AIMS: The presence of accompanying dyspnoea is routinely assessed and common in patients presenting with acute chest pain/discomfort to the emergency department (ED). We aimed to assess the association of accompanying dyspnoea with differential diagnoses, diagnostic work-up, and outcome. METHODS AND RESULTS: We enrolled patients presenting to the ED with chest pain/discomfort. Final diagnoses were adjudicated by independent cardiologists using all information including cardiac imaging. The primary diagnostic endpoint was the final diagnosis. The secondary diagnostic endpoint was the performance of high-sensitivity cardiac troponin (hs-cTn) and the European Society of Cardiology (ESC) 0/1h-algorithms for the diagnosis of myocardial infarction (MI). The prognostic endpoints were cardiovascular and all-cause mortality at two years. Among 6045 patients, 2892/6045 (48%) had accompanying dyspnoea. The prevalence of acute coronary syndrome (ACS) in patients with vs. without dyspnoea was comparable (MI 22.4% vs. 21.9%, P = 0.60, unstable angina 8.7% vs. 7.9%, P = 0.29). In contrast, patients with dyspnoea more often had cardiac, non-coronary disease (15.3% vs. 10.2%, P < 0.001). Diagnostic accuracy of hs-cTnT/I concentrations was not affected by the presence of dyspnoea (area under the curve 0.89-0.91 in both groups), and the safety of the ESC 0/1h-algorithms was maintained with negative predictive values >99.4%. Accompanying dyspnoea was an independent predictor for cardiovascular and all-cause death at two years [hazard ratio 1.813 (95% confidence intervals, 1.453-2.261, P < 0.01)]. CONCLUSION: Accompanying dyspnoea was not associated with a higher prevalence of ACS but with cardiac, non-coronary disease. While the safety of the diagnostic work-up was not affected, accompanying dyspnoea was an independent predictor for cardiovascular and all-cause death. CLINICAL TRIAL REGISTRATION: https://clinicaltrials.gov/ct2/show/NCT00470587, number NCT00470587.

BHF Centre for Cardiovascular Science University of Edinburgh Scotland United Kingdom

Cardiovascular Research Institute Basel and Department of Cardiology University Hospital Basel University of Basel Petersgraben 4 CH 4031 Basel Switzerland

Critical Care Research Group The Prince Charles Hospital Brisbane and the University of Queensland Brisbane Australia

Department of Cardiac Surgery University Hospital Basel University of Basel Switzerland

Department of Cardiology University Hospital Brno Brno Czech Republic and Medical Faculty Masaryk University Brno Czech Republic

Department of Intensive Care Medicine University Hospital Basel University of Basel Basel Switzerland

Division of Internal Medicine University Hospital Basel University of Basel Switzerland

Emergency Department Hospital Clinic Barcelona Catalonia Spain

Emergency Department Kantonsspital Luzern Switzerland

Emergency Department University Hospital Basel University of Basel Switzerland

Emergency Department University Hospital Zurich Zurich Switzerland

GREAT network Rome Italy

Leipzig Heart Center Leipzig Germany

Servicio de Urgencias Hospital Clínico San Carlos Madrid Spain

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Twerenbold  R, Boeddinghaus  J, Nestelberger  T, Wildi  K, Rubini Gimenez  M, Badertscher  P, et al.  Clinical use of high-sensitivity cardiac troponin in patients with suspected myocardial infarction. J Am Coll Cardiol  2017;70:996–1012. PubMed

Virani  SS, Alonso  A, Benjamin  EJ, Bittencourt  MS, Callaway  CW, Carson  AP, et al.  Heart disease and stroke statistics—2020 update: a report from the American Heart Association. Circulation  2020;141:e139–e596. PubMed

Collet  JP, Thiele  H, Barbato  E, Bauersachs  J, Dendale  P, Edvardsen  T, et al.  2020 ESC guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation. Eur Heart J  2021;42:1289–1367. PubMed

Giannitsis  E, Kurz  K, Hallermayer  K, Jarausch  J, Jaffe  AS, Katus  HA. Analytical validation of a high-sensitivity cardiac troponin T assay. Clin Chem  2010;56:254–261. PubMed

Reichlin  T, Hochholzer  W, Bassetti  S, Steuer  S, Stelzig  C, Hartwiger  S, et al.  Early diagnosis of myocardial infarction with sensitive cardiac troponin assays. N Engl J Med  2009;361:858–867. PubMed

