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Pickering JW, Devlin G, Body R, Aldous S, Jaffe AS, Apple FS, Mills N, Troughton RW, Kavsak P, Peacock WF, Cullen L, Lord SJ, Müller C, Joyce L, Frampton C, Lacey CJ, Richards AM, Pitama S, Than M. Protocol for Improving Care by FAster risk-STratification through use of high sensitivity point-of-care troponin in patients presenting with possible acute coronary syndrome in the EmeRgency department (ICare-FASTER): a stepped-wedge cluster randomised quality improvement initiative. BMJ Open 2024; 14:e083752. [PMID: 38871661 DOI: 10.1136/bmjopen-2023-083752] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/15/2024] Open
Abstract
INTRODUCTION Clinical assessment in emergency departments (EDs) for possible acute myocardial infarction (AMI) requires at least one cardiac troponin (cTn) blood test. The turn-around time from blood draw to posting results in the clinical portal for central laboratory analysers is ~1-2 hours. New generation, high-sensitivity, point-of-care cardiac troponin I (POC-cTnI) assays use whole blood on a bedside (or near bedside) analyser that provides a rapid (8 min) result. This may expedite clinical decision-making and reduce length of stay. Our purpose is to determine if utilisation of a POC-cTnI testing reduces ED length of stay. We also aim to establish an optimised implementation process for the amended clinical pathway. METHODS AND ANALYSIS This quality improvement initiative has a pragmatic multihospital stepped-wedge cross-sectional cluster randomised design. Consecutive patients presenting to the ED with symptoms suggestive of possible AMI and having a cTn test will be included. Clusters (comprising one or two hospitals each) will change from their usual-care pathway to an amended pathway using POC-cTnI-the 'intervention'. The dates of change will be randomised. Changes occur at 1 month intervals, with a minimum 2 month 'run-in' period. The intervention pathway will use a POC-cTnI measurement as an alternate to the laboratory-based cTn measurement. Clinical decision-making steps and logic will otherwise remain unchanged. The POC-cTnI is the Siemens (Erlangen Germany) Atellica VTLi high-sensitivity cTnI assay. The primary outcome is ED length of stay. The safety outcome is cardiac death or AMI within 30 days for patients discharged directly from the ED. ETHICS AND DISSEMINATION Ethics approval has been granted by the New Zealand Southern Health and Disability Ethics Committee, reference 21/STH/9. Results will be published in a peer-reviewed journal. Lay and academic presentations will be made. Māori-specific results will be disseminated to Māori stakeholders. TRIAL REGISTRATION NUMBER ACTRN12619001189112.
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Affiliation(s)
- John W Pickering
- Medicine, University of Otago Christchurch, Christchurch, New Zealand
- Emergency, Christchurch Hospital, Christchurch, New Zealand
| | - Gerard Devlin
- Waikato District Health Board, Hamilton, New Zealand
- Heart Foundation of New Zealand, Auckland, New Zealand
| | - Richard Body
- Division of Cardiovascular Sciences, University of Manchester, The Victoria University of Manchester Campus, Manchester, UK
| | - Sally Aldous
- Cardiology, Christchurch Hospital, Christchurch, New Zealand
| | | | - Fred S Apple
- University of Minnesota, Minneapolis, Minnesota, USA
| | - Nicholas Mills
- The University of Edinburgh Centre for Cardiovascular Science, Edinburgh, UK
| | - Richard W Troughton
- Medicine, University of Otago Christchurch, Christchurch, New Zealand
- Cardiology, Christchurch Hospital, Christchurch, New Zealand
