1
|
Kadesjö E, Cyon L, Edgren G, Roos A. Low-Risk Chest Pain Patients: Exploring the Impact of Socioeconomy on Emergency Department Revisits. Am J Med 2024:S0002-9343(24)00629-6. [PMID: 39370031 DOI: 10.1016/j.amjmed.2024.09.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2024] [Revised: 08/26/2024] [Accepted: 09/25/2024] [Indexed: 10/08/2024]
Abstract
BACKGROUND Patients with chest pain and undetectable high-sensitivity cardiac troponin T (hs-cTnT) in the emergency department (ED) have a low short-term risk of cardiovascular events, but the frequency of ED revisits in this group is unknown. This study investigated the associations between disposable income and risk of ED revisits in patients with chest pain and undetectable hs-cTnT. METHODS All first visits to 7 EDs in Sweden from 2010 to 2017 by patients with chest pain and hs-cTnT <5 ng/l were included. Incidence rate ratios (IRR) were calculated to estimate the ED revisit risk in relation to disposable income according to data obtained from Swedish government agencies (Statistics Sweden). RESULTS Altogether, 61,539 patients with a first ED visit were included, in whom 126,650 revisits occurred. The adjusted 30-day risk of a revisit was 1.3- (IRR 1.32, 95% CI: 1.23-1.42) and 1.5-fold (IRR 1.50, 95% CI: 1.40-1.60), and for any revisit during the follow-up 1.6- (IRR 1.63, 95% CI: 1.59-1.66) and 1.8-fold (IRR 1.78, 95% CI 1.72-1.79), in patients with middle-low and low versus high income, respectively. During a median follow-up of 6.8 years, 1714 (2.8%) deaths occurred, and the adjusted cumulative incidence of major adverse cardiovascular events at 1 and 5 years was only 0.3% (95% CI: 0.2-0.4%) and 1.1% (95% CI: 0.8-1.4%) higher in patients with the lowest versus highest income levels. CONCLUSIONS Disposable income level is inversely associated with the risk of ED revisits among patients presenting with chest pain and undetectable hs-cTnT, in whom cardiovascular risks are low.
Collapse
Affiliation(s)
- Erik Kadesjö
- Theme of Acute and Reparative Medicine, Karolinska University Hospital, Huddinge, Stockholm, Sweden.; Department of Medicine, Karolinska Institutet, Solna, Stockholm, Sweden.
| | - Love Cyon
- Theme of Acute and Reparative Medicine, Karolinska University Hospital, Huddinge, Stockholm, Sweden.; Department of Medicine, Clinical Epidemiology Division, Karolinska Institutet, Solna, Stockholm, Sweden
| | - Gustaf Edgren
- Department of Medicine, Clinical Epidemiology Division, Karolinska Institutet, Solna, Stockholm, Sweden.; Department of Cardiology, Södersjukhuset, Stockholm, Sweden
| | - Andreas Roos
- Theme of Acute and Reparative Medicine, Karolinska University Hospital, Huddinge, Stockholm, Sweden.; Department of Medicine, Clinical Epidemiology Division, Karolinska Institutet, Solna, Stockholm, Sweden
| |
Collapse
|
2
|
Lin Y, Zhan H, Wang S, Zhang G, Ye Z, Liu C, Wang D, Gao D, Yang Q, Gong Z, Feng G, Liu M, Li W, Yang Y, Zhu J, Zhou Z, Liang Y. A multicenter prospective study on the ESC algorithm for the early diagnosis of non-ST-elevation myocardial infarction. iScience 2024; 27:110643. [PMID: 39262795 PMCID: PMC11388160 DOI: 10.1016/j.isci.2024.110643] [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: 03/07/2024] [Revised: 06/22/2024] [Accepted: 07/30/2024] [Indexed: 09/13/2024] Open
Abstract
This study aimed to determine the optimal high-sensitivity cardiac troponin I (hs-cTnI)-based algorithm for early diagnosis of non-ST-elevation myocardial infarction (NSTEMI) in Chinese patients. We prospectively enrolled 1,606 patients with suspected NSTEMI from three emergency departments across China, collecting blood samples at 0, 1, and 3 h post-admission. Patients were classified using the 0/1-h and 0/3-h algorithms. The 2015 and 2020 ESC 0/1-h algorithms rapidly triaged 70% of patients with high negative predictive value (NPV) (99.7%) and sensitivity (99.5%). The 0/3-h algorithm showed higher specificity (93.8%) but lower NPV (96.8%) and sensitivity (91.2%). An optimized 0/1-h algorithm improved specificity to 92.1% while maintaining high NPV (99.7%) and sensitivity (99.2%). Low 30-day and 180-day all-cause mortality and major adverse cardiac event (MACE) rates were observed in rule-out groups for all algorithms. The ESC 0/1-h algorithm is a safe and efficient triage method for patients with suspected NSTEMI, with optimization further enhancing specificity and efficiency for the Chinese population.
Collapse
Affiliation(s)
- Yahui Lin
- Center of Laboratory Medicine, National Clinical Research Center of Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College/National Center for Cardiovascular Diseases, Beijing, China
| | - Hong Zhan
- Department of Emergency, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Shukui Wang
- Department of Laboratory Medicine, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Guozheng Zhang
- Emergency Department, Fuwai Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College/National Center for Cardiovascular Diseases, Beijing, China
| | - Zi Ye
- Department of Emergency, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Caidong Liu
- Department of Laboratory Medicine, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Dong Wang
- Department of Laboratory Medicine, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Dongfang Gao
- Emergency Department, Fuwai Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College/National Center for Cardiovascular Diseases, Beijing, China
| | - Qing Yang
- Emergency Department, Fuwai Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College/National Center for Cardiovascular Diseases, Beijing, China
| | - Zebin Gong
- Emergency Department, Fuwai Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College/National Center for Cardiovascular Diseases, Beijing, China
| | - Guangxun Feng
- Emergency Department, Fuwai Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College/National Center for Cardiovascular Diseases, Beijing, China
| | - Min Liu
- Department of Laboratory Medicine, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Wenke Li
- Emergency Department, Fuwai Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College/National Center for Cardiovascular Diseases, Beijing, China
| | - Yanmin Yang
- Emergency Department, Fuwai Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College/National Center for Cardiovascular Diseases, Beijing, China
| | - Jun Zhu
- Emergency Department, Fuwai Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College/National Center for Cardiovascular Diseases, Beijing, China
| | - Zhou Zhou
- Center of Laboratory Medicine, National Clinical Research Center of Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College/National Center for Cardiovascular Diseases, Beijing, China
| | - Yan Liang
- Emergency Department, Fuwai Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College/National Center for Cardiovascular Diseases, Beijing, China
| |
Collapse
|
3
|
Knott JD, Ola O, De Michieli L, Akula A, Yang EH, Gharacholou SM, Slusser J, Lewis B, Mehta RA, Gulati R, Sandoval Y, Jaffe AS. High Baseline High-Sensitivity Cardiac Troponin T Concentrations and Risk of Index Acute Myocardial Infarction. Mayo Clin Proc 2024; 99:1435-1442. [PMID: 38493402 DOI: 10.1016/j.mayocp.2023.12.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Revised: 12/15/2023] [Accepted: 12/26/2023] [Indexed: 03/18/2024]
Abstract
OBJECTIVE To evaluate the diagnostic performance of the previously recommended baseline high-sensitivity cardiac troponin T (hs-cTnT) thresholds of 52 and 100 ng/L in identifying patients at high risk of acute myocardial infarction (AMI). PATIENTS AND METHODS This study compared the positive predictive value (PPV) for index AMI of these high-risk hs-cTnT thresholds in adult patients in the emergency department undergoing hs-cTnT measurement. RESULTS The adjudicated MAyo Southwest Wisconsin 5th Gen Troponin T ImplementatiON cohort included 2053 patients, with 157 (7.6%) who received a diagnosis of AMI. The hs-cTnT concentrations of greater than 52 and greater than 100 ng/L resulted in PPVs of 41% (95% CI, 35%-48%) and 57% (95% CI, 48%-66%). In patients with chest discomfort, hs-cTnT concentrations greater than 52 ng/L resulted in a PPV of 66% (95% CI, 56%-76%) and hs-cTnT concentrations greater than 100 ng/L resulted in a PPV of 77% (95% CI, 65%-87%). The CV Data Mart Biomarker cohort included 143,709 patients, and 3003 (2.1%) received a diagnosis of AMI. Baseline hs-cTnT concentrations greater than 52 and greater than 100 ng/L resulted in PPVs of 12% (95% CI, 11%-12%) and 17% (95% CI, 17%-19%), respectively. In patients with chest pain and hs-cTnT concentrations greater than 52 ng/L, the PPV for MI was 17% (95% CI, 15%-18%) and in those with concentrations greater than 100 ng/L, only 22% (95% CI, 19%-25%). CONCLUSION In unselected patients undergoing hs-cTnT measurement, the hs-cTnT thresholds of greater than 52 and greater than 100 ng/L provide suboptimal performance for identifying high-risk patients. In patients with chest discomfort, an hs-cTnT concentration of greater than 100 ng/L, but not the European Society of Cardiology-recommended threshold of greater than 52 ng/L, provides an acceptable performance but should be used only with other clinical features.
Collapse
Affiliation(s)
- Jonathan D Knott
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN
| | - Olatunde Ola
- Department of Cardiovascular Diseases, Marshall University School of Medicine, Huntington, WV; Center for Clinical and Translational Science, Mayo Clinic Graduate School of Biomedical Sciences, Rochester, MN
| | - Laura De Michieli
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN; Department of Cardiac, Thoracic and Vascular Sciences and Public Health, University of Padova, Padova, Italy
| | - Ashok Akula
- Department of Cardiovascular Diseases, University of Arkansas for Medical Sciences, Little Rock, AK
| | - Eric H Yang
- Department of Cardiovascular Diseases, Mayo Clinic, Phoenix, AZ
| | | | - Josh Slusser
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN
| | - Bradley Lewis
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN
| | - Ramila A Mehta
- Department of Quantitative Health Sciences, Mayo College of Medicine, Rochester, MN
| | - Rajiv Gulati
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN
| | - Yader Sandoval
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN; Minneapolis Heart Institute, Abbott Northwestern Hospital, and Minneapolis Heart Institute Foundation, Minneapolis, MN
| | - Allan S Jaffe
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN; Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN.
| |
Collapse
|
4
|
Koechlin L, Boeddinghaus J, Lopez-Ayala P, Reber C, Nestelberger T, Wildi K, Spagnuolo CC, Strebel I, Glaeser J, Bima P, Crisanti L, Herraiz-Recuenco L, Dubach E, Miró Ò, Martin-Sanchez FJ, Kawecki D, Keller DI, Christ M, Buser A, Giménez MR, Størvold GL, Broughton MN, Omland T, Lyngbakken MN, Røsjø H, Mueller C. Clinical and Analytical Performance of a Novel Point-of-Care High-Sensitivity Cardiac Troponin I Assay. J Am Coll Cardiol 2024; 84:726-740. [PMID: 39142727 DOI: 10.1016/j.jacc.2024.05.056] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2024] [Accepted: 05/03/2024] [Indexed: 08/16/2024]
Abstract
BACKGROUND Point-of-care (POC) high-sensitivity cardiac troponin assays may further accelerate the diagnosis of myocardial infarction (MI). OBJECTIVES This study sought to assess the clinical and analytical performance of the novel high-sensitivity cardiac troponin I (hs-cTnI)-SPINCHIP POC test. METHODS Adult patients presenting with acute chest discomfort to the emergency department were enrolled in an international, diagnostic, multicenter study. The final diagnosis was centrally adjudicated by 2 independent cardiologists using all clinical information. We compared the discriminatory performance of hs-cTnI-SPINCHIP with current established central laboratory assays and derived an assay-specific hs-cTnI-SPINCHIP 0/1-hour algorithm. Secondary analyses included sample type comparisons (whole blood, fresh/frozen plasma, and capillary finger prick) and precision analysis. RESULTS MI was the adjudicated final diagnosis in 214 (19%) of 1,102 patients. Area under the receiver-operating characteristic curve was 0.94 (95% CI: 0.92-0.95) for hs-cTnI-SPINCHIP vs 0.94 (95% CI: 0.92-0.95) for hs-cTnI-Architect (P = 0.907) and 0.93 (95% CI: 0.91-0.95) for high-sensitivity cardiac troponin T Elecsys (P = 0.305). A cutoff <7 ng/L at presentation (if chest pain onset was >3 hours) or <7 ng/L together with a 0/1-hour delta of <4 ng/L ruled out 51% with a sensitivity and negative predictive value of 100% (95% CI: 97.7%-100%) and 100% (95% CI: 99.0%-100%), respectively. A hs-cTnI-SPINCHIP concentration ≥36 ng/L or a 0/1-hour delta ≥11 ng/L ruled in 27% with a specificity and positive predictive value of 90.9% (95% CI: 88.3%-92.9%) and 72.9% (95% CI: 66.4%-78.6%), respectively. Bootstrap internal validation confirmed excellent diagnostic performance. High agreement was observed between different sample types. CONCLUSIONS The SPINCHIP hs-cTnI POC test has very high diagnostic accuracy. Its assay-specific 0/1-hour algorithm achieved very high sensitivity/negative predictive value and specificity/positive predictive value for rule-out/in MI. (Advantageous Predictors of Acute Coronary Syndromes Evaluation [APACE] Study [APACE]; NCT00470587).
Collapse
Affiliation(s)
- Luca Koechlin
- Cardiovascular Research Institute Basel, and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland; Department of Cardiac Surgery, University Hospital Basel, University of Basel, Basel, Switzerland; GREAT Network, Rome, Italy.
| | - Jasper Boeddinghaus
- Cardiovascular Research Institute Basel, and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland; GREAT Network, Rome, Italy; BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
| | - Pedro Lopez-Ayala
- Cardiovascular Research Institute Basel, and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland; GREAT Network, Rome, Italy
| | - Cornelia Reber
- Cardiovascular Research Institute Basel, and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Thomas Nestelberger
- Cardiovascular Research Institute Basel, and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland; GREAT Network, Rome, Italy
| | - Karin Wildi
- Cardiovascular Research Institute Basel, and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland; GREAT Network, Rome, Italy
| | - Carlos C Spagnuolo
- Cardiovascular Research Institute Basel, and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland; GREAT Network, Rome, Italy
| | - Ivo Strebel
- Cardiovascular Research Institute Basel, and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland; GREAT Network, Rome, Italy
| | - Jonas Glaeser
- Cardiovascular Research Institute Basel, and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland; GREAT Network, Rome, Italy
| | - Paolo Bima
- Cardiovascular Research Institute Basel, and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland; GREAT Network, Rome, Italy
| | - Luca Crisanti
- Cardiovascular Research Institute Basel, and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland; GREAT Network, Rome, Italy
| | - Lourdes Herraiz-Recuenco
- Cardiovascular Research Institute Basel, and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland; GREAT Network, Rome, Italy
| | - Elisa Dubach
- Cardiovascular Research Institute Basel, and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Òscar Miró
- GREAT Network, Rome, Italy; Emergency Department, Hospital Clínic, Barcelona, Spain
| | - F Javier Martin-Sanchez
- GREAT Network, Rome, Italy; Servicio de Urgencias, Hospital Clínico San Carlos, Madrid, Spain
| | - Damian Kawecki
- GREAT Network, Rome, Italy; 2nd Department of Cardiology, School of Medicine with the Division of Dentistry in Zabrze, Medical University of Katowice, Katowice, Poland
| | - Dagmar I Keller
- Emergency Department, University Hospital Zurich, Zurich, Switzerland
| | - Michael Christ
- Emergency Department, Kantonsspital Luzern, Lucerne, Switzerland
| | - Andreas Buser
- Department of Hematology and Blood Bank, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Maria Rubini Giménez
- Cardiovascular Research Institute Basel, and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland; Department of Cardiology, University Hospital Valencia, Valencia, Spain
| | | | | | - Torbjørn Omland
- K.G. Jebsen Center for Cardiac Biomarkers, Institute of Clinical Medicine, University of Oslo, Oslo, Norway; Department of Cardiology, Division of Medicine, Akershus University Hospital, Lørenskog, Norway
| | - Magnus N Lyngbakken
- K.G. Jebsen Center for Cardiac Biomarkers, Institute of Clinical Medicine, University of Oslo, Oslo, Norway; Department of Cardiology, Division of Medicine, Akershus University Hospital, Lørenskog, Norway; Akershus Clinical Research Center, Division of Research and Innovation, Akershus University Hospital, Lørenskog, Norway
| | - Helge Røsjø
- K.G. Jebsen Center for Cardiac Biomarkers, Institute of Clinical Medicine, University of Oslo, Oslo, Norway; Akershus Clinical Research Center, Division of Research and Innovation, Akershus University Hospital, Lørenskog, Norway
| | - Christian Mueller
- Cardiovascular Research Institute Basel, and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland; GREAT Network, Rome, Italy.
| |
Collapse
|
5
|
Khand A, Hatherley J, Dakshi A, Miller G, Bailey L, Goulden C, Noori Z, Rawat A, Hornby R, Fearon H, Meah N, Davies S, Sekulska K, Hassan A, Lambert A, Phillips S, Raj R, Wiles T, Collinson P. Safety and feasibility of triage and rapid discharge of patients with chest pain from emergency room: a pragmatic, randomised non-inferiority control trial of the European Society of Cardiology (ESC) 0-1 hour pathway vs. conventional 0-3 hour accelerated diagnostic protocol. Am Heart J 2024:S0002-8703(24)00199-6. [PMID: 39151715 DOI: 10.1016/j.ahj.2024.08.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2024] [Revised: 08/07/2024] [Accepted: 08/07/2024] [Indexed: 08/19/2024]
Abstract
Patients presenting with chest pain represent a significant proportion of Emergency Department (ED) attendances but only a minority, typically 10%, have a final diagnosis of myocardial infarction (MI). Prompt discharge of patients without MI will alleviate ED overcrowding as well as improve patient satisfaction and reduce exposure to risk of hospital acquired infections such as Covid 19. The measurement of cardiac troponin (cTn) by a high sensitivity method is recommended by the National Institute for health and Care Excellence (NICE) for rapid categorisation of patients presenting with chest pain. Strategies proposed include measurement on admission and one hour from admission (ESC 0-1-hour pathway, the recent guideline approved pathway which has not been implemented widely), and measurement on admission and three hours from admission (0-3-hour pathway, which is conventional and widely adopted). The primary objective of this study is twofold: firstly, to assess the safety, feasibility, and impact of implementing the ESC (European Society of Cardiology) 0-1-hour pathway in clinical practice by reference to the more established ESC 0-3-hour protocol. The principal outcome measure will be the safety of the ESC 0-1-hour protocol. However, there are concerns that the time from sample draw to result availability (typically around 60 minutes) will impact on the feasibility of the ESC 0-1-hour pathway. Secondly, therefore, our goal is to evaluate whether measurement of high sensitivity troponin by a bedside analyser (point of care testing, POCT), which will produce results in 15 minutes is a feasible alternative to laboratory testing. We will compare the results produced by POCT with the laboratory results in the context of the ESC 0-1 hour and 0-3-hour pathway, as a nested controlled study in the context of a randomised controlled trial. (clinicaltrials.gov: NCT05322395).
Collapse
Affiliation(s)
- Aleem Khand
- Department of cardiology, Liverpool University Hospital NHS Foundation Trust, Liverpool, UK; Institute of Ageing and Chronic diseases, University of Liverpool, Liverpool, UK; Liverpool Heart and Chest Hospital, Liverpool, UK.
| | - James Hatherley
- Department of cardiology, Liverpool University Hospital NHS Foundation Trust, Liverpool, UK; Institute of Ageing and Chronic diseases, University of Liverpool, Liverpool, UK
| | - Ahmed Dakshi
- Department of cardiology, Liverpool University Hospital NHS Foundation Trust, Liverpool, UK; Institute of Ageing and Chronic diseases, University of Liverpool, Liverpool, UK
| | - Guy Miller
- Department of cardiology, Liverpool University Hospital NHS Foundation Trust, Liverpool, UK
| | - Lisa Bailey
- Department of cardiology, Liverpool University Hospital NHS Foundation Trust, Liverpool, UK; Liverpool Clinical Laboratories, Liverpool University Hospital NHS Foundation Trust, Liverpool, United Kingdom
| | - Christopher Goulden
- Department of cardiology, Liverpool University Hospital NHS Foundation Trust, Liverpool, UK
| | - Zaid Noori
- Department of cardiology, Liverpool University Hospital NHS Foundation Trust, Liverpool, UK
| | - Anju Rawat
- Department of cardiology, Liverpool University Hospital NHS Foundation Trust, Liverpool, UK
| | - Rachel Hornby
- Department of cardiology, Liverpool University Hospital NHS Foundation Trust, Liverpool, UK; Liverpool Heart and Chest Hospital, Liverpool, UK
| | - Hannah Fearon
- Liverpool Clinical Laboratories, Liverpool University Hospital NHS Foundation Trust, Liverpool, United Kingdom
| | - Nirmol Meah
- Department of cardiology, Liverpool University Hospital NHS Foundation Trust, Liverpool, UK
| | - Sarah Davies
- Department of cardiology, Liverpool University Hospital NHS Foundation Trust, Liverpool, UK; Liverpool Clinical Laboratories, Liverpool University Hospital NHS Foundation Trust, Liverpool, United Kingdom
| | - Katarzyna Sekulska
- Department of cardiology, Liverpool University Hospital NHS Foundation Trust, Liverpool, UK; Liverpool Clinical Laboratories, Liverpool University Hospital NHS Foundation Trust, Liverpool, United Kingdom
| | - Awtad Hassan
- Department of cardiology, Liverpool University Hospital NHS Foundation Trust, Liverpool, UK; Liverpool Clinical Laboratories, Liverpool University Hospital NHS Foundation Trust, Liverpool, United Kingdom
| | - Angela Lambert
- Department of cardiology, Liverpool University Hospital NHS Foundation Trust, Liverpool, UK; Liverpool Clinical Laboratories, Liverpool University Hospital NHS Foundation Trust, Liverpool, United Kingdom
| | - Suzannah Phillips
- Department of cardiology, Liverpool University Hospital NHS Foundation Trust, Liverpool, UK; Liverpool Clinical Laboratories, Liverpool University Hospital NHS Foundation Trust, Liverpool, United Kingdom
| | - Ray Raj
- Accident and Emergency Department, Liverpool University Hospital NHS Foundation Trust
| | - Tom Wiles
- Accident and Emergency Department, Liverpool University Hospital NHS Foundation Trust
| | - Paul Collinson
- Department of biochemistry, St.Georges University Hospital NHS Trust, London, UK
| |
Collapse
|
6
|
Bueno H, Bardají A. Ambulance drive-thru troponin, ready to go? EUROPEAN HEART JOURNAL. QUALITY OF CARE & CLINICAL OUTCOMES 2024; 10:384-385. [PMID: 38692850 DOI: 10.1093/ehjqcco/qcae023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/14/2024] [Indexed: 05/03/2024]
Affiliation(s)
- Héctor Bueno
- Multidisciplinary Translational Cardiovascular Research Group, Centro Nacional de Investigaciones Cardiovasculares (CNIC), Melchor Fernández Almagro, 3, 28029-Madrid, Spain
- Cardiology Department, Hospital Universitario 12 de Octubre e Instituto de, Investigación del Hospital Universitario 12 de Octubre (imas12), Av Córdoba s/n, 28049-Madrid, Spain
- Centro de Investigación Biomédica en Red en Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
- Facultad de Medicina, Universidad Complutense de Madrid (UCM), Av Córdoba s/n, 28049-Madrid, Spain
| | - Alfredo Bardají
- Cardiology Department, Joan XXIII University Hospital, Carrer Dr. Mallafré Guasch, 4, 43005-Tarragona, Spain
- Pere Virgili Health Research Institute, Carrer Dr. Mallafré Guasch, 4, 43005-Tarragona, Spain
- Department of Medicine and Surgery, Rovira i Virgili University, Carrer Dr. Mallafré Guasch, 4, 43005-Tarragona, Spain
| |
Collapse
|
7
|
Wang KL, Taggart C, McDermott M, O'Brien R, Oatey K, Keating L, Storey RF, Felmeden D, Curzen N, Kardos A, Roobottom C, Smith J, Goodacre S, Newby DE, Gray AJ. Clinical decision aids and computed tomography coronary angiography in patients with suspected acute coronary syndrome. Emerg Med J 2024; 41:488-494. [PMID: 38857986 DOI: 10.1136/emermed-2024-213904] [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: 01/11/2024] [Accepted: 05/16/2024] [Indexed: 06/12/2024]
Abstract
BACKGROUND The HEART score, the T-MACS model and the GRACE score support early decision-making for acute chest pain, which could be complemented by CT coronary angiography (CTCA). However, their performance has not been directly compared. METHODS In this secondary analysis of a multicentre randomised controlled trial of early CTCA in intermediate-risk patients with suspected acute coronary syndrome, C-statistics and performance metrics (using the predefined cut-offs) of clinical decision aids and CTCA, alone and then in combination, for the index hospital diagnosis of acute coronary syndrome and for 30-day coronary revascularisation were assessed in those who underwent CTCA and had complete data. RESULTS Among 699 patients, 358 (51%) had an index hospital diagnosis of acute coronary syndrome, for which the C-statistic was higher for CTCA (0.80), followed by the T-MACS model (0.78), the HEART score (0.74) and the GRACE score (0.60). The negative predictive value was higher for the absence of coronary artery disease on CTCA (0.90) or a T-MACS estimate of <0.05 (0.83) than a HEART score of <4 (0.81) and a GRACE score of <109 (0.55). For 30-day coronary revascularisation, CTCA had the greatest C-statistic (0.80) with a negative predictive value of 0.96 and 0.92 in the absence of coronary artery disease and obstructive coronary artery disease, respectively. The combination of the T-MACS estimates and the CTCA findings was most discriminative for the index hospital diagnosis of acute coronary syndrome (C-statistic, 0.88) and predictive of 30-day coronary revascularisation (C-statistic, 0.85). No patients with a T-MACS estimate of <0.05 and normal coronary arteries had acute coronary syndrome during index hospitalisation or underwent coronary revascularisation within 30 days. CONCLUSIONS In intermediate-risk patients with suspected acute coronary syndrome, the T-MACS model combined with CTCA improved discrimination of the index hospital diagnosis of acute coronary syndrome and prediction of 30-day coronary revascularisation. TRIAL REGISTRATION NUMBER NCT02284191.
