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Odqvist M, Andersson PO, Tygesen H, Eggers KM, Holzmann MJ. High-Sensitivity Troponins and Outcomes After Myocardial Infarction. J Am Coll Cardiol 2018; 71:2616-2624. [DOI: 10.1016/j.jacc.2018.03.515] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2018] [Revised: 02/12/2018] [Accepted: 03/06/2018] [Indexed: 10/14/2022]
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Summers SM, Long B, April MD, Koyfman A, Hunter CJ. High sensitivity troponin: The Sisyphean pursuit of zero percent miss rate for acute coronary syndrome in the ED. Am J Emerg Med 2018; 36:1088-1097. [DOI: 10.1016/j.ajem.2018.03.075] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2018] [Revised: 03/22/2018] [Accepted: 03/28/2018] [Indexed: 10/17/2022] Open
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Kavsak PA, Andruchow JE, McRae AD, Worster A. Profile of Roche’s Elecsys Troponin T Gen 5 STAT blood test (a high-sensitivity cardiac troponin assay) for diagnosing myocardial infarction in the emergency department. Expert Rev Mol Diagn 2018; 18:481-489. [DOI: 10.1080/14737159.2018.1476141] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Affiliation(s)
- Peter A. Kavsak
- Department of Pathology and Molecular Medicine, McMaster University, Hamilton, Ontario, Canada
| | - James E. Andruchow
- Department of Emergency Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Andrew D. McRae
- Department of Emergency Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Andrew Worster
- Division of Emergency Medicine, McMaster University, Hamilton, Ontario, Canada
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Giannitsis E, Katus HA. Troponins: established and novel indications in the management of cardiovascular disease. Heart 2018; 104:1714-1722. [PMID: 29724751 DOI: 10.1136/heartjnl-2017-311387] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Affiliation(s)
| | - Hugo A Katus
- Medizinische Klinik III, University of Heidelberg, Heidelberg, Germany
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Greenslade J, Cho E, Van Hise C, Hawkins T, Parsonage W, Ungerer J, Tate J, Pretorius C, Than M, Cullen L. Evaluating Rapid Rule-out of Acute Myocardial Infarction Using a High-Sensitivity Cardiac Troponin I Assay at Presentation. Clin Chem 2018; 64:820-829. [DOI: 10.1373/clinchem.2017.283887] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2017] [Accepted: 01/16/2018] [Indexed: 12/12/2022]
Abstract
Abstract
BACKGROUND
Low concentrations of cardiac troponin (cTn) have been recommended for rapid rule-out of acute myocardial infarction (AMI). We examined the Beckman Coulter Access high-sensitivity cardiac troponin I (hs-cTnI) assay to identify a single test threshold that can safely rule out AMI.
METHODS
This analysis used stored samples collected in 2 prospective observational studies. In all, 1871 patients presenting to a tertiary emergency department with symptoms of acute coronary syndrome had blood taken for measurement of cTnI on presentation. The endpoint was type 1 myocardial infarction (T1MI). Sensitivity and negative predictive value (NPV) were calculated for hs-cTnI values below the 99th percentile.
RESULTS
Ninety-eight patients had T1MI (5.2%), and 638 (34.1%) patients had an hs-cTnI <2 ng/L (limit of detection), with sensitivity of 99.0% (95% CI, 94.4%–100%) and NPV of 99.8% (95% CI, 99.1%–100%). No hs-cTnI value above a concentration of 2 ng/L achieved sensitivity of 99%. However, an NPV of 99.5% was achieved at values <6 ng/L. A cutoff <6 ng/L enabled 1475 (78.8%) patients to be ruled out on presentation with sensitivity of 93.9% (95% CI, 87.1%–97.7%).
CONCLUSIONS
A single baseline cTn <2 ng/L measured with the Access hs-cTnI assay performed well for rule-out of AMI. This cutoff concentration identified 99% of patients with AMI and could reduce the number of patients requiring lengthy assessment. A cutoff of <6 ng/L yielded a high NPV but missed more cases of AMI than would be acceptable to clinicians.
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Affiliation(s)
- Jaimi Greenslade
- Royal Brisbane and Women's Hospital, Herston, Australia
- Faculty of Medicine, The University of Queensland, Brisbane, Australia
| | - Elizabeth Cho
- Faculty of Medicine, The University of Queensland, Brisbane, Australia
| | | | | | - William Parsonage
- Royal Brisbane and Women's Hospital, Herston, Australia
- Faculty of Medicine, The University of Queensland, Brisbane, Australia
- Faculty of Health, Queensland University of Technology, Brisbane, Australia
| | | | | | | | - Martin Than
- Christchurch Hospital, Christchurch, New Zealand
| | - Louise Cullen
- Royal Brisbane and Women's Hospital, Herston, Australia
- Faculty of Medicine, The University of Queensland, Brisbane, Australia
- Faculty of Health, Queensland University of Technology, Brisbane, Australia
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106
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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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Van Hise CB, Greenslade JH, Parsonage W, Than M, Young J, Cullen L. External validation of heart-type fatty acid binding protein, high-sensitivity cardiac troponin, and electrocardiography as rule-out for acute myocardial infarction. Clin Biochem 2018; 52:161-163. [DOI: 10.1016/j.clinbiochem.2017.10.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2017] [Revised: 09/14/2017] [Accepted: 10/02/2017] [Indexed: 10/18/2022]
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108
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Twerenbold R, Badertscher P, Boeddinghaus J, Nestelberger T, Wildi K, Puelacher C, Sabti Z, Rubini Gimenez M, Tschirky S, du Fay de Lavallaz J, Kozhuharov N, Sazgary L, Mueller D, Breidthardt T, Strebel I, Flores Widmer D, Shrestha S, Miró Ò, Martín-Sánchez FJ, Morawiec B, Parenica J, Geigy N, Keller DI, Rentsch K, von Eckardstein A, Osswald S, Reichlin T, Mueller C. 0/1-Hour Triage Algorithm for Myocardial Infarction in Patients With Renal Dysfunction. Circulation 2018; 137:436-451. [PMID: 29101287 PMCID: PMC5794234 DOI: 10.1161/circulationaha.117.028901] [Citation(s) in RCA: 105] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2017] [Accepted: 10/19/2017] [Indexed: 12/12/2022]
Abstract
BACKGROUND The European Society of Cardiology recommends a 0/1-hour algorithm for rapid rule-out and rule-in of non-ST-segment elevation myocardial infarction using high-sensitivity cardiac troponin (hs-cTn) concentrations irrespective of renal function. Because patients with renal dysfunction (RD) frequently present with increased hs-cTn concentrations even in the absence of non-ST-segment elevation myocardial infarction, concern has been raised regarding the performance of the 0/1-hour algorithm in RD. METHODS In a prospective multicenter diagnostic study enrolling unselected patients presenting with suspected non-ST-segment elevation myocardial infarction to the emergency department, we assessed the diagnostic performance of the European Society of Cardiology 0/1-hour algorithm using hs-cTnT and hs-cTnI in patients with RD, defined as an estimated glomerular filtration rate <60 mL/min/1.73 m2, and compared it to patients with normal renal function. The final diagnosis was centrally adjudicated by 2 independent cardiologists using all available information, including cardiac imaging. Safety was quantified as sensitivity in the rule-out zone, accuracy as the specificity in the rule-in zone, and efficacy as the proportion of the overall cohort assigned to either rule-out or rule-in based on the 0- and 1-hour sample. RESULTS Among 3254 patients, RD was present in 487 patients (15%). The prevalence of non-ST-segment elevation myocardial infarction was substantially higher in patients with RD compared with patients with normal renal function (31% versus 13%, P<0.001). Using hs-cTnT, patients with RD had comparable sensitivity of rule-out (100.0% [95% confidence interval {CI}, 97.6-100.0] versus 99.2% [95% CI, 97.6-99.8]; P=0.559), lower specificity of rule-in (88.7% [95% CI, 84.8-91.9] versus 96.5% [95% CI, 95.7-97.2]; P<0.001), and lower overall efficacy (51% versus 81%, P<0.001), mainly driven by a much lower percentage of patients eligible for rule-out (18% versus 68%, P<0.001) compared with patients with normal renal function. Using hs-cTnI, patients with RD had comparable sensitivity of rule-out (98.6% [95% CI, 95.0-99.8] versus 98.5% [95% CI, 96.5-99.5]; P=1.0), lower specificity of rule-in (84.4% [95% CI, 79.9-88.3] versus 91.7% [95% CI, 90.5-92.9]; P<0.001), and lower overall efficacy (54% versus 76%, P<0.001; proportion ruled out, 18% versus 58%, P<0.001) compared with patients with normal renal function. CONCLUSIONS In patients with RD, the safety of the European Society of Cardiology 0/1-hour algorithm is high, but specificity of rule-in and overall efficacy are decreased. Modifications of the rule-in and rule-out thresholds did not improve the safety or overall efficacy of the 0/1-hour algorithm. CLINICAL TRIAL REGISTRATION URL: https://www.clinicaltrials.gov. Unique identifier: NCT00470587.
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Affiliation(s)
- Raphael Twerenbold
- Cardiovascular Research Institute Basel and Department of Cardiology, University Hospital Basel, University of Basel, Switzerland (R.T., P.B., J.B., T.N., K.W., C.P., Z.S., M.R.G., S.T., J.d.F.d.L., N.K., L.S., D.M., T.B., I.S., D.F.W., S.S., S.O., T.R., C.M.)
- Department of General and Interventional Cardiology, University Heart Center Hamburg, University Hospital Hamburg-Eppendorf, Germany (R.T.)
| | - Patrick Badertscher
- Cardiovascular Research Institute Basel and Department of Cardiology, University Hospital Basel, University of Basel, Switzerland (R.T., P.B., J.B., T.N., K.W., C.P., Z.S., M.R.G., S.T., J.d.F.d.L., N.K., L.S., D.M., T.B., I.S., D.F.W., S.S., S.O., T.R., C.M.)
| | - Jasper Boeddinghaus
- Cardiovascular Research Institute Basel and Department of Cardiology, University Hospital Basel, University of Basel, Switzerland (R.T., P.B., J.B., T.N., K.W., C.P., Z.S., M.R.G., S.T., J.d.F.d.L., N.K., L.S., D.M., T.B., I.S., D.F.W., S.S., S.O., T.R., C.M.)
| | - Thomas Nestelberger
- Cardiovascular Research Institute Basel and Department of Cardiology, University Hospital Basel, University of Basel, Switzerland (R.T., P.B., J.B., T.N., K.W., C.P., Z.S., M.R.G., S.T., J.d.F.d.L., N.K., L.S., D.M., T.B., I.S., D.F.W., S.S., S.O., T.R., C.M.)
| | - Karin Wildi
- Cardiovascular Research Institute Basel and Department of Cardiology, University Hospital Basel, University of Basel, Switzerland (R.T., P.B., J.B., T.N., K.W., C.P., Z.S., M.R.G., S.T., J.d.F.d.L., N.K., L.S., D.M., T.B., I.S., D.F.W., S.S., S.O., T.R., C.M.)
| | - Christian Puelacher
- Cardiovascular Research Institute Basel and Department of Cardiology, University Hospital Basel, University of Basel, Switzerland (R.T., P.B., J.B., T.N., K.W., C.P., Z.S., M.R.G., S.T., J.d.F.d.L., N.K., L.S., D.M., T.B., I.S., D.F.W., S.S., S.O., T.R., C.M.)
| | - Zaid Sabti
- Cardiovascular Research Institute Basel and Department of Cardiology, University Hospital Basel, University of Basel, Switzerland (R.T., P.B., J.B., T.N., K.W., C.P., Z.S., M.R.G., S.T., J.d.F.d.L., N.K., L.S., D.M., T.B., I.S., D.F.W., S.S., S.O., T.R., C.M.)
| | - Maria Rubini Gimenez
- Cardiovascular Research Institute Basel and Department of Cardiology, University Hospital Basel, University of Basel, Switzerland (R.T., P.B., J.B., T.N., K.W., C.P., Z.S., M.R.G., S.T., J.d.F.d.L., N.K., L.S., D.M., T.B., I.S., D.F.W., S.S., S.O., T.R., C.M.)
| | - Sandra Tschirky
- Cardiovascular Research Institute Basel and Department of Cardiology, University Hospital Basel, University of Basel, Switzerland (R.T., P.B., J.B., T.N., K.W., C.P., Z.S., M.R.G., S.T., J.d.F.d.L., N.K., L.S., D.M., T.B., I.S., D.F.W., S.S., S.O., T.R., C.M.)
| | - Jeanne du Fay de Lavallaz
- Cardiovascular Research Institute Basel and Department of Cardiology, University Hospital Basel, University of Basel, Switzerland (R.T., P.B., J.B., T.N., K.W., C.P., Z.S., M.R.G., S.T., J.d.F.d.L., N.K., L.S., D.M., T.B., I.S., D.F.W., S.S., S.O., T.R., C.M.)
| | - Nikola Kozhuharov
- Cardiovascular Research Institute Basel and Department of Cardiology, University Hospital Basel, University of Basel, Switzerland (R.T., P.B., J.B., T.N., K.W., C.P., Z.S., M.R.G., S.T., J.d.F.d.L., N.K., L.S., D.M., T.B., I.S., D.F.W., S.S., S.O., T.R., C.M.)
| | - Lorraine Sazgary
- Cardiovascular Research Institute Basel and Department of Cardiology, University Hospital Basel, University of Basel, Switzerland (R.T., P.B., J.B., T.N., K.W., C.P., Z.S., M.R.G., S.T., J.d.F.d.L., N.K., L.S., D.M., T.B., I.S., D.F.W., S.S., S.O., T.R., C.M.)
| | - Deborah Mueller
- Cardiovascular Research Institute Basel and Department of Cardiology, University Hospital Basel, University of Basel, Switzerland (R.T., P.B., J.B., T.N., K.W., C.P., Z.S., M.R.G., S.T., J.d.F.d.L., N.K., L.S., D.M., T.B., I.S., D.F.W., S.S., S.O., T.R., C.M.)
| | - Tobias Breidthardt
- Cardiovascular Research Institute Basel and Department of Cardiology, University Hospital Basel, University of Basel, Switzerland (R.T., P.B., J.B., T.N., K.W., C.P., Z.S., M.R.G., S.T., J.d.F.d.L., N.K., L.S., D.M., T.B., I.S., D.F.W., S.S., S.O., T.R., C.M.)
| | - Ivo Strebel
- Cardiovascular Research Institute Basel and Department of Cardiology, University Hospital Basel, University of Basel, Switzerland (R.T., P.B., J.B., T.N., K.W., C.P., Z.S., M.R.G., S.T., J.d.F.d.L., N.K., L.S., D.M., T.B., I.S., D.F.W., S.S., S.O., T.R., C.M.)
| | - Dayana Flores Widmer
- Cardiovascular Research Institute Basel and Department of Cardiology, University Hospital Basel, University of Basel, Switzerland (R.T., P.B., J.B., T.N., K.W., C.P., Z.S., M.R.G., S.T., J.d.F.d.L., N.K., L.S., D.M., T.B., I.S., D.F.W., S.S., S.O., T.R., C.M.)
| | - Samyut Shrestha
- Cardiovascular Research Institute Basel and Department of Cardiology, University Hospital Basel, University of Basel, Switzerland (R.T., P.B., J.B., T.N., K.W., C.P., Z.S., M.R.G., S.T., J.d.F.d.L., N.K., L.S., D.M., T.B., I.S., D.F.W., S.S., S.O., T.R., C.M.)
| | - Òscar Miró
- Emergency Department, Hospital Clinic, Barcelona, Spain (O.M.)
| | | | - Beata Morawiec
- 2nd Cardiology Department, Zabrze, University Silesia, Katowice, Poland (B.M.)
| | - Jiri Parenica
- Department of Cardiology, University Hospital Brno, Czech Republic (J.P.)
