1
|
Helgeland J, Kristoffersen DT, Skyrud KD. Does a Code for Acute Myocardial Infarction Mean the Same in All Norwegian Hospitals? A Likelihood Approach to a Medical Record Review. Clin Epidemiol 2022; 14:1155-1165. [PMID: 36268007 PMCID: PMC9577561 DOI: 10.2147/clep.s369763] [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: 04/30/2022] [Accepted: 09/24/2022] [Indexed: 12/02/2022] Open
Abstract
Objective Health registries are important data sources for epidemiology, quality monitoring, and improvement. Acute myocardial infarction (AMI) is a common, serious condition. Little is known about variation in the positive predictive value (PPV) of a coded AMI diagnosis and its association with hospital quality indicators. The present study aimed to investigate the relationship between PPV and registry-based 30-day mortality after AMI admission and between-hospital variation in PPV. Study Design and Setting An electronic record review was performed in a nationwide sample of Norwegian hospitals. Clinical signs and cardiac troponin measurements were abstracted and analyzed using a mixture model for likelihood ratios and parametric bootstrapping. Results The overall PPV was estimated to be 97%. We found no statistically significant association between hospital PPV and the classification of hospitals into low, intermediate, and high registry-based 30-day mortality. There was significant variation between hospitals, with a PPV range of 91–100%. Conclusion We found no evidence that variation in PPV of AMI diagnosis can explain variation between hospitals in registry-based 30-day mortality after admission. However, PPV varied significantly between hospitals. We were able to use a very efficient statistical approach to the analysis and handling of various sources of uncertainty.
Collapse
Affiliation(s)
- Jon Helgeland
- Division for Health Services, Norwegian Institute of Public Health, Oslo, Norway,Correspondence: Jon Helgeland, Norwegian Institute of Public Health, PO Box 222 Skøyen, Oslo, 0213, Norway, Tel +47 464 00 443, Email
| | | | | |
Collapse
|
2
|
Fitzgerald RL, Hollander JE, Peacock WF, Limkakeng AT, Breitenbeck N, Rivers EJ, Ziegler A, Laimighofer M, deFilippi C. The 99th percentile upper reference limit for the 5th generation cardiac troponin T assay in the United States. Clin Chim Acta 2020; 504:172-179. [PMID: 32001233 DOI: 10.1016/j.cca.2020.01.027] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Revised: 01/23/2020] [Accepted: 01/24/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND Determining diagnostic thresholds for cardiac troponin assays is key to interpreting their clinical performance. We describe the calculation of 99th percentile upper reference limits (URLs) for the Elecsys® Troponin T Gen 5 (TnT Gen 5) assay. METHODS Plasma and serum samples from healthy US participants were prospectively evaluated using TnT Gen 5 Short Turn Around Time and 18-min assays on cobas e 411 and cobas e 601 analyzers (Roche Diagnostics); with, up to 8 TnT Gen 5 results per participant. RESULTS A total of 10,402 TnT Gen 5 results from 1301 participants were included (50.4% female). Across 9 calculation methods, overall 99th percentile URL was 19.2 ng/l (females, 13.5-13.6 ng/l; males, 21.4-22.2 ng/l). Across different sample/assay/analyzer combinations, overall 99th percentile URLs ranged from 18.4-20.2 ng/l. Median TnT Gen 5 results increased with age, were higher in males, and ranged from 3.0-3.7 ng/l across races/ethnicities and from 3.0-3.6 ng/l across body mass index (BMI) classes. Applying additional exclusion criteria (N-terminal pro-brain natriuretic peptide, BMI and estimated glomerular filtration rate) resulted in lower 99th percentile URLs (overall, 16.9 ng/l; females, 11.8 ng/l; males, 18.5 ng/l). CONCLUSION Our findings facilitate the interpretation of TnT Gen 5 results in US clinical practice.
