Coronary Artery DiseaseA proposed strategy for utilization of creatine kinase-MB and troponin I in the evaluation of acute chest pain☆
Section snippets
Patient population
Eligible patients included all 1,139 emergency department patients aged ≥30 years who were admitted to the Brigham and Women’s Hospital between July 27, 1994, and June 30, 1995, for a chief complaint of acute chest pain that could not be explained by local trauma or abnormalities on chest roentgenograms. Eighty-eight patients were excluded because of incomplete cTnI or CK-MB data during the first 24 hours; therefore, 1,051 patients (92 %) constituted the study population.
Data collection
Data from the history,
Results
Among the 1,051 patients, acute myocardial infarction was diagnosed in 14%, and 37% were diagnosed as having unstable angina (Table I). At least 1 major cardiac event occurred within 72 hours from presentation for 9% of patients. The combined outcome of acute myocardial infarction and/or major cardiac events within 72 hours occurred in 19% of patients.
When CK-MB and cTnI results over the first 24 hours were compared for their diagnostic performance for this end point, cTnI was about as
Discussion
Our data indicate that cTnI does not appear to be a superior marker that should replace CK-MB, and that both assays need not be performed for all patients. Instead, our analysis supports a strategy that restricts routine cTnI use to patients with negative CK-MB results and electrocardiographic findings consistent with myocardial ischemia.
The results of our study are consistent with and extend the findings from previous research on cTnI in patients with unstable ischemic syndromes.1, 2, 3, 4, 5,
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Cited by (30)
Biomarkers in acute myocardial injury
2012, Translational ResearchCitation Excerpt :Although CK-MB should not be used as a stand-alone diagnostic cardiac marker,22 it can be used in conjunction with cTn. A study of more than 1000 patients presenting to the ED within 24 h of symptom onset found a PPV of 100% and an NPV of 95% for AMI with the combined use of cTn and CK-MB.23 Myoglobin is a small cytoplasmic heme protein found in all muscles.
Predicting a late positive serum troponin in initially troponin-negative patients with non-ST-elevation acute coronary syndrome: Clinical predictors and validated risk score results from the TIMI IIIB and GUSTO IIA studies
2006, American Heart JournalCitation Excerpt :However, reliance on serum troponin testing for risk stratification and triaging of patients has limitations. Notably, although the positive predictive value of serum troponin testing on first evaluation is high, the negative predictive value is significantly lower.20,21 Accordingly, a significant percentage of patients (eg, 25% in TIMI IIIB) with a suspected NSTE ACS are troponin negative on first clinical presentation, but subsequently develop measurable serum troponin levels,12 which may result in many hours passing from presentation before such patients are recognized as having converted their troponin status.
Effectiveness of a multidisciplinary chest pain unit for the assessment of coronary syndromes and risk stratification in the Florence area
2002, American Heart JournalCitation Excerpt :Patients at intermediate risk with clinical score ≥4 and abnormal ECG (ST-segment elevation <1 mm or ST-segment depression <1 mm at 60 ms from J point) were admitted and managed in the CPU area. Patients at high risk with ECG suggestive for AMI (defined as ST elevation ≥1 mm at 60 ms from J point, ≥2 contiguous leads) were directly transferred to the coronary care unit, and patients with suspected major cardiovascular disease, such as aortic arch dissection, pulmonary embolism, pneumothorax, and acute pericarditis, were admitted and managed with arterial blood gas analysis, chest radiography, echocardiography, and thorax computed tomography if required by clinical assessment.13-18 Clinical chest pain score
Test strategies for the detection of myocardial damage
2002, Clinics in Laboratory MedicineCoronary vasospasm as a possible cause of elevated cardiac troponin I in patients with acute coronary syndrome and insignificant coronary artery disease
2002, American Heart JournalCitation Excerpt :Although this study did not reveal these clinical parameters to be useful, our results still suggest that coronary vasospasm should be investigated in older patients, with a normal or completely recovered ECG and normal left ventricular wall motion, and those without a history of previous myocardial infarction when presenting with acute coronary syndromes, an elevated cTnI level, and coronary angiography showing insignificant disease. Polanczyk et al27 reported that the test for cTnI should be restricted to patients with negative CK-MB results and significant ECG findings consistent with myocardial ischemia. Their study found only a 4% cardiac event rate in patients with acute coronary syndromes and normal ECGs.
Impact of troponin T determinations on hospital resource utilization and costs in the evaluation of patients with suspected myocardial ischemia
2001, The American journal of cardiologyCitation Excerpt :Utilization of TnT determinations in the ED resulted in a 20% to 25% reduction of LOS and total charges in both high- and low-risk patients with and without acute coronary syndromes. The 7% reduction in admissions in our study is consistent with the estimates that troponin I can reduce hospital admissions by 11%,6 but conflicts with a recent analysis suggesting that routine troponin I use be restricted to patients with ischemic electrocardiographic changes and normal CK-MB levels.19 Patients were less likely to be admitted to the hospital and had a lower LOS when TnT values were available.
- ☆
This study was supported by a grant from the Baxter Corporation, Chicago, Illinois.
- 1
Dr. Carisi Polanczyk is sponsored by a scholarship from Postgraduate Federal Agency (CAPES), Brasilia DF, Brazil.
- 2
Dr. Paula A. Johnson is the recipient of a Minority Faculty Development Award from the Robert Wood Johnson Foundation. %Manuscript received September 24, 1998; revised manuscript received and accepted December 15, 1998.