Outcomes in patients with chest pain in emergency departments using high-sensitivity versus conventional troponins.

Objectives. There is a paucity of data regarding the association between the use of high-sensitivity troponin (hs-cTn) compared with conventional troponin (cTn) and outcomes in chest pain patients in emergency departments (EDs). This study examined the impact of hs-cTnT on prognosis in chest pain patients in EDs. Design. In an observational cohort study, we included chest pain patients visiting the EDs of 14 hospitals in Sweden from 2011 to 2016. The study population was retrieved from each hospital, and information on characteristics and outcomes was collected from nationwide registries. Cox regression was used to estimate adjusted hazard ratios with 95% confidence intervals (HR, 95% CI) for (1) 1-year all-cause mortality, (2) missed acute coronary syndromes (ACSs), (3) use of coronary angiography, and (4) revascularizations within 30 days. Results. We included 170461 patients with chest pain where 62669 patients were tested with cTn while 107792 patients were tested with hs-cTnT. We found 4149 (4.6%) deaths in the cTn group and 6087 (3.7%) deaths in the hs-cTnT group. Patients in the hs-cTnT group had 9% lower mortality (0.91, 0.87-0.94), and were 14% more likely to undergo coronary angiography (1.14, 1.10-1.17), and 12% more likely to be revascularized (1.12, 1.08-1.17) than patients in the cTn group. Conclusions. Patients with chest pain visiting EDs using hs-cTnT had lower mortality and a higher likelihood of undergoing coronary angiographies and revascularizations than those using cTn. There may be a survival benefit of being tested with hs-cTnT compared with cTn in patients seeking medical attention for chest pain.

Stable High-Sensitivity Cardiac Troponin T Levels and Outcomes in Patients With Chest Pain.

BACKGROUND: There is a paucity of data on the association between high-sensitivity cardiac troponin (hs-cTn) levels and outcomes in patients with chest pain but no myocardial infarction (MI), or any other condition that may lead to acutely elevated troponin levels. OBJECTIVES: The authors hypothesized that any detectable high-sensitivity cardiac troponin T (hs-cTnT) level is associated with adverse outcomes. METHODS: All patients (N = 22,589) >25 years of age with chest pain and hs-cTnT analyzed concurrently in the emergency department of Karolinska University Hospital, Stockholm, Sweden from 2011 to 2014 were eligible for inclusion. After excluding all patients with acute conditions that may have affected hs-cTnT, or MI associated with the visit, or insufficient information to determine whether troponin levels were stable, Cox regression was used to estimate risks for all-cause, cardiovascular, and noncardiovascular mortality, MI, and heart failure at different levels of troponins. RESULTS: A total of 19,460 patients with a mean age of 54 ± 17 years were included. During a mean follow-up of 3.3 ± 1.2 years, 1,349 (6.9%) patients died. Adjusted hazard ratios (with 95% confidence intervals) for all-cause mortality were 2.00 (1.66 to 2.42), 2.92 (2.38 to 3.59), 4.07 (3.28 to 5.05), 6.77 (5.22 to 8.78), and 9.68 (7.18 to 13.00) in patients with hs-cTnT levels of 5 to 9, 10 to 14, 15 to 29, 30 to 49, and ≥50 ng/l, respectively, compared with patients with hs-cTnT levels <5 ng/l. There was a strong and graded association between all detectable levels of hs-cTnT and risk for MI, heart failure, and cardiovascular and noncardiovascular mortality. CONCLUSIONS: Among patients with chest pain and stable troponin levels, any detectable level of hs-cTnT is associated with an increased risk of death and cardiovascular outcomes and should merit further attention.

Survival and resource utilization in patients with chest pain evaluated with cardiac troponin T compared with high-sensitivity cardiac troponin T.

