Key result
Unmasking high-sensitivity troponin T results in females with concentrations <30 ng/L significantly increased the risk of death or MI compared to masked reporting (HR 2.27; 95% CI 1.87-2.77; P<0.001).
Why the study?
The impact of hs-cTn reporting on downstream interventions in ED patients with suspected ACS—especially those with newly identified hs-cTn elevations and considering sex-related disparities—had not been critically evaluated.
Does unmasked reporting of high sensitivity cardiac troponin T impact downstream interventions and reduce death or MI in patients with suspected ACS, particularly by sex?
RCT (n=5,366)
Does unmasked reporting of high sensitivity cardiac troponin T impact downstream interventions and reduce death or MI in patients with suspected ACS, particularly by sex?
Unmasking of hs-cTnT reporting in suspected ACS patients revealed sex disparities, with females experiencing higher rates of death or MI without corresponding increases in downstream interventions compared to males.
hs-cTnT unmasking changed management in men but not women, with excess death/MI risk in females; challenges equitable troponin-guided ACS care and warrants targeted trials.
BACKGROUND: The impacts of high sensitivity cardiac troponin (hs-cTn) reporting on downstream interventions amongst suspected acute coronary syndrome (ACS) in the emergency department (ED), especially amongst those with newly identified hs-cTn elevations and in consideration of well-established sex-related disparities, has not been critically evaluated to date. This investigation explores the impact of hs-cTnT reporting on care and outcomes, particularly by participant sex. METHODS: Two similarly ED-based randomized controlled trials conducted between July 2011 to March 2013 (n = 1988) and August 2015 to April 2019 (n = 3378) were comparatively evaluated. Clinical outcomes were adjudicated to the Fourth Universal Definition of MI. Changes in practice were assessed at 30 days, and death or MI were explored to 12 months. RESULTS: The HS-Troponin study demonstrated no difference in death or MI with unmasking amongst those with hs-cTnT <30 ng/L, whereas the RAPID TnT study demonstrated a significantly higher rate. In RAPID TnT, there was significant increase in death or MI associated with unmasking for females with hs-cTnT <30 ng/L (masked: 11[1.5%], unmasked: 25[3.4%],HR: 2.27,95%C.I.:1.87-2.77,P < 0.001). Less cardiac stress testing with unmasking amongst those <30 ng/L was observed in males in both studies, which was significant in RAPID TnT (masked: 92[12.0%], unmasked: 55[7.0%], P = 0.008). In RAPID TnT, significantly higher rates of angiography in males were observed with unmasking, with no such changes amongst females <30 ng/L (masked: 28[3.7%], unmasked: 51[6.5%],P = 0.01). CONCLUSION: Compared with males, there were no evident impacts on downstream practices for females with unmasking in RAPID TnT, likely representing missed opportunities to reduce late death or MI.
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Lambrakis et al. (2023) conducted an RCT in suspected acute coronary syndrome (ACS) (n=5,366). High sensitivity cardiac troponin T (hs-cTnT) reporting (unmasking) vs. Masked hs-cTnT reporting was evaluated on Death or MI at 12 months (reported for females with hs-cTnT <30 ng/L in RAPID TnT) (HR 2.27, 95% CI 1.87-2.77, p=< 0.001). Unmasking high-sensitivity troponin T results in females with concentrations <30 ng/L significantly increased the risk of death or MI compared to masked reporting (HR 2.27; 95% CI 1.87-2.77; P<0.001).
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