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. 2022 Mar 16;11(3):201-212.
doi: 10.1093/ehjacc/zuab124.

Adding stress biomarkers to high-sensitivity cardiac troponin for rapid non-ST-elevation myocardial infarction rule-out protocols

Ingar Ziad Restan  1 , Ana Yufera Sanchez  2   3 , Ole-Thomas Steiro  4 , Pedro Lopez-Ayala  2   3 , Hilde L Tjora  5 , Jørund Langørgen  4 , Torbjørn Omland  6   7 , Jasper Boeddinghaus  2   3 , Thomas Nestelberger  2   3   8 , Luca Koechlin  2   3   9 , Paul Collinson  10   11 , Rune Bjørneklett  5   12 , Kjell Vikenes  4   13 , Heidi Strand  14 , Øyvind Skadberg  15 , Øistein R Mjelva  1 , Alf Inge Larsen  1   13 , Vernon V S Bonarjee  1 , Christian Mueller  2   3 , Kristin M Aakre  4   13   16
Affiliations

Adding stress biomarkers to high-sensitivity cardiac troponin for rapid non-ST-elevation myocardial infarction rule-out protocols

Ingar Ziad Restan et al. Eur Heart J Acute Cardiovasc Care. .

Abstract

Aims: This study tested the hypothesis that combining stress-induced biomarkers (copeptin or glucose) with high-sensitivity cardiac troponin (hs-cTn) increases diagnostic accuracy for non-ST-elevation myocardial infarction (NSTEMI) in patients presenting to the emergency department.

Methods and results: The ability to rule-out NSTEMI for combinations of baseline hs-cTnT or hs-cTnI with copeptin or glucose was compared with the European Society of Cardiology (ESC) hs-cTnT/I-only rule-out algorithms in two independent (one Norwegian and one international multicentre) diagnostic studies. Among 959 patients (median age 64 years, 60.5% male) with suspected NSTEMI in the Norwegian cohort, 13% had NSTEMI. Adding copeptin or glucose to hs-cTnT/I as a continuous variable did not improve discrimination as quantified by the area under the curve {e.g. hs-cTnT/copeptin 0.91 [95% confidence interval (CI) 0.89-0.93] vs. hs-cTnT alone 0.91 (95% CI 0.89-0.93); hs-cTnI/copeptin 0.85 (95% CI 0.82-0.87) vs. hs-cTnI alone 0.93 (95% CI 0.91-0.95)}, nor did adding copeptin <9 mmol/L or glucose <5.6 mmol/L increase the sensitivity of the rule-out provided by hs-cTnT <5 ng/L or hs-cTnI <4 ng/L in patients presenting more than 3 h after chest pain onset (target population in the ESC-0 h-algorithm). The combination decreased rule-out efficacy significantly (both P < 0.01). These findings were confirmed among 1272 patients (median age 62 years, 69.3% male) with suspected NSTEMI in the international validation cohort, of which 20.7% had NSTEMI. A trend towards increased sensitivity for the hs-cTnT/I/copeptin combinations (97-100% vs. 91-97% for the ESC-0 h-rule-out cut-offs) was observed in the Norwegian cohort.

Conclusion: Adding copeptin or glucose to hs-cTnT/I did not increase diagnostic performance when compared with current ESC guideline hs-cTnT/I-only 0 h-algorithms.

Keywords: Cardiovascular disease; Copeptin; Glucose; NSTEMI; NSTEMI rule-out; Stress biomarkers.

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Figures

None
Graphical abstract
Figure 1
Figure 1
Admission concentrations (median, 10th and 90th percentile) of high-sensitivity cardiac troponin T (A), high-sensitivity cardiac troponin I (B), glucose (C), and copeptin (D) in the different patient groups. The horizontal lines in C and D denote the cut-offs of copeptin (9 pmol/L) and glucose (5.6 mmol/L), respectively.
Figure 2
Figure 2
Box plot showing logarithmic copeptin concentrations for patients diagnosed with non-ST-elevation myocardial infarction, grouped by time from symptom start until first blood draw.
Figure 3
Figure 3
Receiver operating characteristic curves for the individual hs-cTn concentrations and combinations with copeptin and glucose. Hs-cTnT and combined algorithms for all patients (A), hs-cTnI and combined algorithms for all patients (B), hs-cTnT and combined algorithms in early presenters (C), and hs-cTnI and combined algorithms in early presenters (D).
See this image and copyright information in PMC

Comment in

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