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High-Sensitivity Cardiac Troponin Risk Cutoffs for Acute Cardiac Outcomes at Emergency Department Presentation

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Abstract

The optimal high-sensitivity cardiac troponin (hs-cTn) cutoffs for determining risk in patients who present with acute coronary syndrome symptoms are unknown. In 1137 emergency department patients we calculated adjusted relative risks for a composite outcome (myocardial infarction, unstable angina, heart failure, ventricular arrhythmia, or cardiovascular death) within 7 days for the presentation of hs-cTnT (Roche) and hs-cTnI (Abbott) assay concentrations on the basis of literature cutoffs. Patients with hs-cTn concentrations ≥ 14 ng/L had an adjusted relative risk of 4.9 for the composite outcome, with different hs-cTnT/hs-cTnI concentration ranges yielding higher risks. A common low-risk cutoff of 14 ng/L may be used for hs-cTn with higher cutoffs identifying high-risk patients.

Résumé

Les valeurs seuils optimales du dosage hypersensible de la troponine cardiaque (cTn-hs) pour la détermination du risque chez les patients présentant des symptômes de syndrome coronarien aigu sont inconnues. Nous avons calculé chez 1137 patients admis aux urgences les risques relatifs corrigés de manifestations composant un paramètre mixte (infarctus du myocarde, angine instable, insuffisance cardiaque, arythmie ventriculaire ou décès d’origine cardiovasculaire) au cours des 7 jours suivant la consultation pour présenter les concentrations obtenues par dosage hypersensible des troponines cardiaques T (cTnT-hs, Roche) et I (cTnI-hs, Abbott) en fonction des valeurs seuils mentionnées dans la littérature. Parmi les patients chez qui les concentrations de cTn-hs étaient ≥ 14 ng/l, le risque relatif corrigé de manifestations composant le paramètre mixte était de 4,9, différentes plages de concentrations de cTnT-hs/cTnI-hs se traduisant par des risques plus élevés. Une valeur seuil commune de 14 ng/l peut être utilisée dans le dosage hypersensible de la troponine cardiaque (cTn-hs) pour objectiver un risque faible, des valeurs seuils supérieures correspondant alors à un risque élevé.

Section snippets

Study design and population

This study was a multicentre prospective cohort study conducted across a North American city (Hamilton, Ontario; study: Optimum Troponin Cutoffs for ACS in the ED [Rule-Out Myocardial Infarction-3 (ROMI-3)]; Clinicaltrials.gov: NCT01994577) whose primary outcome measure was a composite cardiac outcome after ED presentation. We followed the Standards for the Reporting of Diagnostic Accuracy Studies (STARD) guideline for our initial reporting of diagnostic accuracy in this population (n = 1137),

Results

The prevalence for the composite outcome (24.0%; 95% CI, 21.3-27.0) was significantly higher than for MI (11.7%; 95% CI, 9.8-13.9) in the study population (average [SD] age = 66.7 [16.5]; n = 1137). The diagnostic accuracy of hs-cTnI at presentation for MI (AUC, 0.90; 95% CI, 0.87-0.93) was significantly higher than hs-cTnT (AUC, 0.86; 95% CI, 0.83-0.89; P < 0.001; Fig. 1A). However, there was no difference in diagnostic performance between hs-cTnI and hs-cTnT for the remaining individual

Discussion

There are a couple of noteworthy findings from the present analyses. First, the performance between hs-cTnI and hs-cTnT laboratory tests are equivalent when assessing important cardiac outcomes whose diagnosis is not dependent on a cardiac troponin concentration exceeding the 99th percentile. The incorporation bias that is present when evaluating new, more analytically sensitive versions of cardiac troponin tests for the diagnosis of MI extends further to whether cardiac troponin I or cardiac

Conclusions

Patients who present to the ED with undetectable and low hs-cTn concentrations below 14 ng/L are at lower risk for an acute cardiac outcome compared with those who present with concentrations above the proposed North American 99th percentile, with hs-cTnT ≥ 20 ng/L and hs-cTnI ≥ 31 ng/L representing a high-risk group. Hence, application of risk cutoffs for hs-cTn at ED presentation can better determine patient risk for an adverse cardiac event compared with using one overall 99th-percentile

Acknowledgements

This study is registered at Clinicaltrials.gov: NCT01994577.

Funding Sources

This study was supported by a Canadian Institutes of Health Research grant with reagent support from Roche Diagnostics and Abbott Diagnostics.

Disclosures

Dr Kavsak has received grants/reagents/consultant/advisor/honoraria from Abbott Laboratories, Abbott Point of Care, Abbott Diagnostics Division Canada, Beckman Coulter, Ortho Clinical Diagnostics, Randox Laboratories, Roche Diagnostics and Siemens Healthcare Diagnostics. McMaster University has filed patents with Dr Kavsak listed as an inventor in the acute cardiovascular biomarker field. The remaining authors have no conflicts of interest to disclose.

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    These authors contributed equally to this work.

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