Consensus Statements on the Use of High-Sensitivity Troponin I as the Assessment of Cardiac Risk in Apparently Healthy Population in Indonesia
Keywords:
Troponin I, high-sensitivity troponin, cardiovascular risk, cardiovascular disease, primary prevention
Abstract
Cardiovascular disease (CVD) is a growing burden in Indonesia, making primary prevention of utmost importance. High sensitivity cardiac troponin I (hsTnI) has been known as one of the biomarkers of choice for diagnosing acute myocardial infarction. Nonetheless, recent studies indicate that hsTnI assay has potential as a predictor of cardiac risk in asymptomatic individuals. An advisory board consisting of renowned cardiologists from the Indonesian Heart Association was convened in Jakarta in March 2023. The meeting aimed to explore the appropriate use of hsTnI for cardiovascular (CV) risk stratification in apparently healthy adults in Indonesia. The board reviewed relevant literature and developed key consensus statements, including hsTnI cut-off for identifying high-risk asymptomatic patients, the proposed algorithm, and monitoring after aggressive risk factor control. This article presents the resulting consensus statements to provide clinicians with a practical tool for planning primary prevention strategies. Furthermore, it is expected to raise awareness and advocacy among stakeholders in the healthcare infrastructure regarding the use of hsTnI as a guide for assessing CV risk in Indonesia.
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References
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33. Jülicher P, Varounis C. Estimating the cost-effectiveness of screening a general population for cardiovascular risk with high-sensitivity troponin-I. European Heart Journal - Quality of Care and Clinical Outcomes. 2021;8:342-51.
34. Marston NA, Bonaca MP, Jarolim P, Goodrich EL, Bhatt DL, Steg PG, Cohen M, Storey RF, Johanson P, Wiviott SD, Braunwald E, Sabatine MS, Morrow DA. Clinical Application of High-Sensitivity Troponin Testing in the Atherosclerotic Cardiovascular Disease Framework of the Current Cholesterol Guidelines. JAMA Cardiology. 2020;5:1255-62.
35. Olson F, Engborg J, Grønhøj MH, Sand NP, Lambrechtsen J, Steffensen FH, Nybo M, Gerke O, Mickley H, Diederichsen ACP. Association between high-sensitive troponin I and coronary artery calcification in a Danish general population. Atherosclerosis. 2016;245:88-93.
36. Omland T, de Lemos JA, Holmen OL, Dalen H, Benth JŠ, Nygård S, Hveem K, Røsjø H. Impact of Sex on the Prognostic Value of High-Sensitivity Cardiac Troponin I in the General Population: The HUNT Study. Clin Chem. 2015;61:646-56.
37. Chinese Society of Health Management CSoLM, Chinese College of Cardiovascular Physicians. Expert consensus on the use of biomarkers for cardiovascular disease risk assessment in physical examination population. Chin J Health Manage. 2022;16:505-19.
38. Pop-Busui R, Januzzi JL, Bruemmer D, Butalia S, Green JB, Horton WB, Knight C, Levi M, Rasouli N, Richardson CR. Heart Failure: An Underappreciated Complication of Diabetes. A Consensus Report of the American Diabetes Association. Diabetes Care. 2022;45:1670-90.
39. Ford I, Shah ASV, Zhang R, McAllister DA, Strachan FE, Caslake M, Newby DE, Packard CJ, Mills NL. High-Sensitivity Cardiac Troponin, Statin Therapy, and Risk of Coronary Heart Disease. J Am Coll Cardiol. 2016;68:2719-28.
40. Li S, Zuo Y, Huang W. Establishment of a reference interval for high-sensitivity cardiac troponin I in healthy adults from the Sichuan area. Medicine. 2017;96.
41. Mills NL, Churchhouse AMD, Lee KK, Anand A, Gamble D, Shah ASV, Paterson E, MacLeod M, Graham C, Walker S, Denvir MA, Fox KAA, Newby DE. Implementation of a Sensitive Troponin I Assay and Risk of Recurrent Myocardial Infarction and Death in Patients With Suspected Acute Coronary Syndrome. JAMA. 2011;305:1210-6.
