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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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Kavsak PA, Neumann JT, Cullen L, Than M, Shortt C, Greenslade JH, Pickering JW, Ojeda F, Ma J, Clayton N, Sherbino J, Hill SA, McQueen M, Westermann D, Sörensen NA, Parsonage WA, Griffith L, Mehta SR, Devereaux PJ, Richards M, Troughton R, Pemberton C, Aldous S, Blankenberg S, Worster A. Clinical chemistry score versus high-sensitivity cardiac troponin I and T tests alone to identify patients at low or high risk for myocardial infarction or death at presentation to the emergency department. CMAJ 2019; 190:E974-E984. [PMID: 30127037 DOI: 10.1503/cmaj.180144] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/09/2018] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND Testing for high-sensitivity cardiac troponin (hs-cTn) may assist triage and clinical decision-making in patients presenting to the emergency department with symptoms of acute coronary syndrome; however, this could result in the misclassification of risk because of analytical variation or laboratory error. We sought to evaluate a new laboratory-based risk-stratification tool that incorporates tests for hs-cTn, glucose level and estimated glomerular filtration rate to identify patients at risk of myocardial infarction or death when presenting to the emergency department. METHODS We constructed the clinical chemistry score (CCS) (range 0-5 points) and validated it as a predictor of 30-day myocardial infarction (MI) or death using data from 4 cohort studies involving patients who presented to the emergency department with symptoms suggestive of acute coronary syndrome. We calculated diagnostic parameters for the CCS score separately using high-sensitivity cardiac troponin I (hs-cTnI) and high-sensitivity cardiac troponin T (hs-cTnT). RESULTS For the combined cohorts (n = 4245), 17.1% of participants had an MI or died within 30 days. A CCS score of 0 points best identified low-risk participants: the hs-cTnI CCS had a sensitivity of 100% (95% confidence interval [CI] 99.5%-100%), with 8.9% (95% CI 8.1%-9.8%) of the population classified as being at low risk of MI or death within 30 days; the hs-cTnT CCS had a sensitivity of 99.9% (95% CI 99.2%-100%), with 10.5% (95% CI 9.6%-11.4%) of the population classified as being at low risk. The CCS had better sensitivity than hs-cTn alone (hs-cTnI < 5 ng/L: 96.6%, 95% CI 95.0%-97.8%; hs-cTnT < 6 ng/L: 98.2%, 95% CI 97.0%-99.0%). A CCS score of 5 points best identified patients at high risk (hs-cTnI CCS: specificity 96.6%, 95% CI 96.0%-97.2%; 11.2% [95% CI 10.3%-12.2%] of the population classified as being at high risk; hs-cTnT CCS: specificity 94.0%, 95% CI 93.1%-94.7%; 13.1% [95% CI 12.1%-14.1%] of the population classified as being at high risk) compared with using the overall 99th percentiles for the hs-cTn assays (specificity of hs-cTnI 93.2%, 95% CI 92.3-94.0; specificity of hs-cTnT 73.8%, 95% CI 72.3-75.2). INTERPRETATION The CCS score at the chosen cut-offs was more sensitive and specific than hs-cTn alone for risk stratification of patients presenting to the emergency department with suspected acute coronary syndrome. Study registration: ClinicalTrials.gov, nos. NCT01994577; NCT02355457.
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Affiliation(s)
- Peter A Kavsak
- Departments of Pathology and Molecular Medicine (Kavsak, Hill, McQueen), Health Research Methods, Evidence and Impact (Ma, Griffith); and Medicine (Clayton); Division of Emergency Medicine (Shortt, Sherbino, Worster); Division of Cardiology (Mehta, Devereaux); Population Health Research Institute (Devereaux), McMaster University, Hamilton, Ont.; Department of General and Interventional Cardiology (Neumann, Ojeda, Westermann, Sörensen, Blankenberg), University Heart Center Hamburg Eppendorf, Hamburg, Germany; Royal Brisbane and Women's Hospital (Cullen, Greenslade, Parsonage), Brisbane, Australia; Christchurch Hospital (Than, Pickering, Troughton, Aldous), Christchurch, New Zealand; Department of Medicine and Christchurch Heart Institute, University of Otago (Richards, Pickering, Troughton, Pemberton), Christchurch, New Zealand; Cardiovascular Research Institute (Richards), National University of Singapore
| | - Johannes T Neumann
- Departments of Pathology and Molecular Medicine (Kavsak, Hill, McQueen), Health Research Methods, Evidence and Impact (Ma, Griffith); and Medicine (Clayton); Division of Emergency Medicine (Shortt, Sherbino, Worster); Division of Cardiology (Mehta, Devereaux); Population Health Research Institute (Devereaux), McMaster University, Hamilton, Ont.; Department of General and Interventional Cardiology (Neumann, Ojeda, Westermann, Sörensen, Blankenberg), University Heart Center Hamburg Eppendorf, Hamburg, Germany; Royal Brisbane and Women's Hospital (Cullen, Greenslade, Parsonage), Brisbane, Australia; Christchurch Hospital (Than, Pickering, Troughton, Aldous), Christchurch, New Zealand; Department of Medicine and Christchurch Heart Institute, University of Otago (Richards, Pickering, Troughton, Pemberton), Christchurch, New Zealand; Cardiovascular Research Institute (Richards), National University of Singapore
| | - Louise Cullen
- Departments of Pathology and Molecular Medicine (Kavsak, Hill, McQueen), Health Research Methods, Evidence and Impact (Ma, Griffith); and Medicine (Clayton); Division of Emergency Medicine (Shortt, Sherbino, Worster); Division of Cardiology (Mehta, Devereaux); Population Health Research Institute (Devereaux), McMaster University, Hamilton, Ont.; Department of General and Interventional Cardiology (Neumann, Ojeda, Westermann, Sörensen, Blankenberg), University Heart Center Hamburg Eppendorf, Hamburg, Germany; Royal Brisbane and Women's Hospital (Cullen, Greenslade, Parsonage), Brisbane, Australia; Christchurch Hospital (Than, Pickering, Troughton, Aldous), Christchurch, New Zealand; Department of Medicine and Christchurch Heart Institute, University of Otago (Richards, Pickering, Troughton, Pemberton), Christchurch, New Zealand; Cardiovascular Research Institute (Richards), National University of Singapore
| | - Martin Than