- Medical Faculty, Masaryk University, Brno, Czech Republic (J.P.)
| | - Nicolas Geigy
- Emergency Department, Kantonsspital Liestal, Switzerland (N.G.)
| | - Dagmar I Keller
- Emergency Department, University Hospital Zürich, Switzerland (D.I.K.)
| | - Katharina Rentsch
- Department of Laboratory Medicine, University Hospital Basel, Switzerland (K.R.)
| | | | - Stefan Osswald
- Cardiovascular Research Institute Basel and Department of Cardiology, University Hospital Basel, University of Basel, Switzerland (R.T., P.B., J.B., T.N., K.W., C.P., Z.S., M.R.G., S.T., J.d.F.d.L., N.K., L.S., D.M., T.B., I.S., D.F.W., S.S., S.O., T.R., C.M.)
| | - Tobias Reichlin
- Cardiovascular Research Institute Basel and Department of Cardiology, University Hospital Basel, University of Basel, Switzerland (R.T., P.B., J.B., T.N., K.W., C.P., Z.S., M.R.G., S.T., J.d.F.d.L., N.K., L.S., D.M., T.B., I.S., D.F.W., S.S., S.O., T.R., C.M.)
| | - Christian Mueller
- Cardiovascular Research Institute Basel and Department of Cardiology, University Hospital Basel, University of Basel, Switzerland (R.T., P.B., J.B., T.N., K.W., C.P., Z.S., M.R.G., S.T., J.d.F.d.L., N.K., L.S., D.M., T.B., I.S., D.F.W., S.S., S.O., T.R., C.M.)
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Alquézar-Arbé A, Sionis A, Ordoñez-Llanos J. Cardiac troponins: 25 years on the stage and still improving their clinical value. Crit Rev Clin Lab Sci 2017; 54:551-571. [PMID: 29226754 DOI: 10.1080/10408363.2017.1410777] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Twenty-five years ago, non-isotopic immunoassays for measuring the cardiac specific isoforms of troponin I (cTnI) and T (cTnT) were developed. Both biomarkers radically changed the diagnosis, prognosis, and therapy indication of acute coronary syndromes (ACS) and, particularly, of myocardial infarction (MI). However, cardiac troponins (cTn) rapidly demonstrated their usefulness in other cardiac and non-cardiac conditions, a part of the ischemic coronary diseases. Consequently, the number of patients to be tested for cTn and the number of tests requested to clinical laboratories sharply increased. Though the manufacturers continuously improved the analytical characteristics of the first cTn assays and produced different cTn assay "generations", the universal definition of myocardial infarction required less-than-available analytical imprecision at the cTn concentration used to assess MI (i.e. the 99th reference percentile). To address the clinical requirements, manufacturers developed the high-sensitivity cTn (hs-cTn) assays that allow to measure the 99th reference percentile with adequate precision, to detect cTn in many healthy subjects and, hence, to calculate the hs-cTn biological variation and especially to observe in very short time intervals serial differences in hs-cTn attributable to cardiac ischemia. Since the number of patients attending the emergency departments (ED) for a suspected ACS or MI is increasing, the improved properties of hs-cTn assays, allowing faster and safer patient assessment, will help to alleviate the sometimes overcrowded EDs. However, there are many biological, analytical, and clinical factors that can influence the true hs-cTn values of a patient. Clinicians and laboratory professionals should know about them for the best interpretation of the otherwise largely useful hs-cTn measurements. In conclusion, 25 years after their introduction for clinical use, "cTn are still on the stage and improving their clinical value".
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Affiliation(s)
| | - Alessandro Sionis
- b Cardiology Department, Acute and Intensive Cardiac Care Unit, IIB-Sant Pau, CIBER-CV , Hospital de la Santa Creu i Sant Pau , Barcelona , Spain.,c Faculty of Medicine , Universitat de Barcelona , Barcelona , Spain
| | - Jorge Ordoñez-Llanos
- d Clinical Biochemistry Department , Hospital de la Santa Creu i Sant Pau, IIB-Sant Pau , Barcelona , Spain.,e Biochemistry and Molecular Biology Department , Universitat Autònoma , Barcelona , Spain.,f Task Force on Clinical Application of Cardiac Biomarkers , International Federation of Clinical Chemistry , Milan , Italy
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110
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Marjot J, Kaier TE, Henderson K, Hunter L, Marber MS, Perera D. A single centre prospective cohort study addressing the effect of a rule-in/rule-out troponin algorithm on routine clinical practice. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2017; 8:404-411. [PMID: 29199434 PMCID: PMC6691597 DOI: 10.1177/2048872617746850] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
AIMS In 2015, the European Society of Cardiology introduced new guidelines for the diagnosis of acute coronary syndromes in patients presenting without persistent ST-segment elevation. These guidelines included the use of high-sensitivity troponin assays for 'rule-in' and 'rule-out' of acute myocardial injury at presentation (using a '0 hour' blood test). Whilst these algorithms have been extensively validated in prospective diagnostic studies, the outcome of their implementation in routine clinical practice has not been described. The present study describes the change in the patient journey resulting from implementation of such an algorithm in a busy innercity Emergency Department. METHODS AND RESULTS Data were prospectively collected from electronic records at a large Central London hospital over seven months spanning the periods before, during and after the introduction of a new high-sensitivity troponin rapid diagnostic algorithm modelled on the European Society of Cardiology guideline. Over 213 days, 4644 patients had high-sensitivity troponin T measured in the Emergency Department. Of these patients, 40.4% could be 'ruled-out' based on the high-sensitivity troponin T concentration at presentation, whilst 7.6% could be 'ruled-in'. Adoption of the algorithm into clinical practice was associated with a 37.5% increase of repeat high-sensitivity troponin T measurements within 1.5 h for those patients classified as 'intermediate risk' on presentation. CONCLUSIONS Introduction of a 0 hour 'rule-in' and 'rule-out' algorithm in routine clinical practice enables rapid triage of 48% of patients, and is associated with more rapid repeat testing in intermediate risk patients.
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Affiliation(s)
- Jack Marjot
- King’s College London BHF Centre, St Thomas’ Hospital, London, UK
| | - Thomas E Kaier
- King’s College London BHF Centre, St Thomas’ Hospital, London, UK
| | | | - Laura Hunter
- Emergency Department, St Thomas’ Hospital London, UK
| | - Michael S Marber
- King’s College London BHF Centre, St Thomas’ Hospital, London, UK
| | - Divaka Perera
- King’s College London BHF Centre, St Thomas’ Hospital, London, UK
- Divaka Perera, The Rayne Institute, 4th Floor Lambeth Wing, St Thomas’ Hospital, Westminster Bridge Road, London, SE1 7EH, UK.
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111
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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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Sandoval Y, Jaffe AS. Using High-Sensitivity Cardiac Troponin T for Acute Cardiac Care. Am J Med 2017; 130:1358-1365.e1. [PMID: 28843652 DOI: 10.1016/j.amjmed.2017.07.033] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2017] [Revised: 07/27/2017] [Accepted: 07/28/2017] [Indexed: 12/21/2022]
Abstract
The recent approval of the fifth-generation cardiac troponin T assay, which has characteristics clinically of a high-sensitivity assay, has led to concern that the problems of increased sensitivity will be greater than the benefits. This will not be the case if cardiology, emergency medicine, and laboratory medicine combine to develop procedures for use of the assay. We advocate sex-specific 99th percentile upper reference limit values of 15 ng/L for men and 10 ng/L for women. We suggest a 2-hour rule-out strategy, including a value less than the 99th percentile upper reference limit and the lack of a change in values of <4 ng/L. Those with values >100 ng/L and or a changing pattern of values ≥10 ng/L are a population much more likely to have acute myocardial infarction. Most of the increment in elevated values will occur not in those with acute coronary problems but in those with primary cardiac disease like heart failure and those with primary noncardiac problems. The former belong on a cardiac service because they are at high risk. The latter should have therapy on the service most apt to provide optimal care for their primary diagnosis, with cardiac consultation as needed.
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Affiliation(s)
- Yader Sandoval
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minn
| | - Allan S Jaffe
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minn; Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minn.
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113
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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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114
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Liebetrau C, Hamm CW. [Management of acute coronary syndrome without ST-segment elevation]. Herz 2017; 42:211-228. [PMID: 28233037 DOI: 10.1007/s00059-017-4541-x] [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] [Indexed: 10/20/2022]
Abstract
Acute coronary syndrome without persistent ST-segment elevation (non-ST segment elevation myocardial infarction and instable angina pectoris NSTEMI-ACS) is common and is associated with a high mortality. In addition to 12-channel echocardiograph (ECG) assessment, measurement of cardiac troponins I and T are important for risk stratification and diagnosis. The introduction of high-sensitivity cardiac troponin assays and their implementation into clinical practice has influenced risk stratification and treatment of these patients. Additional diagnostic validation must supplement routine clinical chemistry testing following the initial measurement to distinguish between different possible causes of troponin elevation above the 99th percentile. The time point for the additional troponin measurement depends on the different protocols and troponin assays and is stipulated in the current guidelines. The use of both 1‑hour and 3‑hour protocols together with the clinical presentation and work-up of possible differential diagnoses provide optimal care of patients. Patients who test positive for troponin dynamics should undergo invasive diagnostics and treatment within 24 h of presentation and within 2 h is recommended for unstable patients. Clopidogrel is indicated only in patients requiring oral anticoagulation.
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Affiliation(s)
- C Liebetrau
- Abteilung Kardiologie, Kerckhoff-Klinik, Zentrum für Herz-, Thorax- und Rheumaerkrankungen, Benekestr. 2-8, 61231, Bad Nauheim, Deutschland.
- Medizinische Klinik I, Abteilung Kardiologie/Angiologie, Universitätsklinikum Gießen, Gießen, Deutschland.
- Partner Site RheinMain, Deutsches Zentrum für Herz-Kreislauf-Forschung (DZHK), Frankfurt am Main, Deutschland.
| | - C W Hamm
- Abteilung Kardiologie, Kerckhoff-Klinik, Zentrum für Herz-, Thorax- und Rheumaerkrankungen, Benekestr. 2-8, 61231, Bad Nauheim, Deutschland
- Medizinische Klinik I, Abteilung Kardiologie/Angiologie, Universitätsklinikum Gießen, Gießen, Deutschland
- Partner Site RheinMain, Deutsches Zentrum für Herz-Kreislauf-Forschung (DZHK), Frankfurt am Main, Deutschland
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115
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Katus H, Ziegler A, Ekinci O, Giannitsis E, Stough WG, Achenbach S, Blankenberg S, Brueckmann M, Collinson P, Comaniciu D, Crea F, Dinh W, Ducrocq G, Flachskampf FA, Fox KAA, Friedrich MG, Hebert KA, Himmelmann A, Hlatky M, Lautsch D, Lindahl B, Lindholm D, Mills NL, Minotti G, Möckel M, Omland T, Semjonow V. Early diagnosis of acute coronary syndrome. Eur Heart J 2017; 38:3049-3055. [PMID: 29029109 DOI: 10.1093/eurheartj/ehx492] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2017] [Accepted: 08/21/2017] [Indexed: 01/01/2023] Open
Abstract
The diagnostic evaluation of acute chest pain has been augmented in recent years by advances in the sensitivity and precision of cardiac troponin assays, new biomarkers, improvements in imaging modalities, and release of new clinical decision algorithms. This progress has enabled physicians to diagnose or rule-out acute myocardial infarction earlier after the initial patient presentation, usually in emergency department settings, which may facilitate prompt initiation of evidence-based treatments, investigation of alternative diagnoses for chest pain, or discharge, and permit better utilization of healthcare resources. A non-trivial proportion of patients fall in an indeterminate category according to rule-out algorithms, and minimal evidence-based guidance exists for the optimal evaluation, monitoring, and treatment of these patients. The Cardiovascular Round Table of the ESC proposes approaches for the optimal application of early strategies in clinical practice to improve patient care following the review of recent advances in the early diagnosis of acute coronary syndrome. The following specific 'indeterminate' patient categories were considered: (i) patients with symptoms and high-sensitivity cardiac troponin <99th percentile; (ii) patients with symptoms and high-sensitivity troponin <99th percentile but above the limit of detection; (iii) patients with symptoms and high-sensitivity troponin >99th percentile but without dynamic change; and (iv) patients with symptoms and high-sensitivity troponin >99th percentile and dynamic change but without coronary plaque rupture/erosion/dissection. Definitive evidence is currently lacking to manage these patients whose early diagnosis is 'indeterminate' and these areas of uncertainty should be assigned a high priority for research.
