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Liu L, Lewandrowski K. Establishing optimal cutoff values for high-sensitivity cardiac troponin algorithms in risk stratification of acute myocardial infarction. Crit Rev Clin Lab Sci 2024; 61:1-22. [PMID: 37466395 DOI: 10.1080/10408363.2023.2235426] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Revised: 06/11/2023] [Accepted: 07/07/2023] [Indexed: 07/20/2023]
Abstract
Acute myocardial infarction (AMI) is a leading cause of mortality globally, highlighting the need for timely and accurate diagnostic strategies. Cardiac troponin has been the biomarker of choice for detecting myocardial injury. A dynamic change in concentrations supports the diagnosis of AMI in the setting of evidence of acute myocardial ischemia. The new generation of high-sensitivity cardiac troponin (hs-cTn) assays has significantly improved analytical sensitivity but at the expense of decreased clinical specificity. As a result, sophisticated algorithms are required to differentiate AMI from non-AMI patients. Establishing optimal hs-cTn cutoffs for these algorithms to rule out and rule in AMI has been the subject of intensive investigations. These efforts have evolved from examining the utility of the hs-cTn 99th percentile upper reference limit, comparing the percentage versus absolute delta thresholds, and evaluating the performance of an early European Society of Cardiology-recommended 3 h algorithm, to the development of accelerated 1 h and 2 h algorithms that combine the admission hs-cTn concentrations and absolute delta cutoffs to rule out and rule in AMI. Specific cutoffs for individual confounding factors such as sex, age, and renal insufficiency have also been investigated. At the same time, concerns such as whether the small delta thresholds exceed the analytical and biological variations of hs-cTn assays and whether the algorithms developed in European study populations fit all other patient cohorts have been raised. In addition, the accelerated algorithms leave a substantial number of patients in a non-diagnostic observation zone. How to properly diagnose patients falling in this zone and those presenting with elevated baseline hs-cTn concentrations due to the presence of confounding factors or comorbidities remain open questions. Here we discuss the developments described above, focusing on criteria and underlying considerations for establishing optimal cutoffs. In-depth analyses are provided on the influence of biological variation, analytical imprecision, local AMI rate, and the timing of presentation on the performance metrics of the accelerated hs-cTn algorithms. Developing diagnostic strategies for patients who remain in the observation zone and those presenting with confounding factors are also reviewed.
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Affiliation(s)
- Li Liu
- Department of Pathology, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Kent Lewandrowski
- Department of Pathology, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
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2
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Haring B, Schmidt A, Frantz S. [Acute Chest Pain: A Stepwise Approach to Management]. Pneumologie 2021; 75:901-909. [PMID: 34788891 DOI: 10.1055/a-1238-5254] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Acute chest pain is one of the most important cardinal symptoms in medicine. There are several important differential diagnoses for chest pain. Therefore, a thorough history and physical examination, as well as the 12-lead ECG and laboratory tests are crucial. In clinical practice, it is useful to distinguish between cardiac chest pain and other forms of chest pain in order to treat patients appropriately and to exclude potentially life-threatening conditions.
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[52/f-Acute chest pain : Preparation for the medical specialist examination: part 93]. Internist (Berl) 2021; 62:594-598. [PMID: 34665274 DOI: 10.1007/s00108-021-01185-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/21/2021] [Indexed: 10/20/2022]
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Heger LA, Glück T, Kaier K, Hortmann M, Rieder M, Siegel PM, Diehl P, Wengenmayer T, Olivier CB, Bode C, Busch HJ, Duerschmied D, Ahrens I. Medical history of coronary artery disease and time to electrocardiogram in the emergency department: a real-life, single-center, retrospective analysis. BMC Cardiovasc Disord 2021; 21:480. [PMID: 34620090 PMCID: PMC8496093 DOI: 10.1186/s12872-021-02274-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Accepted: 08/26/2021] [Indexed: 11/15/2022] Open
Abstract
Background Timely acquisition of 12-lead Electrocardiogram (ECG) in the emergency department (ED) is crucial and recommended by current guidelines.
Objectives To evaluate the association of medical history of coronary artery disease (hCAD) on door-to-ECG time in the ED. Methods In this single center, retrospective cohort study, patients admitted to ED for cardiac evaluation were grouped according to hCAD and no hCAD. The primary outcome was door-to-ECG time. A multivariate analysis adjusted for the cofounders sex, age, type of referral and shift was performed to evaluate the association of hCAD with door-to-ECG time. Results 1101 patients were included in this analysis. 362 patients (33%) had hCAD. Patients with hCAD had shorter door-to-ECG time (20 min. [Inter Quartile Range [IQR] 13–30] vs. 22 min. [IQR 14–37]; p < 0.001) when compared to patients with no hCAD. In a multivariable regression analysis hCAD was significantly associated with a shorter door-to-ECG time (− 3 min [p = 0.007; 95% confidence Interval [CI] − 5.16 to − 0.84 min]). Conclusion In this single center registry, hCAD was associated with shorter door-to-ECG time. In patients presenting in ED for cardiac evaluation, timely ECG diagnostic should be facilitated irrespective of hCAD.
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Affiliation(s)
- Lukas Andreas Heger
- Department of Cardiology and Angiology I, Heart Center Freiburg University, Faculty of Medicine, University of Freiburg, Freiburg, Germany.
| | - Tina Glück
- Department of Cardiology and Angiology I, Heart Center Freiburg University, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Klaus Kaier
- Institute of Medical Biometry and Statistics, Faculty of Medicine and Medical Center, University of Freiburg, Freiburg, Germany.,Center of Big Data Analysis in Cardiology (CeBAC), Heart Center Freiburg University, Department of Cardiology and Angiology I, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Marcus Hortmann
- Department of Cardiology and Angiology I, Heart Center Freiburg University, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Marina Rieder
- Department of Cardiology and Angiology I, Heart Center Freiburg University, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Patrick M Siegel
- Department of Cardiology and Angiology I, Heart Center Freiburg University, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Philipp Diehl
- Department of Cardiology and Angiology I, Heart Center Freiburg University, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Tobias Wengenmayer
- Department of Cardiology and Angiology I, Heart Center Freiburg University, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Christoph B Olivier
- Department of Cardiology and Angiology I, Heart Center Freiburg University, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Christoph Bode
- Department of Cardiology and Angiology I, Heart Center Freiburg University, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Hans-Joerg Busch
- Departement of Emergency Medicine, University Medical Center Freiburg, Medical Faculty, University of Freiburg, Freiburg, Germany
| | - Daniel Duerschmied
- Department of Cardiology and Angiology I, Heart Center Freiburg University, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Ingo Ahrens
- Department of Cardiology and Medical Intensive Care, Augustinerinnen Hospital, Academic Teaching Hospital University of Cologne, Cologne, Germany
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Westwood M, Ramaekers B, Grimm S, Worthy G, Fayter D, Armstrong N, Buksnys T, Ross J, Joore M, Kleijnen J. High-sensitivity troponin assays for early rule-out of acute myocardial infarction in people with acute chest pain: a systematic review and economic evaluation. Health Technol Assess 2021; 25:1-276. [PMID: 34061019 PMCID: PMC8200931 DOI: 10.3310/hta25330] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Early diagnosis of acute myocardial infarction is important, but only 20% of emergency admissions for chest pain will actually have an acute myocardial infarction. High-sensitivity cardiac troponin assays may allow rapid rule out of myocardial infarction and avoid unnecessary hospital admissions. OBJECTIVES To assess the clinical effectiveness and cost-effectiveness of high-sensitivity cardiac troponin assays for the management of adults presenting with acute chest pain, in particular for the early rule-out of acute myocardial infarction. METHODS Sixteen databases were searched up to September 2019. Review methods followed published guidelines. Studies were assessed for quality using appropriate risk-of-bias tools. The bivariate model was used to estimate summary sensitivity and specificity for meta-analyses involving four or more studies; otherwise, random-effects logistic regression was used. The health economic analysis considered the long-term costs and quality-adjusted life-years associated with different troponin testing methods. The de novo model consisted of a decision tree and a state-transition cohort model. A lifetime time horizon (of 60 years) was used. RESULTS Thirty-seven studies (123 publications) were included in the review. The high-sensitivity cardiac troponin test strategies evaluated are defined by the combination of four factors (i.e. assay, number and timing of tests, and threshold concentration), resulting in a large number of possible combinations. Clinical opinion indicated a minimum clinically acceptable sensitivity of 97%. When considering single test strategies, only those using a threshold at or near to the limit of detection for the assay, in a sample taken at presentation, met the minimum clinically acceptable sensitivity criterion. The majority of the multiple test strategies that met this criterion comprised an initial rule-out step, based on high-sensitivity cardiac troponin levels in a sample taken on presentation and a minimum symptom duration, and a second stage for patients not meeting the initial rule-out criteria, based on presentation levels of high-sensitivity cardiac troponin and absolute change after 1, 2 or 3 hours. Two large cluster randomised controlled trials found that implementation of an early rule-out pathway for myocardial infarction reduced length of stay and rate of hospital admission without increasing cardiac events. In the base-case analysis, standard troponin testing was both the most effective and the most costly. Other testing strategies with a sensitivity of 100% (subject to uncertainty) were almost equally effective, resulting in the same life-year and quality-adjusted life-year gain at up to four decimal places. Comparisons based on the next best alternative showed that for willingness-to-pay values below £8455 per quality-adjusted life-year, the Access High Sensitivity Troponin I (Beckman Coulter, Brea, CA, USA) [(symptoms > 3 hours AND < 4 ng/l at 0 hours) OR (< 5 ng/l AND Δ < 5 ng/l at 0 to 2 hours)] would be cost-effective. For thresholds between £8455 and £20,190 per quality-adjusted life-year, the Elecsys® Troponin-T high sensitive (Roche, Basel, Switzerland) (< 12 ng/l at 0 hours AND Δ < 3 ng/l at 0 to 1 hours) would be cost-effective. For a threshold > £20,190 per quality-adjusted life-year, the Dimension Vista® High-Sensitivity Troponin I (Siemens Healthcare, Erlangen, Germany) (< 5 ng/l at 0 hours AND Δ < 2 ng/l at 0 to 1 hours) would be cost-effective. CONCLUSIONS High-sensitivity cardiac troponin testing may be cost-effective compared with standard troponin testing. STUDY REGISTRATION This study is registered as PROSPERO CRD42019154716. FUNDING This project was funded by the National Institute for Health Research (NIHR) Evidence Synthesis programme and will be published in full in Health Technology Assessment; Vol. 25, No. 33. See the NIHR Journals Library website for further project information.
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Affiliation(s)
| | - Bram Ramaekers
- Department of Clinical Epidemiology and Medical Technology Assessment, Maastricht University, Maastricht, the Netherlands
| | - Sabine Grimm
- Department of Clinical Epidemiology and Medical Technology Assessment, Maastricht University, Maastricht, the Netherlands
| | | | | | | | | | | | - Manuela Joore
- Department of Clinical Epidemiology and Medical Technology Assessment, Maastricht University, Maastricht, the Netherlands
| | - Jos Kleijnen
- Kleijnen Systematic Reviews Ltd, York, UK
- School for Public Health and Primary Care, Care and Public Health Research Institute, Maastricht University, Maastricht, the Netherlands
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Plötzlicher Brustschmerz und Unterleibsschmerzen. Notf Rett Med 2021. [DOI: 10.1007/s10049-021-00848-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Lau G, Koh M, Kavsak PA, Schull MJ, Armstrong DWJ, Udell JA, Austin PC, Wang X, Ko DT. Clinical outcomes for chest pain patients discharged home from emergency departments using high-sensitivity versus conventional cardiac troponin assays. Am Heart J 2020; 221:84-94. [PMID: 31954328 DOI: 10.1016/j.ahj.2019.12.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Accepted: 12/06/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND High-sensitivity cardiac troponin (hs-cTn) assays enhance detection of lower circulating troponin concentrations, but the impact on outcomes in clinical practice is unclear. Our objective was to compare outcomes of chest pain patients discharged from emergency departments (EDs) using hs-cTn and conventional troponin (cTn) assays. METHODS We conducted an observational study of chest pain patients aged 40-105 years who presented to an ED from April 1, 2013, to March 31, 2017, and were discharged home. We compared 30-day and 1-year outcomes of EDs that used hs-cTn versus cTn assays. The primary outcome was a composite of all-cause death, myocardial infarction or unstable angina. Comparisons were conducted with (1) no adjustment; (2) adjustment for demographic, socioeconomic, and hospital characteristics; and (3) full clinical adjustment. RESULTS Among the 394,910 patients, 62,138 (15.7%) were evaluated at hs-cTn EDs and 332,772 (84.3%) were evaluated at cTn EDs. Patients discharged from hs-cTn EDs were less likely to have diabetes, hypertension, or prior heart disease. At 30 days, the unadjusted primary outcome rate was lower in hs-cTn EDs (0.9% vs 1.0%, P < .001). The 30-day hazard ratios for the primary outcome were 0.84 (95% CI 0.77-0.92) for no adjustment and 0.98 (95% CI 0.88-1.08) for full adjustment. Over 1 year, patients discharged from hs-cTn EDs had significantly fewer primary outcomes (3.7% vs 4.1%, P < .001) and lower hazard ratio (0.93; 95% CI 0.89-0.98) even after full adjustment. CONCLUSIONS Hs-cTn testing was associated with a significantly lower adjusted hazard of myocardial infarction, angina, and all-cause hospitalization at 1 year but not 30 days.
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Affiliation(s)
- Geoffrey Lau
- ICES, Toronto, Ontario, Canada; Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | | | - Peter A Kavsak
- Department of Pathology and Molecular Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Michael J Schull
- ICES, Toronto, Ontario, Canada; Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | | | - Jacob A Udell
- ICES, Toronto, Ontario, Canada; Women's College Hospital, University of Toronto, Toronto, Ontario, Canada
| | | | | | - Dennis T Ko
- ICES, Toronto, Ontario, Canada; Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada; Schulich Heart Center, Sunnybrook Health Sciences, University of Toronto, Toronto, Ontario, Canada.
