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Millard MJ, Ashburn NP, Snavely AC, Hashemian T, Supples M, Allen B, Christenson R, Madsen T, McCord J, Mumma B, Stopyra J, Wilkerson RG, Mahler SA. European Society of Cardiology 0/1-hour algorithm (high-sensitivity cardiac troponin T) performance across distinct age groups. Heart 2024; 110:838-845. [PMID: 38471727 DOI: 10.1136/heartjnl-2023-323621] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2023] [Accepted: 02/06/2024] [Indexed: 03/14/2024] Open
Abstract
BACKGROUND To determine if the European Society of Cardiology 0/1-hour (ESC 0/1-h) algorithm with high-sensitivity cardiac troponin T (hs-cTnT) meets the ≥99% negative predictive value (NPV) safety threshold for 30-day cardiac death or myocardial infarction (MI) in older, middle-aged and young subgroups. METHODS We conducted a subgroup analysis of adult emergency department patients with chest pain prospectively enrolled from eight US sites (January 2017 to September 2018). Patients were stratified into rule-out, observation and rule-in zones using the hs-cTnT ESC 0/1-h algorithm and classified as older (≥65 years), middle aged (46-64 years) or young (21-45 years). Patients had 0-hour and 1-hour hs-cTnT measures (Roche Diagnostics) and a History, ECG, Age, Risk factor and Troponin (HEART) score. Fisher's exact tests compared rule-out and 30-day cardiac death or MI rates between ages. NPVs with 95% CIs were calculated for the ESC 0/1-h algorithm with and without the HEART score. RESULTS Of 1430 participants, 26.9% (385/1430) were older, 57.4% (821/1430) middle aged and 15.7% (224/1430) young. Cardiac death or MI at 30 days occurred in 12.8% (183/1430). ESC 0/1-h algorithm ruled out 35.6% (137/385) of older, 62.1% (510/821) of middle-aged and 79.9% of (179/224) young patients (p<0.001). NPV for 30-day cardiac death or MI was 97.1% (95% CI 92.7% to 99.2%) among older patients, 98.4% (95% CI 96.9% to 99.3%) in middle-aged patients and 99.4% (95% CI 96.9% to 100%) among young patients. Adding a HEART score increased NPV to 100% (95% CI 87.7% to 100%) for older, 99.2% (95% CI 97.2% to 99.9%) for middle-aged and 99.4% (95% CI 96.6% to 100%) for young patients. CONCLUSIONS In older and middle-aged adults, the hs-cTnT ESC 0/1-h algorithm was unable to reach a 99% NPV for 30-day cardiac death or MI unless combined with a HEART score. TRIAL REGISTRATION NUMBER NCT02984436.
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Affiliation(s)
- Marissa J Millard
- Department of Emergency Medicine, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| | - Nicklaus P Ashburn
- Department of Emergency Medicine, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| | - Anna C Snavely
- Department of Emergency Medicine, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
- Department of Biostatistics and Data Science, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| | - Tara Hashemian
- Department of Emergency Medicine, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| | - Michael Supples
- Department of Emergency Medicine, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| | - Brandon Allen
- Department of Emergency Medicine, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Robert Christenson
- Department of Pathology, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Troy Madsen
- Department of Emergency Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - James McCord
- Department of Cardiology, Henry Ford Hospital, Detroit, Michigan, USA
| | - Bryn Mumma
- Department of Emergency Medicine, University of California Davis School of Medicine, Sacramento, California, USA
| | - Jason Stopyra
- Department of Emergency Medicine, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| | - Richard Gentry Wilkerson
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Simon A Mahler
- Department of Emergency Medicine, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
- Department of Epidemiology and Prevention, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
- Department of Implementation Science, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
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Ashburn NP, Snavely AC, Allen BR, Christenson RH, Madsen T, McCord JK, Mumma BE, Hashemian T, Stopyra JP, Wilkerson RG, Mahler SA. Performance of the European Society of Cardiology 0/1-hour algorithm with high-sensitivity cardiac troponin T at 90 days among patients with known coronary artery disease. Am J Emerg Med 2024; 79:111-115. [PMID: 38417221 DOI: 10.1016/j.ajem.2024.02.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Revised: 02/07/2024] [Accepted: 02/19/2024] [Indexed: 03/01/2024] Open
Abstract
BACKGROUND The European Society of Cardiology (ESC) 0/1-h high sensitivity troponin T (hs-cTnT) algorithm does not differentiate risk based on known coronary artery disease (CAD: prior myocardial infarction [MI], coronary revascularization, or ≥ 70% coronary stenosis). We recently evaluated its performance among patients with known CAD at 30-days, but little is known about its longer-term risk prediction. The objective of this study is to determine and compare the performance of the algorithm at 90-days among patients with and without known CAD. METHODS We performed a pre-planned subgroup analysis of the STOP-CP cohort, which prospectively enrolled ED patients ≥21 years old with symptoms suggestive of ACS without ST-elevation on initial ECG across 8 US sites (1/25/2017-9/6/2018). Participants with 0- and 1-h hs-cTnT measures (Roche, Basel, Switzerland) were stratified into rule-out, observe, and rule-in groups using the ESC 0/1-h algorithm. Algorithm performance was tested among patients with or without known CAD, as determined by the treating provider. The primary outcome was cardiac death or MI at 90-days. Fisher's exact tests were used to compare 90-day event and rule-out rates between patients with and without known CAD. Negative predictive values (NPVs) for 90-day cardiac death or MI with exact 95% confidence intervals were calculated and compared using Fisher's exact test. RESULTS The STOP-CP study accrued 1430 patients, of which 31.4% (449/1430) had known CAD. Cardiac death or MI at 90 days was more common in patients with known CAD than in those without [21.2% (95/449) vs. 10.0% (98/981); p < 0.001]. Using the ESC 0/1-h algorithm, 39.6% (178/449) of patients with known CAD and 66.1% (648/981) of patients without known CAD were ruled-out (p < 0.001). Among rule-out patients, 90-day cardiac death or MI occurred in 3.4% (6/178) of patients with known CAD and 1.2% (8/648) without known CAD (p = 0.09). NPV for 90-day cardiac death or MI was 96.6% (95%CI 92.8-98.8) among patients with known CAD and 98.8% (95%CI 97.6-99.5) in patients without known CAD (p = 0.09). CONCLUSION Patients with known CAD who were ruled-out using the ESC 0/1-h hs-cTnT algorithm had a high rate of missed 90-day cardiac events, suggesting that the ESC 0/1-h hs-cTnT algorithm may not be safe for use among patients with known CAD. TRIAL REGISTRATION High-Sensitivity Cardiac Troponin T to Optimize Chest Pain Risk Stratification (STOP-CP; ClinicalTrials.gov: NCT02984436; https://clinicaltrials.gov/ct2/show/NCT02984436).
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Affiliation(s)
- Nicklaus P Ashburn
- Department of Emergency Medicine, Wake Forest University School of Medicine, Winston-Salem, NC, USA.
