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Abstract
We determined whether high-sensitivity cardiac troponin I can improve the estimation of the pretest probability for obstructive coronary artery disease (CAD) in patients with suspected stable angina. In a prespecified substudy of the SCOT-HEART trial (Scottish Computed Tomography of the Heart), plasma cardiac troponin was measured using a high-sensitivity single-molecule counting assay in 943 adults with suspected stable angina who had undergone coronary computed tomographic angiography. Rates of obstructive CAD were compared with the pretest probability determined by the CAD Consortium risk model with and without cardiac troponin concentrations. External validation was undertaken in an independent study population from Denmark comprising 487 patients with suspected stable angina. Higher cardiac troponin concentrations were associated with obstructive CAD with a 5-fold increase across quintiles (9%-48%; P<0.001) independent of known cardiovascular risk factors (odds ratio, 1.35; 95% confidence interval, 1.25-1.46 per doubling of troponin). Cardiac troponin concentrations improved the discrimination and calibration of the CAD Consortium model for identifying obstructive CAD (C statistic, 0.788-0.800; P=0.004; χ2=16.8 [P=0.032] to 14.3 [P=0.074]). The updated model also improved classification of the American College of Cardiology/American Heart Association pretest probability risk categories (net reclassification improvement, 0.062; 95% confidence interval, 0.035-0.089). The revised model achieved similar improvements in discrimination and calibration when applied in the external validation cohort. High-sensitivity cardiac troponin I concentration is an independent predictor of obstructive CAD in patients with suspected stable angina. Use of this test may improve the selection of patients for further investigation and treatment. URL: https://www.clinicaltrials.gov. Unique identifier: NCT01149590.
Highlights
Presentations with suspected stable angina are common yet determining an accurate diagnosis is frequently challenging
The updated model improved classification of the American College of Cardiology/American Heart Association pretest probability risk categories
High-sensitivity cardiac troponin I concentration is an independent predictor of obstructive coronary artery disease in patients with suspected stable angina
Summary
Presentations with suspected stable angina are common yet determining an accurate diagnosis is frequently challenging. Of equal importance, is the concern that these symptoms may reflect prognostically significant atherosclerotic disease with the associated risk of future cardiovascular events. These concerns are appropriate given that 1 in 6 patients will suffer coronary death or non-fatal acute coronary syndrome in the 3 years following a diagnosis of stable angina [1]. This risk remains substantial even in those patients with symptoms deemed non-cardiac in origin [1]. We determined whether high-sensitivity cardiac troponin I can improve the estimation of the pre-test probability for obstructive coronary artery disease in patients with suspected stable angina
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