Risk stratification and role for additional diagnostic testing in patients with acute chest pain and normal high-sensitivity cardiac troponin levels.

Autor: Smulders MW; Department of Cardiology, Maastricht University Medical Center, Maastricht, The Netherlands.; Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands., Bekkers SCAM; Department of Cardiology, Maastricht University Medical Center, Maastricht, The Netherlands.; Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands.; Department of Radiology, Maastricht University Medical Center, Maastricht, The Netherlands., van Cauteren YJM; Department of Cardiology, Maastricht University Medical Center, Maastricht, The Netherlands.; Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands.; Department of Radiology, Maastricht University Medical Center, Maastricht, The Netherlands., Liefhebber A; Department of Cardiology, Maastricht University Medical Center, Maastricht, The Netherlands., Vermeer JR; Department of Cardiology, Maastricht University Medical Center, Maastricht, The Netherlands., Vervuurt J; Department of Cardiology, Maastricht University Medical Center, Maastricht, The Netherlands., van Dieijen-Visser MP; Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands.; Department of Clinical Chemistry, Maastricht University Medical Center, Maastricht, The Netherlands., Mingels AMA; Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands.; Department of Clinical Chemistry, Maastricht University Medical Center, Maastricht, The Netherlands., Brunner-La Rocca HP; Department of Cardiology, Maastricht University Medical Center, Maastricht, The Netherlands.; Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands., Dagnelie PC; Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands.; Department of Epidemiology, Maastricht University, Maastricht, The Netherlands.; School for Public Health and Primary Care (CAPHRI), Maastricht University, Maastricht, The Netherlands., Wildberger JE; Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands.; Department of Radiology, Maastricht University Medical Center, Maastricht, The Netherlands., Crijns HJGM; Department of Cardiology, Maastricht University Medical Center, Maastricht, The Netherlands.; Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands., Kietselaer BLJH; Department of Cardiology, Maastricht University Medical Center, Maastricht, The Netherlands.; Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands.; Department of Radiology, Maastricht University Medical Center, Maastricht, The Netherlands.; Department of Cardiology, Zuyderland Medical Center7, Heerlen, The Netherlands.
Jazyk: angličtina
Zdroj: PloS one [PLoS One] 2018 Sep 07; Vol. 13 (9), pp. e0203506. Date of Electronic Publication: 2018 Sep 07 (Print Publication: 2018).
DOI: 10.1371/journal.pone.0203506
Abstrakt: Background: Normal high sensitivity cardiac troponin (hs-cTn) assays rule out acute myocardial infarction (AMI) with great accuracy, but additional non-invasive testing is frequently ordered. This observational study evaluates whether clinical characteristics can contribute to risk stratification and could guide referral for additional testing.
Methods: 918 serial patients with acute chest pain and normal hs-cTnT levels were prospectively included. Major adverse cardiac events (MACE) and non-invasive test results were assessed during one-year follow-up. Patients were classified as low and high risk based on clinical characteristics.
Results: MACE occurred in 6.1% of patients and mainly comprised revascularizations (86%). A recent abnormal stress test, suspicious history, a positive family history and higher baseline hs-cTnT levels were independent predictors of MACE with odds ratios of 16.00 (95%CI:6.25-40.96), 16.43 (6.36-42.45), 2.33 (1.22-4.42) and 1.10 (1.01-1.21), respectively. Absence of both recent abnormal stress test and suspicious history identified 86% of patients. These patients were at very low risk for MACE (0.4% in 30-days and 2.3% in one-year). Despite this, the majority (287/345 = 83%) of additional tests were performed in low risk patients, with <10% abnormal test findings. The diagnostic yield was significantly higher in the remaining higher risk patients, 40% abnormal test findings and a positive predictive value of 70% for MACE. Similar results were observed in patients without known coronary artery disease.
Conclusions: Clinical characteristics can be used to identify low risk patients with acute chest pain and normal hs-cTnT levels. Current strategies in the emergency department result in numerous additional tests, which are mostly ordered in patients at very low risk and have a low diagnostic yield.
Competing Interests: This work was supported by the Netherlands Heart Foundation [grant number 2014T051 to MWS]. Dr. Bekkers, Dr Kietselaer and Dr. Wildberger report funding from The Weijerhorst foundation. Prof. Dr. Wildberger reports institutional grants from Siemens, Philips, GE, Bayer, AGFA, personal fees (speaker's bureau) from Siemens, GE and Bayer outside the submitted work. Dr. Kietselaer reports unrestricted grants from Astra Zeneca and Boehringer Ingelheim outside the submitted work. The other authors do not declare any relevant conflicts of interest. The funders did not have any role in the study design; collection, analysis, and interpretation of data; writing of the paper; and/or decision to submit for publication. This does not alter our adherence to PLOS ONE policies on sharing data and materials.
Databáze: MEDLINE
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