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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.
ESC 365 is supported by Bayer, Boehringer Ingelheim and Lilly Alliance, Bristol-Myers Squibb and Pfizer Alliance, Novartis Pharma AG and Vifor Pharma in the form of educational grants. The sponsors were not involved in the development of this platform and had no influence on its content.
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