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Reichelt A, Meinel FG, Wirth S, Weber MA, Bath K. [Sudden chest pain and lower abdominal pain : The usual suspects]. Radiologe 2019; 60:216-225. [PMID: 31820015 DOI: 10.1007/s00117-019-00618-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
CLINICAL PROBLEM Sudden chest pain and sudden abdominal pain are among the most common reasons that lead patients to the emergency room. The heterogeneous field of possible, sometimes serious diagnoses requires a structured and rapid interdisciplinary clarification in order to be able to promptly provide patients with an adequate therapy. STANDARD RADIOLOGICAL PROCEDURES Knowing the "usual suspects" of sudden chest and abdominal pain enables the radiologist to quickly select the appropriate imaging method that allows a diagnosis to be made without delay. In addition to pain localization and character, age, gender, any previous illnesses and laboratory results are taken into account in the differential diagnosis. METHODICAL INNOVATION AND EVALUATION The technical state of computer tomography (CT) now ensures that most diagnoses can be clarified due to its excellent spatial and temporal resolution. In the abdomen, however, ultrasound should continue to be used at least for primary evaluation. Only if there is a further need for abdominal imaging afterwards is CT indicated for clarification. Magnetic resonance imaging is rarely used in the emergency setting of abdominal pain except to avoid radiation exposure in children or pregnant women. RECOMMENDATION FOR THE PRACTICE Knowledge of the usual diagnoses that cause sudden chest or abdominal pain, as well as knowledge of the appropriate examination procedures and classic radiological signs are essential to avoid errors and delays in the emergency diagnosis of sudden chest and abdominal pain.
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Affiliation(s)
- Angela Reichelt
- Institut für Diagnostische und Interventionelle Radiologie, Kinder- und Neuroradiologie, Universitätsmedizin Rostock, Ernst-Heydemann-Str. 6, 18057, Rostock, Deutschland.
| | - Felix G Meinel
- Institut für Diagnostische und Interventionelle Radiologie, Kinder- und Neuroradiologie, Universitätsmedizin Rostock, Ernst-Heydemann-Str. 6, 18057, Rostock, Deutschland
| | - Stefan Wirth
- Institut für Radiologie, Schnittbilddiagnostik, DONAUISAR Klinikum Deggendorf, Akademisches Lehrkrankenhaus der Medizinischen Hochschule Hannover, Perlasberger Str. 41, 94469, Deggendorf, Deutschland
| | - Marc-André Weber
- Institut für Diagnostische und Interventionelle Radiologie, Kinder- und Neuroradiologie, Universitätsmedizin Rostock, Ernst-Heydemann-Str. 6, 18057, Rostock, Deutschland
| | - Kristina Bath
- Institut für Diagnostische und Interventionelle Radiologie, Kinder- und Neuroradiologie, Universitätsmedizin Rostock, Ernst-Heydemann-Str. 6, 18057, Rostock, Deutschland
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Adler C, Baldus S. [Troponin elevation-does every patient require coronary angiography?]. Med Klin Intensivmed Notfmed 2019; 115:690-698. [PMID: 31218391 DOI: 10.1007/s00063-019-0593-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2018] [Revised: 04/29/2019] [Accepted: 05/22/2019] [Indexed: 02/06/2023]
Abstract
The determination of high-sensitivity troponin remains the gold standard in patients with acute chest pain and allows the early diagnosis and therapy of patients with acute myocardial infarction (AMI). Increased cardiac troponin levels are highly specific for myocardial damage. However, elevated troponin levels are not equivalent to AMI and therefore the clinical presentation and the electrocardiogram of each patient must be taken into account. Elevated troponin levels are found in numerous diseases but not every patient needs invasive coronary angiography.
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Affiliation(s)
- Christoph Adler
- Klinik für Kardiologie, Angiologie, Pneumologie und internistische Intensivmedizin, Klinik III für Innere Medizin, Herzzentrum, Universität zu Köln, Kerpener Str. 62, 50937, Köln, Deutschland.
| | - Stephan Baldus
- Klinik für Kardiologie, Angiologie, Pneumologie und internistische Intensivmedizin, Klinik III für Innere Medizin, Herzzentrum, Universität zu Köln, Kerpener Str. 62, 50937, Köln, Deutschland
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Fitzpatrick D, Longondjo M. Gastric perforation through a hiatus hernia into the left lung in an 84-year-old woman. BMJ Case Rep 2019; 12:12/5/e227956. [PMID: 31092492 DOI: 10.1136/bcr-2018-227956] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
An 84-year-old woman presented to the emergency department with a sudden onset of chest pain, shortness of breath and vomiting. She had a medical history of hiatus hernia, gastro-oesophgeal reflux disease and asthma only, but had several recent courses of oral steroids to treat her asthma. Initially she was hypoxic, tachycardic and normotensive. ECG was normal, chest X-ray showed a hiatus hernia and right middle zone consolidation. Inflammatory markers were normal. CT angiogram was performed to exclude aortic pathology, for which it was negative. It did however show a large hiatus hernia which had perforated and was communicating with the left lung. The patient deteriorated clinically and became hypotensive and more hypoxic. She was transferred to the intensive care unit but died 36 hours later as she was too unwell to undergo any exploratory surgery.
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Affiliation(s)
| | - Mario Longondjo
- Emergency Department, University Hospital Lewisham, London, UK
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11
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Shah ASV, Anand A, Strachan FE, Ferry AV, Lee KK, Chapman AR, Sandeman D, Stables CL, Adamson PD, Andrews JPM, Anwar MS, Hung J, Moss AJ, O'Brien R, Berry C, Findlay I, Walker S, Cruickshank A, Reid A, Gray A, Collinson PO, Apple FS, McAllister DA, Maguire D, Fox KAA, Newby DE, Tuck C, Harkess R, Parker RA, Keerie C, Weir CJ, Mills NL. High-sensitivity troponin in the evaluation of patients with suspected acute coronary syndrome: a stepped-wedge, cluster-randomised controlled trial. Lancet 2018; 392:919-928. [PMID: 30170853 PMCID: PMC6137538 DOI: 10.1016/s0140-6736(18)31923-8] [Citation(s) in RCA: 245] [Impact Index Per Article: 40.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2018] [Revised: 08/08/2018] [Accepted: 08/10/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND High-sensitivity cardiac troponin assays permit use of lower thresholds for the diagnosis of myocardial infarction, but whether this improves clinical outcomes is unknown. We aimed to determine whether the introduction of a high-sensitivity cardiac troponin I (hs-cTnI) assay with a sex-specific 99th centile diagnostic threshold would reduce subsequent myocardial infarction or cardiovascular death in patients with suspected acute coronary syndrome. METHODS In this stepped-wedge, cluster-randomised controlled trial across ten secondary or tertiary care hospitals in Scotland, we evaluated the implementation of an hs-cTnI assay in consecutive patients who had been admitted to the hospitals' emergency departments with suspected acute coronary syndrome. Patients were eligible for inclusion if they presented with suspected acute coronary syndrome and had paired cardiac troponin measurements from the standard care and trial assays. During a validation phase of 6-12 months, results from the hs-cTnI assay were concealed from the attending clinician, and a contemporary cardiac troponin I (cTnI) assay was used to guide care. Hospitals were randomly allocated to early (n=5 hospitals) or late (n=5 hospitals) implementation, in which the high-sensitivity assay and sex-specific 99th centile diagnostic threshold was introduced immediately after the 6-month validation phase or was deferred for a further 6 months. Patients reclassified by the high-sensitivity assay were defined as those with an increased hs-cTnI concentration in whom cTnI concentrations were below the diagnostic threshold on the contemporary assay. The primary outcome was subsequent myocardial infarction or death from cardiovascular causes at 1 year after initial presentation. Outcomes were compared in patients reclassified by the high-sensitivity assay before and after its implementation by use of an adjusted generalised linear mixed model. This trial is registered with ClinicalTrials.gov, number NCT01852123. FINDINGS Between June 10, 2013, and March 3, 2016, we enrolled 48 282 consecutive patients (61 [SD 17] years, 47% women) of whom 10 360 (21%) patients had cTnI concentrations greater than those of the 99th centile of the normal range of values, who were identified by the contemporary assay or the high-sensitivity assay. The high-sensitivity assay reclassified 1771 (17%) of 10 360 patients with myocardial injury or infarction who were not identified by the contemporary assay. In those reclassified, subsequent myocardial infarction or cardiovascular death within 1 year occurred in 105 (15%) of 720 patients in the validation phase and 131 (12%) of 1051 patients in the implementation phase (adjusted odds ratio for implementation vs validation phase 1·10, 95% CI 0·75 to 1·61; p=0·620). INTERPRETATION Use of a high-sensitivity assay prompted reclassification of 1771 (17%) of 10 360 patients with myocardial injury or infarction, but was not associated with a lower subsequent incidence of myocardial infarction or cardiovascular death at 1 year. Our findings question whether the diagnostic threshold for myocardial infarction should be based on the 99th centile derived from a normal reference population. FUNDING The British Heart Foundation.
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Affiliation(s)
- Anoop S V Shah
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK; Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK
| | - Atul Anand
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Fiona E Strachan
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Amy V Ferry
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Kuan Ken Lee
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Andrew R Chapman
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | | | - Catherine L Stables
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Philip D Adamson
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Jack P M Andrews
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Mohamed S Anwar
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - John Hung
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Alistair J Moss
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Rachel O'Brien
- Emergency Medicine Research Group of Edinburgh, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Colin Berry
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Iain Findlay
- Department of Cardiology, Royal Alexandra Hospital, Paisley, UK
| | - Simon Walker
- Department of Clinical Biochemistry, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Anne Cruickshank
- Department of Biochemistry, Queen Elizabeth University Hospital, Glasgow, UK
| | - Alan Reid
- Department of Biochemistry, Queen Elizabeth University Hospital, Glasgow, UK
| | - Alasdair Gray
- Emergency Medicine Research Group of Edinburgh, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Paul O Collinson
- Department of Clinical Blood Sciences and Department of Cardiology, St George's University Hospitals NHS Trust and St George's University of London, London, UK
| | - Fred S Apple
- Department of Laboratory Medicine and Pathology, Hennepin County Medical Center and University of Minnesota, Minneapolis, MN, USA
| | | | - Donogh Maguire
- Emergency Medicine Department, Glasgow Royal Infirmary, Glasgow, UK
| | - Keith A A Fox
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - David E Newby
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Christopher Tuck
- Edinburgh Clinical Trials Unit, University of Edinburgh, Edinburgh, UK
| | - Ronald Harkess
- Edinburgh Clinical Trials Unit, University of Edinburgh, Edinburgh, UK
| | - Richard A Parker
- Edinburgh Clinical Trials Unit, University of Edinburgh, Edinburgh, UK
| | - Catriona Keerie
- Edinburgh Clinical Trials Unit, University of Edinburgh, Edinburgh, UK
| | | | - Nicholas L Mills
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK; Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK.
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Liu G, Niu X, Meng X, Zhang Z. Sensitive miRNA markers for the detection and management of NSTEMI acute myocardial infarction patients. J Thorac Dis 2018; 10:3206-3215. [PMID: 30069316 DOI: 10.21037/jtd.2018.05.141] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Background NSTEMI patients will benefit greatly with better biomarker screening to detect and prognose the disease. Using miRNAs, we evaluated the clinical utility in acute myocardial infarction (AMI) patients during disease onset and therapy. Methods A total of 145 NSTEMI patients and 30 healthy volunteers with no history of cardiovascular disease (CVD) were recruited. miRNA levels in plasma were measured during disease manifestation and serially during treatment phase. Levels of multiple candidates (miR-1, miR-133, miR-208, miR-499) were analysed. The miRNA levels were directly compared between NSTEMI and healthy volunteers. Results Cardiac related miRNAs levels demonstrated significant increase compared with healthy controls. miR-499 exhibited the highest elevation with more than 6.03-fold change compared with healthy participants. Conventional cTnT measurements were in good agreement to miRNA relative expressions. In serial measurements, miR-499 demonstrated large fluctuations and could be linked to the secondary complications. In contrast, miR-133 showed insignificant variations in mean levels during serial sampling. Conclusions miRNA is a potentially sensitive biomarker for NSTEMI AMI patients for disease detection and treatment monitoring. The sensitivities were comparable to cTnT for diagnostic accuracy and patients with sustained or higher levels were correlated to secondary complications.
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Affiliation(s)
- Guoyong Liu
- Heart Center, The First Affiliated Hospital of Lanzhou University, Lanzhou 730000, China.,The Cardiovascular Department, Qinghai Provincial People's Hospital, Xining 810007, China
| | - Xiaowei Niu
- Heart Center, The First Affiliated Hospital of Lanzhou University, Lanzhou 730000, China
| | - Xiaoxue Meng
- Heart Center, The First Affiliated Hospital of Lanzhou University, Lanzhou 730000, China
| | - Zheng Zhang
- Heart Center, The First Affiliated Hospital of Lanzhou University, Lanzhou 730000, China
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Gastroenterological Perspectives on Acute Cardiac Care — the Management of Patients with Implanted Coronary Stents Following an Acute Coronary Syndrome. JOURNAL OF CARDIOVASCULAR EMERGENCIES 2018. [DOI: 10.2478/jce-2018-0006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Abstract
Cardiovascular and digestive diseases frequently share the same risk factors such as obesity, unhealthy diet, or several social behaviors, and the increasing prevalence of patients with overlapped cardiovascular and digestive symptoms is a challenging problem in the daily practice. Patients with gastro-esophageal reflux disease can exhibit various forms of chest pain that can be very similar to angina. Furthermore, antithrombotic therapies used for preventive or curative purposes in patients with cardiovascular diseases are frequently associated with gastrointestinal side effects including bleeding. At the same time, in patients with coronary stents presenting to the emergency department with chest pain, angina triggered by stent thrombosis or restenosis should be differentiated from angina-like symptoms caused by a gastrointestinal disease. The aim of this review was to present the complex inter-relation between gastroesophageal diseases and angina in patients on dual antiplatelet therapy following an acute coronary syndrome, with a particular emphasis on the role of anemia resulting from occult or manifest gastrointestinal bleeding, as a precipitating factor for triggering or aggravating angina.
