Sex-Specific Thresholds of High-Sensitivity Troponin in Patients With Suspected Acute Coronary Syndrome

High-STEACS investigators

doi:10.1016/j.jacc.2019.07.082

Sex-Specific Thresholds of High-Sensitivity Troponin in Patients With Suspected Acute Coronary Syndrome

High-STEACS investigators

Laboratory Medicine and Pathology

Research output: Contribution to journal › Article › peer-review

99 Scopus citations

Abstract

Background: Major disparities between women and men in the diagnosis, management, and outcomes of acute coronary syndrome are well recognized. Objectives: The aim of this study was to evaluate the impact of implementing a high-sensitivity cardiac troponin I assay with sex-specific diagnostic thresholds for myocardial infarction in women and men with suspected acute coronary syndrome. Methods: Consecutive patients with suspected acute coronary syndrome were enrolled in a stepped-wedge, cluster-randomized controlled trial across 10 hospitals. Myocardial injury was defined as high-sensitivity cardiac troponin I concentration >99th centile of 16 ng/l in women and 34 ng/l in men. The primary outcome was recurrent myocardial infarction or cardiovascular death at 1 year. Results: A total of 48,282 patients (47% women) were included. Use of the high-sensitivity cardiac troponin I assay with sex-specific thresholds increased myocardial injury in women by 42% and in men by 6%. Following implementation, women with myocardial injury remained less likely than men to undergo coronary revascularization (15% vs. 34%) and to receive dual antiplatelet (26% vs. 43%), statin (16% vs. 26%), or other preventive therapies (p < 0.001 for all). The primary outcome occurred in 18% (369 of 2,072) and 17% (488 of 2,919) of women with myocardial injury before and after implementation, respectively (adjusted hazard ratio: 1.11; 95% confidence interval: 0.92 to 1.33), compared with 18% (370 of 2,044) and 15% (513 of 3,325) of men (adjusted hazard ratio: 0.85; 95% confidence interval: 0.71 to 1.01). Conclusions: Use of sex-specific thresholds identified 5 times more additional women than men with myocardial injury. Despite this increase, women received approximately one-half the number of treatments for coronary artery disease as men, and outcomes were not improved. (High-Sensitivity Troponin in the Evaluation of Patients With Acute Coronary Syndrome [High-STEACS]; NCT01852123).

Original language	English (US)
Pages (from-to)	2032-2043
Number of pages	12
Journal	Journal of the American College of Cardiology
Volume	74
Issue number	16
DOIs	https://doi.org/10.1016/j.jacc.2019.07.082
State	Published - Oct 22 2019

Bibliographical note

Funding Information:
This trial was funded by a Special Project Grant from the British Heart Foundation (BHF) (SP/12/10/29922) with additional support from a BHF-Turing Cardiovascular Data Science Award (BCDSA/100003) and a BHF Research Excellence Award (RE/18/5/34216). Drs. Lee, Shah, and Mills are supported by a Clinical Research Training Fellowship (FS/18/25/33454), an Intermediate Clinical Research Fellowship (FS/19/17/34172), and the Butler Senior Clinical Research Fellowship (FS/16/14/32023) from the BHF. Dr. Weir was supported by National Health Service Lothian through the Edinburgh Clinical Trials Unit. Abbott Laboratories provided cardiac troponin assay reagents, calibrators, and controls without charge. Drs. Shah, Chapman, and Lee have received honoraria from Abbott Diagnostics. Dr. Berry has received a research grant awarded to the University of Glasgow from AstraZeneca outside the submitted work. Dr. Apple has received research grants awarded to the Minneapolis Medical Research Foundation from Abbott Diagnostics, Siemens Diagnostics, Ortho-Clinical Diagnostics, and Beckman Coulter outside the submitted work; and has received personal fees from HyTest. Dr. Mills has received research grants awarded to the University of Edinburgh from Abbott Diagnostics and Siemens Diagnostics outside the submitted work; and has received honoraria from Abbott Diagnostics, Siemens Diagnostics, Roche Diagnostics, and Singulex. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.