BACKGROUND: It is uncertain how the implementation of high-sensitivity cardiac troponin T (hs-cTnT) has affected the survival of patients with chest pain in the emergency department (ED). We studied prognosis and resource utilization in terms of coronary angiographies and revascularizations (percutaneous coronary intervention or coronary artery bypass grafting) in patients evaluated with hs-cTnT compared with conventional troponin T (cTnT). METHODS: All patients >25years presenting with chest pain and at least one troponin level analyzed in the ED at the Karolinska University Hospital, Sweden, were included. Hazard ratios (HR) for all-cause mortality, coronary angiographies and revascularizations were adjusted for age, sex and comorbidities during 1year of follow-up comparing patients tested with hs-cTnT (December 10, 2010 to December 31, 2013) with patients tested with cTnT (January 1, 2009 to December 9, 2010). RESULTS: In total, 31,904 patients were included (n=12,485 tested with cTnT and n=24,729 using hs-cTnT). Patient characteristics, comorbidities, and medications were similar during the study period. The absolute risk of all-cause mortality was 3.7% for those tested with cTnT compared with 3.4% for hs-cTnT. After adjustment for confounders, an increased all-cause mortality was observed for patients tested with hs-cTnT (HR 1.15; 95% confidence interval (CI) 1.02-1.29). Coronary angiographies increased by 13% (HR 1.13; 95% CI 1.00-1.28) and revascularizations by 18% (HR 1.18; 95% CI 1.01-1.37) when using hs-cTnT. CONCLUSIONS: In an observational cohort study including patients with chest pain in the ED we found a small increase in mortality, coronary angiographies and revascularizations after the introduction of hs-cTnT.

Trends in admissions for chest pain after the introduction of high-sensitivity cardiac troponin T.

BACKGROUND: The aim was to describe temporal trends in admission rates for chest pain and patient outcomes after the clinical introduction of the high-sensitivity cardiac troponin T (hs-cTnT) assay. METHODS: We included all patients aged >25years presenting with chest pain to the emergency department (ED) at our hospital during 2011-2014. For each year, rates of admissions, coronary angiographies, and revascularizations were determined. After adjustment for confounders, hazard ratios (HR) with 95% confidence intervals (CI) were calculated for mortality or major adverse cardiac events (MACE) within 1year of the ED visit per year, using 2011 as referent. RESULTS: In total, 15,472 chest pain patients were accountable for 18,237 visits to the ED. The chest pain admission rate in 2011 was 44%; 2012, 39%; 2013, 33%; and 2014, 28%, with an overall decrease in 36%. Coronary angiographies within 1year of the ED visit increased from 6.8% in 2011 to 9.6% in 2013, but the proportion of revascularizations was virtually unchanged. The risk of death within 1year of the visit increased by 51% (HR 1.51, 95% CI, 1.18-1.92) in 2014, compared with 2011. Only non-cardiovascular mortality was significantly increased (HR 1.85, 95% CI, 1.34-2.55), with no increase in MACE. CONCLUSION: Admissions for chest pain were reduced by 36% the first 4years of hs-cTnT use. We observed no increase in MACE, but all-cause mortality increased significantly for non-cardiovascular causes only which was paralleled by a significant increase in the use of coronary angiographies.

High-sensitivity cardiac troponin T levels in the emergency department in patients with chest pain but no myocardial infarction.

BACKGROUND: High-sensitivity cardiac troponin T (hs-cTnT) was recently introduced into clinical practice. The increased sensitivity has decreased the specificity. We aimed to determine the predictors for and prevalence of hs-cTnT levels above the 99th percentile in a stable population of patients without myocardial infarction (MI) who sought medical attention for chest pain in the emergency department. METHODS: We included 11,847 patients with chest pain and at least one hs-cTnT measurement during 2011 and 2012. Patients with any acute reasons for an elevated hs-cTnT level were excluded. We used logistic regression to calculate adjusted odds ratios with 95% confidence intervals for the association between patient characteristics and hs-cTnT levels of >14ng/L. We also determined 50th, 75th, 97.5th, and 99th percentile values of hs-cTnT levels in relation to age, sex, estimated glomerular filtration rate (eGFR), and presence or absence of comorbidities. RESULTS: In total, 1360 (11%) patients had hs-cTnT levels of >14ng/L. Men had higher troponin levels than women, and older patients had higher levels than younger patients. The strongest predictor of an elevated troponin level was a reduced eGFR. The 99th percentile for hs-cTnT among all men and among women <50years of age with normal renal function was 20 and 12ng/L, respectively; this level increased to 44 and 36ng/L, respectively, at the age of 70-79years. CONCLUSIONS: A hs-cTnT level above the 99th percentile in patients with chest pain but no MI is common and is related to sex, age, and eGFR.

