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Normal presenting levels of high-sensitivity troponin and myocardial infarction
  1. Rebeca Hoeller1,
  2. María Rubini Giménez1,2,
  3. Tobias Reichlin1,3,
  4. Raphael Twerenbold1,4,
  5. Christa Zellweger1,
  6. Berit Moehring1,
  7. Karin Wildi1,
  8. Michael Freese1,
  9. Claudia Stelzig1,
  10. Beate Hartmann1,
  11. Melanie Stoll1,
  12. Tamina Mosimann1,
  13. Miriam Reiter1,
  14. Philip Haaf1,
  15. Mira Mueller1,
  16. Bernadette Meller1,
  17. Thomas Hochgruber1,
  18. Cathrin Balmelli1,
  19. Seoung Mann Sou1,
  20. Karsten Murray1,
  21. Heike Freidank5,
  22. Stephan Steuer6,
  23. Jan Minners1,
  24. Stefan Osswald1,
  25. Christian Mueller1
  1. 1Department of Cardiology, University Hospital Basel, Basel, Switzerland
  2. 2Pneumology Department, Parc de Salut Mar- IMIM- UPF. CIBERES (ISC iii) Barcelona, Barcelona, Spain
  3. 3Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
  4. 4Universitäres Herz-Zentrum Bad Krozingen, Bad Krozingen, Germany
  5. 5Department of Laboratory Medicine, University Hospital, Basel, Switzerland
  6. 6Emergency Department, Spital Lachen, Lachen, Switzerland
  1. Correspondence to Dr Christian Mueller, Department of Internal Medicine, Division of Cardiology, University Hospital Basel. Petersgraben 4, CH-4031 Basel, Switzerland; chmueller{at}


Objective To analyse whether levels of high-sensitivity cardiac troponin (hs-cTn) below their respective 99th percentile can be used as a single parameter to rule out acute myocardial infarction (AMI) at presentation.

Design Prospective, multicentre study.

Main outcome measures We measured hs-cTn using four different methods (hs-cTnT Roche, hs-cTnI Siemens, hs-cTnI Beckman Coulter and hs-cTnI Abbott) in consecutive patients presenting to the emergency department with acute chest pain. Two independent cardiologists adjudicated the final diagnosis. Patients were followed for death or AMI during a mean period of 24 months.

Results Among 2072 consecutive patients with hs-cTnT measurements available, 21.4% had an adjudicated diagnosis of AMI (sensitivity 89.6%, 95% CI 86.4% to 92.3%, negative predictive value (NPV): 96.5%, 95% CI 95.4% to 97.4%). Among 1180 consecutive patients with hs-cTnI Siemens measurements available, 20.0% had AMI (sensitivity 94.1%, 95% CI 90.3% to 96.7%, NPV: 98.0%, 95% CI: 96.6% to 98.9%). Among 1151 consecutive patients with hs-cTnI Beckman Coulter measurements available, 19.7% had AMI (sensitivity 92.1%, 95% CI 87.8% to 95.2%, NPV: 97.5%, 95% CI 96.0% to 98.5%). Among 1567 consecutive patients with hs-cTnI Abbott measurements available, 20.0% had AMI (sensitivity 77.2%, 95% CI 72.1% to 81.7%, NPV: 94.3%, 95% CI 92.8% to 95.5%).

Conclusions Normal hs-cTn levels at presentation should not be used as a single parameter to rule out AMI as 6%–23% of adjudicated AMI cases had normal levels of hs-cTn levels at presentation. Our data highlight the lack of standardisation among hs-cTnI assays resulting in substantial differences in sensitivity and NPV at the 99th percentile.


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