) and 16.4% (13.0% to 20.3%) in the US. Across both selected patient populations, the positive predictive value was highest in patients with chest pain, with ischaemia on the electrocardiogram, and with a history of ischaemic heart disease.Conclusions When high sensitivity cardiac troponin testing is performed widely or without previous clinical assessment, elevated troponin concentrations are common and predominantly reflect myocardial injury rather than myocardial infarction. These observations highlight how selection of patients for cardiac troponin testing varies across healthcare settings and markedly influences the positive predictive value for a diagnosis of myocardial infarction.
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Affiliation(s)
- Anoop S V Shah
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh EH16 4SB, UK
| | - Yader Sandoval
- Division of Cardiology, Hennepin County Medical Center and Minneapolis Heart Institute, Abbott Northwestern Hospital, Minneapolis, MN, USA
| | - Ala Noaman
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh EH16 4SB, UK
| | - Anne Sexter
- Chronic Disease Research Group of Minneapolis Medical Research Foundation, Hennepin County Medical Center and University of Minnesota, Minneapolis, MN, USA
| | - Amar Vaswani
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh EH16 4SB, UK
| | - Stephen W Smith
- Department of Emergency Medicine, Hennepin County Medical Center and University of Minnesota, Minneapolis, Minnesota, USA
| | - Mathew Gibbins
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh EH16 4SB, UK
| | - Megan Griffiths
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh EH16 4SB, UK
| | - Andrew R Chapman
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh EH16 4SB, UK
| | - Fiona E Strachan
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh EH16 4SB, UK
| | - Atul Anand
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh EH16 4SB, UK
| | - Martin A Denvir
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh EH16 4SB, UK
| | - Philip D Adamson
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh EH16 4SB, UK
| | - Michelle S D'Souza
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh EH16 4SB, UK
| | - Alasdair J Gray
- Emergency Medicine Research Group Edinburgh (EMeRGE) and Department of Emergency Medicine, Royal Infirmary of Edinburgh, Edinburgh, UK
| | | | - David E Newby
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh EH16 4SB, UK
| | - Fred S Apple
- Department of Laboratory Medicine and Pathology, Hennepin County Medical Center and University of Minnesota, Minneapolis, MN, USA
| | - Nicholas L Mills
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh EH16 4SB, UK
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15
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Mokhtari A, Borna C, Gilje P, Tydén P, Lindahl B, Nilsson HJ, Khoshnood A, Björk J, Ekelund U. A 1-h Combination Algorithm Allows Fast Rule-Out and Rule-In of Major Adverse Cardiac Events. J Am Coll Cardiol 2017; 67:1531-1540. [PMID: 27150684 DOI: 10.1016/j.jacc.2016.01.059] [Citation(s) in RCA: 95] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2015] [Revised: 01/12/2016] [Accepted: 01/21/2016] [Indexed: 12/11/2022]
Abstract
BACKGROUND A 1-h algorithm based on high-sensitivity cardiac troponin T (hs-cTnT) testing at presentation and again 1 h thereafter has been shown to accurately rule out acute myocardial infarction. OBJECTIVES The goal of the study was to evaluate the diagnostic accuracy of the 1-h algorithm when supplemented with patient history and an electrocardiogram (ECG) (the extended algorithm) for predicting 30-day major adverse cardiac events (MACE) and to compare it with the algorithm using hs-cTnT alone (the troponin algorithm). METHODS This prospective observational study enrolled consecutive patients presenting to the emergency department (ED) with chest pain, for whom hs-cTnT testing was ordered at presentation. Hs-cTnT results at 1 h and the ED physician's assessments of patient history and ECG were collected. The primary outcome was an adjudicated diagnosis of 30-day MACE defined as acute myocardial infarction, unstable angina, cardiogenic shock, ventricular arrhythmia, atrioventricular block, cardiac arrest, or death of a cardiac or unknown cause. RESULTS In the final analysis, 1,038 patients were included. The extended algorithm identified 60% of all patients for rule-out and had a higher sensitivity than the troponin algorithm (97.5% vs. 87.6%; p < 0.001). The negative predictive value was 99.5% and the likelihood ratio was 0.04 with the extended algorithm versus 97.8% and 0.17, respectively, with the troponin algorithm. The extended algorithm ruled-in 14% of patients with a higher sensitivity (75.2% vs. 56.2%; p < 0.001) but a slightly lower specificity (94.0% vs. 96.4%; p < 0.001) than the troponin algorithm. The rule-in arms of both algorithms had a likelihood ratio >10. CONCLUSIONS A 1-h combination algorithm allowed fast rule-out and rule-in of 30-day MACE in a majority of ED patients with chest pain and performed better than the troponin-alone algorithm.
