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High-sensitivity troponin I of less than 5 ng/L has negative predictive value of 99.9% for cardiac death at 1 year
Clinical Question
Is a cardiac troponin I concentration of less than 5 ng/L at presentation useful in identifying adults with potential acute coronary syndrome at low risk of myocardial infarction or cardiac death?
Bottom line
A cardiac troponin I concentration of less than 5 ng/L in adults who present with potential acute coronary syndrome has a negative predictive value (NPV) of at least 99.9% for cardiac death at 30 days and 1 year. 1a-
Reference
Study design: Systematic review
Funding: Foundation
Setting: Various (meta-analysis)
Synopsis
These investigators thoroughly searched MEDLINE, EMBASE, the Cochrane Register, and the Web of Science without language restrictions for prospective studies that evaluated the accuracy of measured high-sensitive cardiac troponin I in identifying adults with suspected acute coronary syndrome who are at risk for myocardial infarction or cardiac death. Two independent investigators assessed individual studies for inclusion criteria and methodologic quality using a standard risk-of-bias scoring tool. Disagreements were resolved by consensus agreement with a third reviewer. Patients with ST-segment elevation, myocardial infarction, and those who presented in cardiac arrest were excluded. A total of 36 articles (N = 22,457 adults with suspected acute coronary syndrome) reporting observations from 19 individual cohorts met the inclusion criteria. The assessed risk of bias was low to moderate in 8 of the 19 cohorts, and high in the remaining 11 cohorts. High-sensitivity cardiac troponin I concentrations were less than 5 ng/L at presentation in 11,012 patients (49%), with an NPV of 99.5% (95% CI 99.3% - 99.6%) for missed myocardial infarctions at 30 days, with no cardiac deaths at 30 days (NPV = 100%). The NPV for cardiac death at 1 year was 99.9% (99.7% - 99.9%). In subgroup analysis, the NPV was lower in patients with myocardial ischemia on the initial electrocardiogram, those who presented within 2 hours of symptom onset, those 65 years or older, and those with a history of ischemic heart disease.
Reviewer
David C. Slawson, MD
Professor and Vice Chair of Family Medicine for Education and Scholarship
Atrium Health
Professor of Family Medicine, UNC Chapel Hill
Charlotte, NC
Comments
Good poem
We have internists and cardiologists who see most of these patients at our hospital.
Despite this, it seems that this adds a bit to how we all practise;
The really low risk presentations are made even more low risk when reviewed with a HSTI, but it is not done everywhere.
The older, the patient with abnormal ECG and those who present early (odd to know just what this represents) may be more at risk.
We need to know how to best risk stratify without wasting valuable time and money.
This makes one able to think more clearly but not if the test is not available at your institution.
Ah. Chest pain. Difficult problem in emergency setting. Young and otherwise healthy, neg troponin neg everything else.Odds are low of heart death.
Everyone else.timing of blood test? niggly little ST and T wav changes.Getting old.
Still a difficult clinical problem.
Not acceptable to miss that 100th patient.