High-sensitivity Troponin Assays Research Articles

Validation of Analytical Performance Limits for Accuracy with High-Sensitivity Cardiac Troponin Assays.

Validation of Analytical Performance Limits for Accuracy with High-Sensitivity Cardiac Troponin Assays.

High-Sensitivity Cardiac Troponin Assays in Acute Heart Failure, Moving Beyond Myocardial Infarction.

Cardiac troponins are essential structural proteins found in the contractile apparatus of cardiac myocytes. During myocardial damage, such as in myocardial infarction (MI), these troponins are released into the bloodstream. As a result, they play a central role in the diagnosis of MI, serving as sensitive and specific markers for cardiac injury. Earlier assays that were used for measuring troponin levels were considered as a dichotomous test, categorizing patients as being positive or negative for MI. The recent introduction of high-sensitivity cardiac troponin assays has revolutionized cardiac troponin detection. These assays can detect troponin levels that are 100 times lower than what traditional methods can detect. Hence it is now considered a quantitative measure of cardiac myocyte injury not only in the setting of MI but also in subjects without MI such as heart failure, in whom it can be regarded as a marker for myocardial stress. This review aims to establish the relationship between high-sensitivity cardiac troponin levels and the prognosis of patients suffering from acute heart failure. Additionally, this seeks to identify other applications where the release of troponin from the cardiomyocyte can provide prognostic information. This information can be vital in determining the appropriate treatment options for patients, ultimately improving their quality of life and positively impacting health economics.

Outcomes of ED chest pain visits: the prognostic value of negative but measurable high-sensitivity cardiac troponin (hs-cTn) levels.

Chest pain is a common condition in the emergency department (ED). High-sensitivity cardiac troponin (hs-cTn) assays are crucial for diagnosing acute coronary syndrome, but the implications of "negative but measurable" hs-cTn levels are not well understood. This study assesses the outcomes of patients with acute chest pain discharged from the ED based on their hs-cTn levels. This retrospective cohort study analyzed medical records of patients aged 18 and older presenting with chest pain to the Tel Aviv Sourasky Medical Center ED from 2017 to 2022. We compared patients with negative but measurable hs-cTn levels (3-50 ng/L) to those with very low hs-cTn levels (< 3 ng/L). Primary outcomes included 90- days coronary angiogram (CAG), and secondary outcomes were 7- days ED revisits, 14-days hospital admissions, and 30- days mortality. Of 32,162 eligible patients, 23,297 had hs-cTn levels ≤ 50 ng/L. Patients with negative but measurable hs-cTn levels had higher rates of 90-days CAG (1.8% vs. 0.5%, p < 0.001), 7-day ED revisits (5.2% vs. 3.3%, p < 0.001), 14-day hospital admissions (3.1% vs. 0.9%, p < 0.001), and 30-day mortality (0.3% vs. 0.01%, p < 0.001) compared to those with very low hs-cTn levels. Independent predictors for 90 days CAG included age ≥ 57 years, male sex, and hs-cTn ≥ 3.5 ng/L. Negative but measurable hs-cTn levels are linked to worse outcomes than very low hs-cTn levels in discharged ED patients. Closer follow-up and further cardiac evaluation may be warranted for these patients.

Imprecision and real-time clinical performance of a whole blood high sensitivity point of care troponin i: ready for prime time?

