1
|
Pickering JW, Kavsak P, Christenson RH, Troughton RW, Pemberton CJ, Richards AM, Joyce L, Than MP. Determination of Clinically Acceptable Analytical Variation of Cardiac Troponin at Decision Thresholds. Clin Chem 2024:hvae059. [PMID: 38712541 DOI: 10.1093/clinchem/hvae059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2024] [Accepted: 04/01/2024] [Indexed: 05/08/2024]
Abstract
BACKGROUND Clinical decision-making for risk stratification for possible myocardial infarction (MI) uses high-sensitivity cardiac troponin (hs-cTn) thresholds that range from the limit of detection to several-fold higher than the upper reference limit (URL). To establish a minimum analytical variation standard, we can quantify the effect of variation on the population clinical measures of safety (sensitivity) and effectiveness [proportion below threshold, or positive predictive value (PPV)]. METHODS From large datasets of patients investigated for possible MI with the Abbott hs-cTnI and Roche hs-cTnT assays, we synthesized datasets of 1 000 000 simulated patients. Troponin concentrations were randomly varied several times based on absolute deviations of 0.5 to 3 ng/L and relative changes of 2% to 20% around the low-risk threshold (5 ng/L) and URLs, respectively. RESULTS For both assays at the low-risk thresholds, there were negligible differences in sensitivity (<0.3%) with increasing analytical variation. The proportion of patients characterized as low risk reduced by 30% to 29% (Roche) and 53% to 44% (Abbott). At the URL, increasing analytical variation also did not change sensitivity; the PPV fell by less than 3%. For risk stratification, increased delta thresholds (change between serial troponin concentrations) increased sensitivity at the cost of a decreased percentage of patients below the delta threshold, with the largest changes at the greatest analytical variation. CONCLUSIONS At the low-risk threshold, analytical variation up to 3 ng/L minimally impacted the safety metric (sensitivity) but marginally reduced effectiveness. Similarly, at the URL even relative variation up to 25% minimally impacted safety metrics and effectiveness. Analytical variation for delta thresholds did not negatively impact sensitivity but decreased effectiveness.
Collapse
Affiliation(s)
- John W Pickering
- Department of Emergency Medicine, Emergency Care Foundation, Christchurch Hospital, Christchurch, New Zealand
- Department of Medicine, Christchurch Heart Institute, University of Otago Christchurch, Christchurch, New Zealand
| | - Peter Kavsak
- Department of Pathology and Molecular Medicine, McMaster University, Hamilton, ON, Canada
| | - Robert H Christenson
- Department of Pathology, University of Maryland School of Medicine, Baltimore, MD, United States
| | - Richard W Troughton
- Department of Medicine, Christchurch Heart Institute, University of Otago Christchurch, Christchurch, New Zealand
| | - Christopher J Pemberton
- Department of Medicine, Christchurch Heart Institute, University of Otago Christchurch, Christchurch, New Zealand
| | - A Mark Richards
- Department of Medicine, Christchurch Heart Institute, University of Otago Christchurch, Christchurch, New Zealand
| | - Laura Joyce
- Department of Emergency Medicine, Christchurch Hospital, Christchurch, New Zealand
- Department of Surgery and Critical Care, University of Otago Christchurch, Christchurch, New Zealand
| | - Martin P Than
- Department of Emergency Medicine, Christchurch Hospital, Christchurch, New Zealand
- Department of Medicine, Christchurch Heart Institute, University of Otago Christchurch, Christchurch, New Zealand
| |
Collapse
|
2
|
Aakre KM, Apple FS, Mills NL, Meex SJR, Collinson PO. Lower Limits for Reporting High-Sensitivity Cardiac Troponin Assays and Impact of Analytical Performance on Patient Misclassification. Clin Chem 2024; 70:497-505. [PMID: 38102065 DOI: 10.1093/clinchem/hvad185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Accepted: 09/27/2023] [Indexed: 12/17/2023]
Abstract
BACKGROUND Cardiac troponin measurements are indispensable for the diagnosis of myocardial infarction and provide useful information for long-term risk prediction of cardiovascular disease. Accelerated diagnostic pathways prevent unnecessary hospital admission, but require reporting cardiac troponin concentrations at low concentrations that are sometimes below the limit of quantification. Whether analytical imprecision at these concentrations contributes to misclassification of patients is debated. CONTENT The International Federation of Clinical Chemistry Committee on Clinical Application of Cardiac Bio-Markers (IFCC C-CB) provides evidence-based educational statements on analytical and clinical aspects of cardiac biomarkers. This mini-review discusses how the reporting of low concentrations of cardiac troponins impacts on whether or not assays are classified as high-sensitivity and how analytical performance at low concentrations influences the utility of troponins in accelerated diagnostic pathways. Practical suggestions are made for laboratories regarding analytical quality assessment of cardiac troponin results at low cutoffs, with a particular focus on accelerated diagnostic pathways. The review also discusses how future use of cardiac troponins for long-term prediction or management of cardiovascular disease may require improvements in analytical quality. SUMMARY Clinical guidelines recommend using cardiac troponin concentrations as low as the limit of detection of the assay to guide patient care. Laboratories, manufacturers, researchers, and external quality assessment providers should extend analytical performance monitoring of cardiac troponin assays to include the concentration ranges applicable in these pathways.
