Sex-Specific High Sensitivity Troponin Thresholds Do Not Rule Out Cardiac Events in Patients With Coronary Disease

Document Type

Conference Proceeding

Publication Date

4-20-2023

Publication Title

Acad Emerg Med

Abstract

Background and Objectives: Use of sex-specific high sensitivity troponin (hs-cTn) 99th percentile cut-points are recommended for diagnosing myocardial infarction (MI). However, data assessing the diagnostic performance of sex-specific 99th percentile cut-points in patients with known coronary artery disease (CAD: prior myocardial infarction [MI], coronary revascularization, or ≥70% coronary stenosis) is limited. This objective of this study is to evaluate the performance of sex-specific 99th percentile hs-cTnT cut-points in patients with and without known CAD. Methods: We conducted a pre-planned secondary analysis of the STOP-CP cohort, which prospectively enrolled ED patients ≥21 years old with possible ACS who were without ST-elevation on initial ECG across 8 US sites (1/25/2017-9/ 6/2018). Participants with 0-and 1-h hs-cTnT measures (Roche, Basel, Switzerland) less than the 99th percentile (males 22 ng/L, females 14 ng/L) were classified as ruled-out. Patients were stratified based on their history of CAD, as determined by the treating provider. Adjudicated outcomes were cardiac death or myocardial infarction (MI) and major adverse cardiovascular events (MACE; a composite of cardiac death, MI, and coronary revascularization) at 30-days. Fisher's exact tests compared outcome rates between patients with and without known CAD. Negative predictive values (NPV) for each outcome with 95% confidence intervals were calculated. Results: During the study period 1430 patients were accrued, of which 45.8% (655/1430) were female and 31.4% (449/1430) had known CAD. At 30 day, cardiac death or MI occurred in 12.8% (183/1430) and MACE in 14.2% (203/1430) of participants. Sex-specific cut-points resulted in fewer patients with known CAD being ruled-out (56.8% [255/449]) than patients without known CAD (76.3% [748/981]) (p < 0.001). Among rule-out patients with known CAD 3.9% (10/255) experienced 30-day cardiac death or MI and 9.4% (24/255) had 30-day MACE, corresponding to NPVs of 96.1% (95% CI 92.9-98.1) and 90.6% (95% CI 86.3-93.9), respectively. Among patients without known CAD who were ruled-out, 1.6% (12/770) had cardiac death or MI and 2.0% (15/770) had MACE at 30-days, yielding NPVs of 98.4% (95% CI 97.3-99.1) and 98.1% (95% CI 96.8-98.9), respectively. Conclusion: Sex-specific hs-cTnT 99th percentile cut-points were unable to safely rule-out 30-day cardiac events, especially among patients with known CAD.

Volume

30

First Page

50

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