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How to best use high-sensitivity cardiac troponin in patients with suspected myocardial infarction. Clin Biochem 2018; 53:143-155. [DOI: 10.1016/j.clinbiochem.2017.12.006] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2017] [Accepted: 12/15/2017] [Indexed: 11/21/2022]
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Chew PG, Frost F, Mullen L, Fisher M, Zadeh H, Grainger R, Albouaini K, Dodd J, Patel B, Velavan P, Kunadian B, Rawat A, Obafemi T, Tong S, Jones J, Khand A. A direct comparison of decision rules for early discharge of suspected acute coronary syndromes in the era of high sensitivity troponin. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2018; 8:421-431. [PMID: 29480016 DOI: 10.1177/2048872618755369] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND We tested the hypothesis that a single high sensitivity troponin at limits of detection (LOD HSTnT) (<5 ng/l) combined with a presentation non-ischaemic electrocardiogram is superior to low-risk Global Registry of Acute Coronary Events (GRACE) (<75), Thrombolysis in Myocardial Infarction (TIMI) (≤1) and History, ECG, Age, Risk factors and Troponin (HEART) score (≤3) as an aid to early, safe discharge for suspected acute coronary syndrome. METHODS In a prospective cohort study, risk scores were computed in consecutive patients with suspected acute coronary syndrome presenting to the Emergency Room of a large English hospital. Adjudication of myocardial infarction, as per third universal definition, involved a two-physician, blinded, independent review of all biomarker positive chest pain re-presentations to any national hospital. The primary and secondary outcome was a composite of type 1 myocardial infarction, unplanned coronary revascularisation and all cause death (MACE) at six weeks and one year. RESULTS Of 3054 consecutive presentations with chest pain 1642 had suspected acute coronary syndrome (52% male, median age 59 years, 14% diabetic, 20% previous myocardial infarction). Median time from chest pain to presentation was 9.7 h. Re-presentations occurred in eight hospitals with 100% follow-up achieved. Two hundred and eleven (12.9%) and 279 (17%) were adjudicated to suffer MACE at six weeks and one year respectively. Only HEART ≤3 (negative predictive value MACE 99.4%, sensitivity 97.6%, %discharge 53.4) and LOD HSTnT strategy (negative predictive value MACE 99.8%, sensitivity 99.5%, %discharge 36.9) achieved pre-specified negative predictive value of >99% for MACE at six weeks. For type 1 myocardial infarction alone the negative predictive values at six weeks and one year were identical, for both HEART ≤3 and LOD HSTnT at 99.8% and 99.5% respectively. CONCLUSION HEART ≤3 or LOD HSTnT strategy rules out short and medium term myocardial infarction with ≥99.5% certainty, and short-term MACE with >99% certainty, allowing for early discharge of 53.4% and 36.9% respectively of suspected acute coronary syndrome. Adoption of either strategy has the potential to greatly reduce Emergency Room pressures and minimise follow-up investigations. Very early presenters (<3 h), due to limited numbers, are excluded from these conclusions.
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Affiliation(s)
| | | | | | - Michael Fisher
- 2 Royal Liverpool University Hospital NHS Trust, UK.,3 Institute for Cardiovascular Medicine and Science, Liverpool Heart and Chest Hospital NHS Trust, UK
| | - Heidar Zadeh
- 2 Royal Liverpool University Hospital NHS Trust, UK
| | - Ruth Grainger
- 4 Northwest Coast Strategic Clinical Networks, Warrington, UK
| | | | - James Dodd
- 5 Liverpool Cancer and Clinical Trial Units, University of Liverpool, UK
| | - Bilal Patel
- 6 Blackpool Teaching Hospitals NHS Foundation Trust, UK
| | - Periaswamy Velavan
- 3 Institute for Cardiovascular Medicine and Science, Liverpool Heart and Chest Hospital NHS Trust, UK
| | - Babu Kunadian
- 3 Institute for Cardiovascular Medicine and Science, Liverpool Heart and Chest Hospital NHS Trust, UK.,7 Countess of Chester NHS Trust, Chester, UK
| | - Anju Rawat
- 1 Aintree University Hospital NHS Trust, UK
| | | | - Sarah Tong
- 1 Aintree University Hospital NHS Trust, UK
| | | | - Aleem Khand
- 1 Aintree University Hospital NHS Trust, UK.,3 Institute for Cardiovascular Medicine and Science, Liverpool Heart and Chest Hospital NHS Trust, UK.,8 Institute of Aging and Chronic Diseases, University of Liverpool, UK
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Ilangkovan N, Mickley H, Diederichsen A, Lassen A, Sørensen TL, Sheta HM, Stæhr PB, Mogensen CB. Clinical features and prognosis of patients with acute non-specific chest pain in emergency and cardiology departments after the introduction of high-sensitivity troponins: a prospective cohort study. BMJ Open 2017; 7:e018636. [PMID: 29275346 PMCID: PMC5770919 DOI: 10.1136/bmjopen-2017-018636] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES To determine the incidence of clinical, cardiac-related endpoints and mortality among patients presenting to an emergency or cardiology department with non-specific chest pain (NSCP), and who receive testing with a high-sensitivity troponin. A second objective was to identify risk factors for the above-noted endpoints during 12 months of follow-up. DESIGN A prospective multicentre study. SETTING Emergency and cardiology departments in Southern Denmark. SUBJECTS The study enrolled 1027 patients who were assessed for acute chest pain in an emergency or cardiology department, and in whom a myocardial infarction or another obvious reason for chest pain had been ruled out. Patients were enrolled from September 2014 to June 2015 and followed for 1 year. MAIN OUTCOME MEASURES Clinical, cardiac-related endpoints (cardiac-related death, acute myocardial infarction, unstable angina and coronary revascularisation) and all-cause mortality. RESULTS Over a period of 1 year, cardiac-related endpoints were found in 19 patients (1.9%): 0 patients experienced cardiac-related death, 2 (0.2%) had myocardial infarction, 4 (0.4%) had unstable angina pectoris and 17 (1.7%) underwent coronary revascularisation. All-cause mortality was observed in seven patients (0.7%). When compared with the general population, the standardised mortality ratio did not differ. The risk factors associated with the study endpoints included male gender, body mass index >25 kg/m2, previous known coronary artery disease, hypertension, hypercholesterolaemia, diabetes mellitus and the use of statins. A total of 73% of the endpoints occurred in males. CONCLUSION The prognosis for patients with NSCP is favourable, with a 1-year mortality after discharge that is comparable with the background population. Few clinical endpoints took place during follow-up, and those that did were predominantly in males.
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Affiliation(s)
| | - Hans Mickley
- Department of Cardiology, Odense University Hospital, Odense, Denmark
| | - Axel Diederichsen
- Department of Cardiology, Odense University Hospital, Odense, Denmark
| | - Annmarie Lassen
- Department of Emergency Medicine, Odense University Hospital, Odense, Denmark
| | - Thomas L Sørensen
- Department of Internal Medicine, Hospital of Southern Denmark, Sonderborg, Denmark
| | | | - Peter B Stæhr
- Department of Cardiology, Hospital of Southern Denmark, Aabenraa, Denmark
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105
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Kelly AM. Undetectable Troponin I at Presentation Using a Contemporary Assay does not Rule Out Myocardial Infarction. HONG KONG J EMERG ME 2017. [DOI: 10.1177/102490791402100107] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Objective Chest pain is a common reason for presentation to emergency departments (ED). Recent evidence suggests that an undetectable troponin level at ED presentation can rule out the presence of myocardial infarction (MI). The aim of this study was to externally validate that finding using a troponin I (TnI) assay. Methods Unplanned sub-study of a prospective observational cohort study of patients presenting to ED with chest pain without electrocardiogram evidence of ischaemia who underwent a ‘rule out’ acute coronary syndrome process. Clinical, investigational and outcome data were collected. Primary outcome of interest was diagnostic accuracy for type I MI at index visit. Results 685 patients were studied; median age 62, 60% male. Two hundred and seventeen had an undetectable TnI at ED presentation. There were two non-ST elevation myocardial infarctions in the group (2/217, 0.9%, 95% CI 0.16-3.6%). Sensitivity of undetectable TnI for ruling out type I MI was 98. 2% (99% CI 92.9-99.7%) with negative predictive value of 99.1% (96.4-99.8%). Conclusion Approximately 1% of patients with an undetectable TnI at ED presentation were diagnosed with a type I MI. An undetectable initial TnI using a contemporary sensitive TnI assay does not safely exclude MI in an ED chest pain cohort. (Hong Kong j.emerg.med. 2014;21:31-36)
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106
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Andruchow JE, Kavsak PA, McRae AD. Contemporary Emergency Department Management of Patients with Chest Pain: A Concise Review and Guide for the High-Sensitivity Troponin Era. Can J Cardiol 2017; 34:98-108. [PMID: 29407013 DOI: 10.1016/j.cjca.2017.11.012] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2017] [Revised: 11/23/2017] [Accepted: 11/23/2017] [Indexed: 11/17/2022] Open
Abstract
This article synthesizes current best evidence for the evaluation of patients with suspected acute coronary syndrome (ACS) using high-sensitivity troponin assays, enabling physicians to effectively incorporate them into practice. Unlike conventional assays, high-sensitivity assays can precisely measure blood cardiac troponin concentrations in the vast majority of healthy individuals, facilitating the creation of rapid diagnostic algorithms. Very low troponin concentrations on presentation accurately rule out acute myocardial infarction (AMI) and enable the discharge of approximately 20% of patients after a single test, whereas an additional 30%-40% of patients can be safely discharged after short-interval serial sampling in as little as 1 or 2 hours. In contrast, highly abnormal troponin concentrations on presentation (more than 5 times the upper reference limit) or rapidly rising levels on serial testing can rapidly rule in AMI with high specificity. However, approximately one-third of patients remain in a biomarker-indeterminate "observation zone" even after serial sampling. These patients pose a disposition challenge to clinicians because although the differential diagnosis of elevated troponin concentrations is broad, these patients have an increased risk for short-term major adverse cardiac events. Use of repeated serial troponin sampling and structured clinical prediction tools may assist disposition for these patients, because no validated pathways currently exist to guide clinicians. Ongoing research to tailor diagnostic thresholds to individual patient characteristics may enable improved diagnostic accuracy and usher in a new era of personalized medicine in the evaluation of suspected ACS.
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Affiliation(s)
- James E Andruchow
- Department of Emergency Medicine, University of Calgary, Calgary, Alberta, Canada; Alberta Health Services, Calgary, Alberta, Canada.
| | - Peter A Kavsak
- Department of Pathology and Molecular Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Andrew D McRae
- Department of Emergency Medicine, University of Calgary, Calgary, Alberta, Canada; Alberta Health Services, Calgary, Alberta, Canada
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Röttger E, de Vries-Spithoven S, Reitsma JB, Limburg A, van Ofwegen-Hanekamp CEE, Hoes AW, Poldervaart JM. Safety of a 1-hour Rule-out High-sensitive Troponin T Protocol in Patients With Chest Pain at the Emergency Department. Crit Pathw Cardiol 2017; 16:129-134. [PMID: 29135620 DOI: 10.1097/hpc.0000000000000135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
BACKGROUND The 1-hour rule-out high-sensitive cardiac troponin T protocol (hs-cTnT), in which a serial troponin measurement is performed 1 hour after the first to assess the possibility of acute coronary syndrome (ACS), has been implemented in the European guidelines in 2015. Our aim was to assess the safety of this protocol in low-risk patients in the Emergency Department (ED) when implemented in daily practice. METHODS Patients with acute chest pain presenting to the ED of our hospital and younger than 75 years were included (May 2013 to October 2014, The Netherlands). Hs-cTnT was measured at presentation (T0) and 1-1.5 hours after T0 (T1). Patients with a first troponin (T0) ≥ 0.012 ug/l were excluded. Primary endpoint was the 6-week occurrence of major adverse cardiac events (MACEs), defined as unstable angina, acute myocardial infarction (AMI), percutaneous coronary intervention, significant stenosis managed conservatively, coronary artery bypass grafting, and death. RESULTS Of the 374 analyzed patients, 16 patients (4.3%) developed 35 MACE. Of these 16 patients with endpoints, 3 were primarily discharged with noncardiac chest pain but returned within 6 weeks with unstable angina. Importantly, no patients experienced an AMI or died during follow-up. CONCLUSION No AMIs or deaths occurred after introducing the 1-hour hs-cTnT protocol to rule-out ACS in chest pain patients, but other MACE such as unstable angina occurred. Our results suggest the protocol is safe to implement in the ED in The Netherlands.
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Affiliation(s)
- E Röttger
- From the *Department of Emergency Medicine, Albert Schweitzer Hospital, Dordrecht, The Netherlands; †Department of Cardiology, Radboud University Medical Center, Nijmegen, The Netherlands; ‡Julius Center for Health Sciences and Primary Care, University Medical Center, Utrecht, The Netherlands; and §Department of Cardiology, Diakonessenhuis, Utrecht, The Netherlands
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108
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Ambavane A, Lindahl B, Giannitis E, Roiz J, Mendivil J, Frankenstein L, Body R, Christ M, Bingisser R, Alquezar A, Mueller C. Economic evaluation of the one-hour rule-out and rule-in algorithm for acute myocardial infarction using the high-sensitivity cardiac troponin T assay in the emergency department. PLoS One 2017; 12:e0187662. [PMID: 29121105 PMCID: PMC5679593 DOI: 10.1371/journal.pone.0187662] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2017] [Accepted: 10/24/2017] [Indexed: 11/19/2022] Open
Abstract
Background The 1-hour (h) algorithm triages patients presenting with suspected acute myocardial infarction (AMI) to the emergency department (ED) towards “rule-out,” “rule-in,” or “observation,” depending on baseline and 1-h levels of high-sensitivity cardiac troponin (hs-cTn). The economic consequences of applying the accelerated 1-h algorithm are unknown. Methods and findings We performed a post-hoc economic analysis in a large, diagnostic, multicenter study of hs-cTnT using central adjudication of the final diagnosis by two independent cardiologists. Length of stay (LoS), resource utilization (RU), and predicted diagnostic accuracy of the 1-h algorithm compared to standard of care (SoC) in the ED were estimated. The ED LoS, RU, and accuracy of the 1-h algorithm was compared to that achieved by the SoC at ED discharge. Expert opinion was sought to characterize clinical implementation of the 1-h algorithm, which required blood draws at ED presentation and 1h, after which “rule-in” patients were transferred for coronary angiography, “rule-out” patients underwent outpatient stress testing, and “observation” patients received SoC. Unit costs were for the United Kingdom, Switzerland, and Germany. The sensitivity and specificity for the 1-h algorithm were 87% and 96%, respectively, compared to 69% and 98% for SoC. The mean ED LoS for the 1-h algorithm was 4.3h—it was 6.5h for SoC, which is a reduction of 33%. The 1-h algorithm was associated with reductions in RU, driven largely by the shorter LoS in the ED for patients with a diagnosis other than AMI. The estimated total costs per patient were £2,480 for the 1-h algorithm compared to £4,561 for SoC, a reduction of up to 46%. Conclusions The analysis shows that the use of 1-h algorithm is associated with reduction in overall AMI diagnostic costs, provided it is carefully implemented in clinical practice. These results need to be prospectively validated in the future.