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14
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Shah ASV, Sandoval Y, Noaman A, Sexter A, Vaswani A, Smith SW, Gibbins M, Griffiths M, Chapman AR, Strachan FE, Anand A, Denvir MA, Adamson PD, D'Souza MS, Gray AJ, McAllister DA, Newby DE, Apple FS, Mills NL. Patient selection for high sensitivity cardiac troponin testing and diagnosis of myocardial infarction: prospective cohort study. BMJ 2017; 359:j4788. [PMID: 29114078 PMCID: PMC5683043 DOI: 10.1136/bmj.j4788] [Citation(s) in RCA: 86] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/11/2017] [Indexed: 12/28/2022]
Abstract
Objective To evaluate how selection of patients for high sensitivity cardiac troponin testing affects the diagnosis of myocardial infarction across different healthcare settings.Design Prospective study of three independent consecutive patient populations presenting to emergency departments.Setting Secondary and tertiary care hospitals in the United Kingdom and United States.Participants High sensitivity cardiac troponin I concentrations were measured in 8500 consecutive patients presenting to emergency departments: unselected patients in the UK (n=1054) and two selected populations of patients in whom troponin testing was requested by the attending clinician in the UK (n=5815) and the US (n=1631). The final diagnosis of type 1 or type 2 myocardial infarction or myocardial injury was independently adjudicated.Main outcome measures Positive predictive value of an elevated cardiac troponin concentration for a diagnosis of type 1 myocardial infarction.Results Cardiac troponin concentrations were elevated in 13.7% (144/1054) of unselected patients, with a prevalence of 1.6% (17/1054) for type 1 myocardial infarction and a positive predictive value of 11.8% (95% confidence interval 7.0% to 18.2%). In selected patients, in whom troponin testing was guided by the attending clinician, the prevalence and positive predictive value were 14.5% (843/5815) and 59.7% (57.0% to 62.2%) in the UK and 4.2% (68/1631) and 16.4% (13.0% to 20.3%) in the US. Across both selected patient populations, the positive predictive value was highest in patients with chest pain, with ischaemia on the electrocardiogram, and with a history of ischaemic heart disease.Conclusions When high sensitivity cardiac troponin testing is performed widely or without previous clinical assessment, elevated troponin concentrations are common and predominantly reflect myocardial injury rather than myocardial infarction. These observations highlight how selection of patients for cardiac troponin testing varies across healthcare settings and markedly influences the positive predictive value for a diagnosis of myocardial infarction.
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Affiliation(s)
- Anoop S V Shah
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh EH16 4SB, UK
| | - Yader Sandoval
- Division of Cardiology, Hennepin County Medical Center and Minneapolis Heart Institute, Abbott Northwestern Hospital, Minneapolis, MN, USA
| | - Ala Noaman
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh EH16 4SB, UK
| | - Anne Sexter
- Chronic Disease Research Group of Minneapolis Medical Research Foundation, Hennepin County Medical Center and University of Minnesota, Minneapolis, MN, USA
| | - Amar Vaswani
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh EH16 4SB, UK
| | - Stephen W Smith
- Department of Emergency Medicine, Hennepin County Medical Center and University of Minnesota, Minneapolis, Minnesota, USA
| | - Mathew Gibbins
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh EH16 4SB, UK
| | - Megan Griffiths
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh EH16 4SB, UK
| | - Andrew R Chapman
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh EH16 4SB, UK
| | - Fiona E Strachan
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh EH16 4SB, UK
| | - Atul Anand
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh EH16 4SB, UK
| | - Martin A Denvir
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh EH16 4SB, UK
| | - Philip D Adamson
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh EH16 4SB, UK
| | - Michelle S D'Souza
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh EH16 4SB, UK
| | - Alasdair J Gray
- Emergency Medicine Research Group Edinburgh (EMeRGE) and Department of Emergency Medicine, Royal Infirmary of Edinburgh, Edinburgh, UK
| | | | - David E Newby
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh EH16 4SB, UK
| | - Fred S Apple
- Department of Laboratory Medicine and Pathology, Hennepin County Medical Center and University of Minnesota, Minneapolis, MN, USA
| | - Nicholas L Mills
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh EH16 4SB, UK
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Abstract
PURPOSE OF REVIEW Since identification of aspartate aminotransferase as the first cardiac biomarker in the 1950s, there have been a number of new markers used for myocardial damage detection over the decades. There have also been several generations of troponin assays, each with progressively increasing sensitivity for troponin detection. Accordingly, the "standard of care" for myocardial damage detection continues to change. The purpose of this paper is to review the clinical utility, biological mechanisms, and predictive value of these various biomarkers in contemporary clinical studies. RECENT FINDINGS As of this writing, a fifth "next" generation troponin assay has now been cleared by the US Food and Drug Administration for clinical use in the USA for subjects presenting with suspected acute coronary syndromes. Use of these high-sensitivity assays has allowed for earlier detection of myocardial damage as well as greater negative predictive value for infarction after only one or two serial measurements. Recent algorithms utilizing these assays have allowed for more rapid rule-out of myocardial infarction in emergency department settings. In this review, we discuss novel assays available for the risk assessment of subjects presenting with chest pain, including both the "next generation" cardiac troponin assays as well as other novel biomarkers. We review the biological mechanisms for these markers, and explore the positive and negative predictive value of the assays in clinical studies, where reported. We also discuss the potential use of these new markers within the context of future clinical care in the modern era of higher sensitivity troponin testing. Finally, we discuss advances in new platforms (e.g., mass spectrometry) that historically have not been considered for rapid in vitro diagnostic capabilities, but that are taking a larger role in clinical diagnostics, and whose prognostic value and power promise to usher in new markers with potential for future clinical utility in acute coronary syndrome.
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Affiliation(s)
- Haitham M Ahmed
- Preventive Cardiology and Rehabilitation, Cleveland Clinic, Heart and Vascular Institute, 9500 Euclid Ave, Desk JB1, Cleveland, OH, 44195, USA.
| | - Stanley L Hazen
- Preventive Cardiology and Rehabilitation, Cleveland Clinic, Heart and Vascular Institute, 9500 Euclid Ave, Desk JB1, Cleveland, OH, 44195, USA
- Department of Cellular and Molecular Medicine, Cleveland Clinic, Lerner Research Institute, Cleveland, OH, USA
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16
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Push-Alert Notification of Troponin Results to Physician Smartphones Reduces the Time to Discharge Emergency Department Patients: A Randomized Controlled Trial. Ann Emerg Med 2017; 70:348-356. [PMID: 28499728 DOI: 10.1016/j.annemergmed.2017.03.021] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2015] [Revised: 03/05/2017] [Accepted: 03/10/2017] [Indexed: 11/23/2022]
Abstract
STUDY OBJECTIVE For emergency department (ED) patients with chest pain, discharge decisions often hinge on troponin results. Push-alert notifications deliver results immediately to physician smartphones. Our objective is to determine whether troponin push alerts improve the time to discharge decisions for ED patients with chest pain. METHODS In an academic ED, we assessed the effect of a quality improvement initiative using troponin push alerts to physician smartphones, with a cluster-randomized evaluation. Participating physicians were randomized to receive troponin push alerts (intervention) or not receive them (control). We retrospectively identified patients treated by participating physicians during the study period who were discharged from the ED with chest pain. The primary outcome was the time from final troponin result to discharge decision. Secondary outcomes included length of stay. A linear mixed model was used to adjust for physician clustering. RESULTS During the study, 1,554 patients were discharged from the ED with chest pain. There were 551 patients in the control group and 554 in the intervention group who met inclusion criteria. The overall median interval from final troponin result to discharge decision was 79.7 minutes (interquartile range [IQR] 33.6 to 167.8 minutes); it was 94.3 minutes (IQR 36.2 to 177.8 minutes) in the control group and 68.5 minutes (IQR 30.5 to 157.2 minutes) in the intervention group. This 25.8-minute difference in medians (95% confidence interval 24.6 to 28.0 minutes) was statistically significant. Total ED length of stay was 345 minutes (IQR 261 to 419 minutes) in the control group and 328 minutes (IQR 250 to 408 minutes) in the intervention group. CONCLUSION Physicians who received troponin push alerts discharged their patients with chest pain 26 minutes faster than those without troponin notifications. Total ED length of stay did not significantly improve for these patients.
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17
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Mueller C, Patrono C, Roffi M. Background, fundamental concepts, and scientific evidence of the high-sensitivity cardiac troponin 0h/1h-algorithm for early rule-out or rule-in of acute myocardial infarction. Eur Heart J 2016. [DOI: 10.1093/eurheartj/ehw282.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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18
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Crea F, Jaffe AS, Collinson PO, Hamm CW, Lindahl B, Mills NL, Thygesen K, Mueller C, Patrono C, Roffi M. Should the 1h algorithm for rule in and rule out of acute myocardial infarction be used universally? Eur Heart J 2016; 37:3316-3323. [PMID: 28007934 DOI: 10.1093/eurheartj/ehw282] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/17/2023] Open
Affiliation(s)
| | | | | | | | - Bertil Lindahl
- Uppsala University and Uppsala Clinical Research Center, Uppsala University, Sweden
| | | | | | - Christian Mueller
- Department of Cardiology and the Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Switzerland
| | - Carlo Patrono
- Istituto di Farmacologia, Università Cattolica del Sacro Cuore, Largo F. Vito 1, IT-00168 Rome, Italy
| | - Marco Roffi
- Division of Cardiology, University Hospital, Rue Gabrielle Perret-Gentil 4, 1211 Geneva, Switzerland
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19
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Parsonage WA, Mueller C, Greenslade JH, Wildi K, Pickering J, Than M, Aldous S, Boeddinghaus J, Hammett CJ, Hawkins T, Nestelberger T, Reichlin T, Reidt S, Rubin Gimenez M, Tate JR, Twerenbold R, Ungerer JP, Cullen L. Validation of NICE diagnostic guidance for rule out of myocardial infarction using high-sensitivity troponin tests. Heart 2016; 102:1279-86. [PMID: 27288278 DOI: 10.1136/heartjnl-2016-309270] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2016] [Accepted: 05/16/2016] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVE To validate the National Institute for Health and Care Excellence (NICE) recommended algorithms for high-sensitivity troponin (hsTn) assays in adults presenting with chest pain. METHODS International post hoc analysis of three prospective, observational studies from tertiary hospital emergency departments. The primary endpoint was cardiac death or acute myocardial infarction (AMI) within 24 hours of presentation, and the secondary endpoint was major adverse cardiac events (MACE) at 30 days. RESULTS 15% of patients were diagnosed with non-ST elevation myocardial infarction (MI) on admission. The hsTnI algorithm classified 2506/3128 (80.1%) of patients as 'ruled out' with 50 (2.0%) missed MI. 943/3128 (30.1%) of patients had a troponin I level below the limit of detection on admission with 2 (0.2%) missed MI. For the hsTnT algorithm, 1794/3374 (53.1%) of patients were 'ruled out' with 7 (0.4%) missed MI. 490/3374 (14.5%) of patients had a troponin T below the limit of blank on admission with no MI. MACE at 30 days occurred in 10.7% and 8.5% of patients 'ruled out' defined by the hsTnI and hsTnT algorithms, respectively. CONCLUSIONS The NICE algorithms could identify patients with low probability of AMI within 2 hours; however, neither strategy performed as predicted by the NICE diagnostic guidance model. Additionally, the rate of MACE at 30 days was sufficiently high that the algorithms should only be used as one component of a more extensive model of risk stratification. TRIAL REGISTRATION NUMBER ACTRN12611001069943, NCT00470587; post-results.
