0
We're unable to sign you in at this time. Please try again in a few minutes.
Retry
We were able to sign you in, but your subscription(s) could not be found. Please try again in a few minutes.
Retry
There may be a problem with your account. Please contact the AMA Service Center to resolve this issue.
Contact the AMA Service Center:
Telephone: 1 (800) 262-2350 or 1 (312) 670-7827  *   Email: subscriptions@jamanetwork.com
Error Message ......
Research Letter |

The Diagnostic Yield of Cardiac Catheterization in Low-Risk Troponinemia FREE

Benjamin Stripe, MD1; Stephen Rechenmacher, MD1; Daniel Jurewitz, MD2; Cody Lee, BS5; Saul Schaefer, MD3,4
[+] Author Affiliations
1Department of Internal Medicine, University of California, Davis (UC Davis)
2Division of Cardiovascular Medicine, Department of Internal Medicine, UC Davis
3Division of Cardiovascular Medicine and Cardiology Section, Department of Internal Medicine, UC Davis
4Department of Veteran Affairs, VA Northern California Health Care System, Mather
5medical student at UC Davis School of Medicine
JAMA Intern Med. 2013;173(22):2088-2090. doi:10.1001/jamainternmed.2013.11109.
Text Size: A A A
Published online

Serum cardiac troponin I (cTnI) is a sensitive indicator of myocardial necrosis.1 However, many disease states can result in an elevated cTnI level without clinical evidence of myocardial infarction,2 resulting in possible misdiagnosis of epicardial coronary artery disease (CAD).3 In the present study, we investigated the prevalence of CAD and associated patient characteristics in patients with mildly elevated cTnI levels without clinical evidence of acute coronary syndrome.

This study was approved by the institutional review board of the University of California, Davis. All patients had agreed to the use of their medical records for research purposes.

This was a single center, retrospective cohort study that examined patients 18 years or older who presented with a peak cTnI level between 0.05 ng/mL (>99th percentile of normal population) and 2 ng/mL (nanograms per milliliter to micrograms per liter is a 1-to1 conversion)within 30 days prior to coronary angiography. Patients were excluded if they had chest pain with cardiac features, a history of known CAD, or ischemic changes on electrocardiography or stress test.

Baseline characteristics recorded included age, sex, history of heart failure, diabetes, dyslipidemia, peripheral vascular disease, lung disease, smoking, kidney disease, hypertension, and pulmonary hypertension, as well as data related to the index episode such as level of peak troponin, B-type natriuretic peptide (BNP) level, left ventricular ejection fraction, and hemoglobin and serum creatinine levels.

The primary end point was the presence of significant CAD, defined as 50% or greater left main stenosis, 70% or greater stenosis of another epicardial coronary artery, or fractional flow reserve of less than 0.8. Secondary end points were revascularization by percutaneous coronary intervention or coronary artery bypass grafting. The final presumed cause of elevated troponin level was also assessed.

Of 140 patients, 16 (11%) were found to have significant CAD. Of these patients, 12 underwent revascularization, 10 with percutaneous coronary intervention and 2 via coronary artery bypass grafting. Patients with CAD were older (P = .006), with none younger than 49 years. Patients with CAD were more likely to have a presenting symptom of syncope (P = .02) or have evidence of a new arrhythmia (P = .003 by univariate analysis and P = .03 after multiple regression analysis) (Table 1). Patients with diabetes were more likely to have CAD (P = .01) by univariate analysis. A history of stroke was associated with CAD, but only after multiple regression analysis (P = .04). Notably, factors such as sex, smoking history, heart failure, dyslipidemia, and hypertension were not associated with CAD.

The majority of patients (58.9%) without significant CAD had an elevated troponin level associated with heart failure (Table 2). Fluid or pressure overload states—including heart failure, hypertensive emergency, pulmonary hypertension, hypertrophic cardiomyopathy, or significant aortic valve disease—accounted for 81.5% of the patients without CAD. Other causes of “troponinemia” included increased oxygen demand due to infection, tachycardia, or sympathomimetic abuse such as cocaine or methamphetamine.

Table Graphic Jump LocationTable 2.  Common Causes of Troponinemia in Patients Without Significant Coronary Artery Disease

The use of sensitive biomarkers such as cTnI is becoming more widespread, with as many as 50% of hospitalized patients having a troponin test ordered during their hospitalization.4 Given the need to limit ineffective medical testing and associated costs and risks of cardiac catheterization (estimated at a complication rate of approximately 1.7%5 and $5000 for an outpatient procedure6), it is imperative to appropriately triage patients with low-level elevations of troponin in the absence of clinical acute coronary syndrome. Some of the risk factors identified by this study were diabetes, age, chronic kidney disease, and disease of other vascular beds; however, in this population, other risk factors such as syncope and supraventricular tachyarrhythmia appear to confer increased risk as well. Appropriate management of patients with low-level elevations of troponin should consider the pretest probability of CAD and the likelihood that most patients in this population do not have significant CAD.

Corresponding Author: Saul Schaefer, MD, Division of Cardiovascular Medicine and Cardiology Section, Department of Internal Medicine, University of California Davis, One Shields Ave, Davis, CA 95616 (sschaefer@ucdavis.edu).

Published Online: October 7, 2013. doi:10.1001/jamainternmed.2013.11109.

