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Cardiac Troponin Thresholds and Kinetics to Differentiate Myocardial Injury and Myocardial Infarction

BACKGROUND: Although the 99th percentile is the recommended diagnostic threshold for myocardial infarction, some guidelines also advocate the use of higher troponin thresholds to rule in myocardial infarction at presentation. It is unclear whether the magnitude or change in troponin concentration ca...

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Autores principales: Wereski, Ryan, Kimenai, Dorien M., Taggart, Caelan, Doudesis, Dimitrios, Lee, Kuan Ken, Lowry, Matthew T.H., Bularga, Anda, Lowe, David J., Fujisawa, Takeshi, Apple, Fred S., Collinson, Paul O., Anand, Atul, Chapman, Andrew R., Mills, Nicholas L.
Formato: Online Artículo Texto
Lenguaje:English
Publicado: Lippincott Williams & Wilkins 2021
Materias:
Acceso en línea:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8360674/
https://www.ncbi.nlm.nih.gov/pubmed/34167318
http://dx.doi.org/10.1161/CIRCULATIONAHA.121.054302
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author Wereski, Ryan
Kimenai, Dorien M.
Taggart, Caelan
Doudesis, Dimitrios
Lee, Kuan Ken
Lowry, Matthew T.H.
Bularga, Anda
Lowe, David J.
Fujisawa, Takeshi
Apple, Fred S.
Collinson, Paul O.
Anand, Atul
Chapman, Andrew R.
Mills, Nicholas L.
author_facet Wereski, Ryan
Kimenai, Dorien M.
Taggart, Caelan
Doudesis, Dimitrios
Lee, Kuan Ken
Lowry, Matthew T.H.
Bularga, Anda
Lowe, David J.
Fujisawa, Takeshi
Apple, Fred S.
Collinson, Paul O.
Anand, Atul
Chapman, Andrew R.
Mills, Nicholas L.
author_sort Wereski, Ryan
collection PubMed
description BACKGROUND: Although the 99th percentile is the recommended diagnostic threshold for myocardial infarction, some guidelines also advocate the use of higher troponin thresholds to rule in myocardial infarction at presentation. It is unclear whether the magnitude or change in troponin concentration can differentiate causes of myocardial injury and infarction in practice. METHODS: In a secondary analysis of a multicenter randomized controlled trial, we identified 46 092 consecutive patients presenting with suspected acute coronary syndrome without ST-segment–elevation myocardial infarction. High-sensitivity cardiac troponin I concentrations at presentation and on serial testing were compared between patients with myocardial injury and infarction. The positive predictive value and specificity were determined at the sex-specific 99th percentile upper reference limit and rule-in thresholds of 64 ng/L and 5-fold of the upper reference limit for a diagnosis of type 1 myocardial infarction. RESULTS: Troponin was above the 99th percentile in 8188 patients (18%). The diagnosis was type 1 or type 2 myocardial infarction in 50% and 14% and acute or chronic myocardial injury in 20% and 16%, respectively. Troponin concentrations were similar at presentation in type 1 (median [25th–75th percentile] 91 [30–493] ng/L) and type 2 (50 [22–147] ng/L) myocardial infarction and in acute (50 [26–134] ng/L) and chronic (51 [31–130] ng/L) myocardial injury. The 99th percentile and rule-in thresholds of 64 ng/L and 5-fold upper reference limit gave a positive predictive value of 57% (95% CI, 56%–58%), 59% (58%–61%), and 62% (60%–64%) and a specificity of 96% (96%–96%), 96% (96%–96%), and 98% (97%–98%), respectively. The absolute, relative, and rate of change in troponin concentration were highest in patients with type 1 myocardial infarction (P<0.001 for all). Discrimination improved when troponin concentration and change in troponin were combined compared with troponin concentration at presentation alone (area under the curve, 0.661 [0.642–0.680] versus 0.613 [0.594–0.633]). CONCLUSIONS: Although we observed important differences in the kinetics, cardiac troponin concentrations at presentation are insufficient to distinguish type 1 myocardial infarction from other causes of myocardial injury or infarction in practice and should not guide management decisions in isolation. REGISTRATION: URL: https://www.clinicaltrials.gov; Unique identifier: NCT01852123.
