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Pickering JW, Greenslade JH, Cullen L, Flaws D, Parsonage W, Aldous S, George P, Worster A, Kavsak PA, Than MP. Assessment of the European Society of Cardiology 0-Hour/1-Hour Algorithm to Rule-Out and Rule-In Acute Myocardial Infarction. Circulation 2016; 134:1532-1541. [PMID: 27754881 DOI: 10.1161/circulationaha.116.022677] [Citation(s) in RCA: 96] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2016] [Accepted: 09/22/2016] [Indexed: 11/16/2022]
Abstract
BACKGROUND The new European Society of Cardiology guidelines to rule-in and rule-out acute myocardial infarction (AMI) in the emergency department include a rapid assessment algorithm based on high-sensitivity cardiac troponin and sampling at 0 and 1 hour. Emergency department physicians require high sensitivity to confidently rule-out AMI, whereas cardiologists aim to minimize false-positive results. METHODS High-sensitivity troponin I and T assays were used to measure troponin concentrations in patients presenting with chest-pain symptoms and being investigated for possible acute coronary syndrome at hospitals in New Zealand, Australia, and Canada. AMI outcomes were independently adjudicated by at least 2 physicians. The European Society of Cardiology algorithm performance with each assay was assessed by the sensitivity and proportion with AMI ruled out and the positive predictive value and proportion ruled-in. RESULTS There were 2222 patients with serial high-sensitivity troponin T and high-sensitivity troponin I measurements. The high-sensitivity troponin T algorithm ruled out 1425 (64.1%) with a sensitivity of 97.1% (95% confidence interval [CI], 94.0%-98.8%) and ruled-in 292 (13.1%) with a positive predictive value of 63.4% (95% CI, 57.5%-68.9%).The high-sensitivity troponin I algorithm ruled out 1205 (54.2%) with a sensitivity of 98.8% (95% CI, 96.4%-99.7%)) and ruled-in 310 (14.0%) with a positive predictive value of 68.1% (95% CI, 62.6%-73.2%). CONCLUSIONS The sensitivity of the European Society of Cardiology rapid assessment 0-/1-hour algorithm to rule-out AMI with high-sensitivity troponin may be insufficient for some emergency department physicians to confidently send patients home. These algorithms may prove useful to identify patients requiring expedited management. However, the positive predictive value was modest for both algorithms.
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Affiliation(s)
- John W Pickering
- From Emergency Department (J.W.P., M.P.T.), and Cardiology Department (S.A.), Christchurch Hospital, Christchurch, New Zealand; Department of Medicine, University of Otago, Christchurch, New Zealand (J.W.P.); Department of Emergency Medicine, Royal Brisbane and Women's Hospital, The University of Queensland and School of Public Health, Queensland University of Technology, Brisbane, Australia (J.H.G., L.C., D.F.); Department of Cardiology, Royal Brisbane and Women's Hospital, Brisbane, Australia (W.P.); Canterbury Health Laboratories, Christchurch, New Zealand (P.G.); and McMaster University, Hamilton, Ontario, Canada (A.W., P.A.K.)
| | - Jaimi H Greenslade
- From Emergency Department (J.W.P., M.P.T.), and Cardiology Department (S.A.), Christchurch Hospital, Christchurch, New Zealand; Department of Medicine, University of Otago, Christchurch, New Zealand (J.W.P.); Department of Emergency Medicine, Royal Brisbane and Women's Hospital, The University of Queensland and School of Public Health, Queensland University of Technology, Brisbane, Australia (J.H.G., L.C., D.F.); Department of Cardiology, Royal Brisbane and Women's Hospital, Brisbane, Australia (W.P.); Canterbury Health Laboratories, Christchurch, New Zealand (P.G.); and McMaster University, Hamilton, Ontario, Canada (A.W., P.A.K.)
| | - Louise Cullen
- From Emergency Department (J.W.P., M.P.T.), and Cardiology Department (S.A.), Christchurch Hospital, Christchurch, New Zealand; Department of Medicine, University of Otago, Christchurch, New Zealand (J.W.P.); Department of Emergency Medicine, Royal Brisbane and Women's Hospital, The University of Queensland and School of Public Health, Queensland University of Technology, Brisbane, Australia (J.H.G., L.C., D.F.); Department of Cardiology, Royal Brisbane and Women's Hospital, Brisbane, Australia (W.P.); Canterbury Health Laboratories, Christchurch, New Zealand (P.G.); and McMaster University, Hamilton, Ontario, Canada (A.W., P.A.K.)
