Peak Troponin and CMR to Guide Management in Suspected ACS and Nonobstructive Coronary Arteries

Matthew G.L. Williams; Estefania De Garate; Lucrezia Spagnoli; Emiliano Fiori; Amardeep Dastidar; Umberto Benedetto; Giovanni Biglino; Thomas W. Johnson; Thomas Luscher; Chiara Bucciarelli-Ducci

doi:10.1016/j.jcmg.2022.03.017

Peak Troponin and CMR to Guide Management in Suspected ACS and Nonobstructive Coronary Arteries

Matthew G.L. Williams, Estefania De Garate, Lucrezia Spagnoli, Emiliano Fiori, Amardeep Dastidar, Umberto Benedetto, Giovanni Biglino, Thomas W. Johnson, Thomas Luscher, Chiara Bucciarelli-Ducci^*

^*Corresponding author for this work

Research output: Contribution to journal › Article (Academic Journal) › peer-review

26 Citations (Scopus)

Abstract

Background: Patients presenting with acute coronary syndrome (ACS) and nonobstructive coronary arteries are a diagnostic dilemma. Cardiac magnetic resonance (CMR) has an overall diagnostic yield of ∼75%; however, in ∼25% of patients, CMR does not identify any myocardial injury. Identifying the underlying diagnosis has important clinical implications for patients’ management and outcome. Objectives: The authors sought to assess whether the combination of CMR and peak troponin levels in patients with ACS and nonobstructive coronary arteries would lead to increased diagnostic yield. Methods: Consecutive patients with ACS and nonobstructive coronary arteries without an obvious cause underwent CMR. The primary endpoint of the study was the diagnostic yield of CMR. The Youden index was used to find the optimal diagnostic cut point for peak troponin T to combine with CMR to improve diagnostic yield. Logistic or Cox regression models were used to estimate predictors of a diagnosis by CMR. Results: A total of 719 patients met the inclusion criteria. The peak troponin T threshold for optimal diagnostic sensitivity and specificity was 211 ng/L. Overall, CMR has a diagnostic yield of 74%. CMR performed <14 days from presentation and with a peak troponin of ≥211 ng/L (n = 198) leads to an improved diagnostic yield (94% vs 72%) compared with CMR performed ≥14 days (n = 245). When CMR was performed <14 days and with a peak troponin of <211 ng/L, the diagnostic yield was 76% (n = 86) compared with 53% (n = 190) when performed ≥14 days. An increase in 1 peak troponin decile increases the odds of the CMR identifying a diagnosis by 20% (OR: 1.20; P = 0.008, 95% CI: 1.05-1.36). Conclusions: The combination of CMR performed <14 days from presentation and peak troponin T ≥211 ng/L leads to a very high diagnostic yield (94%) on CMR. The diagnostic yield remains high (72%) even when CMR is performed ≥14 days from presentation, but reduces to 53% when peak troponin T was <211 ng/L.

Original language	English
Pages (from-to)	1578-1587
Number of pages	10
Journal	JACC: Cardiovascular Imaging
Volume	15
Issue number	9
Early online date	11 May 2022
DOIs	https://doi.org/10.1016/j.jcmg.2022.03.017
Publication status	Published - 5 Sept 2022

Bibliographical note

Funding Information:
Dr Bucciarelli-Ducci was in part supported by the National Institute for Health Research Biomedical Research Centre at University Hospitals Bristol NHS Foundation Trust and the University of Bristol; and is the Chief Executive Officer (part-time) of the Society for Cardiovascular Magnetic Resonance. The views expressed in this publication are those of the author(s) and not necessarily those of the NHS, the National Institute for Health Research, or the Department of Health and Social Care. The study was kindly supported by grants from the Rosetrees Trust, James Tudor Foundation and Above and Beyond Charitable Trust. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.

Publisher Copyright:
© 2022 American College of Cardiology Foundation

Keywords

ACS
acute myocarditis
CMR
MINOCA
takotsubo syndrome
troponin

Access to Document

10.1016/j.jcmg.2022.03.017

Handle.net

Persistent link

Cite this

@article{767f077f49ae413d9241cb66d6fe1561,

title = "Peak Troponin and CMR to Guide Management in Suspected ACS and Nonobstructive Coronary Arteries",

