Uniform or Sex-Specific Troponin Thresholds to Rule Out MI

May 08, 2024
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Authors:
Li Z, Wereski R, Anand A, et al., on behalf of the High-STEACS and HiSTORIC Investigators.
Citation:
Uniform or Sex-Specific Cardiac Troponin Thresholds to Rule Out Myocardial Infarction at Presentation. J Am Coll Cardiol 2024;83:1855-1866.
Summary By:
Bina Ahmed, MD, FACC

Quick Takes

  • The current study assessed application of a uniform rule-out threshold (NPV 99.5%) for high-sensitivity cardiac troponin I (Abbott ARCHITECTSTAT high-sensitivity troponin I assay) in female and male patients and defined and validated sex-specific high-sensitivity cardiac troponin I assay rule-out thresholds for use in clinical practice.
  • Findings suggest that implementation of a uniform rule-out threshold (<5 ng/L) was safe and more likely to classify women as low risk compared to men.
  • Although there was a sex-specific difference in rule-out thresholds (<6 ng/L in females and <4 ng/L in males), this was unlikely to result in significant clinical impact.

Study Questions:

Is it safe and effective to implement a uniform rule-out threshold using a high-sensitivity cardiac troponin I (hs-cTnI) assay in female and male patients with possible myocardial infarction (MI), and to derive and validate sex-specific thresholds?

Methods:

The implementation of a uniform rule-out threshold (<5 ng/L) with an hs-cTnI assay was evaluated in consecutive patients presenting with possible MI. The proportion of low-risk patients discharged from the emergency department (ED) and incidence of MI or cardiac death at 30 days were determined. Sex-specific thresholds were derived and validated, and the proportion of female and male patients was stratified as low risk compared with uniform threshold.

Results:

In 16,792 patients (58 ± 17 years, 46% female), care was guided using a uniform threshold. This identified more female than male patients as low risk (73% vs. 62%), but a similar proportion of low-risk patients was discharged from the ED (81% for both) with fewer than 5 (<0.1%) patients having a subsequent MI or cardiac death at 30 days. Compared to a uniform threshold of <5 ng/L, use of sex-specific thresholds would increase the proportion of female (61.8% vs. 65.9%) and reduce the proportion of male (54.8% vs. 47.8%) patients identified as low risk.

Conclusions:

Implementation of a uniform rule-out threshold for MI was safe and effective in both sexes. Sex-specific rule-out thresholds should be considered, but their impact on effectiveness and safety may be limited.

Perspective:

The current study assessed application of a uniform rule-out threshold (negative predictive value [NPV] 99.5%) for hs-cTnI (Abbott ARCHITECTSTAT high-sensitivity troponin I assay) in female and male patients and defined and validated sex-specific cTnI assay rule-out thresholds for use in clinical practice. Findings suggest that implementation of a uniform rule-out threshold (<5 ng/L) was safe and more likely to classify women as low risk compared to men. Although there was a sex-specific difference in rule-out thresholds (<6 ng/L in female and <4 ng/L in male patients), this was unlikely to result in significant clinical impact. Based on these findings, there does not appear to be utility in changing rule-out thresholds of hs-cTnI based on sex.

Clinical Topics: ACS and Cardiac Biomarkers

Keywords: Myocardial Infarction, Sex Characteristics, Troponin I


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