| | - Dylan Flaws
- From Emergency Department (J.W.P., M.P.T.), and Cardiology Department (S.A.), Christchurch Hospital, Christchurch, New Zealand; Department of Medicine, University of Otago, Christchurch, New Zealand (J.W.P.); Department of Emergency Medicine, Royal Brisbane and Women's Hospital, The University of Queensland and School of Public Health, Queensland University of Technology, Brisbane, Australia (J.H.G., L.C., D.F.); Department of Cardiology, Royal Brisbane and Women's Hospital, Brisbane, Australia (W.P.); Canterbury Health Laboratories, Christchurch, New Zealand (P.G.); and McMaster University, Hamilton, Ontario, Canada (A.W., P.A.K.)
| | - William Parsonage
- From Emergency Department (J.W.P., M.P.T.), and Cardiology Department (S.A.), Christchurch Hospital, Christchurch, New Zealand; Department of Medicine, University of Otago, Christchurch, New Zealand (J.W.P.); Department of Emergency Medicine, Royal Brisbane and Women's Hospital, The University of Queensland and School of Public Health, Queensland University of Technology, Brisbane, Australia (J.H.G., L.C., D.F.); Department of Cardiology, Royal Brisbane and Women's Hospital, Brisbane, Australia (W.P.); Canterbury Health Laboratories, Christchurch, New Zealand (P.G.); and McMaster University, Hamilton, Ontario, Canada (A.W., P.A.K.)
| | - Sally Aldous
- From Emergency Department (J.W.P., M.P.T.), and Cardiology Department (S.A.), Christchurch Hospital, Christchurch, New Zealand; Department of Medicine, University of Otago, Christchurch, New Zealand (J.W.P.); Department of Emergency Medicine, Royal Brisbane and Women's Hospital, The University of Queensland and School of Public Health, Queensland University of Technology, Brisbane, Australia (J.H.G., L.C., D.F.); Department of Cardiology, Royal Brisbane and Women's Hospital, Brisbane, Australia (W.P.); Canterbury Health Laboratories, Christchurch, New Zealand (P.G.); and McMaster University, Hamilton, Ontario, Canada (A.W., P.A.K.)
| | - Peter George
- From Emergency Department (J.W.P., M.P.T.), and Cardiology Department (S.A.), Christchurch Hospital, Christchurch, New Zealand; Department of Medicine, University of Otago, Christchurch, New Zealand (J.W.P.); Department of Emergency Medicine, Royal Brisbane and Women's Hospital, The University of Queensland and School of Public Health, Queensland University of Technology, Brisbane, Australia (J.H.G., L.C., D.F.); Department of Cardiology, Royal Brisbane and Women's Hospital, Brisbane, Australia (W.P.); Canterbury Health Laboratories, Christchurch, New Zealand (P.G.); and McMaster University, Hamilton, Ontario, Canada (A.W., P.A.K.)
| | - Andrew Worster
- From Emergency Department (J.W.P., M.P.T.), and Cardiology Department (S.A.), Christchurch Hospital, Christchurch, New Zealand; Department of Medicine, University of Otago, Christchurch, New Zealand (J.W.P.); Department of Emergency Medicine, Royal Brisbane and Women's Hospital, The University of Queensland and School of Public Health, Queensland University of Technology, Brisbane, Australia (J.H.G., L.C., D.F.); Department of Cardiology, Royal Brisbane and Women's Hospital, Brisbane, Australia (W.P.); Canterbury Health Laboratories, Christchurch, New Zealand (P.G.); and McMaster University, Hamilton, Ontario, Canada (A.W., P.A.K.)
| | - Peter A Kavsak
- From Emergency Department (J.W.P., M.P.T.), and Cardiology Department (S.A.), Christchurch Hospital, Christchurch, New Zealand; Department of Medicine, University of Otago, Christchurch, New Zealand (J.W.P.); Department of Emergency Medicine, Royal Brisbane and Women's Hospital, The University of Queensland and School of Public Health, Queensland University of Technology, Brisbane, Australia (J.H.G., L.C., D.F.); Department of Cardiology, Royal Brisbane and Women's Hospital, Brisbane, Australia (W.P.); Canterbury Health Laboratories, Christchurch, New Zealand (P.G.); and McMaster University, Hamilton, Ontario, Canada (A.W., P.A.K.)
