How Safe Is the Outpatient Management of Patients with Acute Chest Pain and Mildly Increased Cardiac Troponin Concentrations?

Abstract BACKGROUND The appropriate management of patients discharged from the emergency department (ED) with increased high-sensitivity cardiac troponin T (hs-cTnT) but normal or borderline-high conventional cardiac troponin concentrations is unknown. METHODS We investigated 643 consecutive ED patients with acute chest pain who had been discharged for outpatient management after acute myocardial infarction (AMI) had been ruled out by serial measurements of conventional cardiac troponin. hs-cTnT was measured blindly, and we calculated the rates of all-cause mortality (primary endpoint) and subsequent AMI (secondary endpoint) at 30, 90, and 360 days. RESULTS hs-cTnT concentrations were increased (>14 ng/L) in 114 patients (18%) but <30 ng/L in 95% of these patients. Of those 114 patients, 96 (84%) had an adjudicated noncoronary cause of chest pain. Thirty-day mortality (95% CI) was 0.9% (0.1%–6.1%), 90-day mortality was 2.7% (0.9%–8.1%), and 360-day mortality was 5.2% (2.2%–11.9%) in patients with increased hs-cTnT; respective rates (95% CI) of AMI were 0.0%, 1.9% (0.5%–7.2%), and 7.6% (3.7%–15.3%). Increased hs-cTnT was associated with increased mortality and AMI at 90 days (P = 0.006 and P = 0.081, respectively) and 360 days (P = 0.001 for both). CONCLUSIONS hs-cTnT is a strong prognosticator of intermediate and long-term mortality and AMI in low-risk patients discharged from the ED after AMI has been ruled out. The relatively low rate of 30-day events may suggest that patients without acute coronary syndrome and small increases in cardiac troponin are in need of further investigations and treatments, but not necessarily immediate hospitalization.

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Incremental Value of High-Sensitivity Cardiac Troponin T for Risk Prediction in Patients with Suspected Acute Myocardial Infarction

Clinical Chemistry ◽

10.1373/clinchem.2011.162073 ◽

2011 ◽

Vol 57 (9) ◽

pp. 1318-1326 ◽

Cited By ~ 35

Author(s):

Willibald Hochholzer ◽

Tobias Reichlin ◽

Raphael Twerenbold ◽

Claudia Stelzig ◽

Kirsten Hochholzer ◽

...

Keyword(s):

Myocardial Infarction ◽

Acute Myocardial Infarction ◽

Chest Pain ◽

Risk Score ◽

Cardiac Troponin ◽

Troponin T ◽

Acute Chest Pain ◽

High Sensitivity ◽

Cardiac Troponin T ◽

Coronary Syndrome

BACKGROUND High-sensitivity cardiac troponin assays have better analytical precision and sensitivity than earlier-generation assays when measuring cardiac troponin at low concentrations. We evaluated whether use of a high-sensitivity assay could further improve risk stratification compared with a standard cardiac troponin assay. METHODS We enrolled consecutive patients presenting with acute chest pain, 30% of whom were diagnosed with acute coronary syndrome. Blood samples were drawn at the time of presentation. We measured cardiac troponin T with a standard fourth-generation assay (cTnT) and a high-sensitivity assay (hs-cTnT) (both Roche Diagnostics) and followed the patients for 24 months. RESULTS Of the 1159 patients, 76 died and 42 developed an acute myocardial infarction (AMI). Prognostic accuracy of hs-cTnT for death was significantly higher [area under ROC curve (AUC) 0.79, 95% CI 0.74–0.84] than that of cTnT (AUC 0.69, 95% CI 0.62–0.76; P < 0.001). After adjustment for Thrombolysis in Myocardial Infarction (TIMI) risk score (that included the cTnT assay result), hs-cTnT above the 99th percentile (0.014 μg/L) was associated with a hazard ratio for death of 2.60 (95% CI 1.42–4.74). Addition of hs-cTnT to the risk score improved the reclassification of patients (net reclassification improvement 0.91; 95% CI 0.67–1.14; P < 0.001). Subgroup analyses showed that this effect resulted from the better classification of patients without AMI at time of testing. hs-cTnT outperformed cTnT in the prediction of AMI during follow-up (P=0.02), but was not independently predictive for this endpoint. CONCLUSIONS Concentrations of hs-cTnT >0.014 μg/L improve the prediction of death but not subsequent AMI in unselected patients presenting with acute chest pain.

