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1 Supplementary Online Content Rubini Giménez M, Twerenbold R, Boeddinghaus J, et al. Clinical effect of sex-specific cutoff values of high-sensitivity cardiac troponin T in suspected myocardial infarction. JAMA Cardiol. Published online September 21, doi: /jamacardio emethods. Additional Methods eresults. Detailed Results etable 1. Latest hs-ctnt Value Available x Hours After Chest Pain Onset Maximum and After Presentation (All Patients n=2734) etable 2. Characteristics of the 3 Different Sex-Specific Cut-off Cohorts etable 3. Available Diagnostic Tools for the Reclassification of Gold Standard Diagnoses Among Women etable 4. Classification Regarding Death During Long-term Follow-up According to Levels of hs-ctnt efigure 1. Box-Plot Showing Levels of High-Sensitivity Cardiac Troponin T (hs-ctnt) at Presentation in Women and Men With Myocardial Infarction Using the Uniform Cut-off Level for the Adjudication efigure 2. Flow Diagram Showing Reclassifications Among the Five Diagnostic Categories for Pair 2 and Pair 3 efigure 3. Kaplan-Meier Showing 30-Day MACE in Patients With Myocardial Infarction and Unstable Angina for Pair 2 and Pair 3 This supplementary material has been provided by the authors to give readers additional information about their work American Medical Association. All rights reserved. 1

2 emethods. Additional Methods STARD Checklist for reporting studies of diagnostic accuracy American Medical Association. All rights reserved. 2

3 Routine clinical assessment All patients underwent clinical assessment that included medical history, physical examination, 12-lead ECG, pulse oximetry, standard blood test, and chest radiography. Levels of local ctn/hs-ctn were measured at presentation and serially thereafter as long as clinically indicated. In the majority of the patients (n=1751, 64% of all patients) ctn assays other than hs-ctnt were used to guide clinical decision making. In the remaining 36% of patients, hs-ctnt was used clinically. In the remaining 36% of patients, hs-ctnt was used clinically. Treatment of patients was left to the discretion of the attending physician. Use of local conventional ctn values for adjudication of final diagnoses For the Roche ctnt 4 th generation assay, the 10% CV level is 0.035ug/l. The laboratories of the participating sites reported only two decimals; therefore 0.04ug/l was used as a cut-off for myocardial necrosis. In order to fulfil the criteria of a significant change (30% of 99 th percentile or 10% CV level), a patient would e.g. need to have a level of <0.01ug/l at presentation and 0.04ug/l at 6h. A patient would also qualify if the first level is 0.02ug/l and the second 0.04ug/l. A patient would not fulfil the criteria if the first level is 0.03ug/l and the second is 0.04ug/l. If the first level is 0.04ug/l, the second level needs to be at least 0.06ug/l. For the Abbott AxsymcTnI ADV, the 10% CV level is 0.16ug/l. A patient having 0.16ug/l at presentation would meet the criteria for significant change if the second was 0.21ug/l. A patient having <0.12ug/l at presentation (limit of detection) would qualify if the second is >0.16ug/l. For the Beckmann Coulter AccucTnI, the 10% CV level is 0.06ug/l. A patient having 0.06ug/l at presentation would qualify if the second is 0.08ug/l. A patient having American Medical Association. All rights reserved. 3

4 at presentation would qualify if the second is 0.07ug/l, but not 0.06ug/l. A patient having undetectable ctni (ctni<0.01ug/l) at presentation would qualify if the second is 0.06ug/l. Use of hs-ctnt for adjudication of final diagnoses In order to identify additional patients with small acute myocardial infarctions that were missed by the adjudication using the less sensitive conventional ctn assays a second adjudication using hs-ctnt was performed in all non- acute myocardial infarction patients according to the first adjudication. Two reasons led in 2009 to the inclusion of hs-ctnt into the APACE protocol for adjudication of diagnoses: First, hsctnt was the first and only hs-ctn assay available at that time. Second, previous work from several groups including ours 2 had shown that hs-ctnt has higher diagnostic accuracy for AMI as compared to conventional ctn assays. For hs-ctnt the 99 th percentile (14ng/l) was used as cut-off for myocardial necrosis. 3,4 Absolute changes in hs-ctnt were used to determine significant changes based on the diagnostic superiority of absolute over relative changes. 5,6 Based on studies of the biological variation of ctn 7,8 as well as on data from previous chest pain cohort studies 9,10, a significant absolute change was defined as a rise or fall of at least 10ng/l within six hours or 6ng/l within three hours. Re-adjudication using sex-specific cut-off levels with the alternative cut-off values First, the subgroup of presumably healthy persons from the Dallas Heart Study defined by: subjects free from recent hospitalization (6 months), clinical cardiovascular disease (coronary heart disease, chronic heart failure, atrial fibrillation, 2016 American Medical Association. All rights reserved. 4

