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Body R, Collinson P, Goodacre S, Mills NL, Timmis A. High-sensitivity cardiac troponin at 3 hours: is the cat among the pigeons? Heart 2016; 102:1253-4. [PMID: 27325588 DOI: 10.1136/heartjnl-2016-309461] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
- Richard Body
- Central Manchester University Hospitals Foundation NHS Trust, Manchester Academic Health Science Centre, Manchester, UK Cardiovascular Institute, The University of Manchester, Manchester, UK
| | - Paul Collinson
- Department of Clinical Blood Sciences, St. George's Healthcare NHS Trust, London, UK
| | - Steve Goodacre
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Nicholas L Mills
- University/BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Adam Timmis
- NIHR Biomedical Research Unit, Bart's Heart Centre, London, UK
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152
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Ferencik M, Hoffmann U, Bamberg F, Januzzi JL. Highly sensitive troponin and coronary computed tomography angiography in the evaluation of suspected acute coronary syndrome in the emergency department. Eur Heart J 2016; 37:2397-405. [PMID: 26843275 PMCID: PMC6279199 DOI: 10.1093/eurheartj/ehw005] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2015] [Revised: 12/16/2015] [Accepted: 01/05/2016] [Indexed: 02/02/2023] Open
Abstract
The evaluation of patients presenting to the emergency department with suspected acute coronary syndrome (ACS) remains a clinical challenge. The traditional assessment includes clinical risk assessment based on cardiovascular risk factors with serial electrocardiograms and cardiac troponin measurements, often followed by advanced cardiac testing as inpatient or outpatient (i.e. stress testing, imaging). Despite this costly and lengthy work-up, there is a non-negligible rate of missed ACS with an increased risk of death. There is a clinical need for diagnostic strategies that will lead to rapid and reliable triage of patients with suspected ACS. We provide an overview of the evidence for the role of highly sensitive troponin (hsTn) in the rapid and efficient evaluation of suspected ACS. Results of recent research studies have led to the introduction of hsTn with rapid rule-in and rule-out protocols into the guidelines. Highly sensitive troponin increases the sensitivity for the detection of myocardial infarction and decreases time to diagnosis; however, it may decrease the specificity, especially when used as a dichotomous variable, rather than continuous variable as recommended by guidelines; this may increase clinician uncertainty. We summarize the evidence for the use of coronary computed tomography angiography (CTA) as the rapid diagnostic tool in this population when used with conventional troponin assays. Coronary CTA significantly decreases time to diagnosis and discharge in patients with suspected ACS, while being safe. However, it may lead to increase in invasive procedures and includes radiation exposure. Finally, we outline the opportunities for the combined use of hsTn and coronary CTA that may result in increased efficiency, decreased need for imaging, lower cost, and decreased radiation dose.
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Affiliation(s)
- Maros Ferencik
- Knight Cardiovascular Institute, Oregon Health and Science University, 3180 SW Sam Jackson Park Road, Mail Code UHN62, Portland, OR 97239, USA Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA Cardiac MR PET CT Program, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Udo Hoffmann
- Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA Cardiac MR PET CT Program, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA Cardiology Division, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Fabian Bamberg
- Department of Radiology, University of Tuebingen, Tuebingen, Germany
| | - James L Januzzi
- Cardiology Division, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
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153
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Sandoval Y, Apple FS, Smith SW. High-sensitivity cardiac troponin assays and unstable angina. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2016; 7:120-128. [DOI: 10.1177/2048872616658591] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
The term unstable angina has been conventionally applied to patients with myocardial ischemia without myocardial necrosis. However, while the clinical context has remained constant over time, the biomarkers of myocardial injury and acute myocardial infarction have evolved. High-sensitivity cardiac troponin assays have several key analytical differences from prior cardiac troponin assay generations, which may alter the diagnosis and frequency of unstable angina, as well as affect our understanding of previously developed risk stratification strategies. This document reviews the current challenges in regards to unstable angina when using high-sensitivity cardiac troponin I and T assays.
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Affiliation(s)
- Yader Sandoval
- Division of Cardiology, Department of Medicine, Hennepin County Medical Center, Minneapolis, MN, USA
- Minneapolis Heart Institute, Abbott-Northwestern Hospital, Minneapolis, MN, USA
| | - Fred S Apple
- Department of Laboratory Medicine and Pathology, Hennepin County Medical Center and University of Minnesota, Minneapolis, MN, USA
| | - Stephen W Smith
- Department of Emergency Medicine, Hennepin County Medical Center and University of Minnesota, Minneapolis, MN, USA
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154
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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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155
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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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156
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Fan F, Fang L, Moore XL, Xie X, Du XJ, White DA, O'Brien J, Thomson H, Wang J, Schneider HG, Ellims A, Barber TW, Dart AM. Plasma Macrophage Migration Inhibitor Factor Is Elevated in Response to Myocardial Ischemia. J Am Heart Assoc 2016; 5:JAHA.115.003128. [PMID: 27364992 PMCID: PMC5015363 DOI: 10.1161/jaha.115.003128] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Macrophage migration inhibitory factor (MIF) is a key regulator of inflammatory responses, including in the heart. Plasma MIF is elevated early in the course of acute myocardial infarction. In this study, we hypothesized that plasma MIF may also be increased in acute myocardial ischemia. METHODS AND RESULTS Patients undergoing cardiac stress test (stress nuclear myocardial perfusion scan or stress echocardiography) were recruited. Twenty-two patients had a stress test indicative of myocardial ischemia and were compared with 62 patients who had a negative stress test. Plasma MIF was measured by ELISA before and after the stress test. MIF was also measured in patients with peripheral arterial occlusive disease before and after exercise causing claudication. Gene and protein expression of MIF was measured in mouse cardiac and skeletal muscle tissue by real-time polymerase chain reaction and western blot, respectively. Plasma MIF was elevated at 5 and 15 minutes after stress (relative to before stress) in patients with a positive test, compared with those with a negative test. In contrast, high-sensitivity troponin T and C-reactive protein were not altered after stress in either group. MIF was not altered after exercise in PAOD patients, despite the occurrence of claudication, suggesting that plasma MIF is not a marker for skeletal muscle ischemia. This may be explained by a lower gene and protein expression of MIF in skeletal muscle than the heart. CONCLUSIONS Our results suggest that plasma MIF is an early marker for acute myocardial ischemia.
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Affiliation(s)
- Fenling Fan
- Baker IDI Heart and Diabetes Institute, Melbourne, Victoria, Australia Department of Cardiovascular Medicine, The 1st Affiliated Hospital of Medical College, Xi'an Jiaotong University, Xi'an, China
| | - Lu Fang
- Baker IDI Heart and Diabetes Institute, Melbourne, Victoria, Australia
| | - Xiao-Lei Moore
- Baker IDI Heart and Diabetes Institute, Melbourne, Victoria, Australia
| | - Xuegang Xie
- Department of Cardiovascular Medicine, The 1st Affiliated Hospital of Medical College, Xi'an Jiaotong University, Xi'an, China
| | - Xiao-Jun Du
- Baker IDI Heart and Diabetes Institute, Melbourne, Victoria, Australia
| | - David A White
- Baker IDI Heart and Diabetes Institute, Melbourne, Victoria, Australia
| | - Jessica O'Brien
- Department of Cardiovascular Medicine, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Helen Thomson
- Department of Cardiovascular Medicine, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Jun Wang
- Department of Cardiovascular Medicine, The 1st Affiliated Hospital of Medical College, Xi'an Jiaotong University, Xi'an, China
| | - Hans G Schneider
- Department of Chemical Pathology, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Andris Ellims
- Department of Cardiovascular Medicine, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Thomas W Barber
- Department of Nuclear Medicine, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Anthony M Dart
- Baker IDI Heart and Diabetes Institute, Melbourne, Victoria, Australia Department of Cardiovascular Medicine, The Alfred Hospital, Melbourne, Victoria, Australia
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157
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Parsonage WA, Mueller C, Greenslade JH, Wildi K, Pickering J, Than M, Aldous S, Boeddinghaus J, Hammett CJ, Hawkins T, Nestelberger T, Reichlin T, Reidt S, Rubin Gimenez M, Tate JR, Twerenbold R, Ungerer JP, Cullen L. Validation of NICE diagnostic guidance for rule out of myocardial infarction using high-sensitivity troponin tests. Heart 2016; 102:1279-86. [PMID: 27288278 DOI: 10.1136/heartjnl-2016-309270] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2016] [Accepted: 05/16/2016] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVE To validate the National Institute for Health and Care Excellence (NICE) recommended algorithms for high-sensitivity troponin (hsTn) assays in adults presenting with chest pain. METHODS International post hoc analysis of three prospective, observational studies from tertiary hospital emergency departments. The primary endpoint was cardiac death or acute myocardial infarction (AMI) within 24 hours of presentation, and the secondary endpoint was major adverse cardiac events (MACE) at 30 days. RESULTS 15% of patients were diagnosed with non-ST elevation myocardial infarction (MI) on admission. The hsTnI algorithm classified 2506/3128 (80.1%) of patients as 'ruled out' with 50 (2.0%) missed MI. 943/3128 (30.1%) of patients had a troponin I level below the limit of detection on admission with 2 (0.2%) missed MI. For the hsTnT algorithm, 1794/3374 (53.1%) of patients were 'ruled out' with 7 (0.4%) missed MI. 490/3374 (14.5%) of patients had a troponin T below the limit of blank on admission with no MI. MACE at 30 days occurred in 10.7% and 8.5% of patients 'ruled out' defined by the hsTnI and hsTnT algorithms, respectively. CONCLUSIONS The NICE algorithms could identify patients with low probability of AMI within 2 hours; however, neither strategy performed as predicted by the NICE diagnostic guidance model. Additionally, the rate of MACE at 30 days was sufficiently high that the algorithms should only be used as one component of a more extensive model of risk stratification. TRIAL REGISTRATION NUMBER ACTRN12611001069943, NCT00470587; post-results.
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Affiliation(s)
- W A Parsonage
- Royal Brisbane & Women's Hospital, Herston, Australia
| | - C Mueller
- Cardiovascular Research Institute, University Hospital, Basel, Switzerland
| | | | - K Wildi
- Cardiovascular Research Institute, University Hospital, Basel, Switzerland
| | - J Pickering
- Christchurch Hospital, Christchurch, New Zealand
| | - M Than
- Christchurch Hospital, Christchurch, New Zealand
| | - S Aldous
- Christchurch Hospital, Christchurch, New Zealand
| | - J Boeddinghaus
- Cardiovascular Research Institute, University Hospital, Basel, Switzerland
| | - C J Hammett
- Royal Brisbane & Women's Hospital, Herston, Australia
| | - T Hawkins
- Royal Brisbane & Women's Hospital, Herston, Australia
| | - T Nestelberger
- Cardiovascular Research Institute, University Hospital, Basel, Switzerland
| | - T Reichlin
- Cardiovascular Research Institute, University Hospital, Basel, Switzerland
| | - S Reidt
- Cardiovascular Research Institute, University Hospital, Basel, Switzerland
| | - M Rubin Gimenez
- Cardiovascular Research Institute, University Hospital, Basel, Switzerland
| | - J R Tate
- Royal Brisbane & Women's Hospital, Herston, Australia
| | - R Twerenbold
- Cardiovascular Research Institute, University Hospital, Basel, Switzerland
| | - J P Ungerer
- Royal Brisbane & Women's Hospital, Herston, Australia
| | - L Cullen
- Royal Brisbane & Women's Hospital, Herston, Australia
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158
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Chenevier-Gobeaux C, Meune C, Lefevre G, Doumenc B, Sorbets E, Peschanski N, Ray P. A single value of high-sensitive troponin T below the limit of detection is not enough for ruling out non ST elevation myocardial infarction in the emergency department. Clin Biochem 2016; 49:1113-1117. [PMID: 27234598 DOI: 10.1016/j.clinbiochem.2016.05.021] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2016] [Revised: 05/19/2016] [Accepted: 05/20/2016] [Indexed: 11/17/2022]
Abstract
BACKGROUND Recent 2015 ESC recommendations for the management of patients with suspected acute myocardial infarction (AMI) support that a single value of high-sensitivity cardiac troponin (HS-cTn) measured at presentation could rule out AMI if below the limit of blank (LoB) or detection (LoD). OBJECTIVES We aimed to evaluate whether an undetectable HS-cTnT at presentation safely rules out NSTEMI in unselected patients with chest pain. PATIENTS AND METHODS This is a post hoc analysis of two prospective cohorts with similar design that included patients suspected of AMI at three French university hospitals. Patients were followed-up during one month, before the adjudication of a final diagnosis. RESULTS 413 patients (mean age 58±17years) were analyzed; 45 (11%) had a final diagnosis of NSTEMI, and 26 (6%) had STEMI. The sensitivity of HS-cTnT value at 3ng/L (LoB) for NSTEMI was 97.8% [95% CI: 86.8-99.9], yielding a negative predictive value (NPV) of 99.3% [95% CI: 95.4-100.0]. Proportion of patients ruled out for NSTEMI was 32% when applying the LoB. The sensitivity of HS-cTnT value at 5ng/L (LoD) was 97.8% [95% CI: 86.8-99.9] yielding a NPV of 99.5% [95% CI: 96.5-100.0]. Proportion of patients ruled out for NSTEMI was 43% when applying the LoD. One patient (delay between onset of chest pain and presentation <3h) had NSTEMI and HS-cTnT <LoB at presentation. CONCLUSION The NPV of a single measurement of HS-cTnT below the LoD is high in unselected patients, but not enough to rule out safely NSTEMI for very early presenters.
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Affiliation(s)
- Camille Chenevier-Gobeaux
- Department of Automated Biological Diagnosis, Hôpital Cochin, Hôpitaux Universitaires Paris Centre (HUPC), Assistance Publique des Hôpitaux de Paris (AP-HP), 75014 Paris Cedex, France.
| | - Christophe Meune
- Department of Cardiology, Hôpital Avicenne, Hôpitaux Universitaires Paris Seine Saint Denis, Assistance Publique des Hôpitaux de Paris (AP-HP), Bobigny, Université Paris 13, UMR S-942, Paris, France
| | - Guillaume Lefevre
- Department of Biochemistry and Hormonology, Hôpital Tenon, Hôpitaux Universitaires est Parisiens (HUEP), Assistance Publique des Hôpitaux de Paris (AP-HP), 4 Rue de la Chine, 75020 Paris, France
| | - Benoit Doumenc
- Department of Emergency Medicine, Hôpital Cochin, Hôpitaux Universitaires Paris Centre (HUPC), Assistance Publique des Hôpitaux de Paris (AP-HP), 75014 Paris Cedex, France; Université Paris Descartes, France
| | - Emmanuel Sorbets
- Department of Cardiology, Hôpital Avicenne, Hôpitaux Universitaires Paris Seine Saint Denis, Assistance Publique des Hôpitaux de Paris (AP-HP), Bobigny, Université Paris 13, UMR S-942, Paris, France
| | - Nicolas Peschanski
- Department of Emergency Medicine, Hôpital Tenon, Hôpitaux Universitaires est Parisiens (HUEP), Assistance Publique des Hôpitaux de Paris (AP-HP), 4 Rue de la Chine, 75020 Paris, France
| | - Patrick Ray
- Department of Emergency Medicine, Hôpital Tenon, Hôpitaux Universitaires est Parisiens (HUEP), Assistance Publique des Hôpitaux de Paris (AP-HP), 4 Rue de la Chine, 75020 Paris, France; Sorbonne Universités UMPC Université Paris 06, Paris, DHU Fighting Aging and Stress (FAST) Université Pierre et Marie Curie Paris 6, France
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159
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COSTABEL JUANPABLO, URDAPILLETA MARCELA, LAMBARDI FLORENCIA, CAMPOS ROBERTO, VERGARA JUANMANUEL, ARIZNAVARRETA PAULA, TRIVI MARCELO. High-Sensitivity Cardiac Troponin Levels in Supraventricular Tachyarrhythmias. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2016; 39:588-91. [DOI: 10.1111/pace.12851] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/20/2015] [Revised: 02/15/2016] [Accepted: 03/13/2016] [Indexed: 11/29/2022]
Affiliation(s)
- JUAN PABLO COSTABEL
- Emergency Department; Instituto Cardiovascular de Buenos Aires (ICBA); Buenos Aires Argentina
| | - MARCELA URDAPILLETA
- Emergency Department; Instituto Cardiovascular de Buenos Aires (ICBA); Buenos Aires Argentina
| | - FLORENCIA LAMBARDI
- Emergency Department; Instituto Cardiovascular de Buenos Aires (ICBA); Buenos Aires Argentina
| | - ROBERTO CAMPOS
- Emergency Department; Instituto Cardiovascular de Buenos Aires (ICBA); Buenos Aires Argentina
| | - JUAN MANUEL VERGARA
- Emergency Department; Instituto Cardiovascular de Buenos Aires (ICBA); Buenos Aires Argentina
| | - PAULA ARIZNAVARRETA
- Emergency Department; Instituto Cardiovascular de Buenos Aires (ICBA); Buenos Aires Argentina
| | - MARCELO TRIVI
- Department of Clinical Cardiology; Instituto Cardiovascular de Buenos Aires (ICBA); Buenos Aires Argentina
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160
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Westwood M, van Asselt T, Ramaekers B, Whiting P, Thokala P, Joore M, Armstrong N, Ross J, Severens J, Kleijnen J. High-sensitivity troponin assays for the early rule-out or diagnosis of acute myocardial infarction in people with acute chest pain: a systematic review and cost-effectiveness analysis. Health Technol Assess 2016; 19:1-234. [PMID: 26118801 DOI: 10.3310/hta19440] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Early diagnosis of acute myocardial infarction (AMI) can ensure quick and effective treatment but only 20% of adults with emergency admissions for chest pain have an AMI. High-sensitivity cardiac troponin (hs-cTn) assays may allow rapid rule-out of AMI and avoidance of unnecessary hospital admissions and anxiety. OBJECTIVE To assess the clinical effectiveness and cost-effectiveness of hs-cTn assays for the early (within 4 hours of presentation) rule-out of AMI in adults with acute chest pain. METHODS Sixteen databases, including MEDLINE and EMBASE, research registers and conference proceedings, were searched to October 2013. Study quality was assessed using QUADAS-2. The bivariate model was used to estimate summary sensitivity and specificity for meta-analyses involving four or more studies, otherwise random-effects logistic regression was used. The health-economic analysis considered the long-term costs and quality-adjusted life-years (QALYs) associated with different troponin (Tn) testing methods. The de novo model consisted of a decision tree and Markov model. A lifetime time horizon (60 years) was used. RESULTS Eighteen studies were included in the clinical effectiveness review. The optimum strategy, based on the Roche assay, used a limit of blank (LoB) threshold in a presentation sample to rule out AMI [negative likelihood ratio (LR-) 0.10, 95% confidence interval (CI) 0.05 to 0.18]. Patients testing positive could then have a further test at 2 hours; a result above the 99th centile on either sample and a delta (Δ) of ≥ 20% has some potential for ruling in an AMI [positive likelihood ratio (LR+) 8.42, 95% CI 6.11 to 11.60], whereas a result below the 99th centile on both samples and a Δ of < 20% can be used to rule out an AMI (LR- 0.04, 95% CI 0.02 to 0.10). The optimum strategy, based on the Abbott assay, used a limit of detection (LoD) threshold in a presentation sample to rule out AMI (LR- 0.01, 95% CI 0.00 to 0.08). Patients testing positive could then have a further test at 3 hours; a result above the 99th centile on this sample has some potential for ruling in an AMI (LR+ 10.16, 95% CI 8.38 to 12.31), whereas a result below the 99th centile can be used to rule out an AMI (LR- 0.02, 95% CI 0.01 to 0.05). In the base-case analysis, standard Tn testing was both most effective and most costly. Strategies considered cost-effective depending upon incremental cost-effectiveness ratio thresholds were Abbott 99th centile (thresholds of < £6597), Beckman 99th centile (thresholds between £6597 and £30,042), Abbott optimal strategy (LoD threshold at presentation, followed by 99th centile threshold at 3 hours) (thresholds between £30,042 and £103,194) and the standard Tn test (thresholds over £103,194). The Roche 99th centile and the Roche optimal strategy [LoB threshold at presentation followed by 99th centile threshold and/or Δ20% (compared with presentation test) at 1-3 hours] were extendedly dominated in this analysis. CONCLUSIONS There is some evidence to suggest that hs-CTn testing may provide an effective and cost-effective approach to early rule-out of AMI. Further research is needed to clarify optimal diagnostic thresholds and testing strategies. STUDY REGISTRATION This study is registered as PROSPERO CRD42013005939. FUNDING The National Institute for Health Research Health Technology Assessment programme.
