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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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202
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Greenslade J, Kavsak P, Parsonage W, Shortt C, Than M, Pickering J, Aldous S, Cullen L. Combining presentation high-sensitivity cardiac troponin I and glucose measurements to rule-out an acute myocardial infarction in patients presenting to emergency department with chest pain. Clin Biochem 2015; 48:288-91. [DOI: 10.1016/j.clinbiochem.2014.11.019] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2014] [Accepted: 11/24/2014] [Indexed: 10/24/2022]
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203
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Kriterien der Deutschen Gesellschaft für Kardiologie – Herz- und Kreislaufforschung für „Chest Pain Units“. KARDIOLOGE 2015. [DOI: 10.1007/s12181-014-0646-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
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204
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Body R, Burrows G, Carley S, Lewis PS. Rapid exclusion of acute myocardial infarction in patients with undetectable troponin using a sensitive troponin I assay. Ann Clin Biochem 2015; 52:543-9. [DOI: 10.1177/0004563215576976] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/16/2015] [Indexed: 01/09/2023]
Abstract
Objective With a high-sensitivity troponin assay, it may be possible to exclude acute myocardial infarction with a single blood test on arrival in the emergency department by using a novel ‘rule out’ cut-off set at the limit of detection of the assay. We aimed to determine whether this can also be achieved using a contemporary sensitive troponin assay that does not meet ‘high-sensitivity’ criteria. Methods In a prospective diagnostic cohort study, we included patients presenting to the emergency department with suspected cardiac chest pain. For this secondary analysis, serum samples drawn on arrival were tested using a contemporary sensitive troponin I assay (s-cTnI; Siemens Ultra ADVIA Centaur, 99th percentile 40 ng/L, limit of detection 6 ng/L). Acute myocardial infarction was adjudicated by two independent investigators based on reference standard troponin testing ≥12 h after symptom onset. Results Of 414 participants, 70 (16.9%) had acute myocardial infarction and 205 (49.5%) had initial s-cTnI concentrations below the limit of detection. Using the limit of detection as a ‘rule out’ cut-off gave a sensitivity of 94.3% (95% CI 86.0–98.4%) for acute myocardial infarction. If only patients with s-cTnI below the limit of detection and no electrocardiogram ischaemia were considered to have acute myocardial infarction ‘ruled out’ (41.8% of the cohort, n = 174), sensitivity would rise to 97.1% (90.1–99.7%) and negative predictive value to 98.8% (95.9–99.9%). Conclusions Acute myocardial infarction cannot be excluded in patients with s-cTnI concentrations below the limit of detection using the contemporary sensitive assay evaluated. Future work with this assay should focus on serial sampling over 1–3 h and combination with clinical information and/or additional biomarkers.
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Affiliation(s)
- Richard Body
- Cardiovascular Sciences Research Group, The University of Manchester, Manchester, UK
- Emergency Department, Central Manchester NHS Foundation Trust, Manchester, UK
| | - Gillian Burrows
- Biochemistry Department, Stockport NHS Foundation Trust, Stockport, UK
| | - Simon Carley
- Emergency Department, Central Manchester NHS Foundation Trust, Manchester, UK
- Centre for Effective Emergency Care, Manchester Metropolitan University, Manchester, UK
| | - Philip S Lewis
- Cardiology Department, Stockport NHS Foundation Trust, Stockport, UK
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Carlton EW, Cullen L, Than M, Gamble J, Khattab A, Greaves K. A novel diagnostic protocol to identify patients suitable for discharge after a single high-sensitivity troponin. Heart 2015; 101:1041-6. [PMID: 25691511 PMCID: PMC4484040 DOI: 10.1136/heartjnl-2014-307288] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2014] [Accepted: 01/25/2015] [Indexed: 11/30/2022] Open
Abstract
Objective To establish whether a novel accelerated diagnostic protocol (ADP) for suspected acute coronary syndrome (ACS) could successfully identify low-risk patients suitable for discharge after a single high-sensitivity troponin T (hs-cTnT) taken at presentation to the emergency department. We also compared the diagnostic accuracy of this ADP with strategies using initial undetectable hs-cTnT. Methods This prospective observational study evaluated the ability of the Triage Rule-out Using high-Sensitivity Troponin (TRUST) ADP to identify low-risk patients with suspected ACS. The ADP incorporated a single presentation hs-cTnT of <14 ng/L, a non-ischaemic ECG and a modified Goldman risk score. Diagnostic performance of the ADP was compared with the detection limit cut-offs of hs-cTnT (<5 ng/L and <3 ng/L). The primary end point was fatal/non-fatal acute myocardial infarction (AMI) within 30 days. Results 960 participants were recruited, mean age 58.0 years, 80 (8.3%) had an AMI. The TRUST ADP classified 382 (39.8%) as low-risk with a sensitivity for identifying AMI of 98.8% (95% CI 92.5% to 99.9%). hs-cTnT detection limits (<5 ng/L and <3 ng/L) had a sensitivity of 100% (94.3 to 100) and 100% (94.4 to 100), respectively. The TRUST ADP identified more patients suitable for early discharge at 39.8% vs 29.3% (<5 ng/L) and 7.9% (<3 ng/L) (p<0.001) with a lower false-positive rate for AMI detection; specificity 43.3% (95% CI 42.7% to 43.4%) vs 32.0% (95% CI 31.5% to 32.0%) and 8.6% (95% CI 8.1% to 8.6%), respectively. Conclusions The TRUST ADP, which incorporates structured risk-assessment and a single presentation hs-cTnT blood draw, has potential to allow early discharge in 40% of patients with suspected ACS and has greater clinical utility than undetectable hs-cTnT strategies. Trial registration number ISRCTN No. 21109279.
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Affiliation(s)
- Edward W Carlton
- Bournemouth University, Centre of Postgraduate Medical Research & Education, Faculty of Health and Social Sciences, UK Poole Hospital NHS Foundation Trust, Dorset, UK
| | - Louise Cullen
- Emergency Department, Royal Brisbane and Women's Hospital, Queensland, Australia
| | - Martin Than
- Emergency Department, Christchurch Hospital, New Zealand
| | - James Gamble
- Department of Cardiology, John Radcliffe Hospital, Oxford, UK
| | - Ahmed Khattab
- Bournemouth University, Centre of Postgraduate Medical Research & Education, Faculty of Health and Social Sciences, UK
| | - Kim Greaves
- Sunshine Coast Hospital and Health Services, University of the Sunshine Coast, Queensland, Australia
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Effectiveness of practices for improving the diagnostic accuracy of Non ST Elevation Myocardial Infarction in the Emergency Department: A Laboratory Medicine Best Practices™ systematic review. Clin Biochem 2015; 48:204-12. [PMID: 25661303 DOI: 10.1016/j.clinbiochem.2015.01.014] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2014] [Revised: 01/26/2015] [Accepted: 01/28/2015] [Indexed: 11/21/2022]
Abstract
OBJECTIVES This article is a systematic review of the effectiveness of four practices (assay selection, decision point cardiac troponin (cTn) threshold selection, serial testing, and point of care testing) for improving the diagnostic accuracy Non-ST-Segment Elevation Myocardial Infarction (NSTEMI) in the Emergency Department. DESIGN AND METHODS The CDC-funded Laboratory Medicine Best Practices (LMBP) Initiative systematic review method for quality improvement practices was used. RESULTS The current ACC/AHA guidelines recommend using cardiac troponin assays with a 99th percentile upper reference limit (URL) diagnostic threshold to diagnose NSTEMI. The evidence in this systematic review indicates that contemporary sensitive cTn assays meet the assay profile requirements (sensitivity, specificity, PPV, and NPV) to more accurately diagnose NSTEMI than alternate tests. Additional biomarkers did not increase diagnostic effectiveness of cTn assays. Sensitivity, specificity, and NPV were consistently high and low PPV improved with serial sampling. Evidence for use of point of care cTn testing was insufficient to make recommendation, though some evidence suggests that use may result in reduction to patient length of stay and costs. CONCLUSIONS Based on the review of and the LMBP(TM) A-6 Method criteria, we recommend the use of cardiac troponin assays without additional biomarkers using the 99th percentile URL as the clinical diagnostic threshold for the diagnosis of NSTEMI. We recommend serial sampling with one sample at presentation and at least one additional second sample taken at least 6h later to identify a rise or fall in the troponin level. No recommendation is made either for or against the use of point of care tests. DISCLAIMER The findings and conclusions in this article are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention/the Agency for Toxic Substances and Disease Registry (CDC/ATSDR).
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Wlazeł RN, Kasprzak J, Paradowski M. A new generation of biomarkers tests of myocardial necrosis: the real quality a physician can get from the laboratory. Med Sci Monit 2015; 21:338-44. [PMID: 25629263 PMCID: PMC4318227 DOI: 10.12659/msm.892033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Background Recent guidelines recommended by ESC, ACC, AHA, and WHF concerning biomarkers of myocardial necrosis also apply to the work of clinical laboratories. Methodological modification for tests used in determining cardiac biomarkers reduced the time of the analytical procedure to 9 min (STAT version of the tests). We decided to determine and compare analytical quality of the tests in standard and STAT versions for determining serum level: troponin T, MB isoenzyme of creatine kinase, and myoglobin, as well as to verify whether the TnThs STAT test meets the following requirements: CV <10% at the level close to diagnostic, equal to the 99th percentile of reference population, and turnaround time <60 min. Material/Methods We evaluated real precision and accuracy for both standard and STAT versions of tests as well as the correlation of results of physiological and pathological levels. Additionally, observations of turnaround time were made. Results Calculated values of total errors did not exceed the recommended acceptable total error (<20%). Comparable precision of the 2 measurement methods (CV=3.07%) was obtained. A strong correlation (R>0.99) between both variants of tests for all the parameters was confirmed. Thanks to the application of new reagent kit, the percentage of results with turnaround time <60 min increased from 40% to 75% (n=115; p=0.000008). Conclusions The new generation of STAT cardiac biomarkers has high analytical quality and meets international precision requirements. It guarantees high analytical and clinical reliability of results. Use of the STAT version of biomarkers contributes to a significant decrease in turnaround time and allows obtaining a good result of an analysis.
