Journal Article

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

Beanlands, Robert S., Taljaard, Monica, Nemnom, Marie-Joe, Chaudry, Hina, Wells, George A., Booth, Ronald A., Toarta, Cristian, Hebert, Guy, Stiell, Ian G., Thiruganasambandamoorthy, Venkatesh, Mukarram, Muhammad

2020

Overview

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. 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). 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%). 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.

• Publisher: Public Library of Science,Public Library of Science (PLoS)
• Subject: Aged / Angina / Angina pectoris / Biology and Life Sciences / Calcium-binding protein / Cardiovascular disease / Cohort Studies / Diagnosis / Echocardiography / EKG / Electrocardiography / Emergency medical care / Emergency medical services / Epidemiology / Family medical history / Female / Heart / Heart attacks / Hospitals / Humans / Ischemia / Male / Medical diagnosis / Medicine / Medicine and Health Sciences / Middle Aged / Myocardial infarction / Myocardium - metabolism / Non-ST Elevated Myocardial Infarction - diagnosis / Non-ST Elevated Myocardial Infarction - metabolism / Pain / Patients / People and Places / Physicians / Prognosis / Public health / Risk analysis / Risk factors / Sensitivity / Studies / Troponin / Troponin I - metabolism