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True 99th centile of high sensitivity cardiac troponin for hospital patients: prospective, observational cohort study

True 99th centile of high sensitivity cardiac troponin for hospital patients: prospective, observational cohort study
True 99th centile of high sensitivity cardiac troponin for hospital patients: prospective, observational cohort study

Objective: To determine the distribution, and specifically the true 99th centile, of high sensitivity cardiac troponin I (hs-cTnI) for a whole hospital population by applying the hs-cTnI assay currently used routinely at a large teaching hospital. Design: Prospective, observational cohort study. Setting: University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom, between 29 June 2017 and 24 August 2017. Participants: 20 000 consecutive inpatients and outpatients undergoing blood tests for any clinical reason. Hs-cTnI concentrations were measured in all study participants and nested for analysis except when the supervising doctor had requested hs-cTnI for clinical reasons. Main outcome measures: Distribution of hs-cTnI concentrations of all study participants and specifically the 99th centile. Results: The 99th centile of hs-cTnI for the whole population was 296 ng/L compared with the manufacturer's quoted level of 40 ng/L (currently used clinically as the upper limit of normal; ULN). Hs-cTnI concentrations were greater than 40 ng/L in one in 20 (5.4%, n=1080) of the total population. After excluding participants diagnosed as having acute myocardial infarction (n=122) and those in whom hs-cTnI was requested for clinical reasons (n=1707), the 99th centile was 189 ng/L for the remainder (n=18 171). The 99th centile was 563 ng/L for inpatients (n=4759) and 65 ng/L for outpatients (n=9280). Patients from the emergency department (n=3706) had a 99th centile of 215 ng/L, with 6.07% (n=225) greater than the recommended ULN. 39.02% (n=48) of all patients from the critical care units (n=123) and 14.16% (n=67) of all medical inpatients had an hs-cTnI concentration greater than the recommended ULN. Conclusions: Of 20 000 consecutive patients undergoing a blood test for any clinical reason at our hospital, one in 20 had an hs-cTnI greater than the recommended ULN. These data highlight the need for clinical staff to interpret hs-cTnI concentrations carefully, particularly when applying the recommended ULN to diagnose acute myocardial infarction, in order to avoid misdiagnosis in the absence of an appropriate clinical presentation.

0959-8146
1-8
Mariathas, Mark
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Allan, Rick
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Ramamoorthy, Sanjay
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Olechowski, Bartosz
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Hinton, Jonathan
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Azor, Martin
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Nicholas, Zoe
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Calver, Alison
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Corbett, Simon
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Mahmoudi, Michael
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Rawlins, John
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Simpson, Iain
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Wilkinson, James
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Kwok, Chun Shing
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Cook, Paul
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Mamas, Mamas A.
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Curzen, Nick
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Mariathas, Mark
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Allan, Rick
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Ramamoorthy, Sanjay
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Olechowski, Bartosz
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Hinton, Jonathan
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Azor, Martin
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Nicholas, Zoe
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Calver, Alison
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Corbett, Simon
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Mahmoudi, Michael
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Rawlins, John
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Simpson, Iain
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Wilkinson, James
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Kwok, Chun Shing
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Cook, Paul
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Mamas, Mamas A.
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Curzen, Nick
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Mariathas, Mark, Allan, Rick, Ramamoorthy, Sanjay, Olechowski, Bartosz, Hinton, Jonathan, Azor, Martin, Nicholas, Zoe, Calver, Alison, Corbett, Simon, Mahmoudi, Michael, Rawlins, John, Simpson, Iain, Wilkinson, James, Kwok, Chun Shing, Cook, Paul, Mamas, Mamas A. and Curzen, Nick (2019) True 99th centile of high sensitivity cardiac troponin for hospital patients: prospective, observational cohort study. British Medical Journal, 364, 1-8. (doi:10.1136/bmj.l729).

Record type: Article

Abstract

Objective: To determine the distribution, and specifically the true 99th centile, of high sensitivity cardiac troponin I (hs-cTnI) for a whole hospital population by applying the hs-cTnI assay currently used routinely at a large teaching hospital. Design: Prospective, observational cohort study. Setting: University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom, between 29 June 2017 and 24 August 2017. Participants: 20 000 consecutive inpatients and outpatients undergoing blood tests for any clinical reason. Hs-cTnI concentrations were measured in all study participants and nested for analysis except when the supervising doctor had requested hs-cTnI for clinical reasons. Main outcome measures: Distribution of hs-cTnI concentrations of all study participants and specifically the 99th centile. Results: The 99th centile of hs-cTnI for the whole population was 296 ng/L compared with the manufacturer's quoted level of 40 ng/L (currently used clinically as the upper limit of normal; ULN). Hs-cTnI concentrations were greater than 40 ng/L in one in 20 (5.4%, n=1080) of the total population. After excluding participants diagnosed as having acute myocardial infarction (n=122) and those in whom hs-cTnI was requested for clinical reasons (n=1707), the 99th centile was 189 ng/L for the remainder (n=18 171). The 99th centile was 563 ng/L for inpatients (n=4759) and 65 ng/L for outpatients (n=9280). Patients from the emergency department (n=3706) had a 99th centile of 215 ng/L, with 6.07% (n=225) greater than the recommended ULN. 39.02% (n=48) of all patients from the critical care units (n=123) and 14.16% (n=67) of all medical inpatients had an hs-cTnI concentration greater than the recommended ULN. Conclusions: Of 20 000 consecutive patients undergoing a blood test for any clinical reason at our hospital, one in 20 had an hs-cTnI greater than the recommended ULN. These data highlight the need for clinical staff to interpret hs-cTnI concentrations carefully, particularly when applying the recommended ULN to diagnose acute myocardial infarction, in order to avoid misdiagnosis in the absence of an appropriate clinical presentation.

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Accepted/In Press date: 8 February 2019
Published date: 13 March 2019

Identifiers

Local EPrints ID: 430110
URI: https://eprints.soton.ac.uk/id/eprint/430110
ISSN: 0959-8146
PURE UUID: 1d0fea36-9839-491a-bf02-348bffdc8901
ORCID for Michael Mahmoudi: ORCID iD orcid.org/0000-0003-1293-8461

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Date deposited: 12 Apr 2019 16:30
Last modified: 20 Jul 2019 00:32

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Contributors

Author: Mark Mariathas
Author: Rick Allan
Author: Sanjay Ramamoorthy
Author: Bartosz Olechowski
Author: Jonathan Hinton
Author: Martin Azor
Author: Zoe Nicholas
Author: Alison Calver
Author: Simon Corbett
Author: John Rawlins
Author: Iain Simpson
Author: James Wilkinson
Author: Chun Shing Kwok
Author: Paul Cook
Author: Mamas A. Mamas
Author: Nick Curzen

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