Early diagnosis of acute myocardial infarction in patients with mild elevations of cardiac troponin.
BACKGROUND
The early diagnosis of acute myocardial infarction (AMI) in patients with mild elevations of high-sensitivity cardiac troponin (hs-cTn) is a challenge. It is unclear whether copeptin, a marker of endogenous stress, or 1h-hs-cTn changes are better suited to address this important unmet clinical need.


METHODS
We prospectively enrolled patients presenting with symptoms suggestive of AMI to the emergency department (ED). Two independent cardiologists adjudicated the final diagnosis. Mild hs-cTn elevations were defined as 26.2 ng/L (99th percentile) to 75 ng/L for hs-cTnI, and 14 ng/L (99th percentile) to 50 ng/L (biological-equivalent to 75 ng/L for hs-cTnI) for hs-cTnT.


RESULTS
Among 1356 patients, 80 (6%) had mild hs-cTnI elevations at presentation. Within this group, AMI was the final diagnosis in 39 patients (49%). The diagnostic accuracy for the diagnosis of AMI as quantified by the area under the receiver operating characteristic curve (AUC) was 0.51 (95% CI 0.39-0.64) for hs-cTnI at presentation, 0.58 (95% CI 0.45-0.71) for copeptin at presentation, and 0.78 (95% CI 0.68-0.88) for 1h-hs-cTnI changes, which was significantly higher as compared to copeptin (p = 0.02) or hs-cTnI alone (p < 0.001). The additional use of 1h-hs-cTnI changes, but not of copeptin, improved diagnostic accuracy of hs-cTnI at presentation (AUC 0.80, 95% CI 0.70-0.90; p = 0.002 for comparison). Similar findings regarding copeptin and 1h-hs-cTnT/I changes were obtained for mild hs-cTnT elevations.