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Affiliation(s)
- Apoorva Ambavane
- Modeling and Simulation, Evidera, London, United Kingdom
- * E-mail:
| | - Bertil Lindahl
- Department of Medical Sciences, Uppsala University and Uppsala Clinical Research Center, Uppsala, Sweden
| | | | - Julie Roiz
- Modeling and Simulation, Evidera, London, United Kingdom
| | - Joan Mendivil
- Previous employment: Market Access, Roche Diagnostics International Ltd., Rotkreuz, Switzerland
| | - Lutz Frankenstein
- Department of Cardiology, Angiology, Pulmonology, University Hospital of Heidelberg, Heidelberg, Germany
| | - Richard Body
- Emergency Department, Central Manchester University Hospitals NHS Foundation Trust, Manchester, United Kingdom
| | - Michael Christ
- Department of Emergency and Critical Care Medicine, Paracelsus Medical University, Nuremberg General Hospital, Nuremberg, Germany
| | - Roland Bingisser
- Emergency Department, University of Basel, University Hospital, Basel, Switzerland
| | - Aitor Alquezar
- Servei de Urgencies. Hospital de Sant Pau, Barcelona, Spain
| | - Christian Mueller
- Department of Cardiology and Cardiovascular Research Institute Basel, University Hospital Basel, Basel, Switzerland
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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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Age-sex distribution of patients with high-sensitivity troponin T levels below the 99th percentile. Oncotarget 2017; 8:75638-75645. [PMID: 29088898 PMCID: PMC5650453 DOI: 10.18632/oncotarget.20328] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2017] [Accepted: 08/06/2017] [Indexed: 11/25/2022] Open
Abstract
Background Recently, very low concentrations of high-sensitivity cardiac troponin T (hs-cTnT), below the 99th percentile, have been used to immediately exclude acute myocardial infarction in certain patients without taking their age and sex into consideration. Results The hs-cTnT values below the 99th percentile (≤ 14 ng/L) were higher in men (p = 0.000) and significantly increased with age (p = 0.000) among both men and women. In addition, hs-cTnT was positively associated with age (r = 0.459, p = 0.000), myoglobin (r = 0.392, p = 0.000), and creatine kinase-MB (r = 0.133, p = 0.000). Moreover, males were younger (p = 0.001) and had higher myoglobin (p = 0.000) and creatine kinase-MB (p = 0.000) concentrations than females. Materials and Methods A total of 5585 consecutive subjects who presented with non-traumatic chest pain/discomfort to the inpatient, outpatient, or emergency department and who underwent high-sensitivity troponin T, myoglobin and creatine kinase-MB testing at presentation, with hs-cTnT below the 99thpercentile (≤ 14 ng/L), were eligible for enrollment. Conclusions We suggest that patients’ age, sex and levels of myocardial injury biomarkers should be taken into consideration when ruling out acute myocardial infarction and/or adverse prognostic implications in patients who have very low hs-cTnT concentrations.
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111
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Ferencik M, Mayrhofer T, Lu MT, Woodard PK, Truong QA, Peacock WF, Bamberg F, Sun BC, Fleg JL, Nagurney JT, Udelson JE, Koenig W, Januzzi JL, Hoffmann U. High-Sensitivity Cardiac Troponin I as a Gatekeeper for Coronary Computed Tomography Angiography and Stress Testing in Patients with Acute Chest Pain. Clin Chem 2017; 63:1724-1733. [PMID: 28923845 DOI: 10.1373/clinchem.2017.275552] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2017] [Accepted: 08/02/2017] [Indexed: 11/06/2022]
Abstract
BACKGROUND Most patients presenting to the emergency department (ED) with suspected acute coronary syndrome (ACS) undergo noninvasive cardiac testing with a low diagnostic yield. We determined whether a combination of high-sensitivity cardiac troponin I (hs-cTnI) and cardiovascular risk factors might improve selection of patients for cardiac testing. METHODS We included patients from the Rule Out Myocardial Infarction/Ischemia Using Computer Assisted Tomography (ROMICAT) I and II trials who presented to the ED with acute chest pain and were referred for cardiac testing. Based on serial hs-cTnI measurements and cardiovascular risk factors, we derived and validated the criterion for no need of cardiac testing. We predicted the effect of this criterion on the effectiveness of patient management. RESULTS A combination of baseline hs-cTnI (<4 ng/L) and cardiovascular risk factors (<2) ruled out ACS with a negative predictive value of 100% in ROMICAT I. We validated this criterion in ROMICAT II, identifying 29% patients as not needing cardiac testing. An additional 5% of patients were identified by adding no change or a decrease between baseline and 2 h hs-cTnI as a criterion. Assuming those patients would be discharged from the ED without cardiac testing, implementation of hs-cTnI would increase ED discharge rate (24.3% to 50.2%, P < 0.001) and decrease the length of hospital stay (21.4 to 8.2 h, P < 0.001), radiation dose (10.2 to 7.7 mSv, P < 0.001), and costs of care (4066 to 3342 US$, P < 0.001). CONCLUSIONS We derived and validated a criterion for combined hs-cTnI and cardiovascular risk factors that identified acute chest pain patients with no need for cardiac testing and could improve effectiveness of patient management. ClinicalTrials.gov Identifiers: NCT00990262 and NCT01084239.
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Affiliation(s)
- Maros Ferencik
- Knight Cardiovascular Institute, Oregon Health and Science University, Portland, OR; .,Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Boston, MA.,Cardiac MR PET CT Program, Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - Thomas Mayrhofer
- Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Boston, MA.,Cardiac MR PET CT Program, Massachusetts General Hospital and Harvard Medical School, Boston, MA.,School of Business Studies, Stralsund University of Applied Sciences, Stralsund, Germany
| | - Michael T Lu
- Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Boston, MA.,Cardiac MR PET CT Program, Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - Pamela K Woodard
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, MO
| | - Quynh A Truong
- Dalio Institute of Cardiovascular Imaging, New York-Presbyterian Hospital and Weill Cornell Medical College, New York, NY
| | - W Frank Peacock
- Division of Emergency Medicine, Baylor College of Medicine, Houston, TX
| | - Fabian Bamberg
- Department of Radiology, University of Tuebingen, Tuebingen, Germany
| | - Benjamin C Sun
- Department of Emergency Medicine, Oregon Health and Science University, Portland, OR
| | - Jerome L Fleg
- Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, Bethesda, MD
| | - John T Nagurney
- Department of Emergency Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - James E Udelson
- Division of Cardiology and the Cardio-Vascular Center, Tufts Medical Center, Boston, MA
| | - Wolfgang Koenig
- Deutsches Herzzentrum München, Technische Universität München, Munich, Germany.,DZHK (German Centre for Cardiovascular Research), partner site Munich Heart Alliance, Munich, Germany.,Department of Internal Medicine II-Cardiology, University of Ulm Medical Center, Ulm, Germany
| | - James L Januzzi
- Cardiology Division, Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - Udo Hoffmann
- Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Boston, MA.,Cardiac MR PET CT Program, Massachusetts General Hospital and Harvard Medical School, Boston, MA.,Cardiology Division, Massachusetts General Hospital and Harvard Medical School, Boston, MA
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Carlton EW, Pickering JW, Greenslade J, Cullen L, Than M, Kendall J, Body R, Parsonage WA, Khattab A, Greaves K. Assessment of the 2016 National Institute for Health and Care Excellence high-sensitivity troponin rule-out strategy. Heart 2017; 104:665-672. [PMID: 28864718 PMCID: PMC5890641 DOI: 10.1136/heartjnl-2017-311983] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2017] [Revised: 08/04/2017] [Accepted: 08/05/2017] [Indexed: 11/07/2022] Open
Abstract
Objective We aimed to evaluate the limit of detection of high-sensitivity troponin (hs-cTn) and Thrombolysis In Myocardial Infarction (TIMI) score combination rule-out strategy suggested within the 2016 National Institute for Health and Care Excellence (NICE) Chest Pain of Recent Onset guidelines and establish the optimal TIMI score threshold for clinical use. Methods A pooled analysis of adult patients presenting to the emergency department with chest pain and a non-ischaemic ECG, recruited into six prospective studies, from Australia, New Zealand and the UK. We evaluated the sensitivity of TIMI score thresholds from 0 to 2 alongside hs-cTnT or hs-cTnI for the primary outcome of major adverse cardiac events within 30 days. Results Data were available for 3159 patients for hs-cTnT and 4532 for hs-cTnI, of these 376 (11.9%) and 445 (9.8%) had major adverse cardiac events, respectively. Using a TIMI score of 0, the sensitivity for the primary outcome was 99.5% (95% CI 98.1% to 99.9%) alongside hs-cTnT and 98.9% (97.4% to 99.6%)%) alongside hs-cTnI, identifying 17.9% and 21.0% of patients as low risk, respectively. For a TIMI score ≤1 sensitivity was 98.9% (97.3% to 99.7%)%) alongside hs-cTnT and 98.4% (96.8% to 99.4%)%) alongside hs-cTnI, identifying 28.1% and 35.7% as low risk, respectively. For TIMI≤2, meta-sensitivity was <98% with either assay. Conclusions Our findings support the rule-out strategy suggested by NICE. The TIMI score threshold suggested for clinical use is 0. The proportion of patients identified as low risk (18%–21%) and suitable for early discharge using this threshold may be sufficient to encourage change of practice. Trial registration numbers ADAPT observational study/IMPACT intervention trial ACTRN12611001069943. ADAPT-ADP randomised controlled trial ACTRN12610000766011. EDACS-ADP randomised controlled trial ACTRN12613000745741. TRUST observational study ISRCTN no. 21109279.
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Affiliation(s)
- Edward Watts Carlton
- Emergency Department, Southmead Hospital, North Bristol NHS Trust, Bristol, Avon, UK
| | - John William Pickering
- Department of Medicine, University of Otago, Christchurch, Canterbury, New Zealand.,Department of Emergency Medicine, Christchurch Hospital, Christchurch, New Zealand
| | - Jaimi Greenslade
- Department of Emergency Medicine, Royal Brisbane and Women's Hospital, Brisbane, Australia.,School of Medicine, The University of Queensland, Brisbane, Australia
| | - Louise Cullen
- Department of Emergency Medicine, Royal Brisbane and Women's Hospital, Brisbane, Australia.,School of Medicine, The University of Queensland, Brisbane, Australia
| | - Martin Than
- Department of Emergency Medicine, Christchurch Hospital, Christchurch, New Zealand
| | - Jason Kendall
- Emergency Department, Southmead Hospital, North Bristol NHS Trust, Bristol, Avon, UK
| | - Richard Body
- Department of Emergency Medicine, Central Manchester University Hospitals NHS Foundation Trust, Manchester UK
| | - William A Parsonage
- Department of Emergency Medicine, Royal Brisbane and Women's Hospital, Brisbane, Australia.,School of Medicine, The University of Queensland, Brisbane, Australia
| | - Ahmed Khattab
- School of Health and Social Care, Bournemouth University, Poole, UK
| | - Kim Greaves
- Sunshine Coast Hospital and Health Services, University of the Sunshine Coast, Nambour, Australia
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113
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Sandoval Y, Smith SW, Love SA, Sexter A, Schulz K, Apple FS. Single High-Sensitivity Cardiac Troponin I to Rule Out Acute Myocardial Infarction. Am J Med 2017; 130:1076-1083.e1. [PMID: 28344141 DOI: 10.1016/j.amjmed.2017.02.032] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2017] [Revised: 02/10/2017] [Accepted: 02/13/2017] [Indexed: 01/09/2023]
Abstract
BACKGROUND This study examined the performance of single high-sensitivity cardiac troponin I (hs-cTnI) measurement strategies to rule out acute myocardial infarction. METHODS This was a prospective, observational study of consecutive patients presenting to the emergency department (n = 1631) in whom cTnI measurements were obtained using an investigational hs-cTnI assay. The goals of the study were to determine 1) negative predictive value (NPV) and sensitivity for the diagnosis of acute myocardial infarction, type 1 myocardial infarction, and type 2 myocardial infarction; and 2) safety outcome of acute myocardial infarction or cardiac death at 30 days using hs-cTnI less than the limit of detection (LoD) (<1.9 ng/L) or the High-STEACS threshold (<5 ng/L) alone and in combination with normal electrocardiogram (ECG). RESULTS Acute myocardial infarction occurred in 170 patients (10.4%), including 68 (4.2%) type 1 myocardial infarction and 102 (6.3%) type 2 myocardial infarction. For hs-cTnI<LoD (27%), the NPV and sensitivity for acute myocardial infarction were 99.6% (95% confidence interval 98.9%-100%) and 98.8 (97.2%-100%). For hs-cTnI<5 ng/L (50%), the NPV and sensitivity for acute myocardial infarction were 98.9% (98.2%-99.6%) and 94.7% (91.3%-98.1%). In combination with a normal ECG, 1) hs-cTnI<LoD had an NPV of 99.6% (98.9%-100%) and sensitivity of 99.4% (98.3%-100%); and 2) hs-cTnI<5 ng/L had an NPV of 99.5% (98.8%-100%) and sensitivity of 98.8% (97.2%-100%). The NPV and sensitivity for the safety outcome were excellent for hs-cTnI<LoD alone or in combination with a normal ECG, and for hs-cTnI<5 ng/L in combination with a normal ECG. CONCLUSION Strategies using a single hs-cTnI alone or in combination with a normal ECG allow the immediate identification of patients unlikely to have acute myocardial infarction and who are at very low risk for adverse events at 30 days.
