title: Diagnostic performance of rising, falling, or rising and falling kinetic changes of high-sensitivity cardiac troponin T in an unselected emergency department population.
abstract: BACKGROUND
  Current ESC guidelines for the diagnosis of myocardial infarction consider a rise and/or fall of cardiac biomarkers. However, whether rising or falling patterns of high-sensitivity cardiac troponin T (hs-cTnT) improve the discrimination of ST-elevation myocardial infarction (non-STEMI) from non-acute coronary syndromes (ACS) has not been evaluated yet.
  
  
  METHODS
  We compared protocols of rising and falling absolute and relative hs-cTnT changes in an unselected emergency department population.
  
  
  RESULTS
  A total of 635 patients with unstable angina pectoris (UAP), non-STEMI, or acute symptoms and increased hs-cTnT (>99th percentile) were enrolled. Of these, 572 patients met the inclusion criteria of consistently rising patterns (n=254, 44.4%), consistently falling patterns (n=224, 39.2%), or falling patterns after an initial rise (n=94, 16.4%). Final diagnoses included 66 (11.5%) patients with UAP, 141 (24.7%) patients with non-STEMI, and 365 (63.8%) patients with hs-cTnT elevations not due to ACS. Rising values were found more frequently in patients with non-STEMI, as compared to non-ACS (OR 3.69, 95% CI 2.46-5.53; p<0.0001), and falling patterns were observed more frequently in patients with non-ACS conditions (OR 3.56, 95% CI 2.24-5.63; p<0.001). Addition of rising but not falling changes increased diagnostic performance of hs-cTnT concentrations at presentation: positive: AUC 0.680 (95% CI 0.618-0.742) vs. 0.861 (95% CI 0.822-0.900; p<0.0001), negative: AUC 0.678 (95% CI 0.545-0.812) vs. 0.741 (95% CI 0.635-0.847). A 20% criterion as proposed by ESC guidelines performed equally for positive and negative changes only when admission hs-cTnT values were considered: AUC 0.785 (95% CI 0.726-0.845) vs. AUC 0.763 (95% CI 0.681-0.845); p=ns.
  
  
  CONCLUSIONS
  Detection of rising but not falling hs-cTnT values improves discrimination of non-STEMI from non-ACS in an unselected emergency department population.
authors: University Hospital Heidelberg, Heidelberg, Germany.
authors: Moritz
authors: M
authors: Biener
authors: Matthias
authors: M
authors: Mueller
authors: Mehrshad
authors: M
authors: Vafaie
authors: Allan S
authors: AS
authors: Jaffe
authors: Christian
authors: C
authors: Widera
authors: Hugo A
authors: HA
authors: Katus
authors: Evangelos
authors: E
authors: Giannitsis
mesh_terms: D054058:Acute Coronary Syndrome / Q000097:blood / Q000175:diagnosis*; D000368:Aged; D000789:Angina, Unstable / Q000097:blood / Q000175:diagnosis*; D015415:Biomarkers / Q000097:blood; D004562:Electrocardiography; D004636:Emergency Service, Hospital; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D009203:Myocardial Infarction / Q000097:blood / Q000175:diagnosis*; D011379:Prognosis; D012720:Severity of Illness Index; D013997:Time Factors; D020107:Troponin T / Q000097:blood*
chemical_list: D015415:Biomarkers; D020107:Troponin T
keywords: Diagnostic performance; high-sensitivity troponin T; negative changes; non-STEMI; positive changes