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Koirala S, Danley K, Kerolos M, Chu J, Yucebay E, Purim-Shem-Tov Y, Volgman AS, Attanasio S. Effect of transitioning from conventional cardiac troponin to high-sensitivity cardiac troponin on resource utilization- a single center experience. Am J Emerg Med 2024; 80:174-177. [PMID: 38613986 DOI: 10.1016/j.ajem.2024.04.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Revised: 03/09/2024] [Accepted: 04/06/2024] [Indexed: 04/15/2024] Open
Abstract
BACKGROUND Compared to conventional cardiac troponin (cTn), the high-sensitivity cardiac troponin (hs-cTn) assay is associated with improved detection of myocardial infarction (MI). METHODS We performed a descriptive retrospective analysis of resource utilization at Rush University Medical Center over the transition period (July 1, 2021) from a cTn to a hs-cTn assay. Inclusion criteria included emergency department (ED) encounters between January 1 to December 31, 2021, with chief complaints of "chest pain" or "dyspnea" with associated troponin orders. The primary endpoint was the percentage of ED discharges. Secondary endpoints included the number of cardiac studies ordered. Univariable comparisons of these endpoints were performed using Student's t-test for continuous variables and Chi-square tests for binary/categorical variables. RESULTS A total of 5113 encounters were analyzed. Hs-cTn was associated with an overall increase in ED patient discharges with negative troponin tests (44.1% vs. 29.9%, P < 0.01). In terms of cardiac testing per encounter, hs-cTn was associated with significant increases in the number of troponin tests (1.9 vs. 1.6, P < 0.01), electrocardiograms (3.0 vs. 2.9, P = 0.01), and echocardiograms (0.5 vs. 0.4, P < 0.01). There was a significant decrease in the utilization of stress testing (0.21 vs. 0.26, P < 0.01). There was a significant increase in total coronary angiography use during the hs-cTn period compared to cTn (227/2471 (9.2%) vs. 195/2642 (7.4%), P = 0.02). CONCLUSION Transitioning from cTn to hs-cTn was associated with significantly increased ED discharges and an increase in troponin tests, ECG, echocardiograms, and coronary angiograms. There was a decrease in the number of stress tests.
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Affiliation(s)
- Sushant Koirala
- Department of Internal Medicine, Rush University Medical Center, 600 S. Paulina St., Chicago, IL 60612, USA.
| | - Kelsey Danley
- Department of Internal Medicine, Rush University Medical Center, Chicago, IL, USA.
| | - Mina Kerolos
- Department of Internal Medicine, Rush University Medical Center, Chicago, IL, USA.
| | - Jian Chu
- Department of Internal Medicine, Rush University Medical Center, Chicago, IL, USA.
| | - Elif Yucebay
- Department of Emergency Medicine, Rush University Medical Center, Chicago, IL, USA.
| | | | - Annabelle Santos Volgman
- Division of Cardiology, Department of Internal Medicine, Rush University Medical Center, Chicago, IL, USA.
| | - Steve Attanasio
- Division of Cardiology, Department of Internal Medicine, Rush University Medical Center, Chicago, IL, USA.
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Karády J, Mayrhofer T, Januzzi JL, Udelson JE, Fleg JL, Merkely B, Lu MT, Peacock WF, Nagurney JT, Koenig W, Ferencik M, Hoffmann U. Agreement among high-sensitivity cardiac troponin assays and non-invasive testing, clinical outcomes, and quality-of-care outcomes based on the 2020 European Society of Cardiology Guidelines. EUROPEAN HEART JOURNAL. ACUTE CARDIOVASCULAR CARE 2024; 13:15-23. [PMID: 38001050 PMCID: PMC10853690 DOI: 10.1093/ehjacc/zuad146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Revised: 10/25/2023] [Accepted: 11/08/2023] [Indexed: 11/26/2023]
Abstract
AIMS Quality-of-care and safety of patients with suspected acute coronary syndrome (ACS) would benefit if management was independent of which high-sensitivity cardiac troponin (hs-cTn) assay was used for risk stratification. We aimed to determine the concordance of hs-cTn assays to risk-stratify patients with suspected ACS according to the European Society of Cardiology (ESC) 2020 Guidelines. METHODS AND RESULTS Blood samples were obtained at arrival and at 2 h from patients with suspected ACS using four hs-cTn assays. The patients were classified into rule-out/observe/rule-in strata based on the ESC 2020 Guidelines. Concordance was determined among the assays for rule-out/observe/rule-in strata. The prevalences of significant underlying disease (≥50% stenosis on coronary computed tomography or inducible myocardial ischaemia on stress testing) and adjudicated ACS, plus quality-of-care outcomes, were compared. Among 238 patients (52.7 ± 8.0 years; 40.3% female), the overall concordance across assays to classify patients into rule-out/observe/rule-in strata was 74.0% (176/238). Platforms significantly differed for rule-out (89.9 vs. 76.5 vs. 78.6 vs. 86.6%, P < 0.001) and observe strata (6.7 vs. 20.6 vs. 17.7 vs. 9.2%, P < 0.001), but not for rule-in strata (3.4 vs. 2.9 vs. 3.8 vs. 4.2%, P = 0.62). Among patients in ruled-out strata, 19.1-21.6% had significant underlying disease and 3.3-4.2% had ACS. The predicted disposition of patients and cost-of-care differed across the assays (all P < 0.001). When compared with observed strata, conventional troponin-based management and predicted quality-of-care outcomes significantly improved with hs-cTn-based strategies (direct discharge: 21.0 vs. 80.3-90.8%; cost-of-care: $3889 ± 4833 vs. $2578 ± 2896-2894 ± 4371, all P < 0.001). CONCLUSION Among individuals with suspected ACS, patient management may differ depending on which hs-cTn assay is utilized. More data are needed regarding the implications of inter-assay differences. TRAIL REGISTRATION NCT01084239.