| | | | - W Frank Peacock
- Emergency Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Louise Cullen
- Institute of Health and Biomedical Innovation and School of Public Health and Social Work, Queensland University of Technology, Brisbane, Queensland, Australia
- Emergency and Trauma Centre, Royal Brisbane and Woman's Hospital Health Service District, Herston, Queensland, Australia
| | - Sarah J Lord
- The School of Medicine, University of Notre Dame Australia - Darlinghurst Campus, Darlinghurst, New South Wales, Australia
- NHMRC Clinical Trials Centre, Camperdown, New South Wales, Australia
| | - Christian Müller
- Division of Cardiology, University Hospital Basel, Basel, Switzerland
| | - Laura Joyce
- Emergency, Christchurch Hospital, Christchurch, New Zealand
- Surgery and Critical Care, University of Otago Christchurch, Christchurch, New Zealand
| | - Chris Frampton
- Medicine, University of Otago Christchurch, Christchurch, New Zealand
| | - Cameron James Lacey
- Māori Indigenous Health Institute, University of Otago Christchurch, Christchurch, New Zealand
| | - Arthur M Richards
- Medicine, University of Otago Christchurch, Christchurch, New Zealand
| | - Suzanne Pitama
- Māori Indigenous Health Institute, University of Otago Christchurch, Christchurch, New Zealand
| | - Martin Than
- Medicine, University of Otago Christchurch, Christchurch, New Zealand
- Emergency, Christchurch Hospital, Christchurch, New Zealand
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Harskamp RE, Melessen IM, Manten A, De Clercq L, den Elzen WPJ, Himmelreich JCL. Troponin testing in routine primary care: observations from a dynamic cohort study in the Amsterdam metropolitan area. Diagnosis (Berl) 2024; 11:171-177. [PMID: 38281102 DOI: 10.1515/dx-2023-0183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2023] [Accepted: 01/12/2024] [Indexed: 01/29/2024]
Abstract
OBJECTIVES Troponin testing is indicated in the diagnostic work-up of acute coronary syndrome (ACS) and incorporated in risk stratification pathways. This study aims to gain insights on the use, outcomes, and diagnostic accuracy of troponin testing in routine primary care; a setting that is understudied. METHODS Routine data were used from the academic primary care network in the Amsterdam metropolitan area (968,433 patient records). The study population included adult patients who underwent high-sensitivity troponin I or T (hs-TnI/T) testing between 2011 and 2021. The primary outcome was the reported diagnosis and the secondary outcome was the diagnostic accuracy measured by death or ACS at 30 days. RESULTS 3,184 patients underwent hs-troponin testing, either with hsTNT (n=2,333) or hsTNI (n=851). Median patients' age was 55 (44-65) years, and 62.3 % were female. Predominant symptoms were chest pain and dyspnea (56.7 %). Additional diagnostic laboratory tests were commonly performed (CRP: 47.7 %, natriuretic peptides: 25.6 %, d-dimer: 21.5 %). Most common diagnoses were musculoskeletal symptoms (21.6 %) and coronary heart disease (7.1 %; 1.1 % ACS). Troponin testing showed sensitivity and specificity of 77.8 % (60.9-89.9) and 94.3 % (93.5-95.1), respectively. Negative and positive predictive values were 99.7 (99.5-99.9) and 13.5 (11.1-16.4), and positive and negative likelihood ratios were 13.7 (10.9-17.1) and 0.24 (0.13-0.43). CONCLUSIONS GPs occasionally use troponin testing in very low-risk patients, often as part of a multi-marker rule-out strategy. The diagnostic characteristics of troponin tests, while promising, warrant prospective validation and implementation to facilitate appropriate use.
