. Troponin limit of detection plus cardiac risk

. Troponin limit of detection plus cardiac risk

.

Troponin limit of detection plus cardiac risk stratification scores for the exclusion
of myocardial infarction and 30-day adverse cardiac events in ED patients
Kelly M. Gray, MD; Mitchell D. Datlow, MA; Deborah B. Diercks, MD, MSc; Bryn E. Mumma, MD, MAS
University of California Davis, Department of Emergency Medicine, Sacramento, CA
INTRODUCTION
INTRODUCTION

Over 10 million patients present to EDs in the US
annually with chest pain; 10% have acute coronary
syndromes
Evaluation for acute myocardial infarction (AMI)
typically involves serial troponins
When screening for MI, troponins below the 99th
percentile (0.04ng/ml), including those below the limit
of detection (LOD; 0.01ng/ml), are considered normal
HEART Score and ACS Pretest Probability
assessment can risk-stratify ED patients with possible
AMI
Hypothesis: Low-risk HEART Score (0-3) or an ACS
Pretest Probability Assessment < 2% plus an initial troponin below the LOD would exclude both AMI during admission and 30-day major adverse cardiac events METHODS METHODS Retrospective cohort study at single academic ED Included patients who had a troponin I test (Siemens Ultra Troponin I) from 9/1/13 to 11/13/13 Excluded those with missing encounter diagnosis (n=21) Abstracted data from electronic medical record: Demographic and clinical characteristics Laboratory and ECG results Diagnoses 30-day return visits Calculated HEART Score (Table 1a) & ACS Pretest Probability (Table 1b) An ACS Pretest Probability cutpoint of <2% was chosen because HEART score 0-3 corresponds to <2% risk Primary outcome = Final encounter diagnosis of AMI Secondary outcome = Composite of MI, revascularization, and death from a cardiac or uncertain etiology at 30 days Descriptive statistics presented FIGURE AND AND TABLES TABLES FIGURE Table 1a. HEART Score Variable History Highly suspicious Moderately suspicious Slightly suspicious EKG Significant ST-depression Non-specific repolarization disturbance Normal Age 65 45-64 < 45 Risk Factors 3 or history of atherosclerotic disease 1-2 risk factors No known risk factors Troponin > 3 times the normal limit
1-3 times the normal limit
normal limit
Total Score

Table 1b. ACS
Pretest Probability
Assessment

RESULTS
RESULTS

Table 2. Patient Characteristics
Score

Characteristics

N (%)

Demographic characteristics

2
1
0

Age (median)
Male sex

460 (52%)

2
1

Race/ethnicity
White, non-Hispanic

265 (30%)

62 (IQR 52-74)

White, Hispanic
2
1
0
2
1
0
2
1
0

72 (8%)

Black

115 (13%)

Asian

54 (6%)

Other

56 (6%)

Unreported

266 (30%)

Clinical characteristics
Chief complaint of chest pain

309 (35%)

Coronary artery disease

243 (27%)

Diabetes
Smoking
Troponin below LOD
Risk Categories
Low Risk HEART score (0-3)
ACS Pre-test Probability <2% 329 (37%) 246 (28%) 422 (48%) 30-day follow-up not available 151 (17%) 333 (38%) 143 (16%) Acute MI (n=888) Difference 98% -- Age Race Chest pain w/ palpation HEART Score 0-3 ACS Pretest Probability <2% Personal history of CAD Troponin below LOD Diaphoresis HEART Score 0-3 + Troponin below LOD ACS Pretest Probability <2% + Troponin below LOD EKG ST depression > 0.5mm
T Wave inversion > 0.5mm

LIMITATIONS
LIMITATIONS

Table 3. Comparison of Sensitivities

Variables
Gender

888 patients
Median age 62 (IQR 52-74) years; 460 (52%) male
(Table 2)
422 (48%) had initial troponin below the LOD
49 (5.5%) had encounter diagnosis of AMI
80 (11%) had 30-day composite outcome
HEART score sensitivity for AMI (Table 3)
Alone: 98% (95% CI 89100%)
With troponin below the LOD: 100% (95% CI
93100%; difference 2%, 95% CI -26%)
ACS Pretest Probability <2% sensitivity for AMI (Table 3) Alone: 96% (95% CI 86100%) With troponin below the LOD: 100% (95% CI 93100%; difference 4%, 95% CI -1.510%) (95%CI 89-100%) 96% (95%CI 86-98%) -- (95%CI 86-100%) 97% 30-day Difference Composite (n=737) 94% -95% Single center study Relatively small sample size with low proportion of AMIs 30-day follow-up not available for 151 patients (17%) -- (95%CI 88-99%) -- (95%CI 90-100%) 89% -- (95%CI 80-95%) 100% 2% 100% 6% (95%CI 93-100%) (95%CI -2 to 6%) (95%CI 95-100%) (95%CI 1-12%) 100% 4% 100% 5% (95%CI 93-100%) (95% CI -1.5 to 10%) (95%CI 95-100%) (95%CI 0.2-10%) ACKNOWLEDGEMENTS ACKNOWLEDGEMENTS This project was supported by the National Institutes of Health (NIH) through grants K12HL108964, K08HL130546, and UL1TR001860 CONCLUSIONS CONCLUSIONS Patients with an initial troponin I value below the LOD and a low-risk HEART Score or ACS Pretest Probability <2% had no acute MIs or 30day adverse cardiac events Addition of a single troponin below the LOD to these scores improves sensitivity for 30-day adverse cardiac events

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