Copeptin Improves the Diagnostic Performance of Sensitive Troponin I-Ultra but Cannot Rapidly Rule Out Non–ST-Elevation Myocardial Infarction at Presentation to an Emergency Department

• Published in: Annals of emergency medicine Vol. 61; no. 5; pp. 549 - 558.e1
• Main Authors: Charpentier, Sandrine, MD, PhD, Lepage, Benoit, MD, PhD, Maupas-Schwalm, Françoise, MD, PhD, Cinq-Frais, Christel, MD, Bichard-Bréaud, Morgane, MD, Botella, Jean Marie, MD, Elbaz, Meyer, MD, Lauque, Dominique, MD
• Format: Journal Article
• Language: English
• Published: United States Mosby, Inc 01.05.2013
• Subjects: Aged; Biomarkers - blood; Electrocardiography; Emergency; Emergency Service, Hospital - statistics & numerical data; Female; Glycopeptides - blood; Humans; Male; Middle Aged; Myocardial Infarction - blood; Myocardial Infarction - diagnosis; Myocardial Infarction - physiopathology; Prospective Studies; Risk Factors; ROC Curve; Sensitivity and Specificity; Troponin I - blood
• ISSN: 0196-0644; 1097-6760
• DOI: 10.1016/j.annemergmed.2012.12.018

Study objective We assess the performance of a single multimarker strategy, using a combination of sensitive troponin I-Ultra and copeptin assays to rule out non–ST-elevation myocardial infarction (NSTEMI) at presentation to an emergency department (ED). Methods A secondary analysis was carried out on 587 consecutive patients with chest pain who presented to the ED without ST elevation on ECG and were included in a single-site, prospective observational study. Samples for copeptin and combination of sensitive troponin I-Ultra assays were collected at presentation. The performance of the combination of copeptin and combination of sensitive troponin I-Ultra for NSTEMI was calculated in the whole cohort and after stratification by thrombosis in myocardial infarction (TIMI) risk score. Results NSTEMI was diagnosed in 87 patients (14.8%). The sensitivity and the negative predictive value of the combination of copeptin and combination of sensitive troponin I-Ultra were 96.6% (95% confidence interval [CI] 90.3% to 99.3%) and 99.1% (95% CI 97.4% to 99.8%), respectively, for a cutoff level of copeptin less than 12 pmol/L. Among the 243 patients with a low TIMI score, all 8 who had an NSTEMI were detected with the combination (sensitivity 100%; 95% CI 63.1% to 100%), and 158 were a combination of sensitive troponin I-Ultra and copeptin negative and had no NSTEMI (negative predictive value 100%; 95% CI 97.7% to 100%). Conclusion In this study, the combination of sensitive troponin and copeptin measurements had a high sensitivity and negative predictive value for NSTEMI diagnosis, especially among subjects with a low TIMI risk score. However, the sensitivity was too low to rule out NSTEMI with a single-draw strategy at ED presentation. Future studies are needed on the low-risk TIMI group to further investigate this preliminary finding.