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Młynarska E, Czarnik W, Fularski P, Hajdys J, Majchrowicz G, Stabrawa M, Rysz J, Franczyk B. From Atherosclerotic Plaque to Myocardial Infarction-The Leading Cause of Coronary Artery Occlusion. Int J Mol Sci 2024; 25:7295. [PMID: 39000400 PMCID: PMC11242737 DOI: 10.3390/ijms25137295] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2024] [Revised: 06/30/2024] [Accepted: 07/01/2024] [Indexed: 07/16/2024] Open
Abstract
Cardiovascular disease (CVD) constitutes the most common cause of death worldwide. In Europe alone, approximately 4 million people die annually due to CVD. The leading component of CVD leading to mortality is myocardial infarction (MI). MI is classified into several types. Type 1 is associated with atherosclerosis, type 2 results from inadequate oxygen supply to cardiomyocytes, type 3 is defined as sudden cardiac death, while types 4 and 5 are associated with procedures such as percutaneous coronary intervention and coronary artery bypass grafting, respectively. Of particular note is type 1, which is also the most frequently occurring form of MI. Factors predisposing to its occurrence include, among others, high levels of low-density lipoprotein cholesterol (LDL-C) in the blood, cigarette smoking, chronic kidney disease (CKD), diabetes mellitus (DM), hypertension, and familial hypercholesterolaemia (FH). The primary objective of this review is to elucidate the issues with regard to type 1 MI. Our paper delves into, amidst other aspects, its pathogenesis, risk assessment, diagnosis, pharmacotherapy, and interventional treatment options in both acute and long-term conditions.
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Affiliation(s)
- Ewelina Młynarska
- Department of Nephrocardiology, Medical University of Lodz, ul. Zeromskiego 113, 90-549 Lodz, Poland
| | - Witold Czarnik
- Department of Nephrocardiology, Medical University of Lodz, ul. Zeromskiego 113, 90-549 Lodz, Poland
| | - Piotr Fularski
- Department of Nephrocardiology, Medical University of Lodz, ul. Zeromskiego 113, 90-549 Lodz, Poland
| | - Joanna Hajdys
- Department of Nephrocardiology, Medical University of Lodz, ul. Zeromskiego 113, 90-549 Lodz, Poland
| | - Gabriela Majchrowicz
- Department of Nephrocardiology, Medical University of Lodz, ul. Zeromskiego 113, 90-549 Lodz, Poland
| | - Magdalena Stabrawa
- Department of Nephrocardiology, Medical University of Lodz, ul. Zeromskiego 113, 90-549 Lodz, Poland
| | - Jacek Rysz
- Department of Nephrology, Hypertension and Family Medicine, Medical University of Lodz, ul. Zeromskiego 113, 90-549 Lodz, Poland
| | - Beata Franczyk
- Department of Nephrocardiology, Medical University of Lodz, ul. Zeromskiego 113, 90-549 Lodz, Poland
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Goraya SR, O'Hare C, Grace KA, Schaeffer WJ, Hyder SN, Barnes GD, Greineder CF. Optimizing Use of High-Sensitivity Troponin for Risk-Stratification of Acute Pulmonary Embolism. Thromb Haemost 2024. [PMID: 38788767 DOI: 10.1055/s-0044-1786820] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/26/2024]
Abstract
BACKGROUND High-sensitivity troponin T (HS-TnT) may improve risk-stratification in hemodynamically stable acute pulmonary embolism (PE), but an optimal strategy for combining this biomarker with clinical risk-stratification tools has not been determined. STUDY HYPOTHESIS We hypothesized that different HS-TnT cutoff values may be optimal for identifying (1) low-risk patients who may be eligible for outpatient management and (2) patients at increased risk of clinical deterioration who might benefit from advanced PE therapies. METHODS Retrospective analysis of hemodynamically stable patients in the University of Michigan acute ED-PE registry with available HS-TnT values. Primary and secondary outcomes were 30-day mortality and need for intensive care unit-level care. Receiver operating characteristic curves were used to determine optimal HS-TnT cutoffs in the entire cohort, and for those at higher risk based on the simplified Pulmonary Embolism Severity Index (PESI) or imaging findings. RESULTS The optimal HS-TnT cutoff in the full cohort, 12 pg/mL, was significantly associated with 30-day mortality (odds ratio [OR]: 3.94, 95% confidence interval [CI]: 1.48-10.50) and remained a significant predictor after adjusting for the simplified PESI (sPESI) score and serum creatinine (adjusted OR: 3.05, 95% CI: 1.11-8.38). A HS-TnT cutoff of 87 pg/mL was associated with 30-day mortality (OR: 5.01, 95% CI: 2.08-12.06) in patients with sPESI ≥1 or right ventricular dysfunction. CONCLUSION In this retrospective, single-center study of acute PE patients, we identified distinct optimal HS-TnT values for different clinical uses-a lower cutoff, which identified low-risk patients even in the absence of other risk-stratification methods, and a higher cutoff, which was strongly associated with adverse outcomes in patients at increased risk.
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Affiliation(s)
- Sayhaan R Goraya
- University of Michigan Medical School, Ann Arbor, Michigan, United States
| | - Connor O'Hare
- Department of Emergency Medicine, University of Michigan, Ann Arbor, Michigan, United States
| | - Kelsey A Grace
- Department of Emergency Medicine, University of Michigan, Ann Arbor, Michigan, United States
| | - William J Schaeffer
- Department of Emergency Medicine, University of Michigan, Ann Arbor, Michigan, United States
| | - S Nabeel Hyder
- Division of Cardiovascular Medicine, Department of Internal Medicine, Frankel Cardiovascular Center, University of Michigan, Ann Arbor, Michigan, United States
| | - Geoffrey D Barnes
- University of Michigan Medical School, Ann Arbor, Michigan, United States
- Division of Cardiovascular Medicine, Department of Internal Medicine, Frankel Cardiovascular Center, University of Michigan, Ann Arbor, Michigan, United States
| | - Colin F Greineder
- University of Michigan Medical School, Ann Arbor, Michigan, United States
- Department of Emergency Medicine, University of Michigan, Ann Arbor, Michigan, United States
- Department of Pharmacology, University of Michigan, Ann Arbor, Michigan, United States
- BioInterfaces Institute, University of Michigan, Ann Arbor, Michigan, United States
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Boeddinghaus J, Doudesis D, Lopez-Ayala P, Lee KK, Koechlin L, Wildi K, Nestelberger T, Borer R, Miró Ò, Martin-Sanchez FJ, Strebel I, Rubini Giménez M, Keller DI, Christ M, Bularga A, Li Z, Ferry AV, Tuck C, Anand A, Gray A, Mills NL, Mueller C. Machine Learning for Myocardial Infarction Compared With Guideline-Recommended Diagnostic Pathways. Circulation 2024; 149:1090-1101. [PMID: 38344871 DOI: 10.1161/circulationaha.123.066917] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Accepted: 01/16/2024] [Indexed: 02/29/2024]
Abstract
BACKGROUND Collaboration for the Diagnosis and Evaluation of Acute Coronary Syndrome (CoDE-ACS) is a validated clinical decision support tool that uses machine learning with or without serial cardiac troponin measurements at a flexible time point to calculate the probability of myocardial infarction (MI). How CoDE-ACS performs at different time points for serial measurement and compares with guideline-recommended diagnostic pathways that rely on fixed thresholds and time points is uncertain. METHODS Patients with possible MI without ST-segment-elevation were enrolled at 12 sites in 5 countries and underwent serial high-sensitivity cardiac troponin I concentration measurement at 0, 1, and 2 hours. Diagnostic performance of the CoDE-ACS model at each time point was determined for index type 1 MI and the effectiveness of previously validated low- and high-probability scores compared with guideline-recommended European Society of Cardiology (ESC) 0/1-hour, ESC 0/2-hour, and High-STEACS (High-Sensitivity Troponin in the Evaluation of Patients With Suspected Acute Coronary Syndrome) pathways. RESULTS In total, 4105 patients (mean age, 61 years [interquartile range, 50-74]; 32% women) were included, among whom 575 (14%) had type 1 MI. At presentation, CoDE-ACS identified 56% of patients as low probability, with a negative predictive value and sensitivity of 99.7% (95% CI, 99.5%-99.9%) and 99.0% (98.6%-99.2%), ruling out more patients than the ESC 0-hour and High-STEACS (25% and 35%) pathways. Incorporating a second cardiac troponin measurement, CoDE-ACS identified 65% or 68% of patients as low probability at 1 or 2 hours, for an identical negative predictive value of 99.7% (99.5%-99.9%); 19% or 18% as high probability, with a positive predictive value of 64.9% (63.5%-66.4%) and 68.8% (67.3%-70.1%); and 16% or 14% as intermediate probability. In comparison, after serial measurements, the ESC 0/1-hour, ESC 0/2-hour, and High-STEACS pathways identified 49%, 53%, and 71% of patients as low risk, with a negative predictive value of 100% (99.9%-100%), 100% (99.9%-100%), and 99.7% (99.5%-99.8%); and 20%, 19%, or 29% as high risk, with a positive predictive value of 61.5% (60.0%-63.0%), 65.8% (64.3%-67.2%), and 48.3% (46.8%-49.8%), resulting in 31%, 28%, or 0%, who require further observation in the emergency department, respectively. CONCLUSIONS CoDE-ACS performs consistently irrespective of the timing of serial cardiac troponin measurement, identifying more patients as low probability with comparable performance to guideline-recommended pathways for MI. Whether care guided by probabilities can improve the early diagnosis of MI requires prospective evaluation. REGISTRATION URL: https://www.clinicaltrials.gov; Unique identifier: NCT00470587.
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Affiliation(s)
- Jasper Boeddinghaus
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology (J.B., P.L.-A., L.K., K.W., T.N., R.B., I.S., M.R.G., C.M.), University Hospital Basel, University of Basel, Switzerland
- BHF/University Centre for Cardiovascular Science (J.B., D.D., K.K.L., A.B., Z.L., A.V.F., C.T., A.A., N.L.M.), University of Edinburgh, UK
| | - Dimitrios Doudesis
- BHF/University Centre for Cardiovascular Science (J.B., D.D., K.K.L., A.B., Z.L., A.V.F., C.T., A.A., N.L.M.), University of Edinburgh, UK
- Usher Institute (D.D., K.K.L., A.G., N.L.M.), University of Edinburgh, UK
| | - Pedro Lopez-Ayala
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology (J.B., P.L.-A., L.K., K.W., T.N., R.B., I.S., M.R.G., C.M.), University Hospital Basel, University of Basel, Switzerland
| | - Kuan Ken Lee
- BHF/University Centre for Cardiovascular Science (J.B., D.D., K.K.L., A.B., Z.L., A.V.F., C.T., A.A., N.L.M.), University of Edinburgh, UK
- Usher Institute (D.D., K.K.L., A.G., N.L.M.), University of Edinburgh, UK
| | - Luca Koechlin
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology (J.B., P.L.-A., L.K., K.W., T.N., R.B., I.S., M.R.G., C.M.), University Hospital Basel, University of Basel, Switzerland
- Departments of Cardiac Surgery (L.K.), University Hospital Basel, University of Basel, Switzerland
| | - Karin Wildi
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology (J.B., P.L.-A., L.K., K.W., T.N., R.B., I.S., M.R.G., C.M.), University Hospital Basel, University of Basel, Switzerland
- Intensive Care (K.W.), University Hospital Basel, University of Basel, Switzerland
| | - Thomas Nestelberger
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology (J.B., P.L.-A., L.K., K.W., T.N., R.B., I.S., M.R.G., C.M.), University Hospital Basel, University of Basel, Switzerland
| | - Raphael Borer
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology (J.B., P.L.-A., L.K., K.W., T.N., R.B., I.S., M.R.G., C.M.), University Hospital Basel, University of Basel, Switzerland
| | - Òscar Miró
- Emergency Department, Hospital Clinic, Barcelona, Catalonia, Spain (Ò.M.)
| | | | - Ivo Strebel
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology (J.B., P.L.-A., L.K., K.W., T.N., R.B., I.S., M.R.G., C.M.), University Hospital Basel, University of Basel, Switzerland
| | - Maria Rubini Giménez
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology (J.B., P.L.-A., L.K., K.W., T.N., R.B., I.S., M.R.G., C.M.), University Hospital Basel, University of Basel, Switzerland
| | - Dagmar I Keller
- Emergency Department, University Hospital Zurich, Switzerland (D.I.K.)
| | - Michael Christ
- Emergency Department, Kantonsspital Luzern, Switzerland (M.C.)
| | - Anda Bularga
- BHF/University Centre for Cardiovascular Science (J.B., D.D., K.K.L., A.B., Z.L., A.V.F., C.T., A.A., N.L.M.), University of Edinburgh, UK
| | - Ziwen Li
- BHF/University Centre for Cardiovascular Science (J.B., D.D., K.K.L., A.B., Z.L., A.V.F., C.T., A.A., N.L.M.), University of Edinburgh, UK
| | - Amy V Ferry
- BHF/University Centre for Cardiovascular Science (J.B., D.D., K.K.L., A.B., Z.L., A.V.F., C.T., A.A., N.L.M.), University of Edinburgh, UK
| | - Chris Tuck
- BHF/University Centre for Cardiovascular Science (J.B., D.D., K.K.L., A.B., Z.L., A.V.F., C.T., A.A., N.L.M.), University of Edinburgh, UK
| | - Atul Anand
- BHF/University Centre for Cardiovascular Science (J.B., D.D., K.K.L., A.B., Z.L., A.V.F., C.T., A.A., N.L.M.), University of Edinburgh, UK
| | - Alasdair Gray
- Usher Institute (D.D., K.K.L., A.G., N.L.M.), University of Edinburgh, UK
- Emergency Medicine Research Group Edinburgh, Royal Infirmary of Edinburgh, UK (A.G.)
| | - Nicholas L Mills
- BHF/University Centre for Cardiovascular Science (J.B., D.D., K.K.L., A.B., Z.L., A.V.F., C.T., A.A., N.L.M.), University of Edinburgh, UK
- Usher Institute (D.D., K.K.L., A.G., N.L.M.), University of Edinburgh, UK
| | - Christian Mueller
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology (J.B., P.L.-A., L.K., K.W., T.N., R.B., I.S., M.R.G., C.M.), University Hospital Basel, University of Basel, Switzerland
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4
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Supples MW, Snavely AC, Ashburn NP, Allen BR, Christenson RH, Nowak R, Wilkerson RG, Mumma BE, Madsen T, Stopyra JP, Mahler SA. Performance of the 0/2-hour high-sensitivity cardiac troponin T diagnostic protocol in a multisite United States cohort. Acad Emerg Med 2024; 31:239-248. [PMID: 37925594 DOI: 10.1111/acem.14827] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Revised: 10/04/2023] [Accepted: 10/13/2023] [Indexed: 11/06/2023]
Abstract
BACKGROUND The diagnostic performance of the high-sensitivity troponin T (hs-cTnT) 0/2-h algorithm is unclear among U.S. emergency department (ED) patients with acute chest pain. METHODS A preplanned subgroup analysis of the STOP-CP cohort study was conducted. Participants with 0- and 2-h hs-cTnT measures prospectively enrolled at eight U.S. EDs from January 2017 to September 2018 were stratified into rule-out, observation, and rule-in zones using the hs-cTnT 0/2-h algorithm alone and combined with the history, electrocardiogram, age, and risk factor (HEAR) score. The primary outcome was adjudicated 30-day cardiac death or myocardial infarction (CDMI). The sensitivity and negative predictive value (NPV) of the 0/2-h rule-out zone and specificity and positive predictive value (PPV) of the rule-in zone for 30-day CDMI were calculated. RESULTS Of the 1307 patients accrued, 53.6% (700/1307) were male and 58.6% (762/1307) were White, with a mean ± SD age of 57.5 ± 12.7 years. At 30 days, CDMI occurred in 12.9% (168/1307) of participants. The 0/2-h algorithm ruled out 61.4% (802/1307) of patients. Among rule-out patients, 1.9% (15/802) experienced 30-day CDMI, resulting in a sensitivity of 91.1% (95% confidence interval [CI] 85.7%-94.9%) and NPV of 98.1% (95% CI 96.9%-98.9%). The 0/2-h algorithm ruled in 12.4% (162/1307) patients of whom 61.7% (100/162) experienced 30-day CDMI. The rule-in zone specificity was 94.6% (95% CI 93.1%-95.8%) and PPV was 61.7% (95% CI 53.8%-69.2%) for 30-day CDMI. The 0/2-h algorithm combined with HEAR score ruled out 30.7% (401/1307) of patients with a sensitivity and NPV for 30-day CDMI of 98.2% (95% CI 94.9%-99.6%) and 99.3% (95% CI 97.8%-99.8%), respectively. CONCLUSIONS The hs-cTnT 0/2-h algorithm ruled out most patients. With NPV of <99% for 30-day CDMI, the hs-cTnT 0/2-h algorithm, many emergency physicians may not consider it safe to use for U.S. ED patients. When combined with a low-risk HEAR score, NPV was >99% for 30-day CDMI at the cost of reduced efficacy.
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Affiliation(s)
- Michael W Supples
- Department of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Anna C Snavely
- Department of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
- Department of Biostatistics and Data Science, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Nicklaus P Ashburn
- Department of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
- Section on Cardiovascular Medicine, Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Brandon R Allen
- Department of Emergency Medicine, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Robert H Christenson
- Department of Pathology, University of Maryland School of Medicine, Baltimore, Massachusetts, USA
| | - Richard Nowak
- Department of Emergency Medicine, Henry Ford Health System, Detroit, Michigan, USA
| | - R Gentry Wilkerson
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, Massachusetts, USA
| | - Bryn E Mumma
- Department of Emergency Medicine, University of California Davis School of Medicine, Sacramento, California, USA
| | - Troy Madsen
- Department of Emergency Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Jason P Stopyra
- Department of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Simon A Mahler
- Department of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
- Department of Epidemiology and Prevention, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
- Department of Implementation Science, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
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5
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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: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/24/2023]
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Liu L, Lewandrowski K. Establishing optimal cutoff values for high-sensitivity cardiac troponin algorithms in risk stratification of acute myocardial infarction. Crit Rev Clin Lab Sci 2024; 61:1-22. [PMID: 37466395 DOI: 10.1080/10408363.2023.2235426] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Revised: 06/11/2023] [Accepted: 07/07/2023] [Indexed: 07/20/2023]
Abstract
Acute myocardial infarction (AMI) is a leading cause of mortality globally, highlighting the need for timely and accurate diagnostic strategies. Cardiac troponin has been the biomarker of choice for detecting myocardial injury. A dynamic change in concentrations supports the diagnosis of AMI in the setting of evidence of acute myocardial ischemia. The new generation of high-sensitivity cardiac troponin (hs-cTn) assays has significantly improved analytical sensitivity but at the expense of decreased clinical specificity. As a result, sophisticated algorithms are required to differentiate AMI from non-AMI patients. Establishing optimal hs-cTn cutoffs for these algorithms to rule out and rule in AMI has been the subject of intensive investigations. These efforts have evolved from examining the utility of the hs-cTn 99th percentile upper reference limit, comparing the percentage versus absolute delta thresholds, and evaluating the performance of an early European Society of Cardiology-recommended 3 h algorithm, to the development of accelerated 1 h and 2 h algorithms that combine the admission hs-cTn concentrations and absolute delta cutoffs to rule out and rule in AMI. Specific cutoffs for individual confounding factors such as sex, age, and renal insufficiency have also been investigated. At the same time, concerns such as whether the small delta thresholds exceed the analytical and biological variations of hs-cTn assays and whether the algorithms developed in European study populations fit all other patient cohorts have been raised. In addition, the accelerated algorithms leave a substantial number of patients in a non-diagnostic observation zone. How to properly diagnose patients falling in this zone and those presenting with elevated baseline hs-cTn concentrations due to the presence of confounding factors or comorbidities remain open questions. Here we discuss the developments described above, focusing on criteria and underlying considerations for establishing optimal cutoffs. In-depth analyses are provided on the influence of biological variation, analytical imprecision, local AMI rate, and the timing of presentation on the performance metrics of the accelerated hs-cTn algorithms. Developing diagnostic strategies for patients who remain in the observation zone and those presenting with confounding factors are also reviewed.
