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Li Z, Boeddinghaus J, Mills NL. Cardiac Troponin I or T for the Diagnosis of Myocardial Infarction and Prediction of Outcomes-Does It Matter? Clin Chem 2024:hvae123. [PMID: 39185732 DOI: 10.1093/clinchem/hvae123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2024] [Accepted: 08/05/2024] [Indexed: 08/27/2024]
Affiliation(s)
- Ziwen Li
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
| | - Jasper Boeddinghaus
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Nicholas L Mills
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
- Usher Institute, University of Edinburgh, Edinburgh, United Kingdom
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2
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Ameh A, Brady JJ. Reference intervals for high sensitivity cardiac troponin I and N-terminal pro-B-type natriuretic peptide in children and adolescents on the Siemens Atellica. Clin Chem Lab Med 2024; 62:1636-1642. [PMID: 38373095 DOI: 10.1515/cclm-2023-0977] [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: 09/04/2023] [Accepted: 02/07/2024] [Indexed: 02/21/2024]
Abstract
OBJECTIVES The cardiac biomarkers high sensitivity cardiac troponin I (hs-cTnI) and N-terminal pro-B-type natriuretic peptide (NT-proBNP) are utilised in paediatric healthcare for the diagnosis and prognostic assessment of many conditions including myocarditis, congenital heart disease, multisystem inflammatory syndrome in children (MIS-C) and heart failure. However, the standardised age-related reference intervals, 99th percentile cut-offs and clinical guidelines are not available, making the interpretation of these biomarkers challenging. This study aimed to generate normative data in a paediatric cohort for the Siemens Atellica® IM 1300 analyser. METHODS Residual plasma samples were collected from children aged up to 17 years attending primary care and out-patient settings and with no apparent evidence of cardiac dysfunction, renal dysfunction or other confounders. Reference intervals were generated using the 2.5th-97.5th percentiles, and 99th percentile cut-offs determined according to CLSI EP28-A3c. RESULTS Statistical analysis revealed that partitioning was not required for gender for either biomarker. The reference interval for hs-cTnI for children aged one month to 16 years (n=292, 146 females and 146 males) was <14 ng/L with a 99th percentile cut-off of 19 ng/L. The reference interval for NT-proBNP for children aged one month up to one year was <714 ng/L (n=14) and for children aged 1-16 years (n=339) was <295 ng/L. CONCLUSIONS This is the first paediatric reference interval data generated on the Siemens Atellica® solution. These reference intervals and 99th percentiles will inform clinical decisions in the paediatric cardiology setting.
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Affiliation(s)
- Akoji Ameh
- Department of Biochemistry, Children's Health Ireland at Crumlin, Dublin, Republic of Ireland
| | - Jennifer J Brady
- Department of Biochemistry, Children's Health Ireland at Crumlin, Dublin, Republic of Ireland
- School of Medicine, University College Dublin, Dublin, Ireland
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3
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Zalama-Sánchez D, del Pozo Vegas C, Sanz-García A, de Santos-Castro PÁ, Presencio-Dominguez J, González-Izquierdo P, Sánchez-Ramón S, Pinilla-Arribas LT, Baladrón-Segura M, Cheayeb-Morán J, Fernandez-García M, Velasco de Cos G, López-Izquierdo R, Martín-Rodríguez F. Diagnostic Performance of Point-of-Care High-Sensitivity Troponin in the Exclusion of Non-ST-Elevation Myocardial Infarction in the Emergency Department. J Pers Med 2024; 14:762. [PMID: 39064016 PMCID: PMC11277698 DOI: 10.3390/jpm14070762] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2024] [Revised: 07/12/2024] [Accepted: 07/14/2024] [Indexed: 07/28/2024] Open
Abstract
BACKGROUND This study evaluates the diagnostic performance of high-sensitivity troponin using point-of-care testing (POCT) devices compared with main laboratory measurements for ruling out non-ST-elevation myocardial infarction (NSTEMI) in emergency department (ED) patients presenting with non-traumatic chest pain. METHODS This multicenter, observational, prospective, non-interventional study was conducted in two Spanish hospitals from 1 June to 31 December 2023 and included adult patients presenting with non-traumatic chest pain admitted to the ED. High-sensitivity troponin levels were measured using both the Siemens Atellica® VTLi POCT device and main laboratory testing, with data collected on analytical results and measurement times. RESULTS Of the 201 patients who met the inclusion criteria, a significant correlation was observed between the POCT and laboratory assays. The area under the curve (AUC) of the ROC curve was consistently greater than 0.9, indicating a high diagnostic accuracy for ruling out NSTEMI. In addition, measurement times were significantly reduced using POCT compared to the core laboratory. CONCLUSION These results suggest that high-sensitivity troponin POCT devices offer comparable diagnostic performance to traditional laboratory methods for the diagnosis of NSTEMI in the emergency department, potentially speeding up clinical decisions and optimizing resource utilization.
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Affiliation(s)
- Daniel Zalama-Sánchez
- Emergency Department, Hospital Universitario Virgen de la Victoria, 29010 Málaga, Spain;
| | - Carlos del Pozo Vegas
- Faculty of Medicine, University of Valladolid, 47002 Valladolid, Spain; (C.d.P.V.); (R.L.-I.); (F.M.-R.)
- Emergency Department, Hospital Clínico Universitario, 47003 Valladolid, Spain; (P.Á.d.S.-C.); (P.G.-I.); (L.T.P.-A.); (J.C.-M.)
| | - Ancor Sanz-García
- Faculty of Health Sciences, University of Castilla la Mancha, 45600 Talavera de la Reina, Spain
- Technological Innovation Applied to Health Research Group (ITAS Group), Faculty of Health Sciences, University of Castilla La Mancha, 45004 Toledo, Spain
- Evaluación de Cuidados de Salud (ECUSAL), Instituto de Investigación Sanitaria de Castilla-La Mancha (IDISCAM), 45071 Toledo, Spain
| | - Pedro Ángel de Santos-Castro
- Emergency Department, Hospital Clínico Universitario, 47003 Valladolid, Spain; (P.Á.d.S.-C.); (P.G.-I.); (L.T.P.-A.); (J.C.-M.)
| | | | - Pablo González-Izquierdo
- Emergency Department, Hospital Clínico Universitario, 47003 Valladolid, Spain; (P.Á.d.S.-C.); (P.G.-I.); (L.T.P.-A.); (J.C.-M.)
| | - Susana Sánchez-Ramón
- Emergency Department, Hospital Universitario Rio Hortega, 47012 Valladolid, Spain; (J.P.-D.); (S.S.-R.)
| | - Leyre Teresa Pinilla-Arribas
- Emergency Department, Hospital Clínico Universitario, 47003 Valladolid, Spain; (P.Á.d.S.-C.); (P.G.-I.); (L.T.P.-A.); (J.C.-M.)
| | - Manuel Baladrón-Segura
- Clinical Analysis Department, Hospital Universitario Rio Hortega, 47012 Valladolid, Spain; (M.B.-S.); (M.F.-G.)
| | - Jaldún Cheayeb-Morán
- Emergency Department, Hospital Clínico Universitario, 47003 Valladolid, Spain; (P.Á.d.S.-C.); (P.G.-I.); (L.T.P.-A.); (J.C.-M.)
| | - María Fernandez-García
- Clinical Analysis Department, Hospital Universitario Rio Hortega, 47012 Valladolid, Spain; (M.B.-S.); (M.F.-G.)
| | | | - Raúl López-Izquierdo
- Faculty of Medicine, University of Valladolid, 47002 Valladolid, Spain; (C.d.P.V.); (R.L.-I.); (F.M.-R.)
- Emergency Department, Hospital Universitario Rio Hortega, 47012 Valladolid, Spain; (J.P.-D.); (S.S.-R.)
- CIBER of Respiratory Diseases (CIBERES), Institute of Health Carlos III, 28029 Madrid, Spain
| | - Francisco Martín-Rodríguez
- Faculty of Medicine, University of Valladolid, 47002 Valladolid, Spain; (C.d.P.V.); (R.L.-I.); (F.M.-R.)
- Advanced Life Support, Emergency Medical Services (SACYL), 47007 Valladolid, Spain
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4
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Sammartano A, Buonocore R, Fiorini R, Dieci E, Di Franco A, Di Stasi B, Tortorella G, Ippolito L. A Comparison Study: Possible Bias in Troponin I Measurement Obtained with a Point of Care Testing and a Central Laboratory Analyzers Employing Different Biological Matrices and Anticoagulants. Diagnostics (Basel) 2024; 14:1482. [PMID: 39061619 PMCID: PMC11275273 DOI: 10.3390/diagnostics14141482] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2024] [Revised: 06/25/2024] [Accepted: 06/28/2024] [Indexed: 07/28/2024] Open
Abstract
BACKGROUND high-sensitive cardiac TroponinI (hs-cTnI) is widely used for diagnosis of acute coronary syndromes. The latest recommendation for hs-cTnI determination is the protocol 0-1 h finalized to improve the rule out accuracy of the test. A Point of Care Testing able to guarantee these performances could be very useful due to reducing the turnaround time and ruling out patients suspected of ACS, especially by using biological matrices that are not required for centrifuge. The aim of our work is to compare the results for hs-cTnI obtained using different biological matrices and anticoagulants, obtained between Atellica® VTLi hs-cTnI POCT and Access AccuTnI+3 DxI800 performances, in order to establish a possible bias derived directly from these pre-analytical conditions. METHODS Li-heparinized pool samples were primary employ for hs-cTnI with Atellica® VTLi as whole blood, then centrifuged and tested on Atellica® VTLi and DxI800. K3EDTA pool samples were centrifuged and measured on DxI800 too. A comparison of methods was performed according to CLSI_EP-09A2 protocol. Constant and proportional errors were investigated with Deming regression. Bias between methods was evaluated with the Bland Altman test. RESULTS comparing whole blood lithium heparin results obtained with Atellica versus lithium heparin and K3EDTA plasma tested on DxI 800, the Deming regression revealed a proportional error, whereas in both cases Bland Altman highlighted a minimal underestimation. A similar performance was revealed when considering plasma lithium heparin tested on Atellica versus lithium heparin and K3EDTA plasma obtained with DxI800, confirming the same underestimation. Considering values close to the cut off, no significant differences were found. CONCLUSIONS in the laboratory, the estimation of the bias of two different analyzers is pivotal. Once more this is crucial when different biological matrices and anticoagulants are employed for the analysis. Our study demonstrates that no significant differences among the two matrices are present when comparing Atellica and DxI800 performances.
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Affiliation(s)
- Antonino Sammartano
- U.O. Clinical Pathology, Medical and Diagnostics Department P.O. Fidenza, Azienda AUSL of Parma, 43125 Parma, Italy;
| | - Ruggero Buonocore
- U.O. Biochemical, Department of Clinical Patology, Ospedale Guglielmo da Saliceto of Piacenza, 29121 Piacenza, Italy; (R.B.); (E.D.); (A.D.F.); (B.D.S.)
| | - Roberto Fiorini
- Emergency Department, Vaio Hospital, Azienda AUSL of Parma, 43125 Parma, Italy
| | - Elisabetta Dieci
- U.O. Biochemical, Department of Clinical Patology, Ospedale Guglielmo da Saliceto of Piacenza, 29121 Piacenza, Italy; (R.B.); (E.D.); (A.D.F.); (B.D.S.)
| | - Anna Di Franco
- U.O. Biochemical, Department of Clinical Patology, Ospedale Guglielmo da Saliceto of Piacenza, 29121 Piacenza, Italy; (R.B.); (E.D.); (A.D.F.); (B.D.S.)
| | - Bruna Di Stasi
- U.O. Biochemical, Department of Clinical Patology, Ospedale Guglielmo da Saliceto of Piacenza, 29121 Piacenza, Italy; (R.B.); (E.D.); (A.D.F.); (B.D.S.)
| | - Giovanni Tortorella
- Cardiology Unit, Medical and Diagnostics Department P.O. Fidenza, Azienda AUSL of Parma, 43125 Parma, Italy
| | - Luigi Ippolito
- U.O. Clinical Pathology, Medical and Diagnostics Department P.O. Fidenza, Azienda AUSL of Parma, 43125 Parma, Italy;
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5
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Pickering JW, Kavsak P, Christenson RH, Troughton RW, Pemberton CJ, Richards AM, Joyce L, Than MP. Determination of Clinically Acceptable Analytical Variation of Cardiac Troponin at Decision Thresholds. Clin Chem 2024; 70:967-977. [PMID: 38712541 DOI: 10.1093/clinchem/hvae059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2024] [Accepted: 04/01/2024] [Indexed: 05/08/2024]
Abstract
BACKGROUND Clinical decision-making for risk stratification for possible myocardial infarction (MI) uses high-sensitivity cardiac troponin (hs-cTn) thresholds that range from the limit of detection to several-fold higher than the upper reference limit (URL). To establish a minimum analytical variation standard, we can quantify the effect of variation on the population clinical measures of safety (sensitivity) and effectiveness [proportion below threshold, or positive predictive value (PPV)]. METHODS From large datasets of patients investigated for possible MI with the Abbott hs-cTnI and Roche hs-cTnT assays, we synthesized datasets of 1 000 000 simulated patients. Troponin concentrations were randomly varied several times based on absolute deviations of 0.5 to 3 ng/L and relative changes of 2% to 20% around the low-risk threshold (5 ng/L) and URLs, respectively. RESULTS For both assays at the low-risk thresholds, there were negligible differences in sensitivity (<0.3%) with increasing analytical variation. The proportion of patients characterized as low risk reduced by 30% to 29% (Roche) and 53% to 44% (Abbott). At the URL, increasing analytical variation also did not change sensitivity; the PPV fell by less than 3%. For risk stratification, increased delta thresholds (change between serial troponin concentrations) increased sensitivity at the cost of a decreased percentage of patients below the delta threshold, with the largest changes at the greatest analytical variation. CONCLUSIONS At the low-risk threshold, analytical variation up to 3 ng/L minimally impacted the safety metric (sensitivity) but marginally reduced effectiveness. Similarly, at the URL even relative variation up to 25% minimally impacted safety metrics and effectiveness. Analytical variation for delta thresholds did not negatively impact sensitivity but decreased effectiveness.
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Affiliation(s)
- John W Pickering
- Department of Emergency Medicine, Emergency Care Foundation, Christchurch Hospital, Christchurch, New Zealand
- Department of Medicine, Christchurch Heart Institute, University of Otago Christchurch, Christchurch, New Zealand
| | - Peter Kavsak
- Department of Pathology and Molecular Medicine, McMaster University, Hamilton, ON, Canada
| | - Robert H Christenson
- Department of Pathology, University of Maryland School of Medicine, Baltimore, MD, United States
| | - Richard W Troughton
- Department of Medicine, Christchurch Heart Institute, University of Otago Christchurch, Christchurch, New Zealand
| | - Christopher J Pemberton
- Department of Medicine, Christchurch Heart Institute, University of Otago Christchurch, Christchurch, New Zealand
| | - A Mark Richards
- Department of Medicine, Christchurch Heart Institute, University of Otago Christchurch, Christchurch, New Zealand
| | - Laura Joyce
- Department of Emergency Medicine, Christchurch Hospital, Christchurch, New Zealand
- Department of Surgery and Critical Care, University of Otago Christchurch, Christchurch, New Zealand
| | - Martin P Than
- Department of Emergency Medicine, Christchurch Hospital, Christchurch, New Zealand
- Department of Medicine, Christchurch Heart Institute, University of Otago Christchurch, Christchurch, New Zealand
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6
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Li J, Liu Y, Wu T, Xiao Z, Du J, Liang H, Zhou C, Zhou J. Barbed arrow-like structure membrane with ultra-high rectification coefficient enables ultra-fast, highly-sensitive lateral-flow assay of cTnI. Nat Commun 2024; 15:5603. [PMID: 38961073 PMCID: PMC11222510 DOI: 10.1038/s41467-024-49810-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Accepted: 06/20/2024] [Indexed: 07/05/2024] Open
Abstract
Acute myocardial infarction (AMI) has become a public health disease threatening public life safety due to its high mortality. The lateral-flow assay (LFA) of a typical cardiac biomarker, troponin I (cTnI), is essential for the timely warnings of AMI. However, it is a challenge to achieve an ultra-fast and highly-sensitive assay for cTnI (hs-cTnI) using current LFA, due to the limited performance of chromatographic membranes. Here, we propose a barbed arrow-like structure membrane (BAS Mem), which enables the unidirectional, fast flow and low-residual of liquid. The liquid is rectified through the forces generated by the sidewalls of the barbed arrow-like grooves. The rectification coefficient of liquid flow on BAS Mem is 14.5 (highest to date). Using BAS Mem to replace the conventional chromatographic membrane, we prepare batches of lateral-flow strips and achieve LFA of cTnI within 240 s, with a limit of detection of 1.97 ng mL-1. The lateral-flow strips exhibit a specificity of 100%, a sensitivity of 93.3% in detecting 25 samples of suspected AMI patients. The lateral-flow strips show great performance in providing reliable results for clinical diagnosis, with the potential to provide early warnings for AMI.
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Affiliation(s)
- Juanhua Li
- School of Biomedical Engineering, Shenzhen Campus of Sun Yat-sen University, Shenzhen, Guangdong, China
- Key Laboratory of Sensing Technology and Biomedical Instruments of Guangdong Province, School of Biomedical Engineering, Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Yiren Liu
- School of Biomedical Engineering, Shenzhen Campus of Sun Yat-sen University, Shenzhen, Guangdong, China
- Key Laboratory of Sensing Technology and Biomedical Instruments of Guangdong Province, School of Biomedical Engineering, Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Tianyu Wu
- School of Biomedical Engineering, Shenzhen Campus of Sun Yat-sen University, Shenzhen, Guangdong, China
- Key Laboratory of Sensing Technology and Biomedical Instruments of Guangdong Province, School of Biomedical Engineering, Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Zihan Xiao
- School of Biomedical Engineering, Shenzhen Campus of Sun Yat-sen University, Shenzhen, Guangdong, China
- Key Laboratory of Sensing Technology and Biomedical Instruments of Guangdong Province, School of Biomedical Engineering, Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Jianhang Du
- Guangdong Innovative Engineering and Technology Research Center for Assisted Circulation, the Eighth Affiliated Hospital of Sun Yat-sen University, Shenzhen, Guangdong, China
| | - Hongrui Liang
- School of Biomedical Engineering, Shenzhen Campus of Sun Yat-sen University, Shenzhen, Guangdong, China
- Key Laboratory of Sensing Technology and Biomedical Instruments of Guangdong Province, School of Biomedical Engineering, Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Cuiping Zhou
- Department of Emergency, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, China
| | - Jianhua Zhou
- School of Biomedical Engineering, Shenzhen Campus of Sun Yat-sen University, Shenzhen, Guangdong, China.
- Key Laboratory of Sensing Technology and Biomedical Instruments of Guangdong Province, School of Biomedical Engineering, Sun Yat-sen University, Guangzhou, Guangdong, China.
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7
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Salaun E, Drory S, Coté M, Tremblay V, Bédard E, Steinberg C, Paré D, O'Connor K, Cieza T, Coté N, Poirier P, Douville P, Blais J, Desmeules P, Kalavrouziotis D, Mohammadi S, Voisine P, Bernier M, Pibarot P, Thériault S. Role of Antitroponin Antibodies and Macrotroponin in the Clinical Interpretation of Cardiac Troponin. J Am Heart Assoc 2024; 13:e035128. [PMID: 38879450 PMCID: PMC11255741 DOI: 10.1161/jaha.123.035128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/19/2024]
Abstract
Cardiac troponin is extensively used as a biomarker in modern medicine due to its diagnostic capability for myocardial injury, as well as its predictive and prognostic value for cardiac diseases. However, heterophile antibodies, antitroponin antibodies, and macrotroponin complexes can be observed both in seemingly healthy individuals and patients with cardiac diseases, potentially leading to false positive or disproportionate elevation of cTn (cardiac troponin) assay results and introducing discrepancies in clinical interpretations with impact on medical management. In this review article, we describe the possible mechanisms of cTn release and the sources of variations in the assessment of circulating cTn levels. We also explore the pathophysiological mechanisms underlying antitroponin antibody development and discuss the influence exerted by macrotroponin complexes on the results of immunoassays. Additionally, we explore approaches to detect these complexes by presenting various clinical scenarios encountered in routine clinical practice. Finally, unsolved questions about the development, prevalence, and clinical significance of cardiac autoantibodies are discussed.
