Low High-Sensitivity Troponin Thresholds Identify Low-Risk Patients With Chest Pain Unlikely to Benefit From Further Risk Stratification

Andruchow, J.; Boyne, Timothy; Innes, Grant; Vatanpour, Shabnam; Seiden‐Long, Isolde; Wang, Dongmei; Lang, Eddy; McRae, Andrew

doi:10.1016/j.cjco.2019.08.002

Cited by 7 publications

(7 citation statements)

References 33 publications

(33 reference statements)

Supporting

Mentioning

Contrasting

Order By: Relevance

“…Very low levels of hsTnT are associated with reduced occurrence of 30-day MACE in patients presenting to the ED with chest pain. In one center, for patients presenting with chest pain and non-ischaemic ECG changes, a cut-off of hsTnT<5 ng/L taken at least 3 h from symptoms onset was able to rule out 30-day MACE (defined as AMI, revascularization, or cardiac death) (NPV 99.0%) [24] . Another study used a cut-off of 0- and 3-hour hsTnT ≤ 19 ng/L for 30-day MACE (NPV 99.3%), and found that lowering the cut-off to 6 ng/L did not increase the NPV [25] .…”

Section: Discussionmentioning

confidence: 99%

Comparing conventional and high sensitivity troponin T measurements in identifying adverse cardiac events in patients admitted to an Asian emergency department chest pain observation unit

Lin

Lim

Yap

et al. 2021

IJC Heart & Vasculature

View full text Add to dashboard Cite

Background High sensitive cardiac troponin assays can be used for prediction of major adverse cardiac events (MACE) in patients with chest pain. Methods We included patients with symptoms suggestive of acute coronary syndrome in the emergency department observation unit. We compared the accuracy of conventional troponin T (cTnT) with high sensitive troponin T (hsTnT) at various ranges, as well as the utility of hsTnT and cTnT in prediction of 30-day and 1-year MACE. Results 1023 patients were included (68.1% male, median age 56 years). There were 2712 hsTnT and cTnT values compared. hsTnT had a higher AUC than cTnT for 30-day and 1-year MACE. The optimal cut-off of 0-hour hsTnT for 30-day (PPV 34%, NPV 96.6%) and 1-year MACE (PPV 40.2%, NPV 94.2%) was 16 ng/L. For 844 patients who had values for both 0 and 2 h hsTnT, we proposed a rule-out cut-off of 0 and 2 h hsTnT < 16 ng/L (NPV 97.0%, 95%CI 95.5–98.1%) and a rule-in cut-off of 0 and 2 h hsTnT ≥ 26 ng/L (PPV 58.8%, 95%CI 40.7%-75.4%) for 30-day MACE. Negative 0–2 h delta-hsTnT had poor predictive discriminant capabilities on 30-day (PPV 8.2%) and 1-year MACE (PPV 12.3%). Conclusion The cut off values of hsTnT used in the 0 and 2-hour algorithm to rule-out (16 ng/L) and rule-in MACE (26 ng/L) are in the range that previous cTnT assays are unable to measure accurately. Risk scores can be used to further improve NPV of the rule-out group. A fall in hsTnT level acutely is not predictive of MACE.

show abstract

Section: Discussionmentioning

confidence: 99%

Comparing conventional and high sensitivity troponin T measurements in identifying adverse cardiac events in patients admitted to an Asian emergency department chest pain observation unit

Lin

Lim

Yap

et al. 2021

IJC Heart & Vasculature

View full text Add to dashboard Cite

show abstract

Section: Methodsmentioning

confidence: 99%

“…This study is a secondary analysis of data from a completed prospective cohort study that validated rapid diagnostic algorithms for myocardial infarction using high-sensitivity cardiac troponin-T [15,16] at a large urban level one trauma and regional percutaneous coronary intervention centre in Calgary, AB from August 2014 to September 2016. The detailed methods of the parent study are described elsewhere [15,16]. In brief, trained research assistants approached patients' attending ED physicians who prospectively collected clinical variables including symptoms, cardiovascular risk factors, medical history, physicians' assessment of the probability of acute coronary syndromes (low, moderate, high risk) and HEART score.…”

Section: Methodsmentioning

confidence: 99%

External validation of a low HEAR score to identify emergency department chest pain patients at very low risk of major adverse cardiac events without troponin testing