- Departments of Pathology and Molecular Medicine (Kavsak, Hill, McQueen), Health Research Methods, Evidence and Impact (Ma, Griffith); and Medicine (Clayton); Division of Emergency Medicine (Shortt, Sherbino, Worster); Division of Cardiology (Mehta, Devereaux); Population Health Research Institute (Devereaux), McMaster University, Hamilton, Ont.; Department of General and Interventional Cardiology (Neumann, Ojeda, Westermann, Sörensen, Blankenberg), University Heart Center Hamburg Eppendorf, Hamburg, Germany; Royal Brisbane and Women's Hospital (Cullen, Greenslade, Parsonage), Brisbane, Australia; Christchurch Hospital (Than, Pickering, Troughton, Aldous), Christchurch, New Zealand; Department of Medicine and Christchurch Heart Institute, University of Otago (Richards, Pickering, Troughton, Pemberton), Christchurch, New Zealand; Cardiovascular Research Institute (Richards), National University of Singapore
| | - Colleen Shortt
- Departments of Pathology and Molecular Medicine (Kavsak, Hill, McQueen), Health Research Methods, Evidence and Impact (Ma, Griffith); and Medicine (Clayton); Division of Emergency Medicine (Shortt, Sherbino, Worster); Division of Cardiology (Mehta, Devereaux); Population Health Research Institute (Devereaux), McMaster University, Hamilton, Ont.; Department of General and Interventional Cardiology (Neumann, Ojeda, Westermann, Sörensen, Blankenberg), University Heart Center Hamburg Eppendorf, Hamburg, Germany; Royal Brisbane and Women's Hospital (Cullen, Greenslade, Parsonage), Brisbane, Australia; Christchurch Hospital (Than, Pickering, Troughton, Aldous), Christchurch, New Zealand; Department of Medicine and Christchurch Heart Institute, University of Otago (Richards, Pickering, Troughton, Pemberton), Christchurch, New Zealand; Cardiovascular Research Institute (Richards), National University of Singapore
| | - Jaimi H Greenslade
- Departments of Pathology and Molecular Medicine (Kavsak, Hill, McQueen), Health Research Methods, Evidence and Impact (Ma, Griffith); and Medicine (Clayton); Division of Emergency Medicine (Shortt, Sherbino, Worster); Division of Cardiology (Mehta, Devereaux); Population Health Research Institute (Devereaux), McMaster University, Hamilton, Ont.; Department of General and Interventional Cardiology (Neumann, Ojeda, Westermann, Sörensen, Blankenberg), University Heart Center Hamburg Eppendorf, Hamburg, Germany; Royal Brisbane and Women's Hospital (Cullen, Greenslade, Parsonage), Brisbane, Australia; Christchurch Hospital (Than, Pickering, Troughton, Aldous), Christchurch, New Zealand; Department of Medicine and Christchurch Heart Institute, University of Otago (Richards, Pickering, Troughton, Pemberton), Christchurch, New Zealand; Cardiovascular Research Institute (Richards), National University of Singapore
| | - John W Pickering
- Departments of Pathology and Molecular Medicine (Kavsak, Hill, McQueen), Health Research Methods, Evidence and Impact (Ma, Griffith); and Medicine (Clayton); Division of Emergency Medicine (Shortt, Sherbino, Worster); Division of Cardiology (Mehta, Devereaux); Population Health Research Institute (Devereaux), McMaster University, Hamilton, Ont.; Department of General and Interventional Cardiology (Neumann, Ojeda, Westermann, Sörensen, Blankenberg), University Heart Center Hamburg Eppendorf, Hamburg, Germany; Royal Brisbane and Women's Hospital (Cullen, Greenslade, Parsonage), Brisbane, Australia; Christchurch Hospital (Than, Pickering, Troughton, Aldous), Christchurch, New Zealand; Department of Medicine and Christchurch Heart Institute, University of Otago (Richards, Pickering, Troughton, Pemberton), Christchurch, New Zealand; Cardiovascular Research Institute (Richards), National University of Singapore
| | - Francisco Ojeda
- Departments of Pathology and Molecular Medicine (Kavsak, Hill, McQueen), Health Research Methods, Evidence and Impact (Ma, Griffith); and Medicine (Clayton); Division of Emergency Medicine (Shortt, Sherbino, Worster); Division of Cardiology (Mehta, Devereaux); Population Health Research Institute (Devereaux), McMaster University, Hamilton, Ont.; Department of General and Interventional Cardiology (Neumann, Ojeda, Westermann, Sörensen, Blankenberg), University Heart Center Hamburg Eppendorf, Hamburg, Germany; Royal Brisbane and Women's Hospital (Cullen, Greenslade, Parsonage), Brisbane, Australia; Christchurch Hospital (Than, Pickering, Troughton, Aldous), Christchurch, New Zealand; Department of Medicine and Christchurch Heart Institute, University of Otago (Richards, Pickering, Troughton, Pemberton), Christchurch, New Zealand; Cardiovascular Research Institute (Richards), National University of Singapore
| | - Jinhui Ma
- Departments of Pathology and Molecular Medicine (Kavsak, Hill, McQueen), Health Research Methods, Evidence and Impact (Ma, Griffith); and Medicine (Clayton); Division of Emergency Medicine (Shortt, Sherbino, Worster); Division of Cardiology (Mehta, Devereaux); Population Health Research Institute (Devereaux), McMaster University, Hamilton, Ont.; Department of General and Interventional Cardiology (Neumann, Ojeda, Westermann, Sörensen, Blankenberg), University Heart Center Hamburg Eppendorf, Hamburg, Germany; Royal Brisbane and Women's Hospital (Cullen, Greenslade, Parsonage), Brisbane, Australia; Christchurch Hospital (Than, Pickering, Troughton, Aldous), Christchurch, New Zealand; Department of Medicine and Christchurch Heart Institute, University of Otago (Richards, Pickering, Troughton, Pemberton), Christchurch, New Zealand; Cardiovascular Research Institute (Richards), National University of Singapore
| | - Natasha Clayton
- Departments of Pathology and Molecular Medicine (Kavsak, Hill, McQueen), Health Research Methods, Evidence and Impact (Ma, Griffith); and Medicine (Clayton); Division of Emergency Medicine (Shortt, Sherbino, Worster); Division of Cardiology (Mehta, Devereaux); Population Health Research Institute (Devereaux), McMaster University, Hamilton, Ont.; Department of General and Interventional Cardiology (Neumann, Ojeda, Westermann, Sörensen, Blankenberg), University Heart Center Hamburg Eppendorf, Hamburg, Germany; Royal Brisbane and Women's Hospital (Cullen, Greenslade, Parsonage), Brisbane, Australia; Christchurch Hospital (Than, Pickering, Troughton, Aldous), Christchurch, New Zealand; Department of Medicine and Christchurch Heart Institute, University of Otago (Richards, Pickering, Troughton, Pemberton), Christchurch, New Zealand; Cardiovascular Research Institute (Richards), National University of Singapore
| | - Jonathan Sherbino
- Departments of Pathology and Molecular Medicine (Kavsak, Hill, McQueen), Health Research Methods, Evidence and Impact (Ma, Griffith); and Medicine (Clayton); Division of Emergency Medicine (Shortt, Sherbino, Worster); Division of Cardiology (Mehta, Devereaux); Population Health Research Institute (Devereaux), McMaster University, Hamilton, Ont.; Department of General and Interventional Cardiology (Neumann, Ojeda, Westermann, Sörensen, Blankenberg), University Heart Center Hamburg Eppendorf, Hamburg, Germany; Royal Brisbane and Women's Hospital (Cullen, Greenslade, Parsonage), Brisbane, Australia; Christchurch Hospital (Than, Pickering, Troughton, Aldous), Christchurch, New Zealand; Department of Medicine and Christchurch Heart Institute, University of Otago (Richards, Pickering, Troughton, Pemberton), Christchurch, New Zealand; Cardiovascular Research Institute (Richards), National University of Singapore
