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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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2
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Can the Addition of NT-proBNP and Glucose Measurements Improve the Prognostication of High-Sensitivity Cardiac Troponin Measurements for Patients with Suspected Acute Coronary Syndrome? J Cardiovasc Dev Dis 2021; 8:jcdd8090106. [PMID: 34564124 PMCID: PMC8471149 DOI: 10.3390/jcdd8090106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Revised: 08/19/2021] [Accepted: 08/30/2021] [Indexed: 11/17/2022] Open
Abstract
Guidelines published in 2021 have supported natriuretic peptide (NP) testing for the prognostication in patients with acute coronary syndrome (ACS) and for the diagnosis of chronic and acute heart failure (HF). Our objective was to determine if the addition of N-terminal pro B-type NP (NT-proBNP) and glucose to high-sensitivity cardiac troponin (hs-cTn) could better identify emergency department (ED) patients with potential ACS at low- and high-risk for a serious cardiovascular outcome over the next 72 h. The presentation sample in two different ED cohorts which enrolled patients with symptoms suggestive of ACS within six hours of pain onset (Cohort-1, n = 126 and Cohort-2, n = 143) that had Abbott hs-cTnI, Roche hs-cTnT, NT-proBNP and glucose were evaluated for NT-proBNP alone and combined with hs-cTn and glucose for the primary outcome (composite which included death, myocardial infarction, HF, serious arrhythmia and refractory angina) via receiver-operating characteristic (ROC) curve analyses with area under the curve (AUC) and diagnostic estimates derived. The AUC for NT-proBNP for the primary outcome was 0.68 (95% confidence interval (CI): 0.59-0.76) and 0.75 (95%CI: 0.67-0.82) in Cohort-1 and 2, respectively, with the 125 ng/L cutoff yielding a higher sensitivity (≥75%) as compared to the 300 ng/L cutoff (≥58%). Using the 125 ng/L cutoff for NT-proBNP with the published glucose and hs-cTn cutoffs for risk-stratification produced a new score (GuIDER score for Glucose, Injury and Dysfunction in the Emergency-setting for cardiovascular-Risk) and yielded higher AUCs as compared to NT-proBNP (p < 0.05). GuIDER scores of 0 and 5 using either hs-cTnI/T yielded sensitivity estimates of 100% and specificity estimates > 92% for the primary outcome. A secondary analysis assessing MI alone in the overall population (combined Cohorts 1 and 2) also achieved 100% sensitivity for MI with a GuIDER cutoff ≥ 2, ruling-out 48% (Roche) and 38% (Abbott) of the population at presentation for MI. Additional studies are needed for the GuIDER score in both the acute and ambulatory setting to further refine the utility, however, the preliminary findings reported here may present a pathway forward for inclusion of NP testing for ruling-out serious cardiac events and MI in the emergency setting.
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Collister D, Mazzetti A, Bhalerao A, Tyrwhitt J, Kavsak P, Brimble KS, Devereaux PJ, Walsh M. Variability in Cardiac Biomarkers during Hemodialysis: A Prospective Cohort Study. Clin Chem 2021; 67:308-316. [PMID: 33418576 DOI: 10.1093/clinchem/hvaa299] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Accepted: 10/29/2020] [Indexed: 11/13/2022]
Abstract
BACKGROUND The effect of hemodialysis on cardiac biomarkers is unclear. We sought to evaluate the degree and causes of intradialytic variability of high sensitivity troponin I (hs-TnI), galectin-3 (gal-3), and heart-type fatty acid binding protein (hFABP). METHODS hs-TnI, gal-3, and hFABP were prospectively measured pre-dialysis and post-dialysis for 1 week every month for 6 months in 178 prevalent adult hemodialysis patients at a single center in Hamilton, Canada. The degree of change from pre-dialysis to post-dialysis for each cardiac biomarker was estimated with multilevel linear regression models. RESULTS The median change in the concentration of hs-TnI during hemodialysis was -1 ng/L (interquartile range [IQR] -1 to 2 ng/L) while gal-3 and hFABP changed by -36.3 ng/mL (IQR -27.7 to -46.8 ng/mL) and -19.41 ng/mL (IQR -13.61 to -26.87 ng/mL), respectively. The median (IQR) percentage intradialytic changes for hs-TnI, gal-3, and hFABP were 2.6% (-4.4% to 12.5%), -59.8% (-54.7% to -64.8%) and -35.3% (-28.4% to -42.1%), respectively. Ultrafiltration was associated with an increase in concentration of hs-TnI, gal-3, and hFABP (mean 0.99 ng/L, 1.05 ng/mL, and 1.9 ng/mL per L ultrafiltration, respectively, P < 0.001). Both gal-3 and hFABP concentrations decreased in association with the volume of blood processed (P < 0.001) and with hemodialysis treatment time (P = 0.02 and P = 0.04) while hs-TnI concentration decreased only in association with hemodialysis treatment time (P < 0.001). CONCLUSIONS Ultrafiltration volume and hemodialysis treatment time influenced hs-TnI, gal-3, and hFABP concentrations during hemodialysis and should be considered when interpreting their measurement.
