Results
non-cardiac, death, myocardial infarction, non-ischaemic myocardial injury, Bleeding, elevated cardiac troponin
MYOCARDIAL INFARCTION, DIABETES MELLITUS, TYPE 1 MYOCARDIAL INFARCTION, TYPE 2 MYOCARDIAL INFARCTION, SECONDARY, ACUTE CORONARY SYNDROME, BLEEDING, SUBSEQUENT MYOCARDIAL INFARCTION, CEREBROVASCULAR DISEASE
Between 10 June 2013 and 3 March 2016 we enrolled 48 282 consecutive patients with suspected acute coronary syndrome, 22 565 (46.7%) of whom were women. Mean age was 61 years (standard deviation 17 years). Overall, 18 978 (39.3%) patients were enrolled during standard care and 29 304 (60.7%) after implementation of the high sensitivity assay (Baseline characteristics of trial participants stratified by peak cardiac troponin I level and study phase (standard care and after implementation of the high sensitivity assay). Values are number (percentage) unless stated otherwiseACE=angiotensin converting enzyme; ARB=angiotensin receptor blockers; CABG=coronary artery bypass grafting; eGFR=estimated glomerular filtration rate; IQR=interquartile range; PCI=percutaneous coronary intervention; SD=standard deviation.Missing in 4466 (12%) patients.Combination of two drugs from aspirin, clopidogrel, prasugrel, or ticagrelor.Includes warfarin or direct oral anticoagulants.Electrocardiographic findings and physiological variables only reported for those with elevated cardiac troponin levels.The panel was able to adjudicate the index diagnosis in 88.0% (9115/10 360) of patients with cardiac troponin levels above the sex specific 99th centile. For type 1 myocardial infarction, discordant diagnoses between the first and second adjudicators occurred in 11.6% of all patients (κ=0.76), while across all diagnoses, discordance occurred in 21.7% of patients (κ=0.70). Type 1 myocardial infarction was diagnosed in 55.2% (5028/9115) of patients, type 2 myocardial infarction in 13.8% (1260/9115), and non-ischaemic myocardial injury in 30.8% (2810/9115). The underlying cause of non-ischaemic myocardial injury was cardiac in 47.8% (1335/2792) of patients and non-cardiac in the remainder. Compared with those identified by the contemporary assay, patients reclassified by the high sensitivity assay were more likely to have non-ischaemic myocardial injury (51.3% Duration of hospital stay was longer after implementation of the high sensitivity assay compared with standard care in reclassified patients (median 51 hours (interquartile range 20-134 hours) Compared with patients who received standard care, patients with type 1 myocardial infarction were more likely to receive dual antiplatelet therapy (62.2% At five years, 27.3% (13 179/48 282) of patients had a subsequent myocardial infarction or death from any cause. In all patients with suspected acute coronary syndrome, the primary outcome of subsequent myocardial infarction or death at five years occurred in 29.4% (5588/18 978) of patients before and 25.9% (7591/29 304) of patients after implementation of the high sensitivity assay (Outcomes after five years in participants stratified by peak cardiac troponin I level and study phase (standard care or after implementation of the high sensitivity assay). Values are number (percentage)Defined as Bleeding Academic Research Consortium type 3 or 5.Outcomes at five years in all patients before and after implementation of a high sensitivity cardiac troponin I assay. Forest plot shows the number (percentage) of patients in the standard care and implementation phases, and the hazard ratios for implementation versus standard care for the primary and secondary outcomes adjusted for hospital site, season, age, sex, and comorbidities (diabetes mellitus, previous myocardial infarction, and previous cerebrovascular disease). Whiskers represent 95% confidence intervalsAfter implementation of the high sensitivity assay, a reduction in subsequent myocardial infarction or death was observed in patients with non-ischaemic myocardial injury (0.83, 0.75 to 0.91) but not in those with type 1 or type 2 myocardial infarction (0.92, 0.83 to 1.01 and 0.98, 0.84 to 1.14), respectively (Cumulative incidence of myocardial infarction or all cause death in all patients stratified by index diagnosis of type 1 myocardial infarction (log rank test P=0.006), type 2 myocardial infarction (log rank test P=0.70), and non-ischaemic myocardial injury (log rank test P<0.001) during standard care and following implementation of a high sensitivity cardiac troponin I assay