CLINICAL RESEARCH STUDY

Ultra-Sensitive Copeptin and Cardiac Troponin in

Diagnosing Non-ST-Segment Elevation Acute
Coronary Syndromes—The COPACS Study
Fabrizio Ricci, MD,a Rosa Di Scala, MD,a Cristiano Massacesi, MD,a Marta Di Nicola, PhD,b Gianni Cremonese, MD,a
Doranna De Pace, MD,a Serena Rossi, MD,a Irma Griffo, MD,c Ivana Cataldo, PhD,c Stefano Martinotti, MD, PhD,c
Domenico Rotondo, MD,d Allan S. Jaffe, MD,e Marco Zimarino, MD, PhD,a Raffaele De Caterina, MD, PhDa
a
Institute of Cardiology and Center of Excellence on Aging, “G. d’Annunzio” University, Chieti, Italy; bLaboratory of Biostatistics,
Department of Experimental and Clinical Science, “G. d’Annunzio” University, Chieti, Italy; cDepartment of Biomedical Sciences,
“G. d’Annunzio” University, Chieti, Italy; dEmergency Department, Azienda Sanitaria Locale 2 Abruzzo Lanciano-Vasto-Chieti Hospitals,
Chieti, Italy; eMayo Clinic, Rochester, Minn.

ABSTRACT

OBJECTIVES: We tested the noninferiority of a fast-track rule-out protocol for the diagnosis of non-ST-
segment elevation myocardial infarction vs noncoronary chest pain based on the single-sampling combined
assessment of medium-sensitivity cardiac troponin I and ultra-sensitive copeptin compared with the serial
assessment of medium-sensitivity cardiac troponin I.
METHODS: Ultra-sensitive copeptin and medium-sensitivity cardiac troponin I levels were measured at
presentation in 196 consecutive patients admitted to the emergency department for acute nontraumatic chest
pain within 6 hours from symptoms onset and without ST-segment elevation on a 12-lead electrocardio-
gram. The diagnostic performance for non-ST-segment elevation myocardial infarction diagnosis of the
dual-marker single-sampling strategy with medium-sensitivity cardiac troponin I and ultra-sensitive
copeptin on admission was compared with that of the serial 0- and 3-hour medium-sensitivity cardiac
troponin I sampling in reference to the adjudicated postdischarge diagnosis, using both the comparison of
area under the curve (AUC) receiver operating characteristic and the McNemar chi-square test.
RESULTS: The diagnosis of non-ST-segment elevation myocardial infarction was adjudicated in 29 patients
(14.8%). The combination of medium-sensitivity cardiac troponin I and ultra-sensitive copeptin generated
an AUC of 0.87 (95% confidence interval, 0.82-0.91), which was noninferior with respect to the 3-hour
interval medium-sensitivity cardiac troponin I serial sampling (P ¼ .194 for AUC difference). The com-
bination of medium-sensitivity cardiac troponin I and ultra-sensitive copeptin also yielded a numerically
higher diagnostic sensitivity (100% vs 89.7%; P ¼ not significant).
CONCLUSIONS: A single-sampling strategy of combined ultra-sensitive copeptin and medium-sensitivity cardiac
troponin I is noninferior to a 0- and 3-hour serial medium-sensitivity cardiac troponin I sampling in ruling out
non-ST-segment elevation myocardial infarction and thus may allow an earlier discharge of patients who are
ruled out for non-ST-segment elevation myocardial infarction (ClinicalTrials.gov Identifier NCT01962506).
Ó 2016 The Authors. Published by Elsevier Inc. This is an open access article under the CC BY-NC-ND
license (http://creativecommons.org/licenses/by-nc-nd/4.0/).  The American Journal of Medicine (2016)
129, 105-114

KEYWORDS: Biomarkers; Cardiac troponin; Copeptin; Early discharge; Emergency department; Myocardial infarc-
tion; NoneST-segment elevation myocardial infarction

Funding: See last page of article. Requests for reprints should be addressed to Raffaele De Caterina, MD,
Conflict of Interest: See last page of article. PhD, Institute of Cardiology, “G. d’Annunzio” University e Chieti, C/o
Authorship: See last page of article. Ospedale SS. Annunziata, Via dei Vestini, 31 - 66013 Chieti, Italy.
E-mail address: rdecater@unich.it

0002-9343/Ó 2016 The Authors. Published by Elsevier Inc. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/
licenses/by-nc-nd/4.0/).
http://dx.doi.org/10.1016/j.amjmed.2015.06.033
106 The American Journal of Medicine, Vol 129, No 1, January 2016