Collapse
Affiliation(s)
- Kang-Ling Wang
- Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- General Clinical Research Center, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Caelan Taggart
- Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
- Department of Cardiology, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Michael McDermott
- Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Rachel O'Brien
- EMERGE (Emergency Medicine Research Group, Edinburgh), Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Katherine Oatey
- Edinburgh Clinical Trials Unit, University of Edinburgh, Edinburgh, UK
| | - Liza Keating
- Department of Emergency Medicine, Royal Berkshire NHS Foundation Trust, Reading, UK
| | - Robert F Storey
- Division of Clinical Medicine, University of Sheffield, Sheffield, UK
- NIHR Sheffield Biomedical Research Centre, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Dirk Felmeden
- Department of Cardiology, Torbay and South Devon NHS Foundation Trust, Torquay, UK
| | - Nick Curzen
- Faculty of Medicine, University of Southampton, Southampton, UK
- Department of Cardiology, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Attila Kardos
- TCRG (Translational Cardiovascular Research Group), Milton Keynes University Hospital NHS Foundation Trust, Milton Keynes, UK
| | - Carl Roobottom
- Department of Radiology, University Hospitals Plymouth NHS Trust, Plymouth, UK
| | - Jason Smith
- Emergency Department, University Hospitals Plymouth NHS Trust, Plymouth, UK
| | - Steve Goodacre
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - David E Newby
- Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Alasdair J Gray
- EMERGE (Emergency Medicine Research Group, Edinburgh), Royal Infirmary of Edinburgh, Edinburgh, UK
- Usher Institute, University of Edinburgh, Edinburgh, UK
| |
Collapse
|
8
|
Roos A, Edgren G. High-Sensitivity Cardiac Troponins in Patients With Chest Pain and Treatment With Oral Antineoplastic Agents Associated With Cardiovascular Toxicity. Am J Med 2024; 137:597-607.e5. [PMID: 38490307 DOI: 10.1016/j.amjmed.2024.03.005] [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] [Received: 11/28/2023] [Revised: 01/20/2024] [Accepted: 03/06/2024] [Indexed: 03/17/2024]
Abstract
BACKGROUND Knowledge is limited on the clinical implications of high-sensitivity cardiac troponin (hs-cTn) measurements in patients treated with oral antineoplastic agents associated with cardiovascular side effects. This study investigated the diagnostic performance of hs-cTnT for myocardial infarction. METHODS Among all visits to 7 different emergency departments (EDs) from December 9, 2010 to August 31, 2017, we included visits by patients presenting with chest pain who had ≥1 hs-cTnT measured. Patients treated with oral antineoplastic agents associated with cardiovascular toxicity were identified. Logistic regression models were used to estimate the performance of hs-cTnT for diagnosing myocardial infarction. RESULTS We identified 214,165 visits, of which 2695 (1.3%) occurred in patients with oral antineoplastic treatment associated with cardiovascular toxicity. Treatment was associated with a higher myocardial infarction incidence (8.2% vs 5.7%), but the overall diagnostic accuracy for a myocardial infarction was lower in patients with versus without treatment, paralleled by a lower specificity and PPV with the 0 h hs-cTnT rule-in cut-off of 52 ng/L (92.6% [95% CI: 91.6-93.6] vs 96.8% [95% CI: 96.8-96.9], and 42.8 [95% CI: 37.4-48.2] vs 49.5 [95% CI: 48.6-50.4], respectively). The majority (72%) of patients with treatment were assigned to an intermediate risk group, in whom the risk of myocardial infarction was reduced by 29% (OR 0.71, 95% CI: 0.57-0.89). CONCLUSIONS Diagnostic accuracy of hs-cTnT for myocardial infarction is reduced among patients on treatment with oral antineoplastic agents associated with cardiovascular toxicity. Most patients would be assigned to an intermediate risk group, in whom only 4% will have a final myocardial infarction diagnosis.
Collapse
Affiliation(s)
- Andreas Roos
- Department of Emergency and Reparative Medicine, Karolinska University Hospital, Huddinge, Stockholm, Sweden; Department of Medicine, Clinical Epidemiology Division, Karolinska Institutet, Solna, Stockholm, Sweden.
| | - Gustaf Edgren
- Department of Medicine, Clinical Epidemiology Division, Karolinska Institutet, Solna, Stockholm, Sweden; Department of Cardiology, Södersjukhuset, Stockholm, Sweden
| |
Collapse
|
9
|
Goraya SR, O'Hare C, Grace KA, Schaeffer WJ, Hyder SN, Barnes GD, Greineder CF. Optimizing Use of High-Sensitivity Troponin for Risk-Stratification of Acute Pulmonary Embolism. Thromb Haemost 2024. [PMID: 38788767 DOI: 10.1055/s-0044-1786820] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/26/2024]
Abstract
BACKGROUND High-sensitivity troponin T (HS-TnT) may improve risk-stratification in hemodynamically stable acute pulmonary embolism (PE), but an optimal strategy for combining this biomarker with clinical risk-stratification tools has not been determined. STUDY HYPOTHESIS We hypothesized that different HS-TnT cutoff values may be optimal for identifying (1) low-risk patients who may be eligible for outpatient management and (2) patients at increased risk of clinical deterioration who might benefit from advanced PE therapies. METHODS Retrospective analysis of hemodynamically stable patients in the University of Michigan acute ED-PE registry with available HS-TnT values. Primary and secondary outcomes were 30-day mortality and need for intensive care unit-level care. Receiver operating characteristic curves were used to determine optimal HS-TnT cutoffs in the entire cohort, and for those at higher risk based on the simplified Pulmonary Embolism Severity Index (PESI) or imaging findings. RESULTS The optimal HS-TnT cutoff in the full cohort, 12 pg/mL, was significantly associated with 30-day mortality (odds ratio [OR]: 3.94, 95% confidence interval [CI]: 1.48-10.50) and remained a significant predictor after adjusting for the simplified PESI (sPESI) score and serum creatinine (adjusted OR: 3.05, 95% CI: 1.11-8.38). A HS-TnT cutoff of 87 pg/mL was associated with 30-day mortality (OR: 5.01, 95% CI: 2.08-12.06) in patients with sPESI ≥1 or right ventricular dysfunction. CONCLUSION In this retrospective, single-center study of acute PE patients, we identified distinct optimal HS-TnT values for different clinical uses-a lower cutoff, which identified low-risk patients even in the absence of other risk-stratification methods, and a higher cutoff, which was strongly associated with adverse outcomes in patients at increased risk.
Collapse
Affiliation(s)
- Sayhaan R Goraya
- University of Michigan Medical School, Ann Arbor, Michigan, United States
| | - Connor O'Hare
- Department of Emergency Medicine, University of Michigan, Ann Arbor, Michigan, United States
| | - Kelsey A Grace
- Department of Emergency Medicine, University of Michigan, Ann Arbor, Michigan, United States
| | - William J Schaeffer
- Department of Emergency Medicine, University of Michigan, Ann Arbor, Michigan, United States
| | - S Nabeel Hyder
- Division of Cardiovascular Medicine, Department of Internal Medicine, Frankel Cardiovascular Center, University of Michigan, Ann Arbor, Michigan, United States
| | - Geoffrey D Barnes
- University of Michigan Medical School, Ann Arbor, Michigan, United States
- Division of Cardiovascular Medicine, Department of Internal Medicine, Frankel Cardiovascular Center, University of Michigan, Ann Arbor, Michigan, United States
| | - Colin F Greineder
- University of Michigan Medical School, Ann Arbor, Michigan, United States
- Department of Emergency Medicine, University of Michigan, Ann Arbor, Michigan, United States
- Department of Pharmacology, University of Michigan, Ann Arbor, Michigan, United States
- BioInterfaces Institute, University of Michigan, Ann Arbor, Michigan, United States
| |
Collapse
|
10
|
Millard MJ, Ashburn NP, Snavely AC, Hashemian T, Supples M, Allen B, Christenson R, Madsen T, McCord J, Mumma B, Stopyra J, Wilkerson RG, Mahler SA. European Society of Cardiology 0/1-hour algorithm (high-sensitivity cardiac troponin T) performance across distinct age groups. Heart 2024; 110:838-845. [PMID: 38471727 DOI: 10.1136/heartjnl-2023-323621] [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] [Received: 10/27/2023] [Accepted: 02/06/2024] [Indexed: 03/14/2024] Open
Abstract
BACKGROUND To determine if the European Society of Cardiology 0/1-hour (ESC 0/1-h) algorithm with high-sensitivity cardiac troponin T (hs-cTnT) meets the ≥99% negative predictive value (NPV) safety threshold for 30-day cardiac death or myocardial infarction (MI) in older, middle-aged and young subgroups. METHODS We conducted a subgroup analysis of adult emergency department patients with chest pain prospectively enrolled from eight US sites (January 2017 to September 2018). Patients were stratified into rule-out, observation and rule-in zones using the hs-cTnT ESC 0/1-h algorithm and classified as older (≥65 years), middle aged (46-64 years) or young (21-45 years). Patients had 0-hour and 1-hour hs-cTnT measures (Roche Diagnostics) and a History, ECG, Age, Risk factor and Troponin (HEART) score. Fisher's exact tests compared rule-out and 30-day cardiac death or MI rates between ages. NPVs with 95% CIs were calculated for the ESC 0/1-h algorithm with and without the HEART score. RESULTS Of 1430 participants, 26.9% (385/1430) were older, 57.4% (821/1430) middle aged and 15.7% (224/1430) young. Cardiac death or MI at 30 days occurred in 12.8% (183/1430). ESC 0/1-h algorithm ruled out 35.6% (137/385) of older, 62.1% (510/821) of middle-aged and 79.9% of (179/224) young patients (p<0.001). NPV for 30-day cardiac death or MI was 97.1% (95% CI 92.7% to 99.2%) among older patients, 98.4% (95% CI 96.9% to 99.3%) in middle-aged patients and 99.4% (95% CI 96.9% to 100%) among young patients. Adding a HEART score increased NPV to 100% (95% CI 87.7% to 100%) for older, 99.2% (95% CI 97.2% to 99.9%) for middle-aged and 99.4% (95% CI 96.6% to 100%) for young patients. CONCLUSIONS In older and middle-aged adults, the hs-cTnT ESC 0/1-h algorithm was unable to reach a 99% NPV for 30-day cardiac death or MI unless combined with a HEART score. TRIAL REGISTRATION NUMBER NCT02984436.
Collapse
Affiliation(s)
- Marissa J Millard
- Department of Emergency Medicine, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| | - Nicklaus P Ashburn
- Department of Emergency Medicine, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| | - Anna C Snavely
- Department of Emergency Medicine, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
- Department of Biostatistics and Data Science, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| | - Tara Hashemian
- Department of Emergency Medicine, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| | - Michael Supples
- Department of Emergency Medicine, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| | - Brandon Allen
- Department of Emergency Medicine, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Robert Christenson
- Department of Pathology, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Troy Madsen
- Department of Emergency Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - James McCord
- Department of Cardiology, Henry Ford Hospital, Detroit, Michigan, USA
| | - Bryn Mumma
- Department of Emergency Medicine, University of California Davis School of Medicine, Sacramento, California, USA
| | - Jason Stopyra
- Department of Emergency Medicine, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| | - Richard Gentry Wilkerson
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Simon A Mahler
- Department of Emergency Medicine, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
- Department of Epidemiology and Prevention, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
- Department of Implementation Science, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| |
Collapse
|
11
|
Pickering JW, Young JM, George PM, Watson AS, Aldous SJ, Verryt T, Troughton RW, Pemberton CJ, Richards AM, Cullen LA, Apple FS, Than MP. Derivation and Validation of Thresholds Using Synthetic Data Methods for Single-Test Screening of Emergency Department Patients with Possible Acute Myocardial Infarction Using a Point-of-Care Troponin Assay. J Appl Lab Med 2024; 9:526-539. [PMID: 38442340 DOI: 10.1093/jalm/jfae001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2023] [Accepted: 11/17/2023] [Indexed: 03/07/2024]
Abstract
BACKGROUND Single-sample (screening) rule-out of acute myocardial infarction (AMI) with troponin requires derivation of a single-test screening threshold. In data sets with small event numbers, the lowest one or two concentrations of myocardial infarction (MI) patients dictate the threshold. This is not optimal. We aimed to demonstrate a process incorporating both real and synthetic data for deriving such thresholds using a novel pre-production high-precision point-of-care assay. METHODS cTnI concentrations were measured from thawed plasma using the Troponin I Next (TnI-Nx) assay (i-STAT; Abbott) in adults on arrival to the emergency department with symptoms suggestive of AMI. The primary outcome was an AMI or cardiac death within 30 days. We used internal-external validation with synthetic data production based on clinical and demographic data, plus the measured TnI-Nx concentration, to derive and validate decision thresholds for TnI-Nx. The target low-risk threshold was a sensitivity of 99% and a high-risk threshold specificity of >95%. RESULTS In total, 1356 patients were included, of whom 191 (14.1%) had the primary outcome. A total of 500 synthetic data sets were constructed. The mean low-risk threshold was determined to be 5 ng/L. This categorized 38% (95% CI, 6%-68%) to low-risk with a sensitivity of 99.0% (95% CI, 98.6%-99.5%) and a negative predictive value of 99.4% (95% CI, 97.6%-99.8%). A similarly derived high-risk threshold of 25 ng/L had a specificity of 95.0% (95% CI, 94.8%-95.1%) and a positive predictive value of 74.8% (95% CI, 71.5%-78.0%). CONCLUSIONS With the TnI-Nx assay, we successfully demonstrated an approach using synthetic data generation to derive low-risk thresholds for safe and effective screening.
Collapse
Affiliation(s)
- John W Pickering
- Department of Emergency Medicine, Christchurch Hospital, Christchurch, New Zealand
- Christchurch Heart Institute, University of Otago Christchurch, Christchurch, New Zealand
| | - Joanna M Young
- Department of Emergency Medicine, Christchurch Hospital, Christchurch, New Zealand
| | | | - Antony S Watson
- Department of Emergency Medicine, Christchurch Hospital, Christchurch, New Zealand
| | - Sally J Aldous
- Cardiology Department, Christchurch Hospital, Christchurch, New Zealand
| | - Toby Verryt
- Cardiology Department, Christchurch Hospital, Christchurch, New Zealand
| | - Richard W Troughton
- Christchurch Heart Institute, University of Otago Christchurch, Christchurch, New Zealand
- Cardiology Department, Christchurch Hospital, Christchurch, New Zealand
| | | | - A Mark Richards
- Christchurch Heart Institute, University of Otago Christchurch, Christchurch, New Zealand
- Cardiovascular Research Institute, National University of Singapore, Singapore
| | - Louise A Cullen
- Emergency Department, Royal Brisbane and Women's Hospital, Brisbane, Australia
| | - Fred S Apple
- Department of Laboratory Medicine and Pathology, Hennepin County Medical Center of Hennepin Healthcare and University of Minnesota Minneapolis, Minneapolis, MN, United States
| | - Martin P Than
- Department of Emergency Medicine, Christchurch Hospital, Christchurch, New Zealand
| |
Collapse
|
12
|
Boeddinghaus J, Doudesis D, Lopez-Ayala P, Lee KK, Koechlin L, Wildi K, Nestelberger T, Borer R, Miró Ò, Martin-Sanchez FJ, Strebel I, Rubini Giménez M, Keller DI, Christ M, Bularga A, Li Z, Ferry AV, Tuck C, Anand A, Gray A, Mills NL, Mueller C. Machine Learning for Myocardial Infarction Compared With Guideline-Recommended Diagnostic Pathways. Circulation 2024; 149:1090-1101. [PMID: 38344871 DOI: 10.1161/circulationaha.123.066917] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Accepted: 01/16/2024] [Indexed: 02/29/2024]
Abstract
BACKGROUND Collaboration for the Diagnosis and Evaluation of Acute Coronary Syndrome (CoDE-ACS) is a validated clinical decision support tool that uses machine learning with or without serial cardiac troponin measurements at a flexible time point to calculate the probability of myocardial infarction (MI). How CoDE-ACS performs at different time points for serial measurement and compares with guideline-recommended diagnostic pathways that rely on fixed thresholds and time points is uncertain. METHODS Patients with possible MI without ST-segment-elevation were enrolled at 12 sites in 5 countries and underwent serial high-sensitivity cardiac troponin I concentration measurement at 0, 1, and 2 hours. Diagnostic performance of the CoDE-ACS model at each time point was determined for index type 1 MI and the effectiveness of previously validated low- and high-probability scores compared with guideline-recommended European Society of Cardiology (ESC) 0/1-hour, ESC 0/2-hour, and High-STEACS (High-Sensitivity Troponin in the Evaluation of Patients With Suspected Acute Coronary Syndrome) pathways. RESULTS In total, 4105 patients (mean age, 61 years [interquartile range, 50-74]; 32% women) were included, among whom 575 (14%) had type 1 MI. At presentation, CoDE-ACS identified 56% of patients as low probability, with a negative predictive value and sensitivity of 99.7% (95% CI, 99.5%-99.9%) and 99.0% (98.6%-99.2%), ruling out more patients than the ESC 0-hour and High-STEACS (25% and 35%) pathways. Incorporating a second cardiac troponin measurement, CoDE-ACS identified 65% or 68% of patients as low probability at 1 or 2 hours, for an identical negative predictive value of 99.7% (99.5%-99.9%); 19% or 18% as high probability, with a positive predictive value of 64.9% (63.5%-66.4%) and 68.8% (67.3%-70.1%); and 16% or 14% as intermediate probability. In comparison, after serial measurements, the ESC 0/1-hour, ESC 0/2-hour, and High-STEACS pathways identified 49%, 53%, and 71% of patients as low risk, with a negative predictive value of 100% (99.9%-100%), 100% (99.9%-100%), and 99.7% (99.5%-99.8%); and 20%, 19%, or 29% as high risk, with a positive predictive value of 61.5% (60.0%-63.0%), 65.8% (64.3%-67.2%), and 48.3% (46.8%-49.8%), resulting in 31%, 28%, or 0%, who require further observation in the emergency department, respectively. CONCLUSIONS CoDE-ACS performs consistently irrespective of the timing of serial cardiac troponin measurement, identifying more patients as low probability with comparable performance to guideline-recommended pathways for MI. Whether care guided by probabilities can improve the early diagnosis of MI requires prospective evaluation. REGISTRATION URL: https://www.clinicaltrials.gov; Unique identifier: NCT00470587.