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Affiliation(s)
| | - Thea van Asselt
- Department of Clinical Epidemiology and Medical Technology Assessment, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Bram Ramaekers
- Department of Clinical Epidemiology and Medical Technology Assessment, Maastricht University Medical Centre, Maastricht, The Netherlands
| | | | - Praveen Thokala
- Health Economics and Decision Science Group, School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Manuela Joore
- Department of Clinical Epidemiology and Medical Technology Assessment, Maastricht University Medical Centre, Maastricht, The Netherlands
| | | | | | - Johan Severens
- Institute of Health Policy and Management, Erasmus University Rotterdam, Rotterdam, The Netherlands
| | - Jos Kleijnen
- School for Public Health and Primary Care (CAPHRI), Maastricht University, Maastricht, The Netherlands
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161
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Wildi K, Twerenbold R, Jaeger C, Rubini Giménez M, Reichlin T, Stoll M, Hillinger P, Puelacher C, Boeddinghaus J, Nestelberger T, Grimm K, Grob M, Rentsch K, Arnold C, Mueller C. Clinical impact of the 2010-2012 low-end shift of high-sensitivity cardiac troponin T. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2016; 5:399-408. [PMID: 27055466 DOI: 10.1177/2048872616642952] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/28/2015] [Accepted: 03/15/2016] [Indexed: 01/21/2023]
Abstract
BACKGROUND The clinical implications of the 2010-2012 low-end shift of high-sensitivity cardiac troponin T (hs-cTnT) regarding possible misdiagnosis of acute myocardial infarction are largely unknown. METHODS We aimed to quantify the impact of the 2010-2012 low-end shift and adjustment issue in 857 patients presenting to the emergency department with suspected acute myocardial infarction by comparing measurements performed with affected 2010-2012 lots with recalculated 2010-2012 values using a linear regression formula (provided by the manufacturer) and the corrected assay (re-measured in 2013). The final diagnosis was adjudicated by two independent cardiologists using all information including coronary angiography, echocardiography and serial hs-cTnT levels (with the corrected 2013 assay). RESULTS Acute myocardial infarction was the adjudicated diagnosis in 195 patients (22.7%). Median hs-TnT values were 8.5 ng/l for affected lots, 11.1 ng/l with recalculated and 10 ng/l with the corrected assay (P<0.001 for all comparisons). Spearman correlation coefficient was 0.937 (<0.001) for correct and affected respective correct and recalculated values. The Cusum test indicated significant deviation from linearity (P<0.01) for both correlations. Deviations nearly exclusively affected hs-cTnT levels below the 99th percentile (14 ng/L). Among the 195 patients with an adjudicated diagnosis of acute myocardial infarction, no patient was misclassified using affected lots if using conventional serial sampling. In contrast, misdiagnosis of acute myocardial infarction was significantly increased by affected lots if applying the novel ESC 0 h/1 h algorithm for the early rule-out of acute myocardial infarction (negative predictive value with affected lots 97.7% versus 99.7% with corrected lots). CONCLUSION The 2010-2012 hs-cTnT low-end shift affected nearly exclusively levels below the 99th percentile cut-off. While it did not affect the diagnosis of acute myocardial infarction when using conventional serial sampling as done in 2010-2012, it would impact on new early rule-out strategies using very low levels of hs-cTnT such as the ESC 0 h/1 h algorithm. CLINICAL TRIALS REGISTRATION NCT0047058, NCT00470587.
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Affiliation(s)
- Karin Wildi
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Switzerland
| | - Raphael Twerenbold
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Switzerland
| | - Cedric Jaeger
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Switzerland
| | - Maria Rubini Giménez
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Switzerland Pneumology Department, Parc de Salut Mar-IMIM-UPF, Spain Emergency Department, Parc de Salut Mar, Spain
| | - Tobias Reichlin
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Switzerland
| | - Melanie Stoll
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Switzerland
| | - Petra Hillinger
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Switzerland
| | - Christian Puelacher
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Switzerland
| | - Jasper Boeddinghaus
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Switzerland
| | - Thomas Nestelberger
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Switzerland
| | - Karin Grimm
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Switzerland
| | - Maja Grob
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Switzerland
| | | | | | - Christian Mueller
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Switzerland
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Sandoval Y, Smith SW, Apple FS. Present and Future of Cardiac Troponin in Clinical Practice: A Paradigm Shift to High-Sensitivity Assays. Am J Med 2016; 129:354-65. [PMID: 26743351 DOI: 10.1016/j.amjmed.2015.12.005] [Citation(s) in RCA: 66] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2015] [Revised: 11/30/2015] [Accepted: 12/01/2015] [Indexed: 11/19/2022]
Abstract
Despite its wide utilization and central role in the evaluation of patients with potential ischemic symptoms, misconceptions and confusion about cardiac troponin (cTn) prevail. The implementation of high-sensitivity (hs) cTn assays in clinical practice has multiple potential advantages provided there is an education process tied to the introduction of these assays that emphasizes the appropriate utilization of the test. Several diagnostic strategies have been explored with hs-cTn assays, including the use of undetectable values, accelerated serial hs-cTn sampling, hs-cTn measurements in combination with a clinical-risk score, and the use of a single hs-cTn measurement with a concentration threshold tailored to meet a clinical need. In this document we discuss basic concepts that should facilitate the integration of hs-cTn assays into clinical care in years to come.
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Affiliation(s)
- Yader Sandoval
- Division of Cardiology, Department of Medicine, Hennepin County Medical Center, Minneapolis, Minn; Minneapolis Heart Institute, Abbott-Northwestern Hospital, Minn.
| | - Stephen W Smith
- Department of Emergency Medicine, Hennepin County Medical Center and University of Minnesota, Minneapolis
| | - Fred S Apple
- Department of Laboratory Medicine and Pathology, Hennepin County Medical Center and University of Minnesota, Minneapolis
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Stallone F, Schoenenberger AW, Puelacher C, Rubini Gimenez M, Walz B, Naduvilekoot Devasia A, Bergner M, Twerenbold R, Wildi K, Reichlin T, Hillinger P, Erne P, Mueller C. Incremental value of copeptin in suspected acute myocardial infarction very early after symptom onset. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2016; 5:407-15. [PMID: 27013743 DOI: 10.1177/2048872616641289] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/04/2015] [Accepted: 03/04/2016] [Indexed: 01/30/2023]
Abstract
BACKGROUND Patients presenting very early after chest pain onset may provide a diagnostic challenge even when using a high-sensitivity cardiac troponin (hs-cTnT). We hypothesized that in these patients the incremental value of copeptin in the early diagnosis of acute myocardial infarction (AMI) may be substantial. METHODS We aimed to investigate the incremental value of copeptin in a pre-specified subgroup analysis of patients presenting with suspected AMI to the emergency department within 2 hours of symptom onset in a multicenter study. Copeptin was measured in a blinded fashion. Two independent cardiologists adjudicated the final diagnosis using all available clinical informations, including high-sensitivity cardiac troponin T (hs-cTnT). RESULTS Overall, 2000 patients were enrolled, of whom 519 (26%) arrived within 2 hours of symptom onset. Of these, 102 patients (20%) had an AMI. The additional use of copeptin did not increase diagnostic accuracy as quantified by the area under the receiver-operating characteristic curve (AUC) of hs-cTnT (0.87 (95% confidence interval (CI): 0.83-0.90) for hs-cTnT alone to 0.86 (95% CI: 0.82-0.90) for the combination; p = NS). Copeptin (using 9 pmol/L as a cut-off) increased the negative predictive value (NPV) of hs-cTnT (using 14 ng/L as a cut-off) alone from 93% (95% CI: 90-95%) to 96% (95% CI: 93-98%). The NPV for the combination of hs-cTnT and copeptin was lower in patients arriving in the first 2 hours than in those arriving after 2 hours: 96% (95% CI: 93-98%) versus 99% (95% CI: 99-100%), respectively. CONCLUSIONS The additional use of copeptin on top of hs-cTnT seems to lead to a small increase in NPV, but no increase in AUC. Routine use of copeptin in early presenters does not seem warranted.
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Affiliation(s)
- Fabio Stallone
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Switzerland Department of Internal Medicine, University Hospital Basel, Switzerland
| | - Andreas W Schoenenberger
- Division of Geriatrics, Department of General Internal Medicine, Inselspital, Bern University Hospital, Switzerland University of Bern, Switzerland
| | - Christian Puelacher
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Switzerland Department of Internal Medicine, University Hospital Basel, Switzerland
| | - Maria Rubini Gimenez
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Switzerland Department of Internal Medicine, University Hospital Basel, Switzerland
| | - Brigitte Walz
- Central Laboratory, Luzerner Kantonsspital, Switzerland
| | - Allwin Naduvilekoot Devasia
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Switzerland
| | - Michael Bergner
- Department of Intensive Care Medicine, University Hospital Basel, Switzerland
| | - Raphael Twerenbold
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Switzerland
| | - Karin Wildi
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Switzerland Department of Intensive Care Medicine, University Hospital Basel, Switzerland
| | - Tobias Reichlin
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Switzerland
| | - Petra Hillinger
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Switzerland Department of Internal Medicine, University Hospital Basel, Switzerland
| | - Paul Erne
- Department of Cardiology, Luzerner Kantonsspital, Switzerland
| | - Christian Mueller
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Switzerland
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Nestelberger T, Wildi K, Boeddinghaus J, Twerenbold R, Reichlin T, Giménez MR, Puelacher C, Jaeger C, Grimm K, Sabti Z, Hillinger P, Kozhuharov N, du Fay de Lavallaz J, Pinck F, Lopez B, Salgado E, Miró Ò, Bingisser R, Lohrmann J, Osswald S, Mueller C. Characterization of the observe zone of the ESC 2015 high-sensitivity cardiac troponin 0 h/1 h-algorithm for the early diagnosis of acute myocardial infarction. Int J Cardiol 2016; 207:238-45. [DOI: 10.1016/j.ijcard.2016.01.112] [Citation(s) in RCA: 69] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2015] [Revised: 01/02/2016] [Accepted: 01/04/2016] [Indexed: 01/12/2023]
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Mochmann HC, Scheitz JF, Petzold GC, Haeusler KG, Audebert HJ, Laufs U, Schneider C, Landmesser U, Werner N, Endres M, Witzenbichler B, Nolte CH. Coronary Angiographic Findings in Acute Ischemic Stroke Patients With Elevated Cardiac Troponin: The Troponin Elevation in Acute Ischemic Stroke (TRELAS) Study. Circulation 2016; 133:1264-71. [PMID: 26933082 DOI: 10.1161/circulationaha.115.018547] [Citation(s) in RCA: 81] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2015] [Accepted: 01/28/2016] [Indexed: 12/14/2022]
Abstract
BACKGROUND A relevant proportion of patients with acute ischemic stroke (AIS) have elevated levels of cardiac troponins (cTn). However, the frequency of coronary ischemia as the cause of elevated cTn is unknown. The aim of our study was to analyze coronary vessel status in AIS patients with elevated cTn compared with patients presenting with non-ST-segment-elevation acute coronary syndrome (NSTE-ACS). METHODS AND RESULTS Among 2123 consecutive patients with AIS prospectively screened at 2 tertiary hospitals, 13.7% had cTn elevation (>50 ng/L). According to a prespecified sample size estimation, 29 patients with AIS (median age, 76 years [first-third quartiles, 70-82 years]; 52% male) underwent conventional coronary angiography and were compared with age- and sex-matched patients with NSTE-ACS. The primary end point was presence of coronary culprit lesions on coronary angiograms as analyzed by independent interventional cardiologists blinded for clinical data. Median cTn on presentation did not differ between patients with AIS or NSTE-ACS (95 versus 94 ng/L; P=0.70). Compared with patients with NSTE-ACS, patients with AIS were less likely to have coronary culprit lesions (7 of 29 versus 23 of 29; P<0.001) or any obstructive coronary artery disease (15 of 29 versus 25 of 29; P=0.02; median number of vessels with >50% stenosis, 1 [first-third quartiles, 0-2] versus 2 [first-third quartiles, 1-3]; P<0.01). CONCLUSIONS Coronary culprit lesions are significantly less frequent in AIS patients compared with age- and sex-matched patients with NSTE-ACS despite similar baseline cTn levels. Half of all AIS patients had no angiographic evidence of coronary artery disease. Further studies are needed to clinically identify the minority of patients with AIS and angiographic evidence of a culprit lesion. CLINICAL TRIAL REGISTRATION URL: http://www.clinicaltrials.gov. Unique identifier: NCT01263964.
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Affiliation(s)
- Hans-Christian Mochmann
- From Klinik für Kardiologie (H.-C.M., U.L.) and Klinik für Neurologie (J.F.S., K.G.H., H.J.A., M.E., C.H.N.), Charité-Universitätsmedizin Berlin, Campus Benjamin Franklin, Germany; Center for Stroke Research Berlin (J.F.S., K.G.H., H.J.A., M.E., C.H.N.) and ExcellenceCluster NeuroCure (M.E.), Charité-Universitätsmedizin Berlin, Germany; German Center for Neurodegenerative Diseases and Department of Neurology(G.C.P., C.S.) and Department of Internal Medicine II (N.W.), University of Bonn, Germany; Klinik für Innere Medizin III, Kardiologie, Angiologie undInternistische Intensivmedizin, Universitätsklinikum des Saarlandes, Homburg, Germany (U.L.); German Center for Neurodegenerative Diseases, Berlin,Germany (M.E.); Berlin Institute of Health, Germany (M.E.); and Klinik für Kardiologie und Pneumologie, Helios Amper-Klinikum Dachau, Germany (B.W.)
| | - Jan F Scheitz
- From Klinik für Kardiologie (H.-C.M., U.L.) and Klinik für Neurologie (J.F.S., K.G.H., H.J.A., M.E., C.H.N.), Charité-Universitätsmedizin Berlin, Campus Benjamin Franklin, Germany; Center for Stroke Research Berlin (J.F.S., K.G.H., H.J.A., M.E., C.H.N.) and ExcellenceCluster NeuroCure (M.E.), Charité-Universitätsmedizin Berlin, Germany; German Center for Neurodegenerative Diseases and Department of Neurology(G.C.P., C.S.) and Department of Internal Medicine II (N.W.), University of Bonn, Germany; Klinik für Innere Medizin III, Kardiologie, Angiologie undInternistische Intensivmedizin, Universitätsklinikum des Saarlandes, Homburg, Germany (U.L.); German Center for Neurodegenerative Diseases, Berlin,Germany (M.E.); Berlin Institute of Health, Germany (M.E.); and Klinik für Kardiologie und Pneumologie, Helios Amper-Klinikum Dachau, Germany (B.W.)
| | - Gabor C Petzold
- From Klinik für Kardiologie (H.-C.M., U.L.) and Klinik für Neurologie (J.F.S., K.G.H., H.J.A., M.E., C.H.N.), Charité-Universitätsmedizin Berlin, Campus Benjamin Franklin, Germany; Center for Stroke Research Berlin (J.F.S., K.G.H., H.J.A., M.E., C.H.N.) and ExcellenceCluster NeuroCure (M.E.), Charité-Universitätsmedizin Berlin, Germany; German Center for Neurodegenerative Diseases and Department of Neurology(G.C.P., C.S.) and Department of Internal Medicine II (N.W.), University of Bonn, Germany; Klinik für Innere Medizin III, Kardiologie, Angiologie undInternistische Intensivmedizin, Universitätsklinikum des Saarlandes, Homburg, Germany (U.L.); German Center for Neurodegenerative Diseases, Berlin,Germany (M.E.); Berlin Institute of Health, Germany (M.E.); and Klinik für Kardiologie und Pneumologie, Helios Amper-Klinikum Dachau, Germany (B.W.)
| | - Karl Georg Haeusler
- From Klinik für Kardiologie (H.-C.M., U.L.) and Klinik für Neurologie (J.F.S., K.G.H., H.J.A., M.E., C.H.N.), Charité-Universitätsmedizin Berlin, Campus Benjamin Franklin, Germany; Center for Stroke Research Berlin (J.F.S., K.G.H., H.J.A., M.E., C.H.N.) and ExcellenceCluster NeuroCure (M.E.), Charité-Universitätsmedizin Berlin, Germany; German Center for Neurodegenerative Diseases and Department of Neurology(G.C.P., C.S.) and Department of Internal Medicine II (N.W.), University of Bonn, Germany; Klinik für Innere Medizin III, Kardiologie, Angiologie undInternistische Intensivmedizin, Universitätsklinikum des Saarlandes, Homburg, Germany (U.L.); German Center for Neurodegenerative Diseases, Berlin,Germany (M.E.); Berlin Institute of Health, Germany (M.E.); and Klinik für Kardiologie und Pneumologie, Helios Amper-Klinikum Dachau, Germany (B.W.)
