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Zhou Z, Hsu KS, Eason J, Kauh B, Duchesne J, Desta M, Cranford W, Woodworth A, Moore JD, Stearley ST, Gupta VA. Improvement of Emergency Department Chest Pain Evaluation Using Hs-cTnT and a Risk Stratification Pathway. J Emerg Med 2024; 66:e660-e669. [PMID: 38789352 DOI: 10.1016/j.jemermed.2024.02.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Revised: 01/22/2024] [Accepted: 02/02/2024] [Indexed: 05/26/2024]
Abstract
BACKGROUND Chest pain is among the most common reasons for presentation to the emergency department (ED) worldwide. Additional studies on most cost-effective ways of differentiating serious vs. benign causes of chest pain are needed. OBJECTIVES Our study aimed to evaluate the effectiveness of a novel risk stratification pathway utilizing 5th generation high-sensitivity cardiac troponin T assay (Hs-cTnT) and HEART score (History, Electrocardiogram, Age, Risk factors, Troponin) in assessing nontraumatic chest pain patients in reducing ED resource utilization. METHODS A retrospective chart review was performed 6 months prior to and after the implementation of a novel risk stratification pathway that combined hs-cTnT with HEART score to guide evaluation of adult patients presenting with nontraumatic chest pain at a large academic quaternary care ED. Primary outcome was ED length of stay (LOS); secondary outcomes included cardiology consult rates, admission rates, number of ED boarders, and number of eloped patients. RESULTS A total of 1707 patients and 1529 patients were included pre- and postimplementation, respectively. Median overall ED LOS decreased from 317 to 286 min, an absolute reduction of 31 min (95% confidence interval 22-41 min), after pathway implementation (p < 0.001). Furthermore, cardiology consult rate decreased from 26.9% to 16.0% (p < 0.0001), rate of admission decreased from 30.1% to 22.7% (p < 0.0001), and number of ED boarders as a proportion of all nontraumatic chest pain patients decreased from 25.13% preimplementation to 18.63% postimplementation (p < 0.0001). CONCLUSIONS Implementation of our novel chest pain pathway improved numerous ED throughput metrics in the evaluation of nontraumatic chest pain patients.
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Affiliation(s)
- Zhengqiu Zhou
- Department of Emergency Medicine, College of Medicine, University of Kentucky, Lexington, Kentucky
| | - Kevin S Hsu
- Department of Internal Medicine, College of Medicine, University of Kentucky, Lexington, Kentucky
| | - Joshua Eason
- Gill Heart and Vascular Institute, Division of Cardiovascular Medicine, College of Medicine, University of Kentucky, Lexington, Kentucky
| | - Brian Kauh
- Gill Heart and Vascular Institute, Division of Cardiovascular Medicine, College of Medicine, University of Kentucky, Lexington, Kentucky
| | - Joshua Duchesne
- Gill Heart and Vascular Institute, Division of Cardiovascular Medicine, College of Medicine, University of Kentucky, Lexington, Kentucky
| | - Mikiyas Desta
- College of Medicine, University of Kentucky, Lexington, Kentucky
| | - William Cranford
- Department of Biostatistics, University of Kentucky, Lexington, Kentucky
| | - Alison Woodworth
- Department of Pathology and Laboratory Medicine, University of Kentucky, Lexington, Kentucky
| | - James D Moore
- Department of Emergency Medicine, College of Medicine, University of Kentucky, Lexington, Kentucky
| | - Seth T Stearley
- Department of Emergency Medicine, College of Medicine, University of Kentucky, Lexington, Kentucky
| | - Vedant A Gupta
- Gill Heart and Vascular Institute, Division of Cardiovascular Medicine, College of Medicine, University of Kentucky, Lexington, Kentucky.
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Warren L, Fischer BG, Shemesh A, Scofi J, Pandya N, Kim RJ, Andy C, Rand S, Yee J, Semple S, Chadburn A, Yang HS, Steel PAD, Zhao Z. Improved Utilization of Serial Testing Without Increased Admissions after Implementation of High-Sensitivity Troponin I: a Controlled Retrospective Cohort Study. J Gen Intern Med 2024; 39:739-746. [PMID: 37993739 PMCID: PMC11043247 DOI: 10.1007/s11606-023-08535-3] [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: 05/02/2023] [Accepted: 11/09/2023] [Indexed: 11/24/2023]
Abstract
BACKGROUND Guidelines recommend high-sensitivity cardiac troponin (hs-cTn) for diagnosis of myocardial infarction. Use of hs-cTn is increasing across the U.S., but questions remain regarding clinical and operational impact. Prior studies have had methodologic limitations and yielded conflicting results. OBJECTIVE To evaluate the impact of transitioning from conventional cardiac troponin (cTn) to hs-cTn on test and resource utilization, operational efficiency, and patient safety. DESIGN Retrospective cohort study in two New York City hospitals during the months before and after transition from conventional cTn to hs-cTn at Hospital 1. Hospital 2 served as a control. PARTICIPANTS Consecutive emergency department (ED) patients with at least one cTn test resulted. INTERVENTION Multifaceted hs-cTn intervention bundle, including a 0/2-h diagnostic algorithm for non-ST-elevation myocardial infarction, an educational bundle, enhancements to the electronic medical record, and nursing interventions to facilitate timed sample collection. MAIN MEASURES Primary outcomes included serial cTn test utilization, probability of hospital admission, ED length of stay (LOS), and among discharged patients, probability of ED revisit within 72 h resulting in hospital admission. Multivariable regression models adjusted for age, sex, temporal trends, and interhospital differences. KEY RESULTS The intervention was associated with increased use of serial cTn testing (adjusted risk difference: 48 percentage points, 95% CI: 45-50, P < 0.001) and ED LOS (adjusted geometric mean difference: 50 min, 95% CI: 50-51, P < 0.001). There was no significant association between the intervention and probability of admission (adjusted relative risk [aRR]: 0.99, 95% CI: 0.89-1.1, P = 0.81) or probability of ED revisit within 72 h resulting in admission (aRR: 1.1, 95% CI: 0.44-2.9, P = 0.81). CONCLUSIONS Implementation of a hs-cTn intervention bundle was associated with an improvement in serial cTn testing, a neutral effect on probability of hospital admission, and a modest increase in ED LOS.
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Affiliation(s)
- Laura Warren
- Department of Pathology and Laboratory Medicine, Weill Cornell Medicine, New York, NY, USA
| | - Brett G Fischer
- Weill Department of Medicine, Weill Cornell Medicine, New York, NY, USA
| | - Amos Shemesh
- Department of Emergency Medicine, Weill Cornell Medicine, New York, NY, USA
| | - Jean Scofi
- Department of Emergency Medicine, Weill Cornell Medicine, New York, NY, USA
| | - Nekee Pandya
- Weill Department of Medicine, Weill Cornell Medicine, New York, NY, USA
| | - Robert J Kim
- Weill Department of Medicine, Weill Cornell Medicine, New York, NY, USA
| | - Caroline Andy
- Division of Biostatistics, Weill Cornell Medicine, New York, NY, USA
| | - Sophie Rand
- Department of Pathology and Laboratory Medicine, Weill Cornell Medicine, New York, NY, USA
| | - Jim Yee
- Department of Pathology and Laboratory Medicine, Weill Cornell Medicine, New York, NY, USA
| | - Stacia Semple
- Department of Pathology and Laboratory Medicine, Weill Cornell Medicine, New York, NY, USA
| | - Amy Chadburn
- Department of Pathology and Laboratory Medicine, Weill Cornell Medicine, New York, NY, USA
| | - He S Yang
- Department of Pathology and Laboratory Medicine, Weill Cornell Medicine, New York, NY, USA.
| | - Peter A D Steel
- Department of Emergency Medicine, Weill Cornell Medicine, New York, NY, USA.
| | - Zhen Zhao
- Department of Pathology and Laboratory Medicine, Weill Cornell Medicine, New York, NY, USA.
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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:S0025-6196(24)00026-0. [PMID: 38493402 DOI: 10.1016/j.mayocp.2023.12.019] [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: 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.
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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.
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De Michieli L, Cipriani A, Iliceto S, Dispenzieri A, Jaffe AS. Cardiac Troponin in Patients With Light Chain and Transthyretin Cardiac Amyloidosis: JACC: CardioOncology State-of-the-Art Review. JACC CardioOncol 2024; 6:1-15. [PMID: 38510286 PMCID: PMC10950441 DOI: 10.1016/j.jaccao.2023.12.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Revised: 12/27/2023] [Accepted: 12/29/2023] [Indexed: 03/22/2024] Open
Abstract
Cardiac amyloidosis (CA) is an infiltrative disease caused by amyloid fibril deposition in the myocardium; the 2 forms that most frequently involve the heart are amyloid light chain (AL) and amyloid transthyretin (ATTR) amyloidosis. Cardiac troponin (cTn) is the biomarker of choice for the detection of myocardial injury and is frequently found to be elevated in patients with CA, particularly with high-sensitivity assays. Multiple mechanisms of myocardial injury in CA have been proposed, including cytotoxic effect of amyloid precursors, interstitial amyloid fibril infiltration, coronary microvascular dysfunction, amyloid- and non-amyloid-related coronary artery disease, diastolic dysfunction, and heart failure. Regardless of the mechanisms, cTn values have relevant prognostic (and potentially diagnostic) implications in both AL and ATTR amyloidosis. In this review, the authors discuss the significant aspects of cTn biology and measurement methods, potential mechanisms of myocardial injury in CA, and the clinical application of cTn in the management of both AL and ATTR amyloidosis.
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Affiliation(s)
- Laura De Michieli
- Department of Cardiac, Thoracic and Vascular Sciences and Public Health, University of Padua, Padua, Italy
- Cardiovascular Department, Mayo Clinic and Medical School, Rochester, Minnesota, USA
| | - Alberto Cipriani
- Department of Cardiac, Thoracic and Vascular Sciences and Public Health, University of Padua, Padua, Italy
- Cardiology Unit, University Hospital of Padua, Padua, Italy
| | - Sabino Iliceto
- Department of Cardiac, Thoracic and Vascular Sciences and Public Health, University of Padua, Padua, Italy
- Cardiology Unit, University Hospital of Padua, Padua, Italy
| | | | - Allan S. Jaffe
- Cardiovascular Department, Mayo Clinic and Medical School, Rochester, Minnesota, USA
- Department of Laboratory Medicine and Pathology, Mayo Clinic and Medical School, Rochester, Minnesota, USA
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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.
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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
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Chen Q, Chen GY, Chen JM, Yang FF, Han Y, Wang LH, Wu JH, Ji DD, Yuan SQ, Zhang MQ, Ma LL, Zhu F, Wang QS, Ouyang XL, Zhang LW. Effect of large volume red blood cell apheresis on cardiovascular functions in healthy donors. Eur J Clin Invest 2023; 53:e14047. [PMID: 37386687 DOI: 10.1111/eci.14047] [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: 04/08/2023] [Revised: 06/12/2023] [Accepted: 06/15/2023] [Indexed: 07/01/2023]
Abstract
BACKGROUND Requirements of blood transfusions rise rapidly in China. Improving the efficiency of blood donation could help maintaining sufficient blood supplement. We conducted a pilot research to investigate the reliability and safety of collecting more units of red blood cell by apheresis. METHODS Thirty-two healthy male volunteers were randomized into two groups: red blood cell apheresis (RA) (n = 16) and whole blood (WB) donation (n = 16). RA group donated individualized RBC volumes by apheresis according to the volunteers' basal total blood volumes and haematocrit levels, WB group donated 400 mL whole blood. All volunteers were scheduled seven visit times in 8 weeks' study period. The cardiovascular functions were assessed by laboratory examinations, echocardiography and cardiopulmonary functional tests. All results were compared between groups at the same visit time and compared between visit 1(before donation) and other visit times within the same group. RESULTS The average donated RBC volume in RA group and in WB group was 627.25 ± 109.74 mL and 175.28 ± 8.85 mL, respectively(p < 0.05); the RBC, haemoglobin and haematocrit levels changed significantly between times and between groups (p < 0.05). Cardiac biomarker levels such as NT-proBNP, hs-TnT and CK-MB did not change significantly between times or between groups (p > 0.05). The echocardiographic and cardiopulmonary results did not change significantly between times or between groups during the whole study period(p > 0.05). CONCLUSIONS We provided an efficient and secure method for RBC apheresis. By harvesting more RBC volumes at one single-time, the cardiovascular functions did not change significantly compared with traditional whole blood donation.
