Outcomes of non–acute coronary syndrome patients discharged from the emergency department with troponin positivity

Abstract

Background: Cardiac troponin elevation portends a worse prognosis in diverse patient populations. The significance of troponin elevation in patients discharged from emergency departments (EDs) without inpatient admission is not well known. Methods: Patients without a diagnosis of acute coronary syndrome discharged from two EDs between April 1, 2006, and December 31, 2007, with an abnormal cardiac troponin (troponin positive [TP]) were compared to a troponin-negative (TN) cohort matched for age, sex, and primary discharge diagnosis. Outcomes were obtained by linking with a regional ED and a provincial vital statistics database and adjusted for the following: estimated glomerular filtration rate, do-notresuscitate status, history of coronary artery disease, Canadian Triage and Acuity Scale, and left ventricular hypertrophy on electrocardiography. The primary outcome was a composite of death or admission to hospital within 1 year. Results: Our total cohort (n 5 344) consisted of 172 TP and 172 TN patients. In the univariate analysis, TP patients had a higher rate of the primary outcome (OR 3.2, 95% CI 2.1-5.0, p , 0.001) and both of its components (p , 0.001). After adjusting for covariates, positive troponin remained an independent predictor of the primary outcome (OR 2.1, 95% CI 1.3-3.4, p 5 0.005) and inpatient admission (OR 2.0, 95% CI 1.2-3.4, p 5 0.006). There was no significant difference in death (OR 1.3, 95% CI 0.6-2.9, p 5 0.5) after adjustment. Conclusions: A positive troponin assay during ED stay in discharged patients is an independent marker for risk of subsequent admission. Our findings suggest that the prognostic power of an abnormal troponin extends to patients discharged from the ED.

Outcomes with type 2 myocardial infarction compared with non-ischaemic myocardial injury

“…The number of hospital admissions among these patients is quite low if compared with that of patients with type 1 MI. These results are consistent with the findings by Brunner24 and Fundaro,25 demonstrating that many patients with high troponin levels are not hospitalised. The apparently lower rate of hospital admissions may in fact reflect that the attending physician is prone to institute less aggressive treatments due to the lack of evidence of ongoing myocardial ischaemia.…”

Troponin Elevation in Patients Without Acute Coronary Syndrome

“…Almost half our patients with troponin elevation not diagnosed with ACS were discharged from the emergency room without hospitalization. This percentage may seem very high, but has also been described by other authors 22 and is probably similar to that of most emergency rooms that must match hospital admissions to the patient's main diagnosis, need for acute nursing care, and hospital bed availability. Therefore, it is not surprising that elderly patients with a high-risk clinical profile but a diagnosis other than ACS are not admitted, despite increased troponin, and are managed by outpatient services.…”

Valor Prognóstico de Níveis Elevados de Troponina I Isolados em Pacientes sem Síndrome Coronariana Aguda Admitidos no Serviço de Emergência

“…O nível de troponina I foi determinado utilizando o mesmo imunoensaio TncI padrão (Troponina I Siemens Dimension EXL) [17][18][19] em todos os pacientes. O teste foi realizado no laboratório central do hospital.…”

“…O ensaio de troponina utilizado anteriormente em nosso hospital era um ensaio contemporâneo denominado 'troponina sensível' e não era altamente sensível, ao contrário do ensaio de troponina utilizado atualmente, através do qual espera-se detectar valores positivos de troponina em mais pacientes, como descrito para este ensaio de troponina. 18,19 Conclusão Uma alta porcentagem de pacientes com um nível elevado de troponina medido no PS não foi diagnosticada com SCA. Esses pacientes apresentavam perfil clínico de alto risco, ampla heterogeneidade em relação ao diagnóstico principal e prognóstico adverso aos 16 meses.…”