Incidence and outcomes of perioperative myocardial infarction/injury diagnosed by high-sensitivity cardiac troponin I

Abstract Background Perioperative myocardial infarction/injury (PMI) diagnosed by high-sensitivity troponin (hs-cTn) T is frequent and a prognostically important complication of non-cardiac surgery. We aimed to evaluate the incidence and outcome of PMI diagnosed using hs-cTnI, and compare it to PMI diagnosed using hs-cTnT. Methods We prospectively included 2455 patients at high cardiovascular risk undergoing 3111 non-cardiac surgeries, for whom hs-cTnI and hs-cTnT concentrations were measured before surgery and on postoperative days 1 and 2. PMI was defined as a composite of perioperative myocardial infarction (PMIInfarct) and perioperative myocardial injury (PMIInjury), according to the Fourth Universal Definition of Myocardial Infarction. All-cause mortality was the primary endpoint. Results Using hs-cTnI, the incidence of overall PMI was 9% (95% confidence interval [CI] 8–10%), including PMIInfarct 2.6% (95% CI 2.0–3.2) and PMIInjury 6.1% (95% CI 5.3–6.9%), which was lower versus using hs-cTnT: overall PMI 15% (95% CI 14–16%), PMIInfarct 3.7% (95% CI 3.0–4.4) and PMIInjury 11.3% (95% CI 10.2–12.4%). All-cause mortality occurred in 52 (2%) patients within 30 days and 217 (9%) within 1 year. Using hs-cTnI, both PMIInfarct and PMIInjury were independent predictors of 30-day all-cause mortality (adjusted hazard ratio [aHR] 2.5 [95% CI 1.1–6.0], and aHR 2.8 [95% CI 1.4–5.5], respectively) and, 1-year all-cause mortality (aHR 2.0 [95% CI 1.2–3.3], and aHR 1.8 [95% CI 1.2–2.7], respectively). Overall, the prognostic impact of PMI diagnosed by hs-cTnI was comparable to the prognostic impact of PMI using hs-cTnT. Conclusions Using hs-cTnI, PMI is less common versus using hs-cTnT. Using hs-cTnI, both PMIInfarct and PMIInjury remain independent predictors of 30-day and 1-year mortality. Graphic abstract

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Abstract 19710: Causes for Increased Cardiac Troponin I Using Gender-Specific 99th Percentiles From a High Sensitivity Assay in a US Population

Circulation ◽

10.1161/circ.130.suppl_2.19710 ◽

2014 ◽

Vol 130 (suppl_2) ◽

Author(s):

Yader Sandoval ◽

Stephen W Smith ◽

Karen M Schulz ◽

MaryAnn M Murakami ◽

Fred S Apple

Keyword(s):

Myocardial Ischemia ◽

Cardiac Troponin ◽

Myocardial Injury ◽

Troponin I ◽

Plaque Rupture ◽

High Sensitivity ◽

The United States ◽

Universal Definition ◽

Definition Of ◽

Gender Specific

Introduction: High-sensitivity cardiac troponin (hs-cTn) assays have not yet been FDA cleared for clinical use in the United States (US). Pending expected approval of hs-cTn assays, which will use gender-specific cutoffs (GSC), it is relevant to recognize the causes of cTn increases using hs-cTnI assays in a US population. Our purpose was to describe the frequency of distinct etiologies of hs-cTnI assay increases using GSC. Methods: Retrospective study of 310 patients with serial hs-cTnI (Abbott ARCHITECT, 99th percentiles: F:16 ng/L; M:34 ng/L) measurements. Patients with an increased hs-cTnI were adjudicated into categories according to the 3rd Universal Definition of MI. Categories included, A: primary myocardial ischemia (i.e. plaque rupture); B: injury secondary to supply/demand imbalance; C: injury not related to myocardial ischemia (i.e. cardiac contusion, ablation, shock, surgery); D: multifactorial or indeterminate myocardial injury (i.e. heart failure, critically ill, pulmonary HTN, sepsis, stroke, renal failure, pulmonary embolism); E: Unknown. Results: 127 (41%) had an increased hs-cTnI above the GSC 99th percentile, whereas 183 (59%) had a normal hs-cTnI. The most common causes of hs-cTnI increases were: a) multifactorial or indeterminate injury - 43% among all patients and 52% in males, and b) supply/demand imbalance - 39% in women (Table). Injury related to primary myocardial ischemia was present in 10% (n=13). Females had more injury related to supply/demand ischemia than males (39% vs. 18%, p=0.01), whereas males had more multifactorial or indeterminate injury (52% vs. 33%, p=0.05). Conclusions: Most increased hs-cTnI values were explained by non-plaque rupture conditions. Males tended to have hs-cTnI increases due to multifactorial/indeterminate causes, whereas in women supply/demand imbalance was the most common etiology. Investigations are needed to better understand if etiologies of myocardial injury have gender differences.