Collapse
Affiliation(s)
| | - Judd E Hollander
- Department of Emergency Medicine, Thomas Jefferson University, Philadelphia, PA, USA
| | - W Frank Peacock
- Department of Emergency Medicine, Baylor College of Medicine, Houston, TX, USA
| | | | | | - E Joy Rivers
- Agent Representing Roche Professional Diagnostics, Indianapolis, IN, USA
| | - André Ziegler
- Roche Diagnostics International Ltd, Rotkreuz, Switzerland
| | | | | |
Collapse
|
3
|
Rubini Gimenez M. Comment on: Increased level of high-sensitivity cardiac troponin T in a geriatric population is determined by comorbidities compared to age. IJC HEART & VASCULATURE 2019; 23:100361. [PMID: 31080875 PMCID: PMC6503161 DOI: 10.1016/j.ijcha.2019.100361] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2019] [Revised: 04/04/2019] [Accepted: 04/06/2019] [Indexed: 11/06/2022]
Affiliation(s)
- Maria Rubini Gimenez
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Switzerland.,Department of Cardiology, University Heart Center Leipzig, Germany
| |
Collapse
|
4
|
Ognissanti D, Bjurman C, Holzmann MJ, Theodorsson E, Petzold M, Cvijovic M, Hammarsten O. Cardiac troponin T concentrations and patient-specific risk of myocardial infarction using the novel PALfx parameter. Clin Biochem 2019; 66:21-28. [DOI: 10.1016/j.clinbiochem.2019.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2018] [Revised: 01/23/2019] [Accepted: 02/03/2019] [Indexed: 11/16/2022]
|
5
|
Romiti GF, Cangemi R, Toriello F, Ruscio E, Sciomer S, Moscucci F, Vincenti M, Crescioli C, Proietti M, Basili S, Raparelli V. Sex-Specific Cut-Offs for High-Sensitivity Cardiac Troponin: Is Less More? Cardiovasc Ther 2019; 2019:9546931. [PMID: 31772621 PMCID: PMC6739766 DOI: 10.1155/2019/9546931] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2018] [Revised: 01/08/2019] [Accepted: 01/16/2019] [Indexed: 12/25/2022] Open
Abstract
Management of patients presenting to the Emergency Department with chest pain is continuously evolving. In the setting of acute coronary syndrome, the availability of high-sensitivity cardiac troponin assays (hs-cTn) has allowed for the development of algorithms aimed at rapidly assessing the risk of an ongoing myocardial infarction. However, concerns were raised about the massive application of such a simplified approach to heterogeneous real-world populations. As a result, there is a potential risk of underdiagnosis in several clusters of patients, including women, for whom a lower threshold for hs-cTn was suggested to be more appropriate. Implementation in clinical practice of sex-tailored cut-off values for hs-cTn represents a hot topic due to the need to reduce inequality and improve diagnostic performance in females. The aim of this review is to summarize current evidence on sex-specific cut-off values of hs-cTn and their application and usefulness in clinical practice. We also offer an extensive overview of thresholds reported in literature and of the mechanisms underlying such differences among sexes, suggesting possible explanations about debated issues.
Collapse
Affiliation(s)
- Giulio Francesco Romiti
- Department of Internal Medicine and Medical Specialties, Sapienza–University of Rome, Rome, Italy
| | - Roberto Cangemi
- Department of Internal Medicine and Medical Specialties, Sapienza–University of Rome, Rome, Italy
| | - Filippo Toriello
- Division of Cardiology, San Paolo Hospital, Department of Health Sciences, University of Milan, Milan, Italy
| | - Eleonora Ruscio
- Department of Cardiovascular and Thoracic Sciences, Catholic University of the Sacred Heart, Rome, Italy
| | - Susanna Sciomer
- Department of Cardiovascular, Respiratory, Nephrology, Anesthesiology and Geriatric Sciences, Sapienza–University of Rome, Rome, Italy
| | - Federica Moscucci
- Department of Cardiovascular, Respiratory, Nephrology, Anesthesiology and Geriatric Sciences, Sapienza–University of Rome, Rome, Italy
| | - Marianna Vincenti
- Department of Internal Medicine and Medical Specialties, Sapienza–University of Rome, Rome, Italy
| | - Clara Crescioli
- Department of Movement, Human and Health Sciences, University of Rome “Foro Italico”, Rome, Italy
| | - Marco Proietti
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milan, Italy
| | - Stefania Basili
- Department of Internal Medicine and Medical Specialties, Sapienza–University of Rome, Rome, Italy
| | - Valeria Raparelli
- Department of Experimental Medicine, Sapienza–University of Rome, Rome, Italy
- Center for Outcomes Research and Evaluation, Research Institute, McGill University Health Centre, Montreal, Quebec, Canada
| |
Collapse
|
6
|
Hammarsten O, Mair J, Möckel M, Lindahl B, Jaffe AS. Possible mechanisms behind cardiac troponin elevations. Biomarkers 2018; 23:725-734. [DOI: 10.1080/1354750x.2018.1490969] [Citation(s) in RCA: 50] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Affiliation(s)
- Ola Hammarsten
- Department of Clinical Chemistry and Transfusion Medicine, University of Gothenburg, Gothenburg, Sweden
| | - Johannes Mair
- Department of Internal Medicine III – Cardiology and Angiology, Heart Center, Medical University of Innsbruck, Innsbruck, Austria
| | - Martin Möckel
- Division of Emergency Medicine and Department of Cardiology, Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Bertil Lindahl
- Department of Medical Sciences, Uppsala University and Uppsala Clinical Research Center, Uppsala, Sweden
| | - Allan S. Jaffe
