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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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Danagoulian S, Miller J, Cook B, Gunaga S, Fadel R, Gandolfo C, Mills NL, Modi S, Mahler SA, Levy PD, Parikh S, Krupp S, Abdul‐Nour K, Klausner H, Rockoff S, Gindi R, Lewandowski A, Hudson M, Perrotta G, Zweig B, Lanfear D, Kim H, Shaheen E, Darnell G, Nassereddine H, Hawatian K, Tang A, Keerie C, McCord J. Is rapid acute coronary syndrome evaluation with high-sensitivity cardiac troponin less costly? An economic evaluation. J Am Coll Emerg Physicians Open 2024; 5:e13140. [PMID: 38567033 PMCID: PMC10985545 DOI: 10.1002/emp2.13140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Revised: 02/04/2024] [Accepted: 02/22/2024] [Indexed: 04/04/2024] Open
Abstract
Objective Protocols to evaluate for myocardial infarction (MI) using high-sensitivity cardiac troponin (hs-cTn) have the potential to drive costs upward due to the added sensitivity. We performed an economic evaluation of an accelerated protocol (AP) to evaluate for MI using hs-cTn to identify changes in costs of treatment and length of stay compared with conventional testing. Methods We performed a planned secondary economic analysis of a large, cluster randomized trial across nine emergency departments (EDs) from July 2020 to April 2021. Patients were included if they were 18 years or older with clinical suspicion for MI. In the AP, patients could be discharged without further testing at 0 h if they had a hs-cTnI < 4 ng/L and at 1 h if the initial value were 4 ng/L and the 1-h value ≤7 ng/L. Patients in the standard of care (SC) protocol used conventional cTn testing at 0 and 3 h. The primary outcome was the total cost of treatment, and the secondary outcome was ED length of stay. Results Among 32,450 included patients, an AP had no significant differences in cost (+$89, CI: -$714, $893 hospital cost, +$362, CI: -$414, $1138 health system cost) or ED length of stay (+46, CI: -28, 120 min) compared with the SC protocol. In lower acuity, free-standing EDs, patients under the AP experienced shorter length of stay (-37 min, CI: -62, 12 min) and reduced health system cost (-$112, CI: -$250, $25). Conclusion Overall, the implementation of AP using hs-cTn does not result in higher costs.
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Affiliation(s)
| | - Joseph Miller
- Department of Emergency MedicineHenry Ford Health SystemDetroitMichiganUSA
| | - Bernard Cook
- Department of ChemistryHenry Ford Health SystemDetroitMichiganUSA
| | - Satheesh Gunaga
- Department of Emergency MedicineHenry Ford Wyandotte HospitalWyandotteMichiganUSA
| | - Raef Fadel
- Department of CardiologyHenry Ford Health SystemDetroitMichiganUSA
| | - Chaun Gandolfo
- Department of CardiologyHenry Ford Health SystemDetroitMichiganUSA
| | - Nicholas L. Mills
- Department of CardiologyThe University of Edinburgh Usher Institute of Population Health Sciences and InformaticsUnited Kingdom of Great Britain and Northern IrelandEdinburghUK
| | - Shalini Modi
- Department of CardiologyHenry Ford West Bloomfield HospitalWest Bloomfield TownshipMichiganUSA
| | - Simon A. Mahler
- Department of Emergency MedicineWake Forest School of MedicineWinston‐SalemNorth CarolinaUSA
| | - Phillip D. Levy
- Department of Emergency Medicine and Integrative Biosciences CenterWayne State University School of MedicineDetroitMichiganUSA
| | - Sachin Parikh
- Department of CardiologyHenry Ford Health SystemDetroitMichiganUSA
| | - Seth Krupp
- Department of Emergency MedicineHenry Ford Health SystemDetroitMichiganUSA
| | | | - Howard Klausner
- Department of Emergency MedicineHenry Ford Health SystemDetroitMichiganUSA
| | - Steven Rockoff
- Department of Emergency MedicineHenry Ford Health SystemDetroitMichiganUSA
| | - Ryan Gindi
- Department of CardiologyHenry Ford Health SystemDetroitMichiganUSA
| | - Aaron Lewandowski
- Department of CardiologyHenry Ford West Bloomfield HospitalWest Bloomfield TownshipMichiganUSA
| | - Michael Hudson
- Department of CardiologyHenry Ford Health SystemDetroitMichiganUSA
| | - Giuseppe Perrotta
- Department of Emergency MedicineHenry Ford Health SystemDetroitMichiganUSA
| | - Bryan Zweig
- Department of CardiologyHenry Ford Health SystemDetroitMichiganUSA
| | - David Lanfear
- Department of CardiologyHenry Ford Health SystemDetroitMichiganUSA
| | - Henry Kim
- Department of CardiologyHenry Ford Health SystemDetroitMichiganUSA
| | - Elizabeth Shaheen
- Department of Emergency MedicineHenry Ford Wyandotte HospitalWyandotteMichiganUSA
| | - Gale Darnell
- Department of Emergency MedicineHenry Ford Wyandotte HospitalWyandotteMichiganUSA
| | | | - Kegham Hawatian
- Department of Emergency MedicineHenry Ford Health SystemDetroitMichiganUSA
| | - Amy Tang
- Department of ResearchHenry Ford Health SystemDetroitMichiganUSA
| | - Catriona Keerie
- Department of CardiologyThe University of Edinburgh Usher Institute of Population Health Sciences and InformaticsUnited Kingdom of Great Britain and Northern IrelandEdinburghUK
| | - James McCord
- Department of CardiologyHenry Ford Health SystemDetroitMichiganUSA
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Byrne RA, Rossello X, Coughlan JJ, Barbato E, Berry C, Chieffo A, Claeys MJ, Dan GA, Dweck MR, Galbraith M, Gilard M, Hinterbuchner L, Jankowska EA, Jüni P, Kimura T, Kunadian V, Leosdottir M, Lorusso R, Pedretti RFE, Rigopoulos AG, Rubini Gimenez M, Thiele H, Vranckx P, Wassmann S, Wenger NK, Ibanez B. 2023 ESC Guidelines for the management of acute coronary syndromes. EUROPEAN HEART JOURNAL. ACUTE CARDIOVASCULAR CARE 2024; 13:55-161. [PMID: 37740496 DOI: 10.1093/ehjacc/zuad107] [Citation(s) in RCA: 32] [Impact Index Per Article: 32.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/24/2023]
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Metsu D, Mille D, Pailly C, Oancea VG, Essemilaire L, Coppin D. Analytical assays and bootstrap resampling method to validate performance of the Roche Elecsys STAT highly sensitive troponin T assay and its application for the 'rule-out' part of ESC guidelines for NTSTEMI. Ann Clin Biochem 2024; 61:63-69. [PMID: 37525403 DOI: 10.1177/00045632231194449] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/02/2023]
Abstract
BACKGROUND The European Society of Cardiology (ESC) guidelines recommend a dynamic (0-1h) cardiac troponin (cTn) determination for non-ST elevation myocardial infarction diagnosis. For patients with low cTn levels, a discharge from emergency can be considered. Nevertheless, cTn cutoffs for discharge are lower than the limits of quantification proposed by laboratory reagent suppliers. AIM Validate cTn assay on the Elecsys STAT kit. MATERIALS AND METHODS Precision, trueness, repeatability and within-laboratory variability were calculated from internal quality control and plasma pooled at 5.78 and 10.73 ng/L. Accuracy was calculated from external quality control. Uncertainty of measurement was calculated from (i) the uncertainty of the standard and control values and (ii) by precision from pooled plasma. Distribution of precision results from pooled plasma has been evaluated by bootstrap simulations. Dilution linearity tests with patient plasma were performed to evaluate the method for values near 5 ng/L. RESULTS Precision and trueness ranged from 1.35 to 4.45% and from 0.14 to -3.74%, respectively. Accuracy results ranged from 101.40 to 104.90%. Within laboratory variability was 2.91%. Uncertainty ranged from 3.66% to 19.90% for higher (2188) to lower values (5.78 ng/L). Bootstrap simulations allowed utilization of precision data from pooled plasma to evaluate cTn assay. The method was linear from 4.48 to 39.80 ng/L. A linear regression model best described the data. CONCLUSION Elecsys STAT method provides accurate cTn results, including patients with cTn results categorizing them as 'rule-out' in the ESC guidelines.
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Affiliation(s)
- David Metsu
- Department of Laboratory Medicine, Montauban Hospital, Montauban, France
| | - Daphné Mille
- Department of Emergency Medicine, Montauban Hospital, Montauban, France
| | - Carole Pailly
- Department of Emergency Medicine, Montauban Hospital, Montauban, France
| | - Valerica G Oancea
- Department of Laboratory Medicine, Montauban Hospital, Montauban, France
- Université Toulouse III, Toulouse University Hospital, Toulouse, France
| | - Luc Essemilaire
- Accredited Medical Laboratories Network (LABAC), Lyon, France
| | - Dominique Coppin
- Department of Emergency Medicine, Montauban Hospital, Montauban, France
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Byrne RA, Rossello X, Coughlan JJ, Barbato E, Berry C, Chieffo A, Claeys MJ, Dan GA, Dweck MR, Galbraith M, Gilard M, Hinterbuchner L, Jankowska EA, Jüni P, Kimura T, Kunadian V, Leosdottir M, Lorusso R, Pedretti RFE, Rigopoulos AG, Rubini Gimenez M, Thiele H, Vranckx P, Wassmann S, Wenger NK, Ibanez B. 2023 ESC Guidelines for the management of acute coronary syndromes. Eur Heart J 2023; 44:3720-3826. [PMID: 37622654 DOI: 10.1093/eurheartj/ehad191] [Citation(s) in RCA: 781] [Impact Index Per Article: 781.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/26/2023] Open
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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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Yildirim M, Mueller‐Hennessen M, Milles BR, Biener M, Hund H, Frey N, Giannitsis E, Salbach C. Real-World Evidence on Disparities on the Initiation of Ticagrelor Versus Prasugrel in Patients With Acute Coronary Syndrome. J Am Heart Assoc 2023; 12:e030879. [PMID: 37581388 PMCID: PMC10492934 DOI: 10.1161/jaha.123.030879] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Accepted: 07/20/2023] [Indexed: 08/16/2023]
Abstract
Background Management of patients with non-ST-segment-elevation acute coronary syndrome (NSTE-ACS) is based on 2020 European Society of Cardiology guidelines, which recommend the preferential use of prasugrel over ticagrelor. Because the selection of the respective P2Y12 inhibitor has to consider label restrictions, we sought to evaluate the proportion of patients qualifying for either ticagrelor or prasugrel and reasons for noneligibility in an unselected cohort of patients with acute coronary syndrome. Methods and Results In this retrospective observational study, patients with ST-segment-elevation myocardial infarction (STEMI) or NSTE-ACS presenting consecutively during a 24-month period were enrolled. The eligibility of patients for a dual antiplatelet therapy option was assessed retrospectively. A total of 1502 patients had confirmed acute coronary syndrome (287 STEMI and 1215 NSTE-ACS). Eligibility for ticagrelor and full-dose prasugrel differed significantly for STEMI and NSTE-ACS (93% versus 51%, P<0.0001 versus 80% versus 31%, P<0.0001). Eligibility remained significantly lower (STEMI 78% versus NSTE-ACS 52%) if low-dose prasugrel was considered. Patients eligible for full-dose prasugrel had lower ischemic risk per GRACE (Global Registry of Acute Coronary Events) score (109 points [90-129 points] versus 121 points [98-146 points], P<0.0001) and lower bleeding risk (14 points [13-15 points] versus 20 points [12-29 points], P<0.0001) per PRECISE-DAPT (Predicting Bleeding Complications in Patients Undergoing Stent Implantation and Subsequent Dual Antiplatelet Therapy) score. Conclusions In real life, eligibility for prasugrel in patients requiring dual antiplatelet therapy is considerably lower than for ticagrelor, even in a cohort with high rates of coronary angiography and percutaneous coronary interventions. The recommended use of prasugrel over ticagrelor in current acute coronary syndrome guidelines contrasts with our observations of a substantial disparity on the eligibility. This important aspect has not received appropriate attention yet. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT05774431.