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Discordance between ICD-Coded Myocardial Infarction and Diagnosis according to the Universal Definition of Myocardial Infarction

Clinical Chemistry ◽

10.1373/clinchem.2016.263764 ◽

2017 ◽

Vol 63 (1) ◽

pp. 415-419 ◽

Cited By ~ 25

Author(s):

Jorge Díaz-Garzón ◽

Yader Sandoval ◽

Stephen W Smith ◽

Sara Love ◽

Karen Schulz ◽

...

Keyword(s):

Myocardial Infarction ◽

Troponin I ◽

High Sensitivity ◽

International Classification Of Diseases ◽

Healthcare Management ◽

Clinical Indication ◽

Kappa Index ◽

Universal Definition ◽

Definition Of

Abstract BACKGROUND International Classification of Diseases (ICD) coding is the standard diagnostic tool for healthcare management. At present, type 2 myocardial infarction (T2MI) classification by the Universal Definition of Myocardial Infarction (MI) remains ignored in the ICD system. We determined the concordance for the diagnosis of MI using ICD-9 coding vs the Universal Definition. METHODS Cardiac troponin I (cTnI) was measured by both contemporary (cTnI) and high-sensitivity (hs-cTnI) assays in 1927 consecutive emergency department (ED) patients [Use of TROPonin In Acute coronary syndromes (UTROPIA) cohort] who had cTnI ordered on clinical indication. All patients were adjudicated using both contemporary and hs-cTnI assays. The Kappa index and McNemar test were used to assess concordance between ICD-9 code 410 and type 1 MI (T1MI) and type 2 MI (T2MI). RESULTS Among the 249 adjudicated MIs using the contemporary cTnI, only 69 (28%) were ICD-coded MIs. Of 180 patients not ICD coded as MI, 34 (19%) were T1MI and 146 (81%) were T2MI. For the ICD-coded MIs, 79% were T1MI and 21% were T2MI. A fair Kappa index, 0.386, and a McNemar difference of 0.0892 (P < 0.001) were found. Among the 207 adjudicated MIs using the hs-cTnI assay, 67 (32%) were ICD coded as MI. Of the 140 patients not ICD coded as MI, 27 (19%) were T1MI and 113 (81%) were T2MI. For the ICD-coded MIs, 85% were T1MI and 15% T2MI. A moderate Kappa index, 0.439, and a McNemar difference of 0.0674 (P < 0.001) were found. CONCLUSIONS ICD-9–coded MIs captured only a small proportion of adjudicated MIs, primarily from not coding T2MI. Our findings emphasize the need for an ICD code for T2MI.

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Troponin elevation pattern and subsequent cardiac and non-cardiac outcomes: Implementing the Fourth Universal Definition of Myocardial Infarction and high-sensitivity troponin at a population level

PLoS ONE ◽

10.1371/journal.pone.0248289 ◽

2021 ◽

Vol 16 (3) ◽

pp. e0248289

Author(s):

Anthony (Ming-yu) Chuang ◽

Mau T. Nguyen ◽

Ehsan Khan ◽

Dylan Jones ◽

Matthew Horsfall ◽

...

