Troponin T does not rule out myocardial damage until 12 hours after the onset of chest pain
Date First Published:
March 1, 2000
Last Updated:
May 24, 2001
Report by:
Katrina Richell-Herren, Research Fellow (Manchester Royal Infirmary)
Search checked by:
Sue Maurice, Manchester Royal Infirmary
Three-Part Question:
In [patients with cardiac chest pain and a normal ECG] is [a troponin T measurement at 12 hours] sensitive enough to [rule out myocardial damage in the first 12 hours]?
Clinical Scenario:
A 50 year old man attends the emergency department with a 12 hour history of chest pain that may be cardiac in origin. His ECG is normal. You want to rule out possible myocardial damage and wonder whether a single troponin T measurement taken at this time is sensitive enough to do this.
Search Strategy:
Medline 1966-01/00 using the OVID interface.
Search Details:
({exp diagnosis OR diagnosis.mp} AND troponin$.mp) LIMIT to human AND english.
Outcome:
590 papers found of which 581 were irrelevant or of insufficient quality. The remaining 9 papers are shown in the table.
Relevant Paper(s):
| Study Title | Patient Group | Study type (level of evidence) | Outcomes | Key results | Study Weaknesses |
|---|---|---|---|---|---|
| Rapid accurate diagnosis of acute myocardial infarction in patients with non-traumatic chest pain withn one hour of admission. Mair J, Smidt J, Lechleitner P at al. 1995, Austria | 114 emergency department patients with chest pain | Diagnostic test study | AMI | Sensitivity 46% on admission | Only admitted patients. Troponin cut-off set at 0.032 ng/l |
| Value of myoglobin, troponin T and CK-MB mass in ruling out acute myocardial infarction in the emergency room. De Winter RJ, Koster RW, Sturk A at al. 1995, Netherlands | 309 emergency department patients with chest pain | Diagnostic test study | AMI | Sensitivity 67% in patients with less than 75% chance of AMI | Unclear if gold standard blinded. Risk assessment was by clinical judgement. Patients with abnormal ECGs included |
| Early diagnostic efficiency of cardiac troponin I and troponin T for acute myocardial infarction. Tucker JF, Collins RA, Anderson AJ at al. 1997, USA | 177 emergency department patients within 24h of onset of chest pain | Diagnostic test study | AMI | Sensitivity 33.3% at 1h<br><br>Sensitivity 33.3% at 2h<br><br>Sensitivity 59.3% at 6h<br><br>Sensitivity 96.3% at 12-24h<br><br>Specificity 86.7% at 12-24h | Only admitted patients. |
| Evaluation of a bedside whole blood rapid troponin T assay in the Emergency Department. Rapid evaluation by assay of cardiac troponin T (REACTT). REACTT investigators study group. 1997, USA | 926 emergency department patients with chest pain Rapid bedside test vs laboratory test |
Diagnostic test study | AMI | Sensitivity 19.6% vs 25% on admission<br><br>Sensitivity 59% vs 69.6% at 3h<br><br>Sensitivity 69.7% vs 79.8% at 6h | 206 patients excluded due to lack of data. Discharged patients not followed up with same gold standard |
| Emergency room triage of patients with acute chest pain by means of rapid testing for cardiac troponin T or I. Hamm CW, Goldman BU, Heeschen C at al. 1997, Germany | 773 emergency department patients within 12h of onset of chest pain, with no ST elevation | Observational | Death or non-fatal AMI within 30 days | 44% predicted on arrival<br><br>79% predicted after 4h | No indipendent gold standard applied to all patients. Inadequate follow up of discharged patients. Sensitivity could not be calculated |
| Clinical utility of troponin T levels and echocardiography in the Emergency Department. Moher ER 3rd, Ryan T, Segar DS at al. 1998, USA | 100 patients with chest discomfort | Diagnostic test study | AMI | Sensitivity 90% at 4h | Cumulative sensitivities at 4h. |
| Measurement of cardiac troponin T is an effective method for predicting complications among emergency department patients with chest pain. Sayre MR, Kaufmann KH, Chen IW at al. 1998, USA | 667 patients with chest pain | Diagnostic test study | AMI | Sensitivity 88% at 12h post admission<br><br>Sensitivity 97% at 24h post admission | Only admitted patients studied. |
| Diagnostic marker cooperative study for the diagnosis of myocardial infarction. Zimmerman J, Fromm R, Meyer D at al. 1999, USA | 955 emergency department patients with chest pain | Diagnostic test study | AMI | Sensitivity 87% at 10h post onset | |
| Cardiac troponin T as a marker for myocardial ischaemia in patients seen at the Emergency Department for acute chest pain. Johnson PA, Goldmman L, Sacks DB at al. 1999, USA | 1477 emergency department patients with chest pain | Diagnostic test study | AMI in the 24h following presentation | Sensitivity 99% at 24h<br><br>Specificity 86% at 24h | 174 cases excluded |
Author Commentary:
No study has evaluated the point at which troponin T becomes sensitive enough to effectively rule-out acute myocardial infarction in emergency department patients. However no study has shown a high enough sensitivity (> 95%) to allow use as a SnNout at less than 12-24 hours.
Bottom Line:
Troponin T is not sensitive enough to rule out myocardial damage in the first 12 hours after onset of chest pain.
References:
- Mair J, Smidt J, Lechleitner P at al.. Rapid accurate diagnosis of acute myocardial infarction in patients with non-traumatic chest pain withn one hour of admission.
- De Winter RJ, Koster RW, Sturk A at al.. Value of myoglobin, troponin T and CK-MB mass in ruling out acute myocardial infarction in the emergency room.
- Tucker JF, Collins RA, Anderson AJ at al.. Early diagnostic efficiency of cardiac troponin I and troponin T for acute myocardial infarction.
- REACTT investigators study group.. Evaluation of a bedside whole blood rapid troponin T assay in the Emergency Department. Rapid evaluation by assay of cardiac troponin T (REACTT).
- Hamm CW, Goldman BU, Heeschen C at al.. Emergency room triage of patients with acute chest pain by means of rapid testing for cardiac troponin T or I.
- Moher ER 3rd, Ryan T, Segar DS at al.. Clinical utility of troponin T levels and echocardiography in the Emergency Department.
- Sayre MR, Kaufmann KH, Chen IW at al.. Measurement of cardiac troponin T is an effective method for predicting complications among emergency department patients with chest pain.
- Zimmerman J, Fromm R, Meyer D at al.. Diagnostic marker cooperative study for the diagnosis of myocardial infarction.
- Johnson PA, Goldmman L, Sacks DB at al.. Cardiac troponin T as a marker for myocardial ischaemia in patients seen at the Emergency Department for acute chest pain.