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Affiliation(s)
- Hugo Katus
- Medizinische Klinik III, University of Heidelberg, Im Neuenheimer Feld 410, 69120 Heidelberg, Germany
| | | | - Okan Ekinci
- Siemens Healthineers, Erlangen, Germany
- University College Dublin, Dublin, Ireland
| | - Evangelos Giannitsis
- Medizinische Klinik III, University of Heidelberg, Im Neuenheimer Feld 410, 69120 Heidelberg, Germany
| | | | - Stephan Achenbach
- Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | | | - Martina Brueckmann
- Boehringer-Ingelheim GmbH & Co. KG, Ingelheim am Rhein, Germany
- Faculty of Medicine Mannheim, University of Heidelberg, Mannheim, Germany
| | - Paul Collinson
- St. George's University Hospitals NHS Foundation Trust, London, UK
- St. Georges, University of London, London, UK
| | | | - Filippo Crea
- Universita Cattolica del Sacro Cuore, Rome, Italy
| | - Wilfried Dinh
- Bayer AG Pharmaceuticals, Drug Discovery, Wuppertal, Germany
- Department of Cardiology, HELIOS Clinic Wuppertal, University Hospital Witten/Herdecke, Wuppertal, Germany
| | | | - Frank A Flachskampf
- Department of Medical Sciences, Clinical Physiology/Cardiology, Uppsala University, Uppsala, Sweden
| | - Keith A A Fox
- Centre for Cardiovascular Science, University and Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Matthias G Friedrich
- Departments of Medicine and Diagnostic Radiology, McGill University Health Centre, Montreal, Canada
- Heidelberg University, Heidelberg, Germany
| | | | | | - Mark Hlatky
- Stanford University School of Medicine, Stanford, CA, USA
| | | | - Bertil Lindahl
- Department of Medical Sciences, Clinical Physiology/Cardiology, Uppsala University, Uppsala, Sweden
| | - Daniel Lindholm
- Department of Medical Sciences, Cardiology, Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - Nicholas L Mills
- BHF Center for Cardiovascular Sciences, University of Edinburgh, Edinburgh, UK
| | | | | | - Torbjørn Omland
- Akershus University Hospital and University of Oslo, Oslo, Norway
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Brown JC, Samaha E, Rao S, Helwani MA, Duma A, Brown F, Gage BF, Miller JP, Jaffe AS, Apple FS, Scott MG, Nagele P. High-Sensitivity Cardiac Troponin T Improves the Diagnosis of Perioperative MI. Anesth Analg 2017; 125:1455-1462. [PMID: 28719430 DOI: 10.1213/ane.0000000000002240] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND The diagnosis of myocardial infarction (MI) after noncardiac surgery has traditionally relied on using relatively insensitive contemporary cardiac troponin (cTn) assays. We hypothesized that using a recently introduced novel high-sensitivity cTnT (hscTnT) assay would increase the detection rate of perioperative MI. METHODS In this ancillary study of the Vitamins in Nitrous Oxide trial, readjudicated incidence rates of myocardial injury (new isolated cTn elevation) and MI were compared when diagnosed by contemporary cTnI versus hscTnT. We probed various relative (eg, >50%) or absolute (eg, +5 ng/L) hscTnT change metrics. Inclusion criteria for this ancillary study were the presence of a baseline and at least 1 postoperative hscTnT value. RESULTS Among 605 patients, 70 patients (12%) had electrocardiogram changes consistent with myocardial ischemia; 82 patients (14%) had myocardial injury diagnosed by contemporary cTnI, 31 (5.1%) of which had an adjudicated MI. After readjudication, 67 patients (11%) were diagnosed with MI when using hscTnT, a 2-fold increase. Incidence rates of postoperative myocardial injury ranged from 12% (n = 73) to 65% (n = 393) depending on the hscTnT metric used. Incidence rates of MI using various hscTnT change metrics and the presence of ischemic electrocardiogram changes, but without event adjudication, ranged from 3.6% (n = 22) to 12% (n = 74), a >3-fold difference. New postoperative hscTnT elevation, either by absolute or relative hscTnT change metric, was associated with an up to 5-fold increase in 6-month mortality. CONCLUSIONS The use of hscTnT compared to contemporary cTnI increases the detection rate of perioperative MI by a factor of 2. Using different absolute or relative hscTnT change metrics may lead to under- or overdiagnosis of perioperative MI.
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Affiliation(s)
- Jamie C Brown
- From the *Division of Clinical and Translational Research, Department of Anesthesiology, †Department of Internal Medicine, and ‡Division of Biostatistics, Washington University School of Medicine, St Louis, Missouri; §Cardiovascular Division, Department of Internal Medicine and Division of Core Clinical Laboratory Services, Department of Laboratory Medicine and Pathology, Mayo Clinic and Medical School, Rochester, Minnesota; ‖Department of Laboratory Medicine & Pathology, Hennepin County Medical Center and University of Minnesota School of Medicine, Minneapolis, Minnesota; and ¶Department of Pathology & Immunology, Washington University School of Medicine, St Louis, Missouri
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Diferencias angiográficas y epidemiológicas entre hombres y mujeres que desarrollan síndrome coronario agudo. REVISTA COLOMBIANA DE CARDIOLOGÍA 2017. [DOI: 10.1016/j.rccar.2017.04.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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118
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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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119
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Mokhtari A, Lindahl B, Schiopu A, Yndigegn T, Khoshnood A, Gilje P, Ekelund U. A 0-Hour/1-Hour Protocol for Safe, Early Discharge of Chest Pain Patients. Acad Emerg Med 2017; 24:983-992. [PMID: 28500753 DOI: 10.1111/acem.13224] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2017] [Revised: 02/26/2017] [Accepted: 02/27/2017] [Indexed: 11/30/2022]
Abstract
OBJECTIVES Guidelines recommend a 0-hour/1-hour high-sensitivity cardiac troponin T (hs-cTnT) diagnostic strategy in acute chest pain patients. There are, however, little data on the performance of this strategy when combined with clinical risk stratification. We aimed to evaluate the diagnostic accuracy of an accelerated diagnostic protocol (ADP) using the 0-hour/1-hour hs-cTnT strategy together with an adapted Thrombolysis In Myocardial Infarction (TIMI) score and electrocardiogram (ECG) for ruling out major adverse cardiac events (MACE) within 30 days. METHODS This prospective observational study enrolled consecutive emergency department (ED) chest pain patients. TIMI score variables, ED physicians' assessments of the ECG, and 0- and 1-hour hs-cTnT were collected. Thirty-day MACE was defined as acute myocardial infarction (AMI), unstable angina (UA), cardiogenic shock, ventricular arrhythmia, atrioventricular block, cardiac arrest, or death of cardiac or unknown cause. RESULTS A total of 1,020 patients were included in the final analysis. The combination of an adapted TIMI score ≤1, a nonischemic ECG, and either a 0-hour hs-cTnT < 5 ng/L or a 0-hour hs-cTnT < 12 ng/L combined with a 1-hour increase < 3 ng/L identified 432 (42.4%) patients as very low risk with a negative predictive value of 99.5% (95% confidence interval [CI] = 98.3%-99.9%) and a negative likelihood ratio of 0.04 (95% CI = 0.01-0.14) for 30-day MACE. The ADP missed only two patients with UA and no patients with AMI or other forms of MACE. CONCLUSION An ADP using the guideline recommended 0-hour/1-hour hs-cTnT strategy rapidly identified patients with a very low risk of 30-day MACE including UA where no further cardiac testing would be needed. This could potentially allow safe early discharge of about 40% of ED chest pain patients.
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Affiliation(s)
- Arash Mokhtari
- Department of Internal and Emergency Medicine; Skåne University Hospital; Lund
- Department of Cardiology; Lund University; Skåne University Hospital; Lund
| | - Bertil Lindahl
- Department of Medical Sciences and Uppsala Clinical Research Center; Uppsala University; Uppsala Sweden
| | - Alexandru Schiopu
- Department of Cardiology; Lund University; Skåne University Hospital; Lund
| | - Troels Yndigegn
- Department of Cardiology; Lund University; Skåne University Hospital; Lund
| | - Ardavan Khoshnood
- Department of Internal and Emergency Medicine; Skåne University Hospital; Lund
| | - Patrik Gilje
- Department of Cardiology; Lund University; Skåne University Hospital; Lund
| | - Ulf Ekelund
- Department of Internal and Emergency Medicine; Skåne University Hospital; Lund
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120
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Abstract
PURPOSE OF REVIEW Since identification of aspartate aminotransferase as the first cardiac biomarker in the 1950s, there have been a number of new markers used for myocardial damage detection over the decades. There have also been several generations of troponin assays, each with progressively increasing sensitivity for troponin detection. Accordingly, the "standard of care" for myocardial damage detection continues to change. The purpose of this paper is to review the clinical utility, biological mechanisms, and predictive value of these various biomarkers in contemporary clinical studies. RECENT FINDINGS As of this writing, a fifth "next" generation troponin assay has now been cleared by the US Food and Drug Administration for clinical use in the USA for subjects presenting with suspected acute coronary syndromes. Use of these high-sensitivity assays has allowed for earlier detection of myocardial damage as well as greater negative predictive value for infarction after only one or two serial measurements. Recent algorithms utilizing these assays have allowed for more rapid rule-out of myocardial infarction in emergency department settings. In this review, we discuss novel assays available for the risk assessment of subjects presenting with chest pain, including both the "next generation" cardiac troponin assays as well as other novel biomarkers. We review the biological mechanisms for these markers, and explore the positive and negative predictive value of the assays in clinical studies, where reported. We also discuss the potential use of these new markers within the context of future clinical care in the modern era of higher sensitivity troponin testing. Finally, we discuss advances in new platforms (e.g., mass spectrometry) that historically have not been considered for rapid in vitro diagnostic capabilities, but that are taking a larger role in clinical diagnostics, and whose prognostic value and power promise to usher in new markers with potential for future clinical utility in acute coronary syndrome.
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Affiliation(s)
- Haitham M Ahmed
- Preventive Cardiology and Rehabilitation, Cleveland Clinic, Heart and Vascular Institute, 9500 Euclid Ave, Desk JB1, Cleveland, OH, 44195, USA.
| | - Stanley L Hazen
- Preventive Cardiology and Rehabilitation, Cleveland Clinic, Heart and Vascular Institute, 9500 Euclid Ave, Desk JB1, Cleveland, OH, 44195, USA
- Department of Cellular and Molecular Medicine, Cleveland Clinic, Lerner Research Institute, Cleveland, OH, USA
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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; 205:128-33. [PMID: 27465769 DOI: 10.5694/mja16.00368] [Citation(s) in RCA: 103] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2016] [Accepted: 05/10/2016] [Indexed: 11/17/2022]
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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122
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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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Brush JE, Kaul S, Krumholz HM. Troponin Testing for Clinicians. J Am Coll Cardiol 2017; 68:2365-2375. [PMID: 27884254 DOI: 10.1016/j.jacc.2016.08.066] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2016] [Revised: 08/16/2016] [Accepted: 08/23/2016] [Indexed: 11/24/2022]
Abstract
The analytical performance of troponin assays has improved markedly in the last 2 decades. The variety of assays, their evolution over time, and their critical importance in influencing care, mandates the need for skills in their use. There are 3 critical elements necessary for optimal use of troponin testing in clinical care, as follows: 1) the analytical performance of the assay; 2) the clinical sensitivity and specificity of the test result; and 3) the clinical reasoning for ordering and the proper clinical context for interpreting the test result. This paper provides further explanation that will assist clinicians in their clinical decision making and interpretation of troponin test results. Schematic visual explanations are provided to help clinicians develop a more intuitive understanding of troponin testing.
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Affiliation(s)
- John E Brush
- Department of Internal Medicine, Eastern Virginia Medical School and Sentara Healthcare, Norfolk, Virginia.
| | - Sanjay Kaul
- Division of Cardiology, Cedars-Sinai Medical Center, Los Angeles, California, and David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Harlan M Krumholz
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
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Árnadóttir Á, Falk Klein C, Iversen K. Head-to-head comparison of cardiac troponin T and troponin I in patients without acute coronary syndrome: a systematic review. Biomarkers 2017; 22:701-708. [DOI: 10.1080/1354750x.2017.1335779] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Affiliation(s)
| | | | - Kasper Iversen
- Department of Cardiology, Herlev-Gentofte Hospital, Copenhagen, Denmark
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125
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Jülicher P, Greenslade JH, Parsonage WA, Cullen L. The organisational value of diagnostic strategies using high-sensitivity troponin for patients with possible acute coronary syndromes: a trial-based cost-effectiveness analysis. BMJ Open 2017; 7:e013653. [PMID: 28601817 PMCID: PMC5577894 DOI: 10.1136/bmjopen-2016-013653] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [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 evaluate hospital-specific health economic implications of different protocols using high-sensitivity troponin I for the assessment of patients with chest pain. DESIGN A cost prediction model and an economic microsimulation were developed using a cohort from a single centre recruited as part of the (ADAPT) trial, a prospective observational trial conducted from 2008 to 2011. The model was populated with 40 000 bootstrapped samples in five high-sensitivity troponin I-enabled algorithms versus standard care. SETTING Adult emergency department (ED) of a tertiary referral hospital. PARTICIPANTS Data were available for 938 patients who presented to the ED with at least 5 min of symptoms suggestive of acute coronary syndrome. The analyses included 719 patients with complete data. MAIN OUTCOMES/MEASURES This study examined direct hospital costs, number of false-negative and false-positive cases in the assessment of acute coronary syndrome. RESULTS High-sensitivity troponin I-supported algorithms increased diagnostic accuracy from 90.0% to 94.0% with an average cost reduction per patient compared with standard care of $490. The inclusion of additional criteria for accelerated rule-out (limit of detection and the modified 2-hour ADAPT trial rules) avoided 7.5% of short-stay unit admissions or 25% of admissions to a cardiac ward. Protocols using high-sensitivity troponin I alone or high-sensitivity troponin I within accelerated diagnostic algorithms reduced length of stay by 6.2 and 13.6 hours, respectively. Overnight stays decreased up to 43%. Results were seen for patients with non-acute coronary syndrome; no difference was found for patients with acute coronary syndrome. CONCLUSIONS High-sensitivity troponin I algorithms are likely to be cost-effective on a hospital level compared with sensitive troponin protocols. The positive effect is conferred by patients not diagnosed with acute coronary syndrome. Implementation could improve referral accuracy or facilitate safe discharge. It would decrease costs and provide significant hospital benefits. TRIAL REGISTRATION The original ADAPT trial was registered with the Australia-New Zealand Clinical trials Registry, ACTRN12611001069943.