| | - Stephen A Hill
- Departments of Pathology and Molecular Medicine (Kavsak, Hill, McQueen), Health Research Methods, Evidence and Impact (Ma, Griffith); and Medicine (Clayton); Division of Emergency Medicine (Shortt, Sherbino, Worster); Division of Cardiology (Mehta, Devereaux); Population Health Research Institute (Devereaux), McMaster University, Hamilton, Ont.; Department of General and Interventional Cardiology (Neumann, Ojeda, Westermann, Sörensen, Blankenberg), University Heart Center Hamburg Eppendorf, Hamburg, Germany; Royal Brisbane and Women's Hospital (Cullen, Greenslade, Parsonage), Brisbane, Australia; Christchurch Hospital (Than, Pickering, Troughton, Aldous), Christchurch, New Zealand; Department of Medicine and Christchurch Heart Institute, University of Otago (Richards, Pickering, Troughton, Pemberton), Christchurch, New Zealand; Cardiovascular Research Institute (Richards), National University of Singapore
| | - Matthew McQueen
- Departments of Pathology and Molecular Medicine (Kavsak, Hill, McQueen), Health Research Methods, Evidence and Impact (Ma, Griffith); and Medicine (Clayton); Division of Emergency Medicine (Shortt, Sherbino, Worster); Division of Cardiology (Mehta, Devereaux); Population Health Research Institute (Devereaux), McMaster University, Hamilton, Ont.; Department of General and Interventional Cardiology (Neumann, Ojeda, Westermann, Sörensen, Blankenberg), University Heart Center Hamburg Eppendorf, Hamburg, Germany; Royal Brisbane and Women's Hospital (Cullen, Greenslade, Parsonage), Brisbane, Australia; Christchurch Hospital (Than, Pickering, Troughton, Aldous), Christchurch, New Zealand; Department of Medicine and Christchurch Heart Institute, University of Otago (Richards, Pickering, Troughton, Pemberton), Christchurch, New Zealand; Cardiovascular Research Institute (Richards), National University of Singapore
| | - Dirk Westermann
- Departments of Pathology and Molecular Medicine (Kavsak, Hill, McQueen), Health Research Methods, Evidence and Impact (Ma, Griffith); and Medicine (Clayton); Division of Emergency Medicine (Shortt, Sherbino, Worster); Division of Cardiology (Mehta, Devereaux); Population Health Research Institute (Devereaux), McMaster University, Hamilton, Ont.; Department of General and Interventional Cardiology (Neumann, Ojeda, Westermann, Sörensen, Blankenberg), University Heart Center Hamburg Eppendorf, Hamburg, Germany; Royal Brisbane and Women's Hospital (Cullen, Greenslade, Parsonage), Brisbane, Australia; Christchurch Hospital (Than, Pickering, Troughton, Aldous), Christchurch, New Zealand; Department of Medicine and Christchurch Heart Institute, University of Otago (Richards, Pickering, Troughton, Pemberton), Christchurch, New Zealand; Cardiovascular Research Institute (Richards), National University of Singapore
| | - Nils A Sörensen
- Departments of Pathology and Molecular Medicine (Kavsak, Hill, McQueen), Health Research Methods, Evidence and Impact (Ma, Griffith); and Medicine (Clayton); Division of Emergency Medicine (Shortt, Sherbino, Worster); Division of Cardiology (Mehta, Devereaux); Population Health Research Institute (Devereaux), McMaster University, Hamilton, Ont.; Department of General and Interventional Cardiology (Neumann, Ojeda, Westermann, Sörensen, Blankenberg), University Heart Center Hamburg Eppendorf, Hamburg, Germany; Royal Brisbane and Women's Hospital (Cullen, Greenslade, Parsonage), Brisbane, Australia; Christchurch Hospital (Than, Pickering, Troughton, Aldous), Christchurch, New Zealand; Department of Medicine and Christchurch Heart Institute, University of Otago (Richards, Pickering, Troughton, Pemberton), Christchurch, New Zealand; Cardiovascular Research Institute (Richards), National University of Singapore
| | - William A Parsonage
- Departments of Pathology and Molecular Medicine (Kavsak, Hill, McQueen), Health Research Methods, Evidence and Impact (Ma, Griffith); and Medicine (Clayton); Division of Emergency Medicine (Shortt, Sherbino, Worster); Division of Cardiology (Mehta, Devereaux); Population Health Research Institute (Devereaux), McMaster University, Hamilton, Ont.; Department of General and Interventional Cardiology (Neumann, Ojeda, Westermann, Sörensen, Blankenberg), University Heart Center Hamburg Eppendorf, Hamburg, Germany; Royal Brisbane and Women's Hospital (Cullen, Greenslade, Parsonage), Brisbane, Australia; Christchurch Hospital (Than, Pickering, Troughton, Aldous), Christchurch, New Zealand; Department of Medicine and Christchurch Heart Institute, University of Otago (Richards, Pickering, Troughton, Pemberton), Christchurch, New Zealand; Cardiovascular Research Institute (Richards), National University of Singapore
| | - Lauren Griffith
- Departments of Pathology and Molecular Medicine (Kavsak, Hill, McQueen), Health Research Methods, Evidence and Impact (Ma, Griffith); and Medicine (Clayton); Division of Emergency Medicine (Shortt, Sherbino, Worster); Division of Cardiology (Mehta, Devereaux); Population Health Research Institute (Devereaux), McMaster University, Hamilton, Ont.; Department of General and Interventional Cardiology (Neumann, Ojeda, Westermann, Sörensen, Blankenberg), University Heart Center Hamburg Eppendorf, Hamburg, Germany; Royal Brisbane and Women's Hospital (Cullen, Greenslade, Parsonage), Brisbane, Australia; Christchurch Hospital (Than, Pickering, Troughton, Aldous), Christchurch, New Zealand; Department of Medicine and Christchurch Heart Institute, University of Otago (Richards, Pickering, Troughton, Pemberton), Christchurch, New Zealand; Cardiovascular Research Institute (Richards), National University of Singapore
| | - Shamir R Mehta
- Departments of Pathology and Molecular Medicine (Kavsak, Hill, McQueen), Health Research Methods, Evidence and Impact (Ma, Griffith); and Medicine (Clayton); Division of Emergency Medicine (Shortt, Sherbino, Worster); Division of Cardiology (Mehta, Devereaux); Population Health Research Institute (Devereaux), McMaster University, Hamilton, Ont.; Department of General and Interventional Cardiology (Neumann, Ojeda, Westermann, Sörensen, Blankenberg), University Heart Center Hamburg Eppendorf, Hamburg, Germany; Royal Brisbane and Women's Hospital (Cullen, Greenslade, Parsonage), Brisbane, Australia; Christchurch Hospital (Than, Pickering, Troughton, Aldous), Christchurch, New Zealand; Department of Medicine and Christchurch Heart Institute, University of Otago (Richards, Pickering, Troughton, Pemberton), Christchurch, New Zealand; Cardiovascular Research Institute (Richards), National University of Singapore
