Early Diagnosis of Myocardial Infarction with Sensitive Cardiac Troponin Assays

Featured Article: Reichlin T, Hochholzer W, Bassetti S, Steuer S, Stelzig C, Hartwiger S, et al. Early diagnosis of acute myocardial infarction using more sensitive cardiac troponin assays. N Engl J Med 2009;361:858–67.3 In our 2009 article featured here we were able to demonstrate, in an international diagnostic multicenter study using central adjudication by 2 independent cardiologists, that more sensitive cardiac troponin assays substantially increased the diagnostic accuracy for acute myocardial infarction (AMI)4 as compared with conventional cardiac troponin assays. In the following years, several research groups have further expanded our knowledge on how to best use these new tools as quantitative markers of cardiomyocyte injury in the early diagnosis of AMI, resulting in the derivation and validation of safe and effective triage algorithms, including the European Society of Cardiology 0/1-h algorithm for the rapid rule-out and/or rule-in of AMI (1–5). More rapid and accurate rule-out and rule-in of AMI provides medical value to patients, physicians, and the health-care system. It is exciting to see that more sensitive cardiac troponin assays are increasingly being explored in other emerging indications (6). When considering key factors for these and other important scientific advances, several recurrent factors have emerged: the wonderful hard-working persons outside the spotlight, the transfer of knowledge from a related medical area, smart academic programs, recognition by clinician scientists of a major unmet clinical need, an open-minded and research-friendly clinical setting, and opportunities identified during informal late evening conversations among colleagues and friends. State-of-the art biobanking is a prerequisite for studies analyzing the performance of biomarkers. Kirsten Hochholzer (formerly Laule) was the hard-working mastermind setting up our biobank, first for our studies related to the implementation of B-type natriuretic peptide into clinical practice, and then for the Advantageous Predictors of Adverse Coronary Evaluation (APACE) study. Her enormous dedication to detail and her extensive laboratory background still benefit the study 13 years after its initiation. APACE is an international diagnostic multicenter study using central adjudication by 2 independent cardiologists as a reference standard. We transferred this design from our previous work on improving the early diagnosis of acute heart failure in patients presenting with acute dyspnea. When developing and implementing the APACE protocol, Dr. Mueller was supported by a professorship from the Swiss National Science Foundation. This allowed him to build up his own research group and to balance well clinical research with clinical patient care. For a physician scientist, continuous involvement in clinical work is a prerequisite to detect unmet clinical needs and to put own research findings into clinical perspective. André Perruchoud, Juerg Schifferli, and Roland Bingisser, in their roles as head of departments and physician scientists, and Werner Kuebler as physician and hospital CEO created an open-minded, research-friendly clinical setting fostering the development of research projects and the implementation of research finding into clinical practice at the University Hospital of Basel, Switzerland. APACE could not have had the same impact if performed only in Switzerland. Dr. Mueller first met Kathrin Burri (formerly Winkler) at the farewell party that her husband Emanuel gave at the riverside on a warm summer evening before starting a research fellowship in Barcelona. Kathrin had just been informed that for regulatory reasons she would not be able to work as a clinician there. Brainstorming about job possibilities for Kathrin that would help secure their living, we came up with the idea that she could try to set up and run an additional recruiting site for APACE in Barcelona. Using her enormous social skills, power, persistence, and sharp intellect, Kathrin succeeded and thereby contributed substantially to further improving the methodology of APACE. Thanks to this successful start abroad, our international network has grown, and APACE meanwhile has been initiated in 5 countries. acute myocardial infarction Advantageous Predictors of Adverse Coronary Evaluation (study). The authors thank all wonderful coworkers for their enormous and most valuable contributions to APACE.