Symptoms Predictive of Acute Myocardial Infarction in the Troponin Era: Analysis From the TRAPID-AMI Study

The TRAPID-AMI (High Sensitivity Cardiac Troponin T assay for rapid Rule-out of Acute Myocardial Infarction) study evaluated a rapid “rule-out” acute myocardial infarction (AMI). We evaluated what symptoms were associated with AMI as part of a substudy of TRAPID-AMI. There were 1282 patients evaluated from 12 centers in Europe, the United States of America, and Australia from 2011 to 2013. Multiple symptom variables were prospectively obtained and evaluated for association with the final diagnosis of AMI. Multivariate logistic regression analysis was done, and odds ratios (OR) were calculated. There were 213/1282 (17%) AMIs. Four independent predictors for the diagnosis of AMI were identified: radiation to right arm or shoulder [OR = 3.0; confidence interval (CI): 1.8–5.0], chest pressure (OR = 2.5; CI: 1.3–4.6), worsened by physical activity (OR = 1.7; CI: 1.2–2.5), and radiation to left arm or shoulder (OR = 1.7; CI: 1.1–2.4). In the entire group, 131 (10%) had radiation to right arm or shoulder, 897 (70%) had chest pressure, 385 (30%) worsened with physical activity, and 448 (35%) had radiation to left arm or shoulder. Duration of symptoms was not predictive of AMI. There were no symptoms predictive of non-AMI. Relationship between AMI size and symptoms was also studied. For 213 AMI patients, cardiac troponins I values were divided into 4 quartiles. Symptoms including pulling chest pain, supramammillary right location, and right arm/shoulder radiation were significantly more likely to occur in patients with larger AMIs. In a large multicenter trial, only 4 symptoms were associated with the diagnosis of AMI, and no symptoms that were associated with a non-AMI diagnosis.

[1]  A. Singer,et al.  Missed myocardial infarctions in ED patients prospectively categorized as low risk by established risk scores , 2017, The American journal of emergency medicine.

[2]  R. Body,et al.  Multicenter Evaluation of a 0-Hour/1-Hour Algorithm in the Diagnosis of Myocardial Infarction With High-Sensitivity Cardiac Troponin T. , 2016, Annals of emergency medicine.

[3]  Y. Vorasettakarnkij,et al.  CK-MB Activity, Any Additional Benefit to Negative Troponin in Evaluating Patients with Suspected Acute Myocardial Infarction in the Emergency Department. , 2015, Journal of the Medical Association of Thailand = Chotmaihet thangphaet.

[4]  Alana D. Steffen,et al.  Sensitivity, Specificity, and Sex Differences in Symptoms Reported on the 13‐Item Acute Coronary Syndrome Checklist , 2014, Journal of the American Heart Association.

[5]  Talicia Tarver,et al.  HEART DISEASE AND STROKE STATISTICS–2014 UPDATE: A REPORT FROM THE AMERICAN HEART ASSOCIATION , 2014 .

[6]  C. Mueller.  Biomarkers and acute coronary syndromes: an update. , 2014, European heart journal.

[7]  K. Denhaerynck,et al.  Sex-specific chest pain characteristics in the early diagnosis of acute myocardial infarction. , 2014, JAMA internal medicine.

[8]  Johannes B Reitsma,et al.  The impact of the HEART risk score in the early assessment of patients with acute chest pain: design of a stepped wedge, cluster randomised trial , 2013, BMC Cardiovascular Disorders.

[9]  Jeroen J. Bax,et al.  Third universal definition of myocardial infarction. , 2012, Global heart.

[10]  M. Petzold,et al.  Troponin T percentiles from a random population sample, emergency room patients and patients with myocardial infarction. , 2012, Clinical chemistry.

[11]  R. Twerenbold,et al.  Utility of Absolute and Relative Changes in Cardiac Troponin Concentrations in the Early Diagnosis of Acute Myocardial Infarction , 2011, Circulation.