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Affiliation(s)
- Arash Mokhtari
- Department of Internal and Emergency Medicine, Skåne University Hospital, Lund, Sweden; Department of Cardiology, Skåne University Hospital, Lund, Sweden; Department of Clinical Sciences at Lund, Lund University, Lund, Sweden.
| | - Catharina Borna
- Department of Clinical Sciences at Lund, Lund University, Lund, Sweden; Division Specialised Local Health Care, Helsingborg General Hospital, Helsingborg, Sweden
| | - Patrik Gilje
- Department of Cardiology, Skåne University Hospital, Lund, Sweden
| | - Patrik Tydén
- Department of Cardiology, Skåne University Hospital, Lund, Sweden
| | - Bertil Lindahl
- Department of Medical Sciences and Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | | | - Ardavan Khoshnood
- Department of Internal and Emergency Medicine, Skåne University Hospital, Lund, Sweden; Department of Clinical Sciences at Lund, Lund University, Lund, Sweden
| | - Jonas Björk
- Occupational and Environmental Medicine, Lund University, Lund, Sweden
| | - Ulf Ekelund
- Department of Internal and Emergency Medicine, Skåne University Hospital, Lund, Sweden; Department of Clinical Sciences at Lund, Lund University, Lund, Sweden
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16
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Yiadom MYAB, Liu X, McWade CM, Liu D, Storrow AB. Acute Coronary Syndrome Screening and Diagnostic Practice Variation. Acad Emerg Med 2017; 24:701-709. [DOI: 10.1111/acem.13184] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2017] [Revised: 02/18/2017] [Accepted: 02/27/2017] [Indexed: 01/16/2023]
Affiliation(s)
| | - Xulei Liu
- Department of Biostatistics; Vanderbilt University; Nashville TN
| | - Conor M. McWade
- Schools of Medicine and Public Health; Vanderbilt University; Nashville TN
| | - Dandan Liu
- Department of Biostatistics; Vanderbilt University; Nashville TN
| | - Alan B. Storrow
- Department of Emergency Medicine; Vanderbilt University; Nashville TN
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17
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Hazarika S, Annex BH. Circulating micro-RNAs as biomarkers of coronary artery disease: is it ready for primetime or still a work in progress? ANNALS OF TRANSLATIONAL MEDICINE 2017; 5:10. [PMID: 28164095 DOI: 10.21037/atm.2017.01.05] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Affiliation(s)
- Surovi Hazarika
- Division of Cardiovascular Medicine, Robert M. Berne Cardiovascular Research Center, University of Virginia, Charlottesville, USA
| | - Brian H Annex
- Division of Cardiovascular Medicine, Robert M. Berne Cardiovascular Research Center, University of Virginia, Charlottesville, USA
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18
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Pretorius CJ, Ungerer JPJ. Improved Diagnostic Performance of High-Sensitivity Cardiac Troponin Assays Is an Artifact of Censored Data. Clin Chem 2016; 62:1654-1657. [DOI: 10.1373/clinchem.2016.262634] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2016] [Accepted: 07/27/2016] [Indexed: 11/06/2022]
Abstract
Abstract
BACKGROUND
High-sensitivity cardiac troponin assays with improved analytical performance at low concentrations are credited with increased diagnostic sensitivity in acute coronary syndrome patients. We investigated the relationship between analytical sensitivity (detection capability) and diagnostic accuracy and tested the effect of censoring data with a software model.
METHOD
We generated 4 sets of results with decreasing detection capability and compared the ROC curves with and without censored data.
RESULTS
There was no relationship between diagnostic performance and detection capability. When data were censored the diagnostic accuracy decreased progressively with an increase in the threshold concentration for censoring. The ROC curves constructed with censored data have a characteristic appearance with a straight line between the censoring point and the top right hand corner.
CONCLUSIONS
There is not a direct relationship between the diagnostic accuracy and the detection capability of cardiac troponin assays. The artifactual decrease in diagnostic accuracy can be added to the list of reasons why data should not be censored and this practice should be disclosed in studies on diagnostic accuracy.
