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Cullen L, Greenslade JH, Stephensen L, Ranasinghe I, Gaikwad N, Khorramshahi Bayat M, Mahmoodi E, Than M, Apple F, Parsonage W. External validation of a rapid algorithm using high-sensitivity troponin assay results for evaluating patients with suspected acute myocardial infarction. Emerg Med J 2024; 41:313-319. [PMID: 38316538 DOI: 10.1136/emermed-2023-213539] [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: 08/07/2023] [Accepted: 01/22/2024] [Indexed: 02/07/2024]
Abstract
OBJECTIVE We sought to validate the clinical performance of a rapid assessment pathway incorporating the Siemens Atellica IM high sensitivity cardiac troponin I (hs-cTnI) assay in patients presenting to the emergency department (ED) with suspected acute myocardial infarction (AMI). METHODS This was a multicentre prospective observational study of adult ED patients presenting to five Australian hospitals between November 2020 and September 2021. Participants included those with symptoms of suspected AMI (without ST-segment elevation MI on presentation ECG). The Siemen's Atellica IM hs-cTnI laboratory-based assay was used to measure troponin concentrations at admission and after 2-3 hours and cardiologists adjudicated final diagnoses. The HighSTEACS diagnostic algorithm was evaluated, incorporating hs-cTnI concentrations at presentation and absolute changes within the first 2 to 3 hours. The primary outcome was index AMI, including type 1 or 2 non-ST segment elevation MI (NSTEMI) or ST-elevation MI (STEMI) following presentation. 30-day major adverse cardiac outcomes (including AMI, urgent revascularisation or cardiac death) were also reported. The trial was registered with the Australian and New Zealand Clinical Trials Registry. RESULTS 1994 patients were included. The average age was 56.2 years (SD=15.6), and 44.9% were women. 118 (5.9%) patients had confirmed index AMI. The 2-hour algorithm defined 61.3% of patients as low risk. Sensitivity was 99.1% (94.0%-99.9%) and negative predictive value was 99.9% (99.3%-100%). 24.4% of patients were deemed intermediate risk. When applying the parameters for high risk, 252 (14.3%) were identified, with a specificity of 91.5% (88.7%-93.6%) and a PPV of 42.0% (35.6-48.7%). CONCLUSIONS A 2-hour algorithm based on the HighSTEACS strategy using the Siemens Atellica IM hs-cTnI laboratory-based assay enables safe and efficient risk assessment of emergency patients with suspected AMI. TRIAL REGISTRATION NUMBER ACTRN12621000053820.
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Affiliation(s)
- Louise Cullen
- Emergency and Trauma Centre, Royal Brisbane and Women's Hospital, Herston, Queensland, Australia
| | - Jaimi H Greenslade
- Department of Emergency Medicine, Royal Brisbane and Women\'s Hospital, Herston, Queensland, Australia
- School of Public Health, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Laura Stephensen
- Department of Emergency Medicine, Royal Brisbane and Women\'s Hospital, Herston, Queensland, Australia
- School of Public Health, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Isuru Ranasinghe
- Cardiology, The University of Queensland, Saint Lucia, Queensland, Australia
- The Prince Charles Hospital, Chermside, Queensland, Australia
| | | | | | - Ehsan Mahmoodi
- The Prince Charles Hospital, Chermside, Queensland, Australia
| | - Martin Than
- Emergency Department, Christchurch Hospital, Christchurch, New Zealand
| | - Fred Apple
- Hennepin County Medical Center, Minneapolis, Minnesota, USA
| | - William Parsonage
- Royal Brisbane & Women's Hospital, Brisbane, Queensland, Australia
- Queensland University of Technology, Brisbane, Queensland, Australia
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Bima P, Lopez-Ayala P, Koechlin L, Boeddinghaus J, Nestelberger T, Okamura B, Muench-Gerber TS, Sanzone A, Skolozubova D, Djurdjevic D, Rubini Gimenez M, Wildi K, Miro O, Martínez-Nadal G, Martin-Sanchez FJ, Christ M, Keller D, Lindahl B, Giannitsis E, Mueller C. Chest Pain in Cancer Patients: Prevalence of Myocardial Infarction and Performance of High-Sensitivity Cardiac Troponins. JACC CardioOncol 2023; 5:591-609. [PMID: 37969646 PMCID: PMC10635894 DOI: 10.1016/j.jaccao.2023.08.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Revised: 08/06/2023] [Accepted: 08/07/2023] [Indexed: 11/17/2023] Open
Abstract