- Department of Cardiovascular Medicine, Mayo Clinic and Medical School, Rochester, MN, USA
| |
Collapse
|
7
|
Roos A, Holzmann MJ. Diurnal variation in admission troponin concentrations in patients with chest pain in the emergency department. Clin Biochem 2018; 54:18-24. [DOI: 10.1016/j.clinbiochem.2018.02.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2017] [Revised: 01/05/2018] [Accepted: 02/07/2018] [Indexed: 12/15/2022]
|
8
|
Use of troponin assay 99th percentile as the decision level for myocardial infarction diagnosis. Am Heart J 2017; 190:135-139. [PMID: 28760208 DOI: 10.1016/j.ahj.2017.04.016] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2017] [Accepted: 04/11/2017] [Indexed: 11/21/2022]
Abstract
BACKGROUND The Universal Definition of Myocardial Infarction recommends the 99th percentile concentration of cardiac troponin in a normal reference population as part of the decision threshold to diagnose type 1 spontaneous myocardial infarction. Adoption of this recommendation in contemporary worldwide practice is not well known. METHODS We performed a cohort study of 276 hospital laboratories in 31 countries participating in the National Heart, Lung, and Blood Institute-sponsored International Study of Comparative Health Effectiveness with Medical and Invasive Approaches trial. Each hospital laboratory's troponin assay manufacturer and model, the recommended assay's 99th percentile upper reference limit (URL) from the manufacturer's package insert, and the troponin concentration used locally as the decision level to diagnose myocardial infarction were ascertained. RESULTS Twenty-one unique troponin assays from 9 manufacturers were used by the surveyed hospital laboratories. The ratio of the troponin concentration used locally to diagnose myocardial infarction to the assay manufacturer-determined 99th percentile URL was <1 at 19 (6.6%) laboratories, equal to 1 at 91 (31.6%) laboratories, >1 to ≤5 at 101 (35.1%) laboratories, >5 to ≤10 at 34 (11.8%) laboratories, and >10 at 43 (14.9%) laboratories. The variability in troponin decision level for myocardial infarction relative to the assay 99th percentile URL was present for laboratories in and outside of the United States, as well as for high- and standard-sensitivity assays. CONCLUSIONS There is substantial hospital-level variation in the troponin threshold used to diagnose myocardial infarction; only one-third of hospital laboratories currently follow the Universal Definition of Myocardial Infarction consensus recommendation for use of troponin concentration at the 99th percentile of a normal reference population as the decision level to diagnose myocardial infarction. This variability across laboratories has important implications for both the diagnosis of myocardial infarction in clinical practice as well as adjudication of myocardial infarction in clinical trials.
Collapse
|
9
|
Mion MM, Bragato G, Casarotti A, Cosma C, Vigolo S, Vettore G, Tosato F, Zaninotto M, Plebani M. Clinical performance of cardiac Troponin I: A comparison between the POCT AQT90 FLEX and the Dimension Vista analyzer in an emergency setting. Clin Biochem 2017; 50:763-767. [PMID: 28377153 DOI: 10.1016/j.clinbiochem.2017.03.027] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2016] [Revised: 03/15/2017] [Accepted: 03/16/2017] [Indexed: 12/15/2022]
Abstract
BACKGROUND Cardiac troponin [cTn (I or T)] is the preferred biomarker for the diagnosis of myocardial infarction (MI). AIM We studied the analytical performance of the POCT AQT90 FLEX cTnI assay and its diagnostic accuracy, in comparison to the Dimension Vista cTnI method, in patients presenting to the Emergency Department (ED) with suspect of acute coronary syndrome (ACS). METHODS 786 consecutive patients were enrolled. cTnI was measured at admission to the ED and about 3 and 6 hours later. The imprecision study was carried out using different lots of quality controls (QCs). ROC curve analysis was conducted using discharge diagnoses in order to verify the global diagnostic accuracy. RESULTS The concentrations measured in the QCs ranging from 0.033 to 1.26μg/L show CVs% ranging from 2.81 to 7.56%, comparable to those declared by the manufacturer. Passing-Bablok and linear regression analysis show a high significant correlation (R2=0.90, p<0.0001); Bland-Altman test describes a statistically significant negative bias (Bias=-0.2336; 95%CI=-0.4217/-0.0456, p=0.0150). ROC curves obtained using Dimension Vista and AQT90 FLEX cTnI assays displayed similar clinical performance being not statistically significant the difference of the corresponding AUC. Comparing sensitivity and specificity of cTnI concentrations obtained from the ROC curve analysis using AQT90 FLEX, we found a "best cut-off" (0.014μg/L) lower than that declared from the manufacturer (0.023μg/L). CONCLUSIONS The comparison of two different assays of cTnI against a diagnosis of acute MI (AMI) shows that both assays behave equally well with a high degree of sensitivity and specificity. The resulting "best cut-off" suggests that this AQT90 FLEX cTnI concentration could be evaluated as the potentially new "clinically usable" cut-off for AMI/myocardial necrosis diagnoses.
Collapse
Affiliation(s)
- Monica Maria Mion
- Department of Laboratory Medicine, University-Hospital of Padova, Padova, Italy; Emergency Department, University-Hospital of Padova, Padova, Italy.
