High-sensitivity cardiac troponins: sex-specific values in clinical practice. Precision or confusion?

Cardiac troponins are pivotal in the evaluation of patients who suffer from acute chest pain, and the introduction of the high-sensitivity cardiac troponins (hs-cTn) has shown that there are differences between male and female patients. Recent recommendations from experts point out that an appropriate evaluation must take into account the patients' sex, but there is no clear evidence of the implementation of this recommendation in the clinical practice, and the matter has sparked controversy. If the same cutoff value is used for both sexes, myocardial infarction in men might be overdiagnosed, especially in the elderly, who have relatively higher values, and might be underdiagnosed in most women. The International Federation of Clinical Chemistry and Laboratory Medicine Task Force on Clinical Applications of Cardiac Bio-Markers (IFCCLM, TF-CB) 2018 and the Fourth Universal Definition of Acute Myocardial Infarction support the overall and sex-specific 99^th percentile Upper Reference Limit (URL) cutoff value, but based on the definition of hs-cTn assays, the Limit of Detection (LoD) may be considered a starting point for an assessment method that does not differentiate between the levels of hs-cTn in male and female patients suspected of suffering from acute coronary syndrome (ACS). In this paper, we discuss the evidence and a novel strategy based on hs-cTn for rapidly ruling out myocardial infarction in low-risk patients who suffer from acute chest pain.