Is high-sensitivity troponin, alone or in combination with copeptin, sensitive enough for ruling out NSTEMI in very early presenters at admission? A post hoc analysis performed in emergency departments

Combining glucose and high-sensitivity cardiac troponin in the early diagnosis of acute myocardial infarction

Glucose is a universally available inexpensive biomarker, which is increased as part of the physiological stress response to acute myocardial infarction (AMI) and may therefore help in its early diagnosis. To test this hypothesis, glucose, high-sensitivity cardiac troponin (hs-cTn) T, and hs-cTnI were measured in consecutive patients presenting with acute chest discomfort to the emergency department (ED) and enrolled in a large international diagnostic study (NCT00470587). Two independent cardiologists centrally adjudicated the final diagnosis using all clinical data, including serial hs-cTnT measurements, cardiac imaging and clinical follow-up. The primary diagnostic endpoint was index non-ST-segment elevation MI (NSTEMI). Prognostic endpoints were all-cause death, and cardiovascular (CV) death or future AMI, all within 730-days. Among 5639 eligible patients, NSTEMI was the adjudicated final diagnosis in 1051 (18.6%) patients. Diagnostic accuracy quantified using the area under the receiver-operating characteristics curve (AUC) for the combination of glucose with hs-cTnT and glucose with hs-cTnI was very high, but not higher versus that of hs-cTn alone (glucose/hs-cTnT 0.930 [95% CI 0.922-0.937] versus hs-cTnT 0.929 [95% CI 0.922-0.937]; glucose/hs-cTnI 0.944 [95% CI 0.937-0.951] versus hs-cTnI 0.944 [95% CI 0.937-0.951]). In early-presenters, a dual-marker strategy (glucose < 7 mmol/L and hs-cTnT < 5/hs-cTnI < 4 ng/L) provided very high and comparable sensitivity to slightly lower hs-cTn concentrations (cTnT/I < 4/3 ng/L) alone, and possibly even higher efficacy. Glucose was an independent predictor of 730-days endpoints. Our results showed that a dual marker strategy of glucose and hs-cTn did not increase the diagnostic accuracy when used continuously. However, a cutoff approach combining glucose and hs-cTn may provide diagnostic utility for patients presenting ≤ 3 h after onset of symptoms, also providing important prognostic information.

Copeptin with high-sensitivity cardiac troponin to rule out non-ST-elevation myocardial infarction early on: A systematic review and meta-analysis

High-sensitivity cardiac troponin (hs-cTn) with copeptin in rapidly ruling out non-ST-elevation myocardial infarction (NSTEMI) remains controversial. We aimed to evaluate the diagnostic accuracy of this combination compared to hs-cTn alone. A literature search of electronic databases was performed from inception to 26 March 2022. Primary studies that evaluated the diagnostic accuracy of hs-cTn with and without copeptin in patients with NSTEMI were eligible. The reference standard consisted of all available medical results, including a significant rise or fall of cTn with at least one value above the 99th percentile of the reference population. The QUality Assessment of Diagnostic Accuracy Studies (QUADAS-2) was used to assess the quality of the included studies. Thirteen studies involving 8,966 patients, 1,405 of whom were diagnosed with NSTEMI (prevalence, 15.67 %), were included. Combining copeptin with hs-cTn (99th percentile of the healthy population as the threshold) at admission improved the sensitivity from 0.89 to 0.96 (95 % confidence interval [CI] 0.84-0.93 vs 0.93-0.98); the specificity reduced from 0.79 to 0.56 (95 % CI 0.71-0.86 vs 0.51-0.60). In five studies with 6,073 participants (900 NSTEMI), the hs-cTn alone (with 'very low' or limit of detection [LoD] threshold) had higher diagnostic sensitivity than the dual-marker strategy (0.98 vs 0.96). Combining copeptin with hs-cTn (99th percentile of the population as the threshold) at admission improved sensitivity in NSTEMI identification at the expense of specificity. However, with the LoD threshold for hs-cTn, copeptin had no additional value, deterring the widespread use of copeptin if the hs-cTn assay is clinically available.

