Troponin Thresholds for Risk Stratification of Chest Pain Patients Presenting to the Emergency Department: Alternatives to the 99th Percentile
In brief
Troponin's 99th-percentile cutoff gave men nearly twice women's likelihood ratio for MI
In 2,584 emergency patients, sex-specific 99th-percentile troponin cutoffs produced nearly twice the positive likelihood ratio for men as for women, with 2- to 3-fold differences between assays. Thresholds set to achieve 70% positive predictive value shifted substantially with cohort prevalence, while specificity- or likelihood-ratio-based thresholds were more consistent across sexes; assay differences remained.
- Journal
- Clinical chemistry (Q1)
- Published
- 2 November 2026
- Study design
- Unclassified
- Evidence level
- Level 5, Expert Opinion (CEBM 5)
- Authors
- John W Pickering, Dimitrios Doudesis, Lori B Daniels, W Frank Peacock, Laura R Joyce, A Mark Richards, et al.
- PMID
- 42969682
- DOI
- 10.1093/clinchem/hvag139
Why clinicians should know about it
- Picked for Biochemistry (medical) (top studies of the week, 8 November 2026): Compares troponin assay thresholds, sex effects, and predictive performance
Abstract
BACKGROUND: Two methods are used to determine cardiac troponin (cTn) thresholds for high-risk stratification for myocardial infarction (MI), namely the assay's healthy population 99th percentiles and a threshold that has a positive predictive value (PPV) of about 70%. We hypothesized that these methods may produce inconsistent prediction of MI risk. METHODS: We compared the positive likelihood ratio (LR+), sensitivity, and specificity at 99th percentiles and published high-risk thresholds for a high-sensitivity (hs) cTnI (Abbott) and cTnT (Roche) assay. We simulated the high-risk threshold derivation methodology that derives thresholds with 70% PPV as a function of prevalence and sample size. We derived and validated thresholds based on LR+ = 20 and specificity = 95%. RESULTS: In 2584 patients there was an almost 2-fold difference in LR+ between males and females at the sex-specific 99th percentiles, and a 2- to 3-fold difference between assays. Thresholds giving 70% PPV were much higher in lower-prevalence cohorts for both assays, being 3- to 10-fold lower at 5% than 20% prevalence. Thresholds derived using a LR+ or specificity had similar performance in a validation cohort between sexes but had a 2-fold difference in LR+ in a validation cohort between assays. CONCLUSIONS: In patients presenting to the emergency department with possible MI, sex-specific 99th percentile thresholds convey lower risk of MI for females than males. Risks also differed between assays. Risk thresholds derived using the PPV vary considerably with the prevalence and size of cohort. Thresholds derived with specificity or positive likelihood ratio had more consistent risk-prediction.
Abstract as published, via PubMed.
For healthcare professionals. The summary is generated by AI from the published abstract, and the evidence level is assigned automatically from the study design on the Oxford CEBM hierarchy. Neither is medical advice. Read the full paper before changing practice.