Collapse
Affiliation(s)
- Kristin M Aakre
- Department of Medical Biochemistry and Pharmacology and Department of Heart Disease, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Science, University of Bergen, Bergen, Norway
| | - Fred S Apple
- Department of Laboratory Medicine and Pathology, Hennepin Healthcare/HCMC, Minneapolis, MN, United States
- Department of Laboratory Medicine and Pathology, University of Minnesota, Minneapolis, MN, United States
| | - Nicolas L Mills
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
- Usher Institute, University of Edinburgh, Edinburgh, United Kingdom
| | - Steven J R Meex
- Central Diagnostic Laboratory, Maastricht University Medical Center, Maastricht, the Netherlands
- CARIM School for Cardiovascular Diseases, Maastricht University, Maastricht, the Netherlands
| | - Paul O Collinson
- Department of Clinical Blood Sciences and Cardiology, St.George's University Hospitals NHS Foundation Trust, London, United Kingdom
- St.George's University of London, London, United Kingdom
| |
Collapse
|
3
|
Thulin IVL, Jordalen SMF, Lekven OC, Krishnapillai J, Steiro OT, Collinson P, Apple F, Cullen L, Norekvål TM, Wisløff T, Vikenes K, Omland T, Bjørneklett RO, Aakre KM. Aiming toWards Evidence baSed inTerpretation of Cardiac biOmarkers in patients pResenting with chest pain using Point of Care Testing (WESTCOR-POC): study design. SCAND CARDIOVASC J 2023; 57:2272585. [PMID: 37905548 DOI: 10.1080/14017431.2023.2272585] [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: 06/12/2023] [Accepted: 10/15/2023] [Indexed: 11/02/2023]
Abstract
OBJECTIVES Patients presenting with symptoms suggestive of acute coronary syndrome (ACS) contribute to a high workload and overcrowding in the Emergency Department (ED). Accelerated diagnostic protocols for non-ST-elevation myocardial infarction have proved challenging to implement. One obstacle is the turnaround time for analyzing high-sensitivity cardiac troponin (hs-cTn). In the WESTCOR-POC study (Clinical Trials number NCT05354804) we aim to evaluate safety and efficiency of a 0/1 h hs-cTn algorithm utilizing a hs-cTnI point of care (POC) instrument in comparison to central laboratory hs-cTnT measurements. DESIGN This is a prospective single-center randomized clinical trial aiming to include 1500 patients admitted to the ED with symptoms suggestive of ACS. Patients will receive standard investigations following the European Society of Cardiology 0/1h protocols for centralized hs-cTnT measurements or the intervention using a 0/1h POC hs-cTnI algorithm. Primary end-points are 1) Safety; death, myocardial infarction or acute revascularization within 30 days 2) Efficiency; length of stay in the ED, 3) Cost- effectiveness; total episode cost, 4) Patient satisfaction, 5) Patient symptom burden and 6) Patients quality of life. Secondary outcomes are 12-months death, myocardial infarction or acute revascularization, percentage discharged after 3 and 6 h, total length of hospital stay and all costs related to hospital contact within 12 months. CONCLUSION Results from this study may facilitate implementation of POC hs-cTn testing assays and accelerated diagnostic protocols in EDs, and may serve as a valuable resource for guiding future investigations for the use of POC high sensitivity troponin assays in outpatient clinics and prehospital settings.