Abstract Introduction High sensitivity troponin (hs-cTn) measurement is central to rapid diagnostic algorithms in acute coronary syndrome (ACS). Point of care (POC) testing reduces turnaround time when compared to central lab (CL) testing. Currently there is very little data on the performance of POC hs-cTn assays in a clinical environment with non-expert operators. Method In a nested sub-study of a randomised controlled trial (RCT), patients with suspected ACS were randomised to either the ESC 0/1 or 0/3 hour algorithm. They underwent whole blood (WB) sampling for Siemens Atellica VTLi hs-cTnI POC (VTLi POC), CL hs-cTnI and CL hs-cTnT assays. This was for both initial and repeat samples. Assay imprecision of the VTLi POC assay was assessed by 2 runs of 10 tests with whole blood at 9 different troponin levels. 4 devices were used with samples stored at room temperature.Final diagnosis was adjudicated based on all relevant clinical and imaging data together with CL hs-cTnT as the diagnostic biomarker in clinical use (10% coefficient of variation (CV) 3-5 ng/L, 99th percentile 14 ng/L) and using the 4th universal definition of myocardial infarction (MI). Clinical performance was assessed using Receiver Operator Characteristics (ROC) curves. Results 2144 patients consented and had WB VTLi POC, CL hs-cTnI and CL hs-cTnT available. The index adjudicated type 1 MI rate was 6.1%. Assay imprecision of the VTLi POC assay demonstrated a 10% Coefficient of Variation (CV) at 9.8ng/l. This was &amp;gt;50% lower than the 99th centile of 23ng/l (average for males and females) (Figure 1). Clinical performance of the VTLi POC assay was acceptable and equivalent to CL hs-cTnT: Area Under Curve (AUC) 0.92 (0.89-0.96), 0.98 (0.96-0.99) and 0.93 (0.87-0.98) at presentation (Figure 2), 1 and 3 hours respectively. However, clinical performance was inferior to CL hs-cTnI: AUC 0.96 (0.95-0.98) and 0.96 (0.93-0.98) at presentation (p=0.0007) and 3 hours (p&amp;lt;0.0001) respectively. Conclusion The Siemens Altellica VTLi hs-cTnI POC assay has imprecision levels consistent with a high sensitivity troponin assay. It has acceptable clinical performance though inferior to the equivalent CL hs-cTnI. Further validation of this assay, particularly with optimised single sample rule-out, could facilitate its use in routine clinical practice.

Myocarditis in the modern era: analysing the impact of high-sensitivity troponin &amp; C-reactive protein in predicting the extent of myocarditis and LV systolic dysfunction on cardiac magnetic resonance

Abstract Background The diagnostic yield of acute myocarditis has improved considerably since the advent of high-sensitivity troponin (hs-Tn) assays and adoption of the 2018 Lake Louise criteria for cardiac magnetic resonance (CMR)-based imaging for myocardial oedema and injury (1). Yet, a seminal 1997 study, predating these technological advances, remains widely cited for highlighting an absence of troponin rise in two-thirds of myocarditis cases (2). We hypothesize that all cases of myocarditis exhibit hs-Tn rise. However, whether such elevations in hs-Tn or inflammatory markers correlate with the extent of myocardial injury and left ventricular systolic dysfunction (LVSD) on CMR remain unclear. To provide insight into this, we examined a contemporary cohort of cases between 2019-2023. Methods Two authors independently conducted case-notes reviews to verify the diagnosis of myocarditis. CMR findings were stratified into regional (e.g. inferolateral) and global myocarditis (e.g. subepicardial LGE in all segments). This classification aimed to explore potential correlations with LVSD severity, peak hs-Tn and other inflammatory markers. Receiver operating characteristics (ROC) curves was calculated to determine any cut-off value for predicting CMR findings and adverse patient outcomes. Results 103 inpatients were clinically coded as ‘myocarditis’ upon discharge, but subsequent CMR (within 4 weeks) reclassified 23 patients into other causes (Figure 1). Analysis of the myocarditis cohort revealed a predominantly male population (76%) with median age 53, commonly presenting with chest pain without a viral prodrome (Figure 2A-D). Elevated hs-Tn levels were observed universally, with a median peak hs-TnT of 610ng/L (IQR 1081.5ng/L) and hs-TnI of 3820ng/L (IQR 12416ng/L). In contrast, peak CRP ranged between 2mg/L (normal) and 600mg/L. Global myocarditis was detected in 11/80 patients (13.8%); however, this finding did not correlate with adverse patient outcomes which included all-cause mortality (9.6%) and cardiac re-admissions within 12 months (9.6%, namely for chest pains). No arrhythmic deaths were noted. COVID was present in 4% on admission. CRP cut-off of 140mg/L predicted the occurrence of global myocarditis with a sensitivity of 72.7% and specificity of 87.0% (AUC 0.74, 95% CI 0.52-0.96, p=0.014) (Figure 2E). However, neither hs-Tn or CRP levels correlated with the degree of LVSD (Figure 2F) or adverse outcomes. This is likely limited by the small sample. Conclusion Although all cases of myocarditis exhibited raised hs-Tn, this did not correlate with the degree of LV systolic impairment on CMR. Myocarditis with regional LV involvement can have normal CRP levels, while a CRP cut-off &amp;gt;140mg/L may predict the occurrence of global myocarditis. However, CMR stratification into regional and global was not associated with adverse patient outcome within 12 months. A larger sample size is required to verify this finding, including longer term follow-ups.Flowchart of patients included in studyMain findings