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Affiliation(s)
- Qiang Chen
- Department of Cardiology, The Sixth Medical Center of Chinese PLA General Hospital, Beijing, P.R. China
| | - Guan Yi Chen
- Department of Blood Transfusion, The Fourth Medical Center of Chinese PLA General Hospital, Beijing, P.R. China
| | - Jian Mei Chen
- Department of Health medicine, The Fourth Medical Center of Chinese PLA General Hospital, Beijing, P.R. China
| | - Fei Fei Yang
- Department of Cardiology, The Sixth Medical Center of Chinese PLA General Hospital, Beijing, P.R. China
| | - Yue Han
- Department of Blood Transfusion, The Fourth Medical Center of Chinese PLA General Hospital, Beijing, P.R. China
| | - Li Hua Wang
- Department of Blood Transfusion, The Fourth Medical Center of Chinese PLA General Hospital, Beijing, P.R. China
| | - Jing Hui Wu
- Department of Blood Transfusion, The Fourth Medical Center of Chinese PLA General Hospital, Beijing, P.R. China
| | - Dong Dong Ji
- Department of Health medicine, The Fourth Medical Center of Chinese PLA General Hospital, Beijing, P.R. China
| | - Su Qin Yuan
- Department of Health medicine, The Fourth Medical Center of Chinese PLA General Hospital, Beijing, P.R. China
| | - Mei Qing Zhang
- Department of Health medicine, The Fourth Medical Center of Chinese PLA General Hospital, Beijing, P.R. China
| | - Ling Ling Ma
- Department of Health medicine, The Fourth Medical Center of Chinese PLA General Hospital, Beijing, P.R. China
| | - Fei Zhu
- Department of Health medicine, The Fourth Medical Center of Chinese PLA General Hospital, Beijing, P.R. China
| | - Qiu Shuang Wang
- Department of Health medicine, The Fourth Medical Center of Chinese PLA General Hospital, Beijing, P.R. China
| | - Xi Lin Ouyang
- Department of Blood Transfusion, The Fourth Medical Center of Chinese PLA General Hospital, Beijing, P.R. China
| | - Li Wei Zhang
- Department of Cardiology, The Sixth Medical Center of Chinese PLA General Hospital, Beijing, P.R. China
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7
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McCarthy CP, Murphy SP, Amponsah DK, Rambarat PK, Lin C, Liu Y, Mohebi R, Levin A, Raghavan A, Miksenas H, Rogers C, Wasfy JH, Blankstein R, Ghoshhajra B, Hedgire S, Januzzi JL. Coronary Computed Tomographic Angiography With Fractional Flow Reserve in Patients With Type 2 Myocardial Infarction. J Am Coll Cardiol 2023; 82:1676-1687. [PMID: 37777947 DOI: 10.1016/j.jacc.2023.08.020] [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: 06/01/2023] [Revised: 07/24/2023] [Accepted: 08/14/2023] [Indexed: 10/02/2023]
Abstract
BACKGROUND Type 2 myocardial infarction (T2MI) related to a supply/demand imbalance of coronary blood flow is common and associated with poor prognosis. Coronary artery disease (CAD) may predispose some individuals to T2MI and contribute to its high rate of recurrent cardiovascular events. Little is known about the presence and extent of CAD in this population. OBJECTIVES The goal of this study was to evaluate the presence and characteristics of CAD among patients with T2MI. METHODS In this prospective study, consecutive eligible individuals with Fourth Universal Definition of Myocardial Infarction criteria for T2MI were enrolled. Participants underwent coronary computed tomography angiography (CTA), fractional flow reserve derived with coronary CTA (FFRCT), and plaque volume analyses. RESULTS Among 50 participants, 25 (50%) were female, and the mean age was 68.0 ± 11.4 years. Atherosclerotic risk factors were common. Coronary CTA revealed coronary plaque in 46 participants (92%). A moderate or greater stenosis (≥50%) was identified in 42% of participants, and obstructive disease (≥50% left main stenosis or ≥70% stenosis in any other epicardial coronary artery) was present in 26%. Prevalence of obstructive CAD did not differ according to T2MI cause (P = 0.54). A hemodynamically significant focal stenosis identified by FFRCT was present in 13 participants (26%). Among participants with a stenosis ≥50% (n = 21), FFRCT excluded lesion-specific hemodynamically significant stenosis in 8 cases (38%). CONCLUSIONS Among individuals with adjudicated T2MI, CAD was prevalent, but the majority of patients had nonobstructive CAD. Mediators of ischemia are likely multifactorial in this population. (Defining the Prevalence and Characteristics of Coronary Artery Disease Among Patients with Type 2 Myocardial Infarction using CT-FFR [DEFINE TYPE 2 MI]; NCT04864119).
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Affiliation(s)
- Cian P McCarthy
- Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA. https://twitter.com/CianPMcCarthy
| | - Sean P Murphy
- Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Daniel K Amponsah
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Paula K Rambarat
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Claire Lin
- Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Yuxi Liu
- Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Reza Mohebi
- Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Allison Levin
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Avanthi Raghavan
- Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Hannah Miksenas
- Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | | | - Jason H Wasfy
- Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Ron Blankstein
- Department of Medicine (Cardiovascular Division) and Radiology, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Brian Ghoshhajra
- Division of Cardiovascular Imaging, Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Sandeep Hedgire
- Division of Cardiovascular Imaging, Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - James L Januzzi
- Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA; Baim Institute for Clinical Research, Boston, Massachusetts, USA.
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Sasaki S, Inoue K, Shiozaki M, Hanada K, Watanabe R, Minamino T. Diagnostic and Cost Efficiency of the 0-h/1-h Rule-out and Rule-in Algorithm for Patients With Chest Pain in the Emergency Department. Circ J 2023; 87:1362-1368. [PMID: 37394574 DOI: 10.1253/circj.cj-23-0064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/04/2023]
Abstract
BACKGROUND This study investigated the economic impact of the European Society of Cardiology (ESC) clinical practice guideline recommendation of using the 0-h/1-h rule-out and rule-in algorithm with high-sensitivity cardiac troponin assays (0/1-h algorithm) to triage patients presenting with chest pain.Methods and Results: This post hoc cost-effectiveness evaluation (DROP-ACS; UMIN000030668) used deidentified electronic medical records from health insurance claims from 2 diagnostic centers in Japan. A cost-effectiveness analysis was conducted with 472 patients with care provided following the 0/1-h algorithm (Hospital A) and 427 patients following point-of-care testing (Hospital B). The clinical outcome of interest was all-cause mortality or subsequent myocardial infarction within 30 days of the index presentation. The sensitivity and specificity for the clinical outcome were 100% (95% confidence interval [CI] 91.1-100%) and 95.0% (95% CI 94.3-95.0%), respectively, in Hospital A and 92.9% (95% CI 69.6-98.7%) and 89.8% (95% CI 89.0-90.0%), respectively, in Hospital B. If the diagnostic accuracy of the 0/1-h algorithm was implemented in Hospital B, it is expected that the number of urgent (<24-h) coronary angiograms would decrease by 50%. Incorporating this assumption, implementing the 0/1-h algorithm could potentially reduce medical costs by JPY4,033,874 (95% CI JPY3,440,346-4,627,402) in Hospital B (JPY9,447 per patient; 95% CI JPY 8,057-10,837 per patient). CONCLUSIONS The ESC 0/1-h algorithm was efficient for risk stratification and for reducing medical costs.
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Affiliation(s)
- Shun Sasaki
- Department of Cardiovascular Biology and Medicine, Juntendo University Nerima Hospital
| | - Kenji Inoue
- Department of Cardiovascular Biology and Medicine, Juntendo University Nerima Hospital
| | | | | | - Ryo Watanabe
- Graduate School of Health Innovation, Kanagawa University of Human Service
| | - Tohru Minamino
- Department of Cardiovascular Biology and Medicine, Juntendo University School of Medicine
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Greer C, Williams MC, Newby DE, Adamson PD. Role of computed tomography cardiac angiography in acute chest pain syndromes. Heart 2023; 109:1350-1356. [PMID: 36914247 DOI: 10.1136/heartjnl-2022-321360] [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: 12/20/2022] [Accepted: 02/27/2023] [Indexed: 03/16/2023] Open
Abstract
Use of CT coronary angiography (CTCA) to evaluate chest pain has rapidly increased over the recent years. While its utility in the diagnosis of coronary artery disease in stable chest pain syndromes is clear and is strongly endorsed by international guidelines, the role of CTCA in the acute setting is less certain. In the low-risk setting, CTCA has been shown to be accurate, safe and efficient but inherent low rates of adverse events in this population and the advent of high-sensitivity troponin testing have left little room for CTCA to show any short-term clinical benefit.In higher-risk populations, CTCA has potential to fulfil a gatekeeper role to invasive angiography. The high negative predictive value of CTCA is maintained while also identifying non-obstructive coronary disease and alternative diagnoses in the substantial group of patients presenting with chest pain who do not have type 1 myocardial infarction. For those with obstructive coronary disease, CTCA provides accurate assessment of stenosis severity, characterisation of high-risk plaque and findings associated with perivascular inflammation. This may allow more appropriate selection of patients to proceed to invasive management with no disadvantage in outcomes and can provide a more comprehensive risk stratification to guide both acute and long-term management than routine invasive angiography.
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Affiliation(s)
- Charlotte Greer
- Christchurch Heart Institute, University of Otago Christchurch, Christchurch, Canterbury, New Zealand
| | | | - David E Newby
- Centre for Cardiovascular Sciences, University of Edinburgh, Edinburgh, UK
| | - Philip D Adamson
- Christchurch Heart Institute, University of Otago Christchurch, Christchurch, Canterbury, New Zealand
- Centre for Cardiovascular Sciences, University of Edinburgh, Edinburgh, UK
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10
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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.
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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
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11
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Miller CD, Mahler SA, Snavely AC, Raman SV, Caterino JM, Clark CL, Jones AE, Hall ME, Koehler LE, Lovato JF, Hiestand BC, Stopyra JP, Park CJ, Vasu S, Kutcher MA, Hundley WG. Cardiac Magnetic Resonance Imaging Versus Invasive-Based Strategies in Patients With Chest Pain and Detectable to Mildly Elevated Serum Troponin: A Randomized Clinical Trial. Circ Cardiovasc Imaging 2023; 16:e015063. [PMID: 37339173 PMCID: PMC10287041 DOI: 10.1161/circimaging.122.015063] [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: 11/08/2022] [Accepted: 04/25/2023] [Indexed: 06/22/2023]
Abstract
BACKGROUND The optimal diagnostic strategy for patients with chest pain and detectable to mildly elevated serum troponin is not known. The objective was to compare clinical outcomes among an early decision for a noninvasive versus an invasive-based care pathway. METHODS The CMR-IMPACT trial (Cardiac Magnetic Resonance Imaging Strategy for the Management of Patients with Acute Chest Pain and Detectable to Elevated Troponin) was conducted at 4 United States tertiary care hospitals from September 2013 to July 2018. A convenience sample of 312 participants with acute chest pain symptoms and a contemporary troponin between detectable and 1.0 ng/mL were randomized early in their care to 1 of 2 care pathways: invasive-based (n=156) or cardiac magnetic resonance (CMR)-based (n=156) with modification allowed as the patient condition evolved. The primary outcome was a composite including death, myocardial infarction, and cardiac-related hospital readmission or emergency visits. RESULTS Participants (N=312, mean age, 60.6 years, SD 11.3; 125 women [59.9%]), were followed over a median of 2.6 years (95% CI, 2.4-2.9). Early assigned testing was initiated in 102 out of 156 (65.3%) CMR-based and 110 out of 156 (70.5%) invasive-based participants. The primary outcome (CMR-based versus invasive-based) occurred in 59% versus 52% (hazard ratio, 1.17 [95% CI, 0.86-1.57]), acute coronary syndrome after discharge 23% versus 22% (hazard ratio, 1.07 [95% CI, 0.67-1.71]), and invasive angiography at any time 52% versus 74% (hazard ratio, 0.66 [95% CI, 0.49-0.87]). Among patients completing CMR imaging, 55 out of 95 (58%) were safely identified for discharge based on a negative CMR and did not have angiography or revascularization within 90 days. Therapeutic yield of angiography was higher in the CMR-based arm (52 interventions in 81 angiographies [64.2%] versus 46 interventions in 115 angiographies [40.0%] in the invasive-based arm [P=0.001]). CONCLUSIONS Initial management with CMR or invasive-based care pathways resulted in no detectable difference in clinical and safety event rates. The CMR-based pathway facilitated safe discharge, enriched the therapeutic yield of angiography, and reduced invasive angiography utilization over long-term follow-up. REGISTRATION URL: https://www. CLINICALTRIALS gov; Unique identifier: NCT01931852.
