Agreement among high-sensitivity cardiac troponin assays and non-invasive testing, clinical outcomes, and quality-of-care outcomes based on the 2020 European Society of Cardiology Guidelines.

AIMS: Quality-of-care and safety of patients with suspected acute coronary syndrome (ACS) would benefit if management was independent of which high-sensitivity cardiac troponin (hs-cTn) assay was used for risk stratification. We aimed to determine the concordance of hs-cTn assays to risk-stratify patients with suspected ACS according to the European Society of Cardiology (ESC) 2020 Guidelines. METHODS AND RESULTS: Blood samples were obtained at arrival and at 2 h from patients with suspected ACS using four hs-cTn assays. The patients were classified into rule-out/observe/rule-in strata based on the ESC 2020 Guidelines. Concordance was determined among the assays for rule-out/observe/rule-in strata. The prevalences of significant underlying disease (≥50% stenosis on coronary computed tomography or inducible myocardial ischaemia on stress testing) and adjudicated ACS, plus quality-of-care outcomes, were compared. Among 238 patients (52.7 ± 8.0 years; 40.3% female), the overall concordance across assays to classify patients into rule-out/observe/rule-in strata was 74.0% (176/238). Platforms significantly differed for rule-out (89.9 vs. 76.5 vs. 78.6 vs. 86.6%, P < 0.001) and observe strata (6.7 vs. 20.6 vs. 17.7 vs. 9.2%, P < 0.001), but not for rule-in strata (3.4 vs. 2.9 vs. 3.8 vs. 4.2%, P = 0.62). Among patients in ruled-out strata, 19.1-21.6% had significant underlying disease and 3.3-4.2% had ACS. The predicted disposition of patients and cost-of-care differed across the assays (all P < 0.001). When compared with observed strata, conventional troponin-based management and predicted quality-of-care outcomes significantly improved with hs-cTn-based strategies (direct discharge: 21.0 vs. 80.3-90.8%; cost-of-care: $3889 ± 4833 vs. $2578 ± 2896-2894 ± 4371, all P < 0.001). CONCLUSION: Among individuals with suspected ACS, patient management may differ depending on which hs-cTn assay is utilized. More data are needed regarding the implications of inter-assay differences. TRAIL REGISTRATION: NCT01084239.

Investigating Pregnancy Outcomes After Abnormal Cell-Free DNA Test Results.

Cell-free DNA (cfDNA) testing has increased sensitivity and specificity compared to other prenatal screening methods, but invasive diagnostic testing (IDT) is recommended for confirmation. We performed a retrospective chart review of 39 women with abnormal cfDNA results between March 2012 and September 2015 at an urban academic hospital to evaluate patient choice and pregnancy outcomes. We analyzed data using descriptive statistics, Fisher's exact tests, and Wilcoxon rank-sum tests. Median maternal age was 36.0 years [interquartile range (IQR) 31, 39]; 64.1% of women (25/39) were advanced maternal age and 69.2% (27/39) had abnormal ultrasounds. Median gestational age at time of cfDNA testing was 18 3/7 weeks [IQR 12 2/7, 20 5/7]. cfDNA results included trisomy 21 (89.7%, 35/39), trisomy 18 (7.7%, 3/39), and both trisomy 21/monosomy X (2.6%, 1/39). Of 39 women, 22 (56.4%) continued and 10 (25.6%) terminated the pregnancy; six (15.4%) had fetal demises, and one was lost to follow-up. Of women continuing their pregnancies, 54.6% (12/22) declined further genetic counseling, and 77.3% (17/22) declined IDT. Only 14 women pursued IDT; not pursuing IDT was associated with continuing the pregnancy (Fisher's exact test, p = .001). All women terminating their pregnancy (90.0%, 9/10) pursued IDT or had major anomalies on ultrasound, suggesting that women considering termination undergo more confirmatory tests or already have high suspicion for an abnormal pregnancy.

The diagnostic accuracy and outcomes after coronary computed tomography angiography vs. conventional functional testing in patients with stable angina pectoris: a systematic review and meta-analysis.

AIMS: To systematically review and perform a meta-analysis of the diagnostic accuracy and post-test outcomes of conventional exercise electrocardiography (XECG) and single-photon emission computed tomography (SPECT) compared with coronary computed tomography angiography (coronary CTA) in patients suspected of stable coronary artery disease (CAD). METHODS AND RESULTS: We systematically searched for studies published from January 2002 to February 2013 examining the diagnostic accuracy (defined as at least ≥50% luminal obstruction on invasive coronary angiography) and outcomes of coronary CTA (≥16 slice) in comparison with XECG and SPECT. The search revealed 11 eligible studies (N = 1575) comparing the diagnostic accuracy and 7 studies (N = 216.603) the outcomes of coronary CTA vs. XECG or/and SPECT. The per-patient sensitivity [95% confidence interval (95% CI)] to identify significant CAD was 98% (93-99%) for coronary CTA vs. 67% (54-78%) (P < 0.001) for XECG and 99% (96-100%) vs. 73% (59-83%) (P = 0.001) for SPECT. The specificity (95% CI) of coronary CTA was 82% (63-93%) vs. 46% (30-64%) (P < 0.001) for XECG and 71% (60-80%) vs. 48% (31-64%) (P = 0.14) for SPECT. The odds ratio (OR) of downstream test utilization (DTU) for coronary CTA vs. XECG/SPECT was 1.38 (1.33-1.43, P < 0.001), for revascularization 2.63 (2.50-2.77, P < 0.001), for non-fatal myocardial infarction 0.53 (0.39-0.72, P < 0.001), and for all-cause mortality 1.01 (0.87-1.18, P = 0.87). CONCLUSION: The up-front diagnostic performance of coronary CTA is higher than of XECG and SPECT. When compared with XECG/SPECT testing, coronary CTA testing is associated with increased DTU and coronary revascularization.