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Affiliation(s)
- Yader Sandoval
- Division of Cardiology, Hennepin County Medical Center and Minneapolis Heart Institute, Abbott Northwestern Hospital, Minn
| | - Stephen W Smith
- Department of Emergency Medicine, Hennepin County Medical Center and University of Minnesota, Minneapolis
| | - Sara A Love
- Minneapolis Medical Research Foundation, Minn; Department of Laboratory Medicine and Pathology, Hennepin County Medical Center and University of Minnesota, Minneapolis
| | - Anne Sexter
- Minneapolis Medical Research Foundation, Minn
| | | | - Fred S Apple
- Minneapolis Medical Research Foundation, Minn; Department of Laboratory Medicine and Pathology, Hennepin County Medical Center and University of Minnesota, Minneapolis.
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114
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Fournier S, Iten L, Marques-Vidal P, Boulat O, Bardy D, Beggah A, Calderara R, Morawiec B, Lauriers N, Monney P, Iglesias JF, Pascale P, Harbaoui B, Eeckhout E, Muller O. Circadian rhythm of blood cardiac troponin T concentration. Clin Res Cardiol 2017; 106:1026-1032. [DOI: 10.1007/s00392-017-1152-8] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2017] [Accepted: 08/07/2017] [Indexed: 11/29/2022]
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115
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Wächter C, Markus B, Schieffer B. [Cardiac causes of chest pain]. Internist (Berl) 2017; 58:8-21. [PMID: 27981367 DOI: 10.1007/s00108-016-0165-0] [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: 10/20/2022]
Abstract
Because of the life-threatening character and a high prevalence in emergency rooms, cardiac causes are important differential diagnoses of acute chest pain with the need for rapid clarification. In this context the working diagnosis "acute coronary syndrome" (ACS) plays a major role. In a synopsis of the clinical presentation, medical history, electrocardiogram and analysis of cardiac biomarkers, ST-segment elevation myocardial infarction (STEMI), non-ST-segment elevation myocardial infarction (NSTEMI) and unstable angina pectoris can be specified as entities of ACS. The treatment of ACS consists of an immediate anti-ischemic therapy, anti-thrombotic therapy and invasive coronary diagnostics with subsequent interventional or operative revascularization therapy. The timing of invasive management is essentially determined by the individual patient risk, with the exception of STEMI where interventional revascularization must be undertaken within 120 min of diagnosis. In this context the GRACE 2.0 and TIMI risk score have become established as reliable tools. Another rare but fatal cause of acute chest pain is aortic dissection. An abrupt onset of tearing and sharp chest pains, deficits in pulse as well as the presence of high-risk factors, such as advanced age, arterial hypertension, atherosclerosis, known collagenosis and previous aortic or coronary artery procedures are highly indicative for aortic dissection and additional diagnostic imaging and the highly sensitive D‑dimer should be undertaken. Additionally, inflammatory diseases, such as pericarditis and myocarditis can be associated with chest pains and mimic the character of ACS and should also be considered in the differential diagnostics.
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Affiliation(s)
- C Wächter
- Klinik für Kardiologie, Angiologie und internistische Intensivmedizin, Universitäres Herzzentrum Marburg, Uniklinikum Gießen und Marburg, Standort Marburg, Baldingerstr., 35043, Marburg, Deutschland
| | - B Markus
- Klinik für Kardiologie, Angiologie und internistische Intensivmedizin, Universitäres Herzzentrum Marburg, Uniklinikum Gießen und Marburg, Standort Marburg, Baldingerstr., 35043, Marburg, Deutschland
| | - B Schieffer
- Klinik für Kardiologie, Angiologie und internistische Intensivmedizin, Universitäres Herzzentrum Marburg, Uniklinikum Gießen und Marburg, Standort Marburg, Baldingerstr., 35043, Marburg, Deutschland.
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116
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Twerenbold R, Boeddinghaus J, Nestelberger T, Wildi K, Rubini Gimenez M, Badertscher P, Mueller C. Clinical Use of High-Sensitivity Cardiac Troponin in Patients With Suspected Myocardial Infarction. J Am Coll Cardiol 2017; 70:996-1012. [DOI: 10.1016/j.jacc.2017.07.718] [Citation(s) in RCA: 142] [Impact Index Per Article: 20.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2017] [Revised: 07/09/2017] [Accepted: 07/10/2017] [Indexed: 12/12/2022]
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117
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Trends in admissions for chest pain after the introduction of high-sensitivity cardiac troponin T. Int J Cardiol 2017; 240:1-7. [DOI: 10.1016/j.ijcard.2017.04.028] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2016] [Revised: 03/08/2017] [Accepted: 04/10/2017] [Indexed: 11/23/2022]
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118
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Chew DP, Scott IA, Cullen L, French JK, Briffa TG, Tideman PA, Woodruffe S, Kerr A, Branagan M, Aylward PE. National Heart Foundation of Australia and Cardiac Society of Australia and New Zealand: Australian clinical guidelines for the management of acute coronary syndromes 2016. Med J Aust 2017; 25:895-951. [PMID: 27465769 DOI: 10.1016/j.hlc.2016.06.789] [Citation(s) in RCA: 197] [Impact Index Per Article: 28.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
INTRODUCTION The modern care of suspected and confirmed acute coronary syndrome (ACS) is informed by an extensive and evolving evidence base. This clinical practice guideline focuses on key components of management associated with improved clinical outcomes for patients with chest pain or ACS. These are presented as recommendations that have been graded on both the strength of evidence and the likely absolute benefit versus harm. Additional considerations influencing the delivery of specific therapies and management strategies are presented as practice points. MAIN RECOMMENDATIONS This guideline provides advice on the standardised assessment and management of patients with suspected ACS, including the implementation of clinical assessment pathways and subsequent functional and anatomical testing. It provides guidance on the: diagnosis and risk stratification of ACS; provision of acute reperfusion therapy and immediate post-fibrinolysis care for patients with ST segment elevation myocardial infarction; risk stratification informing the use of routine versus selective invasive management for patients with non-ST segment elevation ACS; administration of antithrombotic therapies in the acute setting and considerations affecting their long term use; and implementation of an individualised secondary prevention plan that includes both pharmacotherapies and cardiac rehabilitation. Changes in management as a result of the guideline: This guideline has been designed to facilitate the systematic integration of the recommendations into a standardised approach to ACS care, while also allowing for contextual adaptation of the recommendations in response to the individual's needs and preferences. The provision of ACS care should be subject to continuous monitoring, feedback and improvement of quality and patient outcomes.
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Affiliation(s)
- Derek P Chew
- Department of Cardiology, Flinders University, Adelaide, SA
| | - Ian A Scott
- Department of Internal Medicine, Princess Alexandra Hospital, Brisbane, QLD
| | - Louise Cullen
- Australian Centre for Health Services Innovation, Brisbane, QLD
| | - John K French
- Coronary Care and Cardiovascular Research, Liverpool Hospital, Sydney, NSW
| | - Tom G Briffa
- School of Population Health, University of Western Australia, Perth, WA
| | - Philip A Tideman
- Department of Cardiovascular Medicine, Flinders Medical Centre, Adelaide, SA
| | - Stephen Woodruffe
- Ipswich Cardiac Rehabilitation and Heart Failure Service, Ipswich Hospital, Ipswich, QLD
| | - Alistair Kerr
- Cardiomyopathy Association of Australia, Melbourne, VIC
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119
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Morawiec B, Fournier S, Tapponnier M, Prior JO, Monney P, Dunet V, Lauriers N, Recordon F, Trana C, Iglesias JF, Kawecki D, Boulat O, Bardy D, Lamsidri S, Eeckhout E, Hugli O, Muller O. Performance of highly sensitive cardiac troponin T assay to detect ischaemia at PET-CT in low-risk patients with acute coronary syndrome: a prospective observational study. BMJ Open 2017; 7:e014655. [PMID: 28698323 PMCID: PMC5734281 DOI: 10.1136/bmjopen-2016-014655] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND Highly sensitive troponin T (hs-TnT) assay has improved clinical decision-making for patients admitted with chest pain. However, this assay's performance in detecting myocardial ischaemia in a lowrisk population has been poorly documented. PURPOSE To assess hs-TnT assay's performance to detect myocardial ischaemia at positron emission tomography/CT (PET-CT) in low-risk patients admitted with chest pain. METHODS Patients admitted for chest pain with a nonconclusive ECG and negative standard cardiac troponin T results at admission and after 6 hours were prospectively enrolled. Their hs-TnT samples were at T0, T2 and T6. Physicians were blinded to hs-TnT results. All patients underwent a PET-CT at rest and during adenosine-induced stress. All patients with a positive PET-CT result underwent a coronary angiography. RESULTS Forty-eight patients were included. Six had ischaemia at PET-CT. All of them had ≥1 significant stenosis at coronary angiography. Areas under the curve (95% CI) for predicting significant ischaemia at PET-CT using hs-TnT were 0.764 (0.515 to 1.000) at T0, 0.812(0.616 to 1.000) at T2 and 0.813(0.638 to 0.989) at T6. The receiver operating characteristicbased optimal cut-off value for hs-TnT at T0, T2 and T6 needed to exclude significant ischaemia at PET-CT was <4 ng/L. Using this value, sensitivity, specificity, positive and negative predictive values of hs-TnT to predict significant ischaemia were 83%/38%/16%/94% at T0, 100%/40%/19%/100% at T2 and 100%/43%/20%/100% at T6, respectively. CONCLUSIONS Our findings suggest that in low-risk patients, using the hs-TnT assay with a cut-off value of 4 ng/L demonstrates excellent negative predictive value to exclude myocardial ischaemia detection at PET-CT, at the expense of weak specificity and positive predictive value. TRIAL REGISTRATION NUMBER ClinicalTrials.gov Identifier: NCT01374607.
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Affiliation(s)
- Beata Morawiec
- Department of Cardiology, University Hospital, Lausanne, Switzerland
- 2 Department of Cardiology, School of Medicine with the Division of Dentistry, Zabrze, Medical University of Silesia, Katowice, Poland
| | - Stephane Fournier
- Department of Cardiology, University Hospital, Lausanne, Switzerland
| | - Maxime Tapponnier
- Department of Cardiology, University Hospital, Lausanne, Switzerland
| | - John O Prior
- Department of Nuclear Medicine and Molecular Imaging, Lausanne University Hospital, Lausanne, Switzerland
| | - Pierre Monney
- Department of Cardiology, University Hospital, Lausanne, Switzerland
| | - Vincent Dunet
- Department of Nuclear Medicine and Molecular Imaging, Lausanne University Hospital, Lausanne, Switzerland
| | - Nathalie Lauriers
- Department of Cardiology, University Hospital, Lausanne, Switzerland
| | | | - Catalina Trana
- Department of Cardiology, University Hospital, Lausanne, Switzerland
| | | | - Damian Kawecki
- 2 Department of Cardiology, School of Medicine with the Division of Dentistry, Zabrze, Medical University of Silesia, Katowice, Poland
| | - Olivier Boulat
- Department of Laboratory, Lausanne University Hospital, Lausanne, Switzerland
| | - Daniel Bardy
- Department of Laboratory, Lausanne University Hospital, Lausanne, Switzerland
| | - Sabine Lamsidri
- Department of Cardiology, University Hospital, Lausanne, Switzerland
| | - Eric Eeckhout
- Department of Cardiology, University Hospital, Lausanne, Switzerland
| | - Olivier Hugli
- Emergency Department, Lausanne University Hospital, Lausanne, Switzerland
| | - Olivier Muller
- Department of Cardiology, University Hospital, Lausanne, Switzerland
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120
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Velilla Moliner J, Lahoz Rodríguez D, Giménez Valverde A, Bustamante Rodríguez E. Detección de troponina T ultrasensible en pacientes con riesgo cardiovascular. Rev Esp Cardiol 2017. [DOI: 10.1016/j.recesp.2017.01.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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121
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Velilla Moliner J, Lahoz Rodríguez D, Giménez Valverde A, Bustamante Rodríguez E. Detection of High-sensitivity Troponin T in Patients With Cardiovascular Risk. REVISTA ESPANOLA DE CARDIOLOGIA (ENGLISH ED.) 2017; 70:615. [PMID: 28454889 DOI: 10.1016/j.rec.2017.01.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/19/2017] [Accepted: 01/27/2017] [Indexed: 06/07/2023]
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122
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Wildi K, Cullen L, Twerenbold R, Greenslade JH, Parsonage W, Boeddinghaus J, Nestelberger T, Sabti Z, Rubini-Giménez M, Puelacher C, Cupa J, Schumacher L, Badertscher P, Grimm K, Kozhuharov N, Stelzig C, Freese M, Rentsch K, Lohrmann J, Kloos W, Buser A, Reichlin T, Pickering JW, Than M, Mueller C. Direct Comparison of 2 Rule-Out Strategies for Acute Myocardial Infarction: 2-h Accelerated Diagnostic Protocol vs 2-h Algorithm. Clin Chem 2017; 63:1227-1236. [DOI: 10.1373/clinchem.2016.268359] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2016] [Accepted: 03/16/2017] [Indexed: 12/21/2022]
Abstract
Abstract
BACKGROUND
We compared 2 high-sensitivity cardiac troponin (hs-cTn)-based 2-h strategies in patients presenting with suspected acute myocardial infarction (AMI) to the emergency department (ED): the 2-h accelerated diagnostic protocol (2h-ADP) combining hs-cTn, electrocardiogram, and a risk score, and the 2-h algorithm exclusively based on hs-cTn concentrations and their absolute changes.
