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(Circulation. 1995;92:3401-3407.)
© 1995 American Heart Association, Inc.
Articles |
Value of Myoglobin, Troponin T, and CK-MBmass in Ruling Out an Acute Myocardial Infarction in the Emergency Room
From the Departments of Cardiology (R.J. de W., R.W.K.) and Clinical Chemistry (G.T.S), Academic Medical Center, University of Amsterdam (the Netherlands), and the Department of Clinical Chemistry (A.S.), University of Leiden (the Netherlands).
Correspondence to Robbert J. de Winter, Department of Cardiology, Room G3-231, Academic Medical Center, Meibergdreef 9, Amsterdam 1105 AZ, Netherlands.
Background Ruling out acute myocardial infarction (AMI) on the basis of rapid assays for cardiac markers will allow early triage of patients and cost-effective use of available coronary care facilities.
Methods and Results We studied the value of myoglobin, creatine kinase (CK)–MBmass, and troponin T in ruling out an AMI in the emergency room in 309 consecutive patients presenting with chest pain. The gold standard for AMI was the combination of history, ECG, and a typical curve of the CK-MB activity (CK-MBact). Myoglobin was the earliest marker, and its negative predictive value (NPV) was significantly higher than for CK-MBmass and troponin T from 3 to 6 hours after the onset of symptoms (myoglobin versus CK-MBmass, P<.03; myoglobin versus troponin T, P<.01). The NPV of myoglobin reached 89% 4 hours after the onset of symptoms. The NPV of CK-MBmass reached 95% 7 hours after the onset of symptoms. Troponin T was not an early marker for ruling out AMI, and NPV changed over time, together with CK-MBact. The early NPV was higher in a subgroup of patients with a low probability of the presence of AMI for the three markers. Cardiac markers rise earlier in patients with large infarcts than in patients with small infarcts as indicated by the cumulative proportion of the marker above the upper reference limit at each time point (myoglobin, P=.04; CK-MBmass, P=.013; troponin T, P=.016).
Conclusions For ruling out AMI in the emergency room, myoglobin is a better marker than CK-MBmass or troponin T from 3 until 6 hours after the onset of symptoms, but the maximal NPV reaches only 89%. At 7 hours, the NPV of CK-MBmass is 95%. The test characteristics are influenced by the probability of the presence of AMI in the patients studied and by the size of their AMI. Infarct size of AMI patients should be reported in studies evaluating cardiac markers.
Key Words: mycardial infarction • diagnosis • myoglobin • troponin T • creatine kinase
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