1. Early Diagnosis of Myocardial Infarction with Sensitive Cardiac Troponin Assays
Tobias Reichlin, M.D., Willibald Hochholzer, M.D., Stefano Bassetti, M.D.,Stephan Steuer, M.D., Claudia Stelzig, M.Sc.,
N Engl J Med 2009;361:858-67
R2. hoehoon Chung / Prof. soo joong Kim

2. Background Acute myocardial infarction
Major cause of death and disability
15 million patients per year in the US. and Europe present
to the emergency department
Rapid identification of AMI is critical for the initiation
of effective evidence-based medical treatment and management
Electrocardiography and cardiac troponins
 Current diagnostic cornerstones

3. Standard cardiac troponin
Structural proteins unique to the heart
Sensitive and specific markers of myocardial damage
Very helpful for identifying patients with ACS
Superior to all other clinically available biomarkers
(myoglobin, CK-MB, myeloperoxidase, and heart fatty acid–binding protein)
: Limitation
Delayed increase in circulating levels
 Low sensitivity at the time of a patient’s presentation
Requires prolonged monitoring over a period of 6 to 12 hours
 Delay in confirming a diagnosis

4. Methods Study design and population Clinical assessment
The Advantageous Predictors of Acute Coronary Syndromes Evaluation (APACE)
Ongoing prospective, international, multicenter study designe
~ , 786 consecutive patients
Presented to the emergency department with symptoms
chest pain and angina pectoris,
Onset or peak of symptoms had occurred within 12 hours
Patients with terminal kidney failure requiring dialysis were excluded.
Clinical assessment
Clinical history taking, physical examination
12-lead ECG, continuous ECG monitoring, pulse oximetry
Standard blood measurements, and chest radiography
Cardiac troponin I or cardiac troponin T, CK-MB, and myoglobin

5. Adjudicated Final Diagnosis
Two independent cardiologists reviewed all available medical records
AMI was defined in accordance with current guidelines.
evidence of myocardial necrosis + clinical signs of ischemia.
Necrosis was diagnosed on the basis of the local cardiac troponin level
Investigational Assays of Cardiac Troponins
Five investigational cardiac troponin assays
Abbott–Architect Troponin I
Siemens Troponin I Ultra
Roche High-Sensitive Troponin T
Roche Troponin I
Blood samples at the time of the patient’s presentation to the ED.
Additional samples were obtained 1, 2, 3, and 6 hours after presentation
CK-MB and myoglobin were measured

6. Results

7. Characteristics of the Patients
Unstable angina 16%
Cardiac causes 13%
Noncadiac causes 46%
Unknown %
17%

9. Diagnostic Accuracy of Cardiac Troponin Levels at Presentation
Figure 1. Levels of Cardiac Troponins at Presentation, as Assessed by Four
Sensitive Assays and a Standard Assay, According to the Final Diagnosis.

11. Sensitive assays Standard assays AUC Abbott–Architect Troponin I 0.96
Roche High-Sensitive Troponin T 0.96
Roche Troponin I
Siemens Troponin I Ultra
Standard assay
Figure 2. Diagnostic Performance of Cardiac Troponin Assays at Presentation.

12. Cardiac Troponin Levels at Presentation in Patients with Recent Onset of Chest Pain
Sensitive assays
Standard assays
AUC
Abbott–Architect Troponin I
Roche High-Sensitive Troponin T 0.92
Roche Troponin I
Siemens Troponin I Ultra
Standard assay

13. 3 hr Sensitive assays Standard assays 0.94 0.93 0.92 0.85 0.71 0.76
Figure 3. Diagnostic Accuracy of Cardiac Troponin Assays at Presentation
According to Time since Onset of Chest Pain.

14. Conclusion The diagnostic performance of
sensitive cardiac troponin assays is excellent.
These assays can substantially improve
the early diagnosis of acute myocardial infarction,
particularly in patients with a recent onset of chest pain.