Article Figures & Tables
Figures
- Figure 1:
Identification of studies comparing high-sensitivity testing with conventional testing of cardiac troponin levels to diagnose myocardial infarction in the emergency department.
- Figure 2:
Summary receiver operating characteristic curve (bivariable model) for the high-sensitivity troponin T assay for the diagnosis of acute myocardial infarction at presentation, based on meta-analysis of 9 studies.
- Figure 3:
Comparison of receiver operating characteristic curves for the high-sensitivity troponin T assay and the conventional troponin assay for the diagnosis of acute myocardial infarction at presentation. The loops surrounding the filled shapes summarize the 95% confidence regions (CRs) for each test.
Tables
- Table 1: Characteristics of the studies that compared the high-sensitivity troponin T assay or high-sensitivity troponin I assay with the conventional assay
Study Participants,
no. (% male)Funding Design Centre(s) Timing of troponin measurement Outcome,
no. (%)Follow-up period Troponin T Reichlin et al. 20099 718 (66) Swiss Heart Foundation, University Hospital, Basel, Abbott, Roche, Siemens Prospective Multicentre: Switzerland, Italy and Spain At presentation and 6–9 h later MI
123 (17)60 d Christ et al. 201010 2340 (64) Roche Diagnostics Retrospective Single centre:
GermanyAt presentation and about 6 h later MI
20 (15)2 wk Aldous et al. 201111 332 (60) National Heart Foundation of New Zealand, Christchurch Hospital,
Roche DiagnosticsProspective Single centre:
New ZealandAt presentation and 6–24 h later MI
110 (33)Not reported Body et al. 201112 703 (61) Manchester NHS Foundation Trust, Roche Diagnostics Prospective Single centre:
United KingdomAt presentation and (at least) 12 h after onset of symptoms MI
130 (18)6 mo Freund et al. 201113 317 (65) Université Pierre et Marie Curie-Paris 6, Roche Diagnostics Prospective 3 centres:
FranceAt presentation and 3–9 h later (if clinically indicated) MI
45 (14)30 d Melki et al. 201114 233 (67) Stockholm County Council and Karolinska Institute, Swedish Heart and Lung Foundation, National Board of Health and Welfare, Roche Diagnostics Prospective Single centre:
SwedenAt presentation and 9–12 h later MI
114 (48)Discharge from hospital Reiter et al. 201115 1098 (67)* Swiss Heart Foundation, University Hospital, Basel, Abbott, Roche, Siemens Prospective Multicentre: Switzerland, Italy and Spain At presentation and 6–9 h later MI
159 (14)90 d Weber et al. 201116 2506 (66) Kerckhoff-Stiftung Foundation, Sanofi Aventis, Roche Diagnostics Retrospective analysis of data from 2 acute coronary syndrome registries Multicentre:
Germany and
ArgentinaAt presentation MI
1082 (43)6 mo Aldous et al. 201217 939 (59) National Heart Foundation of New Zealand, Health Research Council of New Zealand,
Roche DiagnosticsProspective Multicentre:
9 countries in the Asia-Pacific regionAt presentation, 2 h and 6–12 h later MI
205 (21)1 yr Troponin I Reichlin et al. 20099 718 (66) Swiss Heart Foundation, University Hospital, Basel, Abbott, Roche, Siemens Prospective Multicentre:
Switzerland, Italy and SpainAt presentation and 6–9 h later MI
123 (17)60 d Keller et al. 200924 1818 (66) Not available Prospective Multicentre:
GermanyAt presentation and 3–6 h later MI
413 (23)30 d Bhardwaj et al. 201123 318 (54) Inverness Medical Innovations Prospective Multicentre:
United StatesAt presentation and repeated if clinically indicated ACS
62 (20)30 d Note: ACS = acute coronary syndrome, MI = myocardial infarction. *Older population (≥ 70 yr).