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Affiliation(s)
- Rafał Nikodem Wlazeł
- Department of Laboratory Diagnostics and Clinical Biochemistry, Medical University of Łódź, Łódź, Poland
| | - Jarosław Kasprzak
- Chair and Department of Cardiology, Medical University of Łódź, Łódź, Poland
| | - Marek Paradowski
- Department of Laboratory Diagnostics and Clinical Biochemistry, Medical University of Łódź, Łódź, Poland
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Zhelev Z, Hyde C, Youngman E, Rogers M, Fleming S, Slade T, Coelho H, Jones-Hughes T, Nikolaou V. Diagnostic accuracy of single baseline measurement of Elecsys Troponin T high-sensitive assay for diagnosis of acute myocardial infarction in emergency department: systematic review and meta-analysis. BMJ 2015; 350:h15. [PMID: 25646632 PMCID: PMC4300724 DOI: 10.1136/bmj.h15] [Citation(s) in RCA: 139] [Impact Index Per Article: 15.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/10/2014] [Indexed: 12/29/2022]
Abstract
OBJECTIVE To obtain summary estimates of the accuracy of a single baseline measurement of the Elecsys Troponin T high-sensitive assay (Roche Diagnostics) for the diagnosis of acute myocardial infarction in patients presenting to the emergency department. DESIGN Systematic review and meta-analysis of diagnostic test accuracy studies. DATA SOURCES Medline, Embase, and other relevant electronic databases were searched for papers published between January 2006 and December 2013. STUDY SELECTION Studies were included if they evaluated the diagnostic accuracy of a single baseline measurement of Elecsys Troponin T high-sensitive assay for the diagnosis of acute myocardial infarction in patients presenting to the emergency department with suspected acute coronary syndrome. STUDY APPRAISAL AND DATA SYNTHESIS The first author screened all titles and abstracts identified through the searches and selected all potentially relevant papers. The screening of the full texts, the data extraction, and the methodological quality assessment, using the adapted QUADAS-2 tool, were conducted independently by two reviewers with disagreements being resolved through discussion or arbitration. If appropriate, meta-analysis was conducted using the hierarchical bivariate model. RESULTS Twenty three studies reported the performance of the evaluated assay at presentation. The results for 14 ng/L and 3-5 ng/L cut-off values were pooled separately. At 14 ng/L (20 papers), the summary sensitivity was 89.5% (95% confidence interval 86.3% to 92.1%) and the summary specificity was 77.1% (68.7% to 83.7%). At 3-5 ng/L (six papers), the summary sensitivity was 97.4% (94.9% to 98.7%) and the summary specificity was 42.4% (31.2% to 54.5%). This means that if 21 of 100 consecutive patients have the target condition (21%, the median prevalence across the studies), 2 (95% confidence interval 2 to 3) of 21 patients with acute myocardial infarction will be missed (false negatives) if 14 ng/L is used as a cut-off value and 18 (13 to 25) of 79 patients without acute myocardial infarction will test positive (false positives). If the 3-5 ng/L cut-off value is used, <1 (0 to 1) patient with acute myocardial infarction will be missed and 46 (36 to 54) patients without acute myocardial infarction will test positive. CONCLUSIONS The results indicate that a single baseline measurement of the Elecsys Troponin T high-sensitive assay could be used to rule out acute myocardial infarction if lower cut-off values such as 3 ng/L or 5 ng/L are used. However, this method should be part of a comprehensive triage strategy and may not be appropriate for patients who present less than three hours after symptom onset. Care must also be exercised because of the higher imprecision of the evaluated assay and the greater effect of lot-to-lot reagent variation at low troponin concentrations. SYSTEMATIC REVIEW REGISTRATION PROSPERO registration number CRD42013003926.
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Affiliation(s)
- Zhivko Zhelev
- Institute of Health Research, University of Exeter Medical School, Exeter EX2 4SG, UK
| | - Christopher Hyde
- Institute of Health Research, University of Exeter Medical School, Exeter EX2 4SG, UK
| | - Emily Youngman
- Institute of Health Research, University of Exeter Medical School, Exeter EX2 4SG, UK
| | - Morwenna Rogers
- Institute of Health Research, University of Exeter Medical School, Exeter EX2 4SG, UK
| | - Simon Fleming
- Clinical Chemistry, Royal Cornwall Hospital, Treliske, Truro TR1 3LQ, UK
| | - Toby Slade
- Emergency Department, Royal Cornwall Hospital, Truro TR1 3LJ, UK
| | - Helen Coelho
- Institute of Health Research, University of Exeter Medical School, Exeter EX2 4SG, UK
| | - Tracey Jones-Hughes
- Institute of Health Research, University of Exeter Medical School, Exeter EX2 4SG, UK
| | - Vasilis Nikolaou
- Institute of Health Research, University of Exeter Medical School, Exeter EX2 4SG, UK
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209
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McKeeman GC, Auld PW. A national survey of troponin testing and recommendations for improved practice. Ann Clin Biochem 2015; 52:527-42. [DOI: 10.1177/0004563214568163] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/19/2014] [Indexed: 11/16/2022]
Abstract
Background The introduction of troponin assays with higher analytical sensitivity and enhanced performance has produced new challenges for both laboratory and clinician in the optimal investigation of patients with cardiovascular disease. After some years of collective experience with this new generation of assays, this survey aimed to assess the level of consensus that exists regarding their application. Methods A questionnaire was designed, based on a review of published evidence and current opinion, to obtain information on a number of key areas relating to troponin analysis and reporting and was circulated to lead laboratory consultants across the UK and Ireland. Results Completed questionnaires were received from 94 laboratory contacts. Sixty per cent of those who responded had implemented a high-sensitivity troponin assay, with the Roche Cobas troponin T high sensitivity assay the most widely used. It is evident that some confusion remains regarding the definition of high-sensitivity assays and there was considerable variation in practice, even among those using the same manufacturer’s assay. Conclusions There is a need for greater consensus in the approach to the clinical utilization of troponin assays with improved sensitivity and it is important that laboratories are fully aware of the capabilities of their assay and provide useful guidance to users. On the basis of survey findings and the existing evidence base, a number of recommendations have been proposed to improve current practice and enhance patient safety.
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Affiliation(s)
- Gareth C McKeeman
- Department of Clinical Biochemistry, Belfast Health & Social Care Trust, Royal Victoria Hospital, Grosvenor Road, Belfast, UK
| | - Peter W Auld
- Department of Clinical Biochemistry, Belfast Health & Social Care Trust, Royal Victoria Hospital, Grosvenor Road, Belfast, UK
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Ferraro S, Panteghini M. Laboratory medicine as the science that underpins medicine: the “high-sensitivity” troponin paradigm. ACTA ACUST UNITED AC 2015; 53:653-64. [DOI: 10.1515/cclm-2014-0812] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2014] [Accepted: 09/03/2014] [Indexed: 01/10/2023]
Abstract
AbstractThe availability of so-called high-sensitivity troponin assays (hsTn) has scored a compelling goal for laboratory medicine, allowing the safe clinical application of international recommendations for the definition of acute myocardial infarction (AMI). However, the introduction of hsTn has not been welcomed by clinicians, claiming an increase in false-positive results. Here we critically trace back the steps following the introduction of hsTn by referring to the 5-year practical experience in our academic hospital and to suitable information available in the literature. In agreement with published data, we found that hsTn introduction was associated with an increased number of AMI diagnoses, whereas the test volume, the revascularization rate, and the proportion of cases with negative angiography findings remained virtually unchanged. Fast-track protocols for ruling out AMI have been further optimized to recommend sampling at presentation and after 3 h only. We focus on a cost-effective use of hsTn that can account for all clinical variables increasing the pre-test probability in order to ensure that tests are ordered only for patients at medium to high risk for acute coronary syndrome (ACS). To guide interpretation of results, hsTn typical release patterns suggestive for AMI should be identified by evaluating the significance of concentration changes. hsTn have markedly shortened the time to rule out or rule in AMI and has the potential to improve the prognostic assessment of critical patients in clinical contexts different from ACS.
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211
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Lipinski MJ, Baker NC, Escárcega RO, Torguson R, Chen F, Aldous SJ, Christ M, Collinson PO, Goodacre SW, Mair J, Inoue K, Lotze U, Sebbane M, Cristol JP, Freund Y, Chenevier-Gobeaux C, Meune C, Eggers KM, Pracoń R, Schreiber DH, Wu AHB, Ordoñez-Llanos J, Jaffe AS, Twerenbold R, Mueller C, Waksman R. Comparison of conventional and high-sensitivity troponin in patients with chest pain: a collaborative meta-analysis. Am Heart J 2015; 169:6-16.e6. [PMID: 25497242 DOI: 10.1016/j.ahj.2014.10.007] [Citation(s) in RCA: 73] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2014] [Accepted: 10/10/2014] [Indexed: 02/07/2023]
Abstract
BACKGROUND Multiple studies have evaluated the diagnostic and prognostic performance of conventional troponin (cTn) and high-sensitivity troponin (hs-cTn). We performed a collaborative meta-analysis comparing cTn and hs-cTn for diagnosis of acute myocardial infarction (AMI) and assessment of prognosis in patients with chest pain. METHODS MEDLINE/PubMed, Cochrane CENTRAL, and EMBASE were searched for studies assessing both cTn and hs-cTn in patients with chest pain. Study authors were contacted and many provided previously unpublished data. RESULTS From 17 included studies, there were 8,644 patients. Compared with baseline cTn, baseline hs-cTn had significantly greater sensitivity (0.884 vs 0.749, P < .001) and negative predictive value (NPV; 0.964 vs 0.935, P < .001), whereas specificity (0.816 vs 0.938, P < .001) and positive predictive value (0.558 vs 0.759, P < .001) were significantly reduced. Based on summary receiver operating characteristic curves, test performance for the diagnosis of AMI was not significantly different between baseline cTn and hs-cTn (0.90 [95% CI 0.85-0.95] vs 0.92 [95% CI 0.90-0.94]). In a subanalysis of 6 studies that alternatively defined AMI based on hs-cTn, cTn had lower sensitivity (0.666, P < .001) and NPV (0.906, P < .001). Elevation of baseline hs-cTn, but negative baseline cTn, was associated with increased risk of death or nonfatal myocardial infarction during follow-up (P < .001) compared with both negative. CONCLUSION High-sensitivity troponin has significantly greater early sensitivity and NPV for the diagnosis of AMI at the cost of specificity and positive predictive value, which may enable early rule in/out of AMI in patients with chest pain. Baseline hs-cTn elevation in the setting of negative cTn is also associated with increased nonfatal myocardial infarction or death during follow-up.