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TCT-203 The Role of CT Angiography in a Management Strategy Based on High-Sensitivity Cardiac Troponin-T for Predicting an Early Prognosis in Patients With Acute Chest Pain Admitted to the Emergency Department

Journal of the American College of Cardiology ◽

10.1016/j.jacc.2019.08.264 ◽

2019 ◽

Vol 74 (13) ◽

pp. B202

Author(s):

Jae Gyung Kim ◽

Eun Ho Choo

Keyword(s):

Emergency Department ◽

Chest Pain ◽

Ct Angiography ◽

Cardiac Troponin ◽

Management Strategy ◽

Troponin T ◽

Acute Chest Pain ◽

High Sensitivity ◽

Cardiac Troponin T

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Copeptin Does Not Add Diagnostic Information to High-Sensitivity Troponin T in Low- to Intermediate-Risk Patients with Acute Chest Pain: Results from the Rule Out Myocardial Infarction by Computed Tomography (ROMICAT) Study

Clinical Chemistry ◽

10.1373/clinchem.2010.160192 ◽

2011 ◽

Vol 57 (8) ◽

pp. 1137-1145 ◽

Cited By ~ 39

Author(s):

Mahir Karakas ◽

James L Januzzi ◽

Julia Meyer ◽

Hang Lee ◽

Christopher L Schlett ◽

...

Keyword(s):

Computed Tomography ◽

Chest Pain ◽

Predictive Value ◽

Troponin T ◽

Cardiac Computed Tomography ◽

Acute Chest Pain ◽

High Sensitivity ◽

Left Ventricular ◽

Intermediate Risk ◽

Coronary Syndrome

PURPOSE Copeptin, a stable peptide derived from the AVP precursor, has been linked to presence and severity of myocardial ischemia. We sought to evaluate the predictive value of copeptin and its incremental value beyond that of high-sensitivity cardiac troponin T (hs-cTnT) in patients with acute chest pain and low to intermediate risk for acute coronary syndrome (ACS). METHODS We recruited patients who presented with acute chest pain to the emergency department and had a negative initial conventional troponin T test (<0.03 μg/L). In all patients, hs-cTnT and copeptin measurements were taken. Each patient also underwent cardiac computed tomography (CT) and coronary angiography. RESULTS Baseline copeptin concentrations, in contrast to hs-cTnT, were not significantly higher in patients with ACS than in those without (P = 0.24). hs-cTnT showed an earlier rise in patients with ACS than copeptin, when analyses were stratified by time. A copeptin concentration ≥7.38 pmol/L had a negative predictive value (NPV) of 94% and a sensitivity of 51%, whereas hs-cTnT (≥13.0 pg/mL) had a NPV of 96% and a sensitivity of 63%. The combination of copeptin and hs-cTnT resulted in a lower diagnostic accuracy than hs-cTnT alone. Finally, on cardiac CT, copeptin concentrations were not associated with coronary artery morphology, although they were related to the presence of left ventricular dysfunction (P = 0.02). CONCLUSIONS Among patients with acute chest pain and low to intermediate risk for ACS, copeptin concentrations are not independently predictive of ACS and do not add diagnostic value beyond that of hs-cTnT measurements.

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Impact of Leading Presenting Symptoms on the Diagnostic Performance of High-Sensitivity Cardiac Troponin T and on Outcomes in Patients with Suspected Acute Coronary Syndrome

Clinical Chemistry ◽

10.1373/clinchem.2014.235317 ◽

2015 ◽

Vol 61 (5) ◽

pp. 744-751 ◽

Cited By ~ 4

Author(s):

Moritz Biener ◽

Matthias Mueller ◽

Mehrshad Vafaie ◽

Hugo A Katus ◽

Evangelos Giannitsis

Keyword(s):