METHODS
Analyses were performed in 2 independent diagnostic cohorts [European Advantageous Predictors of Acute Coronary Syndrome Evaluation (APACE) study, Australian–New Zealand 2-h Accelerated Diagnostic Protocol to Assess patients with chest Pain symptoms using contemporary Troponins as the only biomarker (ADAPT) study] employing hs-cTnT (Elecsys) and hs-cTnI (Architect). The final diagnosis was adjudicated by 2 independent cardiologists.
RESULTS
AMI was the final diagnosis in 16.5% (95% CI, 14.6%–18.6%) of the 1372 patients in APACE, and 12.6% (95% CI, 10.7%–14.7%) of 1153 patients in ADAPT. The negative predictive value (NPV) and sensitivity for AMI were very high and comparable with both strategies using either hs-cTnT or hs-cTnI in both cohorts (all statistical comparisons nonsignificant). The percentage of patients triaged toward rule-out was significantly lower with the 2h-ADP (36%–43%) vs the 2-h algorithm (55%–68%) with both assays and in both cohorts (P < 0.001). The sensitivity of the 2h-ADP was higher for 30-day major adverse cardiovascular events.
CONCLUSIONS
Both algorithms provided very high and comparable safety as quantified by the NPV and sensitivity for AMI and major adverse cardiac events (MACE) at 30 days in patients triaged toward rule-out, although sensitivity for MACE at 30 days was lower with both algorithms in cohort 2. Although the 2-h algorithm was more efficacious, not all patients ruled out for AMI by this algorithm were appropriate candidates for early discharge. The 2h-ADP seems superior in the selection of patients for early discharge from the ED.
CLINICAL TRIAL REGISTRATION
APACE: http://clinicaltrials.gov/show/NCT00470587
ADAPT: Australia-New Zealand Clinical Trials Registry ACTRN12611001069943
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Affiliation(s)
- Karin Wildi
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, Basel, Switzerland
- Department of Intensive Care Medicine, University Hospital Basel, Basel, Switzerland
| | - Louise Cullen
- Department of Emergency Medicine, Royal Brisbane and Women's Hospital, Brisbane, Australia; School of Public Health, Queensland University of Technology, Brisbane, Australia; School of Medicine, The University of Queensland, Brisbane, Australia
| | - Raphael Twerenbold
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, Basel, Switzerland
| | - Jaimi H Greenslade
- Department of Emergency Medicine, Royal Brisbane and Women's Hospital, Brisbane, Australia; School of Public Health, Queensland University of Technology, Brisbane, Australia; School of Medicine, The University of Queensland, Brisbane, Australia
| | - William Parsonage
- Department of Emergency Medicine, Royal Brisbane and Women's Hospital, Brisbane, Australia; School of Public Health, Queensland University of Technology, Brisbane, Australia; School of Medicine, The University of Queensland, Brisbane, Australia
| | - Jasper Boeddinghaus
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, Basel, Switzerland
- Department of Internal Medicine, University Hospital Basel, Switzerland
| | - Thomas Nestelberger
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, Basel, Switzerland
- Department of Internal Medicine, University Hospital Basel, Switzerland
| | - Zaid Sabti
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, Basel, Switzerland
| | - Maria Rubini-Giménez
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, Basel, Switzerland
- Department of Internal Medicine, University Hospital Basel, Switzerland
- Laboratory Medicine, University Hospital Basel, Basel, Switzerland
| | - Christian Puelacher
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, Basel, Switzerland
| | - Janosch Cupa
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, Basel, Switzerland
| | - Lukas Schumacher
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, Basel, Switzerland
| | - Patrick Badertscher
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, Basel, Switzerland
| | - Karin Grimm
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, Basel, Switzerland
- Department of Internal Medicine, University Hospital Basel, Switzerland
| | - Nikola Kozhuharov
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, Basel, Switzerland
| | - Claudia Stelzig
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, Basel, Switzerland
| | - Michael Freese
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, Basel, Switzerland
| | | | - Jens Lohrmann
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, Basel, Switzerland
| | - Wanda Kloos
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, Basel, Switzerland
| | - Andreas Buser
- Blood Transfusion Centre, Swiss Red Cross, Basel, Switzerland and Department of Hematology, University Hospital Basel, Switzerland
| | - Tobias Reichlin
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, Basel, Switzerland
| | | | - Martin Than
- Department of Emergency Medicine, Christchurch, New Zealand
| | - Christian Mueller
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, Basel, Switzerland
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Liu T, Wang G, Li P, Dai X. Risk classification of highly sensitive troponin I predict presence of vulnerable plaque assessed by dual source coronary computed tomography angiography. Int J Cardiovasc Imaging 2017; 33:1831-1839. [PMID: 28528430 DOI: 10.1007/s10554-017-1174-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2017] [Accepted: 05/17/2017] [Indexed: 01/10/2023]
Abstract
Patients presenting to the emergency department with acute chest pain, negative conventional troponin and electrocardiogram require serial testing to rule out acute coronary syndrome (ACS). We studied the association of highly sensitive troponin (hsTn) I with vulnerable plaque features as detected by coronary dual source computed tomography angiography (DSCTA) and determined whether hsTn I at the time of presentation combined with early DSCTA could improve classification of patients as high-risk or low risk for ACS. We included 220 patients with acute chest pain, negative electrocardiogram and conventional troponin who underwent DSCTA and had hsTn I measured at the time of presentation. The patients were categorized as having hsTn I below the limit of detection (low risk), intermediate and above the 99th percentile (high risk). Readers assessed DSCTA qualitatively for the presence of significant CAD (≥50% stenosis), calcified and non-calcified coronary plaque, and vulnerable plaque features (positive remodeling, low CT attenuation plaque, napkin-ring sign, spotty calcium). The mean age of the population was 50.3 ± 8.2 years (43% women). ACS during the index hospitalization occurred in 36 (16.3%) patients (myocardial infarction n = 8, unstable angina pectoris n = 28). HsTn I was below the limit of detection, intermediate, and above 99th percentile in 39 (17.7%), 139 (86.9%), and 42 (19.1%) patients, respectively. Across the categories of low risk, intermediate and high risk of hsTn I, there was increase in prevalence of ≥50% stenosis (0, 11.5, and 61.9% of patients; p < 0.001), any plaque (35.9, 51.1, and 85.7% of patients; p < 0.001) and high-risk plaque (0, 36.0, and 85.7% of patients; p < 0.001). None of the patients in low risk HsTn I group had ACS. ACS occurred in 10.1% of the intermediate hsTn I group and in 52.3% of the patients with high risk hsTnI group. Severity of stenosis and presence of vunerable plaque as detected by DSCTA are associated with increasing levels of hsTn I. DSCTA at the time of presentation with the assessment for both stenosis and high-risk plaque improved the diagnostic accuracy for ACS in the intermediate hsTn I group patients.
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Affiliation(s)
- Ting Liu
- Department of Radiology, The First Affiliated Hospital of China Medical University, 155 Nanjing Bei St, Heping District, Shenyang, China
| | - Guan Wang
- Department of Radiology, The First Affiliated Hospital of China Medical University, 155 Nanjing Bei St, Heping District, Shenyang, China
| | - Peiling Li
- Department of Radiology, The First Affiliated Hospital of China Medical University, 155 Nanjing Bei St, Heping District, Shenyang, China
| | - Xu Dai
- Department of Radiology, The First Affiliated Hospital of China Medical University, 155 Nanjing Bei St, Heping District, Shenyang, China.
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Body R, Boachie C, McConnachie A, Carley S, Van Den Berg P, Lecky FE. Feasibility of the Manchester Acute Coronary Syndromes (MACS) decision rule to safely reduce unnecessary hospital admissions: a pilot randomised controlled trial. Emerg Med J 2017; 34:586-592. [PMID: 28500087 PMCID: PMC5574380 DOI: 10.1136/emermed-2016-206148] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2016] [Revised: 02/03/2017] [Accepted: 02/23/2017] [Indexed: 12/27/2022]
Abstract
Background Observational studies suggest that the Manchester Acute Coronary Syndromes (MACS) decision rule can effectively ‘rule out’ and ‘rule in’ acute coronary syndromes (ACS) following a single blood test. In a pilot randomised controlled trial, we aimed to determine whether a large trial is feasible. Methods Patients presenting to two EDs with suspected cardiac chest pain were randomised to receive care guided by the MACS decision rule (intervention group) or standard care (controls). The primary efficacy outcome was a successful discharge from the ED, defined as a decision to discharge within 4 hours of arrival providing that the patient did not have a missed acute myocardial infarction (AMI) or develop a major adverse cardiac event (MACE: death, AMI or coronary revascularisation) within 30 days. Feasibility outcomes included recruitment and attrition rates. Results In total, 138 patients were included between October 2013 and October 2014, of whom 131 (95%) were randomised (66 to intervention and 65 controls). Nine (7%) patients had prevalent AMI and six (5%) had incident MACE within 30 days. All 131 patients completed 30-day follow-up and were included in the final analysis with no missing data for the primary analyses. Compared with standard care, a significantly greater proportion of patients whose care was guided by the MACS rule were successfully discharged within 4 hours (26% vs 8%, adjusted OR 5.45, 95% CI 1.73 to 17.11, p=0.004). No patients in either group who were discharged within 4 hours had a diagnosis of AMI or incident MACE within 30 days (0.0%, 95% CI 0% to 20.0% in the intervention group). Conclusions In this pilot trial, use of the MACS rule led to a significant increase in safe discharges from the ED but a larger, fully powered trial remains necessary. Our findings seem to support the feasibility of that trial. Trial registration number ISRCTN 86818215. Research Ethics Committee reference 13/NW/0081. UKCRN registration ID 14334.
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Affiliation(s)
- Richard Body
- Cardiovascular Sciences, The University of Manchester, Manchester, UK.,Emergency Department, Central Manchester University Hospitals Foundation NHS Trust, Manchester, UK
| | - Charles Boachie
- Robertson Centre for Biostatistics, Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - Alex McConnachie
- Robertson Centre for Biostatistics, Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - Simon Carley
- Emergency Department, Central Manchester University Hospitals Foundation NHS Trust, Manchester, UK.,Healthcare Sciences, Manchester Metropolitan University, Manchester, UK
| | | | - Fiona E Lecky
- Emergency Department, Salford Royal Infirmary, Manchester, UK
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Early Diagnostic Performance of Heart-Type Fatty Acid Binding Protein in Suspected Acute Myocardial Infarction: Evidence From a Meta-Analysis of Contemporary Studies. Heart Lung Circ 2017; 27:503-512. [PMID: 28566132 DOI: 10.1016/j.hlc.2017.03.165] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2016] [Revised: 01/11/2017] [Accepted: 03/29/2017] [Indexed: 11/21/2022]
Abstract
BACKGROUND Although cardiac troponin is the cornerstone in diagnosis of acute myocardial infarction (AMI), the accuracy is still suboptimal in the early hours after chest pain onset. Due to its small size, heart-type fatty acid-binding protein (H-FABP) has been reported accurate in diagnosis of AMI, however, this remains undetermined. The aim is to investigate the diagnostic performance of H-FABP alone and in conjunction with high-sensitivity troponin (hs-Tn) within 6 hours of symptom onset. Furthermore, accuracy in 0h/3h algorithm was also assessed. METHODS Medline and EMBASE databases were searched; sensitivity, specificity and area under ROC curve (AUC) were used as measures of the diagnostic accuracy. We pooled data on bivariate modelling, threshold effect and publication bias was applied for heterogeneity analysis. RESULTS Twenty-two studies with 6602 populations were included, pooled sensitivity, specificity and AUC of H-FABP were 0.75 (0.68-0.81), 0.81 (0.75-0.86) and 0.85 (0.82-0.88) within 6 hours. Similar sensitivity (0.76, 0.69-0.82), specificity (0.80, 0.71-0.87) and AUC (0.85, 0.82-0.88) of H-FABP were observed in 4185 (63%) patients in 0h/3h algorithm. The additional use of H-FABP improved the sensitivity of hs-Tn alone but worsened its specificity (all p<0.001), and resulted in no improvement of AUC (p>0.99). There was no threshold effect (p=0.18) and publication bias (p=0.31) in this study. CONCLUSIONS H-FABP has modest accuracy for early diagnosis of AMI within 3 and 6 hours of symptom onset. The incremental value of H-FABP seemed much smaller and was of uncertain clinical significance in addition to hs-Tn in patients with suspected AMI. Routine use of H-FABP in early presentation does not seem warranted.
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Chapman AR, Anand A, Boeddinghaus J, Ferry AV, Sandeman D, Adamson PD, Andrews J, Tan S, Cheng SF, D'Souza M, Orme K, Strachan FE, Nestelberger T, Twerenbold R, Badertscher P, Reichlin T, Gray A, Shah ASV, Mueller C, Newby DE, Mills NL. Comparison of the Efficacy and Safety of Early Rule-Out Pathways for Acute Myocardial Infarction. Circulation 2017; 135:1586-1596. [PMID: 28034899 PMCID: PMC5404406 DOI: 10.1161/circulationaha.116.025021] [Citation(s) in RCA: 136] [Impact Index Per Article: 19.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2016] [Accepted: 12/15/2016] [Indexed: 01/25/2023]
Abstract
BACKGROUND High-sensitivity cardiac troponin assays enable myocardial infarction to be ruled out earlier, but the optimal approach is uncertain. We compared the European Society of Cardiology rule-out pathway with a pathway that incorporates lower cardiac troponin concentrations to risk stratify patients. METHODS Patients with suspected acute coronary syndrome (n=1218) underwent high-sensitivity cardiac troponin I measurement at presentation and 3 and 6 or 12 hours. We compared the European Society of Cardiology pathway (<99th centile at presentation or at 3 hours if symptoms <6 hours) with a pathway developed in the High-STEACS study (High-Sensitivity Troponin in the Evaluation of Patients With Acute Coronary Syndrome) population (<5 ng/L at presentation or change <3 ng/L and <99th centile at 3 hours). The primary outcome was a comparison of the negative predictive value of both pathways for index type 1 myocardial infarction or type 1 myocardial infarction or cardiac death at 30 days. We evaluated the primary outcome in prespecified subgroups stratified by age, sex, time of symptom onset, and known ischemic heart disease. RESULTS The primary outcome occurred in 15.7% (191 of 1218) patients. In those less than the 99th centile at presentation, the European Society of Cardiology pathway ruled out myocardial infarction in 28.1% (342 of 1218) and 78.9% (961 of 1218) at presentation and 3 hours, respectively, missing 18 index and two 30-day events (negative predictive value, 97.9%; 95% confidence interval, 96.9-98.7). The High-STEACS pathway ruled out 40.7% (496 of 1218) and 74.2% (904 of 1218) at presentation and 3 hours, missing 2 index and two 30-day events (negative predictive value, 99.5%; 95% confidence interval, 99.0-99.9; P<0.001 for comparison). The negative predictive value of the High-STEACS pathway was greater than the European Society of Cardiology pathway overall (P<0.001) and in all subgroups, including those presenting early or known to have ischemic heart disease. CONCLUSIONS Use of the High-STEACS pathway incorporating low high-sensitivity cardiac troponin concentrations rules out myocardial infarction in more patients at presentation and misses 5-fold fewer index myocardial infarctions than guideline-approved pathways based exclusively on the 99th centile. CLINICAL TRIAL REGISTRATION URL: http://clinicaltrials.gov. Unique identifier: NCT01852123.
