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

Keywords

endogenous compound, troponin T, adult, cohort analysis, conference abstract, controlled study, diagnostic test accuracy study, diagnostic value, electrocardiogram, electrocardiography, female, heart death, heart infarction, heart muscle revascularization, human, major adverse cardiac event, major clinical study, male, outcome assessment, outpatient, predictive value, prospective study, secondary analysis, ST segment elevation, surgery, Switzerland

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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