The rapid and reliable ruling out of non-ST-elevation information of cardiac troponin. Copeptin, also known as C-
myocardial infarction in patients who are admitted to the terminal pro-arginine-vasopressin, is a 39 amino acid peptide
emergency department for acute chest pain is a major unmet derived from pre-pro-vasopressin and reflects arginine-
clinical need.1 In the absence of ST elevation at the stand- vasopressin release with a 1:1 stoichiometric generation
ard electrocardiogram (ECG), evaluation of cardiac tropo- ratio. Activation of the arginine-vasopressin system may mark
nins is currently the gold standard for the diagnosis of the individual’s response to acute endogenous stress, as
non-ST-segment elevation occurs in acute myocardial infarc-
myocardial infarction.2,3 However, tion.12 Two large cohort studies
a normal single value from a CLINICAL SIGNIFICANCE have demonstrated that levels of
contemporary cardiac troponin  We tested the noninferiority of a fast- copeptin are increased during acute
assay—not exceeding the 99th track rule-out protocol for the diag- myocardial infarction,13,14 and that
percentile of a normal reference the combined determination of
nosis of non-ST-segment elevation
population—on admission does copeptin and medium-sensitivity
myocardial infarction vs noncoronary
not effectively rule out an evolving cardiac troponin in patients pre-
myocardial infarction because of chest pain based on the single-sampling senting early with myocardial
the delayed release kinetics of combined assessment of high-sensitivity infarction allows for a rapid and
cardiac troponin (the cardiac cardiac troponin I and ultra-sensitive safe ruling out of acute myocardial
troponin “blind period”).4,5 High- copeptin compared with the serial infarction.13,14 A recent controlled
sensitivity cardiac troponin as- assessment of high-sensitivity cardiac trial has shown that early discharge
says, the definition of which has troponin I. of low- to intermediate-risk pa-
changed over time,6 improve tients with suspected acute coro-
 In this study, such single-sampling
sensitivity compared with most nary syndromes and both negative
contemporary cardiac troponin as- strategy, proving noninferior to a 0- copeptin and troponin at admission
says. Although it is not clear that and 3-hour serial high-sensitivity car- is safe, with the potential for
this improvement in performance diac troponin I sampling in ruling out reducing costs and shortening stay
would bring additional value in the non-ST-segment elevation myocardial in the emergency department.15
6
clinical setting, these assays now infarction, may thus allow an earlier However, the diagnostic accuracy
are considered to be preferable for discharge of patients ruled out for of a combination of both the newer
their ability to detect early minor non-ST-segment elevation myocardial ultra-sensitive copeptin assay and
increases in the analyte,7 but even infarction. the medium-sensitivity cardiac
with these assays there may be still troponin for the instant rule out of
a short “blind period” in cases of non-ST-segment elevation myo-
early admissions. Therefore, current European Society of cardial infarction has not been tested prospectively within the
Cardiology (ESC) guidelines for pain-free patients with a 6-hour time window of symptom onset.
Global Registry of Acute Cardiac Events score <140 Therefore, we designed the ultra-sensitive COPeptin in
recommend a “rapid” rule-out protocol for non-ST-segment addition to medium sensitivity cardiac troponin for the early
elevation acute coronary syndromes with serial sampling of diagnosis of non-ST-elevation Acute Coronary Syndromes
high-sensitivity cardiac troponin within 3 hours (class I (COPACS) study to test the hypothesis of a diagnostic non-
recommendation, level of evidence B).8 Both the ESC and inferiority for a dual-marker single-sampling strategy based
the American College of Cardiology/American Heart Asso- on the combination of ultra-sensitive copeptin and medium-
ciation guidelines8,9 highlight the importance of the time sensitivity cardiac troponin I compared with both single and
interval from chest pain onset to hospital admission. In rec- serial assessments (0 and 3 hours) of medium-sensitivity
ommending the use of high-sensitivity cardiac troponin, the cardiac troponin for the early diagnosis of non-ST-segment
ESC guidelines suggest retesting after 3 hours if patient elevation myocardial infarction in patients admitted within 6
presentation is within 6 hours from symptom onset or hours of chest pain onset.
in cases in which this information cannot be reliably ob-
tained. A dual sampling strategy is not needed with later
presentations.10 MATERIALS AND METHODS
The need for serial blood sampling in an emergency
department to rule out non-ST-segment elevation myocardial Study Design
infarction in patients presenting early is not ideal, because it The COPACS study was a prospective cohort single-center
does not allow an immediate diagnosis and a quick patient study carried out from July to December 2013, complying
triage on presentation. Therefore, a fast-track rule-out proto- with the Declaration of Helsinki and approved by the Ethics
col based on multi-marker single-sampling strategies has been Committee of the “G. d’Annunzio” University. The study
advocated.11 Among emerging biomarkers in myocardial was registered prospectively (ClinicalTrials.gov Identifier
infarction, copeptin has a virtually immediate increase and NCT01962506). Each patient gave written informed consent
rapid decrease,11 which complements the diagnostic before participation.
Ricci et al Ultra-sensitive Copeptin in Non-ST-Segment Elevation-Acute Coronary Syndrome
Selection of Participants
We screened all consecutive patients who were admitted to
the emergency department because of acute nontraumatic
