The impact of high-sensitivity troponin implementation on hospital operations and patient outcomes in 3 tertiary care centers

Crowder, K.; Jones, Tristan D.; Lang, Eddy; Wang, Dongmei M.; Clark, Steve; Innes, Grant; McMeekin, James; Graham, Michelle M.; McRae, Andrew

doi:10.1016/j.ajem.2015.08.041

Cited by 19 publications

(14 citation statements)

References 16 publications

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“…This assay has been in use at these sites since February 2012. Per local recommendations, AMI was considered ruled out if a patient's hsTnT concentration was less than 14 ng/L when measured more than 6 hours after onset of the patient's most significant symptoms …”

Section: Methodsmentioning

confidence: 99%

Undetectable Concentrations of a Food and Drug Administration–approved High‐sensitivity Cardiac Troponin T Assay to Rule Out Acute Myocardial Infarction at Emergency Department Arrival

McRae

Innes

Graham

et al. 2017

Academic Emergency Medicine

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BackgroundThe objective of this study was to quantify the sensitivity of very low concentrations of high‐sensitivity cardiac troponin T (hsTnT) at ED arrival for acute myocardial infarction (AMI) in a large cohort of chest pain patients evaluated in real‐world clinical practice.MethodsThis retrospective study included consecutive ED patients with suspected cardiac chest pain evaluated in four urban EDs, excluding those with ST‐elevation AMI, cardiac arrest or abnormal kidney function. The primary outcomes were AMI at 7, 30, and 90 days. Secondary outcomes included major adverse cardiac events (MACE; all‐cause mortality, AMI, and revascularization) and the individual MACE components. Test characteristics were calculated for hsTnT values from 3 to 200 ng/L .ResultsA total of 7,130 patients met inclusion criteria. AMI incidences at 7, 30, and 90 days were 5.8, 6.0, and 6.2%. When the hsTnT assay was performed at ED arrival, the limit of blank of the assay (3 ng/L) ruled out 7‐day AMI in 15.5% of patients with 100% sensitivity and negative predictive value (NPV). The limit of detection of the assay (5 ng/L) ruled out AMI in 33.6% of patients with 99.8% sensitivity and 99.95% NPV for 7‐day AMI. The limit of quantification (the Food and Drug Administration [FDA]‐approved cutoff for lower the reportable limit) of 6 ng/L ruled out AMI in 42.2% of patients with 99.8% sensitivity and 99.95% NPV. The sensitivities of the cutoffs of <3, <5, and <6 ng/L for 7‐day MACE were 99.6, 97.4, and 96.6%, respectively. The NPVs of the cutoffs of <3, <5, and <6 ng/L for 7‐day MACE were 99.8, 99.5, and 99.4%, respectively. A secondary analysis was performed in a subgroup of 3,549 higher‐risk patients who underwent serial troponin testing. In this subgroup, a cutoff of 3 ng/L ruled out 7‐day AMI in 9.6% of patients with 100% sensitivity and NPV, a cutoff of 5 ng/L ruled out 7‐day AMI in 23.3% of patients with 99.7% sensitivity and 99.9% NPV, and a cutoff of 6 ng/L ruled out 7‐day AMI in 29.8% of patients with 99.7 and 99.9% NPV. In the higher‐risk subgroup, the sensitivities of cutoffs of <3, <5, and <6 ng/L for 7‐day MACE were 99.8, 97.4, and 96.6%, respectively. In this higher‐risk subgroup, the NPV of cutoffs of <3, <5, and <6 ng/L for 7‐day MACE were 99.7, 98.5, and 98.4%, respectively.ConclusionsWhen used in real‐world clinical practice conditions, hsTnT concentrations < 6 ng/L (below the lower reportable limit for an FDA‐approved assay) at the time of ED arrival can rule out AMI with very high sensitivity and NPV. The sensitivity for MACE is unacceptably low, and thus a single‐troponin rule‐out strategy should only be used in the context of a structured risk evaluation.