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Affiliation(s)
- Júlia Karády
- Cardiovascular Imaging Research Center, Massachusetts General Hospital, Harvard Medical School, 165 Cambridge St Suite 400, Boston, MA 02114, USA
- Heart and Vascular Center, Semmelweis University, 9-11 Gaál József Street, Budapest 1122, Hungary
| | - Thomas Mayrhofer
- Cardiovascular Imaging Research Center, Massachusetts General Hospital, Harvard Medical School, 165 Cambridge St Suite 400, Boston, MA 02114, USA
- School of Business Studies, Stralsund University of Applied Sciences, Stralsund, Germany
| | - James L Januzzi
- Division of Cardiology, Massachusetts General Hospital, Boston, MA, USA
| | - James E Udelson
- Department of Medicine, Tufts Medical Center, Boston, MA, USA
| | - Jerome L Fleg
- Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, Bethesda, MD, USA
| | - Bela Merkely
- Heart and Vascular Center, Semmelweis University, 9-11 Gaál József Street, Budapest 1122, Hungary
| | - Michael T Lu
- Cardiovascular Imaging Research Center, Massachusetts General Hospital, Harvard Medical School, 165 Cambridge St Suite 400, Boston, MA 02114, USA
| | - William F Peacock
- Department of Emergency Medicine, Baylor College of Medicine, Boston, MA, USA
| | - John T Nagurney
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Wolfgang Koenig
- Institute of Epidemiology and Medical Biometry, University of Ulm, Ulm, Germany
- Deutsches Herzzentrum München, Technische Universität München, Munich, Germany
- DZHK (German Centre for Cardiovascular Research), Partner Site Munich Heart Alliance, Munich, Germany
| | - Maros Ferencik
- Cardiovascular Imaging Research Center, Massachusetts General Hospital, Harvard Medical School, 165 Cambridge St Suite 400, Boston, MA 02114, USA
- Knight Cardiovascular Institute, Oregon Health & Science University, Portland, OR, USA
| | - Udo Hoffmann
- Cardiovascular Imaging Research Center, Massachusetts General Hospital, Harvard Medical School, 165 Cambridge St Suite 400, Boston, MA 02114, USA
- Innovative Imaging Consulting LLC, 163 Longfellow Rd., Waltham, MA 02453, USA
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3
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Sanders S, Barratt A, Buchbinder R, Doust J, Kazda L, Jones M, Glasziou P, Bell K. Evidence for overdiagnosis in noncancer conditions was assessed: a metaepidemiological study using the 'Fair Umpire' framework. J Clin Epidemiol 2024; 165:111215. [PMID: 37952702 DOI: 10.1016/j.jclinepi.2023.11.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Revised: 11/04/2023] [Accepted: 11/06/2023] [Indexed: 11/14/2023]
Abstract
OBJECTIVES To evaluate the strength of the evidence for, and the extent of, overdiagnosis in noncancer conditions. STUDY DESIGN AND SETTING We systematically searched for studies investigating overdiagnosis in noncancer conditions. Using the 'Fair Umpire' framework to assess the evidence that cases diagnosed by one diagnostic strategy but not by another may be overdiagnosed, two reviewers independently identified whether a Fair Umpire-a disease-specific clinical outcome, a test result or risk factor that can determine whether an additional case does or does not have disease-was present. Disease-specific clinical outcomes provide the strongest evidence for overdiagnosis, follow-up or concurrent tests provide weaker evidence, and risk factors provide only weak evidence. Studies without a Fair Umpire provide the weakest evidence of overdiagnosis. RESULTS Of 132 studies, 47 (36%) did not include a Fair Umpire to adjudicate additional diagnoses. When present, the most common Umpire was a single test or risk factor (32% of studies), with disease-specific clinical outcome Umpires used in only 21% of studies. Estimates of overdiagnosis included 43-45% of screen-detected acute abdominal aneurysms, 54% of cases of acute kidney injury, and 77% of cases of oligohydramnios in pregnancy. CONCLUSION Much of the current evidence for overdiagnosis in noncancer conditions is weak. Application of the framework can guide development of robust studies to detect and estimate overdiagnosis in noncancer conditions, ultimately informing evidence-based policies to reduce it.
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Affiliation(s)
- Sharon Sanders
- Institute for Evidence-Based Healthcare, Bond University, Gold Coast, Queensland 4229, Australia.
| | - Alexandra Barratt
- Sydney School of Public Health, Sydney Medical School, Faculty of Medicine and Health, The University of Sydney, New South Wales 2006, Australia
| | - Rachelle Buchbinder
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria 3800, Australia
| | - Jenny Doust
- Centre for Longitudinal and Life Course Research, School of Public Health, University of Queensland, Herston, Queensland 4006, Australia
| | - Luise Kazda
- NHMRC Healthy Environments And Lives (HEAL) National Research Network, National Centre for Epidemiology and Population Health, College of Health and Medicine, The Australian National University, Canberra, Australian Capital Territory 2601, Australia
| | - Mark Jones
- Institute for Evidence-Based Healthcare, Bond University, Gold Coast, Queensland 4229, Australia
| | - Paul Glasziou
- Institute for Evidence-Based Healthcare, Bond University, Gold Coast, Queensland 4229, Australia
| | - Katy Bell
- Sydney School of Public Health, Sydney Medical School, Faculty of Medicine and Health, The University of Sydney, New South Wales 2006, Australia
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Yore M, Sharp A, Wu YL, Kawatkar A, Lee MS, Ferencik M, Redberg R, Shen E, Zheng C, Sun B. Emergency Department Cardiac Risk Stratification With High-Sensitivity vs Conventional Troponin HEART Pathway. JAMA Netw Open 2023; 6:e2348351. [PMID: 38113042 PMCID: PMC10731477 DOI: 10.1001/jamanetworkopen.2023.48351] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2023] [Accepted: 10/26/2023] [Indexed: 12/21/2023] Open
Abstract
Importance Patients presenting to the emergency department with chest pain are routinely risk stratified for major adverse cardiac events using the HEART (History, Electrocardiogram, Age, Risk factors, and Troponin) score pathway, which incorporates clinical features, risk factors, electrocardiography findings, and initial serum troponin testing. A new HEART pathway incorporating high-sensitivity troponin level may improve risk stratification among patients with possible acute myocardial infarction (AMI). Objective To compare health outcomes and resource use among emergency department patients undergoing cardiac risk stratification with a HEART pathway using conventional vs high-sensitivity serum troponin. Design, Setting, and Participants This multicenter pre-post cohort study was conducted between January 1 and September 6, 2021, at 16 Kaiser Permanente Southern California hospitals during uptake of a high-sensitivity serum troponin assay and included 17 384 adult patients who presented to an emergency department with chest pain and were risk stratified with a HEART pathway based on conventional troponin or high-sensitivity troponin. Exposures A HEART pathway incorporating either conventional or high-sensitivity serum troponin was used to stratify study groups for risk of major adverse cardiac events within 30 days. Main Outcomes and Measures The primary outcome was detection of AMI in the emergency department and within 30 days. Results Of the 17 384 patients (median age, 58 years [IQR, 45-69 years]; 9767 women [56.2%]), 12 440 (71.6%) were risk stratified with a HEART pathway based on conventional troponin, and 4944 (28.4%) were risk stratified with a HEART pathway based on high-sensitivity troponin. Detection of AMI within 30 days was higher for the high-sensitivity troponin group than the conventional troponin group (288 [5.8%] vs 545 [4.4%]; P < .001), while the 30-day all-cause mortality rate was unchanged (16 [0.3%] vs 50 [0.4%]; P = .50). In the emergency department, 228 of 4944 patients (4.6%) in the high-sensitivity troponin group received a diagnosis of AMI compared with 251 of 12 440 patients (2.0%) in the conventional troponin group (P < .001). Among those who did not receive a diagnosis of AMI in the emergency department, an additional 60 patients (1.2%) in the high-sensitivity troponin group and 294 (2.4%) in the conventional troponin group (P < .001) received a diagnosis within 30 days. Patients in the high-sensitivity troponin group had lower rates of health care use compared with the conventional troponin group, including admission (605 [12.2%] vs 1862 [15.0%]; P < .001), stress testing within 7 days (506 [10.2%] vs 1591 [12.8%]; P < .001), and coronary revascularization within 30 days (51 [1.0%] vs 244 [2.0%]; P < .001). Conclusions and Relevance This multicenter pre-post cohort study suggests that a new HEART pathway incorporating high-sensitivity troponin may improve detection of AMI and decrease resource use among emergency department patients with chest pain.