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Affiliation(s)
- David Collister
- Division of Nephrology, Department of Medicine, St. Joseph's Healthcare Hamilton, Hamilton, ON, Canada.,Population Health Research Institute, McMaster University, Hamilton, ON, Canada.,Division of Nephrology, Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Andrea Mazzetti
- Division of Nephrology, Department of Medicine, St. Joseph's Healthcare Hamilton, Hamilton, ON, Canada
| | - Anuja Bhalerao
- Division of Nephrology, Department of Medicine, St. Joseph's Healthcare Hamilton, Hamilton, ON, Canada
| | - Jessica Tyrwhitt
- Population Health Research Institute, McMaster University, Hamilton, ON, Canada
| | - Peter Kavsak
- Department of Pathology and Molecular Medicine, McMaster University, Hamilton, ON, Canada
| | - Kenneth S Brimble
- Division of Nephrology, Department of Medicine, St. Joseph's Healthcare Hamilton, Hamilton, ON, Canada.,Division of Nephrology, Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - P J Devereaux
- Population Health Research Institute, McMaster University, Hamilton, ON, Canada
| | - Michael Walsh
- Division of Nephrology, Department of Medicine, St. Joseph's Healthcare Hamilton, Hamilton, ON, Canada.,Population Health Research Institute, McMaster University, Hamilton, ON, Canada.,Division of Nephrology, Department of Medicine, McMaster University, Hamilton, ON, Canada
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4
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Chapman AR, Lee KK, McAllister DA, Cullen L, Greenslade JH, Parsonage W, Worster A, Kavsak PA, Blankenberg S, Neumann J, Söerensen NA, Westermann D, Buijs MM, Verdel GJE, Pickering JW, Than MP, Twerenbold R, Badertscher P, Sabti Z, Mueller C, Anand A, Adamson P, Strachan FE, Ferry A, Sandeman D, Gray A, Body R, Keevil B, Carlton E, Greaves K, Korley FK, Metkus TS, Sandoval Y, Apple FS, Newby DE, Shah ASV, Mills NL. Association of High-Sensitivity Cardiac Troponin I Concentration With Cardiac Outcomes in Patients With Suspected Acute Coronary Syndrome. JAMA 2017; 318:1913-1924. [PMID: 29127948 PMCID: PMC5710293 DOI: 10.1001/jama.2017.17488] [Citation(s) in RCA: 169] [Impact Index Per Article: 24.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2017] [Accepted: 10/22/2017] [Indexed: 12/17/2022]
Abstract
Importance High-sensitivity cardiac troponin I testing is widely used to evaluate patients with suspected acute coronary syndrome. A cardiac troponin concentration of less than 5 ng/L identifies patients at presentation as low risk, but the optimal threshold is uncertain. Objective To evaluate the performance of a cardiac troponin I threshold of 5 ng/L at presentation as a risk stratification tool in patients with suspected acute coronary syndrome. Data Sources Systematic search of MEDLINE, EMBASE, Cochrane, and Web of Science databases from January 1, 2006, to March 18, 2017. Study Selection Prospective studies measuring high-sensitivity cardiac troponin I concentrations in patients with suspected acute coronary syndrome in which the diagnosis was adjudicated according to the universal definition of myocardial infarction. Data Extraction and Synthesis The systematic review identified 19 cohorts. Individual patient-level data were obtained from the corresponding authors of 17 cohorts, with aggregate data from 2 cohorts. Meta-estimates for primary and secondary outcomes were derived using a binomial-normal random-effects model. Main Outcomes and Measures The primary outcome was myocardial infarction or cardiac death at 30 days. Performance was evaluated in subgroups and across a range of troponin concentrations (2-16 ng/L) using individual patient data. Results Of 11 845 articles identified, 104 underwent full-text review, and 19 cohorts from 9 countries were included. Among 22 457 patients included in the meta-analysis (mean age, 62 [SD, 15.5] years; n = 9329 women [41.5%]), the primary outcome occurred in 2786 (12.4%). Cardiac troponin I concentrations were less than 5 ng/L at presentation in 11 012 patients (49%), in whom there were 60 missed index or 30-day events (59 index myocardial infarctions, 1 myocardial infarction at 30 days, and no cardiac deaths at 30 days). This resulted in a negative predictive value of 99.5% (95% CI, 99.3%-99.6%) for the primary outcome. There were no cardiac deaths at 30 days and 7 (0.1%) at 1 year, with a negative predictive value of 99.9% (95% CI, 99.7%-99.9%) for cardiac death. Conclusions and Relevance Among patients with suspected acute coronary syndrome, a high-sensitivity cardiac troponin I concentration of less than 5 ng/L identified those at low risk of myocardial infarction or cardiac death within 30 days. Further research is needed to understand the clinical utility and cost-effectiveness of this approach to risk stratification.
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Affiliation(s)
- Andrew R. Chapman
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, Scotland
| | - Kuan Ken Lee
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, Scotland
| | | | - Louise Cullen
- Department of Emergency Medicine, Royal Brisbane and Women’s Hospital, Brisbane, Australia
- School of Medicine, University of Queensland, Brisbane, Australia
- Faculty of Health, Queensland University of Technology, Brisbane, Australia
| | - Jaimi H. Greenslade
- Department of Emergency Medicine, Royal Brisbane and Women’s Hospital, Brisbane, Australia
- School of Medicine, University of Queensland, Brisbane, Australia
- Faculty of Health, Queensland University of Technology, Brisbane, Australia
| | - William Parsonage
- Department of Emergency Medicine, Royal Brisbane and Women’s Hospital, Brisbane, Australia
- School of Medicine, University of Queensland, Brisbane, Australia
- Faculty of Health, Queensland University of Technology, Brisbane, Australia
| | - Andrew Worster
- Division of Emergency Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Peter A. Kavsak
- Department of Pathology and Molecular Medicine, McMaster University, Hamilton, Ontario, Canada
| | | | | | | | | | | | | | - John W. Pickering
- Department of Medicine, University of Otago, Christchurch, New Zealand
- Emergency Department, Christchurch Hospital, Christchurch, New Zealand
| | - Martin P. Than
- Emergency Department, Christchurch Hospital, Christchurch, New Zealand
| | - Raphael Twerenbold
- Cardiovascular Research Institute Basel and Department of Cardiology, University Hospital, Basel, Switzerland
| | - Patrick Badertscher
- Cardiovascular Research Institute Basel and Department of Cardiology, University Hospital, Basel, Switzerland
| | - Zaid Sabti
- Cardiovascular Research Institute Basel and Department of Cardiology, University Hospital, Basel, Switzerland
| | - Christian Mueller
- Cardiovascular Research Institute Basel and Department of Cardiology, University Hospital, Basel, Switzerland
