https://doi.org/10.1177/2048872620907539 European Heart Journal: Acute Cardiovascular Care 2020, Vol. 9(6) 567–575 © The European Society of Cardiology 2020 Article reuse guidelines: sagepub.com/journals-permissions DOI: 10.1177/2048872620907539 journals.sagepub.com/home/acc Introduction Decision making in acute chest pain is challenging. As one of the most frequent causes of emergency department vis- its, rapid and safe discharge of low-risk patients is crucial. Troponin concentrations below the upper reference limit measured (the 99th percentile) are commonly regarded as normal. Though these normal concentrations at arrival imply a potential low risk, yet some patients have a non- negligible risk of events despite normal troponin. 1,2 Undetectable high-sensitivity troponin in combination with clinical assessment for risk stratification of patients with chest pain and normal troponin at hospital arrival Juan Sanchis 1 , Ernesto Valero 1 , Sergio García Blas 1 , Esther Barba 2 , Vicente Pernias 1 , Gema Miñana 1 , José Brasó 3 , Agustín Fernandez-Cisnal 1 , Jessika Gonzalez 1 , José Noceda 3 , Arturo Carratalá 2 , Francisco J Chorro 1 , Julio Núñez 1 and John W Pickering 4 Abstract Background Undetectable high-sensitivity cardiac troponin (hs-cTn) in a single determination upon admission may rule out acute coronary syndrome. We investigated undetectable hs-cTnT (<detection limit; <5 ng/l) together with clinical risk scores (GRACE, TIMI, HEART and a previously published simple score), for one-year outcomes in patients with chest pain and normal hs-cTnT (<99th percentile; <14 ng/l) upon admission. Methods This study was a retrospective design involving 2254 consecutive patients (July 2016–November 2017). The primary endpoint was one-year death or acute myocardial infarction; the secondary endpoint added unstable angina requiring revascularization. Early (<90 minutes since pain onset, n = 661) and late (n = 1593) presenters were separately considered. Results A total of 56 (2.5%) patients reached the primary endpoint and 91 (4%) the secondary endpoint. Undetectable hs-cTnT had a poor C-statistic in early and late presenters (0.648 and 0.703, respectively). Adding hs-cTnT measurable concentrations above the detection limit (as continuous variable) significantly enhanced the C-statistics (0.754 and 0.847, respectively). Addition of the HEART (0.809, p = 0.005) or simple clinical scores (0.804, p = 0.02) further improved the model and significantly reclassified patient risk, in early presenters. The results were similar for the secondary endpoint. The TIMI risk score performed worse and the GRACE score did not give additional information. In late presenters, no clinical score provided significant additional information over hs-cTnT. Conclusions Diagnostic algorithms should consider not only whether hs-cTnT is above or below the detection limit but also its concentration if above, for risk stratification over one year in patients with initial normal hs-cTnT. The clinical scores provide valuable additional information in early presenters. Keywords Acute coronary syndrome, chest pain, high-sensitivity troponin, clinical scores Date received: 12 August 2019; accepted: 29 January 2020 1 Servei de Cardiologia, Hospital Clínic Universitari de València, INCLIVA, Universitat de València, CIBERCV, Spain 2 Servei de Bioquímica Clínica, Hospital Clínic Universitari de València, Spain 3 Servei d’Urgències Mèdiques, Hospital Clínic Universitari de València, Spain 4 Department of Medicine, University of Otago Christchurch, New Zealand Corresponding author: Juan Sanchis, Servei de Cardiologia, Hospital Clínic Universitari, Blasco Ibáñez 17, València, 46010, Spain. Email: sanchis_juafor@gva.es 907539ACC European Heart Journal: Acute Cardiovascular CareSanchis et al. Original scientific paper Downloaded from https://academic.oup.com/ehjacc/article/9/6/567/6125569 by guest on 06 December 2022