High-sensitivity cardiac troponin T for diagnosis of NSTEMI in the elderly emergency department patient: a clinical cohort study

Purpose: The aim of this study is to evaluate the impact of age on the diagnostic performance of high-sensitivity troponin T (hsTnT) under routine conditions.

Materials and methods: Data of 4118 consecutive emergency department (ED) patients who underwent a routine TnT measurement between 11 October 2012 and 30 November 2013 were analysed. Diagnostic accuracy of hsTnT was compared in four age categories (<50, 50–64, 65–74, ≥75 years of age) for different cut-off values. Primary endpoint was a main hospital diagnosis of NSTEMI.

Results: The median age of the study population (n?=?4118) was 61 years (IQR: 45–75 years). NSTEMI was diagnosed in 3.3% (n?=?136) of all patients. There were significant differences in hsTnT concentrations between age-groups (p?p?=?0.297). 72.2% of all patients ≥75 years of age (583/808) without NSTEMI had hsTnT concentrations above the 99th percentile of a healthy reference population. Specificity at 14?ng/L was 93.6% (95% CI: 92.12–94.87) in patients below 50 years of age and 27.9% (95% CI: 24.78–31.08) in patients 75 years of age and older.

Conclusions: Patients’ age needs to be considered at least one influencing factor on hsTnT concentrations at admission and should be included in the clinical interpretation of hsTnT concentrations for further clinical workup beneath other influencing factors like comorbidities and symptom onset time. The implementation of age-specific cut-off values could be considered for single troponin testing at admission but is associated with an increased risk of underdiagnosis of NSTEMI.     

Addition of heart score to high-sensitivity troponin T versus conventional troponin T in risk stratification of patients with chest pain at the coronary emergency rooms

Patients with chest pain have a large impact on available resources in coronary emergency rooms (CER). Clinical judgement, ECG, risk scores and biomarkers guide in risk stratification. We investigated if high-sensitivity troponin T (HsT) and the HEART Score could contribute to risk stratification at the CER. All patients with chest pain, without elevated conventional troponin levels at presentation, were included. HsT levels were determined at admission (T1), at 4–6 h (T2) and 8–10 h after symptom onset (T3). The HEART Score was calculated as risk score for the occurrence of a major adverse cardiac event (MACE). Thirty days after discharge, occurrence of MACE was registered. Eighty-nine patients were included (overall mean age 61 years (range 20–90)). At presentation, 68 patients (76 %) had a HsT below cut-off value of 14 ng/l (mean HEART Score 3.7, range 1–9). Thirty-one of these 68 patients had a HEART Score between 1–3, no MACE occurred in this group. For 3 patients (4 %) HsT levels increased above 14 ng/l. These 3 patients had a HEART Score between 4–6. The majority of patients with chest pain can be safely discharged within 4–6 h after onset of symptoms using HsT and the HEART Score. In contrast, patients with initially normal HsT but a high HEART Score need longer follow-up and repeat HsT determination.