Troponin use for suspected coronary syndrome limited in chronic kidney disease

1. This systematic review of the literature demonstrated weak or inconclusive evidence regarding the diagnostic accuracy of troponin I (TnI) and troponin I (TnT) in detecting acute coronary syndromes (ACS) for patients with chronic kidney disease (CKD) .

2.  Elevated troponins in patients with CKD may be associated with worse prognosis.

Evidence Rating Level: 1 (Excellent)

Study Rundown: Serum troponin is a specific marker of myocardial damage, and is important in the diagnosis of ACS. In patients with CKD, troponin levels are often persistently elevated, which can make diagnosing ACS challenging in these patients.  This systematic review described 23 peer-reviewed studies on the use of TnI and TnT in suspected ACS in patients with CKD. In this review, 14 studies reported operating characteristics (sensitivity, specificity, positive predictive value, negative predictive value) of troponins in the final diagnosis of an ACS in patients with CKD and the results were variable. Regarding the prognostic value of these assays, TnI or TnT elevation was associated with increased short-term mortality based, although this findings was based on weak evidence. Evidence was insufficient regarding the long-term prognostic value of either TnI or TnT. This study was limited by lack of blinding and moderate to high risk of bias in some studies as well as heterogeneity in the methods for ACS diagnosis and defining CKD. Moreover, there is no standardized cut off level for these assays making comparison across studies challenging. Overall, this systematic review demonstrated that elevated troponins may be useful in the diagnosis and prognosis of ACS in patients with CKD, but standardization of the assays is needed for further study.

Click to read the study, published today in the Annals of Internal Medicine

Relevant Reading: Interpreting cardiac troponin results from highly sensitive assays in patients with chronic kidney disease: acute coronary syndromes and beyond

In-Depth [systematic review]: This systematic review of available peer-reviewed literature identified 23 studies on the use of elevated TnI and TnT in suspected ACS in patients with CKD. Six studies reported the sensitivity and specificity of troponin T ranging from 71-100% and 31-86%, respectively. Eight studies reported the sensitivity and specificity of troponin I ranging from 43-94% and 48-100%, respectively. Three studies used greater than 1 cut off level for these assays indicating a need for standardization to allow for comparison. None of the studies addressed the potential harms of false positives or the harms/benefits of treating patients based on diagnoses made with these assays. Twelve studies looked at the short and long term prognostic value of troponins, though different methods limited comparison. Low strength evidence showed that elevated TnI and TnT were associated with increased short term mortality, but insufficient evidence limited the determination of long-term outcomes for these assays.

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