Copeptin plus troponin in the rapid rule out of acute myocardial infarction and prognostic value on post-myocardial infarction outcomes: a systematic review and diagnostic accuracy study

BACKGROUND

A critical and unmet therapeutic need is the prompt and reliable exclusion of acute myocardial infarction (AMI), which would allow for prompt discharge from the emergency department. High-sensitivity troponin (HS-TnT) combined with copeptin has been proposed to expedite the diagnostic exclusion of AMI in addition to its predictive usefulness in the intermediate and long-term outcomes of AMI. The European Society of Cardiology recommends the Global Registry of Acute Coronary Events (GRACE) as a prognostic score to manage acute coronary syndrome (ACS) without ST segment elevation. The purpose of this study was to compare the diagnostic accuracy of HS-TnT combined with copeptin in ruling out AMI compared to HS-TnT alone. By combining a low GRACE score (108) with negative HS-TnT (14 ng/L) and copeptin (14 pmol/L), non-ST and ACS were reliably ruled out, including non-ST segment elevation MI and unstable angina.

RESULTS

The present research included nine studies with a total of 13,232 participants. The negative predictive value (NPV) for copeptin and HS-TnT was found to be slightly higher in combination (62-99%) than for HS-TnT alone (60-99%). The sensitivity of copeptin ranged from 0% to 100%, with a pooled sensitivity of 0.79 (CI 95% 0.76, 0.82). The specificity of copeptin ranged from 13% to 100%, with a pooled specificity of 0.89 (CI 95% 0.85, 0.91), a pooled positive likelihood ratio (PLR) of 9.86 (CI 95% 4.42, 22.02), and a pooled negative likelihood ratio (NLR) of 0.08. (95% CI 0.01, 0.44).

CONCLUSIONS

The use of combined negative copeptin and highly sensitive troponin testing in low-to-intermediate risk patients with suspected acute coronary syndrome resulted in a quick discharge with a safe and rapid rule out of non-ST + ACS.

Copeptin as a Diagnostic and Prognostic Biomarker in Cardiovascular Diseases

Copeptin is the carboxyl-terminus of the arginine vasopressin (AVP) precursor peptide. The main physiological functions of AVP are fluid and osmotic balance, cardiovascular homeostasis, and regulation of endocrine stress response. Copeptin, which is released in an equimolar mode with AVP from the neurohypophysis, has emerged as a stable and simple-to-measure surrogate marker of AVP and has displayed enormous potential in clinical practice. Cardiovascular disease (CVD) is currently recognized as a primary threat to the health of the population worldwide, and thus, rapid and effective approaches to identify individuals that are at high risk of, or have already developed CVD are required. Copeptin is a diagnostic and prognostic biomarker in CVD, including the rapid rule-out of acute myocardial infarction (AMI), mortality prediction in heart failure (HF), and stroke. This review summarizes and discusses the value of copeptin in the diagnosis, discrimination, and prognosis of CVD (AMI, HF, and stroke), as well as the caveats and prospects for the application of this potential biomarker.

Could Serum Copeptin Level Be an Indicator of Coronary Artery Disease Severity in Patients with Unstable Angina?

This study aimed to identify the serum copeptin levels in patients diagnosed with unstable angina (UA) and evaluate the relationship between the patients' copeptin levels and angiographic severity.A total of 200 patients who were diagnosed with UA and underwent coronary angiography were included in the study. Clinical, electrocardiographic, echocardiographic, and laboratory data (high-sensitivity cardiac troponin T and copeptin levels) as well as The Global Registry of Acute Coronary Events (GRACE) 1.0 risk score were recorded upon admission. Moreover, the Synergy Between Percutaneous Coronary Intervention with Taxus and Cardiac Surgery (SYNTAX) score was calculated following coronary angiography.We isolated and defined two subgroups within our study population: group 1 included patients with non-significant coronary artery disease (CAD) (< 50% diameter stenosis, n = 105); group 2 included patients with significant CAD (≥ 50% diameter stenosis, n = 95). The number of cases with a GRACE score higher than 140 was significantly higher in group 2 than in group 1 (P < 0.001). The SYNTAX scores and copeptin levels were significantly higher in group 2 than in group 1 (P < 0.001 for both). A positive correlation was observed between the copeptin levels and SYNTAX scores (r = 0.683; P < 0.001), and the cut-off level of copeptin was 18.3 pmol/L (sensitivity of 74.7%, specificity of 83.8%, and area under the curve of 0.795).This study suggests that it may be beneficial to use conventional scoring systems and serum copeptin levels when identifying high-risk UA patients.