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Affiliation(s)
- Carel J Pretorius
- Department of Chemical Pathology, Pathology Queensland, Queensland Health, Brisbane, Australia
- University of Queensland, School of Medicine, Brisbane, Australia
| | - Jacobus P J Ungerer
- Department of Chemical Pathology, Pathology Queensland, Queensland Health, Brisbane, Australia
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19
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An incremental double-layer capacitance of a planar nano gap and its application in cardiac-troponin T detection. Biosens Bioelectron 2015; 79:636-43. [PMID: 26761619 DOI: 10.1016/j.bios.2015.12.105] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2015] [Revised: 12/24/2015] [Accepted: 12/29/2015] [Indexed: 11/20/2022]
Abstract
Surface potential is one of the most important properties at solid-liquid interfaces. It can be modulated by the voltage applied on the electrode or by the surface properties. Hence, surface potential is a good indicator for surface modifications, such as biomolecular bindings. In this work, we proposed a planar nano-gap structure for surface-potential difference monitoring. Based on the proposed architecture, the variance of surface-potential difference can be determined by electrical double layer capacitance (EDLC) between the nano-gap electrodes. Using cyclic voltammetry method, in this work, we demonstrated a relationship between surface potential and EDLC by chemically modifying surface properties. Finally, we also showed the proposed planar nano-gap device provides the capability for cardiac-troponin T (cTnT) measurements with co-existed 10 µg/ml BSA interference. The detection dynamic range is from 100 pg/ml to 1 µg/ml. Based on experimental results and extrapolation, the detection limit is less than 100 pg/ml in diluted PBS buffer (0.01X PBS). These results demonstrated the planar nano-gap architecture having potentials on biomolecular detection through monitoring of surface-potential variation.
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20
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Lee J, Young J, Frampton C, Aldous S, Troughton R, Than M, Richards A, Pemberton C. A novel troponin T peptide in humans: Assay, biochemistry and preliminary findings in acute coronary syndromes. Int J Cardiol 2015; 190:68-74. [DOI: 10.1016/j.ijcard.2015.04.145] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2014] [Revised: 03/17/2015] [Accepted: 04/16/2015] [Indexed: 10/23/2022]
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21
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Saad YME, McEwan J, Shugman IM, Mussap C, Juergens CP, Ferguson I, French JK. Use of a high-sensitivity troponin T assay in the assessment and disposition of patients attending a tertiary Australian emergency department: A cross-sectional pilot study. Emerg Med Australas 2015; 27:405-11. [DOI: 10.1111/1742-6723.12430] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/25/2015] [Indexed: 11/29/2022]
Affiliation(s)
- Yousef ME Saad
- Department of Cardiology; Liverpool Hospital; Sydney New South Wales Australia
- South Western Sydney Clinical School; The University of New South Wales; Sydney New South Wales Australia
| | - James McEwan
- South Western Sydney Clinical School; The University of New South Wales; Sydney New South Wales Australia
- Department of Emergency; Liverpool Hospital; Sydney New South Wales Australia
| | - Ibrahim M Shugman
- Department of Cardiology; Liverpool Hospital; Sydney New South Wales Australia
- South Western Sydney Clinical School; The University of New South Wales; Sydney New South Wales Australia
| | - Christian Mussap
- Department of Cardiology; Liverpool Hospital; Sydney New South Wales Australia
- South Western Sydney Clinical School; The University of New South Wales; Sydney New South Wales Australia
| | - Craig P Juergens
- Department of Cardiology; Liverpool Hospital; Sydney New South Wales Australia
- South Western Sydney Clinical School; The University of New South Wales; Sydney New South Wales Australia
| | - Ian Ferguson
- South Western Sydney Clinical School; The University of New South Wales; Sydney New South Wales Australia
- Department of Emergency; Liverpool Hospital; Sydney New South Wales Australia
| | - John K French
- Department of Cardiology; Liverpool Hospital; Sydney New South Wales Australia
- South Western Sydney Clinical School; The University of New South Wales; Sydney New South Wales Australia
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22
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Chawla LS, Goldstein SL, Kellum JA, Ronco C. Renal angina: concept and development of pretest probability assessment in acute kidney injury. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2015; 19:93. [PMID: 25887311 PMCID: PMC4344798 DOI: 10.1186/s13054-015-0779-y] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
The context of a diagnostic test is a critical component for the interpretation of its result. This context defines the pretest probability of the diagnosis and forms the basis for the interpretation and value of adding the diagnostic test. In the field of acute kidney injury, a multitude of early diagnostic biomarkers have been developed, but utilization in the appropriate context is less well understood and has not been codified until recently. In order to better operationalize the context and pretest probability assessment for acute kidney injury diagnosis, the renal angina concept was proposed in 2010 for use in both children and adults. Renal angina has been assessed in approximately 1,000 subjects. However, renal angina as a concept is still unfamiliar to most clinicians and the rationale for introducing the term is not obvious. We therefore review the concept and development of renal angina, and the currently available data validating it. We discuss the various arguments for and against this construct. Future research testing the performance of renal angina with acute kidney injury biomarkers is warranted.
