Abstract
BackgroundInternational guidelines recommend that the decision threshold for troponin should be the 99th percentile of a normal population, or, if the laboratory assay is not sufficiently precise at this low level, the level at which the assay achieves a 10% or better coefficient of variation (CV). Our objectives were to examine US hospital laboratory troponin reports to determine whether either the 99th percentile or the 10% CV level were clearly indicated, and whether nonconcordance with these guidelines was a potential barrier to detecting clinically important microscopic or ‘microsize’ myocardial infarctions (MIs). To confirm past reports of the clinical importance of microsize MIs, we also contrasted in-hospital, 28-day and 1-year mortality among those with microsize and nonmicrosize MI.MethodsIn the REasons for Geographic And Racial Differences in Stroke national prospective cohort study (n=30,239), 1029 participants were hospitalized for acute coronary syndrome (ACS) between 2003–2009. For each case, we recorded all thresholds of abnormal troponin on the laboratory report and whether the 99th percentile or 10% CV value were clearly identified. All cases were expert adjudicated for presence of MI. Peak troponin values were used to classify MIs as microsize MI (< five times the lowest listed upper limit of normal) and nonmicrosize MI.ResultsParticipants were hospitalized at 649 acute care US hospitals, only 2% of whose lab reports clearly identified the 99th percentile or the 10% CV level; 52% of reports indicated an indeterminate range, a practice that is no longer recommended. There were 183 microsize MIs and 353 nonmicrosize MIs. In-hospital mortality tended to be lower in the microsize than in the nonmicrosize MI group (1.1 vs. 3.6%, p = 0.09), but 28-day and 1-year mortality were similar (2.5% vs. 2.7% [p = 0.93] and 5.2% vs. 4.3% [p = 0.64], respectively).ConclusionsCurrent practices in many US hospitals created barriers to the clinical recognition of microsize MI, which was common and clinically important in our study. Improved hospital troponin reporting is warranted.
Highlights
International guidelines recommend that the decision threshold for troponin should be the 99th percentile of a normal population, or, if the laboratory assay is not sufficiently precise at this low level, the level at which the assay achieves a 10% or better coefficient of variation (CV)
We examined the hospital laboratory troponin report for documentation of the 99th percentile for healthy adults or the 10% CV level for the assay utilized and whether either was clearly identified as the decision threshold for abnormal troponin
Variations in hospital laboratory troponin reporting No upper limit of normal (ULN) for troponin was provided in 35 laboratory reports, and these hospitals were excluded, resulting in the inclusion of 649 different hospitals located in 490 US cities in 45 states
Summary
International guidelines recommend that the decision threshold for troponin should be the 99th percentile of a normal population, or, if the laboratory assay is not sufficiently precise at this low level, the level at which the assay achieves a 10% or better coefficient of variation (CV). Until assays achieve greater precision at very low levels and become more standardized, experts have recommended defining the threshold for abnormal troponin as either the 99th percentile of a normal reference population or the level at which the assay achieves acceptable precision, defined by a coefficient of variation (CV) of 10% or better [1,2,3,4,10,11,12,13,14]. All values of troponin above this threshold are recommended to be considered myocardial necrosis, which, together with a characteristic rising and/or falling pattern, is used in clinical decision-making to classify an event as an MI
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