42. Cavender MA, White WB, Jarolim P, Bakris GL, Cushman WC, Kupfer S, Gao Q, Mehta CR, Zannad F, Cannon CP, Morrow DA. Serial Measurement of High-Sensitivity Troponin I and Cardiovascular Outcomes in Patients With Type 2 Diabetes Mellitus in the EXAMINE Trial (Examination of Cardiovascular Outcomes With Alogliptin Versus Standard of Care). Circulation. 2017;135:1911-21.
43. Howell SJ, Amsterdam EA, Mumma BE, López JE, Tran NK. Implementation of High-Sensitivity Cardiac Troponin: Challenges From the International Experience. Crit Pathw Cardiol. 2018;17:173-8.
2. Indonesia profile. Institute for Health Metrics and Evaluation (IHME), University of Washington. 2021. https://www.healthdata.org/indonesia. Accessed 16 April 2023.
3. Indonesian Heart Association. One ACS Registry. 2019.
4. Finkelstein EA, Chay J, Bajpai S. The economic burden of self-reported and undiagnosed cardiovascular diseases and diabetes on Indonesian households. PLoS One. 2014;9:e99572.
5. Lam CS, Castillo R, Ho DT, Kasliwal RR, Khurana R, Naik S, Omland T, Parsonage WA, Phrommintikul A, Tobing D. High-sensitivity troponin I for cardiovascular risk stratification in the general asymptomatic population: Perspectives from Asia-Pacific. Int J Cardiol. 2019;282:93-8.
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7. Thygesen K, Alpert JS, Jaffe AS, Simoons ML, Chaitman BR, White HD. Third Universal Definition of Myocardial Infarction. Circulation. 2012;126:2020-35.
8. Iribarren C, Chandra M, Rana JS, Hlatky MA, Fortmann SP, Quertermous T, Go AS. High-sensitivity cardiac troponin I and incident coronary heart disease among asymptomatic older adults. Heart. 2016;102:1177-82.
9. Everett BM, Zeller T, Glynn RJ, Ridker PM, Blankenberg S. High-Sensitivity Cardiac Troponin I and B-Type Natriuretic Peptide as Predictors of Vascular Events in Primary Prevention. Circulation. 2015;131:1851-60.
10. Blankenberg S, Salomaa V, Makarova N, Ojeda F, Wild P, Lackner KJ, Jørgensen T, Thorand B, Peters A, Nauck M, Petersmann A, Vartiainen E, Veronesi G, Brambilla P, Costanzo S, Iacoviello L, Linden G, Yarnell J, Patterson CC, Everett BM, Ridker PM, Kontto J, Schnabel RB, Koenig W, Kee F, Zeller T, Kuulasmaa K, Investigators ftB. Troponin I and cardiovascular risk prediction in the general population: the BiomarCaRE consortium. Eur Heart J. 2016;37:2428-37.
11. Kementerian Kesehatan Republik Indonesia. Hasil Utama Riskesdas 2018. Kementerian Kesehatan Republik Indonesia. 2018. https://www.litbang.kemkes.go.id/hasil-utama-riskesdas-2018/. Accessed 14 May 2023.
12. Kementerian Kesehatan Republik Indonesia. Laporan Nasional Riskesdas 2013. Kementerian Kesehatan Republik Indonesia. 2013. https://labmandat.litbang.kemkes.go.id/images/download/laporan/RKD/2013/Laporan_riskesdas_2013_final.pdf. Accessed 14 May 2023.
13. Uli RE, Satyana RPU, Zomer E, Magliano D, Liew D, Ademi Z. Health and productivity burden of coronary heart disease in the working Indonesian population using life-table modelling. BMJ Open. 2020;10:e039221.
14. Antara News. Reducing heart disease incidence helps Indonesia save Rp7.7 trillion. https://en.antaranews.com/news/252245/reducing-heart-disease-incidence-helps-indonesia-save-rp77-trillion (2021). Accessed 5 May 2023.
