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Analytical evaluation of the novel Mindray high sensitivity cardiac troponin I

immunoassay on CL-1200i

Article in Clinical Chemistry and Laboratory Medicine · January 2024

DOI: 10.1515/cclm-2023-1448

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 Clin Chem Lab Med 2024; aop

Giuseppe Lippi*, Laura Pighi, Elisa Paviati, Davide Demonte, Simone De Nitto, Matteo Gelati,
Martina Montagnana, Giorgio Gandini, Brandon M. Henry and Gian Luca Salvagno

Analytical evaluation of the novel Mindray high

sensitivity cardiac troponin I immunoassay on
CL-1200i
https://doi.org/10.1515/cclm-2023-1448 Conclusions: Although we failed to confirm the very opti-
Received December 15, 2023; accepted December 25, 2023; mistic analytical characteristics previously reported for
published online January 8, 2024 this method, our evaluation of the novel Mindray hs-cTnI
immunoassay on CL-1200i demonstrated that the overall
Abstract
performance is comparable to that of other commercially
available hs-cTnI techniques, making it a viable alternative
Objectives: The current study was designed to evaluate the
to other methods.
analytical performance of the new Mindray highly sensitive
cardiac troponin I (hs-cTnI) chemiluminescent immuno- Keywords: troponin; immunoassay; myocardial infarction;
assay on Mindray CL-1200i, as a thorough validation of novel method evaluation
hs-cTnI methods is required before introduction into clinical
practice.
Methods: The evaluation of the analytical performance of
this hs-cTnI immunoassay encompassed the calculation of
Introduction
the limit of blank (LOB), limit of detection (LOD), functional
sensitivity, imprecision, linearity, 99th percentile upper
Acute myocardial infarction (AMI) remains the leading
reference limit (URL) and concordance with another previ-
cause of death and disability worldwide. According to the
ously validated hs-cTnI chemiluminescent immunoassay.
recent statistics from the American Heart Association (AHA),
Results: The LOB and LOD were 0.32 and 0.35 ng/L, whilst the
ischemic heart disease is the leading cause of years of life lost
functional sensitivity (expressed as cTnI value with <10 %
(YLL) worldwide, ahead of lower respiratory tract infections
imprecision), was 0.35 ng/L. The linearity was excellent
[1]. In the US, coronary heart disease has an overall preva-
throughout a wide range of clinically measurable values
lence of 7.1 % in US adults aged 20 years or older, with a
(r=1.00 between 0.8 and 9,726.9 ng/mL). The intra-assay, inter-
slightly higher prevalence in men than in women, while the
assay and total imprecision were 1.1–1.3 %, 5.5–8.1 % and
overall prevalence of AMI is 3.2 % in the same population,
5.6–8.2 %, respectively. The 99th percentile URL calculated
with higher prevalence in men than in women throughout
using residual plasma from 246 ostensibly healthy blood
all age groups. On this premises, it is estimated that nearly
donors was 9.2 ng/L (4.3 ng/L in women vs. 12.3 ng/L in men). The
720,000 US citizens will be hospitalized each year for a heart
Spearman’s correlation between Mindray hs-cTnI and Access
attack, while 335,000 will suffer a recurrent ischemic attack.
hs-TnI was 0.97, with mean bias of 7.2 % (95 % CI, 2.6–11.9 %).
The annual direct and indirect costs are estimated at around
240 billion US dollars, making myocardial ischemia the most
expensive condition treated in US hospitals [1].
Giuseppe Lippi and Laura Pighi contributed equally to this work. In view of these concerning figures, the timely diagnosis
and treatment of myocardial ischemia remains a key
*Corresponding author: Prof. Giuseppe Lippi, Section of Clinical
healthcare issue in all countries, as the prognosis of an
Biochemistry, University Hospital of Verona, P.le LA Scuro 10, 37134 Verona,
Italy, E-mail: giuseppe.lippi@univr.it. https://orcid.org/0000-0001-9523-9054
ischemic attack is highly dependent on rapid therapeutic
Laura Pighi, Elisa Paviati, Davide Demonte, Simone De Nitto, Matteo management. A landmark study published by De Luca et al.
Gelati, Martina Montagnana and Gian Luca Salvagno, Section of Clinical has shown that every 30 min delay in treating a heart attack
Biochemistry, University Hospital of Verona, Verona, Italy is associated with a 7.5 % increased one-year mortality risk
Giorgio Gandini, Transfusion Center, University Hospital of Verona, [2]. This paves the way for the introduction of rapid and
Verona, Italy
accurate diagnostic strategies that allow patients with non-
Brandon M. Henry, Clinical Laboratory, Division of Nephrology and
Hypertension, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, ischemic symptoms to be quickly ruled out, while concomi-
USA tantly achieving an accurate diagnosis of AMI in those with
2 Lippi et al.: Evaluation of Mindray hs-cTnI
irreversible myocardial ischemia. In the history of AMI
diagnostics, the way in which patients with suspected
myocardial ischemia have been triaged has been changed
tremendously with the introduction of many different bio-
markers and diagnostic algorithms [3]. Nevertheless, some
milestones have been eventually defined, including the use
of cardiac troponin I (cTnI) or T (cTnT) measured with highly
sensitive (hs) immunoassays and incorporated into the
so-called “fast-track algorithms” [4, 5]. The guidelines recently
published by the European Society of Cardiology (ESC) at
