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Sensitivity, specificity and predictive value of the echocardiography and troponin-T test combination in patients with non-ST elevation acute coronary syndromes

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Abstract

Introduction: Patients with a negative troponin (TnT) result showed 1.4% mortality during a mean follow-up of 9–10 weeks. Mortality was greater in patients with an evidence of ischemic ECG changes and a negative TnT test (1.6–4.4%). Few studies have examined the efficacy of echocardiography (2DE) in patients with chest pain. The purpose of the present study was to determine the clinical utility, sensitivity and specificity of the combination of TnT levels and 2DE in patients presenting with chest pain, ST-depression, T-wave negative and no diagnostic ECG. Methods: 280 consecutive patients with chest pain and presence of ST depression, T-wave inversion, and non-diagnostic ECG, acceptable 2DE window, evidence or no evidence of alterations of the segmentary motion, and evidence and no evidence of injury, as assessed by TnT and normal value of CK-CK MB, were enrolled. 2DE, blood CK, and TnT levels were controlled at entry and subsequent samples were obtained every 4 h for the first 12 h and then every 12 h. All patients performed angiography within 12–72 from admission. PTCA or CABG were performed according to angiographic findings and left ventricular function. Results: The 280 patients (98 F/M 182), mean age 59.7 ± 11.9 years, who met the entry criteria, were divided as follows: group 1: ST-segment depression (192 patients); group 2: T-wave inversion (36 patients); and group 3: non-diagnostic ECG (52 patients). The combination of positive TnT and wall motion alterations showed a higher sensitivity, specificity and predictive values in comparison with alone TnT or 2DE. Patients, with the concordance between TnT and 2DE, were at higher risk. Patients with negative combination in all groups (94), showed a low incidence of coronary stenosis (10.6%), as well as negative 2DE alone (102 patients) (12.7%), while patients with negative TnT (128) showed higher incidence of coronary stenosis (39%), p < 0.0001. Conclusion: Our results suggest that the combination of negative TnT test and negative 2DE in patients presenting to EDs with chest pain either with ECG changes or without ECG changes is a useful tool to identify those who can be discharged safely. We think that our data are important because by the combination we can identify the high risk (when positive) patients, reduce incidence of the false negative, but mostly it allows us to identify true negative patients to discharge safely.

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References

  1. Antman EM, Tanasijevic MJ, Thompson B, et al. Cardiac-specific troponin I levels to predict the risk of mortality in patients with acute coronary syndromes. N Engl J Med 1996; 335: 1342–1349.

    Google Scholar 

  2. Hamm CW, Goldmann BU, Heeshen C, Kreymann G, Berger J, Meinertz T. Emergency room triage of patients with acute chest pain by means of rapid testing for cardiac troponin T or I. N Engl J Med 1997; 337: 1648–1653.

    Google Scholar 

  3. Ohman EM, Amstrong PW, Christenson RH, et al. Cardiac troponin T levels for risk stratification in acute myocardial ischemia. GUSTO II investigators. N Engl J Med 1996; 335: 1333–1341.

    Google Scholar 

  4. De Filippi CR, Parmar RJ, Potter MA, Tocchi M. Diagnostic accuracy, angiographic correlates and long term risk stratification with the troponin T ultra sensitive rapid assay in chest pain patients at low risk for acute myocardial infarction. Eur Heart J 1998; 19 (Suppl N): N42–N47.

    Google Scholar 

  5. Mockel M, Stork T, Heller G, et al. Troponin T in patients with low grade or atypical angina. Identification of a high risk group for short and long term cardiovascular events. Eur Heart J 1998; 19: 1802–1807.

    Google Scholar 

  6. Sarullo FM, Di Pasquale P, Orlando G, et al. Utility and safety of immediate exercise testing of low-risk patients admitted to the hospital with acute chest pain. Int J Cardiol 2000; 75: 239–243.

    Google Scholar 

  7. Kirk JD, Diercks DB, Turnipseed SD, Amsterdam EA. Evaluation of chest pain suspicious for acute coronary syndrome: use of an accelerated diagnostic protocol in a chest pain evaluation unit. Am J Cardiol 1998; 85; (Suppl 1): 40–48.