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Affiliation(s)
- Paul Jülicher
- Health Economics and Outcomes Research, Medical Affairs, Abbott Laboratories, Wiesbaden, Germany
| | - Jaimi H Greenslade
- Department of Emergency Medicine, Royal Brisbane and Women's Hospital, Herston, Australia
| | - William A Parsonage
- Department of Cardiology, Royal Brisbane and Women’s Hospital, Herston, Australia
| | - Louise Cullen
- Department of Emergency Medicine, Royal Brisbane and Women's Hospital, Herston, Australia
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126
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Mokhtari A, Borna C, Gilje P, Tydén P, Lindahl B, Nilsson HJ, Khoshnood A, Björk J, Ekelund U. A 1-h Combination Algorithm Allows Fast Rule-Out and Rule-In of Major Adverse Cardiac Events. J Am Coll Cardiol 2017; 67:1531-1540. [PMID: 27150684 DOI: 10.1016/j.jacc.2016.01.059] [Citation(s) in RCA: 95] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2015] [Revised: 01/12/2016] [Accepted: 01/21/2016] [Indexed: 12/11/2022]
Abstract
BACKGROUND A 1-h algorithm based on high-sensitivity cardiac troponin T (hs-cTnT) testing at presentation and again 1 h thereafter has been shown to accurately rule out acute myocardial infarction. OBJECTIVES The goal of the study was to evaluate the diagnostic accuracy of the 1-h algorithm when supplemented with patient history and an electrocardiogram (ECG) (the extended algorithm) for predicting 30-day major adverse cardiac events (MACE) and to compare it with the algorithm using hs-cTnT alone (the troponin algorithm). METHODS This prospective observational study enrolled consecutive patients presenting to the emergency department (ED) with chest pain, for whom hs-cTnT testing was ordered at presentation. Hs-cTnT results at 1 h and the ED physician's assessments of patient history and ECG were collected. The primary outcome was an adjudicated diagnosis of 30-day MACE defined as acute myocardial infarction, unstable angina, cardiogenic shock, ventricular arrhythmia, atrioventricular block, cardiac arrest, or death of a cardiac or unknown cause. RESULTS In the final analysis, 1,038 patients were included. The extended algorithm identified 60% of all patients for rule-out and had a higher sensitivity than the troponin algorithm (97.5% vs. 87.6%; p < 0.001). The negative predictive value was 99.5% and the likelihood ratio was 0.04 with the extended algorithm versus 97.8% and 0.17, respectively, with the troponin algorithm. The extended algorithm ruled-in 14% of patients with a higher sensitivity (75.2% vs. 56.2%; p < 0.001) but a slightly lower specificity (94.0% vs. 96.4%; p < 0.001) than the troponin algorithm. The rule-in arms of both algorithms had a likelihood ratio >10. CONCLUSIONS A 1-h combination algorithm allowed fast rule-out and rule-in of 30-day MACE in a majority of ED patients with chest pain and performed better than the troponin-alone algorithm.
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Affiliation(s)
- Arash Mokhtari
- Department of Internal and Emergency Medicine, Skåne University Hospital, Lund, Sweden; Department of Cardiology, Skåne University Hospital, Lund, Sweden; Department of Clinical Sciences at Lund, Lund University, Lund, Sweden.
| | - Catharina Borna
- Department of Clinical Sciences at Lund, Lund University, Lund, Sweden; Division Specialised Local Health Care, Helsingborg General Hospital, Helsingborg, Sweden
| | - Patrik Gilje
- Department of Cardiology, Skåne University Hospital, Lund, Sweden
| | - Patrik Tydén
- Department of Cardiology, Skåne University Hospital, Lund, Sweden
| | - Bertil Lindahl
- Department of Medical Sciences and Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | | | - Ardavan Khoshnood
- Department of Internal and Emergency Medicine, Skåne University Hospital, Lund, Sweden; Department of Clinical Sciences at Lund, Lund University, Lund, Sweden
| | - Jonas Björk
- Occupational and Environmental Medicine, Lund University, Lund, Sweden
| | - Ulf Ekelund
- Department of Internal and Emergency Medicine, Skåne University Hospital, Lund, Sweden; Department of Clinical Sciences at Lund, Lund University, Lund, Sweden
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127
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Kozinski M, Krintus M, Kubica J, Sypniewska G. High-sensitivity cardiac troponin assays: From improved analytical performance to enhanced risk stratification. Crit Rev Clin Lab Sci 2017; 54:143-172. [DOI: 10.1080/10408363.2017.1285268] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Affiliation(s)
- Marek Kozinski
- Department of Principles of Clinical Medicine, Nicolaus Copernicus University, Collegium Medicum, Bydgoszcz, Poland
| | - Magdalena Krintus
- Department of Laboratory Medicine, Nicolaus Copernicus University, Collegium Medicum, Bydgoszcz, Poland
| | - Jacek Kubica
- Department of Cardiology and Internal Medicine, Nicolaus Copernicus University, Collegium Medicum, Bydgoszcz, Poland
| | - Grazyna Sypniewska
- Department of Laboratory Medicine, Nicolaus Copernicus University, Collegium Medicum, Bydgoszcz, Poland
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128
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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: 141] [Impact Index Per Article: 20.1] [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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129
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Boeddinghaus J, Nestelberger T, Twerenbold R, Wildi K, Badertscher P, Cupa J, Bürge T, Mächler P, Corbière S, Grimm K, Giménez MR, Puelacher C, Shrestha S, Flores Widmer D, Fuhrmann J, Hillinger P, Sabti Z, Honegger U, Schaerli N, Kozhuharov N, Rentsch K, Miró Ò, López B, Martin-Sanchez FJ, Rodriguez-Adrada E, Morawiec B, Kawecki D, Ganovská E, Parenica J, Lohrmann J, Kloos W, Buser A, Geigy N, Keller DI, Osswald S, Reichlin T, Mueller C. Direct Comparison of 4 Very Early Rule-Out Strategies for Acute Myocardial Infarction Using High-Sensitivity Cardiac Troponin I. Circulation 2017; 135:1597-1611. [DOI: 10.1161/circulationaha.116.025661] [Citation(s) in RCA: 116] [Impact Index Per Article: 16.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2016] [Accepted: 03/01/2017] [Indexed: 12/23/2022]
Abstract
Background:
Four strategies for very early rule-out of acute myocardial infarction using high-sensitivity cardiac troponin I (hs-cTnI) have been identified. It remains unclear which strategy is most attractive for clinical application.
Methods:
We prospectively enrolled unselected patients presenting to the emergency department with symptoms suggestive of acute myocardial infarction. The final diagnosis was adjudicated by 2 independent cardiologists. Hs-cTnI levels were measured at presentation and after 1 hour in a blinded fashion. We directly compared all 4 hs-cTnI–based rule-out strategies: limit of detection (LOD, hs-cTnI<2 ng/L), single cutoff (hs-cTnI<5 ng/L), 1-hour algorithm (hs-cTnI<5 ng/L and 1-hour change<2 ng/L), and the 0/1-hour algorithm recommended in the European Society of Cardiology guideline combining LOD and 1-hour algorithm.
Results:
Among 2828 enrolled patients, acute myocardial infarction was the final diagnosis in 451 (16%) patients. The LOD approach ruled out 453 patients (16%) with a sensitivity of 100% (95% confidence interval [CI], 99.2%–100%), the single cutoff 1516 patients (54%) with a sensitivity of 97.1% (95% CI, 95.1%–98.3%), the 1-hour algorithm 1459 patients (52%) with a sensitivity of 98.4% (95% CI, 96.8%–99.2%), and the 0/1-hour algorithm 1463 patients (52%) with a sensitivity of 98.4% (95% CI, 96.8%–99.2%). Predefined subgroup analysis in early presenters (≤2 hours) revealed significantly lower sensitivity (94.2%, interaction
P
=0.03) of the single cutoff, but not the other strategies. Two-year survival was 100% with LOD and 98.1% with the other strategies (
P
<0.01 for LOD versus each of the other strategies).
Conclusions:
All 4 rule-out strategies balance effectiveness and safety equally well. The single cutoff should not be applied in early presenters, whereas the 3 other strategies seem to perform well in this challenging subgroup.
Clinical Trial Registration:
URL:
http://www.clinicaltrials.gov
. Unique identifier: NCT00470587.
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Affiliation(s)
- Jasper Boeddinghaus
- From Cardiovascular Research Institute Basel and Department of Cardiology, University Hospital Basel, University of Basel, Switzerland (J.B., T.N., R.T., K.W., P.B., J.C., T.B., P.M., S.C., K.G., M.R.G., C.P., S.S., D.F.W., J.F., P.H., Z.S., U.H., N.S., N.K., J.L. W.K., S.O., T.R., C.M.); Department of Internal Medicine, University Hospital Basel, University of Basel, Switzerland (J.B., T.N., K.G., P.H., N.S.); GREAT Network (J.B., T.N., R.T., K.W., P.B., J.C., S.C., K.G., M.R.G., C.P., S.S., D.F.W
| | - Thomas Nestelberger
- From Cardiovascular Research Institute Basel and Department of Cardiology, University Hospital Basel, University of Basel, Switzerland (J.B., T.N., R.T., K.W., P.B., J.C., T.B., P.M., S.C., K.G., M.R.G., C.P., S.S., D.F.W., J.F., P.H., Z.S., U.H., N.S., N.K., J.L. W.K., S.O., T.R., C.M.); Department of Internal Medicine, University Hospital Basel, University of Basel, Switzerland (J.B., T.N., K.G., P.H., N.S.); GREAT Network (J.B., T.N., R.T., K.W., P.B., J.C., S.C., K.G., M.R.G., C.P., S.S., D.F.W
| | - Raphael Twerenbold
- From Cardiovascular Research Institute Basel and Department of Cardiology, University Hospital Basel, University of Basel, Switzerland (J.B., T.N., R.T., K.W., P.B., J.C., T.B., P.M., S.C., K.G., M.R.G., C.P., S.S., D.F.W., J.F., P.H., Z.S., U.H., N.S., N.K., J.L. W.K., S.O., T.R., C.M.); Department of Internal Medicine, University Hospital Basel, University of Basel, Switzerland (J.B., T.N., K.G., P.H., N.S.); GREAT Network (J.B., T.N., R.T., K.W., P.B., J.C., S.C., K.G., M.R.G., C.P., S.S., D.F.W
| | - Karin Wildi
- From Cardiovascular Research Institute Basel and Department of Cardiology, University Hospital Basel, University of Basel, Switzerland (J.B., T.N., R.T., K.W., P.B., J.C., T.B., P.M., S.C., K.G., M.R.G., C.P., S.S., D.F.W., J.F., P.H., Z.S., U.H., N.S., N.K., J.L. W.K., S.O., T.R., C.M.); Department of Internal Medicine, University Hospital Basel, University of Basel, Switzerland (J.B., T.N., K.G., P.H., N.S.); GREAT Network (J.B., T.N., R.T., K.W., P.B., J.C., S.C., K.G., M.R.G., C.P., S.S., D.F.W
| | - Patrick Badertscher
- From Cardiovascular Research Institute Basel and Department of Cardiology, University Hospital Basel, University of Basel, Switzerland (J.B., T.N., R.T., K.W., P.B., J.C., T.B., P.M., S.C., K.G., M.R.G., C.P., S.S., D.F.W., J.F., P.H., Z.S., U.H., N.S., N.K., J.L. W.K., S.O., T.R., C.M.); Department of Internal Medicine, University Hospital Basel, University of Basel, Switzerland (J.B., T.N., K.G., P.H., N.S.); GREAT Network (J.B., T.N., R.T., K.W., P.B., J.C., S.C., K.G., M.R.G., C.P., S.S., D.F.W
| | - Janosch Cupa
- From Cardiovascular Research Institute Basel and Department of Cardiology, University Hospital Basel, University of Basel, Switzerland (J.B., T.N., R.T., K.W., P.B., J.C., T.B., P.M., S.C., K.G., M.R.G., C.P., S.S., D.F.W., J.F., P.H., Z.S., U.H., N.S., N.K., J.L. W.K., S.O., T.R., C.M.); Department of Internal Medicine, University Hospital Basel, University of Basel, Switzerland (J.B., T.N., K.G., P.H., N.S.); GREAT Network (J.B., T.N., R.T., K.W., P.B., J.C., S.C., K.G., M.R.G., C.P., S.S., D.F.W
| | - Tobias Bürge
- From Cardiovascular Research Institute Basel and Department of Cardiology, University Hospital Basel, University of Basel, Switzerland (J.B., T.N., R.T., K.W., P.B., J.C., T.B., P.M., S.C., K.G., M.R.G., C.P., S.S., D.F.W., J.F., P.H., Z.S., U.H., N.S., N.K., J.L. W.K., S.O., T.R., C.M.); Department of Internal Medicine, University Hospital Basel, University of Basel, Switzerland (J.B., T.N., K.G., P.H., N.S.); GREAT Network (J.B., T.N., R.T., K.W., P.B., J.C., S.C., K.G., M.R.G., C.P., S.S., D.F.W
