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Toprak B, Solleder H, Di Carluccio E, Greenslade JH, Parsonage WA, Schulz K, Cullen L, Apple FS, Ziegler A, Blankenberg S. Diagnostic accuracy of a machine learning algorithm using point-of-care high-sensitivity cardiac troponin I for rapid rule-out of myocardial infarction: a retrospective study. Lancet Digit Health 2024; 6:e729-e738. [PMID: 39214763 DOI: 10.1016/s2589-7500(24)00191-2] [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: 07/29/2024] [Revised: 08/08/2024] [Accepted: 08/13/2024] [Indexed: 09/04/2024]
Abstract
BACKGROUND Point-of-care (POC) high-sensitivity cardiac troponin (hs-cTn) assays have been shown to provide similar analytical precision despite substantially shorter turnaround times compared with laboratory-based hs-cTn assays. We applied the previously developed machine learning based personalised Artificial Intelligence in Suspected Myocardial Infarction Study (ARTEMIS) algorithm, which can predict the individual probability of myocardial infarction, with a single POC hs-cTn measurement, and compared its diagnostic performance with standard-of-care pathways for rapid rule-out of myocardial infarction. METHODS We retrospectively analysed pooled data from consecutive patients of two prospective observational cohorts in geographically distinct regions (the Safe Emergency Department Discharge Rate cohort from the USA and the Suspected Acute Myocardial Infarction in Emergency cohort from Australia) who presented to the emergency department with suspected myocardial infarction. Patients with ST-segment elevation myocardial infarction were excluded. Safety and efficacy of direct rule-out of myocardial infarction by the ARTEMIS algorithm (at a pre-specified probability threshold of <0·5%) were compared with the European Society of Cardiology (ESC)-recommended and the American College of Cardiology (ACC)-recommended 0 h pathways using a single POC high-sensitivity cardiac troponin I (hs-cTnI) measurement (Siemens Atellica VTLi as investigational assay). The primary diagnostic outcome was an adjudicated index diagnosis of type 1 or type 2 myocardial infarction according to the Fourth Universal Definition of Myocardial Infarction. The safety outcome was a composite of incident myocardial infarction and cardiovascular death (follow-up events) at 30 days. Additional analyses were performed for type I myocardial infarction only (secondary diagnostic outcome), and for each cohort separately. Subgroup analyses were performed for age (<65 years vs ≥65 years), sex, symptom onset (≤3 h vs >3 h), estimated glomerular filtration rate (<60 mL/min per 1·73 m2vs ≥60 mL/min per 1·73 m2), and absence or presence of arterial hypertension, diabetes, a history of coronary artery disease, myocardial infarction, or heart failure, smoking, and ischaemic electrocardiogram signs. FINDINGS Among 2560 patients (1075 [42%] women, median age 58 years [IQR 48·0-69·0]), prevalence of myocardial infarction was 6·5% (166/2560). The ARTEMIS-POC algorithm classified 899 patients (35·1%) as suitable for rapid rule-out with a negative predictive value of 99·96% (95% CI 99·64-99·96) and a sensitivity of 99·68% (97·21-99·70). For type I myocardial infarction only, negative predictive value and sensitivity were both 100%. Proportions of missed index myocardial infarction (0·05% [0·04-0·42]) and follow-up events at 30 days (0·07% [95% CI 0·06-0·59]) were low. While maintaining high safety, the ARTEMIS-POC algorithm identified more than twice as many patients as eligible for direct rule-out compared with guideline-recommended ESC 0 h (15·2%) and ACC 0 h (13·8%) pathways. Superior efficacy persisted across all clinically relevant subgroups. INTERPRETATION The patient-tailored, medical decision support ARTEMIS-POC algorithm applied with a single POC hs-cTnI measurement allows for very rapid, safe, and more efficient direct rule-out of myocardial infarction than guideline-recommended pathways. It has the potential to expedite the safe discharge of low-risk patients from the emergency department including early presenters with symptom onset less than 3 h at the time of admission and might open new opportunities for the triage of patients with suspected myocardial infarction even in ambulatory, preclinical, or geographically isolated care settings. FUNDING The German Center for Cardiovascular Research (DZHK).
