Incremental value of copeptin to highly sensitive cardiac Troponin i for rapid rule-out of myocardial infarction

Background: The incremental value of copeptin, a novel marker of endogenous stress, for rapid rule-out of non- ST-elevation myocardial infarction (NSTEMI) is unclear when sensitive or even high-sensitivity cardiac troponin cTn (hs-cTn) assays are used. Methods: In an international multicenter study we evaluated 1929 consecutive patients with symptoms suggestive of acute myocardial infarction (AMI). Measurements of copeptin, three sensitive and three hs-cTn assays were performed at presentation in a blinded fashion. The final diagnosis was adjudicated by two independent cardiologists using all clinical information including coronary angiography and levels of hs-cTnT. The incremental value in the diagnosis of NSTEMIwas quantified using four outcomemeasures: area under the receiver-operating characteristic curve (AUC), integrated discrimination improvement (IDI), sensitivity and negative predictive value (NPV). Early presenters (b4 h since chest pain onset) were a pre-defined subgroup. Results: NSTEMI was the adjudicated final diagnosis in 358 (18.6%) patients. As compared to the use of cTn alone, copeptin significantly increased AUC for two (33%) and IDI (between 0.010 and 0.041 (all p b 0.01)), sensitivity and NPV for all six cTn assays (100%); NPV to 96-99% when the 99th percentile of the respective cTnI assay was combinedwith a copeptin level of 9 pmol/l (all p b 0.01). The incremental value in early presenterswas similar to that of the overall cohort. Conclusion: When used for rapid rule-out of NSTEM in combination with sensitive or hs-cTnI assays, copeptin provides a numerically small, but statistically and likely also clinically significant incremental value.