Chest pain with less than 20% change in high sensitivity troponin T - a low risk cohort?. Issue 2 (3rd March 2020)

• Record Type: Journal Article
• Authors: Weir, Robin A. P.; Osmanska, Joanna; Docherty, Kieran F.; Petrie, Colin J.
• Is Part Of: Acta cardiologica. Volume 75:Issue 2(2020)
• Page Start: 149
• Page End: 155
• Publication Date: 2020-03-03
• Subjects: High sensitivity troponin -- biomarkers -- acute coronary syndromes -- clinical risk stratification; Cardiology -- Periodicals; Cardiology; Cardiologie -- Périodiques; Cardiology; Cardiologie; Periodicals; Periodicals; 616.12005
• DOI: 10.1080/00015385.2018.1561598
• Languages: English
• ISSNs: 0001-5385

Abstract

Abstract: Background: Patients with chest pain are risk-stratified using serial high-sensitivity troponin (T) assays (hsTnT). Those with change in (Δ)hsTnT <20% are often categorised as low-risk and are less likely to be managed as acute coronary syndromes (ACS). We sought to characterise such a population of 'low-risk' chest pain presenters. Methods: We performed a retrospective cohort analysis of sequential patients admitted to our centre over a 1-year period with chest pain, absence of ST-elevation, with elevated hsTnT concentrations, and compared demographic, clinical and outcome data according to ΔhsTnT. Results: Three hundred and eleven patients were subdivided by ΔhsTnT [<20% ( n = 80), 20–100% ( n = 78), >100% ( n = 153)]. Baseline demographic data were well-matched across the three subgroups; atrial fibrillation was more common in the two lower magnitude ΔhsTnT groups. Obstructive coronary artery disease (CAD) – while less common in those with ΔhsTnT <20% (66.2%) compared to the 20–100% (73.1%) and >100% (75.9%) groups ( p = 0.03) – remained high in this lower risk group, and indeed revascularisation occurred in >60% of patients, equally frequently in all three groups. Using absolute ΔhsTnT ≥9ng/L within the ΔhsTnT <20% group provided incremental value in ruling in ACS, with a positive predictive value of 74.1%. ΔhsTnT was a univariate but not a multivariate predictor of obstructive CAD. Conclusions: Obstructive CAD and need for revascularisation are frequent in chest pain presenters with ΔhsTnT <20%. The increasing focus on hsTnT algorithms to exclude ACS and promote early discharge without adequate clinical risk stratification modelling risks misdiagnosis of patients presenting with acute myocardial ischaemia with a low-level hsTnT rise.