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Original Investigation
November 2016

Clinical Effect of Sex-Specific Cutoff Values of High-Sensitivity Cardiac Troponin T in Suspected Myocardial Infarction

Author Affiliations
  • 1Department of Cardiology and Cardiovascular Research Institute Basel, University Hospital Basel, Switzerland
  • 2Global Research in Acute Conditions Network
  • 3Emergency Department, Centro de Investigación Biomédica en Red Enfermedades Respiratorias Instituto de Salud Carlos III, Institut Hospital del Mar d'Investigacions Mèdiques, Barcelona, Spain
  • 4Emergency Department, Hospital Clinic, Barcelona, Spain
  • 5Emergency Department, Hospital Clinic San Carlos, Madrid, Spain
  • 6Second Cardiology Department, Zabrze, University of Silesia, Katowice, Poland
  • 7Department of Cardiology, University Hospital, Brno, Czech Republic
  • 8Laboratory Medicine, University Hospital Basel, Basel, Switzerland
JAMA Cardiol. 2016;1(8):912-920. doi:10.1001/jamacardio.2016.2882
Key Points

Question  Do we need implementation of sex-specific cutoff levels for high-sensitivity cardiac troponin T in the diagnosis of acute myocardial infarction (AMI)?

Findings  In the Advantageous Predictors of Acute Coronary Syndrome Evaluation Study, a prospective, diagnostic, multicenter trial of 2734 adults (876 women and 1858 men) presenting with suspected AMI, only 3 patients were reclassified when using sex-specific cutoff levels compared with the uniform values. The diagnosis in 2 women was upgraded from unstable angina to AMI, and the diagnosis in 1 man was downgraded from AMI to unstable angina.

Meaning  The uniform 99th percentile should remain the standard of care when using high-sensitivity cardiac troponin levels for the diagnosis of AMI.

Abstract

Importance  It is currently unknown whether the uniform (universal clinical practice for more than 2 decades) or 2 sex-specific cutoff levels are preferable when using high-sensitivity cardiac troponin T (hs-cTnT) levels in the diagnosis of acute myocardial infarction (AMI).

Objective  To improve the management of suspected AMI in women by exploring sex-specific vs uniform cutoff levels for hs-cTnT.

Design, Setting, and Participants  In an ongoing prospective, diagnostic, multicenter study conducted at 9 emergency departments, the present study evaluated patients enrolled from April 21, 2006, through June 5, 2013. The participants included 2734 adults presenting with suspected AMI. Duration of follow-up was 2 years, and data analysis occurred from June 5 to December 21, 2015.

Interventions  The final diagnosis was centrally adjudicated by 2 independent cardiologists using all available information, including measurements of serial hs-cTnT blood concentrations twice: once using the uniform 99th percentile cutoff value level of 14 ng/L and once using sex-specific 99th percentile levels of hs-cTnT (women, 9 ng/L; men, 15.5 ng/L).

Main Outcomes and Measures  Diagnostic reclassification in women and men using sex-specific vs the uniform cutoff level in the diagnosis of AMI.

Results  Of the 2734 participants, 876 women (32%) and 1858 men (68%) were included. Median (interquartile range) age was 68 (55-77) and 59 (48-71) years, respectively. With the use of the uniform cutoff value, 127 women (14.5%) and 345 men (18.6%) received a final diagnosis of AMI. Among these, at emergency department presentation, levels of hs-cTnT were already above the uniform cutoff value in 427 patients (sensitivity, 91.3% [95% CI, 85%-95.6%] in women vs 90.7% [95% CI, 87.1%-93.5% in men]; specificity, 79.2% [95% CI, 76.1%-82.1%] in women vs 78.5% [95% CI, 76.4%-80.6%] in men). After readjudication using sex-specific 99th percentile levels, diagnostic reclassification regarding AMI occurred in only 3 patients: 0.11% (95% CI, 0.02-0.32) of all patients and 0.6% (95% CI, 0.13-1.85) of patients with AMI. The diagnosis in 2 women was upgraded from unstable angina to AMI, and the diagnosis in 1 man was downgraded from AMI to unstable angina. These diagnostic results were confirmed when using 2 alternative pairs of uniform and sex-specific cutoff values.

Conclusions and Relevance  The uniform 99th percentile should remain the standard of care when using hs-cTnT levels for the diagnosis of AMI.

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