abstract = "Background: Patients presenting with acute coronary syndrome (ACS) and nonobstructive coronary arteries are a diagnostic dilemma. Cardiac magnetic resonance (CMR) has an overall diagnostic yield of ∼75%; however, in ∼25% of patients, CMR does not identify any myocardial injury. Identifying the underlying diagnosis has important clinical implications for patients{\textquoteright} management and outcome. Objectives: The authors sought to assess whether the combination of CMR and peak troponin levels in patients with ACS and nonobstructive coronary arteries would lead to increased diagnostic yield. Methods: Consecutive patients with ACS and nonobstructive coronary arteries without an obvious cause underwent CMR. The primary endpoint of the study was the diagnostic yield of CMR. The Youden index was used to find the optimal diagnostic cut point for peak troponin T to combine with CMR to improve diagnostic yield. Logistic or Cox regression models were used to estimate predictors of a diagnosis by CMR. Results: A total of 719 patients met the inclusion criteria. The peak troponin T threshold for optimal diagnostic sensitivity and specificity was 211 ng/L. Overall, CMR has a diagnostic yield of 74%. CMR performed <14 days from presentation and with a peak troponin of ≥211 ng/L (n = 198) leads to an improved diagnostic yield (94% vs 72%) compared with CMR performed ≥14 days (n = 245). When CMR was performed <14 days and with a peak troponin of <211 ng/L, the diagnostic yield was 76% (n = 86) compared with 53% (n = 190) when performed ≥14 days. An increase in 1 peak troponin decile increases the odds of the CMR identifying a diagnosis by 20% (OR: 1.20; P = 0.008, 95% CI: 1.05-1.36). Conclusions: The combination of CMR performed <14 days from presentation and peak troponin T ≥211 ng/L leads to a very high diagnostic yield (94%) on CMR. The diagnostic yield remains high (72%) even when CMR is performed ≥14 days from presentation, but reduces to 53% when peak troponin T was <211 ng/L.",

keywords = "ACS, acute myocarditis, CMR, MINOCA, takotsubo syndrome, troponin",

author = "Williams, {Matthew G.L.} and {De Garate}, Estefania and Lucrezia Spagnoli and Emiliano Fiori and Amardeep Dastidar and Umberto Benedetto and Giovanni Biglino and Johnson, {Thomas W.} and Thomas Luscher and Chiara Bucciarelli-Ducci",

note = "Funding Information: Dr Bucciarelli-Ducci was in part supported by the National Institute for Health Research Biomedical Research Centre at University Hospitals Bristol NHS Foundation Trust and the University of Bristol; and is the Chief Executive Officer (part-time) of the Society for Cardiovascular Magnetic Resonance. The views expressed in this publication are those of the author(s) and not necessarily those of the NHS, the National Institute for Health Research, or the Department of Health and Social Care. The study was kindly supported by grants from the Rosetrees Trust, James Tudor Foundation and Above and Beyond Charitable Trust. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose. Publisher Copyright: {\textcopyright} 2022 American College of Cardiology Foundation",

year = "2022",

month = sep,

day = "5",

doi = "10.1016/j.jcmg.2022.03.017",

language = "English",

volume = "15",

pages = "1578--1587",

journal = "JACC: Cardiovascular Imaging",

issn = "1936-878X",

publisher = "Elsevier Inc.",

number = "9",

}

TY - JOUR

T1 - Peak Troponin and CMR to Guide Management in Suspected ACS and Nonobstructive Coronary Arteries

AU - Williams, Matthew G.L.

AU - De Garate, Estefania

AU - Spagnoli, Lucrezia

AU - Fiori, Emiliano

AU - Dastidar, Amardeep

AU - Benedetto, Umberto

AU - Biglino, Giovanni

AU - Johnson, Thomas W.

AU - Luscher, Thomas

AU - Bucciarelli-Ducci, Chiara

N1 - Funding Information: Dr Bucciarelli-Ducci was in part supported by the National Institute for Health Research Biomedical Research Centre at University Hospitals Bristol NHS Foundation Trust and the University of Bristol; and is the Chief Executive Officer (part-time) of the Society for Cardiovascular Magnetic Resonance. The views expressed in this publication are those of the author(s) and not necessarily those of the NHS, the National Institute for Health Research, or the Department of Health and Social Care. The study was kindly supported by grants from the Rosetrees Trust, James Tudor Foundation and Above and Beyond Charitable Trust. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose. Publisher Copyright: © 2022 American College of Cardiology Foundation

