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Published on: August 28, 2018
Computed tomography coronary angiography after excluding myocardial infarction: high-sensitivity troponin versus risk
Won Jae Yoo1, Shin Ahn1, Bora Chae1
1Department of Emergency Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul 05505, Republic of Korea.
Insights
The HEART score is more effective than high-sensitivity troponin I (hsTnI) in identifying obstructive coronary artery disease (CAD) in patients with suspected acute coronary syndrome (ACS) after myocardial infarction is ruled out.
Area of Science:
- Cardiology
- Medical Imaging
- Diagnostic Accuracy
Background:
- Patients with suspected acute coronary syndrome (ACS) but no myocardial infarction can still have obstructive coronary artery disease (CAD).
- Intermediate high-sensitivity troponin I (hsTnI) concentrations are associated with a higher risk of obstructive CAD.
- Computed tomography coronary angiography (CTCA) is a potential downstream investigation for these patients.
Purpose of the Study:
- To compare the diagnostic performance of the HEART score versus hsTnI concentration in identifying obstructive CAD.
- To evaluate which approach better selects patients for CTCA.
Main Methods:
- Analysis of a prospective cohort of 433 patients presenting with suspected ACS.
- Patients had no elevated hsTnI and underwent CTCA.
- Comparison of HEART score and hsTnI using sensitivity, specificity, PPV, and NPV.
Main Results:
- Obstructive CAD was present in 27.7% of patients.
- Intermediate hsTnI and non-low-risk HEART scores were associated with higher rates of obstructive CAD.
- The HEART score demonstrated superior sensitivity (89.2% vs. 63.3%) and NPV (92.4% vs. 81.9%) compared to hsTnI.
Conclusions:
- The HEART score offers improved risk stratification for obstructive CAD compared to hsTnI in patients with suspected ACS after myocardial infarction exclusion.
- Utilizing the HEART score can enhance patient selection for CTCA, leading to more accurate diagnosis.
Background:
Patients with suspected acute coronary syndrome (ACS) in whom myocardial infarction has been ruled out are still at risk of having obstructive coronary artery disease (CAD). This rate is higher among patients with intermediate high-sensitivity troponin I (hsTnI) concentrations (5 ng/L to 99th percentile) than low concentrations (<5 ng/L). Therefore, an intermediate concentration has been suggested as a candidate for downstream investigation with computed tomography coronary angiography (CTCA). We tried to compare the HEART score-guided vs. hsTnI-guided approach for identifying obstructive CAD.
Methods:
From a prospective cohort study of patients presenting to the emergency department with suspected ACS, 433 patients without elevated hsTnI who also underwent CTCA were selected and analyzed. The performances of hsTnI concentration and HEART score were compared using sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV).
Results:
Overall, 120 (27.7%) patients had obstructive CAD. Patients with intermediate hsTnI concentrations were more likely to have obstructive CAD than those with low hsTnI concentrations (40.0% vs. 18.1%); patients with non-low-risk HEART scores (≥4 points) were also more likely to have obstructive CAD than those with low-risk scores (0 to 3 points) (41.0% vs. 7.6%). The HEART score had higher sensitivity and NPV for detecting obstructive CAD in each classification than hsTnI concentration (sensitivity: 89.2% vs. 63.3% NPV: 92.4% vs. 81.9%, respectively).
Conclusion:
After excluding myocardial infarction in patients with suspected ACS, adding the HEART score for selecting candidates for CTCA could improve patient risk stratification more accurately than relying on hsTnI concentration.
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