title: Hospital laboratory reporting may be a barrier to detection of 'microsize' myocardial infarction in the US: an observational study.
abstract: BACKGROUND
  International guidelines recommend that the decision threshold for troponin should be the 99th percentile of a normal population, or, if the laboratory assay is not sufficiently precise at this low level, the level at which the assay achieves a 10% or better coefficient of variation (CV). Our objectives were to examine US hospital laboratory troponin reports to determine whether either the 99th percentile or the 10% CV level were clearly indicated, and whether nonconcordance with these guidelines was a potential barrier to detecting clinically important microscopic or 'microsize' myocardial infarctions (MIs). To confirm past reports of the clinical importance of microsize MIs, we also contrasted in-hospital, 28-day and 1-year mortality among those with microsize and nonmicrosize MI.
  
  
  METHODS
  In the REasons for Geographic And Racial Differences in Stroke national prospective cohort study (n=30,239), 1029 participants were hospitalized for acute coronary syndrome (ACS) between 2003-2009. For each case, we recorded all thresholds of abnormal troponin on the laboratory report and whether the 99th percentile or 10% CV value were clearly identified. All cases were expert adjudicated for presence of MI. Peak troponin values were used to classify MIs as microsize MI (< five times the lowest listed upper limit of normal) and nonmicrosize MI.
  
  
  RESULTS
  Participants were hospitalized at 649 acute care US hospitals, only 2% of whose lab reports clearly identified the 99th percentile or the 10% CV level; 52% of reports indicated an indeterminate range, a practice that is no longer recommended. There were 183 microsize MIs and 353 nonmicrosize MIs. In-hospital mortality tended to be lower in the microsize than in the nonmicrosize MI group (1.1 vs. 3.6%, p = 0.09), but 28-day and 1-year mortality were similar (2.5% vs. 2.7% [p = 0.93] and 5.2% vs. 4.3% [p = 0.64], respectively).
  
  
  CONCLUSIONS
  Current practices in many US hospitals created barriers to the clinical recognition of microsize MI, which was common and clinically important in our study. Improved hospital troponin reporting is warranted.
authors: Division of Preventive Medicine, University of Alabama at Birmingham School of Medicine, Medical Towers 621, 1717 11th Avenue South, Birmingham, AL 35294-4410, USA. msafford@uab.edu
authors: Monika M
authors: MM
authors: Safford
authors: Gaurav
authors: G
authors: Parmar
authors: Codrin S
authors: CS
authors: Barasch
authors: Jewell H
authors: JH
authors: Halanych
authors: Stephen P
authors: SP
authors: Glasser
authors: David C
authors: DC
authors: Goff
authors: Ronald J
authors: RJ
authors: Prineas
authors: Todd M
authors: TM
authors: Brown
mesh_terms: D000368:Aged; D015415:Biomarkers / Q000032:analysis; D005260:Female; D006760:Hospitalization / Q000706:statistics & numerical data*; D006801:Humans; D007755:Laboratories, Hospital / Q000592:standards*; D016015:Logistic Models; D008297:Male; D009203:Myocardial Infarction / Q000175:diagnosis* / Q000208:ethnology / Q000401:mortality; D012015:Reference Standards; D018570:Risk Assessment; D014336:Troponin / Q000032:analysis*; D014481:United States / Q000453:epidemiology
chemical_list: D015415:Biomarkers; D014336:Troponin
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