Use of conventional cardiac troponin assay for diagnosis of non-ST-elevation myocardial infarction: ‘The Ottawa Troponin Pathway’

Autoři: Venkatesh Thiruganasambandamoorthy aff001;  Ian G. Stiell aff001;  Hina Chaudry aff002;  Muhammad Mukarram aff002;  Ronald A. Booth aff004;  Cristian Toarta aff003;  Guy Hebert aff001;  Robert S. Beanlands aff006;  George A. Wells aff003;  Marie-Joe Nemnom aff002;  Monica Taljaard aff002
Působiště autorů: Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada aff001;  Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, ON, Canada aff002;  School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada aff003;  Department of Pathology and Laboratory Medicine, University of Ottawa, Ottawa, ON, Canada aff004;  Division of Emergency Medicine, University of Toronto, Toronto, ON, Canada aff005;  Division of Cardiology, University of Ottawa, Ottawa, ON, Canada aff006
Vyšlo v časopise: PLoS ONE 15(1)
Kategorie: Research Article



Serial conventional cardiac troponin (cTn) measurements 6–9 hours apart are recommended for non-ST-elevation MI (NSTEMI) diagnosis. We sought to develop a pathway with 3-hour changes for major adverse cardiac event (MACE) identification and assess the added value of the HEART [History, Electrocardiogram (ECG), Age, Risk factors, Troponin] score to the pathway.


We prospectively enrolled adults with NSTEMI symptoms at two-large emergency departments (EDs) over 32-months. Patients with STEMI, unstable angina and one cTn were excluded. We collected baseline characteristics, Siemens Vista conventional cTnI at 0, 3 or 6-hours after ED presentation; HEART score predictors; disposition and ED length of stay (LOS). Adjudicated primary outcome was 15-day MACE (acute MI, revascularization, or death due to cardiac ischemia/unknown cause). We analyzed multiples of 99th percentile cut-off cTnI values (45, 100 and 250ng/L).


1,683 patients (mean age 64.7 years; 55.3% female; median LOS 7-hours; 88 patients with 15-day MACE) were included. 1,346 (80.0%) patients with both cTnI≤45 ng/L; and 155 (9.2%) of the 213 patients with one value≥100ng/L but both<250ng/L or ≤20% change did not suffer MACE. Among 124 patients (7.4%) with one of the two values>45ng/L but<100ng/L based on 3 or 6-hour cTnI, one patient with absolute change<10ng/L and 6 of the 19 patients with≥20ng/L were diagnosed with NSTEMI (patients with Δ10-19ng/L between first and second cTnI had third one at 6-hours). Based on the results, we developed the Ottawa Troponin Pathway (OTP) with a 98.9% sensitivity (95% CI 93.8–100%) and 94.6% specificity (95% CI 93.3–95.6%). Addition of the HEART score improved the sensitivity to 100% (95% CI 95.9–100%) and decreased the specificity to 26.5% (95% CI 24.3–28.7%).


The OTP with conventional cTnI 3-hours apart, should lead to better NSTEMI identification particularly those with values >99th percentile, standardize management and reduce the ED LOS.

Klíčová slova:

Angina – Cardiology – Coronary heart disease – Critical care and emergency medicine – Heart – Myocardial infarction – Physicians – Troponin


1. Rui PK, K. National Hospital Ambulatory Mediacl Care Survey: Emergency Department Summary Tables. Atlanta, GA, USA: National Center for Health Statistics; 2015.

2. American College of Emergency Physicians Clinical Policies Subcommittee on Suspected Non STEACS, Tomaszewski CA, Nestler D, Shah KH, Sudhir A, Brown MD. Clinical Policy: Critical Issues in the Evaluation and Management of Emergency Department Patients With Suspected Non-ST-Elevation Acute Coronary Syndromes. Ann Emerg Med. 2018;72(5):e65–e106. doi: 10.1016/j.annemergmed.2018.07.045 30342745

3. Torio CM, Moore BJ. National Inpatient Hospital Costs: The Most Expensive Conditions by Payer, 2013: Statistical Brief #204. Healthcare Cost and Utilization Project (HCUP) Statistical Briefs. Rockville (MD): Agency for Healthcare Research and Quality (US); 2006.

4. Go AS, Mozaffarian D, Roger VL, Benjamin EJ, Berry JD, Blaha MJ, et al. Heart disease and stroke statistics—2014 update: a report from the American Heart Association. Circulation. 2014;129(3):e28–e292. doi: 10.1161/01.cir.0000441139.02102.80 24352519

5. Bhuiya FA, Pitts SR, McCaig LF. Emergency department visits for chest pain and abdominal pain: United States, 1999–2008. NCHS data brief. 2010(43):1–8.

