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Symptoms Predictive of Acute Myocardial Infarction in the Troponin Era

Analysis From the TRAPID-AMI Study

McCord, James, MD*; Aurora, Lindsey, MD; Lindahl, Bertil, MD; Giannitsis, Evangelos, MD§; Calle-Muller, Carlos, MD; Nowak, Richard, MD; Body, Richard, MB ChB, PhD**; Christ, Michael, MD††; deFilippi, Christopher R., MD‡‡; Christenson, Robert H., PhD§§; Jacobsen, Gordon, MS¶¶; Alquezar, Aitor, MD, PhD‖‖; Panteghini, Mauro, MD***; Melki, Dina, MD, PhD†††; Plebani, Mario, MD‡‡‡; Verschuren, Franck, PhD§§§; French, John, PhD¶¶¶; Bendig, Garnet, PhD‖‖‖; Weiser, Silvia, PhD‖‖‖; Mueller, Christian, MD**** for the TRAPID-AMI Investigators

Critical Pathways in Cardiology: March 2019 - Volume 18 - Issue 1 - p 10–15
doi: 10.1097/HPC.0000000000000163
Original Articles
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The TRAPID-AMI (High Sensitivity Cardiac Troponin T assay for rapid Rule-out of Acute Myocardial Infarction) study evaluated a rapid “rule-out” acute myocardial infarction (AMI). We evaluated what symptoms were associated with AMI as part of a substudy of TRAPID-AMI. There were 1282 patients evaluated from 12 centers in Europe, the United States of America, and Australia from 2011 to 2013. Multiple symptom variables were prospectively obtained and evaluated for association with the final diagnosis of AMI. Multivariate logistic regression analysis was done, and odds ratios (OR) were calculated. There were 213/1282 (17%) AMIs. Four independent predictors for the diagnosis of AMI were identified: radiation to right arm or shoulder [OR = 3.0; confidence interval (CI): 1.8–5.0], chest pressure (OR = 2.5; CI: 1.3–4.6), worsened by physical activity (OR = 1.7; CI: 1.2–2.5), and radiation to left arm or shoulder (OR = 1.7; CI: 1.1–2.4). In the entire group, 131 (10%) had radiation to right arm or shoulder, 897 (70%) had chest pressure, 385 (30%) worsened with physical activity, and 448 (35%) had radiation to left arm or shoulder. Duration of symptoms was not predictive of AMI. There were no symptoms predictive of non-AMI. Relationship between AMI size and symptoms was also studied. For 213 AMI patients, cardiac troponins I values were divided into 4 quartiles. Symptoms including pulling chest pain, supramammillary right location, and right arm/shoulder radiation were significantly more likely to occur in patients with larger AMIs. In a large multicenter trial, only 4 symptoms were associated with the diagnosis of AMI, and no symptoms that were associated with a non-AMI diagnosis.

From the *Heart & Vascular Institute

Department of Internal Medicine, Henry Ford Hospital, Detroit, MI

Department of Medical Sciences and Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden

§Department of Internal Medicine III, Cardiology, Angiology, and Pulmonology, University Hospital Heidelberg, Heidelberg, Germany

Cardiology Division, Emory University School of Medicine, Atlanta, GA

Department of Emergency Medicine, Henry Ford Hospital, Detroit, MI

**Central Manchester University Hospitals NHS Foundation Trust, Manchester, United Kingdom

††Department of Emergency and Critical Care Medicine, General Hospital, Paracelsus Medical University, Nuremberg, Germany

‡‡Department of Medicine, Inova Heart and Vascular Institute, Falls Church, VA

§§Department of Pathology, University of Maryland School of Medicine, Baltimore, MD

¶¶Department of Public Health Sciences, Henry Ford Health System, Detroit, MI

‖‖Department of Emergency Medicine, Hospital de Sant Pau, Barcelona, Spain

***Department of Biomedical and Clinical Sciences ‘Luigi Sacco’, University of Milan Medical School, Milano, Italy

†††Department of Medicine, Karolinska Institutet, Huddinge, Sweden and Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden

‡‡‡Department of Laboratory Medicine, University Hospital of Padova, Padua, Italy

§§§Cliniques Universitaires St-Luc and Universite Catholique de Louvain, Brussels, Belgium

¶¶¶Liverpool Hospital and University of New South Wales, Sydney, Australia

‖‖‖Roche Diagnostics Germany, Penzberg, Germany

****Cardiology and Cardiovascular Research Institute Basel, University Hospital Basel, Switzerland.

Received for publication June 12, 2018; accepted August 9, 2018.

The study was financially supported by Roche Diagnostics.

Reprints: James McCord, MD, Henry Ford Heart and Vascular Institute, Henry Ford Health System, 2799 West Grand Blvd K-14, Detroit, MI 48202. E-mail: jmccord1@hfhs.org.

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