| | - Atul Anand
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, Scotland
| | - Philip Adamson
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, Scotland
| | - Fiona E. Strachan
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, Scotland
| | - Amy Ferry
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, Scotland
| | - Dennis Sandeman
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, Scotland
| | - Alasdair Gray
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, Scotland
- Department of Emergency Medicine and EMERGE, Royal Infirmary of Edinburgh, Edinburgh, Scotland
| | - Richard Body
- Central Manchester University Hospitals NHS Foundation Trust and the University of Manchester, Manchester, England
| | - Brian Keevil
- University Hospital South Manchester NHS Foundation Trust, Manchester, England
| | - Edward Carlton
- Department of Emergency Medicine, Southmead Hospital, Bristol, England
| | - Kim Greaves
- Department of Cardiology, Sunshine Coast University Hospital, University of the Sunshine Coast, Birtinya, Australia
| | | | | | - Yader Sandoval
- Hennepin County Medical Center and Minneapolis Heart Institute, Abbott Northwestern Hospital, Minneapolis, Minnesota
| | - Fred S. Apple
- Department of Laboratory Medicine and Pathology, Hennepin County Medical Center and University of Minnesota, Minneapolis
| | - David E. Newby
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, Scotland
| | - Anoop S. V. Shah
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, Scotland
| | - Nicholas L. Mills
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, Scotland
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5
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Lyon AW, Kavsak PA, Lyon OAS, Worster A, Lyon ME. Simulation Models of Misclassification Error for Single Thresholds of High-Sensitivity Cardiac Troponin I Due to Assay Bias and Imprecision. Clin Chem 2017; 63:585-592. [DOI: 10.1373/clinchem.2016.265058] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2016] [Accepted: 09/14/2016] [Indexed: 11/06/2022]
Abstract
Abstract
BACKGROUND
Clinical outcome studies for cardiac troponins (cTn) are expensive and difficult to design owing to variation in patients, in the assays, and in the incidence of different types of myocardial infarction (MI). To overcome these difficulties, simulation models were used to estimate the rate of misclassification error for MI and risk prediction resulting from assay bias and imprecision.
METHODS
Finite mixture analysis of Abbott high-sensitivity cTnI (hs-cTnI) results at time 0 h in patients presenting early with acute coronary syndrome (ACS) symptoms to the emergency department (ED) [n = 145, Reducing the Time Interval for Identifying New Guideline (RING) study] allowed derivation of a simulation data set (n = 10000). hs-cTnI concentrations were modified by addition of bias or imprecision error. The percentage of all 10000 modified hs-cTnI results that were misclassified for MI at thresholds of 2, 5, 26.2, and 52 ng/L was determined by Monte Carlo simulation. Analyses were replicated with an all-comer emergency department (ED) population (n = 1137) ROMI (Optimum Troponin Cutoffs for ACS in the ED) study.
RESULTS
In the RING study, simulation at 26.2-ng/L (99th percentile) and 52-ng/L thresholds were affected by both bias ±2 ng/L and imprecision (10%–20%) and had misclassification rates of 0.4% to 0.6%. Simulations at the 2-ng/L and 5-ng/L thresholds were only affected by bias. Misclassification rates at bias of ±1 ng/L were 10% for the 2-ng/L threshold, and 5% for the 5-ng/L threshold.
CONCLUSIONS
Simulation models predicted that hs-cTnI results are seldom misclassified (<1% of patients) when interpretative thresholds are near or exceed the overall 99th percentile. However, simulation models also predicted that low hs-cTnI results, as recommended in guidelines, are prone to misclassification of 5%–10% of patients.
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Affiliation(s)
- Andrew W Lyon
- Department of Pathology and Laboratory Medicine, Saskatoon Health Region, Saskatoon, SK, Canada
| | | | - Oliver A S Lyon
- Department of Pathology and Laboratory Medicine, Saskatoon Health Region, Saskatoon, SK, Canada
| | - Andrew Worster
- Division of Emergency Medicine, McMaster University, Hamilton, ON, Canada
| | - Martha E Lyon
- Department of Pathology and Laboratory Medicine, Saskatoon Health Region, Saskatoon, SK, Canada
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6
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Pickering JW, Greenslade JH, Cullen L, Flaws D, Parsonage W, Aldous S, George P, Worster A, Kavsak PA, Than MP. Assessment of the European Society of Cardiology 0-Hour/1-Hour Algorithm to Rule-Out and Rule-In Acute Myocardial Infarction. Circulation 2016; 134:1532-1541. [PMID: 27754881 DOI: 10.1161/circulationaha.116.022677] [Citation(s) in RCA: 95] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2016] [Accepted: 09/22/2016] [Indexed: 11/16/2022]
Abstract
BACKGROUND The new European Society of Cardiology guidelines to rule-in and rule-out acute myocardial infarction (AMI) in the emergency department include a rapid assessment algorithm based on high-sensitivity cardiac troponin and sampling at 0 and 1 hour. Emergency department physicians require high sensitivity to confidently rule-out AMI, whereas cardiologists aim to minimize false-positive results. METHODS High-sensitivity troponin I and T assays were used to measure troponin concentrations in patients presenting with chest-pain symptoms and being investigated for possible acute coronary syndrome at hospitals in New Zealand, Australia, and Canada. AMI outcomes were independently adjudicated by at least 2 physicians. The European Society of Cardiology algorithm performance with each assay was assessed by the sensitivity and proportion with AMI ruled out and the positive predictive value and proportion ruled-in. RESULTS There were 2222 patients with serial high-sensitivity troponin T and high-sensitivity troponin I measurements. The high-sensitivity troponin T algorithm ruled out 1425 (64.1%) with a sensitivity of 97.1% (95% confidence interval [CI], 94.0%-98.8%) and ruled-in 292 (13.1%) with a positive predictive value of 63.4% (95% CI, 57.5%-68.9%).The high-sensitivity troponin I algorithm ruled out 1205 (54.2%) with a sensitivity of 98.8% (95% CI, 96.4%-99.7%)) and ruled-in 310 (14.0%) with a positive predictive value of 68.1% (95% CI, 62.6%-73.2%). CONCLUSIONS The sensitivity of the European Society of Cardiology rapid assessment 0-/1-hour algorithm to rule-out AMI with high-sensitivity troponin may be insufficient for some emergency department physicians to confidently send patients home. These algorithms may prove useful to identify patients requiring expedited management. However, the positive predictive value was modest for both algorithms.
