{
  "abstract": "Background Serum troponin measurement forms a cornerstone of acute myocardial infarction (AMI) diagnosis. A major challenge is interpretation of an elevated first troponin in patients with impaired renal function. We aimed to (1) evaluate the relationship between estimated glomerular filtration rate (eGFR) and first troponin, (2) characterise the performance of different troponin assays for diagnosing AMI and (3) derive eGFR-specific thresholds for potential clinical use.Methods We analysed the distribution of troponin values stratified by eGFR and AMI. Diagnostic performance was analysed using the C-statistic. Test detection rate, false positive rate and positive predictive value were calculated for different cut-offs.Results We included 221 175 patients between 2010 and 2017 from four acute tertiary care hospitals in London, UK, with a median age of 65 years (IQR 49–79). eGFR was<60 mL/min/1.73 m 2 in 20.6% of patients and 6.4% of patients had a diagnosis of AMI. In patients without AMI, we observed an inverse log-linear relationship between eGFR and troponin. Diagnostic performance for AMI was best in patients with eGFR>90 (C-statistic 0.93) and worst in eGFR<15 (C-statistic 0.81). For high-sensitive troponin T, using the conventional cut-off of 14 ng/L, false positive rates ranged from 68–93% for eGFRs between 15 and 60 mL/min/1.73 m2. Restricting the false positive rate to 15% yields eGFR specific cut-offs of 73, 112 and 184 ng/L, with detection rates of 73%, 70% and 68% in patients with an eGFR of 45–60, 30–45 or 15–30 mL/min/1.73 m2.Conclusions The diagnostic performance of an unadjusted troponin cut-off for AMI falls with worsening renal function. We propose consideration of eGFR specific cut-offs to support more effective triage and early management of suspected AMI in patients with renal impairment.Trial registration number NCT03507309.",
  "authors": [
    {
      "affiliations": [
        "Department of Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands",
        "Institute of Health Informatics, University College London, London, UK",
        "Department of Vascular Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands"
      ],
      "name": "Didier Collard"
    },
    {
      "affiliations": [
        "Institute of Health Informatics, University College London, London, UK",
        "NIHR Biomedical Research Centre, University College London Hospitals, London, UK"
      ],
      "name": "Yang Chen"
    },
    {
      "affiliations": [
        "NIHR Imperial Biomedical Research Centre, Imperial College London and Imperial College Healthcare NHS Trust, London, UK"
      ],
      "name": "Amit Kaura"
    },
    {
      "affiliations": [
        "NIHR Imperial Biomedical Research Centre, Imperial College London and Imperial College Healthcare NHS Trust, London, UK"
      ],
      "name": "Abdulrahim Mulla"
    },
    {
      "affiliations": [
        "NIHR Imperial Biomedical Research Centre, Imperial College London and Imperial College Healthcare NHS Trust, London, UK"
      ],
      "name": "Ben Glampson"
    },
    {
      "affiliations": [
        "NIHR Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK"
      ],
      "name": "Jim Davies"
    },
    {
      "affiliations": [
        "NIHR Imperial Biomedical Research Centre, Imperial College London and Imperial College Healthcare NHS Trust, London, UK"
      ],
      "name": "Dimitri Papadimitriou"
    },
    {
      "affiliations": [
        "NIHR Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK"
      ],
      "name": "Kerrie Woods"
    },
    {
      "affiliations": [
        "NIHR King’s Biomedical Research Centre, King’s College London and King’s College Hospital NHS Foundation Trust, London, UK"
      ],
      "name": "Kevin O’Gallagher"
    },
    {
      "affiliations": [
        "Translational Health Sciences, University of Bristol, Bristol, UK",
        "Imperial Clinical Analytics, Research & Evaluation (iCARE) and Department of Surgery & Cancer, Imperial College, London, UK"
      ],
      "name": "Erik Mayer"
    },
    {
      "affiliations": [
        "NIHR BRC, The Royal Marsden and Institute of Cancer Research, London, UK"
      ],
      "name": "Richard Lee"
    },
    {
      "affiliations": [
        "NIHR Leeds Clinical Research Facility, Leeds Teaching Hospitals Trust and University of Leeds, Leeds, UK"
      ],
      "name": "Christopher Herbert"
    },
    {
      "affiliations": [
        "NIHR Manchester Biomedical Research Centre, Manchester University NHS Foundation Trust and the University of Manchester, Manchester, UK"
      ],
      "name": "Stuart W Grant"
    },
    {
      "affiliations": [
        "NIHR Southampton Clinical Research Facility and Biomedical Research Centre, Faculty of Medicine, University of Southampton and University Hospital Southampton NHS Foundation Trust, Southampton, UK"
      ],
      "name": "Nick Curzen"
    },
    {
      "affiliations": [
        "NIHR Leicester Biomedical Research Centre, Glenfield Hospital, and Department of Cardiovascular Sciences, University of Leicester, Leicester, UK"
      ],
      "name": "Iain Squire"
    },
    {
      "affiliations": [
        "Translational Health Sciences, University of Bristol, Bristol, UK",
        "Bristol Heart Institute, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK"
      ],
      "name": "Tom Johnson"
    },
    {
      "affiliations": [
        "NIHR Guys & St Thomas' Hospital Clinical Research Facility, King's College Hospital and King's College London British Heart Foundation Centre of Excellence, London, UK"
      ],
      "name": "Ajay M Shah"
    },
    {
      "affiliations": [
        "NIHR King’s Biomedical Research Centre, King’s College London and King’s College Hospital NHS Foundation Trust, London, UK"
      ],
      "name": "Divaka Perera"
    },
    {
      "affiliations": [
        "NIHR Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK"
      ],
      "name": "Rajesh K Kharbanda"
    },
    {
      "affiliations": [
        "NIHR Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK"
      ],
      "name": "Keith Channon"
    },
    {
      "affiliations": [
        "NIHR Biomedical Research Centre, University College London Hospitals, London, UK"
      ],
      "name": "Bryan Williams"
    },
    {
      "affiliations": [
        "Institute of Health Informatics, University College London, London, UK"
      ],
      "name": "Harry Hemingway"
    },
    {
      "affiliations": [
        "Institute of Health Informatics, University College London, London, UK"
      ],
      "name": "Aroon D Hingorani"
    },
    {
      "affiliations": [
        "Department of Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands",
        "Institute of Health Informatics, University College London, London, UK"
      ],
      "name": "Folkert W Asselbergs"
    },
    {
      "affiliations": [
        "NIHR Imperial Biomedical Research Centre, Imperial College London and Imperial College Healthcare NHS Trust, London, UK"
      ],
      "name": "Jamil Mayet"
    },
    {
      "affiliations": [
        "Institute of Health Informatics, University College London, London, UK",
        "NIHR Biomedical Research Centre, University College London Hospitals, London, UK",
        "Institute of Cardiovascular Science, University College London, London, UK"
      ],
      "name": "Anoop Dinesh Shah"
    },
    {
      "affiliations": [
        "NIHR Biomedical Research Centre, University College London Hospitals, London, UK",
        "Institute of Cardiovascular Science, University College London, London, UK"
      ],
      "name": "Riyaz S Patel"
    }
  ],
  "title": "Improving the diagnostic performance of troponin assays for acute myocardial infarction in renal impairment",
  "uid": "c17d6329-ab94-5a06-8456-d2246cd1fce1"
}