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

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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