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Risk stratification and role for additional diagnostic testing in patients with acute chest pain and normal high-sensitivity cardiac troponin levels
BACKGROUND: Normal high sensitivity cardiac troponin (hs-cTn) assays rule out acute myocardial infarction (AMI) with great accuracy, but additional non-invasive testing is frequently ordered. This observational study evaluates whether clinical characteristics can contribute to risk stratification an...
Autores principales: | , , , , , , , , , , , , |
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Formato: | Online Artículo Texto |
Lenguaje: | English |
Publicado: |
Public Library of Science
2018
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Materias: | |
Acceso en línea: | https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6128560/ https://www.ncbi.nlm.nih.gov/pubmed/30192899 http://dx.doi.org/10.1371/journal.pone.0203506 |
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author | Smulders, Martijn W. Bekkers, Sebastiaan C. A. M. van Cauteren, Yvonne J. M. Liefhebber, Anna Vermeer, Jasper R. Vervuurt, Juliette van Dieijen-Visser, Marja P. Mingels, Alma M. A. Brunner-La Rocca, Hans-Peter Dagnelie, Pieter C. Wildberger, Joachim E. Crijns, Harry J. G. M. Kietselaer, Bas L. J. H. |
author_facet | Smulders, Martijn W. Bekkers, Sebastiaan C. A. M. van Cauteren, Yvonne J. M. Liefhebber, Anna Vermeer, Jasper R. Vervuurt, Juliette van Dieijen-Visser, Marja P. Mingels, Alma M. A. Brunner-La Rocca, Hans-Peter Dagnelie, Pieter C. Wildberger, Joachim E. Crijns, Harry J. G. M. Kietselaer, Bas L. J. H. |
author_sort | Smulders, Martijn W. |
collection | PubMed |
description | BACKGROUND: Normal high sensitivity cardiac troponin (hs-cTn) assays rule out acute myocardial infarction (AMI) with great accuracy, but additional non-invasive testing is frequently ordered. This observational study evaluates whether clinical characteristics can contribute to risk stratification and could guide referral for additional testing. METHODS: 918 serial patients with acute chest pain and normal hs-cTnT levels were prospectively included. Major adverse cardiac events (MACE) and non-invasive test results were assessed during one-year follow-up. Patients were classified as low and high risk based on clinical characteristics. RESULTS: MACE occurred in 6.1% of patients and mainly comprised revascularizations (86%). A recent abnormal stress test, suspicious history, a positive family history and higher baseline hs-cTnT levels were independent predictors of MACE with odds ratios of 16.00 (95%CI:6.25–40.96), 16.43 (6.36–42.45), 2.33 (1.22–4.42) and 1.10 (1.01–1.21), respectively. Absence of both recent abnormal stress test and suspicious history identified 86% of patients. These patients were at very low risk for MACE (0.4% in 30-days and 2.3% in one-year). Despite this, the majority (287/345 = 83%) of additional tests were performed in low risk patients, with <10% abnormal test findings. The diagnostic yield was significantly higher in the remaining higher risk patients, 40% abnormal test findings and a positive predictive value of 70% for MACE. Similar results were observed in patients without known coronary artery disease. CONCLUSIONS: Clinical characteristics can be used to identify low risk patients with acute chest pain and normal hs-cTnT levels. Current strategies in the emergency department result in numerous additional tests, which are mostly ordered in patients at very low risk and have a low diagnostic yield. |
format | Online Article Text |
id | pubmed-6128560 |
institution | National Center for Biotechnology Information |
language | English |
publishDate | 2018 |
publisher | Public Library of Science |
record_format | MEDLINE/PubMed |
