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



Khand, Aleem, Frost, Freddy, Grainger, Ruth, Fisher, Michael, Chew, Pei, Mullen, Liam, Patel, Billal, Obeidat, Mohammed, Albouaini, Khaled and Dodd, James
(2020) Identification of high-risk non-ST elevation myocardial infarction at presentation to emergency department. A prospective observational cohort study in North West England. BMJ open, 10 (6). e030128-e030128.

[thumbnail of Identification.pdf] Text
Identification.pdf - Published version

Download (497kB) | Preview

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.

Item Type: Article
Uncontrolled Keywords: myocardial infarction, coronary heart disease, accident & emergency medicine
Depositing User: Symplectic Admin
Date Deposited: 23 Jun 2020 08:03
Last Modified: 26 Jan 2023 01:52
DOI: 10.1136/bmjopen-2019-030128
Related URLs:
URI: https://livrepository.liverpool.ac.uk/id/eprint/3091380