chest pain with chest pain onset within the previous 6 hours
in a time interval of 6 months. Exclusion criteria included
age <18 years, patients presenting with ST-segment eleva-
tion myocardial infarction or new-onset left bundle branch
block, and cardiac arrest survivors. Subjects with any
missing data, who were lost to follow-up, or in whom serum
interferences with the assay were found in accordance with
Clinical and Laboratory Standards Institute guideline EP
7-A216 (ie, bilirubin >5 mg/dL, triglycerides >5 mg/L, al-
bumin >5 g/dL, or hemolysis in the sample) were excluded
from statistical analyses. Of 210 eligible patients, 14 were
excluded because of missing clinical data or no available
follow-up (n ¼ 8) and for insufficient sampling, freezing
problems, or serum interferences (n ¼ 6). The final study
population consisted of 196 patients.
Clinical Assessment
On admission, all patients enrolled underwent a clinical
assessment, including medical history, physical evaluation,
screening blood tests (serum electrolytes and creatinine),
chest x-ray, and an echocardiogram or a coronary angiogram
at the discretion of the emergency medicine physicians. In all
patients, medium-sensitivity cardiac troponin I was measured
on admission and, serially, after 3 and 6 and 12 hours. A
12-lead ECG was obtained at the same time points. Blood
samples for determination of ultra-sensitive copeptin were
collected only on admission. In addition to these assessments,
the pretest probability of coronary artery disease was evalu-
ated for each patient by means of the Chest Pain Score17,18
and the Thrombolysis in Myocardial Infarction risk score.19
Final Diagnosis
The final diagnosis for each patient was adjudicated inde-
pendently by 2 cardiologists (FR and DDP, among the study
authors), blinded to ultra-sensitive copeptin values, on the
basis of all available data; disagreements were settled by
consensus. Further investigations and treatment of patients
were not affected by the study. At 90 (10) days, clinical
events were recorded with a face-to-face visit or through
telephone contact with the patients, their general practi-
tioners, or the hospitals where they were readmitted. Non-
ST-segment elevation myocardial infarction was defined as
per the Universal Myocardial Infarction Definition.3 Non-
coronary chest pain was defined in the presence of a clear
noncoronary chest pain alternative diagnosis.
Biomarker Testing
Blood samples for measurement of ultra-sensitive cope-
ptin were collected in tubes containing potassium ethyl-
enediaminetetraacetic acid, centrifuged, and frozen at 80 C.
Copeptin was measured by the BRAHMS copeptin ultra-
sensitive immunoluminometric assay on the KRYPTOR
107
Compact Plus system (Thermo Fisher Scientific, Hennigsdorf,
Germany). This assay has a lower limit of detection of 0.9
pmol/L and a functional assay sensitivity of <2 pmol/L. The
direct measuring range was 0.9 to 500 pmol/L. The 95th
centile among healthy participants was <10 pmol/L. This
threshold of 10 pmol/L was chosen with reference to Keller
et al,13 who determined different cutoffs in a reference pop-
ulation and tested their diagnostic performance in a population
with acute coronary syndromes. Serum concentration of car-
diac troponin I was measured using a guideline-acceptable,20
now properly labeled “medium-sensitivity,”6,21 Dimension
VISTA cardiac troponin I assay (Siemens Healthcare Di-
agnostics, Erlangen, Germany). The analytic evaluation of the
assay established by the manufacturer yielded a limit of blank
of this assay of 0.015 mg/L, with the 99th centile concentration
of 0.045 mg/L and the lowest concentration measurable with a
coefficient of variation <10% of 0.040 mg/L. The 99th centile
(0.045 mg/L) of the value distribution in normal subjects was
used as the diagnostic cutoff to fulfill the Universal Myocar-
dial Infarction Definition criteria.3
Statistical Analysis
We calculated a sample size of 180 patients to achieve 80%
power to detect a noninferiority difference of 0.10 between the
area under the curve (AUC) receiver operating characteristic
under the null hypothesis of 0.80 and an AUC under the
alternative hypothesis of 0.90 using a 1-sided z test at a sig-
nificance level (alpha) of 5% on the basis of the noneST-
segment elevation myocardial infarction incidence among the
population of subjects presenting to our emergency depart-
ment with chest pain onset <6 hours, as well as previous
studies.14,22 These calculations were performed using PASS
2005 software (NCSS Statistical Software, Kaysville, UT).
Continuous variables are presented as mean  standard de-
viation or median with interquartile range. Means were
compared using the Student t test for normally distributed
variables or the Wilcoxon rank-sum test or ManneWhitney
test for data not fitting the assumptions of parametric testing.
Categoric variables are reported as distribution of frequency,
absolute and percentage, and compared using chi-square
analysis or Fisher exact test as appropriate. Biomarkers were
treated as categoric variables (positive or negative) at the
prespecified cutoffs. Receiver operating characteristic curves
were constructed to assess the sensitivity, specificity, and
positive and negative predictive values (with their 95% con-
fidence interval). Comparisons of AUCs were performed ac-
cording to Hanley and McNeil.23 A margin to define
noninferiority between AUCs was set at <0.05. Sensitivity
and specificity were compared with the McNemar chi-square
test.24 All tests were 2-tailed, and a P value <.05 was
considered statistically significant. Statistical analysis was
performed using the 2004 SPSS (Advanced Statistical 13;
SPSS Inc, Chicago, IL), MedCalc 10.3.2.0 for Windows
(MedCalc Software, Mariakerke, Belgium), and the R open
source software.
108 The American Journal of Medicine, Vol 129, No 1, January 2016