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Affiliation(s)
- Chadwick D Miller
- Department of Emergency Medicine (C.D.M., S.AM., A.S., L.K., B.H., J.S.), Wake Forest School of Medicine, Winston-Salem, NC
| | - Simon A Mahler
- Department of Emergency Medicine (C.D.M., S.AM., A.S., L.K., B.H., J.S.), Wake Forest School of Medicine, Winston-Salem, NC
- Department of Epidemiology and Prevention (S.A.M.), Wake Forest School of Medicine, Winston-Salem, NC
- Department of Implementation Science (S.A.M.), Wake Forest School of Medicine, Winston-Salem, NC
| | - Anna C Snavely
- Department of Emergency Medicine (C.D.M., S.AM., A.S., L.K., B.H., J.S.), Wake Forest School of Medicine, Winston-Salem, NC
- Department of Biostatistics and Data Science (A.S., J.F.L.), Wake Forest School of Medicine, Winston-Salem, NC
| | - Subha V Raman
- Division of Cardiovascular Medicine (S.V.R.), The Ohio State University, Columbus, OH
- Now with Indiana University Krannert Institute of Cardiology, Indianapolis, IN (S.V.R.)
| | - Jeffrey M Caterino
- Department of Emergency Medicine (J.M.C.), The Ohio State University, Columbus, OH
| | - Carol L Clark
- Department of Emergency Medicine, Corewell Health William Beaumont University Hospital, Royal Oak, MI (C.L.C.)
| | - Alan E Jones
- Department of Emergency Medicine (A.E.J.), University of Mississippi Medical Center, Jackson, MS
| | - Michael E Hall
- Department of Medicine (M.E.H.), University of Mississippi Medical Center, Jackson, MS
| | - Lauren E Koehler
- Department of Emergency Medicine (C.D.M., S.AM., A.S., L.K., B.H., J.S.), Wake Forest School of Medicine, Winston-Salem, NC
| | - James F Lovato
- Department of Biostatistics and Data Science (A.S., J.F.L.), Wake Forest School of Medicine, Winston-Salem, NC
| | - Brian C Hiestand
- Department of Emergency Medicine (C.D.M., S.AM., A.S., L.K., B.H., J.S.), Wake Forest School of Medicine, Winston-Salem, NC
| | - Jason P Stopyra
- Department of Emergency Medicine (C.D.M., S.AM., A.S., L.K., B.H., J.S.), Wake Forest School of Medicine, Winston-Salem, NC
| | - Carolyn J Park
- Department of Internal Medicine/Cardiology (C.P., S.V., M.A.K., W.G.H.), Wake Forest School of Medicine, Winston-Salem, NC
| | - Sujethra Vasu
- Department of Internal Medicine/Cardiology (C.P., S.V., M.A.K., W.G.H.), Wake Forest School of Medicine, Winston-Salem, NC
| | - Michael A Kutcher
- Department of Internal Medicine/Cardiology (C.P., S.V., M.A.K., W.G.H.), Wake Forest School of Medicine, Winston-Salem, NC
| | - W Gregory Hundley
- Department of Internal Medicine/Cardiology (C.P., S.V., M.A.K., W.G.H.), Wake Forest School of Medicine, Winston-Salem, NC
- Department of Radiology (W.G.H.), Wake Forest School of Medicine, Winston-Salem, NC
- Department of Internal Medicine/Cardiology, Virginia Commonwealth University School of Medicine, Richmond, VA (W.G.H.)
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12
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McEvoy JW, Tang O, Wang D, Ndumele CE, Coresh J, Christenson RH, Selvin E. Myocardial Injury Thresholds for 4 High-Sensitivity Troponin Assays in U.S. Adults. J Am Coll Cardiol 2023; 81:2028-2039. [PMID: 37197846 DOI: 10.1016/j.jacc.2023.03.403] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Revised: 03/09/2023] [Accepted: 03/13/2023] [Indexed: 05/19/2023]
Abstract
BACKGROUND Myocardial injury is currently defined as a cardiac troponin above the sex-specific 99th percentile of a healthy reference population (upper reference limit [URL]). OBJECTIVES The purpose of this study was to estimate high-sensitivity (hs) troponin URLs in a representative sample of the U.S. adult population; overall and by sex, race/ethnicity, and age group. METHODS Among adults participating in the 1999-2004 National Health and Nutrition Examination Survey (NHANES), we measured hs-troponin T using 1 assay (Roche) and hs-troponin I using 3 assays (Abbott, Siemens, and Ortho). In a strictly defined healthy reference subgroup, we estimated 99th percentile URLs for each assay using the recommended nonparametric method. RESULTS Of 12,545 participants, 2,746 met criteria for the healthy subgroup (mean age 37 years, 50% men). The NHANES 99th percentile URL for hs-troponin T (19 ng/L) matched the manufacturer-reported URL (19 ng/L). NHANES URLs were 13 ng/L (95% CI: 10-15 ng/L) for Abbott hs-troponin I (manufacturer: 28 ng/L), 5 ng/L (95% CI: 4-7 ng/L) for Ortho hs-troponin I (manufacturer: 11 ng/L), and 37 ng/L (95% CI: 27-66 ng/L) for Siemens hs-troponin I (manufacturer: 46.5 ng/L). There were significant differences in URLs by sex, but none by race/ethnicity. Furthermore, the 99th percentile URLs for all 4 hs-troponin assays were statistically significantly lower in healthy adults aged <40 years compared with healthy adults ≥60 years (all P < 0.001 by rank sum testing). CONCLUSIONS We found URLs for hs-troponin I assays that were substantially lower than currently listed 99th percentile URLs. There were significant differences in hs-troponin T and I URLs by sex and by age group in healthy U.S. adults but none by race/ethnicity.
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Affiliation(s)
- John W McEvoy
- Division of Cardiology and National Institute for Prevention and Cardiovascular Health, University of Galway, Galway, Ireland; Johns Hopkins School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA; Department of Epidemiology and the Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA.
| | - Olive Tang
- Johns Hopkins School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Dan Wang
- Department of Epidemiology and the Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Chiadi E Ndumele
- Johns Hopkins School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA; Department of Epidemiology and the Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Josef Coresh
- Department of Epidemiology and the Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Robert H Christenson
- Department of Pathology, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Elizabeth Selvin
- Department of Epidemiology and the Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
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13
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Hughes AEO, Forbriger A, May AM, Scott MG, Char D, Farnsworth CW. Implementation of High-Sensitivity Troponin with a Rapid Diagnostic Algorithm Reduces Emergency Department Length of Stay for Discharged Patients. Clin Biochem 2023; 116:87-93. [PMID: 37054770 DOI: 10.1016/j.clinbiochem.2023.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Revised: 04/05/2023] [Accepted: 04/10/2023] [Indexed: 04/15/2023]
Abstract
INTRODUCTION High sensitivity troponin (hs-cTn) and diagnostic algorithms are used to rapidly triage patients with symptoms of acute myocardial infarction in emergency departments (ED). However, few studies have evaluated the impact of simultaneously implementing hs-cTn and a rapid rule-out algorithm on length of stay (LOS). METHODS We assessed the impact of transitioning from contemporary cTnI to hs-cTnI in 59,232 ED encounters over three years. hs-cTnI was implemented with an orderable series that included baseline, two-, four-, and six-hour specimens collected at provider discretion and operationalized with an algorithm to calculate the change in hs-cTnI from baseline and provide interpretations of "insignificant", "significant," or "equivocal." Patient demographics, results, chief complaint, disposition, and ED LOS were captured from the electronic medical record. RESULTS cTnI was ordered for 31,875 encounters prior to hs-cTnI implementation and 27,357 after. The proportion of cTnI results above the 99th percentile upper reference limit decreased from 35.0% to 27.0% for men and increased from 27.8% to 34.8% for women. Among discharged patients, the median LOS decreased by 0.6 h (0.5-0.7). LOS among discharged patients with a chief complaint of chest pain decreased by 1.0 h (0.8-1.1) and further decreased by 1.2 h (1.0-1.3) if the initial hs-cTnI was below the limit of quantitation. The rate of acute coronary syndrome upon re-presentation within 30 days did not change post-implementation (0.10% versus 0.07%). CONCLUSION Implementation of an hs-cTnI assay with a rapid rule-out algorithm decreased ED LOS among discharged patients, particularly among those with a chief complaint of chest pain.
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Affiliation(s)
- Andrew E O Hughes
- Department of Pathology & Immunology. Washington University School of Medicine. St. Louis, MO
| | - Arthur Forbriger
- Department of Emergency Medicine. Washington University School of Medicine. St. Louis, MO
| | - Adam M May
- Department of Medicine. Washington University School of Medicine. St. Louis, MO
| | - Mitchell G Scott
- Department of Pathology & Immunology. Washington University School of Medicine. St. Louis, MO
| | - Douglas Char
- Department of Emergency Medicine. Washington University School of Medicine. St. Louis, MO
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14
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Knott JD, De Michieli L, Ola O, Akula A, Mehta RA, Hodge DO, Tak T, Cagin C, Gulati R, Jaffe AS, Sandoval Y. Diagnosis and prognosis of type 2 myocardial infarction using objective evidence of acute myocardial ischemia: a validation study. Am J Med 2023:S0002-9343(23)00209-7. [PMID: 37030534 DOI: 10.1016/j.amjmed.2023.03.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Revised: 02/28/2023] [Accepted: 03/01/2023] [Indexed: 04/10/2023]
Abstract
BACKGROUND Differentiating type 2 myocardial infarction from myocardial injury can be difficult. In addition, the presence of objective evidence of myocardial ischemia may facilitate identification of high-risk type 2 myocardial infarction patients. METHODS Observational cohort study of adult emergency department patients undergoing hs-cTnT measurement. Patients with ≥1 hs-cTnT>99th percentile were adjudicated following the Fourth Universal Definition of Myocardial Infarction. Patients were categorized as "subjective type 2 myocardial infarction" when ischemic symptoms were the lone criteria supporting type 2 myocardial infarction, or "objective type 2 myocardial infarction" when there was ≥1 objective clinical feature (electrocardiography, imaging, angiography) of acute myocardial ischemia. The primary outcome was mortality. RESULTS A total of 857 patients were included, amongst which 55 (6.4%) were classified as subjective type 2 myocardial infarction, 36 (4.2%) as objective type 2 myocardial infarction, and 702 (82%) as myocardial injury. Those with objective type 2 myocardial infarction had a higher risk of mortality during the index presentation (17% vs. 1.7%, p<0.0001; HR 11.1 95% CI 3.7-33.4) and at 2-year follow-up (47% vs. 31%, p=0.04; HR 1.92, 95% CI 1.17-3.14) than those with myocardial injury. Objective type 2 myocardial infarction had a higher mortality than subjective type 2 myocardial infarction at index presentation (17% vs. 2.0%, p=0.01) and at 1- (25% vs. 9.1%, p=0.04) and 3-months (31% vs. 13%, p=0.04) follow-up. There were no mortality differences between subjective type 2 myocardial infarction and myocardial injury. CONCLUSION In patients diagnosed with type 2 myocardial infarction, those with objective evidence of myocardial ischemia have significantly worse outcomes compared to those with myocardial injury and subjective type 2 myocardial infarction. A more rigorous type 2 myocardial infarction definition that emphasizes these criteria may facilitate diagnosis and risk-stratification.