Keyword(s):

Myocardial Infarction ◽

Ventricular Arrhythmia ◽

Myocardial Injury ◽

High Sensitivity ◽

Cardiac Outcomes ◽

High Sensitivity Troponin ◽

Acute Myocardial Injury ◽

Acute Mi ◽

Universal Definition ◽

Definition Of

Background The Fourth Universal Definition of Myocardial Infarction (MI) differentiates MI from myocardial injury. We characterised the temporal course of cardiac and non-cardiac outcomes associated with MI, acute and chronic myocardial injury. Methods We included all patients presenting to public emergency departments in South Australia between June 2011–Sept 2019. Episodes of care (EOCs) were classified into 5 groups based on high-sensitivity troponin-T (hs-cTnT) and diagnostic codes: 1) Acute MI [rise/fall in hs-cTnT and primary diagnosis of acute coronary syndrome], 2) Acute myocardial injury with coronary artery disease (CAD) [rise/fall in hs-cTnT and diagnosis of CAD], 3) Acute myocardial injury without CAD [rise/fall in hs-cTnT without diagnosis of CAD], 4) Chronic myocardial injury [elevated hs-cTnT without rise/fall], and 5) No myocardial injury. Multivariable flexible parametric models were used to characterize the temporal hazard of death, MI, heart failure (HF), and ventricular arrhythmia. Results 372,310 EOCs (218,878 individuals) were included: acute MI (19,052 [5.12%]), acute myocardial injury with CAD (6,928 [1.86%]), acute myocardial injury without CAD (32,231 [8.66%]), chronic myocardial injury (55,056 [14.79%]), and no myocardial injury (259,043 [69.58%]). We observed an early hazard of MI and HF after acute MI and acute myocardial injury with CAD. In contrast, subsequent MI risk was lower and more constant in patients with acute injury without CAD or chronic injury. All patterns of myocardial injury were associated with significantly higher risk of all-cause mortality and ventricular arrhythmia. Conclusions Different patterns of myocardial injury were associated with divergent profiles of subsequent cardiac and non-cardiac risk. The therapeutic approach and modifiability of such excess risks require further research.

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Diagnosis of Type 1 and Type 2 Myocardial Infarction Using a High-Sensitivity Cardiac Troponin I Assay with Sex-Specific 99th Percentiles Based on the Third Universal Definition of Myocardial Infarction Classification System

Clinical Chemistry ◽

10.1373/clinchem.2014.236638 ◽

2015 ◽

Vol 61 (4) ◽

pp. 657-663 ◽

Cited By ~ 45

Author(s):

Yader Sandoval ◽

Stephen W Smith ◽

Karen M Schulz ◽

MaryAnn M Murakami ◽

Sara A Love ◽

...

Keyword(s):

Myocardial Infarction ◽

Classification System ◽

Cardiac Troponin ◽

Troponin I ◽

High Sensitivity ◽

The Third ◽

Universal Definition ◽

Definition Of

Abstract BACKGROUND The frequency and characteristics of myocardial infarction (MI) subtypes per the Third Universal Definition of MI (TUDMI) classification system using high-sensitivity (hs) cardiac troponin assays with sex-specific cutoffs is not well known. We sought to describe the diagnostic characteristics of type 1 (T1MI) and type 2 (T2MI) MI using an hs–cardiac troponin I (hs-cTnI) assay with sex-specific cutoffs. METHODS A total of 310 consecutive patients with serial cTnI measurements obtained on clinical indication were studied with contemporary and hs-cTnI assays. Ninety-ninth percentile sex-specific upper reference limits (URLs) for the hs-cTnI assay were 16 ng/L for females and 34 ng/L for males. The TUDMI consensus recommendations were used to define and adjudicate MI based on each URL. RESULTS A total of 127 (41%) patients had at least 1 hs-cTnI exceeding the sex-specific 99th percentiles, whereas 183 (59%) had hs-cTnI within the reference interval. Females had more myocardial injury related to supply/demand ischemia than males (39% vs 18%, P = 0.01), whereas males had more multifactorial or indeterminate injury (52% vs 33%, P = 0.05). By hs-cTnI, there were 32 (10%) acute MIs, among which 10 (3%) were T1MI and 22 (7%) were T2MI. T2MI represented 69% (22 out of 32) of all acute MIs, whereas T1MI represented 31% (10 out of 32). Ninety-five patients (31%) had an increased hs-cTnI above the 99th percentile but did not meet criteria for acute MI. The most common triggers for T2MI were tachyarrhythmias, hypotension/shock, and hypertension. By contemporary cTnI, more MIs (14 T1MI and 29 T2MI) were diagnosed. By contemporary cTnI, there were 43 MIs, 14 T1MI, and 29 T2MI. CONCLUSIONS Fewer MI diagnoses were found with the hs-cTnI assay, contrary to the commonly accepted idea that hs-cTnI will lead to excessive false-positive diagnoses.