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Affiliation(s)
- Mustafa Yildirim
- Department of Internal Medicine III, CardiologyUniversity Hospital of HeidelbergHeidelbergGermany
| | | | - Barbara Ruth Milles
- Department of Internal Medicine III, CardiologyUniversity Hospital of HeidelbergHeidelbergGermany
| | - Moritz Biener
- Department of Internal Medicine III, CardiologyUniversity Hospital of HeidelbergHeidelbergGermany
| | - Hauke Hund
- Department of Internal Medicine III, CardiologyUniversity Hospital of HeidelbergHeidelbergGermany
| | - Norbert Frey
- Department of Internal Medicine III, CardiologyUniversity Hospital of HeidelbergHeidelbergGermany
| | - Evangelos Giannitsis
- Department of Internal Medicine III, CardiologyUniversity Hospital of HeidelbergHeidelbergGermany
| | - Christian Salbach
- Department of Internal Medicine III, CardiologyUniversity Hospital of HeidelbergHeidelbergGermany
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Moscarella E, Calabrò P. Time for implementing high-sensitivity cardiac troponin assays in emergency departments in Italy. Intern Emerg Med 2023; 18:689-690. [PMID: 36859648 DOI: 10.1007/s11739-023-03225-8] [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: 02/02/2023] [Accepted: 02/10/2023] [Indexed: 03/03/2023]
Affiliation(s)
- Elisabetta Moscarella
- Department of Translational Medical Sciences, University of Campania, Luigi Vanvitelli, Naples, Italy
- Division of Clinical Cardiology, A.O.R.N., Sant'Anna e San Sebastiano, Caserta, Italy
| | - Paolo Calabrò
- Department of Translational Medical Sciences, University of Campania, Luigi Vanvitelli, Naples, Italy.
- Division of Clinical Cardiology, A.O.R.N., Sant'Anna e San Sebastiano, Caserta, Italy.
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Evaluation of the Practice Guideline Used for Rule-Out of Myocardial Infarction at a Tertiary Cardiology Center. Crit Pathw Cardiol 2022; 21:183-190. [PMID: 36413397 DOI: 10.1097/hpc.0000000000000300] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
INTRODUCTION With the current high burden on the healthcare system and limited resources, the efficient utilization of facilities is of utmost importance. We sought to present the practice guideline used at a high prevalence tertiary cardiology center and compare its safety and efficacy performance with the single high-sensitivity cardiac troponin T strategy, conventional and modified HEART score. METHODS In this prospective cohort study, consecutive patients presenting to the emergency department with chest pain or an angina equivalent were recruited. The primary endpoints consisted of major adverse cardiac events at index visits and 30-day follow-up. Patients were managed according to the practice guideline, and sensitivity and negative predictive values were compared. RESULTS Of the total 1548 patients, the mean age was 50.4 ± 15.7 years. Ninety-nine (10.9%) patients were admitted at the index visit, and 89 patients were consequently diagnosed with acute coronary symptoms. Six (0.007%) patients experienced major adverse cardiac events within the 30-day follow-up among discharged patients. Among 911 patients with at least 1 troponin, using single high-sensitivity cardiac troponin T, HEART score, and modified HEART score would have further admitted 805, 450, and 609 patients, respectively. The negative predictive value for all 4 algorithms did not significantly differ (99.2% vs. 100% vs. 99.3% vs. 99.6%, respectively). CONCLUSIONS The Tehran Herat Center protocol was a relatively safe protocol with high efficacy. Despite the high safety of the other diagnostic pathways, the high volume of patients needing additional evaluation could impose a high burden on the health care system.
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Advantage of Using of High-Sensitivity Troponin I Compared to Conventional Troponin I in Shortening Time to Rule out/in Acute Coronary Syndrome in Chest Pain Patients Presenting to the Emergency Department. MEDICINA (KAUNAS, LITHUANIA) 2022; 58:medicina58101391. [PMID: 36295552 PMCID: PMC9608198 DOI: 10.3390/medicina58101391] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Revised: 09/25/2022] [Accepted: 09/26/2022] [Indexed: 11/16/2022]
Abstract
Background and Objectives: We aimed to compare the time to diagnosis for acute coronary syndromes using high-sensitivity troponin I (hsTnI) and conventional troponin I (TnI) in patients presenting to the emergency department (ED) with chest pain. Materials and Methods: This was an observational prospective study involving patients presenting to the ED of Sant’Andrea Hospital University la Sapienza in Rome (Italy) with chest pain from January to December 2014. Serum troponin was drawn at presentation, and at 3, 6, 9, and/or 12 h if clinically indicated. Depending on date of recruitment, patients had either hsTnI (Abbott Laboratories) or TnI (Abbott Laboratories) performed. The primary endpoint was the time to diagnosis at index visit. Results: A total of 1059 patients were recruited, (673 [63.6%] male, median age 60 years [interquartile range 49−73 years]), out of whom 898 (84.8%) patients were evaluated with hsTnI and 161 (15.2%) with TnI. A total of 393 (37.1%) patients had the diagnosis of acute coronary syndrome in ED. The median time to diagnosis for those evaluated with TnI was 400 min, IQR 120−720 min, while the use of hsTnI led to a significantly shorter time to diagnosis (median 200 min, IQR 100−200 min, p < 0.001). Conclusions: This study confirms that in patients presenting to the emergency department with chest pain, the use of hsTnI is associated with a reduced time to ruling in/out ACS, and, consequently, hsTnI should be routinely used over TnI for more rapid identification of ACS with benefits for patients and related costs.
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11
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Kaier TE, Twerenbold R, Lopez-Ayala P, Nestelberger T, Boeddinghaus J, Alaour B, Huber IM, Zhi Y, Koechlin L, Wussler D, Wildi K, Shrestha S, Strebel I, Miro O, Martín-Sánchez JF, Christ M, Kawecki D, Keller DI, Rubini Gimenez M, Marber M, Mueller C. A 0/1h-algorithm using cardiac myosin-binding protein C for early diagnosis of myocardial infarction. EUROPEAN HEART JOURNAL. ACUTE CARDIOVASCULAR CARE 2022; 11:325-335. [PMID: 35149868 PMCID: PMC9173679 DOI: 10.1093/ehjacc/zuac007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Revised: 01/18/2022] [Accepted: 01/25/2022] [Indexed: 11/13/2022]
Abstract
AIMS Cardiac myosin-binding protein C (cMyC) demonstrated high diagnostic accuracy for the early detection of non-ST-elevation myocardial infarction (NSTEMI). Its dynamic release kinetics may enable a 0/1h-decision algorithm that is even more effective than the ESC hs-cTnT/I 0/1 h rule-in/rule-out algorithm. METHODS AND RESULTS In a prospective international diagnostic study enrolling patients presenting with suspected NSTEMI to the emergency department, cMyC was measured at presentation and after 1 h in a blinded fashion. Modelled on the ESC hs-cTnT/I 0/1h-algorithms, we derived a 0/1h-cMyC-algorithm. Final diagnosis of NSTEMI was centrally adjudicated according to the 4th Universal Definition of Myocardial Infarction. Among 1495 patients, the prevalence of NSTEMI was 17%. The optimal derived 0/1h-algorithm ruled-out NSTEMI with cMyC 0 h concentration below 10 ng/L (irrespective of chest pain onset) or 0 h cMyC concentrations below 18 ng/L and 0/1 h increase <4 ng/L. Rule-in occurred with 0 h cMyC concentrations of at least 140 ng/L or 0/1 h increase ≥15 ng/L. In the validation cohort (n = 663), the 0/1h-cMyC-algorithm classified 347 patients (52.3%) as 'rule-out', 122 (18.4%) as 'rule-in', and 194 (29.3%) as 'observe'. Negative predictive value for NSTEMI was 99.6% [95% confidence interval (CI) 98.9-100%]; positive predictive value 71.1% (95% CI 63.1-79%). Direct comparison with the ESC hs-cTnT/I 0/1h-algorithms demonstrated comparable safety and even higher triage efficacy using the 0h-sample alone (48.1% vs. 21.2% for ESC hs-cTnT-0/1 h and 29.9% for ESC hs-cTnI-0/1 h; P < 0.001). CONCLUSION The cMyC 0/1h-algorithm provided excellent safety and identified a greater proportion of patients suitable for direct rule-out or rule-in based on a single measurement than the ESC 0/1h-algorithm using hs-cTnT/I. TRIAL REGISTRATION ClinicalTrials.gov number, NCT00470587.
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Affiliation(s)
- Thomas E Kaier
- King's College London BHF Centre, The Rayne Institute, St Thomas' Hospital, London, UK
| | - Raphael Twerenbold
- Department of Cardiology, Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Petersgraben 4, CH-4031 Basel, Switzerland
- GREAT Network
- University Center of Cardiovascular Science and Department of Cardiology, University Heart and Vascular Center Hamburg, Hamburg, Germany
| | - Pedro Lopez-Ayala
- Department of Cardiology, Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Petersgraben 4, CH-4031 Basel, Switzerland
- GREAT Network
| | - Thomas Nestelberger
- Department of Cardiology, Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Petersgraben 4, CH-4031 Basel, Switzerland
- GREAT Network
- Division of Cardiology, Vancouver General Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Jasper Boeddinghaus
- Department of Cardiology, Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Petersgraben 4, CH-4031 Basel, Switzerland
- GREAT Network
| | - Bashir Alaour
- King's College London BHF Centre, The Rayne Institute, St Thomas' Hospital, London, UK
| | - Iris-Martina Huber
- Department of Cardiology, Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Petersgraben 4, CH-4031 Basel, Switzerland
- GREAT Network
| | - Yuan Zhi
- Department of Cardiology, Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Petersgraben 4, CH-4031 Basel, Switzerland
- GREAT Network
| | - Luca Koechlin
- Department of Cardiology, Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Petersgraben 4, CH-4031 Basel, Switzerland
- GREAT Network
- Department of Cardiac Surgery, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Desiree Wussler
- Department of Cardiology, Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Petersgraben 4, CH-4031 Basel, Switzerland
- GREAT Network
| | - Karin Wildi
- Department of Cardiology, Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Petersgraben 4, CH-4031 Basel, Switzerland
- GREAT Network
- Critical Care Research Institute, The Prince Charles Hospital, Brisbane, Queensland, Australia
- University of Queensland, Brisbane, Queensland, Australia
| | - Samyut Shrestha
- Department of Cardiology, Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Petersgraben 4, CH-4031 Basel, Switzerland
- GREAT Network
| | - Ivo Strebel
- Department of Cardiology, Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Petersgraben 4, CH-4031 Basel, Switzerland
- GREAT Network
| | - Oscar Miro
- Department of Cardiology, Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Petersgraben 4, CH-4031 Basel, Switzerland
- GREAT Network
- Emergency Department, Hospital Clinic, Barcelona, Catalonia, Spain
| | - Javier F Martín-Sánchez
- Department of Cardiology, Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Petersgraben 4, CH-4031 Basel, Switzerland
- GREAT Network
- Emergency Department, Hospital Clinico San Carlos, Madrid, Spain
| | - Michael Christ
- GREAT Network
- Department of Emergency Medicine, Luzerner Kantonsspital, Lucerne, Switzerland
| | - Damien Kawecki
- Department of Cardiology, Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Petersgraben 4, CH-4031 Basel, Switzerland
- GREAT Network
| | - Dagmar I Keller
- Emergency Department, University Hospital Zurich, Zurich, Switzerland
| | - Maria Rubini Gimenez
- Department of Cardiology, Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Petersgraben 4, CH-4031 Basel, Switzerland
- GREAT Network
- Department of Internal Medicine/Cardiology, Heart Center Leipzig, University of Leipzig, Leipzig Heart Institute, 04289 Leipzig, Germany
| | - Michael Marber
- King's College London BHF Centre, The Rayne Institute, St Thomas' Hospital, London, UK
| | - Christian Mueller
- Department of Cardiology, Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Petersgraben 4, CH-4031 Basel, Switzerland
- GREAT Network
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12
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Suh EH, Tichter AM, Ranard LS, Amaranto A, Chang BC, Huynh PA, Kratz A, Lee RJ, Rabbani LE, Sacco D, Einstein AJ. Impact of a rapid high‐sensitivity troponin pathway on patient flow in an urban emergency department. J Am Coll Emerg Physicians Open 2022; 3:e12739. [PMID: 35571147 PMCID: PMC9071237 DOI: 10.1002/emp2.12739] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Revised: 04/16/2022] [Accepted: 04/19/2022] [Indexed: 11/08/2022] Open
Affiliation(s)
- Edward Hyun Suh
- Department of Emergency Medicine Columbia University Irving Medical Center New York City New York USA
| | | | - Lauren S. Ranard
- Division of Cardiology Columbia University Irving Medical Center New York City New York USA
| | - Andrew Amaranto
- Department of Emergency Medicine Hackensack School of Medicine Hackensack New Jersey USA
| | - Betty C. Chang
- Department of Emergency Medicine Columbia University Irving Medical Center New York City New York USA
| | - Phong Anh Huynh
- Department of Emergency Medicine Baylor College of Medicine Houston Texas USA
| | - Alexander Kratz
- Department of Pathology and Cell Biology Columbia University New York City New York USA
| | | | - LeRoy E. Rabbani
- Division of Cardiology Columbia University Irving Medical Center New York City New York USA
| | - Dana Sacco
- Department of Emergency Medicine Columbia University Irving Medical Center New York City New York USA
| | - Andrew J. Einstein
- Division of Cardiology Columbia University Irving Medical Center New York City New York USA
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13
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Wang H, Wang X, Wang K, Duan X, Jiang W, Tang B, Pan B, Wang B, Guo W. Evaluation of a cardiac troponin process flow at the chest pain center with the shortest turnaround time. J Clin Lab Anal 2022; 36:e24335. [PMID: 35263018 PMCID: PMC8993626 DOI: 10.1002/jcla.24335] [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: 12/22/2021] [Revised: 02/17/2022] [Accepted: 02/26/2022] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Early diagnosis of myocardial infarction is crucial in chest pain management and cardiac troponin (cTn) test is an important step in it. Process improvement to shorten the test turnaround time (TAT) may improve patients' outcomes. The cTn test at chest pain center (CPC) of Zhongshan Hospital had the shortest TAT ever reported, but its process flow was not fully evaluated. METHODS We performed a stepwise evaluation of CPC cTn TAT and explored the potential factor that might cause delay. The performance of CPC cTn test was also compared with cTn test and human chorionic gonadotropin (HCG) test ordered from emergency department (ED). RESULTS At least 95% of CPC cTn tests were completed in 60 min, while 62% in 30 min. The medians of monthly order-to-collect time, collect-to-received time, and received-to-result time were ~7 min, ~3 min, and ~13 min, respectively. The samples collected at the bedside had longer collect-to-received time than the ones collected at the blood draw site next to the laboratory. Compared to ED cTn test and ED HCG test, CPC cTn test took less time in each step. A combination of the sample type switch and the centrifugation time reduction contributed the most to the shortening of TAT, which was reflected in the received-to-result time. CONCLUSIONS The current process flow of CPC cTn test satisfied the requirements of chest pain management, giving an example of how to implement process improvement for emergency medicine to shorten TAT of laboratory tests.