Comparison of rapid test for high-sensitivity troponin I with laboratory high-sensitivity troponin T in patients with acute chest pain - a prospective monocentric study

Abstract Background and purpose High-sensitivity troponin (hs-Tn) assays are recommended for routine clinical use for diagnosis of acute coronary syndrome (ACS). However, laboratory hs-TnT can be elevated due to non-cardiac conditions, such as pulmonary embolism, skeletal muscle injury or chronic kidney disease. The aim of our study was to compare the diagnostic accuracy of the bed-side rapid hs-troponin I (hs-TnI) assay with hs-TnT measured by routine laboratory. Methods This prospective monocentric study was conducted at a tertiary hospital outpatient cardiac unit with an emergency clinic for patients with acute symptoms. A total of 129 patients were included between May 2021 and August 2022. Hs-TnI was measured via a bed-side test from whole blood directly in the emergency room, while hs-TnT was measured from plasma through the routine laboratory. Definite ACS was confirmed by coronary angiography. Patients were compared by grouping them into definitive diagnosis of ACS or no ACS. Hs-TnI as well as hs-TnT values were compared for accuracy and predictive values. Routine clinical parameters and comorbidities were documented and compared as well. Agreement between hs-TnI and hs-TnT was assessed by likelihood ratios and Bland Altman plot. Results Overall, 129 patients (65.1% male, 61.8 ± 15.6 years) with acute chest pain were analysed. Median hs-TnI was 7.0 ng/L (IQR: 2.7-15.8), while median hs-TnT was 14 ng/L (IQR: 7.0-31.0). Results for TnI were available faster (average: 1:14 h ± 0:54) compared to TnT. Coronary angiography confirmed ACS in 17 patients (13.2%) displaying significant coronary stenoses requiring intervention. The relative risk of ACS patients to have an elevated hs-TnI result was 6.59 compared to that of 2.29 for the hs-TnT test, meaning that a positive hs-TnI test was a better classifier for validated ACS than that of hs-TnT. Hs-TnI exhibited equivalent negative predictive value to hs-TnT (99%) for definite ACS diagnosis, but had comparatively higher positive predictive value (50.0 vs. 25.8%). Bland Altman plot of hs-TnI versus hs-TnT showed an average difference of -4.6 ng/L (95% CI: -12.4 to 3.2) between the tests. In 39 patients with chronic kidney disease (minimum stage 3a CKD) median hs-TnT (27.0 ng/L, IQR: 16.0-55.0) values were higher than hs-TnI (11.2 ng/L, IQR: 7.5-30.7). Conclusion Bed-side hs-TnI is comparable to hs-TnT with a high degree of agreement. Measurement of troponin I using the rapid bed-side hs-TnI assay possesses a shorter blood-draw-to-result-time than routine troponin T measurement.

Incidence of MINOCA in the high-sensitivity troponin era: a meta-analysis

Abstract Background and Aim Myocardial infarction with non-obstructive coronary arteries (MINOCA) is often under-recognised in clinical practice. The reported incidence of MINOCA was estimated to be 6% of MI presentations by Pasupathy et al. in the era preceding adoption of high sensitivity troponin assays. We sought to investigate the incidence of MINOCA in the high-sensitivity troponin era as compared to incidence of MINOCA during the era of traditional cardiac biomarkers (standard troponin assays, CK, CK-MB). Methods A prospective systematic review and meta-analysis using MEDLINE and EMBASE to capture relevant papers from 1996-2022 was performed. Papers detailing incidence of MI-CAD and MINOCA as well as the utilised biomarkers were included. Patient demographics, presentation and recorded biomarkers were also analysed for pre-specified analysis. Results 47 studies detailing the results of 667 850 patients were included. 53 586 patients were identified to have MINOCA with a mean weight incidence of 9.1% (7.3-11.3, 95% CI). MI-CAD patients were more likely to be male (68.5% vs 39.3%, RR (0.59, 0.74)) and had higher incidence of traditional cardiac risk factors. Notably chronic kidney disease was not associated with higher incidence of MICAD over MINOCA (RR 0.72, 0.5-1.03). There were no significant trends in incidence of MINOCA according to median year of study recruitment (ß=-0.18, (-0.76, 0.4) p=0.537). MINOCA patients were more likely to present as NSTEMI (14.5% (11.3-18.3, 95%CI)) rather than STEMI (3.5% (2.7-4.7%)). MINOCA patients had lower cardiac biomarker elevations than patients with MICAD. Conclusions The incidence of MINOCA higher than previously estimated in the era of high sensitivity troponin. MINOCA patients are less likely to have traditional cardiac risk factors and more likely to present with NSTEMI and smaller cardiac biomarker elevations than patients with MI-CAD.MINOCA RateMINOCA vs MI-CAD Risk Factors