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Affiliation(s)
- Jonathan D Knott
- Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Laura De Michieli
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA; Department of Cardiac, Thoracic and Vascular Sciences and Public Health, University of Padova, Italy
| | - Olatunde Ola
- Division of Hospital Internal Medicine, Mayo Clinic Health System, La Crosse, WI, USA; Center for Clinical and Translational Science, Mayo Clinic Graduate School of Biomedical Sciences, Rochester MN, USA
| | - Ashok Akula
- Division of Hospital Internal Medicine, Mayo Clinic Health System, La Crosse, WI, USA; Center for Clinical and Translational Science, Mayo Clinic Graduate School of Biomedical Sciences, Rochester MN, USA
| | - Ramila A Mehta
- Department of Quantitative Health Sciences, Mayo College of Medicine, Rochester, MN, USA
| | - David O Hodge
- Department of Quantitative Health Sciences, Mayo College of Medicine, Jacksonville, FL, USA
| | - Tahir Tak
- Department of Cardiovascular Diseases, Mayo Clinic Health System, La Crosse, WI, USA
| | - Charles Cagin
- Department of Cardiovascular Diseases, Mayo Clinic Health System, La Crosse, WI, USA
| | - Rajiv Gulati
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA
| | - Allan S Jaffe
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA; Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | - Yader Sandoval
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA; Minneapolis Heart Institute, Abbott Northwestern Hospital, and Minneapolis Heart Institute Foundation, Minneapolis, MN, USA.
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15
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De Michieli L, Knott JD, Attia ZI, Ola O, Mehta RA, Akula A, Hodge DO, Gulati R, Friedman PA, Jaffe AS, Sandoval Y. Artificial intelligence-augmented electrocardiography for left ventricular systolic dysfunction in patients undergoing high-sensitivity cardiac troponin T. EUROPEAN HEART JOURNAL. ACUTE CARDIOVASCULAR CARE 2023; 12:106-114. [PMID: 36537652 DOI: 10.1093/ehjacc/zuac156] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Revised: 12/06/2022] [Accepted: 12/15/2022] [Indexed: 12/24/2022]
Abstract
AIMS Our goal was to evaluate a previously validated artificial intelligence-augmented electrocardiography (AI-ECG) screening tool for left ventricular systolic dysfunction (LVSD) in patients undergoing high-sensitivity-cardiac troponin T (hs-cTnT). METHODS AND RESULTS Retrospective application of AI-ECG for LVSD in emergency department (ED) patients undergoing hs-cTnT. AI-ECG scores (0-1) for probability of LVSD (left ventricular ejection fraction ≤ 35%) were obtained. An AI-ECG score ≥0.256 indicates a positive screen. The primary endpoint was a composite of post-discharge major adverse cardiovascular events (MACEs) at two years follow-up. Among 1977 patients, 248 (13%) had a positive AI-ECG. When compared with patients with a negative AI-ECG, those with a positive AI-ECG had a higher risk for MACE [48 vs. 21%, P < 0.0001, adjusted hazard ratio (HR) 1.39, 95% confidence interval (CI) 1.11-1.75]. This was largely because of a higher rate of deaths (32 vs. 14%, P < 0.0001; adjusted HR 1.26, 95% 0.95-1.66) and heart failure hospitalizations (26 vs. 6.1%, P < 0.001; adjusted HR 1.75, 95% CI 1.25-2.45). Together, hs-cTnT and AI-ECG resulted in the following MACE rates and adjusted HRs: hs-cTnT < 99th percentile and negative AI-ECG: 116/1176 (11%; reference), hs-cTnT < 99th percentile and positive AI-ECG: 28/107 (26%; adjusted HR 1.54, 95% CI 1.01-2.36), hs-cTnT > 99th percentile and negative AI-ECG: 233/553 (42%; adjusted HR 2.12, 95% CI 1.66, 2.70), and hs-cTnT > 99th percentile and positive AI-ECG: 91/141 (65%; adjusted HR 2.83, 95% CI 2.06, 3.87). CONCLUSION Among ED patients evaluated with hs-cTnT, a positive AI-ECG for LVSD identifies patients at high risk for MACE. The conjoint use of hs-cTnT and AI-ECG facilitates risk stratification.
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Affiliation(s)
- Laura De Michieli
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA.,Department of Cardiac, Thoracic and Vascular Sciences and Public Health, University of Padova, Padova, Italy
| | - Jonathan D Knott
- Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Zachi I Attia
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA
| | - Olatunde Ola
- Department of Hospital Internal Medicine, Mayo Clinic Health System, La Crosse, WI, USA.,Center for Clinical and Translational Science, Mayo Clinic Graduate School of Biomedical Sciences, Rochester MN, USA
| | - Ramila A Mehta
- Department of Quantitative Health Sciences, Mayo College of Medicine, Rochester, MN, USA
| | - Ashok Akula
- Department of Hospital Internal Medicine, Mayo Clinic Health System, La Crosse, WI, USA.,Center for Clinical and Translational Science, Mayo Clinic Graduate School of Biomedical Sciences, Rochester MN, USA
| | - David O Hodge
- Department of Quantitative Health Sciences, Mayo College of Medicine, Jacksonville, FL, USA
| | - Rajiv Gulati
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA
| | - Paul A Friedman
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA
| | - Allan S Jaffe
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA.,Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | - Yader Sandoval
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA.,Interventional Section, Minneapolis Heart Institute, Abbott Northwestern Hospital and Minneapolis Heart Institute Foundation, 920 E 28th Street Suite 300, Minneapolis, MN 55407, USA
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16
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Wanamaker BL, Shoaib A, Seth M, Sukul D, Mamas MA, Gurm HS. Comparative analysis of percutaneous revascularization practice in the United States and the United Kingdom: Insights from the BMC2 and BCIS databases. Catheter Cardiovasc Interv 2023; 101:495-504. [PMID: 36758556 DOI: 10.1002/ccd.30567] [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: 08/19/2022] [Revised: 11/22/2022] [Accepted: 12/25/2022] [Indexed: 02/11/2023]
Abstract
BACKGROUND International registry comparisons provide insight into regional differences in clinical practice patterns, procedural outcomes, and general trends in population health and resource utilization in percutaneous coronary intervention (PCI). We sought to compare data from a state-wide PCI registry in the United States with a national registry from the United Kingdom (UK). METHODS We analyzed all PCI cases from the Blue Cross Blue Shield of Michigan Cardiovascular Consortium and the British Cardiovascular Intervention Society registries from 2010 to 2017. Procedural characteristics and in-hospital outcomes were stratified by PCI indication. RESULTS A total of 248,283 cases were performed in Michigan and 773,083 in the United Kingdom during the study period. The proportion of patients with a prior diagnosis of diabetes in Michigan was nearly double that in the United Kingdom (38.9% vs. 21.0%). PCI for ST-elevation myocardial infarction was more frequent in the UK (25% UK vs. 14.3% Michigan). Radial access increased in both registries, reaching 86.8% in the United Kingdom versus 45.1% in Michigan during the final study year. Mechanical support utilization was divergent, falling to 0.9% of cases in the United Kingdom and rising to 3.95% of cases in Michigan in 2017. Unadjusted crude mortality rates were similar in the two cohorts, with higher rates of post-PCI transfusion and other complications in the Michigan population. CONCLUSIONS In a real-world comparison using PCI registries from the US and UK, notable findings include marked differences in the prevalence of diabetes and other comorbidities, a greater proportion of primary PCI with more robust adoption of transradial PCI in the United Kingdom, and divergent trends in mechanical support with increasing use in Michigan.
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Affiliation(s)
- Brett L Wanamaker
- Department of Internal Medicine, Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Ahmad Shoaib
- Keele Cardiovascular Research Group, University of Keele, Stoke-on-Trent, UK.,Royal Stoke Hospital, University Hospitals of North Midlands, Stoke-on-Trent, UK
| | - Milan Seth
- Department of Internal Medicine, Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Devraj Sukul
- Department of Internal Medicine, Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Mamas A Mamas
- Keele Cardiovascular Research Group, University of Keele, Stoke-on-Trent, UK.,Royal Stoke Hospital, University Hospitals of North Midlands, Stoke-on-Trent, UK
| | - Hitinder S Gurm
- Department of Internal Medicine, Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, Michigan, USA
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17
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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: 11] [Impact Index Per Article: 11.0] [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.
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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
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18
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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: 40] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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19
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Meah MN, Bularga A, Tzolos E, Chapman AR, Daghem M, Hung JD, Chiong J, Taggart C, Wereski R, Gray A, Dweck MR, Roobottom C, Curzen N, Kardos A, Felmeden D, Mills NL, Slomka PJ, Newby DE, Dey D, Williams MC. Distinguishing Type 1 from Type 2 Myocardial Infarction by Using CT Coronary Angiography. Radiol Cardiothorac Imaging 2022; 4:e220081. [PMID: 36339063 PMCID: PMC9627233 DOI: 10.1148/ryct.220081] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Revised: 09/23/2022] [Accepted: 10/04/2022] [Indexed: 01/25/2023]
Abstract
Purpose To determine whether quantitative plaque characterization by using CT coronary angiography (CTCA) can discriminate between type 1 and type 2 myocardial infarction. Materials and Methods This was a secondary analysis of two prospective studies (ClinicalTrials.gov registration nos. NCT03338504 [2014-2019] and NCT02284191 [2018-2020]) that performed blinded quantitative plaque analysis on findings from CTCA in participants with type 1 myocardial infarction, type 2 myocardial infarction, and chest pain without myocardial infarction. Logistic regression analyses were performed to identify predictors of type 1 myocardial infarction. Results Overall, 155 participants (mean age, 64 years ± 12 [SD]; 114 men) and 36 participants (mean age, 67 years ± 12; 19 men) had type 1 and type 2 myocardial infarction, respectively, and 136 participants (62 years ± 12; 78 men) had chest pain without myocardial infarction. Participants with type 1 myocardial infarction had greater total (median, 44% [IQR: 35%-50%] vs 35% [IQR: 29%-46%]), noncalcified (39% [IQR: 31%-46%] vs 34% [IQR: 29%-40%]), and low-attenuation (4.15% [IQR: 1.88%-5.79%] vs 1.64% [IQR: 0.89%-2.28%]) plaque burdens (P < .05 for all) than those with type 2. Participants with type 2 myocardial infarction had similar low-attenuation plaque burden to those with chest pain without myocardial infarction (P = .4). Low-attenuation plaque was an independent predictor of type 1 myocardial infarction (adjusted odds ratio, 3.44 [95% CI: 1.84, 6.96]; P < .001), with better discrimination than noncalcified plaque burden and maximal area of coronary stenosis (C statistic, 0.75 [95% CI: 0.67, 0.83] vs 0.62 [95% CI: 0.53, 0.71] and 0.61 [95% CI: 0.51, 0.70] respectively; P ≤ .001 for both). Conclusion Higher low-attenuation coronary plaque burden in patients with type 1 myocardial infarction may help distinguish these patients from those with type 2 myocardial infarction.Keywords: Ischemia/Infarction, CT Angiography, Quantitative CTClinical trial registration nos. NCT03338504 and NCT02284191 Supplemental material is available for this article. © RSNA, 2022.