| | - Anna C Snavely
- Department of Emergency Medicine, Wake Forest University School of Medicine, Winston-Salem, NC, USA; Department of Biostatistics and Data Science, Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - Brandon R Allen
- Department of Emergency Medicine, University of Florida College of Medicine, Gainesville, FL, USA
| | - Robert H Christenson
- Department of Pathology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Troy Madsen
- Department of Emergency Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - James K McCord
- Department of Cardiology, Henry Ford Health System, Detroit, MI, USA
| | - Bryn E Mumma
- Department of Emergency Medicine, University of California Davis School of Medicine, Sacramento, CA, USA
| | - Tara Hashemian
- Department of Emergency Medicine, Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - Jason P Stopyra
- Department of Emergency Medicine, Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - R Gentry Wilkerson
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Simon A Mahler
- Department of Emergency Medicine, Wake Forest University School of Medicine, Winston-Salem, NC, USA; Department of Epidemiology and Prevention, Wake Forest University School of Medicine, Winston-Salem, NC, USA; Department of Implementation Science, Wake Forest University School of Medicine, Winston-Salem, NC, USA
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Supples MW, Snavely AC, Ashburn NP, Allen BR, Christenson RH, Nowak R, Wilkerson RG, Mumma BE, Madsen T, Stopyra JP, Mahler SA. Performance of the 0/2-hour high-sensitivity cardiac troponin T diagnostic protocol in a multisite United States cohort. Acad Emerg Med 2024; 31:239-248. [PMID: 37925594 DOI: 10.1111/acem.14827] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Revised: 10/04/2023] [Accepted: 10/13/2023] [Indexed: 11/06/2023]
Abstract
BACKGROUND The diagnostic performance of the high-sensitivity troponin T (hs-cTnT) 0/2-h algorithm is unclear among U.S. emergency department (ED) patients with acute chest pain. METHODS A preplanned subgroup analysis of the STOP-CP cohort study was conducted. Participants with 0- and 2-h hs-cTnT measures prospectively enrolled at eight U.S. EDs from January 2017 to September 2018 were stratified into rule-out, observation, and rule-in zones using the hs-cTnT 0/2-h algorithm alone and combined with the history, electrocardiogram, age, and risk factor (HEAR) score. The primary outcome was adjudicated 30-day cardiac death or myocardial infarction (CDMI). The sensitivity and negative predictive value (NPV) of the 0/2-h rule-out zone and specificity and positive predictive value (PPV) of the rule-in zone for 30-day CDMI were calculated. RESULTS Of the 1307 patients accrued, 53.6% (700/1307) were male and 58.6% (762/1307) were White, with a mean ± SD age of 57.5 ± 12.7 years. At 30 days, CDMI occurred in 12.9% (168/1307) of participants. The 0/2-h algorithm ruled out 61.4% (802/1307) of patients. Among rule-out patients, 1.9% (15/802) experienced 30-day CDMI, resulting in a sensitivity of 91.1% (95% confidence interval [CI] 85.7%-94.9%) and NPV of 98.1% (95% CI 96.9%-98.9%). The 0/2-h algorithm ruled in 12.4% (162/1307) patients of whom 61.7% (100/162) experienced 30-day CDMI. The rule-in zone specificity was 94.6% (95% CI 93.1%-95.8%) and PPV was 61.7% (95% CI 53.8%-69.2%) for 30-day CDMI. The 0/2-h algorithm combined with HEAR score ruled out 30.7% (401/1307) of patients with a sensitivity and NPV for 30-day CDMI of 98.2% (95% CI 94.9%-99.6%) and 99.3% (95% CI 97.8%-99.8%), respectively. CONCLUSIONS The hs-cTnT 0/2-h algorithm ruled out most patients. With NPV of <99% for 30-day CDMI, the hs-cTnT 0/2-h algorithm, many emergency physicians may not consider it safe to use for U.S. ED patients. When combined with a low-risk HEAR score, NPV was >99% for 30-day CDMI at the cost of reduced efficacy.
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Affiliation(s)
- Michael W Supples
- Department of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Anna C Snavely
- Department of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
- Department of Biostatistics and Data Science, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Nicklaus P Ashburn
- Department of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
- Section on Cardiovascular Medicine, Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Brandon R Allen
- Department of Emergency Medicine, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Robert H Christenson
- Department of Pathology, University of Maryland School of Medicine, Baltimore, Massachusetts, USA
| | - Richard Nowak
- Department of Emergency Medicine, Henry Ford Health System, Detroit, Michigan, USA
| | - R Gentry Wilkerson
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, Massachusetts, USA
| | - Bryn E Mumma
- Department of Emergency Medicine, University of California Davis School of Medicine, Sacramento, California, USA
| | - Troy Madsen
- Department of Emergency Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Jason P Stopyra
- Department of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Simon A Mahler
- Department of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
- Department of Epidemiology and Prevention, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
- Department of Implementation Science, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
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Supples MW, Snavely AC, O'Neill JC, Ashburn NP, Allen BR, Christenson RH, Nowak R, Wilkerson RG, Mumma BE, Madsen T, Stopyra JP, Mahler SA. Sex and race differences in the performance of the European Society of Cardiology 0/1-h algorithm with high-sensitivity troponin T. Clin Cardiol 2024; 47:e24199. [PMID: 38088463 PMCID: PMC10823440 DOI: 10.1002/clc.24199] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Revised: 11/09/2023] [Accepted: 11/15/2023] [Indexed: 02/01/2024] Open
Abstract
The diagnostic performance of the high-sensitivity troponin T (hs-cTnT) European Society of Cardiology (ESC) 0/1-h algorithm in sex and race subgroups of US Emergency Department (ED) patients is unclear. A pre-planned subgroup analysis of the STOP-CP cohort study was conducted. Participants with 0- and 1-h hs-cTnT measures from eight US EDs (1/2017 to 9/2018) were stratified into rule-out, observation, and rule-in zones using the hs-cTnT ESC 0/1 algorithm. The primary outcome was adjudicated 30-day cardiac death or MI. The proportion with the primary outcome in each zone was compared between subgroups with Fisher's exact tests. The negative predictive value (NPV) of the ESC 0/1 rule-out zone for 30-day CDMI was calculated and compared between subgroups using Fisher's exact tests. Of the 1422 patients enrolled, 54.2% (770/1422) were male and 58.1% (826/1422) white with a mean age of 57.6 ± 12.8 years. At 30 days, cardiac death or myocardial infarction (MI) occurred in 12.9% (183/1422) of participants. Among patients stratified to the rule-out zone, 30-day cardiac death or MI occurred in 1.1% (5/436) of women versus 2.1% (8/436) of men (p = .40) and 1.2% (4/331) of non-white patients versus 1.8% (9/490) of white patients (p = .58). The NPV for 30-day cardiac death or MI was similar among women versus men (98.9% [95% confidence interval, CI: 97.3-99.6] vs. 97.9% [95% CI: 95.9-99.1]; p = .40) and among white versus non-white patients (98.8% [95% CI: 96.9-99.7] vs. 98.2% [95% CI: 96.5-99.2]; p = .39). NPVs <99% in each subgroup suggest the hs-cTnT ESC 0/1-h algorithm may not be safe for use in US EDs. Trial Registration: High-Sensitivity Cardiac Troponin T to Optimize Chest Pain Risk Stratification (STOP-CP; ClinicalTrials.gov: NCT02984436; https://clinicaltrials.gov/ct2/show/NCT02984436).
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Affiliation(s)
- Michael W. Supples
- Department of Emergency MedicineWake Forest School of MedicineWinston‐SalemNorth CarolinaUSA
| | - Anna C. Snavely
- Department of Emergency MedicineWake Forest School of MedicineWinston‐SalemNorth CarolinaUSA
- Department of Biostatistics and Data ScienceWake Forest School of MedicineWinston‐SalemNorth CarolinaUSA
| | - James C. O'Neill
- Department of Emergency MedicineWake Forest School of MedicineWinston‐SalemNorth CarolinaUSA
| | - Nicklaus P. Ashburn
- Department of Emergency MedicineWake Forest School of MedicineWinston‐SalemNorth CarolinaUSA
- Section on Cardiovascular Medicine, Department of Internal MedicineWake Forest School of MedicineWinston‐SalemNorth CarolinaUSA
| | - Brandon R. Allen
- Department of Emergency MedicineUniversity of Florida College of MedicineGainesvilleFloridaUSA
| | - Robert H. Christenson
- Department of PathologyUniversity of Maryland School of MedicineBaltimoreMarylandUSA
| | - Richard Nowak
- Department of Emergency MedicineHenry Ford Health SystemDetroitMichiganUSA
| | - R. Gentry Wilkerson
- Department of Emergency MedicineUniversity of Maryland School of MedicineBaltimoreMarylandUSA
| | - Bryn E. Mumma
- Department of Emergency MedicineUniversity of California Davis School of MedicineSacramentoCaliforniaUSA
| | - Troy Madsen
- Division of Emergency MedicineUniversity of Utah School of MedicineSalt Lake CityUtahUSA
| | - Jason P. Stopyra
- Department of Emergency MedicineWake Forest School of MedicineWinston‐SalemNorth CarolinaUSA
| | - Simon A. Mahler
- Department of Emergency MedicineWake Forest School of MedicineWinston‐SalemNorth CarolinaUSA
- Department of Epidemiology and PreventionWake Forest School of MedicineWinston‐SalemNorth CarolinaUSA
- Department of Implementation ScienceWake Forest School of MedicineWinston‐SalemNorth CarolinaUSA
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Rocheleau S, Eng-Frost J, Lambrakis K, Khan E, Chiang B, Wattchow N, Steele S, Lorensini S, Lehman SJ, Papendick C, Chew DP. Twelve-Month Outcomes of Patients With Myocardial Injury not Due to Type-1 Myocardial Infarction. Heart Lung Circ 2023; 32:978-985. [PMID: 37225600 DOI: 10.1016/j.hlc.2023.04.299] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2022] [Revised: 03/14/2023] [Accepted: 04/20/2023] [Indexed: 05/26/2023]
Abstract
BACKGROUND Diagnosis of acute myocardial infarction (AMI) requires a combination of elevated cardiac troponins, and clinical or echocardiographic evidence of coronary ischaemia. Identification of patients with a high likelihood of coronary plaque rupture (Type 1 myocardial infarction [MI]) is crucial as it is these patients for whom coronary intervention has been well-established to provide benefit and reduce subsequent coronary ischemic events. However, high-sensitivity cardiac troponin (hs-cTn) assays have increasingly identified patients with hs-cTn elevations not due to Type 1 MI where recommendations for ongoing care are currently limited. Understanding the profile and clinical outcomes for these patients may inform the development of an emerging evidence-base. METHODS Using two previously published studies (hs-cTnT study n=1,937, RAPID-TnT study n=3,270) and the Fourth Universal Definition of MI, index presentations of patients to South Australian emergency departments with suspected AMI, defined by high sensitivity cardiac troponin T (hs-cTnT) greater than the upper reference limit (14 ng/L) and without obvious corresponding ischaemia on electrocardiogram (ECG), were classified as either Type 1 MI (T1MI), Type 2 MI (T2MI), acute myocardial injury (AI), or chronic myocardial injury (CI). Patients with non-elevated hs-cTnT (defined as <14 ng/L) were excluded. Outcomes assessed included death, MI, unstable angina, and non-coronary cardiovascular events within 12 months. RESULTS In total, 1,192 patients comprising 164 (13.8%) T1MI, 173 (14.5%) T2MI/AI, and 855 (71.7%) CI were included. The rate of death or recurrent acute coronary syndrome was greatest in patients with T1MI, but also occurred with moderate frequency in Type 2 MI/AI and CI (T1MI: 32/164 [19.5%]; T2MI/AI: 24/173 [13.1%]; CI:116/885 [13.6%]; p=0.008). Of all the deaths observed, 74% occurred among those with an initial index diagnostic classification of CI. After adjusting for age, gender and baseline comorbidities, the relative hazard ratios for non-coronary cardiovascular readmissions were similar across all groups: Type 2 MI/AI: 1.30 (95% confidence interval 0.99-1.72, p=0.062); CI: 1.10 (95% confidence interval 0.61-2.00, p=0.75). CONCLUSIONS Non-T1MI accounted for the majority of patients presenting with elevated hs-cTnT without ischaemia on ECG. Patients with T1MI had the highest rates of death or recurrent AMI; however patients with T2MI/AI and CI experienced a substantial rate of non-coronary cardiovascular re-hospitalisations.