Collapse
Affiliation(s)
| | | | - Ole Christian Lekven
- Emergency Care Clinic, Haukeland University Hospital, Bergen, Norway
- Department of Heart Disease, Haukeland University Hospital, Bergen, Norway
| | - Jeyaseelan Krishnapillai
- Emergency Care Clinic, Haukeland University Hospital, Bergen, Norway
- Department of Heart Disease, Haukeland University Hospital, Bergen, Norway
| | - Ole Thomas Steiro
- Department of Heart Disease, Haukeland University Hospital, Bergen, Norway
| | - 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
| | - Fred Apple
- Department of Laboratory Medicine and Pathology, Hennepin Healthcare/HCMC, Minneapolis, MN, USA
- Department of Laboratory Medicine and Pathology, University of Minnesota, Minneapolis, MN, USA
| | - Louise Cullen
- Department of Emergency Medicine, Royal Brisbane and Women's Hospital, Brisbane, Australia
- School of Medicine, University of Queensland, Brisbane, Australia
- Faculty of Health, Queensland University of Technology, Brisbane, Australia
| | - Tone M Norekvål
- Department of Heart Disease, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Science, University of Bergen, Bergen, Norway
| | - Torbjørn Wisløff
- Health Services Research Unit, Akershus University Hospital, Lørenskog, Norway
| | - Kjell Vikenes
- Department of Heart Disease, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Science, University of Bergen, Bergen, Norway
| | - Torbjørn Omland
- Department of Cardiology, Akershus University Hospital, Lørenskog, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Rune O Bjørneklett
- Emergency Care Clinic, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Kristin Moberg Aakre
- Department of Heart Disease, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Science, University of Bergen, Bergen, Norway
- Department of Medical Biochemistry and Pharmacology, Haukeland University Hospital, Bergen, Norway
| |
Collapse
|
4
|
Aakre KM, Saenger AK, Body R, Collinson P, Hammarsten O, Jaffe AS, Kavsak P, Omland T, Ordonez-Lianos J, Apple FS. Analytical Considerations in Deriving 99th Percentile Upper Reference Limits for High-Sensitivity Cardiac Troponin Assays: Educational Recommendations from the IFCC Committee on Clinical Application of Cardiac Bio-Markers. Clin Chem 2022; 68:1022-1030. [PMID: 35716089 DOI: 10.1093/clinchem/hvac092] [Citation(s) in RCA: 29] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Accepted: 04/27/2022] [Indexed: 11/14/2022]
Abstract
The International Federation of Clinical Chemistry Committee on Clinical Application of Cardiac Bio-Markers provides evidence-based educational documents to facilitate uniform interpretation and utilization of cardiac biomarkers in clinical laboratories and practice. The committee's goals are to improve the understanding of certain key analytical and clinical aspects of cardiac biomarkers and how these may interplay in clinical practice. Measurement of high-sensitivity cardiac troponin (hs-cTn) assays is a cornerstone in the clinical evaluation of patients with symptoms and/or signs of acute cardiac ischemia. To define myocardial infarction, the Universal Definition of Myocardial Infarction requires patients who manifest with features suggestive of acute myocardial ischemia to have at least one cTn concentration above the sex-specific 99th percentile upper reference limit (URL) for hs-cTn assays and a dynamic pattern of cTn concentrations to fulfill the diagnostic criteria for MI. This special report provides an overview of how hs-cTn 99th percentile URLs should be established, including recommendations about prescreening and the number of individuals required in the reference cohort, how statistical analysis should be conducted, optimal preanalytical and analytical protocols, and analytical/biological interferences or confounds that can affect accurate determination of the 99th percentile URLs. This document also provides guidance and solutions to many of the issues posed.
Collapse
Affiliation(s)
- Kristin M Aakre
- Department of Medical Biochemistry and Pharmacology and Department of Heart Disease, Haukeland University Hospital, Bergen, Norway.,Department of Clinical Science, University of Bergen, Bergen, Norway
| | - Amy K Saenger
- Department of Laboratory Medicine and Pathology, Hennepin Healthcare/HCMC, Minneapolis, MN, USA.,Department of Laboratory Medicine and Pathology, University of Minnesota, Minneapolis, MN, USA
| | - Rick Body
- Emergency Department, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK.,Division of Cardiovascular Sciences, The University of Manchester, Manchester, UK.,Healthcare Sciences Department, Manchester Metropolitan University, Manchester, UK
| | - Paul Collinson
- Department of Clinical Blood Sciences and Cardiology, St George's University Hospitals NHS Foundation Trust, London, UK.,Departments of Clinical Blood Sciences and Cardiology, St George's University of London, London, UK
| | - Ola Hammarsten
- Department of Clinical Chemistry and Transfusion Medicine, University of Gothenburg, Gothenburg, Sweden
| | - Allan S Jaffe
- Departments of Laboratory Medicine and Pathology and Cardiology, Mayo Clinic, Rochester, MN, USA
| | - Pete Kavsak
- Department of Pathology and Molecular Medicine, McMaster University, Hamilton, ON, Canada
| | - Torbjørn Omland
- Department of Cardiology, Akershus University Hospital, Lørenskog, Norway.,Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Jordi Ordonez-Lianos
- Servicio de Bioquímica Clínica, Institut d'Investigacions Biomèdiques Sant Pau, Barcelona, Spain.,Departamento de Bioquímica y Biología Molecular, Universidad Autònoma de Barcelona, Barcelona, Spain
| | - Fred S Apple
- Department of Laboratory Medicine and Pathology, Hennepin Healthcare/HCMC, Minneapolis, MN, USA.,Department of Laboratory Medicine and Pathology, University of Minnesota, Minneapolis, MN, USA
| |
Collapse
|
5
|
Solsvik AE, Kristoffersen AH, Sandberg S, Gidske G, Stavelin AV, Eikeland J, Amundsen E. A national surveillance program for evaluating new reagent lots in medical laboratories. Clin Chem Lab Med 2022; 60:351-360. [DOI: 10.1515/cclm-2021-1262] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Accepted: 01/10/2022] [Indexed: 11/15/2022]
Abstract
Abstract
Objectives
Differences between laboratory results attributable to the use of different reagent lots can potentially affect the diagnosis and monitoring of patients. To minimize patient risks, all laboratories should verify that new reagent lots meet agreed analytical performance specifications (APS). We propose a simplified, pragmatic approach for laboratories that involves compilating results into a national surveillance program, and present the first results obtained when applying this approach to troponins, glycated hemoglobin (HbA1c), prostate-specific antigen (PSA) and D-dimer.
