TY - JOUR
T1 - Association of high-sensitivity cardiac troponin I concentration with cardiac outcomes in patients with suspected acute coronary syndrome
AU - Chapman, Andrew R.
AU - Lee, Kuan Ken
AU - McAllister, David A.
AU - Cullen, Louise
AU - Greenslade, Jaimi H.
AU - Parsonage, William
AU - Worster, Andrew
AU - Kavsak, Peter A.
AU - Blankenberg, Stefan
AU - Neumann, Johannes
AU - Söerensen, Nils A.
AU - Westermann, Dirk
AU - Buijs, Madelon M.
AU - Verdel, Gerard J.E.
AU - Pickering, John W.
AU - Than, Martin P.
AU - Twerenbold, Raphael
AU - Badertscher, Patrick
AU - Sabti, Zaid
AU - Mueller, Christian
AU - Anand, Atul
AU - Adamson, Philip
AU - Strachan, Fiona E.
AU - Ferry, Amy
AU - Sandeman, Dennis
AU - Gray, Alasdair
AU - Body, Richard
AU - Keevil, Brian
AU - Carlton, Edward
AU - Greaves, Kim
AU - Korley, Frederick K.
AU - Metkus, Thomas S.
AU - Sandoval, Yader
AU - Apple, Fred S.
AU - Newby, David E.
AU - Shah, Anoop S.V.
AU - Mills, Nicholas L.
N1 - Publisher Copyright:
© 2017 American Medical Association. All rights reserved.
PY - 2017/11/21
Y1 - 2017/11/21
N2 - 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.
AB - 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.
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U2 - 10.1001/jama.2017.17488
DO - 10.1001/jama.2017.17488
M3 - Article
C2 - 29127948
AN - SCOPUS:85036587588
SN - 0098-7484
VL - 318
SP - 1913
EP - 1924
JO - JAMA - Journal of the American Medical Association
JF - JAMA - Journal of the American Medical Association
IS - 19
ER -