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Section: Methodsmentioning

confidence: 99%

Undetectable Concentrations of a Food and Drug Administration–approved High‐sensitivity Cardiac Troponin T Assay to Rule Out Acute Myocardial Infarction at Emergency Department Arrival

McRae

Innes

Graham

et al. 2017

Academic Emergency Medicine

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“…While concerns have been raised that hs-cTn implementation in the US will lead to increased admissions and cardiac evaluations, [48][49][50][51] our data align with international and early US data showing no change in admissions or cardiac evaluations in the period shortly after hs-cTnT implementation. 5,34,[52][53][54] The overall low rate of cardiac stress testing and catheterization in our study suggests that physicians are not reflexively performing these tests and procedures for all patients with suspected ACS or all patients with myocardial injury. The prognostic ability of a hs-cTnT result below the limit of quantification (<6 ng/L in the US) combined with a non-ischemic electrocardiogram to indicate low probability of 30-day MI or death may reduce cardiac stress testing for further risk stratification in patients meeting these criteria.…”

Section: Discussionmentioning

confidence: 81%

Diagnostic Reclassification by a High-Sensitivity Cardiac Troponin Assay

Mumma

Casey

Dang

et al. 2020

Annals of Emergency Medicine

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“…Local practice recommendations considered MI ruled out if a patient's hs-cTnT concentration was less than 14 ng/L when measured more than 6 hours after onset of the patient's most significant symptoms. 12…”

Section: Settingmentioning

confidence: 99%

Sex-specific, high-sensitivity cardiac troponin T cut-off concentrations for ruling out acute myocardial infarction with a single measurement

McRae

Graham

Abedin

et al. 2018

CJEM

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ObjectiveSex-specific diagnostic cut-offs may improve the test characteristics of high-sensitivity troponin assays for the diagnosis of myocardial infarction (MI). The objective of this study was to quantify test characteristics of sex-specific cut-offs of a single, high-sensitivity cardiac troponin T (hs-cTnT) assay for 7-day MI in patients with chest pain.MethodsThis observational cohort study included consecutive emergency department (ED) patients with suspected cardiac chest pain from four Canadian EDs who had an hs-cTnT assay performed within 60 minutes of ED arrival. The primary outcome was MI at 7 days. We quantified test characteristics (sensitivity, negative predictive value [NPV], likelihood ratios and proportion of patients ruled out) for multiple combinations of sex-specific, rule-out cut-offs. We calculated the net reclassification index compared to universal rule-out cut-offs.ResultsIn 7,130 patients (3,931 men and 3,199 women), the 7-day MI incidence was 7.38% among men and 3.78% among women. Optimal sex-specific cut-offs (<8 ng/L for men and <7 ng/L for women) had a 98.5% sensitivity for MI and ruled out MI in 55.8% of patients. This would enable an absolute increase in the proportion of patients who were able to be ruled out with a single hs-cTnT of 13.2% to 22.2%, depending on the universal rule-out concentration used as a comparator.ConclusionsSex-specific hs-cTnT cut-offs for ruling out MI at ED arrival may improve classification performance, enabling more patients to be safely ruled out at ED arrival. However, differences between sex-specific and universal cut-off concentrations are within the variation of the assay, limiting the clinical utility of this approach. These findings should be confirmed in other data sets.

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The impact of high-sensitivity troponin implementation on hospital operations and patient outcomes in 3 tertiary care centers

Cited by 19 publications

References 16 publications

Undetectable Concentrations of a Food and Drug Administration–approved High‐sensitivity Cardiac Troponin T Assay to Rule Out Acute Myocardial Infarction at Emergency Department Arrival

Undetectable Concentrations of a Food and Drug Administration–approved High‐sensitivity Cardiac Troponin T Assay to Rule Out Acute Myocardial Infarction at Emergency Department Arrival

Diagnostic Reclassification by a High-Sensitivity Cardiac Troponin Assay

Sex-specific, high-sensitivity cardiac troponin T cut-off concentrations for ruling out acute myocardial infarction with a single measurement

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