[12]  R. Niska,et al.  National Hospital Ambulatory Medical Care Survey: 2007 emergency department summary. , 2010, National health statistics reports.

[13]  R. Mutter,et al.  Emergency department care in the United States: a profile of national data sources. , 2010, Annals of emergency medicine.

[14]  A. Jaffe,et al.  Analytical validation of a high-sensitivity cardiac troponin T assay. , 2010, Clinical chemistry.

[15]  S. Goodacre,et al.  Clinical diagnosis of acute coronary syndrome in patients with chest pain and a normal or non-diagnostic electrocardiogram , 2009, Emergency Medicine Journal.

[16]  F. Buntinx,et al.  Signs and symptoms in diagnosing acute myocardial infarction and acute coronary syndrome: a diagnostic meta-analysis. , 2008, The British journal of general practice : the journal of the Royal College of General Practitioners.

[17]  Eric W Nawar,et al.  National Hospital Ambulatory Medical Care Survey: 2005 emergency department summary. , 2007, Advance data.

[18]  W Frank Peacock,et al.  The Internet Tracking Registry of Acute Coronary Syndromes (i*trACS): a multicenter registry of patients with suspicion of acute coronary syndromes reported using the standardized reporting guidelines for emergency department chest pain studies. , 2006, Annals of emergency medicine.

[19]  M. C. Meyer,et al.  A critical pathway for patients with acute chest pain and low risk for short-term adverse cardiac events: role of outpatient stress testing. , 2006, Annals of emergency medicine.

[20]  John T Nagurney,et al.  Value and limitations of chest pain history in the evaluation of patients with suspected acute coronary syndromes. , 2005, JAMA.

[21]  S Capewell,et al.  The health care burden of acute chest pain , 2005, Heart.

[22]  A. Volschan,et al.  Probability stratification and systematic diagnostic approach for chest pain patients in the emergency department. , 2004, Critical pathways in cardiology.

[23]  Steve Goodacre,et al.  How useful are clinical features in the diagnosis of acute, undifferentiated chest pain? , 2002, Academic emergency medicine : official journal of the Society for Academic Emergency Medicine.

[24]  D. Speake,et al.  First ECG in chest pain , 2001 .

[25]  J P Ornato,et al.  Prevalence, clinical characteristics, and mortality among patients with myocardial infarction presenting without chest pain. , 2000, JAMA.

[26]  W. Gibler,et al.  Do CK-MB results affect chest pain decision making in the emergency department? , 1991, Annals of emergency medicine.

[27]  T. Buclin,et al.  Right arm involvement and pain extension can help to differentiate coronary diseases from chest pain of other origin: a prospective emergency ward study of 278 consecutive patients admitted for chest pain , 1990, Journal of internal medicine.

[28]  R. Wears,et al.  Initial ECG in Q wave and non-Q wave myocardial infarction. , 1989, Annals of emergency medicine.

[29]  M. Silverman.  William heberden and some account of a disorder of the breast , 1987, Clinical cardiology.

[30]  Maarten L. Simoons,et al.  The third universal definition of myocardial infarction , 2013 .

[31]  D. Speake,et al.  Towards evidence based emergency medicine: best BETs from the Manchester Royal Infirmary. First ECG in chest pain. , 2001, Emergency medicine journal : EMJ.

[32]  Clinical policy: critical issues in the evaluation and management of adult patients presenting with suspected acute myocardial infarction or unstable angina. American College of Emergency Physicians. , 2000, Annals of emergency medicine.

[33]  S. Silvers,et al.  Clinical Policy: Critical Issues in the Evaluation and Management of Adult Patients Presenting With Suspected Acute Myocardial Infarction or Unstable Angina. , 2000, Annals of emergency medicine.

[34]  B. Hesse,et al.  Long-term risk of death, cardiac events and recurrent chest pain in patients with acute chest pain of different origin. , 1996, Cardiology.