Introduction of High-sensitivity Troponin Assays: Impact on Myocardial Infarction Incidence and Prognosis

doi:10.1016/j.amjmed.2012.07.015

The American Journal of Medicine

Volume 125, Issue 12, December 2012, Pages 1205-1213.e1

https://doi.org/10.1016/j.amjmed.2012.07.015 Get rights and content

Abstract

Objective

The study objective was to compare the incidence and prognosis of acute myocardial infarction when using high-sensitivity cardiac troponin assays instead of a standard cardiac troponin assay for the diagnosis of acute myocardial infarction.

Methods

In a prospective international multicenter study, we enrolled 1124 consecutive patients presenting with suspected acute myocardial infarction. Final diagnoses were adjudicated by 2 independent cardiologists 2 times using all available clinical information: first using standard cardiac troponin levels and second using high-sensitivity cardiac troponin T levels for adjudication. Patients were followed up for a mean of 19 ± 9 months.

Results

The use of high-sensitivity cardiac troponin T instead of standard cardiac troponin resulted in an increase in the incidence of acute myocardial infarction from 18% to 22% (242 vs 198 patients), a relative increase of 22%. Of the 44 additional acute myocardial infarctions, 35 were type 1 acute myocardial infarctions and 9 were type 2 acute myocardial infarctions. This was accompanied by a reciprocal decrease in the incidence of unstable angina (unstable angina, 11% vs 13%). The most pronounced increase was observed in patients adjudicated with cardiac symptoms of origin other than coronary artery disease with cardiomyocyte damage (83 vs 31 patients, relative increase of 268%). Cumulative 30-month mortality rates were 4.8% in patients without acute myocardial infarction, 16.4% in patients with a small acute myocardial infarction detected only by high-sensitivity cardiac troponin T but not standard cardiac troponin, and 23.9% in patients with a moderate/large acute myocardial infarction according to standard cardiac troponin assays and high-sensitivity cardiac troponin T (P < .001).

Conclusions

The introduction of high-sensitivity cardiac troponin assays leads to only a modest increase in the incidence of acute myocardial infarction. The novel sensitive assays identify an additional high-risk group of patients with increased mortality, therefore appropriately classified with acute myocardial infarction (Advantageous Predictors of Acute Coronary Syndromes Evaluation; NCT00470587).

Section snippets

Study Design and Population

Advantageous Predictors of Acute Coronary Syndrome Evaluation is an ongoing prospective international multicenter study designed and coordinated by the University Hospital Basel (NCT00470587).11, 16, 17 From April 2006 to June 2009, a total of 1247 consecutive patients presenting to the emergency department with symptoms suggestive of acute myocardial infarction, such as chest pain and angina pectoris with an onset or peak within the last 12 hours, were recruited. Patients with terminal kidney

Final Adjudicated Diagnoses According to Standard Cardiac Troponin Assays

Among the 1124 patients presenting to the emergency department with acute chest pain, the final diagnosis adjudicated with the use of the standard cardiac troponin assays was acute myocardial infarction in 198 patients (18%), 25% of whom had ST-elevation myocardial infarction and 75% of whom had non–ST-elevation myocardial infarction. Other diagnoses included unstable angina in 151 patients (13%), cardiac disease other than coronary artery disease with cardiomyocyte damage in 31 patients (3%),

Discussion

This study assessed the change in incidence of acute myocardial infarction associated with the clinical introduction of high-sensitivity cardiac troponin assays and the prognosis of patients newly identified with acute myocardial infarction. We report 2 major findings:

First, our data show an only modest relative increase of 22% in the incidence of acute myocardial infarction from 18% to 22% due to an increase in non-ST-elevation myocardial infarctions. This increase in acute myocardial

Conclusions

The clinical introduction of high-sensitivity cardiac troponin assays will lead to a modest increase in the incidence of acute myocardial infarction, a small decrease in unstable angina, and a marked increase in patients with cardiac diseases other than coronary artery disease but relevant cardiomyocyte damage. The patients with small acute myocardial infarctions also identified by high-sensitivity cardiac troponin assays have a significantly increased mortality during long-term follow-up and

Acknowledgments

The authors thank the patients who participated in the study, the staff of the emergency department, the laboratory technicians, and particularly Kirsten Hochholzer, MS, Irina Klimmeck, RN, Melanie Wieland, RN, Fausta Chiaverio, RN (all at University Hospital Basel, Switzerland), Esther Garrido, MD, Federico Peter, MD, Isabel Campodarve, MD, and Joachim Gea, MD (at Hospital del Mar, IMIM, Barcelona, Spain) for the valuable efforts with data acquisition and sample processing. The authors also

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: Funding: The study was supported by research grants from the Swiss National Science Foundation (PP00B-102853), the Swiss Heart Foundation, Abbott, Brahms, Roche, Siemens, and the Department of Internal Medicine, University Hospital Basel.

: Conflict of Interest: Dr Reichlin has received research grants from the Swiss National Science Foundation (PASMP3-136995), the Swiss Heart Foundation, the Prof Cloetta Foundation, the University of Basel, and the Department of Internal Medicine, University Hospital Basel, as well as speaker honoraria from BRAHMS and Roche. Dr Mueller has received research support from the Swiss National Science Foundation (PP00B-102853), the Swiss Heart Foundation, Abbott, ALERE, Beckman Coulter, BRAHMS, Bühlmann Nanosphere, Roche, Siemens, and the Department of Internal Medicine, University Hospital Basel, as well as speaker honoraria from Abbott, ALERE, BRAHMS, Roche, and Siemens. All other authors declare that they have no conflict of interest. The high-sensitivity cardiac troponin T assay was donated by Roche, which had no role in the design of the study, the analysis of the data, the preparation of the manuscript, or the decision to submit the manuscript for publication.

: Authorship: All authors had access to the data and played a role in writing this manuscript.

View full text

Clinical research studyIntroduction of High-sensitivity Troponin Assays: Impact on Myocardial Infarction Incidence and Prognosis

Abstract

Objective

Methods

Results

Conclusions

Section snippets

Study Design and Population

Final Adjudicated Diagnoses According to Standard Cardiac Troponin Assays

Discussion

Conclusions

Acknowledgments

J Am Coll Cardiol

Am J Med

Am J Cardiol

Am J Cardiol

J Am Coll Cardiol

Am Heart J

J Am Coll Cardiol

Clin Chim Acta

Am J Med

J Am Coll Cardiol

Am Heart J

Clin Chim Acta

Nomenclature and criteria for diagnosis of ischemic heart diseaseReport of the Joint International Society and Federation of Cardiology/World Health Organization task force on standardization of clinical nomenclature

Circulation

Myocardial infarction redefined—a consensus document of The Joint European Society of Cardiology/American College of Cardiology Committee for the redefinition of myocardial infarction

J Am Coll Cardiol

Universal definition of myocardial infarction

Circulation

Population trends in the incidence and outcomes of acute myocardial infarction

N Engl J Med

Clinical research study
Introduction of High-sensitivity Troponin Assays: Impact on Myocardial Infarction Incidence and Prognosis