Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
Multicenter Study
. 2017 Nov 7:359:j4788.
doi: 10.1136/bmj.j4788.

Patient selection for high sensitivity cardiac troponin testing and diagnosis of myocardial infarction: prospective cohort study

Anoop S V Shah  1 , Yader Sandoval  2 , Ala Noaman  1 , Anne Sexter  3 , Amar Vaswani  1 , Stephen W Smith  4 , Mathew Gibbins  1 , Megan Griffiths  1 , Andrew R Chapman  1 , Fiona E Strachan  1 , Atul Anand  1 , Martin A Denvir  1 , Philip D Adamson  1 , Michelle S D'Souza  1 , Alasdair J Gray  5 , David A McAllister  6 , David E Newby  1 , Fred S Apple  7 , Nicholas L Mills  1
Affiliations
Multicenter Study

Patient selection for high sensitivity cardiac troponin testing and diagnosis of myocardial infarction: prospective cohort study

Anoop S V Shah et al. BMJ. .

Erratum in

Abstract

Objective To evaluate how selection of patients for high sensitivity cardiac troponin testing affects the diagnosis of myocardial infarction across different healthcare settings.Design Prospective study of three independent consecutive patient populations presenting to emergency departments.Setting Secondary and tertiary care hospitals in the United Kingdom and United States.Participants High sensitivity cardiac troponin I concentrations were measured in 8500 consecutive patients presenting to emergency departments: unselected patients in the UK (n=1054) and two selected populations of patients in whom troponin testing was requested by the attending clinician in the UK (n=5815) and the US (n=1631). The final diagnosis of type 1 or type 2 myocardial infarction or myocardial injury was independently adjudicated.Main outcome measures Positive predictive value of an elevated cardiac troponin concentration for a diagnosis of type 1 myocardial infarction.Results Cardiac troponin concentrations were elevated in 13.7% (144/1054) of unselected patients, with a prevalence of 1.6% (17/1054) for type 1 myocardial infarction and a positive predictive value of 11.8% (95% confidence interval 7.0% to 18.2%). In selected patients, in whom troponin testing was guided by the attending clinician, the prevalence and positive predictive value were 14.5% (843/5815) and 59.7% (57.0% to 62.2%) in the UK and 4.2% (68/1631) and 16.4% (13.0% to 20.3%) in the US. Across both selected patient populations, the positive predictive value was highest in patients with chest pain, with ischaemia on the electrocardiogram, and with a history of ischaemic heart disease.Conclusions When high sensitivity cardiac troponin testing is performed widely or without previous clinical assessment, elevated troponin concentrations are common and predominantly reflect myocardial injury rather than myocardial infarction. These observations highlight how selection of patients for cardiac troponin testing varies across healthcare settings and markedly influences the positive predictive value for a diagnosis of myocardial infarction.

PubMed Disclaimer

Conflict of interest statement

Competing interests: All authors have completed the ICMJE uniform disclosure form at www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declare: support for the submitted work as described above; NLM has acted as a consultant for Abbott Diagnostics, Roche Diagnostics, and Singulex; ASVS has acted as a consultant for Abbott Diagnostics; AC has received speaker fees from Abbott Diagnostics; FSA has acted as a consultant to Metanomics Healthcare, an advisor to Instrumentation Laboratory and Abbott Diagnostics, and on the Board of Directors of HyTest Ltd; YS has acted as an advisor for Roche Diagnostics; no other relationships or activities that could appear to have influenced the submitted work.

Figures

Fig 1
Fig 1
Flow diagram summarising enrolment of unselected patients and those selected for cardiac troponin testing in the UK and US. ED=emergency department; STEMI=ST segment elevation myocardial infarction. *Troponin used only to guide clinical care in patients with suspected acute coronary syndrome
Fig 2
Fig 2
Prevalence of elevated high sensitivity cardiac troponin concentrations and type 1 myocardial infarction in unselected patients and those selected for cardiac troponin testing in the UK and US
Fig 3
Fig 3
Influence of prevalence on positive predictive value of elevated high sensitivity cardiac troponin concentration for diagnosis of type 1 myocardial infarction. Red dots represent populations of unselected patients in the emergency department (n=1054) and selected patients in the UK (n=5815) and US (n=1631). Blue dots represent reported positive predictive values for high sensitivity cardiac troponin by prevalence of type 1 myocardial infarction in previously published cohorts using high sensitivity cardiac troponin T (black text) and high sensitivity cardiac troponin I (red text) assays. Data for positive predictive values for high sensitivity troponin T cohorts were extracted from a recent systematic review and meta-analysis published by Zhelev et al. Dot size reflects number of patients in each cohort (small dot <500 patients, medium dot 500-1500 patients, large dot >1500 patients). Blue line represents central estimate of positive predictive value with 95% confidence interval (dashed red lines) derived from unselected emergency department population in the UK
Fig 4
Fig 4
Influence of clinical characteristics on positive predictive value of elevated high sensitivity cardiac troponin for diagnosis of type 1 myocardial infarction in patients selected for troponin testing in the UK (top panel) and US (bottom panel). Solid line represents positive predictive value across whole population, with dashed lines representing 95% confidence intervals
See this image and copyright information in PMC

Comment in

References

    1. Shah AS, Newby DE, Mills NL. High sensitivity cardiac troponin in patients with chest pain. BMJ 2013;347:f4222. 10.1136/bmj.f4222 - DOI - PubMed
    1. Shah AS, McAllister DA, Mills R, et al. Sensitive troponin assay and the classification of myocardial infarction. Am J Med 2015;128:493-501.e3. 10.1016/j.amjmed.2014.10.056 - DOI - PMC - PubMed
    1. Newby LK, Jesse RL, Babb JD, et al. ACCF 2012 expert consensus document on practical clinical considerations in the interpretation of troponin elevations: a report of the American College of Cardiology Foundation task force on Clinical Expert Consensus Documents. J Am Coll Cardiol 2012;60:2427-63. 10.1016/j.jacc.2012.08.969 - DOI - PubMed
    1. Saaby L, Poulsen TS, Hosbond S, et al. Classification of myocardial infarction: frequency and features of type 2 myocardial infarction. Am J Med 2013;126:789-97. 10.1016/j.amjmed.2013.02.029 - DOI - PubMed
    1. Saaby L, Poulsen TS, Diederichsen AC, et al. Mortality rate in type 2 myocardial infarction: observations from an unselected hospital cohort. Am J Med 2014;127:295-302. 10.1016/j.amjmed.2013.12.020 - DOI - PubMed

Publication types