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Affiliation(s)
- Ralf E Harskamp
- Department of General Practice, Amsterdam UMC, AmstelHeart Research Unit, University of Amsterdam, Amsterdam, The Netherlands
- Personalized Medicine, Amsterdam Public Health, Amsterdam, The Netherlands
- Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - Indra M Melessen
- Department of General Practice, Amsterdam UMC, AmstelHeart Research Unit, University of Amsterdam, Amsterdam, The Netherlands
- Personalized Medicine, Amsterdam Public Health, Amsterdam, The Netherlands
- Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - Amy Manten
- Department of General Practice, Amsterdam UMC, AmstelHeart Research Unit, University of Amsterdam, Amsterdam, The Netherlands
- Personalized Medicine, Amsterdam Public Health, Amsterdam, The Netherlands
- Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - Lukas De Clercq
- Department of General Practice, Amsterdam UMC, AmstelHeart Research Unit, University of Amsterdam, Amsterdam, The Netherlands
- Personalized Medicine, Amsterdam Public Health, Amsterdam, The Netherlands
- Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - Wendy P J den Elzen
- Department of Laboratory Medicine, Amsterdam UMC, University of Amsterdam, Laboratory Specialized Diagnostics & Research, Amsterdam, The Netherlands
| | - Jelle C L Himmelreich
- Department of General Practice, Amsterdam UMC, AmstelHeart Research Unit, University of Amsterdam, Amsterdam, The Netherlands
- Personalized Medicine, Amsterdam Public Health, Amsterdam, The Netherlands
- Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
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De Iuliis V, Gabriele AR, De Santis F, De Rugeriis R, Di Quinzio L, Aloisi S, Rosati AC, Benvenuto M, Fabiani D, Chiatamone Ranieri S. Diagnostic performance of a point of care high-sensitivity cardiac troponin I assay and single measurement evaluation to rule out and rule in acute coronary syndrome. Clin Chem Lab Med 2024; 0:cclm-2024-0225. [PMID: 38669209 DOI: 10.1515/cclm-2024-0225] [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: 02/17/2024] [Accepted: 04/16/2024] [Indexed: 04/28/2024]
Abstract
OBJECTIVES About 10 million individuals in USA presented annually in the emergency department (ED) with chest pain or with signs and symptoms of acute coronary syndrome (ACS). The advent of point of care (POC) devices, able to measure high sensitivity troponin, are a very interesting tool in the ED setting for its rapid turnaround time (<10 min). METHODS The present study evaluates the diagnostic performance of the Atellica VTLi (Siemens) in real life setting using the clinical data derived from integrated diagnoses of emergency room staff and cardiologist and in comparison with standard laboratory hs-cTnT assay (Cobas 8000, Elecsys, Roche). 966 patients admitted to the emergency department of "G. Mazzini Hospital" in Teramo, Italy, from July 27, 2022, through June 09, 2023, were enrolled. RESULTS The diagnostic performance of POC hs-cTnI was evaluated. An appropriate POC hs-cTnI threshold values <4 ng/L supplied a sensitivity and an NPV of 100 % (95 % CI: 99.5-100) in order to achieve rapid rule out for MI through a single measurement at patient presentation in the ED. Furthermore, a derivation POC hs-cTnI concentration >54 ng/L provided a specificity of 97.2 % (95 % CI: 95.9-98.1) and a PPV of 43.5 % (95 % CI: 40.3-46.7) for ruling in MI. CONCLUSIONS This platform showed comparable diagnostic performance for myocardial infarction to the central laboratory. Our data suggest the possible use of the Atellica VTLi hs-cTnI POC assay either in emergency department of urban medical centre, either in rural hospital for triage and patient management.