15. Maharani A, Sujarwoto, Praveen D, Oceandy D, Tampubolon G, Patel A. Cardiovascular disease risk factor prevalence and estimated 10-year cardiovascular risk scores in Indonesia: The SMARThealth Extend study. PLoS One. 2019;14:e0215219.
16. Qanitha A, Qalby N, Amir M, Uiterwaal CS, Henriques JP, De Mol BA, Mappangara I. Clinical Cardiology in South East Asia: Indonesian Lessons from the Present towards Improvement. Global Heart. 2022;17.
17. BPS-Statistics Indonesia. Statistical Yearbook of Indonesia 2022. BPS-Statistics Indonesia. 2022. https://www.bps.go.id/publication/2022/02/25/0a2afea4fab72a5d052cb315/statistik-indonesia-2022.html. Accessed 5 May 2023.
18. Kaptoge S, Pennells L, De Bacquer D, Cooney MT, Kavousi M, Stevens G, Riley LM, Savin S, Khan T, Altay S, Amouyel P, Assmann G, Bell S, Ben-Shlomo Y, Berkman L, Beulens JW, Björkelund C, Blaha M, Blazer DG, Bolton T, Bonita Beaglehole R, Brenner H, Brunner EJ, Casiglia E, Chamnan P, Choi Y-H, Chowdry R, Coady S, Crespo CJ, Cushman M, Dagenais GR, D'Agostino Sr RB, Daimon M, Davidson KW, Engström G, Ford I, Gallacher J, Gansevoort RT, Gaziano TA, Giampaoli S, Grandits G, Grimsgaard S, Grobbee DE, Gudnason V, Guo Q, Tolonen H, Humphries S, Iso H, Jukema JW, Kauhanen J, Kengne AP, Khalili D, Koenig W, Kromhout D, Krumholz H, Lam TH, Laughlin G, Marín Ibañez A, Meade TW, Moons KGM, Nietert PJ, Ninomiya T, Nordestgaard BG, O'Donnell C, Palmieri L, Patel A, Perel P, Price JF, Providencia R, Ridker PM, Rodriguez B, Rosengren A, Roussel R, Sakurai M, Salomaa V, Sato S, Schöttker B, Shara N, Shaw JE, Shin H-C, Simons LA, Sofianopoulou E, Sundström J, Völzke H, Wallace RB, Wareham NJ, Willeit P, Wood D, Wood A, Zhao D, Woodward M, Danaei G, Roth G, Mendis S, Onuma O, Varghese C, Ezzati M, Graham I, Jackson R, Danesh J, Di Angelantonio E. World Health Organization cardiovascular disease risk charts: revised models to estimate risk in 21 global regions. The Lancet Global Health. 2019;7:e1332-e45.
19. Indonesian Heart Association. Panduan Tatalaksana Dislipidemia 2022. Indonesian Heart Association. 2022. https://inaheart.org/guidelines/panduan-tatalaksana-dislipidemia-2022. Accessed 10 July 2023.
20. Indonesian Heart Association. Panduan Prevensi Penyakit Kardiovaskular Aterosklerosis. Indonesian Heart Association. 2022. https://inaprevent.org/panduan-prevensi-penyakit-kardiovaskular-aterosklerosis/. Accessed 10 July 2023.
21. Diniwati Mukhtar Q, Hasna Luthfiah Fitriani, Karina Ajeng Ridwan. Edukasi Deteksi Awal Penyakit Jantung Koroner dengan WHO/ISH Prediction Charts Pada Kader Kecamatan Cempaka Baru, Jakarta Pusat. Folia Medica Indonesiana. 2022;58:215-21.
22. Arsyad DS, Hamsyah EF, Qalby N, Qanitha A, Westerink J, Cramer MJ, Visseren FLJ, Doevendans PA, Ansariadi A. The readiness of public primary health care (PUSKESMAS) for cardiovascular services in Makasar city, Indonesia. BMC Health Serv Res. 2022;22:1112.
