Clinical outcomes for chest pain patients discharged home from emergency departments using high-sensitivity versus conventional cardiac troponin assays

Abstract BACKGROUND Guidelines for diagnosing acute myocardial infarction (AMI) recommend adding kinetic changes to the initial cardiac troponin (cTn) blood concentration to improve AMI diagnosis. We hypothesized that kinetic changes may not be required in patients presenting with highly abnormal cTn. METHODS Patients presenting with suspected AMI to the emergency department were enrolled in a prospective diagnostic study. We assessed the positive predictive value (PPV) of initial high-sensitivity cardiac troponin T (hs-cTnT) blood concentrations alone and in combination with kinetic changes for AMI. Predefined relative changes (δ change of ≥20%) and absolute changes (Δ change ≥9.2 ng/L) within different time intervals (1 h, 2 h, and 4–14 h after presentation) were assessed. The final diagnosis was adjudicated by 2 independent cardiologists. RESULTS Among 1282 patients, 213 (16.6%) patients had a final diagnosis of AMI. For AMI prediction, PPVs increased from 48.8% for an initial hs-cTnT >14 ng/L to 87.2% for >60 ng/L, whereas PPVs remained unchanged for higher hs-cTnT concentrations at baseline (87.1% for both >80 ng/L and >100 ng/L). With addition of 20% relative Δ change, PPVs were not further improved in patients with baseline hs-cTnT >80 ng/L using the 1-h (84.0%) and 2-h (88.9%) intervals, and only minimally when extending the interval to 4–14 h (91.2% for >80 ng/L and 90.4% for >100 ng/L, respectively). Similar findings were observed when applying absolute changes. CONCLUSIONS In chest pain patients with highly abnormal hs-cTnT concentrations at presentation, subsequent blood draws may not be required, as they do not provide incremental diagnostic value for prediction of AMI diagnosis.

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Accelerated diagnostic protocol using high-sensitivity cardiac troponin T in acute chest pain patients

European Heart Journal ◽

10.1093/eurheartj/eht307.21 ◽

2013 ◽

Vol 34 (suppl 1) ◽

pp. 21-21

Author(s):

B. Meller ◽

L. Cullen ◽

W. A. Parsonage ◽

J. Greenslade ◽

S. Aldous ◽

...

Keyword(s):

Chest Pain ◽

Cardiac Troponin ◽

Troponin T ◽

Acute Chest Pain ◽

High Sensitivity ◽

Cardiac Troponin T ◽

Diagnostic Protocol ◽

Pain Patients

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Accelerated diagnostic protocol using high-sensitivity cardiac troponin T in acute chest pain patients

International Journal of Cardiology ◽

10.1016/j.ijcard.2015.02.006 ◽

2015 ◽

Vol 184 ◽

pp. 208-215 ◽

Cited By ~ 36

Author(s):

Bernadette Meller ◽

Louise Cullen ◽

William A. Parsonage ◽

Jaimi H. Greenslade ◽

Sally Aldous ◽

...

Keyword(s):

Chest Pain ◽

Cardiac Troponin ◽

Troponin T ◽

Acute Chest Pain ◽

High Sensitivity ◽

Cardiac Troponin T ◽

Diagnostic Protocol ◽

Pain Patients

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LO01: Development and validation of an adjustment score for ruling out MI using a single high-sensitivity cardiac troponin T assay in patients with chest pain and kidney dysfunction

CJEM ◽

10.1017/cem.2019.44 ◽

2019 ◽

Vol 21 (S1) ◽

pp. S6-S7

Author(s):

A. McRae ◽

S. Vatanpour ◽

J. Ma ◽

E. Lang ◽

J. Andruchow ◽

...

Keyword(s):

