high sensitivity troponin: friend or foe?

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???