Multi-marker strategy of natriuretic peptide with either

conventional or high-sensitivity troponin-T for acute

coronary syndrome diagnosis in emergency
department patients with chest pain: From the Rule
Out Myocardial Infarction Using Computer Assisted
Tomography (ROMICAT) trial
Quynh A. Truong, MD, MPH,a,b James Bayley, BA,b Udo Hoffmann, MD, MPH,a,b Fabian Bamberg, MD, MPH,b
Christopher L. Schlett, MD, MPH,b John T. Nagurney, MD, MPH,c Wolfgang Koenig, MD,d,e and
James L. Januzzi, MDa,e Boston, MA; and, Ulm, Germany

Background Compared to troponin alone, a dual-marker strategy with natriuretic peptides may improve acute
coronary syndrome (ACS) diagnosis with a single blood draw and provide physiologic information regarding underlying heart
disease. We evaluate the value of adding natriuretic peptides (myocyte stress markers) to troponins (myocardial injury markers)
for diagnosing ACS in emergency department patients with chest pain.
Methods

In 328 patients (53 12 years, 63% men) with an initially negative conventional troponin and nonischemic
electrocardiogram who underwent 64-slice cardiac computed tomography (CT), we measured conventional troponin-T (cTnT),
high-sensitivity troponin-T (hsTnT), N-terminal pro-B type natriuretic peptide, and mid-regional pro-atrial natriuretic peptide.
ACS was defined as myocardial infarction or unstable angina. CT was evaluated for coronary plaque, stenosis, and regional
wall motion abnormality.

Results Patients with ACS (n = 29, 9%) had higher concentrations of each biomarker compared to those without
(all P b .01). Adding natriuretic peptides, especially N-terminal pro-B type natriuretic peptide, to both cTnT or hsTnT improved
the C-statistics and net reclassification index for ACS, largely driven by correctly reclassifying events. Dual-negative marker
results improved sensitivity (cTnT 38% to 83%-86%, hsTnT 59% to 86%-90%; all P b .01) and negative predictive value (cTnT
94% to 97%-98%, hsTnT 96% to 97%-98%) for ACS. Patients with dual-negative markers had the lowest percentage of CT
coronary plaque, stenosis, and regional wall motion abnormality (all P-trend b.001).
Conclusion

Among emergency department patients with low-intermediate likelihood of ACS, combining natriuretic
peptides with either conventional or highly-sensitive troponin improved discriminatory capacity and allowed for better
reclassification of ACS, findings supported by structural and functional CT results. (Am Heart J 2012;163:972-979.e1.)

The current standard for the diagnosis of acute

myocardial infarction (MI) includes the measurement
From the aDivision of Cardiology, Massachusetts General Hospital, Harvard Medical
School, Boston, MA, bDepartment of Radiology, Massachusetts General Hospital, Harvard
Medical School, Boston, MA, cDepartment of Emergency Medicine, Massachusetts
General Hospital, Harvard Medical School, Boston, MA, and dCardiology, University of
Ulm, Ulm, Germany.
e
Both contributed equally to the work.
Submitted December 30, 2011; accepted March 12, 2012.
Reprint requests: Quynh A. Truong, MD, MPH, 165 Cambridge Street, Suite 400, Boston,
MA 02114.
E-mail: [email protected]
0002-8703/$ - see front matter
2012, Mosby, Inc. All rights reserved.
doi:10.1016/j.ahj.2012.03.010

of conventional troponin (cTn) levels due to the high

specicity of this biomarker for detecting myocardial
injury and necrosis, but these assays are limited by their
low rst-draw sensitivity, and the need for serial blood
draws.1 Moreover, unstable angina (UAP) is part of the
spectrum and represents a signicant number of acute
coronary syndrome (ACS) diagnoses that does not
involve an elevation or the typical rise and fall
pattern of cTn.1 Newer and more precise assays of
myocardial injury and necrosis, high-sensitivity troponin
(hsTn) assays, could replace cTn in the future because
of their ability to detect minute quantities of myocardial
injury, thus improving sensitivity for the diagnosis of
acute MI.2-4 As we and others have shown,2-4 high-