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3296Clinical application of the fourth universal definition of myocardial infarction

European Heart Journal ◽

10.1093/eurheartj/ehz745.0060 ◽

2019 ◽

Vol 40 (Supplement_1) ◽

Author(s):

T Hartikainen ◽

N A Soerensen ◽

P M Haller ◽

A Gossling ◽

S Blankenberg ◽

...

Keyword(s):

Myocardial Infarction ◽

Heart Failure ◽

Cardiovascular Events ◽

Myocardial Injury ◽

Troponin T ◽

Chronic Injury ◽

All Cause Mortality ◽

Acute Myocardial Injury ◽

Universal Definition ◽

Definition Of

Abstract Background The recently released fourth version of the Universal Definition of Myocardial Infarction (UDMI) introduced substantial changes such as the implementation of the categories acute and chronic myocardial injury. It further recommends the use of sex-specific troponin cut-offs and consideration of absolute rather than relative changes of troponin concentrations for diagnosis of myocardial infarction (MI). Our aim was to apply the updated UDMI in patients with suspected MI to investigate its effect on diagnosis and prognosis. Methods We included 2'304 patients presenting to the emergency department with suspected MI. The final diagnosis was first adjudicated according to the 3rd UDMI by two physicians in a blinded fashion using all available medical records, laboratory findings including high-sensitivity troponin T results as well as clinical and imaging findings. Thereafter all patients were re-adjudicated based on the 4th UDMI, again all available information was used. Included patients were followed up to 4 years to assess all-cause mortality, incident nonfatal MI, revascularization and rehospitalization. Hazard ratios (HR) were calculated to investigate the effect of the diagnoses based on the 4th UDMI on prognosis. Results Out of 2'304 included patients, 708 got reclassified by the 4th UDMI. 442 (19.2%) were diagnosed as having MI compared to 504 (21.9%) based on the 3rd UDMI. Out of 1'862 non-MI patients, 74 (3.97%) patients had acute and 583 (31.3%) chronic myocardial injury (Figure 1). Patients with acute or chronic injury were older, more often female and had worse renal function than other non-MI patients. The most common causes for acute myocardial injury were heart failure, pulmonary embolism and takotsubo cardiomyopathy. For chronic myocardial injury hypertension, heart failure and non-obstructive coronary artery disease were the most frequent reasons. In cox regression analyses unadjusted HR for all-cause mortality in patients with acute or chronic myocardial injury was considerably higher when compared to patients with non-cardiac chest pain (HR 13.2 (confidence interval (CI) 6.7–26.3) (p<0.001) for acute myocardial injury and 7.2 (CI 4.2–12.5) (p<0.001) for chronic myocardial injury). After adjustment for age and gender, acute and chronic myocardial injury still strongly predicted a poorer outcome and higher rate of cardiovascular events compared to other non-MI patients. Patients with acute or chronic myocardial injury showed equally poor outcome as patients with MI. Figure 1. Re-adjudication Conclusion By introducing the categories of acute and chronic myocardial injury the 4th UDMI succeeds to identify non-MI patients with higher risk for cardiovascular events and poorer outcome and thus seems to improve risk assessment in this heterogeneous population. Prevention strategies for this specific population are yet to be investigated.

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Discrimination of myocardial infarction and myocardial injury using a multibiomarker approach

European Heart Journal ◽

10.1093/ehjci/ehaa946.1682 ◽

2020 ◽

Vol 41 (Supplement_2) ◽

Author(s):

J Neumann ◽

N.A Soerensen ◽

T.S Hartikainen ◽

P.M Haller ◽

J Lehmacher ◽

...