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Affiliation(s)
- Vincenzo De Iuliis
- Department of Clinical Pathology, 92708 G. Mazzini Civil Hospital , Teramo, Italy
| | | | - Francesca De Santis
- Department of Clinical Pathology, 92708 G. Mazzini Civil Hospital , Teramo, Italy
| | - Roberta De Rugeriis
- Department of Clinical Pathology, 92708 G. Mazzini Civil Hospital , Teramo, Italy
| | - Luigi Di Quinzio
- Emergency Department, 92708 G. Mazzini Civil Hospital , Teramo, Italy
| | - Steeve Aloisi
- Emergency Department, 92708 G. Mazzini Civil Hospital , Teramo, Italy
| | - Anna Carla Rosati
- Cardiology Division, 92708 G. Mazzini Civil Hospital , Teramo, Italy
| | - Manuela Benvenuto
- Cardiology Division, 92708 G. Mazzini Civil Hospital , Teramo, Italy
| | - Donatello Fabiani
- Cardiology Division, 92708 G. Mazzini Civil Hospital , Teramo, Italy
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Pickering JW, Hamill L, Aldous S, Joyce L, Stothart RA, Williams O, Florkowski CM, Than M. Determination of a whole-blood single-test low-risk threshold for a point-of-care high-sensitivity troponin assay. Emerg Med J 2024; 41:322-323. [PMID: 38429073 DOI: 10.1136/emermed-2023-213689] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/12/2024] [Indexed: 03/03/2024]
Affiliation(s)
- John W Pickering
- Department of Medicine, University of Otago Christchurch, Christchurch, New Zealand
- Emergency Department, Christchurch Hospital, Christchurch, New Zealand
| | - Laura Hamill
- Pegasus Health 24 Hour Surgery Ltd, Christchurch, New Zealand
| | - Sally Aldous
- Cardiology, Christchurch Hospital, Christchurch, New Zealand
| | - Laura Joyce
- Emergency Department, Christchurch Hospital, Christchurch, New Zealand
- Department of Surgery and Critical Care, University of Otago Christchurch, Christchurch, New Zealand
| | - R Alex Stothart
- Emergency Department, Christchurch Hospital, Christchurch, New Zealand
| | - Otis Williams
- Emergency Department, Christchurch Hospital, Christchurch, New Zealand
| | | | - Martin Than
- Department of Medicine, University of Otago Christchurch, Christchurch, New Zealand
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Metsu D, Mille D, Pailly C, Oancea VG, Essemilaire L, Coppin D. Analytical assays and bootstrap resampling method to validate performance of the Roche Elecsys STAT highly sensitive troponin T assay and its application for the 'rule-out' part of ESC guidelines for NTSTEMI. Ann Clin Biochem 2024; 61:63-69. [PMID: 37525403 DOI: 10.1177/00045632231194449] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/02/2023]
Abstract
BACKGROUND The European Society of Cardiology (ESC) guidelines recommend a dynamic (0-1h) cardiac troponin (cTn) determination for non-ST elevation myocardial infarction diagnosis. For patients with low cTn levels, a discharge from emergency can be considered. Nevertheless, cTn cutoffs for discharge are lower than the limits of quantification proposed by laboratory reagent suppliers. AIM Validate cTn assay on the Elecsys STAT kit. MATERIALS AND METHODS Precision, trueness, repeatability and within-laboratory variability were calculated from internal quality control and plasma pooled at 5.78 and 10.73 ng/L. Accuracy was calculated from external quality control. Uncertainty of measurement was calculated from (i) the uncertainty of the standard and control values and (ii) by precision from pooled plasma. Distribution of precision results from pooled plasma has been evaluated by bootstrap simulations. Dilution linearity tests with patient plasma were performed to evaluate the method for values near 5 ng/L. RESULTS Precision and trueness ranged from 1.35 to 4.45% and from 0.14 to -3.74%, respectively. Accuracy results ranged from 101.40 to 104.90%. Within laboratory variability was 2.91%. Uncertainty ranged from 3.66% to 19.90% for higher (2188) to lower values (5.78 ng/L). Bootstrap simulations allowed utilization of precision data from pooled plasma to evaluate cTn assay. The method was linear from 4.48 to 39.80 ng/L. A linear regression model best described the data. CONCLUSION Elecsys STAT method provides accurate cTn results, including patients with cTn results categorizing them as 'rule-out' in the ESC guidelines.