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Affiliation(s)
- Li Liu
- Department of Pathology, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Kent Lewandrowski
- Department of Pathology, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
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7
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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: 601] [Impact Index Per Article: 601.0] [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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8
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Koechlin L, Strebel I, Zimmermann T, Nestelberger T, Walter J, Lopez-Ayala P, Boeddinghaus J, Shrestha S, Arslani K, Stefanelli S, Reuthebuch B, Wussler D, Ratmann PD, Christ M, Badertscher P, Wildi K, Giménez MR, Gualandro DM, Miró Ò, Fuenzalida C, Martin-Sanchez FJ, Kawecki D, Bürgler F, Keller DI, Abächerli R, Reuthebuch O, Eckstein FS, Twerenbold R, Reichlin T, Mueller C. Hyperacute T Wave in the Early Diagnosis of Acute Myocardial Infarction. Ann Emerg Med 2023; 82:194-202. [PMID: 36774205 DOI: 10.1016/j.annemergmed.2022.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2021] [Revised: 11/28/2022] [Accepted: 12/01/2022] [Indexed: 02/12/2023]
Abstract
STUDY OBJECTIVE The diagnostic performance of T-wave amplitudes for the detection of myocardial infarction is largely unknown. We aimed to address this knowledge gap. METHODS T-wave amplitudes were automatically measured in 12-lead ECGs of patients presenting with acute chest discomfort to the emergency department within a prospective diagnostic multicenter study. The final diagnosis was centrally adjudicated by 2 independent cardiologists. Patients with left ventricular hypertrophy, complete left bundle branch block, or paced ventricular depolarization were excluded. The performance for lead-specific 95th-percentile thresholds were reported as likelihood ratios (lr), specificity, and sensitivity. RESULTS Myocardial infarction was the final diagnosis in 445 (18%) of 2457 patients. In most leads, T-wave amplitudes tended to be greater in patients without myocardial infarction than those with myocardial infarction, and T-wave amplitude exceeding the 95th percentile had positive and negative lr close to 1 or with confidence intervals (CIs) crossing 1. The exceptions were leads III, aVR, and V1, which had positive lrs of 3.8 (95% CI, 2.7 to 5.3), 4.3 (95% CI, 3.1 to 6.0) and 2.0 (95% CI, 1.4 to 2.9), respectively. These leads normally have inverted T waves, so T-wave amplitude exceeding the 95th percentile reflects upright rather than increased-amplitude hyperacute T waves. CONCLUSION Hyperacute T waves, when defined as increased T-wave amplitude exceeding the 95th percentile, did not provide useful information in diagnosing myocardial infarction in this sample.
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Affiliation(s)
- Luca Koechlin
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology University Hospital Basel, University of Basel, Switzerland; Department of Cardiac Surgery, University Hospital Basel, University of Basel, Switzerland; GREAT network
| | - Ivo Strebel
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology University Hospital Basel, University of Basel, Switzerland; GREAT network
| | - Tobias Zimmermann
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology University Hospital Basel, University of Basel, Switzerland; GREAT network
| | - Thomas Nestelberger
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology University Hospital Basel, University of Basel, Switzerland; GREAT network
| | - Joan Walter
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology University Hospital Basel, University of Basel, Switzerland; GREAT network
| | - Pedro Lopez-Ayala
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology University Hospital Basel, University of Basel, Switzerland; GREAT network
| | - Jasper Boeddinghaus
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology University Hospital Basel, University of Basel, Switzerland; GREAT network
| | - Samyut Shrestha
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology University Hospital Basel, University of Basel, Switzerland; GREAT network
| | - Ketina Arslani
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology University Hospital Basel, University of Basel, Switzerland; GREAT network
| | - Sabrina Stefanelli
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology University Hospital Basel, University of Basel, Switzerland; GREAT network
| | - Benedikt Reuthebuch
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology University Hospital Basel, University of Basel, Switzerland
| | - Desiree Wussler
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology University Hospital Basel, University of Basel, Switzerland; GREAT network; Division of Internal Medicine, University Hospital Basel, University of Basel, Switzerland
| | - Paul David Ratmann
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology University Hospital Basel, University of Basel, Switzerland; GREAT network; Division of Internal Medicine, University Hospital Basel, University of Basel, Switzerland
| | - Michael Christ
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology University Hospital Basel, University of Basel, Switzerland; GREAT network; Emergency Department, Kantonsspital Luzern, Switzerland
| | - Patrick Badertscher
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology University Hospital Basel, University of Basel, Switzerland; GREAT network; Department of Cardiology, Medical University of South Carolina, Charleston, United States
| | - Karin Wildi
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology University Hospital Basel, University of Basel, Switzerland; GREAT network; Critical Care Research Group, the Prince Charles Hospital, Brisbane, Australia; University of Queensland, Brisbane, Australia
| | - Maria Rubini Giménez
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology University Hospital Basel, University of Basel, Switzerland; GREAT network; Cardiology Department, Herzzentrum Leipzig, Germany
| | - Danielle M Gualandro
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology University Hospital Basel, University of Basel, Switzerland; GREAT network
| | - Òscar Miró
- GREAT network; Emergency Department, Hospital Clinic, Barcelona, Catalonia, Spain
| | - Carolina Fuenzalida
- GREAT network; Emergency Department, Hospital Clinic, Barcelona, Catalonia, Spain
| | | | - Damian Kawecki
- GREAT network; 2nd Department of Cardiology, School of Medicine with the Division of Dentistry in Zabrze, Medical University of Katowice, Poland
| | - Franz Bürgler
- Emergency Department, Kantonsspital Liestal, Switzerland
| | - Dagmar I Keller
- Emergency Department, University Hospital Zurich, Zurich, Switzerland
| | - Roger Abächerli
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology University Hospital Basel, University of Basel, Switzerland; Institute of Medical Engineering, Lucerne University of Applied Sciences and Arts, Horw, Switzerland
| | - Oliver Reuthebuch
- Department of Cardiac Surgery, University Hospital Basel, University of Basel, Switzerland
| | - Friedrich S Eckstein
- Department of Cardiac Surgery, University Hospital Basel, University of Basel, Switzerland
| | - Raphael Twerenbold
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology University Hospital Basel, University of Basel, Switzerland; GREAT network
| | - Tobias Reichlin
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology University Hospital Basel, University of Basel, Switzerland; GREAT network; Department of Cardiology, Inselspital, University Hospital Bern, University of Bern, Switzerland
| | - Christian Mueller
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology University Hospital Basel, University of Basel, Switzerland; GREAT network.
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9
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Fischer BG, Evans AT. High-Sensitivity Cardiac Troponin Algorithms and the Value of Likelihood Ratios. J Gen Intern Med 2023; 38:2189-2193. [PMID: 36882634 PMCID: PMC10361949 DOI: 10.1007/s11606-023-08103-9] [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: 12/18/2022] [Accepted: 02/09/2023] [Indexed: 03/09/2023]
Abstract
High-sensitivity cardiac troponin (hs-cTn) is now the recommended biomarker for diagnosis of non-ST-elevation myocardial infarction, but proper interpretation varies based on the assay being used. Nearly uniformly, suggested interpretations of assay-specific hs-cTn results are based on predictive values, which are not applicable to most patients. Through application of a published hs-cTn algorithm to several patient scenarios, we will demonstrate that likelihood ratios are superior to predictive values for patient-centered test interpretation and decision-making. Furthermore, we will provide a blueprint for how to use existing published data presented with predictive values to calculate likelihood ratios. Changing the output of diagnostic accuracy studies and diagnostic algorithms from predictive values to likelihood ratios can improve patient care.
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Affiliation(s)
- Brett G Fischer
- Weill Department of Medicine, Weill Cornell Medicine, New York, NY, USA.
| | - Arthur T Evans
- Weill Department of Medicine, Weill Cornell Medicine, New York, NY, USA
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10
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Camoni L, Tosti ME, Pezzullo AM, Marchetti M, Cadeddu C. Clinical and organizational impact of the use of different cardiac troponin assays for the diagnosis of myocardial infarction without persistent elevation of the ST segment at presentation (NSTEMI) in 12 Italian emergency departments (EDs): the TROCAR study. Intern Emerg Med 2023; 18:733-741. [PMID: 36729269 PMCID: PMC9894517 DOI: 10.1007/s11739-022-03169-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2022] [Accepted: 11/30/2022] [Indexed: 02/03/2023]
Abstract
The management of acute chest pain is one of the challenges for emergency departments (EDs) worldwide. This study aims to provide insights into clinical and organizational aspects related to the use of different cardiac troponin tests for the diagnosis of NSTEMI. A prospective observational study was conducted among 12 Italian EDs. Eligible participants had chest pain of suspected cardiac origin and accessed EDs from January 2017 to March 2019. A 30-day follow-up was performed to gather information about the main cardiac outcomes. Tests validity and performance were assessed by computing sensitivity, specificity, positive and negative predictive values and area under the ROC curve. The independent association between adverse event end point at 30 days and type of troponin was evaluated by multiple logistic regression models, using odds ratio and 95% confidence interval. 2913 patients were included. Almost 72% were affected by comorbidities and most of them stayed in the EDs for more than 3 h, with significant differences among the different troponin assays. The results of follow-up at 30 days for the outcomes considered for the patients who were ruled out in 3 h or less did not differ significantly compared to those ruled out after 3 h or more. After adjustment for confounders, patients admitted to an ED that used a high-sensitivity troponin were at a lower risk of having a MACE (OR = 0.53, 95%CI 0.35-0.90) and a non-significant lower risk of myocardial infarction (OR = 0.68, 95% CI 0.41-1.13, p = 0.1314) at 30 days compared to patients admitted to an ED that used a standard troponin. Appropriate troponin testing is extremely important for differential diagnosis and for addressing proper treatment and safe procedures for patients who are not admitted to the hospital.
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Affiliation(s)
- Laura Camoni
- grid.416651.10000 0000 9120 6856Centre for Behavioral Sciences and Mental Health, Istituto Superiore di Sanità, Viale Regina Elena, 299, 00161 Rome, Italy
| | - Maria Elena Tosti
- grid.416651.10000 0000 9120 6856National Centre for Global Health, Istituto Superiore di Sanità, Rome, Italy
| | - Angelo Maria Pezzullo
- grid.8142.f0000 0001 0941 3192Section of Hygiene, Department of Life Sciences and Public Health, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Marco Marchetti
- grid.416651.10000 0000 9120 6856National Centre for Health Technology Assessment, Istituto Superiore di Sanità, Rome, Italy
| | - Chiara Cadeddu
- grid.8142.f0000 0001 0941 3192Section of Hygiene, Department of Life Sciences and Public Health, Università Cattolica del Sacro Cuore, Rome, Italy
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11
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Rubini Gimenez M, Boeddinghaus J, Nestelberger T, Koechlin L, López-Ayala P, Müller C. Implementation of the ESC 0 h/1 h high-sensitivity troponin algorithm for decision-making in the emergency department. REVISTA ESPANOLA DE CARDIOLOGIA (ENGLISH ED.) 2023; 76:468-472. [PMID: 36669731 DOI: 10.1016/j.rec.2023.01.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/10/2022] [Accepted: 12/12/2022] [Indexed: 01/19/2023]
Abstract
Diagnosis of non-ST-segment elevation acute coronary syndromes (NSTEACS) is based on 3 cornerstones: clinical presentation, 12-lead electrocardiogram, and cardiac troponin measurement. Advances in the development of high-sensitivity cardiac troponin (hs-cTn) assays have substantially improved the detection of cardiomyocyte injury in a shorter time period, and hs-cTn has consequently been established as the gold-standard biomarker for the assessment of patients with suspected NSTEACS. The implementation of these assays in clinical practice allows a faster "rule-out", especially among low-risk patients, as well as a safer and more rapid "rule-in", with its therapeutic consequences. Current guidelines for the diagnosis of NSTEACS recommend the use of hs-cTn applied in rapid diagnostic algorithms based on serial hs-cTn sampling within the first few hours. The current work provides an overview of the use of hs-cTn for the early detection of NSTEACS.
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Affiliation(s)
- Maria Rubini Gimenez
- Department of Cardiology and internal Medicine, University Heart Center Leipzig, Leipzig, Germany; Cardiovascular Research Institute of Basel, University Hospital Basel, Basel, Switzerland.
| | - Jasper Boeddinghaus
- Cardiovascular Research Institute of Basel, University Hospital Basel, Basel, Switzerland; BHF/University Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
| | - Thomas Nestelberger
- Cardiovascular Research Institute of Basel, University Hospital Basel, Basel, Switzerland
| | - Luca Koechlin
- Cardiovascular Research Institute of Basel, University Hospital Basel, Basel, Switzerland
| | - Pedro López-Ayala
- Cardiovascular Research Institute of Basel, University Hospital Basel, Basel, Switzerland
| | - Christian Müller
- Cardiovascular Research Institute of Basel, University Hospital Basel, Basel, Switzerland
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12
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Ohtake H, Terasawa T, Zhelev Z, Iwata M, Rogers M, Peters JL, Hyde C. Serial high-sensitivity cardiac troponin testing for the diagnosis of myocardial infarction: a scoping review. BMJ Open 2022; 12:e066429. [PMID: 36414302 PMCID: PMC9685223 DOI: 10.1136/bmjopen-2022-066429] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVES We aimed to assess the diversity and practices of existing studies on several assays and algorithms for serial measurements of high-sensitivity cardiac troponin (hs-cTn) for risk stratification and the diagnosis of myocardial infarction (MI) and 30-day outcomes in patients suspected of having non-ST-segment elevation MI (NSTEMI). METHODS We searched multiple databases including MEDLINE, EMBASE, Science Citation Index, the Cochrane Database of Systematic Reviews and the CENTRAL databases for studies published between January 2006 and November 2021. Studies that assessed the diagnostic accuracy of serial hs-cTn testing in patients suspected of having NSTEMI in the emergency department (ED) were eligible. Data were analysed using the scoping review method. RESULTS We included 86 publications, mainly from research centres in Europe, North America and Australasia. Two hs-cTn assays, manufactured by Abbott (43/86) and Roche (53/86), dominated the evaluations. The studies most commonly measured the concentrations of hs-cTn at two time points, at presentation and a few hours thereafter, to assess the two-strata or three-strata algorithm for diagnosing or ruling out MI. Although data from 83 studies (97%) were prospectively collected, 0%-90% of the eligible patients were excluded from the analysis due to missing blood samples or the lack of a final diagnosis in 53 studies (62%) that reported relevant data. Only 19 studies (22%) reported on head-to-head comparisons of alternative assays. CONCLUSION Evidence on the accuracy of serial hs-cTn testing was largely derived from selected research institutions and relied on two specific assays. The proportions of the eligible patients excluded from the study raise concerns about directly applying the study findings to clinical practice in frontline EDs. PROSPERO REGISTRATION NUMBER CRD42018106379.
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Affiliation(s)
- Hirotaka Ohtake
- Department of Emergency and General Internal Medicine, Fujita Health University, Toyoake, Aichi, Japan
| | - Teruhiko Terasawa
- Department of Emergency and General Internal Medicine, Fujita Health University, Toyoake, Aichi, Japan
| | - Zhivko Zhelev
- University of Exeter Medical School, University of Exeter, Exeter, UK
| | - Mitsunaga Iwata
- Department of Emergency and General Internal Medicine, Fujita Health University, Toyoake, Aichi, Japan
| | - Morwenna Rogers
- NIHR CLAHRC South West Peninsula, University of Exeter, Exeter, UK
| | - Jaime L Peters
- Peninsula Technology Assessment Group (PenTAG), University of Exeter, Exeter, UK
- Peninsula Technology Assessment Group (PenTAG), University of Exeter, Exeter, UK
| | - Chris Hyde
- Exeter Test Group, University of Exeter, Exeter, UK
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13
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Lowry MT, Doudesis D, Wereski R, Kimenai DM, Tuck C, Ferry AV, Bularga A, Taggart C, Lee KK, Chapman AR, Shah AS, Newby DE, Mills NL, Anand A. Influence of Age on the Diagnosis of Myocardial Infarction. Circulation 2022; 146:1135-1148. [PMID: 36106552 PMCID: PMC9555758 DOI: 10.1161/circulationaha.122.059994] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Accepted: 08/04/2022] [Indexed: 01/24/2023]
Abstract
BACKGROUND The 99th centile of cardiac troponin, derived from a healthy reference population, is recommended as the diagnostic threshold for myocardial infarction, but troponin concentrations are strongly influenced by age. Our aim was to assess the diagnostic performance of cardiac troponin in older patients presenting with suspected myocardial infarction. METHODS In a secondary analysis of a multicenter trial of consecutive patients with suspected myocardial infarction, we assessed the diagnostic accuracy of high-sensitivity cardiac troponin I at presentation for the diagnosis of type 1, type 2, or type 4b myocardial infarction across 3 age groups (<50, 50-74, and ≥75 years) using guideline-recommended sex-specific and age-adjusted 99th centile thresholds. RESULTS In 46 435 consecutive patients aged 18 to 108 years (mean, 61±17 years), 5216 (11%) had a diagnosis of myocardial infarction. In patients <50 (n=12 379), 50 to 74 (n=22 380), and ≥75 (n=11 676) years, the sensitivity of the guideline-recommended threshold was similar at 79.2% (95% CI, 75.5-82.9), 80.6% (95% CI, 79.2-82.1), and 81.6% (95% CI, 79.8-83.2), respectively. The specificity decreased with advancing age from 98.3% (95% CI, 98.1-98.5) to 95.5% (95% CI, 95.2-95.8), and 82.6% (95% CI, 81.9-83.4). The use of age-adjusted 99th centile thresholds improved the specificity (91.3% [90.8%-91.9%] versus 82.6% [95% CI, 81.9%-83.4%]) and positive predictive value (59.3% [57.0%-61.5%] versus 51.5% [49.9%-53.3%]) for myocardial infarction in patients ≥75 years but failed to prevent the decrease in either parameter with increasing age and resulted in a marked reduction in sensitivity compared with the use of the guideline-recommended threshold (55.9% [53.6%-57.9%] versus 81.6% [79.8%-83.3%]. CONCLUSIONS Age alters the diagnostic performance of cardiac troponin, with reduced specificity and positive predictive value in older patients when applying the guideline-recommended or age-adjusted 99th centiles. Individualized diagnostic approaches rather than the adjustment of binary thresholds are needed in an aging population.