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Affiliation(s)
- W A Parsonage
- Royal Brisbane & Women's Hospital, Herston, Australia
| | - C Mueller
- Cardiovascular Research Institute, University Hospital, Basel, Switzerland
| | | | - K Wildi
- Cardiovascular Research Institute, University Hospital, Basel, Switzerland
| | - J Pickering
- Christchurch Hospital, Christchurch, New Zealand
| | - M Than
- Christchurch Hospital, Christchurch, New Zealand
| | - S Aldous
- Christchurch Hospital, Christchurch, New Zealand
| | - J Boeddinghaus
- Cardiovascular Research Institute, University Hospital, Basel, Switzerland
| | - C J Hammett
- Royal Brisbane & Women's Hospital, Herston, Australia
| | - T Hawkins
- Royal Brisbane & Women's Hospital, Herston, Australia
| | - T Nestelberger
- Cardiovascular Research Institute, University Hospital, Basel, Switzerland
| | - T Reichlin
- Cardiovascular Research Institute, University Hospital, Basel, Switzerland
| | - S Reidt
- Cardiovascular Research Institute, University Hospital, Basel, Switzerland
| | - M Rubin Gimenez
- Cardiovascular Research Institute, University Hospital, Basel, Switzerland
| | - J R Tate
- Royal Brisbane & Women's Hospital, Herston, Australia
| | - R Twerenbold
- Cardiovascular Research Institute, University Hospital, Basel, Switzerland
| | - J P Ungerer
- Royal Brisbane & Women's Hospital, Herston, Australia
| | - L Cullen
- Royal Brisbane & Women's Hospital, Herston, Australia
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20
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Westwood M, van Asselt T, Ramaekers B, Whiting P, Thokala P, Joore M, Armstrong N, Ross J, Severens J, Kleijnen J. High-sensitivity troponin assays for the early rule-out or diagnosis of acute myocardial infarction in people with acute chest pain: a systematic review and cost-effectiveness analysis. Health Technol Assess 2016; 19:1-234. [PMID: 26118801 DOI: 10.3310/hta19440] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Early diagnosis of acute myocardial infarction (AMI) can ensure quick and effective treatment but only 20% of adults with emergency admissions for chest pain have an AMI. High-sensitivity cardiac troponin (hs-cTn) assays may allow rapid rule-out of AMI and avoidance of unnecessary hospital admissions and anxiety. OBJECTIVE To assess the clinical effectiveness and cost-effectiveness of hs-cTn assays for the early (within 4 hours of presentation) rule-out of AMI in adults with acute chest pain. METHODS Sixteen databases, including MEDLINE and EMBASE, research registers and conference proceedings, were searched to October 2013. Study quality was assessed using QUADAS-2. The bivariate model was used to estimate summary sensitivity and specificity for meta-analyses involving four or more studies, otherwise random-effects logistic regression was used. The health-economic analysis considered the long-term costs and quality-adjusted life-years (QALYs) associated with different troponin (Tn) testing methods. The de novo model consisted of a decision tree and Markov model. A lifetime time horizon (60 years) was used. RESULTS Eighteen studies were included in the clinical effectiveness review. The optimum strategy, based on the Roche assay, used a limit of blank (LoB) threshold in a presentation sample to rule out AMI [negative likelihood ratio (LR-) 0.10, 95% confidence interval (CI) 0.05 to 0.18]. Patients testing positive could then have a further test at 2 hours; a result above the 99th centile on either sample and a delta (Δ) of ≥ 20% has some potential for ruling in an AMI [positive likelihood ratio (LR+) 8.42, 95% CI 6.11 to 11.60], whereas a result below the 99th centile on both samples and a Δ of < 20% can be used to rule out an AMI (LR- 0.04, 95% CI 0.02 to 0.10). The optimum strategy, based on the Abbott assay, used a limit of detection (LoD) threshold in a presentation sample to rule out AMI (LR- 0.01, 95% CI 0.00 to 0.08). Patients testing positive could then have a further test at 3 hours; a result above the 99th centile on this sample has some potential for ruling in an AMI (LR+ 10.16, 95% CI 8.38 to 12.31), whereas a result below the 99th centile can be used to rule out an AMI (LR- 0.02, 95% CI 0.01 to 0.05). In the base-case analysis, standard Tn testing was both most effective and most costly. Strategies considered cost-effective depending upon incremental cost-effectiveness ratio thresholds were Abbott 99th centile (thresholds of < £6597), Beckman 99th centile (thresholds between £6597 and £30,042), Abbott optimal strategy (LoD threshold at presentation, followed by 99th centile threshold at 3 hours) (thresholds between £30,042 and £103,194) and the standard Tn test (thresholds over £103,194). The Roche 99th centile and the Roche optimal strategy [LoB threshold at presentation followed by 99th centile threshold and/or Δ20% (compared with presentation test) at 1-3 hours] were extendedly dominated in this analysis. CONCLUSIONS There is some evidence to suggest that hs-CTn testing may provide an effective and cost-effective approach to early rule-out of AMI. Further research is needed to clarify optimal diagnostic thresholds and testing strategies. STUDY REGISTRATION This study is registered as PROSPERO CRD42013005939. FUNDING The National Institute for Health Research Health Technology Assessment programme.
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Affiliation(s)
| | - Thea van Asselt
- Department of Clinical Epidemiology and Medical Technology Assessment, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Bram Ramaekers
- Department of Clinical Epidemiology and Medical Technology Assessment, Maastricht University Medical Centre, Maastricht, The Netherlands
| | | | - Praveen Thokala
- Health Economics and Decision Science Group, School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Manuela Joore
- Department of Clinical Epidemiology and Medical Technology Assessment, Maastricht University Medical Centre, Maastricht, The Netherlands
| | | | | | - Johan Severens
- Institute of Health Policy and Management, Erasmus University Rotterdam, Rotterdam, The Netherlands
| | - Jos Kleijnen
- School for Public Health and Primary Care (CAPHRI), Maastricht University, Maastricht, The Netherlands
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21
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Fox WR, Diercks DB. Troponin assay use in the emergency department for management of patients with potential acute coronary syndrome: current use and future directions. Clin Exp Emerg Med 2016; 3:1-8. [PMID: 27752608 PMCID: PMC5051615 DOI: 10.15441/ceem.16.120] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2016] [Revised: 02/05/2016] [Accepted: 02/05/2016] [Indexed: 01/01/2023] Open
Abstract
Troponins are proteins commonly found in cardiac tissue that are released during myocardial ischemia or necrosis. These troponins can be detected by assays that can then be used to guide clinical decision-making and disposition, especially if the suspected insult is related to acute coronary syndrome. Timing of troponin measurement can be important as elevations may not be detectible immediately after an insult. New assays have been designed to detect troponin con-centrations previously too low to be detected by conventional assays. These tests are known as high-sensitivity cardiac troponin assays. Current research is aimed at evaluating the clinical sig-nificance of troponin elevations detected by these new assays especially in management of pa-tients with suspected acute coronary syndrome. A number of risk-stratification scores exist to assist physicians with evaluating chest pain in the emergency department in the context of de-tection (or absence) of troponins in systemic circulation. Additionally, investigators are working to integrate data generated by hs-cTn measurements into existing and new risk-stratification scores.
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Affiliation(s)
- William R Fox
- Department of Emergency Medicine, University of Texas Southwestern, Dallas, TX , USA
| | - Deborah B Diercks
- Department of Emergency Medicine, University of Texas Southwestern, Dallas, TX , USA
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22
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One-hour rule-in and rule-out of acute myocardial infarction using high-sensitivity cardiac troponin I. Am Heart J 2016; 171:92-102.e1-5. [PMID: 26699605 DOI: 10.1016/j.ahj.2015.07.022] [Citation(s) in RCA: 84] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2015] [Accepted: 07/20/2015] [Indexed: 11/23/2022]
Abstract
UNLABELLED We aimed to prospectively derive and validate a novel 0-/1-hour algorithm using high-sensitivity cardiac troponin I (hs-cTnI) for the early "rule-out" and "rule-in" of acute myocardial infarction (AMI). METHODS In a prospective multicenter diagnostic study, we enrolled 1,500 patients presenting with suspected AMI to the emergency department. The final diagnosis was centrally adjudicated by 2 independent cardiologists blinded to hs-cTnI concentrations. The hs-cTnI (Siemens Vista) 0-/1-hour algorithm incorporated measurements performed at baseline and absolute changes within 1 hour, was derived in the first 750 patients (derivation cohort), and then validated in the second 750 (validation cohort). RESULTS Overall, AMI was the final diagnosis in 16% of patients. Applying the hs-cTnI 0-/1-hour algorithm developed in the derivation cohort to the validation cohort, 57% of patients could be classified as "rule-out"; 10%, as "rule-in"; and 33%, as "observe." In the validation cohort, the sensitivity and the negative predictive value for AMI in the "rule-out" zone were 100% (95% CI 96%-100%) and 100% (95% CI 99%-100%), respectively. The specificity and the positive predictive value (PPV) for AMI in the "rule-in" zone were 96% (95% CI 94%-97%) and 70% (95% CI 60%-79%), respectively. Negative predictive value and positive predictive value of the 0-/1-hour algorithm were higher compared to the standard of care combining hs-cTnI with the electrocardiogram (both P < .001). CONCLUSION The hs-cTnI 0-/1-hour algorithm performs very well for early rule-out as well as rule-in of AMI. The clinical implications are that used in conjunction with all other clinical information, the 0-/1-hour algorithm will be a safe and effective approach to substantially reduce time to diagnosis.
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23
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Bruno RR, Donner-Banzhoff N, Söllner W, Frieling T, Müller C, Christ M. The Interdisciplinary Management of Acute Chest Pain. DEUTSCHES ARZTEBLATT INTERNATIONAL 2015; 112:768-79; quiz 780. [PMID: 26585188 PMCID: PMC4660855 DOI: 10.3238/arztebl.2015.0768] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/17/2015] [Revised: 09/10/2015] [Accepted: 09/10/2015] [Indexed: 12/12/2022]
Abstract
BACKGROUND Acute chest pain of non-traumatic origin is a common reason for presentation to physician's offices and emergency rooms. Coronary heart disease is the cause in up to 25% of cases. Because acute chest pain, depending on its etiology, may be associated with a high risk of death, rapid, goal-oriented management is mandatory. METHODS This review is based on pertinent articles and guidelines retrieved by a selective search in PubMed. RESULTS History-taking, physical examination, and a 12-lead electrocardiogram (ECG) are the first steps in the differential diagnostic process and generally allow the identification of features signifying a high risk of lifethreatening illness. If the ECG reveals ST-segment elevation, cardiac catheterization is indicated. The timedependent measurement of highly sensitive troponin values is a reliable test for the diagnosis or exclusion of acute myocardial infarction. A wide variety of other potential causes (e.g., vascular, musculoskeletal, gastroenterologic, or psychosomatic) must be identified from the history if they are to be treated appropriately. Elderly patients need special attention. CONCLUSION Acute chest pain is a major diagnostic challenge for the physician. Common errors are traceable to non-recognition of important causes and to an inadequate diagnostic work-up. Future studies should be designed to help optimize the interdisciplinary management of patients with chest pain.
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Affiliation(s)
- Raphael R Bruno
- Department of Emergency and Intensive Care Medicine, Paracelsus Medical University, Nuernberg
| | | | - Wolfgang Söllner
- Department of Psychosomatics and Psychotherapeutic Medicine, Paracelsus Medical University, Nuernberg
| | - Thomas Frieling
- Department of Gastroenterology, Hepatology, Neurogastroenterology, Infectiology, Hematology and Oncology, HELIOS Hospital Krefeld
| | - Christian Müller
- Department of Cardiology, University Hospital Basel, Switzerland
| | - Michael Christ
- Department of Emergency and Intensive Care Medicine, Paracelsus Medical University, Nuernberg
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Rubini Gimenez M, Twerenbold R, Jaeger C, Schindler C, Puelacher C, Wildi K, Reichlin T, Haaf P, Merk S, Honegger U, Wagener M, Druey S, Schumacher C, Krivoshei L, Hillinger P, Herrmann T, Campodarve I, Rentsch K, Bassetti S, Osswald S, Mueller C. 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. [PMID: 25840034 DOI: 10.1016/j.amjmed.2015.01.046] [Citation(s) in RCA: 153] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2014] [Revised: 01/23/2015] [Accepted: 01/23/2015] [Indexed: 10/23/2022]
Abstract
OBJECTIVE We aimed to prospectively derive and validate a novel 1h-algorithm using high-sensitivity cardiac troponin I (hs-cTnI) for early rule-out and rule-in of acute myocardial infarction. METHODS We performed a prospective multicenter diagnostic study enrolling 1811 patients with suspected acute myocardial infarction. The final diagnosis was centrally adjudicated by 2 independent cardiologists using all available information, including coronary angiography, echocardiography, follow-up data, and serial measurements of hs-cTnT (but not hs-cTnI). The hs-cTnI 1h-algorithm, incorporating measurements performed at baseline and absolute changes within 1 hour, was derived in a randomly selected sample of 906 patients (derivation cohort), and then validated in the remaining 905 patients (validation cohort). RESULTS Acute myocardial infarction was the final diagnosis in 18% of patients. After applying the hs-cTnI 1h-algorithm developed in the derivation cohort to the validation cohort, 50.5% of patients could be classified as "rule-out," 19% as "rule-in," 30.5% as "observe." In the validation cohort, the negative predictive value for acute myocardial infarction in the "rule-out" zone was 99.6% (95% confidence interval, 98.4%-100%), and the positive predictive value for acute myocardial infarction in the "rule-in" zone was 73.9% (95% confidence interval, 66.7%-80.2%). Negative predictive value of the 1h-algorithm was higher compared with the classical dichotomous interpretation of hs-cTnI and to the standard of care combining hs-cTnI with the electrocardiogram (both P < .001). Positive predictive value also was higher compared with the standard of care (P < .001). CONCLUSION Using a simple algorithm incorporating baseline hs-cTnI values and the absolute change within the first hour allows safe rule-out as well as accurate rule-in of acute myocardial infarction in 70% of patients presenting with suspected acute myocardial infarction.
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Affiliation(s)
- Maria Rubini Gimenez
- Department of Cardiology and Cardiovascular Research Institute Basel, University Hospital Basel, Switzerland; Servicio de Urgencias y Pneumologia, CIBERES ISC III, Hospital del Mar-Institut Municipal d'Investigació Mèdica, Barcelona, Spain
| | - Raphael Twerenbold
- Department of Cardiology and Cardiovascular Research Institute Basel, University Hospital Basel, Switzerland
| | - Cedric Jaeger
- Department of Cardiology and Cardiovascular Research Institute Basel, University Hospital Basel, Switzerland
| | - Christian Schindler
- Department of Epidemiology and Public Health, Swiss Tropical and Public Health Institute, University Basel, Switzerland
| | - Christian Puelacher
- Department of Cardiology and Cardiovascular Research Institute Basel, University Hospital Basel, Switzerland
| | - Karin Wildi
- Department of Cardiology and Cardiovascular Research Institute Basel, University Hospital Basel, Switzerland
| | - Tobias Reichlin
- Department of Cardiology and Cardiovascular Research Institute Basel, University Hospital Basel, Switzerland
| | - Philip Haaf
- Department of Cardiology and Cardiovascular Research Institute Basel, University Hospital Basel, Switzerland
| | - Salome Merk
- Department of Cardiology and Cardiovascular Research Institute Basel, University Hospital Basel, Switzerland
| | - Ursina Honegger
- Department of Cardiology and Cardiovascular Research Institute Basel, University Hospital Basel, Switzerland
| | - Max Wagener
- Department of Cardiology and Cardiovascular Research Institute Basel, University Hospital Basel, Switzerland
| | - Sophie Druey
- Department of Cardiology and Cardiovascular Research Institute Basel, University Hospital Basel, Switzerland
| | - Carmela Schumacher
- Department of Cardiology and Cardiovascular Research Institute Basel, University Hospital Basel, Switzerland
| | - Lian Krivoshei
- Department of Cardiology and Cardiovascular Research Institute Basel, University Hospital Basel, Switzerland
| | - Petra Hillinger
- Department of Cardiology and Cardiovascular Research Institute Basel, University Hospital Basel, Switzerland
| | - Thomas Herrmann
- Department of Cardiology and Cardiovascular Research Institute Basel, University Hospital Basel, Switzerland
| | - Isabel Campodarve
- Servicio de Urgencias y Pneumologia, CIBERES ISC III, Hospital del Mar-Institut Municipal d'Investigació Mèdica, Barcelona, Spain
| | | | - Stefano Bassetti
- Department of Internal Medicine, University Hospital Basel, Switzerland
| | - Stefan Osswald
- Department of Cardiology and Cardiovascular Research Institute Basel, University Hospital Basel, Switzerland
| | - Christian Mueller
- Department of Cardiology and Cardiovascular Research Institute Basel, University Hospital Basel, Switzerland.
