Cardiac Troponin Thresholds in Children and Young Adults: A Multi-Center Cohort Study
Alexander J F Thurston1, Eirik Å Røys2,3, Ragnhild Røysland4,5
1BHF Centre for Cardiovascular Science, The University of Edinburgh, Edinburgh, United Kingdom.
Insights
Using pediatric-specific thresholds for high-sensitivity cardiac troponin (hs-cTn) assays significantly increases the identification of myocardial injury in children and young adults. Further research is needed to understand the clinical implications of these findings.
Area of Science:
- Pediatric Cardiology
- Biomarker Research
- Diagnostic Thresholds
Background:
- The diagnostic utility of high-sensitivity cardiac troponin (hs-cTn) assays in pediatric populations remains unclear, with a lack of established diagnostic thresholds.
- Current clinical practice often relies on adult reference limits, potentially leading to misinterpretation of hs-cTn results in children and young adults.
Purpose of the Study:
- To evaluate the impact of applying pediatric versus adult upper reference limits (URLs) for hs-cTn assays in diagnosing myocardial injury in pediatric patients.
- To compare the diagnostic yield of different pediatric sex-specific percentile thresholds for hs-cTn.
Main Methods:
- A retrospective, multicenter international cohort study involving 9833 children and young adults (1 day to 18 years) from four tertiary care hospitals in Norway and Scotland (2013-2023).
- Myocardial injury was classified using adult sex-specific 99th percentile URL, pediatric sex-specific 99th percentile URL, and pediatric sex-specific 97.5th percentile URL.
- Myocarditis diagnoses were confirmed through the Norwegian Patient Register and Scottish Morbidity Record.
Main Results:
- Applying a pediatric sex-specific 97.5th percentile URL identified a 28% relative increase in myocardial injury classifications compared to adult thresholds.
- Infants demonstrated a significantly higher frequency of myocardial injury (93.8%) compared to older children and young adults (14.0%) when using the pediatric 97.5th percentile URL.
- Cardiac troponin testing frequency increased substantially over the study period (τ = 0.42, P < 0.001).
Conclusions:
- The adoption of pediatric-specific 97.5th percentile URLs for hs-cTn assays would lead to a greater classification of myocardial injury in pediatric patients.
- The clinical significance and management implications of this increased detection rate require further investigation.
- The rising trend in hs-cTn testing over the past decade underscores the need for age-appropriate diagnostic guidelines.
Background:
The role of high-sensitivity cardiac troponin (cTn) assays for children and young adults is uncertain, and no guidance is available on diagnostic thresholds. This study evaluates the effect of applying pediatric compared to adult upper reference limits (URLs) for cTn.
Methods:
We carried out a retrospective multicenter international cohort study of consecutive children and young adults (1 day to 18 years) undergoing cTn I or T testing at 4 tertiary care hospitals in Norway and Scotland, United Kingdom, from 2013 to 2023. Myocardial injury was classified using the adult sex-specific 99th percentile URL, a pediatric sex-specific 99th percentile, and a pediatric sex-specific 97.5th percentile. Diagnoses of myocarditis were obtained from the Norwegian Patient Register and the Scottish Morbidity Record.
Results:
In total, 9833 (46.6% female) children and young adults underwent cTn testing. Applying the adult sex-specific 99th percentile, 1771 (18.0% [95% CI, 17.3%-18.8%]) had myocardial injury compared with 1762 (17.9% [95% CI, 17.2%-18.7%]) using a pediatric 99th percentile. In contrast, applying a pediatric sex-specific 97.5th percentile would identify 2261 (23.0% [95% CI, 22.2%-23.8%]) with myocardial injury (a 28% relative increase). Infants had a higher frequency of myocardial injury than those 1-18 years old (1035/1104; 93.8% [95% CI, 92.2%-95.1%] vs 1226/8729; 14.0% [95% CI, 13.3%-14.8%] using pediatric sex-specific 97.5th percentile, P < 0.001). Testing for cTn increased over the study period (τ = 0.42, P < 0.001).
Conclusions:
The use of pediatric-specific 97.5th percentile URLs for cTn would increase classification of myocardial injury in children and young adults. The clinical implications of this are uncertain and require further study given cTn testing has increased over the last decade.
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