Clinical research studyPatients with Acute Coronary Syndrome and Normal High-sensitivity Troponin
Section snippets
Study Design and Population
The Advantageous Predictors of Acute Coronary Syndrome Evaluation (APACE) is an ongoing prospective international multicenter study designed and coordinated by the University Hospital Basel, Switzerland.13 Consecutive patients presenting to the ED with symptoms suggestive of AMI of <12 hours duration have been included, after informed consent, and were followed-up at regular intervals. Patients with terminal kidney failure requiring dialysis were excluded. The objective of the present study is
Results
The cohort analyzed in this study consisted of 1181 patients who had levels of hs-cTnT determined in a blinded fashion at presentation. The adjudicated final diagnosis was ACS in 351 patients (30%), including 112 patients with hs-cTnT within the normal range, and 239 patients with elevated hs-cTnT levels. An additional group of 484 patients who were adjudicated to have a noncardiac cause of acute chest pain and hs-cTnT levels within the normal range are reported (Figure).
Discussion
This prospective multicenter study evaluated the characteristics and outcome of patients with ACS as the cause of chest pain who had hs-cTnT, determined at presentation, below the 99th percentile. First, only a minority of patients with AMI had normal hs-cTnT concentration at presentation, whereas a large proportion of patients with UA had normal hs-cTnT concentration. Second, younger age, previous statin treatment, normal renal function, and the absence of ST deviation on ECG were
Acknowledgements
We are indebted to the patients who participated in the study and to the ED staff as well as the laboratory technicians, particularly Esther Garrido, Kirsten Hochholzer, and Fausta Chiaverio for their most valuable efforts, and we thank Kris Denhaerynck and PD Dr. Christian Schindler for expert statistical advice.
References (31)
- et al.
Missed diagnoses of acute myocardial infarction in the emergency department: results from a multicenter study
Ann Emerg Med
(1993) - et al.
Comparison of troponin T versus creatine kinase-MB in suspected acute coronary syndromes
Am J Cardiol
(2000) - et al.
Prediction of short- and long-term outcomes by troponin T levels in low-risk patients evaluated for acute coronary syndromes
Ann Emerg Med
(2000) - et al.
High diagnostic performance of a high-sensitivity cardiac troponin T assay in patients with suspected acute coronary syndrome
Int J Cardiol
(2011) - et al.
Prognostic value of sensitive troponin T in patients with stable and unstable angina and undetectable conventional troponin
Am Heart J
(2011) - et al.
European Society of Cardiology and American College of Cardiology guidelines for redefinition of myocardial infarction: how to use existing assays clinically and for clinical trials
Am Heart J
(2002) - et al.
Coadministration of atorvastatin prevents nitroglycerin-induced endothelial dysfunction and nitrate tolerance in healthy humans
J Am Coll Cardiol
(2011) - et al.
Prospective evaluation of the prognostic implications of improved assay performance with a sensitive assay for cardiac troponin I
J Am Coll Cardiol
(2010) - et al.
High-sensitive troponin T and I are related to invasive hemodynamic data and mortality in patients with left-ventricular dysfunction and precapillary pulmonary hypertension
Clin Chim Acta
(2011) - et al.
Factors predisposing to a nonadmission of patients with acute myocardial infarction
Cardiology
(2002)
Missed diagnoses of acute cardiac ischemia in the emergency department
N Engl J Med
National Hospital Ambulatory Medical Care Survey: 2005 emergency department summary
Adv Data
Adverse outcomes following emergency department discharge of patients with possible acute coronary syndrome
Emerg Med Australas
Guidelines for the diagnosis and treatment of non-ST-segment elevation acute coronary syndromes
Eur Heart J
Recommendations for the use of cardiac troponin measurement in acute cardiac care
Eur Heart J
Cited by (21)
High sensitivity troponin: The Sisyphean pursuit of zero percent miss rate for acute coronary syndrome in the ED
2018, American Journal of Emergency MedicineCitation Excerpt :Most studies adjudicated the primary outcome by two cardiologists with a third available for disagreements. Only a few studies included unstable angina pectoris as an outcome of interest [25,29-32]. The clinical follow up time varied substantially, ranging from 24 h to 2 years.