American Heart Journal

Volume 163, Number 6

sensitivity troponin-T (hsTnT) has greater sensitivity

than cTnT for ACS diagnosis in acute chest pain
patients presenting to the emergency department
(ED); however, its sensitivity remains moderate, particularly for the diagnosis of UAP.5
The natriuretic peptides, including N-terminal pro-B
type natriuretic peptide (NT-proBNP) and the newer
mid-regional pro-atrial natriuretic peptide (MR-proANP),
are cardiac biomarkers secreted into the circulation via
atrial and ventricular myocytes,6 and used for diagnosis
or exclusion of heart failure; both correlating well with
cardiac structure and function.7,8 While natriuretic
peptides are cardiac-specic, their role for diagnostic
evaluation of patients with suspected ACS remains less
well-understood, and results in this regard are mixed.9,10
Given the reduced rst-draw sensitivity of troponin for
ACS diagnosis, in theory, a clinical approach utilizing
biomarkers with complementary physiologies (e.g.,
myocardial stress and necrosis) might be superior to a
single biomarker strategy alone.
There are few data comparing the effectiveness of a
multimarker strategy for ACS diagnosis in a single blood
draw,9,11,12and data are lacking regarding the value of this
approach using newer assays such as hsTnT and MRproANP. Thus, we aim to determine the diagnostic value
of a dual marker strategy, particularly dual-negative
marker results, for ACS and UAP diagnosis by combining
markers of myocardial injury (cTnT or hsTnT) with
markers of myocyte stress (NT-proBNP or MR-proANP) in
acute chest pain patients presenting to the ED. In
addition, we examine the dual marker results with
imaging by evaluating its relationship with prevalence
of cardiac computed tomography (CT) features of
coronary plaque, stenosis, and regional wall motion
abnormalities (RWMA).

Methods
Study population
The Rule Out Myocardial Infarction Using Computer
Assisted Tomography (ROMICAT) trial was a prospective
study of 368 consecutive adult patients at low-to-intermediate
likelihood of ACS who presented to the ED with acute chest
pain, had initially negative cTnT concentrations and nonischemic electrocardiogram, and were awaiting hospital
admission. The details of the study design have been
previously reported.13 All eligible patients who consented
underwent electrocardiogram-gated contrast-enhanced 64slice CT and had blood biomarkers drawn at time of CT
scan acquisition. We included 328 patients, who had
circulating levels of all 4 biomarkers (cTnT, hsTnT, NTproBNP, and MR-proANP), measured at time of CT scan for
the ACS analysis. Since elevated troponin levels are part of
the denition for MI,1 we performed a subgroup analysis in
320 patients for UAP without MI. Our institutional review
board approved the study protocol and all patients provided
written informed consent.

Truong et al 973

Clinical end point

ACS was dened as either (1) a MI or (2) UAP as
previously described.13 For our clinical end points of ACS
and UAP, an outcome panel of two experienced physicians
reviewed patient data forms containing prospectively collected information on the history and nature of chest pain, risk
factors and medical history, as well as medical records
including the serial cTn levels pertaining to the hospital
admission. The outcome panel was blinded to the ndings of
all the biomarker results used in this analysis and the CT
results with disagreement resolved by consensus with an
additional cardiologist.

Biomarker testing
Blood samples for biomarker testing were taken at the time of
CT angiography, at a median of 4.2 hours from initial ED
presentation. The samples were obtained from a peripheral vein
and collected into EDTA coated tubes and non-coated tubes. The
blood was immediately centrifuged and the aliquoted plasma
and serum were stored in microcentrifuge tubes at 80C until
assayed. Specimens were tested on the rst freeze thaw cycle.
All analyses were run in a blinded fashion. The inter-run
coefcient of variation was 6.6% and intra-assay coefcient of
variation was 3.65% for all markers.
Levels of cTnT (Stat T; Roche Diagnostics, Penzberg,
Germany) was measured using a fourth-generation immunoassay on an Elecsys 2010 platform. We used the diagnostic
threshold for acute MI of 0.03 ng/mL for this analysis, which
is the 99th percentile for this assay.1 For hsTnT, we used a
pre-commercial hsTnT method (Roche Diagnostics) on an
Elecsys 2010 platform. Given enhanced sensitivity, this assay is
reported with units of pg/mL (rather than ng/mL for cTnT)
and the 99th percentile for a normal reference population is
reported to be 13 pg/mL, which was the cut-point used for
this analysis.1
Serum NT-proBNP measurements were performed by an
electrochemiluminescence sandwich immunoassay (ELECSYS
2010; Roche Diagnostics). Plasma MR-proANP concentrations
were determined with immunoluminometric assays (BRAHMS
AG), as described elsewhere.14 For NT-proBNP, the median
concentration was 50 ng/L while the optimal cut-point for
ACS using Youden's index was 44 ng/L. For MR-proANP, the
median concentration was 58 pmol/L with an optimal cutpoint for ACS of 65 pmol/L. Since there are currently no
established cut-point for either NT-proBNP or MR-proANP for
ACS diagnosis in non-heart failure cohort, we used the cutpoints of 50 ng/L for NT-proBNP and 60 pmol/L for MRproANP for simplicity.

Cardiac CT imaging
CT imaging was performed using a 64-slice CT scanner
(Sensation 64; Siemens Medical Solutions, Forchheim, Germany), as previously described,13 and evaluated for the presence of
coronary plaque and stenosis, which was dened as a luminal
obstruction N50% diameter or if coronary stenosis could not be
excluded (n = 28) and deemed inconclusive. RWMA was
assessed qualitatively based on the 17-segment model, as
previously described.15 Patients where RWMA could not be
assessed due to incomplete left ventricular (LV) function study
(n = 11) were classied as having no RWMA.

