What are the latest ESC recommendations for the clinical variables that affect the high sensitivity cardiac troponin levels?
We always are troubled by some confounders of troponin levels. These confounders have an effect on the troponin elevated due to comorbidities. These comorbidities are older age, the presence of underlying structural heart disease, chronic kidney disease, and gender.
So, there are sex differences in the baseline troponin concentrations. The genders have different hearts, they have different cardiac masses, they are functionally different, and the 99th percentile value is lower in female than men. But if you try to adjust for this baseline differences depending not only on sex but on all confounding variables, then you end up with a very complicated algorithm, and that cannot be managed by a physician who is in charge of an emergency department. The ESC has decided, I think bravely, to disregard comorbidity or sex-related cut-offs, and to go for a common, general cut-off. I think this is an excellent idea. It is a little bit contrary to recommendations from the universal myocardial infarction definition and the IFCC (International Federation of Clinical Chemistry and Laboratory Medicine), and it is also a little bit different from the information that we have in some package inserts from some troponin I, and from the US package insert from troponin T.
But now it simplifies things a lot and another thing is, I think that the concentration changes in these patients with comorbidities are more important than the baseline values. So, if you have to decide whether a patient with end-stage renal disease or severe chronic kidney disease has suffered an infarct or maybe and unstable angina or non-cardiac chest pain, you have to look at the delta change and not at the baseline value. That is really important, and here, of course, the omittance of specific baseline cut-offs emphasises the role for delta changes.