Methods
In the surveillance program we have (i) determined APS for selected analytes, (ii) implemented a simplified procedure for lot evaluation with patient samples used in laboratories across Norway and (iii) performed central processing of the results from the participating laboratories.
Results
Over a one-year period, 27 Norwegian laboratories returned results from 28 lot changes for troponin I, 11 for troponin T, and 29 for HbA1c, PSA and D-dimer. The mean difference between two reagent lots was 4.5% for troponin I (for a concentration interval of 20–32 ng/L), 5.1% for troponin T (10.7–17.5 ng/L), 2.2% for HbA1c (40–50 mmol/mol), 3.7% for PSA (3–5 μg/L) and 5.5% for D-dimer (0.4–1.0 mg/L FEU).
Conclusions
A novel procedure for reagent lot evaluation is proposed in which information about multiple lot changes from different medical laboratories can be accumulated nationally. Sharing this information allows simplification of lot evaluations in individual laboratories and provides real-world data about lot-to-lot variations.
Collapse
Affiliation(s)
- Anne Elisabeth Solsvik
- Norwegian Organization for Quality Improvement of Laboratory Examinations (Noklus), Haraldsplass Deaconess Hospital , Bergen , Norway
| | - Ann Helen Kristoffersen
- Norwegian Organization for Quality Improvement of Laboratory Examinations (Noklus), Haraldsplass Deaconess Hospital , Bergen , Norway
- Department of Medical Biochemistry and Pharmacology , Haukeland University Hospital , Bergen , Norway
| | - Sverre Sandberg
- Norwegian Organization for Quality Improvement of Laboratory Examinations (Noklus), Haraldsplass Deaconess Hospital , Bergen , Norway
- Department of Medical Biochemistry and Pharmacology , Haukeland University Hospital , Bergen , Norway
- Department of Global Public Health and Primary Care , Faculty of Medicine, University of Bergen , Bergen , Norway
| | - Gro Gidske
- Department of Medical Biochemistry and Pharmacology , Haukeland University Hospital , Bergen , Norway
- Department of Global Public Health and Primary Care , Faculty of Medicine, University of Bergen , Bergen , Norway
| | - Anne Vegard Stavelin
- Norwegian Organization for Quality Improvement of Laboratory Examinations (Noklus), Haraldsplass Deaconess Hospital , Bergen , Norway
| | - Joakim Eikeland
- Department of Medical Biochemistry , Oslo University Hospital , Oslo , Norway
| | - Erik Amundsen
- Norwegian Organization for Quality Improvement of Laboratory Examinations (Noklus), Haraldsplass Deaconess Hospital , Bergen , Norway
- Department of Medical Biochemistry , Oslo University Hospital , Oslo , Norway
| |
Collapse
|
6
|
Tjora HL, Steiro OT, Langørgen J, Bjørneklett RO, Skadberg Ø, Bonarjee VVS, Mjelva ØR, Collinson P, Omland T, Vikenes K, Aakre KM. Diagnostic Performance of Novel Troponin Algorithms for the Rule-Out of Non-ST-Elevation Acute Coronary Syndrome. Clin Chem 2021; 68:291-302. [PMID: 34897415 DOI: 10.1093/clinchem/hvab225] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Accepted: 09/17/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND The European Society of Cardiology (ESC) rule-out algorithms use cutoffs optimized for exclusion of non-ST elevation myocardial infarction (NSTEMI). We investigated these and several novel algorithms for the rule-out of non-ST elevation acute coronary syndrome (NSTE-ACS) including less urgent coronary ischemia. METHOD A total of 1504 unselected patients with suspected NSTE-ACS were included and divided into a derivation cohort (n = 988) and validation cohort (n = 516). The primary endpoint was the diagnostic performance to rule-out NSTEMI and unstable angina pectoris during index hospitalization. The secondary endpoint was combined MI, all-cause mortality (within 30 days) and urgent (24 h) revascularization. The ESC algorithms for high-sensitivity cardiac troponin T (hs-cTnT) and I (hs-cTnI) were compared to different novel low-baseline (limit of detection), low-delta (based on the assay analytical and biological variation), and 0-1-h and 0-3-h algorithms. RESULTS The prevalence of NSTE-ACS was 24.8%, 60.0% had noncardiac chest pain, and 15.2% other diseases. The 0-1/0-3-h algorithms had superior clinical sensitivity for the primary endpoint compared to the ESC algorithm (validation cohort); hs-cTnT: 95% vs 63%, and hs-cTnI: 87% vs 64%, respectively. Regarding the secondary endpoint, the algorithms had similar clinical sensitivity (100% vs 94%-96%) but lower clinical specificity (41%-19%) compared to the ESC algorithms (77%-74%). The rule-out rates decreased by a factor of 2-4. CONCLUSION Low concentration/low-delta troponin algorithms improve the clinical sensitivity for a combined endpoint of NSTEMI and unstable angina pectoris, with the cost of a substantial reduction in total rule-out rate. There was no clear benefit compared to ESC for diagnosing high-risk events.