| | - Heinrich J Audebert
- From Klinik für Kardiologie (H.-C.M., U.L.) and Klinik für Neurologie (J.F.S., K.G.H., H.J.A., M.E., C.H.N.), Charité-Universitätsmedizin Berlin, Campus Benjamin Franklin, Germany; Center for Stroke Research Berlin (J.F.S., K.G.H., H.J.A., M.E., C.H.N.) and ExcellenceCluster NeuroCure (M.E.), Charité-Universitätsmedizin Berlin, Germany; German Center for Neurodegenerative Diseases and Department of Neurology(G.C.P., C.S.) and Department of Internal Medicine II (N.W.), University of Bonn, Germany; Klinik für Innere Medizin III, Kardiologie, Angiologie undInternistische Intensivmedizin, Universitätsklinikum des Saarlandes, Homburg, Germany (U.L.); German Center for Neurodegenerative Diseases, Berlin,Germany (M.E.); Berlin Institute of Health, Germany (M.E.); and Klinik für Kardiologie und Pneumologie, Helios Amper-Klinikum Dachau, Germany (B.W.)
| | - Ulrich Laufs
- From Klinik für Kardiologie (H.-C.M., U.L.) and Klinik für Neurologie (J.F.S., K.G.H., H.J.A., M.E., C.H.N.), Charité-Universitätsmedizin Berlin, Campus Benjamin Franklin, Germany; Center for Stroke Research Berlin (J.F.S., K.G.H., H.J.A., M.E., C.H.N.) and ExcellenceCluster NeuroCure (M.E.), Charité-Universitätsmedizin Berlin, Germany; German Center for Neurodegenerative Diseases and Department of Neurology(G.C.P., C.S.) and Department of Internal Medicine II (N.W.), University of Bonn, Germany; Klinik für Innere Medizin III, Kardiologie, Angiologie undInternistische Intensivmedizin, Universitätsklinikum des Saarlandes, Homburg, Germany (U.L.); German Center for Neurodegenerative Diseases, Berlin,Germany (M.E.); Berlin Institute of Health, Germany (M.E.); and Klinik für Kardiologie und Pneumologie, Helios Amper-Klinikum Dachau, Germany (B.W.)
| | - Christine Schneider
- From Klinik für Kardiologie (H.-C.M., U.L.) and Klinik für Neurologie (J.F.S., K.G.H., H.J.A., M.E., C.H.N.), Charité-Universitätsmedizin Berlin, Campus Benjamin Franklin, Germany; Center for Stroke Research Berlin (J.F.S., K.G.H., H.J.A., M.E., C.H.N.) and ExcellenceCluster NeuroCure (M.E.), Charité-Universitätsmedizin Berlin, Germany; German Center for Neurodegenerative Diseases and Department of Neurology(G.C.P., C.S.) and Department of Internal Medicine II (N.W.), University of Bonn, Germany; Klinik für Innere Medizin III, Kardiologie, Angiologie undInternistische Intensivmedizin, Universitätsklinikum des Saarlandes, Homburg, Germany (U.L.); German Center for Neurodegenerative Diseases, Berlin,Germany (M.E.); Berlin Institute of Health, Germany (M.E.); and Klinik für Kardiologie und Pneumologie, Helios Amper-Klinikum Dachau, Germany (B.W.)
| | - Ulf Landmesser
- From Klinik für Kardiologie (H.-C.M., U.L.) and Klinik für Neurologie (J.F.S., K.G.H., H.J.A., M.E., C.H.N.), Charité-Universitätsmedizin Berlin, Campus Benjamin Franklin, Germany; Center for Stroke Research Berlin (J.F.S., K.G.H., H.J.A., M.E., C.H.N.) and ExcellenceCluster NeuroCure (M.E.), Charité-Universitätsmedizin Berlin, Germany; German Center for Neurodegenerative Diseases and Department of Neurology(G.C.P., C.S.) and Department of Internal Medicine II (N.W.), University of Bonn, Germany; Klinik für Innere Medizin III, Kardiologie, Angiologie undInternistische Intensivmedizin, Universitätsklinikum des Saarlandes, Homburg, Germany (U.L.); German Center for Neurodegenerative Diseases, Berlin,Germany (M.E.); Berlin Institute of Health, Germany (M.E.); and Klinik für Kardiologie und Pneumologie, Helios Amper-Klinikum Dachau, Germany (B.W.)
| | - Nikos Werner
- From Klinik für Kardiologie (H.-C.M., U.L.) and Klinik für Neurologie (J.F.S., K.G.H., H.J.A., M.E., C.H.N.), Charité-Universitätsmedizin Berlin, Campus Benjamin Franklin, Germany; Center for Stroke Research Berlin (J.F.S., K.G.H., H.J.A., M.E., C.H.N.) and ExcellenceCluster NeuroCure (M.E.), Charité-Universitätsmedizin Berlin, Germany; German Center for Neurodegenerative Diseases and Department of Neurology(G.C.P., C.S.) and Department of Internal Medicine II (N.W.), University of Bonn, Germany; Klinik für Innere Medizin III, Kardiologie, Angiologie undInternistische Intensivmedizin, Universitätsklinikum des Saarlandes, Homburg, Germany (U.L.); German Center for Neurodegenerative Diseases, Berlin,Germany (M.E.); Berlin Institute of Health, Germany (M.E.); and Klinik für Kardiologie und Pneumologie, Helios Amper-Klinikum Dachau, Germany (B.W.)
| | - Matthias Endres
- From Klinik für Kardiologie (H.-C.M., U.L.) and Klinik für Neurologie (J.F.S., K.G.H., H.J.A., M.E., C.H.N.), Charité-Universitätsmedizin Berlin, Campus Benjamin Franklin, Germany; Center for Stroke Research Berlin (J.F.S., K.G.H., H.J.A., M.E., C.H.N.) and ExcellenceCluster NeuroCure (M.E.), Charité-Universitätsmedizin Berlin, Germany; German Center for Neurodegenerative Diseases and Department of Neurology(G.C.P., C.S.) and Department of Internal Medicine II (N.W.), University of Bonn, Germany; Klinik für Innere Medizin III, Kardiologie, Angiologie undInternistische Intensivmedizin, Universitätsklinikum des Saarlandes, Homburg, Germany (U.L.); German Center for Neurodegenerative Diseases, Berlin,Germany (M.E.); Berlin Institute of Health, Germany (M.E.); and Klinik für Kardiologie und Pneumologie, Helios Amper-Klinikum Dachau, Germany (B.W.)
| | - Bernhard Witzenbichler
- From Klinik für Kardiologie (H.-C.M., U.L.) and Klinik für Neurologie (J.F.S., K.G.H., H.J.A., M.E., C.H.N.), Charité-Universitätsmedizin Berlin, Campus Benjamin Franklin, Germany; Center for Stroke Research Berlin (J.F.S., K.G.H., H.J.A., M.E., C.H.N.) and ExcellenceCluster NeuroCure (M.E.), Charité-Universitätsmedizin Berlin, Germany; German Center for Neurodegenerative Diseases and Department of Neurology(G.C.P., C.S.) and Department of Internal Medicine II (N.W.), University of Bonn, Germany; Klinik für Innere Medizin III, Kardiologie, Angiologie undInternistische Intensivmedizin, Universitätsklinikum des Saarlandes, Homburg, Germany (U.L.); German Center for Neurodegenerative Diseases, Berlin,Germany (M.E.); Berlin Institute of Health, Germany (M.E.); and Klinik für Kardiologie und Pneumologie, Helios Amper-Klinikum Dachau, Germany (B.W.)
| | - Christian H Nolte
- From Klinik für Kardiologie (H.-C.M., U.L.) and Klinik für Neurologie (J.F.S., K.G.H., H.J.A., M.E., C.H.N.), Charité-Universitätsmedizin Berlin, Campus Benjamin Franklin, Germany; Center for Stroke Research Berlin (J.F.S., K.G.H., H.J.A., M.E., C.H.N.) and ExcellenceCluster NeuroCure (M.E.), Charité-Universitätsmedizin Berlin, Germany; German Center for Neurodegenerative Diseases and Department of Neurology(G.C.P., C.S.) and Department of Internal Medicine II (N.W.), University of Bonn, Germany; Klinik für Innere Medizin III, Kardiologie, Angiologie undInternistische Intensivmedizin, Universitätsklinikum des Saarlandes, Homburg, Germany (U.L.); German Center for Neurodegenerative Diseases, Berlin,Germany (M.E.); Berlin Institute of Health, Germany (M.E.); and Klinik für Kardiologie und Pneumologie, Helios Amper-Klinikum Dachau, Germany (B.W.).
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Boeddinghaus J, Reichlin T, Cullen L, Greenslade JH, Parsonage WA, Hammett C, Pickering JW, Hawkins T, Aldous S, Twerenbold R, Wildi K, Nestelberger T, Grimm K, Rubini Gimenez M, Puelacher C, Kern V, Rentsch K, Than M, Mueller C. Two-Hour Algorithm for Triage toward Rule-Out and Rule-In of Acute Myocardial Infarction by Use of High-Sensitivity Cardiac Troponin I. Clin Chem 2016; 62:494-504. [DOI: 10.1373/clinchem.2015.249508] [Citation(s) in RCA: 81] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2015] [Accepted: 12/23/2015] [Indexed: 11/06/2022]
Abstract
Abstract
BACKGROUND
The early triage of patients toward rule-out and rule-in of acute myocardial infarction (AMI) is challenging. Therefore, we aimed to develop a 2-h algorithm that uses high-sensitivity cardiac troponin I (hs-cTnI).
METHODS
We prospectively enrolled 1435 (derivation cohort) and 1194 (external validation cohort) patients presenting with suspected AMI to the emergency department. The final diagnosis was adjudicated by 2 independent cardiologists. hs-cTnI was measured at presentation and after 2 h in a blinded fashion. We derived and validated a diagnostic algorithm incorporating hs-cTnI values at presentation and absolute changes within the first 2 h.
RESULTS
AMI was the final diagnosis in 17% of patients in the derivation and 13% in the validation cohort. The 2-h algorithm developed in the derivation cohort classified 56% of patients as rule-out, 17% as rule-in, and 27% as observation. Resulting diagnostic sensitivity and negative predictive value (NPV) were 99.2% and 99.8% for rule-out; specificity and positive predictive value (PPV) were 95.2% and 75.8% for rule-in. Applying the 2-h algorithm in the external validation cohort, 60% of patients were classified as rule-out, 13% as rule-in, and 27% as observation. Diagnostic sensitivity and NPV were 98.7% and 99.7% for rule-out; specificity and PPV were 97.4% and 82.2% for rule-in. Thirty-day survival was 100% for rule-out patients in both cohorts.
CONCLUSIONS
A simple algorithm incorporating hs-cTnI baseline values and absolute 2-h changes allowed a triage toward safe rule-out or accurate rule-in of AMI in the majority of patients.
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Affiliation(s)
- Jasper Boeddinghaus
- Cardiovascular Research Institute Basel (CRIB)
- Department of Cardiology, and
- Department of Internal Medicine, University Hospital Basel, Basel, Switzerland
| | - Tobias Reichlin
- Cardiovascular Research Institute Basel (CRIB)
- Department of Cardiology, and
| | - Louise Cullen
- Department of Emergency Medicine, Royal Brisbane and Women's Hospital, Brisbane, Australia
- School of Public Health, The Queensland University of Technology, Brisbane, Australia
| | - Jaimi H Greenslade
- Department of Emergency Medicine, Royal Brisbane and Women's Hospital, Brisbane, Australia
- School of Public Health, The Queensland University of Technology, Brisbane, Australia
| | - William A Parsonage
- School of Public Health, The Queensland University of Technology, Brisbane, Australia
- School of Medicine, The University of Queensland, Brisbane, Australia
| | | | - John W Pickering
- Department of Medicine, University of Otago, Christchurch, New Zealand
- Emergency Department, Christchurch Hospital, Christchurch, New Zealand
| | - Tracey Hawkins
- Department of Emergency Medicine, Royal Brisbane and Women's Hospital, Brisbane, Australia
- School of Public Health, The Queensland University of Technology, Brisbane, Australia
| | - Sally Aldous
- Emergency Department, Christchurch Hospital, Christchurch, New Zealand
| | - Raphael Twerenbold
- Cardiovascular Research Institute Basel (CRIB)
- Department of Cardiology, and
| | - Karin Wildi
- Cardiovascular Research Institute Basel (CRIB)
| | - Thomas Nestelberger
- Cardiovascular Research Institute Basel (CRIB)
- Department of Cardiology, and
- Department of Internal Medicine, University Hospital Basel, Basel, Switzerland
| | - Karin Grimm
- Cardiovascular Research Institute Basel (CRIB)
- Department of Cardiology, and
- Department of Internal Medicine, University Hospital Basel, Basel, Switzerland
| | | | | | - Vera Kern
- Cardiovascular Research Institute Basel (CRIB)
| | | | - Martin Than
- Emergency Department, Christchurch Hospital, Christchurch, New Zealand
| | - Christian Mueller
- Cardiovascular Research Institute Basel (CRIB)
- Department of Cardiology, and
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Prognostic Value of Undetectable hs Troponin T in Suspected Acute Coronary Syndrome. Am J Med 2016; 129:274-82.e2. [PMID: 26524709 DOI: 10.1016/j.amjmed.2015.10.016] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2015] [Revised: 10/06/2015] [Accepted: 10/06/2015] [Indexed: 11/23/2022]
Abstract
BACKGROUND The search for improved strategies for safe and early discharge of patients with suspected acute coronary syndrome in emergency departments is ongoing. This Biomarkers in Cardiology (BIC)-8 biomarker substudy evaluated the usefulness of high-sensitivity troponin T (hsTnT) below or above the limit of detection (LoD) in low-to-intermediate-risk patients with suspected acute coronary syndrome in the emergency department. METHODS Patients were categorized into hsTnT ≥ the 99th percentile, between the 99th percentile and LoD, or undetectable hsTnT (<LoD). HsTnT and copeptin were measured at admission, using a copeptin cut-off of 10 pmol/L. The primary endpoint was death and myocardial infarction within 90 days after admission. RESULTS Of 882 patients with all biomarker results, 577 (65.4%) had detectable hsTnT levels (≥LoD). Among the 305 patients (34.6%) with undetectable hsTnT, no myocardial infarctions or deaths occurred within 90 days. In patients with detectable hsTnT at admission (≥LoD but ≤99th percentile), the combined endpoint occurred in 1.5% (6/410) of the copeptin-negative patients and in 6.3% (6/96) of copeptin-positive patients within 90 days (hazard ratio 4.39; 95% confidence interval, 1.42-13.61; P = .01). In patients with an initially elevated hsTnT (≥14 ng/L), 9.7% (3/31) of the copeptin-negative patients and 15.4% (4/26) of the copeptin-positive patients experienced the combined endpoint (hazard ratio 1.61; 95% confidence interval, 0.36-7.17; P = .536). CONCLUSIONS In low-to-intermediate-risk patients with suspected acute coronary syndrome, undetectable hsTnT values at admission allow a safe discharge without occurrence of death or myocardial infarction within 90 days.
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Chenevier-Gobeaux C, Lefevre G, Bonnefoy-Cudraz E, Charpentier S, Dehoux M, Meune C, Ray P, for the SFBC, SFC and SFMU “Troponi. Why a new algorithm using high-sensitivity cardiac troponins for the rapid rule-out of NSTEMI is not adapted to routine practice. ACTA ACUST UNITED AC 2016; 54:e279-80. [DOI: 10.1515/cclm-2016-0015] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2016] [Accepted: 02/23/2016] [Indexed: 11/15/2022]
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169
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Coronary CT Angiography for Suspected ACS in the Era of High-Sensitivity Troponins. J Am Coll Cardiol 2016; 67:16-26. [DOI: 10.1016/j.jacc.2015.10.045] [Citation(s) in RCA: 108] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2015] [Revised: 08/26/2015] [Accepted: 10/20/2015] [Indexed: 02/07/2023]
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170
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One-hour rule-in and rule-out of acute myocardial infarction using high-sensitivity cardiac troponin I. Am Heart J 2016; 171:92-102.e1-5. [PMID: 26699605 DOI: 10.1016/j.ahj.2015.07.022] [Citation(s) in RCA: 84] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2015] [Accepted: 07/20/2015] [Indexed: 11/23/2022]
Abstract
UNLABELLED We aimed to prospectively derive and validate a novel 0-/1-hour algorithm using high-sensitivity cardiac troponin I (hs-cTnI) for the early "rule-out" and "rule-in" of acute myocardial infarction (AMI). METHODS In a prospective multicenter diagnostic study, we enrolled 1,500 patients presenting with suspected AMI to the emergency department. The final diagnosis was centrally adjudicated by 2 independent cardiologists blinded to hs-cTnI concentrations. The hs-cTnI (Siemens Vista) 0-/1-hour algorithm incorporated measurements performed at baseline and absolute changes within 1 hour, was derived in the first 750 patients (derivation cohort), and then validated in the second 750 (validation cohort). RESULTS Overall, AMI was the final diagnosis in 16% of patients. Applying the hs-cTnI 0-/1-hour algorithm developed in the derivation cohort to the validation cohort, 57% of patients could be classified as "rule-out"; 10%, as "rule-in"; and 33%, as "observe." In the validation cohort, the sensitivity and the negative predictive value for AMI in the "rule-out" zone were 100% (95% CI 96%-100%) and 100% (95% CI 99%-100%), respectively. The specificity and the positive predictive value (PPV) for AMI in the "rule-in" zone were 96% (95% CI 94%-97%) and 70% (95% CI 60%-79%), respectively. Negative predictive value and positive predictive value of the 0-/1-hour algorithm were higher compared to the standard of care combining hs-cTnI with the electrocardiogram (both P < .001). CONCLUSION The hs-cTnI 0-/1-hour algorithm performs very well for early rule-out as well as rule-in of AMI. The clinical implications are that used in conjunction with all other clinical information, the 0-/1-hour algorithm will be a safe and effective approach to substantially reduce time to diagnosis.
