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. 2019 Jun 16;9(6):e023994.
doi: 10.1136/bmjopen-2018-023994.

Is high-sensitivity troponin, alone or in combination with copeptin, sensitive enough for ruling out NSTEMI in very early presenters at admission? A post hoc analysis performed in emergency departments

Camille Chenevier-Gobeaux  1 , Mustapha Sebbane  2 , Christophe Meune  3   4 , Sophie Lefebvre  2 , Anne-Marie Dupuy  5 , Guillaume Lefèvre  6   7 , Nicolas Peschanski  8 , Patrick Ray  9   10
Affiliations

Is high-sensitivity troponin, alone or in combination with copeptin, sensitive enough for ruling out NSTEMI in very early presenters at admission? A post hoc analysis performed in emergency departments

Camille Chenevier-Gobeaux et al. BMJ Open. .

Abstract

Objectives: Copeptin and high-sensitivity cardiac troponin (HS-cTn) assays improve the early detection of non-ST-segment elevation myocardial infarction (NSTEMI). Their sensitivities may, however, be reduced in very early presenters.

Setting: We performed a post hoc analysis of three prospective studies that included patients who presented to the emergency department for chest pain onset (CPO) of less than 6 hours.

Participants: 449 patients were included, in whom 12% had NSTEMI. CPO occurred <2 hours from ED presentation in 160, between 2 and 4 hours in 143 and >4 hours in 146 patients. The prevalence of NSTEMI was similar in all groups (9%, 13% and 12%, respectively, p=0.281).

Measures: Diagnostic performances of HS-cTn and copeptin at presentation were examined according to CPO. The discharge diagnosis was adjudicated by two experts, including cardiac troponin I (cTnI). HS-cTn and copeptin were blindly measured.

Results: Diagnostic accuracies of cTnI, cTnI +copeptin and HS-cardiac troponin T (HS-cTnT) (but not HS-cTnT +copeptin) lower through CPO categories. For patients with CPO <2 hours, the choice of a threshold value of 14 ng/L for HS-cTnT resulted in three false negative (Sensitivity 80%(95% CI 51% to 95%); specificity 85% (95% CI 78% to 90%); 79% of correctly ruled out patients) and that of 5 ng/L in two false negative (sensitivity 87% (95% CI 59% to 98%); specificity 58% (95% CI 50% to 66%); 52% of correctly ruled out patients). The addition of copeptin to HS-cTnT induced a decrease of misclassified patients to 1 in patients with CPO <2 hours (sensitivity 93% (95% CI 66% to 100%); specificity 41% (95% CI 33% to 50%)).

Conclusion: A single measurement of HS-cTn, alone or in combination with copeptin at admission, seems not safe enough for ruling out NSTEMI in very early presenters (with CPO <2 hours).

Trial registration number: DC-2009-1052.

Keywords: chest pain; chest pain onset; copeptin; high sensitive cardiac troponin; non st-elevation acute myocardial infarction; very early presenters.

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Conflict of interest statement

Competing interests: CC-G, PR and CM received honorarias and lecture fees from Roche Diagnostics andThermofisher Scientific.

Figures

Figure 1
Figure 1
Flow chart of the studied population. CPO, chest pain onset; cTnI, cardiac troponin I; STEMI, ST-segment elevation myocardial infarction.
Figure 2
Figure 2
ROC curves of cTn for the diagnosis of NSTEMI, alone or in combination with copeptin. (A) CPO <2 hours; (B) CPO 2–4 hours; (C) CPO >4 hours. AUC, area under the ROC curve; cTn, cardiac troponin; cTnI, cardiac troponin I; CPO, chest pain onset; HS-cTnT, high-sensitivity cardiac troponin T; ROC, receiver operating characteristic; NSTEMI, non-ST-segment elevation myocardial infarction.
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