American Heart Journal

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974 Truong et al

Table I. Characteristics of the overall cohort and as stratified by presence of ACS

Demographics
Age (years)
Male
Caucasian
BMI (kg/m2)
Risk factors
Diabetes
Hypertension
Hyperlipidemia
Smoking
Family history of CAD
Vital signs at triage
Systolic blood pressure (mmHg)
Diastolic blood pressure (mmHg)
Heart rate (bpm)
Medications on presentation
Aspirin
Beta-blockers
Statins
ACE-I
Cardiac CT results
Any coronary plaque
Extent of plaque, median (IQR)
Coronary stenosis
RWMA
LVEF (%)
LV end-systolic volume (ml)
LV end-diastolic volume (ml)
LV mass (g/m2)
Laboratory tests
cTnT (ng/mL)
hsTnT (pg/mL)
NT-proBNP (ng/L)
MR-proANP (pmol/L)

Overall
(n = 328)

ACS
(n = 29)

No ACS
(n = 299)

52.6 11.6
206 (62.8%)
281 (85.7%)
28.9 5.7

61.7 11.6
23 (79.3%)
27 (93.1%)
28.9 4.4

51.7 11.3
183 (61.2%)
254 (85.0%)
28.9 5.8

b.0001
.07
.40
.63

37 (11.3%)
129 (39.3%)
121 (36.9%)
155 (47.3%)
80 (24.4%)

4 (13.8%)
18 (62.1%)
16 (55.2%)
17 (58.6%)
9 (31.0%)

33 (11.0%)
111 (37.1%)
105 (35.1%)
138 (46.2%)
71 (23.8%)

.55
.02
.04
.24
.37

139 22
81 14
77 16

138 21
75 14
72 18

139 22
81 13
78 16

.89
.05
.03

108 (32.9%)
73 (22.3%)
93 (28.4%)
50 (15.2%)

15 (51.8%)
11 (37.9%)
15 (51.8%)
6 (20.7%)

164 (50.0%)
0.5 (0,3.5)
61 (18.6%)
40 (12.2%)
67.5 9.7
39.5 20.9
118.1 31.4
149.6 42.3

29 (100%)
7 (4,10)
22 (75.9%)
21 (72.4%)
66.8 11.3
43.7 27.5
123.2 35.6
153.5 34.9

135 (45.2%)
0 (0,2)
39 (13.0%)
19 (6.4%)
67.6 9.6
39.1 20.2
117.7 31.0
149.2 43.0

b.0001
b.0001
b.0001
b.0001
.86
.998
.62
.51

0.005 0.029
5.2 (2.5,8.6)
50 (24,108)
58 (41,84)

0.050 0.085
30.5 (8.6,68.7)
100 (53,238)
83 (55,127)

0.0006 0.005
4.9 (2.4,7.7)
45 (22,98)
57 (41,80)

b.0001
b.0001
b.0001
.005

93
62
78
44

(31.1%)
(20.7%)
(26.1%)
(14.7%)

.037
.058
.0082
.42

BMI, Body mass index; ACE-I, angiotensin converting enzyme inhibitor; IQR, interquartile range; LVEF, LV ejection fraction.

Statistical analysis
Descriptive statistics were expressed as mean SD or median
with interquartile range for continuous variables and as
frequency and percentages for nominal variables. Differences
between groups were assessed using Student t test or Wilcoxon
rank sum test for continuous variables and 2 test or Fisher exact
test for categorical variables, as appropriate. For the diagnostic
accuracy of the biomarkers for detecting ACS, we calculated the
sensitivity, specicity, positive predictive value (PPV), and
negative predictive value (NPV). Comparisons between sensitivities of two tests and specicities of two tests were performed
using McNemar's test. Logistic regression was used to determine
the C-statistic, or area under the receiver operating characteristic curve (AUC), for each biomarker to evaluate the
discriminatory capacity of the individual dichotomous biomarker model for ACS. We compared the difference in C-statistics of
nested models (model 1 contains rst biomarker, model 2
contains the rst and second biomarker) using the likelihood
ratio test to determine the incremental value. Lastly, net
reclassication improvement (NRI) was performed with biomarkers kept as dichotomous variables as described by Pencina
et al.16 When comparing added value of one biomarker to

another, NRI measures the correctness of reclassication of

subjects based on their predicted probabilities of events using
the new model. We performed similar analyses for the subgroup
of patients without MI for the clinical outcome of UAP. A 2-tailed
P value of b.05 was considered to indicate statistical significance. All analyses were performed using SAS (Version 9.2,
Cary, NC) and MedCalc (Version 11.6 for Windows, Belgium).
Sources of Funding: This work was supported by the NIH
R01 HL080053 and additional funds from the University of Ulm.
Dr. Truong received support from NIH grant K23HL098370
and L30HL093896.