RESULTS pneumothorax, pleural effusion, pancreatitis, cholecystitis);

Baseline Characteristics, Outcomes, and Final
Diagnosis
Baseline characteristics of the study population are summa-
rized in Table 1. In 29 patients (14.8%), the final adjudicated
diagnosis was non-ST-segment elevation myocardial
infarction. They had a significantly lower glomerular
filtration rate and a higher Thrombolysis in Myocardial
Infarction risk score compared with subjects with
noncoronary chest pain; of note, the Chest Pain Score was
similar in the 2 groups. Diagnoses in the 167 patients with
noncoronary chest pain were cardiac related in 12 cases
(7%) (acute heart failure in 3, atrial fibrillation in 1,
myopericarditis in 1, hypertensive emergency in 5, severe
valvular aortic stenosis in 1, and Takotsubo syndrome
in 1) and noncardiac-related in 75 cases (44.9%) (eg,
no cause was identified in the remaining patients (Figure 1).
Ultra-sensitive copeptin was higher in patients with non-ST-
segment elevation myocardial infarction compared with
noncoronary chest pain (Figure 2). Baseline characteristics
of the study population across ultra-sensitive copeptin quar-
tiles are shown in Table 2. In-hospital and 90-day outcomes
are summarized in Table 3. Among patients with an ultra-
sensitive copeptin/medium-sensitivity cardiac troponin I
pattern (124/196, 63%), hospital readmission was required in
9.6% of cases, but no adverse cardiac event was experienced
at 90 days. Among patients with an ultra-sensitive copeptinþ/
medium-sensitivity cardiac troponin I pattern, non-ST-
segment elevation myocardial infarction was diagnosed later
(>3 hours) during hospital stay in 6.4% of patients and after
discharge adverse cardiac events occurred in 4.2% of
patients.

Table 1 Baseline Characteristics of Patients in Relation to Final Diagnosis

All (n ¼ 196) NSTEMI (n ¼ 29) NCCP (n ¼ 167) P Value*
Age (y), mean  SD 61.4  16.2 64.9  15.0 60.8  16.4 .213†
Gender (male), n (%) 126 (64.3) 21 (72.4) 105 (62.9) NS
Cardiovascular risk factors, n (%)
Hypertension 119 (60.7) 20 (69.0) 99 (59.3) NS
Dyslipidemia 59 (30.1) 11 (37.9) 48 (28.7) NS
Diabetes 38 (19.4) 9 (31.0) 29 (17.4) NS
BMI >30 kg/m2 49 (25.0) 8 (27.6) 41 (24.6) NS
Family history of premature CAD 48 (24.5) 9 (31.0) 39 (23.4) NS
Active smoking 48 (24.5) 8 (27.6) 40 (24.0) NS
Medical history, n (%)
Previous myocardial infarction 42 (21.4) 9 (31.0) 33 (19.8) NS
Heart failure 6 (3.1) 1 (3.4) 5 (3.0) NS
Previous PCI or CABG 30 (15.3) 5 (17.2) 25 (15.0) NS
Stable angina 6 (3.1) 0 6 (3.6) NS
Unstable angina 13 (6.6) 4 (13.8) 9 (5.4) NS
ST- or T-wave abnormality 39 (19.8%) 21 (72.4) 18 (10.7) <.001
Pharmacologic treatment, n (%)
Aspirin 50 (25.5) 10 (34.5) 40 (24.0) NS
Clopidogrel 14 (7.1) 2 (6.9) 12 (7.2) NS
Prasugrel 3 (1.5) 1 (3.4) 2 (1.2) NS
Beta-blockers 46 (23.5) 7 (24.1) 39 (23.4) NS
ACEIs/ARBs 74 (37.8) 10 (34.5) 64 (38.3) NS
Chest pain onset, n (%)
<3 h 124 (63.3) 14 (48.3) 110 (65.9) NS
3-6 h 72 (36.7) 15 (51.7) 57 (34.1)
Creatinine (mg/dL), mean  SD 0.92  0.58 1.25  1.27 0.86  0.31 .001†
eGFR (mL/min/1.73 m2), mean  SD 82.7  14.9 75.9  22.1 83.9  12.9 .007†
TIMI risk score, median (IQR) 1 (0-2) 2 (2-3) 1 (0-2) <.001‡
Chest Pain Score, median (IQR) 5 (4-7) 6 (5-6.8) 5 (4-7) NS‡
Data are presented as n (%) of patients unless otherwise indicated.
ACEI ¼ angiotensin-converting enzyme inhibitor; ARB ¼ angiotensin receptor blocker; BMI ¼ body mass index; CABG ¼ coronary artery bypass graft;
CAD ¼ coronary artery disease; eGFR ¼ estimated glomerular filtration rate; IQR ¼ interquartile range; NCCP ¼ noncoronary chest pain; NS ¼ not significant;
NSTEMI ¼ non-ST-elevation myocardial infarction; PCI ¼ percutaneous coronary intervention; SD ¼ standard deviation; TIMI ¼ Thrombolysis in Myocardial
Infarction.
*Chi-square test.
†Student t test for unpaired data.
‡ManneWhitney U test.
Ricci et al Ultra-sensitive Copeptin in Non-ST-Segment Elevation-Acute Coronary Syndrome 109

Figure 1 Flow chart of the recruitment and selection process, with biomarker results on admission and
adjudicated final diagnoses. The asterisk (*) indicates that in the subgroup of patients with non-ST-
segment elevation myocardial infarction presenting with a discordant ultra-sensitive copeptinþ/medium-
sensitivity cardiac troponin I pattern on admission, a third high-sensitivity cardiac troponin I sample at
>6 hours was required to confirm the diagnosis of non-ST-segment elevation myocardial infarction in 3
patients. Cop-cTnI ¼ copeptin cardiac troponin I; NCCP ¼ noncoronary chest pain; NSTEMI ¼ with
non-ST-segment elevation myocardial infarction.