| | - Martin P Than
- From Emergency Department (J.W.P., M.P.T.), and Cardiology Department (S.A.), Christchurch Hospital, Christchurch, New Zealand; Department of Medicine, University of Otago, Christchurch, New Zealand (J.W.P.); Department of Emergency Medicine, Royal Brisbane and Women's Hospital, The University of Queensland and School of Public Health, Queensland University of Technology, Brisbane, Australia (J.H.G., L.C., D.F.); Department of Cardiology, Royal Brisbane and Women's Hospital, Brisbane, Australia (W.P.); Canterbury Health Laboratories, Christchurch, New Zealand (P.G.); and McMaster University, Hamilton, Ontario, Canada (A.W., P.A.K.).
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Charpentier S, Chenevier-Gobeaux C. Recommandations ESC 2015 : exclure ou confirmer le diagnostic d’infarctus du myocarde en 1 heure avec la troponine T hypersensible. Presse Med 2016; 45:859-864. [DOI: 10.1016/j.lpm.2016.05.023] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2016] [Accepted: 05/30/2016] [Indexed: 10/21/2022] Open
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Affiliation(s)
- Jason P. Stopyra
- Department of Emergency Medicine; Wake Forest University School of Medicine; Winston-Salem NC
| | - Simon A. Mahler
- Department of Emergency Medicine; Wake Forest University School of Medicine; Winston-Salem NC
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254
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Body R, Mueller C, Giannitsis E, Christ M, Ordonez-Llanos J, de Filippi CR, Nowak R, Panteghini M, Jernberg T, Plebani M, Verschuren F, French JK, Christenson R, Weiser S, Bendig G, Dilba P, Lindahl B. The Use of Very Low Concentrations of High-sensitivity Troponin T to Rule Out Acute Myocardial Infarction Using a Single Blood Test. Acad Emerg Med 2016; 23:1004-13. [PMID: 27178492 DOI: 10.1111/acem.13012] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2016] [Revised: 05/05/2016] [Accepted: 05/10/2016] [Indexed: 11/27/2022]
Abstract
BACKGROUND Recent single-center and retrospective studies suggest that acute myocardial infarction (AMI) could be immediately excluded without serial sampling in patients with initial high-sensitivity cardiac troponin T (hs-cTnT) levels below the limit of detection (LoD) of the assay and no electrocardiogram (ECG) ischemia. OBJECTIVE We aimed to determine the external validity of those findings in a multicenter study at 12 sites in nine countries. METHODS TRAPID-AMI was a prospective diagnostic cohort study including patients with suspected cardiac chest pain within 6 hours of peak symptoms. Blood drawn on arrival was centrally tested for hs-cTnT (Roche; 99th percentile = 14 ng/L, LoD = 5 ng/L). All patients underwent serial troponin sampling over 4-14 hours. The primary outcome, prevalent AMI, was adjudicated based on sensitive troponin I (Siemens Ultra) levels. Major adverse cardiac events (MACE) including AMI, death, or rehospitalization for acute coronary syndrome with coronary revascularization were determined after 30 days. RESULTS We included 1,282 patients, of whom 213 (16.6%) had AMI and 231 (18.0%) developed MACE. Of 560 (43.7%) patients with initial hs-cTnT levels below the LoD, four (0.7%) had AMI. In total, 471 (36.7%) patients had both initial hs-cTnT levels below the LoD and no ECG ischemia. These patients had a 0.4% (n = 2) probability of AMI, giving 99.1% (95% confidence interval [CI] = 96.7% to 99.9%) sensitivity and 99.6% (95% CI = 98.5% to 100.0%) negative predictive value. The incidence of MACE in this group was 1.3% (95% CI = 0.5% to 2.8%). CONCLUSIONS In the absence of ECG ischemia, the detection of very low concentrations of hs-cTnT at admission seems to allow rapid, safe exclusion of AMI in one-third of patients without serial sampling. This could be used alongside careful clinical assessment to help reduce unnecessary hospital admissions.
