Louise Cullen and Rick Body fuel a contentious debate on the clinical significance of the high sensitivity troponin assay. Will your patients benefit from that extra digit ?

1. 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

2. 1. Precision

3. Troponin0
#
Effect of Analytical Variation
CV at 99th % = 10 - 20%

4. Troponin0
#
Effect of Analytical Variation
CV at 99th % = 10 - 20%
99%

5. Troponin0
#
Effect of Analytical Variation
CV at 99th % = 10 - 20%
99%
+-

6. Troponin0
#
Effect of Analytical Variation
Highly sensitive assay
CV at 99th percentile ≤ 10%
99%

7. “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%

8. 2. Time

9. Evaluation of a patient with possible ACS
Hamm CW. Et al. EHJ (2011) 32, 2999-3054.

10. Evaluation of a patient with possible ACS
Hamm CW. Et al. EHJ (2011) 32, 2999-3054.

11. HS assays
Allow accurate measurement of
very low concentrations of troponin
AND
see rises in cTn at very early time points after
necrosis.

12. 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!

13. Delays = Overcrowding

14. Ann Emerg Med. 2007;50:510-516
Ann Emerg Med. 2008;51:1-5.

15. Delays = Overcrowding
Overcrowding = Death

16. Key Rebuttal
SMACC

17. “All these false positives with hs-troponin”
and
“We can’t do anything about an elevated
cTn”

18. Heart specific
Disease Specific

19. An elevated troponin is a bad
thing….

20. ‘We can’t alter the outcome of those
with elevated troponin who don’t
have an AMI’

21. ‘We can’t alter the outcome of those
with elevated troponin who don’t
have an AMI’
WRONG!

22. Physical activity score:
• 2 = low activity
• 3 to 6 = moderate activity
• 7 = high activity .
41
J Am Coll Cardiol 2012;60:2539–47

23. Proportion of patients with a significant
Biomarker Increase vs Physical Activity
42
hsTnT
J Am Coll Cardiol 2012;60:2539–47

24. Rate of Incident HF
43
hsTnT

25. Prescribe…..

26. Exercise!

27. Why use a high sensitivity assay?
1. Precision
2. Time
3. Risk modification
Avoid unnecessary death!

28. Poll
Who is the winner???