Identifying Patients Suitable for Discharge After a Single-Presentation High-Sensitivity Troponin Result: A Comparison of Five Established Risk Scores and Two High-Sensitivity Assays

Abstract

ObjectiveTo compare the ability of five established risk scores to identify patients with suspected acute coronary syndromes (ACS) suitable for discharge after a single presentation highsensitivity troponin (hs-cTn) result. MethodsProspective observational study conducted in a U.K. District General Hospital Emergency Department. Consecutive adults recruited with suspected ACS whom attending physicians determined evaluation with serial troponin testing was required. Index tests were definitions of low risk applied to Goldman, TIMI, GRACE, HEART and Vancouver risk scores, incorporating either hs-cTnT or hs-cTnI results. The endpoint was acute myocardial infarction (AMI) within 30 days. A test sensitivity threshold for AMI of 98% was chosen.Clinical utility was defined as a negative predictive value (NPV) ≥99.5% and identification of >30% suitable for discharge. Results959 patients underwent hs-cTnT and 867 hs-cTnI analysis. In the hs-cTnT group, 79/959 (8.2%) had an AMI and 66/867 (7.6%) in the hs-cTnI group. Two risk scores (GRACE<80, HEART≤3) did not have the potential to achieve a sensitivity of 98% with hs-cTnT and three 2 scores (Goldman≤1, TIMI≤1, GRACE<80) with hs-cTnI. TIMI 0 or ≤1 and m-Goldman≤1 with hs-cTnT, and TIMI 0 and HEART≤3, with hs-cTnI have the potential to achieve an NPV ≥99.5% while identifying >30% for discharge. ConclusionUsing established risk scores, it may be possible to identify >30% of patients suitable for discharge with an NPV ≥99.5% for the diagnosis of AMI using a single hs-cTn result taken at presentation. There is variation in hs-cTn assays which may have implications in introducing rapid rule-out protocols.

Prognostic Utility of a Modified HEART Score in Chest Pain Patients in the Emergency Department

“…A small number of patients had a MACE, although our MACE rate is similar to the findings of other studies. 13,48 Finally, there were 242 patients who had missing data. The majority of patients with missing data were 190 patients who did not have a hs-cTnT value at 4 to 14 hours.…”

High incidence of macrotroponin I with a high-sensitivity troponin I assay

“…The hope is that high-sensitivity troponin assays will lead to earlier diagnosis of acute coronary syndrome and, with their enhanced sensitivity and sex-specific cutoffs, may improve patient outcomes, especially in women. However, there is insufficient evidence yet to conclude whether these outcomes have been achieved [3][4][5][6].…”

Risk stratifying chest pain patients in the emergency department using HEART, GRACE and TIMI scores, with a single contemporary troponin result, to predict major adverse cardiac events

“…Akin to guidance on the use of D-dimer in association with a risk score for the rule-out of venous thromboembolic disease,19 the future of rapid rule-out AMI strategies may be a combination of a risk score and a single admission draw of hs-cTn,20 but questions still remain regarding the clinical use of such an approach,21 particularly the performance of hs-cTn assays early after symptom onset 5. Such caveats have resulted in national guidance in some westernised nations, including the USA, that continue to recommend risk stratification using a contemporary (not high-sensitivity) cTn assay 22.…”