Hostname: page-component-78c5997874-mlc7c Total loading time: 0 Render date: 2024-11-14T19:21:53.411Z Has data issue: false hasContentIssue false
  • English
  • Français

Can troponin I measurement predict short-term serious cardiac outcomes in patients presenting to the emergency department with possible acute coronary syndrome?

Published online by Cambridge University Press:  21 May 2015

Stephen A. Hill ,
P.J. Devereaux ,
Lauren Griffith ,
John Opie ,
Matthew J. McQueen ,
Akbar Panju ,
Eric Stanton  and
Gordon H. Guyatt
Stephen A. Hill*
Affiliation:
Department Pathology and Molecular Medicine Hamilton Regional Laboratory Medicine Program, Hamilton, Ont
P.J. Devereaux
Affiliation:
Department of Medicine
Lauren Griffith
Affiliation:
Department of Clinical Epidemiology and Biostatistics
John Opie
Affiliation:
Department of Emergency Medicine, McMaster University, Hamilton, Ont
Matthew J. McQueen
Affiliation:
Department Pathology and Molecular Medicine Hamilton Regional Laboratory Medicine Program, Hamilton, Ont
Akbar Panju
Affiliation:
Department of Medicine
Eric Stanton
Affiliation:
Department of Medicine
Gordon H. Guyatt
Affiliation:
Department of Medicine Department of Clinical Epidemiology and Biostatistics
*
Laboratory Medicine, Hamilton General Hospital, 237 Barton St. E, Hamilton ON L8L 2X2; [email protected]

Abstract

Core share and HTML view are not available for this content. However, as you have access to this content, a full PDF is available via the ‘Save PDF’ action button.
Objective:

To determine the ability of troponin I (TnI) measurement to predict the likelihood of a serious cardiac outcome over the subsequent 72 hours in patients presenting to the emergency department (ED) with symptoms suggestive of an acute coronary syndrome.

Methods:

This prospective observational study enrolled consecutive patients presenting to 2 urban tertiary care hospital EDs over a 5-week period. Eligible patients included those for whom a TnI test was ordered within 24 hours of arrival and in whom no serious cardiac outcome occurred before the test result was available. Patients were followed for 72 hours and serious cardiac outcomes documented; these included cardiovascular death, myocardial infarction, congestive heart failure, serious arrhythmia and refractory pain. We calculated likelihood ratios (LRs) to describe the association of the TnI result with serious cardiac outcomes.

Results:

Of the 352 enrolled patients, 20 had a serious cardiac outcome within 72 hours of ED presentation. The derived LRs (and 95% confidence interval [CI]) were 0.5 (0.3–0.9) for TnI values <0.5 µg/L, 1.6 (0.4–6.5) for TnI values from 0.5 to 2.0 µg/L, 5.8 (1.7–19.5) for TnI values from >2.0 to 10.0 µg/L and 14.4 (4.8–42.9) for TnI values >10.0 µg/L.

Conclusions:

TnI values >2.0 µg/L are associated with an increased probability of serious cardiac outcomes within 72 hours. TnI values between 0.5 and 2.0 µg/L are weakly positive predictors. TnI values <0.5 µg/L have LRs in the range of 0.5 and thus are weakly negative predictors, not substantially decreasing the likelihood of serious cardiac outcomes, particularly in patients with a moderate or high pretest probability.

Keywords

cardiac troponinacute coronary syndromeprognosislikelihood ratios
Type
Em Advances • Innovations En Mu
Information
Canadian Journal of Emergency Medicine , Volume 6 , Issue 1 , January 2004 , pp. 22 - 30
Copyright
Copyright © Canadian Association of Emergency Physicians 2004

