Outcomes of ED Chest Pain Visits: the Prognostic Value of Negative but Measurable High-sensitivity Cardiac Troponin (hs-cTn) Levels

Overview

Journal BMC Emerg Med

Publisher Biomed Central

Specialty Emergency Medicine

Date 2024 Nov 26

PMID 39592937

Authors

Sharon A Greenberg

Neta Cohen

Noa Shopen

Reut Aviv Mordechai

David Zeltser

Julieta Werthein

Affiliations

Soon will be listed here.

Abstract

Background: Chest pain is a common condition in the emergency department (ED). High-sensitivity cardiac troponin (hs-cTn) assays are crucial for diagnosing acute coronary syndrome, but the implications of "negative but measurable" hs-cTn levels are not well understood. This study assesses the outcomes of patients with acute chest pain discharged from the ED based on their hs-cTn levels.

Methods: This retrospective cohort study analyzed medical records of patients aged 18 and older presenting with chest pain to the Tel Aviv Sourasky Medical Center ED from 2017 to 2022. We compared patients with negative but measurable hs-cTn levels (3-50 ng/L) to those with very low hs-cTn levels (< 3 ng/L). Primary outcomes included 90- days coronary angiogram (CAG), and secondary outcomes were 7- days ED revisits, 14-days hospital admissions, and 30- days mortality.

Results: Of 32,162 eligible patients, 23,297 had hs-cTn levels ≤ 50 ng/L. Patients with negative but measurable hs-cTn levels had higher rates of 90-days CAG (1.8% vs. 0.5%, p < 0.001), 7-day ED revisits (5.2% vs. 3.3%, p < 0.001), 14-day hospital admissions (3.1% vs. 0.9%, p < 0.001), and 30-day mortality (0.3% vs. 0.01%, p < 0.001) compared to those with very low hs-cTn levels. Independent predictors for 90 days CAG included age ≥ 57 years, male sex, and hs-cTn ≥ 3.5 ng/L.

Conclusions: Negative but measurable hs-cTn levels are linked to worse outcomes than very low hs-cTn levels in discharged ED patients. Closer follow-up and further cardiac evaluation may be warranted for these patients.

References

Greenberg S, Halpern P, Ziv-Baran T, Gamzu R . Reduced hospitalization rates are not associated with increased mortality or readmission rates in an emergency department in Israel. Isr J Health Policy Res. 2018; 7(1):69. PMC: 6247762. DOI: 10.1186/s13584-018-0265-5. View

Ziv-Baran T, Wasserman A, Shteinvil R, Zeltser D, Shapira I, Shenhar-Tsarfaty S . C-reactive protein and emergency department seven days revisit. Clin Chim Acta. 2018; 481:207-211. DOI: 10.1016/j.cca.2018.03.022. View

Reiner Benaim A, Almog R, Gorelik Y, Hochberg I, Nassar L, Mashiach T . Analyzing Medical Research Results Based on Synthetic Data and Their Relation to Real Data Results: Systematic Comparison From Five Observational Studies. JMIR Med Inform. 2020; 8(2):e16492. PMC: 7059086. DOI: 10.2196/16492. View

Roffi M, Patrono C, Collet J, Mueller C, Valgimigli M, Andreotti F . [2015 ESC guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation]. Kardiol Pol. 2016; 73(12):1207-94. DOI: 10.5603/KP.2015.0243. View

Kane A, Howlett S . Differences in Cardiovascular Aging in Men and Women. Adv Exp Med Biol. 2018; 1065:389-411. DOI: 10.1007/978-3-319-77932-4_25. View

Gimenez M, Hoeller R, Reichlin T, Zellweger C, Twerenbold R, Reiter M . Rapid rule out of acute myocardial infarction using undetectable levels of high-sensitivity cardiac troponin. Int J Cardiol. 2013; 168(4):3896-901. DOI: 10.1016/j.ijcard.2013.06.049. View

