A false positive case of high-sensitivity cardiac troponin in a patient with acute chest pain: Analytical study of the interference

BACKGROUND High-sensitivity cardiac troponin assays have better analytical precision and sensitivity than earlier-generation assays when measuring cardiac troponin at low concentrations. We evaluated whether use of a high-sensitivity assay could further improve risk stratification compared with a standard cardiac troponin assay. METHODS We enrolled consecutive patients presenting with acute chest pain, 30% of whom were diagnosed with acute coronary syndrome. Blood samples were drawn at the time of presentation. We measured cardiac troponin T with a standard fourth-generation assay (cTnT) and a high-sensitivity assay (hs-cTnT) (both Roche Diagnostics) and followed the patients for 24 months. RESULTS Of the 1159 patients, 76 died and 42 developed an acute myocardial infarction (AMI). Prognostic accuracy of hs-cTnT for death was significantly higher [area under ROC curve (AUC) 0.79, 95% CI 0.74–0.84] than that of cTnT (AUC 0.69, 95% CI 0.62–0.76; P < 0.001). After adjustment for Thrombolysis in Myocardial Infarction (TIMI) risk score (that included the cTnT assay result), hs-cTnT above the 99th percentile (0.014 μg/L) was associated with a hazard ratio for death of 2.60 (95% CI 1.42–4.74). Addition of hs-cTnT to the risk score improved the reclassification of patients (net reclassification improvement 0.91; 95% CI 0.67–1.14; P < 0.001). Subgroup analyses showed that this effect resulted from the better classification of patients without AMI at time of testing. hs-cTnT outperformed cTnT in the prediction of AMI during follow-up (P=0.02), but was not independently predictive for this endpoint. CONCLUSIONS Concentrations of hs-cTnT >0.014 μg/L improve the prediction of death but not subsequent AMI in unselected patients presenting with acute chest pain.

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Accelerated diagnostic protocol using high-sensitivity cardiac troponin T in acute chest pain patients

European Heart Journal ◽

10.1093/eurheartj/eht307.21 ◽

2013 ◽

Vol 34 (suppl 1) ◽

pp. 21-21

Author(s):

B. Meller ◽

L. Cullen ◽

W. A. Parsonage ◽

J. Greenslade ◽

S. Aldous ◽

...

Keyword(s):

Chest Pain ◽

Cardiac Troponin ◽

Troponin T ◽

Acute Chest Pain ◽

High Sensitivity ◽

Cardiac Troponin T ◽

Diagnostic Protocol ◽

Pain Patients

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Risk stratification and role for additional diagnostic testing in patients with acute chest pain and normal high-sensitivity cardiac troponin levels

PLoS ONE ◽

10.1371/journal.pone.0203506 ◽

2018 ◽

Vol 13 (9) ◽

pp. e0203506 ◽

Cited By ~ 1

Author(s):

Martijn W. Smulders ◽

Sebastiaan C. A. M. Bekkers ◽

Yvonne J. M. van Cauteren ◽

Anna Liefhebber ◽

Jasper R. Vermeer ◽

...

Keyword(s):

Chest Pain ◽

Risk Stratification ◽

Cardiac Troponin ◽

Diagnostic Testing ◽

Acute Chest Pain ◽

High Sensitivity

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Accelerated diagnostic protocol using high-sensitivity cardiac troponin T in acute chest pain patients

International Journal of Cardiology ◽

10.1016/j.ijcard.2015.02.006 ◽

2015 ◽

Vol 184 ◽

pp. 208-215 ◽

Cited By ~ 36

Author(s):

Bernadette Meller ◽

Louise Cullen ◽

William A. Parsonage ◽

Jaimi H. Greenslade ◽

Sally Aldous ◽

...

