Acute chest pain in the high-sensitivity cardiac troponin era: A changing role for noninvasive imaging?
Management of patients with acute chest pain remains challenging. Cardiac biomarker testing reduces the likelihood of erroneously discharging patients with acute myocardial infarction (AMI). Despite normal contemporary troponins, physicians have still been reluctant to discharge patients without additional testing. Nowadays, the extremely high negative predictive value of current high-sensitivity cardiac troponin (hs-cTn) assays challenges this need. However, the decreased specificity of hs-cTn assays to diagnose AMI poses a new problem as noncoronary diseases (eg, pulmonary embolism, myocarditis, cardiomyopathies, hypertension, renal failure, etc) may also cause elevated hs-cTn levels. Subjecting patients with noncoronary diseases to unnecessary pharmacological therapy or invasive procedures must be prevented. Attempts to improve the positive predictive value to diagnose AMI by defining higher initial cutoff values or dynamic changes over time inherently lower the sensitivity of troponin assays. In this review, we anticipate a potential changing role of noninvasive imaging from ruling out myocardial disease when troponin values are normal toward characterizing myocardial disease when hs-cTn values are (mildly) abnormal.
Department of Cardiology, Maastricht University Medical Center, Maastricht, the Netherlands; Cardiovascular Research Institute Maastricht (CARIM), School for Cardiovascular Diseases, Maastricht University Medical Center, Maastricht, the Netherlands.
Martijn W
MW
Smulders
Department of Cardiology, Maastricht University Medical Center, Maastricht, the Netherlands; Cardiovascular Research Institute Maastricht (CARIM), School for Cardiovascular Diseases, Maastricht University Medical Center, Maastricht, the Netherlands; Department of Radiology, Maastricht University Medical Center, Maastricht, the Netherlands.
Bas L J H
BL
Kietselaer
Department of Cardiology, Maastricht University Medical Center, Maastricht, the Netherlands; Cardiovascular Research Institute Maastricht (CARIM), School for Cardiovascular Diseases, Maastricht University Medical Center, Maastricht, the Netherlands.
Simon
S
Schalla
Cardiovascular Research Institute Maastricht (CARIM), School for Cardiovascular Diseases, Maastricht University Medical Center, Maastricht, the Netherlands; Department of Radiology, Maastricht University Medical Center, Maastricht, the Netherlands; Department of Nuclear Medicine, Maastricht University Medical Center, Maastricht, the Netherlands; Department of Nuclear Medicine, University Hospital, RWTH Aachen, Aachen, Germany.
Jan
J
Bucerius
Department of Cardiology, Maastricht University Medical Center, Maastricht, the Netherlands; Cardiovascular Research Institute Maastricht (CARIM), School for Cardiovascular Diseases, Maastricht University Medical Center, Maastricht, the Netherlands.
Caroline
C
Jaarsma
Cardiovascular Research Institute Maastricht (CARIM), School for Cardiovascular Diseases, Maastricht University Medical Center, Maastricht, the Netherlands; Department of Clinical Chemistry, Maastricht University Medical Center, Maastricht, the Netherlands.
Marja P
MP
van Dieijen-Visser
Cardiovascular Research Institute Maastricht (CARIM), School for Cardiovascular Diseases, Maastricht University Medical Center, Maastricht, the Netherlands; Department of Clinical Chemistry, Maastricht University Medical Center, Maastricht, the Netherlands.
Alma M A
AM
Mingels
Department of Cardiology, Maastricht University Medical Center, Maastricht, the Netherlands; Cardiovascular Research Institute Maastricht (CARIM), School for Cardiovascular Diseases, Maastricht University Medical Center, Maastricht, the Netherlands.
Hans-Peter Brunner-La
HP
Rocca
Cardiovascular Research Institute Maastricht (CARIM), School for Cardiovascular Diseases, Maastricht University Medical Center, Maastricht, the Netherlands; Department of Physiology, Maastricht University Medical Center, Maastricht, the Netherlands.
Mark
M
Post
Cardiovascular Research Institute Maastricht (CARIM), School for Cardiovascular Diseases, Maastricht University Medical Center, Maastricht, the Netherlands; Department of Radiology, Maastricht University Medical Center, Maastricht, the Netherlands.
Marco
M
Das
Department of Cardiology, Maastricht University Medical Center, Maastricht, the Netherlands; Cardiovascular Research Institute Maastricht (CARIM), School for Cardiovascular Diseases, Maastricht University Medical Center, Maastricht, the Netherlands.
Harry J G M
HJ
Crijns
Cardiovascular Research Institute Maastricht (CARIM), School for Cardiovascular Diseases, Maastricht University Medical Center, Maastricht, the Netherlands; Department of Radiology, Maastricht University Medical Center, Maastricht, the Netherlands.
Joachim E
JE
Wildberger
Department of Cardiology, Maastricht University Medical Center, Maastricht, the Netherlands; Cardiovascular Research Institute Maastricht (CARIM), School for Cardiovascular Diseases, Maastricht University Medical Center, Maastricht, the Netherlands. Electronic address: s.bekkers@mumc.nl.
Sebastiaan C A M
SC
Bekkers
D009202:Cardiomyopathies / Q000097:blood / Q000150:complications / Q000000981:diagnostic imaging; D002637:Chest Pain / Q000097:blood / Q000000981:diagnostic imaging* / Q000209:etiology; D000072226:Computed Tomography Angiography; D017023:Coronary Angiography; D003324:Coronary Artery Disease / Q000097:blood / Q000150:complications / Q000000981:diagnostic imaging*; D003937:Diagnosis, Differential; D025401:Echocardiography, Stress; D005080:Exercise Test; D006801:Humans; D008279:Magnetic Resonance Imaging; D009203:Myocardial Infarction / Q000097:blood / Q000150:complications / Q000000981:diagnostic imaging*; D055414:Myocardial Perfusion Imaging; D009205:Myocarditis / Q000097:blood / Q000150:complications / Q000000981:diagnostic imaging; D011655:Pulmonary Embolism / Q000097:blood / Q000150:complications / Q000000981:diagnostic imaging; D012680:Sensitivity and Specificity; D015899:Tomography, Emission-Computed, Single-Photon; D014336:Troponin / Q000097:blood*
D014336:Troponin