Vol 24, No 6 (2017)
Original articles — Clinical cardiology
Published online: 2017-07-10

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Decreased admissions and hospital costs with a neutral effect on mortality following lowering of the troponin T cutoff point to the 99th percentile

Christian Bjurman, Matteus Zywczyk, Bertil Lindahl, Tobias Carlsson, Per Johanson, Max Petzold, Martin Holzmann, Michael LX Fu, Ola Hammarsten
Pubmed: 28695975
Cardiol J 2017;24(6):612-622.

Abstract

Background: The implementation of high-sensitivity cardiac troponin T (hs-cTnT) assays and a cutoff based on the 99th cTnT percentile in the evaluation of patients with suspected acute coronary syndrome has not been uniform due to uncertain effects on health benefits and utilization of limited resources. Methods: Clinical and laboratory data from patients with chest pain or dyspnea at the emergency de¬partment (ED) were evaluated before (n = 20516) and after (n = 18485) the lowering of the hs-cTnT cutoff point from 40 ng/L to the 99th hs-cTnT percentile of 14 ng/L in February 2012. Myocardial infarction (MI) was diagnosed at the discretion of the attending clinicians responsible for the patient. Results: Following lowering of the hs-cTnT cutoff point fewer ED patients with chest pain or dyspnea as the principal complaint were analyzed with an hs-cTnT sample (81% vs. 72%, p < 0.001). Overall 30-day mortality was unaffected but increased among patients not analyzed with an hs-cTnT sample (5.3% vs. 7.6%, p < 0.001). The MI frequency was unchanged (4.0% vs. 3.9%, p = 0.72) whereas admission rates decreased (51% vs. 45%, p < 0.001) as well as hospital costs. Coronary angiographies were used more frequently (2.8% vs. 3.3%, p = 0.004) but with no corresponding change in coronary interventions. Conclusions: At the participating hospital, lowering of the hs-cTnT cutoff point to the 99th percentile decreased admissions and hospital costs but did not result in any apparent prognostic or treatment benefits for the patients.

