Myoglobin for early risk stratification of emergency department patients with possible myocardial ischemia

Objectives: To determine and compare the prognostic abilities of early, sin gle-sample myoglobin measurement with that of creatine kinase-MB (CK-MB), w ith cardiac troponin T (cTnT), and with physician judgment in the absence o f marker results among emergency department (ED) patients with possible myo cardial ischemia. Methods: Prospective collection of clinical and serologic data using an identity-unlinked technique from patients with possible myoc ardial ischemia at two urban EDs. Outcome data concerning the occurrence of adverse events (AEs) during the 14 days after enrollment were used to calc ulate and compare the relative risks (RRs) and predictive values (with 95% confidence intervals) of the various markers for predicting AEs. Results: A mong 396 analyzed patients, 65 (16.4%) accrued 104 AEs, including 13 deaths (3.3%) and 31(7.8%) myocardial infarctions. Myoglobin predicted AEs (RR = 3.36 [95% CI = 2.19 to 5.15]) with significantly higher sensitivity (50.8% [95% CI = 38.6 to 62.9]) than either CK-MB (15.4% [95% CI = 6.6 to 24.2]) o r cTnT (24.6% [95% CI = 14.1 to 35.1]) but with lower specificity (81.9% [9 5% CI = 77.7 to 86.0]; CK-MB = 99.7% [95% CI = 99.1 to 100]; cTnT = 93.1% [ 95% CI = 90.3 to 95.8]). Myoglobin had prognostic ability among patients wi th chest pain (3.86 [95% CI = 2.39 to 6.22]) and atypical (non-chest pain) presentations (2.71 [95% CI = 1.09 to 6.71]), including those with a nondia gnostic electrocardiogram (3.11 [95% CI = 1.44 to 6.69]). The combination o f myoglobin and physician decision making identified 63 of the 65 patients (96.9% [95% CI = 92.7 to 100]) with subsequent AEs. Conclusions: The early prognostic sensitivity of myoglobin may allow identification of some high-r isk patients missed by physician judgment, CK-MB, and cTnT. Myoglobin shoul d be considered for use in the ED based on both its diagnostic and prognost ic abilities.