Results
Patient characteristics
Baseline patient characteristics of the overall cohort
and as stratied by ACS are summarized in Table I. There
were 29 (8.8%) patients with ACS diagnosis, of which
8 (2.4%) were MI and 21 (6.4%) were UAP. As compared
to patients without ACS, those with ACS were older,

American Heart Journal

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Truong et al 975

Table II. Diagnostic accuracy of individual troponins and the natriuretic peptides and dual-negative combinations to detect ACS
Analyte, cut-point
cTnT
hsTnT
NT-proBNP
MR-proANP
cTnT (), NT-proBNP ()
hsTnT (), NT-proBNP ()
cTnT (), MR-proANP ()
hsTnT (), MR-proANP ()

Sensitivity
(95% CI)

Specificity
(95% CI)

PPV
(95% CI)

NPV
(95% CI)

11/29
38% (21-58)
17/29
59% (39-76)
24/29
83% (64-94)
20/29
69% (49-85)
25/29
86% (68-96)
26/29
90% (73-98)
24/29
83% (64-94)
25/29
86% (68-96)

295/299
99% (97-100)
268/299
90% (86-93)
160/299
54% (48-59)
162/299
54% (48-60)
160/299
54% (48-59)
154/299
52% (46-57)
162/299
54% (48-60)
153/299
51% (45-57)

11/15
73% (45-92)
17/48
35% (22-51)
24/163
15% (10-21)
20/157
13% (8-19)
25/164
15% (10-21)
26/171
15% (10-21)
24/161
15% (10-21)
25/171
15% (10-21)

295/313
94% (91-97)
268/280
96% (93-98)
160/165
97% (93-99)
162/171
95% (90-98)
160/164
98% (94-99)
154/157
98% (95-100)
162/167
97% (93-99)
153/157
97% (94-99)

Cut-points: cTnT 0.03 ng/mL, hsTnT 13 pg/mL, NT-proBNP 50 ng/L, MR-proANP 60 pmol/L.

more likely to have hypertension, hyperlipidemia, and on

aspirin and statin therapy. They also had higher
prevalence of CT coronary plaque and extent, coronary
stenosis, and RWMA despite similar preserved LV
function, volumes, and mass.

Biomarker results
All 4 of the biomarkers were elevated in patients with
ACS compared to those without (Table I, all P b .01).
Similar results were seen when patients with UAP were
compared to those without (cTnT: 0.005 ng/mL vs. 0.0006
ng/mL, hsTnT: 12.3 pg/mL vs. 4.9 pg/mL, NT-proBNP: 133
ng/L vs. 45 ng/L, and MR-proANP: 84 pmol/L vs. 57
pmol/L; all P b .005).
Diagnostic accuracy of troponins and natriuretic
peptides for ACS and UAP
Diagnostic accuracies of the biomarkers individually
and in combination as dual-negative results are summarized in Table II. In keeping with the use of troponins as
part of the denition of MI, the natriuretic peptides
were less specic for the detection of ACS than
troponin; however, natriuretic peptides were more
sensitive than troponins. Thus, in comparing the single
troponin marker to a dual-negative marker combination
with natriuretic peptides, we found that a dual-negative
marker strategy of troponins and natriuretic peptides
improved sensitivity (cTnT 38% to 83-86%, hsTnT 59%
to 86-90%; all P b .005) and NPV (cTnT 94% to 97-98%,
hsTnT 96% to 97-98%) for ACS. Similar results were seen
for the detection of UAP (online Appendix Table I), as a
dual-negative approach improved both sensitivity (cTnT
19% to 81%, hsTnT 48% to 86%; all P b .005) and NPV
(cTnT 95%-98%, hsTnT 96%-98%).

Incremental value of adding natriuretic peptides to

troponins for ACS diagnosis
Combining natriuretic peptides with both conventional
and highly sensitive methods for troponin improved the
C-statistics (AUC) and had signicant values of NRI for
ACS, largely driven by correct reclassication of events
(Table III). More specically, between the two natriuretic
peptides, NT-proBNP had best improvement in Cstatistics and NRI when added to either troponins.
Impressively, adding NT-proBNP to cTnT and hsTnT
improved the AUC from 0.68 to 0.78 (P = .005) and 0.74
to 0.80 (P = .02), respectively, and correctly reclassied
66% of events (P = .0004). Furthermore, in our
subgroup analysis of patients without MI (online
Appendix Table II), we found that both natriuretic
peptides had similar incremental value for UAP diagnosis
when used in a dual marker strategy with either troponins.
Relation of combined natriuretic peptides and troponins
to cardiac CT features
Coronary plaque was present in 164 (50.0%) patients,
stenosis in 61 (18.6%), and RWMA in 40 (12.2%). All 4 of
the biomarkers were elevated in patients with abnormal
cardiac CT features as compared to those without
(online Appendix Table III, all P b .001). Patients with
dual-negative markers had the lowest percentage of
CT coronary plaque, stenosis, and RWMA (Figure 1, all
P-trend b.001).