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Affiliation(s)
- Lakhmir S Chawla
- Department of Medicine, Division of Intensive Care Medicine and Division of Nephrology, Veterans Affairs Medical Center, 50 Irving Street, Washington, DC, 20422, USA. .,Department of Anesthesiology and Critical Care Medicine, George Washington University Medical Center, 900 23rd Street, Washington, DC, 20037, USA.
| | - Stuart L Goldstein
- Center for Acute Care Nephrology, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, MLC 7022, RILF2, Cininnati, OH, USA.
| | - John A Kellum
- Department of Critical Care Medicine, Center for Critical Care Nephrology, The CRISMA (Clinical Research, Investigation, and Systems Modeling of Acute Illness) Center, University of Pittsburgh School of Medicine, 3550 Terrace Street, Pittsburgh, PA, 15261, USA.
| | - Claudio Ronco
- Department of Nephrology, Dialysis & Transplantation, International Renal Research Institute, San Bortolo Hospital, Via Bertesina, Vicenza, 36100, Italy.
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23
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Positive predictive value of an elevated cardiac troponin for type I myocardial infarction in ED patients based on the chief complaint. Am J Emerg Med 2015; 33:516-20. [PMID: 25680564 DOI: 10.1016/j.ajem.2015.01.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2014] [Revised: 01/06/2015] [Accepted: 01/07/2015] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Cardiac troponin testing is used to aid the diagnosis of myocardial infarction (MI) in the emergency department (ED) for patients who present with a range of symptoms. From a clinical perspective, the distinction between MI due to acute coronary artery thrombosis (type I MI) and other forms of direct and secondary myocardial injury (type II MI) is very important. However, the positive predictive value (PPV) of an elevated troponin for diagnosing type I MI, based on clinical history, has not been described. The objective of this study was to determine the PPV of an elevated troponin for type I MI based on the ED chief complaint. METHODS We retrospectively reviewed the medical records of 1772 consecutive patients who had a troponin ordered in the ED at a tertiary care center over the period of March 1, 2013, to April 30, 2013. The chief complaint was based on official ED coding. For patients with a positive troponin, 2 authors independently reviewed the electronic medical record pertaining to the index encounter and subsequent hospitalization to adjudicate the cause. RESULTS There was a significant association between the PPV of an elevated troponin for type I MI and the chief complaint. Patients with a chief complaint of chest pain were significantly more likely to have a type I MI compared to those without (PPV 84% vs 20%; Adjusted Odds Ratio (AOR), 14.31; P < .0001). There was also a significant association between the rate of type I MI and the chief complaint in all patients who had a troponin drawn. Patients with a chief complaint of chest pain were significantly more likely to have a type I MI compared to those without (PPV 9.8% vs 1.3%; AOR, 7.34; P < .0001). CONCLUSION Applying information on the PPV of troponin for type I MI based on the clinical history could improve troponin utilization and clinical decision making.
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Zhelev Z, Hyde C, Youngman E, Rogers M, Fleming S, Slade T, Coelho H, Jones-Hughes T, Nikolaou V. Diagnostic accuracy of single baseline measurement of Elecsys Troponin T high-sensitive assay for diagnosis of acute myocardial infarction in emergency department: systematic review and meta-analysis. BMJ 2015; 350:h15. [PMID: 25646632 PMCID: PMC4300724 DOI: 10.1136/bmj.h15] [Citation(s) in RCA: 139] [Impact Index Per Article: 15.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/10/2014] [Indexed: 12/29/2022]
Abstract