Collapse
Affiliation(s)
- Jasper Boeddinghaus
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology (J.B., P.L.-A., L.K., K.W., T.N., R.B., I.S., M.R.G., C.M.), University Hospital Basel, University of Basel, Switzerland
- BHF/University Centre for Cardiovascular Science (J.B., D.D., K.K.L., A.B., Z.L., A.V.F., C.T., A.A., N.L.M.), University of Edinburgh, UK
| | - Dimitrios Doudesis
- BHF/University Centre for Cardiovascular Science (J.B., D.D., K.K.L., A.B., Z.L., A.V.F., C.T., A.A., N.L.M.), University of Edinburgh, UK
- Usher Institute (D.D., K.K.L., A.G., N.L.M.), University of Edinburgh, UK
| | - Pedro Lopez-Ayala
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology (J.B., P.L.-A., L.K., K.W., T.N., R.B., I.S., M.R.G., C.M.), University Hospital Basel, University of Basel, Switzerland
| | - Kuan Ken Lee
- BHF/University Centre for Cardiovascular Science (J.B., D.D., K.K.L., A.B., Z.L., A.V.F., C.T., A.A., N.L.M.), University of Edinburgh, UK
- Usher Institute (D.D., K.K.L., A.G., N.L.M.), University of Edinburgh, UK
| | - Luca Koechlin
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology (J.B., P.L.-A., L.K., K.W., T.N., R.B., I.S., M.R.G., C.M.), University Hospital Basel, University of Basel, Switzerland
- Departments of Cardiac Surgery (L.K.), University Hospital Basel, University of Basel, Switzerland
| | - Karin Wildi
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology (J.B., P.L.-A., L.K., K.W., T.N., R.B., I.S., M.R.G., C.M.), University Hospital Basel, University of Basel, Switzerland
- Intensive Care (K.W.), University Hospital Basel, University of Basel, Switzerland
| | - Thomas Nestelberger
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology (J.B., P.L.-A., L.K., K.W., T.N., R.B., I.S., M.R.G., C.M.), University Hospital Basel, University of Basel, Switzerland
| | - Raphael Borer
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology (J.B., P.L.-A., L.K., K.W., T.N., R.B., I.S., M.R.G., C.M.), University Hospital Basel, University of Basel, Switzerland
| | - Òscar Miró
- Emergency Department, Hospital Clinic, Barcelona, Catalonia, Spain (Ò.M.)
| | | | - Ivo Strebel
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology (J.B., P.L.-A., L.K., K.W., T.N., R.B., I.S., M.R.G., C.M.), University Hospital Basel, University of Basel, Switzerland
| | - Maria Rubini Giménez
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology (J.B., P.L.-A., L.K., K.W., T.N., R.B., I.S., M.R.G., C.M.), University Hospital Basel, University of Basel, Switzerland
| | - Dagmar I Keller
- Emergency Department, University Hospital Zurich, Switzerland (D.I.K.)
| | - Michael Christ
- Emergency Department, Kantonsspital Luzern, Switzerland (M.C.)
| | - Anda Bularga
- BHF/University Centre for Cardiovascular Science (J.B., D.D., K.K.L., A.B., Z.L., A.V.F., C.T., A.A., N.L.M.), University of Edinburgh, UK
| | - Ziwen Li
- BHF/University Centre for Cardiovascular Science (J.B., D.D., K.K.L., A.B., Z.L., A.V.F., C.T., A.A., N.L.M.), University of Edinburgh, UK
| | - Amy V Ferry
- BHF/University Centre for Cardiovascular Science (J.B., D.D., K.K.L., A.B., Z.L., A.V.F., C.T., A.A., N.L.M.), University of Edinburgh, UK
| | - Chris Tuck
- BHF/University Centre for Cardiovascular Science (J.B., D.D., K.K.L., A.B., Z.L., A.V.F., C.T., A.A., N.L.M.), University of Edinburgh, UK
| | - Atul Anand
- BHF/University Centre for Cardiovascular Science (J.B., D.D., K.K.L., A.B., Z.L., A.V.F., C.T., A.A., N.L.M.), University of Edinburgh, UK
| | - Alasdair Gray
- Usher Institute (D.D., K.K.L., A.G., N.L.M.), University of Edinburgh, UK
- Emergency Medicine Research Group Edinburgh, Royal Infirmary of Edinburgh, UK (A.G.)
| | - Nicholas L Mills
- BHF/University Centre for Cardiovascular Science (J.B., D.D., K.K.L., A.B., Z.L., A.V.F., C.T., A.A., N.L.M.), University of Edinburgh, UK
- Usher Institute (D.D., K.K.L., A.G., N.L.M.), University of Edinburgh, UK
| | - Christian Mueller
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology (J.B., P.L.-A., L.K., K.W., T.N., R.B., I.S., M.R.G., C.M.), University Hospital Basel, University of Basel, Switzerland
| |
Collapse
|
13
|
Supples MW, Snavely AC, Ashburn NP, Allen BR, Christenson RH, Nowak R, Wilkerson RG, Mumma BE, Madsen T, Stopyra JP, Mahler SA. Performance of the 0/2-hour high-sensitivity cardiac troponin T diagnostic protocol in a multisite United States cohort. Acad Emerg Med 2024; 31:239-248. [PMID: 37925594 DOI: 10.1111/acem.14827] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Revised: 10/04/2023] [Accepted: 10/13/2023] [Indexed: 11/06/2023]
Abstract
BACKGROUND The diagnostic performance of the high-sensitivity troponin T (hs-cTnT) 0/2-h algorithm is unclear among U.S. emergency department (ED) patients with acute chest pain. METHODS A preplanned subgroup analysis of the STOP-CP cohort study was conducted. Participants with 0- and 2-h hs-cTnT measures prospectively enrolled at eight U.S. EDs from January 2017 to September 2018 were stratified into rule-out, observation, and rule-in zones using the hs-cTnT 0/2-h algorithm alone and combined with the history, electrocardiogram, age, and risk factor (HEAR) score. The primary outcome was adjudicated 30-day cardiac death or myocardial infarction (CDMI). The sensitivity and negative predictive value (NPV) of the 0/2-h rule-out zone and specificity and positive predictive value (PPV) of the rule-in zone for 30-day CDMI were calculated. RESULTS Of the 1307 patients accrued, 53.6% (700/1307) were male and 58.6% (762/1307) were White, with a mean ± SD age of 57.5 ± 12.7 years. At 30 days, CDMI occurred in 12.9% (168/1307) of participants. The 0/2-h algorithm ruled out 61.4% (802/1307) of patients. Among rule-out patients, 1.9% (15/802) experienced 30-day CDMI, resulting in a sensitivity of 91.1% (95% confidence interval [CI] 85.7%-94.9%) and NPV of 98.1% (95% CI 96.9%-98.9%). The 0/2-h algorithm ruled in 12.4% (162/1307) patients of whom 61.7% (100/162) experienced 30-day CDMI. The rule-in zone specificity was 94.6% (95% CI 93.1%-95.8%) and PPV was 61.7% (95% CI 53.8%-69.2%) for 30-day CDMI. The 0/2-h algorithm combined with HEAR score ruled out 30.7% (401/1307) of patients with a sensitivity and NPV for 30-day CDMI of 98.2% (95% CI 94.9%-99.6%) and 99.3% (95% CI 97.8%-99.8%), respectively. CONCLUSIONS The hs-cTnT 0/2-h algorithm ruled out most patients. With NPV of <99% for 30-day CDMI, the hs-cTnT 0/2-h algorithm, many emergency physicians may not consider it safe to use for U.S. ED patients. When combined with a low-risk HEAR score, NPV was >99% for 30-day CDMI at the cost of reduced efficacy.
Collapse
Affiliation(s)
- Michael W Supples
- Department of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Anna C Snavely
- Department of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
- Department of Biostatistics and Data Science, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Nicklaus P Ashburn
- Department of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
- Section on Cardiovascular Medicine, Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Brandon R Allen
- Department of Emergency Medicine, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Robert H Christenson
- Department of Pathology, University of Maryland School of Medicine, Baltimore, Massachusetts, USA
| | - Richard Nowak
- Department of Emergency Medicine, Henry Ford Health System, Detroit, Michigan, USA
| | - R Gentry Wilkerson
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, Massachusetts, USA
| | - Bryn E Mumma
- Department of Emergency Medicine, University of California Davis School of Medicine, Sacramento, California, USA
| | - Troy Madsen
- Department of Emergency Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Jason P Stopyra
- Department of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Simon A Mahler
- Department of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
- Department of Epidemiology and Prevention, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
- Department of Implementation Science, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| |
Collapse
|
14
|
Karády J, Mayrhofer T, Januzzi JL, Udelson JE, Fleg JL, Merkely B, Lu MT, Peacock WF, Nagurney JT, Koenig W, Ferencik M, Hoffmann U. Agreement among high-sensitivity cardiac troponin assays and non-invasive testing, clinical outcomes, and quality-of-care outcomes based on the 2020 European Society of Cardiology Guidelines. EUROPEAN HEART JOURNAL. ACUTE CARDIOVASCULAR CARE 2024; 13:15-23. [PMID: 38001050 PMCID: PMC10853690 DOI: 10.1093/ehjacc/zuad146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Revised: 10/25/2023] [Accepted: 11/08/2023] [Indexed: 11/26/2023]
Abstract
AIMS Quality-of-care and safety of patients with suspected acute coronary syndrome (ACS) would benefit if management was independent of which high-sensitivity cardiac troponin (hs-cTn) assay was used for risk stratification. We aimed to determine the concordance of hs-cTn assays to risk-stratify patients with suspected ACS according to the European Society of Cardiology (ESC) 2020 Guidelines. METHODS AND RESULTS Blood samples were obtained at arrival and at 2 h from patients with suspected ACS using four hs-cTn assays. The patients were classified into rule-out/observe/rule-in strata based on the ESC 2020 Guidelines. Concordance was determined among the assays for rule-out/observe/rule-in strata. The prevalences of significant underlying disease (≥50% stenosis on coronary computed tomography or inducible myocardial ischaemia on stress testing) and adjudicated ACS, plus quality-of-care outcomes, were compared. Among 238 patients (52.7 ± 8.0 years; 40.3% female), the overall concordance across assays to classify patients into rule-out/observe/rule-in strata was 74.0% (176/238). Platforms significantly differed for rule-out (89.9 vs. 76.5 vs. 78.6 vs. 86.6%, P < 0.001) and observe strata (6.7 vs. 20.6 vs. 17.7 vs. 9.2%, P < 0.001), but not for rule-in strata (3.4 vs. 2.9 vs. 3.8 vs. 4.2%, P = 0.62). Among patients in ruled-out strata, 19.1-21.6% had significant underlying disease and 3.3-4.2% had ACS. The predicted disposition of patients and cost-of-care differed across the assays (all P < 0.001). When compared with observed strata, conventional troponin-based management and predicted quality-of-care outcomes significantly improved with hs-cTn-based strategies (direct discharge: 21.0 vs. 80.3-90.8%; cost-of-care: $3889 ± 4833 vs. $2578 ± 2896-2894 ± 4371, all P < 0.001). CONCLUSION Among individuals with suspected ACS, patient management may differ depending on which hs-cTn assay is utilized. More data are needed regarding the implications of inter-assay differences. TRAIL REGISTRATION NCT01084239.
Collapse
Affiliation(s)
- Júlia Karády
- Cardiovascular Imaging Research Center, Massachusetts General Hospital, Harvard Medical School, 165 Cambridge St Suite 400, Boston, MA 02114, USA
- Heart and Vascular Center, Semmelweis University, 9-11 Gaál József Street, Budapest 1122, Hungary
| | - Thomas Mayrhofer
- Cardiovascular Imaging Research Center, Massachusetts General Hospital, Harvard Medical School, 165 Cambridge St Suite 400, Boston, MA 02114, USA
- School of Business Studies, Stralsund University of Applied Sciences, Stralsund, Germany
| | - James L Januzzi
- Division of Cardiology, Massachusetts General Hospital, Boston, MA, USA
| | - James E Udelson
- Department of Medicine, Tufts Medical Center, Boston, MA, USA
| | - Jerome L Fleg
- Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, Bethesda, MD, USA
| | - Bela Merkely
- Heart and Vascular Center, Semmelweis University, 9-11 Gaál József Street, Budapest 1122, Hungary
| | - Michael T Lu
- Cardiovascular Imaging Research Center, Massachusetts General Hospital, Harvard Medical School, 165 Cambridge St Suite 400, Boston, MA 02114, USA
| | - William F Peacock
- Department of Emergency Medicine, Baylor College of Medicine, Boston, MA, USA
| | - John T Nagurney
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Wolfgang Koenig
- Institute of Epidemiology and Medical Biometry, University of Ulm, Ulm, Germany
- Deutsches Herzzentrum München, Technische Universität München, Munich, Germany
- DZHK (German Centre for Cardiovascular Research), Partner Site Munich Heart Alliance, Munich, Germany
| | - Maros Ferencik
- Cardiovascular Imaging Research Center, Massachusetts General Hospital, Harvard Medical School, 165 Cambridge St Suite 400, Boston, MA 02114, USA
- Knight Cardiovascular Institute, Oregon Health & Science University, Portland, OR, USA
| | - Udo Hoffmann
- Cardiovascular Imaging Research Center, Massachusetts General Hospital, Harvard Medical School, 165 Cambridge St Suite 400, Boston, MA 02114, USA
- Innovative Imaging Consulting LLC, 163 Longfellow Rd., Waltham, MA 02453, USA
| |
Collapse
|
15
|
Byrne RA, Rossello X, Coughlan JJ, Barbato E, Berry C, Chieffo A, Claeys MJ, Dan GA, Dweck MR, Galbraith M, Gilard M, Hinterbuchner L, Jankowska EA, Jüni P, Kimura T, Kunadian V, Leosdottir M, Lorusso R, Pedretti RFE, Rigopoulos AG, Rubini Gimenez M, Thiele H, Vranckx P, Wassmann S, Wenger NK, Ibanez B. 2023 ESC Guidelines for the management of acute coronary syndromes. EUROPEAN HEART JOURNAL. ACUTE CARDIOVASCULAR CARE 2024; 13:55-161. [PMID: 37740496 DOI: 10.1093/ehjacc/zuad107] [Citation(s) in RCA: 32] [Impact Index Per Article: 32.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/24/2023]
|
16
|
Koechlin L, Boeddinghaus J, Lopez-Ayala P, Wildi K, Nestelberger T, Wussler D, Guzman Tacla CA, Holder T, Muench-Gerber T, Glaeser J, Sanchez AY, Miró Ò, Martin-Sanchez FJ, Kawecki D, Buergler F, Buser A, Huré G, Giménez MR, Keller DI, Christ M, Mueller C. External validation of the 0/1h-algorithm and derivation of a 0/2h-algorithm using a new point-of-care Hs-cTnI assay. Am Heart J 2024; 268:104-113. [PMID: 38042459 DOI: 10.1016/j.ahj.2023.11.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Revised: 11/14/2023] [Accepted: 11/18/2023] [Indexed: 12/04/2023]
Abstract
BACKGROUND The high-sensitivity cardiac troponin (hs-cTn) I point-of-care (POC) hs-cTnI-PATHFAST assay has recently become clinically available. METHODS We aimed to externally validate the hs-cTnI-PATHFAST 0/1h-algorithm recently developed for the early diagnosis of non-ST-segment-elevation myocardial infarction (NSTEMI) and derive and validate a 0/2-algorithm in patients presenting to the emergency department with acute chest discomfort included in a multicenter diagnostic study. Two independent cardiologists centrally adjudicated the final diagnoses using all the clinical and study-specific information available including serial measurements of hs-cTnI-Architect. RESULTS Among 1,532 patients (median age 60 years, 33% [n = 501] women), NSTEMI was the final diagnosis in 13%. External validation of the hs-cTnI-PATHFAST 0/1h-algorithm showed very high negative predictive value (NPV; 100% [95%CI, 99.5%-100%]) and sensitivity 100% (95%CI, 98.2%-100%) for rule-out of NSTEMI. Positive predictive value (PPV) and specificity for rule-in of NSTEMI were high (74.9% [95%CI, 68.3%-80.5%] and 96.4% [95%CI, 95.2%-97.3%], respectively). Among 1,207 patients (median age 61 years, 32% [n = 391] women) available for the derivation (n = 848) and validation (n = 359) of the hs-cTnI-PATHFAST 0/2h-algorithm, a 0h-concentration <3 ng/L or a 0h-concentration <4 ng/L with a 2h-delta <4ng/L ruled-out NSTEMI in 52% of patients with a NPV of 100% (95%CI, 98-100) and sensitivity of 100% (95%CI, 92.9%-100%) in the validation cohort. A 0h-concentration ≥90ng/L or a 2h-delta ≥ 55ng/L ruled-in 38 patients (11%): PPV 81.6% (95%CI, 66.6-90.8), specificity 97.7% (95%CI, 95.4-98.9%). CONCLUSIONS The POC hs-cTnI-PATHFAST assay allows rapid and effective rule-out and rule-in of NSTEMI using both a 0/1h- and a 0/2h-algorithm with high NPV/sensitivity for rule-out and high PPV/specificity for rule-in. CLINICAL TRIAL REGISTRATION NCT00470587.
Collapse
Affiliation(s)
- Luca Koechlin
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland; Department of Cardiac Surgery, University Hospital Basel, University of Basel, Switzerland; GREAT network.
| | - Jasper Boeddinghaus
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland; GREAT network; BHF/University Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
| | - Pedro Lopez-Ayala
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland; GREAT network
| | - Karin Wildi
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland; GREAT network; Critical Care Research Group and the University of Queensland, Brisbane, Queensland, Australia
| | - Thomas Nestelberger
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland; GREAT network
| | - Desiree Wussler
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland; GREAT network
| | - Caroline A Guzman Tacla
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland; GREAT network
| | - Timothy Holder
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Tamar Muench-Gerber
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland; GREAT network
| | - Jonas Glaeser
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland; GREAT network
| | - Ana Yufera Sanchez
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland; GREAT network
| | - Òscar Miró
- GREAT network; Emergency Department, Hospital Clinic, Barcelona, Catalonia, Spain
| | | | - Damian Kawecki
- GREAT network; 2nd Department of Cardiology, School of Medicine with the Division of Dentistry in Zabrze, Medical University of Katowice, Zabrze, Poland
| | - Franz Buergler
- Emergency Department, Kantonsspital Liestal, LIestal, Switzerland
| | - Andreas Buser
- Department of hematology and Blood Bank, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Gabrielle Huré
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland; GREAT network
| | - Maria Rubini Giménez
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland; Department of Cardiology, Heart Center Leipzig, University of Leipzig, Leipzig, Germany
| | - Dagmar I Keller
- Emergency Department, University Hospital Zurich, Zurich, Switzerland
| | - Michael Christ
- Emergency Department, Kantonsspital Luzern, Luzern, Switzerland
| | - Christian Mueller
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland; GREAT network.
| |
Collapse
|
17
|
Supples MW, Snavely AC, O'Neill JC, Ashburn NP, Allen BR, Christenson RH, Nowak R, Wilkerson RG, Mumma BE, Madsen T, Stopyra JP, Mahler SA. Sex and race differences in the performance of the European Society of Cardiology 0/1-h algorithm with high-sensitivity troponin T. Clin Cardiol 2024; 47:e24199. [PMID: 38088463 PMCID: PMC10823440 DOI: 10.1002/clc.24199] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Revised: 11/09/2023] [Accepted: 11/15/2023] [Indexed: 02/01/2024] Open
Abstract
The diagnostic performance of the high-sensitivity troponin T (hs-cTnT) European Society of Cardiology (ESC) 0/1-h algorithm in sex and race subgroups of US Emergency Department (ED) patients is unclear. A pre-planned subgroup analysis of the STOP-CP cohort study was conducted. Participants with 0- and 1-h hs-cTnT measures from eight US EDs (1/2017 to 9/2018) were stratified into rule-out, observation, and rule-in zones using the hs-cTnT ESC 0/1 algorithm. The primary outcome was adjudicated 30-day cardiac death or MI. The proportion with the primary outcome in each zone was compared between subgroups with Fisher's exact tests. The negative predictive value (NPV) of the ESC 0/1 rule-out zone for 30-day CDMI was calculated and compared between subgroups using Fisher's exact tests. Of the 1422 patients enrolled, 54.2% (770/1422) were male and 58.1% (826/1422) white with a mean age of 57.6 ± 12.8 years. At 30 days, cardiac death or myocardial infarction (MI) occurred in 12.9% (183/1422) of participants. Among patients stratified to the rule-out zone, 30-day cardiac death or MI occurred in 1.1% (5/436) of women versus 2.1% (8/436) of men (p = .40) and 1.2% (4/331) of non-white patients versus 1.8% (9/490) of white patients (p = .58). The NPV for 30-day cardiac death or MI was similar among women versus men (98.9% [95% confidence interval, CI: 97.3-99.6] vs. 97.9% [95% CI: 95.9-99.1]; p = .40) and among white versus non-white patients (98.8% [95% CI: 96.9-99.7] vs. 98.2% [95% CI: 96.5-99.2]; p = .39). NPVs <99% in each subgroup suggest the hs-cTnT ESC 0/1-h algorithm may not be safe for use in US EDs. Trial Registration: High-Sensitivity Cardiac Troponin T to Optimize Chest Pain Risk Stratification (STOP-CP; ClinicalTrials.gov: NCT02984436; https://clinicaltrials.gov/ct2/show/NCT02984436).
Collapse
Affiliation(s)
- Michael W. Supples
- Department of Emergency MedicineWake Forest School of MedicineWinston‐SalemNorth CarolinaUSA
| | - Anna C. Snavely
- Department of Emergency MedicineWake Forest School of MedicineWinston‐SalemNorth CarolinaUSA
- Department of Biostatistics and Data ScienceWake Forest School of MedicineWinston‐SalemNorth CarolinaUSA
| | - James C. O'Neill
- Department of Emergency MedicineWake Forest School of MedicineWinston‐SalemNorth CarolinaUSA
| | - Nicklaus P. Ashburn
- Department of Emergency MedicineWake Forest School of MedicineWinston‐SalemNorth CarolinaUSA
- Section on Cardiovascular Medicine, Department of Internal MedicineWake Forest School of MedicineWinston‐SalemNorth CarolinaUSA
| | - Brandon R. Allen
- Department of Emergency MedicineUniversity of Florida College of MedicineGainesvilleFloridaUSA
| | - Robert H. Christenson
- Department of PathologyUniversity of Maryland School of MedicineBaltimoreMarylandUSA
| | - Richard Nowak
- Department of Emergency MedicineHenry Ford Health SystemDetroitMichiganUSA
| | - R. Gentry Wilkerson
- Department of Emergency MedicineUniversity of Maryland School of MedicineBaltimoreMarylandUSA
| | - Bryn E. Mumma
- Department of Emergency MedicineUniversity of California Davis School of MedicineSacramentoCaliforniaUSA
| | - Troy Madsen
- Division of Emergency MedicineUniversity of Utah School of MedicineSalt Lake CityUtahUSA
| | - Jason P. Stopyra
- Department of Emergency MedicineWake Forest School of MedicineWinston‐SalemNorth CarolinaUSA
| | - Simon A. Mahler
- Department of Emergency MedicineWake Forest School of MedicineWinston‐SalemNorth CarolinaUSA
- Department of Epidemiology and PreventionWake Forest School of MedicineWinston‐SalemNorth CarolinaUSA
- Department of Implementation ScienceWake Forest School of MedicineWinston‐SalemNorth CarolinaUSA
| |
Collapse
|
18
|
Abstract
Rapid and accurate triage of patients presenting with chest pain to an emergency department (ED) is critical to prevent ED overcrowding and unnecessary resource use in individuals at low risk of acute myocardial infarction (AMI) and to efficiently and effectively guide patients at high risk to definite therapy. The use of biomarkers for rule-out or rule-in of suspected AMI has evolved substantially over the last several decades. Previously well-established biomarkers have been replaced by cardiac troponin (cTn). High-sensitivity cTn (hs-cTn) assays represent the newest generation of cTn assays and offer tremendous advantages, including improved sensitivity and precision. Still, implementation of these assays in the United States lags behind several other areas of the world. Within this educational review, we discuss the evolution of biomarker testing for detection of myocardial injury, address the specifics of hs-cTn assays and their recommended use within triage algorithms, and highlight potential challenges in their use. Ultimately, we focus on implementation strategies for hs-cTn assays, as they are now clearly ready for prime time.
