Decision limits and the reporting of cardiac troponin: Meeting the needs of both the cardiologist and the ED physician

Referees: Dr. Allan S. Jaffe, Division of Clinical Core Laboratory Services, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA; Dr. Paul O. Collinson, Departments of Cardiology and Clinical Blood Sciences, St. George’s Hospital and Medical School, London, UK.

Abstract

Cardiac troponin is the preferred biomarker for defining the acute coronary syndrome and acute myocardial infarction. Currently, the only decision limit formally endorsed with regard to the cardiac troponins is the 99th percentile. This is a “rule-in” criterion, intended to ensure that only persons with the acute coronary syndrome are reviewed. The 99th percentile is an arbitrary cut point and there are many problems associated with its application, including defining a truly healthy population, the difficulty of standardisation of cardiac troponin assays, especially but not only cardiac troponin I, and the effects of age and sex on this parameter. The Emergency Department (ED) screens many more persons for possible acute coronary syndromes than actually have the condition and their needs are best met by a “rule-out” test that enables them to clear their busy departments of the many persons who do not actually have the condition. The needs of the ED are not optimally met using the 99th percentile. The index of individuality for the cardiac troponins is small and significant changes consistent with an acute coronary syndrome can occur without the 99th percentile being exceeded. It appears that the ED may be better served by use of delta troponin changes rather than the 99th percentile, but there are problems with this approach, particularly in persons who present late when troponin release has plateaued. In addition, there are many non-acute coronary syndrome causes for cardiac troponin release. The needs of the cardiologist and the ED physician are so different that it may be inappropriate for both groups to use the same diagnostic criteria for cardiac troponin, and it is of great importance that cardiac troponin measurement be used as only one part of the assessment of the person presenting with possible acute coronary syndrome.

• 99th Percentile
• acute coronary syndrome
• cardiac troponin
• delta change
• index of individuality
• reference change value

Declarations of interest

P. E. H. did not receive any financial support; B. L. received financial support from Consultancies for Beckman Coulter Inc., Roche Diagnostics, Radiometer Medical, bioMérieux Clinical Diagnostics, Philips Healthcare and Fiomi Diagnostics, and has received research grants from Roche Diagnostics, Fiomi Diagnostics and bioMérieux Clinical Diagnostics; L. C. received Research grants from Alere (formerly Inverness Medical), Radiometer Pacific, Abbott Diagnostics, Roche and Siemens. Consultancy fees from Abbott Diagnostics and Novartis. Support to attend meetings/conferences from Abbott Diagnostics, Alere, Astra Zeneca, Novartis, Radiometer Pacific, Pfizer and Boehringer Ingelheim; G. K., J. T. and J. M. P. did not receive any financial support.

Notes

Referees: Dr. Allan S. Jaffe, Division of Clinical Core Laboratory Services, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA; Dr. Paul O. Collinson, Departments of Cardiology and Clinical Blood Sciences, St. George’s Hospital and Medical School, London, UK.