Physicians' Academy for Cardiovascular Education

Intermediate hs-cTn associated with higher risk of CAD on CCTA in those with suspected ACS without MI

Troponin-Guided Coronary Computed Tomographic Angiography After Exclusion of Myocardial Infarction

Literature - Lee KK, Bularga A, O’Brien R., et al. - J Am Coll Cardiol 2021, 78:1407-1417,

Introduction and methods

Aim of the study

Bedside clinical assessment, electrocardiography and serial cardiac troponin testing are strategies to rule in or rule out acute myocardial infarction (MI) [1]. After ruling out MI though, there is a substantial proportion of patients with underlying coronary artery disease (CAD) and an increased risk of future cardiac events. It is not clear what the optimal strategy is to identify these patients. In this study, in patients with suspected acute coronary syndrome (ACS) in whom MI was ruled out, it was examined whether those with intermediate troponine have a higher prevalence of CAD and whether troponin can be used to select patients for coronary computed tomography angiography (CCTA).

Study design

PRECISE-CTCA (Troponin to Risk Stratify Patients with Acute Chest Pain for Computed Tomography Coronary Angiography) was a prospective cohort study of 250 patients who presented with suspected ACS to the emergency department at the Royal Infirmary of Edinburgh, UK and in whom acute MI was ruled out. Peak high-sensitivity cardiac troponin (hs-cTn) was within the normal range. Patients were recruited in a 2:1 ratio stratified by peak hs-cTn above and below the risk stratification threshold of 5 ng/L [2,3]. All patients underwent CCTA as an outpatient procedure.


Luminal cross-sectional area stenoses were classified as normal (<10%), mild non-obstructive (10-49%), moderate nonobstructive (50-70%), or obstructive (>70% in ≥1 major epicardial artery or >50% in the left main stem). Patients were classified according to the most significant stenosis identified on the CCTA. Atherosclerotic plaque burden was quantified using the segment involvement [4], segment stenosis and computed tomography (CT)-adapted Leaman scores [5].

Main results


In patients presenting with suspected ACS and in whom MI was ruled out, intermediate troponin concentration was associated with increased risk of CAD on CCTA (3 fold higher risk compared to those with low troponin concentration). Using cardiac troponin to select patients for downstream investigation after rule out of MI has major potential for improvement of outcomes, the authors concluded.


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Find this article online at J Am Coll Cardiol

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