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Affiliation(s)
- Erwan Salaun
- Institut Universitaire de Cardiologie et de Pneumologie de QuébecUniversité LavalQuébecCanada
| | - Samuel Drory
- Institut Universitaire de Cardiologie et de Pneumologie de QuébecUniversité LavalQuébecCanada
| | - Marc‐André Coté
- Institut Universitaire de Cardiologie et de Pneumologie de QuébecUniversité LavalQuébecCanada
| | - Veronic Tremblay
- Institut Universitaire de Cardiologie et de Pneumologie de QuébecUniversité LavalQuébecCanada
| | - Elisabeth Bédard
- Institut Universitaire de Cardiologie et de Pneumologie de QuébecUniversité LavalQuébecCanada
| | - Christian Steinberg
- Institut Universitaire de Cardiologie et de Pneumologie de QuébecUniversité LavalQuébecCanada
| | - David Paré
- Institut Universitaire de Cardiologie et de Pneumologie de QuébecUniversité LavalQuébecCanada
| | - Kim O'Connor
- Institut Universitaire de Cardiologie et de Pneumologie de QuébecUniversité LavalQuébecCanada
| | - Tomas Cieza
- Institut Universitaire de Cardiologie et de Pneumologie de QuébecUniversité LavalQuébecCanada
| | - Nancy Coté
- Institut Universitaire de Cardiologie et de Pneumologie de QuébecUniversité LavalQuébecCanada
| | - Paul Poirier
- Institut Universitaire de Cardiologie et de Pneumologie de QuébecUniversité LavalQuébecCanada
- Faculty of pharmacyUniversité LavalQuébecCanada
| | - Pierre Douville
- Centre Hospitalier Universitaire de QuébecUniversité LavalQuébecCanada
| | - Jonatan Blais
- Centre Hospitalier Universitaire de QuébecUniversité LavalQuébecCanada
| | - Philippe Desmeules
- Institut Universitaire de Cardiologie et de Pneumologie de QuébecUniversité LavalQuébecCanada
- Centre Hospitalier Universitaire de QuébecUniversité LavalQuébecCanada
| | - Dimitris Kalavrouziotis
- Institut Universitaire de Cardiologie et de Pneumologie de QuébecUniversité LavalQuébecCanada
| | - Siamak Mohammadi
- Institut Universitaire de Cardiologie et de Pneumologie de QuébecUniversité LavalQuébecCanada
| | - Pierre Voisine
- Institut Universitaire de Cardiologie et de Pneumologie de QuébecUniversité LavalQuébecCanada
- Division of Cardiac SurgeryUniversity of Ottawa Heart InstituteOttawaOntarioCanada
| | - Mathieu Bernier
- Institut Universitaire de Cardiologie et de Pneumologie de QuébecUniversité LavalQuébecCanada
| | - Philippe Pibarot
- Institut Universitaire de Cardiologie et de Pneumologie de QuébecUniversité LavalQuébecCanada
| | - Sébastien Thériault
- Institut Universitaire de Cardiologie et de Pneumologie de QuébecUniversité LavalQuébecCanada
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8
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Wu AHB, Graglia S. Early detection of myocardial infarction with reference to baseline levels during health: impact on biological variation of high-sensitivity cardiac troponin. Lab Med 2024:lmae043. [PMID: 38869173 DOI: 10.1093/labmed/lmae043] [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: 06/14/2024] Open
Abstract
A 78-year-old male was seen in the emergency department (ED) with chest pain. Fifteen months earlier, he had presented to the ED with shoulder and elbow pain. High-sensitivity cardiac troponin I (hs-cTnI) testing was conducted at that time, which produced normal results of 10 and 13 ng/L (cutoff <48 ng/L). During the current admission, his electrocardiogram was unremarkable, with a borderline prolonged PR interval noted. The patient's hs-cTnI results were 25, 47, and 254 ng/L at 0, 1, and 7 hours, respectively. He was diagnosed with demand ischemia and admitted to the hospital. The detection of acute myocardial infarction in this case was made during the first sample collection (t = 0), despite the fact that this result was well within the normal range.
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Affiliation(s)
- Alan H B Wu
- Laboratory Medicine, University of California San Francisco Medical Center at Parnassus, San Francisco, CA, US
| | - Sally Graglia
- Emergency Medicine, University of California San Francisco School of Medicine, San Francisco, CA, US
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9
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Illum E, Kofod DH, Ballegaard EF, Nelveg-Kristensen KE, Hornum M, Schou M, Torp-Pedersen C, Gislason G, Lassen JF, Carlson N. Coronary angiography in patients with kidney dysfunction and myocardial injury: A retrospective cohort study on management of myocardial injury in hospitalized patients with kidney disease. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2024; 63:59-65. [PMID: 38212237 DOI: 10.1016/j.carrev.2024.01.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Revised: 12/22/2023] [Accepted: 01/02/2024] [Indexed: 01/13/2024]
Abstract
BACKGROUND Although kidney insufficiency has been shown to be associated with increased risk of myocardial injury, benefit of coronary angiography (CAG) and revascularization remains uncertain, with implications on management strategies and outcomes. We aimed to compare rates of CAG and revascularization and subsequent risk of cardiovascular and kidney outcomes in hospitalized patients with myocardial injury and kidney dysfunction. METHODS Retrospective cohort study encompassing hospitalized patients with myocardial injury i.e. elevated troponin I or T and an eGFR ≤60 ml/min/1.73 m2 identified between 2011 and 2021 in Danish national registers. 30-day odds for CAG were computed across granular eGFR-categories based on multiple logistic regression. Standardized one-year risks of cardiovascular and kidney outcomes including mortality were determined based on hazards obtained in multiple Cox regression. RESULTS A total of 52,798 patients with myocardial injury were identified. CAG was performed in 14.3 % (n = 7549). 30-day odds ratios for CAG were 0.64 [0.60-0.68], 0.38 [0.34-0.42], 0.18 [0.14-0.22], and 0.35 [0.30-0.40] in patients with eGFR 31-45 ml/min/1.73 m2, eGFR 15-30 ml/min/1.73 m2 for eGFR<15 ml/min/1.73 m2 and chronic dialysis, respectively (eGFR 46-60 ml/min/1.73 m2 as reference). Median follow-up was 4.1 years. One-year mortality risk differences associated with CAG and revascularization (no CAG as reference) were -7.8 [-7.0; -8.7] and -9.1 [-8.4; -9.9] for eGFR 46-60 ml/min/1.73 m2; -7.0 [-5.7;-8-3] and -8.0 [-6.6; -9.5] for eGFR 31-45 ml/min/1.73 m2; -5.4 [-3.0; -7.2] and -5.2 [-2.2; -8.3] for eGFR 15-30 ml/min/1.73 m2; -8.8 [-3.1; -13.7] and -5.4 [3.1; -13.4] for eGFR<15 ml/min/1.73 m2; and -4.9 [-0.1; -9.7] and -4.2 [1.5; -9.2] for chronic dialysis, respectively. CONCLUSION Probability of CAG following myocardial injury declined with progressive kidney dysfunction. Overall, CAG was associated with lower mortality irrespective of kidney function and subsequent revascularization.
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Affiliation(s)
- Emilie Illum
- Department of Nephrology, Copenhagen University Hospital Rigshospitalet, Denmark
| | - Dea Haagensen Kofod
- Department of Nephrology, Copenhagen University Hospital Rigshospitalet, Denmark
| | | | | | - Mads Hornum
- Department of Nephrology, Copenhagen University Hospital Rigshospitalet, Denmark
| | - Morten Schou
- Department of Cardiology, Copenhagen University Hospital Herlev-Gentofte, Denmark
| | - Christian Torp-Pedersen
- Department of Cardiology, Copenhagen University Hospital North Zealand, Denmark; Department of Public Health, University of Copenhagen, Denmark
| | - Gunnar Gislason
- Department of Cardiology, Copenhagen University Hospital Herlev-Gentofte, Denmark; Department of Research, The Danish Heart Foundation, Denmark
| | | | - Nicholas Carlson
- Department of Nephrology, Copenhagen University Hospital Rigshospitalet, Denmark; Department of Research, The Danish Heart Foundation, Denmark.
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10
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Grittani A, Ramos S, Gomez C, Varela CA, Puri N, Zarry S, Suarez JH. Evaluating the Rates of Mortality and Cardiac Catheterization Using High-Sensitivity Troponin and Conventional Troponin Assays. Cureus 2024; 16:e63538. [PMID: 39086787 PMCID: PMC11289078 DOI: 10.7759/cureus.63538] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/30/2024] [Indexed: 08/02/2024] Open
Abstract
Non-ST segment elevation myocardial infarction (NSTEMI) is an acute coronary syndrome event where myocardial ischemia is present, with an increase of cardiac troponins without an elevation of the ST segment. One of the fundamental measures used to diagnose or rule out acute coronary syndrome (ACS) is troponin levels in the blood. Troponin is a broad term used for the category of muscle contraction regulatory proteins and is commonly measured during ACS evaluation. Troponin I is only released by cardiac tissue, while some assay measurements will also pick up troponin released by skeletal muscle injury. This retrospective observational study was performed investigating troponin assays and how they relate to patient's outcomes. The troponin assays used in this Miami hospital where the database of patients was collected between 2018 and 2023 were troponin I (cTnI), the conventional troponin assay, and the newer high-sensitivity troponin I assay (hs-cTn). In this observational study patients who received an admitting diagnosis of NSTEMI corroborated by an independent cardiologist had their respective troponin assay levels included. Patients found to have ECG changes significant for non-ischemic pathologies, or echocardiogram findings suggestive of myocardial dysfunction not clinically correlated to an ACS were excluded from the study. A total of 75 patients were included in this study and the mean age was 75.97 ±14.72 years, with a presentation of chest pain, dyspnea and general weakness recorded in 59% (n = 45) of patients. The median time between troponin samples was 6.63 hours across both assays and hs-cTn showed a 4.99% increase in variation between samples while cTnI had a decrease of 2.53%. The study objective is to support whether there is a difference in rates of cardiac catheterization or mortality based on the type of troponin testing. There was no significant association found between, the type of troponin assay used during hospital admission, and the outcomes of catheterization and death (p > 0.009).
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Affiliation(s)
| | - Saul Ramos
- Internal Medicine, University of Medicine and Health Sciences, Saint Kitts, KNA
| | | | | | - Nikhil Puri
- School of Medicine, St. George's University, St. George, GRD
| | - Samantha Zarry
- Health Sciences, The University of Western Ontario, Toronto, CAN
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11
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Fabre-Estremera B, Schulz K, Ladd A, Sexter A, Apple FS. Analytical validation of the Mindray CL1200i analyzer high sensitivity cardiac troponin I assay: MERITnI study. Clin Chem Lab Med 2024; 0:cclm-2024-0352. [PMID: 38801528 DOI: 10.1515/cclm-2024-0352] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2024] [Accepted: 05/13/2024] [Indexed: 05/29/2024]
Abstract
OBJECTIVES This study performed an analytical validation study of the Mindray high-sensitivity cardiac troponin I (hs-cTnI) assay addressing limit of blank (LoB), limit of detection (LoD), precision, linearity, analytical specificity and sex-specific 99th percentile upper reference limits. METHODS LoB, LoD, precision, linearity and analytical specificity were studied according to Clinical and Laboratory Standards Institute. We used one reagent lot and one CL1200i analyzer. Skeletal troponin I and T, cardiac troponin T, troponin C, actin, tropomyosin, myosin light chain, myoglobin and creatine kinase (CK-MB) were studied for cross-reactivity. Interference with biotin was examined. Lithium heparin samples (one freeze thaw cycle) from healthy males and females were measured to determine the 99th percentiles by using the non-parametric method. Analyses were performed before and after excluding subjects with clinical conditions and/or increased surrogate biomarkers. RESULTS The Mindray hs-cTnI assay met criteria to be considered as a hs-cTn assay. LoB and LoD was <0.1 ng/L and 0.1 ng/L, respectively. Repeatability had a coefficient of variation 1.2-3.8 %, and within-laboratory imprecision 1.7-5.0 %. The measuring interval ranged from 1.1 to 28,180 ng/L. The analytical specificity was clinically acceptable for the interferents studied. After exclusions, the 99th percentile URLs obtained were 10 ng/L overall, 5 ng/L for females and 12 ng/L for males. CONCLUSIONS Analytical observations of the Mindray hs-cTnI assay demonstrated excellent LoB, LoD, precision, linearity and analytical specificity, that were in alignment with the manufacturer's claims and regulatory guidelines for hs-cTnI. The assay is suitable for clinical investigation for patient-oriented studies.
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Affiliation(s)
- Blanca Fabre-Estremera
- Department of Laboratory Medicine, 16268 La Paz University Hospital , Madrid, Spain
- Department of Preventive Medicine and Public Health, Universidad Autónoma de Madrid, Madrid, Spain
| | - Karen Schulz
- 20298 Hennepin Healthcare Research Institute , Minneapolis, MN, USA
| | - Alanna Ladd
- 20298 Hennepin Healthcare Research Institute , Minneapolis, MN, USA
| | - Anne Sexter
- 20298 Hennepin Healthcare Research Institute , Minneapolis, MN, USA
| | - Fred S Apple
- 20298 Hennepin Healthcare Research Institute , Minneapolis, MN, USA
- Department of Laboratory Medicine & Pathology, 5532 Hennepin Healthcare/Hennepin County Medical Center , Minneapolis, MN, USA
- Department of Laboratory Medicine & Pathology, University of Minnesota School of Medicine, Minneapolis, MN, USA
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12
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Strandkjær N, Jørgensen N, Hasselbalch RB, Kristensen J, Knudsen MSS, Kock TO, Lange T, Lindholm MG, Bruun NE, Holmvang L, Terkelsen CJ, Pedersen CK, Christensen MK, Lassen JF, Hilsted L, Ladefoged S, Nybo M, Bor MV, Dahl M, Hansen AB, Kamstrup PR, Bundgaard H, Torp‐Pedersen C, Iversen KK. DANSPOT: A Multicenter Stepped-Wedge Cluster-Randomized Trial of the Reclassification of Acute Myocardial Infarction: Rationale and Study Design. J Am Heart Assoc 2024; 13:e033493. [PMID: 38639348 PMCID: PMC11179950 DOI: 10.1161/jaha.123.033493] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Accepted: 03/13/2024] [Indexed: 04/20/2024]
Abstract
BACKGROUND Cardiac troponins are the preferred biomarkers for the diagnosis of acute myocardial infarction. Although sex-specific 99th percentile thresholds of troponins are recommended in international guidelines, the clinical effect of their use is poorly investigated. The DANSPOT Study (The Danish Study of Sex- and Population-Specific 99th percentile upper reference limits of Troponin) aims to evaluate the clinical effect of a prospective implementation of population- and sex-specific diagnostic thresholds of troponins into clinical practice. METHODS This study is a nationwide, multicenter, stepped-wedge cluster-randomized trial of the implementation of population- and sex-specific thresholds of troponins in 22 of 23 clinical centers in Denmark. We established sex-specific thresholds for 5 different troponin assays based on troponin levels in a healthy Danish reference population. Centers will sequentially cross over from current uniform manufacturer-derived thresholds to the new population- and sex-specific thresholds. The primary cohort is defined as patients with symptoms suggestive of acute coronary syndrome having at least 1 troponin measurement performed within 24 hours of arrival with a peak troponin value between the current uniform threshold and the new sex-specific female and male thresholds. The study will compare the occurrence of the primary outcome, defined as a composite of nonfatal myocardial infarction, unplanned revascularization, and all-cause mortality within 1 year, separately for men and women before and after the implementation of the new sex-specific thresholds. CONCLUSIONS The DANSPOT Study is expected to show the clinical effects on diagnostics, treatment, and clinical outcomes in patients with myocardial infarction of implementing sex-specific diagnostic thresholds for troponin based on a national Danish reference population. REGISTRATION URL: https://www.clinicaltrials.gov; Unique identifier: NCT05336435.
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Affiliation(s)
- Nina Strandkjær
- Department of Emergency MedicineCopenhagen University Hospital—Herlev and GentofteHerlevDenmark
- Department of CardiologyCopenhagen University Hospital—Herlev and GentofteHerlevDenmark
- Department of Clinical MedicineUniversity of CopenhagenDenmark
| | - Nicoline Jørgensen
- Department of Emergency MedicineCopenhagen University Hospital—Herlev and GentofteHerlevDenmark
- Department of CardiologyCopenhagen University Hospital—Herlev and GentofteHerlevDenmark
| | - Rasmus Bo Hasselbalch
- Department of Emergency MedicineCopenhagen University Hospital—Herlev and GentofteHerlevDenmark
- Department of CardiologyCopenhagen University Hospital—Herlev and GentofteHerlevDenmark
- Department of Clinical MedicineUniversity of CopenhagenDenmark
| | - Jonas Kristensen
- Department of Emergency MedicineCopenhagen University Hospital—Herlev and GentofteHerlevDenmark
- Department of CardiologyCopenhagen University Hospital—Herlev and GentofteHerlevDenmark
- Department of Clinical MedicineUniversity of CopenhagenDenmark
| | - Marie Sophie Sander Knudsen
- Department of Emergency MedicineCopenhagen University Hospital—Herlev and GentofteHerlevDenmark
- Department of CardiologyCopenhagen University Hospital—Herlev and GentofteHerlevDenmark
| | - Thilde Olivia Kock
- Department of CardiologyCopenhagen University Hospital—Herlev and GentofteHerlevDenmark
| | - Theis Lange
- Department of Public HealthUniversity of CopenhagenDenmark
| | | | - Niels Eske Bruun
- Department of Clinical MedicineUniversity of CopenhagenDenmark
- Department of CardiologyZealand University HospitalRoskildeDenmark
| | - Lene Holmvang
- Department of CardiologyCopenhagen University Hospital—RigshospitaletCopenhagenDenmark
| | | | | | | | | | - Linda Hilsted
- Department of Clinical BiochemistryCopenhagen University Hospital—RigshospitaletCopenhagenDenmark
| | - Søren Ladefoged
- Department of Clinical BiochemistryAarhus University HospitalAarhusDenmark
| | - Mads Nybo
- Department of Clinical BiochemistryOdense University HospitalOdenseDenmark
| | - Mustafa Vakur Bor
- Department of Clinical BiochemistryUniversity of Hospital of South DenmarkEsbjergDenmark
| | - Morten Dahl
- Department of Clinical MedicineUniversity of CopenhagenDenmark
- Department of Clinical BiochemistryZealand University HospitalKøgeDenmark
| | | | - Pia Rørbæk Kamstrup
- Department of Clinical BiochemistryCopenhagen University Hospital—Herlev and GentofteHerlevDenmark
| | - Henning Bundgaard
- Department of Clinical MedicineUniversity of CopenhagenDenmark
- Department of CardiologyCopenhagen University Hospital—RigshospitaletCopenhagenDenmark
| | - Christian Torp‐Pedersen
- Department of Public HealthUniversity of CopenhagenDenmark
- Department of CardiologyCopenhagen University Hospital—North ZealandHillerødDenmark
| | - Kasper Karmark Iversen
- Department of Emergency MedicineCopenhagen University Hospital—Herlev and GentofteHerlevDenmark
- Department of CardiologyCopenhagen University Hospital—Herlev and GentofteHerlevDenmark
- Department of Clinical MedicineUniversity of CopenhagenDenmark
- Department of Internal MedicineCopenhagen University Hospital—Herlev and GentofteHerlevDenmark
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13
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Pickering JW, Young JM, George PM, Watson AS, Aldous SJ, Verryt T, Troughton RW, Pemberton CJ, Richards AM, Cullen LA, Apple FS, Than MP. Derivation and Validation of Thresholds Using Synthetic Data Methods for Single-Test Screening of Emergency Department Patients with Possible Acute Myocardial Infarction Using a Point-of-Care Troponin Assay. J Appl Lab Med 2024; 9:526-539. [PMID: 38442340 DOI: 10.1093/jalm/jfae001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2023] [Accepted: 11/17/2023] [Indexed: 03/07/2024]
Abstract
BACKGROUND Single-sample (screening) rule-out of acute myocardial infarction (AMI) with troponin requires derivation of a single-test screening threshold. In data sets with small event numbers, the lowest one or two concentrations of myocardial infarction (MI) patients dictate the threshold. This is not optimal. We aimed to demonstrate a process incorporating both real and synthetic data for deriving such thresholds using a novel pre-production high-precision point-of-care assay. METHODS cTnI concentrations were measured from thawed plasma using the Troponin I Next (TnI-Nx) assay (i-STAT; Abbott) in adults on arrival to the emergency department with symptoms suggestive of AMI. The primary outcome was an AMI or cardiac death within 30 days. We used internal-external validation with synthetic data production based on clinical and demographic data, plus the measured TnI-Nx concentration, to derive and validate decision thresholds for TnI-Nx. The target low-risk threshold was a sensitivity of 99% and a high-risk threshold specificity of >95%. RESULTS In total, 1356 patients were included, of whom 191 (14.1%) had the primary outcome. A total of 500 synthetic data sets were constructed. The mean low-risk threshold was determined to be 5 ng/L. This categorized 38% (95% CI, 6%-68%) to low-risk with a sensitivity of 99.0% (95% CI, 98.6%-99.5%) and a negative predictive value of 99.4% (95% CI, 97.6%-99.8%). A similarly derived high-risk threshold of 25 ng/L had a specificity of 95.0% (95% CI, 94.8%-95.1%) and a positive predictive value of 74.8% (95% CI, 71.5%-78.0%). CONCLUSIONS With the TnI-Nx assay, we successfully demonstrated an approach using synthetic data generation to derive low-risk thresholds for safe and effective screening.