Keyword(s):

Myocardial Infarction ◽

Myocardial Injury ◽

Troponin I ◽

Area Under The Curve ◽

Funding Source ◽

Multivariable Model ◽

Multivariable Logistic Regression Model ◽

Wide Range ◽

Universal Definition ◽

Definition Of

Abstract Background In the Universal Definition of Myocardial Infarction (MI) myocardial injury was introduced as a specific diagnosis in patients with elevated troponin concentrations, but without evidence of acute myocardial ischemia. However, their differentiation within the acute setting might be challenging. Therefore, we sought to investigate a multibiomarker panel in these patients and determine the discriminative capacity to differentiation MI from myocardial injury. Methods We use a cohorts of acute patients presenting to the emergency department. All final diagnoses were adjudicated by two physicians in a blinded fashion and based on the fourth universal definition of MI. In case of disagreement a third physician referred. For the present analyses only patients diagnosed with MI or myocardial injury were used. A panel of 28 biomarkers was measured in blood samples collected directly at admission. Spearman correlations were calculated. A multivariable logistic regression model using MI as the dependent variable was used and the predictors were chosen via backward step-back selection. Odds ratios (OR) were calculated for each predictor. Results We included 359 patients; 138 were diagnosed as having MI and 221 has having myocardial injury. The median age of the study population was 73 years and 59.1% were males. Hypertension was diagnosed in 80.4%, dyslipidemia in 45.4% and diabetes in 19.0%.The biomarker panel showed a wide range of correlations (Figure 1). In the multivariable model five logarithmized biomarkers (N-terminal prohormone of brain natriuretic peptide [OR 0.62], pulmonary and activation-regulated chemokine [OR 0.51], tumor-necrosis-factor-receptor 2 [OR 2.22], copeptin [OR 1.59] and high-sensitivity troponin I [OR 1.80]) were significant discriminators between MI and myocardial injury. Internal validation of the model via bootstrap shows a for overoptimism corrected area under the curve of 0.84. Conclusion In the multivariable model five biomarkers were discriminators between MI and myocardial injury. Spearman correlations Funding Acknowledgement Type of funding source: Public grant(s) – National budget only. Main funding source(s): Research fellowship by the Deutsche Forschungsgemeinschaft

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High-Sensitivity Cardiac Troponin and the Universal Definition of Myocardial Infarction

Circulation ◽

10.1161/circulationaha.119.042960 ◽

2020 ◽

Vol 141 (3) ◽

pp. 161-171 ◽

Cited By ~ 26

Author(s):

Andrew R. Chapman ◽

Philip D. Adamson ◽

Anoop S.V. Shah ◽

Atul Anand ◽

Fiona E. Strachan ◽

...

Keyword(s):