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Affiliation(s)
- Hao Wang
- Department of Laboratory Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Xinyue Wang
- Department of Laboratory Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Kouqiong Wang
- Department of Laboratory Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Xincen Duan
- Department of Laboratory Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Wenhai Jiang
- IT Center, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Bin Tang
- Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Baishen Pan
- Department of Laboratory Medicine, Zhongshan Hospital, Fudan University, Shanghai, China.,Department of Laboratory Medicine, Xiamen Branch, Zhongshan Hospital, Fudan University, Xiamen, China
| | - Beili Wang
- Department of Laboratory Medicine, Zhongshan Hospital, Fudan University, Shanghai, China.,Department of Laboratory Medicine, Xiamen Branch, Zhongshan Hospital, Fudan University, Xiamen, China
| | - Wei Guo
- Department of Laboratory Medicine, Zhongshan Hospital, Fudan University, Shanghai, China.,Department of Laboratory Medicine, Xiamen Branch, Zhongshan Hospital, Fudan University, Xiamen, China.,Department of Laboratory Medicine, Wusong Branch, Zhongshan Hospital, Fudan University, Shanghai, China
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14
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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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15
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Chiang CH, Chiang CH, Pickering JW, Stoyanov KM, Chew DP, Neumann JT, Ojeda F, Sörensen NA, Su KY, Kavsak P, Worster A, Inoue K, Johannessen TR, Atar D, Amann M, Hochholzer W, Mokhtari A, Ekelund U, Twerenbold R, Mueller C, Bahrmann P, Buttinger N, Dooley M, Ruangsomboon O, Nowak RM, DeFilippi CR, Peacock WF, Neilan TG, Liu MA, Hsu WT, Lee GH, Tang PU, Ma KSK, Westermann D, Blankenberg S, Giannitsis E, Than MP, Lee CC. Performance of the European Society of Cardiology 0/1-Hour, 0/2-Hour, and 0/3-Hour Algorithms for Rapid Triage of Acute Myocardial Infarction : An International Collaborative Meta-analysis. Ann Intern Med 2022; 175:101-113. [PMID: 34807719 DOI: 10.7326/m21-1499] [Citation(s) in RCA: 36] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND The 2020 European Society of Cardiology (ESC) guidelines recommend using the 0/1-hour and 0/2-hour algorithms over the 0/3-hour algorithm as the first and second choices of high-sensitivity cardiac troponin (hs-cTn)-based strategies for triage of patients with suspected acute myocardial infarction (AMI). PURPOSE To evaluate the diagnostic accuracies of the ESC 0/1-hour, 0/2-hour, and 0/3-hour algorithms. DATA SOURCES PubMed, Embase, Cochrane Central Register of Controlled Trials, Web of Science, and Scopus from 1 January 2011 to 31 December 2020. (PROSPERO: CRD42020216479). STUDY SELECTION Prospective studies that evaluated the ESC 0/1-hour, 0/2-hour, or 0/3-hour algorithms in adult patients presenting with suspected AMI. DATA EXTRACTION The primary outcome was index AMI. Twenty unique cohorts were identified. Primary data were obtained from investigators of 16 cohorts and aggregate data were extracted from 4 cohorts. Two independent authors assessed each study for methodological quality. DATA SYNTHESIS A total of 32 studies (20 cohorts) with 30 066 patients were analyzed. The 0/1-hour algorithm had a pooled sensitivity of 99.1% (95% CI, 98.5% to 99.5%) and negative predictive value (NPV) of 99.8% (CI, 99.6% to 99.9%) for ruling out AMI. The 0/2-hour algorithm had a pooled sensitivity of 98.6% (CI, 97.2% to 99.3%) and NPV of 99.6% (CI, 99.4% to 99.8%). The 0/3-hour algorithm had a pooled sensitivity of 93.7% (CI, 87.4% to 97.0%) and NPV of 98.7% (CI, 97.7% to 99.3%). Sensitivity of the 0/3-hour algorithm was attenuated in studies that did not use clinical criteria (GRACE score <140 and pain-free) compared with studies that used clinical criteria (90.2% [CI, 82.9 to 94.6] vs. 98.4% [CI, 88.6 to 99.8]). All 3 algorithms had similar specificities and positive predictive values for ruling in AMI, but heterogeneity across studies was substantial. Diagnostic performance was similar across the hs-cTnT (Elecsys; Roche), hs-cTnI (Architect; Abbott), and hs-cTnI (Centaur/Atellica; Siemens) assays. LIMITATION Diagnostic accuracy, inclusion and exclusion criteria, and cardiac troponin sampling time varied among studies. CONCLUSION The ESC 0/1-hour and 0/2-hour algorithms have higher sensitivities and NPVs than the 0/3-hour algorithm for index AMI. PRIMARY FUNDING SOURCE National Taiwan University Hospital.
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Affiliation(s)
- Cho-Han Chiang
- Harvard Medical School, Boston, Massachusetts, and National Taiwan University College of Medicine, Taipei, Taiwan (Cho-Han Chiang)
| | - Cho-Hung Chiang
- Taipei Tzu Chi Hospital, Buddhist Tzu Chi Foundation, New Taipei City, Taiwan (Cho-Hung Chiang)
| | - John W Pickering
- Christchurch Hospital and University of Otago Christchurch, Christchurch, New Zealand (J.W.P.)
| | - Kiril M Stoyanov
- University Hospital of Heidelberg, Heidelberg, Germany (K.M.S., E.G.)
| | - Derek P Chew
- Flinders University of South Australia, Adelaide, Australia (D.P.C.)
| | - Johannes T Neumann
- Monash University, Melbourne, Australia, and University Heart & Vascular Center Hamburg, Hamburg, Germany (J.T.N.)
| | - Francisco Ojeda
- University Heart & Vascular Center Hamburg, Hamburg, Germany (F.O., N.A.S., D.W., S.B.)
| | - Nils A Sörensen
- University Heart & Vascular Center Hamburg, Hamburg, Germany (F.O., N.A.S., D.W., S.B.)
| | - Ke-Ying Su
- National Taiwan University Hospital, Taipei, Taiwan (K.S., G.H.L., P.T.)
| | - Peter Kavsak
- McMaster University, Hamilton, Ontario, Canada (P.K., A.W.)
| | - Andrew Worster
- McMaster University, Hamilton, Ontario, Canada (P.K., A.W.)
| | - Kenji Inoue
- Juntendo University Nerima Hospital, Tokyo, Japan (K.I.)
| | - Tonje R Johannessen
- University of Oslo and Oslo Accident and Emergency Outpatient Clinic, Oslo, Norway (T.R.J.)
| | - Dan Atar
- Oslo University Hospital, Ullevaal, and University of Oslo, Oslo, Norway (D.A.)
| | - Michael Amann
- University Heart Center Freiburg-Bad Krozingen, Bad Krozingen, Germany (M.A., W.H.)
| | - Willibald Hochholzer
- University Heart Center Freiburg-Bad Krozingen, Bad Krozingen, Germany (M.A., W.H.)
| | - Arash Mokhtari
- Skåne University Hospital, Lund University, Lund, Sweden (A.M., U.E.)
| | - Ulf Ekelund
- Skåne University Hospital, Lund University, Lund, Sweden (A.M., U.E.)
| | - Raphael Twerenbold
- University of Basel, Basel, Switzerland, University Heart and Vascular Center Hamburg, Hamburg, Germany, and German Center for Cardiovascular Research (DZHK) Partner Site Hamburg-Kiel-Lübeck (R.T.)
| | | | - Philipp Bahrmann
- Friedrich-Alexander-University Erlangen-Nuremberg, Nuremberg, Germany (P.B.)
| | - Nicolas Buttinger
- Brighton and Sussex University Hospitals NHS Trust, Brighton, United Kingdom (N.B., M.D.)
| | - Maureen Dooley
- Brighton and Sussex University Hospitals NHS Trust, Brighton, United Kingdom (N.B., M.D.)
| | | | | | | | | | - Tomas G Neilan
- Cardiovascular Imaging Research Center, Massachusetts General Hospital, Boston, Massachusetts (T.G.N.)
| | - Michael A Liu
- Warren Alpert Medical School of Brown University, Providence, Rhode Island (M.A.L.)
| | - Wan-Ting Hsu
- Harvard School of Public Health, Boston, Massachusetts (W.H.)
| | - Gin Hoong Lee
- National Taiwan University Hospital, Taipei, Taiwan (K.S., G.H.L., P.T.)
| | - Pui-Un Tang
- National Taiwan University Hospital, Taipei, Taiwan (K.S., G.H.L., P.T.)
| | - Kevin Sheng-Kai Ma
- Center for Global Health, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, and National Taiwan University, Taipei, Taiwan (K.S.M.)
| | - Dirk Westermann
- University Heart & Vascular Center Hamburg, Hamburg, Germany (F.O., N.A.S., D.W., S.B.)
| | - Stefan Blankenberg
- University Heart & Vascular Center Hamburg, Hamburg, Germany (F.O., N.A.S., D.W., S.B.)
| | | | - Martin P Than
- Christchurch Hospital and Christchurch Heart Institute, University of Otago Christchurch, Christchurch, New Zealand (M.P.T.)
| | - Chien-Chang Lee
- The Centre for Intelligent Healthcare, National Taiwan University Hospital, Taipei, Taiwan (C.L.)
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16
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Giannitsis E, Blankenberg S, Christenson RH, Frey N, von Haehling S, Hamm CW, Inoue K, Katus HA, Lee CC, McCord J, Möckel M, Chieh JTW, Tubaro M, Wollert KC, Huber K. Critical appraisal of the 2020 ESC guideline recommendations on diagnosis and risk assessment in patients with suspected non-ST-segment elevation acute coronary syndrome. Clin Res Cardiol 2021; 110:1353-1368. [PMID: 33635437 PMCID: PMC8405476 DOI: 10.1007/s00392-021-01821-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Accepted: 02/08/2021] [Indexed: 10/27/2022]
Abstract
Multiple new recommendations have been introduced in the 2020 ESC guidelines for the management of acute coronary syndromes with a focus on diagnosis, prognosis, and management of patients presenting without persistent ST-segment elevation. Most recommendations are supported by high-quality scientific evidence. The guidelines provide solutions to overcome obstacles presumed to complicate a convenient interpretation of troponin results such as age-, or sex-specific cutoffs, and to give practical advice to overcome delays of laboratory reporting. However, in some areas, scientific support is less well documented or even missing, and other areas are covered rather by expert opinion or subjective recommendations. We aim to provide a critical appraisal on several recommendations, mainly related to the diagnostic and prognostic assessment, highlighting the discrepancies between Guideline recommendations and the existing scientific evidence.
