Chapman, A. R. et al. (2020) High-sensitivity cardiac troponin and the universal definition of myocardial infarction. Circulation, 141(3), pp. 161-171. (doi: 10.1161/CIRCULATIONAHA.119.042960) (PMID:31587565) (PMCID:PMC6970546)
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Abstract
Background: The introduction of more sensitive cardiac troponin assays has led to increased recognition of myocardial injury in acute illnesses other than acute coronary syndrome. The Universal Definition of Myocardial Infarction recommends high-sensitivity cardiac troponin (hs-cTn) testing and classification of patients with myocardial injury based on aetiology, but the clinical implications of implementing this guideline are not well understood. Methods: In a stepped-wedge cluster randomized controlled trial, we implemented a hs-cTn assay and the recommendations of the Universal Definition in 48,282 consecutive patients with suspected acute coronary syndrome. In a pre-specified secondary analysis, we compared the primary outcome of myocardial infarction or cardiovascular death and secondary outcome of non-cardiovascular death at one year across diagnostic categories. Results: Implementation increased the diagnosis of type 1 myocardial infarction by 11% (510/4,471), type 2 myocardial infarction by 22% (205/916), and acute and chronic myocardial injury by 36% (443/1,233) and 43% (389/898), respectively. Compared to those without myocardial injury, the rate of the primary outcome was highest in those with type 1 myocardial infarction (cause-specific hazard ratio [csHR] 5.64, 95% confidence interval [CI] 5.12 to 6.22), but was similar across diagnostic categories, whereas non-cardiovascular deaths were highest in those with acute myocardial injury (csHR 2.65, 95%CI 2.33 to 3.01). Despite modest increases in anti-platelet therapy and coronary revascularization after implementation in patients with type 1 myocardial infarction, the primary outcome was unchanged (csHR 1.00, 95%CI 0.82 to 1.21). Increased recognition of type 2 myocardial infarction and myocardial injury did not lead to changes in investigation, treatment or outcomes. Conclusions: Implementation of high-sensitivity cardiac troponin and the recommendations of the Universal Definition of Myocardial Infarction identified patients at high-risk of cardiovascular and non-cardiovascular events, but was not associated with consistent increases in treatment or improved outcomes. Trials of secondary prevention are urgently required to determine whether this risk is modifiable in patients without type 1 myocardial infarction.
| Item Type: | Articles |
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| Additional Information: | This trial was funded by a Special Project Grant from the British Heart Foundation (SP/12/10/29922) with additional support from a British Heart Foundation-Turing 22 Cardiovascular Data Science Award (BCDSA/100003) and British Heart Foundation Research Excellence Award (RE/18/5/34216; RE/18/6/3421). ARC, NLM and DEN are supported by Clinical Research Training Fellowship (FS/16/75/32533), Butler Senior Clinical Research Fellowship (FS/16/14/32023) and Chair (CH/09/002) awards from the British Heart Foundation. ARC also receives support from a Starter Grant for Clinical Lecturers from the Academy of Medical Sciences (SGL021\1075). CJW was supported by the National Health Service (NHS) in Lothian through the Edinburgh Clinical Trials Unit. Abbott Laboratories provided cardiac troponin assay reagents, calibrators, and controls without charge. The funders played no role in the design, conduct, data collection, analysis or reporting of the trial. |
| Status: | Published |
| Refereed: | Yes |
| Glasgow Author(s) Enlighten ID: | McAllister, Professor David and Berry, Professor Colin |
| Authors: | Chapman, A. R., Adamson, P. D., Shah, A. S.V., Anand, A., Strachan, F. E., Ferry, A. V., Lee, K. K., Berry, C., Findlay, I., Cruikshank, A., Reid, A., Gray, A., Collinson, P. O., Apple, F., McAllister, D., McAllister, D. A., Maguire, D., Fox, K. A.A., Vallejos, C. A., Keerie, C., Weir, C. J., Newby, D. E., and Mills, N. L. |
| College/School: | College of Medical Veterinary and Life Sciences > School of Cardiovascular & Metabolic Health College of Medical Veterinary and Life Sciences > School of Health & Wellbeing > Public Health |
| Journal Name: | Circulation |
| Publisher: | American Heart Association |
| ISSN: | 0009-7322 |
| ISSN (Online): | 1524-4539 |
| Published Online: | 07 October 2019 |
| Copyright Holders: | Copyright © 2019 The Authors |
| First Published: | First published in Circulation 141(3):161-171 |
| Publisher Policy: | Reproduced under a Creative Commons License |
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