| | - Giada Bragato
- Department of Laboratory Medicine, University-Hospital of Padova, Padova, Italy; Emergency Department, University-Hospital of Padova, Padova, Italy
| | - Alessandra Casarotti
- Department of Laboratory Medicine, University-Hospital of Padova, Padova, Italy; Emergency Department, University-Hospital of Padova, Padova, Italy
| | - Chiara Cosma
- Department of Laboratory Medicine, University-Hospital of Padova, Padova, Italy; Emergency Department, University-Hospital of Padova, Padova, Italy
| | - Stefania Vigolo
- Department of Laboratory Medicine, University-Hospital of Padova, Padova, Italy; Emergency Department, University-Hospital of Padova, Padova, Italy
| | - Gianna Vettore
- Department of Laboratory Medicine, University-Hospital of Padova, Padova, Italy; Emergency Department, University-Hospital of Padova, Padova, Italy
| | - Franco Tosato
- Department of Laboratory Medicine, University-Hospital of Padova, Padova, Italy; Emergency Department, University-Hospital of Padova, Padova, Italy
| | - Martina Zaninotto
- Department of Laboratory Medicine, University-Hospital of Padova, Padova, Italy; Emergency Department, University-Hospital of Padova, Padova, Italy
| | - Mario Plebani
- Department of Laboratory Medicine, University-Hospital of Padova, Padova, Italy; Emergency Department, University-Hospital of Padova, Padova, Italy
| |
Collapse
|
10
|
Petersmann A, Ittermann T, Frieß C, Lubenow N, Kohlmann T, Greinacher A, Masuch A, Nauck M. Impact of physical activity of individuals and creatine kinase on 99th percentiles of troponin I assays. Clin Chim Acta 2016; 462:187-192. [PMID: 27712987 DOI: 10.1016/j.cca.2016.10.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2016] [Revised: 09/14/2016] [Accepted: 10/02/2016] [Indexed: 01/04/2023]
Abstract
Determination of cardiac troponin I (cTnI) is one central means for diagnosis of myocardial infarction. Assay performance of three troponin I assays was compared previously in a large reference population detecting sex-differences in the 99th percentile only for the Dimension Vista cTnI assay. The present study examined the underlying effects. Values for cTnI were reused. Creatine kinase (CK) activity was determined in 2358 samples from blood donors. Information on physical activity was evaluated from health questionnaires. Using quantile regression data were analysed to investigate the impact of sex, physical activity, and CK on the 99th percentile of the cTnI assay. We report significant sex-differences for the 99th percentile of cTnI. Physical activity was significantly associated with cTnI values. Strong association of CK activity with cTnI values was detected only in men. Adjustment for CK in quantile regression abolished sex-differences in the 99th percentile. Two other contemporary sensitive cTnI assays were not relevantly affected by physical activity or CK. Sex-differences in the 99th percentile for the Dimension Vista cTnI assay arise from a positive association between cTnI and physical activity and were abrogated when data were adjusted for CK activity. These findings should be taken into account when using this assay.
Collapse
Affiliation(s)
- Astrid Petersmann
- Institute of Clinical Chemistry and Laboratory Medicine, University of Greifswald, Germany.
| | - Till Ittermann
- Institute of Clinical Chemistry and Laboratory Medicine, University of Greifswald, Germany; Institute of Community Medicine, University of Greifswald, Germany
| | - Cornelia Frieß
- Institute of Clinical Chemistry and Laboratory Medicine, University of Greifswald, Germany
| | - Norbert Lubenow
- Institute of Immunology and Transfusion Medicine, Division Transfusion Medicine, University of Greifswald, Germany; Department of Immunology, Genetics and Pathology (IGP), Uppsala University, Sweden
| | - Thomas Kohlmann
- Institute of Community Medicine, University of Greifswald, Germany
| | - Andreas Greinacher
- Institute of Immunology and Transfusion Medicine, Division Transfusion Medicine, University of Greifswald, Germany
| | - Annette Masuch
- Institute of Clinical Chemistry and Laboratory Medicine, University of Greifswald, Germany
| | - Matthias Nauck
- Institute of Clinical Chemistry and Laboratory Medicine, University of Greifswald, Germany
| |
Collapse
|
11
|
Turcato G, Serafini V, Dilda A, Bovo C, Caruso B, Ricci G, Lippi G. Red blood cell distribution width independently predicts medium-term mortality and major adverse cardiac events after an acute coronary syndrome. ANNALS OF TRANSLATIONAL MEDICINE 2016; 4:254. [PMID: 27500155 DOI: 10.21037/atm.2016.06.35] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND The value of red blood cell distribution width (RDW), a simple and inexpensive measure of anisocytosis, has been associated with the outcome of many human chronic disorders. Therefore, this retrospective study was aimed to investigate whether RDW may be associated with medium-term mortality and major adverse cardiac events (MACE) after an acute coronary syndrome (ACS). METHODS A total number of 979 patients diagnosed with ACS were enrolled from June 2014 to November 2014, and followed-up until June 2015. RESULTS The RDW value in patients with 3-month MACE and in those who died was significantly higher than that of patients without 3-month MACE (13.3% vs. 14.0%; P<0.001) and those who were still alive at the end of follow-up (13.4% vs. 14.4%; P<0.001). In univariate analysis, RDW was found to be associated with 3-month MACE [odds ratio (OR), 1.70; 95% CI, 1.44-2.00, P<0.001]. In multivariate analysis, RDW remained independently associated with 3-month MACE (adjusted OR, 1.36; 95% CI, 1.19-1.55; P<0.001) and death (adjusted OR, 1.34; 95% CI, 1.05-1.71; P=0.020). The accuracy of RDW for predicting 3-month MACE was 0.67 (95% CI, 0.66-0.72; P<0.001). The most efficient discriminatory RDW value was 14.8%, which was associated with 3.8 (95% CI, 2.6-5.7; P<0.001) higher risk of 3-month MACE. Patients with RDW >14.8% exhibited a significantly short survival than those with RDW ≤14.8% (331 vs. 465 days; P<0.001). CONCLUSIONS The results of this study confirm that RDW may be a valuable, easy and inexpensive parameter for stratifying the medium-term risk in patients with ACS.
