Temporal Release of High-Sensitivity Cardiac Troponin T and I and Copeptin After Brief Induced Coronary Artery Balloon Occlusion in Humans

Sex-Specific Thresholds of High-Sensitivity Troponin in Patients With Suspected Acute Coronary Syndrome

Clinical question: Should we use sex-specific thresholds for high-sensitivity troponin (HST) in patients with suspected acute coronary syndrome (ACS)?

What was already known: The development of high-sensitivity troponin (HST) assays has shown that 99th percentile of the reference range of troponin is almost twice as high in men compared to women, but the same HST cutoff thresholds are used in both sexes, a finding that may contribute to the major disparities that exist between women and men in the diagnosis and management of ACS.

Methods: This is a stepped-wedge, cluster-randomized controlled trial with a sample of 48,282 patients (47% women) with suspected ACS across 10 hospitals in Scotland. It consisted of a validation phase, in which contemporary cardiac troponin I (cTnI) was used to guide care, and an implementation phase, in which HST with sex-specific thresholds were used. Diagnosis rates using cTnI and HST were compared, as well as differences in the rate of recurrent MI or cardiovascular death at 1 year.

Results/implications: Use of HST with sex-specific thresholds (vs. cTnI with uniform threshold) increased the diagnosis of MI in women by 42% and men by 6%, leading to equal rates of diagnosis in men and women. It also increased rates of revascularization and preventative therapy in both men and women, although women remained half as likely to receive evidence-based treatment. There was no significant effect on the rates of subsequent MI or cardiovascular death in men or women, but more women (especially those who fell between the uniform and sex-specific thresholds) were identified as at-risk. 

Bottom line: In men and women presenting with suspected ACS, the use of HST with sex-specific thresholds rather than cTnI with a uniform threshold increases the rate of diagnosis and treatment of MI in women, but rates of evidence-based treatment remain lower in women and rates of adverse events are unchanged in both men and women.