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Affiliation(s)
- Simon Rocheleau
- College of Medicine & Public Health, Flinders University of South Australia, Adelaide, SA, Australia
| | - Joanne Eng-Frost
- College of Medicine & Public Health, Flinders University of South Australia, Adelaide, SA, Australia
| | - Kristina Lambrakis
- College of Medicine & Public Health, Flinders University of South Australia, Adelaide, SA, Australia; South Australian Department of Health, Adelaide, SA, Australia
| | - Ehsan Khan
- College of Medicine & Public Health, Flinders University of South Australia, Adelaide, SA, Australia
| | - Brian Chiang
- College of Medicine & Public Health, Flinders University of South Australia, Adelaide, SA, Australia
| | - Naomi Wattchow
- College of Medicine & Public Health, Flinders University of South Australia, Adelaide, SA, Australia
| | - Simon Steele
- College of Medicine & Public Health, Flinders University of South Australia, Adelaide, SA, Australia
| | - Scott Lorensini
- College of Medicine & Public Health, Flinders University of South Australia, Adelaide, SA, Australia
| | - Sam J Lehman
- College of Medicine & Public Health, Flinders University of South Australia, Adelaide, SA, Australia; South Australian Health and Medical Research Institute, Adelaide, SA, Australia
| | | | - Derek P Chew
- College of Medicine & Public Health, Flinders University of South Australia, Adelaide, SA, Australia; South Australian Health and Medical Research Institute, Adelaide, SA, Australia; South Australian Department of Health, Adelaide, SA, Australia.
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Ashburn NP, Snavely AC, O’Neill JC, Allen BR, Christenson RH, Madsen T, Massoomi MR, McCord JK, Mumma BE, Nowak R, Stopyra JP, in’t Veld MH, Wilkerson RG, Mahler SA. Performance of the European Society of Cardiology 0/1-Hour Algorithm With High-Sensitivity Cardiac Troponin T Among Patients With Known Coronary Artery Disease. JAMA Cardiol 2023; 8:347-356. [PMID: 36857071 PMCID: PMC9979014 DOI: 10.1001/jamacardio.2023.0031] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Accepted: 12/29/2022] [Indexed: 03/02/2023]
Abstract
Importance The European Society of Cardiology (ESC) 0/1-hour algorithm is a validated high-sensitivity cardiac troponin (hs-cTn) protocol for emergency department patients with possible acute coronary syndrome. However, limited data exist regarding its performance in patients with known coronary artery disease (CAD; prior myocardial infarction [MI], coronary revascularization, or ≥70% coronary stenosis). Objective To evaluate and compare the diagnostic performance of the ESC 0/1-hour algorithm for 30-day cardiac death or MI among patients with and without known CAD and determine if the algorithm could achieve the negative predictive value rule-out threshold of 99% or higher. Design, Setting, and Participants This was a preplanned subgroup analysis of the STOP-CP prospective multisite cohort study, which was conducted from January 25, 2017, through September 6, 2018, at 8 emergency departments in the US. Patients 21 years or older with symptoms suggestive of acute coronary syndrome without ST-segment elevation on initial electrocardiogram were included. Analysis took place between February and December 2022. Interventions/Exposures Participants with 0- and 1-hour high-sensitivity cardiac troponin T (hs-cTnT) measures were stratified into rule-out, observation, and rule-in zones using the ESC 0/1-hour hs-cTnT algorithm. Main Outcomes and Measures Cardiac death or MI at 30 days determined by expert adjudicators. Results During the study period, 1430 patients were accrued. In the cohort, 775 individuals (54.2%) were male, 826 (57.8%) were White, and the mean (SD) age was 57.6 (12.8) years. At 30 days, cardiac death or MI occurred in 183 participants (12.8%). Known CAD was present in 449 (31.4%). Among patients with known CAD, the ESC 0/1-hour algorithm classified 178 of 449 (39.6%) into the rule-out zone compared with 648 of 981 (66.1%) without CAD (P < .001). Among rule-out zone patients, 30-day cardiac death or MI occurred in 6 of 178 patients (3.4%) with known CAD and 7 of 648 (1.1%) without CAD (P < .001). The negative predictive value for 30-day cardiac death or MI was 96.6% (95% CI, 92.8-98.8) among patients with known CAD and 98.9% (95% CI, 97.8-99.6) in patients without known CAD (P = .04). Conclusions and Relevance Among patients with known CAD, the ESC 0/1-hour hs-cTnT algorithm was unable to safely exclude 30-day cardiac death or MI. This suggests that clinicians should be cautious if using the algorithm in patients with known CAD. The negative predictive value was significantly higher in patients without a history of CAD but remained less than 99%.