Chest Pain ◽

Cardiac Troponin ◽

Validation Cohort ◽

Troponin T ◽

High Sensitivity ◽

Study Cohort ◽

Kidney Dysfunction ◽

Derivation Cohort ◽

Pain Patients ◽

Rule Out

Introduction: Very low concentrations of high-sensitivity cardiac troponin can rule-out myocardial infarction (MI) at ED arrival in patients with chest pain. However, this single troponin rule-out strategy works poorly in patients with renal impairment and elevated baseline troponin levels. The objective of this study was to develop and validate a troponin adjustment strategy to accurately rule-out MI with a single hs-cTnTmeasurement in patients with kidney dysfunction. Methods: We used data from three cohorts of ED chest pain patients to develop an adjustment score for a high-sensitivity troponin T (hs-cTnT) assay in patients with kidney dysfunction. The derivation cohort (n = 8846) used administrative and registry data. Two validation cohorts (n = 1187 and 1092) were prospectively-collected. The score assigned points for increasing hs-cTnT levels and subtracted points for lower estimated glomerular filtration rate (eGFR). In the derivation cohort, hs-cTnT concentrations achieving 98.5% sensitivity in of patients with eGFR ≥60, 45-59, 30-44, 15-29 and <15 were assigned ascending positive integer values. Negative integer values were assigned to eGFR values 45-59, 30-44, 15-29 and <15. The scpres for troponin and eGFR were summed for each patient, with scores ranging from −4 to +5. The proportion of patients with 7-day MI ruled out by a score ≤0, sensitivity, NPV, negative likelihood ratio (LR-) and area under the curve (AUC) were quantified in each study cohort. Results: The derivation and validation cohorts had 7-day MI rates of 5.7, 8.6 and 9.1%. In the derivation cohort, a score ≤0 ruled out MI in 35% of patients, with a sensitivity for 7-day MI of 99.5% (95% CI 98-100), NPV of 99.9% (95% CI 98.4-99.9), LR- of 0.02 (95% CI 0.01-0.05) and AUC of 0.88. In the first validation cohort, a score ≤0 ruled out MI in 45% of patients, with a sensitivity for 7-day MI of 97% (95% CI 90-100%), NPV of 99% (95% CI 98-100%), LR- 0.06 (0.02-0.18) and AUC of 0.89. In the second validation cohort, a score ≤0 ruled out MI in 20% of patients, with a sensitivity for 7-day MI of 96% (95% CI 93-99%), NPV of 98% (95% CI 96-100%), LR- of 0.16 (95% CI 0.07-0.39) and AUC of 0.78. Conclusion: We developed and validated a simple scoring system to adjust hs-cTnT concentrations for a patient's kidney function that enables MI to be ruled out in a large proportion of chest pain patients using a single measurement on ED presentation.

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High-Sensitivity Cardiac Troponin-Based Strategies for the Assessment of Chest Pain Patients—A Review of Validation and Clinical Implementation Studies

Clinical Chemistry ◽

10.1373/clinchem.2018.287342 ◽

2018 ◽

Vol 64 (11) ◽

pp. 1572-1585 ◽

Cited By ~ 13

Author(s):

Kai M Eggers ◽

Tomas Jernberg ◽

Lina Ljung ◽

Bertil Lindahl

Keyword(s):

Chest Pain ◽

Cardiac Troponin ◽

High Sensitivity ◽

Clinical Implementation ◽

Early Assessment ◽

User Friendliness ◽

Trade Off ◽

Implementation Studies ◽

Pain Patients ◽

Rule Out

Abstract BACKGROUND The introduction of high-sensitivity cardiac troponin (hs-cTn) assays has improved the early assessment of chest pain patients. A number of hs-cTn-based algorithms and accelerated diagnostic protocols (ADPs) have been developed and tested subsequently. In this review, we summarize the data on the performance and clinical utility of these strategies. CONTENT We reviewed studies investigating the diagnostic and prognostic performance of hs-cTn algorithms [level of detection (LoD) strategy, 0/1-h, 0/2-h, and 0/3-h algorithms) and of hs-cTn-based ADPs, together with the implications of these strategies when implemented as clinical routine. The LoD strategy, when combined with a nonischemic electrocardiogram, is best suited for safe rule-out of myocardial infarction and the identification of patients eligible for early discharge from the emergency department. The 0/1-h algorithms appear to identify most patients as being eligible for rule-out. The hs-cTn-based ADPs mainly focus on prognostic assessment, which is in contrast with the hs-cTn algorithms. They identify smaller proportions of rule-out patients, but there is increasing evidence from prospective studies on their successful clinical implementation. Such information is currently lacking for hs-cTn algorithms. CONCLUSIONS There is a trade-off between safety and efficacy for different hs-cTn-based strategies. This trade-off should be considered for the intended strategy, along with its user-friendliness and evidence from clinical implementation studies. However, several gaps in knowledge remain. At present, we suggest the use of an ADP in conjunction with serial hs-cTn results to optimize the early assessment of chest pain patients.

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