Treating the troponin: adverse consequences of over-treatment of elevated troponin in non-coronary presentations.
Acute Coronary Syndrome
/ blood
Aged
Aged, 80 and over
Chest Pain
/ blood
Emergency Service, Hospital
/ statistics & numerical data
Female
Fibrinolytic Agents
/ therapeutic use
Humans
Male
Medical Overuse
/ statistics & numerical data
Middle Aged
Platelet Aggregation Inhibitors
/ therapeutic use
Prospective Studies
Risk Assessment
/ methods
Risk Factors
Troponin
/ blood
Troponin
acute coronary syndrome
intra-cranial haemorrhage
ticagrelor
Journal
Scottish medical journal
ISSN: 0036-9330
Titre abrégé: Scott Med J
Pays: Scotland
ID NLM: 2983335R
Informations de publication
Date de publication:
Feb 2019
Feb 2019
Historique:
pubmed:
15
11
2018
medline:
9
3
2019
entrez:
15
11
2018
Statut:
ppublish
Résumé
Anti-platelet and anti-thrombotic therapy are well-established treatments in acute coronary syndromes. Highly sensitive assays have diminished the positive predictive value of troponin in acute coronary syndromes and increased the importance of the clinical assessment in interpreting positive results. This cohort study sought to investigate over-treatment of non-coronary troponin rises and associated adverse outcomes. We reviewed 223 consecutive patients presenting to Queen Elizabeth University Hospital, Glasgow, with suspected acute coronary syndromes over a six-week period. Of these, 27 (12%) met our 'inappropriate therapy' criteria. This group had a low ischaemic risk (HEART score: 4.2 ± 1.4) (GRACE score: 117 ± 30.8) but an intermediate-high bleeding risk (CRUSADE score: 34 ± 14.5). Approximately half of the patients (14/27, 52%) reported chest pain, with only 4/27 (15%) having ischaemic ECG changes. There were three intracranial haemorrhages, each after the patient had received a single dose of aspirin, ticagrelor and fondaparinux. The combination of injudicious high-sensitivity troponin testing with potent anti-platelet and anti-thrombotic therapy was associated with possible over-treatment of patients and associated harm. Emphasis on interpretation of troponin in the context of clinical presentation and improved awareness of type 2 myocardial infarction are essential to limit iatrogenic pharmacological harm.
Sections du résumé
BACKGROUND AND AIMS
OBJECTIVE
Anti-platelet and anti-thrombotic therapy are well-established treatments in acute coronary syndromes. Highly sensitive assays have diminished the positive predictive value of troponin in acute coronary syndromes and increased the importance of the clinical assessment in interpreting positive results. This cohort study sought to investigate over-treatment of non-coronary troponin rises and associated adverse outcomes.
METHODS AND RESULTS
RESULTS
We reviewed 223 consecutive patients presenting to Queen Elizabeth University Hospital, Glasgow, with suspected acute coronary syndromes over a six-week period. Of these, 27 (12%) met our 'inappropriate therapy' criteria. This group had a low ischaemic risk (HEART score: 4.2 ± 1.4) (GRACE score: 117 ± 30.8) but an intermediate-high bleeding risk (CRUSADE score: 34 ± 14.5). Approximately half of the patients (14/27, 52%) reported chest pain, with only 4/27 (15%) having ischaemic ECG changes. There were three intracranial haemorrhages, each after the patient had received a single dose of aspirin, ticagrelor and fondaparinux.
CONCLUSION
CONCLUSIONS
The combination of injudicious high-sensitivity troponin testing with potent anti-platelet and anti-thrombotic therapy was associated with possible over-treatment of patients and associated harm. Emphasis on interpretation of troponin in the context of clinical presentation and improved awareness of type 2 myocardial infarction are essential to limit iatrogenic pharmacological harm.
Identifiants
pubmed: 30426853
doi: 10.1177/0036933018809754
doi:
Substances chimiques
Fibrinolytic Agents
0
Platelet Aggregation Inhibitors
0
Troponin
0
Types de publication
Journal Article
Langues
eng
Sous-ensembles de citation
IM