    Google Scholar 

  8. Heidenreich PA, Alloggiamento T, Melsop K, McDonald KM, GO AS, Hlatky MA. The prognostic value of troponin in patients with non-ST elevation acute coronary syndromes: a meta-analysis's Am Coll Cardiol 2001; 38: 478–485.

    Google Scholar 

  9. Zimmerman J, Fromm R, Meyer D, et al. Diagnostic marker cooperative study for the diagnosis of myocardial infarction. Circulation 1999; 99: 1671–1677.

    Google Scholar 

  10. De Filippi CR, Rosanio S, Tocchi M, et al. Randomized comparison of a strategy of predischarge coronary angiography versus exercise testing in low-risk patients in a chest pain unit: in-hospital and long term outcomes. J Am Coll Cardiol 2001; 37: 2042–2049.

    Google Scholar 

  11. Peels CH, Visser CA, Kupper AJ, Visser FC, Ross JP. Usefulness of two-dimensional echocardiography for immediate detection of myocardial ischemia in the emergency room. Am J Cardiol 1990: 65; 687–691.

    Google Scholar 

  12. Sabia P, Afrrkteh A, Touchstone DA, Keller MW, Esquivel L, Kaul S. Value of regional wall motion abnormality in the emergency room diagnosis of acute myocardial infarction: a prospective study using two-dimensional echocardiography. Circulation 1991; 84; (Suppl I): 85–92.

    Google Scholar 

  13. Gibler WB, Runyon JP, Levy RC, et al. A rapid diagnostic and treatment center for patients with chest pain in emergency department. Ann Emerg Med 1995; 25: 1–8.

    Google Scholar 

  14. Di Pasquale P, Bucca V, Giuliano P, Maringhini G, Scalzo S, Paterna S. Advantages of immediate two-dimensional echocardiography in patients with acute cardiac ischemic events. Int J Cardiol 1995; 51: 85–91.

    Google Scholar 

  15. Kontos MC, Arrowood JA, Paulsen WH, Nixon JV. Early echocardiography can predict cardiac event in emergency department patients with chest pain. Ann Emerg Med 1998; 31: 550–557.

    Google Scholar 

  16. Feigenbaum H. Role of echocardiography in acute myocardial infarction. Am J Cardiol 1990; 66: 17H–22H.

    Google Scholar 

  17. Parisi AF. The case for echocardiography in acute myocardial infarction. J Am Soc Echocardiogr 1988; 1: 173–178.

    Google Scholar 

  18. Reeder GS, Seward JB, Tajik AJ. The role of two-dimensional echocardiography in coronary artery disease: a critical appraisal. Mayo Clin Proc 1982; 57: 247–258.

    Google Scholar 

  19. Gibson RS, Bishop HL, Stamm RB, Crampton RS, Beller GA, Martin RP. Value of early two dimensional echocardiography in patients with acute myocardial infarction. Am J Cardiol 1982; 49: 1110–1119.

    Google Scholar 

  20. Visser CA, Lie Ki, Kan G, Meltzer R, Durrer D. Detection and quantification of acute, isolated myocardial infarction by two dimensional echocardiography. Am J Cardiol 1981; 47: 1020–1025.

    Google Scholar 

  21. Heger JJ, Weiman AE, Wann LS, Rogers EW, Dillon JC, Feigenbaum H. Cross-sectional echocardiographic analysis of the extent of left ventricular asynergy in acute myocardial infarction. Circulation 1980; 61: 1113–1118.

    Google Scholar 

  22. Ryan T, Vasey CG, Presti CF, O'Donnell JA, Feigenbaum H, Amstrong WF. Exercise echocardiography: detection of coronary artery disease in patients with normal left ventricular wall motion at rest. J Am Coll Cardiol 1988; 11: 993–999.

    Google Scholar 

  23. Sawada SG, Ryan T, Conley MJ, Coya BC, Feigenbaum H, Amstrong WF. Prognostic value of a normal exercise echocardiogram. Am Heart J 1990; 120: 49–55.

