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Multicenter Study
. 2018 Feb;11(2):e004227.
doi: 10.1161/CIRCOUTCOMES.117.004227.

High-Sensitivity Cardiac Troponin I and the Diagnosis of Coronary Artery Disease in Patients With Suspected Angina Pectoris

Philip D Adamson  1 , Amanda Hunter  2 , Debbie M Madsen  2 , Anoop S V Shah  2 , David A McAllister  2 , Tania A Pawade  2 , Michelle C Williams  2 , Colin Berry  2 , Nicholas A Boon  2 , Marcus Flather  2 , John Forbes  2 , Scott McLean  2 , Giles Roditi  2 , Adam D Timmis  2 , Edwin J R van Beek  2 , Marc R Dweck  2 , Hans Mickley  2 , Nicholas L Mills  2 , David E Newby  2
Affiliations
Multicenter Study

High-Sensitivity Cardiac Troponin I and the Diagnosis of Coronary Artery Disease in Patients With Suspected Angina Pectoris

Philip D Adamson et al. Circ Cardiovasc Qual Outcomes. 2018 Feb.

Abstract

Background: We determined whether high-sensitivity cardiac troponin I can improve the estimation of the pretest probability for obstructive coronary artery disease (CAD) in patients with suspected stable angina.

Methods and results: In a prespecified substudy of the SCOT-HEART trial (Scottish Computed Tomography of the Heart), plasma cardiac troponin was measured using a high-sensitivity single-molecule counting assay in 943 adults with suspected stable angina who had undergone coronary computed tomographic angiography. Rates of obstructive CAD were compared with the pretest probability determined by the CAD Consortium risk model with and without cardiac troponin concentrations. External validation was undertaken in an independent study population from Denmark comprising 487 patients with suspected stable angina. Higher cardiac troponin concentrations were associated with obstructive CAD with a 5-fold increase across quintiles (9%-48%; P<0.001) independent of known cardiovascular risk factors (odds ratio, 1.35; 95% confidence interval, 1.25-1.46 per doubling of troponin). Cardiac troponin concentrations improved the discrimination and calibration of the CAD Consortium model for identifying obstructive CAD (C statistic, 0.788-0.800; P=0.004; χ2=16.8 [P=0.032] to 14.3 [P=0.074]). The updated model also improved classification of the American College of Cardiology/American Heart Association pretest probability risk categories (net reclassification improvement, 0.062; 95% confidence interval, 0.035-0.089). The revised model achieved similar improvements in discrimination and calibration when applied in the external validation cohort.

Conclusions: High-sensitivity cardiac troponin I concentration is an independent predictor of obstructive CAD in patients with suspected stable angina. Use of this test may improve the selection of patients for further investigation and treatment.

Clinical trial registration: URL: https://www.clinicaltrials.gov. Unique identifier: NCT01149590.

Keywords: angina, stable; cohort studies; coronary artery disease; humans; odds ratio.

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Conflict of interest statement

Disclosures

Singulex provided reagent, calibrators and controls without charge and undertook the analysis of cardiac troponin I. NLM has acted as a consultant for Abbott Laboratories, Beckman-Coulter, Roche and Singulex. All other authors have no conflicts of interest.

Figures

Figure 1
Figure 1. Cardiac troponin improves predicted risk of obstructive coronary artery disease in patients with suspected angina
The red dots represent the risk of obstructive CAD as estimated by the established CAD Consortium model accounting for age, sex and symptom description. The blue dots represent the revised risk estimates with the addition of cardiac troponin quintiles. The shaded regions correspond to the risk groups and associated recommendations for further investigations as described in the ACC/AHA guidelines on the management of stable CAD. CAD, coronary artery disease; ACC, American College of Cardiology; AHA, American Heart Association; hs-cTnI, high-sensitivity cardiac troponin I; ECG, electrocardiography; y, years.
Figure 2
Figure 2. Model calibration within the external validation cohort
Plot demonstrates poor calibration of predicted probability vs observed proportion of obstructive coronary artery disease using the established CADC model (blue). Good model calibration is demonstrated within the validation cohort following the addition of troponin to the CADC model (red). The dashed line represents perfect calibration. CADC, Coronary Artery Disease Consortium; HL, Hosmer-Lemeshow.
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