Collapse
Affiliation(s)
| | - L Kristin Newby
- Duke Clinical Research Institute, Durham, North Carolina, USA; ,
- Division of Cardiology, Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| |
Collapse
|
19
|
Liu L, Lewandrowski K. Establishing optimal cutoff values for high-sensitivity cardiac troponin algorithms in risk stratification of acute myocardial infarction. Crit Rev Clin Lab Sci 2024; 61:1-22. [PMID: 37466395 DOI: 10.1080/10408363.2023.2235426] [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: 03/31/2023] [Revised: 06/11/2023] [Accepted: 07/07/2023] [Indexed: 07/20/2023]
Abstract
Acute myocardial infarction (AMI) is a leading cause of mortality globally, highlighting the need for timely and accurate diagnostic strategies. Cardiac troponin has been the biomarker of choice for detecting myocardial injury. A dynamic change in concentrations supports the diagnosis of AMI in the setting of evidence of acute myocardial ischemia. The new generation of high-sensitivity cardiac troponin (hs-cTn) assays has significantly improved analytical sensitivity but at the expense of decreased clinical specificity. As a result, sophisticated algorithms are required to differentiate AMI from non-AMI patients. Establishing optimal hs-cTn cutoffs for these algorithms to rule out and rule in AMI has been the subject of intensive investigations. These efforts have evolved from examining the utility of the hs-cTn 99th percentile upper reference limit, comparing the percentage versus absolute delta thresholds, and evaluating the performance of an early European Society of Cardiology-recommended 3 h algorithm, to the development of accelerated 1 h and 2 h algorithms that combine the admission hs-cTn concentrations and absolute delta cutoffs to rule out and rule in AMI. Specific cutoffs for individual confounding factors such as sex, age, and renal insufficiency have also been investigated. At the same time, concerns such as whether the small delta thresholds exceed the analytical and biological variations of hs-cTn assays and whether the algorithms developed in European study populations fit all other patient cohorts have been raised. In addition, the accelerated algorithms leave a substantial number of patients in a non-diagnostic observation zone. How to properly diagnose patients falling in this zone and those presenting with elevated baseline hs-cTn concentrations due to the presence of confounding factors or comorbidities remain open questions. Here we discuss the developments described above, focusing on criteria and underlying considerations for establishing optimal cutoffs. In-depth analyses are provided on the influence of biological variation, analytical imprecision, local AMI rate, and the timing of presentation on the performance metrics of the accelerated hs-cTn algorithms. Developing diagnostic strategies for patients who remain in the observation zone and those presenting with confounding factors are also reviewed.
Collapse
Affiliation(s)
- Li Liu
- Department of Pathology, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Kent Lewandrowski
- Department of Pathology, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| |
Collapse
|
20
|
Yao H, Cottin Y, Chagué F, Maza M, Bichat F, Zeller M, Putot A. Diagnostic and prognostic impact of new pathophysiology-based categorization of type 1 and type 2 myocardial infarction: data from the French RICO survey. Am Heart J 2023; 266:86-97. [PMID: 37703947 DOI: 10.1016/j.ahj.2023.09.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Revised: 09/03/2023] [Accepted: 09/06/2023] [Indexed: 09/15/2023]
Abstract
BACKGROUND A new classification of type 1 and 2 myocardial infarction (MI) derived from the fourth universal definition of MI (UDMI) has been recently proposed, based on pathophysiology of coronary artery disease (CAD). We assessed the impact of this new MI categorization on epidemiology and outcomes, considering type 1 MI (T1MI) and type 2 MI (T2MI), with and without CAD. METHODS Retrospective study including all consecutive patients hospitalized for an acute MI in a multicenter database (RICO). MI was defined according to current UDMI. Rates and outcomes of T1MI and T2MI were addressed according to the new classification. RESULTS Among the 4,573 patients included in our study, 3,710 patients (81.1%) were initially diagnosed with T1M1 and 863 (18.9%) with T2MI. After reclassification, 96 T2MI patients were moved into the T1MI category. Out of the remaining 767 patients with T2MI, 567 underwent coronary angiography, and were adjudicated as type 2A MI (68.6%) with obstructive CAD, and type 2B MI (31.4%) without obstructive CAD. When compared with T1MI and T2BMI, T2AMI patients had worse in-hospital outcomes, including severe heart failure (P < .001), atrial fibrillation or flutter (P < .001) and severe bleeding (P < .001). Kaplan-Meier 1-year survival curves showed higher all-cause and CV causes mortality in T2AMI patients compared to T1MI and T2BMI (P < .001). In multivariate Cox regression analysis, type of MI was independent predictor of death. CONCLUSION Our large observational multicenter study shows major disparities in mortality according to type of MI and support the relevance of the new MI classification to improve risk classification, taking into account CAD in T2MI. Our findings may help identifying specific phenotypes and considering personalized diagnostic and management strategies.
Collapse
Affiliation(s)
- Hermann Yao
- Cardiology department, University Hospital Center Dijon Bourgogne, Dijon, France; PEC2, EA 7460, UFR Health Sciences, University of Bourgogne Franche Comté, Dijon, France; Abidjan Heart Institute, Côte d'Ivoire.
| | - Yves Cottin
- Cardiology department, University Hospital Center Dijon Bourgogne, Dijon, France
| | - Frédéric Chagué
- Cardiology department, University Hospital Center Dijon Bourgogne, Dijon, France
| | - Maud Maza
- Cardiology department, University Hospital Center Dijon Bourgogne, Dijon, France
| | - Florence Bichat
- Cardiology department, University Hospital Center Dijon Bourgogne, Dijon, France
| | - Marianne Zeller
- Cardiology department, University Hospital Center Dijon Bourgogne, Dijon, France; PEC2, EA 7460, UFR Health Sciences, University of Bourgogne Franche Comté, Dijon, France
| | - Alain Putot
- PEC2, EA 7460, UFR Health Sciences, University of Bourgogne Franche Comté, Dijon, France
| |
Collapse
|
21
|
Zilinyi RS, Fertel BS, Chang BC, Abrukin L, Suh EH, Sayan OR, McCarty M, Stant JA, Chuich T, Smyth ET, Neuberg G, Collins MB, Kirtane AJ, Moses J, Rabbani L. Updating a Healthcare System-wide Clinical Pathway for Managing Chest Pain and Acute Coronary Syndromes. Crit Pathw Cardiol 2023; 22:103-109. [PMID: 37782621 DOI: 10.1097/hpc.0000000000000334] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/04/2023]
Abstract
Clinical pathways are useful tools for conveying and reinforcing best practices to standardize care and optimize patient outcomes across myriad conditions. The NewYork-Presbyterian Healthcare System has utilized a clinical chest pain pathway for more than 20 years to facilitate the timely recognition and management of patients presenting with chest pain syndromes and acute coronary syndromes. This chest pain pathway is regularly updated by an expanding group of key stakeholders, which has extended from the Columbia University Irving Medical Center to encompass the entire regional healthcare system, which includes 8 hospitals. In this 2023 update of the NewYork-Presbyterian clinical chest pain pathway, we present the key changes to the healthcare system-wide clinical chest pain pathway.
Collapse
Affiliation(s)
- Robert S Zilinyi
- From the Division of Cardiology, Department of Medicine, NewYork-Presbyterian Hospital/Columbia University Irving Medical Center, New York, NY
| | - Baruch S Fertel
- Quality and Patient Safety, NewYork-Presbyterian Hospital/Columbia University Irving Medical Center, New York, NY
- Department of Emergency Medicine, NewYork-Presbyterian Hospital/Columbia University Irving Medical Center, New York, NY
| | - Betty C Chang
- Department of Emergency Medicine, NewYork-Presbyterian Hospital/Columbia University Irving Medical Center, New York, NY
| | - Liliya Abrukin
- Department of Emergency Medicine, NewYork-Presbyterian Hospital/Columbia University Irving Medical Center, New York, NY
| | - Edward H Suh
- Department of Emergency Medicine, NewYork-Presbyterian Hospital/Columbia University Irving Medical Center, New York, NY
| | - Osman R Sayan
- Department of Emergency Medicine, NewYork-Presbyterian Hospital/Columbia University Irving Medical Center, New York, NY
| | - Matthew McCarty
- Department of Emergency Medicine, NewYork-Presbyterian Hospital/Weill Cornell Medical Center, New York, NY
| | - Jennifer A Stant
- From the Division of Cardiology, Department of Medicine, NewYork-Presbyterian Hospital/Columbia University Irving Medical Center, New York, NY
| | | | - Emily T Smyth
- Department of Emergency Medicine, NewYork-Presbyterian Hospital/Weill Cornell Medical Center, New York, NY
| | - Gerald Neuberg
- Division of Cardiology, Department of Medicine, NewYork-Presbyterian Hospital/Allen Hospital, New York, NY
| | - Michael B Collins
- From the Division of Cardiology, Department of Medicine, NewYork-Presbyterian Hospital/Columbia University Irving Medical Center, New York, NY
| | - Ajay J Kirtane
- From the Division of Cardiology, Department of Medicine, NewYork-Presbyterian Hospital/Columbia University Irving Medical Center, New York, NY
| | - Jeffrey Moses
- From the Division of Cardiology, Department of Medicine, NewYork-Presbyterian Hospital/Columbia University Irving Medical Center, New York, NY
| | - LeRoy Rabbani
- From the Division of Cardiology, Department of Medicine, NewYork-Presbyterian Hospital/Columbia University Irving Medical Center, New York, NY
| |
Collapse
|
22
|
Thangaraj PM, Khera R. Accelerating chest pain evaluation with machine learning. EUROPEAN HEART JOURNAL. ACUTE CARDIOVASCULAR CARE 2023; 12:753-754. [PMID: 37793075 PMCID: PMC11004857 DOI: 10.1093/ehjacc/zuad117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Accepted: 09/29/2023] [Indexed: 10/06/2023]
Affiliation(s)
- Phyllis M Thangaraj
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, 330 Cedar Street, Boardman 110, New Haven, CT 06520, USA
| | - Rohan Khera
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, 330 Cedar Street, Boardman 110, New Haven, CT 06520, USA
- Section of Health Informatics, Department of Biostatistics, Yale School of Public Health, 60 College Street, New Haven, CT 06510, USA
- Section of Biomedical Informatics and Data Science, Yale School of Medicine, 100 College Street, Floor 9, New Haven, CT 06510, USA
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, 195 Church Street, 6th Floor, New Haven, CT 06510, USA
| |
Collapse
|
23
|
de Barros E Silva PGM, Ferreira AA, Malafaia F, Tavares Reis AFM, Sznejder H, Lopes Junior ACDA, Agostinho CA, Fonseca LHDO, Okitoi DVD, Correa CM, Zincone E, Cury MP, Rosa GAL, Ribeiro HB, Soeiro ADM, de Oliveira CAL, Kuusberg GC, Ohe LN, Souza DDO, Manfredi AB, Martins AF, Sampaio PPN, Vaz TB, Franco LF, Ferreira CEDS, Lopes RD. Potential performance of a 0 h/1 h algorithm and a single cut-off measure of high-sensitivity troponin T in a diverse population: main results of the IN-HOPE study. EUROPEAN HEART JOURNAL. ACUTE CARDIOVASCULAR CARE 2023; 12:755-764. [PMID: 37450613 DOI: 10.1093/ehjacc/zuad082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/05/2023] [Revised: 07/04/2023] [Accepted: 07/05/2023] [Indexed: 07/18/2023]
Abstract
AIMS Chest pain is a major cause of medical evaluation at emergency department (ED) and demands observation to exclude the diagnosis of acute myocardial infarction (AMI). High-sensitivity cardiac troponin assays used as isolated measure and by 0- and 1-h algorithms are accepted as a rule-in/rule-out strategy, but there is a lack of validation in specific populations. METHODS AND RESULTS The IN-HOspital Program to systematizE Chest Pain Protocol (IN-HOPE study) is a multicentre study that prospectively included patients admitted to the ED due to suspected symptoms of AMI at 16 sites in Brazil. Medical decisions of all patients followed the standard approach of 0 h/3 h protocol, but, in addition, blood samples were also collected at 0 and 1 h and sent to a central laboratory (core lab) to measure high-sensitivity cardiac troponin T (hs-cTnT). To assess the theoretical performance of 0 h/1 h algorithm, troponin < 12 ng/L with a delta < 3 was considered rule-out while a value ≥ 52 or a delta ≥ 5 was considered a rule-in criterion (the remaining were considered as observation group). The main objective of the study was to assess, in a population managed by the 0 h/3 h protocol, the accuracy of 0 h/1 h algorithm overall and in groups with a higher probability of AMI. All patients were followed up for 30 days, and potential events were adjudicated. In addition to the prospective cohort, a retrospective analysis was performed assessing all patients with hs-cTnT measured during the year of 2021 but not included in the prospective cohort, regardless of the indication of the test. A total of 5.497 patients were included (583 in the prospective and 4.914 in the retrospective analysis). The prospective cohort had a mean age of 57.3 (± 14.8) and 45.6% of females with a mean HEART score of 4.0 ± 2.2. By the core lab analysis, 74.4% would be eligible for a rule-out approach (45.3% of them with a HEART score > 3) while 7.3% would fit the rule-in criteria. In this rule-out group, the negative predictive value for index AMI was 100% (99.1-100) overall and regardless of clinical scores. At 30 days, no death or AMI occurred in the rule-out group of both 0/1 and 0/3 h algorithms while 52.4% of the patients in the rule-in group (0 h/1 h) were considered as AMI by adjudication. In the observation group (grey zone) of 0 h/1 h algorithm, GRACE discriminated the risk of these patients better than HEART score. In the retrospective analysis, 1.091 patients had a troponin value of <5 ng/L and there were no cardiovascular deaths at 30 days in this group. Among all 4.914 patients, the 30-day risk of AMI or cardiovascular death increased according to the level of troponin: 0% in the group < 5 ng/L, 0.6% between 5 and 14 ng/L, 2.2% between 14 and 42 ng/L, 6.3% between 42 and 90 ng/L, and 7.7% in the level ≥ 90 ng/L. CONCLUSION In this large multicentre study, a 0 h/1 h algorithm had the potential to classify as rule-in or rule-out in almost 80% of the patients. The rule-out protocol had high negative predictive value regardless of clinical risk scores. Categories of levels of hs-cTn T also showed good accuracy in discriminating risk of the patients with a very favourable prognosis for cardiovascular death in the group with value < 5 ng/L. CLINICALTRIALS.GOV NCT04756362.
Collapse
Affiliation(s)
- Pedro G M de Barros E Silva
- Cardiologia Americas/United Health Group, São Paulo, Brazil
- Hospital Samaritano Paulista, São Paulo, Brazil
- Brazilian Clinical Research Institute, São Paulo, Brazil
- Centro Universitário São Camilo, São Paulo, Brazil
| | - Ana Amaral Ferreira
- Cardiologia Americas/United Health Group, São Paulo, Brazil
- Hospital Pró-Cardíaco, Rio de Janeiro, Brazil
- Instituto Nacional de Cardiologia (INC), Rio de Janeiro, Brazil
| | - Felipe Malafaia
- Cardiologia Americas/United Health Group, São Paulo, Brazil
- Hospital Samaritano Paulista, São Paulo, Brazil
| | | | - Henry Sznejder
- Cardiologia Americas/United Health Group, São Paulo, Brazil
| | | | | | | | | | - Celso Musa Correa
- Cardiologia Americas/United Health Group, São Paulo, Brazil
- Hospital Vitória-Américas Medical City, Rio de Janeiro, Brazil
- Hospital Samaritano Barra, Rio de Janeiro, Brazil
| | | | - Marcelo Paiva Cury
- Cardiologia Americas/United Health Group, São Paulo, Brazil
- Hospital e Maternidade Metropolitano Lapa, São Paulo, Brazil
- Imed Group Brasil, São Paulo, Brazil
| | | | - Henrique Barbosa Ribeiro
- Cardiologia Americas/United Health Group, São Paulo, Brazil
- Hospital Samaritano Paulista, São Paulo, Brazil
- InCor-Instituto do Coração do Hospital das Clínicas da FMUSP, São Paulo, Brazil
| | | | | | | | | | | | - Adriana Bertolami Manfredi
- Cardiologia Americas/United Health Group, São Paulo, Brazil
- Instituto Dante Pazzanese de Cardiologia, São Paulo, Brazil
- Hospital Alvorada Moema, São Paulo, Brazil
| | - Amanda Francisco Martins
- Cardiologia Americas/United Health Group, São Paulo, Brazil
- Imed Group Brasil, São Paulo, Brazil
- Hospital Alvorada Moema, São Paulo, Brazil
| | | | - Thiago Baganha Vaz
- Cardiologia Americas/United Health Group, São Paulo, Brazil
- Hospital Samaritano Paulista, São Paulo, Brazil
- Hospital Vitória Anália Franco, São Paulo, Brazil
| | | | | | - Renato Delascio Lopes
- Brazilian Clinical Research Institute, São Paulo, Brazil
- Duke Medical Center, Durham, NC, USA
| |
Collapse
|
24
|
Tada M, Matano H, Azuma H, Kano KI, Maeda S, Fujino S, Yamada N, Uzui H, Tada H, Maeno K, Shimada Y, Yoshida H, Ando M, Ichihashi T, Murakami Y, Homma Y, Funakoshi H, Obunai K, Matsushima A, Ohte N, Takeuchi A, Takada Y, Matsukubo S, Ando H, Furukawa Y, Kuriyama A, Fujisawa T, Chapman AR, Mills NL, Hayashi H, Watanabe N, Furukawa TA. Comprehensive validation of early diagnostic algorithms for myocardial infarction in the emergency department. QJM 2023:hcad242. [PMID: 37878823 DOI: 10.1093/qjmed/hcad242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Revised: 09/08/2023] [Indexed: 10/27/2023] Open
Abstract
OBJECTIVE To comprehensively evaluate diagnostic algorithms for myocardial infarction using a high-sensitivity cardiac troponin I (hs-cTnI) assay. PATIENTS AND METHODS We prospectively enrolled patients with suspected myocardial infarction without ST-segment elevation from nine emergency departments in Japan. The diagnostic algorithms evaluated a) based on hs-cTnI alone, such as the European Society of Cardiology (ESC) 0/1-h or 0/2-h and High-STEACS pathways; or b) used medical history and physical findings, such as the ADAPT, EDACS, HEART, and GRACE pathways. We evaluated the negative predictive value (NPV), sensitivity as safety measures, and proportion of patients classified as low or high-risk as an efficiency measure for a primary outcome of type 1 myocardial infarction or cardiac death within 30 days. RESULTS We included 437 patients, and the hs-cTnI was collected at 0 and 1 hours in 407 patients and at 0 and 2 hours in 394. The primary outcome occurred in 8.1% (33/407) and 6.9% (27/394) of patients, respectively. All the algorithms classified low-risk patients without missing those with the primary outcome, except for the GRACE pathway. The hs-cTnI-based algorithms classified more patients as low-risk: the ESC 0/1-h 45.7%; the ESC 0/2-h 50.5%; the High-STEACS pathway 68.5%, than those using history and physical findings (15-30%). The High-STEACS pathway ruled out more patients (20.5%) by hs-cTnI measurement at 0 hours than the ESC 0/1-h and 0/2-h algorithms (7.4%). CONCLUSIONS The hs-cTnI algorithms, especially the High-STEACS pathway, had excellent safety performance for the early diagnosis of myocardial infarction and offered the greatest improvement in efficiency.
Collapse
Affiliation(s)
- Masafumi Tada
- Department of Emergency Medicine, Neurology, Nagoya City University East Medical Center, Aichi, Japan
- Department of Health Promotion and Human Behavior, Kyoto University Graduate School of Medicine/School of Public Health, Kyoto, Japan
| | - Hideyuki Matano
- Department of Emergency Medicine, Fukui-ken Saiseikai Hospital, Fukui, Japan
| | - Hiroyuki Azuma
- Department of Emergency Medicine, Fukui Prefectural Hospital, Fukui, Japan
| | - Ken-Ichi Kano
- Department of Emergency Medicine, Fukui Prefectural Hospital, Fukui, Japan
| | - Shigenobu Maeda
- Department of Emergency Medicine, Fukui Prefectural Hospital, Fukui, Japan
| | - Susumu Fujino
- Department of Cardiology, Vascular Center, Fukui Prefectural Hospital, Fukui, Japan
| | - Naoki Yamada
- Department of Emergency Medicine, University of Fukui, Fukui, Japan
| | - Hiroyasu Uzui
- Department of Cardiovascular Medicine, University of Fukui, Fukui, Japan
| | - Hiroshi Tada
- Department of Cardiovascular Medicine, University of Fukui, Fukui, Japan
| | - Koji Maeno
- Department of Cardiology, Fukui-ken Saiseikai Hospital, Fukui, Japan
| | - Yoshimitsu Shimada
- Department of Emergency Medicine, Japanese Red Cross Fukui Hospital, Fukui, Japan
| | - Hiroyuki Yoshida
- Department of Cardiology, Japanese Red Cross Fukui Hospital, Fukui, Japan
| | - Masaki Ando
- Department of Emergency and Critical Care Medicine, Kariya Toyota General Hospital, Aichi, Japan
| | - Taku Ichihashi
- Department of Cardiology, Nagoya City University East Medical Center, Aichi, Japan
| | - Yoshimasa Murakami
- Department of Cardiology, Nagoya City University East Medical Center, Aichi, Japan
| | - Yosuke Homma
- Department of Emergency Medicine, Chiba Kaihin Municipal Hospital, Chiba, Japan
| | - Hiraku Funakoshi
- Department of Emergency and Critical Care Medicine, Tokyo bay Urayasu Ichikawa Medical Center, Chiba, Japan
| | - Kotaro Obunai
- Department of Cardiology, Tokyo Bay Urayasu Ichikawa Medical Center, Chiba, Japan
| | - Asako Matsushima
- Department of Emergency Medicine and Critical care, Nagoya City University Graduate School of Medical Sciences, Aichi, Japan
| | - Nobuyuki Ohte
- Department of Cardiology, Nagoya City University Graduate School of Medicine, Aichi, Japan
| | - Akinori Takeuchi
- Department of Emergency Medicine, Konan Kosei Hospital, Aichi, Japan
| | - Yasunobu Takada
- Department of Cardiology, Konan Kosei Hospital, Aichi, Japan
| | - Shohei Matsukubo
- Department of Emergency Medicine and General Internal Medicine, Social Medical Corporation Kyouryoukai Ichinomiya Nishi Hospital, Aichi, Japan
| | - Hirotaka Ando
- Department of Emergency Medicine and General Internal Medicine, Social Medical Corporation Kyouryoukai Ichinomiya Nishi Hospital, Aichi, Japan
| | - Yoshio Furukawa
- Department of Cardiology, Social Medical Corporation Kyouryoukai Ichinomiya Nishi Hospital, Aichi, Japan
| | - Akira Kuriyama
- Department of Primary Care and Emergency Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Takeshi Fujisawa
- British Heart Foundation Center for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Andrew R Chapman
- British Heart Foundation Center for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Nicholas L Mills
- British Heart Foundation Center for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
- Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK
| | - Hiroyuki Hayashi
- Department of Emergency Medicine, University of Fukui, Fukui, Japan
| | - Norio Watanabe
- Department of Psychiatry, Soseikai General Hospital, Kyoto, Japan
| | - Toshi A Furukawa
- Department of Health Promotion and Human Behavior, Kyoto University Graduate School of Medicine/School of Public Health, Kyoto, Japan
| |
Collapse
|
25
|
Byrne RA, Rossello X, Coughlan JJ, Barbato E, Berry C, Chieffo A, Claeys MJ, Dan GA, Dweck MR, Galbraith M, Gilard M, Hinterbuchner L, Jankowska EA, Jüni P, Kimura T, Kunadian V, Leosdottir M, Lorusso R, Pedretti RFE, Rigopoulos AG, Rubini Gimenez M, Thiele H, Vranckx P, Wassmann S, Wenger NK, Ibanez B. 2023 ESC Guidelines for the management of acute coronary syndromes. Eur Heart J 2023; 44:3720-3826. [PMID: 37622654 DOI: 10.1093/eurheartj/ehad191] [Citation(s) in RCA: 785] [Impact Index Per Article: 785.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/26/2023] Open
|
26
|
Khand AU, Backus B, Campbell M, Frost F, Mullen L, Fisher M, Theodoropoulos KC, Obeidat M, Batouskaya K, Carlton EW, Van Meerten K, Neoh K, Dakshi A, Mumma BE. HEART Score Recalibration Using Higher Sensitivity Troponin T. Ann Emerg Med 2023; 82:449-462. [PMID: 37306637 DOI: 10.1016/j.annemergmed.2023.04.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Revised: 03/27/2023] [Accepted: 04/21/2023] [Indexed: 06/13/2023]
Abstract
STUDY OBJECTIVE We examined the diagnostic performance of a recalibrated History, Electrocardiogram, Age, Risk factors, Troponin (HEART), and Thrombolysis in Myocardial Infarction (TIMI) score in patients with suspected acute cardiac syndrome (ACS). Recalibration of troponin thresholds was performed, including shifting from the 99th percentile to the limit of detection (LOD) or to the limit of quantification (LOQ) We compared the discharge potential and safety of the recalibrated composite scores using a single presentation high-sensitivity cardiac troponin (hs-cTn) T to the conventional scores and with a LOD/LOQ troponin strategy alone. METHODS We undertook a 2-center prospective cohort study in the United Kingdom (UK) (2018) (Clinicaltrials.gov NCT03619733) to specifically assess recalibrated risk scores (shifting the troponin subset scoring from 99th percentile to LOD [UK]) and combined the results of this with secondary analyses of 2 prospective cohort studies in the UK (2011) and the United States (2018, using LOQ rather than LOD). The primary outcome was major adverse cardiovascular events (MACE), defined as adjudicated type 1 myocardial infarction (MI), urgent coronary revascularization, and all-cause death, at 30 days. We evaluated the original scores using hs-cTn below the 99th percentile and recalibrated scores using hs-cTn RESULTS We studied 3,752 patients (3,003 in the UK and 749 in the United States). Median age was 58 years, and 48% were female. At 30 days, 330/3,752 (8.8%) experienced MACE. The sensitivities of the original HEART less or equal to 3 and recalibrated HEART less or equal to 3 scores for rule-out were 96.1% (95% confidence interval [CI], 93.4 to 97.9) and 98.6% (95% CI, 96.5 to 99.5) respectively; the original TIMI less or equal to 1 and recalibrated TIMI less or equal to 1 scores' sensitivities were 79.7% (95% CI, 74.9 to 83.9) and 96.1% (95% CI, 93.4 to 97.9) respectively; and nonischemic ECG with hs-cTn T below the 99th percentile and hs-cTn T less than LOD/LOQ was 79.7% (95%CI, 0.749 to 0.839) and 99.1% (95% CI, 0.974 to 0.998), respectively. Recalibrated HEART less or equal to 3 was projected to discharge 14% more patients than hs-cTn T less than LOD/LOQ. The improved sensitivity of rule-out for recalibrated HEART less than or equal to 3 came at the cost of reduced specificity (50.8% versus 53.8% for recalibrated HEART and conventional HEART respectively). CONCLUSION This study indicates that recalibrated HEART score of less or equal to 3 is a feasible and safe early discharge strategy using a single presentation hs-cTnT. This finding should be further tested using competitor hs-cTn assays in independent prospective cohorts before implementation.