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Affiliation(s)
- Nicklaus P. Ashburn
- Department of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina
- Section on Cardiovascular Medicine, Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Anna C. Snavely
- Department of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina
- Department of Biostatistics and Data Science, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - James C. O’Neill
- Department of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Brandon R. Allen
- Department of Emergency Medicine, University of Florida College of Medicine, Gainesville
| | | | - Troy Madsen
- Department of Emergency Medicine, University of Utah School of Medicine, Salt Lake City
| | - Michael R. Massoomi
- Department of Cardiology, University of Florida College of Medicine, Gainesville
| | - James K. McCord
- Department of Cardiology, Henry Ford Health System, Detroit, Michigan
| | - Bryn E. Mumma
- Department of Emergency Medicine, University of California, Davis School of Medicine, Sacramento
| | - Richard Nowak
- Department of Emergency Medicine, Henry Ford Health System, Detroit, Michigan
| | - Jason P. Stopyra
- Department of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Maite Huis in’t Veld
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore
| | - R. Gentry Wilkerson
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore
| | - Simon A. Mahler
- Department of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina
- Department of Epidemiology and Prevention, Wake Forest School of Medicine, Winston-Salem, North Carolina
- Department of Implementation Science, Wake Forest School of Medicine, Winston-Salem, North Carolina
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7
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Snavely AC, Paradee BE, Ashburn NP, Allen BR, Christenson R, O'Neill JC, Nowak R, Wilkerson RG, Mumma BE, Madsen T, Stopyra JP, Mahler SA. Derivation and validation of a high sensitivity troponin-T HEART pathway. Am Heart J 2023; 256:148-157. [PMID: 36400184 DOI: 10.1016/j.ahj.2022.11.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2022] [Revised: 11/07/2022] [Accepted: 11/08/2022] [Indexed: 06/16/2023]
Abstract
BACKGROUND The HEART Pathway is widely used for chest pain risk stratification but has yet to be optimized for high sensitivity troponin T (hs-cTnT) assays. METHODS We conducted a secondary analysis of STOP-CP, a prospective cohort study enrolling adult ED patients with symptoms suggestive of acute coronary syndrome at 8 sites in the United States (US). Patients had a 0- and 1-hour hs-cTnT measured and a HEAR score completed. A derivation set consisting of 729 randomly selected participants was used to derive a hs-cTnT HEART Pathway with rule-out, observation, and rule-in groups for 30-day cardiac death or myocardial infarction (MI). Optimal baseline and 1-hour troponin cutoffs were selected using generalized cross validation to achieve a negative predictive value (NPV) >99% for rule out and positive predictive value (PPV) >60% or maximum Youden index for rule-in. Optimal 0-1-hour delta values were derived using generalized cross validation to maximize the NPV for the rule-out group and PPV for the rule-in group. The hs-cTnT HEART Pathway performance was validated in the remaining cohort (n = 723). RESULTS Among the 1452 patients, 30-day cardiac death or MI occurred in 12.7% (184/1452). Within the derivation cohort the optimal hs-cTnT HEART Pathway classified 36.5% (266/729) into the rule-out group, yielding a NPV of 99.2% (95% CI: 98.2-100) for 30-day cardiac death or MI. The rule-in group included 15.4% (112/729) with a PPV of 55.4% (95% CI: 46.2-64.6). In the validation cohort, the hs-cTnT HEART Pathway ruled-out 37.6% (272/723), of which 2 had 30-day cardiac death or MI, yielding a NPV of 99.3% (95% CI: 98.3-100). The rule-in group included 14.5% (105/723), yielding a PPV of 57.1% (95% CI: 47.7-66.6). CONCLUSIONS A novel hs-cTnT HEART Pathway with serial 0- and 1-hour hs-cTnT measures has high NPV and moderate PPV for 30-day cardiac death or MI.
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Affiliation(s)
- Anna C Snavely
- Department of Biostatistics and Data Science, Wake Forest School of Medicine (WFSOM), Winston-Salem, NC; Department of Emergency Medicine, WFSOM, Winston Salem, NC.
| | | | | | - Brandon R Allen
- Department of Emergency Medicine, College of Medicine, University of Florida, Gainesville, FL
| | - Robert Christenson
- Department of Pathology, University of Maryland School of Medicine, Baltimore, MD
| | | | - Richard Nowak
- Department of Emergency Medicine, Henry Ford Health, Detroit, MI
| | - R Gentry Wilkerson
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD
| | - Bryn E Mumma
- Department of Emergency Medicine, School of Medicine, University of California Davis, Sacramento, CA
| | - Troy Madsen
- Department of Emergency Medicine, University of Utah School of Medicine, Salt Lake City, UT
| | | | - Simon A Mahler
- Department of Emergency Medicine, WFSOM, Winston Salem, NC; Department of Implementation Science, WFSOM, Winston-Salem, NC; Department of Epidemiology and Prevention, WFSOM, Winston-Salem, NC
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8
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Concentration of hs-Troponin in small cohort of transgender patients. Clin Chim Acta 2023; 539:66-69. [PMID: 36495928 DOI: 10.1016/j.cca.2022.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Revised: 11/30/2022] [Accepted: 12/02/2022] [Indexed: 12/14/2022]
Abstract
INTRODUCTION Sex-differences in high sensitivity troponin (hs-Tn) concentrations are well established. There is, however, limited data to guide interpretation of hs-Tn in transgender patients, particularly those receiving gender-affirming hormone therapy. Our purpose was to evaluate troponin testing in transgender patients. METHODS Transgender adults attending a routine clinic visit provided demographic data, medical history, and venous blood samples. Patients with congestive heart failure or chronic kidney disease were excluded. hs-Tn was measured using the Architect Stat High Sensitivity Troponin-I (Abbott), Access 2 hsTnI (Beckman Coulter), and Elecsys Troponin T Gen 5 STAT (Roche) assays. hs-Tn below the limit of detection (LOD) is reported as the lower limit of detection (LLOD) RESULTS: Of 63 subjects, 76 % were transgender women. We found no significant difference in median hs-Tn concentrations or proportions of hs-Tn > LOD. CONCLUSION In this cohort of stable transgender patients without CHF or CKD, we did not observe differences in hs-Tn concentrations between transgender women and transgender men. Meaningful conclusions are limited owing to inadequate sample size and population differences. Further research on hs-troponin concentrations in this underrepresented, vulnerable population is needed.
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9
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Defilippi CR, Alemayehu WG, Voors AA, Kaye D, Blaustein RO, Butler J, Ezekowitz JA, Hernandez AF, Lam CSP, Roessig L, Seliger S, Shah P, Westerhout CM, Armstrong PW, O'Connor CM. Assessment of Biomarkers of Myocardial injury, Inflammation, and Renal Function in Heart Failure With Reduced Ejection Fraction: The VICTORIA Biomarker Substudy. J Card Fail 2023; 29:448-458. [PMID: 36634811 DOI: 10.1016/j.cardfail.2022.12.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Revised: 12/12/2022] [Accepted: 12/12/2022] [Indexed: 01/11/2023]
Abstract
BACKGROUND Circulating biomarkers may be useful in understanding prognosis and treatment efficacy in heart failure with reduced ejection fraction. In the VICTORIA (Vericiguat Global Study in Subjects with Heart Failure with Reduced Ejection Fraction) trial, vericiguat, a soluble guanylate cyclase stimulator, decreased the primary outcome of cardiovascular death or heart failure hospitalization in heart failure with reduced ejection fraction. We evaluated biomarkers of cardiac injury, inflammation, and renal function for associations with outcomes and vericiguat treatment effect. METHODS AND RESULTS High-sensitivity cardiac troponin T (hs-cTnT), growth differentiation factor-15 (GDF-15), interleukin-6 (IL-6), high-sensitivity C-reactive protein (hs-CRP), and cystatin C were measured at baseline and 16 weeks. Associations of biomarkers with the primary outcome and its components were estimated. Interaction with study treatment was tested. Changes in biomarkers over time were examined by study treatment. One or more biomarkers were measured in 4652 (92%) of 5050 participants at baseline and 4063 (81%) at 16 weeks. After adjustment, higher values of hs-cTnT, growth differentiation factor-15, and interleukin-6 were associated with the primary outcome, independent of N-terminal pro-B-type natriuretic peptide. Higher hs-cTnT values were associated with a hazard ratio per log standard deviation of 1.21 (95% confidence interval 1.14-1.27). A treatment interaction with vericiguat was evident with hs-cTnT and cardiovascular death (P = .04), but not HF hospitalization (P = .38). All biomarkers except cystatin C decreased over 16 weeks and no relationship between treatment assignment and changes in biomarker levels was observed. CONCLUSIONS hs-cTnT, growth differentiation factor-15, and interleukin-6 levels were associated with risk of the primary outcome in VICTORIA (Vericiguat Global Study in Subjects with Heart Failure with Reduced Ejection Fraction). Uniquely, lower hs-cTnT was associated with a lower rate of cardiovascular death but not HF hospitalization after treatment with vericiguat.