Patterns of Medium-Sensitivity Cardiac The delay from chest pain onset to emergency depart-
Troponin-I and Ultra-Sensitive Copeptin ment admission was significantly shorter among subjects
presenting with an ultra-sensitive copeptinþ/medium-sensi-
Measurements
tivity cardiac troponin I pattern (60  23 minutes) than in
Ultra-sensitive copeptin and medium-sensitivity cardiac
those with an ultra-sensitive copeptin/medium-sensitivity
troponin I were discordant in 57 cases (29%) on admission.
cardiac troponin Iþ pattern (300  42 minutes; P < .001).
Specifically, on admission, 47 patients presented with an ultra-
Diagnostic performances of the combined ultra-sensitive
sensitive copeptinþ/medium-sensitivity cardiac troponin
copeptin/medium-sensitivity cardiac troponin I on admis-
I pattern; 8 (17%) of these had a 3-hour positive medium-
sion vs the serial medium-sensitivity cardiac troponin I
sensitivity cardiac troponin, and 39 (82.9%) had a confirmed
sampling at 0 and 3 hours, and vs the single ms-cTnI sampling
negative medium-sensitivity cardiac troponin I on retesting.
on admission are summarized in Table 4. The dual-marker
Among those 8 patients with a positive medium-sensitivity
single-sampling strategy based on the ultra-sensitive copep-
cardiac troponin I retest, 3 patients were classified as having
tin/medium-sensitivity cardiac troponin I combination
a noneST-segment elevation myocardial infarction, and a
correctly ruled out non-ST-segment elevation myocardial
cardiac-related noncoronary chest pain diagnosis was estab-
infarction with 100% sensitivity and 100% negative predic-
lished in the other 5. Among those 39 patients with a second
tive value. The overall diagnostic performance of combined
medium-sensitivity cardiac troponin I negative test at 3 hours,
ultra-sensitive copeptin/medium-sensitivity cardiac troponin
in 3 patients a medium-sensitivity cardiac troponin I increase
I single-sampling strategy was noninferior to the serial
was detected beyond 6 hours, and a non-ST-segment elevation
assessment of medium-sensitivity cardiac troponin I within
myocardial infarction was finally diagnosed.
3 hours (AUC difference 0.068, P ¼ not significant).
An ultra-sensitive copeptin/medium-sensitivity cardiac
Sensitivity (100% vs 89.7%; P ¼ not significant) was also not
troponin Iþ pattern was documented on admission in 10
significantly different. Sensitivity of the single-sampling
patients: A final diagnosis of non-ST-segment elevation
strategy with ultra-sensitive copeptin/medium-sensiti-
myocardial infarction was adjudicated in 9 patients and of
vity cardiac troponin I for the rapid ruling out of non-ST-
noncoronary chest pain in 1 patient with a hypertensive
segment elevation myocardial infarction was higher than
emergency.
110
Figure 2 Box-whisker graphs of ultra-sensitive copeptin
levels in the groups with noncoronary chest pain and
noneST-segment elevation myocardial infarction. Box-
whisker plots show the 25th and 75th percentile ranges
(box) with 95% confidence intervals (whiskers) and me-
dian values (transverse lines in the box). Statistically
significant differences were found between the 2 groups
(P < .001, ManneWhitney U test). NCCP ¼ noncoronary
chest pain; NSTEMI ¼ non-ST-elevation myocardial
infarction.
admission-only medium-sensitivity cardiac troponin I testing
(100% vs 79.3%; P ¼ .031).
DISCUSSION
This study showed that a dual-marker single-sampling
strategy based on the ultra-sensitive copeptin/medium-
sensitivity cardiac troponin I combination is a safe and
effective strategy for the fast-track ruling out of non-ST-
segment elevation myocardial infarction in low- to
intermediate-risk patients presenting to the emergency
department <6 hours from chest pain onset. Our study
focused on a population of patients in whom the ECG is not
suggestive for ST-segment elevation myocardial infarction,
in whom diagnostic uncertainty is maximum, and in whom
the crucial diagnostic decision has to be between non-ST-
segment elevation myocardial infarction and noncoronary
chest pain. In our population, a concordant ultra-sensitive
copeptin/medium-sensitivity cardiac troponin I pattern
correctly ruled out non-ST-segment elevation myocardial
infarction, with both excellent diagnostic sensitivity and