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Su Q, Guo Y, Liu H, Qin Y, Zhang J, Yuan X, Zhao X. Diagnostic Role of High-Sensitivity Cardiac Troponin T in Acute Myocardial Infarction and Cardiac Noncoronary Artery Disease. Arch Med Res 2015; 46:193-8. [PMID: 25840037 DOI: 10.1016/j.arcmed.2015.03.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2014] [Accepted: 03/18/2015] [Indexed: 11/25/2022]
Abstract
BACKGROUND AND AIMS Currently, the distinction between AMI and cardiac noncoronary artery disease (CNCD) remains a challenge in clinical practice. Our aim was to evaluate the diagnostic role of high-sensitivity cardiac troponin T (hs-cTnT) level at presentation and its change within the first hour to distinguish AMI from CNCD. METHODS hs-cTnT was measured at presentation and after 1 h in 110 consecutive Chinese patients with symptoms suggestive of AMI within 12 h from symptom onset. Receiver-operating characteristics (ROC) analysis was used to estimate the diagnostic accuracy of hs-cTnT. RESULTS Patients with AMI had higher presentation values of hs-cTnT and higher absolute changes in the first h than patients with CNCD. The diagnostic accuracy of hs-cTnT at presentation for the distinction between patients with AMI and CNCD as quantified by the area under the receiver-operating characteristics curve (AUC) was 0.88. The discriminatory power of Δhs-cTnT 0-1 h was higher for absolute (AUC, 0.89; 95% CI, 0.83-0.94) compared to relative (AUC, 0.64; 95% CI, 0.60-0.73) changes. Combining presentation values of hs-cTnT at presentation with absolute changes in the first h increased the AUC to 0.93 (p < 0.001 for comparison with AUC of 0 h hs-cTnT). CONCLUSIONS Overall, our results suggest that the combined use of presentation values of hs-cTnT and its absolute change in the first hour discriminates well between patients with AMI and CNCD, further confirming the role of hs-cTnT as a biomarker for the early diagnosis of AMI.
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Affiliation(s)
- Qin Su
- First Affiliated Hospital of PLA General Hospital, Emergency Department, Hai Dian District, Beijing, China
| | - Yingfei Guo
- First Affiliated Hospital of PLA General Hospital, Emergency Department, Hai Dian District, Beijing, China
| | - Hongsheng Liu
- First Affiliated Hospital of PLA General Hospital, Emergency Department, Hai Dian District, Beijing, China
| | - Yuhong Qin
- First Affiliated Hospital of PLA General Hospital, Emergency Department, Hai Dian District, Beijing, China
| | - Jianbo Zhang
- First Affiliated Hospital of PLA General Hospital, Emergency Department, Hai Dian District, Beijing, China
| | - Xiaoling Yuan
- First Affiliated Hospital of PLA General Hospital, Emergency Department, Hai Dian District, Beijing, China
| | - Xiaodong Zhao
- First Affiliated Hospital of PLA General Hospital, Emergency Department, Hai Dian District, Beijing, China.
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Body R, Burrows G, Carley S, Lewis PS. Rapid exclusion of acute myocardial infarction in patients with undetectable troponin using a sensitive troponin I assay. Ann Clin Biochem 2015; 52:543-9. [DOI: 10.1177/0004563215576976] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/16/2015] [Indexed: 01/09/2023]
Abstract
Objective With a high-sensitivity troponin assay, it may be possible to exclude acute myocardial infarction with a single blood test on arrival in the emergency department by using a novel ‘rule out’ cut-off set at the limit of detection of the assay. We aimed to determine whether this can also be achieved using a contemporary sensitive troponin assay that does not meet ‘high-sensitivity’ criteria. Methods In a prospective diagnostic cohort study, we included patients presenting to the emergency department with suspected cardiac chest pain. For this secondary analysis, serum samples drawn on arrival were tested using a contemporary sensitive troponin I assay (s-cTnI; Siemens Ultra ADVIA Centaur, 99th percentile 40 ng/L, limit of detection 6 ng/L). Acute myocardial infarction was adjudicated by two independent investigators based on reference standard troponin testing ≥12 h after symptom onset. Results Of 414 participants, 70 (16.9%) had acute myocardial infarction and 205 (49.5%) had initial s-cTnI concentrations below the limit of detection. Using the limit of detection as a ‘rule out’ cut-off gave a sensitivity of 94.3% (95% CI 86.0–98.4%) for acute myocardial infarction. If only patients with s-cTnI below the limit of detection and no electrocardiogram ischaemia were considered to have acute myocardial infarction ‘ruled out’ (41.8% of the cohort, n = 174), sensitivity would rise to 97.1% (90.1–99.7%) and negative predictive value to 98.8% (95.9–99.9%). Conclusions Acute myocardial infarction cannot be excluded in patients with s-cTnI concentrations below the limit of detection using the contemporary sensitive assay evaluated. Future work with this assay should focus on serial sampling over 1–3 h and combination with clinical information and/or additional biomarkers.
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Affiliation(s)
- Richard Body
- Cardiovascular Sciences Research Group, The University of Manchester, Manchester, UK
- Emergency Department, Central Manchester NHS Foundation Trust, Manchester, UK
| | - Gillian Burrows
- Biochemistry Department, Stockport NHS Foundation Trust, Stockport, UK
| | - Simon Carley
- Emergency Department, Central Manchester NHS Foundation Trust, Manchester, UK
- Centre for Effective Emergency Care, Manchester Metropolitan University, Manchester, UK
| | - Philip S Lewis
- Cardiology Department, Stockport NHS Foundation Trust, Stockport, UK
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Christ M, Geier F, Popp S, Singler K, Smolarsky A, Bertsch T, Müller C, Greve Y. Diagnostic and prognostic value of high-sensitivity cardiac troponin T in patients with syncope. Am J Med 2015; 128:161-170.e1. [PMID: 25447619 DOI: 10.1016/j.amjmed.2014.09.021] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2014] [Revised: 09/07/2014] [Accepted: 09/08/2014] [Indexed: 11/29/2022]
Abstract
OBJECTIVE We examined the diagnostic and predictive value of high-sensitivity cardiac troponin T (cTnThs) in patients with syncope. METHODS We performed an analysis of consecutive patients with syncope presenting to the emergency department. The primary end point was the accuracy to diagnose a cardiac syncope. In addition, the study explored the prognostic relevance of cTnThs in patients with cardiac and noncardiac syncope. RESULTS A total of 360 patients were enrolled (median age, 70.5 years; male, 55.8%; 23.9% aged >80 years). Cardiac syncope was present in 22% of patients, reflex syncope was present in 40% of patients, syncope due to orthostatic hypotension was present in 20% of patients, and unexplained syncope was present in 17.5% of patients. A total of 148 patients (41%) had cTnThs levels above the 99% confidence interval (CI) (cutoff point). The diagnostic accuracy for cTnThs levels to determine the diagnosis of cardiac syncope was quantified by the area under the curve (0.77; CI, 0.72-0.83; P < .001). A comparable area under the curve (0.78; CI, 0.73-0.83; P < .001) was obtained for the predictive value of cTnThs levels within 30 days: Patients with increased cTnThs levels had a 52% likelihood for adverse events, patients with cTnThs levels below the cutoff point had a low risk (negative predictive value, 83.5%). Increased cTnThs levels indicate adverse prognosis in patients with noncardiac causes of syncope, but not in patients with cardiac syncope being a risk factor for adverse outcome by itself. CONCLUSIONS Patients with syncope presenting to the emergency department have a high proportion of life-threatening conditions. cTnThs levels show a limited diagnostic and predictive accuracy for the identification of patients with syncope at high risk.
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Affiliation(s)
- Michael Christ
- Department of Emergency and Intensive Care Medicine, Paracelsus Medical University, Nuremberg, Germany.
| | - Felicitas Geier
- Department of Emergency and Intensive Care Medicine, Paracelsus Medical University, Nuremberg, Germany
| | - Steffen Popp
- Department of Emergency and Intensive Care Medicine, Paracelsus Medical University, Nuremberg, Germany
| | - Katrin Singler
- Institute for Biomedicine of Aging, Friedrich-Alexander Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Alexander Smolarsky
- Center of Trauma and Orthopaedic Surgery, Helios Vogtland-Klinikum Plauen, Plauen, Germany
| | - Thomas Bertsch
- Department of Clinical Chemistry and Laboratory Medicine, Paracelsus Medical University, Nuremberg, Germany
| | - Christian Müller
- Department of Cardiology, University Hospital Basel, Basel, Switzerland
| | - Yvonne Greve
- Department of Emergency and Intensive Care Medicine, Paracelsus Medical University, Nuremberg, Germany
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Zhelev Z, Hyde C, Youngman E, Rogers M, Fleming S, Slade T, Coelho H, Jones-Hughes T, Nikolaou V. Diagnostic accuracy of single baseline measurement of Elecsys Troponin T high-sensitive assay for diagnosis of acute myocardial infarction in emergency department: systematic review and meta-analysis. BMJ 2015; 350:h15. [PMID: 25646632 PMCID: PMC4300724 DOI: 10.1136/bmj.h15] [Citation(s) in RCA: 139] [Impact Index Per Article: 15.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/10/2014] [Indexed: 12/29/2022]
Abstract
OBJECTIVE To obtain summary estimates of the accuracy of a single baseline measurement of the Elecsys Troponin T high-sensitive assay (Roche Diagnostics) for the diagnosis of acute myocardial infarction in patients presenting to the emergency department. DESIGN Systematic review and meta-analysis of diagnostic test accuracy studies. DATA SOURCES Medline, Embase, and other relevant electronic databases were searched for papers published between January 2006 and December 2013. STUDY SELECTION Studies were included if they evaluated the diagnostic accuracy of a single baseline measurement of Elecsys Troponin T high-sensitive assay for the diagnosis of acute myocardial infarction in patients presenting to the emergency department with suspected acute coronary syndrome. STUDY APPRAISAL AND DATA SYNTHESIS The first author screened all titles and abstracts identified through the searches and selected all potentially relevant papers. The screening of the full texts, the data extraction, and the methodological quality assessment, using the adapted QUADAS-2 tool, were conducted independently by two reviewers with disagreements being resolved through discussion or arbitration. If appropriate, meta-analysis was conducted using the hierarchical bivariate model. RESULTS Twenty three studies reported the performance of the evaluated assay at presentation. The results for 14 ng/L and 3-5 ng/L cut-off values were pooled separately. At 14 ng/L (20 papers), the summary sensitivity was 89.5% (95% confidence interval 86.3% to 92.1%) and the summary specificity was 77.1% (68.7% to 83.7%). At 3-5 ng/L (six papers), the summary sensitivity was 97.4% (94.9% to 98.7%) and the summary specificity was 42.4% (31.2% to 54.5%). This means that if 21 of 100 consecutive patients have the target condition (21%, the median prevalence across the studies), 2 (95% confidence interval 2 to 3) of 21 patients with acute myocardial infarction will be missed (false negatives) if 14 ng/L is used as a cut-off value and 18 (13 to 25) of 79 patients without acute myocardial infarction will test positive (false positives). If the 3-5 ng/L cut-off value is used, <1 (0 to 1) patient with acute myocardial infarction will be missed and 46 (36 to 54) patients without acute myocardial infarction will test positive. CONCLUSIONS The results indicate that a single baseline measurement of the Elecsys Troponin T high-sensitive assay could be used to rule out acute myocardial infarction if lower cut-off values such as 3 ng/L or 5 ng/L are used. However, this method should be part of a comprehensive triage strategy and may not be appropriate for patients who present less than three hours after symptom onset. Care must also be exercised because of the higher imprecision of the evaluated assay and the greater effect of lot-to-lot reagent variation at low troponin concentrations. SYSTEMATIC REVIEW REGISTRATION PROSPERO registration number CRD42013003926.
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Affiliation(s)
- Zhivko Zhelev
- Institute of Health Research, University of Exeter Medical School, Exeter EX2 4SG, UK
| | - Christopher Hyde
- Institute of Health Research, University of Exeter Medical School, Exeter EX2 4SG, UK
| | - Emily Youngman
- Institute of Health Research, University of Exeter Medical School, Exeter EX2 4SG, UK
| | - Morwenna Rogers
- Institute of Health Research, University of Exeter Medical School, Exeter EX2 4SG, UK
| | - Simon Fleming
- Clinical Chemistry, Royal Cornwall Hospital, Treliske, Truro TR1 3LQ, UK
| | - Toby Slade
- Emergency Department, Royal Cornwall Hospital, Truro TR1 3LJ, UK
| | - Helen Coelho
- Institute of Health Research, University of Exeter Medical School, Exeter EX2 4SG, UK
| | - Tracey Jones-Hughes
- Institute of Health Research, University of Exeter Medical School, Exeter EX2 4SG, UK
| | - Vasilis Nikolaou
- Institute of Health Research, University of Exeter Medical School, Exeter EX2 4SG, UK
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Lipinski MJ, Baker NC, Escárcega RO, Torguson R, Chen F, Aldous SJ, Christ M, Collinson PO, Goodacre SW, Mair J, Inoue K, Lotze U, Sebbane M, Cristol JP, Freund Y, Chenevier-Gobeaux C, Meune C, Eggers KM, Pracoń R, Schreiber DH, Wu AHB, Ordoñez-Llanos J, Jaffe AS, Twerenbold R, Mueller C, Waksman R. Comparison of conventional and high-sensitivity troponin in patients with chest pain: a collaborative meta-analysis. Am Heart J 2015; 169:6-16.e6. [PMID: 25497242 DOI: 10.1016/j.ahj.2014.10.007] [Citation(s) in RCA: 73] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2014] [Accepted: 10/10/2014] [Indexed: 02/07/2023]
Abstract
BACKGROUND Multiple studies have evaluated the diagnostic and prognostic performance of conventional troponin (cTn) and high-sensitivity troponin (hs-cTn). We performed a collaborative meta-analysis comparing cTn and hs-cTn for diagnosis of acute myocardial infarction (AMI) and assessment of prognosis in patients with chest pain. METHODS MEDLINE/PubMed, Cochrane CENTRAL, and EMBASE were searched for studies assessing both cTn and hs-cTn in patients with chest pain. Study authors were contacted and many provided previously unpublished data. RESULTS From 17 included studies, there were 8,644 patients. Compared with baseline cTn, baseline hs-cTn had significantly greater sensitivity (0.884 vs 0.749, P < .001) and negative predictive value (NPV; 0.964 vs 0.935, P < .001), whereas specificity (0.816 vs 0.938, P < .001) and positive predictive value (0.558 vs 0.759, P < .001) were significantly reduced. Based on summary receiver operating characteristic curves, test performance for the diagnosis of AMI was not significantly different between baseline cTn and hs-cTn (0.90 [95% CI 0.85-0.95] vs 0.92 [95% CI 0.90-0.94]). In a subanalysis of 6 studies that alternatively defined AMI based on hs-cTn, cTn had lower sensitivity (0.666, P < .001) and NPV (0.906, P < .001). Elevation of baseline hs-cTn, but negative baseline cTn, was associated with increased risk of death or nonfatal myocardial infarction during follow-up (P < .001) compared with both negative. CONCLUSION High-sensitivity troponin has significantly greater early sensitivity and NPV for the diagnosis of AMI at the cost of specificity and positive predictive value, which may enable early rule in/out of AMI in patients with chest pain. Baseline hs-cTn elevation in the setting of negative cTn is also associated with increased nonfatal myocardial infarction or death during follow-up.
