Cargando…
Clinical History and Detectable Troponin Concentrations below the 99th Percentile for Risk Stratification of Patients with Chest Pain and First Normal Troponin
Decision-making is challenging in patients with chest pain and normal high-sensitivity cardiac troponin T (hs-cTnT; <99th percentile; <14 ng/L) at hospital arrival. Most of these patients might be discharged early. We investigated clinical data and hs-cTnT concentrations for risk stratificatio...
Autores principales: | , , , , , , , , , , |
---|---|
Formato: | Online Artículo Texto |
Lenguaje: | English |
Publicado: |
MDPI
2021
|
Materias: | |
Acceso en línea: | https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8073372/ https://www.ncbi.nlm.nih.gov/pubmed/33923925 http://dx.doi.org/10.3390/jcm10081784 |
_version_ | 1783684115109773312 |
---|---|
author | Fernández-Cisnal, Agustín Valero, Ernesto García-Blas, Sergio Pernias, Vicente Pozo, Adela Carratalá, Arturo González, Jessika Noceda, José Miñana, Gema Núñez, Julio Sanchis, Juan |
author_facet | Fernández-Cisnal, Agustín Valero, Ernesto García-Blas, Sergio Pernias, Vicente Pozo, Adela Carratalá, Arturo González, Jessika Noceda, José Miñana, Gema Núñez, Julio Sanchis, Juan |
author_sort | Fernández-Cisnal, Agustín |
collection | PubMed |
description | Decision-making is challenging in patients with chest pain and normal high-sensitivity cardiac troponin T (hs-cTnT; <99th percentile; <14 ng/L) at hospital arrival. Most of these patients might be discharged early. We investigated clinical data and hs-cTnT concentrations for risk stratification. This is a retrospective study including 4476 consecutive patients presenting to the emergency department with chest pain and first normal hs-cTnT. The primary endpoint was one-year death or acute myocardial infarction, and the secondary endpoint added urgent revascularization. The number of primary and secondary endpoints was 173 (3.9%) and 252 (5.6%). Mean hs-cTnT concentrations were 6.9 ± 2.5 ng/L. Undetectable (<5 ng/L) hs-cTnT (n = 1847, 41%) had optimal negative predictive value (99.1%) but suboptimal sensitivity (90.2%) and discrimination accuracy (AUC = 0.664) for the primary endpoint. Multivariable analysis was used to identify the predictive clinical variables. The clinical model showed good discrimination accuracy (AUC = 0.810). The addition of undetectable hs-cTnT (≥ or <5 ng/L; HR, hazard ratio = 3.80; 95% CI, confidence interval 2.27–6.35; p = 0.00001) outperformed the clinical model alone (AUC = 0.836, p = 0.002 compared to the clinical model). Measurable hs-cTnT concentrations (between detection limit and 99th percentile; per 0.1 ng/L, HR = 1.13; CI 1.06–1.20; p = 0.0001) provided further predictive information (AUC = 0.844; p = 0.05 compared to the clinical plus undetectable hs-cTnT model). The results were reproducible for the secondary endpoint and 30-day events. Clinical assessment, undetectable hs-cTnT and measurable hs-cTnT concentrations must be considered for decision-making after a single negative hs-cTnT result in patients presenting to the emergency department with acute chest pain. |
format | Online Article Text |
id | pubmed-8073372 |
institution | National Center for Biotechnology Information |
language | English |
publishDate | 2021 |
publisher | MDPI |
record_format | MEDLINE/PubMed |
spelling | pubmed-80733722021-04-27 Clinical History and Detectable Troponin Concentrations below the 99th Percentile for Risk Stratification of Patients with Chest Pain and First Normal Troponin Fernández-Cisnal, Agustín Valero, Ernesto García-Blas, Sergio Pernias, Vicente Pozo, Adela Carratalá, Arturo González, Jessika Noceda, José Miñana, Gema Núñez, Julio Sanchis, Juan J Clin Med Article Decision-making is challenging in patients with chest pain and normal high-sensitivity cardiac troponin T (hs-cTnT; <99th percentile; <14 ng/L) at hospital arrival. Most of these patients might be discharged early. We investigated clinical data and hs-cTnT concentrations for risk stratification. This is a retrospective study including 4476 consecutive patients presenting to the emergency department with chest pain and first normal hs-cTnT. The primary endpoint was one-year death or acute myocardial infarction, and the secondary endpoint added urgent revascularization. The number of primary and secondary endpoints was 173 (3.9%) and 252 (5.6%). Mean hs-cTnT concentrations were 6.9 ± 2.5 ng/L. Undetectable (<5 ng/L) hs-cTnT (n = 1847, 41%) had optimal negative predictive value (99.1%) but suboptimal sensitivity (90.2%) and discrimination accuracy (AUC = 0.664) for the primary endpoint. Multivariable analysis was used to identify the predictive clinical variables. The clinical model showed good discrimination accuracy (AUC = 0.810). The addition of undetectable hs-cTnT (≥ or <5 ng/L; HR, hazard ratio = 3.80; 95% CI, confidence interval 2.27–6.35; p = 0.00001) outperformed the clinical model alone (AUC = 0.836, p = 0.002 compared to the clinical model). Measurable hs-cTnT concentrations (between detection limit and 99th percentile; per 0.1 ng/L, HR = 1.13; CI 1.06–1.20; p = 0.0001) provided further predictive information (AUC = 0.844; p = 0.05 compared to the clinical plus undetectable hs-cTnT model). The results were reproducible for the secondary endpoint and 30-day events. Clinical assessment, undetectable hs-cTnT and measurable hs-cTnT concentrations must be considered for decision-making after a single negative hs-cTnT result in patients presenting to the emergency department with acute chest pain. MDPI 2021-04-20 /pmc/articles/PMC8073372/ /pubmed/33923925 http://dx.doi.org/10.3390/jcm10081784 Text en © 2021 by the authors. https://creativecommons.org/licenses/by/4.0/Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (https://creativecommons.org/licenses/by/4.0/). |
spellingShingle | Article Fernández-Cisnal, Agustín Valero, Ernesto García-Blas, Sergio Pernias, Vicente Pozo, Adela Carratalá, Arturo González, Jessika Noceda, José Miñana, Gema Núñez, Julio Sanchis, Juan Clinical History and Detectable Troponin Concentrations below the 99th Percentile for Risk Stratification of Patients with Chest Pain and First Normal Troponin |
title | Clinical History and Detectable Troponin Concentrations below the 99th Percentile for Risk Stratification of Patients with Chest Pain and First Normal Troponin |
title_full | Clinical History and Detectable Troponin Concentrations below the 99th Percentile for Risk Stratification of Patients with Chest Pain and First Normal Troponin |
title_fullStr | Clinical History and Detectable Troponin Concentrations below the 99th Percentile for Risk Stratification of Patients with Chest Pain and First Normal Troponin |
title_full_unstemmed | Clinical History and Detectable Troponin Concentrations below the 99th Percentile for Risk Stratification of Patients with Chest Pain and First Normal Troponin |
title_short | Clinical History and Detectable Troponin Concentrations below the 99th Percentile for Risk Stratification of Patients with Chest Pain and First Normal Troponin |
title_sort | clinical history and detectable troponin concentrations below the 99th percentile for risk stratification of patients with chest pain and first normal troponin |
topic | Article |
url | https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8073372/ https://www.ncbi.nlm.nih.gov/pubmed/33923925 http://dx.doi.org/10.3390/jcm10081784 |
work_keys_str_mv | AT fernandezcisnalagustin clinicalhistoryanddetectabletroponinconcentrationsbelowthe99thpercentileforriskstratificationofpatientswithchestpainandfirstnormaltroponin AT valeroernesto clinicalhistoryanddetectabletroponinconcentrationsbelowthe99thpercentileforriskstratificationofpatientswithchestpainandfirstnormaltroponin AT garciablassergio clinicalhistoryanddetectabletroponinconcentrationsbelowthe99thpercentileforriskstratificationofpatientswithchestpainandfirstnormaltroponin AT perniasvicente clinicalhistoryanddetectabletroponinconcentrationsbelowthe99thpercentileforriskstratificationofpatientswithchestpainandfirstnormaltroponin AT pozoadela clinicalhistoryanddetectabletroponinconcentrationsbelowthe99thpercentileforriskstratificationofpatientswithchestpainandfirstnormaltroponin AT carratalaarturo clinicalhistoryanddetectabletroponinconcentrationsbelowthe99thpercentileforriskstratificationofpatientswithchestpainandfirstnormaltroponin AT gonzalezjessika clinicalhistoryanddetectabletroponinconcentrationsbelowthe99thpercentileforriskstratificationofpatientswithchestpainandfirstnormaltroponin AT nocedajose clinicalhistoryanddetectabletroponinconcentrationsbelowthe99thpercentileforriskstratificationofpatientswithchestpainandfirstnormaltroponin AT minanagema clinicalhistoryanddetectabletroponinconcentrationsbelowthe99thpercentileforriskstratificationofpatientswithchestpainandfirstnormaltroponin AT nunezjulio clinicalhistoryanddetectabletroponinconcentrationsbelowthe99thpercentileforriskstratificationofpatientswithchestpainandfirstnormaltroponin AT sanchisjuan clinicalhistoryanddetectabletroponinconcentrationsbelowthe99thpercentileforriskstratificationofpatientswithchestpainandfirstnormaltroponin |