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Affiliation(s)
- John W Pickering
- Department of Emergency Medicine, Christchurch Hospital, Christchurch, New Zealand
- Christchurch Heart Institute, University of Otago Christchurch, Christchurch, New Zealand
| | - Joanna M Young
- Department of Emergency Medicine, Christchurch Hospital, Christchurch, New Zealand
| | | | - Antony S Watson
- Department of Emergency Medicine, Christchurch Hospital, Christchurch, New Zealand
| | - Sally J Aldous
- Cardiology Department, Christchurch Hospital, Christchurch, New Zealand
| | - Toby Verryt
- Cardiology Department, Christchurch Hospital, Christchurch, New Zealand
| | - Richard W Troughton
- Christchurch Heart Institute, University of Otago Christchurch, Christchurch, New Zealand
- Cardiology Department, Christchurch Hospital, Christchurch, New Zealand
| | | | - A Mark Richards
- Christchurch Heart Institute, University of Otago Christchurch, Christchurch, New Zealand
- Cardiovascular Research Institute, National University of Singapore, Singapore
| | - Louise A Cullen
- Emergency Department, Royal Brisbane and Women's Hospital, Brisbane, Australia
| | - Fred S Apple
- Department of Laboratory Medicine and Pathology, Hennepin County Medical Center of Hennepin Healthcare and University of Minnesota Minneapolis, Minneapolis, MN, United States
| | - Martin P Than
- Department of Emergency Medicine, Christchurch Hospital, Christchurch, New Zealand
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14
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Zhang Q, Chen H, Wang M, Lai H, Liu W, Wang L, Zhang J, Li C, Zhou W. Age- and sex-specific 99th percentile upper reference limits for high-sensitivity cardiac troponin T in Chinese older people: Real-world data mining. Clin Biochem 2024; 127-128:110762. [PMID: 38582381 DOI: 10.1016/j.clinbiochem.2024.110762] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Revised: 04/01/2024] [Accepted: 04/03/2024] [Indexed: 04/08/2024]
Abstract
BACKGROUND This study aims to investigate the impact of age and sex on high-sensitivity cardiac troponin T (hs-cTnT) and establish 99th percentile upper reference limits (URLs) in older individuals utilizing large-scale real-world data. METHODS 40,530 outpatient hs-cTnT results were obtained from the laboratory database from January 1, 2018, to December 31, 2023. Our study included 4,199 elderly outpatients (aged ≥ 60) without cardiovascular disease or other heart-related chronic conditions. Nested analysis of variance was used to explore the necessity of partitioning reference intervals (RIs) by sex and age groups. RIs were established by the refineR algorithm and assessed based on ≤ 10% test results of validation data set outside the new RIs. RESULTS RIs for hs-cTnT in the older population needed to be partitioned by sex and age groups ([standard deviation ratio] SDRage = 0.75; SDRsex = 0.49). URLs in older Chinese adults were 21.8 ng/L for males, 16.5 ng/L for females, and 20.7 ng/L for the overall participant group. URLs for males aged 60-69, 70-79, and ≥ 80 were 13.7, 19.4, and 31.0 ng/L, respectively. Female values were 10.1, 17.2, and 22.0 ng/L. Importantly, manufacturer-reported RIs do not suffice for Chinese individuals aged ≥ 70. Validation data showed that 2.7-5.2% of test results fell outside the new RIs, confirming the validity of the results. CONCLUSION This study establishes age- and sex-specific 99th percentile URLs for hs-cTnT in Chinese older individuals, thereby enhancing the accuracy of clinical assessments.
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Affiliation(s)
- Qian Zhang
- Department of Clinical Laboratory, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, P.R. China
| | - Huiyi Chen
- Department of Biological Products, Chinese Pharmacopoeia Commission, Beijing, P.R. China
| | - Meng Wang
- Department of Clinical Laboratory, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, P.R. China
| | - Huiying Lai
- Department of Clinical Laboratory, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, P.R. China
| | - Wensong Liu
- Department of Clinical Laboratory, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, P.R. China
| | - Lijuan Wang
- Department of Clinical Laboratory, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, P.R. China
| | - Jiaqi Zhang
- Department of Clinical Laboratory, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, P.R. China
| | - Chuanbao Li
- Department of Clinical Laboratory, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, P.R. China.
| | - Weiyan Zhou
- National Center for Clinical Laboratories, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing Hospital/National Center of Gerontology, P.R. China.
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15
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Pittie G, Lukas P, Massart M, Cavalier E, Le Goff C. Evaluation of analytical and clinical performance of the AFIAS Tn-I plus assay - a new point-of-care. Acta Cardiol 2024; 79:351-357. [PMID: 38032250 DOI: 10.1080/00015385.2023.2286423] [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: 09/01/2023] [Accepted: 11/16/2023] [Indexed: 12/01/2023]
Abstract
BACKGROUND The objective of this evaluation was to determine the analytical and clinical performance of the AFIAS point-of-care (POC) Tn-I Plus assay (Boditech Med Inc). DESIGN AND METHODS Limit of detection (LOD), limit of quantification (LOQ), repeatability, reproducibility, inter- and intra-individual CV were evaluated using the CLSI guidelines. The study was also designed to estimate the 99th percentile upper reference limit (URL) and to assess the diagnostic sensitivity and specificity. RESULTS The precision repeatability CVs were 6.7-8.5% and reproducibility was 7.5-7.6%. The LOD and LOQ were consistent with the manufacturer's specified values of 0.010 ng/mL and 0.030 ng/mL, respectively. The 99th percentile URLs for males (aged 18-75 years) and females (aged 17-65 years) in serum were 0.0300 ng/mL (7.8% CV) and 0.0239 ng/mL (9.4% CV) respectively. Overall 99th percentile URL was 0.0296 ng/mL (8.2% CV). For the overall apparently healthy population, the percentage of measurable cardiac troponin I (cTn-I) values below the 99th percentile (i.e. 0.0296 ng/mL) and above the assay's LOD (= 0.010 ng/mL) was 47,68% (391/820 samples). The diagnostic sensitivity and specificity were 100% with 95% CI (97% - 100%) and 95.2% with 95% CI (93.6% - 96.5%), respectively. No significant differences were observed for the diagnosis of acute myocardial infarction (AMI) between AFIAS Tn-I plus and Abbott ARCHITECT High Sensitive Troponin-I. CONCLUSION The clinical performance of AFIAS Tn-I Plus assay for AMI is comparable to the established Abbott ALINITY STAT High Sensitive Troponin-I. This assay is suitable for routine use in clinical laboratories.
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Affiliation(s)
- Guillaume Pittie
- Department of Clinical Chemistry Department, CHU de Liège, CIRM, University of Liège, Liège, Belgium
| | - Pierre Lukas
- Department of Clinical Chemistry Department, CHU de Liège, CIRM, University of Liège, Liège, Belgium
| | - Madysone Massart
- Department of Clinical Chemistry Department, CHU de Liège, CIRM, University of Liège, Liège, Belgium
| | - Etienne Cavalier
- Department of Clinical Chemistry Department, CHU de Liège, CIRM, University of Liège, Liège, Belgium
| | - Caroline Le Goff
- Department of Clinical Chemistry Department, CHU de Liège, CIRM, University of Liège, Liège, Belgium
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16
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Celeski M, Segreti A, Piscione M, Monticelli LM, Di Gioia G, Fossati C, Ussia GP, Pigozzi F, Grigioni F. The current paradigm of cardiac troponin increase among athletes. Monaldi Arch Chest Dis 2024. [PMID: 38700130 DOI: 10.4081/monaldi.2024.2878] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Accepted: 03/16/2024] [Indexed: 05/05/2024] Open
Abstract
Although it is known that exercise improves cardiovascular health and extends life expectancy, a significant number of people may also experience an elevation in cardiac troponin levels as a result of exercise. For many years, researchers have argued whether exercise-induced cardiac troponin rises are a consequence of a physiological or pathological reaction and whether they are clinically significant. Differences in cardiac troponin elevation and cardiac remodeling can be seen between athletes participating in different types of sports. When forecasting the exercise-induced cardiac troponin rise, there are many additional parameters to consider, as there is a large amount of interindividual heterogeneity in the degree of cardiac troponin elevation. Although it was previously believed that cardiac troponin increases in athletes represented a benign phenomenon, numerous recent studies disproved this notion by demonstrating that, in specific individuals, cardiac troponin increases may have clinical and prognostic repercussions. This review aims to examine the role of cardiac troponin in athletes and its role in various sporting contexts. This review also discusses potential prognostic and clinical implications, as well as future research methods, and provides a straightforward step-by-step algorithm to help clinicians interpret cardiac troponin rise in athletes in both ischemic and non-ischemic circumstances.
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Affiliation(s)
- Mihail Celeski
- Research Unit of Cardiovascular Science, Department of Medicine and Surgery, Università Campus Bio-Medico di Roma; Cardiology Unit, Fondazione Policlinico Universitario Campus Bio-Medico, Rome.
| | - Andrea Segreti
- Research Unit of Cardiovascular Science, Department of Medicine and Surgery, Università Campus Bio-Medico di Roma; Cardiology Unit, Fondazione Policlinico Universitario Campus Bio-Medico, Rome; Department of Movement, Human and Health Sciences, University of Rome "Foro Italico".
| | - Mariagrazia Piscione
- Research Unit of Cardiovascular Science, Department of Medicine and Surgery, Università Campus Bio-Medico di Roma; Cardiology Unit, Fondazione Policlinico Universitario Campus Bio-Medico, Rome.
| | - Luigi Maria Monticelli
- Research Unit of Cardiovascular Science, Department of Medicine and Surgery, Università Campus Bio-Medico di Roma; Cardiology Unit, Fondazione Policlinico Universitario Campus Bio-Medico, Rome.
| | - Giuseppe Di Gioia
- Research Unit of Cardiovascular Science, Department of Medicine and Surgery, Università Campus Bio-Medico di Roma; Cardiology Unit, Fondazione Policlinico Universitario Campus Bio-Medico, Rome; Department of Movement, Human and Health Sciences, University of Rome "Foro Italico"; Institute of Sport Medicine and Science, Italian National Olympic Committee, Rome.
| | - Chiara Fossati
- Department of Movement, Human and Health Sciences, University of Rome "Foro Italico".
| | - Gian Paolo Ussia
- Research Unit of Cardiovascular Science, Department of Medicine and Surgery, Università Campus Bio-Medico di Roma; Cardiology Unit, Fondazione Policlinico Universitario Campus Bio-Medico, Rome.
| | - Fabio Pigozzi
- Department of Movement, Human and Health Sciences, University of Rome "Foro Italico".
| | - Francesco Grigioni
- Research Unit of Cardiovascular Science, Department of Medicine and Surgery, Università Campus Bio-Medico di Roma; Cardiology Unit, Fondazione Policlinico Universitario Campus Bio-Medico, Rome.
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17
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De Iuliis V, Gabriele AR, De Santis F, De Rugeriis R, Di Quinzio L, Aloisi S, Rosati AC, Benvenuto M, Fabiani D, Chiatamone Ranieri S. Diagnostic performance of a point of care high-sensitivity cardiac troponin I assay and single measurement evaluation to rule out and rule in acute coronary syndrome. Clin Chem Lab Med 2024; 0:cclm-2024-0225. [PMID: 38669209 DOI: 10.1515/cclm-2024-0225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2024] [Accepted: 04/16/2024] [Indexed: 04/28/2024]
Abstract
OBJECTIVES About 10 million individuals in USA presented annually in the emergency department (ED) with chest pain or with signs and symptoms of acute coronary syndrome (ACS). The advent of point of care (POC) devices, able to measure high sensitivity troponin, are a very interesting tool in the ED setting for its rapid turnaround time (<10 min). METHODS The present study evaluates the diagnostic performance of the Atellica VTLi (Siemens) in real life setting using the clinical data derived from integrated diagnoses of emergency room staff and cardiologist and in comparison with standard laboratory hs-cTnT assay (Cobas 8000, Elecsys, Roche). 966 patients admitted to the emergency department of "G. Mazzini Hospital" in Teramo, Italy, from July 27, 2022, through June 09, 2023, were enrolled. RESULTS The diagnostic performance of POC hs-cTnI was evaluated. An appropriate POC hs-cTnI threshold values <4 ng/L supplied a sensitivity and an NPV of 100 % (95 % CI: 99.5-100) in order to achieve rapid rule out for MI through a single measurement at patient presentation in the ED. Furthermore, a derivation POC hs-cTnI concentration >54 ng/L provided a specificity of 97.2 % (95 % CI: 95.9-98.1) and a PPV of 43.5 % (95 % CI: 40.3-46.7) for ruling in MI. CONCLUSIONS This platform showed comparable diagnostic performance for myocardial infarction to the central laboratory. Our data suggest the possible use of the Atellica VTLi hs-cTnI POC assay either in emergency department of urban medical centre, either in rural hospital for triage and patient management.
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Affiliation(s)
- Vincenzo De Iuliis
- Department of Clinical Pathology, 92708 G. Mazzini Civil Hospital , Teramo, Italy
| | | | - Francesca De Santis
- Department of Clinical Pathology, 92708 G. Mazzini Civil Hospital , Teramo, Italy
| | - Roberta De Rugeriis
- Department of Clinical Pathology, 92708 G. Mazzini Civil Hospital , Teramo, Italy
| | - Luigi Di Quinzio
- Emergency Department, 92708 G. Mazzini Civil Hospital , Teramo, Italy
| | - Steeve Aloisi
- Emergency Department, 92708 G. Mazzini Civil Hospital , Teramo, Italy
| | - Anna Carla Rosati
- Cardiology Division, 92708 G. Mazzini Civil Hospital , Teramo, Italy
| | - Manuela Benvenuto
- Cardiology Division, 92708 G. Mazzini Civil Hospital , Teramo, Italy
| | - Donatello Fabiani
- Cardiology Division, 92708 G. Mazzini Civil Hospital , Teramo, Italy
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18
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Li Z, Yang S, Qiao J, Tan Y, Liu Q, Yang B, Feng W, Cui L. Performance evaluation of a novel high-sensitivity cardiac troponin T assay: analytical and clinical perspectives. Clin Chem Lab Med 2024; 62:979-987. [PMID: 37999934 DOI: 10.1515/cclm-2023-0789] [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: 07/25/2023] [Accepted: 10/31/2023] [Indexed: 11/25/2023]
Abstract
OBJECTIVES To evaluate the analytical characteristics of a novel high-sensitivity cardiac troponin T (hs-cTnT) test on the automatic light-initiated chemiluminescent assay (LiCA®) system, and validated its diagnostic performance for non-ST-segment elevation myocardial infarction (NSTEMI). METHODS Studies included an extensive analytical evaluation and established the 99th percentile upper reference limit (URL) from apparently healthy individuals, followed by a diagnostic performance validation for NSTEMI. RESULTS Sex-specific 99th percentile URLs were 16.0 ng/L (1.7 % CV: coefficient of variation) for men (21-92 years) and 13.4 ng/L (2.0 % CV) for women (23-87 years) in serum, and 30.6 ng/L (0.9 % CV) for men (18-87 years) and 20.2 ng/L (1.4 % CV) for women (18-88 years) in heparin plasma. Detection rates in healthy individuals ranged from 98.9 to 100 %. An excellent agreement was identified between LiCA® and Elecsys® assays with a correlation coefficient of 0.993 and mean bias of -0.7 % (-1.8-0.4 %) across the full measuring range, while the correlation coefficient and overall bias were 0.967 and -1.1 % (-2.5-0.3 %) for the lower levels of cTnT (10-100 ng/L), respectively. At the specific medical decision levels (14.0 and 52.0 ng/L), assay difference was estimated to be <5.0 %. No significant difference was found between these two assays in terms of area under curve (AUC), sensitivity and specificity, negative predictive value (NPV) and positive predictive value (PPV) for the diagnosis of NSTEMI. CONCLUSIONS LiCA® hs-cTnT is a reliable 3rd-generation (level 4) high-sensitivity assay for detecting cardiac troponin T. The assay is acceptable for practical use in the diagnosis of NSTEMI.
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Affiliation(s)
- Zhongxin Li
- Department of Laboratory Medicine, Peking University Third Hospital, Beijing, P.R. China
| | - Shuo Yang
- Department of Laboratory Medicine, Peking University Third Hospital, Beijing, P.R. China
| | - Jiao Qiao
- Department of Laboratory Medicine, Peking University Third Hospital, Beijing, P.R. China
| | - Yuan Tan
- Department of Laboratory Medicine, Peking University Third Hospital, Beijing, P.R. China
| | - Qi Liu
- Department of Laboratory Medicine, Peking University Third Hospital, Beijing, P.R. China
| | - Boxin Yang
- Department of Laboratory Medicine, Peking University Third Hospital, Beijing, P.R. China
| | - Weimin Feng
- Department of Laboratory Medicine, Peking University Third Hospital, Beijing, P.R. China
| | - Liyan Cui
- Department of Laboratory Medicine, Peking University Third Hospital, Beijing, P.R. China
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19
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Alkhalaileh H, Wei R, Cordero Rivera A, Goksel M, Lee JKY, Mazzaferri, Jr. E, Jones J, Li J. Evaluation of Age and Sex Differences in Contemporary versus High-Sensitivity Troponin I Measurement in Hospitalized Patients. J Clin Med 2024; 13:2428. [PMID: 38673701 PMCID: PMC11051137 DOI: 10.3390/jcm13082428] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2024] [Revised: 04/13/2024] [Accepted: 04/19/2024] [Indexed: 04/28/2024] Open
Abstract
Background: With the transition from the contemporary (cTnI) to high-sensitivity troponin assay (hs-cTnI), concerns have arisen regarding the diagnostic differences between these two assays due to analytical distinctions. This study aims to evaluate the age and sex differences between these two assays, as well as the differences resulting from using two different 99th percentile values of the high-sensitivity troponin assay. Method: A retrospective observational study was conducted at an academic medical center, encompassing a total of 449 lithium heparin plasma samples included in the dataset. Both contemporary and high-sensitivity troponin were simultaneously measured using Siemens ADVIA Centaur analyzers. Two sets of sex-specific 99th percentile URLs from the Siemens study (cutoff-1) and Universal Sample Bank data (cutoff-2) were used for the data analysis. Results: The use of cutoff-1 or cutoff-2 had a negligible impact on troponin classification. Troponin elevation significantly increased in individuals > 50 years old for males and >40 years old for females, with both troponin assays. A receiver operating characteristic analysis did not find significant differences between the two assays. The Kaplan-Meier curves showed no differences in survival in cTnI according to the non-sex-specific 99th URL or hs-cTnI (cutoff-2) but showed a slight difference in survival in hs-cTnI (cutoff-1). Conclusions: Overall, there were no significant differences in age and sex in the diagnostic performance between the contemporary and high-sensitivity troponin assays. Selection criteria for the establishment of the 99th percentile URL should be standardized to avoid the misinterpretation of the troponin results.