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Affiliation(s)
- Michael J Lipinski
- MedStar Cardiovascular Research Network, MedStar Heart Institute, Medstar Washington Hospital Center, Washington, DC
| | - Nevin C Baker
- MedStar Cardiovascular Research Network, MedStar Heart Institute, Medstar Washington Hospital Center, Washington, DC
| | - Ricardo O Escárcega
- MedStar Cardiovascular Research Network, MedStar Heart Institute, Medstar Washington Hospital Center, Washington, DC
| | - Rebecca Torguson
- MedStar Cardiovascular Research Network, MedStar Heart Institute, Medstar Washington Hospital Center, Washington, DC
| | - Fang Chen
- MedStar Cardiovascular Research Network, MedStar Heart Institute, Medstar Washington Hospital Center, Washington, DC
| | - Sally J Aldous
- Department of Cardiology, Christchurch Hospital, Christchurch, New Zealand
| | - Michael Christ
- Department of Emergency and Critical Care Medicine, Paracelsus Medical University, Nuremberg, Germany
| | - Paul O Collinson
- Clinical Blood Sciences Laboratory, St George's Hospital, London, United Kingdom
| | - Steve W Goodacre
- School of Health and Related Research, University of Sheffield, Sheffield, United Kingdom
| | - Johannes Mair
- Department of Internal Medicine, Innsbruck Medical University, Innsbruck, Austria
| | - Kenji Inoue
- Department of Cardiology, Juntendo University Nerima Hospital, Tokyo, Japan
| | - Ulrich Lotze
- Department of Internal Medicine, DRK-Manniske-Krankenhaus Bad Frankenhausen, Frankenhausen, Germany
| | - Mustapha Sebbane
- Départment des urgences, Centre Hospitalier Régional Universitaire Lapeyronie, Montpellier, France
| | - Jean-Paul Cristol
- Département de Biochimie, Centre Hospitalier Régional Universitaire Lapeyronie, Montpellier, France
| | - Yonathan Freund
- Department of Emergency Medicine and Surgery, Hôspital Pitié-Salpétrière, APHP, Université Pierre et Marie Curie-Paris 6 (UPMC), Paris, France
| | - Camille Chenevier-Gobeaux
- Clinical Chemistry Laboratory, Groupe Hospitalier Cochin-Broca-Hôtel Dieu, Université Paris Descartes, Assistance Publique des Hôpitaux de Paris, Paris, France
| | - Christophe Meune
- Cardiology Department, Groupe Hospitalier Cochin-Broca-Hôtel Dieu, Université Paris Descartes, Assistance Publique des Hôpitaux de Paris, Paris, France; Cardiology Department, Paris XIII University, Avicenne Hospital, Bobigny, France
| | - Kai M Eggers
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - Radosław Pracoń
- Department of Coronary and Structural Heart Diseases, National Insititute of Cardiology, Warsaw, Poland
| | - Donald H Schreiber
- Division of Emergency Medicine, Stanford University School of Medicine, Stanford, CA
| | - Alan H B Wu
- Department of Laboratory Medicine, University of California, San Francisco, CA
| | - Jordi Ordoñez-Llanos
- Servei de Bioquímica Clínica, Hospital de Sant Pau, Barcelona, Spain; Biochemistry and Molecular Biology Department, Universitat Autònoma, Barcelona, Spain
| | - Allan S Jaffe
- Division of Cardiology, Mayo Clinic College of Medicine, Rochester, MN; Department of Laboratory Medicine and Pathology, Mayo Clinic College of Medicine, Rochester, MN
| | - Raphael Twerenbold
- Department of Cardiology, University Hospital Basel, Basel, Switzerland; Universitäres Herz-Zentrum Bad Krozingen, Bad Krozingen, Germany
| | - Christian Mueller
- Department of Cardiology, University Hospital Basel, Basel, Switzerland
| | - Ron Waksman
- MedStar Cardiovascular Research Network, MedStar Heart Institute, Medstar Washington Hospital Center, Washington, DC.
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30
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[Chest pain units or chest pain algorithm?]. Med Klin Intensivmed Notfmed 2014; 109:495-503. [PMID: 25330873 DOI: 10.1007/s00063-013-0342-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2014] [Accepted: 09/01/2014] [Indexed: 10/24/2022]
Abstract
BACKGROUND A large number of patients present to the emergency department (ED) for evaluation of acute chest pain. About 10-15% are caused by acute myocardial infarction (MI), and over 50% of cases are due to noncardiac reasons. Further improvement for chest pain evaluation appears necessary. OBJECTIVES What are current options to improve chest pain evaluation in Germany? METHODS A selective literature search was performed using the following terms: "chest pain", "emergency department", "acute coronary syndrome" and "chest pain evaluation". RESULTS AND DISCUSSION A working group of the German Society of Cardiology published recommendations for infrastructure, equipment and organisation of chest pain units in Germany, which should be separated from the ED of hospitals and be under the leadership of a cardiologist. A symptom-based decision for acute care would be preferable if all differential diagnoses of diseases could be managed by one medical specialty: However, all four main symptoms of patients with acute MI (chest pain, acute dyspnea, abdominal pain, dizziness) are also caused by diseases of different specialties. Evaluation and treatment of acute chest pain by representatives of one specialty would lead to over- or undertreatment of affected patients. Therefore we suggest a multidisciplinary evaluation of patients with acute chest pain including representatives of emergency and critical care physicians, cardiologists, internists, geriatricians, family physicians, premedics and emergency nurses. Definition of key indicators of performance and institutionalized feedback will help to further improve quality of care.
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Corsini A, Vagnarelli F, Bugani G, Bacchi Reggiani ML, Semprini F, Nanni S, Cinti L, Norscini G, Vannini A, Beltrandi E, Cavazza M, Branzi A, Rapezzi C, Melandri G. Impact of high-sensitivity Troponin T on hospital admission, resources utilization, and outcomes. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2014; 4:148-57. [PMID: 25124535 DOI: 10.1177/2048872614547687] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
AIMS The use of high-sensitivity cardiac Troponin T (hs-cTnT) assay might lead to overdiagnosis and overtreatment of Acute Coronary Syndromes (ACS). This study assessed the epidemiological, clinical and prognostic impact of introducing hs-cTnT in the everyday clinical practice of an Emergency Department. METHODS AND RESULTS We compared all consecutive patients presenting with suspected ACS at the Emergency Department, for whom troponin levels were measured. In particular, we considered 597 patients presenting during March 2010, when standard cardiac Troponin T (cTnT) assay was used, and 629 patients presenting during March 2011, when hs-cTnT test was used. Patients with suspected ACS and troponin levels above the 99th percentile (Upper Reference Limit, URL) significantly increased when using an hs-cTnT assay (17.2% vs. 37.4%, p< 0.001). Accordingly, also the mean GRACE risk score increased (124.2 ± 37.2 vs. 136.7 ± 32.2; p< 0.001). However, the final diagnosis of Acute Myocardial Infarction (AMI) did not change significantly (8.7% vs. 6.8%, p=0.263) by using a rising and/or falling pattern of hs-cTnT (change ≥ 50% or ≥ 20% depending on baseline values). In addition, no significant differences were found between the two study groups with respect to in-hospital (2.7% vs. 1.9%, p=0.366) and 1-year mortality (9.8% vs. 7.6%, p=0.216). CONCLUSIONS We did not observe overdiagnosis and overtreatment issues in presenters with suspected ACS managed by appropriate changes in hs-cTnT levels, despite the increase in the number of patients presenting with abnormal troponin levels. This occurred without a rise in short-term and mid-term mortality.
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Affiliation(s)
- Anna Corsini
- Institute of Cardiology, Cardio-Thoraco-Vascular Department, Sant'Orsola-Malpighi Hospital and University of Bologna, Italy
| | - Fabio Vagnarelli
- Institute of Cardiology, Cardio-Thoraco-Vascular Department, Sant'Orsola-Malpighi Hospital and University of Bologna, Italy
| | - Giulia Bugani
- Institute of Cardiology, Cardio-Thoraco-Vascular Department, Sant'Orsola-Malpighi Hospital and University of Bologna, Italy
| | - Maria Letizia Bacchi Reggiani
- Institute of Cardiology, Cardio-Thoraco-Vascular Department, Sant'Orsola-Malpighi Hospital and University of Bologna, Italy
| | - Franco Semprini
- Institute of Cardiology, Cardio-Thoraco-Vascular Department, Sant'Orsola-Malpighi Hospital and University of Bologna, Italy
| | - Samuele Nanni
- Institute of Cardiology, Cardio-Thoraco-Vascular Department, Sant'Orsola-Malpighi Hospital and University of Bologna, Italy
| | - Laura Cinti
- Institute of Cardiology, Cardio-Thoraco-Vascular Department, Sant'Orsola-Malpighi Hospital and University of Bologna, Italy
| | - Giulia Norscini
- Institute of Cardiology, Cardio-Thoraco-Vascular Department, Sant'Orsola-Malpighi Hospital and University of Bologna, Italy
| | - Antonio Vannini
- Emergency and Surgical-Transplantation Department, Sant'Orsola-Malpighi Hospital, Bologna, Italy
| | - Elisabetta Beltrandi
- Haematology, Oncology and Laboratory Medicine Department, Sant'Orsola-Malpighi Hospital, Bologna, Italy
| | - Mario Cavazza
- Emergency and Surgical-Transplantation Department, Sant'Orsola-Malpighi Hospital, Bologna, Italy
| | - Angelo Branzi
- Institute of Cardiology, Cardio-Thoraco-Vascular Department, Sant'Orsola-Malpighi Hospital and University of Bologna, Italy
| | - Claudio Rapezzi
- Institute of Cardiology, Cardio-Thoraco-Vascular Department, Sant'Orsola-Malpighi Hospital and University of Bologna, Italy
| | - Giovanni Melandri
- Institute of Cardiology, Cardio-Thoraco-Vascular Department, Sant'Orsola-Malpighi Hospital and University of Bologna, Italy
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Sethi A, Bajaj A, Malhotra G, Arora RR, Khosla S. Diagnostic accuracy of sensitive or high-sensitive troponin on presentation for myocardial infarction: a meta-analysis and systematic review. Vasc Health Risk Manag 2014; 10:435-50. [PMID: 25092986 PMCID: PMC4115590 DOI: 10.2147/vhrm.s63416] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
Background Recently, high-sensitive troponin (hsTrop) assays consistent with professional societies’ recommendations became available. We aimed to summarize the evidence on the diagnostic accuracy of hsTrop on presentation. Methods We searched electronic databases for studies evaluating the diagnostic accuracy of hsTrop in suspected acute coronary syndrome (ACS) patients. Random effect meta-analyses and meta-regression were performed. Primary and secondary analyses were restricted to studies using conventional Trop and hsTrop in the reference standard, respectively. Results Fifteen studies with a total of 8,628 patients met the inclusion criteria for the primary analysis. hsTrop T (Hoffman-La Roche Ltd) and hsTrop I (Siemens) had sensitivities of 0.89 (95% confidence interval [CI]: 0.86–0.91) and 0.90 (95% CI: 0.87–0.92) and specificities of 0.79 (95% CI: 0.77–0.80) and 0.89 (95% CI: 0.87–0.90), respectively. There was no statistically significant difference in the area under the curve between hsTrop (95% CI: 0.920) and conventional Trop (95% CI: 0.929) at the 99th percentile (P=0.62). hsTrop at the level of detection had a sensitivity of 0.97 (95% CI: 0.96–0.98) and a specificity of 0.41 (95% CI: 0.40–0.42). The studies using a cut-off at coefficient of variance <10% as opposed to the 99th percentile for the conventional assay used for diagnosis reported higher diagnostic accuracy (relative diagnostic odds ratio =2.13, P=0.02). Five studies were included in the secondary analysis; hsTrop T (Hoffman-La Roche Ltd) had a sensitivity of 0.91 (95% CI: 0.89–0.93) and a specificity of 0.67 (95% CI: 0.63–0.70). There was significant heterogeneity among the studies. Conclusion hsTrop have excellent diagnostic accuracy for myocardial infarction on presentation, but may not outperform conventional Trop assays. The variation among the studies can be explained, in part, by the cut-off used for conventional Trop assays.
