Sex and Race Differences in the Performance of the European Society of Cardiology 0/1-Hour Algorithm with High-Sensitivity Troponin T

Abstract

ABSTRACTBackgroundThe diagnostic performance of the high-sensitivity troponin T (hs-cTnT) European Society of Cardiology (ESC) 0/1-hour algorithm in sex and race subgroups is unclear, particularly in U.S. Emergency Department (ED) patients.MethodsA pre-planned subgroup analysis of the STOP-CP cohort study was conducted. Participants with 0- and 1-hour hs-cTnT measures (Roche Diagnostics; Basel, Switzerland), prospectively enrolled at eight U.S. EDs from 1/2017-9/2018, were stratified into rule-out, observation, and rule-in zones using the hs-cTnT ESC 0/1 algorithm. The primary outcome was adjudicated 30-day cardiac death or MI. Rates of patient stratification to each ESC 0/1 zone and the proportion with 30-day cardiac death or MI in each zone were compared between subgroups with Fisher’s-exact tests. The negative predictive value (NPV) of the ESC 0/1 rule-out zone for 30-day cardiac death or MI was calculated and compared between subgroups using Fisher’s exact tests.ResultsOf the 1422 patients enrolled, 54.2% (770/1422) were male and 58.1% (826/1422) white with a mean age of 57.6 ± 12.8 years. At 30 days, cardiac death or MI occurred in 12.9% (183/1422) of participants. The ESC 0/1-h algorithm ruled-out more women than men [66.9% (436/652) vs 50.0% (385/770); p<0.001] and a similar proportion of white vs non-white patients [59.3% (490/826) vs 55.5% (331/596); p=0.16]. Among patients stratified to the rule-out zone, 30-day cardiac death or MI occurred in 1.1% (5/436) of women vs 2.1% (8/436) of men (p=0.40) and 1.2% (4/331) of non-white patients vs 1.8% (9/490) of white patients (p=0.58). The NPV for 30-day cardiac death or MI was similar among women vs men [98.9% (95%CI 97.3-99.6) vs 97.9% (95%CI 95.9-99.1); p = 0.40] and among white vs non-white patients [98.8% (95%CI 96.9-99.7) vs 98.2% (95%CI 96.5-99.2); p=0.39].ConclusionsThe ESC 0/1-h hs-cTnT algorithm ruled-out more women than men, but achieved similar NPV for 30-day cardiac death or MI in all subgroups. NPVs <99% in each subgroup suggests the hs-cTnT ESC 0/1-h algorithm may not be safe for U.S. ED use.Trial RegistrationHigh-Sensitivity Cardiac Troponin T to Optimize Chest Pain Risk Stratification (STOP-CP; ClinicalTrials.gov:NCT02984436;https://clinicaltrials.gov/ct2/show/NCT02984436)What is KnownThe European Society of Cardiology high-sensitivity troponin T (hs-cTnT) 0/1-hour algorithm has been validated as a tool to rule-out myocardial infarction (MI).Evaluations of its performance differences based on sex and race are limited.What the Study AddsIn this multisite U.S. cohort study of 1422 adults, the high-sensitivity troponin T (hs-cTnT) ESC 0/1-hour algorithm had a similar NPV in men vs women and white vs non-white patients but did not achieve ≥99% NPV for 30-day cardiac death or MI in any subgroup.Emergency providers should be aware of the potential limitations of using the ESC 0/1-hour hs-cTnT algorithm for risk stratification because it may not satisfactorily exclude 30-day cardiac death or MI in any subgroup of ED patients (men, women, white patients, or non-white patients) with acute chest pain.