OBJECTIVE To obtain summary estimates of the accuracy of a single baseline measurement of the Elecsys Troponin T high-sensitive assay (Roche Diagnostics) for the diagnosis of acute myocardial infarction in patients presenting to the emergency department. DESIGN Systematic review and meta-analysis of diagnostic test accuracy studies. DATA SOURCES Medline, Embase, and other relevant electronic databases were searched for papers published between January 2006 and December 2013. STUDY SELECTION Studies were included if they evaluated the diagnostic accuracy of a single baseline measurement of Elecsys Troponin T high-sensitive assay for the diagnosis of acute myocardial infarction in patients presenting to the emergency department with suspected acute coronary syndrome. STUDY APPRAISAL AND DATA SYNTHESIS The first author screened all titles and abstracts identified through the searches and selected all potentially relevant papers. The screening of the full texts, the data extraction, and the methodological quality assessment, using the adapted QUADAS-2 tool, were conducted independently by two reviewers with disagreements being resolved through discussion or arbitration. If appropriate, meta-analysis was conducted using the hierarchical bivariate model. RESULTS Twenty three studies reported the performance of the evaluated assay at presentation. The results for 14 ng/L and 3-5 ng/L cut-off values were pooled separately. At 14 ng/L (20 papers), the summary sensitivity was 89.5% (95% confidence interval 86.3% to 92.1%) and the summary specificity was 77.1% (68.7% to 83.7%). At 3-5 ng/L (six papers), the summary sensitivity was 97.4% (94.9% to 98.7%) and the summary specificity was 42.4% (31.2% to 54.5%). This means that if 21 of 100 consecutive patients have the target condition (21%, the median prevalence across the studies), 2 (95% confidence interval 2 to 3) of 21 patients with acute myocardial infarction will be missed (false negatives) if 14 ng/L is used as a cut-off value and 18 (13 to 25) of 79 patients without acute myocardial infarction will test positive (false positives). If the 3-5 ng/L cut-off value is used, <1 (0 to 1) patient with acute myocardial infarction will be missed and 46 (36 to 54) patients without acute myocardial infarction will test positive. CONCLUSIONS The results indicate that a single baseline measurement of the Elecsys Troponin T high-sensitive assay could be used to rule out acute myocardial infarction if lower cut-off values such as 3 ng/L or 5 ng/L are used. However, this method should be part of a comprehensive triage strategy and may not be appropriate for patients who present less than three hours after symptom onset. Care must also be exercised because of the higher imprecision of the evaluated assay and the greater effect of lot-to-lot reagent variation at low troponin concentrations. SYSTEMATIC REVIEW REGISTRATION PROSPERO registration number CRD42013003926.
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Affiliation(s)
- Zhivko Zhelev
- Institute of Health Research, University of Exeter Medical School, Exeter EX2 4SG, UK
| | - Christopher Hyde
- Institute of Health Research, University of Exeter Medical School, Exeter EX2 4SG, UK
| | - Emily Youngman
- Institute of Health Research, University of Exeter Medical School, Exeter EX2 4SG, UK
| | - Morwenna Rogers
- Institute of Health Research, University of Exeter Medical School, Exeter EX2 4SG, UK
| | - Simon Fleming
- Clinical Chemistry, Royal Cornwall Hospital, Treliske, Truro TR1 3LQ, UK
| | - Toby Slade
- Emergency Department, Royal Cornwall Hospital, Truro TR1 3LJ, UK
| | - Helen Coelho
- Institute of Health Research, University of Exeter Medical School, Exeter EX2 4SG, UK
| | - Tracey Jones-Hughes
- Institute of Health Research, University of Exeter Medical School, Exeter EX2 4SG, UK
| | - Vasilis Nikolaou
- Institute of Health Research, University of Exeter Medical School, Exeter EX2 4SG, UK
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Senn A, Meagher T. Highly Sensitive Troponin and Critical Illness Insurance: Have the Goalposts Moved Again? J Insur Med 2015; 45:153-8. [PMID: 27584922 DOI: 10.17849/0743-6661-45.3.153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
An elevated cardiac troponin is a sine qua non for the clinical diagnosis of myocardial infarction. The sensitivity of troponin assays has improved repeatedly since troponin entered clinical use in the late 1990s. Its most recent iteration, "highly sensitive" troponin will shortly enter clinical use in North America. It is able to detect amounts of troponin 10 times smaller than the current assay. As a result, more myocardial infarctions will be diagnosed. This may have an impact on the number of critical illness claims for heart attack.