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Affiliation(s)
- Mohammed N. Meah
- From the British Heart Foundation Centre of Cardiovascular Science,
University of Edinburgh, Edinburgh, Scotland (M.N.M., A.B., E.T., A.R.C., M.D.,
J.D.H., J.C., C.T., R.W., A.G., M.R.D., N.L.M., D.E.N., M.C.W.); Usher
Institute, University of Edinburgh, Edinburgh, Scotland (A.G., N.L.M.);
University Hospital Plymouth, Plymouth, England (C.R.); Faculty of Medicine,
University of Southampton, Southampton, England (N.C.); University Hospital
Southampton, Southampton, England (N.C.); Department of Cardiology, Milton
Keynes University Hospital, School of Sciences and Medicine, University of
Buckingham, Buckingham, England (A.K.); Torbay and South Devon NHS Foundation
Trust, Torquay, England (D.F.); Departments of Medicine and Biomedical Sciences,
Cedars-Sinai Medical Center, Los Angeles, Calif (P.J.S., D.D.); and Edinburgh
Imaging, Queen’s Medical Research Institute University of Edinburgh,
Edinburgh, Scotland (D.E.N., M.C.W.)
| | - Anda Bularga
- From the British Heart Foundation Centre of Cardiovascular Science,
University of Edinburgh, Edinburgh, Scotland (M.N.M., A.B., E.T., A.R.C., M.D.,
J.D.H., J.C., C.T., R.W., A.G., M.R.D., N.L.M., D.E.N., M.C.W.); Usher
Institute, University of Edinburgh, Edinburgh, Scotland (A.G., N.L.M.);
University Hospital Plymouth, Plymouth, England (C.R.); Faculty of Medicine,
University of Southampton, Southampton, England (N.C.); University Hospital
Southampton, Southampton, England (N.C.); Department of Cardiology, Milton
Keynes University Hospital, School of Sciences and Medicine, University of
Buckingham, Buckingham, England (A.K.); Torbay and South Devon NHS Foundation
Trust, Torquay, England (D.F.); Departments of Medicine and Biomedical Sciences,
Cedars-Sinai Medical Center, Los Angeles, Calif (P.J.S., D.D.); and Edinburgh
Imaging, Queen’s Medical Research Institute University of Edinburgh,
Edinburgh, Scotland (D.E.N., M.C.W.)
| | - Evangelos Tzolos
- From the British Heart Foundation Centre of Cardiovascular Science,
University of Edinburgh, Edinburgh, Scotland (M.N.M., A.B., E.T., A.R.C., M.D.,
J.D.H., J.C., C.T., R.W., A.G., M.R.D., N.L.M., D.E.N., M.C.W.); Usher
Institute, University of Edinburgh, Edinburgh, Scotland (A.G., N.L.M.);
University Hospital Plymouth, Plymouth, England (C.R.); Faculty of Medicine,
University of Southampton, Southampton, England (N.C.); University Hospital
Southampton, Southampton, England (N.C.); Department of Cardiology, Milton
Keynes University Hospital, School of Sciences and Medicine, University of
Buckingham, Buckingham, England (A.K.); Torbay and South Devon NHS Foundation
Trust, Torquay, England (D.F.); Departments of Medicine and Biomedical Sciences,
Cedars-Sinai Medical Center, Los Angeles, Calif (P.J.S., D.D.); and Edinburgh
Imaging, Queen’s Medical Research Institute University of Edinburgh,
Edinburgh, Scotland (D.E.N., M.C.W.)
| | - Andrew R. Chapman
- From the British Heart Foundation Centre of Cardiovascular Science,
University of Edinburgh, Edinburgh, Scotland (M.N.M., A.B., E.T., A.R.C., M.D.,
J.D.H., J.C., C.T., R.W., A.G., M.R.D., N.L.M., D.E.N., M.C.W.); Usher
Institute, University of Edinburgh, Edinburgh, Scotland (A.G., N.L.M.);
University Hospital Plymouth, Plymouth, England (C.R.); Faculty of Medicine,
University of Southampton, Southampton, England (N.C.); University Hospital
Southampton, Southampton, England (N.C.); Department of Cardiology, Milton
Keynes University Hospital, School of Sciences and Medicine, University of
Buckingham, Buckingham, England (A.K.); Torbay and South Devon NHS Foundation
Trust, Torquay, England (D.F.); Departments of Medicine and Biomedical Sciences,
Cedars-Sinai Medical Center, Los Angeles, Calif (P.J.S., D.D.); and Edinburgh
Imaging, Queen’s Medical Research Institute University of Edinburgh,
Edinburgh, Scotland (D.E.N., M.C.W.)
| | - Marwa Daghem
- From the British Heart Foundation Centre of Cardiovascular Science,
University of Edinburgh, Edinburgh, Scotland (M.N.M., A.B., E.T., A.R.C., M.D.,
J.D.H., J.C., C.T., R.W., A.G., M.R.D., N.L.M., D.E.N., M.C.W.); Usher
Institute, University of Edinburgh, Edinburgh, Scotland (A.G., N.L.M.);
University Hospital Plymouth, Plymouth, England (C.R.); Faculty of Medicine,
University of Southampton, Southampton, England (N.C.); University Hospital
Southampton, Southampton, England (N.C.); Department of Cardiology, Milton
Keynes University Hospital, School of Sciences and Medicine, University of
Buckingham, Buckingham, England (A.K.); Torbay and South Devon NHS Foundation
Trust, Torquay, England (D.F.); Departments of Medicine and Biomedical Sciences,
Cedars-Sinai Medical Center, Los Angeles, Calif (P.J.S., D.D.); and Edinburgh
Imaging, Queen’s Medical Research Institute University of Edinburgh,
Edinburgh, Scotland (D.E.N., M.C.W.)
| | - John D. Hung
- From the British Heart Foundation Centre of Cardiovascular Science,
University of Edinburgh, Edinburgh, Scotland (M.N.M., A.B., E.T., A.R.C., M.D.,
J.D.H., J.C., C.T., R.W., A.G., M.R.D., N.L.M., D.E.N., M.C.W.); Usher
Institute, University of Edinburgh, Edinburgh, Scotland (A.G., N.L.M.);
University Hospital Plymouth, Plymouth, England (C.R.); Faculty of Medicine,
University of Southampton, Southampton, England (N.C.); University Hospital
Southampton, Southampton, England (N.C.); Department of Cardiology, Milton
Keynes University Hospital, School of Sciences and Medicine, University of
Buckingham, Buckingham, England (A.K.); Torbay and South Devon NHS Foundation
Trust, Torquay, England (D.F.); Departments of Medicine and Biomedical Sciences,
Cedars-Sinai Medical Center, Los Angeles, Calif (P.J.S., D.D.); and Edinburgh
Imaging, Queen’s Medical Research Institute University of Edinburgh,
Edinburgh, Scotland (D.E.N., M.C.W.)
| | - Justin Chiong
- From the British Heart Foundation Centre of Cardiovascular Science,
University of Edinburgh, Edinburgh, Scotland (M.N.M., A.B., E.T., A.R.C., M.D.,
J.D.H., J.C., C.T., R.W., A.G., M.R.D., N.L.M., D.E.N., M.C.W.); Usher
Institute, University of Edinburgh, Edinburgh, Scotland (A.G., N.L.M.);
University Hospital Plymouth, Plymouth, England (C.R.); Faculty of Medicine,
University of Southampton, Southampton, England (N.C.); University Hospital
Southampton, Southampton, England (N.C.); Department of Cardiology, Milton
Keynes University Hospital, School of Sciences and Medicine, University of
Buckingham, Buckingham, England (A.K.); Torbay and South Devon NHS Foundation
Trust, Torquay, England (D.F.); Departments of Medicine and Biomedical Sciences,
Cedars-Sinai Medical Center, Los Angeles, Calif (P.J.S., D.D.); and Edinburgh
Imaging, Queen’s Medical Research Institute University of Edinburgh,
Edinburgh, Scotland (D.E.N., M.C.W.)
| | - Caelan Taggart
- From the British Heart Foundation Centre of Cardiovascular Science,
University of Edinburgh, Edinburgh, Scotland (M.N.M., A.B., E.T., A.R.C., M.D.,
J.D.H., J.C., C.T., R.W., A.G., M.R.D., N.L.M., D.E.N., M.C.W.); Usher
Institute, University of Edinburgh, Edinburgh, Scotland (A.G., N.L.M.);
University Hospital Plymouth, Plymouth, England (C.R.); Faculty of Medicine,
University of Southampton, Southampton, England (N.C.); University Hospital
Southampton, Southampton, England (N.C.); Department of Cardiology, Milton
Keynes University Hospital, School of Sciences and Medicine, University of
Buckingham, Buckingham, England (A.K.); Torbay and South Devon NHS Foundation
Trust, Torquay, England (D.F.); Departments of Medicine and Biomedical Sciences,
Cedars-Sinai Medical Center, Los Angeles, Calif (P.J.S., D.D.); and Edinburgh
Imaging, Queen’s Medical Research Institute University of Edinburgh,
Edinburgh, Scotland (D.E.N., M.C.W.)
| | - Ryan Wereski
- From the British Heart Foundation Centre of Cardiovascular Science,
University of Edinburgh, Edinburgh, Scotland (M.N.M., A.B., E.T., A.R.C., M.D.,
J.D.H., J.C., C.T., R.W., A.G., M.R.D., N.L.M., D.E.N., M.C.W.); Usher
Institute, University of Edinburgh, Edinburgh, Scotland (A.G., N.L.M.);
University Hospital Plymouth, Plymouth, England (C.R.); Faculty of Medicine,
University of Southampton, Southampton, England (N.C.); University Hospital
Southampton, Southampton, England (N.C.); Department of Cardiology, Milton
Keynes University Hospital, School of Sciences and Medicine, University of
Buckingham, Buckingham, England (A.K.); Torbay and South Devon NHS Foundation
Trust, Torquay, England (D.F.); Departments of Medicine and Biomedical Sciences,
Cedars-Sinai Medical Center, Los Angeles, Calif (P.J.S., D.D.); and Edinburgh
Imaging, Queen’s Medical Research Institute University of Edinburgh,
Edinburgh, Scotland (D.E.N., M.C.W.)
| | - Alasdair Gray
- From the British Heart Foundation Centre of Cardiovascular Science,
University of Edinburgh, Edinburgh, Scotland (M.N.M., A.B., E.T., A.R.C., M.D.,
J.D.H., J.C., C.T., R.W., A.G., M.R.D., N.L.M., D.E.N., M.C.W.); Usher
Institute, University of Edinburgh, Edinburgh, Scotland (A.G., N.L.M.);
University Hospital Plymouth, Plymouth, England (C.R.); Faculty of Medicine,
University of Southampton, Southampton, England (N.C.); University Hospital
Southampton, Southampton, England (N.C.); Department of Cardiology, Milton
Keynes University Hospital, School of Sciences and Medicine, University of
Buckingham, Buckingham, England (A.K.); Torbay and South Devon NHS Foundation
Trust, Torquay, England (D.F.); Departments of Medicine and Biomedical Sciences,
Cedars-Sinai Medical Center, Los Angeles, Calif (P.J.S., D.D.); and Edinburgh
Imaging, Queen’s Medical Research Institute University of Edinburgh,
Edinburgh, Scotland (D.E.N., M.C.W.)
| | - Marc R. Dweck
- From the British Heart Foundation Centre of Cardiovascular Science,
University of Edinburgh, Edinburgh, Scotland (M.N.M., A.B., E.T., A.R.C., M.D.,
J.D.H., J.C., C.T., R.W., A.G., M.R.D., N.L.M., D.E.N., M.C.W.); Usher
Institute, University of Edinburgh, Edinburgh, Scotland (A.G., N.L.M.);
University Hospital Plymouth, Plymouth, England (C.R.); Faculty of Medicine,
University of Southampton, Southampton, England (N.C.); University Hospital
Southampton, Southampton, England (N.C.); Department of Cardiology, Milton
Keynes University Hospital, School of Sciences and Medicine, University of
Buckingham, Buckingham, England (A.K.); Torbay and South Devon NHS Foundation
Trust, Torquay, England (D.F.); Departments of Medicine and Biomedical Sciences,
Cedars-Sinai Medical Center, Los Angeles, Calif (P.J.S., D.D.); and Edinburgh
Imaging, Queen’s Medical Research Institute University of Edinburgh,
Edinburgh, Scotland (D.E.N., M.C.W.)
| | - Carl Roobottom
- From the British Heart Foundation Centre of Cardiovascular Science,
University of Edinburgh, Edinburgh, Scotland (M.N.M., A.B., E.T., A.R.C., M.D.,
J.D.H., J.C., C.T., R.W., A.G., M.R.D., N.L.M., D.E.N., M.C.W.); Usher
Institute, University of Edinburgh, Edinburgh, Scotland (A.G., N.L.M.);
University Hospital Plymouth, Plymouth, England (C.R.); Faculty of Medicine,
University of Southampton, Southampton, England (N.C.); University Hospital
Southampton, Southampton, England (N.C.); Department of Cardiology, Milton
Keynes University Hospital, School of Sciences and Medicine, University of
Buckingham, Buckingham, England (A.K.); Torbay and South Devon NHS Foundation
Trust, Torquay, England (D.F.); Departments of Medicine and Biomedical Sciences,
Cedars-Sinai Medical Center, Los Angeles, Calif (P.J.S., D.D.); and Edinburgh
Imaging, Queen’s Medical Research Institute University of Edinburgh,
Edinburgh, Scotland (D.E.N., M.C.W.)