Myocardial Infarction ◽

Cardiac Troponin ◽

Myocardial Injury ◽

Primary Outcome ◽

High Sensitivity ◽

Coronary Syndrome ◽

Diagnostic Categories ◽

Universal Definition ◽

Definition Of

Background: The introduction of more sensitive cardiac troponin assays has led to increased recognition of myocardial injury in acute illnesses other than acute coronary syndrome. The Universal Definition of Myocardial Infarction recommends high-sensitivity cardiac troponin testing and classification of patients with myocardial injury based on pathogenesis, but the clinical implications of implementing this guideline are not well understood. Methods: In a stepped-wedge cluster randomized, controlled trial, we implemented a high-sensitivity cardiac troponin assay and the recommendations of the Universal Definition in 48 282 consecutive patients with suspected acute coronary syndrome. In a prespecified secondary analysis, we compared the primary outcome of myocardial infarction or cardiovascular death and secondary outcome of noncardiovascular death at 1 year across diagnostic categories. Results: Implementation increased the diagnosis of type 1 myocardial infarction by 11% (510/4471), type 2 myocardial infarction by 22% (205/916), and acute and chronic myocardial injury by 36% (443/1233) and 43% (389/898), respectively. Compared with those without myocardial injury, the rate of the primary outcome was highest in those with type 1 myocardial infarction (cause-specific hazard ratio [HR] 5.64 [95% CI, 5.12–6.22]), but was similar across diagnostic categories, whereas noncardiovascular deaths were highest in those with acute myocardial injury (cause specific HR 2.65 [95% CI, 2.33–3.01]). Despite modest increases in antiplatelet therapy and coronary revascularization after implementation in patients with type 1 myocardial infarction, the primary outcome was unchanged (cause specific HR 1.00 [95% CI, 0.82–1.21]). Increased recognition of type 2 myocardial infarction and myocardial injury did not lead to changes in investigation, treatment or outcomes. Conclusions: Implementation of high-sensitivity cardiac troponin assays and the recommendations of the Universal Definition of Myocardial Infarction identified patients at high-risk of cardiovascular and noncardiovascular events but was not associated with consistent increases in treatment or improved outcomes. Trials of secondary prevention are urgently required to determine whether this risk is modifiable in patients without type 1 myocardial infarction. Clinical Trial Registration: https://www.clinicaltrials.gov . Unique identifier: NCT01852123.

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Diagnosis, Investigation and Management of Patients with Acute and Chronic Myocardial Injury

Journal of Clinical Medicine ◽

10.3390/jcm10112331 ◽

2021 ◽

Vol 10 (11) ◽

pp. 2331

Author(s):

Caelan Taggart ◽

Ryan Wereski ◽

Nicholas L. Mills ◽

Andrew R. Chapman

Keyword(s):

Myocardial Infarction ◽

Myocardial Injury ◽

Plaque Rupture ◽

High Sensitivity ◽

Major Adverse Cardiovascular Events ◽

Healthy Individuals ◽

Early Assessment ◽

Universal Definition ◽

Definition Of ◽

Atherosclerotic Plaque Rupture

The application of high-sensitivity cardiac troponins in clinical practice has led to an increase in the recognition of elevated concentrations in patients without myocardial ischaemia. The Fourth Universal Definition of Myocardial Infarction encourages clinicians to classify such patients as having an acute or chronic myocardial injury based on the presence or absence of a rise or a fall in cardiac troponin concentrations. Both conditions may be caused by a variety of cardiac and non-cardiac conditions, and evidence suggests that clinical outcomes are worse than patients with myocardial infarction due to atherosclerotic plaque rupture, with as few as one-third of patients alive at 5 years. Major adverse cardiovascular events are comparable between populations, and up to three-fold higher than healthy individuals. Despite this, no evidence-based strategies exist to guide clinicians in the investigation of non-ischaemic myocardial injury. This review explores the aetiology of myocardial injury and proposes a simple framework to guide clinicians in early assessment to identify those who may benefit from further investigation and treatment for those with cardiovascular disease.

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Abstract 350: Assessment of Clinicians’ Attitudes and Knowledge About Cardiac Troponin Testing

Circulation Cardiovascular Quality and Outcomes ◽

10.1161/hcq.13.suppl_1.350 ◽

2020 ◽

Vol 13 (Suppl_1) ◽

Author(s):

Sandeep Jain ◽

Andrew Hammes ◽

Eric Rudofker ◽

Karen Ream ◽

Andrew E Levy

Keyword(s):

