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BMJ. 2017 Nov 7;359:j4788. doi: 10.1136/bmj.j4788.

Patient selection for high sensitivity cardiac troponin testing and diagnosis of myocardial infarction: prospective cohort study.

Author information

1
BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh EH16 4SB, UK.
2
Division of Cardiology, Hennepin County Medical Center and Minneapolis Heart Institute, Abbott Northwestern Hospital, Minneapolis, MN, USA.
3
Chronic Disease Research Group of Minneapolis Medical Research Foundation, Hennepin County Medical Center and University of Minnesota, Minneapolis, MN, USA.
4
Department of Emergency Medicine, Hennepin County Medical Center and University of Minnesota, Minneapolis, Minnesota, USA.
5
Emergency Medicine Research Group Edinburgh (EMeRGE) and Department of Emergency Medicine, Royal Infirmary of Edinburgh, Edinburgh, UK.
6
Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK.
7
Department of Laboratory Medicine and Pathology, Hennepin County Medical Center and University of Minnesota, Minneapolis, MN, USA.

Abstract

Objective To evaluate how selection of patients for high sensitivity cardiac troponin testing affects the diagnosis of myocardial infarction across different healthcare settings.Design Prospective study of three independent consecutive patient populations presenting to emergency departments.Setting Secondary and tertiary care hospitals in the United Kingdom and United States.Participants High sensitivity cardiac troponin I concentrations were measured in 8500 consecutive patients presenting to emergency departments: unselected patients in the UK (n=1054) and two selected populations of patients in whom troponin testing was requested by the attending clinician in the UK (n=5815) and the US (n=1631). The final diagnosis of type 1 or type 2 myocardial infarction or myocardial injury was independently adjudicated.Main outcome measures Positive predictive value of an elevated cardiac troponin concentration for a diagnosis of type 1 myocardial infarction.Results Cardiac troponin concentrations were elevated in 13.7% (144/1054) of unselected patients, with a prevalence of 1.6% (17/1054) for type 1 myocardial infarction and a positive predictive value of 11.8% (95% confidence interval 7.0% to 18.2%). In selected patients, in whom troponin testing was guided by the attending clinician, the prevalence and positive predictive value were 14.5% (843/5815) and 59.7% (57.0% to 62.2%) in the UK and 4.2% (68/1631) and 16.4% (13.0% to 20.3%) in the US. Across both selected patient populations, the positive predictive value was highest in patients with chest pain, with ischaemia on the electrocardiogram, and with a history of ischaemic heart disease.Conclusions When high sensitivity cardiac troponin testing is performed widely or without previous clinical assessment, elevated troponin concentrations are common and predominantly reflect myocardial injury rather than myocardial infarction. These observations highlight how selection of patients for cardiac troponin testing varies across healthcare settings and markedly influences the positive predictive value for a diagnosis of myocardial infarction.

PMID:
29114078
PMCID:
PMC5683043
DOI:
10.1136/bmj.j4788
[Indexed for MEDLINE]
Free PMC Article

Conflict of interest statement

Competing interests: All authors have completed the ICMJE uniform disclosure form at www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declare: support for the submitted work as described above; NLM has acted as a consultant for Abbott Diagnostics, Roche Diagnostics, and Singulex; ASVS has acted as a consultant for Abbott Diagnostics; AC has received speaker fees from Abbott Diagnostics; FSA has acted as a consultant to Metanomics Healthcare, an advisor to Instrumentation Laboratory and Abbott Diagnostics, and on the Board of Directors of HyTest Ltd; YS has acted as an advisor for Roche Diagnostics; no other relationships or activities that could appear to have influenced the submitted work.

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