Identification of high-risk non-ST elevation myocardial infarction at presentation to emergency department. A prospective observational cohort study in North West England

Abstract

ObjectivesEarly access to invasive coronary angiography and revascularisation for high-risk non-ST elevation myocardial infarction (NSTEMI) improves outcomes and is supported by current guidelines. We sought to determine the most effective criteria at presentation to emergency department (ED) to identify high-risk NSTEMI.SettingSecondary care centre northwest England with national follow-up.Participants1642 consecutive patients (median age 59, 52% male) presenting to ED with a primary symptom of chest pain in whom there is suspicion of NSTEMI.Primary and secondary measuresMultivariate logistic regression analysis for the prediction of all-cause death (primary) and major adverse cardiac event (MACE defined as all-cause death, unplanned coronary revascularisation and adjudicated NSTEMI (third universal definition)) (secondary measure) at 1 year.ResultsThe incidence of adjudicated NSTEMI was 10.7%, and 1-year mortality was 6.3%. Independent predictors for all-cause death at 1 year were Global Registry of Acute Coronary Events (GRACE) >140, age (per decade increase) and high-sensitive cardiac troponin T (hs-cTnT) >50 ng/L. hs-cTnT >50 ng/L was associated with adjudicated index presentation NSTEMI in the greatest proportion of patients (61.7%). When using MACE at 12 months, as opposed to all-cause death, as an end point History, ECG, Age, Risk factors and Troponin (HEART) score ≥7 was included in the multivariate model and had better prediction of index NSTEMI than GRACE>140. Combining hs-cTnT >50 ng/L and a second independent predictor identified both a high proportion of index NSTEMI and elevated risk of all-cause death at 1 year.Conclusionshs-cTnT >50 ng/L or HEART score ≥7 appear effective strategies to identify high-risk NSTEMI at presentation to emergency room with chest pain. Multicentre prospective studies enriched with early presenters, and with competitor high-sensitive and point-of-care troponins, are required to validate and extend these findings.Trial registration numberNCT02581540.

A Case Report of 80-Year-Old Male with Total Atrioventricular Block, Acute Decompensated Heart Failure, and Non-ST-Elevation Myocardial Infarction Very High Risk: A Complicated Case in Limited Resources Setting

“…18 The patient in this case was treated with diuretics in the form of Furosemide Unstable angina and NSTEMI differ primarily in the presence or absence of detectable troponin leaks. 19,20 Our patient experienced disease progression during treatment. On the third day, he experienced chest pain and an increase in Troponin T. In addition, the patient experienced hemodynamic instability accompanied by persistent bradyarrhythmia.…”

“…Other strategies may include enoxaparin, bivalirudin, fondaparinux, and dual antiplatelet therapy. 19,20 Our patient was initially treated with a Norepinephrine drip with a starting dose of 0.1 mcg/BW/minute, Acetylsalicylic Acid 80 mg, Clopidogrel 75 mg, Lovenox 0.4 cc subcutaneous. The patient was then referred for further treatment to a tertiary hospital.…”

Troponin Testing in the Emergency Department—When 2 Become 1

“…7 There are other data to suggest that the HEART score combined with an hs-cTn measurement can achieve a high negative predictive value (NPV) for MACE. Khand et al 8 studied 1642 patients with a modified HEART score based on a single hs-cTn T measurement on arrival at the ED. They identified 48.4% of patients as low risk for a MACE, with an NPV of 99.9%, concluding that a modified HEART score of 3 or less, with the use of a single hs-cTn T measurement (Elecsys [Roche]), appeared to be the optimum early discharge strategy for suspected ACS.…”

“…They identified 48.4% of patients as low risk for a MACE, with an NPV of 99.9%, concluding that a modified HEART score of 3 or less, with the use of a single hs-cTn T measurement (Elecsys [Roche]), appeared to be the optimum early discharge strategy for suspected ACS. 8 In the United States, where Wassie et al 5 performed their study, hs-cTn is not yet commonly used. Also, there is significant physician variability in practice and considerable concern regarding the legal implications of a failed diagnosis, with missed myocardial infarction remaining the top reason for medical malpractice actions.…”