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Affiliation(s)
- Evangelos Giannitsis
- Medizinische Klinik III, Department of Cardiology, Angiology and Pulmology, University Hospital of Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany.
| | - Stefan Blankenberg
- Department of Cardiology, University Heart and Vascular Centre Hamburg, Hamburg, Germany
| | | | - Norbert Frey
- Medizinische Klinik III, Department of Cardiology, Angiology and Pulmology, University Hospital of Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
| | - Stephan von Haehling
- Department of Cardiology and Pneumology, University of Göttingen Medical Center, Göttingen, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Göttingen, Göttingen, Germany
| | - Christian W Hamm
- Department of Cardiology, Kerckhoff Heart and Thorax Centre, Bad Nauheim, Germany
| | - Kenji Inoue
- Department of Cardiovascular Biology and Medicine, Juntendo University Nerima Hospital, Tokyo, Japan
| | - Hugo A Katus
- Medizinische Klinik III, Department of Cardiology, Angiology and Pulmology, University Hospital of Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
| | - Chien-Chang Lee
- Department of Emergency Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - James McCord
- Henry Ford Heart and Vascular Institute Detroit, Detroit, MI, USA
| | - Martin Möckel
- Department of Emergency Medicine, Charité-Universitätsmedizin Berlin, Campus Mitte and Virchow, Berlin, Germany
| | - Jack Tan Wei Chieh
- Department of Cardiology, National Heart Centre and Sengkang General Hospital, Singapore, Singapore
| | | | - Kai C Wollert
- Division of Molecular and Translational Cardiology, Department of Cardiology and Angiology, Hannover Medical School, Hannover, Germany
| | - Kurt Huber
- 3rd Department of Internal Medicine, Cardiology and Intensive Care Medicine, Wilhelminenhospital, Vienna, Austria
- Medical School, Sigmund Freud University, Vienna, Austria
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17
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Chest pain management and biomarkers: the lack of trust in cardiac troponins measurement. Diagnosis (Berl) 2021; 8:279-280. [DOI: 10.1515/dx-2020-0156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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18
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Collet JP, Thiele H, Barbato E, Barthélémy O, Bauersachs J, Bhatt DL, Dendale P, Dorobantu M, Edvardsen T, Folliguet T, Gale CP, Gilard M, Jobs A, Jüni P, Lambrinou E, Lewis BS, Mehilli J, Meliga E, Merkely B, Mueller C, Roffi M, Rutten FH, Sibbing D, Siontis GC. Guía ESC 2020 sobre el diagnóstico y tratamiento del síndrome coronario agudo sin elevación del segmento ST. Rev Esp Cardiol (Engl Ed) 2021. [DOI: 10.1016/j.recesp.2020.12.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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19
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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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20
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Ganguli I, Cui J, Thakore N, Orav EJ, Januzzi JL, Baugh CW, Sequist TD, Wasfy JH. Downstream Cascades of Care Following High-Sensitivity Troponin Test Implementation. J Am Coll Cardiol 2021; 77:3171-3179. [PMID: 34167642 DOI: 10.1016/j.jacc.2021.04.049] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Revised: 04/16/2021] [Accepted: 04/20/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Patients with chest pain are often evaluated for acute myocardial infarction through troponin testing, which may prompt downstream services (cascades) of uncertain value. OBJECTIVES This study sought to determine the association of high-sensitivity cardiac troponin (hs-cTn) assay implementation with cascade events. METHODS Using electronic health record and billing data, this study examined patient-visits to 5 emergency departments from April 1, 2017, to April 1, 2019. Difference-in-differences analysis compared patient-visits for chest pain (n = 7,564) to patient-visits for other symptoms (n = 100,415) (irrespective of troponin testing) before and after hs-cTn assay implementation. Outcomes included presence of any cascade event potentially associated with an initial hs-cTn test (primary), individual cascade events, length of stay, and spending on cardiac services. RESULTS Following hs-cTn implementation, patients with chest pain had a 2.8% (95% confidence interval [CI]: 0.72% to 4.9%) net increase in experiencing any cascade event. They were more likely to have multiple troponin tests (10.5%; 95% CI: 9.0% to 12.0%) and electrocardiograms (7.1 per 100 patient-visits; 95% CI: 1.8 to 12.4). However, they received net fewer computed tomography scans (-1.5 per 100 patient-visits; 95% CI: -1.8 to -1.1), stress tests (-5.9 per 100 patient-visits; 95% CI: -6.5 to -5.3), and percutaneous coronary intervention (PCI) (-0.65 per 100 patient-visits; 95% CI: -1.01 to -0.30) and were less likely to receive cardiac medications, undergo cardiology evaluation (-3.5%; 95% CI: -4.5% to 2.6%), or be hospitalized (-5.8%; 95% CI: -7.7% to -3.8%). Patients with chest pain had lower net mean length of stay (-0.24 days; 95% CI: -0.32 to -0.16) but no net change in spending. CONCLUSIONS Hs-cTn assay implementation was associated with more net upfront tests yet fewer net stress tests, PCI, cardiology evaluations, and hospital admissions in patients with chest pain relative to patients with other symptoms.
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Affiliation(s)
- Ishani Ganguli
- Harvard Medical School, Boston, Massachusetts, USA; Division of General Internal Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA.
| | - Jinghan Cui
- Division of Cardiology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Nitya Thakore
- Division of General Internal Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - E John Orav
- Division of General Internal Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA; Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - James L Januzzi
- Harvard Medical School, Boston, Massachusetts, USA; Division of Cardiology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Christopher W Baugh
- Harvard Medical School, Boston, Massachusetts, USA; Department of Emergency Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA. https://twitter.com/DrChrisBaugh
| | - Thomas D Sequist
- Harvard Medical School, Boston, Massachusetts, USA; Division of General Internal Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA; Mass General Brigham, Boston, Massachusetts, USA. https://twitter.com/TomSequist
| | - Jason H Wasfy
- Harvard Medical School, Boston, Massachusetts, USA; Division of Cardiology, Massachusetts General Hospital, Boston, Massachusetts, USA
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21
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Westwood M, Ramaekers B, Grimm S, Worthy G, Fayter D, Armstrong N, Buksnys T, Ross J, Joore M, Kleijnen J. High-sensitivity troponin assays for early rule-out of acute myocardial infarction in people with acute chest pain: a systematic review and economic evaluation. Health Technol Assess 2021; 25:1-276. [PMID: 34061019 PMCID: PMC8200931 DOI: 10.3310/hta25330] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Early diagnosis of acute myocardial infarction is important, but only 20% of emergency admissions for chest pain will actually have an acute myocardial infarction. High-sensitivity cardiac troponin assays may allow rapid rule out of myocardial infarction and avoid unnecessary hospital admissions. OBJECTIVES To assess the clinical effectiveness and cost-effectiveness of high-sensitivity cardiac troponin assays for the management of adults presenting with acute chest pain, in particular for the early rule-out of acute myocardial infarction. METHODS Sixteen databases were searched up to September 2019. Review methods followed published guidelines. Studies were assessed for quality using appropriate risk-of-bias tools. The bivariate model was used to estimate summary sensitivity and specificity for meta-analyses involving four or more studies; otherwise, random-effects logistic regression was used. The health economic analysis considered the long-term costs and quality-adjusted life-years associated with different troponin testing methods. The de novo model consisted of a decision tree and a state-transition cohort model. A lifetime time horizon (of 60 years) was used. RESULTS Thirty-seven studies (123 publications) were included in the review. The high-sensitivity cardiac troponin test strategies evaluated are defined by the combination of four factors (i.e. assay, number and timing of tests, and threshold concentration), resulting in a large number of possible combinations. Clinical opinion indicated a minimum clinically acceptable sensitivity of 97%. When considering single test strategies, only those using a threshold at or near to the limit of detection for the assay, in a sample taken at presentation, met the minimum clinically acceptable sensitivity criterion. The majority of the multiple test strategies that met this criterion comprised an initial rule-out step, based on high-sensitivity cardiac troponin levels in a sample taken on presentation and a minimum symptom duration, and a second stage for patients not meeting the initial rule-out criteria, based on presentation levels of high-sensitivity cardiac troponin and absolute change after 1, 2 or 3 hours. Two large cluster randomised controlled trials found that implementation of an early rule-out pathway for myocardial infarction reduced length of stay and rate of hospital admission without increasing cardiac events. In the base-case analysis, standard troponin testing was both the most effective and the most costly. Other testing strategies with a sensitivity of 100% (subject to uncertainty) were almost equally effective, resulting in the same life-year and quality-adjusted life-year gain at up to four decimal places. Comparisons based on the next best alternative showed that for willingness-to-pay values below £8455 per quality-adjusted life-year, the Access High Sensitivity Troponin I (Beckman Coulter, Brea, CA, USA) [(symptoms > 3 hours AND < 4 ng/l at 0 hours) OR (< 5 ng/l AND Δ < 5 ng/l at 0 to 2 hours)] would be cost-effective. For thresholds between £8455 and £20,190 per quality-adjusted life-year, the Elecsys® Troponin-T high sensitive (Roche, Basel, Switzerland) (< 12 ng/l at 0 hours AND Δ < 3 ng/l at 0 to 1 hours) would be cost-effective. For a threshold > £20,190 per quality-adjusted life-year, the Dimension Vista® High-Sensitivity Troponin I (Siemens Healthcare, Erlangen, Germany) (< 5 ng/l at 0 hours AND Δ < 2 ng/l at 0 to 1 hours) would be cost-effective. CONCLUSIONS High-sensitivity cardiac troponin testing may be cost-effective compared with standard troponin testing. STUDY REGISTRATION This study is registered as PROSPERO CRD42019154716. FUNDING This project was funded by the National Institute for Health Research (NIHR) Evidence Synthesis programme and will be published in full in Health Technology Assessment; Vol. 25, No. 33. See the NIHR Journals Library website for further project information.
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Affiliation(s)
| | - Bram Ramaekers
- Department of Clinical Epidemiology and Medical Technology Assessment, Maastricht University, Maastricht, the Netherlands
| | - Sabine Grimm
- Department of Clinical Epidemiology and Medical Technology Assessment, Maastricht University, Maastricht, the Netherlands
| | | | | | | | | | | | - Manuela Joore
- Department of Clinical Epidemiology and Medical Technology Assessment, Maastricht University, Maastricht, the Netherlands
| | - Jos Kleijnen
- Kleijnen Systematic Reviews Ltd, York, UK
- School for Public Health and Primary Care, Care and Public Health Research Institute, Maastricht University, Maastricht, the Netherlands
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22
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Elliott P, Cowie MR, Franke J, Ziegler A, Antoniades C, Bax J, Bucciarelli-Ducci C, Flachskampf FA, Hamm C, Jensen MT, Katus H, Maisel A, McDonagh T, Mittmann C, Muntendam P, Nagel E, Rosano G, Twerenbold R, Zannad F. Development, validation, and implementation of biomarker testing in cardiovascular medicine state-of-the-art: proceedings of the European Society of Cardiology-Cardiovascular Round Table. Cardiovasc Res 2021; 117:1248-1256. [PMID: 32960964 DOI: 10.1093/cvr/cvaa272] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Revised: 09/01/2020] [Accepted: 09/08/2020] [Indexed: 01/09/2023] Open
Abstract
Many biomarkers that could be used to assess ejection fraction, heart failure, or myocardial infarction fail to translate into clinical practice because they lack essential performance characteristics or fail to meet regulatory standards for approval. Despite their potential, new technologies have added to the complexities of successful translation into clinical practice. Biomarker discovery and implementation require a standardized approach that includes: identification of a clinical need; identification of a valid surrogate biomarker; stepwise assay refinement, demonstration of superiority over current standard-of-care; development and understanding of a clinical pathway; and demonstration of real-world performance. Successful biomarkers should improve efficacy or safety of treatment, while being practical at a realistic cost. Everyone involved in cardiovascular healthcare, including researchers, clinicians, and industry partners, are important stakeholders in facilitating the development and implementation of biomarkers. This article provides suggestions for a development pathway for new biomarkers, discusses regulatory issues and challenges, and suggestions for accelerating the pathway to improve patient outcomes. Real-life examples of successful biomarkers-high-sensitivity cardiac troponin, T2* cardiovascular magnetic resonance imaging, and echocardiography-are used to illustrate the value of a standardized development pathway in the translation of concepts into routine clinical practice.
