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Diagnosis of acute myocardial infarction in patients with renal failure using high-sensitivity cardiac troponin T
Jonathan D Knott1, Olatunde Ola2, Laura De Michieli3
1Department of Cardiovascular Diseases, Mayo Clinic, 200 1st St SW, Rochester, MN 55905, USA.
Insights
Diagnosing myocardial infarction (MI) in patients with chronic kidney disease (CKD) is challenging due to elevated cardiac troponin levels. Using higher hs-cTnT thresholds improves MI diagnosis accuracy in CKD patients.
Area of Science:
- Cardiology
- Nephrology
- Emergency Medicine
Background:
- Diagnosing myocardial infarction (MI) in patients with chronic kidney disease (CKD) presents challenges due to elevated baseline high-sensitivity cardiac troponin T (hs-cTnT) levels.
- Standard diagnostic thresholds for hs-cTnT may lead to suboptimal accuracy in this population.
Purpose of the Study:
- To evaluate the diagnostic performance of baseline and serial 2-hour hs-cTnT thresholds for ruling in acute MI in patients with and without CKD.
- To determine if adjusted hs-cTnT thresholds can improve MI diagnosis in CKD patients.
Main Methods:
- An observational US cohort study included emergency department patients undergoing hs-cTnT measurement.
- Patients were categorized with or without CKD (eGFR < 60 mL/min/1.73 m²).
- Diagnostic performance, including positive predictive values (PPVs), of various hs-cTnT thresholds was compared between groups.
Main Results:
- The study analyzed 1992 patients, with 501 (25%) having CKD.
- In CKD patients, higher baseline hs-cTnT thresholds (e.g., >200 ng/L, >300 ng/L) showed improved PPVs for MI compared to standard thresholds.
- For serial 2-hour hs-cTnT changes, higher delta values (e.g., >20 ng/L, >30 ng/L) also demonstrated higher PPVs in CKD patients.
Conclusions:
- Standard hs-cTnT thresholds for ruling in MI are suboptimal in patients with CKD.
- Utilizing higher baseline hs-cTnT thresholds and increased delta values in serial measurements significantly improves the diagnostic accuracy for acute MI in CKD patients.
Aims:
Diagnosing myocardial infarction (MI) in patients with chronic kidney disease (CKD) is difficult as they often have increased high-sensitivity cardiac troponin T (hs-cTnT) concentrations.
Methods And Results:
Observational US cohort study of emergency department patients undergoing hs-cTnT measurement. Cases with ≥1 hs-cTnT increase > 99th percentile were adjudicated following the Fourth Universal Definition of MI. Diagnostic performance of baseline and serial 2 h hs-cTnT thresholds for ruling-in acute MI was compared between those without and with CKD (estimated glomerular filtration rate < 60 mL/min/1.73 m2). The study cohort included 1992 patients, amongst whom 501 (25%) had CKD. There were 75 (15%) and 350 (70%) patients with CKD and 80 (5%) and 351 (24%) without CKD who had acute MI and myocardial injury. In CKD patients with baseline hs-cTnT thresholds of ≥52, >100, >200, or >300 ng/L, positive predictive values (PPVs) for MI were 36% (95% CI 28-45), 53% (95% CI 39-67), 73% (95% CI 50-89), and 80% (95% CI 44-98), and in those without CKD, 61% (95% CI 47-73), 69% (95% CI 49-85), 59% (95% CI 33-82), and 54% (95% CI 25-81). In CKD patients with a 2 h hs-cTnT delta of ≥10, >20, or >30 ng/L, PPVs were 66% (95% CI 51-79), 86% (95% CI 68-96), and 88% (95% CI 68-97), and in those without CKD, 64% (95% CI 50-76), 73% (95% CI 57-86), and 75% (95% CI 58-88).
Conclusion:
Diagnostic performance of standard baseline and serial 2 h hs-cTnT thresholds to rule-in MI is suboptimal in CKD patients. It significantly improves when using higher baseline thresholds and delta values.
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