The incremental value of troponin-I testing in patients with intermediate risk unstable angina

Evan Appelbaum, M. Urooj Zafar, H. C. Glick, Sebastian Stec, William N. Southern, Laszlo Sarkozi, Sylvan Wallenstein, James H. Chesebro, Michael E. Farkouh

Research output: Contribution to journalArticle

Abstract

Background: Classification of patients with unstable angina (UA) by Agency for Health Care Policy and Research (AHCPR) guidelines in the emergency department reliably stratifies risk of death or myocardial infarction (MI) for triage to outpatient evaluation (low-risk), hospitalization (high-risk), or additional testing (intermediate-risk). Cardiac troponin-I elevation may identify patients at higher risk, but the incremental value may vary with AHCPR clinical risk. Hypothesis: The objective of this study was to determine whether cardiac troponin-I had any additional value beyond triage based upon history, physical examination, and electrocardiogram, in the evaluation of patients with UA. Methods: In all, 212 consecutive patients with UA and normal serum creatine kinase (CK)-MB levels and elevated troponin-I were risk stratified by AHCPR guidelines to evaluate the incremental value of adding routine troponin-I measurements to our current model for risk stratification. Results: Primary events (death/nonfatal MI) occurred in 35% of high-risk, 15% of intermediate-risk, and 0% of low-risk patients (p<0.001 by chi-square for trend). High troponin-I (≥2.0 ng/dl) occurred in 48% of high-risk, 21% of intermediate-risk, and 19% of low-risk patients. The remaining patients in each risk group had indeterminate troponin-I levels (≥0.4 <2 ng/dl). Of those with high troponin-I, a primary event occurred in 36,42, and 0% in the respective high-, intermediate-, and low-risk groups (p<0.001). High troponin-I levels corresponded with a statistically significant increased rate of primary events only in patients at AHCPR intermediate risk: 42.4 vs. 7.3%, p<0.001. Conclusion: The AHCPR guidelines risk stratify patients with UA, High troponin-I adds significant (p<0.001) prognostic value in the patients at AHCPR intermediate risk and should be evaluated further in larger trials of such patients.

Original languageEnglish (US)
Pages (from-to)646-651
Number of pages6
JournalClinical Cardiology
Volume27
Issue number11
StatePublished - Nov 2004
Externally publishedYes

Fingerprint

Troponin I
Unstable Angina
United States Agency for Healthcare Research and Quality
Triage
Guidelines
Myocardial Infarction
MB Form Creatine Kinase

Keywords

  • Acute myocardial infarction
  • Chest pain
  • Troponin
  • Unstable angina

ASJC Scopus subject areas

  • Cardiology and Cardiovascular Medicine

Cite this

Appelbaum, E., Zafar, M. U., Glick, H. C., Stec, S., Southern, W. N., Sarkozi, L., ... Farkouh, M. E. (2004). The incremental value of troponin-I testing in patients with intermediate risk unstable angina. Clinical Cardiology, 27(11), 646-651.

The incremental value of troponin-I testing in patients with intermediate risk unstable angina. / Appelbaum, Evan; Zafar, M. Urooj; Glick, H. C.; Stec, Sebastian; Southern, William N.; Sarkozi, Laszlo; Wallenstein, Sylvan; Chesebro, James H.; Farkouh, Michael E.

In: Clinical Cardiology, Vol. 27, No. 11, 11.2004, p. 646-651.

Research output: Contribution to journalArticle

Appelbaum, E, Zafar, MU, Glick, HC, Stec, S, Southern, WN, Sarkozi, L, Wallenstein, S, Chesebro, JH & Farkouh, ME 2004, 'The incremental value of troponin-I testing in patients with intermediate risk unstable angina', Clinical Cardiology, vol. 27, no. 11, pp. 646-651.
Appelbaum E, Zafar MU, Glick HC, Stec S, Southern WN, Sarkozi L et al. The incremental value of troponin-I testing in patients with intermediate risk unstable angina. Clinical Cardiology. 2004 Nov;27(11):646-651.
Appelbaum, Evan ; Zafar, M. Urooj ; Glick, H. C. ; Stec, Sebastian ; Southern, William N. ; Sarkozi, Laszlo ; Wallenstein, Sylvan ; Chesebro, James H. ; Farkouh, Michael E. / The incremental value of troponin-I testing in patients with intermediate risk unstable angina. In: Clinical Cardiology. 2004 ; Vol. 27, No. 11. pp. 646-651.
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abstract = "Background: Classification of patients with unstable angina (UA) by Agency for Health Care Policy and Research (AHCPR) guidelines in the emergency department reliably stratifies risk of death or myocardial infarction (MI) for triage to outpatient evaluation (low-risk), hospitalization (high-risk), or additional testing (intermediate-risk). Cardiac troponin-I elevation may identify patients at higher risk, but the incremental value may vary with AHCPR clinical risk. Hypothesis: The objective of this study was to determine whether cardiac troponin-I had any additional value beyond triage based upon history, physical examination, and electrocardiogram, in the evaluation of patients with UA. Methods: In all, 212 consecutive patients with UA and normal serum creatine kinase (CK)-MB levels and elevated troponin-I were risk stratified by AHCPR guidelines to evaluate the incremental value of adding routine troponin-I measurements to our current model for risk stratification. Results: Primary events (death/nonfatal MI) occurred in 35{\%} of high-risk, 15{\%} of intermediate-risk, and 0{\%} of low-risk patients (p<0.001 by chi-square for trend). High troponin-I (≥2.0 ng/dl) occurred in 48{\%} of high-risk, 21{\%} of intermediate-risk, and 19{\%} of low-risk patients. The remaining patients in each risk group had indeterminate troponin-I levels (≥0.4 <2 ng/dl). Of those with high troponin-I, a primary event occurred in 36,42, and 0{\%} in the respective high-, intermediate-, and low-risk groups (p<0.001). High troponin-I levels corresponded with a statistically significant increased rate of primary events only in patients at AHCPR intermediate risk: 42.4 vs. 7.3{\%}, p<0.001. Conclusion: The AHCPR guidelines risk stratify patients with UA, High troponin-I adds significant (p<0.001) prognostic value in the patients at AHCPR intermediate risk and should be evaluated further in larger trials of such patients.",
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author = "Evan Appelbaum and Zafar, {M. Urooj} and Glick, {H. C.} and Sebastian Stec and Southern, {William N.} and Laszlo Sarkozi and Sylvan Wallenstein and Chesebro, {James H.} and Farkouh, {Michael E.}",
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T1 - The incremental value of troponin-I testing in patients with intermediate risk unstable angina

