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Louise Cullen and Rick Body fuel a contentious debate on the clinical significance of the high sensitivity troponin assay. Will your patients benefit from that extra digit ?
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The Debate:High sensitivity troponin assays rule!
COI: Active researcher in this area (incl. industry supported work), Chair of Writing committee for NHF/CS-ANZ guidelines
1. Precision
Troponin0
#
Effect of Analytical Variation
CV at 99th % = 10 - 20%
Troponin0
#
Effect of Analytical Variation
CV at 99th % = 10 - 20%
99%
Troponin0
#
Effect of Analytical Variation
CV at 99th % = 10 - 20%
99%
+-
Troponin0
#
Effect of Analytical Variation
Highly sensitive assay
CV at 99th percentile ≤ 10%
99%
“We believe that the clinical implications of this FP frequency are insignificant” Fred
Apple, Allan Jaffe et al
• Comparing assays with CV 25% instead of 10%
2. Time
Evaluation of a patient with possible ACS
Hamm CW. Et al. EHJ (2011) 32, 2999-3054.
Evaluation of a patient with possible ACS
Hamm CW. Et al. EHJ (2011) 32, 2999-3054.
HS assays
Allow accurate measurement of
very low concentrations of troponin
AND
see rises in cTn at very early time points after necrosis.
Timing of serial samples• ESC guidelines:
– 3hrs after presentation with hs assay.Hamm, C. W., J. P. Bassand, et al. (2011). European Heart Journal 32(23): 2999-3054.
• HFA/CS-ANZ guidelines: – 3hrs after presentation + 6hrs after symptom onset with
a hs assay or Chew, D. P., C. N. Aroney, et al. (2011) Heart Lung Circ 20(8): 487-502
Forget the Yanks – they have none!
Delays = Overcrowding
Ann Emerg Med. 2007;50:510-516
Ann Emerg Med. 2008;51:1-5.
Delays = Overcrowding
Overcrowding = Death
Key Rebuttal
SMACC
“All these false positives with hs-troponin”
and
“We can’t do anything about an elevated cTn”
Heart specific
Disease Specific
An elevated troponin is a bad thing….
‘We can’t alter the outcome of those with elevated troponin who don’t have an AMI’
‘We can’t alter the outcome of those with elevated troponin who don’t have an AMI’
WRONG!
Physical activity score: • 2 = low activity • 3 to 6 = moderate activity• 7 = high activity .
41
J Am Coll Cardiol 2012;60:2539–47
Proportion of patients with a significant Biomarker Increase vs Physical Activity
42
hsTnT
J Am Coll Cardiol 2012;60:2539–47
Rate of Incident HF
43
hsTnT
Prescribe…..
Exercise!
Why use a high sensitivity assay?
1. Precision2. Time3. Risk modification
Avoid unnecessary death!
Poll
Who is the winner???