Identification of high-risk non-ST elevation myocardial infarction at presentation to emergency department. A prospective observational cohort study in North West England

Aleem Khand, Freddy Frost, Ruth Grainger, Michael Fisher, Pei Chew, Liam Mullen, Billal Patel, Mohammed Obeidat, Khaled Albouaini, James Dodd, Aleem Khand, Freddy Frost, Ruth Grainger, Michael Fisher, Pei Chew, Liam Mullen, Billal Patel, Mohammed Obeidat, Khaled Albouaini, James Dodd

Abstract

Objectives: Early access to invasive coronary angiography and revascularisation for high-risk non-ST elevation myocardial infarction (NSTEMI) improves outcomes and is supported by current guidelines. We sought to determine the most effective criteria at presentation to emergency department (ED) to identify high-risk NSTEMI.

Setting: Secondary care centre northwest England with national follow-up.

Participants: 1642 consecutive patients (median age 59, 52% male) presenting to ED with a primary symptom of chest pain in whom there is suspicion of NSTEMI.

Primary and secondary measures: Multivariate logistic regression analysis for the prediction of all-cause death (primary) and major adverse cardiac event (MACE defined as all-cause death, unplanned coronary revascularisation and adjudicated NSTEMI (third universal definition)) (secondary measure) at 1 year.

Results: The incidence of adjudicated NSTEMI was 10.7%, and 1-year mortality was 6.3%. Independent predictors for all-cause death at 1 year were Global Registry of Acute Coronary Events (GRACE) >140, age (per decade increase) and high-sensitive cardiac troponin T (hs-cTnT) >50 ng/L. hs-cTnT >50 ng/L was associated with adjudicated index presentation NSTEMI in the greatest proportion of patients (61.7%). When using MACE at 12 months, as opposed to all-cause death, as an end point History, ECG, Age, Risk factors and Troponin (HEART) score ≥7 was included in the multivariate model and had better prediction of index NSTEMI than GRACE>140. Combining hs-cTnT >50 ng/L and a second independent predictor identified both a high proportion of index NSTEMI and elevated risk of all-cause death at 1 year.

Conclusions: hs-cTnT >50 ng/L or HEART score ≥7 appear effective strategies to identify high-risk NSTEMI at presentation to emergency room with chest pain. Multicentre prospective studies enriched with early presenters, and with competitor high-sensitive and point-of-care troponins, are required to validate and extend these findings.

Trial registration number: NCT02581540.

Keywords: accident & emergency medicine; coronary heart disease; myocardial infarction.

Conflict of interest statement

Competing interests: AK has the following potential conflicts of interest: free of charge material from Roche for research. Submissions pending for research funds for Roche and Abbott. Funding for national conferences from Daiichi Sankyo, Bayer. Funding for research from Bayer Pharmaceuticals. Speaker and expert consultation fees from AstraZeneca, Menarini, Bayer, Daiichi Sankyo.

© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.

Figures

Figure 1
Figure 1
A. All-cause death at 1 year by high-sensitive cardiac troponin T (hs-cTnT). Kaplan-Meier (KM) survival curve by hs-cTnT >50 ng/L HR 5.21 (95% CI 3.45 to 7.88), p

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