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Affiliation(s)
- Hussam Alkhalaileh
- The Ohio State College of Medicine, The Ohio State University, Columbus, OH 43210, USA;
| | - Ruhan Wei
- Department of Pathology, Duke University School of Medicine, Durham, NC 27710, USA;
| | - Ashly Cordero Rivera
- Department of Pathology, Wexner Medical Center, The Ohio State University, 410 W 10th Ave., Columbus, OH 43210, USA; (A.C.R.); (M.G.); (J.J.)
| | - Mustafa Goksel
- Department of Pathology, Wexner Medical Center, The Ohio State University, 410 W 10th Ave., Columbus, OH 43210, USA; (A.C.R.); (M.G.); (J.J.)
| | - Jason K. Y. Lee
- Department of Clinical Laboratory, University Hospital, The Ohio State University, Columbus, OH 43210, USA;
| | - Ernest Mazzaferri, Jr.
- Division of Cardiovascular Medicine, Department of Internal Medicine, Wexner Medical Center, The Ohio State University, Columbus, OH 43210, USA;
| | - JoAnna Jones
- Department of Pathology, Wexner Medical Center, The Ohio State University, 410 W 10th Ave., Columbus, OH 43210, USA; (A.C.R.); (M.G.); (J.J.)
| | - Jieli Li
- Department of Pathology, Wexner Medical Center, The Ohio State University, 410 W 10th Ave., Columbus, OH 43210, USA; (A.C.R.); (M.G.); (J.J.)
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20
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Espejo T, Terhalle L, Malinovska A, Riedel HB, Arntz L, Hafner L, Delport-Lehnen K, Zuppinger J, Geigy N, Leuppi J, Somasundaram R, Bingisser R, Nickel CH. Diagnostic and prognostic value of cardiac troponins in emergency department patients presenting after a fall: A prospective, multicenter study. Acad Emerg Med 2024. [PMID: 38532263 DOI: 10.1111/acem.14897] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Revised: 01/04/2024] [Accepted: 01/23/2024] [Indexed: 03/28/2024]
Abstract
BACKGROUND Emergency department (ED) presentations after a ground-level fall (GLF) are common. Falls were suggested to be another possible presenting feature of a myocardial infarction (MI), as unrecognized MIs are common in older adults. Elevated high-sensitivity cardiac troponin (hs-cTn) concentrations could help determine the etiology of a GLF in ED. We investigated the prevalence of both MI and elevated high-sensitivity cardiac troponin T (hs-cTnT) and I (hs-cTnI), as well as the diagnostic accuracy of hs-cTnT and hs-cTnI regarding MI, and their prognostic value in older ED patients presenting after a GLF. METHODS This was a prospective, international, multicenter, cohort study with a follow-up of up to 1 year. Patients aged 65 years or older presenting to the ED after a GLF were prospectively enrolled. Two outcome assessors independently reviewed all discharge records to ascertain final gold standard diagnoses. Hs-cTnT and hs-cTnI levels were determined from thawed samples for every patient. RESULTS In total, 558 patients were included. Median (IQR) age was 83 (77-89) years, and 67.7% were female. Elevated hs-cTnT levels were found in 384 (68.8%) patients, and elevated hs-cTnI levels in 86 (15.4%) patients. Three patients (0.5%) were ascertained the gold standard diagnosis MI. Within 30 days, 18 (3.2%) patients had died. Nonsurvivors had higher hs-cTnT and hs-cTnI levels compared with survivors (hs-cTnT 40 [23-85] ng/L in nonsurvivors and 20 [13-33] ng/L in survivors; hs-cTnI 25 [14-54] ng/L in nonsurvivors and 8 [4-16] ng/L in survivors; p < 0.001 for both). CONCLUSIONS A majority of patients (n = 364, 68.8%) presenting to the ED after a fall had elevated hs-cTnT levels and 86 (15.4%) elevated hs-cTnI levels. However, the incidence of MI in these patients was low (n = 3, 0.5%). Our data do not support the opinion that falls may be a common presenting feature of MI. We discourage routine troponin testing in this population. However, hs-cTnT and hs-cTnI were both found to have prognostic properties for mortality prediction up to 1 year.
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Affiliation(s)
- Tanguy Espejo
- Emergency Department, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Lukas Terhalle
- Emergency Department, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Alexandra Malinovska
- Emergency Department, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Henk B Riedel
- Emergency Department, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Laura Arntz
- Department of Emergency Medicine, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Livia Hafner
- Emergency Department, University Hospital Basel, University of Basel, Basel, Switzerland
| | | | - Joanna Zuppinger
- Emergency Department, Cantonal Hospital Baselland, Liestal, Switzerland
| | - Nicolas Geigy
- Emergency Department, Cantonal Hospital Baselland, Liestal, Switzerland
| | - Jörg Leuppi
- Medical Faculty University of Basel and Cantonal Hospital Baselland, Liestal, Switzerland
| | - Rajan Somasundaram
- Department of Emergency Medicine, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Roland Bingisser
- Emergency Department, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Christian H Nickel
- Emergency Department, University Hospital Basel, University of Basel, Basel, Switzerland
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21
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Aldo C, Martina Z, Alberto A, Mario P. Cardiovascular risk evaluation in pregnancy: focus on cardiac specific biomarkers. Clin Chem Lab Med 2024; 62:581-592. [PMID: 37942796 DOI: 10.1515/cclm-2023-0609] [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: 06/10/2023] [Accepted: 10/25/2023] [Indexed: 11/10/2023]
Abstract
Despite the evidence demonstrating the clinical utility of cardiac specific biomarkers in improving cardiovascular risk evaluation in several clinical conditions, even the most recent reviews and guidelines fail to consider their measurement in order to enhance the accuracy of the evaluation of cardiovascular risk in pregnant women. The aim of this review article was to examine whether the assay of cardiac specific biomarkers can enhance cardiovascular risk evaluation in pregnant women, first by reviewing the relationships between the physiological state of pregnancy and cardiac specific biomarkers. The clinical relevance of brain natriuretic peptide (BNP)/NT-proBNP and high-sensitivity cardiac troponin I/high-sensitivity cardiac troponin T (hs-cTnI/hs-cTnT) assay in improving cardiovascular risk evaluation is examined based on the results of clinical studies on subjects with normal and those with complicated pregnancy. Finally, the analytical approaches and clinical objectives related to cardio specific biomarkers are advocated in order to allow an early and more accurate evaluation of cardiovascular risk in pregnant women.
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Affiliation(s)
- Clerico Aldo
- Coordinator of the Study Group on Cardiac Biomarkers from Italian Society of Biochemical Chemistry (SIBioC) and European Ligand Assay Society (ELAS), Milan, Italy
| | - Zaninotto Martina
- Department of Laboratory Medicine, University-Hospital Padova, Padova, Italy
| | - Aimo Alberto
- Fondazione CNR - Regione Toscana G. Monasterio, Pisa, Italy
| | - Plebani Mario
- Department of Medicine, University of Padova, Padova, Italy
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22
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Tomaiuolo R, Banfi G. From volume to value: a watershed moment for the clinical laboratory. Clin Chem Lab Med 2024; 62:593-596. [PMID: 37775150 DOI: 10.1515/cclm-2023-0870] [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: 08/08/2023] [Accepted: 09/25/2023] [Indexed: 10/01/2023]
Abstract
The clinical laboratory is often evaluated for the volume of testing. However, it is undeniable that laboratory tests affect clinical decision-making and are included in many clinical guidelines, meaning their contribution to determining clinical outcomes. Therefore, the clinical laboratory professional has the task of enhancing laboratory tests by optimizing the request and reporting phase and addressing patient outcomes. This opinion paper, presenting practical examples of managing value-based health care in the clinical laboratory context, underlines the need to shift towards value-based management to optimize outcome-based health care.
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Affiliation(s)
- Rossella Tomaiuolo
- Vita-Salute San Raffaele University, Milan, Italy
- IRCCS Istituto Ortopedico Galeazzi, Milan, Italy
| | - Giuseppe Banfi
- Vita-Salute San Raffaele University, Milan, Italy
- IRCCS Istituto Ortopedico Galeazzi, Milan, Italy
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23
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Aakre KM, Apple FS, Mills NL, Meex SJR, Collinson PO. Lower Limits for Reporting High-Sensitivity Cardiac Troponin Assays and Impact of Analytical Performance on Patient Misclassification. Clin Chem 2024; 70:497-505. [PMID: 38102065 DOI: 10.1093/clinchem/hvad185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Accepted: 09/27/2023] [Indexed: 12/17/2023]
Abstract
BACKGROUND Cardiac troponin measurements are indispensable for the diagnosis of myocardial infarction and provide useful information for long-term risk prediction of cardiovascular disease. Accelerated diagnostic pathways prevent unnecessary hospital admission, but require reporting cardiac troponin concentrations at low concentrations that are sometimes below the limit of quantification. Whether analytical imprecision at these concentrations contributes to misclassification of patients is debated. CONTENT The International Federation of Clinical Chemistry Committee on Clinical Application of Cardiac Bio-Markers (IFCC C-CB) provides evidence-based educational statements on analytical and clinical aspects of cardiac biomarkers. This mini-review discusses how the reporting of low concentrations of cardiac troponins impacts on whether or not assays are classified as high-sensitivity and how analytical performance at low concentrations influences the utility of troponins in accelerated diagnostic pathways. Practical suggestions are made for laboratories regarding analytical quality assessment of cardiac troponin results at low cutoffs, with a particular focus on accelerated diagnostic pathways. The review also discusses how future use of cardiac troponins for long-term prediction or management of cardiovascular disease may require improvements in analytical quality. SUMMARY Clinical guidelines recommend using cardiac troponin concentrations as low as the limit of detection of the assay to guide patient care. Laboratories, manufacturers, researchers, and external quality assessment providers should extend analytical performance monitoring of cardiac troponin assays to include the concentration ranges applicable in these pathways.
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Affiliation(s)
- Kristin M Aakre
- Department of Medical Biochemistry and Pharmacology and Department of Heart Disease, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Science, University of Bergen, Bergen, Norway
| | - Fred S Apple
- Department of Laboratory Medicine and Pathology, Hennepin Healthcare/HCMC, Minneapolis, MN, United States
- Department of Laboratory Medicine and Pathology, University of Minnesota, Minneapolis, MN, United States
| | - Nicolas L Mills
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
- Usher Institute, University of Edinburgh, Edinburgh, United Kingdom
| | - Steven J R Meex
- Central Diagnostic Laboratory, Maastricht University Medical Center, Maastricht, the Netherlands
- CARIM School for Cardiovascular Diseases, Maastricht University, Maastricht, the Netherlands
| | - Paul O Collinson
- Department of Clinical Blood Sciences and Cardiology, St.George's University Hospitals NHS Foundation Trust, London, United Kingdom
- St.George's University of London, London, United Kingdom
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24
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Kavsak PA, Clark L, Arnoldo S, Lou A, Shea JL, Eintracht S, Lyon AW, Bhayana V, Thorlacius L, Raizman JE, Tsui A, Djiana R, Chen M, Huang Y, Haider A, Booth RA, McCudden C, Yip PM, Beriault D, Blank D, Fung AWS, Taher J, St-Cyr J, Sharif S, Belley-Cote E, Abramson BL, Friedman SM, Cox JL, Sivilotti MLA, Chen-Tournoux A, McLaren J, Mak S, Thiruganasambandamoorthy V, Scheuermeyer F, Humphries KH, Worster A, Ko D, Aakre KM, Mills NL, Jaffe AS. Imprecision of high-sensitivity cardiac troponin assays at the female 99th-percentile. Clin Biochem 2024; 125:110731. [PMID: 38360198 DOI: 10.1016/j.clinbiochem.2024.110731] [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: 12/07/2023] [Revised: 02/02/2024] [Accepted: 02/08/2024] [Indexed: 02/17/2024]
Abstract
BACKGROUND An analytical benchmark for high-sensitivity cardiac troponin (hs-cTn) assays is to achieve a coefficient of variation (CV) of ≤ 10.0 % at the 99th percentile upper reference limit (URL) used for the diagnosis of myocardial infarction. Few prospective multicenter studies have evaluated assay imprecision and none have determined precision at the female URL which is lower than the male URL for all cardiac troponin assays. METHODS Human serum and plasma matrix samples were constructed to yield hs-cTn concentrations near the female URLs for the Abbott, Beckman, Roche, and Siemens hs-cTn assays. These materials were sent (on dry ice) to 35 Canadian hospital laboratories (n = 64 instruments evaluated) participating in a larger clinical trial, with instructions for storage, handling, and monthly testing over one year. The mean concentration, standard deviation, and CV for each instrument type and an overall pooled CV for each manufacturer were calculated. RESULTS The CVs for all individual instruments and overall were ≤ 10.0 % for two manufacturers (Abbott CVpooled = 6.3 % and Beckman CVpooled = 7.0 %). One of four Siemens Atellica instruments yielded a CV > 10.0 % (CVpooled = 7.7 %), whereas 15 of 41 Roche instruments yielded CVs > 10.0 % at the female URL of 9 ng/L used worldwide (6 cobas e411, 1 cobas e601, 4 cobas e602, and 4 cobas e801) (CVpooled = 11.7 %). Four Roche instruments also yielded CVs > 10.0 % near the female URL of 14 ng/L used in the United States (CVpooled = 8.5 %). CONCLUSIONS The number of instruments achieving a CV ≤ 10.0 % at the female 99th-percentile URL varies by manufacturer and by instrument. Monitoring assay precision at the female URL is necessary for some assays to ensure optimal use of this threshold in clinical practice.
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Affiliation(s)
| | | | | | - Amy Lou
- Dalhousie University, Halifax, NS, Canada
| | | | | | | | | | | | | | | | | | - Michael Chen
- University of British Columbia, Vancouver, BC, Canada
| | - Yun Huang
- Queen's University, Kingston, ON, Canada
| | - Ali Haider
- Queen's University, Kingston, ON, Canada
| | | | | | - Paul M Yip
- University of Toronto, Toronto, ON, Canada
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Dennis Ko
- University of Toronto, Toronto, ON, Canada
| | - Kristin M Aakre
- Institute of Clinical Science, University of Bergen, Bergen, Norway; Department of Medical Biochemistry and Pharmacology, Haukeland University Hospital, Bergen, Norway
| | - Nicholas L Mills
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
| | - Allan S Jaffe
- Mayo Clinic and Medical Center, Rochester, MN, United States
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25
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Maayah M, Grubman S, Allen S, Ye Z, Park DY, Vemmou E, Gokhan I, Sun WW, Possick S, Kwan JM, Gandhi PU, Hu JR. Clinical Interpretation of Serum Troponin in the Era of High-Sensitivity Testing. Diagnostics (Basel) 2024; 14:503. [PMID: 38472975 DOI: 10.3390/diagnostics14050503] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2024] [Revised: 02/03/2024] [Accepted: 02/05/2024] [Indexed: 03/14/2024] Open
Abstract
Cardiac troponin (Tn) plays a central role in the evaluation of patients with angina presenting with acute coronary syndrome. The advent of high-sensitivity assays has improved the analytic sensitivity and precision of serum Tn measurement, but this advancement has come at the cost of poorer specificity. The role of clinical judgment is of heightened importance because, more so than ever, the interpretation of serum Tn elevation hinges on the careful integration of findings from electrocardiographic, echocardiographic, physical exam, interview, and other imaging and laboratory data to formulate a weighted differential diagnosis. A thorough understanding of the epidemiology, mechanisms, and prognostic implications of Tn elevations in each cardiac and non-cardiac etiology allows the clinician to better distinguish between presentations of myocardial ischemia and myocardial injury-an important discernment to make, as the treatment of acute coronary syndrome is vastly different from the workup and management of myocardial injury and should be directed at the underlying cause.
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Affiliation(s)
- Marah Maayah
- Yale School of Medicine, Yale University, New Haven, CT 06520, USA
| | - Scott Grubman
- Yale School of Medicine, Yale University, New Haven, CT 06520, USA
| | - Stephanie Allen
- Department of Internal Medicine, Yale School of Medicine, Yale University, New Haven, CT 06520, USA
| | - Zachary Ye
- Department of Internal Medicine, Temple University Medical Center, Philadelphia, PA 19140, USA
| | - Dae Yong Park
- Department of Internal Medicine, Cook County Hospital, Chicago, IL 60612, USA
| | - Evangelia Vemmou
- Department of Internal Medicine, Yale School of Medicine, Yale University, New Haven, CT 06520, USA
| | - Ilhan Gokhan
- Yale School of Medicine, Yale University, New Haven, CT 06520, USA
| | - Wendy W Sun
- Department of Emergency Medicine, Yale School of Medicine, Yale University, New Haven, CT 06520, USA
| | - Stephen Possick
- Section of Cardiovascular Medicine, Yale School of Medicine, Yale University, New Haven, CT 06520, USA
| | - Jennifer M Kwan
- Section of Cardiovascular Medicine, Yale School of Medicine, Yale University, New Haven, CT 06520, USA
| | - Parul U Gandhi
- Section of Cardiovascular Medicine, Yale School of Medicine, Yale University, New Haven, CT 06520, USA
- Department of Cardiology, Veterans Affairs Connecticut Health Care System, West Haven, CT 06516, USA
| | - Jiun-Ruey Hu
- Section of Cardiovascular Medicine, Yale School of Medicine, Yale University, New Haven, CT 06520, USA
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26
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Murtagh G, deFilippi C, Zhao Q, Barac A. Circulating biomarkers in the diagnosis and prognosis of immune checkpoint inhibitor-related myocarditis: time for a risk-based approach. Front Cardiovasc Med 2024; 11:1350585. [PMID: 38410245 PMCID: PMC10894940 DOI: 10.3389/fcvm.2024.1350585] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2023] [Accepted: 01/16/2024] [Indexed: 02/28/2024] Open
Abstract
Immune checkpoint inhibitors (ICIs) are monoclonal antibodies that block immune checkpoints and therefore activate immune cells, allowing them to recognize and attack cancer cells. ICIs have revolutionized oncology practice, but their use has been complicated by immune-related adverse events (irAEs). Of cardiovascular (CV) irAEs, ICI-related myocarditis has received significant attention due to high mortality rates, ranging from 25% to 50%, despite its overall low incidence. Establishing the early diagnosis of ICI-myocarditis is important for early initiation of steroids and consideration of hospitalization in patients who are at risk for hemodynamic compromise and need high acuity care in a tertiary setting. In this review, we summarize the diagnostic and prognostic tools for ICI-myocarditis, including electrocardiography, echocardiography, cardiac magnetic resonance imaging, with emphasis on circulating biomarkers. Cardiac troponins (cTns) are an essential component of the diagnosis of ICI-myocarditis, and we provide a summary of the recent studies that utilized different assays (cTnI vs. cTnT) and outcomes (diagnosis vs. prognosis including major adverse cardiac outcomes). With the exponential increase in ICI use across different oncology indications, there is a major need to include biomarkers in risk stratification to guide diagnosis and treatment. Our review proposes a framework for future multisite registries, including cTn evaluation at baseline and at the time of irAE suspicion, with development of central biobanking to allow head-to-head evaluation and clinical validation of different biomarker assays in ICI-myocarditis. This approach, with the inclusion of CV biomarkers into clinical and pragmatic oncology trials, holds promise to improve the early recognition and management of ICI-myocarditis and CV irAEs, thus leading to better outcomes.
