Peak Troponin and CMR to Guide Management in Suspected ACS and Nonobstructive Coronary Arteries
Matthew G L Williams1, Kate Liang2, Estefania De Garate2
1Bristol Medical School, Faculty of Health Sciences, University of Bristol, Bristol, United Kingdom; Bristol Heart Institute, University Hospitals Bristol and Weston NHS Trust, Bristol, United Kingdom. Electronic address: https://twitter.com/mglwilliams.
Insights
Combining cardiac magnetic resonance (CMR) with peak troponin T levels significantly improves diagnostic yield in acute coronary syndrome (ACS) patients with nonobstructive coronary arteries. Early CMR (<14 days) and elevated troponin (≥211 ng/L) yields 94% diagnostic accuracy.
Area of Science:
- Cardiology
- Medical Imaging
- Biomarkers
Background:
- Acute coronary syndrome (ACS) with nonobstructive coronary arteries presents a diagnostic challenge.
- Cardiac magnetic resonance (CMR) has a diagnostic yield of approximately 75%, but fails to identify myocardial injury in about 25% of cases.
- Accurate diagnosis is crucial for patient management and outcomes.
Purpose of the Study:
- To evaluate if combining CMR with peak troponin levels enhances diagnostic yield in ACS patients with nonobstructive coronary arteries.
- To determine the optimal peak troponin T threshold for improved diagnostic accuracy when used with CMR.
Main Methods:
- Consecutive ACS patients with nonobstructive coronary arteries underwent CMR.
- The Youden index identified the optimal peak troponin T cut-off (211 ng/L).
- Logistic and Cox regression analyses assessed predictors of CMR diagnosis.
Main Results:
- Overall CMR diagnostic yield was 74%.
- Combining CMR with peak troponin T ≥211 ng/L performed <14 days yielded 94% diagnostic accuracy.
- Diagnostic yield was 72% for CMR performed ≥14 days, decreasing to 53% if peak troponin T was <211 ng/L.
Conclusions:
- Early CMR (<14 days) and peak troponin T ≥211 ng/L significantly increases diagnostic yield to 94%.
- Even delayed CMR (≥14 days) shows improved yield (72%) with elevated troponin.
- Peak troponin T levels are a valuable adjunct to CMR for diagnosing ACS in this patient group.
Background:
Patients presenting with acute coronary syndrome (ACS) and nonobstructive coronary arteries are a diagnostic dilemma. Cardiac magnetic resonance (CMR) has an overall diagnostic yield of ∼75%; however, in ∼25% of patients, CMR does not identify any myocardial injury. Identifying the underlying diagnosis has important clinical implications for patients' management and outcome.
Objectives:
The authors sought to assess whether the combination of CMR and peak troponin levels in patients with ACS and nonobstructive coronary arteries would lead to increased diagnostic yield.
Methods:
Consecutive patients with ACS and nonobstructive coronary arteries without an obvious cause underwent CMR. The primary endpoint of the study was the diagnostic yield of CMR. The Youden index was used to find the optimal diagnostic cut point for peak troponin T to combine with CMR to improve diagnostic yield. Logistic or Cox regression models were used to estimate predictors of a diagnosis by CMR.
Results:
A total of 719 patients met the inclusion criteria. The peak troponin T threshold for optimal diagnostic sensitivity and specificity was 211 ng/L. Overall, CMR has a diagnostic yield of 74%. CMR performed <14 days from presentation and with a peak troponin of ≥211 ng/L (n = 198) leads to an improved diagnostic yield (94% vs 72%) compared with CMR performed ≥14 days (n = 245). When CMR was performed <14 days and with a peak troponin of <211 ng/L, the diagnostic yield was 76% (n = 86) compared with 53% (n = 190) when performed ≥14 days. An increase in 1 peak troponin decile increases the odds of the CMR identifying a diagnosis by 20% (OR: 1.20; P = 0.008, 95% CI: 1.05-1.36).
Conclusions:
The combination of CMR performed <14 days from presentation and peak troponin T ≥211 ng/L leads to a very high diagnostic yield (94%) on CMR. The diagnostic yield remains high (72%) even when CMR is performed ≥14 days from presentation, but reduces to 53% when peak troponin T was <211 ng/L.
More Related Videos
06:16Signal Acquisition, Score Interpretation, and Economics of a Non-Invasive Point-of-Care Test for Coronary Artery Disease
Published on: August 9, 2024
06:29Cardiac Magnetic Resonance for the Evaluation of Suspected Cardiac Thrombus: Conventional and Emerging Techniques
Published on: June 11, 2019
Related Concept Videos
01:30Acute Coronary Syndrome III: Diagnostic Studies
01:30Acute Coronary Syndrome I: Introduction
01:19Acute Coronary Syndrome II: Pathophysiology and Clinical Manifestations
01:28Acute Coronary Syndrome IV: Interprofessional Care
01:26Acute Coronary Syndrome V: Nursing Management
01:25Imaging Studies for Cardiovascular System VI: Calcium -Scoring CT