the end of 2023 emphasize several important aspects in
this context [6]. Apart from cardiac troponins being the
only biomarkers at the core of the diagnostic reasoning,
especially in patients with non-ST-elevation myocardial
infarction (STEMI), the guidelines present new concepts for
serial tests to be used in patients with cardiac troponin
levels below the 99th percentile upper reference limit (URL)
of a population of healthy individuals. In these patients, the
ESC advocates the use of rapid “rule-in” and “rule-out”
algorithms, consisting of baseline measurement of cardiac
troponin and a further assessment 1 or 2 h later, with calcu-
lation of an “absolute” diagnostic delta threshold. These
algorithms, validated in large multicenter studies using many
currently available hs immunoassays, require the calculation
of method-specific cutoffs derived from analytical and clinical
studies, such that the validation of the analytical performance
of each new immunoassay is an essential prerequisite for its
introduction in the clinical practice. Therefore, the current
study was designed to evaluate the analytical performance of
the new Mindray hs-cTnI immunoassay on the Mindray
CL-1200i platform.
Materials and methods
Method evaluation
The initial assessment of the analytical characteristics of the Mindray
hs-cTnI immunoassay on the Mindray CL-1200i platform (Mindray,
Shenzhen, China) encompassed the calculation of the limit of blank
(LOB), limit of detection (LOD), functional sensitivity, operating line-
arity, imprecision (intra-assay, inter-assay and total), the 99th percentile
URL and the comparison with another validated commercial hs-cTnI
immunoassay (Access hs-TnI; Beckman Coulter, Brea, CA, USA). The
technical characteristics of the novel Mindray hs-cTnI chemilumines-
cent immunoassay have been described by Li et al. elsewhere [7].
All measurements were conducted using heparin plasma samples
delivered to the local medical laboratory for routine testing. Specifically,
primary evacuated blood tubes (Vacutest Kima, with gel and lithium
heparin; Kima, Padua, Italy) referred for diagnostic assessment by the
local ED, along with specimens drawn from blood donors delivered for
routine testing were centrifuged at 2,000×g for 10 min at room tem-
perature. The lithium heparin plasma was divided into three aliquots of
around 0.8 mL each. The first aliquot was used for patient testing,
whereas the other aliquots were anonymized and then employed for the
analytical study. The entire study was performed always using the same
calibration curve and lot of reagents.
Analytical assay performance
The calculation of the LOB and LOD was performed as follows: [LOB]=
[mean] + 1.645 × [standard deviation (SD)] of 20 repetitions of dilution
buffer; [LOD]=[LOB] + 1.645 × [SD] of 20 repetitions of a routine plasma
sample with the lowest measurable cTnI value (i.e., around 0.3 ng/L, as
derived from the LOD studies), as recommended by Armbruster and Pry
[8]. For the calculation of the LOB, we have planned a further series of
experiments in which the dilution buffer has been replaced with the
Mindray “Calibrator 0”, as expressly recommended by the manufac-
turer. The functional sensitivity of the immunoassay was defined as the
lowest cTnI value that could be measured with less than 10 % impreci-
sion. Specifically, the value was calculated by measuring six consecutive
1:2 scalar dilutions in dilution buffer (i.e. from 1:2 to 1:64) of a routine
plasma sample with baseline cTnI value of 12.6 ng/L. All dilutions were
tested in 10 replicates, with calculation of SD of each dilution and rela-
tive imprecision, finally expressed as coefficient of variation (CV %).
Linearity of the assay
The assay linearity was assessed by serially diluting a routine plasma
sample with a low value of cTnI (i.e. 0.8 ng/L) with another routine
plasma sample displaying a high value of cTnI (i.e. 9,726.9 ng/mL) at
fixed ratios (0.1:9.9; 0.5:9.5; 1:9; 2:8; 3:7; 4:6; 5:5; 6:4; 7:3, 8:2; 9:1). All serial
dilutions were measured in duplicate, the theoretical values of cTnI
were estimated from the measured values of undiluted specimens, and
the linearity was finally reported as Spearman’s correlation coefficient.
Imprecision studies
Intra-assay, inter-assay and total imprecision of Mindray hs-cTnI was
calculated using three plasma pools prepared with low (14–17 ng/L),
medium (85–92 ng/L) and high (1,635–1,754 ng/L) cTnI concentrations.
Intra-assay and inter-assay imprecision were then assayed in 20
consecutive runs and 10 consecutive working days, respectively. The
final values of imprecision were expressed as CV %, while the total
imprecision was estimated with the formula of Krouwer and Rablno-
witz [9].
Calculation of the 99th percentile of the upper reference
limit
The calculation of the 99th percentile URL of the Mindray hs-cTnI
immunoassay was based on the joint document of the International
Federation of Clinical Chemistry (IFCC) and Clinical and Laboratory
Standards Institute (CLSI) EP28-A3C [10], by measuring residual plasma
from blood donors delivered in seven working days from the transfusion
medicine center to the local laboratory medicine service. Prior to blood
collection, blood donors underwent a medical examination and labora-
tory testing, to exclude the presence of major pathological conditions. The
difference between sexes was assessed using Mann-Whitney U test, while
 Lippi et al.: Evaluation of Mindray hs-cTnI 3

