Impact of Leading Presenting Symptoms on the Diagnostic Performance of High-Sensitivity Cardiac Troponin T and on Outcomes in Patients with Suspected Acute Coronary Syndrome

Abstract

BACKGROUND: Diagnostic performance of high-sensitivity cardiac troponin T (hs-cTnT) varies depending on presenting symptoms in patients with suspected acute coronary syndrome (ACS).

Serial high-sensitivity cardiac troponin T measurements to rule out acute myocardial infarction and a single high baseline measurement for swift rule-in: A systematic review and meta-analysis

“…17,[20][21][22][23][24]34,35 Eleven studies used the hs-cTnT assay as part of their reference standard and were considered as high risk for incorporation bias. [20][21][22][23]25,26,28,31,32,35,36 Seven studies did not exclude STEMI patients, 16,17,25,27,29,30,33 thus raising concerns about applicability. All studies formally re-adjudicated the final diagnoses, except the study by Slagman et al 35 in which the initial clinical diagnosis was used to establish the endpoints.…”

“…20 Fourteen out of 21 studies excluded patients with ST-segment elevation myocardial infarction (STEMI) from the analysis. Four studies had a hs-cTnT threshold>14 ng/l as part of their inclusion criteria [21][22][23]28 (see Supplementary Material Table S2). Eleven studies used the hs-cTnT assay as part of their reference standard.…”

“…Eleven studies used the hs-cTnT assay as part of their reference standard. [20][21][22][23]25,26,28,31,32,35,36 Additional characteristics of all included studies, such as the reported cut-offs and the timing of the troponin measurements for serial measurement strategies can be found in Supplementary Material Tables S2, S3 and S5.…”

“…Biener et al demonstrated that in patients presenting with atypical symptoms the sensitivity of a rule-out strategy with hs-cTnT was lower than in patients with typical chest pain. 22 Twerenbold et al showed that in patients with renal failure a rule-out strategy based on hs-cTnT had a comparably high sensitivity and NPV to patients without renal failure, however they found that the efficacy of the strategy was substantially lower. 46 The underlying cause is the increased baseline troponin value in patients with renal failure, which decreases the possibility of a rule-out when using the same cut-off values.…”

A comparison of cardiac troponin T delta change methods and the importance of the clinical context in the assessment of acute coronary syndrome

“…This is consistent with a number of other studies which directly compared at different time points. 3,12,14,23 The better performance of Δ could be explained by improving analytical sensitivity and performance of cTn assays which are able to more precisely measure smaller changes in blood concentrations. The high NPV for Δ and z-scores is vital in a clinical setting to ensure that positive AMI patients are not missed.…”