| | - Nick Curzen
- From the British Heart Foundation Centre of Cardiovascular Science,
University of Edinburgh, Edinburgh, Scotland (M.N.M., A.B., E.T., A.R.C., M.D.,
J.D.H., J.C., C.T., R.W., A.G., M.R.D., N.L.M., D.E.N., M.C.W.); Usher
Institute, University of Edinburgh, Edinburgh, Scotland (A.G., N.L.M.);
University Hospital Plymouth, Plymouth, England (C.R.); Faculty of Medicine,
University of Southampton, Southampton, England (N.C.); University Hospital
Southampton, Southampton, England (N.C.); Department of Cardiology, Milton
Keynes University Hospital, School of Sciences and Medicine, University of
Buckingham, Buckingham, England (A.K.); Torbay and South Devon NHS Foundation
Trust, Torquay, England (D.F.); Departments of Medicine and Biomedical Sciences,
Cedars-Sinai Medical Center, Los Angeles, Calif (P.J.S., D.D.); and Edinburgh
Imaging, Queen’s Medical Research Institute University of Edinburgh,
Edinburgh, Scotland (D.E.N., M.C.W.)
| | - Attila Kardos
- From the British Heart Foundation Centre of Cardiovascular Science,
University of Edinburgh, Edinburgh, Scotland (M.N.M., A.B., E.T., A.R.C., M.D.,
J.D.H., J.C., C.T., R.W., A.G., M.R.D., N.L.M., D.E.N., M.C.W.); Usher
Institute, University of Edinburgh, Edinburgh, Scotland (A.G., N.L.M.);
University Hospital Plymouth, Plymouth, England (C.R.); Faculty of Medicine,
University of Southampton, Southampton, England (N.C.); University Hospital
Southampton, Southampton, England (N.C.); Department of Cardiology, Milton
Keynes University Hospital, School of Sciences and Medicine, University of
Buckingham, Buckingham, England (A.K.); Torbay and South Devon NHS Foundation
Trust, Torquay, England (D.F.); Departments of Medicine and Biomedical Sciences,
Cedars-Sinai Medical Center, Los Angeles, Calif (P.J.S., D.D.); and Edinburgh
Imaging, Queen’s Medical Research Institute University of Edinburgh,
Edinburgh, Scotland (D.E.N., M.C.W.)
| | - Dirk Felmeden
- From the British Heart Foundation Centre of Cardiovascular Science,
University of Edinburgh, Edinburgh, Scotland (M.N.M., A.B., E.T., A.R.C., M.D.,
J.D.H., J.C., C.T., R.W., A.G., M.R.D., N.L.M., D.E.N., M.C.W.); Usher
Institute, University of Edinburgh, Edinburgh, Scotland (A.G., N.L.M.);
University Hospital Plymouth, Plymouth, England (C.R.); Faculty of Medicine,
University of Southampton, Southampton, England (N.C.); University Hospital
Southampton, Southampton, England (N.C.); Department of Cardiology, Milton
Keynes University Hospital, School of Sciences and Medicine, University of
Buckingham, Buckingham, England (A.K.); Torbay and South Devon NHS Foundation
Trust, Torquay, England (D.F.); Departments of Medicine and Biomedical Sciences,
Cedars-Sinai Medical Center, Los Angeles, Calif (P.J.S., D.D.); and Edinburgh
Imaging, Queen’s Medical Research Institute University of Edinburgh,
Edinburgh, Scotland (D.E.N., M.C.W.)
| | - Nicholas L. Mills
- From the British Heart Foundation Centre of Cardiovascular Science,
University of Edinburgh, Edinburgh, Scotland (M.N.M., A.B., E.T., A.R.C., M.D.,
J.D.H., J.C., C.T., R.W., A.G., M.R.D., N.L.M., D.E.N., M.C.W.); Usher
Institute, University of Edinburgh, Edinburgh, Scotland (A.G., N.L.M.);
University Hospital Plymouth, Plymouth, England (C.R.); Faculty of Medicine,
University of Southampton, Southampton, England (N.C.); University Hospital
Southampton, Southampton, England (N.C.); Department of Cardiology, Milton
Keynes University Hospital, School of Sciences and Medicine, University of
Buckingham, Buckingham, England (A.K.); Torbay and South Devon NHS Foundation
Trust, Torquay, England (D.F.); Departments of Medicine and Biomedical Sciences,
Cedars-Sinai Medical Center, Los Angeles, Calif (P.J.S., D.D.); and Edinburgh
Imaging, Queen’s Medical Research Institute University of Edinburgh,
Edinburgh, Scotland (D.E.N., M.C.W.)
| | - Piotr J. Slomka
- From the British Heart Foundation Centre of Cardiovascular Science,
University of Edinburgh, Edinburgh, Scotland (M.N.M., A.B., E.T., A.R.C., M.D.,
J.D.H., J.C., C.T., R.W., A.G., M.R.D., N.L.M., D.E.N., M.C.W.); Usher
Institute, University of Edinburgh, Edinburgh, Scotland (A.G., N.L.M.);
University Hospital Plymouth, Plymouth, England (C.R.); Faculty of Medicine,
University of Southampton, Southampton, England (N.C.); University Hospital
Southampton, Southampton, England (N.C.); Department of Cardiology, Milton
Keynes University Hospital, School of Sciences and Medicine, University of
Buckingham, Buckingham, England (A.K.); Torbay and South Devon NHS Foundation
Trust, Torquay, England (D.F.); Departments of Medicine and Biomedical Sciences,
Cedars-Sinai Medical Center, Los Angeles, Calif (P.J.S., D.D.); and Edinburgh
Imaging, Queen’s Medical Research Institute University of Edinburgh,
Edinburgh, Scotland (D.E.N., M.C.W.)
| | - David E. Newby
- From the British Heart Foundation Centre of Cardiovascular Science,
University of Edinburgh, Edinburgh, Scotland (M.N.M., A.B., E.T., A.R.C., M.D.,
J.D.H., J.C., C.T., R.W., A.G., M.R.D., N.L.M., D.E.N., M.C.W.); Usher
Institute, University of Edinburgh, Edinburgh, Scotland (A.G., N.L.M.);
University Hospital Plymouth, Plymouth, England (C.R.); Faculty of Medicine,
University of Southampton, Southampton, England (N.C.); University Hospital
Southampton, Southampton, England (N.C.); Department of Cardiology, Milton
Keynes University Hospital, School of Sciences and Medicine, University of
Buckingham, Buckingham, England (A.K.); Torbay and South Devon NHS Foundation
Trust, Torquay, England (D.F.); Departments of Medicine and Biomedical Sciences,
Cedars-Sinai Medical Center, Los Angeles, Calif (P.J.S., D.D.); and Edinburgh
Imaging, Queen’s Medical Research Institute University of Edinburgh,
Edinburgh, Scotland (D.E.N., M.C.W.)
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Sandoval Y, Apple FS, Mahler SA, Body R, Collinson PO, Jaffe AS. High-Sensitivity Cardiac Troponin and the 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guidelines for the Evaluation and Diagnosis of Acute Chest Pain. Circulation 2022; 146:569-581. [PMID: 35775423 DOI: 10.1161/circulationaha.122.059678] [Citation(s) in RCA: 41] [Impact Index Per Article: 20.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
The 2021 American Heart Association/American College of Cardiology/American Society of Echocardiography/American College of Chest Physicians/Society for Academic Emergency Medicine/Society of Cardiovascular Computed Tomography/Society for Cardiovascular Magnetic Resonance guidelines for the evaluation and diagnosis of acute chest pain make important recommendations that include the recognition of high-sensitivity cardiac troponin (hs-cTn) as the preferred biomarker, endorsement of 99th percentile upper reference limits to define myocardial injury, and the use of clinical decision pathways, as well as acknowledgment of the uniqueness of women and other patient subsets. Details on how to integrate hs-cTn into clinical practice are less extensively addressed. Clinicians should be aware of some of the analytical aspects related to hs-cTn assays regarding the limit of detection and the limit of quantitation and how they are used clinically, especially for the single sample strategy to rule out acute myocardial infarction. Likewise, it is important for clinicians to understand issues related to the derivation of the 99th percentile upper reference limit; the value of sex-specific 99th percentile upper reference limits; how to use changing concentrations (deltas) to facilitate diagnosis and risk stratification of patients with suspected acute coronary syndrome, including the differentiation of acute from chronic myocardial injury; and how to best integrate the use of hs-cTn with clinical decision pathways. With the use of hs-cTn, conditions such as type 2 myocardial infarction become more common, whereas others such as unstable angina become less frequent but still occur. Sections relating to these issues are included.
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Affiliation(s)
- Yader Sandoval
- Departments of Cardiovascular Diseases (Y.S., A.S.J.), Mayo Clinic, Rochester, MN
| | - Fred S Apple
- Departments of Laboratory Medicine and Pathology, Hennepin Healthcare/Hennepin County Medical Center and University of Minnesota, Minneapolis (F.S.A.)
| | - Simon A Mahler
- Department of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, NC (S.A.M.)
| | - Richard Body
- Emergency Department, Manchester University NSH Foundation Trust, Manchester Academic Health Science Centre, UK (R.B.).,Division of Cardiovascular Sciences, The University of Manchester, UK (R.B.).,Healthcare Sciences Department, Manchester Metropolitan University, UK (R.B.)
| | - Paul O Collinson
- Department of Clinical Blood Sciences and Cardiology, St George's University Hospitals NHS Foundation Trust and St George's University of London, UK (P.O.C.)
| | - Allan S Jaffe
- Departments of Cardiovascular Diseases (Y.S., A.S.J.), Mayo Clinic, Rochester, MN.,Laboratory Medicine and Pathology (A.S.J.), Mayo Clinic, Rochester, MN
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Knott JD, Ola O, De Michieli L, Akula A, Mehta RA, Dworak M, Crockford E, Lobo R, Rastas N, Karturi S, Wohlrab S, Hodge DO, Grube E, Tak T, Cagin C, Gulati R, Jaffe AS, Sandoval Y. Major adverse cardiovascular events after diagnosis of myocardial injury and types 1 and 2 myocardial infarction. EUROPEAN HEART JOURNAL. ACUTE CARDIOVASCULAR CARE 2022; 11:546-557. [PMID: 35715942 DOI: 10.1093/ehjacc/zuac075] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Revised: 05/16/2022] [Accepted: 05/30/2022] [Indexed: 06/15/2023]
Abstract
AIMS Limited US outcome data exist among patients with myocardial injury and types 1 and 2 myocardial infarction (MI) evaluated with high-sensitivity cardiac troponin (hs-cTn). METHODS AND RESULTS This is an observational US cohort study of emergency department (ED) patients undergoing hs-cTnT measurement. Cases with ≥1 hs-cTnT increase >99th percentile were adjudicated following the Fourth Universal Definition of MI. Post-discharge major adverse cardiovascular events (MACE) included death, MI, heart failure (HF) hospitalization, stroke or transient ischaemic attack, and new-onset atrial fibrillation or flutter during 2 years follow-up. Among 2002 patients, 857 (43%) had ≥1 hs-cTnT >99th percentile. Among these, 702 (81.9%) had myocardial injury, 64 (7.5%) had type 1 MI, and 91 (10.6%) had type 2 MI. Compared with patients without myocardial injury, type 2 MI [8.4 vs. 50%; adjusted hazard ratio (HR) 2.31, 95% confidence interval (CI) 1.49-3.58] and myocardial injury (8.4 vs. 47%; adjusted HR 3.13, 95% CI 2.39-4.09) had a higher risk of MACE, in large part because of death and HF hospitalizations. Compared with patients with type 1 MI, type 2 MI (23 vs. 50%; adjusted HR 2.24; 95% CI 1.23-4.10) and myocardial injury (23 vs. 47%; adjusted HR 2.02; 95% CI 1.20-3.40) also have a higher risk of MACE. CONCLUSION Among unselected US ED patients undergoing hs-cTnT measurement, most increases are due to myocardial injury, and type 2 MI is more frequent than type 1 MI. Patients with myocardial injury and type 2 MI have morbid outcomes, in large part due to death and HF.