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Affiliation(s)
- Ankur Sethi
- Department of Medicine, Division of Cardiology, Rosalind Franklin University of Medicine and Science, North Chicago, IL, USA
| | - Anurag Bajaj
- Department of Medicine, Wright Center of Graduate Medical Education, Scranton, PA, USA
| | - Gurveen Malhotra
- Department of Medicine, Division of Cardiology, Rosalind Franklin University of Medicine and Science, North Chicago, IL, USA
| | - Rohit R Arora
- Department of Medicine, Division of Cardiology, Rosalind Franklin University of Medicine and Science, North Chicago, IL, USA
| | - Sandeep Khosla
- Department of Medicine, Division of Cardiology, Rosalind Franklin University of Medicine and Science, North Chicago, IL, USA
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Al-Saleh A, Alazzoni A, Al Shalash S, Ye C, Mbuagbaw L, Thabane L, Jolly SS. Performance of the high-sensitivity troponin assay in diagnosing acute myocardial infarction: systematic review and meta-analysis. CMAJ Open 2014; 2:E199-207. [PMID: 25295240 PMCID: PMC4183183 DOI: 10.9778/cmajo.20130074] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND High-sensitivity cardiac troponin assays have been adopted by many clinical centres worldwide; however, clinicians are uncertain how to interpret the results. We sought to assess the utility of these assays in diagnosing acute myocardial infarction (MI). METHODS We carried out a systematic review and meta-analysis of studies comparing high-sensitivity with conventional assays of cardiac troponin levels among adults with suspected acute MI in the emergency department. We searched MEDLINE, EMBASE and Cochrane databases up to April 2013 and used bivariable random-effects modelling to obtain summary parameters for diagnostic accuracy. RESULTS We identified 9 studies that assessed the use of high-sensitivity troponin T assays (n = 9186 patients). The summary sensitivity of these tests in diagnosing acute MI at presentation to the emergency department was estimated to be 0.94 (95% confidence interval [CI] 0.89-0.97); for conventional tests, it was 0.72 (95% CI 0.63-0.79). The summary specificity was 0.73 (95% CI 0.64-0.81) for the high-sensitivity assay compared with 0.95 (95% CI 0.93-0.97) for the conventional assay. The differences in estimates of the summary sensitivity and specificity between the high-sensitivity and conventional assays were statistically significant (p < 0.01). The area under the curve was similar for both tests carried out 3-6 hours after presentation. Three studies assessed the use of high-sensitivity troponin I assays and showed similar results. INTERPRETATION Used at presentation to the emergency department, the high-sensitivity cardiac troponin assay has improved sensitivity, but reduced specificity, compared with the conventional troponin assay. With repeated measurements over 6 hours, the area under the curve is similar for both tests, indicating that the major advantage of the high-sensitivity test is early diagnosis.
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Affiliation(s)
- Ayman Al-Saleh
- Department of Cardiology, Hamilton Health Sciences, McMaster University, Hamilton, Ont
| | - Ashraf Alazzoni
- Department of Cardiology, Hamilton Health Sciences, McMaster University, Hamilton, Ont
| | - Saleh Al Shalash
- Department of Internal Medicine, McMaster University, Hamilton, Ont
| | - Chenglin Ye
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ont. ; Biostatistics Unit, St Joseph's Healthcare, Hamilton, Ont
| | - Lawrence Mbuagbaw
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ont. ; Biostatistics Unit, St Joseph's Healthcare, Hamilton, Ont. ; Centre for Development of Best Practices in Health, Yaoundé Central Hospital, Yaoundé, Cameroon
| | - Lehana Thabane
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ont. ; Departments of Anesthesia and Pediatrics, McMaster University, Hamilton, Ont. ; Population Health Research Institute, Hamilton Health Sciences, Hamilton, Ont
| | - Sanjit S Jolly
- Department of Cardiology, Hamilton Health Sciences, McMaster University, Hamilton, Ont. ; Population Health Research Institute, Hamilton Health Sciences, Hamilton, Ont
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Recchioni R, Marcheselli F, Olivieri F, Ricci S, Procopio AD, Antonicelli R. Conventional and novel diagnostic biomarkers of acute myocardial infarction: a promising role for circulating microRNAs. Biomarkers 2013; 18:547-58. [PMID: 24025051 DOI: 10.3109/1354750x.2013.833294] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Biomarkers play a critical role in the diagnosis of acute myocardial infarction (AMI), especially in patients with atypical clinical and/or electrocardiographic presentation or co-morbidities, like the elderly. High-sensitivity assays based on specific biomarkers (e.g. cardiac troponins) enabling earlier AMI diagnosis have recently become available in clinical practice. Although no single biomarker of myocardial necrosis is ever likely to afford AMI diagnosis, a combination including different biomarkers for necrosis and ischemia, like new circulating molecules (microRNAs), could enhance diagnostic specificity. We review the recent literature on conventional and novel AMI biomarkers, with special emphasis on circulating microRNAs.
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Affiliation(s)
- Rina Recchioni
- Center of Clinical Pathology and Innovative Therapy, Italian National Research Center on Aging (I.N.R.C.A-IRCCS) , Ancona , Italy
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Kossaify A, Garcia A, Succar S, Ibrahim A, Moussallem N, Kossaify M, Grollier G. Perspectives on the value of biomarkers in acute cardiac care and implications for strategic management. Biomark Insights 2013; 8:115-26. [PMID: 24046510 PMCID: PMC3771707 DOI: 10.4137/bmi.s12703] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Biomarkers in acute cardiac care are gaining increasing interest given their clinical benefits. This study is a review of the major conditions in acute cardiac care, with a focus on biomarkers for diagnostic and prognostic assessment. Through a PubMed search, 110 relevant articles were selected. The most commonly used cardiac biomarkers (cardiac troponin, natriuretic peptides, and C-reactive protein) are presented first, followed by a description of variable acute cardiac conditions with their relevant biomarkers. In addition to the conventional use of natriuretic peptides, cardiac troponin, and C-reactive protein, other biomarkers are outlined in variable critical conditions that may be related to acute cardiac illness. These include ST2 and chromogranin A in acute dyspnea and acute heart failure, matrix metalloproteinase in acute chest pain, heart-type fatty acid binding protein in acute coronary syndrome, CD40 ligand and interleukin-6 in acute myocardial infarction, blood ammonia and lactate in cardiac arrest, as well as tumor necrosis factor-alpha in atrial fibrillation. Endothelial dysfunction, oxidative stress and inflammation are involved in the physiopathology of most cardiac diseases, whether acute or chronic. In summary, natriuretic peptides, cardiac troponin, C-reactive protein are currently the most relevant biomarkers in acute cardiac care. Point-of-care testing and multi-markers use are essential for prompt diagnostic approach and tailored strategic management.
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Affiliation(s)
- Antoine Kossaify
- CCU Acute Cardiac Care Unit (CCU), Cardiology Division, University Hospital Notre Dame de Secours, St. Charbel Street, Byblos, Lebanon
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Retracted article: Concomitant measurement of copeptin and high-sensitivity troponin for fast and reliable rule out of acute myocardial infarction. Intensive Care Med 2013; 38:732. [PMID: 22302027 DOI: 10.1007/s00134-012-2481-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2011] [Accepted: 12/19/2011] [Indexed: 12/24/2022]
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Hammerer-Lercher A, Ploner T, Neururer S, Schratzberger P, Griesmacher A, Pachinger O, Mair J. High-sensitivity cardiac troponin T compared with standard troponin T testing on emergency department admission: how much does it add in everyday clinical practice? J Am Heart Assoc 2013; 2:e000204. [PMID: 23735897 PMCID: PMC3698787 DOI: 10.1161/jaha.113.000204] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Background We compared high‐sensitivity cardiac troponin T (hs‐cTnT) and standard cTnT for acute myocardial infarction (AMI) diagnosis in everyday clinical practice of an emergency department (ED). Methods and Results cTnT was measured in 2384 consecutive patients (60±21 years, 52% female) on ED admission. Readmissions to the ED (n=720) and mortality (n=101) were followed for an average period of 239±49 days. There were 53 AMIs (delay, 1 to 96 hours; median, 3 hours), 440 chest pain patients, 286 dyspnea patients, 785 acute or chronic cardiac diseases, and 540 neurological diseases, with the remaining having various internal diseases. The diagnostic performances of hs‐ and standard cTnT were comparable for AMI diagnosis (area under receiver operating characteristics curves [ROC AUC], 0.91±0.02 versus 0.90±0.03; P=0.31). Using the 99th‐percentile cutoff, the sensitivities and specificities for AMI in the whole population were 91% and 74% for hs‐cTnT and 89% and 80% for standard cTnT. hs‐cTnT detected significantly more patients with cardiac diseases (ROC AUC, 0.77±0.01 versus 0.67±0.01; P<0.001). hs‐cTnT and standard cTnT were significant predictors of ED readmissions but not of mortality, but both were not independent predictors of ED readmissions or the combined end point of readmission or mortality in binary logistic regression analysis. Conclusions In unselected ED patients the diagnostic performances of hs‐cTnT and standard cTnT for AMI diagnosis did not differ significantly. hs‐cTnT detected significantly more cardiac diseases. hs‐cTnT and standard cTnT were not independent predictors of ED readmissions and mortality from all causes.
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Affiliation(s)
- Angelika Hammerer-Lercher
- Central Institute for Medical and Chemical Laboratory Diagnostics, Innsbruck Medical University, Innsbruck, Austria
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Bahrmann P, Christ M, Bahrmann A, Rittger H, Heppner HJ, Achenbach S, Bertsch T, Sieber CC. A 3-hour diagnostic algorithm for non-ST-elevation myocardial infarction using high-sensitivity cardiac troponin T in unselected older patients presenting to the emergency department. J Am Med Dir Assoc 2013; 14:409-16. [PMID: 23375478 DOI: 10.1016/j.jamda.2012.12.005] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2012] [Revised: 12/09/2012] [Accepted: 12/12/2012] [Indexed: 12/30/2022]
Abstract
OBJECTIVES To determine if an algorithm implementing a serial high-sensitive cardiac troponin T (hs-cTnT) measurement at presentation (0 h) and at 3 hours after presentation (3h) is helpful for early diagnosis of non-ST-elevation myocardial infarction (NSTEMI) in older patients. DESIGN Prospective observational cohort study. SETTING An emergency department (ED) of a city hospital covering a population of approximately 1 million in Germany. PARTICIPANTS A total of 332 consecutive unselected patients were recruited, of whom 25 had one or more of the prespecified exclusion criteria and 1 had a missing hs-cTnT at 3h, resulting in a final population of 306 patients. MEASUREMENTS In addition to clinical examination, hs-cTnT was measured at 0 h and 3 h. The final diagnosis of NSTEMI was adjudicated by two independent consultants and an algorithm for rule-in and rule-out of NSTEMI was developed using classification and regression tree analysis. All patients were followed-up for cardiovascular outcome within 12 months. RESULTS Among 306 patients (mean age 81 ± 6 years), 38 (12%) patients had NSTEMI. Accuracy to diagnose NSTEMI was significantly higher for hs-cTnT measurements at 3 h versus 0 h (area under the receiver operating characteristic curve [AUC] 0.88 vs. 0.82, P = .0038) and for absolute versus relative hs-cTnT delta changes (AUC 0.89 versus 0.69, P < .001). A diagnostic algorithm using hs-cTnT values at presentation and absolute delta changes values ruled-in NSTEMI in 23% and ruled-out NSTEMI in 35% of patients. For patients neither fulfilling the rule-in nor the rule-out criteria, an observational zone was established. Cumulative 1-year survival was 79.4%, 88.5%, and 99.1% in patients classified as rule-in, observational zone, and rule-out, respectively. CONCLUSION In older patients, serial hs-cTnT measurements and absolute delta-changes at 3h were valuable for early diagnosis of NSTEMI. An algorithm ruled-in NSTEMI in one quarter of patients with high risk and ruled-out NSTEMI in one-third with low risk.
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Affiliation(s)
- Philipp Bahrmann
- Institute for Biomedicine of Aging, Friedrich-Alexander-University, Nuremberg, Germany.
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Bahrmann P, Bahrmann A, Breithardt OA, Daniel WG, Christ M, Sieber CC, Bertsch T. Additional diagnostic and prognostic value of copeptin ultra-sensitive for diagnosis of non-ST-elevation myocardial infarction in older patients presenting to the emergency department1). Clin Chem Lab Med 2013; 51:1307-19. [DOI: 10.1515/cclm-2012-0401] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2012] [Accepted: 11/09/2012] [Indexed: 12/27/2022]
Abstract
AbstractIdentifying older patients with non-ST- elevation myocardial infarction (NSTEMI) within the very large proportion with elevated high-sensitive cardiac troponin T (hs-cTnT) is a diagnostic challenge because they often present without clear symptoms or electrocardiographic features of acute coronary syndrome to the emergency department (ED). We prospectively investigated the diagnostic and prognostic performance of copeptin ultra-sensitive (copeptin-us) and hs-cTnT compared to hs-cTnT alone for NSTEMI at prespecified cut-offs in unselected older patients.We consecutively enrolled 306 non-surgical patients ≥70 years presenting to the ED. In addition to clinical examination, copeptin-us and hs-cTnT were measured at admission. Two cardiologists independently adjudicated the final diagnosis of NSTEMI after reviewing all available data. All patients were followed up for cardiovascular-related death within the following 12 months.NSTEMI was diagnosed in 38 (12%) patients (age 81±6 years). The combination of copeptin-us ≥14 pmol/L and hs-cTnT ≥0.014 µg/L compared to hs-cTnT ≥0.014 µg/L alone had a positive predictive value of 21% vs. 19% to rule in NSTEMI. The combination of copeptin-us <14 pmol/L and hs-cTnT <0.014 µg/L compared to hs-cTnT <0.014 µg/L alone had a negative predictive value of 100% vs. 99% to rule out NSTEMI. Hs-cTnT ≥0.014 µg/L alone was significantly associated with outcome. When copeptin-us ≥14 pmol/L was added, the net reclassification improvement for outcome was not significant (p=0.809).In unselected older patients presenting to the ED, the additional use of copeptin-us at predefined cut-offs may help to reliably rule out NSTEMI but may not help to increase predicted risk for outcome compared to hs-cTnT alone.
