Rapidly rule out acute myocardial infarction by combining copeptin and heart-type fatty acid-binding protein with cardiac troponin.
BACKGROUND
The rapid exclusion of acute myocardial infarction in patients with chest pain can reduce the length of hospital admission, prevent unnecessary diagnostic work-up and reduce the burden on our health-care systems. The combined use of biomarkers that are associated with different pathophysiological aspects of acute myocardial infarction could improve the early diagnostic assessment of patients presenting with chest pain.


METHODS
We measured cardiac troponin I, copeptin and heart-type fatty acid-binding protein concentrations in 584 patients who presented to the emergency department with acute chest pain. The diagnostic performances for the diagnosis of acute myocardial infarction and NSTEMI were calculated for the individual markers and their combinations. Separate calculations were made for patients presenting to the emergency department <3 h, 3-6 h and 6-12 h after chest pain onset.


RESULTS
For ruling out acute myocardial infarction, the net predictive values (95% CI) of cardiac troponin I, copeptin and heart-type fatty acid-binding protein were 90.4% (87.3-92.9), 84% (79.8-87.6) and 87% (83.5-90), respectively. Combining the three biomarkers resulted in a net predictive value of 95.8% (92.8-97.8). The improvement was most pronounced in the early presenters (<3 h) where the combined net predictive value was 92.9% (87.3-96.5) compared to 84.6% (79.4-88.9) for cardiac troponin I alone. The area under the receiver operating characteristic for the triple biomarker combination increased significantly (P < 0.05) compared to that of cardiac troponin I alone (0.880 [0.833-0.928] vs. 0.840 [0.781-0.898], respectively).


CONCLUSIONS
Combining copeptin, heart-type fatty acid-binding protein and cardiac troponin I measurements improves the diagnostic performance in patients presenting with chest pain. Importantly, in patients who present early (<3 h) after chest pain onset, the combination improves the diagnostic performance compared to the standard cardiac troponin I measurement alone.
Laboratory for Clinical Chemistry and Hematology, Jeroen Bosch Hospital, 's-Hertogenbosch, The Netherlands.
Leo H J
LH
Jacobs
Laboratory for Clinical Chemistry and Hematology, Jeroen Bosch Hospital, 's-Hertogenbosch, The Netherlands.
Marcel
M
van Borren
Laboratory for Clinical Chemistry and Hematology, Jeroen Bosch Hospital, 's-Hertogenbosch, The Netherlands.
Eugenie
E
Gemen
Department of Cardiology, Jeroen Bosch Hospital, 's-Hertogenbosch, The Netherlands.
Martijn
M
van Eck
Department of Cardiology, Jeroen Bosch Hospital, 's-Hertogenbosch, The Netherlands.
Bas
B
van Son
Department of Genetics and Cell Biology, Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, The Netherlands.
Jan F C
JF
Glatz
Department of Cardiology, Jeroen Bosch Hospital, 's-Hertogenbosch, The Netherlands.
Marcel
M
Daniels
Laboratory for Clinical Chemistry and Hematology, Jeroen Bosch Hospital, 's-Hertogenbosch, The Netherlands Department of Health Technology and Services Research, University of Twente, Enschede, The Netherlands r.kusters@jbz.nl.
Ron
R
Kusters
D000368:Aged; D015415:Biomarkers / Q000097:blood; D002637:Chest Pain / Q000097:blood / Q000175:diagnosis; D015331:Cohort Studies; D004636:Emergency Service, Hospital / Q000592:standards*; D000074026:Fatty Acid Binding Protein 3; D050556:Fatty Acid-Binding Proteins / Q000097:blood*; D005260:Female; D006020:Glycopeptides / Q000097:blood*; D006801:Humans; D008297:Male; D008875:Middle Aged; D009203:Myocardial Infarction / Q000097:blood* / Q000175:diagnosis*; D013997:Time Factors; D019210:Troponin I / Q000097:blood*
D015415:Biomarkers; C493408:FABP3 protein, human; D000074026:Fatty Acid Binding Protein 3; D050556:Fatty Acid-Binding Proteins; D006020:Glycopeptides; D019210:Troponin I; C048197:copeptins
Acute myocardial infarction; copeptin; heart-type fatty acid-binding protein; troponin