Troponin in early presenters to rule out myocardial infarction

High-STEACS Investigators, Matthew T H Lowry, Dimitrios Doudesis, Jasper Boeddinghaus, Dorien M Kimenai, Anda Bularga, Caelan Taggart, Ryan Wereski, Amy V Ferry, Stacey D Stewart , Christopher Tuck, Luca Koechlin, Thomas Nestelberger, Pedro Lopez-Ayala, Gabrielle Huré , Kuan Ken Lee, Andrew R Chapman, David E Newby, Atul Anand, Paul O CollinsonChristian Mueller , Nicholas L Mills*

*Corresponding author for this work

Research output: Contribution to journalArticlepeer-review

Abstract / Description of output

Background and aims: Whether a single cardiac troponin measurement can safely rule-out myocardial infarction in patients presenting within a few hours of symptom onset is uncertain. The study aim was to assess the performance of troponin in early presenters.
Methods: In patients with possible myocardial infarction, the diagnostic performance of a single measurement of high-sensitivity cardiac troponin I at presentation was evaluated and externally validated in those tested ≤3, 4-12 and >12 hours from symptom onset. The limit of detection (2 ng/L), rule-out (5 ng/L) and sex-specific 99th centile (16 ng/L women, 34 ng/L men) thresholds were compared.
Results: In 41,103 consecutive patients (60 [17] years, 46% women), 12,595 (31%) presented within 3 hours and 3,728 (9%) had myocardial infarction. In those presenting ≤3 hours, a threshold of 2 ng/L had greater sensitivity and negative predictive value (99.4% [95% confidence interval 99.2-99.5%] and 99.7% [99.6-99.8%]) compared to 5 ng/L (96.5% [96.2-96.8%] and 99.3% [99.1- 99.4%]). In those presenting ≥3 hours, the sensitivity and negative predictive value were similar for both thresholds. The sensitivity of the 99th centile was low in early and late presenters at 71.4% [70.6-72.2%] and 92.5% [92.0-93.0%], respectively. Findings were consistent in an external validation cohort of 7,088 patients.
Conclusions: In early presenters, a single measurement of high-sensitivity cardiac troponin I below the limit of detection may facilitate the safe rule out of myocardial infarction. The 99th centile should not be used to rule out myocardial infarction at presentation even in those presenting later following symptom onset.
Original languageEnglish
JournalEuropean Heart Journal
Early online date23 Jun 2023
Publication statusE-pub ahead of print - 23 Jun 2023


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