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Affiliation(s)
- Matthew T.H. Lowry
- BHF Centre for Cardiovascular Science (M.T.H.L., D.D., R.W., D.M.K., C.T., A.V.F., A.B., C.T., K.K.L., A.R.C., D.E.N., N.L.M., A.A.), University of Edinburgh, UK
| | - Dimitrios Doudesis
- BHF Centre for Cardiovascular Science (M.T.H.L., D.D., R.W., D.M.K., C.T., A.V.F., A.B., C.T., K.K.L., A.R.C., D.E.N., N.L.M., A.A.), University of Edinburgh, UK
- Usher Institute (D.D., N.L.M.), University of Edinburgh, UK
| | - Ryan Wereski
- BHF Centre for Cardiovascular Science (M.T.H.L., D.D., R.W., D.M.K., C.T., A.V.F., A.B., C.T., K.K.L., A.R.C., D.E.N., N.L.M., A.A.), University of Edinburgh, UK
| | - Dorien M. Kimenai
- BHF Centre for Cardiovascular Science (M.T.H.L., D.D., R.W., D.M.K., C.T., A.V.F., A.B., C.T., K.K.L., A.R.C., D.E.N., N.L.M., A.A.), University of Edinburgh, UK
| | - Christopher Tuck
- BHF Centre for Cardiovascular Science (M.T.H.L., D.D., R.W., D.M.K., C.T., A.V.F., A.B., C.T., K.K.L., A.R.C., D.E.N., N.L.M., A.A.), University of Edinburgh, UK
| | - Amy V. Ferry
- BHF Centre for Cardiovascular Science (M.T.H.L., D.D., R.W., D.M.K., C.T., A.V.F., A.B., C.T., K.K.L., A.R.C., D.E.N., N.L.M., A.A.), University of Edinburgh, UK
| | - Anda Bularga
- BHF Centre for Cardiovascular Science (M.T.H.L., D.D., R.W., D.M.K., C.T., A.V.F., A.B., C.T., K.K.L., A.R.C., D.E.N., N.L.M., A.A.), University of Edinburgh, UK
| | - Caelan Taggart
- BHF Centre for Cardiovascular Science (M.T.H.L., D.D., R.W., D.M.K., C.T., A.V.F., A.B., C.T., K.K.L., A.R.C., D.E.N., N.L.M., A.A.), University of Edinburgh, UK
| | - Kuan K. Lee
- BHF Centre for Cardiovascular Science (M.T.H.L., D.D., R.W., D.M.K., C.T., A.V.F., A.B., C.T., K.K.L., A.R.C., D.E.N., N.L.M., A.A.), University of Edinburgh, UK
| | - Andrew R. Chapman
- BHF Centre for Cardiovascular Science (M.T.H.L., D.D., R.W., D.M.K., C.T., A.V.F., A.B., C.T., K.K.L., A.R.C., D.E.N., N.L.M., A.A.), University of Edinburgh, UK
| | - Anoop S.V. Shah
- Department of Non-communicable Disease, London School of Hygiene and Tropical Medicine, UK (A.S.V.S.)
- Department of Cardiology, Imperial College Healthcare NHS Trust, London, UK (A.S.V.S.)
| | - David E. Newby
- BHF Centre for Cardiovascular Science (M.T.H.L., D.D., R.W., D.M.K., C.T., A.V.F., A.B., C.T., K.K.L., A.R.C., D.E.N., N.L.M., A.A.), University of Edinburgh, UK
| | - Nicholas L. Mills
- BHF Centre for Cardiovascular Science (M.T.H.L., D.D., R.W., D.M.K., C.T., A.V.F., A.B., C.T., K.K.L., A.R.C., D.E.N., N.L.M., A.A.), University of Edinburgh, UK
| | - Atul Anand
- BHF Centre for Cardiovascular Science (M.T.H.L., D.D., R.W., D.M.K., C.T., A.V.F., A.B., C.T., K.K.L., A.R.C., D.E.N., N.L.M., A.A.), University of Edinburgh, UK
- Usher Institute (D.D., N.L.M.), University of Edinburgh, UK
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14
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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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15
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Koechlin L, Boeddinghaus J, Nestelberger T, Lopez-Ayala P, Wussler D, Shrestha S, Resa T, Wildi K, Bakula A, Frey S, Miró Ò, Martin-Sanchez FJ, Strebel I, Gualandro DM, Eckstein FS, Reuthebuch O, Keller DI, Twerenbold R, Giménez MR, Mueller C, Zimmermann T, Reichlin T, Christ M, Puelacher C, de Lavallaz JDF, Potlukova E, Diebold M, Kawecki D, Geigy N, Rentsch K, Mitrovic S, Fuenzalida C, Glarner N, Morawiec B, Munzk P, Breidthardt T, Freese M, López B, Calderón S, Adrada ER, Ganovská E, Parenica J, von Eckardstein A, Campodarve I, Gea J. Performance of the ESC 0/2h-algorithm using high-sensitivity cardiac troponin I in the early diagnosis of myocardial infarction. Am Heart J 2021; 242:132-137. [PMID: 34508692 DOI: 10.1016/j.ahj.2021.08.008] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2021] [Accepted: 08/10/2021] [Indexed: 10/20/2022]
Abstract
The 2020 guidelines of the European Society of Cardiology (ESC) recommend a novel ESC 0/2h-algorithm as the preferred alternative to the ESC 0/1h-algorithm in the early triage for rule-out and/or rule-in of Non-ST-segment-elevation myocardial infarction (NSTEMI). The aim was to prospectively validate the performance of the ESC 0/2h-algorithm using the high-sensitivity cardiac troponin I (hs-cTnI) assay (ARCHITECT) in an international, multicenter diagnostic study enrolling patients presenting with acute chest discomfort to the emergency department.
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16
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Wildi K, Boeddinghaus J, Nestelberger T, Lopez-Ayala P, Yufera Sanchez A, Okamura B, Shrestha S, Rohner J, Miró Ò, Martinez-Nadal G, Martin-Sanchez FJ, Koechlin L, Twerenbold R, Christ M, Kawecki D, Rubini Giménez M, Keller DI, Mueller C, Wussler DI, Strebel A, Bakula S, Frey DM, Gualandro T, Zimmermann C, Puelacher J, du Fay de Lavallaz E, Potlukova M, Diebold N, Geigy K, Rentsch S, Mitrovic C, Fuenzalida N, Glarner BMP, Munzk T, Breidthardt M, Freese B, López S, Calderón ER, Adrada E, Ganovská J, Parenica A, von Eckardstein I, Campodarve J, Gea . 0/2 h-Algorithm for Rapid Triage of Suspected Myocardial Infarction Using a Novel High-Sensitivity Cardiac Troponin I Assay. Clin Chem 2021. [DOI: 10.1093/clinchem/hvab203] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Abstract
Background
We aimed to derive and validate a 0/2 h-algorithm using the new high-sensitivity cardiac troponin I (hs-cTnI)-VITROS assay (VITROS® Immunodiagnostic Products hs-Troponin I Reagent Pack, Ortho Clinical Diagnostics) for rapid rule-out/in of non-ST-segment elevation myocardial infarction (NSTEMI).
Methods
The final diagnosis was centrally adjudicated by 2 independent cardiologists according to the fourth universal definition of myocardial infarction (MI) among 1888 patients presenting to the emergency department with acute chest pain. hs-cTnI-VITROS concentrations were measured at presentation and at 2 h in a blinded fashion. The optimal assay-specific thresholds for the hs-cTnI-VITROS 0/2 h-algorithm were derived in a randomly selected 70% of the cohort and validated in the remaining 30%.
Results
NSTEMI was the final diagnosis in 216/1322 (16.3%) patients of the derivation cohort. Rule-out was defined as baseline hs-cTnI concentrations of <1 ng/L in patients presenting with chest pain onset >3 h or a baseline hs-cTnI concentration of <2 ng/L and an absolute change of <3 ng/L within 2 h. Thresholds for rule-in were either ≥40 ng/L at presentation or an absolute change within 2 h of ≥ 5ng/L. In the derivation cohort, these thresholds ruled-out 50.8% of patients with a negative predictive value (NPV) and sensitivity of 99.7% (95% Confidence Interval (CI), 98.8–99.9%) and 99.1% (95% CI, 96.7–99.9%), and ruled-in 17.9% with a positive predictive value (PPV) of 79.2% (95% CI, 74.3–83.5%). In the validation cohort, NSTEMI was the final diagnosis in 91/566 (16.1%) patients. The derived 0/2 h-algorithm ruled-out 46.3% of patients with a NPV and sensitivity of 100% (95% CI, 95.6–100%) and 100% (95% CI, 96.0–100%), and ruled-in 18.9% with a PPV of 73.8% (95% CI, 66.1–80.3%) in the validation cohort.
Conclusion
hs-cTnI-VITROS concentrations at presentation combined with absolute changes within the first 2 h allowed safe rule-out and accurate rule-in of NSTEMI in two-thirds of unselected patients presenting with acute chest pain to the emergency department.
Trial registration
www.clinicaltrials.gov: NCT0047058
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Affiliation(s)
- Karin Wildi
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT Network
- Critical Care Research Group, The Prince Charles Hospital, Brisbane and University of Queensland, Brisbane, Australia
| | - Jasper Boeddinghaus
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT Network
- Division of Internal Medicine, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Thomas Nestelberger
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT Network
- Division of Cardiology, Vancouver General Hospital, University of British Columbia, Vancouver, BC, Canada
| | - Pedro Lopez-Ayala
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT Network
| | - Ana Yufera Sanchez
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT Network
| | - Bernhard Okamura
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT Network
| | - Samyut Shrestha
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT Network
| | - Jennifer Rohner
- GREAT Network
- Emergency Department, University Hospital Zurich, Zurich, Switzerland
| | - Òscar Miró
- GREAT Network
- Emergency Department, Hospital Clinic, Barcelona, Catalonia, Spain
| | | | | | - Luca Koechlin
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT Network
- Department of Cardiac Surgery, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Raphael Twerenbold
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT Network
- Department of Cardiology and University Center of Cardiovascular Science, University Heart and Vascular Center Hamburg, Hamburg, Germany
| | | | - Damian Kawecki
- 2nd Department of Cardiology, School of Medicine with the Division of Dentistry in Zabrze, Medical University of Katowice, Katowice, Poland
| | - Maria Rubini Giménez
- GREAT Network
- Department of Internal Medicine/Cardiology, Heart Center Leipzig at University of Leipzig, Leipzig, Germany
| | - Dagmar I Keller
- Emergency Department, University Hospital Zurich, Zurich, Switzerland
| | - Christian Mueller
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT Network
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17
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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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18
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Kaier TE, Alaour B, Marber M. Cardiac troponin and defining myocardial infarction. Cardiovasc Res 2021; 117:2203-2215. [PMID: 33458742 PMCID: PMC8404461 DOI: 10.1093/cvr/cvaa331] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Revised: 09/12/2020] [Indexed: 12/19/2022] Open
Abstract
The 4th Universal Definition of Myocardial Infarction has stimulated considerable debate since its publication in 2018. The intention was to define the types of myocardial injury through the lens of their underpinning pathophysiology. In this review, we discuss how the 4th Universal Definition of Myocardial Infarction defines infarction and injury and the necessary pragmatic adjustments that appear in clinical guidelines to maximize triage of real-world patients.
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Affiliation(s)
- Thomas E Kaier
- King’s College London BHF Centre, The Rayne Institute, 4th Floor, Lambeth Wing, St Thomas’ Hospital, Westminster Bridge Road, London SE1 7EH, UK
| | - Bashir Alaour
- King’s College London BHF Centre, The Rayne Institute, 4th Floor, Lambeth Wing, St Thomas’ Hospital, Westminster Bridge Road, London SE1 7EH, UK
| | - Michael Marber
- King’s College London BHF Centre, The Rayne Institute, 4th Floor, Lambeth Wing, St Thomas’ Hospital, Westminster Bridge Road, London SE1 7EH, UK
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19
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Wereski R, Kimenai DM, Taggart C, Doudesis D, Lee KK, Lowry MT, Bularga A, Lowe DJ, Fujisawa T, Apple FS, Collinson PO, Anand A, Chapman AR, Mills NL. Cardiac Troponin Thresholds and Kinetics to Differentiate Myocardial Injury and Myocardial Infarction. Circulation 2021; 144:528-538. [PMID: 34167318 PMCID: PMC8360674 DOI: 10.1161/circulationaha.121.054302] [Citation(s) in RCA: 41] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Accepted: 07/07/2021] [Indexed: 11/16/2022]
Abstract
BACKGROUND Although the 99th percentile is the recommended diagnostic threshold for myocardial infarction, some guidelines also advocate the use of higher troponin thresholds to rule in myocardial infarction at presentation. It is unclear whether the magnitude or change in troponin concentration can differentiate causes of myocardial injury and infarction in practice. METHODS In a secondary analysis of a multicenter randomized controlled trial, we identified 46 092 consecutive patients presenting with suspected acute coronary syndrome without ST-segment-elevation myocardial infarction. High-sensitivity cardiac troponin I concentrations at presentation and on serial testing were compared between patients with myocardial injury and infarction. The positive predictive value and specificity were determined at the sex-specific 99th percentile upper reference limit and rule-in thresholds of 64 ng/L and 5-fold of the upper reference limit for a diagnosis of type 1 myocardial infarction. RESULTS Troponin was above the 99th percentile in 8188 patients (18%). The diagnosis was type 1 or type 2 myocardial infarction in 50% and 14% and acute or chronic myocardial injury in 20% and 16%, respectively. Troponin concentrations were similar at presentation in type 1 (median [25th-75th percentile] 91 [30-493] ng/L) and type 2 (50 [22-147] ng/L) myocardial infarction and in acute (50 [26-134] ng/L) and chronic (51 [31-130] ng/L) myocardial injury. The 99th percentile and rule-in thresholds of 64 ng/L and 5-fold upper reference limit gave a positive predictive value of 57% (95% CI, 56%-58%), 59% (58%-61%), and 62% (60%-64%) and a specificity of 96% (96%-96%), 96% (96%-96%), and 98% (97%-98%), respectively. The absolute, relative, and rate of change in troponin concentration were highest in patients with type 1 myocardial infarction (P<0.001 for all). Discrimination improved when troponin concentration and change in troponin were combined compared with troponin concentration at presentation alone (area under the curve, 0.661 [0.642-0.680] versus 0.613 [0.594-0.633]). CONCLUSIONS Although we observed important differences in the kinetics, cardiac troponin concentrations at presentation are insufficient to distinguish type 1 myocardial infarction from other causes of myocardial injury or infarction in practice and should not guide management decisions in isolation. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT01852123.
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Affiliation(s)
- Ryan Wereski
- British Heart Foundation Centre for Cardiovascular Science (R.W., C.T., D.D., K.K.L., M.T.H.L., A.B., T.F., A.A., A.R.C., N.L.M.), University of Edinburgh, UK
| | | | - Caelan Taggart
- British Heart Foundation Centre for Cardiovascular Science (R.W., C.T., D.D., K.K.L., M.T.H.L., A.B., T.F., A.A., A.R.C., N.L.M.), University of Edinburgh, UK
| | - Dimitrios Doudesis
- British Heart Foundation Centre for Cardiovascular Science (R.W., C.T., D.D., K.K.L., M.T.H.L., A.B., T.F., A.A., A.R.C., N.L.M.), University of Edinburgh, UK
- Usher Institute (D.M.K., D.D., N.L.M.), University of Edinburgh, UK
| | - Kuan Ken Lee
- British Heart Foundation Centre for Cardiovascular Science (R.W., C.T., D.D., K.K.L., M.T.H.L., A.B., T.F., A.A., A.R.C., N.L.M.), University of Edinburgh, UK
| | - Matthew T.H. Lowry
- British Heart Foundation Centre for Cardiovascular Science (R.W., C.T., D.D., K.K.L., M.T.H.L., A.B., T.F., A.A., A.R.C., N.L.M.), University of Edinburgh, UK
| | - Anda Bularga
- British Heart Foundation Centre for Cardiovascular Science (R.W., C.T., D.D., K.K.L., M.T.H.L., A.B., T.F., A.A., A.R.C., N.L.M.), University of Edinburgh, UK
| | - David J. Lowe
- University of Glasgow, School of Medicine, UK (D.J.L.)
| | - Takeshi Fujisawa
- British Heart Foundation Centre for Cardiovascular Science (R.W., C.T., D.D., K.K.L., M.T.H.L., A.B., T.F., A.A., A.R.C., N.L.M.), University of Edinburgh, UK
| | - Fred S. Apple
- Department of Laboratory Medicine and Pathology, Hennepin Healthcare/Hennepin County Medical Center and University of Minnesota, Minneapolis (F.S.A.)
| | - Paul O. Collinson
- Department of Clinical Blood Sciences and Cardiology, St. George’s University of London, UK (P.O.C.)
| | - Atul Anand
- British Heart Foundation Centre for Cardiovascular Science (R.W., C.T., D.D., K.K.L., M.T.H.L., A.B., T.F., A.A., A.R.C., N.L.M.), University of Edinburgh, UK
| | - Andrew R. Chapman
- British Heart Foundation Centre for Cardiovascular Science (R.W., C.T., D.D., K.K.L., M.T.H.L., A.B., T.F., A.A., A.R.C., N.L.M.), University of Edinburgh, UK
| | - Nicholas L. Mills
- British Heart Foundation Centre for Cardiovascular Science (R.W., C.T., D.D., K.K.L., M.T.H.L., A.B., T.F., A.A., A.R.C., N.L.M.), University of Edinburgh, UK
- Usher Institute (D.M.K., D.D., N.L.M.), University of Edinburgh, UK
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20
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Prospective comparative evaluation of the European Society of Cardiology (ESC) 1-hour and a 2-hour rapid diagnostic algorithm for myocardial infarction using high-sensitivity troponin-T. CAN J EMERG MED 2021; 22:712-720. [PMID: 32624061 DOI: 10.1017/cem.2020.349] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
OBJECTIVE Both 1- and 2-hour rapid diagnostic algorithms using high-sensitivity troponin (hs-cTn) have been validated to diagnose acute myocardial infarction (MI), leaving physicians uncertain which algorithm is preferable. The objective of this study was to prospectively evaluate the diagnostic performance of 1- and 2-hour algorithms in clinical practice in a Canadian emergency department (ED). METHODS ED patients with chest pain had high-sensitivity cardiac troponin-T (hs-cTnT) collected on presentation and 1- and 2-hours later at a single academic centre over a 2-year period. The primary outcome was index MI, and the secondary outcome was 30-day major adverse cardiac events (MACE). All outcomes were adjudicated. RESULTS We enrolled 608 patients undergoing serial hs-cTnT sampling. Of these, 350 had a valid 1-hour and 550 had a 2-hour hs-cTnT sample. Index MI and 30-day MACE prevalence was ~12% and 14%. Sensitivity of the 1- and 2-hour algorithms was similar for index MI 97.3% (95% CI: 85.8-99.9%) and 100% (95% CI: 91.6-100%) and 30-day MACE: 80.9% (95% CI: 66.7-90.9%) and 83.3% (95% CI: 73.2-90.8%), respectively. Both algorithms accurately identified about 10% of patients as high risk. CONCLUSIONS Both algorithms were able to classify almost two-thirds of patients as low risk, effectively ruling out MI and conferring a low risk of 30-day MACE for this group, while reliably identifying high-risk patients. While both algorithms had equivalent diagnostic performance, the 2-hour algorithm offers several practical advantages, which may make it preferable to implement. Broad implementation of similar algorithms across Canada can expedite patient disposition and lead to resource savings.
