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Sensitive Troponin Assay and the Classification of Myocardial Infarction

BACKGROUND: Lowering the diagnostic threshold for troponin is controversial because it may disproportionately increase the diagnosis of myocardial infarction in patients without acute coronary syndrome. We assessed the impact of lowering the diagnostic threshold of troponin on the incidence, managem...

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Autores principales: Shah, Anoop S.V., McAllister, David A., Mills, Rosamund, Lee, Kuan Ken, Churchhouse, Antonia M.D., Fleming, Kathryn M., Layden, Elizabeth, Anand, Atul, Fersia, Omar, Joshi, Nikhil V., Walker, Simon, Jaffe, Allan S., Fox, Keith A.A., Newby, David E., Mills, Nicholas L.
Formato: Online Artículo Texto
Lenguaje:English
Publicado: Excerpta Medica 2015
Materias:
Acceso en línea:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4414368/
https://www.ncbi.nlm.nih.gov/pubmed/25436428
http://dx.doi.org/10.1016/j.amjmed.2014.10.056
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author Shah, Anoop S.V.
McAllister, David A.
Mills, Rosamund
Lee, Kuan Ken
Churchhouse, Antonia M.D.
Fleming, Kathryn M.
Layden, Elizabeth
Anand, Atul
Fersia, Omar
Joshi, Nikhil V.
Walker, Simon
Jaffe, Allan S.
Fox, Keith A.A.
Newby, David E.
Mills, Nicholas L.
author_facet Shah, Anoop S.V.
McAllister, David A.
Mills, Rosamund
Lee, Kuan Ken
Churchhouse, Antonia M.D.
Fleming, Kathryn M.
Layden, Elizabeth
Anand, Atul
Fersia, Omar
Joshi, Nikhil V.
Walker, Simon
Jaffe, Allan S.
Fox, Keith A.A.
Newby, David E.
Mills, Nicholas L.
author_sort Shah, Anoop S.V.
collection PubMed
description BACKGROUND: Lowering the diagnostic threshold for troponin is controversial because it may disproportionately increase the diagnosis of myocardial infarction in patients without acute coronary syndrome. We assessed the impact of lowering the diagnostic threshold of troponin on the incidence, management, and outcome of patients with type 2 myocardial infarction or myocardial injury. METHODS: Consecutive patients with elevated plasma troponin I concentrations (≥50 ng/L; n = 2929) were classified with type 1 (50%) myocardial infarction, type 2 myocardial infarction or myocardial injury (48%), and type 3 to 5 myocardial infarction (2%) before and after lowering the diagnostic threshold from 200 to 50 ng/L with a sensitive assay. Event-free survival from death and recurrent myocardial infarction was recorded at 1 year. RESULTS: Lowering the threshold increased the diagnosis of type 2 myocardial infarction or myocardial injury more than type 1 myocardial infarction (672 vs 257 additional patients, P < .001). Patients with myocardial injury or type 2 myocardial infarction were at higher risk of death compared with those with type 1 myocardial infarction (37% vs 16%; relative risk [RR], 2.31; 95% confidence interval [CI], 1.98-2.69) but had fewer recurrent myocardial infarctions (4% vs 12%; RR, 0.35; 95% CI, 0.26-0.49). In patients with troponin concentrations 50 to 199 ng/L, lowering the diagnostic threshold was associated with increased healthcare resource use (P < .05) that reduced recurrent myocardial infarction and death for patients with type 1 myocardial infarction (31% vs 20%; RR, 0.64; 95% CI, 0.41-0.99), but not type 2 myocardial infarction or myocardial injury (36% vs 33%; RR, 0.93; 95% CI, 0.75-1.15). CONCLUSIONS: After implementation of a sensitive troponin assay, the incidence of type 2 myocardial infarction or myocardial injury disproportionately increased and is now as frequent as type 1 myocardial infarction. Outcomes of patients with type 2 myocardial infarction or myocardial injury are poor and do not seem to be modifiable after reclassification despite substantial increases in healthcare resource use.
