Do we need implementation of sex-specific cutoff levels for high-sensitivity cardiac troponin T in the diagnosis of acute myocardial infarction (AMI)?
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.
The uniform 99th percentile should remain the standard of care when using high-sensitivity cardiac troponin levels for the diagnosis of AMI.
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).
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.
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.
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.
Rubini Giménez M, Twerenbold R, Boeddinghaus J, Nestelberger T, Puelacher C, Hillinger P, Wildi K, Jaeger C, Grimm K, Heitzelmann K, Sabti Z, Badertscher P, Cupa J, Honegger U, Schaerli N, Kozhuharov N, du Fay de Lavallaz J, Lopez B, Salgado E, Miró Ò, Martín-Sánchez F, Adrada ER, Morawiec B, Parenica J, Ganovska E, Neugebauer C, Rentsch K, Lohrmann J, Osswald S, Reichlin T, Mueller C. Clinical Effect of Sex-Specific Cutoff Values of High-Sensitivity Cardiac Troponin T in Suspected Myocardial Infarction. JAMA Cardiol. 2016;1(8):912-920. doi:10.1001/jamacardio.2016.2882