Author Contributions: Dr Schaefer had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: Rechenmacher, Jurewitz, Schaefer.

Acquisition of data: Stripe, Rechenmacher, Jurewitz, Lee, Schaefer.

Analysis and interpretation of data: Stripe, Rechenmacher, Schaefer.

Drafting of the manuscript: Stripe, Rechenmacher, Schaefer.

Critical revision of the manuscript for important intellectual content: Stripe, Rechenmacher, Jurewitz, Lee, Schaefer.

Statistical analysis: Stripe, Rechenmacher, Lee.

Administrative, technical, or material support: Rechenmacher, Schaefer.

Study supervision: Rechenmacher, Jurewitz, Schaefer.

Funding/Support: The project described was supported by the National Center for Advancing Translational Sciences, National Institutes of Health, through grant #UL1 TR000002.

Role of the Sponsor: The funding agency had no role in design and conduct of the study; in the collection, analysis, and interpretation of the data; or in the preparation, review, or approval of the manuscript.

Additional Contributions: Blythe Durbin-Johnson, PhD, provided statistical analysis. Ayan Patel, MS, performed set up of the REDCap database. Neither was compensated for their work on this project, but they were paid by the sponsor to provide statistical support.

Reichlin  T, Twerenbold  R, Reiter  M,  et al.  Introduction of high-sensitivity troponin assays: impact on myocardial infarction incidence and prognosis. Am J Med. 2012;125(12):1205-1213.
PubMed   |  Link to Article
De Gennaro  L, Brunetti  ND, Cuculo  A,  et al.  Increased troponin levels in nonischemic cardiac conditions and noncardiac diseases. J Interv Cardiol. 2008;21(2):129-139.
PubMed   |  Link to Article
Melanson  SE, Conrad  MJ, Mosammaparast  N, Jarolim  P.  Implementation of a highly sensitive cardiac troponin I assay: test volumes, positivity rates and interpretation of results. Clin Chim Acta. 2008;395(1-2):57-61.
PubMed   |  Link to Article
Seto  A, Tehrani  D.  Troponins should be confirmed with CK-MB in atypical presentations. J Am Coll Cardiol. 2013;61(13):1467-1468.
PubMed   |  Link to Article
Scanlon  PJ, Faxon  DP, Audet  AM,  et al.  ACC/AHA guidelines for coronary angiography: a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines (Committee on Coronary Angiography): developed in collaboration with the Society for Cardiac Angiography and Interventions. J Am Coll Cardiol. 1999;33(6):1756-1824.
PubMed   |  Link to Article
Healthcare Blue Book. 2013. http://www.healthcarebluebook.com. Accessed May 13, 2013.

Figures

Tables

Table Graphic Jump LocationTable 2.  Common Causes of Troponinemia in Patients Without Significant Coronary Artery Disease

References

Reichlin  T, Twerenbold  R, Reiter  M,  et al.  Introduction of high-sensitivity troponin assays: impact on myocardial infarction incidence and prognosis. Am J Med. 2012;125(12):1205-1213.
PubMed   |  Link to Article
De Gennaro  L, Brunetti  ND, Cuculo  A,  et al.  Increased troponin levels in nonischemic cardiac conditions and noncardiac diseases. J Interv Cardiol. 2008;21(2):129-139.
PubMed   |  Link to Article
Melanson  SE, Conrad  MJ, Mosammaparast  N, Jarolim  P.  Implementation of a highly sensitive cardiac troponin I assay: test volumes, positivity rates and interpretation of results. Clin Chim Acta. 2008;395(1-2):57-61.
PubMed   |  Link to Article
Seto  A, Tehrani  D.  Troponins should be confirmed with CK-MB in atypical presentations. J Am Coll Cardiol. 2013;61(13):1467-1468.
PubMed   |  Link to Article
Scanlon  PJ, Faxon  DP, Audet  AM,  et al.  ACC/AHA guidelines for coronary angiography: a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines (Committee on Coronary Angiography): developed in collaboration with the Society for Cardiac Angiography and Interventions. J Am Coll Cardiol. 1999;33(6):1756-1824.
PubMed   |  Link to Article
Healthcare Blue Book. 2013. http://www.healthcarebluebook.com. Accessed May 13, 2013.

Correspondence

CME
Also Meets CME requirements for:
Browse CME for all U.S. States
Accreditation Information
The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.
Note: You must get at least of the answers correct to pass this quiz.
Please click the checkbox indicating that you have read the full article in order to submit your answers.
Your answers have been saved for later.
You have not filled in all the answers to complete this quiz
The following questions were not answered:
Sorry, you have unsuccessfully completed this CME quiz with a score of
The following questions were not answered correctly:
Commitment to Change (optional):
Indicate what change(s) you will implement in your practice, if any, based on this CME course.
Your quiz results:
The filled radio buttons indicate your responses. The preferred responses are highlighted
For CME Course: A Proposed Model for Initial Assessment and Management of Acute Heart Failure Syndromes
Indicate what changes(s) you will implement in your practice, if any, based on this CME course.
Submit a Comment

Multimedia

Some tools below are only available to our subscribers or users with an online account.

Related Content

Customize your page view by dragging & repositioning the boxes below.

Articles Related By Topic
Related Collections
PubMed Articles
JAMAevidence.com

The Rational Clinical Examination
Accuracy of the Examination for Aortic Regurgitation