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Chest Pain in Cancer Patients: Prevalence of MI and Troponin Performance
Quick Takes
- The purpose of this study was to evaluate the prevalence of AMI and related outcomes in patients with active or past cancer presenting with acute chest pain to the ED, and to assess the diagnostic performance of chest pain characteristics, electrocardiographic signatures, and high-sensitivity cardiac troponin concentrations.
- Patients with active or past cancer had a 1.5 times higher prevalence of NSTEMI compared to those without cancer, with a more extended hospital stay and longer ED duration; the diagnostic tools showed similar accuracy for both groups, with the exception of lower efficacy in ruling out AMI in patients with cancer using the ESC 0/1-hour algorithm.
- The differences observed in patients with cancer highlight the complexity of their management and the special considerations warranted in their evaluation.
Study Questions:
In patients with active or past cancer presenting with acute chest pain to the emergency department (ED), how do the diagnostic performance of chest pain characteristics, electrocardiography (ECG), and high-sensitivity cardiac troponin (hs-cTn) compare to those without a history of cancer, in terms of the prevalence of acute myocardial infarction (AMI) (particularly non–ST-segment elevation myocardial infarction [NSTEMI]), time to discharge, hospitalization rates, and long-term outcomes?
Methods:
The study is a secondary analysis from the APACE (Advantageous Predictors of Acute Coronary Syndromes Evaluation) study, a multicenter, international, prospective diagnostic study conducted in 12 EDs across five European countries. The main cohort included 8,267 patients, with 711 (8.6%) having an active or past cancer. The primary outcome measures were the prevalence of AMI, time to discharge from the ED, hospitalization rate, and diagnostic accuracy of chest pain characteristics, ECG, and hs-cTn concentrations. Results were externally validated in an independent, prospective, multicenter, international cohort, the TRAPID-AMI study (High-sensitivity cardiac Troponin T assay for RAPID rule-out of AMI).
Results:
Of 8,267 patients presenting to the ED with acute chest pain, 711 (8.6%) had an active or past cancer (83.3% with a solid malignancy). The prevalence of AMI was significantly higher in patients with active or past cancer (26.8%) compared to those without cancer (21.1%). This difference was largely due to a higher proportion of NSTEMIs in cancer patients (23.8% vs. 16.9%). The diagnostic accuracy of chest pain characteristics and ECG was similar in both groups, but lower for hs-cTn in patients with cancer. The efficacy of the European Society of Cardiology (ESC) 0/1-hour rule-out algorithm was lower in cancer patients (61.0% vs. 80.0%). Hospitalization rates and ED stays were longer for cancer patients, reflecting higher complexity. Cancer patients were also treated with fewer invasive procedures (67.6% vs. 74.7% for coronary angiography). Five-year all-cause mortality was 34.4% in cancer patients versus 8.9% in noncancer patients. Findings in the TRAPID-AMI study were comparable to the main cohort.
Conclusions:
Patients with active or past cancer presenting with acute chest pain are at a higher risk of NSTEMI, prolonged hospitalization, and all-cause mortality, with lower efficacy of the ESC 0/1-hour rule-out algorithm.
Perspective:
This well-conducted secondary analysis of two prospective multicenter diagnostic cohorts offers several intriguing perspectives that broaden the understanding of the relationship between cancer and AMI. One major finding emphasized that patients with active or past cancer had approximately 1.5 times the prevalence of NSTEMI. This result could be attributed to factors such as higher age, prevalence of cardiovascular risk factors, and the prothrombotic effects of malignancies themselves or their treatment. The observation of longer hospitalization rates and ED stays for cancer patients and lower rate of invasive procedures reflects the complexity of managing these patients, suggesting specialized care protocols may be needed for this patient population. These data solidify our understanding of the current landscape of AMI management in patients with cancer and highlight important disparities in that patient population compared to patients without cancer.
Clinical Topics: Acute Coronary Syndromes, Cardio-Oncology, Cardiovascular Care Team, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Prevention, Stable Ischemic Heart Disease, Vascular Medicine, ACS and Cardiac Biomarkers, Interventions and ACS, Interventions and Imaging, Interventions and Vascular Medicine, Angiography, Nuclear Imaging, Chronic Angina
Keywords: Acute Coronary Syndrome, Biomarkers, Cardiotoxicity, Chest Pain, Coronary Angiography, Electrocardiography, Emergency Service, Hospital, ESC23, ESC Congress, Myocardial Infarction, Myocardial Ischemia, Non-ST Elevated Myocardial Infarction, Patient Discharge, Secondary Prevention, Troponin T
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