negative predictive value, and would have thus allowed an
immediate and safe discharge of approximately 65% of our
cases. The subgroup of patients had an uneventful 3-month
follow-up. In this study, the overall diagnostic performance
and the sensitivity of dual-marker single-sampling strategy
based on the ultra-sensitive copeptin/medium-sensitivity
cardiac troponin I combination on admission were non-
inferior to medium-sensitivity cardiac troponin I retesting at
3 hours. The dual-marker strategy showed a significantly
higher diagnostic sensitivity to identify non-ST-segment
elevation myocardial infarction than the single sampling of
medium-sensitivity cardiac troponin I alone. The possibility
of a very early rule out of non-ST-segment elevation
The American Journal of Medicine, Vol 129, No 1, January 2016
myocardial infarction25,26 based on the combination of
complementary pathophysiologic information derived from
the quantification of myocardial necrosis (cardiac troponin I)
and acute endogenous stress response (copeptin) seems to
be real and effective.
Copeptin provides little clinical information when
measured alone because of its nonspecific elevation in many
pathophysiologic conditions.14,27 However, its advantage is
in the almost immediate increase in plasma concentration
after the onset of chest pain, with a rapid decline afterward
over the first 6 to 12 hours. Therefore, its assessment seems
to be valuable only in the cohort of patients presenting early
with suspected acute coronary syndrome, which was indeed
the focus of our study.
Our study corroborates and extends previous findings
supporting the viability of the dual-marker single-sampling
strategy based on the combination of copeptin and cardiac
troponin.4,13,14,28 Overall, positive results of the combined
copeptin-cardiac troponin were supported recently by a
meta-analysis from 13 observational studies,29 in which the
authors documented that the addition of copeptin to cardiac
troponin not only identifies the patients at risk of all-cause
death but also improves the sensitivity and negative likeli-
hood ratio for the diagnosis of non-ST-segment elevation
myocardial infarction compared with cardiac troponin I
alone. The outcomes of such comparisons are likely to be
strongly influenced by patient selection (eg, including or
excluding those with ST-segment elevation myocardial
infarction, in whom the diagnostic uncertainty is trivial),
timing of presentation (including or excluding patients
presenting late), and the choice of the comparator (ie,
contemporary, first-, second-, or third-generation cardiac
troponin assay).6,20,30 Therefore, proper comparisons of
alternative strategies should rely on the appropriate selection
of the target population and the latest generation assays.
The large multicenter Biomarkers in Cardiology-8 trial
recently randomized 902 patients within 12 hours of chest pain
onset to serial cardiac troponin (0 and 3-6 hours) or the com-
bined copeptin and cardiac troponin evaluation, and docu-
mented that patients with negative findings in both groups
were all eligible for discharge and had a similar rate of adverse
events.15 A limitation of that study is the inclusion of patients
admitted at >6 hours, when the contribution of adding
copeptin and even of the dual sampling of cardiac troponin
over single-sampling cardiac troponin is likely negligible.
Only 3 other studies restricted patient eligibility to a delay from
symptom onset to admission <6 hours.4,31,32 Meune et al31
compared the combined standard copeptin and cardiac
troponin evaluation with the serial cardiac troponin evaluation
using a high-sensitivity cardiac troponin I assay, but general-
izability of such results seems to be limited because of the
small sample size in that study (n ¼ 56). Chenevier-Gobeaux
et al32 reported a 98% sensitivity and a 99% negative predic-
tive value for the combination of standard copeptin and cardiac
troponin I in ruling out acute coronary syndromes, but the
cardiac troponin assays used should not be considered as
“guideline acceptable” because of analytic imprecision.3,30 The
Ricci et al Ultra-sensitive Copeptin in Non-ST-Segment Elevation-Acute Coronary Syndrome 111

