Are There Any Differences in Major Adverse Cardiac Events Between Undetectable vs. 99th Percentile High-Sensitivity Troponin? Deshaun Allen, BS; Jennifer Johnson, BA; Cristina Pelin, BA; Ryan Kenny, BS; Ajay Puri, MD; Mark Richman MD Department of Emergency Medicine, Northwell Health – Long Island Jewish Medical Center Donald and Barbara Zucker School of Medicine at Hofstra/Northwell
BACKGROUND •
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Chest pain, one of the primary causes for treatment in the emergency department, is a symptom associated with Acute Coronary Syndromes. Acute Coronary Syndromes are among the leading causes of morbidity and mortality in the United States, affecting more than 15 million people. To ensure timely diagnosis and proper treatment, cardiac biomarkers are used. Troponin, which is considered the “gold-standard,” is used to detect the severity of cardiac injury. However, as time has progressed, cardiac biomarkers such as troponin have resulted in increased “Type 1 Error” or false positives. This can cause significant burden to patients as this may increase emergency room treatment time which impedes on the treatment of other potential critical patients and increased financial burden. Long Island Jewish Medical Center’s Emergency Department ACS work-up algorithm states patients with undetectable high-sensitivity (HS) troponin (<6 ng/L) at least 3 hours after cardiac symptom onset do not need a repeat troponin, whereas patients with troponin 6-14 ng/L (detectable, but within the 99th percentile) require a repeat troponin 1 hour after the first troponin was drawn.
OBJECTIVE + HYPOTHESIS • After analyzing results, we hypothesize that there will not be any significant differences in MACE (Major Adverse Cardiac Events) within 30 days of discharge from the emergency department between patients who initially presented with troponin values between 6-14 ng/L and patients who presented with troponin values less than 6 ng/L. This will support our objective for modifying Long Island Jewish Medical Center’s (LIJ) current algorithm for repeat troponin labs only being required for patients with initial troponin values greater than 14 ng/L in LIJ’s emergency department.
METHODS • Northwell Health’s Long Island Jewish Medical Center is an academic hospital in a urban area that treats a diverse population of patients of different races and socioeconomic status. The emergency department treats over 100,000 patients/year. • Retrospective chart review of data from patients who were treated in Long Island Jewish Medical Center’s Emergency Department and received a high-sensitivity troponin test between July 1, 2018 to December 31, 2018 were analyzed. • Patients who presented with an initial troponin value less than 6 ng/L were designated as “undetectable.” Patients who presented with an initial troponin value between 6-14 ng/L were designated as the “99th percentile.” Analysis of clinically important outcomes, or MACE, within 30 days of ED discharge was also assessed. • Patients with co-morbidities such as congestive heart failure, pulmonary embolism, sepsis, pericarditis, myocarditis, and chronic kidney disease were excluded from this study as these patient’s normally have baseline elevated troponin. Patients younger than 18 years of age were also excluded from this study. • Chi-square analysis was used to compare both categories of troponin (undetectable vs. 99th percentile). • ED discharge diagnoses consistent with ACS were filtered for chest pain, chest tightness, chest pressure, chest discomfort, dyspnea, syncope, angina, dizziness, epigastric pain, epigastric abdominal pain, and shortness of breath. All other ED discharge diagnoses were categorized as not consistent with ACS. POSTER TEMPLATES BY:
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CONCLUSIONS
RESULTS Table 1: Initial Troponin Value, by ED Discharge Diagnosis (Typical vs. Not-Typical of ACS) Troponin < 6 ng/L (N, %) (N = 858)
Troponin 6-14 ng/L (N, %) (N = 858)
P-Value
ED Discharge Diagnoses Typical for ACS
482 (56%)
396 (46%)
p <0.0001
ED Discharge Diagnoses not Typically Associated with ACS
376 (44%)
462 (54%)
p <0.0001
• Contrary to what one might expect, patients without typical ACS ED discharge diagnoses patients were more likely to have a higher (614 ng/L) troponin value than those with typical ACS ED discharge diagnoses. • Emerging evidence suggests age, gender, and clinical context can also influence baseline troponin values. Troponin may appear elevated in the absence of myocardial damage, as “normal” ranges vary by context and population. • It is possible patients in our sample with elevated troponin (6-14 ng/L) who had ED discharge diagnoses not typical for ACS were more likely to be of an age group or gender prone to higher baseline values (e.g., elderly). FUTURE DIRECTION •
REFERENCES • Sethi A, Bajaj A, Malhotra G, Arora RR, Khosla S. Diagnostic accuracy of sensitive or high-sensitive troponin on presentation for myocardial infarction: a metaanalysis and systematic review. Vasc Health Risk Manag. 2014;10:435-450. Published 2014 Jul 21. doi:10.2147/VHRM.S63416 • Morrow DA, Cannon CP, Jesse RL, et al. National Academy of Clinical Biochemistry Laboratory Medicine Practice Guidelines: clinical characteristics and utilization of biochemical markers in acute coronary syndromes. Clin Chem. 2007 Apr;53(4):552-74. PMID: 17384001. • Roongsritong C, Warraich I, Bradley C. Common causes of troponin elevations in the absence of acute myocardial infarction: incidence and clinical significance. Chest. 2004 May;125(5):1877-84. PMID: 15136402. • Anda Bularga, Kuan Ken Lee, Stacey Stewart, Amy V. Ferry, Andrew R. Chapman, Lucy Marshall, Fiona E. Strachan, Anne Cruickshank, Donogh Maguire, Colin Berry, Iain Findlay, Anoop S.V. Shah, David E. Newby, Nicholas L. Mills, Atul Anand, On behalf of the High-STEACS Investigators. High-Sensitivity Troponin and the Application of Risk Stratification Thresholds in Patients With Suspected Acute Coronary Syndrome. Circulation. 2019;140:1557–1568. doi.org/10.1161/CIRCULATIONAHA.119.042866
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Determine why a greater percentage of patients with an initial troponin value less than 6 ng/L have ED discharge diagnoses consistent with Acute Coronary Syndromes. Determine why a greater percentage of patients with an initial troponin value between 6-14 ng/L have ED discharge diagnoses not consistent with Acute Coronary Syndromes. Characterize patients based on age, gender, and race. Determine the 30 MACE rate for patients with initial troponin values less than 6 ng/L and patients with initial troponin values between 6-14 ng/L.