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21
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Lopez-Ayala P, Boeddinghaus J, Koechlin L, Nestelberger T, Mueller C. Early Rule-Out Strategies in the Emergency Department Utilizing High-Sensitivity Cardiac Troponin Assays. Clin Chem 2021; 67:114-123. [PMID: 33279982 DOI: 10.1093/clinchem/hvaa226] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Accepted: 09/09/2020] [Indexed: 11/14/2022]
Abstract
BACKGROUND Over the past decade, intense collaboration between academic investigators and the diagnostic industry have allowed the integration of high-sensitivity cardiac troponin (hs-cTn) assays into clinical practice worldwide. The hs-cTn assays, with their increased diagnostic accuracy for acute myocardial infarction (AMI), have facilitated the maturation of early rule-out strategies. The first iteration was complex and required the combination of a biomarker panel, the electrocardiogram, and a clinical risk score and allowed the safe rule-out of AMI in only 10% of patients with acute chest pain. In contrast, the latest iterations, including the European Society of Cardiology (ESC) 0/1-h algorithm, are simple. They are based on hs-cTn concentrations only and allow the safe rule-out or rule-in of AMI in up to 75% of patients. CONTENT The purposes of this minireview are (a) to describe the best validated hs-cTn-based strategies for early rule-out of AMI, (b) to discuss the advantages and limitations of the different strategies, (c) to identify patient subgroups requiring particular attention, (d) to recognize challenges for widespread clinical implementation, and (e) to provide guidance on strategies for their safe and effective clinical implementation. SUMMARY Physicians and institutions may choose among several well-validated rule-out algorithms. The ESC 0/1-h algorithm for hs-cTnT or hs-cTnI seems to be the most attractive option today. It best balances safety and efficacy, and it has been derived and validated for all currently available hs-cTnT/I assays, facilitating widespread clinical implementation.
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Affiliation(s)
- Pedro Lopez-Ayala
- Department of Cardiology, Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Switzerland.,GREAT Network, Rome, Italy
| | - Jasper Boeddinghaus
- Department of Cardiology, Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Switzerland.,GREAT Network, Rome, Italy
| | - Luca Koechlin
- Department of Cardiology, Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Switzerland.,GREAT Network, Rome, Italy.,Department of Cardiac Surgery, University Hospital Basel, Switzerland
| | - Thomas Nestelberger
- Department of Cardiology, Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Switzerland.,GREAT Network, Rome, Italy.,Division of Cardiology, Vancouver General Hospital, University of British Columbia, Vancouver, BC, Canada
| | - Christian Mueller
- Department of Cardiology, Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Switzerland.,GREAT Network, Rome, Italy
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22
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Chaulin A. Cardiac Troponins: Contemporary Biological Data and New Methods of Determination. Vasc Health Risk Manag 2021; 17:299-316. [PMID: 34113117 PMCID: PMC8184290 DOI: 10.2147/vhrm.s300002] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Accepted: 04/21/2021] [Indexed: 12/19/2022] Open
Abstract
Laboratory diagnosis plays one of the key roles in the diagnosis of many diseases, including cardiovascular diseases (CVD). The methods underlying the in vitro study of many CVD biomarkers, including cardiac troponins (cTnI and cTnT), are imperfect and are continually being improved to enhance their analytical performance, with sensitivity and specificity being the most important. Recently developed improved cTnI and cTnT detection methods, referred to as highly sensitive methods (hs-cTnI, hs-cTnT), have changed many of our ideas about the biology of cardiac troponins and opened up a number of additional diagnostic capabilities for practical healthcare. This article systematizes some relevant data on the biology of cardiac troponins as well as on methods for determining cTnI and cTnT with an analysis of the diagnostic value of their analytical characteristics (limit of blank, limit of detection, 99th percentile, coefficient of variation, and others). Data on extracardiac expression of cTnI and cTnT, mechanisms of formation and potential clinical significance of gender, age, and circadian characteristics of hs-cTnI and hs-cTnT content in serum are discussed. Considerable attention is paid to the discussion of new diagnostic capabilities of hs-cTnI, hs-cTnT, including consideration of promising possibilities for their study in biological fluids that can be obtained by non-invasive methods. Also, some possibilities of using hs-cTnI and hs-cTnT as prognostic laboratory biomarkers in healthy people (for example, to assess the risk of developing CVD) and in patients suffering from a number of pathological conditions that cause damage to cardiomyocytes are examined, and the potential mechanisms underlying the increase in hs-cTnI and hs-cTnT are discussed.
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Affiliation(s)
- Aleksey Chaulin
- Department of Cardiology and Cardiovascular Surgery, Samara State Medical University, Samara, 443099, Russia.,Department of Histology and Embryology, Samara State Medical University, Samara, 443099, Russia
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23
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Rubini Giménez M, Wildi K, Wussler D, Koechlin L, Boeddinghaus J, Nestelberger T, Badertscher P, Sedlmayer R, Puelacher C, Zimmermann T, du Fay de Lavallaz J, Lopez-Ayala P, Leu K, Rentsch K, Miró Ò, López B, Martín-Sánchez FJ, Bustamante J, Kawecki D, Parenica J, Lohrmann J, Kloos W, Buser A, Keller DI, Reichlin T, Twerenbold R, Mueller C. Cinética temprana de troponina en pacientes con sospecha de infarto agudo de miocardio. Rev Esp Cardiol (Engl Ed) 2021. [DOI: 10.1016/j.recesp.2020.04.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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24
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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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25
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Ratmann PD, Boeddinghaus J, Nestelberger T, Lopez-Ayala P, Koechlin L, Wildi K, Miro O, Martín-Sánchez FJ, Christ M, Twerenbold R, Rubini Gimenez M, Keller DI, Mueller C. External Validation of the No Objective Testing Rules in Acute Chest Pain. J Am Heart Assoc 2021; 10:e020031. [PMID: 33977760 PMCID: PMC8200689 DOI: 10.1161/jaha.120.020031] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Paul David Ratmann
- Department of Cardiology and Cardiovascular Research Institute Basel University Hospital BaselUniversity of Basel Switzerland.,GREAT Network Rome Italy
| | - Jasper Boeddinghaus
- Department of Cardiology and Cardiovascular Research Institute Basel University Hospital BaselUniversity of Basel Switzerland.,GREAT Network Rome Italy
| | - Thomas Nestelberger
- Department of Cardiology and Cardiovascular Research Institute Basel University Hospital BaselUniversity of Basel Switzerland.,GREAT Network Rome Italy
| | - Pedro Lopez-Ayala
- Department of Cardiology and Cardiovascular Research Institute Basel University Hospital BaselUniversity of Basel Switzerland.,GREAT Network Rome Italy
| | - Luca Koechlin
- Department of Cardiology and Cardiovascular Research Institute Basel University Hospital BaselUniversity of Basel Switzerland.,GREAT Network Rome Italy.,Department of Cardiac Surgery University Hospital BaselUniversity of Basel Switzerland
| | - Karin Wildi
- Department of Cardiology and Cardiovascular Research Institute Basel University Hospital BaselUniversity of Basel Switzerland.,GREAT Network Rome Italy.,Critical Care Research Group The Prince Charles Hospital Brisbane Australia.,University of Queensland Brisbane Australia
| | - Oscar Miro
- Department of Cardiology and Cardiovascular Research Institute Basel University Hospital BaselUniversity of Basel Switzerland.,GREAT Network Rome Italy.,Emergency Department Hospital Clinic Barcelona, Catalonia Spain
| | - F Javier Martín-Sánchez
- Department of Cardiology and Cardiovascular Research Institute Basel University Hospital BaselUniversity of Basel Switzerland.,GREAT Network Rome Italy.,Emergency Department Hospital Clínico San Carlos Madrid Spain
| | - Michael Christ
- Department of Emergency Medicine Luzerner Kantonsspital Luzern Switzerland
| | - Raphael Twerenbold
- Department of Cardiology and Cardiovascular Research Institute Basel University Hospital BaselUniversity of Basel Switzerland.,GREAT Network Rome Italy
| | - Maria Rubini Gimenez
- Department of Cardiology and Cardiovascular Research Institute Basel University Hospital BaselUniversity of Basel Switzerland.,Cardiology Department Heart Center Leipzig Leipzig Germany
| | - Dagmar I Keller
- Emergency Department University Hospital Zurich Zurich Switzerland
| | - Christian Mueller
- Department of Cardiology and Cardiovascular Research Institute Basel University Hospital BaselUniversity of Basel Switzerland.,GREAT Network Rome Italy
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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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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: 2700] [Impact Index Per Article: 900.0] [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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Karády J, Mayrhofer T, Ferencik M, Nagurney JT, Udelson JE, Kammerlander AA, Fleg JL, Peacock WF, Januzzi JL, Koenig W, Hoffmann U. Discordance of High-Sensitivity Troponin Assays in Patients With Suspected Acute Coronary Syndromes. J Am Coll Cardiol 2021; 77:1487-1499. [PMID: 33766254 PMCID: PMC8040768 DOI: 10.1016/j.jacc.2021.01.046] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Accepted: 01/20/2021] [Indexed: 01/17/2023]
Abstract
BACKGROUND High-sensitivity cardiac troponin (hs-cTn) assays have different analytic characteristics. OBJECTIVES The goal of this study was to quantify differences between assays for common analytical benchmarks and to determine whether they may result in differences in the management of patients with suspected acute coronary syndrome (ACS). METHODS The authors included patients with suspected ACS enrolled in the ROMICAT (Rule Out Myocardial Infarction/Ischemia Using Computer Assisted Tomography) I and II trials, with blood samples taken at emergency department presentation (ROMICAT-I and -II) or at 2 and 4 h thereafter (ROMICAT-II). hs-cTn concentrations were measured using 3 assays (Roche Diagnostics, Elecsys 2010 platform; Abbott Diagnostics, ARCHITECT i2000SR; Siemens Diagnostics, HsVista). Per blood sample, we determined concordance across analytic benchmarks (99th percentile). Per-patient, the authors determined concordance of management recommendations (rule-out/observe/rule-in) per the 0/2-h algorithm, and their association with diagnostic test findings (coronary artery stenosis >50% on coronary computed tomography angiography or inducible ischemia on perfusion imaging) and ACS. RESULTS Among 1,027 samples from 624 patients (52.8 ± 10.0 years; 39.4% women), samples were classified as 99th percentile (7.2% vs. 6.0% vs. 6.2%) by Roche, Abbott, and Siemens, respectively. A total of 37.4% (n = 384 of 1,027) of blood samples were classified into the same analytical benchmark category, with low concordance across benchmarks (99th percentile 43.6%). Serial samples were available in 242 patients (40.1% women; mean age: 52.8 ± 8.0 years). The concordance of management recommendations across assays was 74.8% (n = 181 of 242) considering serial hs-cTn measurements. Of patients who were recommended to discharge, 19.6% to 21.1% had positive diagnostic test findings and 2.8% to 4.3% had ACS at presentation. CONCLUSIONS Caregivers should be aware that there are significant differences between hs-cTn assays in stratifying individual samples and patients with intermediate likelihood of ACS according to analytical benchmarks that may result in different management recommendations. (Rule Out Myocardial Infarction by Computer Assisted Tomography [ROMICAT]; NCT00990262) (Multicenter Study to Rule Out Myocardial Infarction by Cardiac Computed Tomography [ROMICAT-II]; NCT01084239).
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Affiliation(s)
- Júlia Karády
- Cardiovascular Imaging Research Center, Massachusetts General Hospital-Harvard Medical School, Boston, Massachusetts, USA; MTA-SE Cardiovascular Imaging Research Group, Heart and Vascular Center, Semmelweis University, Budapest, Hungary.
| | - Thomas Mayrhofer
- Cardiovascular Imaging Research Center, Massachusetts General Hospital-Harvard Medical School, Boston, Massachusetts, USA; School of Business Studies, Stralsund University of Applied Sciences, Stralsund, Germany
| | - Maros Ferencik
- Cardiovascular Imaging Research Center, Massachusetts General Hospital-Harvard Medical School, Boston, Massachusetts, USA; Knight Cardiovascular Institute, Oregon Health & Science University, Portland, Oregon, USA
| | - John T Nagurney
- Department of Emergency Medicine, Massachusetts General Hospital & Harvard Medical School, Boston, Massachusetts, USA
| | - James E Udelson
- Department of Medicine, Tufts Medical Center, Boston, Massachusetts, USA
| | - Andreas A Kammerlander
- Cardiovascular Imaging Research Center, Massachusetts General Hospital-Harvard Medical School, Boston, Massachusetts, USA; Division of Cardiology, Medical University of Vienna, Vienna, Austria
| | - Jerome L Fleg
- Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, Bethesda, Maryland, USA
| | - W Frank Peacock
- Department of Emergency Medicine, Baylor College of Medicine, Boston, Massachusetts, USA
| | - James L Januzzi
- Division of Cardiology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Wolfgang Koenig
- Institute of Epidemiology and Medical Biometry, University of Ulm, Ulm, Germany; Deutsches Herzzentrum München, Technische Universität München, Munich, Germany; DZHK (German Centre for Cardiovascular Research), partner site Munich Heart Alliance, Munich, Germany
| | - Udo Hoffmann
- Cardiovascular Imaging Research Center, Massachusetts General Hospital-Harvard Medical School, Boston, Massachusetts, USA
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Perrone MA, Storti S, Salvadori S, Pecori A, Bernardini S, Romeo F, Guccione P, Clerico A. Cardiac troponins: are there any differences between T and I? J Cardiovasc Med (Hagerstown) 2021; 22:797-805. [PMID: 33399346 DOI: 10.2459/jcm.0000000000001155] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The most recent international guidelines recommend the measurement of cardiac troponin I (cTnI) and cardiac troponin T (cTnT) using high-sensitivity methods (hs-cTn) for the detection of myocardial injury and the differential diagnosis of acute coronary syndromes. Myocardial injury is a prerequisite for the diagnosis of acute myocardial infarction, but also a distinct entity. The 2018 Fourth Universal Definition of Myocardial Infarction states that myocardial injury is detected when at least one value above the 99th percentile upper reference limit is measured in a patient with high-sensitivity methods for cTnI or cTnT. Not infrequently, increased hs-cTnT levels are reported in patients with congenital or chronic neuromuscular diseases, while the hs-cTnI values are often in the normal range. Furthermore, some discrepancies between the results of laboratory tests for the two troponins are occasionally found in individuals apparently free of cardiac diseases, and also in patients with cardiac diseases. In this review article, authors discuss the biochemical, pathophysiological and analytical mechanisms which may cause discrepancies between hs-cTnI and hs-cTnT test results.
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Affiliation(s)
- Marco A Perrone
- Department of Pediatric Cardiology and Cardiac Surgery, Bambino Gesù Children's Hospital IRCCS Division of Cardiology, University of Rome Tor Vergata, Rome CNR-Regione Toscana G. Monasterio Foundation, Heart Hospital, Massa, and Scuola Superiore Sant'Anna CNR Institute of Clinical Physiology, Pisa Division of Clinical Biochemistry and Clinical Molecular Biology, University of Rome Tor Vergata, Rome, Italy
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Guedeney P, Collet JP. Diagnosis and Management of Acute Coronary Syndrome: What is New and Why? Insight From the 2020 European Society of Cardiology Guidelines. J Clin Med 2020; 9:E3474. [PMID: 33126578 PMCID: PMC7692678 DOI: 10.3390/jcm9113474] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2020] [Revised: 10/25/2020] [Accepted: 10/26/2020] [Indexed: 12/14/2022] Open
Abstract
The management of acute coronary syndrome (ACS) has been at the center of an impressive amount of research leading to a significant improvement in outcomes over the last 50 years. The 2020 European Society of Cardiology (ESC) Guidelines for the management of patients presenting without persistent ST-segment elevation myocardial infarction have incorporated the most recent breakthroughs and updates from large randomized controlled trials (RCT) on the diagnosis and management of this disease. The purpose of the present review is to describe the main novelties and the rationale behind these recommendations. Hence, we describe the accumulating evidence against P2Y12 receptors inhibitors pretreatment prior to coronary angiography, the preference for prasugrel as leading P2Y12 inhibitors in the setting of ACS, and the numerous available antithrombotic regimens based on various durations of dual or triple antithrombotic therapy, according to the patient ischemic and bleeding risk profiles. We also detail the recently implemented 0 h/1 h and 0 h/2 h rule in, rule out algorithms and the growing role of computed coronary tomography angiography to rule out ACS in patients at low-to-moderate risk.