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spelling pubmed-83606742021-08-18 Cardiac Troponin Thresholds and Kinetics to Differentiate Myocardial Injury and Myocardial Infarction Wereski, Ryan Kimenai, Dorien M. Taggart, Caelan Doudesis, Dimitrios Lee, Kuan Ken Lowry, Matthew T.H. Bularga, Anda Lowe, David J. Fujisawa, Takeshi Apple, Fred S. Collinson, Paul O. Anand, Atul Chapman, Andrew R. Mills, Nicholas L. Circulation Original Research Articles BACKGROUND: Although the 99th percentile is the recommended diagnostic threshold for myocardial infarction, some guidelines also advocate the use of higher troponin thresholds to rule in myocardial infarction at presentation. It is unclear whether the magnitude or change in troponin concentration can differentiate causes of myocardial injury and infarction in practice. METHODS: In a secondary analysis of a multicenter randomized controlled trial, we identified 46 092 consecutive patients presenting with suspected acute coronary syndrome without ST-segment–elevation myocardial infarction. High-sensitivity cardiac troponin I concentrations at presentation and on serial testing were compared between patients with myocardial injury and infarction. The positive predictive value and specificity were determined at the sex-specific 99th percentile upper reference limit and rule-in thresholds of 64 ng/L and 5-fold of the upper reference limit for a diagnosis of type 1 myocardial infarction. RESULTS: Troponin was above the 99th percentile in 8188 patients (18%). The diagnosis was type 1 or type 2 myocardial infarction in 50% and 14% and acute or chronic myocardial injury in 20% and 16%, respectively. Troponin concentrations were similar at presentation in type 1 (median [25th–75th percentile] 91 [30–493] ng/L) and type 2 (50 [22–147] ng/L) myocardial infarction and in acute (50 [26–134] ng/L) and chronic (51 [31–130] ng/L) myocardial injury. The 99th percentile and rule-in thresholds of 64 ng/L and 5-fold upper reference limit gave a positive predictive value of 57% (95% CI, 56%–58%), 59% (58%–61%), and 62% (60%–64%) and a specificity of 96% (96%–96%), 96% (96%–96%), and 98% (97%–98%), respectively. The absolute, relative, and rate of change in troponin concentration were highest in patients with type 1 myocardial infarction (P<0.001 for all). Discrimination improved when troponin concentration and change in troponin were combined compared with troponin concentration at presentation alone (area under the curve, 0.661 [0.642–0.680] versus 0.613 [0.594–0.633]). CONCLUSIONS: Although we observed important differences in the kinetics, cardiac troponin concentrations at presentation are insufficient to distinguish type 1 myocardial infarction from other causes of myocardial injury or infarction in practice and should not guide management decisions in isolation. REGISTRATION: URL: https://www.clinicaltrials.gov; Unique identifier: NCT01852123. Lippincott Williams & Wilkins 2021-06-25 2021-08-17 /pmc/articles/PMC8360674/ /pubmed/34167318 http://dx.doi.org/10.1161/CIRCULATIONAHA.121.054302 Text en © 2021 The Authors. https://creativecommons.org/licenses/by/4.0/Circulation is published on behalf of the American Heart Association, Inc., by Wolters Kluwer Health, Inc. This is an open access article under the terms of the Creative Commons Attribution (https://creativecommons.org/licenses/by/4.0/) License, which permits use, distribution, and reproduction in any medium, provided that the original work is properly cited.
spellingShingle Original Research Articles
Wereski, Ryan
Kimenai, Dorien M.
Taggart, Caelan
Doudesis, Dimitrios
Lee, Kuan Ken
Lowry, Matthew T.H.
Bularga, Anda
Lowe, David J.
Fujisawa, Takeshi
Apple, Fred S.
Collinson, Paul O.
Anand, Atul
Chapman, Andrew R.
Mills, Nicholas L.
Cardiac Troponin Thresholds and Kinetics to Differentiate Myocardial Injury and Myocardial Infarction
title Cardiac Troponin Thresholds and Kinetics to Differentiate Myocardial Injury and Myocardial Infarction
title_full Cardiac Troponin Thresholds and Kinetics to Differentiate Myocardial Injury and Myocardial Infarction
title_fullStr Cardiac Troponin Thresholds and Kinetics to Differentiate Myocardial Injury and Myocardial Infarction
title_full_unstemmed Cardiac Troponin Thresholds and Kinetics to Differentiate Myocardial Injury and Myocardial Infarction
title_short Cardiac Troponin Thresholds and Kinetics to Differentiate Myocardial Injury and Myocardial Infarction
title_sort cardiac troponin thresholds and kinetics to differentiate myocardial injury and myocardial infarction
topic Original Research Articles
url https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8360674/
https://www.ncbi.nlm.nih.gov/pubmed/34167318
http://dx.doi.org/10.1161/CIRCULATIONAHA.121.054302
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