Collapse
Affiliation(s)
- Gianni Turcato
- Emergency Department, University Hospital of Verona, Verona, Italy
| | | | - Alice Dilda
- Emergency Department, University Hospital of Verona, Verona, Italy
| | - Chiara Bovo
- Medical Direction, University Hospital of Verona, Verona, Italy
| | - Beatrice Caruso
- Section of Clinical Biochemistry, University of Verona, Verona, Italy
| | - Giorgio Ricci
- Emergency Department, University Hospital of Verona, Verona, Italy
| | - Giuseppe Lippi
- Section of Clinical Biochemistry, University of Verona, Verona, Italy
| |
Collapse
|
12
|
Smulders MW, Kietselaer BL, Schalla S, Bucerius J, Jaarsma C, van Dieijen-Visser MP, Mingels AM, Rocca HPBL, Post M, Das M, Crijns HJ, Wildberger JE, Bekkers SC. Acute chest pain in the high-sensitivity cardiac troponin era: A changing role for noninvasive imaging? Am Heart J 2016; 177:102-11. [PMID: 27297855 DOI: 10.1016/j.ahj.2016.03.025] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2016] [Accepted: 03/30/2016] [Indexed: 02/07/2023]
Abstract
Management of patients with acute chest pain remains challenging. Cardiac biomarker testing reduces the likelihood of erroneously discharging patients with acute myocardial infarction (AMI). Despite normal contemporary troponins, physicians have still been reluctant to discharge patients without additional testing. Nowadays, the extremely high negative predictive value of current high-sensitivity cardiac troponin (hs-cTn) assays challenges this need. However, the decreased specificity of hs-cTn assays to diagnose AMI poses a new problem as noncoronary diseases (eg, pulmonary embolism, myocarditis, cardiomyopathies, hypertension, renal failure, etc) may also cause elevated hs-cTn levels. Subjecting patients with noncoronary diseases to unnecessary pharmacological therapy or invasive procedures must be prevented. Attempts to improve the positive predictive value to diagnose AMI by defining higher initial cutoff values or dynamic changes over time inherently lower the sensitivity of troponin assays. In this review, we anticipate a potential changing role of noninvasive imaging from ruling out myocardial disease when troponin values are normal toward characterizing myocardial disease when hs-cTn values are (mildly) abnormal.
Collapse
|
13
|
Lippi G, Lo Cascio C, Brocco G, Danese E, Montagnana M, Bassi A, Caruso B, Bovo C, Salvagno GL. High-density lipoprotein cholesterol values independently and inversely predict cardiac troponin T and I concentration. ANNALS OF TRANSLATIONAL MEDICINE 2016; 4:188. [PMID: 27294084 DOI: 10.21037/atm.2016.03.03] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND This retrospective study was planned to establish potential associations between circulating values of cardiac troponins and those of conventional blood lipids. METHODS The study population consisted of patients attending an inpatient clinic of the University Hospital of Verona during the year 2015 as part of routine cardiovascular risk assessment. No exclusion criteria were applied. Serum lipids including total cholesterol (TC), high-density lipoprotein cholesterol (HDL-C), low-density lipoprotein cholesterol (LDL-C) and triglycerides (TG) were measured using reference enzymatic techniques, whereas troponin T (TnT) was measured using a high-sensitivity (HS) immunoassay. A second analysis was also performed in the General Hospital of Verona, extracting data from the local laboratory database of all patients in whom troponin I (TnI) and blood lipids were simultaneously measured during the same year. RESULTS In univariate analysis, HS-TnT was found to be associated with age, sex, TC, LDL-C, HDL-C, but not with TG. In multivariate linear regression analysis, age (positive correlation; P<0.001) and HDL-C (negative correlation; P=0.032) remained significantly associated with HS-TnT. The frequency of HS-TnT values >50 ng/L was higher in subjects with HDL-C <1 mmol/L than in those with HDL-C ≥1 mmol/L [odds ratio (OR), 1.84; 95% confidence interval (CI), 1.03-3.32]. The frequency of HS-TnT values >50 ng/L was also higher in elderly subjects than in younger ones (OR, 2.10; 95% CI, 1.15-3.84). The combination of age and HDL-C explained 35% of overall variability of TnT concentration. In the second analysis, HDL-C was also found to be an independent and negative predictor of TnI in multivariate linear regression analysis (P=0.010). The combination of age and HDL-C explained approximately 28% of the overall variability of TnI concentration. CONCLUSIONS Our study suggests that HDL-C values inversely predict cardiac troponins concentration irrespective of age, sex and other blood lipids.