Early high-sensitivity troponin elevation in predicting short-term mortality in sepsis: A protocol for a systematic review with meta-analysis.

Sepsis is a common admission diagnosis in the intensive care unit (ICU). The Sepsis-3 consensus associates sepsis diagnosis with acute organ dysfunction. In these patients troponin elevation is a well-established phenomenon, but its clinical significance is not settled, as no systematic review has addressed the prognostic significance of the increasingly prevalent high-sensitivity troponin assays in acute organ dysfunction setting. This study aims to clarify the association between early serum troponin levels in high-sensitivity assays with short-term mortality risk in septic patients with acute organ dysfunction. We will systematically search PubMed, Scopus and Embase for original articles; additionally, a manual search will be carried out through relevant literature. Generally, studies will be deemed eligible for inclusion if they evaluate the association between high-sensitivity troponin in the first 24 hours of admission and ICU, 30-days, or In-hospital mortality; in patients with septic shock or sepsis related to acute organ dysfunction. Two reviewers will independently select studies and extract the data. A meta-analysis for mortality outcome will be performed for comparative data regarding two effect measures: Odd ratios and Standardized Mean differences. This study will provide further evidence about the role of high-sensitivity troponin assays in predicting mortality in septic patients; potentially helping to guide further research and yielding valuable information for patient assessment. Conclusion about the certainty of evidence will be presented in a ´Summary of findings´ table. PROSPERO registration: (CRD42024468883).

Effectiveness of accelerated diagnostic protocols for reducing emergency department length of stay in patients presenting with chest pain: A systematic review and meta-analysis.

In recent years, there has been an increase in the use of accelerated diagnostic protocols (ADPs) and high-sensitivity troponin assays (hsTn) for the assessment of chest pain in emergency departments (EDs). This study aimed to quantitatively summarize the operational and clinical outcomes of ADPs implemented for patients with suspected cardiac chest pain. To be considered eligible for inclusion, studies must have implemented some form of ADP within the ED for evaluating adult (age ≥18 years) patients presenting with chest pain using Tn assays. The primary outcome was ED length of stay (LOS). Secondary outcomes included the proportion of patients admitted and the proportion with 30-day major adverse cardiac events (MACE). Thirty-seven articles involving 404,566 patients met the inclusion criteria, including five randomized controlled trials (RCTs) and 32 observational studies. A significant reduction in total ED LOS was reported in 22 observational studies and four RCTs. Emergency departments with longer baseline ED LOS showed significantly larger reductions in LOS after ADP implementation. This observed association persisted after adjusting for both the change in serial Tn measurement interval and transition from conventional Tn assay to an hsTn assay (β = -0.26; 95% CI, -0.43 to -0.10). Three studies reported an increase in the proportion of patients admitted after introducing an ADP, one of which was significant while 15 studies reported a significant decrease in admission proportion. There was moderate heterogeneity among the 13 studies that reported MACE proportions, with a non-significant pooled risk ratio of 0.95 (95% CI, 0.86-1.04). Implementation of ADPs for chest pain presentations decreases ED LOS, most noticeably within sites with a high baseline LOS; this decreased LOS is seen even in the absence of any change in troponin assay type. The decrease in LOS occurred alongside reductions in hospital admissions, while not increasing MACE. The observed benefits translated across multiple countries and health regions.

Emergency Department use of a high-sensitivity Point-of-Care troponin assay reduces length of stay: an implementation study preliminary report.