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Affiliation(s)
| | | | - Adriaan A Voors
- University of Groningen, University Medical Center of Groningen, Groningen, the Netherlands
| | - David Kaye
- Baker Heart & Diabetes Institute, Melbourne, Australia
| | | | - Javed Butler
- Department of Medicine, University of Mississippi Medical Center, Jackson, Mississippi
| | - Justin A Ezekowitz
- Canadian VIGOUR Centre, University of Alberta, Edmonton, Alberta, Canada
| | - Adrian F Hernandez
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Carolyn S P Lam
- National Heart Centre Singapore and Duke-National University of Singapore, Singapore
| | | | - Stephen Seliger
- University of Maryland School of Medicine, Baltimore, Maryland
| | - Palak Shah
- Inova Heart and Vascular Institute, Falls Church, Virginia
| | | | - Paul W Armstrong
- Canadian VIGOUR Centre, University of Alberta, Edmonton, Alberta, Canada
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10
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Ashburn NP, Snavely AC, Allen BR, Christenson RH, Herrington DM, Hiestand BC, Miller CD, Stopyra JP, Mahler SA. Monocyte chemoattractant protein-1 is not predictive of cardiac events in patients with non-low-risk chest pain. Emerg Med J 2022; 39:853-858. [PMID: 34933919 PMCID: PMC9209560 DOI: 10.1136/emermed-2021-211266] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Accepted: 12/10/2021] [Indexed: 11/03/2022]
Abstract
BACKGROUND Prior studies suggest monocyte chemoattractant protein-1 (MCP-1) may be useful for risk stratifying ED patients with chest pain. We hypothesise that MCP-1 will be predictive of 90-day major adverse cardiovascular events (MACEs) in non-low-risk patients. METHODS A case-control study was nested within a prospective multicentre cohort (STOP-CP), which enrolled adult patients being evaluated for acute coronary syndrome at eight US EDs from 25 January 2017 to 06 September 2018. Patients with a History, ECG, Age, and Risk factor score (HEAR score) ≥4 or coronary artery disease (CAD), a non-ischaemic ECG, and non-elevated contemporary troponins at 0 and 3 hours were included. Cases were patients with 90-day MACE (all-cause death, myocardial infarction or revascularisation). Controls were patients without MACE selected with frequency matching using age, sex, race, and HEAR score or the presence of CAD. Serum MCP-1 was measured. Sensitivity and specificity were determined for cut-off points of 194 pg/mL, 200 pg/mL, 238 pg/mL and 281 pg/mL. Logistic regression adjusting for age, sex, race, and HEAR score/presence of CAD was used to determine the association between MCP-1 and 90-day MACE. A separate logistic model also included high-sensitivity troponin (hs-cTnT). RESULTS Among 40 cases and 179 controls, there was no difference in age (p=0.90), sex (p=1.00), race (p=0.85), or HEAR score/presence of CAD (p=0.89). MCP-1 was similar in cases (median 191.9 pg/mL, IQR: 161.8-260.1) and controls (median 196.6 pg/mL, IQR: 163.0-261.1) (p=0.48). At a cut-off point of 194 pg/mL, MCP-1 was 50.0% (95% CI 33.8% to 66.2%) sensitive and 46.9% (95% CI 39.4% to 54.5%) specific for 90-day MACE. After adjusting for covariates, MCP-1 was not associated with 90-day MACE at any cut-off point (at 194 pg/mL, OR 0.88 (95% CI 0.43 to 1.79)). When including hs-cTnT in the model, MCP-1 was not associated with 90-day MACE at any cut-off point (at 194 pg/mL, OR 0.85 (95% CI 0.42 to 1.73)). CONCLUSION MCP-1 is not predictive of 90-day MACE in patients with non-low-risk chest pain.
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Affiliation(s)
- Nicklaus P Ashburn
- Department of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
- Department of Cardiology, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Anna C Snavely
- Department of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
- Department of Biostatistics and Data Science, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Brandon R Allen
- Department of Emergency Medicine, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Robert H Christenson
- Department of Pathology, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - David M Herrington
- Department of Cardiology, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Brian C Hiestand
- Department of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Chadwick D Miller
- Department of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Jason P Stopyra
- Department of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Simon A Mahler
- Department of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
- Departments of Epidemiology and Prevention and Implementation Science, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
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11
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Bevins NJ, Chae H, Hubbard JA, Castillo EM, Tolia VM, Daniels LB, Fitzgerald RL. Emergency Department Management of Chest Pain With a High-Sensitivity Troponin-Enabled 0/1-Hour Rule-Out Algorithm. Am J Clin Pathol 2022; 157:774-780. [PMID: 34893795 DOI: 10.1093/ajcp/aqab192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Accepted: 10/06/2021] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES The analytical sensitivity of high-sensitivity cardiac troponin T (hsTnT) assays has enabled rapid myocardial infarction rule-out algorithms for emergency department (ED) presentations. Few studies have analyzed the real-world impact of hsTnT algorithms on outcomes and operations. METHODS Comparison of ED length of stay (LOS) and 30-day outcomes (return to ED, inpatient admission, and mortality) for patients presenting with chest pain during 2 separate 208-day periods using a 0/1-hour hsTnT-enabled algorithm or fourth-generation TnT. RESULTS Discharge, 30-day readmission, and 30-day mortality rates were not significantly different with fourth-generation TnT vs hsTnT. Thirty-day return rates were significantly decreased with hsTnT (17.4% vs 14.9%; P < .01). For encounters with TnT measured at least twice and resulting in discharge, median ED LOS decreased by 61 minutes with the use of hsTnT (488 vs 427 minutes; P < .0001). Median time between first and second TnT results decreased by 82 minutes with hsTnT (202 vs 120 minutes; P < .0001), suggesting that the 0/1-hour algorithm was incompletely adopted. CONCLUSIONS Implementation of the hsTnT algorithm was associated with decreased 30-day return rates and decreased ED LOS for a subset of patients, despite incomplete adoption of the 0/1-hour algorithm.
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Affiliation(s)
- Nicholas J Bevins
- Department of Pathology, University of California San Diego, San Diego, CA, USA
| | - Hyojin Chae
- Department of Laboratory Medicine, Seoul St Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Jacqueline A Hubbard
- Department of Pathology and Laboratory Medicine, Dartmouth University, Lebanon, NH, USA
| | - Edward M Castillo
- Department of Emergency Medicine, University of California San Diego, San Diego, CA, USA
| | - Vaishal M Tolia
- Department of Emergency Medicine, University of California San Diego, San Diego, CA, USA
| | - Lori B Daniels
- Division of Cardiovascular Medicine, University of California San Diego, San Diego, CA, USA
| | - Robert L Fitzgerald
- Department of Pathology, University of California San Diego, San Diego, CA, USA
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12
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Garg PK, Lima J, deFilippi CR, Daniels LB, Seliger SL, de Lemos JA, Maisel AS, Criqui MH, Bahrami H. Associations of cardiac injury biomarkers with risk of peripheral artery disease: The Multi-Ethnic Study of Atherosclerosis. Int J Cardiol 2021; 344:199-204. [PMID: 34600979 DOI: 10.1016/j.ijcard.2021.09.055] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Revised: 09/15/2021] [Accepted: 09/27/2021] [Indexed: 01/08/2023]
Abstract
INTRODUCTION We investigated the associations of high-sensitivity cardiac Troponin T (hs-cTnT) and N-terminal pro B-type natriuretic peptide (NT-proBNP) levels with risk of developing clinical peripheral artery disease (PAD) or a low ankle-brachial index (ABI). METHODS Hs-cTnT and NT-proBNP were measured in 6692 and 5458 participants respectively without baseline PAD between 2000 and 2002 in the Multi-ethnic Study of Atherosclerosis. A significant number also had repeat biomarker measurement between 2004 and 2005. Incident clinical PAD was ascertained through 2017. Incident low ABI, defined as ABI <0.9 and decline of ≥0.15 from baseline, was assessed among 5920 eligible individuals who had an ABI >0.9 at baseline and at least one follow-up ABI measurement 3-10 years later. Multivariable Cox proportional hazards and logistic regression modeling were used to determine the association of these biomarkers with clinical PAD and low ABI, respectively. RESULTS Overall, 121 clinical PAD and 118 low ABI events occurred. Adjusting for demographic and clinical characteristics, each log unit increment in hs-cTnT and NT-proBNP was associated with a 30% (adjusted hazard ratio (HR) 1.3, 95% confidence interval (CI): 1.1, 1.6) and 50% (HR) 1.5, 95% CI: 1.2, 1.8) higher risk of clinical PAD respectively. No significant associations were observed for incident low ABI. Change in these biomarkers was not associated with either of the PAD outcomes. CONCLUSIONS NT-proBNP and hs-cTnT are independently associated with the development of clinical PAD. Further study should determine whether these biomarkers can help to better identify those at higher risk for PAD.
