Performance of high-sensitivity cardiac troponin in the emergency department for myocardial infarction and a composite cardiac outcome across different estimated glomerular filtration rates

Peter A Kavsak; Andrew Worster; Colleen Shortt; Jinhui Ma; Natasha Clayton; Jonathan Sherbino; Stephen A Hill; Matthew McQueen; Lauren E Griffith; Shamir R Mehta; Andrew D McRae; P J Devereaux

doi:10.1016/j.cca.2018.01.034

Performance of high-sensitivity cardiac troponin in the emergency department for myocardial infarction and a composite cardiac outcome across different estimated glomerular filtration rates

Clin Chim Acta. 2018 Apr:479:166-170. doi: 10.1016/j.cca.2018.01.034. Epub 2018 Feb 3.

Authors

Affiliations

¹ Department of Pathology and Molecular Medicine, McMaster University, Hamilton, ON, Canada. Electronic address: kavsakp@mcmaster.ca.
² Division of Emergency Medicine, McMaster University, Hamilton, ON, Canada.
³ Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada.
⁴ Department of Medicine, McMaster University, Hamilton, ON, Canada.
⁵ Department of Pathology and Molecular Medicine, McMaster University, Hamilton, ON, Canada.
⁶ Division of Cardiology, and Population Health Research Institute, McMaster University, Hamilton, ON, Canada.
⁷ Department of Emergency Medicine, University of Calgary, Calgary, Alberta, Canada.

PMID: 29366835
DOI: 10.1016/j.cca.2018.01.034

Abstract

Background: Clinicians regularly observe increased high-sensitivity cardiac troponin (hs-cTn) concentrations in patients with low estimated glomerular filtration rate (eGFR). The challenge is to differentiate acute coronary syndrome (ACS) from increased hs-cTn results across a range of eGFR. The objective of this study was to determined the optimal hs-cTn concentrations for acute myocardial infarction (MI) and a composite cardiovascular outcome across different eGFR ranges and to assess the utility of a low hs-cTn cutoff to rule-out events.

Methods: We undertook an observational study in the emergency department of patients (n = 1212) with symptoms suggestive of ACS who had an eGFR and at least one Roche hs-cTnT and one Abbott hs-cTnI result. The 7-day outcomes were MI or a composite of MI, unstable angina, congestive heart failure, serious ventricular cardiac arrhythmia, or death. The maximum hs-cTn concentration was assessed across different eGFR ranges (<30,30-59,60-89,≥90 ml/min/1.73m²) by spearman correlation, ROC-curve analyses, and sensitivity and negative predictive value (NPV) for the proposed rule-out hs-cTn cutoffs (hs-cTnI<5 ng/l and hs-cTnT<6 ng/l) for the outcomes.

Results: Both hs-cTnI and hs-cTnT concentrations were negatively correlated with eGFR. The lower the eGFR, the lower the AUC and the higher the optimal hs-cTn cutoffs for both MI and the composite outcome. The highest combined sensitivity (100%), NPV (100%) and proportion of low-risk for MI (45% of group) was observed for patients with hs-cTnT<6 ng/l with an eGFR≥90.

Conclusion: The test performance for hs-cTn for diagnosing or ruling-out an acute cardiac event varies per the eGFR. Accurate risk stratification requires knowledge of the eGFR.

Keywords: Acute coronary syndrome; Death; Emergency department; Heart failure; High-sensitivity cardiac troponin; Myocardial infarction; Rule-out.

Publication types

Clinical Trial
Multicenter Study
Observational Study

MeSH terms

Cardiac Surgical Procedures*
Cohort Studies
Emergency Service, Hospital*
Glomerular Filtration Rate*
Humans
Myocardial Infarction / blood*
Myocardial Infarction / diagnosis
Myocardial Infarction / surgery
Troponin I / blood*
Troponin T / blood*

Substances

Troponin I
Troponin T