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Affiliation(s)
- Jonathan D Knott
- Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Olatunde Ola
- Division of Hospital Internal Medicine, Mayo Clinic Health System, La Crosse, WI, USA
- Center for Clinical and Translational Science, Mayo Clinic Graduate School of Biomedical Sciences, Rochester, MN, USA
| | - Laura De Michieli
- Department of Cardiovascular Diseases, Mayo Clinic, 200 1st St SW, Rochester, MN, USA
- Department of Cardiac, Thoracic and Vascular Sciences and Public Health, University of Padova, Padova, Italy
| | - Ashok Akula
- Division of Hospital Internal Medicine, Mayo Clinic Health System, La Crosse, WI, USA
- Center for Clinical and Translational Science, Mayo Clinic Graduate School of Biomedical Sciences, Rochester, MN, USA
| | - Ramila A Mehta
- Department of Quantitative Health Sciences, Mayo College of Medicine, Rochester, MN, USA
| | - Marshall Dworak
- Department of Cardiovascular Diseases, Mayo Clinic Health System, La Crosse, WI, USA
| | - Erika Crockford
- Department of Family Medicine, Mayo Clinic Health System, La Crosse, WI, USA
| | - Ronstan Lobo
- Department of Cardiovascular Diseases, Mayo Clinic, 200 1st St SW, Rochester, MN, USA
| | - Nicholas Rastas
- Department of Cardiovascular Diseases, Mayo Clinic Health System, La Crosse, WI, USA
| | - Swetha Karturi
- Division of Hospital Internal Medicine, Mayo Clinic Health System, La Crosse, WI, USA
| | - Scott Wohlrab
- Department of Laboratory Medicine and Pathology, Mayo Clinic Health System, La Crosse, WI, USA
| | - David O Hodge
- Department of Quantitative Health Sciences, Mayo College of Medicine, Jacksonville, FL, USA
| | - Eric Grube
- Department of Emergency Medicine, Mayo Clinic Health System, La Crosse, WI, USA
| | - Tahir Tak
- Department of Cardiovascular Diseases, Mayo Clinic Health System, La Crosse, WI, USA
| | - Charles Cagin
- Department of Cardiovascular Diseases, Mayo Clinic Health System, La Crosse, WI, USA
| | - Rajiv Gulati
- Department of Cardiovascular Diseases, Mayo Clinic, 200 1st St SW, Rochester, MN, USA
| | - Allan S Jaffe
- Department of Cardiovascular Diseases, Mayo Clinic, 200 1st St SW, Rochester, MN, USA
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | - Yader Sandoval
- Department of Cardiovascular Diseases, Mayo Clinic, 200 1st St SW, Rochester, MN, USA
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22
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Advances in Clinical Cardiology 2021: A Summary of Key Clinical Trials. Adv Ther 2022; 39:2398-2437. [PMID: 35482250 PMCID: PMC9047629 DOI: 10.1007/s12325-022-02136-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Accepted: 03/16/2022] [Indexed: 12/22/2022]
Abstract
Introduction Over the course of 2021, numerous key clinical trials with valuable contributions to clinical cardiology were published or presented at major international conferences. This review seeks to summarise these trials and reflect on their clinical context. Methods The authors reviewed clinical trials presented at major cardiology conferences during 2021 including the American College of Cardiology (ACC), European Association for Percutaneous Cardiovascular Interventions (EuroPCR), European Society of Cardiology (ESC), Transcatheter Cardiovascular Therapeutics (TCT), American Heart Association (AHA), European Heart Rhythm Association (EHRA), Society for Cardiovascular Angiography and Interventions (SCAI), TVT-The Heart Summit (TVT) and Cardiovascular Research Technologies (CRT). Trials with a broad relevance to the cardiology community and those with potential to change current practice were included. Results A total of 150 key cardiology clinical trials were identified for inclusion. Interventional cardiology data included trials evaluating the use of new generation novel stent technology and new intravascular physiology strategies such as quantitative flow ratio (QFR) to guide revascularisation in stable and unstable coronary artery disease. New trials in acute coronary syndromes focused on shock, out of hospital cardiac arrest (OOHCA), the impact of COVID-19 on ST-elevation myocardial infarction (STEMI) networks and optimal duration/type of antiplatelet treatment. Structural intervention trials included latest data on transcatheter aortic valve replacement (TAVR) and mitral, tricuspid and pulmonary valve interventions. Heart failure data included trials with sodium-glucose cotransporter 2 (SGLT2) inhibitors, sacubitril/valsartan and novel drugs such as mavacamten for hypertrophic cardiomyopathy (HCM). Prevention trials included new data on proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors. In electrophysiology, new data regarding atrial fibrillation (AF) screening and new evidence for rhythm vs. rate control strategies were evaluated. Conclusion This article presents a summary of key clinical cardiology trials published and presented during the past year and should be of interest to both practising clinicians and researchers.
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Sandoval Y, Lewis BR, Mehta RA, Ola O, Knott JD, De Michieli L, Akula A, Lobo R, Yang EH, Gharacholou SM, Dworak M, Crockford E, Rastas N, Grube E, Karturi S, Wohlrab S, Hodge DO, Tak T, Cagin C, Gulati R, Jaffe AS. Rapid Exclusion of Acute Myocardial Injury and Infarction with a Single High Sensitivity Cardiac Troponin T in the Emergency Department: a Multicenter United States Evaluation. Circulation 2022; 145:1708-1719. [PMID: 35535607 DOI: 10.1161/circulationaha.122.059235] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND There are good data to support using a single high-sensitivity cardiac troponin T (hs-cTnT) below the limit of detection (LoD) of 5 ng/L to exclude acute myocardial infarction. Per the United States (US) Food and Drug Administration (FDA), hs-cTnT can only report to the limit of quantitation (LoQ) of 6 ng/L, a threshold for which there is limited data. Our goal was to determine whether a single hs-cTnT below the LoQ of 6 ng/L is a safe strategy to identify patients at low-risk for acute myocardial injury and infarction. METHODS The efficacy (proportion identified as low-risk based on baseline hs-cTnT<6 ng/L) of identifying low-risk patients was examined in a multicenter (n=22 sites) US cohort study of emergency department patients undergoing at least one hs-cTnT (CV Data Mart Biomarker cohort). We then determined the performance of a single hs-cTnT<6 ng/L (biomarker alone) to exclude acute myocardial injury (subsequent hs-cTnT >99th percentile in those with an initial hs-cTnT<6 ng/L). The clinically intended rule-out strategy combining a nonischemic electrocardiogram with a baseline hs-cTnT<6 ng/L was subsequently tested in an adjudicated cohort in which the diagnostic performance for ruling-out acute myocardial infarction and safety (myocardial infarction or death at 30-days) were evaluated. RESULTS A total of 85,610 patients were evaluated in the CV Data Mart Biomarker cohort, amongst which 24,646 (29%) had a baseline hs-cTnT<6 ng/L. Women were more likely than men to have hs-cTnT<6 ng/L (38% vs. 20%, p<0.0001). Among 11,962 patients with baseline hs-cTnT<6 ng/L and serial measurements, only 1.2% developed acute myocardial injury, resulting in a negative predictive value of 98.8% (95% CI 98.6, 99.0) and sensitivity of 99.6% (95% CI 99.5, 99.6). In the adjudicated cohort, a nonischemic electrocardiogram with hs-cTnT<6 ng/L identified 33% of patients (610 of 1849) as low-risk and resulted in a negative predictive value and sensitivity of 100% and a 30-day rate of 0.2% for 30-day myocardial infarction or death. CONCLUSIONS A single hs-cTnT below the LoQ of 6 ng/L is a safe and rapid method to identify a substantial number of patients at very low risk for acute myocardial injury and infarction.
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Affiliation(s)
- Yader Sandoval
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN
| | - Bradley R Lewis
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN
| | - Ramila A Mehta
- Department of Health Sciences Research, Mayo College of Medicine, Rochester, MN
| | - Olatunde Ola
- Division of Hospital Internal Medicine, Mayo Clinic Health System, La Crosse, WI; 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, Italy
| | - Ashok Akula
- Division of Hospital Internal Medicine, Mayo Clinic Health System, La Crosse, WI; Center for Clinical and Translational Science, Mayo Clinic Graduate School of Biomedical Sciences, Rochester MN
| | - Ronstan Lobo
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN
| | - Eric H Yang
- Department of Cardiovascular Diseases, Mayo Clinic, Phoenix, AZ
| | | | - Marshall Dworak
- Department of Cardiovascular Diseases, Mayo Clinic Health System, La Crosse, WI
| | - Erika Crockford
- Department of Family Medicine, Mayo Clinic Health System, La Crosse, WI
| | - Nicholas Rastas
- Department of Cardiovascular Diseases, Mayo Clinic Health System, La Crosse, WI
| | - Eric Grube
- Department of Emergency Medicine, Mayo Clinic Health System, La Crosse, WI
| | - Swetha Karturi
- Division of Hospital Internal Medicine, Mayo Clinic Health System, La Crosse, WI
| | - Scott Wohlrab
- Department of Laboratory Medicine and Pathology, Mayo Clinic Health System, La Crosse, WI
| | - David O Hodge
- Department of Health Sciences Research, Mayo College of Medicine, Jacksonville, FL
| | - Tahir Tak
- Department of Cardiovascular Diseases, Mayo Clinic Health System, La Crosse, WI
| | - Charles Cagin
- Department of Cardiovascular Diseases, Mayo Clinic Health System, La Crosse, WI
| | - Rajiv Gulati
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN
| | - Allan S Jaffe
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN; Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
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Bevins NJ, Chae H, Hubbard JA, Castillo EM, Tolia VM, Daniels LB, Fitzgerald RL. Emergency Department Management of Chest Pain With a High-Sensitivity Troponin-Enabled 0/1-Hour Rule-Out Algorithm. Am J Clin Pathol 2022; 157:774-780. [PMID: 34893795 DOI: 10.1093/ajcp/aqab192] [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: 06/28/2021] [Accepted: 10/06/2021] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES The analytical sensitivity of high-sensitivity cardiac troponin T (hsTnT) assays has enabled rapid myocardial infarction rule-out algorithms for emergency department (ED) presentations. Few studies have analyzed the real-world impact of hsTnT algorithms on outcomes and operations. METHODS Comparison of ED length of stay (LOS) and 30-day outcomes (return to ED, inpatient admission, and mortality) for patients presenting with chest pain during 2 separate 208-day periods using a 0/1-hour hsTnT-enabled algorithm or fourth-generation TnT. RESULTS Discharge, 30-day readmission, and 30-day mortality rates were not significantly different with fourth-generation TnT vs hsTnT. Thirty-day return rates were significantly decreased with hsTnT (17.4% vs 14.9%; P < .01). For encounters with TnT measured at least twice and resulting in discharge, median ED LOS decreased by 61 minutes with the use of hsTnT (488 vs 427 minutes; P < .0001). Median time between first and second TnT results decreased by 82 minutes with hsTnT (202 vs 120 minutes; P < .0001), suggesting that the 0/1-hour algorithm was incompletely adopted. CONCLUSIONS Implementation of the hsTnT algorithm was associated with decreased 30-day return rates and decreased ED LOS for a subset of patients, despite incomplete adoption of the 0/1-hour algorithm.
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Affiliation(s)
- Nicholas J Bevins
- Department of Pathology, University of California San Diego, San Diego, CA, USA
| | - Hyojin Chae
- Department of Laboratory Medicine, Seoul St Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Jacqueline A Hubbard
- Department of Pathology and Laboratory Medicine, Dartmouth University, Lebanon, NH, USA
| | - Edward M Castillo
- Department of Emergency Medicine, University of California San Diego, San Diego, CA, USA
| | - Vaishal M Tolia
- Department of Emergency Medicine, University of California San Diego, San Diego, CA, USA
| | - Lori B Daniels
- Division of Cardiovascular Medicine, University of California San Diego, San Diego, CA, USA
| | - Robert L Fitzgerald
- Department of Pathology, University of California San Diego, San Diego, CA, USA
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Shen H, Jiang L, Ji J, Wang C, Ju Q, Zhao Y, Wei J, Xu J. Age-specific reference values for the 5th generation cardiac troponin T assay in Chinese children. Medicine (Baltimore) 2022; 101:e29101. [PMID: 35356945 PMCID: PMC10684185 DOI: 10.1097/md.0000000000029101] [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: 08/30/2021] [Indexed: 11/25/2022] Open
Abstract
ABSTRACT The clinical use of the cardiac troponin T (cTnT) assay was limited to the adult population in the diagnosis and prognosis of myocardial injury. However, emerging studies indicated its significant value in the assessment of pediatric cardiology, and it has been routinely measured in most hospitals. Our study investigated the normative values of cTnT in Chinese children and reported the age-specific 99th percentile cut-off for them.A total of 1280 apparently healthy Chinese children were enrolled in our study. Serum levels of cTnT were analyzed on the Roche Elecsys Troponin T Gen 5 STAT assay. According to the Clinical and Laboratory Standards Institute C28-A3 guideline, the 99th percentile upper reference limits (URLs) with 90% confidence intervals (CIs) were calculated in different age subgroups.The 99th percentile URL was 38 (90%CI: 37.0-51.0) ng/L for 1 to <4months old, 26 (90%CI: 25.2-28.5) ng/L for 4 to ≤ 12months old, and 12 (90%CI: 11.1-12.9) ng/L for 1 to 18 years old, respectively. For subjects aged from 1 to 18years, boys had slightly higher cTnT levels than girls (P = .003), while our assay could not measure low cTnT concentrations (≥the limit of detection) in 50% girls.Our study provided age-specific URLs of cTnT for Chinese children, with the 5th generation cTnT assay from Roche Diagnostics. It had significant clinical implications in the interpretation and use of test results for pediatric cardiology.
