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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...
Autores principales: | , , , , , , , , , , , , , , |
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Formato: | Online Artículo Texto |
Lenguaje: | English |
Publicado: |
Excerpta Medica
2015
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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. |
format | Online Article Text |
id | pubmed-4414368 |
institution | National Center for Biotechnology Information |
language | English |
publishDate | 2015 |
publisher | Excerpta Medica |
record_format | MEDLINE/PubMed |
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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