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Affiliation(s)
- Mackensie Yore
- Department of Emergency Medicine, Veterans Affairs/University of California Los Angeles National Clinician Scholars Program, Los Angeles
| | - Adam Sharp
- Clinical Science Department, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, California
| | - Yi-Lin Wu
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena
| | - Aniket Kawatkar
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena
| | - Ming-Sum Lee
- Department of Cardiology, Kaiser Permanente Los Angeles Medical Center, Los Angeles, California
| | - Maros Ferencik
- Knight Cardiovascular Institute, Oregon Health & Science University, Portland
| | - Rita Redberg
- Division of Cardiology, University of California, San Francisco
- Philip R. Lee Institute for Health Policy Studies, University of California, San Franciscio
| | - Ernest Shen
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena
| | - Chengyi Zheng
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena
| | - Benjamin Sun
- Department of Emergency Medicine, Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
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5
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Odqvist M, Bandstein N, Tygesen H, Eggers KM, Andersson PO, Holzmann MJ. Outcomes in patients with chest pain in emergency departments using high-sensitivity versus conventional troponins. SCAND CARDIOVASC J 2023; 57:2190546. [PMID: 37160719 DOI: 10.1080/14017431.2023.2190546] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/11/2023]
Abstract
Objectives. There is a paucity of data regarding the association between the use of high-sensitivity troponin (hs-cTn) compared with conventional troponin (cTn) and outcomes in chest pain patients in emergency departments (EDs). This study examined the impact of hs-cTnT on prognosis in chest pain patients in EDs. Design. In an observational cohort study, we included chest pain patients visiting the EDs of 14 hospitals in Sweden from 2011 to 2016. The study population was retrieved from each hospital, and information on characteristics and outcomes was collected from nationwide registries. Cox regression was used to estimate adjusted hazard ratios with 95% confidence intervals (HR, 95% CI) for (1) 1-year all-cause mortality, (2) missed acute coronary syndromes (ACSs), (3) use of coronary angiography, and (4) revascularizations within 30 days. Results. We included 170461 patients with chest pain where 62669 patients were tested with cTn while 107792 patients were tested with hs-cTnT. We found 4149 (4.6%) deaths in the cTn group and 6087 (3.7%) deaths in the hs-cTnT group. Patients in the hs-cTnT group had 9% lower mortality (0.91, 0.87-0.94), and were 14% more likely to undergo coronary angiography (1.14, 1.10-1.17), and 12% more likely to be revascularized (1.12, 1.08-1.17) than patients in the cTn group. Conclusions. Patients with chest pain visiting EDs using hs-cTnT had lower mortality and a higher likelihood of undergoing coronary angiographies and revascularizations than those using cTn. There may be a survival benefit of being tested with hs-cTnT compared with cTn in patients seeking medical attention for chest pain.
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Affiliation(s)
- Maria Odqvist
- Department of Medicine, South Älvsborg Hospital, Borås, Sweden
- Department of Medicine, Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden
| | - Nadia Bandstein
- Functional Area of Emergency Medicine, Karolinska University Hospital, Huddinge, Stockholm, Sweden
- Department of Internal Medicine, Solna, Karolinska Institutet, Stockholm, Sweden
| | - Hans Tygesen
- Department of Medicine, South Älvsborg Hospital, Borås, Sweden
- Department of Medicine, Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden
| | - Kai M Eggers
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - Per-Ola Andersson
- Department of Medicine, South Älvsborg Hospital, Borås, Sweden
- Department of Medicine, Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden
| | - Martin J Holzmann
- Functional Area of Emergency Medicine, Karolinska University Hospital, Huddinge, Stockholm, Sweden
- Department of Internal Medicine, Solna, Karolinska Institutet, Stockholm, Sweden
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Khan E, Lambrakis K, Nazir SA, Chuang A, Halabi A, Tiver K, Briffa T, Cullen LA, Horsfall M, French JK, Sun BC, Chew DP. Implementation of more sensitive cardiac troponin T assay in a state-wide health service. Int J Cardiol 2022; 347:66-72. [PMID: 34774641 DOI: 10.1016/j.ijcard.2021.11.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Revised: 10/30/2021] [Accepted: 11/07/2021] [Indexed: 11/29/2022]
Abstract
AIMS Explore the impact of deploying high-sensitivity (hs) cardiac troponin T (cTnT) assay across a state-wide health service. METHODS AND RESULTS Presentations to emergency departments of six tertiary hospitals between January 2008 and August 2019 were included; standard cTnT assay was superseded by hs-cTnT in June 2011 without changing the reference range (≥30 ng/L reported as elevated), despite cTnT level of 30 ng/L being equivalent to ∼44 ng/L with hs-cTnT. Clinical outcomes were captured using state-wide linked health records. Interrupted time series analyses were used adjusted for seasonality and multiple co-morbidities using propensity score matching allowing for correlation within hospitals. In total, 614,847 presentations had ≥1 troponin measurement. Clinical ordering of troponin decreased throughout the study with no increase in elevated measurements amongst those tested with hs-cTnT. Small but statistically significant changes in index myocardial infarction (MI) diagnosis (-0.36%/year, 95%CI [confidence interval]:-0.48, -0.24,p < 0.001) and invasive coronary angiography (0.12%/year,95%CI:0, 0.24,p = 0.02) were seen, with no impact on death/MI at 30 days or 3-year survival in episodes of care (EOCs) with elevated cTnT after hs-cTnT implementation. Length of stay (LOS) was shorter among those with an elevated hs-cTnT (-4.44 h/year, 95%CI:-5.27, -3.60, p < 0.001). Non-elevated cTnT EOCs demonstrated shorter total LOS and improved 3-year survival (adjusted hazard ratio:0.90, 95%CI:0.83, 0.97,p = 0.008) although death/MI at 30 days was unchanged using hs-cTnT. CONCLUSION Widespread implementation of hs-cTnT without altering clinical thresholds reported to clinicians provided significantly shorter LOS without a clinically significant impact on clinical outcomes. A safer cohort with non-elevated cTnT was identified by hs-cTnT compared to the standard cTnT assay.