Discussion
In this low-to-intermediate risk cohort of acute chest
pain patients in the ED with no previous history of
coronary artery disease (CAD) and initial negative cTn,
we found that there was considerable incremental value

American Heart Journal

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976 Truong et al

Table III. Incremental Value of Natriuretic Peptides (NP) beyond Troponins using C-statistics (AUC) and NRI for ACS
AUC
(Troponin)

AUC
(Troponin + NP)

AUC
(95% CI)

cTnT+NT-proBNP

0.68

0.78

hsTnT+NT-proBNP

0.74

0.80

cTnT+MR-proANP

0.68

0.77

hsTnT+MR-proANP

0.74

0.79

0.10
(0.03-0.17)
0.06
(0.01-0.12)
0.08
(0.01-0.15)
0.04
(0.01 to 0.10)

% Events
correctly
reclassified

% Nonevents
Correctly
Reclassified

.005 73% (43-102) .0002

66%

.0004

7%

.23

.02

73% (43-102) .0002

66%

.0004

7%

.23

.02

46% (11-82)

.02

38%

.04

8%

.15

.12

46% (11-82)

.02

38%

.04

8%

.15

NRI
(95% CI)

Analyte cut-points as in Table II.

for ACS and UAP diagnosis by using a dual marker strategy

of combining established and emerging biomarkers of
myocardial injury (either cTnT or hsTnT) with myocyte
stress (NT-proBNP or MR-proANP) from a single blood
draw after ED presentation (median 4.2 hours). Importantly, even in the context of superior sensitivity
provided by hsTnT, the addition of a natriuretic peptide
(particularly NT-proBNP) improved diagnostic accuracy,
and increased NPV for excluding an ACS.
Cardiac troponins have become the biomarker of
choice for the detection of myocardial injury and are
central to the diagnosis of MI.1 The development of hsTn
assays has allowed for the detection of much smaller
concentrations of the biomarker, but the diagnostic and
prognostic implications of this enhanced sensitivity are
still under investigation,2-4 and the ramications of
reduced specicity of the biomarker for ACS are
undened. The additive diagnostic value of natriuretic
peptides to hsTnT in this cohort is intriguing given the
enhanced sensitivity of the latter biomarker. Given this,
it is not surprising that there was value from adding
NT-proBNP to cTnT as well. Because our analyses
include both cTnT and hsTnT, our study is applicable
independent of what type of troponin assay may be used
in the future.
Given the reduced specicity of hsTn methods, adding
a second biomarker may enhance diagnostic performance. The natriuretic peptides are a natural choice,
given their tight association with structural heart disease,
including ischemic heart disease. Indeed, while concentrations of natriuretic peptides have taken on special
meaning relative to the presence and severity of heart
failure,7,17 their release is not limited to this diagnosis.
Early in the course of myocardial ischemia, natriuretic
peptide levels have been shown to rise, correlate with
extent of myocardial damage, and have prognostic
implications after MI.18,19 As the combination of adding
NT-proBNP to cTNT has already provided complementary information for prognosis in those with ACS20 as well
as further risk stratication even in patients with negative
cTnT results,18 strategies employing multiple cardiac

markers will likely improve the diagnostic ability in ACS

beyond single marker strategy alone,9 and may negate the
need for serial blood sampling and prolonged hospitalization, particularly when both markers are low. It is of
note and interest that while NT-proBNP and MR-proANP
delivered relatively comparable diagnostic information,
there were differences in their overall performance,
perhaps favoring NT-proBNP. As these 2 natriuretic
peptides are biologically distinct and released from
different areas in the heart,6 there may be subtle
differences in their clinical behavior. Notably, in this
cohort, we previously showed that another candidate
chest pain marker, copeptin, had no added value to
hsTnT.21 Our ndings extend to the understanding of
which biomarkers can be used synergistically to optimally
evaluate patients with acute chest pain.
When assessed individually, all 4 biomarkers levels
were higher in patients with ACS and those with UAP
compared to those without. Reecting their role as a
clinical mainstay for diagnosis of ACS, both troponins
had excellent specicity (90%-99%) for adjudicated ACS
and UAP diagnoses; however, sensitivity was low for
cTnT (19%-38%) and improved but still modest sensitivity
(48-59%) was noted for hsTnT. Given its high specicity,
a positive troponin value could not be overlooked
clinically because of a negative natriuretic peptide result.
Therefore, we incorporated natriuretic peptides with
troponins in a dual-negative marker strategy, whereby
only patients with negative values for both assays were
considered negative. In a dual-negative marker approach
with the natriuretic peptides, we found enhanced
sensitivities to 81% to 90% with corresponding near
perfect NPV of 97% to 98% for ACS and UAP detection,
thus identifying a cohort at a very low risk of ACS. This is
of particular importance in our study population of
patients presenting to the ED, as this approach can give
clinicians, particularly ED physicians, more condence
to manage patients with dual-negative result in a lesser
aggressive manner.
As reected in differential patterns of sensitivity and
specicity, we found signicantly improved C-statistics

