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High-Sensitivity Troponin in Suspected MI
Study Questions:
How can high-sensitivity troponin (hs-Tn) concentrations, its change during serial sampling, and the time between sample be incorporated as a strategy to rule out myocardial infarction (MI) in patients presenting to the emergency department with chest pain?
Methods:
The COMPASS-MI (Calculation of Myocardial Infarction Risk Probabilities to Manage Patients With Suspicion of Myocardial Infarction) study combined data from 15 different international cohorts of patients (n = 22,651) presenting to the emergency department with symptoms suggestive of MI who had serial hs-Tn (Tn I or T) measurements. Patients with ST-segment elevation MI were excluded. The authors examined a wide range of cut-off concentrations of hs-Tn and a range of absolute changes to assess diagnostic performance in identifying patients at low or high risk of MI. The short-term prognostic endpoint was the composite of subsequent MI (excluding index event) and 30-day mortality. Evaluation of diagnostic performance was performed in 9,604 patients and validated in 13,047 patients. Last, the association between hs-Tn and long-term outcomes was examined in 7,682 matched pairs of participants (from the acute chest pain cohorts and 11 general population cohorts).
Results:
Of 22,651 patients, 3,455 (15.3%) presented with acute MI. The authors present the data by grouping patients according to negative predictive value/positive predictive value categories derived from combinations of hs-Tn cut-offs, absolute change in levels and resampling times (early 45-120 minutes vs. late 120-210 minutes). For example, hs-Tn <6 ng/L and an absolute change of <4 ng/L after 45-120 minutes resulted in a negative predictive value of 99.5% for MI. The authors provide risk-assessment diagrams and an online interactive risk calculator at http://www.compass-mi.com. Last, in patients without acute MI, they show that hs-Tn levels are strongly associated with a higher risk of long-term MI or death at 1 and 2 years.
Conclusions:
The diagnostic performance of hs-Tn for MI is dependent on baseline hs-Tn levels, their absolute change, and the time of sampling—all of which can be incorporated in a simple risk-assessment tool.
Perspective:
Nothing short of ‘landmark’ can be used to describe this study; the largest to define a clinical role for hs-Tn in diagnosing MI in the emergency department, using data from over 22,000 patients. Most importantly, the authors incorporated hs-Tn concentration, its absolute change, and resampling times in an easy-to-use tool that can be easily adopted in the clinical setting to derive negative and positive predictive values for MI. With the widespread use of hs-Tn measurements across large centers in Europe and the United States, such a tool is a boon for healthcare providers and will facilitate interpretation of what will arguably becoming amongst the most frequently performed tests.
Clinical Topics: Acute Coronary Syndromes, Cardiovascular Care Team, Prevention
Keywords: Acute Coronary Syndrome, Chest Pain, Emergency Service, Hospital, Myocardial Infarction, Primary Prevention, Probability, Prognosis, Risk Assessment, Troponin, Troponin I, Troponin T
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