Collapse
Affiliation(s)
- Giuseppe Lippi
- 1 Section of Clinical Biochemistry, University of Verona, Verona, Italy ; 2 Laboratory of Clinical Chemistry and Hematology, General Hospital of Verona, Verona, Italy ; 3 Laboratory of Clinical Chemistry and Hematology, University Hospital of Verona, Verona, Italy ; 4 Medical Direction, University Hospital of Verona, Verona, Italy
| | - Claudia Lo Cascio
- 1 Section of Clinical Biochemistry, University of Verona, Verona, Italy ; 2 Laboratory of Clinical Chemistry and Hematology, General Hospital of Verona, Verona, Italy ; 3 Laboratory of Clinical Chemistry and Hematology, University Hospital of Verona, Verona, Italy ; 4 Medical Direction, University Hospital of Verona, Verona, Italy
| | - Giorgio Brocco
- 1 Section of Clinical Biochemistry, University of Verona, Verona, Italy ; 2 Laboratory of Clinical Chemistry and Hematology, General Hospital of Verona, Verona, Italy ; 3 Laboratory of Clinical Chemistry and Hematology, University Hospital of Verona, Verona, Italy ; 4 Medical Direction, University Hospital of Verona, Verona, Italy
| | - Elisa Danese
- 1 Section of Clinical Biochemistry, University of Verona, Verona, Italy ; 2 Laboratory of Clinical Chemistry and Hematology, General Hospital of Verona, Verona, Italy ; 3 Laboratory of Clinical Chemistry and Hematology, University Hospital of Verona, Verona, Italy ; 4 Medical Direction, University Hospital of Verona, Verona, Italy
| | - Martina Montagnana
- 1 Section of Clinical Biochemistry, University of Verona, Verona, Italy ; 2 Laboratory of Clinical Chemistry and Hematology, General Hospital of Verona, Verona, Italy ; 3 Laboratory of Clinical Chemistry and Hematology, University Hospital of Verona, Verona, Italy ; 4 Medical Direction, University Hospital of Verona, Verona, Italy
| | - Antonella Bassi
- 1 Section of Clinical Biochemistry, University of Verona, Verona, Italy ; 2 Laboratory of Clinical Chemistry and Hematology, General Hospital of Verona, Verona, Italy ; 3 Laboratory of Clinical Chemistry and Hematology, University Hospital of Verona, Verona, Italy ; 4 Medical Direction, University Hospital of Verona, Verona, Italy
| | - Beatrice Caruso
- 1 Section of Clinical Biochemistry, University of Verona, Verona, Italy ; 2 Laboratory of Clinical Chemistry and Hematology, General Hospital of Verona, Verona, Italy ; 3 Laboratory of Clinical Chemistry and Hematology, University Hospital of Verona, Verona, Italy ; 4 Medical Direction, University Hospital of Verona, Verona, Italy
| | - Chiara Bovo
- 1 Section of Clinical Biochemistry, University of Verona, Verona, Italy ; 2 Laboratory of Clinical Chemistry and Hematology, General Hospital of Verona, Verona, Italy ; 3 Laboratory of Clinical Chemistry and Hematology, University Hospital of Verona, Verona, Italy ; 4 Medical Direction, University Hospital of Verona, Verona, Italy
| | - Gian Luca Salvagno
- 1 Section of Clinical Biochemistry, University of Verona, Verona, Italy ; 2 Laboratory of Clinical Chemistry and Hematology, General Hospital of Verona, Verona, Italy ; 3 Laboratory of Clinical Chemistry and Hematology, University Hospital of Verona, Verona, Italy ; 4 Medical Direction, University Hospital of Verona, Verona, Italy
| |
Collapse
|
14
|
Goorden SMI, van Engelen RA, Wong LSM, van der Ploeg T, Verdel GJE, Buijs MM. A novel troponin I rule-out value below the upper reference limit for acute myocardial infarction. Heart 2016; 102:1721-1727. [PMID: 27067356 DOI: 10.1136/heartjnl-2015-308667] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2015] [Accepted: 03/14/2016] [Indexed: 01/09/2023] Open
Abstract
OBJECTIVE To determine cut-off values for a recently introduced high sensitive cardiac troponin assay (hs-cTnI) which provide similar sensitivity, specificity, negative predictive value (NPV) and positive predictive value (PPV) for acute myocardial infarction (AMI) as known cut-off values for an hs-cTnT assay. METHODS A prospective observational study was performed. Hs-cTnT (Roche) and hs-cTnI (Abbott) were measured in consecutive patients with symptoms suggestive of AMI. Representative measurements (obtained at least 3 h after chest pain has started) and serial measurements with a time delay between 2.5 h and 4.5 h were used to determine cut-off levels. Two independent clinicians adjudicated the final diagnosis. RESULTS 1490 patients were included in the study of whom 114 (8%) received a final diagnosis of AMI. Receiver operating characteristics analysis showed no statistically significant differences in the areas under the curve between the two assays. Cut-off values for representative hs-TnI were found to be as follows: rule-out: 10 ng/L (sensitivity: 98.2%; 95% CI 95.7% to 100.0% and NPV: 99.8%; 99.5% to 100.0%); rule-in: 70 ng/L (specificity: 90.8%; 89.3% to 92.4% and PPV: 39.7%; 36.1% to 43.3%). For serial measurements we found a Δ rule-out cut-off value of 20 ng/L (sensitivity: 94.9%; 88.0% to 100.0% and NPV: 98.7%; 96.9% to 100.0%) and Δ rule-in cut-off values of 100 ng/L (specificity: 92.7%; 87.9% to 95.8% and PPV: 57.6%; 39.4% to 74.0%) and 300% (specificity: 93.8%; 90.4% to 97.2% and PPV: 61.3%; 51.1% to 71.5%). CONCLUSIONS Cut-off values for hs-cTnI measurements are determined which allow a similar diagnostic classification as compared with hs-cTnT. Importantly, for a rule-out paradigm this cut-off value is unmistakably lower than the upper reference limit.