| | - Patrick Mächler
- From Cardiovascular Research Institute Basel and Department of Cardiology, University Hospital Basel, University of Basel, Switzerland (J.B., T.N., R.T., K.W., P.B., J.C., T.B., P.M., S.C., K.G., M.R.G., C.P., S.S., D.F.W., J.F., P.H., Z.S., U.H., N.S., N.K., J.L. W.K., S.O., T.R., C.M.); Department of Internal Medicine, University Hospital Basel, University of Basel, Switzerland (J.B., T.N., K.G., P.H., N.S.); GREAT Network (J.B., T.N., R.T., K.W., P.B., J.C., S.C., K.G., M.R.G., C.P., S.S., D.F.W
| | - Sydney Corbière
- From Cardiovascular Research Institute Basel and Department of Cardiology, University Hospital Basel, University of Basel, Switzerland (J.B., T.N., R.T., K.W., P.B., J.C., T.B., P.M., S.C., K.G., M.R.G., C.P., S.S., D.F.W., J.F., P.H., Z.S., U.H., N.S., N.K., J.L. W.K., S.O., T.R., C.M.); Department of Internal Medicine, University Hospital Basel, University of Basel, Switzerland (J.B., T.N., K.G., P.H., N.S.); GREAT Network (J.B., T.N., R.T., K.W., P.B., J.C., S.C., K.G., M.R.G., C.P., S.S., D.F.W
| | - Karin Grimm
- From Cardiovascular Research Institute Basel and Department of Cardiology, University Hospital Basel, University of Basel, Switzerland (J.B., T.N., R.T., K.W., P.B., J.C., T.B., P.M., S.C., K.G., M.R.G., C.P., S.S., D.F.W., J.F., P.H., Z.S., U.H., N.S., N.K., J.L. W.K., S.O., T.R., C.M.); Department of Internal Medicine, University Hospital Basel, University of Basel, Switzerland (J.B., T.N., K.G., P.H., N.S.); GREAT Network (J.B., T.N., R.T., K.W., P.B., J.C., S.C., K.G., M.R.G., C.P., S.S., D.F.W
| | - Maria Rubini Giménez
- From Cardiovascular Research Institute Basel and Department of Cardiology, University Hospital Basel, University of Basel, Switzerland (J.B., T.N., R.T., K.W., P.B., J.C., T.B., P.M., S.C., K.G., M.R.G., C.P., S.S., D.F.W., J.F., P.H., Z.S., U.H., N.S., N.K., J.L. W.K., S.O., T.R., C.M.); Department of Internal Medicine, University Hospital Basel, University of Basel, Switzerland (J.B., T.N., K.G., P.H., N.S.); GREAT Network (J.B., T.N., R.T., K.W., P.B., J.C., S.C., K.G., M.R.G., C.P., S.S., D.F.W
| | - Christian Puelacher
- From Cardiovascular Research Institute Basel and Department of Cardiology, University Hospital Basel, University of Basel, Switzerland (J.B., T.N., R.T., K.W., P.B., J.C., T.B., P.M., S.C., K.G., M.R.G., C.P., S.S., D.F.W., J.F., P.H., Z.S., U.H., N.S., N.K., J.L. W.K., S.O., T.R., C.M.); Department of Internal Medicine, University Hospital Basel, University of Basel, Switzerland (J.B., T.N., K.G., P.H., N.S.); GREAT Network (J.B., T.N., R.T., K.W., P.B., J.C., S.C., K.G., M.R.G., C.P., S.S., D.F.W
| | - Samyut Shrestha
- From Cardiovascular Research Institute Basel and Department of Cardiology, University Hospital Basel, University of Basel, Switzerland (J.B., T.N., R.T., K.W., P.B., J.C., T.B., P.M., S.C., K.G., M.R.G., C.P., S.S., D.F.W., J.F., P.H., Z.S., U.H., N.S., N.K., J.L. W.K., S.O., T.R., C.M.); Department of Internal Medicine, University Hospital Basel, University of Basel, Switzerland (J.B., T.N., K.G., P.H., N.S.); GREAT Network (J.B., T.N., R.T., K.W., P.B., J.C., S.C., K.G., M.R.G., C.P., S.S., D.F.W
| | - Dayana Flores Widmer
- From Cardiovascular Research Institute Basel and Department of Cardiology, University Hospital Basel, University of Basel, Switzerland (J.B., T.N., R.T., K.W., P.B., J.C., T.B., P.M., S.C., K.G., M.R.G., C.P., S.S., D.F.W., J.F., P.H., Z.S., U.H., N.S., N.K., J.L. W.K., S.O., T.R., C.M.); Department of Internal Medicine, University Hospital Basel, University of Basel, Switzerland (J.B., T.N., K.G., P.H., N.S.); GREAT Network (J.B., T.N., R.T., K.W., P.B., J.C., S.C., K.G., M.R.G., C.P., S.S., D.F.W
| | - Jakob Fuhrmann
- From Cardiovascular Research Institute Basel and Department of Cardiology, University Hospital Basel, University of Basel, Switzerland (J.B., T.N., R.T., K.W., P.B., J.C., T.B., P.M., S.C., K.G., M.R.G., C.P., S.S., D.F.W., J.F., P.H., Z.S., U.H., N.S., N.K., J.L. W.K., S.O., T.R., C.M.); Department of Internal Medicine, University Hospital Basel, University of Basel, Switzerland (J.B., T.N., K.G., P.H., N.S.); GREAT Network (J.B., T.N., R.T., K.W., P.B., J.C., S.C., K.G., M.R.G., C.P., S.S., D.F.W
| | - Petra Hillinger
- From Cardiovascular Research Institute Basel and Department of Cardiology, University Hospital Basel, University of Basel, Switzerland (J.B., T.N., R.T., K.W., P.B., J.C., T.B., P.M., S.C., K.G., M.R.G., C.P., S.S., D.F.W., J.F., P.H., Z.S., U.H., N.S., N.K., J.L. W.K., S.O., T.R., C.M.); Department of Internal Medicine, University Hospital Basel, University of Basel, Switzerland (J.B., T.N., K.G., P.H., N.S.); GREAT Network (J.B., T.N., R.T., K.W., P.B., J.C., S.C., K.G., M.R.G., C.P., S.S., D.F.W
| | - Zaid Sabti
- From Cardiovascular Research Institute Basel and Department of Cardiology, University Hospital Basel, University of Basel, Switzerland (J.B., T.N., R.T., K.W., P.B., J.C., T.B., P.M., S.C., K.G., M.R.G., C.P., S.S., D.F.W., J.F., P.H., Z.S., U.H., N.S., N.K., J.L. W.K., S.O., T.R., C.M.); Department of Internal Medicine, University Hospital Basel, University of Basel, Switzerland (J.B., T.N., K.G., P.H., N.S.); GREAT Network (J.B., T.N., R.T., K.W., P.B., J.C., S.C., K.G., M.R.G., C.P., S.S., D.F.W
| | - Ursina Honegger
- From Cardiovascular Research Institute Basel and Department of Cardiology, University Hospital Basel, University of Basel, Switzerland (J.B., T.N., R.T., K.W., P.B., J.C., T.B., P.M., S.C., K.G., M.R.G., C.P., S.S., D.F.W., J.F., P.H., Z.S., U.H., N.S., N.K., J.L. W.K., S.O., T.R., C.M.); Department of Internal Medicine, University Hospital Basel, University of Basel, Switzerland (J.B., T.N., K.G., P.H., N.S.); GREAT Network (J.B., T.N., R.T., K.W., P.B., J.C., S.C., K.G., M.R.G., C.P., S.S., D.F.W
| | - Nicolas Schaerli
- From Cardiovascular Research Institute Basel and Department of Cardiology, University Hospital Basel, University of Basel, Switzerland (J.B., T.N., R.T., K.W., P.B., J.C., T.B., P.M., S.C., K.G., M.R.G., C.P., S.S., D.F.W., J.F., P.H., Z.S., U.H., N.S., N.K., J.L. W.K., S.O., T.R., C.M.); Department of Internal Medicine, University Hospital Basel, University of Basel, Switzerland (J.B., T.N., K.G., P.H., N.S.); GREAT Network (J.B., T.N., R.T., K.W., P.B., J.C., S.C., K.G., M.R.G., C.P., S.S., D.F.W
| | - Nikola Kozhuharov
- From Cardiovascular Research Institute Basel and Department of Cardiology, University Hospital Basel, University of Basel, Switzerland (J.B., T.N., R.T., K.W., P.B., J.C., T.B., P.M., S.C., K.G., M.R.G., C.P., S.S., D.F.W., J.F., P.H., Z.S., U.H., N.S., N.K., J.L. W.K., S.O., T.R., C.M.); Department of Internal Medicine, University Hospital Basel, University of Basel, Switzerland (J.B., T.N., K.G., P.H., N.S.); GREAT Network (J.B., T.N., R.T., K.W., P.B., J.C., S.C., K.G., M.R.G., C.P., S.S., D.F.W
| | - Katharina Rentsch
- From Cardiovascular Research Institute Basel and Department of Cardiology, University Hospital Basel, University of Basel, Switzerland (J.B., T.N., R.T., K.W., P.B., J.C., T.B., P.M., S.C., K.G., M.R.G., C.P., S.S., D.F.W., J.F., P.H., Z.S., U.H., N.S., N.K., J.L. W.K., S.O., T.R., C.M.); Department of Internal Medicine, University Hospital Basel, University of Basel, Switzerland (J.B., T.N., K.G., P.H., N.S.); GREAT Network (J.B., T.N., R.T., K.W., P.B., J.C., S.C., K.G., M.R.G., C.P., S.S., D.F.W
| | - Òscar Miró
- From Cardiovascular Research Institute Basel and Department of Cardiology, University Hospital Basel, University of Basel, Switzerland (J.B., T.N., R.T., K.W., P.B., J.C., T.B., P.M., S.C., K.G., M.R.G., C.P., S.S., D.F.W., J.F., P.H., Z.S., U.H., N.S., N.K., J.L. W.K., S.O., T.R., C.M.); Department of Internal Medicine, University Hospital Basel, University of Basel, Switzerland (J.B., T.N., K.G., P.H., N.S.); GREAT Network (J.B., T.N., R.T., K.W., P.B., J.C., S.C., K.G., M.R.G., C.P., S.S., D.F.W
| | - Beatriz López
- From Cardiovascular Research Institute Basel and Department of Cardiology, University Hospital Basel, University of Basel, Switzerland (J.B., T.N., R.T., K.W., P.B., J.C., T.B., P.M., S.C., K.G., M.R.G., C.P., S.S., D.F.W., J.F., P.H., Z.S., U.H., N.S., N.K., J.L. W.K., S.O., T.R., C.M.); Department of Internal Medicine, University Hospital Basel, University of Basel, Switzerland (J.B., T.N., K.G., P.H., N.S.); GREAT Network (J.B., T.N., R.T., K.W., P.B., J.C., S.C., K.G., M.R.G., C.P., S.S., D.F.W
| | - F. Javier Martin-Sanchez
- From Cardiovascular Research Institute Basel and Department of Cardiology, University Hospital Basel, University of Basel, Switzerland (J.B., T.N., R.T., K.W., P.B., J.C., T.B., P.M., S.C., K.G., M.R.G., C.P., S.S., D.F.W., J.F., P.H., Z.S., U.H., N.S., N.K., J.L. W.K., S.O., T.R., C.M.); Department of Internal Medicine, University Hospital Basel, University of Basel, Switzerland (J.B., T.N., K.G., P.H., N.S.); GREAT Network (J.B., T.N., R.T., K.W., P.B., J.C., S.C., K.G., M.R.G., C.P., S.S., D.F.W
| | - Esther Rodriguez-Adrada
- From Cardiovascular Research Institute Basel and Department of Cardiology, University Hospital Basel, University of Basel, Switzerland (J.B., T.N., R.T., K.W., P.B., J.C., T.B., P.M., S.C., K.G., M.R.G., C.P., S.S., D.F.W., J.F., P.H., Z.S., U.H., N.S., N.K., J.L. W.K., S.O., T.R., C.M.); Department of Internal Medicine, University Hospital Basel, University of Basel, Switzerland (J.B., T.N., K.G., P.H., N.S.); GREAT Network (J.B., T.N., R.T., K.W., P.B., J.C., S.C., K.G., M.R.G., C.P., S.S., D.F.W
| | - Beata Morawiec
- From Cardiovascular Research Institute Basel and Department of Cardiology, University Hospital Basel, University of Basel, Switzerland (J.B., T.N., R.T., K.W., P.B., J.C., T.B., P.M., S.C., K.G., M.R.G., C.P., S.S., D.F.W., J.F., P.H., Z.S., U.H., N.S., N.K., J.L. W.K., S.O., T.R., C.M.); Department of Internal Medicine, University Hospital Basel, University of Basel, Switzerland (J.B., T.N., K.G., P.H., N.S.); GREAT Network (J.B., T.N., R.T., K.W., P.B., J.C., S.C., K.G., M.R.G., C.P., S.S., D.F.W
| | - Damian Kawecki
- From Cardiovascular Research Institute Basel and Department of Cardiology, University Hospital Basel, University of Basel, Switzerland (J.B., T.N., R.T., K.W., P.B., J.C., T.B., P.M., S.C., K.G., M.R.G., C.P., S.S., D.F.W., J.F., P.H., Z.S., U.H., N.S., N.K., J.L. W.K., S.O., T.R., C.M.); Department of Internal Medicine, University Hospital Basel, University of Basel, Switzerland (J.B., T.N., K.G., P.H., N.S.); GREAT Network (J.B., T.N., R.T., K.W., P.B., J.C., S.C., K.G., M.R.G., C.P., S.S., D.F.W
| | - Eva Ganovská
- From Cardiovascular Research Institute Basel and Department of Cardiology, University Hospital Basel, University of Basel, Switzerland (J.B., T.N., R.T., K.W., P.B., J.C., T.B., P.M., S.C., K.G., M.R.G., C.P., S.S., D.F.W., J.F., P.H., Z.S., U.H., N.S., N.K., J.L. W.K., S.O., T.R., C.M.); Department of Internal Medicine, University Hospital Basel, University of Basel, Switzerland (J.B., T.N., K.G., P.H., N.S.); GREAT Network (J.B., T.N., R.T., K.W., P.B., J.C., S.C., K.G., M.R.G., C.P., S.S., D.F.W
| | - Jiri Parenica
- From Cardiovascular Research Institute Basel and Department of Cardiology, University Hospital Basel, University of Basel, Switzerland (J.B., T.N., R.T., K.W., P.B., J.C., T.B., P.M., S.C., K.G., M.R.G., C.P., S.S., D.F.W., J.F., P.H., Z.S., U.H., N.S., N.K., J.L. W.K., S.O., T.R., C.M.); Department of Internal Medicine, University Hospital Basel, University of Basel, Switzerland (J.B., T.N., K.G., P.H., N.S.); GREAT Network (J.B., T.N., R.T., K.W., P.B., J.C., S.C., K.G., M.R.G., C.P., S.S., D.F.W
| | - Jens Lohrmann
- From Cardiovascular Research Institute Basel and Department of Cardiology, University Hospital Basel, University of Basel, Switzerland (J.B., T.N., R.T., K.W., P.B., J.C., T.B., P.M., S.C., K.G., M.R.G., C.P., S.S., D.F.W., J.F., P.H., Z.S., U.H., N.S., N.K., J.L. W.K., S.O., T.R., C.M.); Department of Internal Medicine, University Hospital Basel, University of Basel, Switzerland (J.B., T.N., K.G., P.H., N.S.); GREAT Network (J.B., T.N., R.T., K.W., P.B., J.C., S.C., K.G., M.R.G., C.P., S.S., D.F.W