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Affiliation(s)
- Parveen K Garg
- Division of Cardiology, University of Southern California Keck School of Medicine, Los Angeles, CA, United States of America.
| | - Joao Lima
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States of America
| | | | - Lori B Daniels
- Division of Cardiology, University of California, San Diego School of Medicine, La Jolla, CA, United States of America
| | - Stephen L Seliger
- Division of Nephrology, University of Maryland School of Medicine, Baltimore, MD, United States of America
| | - James A de Lemos
- Division of Cardiology, University of Texas Southwestern Medical Center, Dallas, TX, United States of America
| | - Alan S Maisel
- Division of Cardiology, University of California, San Diego School of Medicine, La Jolla, CA, United States of America
| | - Michael H Criqui
- Division of Preventive Medicine, University of California, San Diego School of Medicine, La Jolla, CA, United States of America
| | - Hossein Bahrami
- Division of Cardiology, University of Southern California Keck School of Medicine, Los Angeles, CA, United States of America
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13
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Does high sensitivity troponin add prognostic value to validated risk scores to predict in-hospital mortality in patients with acute heart failure? Heart Vessels 2021; 36:1679-1687. [PMID: 33885968 DOI: 10.1007/s00380-021-01847-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Accepted: 04/02/2021] [Indexed: 10/21/2022]
Abstract
Troponin elevation correlates with an increased short and long-term mortality in patients with acute decompensated heart failure (AHF). However, it has not been included in the development of multiple validated predictive models of mortality. We aim to determine whether the addition of high-sensitivity troponin T (hs-TnT) to clinical risk scores improves the prediction of in-hospital mortality in patients with AHF. A retrospective analysis of a prospective and consecutive cohort was performed. Adult patients hospitalized between 2015 and 2019 with a primary diagnosis of AHF were included. Hs-TnT was measured on admission. OPTIMIZE-HF, GWTG-HF, and ADHERE risks score were calculated for each patient. The primary endpoint was all-cause in-hospital mortality. Discrimination of isolated hs-TnT and the risk scores with and without the addition of hs-TnT were evaluated using the area under the ROC curve (AUC-ROC). A subanalysis was performed according to left ventricular ejection fraction (LVEF). Of 712 patients, 562 (79%) had hs-TnT measurement upon admission, and was elevated in 91%. In-hospital mortality was 8.7% (n = 49). The AUC-ROC was 0.70 (95% CI 0.63-0.77) for isolated hs-TnT, and 0.80 (0.74-0.87), 0.79 (0.72 -0.86) and 0.79 (0.71-0.86) for the OPTIMIZE-HF, GWTG-HF and ADHERE scores, respectively. The addition of hs-TnT to the models did not increase the AUC: 0.72 (0.66-0.79) for the OPTIMIZE-HF + hs-TnT score (difference between AUC - 0.08 p = 0.04), 0.74 (0.68-0.80) for GWTG-HF (difference between AUC-0.04, p = 0.2) and 0.7 (0.63-0.77) for ADHERE (difference between AUC - 0.085 p = 0.07). The models presented good calibration (p > 0.05). In the sub-analysis, no differences were found between risk scores with the addition of hs-TnT in the population with LVEF < 40% and ≥ 40%. Elevated hs-TnT on admission was frequent and its incorporation into the validated risk scores did not prove an incremental prognostic benefit in patients hospitalized for AHF, regardless of LVEF. Isolated hs-TnT had a modest ability to predict hospital mortality. Additional prospective studies are needed to validate these findings.
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14
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Harley K, Bissonnette S, Inzitari R, Schulz K, Apple FS, Kavsak PA, Gunsolus IL. Independent and combined effects of biotin and hemolysis on high-sensitivity cardiac troponin assays. Clin Chem Lab Med 2021; 59:1431-1443. [PMID: 33761581 DOI: 10.1515/cclm-2021-0124] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Accepted: 03/16/2021] [Indexed: 12/27/2022]
Abstract
OBJECTIVES This study compared the independent and combined effects of hemolysis and biotin on cardiac troponin measurements across nine high-sensitivity cardiac troponin (hs-cTn) assays. METHODS Parallel cTn measurements were made in pooled lithium heparin plasma spiked with hemolysate and/or biotin using nine hs-cTn assays: Abbott Alinity, Abbott ARCHITECT i2000, Beckman Access 2, Ortho VITROS XT 7600, Siemens Atellica, Siemens Centaur, Siemens Dimension EXL cTnI, and two Roche Cobas e 411 Elecsys Troponin T-hs cTnT assays (outside US versions, with and without increased biotin tolerance). Absolute and percent cTn recovery relative to two baseline concentrations were determined in spiked samples and compared to manufacturer's claims. RESULTS All assays except the Ortho VITROS XT 7600 showed hemolysis and biotin interference thresholds equivalent to or greater than manufacturer's claims. While imprecision confounded analysis of Ortho VITROS XT 7600 data, evidence of biotin interference was lacking. Increasing biotin concentration led to decreasing cTn recovery in three assays, specifically both Roche Cobas e 411 Elecsys Troponin T-hs assays and the Siemens Dimension EXL. While one of the Roche assays was the most susceptible to biotin among the nine studied, a new version showed reduced biotin interference by approximately 100-fold compared to its predecessor. Increasing hemolysis also generally led to decreasing cTn recovery for susceptible assays, specifically the Beckman Access 2, Ortho VITROS XT 7600, and both Roche Cobas e 411 Elecsys assays. Equivalent biotin and hemolysis interference thresholds were observed at the two cTn concentrations considered for all but two assays (Beckman Access 2 and Ortho VITROS XT 7600). When biotin and hemolysis were present in combination, biotin interference thresholds decreased with increasing hemolysis for two susceptible assays (Roche Cobas e 411 Elecsys and Siemens Dimension EXL). CONCLUSIONS Both Roche Cobas e 411 Elecsys as well as Ortho VITROS XT assays were susceptible to interference from in vitro hemolysis at levels routinely encountered in clinical laboratory samples (0-3 g/L free hemoglobin), leading to falsely low cTn recovery up to 3 ng/L or 13%. While most assays are not susceptible to biotin at levels expected with over-the-counter supplementation, severely reduced cTn recovery is possible at biotin levels of 10-2000 ng/mL (41-8,180 nmol/L) for some assays. Due to potential additive effects, analytical interferences should not be considered in isolation.
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Affiliation(s)
| | - Sarah Bissonnette
- Department of Pathology, Marshfield Clinic Health System, Marshfield, WI, USA
| | - Rosanna Inzitari
- University College Dublin School of Medicine, Clinical Research Centre, Dublin, Ireland
| | - Karen Schulz
- Hennepin Healthcare Research Institute, Hennepin County Medical Center, Minneapolis, MN, USA
| | - Fred S Apple
- Departments of Laboratory Medicine & Pathology, Hennepin Healthcare/Hennepin County Medical Center, Hennepin Healthcare Research Institute and University of Minnesota, Minneapolis, MN, USA
| | - Peter A Kavsak
- Department of Pathology and Molecular Medicine, McMaster University, Hamilton, ON, Canada
| | - Ian L Gunsolus
- Department of Pathology, Medical College of Wisconsin, 8701 W Watertown Plank Road, Milwaukee, WI, 53226, USA
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António M, Vitorino R, Daniel-da-Silva AL. Gold nanoparticles-based assays for biodetection in urine. Talanta 2021; 230:122345. [PMID: 33934794 DOI: 10.1016/j.talanta.2021.122345] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Revised: 03/16/2021] [Accepted: 03/18/2021] [Indexed: 12/24/2022]
Abstract
Urine is a biofluid easy to collect through a non-invasive technique that allows collecting a large volume of sample. The use of urine for disease diagnosis is not yet well explored. However, it has gained attention over the last three years. It has been applied in the diagnosis of several illnesses such as kidney disease, bladder cancer, prostate cancer and cardiovascular diseases. In the last decade, gold nanoparticles (Au NPs) have attracted attention in biosensors' development for the diagnosis of diseases due to their electrical and optical properties, ability to conjugate with biomolecules, high sensitivity, and selectivity. Therefore, this article aims to present a comprehensive view of state of the art on the advances made in the quantification of analytes in urinary samples using AuNPs based assays, with a focus on protein analysis. The type of diagnosis methods, the Au NPs synthesis approaches and the strategies for surface modification aiming at selectivity towards the different targets are highlighted.
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Affiliation(s)
- Maria António
- CICECO-Aveiro Institute of Materials, Chemistry Department, University of Aveiro, 3810-193, Aveiro, Portugal
| | - Rui Vitorino
- iBiMED-Institute of Biomedicine, Department of Medical Sciences, University of Aveiro, Aveiro, 3810-193, Portugal; Department of Surgery and Physiology, Cardiovascular R&D Center, Faculty of Medicine of the University of Porto, Alameda Professor Hernâni Monteiro, 4200-319, Porto, Portugal; LAQV-REQUIMTE, Chemistry Department, University of Aveiro, Aveiro, Portugal.
| | - Ana L Daniel-da-Silva
- CICECO-Aveiro Institute of Materials, Chemistry Department, University of Aveiro, 3810-193, Aveiro, Portugal.
