Sex-Specific Thresholds of High-Sensitivity Troponin in Patients With Suspected Acute Coronary Syndrome
Authors: Kuan Ken Lee, Amy V. Ferry, Atul Anand, Fiona E. Strachan, Andrew R. Chapman, Dorien M. Kimenai, Steven J.R. Meex, Colin Berry, Iain Findlay, Alan Reid, Anne Cruickshank, Alasdair Gray, Paul O. Collinson, Fred S. Apple, David A. McAllister, Donogh Maguire, Keith A.A. Fox, David E. Newby, Chris Tuck, Catriona Keerie, Christopher J. Weir, Anoop S.V. Shah, Nicholas L. Mills, Nicholas L. Mills, Fiona E. Strachan, Christopher Tuck, Anoop S.V. Shah, Atul Anand, Amy V. Ferry, Kuan Ken Lee, Andrew R. Chapman, Dennis Sandeman, Philip D. Adamson, Catherine L. Stables, Catalina A. Vallejo, Athanasios Tsanasis, Lucy Marshall, Stacey D. Stewart, Takeshi Fujisawa, Mischa Hautvast, Jean McPherson, Lynn McKinlay, Nicholas L. Mills, David E. Newby, Keith A.A. Fox, Colin Berry, Simon Walker, Christopher J. Weir, Ian Ford, Nicholas L. Mills, David E. Newby, Alasdair Gray, Keith A.A. Fox, Colin Berry, Simon Walker, Paul O. Collinson, Fred S. Apple, Alan Reid, Anne Cruikshank, Iain Findlay, Shannon Amoils, David A. McAllister, Donogh Maguire, Jennifer Stevens, John Norrie, Christopher Weir, Anoop S.V. Shah, Atul Anand, Andrew R. Chapman, Kuan Ken Lee, Jack P.M. Andrews, Philip D. Adamson, Alastair Moss, Mohamed S. Anwar, John Hung, Nicholas L. Mills, Simon Walker, Jonathan Malo, Alan Reid, Anne Cruikshank, Paul O. Collinson, Colin M. Fischbacher, Bernard L. Croal, Stephen J. Leslie, Catriona Keerie, Richard A. Parker, Allan Walker, Ronnie Harkess, Christopher Tuck, Tony Wackett, Christopher Weir, Roma Armstrong, Marion Flood, Laura Stirling, Claire MacDonald, Imran Sadat, Frank Finlay, Heather Charles, Pamela Linksted, Stephen Young, Bill Alexander, Chris Duncan
Journal: Journal of the American College of Cardiology (2019)

Major disparities between women and men in the diagnosis, management, and outcomes of acute coronary syndrome are well recognized.The aim of this study was to evaluate the impact of implementing a high-sensitivity cardiac troponin I assay with sex-specific diagnostic thresholds for myocardial infarction in women and men with suspected acute coronary syndrome.Consecutive patients with suspected acute coronary syndrome were enrolled in a stepped-wedge, cluster-randomized controlled trial across 10 hospitals. Myocardial injury was defined as high-sensitivity cardiac troponin I concentration >99th centile of 16 ng/l in women and 34 ng/l in men. The primary outcome was recurrent myocardial infarction or cardiovascular death at 1 year.A total of 48,282 patients (47% women) were included. Use of the high-sensitivity cardiac troponin I assay with sex-specific thresholds increased myocardial injury in women by 42% and in men by 6%. Following implementation, women with myocardial injury remained less likely than men to undergo coronary revascularization (15% vs. 34%) and to receive dual antiplatelet (26% vs. 43%), statin (16% vs. 26%), or other preventive therapies (p < 0.001 for all). The primary outcome occurred in 18% (369 of 2,072) and 17% (488 of 2,919) of women with myocardial injury before and after implementation, respectively (adjusted hazard ratio: 1.11; 95% confidence interval: 0.92 to 1.33), compared with 18% (370 of 2,044) and 15% (513 of 3,325) of men (adjusted hazard ratio: 0.85; 95% confidence interval: 0.71 to 1.01).Use of sex-specific thresholds identified 5 times more additional women than men with myocardial injury. Despite this increase, women received approximately one-half the number of treatments for coronary artery disease as men, and outcomes were not improved. (High-Sensitivity Troponin in the Evaluation of Patients With Acute Coronary Syndrome [High-STEACS]; NCT01852123).