Collapse
Affiliation(s)
- Aleem U Khand
- Liverpool University Hospital, Liverpool, UK; Liverpool Heart and Chest Hospital, Liverpool, UK; Liverpool Centre for Cardiovascular Diseases, University of Liverpool, Liverpool, UK.
| | | | | | - Freddy Frost
- Liverpool Centre for Cardiovascular Diseases, University of Liverpool, Liverpool, UK
| | - Liam Mullen
- Liverpool Heart and Chest Hospital, Liverpool, UK
| | - Michael Fisher
- Liverpool University Hospital, Liverpool, UK; Liverpool Heart and Chest Hospital, Liverpool, UK
| | | | | | | | | | | | - Kai Neoh
- Liverpool University Hospital, Liverpool, UK
| | | | - Bryn E Mumma
- Department of Emergency Medicine, University of California, Davis School of Medicine, Sacramento, CA
| |
Collapse
|
27
|
Neumann JT, Twerenbold R, Ojeda F, Aldous SJ, Allen BR, Apple FS, Babel H, Christenson RH, Cullen L, Di Carluccio E, Doudesis D, Ekelund U, Giannitsis E, Greenslade J, Inoue K, Jernberg T, Kavsak P, Keller T, Lee KK, Lindahl B, Lorenz T, Mahler SA, Mills NL, Mokhtari A, Parsonage W, Pickering JW, Pemberton CJ, Reich C, Richards AM, Sandoval Y, Than MP, Toprak B, Troughton RW, Worster A, Zeller T, Ziegler A, Blankenberg S. Personalized diagnosis in suspected myocardial infarction. Clin Res Cardiol 2023; 112:1288-1301. [PMID: 37131096 PMCID: PMC10449973 DOI: 10.1007/s00392-023-02206-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Accepted: 04/11/2023] [Indexed: 05/04/2023]
Abstract
BACKGROUND In suspected myocardial infarction (MI), guidelines recommend using high-sensitivity cardiac troponin (hs-cTn)-based approaches. These require fixed assay-specific thresholds and timepoints, without directly integrating clinical information. Using machine-learning techniques including hs-cTn and clinical routine variables, we aimed to build a digital tool to directly estimate the individual probability of MI, allowing for numerous hs-cTn assays. METHODS In 2,575 patients presenting to the emergency department with suspected MI, two ensembles of machine-learning models using single or serial concentrations of six different hs-cTn assays were derived to estimate the individual MI probability (ARTEMIS model). Discriminative performance of the models was assessed using area under the receiver operating characteristic curve (AUC) and logLoss. Model performance was validated in an external cohort with 1688 patients and tested for global generalizability in 13 international cohorts with 23,411 patients. RESULTS Eleven routinely available variables including age, sex, cardiovascular risk factors, electrocardiography, and hs-cTn were included in the ARTEMIS models. In the validation and generalization cohorts, excellent discriminative performance was confirmed, superior to hs-cTn only. For the serial hs-cTn measurement model, AUC ranged from 0.92 to 0.98. Good calibration was observed. Using a single hs-cTn measurement, the ARTEMIS model allowed direct rule-out of MI with very high and similar safety but up to tripled efficiency compared to the guideline-recommended strategy. CONCLUSION We developed and validated diagnostic models to accurately estimate the individual probability of MI, which allow for variable hs-cTn use and flexible timing of resampling. Their digital application may provide rapid, safe and efficient personalized patient care. TRIAL REGISTRATION NUMBERS Data of following cohorts were used for this project: BACC ( www. CLINICALTRIALS gov ; NCT02355457), stenoCardia ( www. CLINICALTRIALS gov ; NCT03227159), ADAPT-BSN ( www.australianclinicaltrials.gov.au ; ACTRN12611001069943), IMPACT ( www.australianclinicaltrials.gov.au , ACTRN12611000206921), ADAPT-RCT ( www.anzctr.org.au ; ANZCTR12610000766011), EDACS-RCT ( www.anzctr.org.au ; ANZCTR12613000745741); DROP-ACS ( https://www.umin.ac.jp , UMIN000030668); High-STEACS ( www. CLINICALTRIALS gov ; NCT01852123), LUND ( www. CLINICALTRIALS gov ; NCT05484544), RAPID-CPU ( www. CLINICALTRIALS gov ; NCT03111862), ROMI ( www. CLINICALTRIALS gov ; NCT01994577), SAMIE ( https://anzctr.org.au ; ACTRN12621000053820), SEIGE and SAFETY ( www. CLINICALTRIALS gov ; NCT04772157), STOP-CP ( www. CLINICALTRIALS gov ; NCT02984436), UTROPIA ( www. CLINICALTRIALS gov ; NCT02060760).
Collapse
Affiliation(s)
- Johannes Tobias Neumann
- Department of Cardiology, University Heart and Vascular Center, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
- German Center for Cardiovascular Research (DZHK), Partner SiteHamburg/Kiel/Lübeck, Hamburg, Germany
- Population Health Research Department, University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Raphael Twerenbold
- Department of Cardiology, University Heart and Vascular Center, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
- German Center for Cardiovascular Research (DZHK), Partner SiteHamburg/Kiel/Lübeck, Hamburg, Germany
- Population Health Research Department, University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- University Center of Cardiovascular Science, University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Francisco Ojeda
- Department of Cardiology, University Heart and Vascular Center, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
- Population Health Research Department, University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Sally J Aldous
- Department of Cardiology, Christchurch Hospital, Christchurch, New Zealand
| | - Brandon R Allen
- Department of Emergency Medicine, College of Medicine, University of Florida, Gainesville, FL, USA
| | - Fred S Apple
- Departments of Laboratory Medicine and Pathology, Hennepin Healthcare/HCMC and University of Minnesota, Minneapolis, MN, USA
| | - Hugo Babel
- Cardio-CARE, Medizincampus Davos, Davos, Switzerland
| | - Robert H Christenson
- Department of Pathology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Louise Cullen
- Department of Emergency Medicine, Royal Brisbane and Women's Hospital, Herston, QLD, Australia
| | | | - Dimitrios Doudesis
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Ulf Ekelund
- Department of Internal and Emergency Medicine, Lund University, Skåne University Hospital, Lund, Sweden
| | | | - Jaimi Greenslade
- Department of Emergency Medicine, Royal Brisbane and Women's Hospital, Herston, QLD, Australia
| | - Kenji Inoue
- Juntendo University Nerima Hospital, Tokyo, Japan
| | - Tomas Jernberg
- Department of Clinical Sciences, Danderyd University Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Peter Kavsak
- Department of Pathology and Molecular Medicine, McMaster University, Hamilton, ON, Canada
| | - Till Keller
- Department of Cardiology, Kerckhoff Heart and Thorax Center, Bad Nauheim, Germany
| | - Kuan Ken Lee
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Bertil Lindahl
- Department of Medical Sciences and Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - Thiess Lorenz
- Department of Cardiology, University Heart and Vascular Center, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
- German Center for Cardiovascular Research (DZHK), Partner SiteHamburg/Kiel/Lübeck, Hamburg, Germany
- Population Health Research Department, University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Simon A Mahler
- Department of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Nicholas L Mills
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Arash Mokhtari
- Department of Internal Medicine and Emergency Medicine and Department of Cardiology, Lund University, Skåne University Hospital, Lund, Sweden
| | - William Parsonage
- Australian Centre for Health Service Innovation, Queensland University of Technology, Kelvin Grove, Australia
| | - John W Pickering
- Department of Medicine, Christchurch and Emergency Department, University of Otago, Christchurch Hospital, Christchurch, New Zealand
| | - Christopher J Pemberton
- Department of Medicine, Christchurch Heart Institute, University of Otago, Christchurch, New Zealand
| | - Christoph Reich
- Department of Cardiology, Heidelberg University Hospital, Heidelberg, Germany
| | - A Mark Richards
- Department of Medicine, Christchurch and Emergency Department, University of Otago, Christchurch Hospital, Christchurch, New Zealand
| | - Yader Sandoval
- Minneapolis Heart Institute, Abbott Northwestern Hospital, and Minneapolis Heart Institute Foundation, Minneapolis, MN, USA
| | - Martin P Than
- Department of Medicine, Christchurch and Emergency Department, University of Otago, Christchurch Hospital, Christchurch, New Zealand
| | - Betül Toprak
- Department of Cardiology, University Heart and Vascular Center, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
- German Center for Cardiovascular Research (DZHK), Partner SiteHamburg/Kiel/Lübeck, Hamburg, Germany
- Population Health Research Department, University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- University Center of Cardiovascular Science, University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Richard W Troughton
- Department of Medicine, Christchurch Heart Institute, University of Otago, Christchurch, New Zealand
| | - Andrew Worster
- Division of Emergency Medicine, McMaster University, Hamilton, ON, Canada
| | - Tanja Zeller
- Department of Cardiology, University Heart and Vascular Center, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
- German Center for Cardiovascular Research (DZHK), Partner SiteHamburg/Kiel/Lübeck, Hamburg, Germany
- Population Health Research Department, University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- University Center of Cardiovascular Science, University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Andreas Ziegler
- Cardio-CARE, Medizincampus Davos, Davos, Switzerland
- School of Mathematics, Statistics and Computer Science, University of KwaZulu-Natal, Pietermaritzburg, South Africa
| | - Stefan Blankenberg
- Department of Cardiology, University Heart and Vascular Center, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany.
- German Center for Cardiovascular Research (DZHK), Partner SiteHamburg/Kiel/Lübeck, Hamburg, Germany.
- Population Health Research Department, University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
| |
Collapse
|
28
|
Lowry MTH, Doudesis D, Boeddinghaus J, Kimenai DM, Bularga A, Taggart C, Wereski R, Ferry AV, Stewart SD, Tuck C, Koechlin L, Nestelberger T, Lopez-Ayala P, Huré G, Lee KK, Chapman AR, Newby DE, Anand A, Collinson PO, Mueller C, Mills NL. Troponin in early presenters to rule out myocardial infarction. Eur Heart J 2023; 44:2846-2858. [PMID: 37350492 PMCID: PMC10406338 DOI: 10.1093/eurheartj/ehad376] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Revised: 04/12/2023] [Accepted: 05/24/2023] [Indexed: 06/24/2023] Open
Abstract
AIMS Whether a single cardiac troponin measurement can safely rule out myocardial infarction in patients presenting within a few hours of symptom onset is uncertain. The study aim was to assess the performance of troponin in early presenters. METHODS AND RESULTS In patients with possible myocardial infarction, the diagnostic performance of a single measurement of high-sensitivity cardiac troponin I at presentation was evaluated and externally validated in those tested ≤3, 4-12, and >12 h from symptom onset. The limit-of-detection (2 ng/L), rule-out (5 ng/L), and sex-specific 99th centile (16 ng/L in women; 34 ng/L in men) thresholds were compared. In 41 103 consecutive patients [60 (17) years, 46% women], 12 595 (31%) presented within 3 h, and 3728 (9%) had myocardial infarction. In those presenting ≤3 h, a threshold of 2 ng/L had greater sensitivity and negative predictive value [99.4% (95% confidence interval 99.2%-99.5%) and 99.7% (99.6%-99.8%)] compared with 5 ng/L [96.5% (96.2%-96.8%) and 99.3% (99.1%-99.4%)]. In those presenting ≥3 h, the sensitivity and negative predictive value were similar for both thresholds. The sensitivity of the 99th centile was low in early and late presenters at 71.4% (70.6%-72.2%) and 92.5% (92.0%-93.0%), respectively. Findings were consistent in an external validation cohort of 7088 patients. CONCLUSION In early presenters, a single measurement of high-sensitivity cardiac troponin I below the limit of detection may facilitate the safe rule out of myocardial infarction. The 99th centile should not be used to rule out myocardial infarction at presentation even in those presenting later following symptom onset.
Collapse
Affiliation(s)
- Matthew T H Lowry
- BHF Centre for Cardiovascular Science, University of Edinburgh, Room SU.226, Chancellor’s Building, Edinburgh EH16 4SB, UK
| | - Dimitrios Doudesis
- BHF Centre for Cardiovascular Science, University of Edinburgh, Room SU.226, Chancellor’s Building, Edinburgh EH16 4SB, UK
- Usher Institute, 9 Little France Road, BioQuarter, Edinburgh, EH16 4UX, UK
| | - Jasper Boeddinghaus
- BHF Centre for Cardiovascular Science, University of Edinburgh, Room SU.226, Chancellor’s Building, Edinburgh EH16 4SB, UK
| | - Dorien M Kimenai
- BHF Centre for Cardiovascular Science, University of Edinburgh, Room SU.226, Chancellor’s Building, Edinburgh EH16 4SB, UK
| | - Anda Bularga
- BHF Centre for Cardiovascular Science, University of Edinburgh, Room SU.226, Chancellor’s Building, Edinburgh EH16 4SB, UK
| | - Caelan Taggart
- BHF Centre for Cardiovascular Science, University of Edinburgh, Room SU.226, Chancellor’s Building, Edinburgh EH16 4SB, UK
| | - Ryan Wereski
- BHF Centre for Cardiovascular Science, University of Edinburgh, Room SU.226, Chancellor’s Building, Edinburgh EH16 4SB, UK
| | - Amy V Ferry
- BHF Centre for Cardiovascular Science, University of Edinburgh, Room SU.226, Chancellor’s Building, Edinburgh EH16 4SB, UK
| | - Stacey D Stewart
- BHF Centre for Cardiovascular Science, University of Edinburgh, Room SU.226, Chancellor’s Building, Edinburgh EH16 4SB, UK
| | - Christopher Tuck
- BHF Centre for Cardiovascular Science, University of Edinburgh, Room SU.226, Chancellor’s Building, Edinburgh EH16 4SB, UK
| | - Luca Koechlin
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Switzerland
| | - Thomas Nestelberger
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Switzerland
| | - Pedro Lopez-Ayala
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Switzerland
| | - Gabrielle Huré
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Switzerland
| | - Kuan Ken Lee
- BHF Centre for Cardiovascular Science, University of Edinburgh, Room SU.226, Chancellor’s Building, Edinburgh EH16 4SB, UK
| | - Andrew R Chapman
- BHF Centre for Cardiovascular Science, University of Edinburgh, Room SU.226, Chancellor’s Building, Edinburgh EH16 4SB, UK
| | - David E Newby
- BHF Centre for Cardiovascular Science, University of Edinburgh, Room SU.226, Chancellor’s Building, Edinburgh EH16 4SB, UK
| | - Atul Anand
- BHF Centre for Cardiovascular Science, University of Edinburgh, Room SU.226, Chancellor’s Building, Edinburgh EH16 4SB, UK
| | - Paul O Collinson
- Department of Clinical Blood Sciences, St George’s, University Hospitals NHS Trust and St George’s University of London, London, UK
- Department Cardiology, St George’s, University Hospitals NHS Trust and St George’s University of London, London, UK
| | - Christian Mueller
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Switzerland
| | - Nicholas L Mills
- BHF Centre for Cardiovascular Science, University of Edinburgh, Room SU.226, Chancellor’s Building, Edinburgh EH16 4SB, UK
- Usher Institute, 9 Little France Road, BioQuarter, Edinburgh, EH16 4UX, UK
| |
Collapse
|
29
|
Orji C. Analysis of Sensitivity, Specificity, and Predictive Values of High-Sensitivity Troponin T in a Secondary Care Setting: A Retrospective Cohort Study. Cureus 2023; 15:e44446. [PMID: 37680409 PMCID: PMC10481764 DOI: 10.7759/cureus.44446] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/31/2023] [Indexed: 09/09/2023] Open
Abstract
Background High-sensitivity cardiac troponin (hs-cTn) assays have significantly improved the early detection of myocardial injury and the diagnosis of acute coronary syndrome (ACS). Different diagnostic algorithms exist for the interpretation of hs-cTn in the management of patients with suspected ACS. This study analysed the diagnostic efficacy of hs-cTn using serial and single measurements while also shedding light on the challenges associated with the use of this assay. Methods We reviewed 189 results belonging to 120 unique patient episodes and records for troponin tests performed in a two-week period obtained from the West Cumberland Hospital, North Cumbria Integrated Care (NCIC), Whitehaven, England. These troponin tests were carried out based on the NCIC trust guidelines for the use of troponin assays in the management of acute coronary syndrome (ACS). A positive troponin test is defined using the NCIC trust guidelines and the National Academy of Clinical Biochemistry (NACB) guidelines. The case notes of the unique patients were reviewed to determine the outcome, which is defined as the clinical diagnosis on discharge of the patient following a cardiologist review. These outcomes were then used to calculate the sensitivity, specificity, and predictive values. We also determined the alternate diagnosis for false-positive tests. Results Using both guidelines to assess the clinical effectiveness of the troponin assay yields slightly varying results, with the single positive test of NACB demonstrating a higher sensitivity of 92.8% (>71.4%) and a slightly better negative predictive value of 97.8% (>96%). However, using the serial troponin measurements as per the NCIC trust guideline demonstrates a better specificity of 95.2% (>42.4%) and a positive predictive value of 66% (>17.5%). False positive results are identified, which are due to alternate diagnoses such as stable angina, myocarditis, heart failure, sepsis, and malignancy. Conclusion High-sensitivity troponin (hs-cTn) assays play a crucial role in the early detection and management of patients with suspected ACS. This study supports evidence that serial troponin measurements are more diagnostically accurate than single troponin measurements. Although hs-cTn assays offer significant advantages, there remain challenges and limitations that require careful interpretation and clinical correlation.
Collapse
Affiliation(s)
- Chinedu Orji
- Cardiology, North Cumbria Integrated Care, Whitehaven, GBR
| |
Collapse
|
30
|
Clerico A, Zaninotto M, Aimo A, Cardinale DM, Dittadi R, Sandri MT, Perrone MA, Belloni L, Fortunato A, Trenti T, Plebani M. Variability of cardiac troponin levels in normal subjects and in patients with cardiovascular diseases: analytical considerations and clinical relevance. Clin Chem Lab Med 2023; 61:1209-1229. [PMID: 36695506 DOI: 10.1515/cclm-2022-1285] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Accepted: 01/09/2023] [Indexed: 01/26/2023]
Abstract
In accordance with all the most recent international guidelines, the variation of circulating levels of cardiac troponins I and T, measured with high-sensitivity methods (hs-cTnI and hs-cTnT), should be used for the detection of acute myocardial injury. Recent experimental and clinical evidences have demonstrated that the evaluation of hs-cTnI and hs-cTnT variations is particularly relevant: a) for the differential diagnosis of Acute Coronary Syndromes (ACS) in patients admitted to the Emergency Department (ED); b) for the evaluation of cardiovascular risk in patients undergoing major cardiac or non-cardiac surgery, and in asymptomatic subjects of the general population aged >55 years and with co-morbidities; c) for the evaluation of cardiotoxicity caused by administration of some chemotherapy drugs in patients with malignant tumors. The aim of this document is to discuss the fundamental statistical and biological considerations on the intraindividual variability of hs-cTnI and hs-cTnT over time in the same individual. Firstly, it will be discussed in detail as the variations of circulating levels strictly depend not only on the analytical error of the method used but also on the intra-individual variability of the biomarker. Afterwards, the pathophysiological interpretation and the clinical relevance of the determination of the variability of the hs-cTnI and hs-cTnT values in patients with specific clinical conditions are discussed. Finally, the evaluation over time of the variation in circulating levels of hs-cTnI and hs-cTnT is proposed for a more accurate estimation of cardiovascular risk in asymptomatic subjects from the general population.