| | - P J Devereaux
- Departments of Pathology and Molecular Medicine (Kavsak, Hill, McQueen), Health Research Methods, Evidence and Impact (Ma, Griffith); and Medicine (Clayton); Division of Emergency Medicine (Shortt, Sherbino, Worster); Division of Cardiology (Mehta, Devereaux); Population Health Research Institute (Devereaux), McMaster University, Hamilton, Ont.; Department of General and Interventional Cardiology (Neumann, Ojeda, Westermann, Sörensen, Blankenberg), University Heart Center Hamburg Eppendorf, Hamburg, Germany; Royal Brisbane and Women's Hospital (Cullen, Greenslade, Parsonage), Brisbane, Australia; Christchurch Hospital (Than, Pickering, Troughton, Aldous), Christchurch, New Zealand; Department of Medicine and Christchurch Heart Institute, University of Otago (Richards, Pickering, Troughton, Pemberton), Christchurch, New Zealand; Cardiovascular Research Institute (Richards), National University of Singapore
| | - Mark Richards
- Departments of Pathology and Molecular Medicine (Kavsak, Hill, McQueen), Health Research Methods, Evidence and Impact (Ma, Griffith); and Medicine (Clayton); Division of Emergency Medicine (Shortt, Sherbino, Worster); Division of Cardiology (Mehta, Devereaux); Population Health Research Institute (Devereaux), McMaster University, Hamilton, Ont.; Department of General and Interventional Cardiology (Neumann, Ojeda, Westermann, Sörensen, Blankenberg), University Heart Center Hamburg Eppendorf, Hamburg, Germany; Royal Brisbane and Women's Hospital (Cullen, Greenslade, Parsonage), Brisbane, Australia; Christchurch Hospital (Than, Pickering, Troughton, Aldous), Christchurch, New Zealand; Department of Medicine and Christchurch Heart Institute, University of Otago (Richards, Pickering, Troughton, Pemberton), Christchurch, New Zealand; Cardiovascular Research Institute (Richards), National University of Singapore
| | - Richard Troughton
- Departments of Pathology and Molecular Medicine (Kavsak, Hill, McQueen), Health Research Methods, Evidence and Impact (Ma, Griffith); and Medicine (Clayton); Division of Emergency Medicine (Shortt, Sherbino, Worster); Division of Cardiology (Mehta, Devereaux); Population Health Research Institute (Devereaux), McMaster University, Hamilton, Ont.; Department of General and Interventional Cardiology (Neumann, Ojeda, Westermann, Sörensen, Blankenberg), University Heart Center Hamburg Eppendorf, Hamburg, Germany; Royal Brisbane and Women's Hospital (Cullen, Greenslade, Parsonage), Brisbane, Australia; Christchurch Hospital (Than, Pickering, Troughton, Aldous), Christchurch, New Zealand; Department of Medicine and Christchurch Heart Institute, University of Otago (Richards, Pickering, Troughton, Pemberton), Christchurch, New Zealand; Cardiovascular Research Institute (Richards), National University of Singapore
| | - Chris Pemberton
- Departments of Pathology and Molecular Medicine (Kavsak, Hill, McQueen), Health Research Methods, Evidence and Impact (Ma, Griffith); and Medicine (Clayton); Division of Emergency Medicine (Shortt, Sherbino, Worster); Division of Cardiology (Mehta, Devereaux); Population Health Research Institute (Devereaux), McMaster University, Hamilton, Ont.; Department of General and Interventional Cardiology (Neumann, Ojeda, Westermann, Sörensen, Blankenberg), University Heart Center Hamburg Eppendorf, Hamburg, Germany; Royal Brisbane and Women's Hospital (Cullen, Greenslade, Parsonage), Brisbane, Australia; Christchurch Hospital (Than, Pickering, Troughton, Aldous), Christchurch, New Zealand; Department of Medicine and Christchurch Heart Institute, University of Otago (Richards, Pickering, Troughton, Pemberton), Christchurch, New Zealand; Cardiovascular Research Institute (Richards), National University of Singapore
| | - Sally Aldous
- Departments of Pathology and Molecular Medicine (Kavsak, Hill, McQueen), Health Research Methods, Evidence and Impact (Ma, Griffith); and Medicine (Clayton); Division of Emergency Medicine (Shortt, Sherbino, Worster); Division of Cardiology (Mehta, Devereaux); Population Health Research Institute (Devereaux), McMaster University, Hamilton, Ont.; Department of General and Interventional Cardiology (Neumann, Ojeda, Westermann, Sörensen, Blankenberg), University Heart Center Hamburg Eppendorf, Hamburg, Germany; Royal Brisbane and Women's Hospital (Cullen, Greenslade, Parsonage), Brisbane, Australia; Christchurch Hospital (Than, Pickering, Troughton, Aldous), Christchurch, New Zealand; Department of Medicine and Christchurch Heart Institute, University of Otago (Richards, Pickering, Troughton, Pemberton), Christchurch, New Zealand; Cardiovascular Research Institute (Richards), National University of Singapore
| | - Stefan Blankenberg
- Departments of Pathology and Molecular Medicine (Kavsak, Hill, McQueen), Health Research Methods, Evidence and Impact (Ma, Griffith); and Medicine (Clayton); Division of Emergency Medicine (Shortt, Sherbino, Worster); Division of Cardiology (Mehta, Devereaux); Population Health Research Institute (Devereaux), McMaster University, Hamilton, Ont.; Department of General and Interventional Cardiology (Neumann, Ojeda, Westermann, Sörensen, Blankenberg), University Heart Center Hamburg Eppendorf, Hamburg, Germany; Royal Brisbane and Women's Hospital (Cullen, Greenslade, Parsonage), Brisbane, Australia; Christchurch Hospital (Than, Pickering, Troughton, Aldous), Christchurch, New Zealand; Department of Medicine and Christchurch Heart Institute, University of Otago (Richards, Pickering, Troughton, Pemberton), Christchurch, New Zealand; Cardiovascular Research Institute (Richards), National University of Singapore
| | - Andrew Worster
- Departments of Pathology and Molecular Medicine (Kavsak, Hill, McQueen), Health Research Methods, Evidence and Impact (Ma, Griffith); and Medicine (Clayton); Division of Emergency Medicine (Shortt, Sherbino, Worster); Division of Cardiology (Mehta, Devereaux); Population Health Research Institute (Devereaux), McMaster University, Hamilton, Ont.; Department of General and Interventional Cardiology (Neumann, Ojeda, Westermann, Sörensen, Blankenberg), University Heart Center Hamburg Eppendorf, Hamburg, Germany; Royal Brisbane and Women's Hospital (Cullen, Greenslade, Parsonage), Brisbane, Australia; Christchurch Hospital (Than, Pickering, Troughton, Aldous), Christchurch, New Zealand; Department of Medicine and Christchurch Heart Institute, University of Otago (Richards, Pickering, Troughton, Pemberton), Christchurch, New Zealand; Cardiovascular Research Institute (Richards), National University of Singapore
