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Biomarkers for infarct diagnosis and rapid rule-out/rule-in of acute myocardial infarction

Biomarker für die Infarktdiagnostik und für den schnellen Ein- und Ausschluss des akuten Myokardinfarkts

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Abstract

The 4th edition of the Universal Definition of Myocardial Infarction (MI) recommends measurement of cardiac troponin (cTn) T or I for the diagnosis of MI due to their absolute cardiac tissue specificity. In this MI definition, values exceeding the 99th percentile of a healthy reference population distinguish between detectable troponin due to physiological cell turnover as opposed to pathological myocardial injury. In clinical routine, high-sensitivity (hs) troponin assays that allow earlier diagnosis of MI and detection of myocardial injury that would have escaped detection due to the lower sensitivity of previous assay generations are increasingly used. While the 2015 European Society of Cardiology (ESC) guidelines already recommend a re-testing of cTn after 3 h, if an hs-cTn assay is available, faster protocols that reassess hs-cTn after 60–120 min are increasingly performed, since these protocols allow faster patient disposition, increase discharge rates from the emergency department (ED), and are at least as safe as the standard protocol for the guidance of discharge after rule-out. However, decision cut-offs are lower than the 99th percentile and concentration change criteria depend on the individual hs-cTn assay and protocol used. The following article provides an overview of the recommendations of the 4th universal MI definition as well as the current 2015 ESC guidelines on cTn and other potential biomarker candidates for patients presenting with suspected acute coronary syndromes. Limitations and areas of controversy are discussed.

Zusammenfassung

In der vierten Version der „Universellen Infarktdefinition“ wird die Messung von kardialem Troponin T (cTnT) oder I (cTnI) für die Diagnose des akuten Myokardinfarkts empfohlen, da kardiale Troponine gewebespezifisch sind und den myokardialen Schaden zuverlässig anzeigen. Das 99. Perzentil einer gesunden Referenzpopulation dient dabei der Unterscheidung zwischen dem Vorliegen einer Herzmuskelnekrose im Rahmen der physiologischen Zellregeneration und einer abnormen Myokardschädigung. In der klinischen Routine werden zunehmend hochsensitive (hs) Troponinassays eingesetzt, mit denen sich ein Myokardinfarkt früher diagnostizieren lässt und Myokardschäden erkannt werden können, die in der Vergangenheit aufgrund der geringeren Sensitivität älterer Assays übersehen worden wären. Die European Society of Cardiology (ESC) empfiehlt in ihren Leitlinien schon seit 2015 eine Wiederholungsmessung von hs-cTn nach 3 h, soweit ein entsprechender Test verfügbar ist. Immer öfter werden aber schnellere Protokolle mit Testwiederholung nach 60–120 min angewendet, da sie eine schnellere Patientendisposition ermöglichen, die Rate der Notaufnahmeentlassungen steigern und eine mindestens so sichere Orientierung bezüglich der Entlassung nach Infarktausschluss bieten wie das Standardprotokoll. Allerdings liegen die diagnostischen Cut-offs unter dem 99. Perzentil und die Konzentrationsänderungen sind je nach hs-cTn-Assay und Protokoll sehr unterschiedlich. Der vorliegende Beitrag gibt eine Übersicht über die Empfehlungen der vierten „Universellen Infarktdefinition“ und der aktuellen ESC-Leitlinien aus dem Jahr 2015 im Hinblick auf cTn und weitere mögliche Biomarkerkandidaten bei Verdacht auf ein akutes Koronarsyndrom. Es werden Limitationen und kontroverse Punkte diskutiert.

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  1. Medizinische Klinik III, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany

    Evangelos Giannitsis & Vinayak Gopi

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  1. Evangelos Giannitsis
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Correspondence to Evangelos Giannitsis.

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E. Giannitsis declares honoraria for lectures from AstraZeneca, Daiichi Sankyo, Roche Diagnostics, Brahms Thermo Fisher, Bayer Vital, Boehringer Ingelheim. He has received fees for consultancy from Brahms Thermo Fisher, AstraZeneca, Boehringer Ingelheim, and Roche Diagnostics, and he receives research funding from Daiichi Sankyo, Roche Diagnostics, Deutsche Herzstiftung. V. Gopi declares that he has no competing interests.

For this article no studies with human participants or animals were performed by any of the authors. All studies performed were in accordance with the ethical standards indicated in each case.

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Giannitsis, E., Gopi, V. Biomarkers for infarct diagnosis and rapid rule-out/rule-in of acute myocardial infarction. Herz 45, 509–519 (2020). https://doi.org/10.1007/s00059-020-04943-x

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