Collapse
Affiliation(s)
- Aldo Clerico
- Scuola Superiore Sant'Anna e Fondazione CNR, Regione Toscana G. Monasterio, Pisa, Italy
| | - Martina Zaninotto
- Dipartimento di Medicina di Laboratorio, Università-Ospedale di Padova, Padova, Italy
- Azienda Ospedaliera Universitaria di Padova, e Facoltà di Medicina e Chirurgia, Università di Padova, Padova, Italy
| | - Alberto Aimo
- Scuola Superiore Sant'Anna e Fondazione CNR, Regione Toscana G. Monasterio, Pisa, Italy
| | | | - Ruggero Dittadi
- Unità di Medicina di Laboratorio, Ospedale dell'Angelo, e Centro Regionale dei Biomarcatori, Dipartimento di Patologia Clinica, Azienda ULSS 3, Mestre, Italy
| | - Maria T Sandri
- Laboratorio Bianalisi, Carate Brianza, Monza e Brianza, Italy
| | - Marco Alfonso Perrone
- Dipartimento di Biochimica Clinica e Divisione di Cardiologia, Università e Ospedale di Tor Vergata, Rome, Italy
| | - Lucia Belloni
- Unità di Immunologia Clinica, Allergia e Biotecnologie Avanzate, Arcispedale Santa Maria Nuova-IRCCS, Reggio Emilia, Italy
| | | | - Tommaso Trenti
- Dipartimento di Patologia Clinica e Laboratorio, Azienda USL of Modena, Modena, Italy
| | - Mario Plebani
- Dipartimento di Medicina di Laboratorio, Università-Ospedale di Padova, Padova, Italy
- Azienda Ospedaliera Universitaria di Padova, e Facoltà di Medicina e Chirurgia, Università di Padova, Padova, Italy
| |
Collapse
|
31
|
Lee KK, Lowe D, O'Brien R, Wereski R, Bularga A, Taggart C, Lowry MTH, Ferry AV, Williams MC, Roditi G, Byrne J, Tuck C, Cranley D, Thokala P, Goodacre S, Keerie C, Norrie J, Newby DE, Gray AJ, Mills NL. Troponin in acute chest pain to risk stratify and guide effective use of computed tomography coronary angiography (TARGET-CTCA): a randomised controlled trial. Trials 2023; 24:402. [PMID: 37312104 PMCID: PMC10264092 DOI: 10.1186/s13063-023-07431-9] [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: 03/20/2023] [Accepted: 06/05/2023] [Indexed: 06/15/2023] Open
Abstract
BACKGROUND The majority of patients with suspected acute coronary syndrome presenting to the emergency department will be discharged once myocardial infarction has been ruled out, although a proportion will have unrecognised coronary artery disease. In this setting, high-sensitivity cardiac troponin identifies those at increased risk of future cardiac events. In patients with intermediate cardiac troponin concentrations in whom myocardial infarction has been ruled out, this trial aims to investigate whether outpatient computed tomography coronary angiography (CTCA) reduces subsequent myocardial infarction or cardiac death. METHODS TARGET-CTCA is a multicentre prospective randomised open label with blinded endpoint parallel group event driven trial. After myocardial infarction and clear alternative diagnoses have been ruled out, participants with intermediate cardiac troponin concentrations (5 ng/L to 99th centile upper reference limit) will be randomised 1:1 to outpatient CTCA plus standard of care or standard of care alone. The primary endpoint is myocardial infarction or cardiac death. Secondary endpoints include clinical, patient-centred, process and cost-effectiveness. Recruitment of 2270 patients will give 90% power with a two-sided P value of 0.05 to detect a 40% relative risk reduction in the primary endpoint. Follow-up will continue until 97 primary outcome events have been accrued in the standard care arm with an estimated median follow-up of 36 months. DISCUSSION This randomised controlled trial will determine whether high-sensitivity cardiac troponin-guided CTCA can improve outcomes and reduce subsequent major adverse cardiac events in patients presenting to the emergency department who do not have myocardial infarction. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT03952351. Registered on May 16, 2019.
Collapse
Affiliation(s)
- Kuan Ken Lee
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, EH16 4SA, UK
| | - David Lowe
- Department of Emergency Medicine, Queen Elizabeth University Hospital, NHS Greater Glasgow and Clyde, Glasgow, UK
| | - Rachel O'Brien
- Department of Emergency Medicine, Emergency Medicine Research Group, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Ryan Wereski
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, EH16 4SA, UK
| | - Anda Bularga
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, EH16 4SA, UK
| | - Caelan Taggart
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, EH16 4SA, UK
| | - Matthew T H Lowry
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, EH16 4SA, UK
| | - Amy V Ferry
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, EH16 4SA, UK
| | - Michelle C Williams
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, EH16 4SA, UK
| | - Giles Roditi
- Institute of Cardiovascular and Medical Sciences, Glasgow University, Glasgow, UK
| | - John Byrne
- Department of Cardiology, Queen Elizabeth University Hospital, NHS Greater Glasgow and Clyde, Glasgow, UK
| | - Chris Tuck
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, EH16 4SA, UK
| | - Denise Cranley
- Edinburgh Clinical Trials Unit, Usher Institute, University of Edinburgh, Edinburgh, UK
| | - Praveen Thokala
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Steve Goodacre
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Catriona Keerie
- Edinburgh Clinical Trials Unit, Usher Institute, University of Edinburgh, Edinburgh, UK
| | - John Norrie
- Edinburgh Clinical Trials Unit, Usher Institute, University of Edinburgh, Edinburgh, UK
| | - David E Newby
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, EH16 4SA, UK
| | - Alasdair J Gray
- Department of Emergency Medicine, Emergency Medicine Research Group, Royal Infirmary of Edinburgh, Edinburgh, UK
- Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK
| | - Nicholas L Mills
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, EH16 4SA, UK.
- Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK.
| |
Collapse
|
32
|
Ashburn NP, Snavely AC, O’Neill JC, Allen BR, Christenson RH, Madsen T, Massoomi MR, McCord JK, Mumma BE, Nowak R, Stopyra JP, in’t Veld MH, Wilkerson RG, Mahler SA. Performance of the European Society of Cardiology 0/1-Hour Algorithm With High-Sensitivity Cardiac Troponin T Among Patients With Known Coronary Artery Disease. JAMA Cardiol 2023; 8:347-356. [PMID: 36857071 PMCID: PMC9979014 DOI: 10.1001/jamacardio.2023.0031] [Citation(s) in RCA: 19] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Accepted: 12/29/2022] [Indexed: 03/02/2023]
Abstract
Importance The European Society of Cardiology (ESC) 0/1-hour algorithm is a validated high-sensitivity cardiac troponin (hs-cTn) protocol for emergency department patients with possible acute coronary syndrome. However, limited data exist regarding its performance in patients with known coronary artery disease (CAD; prior myocardial infarction [MI], coronary revascularization, or ≥70% coronary stenosis). Objective To evaluate and compare the diagnostic performance of the ESC 0/1-hour algorithm for 30-day cardiac death or MI among patients with and without known CAD and determine if the algorithm could achieve the negative predictive value rule-out threshold of 99% or higher. Design, Setting, and Participants This was a preplanned subgroup analysis of the STOP-CP prospective multisite cohort study, which was conducted from January 25, 2017, through September 6, 2018, at 8 emergency departments in the US. Patients 21 years or older with symptoms suggestive of acute coronary syndrome without ST-segment elevation on initial electrocardiogram were included. Analysis took place between February and December 2022. Interventions/Exposures Participants with 0- and 1-hour high-sensitivity cardiac troponin T (hs-cTnT) measures were stratified into rule-out, observation, and rule-in zones using the ESC 0/1-hour hs-cTnT algorithm. Main Outcomes and Measures Cardiac death or MI at 30 days determined by expert adjudicators. Results During the study period, 1430 patients were accrued. In the cohort, 775 individuals (54.2%) were male, 826 (57.8%) were White, and the mean (SD) age was 57.6 (12.8) years. At 30 days, cardiac death or MI occurred in 183 participants (12.8%). Known CAD was present in 449 (31.4%). Among patients with known CAD, the ESC 0/1-hour algorithm classified 178 of 449 (39.6%) into the rule-out zone compared with 648 of 981 (66.1%) without CAD (P < .001). Among rule-out zone patients, 30-day cardiac death or MI occurred in 6 of 178 patients (3.4%) with known CAD and 7 of 648 (1.1%) without CAD (P < .001). The negative predictive value for 30-day cardiac death or MI was 96.6% (95% CI, 92.8-98.8) among patients with known CAD and 98.9% (95% CI, 97.8-99.6) in patients without known CAD (P = .04). Conclusions and Relevance Among patients with known CAD, the ESC 0/1-hour hs-cTnT algorithm was unable to safely exclude 30-day cardiac death or MI. This suggests that clinicians should be cautious if using the algorithm in patients with known CAD. The negative predictive value was significantly higher in patients without a history of CAD but remained less than 99%.
Collapse
Affiliation(s)
- Nicklaus P. Ashburn
- Department of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina
- Section on Cardiovascular Medicine, Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Anna C. Snavely
- Department of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina
- Department of Biostatistics and Data Science, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - James C. O’Neill
- Department of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Brandon R. Allen
- Department of Emergency Medicine, University of Florida College of Medicine, Gainesville
| | | | - Troy Madsen
- Department of Emergency Medicine, University of Utah School of Medicine, Salt Lake City
| | - Michael R. Massoomi
- Department of Cardiology, University of Florida College of Medicine, Gainesville
| | - James K. McCord
- Department of Cardiology, Henry Ford Health System, Detroit, Michigan
| | - Bryn E. Mumma
- Department of Emergency Medicine, University of California, Davis School of Medicine, Sacramento
| | - Richard Nowak
- Department of Emergency Medicine, Henry Ford Health System, Detroit, Michigan
| | - Jason P. Stopyra
- Department of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Maite Huis in’t Veld
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore
| | - R. Gentry Wilkerson
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore
| | - Simon A. Mahler
- Department of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina
- Department of Epidemiology and Prevention, Wake Forest School of Medicine, Winston-Salem, North Carolina
- Department of Implementation Science, Wake Forest School of Medicine, Winston-Salem, North Carolina
| |
Collapse
|
33
|
Roos A, Sedin E, Edgren G. Management and outcomes of patients with chest pain and psychiatric disorders in the era of high-sensitivity cardiac troponins. J Intern Med 2023; 293:481-493. [PMID: 36511632 DOI: 10.1111/joim.13598] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND The management of patients with psychiatric disease and chest pain in the emergency department (ED) in the era of high-sensitivity cardiac troponin assays is unexplored. OBJECTIVES To investigate differences in management and outcomes comparing patients with versus without psychiatric disorders who present with chest pain in the ED. METHODS All visits to seven different EDs in Sweden from 9 December 2010 to 31 December 2016 by patients with chest pain were included. Odds ratios (ORs) with 95% confidence intervals (CIs) were calculated to estimate differences in clinical management. Hazard ratios with 95% CIs were used for comparisons of all-cause mortality and risk of cardiovascular events. RESULTS Altogether, 216,653 visits were identified, of which 40,054 (18%) occurred in patients with psychiatric disorders. The risk of a myocardial infarction (MI) was reduced almost by half in patients with an affective (OR 0.63; 95% CI: 0.59-0.68) or psychotic disorder (OR 0.57; 95% CI: 0.47-0.70). These patients were less likely to be treated with any cardiovascular medication or to undergo percutaneous coronary intervention. Contrastingly, patients with psychiatric disease had a 1.8- to 2.6-fold increased risk of being diagnosed with an MI registered after the index visit but within 30 days. CONCLUSIONS Patients with psychiatric disease and chest pain undergo less intense investigation and are less likely to receive cardiovascular medications compared with patients without psychiatric disease, even in the presence of myocardial injury. In addition, they experience a higher risk of being diagnosed with an MI within 30 days after a visit with no MI.
Collapse
Affiliation(s)
- Andreas Roos
- Department of Medicine, Clinical Epidemiology Division, Karolinska Institutet, Solna, Stockholm, Sweden.,Department of Emergency and Reparative Medicine, Karolinska University Hospital, Huddinge, Stockholm, Sweden
| | - Eva Sedin
- Department of Emergency and Reparative Medicine, Karolinska University Hospital, Huddinge, Stockholm, Sweden
| | - Gustaf Edgren
- Department of Medicine, Clinical Epidemiology Division, Karolinska Institutet, Solna, Stockholm, Sweden.,Department of Cardiology, Södersjukhuset, Stockholm, Sweden
| |
Collapse
|
34
|
Karády J, Morrow DA. Critical Appraisal of the Negative Predictive Performance of the European Society of Cardiology 0/1-Hour Algorithm for Evaluating Patients With Chest Pain in the US. JAMA Cardiol 2023; 8:314-316. [PMID: 36857061 DOI: 10.1001/jamacardio.2023.0043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/02/2023]
Affiliation(s)
- Júlia Karády
- Cardiovascular Imaging Research Center, Massachusetts General Hospital, Harvard Medical School, Boston.,Cardiovascular Imaging Research Group, Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - David A Morrow
- TIMI Study Group, Cardiovascular Division, Brigham and Women's Hospital, Boston, Massachusetts
| |
Collapse
|
35
|
McCarthy C, Li S, Wang TY, Raber I, Sandoval Y, Smilowitz NR, Wasfy JH, Pandey A, de Lemos JA, Kontos MC, Apple FS, Daniels LB, Newby LK, Jaffe AS, Januzzi JL. Implementation of High-Sensitivity Cardiac Troponin Assays in the United States. J Am Coll Cardiol 2023; 81:207-219. [PMID: 36328155 PMCID: PMC10037558 DOI: 10.1016/j.jacc.2022.10.017] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Accepted: 10/24/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND Few data exist regarding the implementation of high-sensitivity cardiac troponin (hs-cTn) assays in the United States since their approval. OBJECTIVES This study sought to explore trends in hs-cTn assay implementation over time and assess the association of their use with in-hospital cardiac testing and outcomes. METHODS The study examined trends in implementation of hs-cTn assays among participating hospitals in the National Cardiovascular Data Registry Chest Pain-MI [Myocardial Infarction] Registry from January 1, 2019 through September 30, 2021. Associations among hs-cTn use, use of in-hospital diagnostic imaging, and patient outcomes were assessed using generalized estimating equation models with logistic or gamma distributions. RESULTS Among 550 participating hospitals (N = 251,000), implementation of hs-cTn assays increased from 3.3% in the first quarter of 2019 to 32.6% in the third quarter of 2021 (Ptrend < 0.001). Use of hs-cTn was associated with more echocardiography among persons with non-ST-segment elevation acute coronary syndrome (NSTE-ACS; 82.4% vs 75.0%; adjusted odds ratio: 1.43; 95% CI: 1.19-1.73) but not among low-risk chest pain individuals. Use of hs-cTn was associated with less invasive coronary angiography among low-risk patients (3.7% vs 4.5%; adjusted odds ratio: 0.73; 95% CI: 0.58-0.92) but similar use for patients with NSTE-ACS. There was no association between hs-cTn use and noninvasive stress testing or coronary computed tomography angiography testing. Among individuals with NSTE-ACS, hs-cTn use was not associated with revascularization or in-hospital mortality. Use of hs-cTn was associated with a shorter length of stay (median 47.6 hours vs 48.0 hours; ratio: 0.94; 95% CI: 0.90-0.98). CONCLUSIONS Implementation of hs-cTn among U.S. hospitals is increasing, but most U.S. hospitals continue to use less sensitive assays. The use of hs-cTn was associated with modestly shorter length of stay, greater use of echocardiography for NSTE-ACS, and less use of invasive angiography among low-risk patients.
Collapse
Affiliation(s)
- Cian McCarthy
- Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA.
| | - Shuang Li
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, USA
| | - Tracy Y Wang
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, USA; Division of Cardiology, Duke University Medical Center, Durham, North Carolina, USA
| | - Inbar Raber
- Division of Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Yader Sandoval
- Minneapolis Heart Institute, Abbott Northwestern Hospital, and Minneapolis Heart Institute Foundation, Minneapolis, Minnesota, USA
| | - Nathaniel R Smilowitz
- Leon H. Charney Division of Cardiology, Department of Medicine, New York University School of Medicine, New York, New York, USA
| | - Jason H Wasfy
- Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Ambarish Pandey
- Division of Cardiology, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - James A de Lemos
- Division of Cardiology, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Michael C Kontos
- Division of Cardiology, Pauley Heart Center, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Fred S Apple
- Department of Laboratory Medicine and Pathology, Hennepin Healthcare/HCMC, Minneapolis, Minnesota, USA; Department of Laboratory Medicine and Pathology, University of Minnesota, Minneapolis, Minnesota, USA
| | - Lori B Daniels
- Division of Cardiovascular Medicine, Department of Medicine, University of California San Diego, La Jolla, California, USA
| | - L Kristin Newby
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, USA; Division of Cardiology, Duke University Medical Center, Durham, North Carolina, USA
| | - Allan S Jaffe
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA; Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | - James L Januzzi
- Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA; Heart Failure and Biomarker Trials, Baim Institute for Clinical Research, Boston, Massachusetts, USA
| |
Collapse
|
36
|
Rubini Gimenez M, Boeddinghaus J, Nestelberger T, Koechlin L, López-Ayala P, Müller C. Implementation of the ESC 0 h/1 h high-sensitivity troponin algorithm for decision-making in the emergency department. REVISTA ESPANOLA DE CARDIOLOGIA (ENGLISH ED.) 2023; 76:468-472. [PMID: 36669731 DOI: 10.1016/j.rec.2023.01.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/10/2022] [Accepted: 12/12/2022] [Indexed: 01/19/2023]
Abstract
Diagnosis of non-ST-segment elevation acute coronary syndromes (NSTEACS) is based on 3 cornerstones: clinical presentation, 12-lead electrocardiogram, and cardiac troponin measurement. Advances in the development of high-sensitivity cardiac troponin (hs-cTn) assays have substantially improved the detection of cardiomyocyte injury in a shorter time period, and hs-cTn has consequently been established as the gold-standard biomarker for the assessment of patients with suspected NSTEACS. The implementation of these assays in clinical practice allows a faster "rule-out", especially among low-risk patients, as well as a safer and more rapid "rule-in", with its therapeutic consequences. Current guidelines for the diagnosis of NSTEACS recommend the use of hs-cTn applied in rapid diagnostic algorithms based on serial hs-cTn sampling within the first few hours. The current work provides an overview of the use of hs-cTn for the early detection of NSTEACS.
Collapse
Affiliation(s)
- Maria Rubini Gimenez
- Department of Cardiology and internal Medicine, University Heart Center Leipzig, Leipzig, Germany; Cardiovascular Research Institute of Basel, University Hospital Basel, Basel, Switzerland.
| | - Jasper Boeddinghaus
- Cardiovascular Research Institute of Basel, University Hospital Basel, Basel, Switzerland; BHF/University Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
| | - Thomas Nestelberger
- Cardiovascular Research Institute of Basel, University Hospital Basel, Basel, Switzerland
| | - Luca Koechlin
- Cardiovascular Research Institute of Basel, University Hospital Basel, Basel, Switzerland
| | - Pedro López-Ayala
- Cardiovascular Research Institute of Basel, University Hospital Basel, Basel, Switzerland
| | - Christian Müller
- Cardiovascular Research Institute of Basel, University Hospital Basel, Basel, Switzerland
| |
Collapse
|
37
|
Collinson P, Dakshi A, Khand A. Rapid diagnostic strategies using high sensitivity troponin assays: what is the evidence and how should they be implemented? Ann Clin Biochem 2023; 60:37-45. [PMID: 35491935 DOI: 10.1177/00045632221100347] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
The introduction of high sensitivity measurement of cardiac troponin T (hs cTnT) and cardiac troponin I (hs cTnI) has given the laboratory the ability to measure very low levels of cardiac troponin. The limit of detection of these assays is well below the 99th percentile. These low levels can also be measured with small values of imprecision. A range of algorithms combining presentation measurement with repeat sample intervals of as little as one to 2 hours have been developed. These are able to predict with acceptable accuracy the diagnosis that would be achieved with continued repeat sampling out to six to 12 hours from presentation. In this article, we review the evidence for the diagnostic accuracy of these approaches and the practical aspects of implementation into routine clinical practice.
Collapse
Affiliation(s)
- Paul Collinson
- Departments of Clinical Blood Sciences and Cardiology, 4968St George's University Hospitals NHS Foundation Trust and St George's University of London, London, UK
| | - Ahmed Dakshi
- 4595Liverpool University Hospital NHS Foundation Trust, Liverpool, UK
| | - Aleem Khand
- 4595Liverpool University Hospital NHS Foundation Trust, Liverpool, UK
| |
Collapse
|
38
|
Koechlin L, Boeddinghaus J, Lopez-Ayala P, Nestelberger T, Wussler D, Mais F, Twerenbold R, Zimmermann T, Wildi K, Köppen AM, Miró Ò, Martin-Sanchez FJ, Kawecki D, Geigy N, Keller DI, Christ M, Buser A, Giménez MR, Bernasconi L, Hammerer-Lercher A, Mueller C. Diagnostic discrimination of a novel high-sensitivity cardiac troponin I assay and derivation/validation of an assay-specific 0/1h-algorithm. Am Heart J 2023; 255:58-70. [PMID: 36243111 DOI: 10.1016/j.ahj.2022.10.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Revised: 10/04/2022] [Accepted: 10/05/2022] [Indexed: 06/16/2023]
Abstract
BACKGROUND We aimed to assess the diagnostic utility of the Dimension EXL LOCI High-Sensitivity Troponin I (hs-cTnI-EXL) assay. METHODS This multicenter study included patients with chest discomfort presenting to the emergency department. Diagnoses were centrally and independently adjudicated by two cardiologists using all available clinical information. Adjudication was performed twice including serial measurements of high-sensitivity cardiac troponin (hs-cTn) I-Architect (primary analysis) and serial measurements of hs-cTnT-Elecsys (secondary analysis) in addition to the clinically used (hs)-cTn. The primary objective was to assess and compare the discriminatory performance of hs-cTnI-EXL, hs-cTnI-Architect and hs-cTnT-Elecsys for acute myocardial infarction (MI). Furthermore, we derived and validated a hs-cTnI-EXL-specific 0/1h-algorithm. RESULTS Adjudicated MI was the diagnosis in 204/1454 (14%) patients. The area under the receiver operating characteristics curve for hs-cTnI-EXL was 0.94 (95%CI, 0.93-0.96), and comparable to hs-cTnI-Architect (0.95; 95%CI, 0.93-0.96) and hs-cTnT-Elecsys (0.93; 95%CI, 0.91-0.95). In the derivation cohort (n = 813), optimal criteria for rule-out of MI were <9ng/L at presentation (if chest pain onset >3h) or <9ng/L and 0h-1h-change <5ng/L, and for rule-in ≥160ng/L at presentation or 0h-1h-change ≥100ng/L. In the validation cohort (n = 345), these cut-offs ruled-out 56% of patients (negative predictive value 99.5% (95%CI, 97.1-99.9), sensitivity 97.8% (95%CI, 88.7-99.6)), and ruled-in 9% (positive predictive value 83.3% (95%CI, 66.4-92.7), specificity 98.3% (95%CI, 96.1-99.3)). Secondary analyses using adjudication based on hs-cTnT measurements confirmed the findings. CONCLUSIONS The overall performance of the hs-cTnI-EXL was comparable to best-validated hs-cTnT/I assays and an assay-specific 0/1h-algorithm safely rules out and accurately rules in acute MI. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov number, NCT00470587.