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Affiliation(s)
- Ehsan Khan
- College of Medicine & Public Health, Flinders University of South Australia, Adelaide, Australia; South Australian Department of Health, Adelaide, Australia
| | - Kristina Lambrakis
- College of Medicine & Public Health, Flinders University of South Australia, Adelaide, Australia; South Australian Department of Health, Adelaide, Australia
| | - Sheraz A Nazir
- Department of Cardiology, University Hospitals of Coventry & Warwickshire NHS Trust, Coventry, CV2 2DX, UK; Department of Cardiovascular Sciences, University of Leicester and the National Institute for Health for Research (NIHR) Leicester Cardiovascular Biomedical Research Centre, Glenfield Hospital, Leicester LE3 9QF, UK
| | - Anthony Chuang
- College of Medicine & Public Health, Flinders University of South Australia, Adelaide, Australia; South Australian Department of Health, Adelaide, Australia
| | - Amera Halabi
- College of Medicine & Public Health, Flinders University of South Australia, Adelaide, Australia; South Australian Department of Health, Adelaide, Australia
| | - Kathryn Tiver
- College of Medicine & Public Health, Flinders University of South Australia, Adelaide, Australia; South Australian Department of Health, Adelaide, Australia
| | - Tom Briffa
- School of Population and Global Health, University of Western Australia, Perth, Australia
| | - Louise A Cullen
- Emergency and Trauma Centre, Royal Brisbane and Women's Hospital, Brisbane, Australia; School of Public Health, Queensland University of Technology, Brisbane, Australia; School of Medicine, University of Queensland, Brisbane, Australia
| | - Matthew Horsfall
- College of Medicine & Public Health, Flinders University of South Australia, Adelaide, Australia; South Australian Department of Health, Adelaide, Australia
| | - John K French
- Department of Cardiology, Liverpool Hospital, University of New South Wales, Sydney, Australia
| | - Benjamin C Sun
- Center for Policy Research-Emergency Medicine, Department of Emergency Medicine, Oregon Health and Science University, Portland, OR, United States of America
| | - Derek P Chew
- College of Medicine & Public Health, Flinders University of South Australia, Adelaide, Australia; South Australian Health and Medical Research Institute, Adelaide, Australia; South Australian Department of Health, Adelaide, Australia.
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7
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Meek R, Cullen L, Lu ZX, Nasis A, Kuhn L, Sorace L. Potential impact of a novel pathway for suspected myocardial infarction utilising a new high-sensitivity cardiac troponin I assay. Emerg Med J 2021; 39:847-852. [PMID: 34759013 DOI: 10.1136/emermed-2020-210812] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Accepted: 10/27/2021] [Indexed: 11/04/2022]
Abstract
BACKGROUND High-sensitivity cardiac troponin I (hs-cTnI) assays promise high diagnostic accuracy for myocardial infarction (MI). In an ED where conventional cTnI was in use, we evaluated an assessment pathway using the new Access hsTnI assay. METHODS This retrospective analysis recruited ED patients with suspected MI between June and September 2019. All patients received routine care with a conventional cTnI assay (AccuTnI +3: limit of detection (LoD) 10 ng/L, 99th centile upper reference limit (URL) 40 ng/L, abnormal elevation cut-point 80 ng/L). Arrival, then 90-minute or 360-minute cTnI levels for low and non-low risk patients, respectively (ED Assessment of Chest pain score) guided diagnosis and disposition which was at treating physician discretion. The same patients had arrival and 90-minute or 180-minute samples drawn for hs-cTnI levels (Access hsTnI: LoD 2 ng/L, 99th centile URL 10 ng/L (females) and 20 ng/L (males); abnormal elevation above the URL and delta >30%). Treating physicians were blinded to the hs-cTnI results. Using the hs-cTnI values, investigators retrospectively assigned likely diagnosis, disposition and likelihood of a 30-day major adverse cardiac event (MACE). Admission was recommended for significantly rising hs-cTnI elevations. The primary objective was to demonstrate an acceptable unexpected 30-day post-discharge MACE rate of <1%. cTnI elevation rates, diagnostic outcomes and ED disposition were also compared between pathways. RESULTS For the 935 patients, unexpected 30-day post-discharge MACE rates were 0/935 (0%, 95% CI 0% to 0.4%) with the conventional or novel pathway. For the high-sensitivity and conventional assays, respectively, abnormal elevation rates were 29% (95% CI 26% to 32%) and 19% (95% CI 17% to 22%), for MI were 9% (95% CI 8% to 11%) and 8% (95% CI 6% to 10%), and for hospital admission were 42% (95% CI 39% to 45%) and 43% (95% CI 40% to 47%). CONCLUSION The novel pathway using the Access hsTnI assay has an acceptably low 30-day MACE rate.
