Chest pain and cardiac troponin flat curve: decision making and clinical differences in patients with or without acute coronary syndrome

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Abstract Introduction and Objectives Acute myocardial injury is characterized by elevated levels of cardiac troponin (cTn) above the 99th percentile upper reference limit (URL), showing a dynamic rise and/or fall (Δ). This pattern, when associated with a compatible clinical history, is indicative of acute coronary syndrome (ACS). However, some patients with chest pain present initially elevated cTn levels but with a Δ<20% (flat curve). This study aims to analyze, first of all factors influencing patient management: admission to cardiology, admission to another department, or direct discharge from the emergency room and secondly, the clinical characteristics of patients according to the final diagnosis of ACS vs non-ACS. Patients and Methods We prospectively analyzed clinical data from all patients evaluated by the Cardiology Department due to clinical suspicion of ACS and a cTn-flat curve (defined as Δ<20% in two serial high-sensitivity cTn-T determinations at 0/3 hours) from May 2023 to October 2024. Results 383 patients were included, mean age 75.9±12.4 years, 62.9% males. They were divided into three groups depending on their management: admission to cardiology (102 patients), admission to another department (82 patients) or direct discharge from the emergency department (199 patients). Summary of their clinical characteristics is provided in Table 1. On the other hand, only 82 patients (21%) had a final diagnosis os ACS. Their clinical characteristics are summarized in Table 2. Conclusions In this group of patients with suspected ACS and a cTn-flat curve, decision-making was chiefly influenced by patient symptoms and ECG abnormalities. Thorough clinical evaluation is imperative in managing such patients. In the group of patients with a final diagnosis of ACS we found: * higher percentage of males and younger age. * Higher burden of cardiovascular risk factors. * Higher cTn-T levels. * More ST-T alterations and more ECG changes (evolutive and dynamic). * More new-onset wall motion contractile abnormalities. * More high-probability ischemic symptons with higher percentage of progressive symptoms. On the other hand, ACS patients showed less atrial fibrillation.Table 1Table 2

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