    Google Scholar 

  24. Sutherland GR. Doppler myocardial imaging in the assessment of normal and ischemic myocardial function-past, present and future. Intern J Cardiovasc Imaging 2001; 17(2): 89–98.

    Google Scholar 

  25. Weyman AE. Cross-sectional echocardiography. Philadelphia: Lea and Febiger, 1982.

    Google Scholar 

  26. Touchstone DA, Beller GA, Nygaard TW, Tedesco C, Kaul S. Effects of successful intravenous reperfusion therapy on regional myocardial function and geometry in humans: a tomographic assessment using two-dimensional echocardiography. J Am Coll Cardiol 1989; 13: 1506–1513.

    Google Scholar 

  27. Schiller NB, Maurer G, Ritter SB, et al. Recommendations for quantification of left ventricle by two-dimensional echocardiography. J Am Soc Echo 1989; 2: 358–370.

    Google Scholar 

  28. Antaman EM, Cohen M, Bernink PJ, et al. The TIMI risk score for unstable angina/non-ST elevation MI: a method for prognostication and therapeutic decision making. JAMA 2000; 284: 835–842.

    Google Scholar 

  29. Braunwald E, Antman EM, Beasley JW, et al. ACC/AHA guideline update for the management of patients with unstable angina and non-ST-segment elevation myocardial infarction: a report of the American College of Cardiology/ American Heart Association Task force on Practice Guidelines (Committee on the Management of patients with unstable angina), 2002. Available at: http://www.acc.org/ clinical/guidelines/unstable.pdf.

  30. Tennant R, Wiggers C. The effect of coronary occlusion on myocardial contraction. Am J Physiol 1935; 112: 351–361.

    Google Scholar 

  31. Schaper J, Hein S, Heinrichs CM, Weihrauch D. Myocardial injury and repair. In: Parrat JR editor. Myocardial Response to Acute Injury. London: MacMillan; 1992, 1–6.

    Google Scholar 

  32. Jennings R, Ganote C. Structural changes in myocardium during acute ischemia. Circ Res 1974; 34/35 (Suppl III): III-156–III-172.

    Google Scholar 

  33. Schaper J. Ultrastructure of the myocardium in acute ischemia. In: Schaper W editor. The Pathophysiology of Myocardial Perfusion. Amsterdam: Elsevier, 1979; 581–674.

    Google Scholar 

  34. Schaper J. Ultrastructural changes of the myocardium in regional ischemia and infarction. Eur Heart J 1986; 7: 3–9.

    Google Scholar 

  35. Jeroudi MO, Cheirif J, Habib G, Bolli R. Prolonged wall motion abnormalities after chest pain at rest in patients with unstable angina: a possible manifestation of myocardial stunning. Am Heart J 1994; 127: 1241–1250.

    Google Scholar 

  36. Sten JH, Neuman A, Preston LM, et al. Improved risk stratification in unstable angina: identification of patients at low risk for in-hospital cardiac events by admission echocardiography. Clin Cardiol 1998; 21: 725–730.

    Google Scholar 

  37. Di Pasquale P, Paterna S, Bucca V, et al. Thrombolysis plus heparin versus heparin alone in the acute phases of unstable angina: preliminary findings. Curr Ther Res 1995; 56: 1115–1124.

    Google Scholar 

  38. Selker HP, Zalenski RJ, Antman EM, et al. An evaluation of technologies for identifying acute cardiac ischemia in the emergency department: a report from a National Heart Attack Alert Program Working Group. Ann Emerg Med 1997; 29: 13–87.

    Google Scholar 

  39. Mohler ER, Ryan T, Segar DS, et al. Clinical utility of troponin T levels and echocardiography in the emergency department. Am Heart J 1998; 135: 253–260.

    Google Scholar 

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Di Pasquale, P., Cannizzaro, S., Scalzo, S. et al. Sensitivity, specificity and predictive value of the echocardiography and troponin-T test combination in patients with non-ST elevation acute coronary syndromes. Int J Cardiovasc Imaging 20, 37–46 (2004). https://doi.org/10.1023/B:CAIM.0000013154.61977.eb

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