Collapse
Affiliation(s)
| | | | - Liza S M Wong
- Department of Cardiology, Spaarne Gasthuis, Haarlem, The Netherlands
| | | | - Gerard J E Verdel
- Department of Cardiology, Spaarne Gasthuis, Haarlem, The Netherlands
| | | |
Collapse
|
15
|
Kimenai DM, Henry RMA, van der Kallen CJH, Dagnelie PC, Schram MT, Stehouwer CDA, van Suijlen JDE, Niens M, Bekers O, Sep SJS, Schaper NC, van Dieijen-Visser MP, Meex SJR. Direct comparison of clinical decision limits for cardiac troponin T and I. Heart 2016; 102:610-6. [DOI: 10.1136/heartjnl-2015-308917] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2015] [Accepted: 12/21/2015] [Indexed: 11/03/2022] Open
|
16
|
Defining normality in a European multinational cohort: Critical factors influencing the 99th percentile upper reference limit for high sensitivity cardiac troponin I. Int J Cardiol 2015; 187:256-63. [DOI: 10.1016/j.ijcard.2015.03.282] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2014] [Revised: 01/09/2015] [Accepted: 03/15/2015] [Indexed: 12/25/2022]
|
17
|
Greene DN, Leong TK, Collinson PO, Kamer SM, Huang K, Lorey TS, Go AS. Age, sex, and racial influences on the Beckman Coulter AccuTnI+3 99th percentile. Clin Chim Acta 2015; 444:149-53. [DOI: 10.1016/j.cca.2015.02.005] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2014] [Revised: 01/30/2015] [Accepted: 02/04/2015] [Indexed: 10/24/2022]
|
18
|
High-sensitivity cardiac troponin assays: answers to frequently asked questions. Arch Cardiovasc Dis 2015; 108:132-49. [PMID: 25669958 DOI: 10.1016/j.acvd.2014.11.001] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2014] [Accepted: 11/24/2014] [Indexed: 11/20/2022]
Abstract
Cardiac troponin (cTn) assays have quickly gained in analytical sensitivity to become what are termed 'high-sensitivity cardiac troponin' (hs-cTn) assays, bringing a flurry of dense yet incomplete literature data. The net result is that cTn assays are not yet standardized and there are still no consensus-built data on how to use and interpret cTn assay results. To address these issues, the authors take cues and clues from multiple disciplines to bring responses to frequently asked questions. In brief, the effective use of hs-cTn hinges on knowing: specific assay characteristics, particularly precision at the 99th percentile of a reference population; factors of variation at the 99th percentile value; and the high-individuality of hs-cTn assays, for which the notion of individual kinetics is more informative than straight reference to 'normal' values. The significance of patterns of change between two assay measurements has not yet been documented for every hs-cTn assay. Clinicians need to work hand-in-hand with medical biologists to better understand how to use hs-cTn assays in routine practice.
Collapse
|
19
|
Troponine dosée avec un test de haute sensibilité : éléments de réponse aux questions fréquemment posées. ANNALES FRANCAISES DE MEDECINE D URGENCE 2014. [DOI: 10.1007/s13341-014-0423-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
|
20
|
Abstract
Due to their tissue specificity and ease of detection, the cardiac troponins (cTn) have emerged as the most important and most utilized biomarkers for the diagnosis of acute myocardial infarction (AMI). The recent achievement of greater sensitivity by cTn assay systems, however, has resulted in the detection of cTn in a wide array of medical conditions, highlighting myocardial cellular necrosis as a feature in several, seemingly unrelated medical conditions, yet complicating the interpretation of a positive test. Since elevated cTn levels are associated with worse clinical outcomes and, thereby, influence medical decisions, careful consideration should be given to the method by which these biomarkers are measured, the patient population on which the test is being applied, and applicable thresholds based on particular clinical conditions. The objective of this review is to trace the clinical evolution of the cTn biomarker from a test for AMI to a general marker of myocardial cellular necrosis with clinically important prognostic information.
Collapse
|
21
|
Sandoval Y, Apple FS. The global need to define normality: the 99th percentile value of cardiac troponin. Clin Chem 2013; 60:455-62. [PMID: 24115136 DOI: 10.1373/clinchem.2013.211706] [Citation(s) in RCA: 126] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND How to select a presumably normal population for the establishment of 99th percentile cutoffs for cardiac troponin assays has not been adequately addressed. Lack of attention to this question can result in misleading medical decision cutoffs. CONTENT From our review of the peer-reviewed literature, including international recommendations, no uniform procedure is followed and no uniform guideline has been published by experts or regulatory agencies to guide researchers or manufacturers of cardiac troponin assays in their quest to define the health or "normality" of a reference population that is used to establish an accurate 99th percentile value. As we progress globally into the era of high-sensitivity cardiac troponin assays, we propose several suggested approaches to define presumably normal individuals by use of clinical and biomarker surrogates. SUMMARY Our uniform approach to defining who is normal and who may not be normal will help to define diagnostic and risk outcomes assessments in the management of patients with suspected myocardial injury, both for use in current clinical practice and clinical research, as well as for the potential future use of cardiac troponin in primary prevention.