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Affiliation(s)
- Michael J Lipinski
- MedStar Cardiovascular Research Network, MedStar Heart Institute, Medstar Washington Hospital Center, Washington, DC
| | - Nevin C Baker
- MedStar Cardiovascular Research Network, MedStar Heart Institute, Medstar Washington Hospital Center, Washington, DC
| | - Ricardo O Escárcega
- MedStar Cardiovascular Research Network, MedStar Heart Institute, Medstar Washington Hospital Center, Washington, DC
| | - Rebecca Torguson
- MedStar Cardiovascular Research Network, MedStar Heart Institute, Medstar Washington Hospital Center, Washington, DC
| | - Fang Chen
- MedStar Cardiovascular Research Network, MedStar Heart Institute, Medstar Washington Hospital Center, Washington, DC
| | - Sally J Aldous
- Department of Cardiology, Christchurch Hospital, Christchurch, New Zealand
| | - Michael Christ
- Department of Emergency and Critical Care Medicine, Paracelsus Medical University, Nuremberg, Germany
| | - Paul O Collinson
- Clinical Blood Sciences Laboratory, St George's Hospital, London, United Kingdom
| | - Steve W Goodacre
- School of Health and Related Research, University of Sheffield, Sheffield, United Kingdom
| | - Johannes Mair
- Department of Internal Medicine, Innsbruck Medical University, Innsbruck, Austria
| | - Kenji Inoue
- Department of Cardiology, Juntendo University Nerima Hospital, Tokyo, Japan
| | - Ulrich Lotze
- Department of Internal Medicine, DRK-Manniske-Krankenhaus Bad Frankenhausen, Frankenhausen, Germany
| | - Mustapha Sebbane
- Départment des urgences, Centre Hospitalier Régional Universitaire Lapeyronie, Montpellier, France
| | - Jean-Paul Cristol
- Département de Biochimie, Centre Hospitalier Régional Universitaire Lapeyronie, Montpellier, France
| | - Yonathan Freund
- Department of Emergency Medicine and Surgery, Hôspital Pitié-Salpétrière, APHP, Université Pierre et Marie Curie-Paris 6 (UPMC), Paris, France
| | - Camille Chenevier-Gobeaux
- Clinical Chemistry Laboratory, Groupe Hospitalier Cochin-Broca-Hôtel Dieu, Université Paris Descartes, Assistance Publique des Hôpitaux de Paris, Paris, France
| | - Christophe Meune
- Cardiology Department, Groupe Hospitalier Cochin-Broca-Hôtel Dieu, Université Paris Descartes, Assistance Publique des Hôpitaux de Paris, Paris, France; Cardiology Department, Paris XIII University, Avicenne Hospital, Bobigny, France
| | - Kai M Eggers
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - Radosław Pracoń
- Department of Coronary and Structural Heart Diseases, National Insititute of Cardiology, Warsaw, Poland
| | - Donald H Schreiber
- Division of Emergency Medicine, Stanford University School of Medicine, Stanford, CA
| | - Alan H B Wu
- Department of Laboratory Medicine, University of California, San Francisco, CA
| | - Jordi Ordoñez-Llanos
- Servei de Bioquímica Clínica, Hospital de Sant Pau, Barcelona, Spain; Biochemistry and Molecular Biology Department, Universitat Autònoma, Barcelona, Spain
| | - Allan S Jaffe
- Division of Cardiology, Mayo Clinic College of Medicine, Rochester, MN; Department of Laboratory Medicine and Pathology, Mayo Clinic College of Medicine, Rochester, MN
| | - Raphael Twerenbold
- Department of Cardiology, University Hospital Basel, Basel, Switzerland; Universitäres Herz-Zentrum Bad Krozingen, Bad Krozingen, Germany
| | - Christian Mueller
- Department of Cardiology, University Hospital Basel, Basel, Switzerland
| | - Ron Waksman
- MedStar Cardiovascular Research Network, MedStar Heart Institute, Medstar Washington Hospital Center, Washington, DC.
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Kelly AM, Klim S. Does undetectable troponin I at presentation using a contemporary sensitive assay rule out myocardial infarction? A cohort study. Emerg Med J 2014; 32:760-3. [DOI: 10.1136/emermed-2014-204442] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2014] [Accepted: 12/03/2014] [Indexed: 11/04/2022]
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213
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Body R, Burrows G, Carley S, Lewis PS. The Manchester Acute Coronary Syndromes (MACS) decision rule: validation with a new automated assay for heart-type fatty acid binding protein. Emerg Med J 2014; 32:769-74. [DOI: 10.1136/emermed-2014-204235] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2014] [Accepted: 12/04/2014] [Indexed: 11/04/2022]
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214
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Abstract
Cardiac troponin assays have an established and undisputed role in the diagnosis and risk stratification of patients with acute myocardial infarction. As troponin assays gets more sensitive and more precise, the number of potential uses has rapidly expanded, but the use of this test has also become more complicated and controversial. Highly sensitive troponin assays can now detect troponin levels in most individuals, but accurate interpretation of these levels requires a clear understanding of the assay in the context of the clinical scenario. This paper provides a practical and up-to-date overview of the uses of highly sensitive troponin assays for diagnosis, prognosis, and risk stratification in clinical practice.
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Affiliation(s)
- Lori B Daniels
- Division of Cardiology, Department of Medicine, University of California at San Diego, Mail Code 7411,9444 Medical Center Drive, La Jolla, CA, 92037-7411, USA,
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215
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Scheitz JF, Mochmann HC, Erdur H, Tütüncü S, Haeusler KG, Grittner U, Laufs U, Endres M, Nolte CH. Prognostic relevance of cardiac troponin T levels and their dynamic changes measured with a high-sensitivity assay in acute ischaemic stroke: Analyses from the TRELAS cohort. Int J Cardiol 2014; 177:886-93. [DOI: 10.1016/j.ijcard.2014.10.036] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2014] [Revised: 07/31/2014] [Accepted: 10/18/2014] [Indexed: 11/26/2022]
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Hickman PE, Lindahl B, Cullen L, Koerbin G, Tate J, Potter JM. Decision limits and the reporting of cardiac troponin: Meeting the needs of both the cardiologist and the ED physician. Crit Rev Clin Lab Sci 2014; 52:28-44. [PMID: 25397345 DOI: 10.3109/10408363.2014.972497] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Cardiac troponin is the preferred biomarker for defining the acute coronary syndrome and acute myocardial infarction. Currently, the only decision limit formally endorsed with regard to the cardiac troponins is the 99th percentile. This is a "rule-in" criterion, intended to ensure that only persons with the acute coronary syndrome are reviewed. The 99th percentile is an arbitrary cut point and there are many problems associated with its application, including defining a truly healthy population, the difficulty of standardisation of cardiac troponin assays, especially but not only cardiac troponin I, and the effects of age and sex on this parameter. The Emergency Department (ED) screens many more persons for possible acute coronary syndromes than actually have the condition and their needs are best met by a "rule-out" test that enables them to clear their busy departments of the many persons who do not actually have the condition. The needs of the ED are not optimally met using the 99th percentile. The index of individuality for the cardiac troponins is small and significant changes consistent with an acute coronary syndrome can occur without the 99th percentile being exceeded. It appears that the ED may be better served by use of delta troponin changes rather than the 99th percentile, but there are problems with this approach, particularly in persons who present late when troponin release has plateaued. In addition, there are many non-acute coronary syndrome causes for cardiac troponin release. The needs of the cardiologist and the ED physician are so different that it may be inappropriate for both groups to use the same diagnostic criteria for cardiac troponin, and it is of great importance that cardiac troponin measurement be used as only one part of the assessment of the person presenting with possible acute coronary syndrome.