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Reichlin T, Twerenbold R, Reiter M, Steuer S, Bassetti S, Balmelli C, Winkler K, Kurz S, Stelzig C, Freese M, Drexler B, Haaf P, Zellweger C, Osswald S, Mueller C. Introduction of high-sensitivity troponin assays: impact on myocardial infarction incidence and prognosis. Am J Med 2012; 125:1205-1213.e1. [PMID: 23164485 DOI: 10.1016/j.amjmed.2012.07.015] [Citation(s) in RCA: 134] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2012] [Revised: 07/07/2012] [Accepted: 07/19/2012] [Indexed: 11/25/2022]
Abstract
OBJECTIVE The study objective was to compare the incidence and prognosis of acute myocardial infarction when using high-sensitivity cardiac troponin assays instead of a standard cardiac troponin assay for the diagnosis of acute myocardial infarction. METHODS In a prospective international multicenter study, we enrolled 1124 consecutive patients presenting with suspected acute myocardial infarction. Final diagnoses were adjudicated by 2 independent cardiologists 2 times using all available clinical information: first using standard cardiac troponin levels and second using high-sensitivity cardiac troponin T levels for adjudication. Patients were followed up for a mean of 19±9 months. RESULTS The use of high-sensitivity cardiac troponin T instead of standard cardiac troponin resulted in an increase in the incidence of acute myocardial infarction from 18% to 22% (242 vs 198 patients), a relative increase of 22%. Of the 44 additional acute myocardial infarctions, 35 were type 1 acute myocardial infarctions and 9 were type 2 acute myocardial infarctions. This was accompanied by a reciprocal decrease in the incidence of unstable angina (unstable angina, 11% vs 13%). The most pronounced increase was observed in patients adjudicated with cardiac symptoms of origin other than coronary artery disease with cardiomyocyte damage (83 vs 31 patients, relative increase of 268%). Cumulative 30-month mortality rates were 4.8% in patients without acute myocardial infarction, 16.4% in patients with a small acute myocardial infarction detected only by high-sensitivity cardiac troponin T but not standard cardiac troponin, and 23.9% in patients with a moderate/large acute myocardial infarction according to standard cardiac troponin assays and high-sensitivity cardiac troponin T (P<.001). CONCLUSIONS The introduction of high-sensitivity cardiac troponin assays leads to only a modest increase in the incidence of acute myocardial infarction. The novel sensitive assays identify an additional high-risk group of patients with increased mortality, therefore appropriately classified with acute myocardial infarction (Advantageous Predictors of Acute Coronary Syndromes Evaluation; NCT00470587).
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Affiliation(s)
- Tobias Reichlin
- Department of Cardiology, University Hospital, Basel, Switzerland
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Scott IA, Cullen L, Tate JR, Parsonage W. Highly sensitive troponin assays — a two‐edged sword? Med J Aust 2012; 197:320-3. [DOI: 10.5694/mja11.11199] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Ian A Scott
- Department of Internal Medicine and Clinical Epidemiology, Princess Alexandra Hospital, Brisbane, QLD
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Buccelletti F, Galiuto L, Marsiliani D, Iacomini P, Mattogno P, Carroccia A, Cordischi C, Antonini S, Fedele E, Sabbatini M, Silveri NG, Franceschi F. Comparison of diagnostic accuracy between three different rules of interpreting high sensitivity troponin T results. Intern Emerg Med 2012; 7:365-70. [PMID: 22618889 DOI: 10.1007/s11739-012-0787-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2011] [Accepted: 05/05/2012] [Indexed: 11/26/2022]
Abstract
With the introduction of high sensitivity troponin-T (hs-TnT) assay, clinicians face more patients with 'positive' results but without myocardial infarction. Repeated hs-TnT determinations are warranted to improve specificity. The aim of this study was to compare diagnostic accuracy of three different interpretation rules for two hs-TnT results taken 6 h apart. After adjusting for clinical differences, hs-TnT results were recoded according to the three rules. Rule1: hs-TnT >13 ng/L in at least one determination. Rule2: change of >20 % between the two measures. Rule3: change >50 % if baseline hs-TnT 14-53 ng/L and >20 % if baseline >54 ng/L. The sensitivity, specificity and ROC curves were compared. The sensitivity analysis was used to generate post-test probability for any test result. Primary outcome was the evidence of coronary critical stenosis (CCS) on coronary angiography in patients with high-risk chest pain. 183 patients were analyzed (38.3 %) among all patients presenting with chest pain during the study period. CCS was found in 80 (43.7 %) cases. The specificity was 0.62 (0.52-0.71), 0.76 (0.66-0.84) and 0.83 (0.74-0.89) for rules 1, 2 and 3, respectively (P < 0.01). Sensitivity decreased with increasing specificity (P < 0.01). Overall diagnostic accuracy did not differ among the three rules (AUC curves difference P = 0.12). Sensitivity analysis showed a 25 % relative gain in predicting CCS using rule 3 compared to rule 1. Changes between two determinations of hs-TnT 6 h apart effectively improved specificity for CCS presence in high-risk chest pain patients. There was a parallel loss in sensitivity that discouraged any use of such changes as a unique way to interpret the new hs-TnT results.
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Affiliation(s)
- Francesco Buccelletti
- Department of Emergency Medicine, Catholic University of the Sacred Heart, Largo Francesco Vito 1, 00168 Rome, Italy
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Mirzaii-Dizgah I, Riahi E. Salivary high-sensitivity cardiac troponin T levels in patients with acute myocardial infarction. Oral Dis 2012; 19:180-4. [PMID: 22834943 DOI: 10.1111/j.1601-0825.2012.01968.x] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2012] [Revised: 06/05/2012] [Accepted: 06/25/2012] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Accurate and rapid diagnosis of acute myocardial infarction (MI) is of major medical and economic importance. The objective of this study was to identify whole saliva high-sensitivity cardiac troponin T (hs-cTnT) in patients with acute MI. SUBJECTS AND METHODS A case-control study was carried out in 30 normal healthy individuals, and 30 patients with acute MI were hospitalized in CCU of Imam Hossein hospital, Tehran, Iran. The hs-cTnT levels were assayed in serum and whole saliva in the first and second morning following the MI by ELISA method. Statistical analysis of the Student's t-test and Pearson correlation coefficient was performed. RESULTS The mean stimulated and unstimulated saliva and serum levels of hs-cTnT at both the first and the second morning following the acute MI were significantly higher in patients with acute MI compared with healthy individuals. Furthermore, stimulated and unstimulated saliva hs-TnT levels correlated significantly with serum hs-TnT level (r = 0.415, P < 0.023; r = 0.466, P < 0.021, respectively). CONCLUSION Results suggest that salivary hs-cTnT can be used as an alternative to serum hs-cTnT for diagnosis and monitoring of myocardial infarction.
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Affiliation(s)
- I Mirzaii-Dizgah
- Department of Physiology, Physiology in Unusual States Research Center, School of Medicine, Aja University of Medical Sciences, Tehran, Iran
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Haaf P, Drexler B, Reichlin T, Twerenbold R, Reiter M, Meissner J, Schaub N, Stelzig C, Freese M, Heinzelmann A, Meune C, Balmelli C, Freidank H, Winkler K, Denhaerynck K, Hochholzer W, Osswald S, Mueller C. High-sensitivity cardiac troponin in the distinction of acute myocardial infarction from acute cardiac noncoronary artery disease. Circulation 2012; 126:31-40. [PMID: 22623715 DOI: 10.1161/circulationaha.112.100867] [Citation(s) in RCA: 114] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND We hypothesized that high-sensitivity cardiac troponin (hs-cTn) and its early change are useful in distinguishing acute myocardial infarction (AMI) from acute cardiac noncoronary artery disease. METHODS AND RESULTS In a prospective, international multicenter study, hs-cTn was measured with 3 assays (hs-cTnT, Roche Diagnostics; hs-cTnI, Beckman-Coulter; hs-cTnI Siemens) in a blinded fashion at presentation and serially thereafter in 887 unselected patients with acute chest pain. Accuracy of the combination of presentation values with serial changes was compared against a final diagnosis adjudicated by 2 independent cardiologists. AMI was the adjudicated final diagnosis in 127 patients (15%); cardiac noncoronary artery disease, in 124 (14%). Patients with AMI had higher median presentation values of hs-cTnT (0.113 μg/L [interquartile range, 0.049-0.246 μg/L] versus 0.012 μg/L [interquartile range, 0.006-0.034 μg/L]; P<0.001) and higher absolute changes in hs-cTnT in the first hour (0.019 μg/L [interquartile range, 0.007-0.067 μg/L] versus 0.001 μg/L [interquartile range, 0-0.003 μg/L]; P<0.001) than patients with cardiac noncoronary artery disease. Similar findings were obtained with the hs-cTnI assays. Adding changes of hs-cTn in the first hour to its presentation value yielded a diagnostic accuracy for AMI as quantified by the area under the receiver-operating characteristics curve of 0.94 for hs-cTnT (0.92 for both hs-cTnI assays). Algorithms using ST-elevation, presentation values, and changes in hs-cTn in the first hour accurately separated patients with AMI and those with cardiac noncoronary artery disease. These findings were confirmed when the final diagnosis was readjudicated with the use of hs-cTnT values and validated in an independent validation cohort. CONCLUSION The combined use of hs-cTn at presentation and its early absolute change excellently discriminates between patients with AMI and those with cardiac noncoronary artery disease. CLINICAL TRIAL REGISTRATION URL: http://www.clinicaltrials.gov. Unique identifier: NCT00470587.
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Affiliation(s)
- Philip Haaf
- Department of Internal Medicine, University Hospital Basel, Basel, Switzerland
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46
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Melki D, Lind S, Agewall S, Jernberg T. Prognostic value of combining high sensitive troponin T and N-terminal pro B-type natriuretic peptide in chest pain patients with no persistent ST-elevation. Clin Chim Acta 2012; 413:933-7. [DOI: 10.1016/j.cca.2012.02.008] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2011] [Revised: 01/28/2012] [Accepted: 02/10/2012] [Indexed: 11/17/2022]
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47
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Aldous SJ. Response to ‘High-sensitivity troponin assays and clinical decisions’ by Christ and Bertsch. Ann Clin Biochem 2012. [DOI: 10.1258/acb.2011.011152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
- Sally J Aldous
- Cardiology Department, Christchurch Hospital, Riccarton Road, Christchurch, New Zealand
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48
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Reply. J Am Coll Cardiol 2012. [DOI: 10.1016/j.jacc.2012.01.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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49
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Olivieri F, Galeazzi R, Giavarina D, Testa R, Abbatecola AM, Çeka A, Tamburrini P, Busco F, Lazzarini R, Monti D, Franceschi C, Procopio AD, Antonicelli R. Aged-related increase of high sensitive Troponin T and its implication in acute myocardial infarction diagnosis of elderly patients. Mech Ageing Dev 2012; 133:300-5. [PMID: 22446505 DOI: 10.1016/j.mad.2012.03.005] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2011] [Revised: 02/12/2012] [Accepted: 03/06/2012] [Indexed: 10/28/2022]
Abstract
High sensitive cardiac Troponin T (hs-cTnT) represents an important tool in acute myocardial infarction (AMI) diagnosis. Even though the hs-cTnT evaluation is relevant for AMI diagnosis in elderly patients characterized by clinical and instrumental atypical presentation, the overall reliability in elderly patients is unknown. We aimed at: (1) defining the hs-cTnT 99th percentile value in an aged healthy reference population and (2) testing hs-cTnT diagnostic accuracy in elderly patients with a suspected AMI. 294 healthy subjects (50-105 years old) and 299 elderly patients (75-96 years old) with suspected AMI at presentation, were enrolled. Conventional cTnT, hs-cTnT, NT-proBNP and creatinine levels were determined in all participants. Our main results are: (1) a significant hs-cTnT age-related increase was observed in an healthy reference population ranging 50-105 years old; (2) hs-cTnT levels showed an age-related multimodal distribution in the healthy reference population: 16 ng/L corresponds to the 99th percentile in subjects ranging 50-75 years old, whereas 70.6 ng/L corresponds to the 99th percentile in subjects ≥75 years old; (3) 86.8 ng/L resulted the hs-cTnT cut-off value with the highest efficiency in AMI diagnosis of geriatric patients. Our data suggest that the hs-cTnT cut-off value must be age-tailored to improve the AMI diagnostic accuracy.
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Affiliation(s)
- Fabiola Olivieri
- Department of Clinical and Molecular Sciences, Università Politecnica delle Marche, Ancona, Italy.
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50
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Use of troponin as a screen for chest pain in the pediatric emergency department. Pediatr Cardiol 2012; 33:337-42. [PMID: 22089143 DOI: 10.1007/s00246-011-0149-8] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2011] [Accepted: 11/03/2011] [Indexed: 10/15/2022]
Abstract
Troponin levels are commonly employed in the assessment of adults presenting with chest pain or concern for coronary ischemia. However, the utility of troponin measurements in children is not well defined. The purpose of this study was to review the use and clinical yield of serum troponin assay in a large pediatric emergency department (ED). We identified all patients <22 years of age, not previously known to have cardiac disease, who presented with chest pain and whose troponin levels were evaluated in our pediatric ED during a 7-year period. Test results were correlated to patient factors, such as chief complaint, cardiac history, diagnostic workup, and discharge diagnoses. Of the 212 study patients who presented with chest pain, troponin levels were increased (≥ 0.1 ng/ml) in 37 (17%) subjects. The disposition for these 37 subjects included transfer to adult facility (n = 6), admission to our pediatric inpatient service (n = 27), and discharge to home from the ED (n = 10). Only one subject had an acute myocardial infarction. For those with increased troponin level, 18 of 37 (48%) cases were attributed to a primary cardiac diagnosis with the most common discharge diagnosis of myocarditis or pericarditis. In the pediatric ED setting, selective use of troponin assay may be a useful test in the management of patients with chest pain. Most cases of increased troponin level related to chest pain represent myocarditis, often mild and self-resolving. Given the low likelihood that acute coronary syndrome is the etiology of chest pain, immediate transfer to an adult facility for the majority of patients with increase of troponin does not appear warranted.
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