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Affiliation(s)
- Hanjun Shen
- Department of Laboratory Medicine, Children's Hospital of Soochow University,Suzhou, China,Department of Laboratory Medicine, The First Affiliated Hospitalof Nanjing Medical University, Nanjing, China,National Key Clinical Departmentof Laboratory Medicine, Nanjing, China
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26
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Khan E, Lambrakis K, Nazir SA, Chuang A, Halabi A, Tiver K, Briffa T, Cullen LA, Horsfall M, French JK, Sun BC, Chew DP. Implementation of more sensitive cardiac troponin T assay in a state-wide health service. Int J Cardiol 2022; 347:66-72. [PMID: 34774641 DOI: 10.1016/j.ijcard.2021.11.013] [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: 08/19/2021] [Revised: 10/30/2021] [Accepted: 11/07/2021] [Indexed: 11/29/2022]
Abstract
AIMS Explore the impact of deploying high-sensitivity (hs) cardiac troponin T (cTnT) assay across a state-wide health service. METHODS AND RESULTS Presentations to emergency departments of six tertiary hospitals between January 2008 and August 2019 were included; standard cTnT assay was superseded by hs-cTnT in June 2011 without changing the reference range (≥30 ng/L reported as elevated), despite cTnT level of 30 ng/L being equivalent to ∼44 ng/L with hs-cTnT. Clinical outcomes were captured using state-wide linked health records. Interrupted time series analyses were used adjusted for seasonality and multiple co-morbidities using propensity score matching allowing for correlation within hospitals. In total, 614,847 presentations had ≥1 troponin measurement. Clinical ordering of troponin decreased throughout the study with no increase in elevated measurements amongst those tested with hs-cTnT. Small but statistically significant changes in index myocardial infarction (MI) diagnosis (-0.36%/year, 95%CI [confidence interval]:-0.48, -0.24,p < 0.001) and invasive coronary angiography (0.12%/year,95%CI:0, 0.24,p = 0.02) were seen, with no impact on death/MI at 30 days or 3-year survival in episodes of care (EOCs) with elevated cTnT after hs-cTnT implementation. Length of stay (LOS) was shorter among those with an elevated hs-cTnT (-4.44 h/year, 95%CI:-5.27, -3.60, p < 0.001). Non-elevated cTnT EOCs demonstrated shorter total LOS and improved 3-year survival (adjusted hazard ratio:0.90, 95%CI:0.83, 0.97,p = 0.008) although death/MI at 30 days was unchanged using hs-cTnT. CONCLUSION Widespread implementation of hs-cTnT without altering clinical thresholds reported to clinicians provided significantly shorter LOS without a clinically significant impact on clinical outcomes. A safer cohort with non-elevated cTnT was identified by hs-cTnT compared to the standard cTnT assay.
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Affiliation(s)
- Ehsan Khan
- College of Medicine & Public Health, Flinders University of South Australia, Adelaide, Australia; South Australian Department of Health, Adelaide, Australia
| | - Kristina Lambrakis
- College of Medicine & Public Health, Flinders University of South Australia, Adelaide, Australia; South Australian Department of Health, Adelaide, Australia
| | - Sheraz A Nazir
- Department of Cardiology, University Hospitals of Coventry & Warwickshire NHS Trust, Coventry, CV2 2DX, UK; Department of Cardiovascular Sciences, University of Leicester and the National Institute for Health for Research (NIHR) Leicester Cardiovascular Biomedical Research Centre, Glenfield Hospital, Leicester LE3 9QF, UK
| | - Anthony Chuang
- College of Medicine & Public Health, Flinders University of South Australia, Adelaide, Australia; South Australian Department of Health, Adelaide, Australia
| | - Amera Halabi
- College of Medicine & Public Health, Flinders University of South Australia, Adelaide, Australia; South Australian Department of Health, Adelaide, Australia
| | - Kathryn Tiver
- College of Medicine & Public Health, Flinders University of South Australia, Adelaide, Australia; South Australian Department of Health, Adelaide, Australia
| | - Tom Briffa
- School of Population and Global Health, University of Western Australia, Perth, Australia
| | - Louise A Cullen
- Emergency and Trauma Centre, Royal Brisbane and Women's Hospital, Brisbane, Australia; School of Public Health, Queensland University of Technology, Brisbane, Australia; School of Medicine, University of Queensland, Brisbane, Australia
| | - Matthew Horsfall
- College of Medicine & Public Health, Flinders University of South Australia, Adelaide, Australia; South Australian Department of Health, Adelaide, Australia
| | - John K French
- Department of Cardiology, Liverpool Hospital, University of New South Wales, Sydney, Australia
| | - Benjamin C Sun
- Center for Policy Research-Emergency Medicine, Department of Emergency Medicine, Oregon Health and Science University, Portland, OR, United States of America
| | - Derek P Chew
- College of Medicine & Public Health, Flinders University of South Australia, Adelaide, Australia; South Australian Health and Medical Research Institute, Adelaide, Australia; South Australian Department of Health, Adelaide, Australia.
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Chuang MYA, Gnanamanickam ES, Karnon J, Lambrakis K, Horsfall M, Blyth A, Seshadri A, Nguyen MT, Briffa T, Cullen LA, Quinn S, French JK, Chew DP. Cost effectiveness of a 1-hour high-sensitivity troponin-T protocol: An analysis of the RAPID-TnT trial. IJC HEART & VASCULATURE 2022; 38:100933. [PMID: 35024428 PMCID: PMC8728427 DOI: 10.1016/j.ijcha.2021.100933] [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: 11/07/2021] [Accepted: 12/17/2021] [Indexed: 11/12/2022]
Abstract
This is the first randomised evaluation of the cost-effectiveness of a 0/1-hour high-sensitivity troponin protocol and has implications on clinical practice on a health system level. The results demonstrate that the 0/1-hour hs-cTnT protocol is safe and does not incur excess resource compared to the conventional 0/3-hour protocol. Whilst this cost-effectiveness analysis demonstrates superior ED efficiency and equivalent safety and resource associated with the 0/1-hour hs-cTnT protocol, further refinements in subsequent management is necessary to facilitate large-scale adaptation.
Background To understand the economic impact of an accelerated 0/1-hour high-sensitivity troponin-T (hs-cTnT) protocol. Objective To conduct a patient-level economic analysis of the RAPID-TnT randomised trial in patients presenting with suspected acute coronary syndrome (ACS). Methods An economic evaluation was conducted with 3265 patients randomised to either the 0/1-hour hs-cTnT protocol (n = 1634) or the conventional 0/3-hour standard-of-care protocol (n = 1631) with costs reported in Australian dollars. The primary clinical outcome was all-cause mortality or new/recurrent myocardial infarction. Results Over 12-months, mean per patient costs were numerically higher in the 0/1-hour arm compared to the conventional 0/3-hour arm (by $472.49/patient, 95% confidence interval [95 %CI]: $-1,380.15 to $2,325.13, P = 0.617) with no statistically significant difference in primary outcome (0/1-hour: 62/1634 [3.8%], 0/3-hour: 82/1631 [5.0%], HR: 1.32 [95 %CI: 0.95–1.83], P = 0.100). The mean emergency department (ED) length of stay (LOS) was significantly lower in the 0/1-hour arm (by 0.62 h/patient, 95 %CI: 0.85 to 0.39, P < 0.001), but the subsequent 12-month unplanned inpatient costs was numerically higher (by $891.22/patient, 95 %CI: $-96.07 to 1,878.50, P = 0.077). Restricting the analysis to patients with hs-cTnT concentrations ≤ 29 ng/L, mean per patient cost remained numerically higher in the 0/1-hour arm (by $152.44/patient, 95 %CI:$-1,793.11 to $2,097.99, P = 0.988), whilst the reduction in ED LOS was more pronounced (by 0.70 h/patient, 95 %CI: 0.45–0.95, P < 0.001). Conclusions There were no differences in resource utilization between the 0/1-hour hs-cTnT protocol versus the conventional 0/3-hour protocol for the assessment of suspected ACS, despite improved initial ED efficiency. Further refinements in strategies to improve clinical outcomes and subsequent management efficiency are needed.
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Affiliation(s)
- Ming-Yu Anthony Chuang
- College of Medicine & Public Health, Flinders University of South Australia, Adelaide, Australia.,South Australian Department of Health, Adelaide, Australia
| | - Emmanuel S Gnanamanickam
- College of Medicine & Public Health, Flinders University of South Australia, Adelaide, Australia.,South Australian Department of Health, Adelaide, Australia
| | - Jonathan Karnon
- College of Medicine & Public Health, Flinders University of South Australia, Adelaide, Australia
| | - Kristina Lambrakis
- College of Medicine & Public Health, Flinders University of South Australia, Adelaide, Australia.,South Australian Department of Health, Adelaide, Australia
| | | | - Andrew Blyth
- College of Medicine & Public Health, Flinders University of South Australia, Adelaide, Australia.,South Australian Department of Health, Adelaide, Australia
| | - Anil Seshadri
- College of Medicine & Public Health, Flinders University of South Australia, Adelaide, Australia.,South Australian Department of Health, Adelaide, Australia
| | - Mau T Nguyen
- College of Medicine & Public Health, Flinders University of South Australia, Adelaide, Australia.,South Australian Department of Health, Adelaide, Australia
| | - Tom Briffa
- School of Population and Global Health, University of Western Australia, Perth, Australia
| | - Louise A Cullen
- School of Medicine, University of Adelaide, Adelaide, Australia.,Department of Emergency Medicine, Royal Brisbane and Women's Hospital, Brisbane, Australia
| | - Stephen Quinn
- Department of Health Science and Biostatistics, Swinburne University of Technology, Melbourne, Australia
| | - John K French
- Department of Cardiology, Liverpool Hospital, University of New South Wales, Sydney, Australia
| | - Derek P Chew
- College of Medicine & Public Health, Flinders University of South Australia, Adelaide, Australia.,South Australian Department of Health, Adelaide, Australia
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Reply: Applying High-Sensitivity Cardiac Troponin T. J Am Coll Cardiol 2021; 78:e149-e150. [PMID: 34711345 DOI: 10.1016/j.jacc.2021.08.042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Accepted: 08/27/2021] [Indexed: 11/23/2022]
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Impact of New ICD Codes on Acute MI Characteristics and Outcomes: What You Call It Matters. J Am Coll Cardiol 2021; 78:1254-1256. [PMID: 34531026 DOI: 10.1016/j.jacc.2021.07.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Accepted: 07/20/2021] [Indexed: 11/21/2022]
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Mueller C, Boeddinghaus J, Nestelberger T. Downstream Consequences of Implementing High-Sensitivity Cardiac Troponin: Why Indication and Education Matter. J Am Coll Cardiol 2021; 77:3180-3183. [PMID: 33957240 DOI: 10.1016/j.jacc.2021.04.063] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Accepted: 04/27/2021] [Indexed: 11/19/2022]
Affiliation(s)
- Christian Mueller
- Cardiovascular Research Institute Basel (CRIB), Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland.
| | - Jasper Boeddinghaus
- Cardiovascular Research Institute Basel (CRIB), Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Thomas Nestelberger
- Cardiovascular Research Institute Basel (CRIB), Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland; Division of Cardiology, Vancouver General Hospital, University of British Columbia, Vancouver, British Columbia, Canada
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