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217
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Kavsak PA, Jaffe AS, Hickman PE, Mills NL, Humphries KH, McRae A, Devereaux PJ, Lamy A, Whitlock R, Dhesy-Thind SK, Potter JM, Worster A. Canadian Institutes of Health Research dissemination grant on high-sensitivity cardiac troponin. Clin Biochem 2014; 47:155-7. [PMID: 25304912 DOI: 10.1016/j.clinbiochem.2014.10.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
| | | | - Peter E Hickman
- Australian National University Medical School, Canberra, Australian Capital Territory, Australia
| | - Nicholas L Mills
- BHF/University Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | | | - Andrew McRae
- Department of Emergency Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | | | - Andre Lamy
- McMaster University, Hamilton, Ontario, Canada
| | | | | | - Julia M Potter
- Australian National University Medical School, Canberra, Australian Capital Territory, Australia
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Yip TPY, Pascoe HM, Lane SE. Impact of high-sensitivity cardiac troponin I assays on patients presenting to an emergency department with suspected acute coronary syndrome. Med J Aust 2014; 201:158-61. [PMID: 25128951 DOI: 10.5694/mja13.00117] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2013] [Accepted: 04/10/2014] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To determine whether introduction of high-sensitivity cardiac troponin I (hscTn-I) assays affected management of patients presenting with suspected acute coronary syndrome (ACS) to the emergency department (ED) of a tertiary referral hospital. DESIGN, PATIENTS AND SETTING A retrospective analysis of all patients presenting to the Geelong Hospital ED with suspected ACS from 23 April 2010 to 22 April 2013 -2 years before and 1 year after the changeover to hscTn-I assays on 23 April 2012. MAIN OUTCOME MEASURES Hospital admission rates, time spent in the ED, rates of coronary angiography, rates of percutaneous coronary intervention (PCI) and coronary artery bypass graft surgery (CABGS), rates of discharge with a diagnosis of ACS, and rates of inhospital mortality. RESULTS 12 360 consecutive patients presented with suspected ACS during the study period; 1897 were admitted to Geelong Hospital in the 2 years before and 944 in the 1 year after the changeover to hscTn-I assays. Comparing the two patient groups, there was no statistically significant difference in all-hospital admission rates (95% CI for the difference, - 3.1% to 0.3%; P = 0.10) or proportion of patients subsequently discharged with a diagnosis of ACS (95% CI for the difference, - 2.3% to 5.4%; P = 0.43). After the changeover, the median time patients spent in the ED was 11.5% shorter (3.85 h v 4.35 h; 95% CI for the difference, - 0.59 to - 0.43; P < 0.001) and the proportion of admitted patients undergoing coronary angiography was higher (53.4% v 45.2%; 95% CI for the difference, 4.3 to 12.0 percentage points; P < 0.001), but there was no statistically significant rise in the proportion of patients who had invasive treatment (PCI and/or CABGS) (95% CI for the difference, - 0.4% to 6.3%; P = 0.08). Inhospital mortality rates from ACS did not change significantly (95% CI for the difference, - 1.5% to 0.8%; P = 0.43). CONCLUSION The introduction of hscTn-I assays appeared to be associated with more rapid diagnosis, resulting in less time spent in the ED, without a change in hospital admission rates. A higher proportion of patients had coronary angiographies after the changeover, but there was no significant change in rates of invasive treatment or inhospital mortality.
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Affiliation(s)
- Thomas P Y Yip
- Geelong Cardiology Practice, Barwon Health, Geelong, VIC, Australia.
| | - Heather M Pascoe
- Geelong Cardiology Practice, Barwon Health, Geelong, VIC, Australia
| | - Stephen E Lane
- Biostatistics Unit, Barwon Health, Geelong, VIC, Australia
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Marshall GA, Wijeratne NG, Thomas D. Should general practitioners order troponin tests? Med J Aust 2014; 201:155-7. [PMID: 25128950 DOI: 10.5694/mja13.00173] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2013] [Accepted: 04/02/2014] [Indexed: 11/17/2022]
Abstract
Cardiac troponin I and T are the preferred biomarkers for assessing myocardial injury, and the timing of troponin testing is fundamental to its clinical utility. There are arguments for and against the use of troponin testing in the community, and the stance that general practitioners should never order a troponin test can be considered an oversimplification. GPs have a generally sufficient understanding of the test for use in primary care, and have a better understanding of false-negative troponin test results than false-positive results. We suggest that hospitalisation, rather than troponin testing, should be the default option for patients with symptoms suggestive of acute coronary syndrome. A single troponin test is reasonable in primary care to exclude the possibility of acute myocardial infarction in asymptomatic low-risk patients whose symptoms resolved at least 12 hours prior. GPs should factor in the complex logistics of troponin testing in the community before ordering a troponin test: results need to be accurate and timely, and might be obtained at a time of day when it is difficult to contact the doctor or the patient.
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Thelin J, Melander O, Öhlin B. Early rule-out of acute coronary syndrome using undetectable levels of high sensitivity troponin T. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2014; 4:403-9. [DOI: 10.1177/2048872614554107] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/12/2014] [Accepted: 09/14/2014] [Indexed: 11/17/2022]
Affiliation(s)
- Johan Thelin
- Department of Clinical Sciences, Lund University, Sweden
- Deparment of Internal Medicine, Skåne University Hospital, Sweden
| | - Olle Melander
- Department of Clinical Sciences, Lund University, Sweden
- Deparment of Internal Medicine, Skåne University Hospital, Sweden
| | - Bertil Öhlin
- Department of Clinical Sciences, Lund University, Sweden
- Deparment of Internal Medicine, Skåne University Hospital, Sweden
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221
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Korley FK, Jaffe AS. High-sensitivity troponin: where are we now and where do we go from here? Biomark Med 2014; 8:1021-32. [DOI: 10.2217/bmm.14.54] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
High-sensitivity troponin (hsTn) assays are used clinically in most parts of the world and are expected to be approved by the US FDA for clinical use in the USA soon. Clinical use of hsTn leads to improvements in the detection of myocardial injury, shorter time to ruling out acute myocardial infarction, improved risk-stratification of patients with heart failure and atrial fibrillation among others. HsTn may also guide strategies for primary and secondary prevention of cardiovascular disease. However, unmet challenges remain, including distinguishing between acute and chronic hsTn elevations, distinguishing between type 1 and type 2 acute myocardial infarction and determining whether to use gender-neutral or gender-specific reference values.
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Affiliation(s)
- Frederick K Korley
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Davis Building, Suite 3220, 5801 Smith Avenue, Baltimore, MD 21209, USA
| | - Allan S Jaffe
- Cardiovascular Division & Division of Core Clinical Laboratory Services, Departments of Medicine & Laboratory Medicine and Pathology, Mayo Clinic and Medical School, Rochester, MN, USA
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Sethi A, Bajaj A, Malhotra G, Arora RR, Khosla S. Diagnostic accuracy of sensitive or high-sensitive troponin on presentation for myocardial infarction: a meta-analysis and systematic review. Vasc Health Risk Manag 2014; 10:435-50. [PMID: 25092986 PMCID: PMC4115590 DOI: 10.2147/vhrm.s63416] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
Background Recently, high-sensitive troponin (hsTrop) assays consistent with professional societies’ recommendations became available. We aimed to summarize the evidence on the diagnostic accuracy of hsTrop on presentation. Methods We searched electronic databases for studies evaluating the diagnostic accuracy of hsTrop in suspected acute coronary syndrome (ACS) patients. Random effect meta-analyses and meta-regression were performed. Primary and secondary analyses were restricted to studies using conventional Trop and hsTrop in the reference standard, respectively. Results Fifteen studies with a total of 8,628 patients met the inclusion criteria for the primary analysis. hsTrop T (Hoffman-La Roche Ltd) and hsTrop I (Siemens) had sensitivities of 0.89 (95% confidence interval [CI]: 0.86–0.91) and 0.90 (95% CI: 0.87–0.92) and specificities of 0.79 (95% CI: 0.77–0.80) and 0.89 (95% CI: 0.87–0.90), respectively. There was no statistically significant difference in the area under the curve between hsTrop (95% CI: 0.920) and conventional Trop (95% CI: 0.929) at the 99th percentile (P=0.62). hsTrop at the level of detection had a sensitivity of 0.97 (95% CI: 0.96–0.98) and a specificity of 0.41 (95% CI: 0.40–0.42). The studies using a cut-off at coefficient of variance <10% as opposed to the 99th percentile for the conventional assay used for diagnosis reported higher diagnostic accuracy (relative diagnostic odds ratio =2.13, P=0.02). Five studies were included in the secondary analysis; hsTrop T (Hoffman-La Roche Ltd) had a sensitivity of 0.91 (95% CI: 0.89–0.93) and a specificity of 0.67 (95% CI: 0.63–0.70). There was significant heterogeneity among the studies. Conclusion hsTrop have excellent diagnostic accuracy for myocardial infarction on presentation, but may not outperform conventional Trop assays. The variation among the studies can be explained, in part, by the cut-off used for conventional Trop assays.
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Affiliation(s)
- Ankur Sethi
- Department of Medicine, Division of Cardiology, Rosalind Franklin University of Medicine and Science, North Chicago, IL, USA
| | - Anurag Bajaj
- Department of Medicine, Wright Center of Graduate Medical Education, Scranton, PA, USA
| | - Gurveen Malhotra
- Department of Medicine, Division of Cardiology, Rosalind Franklin University of Medicine and Science, North Chicago, IL, USA
| | - Rohit R Arora
- Department of Medicine, Division of Cardiology, Rosalind Franklin University of Medicine and Science, North Chicago, IL, USA
| | - Sandeep Khosla
- Department of Medicine, Division of Cardiology, Rosalind Franklin University of Medicine and Science, North Chicago, IL, USA
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Al-Saleh A, Alazzoni A, Al Shalash S, Ye C, Mbuagbaw L, Thabane L, Jolly SS. Performance of the high-sensitivity troponin assay in diagnosing acute myocardial infarction: systematic review and meta-analysis. CMAJ Open 2014; 2:E199-207. [PMID: 25295240 PMCID: PMC4183183 DOI: 10.9778/cmajo.20130074] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND High-sensitivity cardiac troponin assays have been adopted by many clinical centres worldwide; however, clinicians are uncertain how to interpret the results. We sought to assess the utility of these assays in diagnosing acute myocardial infarction (MI). METHODS We carried out a systematic review and meta-analysis of studies comparing high-sensitivity with conventional assays of cardiac troponin levels among adults with suspected acute MI in the emergency department. We searched MEDLINE, EMBASE and Cochrane databases up to April 2013 and used bivariable random-effects modelling to obtain summary parameters for diagnostic accuracy. RESULTS We identified 9 studies that assessed the use of high-sensitivity troponin T assays (n = 9186 patients). The summary sensitivity of these tests in diagnosing acute MI at presentation to the emergency department was estimated to be 0.94 (95% confidence interval [CI] 0.89-0.97); for conventional tests, it was 0.72 (95% CI 0.63-0.79). The summary specificity was 0.73 (95% CI 0.64-0.81) for the high-sensitivity assay compared with 0.95 (95% CI 0.93-0.97) for the conventional assay. The differences in estimates of the summary sensitivity and specificity between the high-sensitivity and conventional assays were statistically significant (p < 0.01). The area under the curve was similar for both tests carried out 3-6 hours after presentation. Three studies assessed the use of high-sensitivity troponin I assays and showed similar results. INTERPRETATION Used at presentation to the emergency department, the high-sensitivity cardiac troponin assay has improved sensitivity, but reduced specificity, compared with the conventional troponin assay. With repeated measurements over 6 hours, the area under the curve is similar for both tests, indicating that the major advantage of the high-sensitivity test is early diagnosis.
