Patient selection for high sensitivity cardiac troponin testing and diagnosis of myocardial infarction: prospective cohort study

Anoop S.V. Shah; Yader Sandoval; Ala Noaman; Anne Sexter; Amar Vaswani; Stephen W. Smith; Mathew Gibbins; Megan Griffiths; Andrew R. Chapman; Fiona E. Strachan; Atul Anand; Martin A. Denvir; Philip D. Adamson; Michelle S. D'Souza; Alasdair J. Gray; David A. McAllister; David E. Newby; Fred S. Apple; Nicholas L. Mills

doi:10.1136/bmj.j4788

Patient selection for high sensitivity cardiac troponin testing and diagnosis of myocardial infarction: prospective cohort study

Anoop S.V. Shah, Yader Sandoval, Ala Noaman, Anne Sexter, Amar Vaswani, Stephen W. Smith, Mathew Gibbins, Megan Griffiths, Andrew R. Chapman, Fiona E. Strachan, Atul Anand, Martin A. Denvir, Philip D. Adamson, Michelle S. D'Souza, Alasdair J. Gray, David A. McAllister, David E. Newby, Fred S. Apple, Nicholas L. Mills

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Abstract

Objective To evaluate how selection of patients for high sensitivity cardiac troponin testing affects the diagnosis of myocardial infarction across different healthcare settings.Design Prospective study of three independent consecutive patient populations presenting to emergency departments.Setting Secondary and tertiary care hospitals in the United Kingdom and United States.Participants High sensitivity cardiac troponin I concentrations were measured in 8500 consecutive patients presenting to emergency departments: unselected patients in the UK (n=1054) and two selected populations of patients in whom troponin testing was requested by the attending clinician in the UK (n=5815) and the US (n=1631). The final diagnosis of type 1 or type 2 myocardial infarction or myocardial injury was independently adjudicated.Main outcome measures Positive predictive value of an elevated cardiac troponin concentration for a diagnosis of type 1 myocardial infarction.Results Cardiac troponin concentrations were elevated in 13.7% (144/1054) of unselected patients, with a prevalence of 1.6% (17/1054) for type 1 myocardial infarction and a positive predictive value of 11.8% (95% confidence interval 7.0% to 18.2%). In selected patients, in whom troponin testing was guided by the attending clinician, the prevalence and positive predictive value were 14.5% (843/5815) and 59.7% (57.0% to 62.2%) in the UK and 4.2% (68/1631) and 16.4% (13.0% to 20.3%) in the US. Across both selected patient populations, the positive predictive value was highest in patients with chest pain, with ischaemia on the electrocardiogram, and with a history of ischaemic heart disease.Conclusions When high sensitivity cardiac troponin testing is performed widely or without previous clinical assessment, elevated troponin concentrations are common and predominantly reflect myocardial injury rather than myocardial infarction. These observations highlight how selection of patients for cardiac troponin testing varies across healthcare settings and markedly influences the positive predictive value for a diagnosis of myocardial infarction.

Original language	English (US)
Pages (from-to)	j4788
Journal	BMJ (Clinical research ed.)
Volume	359
DOIs	https://doi.org/10.1136/bmj.j4788
State	Published - Nov 7 2017
Externally published	Yes

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Publisher Copyright:
Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.

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Shah, A. S. V., Sandoval, Y., Noaman, A., Sexter, A., Vaswani, A., Smith, S. W., Gibbins, M., Griffiths, M., Chapman, A. R., Strachan, F. E., Anand, A., Denvir, M. A., Adamson, P. D., D'Souza, M. S., Gray, A. J., McAllister, D. A., Newby, D. E., Apple, F. S., & Mills, N. L. (2017). Patient selection for high sensitivity cardiac troponin testing and diagnosis of myocardial infarction: prospective cohort study. BMJ (Clinical research ed.), 359, j4788. https://doi.org/10.1136/bmj.j4788