Collapse
Affiliation(s)
- Hilde L Tjora
- Emergency Care Clinic, Haukeland University Hospital, Bergen, Norway
| | - Ole-Thomas Steiro
- Department of Heart Disease, Haukeland University Hospital, Bergen, Norway
| | - Jørund Langørgen
- Department of Heart Disease, Haukeland University Hospital, Bergen, Norway
| | - Rune O Bjørneklett
- Emergency Care Clinic, Haukeland University Hospital, Bergen, Norway.,Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Øyvind Skadberg
- Laboratory of Medical Biochemistry, Stavanger University Hospital, Stavanger, Norway
| | | | - Øistein R Mjelva
- Cardiology Department, Stavanger University Hospital, Stavanger, Norway
| | - Paul Collinson
- Cardiovascular Clinical Academic Group St Georges University Hospitals NHS Foundation Trust and St George's University of London, London, UK
| | - Torbjørn Omland
- Department of Cardiology, Akershus University Hospital, Oslo, Norway.,Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Kjell Vikenes
- Department of Heart Disease, Haukeland University Hospital, Bergen, Norway.,Department of Clinical Science, University of Bergen, Bergen, Norway
| | - Kristin M Aakre
- Department of Heart Disease, Haukeland University Hospital, Bergen, Norway.,Department of Clinical Science, University of Bergen, Bergen, Norway.,Department of Medical Biochemistry and Pharmacology, Haukeland University Hospital, Bergen, Norway
| |
Collapse
|
7
|
Du Y, Yang Z. Diagnostic Value of Multislice Spiral CT Cardiothoracic Combined with Angiography in Acute Chest Pain. JOURNAL OF HEALTHCARE ENGINEERING 2021; 2021:5549971. [PMID: 33688419 PMCID: PMC7914098 DOI: 10.1155/2021/5549971] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/17/2021] [Revised: 02/07/2021] [Accepted: 02/13/2021] [Indexed: 12/13/2022]
Abstract
Acute chest pain is a common clinical emergency condition with a variety of causes, including acute coronary syndrome, pulmonary embolism, aortic coarctation, and pneumothorax. It is essential for emergency physicians to quickly and accurately understand the cause of acute chest pain. 64-slice spiral CT combined cardiothoracic angiography is an accurate and rapid way to diagnose and differentiate the cause of acute chest pain. 64-slice combined cardiothoracic angiography can accurately and rapidly display the thoracic aorta, both pulmonary arteries, the main trunk of the coronary artery and its major branches, and also provide a comprehensive view of both lungs and mediastinum, which is an effective test for the diagnosis and differential diagnosis of acute chest pain. Based on this, this study further investigated the value of 64-slice spiral CT triplex examination in the diagnosis of acute chest pain. The results showed that 64-slice spiral CT has the advantages of fast scanning speed, high resolution, and advanced postprocessing technology, and combined cardiothoracic angiography can quickly and accurately help emergency physicians analyze the cause of acute chest pain, which plays a very important role in formulating the correct treatment plan in a timely manner. At the same time, with the continuous development of CT technology, the temporal and spatial resolution has improved the quality of CT images, giving us more options to reduce the effective radiation dose and reduce the total amount of contrast, making the 64-row spiral CT cardiothoracic imaging more perfect.
Collapse
Affiliation(s)
- Yinggan Du
- Jinhua Municipal Central Hospital, Jinhua Hospital of Zhejiang University, Jinhua, Zhejiang 321000, China
- Wuhan University, Wuhan, Hubei 430072, China
| | - Zetian Yang
- Zhongnan Hospital of Wuhan University, Wuhan, Hubei 430071, China
| |
Collapse
|
8
|
High sensitivity troponin, analytical advantages, clinical benefits and clinical challenges - An update. Clin Biochem 2021; 91:1-8. [PMID: 33610525 DOI: 10.1016/j.clinbiochem.2021.02.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2021] [Revised: 01/29/2021] [Accepted: 02/05/2021] [Indexed: 12/26/2022]
Abstract
The measurement of cardiac troponin (cTn) by a high sensitivity method now represents the standard method for cTn measurement in the laboratory. High sensitivity method are not measuring a novel form of troponin but have undergone methodological improvement in assay sensitivity to allow both very low level detection and repeat measurements at low levels with very low degrees of analytical imprecision. The methods identify additional patients with myocardial injury who would benefit from evidence-based interventions. Rapid predictive algorithms utilising measurement on admission as well as short sampling periods (1-2 h) allow much more rapid categorisation of patients to appropriate clinical pathways. The shift in the diagnosis from traditional "cardiac enzymes" to troponin based on the 99th percentile has accounted for the majority of the detection of myocardial injury in patients without acute coronary syndromes. These patients have a worse prognosis irrespective of the underlying cause of their hospital admission. The appropriate management strategy in this group, beyond managing the underlying problem, remains to be defined. Measurement of cTn in otherwise asymptomatic individuals may have a role for patient selection for preventive treatment or for patients monitoring. Clinical trials in this area are awaited.