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Affiliation(s)
- Ayman Al-Saleh
- Department of Cardiology, Hamilton Health Sciences, McMaster University, Hamilton, Ont
| | - Ashraf Alazzoni
- Department of Cardiology, Hamilton Health Sciences, McMaster University, Hamilton, Ont
| | - Saleh Al Shalash
- Department of Internal Medicine, McMaster University, Hamilton, Ont
| | - Chenglin Ye
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ont. ; Biostatistics Unit, St Joseph's Healthcare, Hamilton, Ont
| | - Lawrence Mbuagbaw
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ont. ; Biostatistics Unit, St Joseph's Healthcare, Hamilton, Ont. ; Centre for Development of Best Practices in Health, Yaoundé Central Hospital, Yaoundé, Cameroon
| | - Lehana Thabane
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ont. ; Departments of Anesthesia and Pediatrics, McMaster University, Hamilton, Ont. ; Population Health Research Institute, Hamilton Health Sciences, Hamilton, Ont
| | - Sanjit S Jolly
- Department of Cardiology, Hamilton Health Sciences, McMaster University, Hamilton, Ont. ; Population Health Research Institute, Hamilton Health Sciences, Hamilton, Ont
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Dave DM, Ferencic M, Hoffmann U, Udelson JE. Imaging techniques for the assessment of suspected acute coronary syndromes in the emergency department. Curr Probl Cardiol 2014; 39:191-247. [PMID: 24952880 PMCID: PMC8323766 DOI: 10.1016/j.cpcardiol.2014.05.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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225
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Aboukhoudir F, Rekik S, Latil Plat F, Aboukhoudir I, Kadem M, Benamo E, Pansieri M. [Uselessness of high-sensitivity cardiac troponins to improve diagnostic accuracy of dobutamine stress echocardiography in high-risk diabetic patients]. Ann Cardiol Angeiol (Paris) 2014; 63:307-11. [PMID: 24972986 DOI: 10.1016/j.ancard.2014.05.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2014] [Accepted: 05/25/2014] [Indexed: 10/25/2022]
Abstract
BACKGROUND AND AIM Dobutamine stress echocardiography (DSE) is a well-established noninvasive stress modality for the detection and evaluation of coronary artery disease in diabetic patients. High-sensitivity cardiac troponin T recently emerged as a highly sensitive dosage for the detection of ischemia. The aim of the study was to examine whether high-sensitivity cardiac troponin T may improve the diagnostic accuracy of silent ischemia by DSE in high-risk diabetic patients. METHODS AND RESULTS Twenty-one patients with long-standing (>10years) and/or complicated type II DM but no established CAD were included. In addition to DSE, venous blood samples for measurement of hs-cTnT were collected prior to DSE, 6hours and 24hours after the test. Troponins were deemed positive if>1.5 upper limit for normality. Patients with positive troponins underwent coronary angiography or CT scan regardless of the result of DSE. Among the 21 patients, 7 had positive troponins measured 6hours after stress, (mean peak troponin=44.5). DSE were negative in all of them. Mean age was 64years significantly higher than patients with negative troponins. No differences were noted between the groups in terms of epidemiological, clinical or echocardiographic characteristics. Patients with positive cardiac troponins were evaluated for the presence of coronary lesions but none of them had significant disease. After an 18-month mean follow-up, no adverse cardiac events were noted in either group. CONCLUSION In high-risk diabetic patients, the measurement of hs-cTnT during DSE does not improve the sensitivity at least in those with negative DSE tests.
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Affiliation(s)
- F Aboukhoudir
- Service de cardiologie, centre hospitalier d'Avignon, 305, rue Raoul-Follereau, 84000 Avignon, France; Laboratoire de Pharm écologie cardiovasculaire, université d'Avignon, EA4278, 84000 Avignon, France
| | - S Rekik
- Service de cardiologie, centre hospitalier d'Antibes, 107, route de Nice, 06600 Antibes, France.
| | - F Latil Plat
- Service endocrinologie, centre hospitalier d'Avignon, 305, rue Raoul Follereau, 84000 Avignon, France
| | - I Aboukhoudir
- Service de cardiologie, centre hospitalier d'Avignon, 305, rue Raoul-Follereau, 84000 Avignon, France
| | - M Kadem
- Service endocrinologie, centre hospitalier d'Avignon, 305, rue Raoul Follereau, 84000 Avignon, France
| | - E Benamo
- Service endocrinologie, centre hospitalier d'Avignon, 305, rue Raoul Follereau, 84000 Avignon, France
| | - M Pansieri
- Service de cardiologie, centre hospitalier d'Avignon, 305, rue Raoul-Follereau, 84000 Avignon, France
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Lipinski MJ, Escárcega RO, D'Ascenzo F, Magalhães MA, Baker NC, Torguson R, Chen F, Epstein SE, Miró Ò, Llorens P, Giannitsis E, Lotze U, Lefebvre S, Sebbane M, Cristol JP, Chenevier-Gobeaux C, Meune C, Eggers KM, Charpentier S, Twerenbold R, Mueller C, Biondi-Zoccai G, Waksman R. A systematic review and collaborative meta-analysis to determine the incremental value of copeptin for rapid rule-out of acute myocardial infarction. Am J Cardiol 2014; 113:1581-91. [PMID: 24731654 DOI: 10.1016/j.amjcard.2014.01.436] [Citation(s) in RCA: 98] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2013] [Revised: 01/20/2014] [Accepted: 01/20/2014] [Indexed: 02/08/2023]
Abstract
Multiple studies have evaluated copeptin, a surrogate for arginine vasopressin, in the diagnosis of acute myocardial infarction (AMI) with mixed results. A systematic review and collaborative meta-analysis were performed for diagnosis of AMI and assessment of prognosis in patients presenting to the emergency department with chest pain. MEDLINE/PubMed, Cochrane CENTRAL, and EMBASE were searched for studies assessing copeptin in such patients. Study investigators were contacted, and many provided previously unpublished data. Random-effects methods were used to compare the data for copeptin, troponin, and their combination. There were a total of 9,244 patients from the 14 included studies. Mean age was 62 years; 64% were men; and 18.4% were ultimately diagnosed with AMI. Patients with AMI had a higher presentation copeptin level than those without AMI (22.8 vs 8.3 pmol/L, respectively, p <0.001). Although troponin had better diagnostic accuracy than copeptin for AMI, the combination of copeptin and troponin significantly improved the sensitivity (0.905 [0.888 to 0.921] vs 0.686 [0.661 to 0.710], respectively, p <0.001) and negative predictive value (0.97 [0.964 to 0.975] vs 0.93 [0.924 to 0.936], respectively, p <0.001) compared with troponin alone. Elevation in copeptin carried a similar risk of all-cause mortality to an elevation in troponin (odds ratio 5.84 vs 6.74, respectively, p = 0.67). In conclusion, copeptin not only identifies patients at risk of all-cause mortality, but its addition to troponin improved the sensitivity and negative likelihood ratio for diagnosis of AMI compared with troponin alone. Thus, copeptin may help identify patients who may be safely discharged early from the emergency department.
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Dahlslett T, Karlsen S, Grenne B, Eek C, Sjøli B, Skulstad H, Smiseth OA, Edvardsen T, Brunvand H. Early Assessment of Strain Echocardiography Can Accurately Exclude Significant Coronary Artery Stenosis in Suspected Non–ST-Segment Elevation Acute Coronary Syndrome. J Am Soc Echocardiogr 2014; 27:512-9. [DOI: 10.1016/j.echo.2014.01.019] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2013] [Indexed: 12/22/2022]
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Body R, Carley S, McDowell G, Pemberton P, Burrows G, Cook G, Lewis PS, Smith A, Mackway-Jones K. The Manchester Acute Coronary Syndromes (MACS) decision rule for suspected cardiac chest pain: derivation and external validation. Heart 2014; 100:1462-8. [PMID: 24780911 PMCID: PMC4174131 DOI: 10.1136/heartjnl-2014-305564] [Citation(s) in RCA: 66] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Objective We aimed to derive and validate a clinical decision rule (CDR) for suspected cardiac chest pain in the emergency department (ED). Incorporating information available at the time of first presentation, this CDR would effectively risk-stratify patients and immediately identify: (A) patients for whom hospitalisation may be safely avoided; and (B) high-risk patients, facilitating judicious use of resources. Methods In two sequential prospective observational cohort studies at heterogeneous centres, we included ED patients with suspected cardiac chest pain. We recorded clinical features and drew blood on arrival. The primary outcome was major adverse cardiac events (MACE) (death, prevalent or incident acute myocardial infarction, coronary revascularisation or new coronary stenosis >50%) within 30 days. The CDR was derived by logistic regression, considering reliable (κ>0.6) univariate predictors (p<0.05) for inclusion. Results In the derivation study (n=698) we derived a CDR including eight variables (high sensitivity troponin T; heart-type fatty acid binding protein; ECG ischaemia; diaphoresis observed; vomiting; pain radiation to right arm/shoulder; worsening angina; hypotension), which had a C-statistic of 0.95 (95% CI 0.93 to 0.97) implying near perfect diagnostic performance. On external validation (n=463) the CDR identified 27.0% of patients as ‘very low risk’ and potentially suitable for discharge from the ED. 0.0% of these patients had prevalent acute myocardial infarction and 1.6% developed MACE (n=2; both coronary stenoses without revascularisation). 9.9% of patients were classified as ‘high-risk’, 95.7% of whom developed MACE. Conclusions The Manchester Acute Coronary Syndromes (MACS) rule has the potential to safely reduce unnecessary hospital admissions and facilitate judicious use of high dependency resources.
