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. 2021 Oct 5;78(14):1407-1417.
doi: 10.1016/j.jacc.2021.07.055.

Troponin-Guided Coronary Computed Tomographic Angiography After Exclusion of Myocardial Infarction

Kuan Ken Lee  1 , Anda Bularga  1 , Rachel O'Brien  2 , Amy V Ferry  1 , Dimitrios Doudesis  3 , Takeshi Fujisawa  1 , Shauna Kelly  1 , Stacey Stewart  1 , Ryan Wereski  1 , Denise Cranley  4 , Edwin J R van Beek  5 , David J Lowe  6 , David E Newby  1 , Michelle C Williams  5 , Alasdair J Gray  7 , Nicholas L Mills  8
Affiliations

Troponin-Guided Coronary Computed Tomographic Angiography After Exclusion of Myocardial Infarction

Kuan Ken Lee et al. J Am Coll Cardiol. .

Abstract

Background: Patients with suspected acute coronary syndrome in whom myocardial infarction has been excluded are at risk of future adverse cardiac events.

Objectives: This study evaluated the usefulness of high-sensitivity cardiac troponin I (hs-cTnI) to select patients for further investigation after myocardial infarction has been excluded.

Methods: This is a prospective cohort study of patients presenting to the emergency department with suspected acute coronary syndrome and hs-cTnI concentrations below the sex-specific 99th percentile. Patients were recruited in a 2:1 fashion, stratified by peak hs-cTnI concentration above and below the risk stratification threshold of 5 ng/L. All patients underwent coronary computed tomography angiography (CCTA) after hospital discharge.

Results: Overall, 250 patients were recruited (61.4 ± 12.2 years 31% women) in whom 62.4% (156 of 250 patients) had coronary artery disease (CAD). Patients with intermediate hs-cTnI concentrations (between 5 ng/L and the sex-specific 99th percentile) were more likely to have CAD than those with hs-cTnI concentrations <5 ng/L (71.9% [120 of 167 patients] vs 43.4% [36 of 83 patients]; odds ratio: 3.33; 95% CI: 1.92-5.78). Conversely, there was no association between anginal symptoms and CAD (63.2% [67 of 106 patients] vs 61.8% [89 of 144 patients]; odds ratio: 0.92; 95% CI: 0.48-1.76). Most patients with CAD did not have a previous diagnosis (53.2%; 83 of 156 patients) and were not on antiplatelet and statin therapies (63.5%; 99 of 156 patients) before they underwent CCTA.

Conclusions: In patients who had myocardial infarction excluded, CAD was 3× more likely in those with intermediate hs-cTnI concentrations compared with low hs-cTnI concentrations. In such patients, CCTA could help to identify those with occult CAD and to target preventative treatments, thereby improving clinical outcomes.

Keywords: acute coronary syndrome; coronary computed tomography angiogram; troponin.

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Conflict of interest statement

Funding Support and Author Disclosures Dr Lee was supported by a British Heart Foundation (BHF) Clinical Research Training Fellowship (FS/18/25/33454). Drs Bularga and Wereski and Mr. Doudesis were supported by the Medical Research Council (MR/N013166/1, MR/V007017/1, MR/V007254/1). Dr Williams was supported by the British Heart Foundation (FS/ICRF/20/26002). Dr van Beek was supported by the Scottish Imaging Network. Dr Mills was supported by a Chair Award (CH/F/21/90010), Programme Grant (RG/20/10/34966), and Research Excellence Award (RE/18/5/34216) from the British Heart Foundation. Dr Lee has received honoraria from Abbott Diagnostics. Dr van Beek is founder/owner of QCTIS Ltd; has received honoraria from Aidence NV, Roche Diagnostics, AstraZeneca, and Mentholatum; and has received research support from Siemens Healthineers. Dr Mills has received honoraria from Abbott Diagnostics, Siemens Healthineers, Roche Diagnostics, and LumiraDx; and the University of Edinburgh has received research grants from Abbott Diagnostics and Siemens Healthineers. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.

Figures

None
Graphical abstract
Figure 1
Figure 1
Association Between High-Sensitivity Cardiac Troponin and CAD Odds ratio of any coronary artery disease (CAD) and obstructive CAD on coronary computed tomography angiography in all patients with intermediate (between 5 ng/L and the sex-specific 99th percentile) versus low troponin concentrations (<5 ng/L) and stratified by the presence of anginal symptoms. CI = confidence interval.
Figure 2
Figure 2
Cumulative Proportion With CAD Across Troponin Concentrations Cumulative proportion of patients with CAD across troponin concentrations within the normal reference range. Solid lines represent central estimate and dashed lines represent 95% CIs. CCTA = coronary computed tomography angiography; other abbreviation as Figure 1.
Figure 3
Figure 3
Previous Diagnosis and Treatment in Patients With CAD Identified on CCTA (A) Proportion of patients with CAD identified on CCTA with low (<5 ng/L) and intermediate troponin concentrations (between 5 ng/L and the sex-specific 99th percentile) stratified by medical history of CAD. (B) Proportion of patients with CAD identified on CCTA with low (<5 ng/L) and intermediate troponin concentrations (between 5 ng/L and the sex-specific 99th percentile) stratified by previous treatment with preventative medical therapy. Abbreviations as in Figures 1 and 2.
Central Illustration
Central Illustration
Troponin to Guide Coronary Computed Tomography Angiography After Myocardial Infarction Has Been Ruled Out In this prospective cohort study, 250 patients with suspected acute coronary syndrome underwent outpatient coronary computed tomography angiography (CCTA) after acute myocardial infarction was ruled out. Patients with intermediate high-sensitivity cardiac troponin I concentrations (between 5 ng/L and the sex-specific 99th percentile) were 3× more likely to have coronary artery disease (CAD) than those with high-sensitivity cardiac troponin I concentrations <5 ng/L. This approach to use cardiac troponin to select patients for downstream CCTA after myocardial infarction has been ruled out has the major potential to improve patient outcomes by improving the diagnosis of CAD and use of preventative treatments. High-STEACS = High-Sensitivity Troponin in the Evaluation of patients with suspected Acute Coronary Syndrome; ECG = electrocardiogram.
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