Collapse
|
9
|
Endlich W, Mensink WJ, den Elzen WPJ, Tops LF, Cobbaert CM. Successfully meeting analytical expectations for the fast 0/1-h algorithm for NSTEMI by internal control procedures for cardiac troponin T. Clin Chem Lab Med 2021; 59:e13-e17. [DOI: 10.1515/cclm-2020-0055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Accepted: 07/13/2020] [Indexed: 11/15/2022]
Affiliation(s)
- Wendy Endlich
- Department of Clinical Chemistry and Laboratory Medicine , Leiden University Medical Centre , Leiden , The Netherlands
| | - Willemina J. Mensink
- Department of Clinical Chemistry and Laboratory Medicine , Leiden University Medical Centre , Leiden , The Netherlands
| | - Wendy P. J. den Elzen
- Department of Clinical Chemistry and Laboratory Medicine , Leiden University Medical Centre , Leiden , The Netherlands
| | - Laurens F. Tops
- Department of Cardiology , Leiden University Medical Centre , Leiden , The Netherlands
| | - Christa M. Cobbaert
- Department of Clinical Chemistry and Laboratory Medicine , Leiden University Medical Centre , Leiden , The Netherlands
| |
Collapse
|
10
|
Tjora HL, Steiro OT, Langørgen J, Bjørneklett R, Nygård OK, Skadberg Ø, Bonarjee VVS, Collinson P, Omland T, Vikenes K, Aakre KM. Cardiac Troponin Assays With Improved Analytical Quality: A Trade-Off Between Enhanced Diagnostic Performance and Reduced Long-Term Prognostic Value. J Am Heart Assoc 2020; 9:e017465. [PMID: 33238783 PMCID: PMC7763786 DOI: 10.1161/jaha.120.017465] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Background Cardiac troponin (cTn) permits early rule‐out/rule‐in of patients admitted with possible non–ST‐segment–elevation myocardial infarction. In this study, we developed an admission and a 0/1 hour rule‐out/rule‐in algorithm for a troponin assay with measurable results in >99% of healthy individuals. We then compared its diagnostic and long‐term prognostic properties with other protocols. Methods and Results Blood samples were collected at 0, 1, 3, and 8 to 12 hours from patients admitted with possible non–ST‐segment–elevation myocardial infarction. cTnT (Roche Diagnostics), cTnI(Abbott) (Abbott Diagnostics), and cTnI(sgx) (Singulex Clarity System) were measured in 971 admission and 465 1‐hour samples. An admission and a 0/1 hour rule‐out/rule‐in algorithm were developed for the cTnI(sgx) assay and its diagnostic properties were compared with cTnTESC (European Society of Cardiology), cTnI(Abbott)ESC, and 2 earlier cTnI(sgx) algorithms. The prognostic composite end point was all‐cause mortality and future nonfatal myocardial infarction during a median follow‐up of 723 days. non–ST‐segment–elevation myocardial infarction prevalence was 13%. The novel cTnI(sgx) algorithms showed similar performance regardless of time from symptom onset, and area under the curve was significantly better than comparators. The cTnI(sgx)0/1 hour algorithm classified 92% of patients to rule‐in or rule‐out compared with ≤78% of comparators. Patients allocated to rule‐out by the prior published 0/1 hour algorithms had significantly fewer long‐term events compared with the rule‐in and observation groups. The novel cTnI(sgx)0/1 hour algorithm used a higher troponin baseline concentration for rule‐out and did not allow for prognostication. Conclusions Increasingly sensitive troponin assays may improve identification of non–ST‐segment–elevation myocardial infarction but could rule‐out patients with subclinical chronic myocardial injury. Separate protocols for diagnosis and risk prediction seem appropriate.