cTnI values were expressed as median, interquartile range (IQR) and 99th correlation coefficient (r) of 1.00 (95 % CI, 1.00–1.00; p<0.001)
percentile URL. (Figure 1).

Method comparison
Imprecision studies
The comparison study was performed with the residual plasma
collected from patients admitted to the ED of the University Hospitals of
The results of the imprecision study using three routine
Verona for suspected myocardial ischemia. All samples were immedi-
ately assayed with the local routine immunoassay (Roche hs-cTnT; plasma samples with low (14–17 ng/L), medium (85–92 ng/L)
Roche diagnostics, Basel, Switzerland), and then with the Beckman and high (1,635–1,754 ng/L) cTnI concentrations are sum-
Coulter Access hs-TnI on Access 2 analyzer and Mindray hs-cTnI on marized in Table 1. Specifically, the intra-assay imprecision
CL-1200i. The analytical characteristics of the Beckman Coulter Access was comprised between 1.1 and 1.3 %, the inter-assay
hs-TnI immunoassay have been reported in detail elsewhere [11]. In
imprecision ranged between 5.5 and 8.1 %, while the total
brief, the method is a paramagnetic particle-based chemiluminescent
immunoassay characterized by LOB, LOD and functional sensitivity of
imprecision was 5.6–8.2 %, respectively.
0.14, 0.34 and 1.35 ng/L, respectively, and intra-assay, inter-assay and
overall imprecision of 2.2–2.9 %, 4.6–5.4 % and 5.4–6.1 %, respectively
[11]. The concordance of cTnI values measured with Mindray hs-cTnI
Calculation of the 99th percentile upper
and Access hs-TnI was assessed with Spearman’s correlation and Pass-
ing and Bablok regression, while the absolute difference between values reference limit (URL)
(i.e. percentage bias) was estimated from Bland and Altman plots.
The 99th percentile URL was calculated using residual
Statistical analysis plasma collected from 246 healthy blood donors (149 men
and 97 women; mean age 42 ± 14 years, range 18–66 years).
The statistical analysis was performed with Analyse-it (Analyse-it The median cTnI value was 1.2 ng/L (IQR, 0.6–1.9 ng/L),
Software Ltd, Leeds, UK). The entire study, based on pre-existing whilst the 99th percentile URL was 9.2 ng/L. As predictable,
plasma samples referred for diagnostic testing, was conducted under the median cTnI value was lower in women (0.8 ng/L; IQR,
the ISO 15189:2012 accreditation in accordance with the Declaration of 0.4–1.3 ng/L) compared to men (1.5 ng/L; IQR, 0.9–2.3 ng/L;
Helsinki and under the conditions of relevant local legislation. The
p<0.001), and so was the 99th percentile URL (i.e., 4.3 vs.
study was cleared by the local Institutional Review Board (University
Hospital of Verona, Verona, Italy; SOPAV2, protocol number: 971CESC,
12.3 ng/L). Both values were lower than those indicated by
date of approval: 25 July, 2016). the manufacturer and reported by Li et al. in their evalu-
ation (i.e., 15.3 ng/L in women and 31.3 ng/L in men,
respectively) [7].
Results
Analytical assay performance