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Affiliation(s)
- John W Pickering
- From Emergency Department (J.W.P., M.P.T.), and Cardiology Department (S.A.), Christchurch Hospital, Christchurch, New Zealand; Department of Medicine, University of Otago, Christchurch, New Zealand (J.W.P.); Department of Emergency Medicine, Royal Brisbane and Women's Hospital, The University of Queensland and School of Public Health, Queensland University of Technology, Brisbane, Australia (J.H.G., L.C., D.F.); Department of Cardiology, Royal Brisbane and Women's Hospital, Brisbane, Australia (W.P.); Canterbury Health Laboratories, Christchurch, New Zealand (P.G.); and McMaster University, Hamilton, Ontario, Canada (A.W., P.A.K.)
| | - Jaimi H Greenslade
- From Emergency Department (J.W.P., M.P.T.), and Cardiology Department (S.A.), Christchurch Hospital, Christchurch, New Zealand; Department of Medicine, University of Otago, Christchurch, New Zealand (J.W.P.); Department of Emergency Medicine, Royal Brisbane and Women's Hospital, The University of Queensland and School of Public Health, Queensland University of Technology, Brisbane, Australia (J.H.G., L.C., D.F.); Department of Cardiology, Royal Brisbane and Women's Hospital, Brisbane, Australia (W.P.); Canterbury Health Laboratories, Christchurch, New Zealand (P.G.); and McMaster University, Hamilton, Ontario, Canada (A.W., P.A.K.)
| | - Louise Cullen
- From Emergency Department (J.W.P., M.P.T.), and Cardiology Department (S.A.), Christchurch Hospital, Christchurch, New Zealand; Department of Medicine, University of Otago, Christchurch, New Zealand (J.W.P.); Department of Emergency Medicine, Royal Brisbane and Women's Hospital, The University of Queensland and School of Public Health, Queensland University of Technology, Brisbane, Australia (J.H.G., L.C., D.F.); Department of Cardiology, Royal Brisbane and Women's Hospital, Brisbane, Australia (W.P.); Canterbury Health Laboratories, Christchurch, New Zealand (P.G.); and McMaster University, Hamilton, Ontario, Canada (A.W., P.A.K.)
| | - Dylan Flaws
- From Emergency Department (J.W.P., M.P.T.), and Cardiology Department (S.A.), Christchurch Hospital, Christchurch, New Zealand; Department of Medicine, University of Otago, Christchurch, New Zealand (J.W.P.); Department of Emergency Medicine, Royal Brisbane and Women's Hospital, The University of Queensland and School of Public Health, Queensland University of Technology, Brisbane, Australia (J.H.G., L.C., D.F.); Department of Cardiology, Royal Brisbane and Women's Hospital, Brisbane, Australia (W.P.); Canterbury Health Laboratories, Christchurch, New Zealand (P.G.); and McMaster University, Hamilton, Ontario, Canada (A.W., P.A.K.)
| | - William Parsonage
- From Emergency Department (J.W.P., M.P.T.), and Cardiology Department (S.A.), Christchurch Hospital, Christchurch, New Zealand; Department of Medicine, University of Otago, Christchurch, New Zealand (J.W.P.); Department of Emergency Medicine, Royal Brisbane and Women's Hospital, The University of Queensland and School of Public Health, Queensland University of Technology, Brisbane, Australia (J.H.G., L.C., D.F.); Department of Cardiology, Royal Brisbane and Women's Hospital, Brisbane, Australia (W.P.); Canterbury Health Laboratories, Christchurch, New Zealand (P.G.); and McMaster University, Hamilton, Ontario, Canada (A.W., P.A.K.)
| | - Sally Aldous
- From Emergency Department (J.W.P., M.P.T.), and Cardiology Department (S.A.), Christchurch Hospital, Christchurch, New Zealand; Department of Medicine, University of Otago, Christchurch, New Zealand (J.W.P.); Department of Emergency Medicine, Royal Brisbane and Women's Hospital, The University of Queensland and School of Public Health, Queensland University of Technology, Brisbane, Australia (J.H.G., L.C., D.F.); Department of Cardiology, Royal Brisbane and Women's Hospital, Brisbane, Australia (W.P.); Canterbury Health Laboratories, Christchurch, New Zealand (P.G.); and McMaster University, Hamilton, Ontario, Canada (A.W., P.A.K.)
| | - Peter George
- From Emergency Department (J.W.P., M.P.T.), and Cardiology Department (S.A.), Christchurch Hospital, Christchurch, New Zealand; Department of Medicine, University of Otago, Christchurch, New Zealand (J.W.P.); Department of Emergency Medicine, Royal Brisbane and Women's Hospital, The University of Queensland and School of Public Health, Queensland University of Technology, Brisbane, Australia (J.H.G., L.C., D.F.); Department of Cardiology, Royal Brisbane and Women's Hospital, Brisbane, Australia (W.P.); Canterbury Health Laboratories, Christchurch, New Zealand (P.G.); and McMaster University, Hamilton, Ontario, Canada (A.W., P.A.K.)
