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Effect of Acute Coronary Syndrome Probability on Diagnostic and Prognostic Performance of High-Sensitivity Cardiac
Patrick Badertscher1,2, Jasper Boeddinghaus1,3,2, Thomas Nestelberger1,3,2
1Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland.
Insights
High-sensitivity cardiac troponin assays demonstrate high diagnostic and prognostic accuracy for acute coronary syndrome (ACS) even in patients with low pre-test probability. These findings support the utility of hs-cTn in emergency department chest discomfort evaluations.
Area of Science:
- Cardiology
- Emergency Medicine
- Biomarker Analysis
Background:
- Concerns exist regarding the diagnostic accuracy of high-sensitivity cardiac troponin (hs-cTn) in patients with low pre-test probability for acute coronary syndrome (ACS).
- Accurate risk stratification is crucial for timely diagnosis and management of ACS in the emergency department (ED).
Purpose of the Study:
- To evaluate the diagnostic and prognostic accuracy of hs-cTn assays (hs-cTnT and hs-cTnI) in patients presenting with acute chest discomfort across varying probabilities of ACS.
- To determine if hs-cTn utility is maintained in patients with low ACS probability.
Main Methods:
- A prospective study involving 3828 patients presenting to the ED with acute chest discomfort.
- Patients were stratified into low (≤10%), intermediate (11-79%), and high (≥80%) ACS probability groups based on physician assessment at 90 minutes.
- hs-cTnT and hs-cTnI concentrations were measured, and diagnoses were adjudicated by independent cardiologists.
Main Results:
- The diagnostic accuracy (AUC) of hs-cTnT and hs-cTnI for non-ST-segment elevation myocardial infarction (NSTEMI) was high and comparable across all ACS probability strata (e.g., hs-cTnI AUCs ranging from 0.87 to 0.96).
- While the positive predictive value was lower in the low ACS probability group, overall diagnostic performance remained robust.
- Elevated hs-cTnT/I concentrations independently predicted 2-year all-cause mortality, irrespective of ACS probability.
Conclusions:
- hs-cTn assays maintain high diagnostic and prognostic accuracy for ACS in patients with low pre-test probability.
- The findings support the continued use and clinical utility of hs-cTn in the initial evaluation of patients with acute chest discomfort in the ED.
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.
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