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Affiliation(s)
- Richard Body
- Emergency Department; Central Manchester University Hospitals NHS Foundation Trust; Manchester Academic Health Sciences Centre; Manchester United Kingdom
- Cardiovascular Sciences Research Group; University of Manchester; Oxford Road Manchester United Kingdom
| | - Christian Mueller
- Department of Cardiology; Universitätsspital Basel; Basel Switzerland
| | - Evangelos Giannitsis
- Abteilung Innere Medizin III Kardiologie, Angiologie und Pneumologie; Medizinische Universitätsklinik (Krehl-Linik); Heidelberg Germany
| | - Michael Christ
- Klinik für Notfallmedizin und Internistische Intensivmedizine; Klinikum Nürnberg Nord; Nürnberg Germany
| | - Jorge Ordonez-Llanos
- IIB-Hospital de la Santa Creu i Sant Pau and Universitat Autònoma; Barcelona Spain
| | | | - Richard Nowak
- Henry Ford West Bloomfield Hospital; West Bloomfield MI
| | - Mauro Panteghini
- Azienda Ospedaliera Luigi Sacco Laboratorio Analisi Chimico Cliniche; Milan Italy
| | - Tomas Jernberg
- Department of Cardiology; Karolinska University Hospital; Stockholm Sweden
| | - Mario Plebani
- Servizio Medicina di Laboratorio Azienda Ospedaliera; Università di Padova Via Giustinianeo; Padova Italy
| | - Franck Verschuren
- Department of Acute Medicine; Cliniques Universitaires St-Luc; Université Catholique de Louvain; Brussels Belgium
| | - John K. French
- Department of Cardiology; Liverpool Hospital; Liverpool New South Wales Australia
| | | | | | | | | | - Bertil Lindahl
- Department of Medical Sciences and Uppsala Clinical Research Center; Uppsala University; Uppsala Sweden
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Body R, Carlton E, Sperrin M, Lewis PS, Burrows G, Carley S, McDowell G, Buchan I, Greaves K, Mackway-Jones K. Troponin-only Manchester Acute Coronary Syndromes (T-MACS) decision aid: single biomarker re-derivation and external validation in three cohorts. Emerg Med J 2016; 34:349-356. [PMID: 27565197 PMCID: PMC5502241 DOI: 10.1136/emermed-2016-205983] [Citation(s) in RCA: 79] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2016] [Revised: 06/27/2016] [Accepted: 07/05/2016] [Indexed: 12/27/2022]
Abstract
Background The original Manchester Acute Coronary Syndromes model (MACS) ‘rules in’ and ‘rules out’ acute coronary syndromes (ACS) using high sensitivity cardiac troponin T (hs-cTnT) and heart-type fatty acid binding protein (H-FABP) measured at admission. The latter is not always available. We aimed to refine and validate MACS as Troponin-only Manchester Acute Coronary Syndromes (T-MACS), cutting down the biomarkers to just hs-cTnT. Methods We present secondary analyses from four prospective diagnostic cohort studies including patients presenting to the ED with suspected ACS. Data were collected and hs-cTnT measured on arrival. The primary outcome was ACS, defined as prevalent acute myocardial infarction (AMI) or incident death, AMI or coronary revascularisation within 30 days. T-MACS was built in one cohort (derivation set) and validated in three external cohorts (validation set). Results At the ‘rule out’ threshold, in the derivation set (n=703), T-MACS had 99.3% (95% CI 97.3% to 99.9%) negative predictive value (NPV) and 98.7% (95.3%–99.8%) sensitivity for ACS, ‘ruling out’ 37.7% patients (specificity 47.6%, positive predictive value (PPV) 34.0%). In the validation set (n=1459), T-MACS had 99.3% (98.3%–99.8%) NPV and 98.1% (95.2%–99.5%) sensitivity, ‘ruling out’ 40.4% (n=590) patients (specificity 47.0%, PPV 23.9%). T-MACS would ‘rule in’ 10.1% and 4.7% patients in the respective sets, of which 100.0% and 91.3% had ACS. C-statistics for the original and refined rules were similar (T-MACS 0.91 vs MACS 0.90 on validation). Conclusions T-MACS could ‘rule out’ ACS in 40% of patients, while ‘ruling in’ 5% at highest risk using a single hs-cTnT measurement on arrival. As a clinical decision aid, T-MACS could therefore help to conserve healthcare resources.