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Affiliation(s)
- Gillian Murtagh
- Core Diagnostics, Abbott Laboratories, Abbott Park, IL, United States
| | | | - Qiong Zhao
- Inova Schar Heart and Vascular, Falls Church, VA, United States
| | - Ana Barac
- Inova Schar Heart and Vascular, Falls Church, VA, United States
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27
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Hernández-González V, Conesa-Milian E, Jové-Deltell C, Pano-Rodríguez Á, Legaz-Arrese A, Reverter-Masia J. Global research trends on cardiac troponin and physical activity among pediatric populations: a bibliometric analysis and science mapping study. Front Pediatr 2024; 12:1285794. [PMID: 38374876 PMCID: PMC10875851 DOI: 10.3389/fped.2024.1285794] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Accepted: 01/16/2024] [Indexed: 02/21/2024] Open
Abstract
Background Cardiac troponin (cTn) is a reliable marker for evaluating myocardial damage. cTn is a very specific protein involved in myocardial injury, and it is a key factor in the diagnosis of coronary syndromes. Bibliometric analysis was applied in the present work, with the main goal of evaluating global research on the topic of cardiac troponin in pediatric populations. Methods Publications about cardiac troponin and physical activity in pediatric populations were retrieved from the Social Sciences Citation Index (SSCI) and the Science Citation Index Expanded (SCIE) of the Web of Science Core Collection, and they were then analyzed. The study was able to identify the key bibliometric indicators, such as publications, keywords, authors, countries, institutions, and journals. For the analysis, VOSviewer, R-based Bibliometrix (4.2.2), and MapChart were used. Results Initially, 98 documents were identified; however, once inclusion and exclusion criteria were applied, the number of documents decreased to 88. The search yielded 79 original research articles and 9 reviews, almost all of which were published in the past 2 decades. The total number of citations (Nc) of the retrieved publications was 1,468, and the average number of citations per article (Na) was 16.68. In general, 508 authors were found to have participated in research about troponin; they were associated with 256 institutions, and their work was published in 65 different journals from around the world. The authors hailed from 30 countries and/or regions. The year 2022 was the most productive year for the publication of the selected documents. The bibliometric analysis provided information regarding levels of cooperation among authors and institutions. In fact, China, the United States, and England were the most productive nations, and the journal with the greatest number of publications on the topic was Pediatric Cardiology. Summary The number of publications and the trend line show that research on this topic has not yet reached a stage of maturity. There are referent investigators, countries, and institutions that have laid the foundations for subsequent studies on the analyzed topic.
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Affiliation(s)
- Vicenç Hernández-González
- Human Movement Research Group (RGHM), University of Lleida, Lleida, Spain
- Physical Education and Sport Section, University of Lleida, Lleida, Spain
| | - Enric Conesa-Milian
- Human Movement Research Group (RGHM), University of Lleida, Lleida, Spain
- Physical Education and Sport Section, University of Lleida, Lleida, Spain
| | - Carme Jové-Deltell
- Human Movement Research Group (RGHM), University of Lleida, Lleida, Spain
- Physical Education and Sport Section, University of Lleida, Lleida, Spain
| | - Álvaro Pano-Rodríguez
- Human Movement Research Group (RGHM), University of Lleida, Lleida, Spain
- Physical Education and Sport Section, University of Lleida, Lleida, Spain
| | - Alejandro Legaz-Arrese
- Section of Physical Education and Sports, Faculty of Health and Sport Sciences, University of Zaragoza, Zaragoza, Spain
| | - Joaquin Reverter-Masia
- Human Movement Research Group (RGHM), University of Lleida, Lleida, Spain
- Physical Education and Sport Section, University of Lleida, Lleida, Spain
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Clerico A, Zaninotto M, Plebani M. Rapid rule-in and rule-out protocols of acute myocardial infarction using hs-cTnI and hs-cTnT methods. Clin Chem Lab Med 2024; 62:213-217. [PMID: 37736000 DOI: 10.1515/cclm-2023-1010] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/23/2023]
Affiliation(s)
- Aldo Clerico
- Study Group on Cardiac Biomarkers of the Italian Societies of Laboratory Medicine, Pisa, Italy
- Department of Laboratory Medicine, Fondazione Toscana G. Monasterio, Pisa, Italy
| | - Martina Zaninotto
- Department of Laboratory Medicine, University-Hospital Padova, Padova, Italy
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Hasselbalch RB, Alaour B, Kristensen JH, Couch LS, Kaier TE, Nielsen TL, Plesner LL, Strandkjær N, Schou M, Rydahl C, Goetze JP, Bundgaard H, Marber M, Iversen KK. Hemodialysis and biomarkers of myocardial infarction - a cohort study. Clin Chem Lab Med 2024; 62:361-370. [PMID: 37556843 DOI: 10.1515/cclm-2023-0071] [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: 01/18/2023] [Accepted: 07/24/2023] [Indexed: 08/11/2023]
Abstract
OBJECTIVES End-stage renal disease is associated with a high risk of cardiovascular disease. We compared the concentration and prognostic ability of high sensitivity cardiac troponin T (hs-cTnT) and I (hs-cTnI) and cardiac myosin-binding protein C (cMyC) among stable hemodialysis patients. METHODS Patients were sampled before and after hemodialysis. We measured hs-cTnI, hs-cTnT and cMyC and used Cox regressions to assess the association between quartiles of concentrations and all-cause mortality and a combination of cardiovascular events and all-cause mortality during follow-up. RESULTS A total of 307 patients were included, 204 males, mean age 66 years (SD 14). Before dialysis, 299 (99 %) had a hs-cTnT concentration above the 99th percentile, compared to 188 (66 %) for cMyC and 35 (11 %) for hs-cTnI. Hs-cTnT (23 %, p<0.001) and hs-cTnI (15 %, p=0.049) but not cMyC (4 %, p=0.256) decreased during dialysis. Follow-up was a median of 924 days (492-957 days); patients in the 3rd and 4th quartiles of hs-cTnT (3rd:HR 3.0, 95 % CI 1.5-5.8, 4th:5.2, 2.7-9.8) and the 4th quartile of hs-cTnI (HR 3.8, 2.2-6.8) had an increased risk of mortality. Both were associated with an increased risk of the combined endpoint for patients in the 3rd and 4th quartiles. cMyC concentrations were not associated with risk of mortality or cardiovascular event. CONCLUSIONS Hs-cTnT was above the 99th percentile in almost all patients. This was less frequent for hs-cTnI and cMyC. High cTn levels were associated with a 3-5-fold higher mortality. This association was not present for cMyC. These findings are important for management of hemodialysis patients.
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Affiliation(s)
- Rasmus Bo Hasselbalch
- Department of Cardiology, Copenhagen University Hospital - Herlev and Gentofte Hospital, Copenhagen, Denmark
- Department of Emergency Medicine, Copenhagen University Hospital - Herlev and Gentofte Hospital, Copenhagen, Denmark
| | - Bashir Alaour
- King's College London British Heart Foundation Centre, Rayne Institute, St Thomas' Hospital, London, UK
| | - Jonas Henrik Kristensen
- Department of Cardiology, Copenhagen University Hospital - Herlev and Gentofte Hospital, Copenhagen, Denmark
- Department of Emergency Medicine, Copenhagen University Hospital - Herlev and Gentofte Hospital, Copenhagen, Denmark
| | - Liam S Couch
- King's College London British Heart Foundation Centre, Rayne Institute, St Thomas' Hospital, London, UK
| | - Thomas E Kaier
- King's College London British Heart Foundation Centre, Rayne Institute, St Thomas' Hospital, London, UK
| | - Ture Lange Nielsen
- Department of Cardiology, Copenhagen University Hospital - Herlev and Gentofte Hospital, Copenhagen, Denmark
| | - Louis Lind Plesner
- Department of Cardiology, Copenhagen University Hospital - Herlev and Gentofte Hospital, Copenhagen, Denmark
| | - Nina Strandkjær
- Department of Cardiology, Copenhagen University Hospital - Herlev and Gentofte Hospital, Copenhagen, Denmark
- Department of Emergency Medicine, Copenhagen University Hospital - Herlev and Gentofte Hospital, Copenhagen, Denmark
| | - Morten Schou
- Department of Cardiology, Copenhagen University Hospital - Herlev and Gentofte Hospital, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Casper Rydahl
- Department of Nephrology, Copenhagen University Hospital - Herlev and Gentofte Hospital, Copenhagen, Denmark
| | - Jens P Goetze
- Department of Clinical Biochemistry, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Henning Bundgaard
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Department of Cardiology, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Michael Marber
- King's College London British Heart Foundation Centre, Rayne Institute, St Thomas' Hospital, London, UK
| | - Kasper Karmark Iversen
- Department of Cardiology, Copenhagen University Hospital - Herlev and Gentofte Hospital, Copenhagen, Denmark
- Department of Emergency Medicine, Copenhagen University Hospital - Herlev and Gentofte Hospital, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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Zhang L, Zhu J, Zhang S, Fu H. Investigating outlier rates of cardiac troponin I and troponin T assays: A systematic review. Heliyon 2024; 10:e23788. [PMID: 38205298 PMCID: PMC10776999 DOI: 10.1016/j.heliyon.2023.e23788] [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: 07/03/2023] [Revised: 12/12/2023] [Accepted: 12/13/2023] [Indexed: 01/12/2024] Open
Abstract
Objectives This review aimed to harmoniously summarize and compare outlier rates for various cardiac troponin (cTn) assays, including high-sensitivity-cTn (hs-cTn) assays and contemporary cTn (generation of assays prior to hs-cTn ones) assays, from the published studies. Methods The PRISMA guidelines were utilized to perform this systematic review. Five databases, including PubMed, Scopus, Embase, Cochrane Library, and Web of Science, were searched using specific keywords up to June 30th, 2023. Studies reporting specifically calculated outlier rates for cTn assays when conducting in-vitro diagnosis in human samples were included. Selected studies were then further assessed using the GRADE tool. Results Thirteen studies were included. The data from the studies were summarized statistically in this review. The results showed substantial evidence of improved analytical robustness or reduced respective mean rates of outliers, critical outliers, and analytical outliers for hs-cTn assays (0.14 %, 0.18 %, and 0.18 %) compared to contemporary cTn assays (0.63 %, 0.71 %, and 0.50 %). Conclusion The findings offer promisingly provide a comprehensive reference for laboratory scientists and clinical staff in choosing the most suitable cTn assay for patient care regrading outlier rates. Besides, this review reveals the advancements of hs-cTn assays with lower outlier rates than contemporary cTn assays. The emerging challenges for continuously improving analytical robustness of cTn assays are also elaborated.
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Affiliation(s)
- Litao Zhang
- Clinical Laboratory, Wuhan Asia General Hospital Affiliated to Wuhan University of Science and Technology, Wuhan, Hubei 430000, China
| | - Jia Zhu
- School of Intelligent Manufacturing and Smart Transportation, Suzhou City University, Suzhou, Jiangsu 215000, China
- School of Advanced Technology, Xi'an Jiaotong-Liverpool University, Suzhou, Jiangsu 215000, China
| | - Shiqiang Zhang
- School of Intelligent Manufacturing and Smart Transportation, Suzhou City University, Suzhou, Jiangsu 215000, China
| | - Hao Fu
- Mindray Medical International Ltd., Shenzhen, Guangdong 518000, China
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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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Tiwari D, Aw TC. Optimizing the Clinical Use of High-Sensitivity Troponin Assays: A Review. Diagnostics (Basel) 2023; 14:87. [PMID: 38201396 PMCID: PMC10795745 DOI: 10.3390/diagnostics14010087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Revised: 12/14/2023] [Accepted: 12/29/2023] [Indexed: 01/12/2024] Open
Abstract
Ischemic heart diseases (IHDs) remain a global health concern. Many IHD cases go undiagnosed due to challenges in the initial diagnostic process, particularly in cases of acute myocardial infarction (AMI). High-sensitivity cardiac troponin (hs-cTn) assays have revolutionized myocardial injury assessment, but variations in diagnostic cut-off values and population differences have raised challenges. This review addresses essential laboratory and clinical considerations for hs-cTn assays. Laboratory guidelines discuss the importance of establishing standardized 99th-percentile upper reference limits (URLs) considering factors such as age, sex, health status, and analytical precision. The reference population should exclude individuals with comorbidities like diabetes and renal disease, and rigorous selection is crucial. Some clinical guidelines emphasize the significance of sex-specific URL limits while others do not. They highlight the use of serial troponin assays for AMI diagnosis. In addition, timely reporting of accurate hs-cTn results is essential for effective clinical use. This review aims to provide a clearer understanding among laboratory professionals and clinicians on how to optimize the use of hs-cTn assays in clinical settings in order to ensure accurate AMI diagnosis and thus improve patient care and outcomes.
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Affiliation(s)
- Dipti Tiwari
- Independent Researcher, Singapore 069046, Singapore;
| | - Tar Choon Aw
- Department of Laboratory Medicine, Changi General Hospital, Singapore 529889, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore (NUS), Singapore 119228, Singapore
- Pathology Academic Clinical Program, Duke-NUS Graduate School of Medicine, Singapore 169857, Singapore
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Kaski JC, Lluch N, Lopez-Sendon JL, Gorog DA, Antorrena-Miranda I, Avanzas P, Herrero Puente P, Sionis A, González-Juanatey JR, Íñiguez A, Cordero A, Ako E, Fernández-Avilés F, Atienza F, Recio-Mayoral A, Wu AHB, Crea F, Storey R, Badimon L, Cubedo J. Changes in circulating ApoJ-Glyc levels in patients with suspected acute coronary syndrome: The EDICA trial. Int J Cardiol 2023; 391:131291. [PMID: 37619880 DOI: 10.1016/j.ijcard.2023.131291] [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: 05/15/2023] [Revised: 08/08/2023] [Accepted: 08/20/2023] [Indexed: 08/26/2023]
Abstract
BACKGROUND Myocardial ischemia induces intracellular accumulation of non-glycosylated apolipoprotein J that results in a reduction of circulating glycosylated ApoJ (ApoJ-Glyc). The latter has been suggested to be a marker of transient myocardial ischemia. OBJECTIVE This proof-of-concept clinical study aimed to assess whether changes in circulating ApoJ-Glyc could detect myocardial ischemia in patients attending the emergency department (ED) with chest pain suggestive of acute coronary syndrome (ACS). METHODS In suspected ACS patients, EDICA (Early Detection of Myocardial Ischemia in Suspected Acute Coronary Syndromes by ApoJ-Glyc a Novel Pathologically based Ischemia Biomarker), a multicentre, international, cohort study assessed changes in 2 glycosylated variants of ApoJ-Glyc, (ApoJ-GlycA2 and ApoJ-GlycA6), in serum samples obtained at ED admission (0 h), and 1 h and 3 h thereafter, blinded to the clinical diagnosis (i.e. STEMI, NSTEMI, unstable angina, non-ischemic). RESULTS 404 patients were recruited; 291 were given a clinical diagnosis of "non-ischemic" chest pain and 113 were considered to have had an ischemic event. ApoJ-GlycA6 was lower on admission in ischemic compared with "non-ischemic" patients (66 [46-90] vs. 73 [56-95] μg/ml; P = 0.04). 74% of unstable angina patients (all with undetectable hs-Tn), had ischemic changes in ApoJ-Glyc at 0 h and 89% at 1 h. Initially low ApoJ-Glyc levels in 62 patients requiring coronary revascularization increased significantly after successful percutaneous intervention. CONCLUSIONS Circulating ApoJ-Glyc concentrations decrease early in ED patients with myocardial ischemia compared with "non-ischemic" patients, even in the absence of troponin elevations. ApoJ-Glyc may be a useful marker of myocardial ischemia in the ED setting.
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Affiliation(s)
- Juan Carlos Kaski
- Molecular and Clinical Sciences Research Institute, St George's, University of London, London, United Kingdom; GlyCardial Diagnostics, S.L., Barcelona, Spain
| | - Nuria Lluch
- GlyCardial Diagnostics, S.L., Barcelona, Spain
| | | | - Diana A Gorog
- Postgraduate Medical School, University of Hertfordshire, Hertfordshire, United Kingdom; Faculty of Medicine, National Heart and Lung Institute, Imperial College, London
| | | | - Pablo Avanzas
- Interventional Cardiology Unit, Hospital Universitario Central de Asturias, Department of Medicine, University of Oviedo, Oviedo, Spain Sanitaria del Principado de Asturias, Spain
| | - Pablo Herrero Puente
- Emergency Department, University Central Hospital of Asturias, Instituto de Investigación Sanitaria del Principado de Asturias, Spain
| | - Alessandro Sionis
- Cardiology Department Hospital de la Santa Creu i Sant Pau, IIB-Sant Pau, Barcelona, Spain
| | | | - Andrés Íñiguez
- Department of Cardiology, Hospital Universitario Álvaro Cunqueiro, Vigo, Spain
| | - Alberto Cordero
- Cardiology Department, Hospital Universitario de San Juan, Alicante, Spain
| | - Emmanuel Ako
- Chelsea & Westminster Hospital, London, United Kingdom
| | - Francisco Fernández-Avilés
- Department of Cardiology, Hospital General Universitario Gregorio Marañón, Madrid, Spain; Ciber Cardiovascular (CiberCV), Madrid, Spain
| | - Felipe Atienza
- Department of Cardiology, Hospital General Universitario Gregorio Marañón, Madrid, Spain; Ciber Cardiovascular (CiberCV), Madrid, Spain
| | | | - Alan H B Wu
- Clinical Chemistry and Toxicology Laboratories, San Francisco General Hospital and Dept. Lab. Medicine, University of California, San Francisco, USA
| | - Filippo Crea
- Università Cattolica del Sacro Cuore, and Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy
| | - Robert Storey
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, United Kingdom
| | - Lina Badimon
- GlyCardial Diagnostics, S.L., Barcelona, Spain; Cardiovascular-Program-ICCC, IR-Hospital Santa Creu i Sant Pau, IIB-Sant Pau, 08025 Barcelona, Spain; Cardiovascular Research, Universitat Autònoma de Barcelona, Barcelona, Spain
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Murtagh G, Januzzi JL, Scherrer‐Crosbie M, Neilan TG, Dent S, Ho JE, Appadurai V, McDermott R, Akhter N. Circulating Cardiovascular Biomarkers in Cancer Therapeutics-Related Cardiotoxicity: Review of Critical Challenges, Solutions, and Future Directions. J Am Heart Assoc 2023; 12:e029574. [PMID: 37889193 PMCID: PMC10727390 DOI: 10.1161/jaha.123.029574] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2023] [Accepted: 09/26/2023] [Indexed: 10/28/2023]
Abstract
Cardiotoxicity is a growing concern in the oncology population. Transthoracic echocardiography and multigated acquisition scans have been used for surveillance but are relatively insensitive and resource intensive. Innovative imaging techniques are constrained by cost and availability. More sensitive, cost-effective cardiotoxicity surveillance strategies are needed. Circulating cardiovascular biomarkers could provide a sensitive, low-cost solution. Biomarkers such as troponins, natriuretic peptides (NPs), novel upstream signals of oxidative stress, inflammation, and fibrosis as well as panomic technologies have shown substantial promise, and guidelines recommend baseline measurement of troponins and NPs in all patients receiving potential cardiotoxins. Nonetheless, supporting evidence has been hampered by several limitations. Previous reviews have provided valuable perspectives on biomarkers in cancer populations, but important analytic aspects remain to be examined in depth. This review provides comprehensive assessment of critical challenges and solutions in this field, with focus on analytical issues relating to biomarker measurement and interpretation. Examination of evidence pertaining to common and serious forms of cardiotoxicity reveals that improved study designs incorporating larger, more diverse populations, registry-based approaches, and refinement of current definitions are key. Further efforts to harmonize biomarker methodologies including centralized biobanking and analyses, novel decision limits, and head-to-head comparisons are needed. Multimarker algorithms incorporating machine learning may allow rapid, personalized risk assessment. These improvements will not only augment the predictive value of circulating biomarkers in cardiotoxicity but may elucidate both direct and indirect relationships between cardiovascular disease and cancer, allowing biomarkers a greater role in the development and success of novel anticancer therapies.
