High-sensitivity cardiac troponin in the evaluation of suspected acute coronary syndrome

High-sensitivity cardiac troponin in the evaluation of suspected acute coronary syndrome

The High-STEACS research group are performing a series of stepped-wedge cluster randomised controlled trials (ClinicalTrials.gov Identifier: NCT01852123 and NCT03005158) to evaluate whether implementation of a high-sensitivity cardiac troponin I assay will reduce recurrent myocardial infarction and cardiovascular death in patients with suspected acute coronary syndrome across  tertiary and secondary care hospitals in Scotland.

In patients with chest pain the diagnosis of a heart attack is made where there is evidence of heart muscle damage using a blood test to measure the heart muscle protein, troponin. A new more sensitive test may help us to identify patients with heart attacks earlier and more easily. These studies will determine how to use this more sensitive test and whether it will improve patient care and reduce the risk of death in patients with possible heart attacks.

Our research aims to harness the potential of high-sensitivity cardiac troponin testing to improve the safety and effectiveness of strategies to rule in and rule out acute myocardial infarction. In 10 secondary and tertiary care hospitals across Scotland, we are undertaking a series of cluster randomised controlled trial of the implementation of a novel high-sensitivity cardiac troponin assay in approximately 85,000 patients presenting with suspected acute coronary syndromes. This will establish whether the introduction of high-sensitive assays and an early rule out pathway into routine clinical practice is detrimental or beneficial to patient management and outcome; a fundamental and critical assessment for the modern definition of acute myocardial infarction.

We have linked multiple routinely collected healthcare data sources through our network of NHS safe havens to evaluate the impact of testing in consecutive patients across Scotland. Using this approach, we have demonstrated that the introduction of a lower diagnostic threshold was associated with improved survival (JAMA. 2011;305:1210-6). We subsequently demonstrated that conventional troponin tests were under diagnosing myocardial infarction particularly in women, and may have contributed to sex-inequalities in treatment (BMJ. 2015;350:g7873). Furthermore, we have defined the optimal cardiac troponin concentration to identify low-risk patients at presentation (Lancet. 2015;386:2481-8), showed this risk stratification threshold was generalisable across nine countries (JAMA. 2017;318:1913-1924), and incorporated this into a safe and effective early rule out pathway for myocardial infarction (Circulation. 2017;135:1586-96). In ongoing research, the high-STEACS team are evaluating how these changes in practice have impacted on patient care and the efficiency of our National Health Service. We have embedded qualitative research methods in our clinical trials to improve our understanding of the patient’s experience of their assessment and our early discharge pathways.

Principal Investigator, Co-Investigators

The High-STEACS Investigators are a multi-disciplinary team that includes expertise in cardiology (Professor Nicholas L Mills, Professor David E Newby, Dr Phil Adamson, Dr Andrew Chapman, Dr Ken Lee), emergency medicine (Professor Alasdair Gray), epidemiology and statistics (Dr Anoop Shah, Dr David A McAllister), geriatric medicine (Dr Atul Anand), clinical research (Ms Lucy Marshall, Ms Stacey Stewart), qualitative research (Ms Amy Ferry), data science (Dr Catherine Stables) and trials (Dr Fiona Strachan).

We work with the Edinburgh Clinical Trials Unit and are supported by project grants and research fellowships from the British Heart Foundation. Further information is available at www.highsteacs.com or through our Twitter feed @highSTEACS or @troponinpapers.