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Affiliation(s)
| | - Jean-Philippe Collet
- Institut de Cardiologie, Sorbonne Université, ACTION Study Group, INSERM UMRS_1166, Hôpital Pitié-Salpêtrière (Assistance Publique-Hôpitaux de Paris), 75013 Paris, France;
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31
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Gu W, Tang W, Zhang Z, Xu M, Wu J. Two different troponin isoforms for detecting early myocardial injury after curative resection of oesophageal cancer. J Cardiothorac Surg 2020; 15:189. [PMID: 32711546 PMCID: PMC7382821 DOI: 10.1186/s13019-020-01225-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2020] [Accepted: 07/13/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The objective of this study was to explore the consistency and correlation of two troponin (cTn) subtypes, troponin I (cTnI) and high-sensitivity troponin T (hs-cTnT), which can be used to judge early myocardial injury after curative resection of oesophageal cancer. METHODS This study is a secondary analysis of data obtained from a previous randomized controlled trial on postoperative myocardial injury in 70 patients undergoing elective curative resection of oesophageal cancer who were randomly assigned to undergo aggressive body temperature management (nasopharyngeal temperature 36.61 ± 0.18 °C) or standard body temperature management (35.80 ± 0.18 °C, n = 35 in each arm). The serum cTnI and hs-cTnT levels were measured in each patient at the 4 time points: before the operation and 6 h ~ 12 h, 24 h and 48 h after the operation. The diagnostic criteria of myocardial injury followed the third edition ESC/ACCF definition of myocardial infarction. The primary outcomes included the following: (1) the incidence of myocardial injury and the relationship between hs-cTnT and cTn and (2) the consistency and correlation of the two cTn subtypes. RESULTS A total of 280 pairs of cTn samples were tested. The incidence of postoperative day 2 myocardial injury was 8.6% (3/35) among patients receiving aggressive body temperature management and 31.4% (11/35) among patients receiving standard body temperature management (P < 0.05). Among 3 patients who experienced myocardial injury in the aggressive body temperature management group, 2 met the diagnostic criteria for cTnI and hs-cTnT and only 1 met the diagnostic criteria for hs-cTnT. Among the 11 patients who experienced myocardial injury in the standard body temperature management group, 7 met the diagnostic criteria for cTnI and hs-cTnT and only 3 met the diagnostic criteria for hs-cTnT; only 1 met the diagnostic criteria for cTnI. The bias of cTnI and hs-cTnT was - 8.82 ± 31.91 ng/L. The consistency limit was - 71.37 ~ 53.73 ng/L. The proportion within the scope of the consistency of its corresponding boundary was 98.57%. The correlation coefficient of cTnI and hs-cTnT was 0.845 (P < 0.05). CONCLUSIONS In the evaluation of postoperative myocardial injury in patients undergoing curative resection of oesophageal cancer, cTnI and hs-cTnT exhibit high consistency and a good correlation. The combination of cTnI and hs-cTnT can improve the detection rate of myocardial injury, thus providing a better reference than a single measure alone for reducing the risk of perioperative myocardial injury in patients. TRIAL REGISTRATION ChiCTR-INR-17011621 . Registered June 10, 2017.
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Affiliation(s)
- Wei Gu
- Department of Anaesthesiology, Shanghai Chest Hospital, Shanghai Jiao Tong University, No. 241 Huaihai Rd. West, Shanghai, China
| | - Wei Tang
- Department of Anaesthesiology, Shanghai Chest Hospital, Shanghai Jiao Tong University, No. 241 Huaihai Rd. West, Shanghai, China
| | - Zuojing Zhang
- Department of Anaesthesiology, Shanghai Chest Hospital, Shanghai Jiao Tong University, No. 241 Huaihai Rd. West, Shanghai, China
| | - Meiying Xu
- Department of Anaesthesiology, Shanghai Chest Hospital, Shanghai Jiao Tong University, No. 241 Huaihai Rd. West, Shanghai, China
| | - Jingxiang Wu
- Department of Anaesthesiology, Shanghai Chest Hospital, Shanghai Jiao Tong University, No. 241 Huaihai Rd. West, Shanghai, China.
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Christenson RH, Duh SH, Mullins KE, LeClair MM, Grigorov IL, Peacock WF. Analytical and clinical characterization of a novel high-sensitivity cardiac troponin assay in a United States population. Clin Biochem 2020; 83:28-36. [PMID: 32485169 DOI: 10.1016/j.clinbiochem.2020.05.014] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2020] [Revised: 05/13/2020] [Accepted: 05/26/2020] [Indexed: 11/15/2022]
Abstract
BACKGROUND Cardiac troponin (cTn) is the keystone for diagnosis of acute myocardial infarction (AMI). We examined the analytical and clinical diagnostic characteristics of the ACCESS hsTnI assay in a United States (US) population. METHODS All measurements and studies were conducted using a lithium heparin matrix. Sex-specific 99th percentile upper reference limits (URLs) were determined for 1089 healthy women (54.6%) and men using non-parametric statistics. High-sensitivity (hs) performance was assessed to determine if the total CV was ≤10% at sex-specific URLs, and if ≥50% of cTnI values for each sex exceeded the assay's limit of detection (LoD). Precision, analytical measurement range, high-dose hook effect, and endogenous/exogenous interferences were examined with CLSI guidance. Clinical characterization included serial sampling of 1854 suspected AMI subjects presenting to 14 US Emergency Departments. AMI was adjudicated by a panel of expert cardiologists. The study's only exclusion was end stage renal disease. RESULTS 99th percentile URLs were 11.6-, 19.8- and 17.5-ng/L for respective female, male and all-subject populations. Total %CV was <8% from 6.8 to 19,000 ng/L, and <6% at sex-specific 99th percentiles; ≥99% of ACCESS hsTnI values for each sex exceeded the LoD. No high-dose hook effect or endogenous/exogenous interferences were identified. A comparison of Baseline samples collected at ≤1 h and any-time after presentation, found 4% lower sensitivity for AMI than with earlier sampling. For 1-9 h post presentation, the sensitivity was >90%, specificity >85%; and negative and positive predictive value were ≥99% and >60%, respectively. CONCLUSION Analytical and clinical performance of the ACCESS hsTnI assay meets the definition of a hs cTn method. The ACCESS hsTnI assay has good precision over a wide range, no significant interferences, and sensitivity >90% and NPV ≥99%. Performance is appropriate for aiding in AMI diagnosis.
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Affiliation(s)
- Robert H Christenson
- Department of Pathology, University of Maryland School of Medicine, Baltimore, MD, United States.
| | - Show-Hong Duh
- Department of Pathology, University of Maryland School of Medicine, Baltimore, MD, United States
| | - Kristin E Mullins
- Department of Pathology, University of Maryland School of Medicine, Baltimore, MD, United States
| | - Margot M LeClair
- Beckman Coulter Inc., 1000 Lake Hazeltine Dr, Chaska, MN, United States
| | - Ilya L Grigorov
- Beckman Coulter Inc., 1000 Lake Hazeltine Dr, Chaska, MN, United States
| | - W Frank Peacock
- Department of Emergency Medicine, Baylor College of Medicine, Houston, TX, United States
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Rubini Giménez M, Wildi K, Wussler D, Koechlin L, Boeddinghaus J, Nestelberger T, Badertscher P, Sedlmayer R, Puelacher C, Zimmermann T, du Fay de Lavallaz J, Lopez-Ayala P, Leu K, Rentsch K, Miró Ò, López B, Martín-Sánchez FJ, Bustamante J, Kawecki D, Parenica J, Lohrmann J, Kloos W, Buser A, Keller DI, Reichlin T, Twerenbold R, Mueller C. Early kinetics of cardiac troponin in suspected acute myocardial infarction. ACTA ACUST UNITED AC 2020; 74:502-509. [PMID: 32451223 DOI: 10.1016/j.rec.2020.04.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2019] [Accepted: 04/02/2020] [Indexed: 01/22/2023]
Abstract
INTRODUCTION AND OBJECTIVES Release kinetics of high-sensitivity cardiac troponin (hs-cTn) T and I in patients with acute myocardial infarction (AMI) are incompletely understood. We aimed to assess whether hs-cTnT/I release in early AMI is near linear. METHODS In a prospective diagnostic multicenter study the acute release of hs-cTnT and hs-cTnI within 1 and 2hours from presentation to the emergency department was quantified using 3 hs-cTnT/I assays in patients with suspected AMI. The primary endpoint was correlation between hs-cTn changes from presentation to 1 hour vs changes from presentation to 2hours, among all AMI patients and different prespecified subgroups. The final diagnosis was adjudicated by 2 independent cardiologists, based on serial hs-cTnT from the serial study blood samples and additional locally measured hs-cTn values. RESULTS Among 2437 patients with complete hs-cTnT data, AMI was the adjudicated diagnosis in 376 patients (15%). For hs-cTnT, the correlation coefficient between 0- to 1-hour change and 0- to 2 hour change was 0.931 (95%CI, 0.916-0.944), P <.001. Similar findings were obtained with hs-cTnI (Architect) with correlation coefficients between 0- to 1-hour change and 0- to 2 hour change of 0.969 and hs-cTnI (Centaur) of 0.934 (P <.001 for both). Findings were consistent among type 1 and type 2 AMI and in the subgroup of patients presenting very early after chest pain onset. CONCLUSIONS Patients presenting with early AMI showed a near linear release of hs-cTnT and hs-cTnI. This near linearity provides the pathophysiological basis for rapid diagnostic algorithms using 0- to 1-hour changes as surrogates for 0- to 2 hour or 0- to 3 hour changes. Registered at ClinicalTrials.gov (Identifier: NCT00470587).
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Affiliation(s)
- María Rubini Giménez
- Department of Cardiology and Cardiovascular Research, Institute Basel (CRIB), University Hospital Basel, Basel, Switzerland; Department of Cardiology, Heart Center Leipzig, Leipzig, Germany
| | - Karin Wildi
- Department of Cardiology and Cardiovascular Research, Institute Basel (CRIB), University Hospital Basel, Basel, Switzerland; Critical Care Research Institute, the Prince Charles Hospital, Brisbane and University of Queensland, Brisbane, Australia
| | - Desiree Wussler
- Department of Cardiology and Cardiovascular Research, Institute Basel (CRIB), University Hospital Basel, Basel, Switzerland; Department of Internal Medicine, University Hospital Basel, Basel, Switzerland
| | - Luca Koechlin
- Department of Cardiology and Cardiovascular Research, Institute Basel (CRIB), University Hospital Basel, Basel, Switzerland; Department of Heart Surgery, University Hospital Basel, Basel, Switzerland
| | - Jasper Boeddinghaus
- Department of Cardiology and Cardiovascular Research, Institute Basel (CRIB), University Hospital Basel, Basel, Switzerland; Department of Internal Medicine, University Hospital Basel, Basel, Switzerland
| | - Thomas Nestelberger
- Department of Cardiology and Cardiovascular Research, Institute Basel (CRIB), University Hospital Basel, Basel, Switzerland
| | - Patrick Badertscher
- Department of Cardiology and Cardiovascular Research, Institute Basel (CRIB), University Hospital Basel, Basel, Switzerland; Department of Cardiology, University of Illinois at Chicago, Chicago, United States
| | - Raphael Sedlmayer
- Department of Cardiology and Cardiovascular Research, Institute Basel (CRIB), University Hospital Basel, Basel, Switzerland
| | - Christian Puelacher
- Department of Cardiology and Cardiovascular Research, Institute Basel (CRIB), University Hospital Basel, Basel, Switzerland; Department of Internal Medicine, University Hospital Basel, Basel, Switzerland
| | - Tobias Zimmermann
- Department of Cardiology and Cardiovascular Research, Institute Basel (CRIB), University Hospital Basel, Basel, Switzerland
| | - Jeanne du Fay de Lavallaz
- Department of Cardiology and Cardiovascular Research, Institute Basel (CRIB), University Hospital Basel, Basel, Switzerland; Department of Internal Medicine, University Hospital Basel, Basel, Switzerland
| | - Pedro Lopez-Ayala
- Department of Cardiology and Cardiovascular Research, Institute Basel (CRIB), University Hospital Basel, Basel, Switzerland; Department of Internal Medicine, University Hospital Basel, Basel, Switzerland
| | - Kathrin Leu
- Department of Cardiology and Cardiovascular Research, Institute Basel (CRIB), University Hospital Basel, Basel, Switzerland
| | | | - Òscar Miró
- Servicio de Urgencias, Hospital Clínic, Barcelona, Spain
| | - Beatriz López
- Servicio de Urgencias, Hospital Clínic, Barcelona, Spain
| | | | - José Bustamante
- Servicio de Urgencias, Hospital Clínico San Carlos, Madrid, Spain
| | - Damian Kawecki
- 2nd Department of Cardiology, Medical University of Silesia, Zabrze, Poland
| | - Jiri Parenica
- Department of Cardiology, University Hospital Brno, Brno, Czech Republic and Medical Faculty, Masaryk University, Brno, Czech Republic
| | - Jens Lohrmann
- Department of Cardiology and Cardiovascular Research, Institute Basel (CRIB), University Hospital Basel, Basel, Switzerland; Emergency Department, University Hospital Basel, Basel, Switzerland
| | - Wanda Kloos
- Department of Cardiology and Cardiovascular Research, Institute Basel (CRIB), University Hospital Basel, Basel, Switzerland; Emergency Department, University Hospital Basel, Basel, Switzerland
| | - Andreas Buser
- Blood Transfusion Centre, Swiss Red Cross, Basel, Switzerland and Department of Hematology, University Hospital Basel, Basel, Switzerland
| | - Dagmar I Keller
- Emergency Department, University Hospital Zurich, Zurich, Switzerland
| | - Tobias Reichlin
- Department of Cardiology and Cardiovascular Research, Institute Basel (CRIB), University Hospital Basel, Basel, Switzerland; Department of Department, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Raphael Twerenbold
- Department of Cardiology and Cardiovascular Research, Institute Basel (CRIB), University Hospital Basel, Basel, Switzerland
| | - Christian Mueller
- Department of Cardiology and Cardiovascular Research, Institute Basel (CRIB), University Hospital Basel, Basel, Switzerland.
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Xu W, Wang L, Zhang R, Sun X, Huang L, Su H, Wei X, Chen CC, Lou J, Dai H, Qian K. Diagnosis and prognosis of myocardial infarction on a plasmonic chip. Nat Commun 2020; 11:1654. [PMID: 32245966 PMCID: PMC7125217 DOI: 10.1038/s41467-020-15487-3] [Citation(s) in RCA: 74] [Impact Index Per Article: 18.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2018] [Accepted: 03/13/2020] [Indexed: 01/06/2023] Open
Abstract
Cardiovascular diseases lead to 31.5% of deaths globally, and particularly myocardial infarction (MI) results in 7.4 million deaths per year. Diagnosis of MI and monitoring for prognostic use are critical for clinical management and biomedical research, which require advanced tools with accuracy and speed. Herein, we developed a plasmonic gold nano-island (pGold) chip assay for diagnosis and monitoring of MI. On-chip microarray analysis of serum biomarkers (e.g., cardiac troponin I) afforded up to 130-fold enhancement of near-infrared fluorescence for ultra-sensitive and quantitative detection within controlled periods, using 10 μL of serum only. The pGold chip assay achieved MI diagnostic sensitivity of 100% and specificity of 95.54%, superior to the standard chemiluminescence immunoassay in cardiovascular clinics. Further, we monitored biomarker concentrations regarding percutaneous coronary intervention for prognostic purpose. Our work demonstrated a designed approach using plasmonic materials for enhanced diagnosis and monitoring for prognostic use towards point-of-care testing.
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Affiliation(s)
- Wei Xu
- School of Biomedical Engineering and Med-X Research Institute, Shanghai Jiao Tong University, Shanghai, 200030, China.,State Key Laboratory for Oncogenes and Related Genes, Division of Cardiology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, 160 Pujian Road, Shanghai, 200127, China
| | - Lin Wang
- Department of Laboratory Medicine, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, 200030, China
| | - Ru Zhang
- School of Biomedical Engineering and Med-X Research Institute, Shanghai Jiao Tong University, Shanghai, 200030, China.,State Key Laboratory for Oncogenes and Related Genes, Division of Cardiology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, 160 Pujian Road, Shanghai, 200127, China
| | - Xuming Sun
- School of Biomedical Engineering and Med-X Research Institute, Shanghai Jiao Tong University, Shanghai, 200030, China.,State Key Laboratory for Oncogenes and Related Genes, Division of Cardiology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, 160 Pujian Road, Shanghai, 200127, China
| | - Lin Huang
- School of Biomedical Engineering and Med-X Research Institute, Shanghai Jiao Tong University, Shanghai, 200030, China.,State Key Laboratory for Oncogenes and Related Genes, Division of Cardiology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, 160 Pujian Road, Shanghai, 200127, China
| | - Haiyang Su
- School of Biomedical Engineering and Med-X Research Institute, Shanghai Jiao Tong University, Shanghai, 200030, China.,State Key Laboratory for Oncogenes and Related Genes, Division of Cardiology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, 160 Pujian Road, Shanghai, 200127, China
| | - Xunbin Wei
- School of Biomedical Engineering and Med-X Research Institute, Shanghai Jiao Tong University, Shanghai, 200030, China
| | - Chia-Chun Chen
- Department of Chemistry, National Taiwan Normal University, Taipei, 11677, Taiwan
| | - Jiatao Lou
- Department of Laboratory Medicine, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, 200030, China.
| | - Hongjie Dai
- Department of Chemistry, Stanford University, Stanford, CA, 94305, USA
| | - Kun Qian
- School of Biomedical Engineering and Med-X Research Institute, Shanghai Jiao Tong University, Shanghai, 200030, China. .,State Key Laboratory for Oncogenes and Related Genes, Division of Cardiology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, 160 Pujian Road, Shanghai, 200127, China.
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Early kinetic profiles of troponin I and T measured by high-sensitivity assays in patients with myocardial infarction. Clin Chim Acta 2020; 505:15-25. [PMID: 32061575 DOI: 10.1016/j.cca.2020.02.009] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Revised: 02/07/2020] [Accepted: 02/11/2020] [Indexed: 12/23/2022]
Abstract
The early concentration kinetic profiles of cardiac troponin in patients with non-ST-elevated myocardial infarction (NSTEMI) measured by high-sensitivity cardiac troponin I (hs-cTnI) and T (hs-cTnT) assays have not been described. In intermediate-to-high-risk of NSTEMI patients we measured serial cTn concentrations on ED arrival, at 1, 2, 3, 6-12, 24 and 48-hours with hs-cTnI and hs-cTnT assays. Log-normal curves were fitted to concentrations from time from symptom onset, and the time to rule-out decision thresholds estimated (hs-cTnI: 2 ng/L and 5 ng/L; hs-cTnT: 5 ng/L). Among 164 patients there were 58 NSTEMI. The hs-cTnI to hs-cTnT ratio increased linearly over the first 6-12 h following symptom onset. The estimated times from symptom onset to the 2 ng/L and 5 ng/L thresholds for hs-cTnI were 1.8 (0.1-3.1) and 1.9 (1.1-3.5) hours, and to the 5 ng/L threshold for hs-cTnT 1.9 (1.1-3.8) hours. The estimated time to exceed 5 ng/L was ≥3 hours in 32.6% (95%CI: 20.0% to 48.1%) cases for hs-cTnI and 33.3% (19.6% to 50.0%) for hs-cTnT. cTnI concentrations increased at a much more rapid rate than cTnT concentrations in patients with NSTEMI. Concentrations of a high proportion of patients took longer than 3 hours from symptom onset to exceed the 5 ng/L rule-out decision threshold.