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Risk of revisits to the emergency department in admitted versus discharged patients with chest pain but without myocardial infarction in relation to high-sensitivity cardiac troponin T levels. Int J Cardiol 2016; 203:341-6. [DOI: 10.1016/j.ijcard.2015.10.170] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2015] [Revised: 08/26/2015] [Accepted: 10/19/2015] [Indexed: 11/21/2022]
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172
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Shah ASV, Anand A, Sandoval Y, Lee KK, Smith SW, Adamson PD, Chapman AR, Langdon T, Sandeman D, Vaswani A, Strachan FE, Ferry A, Stirzaker AG, Reid A, Gray AJ, Collinson PO, McAllister DA, Apple FS, Newby DE, Mills NL. High-sensitivity cardiac troponin I at presentation in patients with suspected acute coronary syndrome: a cohort study. Lancet 2015; 386:2481-8. [PMID: 26454362 PMCID: PMC4765710 DOI: 10.1016/s0140-6736(15)00391-8] [Citation(s) in RCA: 374] [Impact Index Per Article: 41.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND Suspected acute coronary syndrome is the commonest reason for emergency admission to hospital and is a large burden on health-care resources. Strategies to identify low-risk patients suitable for immediate discharge would have major benefits. METHODS We did a prospective cohort study of 6304 consecutively enrolled patients with suspected acute coronary syndrome presenting to four secondary and tertiary care hospitals in Scotland. We measured plasma troponin concentrations at presentation using a high-sensitivity cardiac troponin I assay. In derivation and validation cohorts, we evaluated the negative predictive value of a range of troponin concentrations for the primary outcome of index myocardial infarction, or subsequent myocardial infarction or cardiac death at 30 days. This trial is registered with ClinicalTrials.gov (number NCT01852123). FINDINGS 782 (16%) of 4870 patients in the derivation cohort had index myocardial infarction, with a further 32 (1%) re-presenting with myocardial infarction and 75 (2%) cardiac deaths at 30 days. In patients without myocardial infarction at presentation, troponin concentrations were less than 5 ng/L in 2311 (61%) of 3799 patients, with a negative predictive value of 99·6% (95% CI 99·3-99·8) for the primary outcome. The negative predictive value was consistent across groups stratified by age, sex, risk factors, and previous cardiovascular disease. In two independent validation cohorts, troponin concentrations were less than 5 ng/L in 594 (56%) of 1061 patients, with an overall negative predictive value of 99·4% (98·8-99·9). At 1 year, these patients had a lower risk of myocardial infarction and cardiac death than did those with a troponin concentration of 5 ng/L or more (0·6% vs 3·3%; adjusted hazard ratio 0·41, 95% CI 0·21-0·80; p<0·0001). INTERPRETATION Low plasma troponin concentrations identify two-thirds of patients at very low risk of cardiac events who could be discharged from hospital. Implementation of this approach could substantially reduce hospital admissions and have major benefits for both patients and health-care providers. FUNDING British Heart Foundation and Chief Scientist Office (Scotland).
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Affiliation(s)
- Anoop S V Shah
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK.
| | - Atul Anand
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Yader Sandoval
- Division of Cardiology, Department of Medicine, Hennepin County Medical Center, Minneapolis, MN, USA
| | - Kuan Ken Lee
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Stephen W Smith
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, MN, USA; Department of Laboratory Medicine and Pathology, University of Minnesota, Minneapolis, MN, USA
| | - Philip D Adamson
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Andrew R Chapman
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Timothy Langdon
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Dennis Sandeman
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Amar Vaswani
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Fiona E Strachan
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Amy Ferry
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | | | - Alan Reid
- Department of Biochemistry, Queen Elizabeth University Hospital, Glasgow, UK
| | - Alasdair J Gray
- Department of Emergency Medicine, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Paul O Collinson
- Division of Clinical Sciences, St George's, University of London, London, UK
| | - David A McAllister
- Centre for Population Health Sciences, University of Edinburgh, Edinburgh, UK
| | - Fred S Apple
- Department of Laboratory Medicine and Pathology, University of Minnesota, Minneapolis, MN, USA
| | - David E Newby
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Nicholas L Mills
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
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Affiliation(s)
- Louise Cullen
- Department of Emergency Medicine, Royal Brisbane and Women's Hospital, Herston, Brisbane, QLD 4029, Australia.
| | - William Parsonage
- Department of Cardiology, Royal Brisbane and Women's Hospital, Herston, Brisbane, QLD 4029, Australia
| | - Martin Than
- Emergency Department, Christchurch Hospital, Christchurch, New Zealand
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174
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Fanaroff AC, Schulteis RD, Pieper KS, Rao SV, Newby LK. Simplified Predictive Instrument to Rule Out Acute Coronary Syndromes in a High-Risk Population. J Am Heart Assoc 2015; 4:e002351. [PMID: 26667086 PMCID: PMC4845272 DOI: 10.1161/jaha.115.002351] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2015] [Accepted: 10/15/2015] [Indexed: 12/27/2022]
Abstract
BACKGROUND It is unclear whether diagnostic protocols based on cardiac markers to identify low-risk chest pain patients suitable for early release from the emergency department can be applied to patients older than 65 years or with traditional cardiac risk factors. METHODS AND RESULTS In a single-center retrospective study of 231 consecutive patients with high-risk factor burden in which a first cardiac troponin (cTn) level was measured in the emergency department and a second cTn sample was drawn 4 to 14 hours later, we compared the performance of a modified 2-Hour Accelerated Diagnostic Protocol to Assess Patients with Chest Pain Using Contemporary Troponins as the Only Biomarker (ADAPT) rule to a new risk classification scheme that identifies patients as low risk if they have no known coronary artery disease, a nonischemic electrocardiogram, and 2 cTn levels below the assay's limit of detection. Demographic and outcome data were abstracted through chart review. The median age of our population was 64 years, and 75% had Thrombosis In Myocardial Infarction risk score ≥2. Using our risk classification rule, 53 (23%) patients were low risk with a negative predictive value for 30-day cardiac events of 98%. Applying a modified ADAPT rule to our cohort, 18 (8%) patients were identified as low risk with a negative predictive value of 100%. In a sensitivity analysis, the negative predictive value of our risk algorithm did not change when we relied only on undetectable baseline cTn and eliminated the second cTn assessment. CONCLUSIONS If confirmed in prospective studies, this less-restrictive risk classification strategy could be used to safely identify chest pain patients with more traditional cardiac risk factors for early emergency department release.
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Affiliation(s)
| | | | - Karen S. Pieper
- Duke Clinical Research InstituteDuke University Medical CenterDurhamNC
| | - Sunil V. Rao
- Duke Clinical Research InstituteDuke University Medical CenterDurhamNC
- Department of MedicineDurham VA Medical CenterDurhamNC
| | - L. Kristin Newby
- Division of CardiologyDuke University Medical CenterDurhamNC
- Duke Clinical Research InstituteDuke University Medical CenterDurhamNC
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175
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Pickering JW, Young JM, George P, Aldous S, Cullen L, Greenslade JH, Richards AM, Troughton R, Ardagh M, Frampton CM, Than MP. The utility of presentation and 4-hour high sensitivity troponin I to rule-out acute myocardial infarction in the emergency department. Clin Biochem 2015; 48:1219-24. [DOI: 10.1016/j.clinbiochem.2015.07.033] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2015] [Revised: 07/23/2015] [Accepted: 07/25/2015] [Indexed: 11/28/2022]
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176
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Current approaches for the diagnosis, risk stratification and interventional treatment of patients with acute coronary syndromes without st-segment elevation. КЛИНИЧЕСКАЯ ПРАКТИКА 2015. [DOI: 10.17816/clinpract83255] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
This article reviews current approaches to diagnosis and determination of the individual risk of patients with acute coronary syndrome without ST-segment elevation. Guidelines for determining the choice of treatment strategy and the time slots for its implementation are discussed. We describe the technical features of the implementation of interventional treatment in this group of patients; the choice of methods of myocardial revascularization is discussed.
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177
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Collinson P. High-sensitivity troponin measurements: challenges and opportunities for the laboratory and the clinician. Ann Clin Biochem 2015; 53:191-5. [DOI: 10.1177/0004563215619946] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Paul Collinson
- Departments of Clinical Blood Sciences and Cardiology, St George’s Hospital and Medical School, London, UK
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178
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Altara R, Manca M, Sabra R, Eid AA, Booz GW, Zouein FA. Temporal cardiac remodeling post-myocardial infarction: dynamics and prognostic implications in personalized medicine. Heart Fail Rev 2015; 21:25-47. [PMID: 26498937 DOI: 10.1007/s10741-015-9513-8] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Despite dramatic improvements in short-term mortality rates following myocardial infarction (MI), long-term survival for MI patients who progress to heart failure remains poor. MI occurs when the left ventricle (LV) is deprived of oxygen for a sufficient period of time to induce irreversible necrosis of the myocardium. The LV response to MI involves significant tissue, cellular, and molecular level modifications, as well as substantial hemodynamic changes that feedback negatively to amplify the response. Inflammation to remove necrotic myocytes and fibroblast activation to form a scar are key wound healing responses that are highly variable across individuals. Few biomarkers of early remodeling stages are currently clinically adopted. The discovery of underlying pathophysiological mechanisms and associated novel biomarkers has the potential of improving prognostic capability and therapeutic monitoring. Combining these biomarkers with other prominent ones could constitute a powerful diagnostic and prognostic tool that directly reflects the pathophysiological remodeling of the LV. Understanding temporal remodeling at the tissue, cellular, and molecular level and its link to a well-defined set of biomarkers at early stages post-MI is a prerequisite for improving personalized care and devising more successful therapeutic interventions. Here we summarize the integral mechanisms that occur during early cardiac remodeling in the post-MI setting and highlight the most prominent biomarkers for assessing disease progression.
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Affiliation(s)
- Raffaele Altara
- Department of Physiology and Biophysics, University of Mississippi Medical Center, Jackson, MS, USA.,Department of Pharmacology and Toxicology, School of Medicine, University of Mississippi Medical Center, Jackson, MS, USA
| | - Marco Manca
- DG-DI, Medical Applications, CERN, Geneva, Switzerland
| | - Ramzi Sabra
- Department of Pharmacology and Toxicology, Faculty of Medicine, American University of Beirut, Beirut, Lebanon
| | - Assaad A Eid
- Department of Anatomy, Cell Biology and Physiological Sciences, Faculty of Medicine, American University of Beirut, Beirut, Lebanon
| | - George W Booz
- Department of Pharmacology and Toxicology, School of Medicine, University of Mississippi Medical Center, Jackson, MS, USA
| | - Fouad A Zouein
- Department of Pharmacology and Toxicology, School of Medicine, University of Mississippi Medical Center, Jackson, MS, USA. .,Department of Pharmacology and Toxicology, Faculty of Medicine, American University of Beirut, Beirut, Lebanon.
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179
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Ferencik M, Liu T, Mayrhofer T, Puchner SB, Lu MT, Maurovich-Horvat P, Pope JH, Truong QA, Udelson JE, Peacock WF, White CS, Woodard PK, Fleg JL, Nagurney JT, Januzzi JL, Hoffmann U. hs-Troponin I Followed by CT Angiography Improves Acute Coronary Syndrome Risk Stratification Accuracy and Work-Up in Acute Chest Pain Patients: Results From ROMICAT II Trial. JACC Cardiovasc Imaging 2015; 8:1272-1281. [PMID: 26476506 DOI: 10.1016/j.jcmg.2015.06.016] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2015] [Revised: 06/04/2015] [Accepted: 06/04/2015] [Indexed: 01/20/2023]
Abstract
OBJECTIVES This study compared diagnostic accuracy of conventional troponin/traditional coronary artery disease (CAD) assessment and highly sensitive troponin (hsTn) I/advanced CAD assessment for acute coronary syndrome (ACS) during the index hospitalization. BACKGROUND hsTnI and advanced assessment of CAD using coronary computed tomography angiography (CTA) are promising candidates to improve the accuracy of emergency department evaluation of patients with suspected ACS. METHODS We performed an observational cohort study in patients with suspected ACS enrolled in the ROMICAT II (Rule Out Myocardial Infarction/Ischemia using Computer Assisted Tomography) trial and randomized to coronary CTA who also had hsTnI measurement at the time of the emergency department presentation. We assessed coronary CTA for traditional (no CAD, nonobstructive CAD, ≥50% stenosis) and advanced features of CAD (≥50% stenosis, high-risk plaque features: positive remodeling, low <30-Hounsfield units plaque, napkin-ring sign, spotty calcium). RESULTS Of 160 patients (mean age: 53 ± 8 years, 40% women) 10.6% were diagnosed with ACS. The ACS rate in patients with hsTnI below the limit of detection (n = 9, 5.6%), intermediate (n = 139, 86.9%), and above the 99th percentile (n = 12, 7.5%) was 0%, 8.6%, and 58.3%, respectively. Absence of ≥50% stenosis and high-risk plaque ruled out ACS in patients with intermediate hsTnI (n = 87, 54.4%; ACS rate 0%), whereas patients with both ≥50% stenosis and high-risk plaque were at high risk (n = 13, 8.1%; ACS rate 69.2%) and patients with either ≥50% stenosis or high-risk plaque were at intermediate risk for ACS (n = 39, 24.4%; ACS rate 7.7%). hsTnI/advanced coronary CTA assessment significantly improved the diagnostic accuracy for ACS as compared to conventional troponin/traditional coronary CTA (area under the curve 0.84, 95% confidence interval [CI]: 0.80 to .88 vs. 0.74, 95% CI: 0.70 to 0.78; p < 0.001). CONCLUSIONS hsTnI at the time of presentation followed by early advanced coronary CTA assessment improves the risk stratification and diagnostic accuracy for ACS as compared to conventional troponin and traditional coronary CTA assessment. (Multicenter Study to Rule Out Myocardial Infarction/Ischemia by Cardiac Computed Tomography [ROMICAT-II]; NCT01084239).
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Affiliation(s)
- Maros Ferencik
- Knight Cardiovascular Institute, Oregon Health and Science University, Portland, OR.,Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Boston, MA.,Cardiac MR PET CT Program, Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - Ting Liu
- Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Boston, MA.,Cardiac MR PET CT Program, Massachusetts General Hospital and Harvard Medical School, Boston, MA.,Department of Radiology, First Affiliated Hospital of China Medical University, Shenyang, China
| | - Thomas Mayrhofer
- Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Boston, MA.,Cardiac MR PET CT Program, Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - Stefan B Puchner
- Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Boston, MA.,Cardiac MR PET CT Program, Massachusetts General Hospital and Harvard Medical School, Boston, MA.,Department of Biomedical Imaging and Image-Guided Therapy, Medical University Vienna, Vienna, Austria
| | - Michael T Lu
- Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Boston, MA.,Cardiac MR PET CT Program, Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - Pal Maurovich-Horvat
- TA-SE Lendület Cardiovascular Imaging Research Group, Heart and Vascular Centre, Semmelweis University, Budapest, Hungary
| | - J Hector Pope
- Department of Emergency Medicine, Baystate Medical Center, Springfield, MA
| | - Quynh A Truong
- Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Boston, MA.,Cardiac MR PET CT Program, Massachusetts General Hospital and Harvard Medical School, Boston, MA.,Dalio Institute of Cardiovascular Imaging, New York-Presbyterian Hospital and Weill Cornell Medical College
| | - James E Udelson
- Division of Cardiology and the Cardio-Vascular Center, Tufts Medical Center, Boston, MA
| | - W Frank Peacock
- Department of Emergency Medicine, Baylor College of Medicine, Houston, TX
| | | | - Pamela K Woodard
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, MO
| | - Jerome L Fleg
- Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, Bethesda, MD
| | - John T Nagurney
- Department of Emergency Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - James L Januzzi
- Cardiology Division, Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - Udo Hoffmann
- Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Boston, MA.,Cardiac MR PET CT Program, Massachusetts General Hospital and Harvard Medical School, Boston, MA.,Cardiology Division, Massachusetts General Hospital and Harvard Medical School, Boston, MA
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180
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Boeckel JN, Palapies L, Zeller T, Reis SM, von Jeinsen B, Tzikas S, Bickel C, Baldus S, Blankenberg S, Münzel T, Zeiher AM, Lackner KJ, Keller T. Estimation of Values below the Limit of Detection of a Contemporary Sensitive Troponin I Assay Improves Diagnosis of Acute Myocardial Infarction. Clin Chem 2015. [DOI: 10.1373/clinchem.2015.238949] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Abstract
BACKGROUND
The limit of detection (LoD) is the minimal amount of a substance that can be consistently detected. In the diagnosis of acute myocardial infarction (AMI) many patients present with troponin concentrations below the LoD of contemporary sensitive cardiac troponin I (cs-cTnI) assays. These censored values below the LoD influence the diagnostic performance of these assays compared to highly sensitive cTnI (hs-cTnI) assays. Therefore we assessed the impact of a new approach for interpolation of the left-censored data of a cs-cTnI assay in the evaluation of patients with suspected AMI.
METHODS
Our posthoc analysis used a real world cohort of 1818 patients with suspected MI. Data on cs-cTnI was available in 1786 patients. As a comparator the hs-cTnI version of the assay was used. To reconstruct quantities below the LoD of the cs-cTnI assay, a gamma regression approach incorporating the GRACE (Global Registry of Acute Coronary Events) score variables was used.
RESULTS
Censoring of cs-cTnI data below the LoD yielded weaker diagnostic information [area under the curve (AUC), 0.781; 95% CI, 0.731–0.831] regarding AMI compared to the hs-cTnI assay (AUC, 0.949; CI, 0.936–0.961). Use of our model to estimate cs-cTnI values below the LoD showed an AUC improvement to 0.921 (CI, 0.902–0.940). The cs-cTnI LoD concentration had a negative predictive value (NPV) of 0.950. An estimated concentration that was to be undercut by 25% of patients presenting with suspected AMI was associated with an improvement of the NPV to 0.979.
CONCLUSIONS
Estimation of values below the LoD of a cs-cTnI assay with this new approach improves the diagnostic performance in evaluation of patients with suspected AMI.