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Affiliation(s)
- Perry Elliott
- Cardiovascular Medicine, University College London, Gower Street, WC1E 6BT London, UK
| | - Martin R Cowie
- Cardiology (Health Services Research), National Heart and Lung Institute, Imperial College London, Dovehouse Street, SW3 6LY London, UK
| | - Jennifer Franke
- Therapeutic Area, CardioMetabolism Respiratory Medicine, Boehringer-Ingelheim, Binger Straße 173, 55216 Ingelheim am Rhein, Germany
| | - André Ziegler
- Global Clinical Leader CVD, Roche Diagnostics International Ltd, RPD Medical & Scientific Affairs - Bldg 05 / 10th floor / Room 1.34 - Forrenstrasse 2 - CH 6343, Rotkreuz, Switzerland
| | - Charalambos Antoniades
- Cardiovascular Medicine, Oxford University, Headley Way, Headington - OX3 9DU, Oxford, UK
| | - Jeroen Bax
- Non-Invasive Imaging and Echocardiography Lab, Leiden University Medical Centre, Albinusdreef 2 - 2333 ZA, Leiden, Netherlands
| | - Chiara Bucciarelli-Ducci
- Cardiology/Non-Invasive Imaging, Bristol Heart Institute, Bristol National Institute of Health Research (NIHR) Biomedical Research Centre, Clinical Research and Imaging Centre (CRIC) Bristol, University Hospitals Bristol NHS Trust and University of Bristol, Malborough St, Bristol, BS2 8HW, UK
| | - Frank A Flachskampf
- Cardiology/Cardiac Imaging, Department of Medical Sciences, Uppsala University, Ingang 40, Plan 5 - S-751 85, Uppsala, Sweden
- Clinical Physiology and Cardiology, Akademiska sjukhuset, Ingang 40, Plan 5 - S-751 85, Uppsala, Sweden
| | - Christian Hamm
- Internal Medicine and Cardiology, Campus Kerckhoff, University of Giessen, Klinikstr. 33 - D-35392, Germany
| | - Magnus T Jensen
- Department of Cardiology, Copenhagen University Hospital, Amager-Hvidovre, Sankt Jakobs Gade 18, 4. Tv - 2100 Hvidovre, Denmark
| | - Hugo Katus
- Department of Internal Medicine III (Cardiology, Angiology, Pneumology), University of Heidelberg, Im Neuenheimer Feld 410 - D-69120, Heidelberg, Germany
| | - Alan Maisel
- Division of Cardiology, University of California-San Diego, 190 Del Mar Shores, #35; Solana Beach, CA 92075, USA
| | - Theresa McDonagh
- Clinical Lead for Heart Failure, King's College Hospital, Denmark Hill - SE5 9RS London, UK
| | - Clemens Mittmann
- Department of Diabetes and Cardiovascular Diseases, BfArM, Kurt-Georg-Kiesinger-Allee 3, 53175 Bonn, Germany
| | | | - Eike Nagel
- Institute for Experimental and Translational Cardiovascular Imaging, DZHK (German Centre for Cardiovascular Research) Centre for Cardiovascular Imaging, Partner Site RheinMain, University Hospital, Goethe University, Haus 1, Theodor-Stern-Kai 7, 60590 Frankfurt am Main, Germany
| | - Giuseppe Rosano
- Department of Medical Sciences, IRCCS San Raffaele, Via Ardeatina 306-354, 00179 Roma, Italy
- Cardiology, St George's Hospital, University of London, Blackshaw Road, Tooting, SW17 0QT London, UK
| | - Raphael Twerenbold
- Department of Cardiology, University Hospital Basel, Petersgraben 4 - 4031, Basel, Switzerland
| | - Faiez Zannad
- Université de Lorraine, Inserm CIC 1433, CHRU Nancy, FCRIN INI-CRCT, 4, rue du Morvan 54500 Vandoeuvre les Nancy, France
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23
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Collet JP, Thiele H, Barbato E, Barthélémy O, Bauersachs J, Bhatt DL, Dendale P, Dorobantu M, Edvardsen T, Folliguet T, Gale CP, Gilard M, Jobs A, Jüni P, Lambrinou E, Lewis BS, Mehilli J, Meliga E, Merkely B, Mueller C, Roffi M, Rutten FH, Sibbing D, Siontis GCM. 2020 ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation. Eur Heart J 2021; 42:1289-1367. [PMID: 32860058 DOI: 10.1093/eurheartj/ehaa575] [Citation(s) in RCA: 2785] [Impact Index Per Article: 928.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
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24
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Mumma BE, Casey SD, Dang RK, Polen MK, Kaur JC, Rodrigo J, Tancredi DJ, Narverud RA, Amsterdam EA, Tran N. Diagnostic Reclassification by a High-Sensitivity Cardiac Troponin Assay. Ann Emerg Med 2020; 76:566-579. [PMID: 32807538 PMCID: PMC7606506 DOI: 10.1016/j.annemergmed.2020.06.047] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Revised: 06/16/2020] [Accepted: 06/22/2020] [Indexed: 02/07/2023]
Abstract
STUDY OBJECTIVE Our objective is to describe the rates of diagnostic reclassification between conventional cardiac troponin I (cTnI) and high-sensitivity cardiac troponin T (hs-cTnT) and between combined and sex-specific hs-cTnT thresholds in adult emergency department (ED) patients in the United States. METHODS We conducted a prospective, single-center, before-and-after, observational study of ED patients aged 18 years or older undergoing single or serial cardiac troponin testing in the ED for any reason before and after hs-cTnT implementation. Conventional cTnI and hs-cTnT results were obtained from a laboratory quality assurance database. Combined and sex-specific thresholds were the published 99th percentile upper reference limits for each assay. Cases underwent physician adjudication using the Fourth Universal Definition of Myocardial Infarction. Diagnostic reclassification occurred when a patient received a diagnosis of myocardial infarction or myocardial injury with one assay but not the other assay. Our primary outcome was diagnostic reclassification between the conventional cTnI and hs-cTnT assays. Diagnostic reclassification probabilities were assessed with sample proportions and 95% confidence intervals for binomial data. RESULTS We studied 1,016 patients (506 men [50%]; median age 60 years [25th, 75th percentiles 49, 71]). Between the conventional cTnI and hs-cTnT assays, 6 patients (0.6%; 95% confidence interval 0.2% to 1.3%) underwent diagnostic reclassification regarding myocardial infarction (5/6 reclassified as no myocardial infarction) and 166 patients (16%; 95% confidence interval 14% to 19%) underwent diagnostic reclassification regarding myocardial injury (154/166 reclassified as having myocardial injury) by hs-cTnT. CONCLUSION Compared with conventional cTnI, the hs-cTnT assay resulted in no clinically relevant change in myocardial infarction diagnoses but substantially more myocardial injury diagnoses.
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Affiliation(s)
- Bryn E Mumma
- Department of Emergency Medicine, University of California, Davis, Sacramento, CA.
| | - Scott D Casey
- Department of Emergency Medicine, University of California, Davis, Sacramento, CA
| | - Robert K Dang
- Department of Emergency Medicine, University of California, Davis, Sacramento, CA
| | - Michelle K Polen
- Department of Emergency Medicine, University of California, Davis, Sacramento, CA
| | - Jasmanpreet C Kaur
- Department of Emergency Medicine, University of California, Davis, Sacramento, CA
| | - John Rodrigo
- Department of Pathology and Laboratory Medicine, University of California, Davis, Sacramento, CA
| | - Daniel J Tancredi
- Department of Pediatrics, University of California, Davis, Sacramento CA
| | - Robert A Narverud
- Department of Emergency Medicine, University of California, Davis, Sacramento, CA
| | - Ezra A Amsterdam
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of California, Davis, Sacramento CA
| | - Nam Tran
- Department of Pathology and Laboratory Medicine, University of California, Davis, Sacramento, CA
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25
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Giannitsis E, Slagman A, Hamm CW, Gehrig S, Vollert JO, Huber K. Copeptin combined with either non-high sensitivity or high sensitivity cardiac troponin for instant rule-out of suspected non-ST segment elevation myocardial infarction. Biomarkers 2020; 25:649-658. [DOI: 10.1080/1354750x.2020.1833084] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Affiliation(s)
- Evangelos Giannitsis
- Department of Cardiology, Angiology and Pulmology, Medizinische Klinik III, University Hospital of Heidelberg, Heidelberg, Germany
| | - Anna Slagman
- Division of Emergency Medicine and Chest Pain Units, Campus Virchow and Mitte, Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Christian W. Hamm
- Department of Cardiology, Kerckhoff Heart and Thorax Centre, Bad Nauheim, Germany
| | - Stefan Gehrig
- Cardiovascular Biomarkers, Thermo Fisher Scientific, Hennigsdorf, Germany
| | - Joern O. Vollert
- Cardiovascular Biomarkers, Thermo Fisher Scientific, Hennigsdorf, Germany
| | - Kurt Huber
- 3rd Department of Internal Medicine, Cardiology and Intensive Care Medicine, Wilhelminenhospital, Vienna, Austria
- Medical School, Sigmund Freud University, Vienna, Austria
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26
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Abstract
The measurement of cardiac troponin (cTn) is recommended by all guidelines as the gold standard for the differential diagnosis of Acute Coronary Syndromes. The aim of this review is to discuss in details some key issues regarding both analytical and clinical characteristics of the high-sensitivity methods for cTn (hs-cTn), which are still considered controversial or unresolved. In particular, the major clinical concern regarding hs-cTn methods is the difficulty to differentiate the pathophysiological mechanism responsible for biomarker release from cardiomyocytes after reversible or irreversible injury, respectively. Indeed, recent experimental and clinical studies have demonstrated that different circulating forms of cTnI and cTnT can be respectively measured in plasma samples of patients with reversible or irreversible myocardial injury. Accordingly, a new generation of hs-Tn methods should be set up, based on immunometric immunoassays or chromatographic techniques, specific for circulating peptide forms more characteristics for reversible or irreversible myocardial injury. It is conceivable that this new generation of hs-cTn methods will complete the mission regarding the laboratory tests for specific cardiac biomarkers, started more than 20 years ago, which has already revolutionized the diagnosis, prognosis and management of patients with cardiac diseases.
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27
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Stoyanov KM, Biener M, Hund H, Mueller-Hennessen M, Vafaie M, Katus HA, Giannitsis E. Effects of crowding in the emergency department on the diagnosis and management of suspected acute coronary syndrome using rapid algorithms: an observational study. BMJ Open 2020; 10:e041757. [PMID: 33033102 PMCID: PMC7545662 DOI: 10.1136/bmjopen-2020-041757] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
OBJECTIVES Fast diagnostic algorithms using high-sensitivity troponin (hsTn) in suspected acute coronary syndrome (ACS) are regarded as beneficial to expedite diagnosis and safe discharge of patients in crowded emergency departments (ED). This study investigates the effects of crowding on process times related to the diagnostic protocol itself or other time delays, and outcomes. DESIGN Prospective single-centre observational study. SETTING ED (Germany). PARTICIPANTS Final study population of 2525 consecutive patients with suspected ACS within 12 months, after exclusion of patients with ST-elevation myocardial infarction, missing blood samples, referral from other hospitals or repeated visits. INTERVENTIONS Use of fast algorithms as per 2015 European Society of Cardiology guidelines. MAIN OUTCOME MEASURES Crowding was defined as mismatch between patient numbers and monitoring capacities, or mean physician time per case, categorised as normal, high and very high crowding. Outcome measures were length of ED stay, direct discharge from ED, laboratory turn around times (TAT), utilisation of fast algorithms, absolute and relative non-laboratory time, as well as mortality. RESULTS Crowding was associated with increased length of ED stay (3.75-4.89 hours, p<0.001). While median TAT of the first hsTnT increased (53-57 min, p<0.001), total TAT of serial hsTnT did not increase significantly with higher crowding (p=0.170). Lower utilisation of fast algorithms (p=0.009) and increase of additional hsTnT measurements after diagnosis (p=0.001) were observed in higher crowding. Most importantly, crowding was significantly associated with prolonged absolute (p<0.001), and particularly relative non-laboratory time (63.3%-71.3%, p<0.001). However, there was no significant effect of crowding on mortality, even after adjustment for relevant clinical variables. CONCLUSIONS Process times, and particularly non-laboratory times, are prolonged in a crowded ED diminishing some positive effects of fast diagnostic algorithms in suspected ACS. Higher crowding levels were not significantly associated with higher all-cause mortality rates. TRIAL REGISTRATION NUMBER NCT03111862.