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Affiliation(s)
- Andrew R Chapman
- From British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, United Kingdom (A.R.C., A.A., A.V.F., D.S., P.D.A., J.A., S.T., S.F.C., M.D., K.O., F.E.S., A.G., A.S.V.S., D.E.N., N.L.M.); Cardiovascular Research Institute Basel and Department of Cardiology, University Hospital, Switzerland (J.B., T.N., R.T., P.B.., T.R., C.M.); and Department of Emergency Medicine (A.G.) and EMERGE Research Group (A.G.), Royal Infirmary of Edinburgh, United Kingdom.
| | - Atul Anand
- From British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, United Kingdom (A.R.C., A.A., A.V.F., D.S., P.D.A., J.A., S.T., S.F.C., M.D., K.O., F.E.S., A.G., A.S.V.S., D.E.N., N.L.M.); Cardiovascular Research Institute Basel and Department of Cardiology, University Hospital, Switzerland (J.B., T.N., R.T., P.B.., T.R., C.M.); and Department of Emergency Medicine (A.G.) and EMERGE Research Group (A.G.), Royal Infirmary of Edinburgh, United Kingdom
| | - Jasper Boeddinghaus
- From British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, United Kingdom (A.R.C., A.A., A.V.F., D.S., P.D.A., J.A., S.T., S.F.C., M.D., K.O., F.E.S., A.G., A.S.V.S., D.E.N., N.L.M.); Cardiovascular Research Institute Basel and Department of Cardiology, University Hospital, Switzerland (J.B., T.N., R.T., P.B.., T.R., C.M.); and Department of Emergency Medicine (A.G.) and EMERGE Research Group (A.G.), Royal Infirmary of Edinburgh, United Kingdom
| | - Amy V Ferry
- From British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, United Kingdom (A.R.C., A.A., A.V.F., D.S., P.D.A., J.A., S.T., S.F.C., M.D., K.O., F.E.S., A.G., A.S.V.S., D.E.N., N.L.M.); Cardiovascular Research Institute Basel and Department of Cardiology, University Hospital, Switzerland (J.B., T.N., R.T., P.B.., T.R., C.M.); and Department of Emergency Medicine (A.G.) and EMERGE Research Group (A.G.), Royal Infirmary of Edinburgh, United Kingdom
| | - Dennis Sandeman
- From British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, United Kingdom (A.R.C., A.A., A.V.F., D.S., P.D.A., J.A., S.T., S.F.C., M.D., K.O., F.E.S., A.G., A.S.V.S., D.E.N., N.L.M.); Cardiovascular Research Institute Basel and Department of Cardiology, University Hospital, Switzerland (J.B., T.N., R.T., P.B.., T.R., C.M.); and Department of Emergency Medicine (A.G.) and EMERGE Research Group (A.G.), Royal Infirmary of Edinburgh, United Kingdom
| | - Philip D Adamson
- From British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, United Kingdom (A.R.C., A.A., A.V.F., D.S., P.D.A., J.A., S.T., S.F.C., M.D., K.O., F.E.S., A.G., A.S.V.S., D.E.N., N.L.M.); Cardiovascular Research Institute Basel and Department of Cardiology, University Hospital, Switzerland (J.B., T.N., R.T., P.B.., T.R., C.M.); and Department of Emergency Medicine (A.G.) and EMERGE Research Group (A.G.), Royal Infirmary of Edinburgh, United Kingdom
| | - Jack Andrews
- From British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, United Kingdom (A.R.C., A.A., A.V.F., D.S., P.D.A., J.A., S.T., S.F.C., M.D., K.O., F.E.S., A.G., A.S.V.S., D.E.N., N.L.M.); Cardiovascular Research Institute Basel and Department of Cardiology, University Hospital, Switzerland (J.B., T.N., R.T., P.B.., T.R., C.M.); and Department of Emergency Medicine (A.G.) and EMERGE Research Group (A.G.), Royal Infirmary of Edinburgh, United Kingdom
| | - Stephanie Tan
- From British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, United Kingdom (A.R.C., A.A., A.V.F., D.S., P.D.A., J.A., S.T., S.F.C., M.D., K.O., F.E.S., A.G., A.S.V.S., D.E.N., N.L.M.); Cardiovascular Research Institute Basel and Department of Cardiology, University Hospital, Switzerland (J.B., T.N., R.T., P.B.., T.R., C.M.); and Department of Emergency Medicine (A.G.) and EMERGE Research Group (A.G.), Royal Infirmary of Edinburgh, United Kingdom
| | - Sheun F Cheng
- From British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, United Kingdom (A.R.C., A.A., A.V.F., D.S., P.D.A., J.A., S.T., S.F.C., M.D., K.O., F.E.S., A.G., A.S.V.S., D.E.N., N.L.M.); Cardiovascular Research Institute Basel and Department of Cardiology, University Hospital, Switzerland (J.B., T.N., R.T., P.B.., T.R., C.M.); and Department of Emergency Medicine (A.G.) and EMERGE Research Group (A.G.), Royal Infirmary of Edinburgh, United Kingdom
| | - Michelle D'Souza
- From British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, United Kingdom (A.R.C., A.A., A.V.F., D.S., P.D.A., J.A., S.T., S.F.C., M.D., K.O., F.E.S., A.G., A.S.V.S., D.E.N., N.L.M.); Cardiovascular Research Institute Basel and Department of Cardiology, University Hospital, Switzerland (J.B., T.N., R.T., P.B.., T.R., C.M.); and Department of Emergency Medicine (A.G.) and EMERGE Research Group (A.G.), Royal Infirmary of Edinburgh, United Kingdom
| | - Kate Orme
- From British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, United Kingdom (A.R.C., A.A., A.V.F., D.S., P.D.A., J.A., S.T., S.F.C., M.D., K.O., F.E.S., A.G., A.S.V.S., D.E.N., N.L.M.); Cardiovascular Research Institute Basel and Department of Cardiology, University Hospital, Switzerland (J.B., T.N., R.T., P.B.., T.R., C.M.); and Department of Emergency Medicine (A.G.) and EMERGE Research Group (A.G.), Royal Infirmary of Edinburgh, United Kingdom
| | - Fiona E Strachan
- From British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, United Kingdom (A.R.C., A.A., A.V.F., D.S., P.D.A., J.A., S.T., S.F.C., M.D., K.O., F.E.S., A.G., A.S.V.S., D.E.N., N.L.M.); Cardiovascular Research Institute Basel and Department of Cardiology, University Hospital, Switzerland (J.B., T.N., R.T., P.B.., T.R., C.M.); and Department of Emergency Medicine (A.G.) and EMERGE Research Group (A.G.), Royal Infirmary of Edinburgh, United Kingdom
| | - Thomas Nestelberger
- From British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, United Kingdom (A.R.C., A.A., A.V.F., D.S., P.D.A., J.A., S.T., S.F.C., M.D., K.O., F.E.S., A.G., A.S.V.S., D.E.N., N.L.M.); Cardiovascular Research Institute Basel and Department of Cardiology, University Hospital, Switzerland (J.B., T.N., R.T., P.B.., T.R., C.M.); and Department of Emergency Medicine (A.G.) and EMERGE Research Group (A.G.), Royal Infirmary of Edinburgh, United Kingdom
| | - Raphael Twerenbold
- From British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, United Kingdom (A.R.C., A.A., A.V.F., D.S., P.D.A., J.A., S.T., S.F.C., M.D., K.O., F.E.S., A.G., A.S.V.S., D.E.N., N.L.M.); Cardiovascular Research Institute Basel and Department of Cardiology, University Hospital, Switzerland (J.B., T.N., R.T., P.B.., T.R., C.M.); and Department of Emergency Medicine (A.G.) and EMERGE Research Group (A.G.), Royal Infirmary of Edinburgh, United Kingdom
| | - Patrick Badertscher
- From British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, United Kingdom (A.R.C., A.A., A.V.F., D.S., P.D.A., J.A., S.T., S.F.C., M.D., K.O., F.E.S., A.G., A.S.V.S., D.E.N., N.L.M.); Cardiovascular Research Institute Basel and Department of Cardiology, University Hospital, Switzerland (J.B., T.N., R.T., P.B.., T.R., C.M.); and Department of Emergency Medicine (A.G.) and EMERGE Research Group (A.G.), Royal Infirmary of Edinburgh, United Kingdom
| | - Tobias Reichlin
- From British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, United Kingdom (A.R.C., A.A., A.V.F., D.S., P.D.A., J.A., S.T., S.F.C., M.D., K.O., F.E.S., A.G., A.S.V.S., D.E.N., N.L.M.); Cardiovascular Research Institute Basel and Department of Cardiology, University Hospital, Switzerland (J.B., T.N., R.T., P.B.., T.R., C.M.); and Department of Emergency Medicine (A.G.) and EMERGE Research Group (A.G.), Royal Infirmary of Edinburgh, United Kingdom
| | - Alasdair Gray
- From British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, United Kingdom (A.R.C., A.A., A.V.F., D.S., P.D.A., J.A., S.T., S.F.C., M.D., K.O., F.E.S., A.G., A.S.V.S., D.E.N., N.L.M.); Cardiovascular Research Institute Basel and Department of Cardiology, University Hospital, Switzerland (J.B., T.N., R.T., P.B.., T.R., C.M.); and Department of Emergency Medicine (A.G.) and EMERGE Research Group (A.G.), Royal Infirmary of Edinburgh, United Kingdom
| | - Anoop S V Shah
- From British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, United Kingdom (A.R.C., A.A., A.V.F., D.S., P.D.A., J.A., S.T., S.F.C., M.D., K.O., F.E.S., A.G., A.S.V.S., D.E.N., N.L.M.); Cardiovascular Research Institute Basel and Department of Cardiology, University Hospital, Switzerland (J.B., T.N., R.T., P.B.., T.R., C.M.); and Department of Emergency Medicine (A.G.) and EMERGE Research Group (A.G.), Royal Infirmary of Edinburgh, United Kingdom
| | - Christian Mueller
- From British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, United Kingdom (A.R.C., A.A., A.V.F., D.S., P.D.A., J.A., S.T., S.F.C., M.D., K.O., F.E.S., A.G., A.S.V.S., D.E.N., N.L.M.); Cardiovascular Research Institute Basel and Department of Cardiology, University Hospital, Switzerland (J.B., T.N., R.T., P.B.., T.R., C.M.); and Department of Emergency Medicine (A.G.) and EMERGE Research Group (A.G.), Royal Infirmary of Edinburgh, United Kingdom
| | - David E Newby
- From British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, United Kingdom (A.R.C., A.A., A.V.F., D.S., P.D.A., J.A., S.T., S.F.C., M.D., K.O., F.E.S., A.G., A.S.V.S., D.E.N., N.L.M.); Cardiovascular Research Institute Basel and Department of Cardiology, University Hospital, Switzerland (J.B., T.N., R.T., P.B.., T.R., C.M.); and Department of Emergency Medicine (A.G.) and EMERGE Research Group (A.G.), Royal Infirmary of Edinburgh, United Kingdom
| | - Nicholas L Mills
- From British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, United Kingdom (A.R.C., A.A., A.V.F., D.S., P.D.A., J.A., S.T., S.F.C., M.D., K.O., F.E.S., A.G., A.S.V.S., D.E.N., N.L.M.); Cardiovascular Research Institute Basel and Department of Cardiology, University Hospital, Switzerland (J.B., T.N., R.T., P.B.., T.R., C.M.); and Department of Emergency Medicine (A.G.) and EMERGE Research Group (A.G.), Royal Infirmary of Edinburgh, United Kingdom
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Roos A, Hellgren A, Rafatnia F, Hammarsten O, Ljung R, Carlsson AC, Holzmann MJ. Investigations, findings, and follow-up in patients with chest pain and elevated high-sensitivity cardiac troponin T levels but no myocardial infarction. Int J Cardiol 2017; 232:111-116. [DOI: 10.1016/j.ijcard.2017.01.044] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2016] [Revised: 11/12/2016] [Accepted: 01/04/2017] [Indexed: 12/31/2022]
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128
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Greenslade JH, Nayer R, Parsonage W, Doig S, Young J, Pickering JW, Than M, Hammett C, Cullen L. Validating the Manchester Acute Coronary Syndromes (MACS) and Troponin-only Manchester Acute Coronary Syndromes (T-MACS) rules for the prediction of acute myocardial infarction in patients presenting to the emergency department with chest pain. Emerg Med J 2017; 34:517-523. [DOI: 10.1136/emermed-2016-206366] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2016] [Revised: 01/16/2017] [Accepted: 01/20/2017] [Indexed: 11/04/2022]
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Trials of Imaging Use in the Emergency Department for Acute Chest Pain. JACC Cardiovasc Imaging 2017; 10:338-349. [DOI: 10.1016/j.jcmg.2016.10.015] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2016] [Revised: 10/27/2016] [Accepted: 10/27/2016] [Indexed: 02/06/2023]
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130
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Whelton SP, McEvoy JW, Lazo M, Coresh J, Ballantyne CM, Selvin E. High-Sensitivity Cardiac Troponin T (hs-cTnT) as a Predictor of Incident Diabetes in the Atherosclerosis Risk in Communities Study. Diabetes Care 2017; 40:261-269. [PMID: 28108537 PMCID: PMC5250695 DOI: 10.2337/dc16-1541] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2016] [Accepted: 10/24/2016] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Many individuals with prediabetes have evidence of subclinical myocardial damage and are at an increased risk of cardiovascular disease (CVD). If subclinical myocardial damage is independently associated with incident diabetes, this may contribute to the understanding of the association between diabetes and CVD. This study was conducted to determine whether high-sensitivity cardiac troponin T (hs-cTnT) is associated with incident diabetes. RESEARCH DESIGN AND METHODS Using Kaplan-Meier curves and Cox models, we prospectively analyzed 8,153 participants without known diabetes or CVD. We used the Harrell C statistic to investigate whether hs-cTnT added incremental prognostic information for diabetes prediction. RESULTS During a median of 13 years of follow-up, there were 1,830 incident cases of diagnosed diabetes. After adjustment for demographics and traditional risk factors, participants with a baseline hs-cTnT of 9-13 ng/L or ≥14 ng/L had a significantly increased risk for diabetes compared to those with an hs-cTnT of ≤5 ng/L, with hazard ratios of 1.14 (95% CI 0.99-1.33) and 1.25 (95% CI 1.03-1.53), respectively (P = 0.018 for trend). Linear spline modeling that included adjustment for baseline fasting glucose suggested an increased risk of incident diabetes for participants with hs-cTnT levels >8 ng/L. Furthermore, the addition of hs-cTnT to fully adjusted models that included glucose significantly improved the prediction of incident diabetes from 0.7636 to 0.7644 (P = 0.023). CONCLUSIONS Participants with elevated hs-cTnT levels at baseline had an increased risk of incident diabetes, suggesting that the measurement of hs-cTnT may incorporate an underlying pathophysiologic overlap between diabetes and CVD not captured by other traditional risk factors. Measurement of hs-cTnT may be useful to identify individuals at an increased risk for incident diabetes and CVD in order to provide early and more intensive risk factor modification.
