Search

Keywords: acute coronary syndrome; myocardial infarction; troponin I EN acute coronary syndrome myocardial infarction troponin I 447 449 3 02/09/23 20230131 NES 230131 BHF Centre for Cardiovascular Science (A.B. K.K.L. A.A. A.R.C. C.T. D.E.N. N.L.M. D.M.K.), University of Edinburgh, United Kingdom. Overall, more patients had myocardial infarction ruled out by the pathway in the unselected cohort than in the selected cohort (77% [958/1242] versus 66% [1119/1695]; P<0.001),>Figure). Performance... Our findings highlight that the performance of early rule-out pathways for acute myocardial infarction that have been developed in selected patient cohorts are likely to differ substantially when applied in clinical practice because of the lower prevalence of myocardial infarction. [Extracted from the article]

Background: The introduction of more sensitive cardiac troponin assays has led to increased recognition of myocardial injury in acute illnesses other than acute coronary syndrome. The Universal Definition of Myocardial Infarction recommends high-sensitivity cardiac troponin testing and classification of patients with myocardial injury based on pathogenesis, but the clinical implications of implementing this guideline are not well understood.Methods: In a stepped-wedge cluster randomized, controlled trial, we implemented a high-sensitivity cardiac troponin assay and the recommendations of the Universal Definition in 48 282 consecutive patients with suspected acute coronary syndrome. In a prespecified secondary analysis, we compared the primary outcome of myocardial infarction or cardiovascular death and secondary outcome of noncardiovascular death at 1 year across diagnostic categories.Results: Implementation increased the diagnosis of type 1 myocardial infarction by 11% (510/4471), type 2 myocardial infarction by 22% (205/916), and acute and chronic myocardial injury by 36% (443/1233) and 43% (389/898), respectively. Compared with those without myocardial injury, the rate of the primary outcome was highest in those with type 1 myocardial infarction (cause-specific hazard ratio [HR] 5.64 [95% CI, 5.12-6.22]), but was similar across diagnostic categories, whereas noncardiovascular deaths were highest in those with acute myocardial injury (cause specific HR 2.65 [95% CI, 2.33-3.01]). Despite modest increases in antiplatelet therapy and coronary revascularization after implementation in patients with type 1 myocardial infarction, the primary outcome was unchanged (cause specific HR 1.00 [95% CI, 0.82-1.21]). Increased recognition of type 2 myocardial infarction and myocardial injury did not lead to changes in investigation, treatment or outcomes.Conclusions: Implementation of high-sensitivity cardiac troponin assays and the recommendations of the Universal Definition of Myocardial Infarction identified patients at high-risk of cardiovascular and noncardiovascular events but was not associated with consistent increases in treatment or improved outcomes. Trials of secondary prevention are urgently required to determine whether this risk is modifiable in patients without type 1 myocardial infarction.Clinical Trial Registration: https://www.clinicaltrials.gov. Unique identifier: NCT01852123. [ABSTRACT FROM AUTHOR]