Prognostic value of short-interval high-sensitivity troponin delta in acute coronary syndrome: a systematic review and meta-analysis

High-sensitivity cardiac troponin (hs-cTn) testing revolutionized early diagnosis of acute coronary syndrome (ACS). Despite its precision, challenges persist regarding the optimal rule-in threshold, its adaptation in chronic kidney disease (CKD), and the most appropriate timing and interpretation of serial sampling (delta). Elevated baseline hs-cTn levels in CKD reduce the specificity of a single measurement, emphasizing the need for contextualized thresholds and well-defined deltas.

To synthesize evidence defining rule-in thresholds for hs-cTn, propose adaptations for CKD, and compare the diagnostic and prognostic accuracy of 0/1-hour, 0/2-hour and 0/3-hour serial measurement strategies.

A meta-analysis and guideline-based review were performed using MEDLINE, Embase, and Cochrane databases (2017–2025). Studies were included if they reported rule-in thresholds, absolute or relative delta definitions, and sampling intervals (0/1-hour, 0/2-hour, or 0/3-hour) in suspected ACS, including subanalyses for CKD populations.

Rule-in thresholds anchored to the 99th-percentile remain the diagnostic cornerstone, but in CKD, static thresholds cause false positives. Interpretation should focus on absolute delta changes, with larger deltas (≥20% or ≥5–10 ng/L) improving specificity while preserving sensitivity. The 0/2-hour algorithm offers optimal diagnostic balance, maintaining high sensitivity while improving specificity versus 0/1-hour testing. The 0/3-hour strategy works when early sampling isn't feasible.

In suspected ACS, rule-in decisions should prioritize assay-specific thresholds with absolute delta interpretation, compétitionespecially in CKD patients, where baseline hs-cTn is chronically elevated. The 0/2-hour strategy provides the best diagnostic and prognostic balance. Standardized renal-stratified cutoffs require validation before widespread adoption.

Interpreting HscTnT Recommanded approach