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Affiliation(s)
- Richard Body
- Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK.,Emergency Department,Central Manchester University Hospitals Foundation NHS Trust, Manchester, UK
| | - Edward Carlton
- Emergency Department, North Bristol NHS Trust, Southmead Hospital, Bristol, UK
| | - Matthew Sperrin
- Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK
| | - Philip S Lewis
- Cardiology Department, Stockport NHS Foundation Trust, Stockport, UK
| | - Gillian Burrows
- Biochemistry Department, Stockport NHS Foundation Trust, Stockport, UK
| | - Simon Carley
- Emergency Department,Central Manchester University Hospitals Foundation NHS Trust, Manchester, UK.,School of Healthcare Science, Manchester Metropolitan University, Manchester, UK
| | - Garry McDowell
- Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK.,School of Healthcare Science, Manchester Metropolitan University, Manchester, UK
| | - Iain Buchan
- Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK
| | - Kim Greaves
- Department of Cardiology, Sunshine Coast Hospital and Health Services, University of the Sunshine Coast, Nambour, Australia
| | - Kevin Mackway-Jones
- Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK.,Emergency Department,Central Manchester University Hospitals Foundation NHS Trust, Manchester, UK.,School of Healthcare Science, Manchester Metropolitan University, Manchester, UK
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256
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Lindahl B, Jernberg T, Badertscher P, Boeddinghaus J, Eggers KM, Frick M, Rubini Gimenez M, Linder R, Ljung L, Martinsson A, Melki D, Nestelberger T, Rentsch K, Reichlin T, Sabti Z, Schubera M, Svensson P, Twerenbold R, Wildi K, Mueller C. An algorithm for rule-in and rule-out of acute myocardial infarction using a novel troponin I assay. Heart 2016; 103:125-131. [PMID: 27486143 DOI: 10.1136/heartjnl-2016-309951] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2016] [Revised: 07/01/2016] [Accepted: 07/13/2016] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE To derive and validate a hybrid algorithm for rule-out and rule-in of acute myocardial infarction based on measurements at presentation and after 2 hours with a novel cardiac troponin I (cTnI) assay. METHODS The algorithm was derived and validated in two cohorts (605 and 592 patients) from multicentre studies enrolling chest pain patients presenting to the emergency department (ED) with onset of last episode within 12 hours. The index diagnosis and cardiovascular events up to 30 days were adjudicated by independent reviewers. RESULTS In the validation cohort, 32.6% of the patients were ruled out on ED presentation, 6.1% were ruled in and 61.3% remained undetermined. A further 22% could be ruled out and 9.8% ruled in, after 2 hours. In total, 54.6% of the patients were ruled out with a negative predictive value (NPV) of 99.4% (95% CI 97.8% to 99.9%) and a sensitivity of 97.7% (95% CI 91.9% to 99.7%); 15.8% were ruled in with a positive predictive value (PPV) of 74.5% (95% CI 64.8% to 82.2%) and a specificity of 95.2% (95% CI 93.0% to 96.9%); and 29.6% remained undetermined after 2 hours. No patient in the rule-out group died during the 30-day follow-up in the two cohorts. CONCLUSIONS This novel two-step algorithm based on cTnI measurements enabled just over a third of the patients with acute chest pain to be ruled in or ruled out already at presentation and an additional third after 2 hours. This strategy maximises the speed of rule-out and rule-in while maintaining a high NPV and PPV, respectively.