Shah, ASV, Sandoval, Y, Noaman, A, Sexter, A, Vaswani, A, Smith, SW, Gibbins, M, Griffiths, M, Chapman, AR, Strachan, FE, Anand, A, Denvir, MA, Adamson, PD, D'Souza, MS, Gray, AJ, McAllister, DA, Newby, DE, Apple, FS & Mills, NL 2017, 'Patient selection for high sensitivity cardiac troponin testing and diagnosis of myocardial infarction: prospective cohort study', BMJ (Clinical research ed.), vol. 359, pp. j4788. https://doi.org/10.1136/bmj.j4788

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title = "Patient selection for high sensitivity cardiac troponin testing and diagnosis of myocardial infarction: prospective cohort study",

abstract = "Objective To evaluate how selection of patients for high sensitivity cardiac troponin testing affects the diagnosis of myocardial infarction across different healthcare settings.Design Prospective study of three independent consecutive patient populations presenting to emergency departments.Setting Secondary and tertiary care hospitals in the United Kingdom and United States.Participants High sensitivity cardiac troponin I concentrations were measured in 8500 consecutive patients presenting to emergency departments: unselected patients in the UK (n=1054) and two selected populations of patients in whom troponin testing was requested by the attending clinician in the UK (n=5815) and the US (n=1631). The final diagnosis of type 1 or type 2 myocardial infarction or myocardial injury was independently adjudicated.Main outcome measures Positive predictive value of an elevated cardiac troponin concentration for a diagnosis of type 1 myocardial infarction.Results Cardiac troponin concentrations were elevated in 13.7% (144/1054) of unselected patients, with a prevalence of 1.6% (17/1054) for type 1 myocardial infarction and a positive predictive value of 11.8% (95% confidence interval 7.0% to 18.2%). In selected patients, in whom troponin testing was guided by the attending clinician, the prevalence and positive predictive value were 14.5% (843/5815) and 59.7% (57.0% to 62.2%) in the UK and 4.2% (68/1631) and 16.4% (13.0% to 20.3%) in the US. Across both selected patient populations, the positive predictive value was highest in patients with chest pain, with ischaemia on the electrocardiogram, and with a history of ischaemic heart disease.Conclusions When high sensitivity cardiac troponin testing is performed widely or without previous clinical assessment, elevated troponin concentrations are common and predominantly reflect myocardial injury rather than myocardial infarction. These observations highlight how selection of patients for cardiac troponin testing varies across healthcare settings and markedly influences the positive predictive value for a diagnosis of myocardial infarction.",

author = "Shah, {Anoop S.V.} and Yader Sandoval and Ala Noaman and Anne Sexter and Amar Vaswani and Smith, {Stephen W.} and Mathew Gibbins and Megan Griffiths and Chapman, {Andrew R.} and Strachan, {Fiona E.} and Atul Anand and Denvir, {Martin A.} and Adamson, {Philip D.} and D'Souza, {Michelle S.} and Gray, {Alasdair J.} and McAllister, {David A.} and Newby, {David E.} and Apple, {Fred S.} and Mills, {Nicholas L.}",

note = "Publisher Copyright: Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.",

year = "2017",

month = nov,

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doi = "10.1136/bmj.j4788",

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T1 - Patient selection for high sensitivity cardiac troponin testing and diagnosis of myocardial infarction

T2 - prospective cohort study

AU - Shah, Anoop S.V.

AU - Sandoval, Yader

AU - Noaman, Ala

AU - Sexter, Anne

AU - Vaswani, Amar

AU - Smith, Stephen W.

AU - Gibbins, Mathew

AU - Griffiths, Megan

AU - Chapman, Andrew R.

AU - Strachan, Fiona E.

AU - Anand, Atul

AU - Denvir, Martin A.

AU - Adamson, Philip D.

AU - D'Souza, Michelle S.

AU - Gray, Alasdair J.

AU - McAllister, David A.

AU - Newby, David E.