- Table 2: Assessment of the studies that tested the high-sensitivity troponin T assay or high-sensitivity troponin I assay for risk of bias using the Quality Assessment of Diagnostic Accuracy Studies tool8
Study Representative spectrum? Acceptable reference standard? Acceptable delay between tests? Partial verification avoided? Differential verification avoided? Incorporation avoided? Reference standard results blinded? Index test results blinded? Uninterpretable results reported? Withdrawals explained? Sponsoring precluded? Troponin T Reichlin et al. 20099 Yes Yes Yes Yes Yes Yes Yes Yes No Yes Yes Christ et al. 201010 Yes Yes Yes Yes Yes Yes Unclear Unclear Yes Yes Yes Aldous et al. 201111 No Yes Yes Yes Yes Yes No Yes Yes Yes Yes Body et al. 201112 Yes Yes Yes Yes Yes Yes Unclear Yes Yes Yes No Freund et al. 201113 Yes Yes Yes Yes Yes Yes Unclear Yes Yes Yes Unclear Melki et al. 201114 Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Unclear Reiter et al. 201115 Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Weber et al. 201116 Yes Yes Yes Yes Yes Yes Unclear Yes Yes Unclear Unclear Aldous et al. 201217 Yes Yes Yes Yes Yes Yes Unclear Yes Yes Yes Unclear Troponin I Reichlin et al. 20099 Yes Yes Yes Yes Yes Yes Yes Yes No Yes Yes Keller et al. 200924 Yes Yes Yes Yes Yes Yes Unclear Yes Yes Yes Unclear Bhardwaj et al. 201123 Yes Yes Unclear Yes Yes Yes Unclear Yes Yes Yes Yes Note: Yes = high quality, No = low quality. Weighted κ = 0.70, 95% confidence interval 0.54–0.87, p < 0.001 (indicates substantial agreement according to Koch and Landis).18,19
- Table 3: Diagnostic performance of high-sensitivity troponin T versus conventional troponin assay at presentation
Study High-sensitivity troponin T assay* Conventional troponin assay Assay Sensitivity Specificity NPV, % PPV, % Cut-off point and assay Sensitivity Specificity NPV, % PPV, % Reichlin et al. 20099 Elecsys 2010 (Roche Diagnostics) 0.95 0.80 99 50 Troponin T, 0.035 ng/mL (4th generation, Roche) 0.72 0.97 94 85 Christ et al. 201010 Elecsys 2010 (Roche Diagnostics) 0.95 0.62 98.6 29.7 Troponin T, 0.04 ng/mL (4th generation, Roche Diagnostics) 0.65 0.91 93.8 54.2 Aldous et al. 201111 Elecsys (Roche Diagnostics) 0.84 0.84 91.2 71.9 Troponin T, 0.03 ng/mL (Elecsys 2010, Roche Diagnostics) 0.43 0.97 77.4 88.7 Body et al. 201112 Roche 0.85 0.82 96.1 52.4 Troponin T, 0.01 ng/mL (4th generation) 0.75 0.95 94.4 75.8 Freund et al. 201113 Elecsys 2010 (Roche Diagnostics) 0.93 0.82 99 47 Troponin I, 0.06 ng/mL (Access analyzer, Beckman Coulter)
or
Troponin I, 0.14 ng/mL (Xpand HM analyzer, Siemens Healthcare Diagnostics)0.71 0.97 95 78 Melki et al. 201114 Roche Diagnostics 0.97 0.74 97 78 Troponin T, 0.04 ng/mL (4th generation, Roche Diagnostics) 0.79 0.94 82 93 Reiter et al. 201115 Elecsys 2010 (Roche Diagnostics) 0.98 0.49 99 38 Troponin T, 0.035 ng/mL (Roche) 0.76 0.96 93 86 Weber et al. 201116 Elecsys (Roche Diagnostics) 0.96 0.61 80 91 Troponin T, 0.03 ng/mL (Elecsys, Roche Diagnostics) 0.82 0.90 54 97 Aldous et al. 201217 Elecsys (Roche Diagnostics) 0.88 0.82 96.2 57.5 Troponin I, 0.028 ng/mL (Architect system, Abbott Diagnostics) NA NA NA NA Note: NA = not available, NPV = negative predictive value, PPV = positive predictive value. *Cut-off point 14 ng/L.
- Table 4: Diagnostic performance of high-sensitivity troponin T compared with conventional troponin assay at various times after presentation
Study Diagnostic performance using serial high-sensitivity troponin T assays Early assay, AUC (95% CI) Later assay, AUC (95% CI) Reichlin et al. 20099 3 h from presentation:
0.98 (0.97–0.99)6 h from presentation:
0.98 (0.96–0.99)Reiter et al. 2011*15 3 h from presentation:
0.97 ( 0.94–0.99)6 h from presentation:
0.96 (0.92–0.99)Christ et al. 201010 NA NA Aldous et al. 201111 NA 6–24 h from presentation:
0.94 (0.91–0.97)Body et al. 201112 NA NA Freund et al. 201113 NA NA Weber et al. 201116 NA NA Melki et al. 201114 2 h from presentation:
sensitivity 0.99, specificity 0.71
PPV 77%, NPV 99%NA Aldous et al. 201217 2 h from presentation:
sensitivity 0.92, specificity 0.80
PPV 55.9%, NPV 97.3%NA Note: AUC = area under the curve, CI = confidence interval, NA = not available, NPV = negative predictive value, PPV = positive predictive value. *Older population (≥ 70 yr).
- Table 5: Diagnostic performance of high-sensitivity troponin I versus conventional troponin T assay at presentation
Study High-sensitivity troponin I assay Conventional troponin T assay Cut-off point and assay Sensitivity Specificity NPV, % PPV, % Cut-off point and assay Sensitivity Specificity NPV, % PPV, % Reichlin et al. 20099 40 ng/L
ADVIA Centaur Immunoassay System (Siemens)0.89 0.92 98 68 0.035 ng/mL
4th generation (Roche)0.72 0.97 94 85 Bhardwaj et al. 201123 6.28 ng/L
Erenna Immunoassay System (Singulex)0.57 0.86 89 50 0.03 ng/mL
Elecsys 2010 or E170 platforms (Roche Diagnostics)0.22 0.97 84 65 Keller et al. 200924 40 ng/L
Troponin I Ultra (Siemens Healthcare Diagnostics)0.91 0.90 96.4 76.7 0.03 ng/mL (Roche) 0.64 0.97 88.3 88.8 Note: NPV = negative predictive value, PPV = positive predictive value.
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