2021

Self Cite

View full text Add to dashboard Cite

Background The history, ECG, age, risk factor (HEAR) score has been proposed to identify patients at sufficiently low risk of acute coronary syndrome that they may not require troponin testing. The objective of this study was to externally validate a low HEAR score to identify emergency department (ED) patients with chest pain at very low risk of 30-day major adverse cardiac events (MACE). Methods This was a secondary analysis of a prospective cohort of patients requiring troponin testing to rule out myocardial infarction (MI) in a large urban ED. HEAR scores were calculated in two cohorts: (1) patients with no known history of coronary artery disease (CAD); and (2) all eligible patients. The proportion of patients classified as very low risk, sensitivity, specificity, predictive values and likelihood ratios at each cut-off were quantified for index acute myocardial infarction (AMI) and 30-day MACE at HEAR = 0 and HEAR ≤ 1 thresholds. Results Of the 1150 patients included in this study, 820 (71.3%) had no history of CAD, 97 (8.4%) had index AMI and 123 (10.7%) had 30-day MACE. In patients with no prior history of CAD, HEAR ≤ 1 identified 202 (24.6%) of patients as very low risk for 30-day MACE with 98.4% (95% CI 91.6-99.9%) sensitivity. Among all patients, HEAR ≤ 1 identified 202 (17.6%) patients as very low risk for 30-day MACE with 99.2% (95% CI 95.6-99.9%) sensitivity. Conclusions A HEAR score ≤ 1 can identify more than 17% of all patients as very low risk for index AMI and 30-day MACE and unlikely to benefit from troponin testing. Broad implementation of this strategy could lead to significant resource savings. Keywords HEAR score • Chest pain • Risk stratification RésuméContexte Le score HEAR (History, ECG, Age, Risk Factor) a été proposé pour identifier les patients présentant un risque suffisamment faible de syndrome coronarien aigu pour ne pas nécessiter de test à la troponine. L'objectif de cette étude était de valider à l'externe un faible score HEAR afin d'identifier les patients du service d'urgence (DE) souffrant de douleurs thoraciques à très faible risque d'événements cardiaques indésirables majeurs (MACE) de 30 jours. Méthodes Il s'agissait d'une analyse secondaire d'une cohorte prospective de patients nécessitant un test à la troponine pour exclure un infarctus du myocarde (IM) dans un grand service d'urgence urbain. Les scores HEAR ont été calculés dans deux cohortes : (1) les patients sans antécédents connus de maladie coronarienne (MC) ; et (2) tous les patients éligibles. La proportion de patients classés à très faible risque, la sensibilité, la spécificité, les valeurs prédictives et les rapports de vraisemblance à chaque seuil ont été quantifiés pour l'infarctus aigu du myocarde (IAM) de l'index et la MACE à 30 jours aux seuils HEAR = 0 et HEAR ≤ 1.

show abstract

“…A total of 1,167 eligible patients with at least one hs-cTnT sample collected were enrolled as part of a related study examining hs-cTnT concentrations on presentation (0-hour), which has been published separately. 3 Of these, 559 patients were excluded because they did not require serial troponin sampling to rule out MI in the opinion of the attending emergency physician (usually because of prolonged and/or atypical symptoms), leaving 608 patients eligible for this study. The final data set included 350 patients with valid 1-hour and 550 patients with valid 2-hour hs-cTnT samples (Figure 2).…”

Section: Resultsmentioning

confidence: 99%

“…1 Research has demonstrated that very low concentrations of high-sensitivity cardiac troponin (hs-cTn) sampled on ED arrival, especially in combination with a non-ischemic electrocardiogram (ECG), are highly sensitive for index myocardial infarction (MI). 2,3 However, guidelines recommend a single hs-cTn testing strategy only for patients with at least 3-hours since symptom onset given the risk of falsenegative results in early presenters. 4 Because the majority of patients will not meet these stringent criteria, serial hs-cTn sampling is recommended for most patients.…”

Section: Introductionmentioning

confidence: 99%

Prospective comparative evaluation of the European Society of Cardiology (ESC) 1-hour and a 2-hour rapid diagnostic algorithm for myocardial infarction using high-sensitivity troponin-T

Andruchow¹,

Boyne

Seiden‐Long³

et al. 2020

CJEM

Self Cite

View full text Add to dashboard Cite

ABSTRACT Objective Both 1- and 2-hour rapid diagnostic algorithms using high-sensitivity troponin (hs-cTn) have been validated to diagnose acute myocardial infarction (MI), leaving physicians uncertain which algorithm is preferable. The objective of this study was to prospectively evaluate the diagnostic performance of 1- and 2-hour algorithms in clinical practice in a Canadian emergency department (ED). Methods ED patients with chest pain had high-sensitivity cardiac troponin-T (hs-cTnT) collected on presentation and 1- and 2-hours later at a single academic centre over a 2-year period. The primary outcome was index MI, and the secondary outcome was 30-day major adverse cardiac events (MACE). All outcomes were adjudicated. Results We enrolled 608 patients undergoing serial hs-cTnT sampling. Of these, 350 had a valid 1-hour and 550 had a 2-hour hs-cTnT sample. Index MI and 30-day MACE prevalence was ~12% and 14%. Sensitivity of the 1- and 2-hour algorithms was similar for index MI 97.3% (95% CI: 85.8–99.9%) and 100% (95% CI: 91.6–100%) and 30-day MACE: 80.9% (95% CI: 66.7–90.9%) and 83.3% (95% CI: 73.2–90.8%), respectively. Both algorithms accurately identified about 10% of patients as high risk. Conclusions Both algorithms were able to classify almost two-thirds of patients as low risk, effectively ruling out MI and conferring a low risk of 30-day MACE for this group, while reliably identifying high-risk patients. While both algorithms had equivalent diagnostic performance, the 2-hour algorithm offers several practical advantages, which may make it preferable to implement. Broad implementation of similar algorithms across Canada can expedite patient disposition and lead to resource savings.

show abstract

Low High-Sensitivity Troponin Thresholds Identify Low-Risk Patients With Chest Pain Unlikely to Benefit From Further Risk Stratification

Cited by 7 publications

References 33 publications

Comparing conventional and high sensitivity troponin T measurements in identifying adverse cardiac events in patients admitted to an Asian emergency department chest pain observation unit

Comparing conventional and high sensitivity troponin T measurements in identifying adverse cardiac events in patients admitted to an Asian emergency department chest pain observation unit

External validation of a low HEAR score to identify emergency department chest pain patients at very low risk of major adverse cardiac events without troponin testing

Prospective comparative evaluation of the European Society of Cardiology (ESC) 1-hour and a 2-hour rapid diagnostic algorithm for myocardial infarction using high-sensitivity troponin-T

Contact Info

Product

Resources

About