Keller  T, Zeller  T, Peetz  D, Tzikas  S, Roth  A, Czyz  E, et al.  Sensitive troponin I assay in early diagnosis of acute myocardial infarction. N Engl J Med  2009;361:868–877. PubMed

Reichlin  T, Schindler  C, Drexler  B, Twerenbold  R, Reiter  M, Zellweger  C, et al.  One-hour rule-out and rule-in of acute myocardial infarction using high-sensitivity cardiac troponin T. Arch Intern Med  2012;172:1211–1218. PubMed

Gimenez  MR, Twerenbold  R, Jaeger  C, Schindler  C, Puelacher  C, Wildi  K, et al.  One-hour rule-in and rule-out of acute myocardial infarction using high-sensitivity cardiac troponin I. Am J Med  2015;128:861–870.e4. PubMed

Boeddinghaus  J, Reichlin  T, Cullen  L, Greenslade  JH, Parsonage  WA, Hammett  C, et al.  Two-hour algorithm for triage toward rule-out and rule-in of acute myocardial infarction by use of high-sensitivity cardiac troponin I. Clin Chem  2016;62:494–504. PubMed

Reichlin  T, Cullen  L, Parsonage  WA, Greenslade  J, Twerenbold  R, Moehring  B, et al.  Two-hour algorithm for triage toward rule-out and rule-in of acute myocardial infarction using high-sensitivity cardiac troponin T. Am J Med  2015;128:369–379.e4. PubMed

Reichlin  T, Twerenbold  R, Wildi  K, Gimenez  MR, Bergsma  N, Haaf  P, et al.  Prospective validation of a 1-hour algorithm to rule-out and rule-in acute myocardial infarction using a high-sensitivity cardiac troponin T assay. CMAJ  2015;187:E243–E252. PubMed PMC

Biener  M, Mueller  M, Vafaie  M, Katus  HA, Giannitsis  E. Impact of leading presenting symptoms on the diagnostic performance of high-sensitivity cardiac troponin T and on outcomes in patients with suspected acute coronary syndrome. Clin Chem  2015;61:744–751. PubMed

Sörensen  NA, Neumann  JT, Ojeda  F, Schäfer  S, Magnussen  C, Keller  T, et al.  Relations of sex to diagnosis and outcomes in acute coronary syndrome. J Am Heart Assoc  2018;7:e007297. PubMed PMC

Thang  ND, Karlson  BW, Sundström  BW, Karlsson  T, Herlitz  J. Pre-hospital prediction of death or cardiovascular complications during hospitalisation and death within one year in suspected acute coronary syndrome patients. Int J Cardiol  2015;185:308–312. PubMed

Renier  W, Winckelmann  KH, Verbakel  JY, Aertgeerts  B, Buntinx  F. Signs and symptoms in adult patients with acute dyspnea. Eur J Emerg Med  2018;25:3–11. PubMed

Hellenkamp  K, Darius  H, Giannitsis  E, Erbel  R, Haude  M, Hamm  C, et al.  The German CPU Registry: dyspnea independently predicts negative short-term outcome in patients admitted to German chest pain units. Int J Cardiol  2015;181:88–95. PubMed

Pelter  MM, Riegel  B, McKinley  S, Moser  DK, Doering  LV, Meischke  H, et al.  Are there symptom differences in patients with coronary artery disease presenting to the ED ultimately diagnosed with or without ACS?  Am J Emerg Med  2012;30:1822–1828. PubMed PMC

Lippi  G, Sanchis-Gomar  F, Cervellin  G. Chest pain, dyspnea and other symptoms in patients with type 1 and 2 myocardial infarction. A literature review. Int J Cardiol  2016;215:20–22. PubMed

Reichlin  T, Irfan  A, Twerenbold  R, Reiter  M, Hochholzer  W, Burkhalter  H, et al.  Utility of absolute and relative changes in cardiac troponin concentrations in the early diagnosis of acute myocardial infarction. Circulation  2011;124:136–145. PubMed

Reiter  M, Twerenbold  R, Reichlin  T, Haaf  P, Peter  F, Meissner  J, et al.  Early diagnosis of acute myocardial infarction in the elderly using more sensitive cardiac troponin assays. Eur Heart J  2011;32:1379–1389. PubMed

Boeddinghaus  J, Nestelberger  T, Twerenbold  R, Neumann  JT, Lindahl  B, Giannitsis  E, et al.  Impact of age on the performance of the ESC 0/1h-algorithms for early diagnosis of myocardial infarction. Eur Heart J  2018;39:3780–3794. PubMed

