Joel M. Gore, MD reviewing Ricci F et al. Am J Med 2016 Jan.
Measuring both copeptin and cardiac troponin on presentation reliably ruled out acute coronary syndromes in a small study.
Emergency departments (EDs) must quickly and reliably rule out acute coronary syndromes (ACSs). Despite recent research into a 1-hour rule-out using high-sensitivity troponin levels (NEJM JW Cardiol Mar 2016 and Ann Emerg Med 2016 Jan 12; [e-pub]), this approach is insufficient without assessment of cardiac risk. Researchers compared the value of measuring both ultrasensitive copeptin (which peaks rapidly after acute stress) and medium-sensitivity cardiac troponin I (cTnI), using a single sample, with that of measuring cTnI at 0 and 3 hours. They enrolled 196 consecutive patients who presented to an ED in Italy within 6 hours after chest-pain onset; none had ST-segment elevation on 12-lead electrocardiography. Copeptin assays were manufacturer-supplied.
The final, adjudicated diagnosis was ACS in 29 patients (15%). The single-sample, dual-biomarker strategy was found to be noninferior to the 3-hour interval strategy. The two strategies were discordant in 57 patients (29%):
Of 47 patients who had a positive copeptin finding and a negative cTnI on initial presentation, 8 had a 3-hour positive cTnI finding and 39 had a negative finding confirmed by cTnI retesting.
Of 10 patients with an initial finding of negative copeptin and positive cTnI, 9 had a final diagnosis of non–ST-segment-elevation myocardial infarction (NSTEMI) and the other had a hypertensive emergency.
The delay from chest-pain onset to emergency admission was significantly shorter among patients whose initial finding was copeptin-positive and cTnI-negative than among patients with the reverse pattern. The single-sampling, dual-biomarker strategy ruled out NSTEMI with 100% sensitivity and a 100% negative predictive value.
Citation(s):
Ricci F et al. Ultra-sensitive copeptin and cardiac troponin in diagnosing non-ST-segment elevation acute coronary syndromes — the COPACS Study. Am J Med 2016 Jan; 129:105.
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