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Affiliation(s)
- Rob Meek
- Emergency Department, Monash Health, Melbourne, Victoria, Australia .,Medicine, Monash University, Melbourne, Victoria, Australia
| | - Louise Cullen
- Department of Emergency Medicine, Royal Brisbane and Women's Hospital, Herston, Queensland, Australia
| | - Zhong Xian Lu
- Emergency Department, Monash Health, Melbourne, Victoria, Australia.,Medicine, Monash University, Melbourne, Victoria, Australia
| | - Arthur Nasis
- Emergency Department, Monash Health, Melbourne, Victoria, Australia.,Medicine, Monash University, Melbourne, Victoria, Australia
| | - Lisa Kuhn
- Emergency Department, Monash Health, Melbourne, Victoria, Australia.,Medicine, Monash University, Melbourne, Victoria, Australia
| | - Laurence Sorace
- Melbourne Medical School, The University of Melbourne - Parkville Campus, Melbourne, Victoria, Australia.,Medicine, Northern Health, Melbourne, Victoria, Australia
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8
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Ola O, Akula A, De Michieli L, Dworak M, Crockford E, Lobo R, Rastas N, Knott JD, Mehta RA, Hodge DO, Grube E, Karturi S, Wohlrab S, Tak T, Cagin C, Gulati R, Jaffe AS, Sandoval Y. Clinical Impact of High-Sensitivity Cardiac Troponin T Implementation in the Community. J Am Coll Cardiol 2021; 77:3160-3170. [PMID: 34167641 DOI: 10.1016/j.jacc.2021.04.050] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Revised: 04/19/2021] [Accepted: 04/21/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Limited U.S. data exist regarding high-sensitivity cardiac troponin (cTn) implementation. OBJECTIVES This study sought to evaluate the impact of high-sensitivity cardiac troponin T (cTnT) implementation. METHODS Observational U.S. cohort study of emergency department (ED) patients undergoing measurement of cTnT during the transition from 4th (pre-implementation March 12, 2018, to September 11, 2018) to 5th generation (Gen) cTnT (post-implementation September 12, 2018, to March 11, 2019). Diagnoses were adjudicated following the Fourth Universal Definition of Myocardial Infarction (MI). Resources evaluated included length of stay, hospitalizations, and cardiac testing. RESULTS In this study, 3,536 unique patients were evaluated, including 2,069 and 2,491 ED encounters pre- and post-implementation. Compared with 4th Gen cTnT, encounters with ≥1 cTnT >99th percentile increased using 5th Gen cTnT (15% vs. 47%; p < 0.0001). Acute MI (3.3% vs. 8.1%; p < 0.0001) and myocardial injury (11% vs. 38%; p < 0.0001) increased. Although type 1 MIs increased (1.7% vs. 2.9%; p = 0.0097), the overall MI increase was largely due to more type 2 MIs (1.6% vs. 5.2%; p < 0.0001). Women were less likely than men to have MI using 4th Gen cTnT (2.3% vs. 4.4%; p = 0.008) but not 5th Gen cTnT (7.7% vs. 8.5%; p = 0.46). Overall length of stay and stress testing were reduced, and angiography was increased (all p < 0.05). Among those without cTnT increases, there were more ED discharges and a reduction in length of stay, echocardiography, and stress tests (all p < 0.05). CONCLUSIONS High-sensitivity cTnT implementation resulted in a marked increase in myocardial injury and MI, particularly in women and patients with type 2 MI. Despite this, except for angiography, overall resource use did not increase. Among those without cTnT increases, there were more ED discharges and fewer cardiac tests.
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Affiliation(s)
- Olatunde Ola
- Division of Hospital Internal Medicine, Mayo Clinic Health System, La Crosse, Wisconsin, USA; Center for Clinical and Translational Science, Mayo Clinic Graduate School of Biomedical Sciences, Rochester, Minnesota, USA
| | - Ashok Akula
- Division of Hospital Internal Medicine, Mayo Clinic Health System, La Crosse, Wisconsin, USA; Center for Clinical and Translational Science, Mayo Clinic Graduate School of Biomedical Sciences, Rochester, Minnesota, USA
| | - Laura De Michieli
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, USA; Department of Cardiac, Thoracic and Vascular Sciences and Public Health, University of Padova, Italy
| | - Marshall Dworak
- Department of Cardiovascular Diseases, Mayo Clinic Health System, La Crosse, Wisconsin, USA
| | - Erika Crockford
- Department of Family Medicine, Mayo Clinic Health System, La Crosse, Wisconsin, USA
| | - Ronstan Lobo
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, USA
| | - Nicholas Rastas
- Department of Cardiovascular Diseases, Mayo Clinic Health System, La Crosse, Wisconsin, USA
| | - Jonathan D Knott
- Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Ramila A Mehta
- Department of Health Sciences Research, Mayo College of Medicine, Rochester, Minnesota, USA
| | - David O Hodge
- Department of Health Sciences Research, Mayo College of Medicine, Jacksonville, Florida, USA
| | - Eric Grube
- Department of Emergency Medicine, Mayo Clinic Health System, La Crosse, Wisconsin, USA
| | - Swetha Karturi
- Division of Hospital Internal Medicine, Mayo Clinic Health System, La Crosse, Wisconsin, USA
| | - Scott Wohlrab
- Department of Laboratory Medicine and Pathology, Mayo Clinic Health System, La Crosse, Wisconsin, USA
| | - Tahir Tak
- Department of Cardiovascular Diseases, Mayo Clinic Health System, La Crosse, Wisconsin, USA
| | - Charles Cagin
- Department of Cardiovascular Diseases, Mayo Clinic Health System, La Crosse, Wisconsin, USA
| | - Rajiv Gulati
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, USA
| | - Allan S Jaffe
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, USA; Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | - Yader Sandoval
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, USA.
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9
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Ford JS, Chaco E, Tancredi DJ, Mumma BE. Impact of high-sensitivity cardiac troponin implementation on emergency department length of stay, testing, admissions, and diagnoses. Am J Emerg Med 2021; 45:54-60. [PMID: 33662739 DOI: 10.1016/j.ajem.2021.02.021] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Revised: 02/05/2021] [Accepted: 02/08/2021] [Indexed: 01/10/2023] Open
Abstract
OBJECTIVE While high-sensitivity (hs) troponin (cTn) has been associated with shorter emergency department (ED) length of stay (LOS) and decreased hospital admissions outside the United States (US), concerns have been raised that it will have opposite effects in the US. In this study, we aimed to compare ED LOS, admissions, and acute coronary syndrome (ACS) diagnoses before and after the implementation of hs-cTn. METHODS We conducted a single-institution, retrospective study of two temporally matched six-month study periods before and after the implementation of hs-cTn. We included consecutive adults presenting with chest pain. The primary outcome was ED LOS, which was log transformed and analyzed using multiple linear regression. Binary secondary outcomes of admissions, cardiac testing, cardiology consultation, and ACS diagnoses were analyzed using multiple logistic regression. RESULTS We studied 1589 visits before and 1616 visits after implementation of hs-cTn. Median age and sex ratios were similar between study periods. Median ED LOS was longer in the post-implementation period [post: 384 (interquartile range, IQR 260-577) minutes; pre: 374 (IQR 250-564) minutes; adjusted geometric mean ratio 1.05; 95% confidence interval, CI 1.01-1.10)]. Admissions were lower in the post-implementation period [post: 24% (385/1616) vs. pre: 28% (447/1589); adjusted odds ratio, aOR 0.75 (95% CI 0.64-0.88)]. Cardiac risk stratification testing [pre: 9% (142/1589) vs post: 9% (144/1616); aOR 0.95 (95% CI 0.74-1.22)], cardiology consultation [pre: 13% (208/1589) vs post: 13% (207/1616); aOR 0.91 (95% CI 0.73-1.12)], and ACS diagnoses [pre: 7% (116/1589) vs post: 7% (120/1616); aOR 0.94 (95% CI 0.72-1.24)] were similar between the two study periods. CONCLUSION In this single-center study, transition to hs-cTn was associated with an increased ED LOS, decreased admissions, and no substantial change in cardiac risk stratification testing, cardiology consultation, or ACS diagnoses.