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References

  1. Thygesen K, Alpert JS, Jaffe AS, et al. Third universal definition of myocardial infarction. Circulation. 2012; 126(16): 2020–2035.
  2. Thygesen K, Mair J, Giannitsis E, et al. How to use high-sensitivity cardiac troponins in acute cardiac care. Eur Heart J. 2012; 33(18): 2252–2257.
  3. Bandstein N, Ljung R, Johansson M, et al. Undetectable high-sensitivity cardiac troponin T level in the emergency department and risk of myocardial infarction. J Am Coll Cardiol. 2014; 63(23): 2569–2578.
  4. Reichlin T, Schindler C, Drexler B, et al. One-hour rule-out and rule-in of acute myocardial infarction using high-sensitivity cardiac troponin T. Arch Intern Med. 2012; 172(16): 1211–1218.
  5. Eggers KM, Venge P, Lindahl B. High-sensitive cardiac troponin T outperforms novel diagnostic biomarkers in patients with acute chest pain. Clin Chim Acta. 2012; 413(13-14): 1135–1140.
  6. Reiter M, Twerenbold R, Reichlin T, et al. Early diagnosis of acute myocardial infarction in the elderly using more sensitive cardiac troponin assays. Eur Heart J. 2011; 32(11): 1379–1389.
  7. Reichlin T, Hochholzer W, Bassetti S, et al. Early diagnosis of myocardial infarction with sensitive cardiac troponin assays. N Engl J Med. 2009; 361(9): 858–867.
  8. Morrow DA, Cannon CP, Rifai N, et al. Ability of minor elevations of troponins I and T to predict benefit from an early invasive strategy in patients with unstable angina and non-ST elevation myocardial infarction: results from a randomized trial. JAMA. 2001; 286(19): 2405–2412.
  9. Saenger AK, Beyrau R, Braun S, et al. Multicenter analytical evaluation of a high-sensitivity troponin T assay. Clin Chim Acta. 2011; 412(9-10): 748–754.
  10. Hammarsten O, Jacobsson CE, Widegren M, et al. Long-time quality assessment of the Elecsys Troponin T hs assay. Clin Biochem. 2013; 46(12): 1055–1057.
  11. Ravn-Fischer A, Karlsson T, Santos M, et al. Chain of care in chest pain--differences between three hospitals in an urban area. Int J Cardiol. 2013; 166(2): 440–447.
  12. Ludvigsson JF, Andersson E, Ekbom A, et al. External review and validation of the Swedish national inpatient register. BMC Public Health. 2011; 11: 450.
  13. Information available in the National Patient Register (NPR). 2016-July-07 . http://www.socialstyrelsen.se/SiteCollectionDocuments/information-in-the-national-patient-register.pdf.
  14. Wettermark B, Hammar N, Fored CM, et al. The new Swedish Prescribed Drug Register--opportunities for pharmacoepidemiological research and experience from the first six months. Pharmacoepidemiol Drug Saf. 2007; 16(7): 726–735.
  15. Hammarsten O, Fu MLX, Sigurjonsdottir R, et al. Troponin T percentiles from a random population sample, emergency room patients and patients with myocardial infarction. Clin Chem. 2012; 58(3): 628–637.
  16. Mills NL, Churchhouse AMD, Lee KK, et al. Implementation of a sensitive troponin I assay and risk of recurrent myocardial infarction and death in patients with suspected acute coronary syndrome. JAMA. 2011; 305(12): 1210–1216.
  17. Hall TS, Hallén J, Agewall S, et al. Changes in diagnosing non-ST-segment elevation myocardial infarction after the introduction of a new high-sensitivity cardiac troponin T assay: a single-centre experience. Clin Lab. 2012; 58(9-10): 1029–1036.
  18. Eggers KM, Lindahl B, Melki D, et al. Consequences of implementing a cardiac troponin assay with improved sensitivity at Swedish coronary care units: an analysis from the SWEDEHEART registry. Eur Heart J. 2016; 37(30): 2417–2424.
  19. Twerenbold R, Jaeger C, Rubini Gimenez M, et al. Impact of high-sensitivity cardiac troponin on use of coronary angiography, cardiac stress testing, and time to discharge in suspected acute myocardial infarction. Eur Heart J. 2016; 37(44): 3324–3332.
  20. Corsini A, Vagnarelli F, Bugani G, et al. Impact of high-sensitivity Troponin T on hospital admission, resources utilization, and outcomes. Eur Heart J Acute Cardiovasc Care. 2015; 4(2): 148–157.
  21. Sanchis J, García-Blas S, Mainar L, et al. High-sensitivity versus conventional troponin for management and prognosis assessment of patients with acute chest pain. Heart. 2014; 100(20): 1591–1596.
  22. Eggers K, Lindahl B. Application of cardiac troponin in cardiovascular diseases other than acute coronary syndrome. Clin Chem. 2016; 63(1): 223–235.
  23. Bjurman C, Petzold M, Venge P, et al. High-sensitive cardiac troponin, NT-proBNP, hFABP and copeptin levels in relation to glomerular filtration rates and a medical record of cardiovascular disease. Clin Biochem. 2015; 48(4-5): 302–307.
  24. deFilippi C, Seliger SL, Kelley W, et al. Interpreting cardiac troponin results from high-sensitivity assays in chronic kidney disease without acute coronary syndrome. Clin Chem. 2012; 58(9): 1342–1351.
  25. Dubin RF, Li Y, He J, et al. Predictors of high sensitivity cardiac troponin T in chronic kidney disease patients: a cross-sectional study in the chronic renal insufficiency cohort (CRIC). BMC Nephrol. 2013; 14: 229.
  26. Omland T, Røsjø H, Giannitsis E, et al. Troponins in heart failure. Clin Chim Acta. 2015; 443: 78–84.
  27. Kelley WE, Januzzi JL, Christenson RH. Increases of cardiac troponin in conditions other than acute coronary syndrome and heart failure. Clin Chem. 2009; 55(12): 2098–2112.
  28. Sara JDS, Holmes DR, Jaffe AS. Fundamental concepts of effective troponin use: important principles for internists. Am J Med. 2015; 128(2): 111–119.
  29. Jaffe AS. The 10 commandments of troponin, with special reference to high sensitivity assays. Heart. 2011; 97(11): 940–946.
  30. Wildi K, Twerenbold R, Jaeger C, et al. Clinical impact of the 2010-2012 low-end shift of high-sensitivity cardiac troponin T. Eur Heart J Acute Cardiovasc Care. 2016; 5(6): 399–408.