Chest Pain ◽

Cardiac Troponin ◽

Diagnostic Performance ◽

Troponin T ◽

High Sensitivity ◽

Cardiac Troponin T ◽

Atypical Symptoms ◽

Presenting Symptoms ◽

Coronary Syndrome ◽

Typical Chest Pain

Abstract BACKGROUND Diagnostic performance of high-sensitivity cardiac troponin T (hs-cTnT) varies depending on presenting symptoms in patients with suspected acute coronary syndrome (ACS). METHODS We compared performance measures of hs-cTnT among patients admitted to the emergency department with typical chest pain (angina), dyspnea, and atypical symptoms and assessed outcomes by leading presenting symptoms. RESULTS A total of 658 patients suspected of ACS and presenting with typical chest pain (n = 241, 36.6%), dyspnea (n = 142, 21.6%), or atypical symptoms (n = 275, 41.8%) were included. Diagnostic accuracy of hs-cTnT on admission was higher among patients with typical chest pain compared to those with atypical symptoms [area under the curve (AUC) 0.823 vs AUC 0.776 vs AUC 0.705, P > 0.05 and P = 0.04]. Absolute concentration changes within 6 h improved accuracy among all subgroups, with the smallest added benefit in typical chest pain and dyspnea (ΔAUC, 0.078; P = 0.02 and 0.05, P > 0.05). During 1-year follow-up, dyspnea was associated with a higher risk of death (hazard ratio, 2.36; 95% CI, 1.26–4.43, P = 0.008) and death/AMI (hazard ratio, 2.23; 95% CI, 1.21–4.11, P = 0.01) compared to typical chest pain. Optimal discriminating values for hs-cTnT were higher among patients presenting with dyspnea compared to those with typical chest pain (91.2 vs 14.1 ng/L, P < 0.001). CONCLUSION The diagnostic performance of hs-cTnT in patients with suspected ACS depends on the leading presenting symptom. Patients admitted with dyspnea represent a high-risk cohort in which the diagnosis of ACS is less frequent and with inferior performance of serial hs-cTnT measurements. Higher hs-cTnT cutoffs at baseline and absolute changes after 6 h help to identify non-STEMI (ST segment elevation myocardial infarction) in this population.

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3298Prehospital assessment of the one-hour rule-in/rule-out algorithm using a high-sensitivity cardiac troponin t assay in a low-prevalence population for acute coronary syndrome (OUT-ACS)

European Heart Journal ◽

10.1093/eurheartj/ehz745.0062 ◽

2019 ◽

Vol 40 (Supplement_1) ◽

Author(s):

T R Johannessen ◽

D Atar ◽

S Halvorsen ◽

A C Larstorp ◽

I Mdala ◽

...

Keyword(s):

Primary Care ◽

Chest Pain ◽

Predictive Value ◽

Cardiac Troponin ◽

Troponin T ◽

High Sensitivity ◽

Cardiac Troponin T ◽

Emergency Setting ◽

Coronary Syndrome ◽

Rule Out

Abstract Background The majority of patients with chest pain in Norway initially present to the primary health care system, which serves to triage them to the specialist health care services including hospitals. In some emergency primary care institutions, patients who are not hospitalised directly undergo further diagnostic testing to rule out acute myocardial infarction (AMI). Purpose Several studies have shown the advantage of using high-sensitivity assays for fast interpretation of cardiac troponins. The majority of these studies included patient populations from hospital emergency departments. In contrast, we aimed to investigate whether the 1-hour algorithm for high-sensitivity cardiac troponin T (hs-cTnT) is safe and useful for implementation in a primary care emergency setting where the patients have a much lower pre-test probability for an acute coronary syndrome. Methods In this prospective cohort study, we included 1672 patients with acute non-specific chest pain from November 2016 to October 2018 at a primary care emergency outpatient clinic in Norway. Serial hs-cTnT samples were analysed after 0, 1 and 4 hours on the Cobas 8000 e602 analyzer. We divided the results into one of three groups (rule-out, rule-in, or further observation), according to the 0/1-hour algorithm for hs-cTn from the current ESC guidelines on non-ST-elevation myocardial infarction. In the rule-out group, the 0/1-hour results were compared to the standard 4-hour hs-cTnT. Final hospital diagnoses were collected as a gold standard for the patients in the rule-in group. Results A total of 44 (2.6%) of 1672 patients were diagnosed with AMI. By applying the algorithm, 1274 (76.2%) patients were assigned to the rule-out group. One of the rule-out patients had a significant increase in hs-cTnT in the 4-hour sample. This results in a sensitivity for AMI of 97.7% (95% confidence interval [CI] 88.0–99.9) and negative predictive value of 99.9% (95% CI 99.6–100.0). There were 50 (3.0%) patients in the rule-in group, amongst whom 35 had a verified AMI. This gives a specificity for AMI of 99.1% (95% CI 98.5–99.5) and a positive predictive value at 70.0% (95% CI 55.4–82.1). Among the 348 (20.8%) patients assigned to further observation, eight patients had an AMI. The 15 rule-in patients who did not have an AMI, had other acute illnesses that required further diagnostic work-up at the hospital. Conclusions With a negative predictive value at 99.9%, the 1-hour algorithm for hs-cTnT seems safe and applicable for a faster assessment of patients with non-specific chest pain in a primary care emergency setting. Prehospital implementation of this algorithm may reduce the need for hospitalisation of these patients and hence may probably lower the costs. ClinicalTrial.gov identifier: NCT02983123 Acknowledgement/Funding Norwegian Research Fund for General Practice, The Norwegian Physicians' Association Fund for Quality Improvement and Patient Safety

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Copeptin as a Prognostic Marker in Acute Chest Pain and Suspected Acute Coronary Syndrome

Disease Markers ◽

10.1155/2018/6597387 ◽

2018 ◽

Vol 2018 ◽

pp. 1-8 ◽

Cited By ~ 5

Author(s):

Beata Morawiec ◽

Damian Kawecki ◽

Brygida Przywara-Chowaniec ◽

Mariusz Opara ◽

Piotr Muzyk ◽

...