Cotterill P, Deb P, Shrank W, Pines J . Variation in chest pain emergency department admission rates and acute myocardial infarction and death within 30 days in the Medicare population. Acad Emerg Med. 2015; 22(8):955-64. DOI: 10.1111/acem.12728. View

Bandstein N, Ljung R, Lundback M, Johansson M, Holzmann M . Trends in admissions for chest pain after the introduction of high-sensitivity cardiac troponin T. Int J Cardiol. 2017; 240:1-7. DOI: 10.1016/j.ijcard.2017.04.028. View

Goodacre S, Cross E, Arnold J, Angelini K, Capewell S, Nicholl J . The health care burden of acute chest pain. Heart. 2005; 91(2):229-30. PMC: 1768669. DOI: 10.1136/hrt.2003.027599. View

10.

Keller T, Zeller T, Peetz D, Tzikas S, Roth A, Czyz E . Sensitive troponin I assay in early diagnosis of acute myocardial infarction. N Engl J Med. 2009; 361(9):868-77. DOI: 10.1056/NEJMoa0903515. View

11.

Backus B, Six A, Kelder J, Gibler W, Moll F, Doevendans P . Risk scores for patients with chest pain: evaluation in the emergency department. Curr Cardiol Rev. 2012; 7(1):2-8. PMC: 3131711. DOI: 10.2174/157340311795677662. View

12.

Byrne R, Rossello X, Coughlan J, Barbato E, Berry C, Chieffo A . 2023 ESC Guidelines for the management of acute coronary syndromes. Eur Heart J Acute Cardiovasc Care. 2023; 13(1):55-161. DOI: 10.1093/ehjacc/zuad107. View

13.

Neumann J, Twerenbold R, Ojeda F, Sorensen N, Chapman A, Shah A . Application of High-Sensitivity Troponin in Suspected Myocardial Infarction. N Engl J Med. 2019; 380(26):2529-2540. DOI: 10.1056/NEJMoa1803377. View

14.

Gulati M, Levy P, Mukherjee D, Amsterdam E, Bhatt D, Birtcher K . 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol. 2021; 78(22):e187-e285. DOI: 10.1016/j.jacc.2021.07.053. View

15.

Cooney M, Vartiainen E, Laatikainen T, De Bacquer D, McGorrian C, Dudina A . Cardiovascular risk age: concepts and practicalities. Heart. 2012; 98(12):941-6. DOI: 10.1136/heartjnl-2011-301478. View

16.

Six A, Cullen L, Backus B, Greenslade J, Parsonage W, Aldous S . The HEART score for the assessment of patients with chest pain in the emergency department: a multinational validation study. Crit Pathw Cardiol. 2013; 12(3):121-6. DOI: 10.1097/HPC.0b013e31828b327e. View

17.

Burgos L, Trivi M, Costabel J . Performance of the European Society of Cardiology 0/1-hour algorithm in the diagnosis of myocardial infarction with high-sensitivity cardiac troponin: Systematic review and meta-analysis. Eur Heart J Acute Cardiovasc Care. 2020; 10(3):279–286. DOI: 10.1177/2048872620935399. View

18.

North B, Sinclair D . The intersection between aging and cardiovascular disease. Circ Res. 2012; 110(8):1097-108. PMC: 3366686. DOI: 10.1161/CIRCRESAHA.111.246876. View

19.

Lo Y, Chang C, Chen M, Hu F, Lu F . Factors associated with early 14-day unplanned hospital readmission: a matched case-control study. BMC Health Serv Res. 2021; 21(1):870. PMC: 8390214. DOI: 10.1186/s12913-021-06902-6. View

20.

Collet J, Thiele H, Barbato E, Barthelemy O, Bauersachs J, Bhatt D . 2020 ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation. Eur Heart J. 2020; 42(14):1289-1367. DOI: 10.1093/eurheartj/ehaa575. View