6. Chew DP, Zeitz C, Worthley M, Grantham H, Beltrame J, Arstall M, et al. Randomized Comparison of High-Sensitivity Troponin Reporting in Undifferentiated Chest Pain Assessment. Circ Cardiovasc Qual Outcomes. 2016;9(5):542–53. doi: 10.1161/CIRCOUTCOMES.115.002488 27506926

7. Mahler SA, Riley RF, Russell GB, Hiestand BC, Hoekstra JW, Lefebvre CW, et al. Adherence to an Accelerated Diagnostic Protocol for Chest Pain: Secondary Analysis of the HEART Pathway Randomized Trial. Academic emergency medicine: official journal of the Society for Academic Emergency Medicine. 2016;23(1):70–7.

8. Hamm CW, Bassand JP, Agewall S, Bax J, Boersma E, Bueno H, et al. ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation: The Task Force for the management of acute coronary syndromes (ACS) in patients presenting without persistent ST-segment elevation of the European Society of Cardiology (ESC). European heart journal. 2011;32(23):2999–3054. doi: 10.1093/eurheartj/ehr236 21873419

9. Amsterdam EA, Wenger NK, Brindis RG, Casey DE Jr., Ganiats TG, Holmes DR Jr., et al. 2014 AHA/ACC guideline for the management of patients with non-ST-elevation acute coronary syndromes: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. 2014;130(25):2354–94. doi: 10.1161/CIR.0000000000000133 25249586

10. Mahler SA, Riley RF, Hiestand BC, Russell GB, Hoekstra JW, Lefebvre CW, et al. The HEART Pathway randomized trial: identifying emergency department patients with acute chest pain for early discharge. Circ Cardiovasc Qual Outcomes. 2015;8(2):195–203. doi: 10.1161/CIRCOUTCOMES.114.001384 25737484

11. Mahler SA, Miller CD, Hollander JE, Nagurney JT, Birkhahn R, Singer AJ, et al. Identifying patients for early discharge: performance of decision rules among patients with acute chest pain. Int J Cardiol. 2013;168(2):795–802. doi: 10.1016/j.ijcard.2012.10.010 23117012

12. Thygesen K, Alpert JS, Jaffe AS, Simoons ML, Chaitman BR, White HD, et al. Third universal definition of myocardial infarction. Circulation. 2012;126(16):2020–35. doi: 10.1161/CIR.0b013e31826e1058 22923432

13. Apple FS. A new season for cardiac troponin assays: it's time to keep a scorecard. Clin Chem. 2009;55(7):1303–6. doi: 10.1373/clinchem.2009.128363 19478023

14. Hamm CW, Bassand JP, Agewall S, Bax J, Boersma E, Bueno H, et al. ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation: The Task Force for the management of acute coronary syndromes (ACS) in patients presenting without persistent ST-segment elevation of the European Society of Cardiology (ESC). Eur Heart J. 2011;32(23):2999–3054. doi: 10.1093/eurheartj/ehr236 21873419

15. Backus BE, Six AJ, Kelder JC, Bosschaert MA, Mast EG, Mosterd A, et al. A prospective validation of the HEART score for chest pain patients at the emergency department. Int J Cardiol. 2013;168(3):2153–8. doi: 10.1016/j.ijcard.2013.01.255 23465250

16. Hess EP, Brison RJ, Perry JJ, Calder LA, Thiruganasambandamoorthy V, Agarwal D, et al. Development of a clinical prediction rule for 30-day cardiac events in emergency department patients with chest pain and possible acute coronary syndrome. Ann Emerg Med. 2012;59(2):115–25 e1. doi: 10.1016/j.annemergmed.2011.07.026 21885156

17. Chapman AR, Hesse K, Andrews J, Ken Lee K, Anand A, Shah ASV, et al. High-Sensitivity Cardiac Troponin I and Clinical Risk Scores in Patients With Suspected Acute Coronary Syndrome. Circulation. 2018;138(16):1654–65. doi: 10.1161/CIRCULATIONAHA.118.036426 30354460

18. Neumann JT, Twerenbold R, Ojeda F, Sorensen NA, Chapman AR, Shah ASV, et al. Application of High-Sensitivity Troponin in Suspected Myocardial Infarction. N Engl J Med. 2019;380(26):2529–40. doi: 10.1056/NEJMoa1803377 31242362

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2020 Číslo 1
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