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Affiliation(s)
- Alban Senn
- Author Affiliations: Senn - Medical Officer, Munich Re, Munich, Germany; Meagher - Vice-President and Medical Director, Munich Re, Montreal; Associate Professor of Medicine, McGill University, Montréal, Québec
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Lipinski MJ, Baker NC, Escárcega RO, Torguson R, Chen F, Aldous SJ, Christ M, Collinson PO, Goodacre SW, Mair J, Inoue K, Lotze U, Sebbane M, Cristol JP, Freund Y, Chenevier-Gobeaux C, Meune C, Eggers KM, Pracoń R, Schreiber DH, Wu AHB, Ordoñez-Llanos J, Jaffe AS, Twerenbold R, Mueller C, Waksman R. Comparison of conventional and high-sensitivity troponin in patients with chest pain: a collaborative meta-analysis. Am Heart J 2015; 169:6-16.e6. [PMID: 25497242 DOI: 10.1016/j.ahj.2014.10.007] [Citation(s) in RCA: 68] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2014] [Accepted: 10/10/2014] [Indexed: 02/07/2023]
Abstract
BACKGROUND Multiple studies have evaluated the diagnostic and prognostic performance of conventional troponin (cTn) and high-sensitivity troponin (hs-cTn). We performed a collaborative meta-analysis comparing cTn and hs-cTn for diagnosis of acute myocardial infarction (AMI) and assessment of prognosis in patients with chest pain. METHODS MEDLINE/PubMed, Cochrane CENTRAL, and EMBASE were searched for studies assessing both cTn and hs-cTn in patients with chest pain. Study authors were contacted and many provided previously unpublished data. RESULTS From 17 included studies, there were 8,644 patients. Compared with baseline cTn, baseline hs-cTn had significantly greater sensitivity (0.884 vs 0.749, P < .001) and negative predictive value (NPV; 0.964 vs 0.935, P < .001), whereas specificity (0.816 vs 0.938, P < .001) and positive predictive value (0.558 vs 0.759, P < .001) were significantly reduced. Based on summary receiver operating characteristic curves, test performance for the diagnosis of AMI was not significantly different between baseline cTn and hs-cTn (0.90 [95% CI 0.85-0.95] vs 0.92 [95% CI 0.90-0.94]). In a subanalysis of 6 studies that alternatively defined AMI based on hs-cTn, cTn had lower sensitivity (0.666, P < .001) and NPV (0.906, P < .001). Elevation of baseline hs-cTn, but negative baseline cTn, was associated with increased risk of death or nonfatal myocardial infarction during follow-up (P < .001) compared with both negative. CONCLUSION High-sensitivity troponin has significantly greater early sensitivity and NPV for the diagnosis of AMI at the cost of specificity and positive predictive value, which may enable early rule in/out of AMI in patients with chest pain. Baseline hs-cTn elevation in the setting of negative cTn is also associated with increased nonfatal myocardial infarction or death during follow-up.
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Affiliation(s)
- Michael J Lipinski
- MedStar Cardiovascular Research Network, MedStar Heart Institute, Medstar Washington Hospital Center, Washington, DC
| | - Nevin C Baker
- MedStar Cardiovascular Research Network, MedStar Heart Institute, Medstar Washington Hospital Center, Washington, DC
| | - Ricardo O Escárcega
- MedStar Cardiovascular Research Network, MedStar Heart Institute, Medstar Washington Hospital Center, Washington, DC
| | - Rebecca Torguson
- MedStar Cardiovascular Research Network, MedStar Heart Institute, Medstar Washington Hospital Center, Washington, DC
| | - Fang Chen
- MedStar Cardiovascular Research Network, MedStar Heart Institute, Medstar Washington Hospital Center, Washington, DC
| | - Sally J Aldous
- Department of Cardiology, Christchurch Hospital, Christchurch, New Zealand
| | - Michael Christ
- Department of Emergency and Critical Care Medicine, Paracelsus Medical University, Nuremberg, Germany
| | - Paul O Collinson
- Clinical Blood Sciences Laboratory, St George's Hospital, London, United Kingdom
| | - Steve W Goodacre
- School of Health and Related Research, University of Sheffield, Sheffield, United Kingdom
| | - Johannes Mair
- Department of Internal Medicine, Innsbruck Medical University, Innsbruck, Austria
| | - Kenji Inoue
- Department of Cardiology, Juntendo University Nerima Hospital, Tokyo, Japan
| | - Ulrich Lotze
- Department of Internal Medicine, DRK-Manniske-Krankenhaus Bad Frankenhausen, Frankenhausen, Germany
| | - Mustapha Sebbane
- Départment des urgences, Centre Hospitalier Régional Universitaire Lapeyronie, Montpellier, France
| | - Jean-Paul Cristol
- Département de Biochimie, Centre Hospitalier Régional Universitaire Lapeyronie, Montpellier, France
| | - Yonathan Freund
- Department of Emergency Medicine and Surgery, Hôspital Pitié-Salpétrière, APHP, Université Pierre et Marie Curie-Paris 6 (UPMC), Paris, France
| | - Camille Chenevier-Gobeaux
- Clinical Chemistry Laboratory, Groupe Hospitalier Cochin-Broca-Hôtel Dieu, Université Paris Descartes, Assistance Publique des Hôpitaux de Paris, Paris, France
| | - Christophe Meune
- Cardiology Department, Groupe Hospitalier Cochin-Broca-Hôtel Dieu, Université Paris Descartes, Assistance Publique des Hôpitaux de Paris, Paris, France; Cardiology Department, Paris XIII University, Avicenne Hospital, Bobigny, France
| | - Kai M Eggers
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - Radosław Pracoń
- Department of Coronary and Structural Heart Diseases, National Insititute of Cardiology, Warsaw, Poland
| | - Donald H Schreiber
- Division of Emergency Medicine, Stanford University School of Medicine, Stanford, CA
| | - Alan H B Wu
- Department of Laboratory Medicine, University of California, San Francisco, CA
| | - Jordi Ordoñez-Llanos
- Servei de Bioquímica Clínica, Hospital de Sant Pau, Barcelona, Spain; Biochemistry and Molecular Biology Department, Universitat Autònoma, Barcelona, Spain
| | - Allan S Jaffe
- Division of Cardiology, Mayo Clinic College of Medicine, Rochester, MN; Department of Laboratory Medicine and Pathology, Mayo Clinic College of Medicine, Rochester, MN
| | - Raphael Twerenbold
- Department of Cardiology, University Hospital Basel, Basel, Switzerland; Universitäres Herz-Zentrum Bad Krozingen, Bad Krozingen, Germany
| | - Christian Mueller
- Department of Cardiology, University Hospital Basel, Basel, Switzerland
| | - Ron Waksman
- MedStar Cardiovascular Research Network, MedStar Heart Institute, Medstar Washington Hospital Center, Washington, DC.
