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In a Hot Line presentation yesterday, Professor Nicholas Mills (University of Edinburgh, Edinburgh, UK) revealed one-year outcomes data from the High-Sensitivity Troponin in the Evaluation of patients with Acute Coronary Syndrome (High-STEACS) trial.(1)
This was a stepped-wedge cluster randomised controlled trial that evaluated the implementation of the ARCHITECTSTAT high-sensitivity cardiac troponin I (hs-cTnI) assay using the sex-specific 99th centile (34 ng/L for men, 16 ng/mL for women) as a diagnostic threshold in 48,282 consecutive patients with suspected acute coronary syndrome from 10 secondary and tertiary care hospitals across Scotland. The primary endpoint of myocardial infarction (MI) or cardiovascular death at one year was compared in patients reclassified as having myocardial injury by the hs-cTnl assay before and after implementation.
Prof. Mills says, “The trial found that implementation of a high-sensitivity cTnl using the 99th centile as the diagnostic threshold increased the frequency of patients with myocardial injury; but only a third had a diagnosis of MI, and implementation was not associated with lower rates of subsequent MI or cardiovascular death at one year.” He continues, “The findings were surprising. But it was encouraging that there was no evidence of misdiagnosis, inappropriate treatment, excess bleeding or harm. Indeed, the length of stay across the trial population was reduced by almost a third suggesting that use of the high-sensitivity test increased the confidence of clinicians to rule out heart disease, with benefits for health service providers.” When discussing next steps, Prof. Mills concludes, “These results are controversial because they suggest that the Universal Definition of Myocardial Infarction needs to move away from a binary threshold to diagnose and guide treatment for MI. It is now up to the research community to find a superior approach.”
1. Shah ASV, et al. Lancet 2018;august28:doi:10.1016/s0140-6736(18)31923-8.
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