• Muhammad Hammadah, Jeong Hwan Kim, TahhanAyman SammanASEmory University School of Medicine, Atlanta, Georgia (M.H., J.H.K., A.S.T., B.K., C.L., I.A., K.W., R.R., A.A., F.C., M.M.G., N.A., P.S., B.B.L., J.D.B., L.S.S., A.A.Q.)., Bryan Kindya, Chang Liu, Yi-An Ko, Ibhar Al Mheid, Kobina Wilmot, Ronnie Ramadan, Ayman Alkhoder, Fahad Choudhary, Mohamad Mazen Gafeer, Naser Abdelhadi, Pratik Pimple, Pratik Sandesara, Bruno B Lima, Amit J Shah, Laura Ward, Michael Kutner, J Douglas Bremner, David S Sheps, Paolo Raggi, Laurence S Sperling, Viola Vaccarino, and Arshed A Quyyumi.
• Emory University School of Medicine, Atlanta, Georgia (M.H., J.H.K., A.S.T., B.K., C.L., I.A., K.W., R.R., A.A., F.C., M.M.G., N.A., P.S., B.B.L., J.D.B., L.S.S., A.A.Q.).
• Ann. Intern. Med. 2018 Dec 4; 169 (11): 751760751-760.

BackgroundMany patients with coronary artery disease (CAD) are routinely referred for surveillance stress testing despite recommendations against it.ObjectiveTo determine whether low levels of resting high-sensitivity cardiac troponin I (hs-cTnI) can identify persons without inducible myocardial ischemia.DesignObservational study.SettingA university-affiliated hospital network.PatientsPersons with stable CAD: 589 in the derivation group and 118 in the validation cohort.MeasurementsPresence of inducible myocardial ischemia was determined by myocardial perfusion imaging with technetium-99m single-photon emission computed tomography during either treadmill or pharmacologic stress testing. Resting plasma hs-cTnI was measured within 1 week of the stress test, and the negative predictive value (NPV) for inducible ischemia was calculated. The derivation cohort was followed for 3 years for incident cardiovascular death and myocardial infarction.ResultsIn the derivation cohort, 10 of 101 patients with an hs-cTnI level below 2.5 pg/mL had inducible myocardial ischemia (NPV, 90% [95% CI, 83% to 95%]) and 3 of 101 had inducible ischemia involving at least 10% of the myocardium (NPV, 97% [CI, 92% to 99%]). In the validation cohort, 4 of 32 patients with an hs-cTnI level below 2.5 pg/mL had inducible ischemia (NPV, 88% [CI, 71% to 96%]) and 2 of 32 had ischemia of 10% or greater (NPV, 94% [CI, 79% to 99%]). After a median follow-up of 3 years in the derivation cohort, no adverse events occurred in patients with an hs-cTnI level below 2.5 pg/mL, compared with 33 (7%) cardiovascular deaths or incident myocardial infarctions among those with an hs-cTnI level of 2.5 pg/mL or greater.LimitationThe data may not be applicable to a population without known CAD or to persons with unstable angina, and the modest sample sizes warrant further validation in a larger cohort.ConclusionVery low hs-cTnI levels may be useful in excluding inducible myocardial ischemia in patients with stable CAD.Primary Funding SourceNational Institutes of Health.

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