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Affiliation(s)
- Seamus P Whelton
- Ciccarone Center for the Prevention of Heart Disease, Division of Cardiology, Johns Hopkins Department of Medicine, Baltimore, MD .,Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - John W McEvoy
- Ciccarone Center for the Prevention of Heart Disease, Division of Cardiology, Johns Hopkins Department of Medicine, Baltimore, MD.,Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Mariana Lazo
- Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD.,Division of General Internal Medicine, Johns Hopkins Department of Medicine, Baltimore, MD
| | - Josef Coresh
- Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | | | - Elizabeth Selvin
- Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD.,Division of General Internal Medicine, Johns Hopkins Department of Medicine, Baltimore, MD
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Ferraro S, Dolci A, Panteghini M. Fast track protocols using highly sensitive troponin assays for ruling out and ruling in non-ST elevation acute coronary syndrome. ACTA ACUST UNITED AC 2017; 55:1683-1689. [DOI: 10.1515/cclm-2017-0044] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2017] [Accepted: 02/13/2017] [Indexed: 11/15/2022]
Abstract
Abstract:The introduction of “highly sensitive” cardiac troponin assays (hsTn) has reinforced the evidence that only serial testing incorporated in running algorithms allows a more accurate diagnosis of acute myocardial infarction. In this report, we consider the available evidence supporting the use of fast track protocols for ruling out and ruling in non-ST elevation myocardial infarction (NSTEMI) and compare it with the content of recently released guideline by the European Society of Cardiology, noting some uncomfortable aspects that need urgent clarification and/or revision. Firstly, the guideline drafters have to reconsider the available evidence that does not permit to assign the same class and level of evidence to the very well-validated 0–3 h algorithm and to the 0–1 h algorithm. In agreement with the validity of available data, the limitations of fast track protocols, in particular of the 0–1 h algorithm for NSTEMI rule-in, calls for caution. Secondly, as the current diagnostics guidance by the UK National Institute for Health and Care Excellence recommends, rapid diagnostic protocols should be performed only using well-validated hsTn; recommending the use of an assay before being commercially available is not fair and scientifically sound.
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Cullen LA, Mills NL, Mahler S, Body R. Early Rule-Out and Rule-In Strategies for Myocardial Infarction. Clin Chem 2017; 63:129-139. [PMID: 28062616 DOI: 10.1373/clinchem.2016.254730] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2016] [Accepted: 08/09/2016] [Indexed: 02/07/2023]
Abstract
BACKGROUND Patients with chest pain comprise a large proportion of emergency presentations and place a major burden on healthcare resources. Therefore, efforts to safely and rapidly identify those with and without acute myocardial infarction (AMI) are needed. The challenge for clinicians is to accurately identify patients with acute coronary syndromes, while balancing the need to safely and rapidly reassure and discharge those without serious conditions. CONTENT This review summarizes the evidence to date on optimum accelerated strategies for the rule-in and rule-out of AMI, using strategies focused on optimum use of troponin results. Evidence based on both sensitive and highly sensitive troponin assay results is presented. The use of novel biomarkers is also addressed and the combination of biomarkers with other clinical information in accelerated diagnostic strategies is discussed. SUMMARY The majority of patients, who are not at risk of myocardial infarction or other serious harm, may be suitable for discharge directly from the emergency setting using approaches focused on troponin algorithms and accelerated diagnostic protocols. Evidence about the clinical and health economic impact of use of such strategies is needed, as they may have major benefits for both patients and healthcare providers.
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Affiliation(s)
| | - Nicholas L Mills
- BHF Centre for Cardiovascular Sciences, University of Edinburgh, Edinburgh, UK
| | - Simon Mahler
- Wake Forest School of Medicine, Winston-Salem, NC
| | - Richard Body
- Central Manchester University Hospitals NHS Foundation Trust, UK
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133
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Sandoval Y, Smith SW, Shah ASV, Anand A, Chapman AR, Love SA, Schulz K, Cao J, Mills NL, Apple FS. Rapid Rule-Out of Acute Myocardial Injury Using a Single High-Sensitivity Cardiac Troponin I Measurement. Clin Chem 2017; 63:369-376. [PMID: 27811203 DOI: 10.1373/clinchem.2016.264523] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2016] [Accepted: 08/23/2016] [Indexed: 01/07/2023]
Abstract
BACKGROUND Rapid rule-out strategies using high-sensitivity cardiac troponin assays are largely supported by studies performed outside the US in selected cohorts of patients with chest pain that are atypical of US practice, and focused exclusively on ruling out acute myocardial infarction (AMI), rather than acute myocardial injury, which is more common and associated with a poor prognosis. METHODS Prospective, observational study of consecutive patients presenting to emergency departments [derivation (n = 1647) and validation (n = 2198) cohorts], where high-sensitivity cardiac troponin I (hs-cTnI) was measured on clinical indication. The negative predictive value (NPV) and diagnostic sensitivity of an hs-cTnI concentration RESULTS In patients with hs-cTnI concentrations <99th percentile at presentation, acute myocardial injury occurred in 8.3% and 11.0% in the derivation and validation cohorts, respectively. In the derivation cohort, 27% had hs-cTnI < LoD, with NPV and diagnostic sensitivity for acute myocardial injury of 99.1% (95% CI, 97.7-99.8) and 99.0% (97.5-99.7) and an NPV for AMI or cardiac death at 30 days of 99.6% (98.4-100). In the validation cohort, 22% had hs-cTnI CONCLUSIONS A single hs-cTnI concentration
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Affiliation(s)
- Yader Sandoval
- Division of Cardiology, Hennepin County Medical Center, Minneapolis, MN
- Minneapolis Heart Institute, Abbott-Northwestern Hospital, Minneapolis, MN
- Minneapolis Medical Research Foundation, Minneapolis, MN
| | - Stephen W Smith
- Minneapolis Medical Research Foundation, Minneapolis, MN
- Department of Emergency Medicine, Hennepin County Medical Center and University of Minnesota, MN
| | - Anoop S V Shah
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Atul Anand
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Andrew R Chapman
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Sara A Love
- Minneapolis Medical Research Foundation, Minneapolis, MN
- Department of Laboratory Medicine and Pathology, Hennepin County Medical Center and University of Minnesota, Minneapolis, MN
| | - Karen Schulz
- Minneapolis Medical Research Foundation, Minneapolis, MN
| | - Jing Cao
- Minneapolis Medical Research Foundation, Minneapolis, MN
| | - Nicholas L Mills
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Fred S Apple
- Minneapolis Medical Research Foundation, Minneapolis, MN;
- Department of Laboratory Medicine and Pathology, Hennepin County Medical Center and University of Minnesota, Minneapolis, MN
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Abstract
Acute coronary syndrome (ACS) encompasses a pathophysiological spectrum of cardiovascular diseases, all of which have significant morbidity and mortality. ACS was once considered an acute condition; however, new treatment strategies and improvements in biomarker assays have led to ACS being an acute and chronic disease. Cardiac troponin is the preferred biomarker for the diagnosis of myocardial infarction, and there is considerable interest and efforts toward development and implementation of high-sensitivity cardiac troponin (hs-cTn) assays worldwide. Analytical and clinical performance characteristics of hs-cTn assays as well as testing limitations are important for laboratorians and clinicians to understand in order to utilize testing appropriately. Furthermore, expanding the clinical utility of hs-cTn into other cohorts such as asymptomatic community dwelling populations, heart failure, and chronic kidney disease populations supports novel opportunities for improved short- and long-term prognosis.
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135
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The Optimal Cutoff Value of a Diagnostic Test. Med Decis Making 2017. [DOI: 10.1007/978-3-662-53432-8_8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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136
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Chapman AR, Adamson PD, Mills NL. Assessment and classification of patients with myocardial injury and infarction in clinical practice. Heart 2017; 103:10-18. [PMID: 27806987 PMCID: PMC5299097 DOI: 10.1136/heartjnl-2016-309530] [Citation(s) in RCA: 91] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2016] [Revised: 09/22/2016] [Accepted: 09/26/2016] [Indexed: 12/20/2022] Open
Abstract
Myocardial injury is common in patients without acute coronary syndrome, and international guidelines recommend patients with myocardial infarction are classified by aetiology. The universal definition differentiates patients with myocardial infarction due to plaque rupture (type 1) from those due to myocardial oxygen supply-demand imbalance (type 2) secondary to other acute illnesses. Patients with myocardial necrosis, but no symptoms or signs of myocardial ischaemia, are classified as acute or chronic myocardial injury. This classification has not been widely adopted in practice, because the diagnostic criteria for type 2 myocardial infarction encompass a wide range of presentations, and the implications of the diagnosis are uncertain. However, both myocardial injury and type 2 myocardial infarction are common, occurring in more than one-third of all hospitalised patients. These patients have poor short-term and long-term outcomes with two-thirds dead in 5 years. The classification of patients with myocardial infarction continues to evolve, and future guidelines are likely to recognise the importance of identifying coronary artery disease in type 2 myocardial infarction. Clinicians should consider whether coronary artery disease has contributed to myocardial injury, as selected patients are likely to benefit from further investigation and in these patients targeted secondary prevention has the potential to improve outcomes.
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Affiliation(s)
- Andrew R Chapman
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Philip D Adamson
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Nicholas L Mills
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
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137
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Hollander JE, Than M, Mueller C. State-of-the-Art Evaluation of Emergency Department Patients Presenting With Potential Acute Coronary Syndromes. Circulation 2016; 134:547-64. [PMID: 27528647 DOI: 10.1161/circulationaha.116.021886] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
It is well established that clinicians cannot use clinical judgment alone to determine whether an individual patient who presents to the emergency department has an acute coronary syndrome. The history and physical examination do not distinguish sufficiently between the many conditions that can cause acute chest pain syndromes. Cardiac risk factors do not have sufficient discriminatory ability in symptomatic patients presenting to the emergency department. Most patients with non-ST-segment-elevation myocardial infarction do not present with electrocardiographic evidence of active ischemia. The improvement in cardiac troponin assays, especially in conjunction with well-validated clinical decision algorithms, now enables the clinician to rapidly exclude myocardial infarction. In patients in whom unstable angina remains a concern or there is a desire to evaluate for underlying coronary artery disease, coronary computed tomography angiography can be used in the emergency department. Once a process that took ≥24 hours, computed tomography angiography now can rapidly exclude myocardial infarction and coronary artery disease in patients in the emergency department.
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Affiliation(s)
- Judd E Hollander
- From Department of Emergency Medicine, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA (J.E.H.); Department of Emergency Medicine, Christchurch Hospital, Christchurch, New Zealand (M.T.); and Department of Cardiology and Cardiovascular Research Institute Basel, University Hospital Basel, Basel, Switzerland (C.M.)
| | - Martin Than
- From Department of Emergency Medicine, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA (J.E.H.); Department of Emergency Medicine, Christchurch Hospital, Christchurch, New Zealand (M.T.); and Department of Cardiology and Cardiovascular Research Institute Basel, University Hospital Basel, Basel, Switzerland (C.M.)
| | - Christian Mueller
- From Department of Emergency Medicine, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA (J.E.H.); Department of Emergency Medicine, Christchurch Hospital, Christchurch, New Zealand (M.T.); and Department of Cardiology and Cardiovascular Research Institute Basel, University Hospital Basel, Basel, Switzerland (C.M.)