Point-of-care (POC) high-sensitivity troponin (hs-cTn) assays within a clinical pathway may safely reduce length of stay (LoS) for patients presenting to the emergency department (ED) with possible acute myocardial infarction (AMI). In this early-report we present the first evaluation of a POC hs-cTn in real-life care. In adult patients presenting to ED investigated for possible AMI we compared the LoS in patients assessed with a troponin in the 8-weeks before (usual-care phase) and the 8-weeks following introduction of the Siemens Atellica VTLi POC hs-cTnI for decision-making (intervention phase). The VTLi replaced the laboratory (Beckman Coulter) assay as the default hs-cTn test within the clinical pathway. This was the only change to the pathway process. The safety outcome was first event AMI or cardiac death within 30-days. There were 2376 presentations in the usual-care phase with 188 individuals with AMI and 2392 in the intervention phase with 198 AMI. In the intervention phase there was a mean (95% CI) reduction in LoS of 32 minutes (22 mins to 41 mins) compared with the usual-care phase. This represents 21.4 fewer patient-hours in the ED each day (1196 in the 8-week period). In both phases the pathway correctly identified all cases of AMI at index attendance. There were four follow-up events (2 usual-care, 2 intervention) within 30d. The deployment of a hs-cTn POC analyser into a large ED safely reduced length of stay. If translatable to other EDs this could represent an important advancement to patient care.

High-Sensitivity Troponin: Finding a Meaningful Delta.

High-sensitivity cardiac troponin (hs-cTn) assays have significantly refined the resolution of biomarker-level detection and have emerged as the gold standard cardiac biomarker in evaluating myocardial injury. Since its introduction, hs-cTn has been integrated into the Fourth Universal Definition of Myocardial Infarction and various European Society of Cardiology (ESC) and American College of Cardiology/American Heart Association (ACC/AHA) guidelines for the evaluation and diagnosis of chest pain syndromes. However, despite its integral role in caring for patients with chest pain, there are still substantive gaps in our knowledge of the clinical interpretation of dynamic changes in hs-cTn values. Whether a relative or absolute hs-cTn delta should be used to detect acute myocardial injury remains debatable. There are also emerging considerations of possible sex and racial/ethnic differences in clinically significant troponin deltas. In the emergency department, there is debate about the optimal time frame to recheck hs-cTn after symptom onset for myocardial infarction rule-out and whether hs-cTn deltas should be integrated into clinical risk scores. In this review, we will provide an overview of the history of clinical utilization of cardiac biomarkers, the development of hs-cTn assays, and the ongoing search for a meaningful delta that can be clinically applicable.

High-Sensitivity Cardiac Troponin T Reporting, Clinical Outcomes, and Health Care Resource Use

Despite being recommended by clinical guidelines, substantial concerns remain regarding the use of high-sensitivity cardiac troponin assays and whether it is associated with increased resource use, myocardial infarction (MI) or myocardial injury diagnoses, and procedural rates. To characterize the association of reporting high-sensitivity cardiac troponin T (hs-cTnT) to the lowest limit of quantification vs conventional troponin reporting with clinical outcomes. This cohort study used a historically controlled baseline and follow-up design to compare clinical outcomes after changing hs-cTnT reporting to the lowest limit of quantification. All patients aged 18 years or older presenting to any public emergency department (ED) in the state of South Australia between February 1, 2020, and February 28, 2021, who had an hs-cTnT test in the 6 months before and after the change in troponin reporting practice were included. Outcomes were assessed after adjusting for patient characteristics using inverse probability treatment weighting. The data analysis was performed between May 1, 2022, and July 27, 2023. hs-cTcnT reporting. The main outcomes were frequency of diagnosed MI, coronary angiography, percutaneous coronary intervention, and coronary artery bypass graft (CABG); hospital length of stay; and ED discharge rate as measured using time-to-event Cox regression models. The secondary outcome was the composite 12-month event rate of all-cause mortality, MI, and myocardial injury. A total of 40 921 patients were included, of whom 20 206 were included in the unmasked hs-cTnT reporting group (median [IQR] age, 62.0 [46.0-77.0]; 10 120 females [50.1%]) and 20 715 were included in the conventional troponin reporting group (median [IQR] age, 63.0 [47.0-77.0] years; 10 752 males [51.9%]). Unmasked hs-cTnT reporting was associated with higher ED discharge rates (45.2% vs 39.0%; P < .001) and a shorter median hospital length of stay (7.68 [IQR, 4.32-46.80] hours vs 7.92 [IQR, 4.56-49.92] hours; P < .001). There was no difference in diagnosis of MI, coronary angiography, percutaneous coronary intervention, or coronary artery bypass graft. The composite of all-cause mortality, MI, and myocardial injury at 12 months was similar (adjusted hazard ratio, 0.95; 95% CI, 0.90-1.01; P = .09). This cohort study found that unrestricted reporting of hs-cTnT results to the lowest limit of quantification was not associated with an increase in the diagnosis of MI, invasive coronary procedures, or harm at 12 months but may be associated with improved hospital resource use.