| | - Wanda Kloos
- From Cardiovascular Research Institute Basel and Department of Cardiology, University Hospital Basel, University of Basel, Switzerland (J.B., T.N., R.T., K.W., P.B., J.C., T.B., P.M., S.C., K.G., M.R.G., C.P., S.S., D.F.W., J.F., P.H., Z.S., U.H., N.S., N.K., J.L. W.K., S.O., T.R., C.M.); Department of Internal Medicine, University Hospital Basel, University of Basel, Switzerland (J.B., T.N., K.G., P.H., N.S.); GREAT Network (J.B., T.N., R.T., K.W., P.B., J.C., S.C., K.G., M.R.G., C.P., S.S., D.F.W
| | - Andreas Buser
- From Cardiovascular Research Institute Basel and Department of Cardiology, University Hospital Basel, University of Basel, Switzerland (J.B., T.N., R.T., K.W., P.B., J.C., T.B., P.M., S.C., K.G., M.R.G., C.P., S.S., D.F.W., J.F., P.H., Z.S., U.H., N.S., N.K., J.L. W.K., S.O., T.R., C.M.); Department of Internal Medicine, University Hospital Basel, University of Basel, Switzerland (J.B., T.N., K.G., P.H., N.S.); GREAT Network (J.B., T.N., R.T., K.W., P.B., J.C., S.C., K.G., M.R.G., C.P., S.S., D.F.W
| | - Nicolas Geigy
- From Cardiovascular Research Institute Basel and Department of Cardiology, University Hospital Basel, University of Basel, Switzerland (J.B., T.N., R.T., K.W., P.B., J.C., T.B., P.M., S.C., K.G., M.R.G., C.P., S.S., D.F.W., J.F., P.H., Z.S., U.H., N.S., N.K., J.L. W.K., S.O., T.R., C.M.); Department of Internal Medicine, University Hospital Basel, University of Basel, Switzerland (J.B., T.N., K.G., P.H., N.S.); GREAT Network (J.B., T.N., R.T., K.W., P.B., J.C., S.C., K.G., M.R.G., C.P., S.S., D.F.W
| | - Dagmar I. Keller
- From Cardiovascular Research Institute Basel and Department of Cardiology, University Hospital Basel, University of Basel, Switzerland (J.B., T.N., R.T., K.W., P.B., J.C., T.B., P.M., S.C., K.G., M.R.G., C.P., S.S., D.F.W., J.F., P.H., Z.S., U.H., N.S., N.K., J.L. W.K., S.O., T.R., C.M.); Department of Internal Medicine, University Hospital Basel, University of Basel, Switzerland (J.B., T.N., K.G., P.H., N.S.); GREAT Network (J.B., T.N., R.T., K.W., P.B., J.C., S.C., K.G., M.R.G., C.P., S.S., D.F.W
| | - Stefan Osswald
- From Cardiovascular Research Institute Basel and Department of Cardiology, University Hospital Basel, University of Basel, Switzerland (J.B., T.N., R.T., K.W., P.B., J.C., T.B., P.M., S.C., K.G., M.R.G., C.P., S.S., D.F.W., J.F., P.H., Z.S., U.H., N.S., N.K., J.L. W.K., S.O., T.R., C.M.); Department of Internal Medicine, University Hospital Basel, University of Basel, Switzerland (J.B., T.N., K.G., P.H., N.S.); GREAT Network (J.B., T.N., R.T., K.W., P.B., J.C., S.C., K.G., M.R.G., C.P., S.S., D.F.W
| | - Tobias Reichlin
- From Cardiovascular Research Institute Basel and Department of Cardiology, University Hospital Basel, University of Basel, Switzerland (J.B., T.N., R.T., K.W., P.B., J.C., T.B., P.M., S.C., K.G., M.R.G., C.P., S.S., D.F.W., J.F., P.H., Z.S., U.H., N.S., N.K., J.L. W.K., S.O., T.R., C.M.); Department of Internal Medicine, University Hospital Basel, University of Basel, Switzerland (J.B., T.N., K.G., P.H., N.S.); GREAT Network (J.B., T.N., R.T., K.W., P.B., J.C., S.C., K.G., M.R.G., C.P., S.S., D.F.W
| | - Christian Mueller
- From Cardiovascular Research Institute Basel and Department of Cardiology, University Hospital Basel, University of Basel, Switzerland (J.B., T.N., R.T., K.W., P.B., J.C., T.B., P.M., S.C., K.G., M.R.G., C.P., S.S., D.F.W., J.F., P.H., Z.S., U.H., N.S., N.K., J.L. W.K., S.O., T.R., C.M.); Department of Internal Medicine, University Hospital Basel, University of Basel, Switzerland (J.B., T.N., K.G., P.H., N.S.); GREAT Network (J.B., T.N., R.T., K.W., P.B., J.C., S.C., K.G., M.R.G., C.P., S.S., D.F.W
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Mueller C, Roffi M. Letter by Mueller and Roffi Regarding Article, "Assessment of the European Society of Cardiology 0-Hour/1-Hour Algorithm to Rule-Out and Rule-In Acute Myocardial Infarction". Circulation 2017; 135:e921-e922. [PMID: 28416528 DOI: 10.1161/circulationaha.116.026418] [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: 11/16/2022]
Affiliation(s)
- Christian Mueller
- From Department of Cardiology, Cardiovascular Research Institute Basel, University Hospital Basel, Switzerland (C.M.); and Division of Cardiology, University Hospital, Geneva, Switzerland (M.R.)
| | - Marco Roffi
- From Department of Cardiology, Cardiovascular Research Institute Basel, University Hospital Basel, Switzerland (C.M.); and Division of Cardiology, University Hospital, Geneva, Switzerland (M.R.)
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Hammadah M, Al Mheid I, Wilmot K, Ramadan R, Alkhoder A, Obideen M, Abdelhadi N, Fang S, Ibeanu I, Pimple P, Mohamed Kelli H, Shah AJ, Pearce B, Sun Y, Garcia EV, Kutner M, Long Q, Ward L, Bremner JD, Esteves F, Raggi P, Sheps D, Vaccarino V, Quyyumi AA. Association Between High-Sensitivity Cardiac Troponin Levels and Myocardial Ischemia During Mental Stress and Conventional Stress. JACC Cardiovasc Imaging 2017; 11:603-611. [PMID: 28330661 DOI: 10.1016/j.jcmg.2016.11.021] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2016] [Revised: 11/10/2016] [Accepted: 11/17/2016] [Indexed: 01/12/2023]
Abstract
OBJECTIVES This study sought to investigate whether patients with mental stress-induced myocardial ischemia will have high resting and post-mental stress high-sensitivity cardiac troponin I (hs-cTnI). BACKGROUND Hs-cTnI is a marker of myocardial necrosis, and its elevated levels are associated with adverse outcomes. Hs-cTnI levels may increase with exercise in patients with coronary artery disease. Mental stress-induced myocardial ischemia is also linked to adverse outcomes. METHODS In this study, 587 patients with stable coronary artery disease underwent technetium Tc 99m sestamibi-single-photon emission tomography myocardial perfusion imaging during mental stress testing using a public speaking task and during conventional (pharmacological/exercise) stress testing as a control condition. Ischemia was defined as new/worsening impairment in myocardial perfusion using a 17-segment model. RESULTS The median hs-cTnI resting level was 4.3 (interquartile range [IQR]: 2.9 to 7.3) pg/ml. Overall, 16% and 34.8% of patients developed myocardial ischemia during mental and conventional stress, respectively. Compared with those without ischemia, median resting hs-cTnI levels were higher in patients who developed ischemia either during mental stress (5.9 [IQR: 3.9 to 8.3] pg/ml vs. 4.1 [IQR: 2.7 to 7.0] pg/ml; p < 0.001) or during conventional stress (5.4 [IQR: 3.9 to 9.3] pg/ml vs. 3.9 [IQR: 2.5 to 6.5] pg/ml; p < 0.001). Patients with high hs-cTnI (cutoff of 4.6 pg/ml for men and 3.9 pg/ml for women) had greater odds of developing mental (odds ratio [OR]: 2.4; 95% confidence interval [CI]: 1.5 to 3.9; p < 0.001) and conventional (OR: 2.4; 95% CI: 1.7 to 3.4; p < 0.001) stress-induced ischemia. Although there was a significant increase in 45-min post-treadmill exercise hs-cTnI levels in those who developed ischemia, there was no significant increase after mental or pharmacological stress test. CONCLUSIONS In patients with coronary artery disease, myocardial ischemia during either mental stress or conventional stress is associated with higher resting levels of hs-cTnI. This suggests that hs-cTnI elevation is an indicator of chronic ischemic burden experienced during everyday life. Whether elevated hs-cTnI levels are an indicator of adverse prognosis beyond inducible ischemia or whether it is amenable to intervention requires further investigation.
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Affiliation(s)
- Muhammad Hammadah
- Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, Georgia
| | - Ibhar Al Mheid
- Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, Georgia
| | - Kobina Wilmot
- Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, Georgia
| | - Ronnie Ramadan
- Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, Georgia
| | - Ayman Alkhoder
- Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, Georgia
| | - Malik Obideen
- Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, Georgia
| | - Naser Abdelhadi
- Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, Georgia
| | - Shuyang Fang
- Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, Georgia; Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Ijeoma Ibeanu
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Pratik Pimple
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Heval Mohamed Kelli
- Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, Georgia
| | - Amit J Shah
- Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, Georgia; Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Brad Pearce
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Yan Sun
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Ernest V Garcia
- Department of Radiology, Emory University School of Medicine, Atlanta, Georgia
| | - Michael Kutner
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Qi Long
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Laura Ward
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - J Douglas Bremner
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, Georgia
| | - Fabio Esteves
- Department of Radiology, Emory University School of Medicine, Atlanta, Georgia
| | - Paolo Raggi
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia; Department of Radiology, Emory University School of Medicine, Atlanta, Georgia; Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Alberta, Canada
| | - David Sheps
- Department of Epidemiology, University of Florida, Gainesville, Florida
| | - Viola Vaccarino
- Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, Georgia; Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Arshed A Quyyumi
- Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, Georgia.
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Limkakeng AT, Drake W, Lokhnygina Y, Meyers HP, Shogilev D, Christenson RH, Newby LK. Myocardial Ischemia on Exercise Stress Echocardiography Testing Is Not Associated with Changes in Troponin T Concentrations. J Appl Lab Med 2017; 1:532-543. [PMID: 33379806 DOI: 10.1373/jalm.2016.021667] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2016] [Accepted: 11/01/2016] [Indexed: 11/06/2022]
Abstract
BACKGROUND Some posit that any amount of myocardial ischemia can be detected by high-sensitivity cardiac troponin assays. We hypothesized that patients with myocardial ischemia induced by exercise stress would have significantly higher increases in high-sensitivity cardiac troponin T (hs-cTnT) concentrations than patients without ischemia. METHODS We prospectively recruited for a biorepository 317 adult patients who presented to an academic hospital emergency department for evaluation possible ischemic symptoms and who were scheduled for exercise echocardiography. Blood samples were obtained before stress testing and 2-h post-testing. For this study, plasma hs-cTnT (Roche Diagnostics) concentrations were determined in a core laboratory blinded to clinical status. Absolute and relative changes between baseline and 2-h post-stress measurements were compared between patients with and without ischemia induced by stress testing. RESULTS The median age was 51 (44.0, 60.0) years, 45.9% were male, and 37.8% were African American. In total, 26 patients (8.1%) had myocardial ischemia induced by exercise. Median baseline, 2-h post-stress, and absolute δ concentrations were, respectively, 6.0, 8.0, and 0.2 ng/L for patients with evidence of ischemia; 3.8, 4.6, and 0.0 ng/L for those without; and 3.9, 4.9, and 0.0 ng/L overall. Baseline and 2-h hs-cTnT concentrations were higher among patients with abnormal stress tests (all P ≤0.05), but absolute and relative changes in hs-cTnT concentrations were not significantly different between individuals with ischemia and individuals without. CONCLUSIONS There was no evidence of change in hs-cTnT values in response to exercise stress testing, regardless of the presence of myocardial ischemia.