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Affiliation(s)
- Bertil Lindahl
- Department of Medical Sciences and Uppsala Clinical Research Center, Uppsala, University, Uppsala, Sweden
| | - Tomas Jernberg
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden.,Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden
| | - Patrick Badertscher
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Basel, Switzerland
| | - Jasper Boeddinghaus
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Basel, Switzerland
| | - Kai M Eggers
- Department of Medical Sciences and Uppsala Clinical Research Center, Uppsala, University, Uppsala, Sweden
| | - Mats Frick
- Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden
| | - Maria Rubini Gimenez
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Basel, Switzerland.,Pneumology Department, Parc de Salut Mar-IMIM-UPF, Parc de Salut Mar, Spain.,Emergency Department, Parc de Salut Mar, Spain
| | - Rickard Linder
- Department of Cardiology, Danderyd University Hospital, Stockholm, Sweden
| | - Lina Ljung
- Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden
| | | | - Dina Melki
- Department of Medicine, Karolinska Institutet, Huddinge, Sweden.,Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden
| | - Thomas Nestelberger
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Basel, Switzerland
| | - Katharina Rentsch
- Department of Laboratory Medicine, University Hospital Basel, Basel, Switzerland
| | - Tobias Reichlin
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Basel, Switzerland
| | - Zaid Sabti
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Basel, Switzerland
| | - Marie Schubera
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Basel, Switzerland
| | - Per Svensson
- Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden.,Department of Emergency Medicine, Karolinska University Hospital, Stockholm, Sweden
| | - Raphael Twerenbold
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Basel, Switzerland
| | - Karin Wildi
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Basel, Switzerland
| | - Christian Mueller
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Basel, Switzerland
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Mueller C, Giannitsis E, Möckel M, Huber K, Mair J, Plebani M, Thygesen K, Jaffe AS, Lindahl B. Rapid rule out of acute myocardial infarction: novel biomarker-based strategies. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2016; 6:218-222. [DOI: 10.1177/2048872616653229] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Christian Mueller
- Department of Cardiology and Cardiovascular Research Institute Basel, University Hospital Basel, Switzerland
| | | | - Martin Möckel
- Division of Emergency Medicine and Department of Cardiology, Charite, Universitätsmedizin Berlin, Germany
| | - Kurt Huber
- 3rd Department of Medicine, Cardiology and Intensive Care Medicine, Wilhelminen Hospital, Austria
| | - Johannes Mair
- Department of Internal Medicine III – Cardiology and Angiology, Innsbruck Medical University, Austria
| | - Mario Plebani
- Department of Laboratory Medicine, University Hospital Padova, Italy
| | | | | | - Bertil Lindahl
- Department of Medical Sciences, Uppsala University and Uppsala Clinical Research Center, Sweden
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Twerenbold R, Jaeger C, Rubini Gimenez M, Wildi K, Reichlin T, Nestelberger T, Boeddinghaus J, Grimm K, Puelacher C, Moehring B, Pretre G, Schaerli N, Campodarve I, Rentsch K, Steuer S, Osswald S, Mueller C. Impact of high-sensitivity cardiac troponin on use of coronary angiography, cardiac stress testing, and time to discharge in suspected acute myocardial infarction. Eur Heart J 2016; 37:3324-3332. [PMID: 27357358 PMCID: PMC5177796 DOI: 10.1093/eurheartj/ehw232] [Citation(s) in RCA: 122] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2015] [Revised: 03/25/2016] [Accepted: 04/29/2016] [Indexed: 12/13/2022] Open
Abstract
Aims High-sensitivity cardiac troponin (hs-cTn) assays provide higher diagnostic accuracy for acute myocardial infarction (AMI) when compared with conventional assays, but may result in increased use of unnecessary coronary angiographies due to their increased detection of cardiomyocyte injury in conditions other than AMI. Methods and results We evaluated the impact of the clinical introduction of high-sensitivity cardiac troponin T (hs-cTnT) on the use of coronary angiography, stress testing, and time to discharge in 2544 patients presenting with symptoms suggestive of AMI to the emergency department (ED) within a multicentre study either before (1455 patients) or after (1089 patients) hs-cTnT introduction. Acute myocardial infarction was more often the clinical discharge diagnosis after hs-cTnT introduction (10 vs. 14%, P < 0.001), while unstable angina less often the clinical discharge diagnosis (14 vs. 9%, P = 0.007). The rate of coronary angiography was similar before and after the introduction of hs-cTnT (23 vs. 23%, P = 0.092), as was the percentage of coronary angiographies showing no stenosis (11 vs. 7%, P = 0.361). In contrast, the use of stress testing was substantially reduced from 29 to 19% (P < 0.001). In outpatients, median time to discharge from the ED decreased by 79 min (P < 0.001). Mean total costs decreased by 20% in outpatients after the introduction of hs-cTnT (P = 0.002). Conclusion The clinical introduction of hs-cTn does not lead to an increased or inappropriate use of coronary angiography. Introduction of hs-cTn is associated with an improved rule-out process and thereby reduces the need for stress testing and time to discharge. Clinical Trial Registration Information www.clinicaltrials.gov. Identifier, NCT00470587.