| | - Andrew Worster
- From Emergency Department (J.W.P., M.P.T.), and Cardiology Department (S.A.), Christchurch Hospital, Christchurch, New Zealand; Department of Medicine, University of Otago, Christchurch, New Zealand (J.W.P.); Department of Emergency Medicine, Royal Brisbane and Women's Hospital, The University of Queensland and School of Public Health, Queensland University of Technology, Brisbane, Australia (J.H.G., L.C., D.F.); Department of Cardiology, Royal Brisbane and Women's Hospital, Brisbane, Australia (W.P.); Canterbury Health Laboratories, Christchurch, New Zealand (P.G.); and McMaster University, Hamilton, Ontario, Canada (A.W., P.A.K.)
| | - Peter A Kavsak
- From Emergency Department (J.W.P., M.P.T.), and Cardiology Department (S.A.), Christchurch Hospital, Christchurch, New Zealand; Department of Medicine, University of Otago, Christchurch, New Zealand (J.W.P.); Department of Emergency Medicine, Royal Brisbane and Women's Hospital, The University of Queensland and School of Public Health, Queensland University of Technology, Brisbane, Australia (J.H.G., L.C., D.F.); Department of Cardiology, Royal Brisbane and Women's Hospital, Brisbane, Australia (W.P.); Canterbury Health Laboratories, Christchurch, New Zealand (P.G.); and McMaster University, Hamilton, Ontario, Canada (A.W., P.A.K.)
| | - Martin P Than
- From Emergency Department (J.W.P., M.P.T.), and Cardiology Department (S.A.), Christchurch Hospital, Christchurch, New Zealand; Department of Medicine, University of Otago, Christchurch, New Zealand (J.W.P.); Department of Emergency Medicine, Royal Brisbane and Women's Hospital, The University of Queensland and School of Public Health, Queensland University of Technology, Brisbane, Australia (J.H.G., L.C., D.F.); Department of Cardiology, Royal Brisbane and Women's Hospital, Brisbane, Australia (W.P.); Canterbury Health Laboratories, Christchurch, New Zealand (P.G.); and McMaster University, Hamilton, Ontario, Canada (A.W., P.A.K.).
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7
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Westwood M, van Asselt T, Ramaekers B, Whiting P, Thokala P, Joore M, Armstrong N, Ross J, Severens J, Kleijnen J. High-sensitivity troponin assays for the early rule-out or diagnosis of acute myocardial infarction in people with acute chest pain: a systematic review and cost-effectiveness analysis. Health Technol Assess 2016; 19:1-234. [PMID: 26118801 DOI: 10.3310/hta19440] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Early diagnosis of acute myocardial infarction (AMI) can ensure quick and effective treatment but only 20% of adults with emergency admissions for chest pain have an AMI. High-sensitivity cardiac troponin (hs-cTn) assays may allow rapid rule-out of AMI and avoidance of unnecessary hospital admissions and anxiety. OBJECTIVE To assess the clinical effectiveness and cost-effectiveness of hs-cTn assays for the early (within 4 hours of presentation) rule-out of AMI in adults with acute chest pain. METHODS Sixteen databases, including MEDLINE and EMBASE, research registers and conference proceedings, were searched to October 2013. Study quality was assessed using QUADAS-2. 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 (QALYs) associated with different troponin (Tn) testing methods. The de novo model consisted of a decision tree and Markov model. A lifetime time horizon (60 years) was used. RESULTS Eighteen studies were included in the clinical effectiveness review. The optimum strategy, based on the Roche assay, used a limit of blank (LoB) threshold in a presentation sample to rule out AMI [negative likelihood ratio (LR-) 0.10, 95% confidence interval (CI) 0.05 to 0.18]. Patients testing positive could then have a further test at 2 hours; a result above the 99th centile on either sample and a delta (Δ) of ≥ 20% has some potential for ruling in an AMI [positive likelihood ratio (LR+) 8.42, 95% CI 6.11 to 11.60], whereas a result below the 99th centile on both samples and a Δ of < 20% can be used to rule out an AMI (LR- 0.04, 95% CI 0.02 to 0.10). The optimum strategy, based on the Abbott assay, used a limit of detection (LoD) threshold in a presentation sample to rule out AMI (LR- 0.01, 95% CI 0.00 to 0.08). Patients testing positive could then have a further test at 3 hours; a result above the 99th centile on this sample has some potential for ruling in an AMI (LR+ 10.16, 95% CI 8.38 to 12.31), whereas a result below the 99th centile can be used to rule out an AMI (LR- 0.02, 95% CI 0.01 to 0.05). In the base-case analysis, standard Tn testing was both most effective and most costly. Strategies considered cost-effective depending upon incremental cost-effectiveness ratio thresholds were Abbott 99th centile (thresholds of < £6597), Beckman 99th centile (thresholds between £6597 and £30,042), Abbott optimal strategy (LoD threshold at presentation, followed by 99th centile threshold at 3 hours) (thresholds between £30,042 and £103,194) and the standard Tn test (thresholds over £103,194). The Roche 99th centile and the Roche optimal strategy [LoB threshold at presentation followed by 99th centile threshold and/or Δ20% (compared with presentation test) at 1-3 hours] were extendedly dominated in this analysis. CONCLUSIONS There is some evidence to suggest that hs-CTn testing may provide an effective and cost-effective approach to early rule-out of AMI. Further research is needed to clarify optimal diagnostic thresholds and testing strategies. STUDY REGISTRATION This study is registered as PROSPERO CRD42013005939. FUNDING The National Institute for Health Research Health Technology Assessment programme.
