The old biomarkers you know are still useful: D-dimer and troponin I

Article information

Kosin Med J. 2023;38(4):229-230
Publication date (electronic) : 2023 December 19
doi :
Division of Cardiology, Department of Internal Medicine, Pusan National University Yangsan Hospital, Pusan National University College of Medicine, Yangsan, Korea
Corresponding Author: Sanghyun Lee, MD, PhD Division of Cardiology, Department of Internal Medicine, Pusan National University Yangsan Hospital, Pusan National University College of Medicine, 20 Geumo-ro, Mulgeum-eup, Yangsan 50612, Korea Tel: +82-55-360-1594 Fax: +82-55-360-2204 E-mail:
Received 2023 November 22; Revised 2023 December 6; Accepted 2023 December 7.

Acute chest pain and dyspnea remain challenging presentations to diagnose and differentiate in emergency settings. These symptoms can occur in a variety of critical conditions, including acute coronary syndrome, which encompasses non-ST segment elevation myocardial infarction (NSTEMI), as well as acute aortic syndrome (AAS), acute pulmonary thromboembolism (APTE), tension pneumothorax, and esophageal rupture. Although distinguishing between APTE and NSTEMI can be difficult, it is important to identify these conditions promptly and treat them effectively to reduce mortality and improve patient outcomes. D-Dimer (DD), a degradation product of cross-linked fibrin, is widely recognized for its diagnostic value in APTE due to its high negative predictive value. However, DD is not specific and may be elevated in various conditions, including myocardial infarction, infection, cancer, trauma, and other inflammatory diseases [1]. Cardiac troponin I (CTI), a biomarker specific to cardiac tissue, is highly useful for diagnosing myocardial infarction. It can also be elevated in cases of APTE, which may cause right ventricular dysfunction and myocardial damage [1-3]. Several studies have been conducted to differentiate between APTE and NSTEMI using biomarkers such as DD and CTI [4-6]. Kim et al. [6] demonstrated that DD and CTI are useful in differentiating APTE from NSTEMI. Their study proposed a decision tree model for the differential diagnosis of APTE, based on initial DD levels of 3.18 μg/mL and initial CTI levels of 1.14 ng/mL.

In this issue of Kosin Medical Journal, Kim et al. [7] validated the tree model algorithm on an additional dataset by comparing it to a test set including the subjects of a prior study [6]. The estimated accuracy rates for the two sets were notably similar (test set: 91%, validation set: 88.6%). Moreover, Kim et al. [7] introduced a decision-making tree for the rapid diagnosis of APTE or NSTEMI, utilizing an initial DD level of 1.5 μg/mL and an initial CTI level of 0.1 ng/mL. A previous study also indicated that a ratio of DD to CTI with a cutoff value of 1.82 could be clinically useful for distinguishing APTE from NSTEMI [5]. These findings suggest that using both DD and CTI levels is more effective than using either marker alone to differentiate between APTE and NSTEMI. The algorithm proposed by Kim et al., or a metric such as the ratio of DD to CTI, appears to be beneficial for quickly determining the next steps, such as whether to perform chest computed tomography or coronary angiography, and for reducing unnecessary coronary angiography. A prior study reported an 11.1% rate of unnecessary coronary angiography in cases of APTE (10/90), which was linked to bleeding complications following thrombolysis [5]. Therefore, in the emergency setting, this decision-making tree for patients with acute chest pain or dyspnea may prevent unnecessary invasive procedures and improve the clinical outcomes of APTE.

Another recent study showed that the ratio of DD to CTI, with a cutoff value of 81.3, may also be useful for differentiating thoracic AAS from NSTEMI [8]. This value of the ratio of DD to CTI was notably higher than that reported in a previous study [5], although the conditions being compared were different (differentiating APTE from NSTEMI or AAS from NSTEMI). An explanation for this discrepancy is that the recent (or latest) study [8] utilized high-sensitivity troponin T (ng/mL) measurements instead of conventional troponin I. Based on these findings, it is advisable to consider not only the troponin unit but also the type of troponin–whether conventional troponin I or high-sensitivity troponin I–when applying these research findings in clinical practice.

Although this study [7] had several limitations, such as its retrospective nature, being a single-center study, and not accounting for the time interval between symptom onset and emergency room visit–which is significant because DD and CTI levels can change over time–the tree model algorithm and the decision-making tree for the rapid diagnosis of APTE or NSTEMI could be beneficial. These tools offer a rapid and straightforward method to reduce misdiagnoses and unnecessary invasive procedures, potentially improving clinical outcomes for patients presenting with acute chest pain and dyspnea by rapidly assessing DD and CTI levels in the emergency setting. Further large-scale prospective studies are required to validate their effectiveness in real-world clinical practice.


Conflicts of interest

No potential conflict of interest relevant to this article was reported.



Author contributions

All the work was done by SL.


1. Tapson VF. Acute pulmonary embolism. N Engl J Med 2008;358:1037–52.
2. Thygesen K, Alpert JS, Jaffe AS, Chaitman BR, Bax JJ, Morrow DA, et al. Fourth universal definition of myocardial infarction (2018). Circulation 2018;138:e618–51.
3. Becattini C, Vedovati MC, Agnelli G. Prognostic value of troponins in acute pulmonary embolism: a meta-analysis. Circulation 2007;116:427–33.
4. Sakamoto K, Yamamoto Y, Okamatsu H, Okabe M. D-Dimer is helpful for differentiating acute aortic dissection and acute pulmonary embolism from acute myocardial infarction. Hellenic J Cardiol 2011;52:123–7.
5. Kim JY, Kim KH, Cho JY, Sim DS, Yoon HJ, Yoon NS, et al. D-Dimer/troponin ratio in the differential diagnosis of acute pulmonary embolism from non-ST elevation myocardial infarction. Korean J Intern Med 2019;34:1263–71.
6. Kim SJ, Kim MH, Lee KM, Kim TH, Choi SY, Son MK, et al. Troponin I and D-dimer for discriminating acute pulmonary thromboembolism from myocardial infarction. Cardiology 2017;136:222–7.
7. Kim SJ, Kim MH, Lee KM, Lee JW, Cha YS, Koh DE, et al. Troponin I and D-dimer levels as triaging biomarkers to distinguish acute pulmonary thromboembolism from myocardial infarction. Kosin Med J 2023;38:252–8.
8. Lee M, Kim YW, Lee D, Kim TY, Lee S, Seo JS, et al. The D-Dimer to troponin ratio is a novel marker for the differential diagnosis of thoracic acute aortic syndrome from non-ST elevation myocardial infarction. J Clin Med 2023;12:3054.

Article information Continued