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16
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Jing W, Wang Y, Chen C, Zhang F, Yang Y, Ma G, Yang EH, Snozek CLN, Tao N, Wang S. Gradient-Based Rapid Digital Immunoassay for High-Sensitivity Cardiac Troponin T (hs-cTnT) Detection in 1 μL Plasma. ACS Sens 2021; 6:399-407. [PMID: 32985183 DOI: 10.1021/acssensors.0c01681] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Rapid and sensitive detection of biomarkers is the key to the diagnosis of acute diseases. One example is the detection of troponin in myocardial infarction. Here, we report a gradient-based digital immunoassay method, which can achieve high-sensitivity cardiac troponin T (hs-cTnT) detection with only 1 μL of plasma sample. We designed a multizone microfluidic channel functionalized with capture antibody specific to troponin. Taking advantage of limited sample volume, a troponin concentration gradient is created along the channel because of binding induced depletion. We quantified the concentration gradient by counting the detection antibody conjugated gold nanoparticles bound to different test zones with optical imaging. Differential counting between the zones removes most common noises and nonspecific bindings. The total analytical time is about 30 min, and the limit of quantification is 6.2 ng/L. We examined 41 clinical plasma samples from 15 patients and the change in hs-cTnT concentration in serial samples showed good linear correlation with clinical results (R2 = 0.98). Therefore, this simple and sensitive gradient-based digital immunoassay method is a promising technology for clinical hs-cTnT detection and could be adapted for detection of other biomarkers.
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Affiliation(s)
- Wenwen Jing
- Center for Biosensors and Bioelectronics, The Biodesign Institute, Arizona State University, Tempe, Arizona 85287, United States
| | - Yi Wang
- Center for Biosensors and Bioelectronics, The Biodesign Institute, Arizona State University, Tempe, Arizona 85287, United States
- State Key Laboratory of Analytical Chemistry for Life Science, School of Chemistry and Chemical Engineering, Nanjing University, Nanjing 210093, China
| | - Chao Chen
- Center for Biosensors and Bioelectronics, The Biodesign Institute, Arizona State University, Tempe, Arizona 85287, United States
| | - Fenni Zhang
- Center for Biosensors and Bioelectronics, The Biodesign Institute, Arizona State University, Tempe, Arizona 85287, United States
| | - Yunze Yang
- Center for Biosensors and Bioelectronics, The Biodesign Institute, Arizona State University, Tempe, Arizona 85287, United States
| | - Guangzhong Ma
- Center for Biosensors and Bioelectronics, The Biodesign Institute, Arizona State University, Tempe, Arizona 85287, United States
| | - Eric H. Yang
- Department of Cardiovascular Disease, Mayo Clinic Arizona, Phoenix, Arizona 85054, United States
| | - Christine L. N. Snozek
- Department of Laboratory Medicine and Pathology, Mayo Clinic Arizona, Scottsdale, Arizona 85259, United States
| | - Nongjian Tao
- Center for Biosensors and Bioelectronics, The Biodesign Institute, Arizona State University, Tempe, Arizona 85287, United States
| | - Shaopeng Wang
- Center for Biosensors and Bioelectronics, The Biodesign Institute, Arizona State University, Tempe, Arizona 85287, United States
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17
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Allen BR, Christenson RH, Cohen SA, Nowak R, Wilkerson RG, Mumma B, Madsen T, McCord J, Huis In't Veld M, Massoomi M, Stopyra JP, Montero C, Weaver MT, Yang K, Mahler SA. Diagnostic Performance of High-Sensitivity Cardiac Troponin T Strategies and Clinical Variables in a Multisite US Cohort. Circulation 2021; 143:1659-1672. [PMID: 33474976 DOI: 10.1161/circulationaha.120.049298] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
BACKGROUND European data support the use of low high-sensitivity troponin (hs-cTn) measurements or a 0/1-hour (0/1-h) algorithm for myocardial infarction to exclude major adverse cardiac events (MACEs) among patients in the emergency department with possible acute coronary syndrome. However, modest US data exist to validate these strategies. This study evaluated the diagnostic performance of an initial hs-cTnT measure below the limit of quantification (LOQ: 6 ng/L), a 0/1-h algorithm, and their combination with history, ECG, age, risk factors, and initial troponin (HEART) scores for excluding MACE in a multisite US cohort. METHODS A prospective cohort study was conducted at 8 US sites, enrolling adult patients in the emergency department with symptoms suggestive of acute coronary syndrome and without ST-elevation on ECG. Baseline and 1-hour blood samples were collected, and hs-cTnT (Roche; Basel, Switzerland) was measured. Treating providers blinded to hs-cTnT results prospectively calculated HEART scores. MACE (cardiac death, myocardial infarction, and coronary revascularization) at 30 days was adjudicated. The proportion of patients with initial hs-cTnT measures below the LOQ and risk according to a 0/1-h algorithm was determined. The negative predictive value (NPV) was calculated for both strategies when used alone or with a HEART score. RESULTS Among 1462 participants with initial hs-cTnT measures, 46.4% (678 of 1462) were women and 37.1% (542 of 1462) were Black with an age of 57.6±12.9 (mean±SD) years. MACEs at 30 days occurred in 14.4% (210 of 1462) of participants. Initial hs-cTnT measures below the LOQ occurred in 32.8% (479 of 1462), yielding an NPV of 98.3% (95% CI, 96.7-99.3) for 30-day MACEs. A low-risk HEART score with an initial hs-cTnT below the LOQ occurred in 20.1% (294 of 1462), yielding an NPV of 99.0% (95% CI, 97.0-99.8) for 30-day MACEs. A 0/1-h algorithm was complete in 1430 patients, ruling out 57.8% (826 of 1430) with an NPV of 97.2% (95% CI, 95.9-98.2) for 30-day MACEs. Adding a low HEART score to the 0/1-h algorithm ruled out 30.8% (441 of 1430) with an NPV of 98.4% (95% CI, 96.8-99.4) for 30-day MACEs. CONCLUSIONS In a prospective multisite US cohort, an initial hs-cTnT below the LOQ combined with a low-risk HEART score has a 99% NPV for 30-day MACEs. The 0/1-h hs-cTnT algorithm did not achieve an NPV >99% for 30-day MACEs when used alone or with a HEART score. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT02984436.
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Affiliation(s)
- Brandon R Allen
- Department of Emergency Medicine, College of Medicine (B.R.A., S.A.C., C.M.), University of Florida, Gainesville
| | - Robert H Christenson
- Departments of Pathology (R.H.C.), University of Maryland School of Medicine, Baltimore
| | - Scott A Cohen
- Department of Emergency Medicine, College of Medicine (B.R.A., S.A.C., C.M.), University of Florida, Gainesville
| | - Richard Nowak
- Department of Emergency Medicine (R.N.), Henry Ford Hospital, Detroit, MI
| | - R Gentry Wilkerson
- Emergency Medicine (R.G.W., M.H.i.V.), University of Maryland School of Medicine, Baltimore
| | - Bryn Mumma
- Department of Emergency Medicine, School of Medicine, University of California Davis, Sacramento (B.M.)
| | - Troy Madsen
- Division of Emergency Medicine, University of Utah School of Medicine, Salt Lake City (T.M.)
| | - James McCord
- Heart and Vascular Institute (J.M.), Henry Ford Hospital, Detroit, MI
- Department of Internal Medicine (J.M.), Henry Ford Hospital, Detroit, MI
| | - Maite Huis In't Veld
- Emergency Medicine (R.G.W., M.H.i.V.), University of Maryland School of Medicine, Baltimore
| | - Michael Massoomi
- Division of Cardiology, Department of Internal Medicine, College of Medicine (M.M.), University of Florida, Gainesville
| | - Jason P Stopyra
- Department of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, NC (J.P.S., S.A.M.)
| | - Cindy Montero
- Department of Emergency Medicine, College of Medicine (B.R.A., S.A.C., C.M.), University of Florida, Gainesville
| | - Michael T Weaver
- Department of Biobehavioral Nursing Science, College of Nursing (M.T.W.), University of Florida, Gainesville
| | - Kai Yang
- Department of Biostatistics, College of Public Health and Health Professions (K.Y.), University of Florida, Gainesville
| | - Simon A Mahler
- Department of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, NC (J.P.S., S.A.M.)
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18
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Perrone MA, Storti S, Salvadori S, Pecori A, Bernardini S, Romeo F, Guccione P, Clerico A. Cardiac troponins: are there any differences between T and I? J Cardiovasc Med (Hagerstown) 2021; 22:797-805. [PMID: 33399346 DOI: 10.2459/jcm.0000000000001155] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The most recent international guidelines recommend the measurement of cardiac troponin I (cTnI) and cardiac troponin T (cTnT) using high-sensitivity methods (hs-cTn) for the detection of myocardial injury and the differential diagnosis of acute coronary syndromes. Myocardial injury is a prerequisite for the diagnosis of acute myocardial infarction, but also a distinct entity. The 2018 Fourth Universal Definition of Myocardial Infarction states that myocardial injury is detected when at least one value above the 99th percentile upper reference limit is measured in a patient with high-sensitivity methods for cTnI or cTnT. Not infrequently, increased hs-cTnT levels are reported in patients with congenital or chronic neuromuscular diseases, while the hs-cTnI values are often in the normal range. Furthermore, some discrepancies between the results of laboratory tests for the two troponins are occasionally found in individuals apparently free of cardiac diseases, and also in patients with cardiac diseases. In this review article, authors discuss the biochemical, pathophysiological and analytical mechanisms which may cause discrepancies between hs-cTnI and hs-cTnT test results.
