HEART Score Recalibration Using Higher Sensitivity Troponin T

STUDY OBJECTIVE

We examined the diagnostic performance of a recalibrated History, Electrocardiogram, Age, Risk factors, Troponin (HEART), and Thrombolysis in Myocardial Infarction (TIMI) score in patients with suspected acute cardiac syndrome (ACS). Recalibration of troponin thresholds was performed, including shifting from the 99th percentile to the limit of detection (LOD) or to the limit of quantification (LOQ) We compared the discharge potential and safety of the recalibrated composite scores using a single presentation high-sensitivity cardiac troponin (hs-cTn) T to the conventional scores and with a LOD/LOQ troponin strategy alone.

METHODS

We undertook a 2-center prospective cohort study in the United Kingdom (UK) (2018) (Clinicaltrials.gov NCT03619733) to specifically assess recalibrated risk scores (shifting the troponin subset scoring from 99th percentile to LOD [UK]) and combined the results of this with secondary analyses of 2 prospective cohort studies in the UK (2011) and the United States (2018, using LOQ rather than LOD). The primary outcome was major adverse cardiovascular events (MACE), defined as adjudicated type 1 myocardial infarction (MI), urgent coronary revascularization, and all-cause death, at 30 days. We evaluated the original scores using hs-cTn below the 99th percentile and recalibrated scores using hs-cTn

RESULTS

We studied 3,752 patients (3,003 in the UK and 749 in the United States). Median age was 58 years, and 48% were female. At 30 days, 330/3,752 (8.8%) experienced MACE. The sensitivities of the original HEART less or equal to 3 and recalibrated HEART less or equal to 3 scores for rule-out were 96.1% (95% confidence interval [CI], 93.4 to 97.9) and 98.6% (95% CI, 96.5 to 99.5) respectively; the original TIMI less or equal to 1 and recalibrated TIMI less or equal to 1 scores' sensitivities were 79.7% (95% CI, 74.9 to 83.9) and 96.1% (95% CI, 93.4 to 97.9) respectively; and nonischemic ECG with hs-cTn T below the 99th percentile and hs-cTn T less than LOD/LOQ was 79.7% (95%CI, 0.749 to 0.839) and 99.1% (95% CI, 0.974 to 0.998), respectively. Recalibrated HEART less or equal to 3 was projected to discharge 14% more patients than hs-cTn T less than LOD/LOQ. The improved sensitivity of rule-out for recalibrated HEART less than or equal to 3 came at the cost of reduced specificity (50.8% versus 53.8% for recalibrated HEART and conventional HEART respectively).

CONCLUSION

This study indicates that recalibrated HEART score of less or equal to 3 is a feasible and safe early discharge strategy using a single presentation hs-cTnT. This finding should be further tested using competitor hs-cTn assays in independent prospective cohorts before implementation.

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Key Words Collapse

MESH Headings

• Humans
• Female
• Middle Aged
• Male
• Troponin T
• Prospective Studies
• Troponin
• Myocardial Infarction/diagnosis
• Myocardial Infarction/complications
• Acute Coronary Syndrome/diagnosis
• Biomarkers
• Emergency Service, Hospital

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Grants

• K08 HL130546 NHLBI NIH HHS

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Modified HEART score, utilising a single high-sensitive troponin sample, allows early, safe discharge of suspected acute coronary syndrome: a prospective multicentre cohort study of 3016 patients

Background

Combining HSTnT (high sensitive troponin T) values at low levels with composite risk scores may improve early safe, discharge in suspected acute coronary syndromes (ACS). We tested this hypothesis by a prospective study of 3016 consecutive patients with suspected ACS in 2 large hospitals.

Methods

Consecutive chest pain (CP) presentations with HSTnT sampled and ECG undertaken at presentation were prospectively defined in 2 time periods (2011-12, n=1642 [derivation] 2018, n=1376 [validation]).

The HstnT input was modified: dichotomous HSTnT input was lowered to <5 (limit of detection, LOD) or ≥5ng/l (mod TIMI and GRACE), HEART score was re-calibrated (<5 = 0 [LOD], ≥5–14 = 1, >14 = 2 [99th percentile]). All biomarker positive CP index and re-admissions to any regional hospital (catchment population 2.6 million) were independently adjudicated for MI by 2 experienced physicians. Primary outcome was MACE (adjudicated type 1 MI, unplanned coronary revascularisation and all cause death) at 6 weeks.

Results

In the 2 cohorts demographic factors were similar: median age 59 and 56, male 52% and 52%, previous MI 20% and 14% for 2011-12 and 2018 respectively. At 6 weeks 180 (11%) and 75 (5.4%) suffered type 1 MI and 211 (12.9%) and 92 (6.7%) patients suffered MACE in the 2011-12 and 2018 cohorts respectively.

Only Mod HEART ≤3 and undetectable HSTnT, with a nonischaemic ECG, achieved prespecified NPV of >99.5% in both derivation and validation cohorts (table). However Modified HEART ≤3 score could discharge approximately 12% more patients as compared to undetectable HSTnT strategy.

Conclusion

Modified HEART score ≤3, with the use of a single HSTnT, appears the optimum early discharge strategy for suspected ACS

Funding Acknowledgement

Type of funding source: Public Institution(s). Main funding source(s): Liverpool university Hospitals, North-West Educational Cardiac Group

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