American Heart Journal

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Truong et al 977

Figure 1

Distribution of cardiac CT structural and functional findings as stratified by dual-marker approach of troponin/natriuretic peptides.

and NRI for ACS and UAP diagnosis when combining

troponin with a natriuretic peptide, largely driven by
correctly reclassifying events. As conrmed in our
subgroup analysis of patients without MI, these ACS
events that are reclassied are essentially UAP. All
combinations of natriuretic peptides and troponins
showed signicant improvement in C-statistics over the
relevant troponin assay alone for both ACS and UAP, in
addition to improved NRI with impressive reclassication
when natriuretic peptides were added to troponins.
Specically, adding NT-proBNP to either troponin correctly reclassied 62% to 66% of patients for ACS and UAP
diagnosis, while adding MR-proANP to either troponins
correctly reclassied 38% to 52% of patients. Moreover,
NT-proBNP performed much better than MR-proANP for
the diagnosis of ACS but both natriuretic peptides
performed comparably well when used in combination
with the troponins for the diagnosis of UAP. Notably,
neither dual-marker strategies resulted in signicant
degrees of incorrect reclassication, an important point
in this patient population with low rates of diagnoses
likely to affect natriuretic peptide values.
Interestingly, in a higher-risk ED multicenter cohort of
acute chest pain patients, NT-proBNP was incremental to
cTnT 9,12 but did not reclassify patients beyond that
of hsTnI.9 While our ndings of the incremental of

NT-proBNP to cTnT for ACS diagnosis were consistent

despite different cut-points for NT-proBNP (50 ng/L in
this analysis, 100 ng/L in the IMAGINE study,9 and 402
ng/L in the study by Haaf et al12), several reasons could
explain our conicting ndings with high-sensitivity
troponin. First, we used different assays for highsensitivity troponin in the two studies (hsTnT [Roche]
vshsTnI [Singulex]9). Probably most important is the use
of category-free NRI instead of categorical NRI in this
analysis. The use of the category-free NRI provides a
more stable result when lack of optimal risk categories
exist (such as in this ED cohort) and is less prone to
changes of the pre-test categories.16 Lastly, this ROMICAT cohort includes low-intermediate risk patients for
suspected ACS and more strict criteria including normal
renal function and no prior history of CAD. The
IMAGINE cohort consisted of patients with a generally
higher-risk presentation, with a mixture of diagnoses
typical of such a population, including heart failure, as
well as impaired renal function.9 While adding NTproBNP to hsTnI correctly reclassied ACS events by
15%, it incorrectly reclassied 32% of non-ACS cardiac
events due to the majority (78%) being acutely decompensated heart failure patients. Of note, while the study
by Haaf et al. included more heterogeneous patients
such as those with known CAD, NT-proBNP was

American Heart Journal

June 2012

978 Truong et al

examined only with cTnT and not high-sensitivity

troponin.12 Our study specically targets the low risk
patients with acute chest pain and excludes coexisting
diagnosis that causes abnormal natriuretic peptide values
(eg, heart failure, pulmonary thromboembolism, impaired renal function). In aggregate, the multi-marker
approach of troponin plus natriuretic peptide adds
considerable diagnostic value for ACS.
We had the unique opportunity to describe the
relationship between cardiac CT with respect to the
dual marker strategy since both were performed at the
same time and measured or interpreted in a blinded
fashion, without the clinical history or each other results.
Using anatomic imaging with cardiac CT to explain the
etiology of our dual marker results, we found elevated
biomarker levels for all 4 markers in relation to CT
abnormalities (plaque, stenosis, and RWMA). Moreover,
we observe a gradient effect with the lowest proportion
of patients with CT coronary plaque, stenosis, or RWMA
having dual-negative result, followed by those with
negative troponin but positive natriuretic peptide, and
the highest prevalence of CT abnormalities in those with
positive troponin (either cTnT or hsTnT). Thus, above
and beyond delivering important diagnostic value for
ACS, the patterns of biomarker release in this context are
supported by the underlying cardiac structural and
functional ndings.

Limitations
Our cohort is limited to symptomatic patients at low to
intermediate risk of ACS and, so, is not applicable to
medically complex patients or those with heart failure.
Our study population also excluded patients with known
CAD, making this different from an overall ED population.
Nevertheless, our ndings are appropriate in the large
population of patients that present to the ED in whom
troponin assays are of clinical importance. Also, the blood
samples measured for cTnT and hsTnT were drawn at the
time of the CT scan, which was a median of 4.2 hours
after presentation. We could not use the rst draw
troponin blood sample on ED presentation since it was
used to determine study eligibility.13 Since an earlier
hsTnT draw of b3 hours from symptom onset have been
reported to have less sensitivity as compared to that
drawn at N3 hours,22 the initial reduced sensitivity from
an earlier draw of troponin may lead to even more
profound results when used in combination with the
natriuretic peptides. Further prospective studies examining these biomarkers in combination at initial ED
presentation would be of great utility for this ED cohort
and help facilitate triage decision.