5 prior stroke), subclinical cardiovascular disease (left ventricular hypertrophy (LVH) or left ventricular ejection fraction (LVEF) <55% by magnetic resonance imaging, LVH by ECG, N-terminal pro-bnp>125ng/l), and stage III or greater chronic kidney disease (egfr<60ml/min/1.73m 2 ). 11 In this population the uniform 99 th percentile was 14 ng/l, with the sex-specific values for women at 9ng/l and for men at 17 ng/l. 11 Reclassification from MI to UA was performed among men, who had an initial diagnosis of MI and hs-ctnt levels between 14 and 17 ng/l, as they would no longer have a hs-ctnt level above the sex-specific 99 th percentile and no longer fulfill this mandatory criteria for AMI. Reclassification to MI was considered among women, who had an initial diagnosis of UA or symptoms of unknown origin and hs-ctnt levels between 9 and 14 ng/l, as they now were above the sex-specific cut-off level and therefore could potentially have MI, if also fulfilling the change criteria. 12, 23 These patients were reviewed again in great detail. The diagnosis of MI (versus other causes of cardiomyocyte damage) was again based on the integration of chest pain characteristics, ECG-findings, hs-ctnt, coronary angiography, echocardiography and other imaging and follow up as recommended in the universal definition of MI. 23 Second, the subgroup of presumably healthy persons from the Maastricht Study 13, defined by: Individuals free from diabetes mellitus, a history of cardiovascular disease, cardiac ischemia on electrocardiography, N-terminal pro-bnp >125ng/L, or egfr <60mL/minute/1.73m2. In this population the uniform 99 th percentile was 15 ng/l, with the sex-specific values for women at 12ng/l and for men at 16 ng/l. 13 Reclassification from MI to UA was performed among men, who had an initial diagnosis of MI and hs-ctnt levels between 14 and 16 ng/l, as they would no longer have a hs-ctnt level above the sex-specific 99 th percentile and no longer fulfill this mandatory criteria for AMI. Reclassification to MI was considered among women, 2016 American Medical Association. All rights reserved. 5

6 who had an initial diagnosis of UA or symptoms of unknown origin and hs-ctnt levels between 12 and 14 ng/l, as they now were above the sex-specific cut-off level 12, 23,13 and therefore could potentially have MI, if also fulfilling the change criteria. Hs-cTnT analysis from study blood samples Blood samples were collected at presentation to the ED in EDTA or serum tubes for determination of hs-ctnt. Additional samples were collected at 1, 2, 3, and 6 hours. Serial sampling was discontinued when the diagnosis of MI was certain and treatment required transferring the patient to the catheter laboratory or coronary care unit. After centrifugation, samples were frozen at -80 C until assayed in a blinded fashion in a dedicated core laboratory. Hs-cTnT was measured on the Elecsys 2010 (Roche Diagnostics) with a limit of Blank (LoB) of 3 ng/l, a limit of Detection (LoD) 5 ng/l as specified by the manufacturer. The 99 th percentile cut-off point of a healthy reference population of the hs-ctnt assay (women and men) was 14 ng/l with a coefficient of variation (CV) of 10% achieved at 13 ng/l. 6,14,15 Calculation of the glomerular filtration rate was performed using the abbreviated Modification of Diet in Renal disease formula. 16 Follow-up and prognostic end-points After hospital discharge, patients were contacted by telephone interview or written form. In case of reported clinical events in particular cardiovascular events since presentation to the ED, details were reviewed by asking the patients and traced by establishing contact with the respective family physician or treating institution. The primary prognostic endpoint was all-cause mortality. Information regarding death was obtained from the national registry on mortality, the hospital s diagnosis registry or family physician s records American Medical Association. All rights reserved. 6

7 Assumption of linearity of absolute changes within the first hours The assumption of linearity of absolute changes within the first hours is based on unpublished internal data as well as recent data from Ola Hammarsten et al. showing a near-linear increase in levels of ctn with increasing time from symptom onset in their NSTEMI cohort American Medical Association. All rights reserved. 7

