Challenging the 99th percentile: A lower troponin cutoff leads to low mortality of chest pain patients

TY - JOUR

T1 - Challenging the 99th percentile: A lower troponin cutoff leads to low mortality of chest pain patients

AU - Sörensen, Nils Arne

AU - Neumann, Johannes Tobias

AU - Ojeda, Francisco

AU - Schwemer, Tjark

AU - Renné, Thomas

AU - Schnabel, Renate B

AU - Zeller, Tanja

AU - Karakas, Mahir

AU - Blankenberg, Stefan

AU - Westermann, Dirk

N1 - Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.

PY - 2017/4/1

Y1 - 2017/4/1

N2 - BACKGROUND: Rule-out of non-ST-elevation myocardial infarction is based on consecutive measurements of cardiac troponins using the 99th percentile of the respective assay as cutoff. The new ESC guidelines alternatively offer rapid 1h algorithms with lower cutoffs than the 99th percentile for rule-out of non-ST-elevation myocardial infarction. We aimed to compare a recently introduced 1h algorithm based on a high-sensitivity cardiac troponin I (hs-TnI) cutoff of 6ng/L at 0h and 1h to the current standard of care using the 99th percentile (27ng/L) as cutoff with reference to follow-up events in a large chest pain cohort.METHODS: Hs-TnI was measured at three time points (0h, 1h and 3h) in 1625 patients presenting with suspected myocardial infarction to the emergency department of the University-Medical Center Hamburg-Eppendorf. Seventy-five patients with ST-elevation myocardial infarction were excluded from the analysis. All-cause mortality, cardiac death, acute myocardial infarction, revascularization and cardiac rehospitalization after 12months were assessed.RESULTS: Patients ruled out by the 1h algorithm showed significantly less cardiac rehospitalizations (12.84% vs. 17.66%; p<0.001), and overall mortality (1.30% vs 3.46%, p<0.001) compared to using the 99th percentile as cutoff. The majority of deaths were caused by non-cardiac reasons. Cardiac deaths were rare using the 1h algorithm (0.21%).CONCLUSION: The commonly used 99th percentile as cutoff neglects patients with a high risk in the setting of acute chest pain.TRIAL REGISTRATION: www.clinicaltrials.gov (NCT02355457).

AB - BACKGROUND: Rule-out of non-ST-elevation myocardial infarction is based on consecutive measurements of cardiac troponins using the 99th percentile of the respective assay as cutoff. The new ESC guidelines alternatively offer rapid 1h algorithms with lower cutoffs than the 99th percentile for rule-out of non-ST-elevation myocardial infarction. We aimed to compare a recently introduced 1h algorithm based on a high-sensitivity cardiac troponin I (hs-TnI) cutoff of 6ng/L at 0h and 1h to the current standard of care using the 99th percentile (27ng/L) as cutoff with reference to follow-up events in a large chest pain cohort.METHODS: Hs-TnI was measured at three time points (0h, 1h and 3h) in 1625 patients presenting with suspected myocardial infarction to the emergency department of the University-Medical Center Hamburg-Eppendorf. Seventy-five patients with ST-elevation myocardial infarction were excluded from the analysis. All-cause mortality, cardiac death, acute myocardial infarction, revascularization and cardiac rehospitalization after 12months were assessed.RESULTS: Patients ruled out by the 1h algorithm showed significantly less cardiac rehospitalizations (12.84% vs. 17.66%; p<0.001), and overall mortality (1.30% vs 3.46%, p<0.001) compared to using the 99th percentile as cutoff. The majority of deaths were caused by non-cardiac reasons. Cardiac deaths were rare using the 1h algorithm (0.21%).CONCLUSION: The commonly used 99th percentile as cutoff neglects patients with a high risk in the setting of acute chest pain.TRIAL REGISTRATION: www.clinicaltrials.gov (NCT02355457).

U2 - 10.1016/j.ijcard.2016.12.167

DO - 10.1016/j.ijcard.2016.12.167

M3 - SCORING: Journal article

C2 - 28087181

VL - 232

SP - 289

EP - 293

JO - INT J CARDIOL

JF - INT J CARDIOL

SN - 0167-5273

ER -