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van der Linden N, Wildi K, Twerenbold R, Pickering JW, Than M, Cullen L, Greenslade J, Parsonage W, Nestelberger T, Boeddinghaus J, Badertscher P, Rubini Giménez M, Klinkenberg LJJ, Bekers O, Schöni A, Keller DI, Sabti Z, Puelacher C, Cupa J, Schumacher L, Kozhuharov N, Grimm K, Shrestha S, Flores D, Freese M, Stelzig C, Strebel I, Miró Ò, Rentsch K, Morawiec B, Kawecki D, Kloos W, Lohrmann J, Richards AM, Troughton R, Pemberton C, Osswald S, van Dieijen-Visser MP, Mingels AM, Reichlin T, Meex SJR, Mueller C. Combining High-Sensitivity Cardiac Troponin I and Cardiac Troponin T in the Early Diagnosis of Acute Myocardial Infarction. Circulation 2019; 138:989-999. [PMID: 29691270 DOI: 10.1161/circulationaha.117.032003] [Citation(s) in RCA: 51] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND Combining 2 signals of cardiomyocyte injury, cardiac troponin I (cTnI) and T (cTnT), might overcome some individual pathophysiological and analytical limitations and thereby increase diagnostic accuracy for acute myocardial infarction with a single blood draw. We aimed to evaluate the diagnostic performance of combinations of high-sensitivity (hs) cTnI and hs-cTnT for the early diagnosis of acute myocardial infarction. METHODS The diagnostic performance of combining hs-cTnI (Architect, Abbott) and hs-cTnT (Elecsys, Roche) concentrations (sum, product, ratio, and a combination algorithm) obtained at the time of presentation was evaluated in a large multicenter diagnostic study of patients with suspected acute myocardial infarction. The optimal rule-out and rule-in thresholds were externally validated in a second large multicenter diagnostic study. The proportion of patients eligible for early rule-out was compared with the European Society of Cardiology 0/1 and 0/3 hour algorithms. RESULTS Combining hs-cTnI and hs-cTnT concentrations did not consistently increase overall diagnostic accuracy as compared with the individual isoforms. However, the combination improved the proportion of patients meeting criteria for very early rule-out. With the European Society of Cardiology 2015 guideline recommended algorithms and cut-offs, the proportion meeting rule-out criteria after the baseline blood sampling was limited (6% to 24%) and assay dependent. Application of optimized cut-off values using the sum (9 ng/L) and product (18 ng2/L2) of hs-cTnI and hs-cTnT concentrations led to an increase in the proportion ruled-out after a single blood draw to 34% to 41% in the original (sum: negative predictive value [NPV] 100% [95% confidence interval (CI), 99.5% to 100%]; product: NPV 100% [95% CI, 99.5% to 100%]) and in the validation cohort (sum: NPV 99.6% [95% CI, 99.0-99.9%]; product: NPV 99.4% [95% CI, 98.8-99.8%]). The use of a combination algorithm (hs-cTnI <4 ng/L and hs-cTnT <9 ng/L) showed comparable results for rule-out (40% to 43% ruled out; NPV original cohort 99.9% [95% CI, 99.2-100%]; NPV validation cohort 99.5% [95% CI, 98.9-99.8%]) and rule-in (positive predictive value [PPV] original cohort 74.4% [95% Cl, 69.6-78.8%]; PPV validation cohort 84.0% [95% Cl, 79.7-87.6%]). CONCLUSIONS New strategies combining hs-cTnI and hs-cTnT concentrations may significantly increase the number of patients eligible for very early and safe rule-out, but do not seem helpful for the rule-in of acute myocardial infarction. CLINICAL TRIAL REGISTRATION URL (APACE): https://www.clinicaltrial.gov . Unique identifier: NCT00470587. URL (ADAPT): www.anzctr.org.au . Unique identifier: ACTRN12611001069943.
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Affiliation(s)
- Noreen van der Linden
- Department of Clinical Chemistry, Central Diagnostic Laboratory, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center (MUMC), The Netherlands (N.v.d.L., L.J.J.K., O.B., M.P.v.D.-V., A.M.M., S.J.R.M.)
| | - Karin Wildi
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Switzerland (K.W., R.T., T.N., J.B., P.B., M.R.G., A.S., Z.S., C.P., J.C., L.S., N.K., K.G., S.S., D.F., M.F., C.S., I.S., W.K., J.L., S.O., T.R., C.M.)
| | - Raphael Twerenbold
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Switzerland (K.W., R.T., T.N., J.B., P.B., M.R.G., A.S., Z.S., C.P., J.C., L.S., N.K., K.G., S.S., D.F., M.F., C.S., I.S., W.K., J.L., S.O., T.R., C.M.)
| | - John W Pickering
- Department of Medicine, University of Otago, Christchurch, New Zealand (J.W.P., M.T., A.M.R., R.T., C.P.)
| | - Martin Than
- Department of Medicine, University of Otago, Christchurch, New Zealand (J.W.P., M.T., A.M.R., R.T., C.P.)
| | - Louise Cullen
- Department of Emergency Medicine, Royal Brisbane and Women's Hospital, Brisbane, Australia (L.C., W.P.).,School of Public Health, Queensland University of Technology, Brisbane, Australia (L.C., J.G., W.P.).,School of Medicine, The University of Queensland, Brisbane, Australia (L.C., J.G., W.P.)
| | - Jaimi Greenslade
- School of Public Health, Queensland University of Technology, Brisbane, Australia (L.C., J.G., W.P.).,School of Medicine, The University of Queensland, Brisbane, Australia (L.C., J.G., W.P.)
| | - William Parsonage
- Department of Emergency Medicine, Royal Brisbane and Women's Hospital, Brisbane, Australia (L.C., W.P.).,School of Public Health, Queensland University of Technology, Brisbane, Australia (L.C., J.G., W.P.).,School of Medicine, The University of Queensland, Brisbane, Australia (L.C., J.G., W.P.)
| | - Thomas Nestelberger
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Switzerland (K.W., R.T., T.N., J.B., P.B., M.R.G., A.S., Z.S., C.P., J.C., L.S., N.K., K.G., S.S., D.F., M.F., C.S., I.S., W.K., J.L., S.O., T.R., C.M.)
| | - Jasper Boeddinghaus
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Switzerland (K.W., R.T., T.N., J.B., P.B., M.R.G., A.S., Z.S., C.P., J.C., L.S., N.K., K.G., S.S., D.F., M.F., C.S., I.S., W.K., J.L., S.O., T.R., C.M.)
| | - Patrick Badertscher
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Switzerland (K.W., R.T., T.N., J.B., P.B., M.R.G., A.S., Z.S., C.P., J.C., L.S., N.K., K.G., S.S., D.F., M.F., C.S., I.S., W.K., J.L., S.O., T.R., C.M.)
| | - Maria Rubini Giménez
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Switzerland (K.W., R.T., T.N., J.B., P.B., M.R.G., A.S., Z.S., C.P., J.C., L.S., N.K., K.G., S.S., D.F., M.F., C.S., I.S., W.K., J.L., S.O., T.R., C.M.).,Emergency Department, CIBERES ISC III, Hospital del Mar - IMIM, Barcelona, Spain (M.R.)