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Affiliation(s)
- Richard Body
- Cardiovascular Sciences Research Group, The University of Manchester, Manchester, UK Emergency Department, Central Manchester University Hospitals Foundation NHS Trust, Manchester, UK
| | - Simon Carley
- Emergency Department, Central Manchester University Hospitals Foundation NHS Trust, Manchester, UK Department of Health & Social Care, Manchester Metropolitan University, Manchester, UK
| | - Garry McDowell
- Cardiovascular Sciences Research Group, The University of Manchester, Manchester, UK
| | - Philip Pemberton
- Emergency Department, Central Manchester University Hospitals Foundation NHS Trust, Manchester, UK
| | - Gillian Burrows
- Biochemistry Department, Stockport Hospital, Stockport NHS Foundation Trust, Stockport, UK
| | - Gary Cook
- Department of Epidemiology, Stockport Hospital, Stockport NHS Foundation Trust, Stockport, UK
| | - Philip S Lewis
- Cardiology Department, Stockport Hospital, Stockport NHS Foundation Trust, Stockport, UK
| | - Alexander Smith
- Emergency Department, Central Manchester University Hospitals Foundation NHS Trust, Manchester, UK
| | - Kevin Mackway-Jones
- Emergency Department, Central Manchester University Hospitals Foundation NHS Trust, Manchester, UK Department of Health & Social Care, Manchester Metropolitan University, Manchester, UK
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Duvall WL, Savino JA, Levine EJ, Baber U, Lin JT, Einstein AJ, Hermann LK, Henzlova MJ. A comparison of coronary CTA and stress testing using high-efficiency SPECT MPI for the evaluation of chest pain in the emergency department. J Nucl Cardiol 2014; 21:305-18. [PMID: 24310280 DOI: 10.1007/s12350-013-9823-y] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2013] [Accepted: 11/11/2013] [Indexed: 10/25/2022]
Abstract
BACKGROUND Recent studies have compared CTA to stress testing and MPI using older Na-I SPECT cameras and traditional rest-stress protocols, but are limited by often using optimized CTA protocols but suboptimal MPI methodology. We compared CTA to stress testing with modern SPECT MPI using high-efficiency CZT cameras and stress-first protocols in an ED population. METHODS In a retrospective, non-randomized study, all patients who underwent CTA or stress testing (ETT or Tc-99m sestamibi SPECT MPI) as part of their ED assessment in 2010-2011 driven by ED attending preference and equipment availability were evaluated for their disposition from the ED (admission vs discharge, length of time to disposition), subsequent visits to the ED and diagnostic testing (within 3 months), and radiation exposure. CTA was performed using a 64-slice scanner (GE Lightspeed VCT) and MPI was performed using a CZT SPECT camera (GE Discovery 530c). Data were obtained from prospectively acquired electronic medical records and effective doses were calculated from published conversion factors. A propensity-matched analysis was also used to compare outcomes in the two groups. RESULTS A total of 1,458 patients underwent testing in the ED with 192 CTAs and 1,266 stress tests (327 ETTs and 939 MPIs). The CTA patients were a lower-risk cohort based on age, risk factors, and known heart disease. A statistically similar proportion of patients was discharged directly from the ED in the stress testing group (82% vs 73%, P = .27), but their time to disposition was longer (11.0 ± 5 vs 20.5 ± 7 hours, P < .0001). There was no significant difference in cardiac return visits to the ED (5.7% CTA vs 4.3% stress testing, P = .50), but more patients had follow-up studies in the CTA cohort compared to stress testing (14% vs 7%, P = .001). The mean effective dose of 12.6 ± 8.6 mSv for the CTA group was higher (P < .0001) than 5.0 ± 4.1 mSv for the stress testing group (ETT and MPI). A propensity score-matched cohort showed similar results to the entire cohort. CONCLUSIONS Stress testing with ETT, high-efficiency SPECT MPI, and stress-only protocols had a significantly lower patient radiation dose and less follow-up diagnostic testing than CTA with similar cardiac return visits. CTA had a shorter time to disposition, but there was a trend toward more revascularization than with stress testing.
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Affiliation(s)
- W Lane Duvall
- Mount Sinai Division of Cardiology (Mount Sinai Heart), Mount Sinai Medical Center, One Gustave L Levy Place, Box 1030, New York, NY, 10029, USA,
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Bandstein N, Ljung R, Johansson M, Holzmann MJ. Undetectable high-sensitivity cardiac troponin T level in the emergency department and risk of myocardial infarction. J Am Coll Cardiol 2014; 63:2569-2578. [PMID: 24694529 DOI: 10.1016/j.jacc.2014.03.017] [Citation(s) in RCA: 206] [Impact Index Per Article: 20.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2014] [Revised: 03/18/2014] [Accepted: 03/19/2014] [Indexed: 02/07/2023]
Abstract
OBJECTIVES This study sought to evaluate if an undetectable (<5 ng/l) high-sensitivity cardiac troponin T (hs-cTnT) level and an electrocardiogram (ECG) without signs of ischemia can rule out myocardial infarction (MI) in the emergency department (ED). BACKGROUND Chest pain is a common symptom often associated with benign conditions, but may be a sign of MI. Because there is no rapid way to rule out MI, many patients are admitted to the hospital. METHODS All patients who sought medical attention for chest pain and had at least 1 hs-cTnT analyzed during 2 years at the Karolinska University Hospital, Stockholm, Sweden, were included. We calculated the negative predictive values of an undetectable hs-cTnT and ECG without ischemia for MI and death within 30 days. RESULTS We included 14,636 patients, of whom 8,907 (61%) had an initial hs-cTnT of <5 ng/l; 21% had 5 to 14 ng/l, and 18% had >14 ng/l. During 30-day follow-up, 39 (0.44%) patients with undetectable hs-cTnT had a MI, of whom 15 (0.17%) had no ischemic ECG changes. The negative predictive value for MI within 30 days in patients with undetectable hs-cTnT and no ischemic ECG changes was 99.8% (95% confidence interval [CI]: 99.7 to 99.9). The negative predictive value for death was 100% (95% CI: 99.9 to 100). CONCLUSIONS All patients with chest pain who have an initial hs-cTnT level of <5 ng/l and no signs of ischemia on an ECG have a minimal risk of MI or death within 30 days, and can be safely discharged directly from the ED.
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Affiliation(s)
- Nadia Bandstein
- Department of Emergency Medicine, Karolinska University Hospital, Huddinge, Sweden; Department of Internal Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Rickard Ljung
- Unit of Epidemiology, Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Magnus Johansson
- Department of Emergency Medicine, Karolinska University Hospital, Huddinge, Sweden
| | - Martin J Holzmann
- Department of Emergency Medicine, Karolinska University Hospital, Huddinge, Sweden; Department of Internal Medicine, Karolinska Institutet, Stockholm, Sweden.
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Cullen L, Greenslade JH, Than M, Brown AF, Hammett CJ, Lamanna A, Flaws DF, Chu K, Fowles LF, Parsonage WA. The new Vancouver Chest Pain Rule using troponin as the only biomarker: an external validation study. Am J Emerg Med 2014; 32:129-34. [DOI: 10.1016/j.ajem.2013.10.021] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2013] [Revised: 09/16/2013] [Accepted: 10/07/2013] [Indexed: 01/15/2023] Open
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233
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Meune C, Balmelli C, ElianeVogler, Twerenbold R, Reiter M, Reichlin T, Haaf P, Drexler B, Wildi K, Hoeller R, Gimenez MR, Moehring B, Zellweger C, Potocki M, Mueller C. Accuracy of very low concentration of cTn, below the 99th, for the diagnosis of acute myocardial infarction: Comments about Lippi's and coll. letter. Int J Cardiol 2014; 171:e13. [DOI: 10.1016/j.ijcard.2013.11.134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2013] [Accepted: 11/30/2013] [Indexed: 10/25/2022]
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234
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Liebetrau C, Nef HM, Dörr O, Gaede L, Hoffmann J, Hahnel A, Rolf A, Troidl C, Lackner KJ, Keller T, Hamm CW, Möllmann H. Release kinetics of early ischaemic biomarkers in a clinical model of acute myocardial infarction. Heart 2014; 100:652-7. [DOI: 10.1136/heartjnl-2013-305253] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
ObjectiveTo determine the release kinetics of different biomarkers with potential as novel early ischaemic biomarkers in patients with acute coronary syndrome (ACS); it is difficult to establish the detailed release kinetics in patients with acute myocardial infarction (AMI).MethodsWe analysed the release kinetics of soluble fms-like tyrosine kinase (sFlt-1), ischaemia modified albumin (IMA), and heart-type fatty acid binding protein (hFABP) in patients with hypertrophic obstructive cardiomyopathy who were undergoing transcoronary ablation of septal hypertrophy (TASH), a procedure mimicking AMI. Consecutive patients (n=21) undergoing TASH were included. Blood samples were collected before TASH and 15, 30, 45, 60, 75, 90, and 105 min and 2, 4, 8, and 24 h after TASH. sFlt-1 and hFABP were quantified in serum, and IMA was quantified in plasma using immunoassays.ResultssFLT-1 and hFABP increased significantly 15 min after induction of AMI vs baseline as follows: sFlt-1, 3657.5 ng/L (IQR 2302.3–4475.0) vs 76.0 ng/L (IQR 71.2–88.8) (p<0.001); hFABP, 9.0 ng/mL (IQR 7.0–15.4) vs 4.6 ng/mL (IQR 3.4–7.1) (p<0.001). sFlt-1 demonstrated a continuous decrease after the 15th min. hFABP showed a continuous increase until the 8th hour with a decline afterwards. The IMA concentrations increased significantly 30 min after induction of AMI vs baseline, with values of 26.0 U/mL (IQR 21.8–38.6) vs 15.6 U/mL (IQR 10.1–24.7) (p=0.02), and then decreased after 75 min.ConclusionssFlt-1 and hFABP increased very early after induction of myocardial ischaemia, showing different release kinetics. The additional information provided by these findings is helpful for developing their potential combined use with cardiac troponins in patients with suspected AMI.