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Affiliation(s)
- David Metsu
- Department of Laboratory Medicine, Montauban Hospital, Montauban, France
| | - Daphné Mille
- Department of Emergency Medicine, Montauban Hospital, Montauban, France
| | - Carole Pailly
- Department of Emergency Medicine, Montauban Hospital, Montauban, France
| | - Valerica G Oancea
- Department of Laboratory Medicine, Montauban Hospital, Montauban, France
- Université Toulouse III, Toulouse University Hospital, Toulouse, France
| | - Luc Essemilaire
- Accredited Medical Laboratories Network (LABAC), Lyon, France
| | - Dominique Coppin
- Department of Emergency Medicine, Montauban Hospital, Montauban, France
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Aspromonte N, Zaninotto M, Aimo A, Fumarulo I, Plebani M, Clerico A. Measurement of Cardiac-Specific Biomarkers in the Emergency Department: New Insight in Risk Evaluation. Int J Mol Sci 2023; 24:15998. [PMID: 37958981 PMCID: PMC10648028 DOI: 10.3390/ijms242115998] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Revised: 11/02/2023] [Accepted: 11/04/2023] [Indexed: 11/15/2023] Open
Abstract
The aim of this article review is to analyze some models and clinical issues related to the implementation of accelerated diagnostic protocols based on specific cardiac biomarkers in patients admitted to the emergency department (ED) with symptoms compatible with acute cardiac disorders. Four specific clinical issues will be discussed in detail: (a) pathophysiological and clinical interpretations of circulating hs-cTnI and hs-cTnT levels; (b) the clinical relevance and estimation of the biological variation of biomarkers in patients admitted to the ED with acute and severe diseases; (c) the role and advantages of the point-of-care testing (POCT) methods for cardiac-specific biomarkers in pre-hospital and hospital clinical practice; and (d) the clinical role of specific cardiac biomarkers in patients with acute heart failure (AHF). In order to balance the risk between a hasty discharge versus the potential harms caused by a cardiac assessment in patients admitted to the ED with suspected acute cardiovascular disease, the measurement of specific cardiac biomarkers is essential for the early identification of the presence of myocardial dysfunction and/or injury and to significantly reduce the length and costs of hospitalization. Moreover, specific cardiac biomarkers (especially hs-cTnI and hs-cTnT) are useful predictors of mortality and major adverse cardiovascular events (MACE) in patients admitted to the ED with suspected acute cardiovascular disease. To guide the implementation of the most rapid algorithms for the diagnosis of Non-ST-Elevation Myocardial Infarction (NSTEMI) into routine clinical practice, clinical scientific societies and laboratory medicine societies should promote collaborative studies specifically designed for the evaluation of the analytical performance and, especially, the cost/benefit ratio resulting from the use of these clinical protocols and POCT methods in the ED clinical practice.
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Affiliation(s)
- Nadia Aspromonte
- Department of Cardiovascular and Thoracic Sciences, Catholic University of the Sacred Heart, 00168 Rome, Italy; (N.A.); (I.F.)
- Department of Cardiovascular and Thoracic Sciences, A. Gemelli University Policlinic Foundation IRCCS, 00168 Rome, Italy
| | - Martina Zaninotto
- Department of Laboratory Medicine, University-Hospital of Padova, 35129 Padova, Italy;
| | - Alberto Aimo
- CNR Foundation—Regione Toscana G. Monasterio, 56127 Pisa, Italy;
| | - Isabella Fumarulo
- Department of Cardiovascular and Thoracic Sciences, Catholic University of the Sacred Heart, 00168 Rome, Italy; (N.A.); (I.F.)
- Department of Cardiovascular and Thoracic Sciences, A. Gemelli University Policlinic Foundation IRCCS, 00168 Rome, Italy
| | - Mario Plebani
- Department of Medicine-DIMED, University of Padova, 35129 Padova, Italy;
| | - Aldo Clerico
- CNR Foundation—Regione Toscana G. Monasterio, 56127 Pisa, Italy;
- Coordinator of the Study Group on Cardiac Biomarkers of the Italian Societies of Laboratory Medicine, 56127 Pisa, Italy
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Tolsma RT, de Koning ER, Fokkert MJ, van der Waarden NW, van 't Hof AW, Backus BE. Management of patients suspected for non-ST elevation-acute coronary syndrome in the prehospital phase. Future Cardiol 2023; 19:639-647. [PMID: 37916603 DOI: 10.2217/fca-2023-0049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Accepted: 10/03/2023] [Indexed: 11/03/2023] Open
Abstract
The management of patients with suspected acute coronary syndrome, especially in prehospital settings, is challenging. This Special Report focuses on studies in emergency medical services concerning chest pain patients' triage and risk stratification. In addition, it emphasizes advancements in point-of-care cardiac troponin testing. These developments are compared with in-hospital guidelines, proposing an initial framework for a new acute care pathway. This pathway integrates a risk stratification tool with high-sensitivity cardiac troponin testing, aiming to deliver optimal care and collaboration within the acute care chain. It has the potential to contribute to a significant reduction in hospital referrals, reduce observation time and overcrowding at emergency departments and hospital admissions.
