Key result
Non-cardiology admission for flat-curve troponin chest pain is linked to ~4-fold higher 12-month mortality vs discharge.
Why the study?
Patients presenting with chest pain, elevated cardiac troponin, and a flat curve (Δ<20%) represent a diagnostic challenge because current guidelines do not associate this pattern with ACS. Although early prognosis has been described, the temporal evolution of risk and the adequacy of initial clinical management remain uncertain.
Does the initial clinical management strategy (cardiology admission, non-cardiology admission, or emergency department discharge) stratify 12-month mortality and MACE risk in patients presenting with chest pain and a flat high-sensitivity cardiac troponin T curve?
Cohort (n=753)
Does the initial clinical management strategy (cardiology admission, non-cardiology admission, or emergency department discharge) stratify 12-month mortality and MACE risk in patients presenting with chest pain and a flat high-sensitivity cardiac troponin T curve?
In patients presenting with chest pain and a flat cardiac troponin curve, clinically guided risk stratification effectively identifies distinct long-term risk trajectories, validating the safety of emergency department discharge for low-risk individuals.
Answers are grounded in this paper and cite their sources.
Non-cardiology admission was associated with highest mortality; hypothesis-generating for pathway-based stratification in flat-troponin patients.
Introduction Acute myocardial injury is defined by cardiac troponin (cTn) levels above the 99th percentile with a dynamic rise/fall pattern (Δ), usually suggesting acute coronary syndrome (ACS) when associated with compatible symptoms. Patients presenting with chest pain, elevated cTn and a flat curve (Δ<20%) represent a diagnostic challenge, as current guidelines do not associate this pattern with ACS. Early prognosis has been described, but the temporal evolution of risk and the adequacy of initial clinical management remain uncertain. We aimed to assess 12-month outcomes according to initial management strategy: admission in cardiology, admission in other departments or discharge from emergency department. Methods We prospectively analyzed 753 consecutive patients with suspected ACS and a cTn-flat-curve (Δ<20% in two high-sensitivity cTn-T determinations at 0 and 3 hours) between May 2023 and January 2026. Management decisions were based on comprehensive clinical evaluation. Six- and twelve-month follow-up assessed mortality, other major adverse cardiovascular events (MACE), and re-admissions. Results Mean age was 75.7±11.9 years and 63.3% were male. ACS was diagnosed predominantly in patients admitted to cardiology. Six-month follow-up was available in 614 patients and 12-month follow-up in 484 patients. At 12 months, patients admitted to non-cardiology departments showed the highest mortality (29.5%) and MACE rate (39%), largely driven by non-cardiovascular causes. Patients admitted to cardiology had intermediate event rates, whereas discharged patients maintained low mortality (7.5%) throughout follow-up, although they were not event-free. Kaplan–Meier curves demonstrated early and persistent separation between management groups, confirming distinct risk trajectories over time (Figure 1). Conclusions In patients with a cTn-flat-curve, risk extends beyond the early phase and differs markedly according to initial management. The sustained separation of survival curves supports the prognostic relevance of clinical decision-making. Importantly, the low long-term mortality among discharged patients validates the safety of careful, clinically guided risk stratification in this heterogeneous population.
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García et al. (2026) conducted a cohort in Suspected acute coronary syndrome with chest pain and cardiac troponin flat curve (n=753). Initial management strategy (admission to non-cardiology departments vs cardiology admission vs emergency department discharge) vs. Emergency department discharge was evaluated on 12-month mortality and major adverse cardiovascular events (MACE). Initial management strategy in cTn-flat-curve chest pain stratified 12-month risk, with 29.5% mortality (39% MACE) in non-cardiology admissions vs 7.5% mortality in discharged patients.
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