Background: Stable angina is the most common symptom of stable coronary artery disease (sCAD), typically occurring during physical exertion or emotional stress. At present, diagnosis relies on imaging. However, there has been growing interest in the use of high-sensitivity cardiac troponin (hs-cTn) assays to identify patients with such low probability of sCAD that the diagnosis can be considered 'ruled out'. Objective: The overall aim was to explore the role of high-sensitivity cardiac troponin in ruling out sCAD without imaging. My specific objectives were to: (a) systematically review the literature on this topic; (b) evaluate the diagnostic accuracy of two different hs-cTn assays for stable sCAD; and (c) evaluate the diagnostic accuracy of the hs-cTn assays when used in combination with widely used risk scores for sCAD. Methods: To systematically review the literature, two individuals searched two databases and identified relevant papers. Data were extracted and synthesized in a narrative way. A prospective diagnostic test accuracy study was undertaken, including participants attending clinic with suspected stable angina. All patients had blood drawn for hs-cTn and underwent imaging in accordance with routine practice. Samples were tested for two hs-cTn assays (Roche hs-cTnT and Abbott hs-cTnI). Data were collected to calculate several risk scores including Diamond-Forrester and Coronary Artery Disease Consortium (CAD-C). Results: The systematic review identified 570 relevant papers evaluating three hs-cTn assays. In summary, hs-cTn assays alone were insufficiently sensitive to rule-out sCAD, although authors had not consistently evaluated the lowest possible cutoff to maximise sensitivity. Early evidence suggests that combining hs-cTn with risk scores could achieve high negative predictive value. The prospective study recruited 306 participants. This identified that hs-cTnT (cutoff 3ng/L) had a sensitivity of 82.6% (95% CI 71.6% â 90.7%) for sCAD; whereas hs-cTnI had a sensitivity of 65.7% (95% 53.1% - 76.9%). Of the risk scores evaluated, Diamond-Forrester had the highest sensitivity, achieving 95.5% (87.3% - 99.1%) when used alone. Adding hs-cTn to Diamond-Forrester achieved a sensitivity of 98.6% (95% CI 92.3% - 100 %) for hs-cTnT and 96.8% (95% CI 88.8 - 100%) for hs-cTnI. Conclusion: Neither hs-cTnT (Roche) nor hs-cTnI (Abbott) could rule-out sCAD when used alone. The Diamond-Forrester risk score had higher sensitivity. Combining risk scores and hs-cTn gave slightly higher sensitivity still, but the added value of troponin was small. Future research should focus on alternative biomarkers and improving risk scores in patients with suspected sCAD.
Date of Award | 1 Aug 2024 |
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Original language | English |
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Awarding Institution | - The University of Manchester
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Supervisor | Farzin Fath-Ordoubadi (Supervisor), Rick Body (Supervisor) & Reza Aghamohammadzadeh (Supervisor) |
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- Diagnosis
- Stable coronary artery disease
- Stable angina
- High-sensitivity cardiac troponin T
- Cardiac troponin
- High-sensitivity cardiac troponin I
High sensitivity Cardiac troponin to rule-out stable coronary artery disease
Ismael, A. H. (Author). 1 Aug 2024
Student thesis: Phd