Diagnostic accuracy of copeptin sensitivity and specificity in patients with suspected non-ST-elevation myocardial infarction with troponin I below the 99th centile at presentation

Abstract

ObjectiveTo determine whether copeptin-us can rule out diagnosis of non-ST-segment elevation myocardial infarction (NSTEMI) without prolonged monitoring and serial blood sampling in patients with high-sensitive cardiac troponin I (hs-cTnT) below the 99th centile at presentation to the emergency department (ED).DesignProspective, non-randomised, individual blinded diagnostic accuracy study.SettingTwo EDs of a rural region of France.ParticipantsPatients with chest pain suspected of NSTEMI with onset within the last 12 h were considered for enrolment.InterventionsSerial clinical, electrographical and biochemical investigations were performed at admission and after 2, 4, 6 and 12 h. Hs-cTnT was measured using an assay with Dimension VISTA, Siemens. Copeptin was measured by the BRAHMS copeptin-us assay on the KRYPTOR Compact Plus system. The follow-up period was 90 days.Primary and secondary outcome measuresCopeptin, troponin, myoglobin and creatine kinase values. Clinical and paraclinical events. The final diagnosis was adjudicated blinded to copeptin result.ResultsDuring 12 months, 102 patients were analysed. Final diagnosis was NSTEMI for 7.8% (n=8), unstable angina for 3.9% (n=4), cardiac but non-coronary artery disease for 8.8% (n=9), non-cardiac chest pain for 52% (n=53) and unknown for 27.5% (n=28). There was no statistical difference for copeptin values between patients with NSTEMI and others (respectively 5.5 pmol/L IQR (3.1–7.9) and 6.5 pmol/L IQR (3.9–12.1), p=0.49). Only one patient with NSTEMI had a copeptin value above the cut-off of 95th centile at admission.ConclusionsIn this study, copeptin does not add a diagnostic value at admission to ED for patients with suspected acute coronary syndrome without ST-segment elevation and with hs-cTnT below the 99th centile.Trial registration numberClinicaltrials.gov identifier: NCT01334645.

Using expert elicitation to estimate the potential impact of improved diagnostic performance of laboratory tests: a case study on rapid discharge of suspected non–ST elevation myocardial infarction patients

“…Previous studies already investigated the diagnostic accuracy in excluding acute myocardial infarction using combinations of those markers. [26][27][28][29][30][31][32][33][34][35]49,63,64 However, this study is the first study that HsTn measurement costs about €9.55, indicating there is large headroom to achieve a cost-saving outcome.…”

“…In this paper, we illustrate the value of using expert elicitations in the early assessment of new medical tests, using a case of a triple biomarker to inform early exclusion of NSTEMI at the CPU. Previous studies already investigated the diagnostic accuracy in excluding acute myocardial infarction using combinations of those markers . However, this study is the first study that provides an initial estimate of the cost‐effectiveness of this triple biomarker in suspected NSTEMI patients on referral rates and on subsequent interventions.…”

Serial sampling of copeptin levels improves diagnosis and risk stratification in patients presenting with chest pain: results from the CHOPIN trial

“…The addition of copeptin to troponin has demonstrated improved sensitivity for detecting AMI allowing for earlier and more accurate rule out of patients with chest pain 14–19. So far the studies have focused on patients with negative troponin and copeptin levels, as they can potentially be discharged home from the ED with a single blood draw.…”

“…However, higher sensitivity troponin assays are being developed and it is important to consider how this may impact the utility of copeptin. While some data suggest that copeptin may not have any additional value when added to high sensitivity troponin,19 others have demonstrated that copeptin significantly improves diagnostic value 14 15. A likely explanation for the sustained value of copeptin is that it still peaks much earlier than high sensitivity troponin following AMI as demonstrated by Gu et al 8 As the role of copeptin in the high-sensitivity troponin era evolves, the troponin−/copeptin+ cohort will need to be addressed.…”

Copeptin in critical illness

“…Copeptin combined with high-sensitive cardiac troponin T may help in ruling out acute myocardial infarction in patients with acute chest pain of early onset [22,23] and non-ST-elevation myocardial infarction (NSTEMI) in older patients [24], facilitating safe early discharge from the hospital [25]. The relevancy of copeptin measurement is debated in NSTEMI patients with troponin I below the 99th centile at presentation [26]. Copeptin may help prognostication in patients presenting with dyspnea in the emergency department [27] or in patients with non-ST-segment elevation acute coronary syndrome [28].…”