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138
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Gray AJ, Roobottom C, Smith JE, Goodacre S, Oatey K, O’Brien R, Storey RF, Na L, Lewis SC, Thokala P, Newby DE. The RAPID-CTCA trial (Rapid Assessment of Potential Ischaemic Heart Disease with CTCA) - a multicentre parallel-group randomised trial to compare early computerised tomography coronary angiography versus standard care in patients presenting with suspected or confirmed acute coronary syndrome: study protocol for a randomised controlled trial. Trials 2016; 17:579. [PMID: 27923390 PMCID: PMC5142154 DOI: 10.1186/s13063-016-1717-2] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2016] [Accepted: 11/19/2016] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Emergency department attendances with chest pain requiring assessment for acute coronary syndrome (ACS) are a major global health issue. Standard assessment includes history, examination, electrocardiogram (ECG) and serial troponin testing. Computerised tomography coronary angiography (CTCA) enables additional anatomical assessment of patients for coronary artery disease (CAD) but has only been studied in very low-risk patients. This trial aims to investigate the effect of early CTCA upon interventions, event rates and health care costs in patients with suspected/confirmed ACS who are at intermediate risk. METHODS/DESIGN Participants will be recruited in about 35 tertiary and district general hospitals in the UK. Patients ≥18 years old with symptoms with suspected/confirmed ACS with at least one of the following will be included: (1) ECG abnormalities, e.g. ST-segment depression >0.5 mm; (2) history of ischaemic heart disease; (3) troponin elevation above the 99th centile of the normal reference range or increase in high-sensitivity troponin meeting European Society of Cardiology criteria for 'rule-in' of myocardial infarction (MI). The early use of ≥64-slice CTCA as part of routine assessment will be compared to standard care. The primary endpoint will be 1-year all-cause death or recurrent type 1 or type 4b MI at 1 year, measured as the time to such event. A number of secondary clinical, process and safety endpoints will be collected and analysed. Cost effectiveness will be estimated in terms of the lifetime incremental cost per quality-adjusted life year gained. We plan to recruit 2424 (2500 with ~3% drop-out) evaluable patients (1212 per arm) to have 90% power to detect a 20% versus 15% difference in 1-year death or recurrent type 1 MI or type 4b MI, two-sided p < 0.05. Analysis will be on an intention-to-treat basis. The relationship between intervention and the primary outcome will be analysed using Cox proportional hazard regression adjusted for study site (used to stratify the randomisation), age, baseline Global Registry of Acute Coronary Events score, previous CAD and baseline troponin level. The results will be expressed as a hazard ratio with the corresponding 95% confidence intervals and p value. DISCUSSION The Rapid Assessment of Potential Ischaemic Heart Disease with CTCA (RAPID-CTCA) trial will recruit 2500 participants across about 35 hospital sites. It will be the first study to investigate the role of CTCA in the early assessment of patients with suspected or confirmed ACS who are at intermediate risk and including patients who have raised troponin measurements during initial assessment. TRIAL REGISTRATION ISRCTN19102565 . Registered on 3 October 2014. ClinicalTrials.gov: NCT02284191.
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Affiliation(s)
- Alasdair J. Gray
- Department of Emergency Medicine, Emergency Medicine Research Group, Royal Infirmary of Edinburgh, Edinburgh, UK
- University of Edinburgh, British Heart Foundation, Centre for Cardiovascular Science, Edinburgh, UK
| | - Carl Roobottom
- Plymouth University Peninsula Schools of Medicine and Dentistry, Plymouth, UK
- Derriford Hospital, Plymouth Hospitals NHS Trust, Plymouth, UK
| | - Jason E. Smith
- Plymouth University Peninsula Schools of Medicine and Dentistry, Plymouth, UK
- Derriford Hospital, Plymouth Hospitals NHS Trust, Plymouth, UK
- Academic Department of Military Emergency Medicine, Royal Centre for Defence Medicine (Research & Academia), Birmingham, UK
| | - Steve Goodacre
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Katherine Oatey
- Edinburgh Clinical Trials Unit, Usher Institute, University of Edinburgh, Edinburgh, UK
| | - Rachel O’Brien
- Department of Emergency Medicine, Emergency Medicine Research Group, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Robert F. Storey
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK
| | - Lumine Na
- Edinburgh Clinical Trials Unit, Usher Institute, University of Edinburgh, Edinburgh, UK
| | - Steff C. Lewis
- Edinburgh Clinical Trials Unit, Usher Institute, University of Edinburgh, Edinburgh, UK
| | - Praveen Thokala
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - David E. Newby
- University of Edinburgh, British Heart Foundation, Centre for Cardiovascular Science, Edinburgh, UK
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Sanchis J, García-Blas S, Carratalá A, Valero E, Mollar A, Miñana G, Ruiz V, Balaguer JV, Roqué M, Bosch X, Núñez J. Clinical Evaluation Versus Undetectable High-Sensitivity Troponin for Assessment of Patients With Acute Chest Pain. Am J Cardiol 2016; 118:1631-1635. [PMID: 27665208 DOI: 10.1016/j.amjcard.2016.08.040] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2016] [Revised: 08/19/2016] [Accepted: 08/19/2016] [Indexed: 11/15/2022]
Abstract
Decision-making in acute chest pain remains challenging despite normal (below ninety-ninth percentile) high-sensitivity troponin (hs-cTn). Some studies suggest that undetectable hs-cTn, far below the ninety-ninth percentile, might rule out acute coronary syndrome. We investigated clinical data in comparison to undetectable hs-cTnT. The study comprised 682 patients (November 2010 to September 2011) presenting at the emergency department with chest pain and normal hs-cTnT (<14 ng/l). The main end point was major adverse cardiac events (MACE: death, myocardial infarction, readmission for unstable angina, or revascularization) at a 4-year median follow-up; secondary end point was 30-day MACE. A clinical score was built by assigning points according to hazard ratios of the independent predictive variables: 1 point (male and effort-related pain) and 2 points (recurrent pain and prior ischemic heart disease). The negative predictive values of the clinical score and undetectable hs-cTnT (<5 ng/l), were tested. A total of 72 (10.6%) patients suffered long-term MACE. The C-statistics of the clinical score for long-term (0.75) and 30-day (0.88) MACE were higher than with the TIMI(Thrombolysis In Myocardial Infarction) risk (0.68, 0.77) or GRACE(Global Registry of Acute Coronary Events) (0.50, 0.47) scores. Likewise, the negative predictive values of score = 0 (97.5%, 100%) and ≤1 point (95.9%, 100%) were higher than using undetectable hs-cTnT (91.9%, 98.1%). Both clinical scores of 0 and ≤1 better classified patients at risk of MACE (p = 0.0001, log-rank test) than hs-cTnT <5 ng/l (p = 0.06). In conclusion, clinical data can guide decision-making and perform at least equally well as undetectable hs-cTnT, in patients presenting at the emergency department with chest pain and normal hs-cTnT.
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Affiliation(s)
- Juan Sanchis
- Cardiology Department, Hospital Clinico Universitario, INCLIVA, Valencia, Spain; Department of Medicine, University of Valencia, Valencia, Spain.
| | - Sergio García-Blas
- Cardiology Department, Hospital Clinico Universitario, INCLIVA, Valencia, Spain; Department of Medicine, University of Valencia, Valencia, Spain
| | - Arturo Carratalá
- Clinical Biochemistry Department, Hospital Clinico Universitario, Valencia, Spain
| | - Ernesto Valero
- Cardiology Department, Hospital Clinico Universitario, INCLIVA, Valencia, Spain; Department of Medicine, University of Valencia, Valencia, Spain
| | - Anna Mollar
- Cardiology Department, Hospital Clinico Universitario, INCLIVA, Valencia, Spain; Department of Medicine, University of Valencia, Valencia, Spain
| | - Gema Miñana
- Cardiology Department, Hospital Clinico Universitario, INCLIVA, Valencia, Spain; Department of Medicine, University of Valencia, Valencia, Spain
| | - Vicente Ruiz
- Nursing School, Medicine Department, University of Valencia, Valencia, Spain
| | | | - Mercé Roqué
- Cardiology Department, Hospital Clinic, Barcelona, Spain
| | - Xavier Bosch
- Cardiology Department, Hospital Clinic, Barcelona, Spain
| | - Julio Núñez
- Cardiology Department, Hospital Clinico Universitario, INCLIVA, Valencia, Spain; Department of Medicine, University of Valencia, Valencia, Spain
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140
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The Potential Role of Combined Highly Sensitive Troponin and Coronary Computed Tomography Angiography in the Evaluation of Patients with Suspected Acute Coronary Syndrome in the Emergency Department. CURRENT CARDIOVASCULAR IMAGING REPORTS 2016. [DOI: 10.1007/s12410-016-9393-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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141
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Möckel M, Slagman A, Searle J. Biomarker strategies: the diagnostic and management process of patients with suspected AMI. Diagnosis (Berl) 2016. [PMID: 29536898 DOI: 10.1515/dx-2016-0026] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Security standards of our times largely exclude a discharge of patients with chest pain from the emergency departments (EDs) based on clinical assessment alone. Given the increasing use and consequently crowding of EDs worldwide and the large proportion of patients who present to the EDs with, however vague, signs and symptoms of acute coronary syndrome, there is a strong clinical and public health need to achieve a faster but safe rule-in and rule-out of acute myocardial infarction (AMI) to direct patients onto the correct management pathway. A number of approaches for a faster rule-in and rule-out of AMI are currently under research and evaluation and some have already been integrated into current guidelines and/or implemented into the clinical routine in selected centers. This article summarizes these different diagnostic strategies for patients with suspected AMI, using cardiac troponin alone or in combination with copeptin.
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Affiliation(s)
- Martin Möckel
- 1Division of Emergency Medicine/Chest Pain Units, Campus Virchow Klinikum and Campus Charité Mitte, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Anna Slagman
- 1Division of Emergency Medicine/Chest Pain Units, Campus Virchow Klinikum and Campus Charité Mitte, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Julia Searle
- 1Division of Emergency Medicine/Chest Pain Units, Campus Virchow Klinikum and Campus Charité Mitte, Charité - Universitätsmedizin Berlin, Berlin, Germany
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142
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Neumann JT, Sörensen NA, Ojeda F, Schwemer T, Lehmacher J, Gönner S, Jarsetz N, Keller T, Schaefer S, Renné T, Landmesser U, Clemmensen P, Makarova N, Schnabel RB, Zeller T, Karakas M, Pickering JW, Than M, Parsonage W, Greenslade J, Cullen L, Westermann D, Blankenberg S. Immediate Rule-Out of Acute Myocardial Infarction Using Electrocardiogram and Baseline High-Sensitivity Troponin I. Clin Chem 2016; 63:394-402. [PMID: 27903616 DOI: 10.1373/clinchem.2016.262659] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2016] [Accepted: 09/01/2016] [Indexed: 11/06/2022]
Abstract
AIMS Serial measurements of high-sensitivity troponin are used to rule out acute myocardial infarction (AMI) with an assay specific cutoff at the 99th percentile. Here, we evaluated the performance of a single admission troponin with a lower cutoff combined with a low risk electrocardiogram (ECG) to rule out AMI. METHODS Troponin I measured with a high-sensitivity assay (hs-TnI) was determined at admission in 1040 patients presenting with suspected AMI (BACC study). To rule out AMI we calculated the negative predictive value (NPV) utilizing the optimal hs-TnI cutoff combined with a low risk ECG. The results were validated in 3566 patients with suspected AMI [2-h Accelerated Diagnostic Protocol to Assess Patients With Chest Pain Symptoms Using Contemporary Troponins as the Only Biomarker (ADAPT) studies]. Patients were followed for 6 or 12 months. RESULTS 184 of all patients were diagnosed with AMI. An hs-TnI cutoff of 3 ng/L resulted in a NPV of 99.3% (CI 97.3-100.0), ruling out 35% of all non-AMI patients. Adding the information of a low risk ECG resulted in a 100% (CI 97.5-100.0) NPV (28% ruled out). The 2 validation cohorts replicated the high NPV of this approach. The follow-up mortality in the ruled out population was low (0 deaths in BACC and Stenocardia, 1 death in ADAPT). CONCLUSIONS A single hs-TnI measurement on admission combined with a low risk ECG appears to rule out AMI safely without need for serial troponin testing. TRIAL REGISTRATION www.clinicaltrials.gov (NCT02355457).
