Normal presenting levels of high-sensitivity troponin and myocardial infarction
Rebeca Hoeller1, María Rubini Giménez, Tobias Reichlin
1Department of Cardiology, University Hospital Basel, , Basel, Switzerland.
Insights
Normal high-sensitivity cardiac troponin (hs-cTn) levels alone cannot rule out acute myocardial infarction (AMI). A significant percentage of AMI cases presented with normal hs-cTn levels, indicating a need for further diagnostic evaluation.
Area of Science:
- Cardiology
- Biomarkers
- Emergency Medicine
Background:
- Acute myocardial infarction (AMI) is a leading cause of mortality worldwide.
- Early diagnosis and risk stratification are crucial for effective management of patients with suspected AMI.
- High-sensitivity cardiac troponin (hs-cTn) assays are widely used, but their interpretation requires careful consideration.
Purpose of the Study:
- To evaluate the utility of single-point, below-99th-percentile hs-cTn levels for ruling out AMI at presentation.
- To assess the diagnostic performance of different hs-cTn assays in a real-world clinical setting.
Main Methods:
- Prospective, multicentre study involving consecutive patients presenting with acute chest pain.
- Measurement of hs-cTn using four different assays: hs-cTnT Roche, hs-cTnI Siemens, hs-cTnI Beckman Coulter, and hs-cTnI Abbott.
- Adjudication of AMI diagnosis by two independent cardiologists and follow-up for major adverse cardiac events.
Main Results:
- Across all hs-cTn assays, a notable proportion of patients diagnosed with AMI (6%-23%) had hs-cTn levels below the 99th percentile at presentation.
- Negative predictive values (NPVs) for ruling out AMI varied by assay, ranging from 94.3% to 98.0%.
- Significant variability in sensitivity and NPV was observed among the evaluated hs-cTnI assays, highlighting a lack of standardization.
Conclusions:
- Single measurements of hs-cTn below the 99th percentile are insufficient to definitively rule out AMI.
- The observed lack of assay standardization impacts diagnostic accuracy and clinical decision-making.
- Further research and standardization efforts are needed to optimize the use of hs-cTn assays in AMI diagnosis.
Objective:
To analyse whether levels of high-sensitivity cardiac troponin (hs-cTn) below their respective 99th percentile can be used as a single parameter to rule out acute myocardial infarction (AMI) at presentation.
Design:
Prospective, multicentre study.
Main Outcome Measures:
We measured hs-cTn using four different methods (hs-cTnT Roche, hs-cTnI Siemens, hs-cTnI Beckman Coulter and hs-cTnI Abbott) in consecutive patients presenting to the emergency department with acute chest pain. Two independent cardiologists adjudicated the final diagnosis. Patients were followed for death or AMI during a mean period of 24 months.
Results:
Among 2072 consecutive patients with hs-cTnT measurements available, 21.4% had an adjudicated diagnosis of AMI (sensitivity 89.6%, 95% CI 86.4% to 92.3%, negative predictive value (NPV): 96.5%, 95% CI 95.4% to 97.4%). Among 1180 consecutive patients with hs-cTnI Siemens measurements available, 20.0% had AMI (sensitivity 94.1%, 95% CI 90.3% to 96.7%, NPV: 98.0%, 95% CI: 96.6% to 98.9%). Among 1151 consecutive patients with hs-cTnI Beckman Coulter measurements available, 19.7% had AMI (sensitivity 92.1%, 95% CI 87.8% to 95.2%, NPV: 97.5%, 95% CI 96.0% to 98.5%). Among 1567 consecutive patients with hs-cTnI Abbott measurements available, 20.0% had AMI (sensitivity 77.2%, 95% CI 72.1% to 81.7%, NPV: 94.3%, 95% CI 92.8% to 95.5%).
Conclusions:
Normal hs-cTn levels at presentation should not be used as a single parameter to rule out AMI as 6%-23% of adjudicated AMI cases had normal levels of hs-cTn levels at presentation. Our data highlight the lack of standardisation among hs-cTnI assays resulting in substantial differences in sensitivity and NPV at the 99th percentile.
Related Concept Videos
01:20Blood Studies for Cardiovascular System I: Cardiac Biomarkers
The essential diagnostic tools for detecting myocardial necrosis and monitoring individuals suspected of having acute coronary syndrome (ACS) include:
Troponins
Troponins, particularly cardiac troponins I and T, are the most precise and sensitive markers of myocardial injury. They are detectable within 4-6 hours of myocardial injury and remain...
01:30Acute Coronary Syndrome I: Introduction
01:30Acute Coronary Syndrome III: Diagnostic Studies
01:19Acute Coronary Syndrome II: Pathophysiology and Clinical Manifestations
01:27Myocarditis II: Clinical Features and Diagnostic Tests
01:19Blood Studies for Cardiovascular System II: CRP, Hcy, and Cardiac Natriuretic Peptide Markers
These markers indicate stress or strain on the heart muscle:
Natriuretic Peptides (BNP)
Cardiac myocytes produce these hormones in response to ventricular stretching...