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Affiliation(s)
- Alexander T Limkakeng
- Division of Emergency Medicine, Department of Surgery, Duke University School of Medicine, Durham, NC
| | - Weiying Drake
- Division of Emergency Medicine, Department of Surgery, Duke University School of Medicine, Durham, NC
| | - Yuliya Lokhnygina
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, NC
| | - Harvey P Meyers
- Division of Emergency Medicine, Department of Surgery, Duke University School of Medicine, Durham, NC
| | - Daniel Shogilev
- Division of Emergency Medicine, Department of Surgery, Duke University School of Medicine, Durham, NC
| | - Robert H Christenson
- Department of Pathology, University of Maryland School of Medicine, Baltimore, MD
| | - L Kristin Newby
- Division of Cardiology, Department of Medicine, Duke University School of Medicine, Durham, NC
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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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134
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Mueller-Hennessen M, Mueller C, Giannitsis E, Biener M, Vafaie M, deFilippi CR, Christ M, Ordóñez-Llanos J, Panteghini M, Plebani M, Verschuren F, Melki D, French JK, Christenson RH, Body R, McCord J, Dinkel C, Katus HA, Lindahl B. Serial Sampling of High-Sensitivity Cardiac Troponin T May Not Be Required for Prediction of Acute Myocardial Infarction Diagnosis in Chest Pain Patients with Highly Abnormal Concentrations at Presentation. Clin Chem 2016; 63:542-551. [PMID: 27932414 DOI: 10.1373/clinchem.2016.258392] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2016] [Accepted: 08/09/2016] [Indexed: 11/06/2022]
Abstract
BACKGROUND Guidelines for diagnosing acute myocardial infarction (AMI) recommend adding kinetic changes to the initial cardiac troponin (cTn) blood concentration to improve AMI diagnosis. We hypothesized that kinetic changes may not be required in patients presenting with highly abnormal cTn. METHODS Patients presenting with suspected AMI to the emergency department were enrolled in a prospective diagnostic study. We assessed the positive predictive value (PPV) of initial high-sensitivity cardiac troponin T (hs-cTnT) blood concentrations alone and in combination with kinetic changes for AMI. Predefined relative changes (δ change of ≥20%) and absolute changes (Δ change ≥9.2 ng/L) within different time intervals (1 h, 2 h, and 4-14 h after presentation) were assessed. The final diagnosis was adjudicated by 2 independent cardiologists. RESULTS Among 1282 patients, 213 (16.6%) patients had a final diagnosis of AMI. For AMI prediction, PPVs increased from 48.8% for an initial hs-cTnT >14 ng/L to 87.2% for >60 ng/L, whereas PPVs remained unchanged for higher hs-cTnT concentrations at baseline (87.1% for both >80 ng/L and >100 ng/L). With addition of 20% relative Δ change, PPVs were not further improved in patients with baseline hs-cTnT >80 ng/L using the 1-h (84.0%) and 2-h (88.9%) intervals, and only minimally when extending the interval to 4-14 h (91.2% for >80 ng/L and 90.4% for >100 ng/L, respectively). Similar findings were observed when applying absolute changes. CONCLUSIONS In chest pain patients with highly abnormal hs-cTnT concentrations at presentation, subsequent blood draws may not be required, as they do not provide incremental diagnostic value for prediction of AMI diagnosis.
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Affiliation(s)
- Matthias Mueller-Hennessen
- Department of Internal Medicine III, Cardiology, Angiology & Pulmonology, Heidelberg University Hospital, Heidelberg, Germany
| | - Christian Mueller
- Cardiology & Cardiovascular Research Institute Basel, University Hospital Basel, Switzerland
| | - Evangelos Giannitsis
- Department of Internal Medicine III, Cardiology, Angiology & Pulmonology, Heidelberg University Hospital, Heidelberg, Germany;
| | - Moritz Biener
- Department of Internal Medicine III, Cardiology, Angiology & Pulmonology, Heidelberg University Hospital, Heidelberg, Germany
| | - Mehrshad Vafaie
- Department of Internal Medicine III, Cardiology, Angiology & Pulmonology, Heidelberg University Hospital, Heidelberg, Germany
| | | | - Michael Christ
- Department of Emergency and Critical Care Medicine, Community Hospital and Paracelsus Medical University, Nuremberg, Germany
| | - Jorge Ordóñez-Llanos
- Department of Clinical Biochemistry, Institut d'Investigacions Biomèdiques Sant Pau, Barcelona, Spain
| | - Mauro Panteghini
- Department of Biomedical and Clinical Sciences "Luigi Sacco," University of Milan Medical School, Milan, Italy
| | - Mario Plebani
- Department of Laboratory Medicine, University Hospital of Padova, Padua, Italy
| | - Franck Verschuren
- Department of Acute Medicine, Cliniques Universitaires St-Luc and Université Catholique de Louvain, Brussels, Belgium
| | - Dina Melki
- Department of Medicine, Karolinska Institutet, Huddinge and Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden
| | - John K French
- Liverpool Hospital and University of New South Wales, Sydney, Australia
| | - Robert H Christenson
- Department of Pathology, University of Maryland School of Medicine, Baltimore, MD
| | - Richard Body
- Central Manchester University Hospitals NHS Foundation Trust, UK
| | - James McCord
- Henry Ford Heart and Vascular Institute, Henry Ford Health System, Detroit, MI
| | | | - Hugo A Katus
- Department of Internal Medicine III, Cardiology, Angiology & Pulmonology, Heidelberg University Hospital, Heidelberg, Germany
| | - Bertil Lindahl
- Department of Medical Sciences and Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
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135
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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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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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137
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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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138
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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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139
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Impact of lipid markers and high-sensitivity C-reactive protein on the value of the 99th percentile upper reference limit for high-sensitivity cardiac troponin I. Clin Chim Acta 2016; 462:193-200. [DOI: 10.1016/j.cca.2016.09.020] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2016] [Revised: 09/01/2016] [Accepted: 09/25/2016] [Indexed: 01/27/2023]
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140
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Pasterkamp G, den Ruijter HM, Libby P. Temporal shifts in clinical presentation and underlying mechanisms of atherosclerotic disease. Nat Rev Cardiol 2016; 14:21-29. [DOI: 10.1038/nrcardio.2016.166] [Citation(s) in RCA: 105] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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141
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Pickering JW, Greenslade JH, Cullen L, Flaws D, Parsonage W, Aldous S, George P, Worster A, Kavsak PA, Than MP. Assessment of the European Society of Cardiology 0-Hour/1-Hour Algorithm to Rule-Out and Rule-In Acute Myocardial Infarction. Circulation 2016; 134:1532-1541. [PMID: 27754881 DOI: 10.1161/circulationaha.116.022677] [Citation(s) in RCA: 96] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2016] [Accepted: 09/22/2016] [Indexed: 11/16/2022]
Abstract
BACKGROUND The new European Society of Cardiology guidelines to rule-in and rule-out acute myocardial infarction (AMI) in the emergency department include a rapid assessment algorithm based on high-sensitivity cardiac troponin and sampling at 0 and 1 hour. Emergency department physicians require high sensitivity to confidently rule-out AMI, whereas cardiologists aim to minimize false-positive results. METHODS High-sensitivity troponin I and T assays were used to measure troponin concentrations in patients presenting with chest-pain symptoms and being investigated for possible acute coronary syndrome at hospitals in New Zealand, Australia, and Canada. AMI outcomes were independently adjudicated by at least 2 physicians. The European Society of Cardiology algorithm performance with each assay was assessed by the sensitivity and proportion with AMI ruled out and the positive predictive value and proportion ruled-in. RESULTS There were 2222 patients with serial high-sensitivity troponin T and high-sensitivity troponin I measurements. The high-sensitivity troponin T algorithm ruled out 1425 (64.1%) with a sensitivity of 97.1% (95% confidence interval [CI], 94.0%-98.8%) and ruled-in 292 (13.1%) with a positive predictive value of 63.4% (95% CI, 57.5%-68.9%).The high-sensitivity troponin I algorithm ruled out 1205 (54.2%) with a sensitivity of 98.8% (95% CI, 96.4%-99.7%)) and ruled-in 310 (14.0%) with a positive predictive value of 68.1% (95% CI, 62.6%-73.2%). CONCLUSIONS The sensitivity of the European Society of Cardiology rapid assessment 0-/1-hour algorithm to rule-out AMI with high-sensitivity troponin may be insufficient for some emergency department physicians to confidently send patients home. These algorithms may prove useful to identify patients requiring expedited management. However, the positive predictive value was modest for both algorithms.
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Affiliation(s)
- John W Pickering
- From Emergency Department (J.W.P., M.P.T.), and Cardiology Department (S.A.), Christchurch Hospital, Christchurch, New Zealand; Department of Medicine, University of Otago, Christchurch, New Zealand (J.W.P.); Department of Emergency Medicine, Royal Brisbane and Women's Hospital, The University of Queensland and School of Public Health, Queensland University of Technology, Brisbane, Australia (J.H.G., L.C., D.F.); Department of Cardiology, Royal Brisbane and Women's Hospital, Brisbane, Australia (W.P.); Canterbury Health Laboratories, Christchurch, New Zealand (P.G.); and McMaster University, Hamilton, Ontario, Canada (A.W., P.A.K.)
| | - Jaimi H Greenslade
- From Emergency Department (J.W.P., M.P.T.), and Cardiology Department (S.A.), Christchurch Hospital, Christchurch, New Zealand; Department of Medicine, University of Otago, Christchurch, New Zealand (J.W.P.); Department of Emergency Medicine, Royal Brisbane and Women's Hospital, The University of Queensland and School of Public Health, Queensland University of Technology, Brisbane, Australia (J.H.G., L.C., D.F.); Department of Cardiology, Royal Brisbane and Women's Hospital, Brisbane, Australia (W.P.); Canterbury Health Laboratories, Christchurch, New Zealand (P.G.); and McMaster University, Hamilton, Ontario, Canada (A.W., P.A.K.)
| | - Louise Cullen
- From Emergency Department (J.W.P., M.P.T.), and Cardiology Department (S.A.), Christchurch Hospital, Christchurch, New Zealand; Department of Medicine, University of Otago, Christchurch, New Zealand (J.W.P.); Department of Emergency Medicine, Royal Brisbane and Women's Hospital, The University of Queensland and School of Public Health, Queensland University of Technology, Brisbane, Australia (J.H.G., L.C., D.F.); Department of Cardiology, Royal Brisbane and Women's Hospital, Brisbane, Australia (W.P.); Canterbury Health Laboratories, Christchurch, New Zealand (P.G.); and McMaster University, Hamilton, Ontario, Canada (A.W., P.A.K.)
| | - Dylan Flaws
- From Emergency Department (J.W.P., M.P.T.), and Cardiology Department (S.A.), Christchurch Hospital, Christchurch, New Zealand; Department of Medicine, University of Otago, Christchurch, New Zealand (J.W.P.); Department of Emergency Medicine, Royal Brisbane and Women's Hospital, The University of Queensland and School of Public Health, Queensland University of Technology, Brisbane, Australia (J.H.G., L.C., D.F.); Department of Cardiology, Royal Brisbane and Women's Hospital, Brisbane, Australia (W.P.); Canterbury Health Laboratories, Christchurch, New Zealand (P.G.); and McMaster University, Hamilton, Ontario, Canada (A.W., P.A.K.)
| | - William Parsonage
- From Emergency Department (J.W.P., M.P.T.), and Cardiology Department (S.A.), Christchurch Hospital, Christchurch, New Zealand; Department of Medicine, University of Otago, Christchurch, New Zealand (J.W.P.); Department of Emergency Medicine, Royal Brisbane and Women's Hospital, The University of Queensland and School of Public Health, Queensland University of Technology, Brisbane, Australia (J.H.G., L.C., D.F.); Department of Cardiology, Royal Brisbane and Women's Hospital, Brisbane, Australia (W.P.); Canterbury Health Laboratories, Christchurch, New Zealand (P.G.); and McMaster University, Hamilton, Ontario, Canada (A.W., P.A.K.)
| | - Sally Aldous
- From Emergency Department (J.W.P., M.P.T.), and Cardiology Department (S.A.), Christchurch Hospital, Christchurch, New Zealand; Department of Medicine, University of Otago, Christchurch, New Zealand (J.W.P.); Department of Emergency Medicine, Royal Brisbane and Women's Hospital, The University of Queensland and School of Public Health, Queensland University of Technology, Brisbane, Australia (J.H.G., L.C., D.F.); Department of Cardiology, Royal Brisbane and Women's Hospital, Brisbane, Australia (W.P.); Canterbury Health Laboratories, Christchurch, New Zealand (P.G.); and McMaster University, Hamilton, Ontario, Canada (A.W., P.A.K.)
| | - Peter George
- From Emergency Department (J.W.P., M.P.T.), and Cardiology Department (S.A.), Christchurch Hospital, Christchurch, New Zealand; Department of Medicine, University of Otago, Christchurch, New Zealand (J.W.P.); Department of Emergency Medicine, Royal Brisbane and Women's Hospital, The University of Queensland and School of Public Health, Queensland University of Technology, Brisbane, Australia (J.H.G., L.C., D.F.); Department of Cardiology, Royal Brisbane and Women's Hospital, Brisbane, Australia (W.P.); Canterbury Health Laboratories, Christchurch, New Zealand (P.G.); and McMaster University, Hamilton, Ontario, Canada (A.W., P.A.K.)
| | - Andrew Worster
- From Emergency Department (J.W.P., M.P.T.), and Cardiology Department (S.A.), Christchurch Hospital, Christchurch, New Zealand; Department of Medicine, University of Otago, Christchurch, New Zealand (J.W.P.); Department of Emergency Medicine, Royal Brisbane and Women's Hospital, The University of Queensland and School of Public Health, Queensland University of Technology, Brisbane, Australia (J.H.G., L.C., D.F.); Department of Cardiology, Royal Brisbane and Women's Hospital, Brisbane, Australia (W.P.); Canterbury Health Laboratories, Christchurch, New Zealand (P.G.); and McMaster University, Hamilton, Ontario, Canada (A.W., P.A.K.)
| | - Peter A Kavsak
- From Emergency Department (J.W.P., M.P.T.), and Cardiology Department (S.A.), Christchurch Hospital, Christchurch, New Zealand; Department of Medicine, University of Otago, Christchurch, New Zealand (J.W.P.); Department of Emergency Medicine, Royal Brisbane and Women's Hospital, The University of Queensland and School of Public Health, Queensland University of Technology, Brisbane, Australia (J.H.G., L.C., D.F.); Department of Cardiology, Royal Brisbane and Women's Hospital, Brisbane, Australia (W.P.); Canterbury Health Laboratories, Christchurch, New Zealand (P.G.); and McMaster University, Hamilton, Ontario, Canada (A.W., P.A.K.)
| | - Martin P Than
- From Emergency Department (J.W.P., M.P.T.), and Cardiology Department (S.A.), Christchurch Hospital, Christchurch, New Zealand; Department of Medicine, University of Otago, Christchurch, New Zealand (J.W.P.); Department of Emergency Medicine, Royal Brisbane and Women's Hospital, The University of Queensland and School of Public Health, Queensland University of Technology, Brisbane, Australia (J.H.G., L.C., D.F.); Department of Cardiology, Royal Brisbane and Women's Hospital, Brisbane, Australia (W.P.); Canterbury Health Laboratories, Christchurch, New Zealand (P.G.); and McMaster University, Hamilton, Ontario, Canada (A.W., P.A.K.).