Background Little is known about patients with cancer presenting with acute chest discomfort to the emergency department (ED). Objectives The aim of this study was to assess the prevalence of acute myocardial infarction (AMI), outcomes, and the diagnostic utility of recommended diagnostic tools in this population. Methods Patients presenting with chest pain to the ED were prospectively enrolled in an international multicenter diagnostic study with central adjudication. Cancer status was assessed prospectively and additional cancer details retrospectively. Findings were externally validated in an independent multicenter cohort. Results Among 8,267 patients, 711 (8.6%) had cancer. Patients with cancer had a higher burden of cardiovascular risk factors and pre-existing cardiac disease. Total length of stay in the ED (5.2 hours vs 4.3 hours) and hospitalization rate (49.8% vs 34.3%) were both increased in patients with cancer (P < 0.001 for both). Among 8,093 patients eligible for the AMI analyses, those with cancer more often had final diagnoses of AMI (184 of 686 with cancer [26.8%] vs 1,561 of 7,407 without cancer [21.1%]; P < 0.001). In patients with cancer, high-sensitivity cardiac troponin T (hs-cTnT) but not high sensitivity cardiac troponin I (hs-cTnI) concentration had lower diagnostic accuracy for non-ST-segment elevation myocardial infarction (for hs-cTnT, area under the curve: 0.89 [95% CI: 0.86-0.92] vs 0.94 [95% CI: 0.93-0.94] [P < 0.001]; for hs-cTnI, area under the curve: 0.93 [95% CI: 0.91-0.95] vs 0.95 [95% CI: 0.94-0.95] [P = 0.10]). In patients with cancer, the European Society of Cardiology 0/1-hour hs-cTnT and hs-cTnI algorithms maintained very high safety but had lower efficacy, with twice the number of patients remaining in the observe zone. Similar findings were obtained in the external validation cohort. Conclusions Patients with cancer have a substantially higher prevalence of AMI as the cause of chest pain. Length of ED stay and hospitalization rates are increased. The diagnostic performance of hs-cTnT and the efficacy of both the European Society of Cardiology 0/1-hour hs-cTnT and hs-cTnI algorithms is reduced. (Advantageous Predictors of Acute Coronary Syndromes Evaluation [APACE] Study; NCT00470587).
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Affiliation(s)
- Paolo Bima
- Cardiovascular Research Institute Basel and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT Network, Rome, Italy
- Department of Medical Sciences, University of Torino, Torino, Italy
| | - Pedro Lopez-Ayala
- Cardiovascular Research Institute Basel and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT Network, Rome, Italy
| | - Luca Koechlin
- Cardiovascular Research Institute Basel and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT Network, Rome, Italy
- Department of Cardiac Surgery, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Jasper Boeddinghaus
- Cardiovascular Research Institute Basel and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT Network, Rome, Italy
- BHF/University Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
| | - Thomas Nestelberger
- Cardiovascular Research Institute Basel and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT Network, Rome, Italy
| | - Bernhard Okamura
- Cardiovascular Research Institute Basel and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT Network, Rome, Italy
| | - Tamar S. Muench-Gerber
- Cardiovascular Research Institute Basel and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT Network, Rome, Italy
| | - Alessandra Sanzone
- Cardiovascular Research Institute Basel and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT Network, Rome, Italy
| | - Daria Skolozubova
- Cardiovascular Research Institute Basel and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - David Djurdjevic
- Cardiovascular Research Institute Basel and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Maria Rubini Gimenez
- Cardiovascular Research Institute Basel and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- Cardiology Department, Herzzentrum Leipzig, Leipzig, Germany
| | - Karin Wildi
- Cardiovascular Research Institute Basel and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT Network, Rome, Italy
| | - Oscar Miro
- Emergency Department, Hospital Clinic, Barcelona, Spain
| | | | | | - Michael Christ
- Department of Emergency Medicine, Luzerner Kantonsspital, Luzern, Switzerland
| | - Dagmar Keller
- Emergency Department, University Hospital Zurich, Zurich, Switzerland
| | - Bertil Lindahl
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - Evangelos Giannitsis
- Department of Medicine III, University Hospital Heidelberger, Heidelberg, Germany
| | - Christian Mueller
- Cardiovascular Research Institute Basel and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT Network, Rome, Italy
| | - APACE and TRAPID-AMI Investigators
- Cardiovascular Research Institute Basel and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT Network, Rome, Italy
- Department of Medical Sciences, University of Torino, Torino, Italy
- Department of Cardiac Surgery, University Hospital Basel, University of Basel, Basel, Switzerland
- BHF/University Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
- Cardiology Department, Herzzentrum Leipzig, Leipzig, Germany
- Emergency Department, Hospital Clinic, Barcelona, Spain
- Emergency Department, Hospital Clínico San Carlos, Madrid, Spain
- Department of Emergency Medicine, Luzerner Kantonsspital, Luzern, Switzerland
- Emergency Department, University Hospital Zurich, Zurich, Switzerland
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden
- Department of Medicine III, University Hospital Heidelberger, Heidelberg, Germany
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