Diagnostic Performance of Serial High-Sensitivity Cardiac Troponin Measurements in the Emergency Setting

Abstract

Serial high-sensitivity cardiac troponin (hsTn) testing in the emergency department (ED) and the intensive cardiac care unit may assist physicians in ruling out or ruling in acute myocardial infarction (MI). There are three major algorithms proposed for high-sensitivity cardiac troponin I (hsTnI) using serial measurements while incorporating absolute concentration changes for MI or death following ED presentation. We sought to determine the diagnostic estimates of these three algorithms and if one was superior in two different Canadian ED patient cohorts with serial hsTnI measurements. An undifferentiated ED population (Cohort-1) and an ED population with symptoms suggestive of acute coronary syndrome (ACS; Cohort-2) were clinically managed with non-hsTn testing with the hsTnI testing performed in real-time with physicians blinded to these results (i.e., hsTnI not reported). The three algorithms evaluated were the European Society of Cardiology (ESC), the High-STEACS pathway, and the COMPASS-MI algorithm. The diagnostic estimates were derived for each algorithm for the 30-day MI/death outcome for the rule-out and rule-in arm in each cohort and compared to proposed diagnostic benchmarks (i.e., sensitivity ≥ 99.0% and specificity ≥ 90.0%) with 95% confidence intervals (CI). In Cohort-1 (n = 2966 patients, 15.3% had outcome) and Cohort-2 (n = 935 patients, 15.6% had outcome), the algorithm that obtained the highest sensitivity (97.8%; 95% CI: 96.0–98.9 and 98.6%; 95% CI: 95.1–99.8, respectively) in both cohorts was COMPASS-MI. Only Cohort-2 with both the ESC and COMPASS-MI algorithms exceeded the specificity benchmark (97.0%; 95% CI: 95.5–98.0 and 96.7%; 95% CI: 95.2–97.8, respectively). Patient selection for serial hsTnI testing will affect specificity estimates, with no algorithm achieving a sensitivity ≥ 99% for 30-day MI or death.

Serial high-sensitivity cardiac troponin testing for the diagnosis of myocardial infarction: a scoping review

“…After excluding 549 perused full-text articles, we finally included 86 publications, including 72 reports on test accuracy and 52 on 30-day clinical outcomes (online supplemental appendix table 1). 17–102 The excluded articles are listed in online supplemental appendix table 2.…”

Can the Addition of NT-proBNP and Glucose Measurements Improve the Prognostication of High-Sensitivity Cardiac Troponin Measurements for Patients with Suspected Acute Coronary Syndrome?

“…Fourth, the data are from two small cohorts with adjudication for MI performed with non-hs-cTn assays. However, this is not uncommon as many studies that have developed and assessed algorithms have used non-hs-cTn assays for MI adjudication [23,24]. Fifth, large, multicenter studies across different geographical locations are needed to further define the utility of the GuIDER score over hs-cTn alone, as has been demonstrated for the CCS [4][5][6][7][8]22].…”

Accuracy of the European Society of Cardiology 0/1‐, 0/2‐, and 0/3‐hour algorithms for diagnosing acute myocardial infarction

“…The lower sensitivity of the 0/3‐h protocol and wide CIs could be due to the fact that some studies used this algorithm without clinical criteria (GRACE score <140 and pain‐free) while others studies used it combined with clinical criteria (sensitivity without and with clinical criteria = 90% [95% CI = 82.9%–94.6%] vs. 98% [95% CI = 88.6%–99.8%], respectively). In fact, protocol performance may be suboptimal in some populations such as those at high‐risk for AMI clinically 12 . The performance of algorithms for diagnosis of AMI using sex‐specific 99th percentile thresholds are still unclear as many studies did not adjudicate based on this factor.…”