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Affiliation(s)
- James S Ford
- Department of Emergency Medicine, University of California, Davis, USA
| | - Ernestine Chaco
- Department of Emergency Medicine, University of California, Davis, USA
| | | | - Bryn E Mumma
- Department of Emergency Medicine, University of California, Davis, USA.
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10
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Mumma BE, Casey SD, Dang RK, Polen MK, Kaur JC, Rodrigo J, Tancredi DJ, Narverud RA, Amsterdam EA, Tran N. Diagnostic Reclassification by a High-Sensitivity Cardiac Troponin Assay. Ann Emerg Med 2020; 76:566-579. [PMID: 32807538 PMCID: PMC7606506 DOI: 10.1016/j.annemergmed.2020.06.047] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Revised: 06/16/2020] [Accepted: 06/22/2020] [Indexed: 02/07/2023]
Abstract
STUDY OBJECTIVE Our objective is to describe the rates of diagnostic reclassification between conventional cardiac troponin I (cTnI) and high-sensitivity cardiac troponin T (hs-cTnT) and between combined and sex-specific hs-cTnT thresholds in adult emergency department (ED) patients in the United States. METHODS We conducted a prospective, single-center, before-and-after, observational study of ED patients aged 18 years or older undergoing single or serial cardiac troponin testing in the ED for any reason before and after hs-cTnT implementation. Conventional cTnI and hs-cTnT results were obtained from a laboratory quality assurance database. Combined and sex-specific thresholds were the published 99th percentile upper reference limits for each assay. Cases underwent physician adjudication using the Fourth Universal Definition of Myocardial Infarction. Diagnostic reclassification occurred when a patient received a diagnosis of myocardial infarction or myocardial injury with one assay but not the other assay. Our primary outcome was diagnostic reclassification between the conventional cTnI and hs-cTnT assays. Diagnostic reclassification probabilities were assessed with sample proportions and 95% confidence intervals for binomial data. RESULTS We studied 1,016 patients (506 men [50%]; median age 60 years [25th, 75th percentiles 49, 71]). Between the conventional cTnI and hs-cTnT assays, 6 patients (0.6%; 95% confidence interval 0.2% to 1.3%) underwent diagnostic reclassification regarding myocardial infarction (5/6 reclassified as no myocardial infarction) and 166 patients (16%; 95% confidence interval 14% to 19%) underwent diagnostic reclassification regarding myocardial injury (154/166 reclassified as having myocardial injury) by hs-cTnT. CONCLUSION Compared with conventional cTnI, the hs-cTnT assay resulted in no clinically relevant change in myocardial infarction diagnoses but substantially more myocardial injury diagnoses.
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Affiliation(s)
- Bryn E Mumma
- Department of Emergency Medicine, University of California, Davis, Sacramento, CA.
| | - Scott D Casey
- Department of Emergency Medicine, University of California, Davis, Sacramento, CA
| | - Robert K Dang
- Department of Emergency Medicine, University of California, Davis, Sacramento, CA
| | - Michelle K Polen
- Department of Emergency Medicine, University of California, Davis, Sacramento, CA
| | - Jasmanpreet C Kaur
- Department of Emergency Medicine, University of California, Davis, Sacramento, CA
| | - John Rodrigo
- Department of Pathology and Laboratory Medicine, University of California, Davis, Sacramento, CA
| | - Daniel J Tancredi
- Department of Pediatrics, University of California, Davis, Sacramento CA
| | - Robert A Narverud
- Department of Emergency Medicine, University of California, Davis, Sacramento, CA
| | - Ezra A Amsterdam
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of California, Davis, Sacramento CA
| | - Nam Tran
- Department of Pathology and Laboratory Medicine, University of California, Davis, Sacramento, CA
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11
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Hinton J, Gabara L, Curzen N. Is the true clinical value of high-sensitivity troponins as a biomarker of risk? The concept that detection of high-sensitivity troponin 'never means nothing'. Expert Rev Cardiovasc Ther 2020; 18:843-857. [PMID: 32966128 DOI: 10.1080/14779072.2020.1828063] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
INTRODUCTION High-sensitivity troponin (hs-cTn) assays are central to the diagnosis of myocardial infarction (MI). Their increased sensitivity has facilitated rapid pathways for the exclusion of MI. However, hs-cTn is now more readily detectable in patients without symptoms typical of MI, in whom a degree of myocardial injury is assumed. Recently, the practice of using the 99th centile of hs-cTn as a working 'upper reference limit' has been challenged. There is increasing evidence that hs-cTn may provide useful prognostic information, regardless of any suspicion of MI, and as such these assays may have potential as a general biomarker for mortality. This raises the concept that detection of hs-cTn 'never means nothing.' AREAS COVERED In this review, we will evaluate the evidence for the use of hs-cTn assays outside their common clinical indication to rule out or diagnose acute MI. EXPERT OPINION The data presented suggest that hs-cTn testing may in the future have a generalized role as a biomarker of mortality risk and may be used less as a test for ruling in acute MI, but will remain a frontline test to exclude that diagnosis in ED. Further, the data suggest that the detection of hs-cTn 'never means nothing.'
