Clinical Practice Guidelines
The introduction of troponin assays with improved sensitivity has increased the number of chest-pain patients presenting at admission with cTn values exceeding the 99th percentile as a result of causes other than AMI. This can complicate the appropriate triage of patients.1, 2, 3
As a result, guidelines have helped provide guidance around how to use troponin effectively, such as the 2011 European Society of Cardiology guidelines on acute coronary syndromes, the 2012 Third Universal Definition of Myocardial Infarction, and the 2014 ACC/AHA Task Force guidelines.
European Society of Cardiology (2011)
In 2011 European Society of Cardiology recommended a fast-track rule-out protocol (3 hours instead of 6 hours) for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation. It advises cardiac troponin measurement at admission and then 3 hours after the time of presentation.4, 5
Third Universal Definition of Myocardial Infarction (2012)
The Third Universal Definition of Myocardial Infarction6, an expert-consensus document published in the European Heart Journal in 2012 by the Writing Group on behalf of the Joint ESC/ACCF/AHA/WHF Task Force for the Universal Definition of Myocardial Infarction.
- Takes into account that a very small degree of myocardial injury or necrosis can be detected by sensitive or high-sensitive cardiac troponin (cTn) assays and/or imaging.
- Focuses on differentiating the five types of MI and defining cTn cutpoints for each type.
- Reinforces the need to assess cTn change to better differentiate MI-related cTn elevation from other more-chronic causes of cTn release.
- Recommends serial measurement with at least one result above the 99th percentile upper reference limit (URL).
ACC/AHA Task Force (2014)
To determine the significance of a change, clinicians have utilized both relative (a percent change) and absolute changes (a quantitative change using an assigned value). Recent data7 supports the superior performance for absolute vs. relative change, particularly in the lower elevations. In September 2014 the ACC/AHA Task Force published a guideline on the management of patients with non-ST-elevation acute myocardial infarction8 which indicates that absolute changes may provide better accuracy than relative changes.
1Melanson SEF. Earlier detection of myocardial injury in a preliminary evaluation using a new troponin I assay with improved sensitivity. Am J Clin Pthol. 2007;128:282-286
2Reichlin T, et al. Early diagnosis of myocardial infarction with sensitive cardiac troponin assays. N Engl J Med. 2009;361:858-867.
3Keller T, et al .Sensitive troponin I assay in early diagnosis of acute myocardial infarction. N Engl J Med. 2009;361:868-877.
4ESC guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation.
Eur Heart J. 2011;32:2999-3054.
5Mueller C. Sensitive cardiac troponin I in the distinction of acute myocardial infarction from acute cardiac non-coronary artery disease, to be published in 2014 (APACE Study).
6European Heart Journal (2012) 33, 2551–2567European Heart Journal (2012) 33, 2551–2567
7Reichlin T et al.Circulation 2011; 124:136-145
8Amsterdam EA, Wenger NK, Brindis RG, Casey DE Jr, Ganiats TG, Holmes DR Jr, Jaffe AS, Jneid H, Kelly RF, Kontos MC, Levine GN, Liebson PR, Mukherjee D, Peterson ED, Sabatine MS, Smalling RW, Zieman SJ. 2014 ACC/AHA guideline for the management of patients with non–ST-elevation acute coronary syndromes: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. 2014;000:000–000.
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