Coronary angiography findings in emergency department chest pain patients undergoing angiography despite hs-cTnT-based early rule-out angiography after hs-cTnT rule-out in ED chest pain.
Avlac A, Altınbilek E, et al. • Open heart • 2026
Among selected ED patients undergoing urgent CAG despite hs-cTnT-based rule-out, intermediate or significant stenosis was common, with significant stenosis found in 29.0% and intermediate stenosis in 58.5% of the angiographic cohort.
Key Findings
Results
The majority of ED chest pain patients who underwent urgent coronary angiography despite fulfilling hs-cTnT-based early rule-out criteria had anatomically significant or intermediate coronary stenosis.
Of 646 total patients fulfilling rule-out criteria, 376 underwent urgent coronary angiography during index hospitalisation
Significant stenosis (≥70% in a major non-left-main epicardial artery or ≥50% in the left main) was found in 109 patients (29.0%)
Intermediate stenosis (50%-69% in a non-left-main artery) was found in 220 patients (58.5%)
Non-obstructive coronary artery disease (<50%) was found in 47 patients (12.5%)
Combined intermediate or significant stenosis was present in 87.5% of those who underwent angiography
Results
Baseline and 1-hour hs-cTnT concentrations differed significantly across angiographic categories, with the highest values in the significant stenosis group and the lowest in the non-obstructive group.
All patients fulfilled the ESC 0/1-hour rule-out pathway: baseline hs-cTnT <12 ng/L and a 1-hour absolute change <3 ng/L
Despite all patients meeting rule-out thresholds, baseline hs-cTnT concentrations stratified meaningfully across angiographic severity groups
The significant stenosis group had the highest hs-cTnT concentrations and the non-obstructive group had the lowest
HEART scores also differed significantly across angiographic categories in the same directional pattern
Results
The 1-hour and relative 1-hour hs-cTnT changes differed overall across angiographic groups, but significant pairwise differences were limited to the intermediate and non-obstructive groups.
Overall statistical differences in 1-hour absolute and relative hs-cTnT changes were observed across the three angiographic categories
Pairwise comparisons revealed that significant differences were limited to comparisons between the intermediate stenosis and non-obstructive disease groups
Relative hs-cTnT change showed limited discrimination for non-obstructive disease
These findings suggest that delta troponin values within rule-out thresholds have limited ability to distinguish between angiographic severity groups
Results
The HEART score showed moderate discrimination for ≥50% angiographic stenosis, outperforming relative hs-cTnT change for this outcome.
HEART score (History, ECG, Age, Risk factors and Troponin) demonstrated moderate discriminatory ability for detecting ≥50% coronary stenosis
Relative hs-cTnT change showed limited discrimination for non-obstructive disease
HEART scores were highest in the significant stenosis group and lowest in the non-obstructive group, consistent with its directional utility
The authors note these findings are descriptive and do not establish culprit-lesion status, functional significance, or appropriateness of angiography
Methods
This was a retrospective single-centre study of adults with suspected acute coronary syndrome spanning a three-year period from January 2020 to January 2023.
646 total patients fulfilled the serial ESC 0/1-hour rule-out pathway criteria and were included
Rule-out was defined as baseline hs-cTnT <12 ng/L and a 1-hour absolute change <3 ng/L
376 of the 646 qualifying patients underwent urgent CAG during index hospitalisation and comprised the angiographic cohort
The study explicitly states findings do not establish failure of the hs-cTnT rule-out algorithm, as the clinical rationale for proceeding to angiography despite rule-out criteria is not characterized
Background
High-sensitivity cardiac troponin algorithms are established for early rule-out of acute myocardial infarction, but coronary angiographic findings in ED patients undergoing invasive evaluation despite fulfilling rule-out criteria were previously insufficiently described.
The stated gap in knowledge was the characterization of coronary anatomy and clinical profile in this specific population
The ESC 0/1-hour pathway using hs-cTnT was the rule-out algorithm applied
Angiographic findings were categorized into three groups: significant stenosis, intermediate stenosis, and non-obstructive CAD
The authors emphasize the study is descriptive and cannot determine whether angiography was appropriate or whether the rule-out algorithm failed in these cases
What This Means
This research examined what doctors actually found when they performed invasive heart artery imaging (coronary angiography) in emergency department patients who had already tested 'negative' for heart attack using a highly sensitive blood test for troponin (a protein released when heart muscle is damaged). Normally, when patients meet the criteria for early rule-out of heart attack using this blood test, invasive procedures are not expected to be necessary. However, some patients in this study still underwent urgent coronary angiography during their hospital stay. Among those 376 patients, nearly 90% had meaningful narrowing of their coronary arteries — 29% had severe narrowing and 58.5% had intermediate narrowing — with only 12.5% showing no significant disease.
The study also found that even though all patients had troponin levels below the rule-out thresholds, those with more severe artery narrowing tended to have slightly higher troponin values and higher HEART scores (a clinical risk scoring tool) compared to those with less disease. The HEART score showed moderate ability to predict who would have at least 50% artery narrowing, while the change in troponin over one hour was less useful for this purpose. Importantly, the authors caution that these findings are purely descriptive — the study cannot determine whether the angiographies were medically necessary, whether the arteries found to be narrowed were actually responsible for the patients' symptoms, or whether the troponin-based rule-out process 'failed' in these cases.
This research suggests that a substantial proportion of chest pain patients who meet standard blood-test-based rule-out criteria for heart attack may still have significant underlying coronary artery disease detected if invasive testing is performed — though whether that testing was warranted in these cases remains an open question. The findings highlight that troponin-based rule-out algorithms are designed to identify acute heart attacks, not to exclude the presence of stable or pre-existing coronary artery disease, and that clinical judgment and tools like the HEART score may play an important complementary role in managing these patients.
Avlac A, Altınbilek E, Sönmez B, Öztürk D, Civelek &, Çelik S. (2026). Coronary angiography findings in emergency department chest pain patients undergoing angiography despite hs-cTnT-based early rule-out angiography after hs-cTnT rule-out in ED chest pain.. Open heart. https://doi.org/10.1136/openhrt-2026-004186