Risk Scores and Coronary Artery Disease in Patients with Suspected Acute Coronary Syndrome and Intermediate Cardiac Troponin Concentrations

Overview

Journal Open Heart

Publisher BMJ Publishing Group

Specialty Cardiology & Vascular Diseases

Date 2024 Aug 3

PMID 39097328

Authors

Daniel Perez-Vicencio

Alexander J F Thurston

Dimitrios Doudesis

Rachel OBrien

Amy Ferry

Takeshi Fujisawa

Michelle Claire Williams

Alasdair J Gray

Nicholas L Mills

Kuan Ken Lee

Affiliations

Soon will be listed here.

Abstract

Background: Guidelines recommend the use of risk scores to select patients for further investigation after myocardial infarction has been ruled out but their utility to identify those with coronary artery disease is uncertain.

Methods: In a prospective cohort study, patients with intermediate high-sensitivity cardiac troponin I concentrations (5 ng/L to sex-specific 99th percentile) in whom myocardial infarction was ruled out were enrolled and underwent coronary CT angiography (CCTA) after hospital discharge. History, ECG, Age, Risk factors, Troponin (HEART), Emergency Department Assessment of Chest Pain Score (EDACS), Global Registry of Acute Coronary Event (GRACE), Thrombolysis In Myocardial Infarction (TIMI), Systematic COronary Risk Evaluation 2 and Pooled Cohort Equation risk scores were calculated and the odds ratio (OR) and diagnostic performance for obstructive coronary artery disease were determined using established thresholds.

Results: Of 167 patients enrolled (64±12 years, 28% female), 29.9% (50/167) had obstructive coronary artery disease. The odds of having obstructive disease were increased for all scores with the lowest and highest increase observed for an EDACS score ≥16 (OR 2.2 (1.1-4.6)) and a TIMI risk score ≥1 (OR 12.9 (3.0-56.0)), respectively. The positive predictive value (PPV) was low for all scores but was highest for a GRACE score >88 identifying 39% as high risk with a PPV of 41.9% (30.4-54.2%). The negative predictive value (NPV) varied from 77.3% to 95.2% but was highest for a TIMI score of 0 identifying 26% as low risk with an NPV of 95.2% (87.2-100%).

Conclusions: In patients with intermediate cardiac troponin concentrations in whom myocardial infarction has been excluded, clinical risk scores can help identify patients with and without coronary artery disease, although the performance of established risk thresholds is suboptimal for utilisation in clinical practice.

Trial Registration Number: NCT04549805.

References

Mahler S, Riley R, Hiestand B, Russell G, Hoekstra J, Lefebvre C . The HEART Pathway randomized trial: identifying emergency department patients with acute chest pain for early discharge. Circ Cardiovasc Qual Outcomes. 2015; 8(2):195-203. PMC: 4413911. DOI: 10.1161/CIRCOUTCOMES.114.001384. View

Andelius L, Mortensen M, Norgaard B, Abdulla J . Impact of statin therapy on coronary plaque burden and composition assessed by coronary computed tomographic angiography: a systematic review and meta-analysis. Eur Heart J Cardiovasc Imaging. 2018; 19(8):850-858. DOI: 10.1093/ehjci/jey012. View

. SCORE2 risk prediction algorithms: new models to estimate 10-year risk of cardiovascular disease in Europe. Eur Heart J. 2021; 42(25):2439-2454. PMC: 8248998. DOI: 10.1093/eurheartj/ehab309. View

Haase R, Schlattmann P, Gueret P, Andreini D, Pontone G, Alkadhi H . Diagnosis of obstructive coronary artery disease using computed tomography angiography in patients with stable chest pain depending on clinical probability and in clinically important subgroups: meta-analysis of individual patient data. BMJ. 2019; 365:l1945. PMC: 6561308. DOI: 10.1136/bmj.l1945. View

Reichlin T, Schindler C, Drexler B, Twerenbold R, Reiter M, Zellweger C . One-hour rule-out and rule-in of acute myocardial infarction using high-sensitivity cardiac troponin T. Arch Intern Med. 2012; 172(16):1211-8. DOI: 10.1001/archinternmed.2012.3698. View

Scirica B, Cannon C, Antman E, Murphy S, Morrow D, Sabatine M . Validation of the thrombolysis in myocardial infarction (TIMI) risk score for unstable angina pectoris and non-ST-elevation myocardial infarction in the TIMI III registry. Am J Cardiol. 2002; 90(3):303-5. DOI: 10.1016/s0002-9149(02)02468-2. View