Twerenbold  R, Costabel  JP, Nestelberger  T, Campos  R, Wussler  D, Arbucci  R, et al.  Outcome of applying the ESC 0/1-hour algorithm in patients with suspected myocardial infarction. J Am Coll Cardiol  2019;74:483–494. PubMed

Boeddinghaus  J, Nestelberger  T, Koechlin  L, Wussler  D, Lopez-Ayala  P, Walter  JE, et al.  Early diagnosis of myocardial infarction with point-of-care high-sensitivity cardiac troponin I. J Am Coll Cardiol  2020;75:1111–1124. PubMed

von Elm  E, Altman  DG, Egger  M, Pocock  SJ, Gøtzsche  PC, Vandenbroucke  JP, et al.  The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies. Lancet  2007;370:1453–1457. PubMed

Twerenbold  R, Neumann  JT, Sörensen  NA, Ojeda  F, Karakas  M, Boeddinghaus  J, et al.  Prospective validation of the 0/1-h algorithm for early diagnosis of myocardial infarction. J Am Coll Cardiol  2018;72:620–632. PubMed

Boeddinghaus  J, Nestelberger  T, Twerenbold  R, Wildi  K, Badertscher  P, Cupa  J, et al.  Direct comparison of 4 very early rule-out strategies for acute myocardial infarction using high-sensitivity cardiac troponin I. Circulation  2017;135:1597–1611. PubMed

Nestelberger  T, Boeddinghaus  J, Lopez-Ayala  P, Kaier  TE, Marber  M, Gysin  V, et al.  Cardiovascular biomarkers in the early discrimination of type 2 myocardial infarction. JAMA Cardiol  2021;6:771–780. PubMed PMC

Lopez-Ayala  P, Nestelberger  T, Boeddinghaus  J, Koechlin  L, Ratmann  PD, Strebel  I, et al.  Novel criteria for the observe-zone of the ESC 0/1h-hs-cTnT algorithm. Circulation  2021;144:773–787. PubMed

Thygesen  K, Alpert  JS, Jaffe  AS, Chaitman  BR, Bax  JJ, Morrow  DA, et al.  ESC scientific document group. Fourth universal definition of myocardial infarction (2018). Eur Heart J  2019;40:237–269. PubMed

Hanley  JA, McNeil  BJ. The meaning and use of the area under a receiver operating characteristic (ROC) curve. Radiology  1982;143:29–36. PubMed

Twerenbold  R, Badertscher  P, Boeddinghaus  J, Nestelberger  T, Wildi  K, Puelacher  C, et al.  0/1-Hour triage algorithm for myocardial infarction in patients with renal dysfunction. Circulation  2018;137:436–451. PubMed PMC

Miller-Hodges  E, Anand  A, Shah  ASV, Chapman  AR, Gallacher  P, Lee  KK, et al.  High-sensitivity cardiac troponin and the risk stratification of patients with renal impairment presenting with suspected acute coronary syndrome. Circulation  2018;137:425–435. PubMed PMC

Abidov  A, Rozanski  A, Hachamovitch  R, Hayes  SW, Aboul-Enein  F, Cohen  I, et al.  Prognostic significance of dyspnea in patients referred for cardiac stress testing. N Engl J Med  2005;353:1889–1898. PubMed

Green  SM, Martinez-Rumayor  A, Gregory  SA, Baggish  AL, O’Donoghue  ML, Green  JA, et al.  Clinical uncertainty, diagnostic accuracy, and outcomes in emergency department patients presenting with dyspnea. Arch Intern Med  2008;168:741–748. PubMed

Bøtker  MT, Stengaard  C, Andersen  MS, Søndergaard  HM, Dodt  KK, Niemann  T, et al.  Dyspnea, a high-risk symptom in patients suspected of myocardial infarction in the ambulance? A population-based follow-up study. Scand J Trauma Resusc Emerg Med  2016;24:15. PubMed PMC

Jaeger  C, Wildi  K, Twerenbold  R, Reichlin  T, Rubini Gimenez  M, Neuhaus  J-D, et al.  One-hour rule-in and rule-out of acute myocardial infarction using high-sensitivity cardiac troponin I. Am Heart J  2016;171:92–102.e5. PubMed

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ClinicalTrials.gov
NCT00470587