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Affiliation(s)
- Kiril M Stoyanov
- Department of Cardiology, Angiology and Pulmonology, Heidelberg University Hospital, Heidelberg, Germany
| | - Moritz Biener
- Department of Cardiology, Angiology and Pulmonology, Heidelberg University Hospital, Heidelberg, Germany
| | - Hauke Hund
- Department of Cardiology, Angiology and Pulmonology, Heidelberg University Hospital, Heidelberg, Germany
- Faculty of Informatics, Heilbronn University of Applied Sciences, Heilbronn, Germany
| | - Matthias Mueller-Hennessen
- Department of Cardiology, Angiology and Pulmonology, Heidelberg University Hospital, Heidelberg, Germany
| | - Mehrshad Vafaie
- Department of Cardiology, Angiology and Pulmonology, Heidelberg University Hospital, Heidelberg, Germany
| | - Hugo A Katus
- Department of Cardiology, Angiology and Pulmonology, Heidelberg University Hospital, Heidelberg, Germany
| | - Evangelos Giannitsis
- Department of Cardiology, Angiology and Pulmonology, Heidelberg University Hospital, Heidelberg, Germany
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28
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Comparison of High-Sensitivity Troponin T Assay to Conventional Troponin T Assay for Rule Out of Acute Coronary Syndrome in the Emergency Department. Adv Emerg Nurs J 2020; 42:304-314. [DOI: 10.1097/tme.0000000000000324] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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29
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Aarts GWA, Mol JQ, Camaro C, Lemkes J, van Royen N, Damman P. Recent developments in diagnosis and risk stratification of non-ST-elevation acute coronary syndrome. Neth Heart J 2020; 28:88-92. [PMID: 32780337 PMCID: PMC7419413 DOI: 10.1007/s12471-020-01457-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
In the past year, a number of important papers have been published on non-ST-elevation acute coronary syndrome, highlighting progress in clinical care. The current review focuses on early diagnosis and risk stratification using biomarkers and advances in intracoronary imaging.
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Affiliation(s)
- G W A Aarts
- Department of Cardiology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - J Q Mol
- Department of Cardiology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - C Camaro
- Department of Cardiology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - J Lemkes
- Department of Cardiology, Amsterdam UMC, location VUMC, University of Amsterdam, Amsterdam, The Netherlands
| | - N van Royen
- Department of Cardiology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - P Damman
- Department of Cardiology, Radboud University Medical Centre, Nijmegen, The Netherlands.
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30
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Nikhanj A, Nichols BM, Wang K, Siddiqi ZA, Oudit GY. Evaluating the Diagnostic and Prognostic Value of Biomarkers for Heart Disease and Major Adverse Cardiac Events in Patients With Muscular Dystrophy. EUROPEAN HEART JOURNAL. QUALITY OF CARE & CLINICAL OUTCOMES 2020; 7:564-573. [PMID: 32687175 DOI: 10.1093/ehjqcco/qcaa059] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Revised: 07/10/2020] [Accepted: 07/14/2020] [Indexed: 12/17/2022]
Abstract
AIMS Heart disease is recognized as the leading cause of morbidity and mortality in patients with muscular dystrophy (MD). Our study demonstrates the clinical utility of cardiac biomarkers to improve the diagnosis of cardiomyopathy and prognostication of major adverse cardiac events (MACE) in these vulnerable patients. METHODS AND RESULTS We prospectively followed 117 patients (median age, 42 (interquartile range [IQR], 26-50) years; 49 [41.9%] women) at the Neuromuscular Multidisciplinary clinic diagnosed with a dystrophinopathy, limb-girdle MD, type 1 myotonic dystrophy, or facioscapulohumeral MD. We determined that B-type natriuretic peptide (BNP) and high-sensitive troponin I (hsTnI) were effective diagnostic markers of cardiomyopathy (area under the curve [AUC], 0.64; P=0.017; and AUC, 0.69; P=0.001, respectively). Patient risk stratification for MACE was based on cutoff values of BNP and hsTnI defined a priori as 30.5000 pg/mL and 7.6050 ng/L, respectively. Over a median follow-up period of 2.09 (IQR, 1.17-2.81) years there were 36 confirmed MACE. Multivariate regression analyses showed that patients with BNP and hsTnI levels above the respective cutoff values had a 3.70-fold (P=0.001) and 3.24-fold (P=0.002) greater risk of MACE, respectively, compared to patients with biomarker levels below. Furthermore, patients with biomarker levels above both cutoff values had a 4.08-fold (P=0.001) greater risk of MACE. Inflammatory biomarkers did not show clinical utility for heart disease in these patients. CONCLUSION Our study demonstrates important diagnostic and prognostic value of BNP and hsTnI as part of a comprehensive cardiac assessment to augment the management and treatment of heart disease in patients with MD.
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Affiliation(s)
- Anish Nikhanj
- Division of Cardiology, University of Alberta, Edmonton, Canada.,Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Canada
| | - Bailey Miskew Nichols
- Division of Cardiology, University of Alberta, Edmonton, Canada.,Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Canada
| | - Kaiming Wang
- Division of Cardiology, University of Alberta, Edmonton, Canada.,Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Canada
| | - Zaeem A Siddiqi
- Division of Neurology, Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada
| | - Gavin Y Oudit
- Division of Cardiology, University of Alberta, Edmonton, Canada.,Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Canada
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31
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Camm AJ, Henderson R, Brisinda D, Body R, Charles RG, Varcoe B, Fenici R. Clinical utility of magnetocardiography in cardiology for the detection of myocardial ischemia. J Electrocardiol 2019; 57:10-17. [DOI: 10.1016/j.jelectrocard.2019.07.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2019] [Revised: 07/05/2019] [Accepted: 07/15/2019] [Indexed: 11/24/2022]
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32
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Regan B, Boyle F, O'Kennedy R, Collins D. Evaluation of Molecularly Imprinted Polymers for Point-of-Care Testing for Cardiovascular Disease. SENSORS (BASEL, SWITZERLAND) 2019; 19:E3485. [PMID: 31395843 PMCID: PMC6720456 DOI: 10.3390/s19163485] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/18/2019] [Revised: 07/29/2019] [Accepted: 08/06/2019] [Indexed: 12/13/2022]
Abstract
Molecular imprinting is a rapidly growing area of interest involving the synthesis of artificial recognition elements that enable the separation of analyte from a sample matrix and its determination. Traditionally, this approach can be successfully applied to small analyte (<1.5 kDa) separation/ extraction, but, more recently it is finding utility in biomimetic sensors. These sensors consist of a recognition element and a transducer similar to their biosensor counterparts, however, the fundamental distinction is that biomimetic sensors employ an artificial recognition element. Molecularly imprinted polymers (MIPs) employed as the recognition elements in biomimetic sensors contain binding sites complementary in shape and functionality to their target analyte. Despite the growing interest in molecularly imprinting techniques, the commercial adoption of this technology is yet to be widely realised for blood sample analysis. This review aims to assess the applicability of this technology for the point-of-care testing (POCT) of cardiovascular disease-related biomarkers. More specifically, molecular imprinting is critically evaluated with respect to the detection of cardiac biomarkers indicative of acute coronary syndrome (ACS), such as the cardiac troponins (cTns). The challenges associated with the synthesis of MIPs for protein detection are outlined, in addition to enhancement techniques that ultimately improve the analytical performance of biomimetic sensors. The mechanism of detection employed to convert the analyte concentration into a measurable signal in biomimetic sensors will be discussed. Furthermore, the analytical performance of these sensors will be compared with biosensors and their potential implementation within clinical settings will be considered. In addition, the most suitable application of these sensors for cardiovascular assessment will be presented.
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Affiliation(s)
- Brian Regan
- School of Biotechnology, Dublin City University, Dublin 9, Ireland.
| | - Fiona Boyle
- School of Biotechnology, Dublin City University, Dublin 9, Ireland
| | - Richard O'Kennedy
- School of Biotechnology, Dublin City University, Dublin 9, Ireland
- Research Complex, Hamad Bin Khalifa University, Qatar Foundation, Doha, Qatar
| | - David Collins
- School of Biotechnology, Dublin City University, Dublin 9, Ireland
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Development of an algorithm for ruling-out non-ST elevation myocardial infarction in the emergency department using high sensitivity troponin T assay. Clin Chim Acta 2019; 495:1-7. [DOI: 10.1016/j.cca.2019.03.1625] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2019] [Revised: 02/26/2019] [Accepted: 03/21/2019] [Indexed: 12/26/2022]
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Stoyanov KM, Hund H, Biener M, Gandowitz J, Riedle C, Löhr J, Mueller-Hennessen M, Vafaie M, Katus HA, Giannitsis E. RAPID-CPU: a prospective study on implementation of the ESC 0/1-hour algorithm and safety of discharge after rule-out of myocardial infarction. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2019; 9:39-51. [PMID: 31298551 PMCID: PMC7008552 DOI: 10.1177/2048872619861911] [Citation(s) in RCA: 59] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Background: Although the value of fast diagnostic protocols in suspected acute coronary syndrome has been validated, there is insufficient real world evidence including patients with lower pre-test probability, atypical symptoms and confounding comorbidities. The feasibility, efficacy and safety of European Society of Cardiology (ESC) 0/1 and 0/3-hour algorithms using high-sensitivity troponin T were evaluated in a consecutive cohort with suspected acute coronary syndrome. Methods: During 12 months, 2525 eligible patients were enrolled. In a pre-implementation period of 6 months, the prevalence of protocols, disposition, lengths of emergency department stay and treatments were registered. Implementation of the 0/1-hour protocol was monitored for another 6 months. Primary endpoints comprised the change of diagnostic protocols and 30-day mortality after direct discharge from the emergency department. Results: Use of the ESC 0/1-hour algorithm increased by 270% at the cost of the standard 0/3-hour protocol. After rule-out (1588 patients), 1309 patients (76.1%) were discharged directly from the emergency department, with an all-cause mortality of 0.08% at 30 days (one death due to lung cancer). Median lengths of stay were 2.9 (1.9–3.8) and 3.2 (2.7–4.4) hours using a single high-sensitivity troponin T below the limit of detection (5 ng/L) at presentation and the ESC 0/1-hour algorithm, respectively, as compared to 5.3 (4.7–6.5) hours using the ESC 0/3-hour rule-out protocol (P<0.001). Discharge rates increased from 53.9% to 62.8% (P<0.001), without excessive use of diagnostic resources within 30 days. Conclusion: Implementation of the ESC 0/1-hour algorithm is feasible and safe, is associated with shorter emergency department stay than the ESC 0/3-hour protocol, and an increase in discharge rates. Trial registration: ClinicalTrials.gov, Unique identifier: NCT03111862.
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Affiliation(s)
- Kiril M Stoyanov
- Department of Cardiology, Angiology and Pulmonology, Heidelberg University Hospital, Germany
| | - Hauke Hund
- Department of Cardiology, Angiology and Pulmonology, Heidelberg University Hospital, Germany.,Faculty of Informatics, Heilbronn University of Applied Sciences, Germany
| | - Moritz Biener
- Department of Cardiology, Angiology and Pulmonology, Heidelberg University Hospital, Germany
| | - Jochen Gandowitz
- Department of Cardiology, Angiology and Pulmonology, Heidelberg University Hospital, Germany
| | - Christoph Riedle
- Department of Cardiology, Angiology and Pulmonology, Heidelberg University Hospital, Germany
| | - Julia Löhr
- Department of Cardiology, Angiology and Pulmonology, Heidelberg University Hospital, Germany
| | | | - Mehrshad Vafaie
- Department of Cardiology, Angiology and Pulmonology, Heidelberg University Hospital, Germany
| | - Hugo A Katus
- Department of Cardiology, Angiology and Pulmonology, Heidelberg University Hospital, Germany
| | - Evangelos Giannitsis
- Department of Cardiology, Angiology and Pulmonology, Heidelberg University Hospital, Germany
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35
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Frame IJ, Joshi PH, Mwangi C, Gunsolus I, De Lemos JA, Das SR, Sarode R, Balani J, Apple FS, Muthukumar A. Susceptibility of Cardiac Troponin Assays to Biotin Interference. Am J Clin Pathol 2019; 151:486-493. [PMID: 30715102 DOI: 10.1093/ajcp/aqy172] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
OBJECTIVES To investigate biotin interference on three cardiac troponin (cTn) assays and demonstrate a method to overcome biotin interference. METHODS cTn levels were measured in (1) plasma from healthy volunteers on 10-mg daily biotin supplementation mixed with a plasma with known elevated troponin, (2) plasmas with known elevated cTn after mixing in reagent biotin to simulate supplementation, and (3) biotin-spiked plasma specimens pretreated with streptavidin-agarose beads. RESULTS Daily biotin ingestion (10 mg) and studies simulating daily biotin use resulted in significant interference in the Gen5 cardiac troponin T (cTnT) assay; the contemporary Gen 4 cTnT and high-sensitivity cardiac troponin I (hs-cTnI) assays were unaffected. The biotin interference threshold was 31, 315, and more than 2,000 ng/mL for Gen5 cTnT, cTnT, and hs-cTnI assays, respectively. Streptavidin pretreatment blocked biotin interference in cTn assays. CONCLUSIONS Biotin interference is possible at plasma concentrations achievable by ingestion of over-the-counter supplements that may lead to delayed or missed diagnosis of myocardial injury with the Gen5 cTnT assay.