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Affiliation(s)
- Jes-Niels Boeckel
- Institute for Cardiovascular Regeneration, Center of Molecular Medicine and
- DZHK (German Centre for Cardiovascular Research), partner site Rhein-Main, Germany
| | - Lars Palapies
- Division of Cardiology, Department of Medicine III, Goethe University Frankfurt, Frankfurt, Germany
| | - Tanja Zeller
- Clinic for General and Interventional Cardiology, University Heart Centre Hamburg, Hamburg, Germany
- DZHK (German Centre for Cardiovascular Research), partner site Hamburg/Kiel/Lübeck, Germany
| | - Sophia M Reis
- Division of Cardiology, Department of Medicine III, Goethe University Frankfurt, Frankfurt, Germany
| | - Beatrice von Jeinsen
- Division of Cardiology, Department of Medicine III, Goethe University Frankfurt, Frankfurt, Germany
| | - Stergios Tzikas
- Department of Medicine II, University Medical Center, Johannes Gutenberg University, Mainz, Germany
- 3rd Department of Cardiology, Aristotle University of Thessaloniki, Ippokrateio Hospital, Thessaloniki, Greece
| | - Christoph Bickel
- Department of Internal Medicine, Federal Armed Forces Hospital, Koblenz, Germany
| | | | - Stefan Blankenberg
- Clinic for General and Interventional Cardiology, University Heart Centre Hamburg, Hamburg, Germany
- DZHK (German Centre for Cardiovascular Research), partner site Hamburg/Kiel/Lübeck, Germany
| | - Thomas Münzel
- Department of Medicine II, University Medical Center, Johannes Gutenberg University, Mainz, Germany
- DZHK (German Centre for Cardiovascular Research), partner site Rhein-Main, Germany
| | - Andreas M Zeiher
- Division of Cardiology, Department of Medicine III, Goethe University Frankfurt, Frankfurt, Germany
- DZHK (German Centre for Cardiovascular Research), partner site Rhein-Main, Germany
| | - Karl J Lackner
- Institute for Clinical Chemistry and Laboratory Medicine, University Medical Center, Johannes Gutenberg University, Mainz, Germany
| | - Till Keller
- Division of Cardiology, Department of Medicine III, Goethe University Frankfurt, Frankfurt, Germany
- DZHK (German Centre for Cardiovascular Research), partner site Rhein-Main, Germany
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181
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Roffi M, Patrono C, Collet JP, Mueller C, Valgimigli M, Andreotti F, Bax JJ, Borger MA, Brotons C, Chew DP, Gencer B, Hasenfuss G, Kjeldsen K, Lancellotti P, Landmesser U, Mehilli J, Mukherjee D, Storey RF, Windecker S. 2015 ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation. Eur Heart J 2015; 37:267-315. [PMID: 26320110 DOI: 10.1093/eurheartj/ehv320] [Citation(s) in RCA: 4226] [Impact Index Per Article: 469.6] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
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182
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Schønemann-Lund M, Schoos MM, Iversen K, Hansen SI, Thode J, Clemmensen P, Steffensen R. Retrospective Evaluation of Two Fast-track Strategies to Rule Out Acute Coronary Syndrome in a Real-life Chest Pain Population. J Emerg Med 2015; 49:833-42. [PMID: 26281816 DOI: 10.1016/j.jemermed.2015.06.026] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2015] [Revised: 06/02/2015] [Accepted: 06/12/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND The European Society of Cardiology (ESC) guideline on non-ST-elevation acute coronary syndrome (N-STE ACS) proposed a new ACS rule-out protocol. OBJECTIVES To evaluate this new tool, which uses diagnostic levels of high-sensitivity troponin T (hs-TnT; > 14 ng/L) in a slightly modified version and compare this to a recently proposed approach using undetectable levels of hs-TnT to rule out patients. METHODS There were 534 consecutive patients with suspected ACS included. Protocol 1: symptom duration, hs-TnT at 0 and 6-9 h, Global Registry of Acute Coronary Events (GRACE) score, and symptom status at 6-9 h. Protocol 2: a single blood sample of hs-TnT. The primary endpoint was a discharge diagnosis of ACS by blinded adjudication. Secondary endpoints were ACS re-admission < 30 days and 1-year mortality. RESULTS Protocol 1 classified 434/534 (81%) patients, with 27.9% being ruled out. All myocardial infarctions were correctly ruled in, but 15 cases of unstable angina were missed, resulting in a sensitivity and negative predictive value of 87.3% (79.6-92.5%) and 87.6% (80.4-92.9%), respectively. Protocol 2 ruled out 17.5% of the population, yielding a sensitivity and negative predictive value of 94.1% (88.2-97.6%) and 90.8% (81.9-96.2%), respectively. Both protocols correctly ruled in 2/3 patients with ACS re-admission < 30 days and 55/56 1-year fatalities. CONCLUSION The present study confirms the diagnostic value of a modified version of the ESC rule-out protocol (Protocol 1) in N-STE ACS patients, but also suggests that a simpler protocol using undetectable levels of hs-TnT (Protocol 2) could provide a similar or even superior sensitivity.
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Affiliation(s)
| | | | - Kasper Iversen
- Department of Cardiology, University Hospital of Copenhagen, Herlev Hospital, Herlev, Denmark
| | - Steen I Hansen
- Department of Clinical Biochemistry, University Hospital of Copenhagen, Hillerød Hospital, Hillerød, Denmark
| | - Jørgen Thode
- Department of Clinical Biochemistry, University Hospital of Copenhagen, Hillerød Hospital, Hillerød, Denmark
| | - Peter Clemmensen
- Department of Cardiology, Nykøbing Falster Sygehus, Nykøbing Falster, Denmark
| | - Rolf Steffensen
- Department of Cardiology, University Hospital of Copenhagen, Hillerød Hospital, Hillerød, Denmark
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Korley FK, George RT, Jaffe AS, Rothman RE, Sokoll LJ, Fernandez C, Falk H, Post WS, Saheed MO, Gerstenblith G, Berkowitz SA, Hill PM. Low high-sensitivity troponin I and zero coronary artery calcium score identifies coronary CT angiography candidates in whom further testing could be avoided. Acad Radiol 2015; 22:1060-7. [PMID: 26049777 DOI: 10.1016/j.acra.2015.04.007] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2014] [Revised: 04/28/2015] [Accepted: 04/29/2015] [Indexed: 10/23/2022]
Abstract
RATIONALE AND OBJECTIVES Pilot study to determine whether among subjects receiving coronary computed tomography angiography (CTA), the combination of high-sensitivity troponin I (hsTnI) and coronary artery calcium score (CACS) identifies a low-risk population in whom CTA might be avoided. MATERIALS AND METHODS A cross-sectional study of 314 symptomatic patients receiving CTA as part of their acute coronary syndrome evaluation was conducted. hsTnI was measured with Abbott Laboratories' hsTnI assay. CACSs were calculated via the Agatston method. Patients were followed for at least 30 days after discharge for the occurrence of major adverse cardiac events (MACEs; all-cause mortality, acute coronary syndrome, and revascularization). RESULTS Of 314 subjects studied, 213 (67.8%) had no coronary artery stenosis, and 67 (21.3%), 28 (8.9%), and 6 (1.9%) had maximal coronary artery stenosis of 1%-49%, 50%-69%, and 70% or greater, respectively. All MACEs occurred during index hospitalization and include one myocardial infarction and four revascularizations. Sixty-two percent (189/307) of subjects had zero CACS, and 24% (76/314) of subjects had undetected hsTnI. No subjects with undetectable hsTnI or zero CACS had an MACE. A strategy of avoiding further testing in subjects with undetectable initial hsTnI, performing CACS on subjects with detectable initial hsTnI but nonincreased hsTnI (less than 99th percentile), and obtaining CTA in subjects with Agatston greater than 0 will have a negative predictive value of 100.0% (95% confidence interval, 98.2%-100.0%). This strategy will avoid CTA in 63% (198/314) of subjects. CONCLUSIONS In this pilot study, the addition of CACS to hsTnI improves the identification of low-risk subjects in whom CTA might be avoided.
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Rubini Gimenez M, Twerenbold R, Jaeger C, Schindler C, Puelacher C, Wildi K, Reichlin T, Haaf P, Merk S, Honegger U, Wagener M, Druey S, Schumacher C, Krivoshei L, Hillinger P, Herrmann T, Campodarve I, Rentsch K, Bassetti S, Osswald S, Mueller C. One-hour rule-in and rule-out of acute myocardial infarction using high-sensitivity cardiac troponin I. Am J Med 2015; 128:861-870.e4. [PMID: 25840034 DOI: 10.1016/j.amjmed.2015.01.046] [Citation(s) in RCA: 153] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2014] [Revised: 01/23/2015] [Accepted: 01/23/2015] [Indexed: 10/23/2022]
Abstract
OBJECTIVE We aimed to prospectively derive and validate a novel 1h-algorithm using high-sensitivity cardiac troponin I (hs-cTnI) for early rule-out and rule-in of acute myocardial infarction. METHODS We performed a prospective multicenter diagnostic study enrolling 1811 patients with suspected acute myocardial infarction. The final diagnosis was centrally adjudicated by 2 independent cardiologists using all available information, including coronary angiography, echocardiography, follow-up data, and serial measurements of hs-cTnT (but not hs-cTnI). The hs-cTnI 1h-algorithm, incorporating measurements performed at baseline and absolute changes within 1 hour, was derived in a randomly selected sample of 906 patients (derivation cohort), and then validated in the remaining 905 patients (validation cohort). RESULTS Acute myocardial infarction was the final diagnosis in 18% of patients. After applying the hs-cTnI 1h-algorithm developed in the derivation cohort to the validation cohort, 50.5% of patients could be classified as "rule-out," 19% as "rule-in," 30.5% as "observe." In the validation cohort, the negative predictive value for acute myocardial infarction in the "rule-out" zone was 99.6% (95% confidence interval, 98.4%-100%), and the positive predictive value for acute myocardial infarction in the "rule-in" zone was 73.9% (95% confidence interval, 66.7%-80.2%). Negative predictive value of the 1h-algorithm was higher compared with the classical dichotomous interpretation of hs-cTnI and to the standard of care combining hs-cTnI with the electrocardiogram (both P < .001). Positive predictive value also was higher compared with the standard of care (P < .001). CONCLUSION Using a simple algorithm incorporating baseline hs-cTnI values and the absolute change within the first hour allows safe rule-out as well as accurate rule-in of acute myocardial infarction in 70% of patients presenting with suspected acute myocardial infarction.
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Affiliation(s)
- Maria Rubini Gimenez
- Department of Cardiology and Cardiovascular Research Institute Basel, University Hospital Basel, Switzerland; Servicio de Urgencias y Pneumologia, CIBERES ISC III, Hospital del Mar-Institut Municipal d'Investigació Mèdica, Barcelona, Spain
| | - Raphael Twerenbold
- Department of Cardiology and Cardiovascular Research Institute Basel, University Hospital Basel, Switzerland
| | - Cedric Jaeger
- Department of Cardiology and Cardiovascular Research Institute Basel, University Hospital Basel, Switzerland
| | - Christian Schindler
- Department of Epidemiology and Public Health, Swiss Tropical and Public Health Institute, University Basel, Switzerland
| | - Christian Puelacher
- Department of Cardiology and Cardiovascular Research Institute Basel, University Hospital Basel, Switzerland
| | - Karin Wildi
- Department of Cardiology and Cardiovascular Research Institute Basel, University Hospital Basel, Switzerland
| | - Tobias Reichlin
- Department of Cardiology and Cardiovascular Research Institute Basel, University Hospital Basel, Switzerland
| | - Philip Haaf
- Department of Cardiology and Cardiovascular Research Institute Basel, University Hospital Basel, Switzerland
| | - Salome Merk
- Department of Cardiology and Cardiovascular Research Institute Basel, University Hospital Basel, Switzerland
| | - Ursina Honegger
- Department of Cardiology and Cardiovascular Research Institute Basel, University Hospital Basel, Switzerland
| | - Max Wagener
- Department of Cardiology and Cardiovascular Research Institute Basel, University Hospital Basel, Switzerland
| | - Sophie Druey
- Department of Cardiology and Cardiovascular Research Institute Basel, University Hospital Basel, Switzerland
| | - Carmela Schumacher
- Department of Cardiology and Cardiovascular Research Institute Basel, University Hospital Basel, Switzerland
| | - Lian Krivoshei
- Department of Cardiology and Cardiovascular Research Institute Basel, University Hospital Basel, Switzerland
| | - Petra Hillinger
- Department of Cardiology and Cardiovascular Research Institute Basel, University Hospital Basel, Switzerland
| | - Thomas Herrmann
- Department of Cardiology and Cardiovascular Research Institute Basel, University Hospital Basel, Switzerland
| | - Isabel Campodarve
- Servicio de Urgencias y Pneumologia, CIBERES ISC III, Hospital del Mar-Institut Municipal d'Investigació Mèdica, Barcelona, Spain
| | | | - Stefano Bassetti
- Department of Internal Medicine, University Hospital Basel, Switzerland
| | - Stefan Osswald
- Department of Cardiology and Cardiovascular Research Institute Basel, University Hospital Basel, Switzerland
| | - Christian Mueller
- Department of Cardiology and Cardiovascular Research Institute Basel, University Hospital Basel, Switzerland.
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185
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Post F, Gori T, Giannitsis E, Darius H, Baldus S, Hamm C, Hambrecht R, Hofmeister HM, Katus H, Perings S, Senges J, Münzel T. Criteria of the German Society of Cardiology for the establishment of chest pain units: update 2014. Clin Res Cardiol 2015; 104:918-28. [PMID: 26150114 PMCID: PMC4623090 DOI: 10.1007/s00392-015-0888-2] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2014] [Accepted: 06/23/2015] [Indexed: 12/22/2022]
Abstract
Since 2008, the German Cardiac Society (DGK) has been establishing a network of certified chest pain units (CPUs). The goal of CPUs was and is to carry out differential diagnostics of acute or newly occurring chest pain of undetermined origin in a rapid and goal-oriented manner and to take immediate therapeutic measures. The basis for the previous certification process was criteria that have been established and published by the task force on CPUs. These criteria regulate the spatial and technical requirements and determine diagnostic and therapeutic strategies in patients with chest pain. Furthermore, the requirements for the organization of CPUs and the training requirements for the staff of a CPU are defined. The certification process is carried out by the DGK; currently, 225 CPUs are certified and 139 CPUs have been recertified after running for a period of 3 years. The certification criteria have now been revised and updated according to new guidelines.
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Affiliation(s)
- Felix Post
- Katholisches Klinikum Koblenz Montabaur, Koblenz, Germany
| | - Tommaso Gori
- II. Medizinische Klinik und Poliklinik für Kardiologie, Angiologie und internistische Intensivmedizin, Universitätsmedizin Mainz, Langenbeckstr. 1, 55131, Mainz, Germany
| | | | - Harald Darius
- Department für Kardiologie, Innere Medizin und Intensivmedizin, Vivantes-Klinikum Neukölln, Berlin, Germany
| | - Stephan Baldus
- Klinikum III für Innere Medizin Uniklinik Köln, Cologne, Germany
| | | | - Rainer Hambrecht
- Klinik für Kardiologie und Angiologie, Herzzentrum Bremen, Bremen, Germany
| | | | - Hugo Katus
- Klinik für KardiologieAngiologie und Pneumonologie, Heidelberg, Germany
| | | | - Jochen Senges
- Institut für Herzinfarktforschung, Ludwigshafen, Germany
| | - Thomas Münzel
- II. Medizinische Klinik und Poliklinik für Kardiologie, Angiologie und internistische Intensivmedizin, Universitätsmedizin Mainz, Langenbeckstr. 1, 55131, Mainz, Germany.
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186
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Body R, Burrows G, Carley S, Cullen L, Than M, Jaffe AS, Lewis PS. High-Sensitivity Cardiac Troponin T Concentrations below the Limit of Detection to Exclude Acute Myocardial Infarction: A Prospective Evaluation. Clin Chem 2015; 61:983-9. [DOI: 10.1373/clinchem.2014.231530] [Citation(s) in RCA: 87] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2014] [Accepted: 04/30/2015] [Indexed: 11/06/2022]
Abstract
Abstract
BACKGROUND
Initial reports suggest that concentrations of high-sensitivity cardiac troponin T (hs-cTnT) (Roche Diagnostics Elecsys®) below the limit of blank (LoB) (3 ng/L) or limit of detection (LoD) (5 ng/L) of the assay have almost 100% negative predictive value (NPV) for acute myocardial infarction (AMI), particularly among patients without electrocardiograph (ECG) evidence of ischemia. We aimed to prospectively validate those findings.
METHODS
We included adults presenting to the emergency department with suspected cardiac chest pain. Standard troponin T (cTnT) and hs-cTnT (both Roche Elecsys) were tested in samples drawn on arrival. The primary outcome was AMI, adjudicated by 2 investigators on the basis of clinical data and ≥12-h cTnT testing. We also evaluated diagnostic performance when AMI was readjudicated on the basis of hs-cTnT (≥12-h) concentrations.
RESULTS
Of 463 patients included, 79 (17.1%) had AMI. Twenty-four patients (5.2%) had hs-cTnT concentrations below the LoB, although none had AMI. Ninety-six patients (20.7%) had hs-cTnT concentrations below the LoD, 1 of whom had AMI. Thus, diagnostic sensitivity was 98.7% (95% CI 87.5%–98.6%) and NPV was 99.0% (95% CI 94.3%–100.0%). Of the 17.3% (n = 80) patients with hs-cTnT below the LoD and no ECG ischemia, none had AMI. Thus, diagnostic sensitivity was 100.0% (95% CI 95.4%–100.0%) and NPV was 100.0% (95% CI 95.5%–100.0%). Sensitivity and NPV were maintained when AMI was readjudicated on the basis of hs-cTnT.
CONCLUSIONS
Our findings confirm that patients with nonischemic ECG and undetectable hs-cTnT at presentation have a very low probability of AMI, although the proportion of patients affected was smaller than in previous research.
