Patrick Badertscher1,2, Jasper Boeddinghaus1,3,2, Thomas Nestelberger1,3,2, Raphael Twerenbold1,2,4, Karin Wildi1,2, Zaid Sabti1,2, Christian Puelacher1,2, Maria Rubini Giménez1,2, Julian Pfäffli1, Dayana Flores1,2, Jeanne du Fay de Lavallaz1,2, Òscar Miró2,5, F Javier Martin-Sanchez6, Beata Morawiec2,7, Jens Lohrmann1, Andreas Buser8, Dagmar I Keller9, Nicolas Geigy10, Tobias Reichlin1,2, Christian Mueller11,2. 1. Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland. 2. GREAT network, Sao Paulo, Brazil. 3. Department of Internal Medicine, University Hospital Basel, University of Basel, Basel, Switzerland. 4. Department of General and Interventional Cardiology, Hamburg University Heart Center, Hamburg, Germany. 5. Emergency Department, Hospital Clinic, University of Barcelona, Barcelona, Spain. 6. Servicio de Urgencias, Hospital Clínico San Carlos, Madrid, Spain. 7. 2nd Department of Cardiology, School of Medicine with the Division of Dentistry in Zabrze, Medical University of Katowice, Katowice, Poland. 8. Blood Transfusion Centre, Swiss Red Cross, and Department of Hematology, University Hospital Basel, University of Basel, Basel, Switzerland. 9. Emergency Department, University Hospital Zurich, Zurich, Switzerland. 10. Emergency Department, Kantonsspital, Liestal, Switzerland. 11. Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland; christian.mueller@usb.ch.
Abstract
BACKGROUND: There is concern that high-sensitivity cardiac troponin (hs-cTn) may have low diagnostic accuracy in patients with low acute coronary syndrome (ACS) probability. METHODS: We prospectively stratified patients presenting with acute chest discomfort to the emergency department (ED) into 3 groups according to their probability for ACS as assessed by the treating ED physician using a visual analog scale: ≤10%, 11% to 79%, and ≥80%, reviewing all information available at 90 min. hs-cTnT and hs-cTnI concentrations were determined in a blinded fashion. Two independent cardiologists adjudicated the final diagnosis. RESULTS: Among 3828 patients eligible for analysis, 1189 patients had low (≤10%) probability for ACS. The incidence of non-ST-segment elevation myocardial infarction (NSTEMI) increased from 1.3% to 12.2% and 54.8% in patients with low, intermediate, and high ACS probability, respectively. The positive predictive value of hs-cTnT and hs-cTnI was low in patients with low ACS probability and increased with the incidence of NSTEMI, whereas the diagnostic accuracy of hs-cTnT and hs-cTnI for NSTEMI as quantified by the area under the curve (AUC) was very high and comparable among all 3 strata, e.g., AUC hs-cTnI, 0.96 (95% CI, 0.94-0.97); 0.87 (95% CI, 0.85-0.89); and 0.89 (95% CI, 0.87-0.92), respectively. Findings were validated using bootstrap analysis as an alternative methodology to define ACS probability. Similarly, higher hs-cTnT/I concentrations independently predicted all-cause mortality within 2 years (e.g., hs-cTnT hazard ratio, 1.39; 95% CI, 1.27-1.52), irrespective of ACS probability. CONCLUSIONS: Diagnostic and prognostic accuracy and utility of hs-cTnT and hs-cTnI remain high in patients with acute chest discomfort and low ACS probability.ClinicalTrials.gov Identifier: NCT00470587.
BACKGROUND: There is concern that high-sensitivity cardiac troponin (hs-cTn) may have low diagnostic accuracy in patients with low acute coronary syndrome (ACS) probability. METHODS: We prospectively stratified patients presenting with acute chest discomfort to the emergency department (ED) into 3 groups according to their probability for ACS as assessed by the treating ED physician using a visual analog scale: ≤10%, 11% to 79%, and ≥80%, reviewing all information available at 90 min. hs-cTnT and hs-cTnI concentrations were determined in a blinded fashion. Two independent cardiologists adjudicated the final diagnosis. RESULTS: Among 3828 patients eligible for analysis, 1189 patients had low (≤10%) probability for ACS. The incidence of non-ST-segment elevation myocardial infarction (NSTEMI) increased from 1.3% to 12.2% and 54.8% in patients with low, intermediate, and high ACS probability, respectively. The positive predictive value of hs-cTnT and hs-cTnI was low in patients with low ACS probability and increased with the incidence of NSTEMI, whereas the diagnostic accuracy of hs-cTnT and hs-cTnI for NSTEMI as quantified by the area under the curve (AUC) was very high and comparable among all 3 strata, e.g., AUC hs-cTnI, 0.96 (95% CI, 0.94-0.97); 0.87 (95% CI, 0.85-0.89); and 0.89 (95% CI, 0.87-0.92), respectively. Findings were validated using bootstrap analysis as an alternative methodology to define ACS probability. Similarly, higher hs-cTnT/I concentrations independently predicted all-cause mortality within 2 years (e.g., hs-cTnT hazard ratio, 1.39; 95% CI, 1.27-1.52), irrespective of ACS probability. CONCLUSIONS: Diagnostic and prognostic accuracy and utility of hs-cTnT and hs-cTnI remain high in patients with acute chest discomfort and low ACS probability.ClinicalTrials.gov Identifier: NCT00470587.
Authors: Antonio Haddad Tapias Filho; Gustavo Bernardes de Figueiredo Oliveira; João Italo Dias França; Rui Fernando Ramos Journal: Arq Bras Cardiol Date: 2022-05-09 Impact factor: 2.667