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Affiliation(s)
- Ithiel J Frame
- Department of Pathology, Clements University Hospital, University of Texas Southwestern Medical Center, Dallas
| | - Parag H Joshi
- Division of Cardiology, Department of Internal Medicine, Clements University Hospital, University of Texas Southwestern Medical Center, Dallas
- Johns Hopkins Ciccarone Center for the Prevention of Heart Disease, Baltimore, MD
| | - Caroline Mwangi
- Clements University Hospital, University of Texas Southwestern Medical Center, Dallas
| | - Ian Gunsolus
- Department of Pathology, Medical College of Wisconsin, Milwaukee
| | - James A De Lemos
- Division of Cardiology, Department of Internal Medicine, Clements University Hospital, University of Texas Southwestern Medical Center, Dallas
| | - Sandeep R Das
- Division of Cardiology, Department of Internal Medicine, Clements University Hospital, University of Texas Southwestern Medical Center, Dallas
| | - Ravi Sarode
- Department of Pathology, Clements University Hospital, University of Texas Southwestern Medical Center, Dallas
| | - Jyoti Balani
- Department of Pathology, Clements University Hospital, University of Texas Southwestern Medical Center, Dallas
| | - Fred S Apple
- Department of Laboratory Medicine and Pathology, Hennepin County Medical Center and University of Minnesota, Minneapolis
| | - Alagarraju Muthukumar
- Department of Pathology, Clements University Hospital, University of Texas Southwestern Medical Center, Dallas
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36
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Kaier TE, Alaour B, Marber M. Cardiac Myosin-Binding Protein C-From Bench to Improved Diagnosis of Acute Myocardial Infarction. Cardiovasc Drugs Ther 2019; 33:221-230. [PMID: 30617437 PMCID: PMC6509074 DOI: 10.1007/s10557-018-6845-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Chest pain is responsible for 6-10% of all presentations to acute healthcare providers. Triage is inherently difficult and heavily reliant on the quantification of cardiac Troponin (cTn), as a minority of patients with an ultimate diagnosis of acute myocardial infarction (AMI) present with clear diagnostic features such as ST-elevation on the electrocardiogram. Owing to slow release and disappearance of cTn, many patients require repeat blood testing or present with stable but elevated concentrations of the best available biomarker and are thus caught at the interplay of sensitivity and specificity.We identified cardiac myosin-binding protein C (cMyC) in coronary venous effluent and developed a high-sensitivity assay by producing an array of monoclonal antibodies and choosing an ideal pair based on affinity and epitope maps. Compared to high-sensitivity cardiac Troponin (hs-cTn), we demonstrated that cMyC appears earlier and rises faster following myocardial necrosis. In this review, we discuss discovery and structure of cMyC, as well as the migration from a comparably insensitive to a high-sensitivity assay facilitating first clinical studies. This assay was subsequently used to describe relative abundance of the protein, compare sensitivity to two high-sensitivity cTn assays and test diagnostic performance in over 1900 patients presenting with chest pain and suspected AMI. A standout feature was cMyC's ability to more effectively triage patients. This distinction is likely related to the documented greater abundance and more rapid release profile, which could significantly improve the early triage of patients with suspected AMI.
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Affiliation(s)
- Thomas E Kaier
- King's College London BHF Centre, The Rayne Institute, St Thomas' Hospital, 4th Floor Lambeth Wing, Westminster Bridge Road, London, SE1 7EH, UK.
| | - Bashir Alaour
- King's College London BHF Centre, The Rayne Institute, St Thomas' Hospital, 4th Floor Lambeth Wing, Westminster Bridge Road, London, SE1 7EH, UK
| | - Michael Marber
- King's College London BHF Centre, The Rayne Institute, St Thomas' Hospital, 4th Floor Lambeth Wing, Westminster Bridge Road, London, SE1 7EH, UK
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37
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Breidthardt T, Brunner-Schaub N, Balmelli C, Insenser JJS, Burri-Winkler K, Geigy N, Mundorff L, Exadaktylos A, Scholz J, Haaf P, Hamel C, Frey D, Delport K, Peacock WF, Freese M, DiSomma S, Todd J, Rentsch K, Bingisser R, Mueller C, Walter J, Twerenbold R, Nestelberger T, Boeddinghaus J, Badertscher P, du Fay de Lavallaz J, Puelacher C, Wildi K. Inflammatory Biomarkers and Clinical Judgment in the Emergency Diagnosis of Urgent Abdominal Pain. Clin Chem 2018; 65:302-312. [PMID: 30518662 DOI: 10.1373/clinchem.2018.296491] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2018] [Accepted: 11/15/2018] [Indexed: 12/14/2022]
Abstract
BACKGROUND The early diagnosis of urgent abdominal pain (UAP) is challenging. Most causes of UAP are associated with extensive inflammation. Therefore, we hypothesized that quantifying inflammation using interleukin-6 and/or procalcitonin would provide incremental value in the emergency diagnosis of UAP. METHODS This was an investigator-initiated prospective, multicenter diagnostic study enrolling patients presenting to the emergency department (ED) with acute abdominal pain. Clinical judgment of the treating physician regarding the presence of UAP was quantified using a visual analog scale after initial clinical and physician-directed laboratory assessment, and again after imaging. Two independent specialists adjudicated the final diagnosis and the classification as UAP (life-threatening, needing urgent surgery and/or hospitalization for acute medical reasons) using all information including histology and follow-up. Interleukin-6 and procalcitonin were measured blinded in a central laboratory. RESULTS UAP was adjudicated in 376 of 1038 (36%) patients. Diagnostic accuracy for UAP was higher for interleukin-6 [area under the ROC curve (AUC), 0.80; 95% CI, 0.77-0.82] vs procalcitonin (AUC, 0.65; 95% CI, 0.62-0.68) and clinical judgment (AUC, 0.69; 95% CI, 0.65-0.72; both P < 0.001). Combined assessment of interleukin-6 and clinical judgment increased the AUC at presentation to 0.83 (95% CI, 0.80-0.85) and after imaging to 0.87 (95% CI, 0.84-0.89) and improved the correct identification of patients with and without UAP (net improvement in mean predicted probability: presentation, +19%; after imaging, +15%; P < 0.001). Decision curve analysis documented incremental value across the full range of pretest probabilities. A clinical judgment/interleukin-6 algorithm ruled out UAP with a sensitivity of 97% and ruled in UAP with a specificity of 93%. CONCLUSIONS Interleukin-6 significantly improves the early diagnosis of UAP in the ED.
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Affiliation(s)
- Tobias Breidthardt
- Cardiovascular Research Institute Basel (CRIB), Basel, Switzerland; .,Department of Internal Medicine, University Hospital, Basel, and University of Basel, Switzerland
| | | | | | | | - Katrin Burri-Winkler
- Cardiovascular Research Institute Basel (CRIB), Basel, Switzerland.,Hospital del Mar, Barcelona, Spain
| | | | | | | | - Julia Scholz
- Cardiovascular Research Institute Basel (CRIB), Basel, Switzerland
| | - Philip Haaf
- Cardiovascular Research Institute Basel (CRIB), Basel, Switzerland.,Department of Cardiology, University Hospital, Basel, and University of Basel, Switzerland
| | - Christian Hamel
- Department of Visceral Surgery, University Hospital, Basel, and University of Basel, Switzerland.,Department of Visceral Surgery, Kliniken des Landkreises, Lörrach, Germany
| | - Daniel Frey
- Department of Visceral Surgery, University Hospital, Basel, and University of Basel, Switzerland.,Department of Surgery, Spital Wetzikon, Wetzikon, Switzerland
| | - Karen Delport
- Emergency Department, Kantonspital Baselland, Bruderholz, Switzerland
| | - W Frank Peacock
- Department of Emergency Medicine, Baylor College of Medicine, Houston, TX
| | - Michael Freese
- Cardiovascular Research Institute Basel (CRIB), Basel, Switzerland.,Department of Cardiology, University Hospital, Basel, and University of Basel, Switzerland
| | - Salvatore DiSomma
- Emergency Department, San Andrea Hospital, University Sapienza, Rome, Italy
| | - John Todd
- Singulex Inc., Clinical Research, Alameda, CA
| | - Katharina Rentsch
- Department of Laboratory Medicine, University Hospital, Basel, and University of Basel, Switzerland
| | - Roland Bingisser
- Emergency Department, University Hospital, Basel, and University of Basel, Switzerland
| | - Christian Mueller
- Cardiovascular Research Institute Basel (CRIB), Basel, Switzerland.,Department of Cardiology, University Hospital, Basel, and University of Basel, Switzerland
| | | | - Joan Walter
- Cardiovascular Research Institute Basel (CRIB), Basel, Switzerland.,Department of Cardiology, University Hospital, Basel, and University of Basel, Switzerland
| | - Raphael Twerenbold
- Cardiovascular Research Institute Basel (CRIB), Basel, Switzerland.,Department of Medicine, University Hospital, Basel, and University of Basel, Switzerland.,Department of General and Interventional Cardiology, University Heart Center Hamburg, Germany
| | - Thomas Nestelberger
- Cardiovascular Research Institute Basel (CRIB), Basel, Switzerland.,Department of Medicine, University Hospital, Basel, and University of Basel, Switzerland
| | - Jasper Boeddinghaus
- Cardiovascular Research Institute Basel (CRIB), Basel, Switzerland.,Department of Medicine, University Hospital, Basel, and University of Basel, Switzerland
| | - Patrick Badertscher
- Cardiovascular Research Institute Basel (CRIB), Basel, Switzerland.,Department of Medicine, University Hospital, Basel, and University of Basel, Switzerland
| | - Jeanne du Fay de Lavallaz
- Cardiovascular Research Institute Basel (CRIB), Basel, Switzerland.,Department of Medicine, University Hospital, Basel, and University of Basel, Switzerland
| | - Christian Puelacher
- Cardiovascular Research Institute Basel (CRIB), Basel, Switzerland.,Department of Medicine, University Hospital, Basel, and University of Basel, Switzerland
| | - Karin Wildi
- Cardiovascular Research Institute Basel (CRIB), Basel, Switzerland.,Department of Medicine, University Hospital, Basel, and University of Basel, Switzerland
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Sun S, Wang F, Yu M, Kang J. Clinical study of serum procalcitonin level in patients with myocardial infarction complicated by pulmonary infection. Exp Ther Med 2018; 16:5210-5214. [PMID: 30542476 PMCID: PMC6257702 DOI: 10.3892/etm.2018.6841] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2018] [Accepted: 09/27/2018] [Indexed: 01/21/2023] Open
Abstract
This study determined the serum procalcitonin (PCT) levels in patients with myocardial infarction complicated by pulmonary infection and explore its clinical significance and diagnostic value. A total of 473 patients who were admitted to the Third Affiliated Hospital of Qiqihar Medical University from January 2016 to June 2017 were enrolled as research subjects. Patients were divided into four groups based on their symptom status in myocardial infarction and pulmonary infection. There were 109 patients in normal control group who did not experience symptoms of either myocardial infarction or pulmonary infection. Blood samples were collected from each patient, and PCT levels were measured. The data were analyzed. The serum PCT levels prior to treatment were compared with each other. The PCT levels in the myocardial infarction and the pulmonary infection group were all higher than that in the normal control group (0.040±0.015) (p<0.05). On the contrary, the serum PCT level in the myocardial infarction complicated by pulmonary infection group was higher than that in the normal control group (p<0.001). The serum PCT level after treatment was compared with that before treatment within the same group. The serum PCT levels in the three disease groups were comparable after treatment. The differences in PCT levels before and after treatment were all statistically significant within all three groups (p<0.05). A patient's serum PCT level was correlated with myocardial infarction complicated by pulmonary infection, which suggested it can be used as an important diagnostic marker for this complication. This finding has important clinical value for predicting and evaluating the complicated condition of myocardial infarction and pulmonary infection by providing a more accurate, sensitive, and specific method for early diagnosis of the disease.