Circulating fibrocytes as predictors of adverse events in unstable angina
2016, Translational ResearchCitation Excerpt :Although prognostic factors are well established for patients with ST elevation myocardial infarction and non–ST elevation myocardial infarction,1 identification of patients with unstable angina (UA) who are at increased risk of adverse outcomes has proven more elusive. Risk stratification of UA patients is clinically important because this population has high rates of recurrent cardiovascular events over the year after their initial presentation.2 Compared with their troponin-positive counterparts, patients with UA have lower rates of death and myocardial infarction (MI) at 1 year, but half develop recurrent ischemia requiring revascularization,3 resulting in substantial morbidity and cost.
2014 AHA/acc guideline for the management of patients with Non-ST-Elevation acute coronary syndromes: A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines
2014, Journal of the American College of CardiologyCitation Excerpt :Chronic elevations can result from structural cardiac abnormalities such as LV hypertrophy or ventricular dilatation and are also common in patients with renal insufficiency (34). Patients with end-stage renal disease and no clinical evidence of ACS frequently have elevations of cardiac troponin (180–182). With conventional assays, this is more common with cardiac troponin T than with cardiac troponin I (180).
Cardiac biomarkers in patients suspected of acute myocardial infarction: Where do we stand and where do we go?
2014, Archives of Cardiovascular DiseasesConsideration of high-sensitivity troponin values below the 99th percentile at presentation: Does it improve diagnostic accuracy?
2013, International Journal of CardiologyCitation Excerpt :This study sought to examine diagnostic and prognostic utility of hs-cTn measurements at presentation using the limit of Blank (LOB), the 75th or the 95th percentile as cut-off values compared to the 99th percentile. The Advantageous Predictors of Acute Coronary Syndrome Evaluation (APACE) is an ongoing prospective international multicenter study designed and coordinated by the University Hospital Basel, Switzerland; the first results have been previously reported [17–40]. Briefly, consecutive patients presenting to the ED with symptoms suggestive of AMI of less than 12 h have been included and were followed-up at regular intervals.
Classification of myocardial infarction and unstable angina: A re-assessment
2013, International Journal of CardiologyCitation Excerpt :This (temporary) increase could be directly linked to the introduction and more frequent clinical use of troponin testing in that specific time period. Without doubt, the increase in MI incidence following the introduction of the new troponin assays will also be very significant and clinically relevant: in recent studies, the number of patients re-classified from “unstable angina” to “non-ST-segment elevation MI,” on the basis of the lower diagnostic troponin threshold, increased the absolute number of patients with a myocardial infarction with more than 15% [15,16]. The relationship between markers of myocardial necrosis and prognosis has been firmly established, and as the prognostic gradient between patients with ST-segment elevation MI, non-ST-elevation MI and unstable angina attests, a direct relation exists between myocardial damage, troponin levels and outcome [17].
Funding: This study was supported by grants from the Swiss National Science Foundation (PP00B-102853), the Swiss Heart Foundation, Abbott, Roche, Siemens, and the Department of Internal Medicine, University Hospital Basel.
Conflict of Interest: Dr Mueller reports receiving research grant support from Abbott, Brahms, Nanosphere Inc., Roche, and Siemens, consulting fees from Abbott, and lecture fees from Abbott, Biosite, Brahms, Roche, and Siemens. Dr Reichlin has received research grants from the University of Basel and the Department of Internal Medicine, University Hospital Basel as well as speaker honoraria from Brahms and Roche. Dr Meune was supported by a grant from the Freie Akademische Gesellschaft Basel (FAG).
Authorship: The authors designed the study, gathered and analyzed the data, vouch for the data and analysis, wrote the paper, and decided to publish. The sponsors had no role in designing or conducting the study and no role in gathering or analyzing the data or writing the manuscript. All authors had access to the data and a role in writing the manuscript.
- ⁎
These authors worked equally on the manuscript and should be both considered as first author.