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Affiliation(s)
- Raphael Twerenbold
- Department of Cardiology, University Hospital Basel, Petersgraben 4, CH-4031 Basel, Switzerland.,Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Basel, Switzerland
| | - Cedric Jaeger
- Department of Cardiology, University Hospital Basel, Petersgraben 4, CH-4031 Basel, Switzerland.,Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Basel, Switzerland
| | - Maria Rubini Gimenez
- Department of Cardiology, University Hospital Basel, Petersgraben 4, CH-4031 Basel, Switzerland.,Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Basel, Switzerland
| | - Karin Wildi
- Department of Cardiology, University Hospital Basel, Petersgraben 4, CH-4031 Basel, Switzerland.,Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Basel, Switzerland
| | - Tobias Reichlin
- Department of Cardiology, University Hospital Basel, Petersgraben 4, CH-4031 Basel, Switzerland.,Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Basel, Switzerland
| | - Thomas Nestelberger
- Department of Cardiology, University Hospital Basel, Petersgraben 4, CH-4031 Basel, Switzerland.,Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Basel, Switzerland
| | - Jasper Boeddinghaus
- Department of Cardiology, University Hospital Basel, Petersgraben 4, CH-4031 Basel, Switzerland.,Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Basel, Switzerland
| | - Karin Grimm
- Department of Cardiology, University Hospital Basel, Petersgraben 4, CH-4031 Basel, Switzerland.,Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Basel, Switzerland
| | - Christian Puelacher
- Department of Cardiology, University Hospital Basel, Petersgraben 4, CH-4031 Basel, Switzerland.,Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Basel, Switzerland
| | - Berit Moehring
- Department of Cardiology, University Hospital Basel, Petersgraben 4, CH-4031 Basel, Switzerland.,Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Basel, Switzerland
| | - Gil Pretre
- Department of Cardiology, University Hospital Basel, Petersgraben 4, CH-4031 Basel, Switzerland.,Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Basel, Switzerland
| | - Nicolas Schaerli
- Department of Cardiology, University Hospital Basel, Petersgraben 4, CH-4031 Basel, Switzerland.,Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Basel, Switzerland
| | - Isabel Campodarve
- Servicio de Urgencias y Medicina Interna - Hospital del Mar, Barcelona, Spain
| | | | - Stephan Steuer
- Emergency Department, Kantonsspital Luzern, Luzern, Switzerland
| | - Stefan Osswald
- Department of Cardiology, University Hospital Basel, Petersgraben 4, CH-4031 Basel, Switzerland.,Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Basel, Switzerland
| | - Christian Mueller
- Department of Cardiology, University Hospital Basel, Petersgraben 4, CH-4031 Basel, Switzerland .,Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Basel, Switzerland
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Charpentier S, Peschanski N, Chouihed T, Ray P, Chenevier-Gobeaux C. Multicenter Evaluation of a 0-Hour/1-Hour Algorithm in the Diagnosis of Myocardial Infarction With High-Sensitivity Cardiac Troponin T. Ann Emerg Med 2016; 67:793-794. [DOI: 10.1016/j.annemergmed.2016.02.036] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2016] [Indexed: 10/21/2022]
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Mueller C, Giannitsis E, Lindahl B. In reply. Ann Emerg Med 2016; 67:794-795. [PMID: 27217136 DOI: 10.1016/j.annemergmed.2016.02.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2016] [Indexed: 11/29/2022]
Affiliation(s)
- Christian Mueller
- Department of Cardiology & Cardiovascular Research Institute Basel, University Hospital Basel, Basel, Switzerland
| | | | - Bertil Lindahl
- Department of Medical Sciences and Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
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Jaffe AS. How Good Does It Need to Be? ∗. J Am Coll Cardiol 2016; 67:1541-1543. [DOI: 10.1016/j.jacc.2016.01.060] [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: 01/27/2016] [Accepted: 01/28/2016] [Indexed: 10/22/2022]