8 eresults. Detailed Results Secondary diagnostic analyses using the uniform and sex-specific 99 th percentiles derived from two other recent cohorts of healthy volunteers: 11,13 Dallas Heart Study: Pair 2 (uniform 14 ng/l, 9 ng/l in women and 17 ng/l in men) After re-adjudication using sex-specific 99 th percentiles, diagnostic reclassification regarding MI occurred in only 5 patients (0.2% of all patients and 1% of all MI patients). Two women were upgraded from UA to MI, while 3 men were downgraded from MI to UA resulting in 14.7% of women (n=129) and 18.4% of men (n=342) having MI, while 5.4 % of women (n=47) and 12.3% of men (n= 229) had UA (efigure 2). Accordingly, concordant diagnoses were observed in 467 of 472 MI patients (98.9%) and in 2729 of 2734 patients (99.8%) overall. Among all patients with an adjudicated diagnosis of MI (n=471) using sex-specific cut-off levels, at presentation to the ED levels of hs-ctnt were already above the respective sex-specific 99 th percentile (9 ng/l in women and 17 ng/l in men) in 424 (90%) patients, with a higher prevalence in women vs. men (98% vs 88 % p<0.001). The sex-specific 99 th percentile had a sensitivity of 97.7% ( %; specificity 62.1%, %) among women and 87.7% ( %; specificity 83.7%, %) among men (p<0.001). Maastricht Study, Pair 3 (uniform 15 ng/l, 12 ng/l in women and 16 ng/l in men) The adjudicated final diagnosis was MI in 126 (14.4%) women and in 344 (18.5%) men, UA in 50 women (5.7%) and in 227 (12.2%) men. Among all patients with an adjudicated diagnosis of MI using this uniform cut-off (n=470), at presentation to the ED levels of hs-ctnt were already above the 99 th percentile (15 ng/l) in 422 (90%) patients, with a similar prevalence in women and men (91% vs 90% p=ns. The uniform 99 th percentile had a sensitivity of 91.3% ( %; specificity 81.4%, 2016 American Medical Association. All rights reserved. 8

9 %) among women and 89.8% ( %; specificity 80.5%, %) among men (p=ns). After re-adjudication using sex-specific 99 th percentiles, diagnostic reclassification regarding MI occurred in only 3 patients (0.1% of all patients and 0.6% of all MI patients). Two women were upgraded from UA to MI, while one man was downgraded from MI to UA resulting in 14.6% of women (n=128) and 18.5% of men (n=343) having MI, while 5.5 % of women (n=48) and 12.3% of men (n= 228) had UA. Accordingly, concordant diagnoses were observed in 467 of 470 MI patients (99.4%) and in 2731 of 2734 patients (99.9%) overall. (efigure 2). Among all patients with an adjudicated diagnosis of MI (n=469) using sexspecific cut-off levels, at presentation to the ED levels of hs-ctnt were already above the respective sex-specific 99 th percentile (12 ng/l in women and 16 ng/l in men) in 423 (90%) patients, with similar prevalence in women and men (93% vs 89 % p=ns)..the sex-specific 99 th percentile had a sensitivity of 98.5% ( %; specificity 62.0%, %) among women and 89.2% ( %; specificity 82.4%, %) among men (p<0.001). Secondary prognostic analyses using the uniform and sex-specific 99 th percentiles derived from two other recent cohorts of healthy volunteers: 11,13 Re-classification and 30-day MACE in patients with MI and UA Dallas Heart Study: Pair 2 (uniform 14 ng/l, 9 ng/l in women and 17 ng/l in men) Overall, 469 patients had a concordant final diagnosis of MI using either uniform or sexspecific cut-offs. Among these patients, 41 patients (8.7%) suffered a MACE during the first 30 days. Among the 273 patients with a concordant final diagnosis of UA, 4 patients (1.5%) suffered a MACE (0.4%) within 30 days; efigure 3.1). None of the three re-classified patients (two women and one man) had a MACE within 30 days American Medical Association. All rights reserved. 9

