High Sensitivity Troponin: Friend or Foe?

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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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High Sensitivity Troponin: Friend or Foe?

  1. 1. 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
  2. 2. 1. Precision
  3. 3. Troponin0 # Effect of Analytical Variation CV at 99th % = 10 - 20%
  4. 4. Troponin0 # Effect of Analytical Variation CV at 99th % = 10 - 20% 99%
  5. 5. Troponin0 # Effect of Analytical Variation CV at 99th % = 10 - 20% 99% +-
  6. 6. Troponin0 # Effect of Analytical Variation Highly sensitive assay CV at 99th percentile ≤ 10% 99%
  7. 7. “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%
  8. 8. 2. Time
  9. 9. Evaluation of a patient with possible ACS Hamm CW. Et al. EHJ (2011) 32, 2999-3054.
  10. 10. Evaluation of a patient with possible ACS Hamm CW. Et al. EHJ (2011) 32, 2999-3054.
  11. 11. HS assays Allow accurate measurement of very low concentrations of troponin AND see rises in cTn at very early time points after necrosis.
  12. 12. 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!
  13. 13. Delays = Overcrowding
  14. 14. Ann Emerg Med. 2007;50:510-516 Ann Emerg Med. 2008;51:1-5.
  15. 15. Delays = Overcrowding Overcrowding = Death
  16. 16. Key Rebuttal SMACC
  17. 17. “All these false positives with hs-troponin” and “We can’t do anything about an elevated cTn”
  18. 18. Heart specific Disease Specific
  19. 19. An elevated troponin is a bad thing….
  20. 20. ‘We can’t alter the outcome of those with elevated troponin who don’t have an AMI’
  21. 21. ‘We can’t alter the outcome of those with elevated troponin who don’t have an AMI’ WRONG!
  22. 22. Physical activity score: • 2 = low activity • 3 to 6 = moderate activity • 7 = high activity . 41 J Am Coll Cardiol 2012;60:2539–47
  23. 23. Proportion of patients with a significant Biomarker Increase vs Physical Activity 42 hsTnT J Am Coll Cardiol 2012;60:2539–47
  24. 24. Rate of Incident HF 43 hsTnT
  25. 25. Prescribe…..
  26. 26. Exercise!
  27. 27. Why use a high sensitivity assay? 1. Precision 2. Time 3. Risk modification Avoid unnecessary death!
  28. 28. Poll Who is the winner???

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