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- Bandstein, Nadia
(författare)
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High-sensitivity cardiac troponin T in the emergency department : admissions, resource utilization and outcomes
- 2017
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Background: Patients presenting with chest pain in the emergency department (ED) may have myocardial infarction (MI) requiring immediate treatment. High-sensitivity cardiac troponin T (hs-cTnT) was recently introduced as a biomarker that aids in determining whether the patient requires hospital admission or can be safely discharged home. The aim of this thesis was to evaluate the implementation of hs-cTnT in the ED, with respect to hospital admission, resource utilization and patient outcomes. Methods and Results: Two separate datasets were created by combining administrative information from the ED at Karolinska University Hospital with laboratory data and linking several national health care registers through the National Board of Health and Welfare. The first dataset was used for Studies I and II, while the second dataset was used for Studies III and IV. Cox regression was used to calculate hazard ratios (HRs) with 95% confidence intervals (CIs). Study I: In total, 14,636 patients with chest pain who presented to the EDs at Karolinska University Hospital, Solna and Huddinge, during 2011 and 2012 were included to evaluate whether a first undetectable (<5 ng/L) hs-cTnT level and an electrocardiogram (ECG) without signs of ischaemia could be used to safely rule out MI in the ED. We identified 15 patients with an undetectable hs-cTnT level and non-ischaemic ECG who were diagnosed with MI within 30 days. The negative predictive value for MI using this strategy was 99.8%, and for death 100%. Study II: We included 13,046 patients with chest pain who visited the ED at Karolinska University Hospital, Solna and Huddinge, during 2011 and 2012. We calculated HRs at different hs-cTnT levels for the risk of revisits to the ED, readmissions to hospital and resource utilization in terms of whether the patient was discharged or admitted. In patients with a hs-cTnT level of <5 ng/L who were admitted to the hospital compared with discharged home, we observed a 24% increased risk (adjusted HR 1.24, 95% CI 1.05–1.46) of revisiting the ED within 30 days and a three-fold increased risk of coronary angiography or revascularization during follow-up. Study III: We evaluated trends in admission rates among 15,472 patients with chest pain who presented to the ED at Karolinska University Hospital, Huddinge from 2011 to 2014. Proportions of admitted patients were calculated using each year of the study period (2012, 2013 and 2014) as exposure with year 2011 as reference. We found a 36% relative reduction in hospital admissions. All-cause mortality increased (adjusted HR 1.51, 95% CI 1.18–1.92), but for non-cardiovascular causes only. Coronary angiography significantly increased, but revascularizations remained stable. Study IV: Survival and resource utilization in 31,904 patients with chest pain were compared during the initial 3 years (2011 -2013) when the hs-cTnT assay was implemented to the preceding 2 years (2009-2010) when the conventional troponin (cTnT) assay was in use at Karolinska University Hospital, Solna and Huddinge. Patients who were tested with hs-cTnT had a 15% increase in all-cause mortality (adjusted HR 1.15, 95% CI 1.02–1.29), 13% increase in coronary angiography (adjusted HR 1.13, 95% CI 1.00–1.28) and 18% increase in revascularizations (adjusted HR 1.18, 95% CI 1.01 – 1.37). Conclusions: [I] Patients presenting with chest pain, a first undetectable hs-cTnT level and a normal ECG may be safely discharged from the ED because the risk of MI or death is minimal. [II] When patients with chest pain and an undetectable hs-cTnT level are admitted to the hospital instead of discharged home, they have an increased risk of revisits to the ED, recurrent hospital stays, coronary angiography and revascularization. [III] Admissions for chest pain were reduced by 36% during the first 4 years of hscTnT use. All-cause mortality increased, but for non-cardiovascular causes only. [IV] After the introduction of hs-cTnT testing in the ED, an increase in mortality, coronary angiography and revascularizations was observed.
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| 2. |
- Bandstein, Nadia, et al.
(författare)
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Survival and resource utilization in patients with chest pain evaluated with cardiac troponin T compared with high-sensitivity cardiac troponin T
- 2017
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Ingår i: International Journal of Cardiology. - : Elsevier BV. - 0167-5273 .- 1874-1754. ; 245, s. 43-48
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Tidskriftsartikel (refereegranskat)abstract
- Background:It is uncertain how the implementation of high-sensitivity cardiac troponin T (hs-cTnT) has affected the survival of patients with chest pain in the emergency department (ED). We studied prognosis and resource utilization in terms of coronary angiographies and revascularizations (percutaneous coronary intervention or coronary artery bypass grafting) in patients evaluated with hs-cTnT compared with conventional troponin T (cTnT).Methods:All patients >25 years presenting with chest pain and at least one troponin level analyzed in the ED at the Karolinska University Hospital, Sweden, were included. Hazard ratios (HR) for all-cause mortality, coronary angiographies and revascularizations were adjusted for age, sex and comorbidities during 1 year of follow-up comparing patients tested with hs-cTnT (December 10, 2010 to December 31, 2013) with patients tested with cTnT (January 1, 2009 to December 9, 2010).Results:In total, 31,904 patients were included (n=12,485 tested with cTnT and n=24,729 using hs-cTnT). Patient characteristics, comorbidities, and medications were similar during the study period. The absolute risk of all-cause mortality was 3.7% for those tested with cTnT compared with 3.4% for hs-cTnT. After adjustment for confounders, an increased all-cause mortality was observed for patients tested with hs-cTnT (HR 1.15; 95% confidence interval (CI) 1.02-1.29). Coronary angiographies increased by 13% (HR 1.13; 95% CI 1.00-1.28) and revascularizations by 18% (HR 1.18; 95% CI 1.01-1.37) when using hs-cTnT.Conclusions:In an observational cohort study including patients with chest pain in the ED we found a small increase in mortality, coronary angiographies and revascularizations after the introduction of hs-cTnT.
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| 3. |
- Carlsson, Axel C., et al.
(författare)
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High-sensitivity cardiac troponin T levels in the emergency department in patients with chest pain but no myocardial infarction
- 2017
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Ingår i: International Journal of Cardiology. - : ELSEVIER IRELAND LTD. - 0167-5273 .- 1874-1754. ; 228, s. 253-259
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Tidskriftsartikel (refereegranskat)abstract
- Background: High-sensitivity cardiac troponin T (hs-cTnT) was recently introduced into clinical practice. The increased sensitivity has decreased the specificity. We aimed to determine the predictors for and prevalence of hs-cTnT levels above the 99th percentile in a stable population of patients without myocardial infarction (MI) who sought medical attention for chest pain in the emergency department. Methods: We included 11,847 patients with chest pain and at least one hs-cTnT measurement during 2011 and 2012. Patients with any acute reasons for an elevated hs-cTnT level were excluded. We used logistic regression to calculate adjusted odds ratios with 95% confidence intervals for the association between patient characteristics and hs-cTnT levels of >14 ng/L. We also determined 50th, 75th, 97.5th, and 99th percentile values of hs-cTnT levels in relation to age, sex, estimated glomerular filtration rate (eGFR), and presence or absence of comorbidities. Results: In total, 1360 (11%) patients had hs-cTnT levels of >14 ng/L. Men had higher troponin levels than women, and older patients had higher levels than younger patients. The strongest predictor of an elevated troponin level was a reduced eGFR. The 99th percentile for hs-cTnT among all men and among women <50 years of age with normal renal function was 20 and 12 ng/L, respectively; this level increased to 44 and 36 ng/L, respectively, at the age of 70-79 years. Conclusions: A hs-cTnT level above the 99th percentile in patients with chest pain but no MI is common and is related to sex, age, and eGFR.
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