Download - High Sensitivity Troponin: Friend or Foe?
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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
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1. Precision
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Troponin0
#
Effect of Analytical Variation
CV at 99th % = 10 - 20%
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Troponin0
#
Effect of Analytical Variation
CV at 99th % = 10 - 20%
99%
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Troponin0
#
Effect of Analytical Variation
CV at 99th % = 10 - 20%
99%
+-
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Troponin0
#
Effect of Analytical Variation
Highly sensitive assay
CV at 99th percentile ≤ 10%
99%
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“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%
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2. Time
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Evaluation of a patient with possible ACS
Hamm CW. Et al. EHJ (2011) 32, 2999-3054.
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Evaluation of a patient with possible ACS
Hamm CW. Et al. EHJ (2011) 32, 2999-3054.
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HS assays
Allow accurate measurement of
very low concentrations of troponin
AND
see rises in cTn at very early time points after necrosis.
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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!
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Delays = Overcrowding
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Ann Emerg Med. 2007;50:510-516
Ann Emerg Med. 2008;51:1-5.
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Delays = Overcrowding
Overcrowding = Death
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Key Rebuttal
SMACC
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“All these false positives with hs-troponin”
and
“We can’t do anything about an elevated cTn”
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Heart specific
Disease Specific
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An elevated troponin is a bad thing….
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‘We can’t alter the outcome of those with elevated troponin who don’t have an AMI’
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‘We can’t alter the outcome of those with elevated troponin who don’t have an AMI’
WRONG!
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Physical activity score: • 2 = low activity • 3 to 6 = moderate activity• 7 = high activity .
41
J Am Coll Cardiol 2012;60:2539–47
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Proportion of patients with a significant Biomarker Increase vs Physical Activity
42
hsTnT
J Am Coll Cardiol 2012;60:2539–47
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Rate of Incident HF
43
hsTnT
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Prescribe…..
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Exercise!
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Why use a high sensitivity assay?
1. Precision2. Time3. Risk modification
Avoid unnecessary death!
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Poll
Who is the winner???
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