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Circulation. 2019 Oct 7. doi: 10.1161/CIRCULATIONAHA.119.042960. [Epub ahead of print]

High-Sensitivity Cardiac Troponin and the Universal Definition of Myocardial Infarction.

Author information

1
BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK.
2
BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK; Christchurch Heart Institute, University of Otago, Christchurch, NZ.
3
Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK.
4
Department of Cardiology, Royal Alexandra Hospital, Paisley, UK.
5
Department of Biochemistry, Queen Elizabeth University Hospital, Glasgow, UK, UNITED KINGDOM.
6
Department of Biochemistry, Queen Elizabeth University Hospital, Glasgow, UK.
7
Emergency Medicine Research Group Edinburgh, Royal Infirmary of Edinburgh, Edinburgh, UK.
8
Departments of Clinical Blood Sciences and Cardiology, St George's, University Hospitals NHS Trust and St George's University of London, London, UK.
9
Department of Laboratory Medicine and Pathology, Hennepin Healthcare/Hennepin County Medical Center & University of Minnesota, Minneapolis, MN.
10
Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK.
11
Emergency Medicine Department, Glasgow Royal Infirmary, Glasgow, UK, UNITED KINGDOM.
12
MRC Human Genetics Unit, University of Edinburgh, Edinburgh UK; The Alan Turing Institute, London, UK.
13
Edinburgh Clinical Trials Unit, University of Edinburgh, Edinburgh, UK; Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK.
14
BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK; Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK.

Abstract

Background: The introduction of more sensitive cardiac troponin assays has led to increased recognition of myocardial injury in acute illnesses other than acute coronary syndrome. The Universal Definition of Myocardial Infarction recommends high-sensitivity cardiac troponin (hs-cTn) testing and classification of patients with myocardial injury based on aetiology, but the clinical implications of implementing this guideline are not well understood. Methods: In a stepped-wedge cluster randomized controlled trial, we implemented a hs-cTn assay and the recommendations of the Universal Definition in 48,282 consecutive patients with suspected acute coronary syndrome. In a pre-specified secondary analysis, we compared the primary outcome of myocardial infarction or cardiovascular death and secondary outcome of non-cardiovascular death at one year across diagnostic categories. Results: Implementation increased the diagnosis of type 1 myocardial infarction by 11% (510/4,471), type 2 myocardial infarction by 22% (205/916), and acute and chronic myocardial injury by 36% (443/1,233) and 43% (389/898), respectively. Compared to those without myocardial injury, the rate of the primary outcome was highest in those with type 1 myocardial infarction (cause-specific hazard ratio [csHR] 5.64, 95% confidence interval [CI] 5.12 to 6.22), but was similar across diagnostic categories, whereas non-cardiovascular deaths were highest in those with acute myocardial injury (csHR 2.65, 95%CI 2.33 to 3.01). Despite modest increases in anti-platelet therapy and coronary revascularization after implementation in patients with type 1 myocardial infarction, the primary outcome was unchanged (csHR 1.00, 95%CI 0.82 to 1.21). Increased recognition of type 2 myocardial infarction and myocardial injury did not lead to changes in investigation, treatment or outcomes. Conclusions: Implementation of high-sensitivity cardiac troponin and the recommendations of the Universal Definition of Myocardial Infarction identified patients at high-risk of cardiovascular and non-cardiovascular events, but was not associated with consistent increases in treatment or improved outcomes. Trials of secondary prevention are urgently required to determine whether this risk is modifiable in patients without type 1 myocardial infarction. Clinical Trial Registration: URL: https://clinicaltrials.gov Unique Identifier: NCT0185212.

KEYWORDS:

myocardial injury; universal definition

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