CONCLUSIONS
About 6-22% of patients presenting with suggestive AMI to the ED have mild hs-cTnT/I elevations at presentation. In contrast to copeptin, the addition of 1h-hs-cTn changes substantially improves the early diagnosis of AMI.
Department of Cardiology, Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Petersgraben 4, 4031, Basel, Switzerland.|Department of Internal Medicine, University Hospital Basel, University of Basel, Basel, Switzerland.|GREAT Network, Basel, Switzerland.
Jasper
J
Boeddinghaus
Department of Cardiology, Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Petersgraben 4, 4031, Basel, Switzerland.|GREAT Network, Basel, Switzerland.
Tobias
T
Reichlin
Department of Cardiology, Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Petersgraben 4, 4031, Basel, Switzerland.|Department of Internal Medicine, University Hospital Basel, University of Basel, Basel, Switzerland.|GREAT Network, Basel, Switzerland.
Thomas
T
Nestelberger
Department of Cardiology, Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Petersgraben 4, 4031, Basel, Switzerland.|GREAT Network, Basel, Switzerland.
Raphael
R
Twerenbold
Department of Cardiology, Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Petersgraben 4, 4031, Basel, Switzerland.|GREAT Network, Basel, Switzerland.
Yvette
Y
Meili
Department of Cardiology, Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Petersgraben 4, 4031, Basel, Switzerland.|GREAT Network, Basel, Switzerland.
Karin
K
Wildi
Department of Cardiology, Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Petersgraben 4, 4031, Basel, Switzerland.|Department of Internal Medicine, University Hospital Basel, University of Basel, Basel, Switzerland.|GREAT Network, Basel, Switzerland.
Petra
P
Hillinger
Department of Cardiology, Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Petersgraben 4, 4031, Basel, Switzerland.|Department of Internal Medicine, University Hospital Basel, University of Basel, Basel, Switzerland.|GREAT Network, Basel, Switzerland.
Maria Rubini
MR
Giménez
Department of Cardiology, Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Petersgraben 4, 4031, Basel, Switzerland.|GREAT Network, Basel, Switzerland.
Janosch
J
Cupa
Department of Cardiology, Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Petersgraben 4, 4031, Basel, Switzerland.|GREAT Network, Basel, Switzerland.
Lukas
L
Schumacher
Department of Cardiology, Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Petersgraben 4, 4031, Basel, Switzerland.|GREAT Network, Basel, Switzerland.
Marie
M
Schubera
Department of Cardiology, Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Petersgraben 4, 4031, Basel, Switzerland.|GREAT Network, Basel, Switzerland.
Patrick
P
Badertscher
Department of Cardiology, Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Petersgraben 4, 4031, Basel, Switzerland.|GREAT Network, Basel, Switzerland.
Sydney
S
Corbière
Department of Cardiology, Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Petersgraben 4, 4031, Basel, Switzerland.|Department of Internal Medicine, University Hospital Basel, University of Basel, Basel, Switzerland.|GREAT Network, Basel, Switzerland.
Karin
K
Grimm
Department of Cardiology, Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Petersgraben 4, 4031, Basel, Switzerland.|GREAT Network, Basel, Switzerland.
Christian
C
Puelacher
Department of Cardiology, Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Petersgraben 4, 4031, Basel, Switzerland.|GREAT Network, Basel, Switzerland.
Zaid
Z
Sabti
Department of Cardiology, Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Petersgraben 4, 4031, Basel, Switzerland.|GREAT Network, Basel, Switzerland.
Dayana Flores
DF
Widmer
Department of Cardiology, Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Petersgraben 4, 4031, Basel, Switzerland.|Department of Internal Medicine, University Hospital Basel, University of Basel, Basel, Switzerland.|GREAT Network, Basel, Switzerland.
Nicolas
N
Schaerli
Department of Cardiology, Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Petersgraben 4, 4031, Basel, Switzerland.|GREAT Network, Basel, Switzerland.
Nikola
N
Kozhuharov
Department of Cardiology, Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Petersgraben 4, 4031, Basel, Switzerland.|GREAT Network, Basel, Switzerland.
Samyut
S
Shrestha
Department of Cardiology, Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Petersgraben 4, 4031, Basel, Switzerland.
Tobias
T
Bürge
Department of Cardiology, Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Petersgraben 4, 4031, Basel, Switzerland.
Patrick
P
Mächler
Department of Cardiology, Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Petersgraben 4, 4031, Basel, Switzerland.
Michael
M
Büchi
Laboratory Medicine, University Hospital Basel, Basel, Switzerland.
Katharina
K
Rentsch
GREAT Network, Basel, Switzerland.|Emergency Department, Hospital Clinic, Barcelona, Catalonia, Spain.
Òscar
Ò
Miró
GREAT Network, Basel, Switzerland.|Emergency Department, Hospital Clinic, Barcelona, Catalonia, Spain.
Beatriz
B
López
Servicio de Urgencias, Hospital Clínico San Carlos, Madrid, Spain.
F Javier
FJ
Martin-Sanchez
Servicio de Urgencias, Hospital Clínico San Carlos, Madrid, Spain.
Esther
E
Rodriguez-Adrada
2nd Department of Cardiology, Medical University of Silesia, Zabrze, Poland.
Beata
B
Morawiec
2nd Department of Cardiology, Medical University of Silesia, Zabrze, Poland.
Damian
D
Kawecki
GREAT Network, Basel, Switzerland.|Department of Cardiology, University Hospital Brno, Brno, Czech Republic.|Medical Faculty, Masaryk University, Brno, Czech Republic.
Eva
E
Ganovská
GREAT Network, Basel, Switzerland.|Department of Cardiology, University Hospital Brno, Brno, Czech Republic.|Medical Faculty, Masaryk University, Brno, Czech Republic.
Jiri
J
Parenica
Department of Cardiology, Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Petersgraben 4, 4031, Basel, Switzerland.
Jens
J
Lohrmann
Blood Transfusion Centre, Swiss Red Cross, Basel, Switzerland.|Department of Hematology, University Hospital Basel, Basel, Switzerland.
Andreas
A
Buser
Emergency Department, University Hospital Zurich, Zurich, Switzerland.
Dagmar I
DI
Keller
Department of Cardiology, Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Petersgraben 4, 4031, Basel, Switzerland.
Stefan
S
Osswald
Department of Cardiology, Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Petersgraben 4, 4031, Basel, Switzerland. christian.mueller@usb.ch.|GREAT Network, Basel, Switzerland. christian.mueller@usb.ch.
Christian
C
Mueller
D000368:Aged; D000369:Aged, 80 and over; D015415:Biomarkers / Q000097:blood; D042241:Early Diagnosis; D004636:Emergency Service, Hospital; D005260:Female; D005500:Follow-Up Studies; D006020:Glycopeptides / Q000097:blood*; D006801:Humans; D008297:Male; D008875:Middle Aged; D009203:Myocardial Infarction / Q000097:blood / Q000175:diagnosis*; D011446:Prospective Studies; D012372:ROC Curve; D019210:Troponin I / Q000097:blood*; D020107:Troponin T / Q000097:blood*
D015415:Biomarkers; D006020:Glycopeptides; D019210:Troponin I; D020107:Troponin T; C048197:copeptins
Acute myocardial infarction; Copeptin; Diagnosis of AMI