Adoption of high-sensitivity cardiac troponin for risk stratification of patients with suspected myocardial infarction: a multicentre cohort study

Michael McDermott, Dorien Kimenai, Atul Anand, Zen Huang, Andrew Houston, Sophie Williams, Felicity Evison, Suzy Gallier, Catalina Carenzo, Ben Glampson, Madina Hasan, Alexander Robertson, Thomas Phillips, Cai Davis, Elizabeth Sapey, Erik Mayer, Suzanne Mason, Matthew Stammers, Nicholas L Mills*

*Corresponding author for this work

Research output: Contribution to journalArticlepeer-review

Abstract / Description of output

Background
Guidelines recommend high-sensitivity cardiac troponin to risk stratify patients with possible myocardial infarction and identify those eligible for discharge. Our aim was to evaluate adoption of this approach in practice and to determine whether effectiveness and safety varies by age, sex, ethnicity, or socioeconomic deprivation status.
Methods
A multi-centre cohort study was conducted in 13 hospitals across the United Kingdom from November 1st, 2021, to October 31st, 2022. Routinely collected data including high-sensitivity cardiac troponin I or T measurements were linked to outcomes. The primary effectiveness and safety outcomes were the proportion discharged from the Emergency Department, and the proportion dead or with a subsequent myocardial infarction at 30 days, respectively. Patients were stratified using peak troponin concentration as low (<5 ng/L), intermediate (5 ng/L to sex-specific 99th percentile), or high-risk (>sex-specific 99th percentile).
Findings
In total 137,881 patients (49% [67,709/137,881] female) were included of whom 60,707 (44%), 42,727 (31%), and 34,447 (25%) were stratified as low-, intermediate- and high-risk, respectively. Overall, 65·8% (39,918/60,707) of low-risk patients were discharged from the Emergency Department, but this varied from 26·8% [2,200/8,216] to 93·5% [918/982] by site. The safety outcome occurred in 0·5% (277/60,707) and 11·4% (3,917/34,447) of patients classified as low- or high-risk, of whom 0·03% (18/60,707) and 1% (304/34,447) had a subsequent myocardial infarction at 30 days, respectively. A similar proportion of male and female patients were discharged (52% [36,838/70,759] versus 54% [36,113/67,109]), but discharge was more likely if patients were <70 years old (61% [58,533/95,227] versus 34% [14,428/42,654]), from areas of low socioeconomic deprivation (48% [6,697/14,087] versus 43% [12,090/28,116]) or were black or asian compared to caucasian (62% [5,458/8,877] and 55% [10,026/18,231] versus 46% [35,138/75,820]).
Interpretation
Despite high-sensitivity cardiac troponin correctly identifying half of all patients with possible myocardial infarction as being at low risk, only two-thirds of these patients were discharged. Substantial variation in the discharge of patients by age, ethnicity, socioeconomic deprivation, and site was observed identifying important opportunities to improve care.
Funding UK Research and Innovation
Original languageEnglish
Article number100960
Number of pages12
JournalThe Lancet Regional Health Europe
Volume43
Early online date13 Jun 2024
DOIs
Publication statusPublished - 1 Aug 2024

Keywords / Materials (for Non-textual outputs)

  • Healthcare data
  • Data linkage
  • High-sensitivity cardiac troponin
  • Healthcare outcomes
  • Myocardial infarction

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