Faculty Opinions recommendation of High-sensitivity troponin T concentrations in acute chest pain patients evaluated with cardiac computed tomography.

Introduction: The HEART score is a validated tool created to risk stratify emergency department (ED) chest pain patients using 5 simple criteria (History, ECG findings, Age, Risk factors, and Troponin). Several studies have demonstrated the superiority of HEART over other well known risk stratification tools in identifying low risk chest pain patients suitable for early discharge. All but one of these studies used conventional troponin assays, and most were conducted in European populations. This study aims to validate the HEART score using a high-sensitivity troponin T assay in a Canadian population. Methods: This prospective cohort study was conducted at a single urban tertiary centre and regional percutaneous coronary intervention site in Calgary, Alberta. Patients were eligible for enrolment if they presented to the ED with chest pain, were age 25-years or older and required biomarker testing to rule out AMI at the discretion of the attending emergency physician. Patients were excluded if they had clear acute ischemic ECG changes, new arrhythmia or renal failure requiring hemodialysis. Clinical data were recorded by the emergency physician at the time of enrolment and outcomes were obtained from administrative data. High-sensitivity troponin-T (Roche Elecsys hs-cTnT) results were obtained in all patients at presentation. The primary outcome was AMI within 30-days of ED visit, the secondary outcome was 30-day major adverse cardiac events (MACE). Results: A total of 984 ED patients with complete HEART scores were enrolled from August 2014 to September 2016. The 30-day incidence of AMI and MACE in the overall population was 3.3% and 20.6%, respectively. HEART scores were predictive of 30-day AMI incidence: low risk (0-3): 0.77% (95%CI 0.0-1.5%), moderate risk (4-6): 4.3% (95%CI 2.3-6.2%) and high risk (7-10): 12.2% (95%CI 5.5-19.0%). HEART scores also predicted 30-day MACE: low risk (0-3): 5.0% (95%CI 3.1-6.9%), moderate risk (4-6): 31.8% (95%CI 27.2-36.4%) and high-risk (7-10): 61.4% (95%CI 51.2-71.5%). More than half of patients, 522 (53.0%) could be identified as low risk based on the HEART score using a single troponin result. Conclusion: Using a single high-sensitivity troponin result collected at ED presentation, the HEART score can rapidly and effectively identify more than half of ED chest pain patients as low risk for 30-day AMI, but is less sensitive for 30-day MACE.

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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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Pragmatic approach to chest pain patients discharged with undetectable high-sensitivity troponin T and normal electrocardiogram: the STABS + CT protocol

Internal Medicine Journal ◽

10.1111/imj.13443 ◽

2017 ◽

Vol 47 (6) ◽

pp. 698-701

Author(s):

Warrick Bishop ◽

Gary Girao

Keyword(s):

Chest Pain ◽

Troponin T ◽

High Sensitivity ◽

Pragmatic Approach ◽

High Sensitivity Troponin ◽

Ct Protocol ◽

High Sensitivity Troponin T ◽

Pain Patients

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Usefulness of High-sensitivity Troponin T for the Evaluation of Patients with Acute Chest Pain and No or Minimal Myocardial Damage

Journal of Emergency Medicine ◽

10.1016/j.jemermed.2012.10.008 ◽

2012 ◽

Vol 43 (6) ◽

pp. 1208

Author(s):

Mariah Bellinger

Keyword(s):

Chest Pain ◽

Troponin T ◽

Acute Chest Pain ◽

Myocardial Damage ◽

High Sensitivity ◽

High Sensitivity Troponin ◽

High Sensitivity Troponin T

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LO57: Very low concentrations of high-sensitivity troponin T at presentation can rapidly exclude acute myocardial infarction in a significant proportion of ED chest pain patients

CJEM ◽

10.1017/cem.2018.119 ◽

2018 ◽

Vol 20 (S1) ◽

pp. S26-S27

Author(s):

J. E. Andruchow ◽

T. S. Boyne ◽

S. Vatanpour ◽

D. Wang ◽

A. D. McRae

Keyword(s):

Myocardial Infarction ◽

Acute Myocardial Infarction ◽

Chest Pain ◽

Emergency Physician ◽

Troponin T ◽

High Sensitivity ◽

High Sensitivity Troponin ◽

Low Concentrations ◽

High Sensitivity Troponin T ◽

Pain Patients

Introduction: Chest pain is one of the most common presenting complaints to emergency departments (EDs) across the world, and the exclusion of acute myocardial infarction (AMI) using troponin testing is central to the care of many of these patients. While testing strategies using conventional troponin assays require repeat testing over many hours to avoid missed diagnoses, high-sensitivity troponin (hs-cTn) assays may be able to exclude AMI in a large proportion of patients with a single result at presentation. This objective of this study is to validate the ability of very low concentrations of hs-cTn at presentation to exclude AMI in ED chest pain patients. Methods: This prospective cohort study was conducted at a single urban tertiary center and regional percutaneous coronary intervention site in Calgary, Alberta. Patients were eligible for enrolment if they presented to the ED with chest pain, were 25-years or older and required biomarker testing to rule out AMI at the discretion of the attending emergency physician. Patients were excluded if they had clear acute ischemic ECG changes, new arrhythmia or renal failure requiring hemodialysis. A high-sensitivity troponin result (Roche Elecsys hs-cTnT) was obtained in all patients at presentation. The primary outcome was AMI on the index visit. Secondary outcomes included 30-day AMI and major adverse cardiac events (MACE - including AMI, revascularization or cardiac death). Electronic medical records were reviewed and telephone follow-up was obtained for all patients at 30-days to ensure relevant events were captured. Two physician adjudication (board-certified emergency physician and cardiologist) was obtained for all outcomes. This study was REB approved. Results: A total of 1,167 patients were enrolled from August 2014 September 2016, of which 191 (16.3%) patients had an initial troponin below the limit of blank (LoB, <3 ng/L) and 416 (32.8%) were below the limit of detection (LoD, <5 ng/L). The sensitivity of a single troponin below the LoB (<3 ng/L) for index AMI was 100% (95% CI 96.2%-100%) and for 30-day AMI was 100% (95% CI 96.4-100%). The sensitivity of a troponin below the LoD (<5 ng/L) for index AMI was 97.9% (95% CI 92.7%-99.8%) and for 30-day AMI was 98.0% (95% CI 93.0-99.8%). Sensitivity for 30-day MACE at both cutoffs was lower: 98.4% (95% CI 94.3-99.8%) for <3 ng/L, and 94.4% (95% CI 88.8-97.7%) for <5 ng/L, respectively; however, negative predictive values remained high at both cutoffs: <3 ng/L, 99.0% (95% CI 96.3-99.9%) and <5 ng/L, 98.3% (95% CI 96.6-99.3%). Conclusion: A high sensitivity troponin T result below the LoB (<3 ng/L) is highly sensitive for excluding AMI and identifies patients at low risk of 30-day MACE. A result below the LoB (<5 ng/L) will identify a larger population of patients as low risk but has a greater risk of missed AMI and MACE.

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