Résumé
Acute chest pains without troponin raise are challenging in patients with pre-existing coronary artery disease (CAD).
To evaluate the diagnostic and incremental prognostic values of copeptin in patients with normal high sensitivity troponin T (hs-cTnT) value, pre-existing CAD and acute chest pain.
This monocentric prospective study included 91 consecutive patients with documented CAD admitted in the intensive care units for chest pain lasting for less than ten hours. Acute coronary syndrome (ACS) was excluded with ECG and hs-cTnT values<14ng/L at baseline and with dynamic changes≤50% three hours later and<20% if baseline hs-cTnT between 14 and 50ng/L (Roche Diagnostics, COBAS 8000). The hs-cTnT assay was validated with the upper reference limit (99th percentile) of 14ng/L and limit of detection at 5ng/L. Blood samples for determination of copeptin (Thermofisher, Kryptor Compact) were collected at presentation. Copeptin value was considered as positive when >10pmol/L (detection limit at 2pmol/L). Prognosis evaluation concerned absence of severe stenosis (>90%) or fractional flow reserve>0.80 at coronary angiography, or absence of myocardial ischemia induced with nuclear stress imaging.
Mean age of patients was 58±8,72 (79.3%) were male. The mean time between chest pain onset and blood samples was 4±2 hours. According to clinical decision, coronary angiography was performed in 63 patients (69.2%), with 12 severe stenosis diagnosed (19%). No ischemia was detected with the stress tests (28 patients). Among the 52 patients with a negative kinetic of hs-cTnT and a negative copeptin, only 2 (3.8%) had a critical stenosis (NPV 95%) both related to in stent restenosis (table 1).
Abstratct 0291 – Table: Predictive valuesSensitivitySpecificityPositive predictive valueNegative predictive valuehs-cTnT<14 ng/L and<50% change at 3 hours n=910.22 IC (0.028-0.6)0.73IC(0.604-0.83)0.10 IC(0.012-0.317)0.87 IC (0.755-0.947)Copeptin<10 pmol/L+hs-cTnT<14 ng/L n=710.75 IC(0.428-0.945)0.6IC (0.476-0.715)0.24 IC(0.118-0.412)0.93 IC(0.817-0.986)Copeptin<10 pmol/L+negative kinetic of hs-cTnT at 3 hours n=520.79 IC (0.4-0.972)0.54IC (0.418-0.669)0.19 IC (0.08-0.352)0.95 IC (0.823-0.994)
In patients with pre-existing CAD, once ACS is excluded, copeptin provides a useful additional triage strategy in acute chest pain to exclude severe coronary stenosis or stenosis inducing myocardial ischemia.