Table 2 Baseline Characteristics of Patients Across Quartiles of Ultrasensitive Copeptin

4.2 pmol/L 4.2-7.4 pmol/L 7.4-13.8 pmol/L >13.8 pmol/L
(n ¼ 45) (n ¼ 45) (n ¼ 41) (n ¼ 44) P Value*
Age (y), mean  SD 56.0  13.6 55.2  17.5 64.3  15.9 69.9  14.0 <.001†
Gender (male), n (%) 18 (40.0) 26 (57.8) 35 (85.4) 30 (68.2) <.001
Cardiovascular risk factors, n (%)
Hypertension 22 (48.9) 22 (48.9) 27 (65.9) 32 (72.7) .046
Dyslipidemia 12 (26.7) 12 (26.7) 14 (34.1) 13 (29.5) NS
Diabetes 6 (13.3) 8 (17.8) 9 (22.0) 9 (20.5) NS
BMI >30 kg/m2 8 (17.8) 11 (24.4) 9 (22.0) 12 (27.3) NS
Family history of premature CAD 8 (17.8) 12 (26.7) 14 (34.1) 8 (18.2) NS
Active smoking 9 (20.0) 16 (35.6) 11 (26.8) 8 (18.2) NS
Medical history, n (%)
Previous myocardial infarction 5 (11.1) 6 (13.3) 11 (26.8) 12 (27.3) NS
Heart failure 0 0 3 (7.3) 3 (6.8) NS
Previous PCI or CABG 5 (11.1) 5 (11.1) 9 (22.0) 6 (13.6) NS
Stable angina 1 (2.2) 1 (2.2) 0 0 NS
Unstable angina 3 (6.7) 2 (4.4) 3 (7.3) 3 (6.8) NS
Pharmacologic treatment, n (%)
Aspirin 6 (13.3) 8 (17.8) 15 (36.6) 13 (29.5) .045
Clopidogrel 3 (6.7) 1 (2.2) 3 (7.3) 4 (9.1) NS
Prasugrel 2 (4.4) 0 1 (2.4) 0 NS
Beta-blockers 8 (17.8) 8 (17.8) 12 (29.3) 11 (25.0) NS
ACEIs/ARBs 15 (33.3) 13 (28.9) 14 (34.1) 21 (47.7) NS
Chest pain onset, n (%)
<3 h 33 (73.3) 24 (53.3) 27 (65.9) 28 (63.6) NS
3-6 h 12 (26.7) 21 (46.7) 14 (34.1) 16 (36.4)
Creatinine (mg/dL), mean  SD 0.7  0.2 0.8  0.2 0.9  0.2 1.2  1.0 <.001†
eGFR (mL/min/1.73 m2), mean  SD 88.2  3.8 87.8  6.5 82.8  13.0 74.2  20.6 <.001†
TIMI risk score, median (IQR) 1 (0-1) 1 (0-2) 1 (0-2) 2 (1-3) <.001‡
CHEST PAIN score, median (IQR) 5 (3.5-7) 5 (3-7) 5 (4-8) 5 (4-7) NS‡
Data are presented as n (%) of patients unless otherwise indicated.
ACEI ¼ angiotensin-converting enzyme inhibitor; ARB ¼ angiotensin receptor blocker; BMI ¼ body mass index; CABG ¼ coronary artery bypass graft;
CAD ¼ coronary artery disease; eGFR ¼ estimated glomerular filtration rate; IQR ¼ interquartile range; NS ¼ not significant; PCI ¼ percutaneous coronary
intervention; SD ¼ standard deviation; TIMI ¼ Thrombolysis in Myocardial Infarction.
*Chi-square test.
†One-way analysis of variance test.
‡KruskaleWallis H test.

large multicenter prospective Copeptin Helps in the early Study Limitations

detection Of Patients with acute myocardial Infarction study4
used a contemporary medium-sensitivity cardiac troponin I
assay (10% coefficient of variation at 99th percentile of 30
ng/L). The combination of standard copeptin and medium-
sensitivity cardiac troponin I at presentation provided a nega-
tive predictive value >99%, with the potential to rule out non-
ST-segment elevation myocardial infarction in 58% of cases
without serial blood sampling.4 However, the adjudication of
events was predicated on local cardiac troponin results. In our
study, we kept the patients in to ensure complete ascertainment
of the final diagnosis. Our study, with patients managed
similarly in a single emergency department, confirms such
results, also using the recently introduced ultra-sensitive
copeptin, which should allow a better detection of borderline
elevations of this biomarker. Although the added value of such
a sensitive copeptin assay cannot be inferred from our data, no
previous study has used such a combination of sensitive
biomarkers.
We acknowledge a few limitations of the present study.
First, this was a single-center study with limited population
size. Yet, sample size was calculated on the basis of a ful-
filled noninferiority hypothesis, with an observed preva-
lence of non-ST-segment elevation myocardial infarction
similar to that in previous larger studies on the same
topic.13,33,34 Second, because of the lack of statistical power
within subgroups, we could not evaluate the impact of
pretest probability on the diagnostic accuracy of different
biomarker strategies.32 Third, we did not compare the
diagnostic accuracy of a combined assessment of ultra-
sensitive copeptin and medium-sensitivity cardiac troponin
I with a shorter delay (eg, 1 hour) in medium-sensitivity
cardiac troponin I retesting, as recently proposed.35 Last,
serum cardiac troponin I concentrations were not measured
with a high- or ultra-high sensitivity assay. Nonetheless, our
medium-sensitivity assay has a performance target of
112 The American Journal of Medicine, Vol 129, No 1, January 2016

