Prognostic Utility of a Modified HEART Score When Different Troponin Cut Points Are Used
Lindsey Aurora1, James McCord1, Richard Nowak2
1From the Heart and Vascular Institute, Henry Ford Health System, Detroit, MI.
Insights
The HEART score (HS) combined with normal cardiac troponin (cTn) effectively identifies low-risk acute myocardial infarction (AMI) patients. However, using higher cTn cut points significantly reduces the prognostic accuracy of this low-risk strategy.
Area of Science:
- Cardiology
- Emergency Medicine
- Clinical Diagnostics
Background:
- The 99th percentile is the recommended cut point for cardiac troponin (cTn) in diagnosing acute myocardial infarction (AMI).
- Many institutions utilize higher cTn cut points, potentially impacting diagnostic accuracy.
- Prior research suggests a modified HEART score (HS ≤ 3 with normal serial cTn) identifies low-risk patients.
Purpose of the Study:
- To evaluate the prognostic utility of the HEART score (HS) in diagnosing acute myocardial infarction (AMI).
- To assess the impact of various cardiac troponin (cTn) cut points on the prognostic value of the HS.
- To determine the effectiveness of the modified HS in identifying low-risk patients across different cTn thresholds.
Main Methods:
- A substudy of the TRAPID-AMI multicenter trial involving 1282 patients evaluated for AMI.
- High-sensitivity cardiac troponin T (hs-cTnT) levels were measured at presentation and 2 hours.
- The HEART score (HS) was calculated for each patient, using the FDA-approved 99th percentile (19 ng/L) for hs-cTnT.
Main Results:
- 213 (17%) patients were diagnosed with AMI.
- Adverse event rates (death/AMI) at 30 days for HS ≤ 3 and nonelevated hs-cTnT ranged from 0.6% to 5.1% across increasing cTn cut points.
- The prognostic utility of the HS strategy decreased significantly with higher hs-cTnT cut points.
Conclusions:
- Using the 99th percentile cut point for hs-cTnT, a HS ≤ 3 with normal serial hs-cTnT identifies a low-risk cohort for potential emergency department discharge.
- The prognostic value of this low-risk strategy is diminished when higher hs-cTnT cut points are employed.
- This study highlights the importance of adhering to recommended cTn cut points for accurate risk stratification in suspected AMI.
Background:
Although the recommended cut point for cardiac troponin (cTn) is the 99th percentile, many institutions use cut points that are multiples higher than the 99th percentile for diagnosing acute myocardial infarction (AMI). Prior studies have shown that patients with a HEART score (HS) ≤ 3 and normal serial cTn values (modified HS) are at low risk for adverse events. This study aimed to evaluate the prognostic utility of the HS when various cTn cut points are used.
Methods:
This was a substudy of High Sensitivity Cardiac Troponin T assay for RAPID Rule-out of Acute Myocardial Infarction (TRAPID-AMI), a multicenter, international trial evaluating a rapid rule-out AMI study using high-sensitivity cardiac troponin T (hs-cTnT). One-thousand two-hundred eighty-two patients were evaluated for AMI from 12 centers in Europe, United States, and Australia from 2011 to 2013. Blood samples of hs-cTnT were collected at presentation and 2 hours, and each patient had a HS calculated. The US Food and Drug Administration approved 99th percentile for hs-cTnT (19 ng/L) was used.
Results:
There were 213 (17%) AMIs. Within 30 days, there were an additional 2 AMIs and 8 deaths. The adverse event rates at 30 days (death/AMI) for a HS ≤ 3 and nonelevated hs-cTnT over 2 hours using increasing hs-cTnT cut points ranged from 0.6% to 5.1%.
Conclusions:
Using the recommended 99th percentile cut point for hs-cTnT, the combination of a HS ≤ 3 with nonelevated hs-cTnT values over 2 hours identifies a low-risk cohort who can be considered for discharge from the emergency department without further testing. The prognostic utility of this strategy is greatly lessened as higher hs-cTnT cut points are used.
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