Letter by Kavsak and MacRae Regarding Article, “Utility of Absolute and Relative Changes in Cardiac Troponin Concentrations in the Early Diagnosis of Acute Myocardial Infarction”
2012; Lippincott Williams & Wilkins; Volume: 125; Issue: 6 Linguagem: Inglês
10.1161/circulationaha.111.057885
ISSN1524-4539
AutoresPeter A. Kavsak, Andrew R. MacRae,
Tópico(s)Cardiac electrophysiology and arrhythmias
ResumoHomeCirculationVol. 125, No. 6Letter by Kavsak and MacRae Regarding Article, "Utility of Absolute and Relative Changes in Cardiac Troponin Concentrations in the Early Diagnosis of Acute Myocardial Infarction" Free AccessLetterPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessLetterPDF/EPUBLetter by Kavsak and MacRae Regarding Article, "Utility of Absolute and Relative Changes in Cardiac Troponin Concentrations in the Early Diagnosis of Acute Myocardial Infarction" Peter A. Kavsak, PhD and Andrew R. MacRae, PhD Peter A. KavsakPeter A. Kavsak and Andrew R. MacRaeAndrew R. MacRae Originally published14 Feb 2012https://doi.org/10.1161/CIRCULATIONAHA.111.057885Circulation. 2012;125:e358To the Editor:Reichlin and colleagues1 report further findings from the Advantageous Predictors of Acute Coronary Syndrome Evaluation (APACE) trial, this time presenting data assessing absolute versus relative concentration changes in cardiac troponin (cTn) for the diagnosis of acute myocardial infarction (AMI). Their finding that an absolute difference in cTn is superior to relative change is important in reinforcing the value of using change criteria. However, questions persist about whether focusing solely on either the absolute change or on a relative change is appropriate or practical in the context of the diagnosis of AMI, or for subsequent prognosis for an adverse cardiac event.Counter to statements made by the authors, there have been previous retrospective studies that assessed the effect of either an absolute or relative change in cTn concentration on the prevalence of AMI.2 Moreover, these studies were extended to diagnosis and prognosis by the use of both sensitive and high-sensitivity cTn assays.3,4 The method of assessing change is the major difference between these previous studies and the thorough work of Reichlin and colleagues. Rather than treating absolute concentration change and relative change as mutually exclusive variables, as Reichlin and colleagues did, assessing both variables at specific ranges of concentration is likely to provide additional information. Such a dual approach may overcome analytic sensitivity and concentration range issues, and clinical conditions that result in chronic elevations of cTn, as well. Specifically, use of criteria from the 2007 universal definition (ie, >3 SD absolute change, or 20% relative change) and use of an absolute difference of 0.03 μg/L (or >0.02 μg/L) for concentrations <0.10 μg/L and a 20% change for higher concentrations identified patients with acute coronary syndrome at subsequent risk for myocardial infarction/death at 30 days through 1 year.4 This dual-change criteria was informative for specimens collected as little as 1 hour apart with a sensitive cTnI assay; however, the same criterion was not as informative for a high-sensitivity cTnI assay with this short interval sampling. For a high-sensitivity assay, the combination of absolute and relative changes for predicting an adverse cardiac event may need to be empirically determined and assessed in subsequent clinical studies.To this end, Reichlin and colleagues may have evidence to support optimal absolute and relative change criteria for AMI diagnosis, but the performance of both these variables combined was not explored. Moreover, their suggestion that a 7 ng/L change in high-sensitivity cTnT should be useful to "differentiate AMI from other conditions that lead to stable chronic elevations" must be tempered by the fact that, at higher cTn concentrations, 7 ng/L will be within the imprecision of the assay. There must be a concomitant increase in the absolute delta at higher concentrations to avoid misclassification based on imprecision or variation of the assay due to instrumentation.5 Otherwise, analytic issues may again impede progress in understanding and implementing cTn change for the diagnosis and management of