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Affiliation(s)
- Rudolf T Tolsma
- Emergency Medical Service, Ambulance IJsselland, Zwolle, 8013 PM, The Netherlands
| | - Enrico R de Koning
- Department of Cardiology, Leiden University Medical Center, Leiden, 2333 ZA, The Netherlands
| | - Marion J Fokkert
- Department of Clinical Chemistry, Isala, Zwolle, 8025 AB, The Netherlands
| | | | - Arnoud Wj van 't Hof
- Department of Cardiology, Maastricht University Medical Center, Maastricht, 6229 HX, The Netherlands
- Department of Cardiology, Zuyderland MC, Heerlen, 6419 PC, The Netherlands
| | - Barbra E Backus
- Emergency Department, Franciscus Gasthuis & Vlietland, Rotterdam, 3043 PM, The Netherlands
- Emergency Department, Elisabeth-Tweesteden hospital, Tilburg, 5000 LC, The Netherlands
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Tolsma RT, Fokkert MJ, Ottervanger JP, van Dongen DN, Badings EA, der Sluis AV, Van't Hof AW, Slingerland RJ. Consequences of different cut-off values for high-sensitivity cardiac troponin for risk stratification of patients suspected for NSTE-ACS with a modified HEART score. Future Cardiol 2023; 19:497-504. [PMID: 37702223 DOI: 10.2217/fca-2023-0038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/14/2023] Open
Abstract
Aim: This study aims to enhance prehospital risk assessment for suspected non-ST-elevation acute coronary syndrome (NSTE-ACS) patients using the HEART-score. By incorporating novel point-of-care high-sensitivity cardiac troponin devices, a modified HEART-score was developed and compared with the conventional approach. Patients & methods: Troponin points within the modified HEART-score are based on values below the limit of quantitation (LoQ), between the LoQ and 99th percentile and above the 99th percentile of the used device. A total HEART-score of three or lower is considered low-risk for major adverse cardiac events. Results & conclusion: The number of low-risk patients decreased based on the modified HEART-score. The sensitivity and negative predictive value increased which suggests increasing safety in ruling out patients with suspected NSTE-ACS.