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Affiliation(s)
- Jonathan Hinton
- Coronary Research Group, University Hospital Southampton NHS Foundation Trust , Southampton, UK.,Faculty of Medicine, University of Southampton , Southampton, UK
| | - Lavinia Gabara
- Coronary Research Group, University Hospital Southampton NHS Foundation Trust , Southampton, UK.,Faculty of Medicine, University of Southampton , Southampton, UK
| | - Nick Curzen
- Coronary Research Group, University Hospital Southampton NHS Foundation Trust , Southampton, UK.,Faculty of Medicine, University of Southampton , Southampton, UK
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12
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Zachoval CF, Dolscheid-Pommerich R, Graeff I, Goldschmidt B, Grigull A, Stoffel-Wagner B, Nickenig G, Zimmer S. High-Sensitivity Troponin T Testing: Consequences on Daily Clinical Practice and Effects on Diagnosis of Myocardial Infarction. J Clin Med 2020; 9:E775. [PMID: 32178421 PMCID: PMC7141275 DOI: 10.3390/jcm9030775] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Revised: 03/02/2020] [Accepted: 03/06/2020] [Indexed: 11/16/2022] Open
Abstract
It remains unclear how introduction of high-sensitivity troponin T testing, as opposed to conventional troponin testing, has affected the diagnosis of acute myocardial infarction (AMI) and resource utilization in unselected hospitalized patients. In this retrospective analysis, we include all consecutive cases from our center during two corresponding time frames (10/2016-04/2017 and 10/2017-04/2018) for which different troponin tests were performed: conventional troponin I (cTnI) and high-sensitivity troponin T (hs-TnT) assays. Testing was performed in 18,025 cases. The incidence of troponin levels above the 99th percentile was significantly higher in cases tested using hs-TnT. This was not associated with increased utilization of echocardiography, coronary angiography, or percutaneous coronary intervention. Although there were no changes in local standard operating procedures, study site personnel, or national coding guidelines, the number of coded AMI significantly decreased after introduction of hs-TnT. In this single-center retrospective study comprising 18,025 mixed medical and surgical cases with troponin testing, the introduction of hs-TnT was not associated with changes in resource utilization among the general cohort, but instead, led to a decrease in the international classification of diseases (ICD)-10 coded diagnosis of AMI.
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Affiliation(s)
| | - Ramona Dolscheid-Pommerich
- Institut für Klinische Chemie und Klinische Pharmakologie, Universitätsklinikum Bonn, 53127 Bonn, Germany
| | - Ingo Graeff
- Interdisziplinäres Notfallzentrum, Universitätsklinikum Bonn, 53127 Bonn, Germany
| | - Bernd Goldschmidt
- Klinisches Informationsmanagement, Geschäftsbereich 5, Universitätsklinikum Bonn, 53127 Bonn, Germany
| | - Andreas Grigull
- Institut für Klinische Chemie und Klinische Pharmakologie, Universitätsklinikum Bonn, 53127 Bonn, Germany
| | - Birgit Stoffel-Wagner
- Institut für Klinische Chemie und Klinische Pharmakologie, Universitätsklinikum Bonn, 53127 Bonn, Germany
| | - Georg Nickenig
- Medizinische Klinik und Poliklinik II, Universitätsklinikum Bonn, 53127 Bonn, Germany
| | - Sebastian Zimmer
- Medizinische Klinik und Poliklinik II, Universitätsklinikum Bonn, 53127 Bonn, Germany
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13
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Lau G, Koh M, Kavsak PA, Schull MJ, Armstrong DWJ, Udell JA, Austin PC, Wang X, Ko DT. Clinical outcomes for chest pain patients discharged home from emergency departments using high-sensitivity versus conventional cardiac troponin assays. Am Heart J 2020; 221:84-94. [PMID: 31954328 DOI: 10.1016/j.ahj.2019.12.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Accepted: 12/06/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND High-sensitivity cardiac troponin (hs-cTn) assays enhance detection of lower circulating troponin concentrations, but the impact on outcomes in clinical practice is unclear. Our objective was to compare outcomes of chest pain patients discharged from emergency departments (EDs) using hs-cTn and conventional troponin (cTn) assays. METHODS We conducted an observational study of chest pain patients aged 40-105 years who presented to an ED from April 1, 2013, to March 31, 2017, and were discharged home. We compared 30-day and 1-year outcomes of EDs that used hs-cTn versus cTn assays. The primary outcome was a composite of all-cause death, myocardial infarction or unstable angina. Comparisons were conducted with (1) no adjustment; (2) adjustment for demographic, socioeconomic, and hospital characteristics; and (3) full clinical adjustment. RESULTS Among the 394,910 patients, 62,138 (15.7%) were evaluated at hs-cTn EDs and 332,772 (84.3%) were evaluated at cTn EDs. Patients discharged from hs-cTn EDs were less likely to have diabetes, hypertension, or prior heart disease. At 30 days, the unadjusted primary outcome rate was lower in hs-cTn EDs (0.9% vs 1.0%, P < .001). The 30-day hazard ratios for the primary outcome were 0.84 (95% CI 0.77-0.92) for no adjustment and 0.98 (95% CI 0.88-1.08) for full adjustment. Over 1 year, patients discharged from hs-cTn EDs had significantly fewer primary outcomes (3.7% vs 4.1%, P < .001) and lower hazard ratio (0.93; 95% CI 0.89-0.98) even after full adjustment. CONCLUSIONS Hs-cTn testing was associated with a significantly lower adjusted hazard of myocardial infarction, angina, and all-cause hospitalization at 1 year but not 30 days.
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Affiliation(s)
- Geoffrey Lau
- ICES, Toronto, Ontario, Canada; Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | | | - Peter A Kavsak
- Department of Pathology and Molecular Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Michael J Schull
- ICES, Toronto, Ontario, Canada; Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | | | - Jacob A Udell
- ICES, Toronto, Ontario, Canada; Women's College Hospital, University of Toronto, Toronto, Ontario, Canada
| | | | | | - Dennis T Ko
- ICES, Toronto, Ontario, Canada; Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada; Schulich Heart Center, Sunnybrook Health Sciences, University of Toronto, Toronto, Ontario, Canada.
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14
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(Application of 0/1-h high sensitivity cardiac troponin algorithm in the cardiology outpatient department). COR ET VASA 2019. [DOI: 10.33678/cor.2019.051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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15
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Moumneh T, Richard-Jourjon V, Friou E, Prunier F, Soulie-Chavignon C, Choukroun J, Mazet-Guilaumé B, Riou J, Penaloza A, Roy PM. Reliability of the CARE rule and the HEART score to rule out an acute coronary syndrome in non-traumatic chest pain patients. Intern Emerg Med 2018; 13:1111-1119. [PMID: 29500619 DOI: 10.1007/s11739-018-1803-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2017] [Accepted: 02/25/2018] [Indexed: 01/19/2023]
Abstract
In patients consulting in the Emergency Department for chest pain, a HEART score ≤ 3 has been shown to rule out an acute coronary syndrome (ACS) with a low risk of major adverse cardiac event (MACE) occurrence. A negative CARE rule (≤ 1) that stands for the first four elements of the HEART score may have similar rule-out reliability without troponin assay requirement. We aim to prospectively assess the performance of the CARE rule and of the HEART score to predict MACE in a chest pain population. Prospective two-center non-interventional study. Patients admitted to the ED for non-traumatic chest pain were included, and followed-up at 6 weeks. The main study endpoint was the 6-week rate of MACE (myocardial infarction, coronary angioplasty, coronary bypass, and sudden unexplained death). 641 patients were included, of whom 9.5% presented a MACE at 6 weeks. The CARE rule was negative for 31.2% of patients, and none presented a MACE during follow-up [0, 95% confidence interval: (0.0-1.9)]. The HEART score was ≤ 3 for 63.0% of patients, and none presented a MACE during follow-up [0% (0.0-0.9)]. With an incidence below 2% in the negative group, the CARE rule seemed able to safely rule out a MACE without any biological test for one-third of patients with chest pain and the HEART score for another third with a single troponin assay.
