title: High sensitivity cardiac troponin and the under-diagnosis of myocardial infarction in women: prospective cohort study.
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.
  
  
  METHODS
  Prospective cohort study.
  
  
  METHODS
  Regional cardiac centre, United Kingdom.
  
  
  METHODS
  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.
  
  
  METHODS
  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.
authors.affiliation: BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh EH16 4SB, UK.
authors.forename: Anoop S V
authors.initials: AS
authors.lastname: Shah
authors.affiliation: BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh EH16 4SB, UK.
authors.forename: Megan
authors.initials: M
authors.lastname: Griffiths
authors.affiliation: BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh EH16 4SB, UK.
authors.forename: Kuan Ken
authors.initials: KK
authors.lastname: Lee
authors.affiliation: Centre for Population Health Sciences, University of Edinburgh, UK.
authors.forename: David A
authors.initials: DA
authors.lastname: McAllister
authors.affiliation: BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh EH16 4SB, UK.
authors.forename: Amanda L
authors.initials: AL
authors.lastname: Hunter
authors.affiliation: BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh EH16 4SB, UK.
authors.forename: Amy V
authors.initials: AV
authors.lastname: Ferry
authors.affiliation: Department of Biochemistry, Southern General Hospital, UK.
authors.forename: Anne
authors.initials: A
authors.lastname: Cruikshank
authors.affiliation: Department of Biochemistry, Southern General Hospital, UK.
authors.forename: Alan
authors.initials: A
authors.lastname: Reid
authors.affiliation: Department of Biochemistry, Royal Infirmary of Edinburgh, UK.
authors.forename: Mary
authors.initials: M
authors.lastname: Stoddart
authors.affiliation: BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh EH16 4SB, UK.
authors.forename: Fiona
authors.initials: F
authors.lastname: Strachan
authors.affiliation: Department of Biochemistry, Royal Infirmary of Edinburgh, UK.
authors.forename: Simon
authors.initials: S
authors.lastname: Walker
authors.affiliation: Department of Cardiology, St George's Hospital and Medical School, UK.
authors.forename: Paul O
authors.initials: PO
authors.lastname: Collinson
authors.affiliation: Department of Laboratory Medicine and Pathology, University of Minnesota, USA.
authors.forename: Fred S
authors.initials: FS
authors.lastname: Apple
authors.affiliation: Department of Emergency Medicine, Royal Infirmary of Edinburgh, UK.
authors.forename: Alasdair J
authors.initials: AJ
authors.lastname: Gray
authors.affiliation: BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh EH16 4SB, UK.
authors.forename: Keith A A
authors.initials: KA
authors.lastname: Fox
authors.affiliation: BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh EH16 4SB, UK.
authors.forename: David E
authors.initials: DE
authors.lastname: Newby
authors.affiliation: BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh EH16 4SB, UK nick.mills@ed.ac.uk.
authors.forename: Nicholas L
authors.initials: NL
authors.lastname: Mills
mesh_terms: D054058:Acute Coronary Syndrome / Q000097:blood* / Q000175:diagnosis; D000368:Aged; D000369:Aged, 80 and over; D015415:Biomarkers / Q000097:blood; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D009203:Myocardial Infarction / Q000097:blood* / Q000175:diagnosis; D011446:Prospective Studies; D012372:ROC Curve; D012016:Reference Values; D012680:Sensitivity and Specificity; D012737:Sex Factors; D019210:Troponin I / Q000097:blood*
chemical_list: D015415:Biomarkers; D019210:Troponin I