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Affiliation(s)
- Richard Body
- The University of Manchester, Oxford Road, Manchester, UK
- Central Manchester University Hospitals Foundation NHS Trust, Manchester Academic Health Science Centre, Oxford Road, Manchester, UK
| | | | - Simon Carley
- Central Manchester University Hospitals Foundation NHS Trust, Manchester Academic Health Science Centre, Oxford Road, Manchester, UK
- Manchester Metropolitan University, Hathersage Road, Manchester, UK
| | - Louise Cullen
- Royal Brisbane and Women's Hospital, Brisbane, Australia
| | - Martin Than
- University of Otago, Christchurch, New Zealand
| | - Allan S Jaffe
- Mayo Clinic and Mayo College of Medicine, Rochester, MN
| | - Philip S Lewis
- Stockport NHS Foundation Trust, Poplar Grove, Stockport, UK
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187
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Li WJ, Chen XM, Nie XY, Lin XX, Cheng YJ, Hu CH, Du ZM, Dong YG, Ma H, Wu SH. Early diagnostic and prognostic utility of high-sensitive troponin assays in acute myocardial infarction: a meta-analysis. Intern Med J 2015; 45:748-56. [PMID: 25403852 DOI: 10.1111/imj.12642] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2014] [Accepted: 11/12/2014] [Indexed: 11/28/2022]
Affiliation(s)
- W.-J. Li
- Department of Cardiology; The First Affiliated Hospital, Sun Yat-Sen University; Guangzhou China
- Department of Cardiology; Guangzhou First Municipal People's Hospital; Guangzhou China
| | - X.-M. Chen
- Department of Cardiology; The First Affiliated Hospital, Sun Yat-Sen University; Guangzhou China
| | - X.-Y. Nie
- Outpatient Department; The First Affiliated Hospital, Sun Yat-Sen University; Guangzhou China
| | - X.-X. Lin
- Department of Cardiology; The First Affiliated Hospital, Sun Yat-Sen University; Guangzhou China
| | - Y.-J. Cheng
- Department of Cardiology; The First Affiliated Hospital, Sun Yat-Sen University; Guangzhou China
| | - C.-H. Hu
- Department of Cardiology; The First Affiliated Hospital, Sun Yat-Sen University; Guangzhou China
| | - Z.-M. Du
- Department of Cardiology; The First Affiliated Hospital, Sun Yat-Sen University; Guangzhou China
| | - Y.-G. Dong
- Department of Cardiology; The First Affiliated Hospital, Sun Yat-Sen University; Guangzhou China
| | - H. Ma
- Department of Cardiology; The First Affiliated Hospital, Sun Yat-Sen University; Guangzhou China
| | - S.-H. Wu
- Department of Cardiology; The First Affiliated Hospital, Sun Yat-Sen University; Guangzhou China
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188
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Druey S, Wildi K, Twerenbold R, Jaeger C, Reichlin T, Haaf P, Rubini Gimenez M, Puelacher C, Wagener M, Radosavac M, Honegger U, Schumacher C, Delfine V, Kreutzinger P, Herrmann T, Moreno Weidmann Z, Krivoshei L, Freese M, Stelzig C, Isenschmid C, Bassetti S, Rentsch K, Osswald S, Mueller C. Early rule-out and rule-in of myocardial infarction using sensitive cardiac Troponin I. Int J Cardiol 2015; 195:163-70. [PMID: 26043151 DOI: 10.1016/j.ijcard.2015.05.079] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2014] [Revised: 04/22/2015] [Accepted: 05/14/2015] [Indexed: 12/18/2022]
Abstract
BACKGROUND It is currently unknown, whether and to what extent sensitive cardiac troponin (s-cTn) allows shortening of the time required for safe rule-out and rule-in of acute myocardial infarction (AMI). METHODS We aimed to develop and validate early rule-out and rule-in algorithms for AMI using a thoroughly-examined and commonly used s-cTnI assay in a prospective multicenter study including 2173 patients presenting to the emergency department with suspected AMI. S-cTnI was measured in a blinded fashion at 0 h, 1 h, and 2 h. The final diagnosis was centrally adjudicated by two independent cardiologists. In the derivation cohort (n = 1496), we developed 1h- and 2h-algorithms assigning patients to "rule-out", "rule-in", or "observe". The algorithms were then prospectively validated in the validation cohort (n = 677). RESULTS AMI was the adjudicated diagnosis in 17% of patients. After applying the s-cTnI 1h-algorithm developed in the derivation cohort to the validation cohort, 65% of patients were classified as "rule-out", 12% as "rule-in", and 23% to "observe". The negative predictive value for AMI in the "rule-out" group was 98.6% (95% CI, 96.9-99.5), the positive predictive value for AMI in the "rule-in" group 76.3% (95% CI, 65.4-85.1). Overall, 30-day mortality was 0.2% in the "rule-out" group, 1.0% in the "observe" group, and 3.0% in the "rule-in" group. Similar results were obtained for the 2h-algorithm. CONCLUSION When used in conjunction with other clinical information including the ECG, a simple algorithm incorporating s-cTnI values at presentation and after 1h (or 2h) will allow safe rule-out and accurate rule-in of AMI in the majority of patients.
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Affiliation(s)
- Sophie Druey
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Switzerland; Department of Internal Medicine, Kantonsspital Olten, Switzerland
| | - Karin Wildi
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Switzerland
| | - Raphael Twerenbold
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Switzerland
| | - Cédric Jaeger
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Switzerland
| | - Tobias Reichlin
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Switzerland
| | - Philip Haaf
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Switzerland
| | - Maria Rubini Gimenez
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Switzerland; Servicio de Urgencias y Pneumologia, CIBERES ISC III, Hospital del Mar - Institut Municipal d'Investigació Mèdica, Barcelona, Spain
| | - Christian Puelacher
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Switzerland
| | - Max Wagener
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Switzerland
| | - Milos Radosavac
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Switzerland
| | - Ursina Honegger
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Switzerland
| | - Carmela Schumacher
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Switzerland
| | - Valentina Delfine
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Switzerland
| | - Philip Kreutzinger
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Switzerland
| | - Thomas Herrmann
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Switzerland
| | - Zoraida Moreno Weidmann
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Switzerland
| | - Lian Krivoshei
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Switzerland
| | - Michael Freese
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Switzerland
| | - Claudia Stelzig
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Switzerland
| | - Cyril Isenschmid
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Switzerland
| | - Stefano Bassetti
- Department of Internal Medicine, Kantonsspital Olten, Switzerland
| | | | - Stefan Osswald
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Switzerland
| | - Christian Mueller
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Switzerland.
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Cullen L, Greenslade J, Merollini K, Graves N, Hammett CJ, Hawkins T, Than MP, Brown AF, Huang CB, Panahi SE, Dalton E, Parsonage WA. Cost and outcomes of assessing patients with chest pain in an Australian emergency department. Med J Aust 2015; 202:427-32. [DOI: 10.5694/mja14.00472] [Citation(s) in RCA: 70] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2014] [Accepted: 02/05/2015] [Indexed: 11/17/2022]
Affiliation(s)
| | | | | | | | | | | | | | | | | | | | - Emily Dalton
- Royal Brisbane and Women's Hospital, Brisbane, QLD
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190
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Copeptin testing in acute myocardial infarction: ready for routine use? DISEASE MARKERS 2015; 2015:614145. [PMID: 25960596 PMCID: PMC4415476 DOI: 10.1155/2015/614145] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/06/2014] [Accepted: 01/12/2015] [Indexed: 01/11/2023]
Abstract
Suspected acute myocardial infarction is one of the leading causes of admission to emergency departments. In the last decade, biomarkers revolutionized the management of patients with suspected acute coronary syndromes. Besides their pivotal assistance in timely diagnosis, biomarkers provide additional information for risk stratification. Cardiac troponins I and T are the most sensitive and specific markers of acute myocardial injury. Nonetheless, in order to overcome the remaining limitations of these markers, novel candidate biomarkers sensitive to early stage of disease are being extensively investigated. Among them, copeptin, a stable peptide derived from the precursor of vasopressin, emerged as a promising biomarker for the evaluation of suspected acute myocardial infarction. In this review, we summarize the currently available evidence for the usefulness of copeptin in the diagnosis and risk stratification of patients with suspected acute myocardial infarction in comparison with routine biomarkers.
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191
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Diagnostic implications of an elevated troponin in the emergency department. DISEASE MARKERS 2015; 2015:157812. [PMID: 25960590 PMCID: PMC4415742 DOI: 10.1155/2015/157812] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/25/2014] [Revised: 12/12/2014] [Accepted: 01/30/2015] [Indexed: 01/08/2023]
Abstract
Objective. To determine the proportion of initial troponin (cTn) elevations associated with Type I MI versus other cardiovascular and noncardiovascular diagnoses in an emergency department (ED) and whether or not a relationship exists between the cTn level and the likelihood of Type I MI. Background. In the ED, cTn is used as a screening test for myocardial injury. However, the differential diagnosis for an initial positive cTn result is not clear. Methods. Hospital medical records were retrospectively reviewed for visits associated with an initial positive troponin I-ultra (cTnI), ≥0.05 μg/L. Elevated cTnI levels were stratified into low (0.05–0.09), medium (0.1–0.99), or high (≥1.0). Discharge diagnoses were classified into 3 diagnostic groups (Type I MI, other cardiovascular, or noncardiovascular). Results. Of 23,731 ED visits, 4,928 (21%) had cTnI testing. Of those tested, 16.3% had initial cTnI ≥0.05. Among those with elevated cTn, 11% were classified as Type I MI, 34% had other cardiovascular diagnoses, and 55% had a noncardiovascular diagnosis. Type I MI was more common with high cTnI levels (41% incidence) than among subjects with medium (9%) or low (6%). Conclusion. A positive cTn is most likely a noncardiovascular diagnosis, but Type I MI is far more common with cTnI levels ≥1.0.
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192
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Reichlin T, Twerenbold R, Wildi K, Gimenez MR, Bergsma N, Haaf P, Druey S, Puelacher C, Moehring B, Freese M, Stelzig C, Krivoshei L, Hillinger P, Jäger C, Herrmann T, Kreutzinger P, Radosavac M, Weidmann ZM, Pershyna K, Honegger U, Wagener M, Vuillomenet T, Campodarve I, Bingisser R, Miró Ò, Rentsch K, Bassetti S, Osswald S, Mueller C. Prospective validation of a 1-hour algorithm to rule-out and rule-in acute myocardial infarction using a high-sensitivity cardiac troponin T assay. CMAJ 2015; 187:E243-E252. [PMID: 25869867 DOI: 10.1503/cmaj.141349] [Citation(s) in RCA: 169] [Impact Index Per Article: 18.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2015] [Accepted: 03/17/2015] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND We aimed to prospectively validate a novel 1-hour algorithm using high-sensitivity cardiac troponin T measurement for early rule-out and rule-in of acute myocardial infarction (MI). METHODS In a multicentre study, we enrolled 1320 patients presenting to the emergency department with suspected acute MI. The high-sensitivity cardiac troponin T 1-hour algorithm, incorporating baseline values as well as absolute changes within the first hour, was validated against the final diagnosis. The final diagnosis was then adjudicated by 2 independent cardiologists using all available information, including coronary angiography, echocardiography, follow-up data and serial measurements of high-sensitivity cardiac troponin T levels. RESULTS Acute MI was the final diagnosis in 17.3% of patients. With application of the high-sensitivity cardiac troponin T 1-hour algorithm, 786 (59.5%) patients were classified as "rule-out," 216 (16.4%) were classified as "rule-in" and 318 (24.1%) were classified to the "observational zone." The sensitivity and the negative predictive value for acute MI in the rule-out zone were 99.6% (95% confidence interval [CI] 97.6%-99.9%) and 99.9% (95% CI 99.3%-100%), respectively. The specificity and the positive predictive value for acute MI in the rule-in zone were 95.7% (95% CI 94.3%-96.8%) and 78.2% (95% CI 72.1%-83.6%), respectively. The 1-hour algorithm provided higher negative and positive predictive values than the standard interpretation of highsensitivity cardiac troponin T using a single cut-off level (both p < 0.05). Cumulative 30-day mortality was 0.0%, 1.6% and 1.9% in patients classified in the rule-out, observational and rule-in groups, respectively (p = 0.001). INTERPRETATION This rapid strategy incorporating high-sensitivity cardiac troponin T baseline values and absolute changes within the first hour substantially accelerated the management of suspected acute MI by allowing safe rule-out as well as accurate rule-in of acute MI in 3 out of 4 patients. TRIAL REGISTRATION ClinicalTrials.gov, NCT00470587.
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Affiliation(s)
- Tobias Reichlin
- Department of Cardiology and Cardiovascular Research Institute Basel (Reichlin, Twerenbold, Wildi, Rubini Gimenez, Bergsma, Haaf, Druey, Puelacher, Moehring, Freese, Stelzig, Krivoshei, Hillinger, Jäger, Herrmann, Kreutzinger, Radosavac, Weidmann, Pershyna, Honegger, Wagener, Vuillomenet, Osswald, Mueller), Universitätsspital Basel, Basel, Switzerland; Emergency Department (Rubini Gimenez, Campodarve), Internal Medicine Department, Hospital del Mar - Institut Municipal d'Investigació Mèdica, Barcelona, Spain; Emergency Department (Bingisser), Universitätsspital Basel, Basel, Switzerland; Emergency Department (Miró), Hospital Clínic de Barcelona, Barcelona, Spain; Laboratory Medicine (Rentsch), Universitätsspital Basel, Basel, Switzerland; Kantonsspital Olten (Bassetti), Olten, Switzerland
| | - Raphael Twerenbold
- Department of Cardiology and Cardiovascular Research Institute Basel (Reichlin, Twerenbold, Wildi, Rubini Gimenez, Bergsma, Haaf, Druey, Puelacher, Moehring, Freese, Stelzig, Krivoshei, Hillinger, Jäger, Herrmann, Kreutzinger, Radosavac, Weidmann, Pershyna, Honegger, Wagener, Vuillomenet, Osswald, Mueller), Universitätsspital Basel, Basel, Switzerland; Emergency Department (Rubini Gimenez, Campodarve), Internal Medicine Department, Hospital del Mar - Institut Municipal d'Investigació Mèdica, Barcelona, Spain; Emergency Department (Bingisser), Universitätsspital Basel, Basel, Switzerland; Emergency Department (Miró), Hospital Clínic de Barcelona, Barcelona, Spain; Laboratory Medicine (Rentsch), Universitätsspital Basel, Basel, Switzerland; Kantonsspital Olten (Bassetti), Olten, Switzerland
| | - Karin Wildi
- Department of Cardiology and Cardiovascular Research Institute Basel (Reichlin, Twerenbold, Wildi, Rubini Gimenez, Bergsma, Haaf, Druey, Puelacher, Moehring, Freese, Stelzig, Krivoshei, Hillinger, Jäger, Herrmann, Kreutzinger, Radosavac, Weidmann, Pershyna, Honegger, Wagener, Vuillomenet, Osswald, Mueller), Universitätsspital Basel, Basel, Switzerland; Emergency Department (Rubini Gimenez, Campodarve), Internal Medicine Department, Hospital del Mar - Institut Municipal d'Investigació Mèdica, Barcelona, Spain; Emergency Department (Bingisser), Universitätsspital Basel, Basel, Switzerland; Emergency Department (Miró), Hospital Clínic de Barcelona, Barcelona, Spain; Laboratory Medicine (Rentsch), Universitätsspital Basel, Basel, Switzerland; Kantonsspital Olten (Bassetti), Olten, Switzerland
| | - Maria Rubini Gimenez
- Department of Cardiology and Cardiovascular Research Institute Basel (Reichlin, Twerenbold, Wildi, Rubini Gimenez, Bergsma, Haaf, Druey, Puelacher, Moehring, Freese, Stelzig, Krivoshei, Hillinger, Jäger, Herrmann, Kreutzinger, Radosavac, Weidmann, Pershyna, Honegger, Wagener, Vuillomenet, Osswald, Mueller), Universitätsspital Basel, Basel, Switzerland; Emergency Department (Rubini Gimenez, Campodarve), Internal Medicine Department, Hospital del Mar - Institut Municipal d'Investigació Mèdica, Barcelona, Spain; Emergency Department (Bingisser), Universitätsspital Basel, Basel, Switzerland; Emergency Department (Miró), Hospital Clínic de Barcelona, Barcelona, Spain; Laboratory Medicine (Rentsch), Universitätsspital Basel, Basel, Switzerland; Kantonsspital Olten (Bassetti), Olten, Switzerland
| | - Nathalie Bergsma
- Department of Cardiology and Cardiovascular Research Institute Basel (Reichlin, Twerenbold, Wildi, Rubini Gimenez, Bergsma, Haaf, Druey, Puelacher, Moehring, Freese, Stelzig, Krivoshei, Hillinger, Jäger, Herrmann, Kreutzinger, Radosavac, Weidmann, Pershyna, Honegger, Wagener, Vuillomenet, Osswald, Mueller), Universitätsspital Basel, Basel, Switzerland; Emergency Department (Rubini Gimenez, Campodarve), Internal Medicine Department, Hospital del Mar - Institut Municipal d'Investigació Mèdica, Barcelona, Spain; Emergency Department (Bingisser), Universitätsspital Basel, Basel, Switzerland; Emergency Department (Miró), Hospital Clínic de Barcelona, Barcelona, Spain; Laboratory Medicine (Rentsch), Universitätsspital Basel, Basel, Switzerland; Kantonsspital Olten (Bassetti), Olten, Switzerland
| | - Philip Haaf
- Department of Cardiology and Cardiovascular Research Institute Basel (Reichlin, Twerenbold, Wildi, Rubini Gimenez, Bergsma, Haaf, Druey, Puelacher, Moehring, Freese, Stelzig, Krivoshei, Hillinger, Jäger, Herrmann, Kreutzinger, Radosavac, Weidmann, Pershyna, Honegger, Wagener, Vuillomenet, Osswald, Mueller), Universitätsspital Basel, Basel, Switzerland; Emergency Department (Rubini Gimenez, Campodarve), Internal Medicine Department, Hospital del Mar - Institut Municipal d'Investigació Mèdica, Barcelona, Spain; Emergency Department (Bingisser), Universitätsspital Basel, Basel, Switzerland; Emergency Department (Miró), Hospital Clínic de Barcelona, Barcelona, Spain; Laboratory Medicine (Rentsch), Universitätsspital Basel, Basel, Switzerland; Kantonsspital Olten (Bassetti), Olten, Switzerland
| | - Sophie Druey
- Department of Cardiology and Cardiovascular Research Institute Basel (Reichlin, Twerenbold, Wildi, Rubini Gimenez, Bergsma, Haaf, Druey, Puelacher, Moehring, Freese, Stelzig, Krivoshei, Hillinger, Jäger, Herrmann, Kreutzinger, Radosavac, Weidmann, Pershyna, Honegger, Wagener, Vuillomenet, Osswald, Mueller), Universitätsspital Basel, Basel, Switzerland; Emergency Department (Rubini Gimenez, Campodarve), Internal Medicine Department, Hospital del Mar - Institut Municipal d'Investigació Mèdica, Barcelona, Spain; Emergency Department (Bingisser), Universitätsspital Basel, Basel, Switzerland; Emergency Department (Miró), Hospital Clínic de Barcelona, Barcelona, Spain; Laboratory Medicine (Rentsch), Universitätsspital Basel, Basel, Switzerland; Kantonsspital Olten (Bassetti), Olten, Switzerland
| | - Christian Puelacher
