Chest Pain in Cancer Patients: Prevalence of Myocardial Infarction and Performance of High-Sensitivity Cardiac Troponins

Paolo Bima; Pedro Lopez-Ayala; Luca Koechlin; Jasper Boeddinghaus; Thomas Nestelberger; Bernhard Okamura; Tamar S Muench-Gerber; Alessandra Sanzone; Daria Skolozubova; David Djurdjevic; Maria Rubini Gimenez; Karin Wildi; Oscar Miro; Gemma Martínez-Nadal; Francisco J Martin-Sanchez; Michael Christ; Dagmar Keller; Bertil Lindahl; Evangelos Giannitsis; Christian Mueller; APACE and TRAPID-AMI Investigators

doi:10.1016/j.jaccao.2023.08.001

Chest Pain in Cancer Patients: Prevalence of Myocardial Infarction and Performance of High-Sensitivity Cardiac Troponins

JACC CardioOncol. 2023 Aug 26;5(5):591-609. doi: 10.1016/j.jaccao.2023.08.001. eCollection 2023 Oct.

Authors

Paolo Bima^{1

2

3}, Pedro Lopez-Ayala^{1

2}, Luca Koechlin^{1

2

4}, Jasper Boeddinghaus^{1

2

5}, Thomas Nestelberger^{1

2}, Bernhard Okamura^{1

2}, Tamar S Muench-Gerber^{1

2}, Alessandra Sanzone^{1

2}, Daria Skolozubova¹, David Djurdjevic¹, Maria Rubini Gimenez^{1

6}, Karin Wildi^{1

2}, Oscar Miro⁷, Gemma Martínez-Nadal⁷, Francisco J Martin-Sanchez⁸, Michael Christ⁹, Dagmar Keller¹⁰, Bertil Lindahl¹¹, Evangelos Giannitsis¹², Christian Mueller^{1

2}; APACE and TRAPID-AMI Investigators

Affiliations

¹ Cardiovascular Research Institute Basel and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland.
² GREAT Network, Rome, Italy.
³ Department of Medical Sciences, University of Torino, Torino, Italy.
⁴ Department of Cardiac Surgery, University Hospital Basel, University of Basel, Basel, Switzerland.
⁵ BHF/University Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom.
⁶ Cardiology Department, Herzzentrum Leipzig, Leipzig, Germany.
⁷ Emergency Department, Hospital Clinic, Barcelona, Spain.
⁸ Emergency Department, Hospital Clínico San Carlos, Madrid, Spain.
⁹ Department of Emergency Medicine, Luzerner Kantonsspital, Luzern, Switzerland.
¹⁰ Emergency Department, University Hospital Zurich, Zurich, Switzerland.
¹¹ Department of Medical Sciences, Uppsala University, Uppsala, Sweden.
¹² Department of Medicine III, University Hospital Heidelberger, Heidelberg, Germany.

Abstract

Background: Little is known about patients with cancer presenting with acute chest discomfort to the emergency department (ED).

Objectives: The aim of this study was to assess the prevalence of acute myocardial infarction (AMI), outcomes, and the diagnostic utility of recommended diagnostic tools in this population.

Methods: Patients presenting with chest pain to the ED were prospectively enrolled in an international multicenter diagnostic study with central adjudication. Cancer status was assessed prospectively and additional cancer details retrospectively. Findings were externally validated in an independent multicenter cohort.

Results: Among 8,267 patients, 711 (8.6%) had cancer. Patients with cancer had a higher burden of cardiovascular risk factors and pre-existing cardiac disease. Total length of stay in the ED (5.2 hours vs 4.3 hours) and hospitalization rate (49.8% vs 34.3%) were both increased in patients with cancer (P < 0.001 for both). Among 8,093 patients eligible for the AMI analyses, those with cancer more often had final diagnoses of AMI (184 of 686 with cancer [26.8%] vs 1,561 of 7,407 without cancer [21.1%]; P < 0.001). In patients with cancer, high-sensitivity cardiac troponin T (hs-cTnT) but not high sensitivity cardiac troponin I (hs-cTnI) concentration had lower diagnostic accuracy for non-ST-segment elevation myocardial infarction (for hs-cTnT, area under the curve: 0.89 [95% CI: 0.86-0.92] vs 0.94 [95% CI: 0.93-0.94] [P < 0.001]; for hs-cTnI, area under the curve: 0.93 [95% CI: 0.91-0.95] vs 0.95 [95% CI: 0.94-0.95] [P = 0.10]). In patients with cancer, the European Society of Cardiology 0/1-hour hs-cTnT and hs-cTnI algorithms maintained very high safety but had lower efficacy, with twice the number of patients remaining in the observe zone. Similar findings were obtained in the external validation cohort.

Conclusions: Patients with cancer have a substantially higher prevalence of AMI as the cause of chest pain. Length of ED stay and hospitalization rates are increased. The diagnostic performance of hs-cTnT and the efficacy of both the European Society of Cardiology 0/1-hour hs-cTnT and hs-cTnI algorithms is reduced. (Advantageous Predictors of Acute Coronary Syndromes Evaluation [APACE] Study; NCT00470587).

Keywords: acute coronary syndrome; biomarkers; cancer survivorship; coronary artery disease; diagnosis; outcomes.

Associated data

ClinicalTrials.gov/NCT00470587