Considerations for early acute myocardial infarction rule-out for emergency department chest pain patients: the case of copeptin

Abstract

The evaluation of patients admitted at the emergency department (ED) for chest pain is challenging and involves many different clinical specialists including emergency physicians, laboratory professionals and cardiologists. The preferable approach to deal with this issue is to develop joint protocols that will assist the clinical decision-making to quickly and accurately rule-out patients with non life-threatening conditions that can be considered for early and safe discharge or further outpatient follow-up, rule-in patients with acute coronary syndrome and raise the degree of alert of the emergency physicians on non-cardiac life-threatening emergencies. The introduction of novel biomarkers alongside the well-established troponins might support this process and also provide prognostic information about acute short-term or chronic long-term risk and severity. Among the various biomarkers, copeptin measurement holds appealing perspectives. The utility of combining troponin with copeptin might be cost-effective due to the high negative predictive value of the latter biomarker in the rule-out of an acute coronary syndrome. Moreover, in the presence of a remarkably increased concentration (e.g., more than 10 times the upper limit of the reference range), to reveal the presence of acute life-threatening conditions that may not necessarily be identified with the use of troponin alone. The aim of this article is to review current evidence about the clinical significance of copeptin testing in the ED as well as its appropriate placing within diagnostic protocols.

Copeptin (CTproAVP), a new tool for understanding the role of vasopressin in pathophysiology

“…The evaluation of chest pain patients is critical and involves several clinical specialities. The utility of combining CTproAVP to troponin may provide additional value in ruling-out or -in patients in life-threatening emergencies [52].…”

Copeptin in acute coronary syndromes and heart failure management: State of the art and future directions

“…The use of copeptin in suspected NSTE-ACS has been shown to slightly improve the sensitivity and NPV of troponins in 'early presenters' after CPO (<3 hours) even when a high-sensitivity troponin is used as the reference, but at the cost of a decrease in specificity [33,34]. The possibility of a safe early discharge should, however, be better demonstrated before widely recommending such a strategy in clinical practice [35]. In addition, adapting therapies and management on the result of copeptin dosage has not been adequately studied and should be further explored.…”

Laboratory diagnostics of myocardial infarction – troponins and beyond

“…Several other studies with conventional cTn assays support the conclusions of the two studies. Again the NPV is increased, but does not reach 100 % [28,29].…”