Collapse
Affiliation(s)
- Hilde L Tjora
- Emergency Care Clinic Haukeland University Hospital Bergen Norway
| | - Ole-Thomas Steiro
- Department of Heart Disease Haukeland University Hospital Bergen Norway
| | - Jørund Langørgen
- Department of Heart Disease Haukeland University Hospital Bergen Norway
| | - Rune Bjørneklett
- Emergency Care Clinic Haukeland University Hospital Bergen Norway.,Department of Clinical Medicine University of Bergen Norway
| | - Ottar K Nygård
- Department of Heart Disease Haukeland University Hospital Bergen Norway.,Department of Clinical Science University of Bergen Norway
| | - Øyvind Skadberg
- Laboratory of Medical Biochemistry Stavanger University Hospital Stavanger Norway
| | | | - Paul Collinson
- Departments of Clinical Blood Sciences and Cardiology St Georges University Hospitals NHS Foundation Trust and St George's University of London London United Kingdom
| | - Torbjørn Omland
- Division of Medicine Akershus University Hospital Oslo Norway.,Center for Heart Failure Research Institute of Clinical Medicine University of Oslo Norway
| | - Kjell Vikenes
- Department of Heart Disease Haukeland University Hospital Bergen Norway.,Department of Clinical Science University of Bergen Norway
| | - Kristin M Aakre
- Department of Heart Disease Haukeland University Hospital Bergen Norway.,Department of Clinical Science University of Bergen Norway.,Department of Medical Biochemistry and Pharmacology Haukeland University Hospital Bergen Norway
| |
Collapse
|
11
|
van der Hagen EAE, Cobbaert CM, Meijer R, Thelen MHM. Fast 0/1-h algorithm for detection of NSTEMI: are current high-sensitivity cardiac troponin assays fit for purpose? An EQA-based evaluation. Clin Chem Lab Med 2020; 57:1999-2007. [PMID: 31326959 DOI: 10.1515/cclm-2019-0253] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2019] [Accepted: 06/20/2019] [Indexed: 02/06/2023]
Abstract
Background High-sensitivity cardiac troponin T/I (hs-cTnT/I) assays have improved analytical sensitivity for the detection of myocardial infarction (MI). To gain clinical specificity and sensitivity, interpretation of changes in cTn concentrations over time is crucial. The 2015 ESC NSTEMI guideline defines absolute delta values as additional rule-in and rule-out criteria for MI. A critical assumption for application of this rule is that total analytical imprecision within the delta period, including inter-instrument bias, is comparable to analytical imprecision in the validation studies. Methods Data from the Dutch External Quality Assessment Scheme (EQAS) were used to calculate inter-instrument bias and estimate imprecision for the measuring range where the proposed delta values are relevant: for Roche Elecsys hs-cTnT, 5-52 and 5-12 ng/L; for Abbott Architect hs-cTnI, 2-52 and 2-5 ng/L for rule-in and rule-out, respectively. Results For Elecsys, the median inter-instrument bias is 0.3 ng/L (n = 33 laboratories), resulting in reference change values (RCVs) of 3.0 and 1.7 ng/L, respectively, for rule-in and rule-out with imprecision as claimed by the manufacturer. With RCVs smaller than the guideline's delta thresholds, 100% of the laboratories have adequate specifications. RCVs for rule-in/rule-out increased to 4.6 ng/L/2.5 ng/L, respectively, with individual imprecisions as estimated from EQA data, resulting in 64% and 82% of laboratories with adequate specifications. For Architect, 40% of instruments (n = 10) might falsely qualify the result as clinically relevant; hence, inter-instrument bias could not be determined. Conclusions We advise laboratories that use the fast 0/1-h algorithm to introduce stringent internal quality procedures at the relevant/low concentration level, especially when multiple analyzers are randomly used.
Collapse
Affiliation(s)
- Eline A E van der Hagen
- Dutch Foundation for Quality Assessment in Medical Laboratories (SKML), Nijmegen, The Netherlands.,Department of Clinical Chemistry, Queen Beatrix Hospital, Beatrixpark 1, 7101 BN Winterswijk, The Netherlands, Phone: +31 543544774
| | - Christa M Cobbaert
- Department of Clinical Chemistry and Laboratory Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - Ron Meijer
- Dutch Foundation for Quality Assessment in Medical Laboratories (SKML), Nijmegen, The Netherlands
| | - Marc H M Thelen
- Dutch Foundation for Quality Assessment in Medical Laboratories (SKML), Nijmegen, The Netherlands.,Department of Clinical Chemistry and Haematology, Amphia Hospital, Breda, The Netherlands
| |
Collapse
|
12
|
Wu AHB, Kavsak PA, Aakre KM, Christenson RH, Greene DN, Apple FS, Peacock WF, Hollander JE, de Lemos JA, Morrow D, Januzzi J, Jaffe AS. Lot-to-Lot Variation for Commercial High-Sensitivity Cardiac Troponin: Can We Realistically Report Down to the Assay’s Limit of Detection? Clin Chem 2020; 66:1146-1149. [DOI: 10.1093/clinchem/hvaa160] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Accepted: 07/01/2020] [Indexed: 11/14/2022]
Affiliation(s)
| | | | | | | | - Dina N Greene
- Department of Laboratory Medicine, University of Washington, Seattle, WA
| | | | | | | | | | | | | | | |
Collapse
|
13
|
Aakre KM, Saeed N, Wu AHB, Kavsak PA. Analytical performance of cardiac troponin assays - Current status and future needs. Clin Chim Acta 2020; 509:149-155. [PMID: 32540128 DOI: 10.1016/j.cca.2020.06.021] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Revised: 06/03/2020] [Accepted: 06/11/2020] [Indexed: 02/06/2023]
Abstract
Concurrent with the introduction of cardiac troponin measurements into the diagnostic definition of myocardial infarction (MI), clinicians and laboratory professionals signaled a clear clinical need for improved analytical quality. This was an important precipitant for developing high-sensitivity cardiac troponin (hs-cTn) assays, currently used in rapid algorithms guiding investigations of patients presenting to the emergency department with possible MI. The hs-cTn assays were also important for the detection and monitoring of low-grade chronic myocardial injury, a condition that has been linked to increased long-term risk of cardiovascular morbidity and mortality. This review summarizes the general recommendations for defining analytical performance specifications while providing relevant clinical situations related to analytical performance. Importantly, outcome studies suggest analytical quality performance for hs-cTn is sufficient for early discharge of patients investigated for possible MI. However, bias due to change in calibrators or reagents may significantly affect the percentage of patients discharged. Biological variation data is suitable for defining performance specifications when hs-cTn measurements are used for diagnosing and monitoring chronic myocardial injury. Further improvement in analytical performance for hs-cTn testing may result in even faster decision making in the emergency setting; while also identifying those with chronic injury at risk for an adverse cardiac event.