AU - Appelbaum, Evan

AU - Zafar, M. Urooj

AU - Glick, H. C.

AU - Stec, Sebastian

AU - Southern, William N.

AU - Sarkozi, Laszlo

AU - Wallenstein, Sylvan

AU - Chesebro, James H.

AU - Farkouh, Michael E.

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N2 - Background: Classification of patients with unstable angina (UA) by Agency for Health Care Policy and Research (AHCPR) guidelines in the emergency department reliably stratifies risk of death or myocardial infarction (MI) for triage to outpatient evaluation (low-risk), hospitalization (high-risk), or additional testing (intermediate-risk). Cardiac troponin-I elevation may identify patients at higher risk, but the incremental value may vary with AHCPR clinical risk. Hypothesis: The objective of this study was to determine whether cardiac troponin-I had any additional value beyond triage based upon history, physical examination, and electrocardiogram, in the evaluation of patients with UA. Methods: In all, 212 consecutive patients with UA and normal serum creatine kinase (CK)-MB levels and elevated troponin-I were risk stratified by AHCPR guidelines to evaluate the incremental value of adding routine troponin-I measurements to our current model for risk stratification. Results: Primary events (death/nonfatal MI) occurred in 35% of high-risk, 15% of intermediate-risk, and 0% of low-risk patients (p<0.001 by chi-square for trend). High troponin-I (≥2.0 ng/dl) occurred in 48% of high-risk, 21% of intermediate-risk, and 19% of low-risk patients. The remaining patients in each risk group had indeterminate troponin-I levels (≥0.4 <2 ng/dl). Of those with high troponin-I, a primary event occurred in 36,42, and 0% in the respective high-, intermediate-, and low-risk groups (p<0.001). High troponin-I levels corresponded with a statistically significant increased rate of primary events only in patients at AHCPR intermediate risk: 42.4 vs. 7.3%, p<0.001. Conclusion: The AHCPR guidelines risk stratify patients with UA, High troponin-I adds significant (p<0.001) prognostic value in the patients at AHCPR intermediate risk and should be evaluated further in larger trials of such patients.

AB - Background: Classification of patients with unstable angina (UA) by Agency for Health Care Policy and Research (AHCPR) guidelines in the emergency department reliably stratifies risk of death or myocardial infarction (MI) for triage to outpatient evaluation (low-risk), hospitalization (high-risk), or additional testing (intermediate-risk). Cardiac troponin-I elevation may identify patients at higher risk, but the incremental value may vary with AHCPR clinical risk. Hypothesis: The objective of this study was to determine whether cardiac troponin-I had any additional value beyond triage based upon history, physical examination, and electrocardiogram, in the evaluation of patients with UA. Methods: In all, 212 consecutive patients with UA and normal serum creatine kinase (CK)-MB levels and elevated troponin-I were risk stratified by AHCPR guidelines to evaluate the incremental value of adding routine troponin-I measurements to our current model for risk stratification. Results: Primary events (death/nonfatal MI) occurred in 35% of high-risk, 15% of intermediate-risk, and 0% of low-risk patients (p<0.001 by chi-square for trend). High troponin-I (≥2.0 ng/dl) occurred in 48% of high-risk, 21% of intermediate-risk, and 19% of low-risk patients. The remaining patients in each risk group had indeterminate troponin-I levels (≥0.4 <2 ng/dl). Of those with high troponin-I, a primary event occurred in 36,42, and 0% in the respective high-, intermediate-, and low-risk groups (p<0.001). High troponin-I levels corresponded with a statistically significant increased rate of primary events only in patients at AHCPR intermediate risk: 42.4 vs. 7.3%, p<0.001. Conclusion: The AHCPR guidelines risk stratify patients with UA, High troponin-I adds significant (p<0.001) prognostic value in the patients at AHCPR intermediate risk and should be evaluated further in larger trials of such patients.

KW - Acute myocardial infarction

KW - Chest pain

KW - Troponin

KW - Unstable angina

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