Is the true clinical value of high-sensitivity troponins as a biomarker of risk? The concept that detection of high-sensitivity troponin ‘never means nothing’

ABSTRACT

Introduction

High-sensitivity troponin (hs-cTn) assays are central to the diagnosis of myocardial infarction (MI). Their increased sensitivity has facilitated rapid pathways for the exclusion of MI. However, hs-cTn is now more readily detectable in patients without symptoms typical of MI, in whom a degree of myocardial injury is assumed. Recently, the practice of using the 99^th centile of hs-cTn as a working ‘upper reference limit’ has been challenged. There is increasing evidence that hs-cTn may provide useful prognostic information, regardless of any suspicion of MI, and as such these assays may have potential as a general biomarker for mortality. This raises the concept that detection of hs-cTn ‘never means nothing.’

Areas covered

In this review, we will evaluate the evidence for the use of hs-cTn assays outside their common clinical indication to rule out or diagnose acute MI.

Expert opinion

The data presented suggest that hs-cTn testing may in the future have a generalized role as a biomarker of mortality risk and may be used less as a test for ruling in acute MI, but will remain a frontline test to exclude that diagnosis in ED. Further, the data suggest that the detection of hs-cTn ‘never means nothing.’

KEYWORDS:

• High-sensitivity troponin
• myocardial infarction
• myocardial injury
• type two myocardial infarction
• troponin

Declaration of interest

J Hinton has received honorarium from Pfizer, and travel sponsorship from Bayer. N. Curzen has received unrestricted research grants from: Boston Scientific; Haemonetics; Heartflow; Beckman Coulter. He has also received speaker fees/consultancy from: Haemonetics, Abbot Vascular; Heartflow; Boston Scientific. He has also received travel sponsorship from Edwards; Biosensors, Abbot, Lilly/D-S; St Jude Medical, Medtronic. The authors have no other relevant affiliations or financial interest or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

Reviewer disclosures

A reviewer on this manuscript has disclosed that they have received personal honoraria from SpinChip Diagnostics in 2018. Peer reviewers on this manuscript have no other relevant financial relationships or otherwise to disclose.

Additional information

Funding

This paper was not funded.