Collapse
Affiliation(s)
- Luca Koechlin
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Basel, Switzerland; Department of Cardiac Surgery, University Hospital Basel, University of Basel, Basel, Basel, Switzerland; GREAT network, Basel, Basel, Switzerland.
| | - Jasper Boeddinghaus
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Basel, Switzerland; GREAT network, Basel, Basel, Switzerland; Division of Internal Medicine, University Hospital Basel, University of Basel, Basel, Basel, Switzerland; BHF/University Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Pedro Lopez-Ayala
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Basel, Switzerland; GREAT network, Basel, Basel, Switzerland
| | - Thomas Nestelberger
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Basel, Switzerland; GREAT network, Basel, Basel, Switzerland; Division of Cardiology, Vancouver General Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Desiree Wussler
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Basel, Switzerland; GREAT network, Basel, Basel, Switzerland; Division of Internal Medicine, University Hospital Basel, University of Basel, Basel, Basel, Switzerland
| | - Felix Mais
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Basel, Switzerland; Emergency Department, University Hospital Zurich, Zurich, Zurich, Switzerland
| | - Raphael Twerenbold
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Basel, Switzerland; University Center of Cardiovascular Science & Department of Cardiology, University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Hamburg, Germany
| | - Tobias Zimmermann
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Basel, Switzerland; GREAT network, Basel, Basel, Switzerland
| | - Karin Wildi
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Basel, Switzerland; GREAT network, Basel, Basel, Switzerland; Critical Care Research Group and the University of Queensland, Brisbane, Queensland, Australia
| | - Anne Marie Köppen
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Basel, Switzerland
| | - Òscar Miró
- GREAT network, Basel, Basel, Switzerland; Emergency Department, Hospital Clinic, Barcelona, Catalonia, Spain
| | - F Javier Martin-Sanchez
- GREAT network, Basel, Basel, Switzerland; Servicio de Urgencias, Hospital Clínico San Carlos, Madrid, Madrid, Spain
| | - Damian Kawecki
- GREAT network, Basel, Basel, Switzerland; 2nd Department of Cardiology, School of Medicine with the Division of Dentistry in Zabrze, Medical University of Katowice, Silesian, Poland
| | - Nicolas Geigy
- Emergency Department, Kantonsspital Liestal, Liestal Liestal, Switzerland
| | - Dagmar I Keller
- Emergency Department, University Hospital Zurich, Zurich, Zurich, Switzerland
| | - Michael Christ
- Emergency Department, Kantonsspital Luzern, Luzern, Luzern, Switzerland
| | - Andreas Buser
- Department of hematology and Blood Bank, University Hospital Basel, University of Basel, Basel, Basel Switzerland
| | - Maria Rubini Giménez
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Basel, Switzerland; Department of Cardiology, Heart Center Leipzig, University of Leipzig, Leipzig, Saxony, Germany
| | - Luca Bernasconi
- Institute of Laboratory Medicine, County Hospital Aarau, Aarau, Aarau, Switzerland
| | | | - Christian Mueller
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Basel, Switzerland; GREAT network, Basel, Basel, Switzerland.
| |
Collapse
|
39
|
Roos A, Edgren G. Using historical cardiac troponins to identify patients at a high risk of myocardial infarction. HEART (BRITISH CARDIAC SOCIETY) 2023; 109:127-133. [PMID: 35948410 PMCID: PMC9811078 DOI: 10.1136/heartjnl-2022-321198] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Accepted: 07/18/2022] [Indexed: 02/04/2023]
Abstract
OBJECTIVE Many patients who present with chest pain have previous measurements of high-sensitivity cardiac troponin T (hs-cTnT). The clinical usefulness of incorporating these measurements in identifying patients who are at a high risk of myocardial infarction (MI) is unknown. We investigated if the relative change between a historical hs-cTnT and the admission hs-cTnT could improve early identification of patients with a high risk of MI. METHODS We included all patients presenting with chest pain to seven different emergency departments (EDs) in Sweden from December 2009 to December 2016, who had at least one hs-cTnT measurement at the presentation and at least one available prior measurement. We used logistic regression to investigate the diagnostic performance of using various combinations of current and historical hs-cTnT measurements in diagnosing MI within 30 days. RESULTS A total of 27 809 visits were included, among whom 2686 (9.7%) had an MI within 30 days. A cut-off value for historical hs-cTnT-adjusted admission hs-cTnT with similar specificity (91.2%) as an admission hs-cTnT of ≥52 ng/L identified 4% more MIs (43% vs 39%) and had a higher positive predictive value, 42.6% (95% CI, 41.0% to 44.3%) vs 38.9% (95% CI 37.4% to 40.4%), as well as a higher positive likelihood ratio, 6.95 (95% CI 6.69 to 7.22) vs 5.95 (95% CI 5.73 to 6.18). Among patients with an admission hs-cTnT of <52 ng/L who were classified as high-risk patients when incorporating past hs-cTnT measurements, 28% suffered an MI. CONCLUSIONS Historical hs-cTnT levels can be used with admission hs-cTnT to improve early risk stratification of MI in the ED.
Collapse
Affiliation(s)
- Andreas Roos
- Department of Emergency and Reparative Medicine, Karolinska University Hospital, Huddinge Stockholm, Sweden,Department of Medicine Clinical Epidemiology Division, Karolinska Institutet, Solna Stockholm, Sweden
| | - Gustaf Edgren
- Department of Medicine Clinical Epidemiology Division, Karolinska Institutet, Solna Stockholm, Sweden
| |
Collapse
|
40
|
Breuckmann F, Settelmeier S, Rassaf T, Post F, Haerer W, Bauersachs J, Mudra H, Voigtländer T, Senges J, Münzel T, Giannitsis E. Survey of clinical practice pattern in Germany's certified chest pain units : Adherence to the European Society of Cardiology guidelines on non-ST-segment elevation acute coronary syndrome. Herz 2022; 47:543-552. [PMID: 34755215 PMCID: PMC8577645 DOI: 10.1007/s00059-021-05079-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Revised: 09/16/2021] [Accepted: 10/16/2021] [Indexed: 11/16/2022]
Abstract
BACKGROUND We aimed to analyze the 2020 standard of care in certified German chest pain units (CPU) with a special focus on non-ST-segment elevation acute coronary syndrome (NSTE-ACS) through a voluntary survey obtained from all certified units, using a prespecified questionnaire. METHODS The assessment included the collection of information on diagnostic protocols, risk assessment, management and treatment strategies in suspected NSTE-ACS, the timing of invasive therapy in non-ST-segment elevation myocardial infarction (NSTEMI), and the choice of antiplatelet therapy. RESULTS The response rate was 75%. Among all CPUs, 77% are currently using the European Society of Cardiology (ESC) 0/3‑h high-sensitive troponin protocol, and only 20% use the ESC 0/1‑h high-sensitive troponin protocol as a default strategy. Conventional ergometry is still the commonly performed stress test with a utilization rate of 47%. Among NSTEMI patients, coronary angiography is planned within 24 h in 96% of all CPUs, irrespective of the day of the week. Prasugrel is the P2Y12 inhibitor of choice in ST-segment elevation myocardial infarction (STEMI), but despite the impact of the ISAR-REACT 5 trial on selection of antiplatelet therapy, ticagrelor is still favored over prasugrel in NSTE-ACS. If triple therapy is used in NSTE-ACS with atrial fibrillation, it is maintained up to 4 weeks in 51% of these patients. CONCLUSION This survey provides evidence that Germany's certified CPUs ensure a high level of guideline adherence and quality of care. The survey also identified areas in need of improvement such as the high utilization rate of stress electrocardiogram (ECG).
Collapse
Affiliation(s)
- Frank Breuckmann
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center Essen, University Duisburg-Essen, Essen, Germany.
| | - Stephan Settelmeier
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center Essen, University Duisburg-Essen, Essen, Germany
| | - Tienush Rassaf
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center Essen, University Duisburg-Essen, Essen, Germany
| | - Felix Post
- Department of Cardiology, Katholisches Klinikum Koblenz-Montabaur, Koblenz, Germany
| | | | - Johann Bauersachs
- Department of Cardiology and Angiology, Hannover Medical School, Hannover, Germany
| | - Harald Mudra
- Heart and Vascular Center Munich Maffeistraße and Nymphenburg (Klinikum 3. Orden), Munich, Germany
| | | | - Jochen Senges
- Institute for Myocardial Infarction Research Foundation, Ludwigshafen, Germany
| | - Thomas Münzel
- Department of Cardiology, University Medical Center Mainz, Johannes Gutenberg-University Mainz, Mainz, Germany
| | | |
Collapse
|
41
|
Ohtake H, Terasawa T, Zhelev Z, Iwata M, Rogers M, Peters JL, Hyde C. Serial high-sensitivity cardiac troponin testing for the diagnosis of myocardial infarction: a scoping review. BMJ Open 2022; 12:e066429. [PMID: 36414302 PMCID: PMC9685223 DOI: 10.1136/bmjopen-2022-066429] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVES We aimed to assess the diversity and practices of existing studies on several assays and algorithms for serial measurements of high-sensitivity cardiac troponin (hs-cTn) for risk stratification and the diagnosis of myocardial infarction (MI) and 30-day outcomes in patients suspected of having non-ST-segment elevation MI (NSTEMI). METHODS We searched multiple databases including MEDLINE, EMBASE, Science Citation Index, the Cochrane Database of Systematic Reviews and the CENTRAL databases for studies published between January 2006 and November 2021. Studies that assessed the diagnostic accuracy of serial hs-cTn testing in patients suspected of having NSTEMI in the emergency department (ED) were eligible. Data were analysed using the scoping review method. RESULTS We included 86 publications, mainly from research centres in Europe, North America and Australasia. Two hs-cTn assays, manufactured by Abbott (43/86) and Roche (53/86), dominated the evaluations. The studies most commonly measured the concentrations of hs-cTn at two time points, at presentation and a few hours thereafter, to assess the two-strata or three-strata algorithm for diagnosing or ruling out MI. Although data from 83 studies (97%) were prospectively collected, 0%-90% of the eligible patients were excluded from the analysis due to missing blood samples or the lack of a final diagnosis in 53 studies (62%) that reported relevant data. Only 19 studies (22%) reported on head-to-head comparisons of alternative assays. CONCLUSION Evidence on the accuracy of serial hs-cTn testing was largely derived from selected research institutions and relied on two specific assays. The proportions of the eligible patients excluded from the study raise concerns about directly applying the study findings to clinical practice in frontline EDs. PROSPERO REGISTRATION NUMBER CRD42018106379.
Collapse
Affiliation(s)
- Hirotaka Ohtake
- Department of Emergency and General Internal Medicine, Fujita Health University, Toyoake, Aichi, Japan
| | - Teruhiko Terasawa
- Department of Emergency and General Internal Medicine, Fujita Health University, Toyoake, Aichi, Japan
| | - Zhivko Zhelev
- University of Exeter Medical School, University of Exeter, Exeter, UK
| | - Mitsunaga Iwata
- Department of Emergency and General Internal Medicine, Fujita Health University, Toyoake, Aichi, Japan
| | - Morwenna Rogers
- NIHR CLAHRC South West Peninsula, University of Exeter, Exeter, UK
| | - Jaime L Peters
- Peninsula Technology Assessment Group (PenTAG), University of Exeter, Exeter, UK
- Peninsula Technology Assessment Group (PenTAG), University of Exeter, Exeter, UK
| | - Chris Hyde
- Exeter Test Group, University of Exeter, Exeter, UK
| |
Collapse
|
42
|
Kontos MC, de Lemos JA, Deitelzweig SB, Diercks DB, Gore MO, Hess EP, McCarthy CP, McCord JK, Musey PI, Villines TC, Wright LJ. 2022 ACC Expert Consensus Decision Pathway on the Evaluation and Disposition of Acute Chest Pain in the Emergency Department: A Report of the American College of Cardiology Solution Set Oversight Committee. J Am Coll Cardiol 2022; 80:1925-1960. [PMID: 36241466 PMCID: PMC10691881 DOI: 10.1016/j.jacc.2022.08.750] [Citation(s) in RCA: 61] [Impact Index Per Article: 30.5] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
|
43
|
Kaur G, Chand S, Rai D, Baibhav B, Blankstein R, Mukherjee D, Levy P, Gulati M. Contemporary Risk Stratification of Acute Coronary Syndrome. US CARDIOLOGY REVIEW 2022. [DOI: 10.15420/usc.2022.10] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Chest pain is one of the most common presenting concerns of patients seeking care in the emergency department, and the underlying etiology can range from acute coronary syndrome to various other non-cardiac causes. Initial evaluation should focus on characterizing symptoms and identifying risk factors, but further risk stratification using clinical decision pathways and biomarkers (cardiac troponin) is essential. The 2021 American Heart Association/American College of Cardiology guidelines for the evaluation and diagnosis of chest pain represent the first ever guidelines for the evaluation of patients with acute chest pain. The contemporary risk stratification methods described in these guidelines allow for the identification of patient subgroups: patients who do not require further testing, patients who should proceed directly to the cath lab, and patients who will benefit from further anatomic or functional testing. In this review, we describe contemporary risk stratification methods for acute coronary syndrome and summarize the recommendations put forth by the guidelines.
Collapse
Affiliation(s)
- Gurleen Kaur
- Department of Internal Medicine, Brigham and Women’s Hospital, Boston, MA
| | - Swati Chand
- Department of Internal Medicine, Rochester General Hospital, Rochester, NY
| | - Devesh Rai
- Department of Cardiology, Sands-Constellation Heart Institute, Rochester Regional Health, Rochester, NY
| | - Bipul Baibhav
- Department of Cardiology, Sands-Constellation Heart Institute, Rochester Regional Health, Rochester, NY
| | - Ron Blankstein
- Cardiovascular Division, Brigham and Women’s Hospital, Boston, MA
| | - Debabrata Mukherjee
- Division of Cardiovascular Diseases, Texas Tech University Health Sciences Center at El Paso, El Paso, TX
| | - Phillip Levy
- Department of Emergency Medicine, Wayne State University, Detroit, MI
| | - Martha Gulati
- Department of Cardiology, Barbra Streisand Women’s Heart Center, Cedars-Sinai Smidt Heart Institute, Los Angeles, CA
| |
Collapse
|
44
|
Lowry MT, Doudesis D, Wereski R, Kimenai DM, Tuck C, Ferry AV, Bularga A, Taggart C, Lee KK, Chapman AR, Shah AS, Newby DE, Mills NL, Anand A. Influence of Age on the Diagnosis of Myocardial Infarction. Circulation 2022; 146:1135-1148. [PMID: 36106552 PMCID: PMC9555758 DOI: 10.1161/circulationaha.122.059994] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Accepted: 08/04/2022] [Indexed: 01/24/2023]
Abstract
BACKGROUND The 99th centile of cardiac troponin, derived from a healthy reference population, is recommended as the diagnostic threshold for myocardial infarction, but troponin concentrations are strongly influenced by age. Our aim was to assess the diagnostic performance of cardiac troponin in older patients presenting with suspected myocardial infarction. METHODS In a secondary analysis of a multicenter trial of consecutive patients with suspected myocardial infarction, we assessed the diagnostic accuracy of high-sensitivity cardiac troponin I at presentation for the diagnosis of type 1, type 2, or type 4b myocardial infarction across 3 age groups (<50, 50-74, and ≥75 years) using guideline-recommended sex-specific and age-adjusted 99th centile thresholds. RESULTS In 46 435 consecutive patients aged 18 to 108 years (mean, 61±17 years), 5216 (11%) had a diagnosis of myocardial infarction. In patients <50 (n=12 379), 50 to 74 (n=22 380), and ≥75 (n=11 676) years, the sensitivity of the guideline-recommended threshold was similar at 79.2% (95% CI, 75.5-82.9), 80.6% (95% CI, 79.2-82.1), and 81.6% (95% CI, 79.8-83.2), respectively. The specificity decreased with advancing age from 98.3% (95% CI, 98.1-98.5) to 95.5% (95% CI, 95.2-95.8), and 82.6% (95% CI, 81.9-83.4). The use of age-adjusted 99th centile thresholds improved the specificity (91.3% [90.8%-91.9%] versus 82.6% [95% CI, 81.9%-83.4%]) and positive predictive value (59.3% [57.0%-61.5%] versus 51.5% [49.9%-53.3%]) for myocardial infarction in patients ≥75 years but failed to prevent the decrease in either parameter with increasing age and resulted in a marked reduction in sensitivity compared with the use of the guideline-recommended threshold (55.9% [53.6%-57.9%] versus 81.6% [79.8%-83.3%]. CONCLUSIONS Age alters the diagnostic performance of cardiac troponin, with reduced specificity and positive predictive value in older patients when applying the guideline-recommended or age-adjusted 99th centiles. Individualized diagnostic approaches rather than the adjustment of binary thresholds are needed in an aging population.
Collapse
Affiliation(s)
- Matthew T.H. Lowry
- BHF Centre for Cardiovascular Science (M.T.H.L., D.D., R.W., D.M.K., C.T., A.V.F., A.B., C.T., K.K.L., A.R.C., D.E.N., N.L.M., A.A.), University of Edinburgh, UK
| | - Dimitrios Doudesis
- BHF Centre for Cardiovascular Science (M.T.H.L., D.D., R.W., D.M.K., C.T., A.V.F., A.B., C.T., K.K.L., A.R.C., D.E.N., N.L.M., A.A.), University of Edinburgh, UK
- Usher Institute (D.D., N.L.M.), University of Edinburgh, UK
| | - Ryan Wereski
- BHF Centre for Cardiovascular Science (M.T.H.L., D.D., R.W., D.M.K., C.T., A.V.F., A.B., C.T., K.K.L., A.R.C., D.E.N., N.L.M., A.A.), University of Edinburgh, UK
| | - Dorien M. Kimenai
- BHF Centre for Cardiovascular Science (M.T.H.L., D.D., R.W., D.M.K., C.T., A.V.F., A.B., C.T., K.K.L., A.R.C., D.E.N., N.L.M., A.A.), University of Edinburgh, UK
| | - Christopher Tuck
- BHF Centre for Cardiovascular Science (M.T.H.L., D.D., R.W., D.M.K., C.T., A.V.F., A.B., C.T., K.K.L., A.R.C., D.E.N., N.L.M., A.A.), University of Edinburgh, UK
| | - Amy V. Ferry
- BHF Centre for Cardiovascular Science (M.T.H.L., D.D., R.W., D.M.K., C.T., A.V.F., A.B., C.T., K.K.L., A.R.C., D.E.N., N.L.M., A.A.), University of Edinburgh, UK
| | - Anda Bularga
- BHF Centre for Cardiovascular Science (M.T.H.L., D.D., R.W., D.M.K., C.T., A.V.F., A.B., C.T., K.K.L., A.R.C., D.E.N., N.L.M., A.A.), University of Edinburgh, UK
| | - Caelan Taggart
- BHF Centre for Cardiovascular Science (M.T.H.L., D.D., R.W., D.M.K., C.T., A.V.F., A.B., C.T., K.K.L., A.R.C., D.E.N., N.L.M., A.A.), University of Edinburgh, UK
| | - Kuan K. Lee
- BHF Centre for Cardiovascular Science (M.T.H.L., D.D., R.W., D.M.K., C.T., A.V.F., A.B., C.T., K.K.L., A.R.C., D.E.N., N.L.M., A.A.), University of Edinburgh, UK
| | - Andrew R. Chapman
- BHF Centre for Cardiovascular Science (M.T.H.L., D.D., R.W., D.M.K., C.T., A.V.F., A.B., C.T., K.K.L., A.R.C., D.E.N., N.L.M., A.A.), University of Edinburgh, UK
| | - Anoop S.V. Shah
- Department of Non-communicable Disease, London School of Hygiene and Tropical Medicine, UK (A.S.V.S.)
- Department of Cardiology, Imperial College Healthcare NHS Trust, London, UK (A.S.V.S.)
| | - David E. Newby
- BHF Centre for Cardiovascular Science (M.T.H.L., D.D., R.W., D.M.K., C.T., A.V.F., A.B., C.T., K.K.L., A.R.C., D.E.N., N.L.M., A.A.), University of Edinburgh, UK
| | - Nicholas L. Mills
- BHF Centre for Cardiovascular Science (M.T.H.L., D.D., R.W., D.M.K., C.T., A.V.F., A.B., C.T., K.K.L., A.R.C., D.E.N., N.L.M., A.A.), University of Edinburgh, UK
| | - Atul Anand
- BHF Centre for Cardiovascular Science (M.T.H.L., D.D., R.W., D.M.K., C.T., A.V.F., A.B., C.T., K.K.L., A.R.C., D.E.N., N.L.M., A.A.), University of Edinburgh, UK
- Usher Institute (D.D., N.L.M.), University of Edinburgh, UK
| |
Collapse
|
45
|
Fladseth K, Wilsgaard T, Lindekleiv H, Kristensen A, Mannsverk J, Løchen ML, Njølstad I, Mathiesen EB, Trovik T, Rotevatn S, Forsdahl S, Schirmer H. Outcomes after coronary angiography for unstable angina compared to stable angina, myocardial infarction and an asymptomatic general population. IJC HEART & VASCULATURE 2022; 42:101099. [PMID: 35937948 PMCID: PMC9352908 DOI: 10.1016/j.ijcha.2022.101099] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Revised: 07/24/2022] [Accepted: 07/26/2022] [Indexed: 11/22/2022]
Abstract
Background The outcomes of real-world unstable angina (UA) in the high-sensitivity troponin era are unclear. We aimed to investigate the outcomes of UA referred to coronary angiography compared to stable angina (SA), non-ST-segment elevation myocardial infarction (NSTEMI), STEMI and a general population. Methods We included the 9,694 patients with no prior coronary artery disease (CAD) referred to invasive or CT coronary angiography from 2013 to 2018 in Northern Norway (51% SA, 12% UA, 23% NSTEMI and 14% STEMI), and 11,959 asymptomatic individuals recruited from the Tromsø Study. We used Cox models to estimate the hazard ratios (HR) for all-cause mortality and major adverse cardiovascular events (MACE), defined as cardiovascular death, MI or obstructive CAD. Results The median follow-up time was 2.8 years. The incidence rate of death was 8.5 per 1000 person-years (95 % confidence interval [CI] 8.0-9.0) in the general population, 9.7 (95 % CI 8.3-11.5) in SA, 14.9 (95 % CI 11.4-19.6) in UA, 29.7 (95 % CI 25.6-34.3) in NSTEMI and 36.5 (95 % CI 30.9-43.2) in STEMI. In multivariable adjusted analyses, compared with UA, SA had a 38 % lower risk of death and a non-significant lower risk of MACE (HR 0.62, 95 % CI 0.44-0.89; HR 0.86, 95 % CI 0.66-1.11). NSTEMI had a 2.4-fold higher risk of death (HR 2.39, 95 % CI 1.38-4.14) and a 1.6-fold higher risk of MACE (HR 1.62, 95 % CI 1.11-2.38) compared tox UA during the first year after coronary angiography, but a similar risk thereafter. There was no difference in the risk of death for UA with non-obstructive CAD and obstructive CAD (HR 0.78, 95 % CI 0.39-1.57). Conclusion UA had a higher risk of death but a similar risk of MACE compared to SA and a lower 1-year risk of death and MACE compared to NSTEMI.