Collapse
|
22
|
Kim J, Gaddam S, Wu W, Behera V, Sharma S, Choudhary G. Stratified reporting of high sensitivity troponin I assay is associated with suboptimal management of patients with acute coronary syndrome and intermediate troponin elevation. J Clin Lab Anal 2013; 27:402-6. [PMID: 24038227 PMCID: PMC6807442 DOI: 10.1002/jcla.21618] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2012] [Accepted: 03/28/2013] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Newer troponin assays provide high sensitivity and precision and are reported in a stratified manner by some laboratories. We sought to investigate the clinical impact of such reporting in the treatment of patients with suspected acute coronary syndrome (ACS). METHODS We identified patients presenting with suspected ACS over a one-year period. Patients were stratified based on their peak troponin I values within 24 hours of admission into the following categories as reported by our laboratory: troponin value ≤0.03 ng/ml, which is reported as normal (negative troponin group), troponin value 0.04-0.29 ng/ml, which is reported as suggestive of myocardial damage (intermediate troponin group), and troponin value ≥0.3 ng/ml which is reported as indicative of myocardial necrosis (high troponin group). RESULTS Plasma troponin concentrations were ≤0.03 ng/ml in 77 patients (68.7%), 0.04-0.29 ng/ml in 18 patients (16.1%), and ≥0.30 ng/ml in 17 patients (15.2%). Patients in the intermediate troponin group had thrombolysis in myocardial infarction (TIMI) risk scores that were similar to that of the high troponin group. Despite this, patients in the intermediate troponin group were almost 50% less likely to receive coronary angiography, anticoagulation, and clopidogrel when compared to the high troponin group. CONCLUSION Patients in the intermediate troponin group that meet the guideline definition of acute myocardial infarction are less likely to receive optimal medical and invasive therapy as compared to the high troponin group even though TIMI risk scores were similar in the two groups.
Collapse
Affiliation(s)
- Jiwon Kim
- Vascular Research Laboratory, Providence VA Medical Center, ProvidenceRhode Island
- Department of MedicineWarren Alpert Medical School of Brown UniversityProvidenceRhode Island
| | - Sainath Gaddam
- Vascular Research Laboratory, Providence VA Medical Center, ProvidenceRhode Island
- Department of MedicineWarren Alpert Medical School of Brown UniversityProvidenceRhode Island
| | - Wen‐Chih Wu
- Vascular Research Laboratory, Providence VA Medical Center, ProvidenceRhode Island
- Department of MedicineWarren Alpert Medical School of Brown UniversityProvidenceRhode Island
| | - Vikram Behera
- Vascular Research Laboratory, Providence VA Medical Center, ProvidenceRhode Island
- Department of MedicineWarren Alpert Medical School of Brown UniversityProvidenceRhode Island
| | - Satish Sharma
- Vascular Research Laboratory, Providence VA Medical Center, ProvidenceRhode Island
- Department of MedicineWarren Alpert Medical School of Brown UniversityProvidenceRhode Island
| | - Gaurav Choudhary
- Vascular Research Laboratory, Providence VA Medical Center, ProvidenceRhode Island
- Department of MedicineWarren Alpert Medical School of Brown UniversityProvidenceRhode Island
| |
Collapse
|
23
|
Vasatova M, Pudil R, Horacek JM, Buchler T. Current applications of cardiac troponin T for the diagnosis of myocardial damage. Adv Clin Chem 2013; 61:33-65. [PMID: 24015599 DOI: 10.1016/b978-0-12-407680-8.00002-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Biochemical markers of myocardial injury play an important role in the diagnosis of cardiovascular diseases. Measurement of cardiac biomarkers is one of the most important diagnostic tests in acute myocardial infarction (AMI), heart failure, and other cardiovascular disorders. Recently, the European Society of Cardiology, the American College of Cardiology Foundation, the American Heart Association, and the World Heart Federation have published a consensus definition of AMI that includes a detailed guideline for the assessment of biochemical markers in suspected disease. The cardiac troponins (cTI and cTnT) were recommended as preferred markers of myocardial necrosis in this setting. Herein, we review cardiac troponin biochemistry, the performance characteristics of cTnT assays, and optimal utilization of troponin in patients with proven or possible cardiovascular disease. We also discuss the use of troponin tests, with emphasis on cTnT, in different clinical situations in which its levels may be elevated.
Collapse
|
24
|
Lippi G, Plebani M. False myths and legends in laboratory diagnostics. Clin Chem Lab Med 2013; 51:2087-97. [DOI: 10.1515/cclm-2013-0105] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2013] [Accepted: 02/26/2013] [Indexed: 11/15/2022]
|