Collapse
Affiliation(s)
- Kristin M Aakre
- Department of Medical Biochemistry and Pharmacology, Haukeland University Hospital, Bergen, Norway; Department of Clinical Science, University of Bergen, Bergen, Norway; Department of Heart Disease, Haukeland University Hospital, Bergen, Norway.
| | - Nasir Saeed
- Department of Clinical Science, University of Bergen, Bergen, Norway
| | - Alan H B Wu
- University of California, San Francisco, CA, United States
| | - Peter A Kavsak
- Department of Pathology and Molecular Medicine, McMaster University, Hamilton, ON, Canada
| |
Collapse
|
14
|
Flowers KC, Hunt C, Collinson PO. Interanalyzer Analytical Variation of a High-Sensitivity Cardiac Troponin T Assay Can Exceed the Cutoff of the European Society of Cardiology 1-Hour Algorithm for Ruling Out Non–ST-Segment Elevated Myocardial Infarction. Clin Chem 2020; 66:495-496. [DOI: 10.1093/clinchem/hvz037] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/30/2019] [Indexed: 11/14/2022]
Affiliation(s)
- Kade C Flowers
- Department of Clinical Blood Sciences, St George’s University Hospitals NHS Foundation Trust, London, UK
| | - Clare Hunt
- Department of Clinical Blood Sciences, St George’s University Hospitals NHS Foundation Trust, London, UK
| | - Paul O Collinson
- Department of Clinical Blood Sciences, St George’s University Hospitals NHS Foundation Trust, London, UK
| |
Collapse
|
15
|
Kavsak PA, McRae A, Vatanpour S, Ismail OZ, Worster A. A Multicenter Assessment of the Sensitivity and Specificity for a Single High-Sensitivity Cardiac Troponin Test at Emergency Department Presentation for Hospital Admission. J Appl Lab Med 2019; 4:170-179. [DOI: 10.1373/jalm.2019.029512] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Accepted: 06/24/2019] [Indexed: 12/11/2022]
Abstract
Abstract
Background
Studies have illustrated how a low or undetectable high-sensitivity cardiac troponin (hs-cTn) concentration at emergency department (ED) presentation can rule out myocardial infarction (MI). A problem with using an undetectable hs-cTn cutoff is that this value may be defined differently among hospitals and is also difficult to monitor. In the present study, we assess the diagnostic performance of a clinical chemistry score (CCS) vs hs-cTn alone in the presentation blood sample in the ED for patient hospital admission in a multicenter setting.
Methods
From January 1 to June 30, 2018, consecutive patients with random glucose, creatinine (for an estimated glomerular filtration rate calculation), and hs-cTnI (Abbott, 2 hospitals, Hamilton, Ontario, n = 10496) or hs-cTnT (Roche, 4 hospitals, Calgary, Alberta, n = 25177) were assessed for hospital admission with the CCS (range of scores, 0–5) or hs-cTn alone. Sensitivity, specificity, predicative values, and likelihood ratios were calculated for a CCS of 0 and 5 and for hs-cTn alone (hs-cTnI cutoffs, 5 and 26 ng/L; hs-cTnT cutoffs, 6 and 14 ng/L).
Results
The CCS of 0 (CCS <1) identified approximately 10% of all patients as low risk and had a sensitivity for hospital admission of nearly 98% as compared to <93% when hs-cTnT (<6 ng/L) or hs-cTnI (<5 ng/L) cutoffs alone were used. A CCS ≥5 had a specificity for hospital admission >95%, with approximately 14% of patients at high risk.
Conclusions
An ED disposition (admit or send home) using the presentation blood sample could occur in nearly 25% of all patients by use of the CCS.
Collapse
Affiliation(s)
- Peter A Kavsak
- Departments of Pathology and Molecular Medicine, McMaster University, Hamilton, Canada
| | - Andrew McRae
- Department of Emergency Medicine, University of Calgary, Calgary, Alberta
| | - Shabnam Vatanpour
- Department of Emergency Medicine, University of Calgary, Calgary, Alberta
| | - Ola Z Ismail
- Departments of Pathology and Molecular Medicine, McMaster University, Hamilton, Canada
| | - Andrew Worster
- Division of Emergency Medicine, McMaster University, Hamilton, Canada
| |
Collapse
|