Conclusion
Among ED chest pain patients, a dual marker strategy of
combining natriuretic peptides to troponins improved

discriminatory capacity and allowed for better reclassication of ACS, largely driven by correctly identifying
events. These ndings are supported by structural and
functional cardiac CT results.

Disclosures
No conicts of interest.

References
1. Thygesen K, Alpert JS, White HD, et al. Universal definition of
myocardial infarction. Circulation 2007;116:2634-53.
2. Giannitsis E, Becker M, Kurz K, et al. High-sensitivity cardiac troponin
T for early prediction of evolving non-ST-segment elevation myocardial infarction in patients with suspected acute coronary syndrome
and negative troponin results on admission. Clin Chem 2010;56:
642-50.
3. Keller T, Zeller T, Peetz D, et al. Sensitive troponin I assay in early
diagnosis of acute myocardial infarction. N Engl J Med 2009;361:
868-77.
4. Reichlin T, Hochholzer W, Bassetti S, et al. Early diagnosis of
myocardial infarction with sensitive cardiac troponin assays. N Engl J
Med 2009;361:858-67.
5. Januzzi Jr JL, Bamberg F, Lee H, et al. High-sensitivity troponin T
concentrations in acute chest pain patients evaluated with cardiac
computed tomography. Circulation 2010;121:1227-34.
6. Yasue H, Yoshimura M, Sumida H, et al. Localization and mechanism
of secretion of B-type natriuretic peptide in comparison with those of
A-type natriuretic peptide in normal subjects and patients with heart
failure. Circulation 1994;90:195-203.
7. Neuhold S, Huelsmann M, Strunk G, et al. Comparison of
copeptin, B-type natriuretic peptide, and amino-terminal pro-B-type
natriuretic peptide in patients with chronic heart failure: prediction
of death at different stages of the disease. J Am Coll Cardiol 2008;
52:266-72.
8. Truong QA, Siegel E, Karakas M, et al. Relation of natriuretic
peptides and midregional proadrenomedullin to cardiac chamber
volumes by computed tomography in patients without heart failure:
from the ROMICAT Trial. Clin Chem 2010;56:651-60.
9. Bhardwaj A, Truong QA, Peacock WF, et al. A multicenter
comparison of established and emerging cardiac biomarkers for the
diagnostic evaluation of chest pain in the emergency department. Am
Heart J 2011;162:276 e1-82 e1.
10. Haaf P, Reichlin T, Corson N, et al. B-type natriuretic peptide in the
early diagnosis and risk stratification of acute chest pain. Am J Med
2011;124:444-52.
11. McCann CJ, Glover BM, Menown IB, et al. Investigation of a
multimarker approach to the initial assessment of patients with acute
chest pain. Adv Ther 2009;26:531-4.
12. Haaf P, Balmelli C, Reichlin T, et al. N-terminal pro B-type natriuretic
peptide in the early evaluation of suspected acute myocardial
infarction. Am J Med 2011;124:731-9.
13. Hoffmann U, Bamberg F, Chae CU, et al. Coronary computed
tomography angiography for early triage of patients with acute chest
pain: the ROMICAT (Rule Out Myocardial Infarction using Computer
Assisted Tomography) trial. J Am Coll Cardiol 2009;53:1642-50.
14. Morgenthaler NG, Struck J, Thomas B, et al. Immunoluminometric
assay for the midregion of pro-atrial natriuretic peptide in human
plasma. Clin Chem 2004;50:234-6.
15. Seneviratne SK, Truong QA, Bamberg F, et al. Incremental diagnostic
value of regional left ventricular function over coronary assessment by

American Heart Journal

Volume 163, Number 6

cardiac computed tomography for the detection of acute coronary

syndrome in patients with acute chest pain: from the ROMICAT trial.
Circ Cardiovasc Imaging 2010;3:375-83.
16. Pencina MJ, D'Agostino Sr RB, Steyerberg EW. Extensions of net
reclassification improvement calculations to measure usefulness of
new biomarkers. Stat Med 2011;30:11-21.
17. Jourdain P, Jondeau G, Funck F, et al. Plasma brain natriuretic
peptide-guided therapy to improve outcome in heart failure: the
STARS-BNP Multicenter Study. J Am Coll Cardiol 2007;49:1733-9.
18. Weber M, Bazzino O, Navarro Estrada JL, et al. N-terminal B-type
natriuretic peptide assessment provides incremental prognostic
information in patients with acute coronary syndromes and normal
troponin T values upon admission. J Am Coll Cardiol 2008;51:
1188-95.