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Walter J, du Fay de Lavallaz J, Koechlin L, Zimmermann T, Boeddinghaus J, Honegger U, Strebel I, Twerenbold R, Amrein M, Nestelberger T, Wussler D, Puelacher C, Badertscher P, Zellweger M, Fahrni G, Jeger R, Kaiser C, Reichlin T, Mueller C. Using High-Sensitivity Cardiac Troponin for the Exclusion of Inducible Myocardial Ischemia in Symptomatic Patients: A Cohort Study. Ann Intern Med 2020; 172:175-185. [PMID: 31905377 DOI: 10.7326/m19-0080] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND The optimal noninvasive method for surveillance in symptomatic patients with stable coronary artery disease (CAD) is unknown. OBJECTIVE To apply a novel approach using very low concentrations of high-sensitivity cardiac troponin I (hs-cTnI) for exclusion of inducible myocardial ischemia in symptomatic patients with CAD. DESIGN Prospective diagnostic cohort study. (ClinicalTrials.gov: NCT01838148). SETTING University hospital. PATIENTS 1896 consecutive patients with CAD referred with symptoms possibly related to inducible myocardial ischemia. MEASUREMENTS Presence of inducible myocardial ischemia was adjudicated using myocardial perfusion imaging with single-photon emission computed tomography, as well as coronary angiography and fractional flow reserve measurements where available. Staff blinded to adjudication measured circulating hs-cTn concentrations. An hs-cTnI cutoff of 2.5 ng/L, derived previously in mostly asymptomatic patients with CAD, was assessed. Predefined target performance criteria were at least 90% negative predictive value (NPV) and at least 90% sensitivity for exclusion of inducible myocardial ischemia. Sensitivity analyses were based on measurements with an hs-cTnT assay and an alternative hs-cTnI assay with even higher analytic sensitivity (limit of detection, 0.1 ng/L). RESULTS Overall, 865 patients (46%) had inducible myocardial ischemia. The hs-cTnI cutoff of 2.5 ng/L provided an NPV of 70% (95% CI, 64% to 75%) and a sensitivity of 90% (CI, 88% to 92%) for exclusion of inducible myocardial ischemia. No hs-cTnI cutoff reached both performance characteristics predefined as targets. Similarly, using the alternative assays for hs-cTnI or hs-cTnT, no cutoff achieved the target performance: hs-cTnT concentrations less than 5 ng/L yielded an NPV of 66% (CI, 59% to 72%), and hs-cTnI concentrations less than 2 ng/L yielded an NPV of 68% (CI, 62% to 74%). LIMITATION Data were generated in a large single-center diagnostic study using central adjudication. CONCLUSION In symptomatic patients with CAD, very low hs-cTn concentrations, including hs-cTnI concentrations less than 2.5 ng/L, do not generally allow users to safely exclude inducible myocardial ischemia. PRIMARY FUNDING SOURCE European Union, Swiss National Science Foundation, Kommission für Technologie und Innovation (Innosuisse), Swiss Heart Foundation, Cardiovascular Research Foundation Basel, University of Basel, University Hospital Basel, Roche, Abbott, and Singulex.
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Affiliation(s)
- Joan Walter
- Cardiovascular Research Institute Basel, University Hospital Basel, and University of Basel, Basel, Switzerland (J.W., J.D., L.K., T.Z., J.B., U.H., I.S., R.T., M.A., T.N., D.W., C.P., M.Z., G.F., R.J., C.K., C.M.)
| | - Jeanne du Fay de Lavallaz
- Cardiovascular Research Institute Basel, University Hospital Basel, and University of Basel, Basel, Switzerland (J.W., J.D., L.K., T.Z., J.B., U.H., I.S., R.T., M.A., T.N., D.W., C.P., M.Z., G.F., R.J., C.K., C.M.)
| | - Luca Koechlin
- Cardiovascular Research Institute Basel, University Hospital Basel, and University of Basel, Basel, Switzerland (J.W., J.D., L.K., T.Z., J.B., U.H., I.S., R.T., M.A., T.N., D.W., C.P., M.Z., G.F., R.J., C.K., C.M.)
| | - Tobias Zimmermann
- Cardiovascular Research Institute Basel, University Hospital Basel, and University of Basel, Basel, Switzerland (J.W., J.D., L.K., T.Z., J.B., U.H., I.S., R.T., M.A., T.N., D.W., C.P., M.Z., G.F., R.J., C.K., C.M.)
| | - Jasper Boeddinghaus
- Cardiovascular Research Institute Basel, University Hospital Basel, and University of Basel, Basel, Switzerland (J.W., J.D., L.K., T.Z., J.B., U.H., I.S., R.T., M.A., T.N., D.W., C.P., M.Z., G.F., R.J., C.K., C.M.)
| | - Ursina Honegger
- Cardiovascular Research Institute Basel, University Hospital Basel, and University of Basel, Basel, Switzerland (J.W., J.D., L.K., T.Z., J.B., U.H., I.S., R.T., M.A., T.N., D.W., C.P., M.Z., G.F., R.J., C.K., C.M.)
| | - Ivo Strebel
- Cardiovascular Research Institute Basel, University Hospital Basel, and University of Basel, Basel, Switzerland (J.W., J.D., L.K., T.Z., J.B., U.H., I.S., R.T., M.A., T.N., D.W., C.P., M.Z., G.F., R.J., C.K., C.M.)
| | - Raphael Twerenbold
- Cardiovascular Research Institute Basel, University Hospital Basel, and University of Basel, Basel, Switzerland (J.W., J.D., L.K., T.Z., J.B., U.H., I.S., R.T., M.A., T.N., D.W., C.P., M.Z., G.F., R.J., C.K., C.M.)
| | - Melissa Amrein
- Cardiovascular Research Institute Basel, University Hospital Basel, and University of Basel, Basel, Switzerland (J.W., J.D., L.K., T.Z., J.B., U.H., I.S., R.T., M.A., T.N., D.W., C.P., M.Z., G.F., R.J., C.K., C.M.)
| | - Thomas Nestelberger
- Cardiovascular Research Institute Basel, University Hospital Basel, and University of Basel, Basel, Switzerland (J.W., J.D., L.K., T.Z., J.B., U.H., I.S., R.T., M.A., T.N., D.W., C.P., M.Z., G.F., R.J., C.K., C.M.)
| | - Desiree Wussler
- Cardiovascular Research Institute Basel, University Hospital Basel, and University of Basel, Basel, Switzerland (J.W., J.D., L.K., T.Z., J.B., U.H., I.S., R.T., M.A., T.N., D.W., C.P., M.Z., G.F., R.J., C.K., C.M.)
| | - Christian Puelacher
- Cardiovascular Research Institute Basel, University Hospital Basel, and University of Basel, Basel, Switzerland (J.W., J.D., L.K., T.Z., J.B., U.H., I.S., R.T., M.A., T.N., D.W., C.P., M.Z., G.F., R.J., C.K., C.M.)
| | - Patrick Badertscher
- Cardiovascular Research Institute Basel, University Hospital Basel, and University of Basel, Basel, Switzerland, and University of Illinois at Chicago, Chicago, Illinois (P.B.)
| | - Michael Zellweger
- Cardiovascular Research Institute Basel, University Hospital Basel, and University of Basel, Basel, Switzerland (J.W., J.D., L.K., T.Z., J.B., U.H., I.S., R.T., M.A., T.N., D.W., C.P., M.Z., G.F., R.J., C.K., C.M.)
| | - Gregor Fahrni
- Cardiovascular Research Institute Basel, University Hospital Basel, and University of Basel, Basel, Switzerland (J.W., J.D., L.K., T.Z., J.B., U.H., I.S., R.T., M.A., T.N., D.W., C.P., M.Z., G.F., R.J., C.K., C.M.)
| | - Raban Jeger
- Cardiovascular Research Institute Basel, University Hospital Basel, and University of Basel, Basel, Switzerland (J.W., J.D., L.K., T.Z., J.B., U.H., I.S., R.T., M.A., T.N., D.W., C.P., M.Z., G.F., R.J., C.K., C.M.)
| | - Christoph Kaiser
- Cardiovascular Research Institute Basel, University Hospital Basel, and University of Basel, Basel, Switzerland (J.W., J.D., L.K., T.Z., J.B., U.H., I.S., R.T., M.A., T.N., D.W., C.P., M.Z., G.F., R.J., C.K., C.M.)
| | - Tobias Reichlin
- Cardiovascular Research Institute Basel, University Hospital Basel, and University of Basel, Basel, and University Hospital Bern, University of Bern, Bern, Switzerland (T.R.)
| | - Christian Mueller
- Cardiovascular Research Institute Basel, University Hospital Basel, and University of Basel, Basel, Switzerland (J.W., J.D., L.K., T.Z., J.B., U.H., I.S., R.T., M.A., T.N., D.W., C.P., M.Z., G.F., R.J., C.K., C.M.)
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37
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Nestelberger T, Boeddinghaus J, Greenslade J, Parsonage WA, Than M, Wussler D, Lopez-Ayala P, Zimmermann T, Meier M, Troester V, Badertscher P, Koechlin L, Wildi K, Anwar M, Freese M, Keller DI, Reichlin T, Twerenbold R, Cullen L, Mueller C, Puelacher C, du Fay de Lavallaz J, Rubini Giménez M, Strebel I, Walter J, Huber J, Christ M, Kozhuharov N, Gualandro DM, Potlukova E, Baumgartner B, Hafner B, Rentsch K, Miró Ò, Fuenzalida C, Gil B, Martin-Sanchez FJ, Kawecki D, Geigy N, Meissner K, Kulangara C, López B, Rodriguez Adrada E, Ganovská E, Lohrmann J, Kloos W, Steude J, Buser A, von Eckardstein A, Nowalany-Kozielska E, Muzyk P. Two-Hour Algorithm for Rapid Triage of Suspected Acute Myocardial Infarction Using a High-Sensitivity Cardiac Troponin I Assay. Clin Chem 2019; 65:1437-1447. [DOI: 10.1373/clinchem.2019.305193] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2019] [Accepted: 08/07/2019] [Indexed: 11/06/2022]
Abstract
Abstract
BACKGROUND
We aimed to derive and externally validate a 0/2-h algorithm using the high-sensitivity cardiac troponin I (hs-cTnI)-Access assay.
METHODS
We enrolled patients presenting to the emergency department with symptoms suggestive of acute myocardial infarction (AMI) in 2 prospective diagnostic studies using central adjudication. Two independent cardiologists adjudicated the final diagnosis, including all available medical information including cardiac imaging. hs-cTnI-Access concentrations were measured at presentation and after 2 h in a blinded fashion.
RESULTS
AMI was the adjudicated final diagnosis in 164 of 1131 (14.5%) patients in the derivation cohort. Rule-out by the hs-cTnI-Access 0/2-h algorithm was defined as 0-h hs-cTnI-Access concentration <4 ng/L in patients with an onset of chest pain >3 h (direct rule-out) or a 0-h hs-cTnI-Access concentration <5 ng/L and an absolute change within 2 h <5 ng/L in all other patients. Derived thresholds for rule-in were a 0-h hs-cTnI-Access concentration ≥50 ng/L (direct rule-in) or an absolute change within 2 h ≥20 ng/L. In the derivation cohort, these cutoffs ruled out 55% of patients with a negative predictive value (NPV) of 99.8% (95% CI, 99.3–100) and sensitivity of 99.4% (95% CI, 96.5–99.9), and ruled in 30% of patients with a positive predictive value (PPV) of 73% (95% CI, 66.1–79). In the validation cohort, AMI was the adjudicated final diagnosis in 88 of 1280 (6.9%) patients. These cutoffs ruled out 77.9% of patients with an NPV of 99.8% (95% CI, 99.3–100) and sensitivity of 97.7% (95% CI, 92.0–99.7), and ruled in 5.8% of patients with a PPV of 77% (95% CI, 65.8–86) in the validation cohort.
CONCLUSIONS
Safety and efficacy of the l hs-cTnI-Access 0/2-h algorithm for triage toward rule-out or rule-in of AMI are very high.
TRIAL REGISTRATION
APACE, NCT00470587; ADAPT, ACTRN1261100106994; IMPACT, ACTRN12611000206921.
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Affiliation(s)
- Thomas Nestelberger
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT network
| | - Jasper Boeddinghaus
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT network
- Division of Internal Medicine, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Jaimi Greenslade
- Royal Brisbane and Women's Hospital, Brisbane, Australia
- Queensland University of Technology, Brisbane, Australia
- University of Queensland, Brisbane, Australia
| | - William A Parsonage
- Royal Brisbane and Women's Hospital, Brisbane, Australia
- Queensland University of Technology, Brisbane, Australia
- University of Queensland, Brisbane, Australia
| | - Martin Than
- Emergency Department, Christchurch Hospital, Christchurch, New Zealand
| | - Desiree Wussler
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT network
- Division of Internal Medicine, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Pedro Lopez-Ayala
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT network
| | - Tobias Zimmermann
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT network
| | - Mario Meier
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT network
| | - Valentina Troester
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT network
| | - Patrick Badertscher
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT network
- Division of Cardiology, University of Illinois at Chicago, Chicago, IL
| | - Luca Koechlin
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT network
- Department of Cardiac Surgery, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Karin Wildi
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- Division of Internal Medicine, University Hospital Basel, University of Basel, Basel, Switzerland
- Critical Care Research Institute, The Prince Charles Hospital, Brisbane and University of Queensland, Brisbane, Australia
| | - Mahnoor Anwar
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT network
| | - Michael Freese
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT network
| | - Dagmar I Keller
- Emergency Department, University Hospital Zurich, Zurich, Switzerland
| | - Tobias Reichlin
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT network
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Raphael Twerenbold
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT network
| | - Louise Cullen
- GREAT network
- Royal Brisbane and Women's Hospital, Brisbane, Australia
- Queensland University of Technology, Brisbane, Australia
- University of Queensland, Brisbane, Australia
| | - Christian Mueller
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT network
| | - Christian Puelacher
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- Department of Internal Medicine, University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT network
| | - Jeanne du Fay de Lavallaz
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT network
| | - Maria Rubini Giménez
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT network
- Heart Centre Leipzig, University Hospital of Cardiology, Leipzig, Germany
| | - Ivo Strebel
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT network
| | - Joan Walter
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- Department of Internal Medicine, University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT network
| | - Jeffrey Huber
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT network
| | - Michael Christ
- Department of Emergency Medicine Lucerne Hospital, Lucerne, Switzerland
| | - Nikola Kozhuharov
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT network
| | - Danielle M Gualandro
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT network
| | - Eliska Potlukova
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- Department of Internal Medicine, University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT network
| | - Benjamin Baumgartner
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT network
| | - Benjamin Hafner
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT network
| | - Katharina Rentsch
- Department of Laboratory Medicine, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Òscar Miró
- GREAT network
- Emergency Department, Hospital Clinic, Barcelona, Catalonia, Spain
| | - Carolina Fuenzalida
- GREAT network
- Emergency Department, Hospital Clinic, Barcelona, Catalonia, Spain
| | - Beatriz Gil
- Emergency Department, Hospital Clinic, Barcelona, Catalonia, Spain
| | | | - Damian Kawecki
- GREAT network
- Department of Cardiology, University Hospital Brno, Brno, Czech Republic and Medical Faculty, Masaryk University, Brno, Czech Republic
| | - Nicolas Geigy
- Department of Emergency Medicine, Hospital Baselland, Liestal, Switzerland
| | - Kathrin Meissner
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT network
| | - Caroline Kulangara
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT network
| | - Beatriz López
- GREAT network
- Emergency Department, Hospital Clinic, Barcelona, Catalonia, Spain
| | | | - Eva Ganovská
- GREAT network
- Emergency Department, Hospital Clinic, Barcelona, Catalonia, Spain
| | - Jens Lohrmann
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Wanda Kloos
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Jana Steude
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Andreas Buser
- Blood Transfusion Centre, Swiss Red Cross, Basel, Switzerland and Department of Hematology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Arnold von Eckardstein
- Emergency Department of Laboratory Medicine, University Hospital Zurich, Zurich, Switzerland
| | - Ewa Nowalany-Kozielska
- 2nd Department of Cardiology, School of Medicine with the Division of Dentistry in Zabrze, Medical University of Katowice, Katowice, Poland
| | - Piotr Muzyk
- GREAT network
- 2nd Department of Cardiology, School of Medicine with the Division of Dentistry in Zabrze, Medical University of Katowice, Katowice, Poland
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Lan NSR, Bell DA. Revisiting the Biological Variability of Cardiac Troponin: Implications for Clinical Practice. Clin Biochem Rev 2019; 40:201-216. [PMID: 31857741 PMCID: PMC6892703 DOI: 10.33176/aacb-19-00032] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
The diagnosis of acute myocardial injury requires a rise and/or fall of cardiac troponin (cTn) on serial testing, with at least one concentration above the 99th percentile value of a normal reference population according to the recently published Fourth Universal Definition of Myocardial Infarction.1 However, the magnitude of change in cTn that constitutes a significant rise and/or fall was again not specified in detail. High-sensitivity cardiac troponin (hs-cTn) assays can measure ten-fold lower concentrations of cTn with more precision than older assays, and can accurately quantify cTn in more than 50% of healthy individuals with a coefficient of variation of less than 10% at the 99th percentile. These hs-cTn assays are also able to detect the normal variations in cTn results that are due to biological variability. Understanding and quantifying the normal variations in cTn is important as this would allow significant changes to be better defined. Numerous studies have sought to investigate the biological variability of cTn over the last ten years. Such studies are usually conducted in healthy individuals, however individuals with chronic cardiac disease or chronic renal failure have also been examined. These studies have yielded varying results in regards to significant change values for cTn. In light of the recent redefinition for myocardial infarction, the purpose of this mini-review is to revisit the biological variability of cTn. In particular, we outline concepts for determining a significant change value, review the results of previous studies on the biological variation of cTn and discuss potential considerations for clinical practice.
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Affiliation(s)
- Nick S R Lan
- Department of Cardiology, Fiona Stanley Hospital, Perth, WA
- Medical School, The University of Western Australia, Perth, WA
| | - Damon A Bell
- Medical School, The University of Western Australia, Perth, WA
- Department of Cardiology, Lipid Disorders Clinic, Royal Perth Hospital, Perth, WA
- Department of Clinical Biochemistry, PathWest Laboratory Medicine, Royal Perth and Fiona Stanley Hospitals, Perth, WA
- Department of Clinical Biochemistry, Clinipath Pathology, Perth, WA, Australia
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39
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Buja LM, Zehr B, Lelenwa L, Ogechukwu E, Zhao B, Dasgupta A, Barth RF. Clinicopathological complexity in the application of the universal definition of myocardial infarction. Cardiovasc Pathol 2019; 44:107153. [PMID: 31760238 DOI: 10.1016/j.carpath.2019.107153] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2019] [Revised: 08/28/2019] [Accepted: 09/09/2019] [Indexed: 12/13/2022] Open
Abstract
A universal definition of myocardial infarction (UDMI) has been established, periodically updated, and refined over the past twenty years. The primary purpose of the UDMI is to bring uniformity and accuracy to clinical diagnosis. Herein, a review and analysis of the UDMI is presented with emphasis on clinicopathological correlation. Determination of the presence of myocardial injury is based on the detection of abnormal serum cardiac biomarkers, particularly cardiac troponin (cTn), and in the current fourth iteration of the UDMI, high sensitivity (hs)-cTn. Differentiation of myocardial infarction from other causes of myocardial injury requires the documentation of clinical evidence of myocardial ischemia. In this review, difficulties in applying the UDMI in actual practice are discussed, based on the experience and perspective of those of us who face these problems as part of our own practice of pathology. The complexity in application of the UDMI is highlighted by the presentation of five illustrative cases involving the differential diagnosis of myocardial injury and myocardial infarction due to atherothrombotic and nonatherothrombotic coronary artery disease. The cases include myocardial infarction due to severe coronary atherosclerosis, supply-demand mismatch, coronary artery dissection associated with an eosinophilic coronary periarteritis, and coronary thromboembolism, and a case with a differential diagnosis of myocarditis and myocardial infarction. These cases illustrate how pathological findings can contribute to more accurate application of the UDMI and how, when critically applied, the UDMI can be used to better characterize myocardial infarcts in clinical practice.