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Affiliation(s)
- Marco A Perrone
- Department of Pediatric Cardiology and Cardiac Surgery, Bambino Gesù Children's Hospital IRCCS Division of Cardiology, University of Rome Tor Vergata, Rome CNR-Regione Toscana G. Monasterio Foundation, Heart Hospital, Massa, and Scuola Superiore Sant'Anna CNR Institute of Clinical Physiology, Pisa Division of Clinical Biochemistry and Clinical Molecular Biology, University of Rome Tor Vergata, Rome, Italy
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19
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von Meyer A, Albert G, Kunzelmann S, Rank C, Zerback R, Imdahl R. Evaluating the performance of an updated high-sensitivity troponin T assay with increased tolerance to biotin. Clin Chem Lab Med 2020; 59:591-597. [PMID: 33112775 DOI: 10.1515/cclm-2020-0104] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2020] [Accepted: 09/27/2020] [Indexed: 11/15/2022]
Abstract
OBJECTIVES Biotin >20 ng/mL may interfere with the Elecsys® Troponin T-high sensitive assay (cTnT-hs; Roche Diagnostics International Ltd). We evaluated the performance of an updated assay, cTnT-hs*, which was designed to reduce biotin interference. METHODS cTnT-hs* assay performance was assessed using up to two applications (18 min/9 min) on three analyzers (cobas e 411/cobas e 601/cobas e 801). Biotin interference was determined by measuring recovery in an 11-sample series dilution with biotin ranging from 0-3600 ng/mL. Repeatability/reproducibility were evaluated in five serum sample pools (n=75 each). Method comparisons tested: cTnT-hs* vs. cTnT-hs (18 min/cobas e 601); cTnT-hs* assay 18 vs. 9 min (cobas e 601); cTnT-hs* (18 min) on cobas e 601 vs. cobas e 411 and cobas e 601 vs. cobas e 801. Concordance at the 99th percentile decision limit between cTnT-hs* and cTnT-hs (9 min/cobas e 601) was calculated using 300 lithium-heparin plasma samples and a 14 ng/L assay cutoff. RESULTS cTnT-hs* assay (18 min/cobas e 601) recovery was ≥96% for biotin ≤1250 ng/mL. Across all applications/analyzers, coefficients of variation for repeatability/reproducibility with the cTnT-hs* assay were <5% in most serum sample pools (mean cardiac troponin T: 8.528-9484 ng/L). High correlation (Pearson's r=1.000) was demonstrated for all method comparisons. Concordance at the 99th percentile decision limit was high between the cTnT-hs* and cTnT-hs assays. CONCLUSIONS The updated cTnT-hs* assay may provide greater tolerance to biotin interference, and shows good analytical and clinical agreement/concordance with the previous cTnT-hs assay.
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Affiliation(s)
- Alexander von Meyer
- Institute for Laboratory Medicine, Medical Microbiology and Technical Hygiene, München Klinik, Munich, Germany
| | - Gesa Albert
- Roche Diagnostics International Ltd., Rotkreuz, Switzerland
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20
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Collinson P. Biotin interference in cardiac troponin immunoassay – where the wild things are? Clin Chem Lab Med 2020; 58:1769-1771. [DOI: 10.1515/cclm-2020-0936] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Paul Collinson
- Departments of Clinical Blood Sciences and Cardiology , St George’s University Hospitals NHS Foundation Trust , London , UK
- St George’s University of London , London , UK
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21
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Clinical risk assessment of biotin interference with a high-sensitivity cardiac troponin T assay. Clin Chem Lab Med 2020; 58:1931-1940. [DOI: 10.1515/cclm-2019-0962] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2019] [Accepted: 07/20/2020] [Indexed: 12/12/2022]
Abstract
Abstract
Objectives
Biotin >20.0 ng/mL (81.8 nmol/L) can reduce Elecsys® Troponin T Gen 5 (TnT Gen 5; Roche Diagnostics) assay recovery, potentially leading to false-negative results in patients with suspected acute myocardial infarction (AMI). We aimed to determine the prevalence of elevated biotin and AMI misclassification risk from biotin interference with the TnT Gen 5 assay.
Methods
Biotin was measured using an Elecsys assay in two cohorts: (i) 797 0-h and 646 3-h samples from 850 US emergency department patients with suspected acute coronary syndrome (ACS); (ii) 2023 random samples from a US laboratory network, in which biotin distributions were extrapolated for higher values using pharmacokinetic modeling. Biotin >20.0 ng/mL (81.8 nmol/L) prevalence and biotin 99th percentile values were calculated. AMI misclassification risk due to biotin interference with the TnT Gen 5 assay was modeled using different assay cutoffs and test timepoints.
Results
ACS cohort: 1/797 (0.13%) 0-h and 1/646 (0.15%) 3-h samples had biotin >20.0 ng/mL (81.8 nmol/L); 99th percentile biotin was 2.62 ng/mL (10.7 nmol/L; 0-h) and 2.38 ng/mL (9.74 nmol/L; 3-h). Using conservative assumptions, the likelihood of false-negative AMI prediction due to biotin interference was 0.026% (0-h result; 19 ng/L TnT Gen 5 assay cutoff). US laboratory cohort: 15/2023 (0.74%) samples had biotin >20.0 ng/mL (81.8 nmol/L); 99th percentile biotin was 16.6 ng/mL (68.0 nmol/L). Misclassification risk due to biotin interference (19 ng/L TnT Gen 5 assay cutoff) was 0.025% (0-h), 0.0064% (1-h), 0.00048% (3-h), and <0.00001% (6-h).
Conclusions
Biotin interference has minimal impact on the TnT Gen 5 assay’s clinical utility, and the likelihood of false-negative AMI prediction is extremely low.
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22
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Fitzgerald RL, Hollander JE, Peacock WF, Limkakeng AT, Breitenbeck N, Rivers EJ, Ziegler A, Laimighofer M, deFilippi C. The 99th percentile upper reference limit for the 5th generation cardiac troponin T assay in the United States. Clin Chim Acta 2020; 504:172-179. [PMID: 32001233 DOI: 10.1016/j.cca.2020.01.027] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Revised: 01/23/2020] [Accepted: 01/24/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND Determining diagnostic thresholds for cardiac troponin assays is key to interpreting their clinical performance. We describe the calculation of 99th percentile upper reference limits (URLs) for the Elecsys® Troponin T Gen 5 (TnT Gen 5) assay. METHODS Plasma and serum samples from healthy US participants were prospectively evaluated using TnT Gen 5 Short Turn Around Time and 18-min assays on cobas e 411 and cobas e 601 analyzers (Roche Diagnostics); with, up to 8 TnT Gen 5 results per participant. RESULTS A total of 10,402 TnT Gen 5 results from 1301 participants were included (50.4% female). Across 9 calculation methods, overall 99th percentile URL was 19.2 ng/l (females, 13.5-13.6 ng/l; males, 21.4-22.2 ng/l). Across different sample/assay/analyzer combinations, overall 99th percentile URLs ranged from 18.4-20.2 ng/l. Median TnT Gen 5 results increased with age, were higher in males, and ranged from 3.0-3.7 ng/l across races/ethnicities and from 3.0-3.6 ng/l across body mass index (BMI) classes. Applying additional exclusion criteria (N-terminal pro-brain natriuretic peptide, BMI and estimated glomerular filtration rate) resulted in lower 99th percentile URLs (overall, 16.9 ng/l; females, 11.8 ng/l; males, 18.5 ng/l). CONCLUSION Our findings facilitate the interpretation of TnT Gen 5 results in US clinical practice.
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Affiliation(s)
| | - Judd E Hollander
- Department of Emergency Medicine, Thomas Jefferson University, Philadelphia, PA, USA
| | - W Frank Peacock
- Department of Emergency Medicine, Baylor College of Medicine, Houston, TX, USA
| | | | | | - E Joy Rivers
- Agent Representing Roche Professional Diagnostics, Indianapolis, IN, USA
| | - André Ziegler
- Roche Diagnostics International Ltd, Rotkreuz, Switzerland
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