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Who Should be Considered for Testing Beyond hs-cTn ?

James McCord MDHenry Ford Heart & Vascular

InstituteFeb 26 2020

Disclosures

• Consultant: Roche, Siemens• Research Support: Roche, Siemens,

Abbott, Beckman

Answer

1. Pts not low risk with very low hs-cTnat time 0, or rule-out by 0/1-hr algorithm

2. Those not low risk by low hs-cTn with a risk score

Bottom Line: Large % can/should go home for out-patient follow-up

HIGH-US Trial < LOD

HIGH-US Trial

• 29 US Hospitals• 2,212 patients• 259 (12%) AMIs

JACC 2019

Time 0 hs-cTnI < LOD (2 ng/L)

JACC 2019

Ann Emerg Med Feb 2020

3 Missed AMIs

30-Day Death/AMI

Rule-Out Group: 30-Day Death/AMI 2 (0.2%)

COMPASS-MI Project

COMPASS-MI

Combined 15 International Trialshs-cTnI and hs-cTnT22,651 patients

NEJM 2019

COMPASS-MI

NEJM 2019

hs-cTnT and CTA

124 patients 256-slice CTA hs-cTnT measurements Coronary calcification, stenosis, non-

calcified plaque volume, plaque composition ( soft or calcified), vascular remodeling

Heart 2011;97:823-831

CTA & hs-cTnT

HEART 2011

European Society of Cardiology 2020

Intermediate hs-cTn

• Those that do not meet 0/1-hr algorithm as low risk

• But are still < 99th%• Risk scores can be applied here

• 8,474 pts• cTn < 99th% over 3 hrs• 30-day MACE (death/AMI): 0.4%

Circulation. 2018;138:2456-2468

Potential Harm

• Medical Radiation Exposure

ROMICAT-II

N ENGL J MED 357:22:2007

Estimate 1.5-2.0% of cancers from CT Scans

Controversy/Caution

• Symptoms < 3 hrs 0/1-hr algorithm• Many studies only CP pts• Role of ECG in 0/1-hr algorithm• Role of history in 0/1-hr algorithm

Conclusion

1. Rule-out 0/1-hr algorithm no test2. Intermediate hs-cTn apply risk score

and no test if low-risk3. Not low risk: Echo, CTA, Stress Test ?4. Radiation exposure should be

considered

JMCCORD1@HFHS.ORG

THANKS