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Affiliation(s)
| | - Thea van Asselt
- Department of Clinical Epidemiology and Medical Technology Assessment, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Bram Ramaekers
- Department of Clinical Epidemiology and Medical Technology Assessment, Maastricht University Medical Centre, Maastricht, The Netherlands
| | | | - Praveen Thokala
- Health Economics and Decision Science Group, School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Manuela Joore
- Department of Clinical Epidemiology and Medical Technology Assessment, Maastricht University Medical Centre, Maastricht, The Netherlands
| | | | | | - Johan Severens
- Institute of Health Policy and Management, Erasmus University Rotterdam, Rotterdam, The Netherlands
| | - Jos Kleijnen
- School for Public Health and Primary Care (CAPHRI), Maastricht University, Maastricht, The Netherlands
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8
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Lee GR, Browne TCA, Guest B, Khan I, Murphy E, McGorrian C, Mahon NG, Fitzgibbon MC. Transitioning high sensitivity cardiac troponin I (hs-cTnI) into routine diagnostic use: More than just a sensitivity issue. Pract Lab Med 2016; 4:62-75. [PMID: 28856194 PMCID: PMC5574510 DOI: 10.1016/j.plabm.2016.01.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2015] [Revised: 01/04/2016] [Accepted: 01/09/2016] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES High sensitivity cardiac troponin T and I (hs-cTnT and hs-cTnI) assays show analytical, diagnostic and prognostic improvement over contemporary sensitive cTn assays. However, given the importance of troponin in the diagnosis of myocardial infarction, implementing this test requires rigorous analytical and clinical verification across the total testing pathway. This was the aim of this study. DESIGN AND METHODS Analytical verification included assessment of critical outlier frequency, for hs-cTnI and cTnI assays. Concordance for paired cTnI and hs-cTnI measurements (n=1096) was verified using 99th percentiles for both genders (cTnI: 30 ng/L, hs-cTnI: 25 ng/L) and for men and women separately (hs-cTnI: M: 34;F: 16 ng/L). Discordant data was correlated with clinical and laboratory information. Diagnosis of Acute Coronary Syndrome (ACS) or Non-ACS was adjudicated by two cardiologists independently. RESULTS The hs-cTnI assay showed a lower (10-fold) critical outlier rate (0.091%) and more detectable results above the limit of detection (LOD) (23.4%) and 99th percentile (2.4%), compared to cTnI. Analytical concordance between the two assays was high (94.5%) but decreased (91.7%) when gender-specific hs-cTnI cut-offs were used. The hs-cTnI assay gave fewer false negatives (up to 1.0%) but disproportionately more false positives (up to 6.7%) overall, which improved (3.9%) for serial measurements. CONCLUSIONS Laboratories should analytically and clinically verify hs-cTn assays before use, with attention to performance and the clinical and diagnostic algorithms that support appropriate testing and result interpretation. Work in the pre- and post-analytical phases is necessary to augment the analytical improvement in the new era of troponin testing.
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Key Words
- ACS, Acute Coronary Syndrome
- AMI, Acute Myocardial Infarction
- Acute Coronary Syndrome
- CABG, Coronary Artery Bypass Graft
- CD, Critical Difference
- CI, Confidence Interval
- COPD, Chronic Obstructive Pulmonary Disease
- CV, Coefficient of Variation
- FN, False Negative
- FP, False Positive
- High sensitivity
- IQR, Inter-quartile range
- LOD, Limit of Detection
- NSTEMI, Non-ST-segment Elevation Myocardial Infarction
- TN, True Negative
- TP, True Positive
- TTP, Total Testing Pathway.
- Troponin
- cTn, Cardiac troponin
- hs-cTn, High sensitivity cardiac troponin
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Affiliation(s)
- Graham R Lee
- Department of Clinical Biochemistry & Diagnostic Endocrinology, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Tara CA Browne
- Department of Clinical Biochemistry & Diagnostic Endocrinology, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Berna Guest
- Department of Clinical Biochemistry & Diagnostic Endocrinology, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Imran Khan
- Department of Cardiology, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Eamon Murphy
- Department of Cardiology, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Catherine McGorrian
- Department of Cardiology, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Niall G Mahon
- Department of Cardiology, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Maria C Fitzgibbon
- Department of Clinical Biochemistry & Diagnostic Endocrinology, Mater Misericordiae University Hospital, Dublin, Ireland
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9
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Pickering JW, Greenslade JH, Cullen L, Flaws D, Parsonage W, George P, Worster A, Kavsak PA, Than MP. Validation of presentation and 3 h high-sensitivity troponin to rule-in and rule-out acute myocardial infarction. Heart 2016; 102:1270-8. [PMID: 26955848 DOI: 10.1136/heartjnl-2015-308505] [Citation(s) in RCA: 65] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2015] [Accepted: 02/14/2016] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVE International guidelines to rule-in acute myocardial infarction (AMI) in patients presenting with chest pain to the emergency department (ED) recommend an algorithm using high-sensitivity cardiac troponin (hs-cTn) sampling on presentation and 3 h following presentation. We tested the diagnostic accuracy of this algorithm by pooling data from five distinct cohorts from three countries of prospectively recruited patients with independently adjudicated outcomes. METHOD We measured high-sensitivity cardiac troponin I (hs-cTnI) and high-sensitivity cardiac troponin T (hs-cTnT) on presentation (0 h) and 3 h post-presentation samples in adult patients attending an ED with possible AMI to validate the European Society of Cardiology (ESC) Working Group on Acute Cardiac Care rule-in algorithm (ESC-rule-in). Specifically, (i) in patients with a 0 h hs-cTn concentration ≤99th percentile and a 3 h hs-cTn >99th percentile, positive patients are those with an absolute change in troponin ≥50% of the 99th percentile, and (ii) in patients with a 0 and 3 h hs-cTn >99th percentile, positive patients are those with a relative change in troponin of ≥20%. We concurrently assessed the efficacy of the 0 and 3 h hs-cTn <99th percentile to rule-out AMI. RESULTS 1061 patients with hs-cTnI and 985 with hs-cTnT were included. The ESC-rule-in positive predictive value (PPV) was 83.5% (95% CI 74.9% to 90.1%) for hs-cTnI and 72.0% (95% CI 62.1% to 80.5%) for hs-cTnT. Forty-six AMIs (34.9%) were not ruled in using hs-cTnI and 62 (46.2%) using hs-cTnT. The sensitivity of the 99th percentile to rule-out AMI was 93.2% (95% CI 87.5% to 96.8%) for hs-cTnI and 94.8% (95% CI 89.5% to 97.9%) for hs-cTnT. CONCLUSIONS The ESC-rule-in algorithm has good PPV with hs-cTnI and reasonable with hs-cTnT and can rule-in over 50% of AMIs. However, the sensitivity of the 99th percentile to rule-out AMI is too low for clinical use.
