Computed tomography coronary angiography after excluding myocardial infarction: high-sensitivity troponin versus risk score-guided approach

doi:10.5847/wjem.j.1920-8642.2023.094

Abstract

Abstract:

BACKGROUND: Patients with suspected acute coronary syndrome (ACS) in whom myocardial infarction has been ruled out are still at risk of having obstructive coronary artery disease (CAD). This rate is higher among patients with intermediate high-sensitivity troponin I (hsTnI) concentrations (5 ng/L to 99^th percentile) than low concentrations (<5 ng/L). Therefore, an intermediate concentration has been suggested as a candidate for downstream investigation with computed tomography coronary angiography (CTCA). We tried to compare the HEART score-guided vs. hsTnI-guided approach for identifying obstructive CAD.

METHODS: From a prospective cohort study of patients presenting to the emergency department with suspected ACS, 433 patients without elevated hsTnI who also underwent CTCA were selected and analyzed. The performances of hsTnI concentration and HEART score were compared using sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV).

RESULTS: Overall, 120 (27.7%) patients had obstructive CAD. Patients with intermediate hsTnI concentrations were more likely to have obstructive CAD than those with low hsTnI concentrations (40.0% vs. 18.1%); patients with non-low-risk HEART scores (≥4 points) were also more likely to have obstructive CAD than those with low-risk scores (0 to 3 points) (41.0% vs. 7.6%). The HEART score had higher sensitivity and NPV for detecting obstructive CAD in each classification than hsTnI concentration (sensitivity: 89.2% vs. 63.3%; NPV: 92.4% vs. 81.9%, respectively).

CONCLUSION: After excluding myocardial infarction in patients with suspected ACS, adding the HEART score for selecting candidates for CTCA could improve patient risk stratification more accurately than relying on hsTnI concentration.

Key words: Chest pain, Coronary artery disease, Acute coronary syndrome, Troponin, HEART score

Won Jae Yoo, Shin Ahn, Bora Chae, Won Young Kim. Computed tomography coronary angiography after excluding myocardial infarction: high-sensitivity troponin versus risk score-guided approach[J]. World Journal of Emergency Medicine, 2023, 14(6): 428-433.

Figures/Tables 4

Figure 1.

Table 1.

Table 2.

Figure 2.

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Variables	Overall (n=433)	hsTnI			HEART score
Variables	Overall (n=433)	<5 ng/L (n=243)	5 ng/L to 99^th percentile (n=190)	P-value	0-3 (n=172)	≥4 (n=261)	P-value
Sex, male	252 (58.2)	131 (53.9)	121 (63.7)	0.041	95 (55.2)	157 (60.2)	0.310
Age, years	63.9 ± 12.5	60.6 ±1.8	68.2 ± 12.2	<0.001	55.6 ±11.8	69.5 ± 9.6	<0.001
Risk factors
Hypertension	215 (49.7)	106 (43.6)	109 (57.4)	0.005	54 (31.4)	161 (61.7)	<0.001
Diabetes mellitus	97 (22.4)	50 (20.6)	47 (24.7)	0.303	19 (11.0)	78 (29.9)	<0.001
Hyperlipidemia	135 (31.2)	78 (32.1)	57 (30.0)	0.640	48 (27.9)	87 (33.3)	0.233
Family history of CAD	52 (12.0)	37 (15.2)	15 (7.9)	0.020	23 (13.4)	29 (11.1)	0.479
Smoking	48 (11.1)	26 (10.7)	22 (11.6)	0.772	20 (11.6)	28 (10.7)	0.770
Obesity	172 (39.7)	97 (39.9)	75 (39.5)	0.925	66 (38.4)	106 (40.6)	0.641
History of CAD
AMI	22 (5.1)	8 (3.3)	15 (7.9)	0.034	0 (0.0)	22 (8.4)	<0.001
PCI	92 (21.2)	40 (16.5)	52 (27.4)	0.006	6 (3.5)	86 (33.0)	<0.001
CABG	18 (4.2)	5 (2.1)	13 (6.8)	0.013	2 (1.2)	16 (6.1)	0.011
Medication
Aspirin	119 (27.5)	51 (21.0)	68 (35.8)	0.001	16 (9.3)	103 (39.5)	<0.001
Oral anticoagulant	19 (4.4)	6 (2.5)	13 (6.8)	0.027	4 (2.3)	15 (5.7)	0.089
TIMI score	1.7 ± 1.3	1.4 ± 1.1	2.1 ± 1.3	<0.001	0.9 ± 0.8	2.3 ±1.2	<0.001
GRACE score	100.9 ± 26.1	94.7 ± 23.3	108.9 ± 27.3	<0.001	85.8 ± 22.3	110.9 ± 23.4	<0.001
New ECG changes	49 (11.3)	16 (6.6)	33 (17.4)	<0.001	11 (6.4)	13 (14.6)	0.009

Variables	Overall (n=433)	hsTnI			HEART score
Variables	Overall (n=433)	<5 ng/L (n=243)	5 ng/L to 99^th percentile (n=190)	P-value	0-3 (n=172)	≥4 (n=261)	P-value
Stenosis
Normal	112 (25.9)	80 (32.9)	32 (16.8)	<0.001	86 (50.0)	26 (10.0)	<0.001
Any CAD	321 (74.1)	163 (67.1)	158 (83.2)	<0.001	86 (50.0)	235 (90.0)	<0.001
Normal or non-obstructive CAD	313 (72.3)	199 (81.9)	114 (60.0)	<0.001	159 (92.4)	154 (59.0)	<0.001
Obstructive CAD	120 (27.7)	44 (18.1)	76 (40.0)	<0.001	13 (7.6)	107 (41.0)	<0.001
Atherosclerotic burden
Segmental involvement score	2 (0-5)	2 (0-4)	4 (1-6)	<0.001	1 (0-2)	4 (2-6)	<0.001
Calcium score	15.4 (0-193.5)	2.5 (0.0-99.3)	91.5 (1.1-466.9)	<0.001	0.0 (0.0-12.0)	112.1 (5.25-458.1)	<0.001
Performance for detecting obstructive CAD, % (95% CI)
Sensitivity		63.3 (54.1-71.9)			89.2 (82.2-94.1)
Specificity		63.6 (58.0-68.9)			50.8 (45.1-56.5)
Positive predictive value		40.0 (35.3-44.9)			41.0 (37.9-44.1)
Negative predictive value		81.9 (77.9-85.3)			92.4 (87.9-95.4)

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