Truong et al 979

19. Eggers KM, Lagerqvist B, Venge P, et al. Prognostic value of

biomarkers during and after non-ST-segment elevation acute
coronary syndrome. J Am Coll Cardiol 2009;54:357-64.
20. Cameron SJ, Sokoll LJ, Laterza OF, et al. A multi-marker approach for
the prediction of adverse events in patients with acute coronary
syndromes. Clin Chim Acta 2007;376:168-73.
21. Karakas M, Januzzi Jr JL, Meyer J, et al. Copeptin Does Not Add
Diagnostic Information to High-Sensitivity Troponin T in Low- to
Intermediate-Risk Patients with Acute Chest Pain: Results from the Rule
Out Myocardial Infarction by Computed Tomography (ROMICAT)
Study. Clin Chem 2011;57:1137-45.
22. Body R, Carley S, McDowell G, et al. Rapid exclusion of acute
myocardial infarction in patients with undetectable troponin using a
high-sensitivity assay. J Am Coll Cardiol 2011;58:1332-9.

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Truong et al 979.e1

Appendix
Appendix Table I. Diagnostic accuracy of individual troponins and the natriuretic peptides and dual-negative combinations to detect unstable
angina; cut-points: cTnT 0.03 ng/mL, hsTnT, 13 pg/mL, NT-proBNP 50 ng/L, MR-proANP 60 pmol/L
Analyte, cut-point
cTnT
hsTnT
NT-proBNP
MR-proANP
cTnT (), NT-proBNP ()
hsTnT (), NT-proBNP ()
cTnT (), MR-proANP ()
hsTnT (), MR-proANP ()

Sensitivity (95% CI)

Specificity (95% CI)

PPV (95% CI)

NPV (95% CI)

4/21
19% (5-42)
10/21
48% (26-70)
17/21
81% (58-95)
16/21
76% (53-92)
17/21
81% (58-95)
18/21
86% (64-97)
17/21
81% (58-95)
18/21
86% (94-97)

295/299
99% (97-100)
268/299
90% (86-93)
160/299
54% (48-59)
162/299
54% (48-60)
160/299
54% (48-59)
154/299
52% (46-57)
162/299
54% (48-60)
153/299
51% (45-57)

4/8
50% (16-84)
10/41
24% (12-40)
17/156
11% (6-17)
16/153
10% (6-16)
17/156
11% (6-17)
18/163
11% (7-17)
17/154
11% (7-17)
18/164
11% (7-17)

295/312
95% (91-97)
268/279
96% (93-98)
160/164
98% (94-99)
162/167
97% (93-99)
160/164
98% (94-99)
154/157
98% (95-100)
162/166
98% (64-99)
153/156
98% (94-100)

Appendix Table II. Incremental value of natriuretic peptides beyond troponins using C-statistics (AUC) and NRI for unstable angina (in patients
without myocardial infarction)
AUC
(Troponin)

AUC
(Troponin
+ NP)

AUC
(95% CI)

0.59
0.69
0.59
0.69

0.71
0.76
0.71
0.76

0.12 (0.03-0.21)
0.07 (0.002-0.14)
0.13 (0.04-0.21)
0.07 (0.001-0.14)

cTnT+NT-proBNP
hsTnT+NT-proBNP
cTnT+MR-proANP
hsTnT+MR-proANP

NRI
(95% CI)

.007
.04
.006
.047

69% (33-104)
69% (33-104)
61% (23-99)
61% (23-99)

% Events
correctly
reclassified

.002
.002
.007
.007

62%
62%
52%
52%

% Nonevents
correctly
reclassified

.005
.005
.02
.02

7%
7%
8%
8%

.23
.23
.15
.15

Analyte cut-points as in Table II. NP, natriuretic peptides.

Appendix Table III. Difference in biomarkers levels as stratified by cardiac CT features

cTnT (ng/mL)
hsTnT (pg/mL)
NT-proBNP (ng/L)
MR-proANP (pmol/L)

cTnT (ng/mL)
hsTnT (pg/mL)
NT-proBNP (ng/L)
MR-proANP (pmol/L)

cTnT (ng/mL)
HsTnT (pg/mL)
NT-proBNP (ng/L)
MR-proANP (pmol/L)
Abbreviations as in Table I.

Plaque (n = 164)

No plaque (n = 164)

0.009 0.04
6.3 (3.6,12.3)
59 (27,156)
67 (45,102)

0.0005 0.004
4.2 (2.1,6.5)
42 (21,75)
53 (38,71)

.0001
b.0001
.0004
b.0001

Stenosis (n = 61)

No stenosis (n = 267)

0.016 0.048
8.9 (5.5,30.5)
100 (51,238)
75 (53,114)

0.002 0.021
4.6 (2.3,7.4)
42 (21,81)
54 (41,78)

RWMA (n = 40)

No RWMA (n = 288)

0.038 0.074
19.9 (6.6,60.1)
97 (44,331)
84 (57,130)

0.0004 0.004
4.9 (2.4,7.7)
47 (22,94)
55 (41,78)

b.0001
b.0001
b.0001
.0005

b.0001
b.0001
b.0001
b.0001