PY - 2022/9/5

Y1 - 2022/9/5

N2 - Background: Patients presenting with acute coronary syndrome (ACS) and nonobstructive coronary arteries are a diagnostic dilemma. Cardiac magnetic resonance (CMR) has an overall diagnostic yield of ∼75%; however, in ∼25% of patients, CMR does not identify any myocardial injury. Identifying the underlying diagnosis has important clinical implications for patients’ management and outcome. Objectives: The authors sought to assess whether the combination of CMR and peak troponin levels in patients with ACS and nonobstructive coronary arteries would lead to increased diagnostic yield. Methods: Consecutive patients with ACS and nonobstructive coronary arteries without an obvious cause underwent CMR. The primary endpoint of the study was the diagnostic yield of CMR. The Youden index was used to find the optimal diagnostic cut point for peak troponin T to combine with CMR to improve diagnostic yield. Logistic or Cox regression models were used to estimate predictors of a diagnosis by CMR. Results: A total of 719 patients met the inclusion criteria. The peak troponin T threshold for optimal diagnostic sensitivity and specificity was 211 ng/L. Overall, CMR has a diagnostic yield of 74%. CMR performed <14 days from presentation and with a peak troponin of ≥211 ng/L (n = 198) leads to an improved diagnostic yield (94% vs 72%) compared with CMR performed ≥14 days (n = 245). When CMR was performed <14 days and with a peak troponin of <211 ng/L, the diagnostic yield was 76% (n = 86) compared with 53% (n = 190) when performed ≥14 days. An increase in 1 peak troponin decile increases the odds of the CMR identifying a diagnosis by 20% (OR: 1.20; P = 0.008, 95% CI: 1.05-1.36). Conclusions: The combination of CMR performed <14 days from presentation and peak troponin T ≥211 ng/L leads to a very high diagnostic yield (94%) on CMR. The diagnostic yield remains high (72%) even when CMR is performed ≥14 days from presentation, but reduces to 53% when peak troponin T was <211 ng/L.

AB - Background: Patients presenting with acute coronary syndrome (ACS) and nonobstructive coronary arteries are a diagnostic dilemma. Cardiac magnetic resonance (CMR) has an overall diagnostic yield of ∼75%; however, in ∼25% of patients, CMR does not identify any myocardial injury. Identifying the underlying diagnosis has important clinical implications for patients’ management and outcome. Objectives: The authors sought to assess whether the combination of CMR and peak troponin levels in patients with ACS and nonobstructive coronary arteries would lead to increased diagnostic yield. Methods: Consecutive patients with ACS and nonobstructive coronary arteries without an obvious cause underwent CMR. The primary endpoint of the study was the diagnostic yield of CMR. The Youden index was used to find the optimal diagnostic cut point for peak troponin T to combine with CMR to improve diagnostic yield. Logistic or Cox regression models were used to estimate predictors of a diagnosis by CMR. Results: A total of 719 patients met the inclusion criteria. The peak troponin T threshold for optimal diagnostic sensitivity and specificity was 211 ng/L. Overall, CMR has a diagnostic yield of 74%. CMR performed <14 days from presentation and with a peak troponin of ≥211 ng/L (n = 198) leads to an improved diagnostic yield (94% vs 72%) compared with CMR performed ≥14 days (n = 245). When CMR was performed <14 days and with a peak troponin of <211 ng/L, the diagnostic yield was 76% (n = 86) compared with 53% (n = 190) when performed ≥14 days. An increase in 1 peak troponin decile increases the odds of the CMR identifying a diagnosis by 20% (OR: 1.20; P = 0.008, 95% CI: 1.05-1.36). Conclusions: The combination of CMR performed <14 days from presentation and peak troponin T ≥211 ng/L leads to a very high diagnostic yield (94%) on CMR. The diagnostic yield remains high (72%) even when CMR is performed ≥14 days from presentation, but reduces to 53% when peak troponin T was <211 ng/L.

KW - ACS

KW - acute myocarditis

KW - CMR

KW - MINOCA

KW - takotsubo syndrome

KW - troponin

UR - http://www.scopus.com/inward/record.url?scp=85136552632&partnerID=8YFLogxK

U2 - 10.1016/j.jcmg.2022.03.017

DO - 10.1016/j.jcmg.2022.03.017

M3 - Article (Academic Journal)

C2 - 36075617

AN - SCOPUS:85136552632

SN - 1936-878X

VL - 15

SP - 1578

EP - 1587

JO - JACC: Cardiovascular Imaging

JF - JACC: Cardiovascular Imaging

IS - 9

ER -

Peak Troponin and CMR to Guide Management in Suspected ACS and Nonobstructive Coronary Arteries

Abstract

Bibliographical note

Keywords

Access to Document

Handle.net

Other files and links

Fingerprint

Cite this