23. Arad Y, Goodman KJ, Roth M, Newstein D, Guerci AD. Coronary Calcification, Coronary Disease Risk Factors, C-Reactive Protein, and Atherosclerotic Cardiovascular Disease Events. J Am Coll Cardiol. 2005;46:158-65.
24. Selvarajah S, Kaur G, Haniff J, Cheong KC, Hiong TG, van der Graaf Y, Bots ML. Comparison of the Framingham Risk Score, SCORE and WHO/ISH cardiovascular risk prediction models in an Asian population. Int J Cardiol. 2014;176:211-8.
25. Bansal M, Kasliwal RR, Trehan N. Comparative accuracy of different risk scores in assessing cardiovascular risk in Indians: A study in patients with first myocardial infarction. Indian Heart J. 2014;66:580-6.
26. DeFilippis AP, Young R, Carrubba CJ, McEvoy JW, Budoff MJ, Blumenthal RS, Kronmal RA, McClelland RL, Nasir K, Blaha MJ. An Analysis of Calibration and Discrimination Among Multiple Cardiovascular Risk Scores in a Modern Multiethnic Cohort. Ann Intern Med. 2015;162:266-75.
27. Wu AHB, Christenson RH, Greene DN, Jaffe AS, Kavsak PA, Ordonez-Llanos J, Apple FS. Clinical Laboratory Practice Recommendations for the Use of Cardiac Troponin in Acute Coronary Syndrome: Expert Opinion from the Academy of the American Association for Clinical Chemistry and the Task Force on Clinical Applications of Cardiac Bio-Markers of the International Federation of Clinical Chemistry and Laboratory Medicine. Clin Chem. 2018;64:645-55.
28. Tahhan AS, Sandesara P, Hayek SS, Hammadah M, Alkhoder A, Kelli HM, Topel M, O'Neal WT, Ghasemzadeh N, Ko YA, Gafeer MM, Abdelhadi N, Choudhary F, Patel K, Beshiri A, Murtagh G, Kim J, Wilson P, Shaw L, Vaccarino V, Epstein SE, Sperling L, Quyyumi AA. High‐Sensitivity Troponin I Levels and Coronary Artery Disease Severity, Progression, and Long‐Term Outcomes. Journal of the American Heart Association. 2018;7:e007914.
29. Neumann JT, Sörensen NA, Schwemer T, Ojeda F, Bourry R, Sciacca V, Schaefer S, Waldeyer C, Sinning C, Renné T, Than M, Parsonage W, Wildi K, Makarova N, Schnabel RB, Landmesser U, Mueller C, Cullen L, Greenslade J, Zeller T, Blankenberg S, Karakas M, Westermann D. Diagnosis of Myocardial Infarction Using a High-Sensitivity Troponin I 1-Hour Algorithm. JAMA Cardiology. 2016;1:397-404.
30. Aw T-C, Huang W-t, Le T-T, Pua C-J, Ang B, Phua S-K, Yeo K-K, Cook SA, Chin CWL. High-Sensitivity cardiac Troponins in Cardio-Healthy Subjects: A Cardiovascular Magnetic Resonance Imaging Study. Sci Rep. 2018;8:15409.
31. Sigurdardottir FD, Lyngbakken MN, Holmen OL, Dalen H, Hveem K, Røsjø H, Omland T. Relative Prognostic Value of Cardiac Troponin I and C-Reactive Protein in the General Population (from the Nord-Trøndelag Health [HUNT] Study). The American Journal of Cardiology. 2018;121:949-55.
32. Oomman A, Dalal J, Ponde CK, Bansal M, Sawhney JP, Pinto B, Bhalla N, Gera S, Jain P, Gupta R, Shivdasani B, Varghese K, Mehta A, Shetty SR, ChandManchanda S, Parchure N, Kathiresan M, Chanana BB, Arora K, Bharadwaj S, Shah V. Consensus Statement on the Use of High-Sensitivity Troponin I Assay for Risk Stratification of Apparently Healthy Individuals – An Indian Dimension. International Journal of Current Research. 2021;13:15771-8.