AU - Apple, Fred S.

AU - Mills, Nicholas L.

N1 - Publisher Copyright: Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.

PY - 2017/11/7

Y1 - 2017/11/7

N2 - Objective To evaluate how selection of patients for high sensitivity cardiac troponin testing affects the diagnosis of myocardial infarction across different healthcare settings.Design Prospective study of three independent consecutive patient populations presenting to emergency departments.Setting Secondary and tertiary care hospitals in the United Kingdom and United States.Participants High sensitivity cardiac troponin I concentrations were measured in 8500 consecutive patients presenting to emergency departments: unselected patients in the UK (n=1054) and two selected populations of patients in whom troponin testing was requested by the attending clinician in the UK (n=5815) and the US (n=1631). The final diagnosis of type 1 or type 2 myocardial infarction or myocardial injury was independently adjudicated.Main outcome measures Positive predictive value of an elevated cardiac troponin concentration for a diagnosis of type 1 myocardial infarction.Results Cardiac troponin concentrations were elevated in 13.7% (144/1054) of unselected patients, with a prevalence of 1.6% (17/1054) for type 1 myocardial infarction and a positive predictive value of 11.8% (95% confidence interval 7.0% to 18.2%). In selected patients, in whom troponin testing was guided by the attending clinician, the prevalence and positive predictive value were 14.5% (843/5815) and 59.7% (57.0% to 62.2%) in the UK and 4.2% (68/1631) and 16.4% (13.0% to 20.3%) in the US. Across both selected patient populations, the positive predictive value was highest in patients with chest pain, with ischaemia on the electrocardiogram, and with a history of ischaemic heart disease.Conclusions When high sensitivity cardiac troponin testing is performed widely or without previous clinical assessment, elevated troponin concentrations are common and predominantly reflect myocardial injury rather than myocardial infarction. These observations highlight how selection of patients for cardiac troponin testing varies across healthcare settings and markedly influences the positive predictive value for a diagnosis of myocardial infarction.

AB - Objective To evaluate how selection of patients for high sensitivity cardiac troponin testing affects the diagnosis of myocardial infarction across different healthcare settings.Design Prospective study of three independent consecutive patient populations presenting to emergency departments.Setting Secondary and tertiary care hospitals in the United Kingdom and United States.Participants High sensitivity cardiac troponin I concentrations were measured in 8500 consecutive patients presenting to emergency departments: unselected patients in the UK (n=1054) and two selected populations of patients in whom troponin testing was requested by the attending clinician in the UK (n=5815) and the US (n=1631). The final diagnosis of type 1 or type 2 myocardial infarction or myocardial injury was independently adjudicated.Main outcome measures Positive predictive value of an elevated cardiac troponin concentration for a diagnosis of type 1 myocardial infarction.Results Cardiac troponin concentrations were elevated in 13.7% (144/1054) of unselected patients, with a prevalence of 1.6% (17/1054) for type 1 myocardial infarction and a positive predictive value of 11.8% (95% confidence interval 7.0% to 18.2%). In selected patients, in whom troponin testing was guided by the attending clinician, the prevalence and positive predictive value were 14.5% (843/5815) and 59.7% (57.0% to 62.2%) in the UK and 4.2% (68/1631) and 16.4% (13.0% to 20.3%) in the US. Across both selected patient populations, the positive predictive value was highest in patients with chest pain, with ischaemia on the electrocardiogram, and with a history of ischaemic heart disease.Conclusions When high sensitivity cardiac troponin testing is performed widely or without previous clinical assessment, elevated troponin concentrations are common and predominantly reflect myocardial injury rather than myocardial infarction. These observations highlight how selection of patients for cardiac troponin testing varies across healthcare settings and markedly influences the positive predictive value for a diagnosis of myocardial infarction.

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Patient selection for high sensitivity cardiac troponin testing and diagnosis of myocardial infarction: prospective cohort study

Abstract

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