Reliable Exclusion of Acute Coronary Syndrome Among Hospitalized Patients With Elevated Troponin

Background Elevated cardiac troponin I ( cTnI ) occurs in acute coronary syndrome ( ACS ) as well as various scenarios not associated with ACS . Hypothesis Simple clinical criteria can reliably exclude ACS among hospitalized patients with elevated cTnI. Methods Records for patients hospitalized from January to April 2011 with elevated cTnI (>0.29 ng/ dL ) and an available echocardiogram were retrospectively reviewed. Patients with ST ‐segment elevation myocardial infarction were excluded. Based on available clinical data, patients were classified as having ACS or elevation of cTnI unrelated to ACS (non‐ ACS ). Median follow‐up was 365 days. Results Of 265 records meeting inclusion criteria, 82 (31%) had ACS and 183 (69%) had non‐ ACS . In multivariable analysis, odds ratios for non‐ ACS were 7.6 (95% confidence interval [ CI ]: 3.8‐15.3) for peak cTnI <2 ng/ dL , 6.3 (95% CI : 3.1‐13.0) for absent wall‐motion abnormality, and 4.4 (95% CI : 2.2‐8.6) for no prior coronary artery disease history. The area under the receiver operating curve for a model using these 3 variables was 0.86, with a 98% negative predictive value for excluding ACS . Patients who met these 3 criteria had no ACS ‐related deaths over 1‐year follow‐up. Conclusions Hospitalized patients with peak Tn level <2 ng/ dL , no prior history of coronary artery disease, and no new echocardiographic wall‐motion abnormality appear to have a very low likelihood of ACS . Prospective validation of these results is needed to determine whether additional diagnostic testing could be safely avoided in hospitalized patients meeting these simple clinical criteria.