Publisher Copyright:
© 2019

Keywords

acute coronary syndrome
high-sensitivity cardiac troponin
myocardial infarction
sex-specific threshold

PubMed: MeSH publication types

Journal Article
Multicenter Study
Randomized Controlled Trial
Research Support, Non-U.S. Gov't

UN SDGs

This output contributes to the following UN Sustainable Development Goals (SDGs)

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10.1016/j.jacc.2019.07.082

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title = "Sex-Specific Thresholds of High-Sensitivity Troponin in Patients With Suspected Acute Coronary Syndrome",

abstract = "Background: Major disparities between women and men in the diagnosis, management, and outcomes of acute coronary syndrome are well recognized. Objectives: The aim of this study was to evaluate the impact of implementing a high-sensitivity cardiac troponin I assay with sex-specific diagnostic thresholds for myocardial infarction in women and men with suspected acute coronary syndrome. Methods: Consecutive patients with suspected acute coronary syndrome were enrolled in a stepped-wedge, cluster-randomized controlled trial across 10 hospitals. Myocardial injury was defined as high-sensitivity cardiac troponin I concentration >99th centile of 16 ng/l in women and 34 ng/l in men. The primary outcome was recurrent myocardial infarction or cardiovascular death at 1 year. Results: A total of 48,282 patients (47% women) were included. Use of the high-sensitivity cardiac troponin I assay with sex-specific thresholds increased myocardial injury in women by 42% and in men by 6%. Following implementation, women with myocardial injury remained less likely than men to undergo coronary revascularization (15% vs. 34%) and to receive dual antiplatelet (26% vs. 43%), statin (16% vs. 26%), or other preventive therapies (p < 0.001 for all). The primary outcome occurred in 18% (369 of 2,072) and 17% (488 of 2,919) of women with myocardial injury before and after implementation, respectively (adjusted hazard ratio: 1.11; 95% confidence interval: 0.92 to 1.33), compared with 18% (370 of 2,044) and 15% (513 of 3,325) of men (adjusted hazard ratio: 0.85; 95% confidence interval: 0.71 to 1.01). Conclusions: Use of sex-specific thresholds identified 5 times more additional women than men with myocardial injury. Despite this increase, women received approximately one-half the number of treatments for coronary artery disease as men, and outcomes were not improved. (High-Sensitivity Troponin in the Evaluation of Patients With Acute Coronary Syndrome [High-STEACS]; NCT01852123).",

keywords = "acute coronary syndrome, high-sensitivity cardiac troponin, myocardial infarction, sex-specific threshold",

author = "{High-STEACS investigators} and Lee, {Kuan Ken} and Ferry, {Amy V.} and Atul Anand and Strachan, {Fiona E.} and Chapman, {Andrew R.} and Kimenai, {Dorien M.} and Meex, {Steven J.R.} and Colin Berry and Iain Findlay and Alan Reid and Anne Cruickshank and Alasdair Gray and Collinson, {Paul O.} and Apple, {Fred S.} and McAllister, {David A.} and Donogh Maguire and Fox, {Keith A.A.} and Newby, {David E.} and Chris Tuck and Catriona Keerie and Weir, {Christopher J.} and Shah, {Anoop S.V.} and Mills, {Nicholas L.} and Newby, {David E.} and Alasdair Gray and Fox, {Keith A.A.} and Colin Berry and Simon Walker and Collinson, {Paul O.} and Apple, {Fred S.} and Alan Reid and Anne Cruikshank and Iain Findlay and Shannon Amoils and McAllister, {David A.} and Donogh Maguire and Jennifer Stevens and John Norrie and Christopher Weir and Shah, {Anoop S.V.} and Atul Anand and Chapman, {Andrew R.} and Lee, {Kuan Ken} and Andrews, {Jack P.M.} and Adamson, {Philip D.} and Alastair Moss and Anwar, {Mohamed S.} and John Hung and Mills, {Nicholas L.} and Simon Walker",

note = "Funding Information: This trial was funded by a Special Project Grant from the British Heart Foundation (BHF) (SP/12/10/29922) with additional support from a BHF-Turing Cardiovascular Data Science Award (BCDSA/100003) and a BHF Research Excellence Award (RE/18/5/34216). Drs. Lee, Shah, and Mills are supported by a Clinical Research Training Fellowship (FS/18/25/33454), an Intermediate Clinical Research Fellowship (FS/19/17/34172), and the Butler Senior Clinical Research Fellowship (FS/16/14/32023) from the BHF. Dr. Weir was supported by National Health Service Lothian through the Edinburgh Clinical Trials Unit. Abbott Laboratories provided cardiac troponin assay reagents, calibrators, and controls without charge. Drs. Shah, Chapman, and Lee have received honoraria from Abbott Diagnostics. Dr. Berry has received a research grant awarded to the University of Glasgow from AstraZeneca outside the submitted work. Dr. Apple has received research grants awarded to the Minneapolis Medical Research Foundation from Abbott Diagnostics, Siemens Diagnostics, Ortho-Clinical Diagnostics, and Beckman Coulter outside the submitted work; and has received personal fees from HyTest. Dr. Mills has received research grants awarded to the University of Edinburgh from Abbott Diagnostics and Siemens Diagnostics outside the submitted work; and has received honoraria from Abbott Diagnostics, Siemens Diagnostics, Roche Diagnostics, and Singulex. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose. Publisher Copyright: {\textcopyright} 2019",