Optimal triage of patients with acute chest pain.

Acute chest pain (ACP) is one of the most common symptoms in patients admitted to emergency departments (ED). It can be related to several life-threatening cardiovascular conditions such as acute coronary syndrome (ACS), aortic dissection, and pulmonary embolism. The optimal triage of patients with ACP is a clinical and healthcare necessity given the large number of patients daily admitted to ED with this symptom. The first contact with the patient in ED includes the clinical appraisal of the characteristics of ACP and coexisting symptoms, and the assessment of the patient's medical history. Risk scores may help stratify a patient's likelihood of having cardiac chest pain. The ECG examination allows the identification of patients with ST-segment elevation, depression, or T-wave changes, but may be normal in patients with non-ST-segment elevation ACS. Rapid protocols based on serial high-sensitivity cardiac troponin assays within one or two hours are recommended for identifying candidates for early discharge. Due to the bedside feasibility, non-invasiveness, and wide availability, transthoracic echocardiography represents the first-line imaging modality for evaluating patients with ACP. In selected cases, computed tomography angiography may also be performed. A practical approach to ACP in ED should improve patient outcomes and reduce healthcare system costs. This review aimed to provide an overview of the characteristics of patients with ACP of cardiac origin and to describe the state of the art about their management in the ED.

Implementation of a High-sensitivity Troponin Assay for Adult Patients Who Present to the Emergency Department With Chest Pain: The Role of Clinical Decision Support

BackgroundThe objective of this study was to assess the health outcomes for patients who present to the emergency department (ED) with cardiac chest pain after the implementation of an accelerated diagnostic protocol using a high-sensitivity troponin assay (hs-TnI). MethodsThis prospective before-after cohort study used population-based linked health administrative data for adult patients who presented to a Canadian urban ED with chest pain of suspected cardiac origin over a 2-year study period. The primary outcome was ED length of stay (LOS). Secondary outcomes included operational and clinical outcomes within 30 days of the index ED visit. ResultsDuring the study period, 4339 patients were included, with 2031 in the conventional troponin group and 2308 in the hs-TnI group. Overall, the median age was 56 years and 52% were male. The median ED LOS was reduced from 430 minutes to 400 minutes after protocol implementation (median difference, -30.0; 95% confidence interval, -47.8 to -12.3). For discharged patients who underwent serial troponin tests, the LOS was 89 minutes shorter (95% confidence interval, -110.8 to -67.2). The proportion of patients discharged increased from 73% to 78% after implementation (P = 0.0001). At 30 days, there were no differences in hospital readmission or major adverse event outcomes. ConclusionsUsing clinical decision support, the implementation of a new hs-TnI and accelerated diagnostic protocol was associated with shorter ED LOS and fewer hospitalizations for adult patients with chest pain who were assessed in the ED. These results suggest that the protocol is effective and safe in real-world clinical settings.