Keyword(s):

Chest Pain ◽

Cardiac Troponin ◽

Troponin T ◽

Acute Chest Pain ◽

High Sensitivity ◽

Cardiac Troponin T ◽

Diagnostic Protocol ◽

Pain Patients

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Impact of Sex on Cardiac Troponin Concentrations—A Critical Appraisal

Clinical Chemistry ◽

10.1373/clinchem.2017.271684 ◽

2017 ◽

Vol 63 (9) ◽

pp. 1457-1464 ◽

Cited By ~ 22

Author(s):

Kai M Eggers ◽

Bertil Lindahl

Keyword(s):

Chest Pain ◽

Cardiac Troponin ◽

Acute Chest Pain ◽

High Sensitivity ◽

Community Dwelling ◽

Net Benefit ◽

Study Results ◽

Coronary Syndromes ◽

The Cost ◽

Methodological Aspects

Abstract BACKGROUND The use of sex-specific cutoffs for cardiac troponin (cTn) is currently debated. Although endorsed by scientific working groups, concerns have been raised that sex-specific cutoffs may have only a small clinical effect at the cost of increased complexity in decision-making. METHODS We reviewed studies investigating the interrelations between high-sensitivity (hs) cTn results and sex, diagnoses, and outcome. Investigated populations included community-dwelling subjects and patients with stable angina, congestive heart failure, or acute chest pain including those with acute coronary syndromes. RESULTS Men usually have higher hs-cTn concentrations compared with women, regardless of the assessed population or the applied assay. The distribution and prognostic implications of hs-cTn concentrations indicate that women have a broader cardiovascular risk panorama compared with men, particularly at lower hs-cTn concentrations. At higher concentrations, particularly above the 99th percentile, this variation is often attenuated. Sex-specific hs-cTn 99th percentiles have so far shown clinical net benefit in only 1 study assessing patients with chest pain. However, several methodological aspects need to be considered when interpreting study results, e.g., issues related to the determination of the 99th percentiles, the selection bias, and the lack of prospective and sufficiently powered analyses. CONCLUSIONS Available studies do not show a consistent clinical superiority of sex-specific hs-cTn 99th percentiles. This may reflect methodological aspects. However, from a pathobiological perspective, the use of sex-specific hs-cTn 99th percentiles makes sense for the ruling in of myocardial infarction. We propose a new approach to hs-cTn 99th cutoffs taking into account the analytical properties of the used assays.

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How Safe Is the Outpatient Management of Patients with Acute Chest Pain and Mildly Increased Cardiac Troponin Concentrations?

Clinical Chemistry ◽

10.1373/clinchem.2011.178053 ◽

2012 ◽

Vol 58 (5) ◽

pp. 916-924 ◽

Cited By ~ 16

Author(s):

Christophe Meune ◽

Tobias Reichlin ◽

Affan Irfan ◽

Nora Schaub ◽

Raphael Twerenbold ◽

...

Keyword(s):

Chest Pain ◽

Cardiac Troponin ◽

Troponin T ◽

Acute Chest Pain ◽

High Sensitivity ◽

Outpatient Management ◽

Coronary Syndrome ◽

Risk Patients ◽

Serial Measurements

Abstract BACKGROUND The appropriate management of patients discharged from the emergency department (ED) with increased high-sensitivity cardiac troponin T (hs-cTnT) but normal or borderline-high conventional cardiac troponin concentrations is unknown. METHODS We investigated 643 consecutive ED patients with acute chest pain who had been discharged for outpatient management after acute myocardial infarction (AMI) had been ruled out by serial measurements of conventional cardiac troponin. hs-cTnT was measured blindly, and we calculated the rates of all-cause mortality (primary endpoint) and subsequent AMI (secondary endpoint) at 30, 90, and 360 days. RESULTS hs-cTnT concentrations were increased (>14 ng/L) in 114 patients (18%) but <30 ng/L in 95% of these patients. Of those 114 patients, 96 (84%) had an adjudicated noncoronary cause of chest pain. Thirty-day mortality (95% CI) was 0.9% (0.1%–6.1%), 90-day mortality was 2.7% (0.9%–8.1%), and 360-day mortality was 5.2% (2.2%–11.9%) in patients with increased hs-cTnT; respective rates (95% CI) of AMI were 0.0%, 1.9% (0.5%–7.2%), and 7.6% (3.7%–15.3%). Increased hs-cTnT was associated with increased mortality and AMI at 90 days (P = 0.006 and P = 0.081, respectively) and 360 days (P = 0.001 for both). CONCLUSIONS hs-cTnT is a strong prognosticator of intermediate and long-term mortality and AMI in low-risk patients discharged from the ED after AMI has been ruled out. The relatively low rate of 30-day events may suggest that patients without acute coronary syndrome and small increases in cardiac troponin are in need of further investigations and treatments, but not necessarily immediate hospitalization.

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