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Clinical effect of sex-specific cutoff values of high-sensitivity cardiac troponin i in suspected myocardial infarction
Authors : M Rubini Gimenez (Basel,CH), P Badertscher (Basel,CH), R Twerenbold (Basel,CH), J Boeddinghaus (Basel,CH), T Nestelberger (Basel,CH), D Wussler (Basel,CH), O Miro (Barcelona,ES), J Martin-Sanchez (Madrid,ES), T Reichlin (Basel,CH), C Mueller (Basel,CH)
M. Rubini Gimenez1
,
P. Badertscher1
,
R. Twerenbold1
,
J. Boeddinghaus1
,
T. Nestelberger1
,
D. Wussler1
,
O. Miro2
,
J. Martin-Sanchez3
,
T. Reichlin1
,
C. Mueller1
,
1University Hospital Basel, Department of Cardiology - Basel - Switzerland
,
2Hospital Clinic de Barcelona, Emergency Department - Barcelona - Spain
,
3Hospital Clinic San Carlos, Emergency Department - Madrid - Spain
,
Background: Recent studies supported the use of a uniform 99th percentile for high sensitive cardiac troponin (hs-cTn) T in the diagnosis of myocardial infarction (MI). Data regarding hs-cTnI from observational studies have been controversial. hs-cTn I and T have shown pathophysiological differences, additionally the currently used 99th percentile for hs-cTnI has shown not to be biologically equivalent to the 99th percentile for hs-cTnT. Hence the diagnostic changes in women and men induced by sex-specific cutoff values hs-cTnIneed to be explored in more detail to corroborate whether also uniform values of hs-cTnI should remain the standard of care.
Methods: In an ongoing prospective, diagnostic, multicenter study conducted at 9 emergency departments (ED), we evaluated patients presenting to the ED with suspected MI. Patients presenting with ST-Segment-Elevation MI were excluded. The final diagnosis was centrally adjudicated by 2 independent cardiologists using all available information, including measurements of serial hs-cTnI blood concentrations twice: once using the uniform 99th percentile cutoff value level of 26.2 ng/L and once using sex-specific 99th percentile values of hs-cTnI (women, 16 ng/L; men, 34 ng/L). The clinical impact of using sex-specific cutoffs was quantified by assessing diagnostic reclassifications when using sex-specific values.
Results: Among 3789 patients, 1230 were women (32.5%) and 2559 men (67.5%). Median (interquartile range) age was 68 (54–78) and 59 (47–72) years, respectively. With the use of the uniform cutoff value, 159 women (12.9%) and 431 men (16.8%) received a final diagnosis of MI. Among these, at ED presentation, levels of hs-cTnI were already above the uniform cutoff value in 474 patients (sensitivity, 78.0% [95% CI, 70.7–84.2] in women vs 81.2% [95% CI, 77.2–84.8 in men]; specificity, 91.5% [95% CI, 89.7–93.1] in women vs 92.1% [95% CI, 90.9%-93.2%] in men). After readjudication using sex-specific 99th percentile values, diagnostic reclassification regarding MI occurred in only 5 patients: 0.13% (95% CI, 0.04–0.30) of all patients and 0.84% (95% CI, 0.27–1.96) of patients with MI. The diagnosis in 1 woman was upgraded from unstable angina to MI, and the diagnosis in 4 men was downgraded from MI to unstable angina. Figure.
Conclusions: The uniform 99th percentile should remain the standard of care also when using hs-cTnI values for the diagnosis of MI.