Myocardial Infarction ◽

Cardiac Troponin ◽

Myocardial Injury ◽

The United States ◽

Advanced Practice ◽

Attitudes And Knowledge ◽

Universal Definition ◽

Definition Of ◽

Attending Physicians

In the United States, the positive predictive value (PPV) of cardiac troponin for type 1 myocardial infarction is substantially lower than in Europe (15% vs. 50%). Further, even with publication of the 4 th Universal Definition of Myocardial Infarction, recent studies have shown that inaccurate classification of myocardial injury is common among clinicians in the United States. These findings are at least partly attributable to clinicians’ knowledge and attitudes about cardiac troponin testing; a survey of these parameters has never been conducted. Clinicians at the University of Colorado completed a brief 8-question multiple-choice survey related to troponin use, definitions of myocardial infarction and clinical assessment of elevated troponin levels. The survey was distributed via secure email and administered electronically using the Qualtrics™ platform. Responses were anonymous, completion was estimated to take 3 minutes and a lottery award system was used as an incentive for participation. Respondents included trainees, advanced practice providers and attending physicians from internal medicine, emergency medicine and medical subspecialties. We plan to obtain a total of 300 responses with descriptive findings of preliminary results included below. The survey was completed by 114 clinicians: 37 interns (32%), 45 residents (39%), 9 advanced practice providers (8%), 11 fellows (10%), and 12 attending physicians (11%). Regarding indications for troponin testing, 93% (106/114) indicated that they “usually” or “always” check troponin levels in patients with chest pain. More interestingly, 46% (52/112) reported checking troponin on “undifferentiated patients” at least half the time. For troponin interpretation, 97% (110/114) of participants identified that troponin levels alone cannot rule in or rule out coronary artery disease. In contrast, only 36% (41/114) and 55% (63/114), respectively, identified the NPV and PPV of a contemporary troponin assay for type 1 MI. Further, only 50% (57/114) of respondents identified that the likelihood of type 1 MI increases as troponin levels increase. Three brief clinical vignettes revealed that, while 78% (89/114) and 74% (45/61) of participants, respectively, identified type 1 MI and type 2 MI presentations, only 40% (21/53) of respondents correctly identified a vignette for non-ischemic myocardial injury. Concordant with this finding, 54% (61/114) of clinicians correctly identified the 4 th Universal Definition of Myocardial Infarction. These preliminary findings highlight important facets of clinician attitudes and knowledge about troponin testing that help explain the poor PPV for troponin and diagnostic misclassification observed among U.S. clinicians. These results could help guide curricular and clinical decision support interventions designed to improve the use and interpretation of cardiac troponin testing.

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Global Adoption of High-Sensitivity Cardiac Troponins and the Universal Definition of Myocardial Infarction

Clinical Chemistry ◽

10.1373/clinchem.2018.298059 ◽

2019 ◽

Vol 65 (3) ◽

pp. 484-489 ◽

Cited By ~ 21

Author(s):

Atul Anand ◽

Anoop S V Shah ◽

Agim Beshiri ◽

Allan S Jaffe ◽

Nicholas L Mills

Keyword(s):

Myocardial Infarction ◽

Cardiac Troponin ◽

Clinical Pathways ◽

High Sensitivity ◽

Diagnosis And Management ◽

Coronary Syndrome ◽

Diagnostic Threshold ◽

Serial Sampling ◽

Universal Definition ◽

Definition Of

Abstract BACKGROUND The universal definition of myocardial infarction (UDMI) standardizes the approach to the diagnosis and management of myocardial infarction. High-sensitivity cardiac troponin testing is recommended because these assays have improved precision at low concentrations, but concerns over specificity may have limited their implementation. METHODS We undertook a global survey of 1902 medical centers in 23 countries evenly distributed across 5 continents to assess adoption of key recommendations from the UDMI. Respondents involved in the diagnosis and management of patients with suspected acute coronary syndrome completed a structured telephone questionnaire detailing the primary biomarker, diagnostic thresholds, and clinical pathways used to identify myocardial infarction. RESULTS Cardiac troponin was the primary diagnostic biomarker at 96% of surveyed sites. Only 41% of centers had adopted high-sensitivity assays, with wide variation from 7% in North America to 60% in Europe. Sites using high-sensitivity troponin more frequently used serial sampling pathways (91% vs 78%) and the 99th percentile diagnostic threshold (74% vs 66%) than sites using previous-generation assays. Furthermore, high-sensitivity institutions more often used earlier serial sampling (≤3 h) and accelerated diagnostic pathways. Fewer than 1 in 5 high-sensitivity sites had adopted sex-specific thresholds (18%). CONCLUSIONS There has been global progress toward the recommendations of the UDMI, particularly in the use of the 99th percentile diagnostic threshold and serial sampling. However, high-sensitivity assays are still used by a minority of sites, and sex-specific thresholds by even fewer. Additional efforts are required to improve risk stratification and diagnosis of patients with myocardial infarction.

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