1. Which troponin assay to choose? Clinical performances of troponin T and troponin I assays Per Venge, MD PhD Professor Department of Medical Sciences Uppsala University and Department of Clinical Chemistry and Pharmacology University Hospital Uppsala Sweden

2. 544842363024181260 20 10 0 Probability of cardiac death % Months TnT  0.60  g/L TnT 0.06- 0.59  g/L TnT <0.06  g/L p=0.001 p=0.007 FRISC-1 Lindahl B et al,NEJM 2000

3. Non-invasive / TnI  0.02  g/L Invasive / TnI  0.02  g/L Invasive / TnI <0.02  g/L Non-invasive / TnI<0.02  g/L 720640560480400320240160800 20 10 0 p=0.002 Days RR (95 % CI) 0.70 (0.56 - 0.86) p=NS FRISC-II invasive study - death/AMI (%) AccuTnI

4. What is the true 99th percentile URL of Cardiac Troponin Assays? Clinical Performances of Cardiac Troponin Assays Possible Impacts of Highly Sensitive Cardiac Troponin Assays

5. Healthy subjects with no myocardial damage? Subjects at risk with minor myocardial damage Subjects with major myocardial damage Conventional MI cut-off Consensus cut-off for MI 99th percentile URL In search for the optimal MI (myocardial injury/infarction) cut-off ECG, CK, ASAT, CK-MB Size of myocardial damage=Level of cTroponin

6. Healthy subjects with no myocardial damage? Subjects with major myocardial damage Conventional MI cut-off Consensus cut-off for MI 99th percentile URL In search for the optimal MI (myocardial injury/infarction) cut-off ECG, CK, ASAT, CK-MB Size of myocardial damage=Level of cTroponin Pragmatic MI cut-off= Assay imprecision of ≤10% CV

7. cTnI, AccuTnI in a healthy reference population n=436 (SWISCH) 99 th percentile URL 99 th percentile <60 y

8. Serum troponin levels in 758 healthy subjects

9. Prediction of Death/AMI by the cTnI AccuTnI assay (FRISC II)

10. ULSAM-study U ppsala L ongitudinal S tudy of A dult M en All men in Uppsala born between 1920 and 1924 All 50 years old men (n=2841) were invited for the investigation, 81.7% (n=2322) participated Remaining cohort at 70 years of age n =1673 (73% participated n=1221) –Men without cardiovascular disease disease n = 853 –Men with cardiovascular disease n = 368 Follow-up period 10.4 years

12. Healthy subjects with no myocardial damage? Subjects at risk with minor myocardial damage Subjects with major myocardial damage Conventional MI cut-off Consensus cut-off for MI 99th percentile URL In search for the optimal MI (myocardial injury/infarction) cut-off ECG, CK, ASAT, CK-MB Size of myocardial damage=Level of cTroponin Subjects at risk with minor myocardial damage Healthy subjects with no myocardial damage True 99th percentile URL?

13. Clinical Performances of Cardiac Troponin Assays FRISC II Study GUSTO IV Study

14. AccuTnI ≥0.04  g/L n=275 (9.4%) n=1975 (67.8%) cTnT, Elecsys <0.03  g/L cTnT, Elecsys  0.03  g/L AccuTnI <0.04  g/L n=648 (22.2%) n=15 (0.51%) ** *** FRISC II All patients n=2913 Outcome after 6 months % *** Concordance: 90 %

15. cTnI, AxSYM+ <1.0  g/L cTnI, AxSYM+  1.0  g/L AccuTnI <0.04  g/L n=207 (23.2%) n=3 (0.34%) AccuTnI  0.04  g/L n=99 (11.1%) n=582 (65.3%) FRISC II All patients n=891 Outcome after 6 months ** * * % Concordance: 87% + original assay; no longer sold

16. 1.AccuTnI from Beckman Coulter 10% CV (multicenter) = 0.06  g/L 10% CV (unicenter) = 0.03  g/L 99th percentile URL = 0.04  g/L 2.Liaison assay from DiaSorin (former Byk- Sangtec) 10% CV (unicenter) = 0.027  g/L 99th percentile URL = 0.041  g/L Highly sensitive troponin assays

17. <0.041  g/L Liaison  0.041  g/L Liaison <0.04  g/L AccuTn I n=622 22.2 % n=22 0.7 %  0.04  g/L AccuTnI n=287 10.2 % n=1877 66.8 % % ** *** FRISC II All patients n=2808 Outcome after 6 months Concordance: 89 %

18. Cardiac Troponin I 24-40 + 41-49 Liaison Binding Regions 27-39 + 80-110 AxSYM Binding Regions, 1st gen 20-39 + 87-91 Regions subject to auto-antibody formation Circulating autoantibodies against cardiac troponin I are common

