High sensitivity troponin - Six hours is the magic number
Rahul G Bhat1, Michael V Nguyen1, Omoyemen Blue1
1Department of Emergency Medicine, MedStar Georgetown University Hospital, 3800 Reservoir Rd. NW, Washington, DC, United States of America; Department of Emergency Medicine, MedStar Washington Hospital Center, 110 Irving St. NW, Washington, DC, United States of America.
Insights
High sensitivity troponin assays can safely rule out acute coronary syndrome in emergency department patients. A troponin level below the 99th percentile at 6 hours post-symptom onset indicates a low risk of adverse cardiac events.
Area of Science:
- Cardiology
- Emergency Medicine
- Biomarkers
Background:
- High sensitivity troponin (hs-cTn) assays are standard in emergency departments for acute chest pain evaluation.
- Assessing the utility of hs-cTn in ruling out acute coronary syndrome (ACS) is crucial for patient management.
Purpose of the Study:
- To determine if hs-cTn below the 99th percentile upper reference limit (URL) at ≥6 hours from symptom onset can safely exclude ACS.
- To evaluate the rate of adverse cardiac events in patients with specific hs-cTn levels and ECG findings.
Main Methods:
- A multicenter retrospective study of emergency department patients with chest pain admitted for further evaluation.
- Analysis of clinically relevant adverse cardiac events and non-ST-elevation myocardial infarction (NSTEMI) in relation to hs-cTn levels ( < 99th percentile URL) at ≥6 hours post-symptom onset.
Main Results:
- Among 1187 admitted patients, 30 adverse cardiac events occurred, all in patients with compelling reasons for admission or ischemic ECG.
- Three cases of NSTEMI were observed among 429 patients with hs-cTn < 99th percentile URL at ≥6 hours, non-ischemic ECG, and no other admission indication.
- No clinically relevant adverse cardiac events were found in this low-risk subgroup.
Conclusions:
- Patients with chest pain and hs-cTn levels between 3 ng/L and the 99th percentile URL at ≥6 hours have a low incidence of adverse cardiac events and NSTEMI.
- This finding supports the safe exclusion of ACS in selected patients presenting with chest pain.
Background:
High sensitivity troponin assays have become widespread for emergency department evaluation of acute chest pain. We assessed if a high sensitivity troponin under the 99th percentile upper reference limit drawn at 6 h or greater from symptom onset could safely rule out acute coronary syndrome in patients who did not meet the rapid rule-out strategy.
Methods:
We conducted a multicenter retrospective study examining emergency department patients with chest pain who did not meet rapid-rule out criteria and were admitted for further evaluation. Among these admitted patients, we assessed the rate of clinically relevant adverse cardiac events (death, cardiac or respiratory arrest, STEMI, or life-threatening arrhythmia) and NSTEMI in patients with high sensitivity troponin less than the 99th percentile value obtained after at least 6 h of chest pain.
Results:
Out of 1187 patients admitted, we found 30 clinically relevant adverse cardiac events, all of which occurred in patients admitted for another compelling reason or ischemic ECG. 36 patients had an NSTEMI, of which 33 were identified with high sensitivity troponin greater than 99th percentile upper reference limit within 6 h of chest pain onset. This left 0 clinically relevant adverse cardiac events and 3 NSTEMI among the 429 patients with high sensitivity troponin less than the 99th percentile at 6 h and nonischemic ECG and no other compelling reason for admission.
Conclusion:
This study assessed patients with chest pain with high sensitivity troponin values between 3 ng/L and the 99th percentile upper reference limit after 6 h of chest pain and found that they have a low rate of clinically relevant adverse cardiac events and NSTEMI.
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