The calculation of LOB and LOD, performed according to the

protocol of Armbruster and Pry [8], yielded the following
results: LOB: [0.287 ng/L] + [1.645 × 0.021 ng/L]=0.32 ng/L;
LOD: [0.32 ng/L] + [1.645 × 0.02 ng/L]=0.35 ng/L. The func-
tional sensitivity, expressed as cTnI value with <10 % CV, was
0.35 ng/L, thus corresponding exactly to the LOB. Notably,
the LOB calculated using the Mindray “Calibrator 0” was
<0.1, with all measurements yielding this same threshold.

Linearity of the assay

The assay linearity obtained by a serial dilution of a routine

plasma specimen with low cTnI value (i.e. 0.8 ng/L) with
another routine plasma specimen with high cTnI value
(i.e. 9,726.9 ng/mL) was optimal, displaying a Spearman’s Figure 1: Linearity of the assay.
4 Lippi et al.: Evaluation of Mindray hs-cTnI
Table : With-in run, between-run and total imprecision of the Mindray hs-TnI immunoassay.
Pools Intra-assay (n=)
Mean ± SD, ng/L Imprecision, CV %
Low . ± . . %
Medium . ± . . %
High ,. ± . . %
CV, coefficient of variation; SD, standard deviation.
Method comparison
The final population included in the method comparison
study consisted of 265 subjects (166 men and 99 women;
mean age: 73 ± 14 years) admitted to the local ED for sus-
pected AMI, 166 (62.6 %) displaying cTnI values above the
99th percentile URL defined by Mindray (i.e., 24.2 ng/L) and
176 (66.4 %) with cTnI values above the 99th percentile URL
defined by Beckman Coulter (i.e., 17.5 ng/L), respectively. The
Spearman’s correlation between Mindray hs-cTnI and
Access hs-TnI was 0.97 (95 % CI, 0.97–0.98; p<0.001), whilst the
Passing & Bablok linear fit was [Mindray hs-cTnI]=[Access
hs-TnI × 1.09] − [0.98]. The Bland and Altman plot analysis is
shown in Figure 2, revealing a cumulative percentage bias of
7.2 % (95 % CI, 2.6–11.9 %; p=0.002) between paired patient
samples measured with the two immunoassays.
Discussion
AMI remains the leading cause of preventable death and
disability worldwide. Today, there is no question that timely
diagnosis and early revascularization therapy are the most
Inter-assay (n=) Total
Mean ± SD, ng/L Imprecision, CV % Imprecision, CV %
. ± . . % . %
. ± . . % . %
,. ± . . % . %
important factors that can influence the short- and long-
term prognosis of patients with myocardial ischemia. The
development and introduction of accurate and efficient
cardiac biomarkers such as cardiac troponins into clinical
pathways have virtually revolutionized the diagnostic
approach in patients with suspected AMI, allowing for rapid
rule-out and more efficient diagnosis. The introduction of hs
immunoassays was a further step forward in the diagnostic
reasoning of patients with suspected myocardial infarction
and enabled the introduction of fast-track algorithms [4, 5],
which allow a near definitive diagnosis of myocardial
ischemia to be made within 1–2 h of hospital admission. To
be truly efficient, these diagnostic algorithms, which are
essentially based on serial measurement of cardiac tropo-
nins, require a thorough clinical validation aimed at
reporting the main analytical characteristics (LOB, LOD,
functional sensitivity) for allowing development of assay-
specific algorithms. To this end, we designed this study to
evaluate and validate the analytical performance of the
novel Mindray hs-cTnI immunoassay.
The results of our study show that this fully automated
method has optimal analytical performance, with LOD, LOB
and functional sensitivity of 0.32, 0.35 and 0.35 ng/L,
Figure 2: Bland and Altman plot of cardiac
troponin I (cTnI) values obtained in paired
plasma samples with Mindray hs-cTnI and
Beckman Coulter Access hs-TnI immunoassays
(n=265). The dotted lined are traced at the
95 % limits of agreement.