Diagnostic accuracy of a machine learning algorithm using point-of-care high-sensitivity cardiac troponin I for rapid rule-out of myocardial infarction: a retrospective study

Point-of-care (POC) high-sensitivity cardiac troponin (hs-cTn) assays have been shown to provide similar analytical precision despite substantially shorter turnaround times compared with laboratory-based hs-cTn assays. We applied the previously developed machine learning based personalised Artificial Intelligence in Suspected Myocardial Infarction Study (ARTEMIS) algorithm, which can predict the individual probability of myocardial infarction, with a single POC hs-cTn measurement, and compared its diagnostic performance with standard-of-care pathways for rapid rule-out of myocardial infarction. We retrospectively analysed pooled data from consecutive patients of two prospective observational cohorts in geographically distinct regions (the Safe Emergency Department Discharge Rate cohort from the USA and the Suspected Acute Myocardial Infarction in Emergency cohort from Australia) who presented to the emergency department with suspected myocardial infarction. Patients with ST-segment elevation myocardial infarction were excluded. Safety and efficacy of direct rule-out of myocardial infarction by the ARTEMIS algorithm (at a pre-specified probability threshold of <0·5%) were compared with the European Society of Cardiology (ESC)-recommended and the American College of Cardiology (ACC)-recommended 0 h pathways using a single POC high-sensitivity cardiac troponin I (hs-cTnI) measurement (Siemens Atellica VTLi as investigational assay). The primary diagnostic outcome was an adjudicated index diagnosis of type 1 or type 2 myocardial infarction according to the Fourth Universal Definition of Myocardial Infarction. The safety outcome was a composite of incident myocardial infarction and cardiovascular death (follow-up events) at 30 days. Additional analyses were performed for type I myocardial infarction only (secondary diagnostic outcome), and for each cohort separately. Subgroup analyses were performed for age (<65 years vs ≥65 years), sex, symptom onset (≤3 h vs >3 h), estimated glomerular filtration rate (<60 mL/min per 1·73 m2vs ≥60 mL/min per 1·73 m2), and absence or presence of arterial hypertension, diabetes, a history of coronary artery disease, myocardial infarction, or heart failure, smoking, and ischaemic electrocardiogram signs. Among 2560 patients (1075 [42%] women, median age 58 years [IQR 48·0-69·0]), prevalence of myocardial infarction was 6·5% (166/2560). The ARTEMIS-POC algorithm classified 899 patients (35·1%) as suitable for rapid rule-out with a negative predictive value of 99·96% (95% CI 99·64-99·96) and a sensitivity of 99·68% (97·21-99·70). For type I myocardial infarction only, negative predictive value and sensitivity were both 100%. Proportions of missed index myocardial infarction (0·05% [0·04-0·42]) and follow-up events at 30 days (0·07% [95% CI 0·06-0·59]) were low. While maintaining high safety, the ARTEMIS-POC algorithm identified more than twice as many patients as eligible for direct rule-out compared with guideline-recommended ESC 0 h (15·2%) and ACC 0 h (13·8%) pathways. Superior efficacy persisted across all clinically relevant subgroups. The patient-tailored, medical decision support ARTEMIS-POC algorithm applied with a single POC hs-cTnI measurement allows for very rapid, safe, and more efficient direct rule-out of myocardial infarction than guideline-recommended pathways. It has the potential to expedite the safe discharge of low-risk patients from the emergency department including early presenters with symptom onset less than 3 h at the time of admission and might open new opportunities for the triage of patients with suspected myocardial infarction even in ambulatory, preclinical, or geographically isolated care settings. The German Center for Cardiovascular Research (DZHK).

THE ANALYSIS STUDY OF DIAGNOSTIC ACCURACY OF SINGLE SAMPLE RULE-OUT OF HIGH-SENSITIVITY CARDIAC TROPONIN IN DIAGNOSIS OF ACUTE MYOCARDIAL INFARCTION IN EMERGENCY DEPARTEMENT: A COMPREHENSIVE SYSTEMATIC REVIEW FROM LABORATORY DEPARTMENT

Background: High-sensitivity cardiac troponin (hs-cTn) assays has significantly enhanced the diagnostic of acute myocard infark (AMI). Recent studies have shown that hs-cTn assays can effectively rule out AMI with a single sample. This systematic review aim to evaluate the diagnostic accuracy of single sample rule-out of high-sensitivity cardiac troponin in diagnosis of acute myocardial infarction in emergency departement based on literatures of the last 10 years. Methods: The study adhered to PRISMA 2020 standards, examining English literature from 2014 to 2024. It excluded editorials, reviews from the same journal, and submissions without a DOI. PubMed, SagePub, SpringerLink, and Google Scholar were utilized as literature sources. Result: Initially retrieving 360 articles from online databases (PubMed, SagePub, SpringerLink and Google Scholar) eight relevant papers were selected after three rounds of screening for full-text analysis. Conclusion: High-sensitivity cardiac troponin I assays enable rapid AMI rule-out in emergency departments, offering high sensitivity and negative predictive value. However, caution is needed when ruling in AMI, and further research is required to optimize their use.

