Characteristics of a 20-minute whole blood rapid assay for cardiac troponin T

Development and evaluation of classifiers

Diagnostic tests, medical tests, screening tests, biomarkers, and prediction rules are all types of classifiers. This chapter introduces methods for classifier development and evaluation. We first introduce measures of classification performance including sensitivity, specificity, and receiver operating characteristic (ROC) curves. We then review some issues in the design of studies to assess and compare the performance of classifiers. Approaches for using the data to estimate and compare classifier accuracy are then introduced. Next, methods for combining multiple classifiers into a single classifier are presented. Lastly, we discuss other important aspects of classifier development and evaluation. The methods presented are illustrated with real data.

Measurement of cardiac troponins

The cardiac troponins form part of the regulatory mechanism for muscle contraction. Specific cardiac isoforms of cardiac troponin T and cardiac troponin I exist and commercially available immunoassay systems have been developed for their measurement. A large number of clinical and analytical studies have been performed and the measurement of cardiac troponins is now considered the 'gold standard' biochemical test for diagnosis of myocardial damage. There have been advances in understanding the development and structure of troponins and their degradation following myocardial cell necrosis. This has contributed to the understanding of the problems with current assays. Greater clinical use has also highlighted areas of analytical and clinical confusion. The assays are reviewed based on manufacturers' information, current published material as well as the authors' in-house experience.

Evaluation of a point-of-care system for quantitative determination of troponin T and myoglobin

We present the results of a multicenter evaluation of a new point-of-care system (Cardiac Reader) for the quantitative determination of cardiac troponin T (CARDIAC T Quantitative test) and myoglobin (CARDIAC M test) in whole blood samples. The Cardiac Reader is a CCD camera that optically reads the immunochemical test strips. The measuring range is 0.1 to 3 microg/l for CARDIAC T Quantitative and 30 to 700 microg/l for CARDIAC M. Both tests are calibrated by the manufacturer. The reaction times of the tests are 12 or 8 minutes, respectively. Method comparisons were performed with 281 heparinized blood samples from patients with suspected acute coronary syndromes. The results obtained with CARDIAC T Quantitative showed a good agreement compared with cardiac troponin T ELISA (r = 0.89; y = 0.93x + 0.02). The method comparison between CARDIAC M and Tina-quant Myoglobin also showed a good agreement between both assays (r = 0.98; y = 0.92x + 1.6). Test lot-to-lot comparisons yielded differences of 2% and 6% for CARDIAC T Quantitative and of 0 to 11% for CARDIAC M. The within-run imprecision with blood samples and control materials was acceptable for CARDIAC T Quantitative (CV 10 to 15%) and good for CARDIAC M (CV 5 to 10%). The between-instrument CV was below 7% for CARDIACT Quantitative and below 5% for CARDIAC M. The cross-reactivity of CARDIAC T Quantitative with skeletal troponin T was approximately 0.003%. No significant analytical interference was detected for any of the assays in investigations with biotin (up to 100 microg/l), hemoglobin (up to 0.125 mmol/l), hematocrit (26 to 52%), bilirubin (up to 340 micromol/l), triglycerides (up to 5.0 mmol/l), and 18 standard drugs. With the Cardiac Reader reliable quantitative results can be easily obtained for both cardiac markers. The system is, therefore, particularly suitable for use in emergency rooms, coronary care units and small hospitals.

A new sensitive cardiac Troponin T rapid test (TROPT) for the detection of experimental acute myocardial damage in rats

Cardiac Troponin T (cTnT) is a cardiac structural protein which is released in the circulation during myocardial cell damage. In this study we addressed the question of whether beta-sympathomimetic induced myocardial cell damage in rats can be detected in blood by the TROPT sensitive rapid test strip which is primarily manufactured for the detection of acute myocardial infarction in humans. Sixteen male rats and 16 female animals were treated once with orciprenalinesulphate s.c. to induce tachycardia. The control group which consisted of 16 rats of both sexes received vehicle (physiological saline). The heart rate of two groups of 10 rats (5 of each sex) was measured after orciprenaline or saline treatment. After 1-2 hours we could demonstrate an increased heart rate in the orciprenaline group. Furthermore in this group we could show elevated cTnT levels in peripheral blood measured with the enzyme-linked immunosorbent assay (ELISA) Enzymun-Test Troponin T for troponin T and a positive reaction of the TROPT sensitive test strip. When compared with the ELISA method, the test strip showed a positive reaction at cTnT levels of 0.64 ng/ml upwards. After 24 hours and 96 hours half of the animals were sacrificed for histological examination of the heart tissue. After 24 hours all orciprenaline treated and examined animals showed myofibrillar degeneration of the myocardial cells. The second half of the animals sacrificed 96 hours after treatment with the sympathomimetic drug showed reparative fibrosis of the myocardium. All animals with myocardial damage due to orciprenaline showed a positive test strip result 2 hours after injection. Twenty-four hours after injection only 8 of the 16 animals had a positive test strip result although histological cell damage was demonstrated. All animals treated with physiological saline had negative results of the test strip and showed no signs of myocardial cell damage. We conclude that the TROPT sensitive test strip is a rapid and reliable screening tool for detecting myocardial cell alteration in rats without the need of an expensive and time-consuming ELISA procedure if it is used in early phases of the experiment because all animals with myocardial damage were identified by the test 2 hours after induction of the damage. If the time range between the induction of the injury and the use of the test strip or the ELISA procedure is too wide, in our experiments 24 h, false negative results may occur.

Multisite study of a second generation whole blood rapid assay for cardiac troponin T

We evaluated a second generation, qualitative, whole blood rapid assay for cardiac troponin T (cTnT), which employs a more cardio-specific troponin T mouse monoclonal capture antibody. Using quantitative cTnT enzyme-linked immunosorbent assay (ELISA) results as the benchmark for accuracy, we compared the performance of the second generation and the original whole blood rapid assays in 445 samples from patients with the following diagnoses, determined by medical record review: myocardial infarction, coronary bypass surgery, ischaemic heart disease, musculoskeletal disease, renal failure or other noncardiac conditions. Overall, concordance between the second generation cTnT Rapid Assay and the quantitative cTnT ELISA, compared using the McNemar test and a cut-off concentration of 0.1 microgram/L, was in the range 76-94% for each patient group. Using a receiver operating characteristic plot, the cut-off for the second generation cTnT Rapid Assay was in the range 0.06-0.08 microgram/L. We conclude that the second generation cTnT whole blood assay has a 2.5-fold lower analytical cut-off than the original rapid assay (0.2 microgram/L) and may represent a more sensitive clinical tool for the rapid triage and risk stratification of cardiac patients.

The laboratory-clinical interface: point-of-care testing

POC testing provides an opportunity for clinicians and laboratorians to work together to consider how best to serve the patients within an individual institution. Each health system has unique characteristics relative to patient population, as well as a unique laboratory structure. If physicians, nurses, laboratorians, and pathologists work collaboratively, the best interests of patients will be served. In some institutions that cater to specific patient groups, POC testing may offer clear and distinct advantages. In other institutions with sophisticated transport systems and established rapid response capabilities, the quality resulting from central laboratory testing may outweigh any advantages of bedside testing. Clearly, attention to regulatory issues, QC issues, the importance of proper documentation, proficiency testing, performance enhancement, and cost-effectiveness is requisite. As the technology for diagnostic testing advances through more microcomputerization, microchemistry, and enhanced test menus, the concept of POC testing will need perpetual revisiting. We hope that the information provided here will aid clinicians, laboratorians, and administrators in their quest to best serve their patients.