Collapse
Key Words
- CABG, Coronary artery bypass graft
- CAD, Coronary artery disease
- CCTA, Coronary computed tomography angiography
- ESC, European Society of Cardiology
- FFR, Fractional flow reserve
- High-sensitivity troponins
- Hs-cTn, High-sensitivity troponin
- ICA, Invasive coronary angiography
- MACE, Major cardiovascular events
- MI, Myocardial infarction
- NORIC, Norwegian Registry of Invasive Cardiology
- NSTE-ACS, Non-ST-segment elevation acute coronary syndrome
- NSTEMI, Non-ST-segment elevation myocardial infarction
- Non-ST elevation acute coronary syndrome
- Non-obstructive coronary artery disease
- PCI, Percutaneous coronary intervention
- Prognosis
- SA, Stable angina
- STEMI, ST-segment elevation myocardial infarction
- UA, Unstable angina
Collapse
Affiliation(s)
- Kristina Fladseth
- Department of Clinical Medicine, UiT The Arctic University of Norway, Tromsø, Norway
- Department of Cardiology, University Hospital of North Norway, Tromsø, Norway
| | - Tom Wilsgaard
- Department of Community Medicine, UiT The Arctic University of Norway, Tromsø, Norway
| | - Haakon Lindekleiv
- Department of Cardiology, University Hospital of North Norway, Tromsø, Norway
| | - Andreas Kristensen
- Department of Cardiology, University Hospital of North Norway, Tromsø, Norway
| | - Jan Mannsverk
- Department of Cardiology, University Hospital of North Norway, Tromsø, Norway
| | - Maja-Lisa Løchen
- Department of Community Medicine, UiT The Arctic University of Norway, Tromsø, Norway
| | - Inger Njølstad
- Department of Community Medicine, UiT The Arctic University of Norway, Tromsø, Norway
| | - Ellisiv B Mathiesen
- Department of Clinical Medicine, UiT The Arctic University of Norway, Tromsø, Norway
- Department of Neurology, University Hospital of North Norway, Tromsø, Norway
| | - Thor Trovik
- Department of Cardiology, University Hospital of North Norway, Tromsø, Norway
| | - Svein Rotevatn
- Department of Heart Disease, Haukeland University Hospital, Bergen, Norway
- Norwegian Registry of Invasive Cardiology, Bergen, Norway
| | - Signe Forsdahl
- Department of Radiology, University Hospital North Norway, Tromsø, Norway
| | - Henrik Schirmer
- Department of Clinical Medicine, UiT The Arctic University of Norway, Tromsø, Norway
- Institute of Clinical Medicine, University of Oslo, Lørenskog, Norway
- Department of Cardiology, Akershus University Hospital, Lørenskog, Norway
| |
Collapse
|
46
|
Schulte C, Singh B, Theofilatos K, Sörensen NA, Lehmacher J, Hartikainen T, Haller PM, Westermann D, Zeller T, Blankenberg S, Neumann JT, Mayr M. Serial measurements of protein and microRNA biomarkers to specify myocardial infarction subtypes. JOURNAL OF MOLECULAR AND CELLULAR CARDIOLOGY PLUS 2022; 1:None. [PMID: 36185590 PMCID: PMC9514835 DOI: 10.1016/j.jmccpl.2022.100014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Accepted: 08/10/2022] [Indexed: 11/19/2022]
Abstract
Background While cardiac-specific troponin (cTn) allows for rapid diagnosis of acute type 1 myocardial infarction (T1MI), its performance to differentiate acute myocardial injury (AI) or type 2 myocardial infarction (T2MI) is limited. The objective was to combine biomarkers to improve discrimination of different myocardial infarction (MI) aetiologies. Methods We determined levels of cardiac troponin T and I (cTnT, cTnI), cardiac myosin-binding protein C (cMyBP-C), NT-proBNP and ten miRNAs, known to be associated with cardiac pathology in a total of n = 495 serial plasma samples at three time points (on admission, after 1 h and 3 h) from 57 NSTEMI (non-ST-elevation myocardial infarction), 18 AI, and 31 STEMI patients, as defined by fourth universal definition of MI (UDMI4) and 59 control individuals. We then applied linear mixed effects model to compare the kinetics of all molecules in these MI sub-types. Results Established (cTnT, cTnI) and novel (cMyBP-C) cardiac necrosis markers failed in differentiating T1MI vs T2MI at early time points. All cardiac necrosis markers were higher in T1MI than in T2MI at 3 h after admission. Muscle-enriched miRNAs (miR-1 and miR-133a) were correlated with cardiac necrosis protein markers and did not offer better discrimination. Established cardiac strain marker NT-proBNP differentiated AI and T1MI at all time points but failed to discriminate T2MI from T1MI. However, the combination of NT-proBNP and cTnT along with age returned an overall AUC of 0.76 [95 % CI 0.67-0.84] for differentiating T1MI, T2MI and AI. Conclusions Rather than using single biomarkers of myocardial necrosis, a combination of clinical biomarkers for cardiac necrosis (troponin) and cardiac strain (NT-proBNP) might aid in differentiating T1MI, T2MI and AI.
Collapse
Affiliation(s)
- Christian Schulte
- King's British Heart Foundation Centre, King's College London, United Kingdom
- Department of Cardiology, University Heart & Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- German Centre of Cardiovascular Research (DZHK), Partner Site Hamburg, Luebeck, Kiel, Hamburg, Germany
| | - Bhawana Singh
- King's British Heart Foundation Centre, King's College London, United Kingdom
| | | | - Nils A. Sörensen
- Department of Cardiology, University Heart & Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- German Centre of Cardiovascular Research (DZHK), Partner Site Hamburg, Luebeck, Kiel, Hamburg, Germany
| | - Jonas Lehmacher
- Department of Cardiology, University Heart & Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- German Centre of Cardiovascular Research (DZHK), Partner Site Hamburg, Luebeck, Kiel, Hamburg, Germany
| | - Tau Hartikainen
- Department of Cardiology and Angiology, University Heart Center Freiburg-Bad Krozingen, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Paul M. Haller
- Department of Cardiology, University Heart & Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- German Centre of Cardiovascular Research (DZHK), Partner Site Hamburg, Luebeck, Kiel, Hamburg, Germany
| | - Dirk Westermann
- Department of Cardiology and Angiology, University Heart Center Freiburg-Bad Krozingen, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Tanja Zeller
- Department of Cardiology, University Heart & Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- German Centre of Cardiovascular Research (DZHK), Partner Site Hamburg, Luebeck, Kiel, Hamburg, Germany
- University Center of Cardiovascular Science, Hamburg, Germany
| | - Stefan Blankenberg
- Department of Cardiology, University Heart & Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- German Centre of Cardiovascular Research (DZHK), Partner Site Hamburg, Luebeck, Kiel, Hamburg, Germany
| | - Johannes T. Neumann
- Department of Cardiology, University Heart & Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- German Centre of Cardiovascular Research (DZHK), Partner Site Hamburg, Luebeck, Kiel, Hamburg, Germany
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Manuel Mayr
- King's British Heart Foundation Centre, King's College London, United Kingdom
| |
Collapse
|
47
|
Prognosis is worse with elevated cardiac troponin in nonacute coronary syndrome compared with acute coronary syndrome. Coron Artery Dis 2022; 33:376-384. [PMID: 35880560 DOI: 10.1097/mca.0000000000001135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Cardiac troponin (cTn) can be elevated in many patients presenting to the emergency department (ED) with chest pain but without a diagnosis of acute coronary syndrome (ACS). We compared the prognostic significance of cTn in these different populations. METHODS We retrospectively analyzed the CHOPIN study, which enrolled patients who presented to the ED with chest pain. Patients were grouped as ACS, non-ACS cardiovascular disease, noncardiac chest pain and chest pain not otherwise specified (NOS). We examined the prognostic ability of cTnI for the clinical endpoints of mortality and major adverse cardiovascular event (MACE; a composite of acute myocardial infarction, unstable angina, revascularization, reinfarction, and congestive heart failure and stroke) at 180-day follow-up. RESULTS Among 1982 patients analyzed, 14% had ACS, 21% had non-ACS cardiovascular disease, 31% had a noncardiac diagnosis and 34% had chest pain NOS. cTnI elevation above the 99th percentile was observed in 52, 18, 6 and 7% in these groups, respectively. cTnI elevation was associated with mortality and MACE, and their relationships were more prominent in noncardiac diagnosis and chest pain NOS than in ACS and non-ACS cardiovascular diagnoses for mortality, and in non-ACS patients than in ACS patients for MACE (hazard ratio for doubling of cTnI 1.85, 2.05, 8.26 and 4.14, respectively; P for interaction 0.011 for mortality; 1.04, 1.23, 1.54 and 1.42, respectively; P for interaction <0.001 for MACE). CONCLUSION In patients presenting to the ED with chest pain, cTnI elevation was associated with a worse prognosis in non-ACS patients than in ACS patients.
Collapse
|
48
|
Golino M, Marazzato J, Blasi F, Morello M, Chierchia V, Cadonati C, Matteo F, Licciardello C, Zappa M, Ageno W, Passi A, Angeli F, De Ponti R. High-Sensitivity Cardiac Troponin T and the Diagnosis of Cardiovascular Disease in the Emergency Room: The Importance of Combining Cardiovascular Biomarkers with Clinical Data. J Clin Med 2022; 11:jcm11133798. [PMID: 35807089 PMCID: PMC9267782 DOI: 10.3390/jcm11133798] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Revised: 06/28/2022] [Accepted: 06/29/2022] [Indexed: 01/27/2023] Open
Abstract
Background. Nowadays, it is still not possible to clinically distinguish whether an increase in high-sensitivity cardiac troponin (hs-cTn) values is due to myocardial injury or an acute coronary syndrome (ACS). Moreover, predictive data regarding hs-cTnT in an emergency room (ER) setting are scarce. This monocentric retrospective study aimed to improve the knowledge and interpretation of this cardiac biomarker in daily clinical practice. Methods. Consecutive adult patients presenting at the ER and hospitalized with a first abnormal hs-cTnT value (≥14 ng/L) were enrolled for 6 months. The baseline hs-cTnT value and the ensuing changes and variations were correlated with the clinical presentation and the type of diagnosis. Subsequently, multivariable models were built to assess which clinical/laboratory variables most influenced hospital admissions in the investigated population analyzed according to the final reason for hospitalization: (1) cardiovascular vs. non-cardiovascular diagnosis, and (2) ACS vs. non-ACS one. Results. A total of 4660 patients were considered, and, after a first screening, 4149 patients were enrolled. Out of 4129 patients, 1555 (37.5%) had a first hs-cTnT ≥14 ng/L, and 1007 (65%) were hospitalized with the following types of diagnosis: ACS (182; 18%), non-ACS cardiovascular disease (337; 34%) and non-cardiovascular disease (487; 48%). Higher hs-cTnT values and significant hs-cTnT variations were found in the ACS group (p < 0.01). The mean percentage of variation was higher in patients with ACS, intermediate in those with non-ACS cardiovascular disease, and low in those with non-cardiovascular disease (407.5%, 270.6% and 12.4%, respectively). Only syncope and CRP (OR: 0.08, 95% CI: 0.02−0.39, p < 0.01 and OR: 0.9988, 95% CI: 0.9979−0.9998, p = 0.02, respectively) or CRP (OR: 0.9948, 95% CI: 0.9908−0.9989, p = 0.01) and NT-proBNP (OR: 1.0002, 95% CI: 1.0000−1.0004, p = 0.02) were independent predictors of a cardiovascular disease diagnosis. On the other hand, only chest pain (OR: 22.91, 95% CI: 3.97−132.32, p < 0.01) and eGFR (OR: 1.04, 95% CI: 1.004−1.083, p = 0.03) were associated with the ACS diagnosis. Conclusions. Differently from the investigated biomarkers, in this study, only clinical variables predicted hospitalizations in different patients’ subgroups.
Collapse
Affiliation(s)
- Michele Golino
- Department of Medicine and Surgery, University of Insubria, 21100 Varese, Italy; (J.M.); (F.B.); (V.C.); (F.M.); (C.L.); (M.Z.); (W.A.); (A.P.); (F.A.); (R.D.P.)
- Ospedale di Circolo, ASST Settelaghi, 21100 Varese, Italy; (M.M.); (C.C.)
- Correspondence:
| | - Jacopo Marazzato
- Department of Medicine and Surgery, University of Insubria, 21100 Varese, Italy; (J.M.); (F.B.); (V.C.); (F.M.); (C.L.); (M.Z.); (W.A.); (A.P.); (F.A.); (R.D.P.)
- Ospedale di Circolo, ASST Settelaghi, 21100 Varese, Italy; (M.M.); (C.C.)
| | - Federico Blasi
- Department of Medicine and Surgery, University of Insubria, 21100 Varese, Italy; (J.M.); (F.B.); (V.C.); (F.M.); (C.L.); (M.Z.); (W.A.); (A.P.); (F.A.); (R.D.P.)
- Ospedale di Circolo, ASST Settelaghi, 21100 Varese, Italy; (M.M.); (C.C.)
| | - Matteo Morello
- Ospedale di Circolo, ASST Settelaghi, 21100 Varese, Italy; (M.M.); (C.C.)
- School of Cardiology, University of Brescia, 25121 Brescia, Italy
| | - Valentina Chierchia
- Department of Medicine and Surgery, University of Insubria, 21100 Varese, Italy; (J.M.); (F.B.); (V.C.); (F.M.); (C.L.); (M.Z.); (W.A.); (A.P.); (F.A.); (R.D.P.)
| | - Cristina Cadonati
- Ospedale di Circolo, ASST Settelaghi, 21100 Varese, Italy; (M.M.); (C.C.)
- School of Cardiology, University of Brescia, 25121 Brescia, Italy
| | - Federica Matteo
- Department of Medicine and Surgery, University of Insubria, 21100 Varese, Italy; (J.M.); (F.B.); (V.C.); (F.M.); (C.L.); (M.Z.); (W.A.); (A.P.); (F.A.); (R.D.P.)
- Ospedale di Circolo, ASST Settelaghi, 21100 Varese, Italy; (M.M.); (C.C.)
| | - Claudio Licciardello
- Department of Medicine and Surgery, University of Insubria, 21100 Varese, Italy; (J.M.); (F.B.); (V.C.); (F.M.); (C.L.); (M.Z.); (W.A.); (A.P.); (F.A.); (R.D.P.)
- Ospedale di Circolo, ASST Settelaghi, 21100 Varese, Italy; (M.M.); (C.C.)
| | - Martina Zappa
- Department of Medicine and Surgery, University of Insubria, 21100 Varese, Italy; (J.M.); (F.B.); (V.C.); (F.M.); (C.L.); (M.Z.); (W.A.); (A.P.); (F.A.); (R.D.P.)
- Department of Medicine and Cardiopulmonary Rehabilitation, Maugeri Care and Research Institute, IRCCS Tradate, 21049 Tradate, Italy
| | - Walter Ageno
- Department of Medicine and Surgery, University of Insubria, 21100 Varese, Italy; (J.M.); (F.B.); (V.C.); (F.M.); (C.L.); (M.Z.); (W.A.); (A.P.); (F.A.); (R.D.P.)
- Ospedale di Circolo, ASST Settelaghi, 21100 Varese, Italy; (M.M.); (C.C.)
| | - Alberto Passi
- Department of Medicine and Surgery, University of Insubria, 21100 Varese, Italy; (J.M.); (F.B.); (V.C.); (F.M.); (C.L.); (M.Z.); (W.A.); (A.P.); (F.A.); (R.D.P.)
- Ospedale di Circolo, ASST Settelaghi, 21100 Varese, Italy; (M.M.); (C.C.)
| | - Fabio Angeli
- Department of Medicine and Surgery, University of Insubria, 21100 Varese, Italy; (J.M.); (F.B.); (V.C.); (F.M.); (C.L.); (M.Z.); (W.A.); (A.P.); (F.A.); (R.D.P.)
- Department of Medicine and Cardiopulmonary Rehabilitation, Maugeri Care and Research Institute, IRCCS Tradate, 21049 Tradate, Italy
| | - Roberto De Ponti
- Department of Medicine and Surgery, University of Insubria, 21100 Varese, Italy; (J.M.); (F.B.); (V.C.); (F.M.); (C.L.); (M.Z.); (W.A.); (A.P.); (F.A.); (R.D.P.)
- Ospedale di Circolo, ASST Settelaghi, 21100 Varese, Italy; (M.M.); (C.C.)
| |
Collapse
|
49
|
Aakre KM, Saenger AK, Body R, Collinson P, Hammarsten O, Jaffe AS, Kavsak P, Omland T, Ordonez-Lianos J, Apple FS. Analytical Considerations in Deriving 99th Percentile Upper Reference Limits for High-Sensitivity Cardiac Troponin Assays: Educational Recommendations from the IFCC Committee on Clinical Application of Cardiac Bio-Markers. Clin Chem 2022; 68:1022-1030. [PMID: 35716089 DOI: 10.1093/clinchem/hvac092] [Citation(s) in RCA: 33] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Accepted: 04/27/2022] [Indexed: 11/14/2022]
Abstract
The International Federation of Clinical Chemistry Committee on Clinical Application of Cardiac Bio-Markers provides evidence-based educational documents to facilitate uniform interpretation and utilization of cardiac biomarkers in clinical laboratories and practice. The committee's goals are to improve the understanding of certain key analytical and clinical aspects of cardiac biomarkers and how these may interplay in clinical practice. Measurement of high-sensitivity cardiac troponin (hs-cTn) assays is a cornerstone in the clinical evaluation of patients with symptoms and/or signs of acute cardiac ischemia. To define myocardial infarction, the Universal Definition of Myocardial Infarction requires patients who manifest with features suggestive of acute myocardial ischemia to have at least one cTn concentration above the sex-specific 99th percentile upper reference limit (URL) for hs-cTn assays and a dynamic pattern of cTn concentrations to fulfill the diagnostic criteria for MI. This special report provides an overview of how hs-cTn 99th percentile URLs should be established, including recommendations about prescreening and the number of individuals required in the reference cohort, how statistical analysis should be conducted, optimal preanalytical and analytical protocols, and analytical/biological interferences or confounds that can affect accurate determination of the 99th percentile URLs. This document also provides guidance and solutions to many of the issues posed.
Collapse
Affiliation(s)
- Kristin M Aakre
- Department of Medical Biochemistry and Pharmacology and Department of Heart Disease, Haukeland University Hospital, Bergen, Norway.,Department of Clinical Science, University of Bergen, Bergen, Norway
| | - 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
| | - Rick Body
- Emergency Department, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK.,Division of Cardiovascular Sciences, The University of Manchester, Manchester, UK.,Healthcare Sciences Department, Manchester Metropolitan University, Manchester, UK
| | - Paul Collinson
- Department of Clinical Blood Sciences and Cardiology, St George's University Hospitals NHS Foundation Trust, London, UK.,Departments of Clinical Blood Sciences and Cardiology, St George's University of London, London, UK
| | - Ola Hammarsten
- Department of Clinical Chemistry and Transfusion Medicine, University of Gothenburg, Gothenburg, Sweden
| | - Allan S Jaffe
- Departments of Laboratory Medicine and Pathology and Cardiology, Mayo Clinic, Rochester, MN, USA
| | - Pete Kavsak
- Department of Pathology and Molecular Medicine, McMaster University, Hamilton, ON, Canada
| | - Torbjørn Omland
- Department of Cardiology, Akershus University Hospital, Lørenskog, Norway.,Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Jordi Ordonez-Lianos
- Servicio de Bioquímica Clínica, Institut d'Investigacions Biomèdiques Sant Pau, Barcelona, Spain.,Departamento de Bioquímica y Biología Molecular, Universidad Autònoma de Barcelona, Barcelona, Spain
| | - Fred S Apple
- Department of Laboratory Medicine and Pathology, Hennepin Healthcare/HCMC, Minneapolis, MN, USA.,Department of Laboratory Medicine and Pathology, University of Minnesota, Minneapolis, MN, USA
| |
Collapse
|
50
|
González de la Presa B, Chicha-Cattoir V, Bedini JL, Vecchia L, Lefevre G, Mira A, Fernández Calle P, Bonelli E, Robert T, Rico N, de Pedro MS, Canovi S, Buño Soto A, Peoc’h K, Fasano T, Diaz-Garzon J. Performance evaluation of the high sensitive troponin I assay on the Atellica IM analyser. Biochem Med (Zagreb) 2022; 32:020709. [PMID: 35799986 PMCID: PMC9195607 DOI: 10.11613/bm.2022.020709] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2021] [Accepted: 03/23/2022] [Indexed: 11/06/2022] Open
Abstract
Introduction The Fourth Universal Definition of Myocardial Infarction Global Taskforce recommends the use of high sensitive troponin (hs-Tn) assays in the diagnosis of acute myocardial infarction. We evaluated the analytical performance of the Atellica IM High-sensitivity Troponin I Assay (hs-TnI) (Siemens Healthcare Diagnostics Inc., Tarrytown, USA) and compared its performance to other hs-TnI assays (Siemens Advia Centaur, Dimension Vista, Dimension EXL, and Abbott Architect (Wiesbaden, Germany)) at one or more sites across Europe. Materials and methods Precision, detection limit, linearity, method comparison, and interference studies were performed according to Clinical and Laboratory Standards Institute protocols. Values in 40 healthy individuals were compared to the manufacturer’s cut-offs. Sample turnaround time (TAT) was examined. Results Imprecision repeatability CVs were 1.1–4.7% and within-lab imprecision were 1.8–7.6% (10.0–25,000 ng/L). The limit of blank (LoB), detection (LoD), and quantitation (LoQ) aligned with the manufacturer’s values of 0.5 ng/L, 1.6 ng/L, and 2.5 ng/L, respectively. Passing-Bablok regression demonstrated good correlations between Atellica IM analyser with other systems; some minor deviations were observed. All results in healthy volunteers fell below the 99th percentile URL, and greater than 50% of each sex demonstrated values above the LoD. No interference was observed for biotin (≤ 1500 µg/L), but a slight bias at 5.0 g/L haemoglobin and 50 ng/L Tn was observed. TAT from was fast (mean time = 10.9 minutes) and reproducible (6%CV). Conclusions Real-world analytical and TAT performance of the hs-TnI assay on the Atellica IM analyser make this assay fit for routine use in clinical laboratories.
Collapse
Affiliation(s)
| | | | | | - Luigi Vecchia
- Clinical Chemistry and Endocrinology Laboratory, Department of Diagnostic Imaging and Laboratory Medicine, Hospital Santa Maria Nuova, Reggio Emilia, Italy
| | - Guillaume Lefevre
- Biochemistry and Hormonology Department, Hospital Tenon, Paris, France
| | - Aurea Mira
- Biomedical Diagnostic Center, Hospital Clinic, Barcelona, Spain
| | | | - Efrem Bonelli
- Clinical Chemistry and Endocrinology Laboratory, Department of Diagnostic Imaging and Laboratory Medicine, Hospital Santa Maria Nuova, Reggio Emilia, Italy
| | - Tiphaine Robert
- Clinical and Metabolic Biochemistry Department, Hospital Bichat, Paris, France
| | - Nayra Rico
- Biomedical Diagnostic Center, Hospital Clinic, Barcelona, Spain
| | | | - Simone Canovi
- Clinical Chemistry and Endocrinology Laboratory, Department of Diagnostic Imaging and Laboratory Medicine, Hospital Santa Maria Nuova, Reggio Emilia, Italy
| | - Antonio Buño Soto
- Laboratory Medicine Department, La Paz University Hospital, Madrid, Spain
| | - Katell Peoc’h
- Clinical Biochemistry Department, Hospital Beaujon, Clichy, France
| | - Tommaso Fasano
- Clinical Chemistry and Endocrinology Laboratory, Department of Diagnostic Imaging and Laboratory Medicine, Hospital Santa Maria Nuova, Reggio Emilia, Italy
| | - Jorge Diaz-Garzon
- Laboratory Medicine Department, La Paz University Hospital, Madrid, Spain
| |
Collapse
|