TY - JOUR
T1 - Influence of age on the diagnosis of myocardial infarction
AU - High-STEACS Investigators
AU - Lowry, Matthew TH
AU - Doudesis, Dimitrios
AU - Wereski, Ryan
AU - Kimenai, Dorien M
AU - Tuck, Chris
AU - Ferry, Amy V
AU - Bularga, Anda
AU - Taggart, Caelan
AU - Lee, Ken
AU - Chapman, Andrew R
AU - Shah, Anoop S V
AU - Newby, David E
AU - Mills, Nicholas L
AU - Anand, Atul
N1 - Funding Information:
Dr Mills reports research grants awarded to the University of Edinburgh from Abbott Diagnostics and Siemens Healthineers outside the submitted work, and honoraria from Abbott Diagnostics, Siemens Healthineers, Roche Diagnostics, and LumiraDx. The other authors report no conflicts.
Funding Information:
This work was supported by the British Heart Foundation (grant number SP/12/10/29922) with support from a Research Excellence Award (grant number RE/18/5/34216). Drs Lowry, Doudesis, Wereski, and Bularga and are supported by Clinical Research Training Fellowships (grant numbers MR/W000598/1, MR/N013166/1, MR/V007017/1, and MR/V007254/1, respectively) from the Medical Research Council. Dr Lee is supported by a Clinical Research Training Fellowship (grant number FS/18/25/33454) from the British Heart Foundation. Dr Kimenai is supported by a grant from Health Data Research UK, which receives its funding from HDR UK Ltd (grant number HDR-5012) funded by the UK Medical Research Council, Engineering and Physical Sciences Research Council, Economic and Social Research Council, Department of Health and Social Care (England), Chief Scientist Office of the Scottish Government Health and Social Care Directorates, Health and Social Care Research and Development Division (Welsh Government), Public Health Agency (Northern Ireland), British Heart Foundation and the Wellcome Trust. Dr Newby is supported by the British Heart Foundation (grant number CH/09/002, RG/16/10/32375, RE/18/5/34216) and is the recipient of a Wellcome Trust Senior Investigator Award (grant number WT103782AIA). Dr Mills is supported by a Chair Award (grant number CH/F/21/90010), a Programme Grant (grant number RG/20/10/34966), and a Research Excellence Award (grant number RE/18/5/34216) from the British Heart Foundation. Dr Chapman receives support from a Starter Grant for Clinical Lecturers by the Academy of Medical Sciences (grant number SGL021/1075). Abbott Laboratories provided cardiac troponin assay reagents, calibrators, and controls without charge. The funders played no role in the design, conduct, data collection, analysis or reporting of the trial.
Publisher Copyright:
© 2022 Lippincott Williams and Wilkins. All rights reserved.
PY - 2022/9/15
Y1 - 2022/9/15
N2 - Background: The 99th centile of cardiac troponin, derived from a healthy reference population, is recommended as the diagnostic threshold for myocardial infarction, but troponin concentrations are strongly influenced by age. Our aim was to assess the diagnostic performance of cardiac troponin in older patients presenting with suspected myocardial infarction. Methods: In a secondary analysis of a multicenter trial of consecutive patients with suspected myocardial infarction, we assessed the diagnostic accuracy of high-sensitivity cardiac troponin I at presentation for the diagnosis of type 1, type 2, or type 4b myocardial infarction across 3 age groups (<50, 50-74, and ≥75 years) using guideline-recommended sex-specific and age-adjusted 99th centile thresholds. Results: In 46 435 consecutive patients aged 18 to 108 years (mean, 61±17 years), 5216 (11%) had a diagnosis of myocardial infarction. In patients <50 (n=12 379), 50 to 74 (n=22 380), and ≥75 (n=11 676) years, the sensitivity of the guideline-recommended threshold was similar at 79.2% (95% CI, 75.5-82.9), 80.6% (95% CI, 79.2-82.1), and 81.6% (95% CI, 79.8-83.2), respectively. The specificity decreased with advancing age from 98.3% (95% CI, 98.1-98.5) to 95.5% (95% CI, 95.2-95.8), and 82.6% (95% CI, 81.9-83.4). The use of age-adjusted 99th centile thresholds improved the specificity (91.3% [90.8%-91.9%] versus 82.6% [95% CI, 81.9%-83.4%]) and positive predictive value (59.3% [57.0%-61.5%] versus 51.5% [49.9%-53.3%]) for myocardial infarction in patients ≥75 years but failed to prevent the decrease in either parameter with increasing age and resulted in a marked reduction in sensitivity compared with the use of the guideline-recommended threshold (55.9% [53.6%-57.9%] versus 81.6% [79.8%-83.3%]. Conclusions: Age alters the diagnostic performance of cardiac troponin, with reduced specificity and positive predictive value in older patients when applying the guideline-recommended or age-adjusted 99th centiles. Individualized diagnostic approaches rather than the adjustment of binary thresholds are needed in an aging population.
AB - Background: The 99th centile of cardiac troponin, derived from a healthy reference population, is recommended as the diagnostic threshold for myocardial infarction, but troponin concentrations are strongly influenced by age. Our aim was to assess the diagnostic performance of cardiac troponin in older patients presenting with suspected myocardial infarction. Methods: In a secondary analysis of a multicenter trial of consecutive patients with suspected myocardial infarction, we assessed the diagnostic accuracy of high-sensitivity cardiac troponin I at presentation for the diagnosis of type 1, type 2, or type 4b myocardial infarction across 3 age groups (<50, 50-74, and ≥75 years) using guideline-recommended sex-specific and age-adjusted 99th centile thresholds. Results: In 46 435 consecutive patients aged 18 to 108 years (mean, 61±17 years), 5216 (11%) had a diagnosis of myocardial infarction. In patients <50 (n=12 379), 50 to 74 (n=22 380), and ≥75 (n=11 676) years, the sensitivity of the guideline-recommended threshold was similar at 79.2% (95% CI, 75.5-82.9), 80.6% (95% CI, 79.2-82.1), and 81.6% (95% CI, 79.8-83.2), respectively. The specificity decreased with advancing age from 98.3% (95% CI, 98.1-98.5) to 95.5% (95% CI, 95.2-95.8), and 82.6% (95% CI, 81.9-83.4). The use of age-adjusted 99th centile thresholds improved the specificity (91.3% [90.8%-91.9%] versus 82.6% [95% CI, 81.9%-83.4%]) and positive predictive value (59.3% [57.0%-61.5%] versus 51.5% [49.9%-53.3%]) for myocardial infarction in patients ≥75 years but failed to prevent the decrease in either parameter with increasing age and resulted in a marked reduction in sensitivity compared with the use of the guideline-recommended threshold (55.9% [53.6%-57.9%] versus 81.6% [79.8%-83.3%]. Conclusions: Age alters the diagnostic performance of cardiac troponin, with reduced specificity and positive predictive value in older patients when applying the guideline-recommended or age-adjusted 99th centiles. Individualized diagnostic approaches rather than the adjustment of binary thresholds are needed in an aging population.
KW - acute coronary syndrome
KW - aging
KW - frail elderly
KW - myocardial infarction
KW - troponin
U2 - 10.1161/CIRCULATIONAHA.122.059994
DO - 10.1161/CIRCULATIONAHA.122.059994
M3 - Article
C2 - 36106552
SN - 0009-7322
VL - 146
SP - 1135
EP - 1148
JO - Circulation
JF - Circulation
IS - 15
ER -