Dr Evangelos Giannitsis
Cardiologist, Medical Director of Chest Pain Unit, University Hospital of Heidelberg, Germany
Dr Raphael Twerenbold
Cardiologist, University Hospital Basel, Switzerland

Clinical Relevance of hs-TnT gender specific cut-offs


  • Gender specific cut-offs for hs-cTnT have very little clinical significance in re-classification of patients with suspected AMI
  • Gender specific cut-offs for hs-cTnT tests are not recommended as they can complicate clinical decision making
  • Latest ESC Guidelines state that the use of uniform cut-off concentrations should remain the standard of care in the early diagnosis of MI

The use of high-sensitivity troponins allow the identification of higher 99th percentile values for men than for women. That is biologically plausible, as the hearts of men and female are different in their morphology and maybe also in their function. However, it is not consistently shown that the use of sex-specific cut-offs will really change significantly diagnosis and prognosis, by use of gender-specific cut-offs.

There are several studies with conflicting results, and in a sub-study from the TRAPID-AMI, it was shown that use of sex-specific cut-off for Troponin T did not result in a relevant diagnostic reclassification because there is an increase in infarct diagnosis among female but also a decrease in infarct diagnosis in men, and the net reclassification is very, very low.

Regarding prognosis, there was no relevant prognostic improvement by application of sex-specific cut-offs. Conversely, females were found to have worse outcomes by use of sex-specific cut-offs in this specific sub-study. So, in conclusion, I personally do not recommend the use of sex-specific cut-offs as it also would further complicate decision-making. A diagnosis, based on a biomarker, should be as convenient as possible for a physician in a chest pain unit.

Women and men have different 99th percentile, so we wanted to see whether this has a clinical impact that we should use sex-specific cut-off levels. And we’ve investigated this question within more than 2,500 patients. So, we only could see that two women would have got an upgrade from unstable angina to acute myocardial infarction, and one man a downgrade from non-STEMI to unstable angina.

So only 3 patients out of 2,500 would have got reclassifications, so we consider it not being clinically relevant, even though there’s a biological theoretical difference.

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