Cardiac Troponins for the Diagnosis of Acute Myocardial Infarction in Chronic Kidney Disease

Abstract

Background Patients with chronic kidney disease ( CKD ) are at high risk of myocardial infarction. Cardiac troponins are the biomarkers of choice for the diagnosis of acute myocardial infarction ( AMI ) without ST ‐segment elevation ( NSTE ). In patients with CKD , troponin levels are often chronically elevated, which reduces their diagnostic utility when NSTE ‐ AMI is suspected. The aim of this study was to derive a diagnostic algorithm for serial troponin measurements in patients with CKD and suspected NSTE ‐ AMI . Methods and Results Two cohorts, 1494 patients from a prospective cohort study with high‐sensitivity troponin I (hs‐ cTnI ) measurements and 7059 cases from a clinical registry with high‐sensitivity troponin T (hs‐ cTnT ) measurements, were analyzed. The prospective cohort comprised 280 CKD patients (estimated glomerular filtration rate <60 mL/min/1.73 m 2 ). The registry data set contained 1581 CKD patients. In both cohorts, CKD patients were more likely to have adjudicated NSTE ‐ AMI than non‐ CKD patients. The specificities of hs‐ cTnI and hs‐ cTnT to detect NSTE ‐ AMI were reduced with CKD (0.82 versus 0.91 for hs‐ cTnI and 0.26 versus 0.73 for hs‐ cTnT ) but could be restored by applying optimized cutoffs to either the first or a second measurement after 3 hours. The best diagnostic performance was achieved with an algorithm that incorporates serial measurements and rules in or out AMI in 69% (hs‐ cTnI ) and 55% (hs‐ cTnT ) of CKD patients. Conclusions The diagnostic performance of high‐sensitivity cardiac troponins in patients with CKD with suspected NSTE ‐ AMI is improved by use of an algorithm based on admission troponin and dynamic changes in troponin concentration.

Value of the high-sensitivity troponin T assay for diagnosis of acute myocardial infarction in patients with and without renal insufficiency

“…Diagnostic performance of dynamic change for highsensitivity cardiac troponin-T levels for the diagnosis of acute myocardial infarction. change in hs-cTnT increases the diagnostic accuracy for AMI in patients with CKD [29][30][31][32]. A study with 670 patients (undergoing regular hemodialysis presented with chest pain or dyspnea) proposed the optimal cutoff value of the relative changes in hs-cTnT after 3 h was 24% for the diagnosis of AMI [29].…”

“…A study with 670 patients (undergoing regular hemodialysis presented with chest pain or dyspnea) proposed the optimal cutoff value of the relative changes in hs-cTnT after 3 h was 24% for the diagnosis of AMI [29]. Recently, a large prospective study showed that a relative change in hs-cTnT of 250% after 3 h could be used to rule in AMI, with a positive predictive value of 0.8 in patients with CKD who presented with chest pain [31]. Most studies enrolled patients with CKD or end-stage renal disease (ESRD) with typical chest pain.…”

“…Ascertainment of the final diagnosis of AMI is a critical issue. Previous studies have adjudicated the final diagnosis based on clinical, laboratory, and imaging findings by cardiologists [2,29,31]. However, we defined AMI clearly and objectively according to image findings (coronary angiography or echocardiography combined with electrocardiography).…”

Revisiting the Biological Variability of Cardiac Troponin: Implications for Clinical Practice

“…100 For example, a recent study in individuals with chronic kidney disease proposed algorithms where the relative change cut-off for hs-cTnI was 280% and for hs-cTnT was 250%, which are vastly different from the 20% cut-off defined by international recommendations. 101 Serial measurements of cTn over the long term may also be useful in providing prognostic information. 102 Measurable concentrations of cTn using hs-cTn assays in the general population have been associated with structural cardiac disease, cardiac failure, and an increased risk of both cardiovascular and all-cause mortality, even at concentrations well below the 99 th percentile value.…”

Diagnostic value of the Hs-cTnT/CysC ratio in patients with stage ≥3 CKD and acute myocardial infarction

“…It is generally believed, therefore, that a diagnosis cannot rely only on a single increase of troponin (99th percentile)-dynamic observation would be more significant 15,16 . Continuous monitoring of hs-cTnT (during 3 to 6 h intervals) is helpful for distinguishing acute myocardial ischemia from noncardiac diseases 17 .…”