Historia clínica y niveles indetectables de troponina de alta sensibilidad en la evaluación del riesgo de pacientes con dolor torácico agudo y primera determinación de troponina normal

Introduction: Actually, risk stratification of patients with acute chest pain of uncertain origin and normal cardiac troponin (cTn) remains a challenge. In recent years, several management algorithms have been developed based on high-sensitivity cTn (hs-cTn), regardless of clinical data in decision-making. Hypothesis: In patients with acute chest pain of uncertain origin and normal levels of hs-cTn in the first determination at the emergency department, a predictive model can be developed based on the combination of the hs-cTn levels together with clinical risk scores, which allows a better risk stratification of these patients. Objective: To study the prognostic value of combining hs-cTn levels in the first determination together with clinical risk scores in these patients, by analyzing the combined objective derived from: death, AMI or need for revascularization at 1 year follow-up. Material and methods: A sample of consecutive patients who consulted to our hospital due to an episode of acute chest pain of uncertain origin with a normal initial hs-cTn determination was retrospectively analysed. All sociodemographic and clinical history data of the study population were collected, as well as the clinical characteristics at presentation and hospital admission. In addition, major adverse cardiac events (MACE) - death, AMI and need for revascularization - up to 1 year after discharge were collected. Subsequently, the statistical analysis of the data was carried out, paying special attention to the analysis of the independent predictors of MACE, as well as the prognostic value of hs-cTn in the first determination and of the clinical risk scores individually, and subsequently when combined. Results: The study population was finally made up of 2254 patients. A total of 91 (4%) patients presented the primary endpoint (death, AMI, or revascularization), while 56 (2.5%) presented the secondary endpoint (death or AMI). When carrying out the analysis of the predictive models, we observed that the prognostic value of the combination of hs-TnC together with the HEART (AUC 0.870) and Sanchis (0.876) clinical risk scores, was the best predictive model. Significantly better than the models of hs-cTn in the first determination (dichotomous (0.686) and continuous (0.783)), and clinical risk scores (GRACE 0.692; TIMI 0.794; HEART 0.843; Sanchis: 0.806) individually. Conclusions: In the evaluation of patients presenting to the emergency department with acute chest pain of uncertain origin and first determination of normal hs-cTn, the combination of determining undetectable levels and the quantification of detectable concentrations of hs-cTn in the first determination, together with clinical risk scores, has been shown to have the best discriminative capacity in the risk stratification of these patients at 1 year.