- Department of Cardiology and Cardiovascular Research Institute Basel (Reichlin, Twerenbold, Wildi, Rubini Gimenez, Bergsma, Haaf, Druey, Puelacher, Moehring, Freese, Stelzig, Krivoshei, Hillinger, Jäger, Herrmann, Kreutzinger, Radosavac, Weidmann, Pershyna, Honegger, Wagener, Vuillomenet, Osswald, Mueller), Universitätsspital Basel, Basel, Switzerland; Emergency Department (Rubini Gimenez, Campodarve), Internal Medicine Department, Hospital del Mar - Institut Municipal d'Investigació Mèdica, Barcelona, Spain; Emergency Department (Bingisser), Universitätsspital Basel, Basel, Switzerland; Emergency Department (Miró), Hospital Clínic de Barcelona, Barcelona, Spain; Laboratory Medicine (Rentsch), Universitätsspital Basel, Basel, Switzerland; Kantonsspital Olten (Bassetti), Olten, Switzerland
| | - Berit Moehring
- Department of Cardiology and Cardiovascular Research Institute Basel (Reichlin, Twerenbold, Wildi, Rubini Gimenez, Bergsma, Haaf, Druey, Puelacher, Moehring, Freese, Stelzig, Krivoshei, Hillinger, Jäger, Herrmann, Kreutzinger, Radosavac, Weidmann, Pershyna, Honegger, Wagener, Vuillomenet, Osswald, Mueller), Universitätsspital Basel, Basel, Switzerland; Emergency Department (Rubini Gimenez, Campodarve), Internal Medicine Department, Hospital del Mar - Institut Municipal d'Investigació Mèdica, Barcelona, Spain; Emergency Department (Bingisser), Universitätsspital Basel, Basel, Switzerland; Emergency Department (Miró), Hospital Clínic de Barcelona, Barcelona, Spain; Laboratory Medicine (Rentsch), Universitätsspital Basel, Basel, Switzerland; Kantonsspital Olten (Bassetti), Olten, Switzerland
| | - Michael Freese
- Department of Cardiology and Cardiovascular Research Institute Basel (Reichlin, Twerenbold, Wildi, Rubini Gimenez, Bergsma, Haaf, Druey, Puelacher, Moehring, Freese, Stelzig, Krivoshei, Hillinger, Jäger, Herrmann, Kreutzinger, Radosavac, Weidmann, Pershyna, Honegger, Wagener, Vuillomenet, Osswald, Mueller), Universitätsspital Basel, Basel, Switzerland; Emergency Department (Rubini Gimenez, Campodarve), Internal Medicine Department, Hospital del Mar - Institut Municipal d'Investigació Mèdica, Barcelona, Spain; Emergency Department (Bingisser), Universitätsspital Basel, Basel, Switzerland; Emergency Department (Miró), Hospital Clínic de Barcelona, Barcelona, Spain; Laboratory Medicine (Rentsch), Universitätsspital Basel, Basel, Switzerland; Kantonsspital Olten (Bassetti), Olten, Switzerland
| | - Claudia Stelzig
- Department of Cardiology and Cardiovascular Research Institute Basel (Reichlin, Twerenbold, Wildi, Rubini Gimenez, Bergsma, Haaf, Druey, Puelacher, Moehring, Freese, Stelzig, Krivoshei, Hillinger, Jäger, Herrmann, Kreutzinger, Radosavac, Weidmann, Pershyna, Honegger, Wagener, Vuillomenet, Osswald, Mueller), Universitätsspital Basel, Basel, Switzerland; Emergency Department (Rubini Gimenez, Campodarve), Internal Medicine Department, Hospital del Mar - Institut Municipal d'Investigació Mèdica, Barcelona, Spain; Emergency Department (Bingisser), Universitätsspital Basel, Basel, Switzerland; Emergency Department (Miró), Hospital Clínic de Barcelona, Barcelona, Spain; Laboratory Medicine (Rentsch), Universitätsspital Basel, Basel, Switzerland; Kantonsspital Olten (Bassetti), Olten, Switzerland
| | - Lian Krivoshei
- Department of Cardiology and Cardiovascular Research Institute Basel (Reichlin, Twerenbold, Wildi, Rubini Gimenez, Bergsma, Haaf, Druey, Puelacher, Moehring, Freese, Stelzig, Krivoshei, Hillinger, Jäger, Herrmann, Kreutzinger, Radosavac, Weidmann, Pershyna, Honegger, Wagener, Vuillomenet, Osswald, Mueller), Universitätsspital Basel, Basel, Switzerland; Emergency Department (Rubini Gimenez, Campodarve), Internal Medicine Department, Hospital del Mar - Institut Municipal d'Investigació Mèdica, Barcelona, Spain; Emergency Department (Bingisser), Universitätsspital Basel, Basel, Switzerland; Emergency Department (Miró), Hospital Clínic de Barcelona, Barcelona, Spain; Laboratory Medicine (Rentsch), Universitätsspital Basel, Basel, Switzerland; Kantonsspital Olten (Bassetti), Olten, Switzerland
| | - Petra Hillinger
- Department of Cardiology and Cardiovascular Research Institute Basel (Reichlin, Twerenbold, Wildi, Rubini Gimenez, Bergsma, Haaf, Druey, Puelacher, Moehring, Freese, Stelzig, Krivoshei, Hillinger, Jäger, Herrmann, Kreutzinger, Radosavac, Weidmann, Pershyna, Honegger, Wagener, Vuillomenet, Osswald, Mueller), Universitätsspital Basel, Basel, Switzerland; Emergency Department (Rubini Gimenez, Campodarve), Internal Medicine Department, Hospital del Mar - Institut Municipal d'Investigació Mèdica, Barcelona, Spain; Emergency Department (Bingisser), Universitätsspital Basel, Basel, Switzerland; Emergency Department (Miró), Hospital Clínic de Barcelona, Barcelona, Spain; Laboratory Medicine (Rentsch), Universitätsspital Basel, Basel, Switzerland; Kantonsspital Olten (Bassetti), Olten, Switzerland
| | - Cedric Jäger
- Department of Cardiology and Cardiovascular Research Institute Basel (Reichlin, Twerenbold, Wildi, Rubini Gimenez, Bergsma, Haaf, Druey, Puelacher, Moehring, Freese, Stelzig, Krivoshei, Hillinger, Jäger, Herrmann, Kreutzinger, Radosavac, Weidmann, Pershyna, Honegger, Wagener, Vuillomenet, Osswald, Mueller), Universitätsspital Basel, Basel, Switzerland; Emergency Department (Rubini Gimenez, Campodarve), Internal Medicine Department, Hospital del Mar - Institut Municipal d'Investigació Mèdica, Barcelona, Spain; Emergency Department (Bingisser), Universitätsspital Basel, Basel, Switzerland; Emergency Department (Miró), Hospital Clínic de Barcelona, Barcelona, Spain; Laboratory Medicine (Rentsch), Universitätsspital Basel, Basel, Switzerland; Kantonsspital Olten (Bassetti), Olten, Switzerland
| | - Thomas Herrmann
- Department of Cardiology and Cardiovascular Research Institute Basel (Reichlin, Twerenbold, Wildi, Rubini Gimenez, Bergsma, Haaf, Druey, Puelacher, Moehring, Freese, Stelzig, Krivoshei, Hillinger, Jäger, Herrmann, Kreutzinger, Radosavac, Weidmann, Pershyna, Honegger, Wagener, Vuillomenet, Osswald, Mueller), Universitätsspital Basel, Basel, Switzerland; Emergency Department (Rubini Gimenez, Campodarve), Internal Medicine Department, Hospital del Mar - Institut Municipal d'Investigació Mèdica, Barcelona, Spain; Emergency Department (Bingisser), Universitätsspital Basel, Basel, Switzerland; Emergency Department (Miró), Hospital Clínic de Barcelona, Barcelona, Spain; Laboratory Medicine (Rentsch), Universitätsspital Basel, Basel, Switzerland; Kantonsspital Olten (Bassetti), Olten, Switzerland
| | - Philip Kreutzinger
- Department of Cardiology and Cardiovascular Research Institute Basel (Reichlin, Twerenbold, Wildi, Rubini Gimenez, Bergsma, Haaf, Druey, Puelacher, Moehring, Freese, Stelzig, Krivoshei, Hillinger, Jäger, Herrmann, Kreutzinger, Radosavac, Weidmann, Pershyna, Honegger, Wagener, Vuillomenet, Osswald, Mueller), Universitätsspital Basel, Basel, Switzerland; Emergency Department (Rubini Gimenez, Campodarve), Internal Medicine Department, Hospital del Mar - Institut Municipal d'Investigació Mèdica, Barcelona, Spain; Emergency Department (Bingisser), Universitätsspital Basel, Basel, Switzerland; Emergency Department (Miró), Hospital Clínic de Barcelona, Barcelona, Spain; Laboratory Medicine (Rentsch), Universitätsspital Basel, Basel, Switzerland; Kantonsspital Olten (Bassetti), Olten, Switzerland
| | - Milos Radosavac
- Department of Cardiology and Cardiovascular Research Institute Basel (Reichlin, Twerenbold, Wildi, Rubini Gimenez, Bergsma, Haaf, Druey, Puelacher, Moehring, Freese, Stelzig, Krivoshei, Hillinger, Jäger, Herrmann, Kreutzinger, Radosavac, Weidmann, Pershyna, Honegger, Wagener, Vuillomenet, Osswald, Mueller), Universitätsspital Basel, Basel, Switzerland; Emergency Department (Rubini Gimenez, Campodarve), Internal Medicine Department, Hospital del Mar - Institut Municipal d'Investigació Mèdica, Barcelona, Spain; Emergency Department (Bingisser), Universitätsspital Basel, Basel, Switzerland; Emergency Department (Miró), Hospital Clínic de Barcelona, Barcelona, Spain; Laboratory Medicine (Rentsch), Universitätsspital Basel, Basel, Switzerland; Kantonsspital Olten (Bassetti), Olten, Switzerland
| | - Zoraida Moreno Weidmann
- Department of Cardiology and Cardiovascular Research Institute Basel (Reichlin, Twerenbold, Wildi, Rubini Gimenez, Bergsma, Haaf, Druey, Puelacher, Moehring, Freese, Stelzig, Krivoshei, Hillinger, Jäger, Herrmann, Kreutzinger, Radosavac, Weidmann, Pershyna, Honegger, Wagener, Vuillomenet, Osswald, Mueller), Universitätsspital Basel, Basel, Switzerland; Emergency Department (Rubini Gimenez, Campodarve), Internal Medicine Department, Hospital del Mar - Institut Municipal d'Investigació Mèdica, Barcelona, Spain; Emergency Department (Bingisser), Universitätsspital Basel, Basel, Switzerland; Emergency Department (Miró), Hospital Clínic de Barcelona, Barcelona, Spain; Laboratory Medicine (Rentsch), Universitätsspital Basel, Basel, Switzerland; Kantonsspital Olten (Bassetti), Olten, Switzerland
| | - Kateryna Pershyna
- Department of Cardiology and Cardiovascular Research Institute Basel (Reichlin, Twerenbold, Wildi, Rubini Gimenez, Bergsma, Haaf, Druey, Puelacher, Moehring, Freese, Stelzig, Krivoshei, Hillinger, Jäger, Herrmann, Kreutzinger, Radosavac, Weidmann, Pershyna, Honegger, Wagener, Vuillomenet, Osswald, Mueller), Universitätsspital Basel, Basel, Switzerland; Emergency Department (Rubini Gimenez, Campodarve), Internal Medicine Department, Hospital del Mar - Institut Municipal d'Investigació Mèdica, Barcelona, Spain; Emergency Department (Bingisser), Universitätsspital Basel, Basel, Switzerland; Emergency Department (Miró), Hospital Clínic de Barcelona, Barcelona, Spain; Laboratory Medicine (Rentsch), Universitätsspital Basel, Basel, Switzerland; Kantonsspital Olten (Bassetti), Olten, Switzerland
| | - Ursina Honegger
- Department of Cardiology and Cardiovascular Research Institute Basel (Reichlin, Twerenbold, Wildi, Rubini Gimenez, Bergsma, Haaf, Druey, Puelacher, Moehring, Freese, Stelzig, Krivoshei, Hillinger, Jäger, Herrmann, Kreutzinger, Radosavac, Weidmann, Pershyna, Honegger, Wagener, Vuillomenet, Osswald, Mueller), Universitätsspital Basel, Basel, Switzerland; Emergency Department (Rubini Gimenez, Campodarve), Internal Medicine Department, Hospital del Mar - Institut Municipal d'Investigació Mèdica, Barcelona, Spain; Emergency Department (Bingisser), Universitätsspital Basel, Basel, Switzerland; Emergency Department (Miró), Hospital Clínic de Barcelona, Barcelona, Spain; Laboratory Medicine (Rentsch), Universitätsspital Basel, Basel, Switzerland; Kantonsspital Olten (Bassetti), Olten, Switzerland
| | - Max Wagener
- Department of Cardiology and Cardiovascular Research Institute Basel (Reichlin, Twerenbold, Wildi, Rubini Gimenez, Bergsma, Haaf, Druey, Puelacher, Moehring, Freese, Stelzig, Krivoshei, Hillinger, Jäger, Herrmann, Kreutzinger, Radosavac, Weidmann, Pershyna, Honegger, Wagener, Vuillomenet, Osswald, Mueller), Universitätsspital Basel, Basel, Switzerland; Emergency Department (Rubini Gimenez, Campodarve), Internal Medicine Department, Hospital del Mar - Institut Municipal d'Investigació Mèdica, Barcelona, Spain; Emergency Department (Bingisser), Universitätsspital Basel, Basel, Switzerland; Emergency Department (Miró), Hospital Clínic de Barcelona, Barcelona, Spain; Laboratory Medicine (Rentsch), Universitätsspital Basel, Basel, Switzerland; Kantonsspital Olten (Bassetti), Olten, Switzerland
| | - Thierry Vuillomenet
- Department of Cardiology and Cardiovascular Research Institute Basel (Reichlin, Twerenbold, Wildi, Rubini Gimenez, Bergsma, Haaf, Druey, Puelacher, Moehring, Freese, Stelzig, Krivoshei, Hillinger, Jäger, Herrmann, Kreutzinger, Radosavac, Weidmann, Pershyna, Honegger, Wagener, Vuillomenet, Osswald, Mueller), Universitätsspital Basel, Basel, Switzerland; Emergency Department (Rubini Gimenez, Campodarve), Internal Medicine Department, Hospital del Mar - Institut Municipal d'Investigació Mèdica, Barcelona, Spain; Emergency Department (Bingisser), Universitätsspital Basel, Basel, Switzerland; Emergency Department (Miró), Hospital Clínic de Barcelona, Barcelona, Spain; Laboratory Medicine (Rentsch), Universitätsspital Basel, Basel, Switzerland; Kantonsspital Olten (Bassetti), Olten, Switzerland
| | - Isabel Campodarve
- Department of Cardiology and Cardiovascular Research Institute Basel (Reichlin, Twerenbold, Wildi, Rubini Gimenez, Bergsma, Haaf, Druey, Puelacher, Moehring, Freese, Stelzig, Krivoshei, Hillinger, Jäger, Herrmann, Kreutzinger, Radosavac, Weidmann, Pershyna, Honegger, Wagener, Vuillomenet, Osswald, Mueller), Universitätsspital Basel, Basel, Switzerland; Emergency Department (Rubini Gimenez, Campodarve), Internal Medicine Department, Hospital del Mar - Institut Municipal d'Investigació Mèdica, Barcelona, Spain; Emergency Department (Bingisser), Universitätsspital Basel, Basel, Switzerland; Emergency Department (Miró), Hospital Clínic de Barcelona, Barcelona, Spain; Laboratory Medicine (Rentsch), Universitätsspital Basel, Basel, Switzerland; Kantonsspital Olten (Bassetti), Olten, Switzerland
| | - Roland Bingisser
- Department of Cardiology and Cardiovascular Research Institute Basel (Reichlin, Twerenbold, Wildi, Rubini Gimenez, Bergsma, Haaf, Druey, Puelacher, Moehring, Freese, Stelzig, Krivoshei, Hillinger, Jäger, Herrmann, Kreutzinger, Radosavac, Weidmann, Pershyna, Honegger, Wagener, Vuillomenet, Osswald, Mueller), Universitätsspital Basel, Basel, Switzerland; Emergency Department (Rubini Gimenez, Campodarve), Internal Medicine Department, Hospital del Mar - Institut Municipal d'Investigació Mèdica, Barcelona, Spain; Emergency Department (Bingisser), Universitätsspital Basel, Basel, Switzerland; Emergency Department (Miró), Hospital Clínic de Barcelona, Barcelona, Spain; Laboratory Medicine (Rentsch), Universitätsspital Basel, Basel, Switzerland; Kantonsspital Olten (Bassetti), Olten, Switzerland
| | - Òscar Miró
- Department of Cardiology and Cardiovascular Research Institute Basel (Reichlin, Twerenbold, Wildi, Rubini Gimenez, Bergsma, Haaf, Druey, Puelacher, Moehring, Freese, Stelzig, Krivoshei, Hillinger, Jäger, Herrmann, Kreutzinger, Radosavac, Weidmann, Pershyna, Honegger, Wagener, Vuillomenet, Osswald, Mueller), Universitätsspital Basel, Basel, Switzerland; Emergency Department (Rubini Gimenez, Campodarve), Internal Medicine Department, Hospital del Mar - Institut Municipal d'Investigació Mèdica, Barcelona, Spain; Emergency Department (Bingisser), Universitätsspital Basel, Basel, Switzerland; Emergency Department (Miró), Hospital Clínic de Barcelona, Barcelona, Spain; Laboratory Medicine (Rentsch), Universitätsspital Basel, Basel, Switzerland; Kantonsspital Olten (Bassetti), Olten, Switzerland
| | - Katharina Rentsch
- Department of Cardiology and Cardiovascular Research Institute Basel (Reichlin, Twerenbold, Wildi, Rubini Gimenez, Bergsma, Haaf, Druey, Puelacher, Moehring, Freese, Stelzig, Krivoshei, Hillinger, Jäger, Herrmann, Kreutzinger, Radosavac, Weidmann, Pershyna, Honegger, Wagener, Vuillomenet, Osswald, Mueller), Universitätsspital Basel, Basel, Switzerland; Emergency Department (Rubini Gimenez, Campodarve), Internal Medicine Department, Hospital del Mar - Institut Municipal d'Investigació Mèdica, Barcelona, Spain; Emergency Department (Bingisser), Universitätsspital Basel, Basel, Switzerland; Emergency Department (Miró), Hospital Clínic de Barcelona, Barcelona, Spain; Laboratory Medicine (Rentsch), Universitätsspital Basel, Basel, Switzerland; Kantonsspital Olten (Bassetti), Olten, Switzerland
| | - Stefano Bassetti
- Department of Cardiology and Cardiovascular Research Institute Basel (Reichlin, Twerenbold, Wildi, Rubini Gimenez, Bergsma, Haaf, Druey, Puelacher, Moehring, Freese, Stelzig, Krivoshei, Hillinger, Jäger, Herrmann, Kreutzinger, Radosavac, Weidmann, Pershyna, Honegger, Wagener, Vuillomenet, Osswald, Mueller), Universitätsspital Basel, Basel, Switzerland; Emergency Department (Rubini Gimenez, Campodarve), Internal Medicine Department, Hospital del Mar - Institut Municipal d'Investigació Mèdica, Barcelona, Spain; Emergency Department (Bingisser), Universitätsspital Basel, Basel, Switzerland; Emergency Department (Miró), Hospital Clínic de Barcelona, Barcelona, Spain; Laboratory Medicine (Rentsch), Universitätsspital Basel, Basel, Switzerland; Kantonsspital Olten (Bassetti), Olten, Switzerland
| | - Stefan Osswald
- Department of Cardiology and Cardiovascular Research Institute Basel (Reichlin, Twerenbold, Wildi, Rubini Gimenez, Bergsma, Haaf, Druey, Puelacher, Moehring, Freese, Stelzig, Krivoshei, Hillinger, Jäger, Herrmann, Kreutzinger, Radosavac, Weidmann, Pershyna, Honegger, Wagener, Vuillomenet, Osswald, Mueller), Universitätsspital Basel, Basel, Switzerland; Emergency Department (Rubini Gimenez, Campodarve), Internal Medicine Department, Hospital del Mar - Institut Municipal d'Investigació Mèdica, Barcelona, Spain; Emergency Department (Bingisser), Universitätsspital Basel, Basel, Switzerland; Emergency Department (Miró), Hospital Clínic de Barcelona, Barcelona, Spain; Laboratory Medicine (Rentsch), Universitätsspital Basel, Basel, Switzerland; Kantonsspital Olten (Bassetti), Olten, Switzerland
| | - Christian Mueller
- Department of Cardiology and Cardiovascular Research Institute Basel (Reichlin, Twerenbold, Wildi, Rubini Gimenez, Bergsma, Haaf, Druey, Puelacher, Moehring, Freese, Stelzig, Krivoshei, Hillinger, Jäger, Herrmann, Kreutzinger, Radosavac, Weidmann, Pershyna, Honegger, Wagener, Vuillomenet, Osswald, Mueller), Universitätsspital Basel, Basel, Switzerland; Emergency Department (Rubini Gimenez, Campodarve), Internal Medicine Department, Hospital del Mar - Institut Municipal d'Investigació Mèdica, Barcelona, Spain; Emergency Department (Bingisser), Universitätsspital Basel, Basel, Switzerland; Emergency Department (Miró), Hospital Clínic de Barcelona, Barcelona, Spain; Laboratory Medicine (Rentsch), Universitätsspital Basel, Basel, Switzerland; Kantonsspital Olten (Bassetti), Olten, Switzerland
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Januzzi JL, Sharma U, Zakroysky P, Truong QA, Woodard PK, Pope JH, Hauser T, Mayrhofer T, Nagurney JT, Schoenfeld D, Peacock W, Fleg JL, Wiviott S, Pang PS, Udelson J, Hoffmann U. Sensitive troponin assays in patients with suspected acute coronary syndrome: Results from the multicenter rule out myocardial infarction using computer assisted tomography II trial. Am Heart J 2015; 169:572-8.e1. [PMID: 25819865 DOI: 10.1016/j.ahj.2014.12.023] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2014] [Accepted: 12/20/2014] [Indexed: 10/24/2022]
Abstract
BACKGROUND Sensitive troponin (Tn) assays have been developed for the evaluation of patients with suspected acute coronary syndrome (ACS). We sought to compare the performance of a commercially available sensitive Tn I (sTnI) and precommercial highly sTnI (hsTnI) method to conventional Tn (cTn) assays. METHODS Among patients with acute chest pain but normal cTn in the emergency department of 6 centers, sTnI and hsTnI were measured at baseline, 2 and 4 hours after presentation. Diagnostic accuracy of sTnI and hsTnI relative to cTn for diagnosis during index hospitalization as well as their associations with coronary artery disease in patients randomized to coronary computed tomographic angiography (CTA) was assessed. RESULTS Overall, 322 patients were enrolled, of whom 161 had a CTA; 28 had ACS (8.7%), including 21 with unstable angina pectoris (UAP). Both sTnI and hsTnI values at baseline and second draw had significantly higher sensitivity for ACS and UAP than cTn and had significantly greater area under the receiver operator characteristic curve than cTn at first and second draws. Compared with cTn, 29% of ACS cases previously categorized as UAP were reclassified to acute myocardial infarction with sTnI or hsTnI. An hsTnI below limit of detection had 100% negative predictive value for ACS or significant coronary artery stenosis in those randomized to CTA. CONCLUSIONS In patients with acute chest discomfort, use of sTnI and hsTnI methods led to significant improvement in the early diagnostic accuracy for ACS, reclassifying one-third of UAP to myocardial infarction. Very low values for hsTnI excluded underlying coronary artery disease.