year = "2019",

month = oct,

day = "22",

doi = "10.1016/j.jacc.2019.07.082",

language = "English (US)",

volume = "74",

pages = "2032--2043",

journal = "Journal of the American College of Cardiology",

issn = "0735-1097",

publisher = "Elsevier Inc.",

number = "16",

}

TY - JOUR

T1 - Sex-Specific Thresholds of High-Sensitivity Troponin in Patients With Suspected Acute Coronary Syndrome

AU - High-STEACS investigators

AU - Lee, Kuan Ken

AU - Ferry, Amy V.

AU - Anand, Atul

AU - Strachan, Fiona E.

AU - Chapman, Andrew R.

AU - Kimenai, Dorien M.

AU - Meex, Steven J.R.

AU - Berry, Colin

AU - Findlay, Iain

AU - Reid, Alan

AU - Cruickshank, Anne

AU - Gray, Alasdair

AU - Collinson, Paul O.

AU - Apple, Fred S.

AU - McAllister, David A.

AU - Maguire, Donogh

AU - Fox, Keith A.A.

AU - Newby, David E.

AU - Tuck, Chris

AU - Keerie, Catriona

AU - Weir, Christopher J.

AU - Shah, Anoop S.V.

AU - Mills, Nicholas L.

AU - Newby, David E.

AU - Gray, Alasdair

AU - Fox, Keith A.A.

AU - Berry, Colin

AU - Walker, Simon

AU - Collinson, Paul O.

AU - Apple, Fred S.

AU - Reid, Alan

AU - Cruikshank, Anne

AU - Findlay, Iain

AU - Amoils, Shannon

AU - McAllister, David A.

AU - Maguire, Donogh

AU - Stevens, Jennifer

AU - Norrie, John

AU - Weir, Christopher

AU - Shah, Anoop S.V.

AU - Anand, Atul

AU - Chapman, Andrew R.

AU - Lee, Kuan Ken

AU - Andrews, Jack P.M.

AU - Adamson, Philip D.

AU - Moss, Alastair

AU - Anwar, Mohamed S.

AU - Hung, John

AU - Mills, Nicholas L.

AU - Walker, Simon

N1 - Funding Information: This trial was funded by a Special Project Grant from the British Heart Foundation (BHF) (SP/12/10/29922) with additional support from a BHF-Turing Cardiovascular Data Science Award (BCDSA/100003) and a BHF Research Excellence Award (RE/18/5/34216). Drs. Lee, Shah, and Mills are supported by a Clinical Research Training Fellowship (FS/18/25/33454), an Intermediate Clinical Research Fellowship (FS/19/17/34172), and the Butler Senior Clinical Research Fellowship (FS/16/14/32023) from the BHF. Dr. Weir was supported by National Health Service Lothian through the Edinburgh Clinical Trials Unit. Abbott Laboratories provided cardiac troponin assay reagents, calibrators, and controls without charge. Drs. Shah, Chapman, and Lee have received honoraria from Abbott Diagnostics. Dr. Berry has received a research grant awarded to the University of Glasgow from AstraZeneca outside the submitted work. Dr. Apple has received research grants awarded to the Minneapolis Medical Research Foundation from Abbott Diagnostics, Siemens Diagnostics, Ortho-Clinical Diagnostics, and Beckman Coulter outside the submitted work; and has received personal fees from HyTest. Dr. Mills has received research grants awarded to the University of Edinburgh from Abbott Diagnostics and Siemens Diagnostics outside the submitted work; and has received honoraria from Abbott Diagnostics, Siemens Diagnostics, Roche Diagnostics, and Singulex. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose. Publisher Copyright: © 2019