Risk of revisits to the emergency department in admitted versus discharged patients with chest pain but without myocardial infarction in relation to high-sensitivity cardiac troponin T levels.

BACKGROUND: Recent studies have indicated that it may be safe to discharge chest pain patients with an initial high-sensitivity cardiac troponin T (hs-cTnT) level of <5 ng/L from the emergency department (ED) without further evaluation. We sought to assess the effects of discharge from the ED versus admission to hospital on downstream resource utilisation in low-risk chest pain patients. METHODS: We included all patients who sought medical attention for chest pain during 2 years at the Karolinska University Hospital and who had no myocardial infarction (MI). Adjusted hazard ratios (HRs) were calculated for revisits to the ED, revisits leading to hospitalisation, coronary angiography, or revascularisation during follow-up for admitted compared with discharged patients. RESULTS: 13,046 patients were included, of whom 7694 (59%) had at least one revisit to the ED during a mean of 516 days' follow-up. Admitted patients with hs-cTnT levels of <5 ng/L were 12% more likely to return to the ED during follow-up (HR 1.12, 95% confidence interval (CI) 1.04 to 1.20), and 24% more likely to return to the ED within 30 days (HR 1.24, CI 1.05 to 1.46) than patients who were discharged. The risk of revisit leading to hospitalisation was almost doubled, and the likelihood of undergoing coronary angiography or revascularisation was three-fold in admitted compared with discharged patients. CONCLUSIONS: Increased risks of revisit to the ED, hospitalisation, coronary angiography, and revascularisation were observed when patients with chest pain and hs-cTnT levels of <5 ng/L were admitted instead of discharged home.

Undetectable high-sensitivity cardiac troponin T level in the emergency department and risk of myocardial infarction.

OBJECTIVES: This study sought to evaluate if an undetectable (<5 ng/l) high-sensitivity cardiac troponin T (hs-cTnT) level and an electrocardiogram (ECG) without signs of ischemia can rule out myocardial infarction (MI) in the emergency department (ED). BACKGROUND: Chest pain is a common symptom often associated with benign conditions, but may be a sign of MI. Because there is no rapid way to rule out MI, many patients are admitted to the hospital. METHODS: All patients who sought medical attention for chest pain and had at least 1 hs-cTnT analyzed during 2 years at the Karolinska University Hospital, Stockholm, Sweden, were included. We calculated the negative predictive values of an undetectable hs-cTnT and ECG without ischemia for MI and death within 30 days. RESULTS: We included 14,636 patients, of whom 8,907 (61%) had an initial hs-cTnT of <5 ng/l; 21% had 5 to 14 ng/l, and 18% had >14 ng/l. During 30-day follow-up, 39 (0.44%) patients with undetectable hs-cTnT had a MI, of whom 15 (0.17%) had no ischemic ECG changes. The negative predictive value for MI within 30 days in patients with undetectable hs-cTnT and no ischemic ECG changes was 99.8% (95% confidence interval [CI]: 99.7 to 99.9). The negative predictive value for death was 100% (95% CI: 99.9 to 100). CONCLUSIONS: All patients with chest pain who have an initial hs-cTnT level of <5 ng/l and no signs of ischemia on an ECG have a minimal risk of MI or death within 30 days, and can be safely discharged directly from the ED.