10 Maastricht Study, Pair 3 (uniform 15 ng/l, 12 ng/l in women and 16 ng/l in men) Overall, 469 patients had a concordant final diagnosis of MI using either uniform or sexspecific cut-offs. Among these patients, 41 patients (8.7%) suffered a MACE during the first 30 days. Among the 275 patients with a concordant final diagnosis of UA, 4 patients (1.5%) suffered a MACE within 30 days; efigure 3.2). None of the three re-classified patients (two women and one man) died within 30 days. Re-classification and long-term mortality in patients according to levels of hsctnt at presentation Dallas Heart Study: Pair 2 (uniform 14 ng/l, 9 ng/l in women and 17 ng/l in men) Using the uniform cut-off level (14 ng/l), 132 (80%) of patients dying during follow-up had elevated levels of hs-ctnt (etable 1B). Using the sex-specific cut-off levels, 134 (81%) of patients dying during follow-up had elevated levels of hs-ctnt. Maastricht Study, Pair 3 (uniform 15 ng/l, 12 ng/l in women and 16 ng/l in men) Using the uniform cut-off level (15 ng/l), 130 (78%) of patients dying during follow-up had elevated levels of hs-ctnt (etable 1B). Using the sex-specific cut-off levels, 130 (78%) of patients dying during follow-up had elevated levels of hs-ctnt 2016 American Medical Association. All rights reserved. 10

11 etable 1. Latest hs-ctnt Value Available x Hours After Chest Pain Onset Maximum and After Presentation (All Patients n=2734) etable 1A Latest hs-ctnt value available x hours after chest pain onset/maximum (all patients n=2734) n % 0h after CPO h after CPO h after CPO h after CPO h after CPO American Medical Association. All rights reserved. 11

12 etable 1B Latest hs-ctnt value available x hours after presentation (all patients n=2734) n % 0h after presentation h after presentation h after presentation h after presentation h after presentation American Medical Association. All rights reserved. 12

13 etable 1C Latest hs-ctnt value available x hours after chest pain onset/maximum Women Men n % n % 0h after CPO h after CPO h after CPO h after CPO h after CPO American Medical Association. All rights reserved. 13

14 etable 2 Characteristics of the 3 different sex specific cut offs cohorts Pair 1 Pair 2 Pair 3 N of participants Age (Mean) Women, no (%) 265 (49.7) 1011 (54.0) 807 (52.4) hs ctnt (ng/l) uniform 99th percentile women 99th percentile men 99th percentile American Medical Association. All rights reserved. 14

15 etable 3 Available diagnostic tools for the reclassification of gold standard diagnoses among women Women with levels hs ctnt Women with levels hs ctnt 9 14 ng/l Women with levels hs ctnt 14 42ng/l n=430 n=138 n= 166 Diagnostic local clinical information, n (%) Diagnostic local clinical information, n (%) Diagnostic local clinical information, n (%) clinical history, 430 (100%) clinical history, 138 (100%) clinical history 166 (100%) physical examination, 430 (100%) physical examination, 138 (100%) physical examination 166 (100%) ecg, 430 (100%) ecg, 138 (100%) ecg 166 (100%) clinical troponin, 430 (100%) clinical troponin, 138 (100%) clinical troponin 166 (100%) stress testing, 110 (26%) stress testing, 29 (21%) stress testing, 31 (19%) coronarangiography, 32 (7%) coronarangiography, 15 (11%) coronarangiography, 39 (24%) Diagnostic information from APACE study, n (%) Diagnostic information from APACE study, n (%) Diagnostic information from APACE study, n (%) serial hs ctnt serial hs ctnt serial hs ctnt 0h after CPO, 430 (100%) 0h after CPO, 138 (100%) 0h after CPO 166 (100%) 1h after CPO, 428 (97%) 1h after CPO, 138 (100%) 1h after CPO, 166 (100%) 2h after CPO, 423 (96%) 2h after CPO, 138 (100%) 2h after CPO, 165 (99%) 3h after CPO, 404 (94%) 3h after CPO, 135 (98%) 3h after CPO, 162 (98%) 6h after CPO, 318 (74%) 6h after CPO, 116 (84%) 6h after CPO, 150 (90%) Assessment of 34 chest pain characteristics, 430 (100%) Assessment of 34 chest pain characteristics, 138 (100%)Assessment of 34 chest pain characteristics 166 (100%) 30d Follow up, 430 (100%) 30d Follow up, 138 (100%) 30d Follow up, 166 (100%) Time at the ED, h (Mean±SD) 6±3 Time at the ED, h (Mean±SD) 7±5 Time at the ED, h (Mean±SD) 7± American Medical Association. All rights reserved. 15

16 etable 4. Classification Regarding Death During Long-term Follow-up According to Levels of hs-ctnt etable 4A Classification regarding death during long-term follow-up according to levels of hs-ctnt at 0h Women Men All Died Alive Died Alive Died Alive hs-ctnt (ng/l) hs-ctnt (ng/l) hs-ctnt (ng/l) Pair 1 < < < < < American Medical Association. All rights reserved. 16

