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Sex-Specific Thresholds of High-Sensitivity Troponin in ACS Patients
Study Questions:
How do sex-specific thresholds for high-sensitivity troponin I (hs-TnI) in the evaluation of patients with suspected acute coronary syndrome (ACS) impact differences in diagnosis of myocardial injury and outcomes between men and women?
Methods:
This study is a prespecified secondary analysis of the High-STEACS (High-Sensitivity Troponin in the Evaluation of Patients With Suspected Acute Coronary Syndrome) trial, which evaluated the impact of incorporating hs-TnI in the evaluation of patients suspected of ACS on outcomes. A total of 48,282 consecutive patients (47% women) with suspected ACS were enrolled across 10 hospitals in Scotland, in two phases: a validation phase of 6 months during which the contemporary TnI assay was used to guide clinical decisions, and an implementation phase of 6-24 months during which only results of the high-sensitivity assays were disclosed. Myocardial injury was defined as hs-TnI >99th percentile of 16 ng/L in women and 34 ng/L in men. The primary outcome was recurrent myocardial infarction or cardiovascular death at 1 year.
Results:
The majority of patients reclassified by the hs-cTnI assay and sex-specific thresholds were women (1,470 of 1,771 women [83%] vs. 301 of 1,771 men [17%]). Women were also more likely to be reclassified in all diagnoses; nonischemic myocardial injury and both type 1 and type 2 myocardial infarctions. Both women and men reclassified by the hs-cTnI assay were less likely to have myocardial ischemia on electrocardiography but had similar age, presenting symptoms, and cardiovascular risk factors. There was no significant difference in the primary outcome in women before (18%) and after (17%) implementation. Despite the use of gender-specific thresholds and overall increase in downstream use of coronary angiography, women with myocardial injury remained less likely than men to undergo coronary revascularization (15% vs. 34%) and to receive dual antiplatelet (26% vs. 43%), statin (16% vs. 26%), or other preventive therapies (p < 0.001 for all). Interestingly, the efficacy of coronary revascularization and dual antiplatelet therapy in reducing the primary outcome was lower in women compared to men.
Conclusions:
Use of sex-specific thresholds identified 5 times more additional women than men with myocardial injury. Despite this increase, women received approximately one-half the number of treatments for coronary artery disease as men, and outcomes were not improved.
Perspective:
The study’s major highlight is that the disparities in treatment between men and women extend beyond diagnostic thresholds. Despite the use of gender-specific thresholds and the increase in the rate of diagnosis of myocardial injury, women were still less likely to receive treatment for coronary artery disease compared to men. While there was an increase in the diagnosis in nonischemic myocardial injury in women, the disparities in treatment were persistent even in the subgroup with type 1 myocardial infarction. Overall there were no differences in outcomes, and the study design does not allow us to determine whether these disparities translate to relatively worse outcomes in women with ACS.
Clinical Topics: Acute Coronary Syndromes, Cardiac Surgery, Dyslipidemia, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Prevention, Atherosclerotic Disease (CAD/PAD), Cardiac Surgery and Arrhythmias, Nonstatins, Novel Agents, Statins, Interventions and ACS, Interventions and Coronary Artery Disease, Interventions and Imaging, Angiography, Nuclear Imaging
Keywords: Acute Coronary Syndrome, Anterior Wall Myocardial Infarction, Coronary Angiography, Coronary Artery Disease, Electrocardiography, Hydroxymethylglutaryl-CoA Reductase Inhibitors, Myocardial Infarction, Myocardial Ischemia, Myocardial Revascularization, Platelet Aggregation Inhibitors, Primary Prevention, Risk Factors, Troponin I
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