Effect of Acute Coronary Syndrome Probability on Diagnostic and Prognostic Performance of High-Sensitivity Cardiac Troponin.

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.

• Authors: Patrick Badertscher, Jasper Boeddinghaus, Thomas Nestelberger, Raphael Twerenbold, Karin Wildi, Zaid Sabti, Christian Puelacher, Maria Rubini Giménez, Julian Pfäffli, Dayana Flores, Jeanne du Fay de Lavallaz, Òscar Miró, F Javier Martin-Sanchez, Beata Morawiec, Jens Lohrmann, Andreas Buser, Dagmar I Keller, Nicolas Geigy, Tobias Reichlin, Christian Mueller
• Journal: Clinical chemistry (Clin Chem) Vol. 64 Issue 3 Pg. 515-525 (03 2018) ISSN: 1530-8561 [Electronic] England
• PMID: 29343534 (Publication Type: Journal Article, Multicenter Study, Observational Study, Research Support, Non-U.S. Gov't)
• Copyright: © 2017 American Association for Clinical Chemistry.

Chemical References

• Biomarkers
• Troponin I
• Troponin T

Topics

• Acute Coronary Syndrome (blood, diagnosis)
• Adult
• Aged
• Biomarkers (blood)
• Female
• Humans
• Incidence
• Male
• Middle Aged
• Myocardial Infarction (blood, diagnosis, epidemiology)
• Probability
• Sensitivity and Specificity
• Troponin I (blood)
• Troponin T (blood)