Diagnostic strategies in acute chest pain assessment -with focus on high-sensitivity cardiac troponin T
Year: 2017
Type: dissertation
Study design: Observational Study
Abstract: Introduction:Chest pain is a common presenting complaint among patients in the emergency department (ED).The aims of this thesis were to evaluate the diagnostic accuracy of strategies, focusing mainly on high-sensitivity cardiac troponin T (hs-cTnT), for ruling out 30-day major adverse cardiac events (MACE).The goal was to find strategies that could rapidly identify patients with a low enough risk of 30-day MACE that they may be suitable for early discharge without the need for further cardiac testing. MethodsIn two prospective observational cohort studies, ED physicians' assessment of history and ECG, and troponin T values, were collected. Results Paper I:The overall clinical assessment was better than its separate components (history, ECG, troponin T) both at ruling in and at ruling out acute coronary syndrome (ACS).Among the components, TnT and ECG were superior to the chest pain history for ruling in ACS, while history was superior for ruling out ACS. Paper II: An algorithm combining patient history, ECG and 0h and 1h hs-cTnT identified 60% of all patients for ruleout with a negative predictive value (NPV) of 99.5% and a LR-of 0.04 for 30-day MACE.It ruled in 14% of patients with a positive predictive value of 62.3% and LR+ of 12.5. Paper III:The combination of hs-cTnT <5 ng/L, a non-ischemic ECG, and a non-high risk history was present in 29.2% of patients and yielded a NPV of 99.7% and a LR-of 0.02 for 30-day MACE.The combination with hs-cTnT ≤14 ng/L was present in 66.7% of patients, with a NPV of 98.7% and a LR-of 0.11 Paper IV: The combination of an adapted TIMI score ≤1, a non-ischemic ECG, and either a 0h hs-cTnT <5 ng/L, or a 0h hs-cTnT <12 ng/L combined with a 1h increase <3 ng/L, identified 432 (42.4%) patients as very low risk with a negative predictive value of 99.5% and a negative likelihood ratio of 0.04 for 30-day MACE. ConclusionOur results indicate that a combination of history, ECG and hs-cTnT provides a rapid disposition strategy in approximately 75% of ED chest pain patients.With this combination, about 60% of all patients may potentially be discharged without the need for further cardiac assessment, almost half of whom could be identified for rule-out with a single hs-cTnT at presentation, and with the remainder identified by a subsequent 1h hs-cTnT.As an alternative, utilizing a 0h/1h hs-cTnT strategy in conjunction with an adapted TIMI score and ECG also allows safe early discharge of chest pain patients.These strategies could potentially reduce ED crowding, unnecessary admissions, stress testing and costs.
Author: Arash Mokhtari
Institution: Lund University
Language: English
Subfield: Cardiology and Cardiovascular Medicine
Field: Medicine
Domain: Health Sciences
Open Access status: green
OpenAlex ID: W2614127634