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Affiliation(s)
| | - James L. Januzzi
- Division of Cardiology, Department of MedicineMassachusetts General Hospital, Harvard Medical SchoolBostonMAUSA
| | | | - Tomas G. Neilan
- Division of Cardiology, Department of MedicineMassachusetts General Hospital, Harvard Medical SchoolBostonMAUSA
| | - Susan Dent
- Duke Cancer Institute, Department of MedicineDuke UniversityDurhamNCUSA
| | - Jennifer E. Ho
- CardioVascular Institute and Division of Cardiology, Department of MedicineBeth Israel Deaconess Medicine CenterBostonMAUSA
| | - Vinesh Appadurai
- Division of Cardiovascular MedicineNorthwestern University Feinberg School of MedicineChicagoILUSA
- School of MedicineThe University of QueenslandSt LuciaQueenslandAustralia
| | - Ray McDermott
- Medical OncologySt. Vincent’s University HospitalDublinIreland
| | - Nausheen Akhter
- Division of Cardiovascular MedicineNorthwestern University Feinberg School of MedicineChicagoILUSA
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Aspromonte N, Zaninotto M, Aimo A, Fumarulo I, Plebani M, Clerico A. Measurement of Cardiac-Specific Biomarkers in the Emergency Department: New Insight in Risk Evaluation. Int J Mol Sci 2023; 24:15998. [PMID: 37958981 PMCID: PMC10648028 DOI: 10.3390/ijms242115998] [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: 09/19/2023] [Revised: 11/02/2023] [Accepted: 11/04/2023] [Indexed: 11/15/2023] Open
Abstract
The aim of this article review is to analyze some models and clinical issues related to the implementation of accelerated diagnostic protocols based on specific cardiac biomarkers in patients admitted to the emergency department (ED) with symptoms compatible with acute cardiac disorders. Four specific clinical issues will be discussed in detail: (a) pathophysiological and clinical interpretations of circulating hs-cTnI and hs-cTnT levels; (b) the clinical relevance and estimation of the biological variation of biomarkers in patients admitted to the ED with acute and severe diseases; (c) the role and advantages of the point-of-care testing (POCT) methods for cardiac-specific biomarkers in pre-hospital and hospital clinical practice; and (d) the clinical role of specific cardiac biomarkers in patients with acute heart failure (AHF). In order to balance the risk between a hasty discharge versus the potential harms caused by a cardiac assessment in patients admitted to the ED with suspected acute cardiovascular disease, the measurement of specific cardiac biomarkers is essential for the early identification of the presence of myocardial dysfunction and/or injury and to significantly reduce the length and costs of hospitalization. Moreover, specific cardiac biomarkers (especially hs-cTnI and hs-cTnT) are useful predictors of mortality and major adverse cardiovascular events (MACE) in patients admitted to the ED with suspected acute cardiovascular disease. To guide the implementation of the most rapid algorithms for the diagnosis of Non-ST-Elevation Myocardial Infarction (NSTEMI) into routine clinical practice, clinical scientific societies and laboratory medicine societies should promote collaborative studies specifically designed for the evaluation of the analytical performance and, especially, the cost/benefit ratio resulting from the use of these clinical protocols and POCT methods in the ED clinical practice.
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Affiliation(s)
- Nadia Aspromonte
- Department of Cardiovascular and Thoracic Sciences, Catholic University of the Sacred Heart, 00168 Rome, Italy; (N.A.); (I.F.)
- Department of Cardiovascular and Thoracic Sciences, A. Gemelli University Policlinic Foundation IRCCS, 00168 Rome, Italy
| | - Martina Zaninotto
- Department of Laboratory Medicine, University-Hospital of Padova, 35129 Padova, Italy;
| | - Alberto Aimo
- CNR Foundation—Regione Toscana G. Monasterio, 56127 Pisa, Italy;
| | - Isabella Fumarulo
- Department of Cardiovascular and Thoracic Sciences, Catholic University of the Sacred Heart, 00168 Rome, Italy; (N.A.); (I.F.)
- Department of Cardiovascular and Thoracic Sciences, A. Gemelli University Policlinic Foundation IRCCS, 00168 Rome, Italy
| | - Mario Plebani
- Department of Medicine-DIMED, University of Padova, 35129 Padova, Italy;
| | - Aldo Clerico
- CNR Foundation—Regione Toscana G. Monasterio, 56127 Pisa, Italy;
- Coordinator of the Study Group on Cardiac Biomarkers of the Italian Societies of Laboratory Medicine, 56127 Pisa, Italy
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Gessner R, Gärtner C, Schmidt M, Eckelt F, Wirkner K, Löffler M, Uhe T, Isermann B, Laufs U, Kaiser T, Wachter R. Higher troponin T serum concentrations in hospital patients without diagnosed cardiac diseases compared to a population-based cohort. Clin Chem Lab Med 2023; 61:2046-2052. [PMID: 37272166 DOI: 10.1515/cclm-2023-0040] [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: 08/05/2022] [Accepted: 05/19/2023] [Indexed: 06/06/2023]
Abstract
OBJECTIVES Upper reference limits of high-sensitivity cardiac troponin T (hs-cTnT) are derived from healthy, population-based cohorts, and are frequently exceeded in hospitalized patients. In this study we aim to systematically examine the differences between in-hospital patients with no diagnosed cardiac diseases and a population-based cohort. METHODS Retrospective analyses were performed in two independent cohorts. We included 5,652 participants of the prospective population-based LIFE cohort as well as 9,300 patients having been treated at our hospital between 2014 and 2021. In both cohorts, subjects with diagnosed or suspected cardiac diseases were excluded. We used Spearman's rank correlation for correlation analyses of hs-cTnT serum concentrations and age. Sex- and age-adjusted 99th percentiles for hs-cTnT in subjects with preserved renal function were obtained in both cohorts. RESULTS In both cohorts, hs-cTnT serum concentrations positively correlated with age. Male sex was associated with higher hs-cTnT serum concentrations. Persons treated in hospital showed significantly higher hs-cTnT concentrations in females and males aged above 50. While in the population-based cohort only 99th percentile hs-cTnT results of females aged above 70 and males aged above 60 years exceeded the assay's upper reference limit, the 99th percentiles of in-hospital females over 40 years and males of all age groups exceeded this threshold. CONCLUSIONS Besides age and sex, hospitalization per se is correlated with higher serum concentrations of hs-cTnT in most age groups. Our results indicate, that unconditionally applying current hs-cTnT cut-offs to inpatients might overestimate myocardial infarction and potentially lead to overdiagnosis.
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Affiliation(s)
- Romy Gessner
- Department of Cardiology, University of Leipzig Medical Center, Leipzig, Germany
| | - Christiane Gärtner
- Institute for Laboratory Medicine, Clinical Chemistry and Molecular Diagnostics, University of Leipzig Medical Center and Medical Faculty, Leipzig, Germany
- Institute for Laboratory Medicine, Microbiology and Pathobiochemistry, University Hospital Ostwestfalen-Lippe (UK-OWL), Lippe, Germany
| | - Maria Schmidt
- Institute for Laboratory Medicine, Clinical Chemistry and Molecular Diagnostics, University of Leipzig Medical Center and Medical Faculty, Leipzig, Germany
| | - Felix Eckelt
- Institute for Laboratory Medicine, Clinical Chemistry and Molecular Diagnostics, University of Leipzig Medical Center and Medical Faculty, Leipzig, Germany
| | - Kerstin Wirkner
- LIFE - Leipzig Research Center for Civilization Diseases, University of Leipzig, Leipzig, Germany
- Institute for Medical Informatics, Statistics, and Epidemiology (IMISE), University of Leipzig, Leipzig, Germany
| | - Markus Löffler
- LIFE - Leipzig Research Center for Civilization Diseases, University of Leipzig, Leipzig, Germany
- Institute for Medical Informatics, Statistics, and Epidemiology (IMISE), University of Leipzig, Leipzig, Germany
| | - Tobias Uhe
- Department of Cardiology, University of Leipzig Medical Center, Leipzig, Germany
| | - Berend Isermann
- Institute for Laboratory Medicine, Clinical Chemistry and Molecular Diagnostics, University of Leipzig Medical Center and Medical Faculty, Leipzig, Germany
| | - Ulrich Laufs
- Department of Cardiology, University of Leipzig Medical Center, Leipzig, Germany
| | - Thorsten Kaiser
- Institute for Laboratory Medicine, Clinical Chemistry and Molecular Diagnostics, University of Leipzig Medical Center and Medical Faculty, Leipzig, Germany
- Institute for Laboratory Medicine, Microbiology and Pathobiochemistry, University Hospital Ostwestfalen-Lippe (UK-OWL), Lippe, Germany
| | - Rolf Wachter
- Department of Cardiology, University of Leipzig Medical Center, Leipzig, Germany
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Ollila MM, Arffman RK, Kaikkonen K, Morin-Papunen L, Junttila J, Piltonen TT. High-sensitivity troponin-T levels and associated health conditions in 3146 women aged 46. Ann Med 2023; 55:2264340. [PMID: 37795692 PMCID: PMC10557532 DOI: 10.1080/07853890.2023.2264340] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Accepted: 09/24/2023] [Indexed: 10/06/2023] Open
Abstract
OBJECTIVE The aim of the study was to investigate are there associations between common female sex-specific health conditions (oligo/amenorrhea, hyperandrogenism, menopause and polycystic ovary syndrome [PCOS]) and high-sensitivity troponin-T (hs-TnT) levels. METHODS Cross-sectional and longitudinal analyses of a general population-based prospective cohort study were performed. The hs-TnT levels of 3146 women aged 46 were measured using an Elecsys® Troponin T high-sensitivity assay. Median hs-TnT levels and 25 and 75 percentiles of the cases and controls were compared. Also, a logistic regression analysis using a binary outcome - undetectable hs-TnT (< 3.0 ng/L) versus detectable hs-TnT (≥ 3.0 ng/L) - was performed. RESULTS Women with oligo/amenorrhea at age 31 had significantly higher hs-TnT levels at age 46 than women without oligo/amenorrhea (4.06 [3.59; 4.86] vs 3.98 [3.44; 4.71] ng/L, p = .042). Menopausal women had significantly higher hs-TnT levels than premenopausal women (4.15 [3.54; 4.91] vs 3.95 [3.45; 4.68] ng/L, p = .012) at age 46. Women with PCOS or hyperandrogenism had comparable hs-TnT levels with their controls. In the adjusted logistic regression analysis, oligo/amenorrhea (odds ratio [OR] = 1.52 [0.90-2.57]), hyperandrogenism (OR = 1.20 [0.75-1.92]), PCOS (OR = 1.51 [0.81-2.84]) and menopause (OR = 1.05 [0.63-1.74]) were not significantly associated with detectable hs-TnT. CONCLUSIONS This study was the first to investigate how oligo/amenorrhea, hyperandrogenism, PCOS and menopause are associated with hs-TnT. Although women with oligo/amenorrhea and menopause had higher hs-TnT levels than women without these conditions, the difference was small. Larger studies are required to better understand the effects of oligo/amenorrhea on cardiovascular health.
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Affiliation(s)
- Meri-Maija Ollila
- Department of Obstetrics and Gynaecology, Medical Research Center Oulu, Research Unit of Clinical Medicine, University of Oulu and Oulu University Hospital, Oulu, Finland
| | - Riikka K. Arffman
- Department of Obstetrics and Gynaecology, Medical Research Center Oulu, Research Unit of Clinical Medicine, University of Oulu and Oulu University Hospital, Oulu, Finland
| | - Kari Kaikkonen
- Research Unit of Internal Medicine, Medical Research Center Oulu, University of Oulu and Oulu University Hospital, Oulu, Finland
| | - Laure Morin-Papunen
- Department of Obstetrics and Gynaecology, Medical Research Center Oulu, Research Unit of Clinical Medicine, University of Oulu and Oulu University Hospital, Oulu, Finland
| | - Juhani Junttila
- Research Unit of Internal Medicine, Medical Research Center Oulu, University of Oulu and Oulu University Hospital, Oulu, Finland
| | - Terhi T. Piltonen
- Department of Obstetrics and Gynaecology, Medical Research Center Oulu, Research Unit of Clinical Medicine, University of Oulu and Oulu University Hospital, Oulu, Finland
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Sasaki S, Inoue K, Shiozaki M, Hanada K, Watanabe R, Minamino T. Diagnostic and Cost Efficiency of the 0-h/1-h Rule-out and Rule-in Algorithm for Patients With Chest Pain in the Emergency Department. Circ J 2023; 87:1362-1368. [PMID: 37394574 DOI: 10.1253/circj.cj-23-0064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/04/2023]
Abstract
BACKGROUND This study investigated the economic impact of the European Society of Cardiology (ESC) clinical practice guideline recommendation of using the 0-h/1-h rule-out and rule-in algorithm with high-sensitivity cardiac troponin assays (0/1-h algorithm) to triage patients presenting with chest pain.Methods and Results: This post hoc cost-effectiveness evaluation (DROP-ACS; UMIN000030668) used deidentified electronic medical records from health insurance claims from 2 diagnostic centers in Japan. A cost-effectiveness analysis was conducted with 472 patients with care provided following the 0/1-h algorithm (Hospital A) and 427 patients following point-of-care testing (Hospital B). The clinical outcome of interest was all-cause mortality or subsequent myocardial infarction within 30 days of the index presentation. The sensitivity and specificity for the clinical outcome were 100% (95% confidence interval [CI] 91.1-100%) and 95.0% (95% CI 94.3-95.0%), respectively, in Hospital A and 92.9% (95% CI 69.6-98.7%) and 89.8% (95% CI 89.0-90.0%), respectively, in Hospital B. If the diagnostic accuracy of the 0/1-h algorithm was implemented in Hospital B, it is expected that the number of urgent (<24-h) coronary angiograms would decrease by 50%. Incorporating this assumption, implementing the 0/1-h algorithm could potentially reduce medical costs by JPY4,033,874 (95% CI JPY3,440,346-4,627,402) in Hospital B (JPY9,447 per patient; 95% CI JPY 8,057-10,837 per patient). CONCLUSIONS The ESC 0/1-h algorithm was efficient for risk stratification and for reducing medical costs.
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Affiliation(s)
- Shun Sasaki
- Department of Cardiovascular Biology and Medicine, Juntendo University Nerima Hospital
| | - Kenji Inoue
- Department of Cardiovascular Biology and Medicine, Juntendo University Nerima Hospital
| | | | | | - Ryo Watanabe
- Graduate School of Health Innovation, Kanagawa University of Human Service
| | - Tohru Minamino
- Department of Cardiovascular Biology and Medicine, Juntendo University School of Medicine
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Hasselbalch RB, Schultz M, Schytz PA, Kristensen JH, Strandkjær N, Pries-Heje M, Carlson N, Schou M, Bundgaard H, Torp-Pedersen C, Iversen KK. Predictive and prognostic value of different cardiac troponin assays: a nationwide register-based cohort study. EUROPEAN HEART JOURNAL. QUALITY OF CARE & CLINICAL OUTCOMES 2023; 9:592-599. [PMID: 36264293 DOI: 10.1093/ehjqcco/qcac065] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Revised: 10/03/2022] [Accepted: 10/17/2022] [Indexed: 09/13/2023]
Abstract
AIMS Guidelines do not differentiate between the available assays of cardiac troponin (cTn). We compared the prognostic and predictive ability of cTn assays. METHODS AND RESULTS This was a nationwide cohort study of patients with acute coronary syndrome (ACS) and ≥ 2 cTn measurements of one of four assays: Roche high-sensitivity cTnT (hs-cTnT), Abbott high sensitivity cTnI (hs-cTnI), Siemens Vista cTnI, and Siemens cTnI Ultra. Data were collected from Danish registries from 2009-18. Peak cTn concentration normalized to the 99th percentile was used. Outcomes were myocardial infarction (MI) during admission, one-year all-cause-, cardiovascular-, and non-cardiovascular mortality. Receiver operating characteristics and logistic regression calculating odds ratios (OR) were used. A total of 90 705 patients were included, of which 20 550 (23%) had MI. Siemens Vista cTnI was the strongest predictor of MI, Area under the curve (auc) 0.93 (95% CI 0.93-0.93). In 1 year 9012 (9.9%) of patients had died. An inverted U-shape relationship was observed between concentration of cTn and all-cause mortality. Hs-cTnT OR 21.3 (95% CI 18.4-24.8) at 2-5 times the 99th percentile and 12.1 (95% CI 10.3-14.1) for concentrations >100 times the 99th percentile. The inverted U-shape relationship was only present for non-cardiovascular mortality. The strongest predictor of cardiovascular mortality was hs-cTnT, OR 11.3 (95% CI 6.4-21.8) at 1-2 times the 99th percentile and 88.8 (95% CI 53.2-163.0) for concentrations >100 times the 99th percentile. CONCLUSION Siemens Vista cTnI was the strongest predictor of MI and hs-cTnT was the strongest predictor of mortality. An inverted U-shape relationship was observed between cTn concentration and non-cardiovascular mortality.
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Affiliation(s)
- Rasmus B Hasselbalch
- Department of Cardiology, Copenhagen University Hospital, Herlev and Gentofte Hospital, Copenhagen 2730, Denmark
- Department of Emergency Medicine, Copenhagen University Hospital, Herlev and Gentofte Hospital, Copenhagen 2730, Denmark
| | - Martin Schultz
- Department of Cardiology, Copenhagen University Hospital, Herlev and Gentofte Hospital, Copenhagen 2730, Denmark
- Department of Emergency Medicine, Copenhagen University Hospital, Herlev and Gentofte Hospital, Copenhagen 2730, Denmark
| | - Philip A Schytz
- Department of Cardiology, Copenhagen University Hospital, Herlev and Gentofte Hospital, Copenhagen 2730, Denmark
| | - Jonas H Kristensen
- Department of Cardiology, Copenhagen University Hospital, Herlev and Gentofte Hospital, Copenhagen 2730, Denmark
- Department of Emergency Medicine, Copenhagen University Hospital, Herlev and Gentofte Hospital, Copenhagen 2730, Denmark
| | - Nina Strandkjær
- Department of Cardiology, Copenhagen University Hospital, Herlev and Gentofte Hospital, Copenhagen 2730, Denmark
- Department of Emergency Medicine, Copenhagen University Hospital, Herlev and Gentofte Hospital, Copenhagen 2730, Denmark
| | - Mia Pries-Heje
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen 2100, Denmark
| | - Nicholas Carlson
- Department of Nephrology, Copenhagen University Hospital, Rigshospitalet, Copenhagen 2100, Denmark
- The Danish Heart Foundation, Copenhagen 1120, Denmark
| | - Morten Schou
- Department of Emergency Medicine, Copenhagen University Hospital, Herlev and Gentofte Hospital, Copenhagen 2730, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen 2200, Denmark
| | - Henning Bundgaard
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen 2100, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen 2200, Denmark
| | - Christian Torp-Pedersen
- Department of Cardiology, Nordsjaellands Hospital, Hilleroed 3400, Denmark
- Department of Public Health, University of Copenhagen, Copenhagen 2200, Denmark
| | - Kasper K Iversen
- Department of Cardiology, Copenhagen University Hospital, Herlev and Gentofte Hospital, Copenhagen 2730, Denmark
- Department of Emergency Medicine, Copenhagen University Hospital, Herlev and Gentofte Hospital, Copenhagen 2730, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen 2200, Denmark
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Chand DH, Sun R, Diab KA, Kenny D, Tukov FF. Review of cardiac safety in onasemnogene abeparvovec gene replacement therapy: translation from preclinical to clinical findings. Gene Ther 2023; 30:685-697. [PMID: 37095320 PMCID: PMC10125853 DOI: 10.1038/s41434-023-00401-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Revised: 04/03/2023] [Accepted: 04/12/2023] [Indexed: 04/26/2023]
Abstract
Human gene replacement therapies such as onasemnogene abeparvovec (OA) use recombinant adeno-associated virus (rAAV) vectors to treat monogenic disorders. The heart and liver are known target organs of toxicity in animals; with cardiac and hepatic monitoring recommended in humans after OA dosing. This manuscript provides a comprehensive description of cardiac data from preclinical studies and clinical sources including clinical trials, managed access programs and the post-marketing setting following intravenous OA administration through 23 May 2022. Single dose mouse GLP-Toxicology studies revealed dose-dependent cardiac findings including thrombi, myocardial inflammation and degeneration/regeneration, which were associated with early mortality (4-7 weeks) in the high dose groups. No such findings were documented in non-human primates (NHP) after 6 weeks or 6 months post-dose. No electrocardiogram or echocardiogram abnormalities were noted in NHP or humans. After OA dosing, some patients developed isolated elevations in troponin without associated signs/symptoms; the reported cardiac adverse events in patients were considered of secondary etiology (e.g. respiratory dysfunction or sepsis leading to cardiac events). Clinical data indicate cardiac toxicity observed in mice does not translate to humans. Cardiac abnormalities have been associated with SMA. Healthcare professionals should use medical judgment when evaluating the etiology and assessment of cardiac events post OA dosing so as to consider all possibilities and manage the patient accordingly.