Evaluating the Rates of Mortality and Cardiac Catheterization Using High-Sensitivity Troponin and Conventional Troponin Assays.

Non-ST segment elevation myocardial infarction (NSTEMI) is an acute coronary syndrome event where myocardial ischemia is present, with an increase of cardiac troponins without an elevation of the ST segment.One of the fundamental measures used to diagnose or rule out acute coronary syndrome (ACS) is troponin levels in the blood.Troponin is a broad term used for the category of muscle contraction regulatory proteins and is commonly measured during ACS evaluation. Troponin I is only released by cardiac tissue, while some assay measurements will also pick up troponin released by skeletal muscle injury. This retrospective observational study was performed investigating troponin assays and how they relate to patient's outcomes. The troponin assays used in this Miami hospital where the database of patients was collected between 2018 and 2023 were troponin I (cTnI), the conventional troponin assay, and the newer high-sensitivity troponin I assay (hs-cTn). In this observational study patients who received an admitting diagnosis of NSTEMI corroborated by an independent cardiologist had their respective troponin assay levels included. Patients found to have ECG changes significant for non-ischemic pathologies, or echocardiogram findings suggestive of myocardial dysfunction not clinically correlated to an ACS were excluded from the study. A total of 75 patients were included in this study and the mean age was 75.97 ±14.72 years, with a presentation of chest pain, dyspnea and general weakness recorded in 59% (n = 45) of patients. The median time between troponin samples was 6.63 hours across both assays and hs-cTn showed a 4.99% increase in variation between samples while cTnI had a decrease of 2.53%. The study objective is to support whether there is a difference in rates of cardiac catheterization or mortality based on the type of troponin testing. There was no significant association found between, the type of troponin assay used during hospital admission, and the outcomes of catheterization and death (p > 0.009).

Prehospital tirofiban increases the rate of disrupted myocardial infarction in patients with ST-segment elevation myocardial infarction: insights from the On-TIME 2 trial.

In patients with ST-segment elevation myocardial infarction (STEMI), prehospital tirofiban significantly improved myocardial reperfusion. However, its impact on the rate of disrupted myocardial infarction (MI), particularly in the context of high-sensitivity cardiac troponin (hs-cTn) assays, is still unclear. The On-TIME 2 (Ongoing Tirofiban In Myocardial infarction Evaluation 2) trial randomly assigned STEMI patients to prehospital tirofiban or placebo before transportation to a percutaneous coronary intervention (PCI) centre. In this post hoc analysis, we evaluated STEMI patients that underwent primary PCI and had measured hs-cTn levels. Troponin T levels were collected at 18-24 and 72-96 h after PCI. Disrupted MI was defined as peak hs-cTn T levels ≤ 10 times the upper limit of normal (≤140 ng/L). Out of 786 STEMI patients, 47 (6%) had a disrupted MI. Disrupted MI occurred in 31 of 386 patients (8.0%) in the tirofiban arm and in 16 of 400 patients (4.0%) in the placebo arm (P = 0.026). After multivariate adjustment, prehospital tirofiban remained independently associated with disrupted MI (odds ratio 2.03; 95% confidence interval 1.10-3.87; P = 0.027). None of the patients with disrupted MI died during the 1-year follow-up, compared with a mortality rate of 2.6% among those without disrupted MI. Among STEMI patients undergoing primary PCI, the use of prehospital tirofiban was independently associated with a higher rate of disrupted MI. These results, highlighting a potential benefit, underscore the need for future research focusing on innovative pre-treatment approaches that may increase the rate of disrupted MI.

High-Sensitivity Troponin Assays are Safe to Rule-Out Myocardial Infarction Even if They Have High Imprecision

High-Sensitivity Troponin Assays are Safe to Rule-Out Myocardial Infarction Even if They Have High Imprecision

Knowledge of the high-sensitivity cardiac troponin assay among medical officers in Gampaha District, Sri Lanka: A cross sectional study

Knowledge of the high-sensitivity cardiac troponin assay among medical officers in Gampaha District, Sri Lanka: A cross sectional study