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Affiliation(s)
- Louis Maximilian Buja
- Department of Pathology and Laboratory Medicine, McGovern Medical School, The University of Texas Health Science Center at Houston (UT Health), United States.
| | - Bradley Zehr
- Department of Pathology, The Ohio State University (OSU), United States
| | - Laura Lelenwa
- Department of Pathology and Laboratory Medicine, McGovern Medical School, The University of Texas Health Science Center at Houston (UT Health), United States
| | - Eze Ogechukwu
- Department of Pathology, The Ohio State University (OSU), United States
| | - Bihong Zhao
- Department of Pathology and Laboratory Medicine, McGovern Medical School, The University of Texas Health Science Center at Houston (UT Health), United States
| | - Amitava Dasgupta
- Department of Pathology and Laboratory Medicine, McGovern Medical School, The University of Texas Health Science Center at Houston (UT Health), United States
| | - Rolf F Barth
- Department of Pathology, The Ohio State University (OSU), United States
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40
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Boeddinghaus J, Twerenbold R, Nestelberger T, Koechlin L, Wussler D, Meier M, Troester V, Zimmermann T, Badertscher P, Wildi K, Rubini Giménez M, Lopez-Ayala P, Potlukova E, Miró Ò, Martin-Sanchez FJ, Kawecki D, Geigy N, Keller DI, Reichlin T, Mueller C. Clinical Use of a New High-Sensitivity Cardiac Troponin I Assay in Patients with Suspected Myocardial Infarction. Clin Chem 2019; 65:1426-1436. [PMID: 31570633 DOI: 10.1373/clinchem.2019.304725] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2019] [Accepted: 08/07/2019] [Indexed: 11/06/2022]
Abstract
BACKGROUND We aimed to validate the clinical performance of the high-sensitivity cardiac troponin I [VITROS® Immunodiagnostic Products hs Troponin I (hs-cTnI-VITROS)] assay. METHODS We enrolled patients presenting to the emergency department with symptoms suggestive of acute myocardial infarction (AMI). Final diagnoses were centrally adjudicated by 2 independent cardiologists considering all clinical information, including cardiac imaging: first, using serial hs-cTnT-Elecsys (primary analysis) and, second, using hs-cTnI-Architect (secondary analysis) measurements in addition to the clinically used (hs)-cTn. hs-cTnI-VITROS was measured at presentation and at 1 h in a blinded fashion. The primary objective was direct comparison of diagnostic accuracy as quantified by the area under the ROC curve (AUC) of hs-cTnI-VITROS vs hs-cTnT-Elecsys and hs-cTnI-Architect, and in a subgroup also hs-cTnI-Centaur and hs-cTnI-Access. Secondary objectives included the derivation and validation of an hs-cTnI-VITROS-0/1-h algorithm. RESULTS AMI was the adjudicated final diagnosis in 158 of 1231 (13%) patients. At presentation, the AUC for hs-cTnI-VITROS was 0.95 (95% CI, 0.93-0.96); for hs-cTnT-Elecsys, 0.94 (95% CI, 0.92-0.95); and for hs-cTnI-Architect, 0.92 (95% CI, 0.90-0.94). AUCs for hs-cTnI-Centaur and hs-cTnI-Access were 0.95 (95% CI, 0.94-0.97). Applying the derived hs-cTnI-VITROS-0/1-h algorithm (derivation cohort n = 519) to the validation cohort (n = 520), 53% of patients were ruled out [sensitivity, 100% (95% CI, 94.1-100)] and 14% of patients were ruled in [specificity, 95.6% (95% CI, 93.4-97.2)]. Patients ruled out by the 0/1-h algorithm had a survival rate of 99.8% at 30 days. Findings were confirmed in the secondary analyses using the adjudication including serial measurements of hs-cTnI-Architect. CONCLUSIONS The hs-cTnI-VITROS assay has at least comparable diagnostic accuracy with the currently best validated hs-cTnT and hs-cTnI assays. CLINICALTRIALSGOV IDENTIFIER NCT00470587.
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Affiliation(s)
- Jasper Boeddinghaus
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland.,Division of Internal Medicine, University Hospital Basel, University of Basel, Basel, Switzerland.,GREAT network
| | - Raphael Twerenbold
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland.,GREAT network
| | - Thomas Nestelberger
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland.,GREAT network
| | - Luca Koechlin
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland.,Department of Cardiac Surgery, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Desiree Wussler
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland.,Division of Internal Medicine, University Hospital Basel, University of Basel, Basel, Switzerland.,GREAT network
| | - Mario Meier
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland.,GREAT network
| | - Valentina Troester
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland.,GREAT network
| | - Tobias Zimmermann
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland.,GREAT network
| | - Patrick Badertscher
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland.,GREAT network.,Division of Cardiology, University of Illinois at Chicago, Chicago, IL
| | - Karin Wildi
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland.,GREAT network.,Critical Care Research Group, the Prince Charles Hospital, Brisbane and the University of Queensland, Brisbane, Australia
| | - Maria Rubini Giménez
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland.,GREAT network
| | - Pedro Lopez-Ayala
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland.,GREAT network
| | - Eliska Potlukova
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland.,Division of Internal Medicine, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Òscar Miró
- GREAT network.,Emergency Department, Hospital Clinic, Barcelona, Catalonia, Spain
| | | | - Damian Kawecki
- GREAT network.,2nd Department of Cardiology, School of Medicine with the Division of Dentistry in Zabrze, Medical University of Katowice, Katowice, Poland
| | - Nicolas Geigy
- Emergency Department, Kantonsspital Liestal, Liestal, Switzerland
| | - Dagmar I Keller
- Emergency Department, University Hospital Zurich, Zurich, Switzerland
| | - Tobias Reichlin
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland.,GREAT network.,Department of Cardiology, Inselspital, University of Bern, Bern, Switzerland
| | - Christian Mueller
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland; .,GREAT network
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41
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Tada M, Azuma H, Yamada N, Kano KI, Nagai H, Maeda S, Ishida H, Aoyama T, Okada R, Kawano T, Kobuchi T, Uzui H, Matano H, Iwasaki H, Maeno K, Shimada Y, Yoshida H, Ando M, Murakami Y, Iwakami N, Kishimoto S, Iwami T, Tada H, Chapman A, Mills N, Hayashi H, Furukawa TA, Watanabe N. A comprehensive validation of very early rule-out strategies for non-ST-segment elevation myocardial infarction in emergency departments: protocol for a multicentre prospective cohort study. BMJ Open 2019; 9:e026985. [PMID: 31481550 PMCID: PMC6731951 DOI: 10.1136/bmjopen-2018-026985] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2018] [Revised: 06/06/2019] [Accepted: 07/11/2019] [Indexed: 01/16/2023] Open
Abstract
INTRODUCTION Recent advances in troponin sensitivity enabled early and accurate judgement of ruling-out myocardial infarction, especially non-ST elevation myocardial infarction (NSTEMI) in emergency departments (EDs) with development of various prediction-rules and high-sensitive-troponin-based strategies (hs-troponin). Reliance on clinical impression, however, is still common, and it remains unknown which of these strategies is superior. Therefore, our objective in this prospective cohort study is to comprehensively validate the diagnostic accuracy of clinical impression-based strategies, prediction-rules and hs-troponin-based strategies for ruling-out NSTEMIs. METHODS AND ANALYSIS In total, 1500 consecutive adult patients with symptoms suggestive of acute coronary syndrome will be prospectively recruited from five EDs in two tertiary-level, two secondary-level community hospitals and one university hospital in Japan. The study has begun in July 2018, and recruitment period will be about 1 year. A board-certified emergency physician will complete standardised case report forms, and independently perform a clinical impression-based risk estimation of NSTEMI. Index strategies to be compared will include the clinical impression-based strategy; prediction rules and hs-troponin-based strategies for the following types of troponin (Roche Elecsys hs-troponin T; Abbott ARCHITECT hs-troponin I; Siemens ADVIA Centaur hs-troponin I; Siemens ADVIA Centaur sensitive-troponin I). The reference standard will be the composite of type 1 MI and cardiac death within 30 days after admission to the ED. Outcome measures will be negative predictive value, sensitivity and effectiveness, defined as the proportion of patients categorised as low risk for NSTEMI. We will also evaluate inter-rater reliability of the clinical impression-based risk estimation. ETHICS AND DISSEMINATION The study is approved by the Ethics Committees of the Kyoto University Graduate School and Faculty of Medicine and of the five hospitals where we will recruit patients. We will disseminate the study results through conference presentations and peer-reviewed journals.
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Affiliation(s)
- Masafumi Tada
- Department of Human Behavior and Health Promotion, Kyoto University, Kyoto, Japan
| | - Hiroyuki Azuma
- Department of Emergency Medicine, Fukui Prefectural Hospital, Fukui, Japan
| | - Naoki Yamada
- Department of Emergency Medicine, Fukui University Hospital, Fukui, Japan
| | - Ken-Ichi Kano
- Department of Emergency Medicine, Fukui Prefectural Hospital, Fukui, Japan
| | - Hideya Nagai
- Department of Emergency Medicine, Fukui Prefectural Hospital, Fukui, Japan
| | - Shigenobu Maeda
- Department of Emergency Medicine, Fukui Prefectural Hospital, Fukui, Japan
| | - Hiroshi Ishida
- Department of Emergency Medicine, Fukui Prefectural Hospital, Fukui, Japan
| | - Takahiko Aoyama
- Cardiology, Vascular Center, Fukui Prefectural Hospital, Fukui, Japan
| | - Ryota Okada
- Department of Emergency Medicine, Fukui University Hospital, Fukui, Japan
| | - Takahisa Kawano
- Department of Emergency Medicine, Fukui University Hospital, Fukui, Japan
| | - Taketsune Kobuchi
- Department of Emergency Medicine, Fukui University Hospital, Fukui, Japan
| | - Hiroyasu Uzui
- Department of Cardiovascular Medicine, Fukui University Hospital, Fukui, Japan
| | - Hideyuki Matano
- Department of Emergency Medicine, Fukui-ken Saiseikai Hospital, Fukui, Japan
| | - Hose Iwasaki
- Department of Emergency Medicine, Fukui-ken Saiseikai Hospital, Fukui, Japan
| | - Koji Maeno
- Department of Cardiology, Fukui-ken Saiseikai Hospital, Fukui, Japan
| | - Yoshimitsu Shimada
- Department of Emergency Medicine, Japanese Red Cross Fukui Hospital, Fukui, Japan
| | - Hiroyuki Yoshida
- Department of Cardiology, Japanese Red Cross Fukui Hospital, Fukui, Japan
| | - Masaki Ando
- Department of Emergency Medicine, Nagoya City East Medical Center, Nagoya, Japan
| | - Yoshimasa Murakami
- Department of Cardiovascular Medicine, Nagoya City East Medical Center, Nagoya, Japan
| | - Naotsugu Iwakami
- Department of Research Promotion and Management, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Sanae Kishimoto
- Department of Human Behavior and Health Promotion, Kyoto University, Kyoto, Japan
| | - Taku Iwami
- Department of Health Service, Kyoto University, Kyoto, Japan
| | - Hiroshi Tada
- Department of Cardiovascular Medicine, Fukui University Hospital, Fukui, Japan
| | - Andrew Chapman
- British Heart Foundation Center for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Nicholas Mills
- British Heart Foundation Center for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Hiroyuki Hayashi
- Department of Emergency Medicine, Fukui University Hospital, Fukui, Japan
| | - Toshi A Furukawa
- Department of Human Behavior and Health Promotion, Kyoto University, Kyoto, Japan
| | - Norio Watanabe
- Department of Human Behavior and Health Promotion, Kyoto University, Kyoto, Japan
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42
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Wang Y, Dai L, Wang N, Zhu Y, Chen M, Wang H. Rapid rule out of acute myocardial infarction in the observe zone using a combination of presentation N-terminal pro-B-type natriuretic peptide and high-sensitivity cardiac troponin I. Clin Biochem 2019; 70:34-38. [DOI: 10.1016/j.clinbiochem.2019.06.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2018] [Revised: 06/02/2019] [Accepted: 06/03/2019] [Indexed: 10/26/2022]
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43
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Boeddinghaus J, Nestelberger T, Twerenbold R, Koechlin L, Meier M, Troester V, Wussler D, Badertscher P, Wildi K, Puelacher C, du Fay de Lavallaz J, Rubini Giménez M, Zimmermann T, Hafner B, Potlukova E, Miró Ò, Martin-Sanchez FJ, Keller DI, Reichlin T, Mueller C, Walter JE, Strebel I, Kozhuharov N, Freese M, Fuenzalida C, Stelzig C, Gualandro DM, Michou E, Meissner K, Kulangara C, Shrestha S, Fahrni G, Osswald S, López B, Adrada ER, Ganovská E, Lohrmann J, Kloos W, Steude J, Buser A, von Eckardstein A, Morawiec B, Kawecki D, Nowalany-Kozielska E, Muzyk P, Geigy N, Rentsch K. High-Sensitivity Cardiac Troponin I Assay for Early Diagnosis of Acute Myocardial Infarction. Clin Chem 2019; 65:893-904. [DOI: 10.1373/clinchem.2018.300061] [Citation(s) in RCA: 44] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Accepted: 02/25/2019] [Indexed: 12/17/2022]
Abstract
Abstract
BACKGROUND
The aim of this study was to validate the clinical performance of the Beckman Access high-sensitivity cardiac troponin I (hs-cTnI) assay.
METHODS
We enrolled patients presenting to the emergency department with symptoms suggestive of acute myocardial infarction (AMI). Final diagnoses were centrally adjudicated by 2 independent cardiologists with all clinical information including cardiac imaging twice: first, using serial hs-cTnT (Elecsys, primary analysis), and second, using hs-cTnI (Architect, secondary analysis) measurements in addition to the clinically used hs-cTn. hs-cTnI Access was measured at presentation and at 1 h. The primary objective was a direct comparison of diagnostic accuracy as quantified by the area under the ROC curve (AUC) of hs-cTnI Access vs the hs-cTnT Elecsys and hs-cTnI Architect assays. Secondary objectives included the derivation and validation of an hs-cTnI Access-specific 0/1-h algorithm.
RESULTS
AMI was the adjudicated final diagnosis in 243 of 1579 (15.4%) patients. The AUC at presentation for hs-cTnI Access was 0.95 (95% CI, 0.94–0.96), higher than hs-cTnI Architect [0.92 (95% CI, 0.91–0.94; P < 0.001)] and comparable to hs-cTnT Elecsys [0.94 (95% CI, 0.93–0.95; P = 0.12)]. Applying the derived hs-cTnI Access 0/1-h algorithm (derivation cohort n = 686) to the validation cohort (n = 680), 60% of patients were ruled out [sensitivity, 98.9% (95% CI, 94.3–99.8)], and 15% of patients were ruled in [specificity, 95.9% (95% CI, 94.0–97.2)]. Patients ruled out by the 0/1-h algorithm had a survival rate of 100% at 30 days. Findings were confirmed in the secondary analyses by the adjudication including serial measurements of Architect hs-cTnI.
CONCLUSIONS
Diagnostic accuracy and clinical utility of the Beckman hs-cTnI Access assay are very high and at least comparable to Roche hs-cTnT and Abbott hs-cTnI assays. ClinicalTrials.gov Identifier: NCT00470587.
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Affiliation(s)
- Jasper Boeddinghaus
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- Division of Internal Medicine, University Hospital Basel, University of Basel, Basel, Switzerland
- the APACE investigators GREAT network
| | - Thomas Nestelberger
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- the APACE investigators GREAT network
| | - Raphael Twerenbold
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- the APACE investigators GREAT network
| | - Luca Koechlin
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- Department of Cardiac Surgery, University Hospital Basel, University of Basel, Switzerland
| | - Mario Meier
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- the APACE investigators GREAT network
| | - Valentina Troester
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- the APACE investigators GREAT network
| | - Desiree Wussler
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- Division of Internal Medicine, University Hospital Basel, University of Basel, Basel, Switzerland
- the APACE investigators GREAT network
| | - Patrick Badertscher
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- the APACE investigators GREAT network
- Division of Cardiology, University of Illinois at Chicago, Chicago, IL
| | - Karin Wildi
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- the APACE investigators GREAT network
| | - Christian Puelacher
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- the APACE investigators GREAT network
| | - Jeanne du Fay de Lavallaz
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- Division of Internal Medicine, University Hospital Basel, University of Basel, Basel, Switzerland
- the APACE investigators GREAT network
| | - Maria Rubini Giménez
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- the APACE investigators GREAT network
| | - Tobias Zimmermann
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- the APACE investigators GREAT network
| | - Benjamin Hafner
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- the APACE investigators GREAT network
| | - Eliska Potlukova
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- Division of Internal Medicine, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Òscar Miró
- the APACE investigators GREAT network
- Emergency Department, Hospital Clinic, Barcelona, Catalonia, Spain
| | - F Javier Martin-Sanchez
- the APACE investigators GREAT network
- Servicio de Urgencias, Hospital Clínico San Carlos, Madrid, Spain
| | - Dagmar I Keller
- Emergency Department, University Hospital Zurich, Zurich, Switzerland
| | - Tobias Reichlin
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- Department of Cardiology, Inselspital, University of Bern, Bern, Switzerland
| | - Christian Mueller
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- the APACE investigators GREAT network
| | - Joan Elias Walter
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel
- Division of Internal Medicine, University Hospital Basel, University of Basel, both Switzerland
- the APACE investigators GREAT network
| | - Ivo Strebel
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel
- the APACE investigators GREAT network
| | - Nikola Kozhuharov
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel
- the APACE investigators GREAT network
| | - Michael Freese
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel
- the APACE investigators GREAT network
| | - Carolina Fuenzalida
- the APACE investigators GREAT network
- Emergency Department, Hospital Clinic, Barcelona, Catalonia, Spain
| | - Claudia Stelzig
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel
- the APACE investigators GREAT network
| | - Danielle M Gualandro
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel
- the APACE investigators GREAT network
| | - Eleni Michou
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel
- the APACE investigators GREAT network
| | - Kathrin Meissner
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel
- the APACE investigators GREAT network
| | - Caroline Kulangara
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel
- the APACE investigators GREAT network
| | - Samyut Shrestha
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel
- the APACE investigators GREAT network
| | - Gregor Fahrni
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel
| | - Stefan Osswald
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel
| | - Beatriz López
- the APACE investigators GREAT network
- Emergency Department, Hospital Clinic, Barcelona, Catalonia, Spain
| | | | - Eva Ganovská
- the APACE investigators GREAT network
- Department of Cardiology, University Hospital Brno, Brno, Czech Republic and Medical Faculty, Masaryk University, Brno, Czech Republic
| | - Jens Lohrmann
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel
| | - Wanda Kloos
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel
| | - Jana Steude
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel
| | - Andreas Buser
- Blood Transfusion Centre, Swiss Red Cross, Basel, Switzerland and Department of Hematology, University Hospital Basel, University of Basel, Switzerland
| | | | - Beata Morawiec
- the APACE investigators GREAT network
- 2nd Department of Cardiology, School of Medicine with the Division of Dentistry in Zabrze, Medical University of Katowice, Poland
| | - Damian Kawecki
- the APACE investigators GREAT network
- 2nd Department of Cardiology, School of Medicine with the Division of Dentistry in Zabrze, Medical University of Katowice, Poland
| | - Ewa Nowalany-Kozielska
- 2nd Department of Cardiology, School of Medicine with the Division of Dentistry in Zabrze, Medical University of Katowice, Poland
| | - Piotr Muzyk
- the APACE investigators GREAT network
- 2nd Department of Cardiology, School of Medicine with the Division of Dentistry in Zabrze, Medical University of Katowice, Poland
| | - Nicolas Geigy
- Emergency Department, Kantonsspital Liestal, Switzerland
| | - Katharina Rentsch
- Department of Laboratory Medicine, University Hospital Basel, University of Basel, Switzerland
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44
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Abstract
Objective, noninvasive, clinical assessment of patients with heart failure can be made using biomarker measurements, including natriuretic peptides, cardiac troponins, soluble suppression of tumorigenicity 2, and galectin-3. The aim of this review is to provide clinicians with guidance on the use of heart failure biomarkers in clinical practice. The authors provide a didactic narrative based on current literature, an exemplary case study, and their clinical experience.
