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Association of High-Sensitivity Cardiac Troponin I Concentration With Cardiac Outcomes in Patients With Suspected Acute Coronary Syndrome

Research output: Contribution to journalArticle

  • Louise Cullen
  • Jaimi H Greenslade
  • William Parsonage
  • Andrew Worster
  • Peter A Kavsak
  • Stefan Blankenberg
  • Johannes Neumann
  • Nils A Söerensen
  • Dirk Westermann
  • Madelon M Buijs
  • Gerard J E Verdel
  • John W Pickering
  • Martin P Than
  • Raphael Twerenbold
  • Patrick Badertscher
  • Zaid Sabti
  • Christian Mueller
  • Atul Anand
  • Amy Ferry
  • Dennis Sandeman
  • Richard Body
  • Brian Keevil
  • Edward Carlton
  • Kim Greaves
  • Frederick K Korley
  • Thomas S Metkus
  • Yader Sandoval
  • Fred S Apple
  • Anoop S V Shah

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Original languageEnglish
Pages (from-to)1913-1924
Number of pages12
JournalJAMA: the Journal of the American Medical Association
Volume318
Issue number19
Early online date11 Nov 2017
DOIs
Publication statusPublished - 21 Nov 2017

Abstract

Importance: High-sensitivity cardiac troponin I testing is widely used to evaluate patients with suspected acute coronary syndrome. A cardiac troponin concentration of less than 5 ng/L identifies patients at presentation as low risk, but the optimal threshold is uncertain.

Objective: To evaluate the performance of a cardiac troponin I threshold of 5 ng/L at presentation as a risk stratification tool in patients with suspected acute coronary syndrome.

Data Sources: Systematic search of MEDLINE, EMBASE, Cochrane, and Web of Science databases from January 1, 2006, to March 18, 2017.

Study Selection: Prospective studies measuring high-sensitivity cardiac troponin I concentrations in patients with suspected acute coronary syndrome in which the diagnosis was adjudicated according to the universal definition of myocardial infarction.

Data Extraction and Synthesis: The systematic review identified 19 cohorts. Individual patient-level data were obtained from the corresponding authors of 17 cohorts, with aggregate data from 2 cohorts. Meta-estimates for primary and secondary outcomes were derived using a binomial-normal random-effects model.

Main Outcomes and Measures: The primary outcome was myocardial infarction or cardiac death at 30 days. Performance was evaluated in subgroups and across a range of troponin concentrations (2-16 ng/L) using individual patient data.

Results: Of 11 845 articles identified, 104 underwent full-text review, and 19 cohorts from 9 countries were included. Among 22 457 patients included in the meta-analysis (mean age, 62 [SD, 15.5] years; n = 9329 women [41.5%]), the primary outcome occurred in 2786 (12.4%). Cardiac troponin I concentrations were less than 5 ng/L at presentation in 11 012 patients (49%), in whom there were 60 missed index or 30-day events (59 index myocardial infarctions, 1 myocardial infarction at 30 days, and no cardiac deaths at 30 days). This resulted in a negative predictive value of 99.5% (95% CI, 99.3%-99.6%) for the primary outcome. There were no cardiac deaths at 30 days and 7 (0.1%) at 1 year, with a negative predictive value of 99.9% (95% CI, 99.7%-99.9%) for cardiac death.

Conclusions and Relevance: Among patients with suspected acute coronary syndrome, a high-sensitivity cardiac troponin I concentration of less than 5 ng/L identified those at low risk of myocardial infarction or cardiac death within 30 days. Further research is needed to understand the clinical utility and cost-effectiveness of this approach to risk stratification.

    Research areas

  • Acute Coronary Syndrome, Adult, Biomarkers, Death, Humans, Male, Myocardial Infarction, Prognosis, Prospective Studies, Risk Assessment, Troponin I, Journal Article, Meta-Analysis, Review

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