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Affiliation(s)
- John W Pickering
- Emergency Department, Christchurch Hospital, Christchurch, New Zealand Department of Medicine, University of Otago, Christchurch, New Zealand
| | - Jaimi H Greenslade
- Department of Emergency Medicine, Royal Brisbane and Women's Hospital, and The University of Queensland and School of Public Health, Queensland University of Technology Brisbane, Brisbane, Australia
| | - Louise Cullen
- Department of Emergency Medicine, Royal Brisbane and Women's Hospital, and The University of Queensland and School of Public Health, Queensland University of Technology Brisbane, Brisbane, Australia
| | - Dylan Flaws
- Department of Emergency Medicine, Royal Brisbane and Women's Hospital, and The University of Queensland and School of Public Health, Queensland University of Technology Brisbane, Brisbane, Australia
| | - William Parsonage
- Department of Cardiology, Royal Brisbane and Women's Hospital, Brisbane, Australia
| | - Peter George
- Canterbury Health Laboratories, Christchurch, New Zealand
| | | | | | - Martin P Than
- Emergency Department, Christchurch Hospital, Christchurch, New Zealand
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Lupi A, Rognoni A, Lazzero M, Rolla R, Pergolini P, Bellomo G, Rossi L, Sante Bongo A, Jaffe AS. Below normal pre-procedural cardiac troponin I levels are associated with an adverse prognosis after percutaneous coronary interventions. EUROINTERVENTION 2016; 11:1380-8. [DOI: 10.4244/eijy14m11_04] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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11
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Evaluation of Abbott Architect high-sensitivity troponin I assay for haemolysis interference. Pathology 2015; 47:716-8. [DOI: 10.1097/pat.0000000000000342] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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12
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Kavsak PA, Beattie J, Pickersgill R, Ford L, Caruso N, Clark L. A practical approach for the validation and clinical implementation of a high-sensitivity cardiac troponin I assay across a North American city. Pract Lab Med 2015; 1:28-34. [PMID: 28932796 PMCID: PMC5597710 DOI: 10.1016/j.plabm.2015.02.001] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2014] [Revised: 01/20/2015] [Accepted: 02/11/2015] [Indexed: 02/03/2023] Open
Abstract
Objectives Despite several publications on the analytical performance of high-sensitivity cardiac troponin (hs-cTn) assays, there has been little information on how laboratories should validate and implement these assays into clinical service. Our study provides a practical approach for the validation and implementation of a hs-cTn assay across a large North American City. Design and methods Validation for the Abbott ARCHITECT hs-cTnI assay (across 5 analyzers) consisted of verification of limit of blank (LoB), precision (i.e., coefficient of variation; CV) testing at the reported limit of detection (LoD) and within and outside the 99th percentile, linearity testing, cTnI versus hs-cTnI patient comparison within and between analyzers (Passing and Bablok and non-parametric analyses). Education, clinical communications, and memorandums were issued in advance to inform all staff across the city as well as a selected reminder the day before live-date to important users. All hospitals switched to the hs-cTnI assay concurrently (the contemporary cTnI assay removed) with laboratory staff instructed to repeat samples previously measured with the contemporary cTnI assay with the hs-cTnI assay only by physician request. Results Across the 5 analyzers and 6 reagent packs the overall LoB was 0.6 ng/L (n=60) with a CV of 33% at an overall mean of 1.2 ng/L (n=60; reported LoD=1.0 ng/L), with linearity demonstrated from 45,005 ng/L to 1.1 ng/L. Precision testing with a normal patient-pool QC material (mean range across 5 analyzers was 3.9–4.4 ng/L) yielded a range of CVs from 7% to 10% (within-run) and CVs from 7% to 18% (between-run) with the high patient-pool QC material (mean range across 5 analyzers was 29.6–36.3 ng/L) yielding a range of CVs from 2% to 5% (within-run) and CVs from 4% to 8% (between-run). There was agreement between hs-cTnI versus cTnI with the patient samples (slope ranges: 0.89–1.03; intercept ranges: 1.9–3.8 ng/L), however, the median CV on patient samples <100 ng/L across the analyzers was 5.6% for hs-cTnI versus 18.7% for the contemporary assay (p<0.001). Following the switch to hs-cTnI testing, no requests for repeat measurements were received. Conclusions Validation and implementation of hs-cTnI testing across multiple sites requires collaboration within the laboratories and between hospital laboratories and clinical staff. City-wide analytical validation of a high-sensitivity cardiac troponin assay. Practical approach to hs-cTnI validation and clinical implementation. Clinical support and communication are important for a successful implementation. New QC practices and comparability testing for hs-cTnI monitoring.