| | - Lieke J J Klinkenberg
- Department of Clinical Chemistry, Central Diagnostic Laboratory, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center (MUMC), The Netherlands (N.v.d.L., L.J.J.K., O.B., M.P.v.D.-V., A.M.M., S.J.R.M.)
| | - Otto Bekers
- Department of Clinical Chemistry, Central Diagnostic Laboratory, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center (MUMC), The Netherlands (N.v.d.L., L.J.J.K., O.B., M.P.v.D.-V., A.M.M., S.J.R.M.)
| | - Aline Schöni
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Switzerland (K.W., R.T., T.N., J.B., P.B., M.R.G., A.S., Z.S., C.P., J.C., L.S., N.K., K.G., S.S., D.F., M.F., C.S., I.S., W.K., J.L., S.O., T.R., C.M.).,Emergency Department, University Hospital Zürich, Switzerland (A.S., D.I.K.)
| | - Dagmar I Keller
- Emergency Department, University Hospital Zürich, Switzerland (A.S., D.I.K.)
| | - Zaid Sabti
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Switzerland (K.W., R.T., T.N., J.B., P.B., M.R.G., A.S., Z.S., C.P., J.C., L.S., N.K., K.G., S.S., D.F., M.F., C.S., I.S., W.K., J.L., S.O., T.R., C.M.)
| | - Christian Puelacher
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Switzerland (K.W., R.T., T.N., J.B., P.B., M.R.G., A.S., Z.S., C.P., J.C., L.S., N.K., K.G., S.S., D.F., M.F., C.S., I.S., W.K., J.L., S.O., T.R., C.M.)
| | - Janosch Cupa
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Switzerland (K.W., R.T., T.N., J.B., P.B., M.R.G., A.S., Z.S., C.P., J.C., L.S., N.K., K.G., S.S., D.F., M.F., C.S., I.S., W.K., J.L., S.O., T.R., C.M.)
| | - Lukas Schumacher
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Switzerland (K.W., R.T., T.N., J.B., P.B., M.R.G., A.S., Z.S., C.P., J.C., L.S., N.K., K.G., S.S., D.F., M.F., C.S., I.S., W.K., J.L., S.O., T.R., C.M.)
| | - Nikola Kozhuharov
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Switzerland (K.W., R.T., T.N., J.B., P.B., M.R.G., A.S., Z.S., C.P., J.C., L.S., N.K., K.G., S.S., D.F., M.F., C.S., I.S., W.K., J.L., S.O., T.R., C.M.)
| | - Karin Grimm
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Switzerland (K.W., R.T., T.N., J.B., P.B., M.R.G., A.S., Z.S., C.P., J.C., L.S., N.K., K.G., S.S., D.F., M.F., C.S., I.S., W.K., J.L., S.O., T.R., C.M.)
| | - Samyut Shrestha
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Switzerland (K.W., R.T., T.N., J.B., P.B., M.R.G., A.S., Z.S., C.P., J.C., L.S., N.K., K.G., S.S., D.F., M.F., C.S., I.S., W.K., J.L., S.O., T.R., C.M.)
| | - Dayana Flores
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Switzerland (K.W., R.T., T.N., J.B., P.B., M.R.G., A.S., Z.S., C.P., J.C., L.S., N.K., K.G., S.S., D.F., M.F., C.S., I.S., W.K., J.L., S.O., T.R., C.M.)
| | - Michael Freese
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Switzerland (K.W., R.T., T.N., J.B., P.B., M.R.G., A.S., Z.S., C.P., J.C., L.S., N.K., K.G., S.S., D.F., M.F., C.S., I.S., W.K., J.L., S.O., T.R., C.M.)
| | - Claudia Stelzig
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Switzerland (K.W., R.T., T.N., J.B., P.B., M.R.G., A.S., Z.S., C.P., J.C., L.S., N.K., K.G., S.S., D.F., M.F., C.S., I.S., W.K., J.L., S.O., T.R., C.M.)
| | - Ivo Strebel
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Switzerland (K.W., R.T., T.N., J.B., P.B., M.R.G., A.S., Z.S., C.P., J.C., L.S., N.K., K.G., S.S., D.F., M.F., C.S., I.S., W.K., J.L., S.O., T.R., C.M.)
| | - Òscar Miró
- Emergency Department, Hospital Clinic, Barcelona, Spain (O.M.)
| | | | - Beata Morawiec
- 2nd Department of Cardiology and School of Medicine with the Division of Dentistry, Zabrze, Medical University of Katowice, Katowice, Poland (B.M., D.K.)
| | - Damian Kawecki
- 2nd Department of Cardiology and School of Medicine with the Division of Dentistry, Zabrze, Medical University of Katowice, Katowice, Poland (B.M., D.K.)
| | - Wanda Kloos
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Switzerland (K.W., R.T., T.N., J.B., P.B., M.R.G., A.S., Z.S., C.P., J.C., L.S., N.K., K.G., S.S., D.F., M.F., C.S., I.S., W.K., J.L., S.O., T.R., C.M.).,Critical Care Research Group, The Prince Charles Hospital, Brisbane, Australia (K.W.)
| | - Jens Lohrmann
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Switzerland (K.W., R.T., T.N., J.B., P.B., M.R.G., A.S., Z.S., C.P., J.C., L.S., N.K., K.G., S.S., D.F., M.F., C.S., I.S., W.K., J.L., S.O., T.R., C.M.)
| | - A Mark Richards
- Department of Medicine, University of Otago, Christchurch, New Zealand (J.W.P., M.T., A.M.R., R.T., C.P.)
| | - Richard Troughton
- Department of Medicine, University of Otago, Christchurch, New Zealand (J.W.P., M.T., A.M.R., R.T., C.P.)
| | - Christopher Pemberton
- Department of Medicine, University of Otago, Christchurch, New Zealand (J.W.P., M.T., A.M.R., R.T., C.P.)
| | - Stefan Osswald
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Switzerland (K.W., R.T., T.N., J.B., P.B., M.R.G., A.S., Z.S., C.P., J.C., L.S., N.K., K.G., S.S., D.F., M.F., C.S., I.S., W.K., J.L., S.O., T.R., C.M.)
| | - Marja P van Dieijen-Visser
- Department of Clinical Chemistry, Central Diagnostic Laboratory, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center (MUMC), The Netherlands (N.v.d.L., L.J.J.K., O.B., M.P.v.D.-V., A.M.M., S.J.R.M.)
| | - Alma M Mingels
- Department of Clinical Chemistry, Central Diagnostic Laboratory, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center (MUMC), The Netherlands (N.v.d.L., L.J.J.K., O.B., M.P.v.D.-V., A.M.M., S.J.R.M.)
| | - Tobias Reichlin
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Switzerland (K.W., R.T., T.N., J.B., P.B., M.R.G., A.S., Z.S., C.P., J.C., L.S., N.K., K.G., S.S., D.F., M.F., C.S., I.S., W.K., J.L., S.O., T.R., C.M.)
| | - Steven J R Meex
- Department of Clinical Chemistry, Central Diagnostic Laboratory, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center (MUMC), The Netherlands (N.v.d.L., L.J.J.K., O.B., M.P.v.D.-V., A.M.M., S.J.R.M.)
| | - Christian Mueller
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Switzerland (K.W., R.T., T.N., J.B., P.B., M.R.G., A.S., Z.S., C.P., J.C., L.S., N.K., K.G., S.S., D.F., M.F., C.S., I.S., W.K., J.L., S.O., T.R., C.M.)