17 etable 4B Classification regarding death during long-term follow-up according to levels of hs-ctnt at 0h with pair 2 and 3 Women Men All Died Alive Died Alive Died Alive hs-ctnt (ng/l) hs-ctnt (ng/l) hs-ctnt (ng/l) Pair 2 < < < < < Pair 3 < < < < < American Medical Association. All rights reserved. 17

18 efigure 1. Box-Plot Showing Levels of High-Sensitivity Cardiac Troponin T (hs-ctnt) at Presentation in Women and Men With Myocardial Infarction Using the Uniform Cut-off Level for the Adjudication 2016 American Medical Association. All rights reserved. 18

19 efigure 2. Flow Diagram Showing Reclassifications Among the Five Diagnostic Categories for Pair 2 and Pair 3 Pair American Medical Association. All rights reserved. 19

20 Pair American Medical Association. All rights reserved. 20

21 efigure 3. Kaplan-Meier Showing 30-Day MACE in Patients With Myocardial Infarction and Unstable Angina for Pair 2 and Pair 3 Pair American Medical Association. All rights reserved. 21

22 Pair American Medical Association. All rights reserved. 22

23 ereferences 1. Bossuyt PM, Reitsma JB, Bruns DE, et al. Towards complete and accurate reporting of studies of diagnostic accuracy: The STARD Initiative. Annals of internal medicine. Jan ;138(1): Reichlin T, Hochholzer W, Bassetti S, et al. Early diagnosis of myocardial infarction with sensitive cardiac troponin assays. The New England journal of medicine. Aug ;361(9): Apple FS, Wu AH, Jaffe AS. European Society of Cardiology and American College of Cardiology guidelines for redefinition of myocardial infarction: how to use existing assays clinically and for clinical trials. American heart journal. Dec 2002;144(6): Apple FS, Jesse RL, Newby LK, et al. National Academy of Clinical Biochemistry and IFCC Committee for Standardization of Markers of Cardiac Damage Laboratory Medicine Practice Guidelines: Analytical issues for biochemical markers of acute coronary syndromes. Circulation. Apr ;115(13):e Reichlin T, Irfan A, Twerenbold R, et al. Utility of absolute and relative changes in cardiac troponin concentrations in the early diagnosis of acute myocardial infarction. Circulation. Jul ;124(2): Thygesen K, Mair J, Giannitsis E, et al. How to use high sensitivity cardiac troponins in acute cardiac care. European heart journal. Jun Vasile VC, Saenger AK, Kroning JM, Jaffe AS. Biological and analytical variability of a novel high sensitivity cardiac troponin T assay. Clin Chem. Jul 2010;56(7): Wu AH, Lu QA, Todd J, Moecks J, Wians F. Short and long term biological variation in cardiac troponin I measured with a high sensitivity assay: implications for clinical practice. Clin Chem. Jan 2009;55(1): Keller T, Zeller T, Peetz D, et al. Sensitive troponin I assay in early diagnosis of acute myocardial infarction. The New England journal of medicine. Aug ;361(9): Apple FS, Pearce LA, Smith SW, Kaczmarek JM, Murakami MM. Role of monitoring changes in sensitive cardiac troponin I assay results for early diagnosis of myocardial infarction and prediction of risk of adverse events. Clin Chem. May 2009;55(5): Gore MO, Seliger SL, Defilippi CR, et al. Age and sex dependent upper reference limits for the high sensitivity cardiac troponin T assay. Journal of the American College of Cardiology. Apr ;63(14): Saenger AK, Beyrau R, Braun S, et al. Multicenter analytical evaluation of a high sensitivity troponin T assay. Clinica chimica acta; international journal of clinical chemistry. Apr ;412(9 10): Kimenai D. Direct comparison of clinical decision limits for cardiac troponin T and I: The Maastricht Study. Heart Giannitsis E, Kurz K, Hallermayer K, Jarausch J, Jaffe AS, Katus HA. Analytical validation of a high sensitivity cardiac troponin T assay. Clin Chem. Feb 2010;56(2): Apple FS, Collinson PO, Biomarkers ITFoCAoC. Analytical characteristics of high sensitivity cardiac troponin assays. Clin Chem. Jan 2012;58(1): Levey AS, Coresh J, Greene T, et al. Using standardized serum creatinine values in the modification of diet in renal disease study equation for estimating glomerular filtration rate. Annals of internal medicine. Aug ;145(4): Hammarsten O, Fu ML, Sigurjonsdottir R, et al. Troponin T percentiles from a random population sample, emergency room patients and patients with myocardial infarction. Clinical chemistry. Mar 2012;58(3): American Medical Association. All rights reserved. 23