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Affiliation(s)
- Deepa H Chand
- Novartis Pharmaceuticals Corporation, East Hanover, NJ, USA.
- Department of Pediatrics, University of Illinois College of Medicine and Children's Hospital of Illinois, Peoria, IL, USA.
| | - Rui Sun
- Novartis Pharmaceuticals Corporation, East Hanover, NJ, USA
| | - Karim A Diab
- Division of Cardiology, Department of Pediatrics, Inova Children's Hospital, Fairfax, VA, USA
| | - Damien Kenny
- Department of Paediatric Cardiology, CHI at Crumlin, Dublin, Ireland
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Kanani F, Maqsood S, Wadhwani V, Zubairy M, Iftikhar I, Zubairi AM. Diagnoses and Outcomes of Patients with Suspicion of Acute Coronary Syndrome and Raised High Sensitive Troponin I: A Single Center Study from Pakistan. J Lab Physicians 2023; 15:409-418. [PMID: 37564233 PMCID: PMC10411135 DOI: 10.1055/s-0043-1761940] [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: 04/07/2023] Open
Abstract
Objectives Troponins are classically raised in acute coronary syndrome (ACS) although other cardiovascular and non-cardiovascular causes are recognized. We aimed to see the association of high sensitivity (Hs) Troponin I values exceeding the sex-specific 99th percentile upper reference limit (URL) with diagnoses, emergency department (ED) outcomes, 30-day outcomes of admitted patients and predictors of ACS in both genders. Materials and Methods A retrospective study of all patients presenting to the emergency department from January 2019 to April 2021 with suspicion of ACS and Hs-Troponin I values greater than the sex-specific 99th percentile URL. Statistical Analysis SPSS version 24 was used, Pearson's chi-square tests, Fisher's exact test, Kruskal-Wallis test, Mann-Whitney U test, and odds ratios, including the 95% confidence intervals, for each characteristic were used for analysis. A p -value of < 0.05 was considered significant. Results There were a total of 5,982 patients (3,031 males, 2,951 females), out of which 878 patients were admitted under the cardiology specialty. In patients who were admitted to the ward, mortality was higher in females (8.2%) with less than a 10-fold rise in Hs-Troponin I while similar in both genders (7.6%) in patients with Hs-troponin I greater than 10-fold of sex-specific 99th percentile URL. Raised low-density lipoprotein-cholesterol was a significant factor associated with 2.4 times higher odds of ACS. Conclusion Women with Hs-Troponin values up to 10 times the URL, i.e., 15.6-160 ng/L have higher mortality than their male counterparts. LDL-cholesterol is a significant risk factor for ACS which should be controlled for its prevention.
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Affiliation(s)
- Fatima Kanani
- Section of Chemical Pathology, Indus Hospital & Health Network, Karachi, Pakistan
| | - Sidra Maqsood
- Indus Hospital Research Centre, Indus Hospital & Health Network, Karachi, Pakistan
| | - Vandana Wadhwani
- Department of Cardiology, Indus Hospital & Health Network, Karachi, Pakistan
| | - Maliha Zubairy
- Section of Chemical Pathology, Indus Hospital & Health Network, Karachi, Pakistan
| | - Imran Iftikhar
- Department of Cardiology, Indus Hospital & Health Network, Karachi, Pakistan
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Lehmann LH, Heckmann MB, Bailly G, Finke D, Procureur A, Power JR, Stein F, Bretagne M, Ederhy S, Fenioux C, Hamwy O, Funck-Brentano E, Romano E, Pieroni L, Münster J, Allenbach Y, Anquetil C, Leonard-Louis S, Palaskas NL, Hayek SS, Katus HA, Giannitsis E, Frey N, Kaya Z, Moslehi J, Prifti E, Salem JE. Cardiomuscular Biomarkers in the Diagnosis and Prognostication of Immune Checkpoint Inhibitor Myocarditis. Circulation 2023; 148:473-486. [PMID: 37317858 PMCID: PMC10527069 DOI: 10.1161/circulationaha.123.062405] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Accepted: 05/19/2023] [Indexed: 06/16/2023]
Abstract
BACKGROUND Immune checkpoint inhibitors (ICIs) are approved for multiple cancers but can result in ICI-associated myocarditis, an infrequent but life-threatening condition. Elevations in cardiac biomarkers, specifically troponin-I (cTnI), troponin-T (cTnT), and creatine kinase (CK), are used for diagnosis. However, the association between temporal elevations of these biomarkers with disease trajectory and outcomes has not been established. METHODS We analyzed the diagnostic accuracy and prognostic performances of cTnI, cTnT, and CK in patients with ICI myocarditis (n=60) through 1-year follow-up in 2 cardio-oncology units (APHP Sorbonne, Paris, France and Heidelberg, Germany). A total of 1751 (1 cTnT assay type), 920 (4 cTnI assay types), and 1191 CK sampling time points were available. Major adverse cardiomyotoxic events (MACE) were defined as heart failure, ventricular arrhythmia, atrioventricular or sinus block requiring pacemaker, respiratory muscle failure requiring mechanical ventilation, and sudden cardiac death. Diagnostic performance of cTnI and cTnT was also assessed in an international ICI myocarditis registry. RESULTS Within 72 hours of admission, cTnT, cTnI, and CK were increased compared with upper reference limits (URLs) in 56 of 57 (98%), 37 of 42 ([88%] P=0.03 versus cTnT), and 43 of 57 ([75%] P<0.001 versus cTnT), respectively. This increased rate of positivity for cTnT (93%) versus cTnI ([64%] P<0.001) on admission was confirmed in 87 independent cases from an international registry. In the Franco-German cohort, 24 of 60 (40%) patients developed ≥1 MACE (total, 52; median time to first MACE, 5 [interquartile range, 2-16] days). The highest value of cTnT:URL within the first 72 hours of admission performed best in terms of association with MACE within 90 days (area under the curve, 0.84) than CK:URL (area under the curve, 0.70). A cTnT:URL ≥32 within 72 hours of admission was the best cut-off associated with MACE within 90 days (hazard ratio, 11.1 [95% CI, 3.2-38.0]; P<0.001), after adjustment for age and sex. cTnT was increased in all patients within 72 hours of the first MACE (23 of 23 [100%]), whereas cTnI and CK values were less than the URL in 2 of 19 (11%) and 6 of 22 (27%) of patients (P<0.001), respectively. CONCLUSIONS cTnT is associated with MACE and is sensitive for diagnosis and surveillance in patients with ICI myocarditis. A cTnT:URL ratio <32 within 72 hours of diagnosis is associated with a subgroup at low risk for MACE. Potential differences in diagnostic and prognostic performances between cTnT and cTnI as a function of the assays used deserve further evaluation in ICI myocarditis.
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Affiliation(s)
- Lorenz H. Lehmann
- Department of Cardiology, Angiology, and Pneumology, Heidelberg University Hospital, Heidelberg, Germany; German Centre for Cardiovascular Research (DZHK), Heidelberg/Mannheim partner site, Heidelberg, Germany
| | - Markus B. Heckmann
- Department of Cardiology, Angiology, and Pneumology, Heidelberg University Hospital, Heidelberg, Germany; German Centre for Cardiovascular Research (DZHK), Heidelberg/Mannheim partner site, Heidelberg, Germany
| | - Guillaume Bailly
- Sorbonne Université, Assistance Publique-Hôpitaux de Paris, INSERM, Department of Pharmacology, CIC-1901, UNICO-GRECO Cardio-oncology program, Pitié-salpétrière Hospital, Paris, France
| | - Daniel Finke
- Department of Cardiology, Angiology, and Pneumology, Heidelberg University Hospital, Heidelberg, Germany; German Centre for Cardiovascular Research (DZHK), Heidelberg/Mannheim partner site, Heidelberg, Germany
| | - Adrien Procureur
- Sorbonne Université, Assistance Publique-Hôpitaux de Paris, INSERM, Department of Pharmacology, CIC-1901, UNICO-GRECO Cardio-oncology program, Pitié-salpétrière Hospital, Paris, France
| | - John R. Power
- University of California San Diego, San Diego, California, USA
| | - Frederic Stein
- Department of Cardiology, Angiology, and Pneumology, Heidelberg University Hospital, Heidelberg, Germany; German Centre for Cardiovascular Research (DZHK), Heidelberg/Mannheim partner site, Heidelberg, Germany
- Sorbonne Université, Assistance Publique-Hôpitaux de Paris, INSERM, Department of Pharmacology, CIC-1901, UNICO-GRECO Cardio-oncology program, Pitié-salpétrière Hospital, Paris, France
| | - Marie Bretagne
- Sorbonne Université, Assistance Publique-Hôpitaux de Paris, INSERM, Department of Pharmacology, CIC-1901, UNICO-GRECO Cardio-oncology program, Pitié-salpétrière Hospital, Paris, France
| | - Stephane Ederhy
- Sorbonne Université, Assistance Publique-Hôpitaux de Paris,, INSERM, Department of Cardiology, CIC-1901, UNICO-GRECO Cardio-oncology program, Saint-Antoine Hospital, Paris, France
| | - Charlotte Fenioux
- Sorbonne Université, Assistance Publique-Hôpitaux de Paris, INSERM, Department of Pharmacology, CIC-1901, UNICO-GRECO Cardio-oncology program, Pitié-salpétrière Hospital, Paris, France
| | - Omar Hamwy
- Sorbonne Université, Assistance Publique-Hôpitaux de Paris, INSERM, Department of Pharmacology, CIC-1901, UNICO-GRECO Cardio-oncology program, Pitié-salpétrière Hospital, Paris, France
| | | | - Emanuela Romano
- Center for Cancer Immunotherapy, Department of Oncology, PSL Research University, Institut Curie, Paris, France
| | - Laurence Pieroni
- Sorbonne Université, Assistance Publique-Hôpitaux de Paris, Biochimie- Hormonologie, Hôpital Tenon, Paris, France
| | - Jan Münster
- Department of Cardiology, Angiology, and Pneumology, Heidelberg University Hospital, Heidelberg, Germany; German Centre for Cardiovascular Research (DZHK), Heidelberg/Mannheim partner site, Heidelberg, Germany
| | - Yves Allenbach
- Sorbonne Université, Assistance Publique-Hôpitaux de Paris, INSERM, Department of internal medecine, Hôpital Pitié-Salpêtrière, Paris, France
| | - Céline Anquetil
- Sorbonne Université, Assistance Publique-Hôpitaux de Paris, INSERM, Department of internal medecine, Hôpital Pitié-Salpêtrière, Paris, France
| | - Sarah Leonard-Louis
- Sorbonne Université, Assistance Publique-Hôpitaux de Paris, INSERM, Department of Neuropathology, Hôpital Pitié-Salpêtrière, F-75013 Paris, France
| | - Nicolas L. Palaskas
- Department of Cardiology, The University of Texas MD Anderson Cancer Center, Houston, TX USA
| | | | - Salim S. Hayek
- Department of Internal Medicine, Division of Cardiology, University of Michigan, Ann Arbor, MI
| | - Hugo A. Katus
- Department of Cardiology, Angiology, and Pneumology, Heidelberg University Hospital, Heidelberg, Germany; German Centre for Cardiovascular Research (DZHK), Heidelberg/Mannheim partner site, Heidelberg, Germany
| | - Evangelos Giannitsis
- Department of Cardiology, Angiology, and Pneumology, Heidelberg University Hospital, Heidelberg, Germany; German Centre for Cardiovascular Research (DZHK), Heidelberg/Mannheim partner site, Heidelberg, Germany
| | - Norbert Frey
- Department of Cardiology, Angiology, and Pneumology, Heidelberg University Hospital, Heidelberg, Germany; German Centre for Cardiovascular Research (DZHK), Heidelberg/Mannheim partner site, Heidelberg, Germany
| | - Ziya Kaya
- Department of Cardiology, Angiology, and Pneumology, Heidelberg University Hospital, Heidelberg, Germany; German Centre for Cardiovascular Research (DZHK), Heidelberg/Mannheim partner site, Heidelberg, Germany
| | - Javid Moslehi
- Section of Cardio-Oncology & Immunology, Cardiovascular Research Institute, University of California San Francisco, San Francisco, CA, USA
| | - Edi Prifti
- IRD, Sorbonne University, UMMISCO, 32 Avenue Henri Varagnat, F-93143 Bondy, France; Sorbonne Université, INSERM (NutriOmics), Paris, France
| | - Joe-Elie Salem
- Sorbonne Université, Assistance Publique-Hôpitaux de Paris, INSERM, Department of Pharmacology, CIC-1901, UNICO-GRECO Cardio-oncology program, Pitié-salpétrière Hospital, Paris, France
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McEvoy JW, Wang D, Brady T, Tang O, Ndumele C, Coresh J, Christenson RH, Selvin E. Myocardial Injury Thresholds for 4 High-Sensitivity Troponin Assays in a Population-Based Sample of US Children and Adolescents. Circulation 2023; 148:7-16. [PMID: 37078280 PMCID: PMC10330102 DOI: 10.1161/circulationaha.122.063281] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Accepted: 03/30/2023] [Indexed: 04/21/2023]
Abstract
BACKGROUND Myocardial injury is an important pediatric diagnosis. Establishing normative data from a representative pediatric sample is vital to provide accurate upper reference limits (URLs) for defining myocardial injury using high-sensitivity cardiac troponin. METHODS Among participants 1 to 18 years of age in the 1999-2004 National Health and Nutrition Examination Survey, we measured high-sensitivity troponin T using one assay (Roche) and high-sensitivity troponin I using 3 assays (Abbott, Siemens, and Ortho). In a strictly defined healthy subgroup, we estimated 97.5th and 99th percentile URLs for each assay using the recommended nonparametric method. RESULTS Of 5695 pediatric participants, 4029 met criteria for the healthy subgroup (50% males; mean age 12.6 years). Our 99th percentile URL estimates for all 4 high-sensitivity troponin assays among children and adolescents were lower than the manufacturer-reported URLs (derived from adults). The 99th percentile URLs (95% CI) were 15 ng/L (95% CI, 12-17) for high-sensitivity troponin T, 16 ng/L (95% CI, 12-19) for high-sensitivity troponin I with the Abbott assay, 38 ng/L (95% CI, 25-46) for high-sensitivity troponin I with the Siemens assay, and 7 ng/L (95% CI, 5, 12) for high-sensitivity troponin I with the Ortho assay. The 95% CIs for age-, sex-, and race and ethnicity-specific 99th percentile URLs overlapped. However, the 97.5th percentile URL for each assay was measured with superior statistical precision (ie, tighter 95% CIs) and demonstrated differences by sex. For male compared with female children and adolescents, 97.5th percentile URLs were 11 ng/L (95% CI, 10-12) versus 6 ng/L (95% CI, 6-7) for high-sensitivity troponin T, 9 ng/L (95% CI, 7-10) versus 5 ng/L (95% CI, 4-6) for high-sensitivity troponin I with the Abbott assay, 21 ng/L (95% CI, 18-25) versus 11 ng/L (95% CI, 9-13) for high-sensitivity troponin I with the Siemens assay, and 4 ng/L (95% CI, 3-5) versus 2 ng/L (95% CI, 1-3) for high-sensitivity troponin I with the Ortho assay. In contrast to the 99th percentiles, the point estimates of 97.5th percentile pediatric URLs for high-sensitivity troponin were also much more stable to differences in the analytic approaches taken to estimate URLs. CONCLUSIONS Because myocardial infarction is rare in children and adolescents, the use of statistically more precise and reliable sex-specific 97.5th percentile high-sensitivity troponin URLs might be considered to define pediatric myocardial injury.
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Affiliation(s)
- John W. McEvoy
- Division of Cardiology and National Institute for Prevention & Cardiovascular Health, University of Galway, Ireland
- Department of Epidemiology and the Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
- Johns Hopkins School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Dan Wang
- Department of Epidemiology and the Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Tammy Brady
- Division of Nephrology, Department of Pediatrics, Johns Hopkins University, Baltimore, MD, USA
| | - Olive Tang
- Johns Hopkins School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Chiadi Ndumele
- Department of Epidemiology and the Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
- Johns Hopkins School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Josef Coresh
- Department of Epidemiology and the Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Robert H. Christenson
- Department of Pathology, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Elizabeth Selvin
- Department of Epidemiology and the Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
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Jaffe AS, Body R, Mills NL, Aakre KM, Collinson PO, Saenger A, Hammarsten O, Wereski R, Omland T, Sandoval Y, Ordonez-Llanos J, Apple FS. Single Troponin Measurement to Rule Out Myocardial Infarction: JACC Review Topic of the Week. J Am Coll Cardiol 2023; 82:60-69. [PMID: 37380305 DOI: 10.1016/j.jacc.2023.04.040] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Revised: 04/05/2023] [Accepted: 04/10/2023] [Indexed: 06/30/2023]
Abstract
The term "single-sample rule-out" refers to the ability of very low concentrations of high-sensitivity cardiac troponin (hs-cTn) on presentation to exclude acute myocardial infarction with high clinical sensitivity and negative predictive value. Observational and randomized studies have confirmed this ability. Some guidelines endorse use of a concentration of hs-cTn at the assay's limit of detection, while other studies have validated the use of higher concentrations, allowing this approach to identify a greater proportion of patients at low risk. In most studies, at least 30% of patients can be triaged with this approach. The concentration of hs-cTn varies according to the assay used and sometimes how regulations permit reporting. It is clear that patients need to be at least 2 hours from the onset of symptoms being evaluated. Caution is warranted, particularly with older patients, women, and patients with underlying cardiac comorbidities.