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4
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Reinhold T, Giannitsis E, Möckel M, Frankenstein L, Vafaie M, Vollert JO, Slagman A. Cost analysis of early discharge using combined copeptin/cardiac troponin testing versus serial cardiac troponin testing in patients with suspected acute coronary syndrome. PLoS One 2018; 13:e0202133. [PMID: 30138394 PMCID: PMC6107144 DOI: 10.1371/journal.pone.0202133] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2018] [Accepted: 07/26/2018] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Symptoms indicating acute coronary syndrome are commonly seen in emergency rooms, but only 10% of patients are actually diagnosed with acute myocardial infarction (AMI). The Guidelines for the diagnosis of patients with suspected AMI include either multiple testing of cardiac troponin (cTN) or a single combined test of cTN and copeptin, which facilitates earlier diagnosis or exclusion of AMI. The aim of the present analysis was to investigate the impact of combined copeptin/cTN testing on health care resource consumption and related costs both during and after initial hospital treatment. METHODS AND RESULTS The analysis was based on the BIC-8 trial and financial data of participating study sites. A cost analysis was carried out primarily from the hospital perspective and secondarily from the perspective of German statutory health insurers. The underlying assumptions of the investigation were tested for robustness in additional sensitivity analyses. In total, the data of 713 patients (n = 359 combined copeptin/cTN testing, n = 354 serial cTN testing) were evaluated. From a hospital perspective, the combined copeptin/cTN testing showed a reduced number of medical procedures and a lower frequency of inpatient admissions. The average staff time was significantly reduced by a mean of 49 minutes (95% confidence interval (CI) 46 to 53) per patient, accompanied by a significant mean reduction of 131 minutes (95%CI 104 to 158) in the time patients stayed in the emergency room. The initial hospital treatment was less cost-intensive. Over the entire study period, no significant cost differences were observed between the groups for health insurance. CONCLUSION The combined copeptin/cTN testing has the potential to save costs and staff time in acute care and for the entire hospital stay. The primary explanations for these findings are early identification and ruling out patients without AMI along with the associated reduced need for acute medical treatment. TRIAL REGISTRATION ClinicalTrials.gov NCT01498731.
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Affiliation(s)
- Thomas Reinhold
- Institute for Social Medicine, Epidemiology and Health Economics, Charité –Universitätsmedizin Berlin, Berlin, Germany
| | - Evangelos Giannitsis
- Department of Angiology, Cardiology and Pneumology, University Hospital Heidelberg, Heidelberg, Germany
| | - Martin Möckel
- Division of Emergency Medicine and CPU, Department of Cardiology, Charité –Universitätsmedizin Berlin, Berlin, Germany
- James Cook University (JCU), Cairns, Australia
| | - Lutz Frankenstein
- Department of Angiology, Cardiology and Pneumology, University Hospital Heidelberg, Heidelberg, Germany
| | - Mehrshad Vafaie
- Department of Angiology, Cardiology and Pneumology, University Hospital Heidelberg, Heidelberg, Germany
| | | | - Anna Slagman
- Division of Emergency Medicine and CPU, Department of Cardiology, Charité –Universitätsmedizin Berlin, Berlin, Germany
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5
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Mueller T, Egger M, Peer E, Dieplinger B. 5th generation cardiac troponin I and T assays in clinical routine - A head-to-head comparison with data from the Linz troponin (LITROP) study. Clin Chim Acta 2018; 485:195-204. [PMID: 29958891 DOI: 10.1016/j.cca.2018.06.027] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2018] [Revised: 06/13/2018] [Accepted: 06/21/2018] [Indexed: 01/22/2023]
Abstract
BACKGROUND In Europe, clinicians use so called high-sensitivity assays for the measurement of cardiac troponin I and T (i.e., hs-cTnI and hs-cTnT assays, also termed 5th generation assays) since several years. We aimed at performing a head-to-head comparison of two 5th generation assays in "real life use". METHODS We studied 3588 consecutive patients presenting to an emergency department. We used both, a hs-cTnI assay from Abbott and a hs-cTnT assay from Roche in clinical routine. We assessed (1) the capabilities of hs-cTnI and hs-cTnT for the prediction of 3.7 year all-cause mortality; (2) discordant diagnoses of myocardial injury by hs-cTnI and hs-cTnT according to the European gender-neutral 99th percentile upper reference limits (i.e., 26 ng/L and 14 ng/L, respectively); and (3) analyte kinetics in patient with serial troponin measurements. RESULTS With respect to prognosis of all-cause mortality, the AUC of hs-cTnI was 0.81 (95% CI, 0.80-0.82), and the AUC of hs-cTnT was 0.85 (95% CI, 0.84-0.86). With respect to discordant diagnoses, 21% of the 3588 patients were classified as having myocardial injury by hs-cTnT but not by hs-cTnI, and < 1% were classified as having myocardial injury by hs-cTnI but not by hs-cTnT. In the patients with serial blood sampling, the median delta values were 6.3 ng/L and 25% for hs-cTnI, and 4.2 ng/L and 16% for hs-cTnT. CONCLUSION We found different characteristics of the Abbott hs-cTnI and the Roche hs-cTnT assays, especially when using the European gender-neutral 99th percentile upper reference limits. Clinically, these different characteristics are related to discordant results in the diagnosis and prognosis of patients presenting to an emergency department.
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Affiliation(s)
- Thomas Mueller
- Department of Clinical Pathology, Hospital of Bolzano, Bolzano, Italy.