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Affiliation(s)
- Rudolf T Tolsma
- Emergency Medical Service, Ambulance IJsselland, 8013 PM, Zwolle, The Netherlands
| | - Marion J Fokkert
- Department of Innovation & Science, Isala, 8025 AB, Zwolle, The Netherlands
- Department of Clinical Chemistry, Isala, 8025 AB, Zwolle, The Netherlands
| | | | | | - Erik A Badings
- Department of Cardiology, Deventer Hospital, 7416 SE, Deventer, The Netherlands
| | - Aize van der Sluis
- Department of Cardiology, Deventer Hospital, 7416 SE, Deventer, The Netherlands
| | - Arnoud Wj Van't Hof
- Department of Cardiology, MUMC, 6229 HX, Maastricht, The Netherlands
- Department of Cardiology, Zuyderland MC, 6419 PC, Heerlen, The Netherlands
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Cooper JG, Ferguson J, Donaldson LA, Black KMM, Livock KJ, Horrill JL, Davidson EM, Scott NW, Lee AJ, Fujisawa T, Lee KK, Anand A, Shah ASV, Mills NL. Performance of a prehospital HEART score in patients with possible myocardial infarction: a prospective evaluation. Emerg Med J 2023; 40:474-481. [PMID: 37268413 DOI: 10.1136/emermed-2022-213003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2022] [Accepted: 05/14/2023] [Indexed: 06/04/2023]
Abstract
INTRODUCTION The History, Electrocardiogram (ECG), Age, Risk Factors and Troponin (HEART) score is commonly used to risk stratify patients with possible myocardial infarction as low risk or high risk in the Emergency Department (ED). Whether the HEART score can be used by paramedics to guide care were high-sensitivity cardiac troponin testing available in a prehospital setting is uncertain. METHODS In a prespecified secondary analysis of a prospective cohort study where paramedics enrolled patients with suspected myocardial infarction, a paramedic Heart, ECG, Age, Risk Factors (HEAR) score was recorded contemporaneously, and a prehospital blood sample was obtained for subsequent cardiac troponin testing. HEART and modified HEART scores were derived using laboratory contemporary and high-sensitivity cardiac troponin I assays. HEART and modified HEART scores of ≤3 and ≥7 were applied to define low-risk and high-risk patients, and performance was evaluated for an outcome of major adverse cardiac events (MACEs) at 30 days. RESULTS Between November 2014 and April 2018, 1054 patients were recruited, of whom 960 (mean 64 (SD 15) years, 42% women) were eligible for analysis and 255 (26%) experienced a MACE at 30 days. A HEART score of ≤3 identified 279 (29%) as low risk with a negative predictive value of 93.5% (95% CI 90.0% to 95.9%) for the contemporary assay and 91.4% (95% CI 87.5% to 94.2%) for the high-sensitivity assay. A modified HEART score of ≤3 using the limit of detection of the high-sensitivity assay identified 194 (20%) patients as low risk with a negative predictive value of 95.9% (95% CI 92.1% to 97.9%). A HEART score of ≥7 using either assay gave a lower positive predictive value than using the upper reference limit of either cardiac troponin assay alone. CONCLUSIONS A HEART score derived by paramedics in the prehospital setting, even when modified to harness the precision of a high-sensitivity assay, does not allow safe rule-out of myocardial infarction or enhanced rule-in compared with cardiac troponin testing alone.
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Affiliation(s)
- Jamie G Cooper
- Emergency Department, Aberdeen Royal Infirmary, Aberdeen, UK
- School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Aberdeen, UK
| | - James Ferguson
- Emergency Department, Aberdeen Royal Infirmary, Aberdeen, UK
| | - Lorna A Donaldson
- Department of Research Development and Innovation, Scottish Ambulance Service, Edinburgh, UK
| | - Kim M M Black
- Emergency Department, Aberdeen Royal Infirmary, Aberdeen, UK
| | - Kate J Livock
- Emergency Department, Aberdeen Royal Infirmary, Aberdeen, UK
| | | | - Elaine M Davidson
- Department of Clinical Biochemistry, Aberdeen Royal Infirmary, Aberdeen, UK
| | - Neil W Scott
- Medical Statistics Team, University of Aberdeen, Aberdeen, UK
| | - Amanda J Lee
- Medical Statistics Team, University of Aberdeen, Aberdeen, UK
| | - Takeshi Fujisawa
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
- BHF Cardiovascular Biomarker Laboratory, University of Edinburgh, Edinburgh, UK
| | - Kuan Ken Lee
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Atul Anand
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Anoop S V Shah
- Department of Non Communicable Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | - Nicholas L Mills
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
- Usher Institute, University of Edinburgh, Edinburgh, UK
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Pretorius CJ, Ungerer JPJ. Are discordant cTnI results detected in an analytical comparison clinically irrelevant? Clin Biochem 2023; 116:132. [PMID: 37149209 DOI: 10.1016/j.clinbiochem.2023.04.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Revised: 04/26/2023] [Accepted: 04/27/2023] [Indexed: 05/08/2023]
Affiliation(s)
- Carel J Pretorius
- Pathology Queensland, Brisbane, Australia; Faculty of Medicine, The University of Queensland, Brisbane, Australia.