References

1.Richardson, WS, Wilson, M, Guyatt, GH.The process of diagnosis. In: Guyatt, G, Rennie, D.The users’ guide to the medical literature: a manual for evidence-based clinical practice. Chicago (IL): American Medical Association; 2002. p. 155–67.Google Scholar
2.Morrow, DA, Antman, EM, Tanasijevic, M, Rifai, N, de Lemos, JA, McCabe, CH, et al. Cardiac troponin I for stratification of early outcomes and the efficacy of enoxaparin in unstable angina: a TIMI-11B substudy. J Am Coll Cardiol 2000;36:1812–7.CrossRefGoogle ScholarPubMed
3.Antman, EM, Tanasijevic, MJ, Thompson, B, Schactman, M, Mc-Cabe, CH, Cannon, CP, et al. Cardiac-specific troponin I levels to predict the risk of mortality in patients with acute coronary syndromes. N Engl J Med 1996;335:1342–9.CrossRefGoogle ScholarPubMed
4.Lindahl, B, Toss, H, Siegbahn, A, Venge, P, Wallentin, L.Markers of myocardial damage and inflammation in relation to long-term mortality in unstable coronary artery disease. N Engl J Med 2000;343:1139–47.CrossRefGoogle ScholarPubMed
5.DeFilippi, CR, Tocchi, M, Parmar, RJ, Rosanio, S, Abreo, G, Potter, MA, et al. Cardiac troponin T in chest pain unit patients without ischemic electrocardiographic changes: angiographic correlates and long-term clinical outcomes. J Am Coll Cardiol 2000;35:1827–34.Google Scholar
6.Tanasijevic, MJ, Cannon, CP, Antman, EM.The role of cardiac troponin-I (cTnI) in risk stratification of patients with unstable coronary artery disease. Clin Chem Biol 1999;22:13–6.Google ScholarPubMed
7.Christenson, RH.Evidence based approach to practice guides and decision thresholds for cardiac markers. Scand J Clin Lab Invest 1999;230:90–102.Google Scholar
8.Möckel, M, Störk, T, Heller, G, Röcker, OD, Darrelmann, K, Eichstädt, H, et al. Troponin T in patients with low grade or atypical angina. Eur Heart J 1998;19:1802–7.CrossRefGoogle ScholarPubMed
9.Heidenreich, PA, Alloggiamento, T, Melsop, K, McDonald, KM, Go, AS, Hlatky, MA.The prognostic value of troponin in patients with non-ST elevation acute coronary artery syndromes: a metaanalysis. J Am Coll Cardiol 2001;38:478–85.Google Scholar
10.Green, GB, Beaudreau, RW, Chan, DW, DeLong, D, Kelly, CA, Gabor, KD.Use of troponin T and creatine kinase-MB subunit levels for risk stratification of emergency department patients with possible myocardial ischemia. Ann Emerg Med 1998;31:19–29.CrossRefGoogle ScholarPubMed
11.Hamm, CW, Goldman, BU, Heeschen, C, Kreyman, G, Berger, J, Meinertz, T.Emergency room triage of patients with acute chest pain by means of rapid testing for cardiac troponin T or troponin I. N Engl J Med 1997;337:1648–53.Google Scholar
12.Limkakeng, A, Gibler, WB, Pollack, C, Hoekstra, JW, Sites, F, Shofer, FS, et al. Combination of Goldman risk and initial cardiac troponin I for emergency department chest pain patient risk stratification. Acad Emerg Med 2001;8:696–702.CrossRefGoogle ScholarPubMed
13.Kontos, M, Anderson, FP, Alimard, R, Ornato, JP, Tatum, JL, Jesse, RL.Ability of troponin I to predict cardiac events in patients admitted from the emergency department. J Am Coll Cardiol 2000;36:1818–23.Google Scholar
14.Polanczyk, CA, Lee, TH, Cook, EF, Walls, R, Wybenga, D, Printy-Klein, G, et al. Cardiac troponin I as a predictor of major cardiac events in emergency department patients with acute chest pain. J Am Coll Cardiol 1998;32:8–14.Google Scholar
15.Zarich, S, Bradley, K, Seymour, J, Wael, G, Traboulsi, A, Mayall, ID, et al. Impact of troponin T determinations on hospital resource utilization and costs in the evaluation of patients with suspected myocardial ischemia. Am J Cardiol 2001;88:732–6.Google Scholar
16.Hamm, CW, Ravkilde, J, Gerhardt, W, Jorgensen, P, Pedheim, E, Ljungdahl, L, et al. The prognostic value of serum troponin T in unstable angina. N Engl J Med 1992;327:146–50.CrossRefGoogle ScholarPubMed
17.Hetlund, O, Dickstein, K.Cardiac markers in the early hours of acute myocardial infarction: clinical performance of creatine kinase, creatine kinase MB isoenzyme (activity and mass concentration), creatine kinase MM and MB subform ratios, myoglobin and cardiac troponin T. Scand J Lab Invest 1996;56:701–13.CrossRefGoogle Scholar
18.Ebell, MH, Flewelling, D, Flynn, CA.A systematic review of troponin T and troponin I for diagnosing acute myocardial infarction. J Fam Pract 2000;49:550–6.Google Scholar
19.Ellestad, MH, Starr-Selvester, R, Stanon, E, VanNatta, B, Ahmad, J, Swinger, F.The utility of four biochemical markers in the triage of chest pain patients. Cardiology 2000;933:242–8.Google Scholar
20.Taylor, C, Forrest-Hay, A, Meek, S.ROMEO: a rapid rule out strategy for low risk chest pain. Does it work in a UK emergency department? Emerg Med J 2002;19:395–9.Google Scholar
21.Missov, E, Calzolari, C, Pau, B.Circulating cardiac troponin I in severe congestive heart failure. Circulation 1997;96:2953–8.Google Scholar
22.Missov, E, DeMarco, T.Clinical insights on the use of highly sensitive cardiac troponin assays. Clin Chim Acta 1999;284: 175–85.CrossRefGoogle ScholarPubMed
23.Setsuta, K, Seino, Y, Takahashi, N, Ogawa, T, Sasaki, K, Harada, A, et al. Clinical significance of elevated levels of cardiac troponin T in patients with chronic heart failure. Am J Cardiol 1999;84:608–11.Google Scholar
24.Worster, A, Innes, G, Abu-Laban, RB.Diagnostic testing: an emergency medicine perspective. Can J Emerg Med 2002; 4(5):348–54.Google Scholar
25.Braunwald, E, Mark, DB, Jones, RH, Brown, J, Brown, L, Cheitlin, MD, et al. Unstable angina: diagnosis and management. Clinical practice guideline number 10. AHCPR publication no. 94-0606. Rockville (MD): Agency for Health Care Policy and Research and the National Heart, Lung and Blood Institute, Public Health Service, US Department of Health and Human Services; 1994 (amended).Google Scholar
26.Gillum, RF, Fortmann, SP, Prineas, RJ, Kottke, TE.International diagnostic criteria for acute myocardial infarction and acute stroke. Am Heart J 1984;108:150–8.CrossRefGoogle ScholarPubMed
27.Ontario Medical Association Quality Management Program — Laboratory Services. Enzymes, Cardiac Markers and Lipids Committee Comment. Toronto: The Association; 2002. p. 122–3.Google Scholar
28.Pagani, F, Yeo, J, Apple, F, Christenson, R, Dati, F, Mair, J, et al. Evaluation of the imprecision at the low-range concentration of the assays for cardiac troponin determination. Clin Chem 2003;49(suppl):A34.Google Scholar
29.Myocardial infarction redefined: a consensus document of the joint European Society of Cardiology/American College of Cardiology Committee for the Redefinition of Myocardial Infarction. J Am Coll Cardiol 2000;36:959–69.Google Scholar