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235
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Sukul D, Bonaca MP, Ruff CT, Kosowsky J, Conrad M, Murphy SA, Sabatine MS, Jarolim P, Morrow DA. Diagnostic performance of copeptin in patients with acute nontraumatic chest pain: BWH-TIMI ED chest pain study. Clin Cardiol 2014; 37:227-32. [PMID: 24452775 DOI: 10.1002/clc.22244] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2013] [Revised: 12/05/2013] [Indexed: 11/07/2022] Open
Abstract
BACKGROUND Arginine-vasopressin (AVP) is an acute marker of physiologic stress. Copeptin is the C-terminal fragment of vasopressin precursor hormone that is more easily measured than AVP. Studies assessing the utility of copeptin in the diagnosis of myocardial infarction (MI) have demonstrated mixed results. HYPOTHESIS The aim of this study was to test the hypothesis that copeptin improves diagnostic performance when added to troponin for detecting MI in patients presenting to the emergency department with nontraumatic chest pain. METHODS We measured copeptin, local cardiac troponin I (local cTnI), and a contemporary sensitive cardiac troponin I (sensitive cTnI) at presentation and serially in patients who presented with acute chest pain. A copeptin cutoff of 14 pmol/L was utilized. RESULTS MI was diagnosed in 25.7% of patients. Noncoronary acute cardiopulmonary causes of chest pain occurred in 12.8%. Patients with MI had significantly higher copeptin levels than patients with noncardiac chest pain (P < 0.001). The area under the receiver operating characteristic curve (AUC) for copeptin was 0.60 (95% confidence interval: 0.54-0.66), significantly less than the AUC for local cTnI (0.92) or sensitive cTnI (0.96). The combination of copeptin with either the local or sensitive troponin assay (c-statistics 0.92 and 0.95, respectively) did not significantly improve the AUC as compared to either troponin assay alone. This finding persisted in the subgroup of early presenters (≤ 6 hours from symptom onset). CONCLUSIONS Copeptin did not improve the diagnostic performance for detecting MI when used alone or in combination with a contemporary sensitive cTnI assay, though our cohort had relatively few early presenters.
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Affiliation(s)
- Devraj Sukul
- TIMI Study Group, Cardiovascular Division, Department of Medicine, Harvard Medical School, Boston, Massachusetts
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236
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Abstract
Biomarkers complement clinical assessment and the 12-lead ECG in the diagnosis, risk stratification, triage, and management of patients with suspected acute coronary syndrome (ACS). While there is broad consensus that cardiac troponin (cTn) I or T is the preferred biomarker in clinical practice, important uncertainties remain regarding the value of high-sensitivity cTn assays, their best clinical use including the most appropriate timing of serial measurements, as well as the added value of other biomarkers reflecting and quantifying other pathophysiological signals including copeptin and natriuretic peptides. This review will address these aspects with a focus on the diagnostic application of biomarkers, as they are associated with immediate therapeutic consequences. In addition, this review will briefly highlight that increased diagnostic accuracy offered by high-sensitivity cTn assays has contributed to improve our understanding of the incidence, pathophysiology, and mortality of the two distinct components currently summarized under the term ACS: acute myocardial infarction and unstable angina.
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Affiliation(s)
- Christian Mueller
- Department of Cardiology, University Hospital Basel, Petersgraben 4, CH-4031 Basel, Switzerland
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237
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How Low Can We Go? The High-Sensitivity Cardiac Troponin Debate. Ann Emerg Med 2013; 62:580-3. [DOI: 10.1016/j.annemergmed.2013.03.021] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2013] [Revised: 03/06/2013] [Accepted: 03/18/2013] [Indexed: 11/21/2022]
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238
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Chan W, White DA, Wang XY, Bai RF, Liu Y, Yu HY, Zhang YY, Fan F, Schneider HG, Duffy SJ, Taylor AJ, Du XJ, Gao W, Gao XM, Dart AM. Macrophage migration inhibitory factor for the early prediction of infarct size. J Am Heart Assoc 2013; 2:e000226. [PMID: 24096574 PMCID: PMC3835222 DOI: 10.1161/jaha.113.000226] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Early diagnosis and knowledge of infarct size is critical for the management of acute myocardial infarction (MI). We evaluated whether early elevated plasma level of macrophage migration inhibitory factor (MIF) is useful for these purposes in patients with ST-elevation MI (STEMI). METHODS AND RESULTS We first studied MIF level in plasma and the myocardium in mice and determined infarct size. MI for 15 or 60 minutes resulted in 2.5-fold increase over control values in plasma MIF levels while MIF content in the ischemic myocardium reduced by 50% and plasma MIF levels correlated with myocardium-at-risk and infarct size at both time-points (P < 0.01). In patients with STEMI, we obtained admission plasma samples and measured MIF, conventional troponins (TnI, TnT), high sensitive TnI (hsTnI), creatine kinase (CK), CK-MB, and myoglobin. Infarct size was assessed by cardiac magnetic resonance (CMR) imaging. Patients with chronic stable angina and healthy volunteers were studied as controls. Of 374 STEMI patients, 68% had elevated admission MIF levels above the highest value in healthy controls (> 41.6 ng/mL), a proportion similar to hsTnI (75%) and TnI (50%), but greater than other biomarkers studied (20% to 31%, all P < 0.05 versus MIF). Only admission MIF levels correlated with CMR-derived infarct size, ventricular volumes and ejection fraction (n = 42, r = 0.46 to 0.77, all P < 0.01) at 3 day and 3 months post-MI. CONCLUSION Plasma MIF levels are elevated in a high proportion of STEMI patients at the first obtainable sample and these levels are predictive of final infarct size and the extent of cardiac remodeling.
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Affiliation(s)
- William Chan
- Department of Cardiovascular Medicine, Alfred Hospital, Melbourne, Australia
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239
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Meune C, Balmelli C, Vogler E, Twerenbold R, Reiter M, Reichlin T, Haaf P, Drexler B, Wildi K, Hoeller R, Rubini Gimenez M, Moehring B, Zellweger C, Potocki M, Mueller C. Consideration of high-sensitivity troponin values below the 99th percentile at presentation: Does it improve diagnostic accuracy? Int J Cardiol 2013; 168:3752-7. [DOI: 10.1016/j.ijcard.2013.06.011] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2012] [Revised: 04/25/2013] [Accepted: 06/15/2013] [Indexed: 11/15/2022]
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240
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Munoz Saravia SG, Haberland A, Bartel S, Araujo R, Valda G, Reynaga DD, Ramirez ID, Borges AC, Wallukat G, Ziebig R, Schimke I. Combined measurement of N-terminal pro-B-type natriuretic peptide and highly sensitive cardiac troponin T for diagnosis and monitoring of heart injury in chronic Chagas' disease. Clin Biochem 2013; 46:1615-8. [DOI: 10.1016/j.clinbiochem.2013.06.011] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2013] [Revised: 06/06/2013] [Accepted: 06/11/2013] [Indexed: 10/26/2022]
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241
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Rubini Giménez M, Hoeller R, Reichlin T, Zellweger C, Twerenbold R, Reiter M, Moehring B, Wildi K, Mosimann T, Mueller M, Meller B, Hochgruber T, Ziller R, Sou SM, Murray K, Sakarikos K, Ernst S, Gea J, Campodarve I, Vilaplana C, Haaf P, Steuer S, Minners J, Osswald S, Mueller C. Rapid rule out of acute myocardial infarction using undetectable levels of high-sensitivity cardiac troponin. Int J Cardiol 2013; 168:3896-901. [DOI: 10.1016/j.ijcard.2013.06.049] [Citation(s) in RCA: 150] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2012] [Revised: 06/22/2013] [Accepted: 06/28/2013] [Indexed: 11/26/2022]
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242
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Gamble JHP, Carlton EW, Orr WP, Greaves K. High-sensitivity cardiac troponins: no more 'negatives'. Expert Rev Cardiovasc Ther 2013; 11:1129-39. [PMID: 23977868 DOI: 10.1586/14779072.2013.828978] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
According to recently published expert guidelines, cardiac troponins are the only accepted biomarkers to define acute myocardial infarction. New high sensitivity cardiac troponin assays provide exciting opportunities for early rule-out and rule-in strategies and for identifying high-risk patients early in their presentation to guide early treatment and intervention. This review briefly discusses the history of troponin testing, before going on to cover clinical uses of the new highly sensitive assays in the early assessment of acute myocardial infection. Common clinical pitfalls with the use of these assays are discussed, as is the use of highly sensitive troponins more widely as prognostic markers. Likely future developments in this area are discussed.
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Affiliation(s)
- James H P Gamble
- Cardiovascular Clinical Research Facility, John Radcliffe Hospital, Oxford OX3 9DU, UK
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243
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Tissue Doppler imaging for rejection surveillance in pediatric heart transplant recipients. J Heart Lung Transplant 2013; 32:1027-33. [PMID: 23937884 DOI: 10.1016/j.healun.2013.06.016] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2013] [Revised: 06/13/2013] [Accepted: 06/20/2013] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Most transplant centers perform serial cardiac biopsies for rejection surveillance in pediatric heart transplant (HT) recipients. We sought to assess tissue Doppler imaging (TDI) findings during biopsy specimen-proven rejection in pediatric HT recipients and to develop TDI criteria for absence of rejection with high predictive accuracy. METHODS We included the 122 HT recipients in follow-up at our center (median age at HT, 8.7 years). We identified all echocardiograms with adequate TDI data performed within 24 hours of a cardiac biopsy during 2005 to 2011. Rejection was defined as Grade ≥ 2R cellular rejection or antibody-mediated rejection. Paired comparisons of TDI velocities were made using patients' baseline velocities as the control. RESULTS Overall, 647 specimen-pairs were identified where there was no rejection at baseline. In 24 of these, the second biopsy specimen demonstrated rejection. Using receiver operating characteristic curve analysis of percentage change from baseline, we identified < 15% decline in left ventricular (LV) S' velocity and < 5% decline in LV A' velocity to individually predict non-rejection with > 99% accuracy. When joint criteria were used, the predictive accuracy was 100%, and no rejection event was misclassified. More than 75% of TDI pairs met these criteria for non-rejection. CONCLUSIONS Biopsy specimen-proven rejection is associated with a significant decline in biventricular TDI velocities from baseline in pediatric HT recipients. By using well-defined TDI criteria to predict non-rejection, a substantial proportion of planned biopsies may be deferred or avoided at minimal risk to pediatric HT recipients.