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Affiliation(s)
- Shiming Sun
- Clinical Laboratory, The Third Affiliated Hospital of Qiqihar Medical University, Qiqihar, Heilongjiang 161000, P.R. China
| | - Fengli Wang
- Clinical Laboratory, Dalian Municipal Central Hospital, Dalian, Liaoning 116033, P.R. China
| | - Miao Yu
- Clinical Laboratory, The Third Affiliated Hospital of Qiqihar Medical University, Qiqihar, Heilongjiang 161000, P.R. China
| | - Jing Kang
- Clinical Laboratory, The Third Affiliated Hospital of Qiqihar Medical University, Qiqihar, Heilongjiang 161000, P.R. China
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Abstract
The definition of a high-sensitivity cardiac Troponin (cTn) assay describes the ability to quantify a cardiac biomarker level in at least 50% of healthy individuals. This advance in analytic sensitivity has come with a perceived loss of specificity in the most classic application - chest pain triage and the diagnosis of acute myocardial infarction (AMI). As cardiac Troponin can no longer be used as a dichotomous test, the medical field is increasingly moving towards a more granular interpretation. However, rapid rule-out/rule-in algorithms for AMI still rely on concrete thresholds for efficient triage, irrespective of the patient's comorbidities. Owing to a slightly elevated cTn value, evermore patients appear to fall into an indeterminate risk zone of diagnostic uncertainty. The reasons are manifold, spanning biological variation, analytical issues, increased plasma membrane permeability and the potential cytosolic release of cTn. This review provides a contemporary overview of the literature concerning the use of cardiac Troponin in chronic and acute cardiovascular care. Key messages High-sensitivity cardiac Troponin assays have transformed the assessment of cardiovascular disease. Rapid rule-out algorithms for chest pain triage have become increasingly complicated, but enable safe rule-out. Cardiac Troponin tracks mid- to long-term risk in patients with hyperlipidaemia, heart failure and renal dysfunction.
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Affiliation(s)
- Bashir Alaour
- a King's College London BHF Centre , The Rayne Institute, St Thomas' Hospital , London , UK
| | | | - Thomas E Kaier
- a King's College London BHF Centre , The Rayne Institute, St Thomas' Hospital , London , UK
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40
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Mueller-Hennessen M, Lindahl B, Giannitsis E, Vafaie M, Biener M, Haushofer AC, Seier J, Christ M, Alquézar-Arbé A, deFilippi CR, McCord J, Body R, Panteghini M, Jernberg T, Plebani M, Verschuren F, French JK, Christenson RH, Dinkel C, Katus HA, Mueller C. Combined testing of copeptin and high-sensitivity cardiac troponin T at presentation in comparison to other algorithms for rapid rule-out of acute myocardial infarction. Int J Cardiol 2018; 276:261-267. [PMID: 30404726 DOI: 10.1016/j.ijcard.2018.10.084] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2018] [Revised: 10/04/2018] [Accepted: 10/23/2018] [Indexed: 12/22/2022]
Abstract
BACKGROUND We aimed to directly compare the diagnostic and prognostic performance of a dual maker strategy (DMS) with combined testing of copeptin and high-sensitivity (hs) cardiac troponin T (cTnT) at time of presentation with other algorithms for rapid rule-out of acute myocardial infarction (AMI). METHODS 922 patients presenting to the emergency department with suspected AMI and available baseline copeptin measurements qualified for the present TRAPID-AMI substudy. Diagnostic measures using the DMS (copeptin <10, <14 or < 20 pmol/L and hs-cTnT≤14 ng/L), the 1 h-algorithm (hs-cTnT<12 ng/L and change <3 ng/L at 1 h), as well as the hs-cTnT limit-of-blank (LoB, <3 ng/L) and -detection (LoD, <5 ng/L) were compared. Outcomes were assessed as combined end-points of death and myocardial re-infarction. RESULTS True-negative rule-out using the DMS could be achieved in 50.9%-62.3% of all patients compared to 35.0%, 45.3% and 64.5% using LoB, LoD or the 1 h-algorithm, respectively. The DMS showed NPVs of 98.1%-98.3% compared to 99.2% for the 1 h-algorithm, 99.4% for the LoB and 99.3% for the LoD. Sensitivities were 93.5%-94.8%, as well as 96.8%, 98.7% and 98.1%, respectively. Addition of clinical low-risk criteria such as a HEART-score ≤ 3 to the DMS resulted in NPVs and sensitivities of 100% with a true-negative rule-out to 33.8%-41.6%. Rates of the combined end-point of death/MI within 30 days ranged between 0.2% and 0.3% for all fast-rule-out protocols. CONCLUSION Depending on the applied copeptin cut-off and addition of clinical low-risk criteria, the DMS might be an alternative to the hs-cTn-only-based algorithms for rapid AMI rule-out with comparable diagnostic measures and outcomes.
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Affiliation(s)
- Matthias Mueller-Hennessen
- Department of Internal Medicine III, Cardiology, Angiology & Pulmonology, Heidelberg University Hospital, Heidelberg, Germany
| | - Bertil Lindahl
- Department of Medical Sciences and Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - Evangelos Giannitsis
- Department of Internal Medicine III, Cardiology, Angiology & Pulmonology, Heidelberg University Hospital, Heidelberg, Germany.
| | - Mehrshad Vafaie
- Department of Internal Medicine III, Cardiology, Angiology & Pulmonology, Heidelberg University Hospital, Heidelberg, Germany
| | - Moritz Biener
- Department of Internal Medicine III, Cardiology, Angiology & Pulmonology, Heidelberg University Hospital, Heidelberg, Germany
| | | | - Josef Seier
- Central Laboratory, Klinikum Wels-Grieskirchen, Wels, Austria
| | - Michael Christ
- Department of Emergency and Critical Care Medicine, Community Hospital and Paracelsus Medical University, Nuremberg, Germany
| | | | - Christopher R deFilippi
- Department of Medicine, University of Maryland School of Medicine, Baltimore, MD, United States of America
| | - James McCord
- Henry Ford Heart and Vascular Institute, Henry Ford Health System, Detroit, MI, United States of America
| | - Richard Body
- Division of Cardiovascular Sciences, The University of Manchester, and Manchester University NHS Foundation Trust, United Kingdom
| | - Mauro Panteghini
- Department of Biomedical and Clinical Sciences 'Luigi Sacco', University of Milan Medical School, Milano, Italy
| | - Tomas Jernberg
- Department of Clinical Sciences, Danderyd University, Karolinska Institutet, Stockholm, Sweden
| | - Mario Plebani
- Department of Laboratory Medicine, University Hospital of Padova, Padua, Italy
| | - Franck Verschuren
- Department of Acute Medicine, Cliniques Universitaires St-Luc and Université Catholique de Louvain, Brussels, Belgium
| | - John K French
- Liverpool Hospital and University of New South Wales, Sydney, Australia
| | - Robert H Christenson
- Department of Pathology, University of Maryland School of Medicine, Baltimore, MD, United States of America
| | | | - Hugo A Katus
- Department of Internal Medicine III, Cardiology, Angiology & Pulmonology, Heidelberg University Hospital, Heidelberg, Germany
| | - Christian Mueller
- Cardiology & Cardiovascular Research Institute Basel, University Hospital Basel, Switzerland
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Lippi G, Sanchis-Gomar F. "Ultra-sensitive" cardiac troponins: Requirements for effective implementation in clinical practice. Biochem Med (Zagreb) 2018; 28:030501. [PMID: 30429666 PMCID: PMC6214691 DOI: 10.11613/bm.2018.030501] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2018] [Accepted: 05/16/2018] [Indexed: 12/16/2022] Open
Abstract
The measurement of cardiac troponins, either cardiac troponin I or T, has become the culprit of clinical decision making in patients with suspected acute coronary syndrome (ACS), especially in those with non-ST elevation myocardial infarction (NSTEMI). The leading analytical mainstays of cardiac troponin immunoassays include the limit of blank (LoB), limit of detection (LoD), functional sensitivity, the 99th percentile of a healthy reference population, along with the percentage of "ostensibly healthy" subjects displaying measurable values < 99th percentile. The latest generation of cardiac troponin immunoassays, conventionally defined as "high-sensitive" (HS), is characterized by a LoD over 100-fold lower compared to the first commercialized techniques and a percentage of measurable values consistently > 50% in the general healthy population. The very recent commercialization of methods with further improved analytical sensitivity (i.e., "ultra-sensitive" assays), which allow to measure cardiac troponin values in the vast majority of healthy subjects, is now challenging the diagnostic paradigm based on early rule-out of subjects with cardiac troponin values comprised between the 99th percentile and LoD. New diagnostic strategies, entailing assay-specific cut-offs, must hence be developed and validated in large multicenter studies. The aim of this article is to provide an update on commercially available HS and "ultra"-sensitive techniques for measuring cardiac troponins, along with possible implications of increasingly enhanced analytical sensitivity on diagnostic algorithms for evaluating patients with suspected ACS.
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Affiliation(s)
- Giuseppe Lippi
- Section of Clinical Biochemistry, University of Verona, Verona, Italy
| | - Fabian Sanchis-Gomar
- Leon H. Charney Division of Cardiology, New York University School of Medicine, New York, USA
- Department of Physiology, Faculty of Medicine, University of Valencia, Valencia, Spain
- INCLIVA Biomedical Research Institute, Valencia, Spain
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42
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Affiliation(s)
- Judd E Hollander
- Department of Emergency Medicine, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA.
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Reinhold T, Giannitsis E, Möckel M, Frankenstein L, Vafaie M, Vollert JO, Slagman A. Cost analysis of early discharge using combined copeptin/cardiac troponin testing versus serial cardiac troponin testing in patients with suspected acute coronary syndrome. PLoS One 2018; 13:e0202133. [PMID: 30138394 PMCID: PMC6107144 DOI: 10.1371/journal.pone.0202133] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2018] [Accepted: 07/26/2018] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Symptoms indicating acute coronary syndrome are commonly seen in emergency rooms, but only 10% of patients are actually diagnosed with acute myocardial infarction (AMI). The Guidelines for the diagnosis of patients with suspected AMI include either multiple testing of cardiac troponin (cTN) or a single combined test of cTN and copeptin, which facilitates earlier diagnosis or exclusion of AMI. The aim of the present analysis was to investigate the impact of combined copeptin/cTN testing on health care resource consumption and related costs both during and after initial hospital treatment. METHODS AND RESULTS The analysis was based on the BIC-8 trial and financial data of participating study sites. A cost analysis was carried out primarily from the hospital perspective and secondarily from the perspective of German statutory health insurers. The underlying assumptions of the investigation were tested for robustness in additional sensitivity analyses. In total, the data of 713 patients (n = 359 combined copeptin/cTN testing, n = 354 serial cTN testing) were evaluated. From a hospital perspective, the combined copeptin/cTN testing showed a reduced number of medical procedures and a lower frequency of inpatient admissions. The average staff time was significantly reduced by a mean of 49 minutes (95% confidence interval (CI) 46 to 53) per patient, accompanied by a significant mean reduction of 131 minutes (95%CI 104 to 158) in the time patients stayed in the emergency room. The initial hospital treatment was less cost-intensive. Over the entire study period, no significant cost differences were observed between the groups for health insurance. CONCLUSION The combined copeptin/cTN testing has the potential to save costs and staff time in acute care and for the entire hospital stay. The primary explanations for these findings are early identification and ruling out patients without AMI along with the associated reduced need for acute medical treatment. TRIAL REGISTRATION ClinicalTrials.gov NCT01498731.
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Affiliation(s)
- Thomas Reinhold
- Institute for Social Medicine, Epidemiology and Health Economics, Charité –Universitätsmedizin Berlin, Berlin, Germany
| | - Evangelos Giannitsis
- Department of Angiology, Cardiology and Pneumology, University Hospital Heidelberg, Heidelberg, Germany
| | - Martin Möckel
- Division of Emergency Medicine and CPU, Department of Cardiology, Charité –Universitätsmedizin Berlin, Berlin, Germany
- James Cook University (JCU), Cairns, Australia
| | - Lutz Frankenstein
- Department of Angiology, Cardiology and Pneumology, University Hospital Heidelberg, Heidelberg, Germany
| | - Mehrshad Vafaie
- Department of Angiology, Cardiology and Pneumology, University Hospital Heidelberg, Heidelberg, Germany
| | | | - Anna Slagman
- Division of Emergency Medicine and CPU, Department of Cardiology, Charité –Universitätsmedizin Berlin, Berlin, Germany
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Correction: Economic evaluation of the one-hour rule-out and rule-in algorithm for acute myocardial infarction using the high-sensitivity cardiac troponin T assay in the emergency department. PLoS One 2018; 13:e0191348. [PMID: 29324828 PMCID: PMC5764412 DOI: 10.1371/journal.pone.0191348] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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