High sensitivity cardiac troponin and the under-diagnosis of myocardial infarction in women: prospective cohort study

Anoop S V Shah, Megan Griffiths, Kuan Ken Lee, David A McAllister, Amanda L Hunter, Amy V Ferry, Anne Cruikshank, Alan Reid, Mary Stoddart, Fiona Strachan, Simon Walker, Paul O Collinson, Fred S Apple, Alasdair J Gray, Keith A A Fox, David E Newby, Nicholas L Mills*

*Corresponding author for this work

Research output: Contribution to journalArticlepeer-review

Abstract

Objective: To evaluate the diagnosis of myocardial infarction using a high sensitivity troponin I assay and sex specific diagnostic thresholds in men and women with suspected acute coronary syndrome. 

Design: Prospective cohort study.

Setting: Regional cardiac centre, United Kingdom. 

Participants: Consecutive patients with suspected acute coronary syndrome (n = 1126, 46% women). Two cardiologists independently adjudicated the diagnosis of myocardial infarction by using a high sensitivity troponin I assay with sex specific diagnostic thresholds (men 34 ng/L, women 16 ng/L) and compared with current practice where a contemporary assay (50 ng/L, single threshold) was used to guide care. 

Main outcome measure: Diagnosis of myocardial infarction. 

Results: The high sensitivity troponin I assay noticeably increased the diagnosis of myocardial infarction in women (from 11% to 22%; P < 0.001) but had a minimal effect in men (from 19% to 21%, P = 0.002). Women were less likely than men to be referred to a cardiologist or undergo coronary revascularisation (P < 0.05 for both). At 12 months, women with undisclosed increases in troponin concentration (17-49 ng/L) and those with myocardial infarction (≥50 ng/L) had the highest rate of death or reinfarction compared with women without (≤16 ng/L) myocardial infarction (25%, 24%, and 4%, respectively; P < 0.001). 

Conclusions: Although having little effect in men, a high sensitivity troponin assay with sex specific diagnostic thresholds may double the diagnosis of myocardial infarction in women and identify those at high risk of reinfarction and death. Whether use of sex specific diagnostic thresholds will improve outcomes and tackle inequalities in the treatment of women with suspected acute coronary syndrome requires urgent attention.

Original languageEnglish
Article numberg7873
Number of pages8
JournalBritish Medical Journal (BMJ)
Volume350
Issue number7992
DOIs
Publication statusPublished - 21 Jan 2015

Keywords

  • Acute Coronary Syndrome
  • Aged
  • Aged, 80 and over
  • Biomarkers
  • Female
  • Humans
  • Male
  • Middle Aged
  • Myocardial Infarction
  • Prospective Studies
  • ROC Curve
  • Reference Values
  • Sensitivity and Specificity
  • Sex Factors
  • Troponin I

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