Performance of the high-sensitivity troponin assay in diagnosing acute myocardial infarction: systematic review and meta-analysis

Abstract

Background: High-sensitivity cardiac troponin assays have been adopted by many clinical centres worldwide; however, clinicians are uncertain how to interpret the results. We sought to assess the utility of these assays in diagnosing acute myocardial infarction (MI). Methods:We carried out a systematic review and meta-analysis of studies comparing high-sensitivity with conventional assays of cardiac troponin levels among adults with suspected acute MI in the emergency department. We searched MEDLINE, EMBASE and Cochrane databases up to April 2013 and used bivariable random-effects modelling to obtain summary parameters for diagnostic accuracy. Results:We identified 9 studies that assessed the use of high-sensitivity troponin T assays (n = 9186 patients). The summary sensitivity of these tests in diagnosing acute MI at presentation to the emergency department was estimated to be 0.94 (95% confidence interval [CI] 0.89-0.97); for conventional tests, it was 0.72 (95% CI 0.63-0.79). The summary specificity was 0.73 (95% CI 0.64-0.81) for the high-sensitivity assay compared with 0.95 (95% CI 0.93-0.97) for the conventional assay. The differences in estimates of the summary sensitivity and specificity between the high-sensitivity and conventional assays were statistically significant (p < 0.01). The area under the curve was similar for both tests carried out 3-6 hours after presentation. Three studies assessed the use of high-sensitivity troponin I assays and showed similar results.Interpretation: Used at presentation to the emergency department, the high-sensitivity cardiac troponin assay has improved sensitivity, but reduced specificity, compared with the conventional troponin assay. With repeated measurements over 6 hours, the area under the curve is similar for both tests, indicating that the major advantage of the high-sensitivity test is early diagnosis. Abstract

Validation of the Baveno VI criteria to identify low risk cirrhotic patients not requiring endoscopic surveillance for varices

“…Four aspects of our results should be commented on: firstly, these data suggest there is a role for non-invasive markers in identifying patients at low risk of having clinically significant varices who can safely avoid screening endoscopy. Our reported NPV of 0.98 is similar to the NPV of troponin, which is widely implemented to exclude the diagnosis of myocardial infarction (Al-Saleh et al 2014). This presents an opportunity to reduce the burden of unnecessary endoscopies for patients who often face many invasive investigations through the course of their disease, but the poor PPV and LR+ show these non-invasive tests cannot replace endoscopy in the diagnosis of varices and deciding which patients warrant treatment with primary prophylaxis.…”

National Heart Foundation of Australia & Cardiac Society of Australia and New Zealand: Australian Clinical Guidelines for the Management of Acute Coronary Syndromes 2016

“…The majority of cardiac troponin assays are performed on automated platforms within centralised laboratories using sensitive or highly sensitive assays. Without access to central laboratories or automated assay platforms, POC assays are also in use and those with highest sensitivity for detecting troponin are recommended [68]. The analytical characteristics of assays as reported by the manufacturers are available at <www.ifcc.org/media/ 276661/IFCC%20Troponin%20Tables%20ng_L%20DRAFT %20Update%20NOVEMBER%202014.pdf> Highly sensitive assays are those with total imprecision (coefficient of variation) at the 99th percentile value 10% and the ability to measure troponin concentrations below the 99th percentile that are above the assay's limit of detection in at least 50% (and ideally >95%) of healthy individuals [67,69].…”

Transformative Impact of Proteomics on Cardiovascular Health and Disease

“…7 The development of more sensitive troponin assays is another example of how proteomics has enabled the development of improved diagnostic methods, 8 with high-sensitivity troponin assays permitting earlier diagnosis of acute coronary syndromes. 9,10 MS was an integral part of the harmonization of cardiac troponin I assays, which was accomplished by development of a human cardiac standard to calibrate troponin assays. 11 Previously established troponin assays served as diagnostic tools for patient risk stratification and guided treatment strategies in patients suspected of having an acute coronary syndrome.…”