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McEvoy JW, Lazo M, Chen Y, Shen L, Nambi V, Hoogeveen RC, Ballantyne CM, Blumenthal RS, Coresh J, Selvin E. Patterns and determinants of temporal change in high-sensitivity cardiac troponin-T: The Atherosclerosis Risk in Communities Cohort Study. Int J Cardiol 2015; 187:651-7. [PMID: 25880403 DOI: 10.1016/j.ijcard.2015.03.436] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2014] [Revised: 02/15/2015] [Accepted: 03/31/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND Patterns and determinants of temporal change in highly-sensitivity troponin-T (hs-cTNT), a novel measure of subclinical myocardial injury, among asymptomatic persons have not been well characterized. METHODS We studied 8571 ARIC Study participants, free of cardiovascular disease, who had hs-cTNT measured at two time-points, 6 years apart (1990-1992 and 1996-1998). We examined the association of baseline 10-year atherosclerotic cardiovascular (ASCVD) risk-group (<5%, 5-7.4%, ≥ 7.5%) and individual cardiac risk-factors with change across hs-cTNT categories using Poisson and Multinomial Logistic regression and with mean continuous hs-cTNT change using linear regression. RESULTS Mean age was 57 years and 43% were male. Mean (SD) 6-year hs-cTNT change was higher across increasing ASCVD risk-groups; +1.2 (6.1) ng/L [<5%], +2.1 (5.4) ng/L [5-7.4%], and +2.8 (8.8) ng/L [≥ 7.5%]. Major baseline determinants of temporal hs-cTNT increases were: age, male gender, hypertension, diabetes, and obesity. In addition, the relative risk (RR) of incident elevated hs-cTNT (≥ 14 ng/L) was 1.46 (95% CI 1.1-2.0) for persons with sustained hypertension compared to those who remained normotensive. Results for sustained obesity (RR 1.65 [1.19-2.29]) and hyperglycemia (RR 1.76 [1.16-2.67]) were similar. These associations were generally stronger after accounting for survival bias. However, smoking, LDL-cholesterol and triglycerides were not associated with hs-cTNT change. HDL-cholesterol was associated with declining hs-cTNT. CONCLUSIONS Persons in higher ASCVD risk-groups were more likely to have increases in hs-cTNT over 6 years of follow-up. The modifiable risk-factors primarily driving this association were diabetes, hypertension, and obesity; particularly when they were persistently elevated over follow-up. Future studies are needed to determine whether modifying these risk factors can prevent progression of subclinical myocardial injury.
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Affiliation(s)
- John W McEvoy
- Ciccarone Center for the Prevention of Heart Disease, Johns Hopkins University School of Medicine, Baltimore, MD, United States; Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States; The Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States
| | - Mariana Lazo
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States; The Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States
| | - Yuan Chen
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States; The Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States
| | - Lu Shen
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States; The Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States
| | - Vijay Nambi
- Michael E DeBakey Veterans Affairs Hospital, Houston, TX, United States
| | - Ron C Hoogeveen
- Department of Medicine, Section of Cardiovascular Research, Baylor College of Medicine, Houston TX, United States; Houston Methodist DeBakey Heart and Vascular Center, Houston TX, United States
| | - Christie M Ballantyne
- Department of Medicine, Section of Cardiovascular Research, Baylor College of Medicine, Houston TX, United States; Houston Methodist DeBakey Heart and Vascular Center, Houston TX, United States
| | - Roger S Blumenthal
- Ciccarone Center for the Prevention of Heart Disease, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Josef Coresh
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States; The Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States
| | - Elizabeth Selvin
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States; The Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States.
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195
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What to Expect When Measuring High-Sensitivity Troponin. J Am Coll Cardiol 2015; 65:1665-1667. [DOI: 10.1016/j.jacc.2015.02.045] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2015] [Accepted: 02/23/2015] [Indexed: 01/08/2023]
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196
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Ashmore D. Chest pain and high-sensitivity troponin: What is the evidence? SAGE Open Med 2015; 3:2050312115577729. [PMID: 26770774 PMCID: PMC4679282 DOI: 10.1177/2050312115577729] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2014] [Accepted: 02/22/2015] [Indexed: 01/31/2023] Open
Abstract
The number of attendances and admissions of patients with chest pain to hospitals in England and Wales is increasing. Initial assessment may be unrewarding. Consequently, cardiac troponin has become the mainstay of investigation for non-ST-segment-elevation myocardial infarction and unstable angina, although only a small proportion of patients are eventually diagnosed as such. Current National Institute for Healthcare and Clinical Excellence guidance recommends measuring cardiac troponin levels on presentation and 10-12 h after onset of symptoms. A more effective diagnostic tool is needed. The aims are twofold: to increase accuracy of acute coronary syndrome diagnosis thus implementing the most appropriate management at an earlier stage while reducing costs and to provide a more rapid diagnosis to ease the anxieties of patients. Three key issues have been highlighted. The first is that many current studies do not have a 'normal/reference' population, making comparison between two studies difficult to interpret. Second, whether newer 'high-sensitivity' cardiac troponin tests can be used to rule out a myocardial infarction in a patient with chest pain is discussed. Third, whether a 'high-sensitivity' cardiac troponin has great enough specificity to differentiate between the number of other causes of raised troponin in a single test or whether serial testing is needed is assessed. A strategy for such serial testing is discussed. Finally, use of 'high-sensitivity' cardiac troponin in risk stratification of other disease processes is highlighted, which is likely to become common practice, changing the way we manage patients with, and without, chest pain.
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Affiliation(s)
- Daniel Ashmore
- Pinderfields General Hospital, The Mid Yorkshire Hospitals NHS Trust, Wakefield, UK
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197
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Eggers KM, Aldous S, Greenslade JH, Johnston N, Lindahl B, Parsonage WA, Pickering JW, Than M, Cullen L. Two-hour diagnostic algorithms for early assessment of patients with acute chest pain--Implications of lowering the cardiac troponin I cut-off to the 97.5th percentile. Clin Chim Acta 2015; 445:19-24. [PMID: 25771107 DOI: 10.1016/j.cca.2015.03.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2015] [Revised: 02/22/2015] [Accepted: 03/03/2015] [Indexed: 11/18/2022]
Abstract
AIMS Assessment of patients with suspected non-ST elevation myocardial infarction (NSTEMI) is based on cardiac troponin (cTn) levels with the 99th percentile as cut-off. However, cardiovascular risk starts already at lower troponin concentrations. We therefore, aimed to investigate the utility of 2-hour algorithms using the high-sensitivity cardiac troponin I (hs-cTnI) 97.5th percentile as cut-off which corresponds to the standard URL for most biomarkers. METHODS Hs-cTnI was measured at presentation and 2h in 1624 chest pain patients. Diagnostic algorithms were developed applying hs-cTnI levels dichotomized at the 99th and 97.5th percentiles combined with hs-cTnI changes and/or ECG findings. RESULTS The prevalence of NSTEMI was 13.9%. The adjusted odds ratios for 1-year mortality were 2.7 (95% CI 1.4-5.1) for the 99th percentile and 3.1 (95% CI 1.6-5.9) for the 97.5th percentile. The best-performing 99th percentile-based algorithms provided a positive predictive value (PPV) of 86.3% and a negative predictive value (NPV) of 99.3%. Using 97.5th percentile-based algorithms to define NSTEMI resulted in few reclassifications and yielded similar diagnostic estimates (PPV 85.4%, NPV 99.4%). CONCLUSION The hs-cTnI 97.5th percentile integrated into 2-hour algorithms provided high diagnostic estimates and could, due to better prognostic properties serve as an alternative to the 99th percentile.
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Affiliation(s)
- Kai M Eggers
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden.
| | - Sally Aldous
- Christchurch Hospital, Christchurch, New Zealand
| | - Jaimi H Greenslade
- Royal Brisbane and Women's Hospital, Brisbane, Australia; University of Queensland, Brisbane, Australia
| | - Nina Johnston
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - Bertil Lindahl
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden; Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - William A Parsonage
- Royal Brisbane and Women's Hospital, Brisbane, Australia; University of Technology, Brisbane, Australia
| | - John W Pickering
- Christchurch Hospital, Christchurch, New Zealand; University of Otago Christchurch, Christchurch, New Zealand
| | - Martin Than
- Christchurch Hospital, Christchurch, New Zealand
| | - Louise Cullen
- Royal Brisbane and Women's Hospital, Brisbane, Australia; University of Technology, Brisbane, Australia
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198
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Pernès JM, Dupouy P, Labbé R, Sotirov Y, Pongas D, Mansour H, Gaux JC. Management of acute chest pain: A major role for coronary CT angiography. Diagn Interv Imaging 2015; 96:1105-12. [PMID: 25767006 DOI: 10.1016/j.diii.2014.09.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2014] [Revised: 05/31/2014] [Accepted: 09/02/2014] [Indexed: 11/26/2022]
Abstract
Most patients presenting with acute chest pain (ACP) at the emergency unit do not have any marked electrocardiogram abnormalities or known history of heart disease. Identifying the few patients who have, or will actually develop acute coronary syndrome in this group that is considered to be at low risk, is an actual clinical challenge for emergency department physicians. In these patients, the goal of complementary non-invasive morphological or functional imaging tests is to exclude heart disease. The diagnostic values of coronary CT angiography include a sensitivity of 96% and a negative likelihood ratio of 0.09, which are highly contributory to the diagnosis, and the integration of this imaging test into a decision tree algorithm appears to be the least expensive strategy with the best cost/effective ratio. Coronary CT angiography is indicated in the presence of ACP associated with an inconclusive electrocardiogram, in the absence of any other obvious diagnoses, when the ultrasensitive troponin assay is negative or the dynamic changes are modest, slow and/or inconclusive. Ideally, coronary CT angiography should be performed within 3 to 48hours after the initial consultation.
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Affiliation(s)
- J-M Pernès
- Pôle cardiovasculaire interventionnel et d'imagerie, hôpital Privé Antony, rue Velpeau, 92160 Antony, France.
| | - P Dupouy
- Pôle cardiovasculaire interventionnel et d'imagerie, hôpital Privé Antony, rue Velpeau, 92160 Antony, France
| | - R Labbé
- Pôle cardiovasculaire interventionnel et d'imagerie, hôpital Privé Antony, rue Velpeau, 92160 Antony, France
| | - Y Sotirov
- Pôle cardiovasculaire interventionnel et d'imagerie, hôpital Privé Antony, rue Velpeau, 92160 Antony, France
| | - D Pongas
- Pôle cardiovasculaire interventionnel et d'imagerie, hôpital Privé Antony, rue Velpeau, 92160 Antony, France
| | - H Mansour
- Pôle cardiovasculaire interventionnel et d'imagerie, hôpital Privé Antony, rue Velpeau, 92160 Antony, France
| | - J-C Gaux
- Pôle cardiovasculaire interventionnel et d'imagerie, hôpital Privé Antony, rue Velpeau, 92160 Antony, France
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199
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Kavsak PA, Beattie J, Pickersgill R, Ford L, Caruso N, Clark L. A practical approach for the validation and clinical implementation of a high-sensitivity cardiac troponin I assay across a North American city. Pract Lab Med 2015; 1:28-34. [PMID: 28932796 PMCID: PMC5597710 DOI: 10.1016/j.plabm.2015.02.001] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2014] [Revised: 01/20/2015] [Accepted: 02/11/2015] [Indexed: 02/03/2023] Open
Abstract
Objectives Despite several publications on the analytical performance of high-sensitivity cardiac troponin (hs-cTn) assays, there has been little information on how laboratories should validate and implement these assays into clinical service. Our study provides a practical approach for the validation and implementation of a hs-cTn assay across a large North American City. Design and methods Validation for the Abbott ARCHITECT hs-cTnI assay (across 5 analyzers) consisted of verification of limit of blank (LoB), precision (i.e., coefficient of variation; CV) testing at the reported limit of detection (LoD) and within and outside the 99th percentile, linearity testing, cTnI versus hs-cTnI patient comparison within and between analyzers (Passing and Bablok and non-parametric analyses). Education, clinical communications, and memorandums were issued in advance to inform all staff across the city as well as a selected reminder the day before live-date to important users. All hospitals switched to the hs-cTnI assay concurrently (the contemporary cTnI assay removed) with laboratory staff instructed to repeat samples previously measured with the contemporary cTnI assay with the hs-cTnI assay only by physician request. Results Across the 5 analyzers and 6 reagent packs the overall LoB was 0.6 ng/L (n=60) with a CV of 33% at an overall mean of 1.2 ng/L (n=60; reported LoD=1.0 ng/L), with linearity demonstrated from 45,005 ng/L to 1.1 ng/L. Precision testing with a normal patient-pool QC material (mean range across 5 analyzers was 3.9–4.4 ng/L) yielded a range of CVs from 7% to 10% (within-run) and CVs from 7% to 18% (between-run) with the high patient-pool QC material (mean range across 5 analyzers was 29.6–36.3 ng/L) yielding a range of CVs from 2% to 5% (within-run) and CVs from 4% to 8% (between-run). There was agreement between hs-cTnI versus cTnI with the patient samples (slope ranges: 0.89–1.03; intercept ranges: 1.9–3.8 ng/L), however, the median CV on patient samples <100 ng/L across the analyzers was 5.6% for hs-cTnI versus 18.7% for the contemporary assay (p<0.001). Following the switch to hs-cTnI testing, no requests for repeat measurements were received. Conclusions Validation and implementation of hs-cTnI testing across multiple sites requires collaboration within the laboratories and between hospital laboratories and clinical staff. City-wide analytical validation of a high-sensitivity cardiac troponin assay. Practical approach to hs-cTnI validation and clinical implementation. Clinical support and communication are important for a successful implementation. New QC practices and comparability testing for hs-cTnI monitoring.
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Affiliation(s)
- Peter A. Kavsak
- Department of Pathology and Molecular Medicine, McMaster University, Hamilton, ON, Canada
- Juravinski Hospital and Cancer Centre, Hamilton, Canada
- Hamilton Regional Laboratory Medicine Program, Canada
- Correspondence to: Juravinski Hospital and Cancer Centre, 711 Concession Street Hamilton, ON, Canada L8V 1C3. Tel.: +1 905 521 2100.
| | - John Beattie
- Hamilton Regional Laboratory Medicine Program, Canada
- Hamilton General Hospital, Hamilton, Canada
| | - Robin Pickersgill
- Hamilton Regional Laboratory Medicine Program, Canada
- St. Joseph׳s Hospital, Hamilton, Canada
| | - Lynn Ford
- Hamilton Regional Laboratory Medicine Program, Canada
- McMaster Children׳s Hospital, Hamilton, Canada
| | - Nadia Caruso
- Hamilton Regional Laboratory Medicine Program, Canada
- Hamilton General Hospital, Hamilton, Canada
| | - Lorna Clark
- Juravinski Hospital and Cancer Centre, Hamilton, Canada
- Hamilton Regional Laboratory Medicine Program, Canada
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200
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Shortt C, Phan K, Hill SA, Worster A, Kavsak PA. An approach to rule-out an acute cardiovascular event or death in emergency department patients using outcome-based cutoffs for high-sensitivity cardiac troponin assays and glucose. Clin Biochem 2015; 48:282-7. [DOI: 10.1016/j.clinbiochem.2014.11.010] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2014] [Revised: 11/04/2014] [Accepted: 11/08/2014] [Indexed: 01/04/2023]
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