TY - JOUR
T1 - Risk stratification and role for additional diagnostic testing in patients with acute chest pain and normal high-sensitivity cardiac troponin levels
AU - Smulders, Martijn W.
AU - Bekkers, Sebastiaan C. A. M.
AU - van Cauteren, Yvonne J. M.
AU - Liefhebber, Anna
AU - Vermeer, Jasper R.
AU - Vervuurt, Juliette
AU - van Dieijen-Visser, Marja P.
AU - Mingels, Alma M. A.
AU - Rocca, Hans-Peter Brunner-La
AU - Dagnelie, Pieter C.
AU - Wildberger, Joachim E.
AU - Crijns, Harry J. G. M.
AU - Kietselaer, Bas L. J. H.
PY - 2018/9/7
Y1 - 2018/9/7
N2 - Background Normal high sensitivity cardiac troponin (hs-cTn) assays rule out acute myocardial infarction (AMI) with great accuracy, but additional non-invasive testing is frequently ordered. This observational study evaluates whether clinical characteristics can contribute to risk stratification and could guide referral for additional testing. Methods 918 serial patients with acute chest pain and normal hs-cTnT levels were prospectively included. Major adverse cardiac events (MACE) and non-invasive test results were assessed during one-year follow-up. Patients were classified as low and high risk based on clinical characteristics. Results MACE occurred in 6.1% of patients and mainly comprised revascularizations (86%). A recent abnormal stress test, suspicious history, a positive family history and higher baseline hs-cTnT levels were independent predictors of MACE with odds ratios of 16.00 (95% CI: 6.25 +/- 40.96), 16.43 (6.36 +/- 42.45), 2.33 (1.22 +/- 4.42) and 1.10 (1.01 +/- 1.21), respectively. Absence of both recent abnormal stress test and suspicious history identified 86% of patients. These patients were at very low risk for MACE (0.4% in 30-days and 2.3% in oneyear). Despite this, the majority (287/345 = 83%) of additional tests were performed in low risk patients, with <10% abnormal test findings. The diagnostic yield was significantly higher in the remaining higher risk patients, 40% abnormal test findings and a positive predictive value of 70% for MACE. Similar results were observed in patients without known coronary artery disease. Conclusions Clinical characteristics can be used to identify low risk patients with acute chest pain and normal hs-cTnT levels. Current strategies in the emergency department result in numerous additional tests, which are mostly ordered in patients at very low risk and have a low diagnostic yield.
AB - Background Normal high sensitivity cardiac troponin (hs-cTn) assays rule out acute myocardial infarction (AMI) with great accuracy, but additional non-invasive testing is frequently ordered. This observational study evaluates whether clinical characteristics can contribute to risk stratification and could guide referral for additional testing. Methods 918 serial patients with acute chest pain and normal hs-cTnT levels were prospectively included. Major adverse cardiac events (MACE) and non-invasive test results were assessed during one-year follow-up. Patients were classified as low and high risk based on clinical characteristics. Results MACE occurred in 6.1% of patients and mainly comprised revascularizations (86%). A recent abnormal stress test, suspicious history, a positive family history and higher baseline hs-cTnT levels were independent predictors of MACE with odds ratios of 16.00 (95% CI: 6.25 +/- 40.96), 16.43 (6.36 +/- 42.45), 2.33 (1.22 +/- 4.42) and 1.10 (1.01 +/- 1.21), respectively. Absence of both recent abnormal stress test and suspicious history identified 86% of patients. These patients were at very low risk for MACE (0.4% in 30-days and 2.3% in oneyear). Despite this, the majority (287/345 = 83%) of additional tests were performed in low risk patients, with <10% abnormal test findings. The diagnostic yield was significantly higher in the remaining higher risk patients, 40% abnormal test findings and a positive predictive value of 70% for MACE. Similar results were observed in patients without known coronary artery disease. Conclusions Clinical characteristics can be used to identify low risk patients with acute chest pain and normal hs-cTnT levels. Current strategies in the emergency department result in numerous additional tests, which are mostly ordered in patients at very low risk and have a low diagnostic yield.
KW - ACUTE MYOCARDIAL-INFARCTION
KW - CORONARY-ARTERY-DISEASE
KW - EMERGENCY-DEPARTMENT PATIENTS
KW - CT ANGIOGRAPHY
KW - RULE-OUT
KW - OUTCOMES
KW - YIELD
KW - INTERVENTIONS
KW - PCI
U2 - 10.1371/journal.pone.0203506
DO - 10.1371/journal.pone.0203506
M3 - Article
C2 - 30192899
SN - 1932-6203
VL - 13
JO - PLOS ONE
JF - PLOS ONE
IS - 9
M1 - e0203506
ER -