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Risk Stratification in Patients With Acute Chest Pain Using Three High-Sensitivity Cardiac Troponin Assays
Study Questions:
What is the early and long-term prognostic accuracy of three novel high-sensitivity cardiac troponin (hs-cTn) assays in comparison with a conventional cTn assay?
Methods:
In a prospective, international, multicenter study, cTn was simultaneously measured with three novel (hs-cTnT, Roche Diagnostics; hs-cTnI, Beckman-Coulter; hs-cTnI, Siemens) and a conventional assay (cTnT, Roche Diagnostics) in a blinded fashion in 1,117 unselected patients with acute chest pain. Patients were followed up at 2 years regarding mortality. The Kaplan-Meier method was employed to analyze the timing of events during the follow-up. Statistical assessment was performed using the log-rank test.
Results:
Eighty-two (7.3%) patients died during the follow-up. The 2-year prognostic accuracy of hs-cTn was most accurate for hs-cTnT (area under the receiver operating characteristic curve [AUC], 0.78; 95% confidence interval [CI], 0.73-0.83) and outperformed both hs-cTnI (Beckman-Coulter, 0.71; 95% CI, 0.65-0.77; p = 0.001 for comparison), hs-cTnI (Siemens, 0.70; 95% CI, 0.64-0.76; p < 0.001 for comparison), and cTnT (0.67; 95% CI, 0.61-0.74; p < 0.001 for comparison). Absolute changes of hs-cTnT were more accurate than relative changes in predicting mortality, but inferior to presentation values of hs-cTnT. Combining changes of hs-cTnT within the first 6 hours with their presentation values did not further improve prognostic accuracy. Similar results were obtained for both hs-cTnI assays regarding the incremental value of changes. Hs-cTn concentrations remained predictors of death in clinically challenging subgroups such as patients with pre-existing coronary artery disease, impaired renal function, and patients older than 75 years.
Conclusions:
The authors concluded that changes of hs-cTn do not seem to further improve risk stratification beyond initial presentation values.
Perspective:
This study reported that hs-cTn outperforms hs-cTnI in its prognostic accuracy both in all patients and in important subgroups such as patients with acute myocardial infarction (AMI) at presentation, pre-existing coronary artery disease, impaired renal function, or patients older than 70 years. Unlike in the diagnosis of AMI, serial measurements and changes of hs-cTn do not seem to further improve the prognostic accuracy of presentation values of hs-cTn. Based on these data, it appears that although cTnI and cTnT reflect the same pathological process, they do not seem to be interchangeable with each other as to their prognostic accuracy.
Keywords: Prognosis, Coronary Artery Disease, Myocardial Infarction, Renal Insufficiency, Follow-Up Studies, Biomarkers, Chest Pain, Troponin I, Troponin T
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