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spelling pubmed-44143682015-05-04 Sensitive Troponin Assay and the Classification of Myocardial Infarction Shah, Anoop S.V. McAllister, David A. Mills, Rosamund Lee, Kuan Ken Churchhouse, Antonia M.D. Fleming, Kathryn M. Layden, Elizabeth Anand, Atul Fersia, Omar Joshi, Nikhil V. Walker, Simon Jaffe, Allan S. Fox, Keith A.A. Newby, David E. Mills, Nicholas L. Am J Med Clinical Research Study BACKGROUND: Lowering the diagnostic threshold for troponin is controversial because it may disproportionately increase the diagnosis of myocardial infarction in patients without acute coronary syndrome. We assessed the impact of lowering the diagnostic threshold of troponin on the incidence, management, and outcome of patients with type 2 myocardial infarction or myocardial injury. METHODS: Consecutive patients with elevated plasma troponin I concentrations (≥50 ng/L; n = 2929) were classified with type 1 (50%) myocardial infarction, type 2 myocardial infarction or myocardial injury (48%), and type 3 to 5 myocardial infarction (2%) before and after lowering the diagnostic threshold from 200 to 50 ng/L with a sensitive assay. Event-free survival from death and recurrent myocardial infarction was recorded at 1 year. RESULTS: Lowering the threshold increased the diagnosis of type 2 myocardial infarction or myocardial injury more than type 1 myocardial infarction (672 vs 257 additional patients, P < .001). Patients with myocardial injury or type 2 myocardial infarction were at higher risk of death compared with those with type 1 myocardial infarction (37% vs 16%; relative risk [RR], 2.31; 95% confidence interval [CI], 1.98-2.69) but had fewer recurrent myocardial infarctions (4% vs 12%; RR, 0.35; 95% CI, 0.26-0.49). In patients with troponin concentrations 50 to 199 ng/L, lowering the diagnostic threshold was associated with increased healthcare resource use (P < .05) that reduced recurrent myocardial infarction and death for patients with type 1 myocardial infarction (31% vs 20%; RR, 0.64; 95% CI, 0.41-0.99), but not type 2 myocardial infarction or myocardial injury (36% vs 33%; RR, 0.93; 95% CI, 0.75-1.15). CONCLUSIONS: After implementation of a sensitive troponin assay, the incidence of type 2 myocardial infarction or myocardial injury disproportionately increased and is now as frequent as type 1 myocardial infarction. Outcomes of patients with type 2 myocardial infarction or myocardial injury are poor and do not seem to be modifiable after reclassification despite substantial increases in healthcare resource use. Excerpta Medica 2015-05 /pmc/articles/PMC4414368/ /pubmed/25436428 http://dx.doi.org/10.1016/j.amjmed.2014.10.056 Text en © 2015 The Authors http://creativecommons.org/licenses/by-nc-nd/3.0/ This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/3.0/).
spellingShingle Clinical Research Study
Shah, Anoop S.V.
McAllister, David A.
Mills, Rosamund
Lee, Kuan Ken
Churchhouse, Antonia M.D.
Fleming, Kathryn M.
Layden, Elizabeth
Anand, Atul
Fersia, Omar
Joshi, Nikhil V.
Walker, Simon
Jaffe, Allan S.
Fox, Keith A.A.
Newby, David E.
Mills, Nicholas L.
Sensitive Troponin Assay and the Classification of Myocardial Infarction
title Sensitive Troponin Assay and the Classification of Myocardial Infarction
title_full Sensitive Troponin Assay and the Classification of Myocardial Infarction
title_fullStr Sensitive Troponin Assay and the Classification of Myocardial Infarction
title_full_unstemmed Sensitive Troponin Assay and the Classification of Myocardial Infarction
title_short Sensitive Troponin Assay and the Classification of Myocardial Infarction
title_sort sensitive troponin assay and the classification of myocardial infarction
topic Clinical Research Study
url https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4414368/
https://www.ncbi.nlm.nih.gov/pubmed/25436428
http://dx.doi.org/10.1016/j.amjmed.2014.10.056
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