Keyword(s):

Acute Coronary Syndrome ◽

Chest Pain ◽

Troponin T ◽

Strong Predictor ◽

Acute Chest Pain ◽

Coronary Syndrome ◽

Cerebrovascular Events ◽

Registration Number ◽

Cox Analysis

Background. In patients admitted with chest pain and suspected acute coronary syndrome (ACS), it is crucial to early identify those who are at higher risk of adverse events. The study aim was to assess the predictive value of copeptin in patients admitted to the emergency department with chest pain and nonconclusive ECG. Methods. Consecutive patients suspected for an ACS were enrolled prospectively. Copeptin and high-sensitive troponin T (hs-TnT) were measured at admission. Patients were followed up at six and 12 months for the occurrence of death and major adverse cardiac and cerebrovascular events (MACCE). Results. Among 154 patients, 11 patients died and 26 experienced MACCE. Mortality was higher in copeptin-positive than copeptin-negative patients with no difference in the rate of MACCE. Copeptin reached the AUC 0.86 (0.75–0.97) for prognosis of mortality at six and 0.77 (0.65–0.88) at 12 months. It was higher than for hs-TnT and their combination at both time points. Copeptin was a strong predictor of mortality in the Cox analysis (HR14.1 at six and HR4.3 at 12 months). Conclusions. Copeptin appears to be an independent predictor of long-term mortality in a selected population of patients suspected for an ACS. The study registration number is ISRCTN14112941.

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Biomarkers-in-Cardiology 8 RE-VISITED—Consistent Safety of Early Discharge with a Dual Marker Strategy Combining a Normal hs-cTnT with a Normal Copeptin in Low-to-Intermediate Risk Patients with Suspected Acute Coronary Syndrome—A Secondary Analysis of the Randomized Biomarkers-in-Cardiology 8 Trial

Cells ◽

10.3390/cells11020211 ◽

2022 ◽

Vol 11 (2) ◽

pp. 211

Author(s):

Evangelos Giannitsis ◽

Tania Garfias-Veitl ◽

Anna Slagman ◽

Julia Searle ◽

Christian Müller ◽

...

Keyword(s):

Acute Coronary Syndrome ◽

Cardiac Troponin ◽

Troponin T ◽

High Sensitivity ◽

Early Discharge ◽

Cardiac Troponin T ◽

Cardiac Events ◽

Coronary Syndrome ◽

Adverse Cardiac Events ◽

Risk Patients

Regarding the management of suspected Non-ST-segment-elevation acute coronary syndrome (ACS), the main Biomarker-in-Cardiology (BIC)-8 randomized controlled trial study had reported non-inferiority for the incidence of major adverse cardiac events at 30 days in the Copeptin group (dual marker strategy of copeptin and hs-cTnT at presentation) compared to the standard process (serial hs-cTnT testing). However, in 349 (38.7%) of the 902 patients, high-sensitivity cardiac troponin was not available for the treating physicians. High sensitivity cardiac troponin T was re-measured from thawed blood samples collected at baseline. This cohort qualified for a re-analysis of the 30-day incidence rate of MACE (death, survived cardiac death, acute myocardial infarction, re-hospitalization for acute coronary syndrome, acute unplanned percutaneous coronary intervention, coronary bypass grafting, or documented life-threatening arrhythmias), or components of the primary endpoint including death or death/MI. After re-measurement of troponin and exclusion of 9 patients with insufficient blood sample volume, 893 patients qualified for re-analysis. A total of 57 cases were detected with high sensitivity cardiac troponin T ≥ 14 ng/L who had been classified as “troponin negative” based on a conventional cardiac troponin T or I < 99th percentile upper limit of normal. Major adverse cardiac events rates after exclusion were non-inferior in the Copeptin group compared to the standard group (4.34% (95% confidence intervals 2.60–6.78%) vs. 4.27% (2.55–6.66%)). Rates were 53% lower in the per-protocol analysis (HR 0.47, 95% CI: 0.18–1.15, p = 0.09). No deaths occurred within 30 days in the discharged low risk patients of the Copeptin group. Copeptin combined with high sensitivity cardiac troponin is useful for risk stratification and allows early discharge of low-to-intermediate risk patients with suspected acute coronary syndrome is as safe as a re-testing strategy at 3 h or later.

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