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Affiliation(s)
- Peter A. Kavsak
- Department of Pathology and Molecular Medicine, McMaster University, Hamilton, ON, Canada
- Juravinski Hospital and Cancer Centre, Hamilton, Canada
- Hamilton Regional Laboratory Medicine Program, Canada
- Correspondence to: Juravinski Hospital and Cancer Centre, 711 Concession Street Hamilton, ON, Canada L8V 1C3. Tel.: +1 905 521 2100.
| | - John Beattie
- Hamilton Regional Laboratory Medicine Program, Canada
- Hamilton General Hospital, Hamilton, Canada
| | - Robin Pickersgill
- Hamilton Regional Laboratory Medicine Program, Canada
- St. Joseph׳s Hospital, Hamilton, Canada
| | - Lynn Ford
- Hamilton Regional Laboratory Medicine Program, Canada
- McMaster Children׳s Hospital, Hamilton, Canada
| | - Nadia Caruso
- Hamilton Regional Laboratory Medicine Program, Canada
- Hamilton General Hospital, Hamilton, Canada
| | - Lorna Clark
- Juravinski Hospital and Cancer Centre, Hamilton, Canada
- Hamilton Regional Laboratory Medicine Program, Canada
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13
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Shortt C, Phan K, Hill SA, Worster A, Kavsak PA. An approach to rule-out an acute cardiovascular event or death in emergency department patients using outcome-based cutoffs for high-sensitivity cardiac troponin assays and glucose. Clin Biochem 2015; 48:282-7. [DOI: 10.1016/j.clinbiochem.2014.11.010] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2014] [Revised: 11/04/2014] [Accepted: 11/08/2014] [Indexed: 01/04/2023]
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14
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Kavsak PA, Jaffe AS, Hickman PE, Mills NL, Humphries KH, McRae A, Devereaux PJ, Lamy A, Whitlock R, Dhesy-Thind SK, Potter JM, Worster A. Canadian Institutes of Health Research dissemination grant on high-sensitivity cardiac troponin. Clin Biochem 2014; 47:155-7. [PMID: 25304912 DOI: 10.1016/j.clinbiochem.2014.10.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
| | | | - Peter E Hickman
- Australian National University Medical School, Canberra, Australian Capital Territory, Australia
| | - Nicholas L Mills
- BHF/University Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | | | - Andrew McRae
- Department of Emergency Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | | | - Andre Lamy
- McMaster University, Hamilton, Ontario, Canada
| | | | | | - Julia M Potter
- Australian National University Medical School, Canberra, Australian Capital Territory, Australia
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Kavsak PA, Clark L, Lancaster S, Don-Wauchope AC. Within-run precision and outlier detection for the Abbott ARCHITECT cardiac troponin I assay. Ann Clin Biochem 2014; 51:512-4. [DOI: 10.1177/0004563214534400] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Peter A Kavsak
- Department of Pathology and Molecular Medicine, McMaster University, Canada
- Juravinski Hospital and Cancer Centre, Hamilton, Canada
| | - Lorna Clark
- Juravinski Hospital and Cancer Centre, Hamilton, Canada
| | | | - Andrew C Don-Wauchope
- Department of Pathology and Molecular Medicine, McMaster University, Canada
- Juravinski Hospital and Cancer Centre, Hamilton, Canada
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Ryan JB, Southby SJ, Stuart LA, Mackay R, Florkowski CM, George PM. Comparison of cardiac TnI outliers using a contemporary and a high-sensitivity assay on the Abbott Architect platform. Ann Clin Biochem 2014; 51:507-11. [PMID: 24757182 DOI: 10.1177/0004563214534637] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Assays for cardiac troponin (cTn) have undergone improvements in sensitivity and precision in recent years. Increased rates of outliers, however, have been reported on various cTn platforms, typically giving irreproducible, falsely higher results. We aimed to evaluate the outlier rate occurring in patients with elevated cTnI using a contemporary and high-sensitivity assay. METHODS All patients with elevated cTnI (up to 300 ng/L) performed over a 21-month period were assayed in duplicate. A contemporary assay (Abbott STAT Troponin-I) was used for the first part of the study and subsequently a high-sensitivity assay (Abbott STAT High-Sensitive Troponin-I) was used. Outliers exceeded a calculated critical difference (CD) (CD = z × √2 × SDAnalytical) where z = 3.5 (for probability of 0.0005) and critical outliers also were on a different side of the decision level. RESULTS The respective outlier and critical outlier rates were 0.22% and 0.10% for the contemporary assay (n = 4009) and 0.18% and 0.13% for the high-sensitivity assay (n = 3878). There was no significant reduction in outlier rate between the two assays (χ(2) = 0.034, P = 0.854). Fifty-six percent of outliers occurred in samples where cTn was an 'add-on' test (and was stored and refrigerated prior to assay). CONCLUSION Despite recent improvements in cTn methods, outliers (including critical outliers) still occur at a low rate in both a contemporary and high-sensitivity cTnI assay. Laboratory and clinical staff should be aware of this potential analytical error, particularly in samples with suboptimal sample handling such as add-on tests.
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Affiliation(s)
- J B Ryan
- Canterbury Health Laboratories, Christchurch, New Zealand
| | - S J Southby
- Canterbury Health Laboratories, Christchurch, New Zealand
| | - L A Stuart
- Canterbury Health Laboratories, Christchurch, New Zealand
| | - R Mackay
- Canterbury Health Laboratories, Christchurch, New Zealand
| | - C M Florkowski
- Canterbury Health Laboratories, Christchurch, New Zealand
| | - P M George
- Canterbury Health Laboratories, Christchurch, New Zealand
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Conrad MJ, Jarolim P. Cardiac Troponins and High-sensitivity Cardiac Troponin Assays. Clin Lab Med 2014; 34:59-73, vi. [DOI: 10.1016/j.cll.2013.11.008] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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18
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Rezvanpour A, Shortt C, Clark L, Worster A, Kavsak PA. Analytical factors to consider when assessing a high-sensitivity cardiac troponin I assay compared to a contemporary assay in clinical studies. Clin Chim Acta 2014; 429:6-7. [DOI: 10.1016/j.cca.2013.11.012] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2013] [Revised: 11/10/2013] [Accepted: 11/12/2013] [Indexed: 11/25/2022]
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