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Boeddinghaus J, Nestelberger T, Badertscher P, Twerenbold R, Fitze B, Wussler D, Strebel I, Rubini Giménez M, Wildi K, Puelacher C, du Fay de Lavallaz J, Oehen L, Walter J, Miró Ò, Martin-Sanchez FJ, Morawiec B, Potlukova E, Keller DI, Reichlin T, Mueller C, Sabti Z, Freese M, Stelzig C, Shrestha S, Schaerli N, Kozhuharov N, Flores D, Lohrmann J, Biskup E, Kloos W, Osswald S, Mueller D, Sazgary L, López B, Adrada ER, Kawecki D, Muzyk P, Nowalany-Kozielska E, Parenica J, Ganovská E, Meissner K, Kulangara C, Mahfouz R, Hartmann B, Ferel I, Campodarve I, Rentsch K, von Eckardstein A, Buser A, Geigy N. Predicting Acute Myocardial Infarction with a Single Blood Draw. Clin Chem 2019; 65:437-450. [DOI: 10.1373/clinchem.2018.294124] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2018] [Accepted: 11/28/2018] [Indexed: 11/06/2022]
Abstract
Abstract
BACKGROUND
We desired to determine cardiac troponin (cTn) concentrations necessary to achieve a positive predictive value (PPV) of ≥75% for acute myocardial infarction (AMI) to justify immediate admission of patients to a monitored unit and, in general, early coronary angiography.
METHODS
In a prospective multicenter diagnostic study enrolling patients presenting to the emergency department with symptoms suggestive of AMI, final diagnoses were adjudicated by 2 independent cardiologists based on clinical information including cardiac imaging. cTn concentrations were measured using 5 different sensitive and high-sensitivity cTn (hs-cTn) assays in a blinded fashion at presentation and serially thereafter. The diagnostic end point was PPV for rule-in of AMI of initial cTn concentrations alone and in combination with early changes.
RESULTS
Among 3828 patients, 616 (16%) had an AMI. At presentation, 7% to 14% of patients had cTnT/I concentrations associated with a PPV of ≥75%. Adding absolute or relative changes did not significantly further increase the PPV. PPVs increased from 46.5% (95% CI, 43.6–49.4) for hs-cTnT at presentation >14 ng/L to 78.9% (95% CI, 74.7–82.5) for >52 ng/L (P < 0.001), whereas PPVs in higher hs-cTnT strata remained largely unchanged [e.g., 82.4% (95% CI, 77.5–86.7) for >80 ng/L vs 83.9% (95% CI, 76.0–90.1) for >200 ng/L (P = 0.72)]. The addition of early changes in hs-cTnT further increased the PPV up to 60 ng/L, but not for higher concentrations.
CONCLUSIONS
Serial sampling does not seem necessary for predicting AMI and concurrent decision-making in about 10% of patients, as it only marginally increases the PPV for AMI and not in a statistically or clinically significant way.
ClinicalTrials.gov Identifier
NCT00470587.
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Affiliation(s)
- Jasper Boeddinghaus
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- Division of Internal Medicine, University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT Network, Rome, Italy
| | - Thomas Nestelberger
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT Network, Rome, Italy
| | - Patrick Badertscher
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT Network, Rome, Italy
| | - Raphael Twerenbold
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT Network, Rome, Italy
- Department of General and Interventional Cardiology, Hamburg University Heart Center, Hamburg, Germany
| | - Brigitte Fitze
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Desiree Wussler
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- Division of Internal Medicine, University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT Network, Rome, Italy
| | - Ivo Strebel
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT Network, Rome, Italy
| | - Maria Rubini Giménez
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT Network, Rome, Italy
| | - Karin Wildi
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT Network, Rome, Italy
| | - Christian Puelacher
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT Network, Rome, Italy
| | - Jeanne du Fay de Lavallaz
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT Network, Rome, Italy
| | - Loris Oehen
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Joan Walter
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT Network, Rome, Italy
| | - Òscar Miró
- GREAT Network, Rome, Italy
- Emergency Department, Hospital Clinic, Barcelona, Catalonia, Spain
| | | | - Beata Morawiec
- GREAT Network, Rome, Italy
- 2nd Department of Cardiology, School of Medicine with the Division of Dentistry in Zabrze, Medical University of Katowice, Katowice, Poland
| | - Eliska Potlukova
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- Division of Internal Medicine, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Dagmar I Keller
- Emergency Department, University Hospital Zurich, Zurich, Switzerland
| | - Tobias Reichlin
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT Network, Rome, Italy
| | - Christian Mueller
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT Network, Rome, Italy
| | - Zaid Sabti
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT Network, Rome, Italy
| | - Michael Freese
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT Network, Rome, Italy
| | - Claudia Stelzig
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT Network, Rome, Italy
| | - Samyut Shrestha
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT Network, Rome, Italy
| | - Nicolas Schaerli
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT Network, Rome, Italy
- Division of Internal Medicine, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Nikola Kozhuharov
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT Network, Rome, Italy
| | - Dayana Flores
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT Network, Rome, Italy
| | - Jens Lohrmann
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Ewalina Biskup
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- Division of Internal Medicine, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Wanda Kloos
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Stefan Osswald
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Deborah Mueller
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT Network, Rome, Italy
| | - Lorraine Sazgary
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT Network, Rome, Italy
| | - Beatriz López
- GREAT Network, Rome, Italy
- Emergency Department, Hospital Clinic, Barcelona, Catalonia, Spain
| | | | - Damian Kawecki
- GREAT Network, Rome, Italy
- 2nd Department of Cardiology, School of Medicine with the Division of Dentistry in Zabrze, Medical University of Katowice, Katowice, Poland
| | - Piotr Muzyk
- GREAT Network, Rome, Italy
- 2nd Department of Cardiology, School of Medicine with the Division of Dentistry in Zabrze, Medical University of Katowice, Katowice, Poland
| | - Ewa Nowalany-Kozielska
- 2nd Department of Cardiology, School of Medicine with the Division of Dentistry in Zabrze, Medical University of Katowice, Katowice, Poland
| | - Jiri Parenica
- GREAT Network, Rome, Italy
- Department of Cardiology, University Hospital Brno, Brno, Czech Republic and Medical Faculty, Masaryk University, Brno, Czech Republic
| | - Eva Ganovská
- GREAT Network, Rome, Italy
- Department of Cardiology, University Hospital Brno, Brno, Czech Republic and Medical Faculty, Masaryk University, Brno, Czech Republic
| | - Kathrin Meissner
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT Network, Rome, Italy
| | - Caroline Kulangara
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT Network, Rome, Italy
| | - Riham Mahfouz
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Beate Hartmann
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT Network, Rome, Italy
| | - Ina Ferel
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Isabel Campodarve
- GREAT Network, Rome, Italy
- Emergency Medicine, Hospital del Mar, Barcelona, Spain
| | | | | | - Andreas Buser
- Blood Transfusion Centre, Swiss Red Cross, Basel, Switzerland and Department of Hematology, University Hospital Basel, Basel, Switzerland
| | - Nicolas Geigy
- Emergency Department, Kantonsspital Liestal, Switzerland
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Januzzi JL, Mahler SA, Christenson RH, Rymer J, Newby LK, Body R, Morrow DA, Jaffe AS. Recommendations for Institutions Transitioning to High-Sensitivity Troponin Testing: JACC Scientific Expert Panel. J Am Coll Cardiol 2019; 73:1059-1077. [PMID: 30798981 DOI: 10.1016/j.jacc.2018.12.046] [Citation(s) in RCA: 95] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2018] [Revised: 12/05/2018] [Accepted: 12/06/2018] [Indexed: 02/07/2023]
Abstract
High-sensitivity cardiac troponin (hs-cTn) I or T methods have been in use in certain regions for years but are now increasingly globally adopted, including in the United States. Accordingly, inevitable challenges are created for institutions transitioning from conventional cardiac troponin (cTn) assays. hs-cTn assays have higher analytic precision at lower concentrations, yielding greater clinical sensitivity for myocardial injury and allowing accurate recognition of small changes in troponin concentration (rise or fall) within a short time frame. Although much of the knowledge regarding troponin biology that was applicable with older troponin assays still holds true, considerable education regarding the differences between conventional cTn and hs-cTn is needed before medical systems convert to the newer methods. This includes a basic understanding of how hs-cTn testing differs from conventional cTn testing and how it is best deployed in different settings, such as the emergency department and inpatient services. This Expert Panel will review important concepts for institutional transition to hs-cTn methodology, providing recommendations useful for education before implementation.
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Affiliation(s)
- James L Januzzi
- Cardiology Division, Massachusetts General Hospital, Harvard Medical School, Baim Institute for Clinical Research, Boston, Massachusetts.
| | - Simon A Mahler
- Departments of Emergency Medicine, Implementation Science, and Epidemiology and Prevention, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Robert H Christenson
- Core Laboratories and Point of Care Services, University of Maryland School of Medicine, Baltimore, Maryland
| | - Jennifer Rymer
- Division of Cardiology, Department of Medicine and Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina
| | - L Kristin Newby
- Division of Cardiology, Department of Medicine and Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina
| | - Richard Body
- Division of Cardiovascular Sciences, The University of Manchester, Emergency Department, Manchester Royal Infirmary, School of Healthcare Science, Manchester Metropolitan University, Manchester, United Kingdom
| | - David A Morrow
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Allan S Jaffe
- Cardiology Department and Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota
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Modified HEART Score and High-Sensitivity Cardiac Troponin in Patients With Suspected Acute Myocardial Infarction. J Am Coll Cardiol 2019; 73:873-875. [DOI: 10.1016/j.jacc.2018.12.013] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2018] [Revised: 12/11/2018] [Accepted: 12/11/2018] [Indexed: 12/31/2022]
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Combined Use of High-Sensitive Cardiac Troponin, Copeptin, and the Modified HEART Score for Rapid Evaluation of Chest Pain Patients. DISEASE MARKERS 2018; 2018:9136971. [PMID: 30538785 PMCID: PMC6260526 DOI: 10.1155/2018/9136971] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/23/2018] [Revised: 10/04/2018] [Accepted: 10/15/2018] [Indexed: 12/27/2022]
Abstract
Background Clinical short-term risk stratification is a recommended approach in patients with chest pain and possible acute myocardial infarction (AMI) to further improve high safety of biomarker-based rule-out algorithms. The study aim was to assess clinical performance of baseline concentrations of high-sensitivity cardiac troponin T (hs-TnT) and copeptin and the modified HEART score (mHS) in early presenters to the emergency department with chest pain. Methods This cohort study included patients with chest pain with onset maximum of 6 h before admission and no persistent ST-segment elevation on electrocardiogram. hs-TnT, copeptin, and the mHS were assessed from admission data. The diagnostic and prognostic value for three baseline rule-out algorithms: (1) single hs-TnT < 14 ng/l, (2) hs-TnT < 14 ng/l/mHS ≤ 3, and (3) hs-TnT < 14 ng/l/mHS ≤ 3/copeptin < 17.4 pmol/l, was assessed with sensitivity and negative predictive value. Primary diagnostic endpoint was the diagnosis of AMI. Prognostic endpoint was death and/or AMI within 30 days. Results Among 154 enrolled patients, 44 (29%) were classified as low-risk according to the mHS; AMI was diagnosed in 105 patients (68%). For ruling out AMI, the highest sensitivity and NPV from all studied algorithms were observed for hs-TnT/mHS/copeptin (100%, 95% CI 96.6–100, and 100%, 95% CI 75.3–100). At 30 days, the highest event-free survival was achieved in patients stratified with hs-TnT/mHS/copeptin algorithm (100%) with 100% (95% CI 75.3–100) NPV and 100% (95% CI 96.6–100) sensitivity. Conclusions The combination of baseline hs-TnT, copeptin, and the mHS has an excellent sensitivity and NPV for short-term risk stratification. Such approach might improve the triage system in emergency departments and be a bridge for inclusion to serial blood sampling algorithms.
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Wildi K, Boeddinghaus J, Nestelberger T, Twerenbold R, Badertscher P, Wussler D, Giménez MR, Puelacher C, du Fay de Lavallaz J, Dietsche S, Walter J, Kozhuharov N, Morawiec B, Miró Ò, Javier Martin-Sanchez F, Subramaniam S, Geigy N, Keller DI, Reichlin T, Mueller C. Comparison of fourteen rule-out strategies for acute myocardial infarction. Int J Cardiol 2018; 283:41-47. [PMID: 30545622 DOI: 10.1016/j.ijcard.2018.11.140] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2018] [Revised: 10/10/2018] [Accepted: 11/30/2018] [Indexed: 11/18/2022]
Abstract
BACKGROUND The clinical availability of high-sensitivity cardiac troponin (hs-cTn) has enabled the development of several innovative strategies for the rapid rule-out of acute myocardial infarction (AMI). Due to the lack of direct comparisons, selection of the best strategy for clinical practice is challenging. METHODS In a prospective international multicenter diagnostic study enrolling 3696 patients presenting with suspected AMI to the emergency department, we compared the safety and efficacy of 14 different hs-cTn-based strategies: hs-cTn concentrations below the limit of detection (LoD), dual-marker combining hs-cTn with copeptin, ESC 0 h/1 h-algorithm, 0 h/2 h-algorithm, 2 h-ADP-algorithm, NICE-algorithm, and ESC 0 h/3 h-algorithm, each using either hs-cTnT or hs-cTnI. The final diagnosis of AMI was adjudicated by two independent cardiologists using all available clinical information including cardiac imaging and serial hs-cTn concentrations. RESULTS AMI was the final diagnosis in 16% of patients. Using hs-cTnT, safety quantified by the negative predictive value (NPV) and sensitivity was very high (99.8-100% and 99.5-100%) and comparable for all strategies, except the dual-marker approach (NPV 98.7%, sensitivity 96.7%). Similarly, using hs-cTnI, safety quantified by the NPV and sensitivity was very high (99.7-100% and 98.9-100%) and comparable for all strategies, except the dual-marker approach (NPV 96.9%, sensitivity 90.4%) and the NICE-algorithm (NPV 99.1%, sensitivity 94.7%). Efficacy, quantified by the percentage of patients eligible for rule-out, differed markedly, and was lowest for LoD-algorithm (15.7-26.8%). CONCLUSION All rapid rule-out algorithms, except the dual-marker strategy and the NICE-algorithm using hs-cTnI, favorably combine safety and efficacy, and can be considered for routine clinical practice. CLINICAL TRIAL REGISTRATION NCT00470587, http://clinicaltrials.gov/show/NCT00470587.
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Affiliation(s)
- Karin Wildi
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Switzerland; GREAT network; Critical Care Research Group, The Prince Charles Hospital, Brisbane, Australia
| | - Jasper Boeddinghaus
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Switzerland; GREAT network; Department of Internal Medicine, University Hospital Basel, University of Basel, Switzerland
| | - Thomas Nestelberger
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Switzerland; GREAT network; Department of Internal Medicine, University Hospital Basel, University of Basel, Switzerland
| | - Raphael Twerenbold
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Switzerland; GREAT network; Department of General and Interventional Cardiology, Hamburg University Heart Center, Hamburg, Germany
| | - Patrick Badertscher
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Switzerland; GREAT network
| | - Desiree Wussler
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Switzerland; GREAT network; Department of Internal Medicine, University Hospital Basel, University of Basel, Switzerland
| | - Maria Rubini Giménez
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Switzerland; GREAT network
| | - Christian Puelacher
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Switzerland; GREAT network; Department of Internal Medicine, University Hospital Basel, University of Basel, Switzerland
| | - Jeanne du Fay de Lavallaz
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Switzerland; GREAT network; Department of Internal Medicine, University Hospital Basel, University of Basel, Switzerland
| | - Sebastian Dietsche
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Switzerland; GREAT network
| | - Joan Walter
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Switzerland; GREAT network; Department of Internal Medicine, University Hospital Basel, University of Basel, Switzerland
| | - Nikola Kozhuharov
- GREAT network; Department of Internal Medicine, University Hospital Basel, University of Basel, Switzerland
| | - Beata Morawiec
- GREAT network; 2nd Department of Cardiology, School of Medicine with the Division of Dentistry, Zabrze, Medical University of Katowice, Poland
| | - Òscar Miró
- GREAT network; Emergency Department, Hospital Clinic, Barcelona, Catalonia, Spain
| | | | - Sinthuri Subramaniam
- GREAT network; Department of Internal Medicine, University Hospital Basel, University of Basel, Switzerland
| | - Nicolas Geigy
- Emergency Department, Kantonsspital Liestal, Switzerland
| | - Dagmar I Keller
- Emergency Department, University Hospital Zurich, Zurich, Switzerland
| | - Tobias Reichlin
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Switzerland; GREAT network
| | - Christian Mueller
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Switzerland; GREAT network.
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Tajsic M, Járai R, Koch J, Stangl K, Wojta J, Dreger H, Huber K. Midregional pro-A-type natriuretic peptide as part of a dual biomarker strategy for the early rule out of non-ST segment elevation acute coronary syndrome – The WilCop study. Int J Cardiol 2018; 273:243-248. [DOI: 10.1016/j.ijcard.2018.09.084] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2018] [Revised: 09/07/2018] [Accepted: 09/24/2018] [Indexed: 12/01/2022]
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