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Corsini A, Vagnarelli F, Bugani G, Bacchi Reggiani ML, Semprini F, Nanni S, Cinti L, Norscini G, Vannini A, Beltrandi E, Cavazza M, Branzi A, Rapezzi C, Melandri G. Impact of high-sensitivity Troponin T on hospital admission, resources utilization, and outcomes. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2014; 4:148-57. [PMID: 25124535 DOI: 10.1177/2048872614547687] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
AIMS The use of high-sensitivity cardiac Troponin T (hs-cTnT) assay might lead to overdiagnosis and overtreatment of Acute Coronary Syndromes (ACS). This study assessed the epidemiological, clinical and prognostic impact of introducing hs-cTnT in the everyday clinical practice of an Emergency Department. METHODS AND RESULTS We compared all consecutive patients presenting with suspected ACS at the Emergency Department, for whom troponin levels were measured. In particular, we considered 597 patients presenting during March 2010, when standard cardiac Troponin T (cTnT) assay was used, and 629 patients presenting during March 2011, when hs-cTnT test was used. Patients with suspected ACS and troponin levels above the 99th percentile (Upper Reference Limit, URL) significantly increased when using an hs-cTnT assay (17.2% vs. 37.4%, p< 0.001). Accordingly, also the mean GRACE risk score increased (124.2 ± 37.2 vs. 136.7 ± 32.2; p< 0.001). However, the final diagnosis of Acute Myocardial Infarction (AMI) did not change significantly (8.7% vs. 6.8%, p=0.263) by using a rising and/or falling pattern of hs-cTnT (change ≥ 50% or ≥ 20% depending on baseline values). In addition, no significant differences were found between the two study groups with respect to in-hospital (2.7% vs. 1.9%, p=0.366) and 1-year mortality (9.8% vs. 7.6%, p=0.216). CONCLUSIONS We did not observe overdiagnosis and overtreatment issues in presenters with suspected ACS managed by appropriate changes in hs-cTnT levels, despite the increase in the number of patients presenting with abnormal troponin levels. This occurred without a rise in short-term and mid-term mortality.
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Affiliation(s)
- Anna Corsini
- Institute of Cardiology, Cardio-Thoraco-Vascular Department, Sant'Orsola-Malpighi Hospital and University of Bologna, Italy
| | - Fabio Vagnarelli
- Institute of Cardiology, Cardio-Thoraco-Vascular Department, Sant'Orsola-Malpighi Hospital and University of Bologna, Italy
| | - Giulia Bugani
- Institute of Cardiology, Cardio-Thoraco-Vascular Department, Sant'Orsola-Malpighi Hospital and University of Bologna, Italy
| | - Maria Letizia Bacchi Reggiani
- Institute of Cardiology, Cardio-Thoraco-Vascular Department, Sant'Orsola-Malpighi Hospital and University of Bologna, Italy
| | - Franco Semprini
- Institute of Cardiology, Cardio-Thoraco-Vascular Department, Sant'Orsola-Malpighi Hospital and University of Bologna, Italy
| | - Samuele Nanni
- Institute of Cardiology, Cardio-Thoraco-Vascular Department, Sant'Orsola-Malpighi Hospital and University of Bologna, Italy
| | - Laura Cinti
- Institute of Cardiology, Cardio-Thoraco-Vascular Department, Sant'Orsola-Malpighi Hospital and University of Bologna, Italy
| | - Giulia Norscini
- Institute of Cardiology, Cardio-Thoraco-Vascular Department, Sant'Orsola-Malpighi Hospital and University of Bologna, Italy
| | - Antonio Vannini
- Emergency and Surgical-Transplantation Department, Sant'Orsola-Malpighi Hospital, Bologna, Italy
| | - Elisabetta Beltrandi
- Haematology, Oncology and Laboratory Medicine Department, Sant'Orsola-Malpighi Hospital, Bologna, Italy
| | - Mario Cavazza
- Emergency and Surgical-Transplantation Department, Sant'Orsola-Malpighi Hospital, Bologna, Italy
| | - Angelo Branzi
- Institute of Cardiology, Cardio-Thoraco-Vascular Department, Sant'Orsola-Malpighi Hospital and University of Bologna, Italy
| | - Claudio Rapezzi
- Institute of Cardiology, Cardio-Thoraco-Vascular Department, Sant'Orsola-Malpighi Hospital and University of Bologna, Italy
| | - Giovanni Melandri
- Institute of Cardiology, Cardio-Thoraco-Vascular Department, Sant'Orsola-Malpighi Hospital and University of Bologna, Italy