33. Jülicher P, Varounis C. Estimating the cost-effectiveness of screening a general population for cardiovascular risk with high-sensitivity troponin-I. European Heart Journal - Quality of Care and Clinical Outcomes. 2021;8:342-51.
34. Marston NA, Bonaca MP, Jarolim P, Goodrich EL, Bhatt DL, Steg PG, Cohen M, Storey RF, Johanson P, Wiviott SD, Braunwald E, Sabatine MS, Morrow DA. Clinical Application of High-Sensitivity Troponin Testing in the Atherosclerotic Cardiovascular Disease Framework of the Current Cholesterol Guidelines. JAMA Cardiology. 2020;5:1255-62.
35. Olson F, Engborg J, Grønhøj MH, Sand NP, Lambrechtsen J, Steffensen FH, Nybo M, Gerke O, Mickley H, Diederichsen ACP. Association between high-sensitive troponin I and coronary artery calcification in a Danish general population. Atherosclerosis. 2016;245:88-93.
36. Omland T, de Lemos JA, Holmen OL, Dalen H, Benth JŠ, Nygård S, Hveem K, Røsjø H. Impact of Sex on the Prognostic Value of High-Sensitivity Cardiac Troponin I in the General Population: The HUNT Study. Clin Chem. 2015;61:646-56.
37. Chinese Society of Health Management CSoLM, Chinese College of Cardiovascular Physicians. Expert consensus on the use of biomarkers for cardiovascular disease risk assessment in physical examination population. Chin J Health Manage. 2022;16:505-19.
38. Pop-Busui R, Januzzi JL, Bruemmer D, Butalia S, Green JB, Horton WB, Knight C, Levi M, Rasouli N, Richardson CR. Heart Failure: An Underappreciated Complication of Diabetes. A Consensus Report of the American Diabetes Association. Diabetes Care. 2022;45:1670-90.
39. Ford I, Shah ASV, Zhang R, McAllister DA, Strachan FE, Caslake M, Newby DE, Packard CJ, Mills NL. High-Sensitivity Cardiac Troponin, Statin Therapy, and Risk of Coronary Heart Disease. J Am Coll Cardiol. 2016;68:2719-28.
40. Li S, Zuo Y, Huang W. Establishment of a reference interval for high-sensitivity cardiac troponin I in healthy adults from the Sichuan area. Medicine. 2017;96.
41. Mills NL, Churchhouse AMD, Lee KK, Anand A, Gamble D, Shah ASV, Paterson E, MacLeod M, Graham C, Walker S, Denvir MA, Fox KAA, Newby DE. Implementation of a Sensitive Troponin I Assay and Risk of Recurrent Myocardial Infarction and Death in Patients With Suspected Acute Coronary Syndrome. JAMA. 2011;305:1210-6.
42. Cavender MA, White WB, Jarolim P, Bakris GL, Cushman WC, Kupfer S, Gao Q, Mehta CR, Zannad F, Cannon CP, Morrow DA. Serial Measurement of High-Sensitivity Troponin I and Cardiovascular Outcomes in Patients With Type 2 Diabetes Mellitus in the EXAMINE Trial (Examination of Cardiovascular Outcomes With Alogliptin Versus Standard of Care). Circulation. 2017;135:1911-21.
43. Howell SJ, Amsterdam EA, Mumma BE, López JE, Tran NK. Implementation of High-Sensitivity Cardiac Troponin: Challenges From the International Experience. Crit Pathw Cardiol. 2018;17:173-8.
Published
2024-07-03
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How to Cite
Ambari, A. M., Ng, S., Rejeki, V. G., Rina Artha, I. M. J., Raynaldo, A. H., Alsagaff, M. Y., Wicaksono, S. H., Dwiputra, B., & Desandri, D. (2024). Consensus Statements on the Use of High-Sensitivity Troponin I as the Assessment of Cardiac Risk in Apparently Healthy Population in Indonesia. Indonesian Journal of Cardiology, 44(3), 120-7. https://doi.org/10.30701/ijc.1544
Section
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