Abstract 4370630: Troponin Thresholds May Not Be Equal: A Systematic Review of Sex-Based Diagnostic Performance in NSTEMI

Background: High sensitivity cardiac troponin is essential for diagnosing non-ST elevation myocardial infarction. However, the use of uniform thresholds may underdiagnose women due to physiological differences in myocardial mass and baseline troponin levels. This review evaluates whether sex-specific thresholds improve diagnostic accuracy and clinical outcomes in women. Methods: We conducted a systematic search of PubMed, Scopus, and the Cochrane Library for studies published between 2012 and 2024. Eligible studies reported sex-stratified diagnostic performance of high sensitivity troponin I or T in patients with suspected myocardial infarction. Extracted data included sensitivity, specificity, area under the curve, and outcome measures. Study quality was assessed using standardized tools. Results: Sixteen studies involving over 98,000 patients (42 percent women) met inclusion criteria. Ten studies evaluated high sensitivity troponin I and six assessed troponin T. Four studies implemented sex-specific thresholds prospectively, while the rest examined them retrospectively. Uniform thresholds resulted in lower diagnostic sensitivity in women (mean 73 percent) compared to men (86 percent). When sex-specific thresholds were used, sensitivity in women improved to 89 percent, while remaining stable in men. Specificity remained similar across groups. The area under the curve for women increased from 0.78 to 0.86 with sex-specific thresholds, matching values reported in men. Net reclassification improvement ranged from 11 to 14 percent. Among studies reporting clinical impact, the use of sex-specific thresholds led to faster diagnosis, improved triage accuracy, and increased initiation of appropriate therapy in women. Importantly, sex-specific thresholds improve diagnostic sensitivity in women without reducing specificity, ensuring that increased detection does not come at the cost of more false positives. Conclusion: Uniform troponin thresholds underdiagnose non-ST elevation myocardial infarction in women, contributing to disparities in diagnosis and treatment. Use of sex-specific thresholds improves sensitivity and diagnostic accuracy and may help guide more equitable care for women.