respectively, and with optimal linearity over a wide range of
clinically significant measurable values (i.e. r=1.00 between
0.8 and 9,727 ng/L). Notably, we were unable to replicate the
values found in the earlier study by Li et al. using sample
buffer [7], which reported values of LOD and LOB corre-
sponding to 0.07, 0.21 ng/L, whilst we found a lower value of
functional sensitivity (i.e., 0.35 vs. 0.51 ng/L). We could only
approximate that LOD with 20 replicates of the Mindray
“Calibrator 0”, which always yielded cTnI values <0.1 ng/L in
our hands. One possible explanation for the difference
observed between the LOD and LOB, is that our instrument
was a Mindray CL-1200i, set by the manufacturer with a
detection limit of 0.1 ng/L. Conversely, Li et al. conducted a
pilot study with the Mindray CL-8000i [7], which could have
been characterized by extended range of reportable values,
even if the analytical methodology was essentially identical.
Another possible interpretation is that Li et al. [7] may have
used a different sample matrix (e.g., the lowest calibrator)
for calculating the LOD. In its instructions for use, the
manufacturer reported values of LOD, LOB and functional
sensitivity of 0.5, 0.7 and 2.4 ng/L, which are however higher
than those found in our analytical evaluation.
Regarding imprecision, the manufacturer states that the
intra-assay and inter-assay imprecision in routine samples
ranges between 1.2 and 2.9 % and 2.0–2.9 %, which are lower
than the values found in our study (Table 1). The overall
imprecision found by Li et al. on two routine serum samples
with cTnI values of 42 and 9,656 ng/L was between 2.8 and
3.5 %, which is also lower than the total imprecision calcu-
lated on our data (i.e., 5.6–8.2 %). We thus agree with Clerico
et al. [5], who suggested that Li et al. may have under-
estimated the imprecision of this novel hs-cTnI immuno-
assay, and that even the LOD and LOB are perhaps too
optimistic, consistently lower than those of many other
commercially available cTnI immunoassays. In contrast, the
findings of our study are more closely aligned with those
shown by Clerico et al. for the vast majority of commercially
available cardiac troponin immunoassays [5].
Although an excellent correlation was found with
another commercial hs-cTnI method (Access hs-TnI), we
observed a statistically significant bias of around 7 % between
paired patient samples measured with the two methods, thus
confirming the compelling need for improving the standard-
ization of cTnI immunoassays [12].
In conclusion, although we were unable to confirm the
otherwise very optimistic analytical characteristics reported
by Li et al. [7], our evaluation of the novel Mindray hs-cTnI
immunoassay on CL-1200i showed that the overall analytical
performance is comparable to that of other commercially
available cTnI techniques, making it a viable alternative to
other methods.
View publication stats
Lippi et al.: Evaluation of Mindray hs-cTnI 5
Research ethics: The study was cleared by the local
Institutional Review Board (University Hospital of Verona,
Verona, Italy; SOPAV2, protocol number: 971CESC, date of
approval: 25 July, 2016).
Informed consent: Not applicable.
Author contributions: The authors have accepted respon-
sibility for the entire content of this manuscript and
approved its submission.
Competing interests: The instrumentation and reagents
used in this study were provided by Mindray, but the
company played no role in the study design; in the collection,
analysis, and interpretation of data; in the writing of the
report; or in the decision to submit the report for publication.
Research funding: None declared.
Data availability: Data will be available upon reasonable
request to the corresponding author.
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