Global Adoption of High-Sensitivity Cardiac Troponins and the Universal Definition of Myocardial Infarction

Abstract

Word count abstract: 302Words count main text: 1,198 Tables and Figures: 3 References: 15Key words: high-sensitivity cardiac troponin; myocardial infarction; universal definition; guidelines; global . CC-BY-NC-ND 4.0 International license It is made available under a (which was not peer-reviewed) is the author/funder, who has granted bioRxiv a license to display the preprint in perpetuity.The copyright holder for this preprint . http://dx.doi.org/10.1101/371138 doi: bioRxiv preprint first posted online Jul. 17, 2018; 2 Abstract Importance: The third Universal Definition of Myocardial Infarction aimed to standardize the approach to the diagnosis and management of myocardial infarction. High-sensitivity cardiac troponin testing was recommended, as these assays have improved precision at low concentrations, but concerns over specificity may have limited implementation.Objective: To determine the global adoption of high-sensitivity cardiac troponin assays and key recommendations from the Universal Definition. Results: Cardiac troponin was the primary diagnostic biomarker for myocardial infarction at 96% of all sites surveyed. Only 41% of centers had adopted high-sensitivity cardiac troponin assays, with wide variation from 7% in North America to 60% in Europe. Sites using highsensitivity assays more frequently employed serial sampling pathways (91% vs. 78%) and the 99 th percentile diagnostic threshold (74% vs. 66%) when compared to sites using the previous generation of troponin assays. Furthermore, sites using high-sensitivity assays more often used earlier serial sampling (≤3 hours) and accelerated diagnostic pathways. However, fewer than 1 in 5 sites using high-sensitivity assays had adopted sex-specific thresholds (18%).

Laboratory-related issues in the measurement of cardiac troponins with highly sensitive assays

“…The reaction of clinicians to hs-cTn assays is perfectly illustrated in the Robert Jesse's statement: "when troponin was a lousy assay it was a great test, but now that it's becoming a great assay, it's getting to be a lousy test" [7]. According to data from a survey carried out in 2016 involving ~1900 medical centers in 23 countries evenly distributed across five continents, 41% of them adopted hs-cTn assays, varying from 60% in Europe to only 7% in North America [8]. More recently, the fourth universal definition of AMI, in providing practical updates to the previous 2012 version, has for the first time explicitly recommended the introduction of hs-cTn assays for their ability to detect even very small amounts of myocardial necrosis, expanding the use of cTn testing from the classical AMI diagnosis to the broad detection of myocardial injury of any cause [9].…”

Safety and efficacy of the European Society of Cardiology 0/1-hour algorithm for diagnosis of myocardial infarction: systematic review and meta-analysis

“…Even though the ESC 0/1 hour algorithm has been validated in a large number of prospective studies6–12, use of this algorithm has been limited to less than 15% of the hospital institutions globally 13. Because the algorithm has primarily been evaluated in Europe, America and Australasia,6–9 there are some concerns about its safety outside of these settings.…”

Implementation of rapid rule out of myocardial infarction using high-sensitivity troponin: cross-sectional survey of English hospitals

“…The findings suggest that availability of high-sensitivity troponin has increased since a survey of 94 hospital laboratories in 2015 reported that 60% had implemented a high-sensitivity troponin assay 4. A recent international survey reported that 72% of 80 UK sites use high-sensitivity troponin, with serial sampling at 3–6 hours in 78% 5. Our findings report a slightly higher use of high-sensitivity troponin (88%) across a larger and potentially more representative sample, with additional detail regarding timings and assays used.…”