spelling | pubmed-61285602018-09-15 Risk stratification and role for additional diagnostic testing in patients with acute chest pain and normal high-sensitivity cardiac troponin levels Smulders, Martijn W. Bekkers, Sebastiaan C. A. M. van Cauteren, Yvonne J. M. Liefhebber, Anna Vermeer, Jasper R. Vervuurt, Juliette van Dieijen-Visser, Marja P. Mingels, Alma M. A. Brunner-La Rocca, Hans-Peter Dagnelie, Pieter C. Wildberger, Joachim E. Crijns, Harry J. G. M. Kietselaer, Bas L. J. H. PLoS One Research Article BACKGROUND: Normal high sensitivity cardiac troponin (hs-cTn) assays rule out acute myocardial infarction (AMI) with great accuracy, but additional non-invasive testing is frequently ordered. This observational study evaluates whether clinical characteristics can contribute to risk stratification and could guide referral for additional testing. METHODS: 918 serial patients with acute chest pain and normal hs-cTnT levels were prospectively included. Major adverse cardiac events (MACE) and non-invasive test results were assessed during one-year follow-up. Patients were classified as low and high risk based on clinical characteristics. RESULTS: MACE occurred in 6.1% of patients and mainly comprised revascularizations (86%). A recent abnormal stress test, suspicious history, a positive family history and higher baseline hs-cTnT levels were independent predictors of MACE with odds ratios of 16.00 (95%CI:6.25–40.96), 16.43 (6.36–42.45), 2.33 (1.22–4.42) and 1.10 (1.01–1.21), respectively. Absence of both recent abnormal stress test and suspicious history identified 86% of patients. These patients were at very low risk for MACE (0.4% in 30-days and 2.3% in one-year). Despite this, the majority (287/345 = 83%) of additional tests were performed in low risk patients, with <10% abnormal test findings. The diagnostic yield was significantly higher in the remaining higher risk patients, 40% abnormal test findings and a positive predictive value of 70% for MACE. Similar results were observed in patients without known coronary artery disease. CONCLUSIONS: Clinical characteristics can be used to identify low risk patients with acute chest pain and normal hs-cTnT levels. Current strategies in the emergency department result in numerous additional tests, which are mostly ordered in patients at very low risk and have a low diagnostic yield. Public Library of Science 2018-09-07 /pmc/articles/PMC6128560/ /pubmed/30192899 http://dx.doi.org/10.1371/journal.pone.0203506 Text en © 2018 Smulders et al http://creativecommons.org/licenses/by/4.0/ This is an open access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0/) , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. |
spellingShingle | Research Article Smulders, Martijn W. Bekkers, Sebastiaan C. A. M. van Cauteren, Yvonne J. M. Liefhebber, Anna Vermeer, Jasper R. Vervuurt, Juliette van Dieijen-Visser, Marja P. Mingels, Alma M. A. Brunner-La Rocca, Hans-Peter Dagnelie, Pieter C. Wildberger, Joachim E. Crijns, Harry J. G. M. Kietselaer, Bas L. J. H. Risk stratification and role for additional diagnostic testing in patients with acute chest pain and normal high-sensitivity cardiac troponin levels |
title | Risk stratification and role for additional diagnostic testing in patients with acute chest pain and normal high-sensitivity cardiac troponin levels |
title_full | Risk stratification and role for additional diagnostic testing in patients with acute chest pain and normal high-sensitivity cardiac troponin levels |
title_fullStr | Risk stratification and role for additional diagnostic testing in patients with acute chest pain and normal high-sensitivity cardiac troponin levels |
title_full_unstemmed | Risk stratification and role for additional diagnostic testing in patients with acute chest pain and normal high-sensitivity cardiac troponin levels |
title_short | Risk stratification and role for additional diagnostic testing in patients with acute chest pain and normal high-sensitivity cardiac troponin levels |
title_sort | risk stratification and role for additional diagnostic testing in patients with acute chest pain and normal high-sensitivity cardiac troponin levels |
topic | Research Article |
url | https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6128560/ https://www.ncbi.nlm.nih.gov/pubmed/30192899 http://dx.doi.org/10.1371/journal.pone.0203506 |
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