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244
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Baxi S, Lakin J, Stapleton S, Redberg R. High-sensitivity troponin: elevated without infarction, is the horse out of the barn? Emerg Med J 2013; 31:354-5. [DOI: 10.1136/emermed-2013-202796] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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245
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Greenslade JH, Cullen L, Than M, Aldous S, Chu K, Brown AF, Richards AM, Pemberton CJ, George P, Parsonage WA. Validation of the Vancouver Chest Pain Rule using troponin as the only biomarker: a prospective cohort study. Am J Emerg Med 2013; 31:1103-7. [DOI: 10.1016/j.ajem.2013.04.016] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2013] [Revised: 04/03/2013] [Accepted: 04/10/2013] [Indexed: 11/30/2022] Open
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246
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Skinner JS. The diagnostic utility of CT coronary angiography in patients with acute chest pain. BRITISH HEART JOURNAL 2013. [DOI: 10.1136/heartjnl-2012-302971] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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247
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van der Laarse A, Cobbaert CM, Gorgels AP, Swenne CA. Will future troponin measurement overrule the ECG as the primary diagnostic tool in patients with acute coronary syndrome? J Electrocardiol 2013; 46:312-7. [DOI: 10.1016/j.jelectrocard.2013.02.007] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2013] [Indexed: 11/17/2022]
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248
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Boswood A. Veterinary cardiology: a journey through time. Vet Rec 2013; 172:678-82. [PMID: 23813033 DOI: 10.1136/vr.f4045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Affiliation(s)
- Adrian Boswood
- Royal Veterinary College, Hawkshead Lane, North Mymms, Hatfield, Hertfordshire AL9 7TA, UK.
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249
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Cullen L, Mueller C, Parsonage WA, Wildi K, Greenslade JH, Twerenbold R, Aldous S, Meller B, Tate JR, Reichlin T, Hammett CJ, Zellweger C, Ungerer JPJ, Rubini Gimenez M, Troughton R, Murray K, Brown AFT, Mueller M, George P, Mosimann T, Flaws DF, Reiter M, Lamanna A, Haaf P, Pemberton CJ, Richards AM, Chu K, Reid CM, Peacock WF, Jaffe AS, Florkowski C, Deely JM, Than M. Validation of high-sensitivity troponin I in a 2-hour diagnostic strategy to assess 30-day outcomes in emergency department patients with possible acute coronary syndrome. J Am Coll Cardiol 2013; 62:1242-1249. [PMID: 23583250 DOI: 10.1016/j.jacc.2013.02.078] [Citation(s) in RCA: 235] [Impact Index Per Article: 21.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2012] [Revised: 02/05/2013] [Accepted: 02/25/2013] [Indexed: 12/15/2022]
Abstract
OBJECTIVES The study objective was to validate a new high-sensitivity troponin I (hs-TnI) assay in a clinical protocol for assessing patients who present to the emergency department with chest pain. BACKGROUND Protocols using sensitive troponin assays can accelerate the rule out of acute myocardial infarction in patients with low-risk (suspected) acute coronary syndrome (ACS). METHODS This study evaluated 2 prospective cohorts of patients in the emergency department with ACS in an accelerated diagnostic pathway integrating 0- and 2-h hs-TnI results, Thrombolysis In Myocardial Infarction (TIMI) risk scores, and electrocardiography. Strategies to identify low-risk patients incorporated TIMI risk scores= 0 or ≤ 1. The primary endpoint was a major adverse cardiac event (MACE) within 30 days. RESULTS In the primary cohort, 1,635 patients were recruited and had 30-day follow-up. A total of 247 patients (15.1%) had a MACE. The finding of no ischemic electrocardiogram and hs-TnI ≤ 26.2 ng/l with the TIMI = 0 and TIMI ≤ 1 pathways, respectively, classified 19.6% (n = 320) and 41.5% (n = 678) of these patients as low risk; 0% (n = 0) and 0.8% (n = 2) had a MACE, respectively. In the secondary cohort, 909 patients were recruited. A total of 156 patients (17.2%) had a MACE. The TIMI = 0 and TIMI ≤ 1 pathways classified 25.3% (n = 230) and 38.6% (n = 351), respectively, of these patients as low risk; 0% (n = 0) and 0.8% (n = 1) had a MACE, respectively. Sensitivity, specificity, and negative predictive value for TIMI = 0 in the primary cohort were 100% (95% confidence interval [CI]: 98.5% to 100%), 23.1% (95% CI: 20.9% to 25.3%), and 100% (95% CI: 98.8% to 100%), respectively. Sensitivity, specificity, and negative predictive value for TIMI ≤ 1 in the primary cohort were 99.2 (95% CI: 97.1 to 99.8), 48.7 (95% CI: 46.1 to 51.3), and 99.7 (95% CI: 98.9 to 99.9), respectively. Sensitivity, specificity, and negative value for TIMI ≤ 1 in the secondary cohort were 99.4% (95% CI: 96.5 to 100), 46.5% (95% CI: 42.9 to 50.1), and 99.7% (95% CI: 98.4 to 100), respectively. CONCLUSIONS An early-discharge strategy using an hs-TnI assay and TIMI score ≤ 1 had similar safety as previously reported, with the potential to decrease the observation periods and admissions for approximately 40% of patients with suspected ACS. (Advantageous Predictors of Acute Coronary Syndromes Evaluation [APACE] Study, NCT00470587; A 2 hr Accelerated Diagnostic Protocol to Assess patients with chest Pain symptoms using contemporary Troponins as the only biomarker [ADAPT]: a prospective observational validation study, ACTRN12611001069943).
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Affiliation(s)
- Louise Cullen
- Royal Brisbane and Women's Hospital, Herston, Australia; Queensland University of Technology, Brisbane, Australia.
| | | | - William A Parsonage
- Royal Brisbane and Women's Hospital, Herston, Australia; University of Queensland, Brisbane, Australia
| | - Karin Wildi
- University Hospital Basel, Basel, Switzerland
| | - Jaimi H Greenslade
- Royal Brisbane and Women's Hospital, Herston, Australia; Queensland University of Technology, Brisbane, Australia; University of Queensland, Brisbane, Australia
| | | | - Sally Aldous
- Christchurch Hospital, Christchurch, New Zealand
| | | | | | - Tobias Reichlin
- University Hospital Basel, Basel, Switzerland; Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | | | | | | | | | | | | | - Anthony F T Brown
- Royal Brisbane and Women's Hospital, Herston, Australia; University of Queensland, Brisbane, Australia
| | | | - Peter George
- Christchurch Hospital, Christchurch, New Zealand
| | | | | | | | - Arvin Lamanna
- Royal Brisbane and Women's Hospital, Herston, Australia
| | - Philip Haaf
- University Hospital Basel, Basel, Switzerland
| | | | | | - Kevin Chu
- Royal Brisbane and Women's Hospital, Herston, Australia; University of Queensland, Brisbane, Australia
| | | | | | | | | | - Joanne M Deely
- Canterbury District Health Board, Christchurch, New Zealand
| | - Martin Than
- Christchurch Hospital, Christchurch, New Zealand
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250
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Cullen L, Parsonage WA, Greenslade J, Lamanna A, Hammett CJ, Than M, Tate J, Kalinowski L, Ungerer JPJ, Chu K, Brown A. Delta troponin for the early diagnosis of AMI in emergency patients with chest pain. Int J Cardiol 2013; 168:2602-8. [PMID: 23582689 DOI: 10.1016/j.ijcard.2013.03.044] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2012] [Revised: 11/26/2012] [Accepted: 03/17/2013] [Indexed: 10/27/2022]
Abstract
OBJECTIVES In patients presenting to the Emergency Department (ED) with potential acute myocardial infarction (AMI), elevated cardiac troponin (cTn) levels are indicative of myocardial necrosis. We assessed the accuracy of 'delta cTn' at 2h or 6h compared to the cTn concentration above the 99th percentile reference value for AMI in a prospective study of adult patients presenting to ED with symptoms suggestive of possible acute coronary syndrome. METHODS Blood was sampled for cardiac troponin I (cTnI) on presentation, and at 2h and 6h following presentation using a sensitive assay (Beckman AccuTnI). All clinical endpoints were adjudicated by a cardiologist who was blinded to the 2h cTn assay result. RESULTS Of the 874 patients, 70 (8%) were diagnosed with an AMI during their index presentation. The area under the ROC curve for diagnosing AMI at 2h was 0.89 [95%CI, 0.84-0.95] for absolute delta cTn versus 0.79 [95%CI 0.73-0.85] for the relative change. Specificity and PPV at 2h were optimized using a delta cTnI ≥ 0.03 μg/L (95.8% [95%CI 94.1-97.0] and 61.4% [95%CI 50.9-70.9] respectively). Sensitivity and NPV for AMI were optimized using the 99th percentile with the addition of a delta of<0.03 μg/L (97.1% [95%CI 90.2-99.2] and 99.7% [95%CI 99-99.9] respectively). CONCLUSIONS An algorithm incorporating cTnI concentration and delta cTn values with a sensitive troponin assay allows accurate diagnosis of AMI within 2h from presentation and earlier rule-out of AMI in the majority of patients.
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Affiliation(s)
- Louise Cullen
- Department of Emergency Medicine, Royal Brisbane and Women's Hospital, Brisbane, Australia; School of Public Health, Queensland University of Technology, Brisbane, Australia; School of Medicine, University of Queensland, Brisbane, Australia.
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