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Influence of Age on the Diagnosis of Myocardial Infarction
Matthew T H Lowry1, Dimitrios Doudesis1,2, Ryan Wereski1
1BHF Centre for Cardiovascular Science (M.T.H.L., D.D., R.W., D.M.K., C.T., A.V.F., A.B., C.T., K.K.L., A.R.C., D.E.N., N.L.M., A.A.), University of Edinburgh, UK.
Insights
Cardiac troponin test accuracy for myocardial infarction decreases in older adults. Standard thresholds show reduced specificity and positive predictive value in elderly patients, necessitating individualized diagnostic strategies.
Area of Science:
- Cardiology
- Medical Diagnostics
- Geriatric Medicine
Background:
- Cardiac troponin is a key biomarker for diagnosing myocardial infarction (MI).
- Standard diagnostic thresholds for troponin are based on the 99th centile from healthy populations.
- Troponin concentrations are significantly influenced by patient age, impacting diagnostic accuracy.
Purpose of the Study:
- To evaluate the diagnostic performance of cardiac troponin assays in older individuals with suspected myocardial infarction.
- To assess the impact of age on the sensitivity and specificity of cardiac troponin testing.
- To compare guideline-recommended thresholds with age-adjusted thresholds for MI diagnosis in different age groups.
Main Methods:
- Secondary analysis of a multicenter trial involving patients with suspected myocardial infarction.
- Assessment of high-sensitivity cardiac troponin I diagnostic accuracy across three age groups: <50, 50-74, and ≥75 years.
- Utilized guideline-recommended sex-specific and age-adjusted 99th centile thresholds for analysis.
Main Results:
- In 46,435 patients, MI prevalence was 11%.
- Sensitivity for MI was similar across age groups (79.2% to 81.6%) using guideline thresholds.
- Specificity decreased significantly with age, from 98.3% in <50 years to 82.6% in ≥75 years.
Conclusions:
- Age significantly affects cardiac troponin diagnostic performance, reducing specificity and positive predictive value in older patients.
- Neither guideline-recommended nor age-adjusted thresholds fully overcome the age-related decline in diagnostic accuracy.
- Individualized diagnostic approaches are required for MI diagnosis in the aging population, rather than solely adjusting binary thresholds.
Background:
The 99th centile of cardiac troponin, derived from a healthy reference population, is recommended as the diagnostic threshold for myocardial infarction, but troponin concentrations are strongly influenced by age. Our aim was to assess the diagnostic performance of cardiac troponin in older patients presenting with suspected myocardial infarction.
Methods:
In a secondary analysis of a multicenter trial of consecutive patients with suspected myocardial infarction, we assessed the diagnostic accuracy of high-sensitivity cardiac troponin I at presentation for the diagnosis of type 1, type 2, or type 4b myocardial infarction across 3 age groups (<50, 50-74, and ≥75 years) using guideline-recommended sex-specific and age-adjusted 99th centile thresholds.
Results:
In 46 435 consecutive patients aged 18 to 108 years (mean, 61±17 years), 5216 (11%) had a diagnosis of myocardial infarction. In patients <50 (n=12 379), 50 to 74 (n=22 380), and ≥75 (n=11 676) years, the sensitivity of the guideline-recommended threshold was similar at 79.2% (95% CI, 75.5-82.9), 80.6% (95% CI, 79.2-82.1), and 81.6% (95% CI, 79.8-83.2), respectively. The specificity decreased with advancing age from 98.3% (95% CI, 98.1-98.5) to 95.5% (95% CI, 95.2-95.8), and 82.6% (95% CI, 81.9-83.4). The use of age-adjusted 99th centile thresholds improved the specificity (91.3% [90.8%-91.9%] versus 82.6% [95% CI, 81.9%-83.4%]) and positive predictive value (59.3% [57.0%-61.5%] versus 51.5% [49.9%-53.3%]) for myocardial infarction in patients ≥75 years but failed to prevent the decrease in either parameter with increasing age and resulted in a marked reduction in sensitivity compared with the use of the guideline-recommended threshold (55.9% [53.6%-57.9%] versus 81.6% [79.8%-83.3%].
Conclusions:
Age alters the diagnostic performance of cardiac troponin, with reduced specificity and positive predictive value in older patients when applying the guideline-recommended or age-adjusted 99th centiles. Individualized diagnostic approaches rather than the adjustment of binary thresholds are needed in an aging population.
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