PY - 2019/10/22

Y1 - 2019/10/22

N2 - Background: Major disparities between women and men in the diagnosis, management, and outcomes of acute coronary syndrome are well recognized. Objectives: The aim of this study was to evaluate the impact of implementing a high-sensitivity cardiac troponin I assay with sex-specific diagnostic thresholds for myocardial infarction in women and men with suspected acute coronary syndrome. Methods: Consecutive patients with suspected acute coronary syndrome were enrolled in a stepped-wedge, cluster-randomized controlled trial across 10 hospitals. Myocardial injury was defined as high-sensitivity cardiac troponin I concentration >99th centile of 16 ng/l in women and 34 ng/l in men. The primary outcome was recurrent myocardial infarction or cardiovascular death at 1 year. Results: A total of 48,282 patients (47% women) were included. Use of the high-sensitivity cardiac troponin I assay with sex-specific thresholds increased myocardial injury in women by 42% and in men by 6%. Following implementation, women with myocardial injury remained less likely than men to undergo coronary revascularization (15% vs. 34%) and to receive dual antiplatelet (26% vs. 43%), statin (16% vs. 26%), or other preventive therapies (p < 0.001 for all). The primary outcome occurred in 18% (369 of 2,072) and 17% (488 of 2,919) of women with myocardial injury before and after implementation, respectively (adjusted hazard ratio: 1.11; 95% confidence interval: 0.92 to 1.33), compared with 18% (370 of 2,044) and 15% (513 of 3,325) of men (adjusted hazard ratio: 0.85; 95% confidence interval: 0.71 to 1.01). Conclusions: Use of sex-specific thresholds identified 5 times more additional women than men with myocardial injury. Despite this increase, women received approximately one-half the number of treatments for coronary artery disease as men, and outcomes were not improved. (High-Sensitivity Troponin in the Evaluation of Patients With Acute Coronary Syndrome [High-STEACS]; NCT01852123).

AB - Background: Major disparities between women and men in the diagnosis, management, and outcomes of acute coronary syndrome are well recognized. Objectives: The aim of this study was to evaluate the impact of implementing a high-sensitivity cardiac troponin I assay with sex-specific diagnostic thresholds for myocardial infarction in women and men with suspected acute coronary syndrome. Methods: Consecutive patients with suspected acute coronary syndrome were enrolled in a stepped-wedge, cluster-randomized controlled trial across 10 hospitals. Myocardial injury was defined as high-sensitivity cardiac troponin I concentration >99th centile of 16 ng/l in women and 34 ng/l in men. The primary outcome was recurrent myocardial infarction or cardiovascular death at 1 year. Results: A total of 48,282 patients (47% women) were included. Use of the high-sensitivity cardiac troponin I assay with sex-specific thresholds increased myocardial injury in women by 42% and in men by 6%. Following implementation, women with myocardial injury remained less likely than men to undergo coronary revascularization (15% vs. 34%) and to receive dual antiplatelet (26% vs. 43%), statin (16% vs. 26%), or other preventive therapies (p < 0.001 for all). The primary outcome occurred in 18% (369 of 2,072) and 17% (488 of 2,919) of women with myocardial injury before and after implementation, respectively (adjusted hazard ratio: 1.11; 95% confidence interval: 0.92 to 1.33), compared with 18% (370 of 2,044) and 15% (513 of 3,325) of men (adjusted hazard ratio: 0.85; 95% confidence interval: 0.71 to 1.01). Conclusions: Use of sex-specific thresholds identified 5 times more additional women than men with myocardial injury. Despite this increase, women received approximately one-half the number of treatments for coronary artery disease as men, and outcomes were not improved. (High-Sensitivity Troponin in the Evaluation of Patients With Acute Coronary Syndrome [High-STEACS]; NCT01852123).

KW - acute coronary syndrome

KW - high-sensitivity cardiac troponin

KW - myocardial infarction

KW - sex-specific threshold

UR - http://www.scopus.com/inward/record.url?scp=85072750509&partnerID=8YFLogxK

UR - http://www.scopus.com/inward/citedby.url?scp=85072750509&partnerID=8YFLogxK

U2 - 10.1016/j.jacc.2019.07.082

DO - 10.1016/j.jacc.2019.07.082

M3 - Article

C2 - 31623760

AN - SCOPUS:85072750509

SN - 0735-1097

VL - 74

SP - 2032

EP - 2043

JO - Journal of the American College of Cardiology

JF - Journal of the American College of Cardiology

IS - 16

ER -

Sex-Specific Thresholds of High-Sensitivity Troponin in Patients With Suspected Acute Coronary Syndrome

Abstract

Bibliographical note

Keywords

PubMed: MeSH publication types

UN SDGs

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