19. Cardiac Troponin I 24-40 + 41-49 Liaison Binding Regions 27-39 + 80-110 AxSYM Binding Regions, 1st gen 20-39 + 87-91 24-40 + 87-91 + 41-49 = Architect and new gen AxSYM ADV Regions subject to auto-antibody formation

20. GUSTO IV Study 99 th percentile URL≤10 % CV AccuTnI, Beckman Coulter 1 0.032 µg/L0.030 µg/L Architect cTnI, Abbott 2 0.027 µg/L0.032 µg/L Immulite 2500 cTnI, DPC 3 0.22 µg/L0.33 µg/L cTnT, Roche 4 <0.01 µg/L0.03 µg/L 1 The cut-off levels were adopted from reference (27) 2 The cut-off levels were adopted from the manufacturer and from the present study 3 The cut-off levels were adopted from the present study 4 The cut-off levels were adopted from the manufacturer Cut-offs used in the assay comparisons

21. 99 th percentiles URL ≤10% CV Cut-off limits, µg/L p=0.05 p<0.05 Sensitivity cTnT Architect cTnI Architect cTnI AccuTnI Immulite 2500 cTnI Immulite 2500 cTnI Death after one year, sensitivity (GUSTO IV) n=696

22. Access < 0.032 µg/LAccess > 0.032 µg/L Architect < 0.027 µg/L Architect > 0.027 µg/L Clinical performances of AccuTnI and Architect cTnI (GUSTO IV) Cut-offs 99th percentiles URL Concordance 97% 113 (16.5%) 5 deaths (4.4%) 549 (80.4%) 56 death (10.2%) 9 (1.3%) 1 death (11.1%) 12 (1.8%) 0 deaths (0%) Conclusion: Architect cTnI (Abbott) and AccuTnI (Beckman Coulter) have similar clinical performances

23. Clinical performances of Elecsys, cTnT and Architect cTnI (GUSTO-IV trial) Cut-offs based on Imprecision ≤10% CV cTnT <0.03 µ g/LcTnT ≥0.03 µ g/L Architect <0.032 µ g/L Architect ≥ 0.032 µ g/L Concordance 89 % 2 1 death 144 (20.7 %) 5 death (3%) 475 (68.2 %) 47 death (10%) 75 (10.8 %) 9 death (12%) p<0.001

24. Clinical performances of Elecsys, cTnT and Architect cTnI (GUSTO IV) Cut-offs based on 99th percentile URL cTnT < 0.01 µg/LcTnT ≥ 0.01 µg/L Architect < 0.027 µg/L Architect > 0.027 µg/L Concordance 92% 12 (1.7%) 0 death (0%) 126 (18 %) 5 death (4%) 514 (73.8 %) 52 death (10%) 44 (6.3 %) 5 death (11%) Conclusion: The clinical performances of Architect cTnI (Abbott) and AccuTnI (Beckman Coulter) are superior to Elecsys, cTnT (Roche) p<0.001

25. Possible impacts of highly sensitive cardiac troponin assays Redefinition of 99 th percentile URL

26. Possible impacts of highly sensitive cardiac troponin assays Redefinition of 99 th percentile URL Changes in the clinical management

27. Possible impacts of highly sensitive cardiac troponin assays Redefinition of 99 th percentile URL Changes in the clinical management Screening of select populations

28. Acute coronary syndrome - The diagnostic dilemma Time 99th percentile URL Troponin AMI ?

29. Acute coronary syndrome - The diagnostic dilemma No AMI – rule out AMI – rule in Outcome prediction Troponin 99 th percentile, but no symptoms or signs of ischemia Troponin >99th percentile or >10% CV cut-off, and symptoms and/or signs of ischemia Increased risk: Troponin >99 th percentileNo increased risk: Troponin <99 th percentile No AMI – rule out: AMI – rule in:

30. Clinical Importance of Troponin Assays with Enhanced Sensitivity Elevated levels of troponins in both diseased and seemingly healthy subjects are predictive of adverse events Different cardiac troponin I assays may identify different forms of troponin I, which determine their clinical performance and predictive power The troponin I assays of Abbott and Beckman Coulter have superior clinical performances as compared to Roche troponin T and other troponin I assays Troponin assays should be sufficiently sensitive for the identification of the great majority of subjects at risk of adverse cardio-vascular events The optimal clinical decision limit for cardiac troponin I remains to be defined and may vary dependent on the clinical situation Our data imply that the clinical utility of troponin assays is broadened and the clinical management should be revised accordingly

31. Collaborators Bertil Lindahl Lars Wallentin Erik Diderholm Stefan James Tomas Jernberg Nina Johnston Kai Eggers Several others at the Cardiology Department, Uppsala The FRISC II Study group ULSAM Study group Björn Zethelius The laboratory staff at the Department of Clinical Chemistry, Uppsala