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Affiliation(s)
- Thomas Moumneh
- Institut MITOVASC, Département de Médecine d'Urgence, CHU d'Angers, Université d'Angers, Angers, France.
| | | | - Emilie Friou
- Institut MITOVASC, Département de Médecine d'Urgence, CHU d'Angers, Université d'Angers, Angers, France
| | - Fabrice Prunier
- Institut MITOVASC, Service de Cardiologie, CHU d'Angers, Université d'Angers, Angers, France
| | - Caroline Soulie-Chavignon
- Institut MITOVASC, Département de Médecine d'Urgence, CHU d'Angers, Université d'Angers, Angers, France
| | | | - Betty Mazet-Guilaumé
- Institut MITOVASC, Département de Médecine d'Urgence, CHU d'Angers, Université d'Angers, Angers, France
| | - Jérémie Riou
- Unité de Formation-Recherche Santé, Université d'Angers, MINT INSERM, UMR 6021, Angers, France
| | - Andréa Penaloza
- Service de Médecine d'Urgence, Cliniques Universitaires St-Luc, Brussels, Belgium
| | - Pierre-Marie Roy
- Institut MITOVASC, Département de Médecine d'Urgence, CHU d'Angers, Université d'Angers, Angers, France
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16
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Abstract
Cardiac troponin assays have become more sensitive over the years leading to the clinical introduction of high-sensitivity cardiac troponin assays in 2010. Their use has revolutionized the assessment of patients with chest pain in the emergency department by allowing earlier rule-in and rule-out of myocardial infarction leading to shorter stays in the emergency department and reduced admissions for chest pain. The incidence of myocardial infarction has increased slightly, and patients with myocardial infarction diagnosed with high-sensitivity cardiac troponins have been found to have a reduced risk of reinfarction, though without an impact on survival. High-sensitivity cardiac troponins are powerful predictors of long-term mortality and cardiovascular disease in the general population as well as in patients with chest pain with or without cardiovascular disease. The increase in risk for death and cardiovascular disease associated with high-sensitivity cardiac troponins is graded and starts already at detectable levels, well below the upper normal level. The aim of this review was to describe the clinical use and consequences of the introduction of high-sensitivity cardiac troponins. In addition, the importance of persistently elevated troponin levels for prognosis and what investigations may be appropriate to perform in patients with stable troponin elevations are discussed.
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Affiliation(s)
- M J Holzmann
- Department of Medicine, Karolinska Institutet, Solna, Sweden.,Functional area of Emergency Medicine, Karolinska University Hospital, Huddinge, Sweden
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17
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Odqvist M, Andersson PO, Tygesen H, Eggers KM, Holzmann MJ. High-Sensitivity Troponins and Outcomes After Myocardial Infarction. J Am Coll Cardiol 2018; 71:2616-2624. [DOI: 10.1016/j.jacc.2018.03.515] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2018] [Revised: 02/12/2018] [Accepted: 03/06/2018] [Indexed: 10/14/2022]
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18
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Winchester DE, Kline K, Estel C, Mahtta D, Taasan S, Peacock FW. Associations between cardiac troponin, mortality and subsequent use of cardiovascular services: differences in sex and ethnicity. Open Heart 2018. [PMID: 29531759 PMCID: PMC5845416 DOI: 10.1136/openhrt-2017-000713] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
Background The impact of cardiac troponin (cTn) testing on the downstream use of cardiovascular services is not well understood. We conducted this large-scale single centre cohort study to investigate the patterns of testing that result from the use of cTn. Methods We conducted this investigation using data collected between 1 January 2013 and 18 December 2015 from an academically affiliated tertiary care centre. Data from all hospitalised patients evaluated with cTn (Roche Elecsys cTn-T) assay were collected from our integrated data repository and divided into two cohorts: all cTn assays negative (<0.03 µg/L) versus at least one elevated (≥0.03 µg/L). The main outcomes were the frequency of use cardiovascular services and mortality. Results Among 26 663 subjects, 18.6% had at least one elevated cTn assay; acute myocardial infarction was diagnosed in 3.9% overall. More men received cardiac catheterisation and cardiology consultation (OR 1.29, 95% CI 1.20 to 1.39 and OR 1.45, 95% CI 1.31 to 1.61) while African-American patients were less likely to have either catheterisation (OR 0.85, 95% CI 0.77 to 0.93) or consultation (OR 0.72, 95% CI 0.63 to 0.82) performed. Mortality was associated with detectable cTn (HR 2.05, P<0.0001). Conclusions Among hospitalised patients evaluated with cTn, we observed patterns of underuse and overuse of cardiovascular services. These patterns may have further relevance when high-sensitivity cTn assays are available in the USA. Sex and race-based disparities in cardiovascular services persist.
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Affiliation(s)
- David E Winchester
- Division of Cardiovascular Medicine, Department of Medicine, College of Medicine, University of Florida, Gainesville, Florida, USA.,Cardiology Section, Medical Service, Malcom Randall VA Medical Center, Gainesville, Florida, USA
| | - Kristopher Kline
- Department of Medicine, College of Medicine, University of Florida, Gainesville, Florida, USA
| | - Christopher Estel
- Division of Cardiovascular Medicine, Department of Medicine, College of Medicine, University of Florida, Gainesville, Florida, USA
| | - Dhruv Mahtta
- Department of Medicine, College of Medicine, University of Florida, Gainesville, Florida, USA
| | - Sean Taasan
- College of Medicine, University of Florida, Gainesville, Florida, USA
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19
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Bandstein N, Wikman A, Ljung R, Holzmann MJ. Survival and resource utilization in patients with chest pain evaluated with cardiac troponin T compared with high-sensitivity cardiac troponin T. Int J Cardiol 2017; 245:43-48. [DOI: 10.1016/j.ijcard.2017.05.111] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2017] [Revised: 04/14/2017] [Accepted: 05/29/2017] [Indexed: 10/18/2022]
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20
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Trends in admissions for chest pain after the introduction of high-sensitivity cardiac troponin T. Int J Cardiol 2017; 240:1-7. [DOI: 10.1016/j.ijcard.2017.04.028] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2016] [Revised: 03/08/2017] [Accepted: 04/10/2017] [Indexed: 11/23/2022]
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