| | - Margot Egger
- Department of Laboratory Medicine, Konventhospital Barmherzige Brueder Linz, Linz, Austria
| | - Evi Peer
- Department of Clinical Pathology, Hospital of Bolzano, Bolzano, Italy
| | - Benjamin Dieplinger
- Department of Laboratory Medicine, Konventhospital Barmherzige Brueder Linz, Linz, Austria
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6
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Kavsak PA, Andruchow JE, McRae AD, Worster A. Profile of Roche’s Elecsys Troponin T Gen 5 STAT blood test (a high-sensitivity cardiac troponin assay) for diagnosing myocardial infarction in the emergency department. Expert Rev Mol Diagn 2018; 18:481-489. [DOI: 10.1080/14737159.2018.1476141] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Affiliation(s)
- Peter A. Kavsak
- Department of Pathology and Molecular Medicine, McMaster University, Hamilton, Ontario, Canada
| | - James E. Andruchow
- Department of Emergency Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Andrew D. McRae
- Department of Emergency Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Andrew Worster
- Division of Emergency Medicine, McMaster University, Hamilton, Ontario, Canada
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7
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Kavsak PA, Worster A, Shortt C, Ma J, Clayton N, Sherbino J, Hill SA, McQueen M, Griffith LE, Mehta SR, McRae AD, Devereaux PJ. Performance of high-sensitivity cardiac troponin in the emergency department for myocardial infarction and a composite cardiac outcome across different estimated glomerular filtration rates. Clin Chim Acta 2018; 479:166-170. [PMID: 29366835 DOI: 10.1016/j.cca.2018.01.034] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2017] [Revised: 01/11/2018] [Accepted: 01/19/2018] [Indexed: 10/18/2022]
Abstract
BACKGROUND Clinicians regularly observe increased high-sensitivity cardiac troponin (hs-cTn) concentrations in patients with low estimated glomerular filtration rate (eGFR). The challenge is to differentiate acute coronary syndrome (ACS) from increased hs-cTn results across a range of eGFR. The objective of this study was to determined the optimal hs-cTn concentrations for acute myocardial infarction (MI) and a composite cardiovascular outcome across different eGFR ranges and to assess the utility of a low hs-cTn cutoff to rule-out events. METHODS We undertook an observational study in the emergency department of patients (n = 1212) with symptoms suggestive of ACS who had an eGFR and at least one Roche hs-cTnT and one Abbott hs-cTnI result. The 7-day outcomes were MI or a composite of MI, unstable angina, congestive heart failure, serious ventricular cardiac arrhythmia, or death. The maximum hs-cTn concentration was assessed across different eGFR ranges (<30,30-59,60-89,≥90 ml/min/1.73m2) by spearman correlation, ROC-curve analyses, and sensitivity and negative predictive value (NPV) for the proposed rule-out hs-cTn cutoffs (hs-cTnI<5 ng/l and hs-cTnT<6 ng/l) for the outcomes. RESULTS Both hs-cTnI and hs-cTnT concentrations were negatively correlated with eGFR. The lower the eGFR, the lower the AUC and the higher the optimal hs-cTn cutoffs for both MI and the composite outcome. The highest combined sensitivity (100%), NPV (100%) and proportion of low-risk for MI (45% of group) was observed for patients with hs-cTnT<6 ng/l with an eGFR≥90. CONCLUSION The test performance for hs-cTn for diagnosing or ruling-out an acute cardiac event varies per the eGFR. Accurate risk stratification requires knowledge of the eGFR.
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Affiliation(s)
- Peter A Kavsak
- Department of Pathology and Molecular Medicine, McMaster University, Hamilton, ON, Canada.
| | - Andrew Worster
- Division of Emergency Medicine, McMaster University, Hamilton, ON, Canada
| | - Colleen Shortt
- Division of Emergency Medicine, McMaster University, Hamilton, ON, Canada
| | - Jinhui Ma
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Natasha Clayton
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Jonathan Sherbino
- Division of Emergency Medicine, McMaster University, Hamilton, ON, Canada
| | - Stephen A Hill
- Department of Pathology and Molecular Medicine, McMaster University, Hamilton, ON, Canada
| | - Matthew McQueen
- Department of Pathology and Molecular Medicine, McMaster University, Hamilton, ON, Canada
| | - Lauren E Griffith
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Shamir R Mehta
- Division of Cardiology, and Population Health Research Institute, McMaster University, Hamilton, ON, Canada
| | - Andrew D McRae
- Department of Emergency Medicine, University of Calgary, Calgary, Alberta, Canada
| | - P J Devereaux
- Division of Cardiology, and Population Health Research Institute, McMaster University, Hamilton, ON, Canada
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8
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Ambavane A, Lindahl B, Giannitis E, Roiz J, Mendivil J, Frankenstein L, Body R, Christ M, Bingisser R, Alquezar A, Mueller C. Economic evaluation of the one-hour rule-out and rule-in algorithm for acute myocardial infarction using the high-sensitivity cardiac troponin T assay in the emergency department. PLoS One 2017; 12:e0187662. [PMID: 29121105 PMCID: PMC5679593 DOI: 10.1371/journal.pone.0187662] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2017] [Accepted: 10/24/2017] [Indexed: 11/19/2022] Open
Abstract
Background The 1-hour (h) algorithm triages patients presenting with suspected acute myocardial infarction (AMI) to the emergency department (ED) towards “rule-out,” “rule-in,” or “observation,” depending on baseline and 1-h levels of high-sensitivity cardiac troponin (hs-cTn). The economic consequences of applying the accelerated 1-h algorithm are unknown. Methods and findings We performed a post-hoc economic analysis in a large, diagnostic, multicenter study of hs-cTnT using central adjudication of the final diagnosis by two independent cardiologists. Length of stay (LoS), resource utilization (RU), and predicted diagnostic accuracy of the 1-h algorithm compared to standard of care (SoC) in the ED were estimated. The ED LoS, RU, and accuracy of the 1-h algorithm was compared to that achieved by the SoC at ED discharge. Expert opinion was sought to characterize clinical implementation of the 1-h algorithm, which required blood draws at ED presentation and 1h, after which “rule-in” patients were transferred for coronary angiography, “rule-out” patients underwent outpatient stress testing, and “observation” patients received SoC. Unit costs were for the United Kingdom, Switzerland, and Germany. The sensitivity and specificity for the 1-h algorithm were 87% and 96%, respectively, compared to 69% and 98% for SoC. The mean ED LoS for the 1-h algorithm was 4.3h—it was 6.5h for SoC, which is a reduction of 33%. The 1-h algorithm was associated with reductions in RU, driven largely by the shorter LoS in the ED for patients with a diagnosis other than AMI. The estimated total costs per patient were £2,480 for the 1-h algorithm compared to £4,561 for SoC, a reduction of up to 46%. Conclusions The analysis shows that the use of 1-h algorithm is associated with reduction in overall AMI diagnostic costs, provided it is carefully implemented in clinical practice. These results need to be prospectively validated in the future.
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Affiliation(s)
- Apoorva Ambavane
- Modeling and Simulation, Evidera, London, United Kingdom
- * E-mail:
| | - Bertil Lindahl
- Department of Medical Sciences, Uppsala University and Uppsala Clinical Research Center, Uppsala, Sweden
| | | | - Julie Roiz
- Modeling and Simulation, Evidera, London, United Kingdom
| | - Joan Mendivil
- Previous employment: Market Access, Roche Diagnostics International Ltd., Rotkreuz, Switzerland
| | - Lutz Frankenstein
- Department of Cardiology, Angiology, Pulmonology, University Hospital of Heidelberg, Heidelberg, Germany
| | - Richard Body
- Emergency Department, Central Manchester University Hospitals NHS Foundation Trust, Manchester, United Kingdom
| | - Michael Christ
- Department of Emergency and Critical Care Medicine, Paracelsus Medical University, Nuremberg General Hospital, Nuremberg, Germany
| | - Roland Bingisser
- Emergency Department, University of Basel, University Hospital, Basel, Switzerland
| | - Aitor Alquezar
- Servei de Urgencies. Hospital de Sant Pau, Barcelona, Spain
| | - Christian Mueller
- Department of Cardiology and Cardiovascular Research Institute Basel, University Hospital Basel, Basel, Switzerland
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