Article Impact Level: HIGH Data Quality: STRONG Summary of European Heart Journal, ehad376. https://doi.org/10.1093/eurheartj/ehad376 Dr. Matthew T. H. Lowry et al.
Points
- This research aimed to evaluate the effectiveness of a single measurement of high-sensitivity cardiac troponin in ruling out myocardial infarction in early presenters.
- The study analyzed data from over 41,000 patients, with 31% presenting within 3 hours and 9% diagnosed with myocardial infarction.
- For patients presenting within 3 hours, a troponin threshold of 2 ng/L demonstrated higher sensitivity and negative predictive value than the 5 ng/L threshold.
- The 99th centile threshold showed low sensitivity in both early and late presenters.
- The findings suggest that a troponin measurement below the detection limit (2 ng/L) can safely rule out myocardial infarction in early presenters. At the same time, the 99th centile threshold should not be used for ruling out myocardial infarction at presentation.
Summary
This research paper aimed to determine whether a single measurement of cardiac troponin could effectively rule out myocardial infarction in patients presenting within a few hours of symptom onset. The study evaluated the diagnostic performance of high-sensitivity cardiac troponin I in patients with possible myocardial infarction, testing troponin levels at different time intervals from symptom onset: ≤3 hours, 4-12 hours, and >12 hours. The study compared the limit-of-detection (2 ng/L), rule-out (5 ng/L), and sex-specific 99th centile (16 ng/L in women; 34 ng/L in men) thresholds.
The study analyzed data from 41,103 consecutive patients, with 31% presenting within 3 hours and 9% diagnosed with myocardial infarction. For patients presenting within 3 hours, a threshold of 2 ng/L exhibited higher sensitivity and negative predictive value (99.4% and 99.7%, respectively) compared to the 5 ng/L threshold (96.5% and 99.3%, respectively). However, in patients presenting ≥3 hours, both thresholds demonstrated similar sensitivity and negative predictive value. The 99th centile threshold showed low sensitivity in both early and late presenters (71.4% and 92.5%, respectively). The findings were externally validated in a cohort of 7,088 patients, yielding consistent results.
In conclusion, for early presenters, a single measurement of high-sensitivity cardiac troponin I below the detection limit (2 ng/L) may be utilized to rule out myocardial infarction safely. However, the 99th centile threshold should not be employed to rule out myocardial infarction at presentation, even in patients presenting later following symptom onset. These findings provide valuable insights into the diagnostic performance of troponin measurements and can improve clinical decision-making in patients with possible myocardial infarction.
Link to the article: https://academic.oup.com/eurheartj/advance-article/doi/10.1093/eurheartj/ehad376/7205643
References Lowry, M. T. H., Doudesis, D., Boeddinghaus, J., Kimenai, D. M., Bularga, A., Taggart, C., Wereski, R., Ferry, A. V., Stewart, S. D., Tuck, C., Koechlin, L., Nestelberger, T., Lopez-Ayala, P., Huré, G., Lee, K. K., Chapman, A. R., Newby, D. E., Anand, A., Collinson, P. O., … Lavenberg, S. (2023). Troponin in early presenters to rule out myocardial infarction. European Heart Journal, ehad376. https://doi.org/10.1093/eurheartj/ehad376
