Association of high-sensitivity cardiac troponin I concentration with cardiac outcomes in patients with suspected acute coronary syndrome

Chapman, A. R. et al. (2017) Association of high-sensitivity cardiac troponin I concentration with cardiac outcomes in patients with suspected acute coronary syndrome. JAMA: Journal of the American Medical Association, 318(19), pp. 1913-1924. (doi: 10.1001/jama.2017.17488) (PMID:29127948) (PMCID:PMC5710293)

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Abstract

Importance: High-sensitivity cardiac troponin I testing is widely used to evaluate patients with suspected acute coronary syndrome. A cardiac troponin concentration of less than 5 ng/L identifies patients at presentation as low risk, but the optimal threshold is uncertain. Objective: To evaluate the performance of a cardiac troponin I threshold of 5 ng/L at presentation as a risk stratification tool in patients with suspected acute coronary syndrome. Data Sources: Systematic search of MEDLINE, EMBASE, Cochrane, and Web of Science databases from January 1, 2006, to March 18, 2017. Study Selection: Prospective studies measuring high-sensitivity cardiac troponin I concentrations in patients with suspected acute coronary syndrome in which the diagnosis was adjudicated according to the universal definition of myocardial infarction. Data Extraction and Synthesis: The systematic review identified 19 cohorts. Individual patient-level data were obtained from the corresponding authors of 17 cohorts, with aggregate data from 2 cohorts. Meta-estimates for primary and secondary outcomes were derived using a binomial-normal random-effects model. Main Outcomes and Measures: The primary outcome was myocardial infarction or cardiac death at 30 days. Performance was evaluated in subgroups and across a range of troponin concentrations (2-16 ng/L) using individual patient data. Results: Of 11 845 articles identified, 104 underwent full-text review, and 19 cohorts from 9 countries were included. Among 22 457 patients included in the meta-analysis (mean age, 62 [SD, 15.5] years; n = 9329 women [41.5%]), the primary outcome occurred in 2786 (12.4%). Cardiac troponin I concentrations were less than 5 ng/L at presentation in 11 012 patients (49%), in whom there were 60 missed index or 30-day events (59 index myocardial infarctions, 1 myocardial infarction at 30 days, and no cardiac deaths at 30 days). This resulted in a negative predictive value of 99.5% (95% CI, 99.3%-99.6%) for the primary outcome. There were no cardiac deaths at 30 days and 7 (0.1%) at 1 year, with a negative predictive value of 99.9% (95% CI, 99.7%-99.9%) for cardiac death. Conclusions and Relevance: Among patients with suspected acute coronary syndrome, a high-sensitivity cardiac troponin I concentration of less than 5 ng/L identified those at low risk of myocardial infarction or cardiac death within 30 days. Further research is needed to understand the clinical utility and cost-effectiveness of this approach to risk stratification.

Item Type:Articles
Status:Published
Refereed:Yes
Glasgow Author(s) Enlighten ID:McAllister, Professor David
Authors: Chapman, A. R., Lee, K. K., McAllister, D. A., Cullen, L., Greenslade, J. H., Parsonage, W., Worster, A., Kavsak, P. A., Blankenberg, S., Neumann, J., Söerensen, N. S., Westermann, D., Buijs, M. M., Verdel, G. J.E., Pickering, J. W., Than, M. P., Twerenbold, R., Badertscher, P., Sabti, Z., Mueller, C., Anand, A., Adamson, P., Strachan, F., Ferry, A., Sandeman, D., Gray, A., Body, R., Keevil, B., Carlton, E., Greaves, K., Korley, F. K., Metkus, T. S., Sandoval, Y., Apple, F. S., Newby, D. E., Shah, A. S.V., and Mills, N. L.
College/School:College of Medical Veterinary and Life Sciences
College of Medical Veterinary and Life Sciences > Institute of Health and Wellbeing > Public Health
Journal Name:JAMA: Journal of the American Medical Association
Publisher:American Medical Association
ISSN:0098-7484
ISSN (Online):1538-3598
Published Online:11 November 2017

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Project CodeAward NoProject NamePrincipal InvestigatorFunder's NameFunder RefLead Dept
620161High-Sensitive Troponin in the evaluation of patients with Acute Coronary Syndrome (HighSTEACS): A randomised control trialColin BerryBritish Heart Foundation (BHF)SP/12/10/29922RI CARDIOVASCULAR & MEDICAL SCIENCES
754451Combining efficacy estimates from clinical trials with the natural history obtained from large routine healthcare databases to determine net overall treatment benefitsDavid McAllisterWellcome Trust (WELLCOTR)201492/Z/16/ZIHW - PUBLIC HEALTH