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142
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Al-Mohaissen MA, Carere RG, Mancini GBJ, Humphries KH, Whalen BA, Lee T, Scheuermeyer FX, Ignaszewski AP. A Plaque Disruption Index Identifies Patients with Non-STE-Type 1 Myocardial Infarction within 24 Hours of Troponin Positivity. PLoS One 2016; 11:e0164315. [PMID: 27711184 PMCID: PMC5053518 DOI: 10.1371/journal.pone.0164315] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2016] [Accepted: 09/22/2016] [Indexed: 12/11/2022] Open
Abstract
Background Markers of plaque destabilization and disruption may have a role in identifying non-STE- type 1 Myocardial Infarction in patients presenting with troponin elevation. We hypothesized that a plaque disruption index (PDI) derived from multiple biomarkers and measured within 24 hours from the first detectable troponin in patients with acute non-STE- type 1 MI (NSTEMI-A) will confirm the diagnosis and identify these patients with higher specificity when compared to individual markers and coronary angiography. Methods We examined 4 biomarkers of plaque destabilization and disruption: myeloperoxidase (MPO), high-sensitivity interleukin-6, myeloid-related protein 8/14 (MRP8/14) and pregnancy-associated plasma protein-A (PAPP-A) in 83 consecutive patients in 4 groups: stable non-obstructive coronary artery disease (CAD), stable obstructive CAD, NSTEMI-A (enrolled within 24 hours of troponin positivity), and NSTEMI-L (Late presentation NSTEMI, enrolled beyond the 24 hour limit). The PDI was calculated and the patients’ coronary angiograms were reviewed for evidence of plaque disruption. The diagnostic performance of the PDI and angiography were compared. Results Compared to other biomarkers, MPO had the highest specificity (83%) for NSTEMI-A diagnosis (P<0.05). The PDI computed from PAPP-A, MRP8/14 and MPO was higher in NSTEMI-A patients compared to the other three groups (p<0.001) and had the highest diagnostic specificity (87%) with 79% sensitivity and 86% accuracy, which were higher compared to those obtained with MPO, but did not reach statistical significance (P>0.05 for all comparisons). The PDI had higher specificity and accuracy for NSTEMI-A diagnosis compared to coronary angiography (P<0.05). Conclusions A PDI measured within 24 hour of troponin positivity has potential to identify subjects with acute Non-ST-elevation type 1 MI. Additional evidence using other marker combinations and investigation in a sufficiently large non-selected cohort is warranted to establish the diagnostic accuracy of the PDI and its potential role in differentiating type 1 and type 2 MI in patients presenting with troponin elevation of uncertain etiology.
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Affiliation(s)
- Maha A. Al-Mohaissen
- Department of Clinical Sciences, Princess Nourah bint Abdulrahman University, Riyadh, Saudi Arabia
- * E-mail:
| | - Ronald G. Carere
- Department of Medicine, Division of Cardiology, St. Paul's Hospital and the University of British Columbia, Vancouver, BC, Canada
| | - G. B. John Mancini
- Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Karin H. Humphries
- Department of Medicine, Division of Cardiology, St. Paul's Hospital and the University of British Columbia, Vancouver, BC, Canada
| | - Beth A. Whalen
- Centre for Heart Lung Innovation, St. Paul's Hospital and University of British Columbia, Vancouver, BC, Canada
| | - Terry Lee
- Centre for Health Evaluation and Outcome Sciences, St. Paul’s Hospital and University of British Columbia, Vancouver, BC, Canada
| | - Frank X. Scheuermeyer
- Department of Emergency Medicine, St. Paul's Hospital and the University of British Columbia, Vancouver, BC, Canada
| | - Andrew P. Ignaszewski
- Department of Medicine, Division of Cardiology, St. Paul's Hospital and the University of British Columbia, Vancouver, BC, Canada
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Charpentier S, Chenevier-Gobeaux C. Recommandations ESC 2015 : exclure ou confirmer le diagnostic d’infarctus du myocarde en 1 heure avec la troponine T hypersensible. Presse Med 2016; 45:859-864. [DOI: 10.1016/j.lpm.2016.05.023] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2016] [Accepted: 05/30/2016] [Indexed: 10/21/2022] Open
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Mueller C, Giannitsis E, Möckel M, Huber K, Mair J, Plebani M, Thygesen K, Jaffe AS, Lindahl B. Rapid rule out of acute myocardial infarction: novel biomarker-based strategies. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2016; 6:218-222. [DOI: 10.1177/2048872616653229] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Christian Mueller
- Department of Cardiology and Cardiovascular Research Institute Basel, University Hospital Basel, Switzerland
| | | | - Martin Möckel
- Division of Emergency Medicine and Department of Cardiology, Charite, Universitätsmedizin Berlin, Germany
| | - Kurt Huber
- 3rd Department of Medicine, Cardiology and Intensive Care Medicine, Wilhelminen Hospital, Austria
| | - Johannes Mair
- Department of Internal Medicine III – Cardiology and Angiology, Innsbruck Medical University, Austria
| | - Mario Plebani
- Department of Laboratory Medicine, University Hospital Padova, Italy
| | | | | | - Bertil Lindahl
- Department of Medical Sciences, Uppsala University and Uppsala Clinical Research Center, Sweden
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145
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Smulders MW, Kietselaer BL, Schalla S, Bucerius J, Jaarsma C, van Dieijen-Visser MP, Mingels AM, Rocca HPBL, Post M, Das M, Crijns HJ, Wildberger JE, Bekkers SC. Acute chest pain in the high-sensitivity cardiac troponin era: A changing role for noninvasive imaging? Am Heart J 2016; 177:102-11. [PMID: 27297855 DOI: 10.1016/j.ahj.2016.03.025] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2016] [Accepted: 03/30/2016] [Indexed: 02/07/2023]
Abstract
Management of patients with acute chest pain remains challenging. Cardiac biomarker testing reduces the likelihood of erroneously discharging patients with acute myocardial infarction (AMI). Despite normal contemporary troponins, physicians have still been reluctant to discharge patients without additional testing. Nowadays, the extremely high negative predictive value of current high-sensitivity cardiac troponin (hs-cTn) assays challenges this need. However, the decreased specificity of hs-cTn assays to diagnose AMI poses a new problem as noncoronary diseases (eg, pulmonary embolism, myocarditis, cardiomyopathies, hypertension, renal failure, etc) may also cause elevated hs-cTn levels. Subjecting patients with noncoronary diseases to unnecessary pharmacological therapy or invasive procedures must be prevented. Attempts to improve the positive predictive value to diagnose AMI by defining higher initial cutoff values or dynamic changes over time inherently lower the sensitivity of troponin assays. In this review, we anticipate a potential changing role of noninvasive imaging from ruling out myocardial disease when troponin values are normal toward characterizing myocardial disease when hs-cTn values are (mildly) abnormal.
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146
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Mueller C, Giannitsis E, Christ M, Ordóñez-Llanos J, deFilippi C, McCord J, Body R, Panteghini M, Jernberg T, Plebani M, Verschuren F, French J, Christenson R, Weiser S, Bendig G, Dilba P, Lindahl B, Twerenbold R, Katus HA, Popp S, Santalo-Bel M, Nowak RM, Horner D, Dolci A, Zaninotto M, Manara A, Menassanch-Volker S, Jarausch J, Zaugg C. Multicenter Evaluation of a 0-Hour/1-Hour Algorithm in the Diagnosis of Myocardial Infarction With High-Sensitivity Cardiac Troponin T. Ann Emerg Med 2016; 68:76-87.e4. [DOI: 10.1016/j.annemergmed.2015.11.013] [Citation(s) in RCA: 206] [Impact Index Per Article: 25.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2015] [Revised: 10/22/2015] [Accepted: 11/05/2015] [Indexed: 10/22/2022]
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147
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Korley FK, Jaffe AS. High Sensitivity Cardiac Troponin Assays - How to Implement them Successfully. EJIFCC 2016; 27:217-23. [PMID: 27683535 PMCID: PMC5009946] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
High sensitivity troponin (hsTn) assays provide an unprecedented opportunity to improve the detection and treatment of cardiac injury from coronary and non-coronary causes. They may also play a role in guiding the primary and secondary prevention of cardiovascular disease. However, to derive maximal benefit from their use, careful planning for the implementation of these new assays is required. In this manuscript, we will discuss actions that can be taken during hsTn pre-implementation, implementation and post-implementation phases. Key concepts for consideration in the pre-implementation phase include: the establishment of a multi-disciplinary implementation team; development of quality control procedures; education of clinical staff; modification of existing clinical workflow and provision of computerized decision support. Strategies for ensuring successful implementation and post-implementation phases will also be discussed.
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Affiliation(s)
- Frederick K. Korley
- Department of Emergency Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA,2800 Plymouth Road North Campus Research Building 026-333N Ann Arbor, Ml 48105 USA Phone: 734-647-0261
| | - Allan S. Jaffe
- Cardiovascular Division and Division of Core Clinical Laboratory Services, Departments of Medicine and Laboratory Medicine and Pathology, Mayo Clinic and Medical School, Rochester, Minnesota, USA
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Cervellin G, Mattiuzzi C, Bovo C, Lippi G. Diagnostic algorithms for acute coronary syndrome-is one better than another? ANNALS OF TRANSLATIONAL MEDICINE 2016; 4:193. [PMID: 27294089 DOI: 10.21037/atm.2016.05.16] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
The rather short history of diagnostic algorithms for investigating patients with a suspected acute coronary syndrome (ACS) has led to a constantly evolving and unquestionably chaotic scenario. Although the recent development and introduction of high-sensitivity immunoassays for the measurement of cardiac troponins has represented a paradigm shift for dispersing part of the overwhelming fog, many uncertainties remain, especially concerning the appropriate timing for serial testing and the interpretation of cardiac troponin variations over time. Therefore, the aim of this article is to review the available evidence about diagnostic algorithms for ACS which incorporate the measurement of cardiac troponins, and generate a final algorithm attempting to integrate and harmonize the many clinical and laboratory findings emerged from the recent scientific literature.
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Affiliation(s)
- Gianfranco Cervellin
- 1 Emergency Department, Academic Hospital of Parma, Parma, Italy ; 2 Medical Direction, General Hospital of Trento, Trento, Italy ; 3 Medical Direction, University Hospital of Verona, Verona, Italy ; 4 Section of Clinical Biochemistry, University of Verona, Verona, Italy
| | - Camilla Mattiuzzi
- 1 Emergency Department, Academic Hospital of Parma, Parma, Italy ; 2 Medical Direction, General Hospital of Trento, Trento, Italy ; 3 Medical Direction, University Hospital of Verona, Verona, Italy ; 4 Section of Clinical Biochemistry, University of Verona, Verona, Italy
| | - Chiara Bovo
- 1 Emergency Department, Academic Hospital of Parma, Parma, Italy ; 2 Medical Direction, General Hospital of Trento, Trento, Italy ; 3 Medical Direction, University Hospital of Verona, Verona, Italy ; 4 Section of Clinical Biochemistry, University of Verona, Verona, Italy
| | - Giuseppe Lippi
- 1 Emergency Department, Academic Hospital of Parma, Parma, Italy ; 2 Medical Direction, General Hospital of Trento, Trento, Italy ; 3 Medical Direction, University Hospital of Verona, Verona, Italy ; 4 Section of Clinical Biochemistry, University of Verona, Verona, Italy
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Möckel M, Giannitsis E, Mueller C, Huber K, Jaffe AS, Mair J, Plebani M, Thygesen K, Lindahl B. Editor’s Choice-Rule-in of acute myocardial infarction: Focus on troponin. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2016; 6:212-217. [DOI: 10.1177/2048872616653228] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Affiliation(s)
- Martin Möckel
- Division of Emergency Medicine and Department of Cardiology, Charite, Universitätsmedizin Berlin, Germany
| | | | - Christian Mueller
- Department of Cardiology and Cardiovascular Research Institute Basel, University Hospital Basel, Switzerland
| | - Kurt Huber
- 3rd Department of Medicine, Cardiology and Intensive Care Medicine, Wilhelminen Hospital, Austria
| | - Allan S Jaffe
- Cardiovascular Division and Department of Laboratory Medicine and Pathology, Mayo Clinic and Medical School, USA
| | - Johannes Mair
- Department of Internal Medicine III – Cardiology and Angiology, Innsbruck Medical University, Austria
| | - Mario Plebani
- Department of Laboratory Medicine, University Hospital Padova, Italy
| | | | - Bertil Lindahl
- Department of Medical Sciences, Uppsala University and Uppsala Clinical Research Centre, Uppsala University, Sweden
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Charpentier S, Peschanski N, Chouihed T, Ray P, Chenevier-Gobeaux C. Multicenter Evaluation of a 0-Hour/1-Hour Algorithm in the Diagnosis of Myocardial Infarction With High-Sensitivity Cardiac Troponin T. Ann Emerg Med 2016; 67:793-794. [DOI: 10.1016/j.annemergmed.2016.02.036] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2016] [Indexed: 10/21/2022]
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