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Published byAdelia Jefferson Modified over 6 years ago
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. 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 FIGURE AND TABLES RESULTS 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 89–100%) With troponin below the LOD: 100% (95% CI 93–100%; difference 2%, 95% CI -2–6%) ACS Pretest Probability <2% sensitivity for AMI (Table 3) Alone: 96% (95% CI 86–100%) With troponin below the LOD: 100% (95% CI 93–100%; difference 4%, 95% CI -1.5–10%) 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 Table 1a. HEART Score Table 2. Patient Characteristics Variable Score History Highly suspicious 2 Moderately suspicious 1 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 Characteristics N (%) Demographic characteristics Age (median) 62 (IQR 52-74) Male sex 460 (52%) Race/ethnicity White, non-Hispanic 265 (30%) White, Hispanic 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 329 (37%) Smoking 246 (28%) Troponin below LOD 422 (48%) Risk Categories Low Risk HEART score (0-3) 333 (38%) ACS Pre-test Probability <2% 143 (16%) 30-day follow-up not available 151 (17%) LIMITATIONS METHODS Table 1b. ACS Pretest Probability Assessment Single center study Relatively small sample size with low proportion of AMIs 30-day follow-up not available for 151 patients (17%) 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 Table 3. Comparison of Sensitivities Acute MI (n=888) Difference 30-day Composite (n=737) HEART Score 0-3 98% (95%CI %) -- 94% (95%CI 86-98%) ACS Pretest Probability <2% 96% (95%CI %) 95% (95%CI 88-99%) Troponin below LOD 97% (95%CI %) 89% (95%CI 80-95%) HEART Score Troponin below LOD 100% (95%CI %) 2% (95%CI -2 to 6%) (95%CI %) 6% (95%CI 1-12%) ACS Pretest Probability <2% + Troponin below LOD 4% (95% CI -1.5 to 10%) 5% (95%CI %) Variables Age Gender Race Chest pain w/ palpation Personal history of CAD Diaphoresis EKG ST depression > 0.5mm T Wave inversion > 0.5mm 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 30-day adverse cardiac events Addition of a single troponin below the LOD to these scores improves sensitivity for 30-day adverse cardiac events ACKNOWLEDGEMENTS This project was supported by the National Institutes of Health (NIH) through grants K12HL108964, K08HL130546, and UL1TR001860
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