Why We Might Not Need to Stress About Ruling Out Inducible Myocardial Ischemia
Authors: Katy J.L. Bell, Christopher Semsarian, Jenny Doust
Journal: Annals of Internal Medicine (2020)

Editorials4 February 2020Why We Might Not Need to Stress About Ruling Out Inducible Myocardial IschemiaKaty J.L. Bell, MBChB, MMed(Clin Epi), PhD, Christopher Semsarian, MBBS, PhD, MPH, and Jenny Doust, BMBS, PhDKaty J.L. Bell, MBChB, MMed(Clin Epi), PhDThe University of Sydney, Sydney, New South Wales, Australia (K.J.B.)Search for more papers by this author, Christopher Semsarian, MBBS, PhD, MPHThe University of Sydney and Royal Prince Alfred Hospital, Sydney, New South Wales, Australia (C.S.)Search for more papers by this author, and Jenny Doust, BMBS, PhDBond University, Gold Coast, Queensland, Australia (J.D.)Search for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/M19-3731 SectionsAboutFull TextPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail In patients with symptoms of stable angina, cardiac stress testing and angiography have been recommended to evaluate for inducible myocardial ischemia and obstructive coronary artery disease (CAD). Walter and colleagues (1) investigated whether high-sensitivity cardiac troponin (hs-cTn) tests could be introduced in this diagnostic pathway. Because of the tests' high sensitivity for detecting myocardial injury, negative results are used to rule out acute coronary syndrome in patients presenting with acute chest pain, allowing safe discharge home from the emergency department (the tests' clinical utility for ruling in myocardial infarction is more uncertain [2]). Walter and colleagues (1) hypothesized that hs-cTn ...References1. Walter J, du Fay de Lavallaz J, Koechlin L, et al. Using high-sensitivity cardiac troponin for the exclusion of inducible myocardial ischemia in symptomatic patients. A cohort study. Ann Intern Med. 2020;172:175-85. doi:10.7326/M19-0080 LinkGoogle Scholar2. Bell KJL, Doust J, Glasziou P, et al. Recognizing the potential for overdiagnosis: are high-sensitivity cardiac troponin assays an example? Ann Intern Med. 2019;170:259-61. [PMID: 30716768]. doi:10.7326/M18-2645 LinkGoogle Scholar3. Lord SJ, St John A, Bossuyt PM, et al; Test Evaluation Working Group of the European Federation of Clinical Chemistry and Laboratory Medicine. Setting clinical performance specifications to develop and evaluate biomarkers for clinical use. Ann Clin Biochem. 2019;56:527-35. [PMID: 30987429] doi:10.1177/0004563219842265 CrossrefMedlineGoogle Scholar4. Bairey Merz CN, Pepine CJ, Walsh MN, et al. Ischemia and no obstructive coronary artery disease (INOCA): developing evidence-based therapies and research agenda for the next decade. Circulation. 2017;135:1075-92. [PMID: 28289007] doi:10.1161/CIRCULATIONAHA.116.024534 CrossrefMedlineGoogle Scholar5. Mitchell JD, Brown DL. Harmonizing the paradigm with the data in stable coronary artery disease: a review and viewpoint. J Am Heart Assoc. 2017;6. [PMID: 29133520] doi:10.1161/JAHA.117.007006 CrossrefMedlineGoogle Scholar6. Phend C. Post-ISCHEMIA: focus turns to testing for stable angina. 17 November 2019. Accessed at www.medpagetoday.com/meetingcoverage/aha/83400 on 29 November 2019. Google Scholar7. Sedlis SP, Hartigan PM, Teo KK, et al; COURAGE Trial Investigators. Effect of PCI on long-term survival in patients with stable ischemic heart disease. N Engl J Med. 2015;373:1937-46. [PMID: 26559572] doi:10.1056/NEJMoa1505532 CrossrefMedlineGoogle Scholar8. Al-Lamee R, Thompson D, Dehbi HM, et al; ORBITA investigators. Percutaneous coronary intervention in stable angina (ORBITA): a double-blind, randomised controlled trial. Lancet. 2018;391:31-40. [PMID: 29103656] doi:10.1016/S0140-6736(17)32714-9 CrossrefMedlineGoogle Scholar9. Glasziou P, Irwig L, Deeks JJ. When should a new test become the current reference standard? Ann Intern Med. 2008;149:816-22. [PMID: 19047029] LinkGoogle Scholar10. Kaura A, Panoulas V, Glampson B, et al. Association of troponin level and age with mortality in 250 000 patients: cohort study across five UK acute care centres. BMJ. 2019;367:l6055. [PMID: 31748235] doi:10.1136/bmj.l6055 CrossrefMedlineGoogle Scholar Author, Article, and Disclosure InformationAffiliations: The University of Sydney, Sydney, New South Wales, Australia (K.J.B.)The University of Sydney and Royal Prince Alfred Hospital, Sydney, New South Wales, Australia (C.S.)Bond University, Gold Coast, Queensland, Australia (J.D.)Financial Support: Dr. Bell is the recipient of a National Health and Medical Research Council Investigator Grant (1174523). Dr. Semsarian is the recipient of a National Health and Medical Research Council Practitioner Fellowship (1154992).Disclosures: Authors have disclosed no conflicts of interest. Forms can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M19-3731.Corresponding Author: Katy J.L. Bell, MBChB, MMed(Clin Epi), PhD, School of Public Health, Edward Ford Building (A27), The University of Sydney, Sydney, NSW 2006, Australia; e-mail, katy.[email protected]edu.au.Current Author Addresses: Dr. Bell: School of Public Health, Edward Ford Building (A27), The University of Sydney, Sydney, NSW 2006, Australia.Dr. Semsarian: Centenary Institute, The University of Sydney, Sydney, NSW 2006, Australia.Dr. Doust: Centre for Research in Evidence-Based Practice, Health Sciences and Medicine, Bond University, Bond, QLD 4229, Australia.This article was published at Annals.org on 7 January 2020. PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetailsSee AlsoUsing High-Sensitivity Cardiac Troponin for the Exclusion of Inducible Myocardial Ischemia in Symptomatic Patients Joan Walter , Jeanne du Fay de Lavallaz , Luca Koechlin , Tobias Zimmermann , Jasper Boeddinghaus , Ursina Honegger , Ivo Strebel , Raphael Twerenbold , Melissa Amrein , Thomas Nestelberger , Desiree Wussler , Christian Puelacher , Patrick Badertscher , Michael Zellweger , Gregor Fahrni , Raban Jeger , Christoph Kaiser , Tobias Reichlin , and Christian Mueller Metrics 4 February 2020Volume 172, Issue 3Page: 214-215KeywordsAcute coronary syndromeAnginaAngiographyCoronary revascularizationHigh sensitivity cardiac troponinIschemiaMyocardial infarctionPercutaneous coronary interventionRevascularizationStable coronary artery disease ePublished: 7 January 2020 Issue Published: 4 February 2020 Copyright & PermissionsCopyright © 2020 by American College of Physicians. 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