Abstract
Recently published investigations using high-sensitivity cardiac troponin assays highlight many challenges we will encounter as these tests are deployed. 1 Aldous S.J. Richards M.A. Cullen L. et al. A new improved accelerated diagnostic protocol safely identifies low-risk patients with chest pain in the emergency department. Acad Emerg Med. 2012; 19: 510-516 Crossref PubMed Scopus (37) Google Scholar , 2 Keller T. Zeller T. Ojeda F. et al. Serial changes in highly sensitive troponin I assay and early diagnosis of myocardial infarction. JAMA. 2011; 306: 2684-2693 Crossref PubMed Scopus (395) Google Scholar , 3 Reichlin T. Irfan A. Twerenbold R. et al. Utility of absolute and relative changes in cardiac troponin concentrations in the early diagnosis of acute myocardial infarction. Circulation. 2011; 124: 136-145 Crossref PubMed Scopus (349) Google Scholar , 4 Reichlin T. Schindler C. Drexler B. et al. One-hour rule-out and rule-in of acute myocardial infarction using high-sensitivity cardiac troponin T. Arch Intern Med. 2012; 172: 1211-1218 Crossref PubMed Scopus (384) Google Scholar , 5 Schreiber D.H. Agbo C. Wu A.H. Short-term (90min) diagnostic performance for acute non-ST segment elevation myocardial infarction and 30-day prognostic evaluation of a novel third-generation high sensitivity troponin I assay. Clin Biochem. 2012; 45: 1295-1301 Crossref PubMed Scopus (14) Google Scholar , 6 Haaf P. Drexler B. Reichlin T. et al. High-sensitivity cardiac troponin in the distinction of acute myocardial infarction from acute cardiac noncoronary artery disease. Circulation. 2012; 126: 31-40 Crossref PubMed Scopus (128) Google Scholar , 7 Mueller M. Biener M. Vafaie M. et al. Absolute and relative kinetic changes of high-sensitivity cardiac troponin T in acute coronary syndrome and in patients with increased troponin in the absence of acute coronary syndrome. Clin Chem. 2012; 58: 209-218 Crossref PubMed Scopus (192) Google Scholar , 8 Sanchis J. Bardaji A. Bosch X. et al. Usefulness of high-sensitivity troponin T for the evaluation of patients with acute chest pain and no or minimal myocardial damage. Am Heart J. 2012; 164: 194-200.e191 Abstract Full Text Full Text PDF PubMed Scopus (21) Google Scholar Cardiac troponin's analytic sensitivity has decreased into the nanograms per liter (picograms per milliliter) range and is now measurable in the serum and plasma of healthy individuals with normal levels. A test once simply considered a dichotomous yes or no for the diagnosis of acute myocardial infarction has become considerably more complex and detectable in a wide range of clinical conditions. 9 Collinson P.O. Diagnosing myocardial infarction by serial measurement of high sensitivity troponin: what type of relative change value (delta) and how much should it be?. Clin Biochem. 2012; 45: 717-718 Crossref PubMed Scopus (6) Google Scholar , 10 Newby L.K. Myocardial infarction rule-out in the emergency department: comment on “One-Hour Rule-out and Rule-in of Acute Myocardial Infarction Using High-Sensitivity Cardiac Troponin T.”. Arch Intern Med. 2012; 89 Google Scholar , 11 Apple F.S. Steffen L.M. Pearce L.A. et al. Increased cardiac troponin I as measured by a high-sensitivity assay is associated with high odds of cardiovascular death: the Minnesota Heart Survey. Clin Chem. 2012; 58: 930-935 Crossref PubMed Scopus (55) Google Scholar Our discipline would benefit from a deeper understanding of these analytically improved, evolving tests and related clinical implications. Better insight into the debate surrounding high-sensitivity cardiac troponin assays will act as an essential driver to promote collaboration with laboratory medicine, primary care physicians, and cardiology, as well as encourage a unified approach to their use at the institutional level. This begins with defining high sensitivity, discussing how our clinical approach must adapt, and understanding that cardiac troponin levels represent a continuum of cardiac myocardial necrosis, rather than simply a dichotomous biomarker for acute myocardial infarction.
Published Version
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