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Affiliation(s)
- Johannes Tobias Neumann
- Department of General and Interventional Cardiology, University Heart Center Hamburg Eppendorf, Hamburg, Germany; .,German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - Nils Arne Sörensen
- Department of General and Interventional Cardiology, University Heart Center Hamburg Eppendorf, Hamburg, Germany
| | - Francisco Ojeda
- Department of General and Interventional Cardiology, University Heart Center Hamburg Eppendorf, Hamburg, Germany
| | - Tjark Schwemer
- Department of General and Interventional Cardiology, University Heart Center Hamburg Eppendorf, Hamburg, Germany
| | - Jonas Lehmacher
- Department of General and Interventional Cardiology, University Heart Center Hamburg Eppendorf, Hamburg, Germany
| | - Saskia Gönner
- Department of General and Interventional Cardiology, University Heart Center Hamburg Eppendorf, Hamburg, Germany
| | - Nikolas Jarsetz
- Department of General and Interventional Cardiology, University Heart Center Hamburg Eppendorf, Hamburg, Germany
| | - Till Keller
- Department of Cardiology, Johann Wolfgang Goethe University Hospital, Frankfurt/Main, Germany
| | - Sarina Schaefer
- Department of General and Interventional Cardiology, University Heart Center Hamburg Eppendorf, Hamburg, Germany.,German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - Thomas Renné
- Institute of Clinical Chemistry and Laboratory Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany and Clinical Chemistry, Department of Molecular Medicine and Surgery, Karolinska Institute, Stockholm, Sweden
| | - Ulf Landmesser
- Department of Cardiology, Charite Universitätsmedizin Berlin, Campus Benjamin Franklin, Berlin, Germany
| | - Peter Clemmensen
- Department of General and Interventional Cardiology, University Heart Center Hamburg Eppendorf, Hamburg, Germany.,Department of Medicine, Nykoebing F Hospital, University of Southern Denmark, Odense, Denmark
| | - Nataliya Makarova
- Department of General and Interventional Cardiology, University Heart Center Hamburg Eppendorf, Hamburg, Germany.,German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - Renate B Schnabel
- Department of General and Interventional Cardiology, University Heart Center Hamburg Eppendorf, Hamburg, Germany.,German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - Tanja Zeller
- Department of General and Interventional Cardiology, University Heart Center Hamburg Eppendorf, Hamburg, Germany.,German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - Mahir Karakas
- Department of General and Interventional Cardiology, University Heart Center Hamburg Eppendorf, Hamburg, Germany.,German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - John W Pickering
- Emergency Department, Christchurch Hospital, Christchurch, New Zealand
| | - Martin Than
- Emergency Department, Christchurch Hospital, Christchurch, New Zealand
| | - William Parsonage
- Department of Emergency Medicine, Royal Brisbane and Women's Hospital, Brisbane, Australia
| | - Jaimi Greenslade
- Department of Emergency Medicine, Royal Brisbane and Women's Hospital, Brisbane, Australia
| | - Louise Cullen
- Department of Emergency Medicine, Royal Brisbane and Women's Hospital, Brisbane, Australia
| | - Dirk Westermann
- Department of General and Interventional Cardiology, University Heart Center Hamburg Eppendorf, Hamburg, Germany.,German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - Stefan Blankenberg
- Department of General and Interventional Cardiology, University Heart Center Hamburg Eppendorf, Hamburg, Germany.,German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany
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143
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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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144
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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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145
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Body R, Reynard C. One Shot to Rule Out: Does the Limit of Detection of a High-Sensitivity Troponin Assay Hit the Mark? Clin Chem 2016; 63:21-23. [PMID: 27864385 DOI: 10.1373/clinchem.2016.266460] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2016] [Accepted: 11/01/2016] [Indexed: 11/06/2022]
Affiliation(s)
- Richard Body
- Cardiovascular Sciences Research Group, The University of Manchester, Manchester, UK; .,Emergency Department, Central Manchester University Hospitals Foundation NHS Trust, Manchester, UK.,Healthcare Sciences Research Group, Manchester Metropolitan University, Manchester, UK
| | - Charles Reynard
- Emergency Department, Central Manchester University Hospitals Foundation NHS Trust, Manchester, UK
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Wildi K, Nelles B, Twerenbold R, Rubini Giménez M, Reichlin T, Singeisen H, Druey S, Haaf P, Sabti Z, Hillinger P, Jaeger C, Campodarve I, Kreutzinger P, Puelacher C, Moreno Weidmann Z, Gugala M, Pretre G, Doerflinger S, Wagener M, Stallone F, Freese M, Stelzig C, Rentsch K, Bassetti S, Bingisser R, Osswald S, Mueller C. Safety and efficacy of the 0 h/3 h protocol for rapid rule out of myocardial infarction. Am Heart J 2016; 181:16-25. [PMID: 27823689 DOI: 10.1016/j.ahj.2016.07.013] [Citation(s) in RCA: 58] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2015] [Accepted: 07/20/2016] [Indexed: 12/22/2022]
Abstract
BACKGROUND The early and accurate diagnosis of acute myocardial infarction (AMI) is an important medical and economic challenge. We aimed to prospectively evaluate the performance of the new European Society of Cardiology rapid 0-hour/3-hour (0 h/3 h) rule out protocol for AMI. METHODS We enrolled 2,727 consecutive patients presenting with suspected AMI without persistent ST-segment elevation to the emergency department in a prospective international multicenter study. The final diagnosis was adjudicated by 2 independent cardiologists. The performance of the 0 h/3 h rule out protocol was evaluated using 4 high-sensitivity (primary analysis) and 3 sensitive cardiac troponin (cTn) assays. RESULTS Acute myocardial infarction was the final diagnosis in 473 patients (17.3%). Using the 4 high-sensitivity cTn assays, the 0-hour rule out protocol correctly ruled out 99.8% (95% [confidence interval] CI, 98.7%-100%), 99.6% (95% CI, 98.5%-99.9%), 100% (95% CI, 97.9%-100%), and 100% (95% CI, 98.0%-100%) of late presenters (>6 h from chest pain onset). The 3-hour rule out protocol correctly ruled out 99.9% (95% CI, 99.1%-100%), 99.5% (95% CI, 98.3%-99.9%), 100% (95% CI, 98.1%-100%), and 100% (95% CI, 98.2%-100%) of early presenters (<6 h from chest pain onset). Using the 3 sensitive cTn assays, the 0-hour rule out protocol correctly ruled out 99.6% (95% CI, 98.6%-99.9%), 99.0% (95% CI, 96.9%-99.7%), and 99.1% (95% CI, 97.2%-99.8%) of late presenters; and the 3-hour rule out protocol correctly ruled out 99.4% (95% CI, 98.3%-99.8%), 99.2% (95% CI, 97.3%-99.8%), and 99.0% (95% CI, 97.2%-99.7%) of early presenters. Overall, the 0 h/3 h rule out protocol assigned 40% to 60% of patients to rule out. None of the patients assigned rule out died during 3-months follow-up. CONCLUSIONS The 0 h/3 h rule out protocol seems to allow the accurate rule out of AMI using both high-sensitivity and sensitive cTn measurements in conjunction with clinical assessment. Additional studies are warranted for external validation.
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Affiliation(s)
- Karin Wildi
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Basel, Switzerland; Department of Internal Medicine, University Hospital, Basel, Switzerland; Department of Intensive Care, University Hospital Basel, Basel, Switzerland
| | - Berit Nelles
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Basel, Switzerland; Department of Internal Medicine, University Hospital, Basel, Switzerland
| | - Raphael Twerenbold
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Basel, Switzerland
| | - Maria Rubini Giménez
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Basel, Switzerland; Department of Internal Medicine, University Hospital, Basel, Switzerland; Servicio de Urgencias y Pneumologia, CIBERES ISC III, Hospital del Mar-Institut Municipal d'Investigació Mèdica, Barcelona, Spain
| | - Tobias Reichlin
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Basel, Switzerland
| | - Hélène Singeisen
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Basel, Switzerland
| | - Sophie Druey
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Basel, Switzerland
| | - Philip Haaf
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Basel, Switzerland
| | - Zaid Sabti
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Basel, Switzerland
| | - Petra Hillinger
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Basel, Switzerland
| | - Cedric Jaeger
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Basel, Switzerland
| | - Isabel Campodarve
- Servicio de Urgencias y Pneumologia, CIBERES ISC III, Hospital del Mar-Institut Municipal d'Investigació Mèdica, Barcelona, Spain
| | - Philip Kreutzinger
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Basel, Switzerland
| | - Christian Puelacher
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Basel, Switzerland
| | - Zoraida Moreno Weidmann
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Basel, Switzerland
| | - Mathias Gugala
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Basel, Switzerland
| | - Gilles Pretre
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Basel, Switzerland
| | - Stephanie Doerflinger
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Basel, Switzerland
| | - Max Wagener
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Basel, Switzerland
| | - Fabio Stallone
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Basel, Switzerland
| | - Michael Freese
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Basel, Switzerland
| | - Claudia Stelzig
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Basel, Switzerland
| | | | | | | | - Stefan Osswald
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Basel, Switzerland
| | - Christian Mueller
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Basel, Switzerland.
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147
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Nallet O, Ketata N, Ferrier N, Marcaggi X. [Fast track chest pain pathway in emergency department]. Ann Cardiol Angeiol (Paris) 2016; 65:326-329. [PMID: 27693165 DOI: 10.1016/j.ancard.2016.09.001] [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: 08/12/2016] [Accepted: 09/02/2016] [Indexed: 06/06/2023]
Abstract
Acute chest pain is a common reason of consultation in the emergency department. The difficulty lies in discriminating patients with acute coronary syndrome or other life-threatening conditions from those non-cardiovascular, non-life-threatening chest pain. Only 15 to 25 % of patients with acute chest pain actually have acute coronary syndrome. Algorithms using high sensitivity troponin at admission and a second assessment 1 or 3hours later are validated to "rule in" or "rule out" the diagnosis of non ST-elevation myocardial infarction. This may reduce the delay for the diagnosis translating into shorter stay in the emergency department. Those algorithms must be interpreted in the context of clinical and ECG criteria.
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Affiliation(s)
- O Nallet
- Service de cardiologie, centre hospitalier Le Raincy-Montfermeil, rue du Général-Leclerc, 93370 Montfermeil, France.
| | - N Ketata
- Service de cardiologie, centre hospitalier de Vichy, 03200 Vichy, France
| | - N Ferrier
- Service de cardiologie, centre hospitalier de Vichy, 03200 Vichy, France
| | - X Marcaggi
- Service de cardiologie, centre hospitalier de Vichy, 03200 Vichy, France
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148
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Vakili H, Sadeghi R, Toofaninejad N, SadeAkbarighi T, Kachoueian N. One- and Six-month Outcomes of Patients with Non-ST Elevation Myocardial Infarction. INTERNATIONAL JOURNAL OF CARDIOVASCULAR PRACTICE 2016. [DOI: 10.21859/ijcp-010303] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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149
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Cardiac troponin I exacerbates myocardial ischaemia/reperfusion injury by inducing the adhesion of monocytes to vascular endothelial cells via a TLR4/NF-κB-dependent pathway. Clin Sci (Lond) 2016; 130:2279-2293. [PMID: 27682003 DOI: 10.1042/cs20160373] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2016] [Revised: 06/29/2016] [Accepted: 09/28/2016] [Indexed: 12/20/2022]
Abstract
Cardiac troponin I (cTnI), a biomarker for myocardial damage and risk stratification, may be involved in the pathogenesis of cardiovascular diseases, which was ascribed to the effect of cTnI auto-antibodies. Whether or not cTnI itself has a direct impact on acute myocardial injury is unknown. To exclude the influence of cTnI antibody on the cardiac infarct size, we studied the effect of cTnI shortly after myocardial ischaemia-reperfusion (I/R) injury when cTnI antibodies were not elevated. Pretreatment with cTnI augmented the myocardial infarct size caused by I/R, accompanied by an increase in inflammatory markers in the blood and myocardium. Additional experiments using human umbilical vein endothelial cells (HUVECs) showed that the detrimental effect of cTnI was related to cTnI-induced increase in vascular cell adhesion molecule-1 (VCAM-1) expression and VCAM-1 mediated adhesion of human monocytes (THP-1) to HUVECs, which could be neutralized by VCAM-1 antibody. Both toll-like receptor 4 (TLR4) and nuclear factor-κB (NF-κB) were involved in the signalling pathway, because blockade of either TLR4 or NF-κB inhibited the cTnI's effect on VCAM-1 expression and adhesion of monocytes to endothelial cells. Moreover, TLR4 inhibition reduced cTnI-augmented cardiac injury in rats with I/R injury. We conclude that cTnI exacerbates myocardial I/R injury by inducing the adhesion of monocytes to vascular endothelial cells via activation of the TLR4/NF-κB pathway. Inhibition of TLR4 may be an alternative strategy to reduce cTnI-induced myocardial I/R injury.
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150
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Body R, Carlton E, Sperrin M, Lewis PS, Burrows G, Carley S, McDowell G, Buchan I, Greaves K, Mackway-Jones K. Troponin-only Manchester Acute Coronary Syndromes (T-MACS) decision aid: single biomarker re-derivation and external validation in three cohorts. Emerg Med J 2016; 34:349-356. [PMID: 27565197 PMCID: PMC5502241 DOI: 10.1136/emermed-2016-205983] [Citation(s) in RCA: 68] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2016] [Revised: 06/27/2016] [Accepted: 07/05/2016] [Indexed: 12/27/2022]
Abstract
Background The original Manchester Acute Coronary Syndromes model (MACS) ‘rules in’ and ‘rules out’ acute coronary syndromes (ACS) using high sensitivity cardiac troponin T (hs-cTnT) and heart-type fatty acid binding protein (H-FABP) measured at admission. The latter is not always available. We aimed to refine and validate MACS as Troponin-only Manchester Acute Coronary Syndromes (T-MACS), cutting down the biomarkers to just hs-cTnT. Methods We present secondary analyses from four prospective diagnostic cohort studies including patients presenting to the ED with suspected ACS. Data were collected and hs-cTnT measured on arrival. The primary outcome was ACS, defined as prevalent acute myocardial infarction (AMI) or incident death, AMI or coronary revascularisation within 30 days. T-MACS was built in one cohort (derivation set) and validated in three external cohorts (validation set). Results At the ‘rule out’ threshold, in the derivation set (n=703), T-MACS had 99.3% (95% CI 97.3% to 99.9%) negative predictive value (NPV) and 98.7% (95.3%–99.8%) sensitivity for ACS, ‘ruling out’ 37.7% patients (specificity 47.6%, positive predictive value (PPV) 34.0%). In the validation set (n=1459), T-MACS had 99.3% (98.3%–99.8%) NPV and 98.1% (95.2%–99.5%) sensitivity, ‘ruling out’ 40.4% (n=590) patients (specificity 47.0%, PPV 23.9%). T-MACS would ‘rule in’ 10.1% and 4.7% patients in the respective sets, of which 100.0% and 91.3% had ACS. C-statistics for the original and refined rules were similar (T-MACS 0.91 vs MACS 0.90 on validation). Conclusions T-MACS could ‘rule out’ ACS in 40% of patients, while ‘ruling in’ 5% at highest risk using a single hs-cTnT measurement on arrival. As a clinical decision aid, T-MACS could therefore help to conserve healthcare resources.
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Affiliation(s)
- Richard Body
- Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK.,Emergency Department,Central Manchester University Hospitals Foundation NHS Trust, Manchester, UK
| | - Edward Carlton
- Emergency Department, North Bristol NHS Trust, Southmead Hospital, Bristol, UK
| | - Matthew Sperrin
- Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK
| | - Philip S Lewis
- Cardiology Department, Stockport NHS Foundation Trust, Stockport, UK
| | - Gillian Burrows
- Biochemistry Department, Stockport NHS Foundation Trust, Stockport, UK
| | - Simon Carley
- Emergency Department,Central Manchester University Hospitals Foundation NHS Trust, Manchester, UK.,School of Healthcare Science, Manchester Metropolitan University, Manchester, UK
| | - Garry McDowell
- Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK.,School of Healthcare Science, Manchester Metropolitan University, Manchester, UK
| | - Iain Buchan
- Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK
| | - Kim Greaves
- Department of Cardiology, Sunshine Coast Hospital and Health Services, University of the Sunshine Coast, Nambour, Australia
| | - Kevin Mackway-Jones
- Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK.,Emergency Department,Central Manchester University Hospitals Foundation NHS Trust, Manchester, UK.,School of Healthcare Science, Manchester Metropolitan University, Manchester, UK
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