Diamond G, Forrester J . Analysis of probability as an aid in the clinical diagnosis of coronary-artery disease. N Engl J Med. 1979; 300(24):1350-8. DOI: 10.1056/NEJM197906143002402. View

Than M, Flaws D, Sanders S, Doust J, Glasziou P, Kline J . Development and validation of the Emergency Department Assessment of Chest pain Score and 2 h accelerated diagnostic protocol. Emerg Med Australas. 2014; 26(1):34-44. DOI: 10.1111/1742-6723.12164. View

Williams M, Moss A, Dweck M, Adamson P, Alam S, Hunter A . Coronary Artery Plaque Characteristics Associated With Adverse Outcomes in the SCOT-HEART Study. J Am Coll Cardiol. 2019; 73(3):291-301. PMC: 6342893. DOI: 10.1016/j.jacc.2018.10.066. View

10.

Bularga A, Lee K, Stewart S, Ferry A, Chapman A, Marshall L . High-Sensitivity Troponin and the Application of Risk Stratification Thresholds in Patients With Suspected Acute Coronary Syndrome. Circulation. 2019; 140(19):1557-1568. PMC: 6831036. DOI: 10.1161/CIRCULATIONAHA.119.042866. View

11.

Shah A, Griffiths M, Lee K, McAllister D, Hunter A, Ferry A . High sensitivity cardiac troponin and the under-diagnosis of myocardial infarction in women: prospective cohort study. BMJ. 2015; 350:g7873. PMC: 4301191. DOI: 10.1136/bmj.g7873. View

12.

Shah A, Anand A, Strachan F, Ferry A, Lee K, Chapman A . High-sensitivity troponin in the evaluation of patients with suspected acute coronary syndrome: a stepped-wedge, cluster-randomised controlled trial. Lancet. 2018; 392(10151):919-928. PMC: 6137538. DOI: 10.1016/S0140-6736(18)31923-8. View

13.

Balasubramanian R, Mills G, Wilkinson C, Mehran R, Kunadian V . Role and relevance of risk stratification models in the modern-day management of non-ST elevation acute coronary syndromes. Heart. 2022; 109(7):504-510. DOI: 10.1136/heartjnl-2022-321470. View

14.

Shah A, Anand A, Sandoval Y, Lee K, Smith S, Adamson P . High-sensitivity cardiac troponin I at presentation in patients with suspected acute coronary syndrome: a cohort study. Lancet. 2015; 386(10012):2481-8. PMC: 4765710. DOI: 10.1016/S0140-6736(15)00391-8. View

15.

Elbarouni B, Goodman S, Yan R, Welsh R, Kornder J, DeYoung J . Validation of the Global Registry of Acute Coronary Event (GRACE) risk score for in-hospital mortality in patients with acute coronary syndrome in Canada. Am Heart J. 2009; 158(3):392-9. DOI: 10.1016/j.ahj.2009.06.010. View

16.

Flaws D, Than M, Scheuermeyer F, Christenson J, Boychuk B, Greenslade J . External validation of the emergency department assessment of chest pain score accelerated diagnostic pathway (EDACS-ADP). Emerg Med J. 2016; 33(9):618-25. DOI: 10.1136/emermed-2015-205028. View

17.

Jaffe A, Body R, Mills N, Aakre K, Collinson P, Saenger A . Single Troponin Measurement to Rule Out Myocardial Infarction: JACC Review Topic of the Week. J Am Coll Cardiol. 2023; 82(1):60-69. DOI: 10.1016/j.jacc.2023.04.040. View

18.

. SCORE2-OP risk prediction algorithms: estimating incident cardiovascular event risk in older persons in four geographical risk regions. Eur Heart J. 2021; 42(25):2455-2467. PMC: 8248997. DOI: 10.1093/eurheartj/ehab312. View

19.

Chapman A, Lee K, McAllister D, Cullen L, Greenslade J, Parsonage W . Association of High-Sensitivity Cardiac Troponin I Concentration With Cardiac Outcomes in Patients With Suspected Acute Coronary Syndrome. JAMA. 2017; 318(19):1913-1924. PMC: 5710293. DOI: 10.1001/jama.2017.17488. View

20.

Lee K, Bularga A, OBrien R, Ferry A, Doudesis D, Fujisawa T . Troponin-Guided Coronary Computed Tomographic Angiography After Exclusion of Myocardial Infarction. J Am Coll Cardiol. 2021; 78(14):1407-1417. PMC: 8482793. DOI: 10.1016/j.jacc.2021.07.055. View