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Multicenter Study
. 2018 Oct 2;7(19):e008032.
doi: 10.1161/JAHA.117.008032.

Cardiac Troponins for the Diagnosis of Acute Myocardial Infarction in Chronic Kidney Disease

Daniel Kraus  1 , Beatrice von Jeinsen  2   3 , Stergios Tzikas  4 , Lars Palapies  2 , Tanja Zeller  5   6 , Christoph Bickel  7 , Georg Fette  8 , Karl J Lackner  9 , Christiane Drechsler  1 , Johannes T Neumann  5   6 , Stephan Baldus  10 , Stefan Blankenberg  5   6 , Thomas Münzel  11 , Christoph Wanner  1   12 , Andreas M Zeiher  2   3 , Till Keller  2   3   13
Affiliations
Multicenter Study

Cardiac Troponins for the Diagnosis of Acute Myocardial Infarction in Chronic Kidney Disease

Daniel Kraus et al. J Am Heart Assoc. .

Abstract

Background Patients with chronic kidney disease ( CKD ) are at high risk of myocardial infarction. Cardiac troponins are the biomarkers of choice for the diagnosis of acute myocardial infarction ( AMI ) without ST -segment elevation ( NSTE ). In patients with CKD , troponin levels are often chronically elevated, which reduces their diagnostic utility when NSTE - AMI is suspected. The aim of this study was to derive a diagnostic algorithm for serial troponin measurements in patients with CKD and suspected NSTE - AMI . Methods and Results Two cohorts, 1494 patients from a prospective cohort study with high-sensitivity troponin I (hs- cTnI ) measurements and 7059 cases from a clinical registry with high-sensitivity troponin T (hs- cTnT ) measurements, were analyzed. The prospective cohort comprised 280 CKD patients (estimated glomerular filtration rate <60 mL/min/1.73 m2). The registry data set contained 1581 CKD patients. In both cohorts, CKD patients were more likely to have adjudicated NSTE - AMI than non- CKD patients. The specificities of hs- cTnI and hs- cTnT to detect NSTE - AMI were reduced with CKD (0.82 versus 0.91 for hs- cTnI and 0.26 versus 0.73 for hs- cTnT ) but could be restored by applying optimized cutoffs to either the first or a second measurement after 3 hours. The best diagnostic performance was achieved with an algorithm that incorporates serial measurements and rules in or out AMI in 69% (hs- cTnI ) and 55% (hs- cTnT ) of CKD patients. Conclusions The diagnostic performance of high-sensitivity cardiac troponins in patients with CKD with suspected NSTE - AMI is improved by use of an algorithm based on admission troponin and dynamic changes in troponin concentration.

Keywords: biomarker; chronic kidney disease; cohort study; decision aids; non‐ST‐segment elevation acute coronary syndrome.

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Figures

Figure 1
Figure 1
Flow charts for the inclusion of study subjects. Flow charts for subjects from (A) the prospective study cohort and (B) the clinical registry. ACS indicates acute coronary syndrome; AMI, acute myocardial infarction; CKD, chronic kidney disease; NSTE, non–ST‐segment elevation; STE, ST‐segment elevation; TnI, troponin I; TnT, troponin T.
Figure 2
Figure 2
Receiver operator characteristics of initial troponin measurements for the diagnosis of NSTE‐AMI in patients with or without CKD. Receiver operating characteristic analysis in patients with acute chest pain for identification of an acute myocardial infarction by (A) hs‐cTnI and (B) hs‐cTnT levels on admission. AUC indicates area under the concentration‐time curve; CKD, chronic kidney disease; cTnI, cardiac troponin I; cTnT, cardiac troponin T; eGFR, estimated glomerular filtration rate; hs, high‐sensitivity; NSTE‐AMI, non–ST‐segment elevation acute myocardial infarction.
Figure 3
Figure 3
Algorithms for the diagnosis of NSTE‐AMI in patients with CKD. Diagnostic algorithms for patients with CKD, suspected myocardial infarction, and nonspecific ECGs with the (A) hs‐cTnI and (B) hs‐cTnT assays. Numbers indicate how many patients were affected in the corresponding cohorts. AMI indicates acute myocardial infarction; CKD, chronic kidney disease; Δ, change; ECG, electrocardiogram; hs‐cTnI and hs‐cTnT, high‐sensitivity cardiac troponin I and T, respectively; NSTE‐AMI, non–ST‐segment elevation acute myocardial infarction.
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