Highly sensitive troponin I assay in the diagnosis of coronary artery disease in patients with suspected stable angina

Abstract

Background: Evaluation of suspected stable angina patients with probable coronary artery disease (CAD) in the community is challenging. In the United Kingdom, patients with suspected stable angina are referred by community physicians to be assessed by specialists within the hospital system in rapid access chest pain clinics (RACPC). The role of a highly sensitive troponin I (uscTnI) assay in the diagnosis of suspected CAD in a RACPC in a "real-life" setting in a non-academic hospital has not been explored.

Aim: To examine the diagnostic value of uscTnI (detection limit 0.12 ng/L, upper reference range 8.15 ng/L, and detected uscTnI in 96.8% of the reference population), in the evaluation of stable CAD in a non-selected patient group, with several co-morbidities, who presented to the RACPC.

Methods: One hundred and seventy two RACPC patients were assigned to either functional or anatomical testing according to the hospital protocol.

Results: The investigations offered to patients were exercise tolerance test 7.6%, 24 h ECG 1.2%, Echocardiogram 14.5%, stress echocardiogram 8.1%, coronary computed tomography angiography (CCTA) 12.8%, coronary angiogram 13.4%, 17.4% were diagnosed with non-cardiac chest pain, 3.5% treated as stable angina, 8.2% reviewed by cardiologists, electronic medical records were not available in 10.4%. Receiver operating characteristic curves for CAD used uscTnI values measured in patients who underwent functional testing, angiogram or CCTA. Values > 0.52 ng/L showed 100% sensitivity and at > 11.6 ng/L showed 100% specificity. In the range > 0.52-11.6 ng/L, uscTnI may not have the same diagnostic potential. In patients assigned to coronary angiogram higher concentrations of uscTnI was associated with severe CAD. Low levels of uscTnI and low pre-test probability of CAD (QRISK3) may decrease patient numbers assigned to CCTA.

Conclusion: The uscTnI diagnostic cut-off values in a RACPC will depend on patient population and their presenting co-morbidity. In the presence of clinical comorbidities and previous CAD the uscTnI needs to be used in conjunction with clinical assessment.

Keywords: Coronary angiogram; Coronary artery disease; Coronary computed tomography angiography; Rapid access chest pain clinic; Suspected stable angina; Troponin I.