Table 3 Outcomes Related to Ultrasensitive Copeptin and Medium-Sensitivity Cardiac Troponin I Values at Admission to the Emergency
Department
us-Cop/ms-cTnIþ us-Copþ/ms-cTnI us-Copþ/ms-cTnIþ us-Cop/ms-cTnI
(n ¼ 10) (n ¼ 47) (n ¼ 15) (n ¼ 124)
Outcome during hospital stay
UA 0 (0) 0 (0) 0 (0) 0 (0)
NSTEMI 9 (90) 6 (12.8) 14 (93.3) 0 (0)
Coronary angiography 7 (70) 6 (12.8) 13 (86.7) 0 (0)
PCI 6 (70) 5 (10.6) 8 (53.3) 0 (0)
CABG 0 (0) 1 (2.1) 4 (26.7) 0 (0)
AHF 0 (0) 2 (4.3) 9 (60) 0 (0)
CV death 0 (0) 0 (0) 2 (13.3) 0 (0)
Non-CV death 0 (0) 0 (0) 0 (0) 0 (0)
Outcome at 90 d of follow-up
Readmission to ED for NCCP 1 (10) 6 (12.7) 2 (13.3) 12 (9.6)
UA 1 (10) 1 (2.1) 0 (0) 0 (0)
STEMI 0 (0) 0 (0) 0 (0) 0 (0)
NSTEMI 0 (0) 1 (2.1) 1 (6.7) 0 (0)
Coronary angiography 1 (10) 2 (4.3) 1 (6.7) 0 (0)
PCI 1 (10) 1 (2.1) 1 (6.7) 0 (0)
CABG 0 (0) 0 (0) 0 (0) 0 (0)
AHF 0 (0) 0 (0) 1 (6.7) 0 (0)
CV death 0 (0) 1 (2.1) 0 () 0 (0)
Non-CV death 0 (0) 0 (0) 0 (0) 0 (0)
Data are presented as n (%) of patients.
AHF ¼ acute heart failure; CABG ¼ coronary artery bypass graft; CV ¼ cardiovascular; ED ¼ emergency department; ms-cTnI ¼ medium-sensitivity
cardiac troponin I; NCCP ¼ noncoronary chest pain; NSTEMI ¼ non-ST-elevation myocardial infarction; PCI ¼ percutaneous coronary intervention;
STEMI ¼ ST-elevation myocardial infarction; UA ¼ unstable angina; us-Cop ¼ ultrasensitive copeptin.

measuring cardiac troponin with a 10% coefficient of vari-
ation at the 99th percentile of the reference population, is
currently classified as “guideline acceptable,”30 and is in the
sensitivity range of tests currently approved for use in the
United States.6 Furthermore, a previous study by Keller
et al36 reported that among 1818 patients with suspected
acute myocardial infarction, a serial change in cardiac
troponin I levels within 3 hours from admission (using the
99th percentile diagnostic cutoff value) would have deter-
mined a 99% negative predictive value and a 96% positive
predictive value for both high-sensitivity cardiac troponin I
and medium-sensitivity cardiac troponin I assays. However,
whether the use of a higher sensitivity cardiac troponin
assay would have changed the main message of this study
remains questionable, because increased diagnostic sensi-
tivity of the cardiac troponin assay is likely to reduce, but
not eliminate, the troponin-blind period after the onset of a
myocardial infarction.
CONCLUSIONS
In patients presenting to the emergency department within
6 hours for acute chest pain, a strategy of single-sampling
dual-marker ultra-sensitive copeptin/medium-sensitivity
cardiac troponin I is noninferior to serial medium-sensitivity
cardiac troponin I sampling in allowing a rapid and reliable
ruling out of non-ST-segment elevation myocardial infarc-
tion, and may thus obviate the need for prolonged

Table 4 Comparison of the Diagnostic Performances of Various Biomarker Strategies for the Diagnosis of Non-ST-Elevation Myocardial
Infarction vs Noncoronary Chest Pain with Time Between Chest Pain Onset and Emergency Department Admission <6 Hours
Sensitivity AUC Difference
Biomarker Strategy (P value)* Specificity PPV NPV AUC (95% CI) (P Value)†
Serial ms-cTnI at 3 h 89.7% (.250) 98.2% 89.7% 98.2% 0.939 (0.896-0.968) -
ms-cTnI on admission 79.3% (.031) 98.8% 92% 96.5% 0.891 (0.838-0.931) 0.049 (.117)
us-Cop/ms-cTnI on admission 100% 74.2% 40.3% 100% 0.871 (0.816-0.915) 0.068 (.194)
Adjudicated final diagnosis by 2 independent cardiologists blinded to the results of copeptin.
AUC ¼ area under the curve; CI ¼ confidence interval; ms-cTnI ¼ medium-sensitivity cardiac troponin I; NPV ¼ negative predictive value;
PPV ¼ positive predictive value; us-Cop ¼ ultrasensitive copeptin.
*McNemar test comparing sensitivity of Cop-us/ms-cTnI.
†Hanley method comparing AUC of serial ms-cTnI.
Ricci et al Ultra-sensitive Copeptin in Non-ST-Segment Elevation-Acute Coronary Syndrome
monitoring and serial blood biomarker sampling. The
diagnostic utility of ultra-sensitive copeptin may result in
substantial benefits for both healthcare providers and pa-
tients, decreasing costs and reducing self-discharge and
readmission rates.
ACKNOWLEDGMENTS
The authors thank the personnel of the Emergency Depart-
ment of the Chieti University Hospital for collaboration in
the study performance.
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Funding: The study was supported by institutional grants to the Insti-
tute of Cardiology, G. d’Annunzio University, Italy (to RDC). Copeptin
The American Journal of Medicine, Vol 129, No 1, January 2016
assays were provided by Thermo Fisher Scientific Italy, through Dr Mary
Lou Wratten and Dr Michele Anzelmo.
Conflict of Interest: ASJ has in the past consulted or presently consults
for most of the major biomarker diagnostic companies (Abbott Labora-
tories; Alere; Amgen Inc.; Beckman Coulter, Inc.; Critical Diagnostics;
Radiometer Medical ApS.).
Authorship: All authors had access to the data and played a role in
writing this manuscript.