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Mueller-Hennessen M, Lindahl B, Giannitsis E, Biener M, Vafaie M, deFilippi CR, Christ M, Santalo-Bel M, Panteghini M, Plebani M, Verschuren F, Jernberg T, French JK, Christenson RH, Body R, McCord J, Dilba P, Katus HA, Mueller C. Diagnostic and prognostic implications using age- and gender-specific cut-offs for high-sensitivity cardiac troponin T — Sub-analysis from the TRAPID-AMI study. Int J Cardiol 2016; 209:26-33. [DOI: 10.1016/j.ijcard.2016.01.213] [Citation(s) in RCA: 65] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2015] [Revised: 01/13/2016] [Accepted: 01/14/2016] [Indexed: 01/20/2023]
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Stallone F, Schoenenberger AW, Puelacher C, Rubini Gimenez M, Walz B, Naduvilekoot Devasia A, Bergner M, Twerenbold R, Wildi K, Reichlin T, Hillinger P, Erne P, Mueller C. Incremental value of copeptin in suspected acute myocardial infarction very early after symptom onset. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2016; 5:407-15. [PMID: 27013743 DOI: 10.1177/2048872616641289] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/04/2015] [Accepted: 03/04/2016] [Indexed: 01/30/2023]
Abstract
BACKGROUND Patients presenting very early after chest pain onset may provide a diagnostic challenge even when using a high-sensitivity cardiac troponin (hs-cTnT). We hypothesized that in these patients the incremental value of copeptin in the early diagnosis of acute myocardial infarction (AMI) may be substantial. METHODS We aimed to investigate the incremental value of copeptin in a pre-specified subgroup analysis of patients presenting with suspected AMI to the emergency department within 2 hours of symptom onset in a multicenter study. Copeptin was measured in a blinded fashion. Two independent cardiologists adjudicated the final diagnosis using all available clinical informations, including high-sensitivity cardiac troponin T (hs-cTnT). RESULTS Overall, 2000 patients were enrolled, of whom 519 (26%) arrived within 2 hours of symptom onset. Of these, 102 patients (20%) had an AMI. The additional use of copeptin did not increase diagnostic accuracy as quantified by the area under the receiver-operating characteristic curve (AUC) of hs-cTnT (0.87 (95% confidence interval (CI): 0.83-0.90) for hs-cTnT alone to 0.86 (95% CI: 0.82-0.90) for the combination; p = NS). Copeptin (using 9 pmol/L as a cut-off) increased the negative predictive value (NPV) of hs-cTnT (using 14 ng/L as a cut-off) alone from 93% (95% CI: 90-95%) to 96% (95% CI: 93-98%). The NPV for the combination of hs-cTnT and copeptin was lower in patients arriving in the first 2 hours than in those arriving after 2 hours: 96% (95% CI: 93-98%) versus 99% (95% CI: 99-100%), respectively. CONCLUSIONS The additional use of copeptin on top of hs-cTnT seems to lead to a small increase in NPV, but no increase in AUC. Routine use of copeptin in early presenters does not seem warranted.
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Affiliation(s)
- Fabio Stallone
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Switzerland Department of Internal Medicine, University Hospital Basel, Switzerland
| | - Andreas W Schoenenberger
- Division of Geriatrics, Department of General Internal Medicine, Inselspital, Bern University Hospital, Switzerland University of Bern, Switzerland
| | - Christian Puelacher
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Switzerland Department of Internal Medicine, University Hospital Basel, Switzerland
| | - Maria Rubini Gimenez
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Switzerland Department of Internal Medicine, University Hospital Basel, Switzerland
| | - Brigitte Walz
- Central Laboratory, Luzerner Kantonsspital, Switzerland
| | - Allwin Naduvilekoot Devasia
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Switzerland
| | - Michael Bergner
- Department of Intensive Care Medicine, University Hospital Basel, Switzerland
| | - Raphael Twerenbold
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Switzerland
| | - Karin Wildi
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Switzerland Department of Intensive Care Medicine, University Hospital Basel, Switzerland
| | - Tobias Reichlin
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Switzerland
| | - Petra Hillinger
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Switzerland Department of Internal Medicine, University Hospital Basel, Switzerland
| | - Paul Erne
- Department of Cardiology, Luzerner Kantonsspital, Switzerland
| | - Christian Mueller
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Switzerland
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