Usefulness of early rule-in and rule-out biomarker protocols to estimate ischemia-induced myocardial injury in early chest pain presenters.
Protocols to minimize the time between 2 measurements of troponin or a combination with copeptin have been developed to rapidly rule-in or rule-out myocardial injury (MI) in patients with chest pain. These fast track protocols to rule-in and rule-out MI are not sufficiently validated for early chest pain presenters. The "early presenter" model was tested in 107 stable patients after a short period of myocardial ischemia, induced by stenting of a significant coronary artery stenosis. High-sensitivity troponin T (hsTnT), high-sensitivity troponin I (hsTnI), and copeptin were measured at the start and 90, 180, and 360 minutes after stent implantation. MI was defined as a troponin level more than the upper limit of normal (ULN) and an absolute increase of >50% ULN on the 360-minute sample. A single combined measurement of troponin and copeptin 90 minutes after the onset of ischemia has a low diagnostic value. This increases when serial measurements with 90-minute intervals are included. For ruling in MI, the highest positive predictive value (with a 95% confidence interval [CI]) can be obtained when focusing only on the increase in troponin level, with a positive predictive value of 86% (70, 93) and 80% (67, 90) for hsTnT and hsTnI, respectively. For ruling out MI, a combined absence of any troponin more than the ULN and any significant increase in troponin level perform best with a negative predictive value of 75% (55, 89) and 75% (55, 89) for hsTnT and hsTnI, respectively. In conclusion, in early presenters, rapid biomarker protocols underestimate MI. A standard biomarker assessment after 3 hours is required to adequately rule-in or rule-out myonecrosis.
Department of Cardiology, Antwerp University Hospital, Edegem, Belgium. Electronic address: anne.vorlat@uza.be.
Anne
A
Vorlat
Department of Clinical Chemistry, Antwerp University Hospital, Edegem, Belgium; Translational Pathophysiological Research Group, University of Antwerp, Edegem, Belgium.
Viviane O
VO
Van Hoof
Department of Cardiology, Antwerp University Hospital, Edegem, Belgium.
Rania
R
Hammami
Department of Clinical Chemistry, Antwerp University Hospital, Edegem, Belgium; Translational Pathophysiological Research Group, University of Antwerp, Edegem, Belgium.
Stephanie
S
van Kerckhoven
Department of Clinical Chemistry, Antwerp University Hospital, Edegem, Belgium; Translational Pathophysiological Research Group, University of Antwerp, Edegem, Belgium.
Catharina M
CM
Van der Heijden
Department of Clinical Chemistry, Antwerp University Hospital, Edegem, Belgium; Translational Pathophysiological Research Group, University of Antwerp, Edegem, Belgium.
Dries
D
Coenen
Department of Cardiology, Antwerp University Hospital, Edegem, Belgium.
Johan M
JM
Bosmans
Department of Cardiology, Antwerp University Hospital, Edegem, Belgium.
Steven
S
Haine
Department of Cardiology, Antwerp University Hospital, Edegem, Belgium.
Tom R
TR
Vandendriessche
Department of Cardiology, Antwerp University Hospital, Edegem, Belgium.
Christiaan J
CJ
Vrints
Department of Cardiology, Antwerp University Hospital, Edegem, Belgium.
Marc J
MJ
Claeys
D000368:Aged; D015415:Biomarkers / Q000097:blood; D002637:Chest Pain / Q000097:blood*; D023921:Coronary Stenosis / Q000601:surgery; D042241:Early Diagnosis; D005260:Female; D006020:Glycopeptides / Q000097:blood*; D006801:Humans; D008297:Male; D008875:Middle Aged; D017202:Myocardial Ischemia / Q000097:blood / Q000175:diagnosis*; D011237:Predictive Value of Tests; D012307:Risk Factors; D012680:Sensitivity and Specificity; D015607:Stents; D013997:Time Factors; D019210:Troponin I / Q000097:blood*; D020107:Troponin T / Q000097:blood*
D015415:Biomarkers; D006020:Glycopeptides; D019210:Troponin I; D020107:Troponin T; C048197:copeptins