Outcomes in ED patients with non-specific ECG findings and low high-sensitivity troponin.
Abstract
<h4>Background</h4>Although some emergency department risk stratification tools consider
non-specific ECG findings as an aid in disposition decisions, their clinical value
in patients with an initially low high-sensitivity cardiac troponin I (hsTnI) is unclear.<h4>Objective</h4>Our
purpose was to determine if non-specific ECG (ns-ECG) findings are associated with
30-day major adverse cardiac events (MACE) in ED patients presenting with suspected
acute coronary syndromes (ACS) who have a low initial hsTnI.<h4>Methods</h4>Using
the prospective Siemens Atellica hsTnI Food and Drug Administration submission observational
database, we conducted a retrospective cohort study of the association between ns-ECG
findings (defined as left bundle branch block [LBBB], ST depression [STD], or T-wave
inversions [TWI]) and 30-day MACE (death, myocardial infarction, heart failure hospitalization,
or coronary revascularization). Eligible patients presented with suspected ACS to
one of 29 US EDs from April 2015 to April 2016, had stable vital signs, a blood sample
for hsTnI (Siemen's Atellica, Siemens Healthineers, Inc, Malvern, PA) obtained at
1, 3, and 6 hours after ED presentation, and were followed for 30 days. The relationship
between 30-day outcome, initial hsTnI, and ns-ECG was evaluated using chi-square testing.<h4>Results</h4>Of
2676 enrolled, 1313 patients met the inclusion criteria and are included in the analysis.
Median (interquartile range) age was 62 years (54, 72), 54% were male, with 56% white,
and 39% African American. Median (interquartile range) times from symptom onset to
presentation and presentation to specimen collection were 92 (0, 216) and 146 (117,
177) minutes, respectively. The most common presenting symptoms were chest pain (84%),
followed by dyspnea (9%). ECG findings were categorized as T-wave inversion or non-specific
T wave changes (42%), ST depression ns-ECG ST changes (16%), or LBBB (2%). Thirty-day
MACE occurred in 72 (5.5%) patients, with coronary revascularization (35 patients,
2.7%) and heart failure (25 patients, 1.9%) being the most frequent outcomes. In patients
with an initial hsTnI below the limit of quantitation (LOQ) of 2.5 ng/L (n = 449),
there was no association between ns-ECG changes and 30-day MACE (P = 0.42). If the hsTnI was ≥LOQ (2.5 ng/L), there were increased rates of 30-day MACE
and ns-ECG findings (P = 0.01).<h4>Conclusion</h4>In ED suspected ACS patients without unstable vital signs,
and an initial hsTnI less than the LOQ (2.5 ng/L), ns-ECG findings are not associated
with 30-day major adverse cardiac events. The use of ns-ECG findings in ACS disposition
should be considered in the context of hsTnI levels.
Type
Journal articleSubject
ACSEmergency
High‐sensitivity cardiac troponin
LBBB
MACE
ST depressions
T‐wave inversions
hsTnI
non‐specific ECG findings
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https://hdl.handle.net/10161/26300Published Version (Please cite this version)
10.1002/emp2.12844Publication Info
Alshaikh, Lamees M; Apple, Fred S; Christenson, Robert H; deFilippi, Christopher R;
Limkakeng, Alexander T; McCord, James; ... Peacock, W Frank (2022). Outcomes in ED patients with non-specific ECG findings and low high-sensitivity troponin.
Journal of the American College of Emergency Physicians open, 3(6). pp. e12844. 10.1002/emp2.12844. Retrieved from https://hdl.handle.net/10161/26300.This is constructed from limited available data and may be imprecise. To cite this
article, please review & use the official citation provided by the journal.
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Show full item recordScholars@Duke
Alexander Tan Limkakeng Jr.
Professor of Emergency Medicine
Dr. Alexander T. Limkakeng, Jr., MD, MHSc, FACEP is a Professor of Emergency Medicine,
Vice Chair of Clinical Research, Director of the Acute Care Research Team, and Director
of the Resident Research Fellowship for the Department of Emergency Medicine in the
Duke University School of Medicine in Durham, North Carolina.
Dr. Limkakeng has served as chair of the American College of Emergency Physicians
(ACEP) Research Committee, and been the Course Directo

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