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Affiliation(s)
- Allan S Jaffe
- Department of Cardiology, Mayo Clinic, Rochester, Minnesota, USA; Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA.
| | - Richard Body
- Emergency Department, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, United Kingdom; Division of Cardiovascular Sciences, University of Manchester, Manchester, United Kingdom; Healthcare Sciences Department, Manchester Metropolitan University, Manchester, United Kingdom
| | - Nicholas L Mills
- Usher Institute, University of Edinburgh, Edinburgh, United Kingdom; British Heart Foundation/University Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
| | - Kristin M Aakre
- Department of Medical Biochemistry and Pharmacology, Haukeland University Hospital, Bergen, Norway; Department of Heart Disease, Haukeland University Hospital, Bergen, Norway; Department of Clinical Science, University of Bergen, Bergen, Norway
| | - Paul O Collinson
- Department of Clinical Blood Sciences, St George's University Hospitals NHS Foundation Trust, London, United Kingdom; Department of Cardiology, St George's University Hospitals NHS Foundation Trust, London, United Kingdom; St George's University of London, London, United Kingdom
| | - Amy Saenger
- Department of Laboratory Medicine and Pathology, Hennepin Healthcare/Hennepin County Medical Center, Minneapolis, Minnesota, USA; Department of Laboratory Medicine and Pathology, University of Minnesota, Minneapolis, Minnesota, USA
| | - Ole Hammarsten
- Department of Clinical Chemistry and Transfusion Medicine, University of Gothenburg, Gothenburg, Sweden
| | - Ryan Wereski
- Usher Institute, University of Edinburgh, Edinburgh, United Kingdom
| | - Torbjørn Omland
- Department of Cardiology, Akershus University Hospital, Lørenskog, Norway; Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Yader Sandoval
- Minneapolis Heart Institute, Abbott Northwestern Hospital, and Minneapolis Heart Institute Foundation, Minneapolis, Minnesota, USA
| | - Jordi Ordonez-Llanos
- Clinical Biochemistry Department, Hospital de Sant Pau, Barcelona, Spain; Foundation for Biochemistry and Molecular Pathology, Barcelona, Spain
| | - Fred S Apple
- Department of Laboratory Medicine and Pathology, Hennepin Healthcare/Hennepin County Medical Center, Minneapolis, Minnesota, USA; Department of Laboratory Medicine and Pathology, University of Minnesota, Minneapolis, Minnesota, USA
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Kavsak PA, Clark L, Arnoldo S, Lou A, Shea JL, Eintracht S, Lyon AW, Bhayana V, Thorlacius L, Raizman JE, Tsui AKY, Djiana R, Chen M, Huang Y, Booth RA, McCudden C, Lavoie J, Beriault DR, Blank DW, Fung AWS, Hoffman B, Taher J, St-Cyr J, Yip PM, Belley-Cote EP, Abramson BL, Borgundvaag B, Friedman SM, Mak S, McLaren J, Steinhart B, Udell JA, Wijeysundera HC, Atkinson P, Campbell SG, Chandra K, Cox JL, Mulvagh S, Quraishi AUR, Chen-Tournoux A, Clark G, Segal E, Suskin N, Johri AM, Sivilotti MLA, Garuba H, Thiruganasambandamoorthy V, Robinson S, Scheuermeyer F, Humphries KH, Than M, Pickering JW, Worster A, Mills NL, Devereaux PJ, Jaffe AS. Analytic Result Variation for High-Sensitivity Cardiac Troponin: Interpretation and Consequences. Can J Cardiol 2023; 39:947-951. [PMID: 37094710 DOI: 10.1016/j.cjca.2023.04.013] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Revised: 04/06/2023] [Accepted: 04/18/2023] [Indexed: 04/26/2023] Open
Affiliation(s)
| | - Lorna Clark
- McMaster University, Hamilton, Ontario, Canada
| | | | - Amy Lou
- Dalhousie University, Halifax, Nova Scotia, Canada
| | - Jennifer L Shea
- Department of Laboratory Medicine, Saint John Regional Hospital, Saint John, New Brunswick, Canada
| | | | - Andrew W Lyon
- University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | | | | | - Joshua E Raizman
- Department of Laboratory Medicine, Faculty of Medicine and Dentistry, College of Health Sciences, University of Alberta, Edmonton, Alberta, Canada
| | - Albert K Y Tsui
- Department of Laboratory Medicine, Faculty of Medicine and Dentistry, College of Health Sciences, University of Alberta, Edmonton, Alberta, Canada
| | | | - Michael Chen
- University of British Columbia, Vancouver, British Columbia, Canada
| | - Yun Huang
- Queen's University, Kingston, Ontario, Canada
| | | | | | - Joël Lavoie
- Institut de Cardiologie de Montréal, Montréal, Québec, Canada
| | | | | | - Angela W S Fung
- University of British Columbia, Vancouver, British Columbia, Canada
| | | | | | | | - Paul M Yip
- University of Toronto, Toronto, Ontario, Canada
| | - Emilie P Belley-Cote
- McMaster University, Hamilton, Ontario, Canada; Population Health Research Institute, Hamilton, Ontario, Canada
| | | | | | | | - Susanna Mak
- University of Toronto, Toronto, Ontario, Canada
| | | | | | | | | | | | | | | | - Jafna L Cox
- Dalhousie University, Halifax, Nova Scotia, Canada
| | | | | | | | | | - Eli Segal
- McGill University, Montréal, Québec, Canada
| | | | | | | | | | | | - Simon Robinson
- University of British Columbia, Vancouver, British Columbia, Canada
| | | | | | - Martin Than
- Department of Emergency Medicine, Christchurch Hospital, Christchurch, New Zealand
| | - John W Pickering
- Department of Emergency Medicine, Christchurch Hospital, Christchurch, New Zealand; Department of Medicine, University of Otago, Christchurch, New Zealand
| | | | - Nicholas L Mills
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
| | - P J Devereaux
- McMaster University, Hamilton, Ontario, Canada; Population Health Research Institute, Hamilton, Ontario, Canada
| | - Allan S Jaffe
- Mayo Clinic and Medical Center, Rochester, Minnesota, United States
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Clerico A, Zaninotto M, Aimo A, Cardinale DM, Dittadi R, Sandri MT, Perrone MA, Belloni L, Fortunato A, Trenti T, Plebani M. Variability of cardiac troponin levels in normal subjects and in patients with cardiovascular diseases: analytical considerations and clinical relevance. Clin Chem Lab Med 2023; 61:1209-1229. [PMID: 36695506 DOI: 10.1515/cclm-2022-1285] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Accepted: 01/09/2023] [Indexed: 01/26/2023]
Abstract
In accordance with all the most recent international guidelines, the variation of circulating levels of cardiac troponins I and T, measured with high-sensitivity methods (hs-cTnI and hs-cTnT), should be used for the detection of acute myocardial injury. Recent experimental and clinical evidences have demonstrated that the evaluation of hs-cTnI and hs-cTnT variations is particularly relevant: a) for the differential diagnosis of Acute Coronary Syndromes (ACS) in patients admitted to the Emergency Department (ED); b) for the evaluation of cardiovascular risk in patients undergoing major cardiac or non-cardiac surgery, and in asymptomatic subjects of the general population aged >55 years and with co-morbidities; c) for the evaluation of cardiotoxicity caused by administration of some chemotherapy drugs in patients with malignant tumors. The aim of this document is to discuss the fundamental statistical and biological considerations on the intraindividual variability of hs-cTnI and hs-cTnT over time in the same individual. Firstly, it will be discussed in detail as the variations of circulating levels strictly depend not only on the analytical error of the method used but also on the intra-individual variability of the biomarker. Afterwards, the pathophysiological interpretation and the clinical relevance of the determination of the variability of the hs-cTnI and hs-cTnT values in patients with specific clinical conditions are discussed. Finally, the evaluation over time of the variation in circulating levels of hs-cTnI and hs-cTnT is proposed for a more accurate estimation of cardiovascular risk in asymptomatic subjects from the general population.
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Affiliation(s)
- Aldo Clerico
- Scuola Superiore Sant'Anna e Fondazione CNR, Regione Toscana G. Monasterio, Pisa, Italy
| | - Martina Zaninotto
- Dipartimento di Medicina di Laboratorio, Università-Ospedale di Padova, Padova, Italy
- Azienda Ospedaliera Universitaria di Padova, e Facoltà di Medicina e Chirurgia, Università di Padova, Padova, Italy
| | - Alberto Aimo
- Scuola Superiore Sant'Anna e Fondazione CNR, Regione Toscana G. Monasterio, Pisa, Italy
| | | | - Ruggero Dittadi
- Unità di Medicina di Laboratorio, Ospedale dell'Angelo, e Centro Regionale dei Biomarcatori, Dipartimento di Patologia Clinica, Azienda ULSS 3, Mestre, Italy
| | - Maria T Sandri
- Laboratorio Bianalisi, Carate Brianza, Monza e Brianza, Italy
| | - Marco Alfonso Perrone
- Dipartimento di Biochimica Clinica e Divisione di Cardiologia, Università e Ospedale di Tor Vergata, Rome, Italy
| | - Lucia Belloni
- Unità di Immunologia Clinica, Allergia e Biotecnologie Avanzate, Arcispedale Santa Maria Nuova-IRCCS, Reggio Emilia, Italy
| | | | - Tommaso Trenti
- Dipartimento di Patologia Clinica e Laboratorio, Azienda USL of Modena, Modena, Italy
| | - Mario Plebani
- Dipartimento di Medicina di Laboratorio, Università-Ospedale di Padova, Padova, Italy
- Azienda Ospedaliera Universitaria di Padova, e Facoltà di Medicina e Chirurgia, Università di Padova, Padova, Italy
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McEvoy JW, Tang O, Wang D, Ndumele CE, Coresh J, Christenson RH, Selvin E. Myocardial Injury Thresholds for 4 High-Sensitivity Troponin Assays in U.S. Adults. J Am Coll Cardiol 2023; 81:2028-2039. [PMID: 37197846 DOI: 10.1016/j.jacc.2023.03.403] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Revised: 03/09/2023] [Accepted: 03/13/2023] [Indexed: 05/19/2023]
Abstract
BACKGROUND Myocardial injury is currently defined as a cardiac troponin above the sex-specific 99th percentile of a healthy reference population (upper reference limit [URL]). OBJECTIVES The purpose of this study was to estimate high-sensitivity (hs) troponin URLs in a representative sample of the U.S. adult population; overall and by sex, race/ethnicity, and age group. METHODS Among adults participating in the 1999-2004 National Health and Nutrition Examination Survey (NHANES), we measured hs-troponin T using 1 assay (Roche) and hs-troponin I using 3 assays (Abbott, Siemens, and Ortho). In a strictly defined healthy reference subgroup, we estimated 99th percentile URLs for each assay using the recommended nonparametric method. RESULTS Of 12,545 participants, 2,746 met criteria for the healthy subgroup (mean age 37 years, 50% men). The NHANES 99th percentile URL for hs-troponin T (19 ng/L) matched the manufacturer-reported URL (19 ng/L). NHANES URLs were 13 ng/L (95% CI: 10-15 ng/L) for Abbott hs-troponin I (manufacturer: 28 ng/L), 5 ng/L (95% CI: 4-7 ng/L) for Ortho hs-troponin I (manufacturer: 11 ng/L), and 37 ng/L (95% CI: 27-66 ng/L) for Siemens hs-troponin I (manufacturer: 46.5 ng/L). There were significant differences in URLs by sex, but none by race/ethnicity. Furthermore, the 99th percentile URLs for all 4 hs-troponin assays were statistically significantly lower in healthy adults aged <40 years compared with healthy adults ≥60 years (all P < 0.001 by rank sum testing). CONCLUSIONS We found URLs for hs-troponin I assays that were substantially lower than currently listed 99th percentile URLs. There were significant differences in hs-troponin T and I URLs by sex and by age group in healthy U.S. adults but none by race/ethnicity.
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Affiliation(s)
- John W McEvoy
- Division of Cardiology and National Institute for Prevention and Cardiovascular Health, University of Galway, Galway, Ireland; Johns Hopkins School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA; Department of Epidemiology and the Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA.
| | - Olive Tang
- Johns Hopkins School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Dan Wang
- Department of Epidemiology and the Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Chiadi E Ndumele
- Johns Hopkins School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA; Department of Epidemiology and the Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Josef Coresh
- Department of Epidemiology and the Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Robert H Christenson
- Department of Pathology, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Elizabeth Selvin
- Department of Epidemiology and the Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
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McCarthy CP, Vyas A, Januzzi JL. What Is a Normal Troponin, Anyway? J Am Coll Cardiol 2023; 81:2040-2042. [PMID: 37197847 DOI: 10.1016/j.jacc.2023.03.404] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Revised: 03/14/2023] [Accepted: 03/15/2023] [Indexed: 05/19/2023]
Affiliation(s)
- Cian P McCarthy
- Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA.
| | - Austin Vyas
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - James L Januzzi
- Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA; Baim Institute for Clinical Research, Boston, Massachusetts, USA. https://twitter.com/JJheart_doc
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49
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Liu C, Deng Z, Wu W, Li Y, Yang F, Ge R, Ge M, Niu S, Liu H, Ji L, Li X, Huang X, Yusufu D, Zhang X. Ethnicity and sex-specific 99th percentile upper reference limits of high-sensitivity cardiac troponin I among adults in Xinjiang, China. Clin Biochem 2023; 116:94-99. [PMID: 37084997 DOI: 10.1016/j.clinbiochem.2023.04.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Revised: 04/05/2023] [Accepted: 04/11/2023] [Indexed: 04/23/2023]
Abstract
OBJECTIVES To determine the 99th percentile upper reference limit (URL) of high-sensitivity cardiac troponin I (hs-cTnI) in a healthy population in Xinjiang, China, and investigate the impact of ethnicity, sex, and age on this limit. DESIGN AND METHODS From September 2018 to March 2022, 5,090 Han and Uyghur adults aged 20-79 years were recruited. After questionnaire screening, 2,970 participants with physical and/or laboratory normality were enrolled. Participants recruited between September 2018 and October 2021 (2,109/2,970) were evaluated by ARCHITECTi2000 to determine the 99th percentile URL of hs-cTnI. The results were then validated in 861/2,970 participants recruited from November 2021 to March 2022. A criterion of ≤10% of test results falling outside the original determined value was used to determine whether the newly established reference intervals were valid. RESULTS The hs-cTnI concentration was higher among Uyghurs than among Han participants (p<0.001). The 99th percentile URLs were 17.52 ng/L for all participants, 18.96 ng/L for Uyghur, and 16.93 ng/L for Han. Hs-cTnI concentration was also correlated with sex and age. In the Han and Uyghur groups, male participants had a higher hs-cTnI concentration than female participants (p<0.001); the 99th percentile URLs of hs-cTnI among male and female participants were 17.80 vs. 13.67 ng/L and 19.47 vs. 16.52 ng/L, respectively. Stratified by age, hs-cTnI concentrations were higher in participants aged >60 years than in those of other age categories (p<0.001), in both the Han and Uyghur groups. Finally, <2% of these test results exceeded the newly established reference, validating the results. CONCLUSIONS This study established the 99th percentile URLs of hs-cTnI in the Xinjiang. Ethnicity and sex influence the value and should be considered.
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Affiliation(s)
- Chunyan Liu
- Department of Clinical Laboratory, Hospital of Xinjiang Production and Construction Corps, No. 232, Qingnian Road, Tianshan District, Urumqi, Xinjiang, China.
| | - Zhaohui Deng
- Department of Clinical Laboratory, Hospital of Xinjiang Production and Construction Corps, No. 232, Qingnian Road, Tianshan District, Urumqi, Xinjiang, China.
| | - Wenli Wu
- Department of Clinical Laboratory, Fourth Division Hospital of Xinjiang Production and Construction Corps, No. 56, Xinhua West Road, Yining, Xinjiang, China.
| | - Yan Li
- Department of Clinical Laboratory, Fourth Division Hospital of Xinjiang Production and Construction Corps, No. 56, Xinhua West Road, Yining, Xinjiang, China.
| | - Fang Yang
- Department of Clinical Laboratory, Tumushuke General Hospital of the Third Division of Xinjiang Production and Construction Corps, No. 13, Qianhai East Street, Tumushuke, Xinjiang, China.
| | - Ruoqing Ge
- Department of Clinical Laboratory, Hospital of Xinjiang Production and Construction Corps, No. 232, Qingnian Road, Tianshan District, Urumqi, Xinjiang, China.
| | - Min Ge
- Department of Clinical Laboratory, Hospital of Xinjiang Production and Construction Corps, No. 232, Qingnian Road, Tianshan District, Urumqi, Xinjiang, China.
| | - Shumin Niu
- Department of Clinical Laboratory, Hospital of Xinjiang Production and Construction Corps, No. 232, Qingnian Road, Tianshan District, Urumqi, Xinjiang, China.
| | - Huimin Liu
- Department of Clinical Laboratory, Hospital of Xinjiang Production and Construction Corps, No. 232, Qingnian Road, Tianshan District, Urumqi, Xinjiang, China.
| | - Linlin Ji
- Department of Clinical Laboratory, Hospital of Xinjiang Production and Construction Corps, No. 232, Qingnian Road, Tianshan District, Urumqi, Xinjiang, China.
| | - Xin Li
- Department of Clinical Laboratory, Hospital of Xinjiang Production and Construction Corps, No. 232, Qingnian Road, Tianshan District, Urumqi, Xinjiang, China.
| | - Xibei Huang
- Department of Clinical Laboratory, Fourth Division Hospital of Xinjiang Production and Construction Corps, No. 56, Xinhua West Road, Yining, Xinjiang, China.
| | - Dilibaier Yusufu
- Department of Clinical Laboratory, Tumushuke General Hospital of the Third Division of Xinjiang Production and Construction Corps, No. 13, Qianhai East Street, Tumushuke, Xinjiang, China.
| | - Xin Zhang
- Department of Clinical Laboratory, Hospital of Xinjiang Production and Construction Corps, No. 232, Qingnian Road, Tianshan District, Urumqi, Xinjiang, China.
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Hughes AEO, Forbriger A, May AM, Scott MG, Char D, Farnsworth CW. Implementation of High-Sensitivity Troponin with a Rapid Diagnostic Algorithm Reduces Emergency Department Length of Stay for Discharged Patients. Clin Biochem 2023; 116:87-93. [PMID: 37054770 DOI: 10.1016/j.clinbiochem.2023.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Revised: 04/05/2023] [Accepted: 04/10/2023] [Indexed: 04/15/2023]
Abstract
INTRODUCTION High sensitivity troponin (hs-cTn) and diagnostic algorithms are used to rapidly triage patients with symptoms of acute myocardial infarction in emergency departments (ED). However, few studies have evaluated the impact of simultaneously implementing hs-cTn and a rapid rule-out algorithm on length of stay (LOS). METHODS We assessed the impact of transitioning from contemporary cTnI to hs-cTnI in 59,232 ED encounters over three years. hs-cTnI was implemented with an orderable series that included baseline, two-, four-, and six-hour specimens collected at provider discretion and operationalized with an algorithm to calculate the change in hs-cTnI from baseline and provide interpretations of "insignificant", "significant," or "equivocal." Patient demographics, results, chief complaint, disposition, and ED LOS were captured from the electronic medical record. RESULTS cTnI was ordered for 31,875 encounters prior to hs-cTnI implementation and 27,357 after. The proportion of cTnI results above the 99th percentile upper reference limit decreased from 35.0% to 27.0% for men and increased from 27.8% to 34.8% for women. Among discharged patients, the median LOS decreased by 0.6 h (0.5-0.7). LOS among discharged patients with a chief complaint of chest pain decreased by 1.0 h (0.8-1.1) and further decreased by 1.2 h (1.0-1.3) if the initial hs-cTnI was below the limit of quantitation. The rate of acute coronary syndrome upon re-presentation within 30 days did not change post-implementation (0.10% versus 0.07%). CONCLUSION Implementation of an hs-cTnI assay with a rapid rule-out algorithm decreased ED LOS among discharged patients, particularly among those with a chief complaint of chest pain.
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Affiliation(s)
- Andrew E O Hughes
- Department of Pathology & Immunology. Washington University School of Medicine. St. Louis, MO
| | - Arthur Forbriger
- Department of Emergency Medicine. Washington University School of Medicine. St. Louis, MO
| | - Adam M May
- Department of Medicine. Washington University School of Medicine. St. Louis, MO
| | - Mitchell G Scott
- Department of Pathology & Immunology. Washington University School of Medicine. St. Louis, MO
| | - Douglas Char
- Department of Emergency Medicine. Washington University School of Medicine. St. Louis, MO
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