30-Day Performance of High-Sensitivity Troponin in the Evaluation of Patients With Acute Coronary Syndrome, Early Rule-Out Pathway for Cardiac Troponin T in a United States Population

Document Type

Conference Proceeding

Publication Date

4-20-2023

Publication Title

Acad Emerg Med

Keywords

endogenous compound, troponin T, acute coronary syndrome, adult, algorithm, clinical evaluation, cohort analysis, conference abstract, controlled study, diagnostic test accuracy study, electrocardiogram, electrocardiography, heart death, heart infarction, heart muscle revascularization, human, major adverse cardiac event, major clinical study, male, middle aged, outpatient, predictive value, secondary analysis, signal transduction, ST segment elevation, surgery, Switzerland, United States

Abstract

Background and Objectives: The High-STEACS Early Rule-Out Pathway for High Sensitivity Cardiac Troponin T (hs-cTnT) is an algorithm designed to rule-out myocardial infarction (MI) in ED patients with symptoms suggestive of acute coronary syndrome (ACS). High-STEACS was validated in the UK, but has yet to be evaluated in the US. The study objective is to determine the performance of the High-STEACS hs-cTnT Pathway in a multisite US cohort. Methods: We conducted a pre-planned secondary analysis using the STOP-CP cohort, which enrolled ED patients ≥21 years old with possible ACS without ST-elevation on their initial ECG at 8 US sites (1/25/2017-9/ 6/2018). Participants with 0-and 1-h hs-cTnT measures (Roche, Basel, Switzerland) were stratified into outpatient and admission dispositions using the established High-STEACS hs-cTnT cut-points. Cardiac death or MI and major adverse cardiovascular events (MACE; a composite of cardiac death, MI, and coronary revascularization) at 30-days were adjudicated. Negative and positive predictive values (NPV and PPV) and negative and positive likelihood ratios (-LR and +LR) for the High-STEACS pathway were calculated for each outcome with 95% confidence intervals. Results: During the study period 1430 patients were accrued, of which 54.2% (775/1430) were male with a mean age of 57.6 ± 12.8 years. At 30-days, 12.8% (183/1430) of patients experienced cardiac death or MI and 14.2% (203/1430) had MACE. High-STEACS classified 59.9% (857/1430) to the outpatient disposition and 40.1% (573/1430) to admission. Among patients stratified to the outpatient group, 1.9% (16/857) experienced cardiac death or MI and 3.4% (29/857) had MACE at 30-days. The NPV and -LR for High-STEACS were 98.1% (95% CI 97.0-98.9) and 0.13 (95% CI 0.08-0.21) for 30-day cardiac death or MI and 96.6% (95% CI 95.2-97.7) and 0.21 (95% CI 0.15-0.30) for 30-day MACE. For patients stratified to admission, 29.1% (167/573) had 30-day cardiac death or MI and 30.4% (174/573) had MACE. This yielded a PPV and +LR for 30-day cardiac death or MI of 29.1% (95% CI 25.5-33.1) and 2.8 (95% CI 2.6-3.1) and 30.4% (95% CI 26.6-34.3) and 2.6 (95% CI 2.4-2.9) for 30-day MACE. Conclusion: The High-STEACS hs-cTnT Pathway stratified nearly 60% of patients to an outpatient disposition, but these patients had high rates of 30-day cardiac events. These findings suggest that providers should be cautious before using this pathway among US patients with possible ACS.

Volume

30

First Page

52

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