| | - Jacobus P J Ungerer
- Pathology Queensland, Brisbane, Australia; Faculty of Medicine, The University of Queensland, Brisbane, Australia
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11
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Xiong-Hang K, Schulz K, Sandoval Y, Smith SW, Saenger AK, Apple FS. Analytical performance comparing siemens whole blood point of care Atellica VTLi to the central laboratory plasma Atellica IM high-sensitivity cardiac troponin I assays. Clin Biochem 2023; 114:79-85. [PMID: 36780933 DOI: 10.1016/j.clinbiochem.2023.02.004] [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: 11/24/2022] [Revised: 01/27/2023] [Accepted: 02/09/2023] [Indexed: 02/13/2023]
Abstract
INTRODUCTION This study examined the analytical performance of a whole blood (WB) point of care (POC) hs-cTnI assay compared to a plasma central laboratory hs-cTnI assay in patients presenting with ischemic symptoms to a US emergency department. METHODS Fresh WB specimens collected at 0 and 2 h from 1089 consecutive patients (2152 total from 1076 matched specimens) were analyzed for hs-cTnI using WB on POC Siemens Atellica VTLi assay and plasma on central laboratory Siemens Atellica IM assay. Concordances were determined based on concentrations ranging from < limit of detection (LoD), LoD to overall and sex specific 99th percentiles from both the IFCC manufacturer package inserts and Universal Sample Bank (USB) data, and > 99th percentiles. Method comparisons were calculated using Passing Bablok regression and Bland Altmann plots, and linear regression determined by Pearson correlation coefficient. RESULTS Baseline concentration comparisons showed: POC VTLi < LoD 4-5 %, ≥ LoD 95 %; Atellica IM < LoD 5-7 %, and ≥ LoD 94-95 %. From the 2152 paired 0 and 2-hour samples, based on 99th percentiles, overall concordance was 91-92 % (kappa 0.72-0.77) and discordance 8 %. Passing Bablok regression analysis using 1924 specimens between LoD to 500 ng/L showed: slopes 0.469-0.490; y-intercepts 1.753-2.028; r values 0.631-0.817. Pearson correlation coefficient showed moderate to strong correlation strength, even with up to 53 % cTnI concentrations variance (Passing Bablok slopes) vs 27.0-40.1 % (Bland-Altmann plots). CONCLUSIONS Up to 95 % of measured samples were > LoD for both the POC (Atellica VTLi) and central laboratory (Atellica IM) hs-cTnI assays. Moderate to strong concordance and correlation were observed between assays, despite up to 53 % variances in cTnI concentration.
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Affiliation(s)
- Kang Xiong-Hang
- Department of Laboratory Medicine and Pathology, Hennepin Healthcare/HCMC, Minneapolis, MN, USA
| | - Karen Schulz
- Hennepin Healthcare Research Institute, Minneapolis, MN, USA
| | - Yader Sandoval
- Minneapolis Heart Institute, Abbott Northwestern Hospital, and Minneapolis Heart Institute Foundation, Minneapolis, MN, USA
| | - Stephen W Smith
- Departments of Emergency Medicine at Hennepin Healthcare/Hennepin County Medical Center & University of Minnesota School of Medicine, Minneapolis, MN, USA
| | - Amy K Saenger
- Department of Laboratory Medicine and Pathology, Hennepin Healthcare/HCMC, Minneapolis, MN, USA; Department of Laboratory Medicine and Pathology, University of Minnesota, Minneapolis, MN, USA
| | - Fred S Apple
- Department of Laboratory Medicine and Pathology, Hennepin Healthcare/HCMC, Minneapolis, MN, USA; Hennepin Healthcare Research Institute, Minneapolis, MN, USA; Department of Laboratory Medicine and Pathology, University of Minnesota, Minneapolis, MN, USA.
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