Use of conventional cardiac troponin assay for diagnosis of non-ST-elevation myocardial infarction: ‘The Ottawa Troponin Pathway’

English version

Autoři: Venkatesh Thiruganasambandamoorthy ^aff001; Ian G. Stiell ^aff001; Hina Chaudry ^aff002; Muhammad Mukarram ^aff002; Ronald A. Booth ^aff004; Cristian Toarta ^aff003; Guy Hebert ^aff001; Robert S. Beanlands ^aff006; George A. Wells ^aff003; Marie-Joe Nemnom ^aff002; Monica Taljaard ^aff002
Působiště autorů: Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada ^aff001; Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, ON, Canada ^aff002; School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada ^aff003; Department of Pathology and Laboratory Medicine, University of Ottawa, Ottawa, ON, Canada ^aff004; Division of Emergency Medicine, University of Toronto, Toronto, ON, Canada ^aff005; Division of Cardiology, University of Ottawa, Ottawa, ON, Canada ^aff006
Vyšlo v časopise: PLoS ONE 15(1)
Kategorie: Research Article
prolekare.web.journal.doi_sk: https://doi.org/10.1371/journal.pone.0226892

Souhrn

Background

Serial conventional cardiac troponin (cTn) measurements 6–9 hours apart are recommended for non-ST-elevation MI (NSTEMI) diagnosis. We sought to develop a pathway with 3-hour changes for major adverse cardiac event (MACE) identification and assess the added value of the HEART [History, Electrocardiogram (ECG), Age, Risk factors, Troponin] score to the pathway.

Methods

We prospectively enrolled adults with NSTEMI symptoms at two-large emergency departments (EDs) over 32-months. Patients with STEMI, unstable angina and one cTn were excluded. We collected baseline characteristics, Siemens Vista conventional cTnI at 0, 3 or 6-hours after ED presentation; HEART score predictors; disposition and ED length of stay (LOS). Adjudicated primary outcome was 15-day MACE (acute MI, revascularization, or death due to cardiac ischemia/unknown cause). We analyzed multiples of 99th percentile cut-off cTnI values (45, 100 and 250ng/L).

Results

1,683 patients (mean age 64.7 years; 55.3% female; median LOS 7-hours; 88 patients with 15-day MACE) were included. 1,346 (80.0%) patients with both cTnI≤45 ng/L; and 155 (9.2%) of the 213 patients with one value≥100ng/L but both<250ng/L or ≤20% change did not suffer MACE. Among 124 patients (7.4%) with one of the two values>45ng/L but<100ng/L based on 3 or 6-hour cTnI, one patient with absolute change<10ng/L and 6 of the 19 patients with≥20ng/L were diagnosed with NSTEMI (patients with Δ10-19ng/L between first and second cTnI had third one at 6-hours). Based on the results, we developed the Ottawa Troponin Pathway (OTP) with a 98.9% sensitivity (95% CI 93.8–100%) and 94.6% specificity (95% CI 93.3–95.6%). Addition of the HEART score improved the sensitivity to 100% (95% CI 95.9–100%) and decreased the specificity to 26.5% (95% CI 24.3–28.7%).

Conclusion

The OTP with conventional cTnI 3-hours apart, should lead to better NSTEMI identification particularly those with values >99th percentile, standardize management and reduce the ED LOS.

Klíčová slova:

Critical care and emergency medicine – Physicians – Cardiology – Heart – Coronary heart disease – Troponin – Angina – Myocardial infarction

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