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Mair J. High-sensitivity cardiac troponins in everyday clinical practice. World J Cardiol 2014; 6:175-182. [PMID: 24772257 PMCID: PMC3999337 DOI: 10.4330/wjc.v6.i4.175] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2013] [Accepted: 03/17/2014] [Indexed: 02/06/2023] Open
Abstract
High-sensitivity cardiac troponin (hs-cTn) assays are increasingly being used in many countries worldwide, however, a generally accepted definition of high-sensitivity is still pending. These assays enable cTn measurement with a high degree of analytical sensitivity with a low analytical imprecision at the low measuring range of cTn assays (coefficient of variation of < 10% at the 99th percentile upper reference limit). One of the most important advantages of these new assays is that they allow novel, more rapid approaches to rule in or rule out acute coronary syndromes (ACSs) than with previous cTn assay generations which are still more commonly used in practice worldwide. hs-cTn is also more sensitive for the detection of myocardial damage unrelated to acute myocardial ischemia. Therefore, the increase in early diagnostic sensitivity of hs-cTn assays for ACS comes at the cost of a reduced ACS specificity, because more patients with other causes of acute or chronic myocardial injury without overt myocardial ischemia are detected than with previous cTn assays. As hs-cTn assays are increasingly being adopted in clinical practice and more hs-cTn assays are being developed, this review attempts to synthesize the available clinical data to make recommendations for their everyday clinical routine use.
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Chatterjee S, Kim J, Dahhan A, Choudhary G, Sharma S, Wu WC. Use of high-sensitivity troponin assays predicts mortality in patients with normal conventional troponin assays on admission-insights from a meta-analysis. Clin Cardiol 2013; 36:649-53. [PMID: 24037966 DOI: 10.1002/clc.22196] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2013] [Accepted: 07/15/2013] [Indexed: 11/05/2022] Open
Abstract
BACKGROUND Use of high-sensitivity troponin (hs-Tn) assays can detect small levels of myocardial damage previously undetectable with conventional troponin (c-Tn) assays. However, prognostic utility of these hs-Tn assays in prediction of mortality remains unclear in the presence of nonelevated c-Tn levels on admission. A systematic review and meta-analysis was performed to assess mortality risk of patients with hs-Tn elevations in the setting of normal c-Tn levels. HYPOTHESIS Patients with hs-Tn elevations with normal c-Tn levels on admission blood samples, drawn to rule out acute coronary syndrome (ACS), have a higher mortality risk than those without hs-Tn or c-Tn elevations. METHODS A search was made of the PubMed, CENTRAL, EMBASE, CINAHL, EBSCO, and Web of Science databases. Studies evaluating patients with suspected ACS that reported mortality rates for those with elevated hs-Tn levels but normal c-Tn levels on admission were included. A random-effects model was used to pool event rates, and data were reported in odds ratios (95% confidence interval). RESULTS Four studies (N = 2033, mean age 64-75 years, 49%-70% male) revealed that nearly 32% of suspected ACS patients with normal c-Tn levels on admission had elevated hs-Tn levels. Elevated hs-Tn levels conferred a significantly higher risk of all-cause mortality vs normal hs-Tn levels (odds ratio: 4.35, 95% confidence interval: 2.81-6.73, P < 0.01), with negligible heterogeneity (I(2) = 0%). CONCLUSIONS Elevation of hs-Tn levels predicted a higher risk of mortality in patients with suspected ACS and may aid in the early identification of higher-risk patients in this setting. Future studies are needed to investigate further optimal management strategies.
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Affiliation(s)
- Saurav Chatterjee
- Division of Cardiology, Providence VA Medical Center, Providence, Rhode Island; Department of Medicine, Brown University, Providence, Rhode Island
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