Original ContributionsPrediction of short- and long-term outcomes by troponin t levels in low-risk patients evaluated for acute coronary syndromes☆,☆☆
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INTRODUCTION
Chest pain is a common but difficult problem to assess in the emergency department. Observation and serial testing are used to overcome the limitations of the initial history, physical examination, ECG, and enzyme assay results.1 Between 2% and 5% of patients with chest discomfort are inappropriately discharged from the ED,2, 3, 4, 5 but only about one third of patients admitted with suspected acute coronary syndromes ultimately have a diagnosis of myocardial infarction.6 An accurate marker of
MATERIALS AND METHODS
We conducted a prospective longitudinal study in a convenience sample of low-risk patients admitted to the observation unit in the ED of a large, urban, academic tertiary care center. This was part of a larger program examining the value of troponin T testing in all patients with suspected acute coronary syndromes. The annual ED census is approximately 40,000 patients, of whom 9% have an acute chest pain syndrome. Nearly 4% of ED patients with an acute chest pain syndrome are immediately
RESULTS
Two hundred sixty-six patients were studied with a mean age of 59.8±14.0 years; 139 (52.3%) were women. One hundred twenty-eight (48.1%) of the patients were white and 125 (47%) were black. The mean time to presentation was 5 hours after symptom onset. Average time of follow-up was 6.3 (±0.9) months. At the 6-month evaluation, all patients had complete follow-up. Most patients (94%) had at least one historical cardiac risk factor, with an average of 3.2±1.9 risk factors per patient.
Because an
DISCUSSION
In patients with AMI, many studies have found cTnT testing to be a useful diagnostic test.7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19 However, none have evaluated the prospectively defined low-risk acute coronary syndrome ED patient. Hamm et al8 suggested that negative results on serial troponin testing are associated with such low risk as to allow rapid and safe discharge of ED patients. They recommended that patients with suspected acute coronary syndromes, but with 2 normal troponin
References (33)
- et al.
Clinical characteristics and natural history of patients with acute myocardial infarction sent home from the emergency room
Am J Cardiol
(1987) - et al.
Litigation against the emergency physician: common features in cases of missed myocardial infarction
Ann Emerg Med
(1989) - et al.
Use of cardiac enzymes identifies patients with acute myocardial infarction otherwise unrecognized in the emergency department
Ann Emerg Med
(1987) - et al.
Cardiac troponin. See ya later, CK
Chest
(1997) - et al.
A decision tree for the early diagnosis of acute myocardial infarction in nontraumatic chest pain patients at hospital admission
Chest
(1995) - et al.
Rapid diagnosis of acute myocardial infarction
Cardiol Clin
(1995) - et al.
Creatine kinase-MB fraction and cardiac troponin T to diagnose acute myocardial infarction after cardiopulmonary resuscitation
J Am Coll Cardiol
(1996) - et al.
Independent prognostic value of serum creatine kinase isoenzyme MN bass, cardiac troponin T and myosin light chain levels in suspected acute myocardial infarction: analysis of 28 months of follow-up in 196 patients
J Am Coll Cardiol
(1995) - et al.
Prognostic value of cardiac troponin T in unstable angina pectoris
Am J Cardiol
(1995) - et al.
Noninvasive risk stratification in unstable coronary artery disease: exercise test and biochemical markers
Am J Cardiol
(1997)
Measurement of cardiac troponin T is an effective method for predicting complications among emergency department patients with chest pain
Ann Emerg Med
Myocardial markers of injury. Evolution and insights
Am J Clin Pathol
Dispositions of presumed coronary patients from an emergency room: a follow-up study
JAMA
Detecting acute cardiac ischemia in the emergency department
J Gen Intern Med
Emergency room triage of patients with acute chest pain by means of rapid testing for cardiac troponin T or troponin I
N Engl J Med
Evaluation of chest pain in the emergency department
N Engl J Med
Cited by (32)
Patients with acute coronary syndrome and normal high-sensitivity troponin
2011, American Journal of MedicineCitation Excerpt :Although this population is assumed to be small, ranging from 1% to 8% among studies, these patients are at high risk of short-term cardiac events or re-hospitalization.2,4,5 In a study combining data from 3 large trials, Mehta and colleagues22 reported that over 20% of adverse events following non-ST-elevation AMI occurred more than 30 days later; this suggests that the risk of these patients might be even more considerable if long-term follow-up is considered.6,7 The recent development of high-sensitivity assays of cTn is considered a major opportunity to improve the safety and efficiency of chest pain assessment in the ED.
Outcomes associated with small changes in normal-range cardiac markers
2011, American Journal of Emergency MedicineOutcomes Research in Cardiovascular Imaging. Report of a Workshop Sponsored by the National Heart, Lung, and Blood Institute
2009, JACC: Cardiovascular ImagingOutcomes Research in Cardiovascular Imaging: Report of a Workshop Sponsored by the National Heart, Lung, and Blood Institute
2009, Journal of Cardiovascular Computed TomographyCitation Excerpt :Highly specific testing, though valuable when positive, may be inadequate for safe discharge. Unfortunately, currently available biomarker tests have high specificity but sensitivity as low as 10%,53 although a “chest pain center” strategy of serial markers and selective stress testing decreases mortality and increases discharges by 37% and 36%, respectively, compared with usual care.54 Thus, use of this model has sky rocketed,55–59 despite tremendous cost, average length of hospitalization of 17h, and great inconvenience to the patient.
Outcomes Research in Cardiovascular Imaging: Report of a Workshop Sponsored by the National Heart, Lung, and Blood Institute
2009, Journal of the American Society of Echocardiography
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Supported by a grant from Boehringer-Mannheim.
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Address for reprints: William Franklin Peacock IV, MD, Emergency Department, E19, The Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH 44195; 216-445-4546, fax 216-445-4552;E-mail [email protected] .