patients with symptoms suggestive of acute coronary syndrome.Peter A.Kavsak, PhD Department of Pathology and Molecular Medicine McMaster University Hamilton, ON, CanadaAndrew R. MacRae, PhD Department of Biochemistry and Medical Genetics University of Manitoba Winnipeg, MB, CanadaDisclosuresDr Kavsak has received speaker fees or grant support from the following diagnostic companies that manufacture troponin assays: Beckman Coulter, Roche, Ortho Clinical Diagnostics, Randox Ltd, and Abbott.References1. Reichlin T, Irfan A, Twerenbold R, Reiter M, Hochholzer W, Burkhalter H, Bassetti S, Steuer S, Winkler K, Peter F, Meissner J, Haaf P, Potocki M, Drexler B, Osswald S, Mueller C. Utility of absolute and relative changes in cardiac troponin concentrations in the early diagnosis of acute myocardial infarction. Circulation. 2011; 124:136–145.LinkGoogle Scholar2. Kavsak PA, MacRae AR, Lustig V, Bhargava R, Vandersluis R, Palomaki GE, Yerna MJ, Jaffe AS. The impact of the ESC/ACC redefinition of myocardial infarction and new sensitive troponin assays on the frequency of acute myocardial infarction. Am Heart J. 2006; 152:118–125.CrossrefMedlineGoogle Scholar3. Kavsak PA, MacRae AR, Yerna MJ, Jaffe AS. Analytic and clinical utility of a next-generation, highly sensitive cardiac troponin I assay for early detection of myocardial injury. Clin Chem. 2009; 55:573–577.CrossrefMedlineGoogle Scholar4. Kavsak PA, Ko DT, Wang X, Macrae AR, Jaffe AS. 2007 universal myocardial infarction definition change criteria for risk stratification by use of a high-sensitivity cardiac troponin I assay. Clin Chem. 2010; 56:487–489.CrossrefMedlineGoogle Scholar5. Saenger AK, Beyrau R, Braun S, Cooray R, Dolci A, Freidank H, Giannitsis E, Gustafson S, Handy B, Katus H, Melanson SE, Panteghini M, Venge P, Zorn M, Jarolim P, Bruton D, Jarausch J, Jaffe AS. Multicenter analytical evaluation of a high-sensitivity troponin T assay. Clin Chim Acta. 2011; 412:748–754.CrossrefMedlineGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetailsCited By Consuegra-Sánchez L, Martínez-Díaz J, de Guadiana-Romualdo L, Wasniewski S, Esteban-Torrella P, Clavel-Ruipérez F, Bardají A, Castillo-Moreno J and Kaski J (2018) No additional value of conventional and high-sensitivity cardiac troponin over clinical scoring systems in the differential diagnosis of type 1 vs. type 2 myocardial infarction, Clinical Chemistry and Laboratory Medicine (CCLM), 10.1515/cclm-2017-0609, 56:5, (857-864), Online publication date: 25-Apr-2018., Online publication date: 1-May-2018. Eggers K, Aldous S, Greenslade J, Johnston N, Lindahl B, Parsonage W, Pickering J, Than M and Cullen L (2015) Two-hour diagnostic algorithms for early assessment of patients with acute chest pain — Implications of lowering the cardiac troponin I cut-off to the 97.5th percentile, Clinica Chimica Acta, 10.1016/j.cca.2015.03.002, 445, (19-24), Online publication date: 1-May-2015. Aldous S, Elliott J, McClean D, Puri A and Richards A (2015) Outcomes in Patients Presenting with Symptoms Suggestive of Acute Coronary Syndrome with Elevated Cardiac Troponin but Non-obstructive Coronary Disease on Angiography, Heart, Lung and Circulation, 10.1016/j.hlc.2015.02.019, 24:9, (869-878), Online publication date: 1-Sep-2015. Korley F and Jaffe A (2014) High-sensitivity troponin: where are we now and where do we go from here?, Biomarkers in Medicine, 10.2217/bmm.14.54, 8:8, (1021-1032), Online publication date: 1-Aug-2014. Irfan A, Reichlin T, Twerenbold R, Meister M, Moehring B, Wildi K, Bassetti S, Zellweger C, Gimenez M, Hoeller R, Murray K, Sou S, Mueller M, Mosimann T, Reiter M, Haaf P, Ziller R, Freidank H, Osswald S and Mueller C (2013) Early Diagnosis of Myocardial Infarction Using Absolute and Relative Changes in Cardiac Troponin Concentrations, The American Journal of Medicine, 10.1016/j.amjmed.2013.02.031, 126:9, (781-788.e2), Online publication date: 1-Sep-2013. February 14, 2012Vol 125, Issue 6 Advertisement Article InformationMetrics © 2012 American Heart Association, Inc.https://doi.org/10.1161/CIRCULATIONAHA.111.057885PMID: 22331927 Originally publishedFebruary 14, 2012 PDF download Advertisement SubjectsAcute Coronary SyndromesDiagnostic TestingMyocardial Infarction
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