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Affiliation(s)
- Betül Toprak
- Department of Cardiology, University Heart and Vascular Center, University Medical Center Hamburg-Eppendorf, Hamburg, Germany; University Center of Cardiovascular Science, University Heart and Vascular Center, University Medical Center Hamburg-Eppendorf, Hamburg, Germany; Department for Population Health Innovation, University Heart and Vascular Center, University Medical Center Hamburg-Eppendorf, Hamburg, Germany; German Center for Cardiovascular Research (DZHK), Partner Sites Hamburg/Kiel/Luebeck, Hamburg, Germany
| | - Hugo Solleder
- Cardio-CARE, Medizincampus Davos, Davos, Switzerland
| | | | - Jaimi H Greenslade
- Emergency and Trauma Centre, Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia
| | - William A Parsonage
- Australian Centre for Health Services Innovation, School of Public Health and Social Work, Queensland University of Technology, Brisbane, QLD, Australia
| | - Karen Schulz
- Department of Laboratory Medicine and Pathology, University of Minnesota, Minneapolis, MN, USA
| | - Louise Cullen
- Emergency and Trauma Centre, Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia; Australian Centre for Health Services Innovation, School of Public Health and Social Work, Queensland University of Technology, Brisbane, QLD, Australia; Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia
| | - Fred S Apple
- Department of Laboratory Medicine and Pathology, University of Minnesota, Minneapolis, MN, USA; Hennepin Healthcare Research Institute, Minneapolis, MN, USA
| | - Andreas Ziegler
- Department of Cardiology, University Heart and Vascular Center, University Medical Center Hamburg-Eppendorf, Hamburg, Germany; German Center for Cardiovascular Research (DZHK), Partner Sites Hamburg/Kiel/Luebeck, Hamburg, Germany; Cardio-CARE, Medizincampus Davos, Davos, Switzerland; School of Mathematics, Statistics and Computer Science, University of KwaZulu-Natal, Pietermaritzburg, South Africa
| | - Stefan Blankenberg
- Department of Cardiology, University Heart and Vascular Center, University Medical Center Hamburg-Eppendorf, Hamburg, Germany; University Center of Cardiovascular Science, University Heart and Vascular Center, University Medical Center Hamburg-Eppendorf, Hamburg, Germany; Department for Population Health Innovation, University Heart and Vascular Center, University Medical Center Hamburg-Eppendorf, Hamburg, Germany; German Center for Cardiovascular Research (DZHK), Partner Sites Hamburg/Kiel/Luebeck, Hamburg, Germany.
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Neumann JT, Weimann J, Sörensen NA, Hartikainen TS, Haller PM, Lehmacher J, Brocks C, Tenhaeff S, Karakas M, Renné T, Blankenberg S, Zeller T, Westermann D. A Biomarker Model to Distinguish Types of Myocardial Infarction and Injury. J Am Coll Cardiol 2021; 78:781-790. [PMID: 34412811 DOI: 10.1016/j.jacc.2021.06.027] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Revised: 06/07/2021] [Accepted: 06/09/2021] [Indexed: 02/06/2023]
Abstract
BACKGROUND Discrimination among patients with type 1 myocardial infarction (T1MI), type 2 myocardial infarction (T2MI), and myocardial injury is difficult. OBJECTIVES The aim of this study was to investigate the discriminative value of a 29-biomarker panel in an emergency department setting. METHODS Patients presenting with suspected myocardial infarction (MI) were recruited. The final diagnosis in all patients was adjudicated on the basis of the fourth universal definition of MI. A panel of 29 biomarkers was measured, and multivariable logistic regression analysis was used to evaluate the associations of these biomarkers with the diagnosis of MI or myocardial injury. Biomarkers were chosen using backward selection. The model was internally validated using bootstrapping. RESULTS Overall, 748 patients were recruited (median age 64 years), of whom 138 had MI (107 T1MI and 31 T2MI) and 221 had myocardial injury. In the multivariable model, 4 biomarkers (apolipoprotein A-II, N-terminal prohormone of brain natriuretic peptide, copeptin, and high-sensitivity cardiac troponin I) remained significant discriminators between T1MI and T2MI. Internal validation of the model showed an area under the curve of 0.82. For discrimination between MI and myocardial injury, 6 biomarkers (adiponectin, N-terminal prohormone of brain natriuretic peptide, pulmonary and activation-regulated chemokine, transthyretin, copeptin, and high-sensitivity troponin I) were selected. Internal validation showed an area under the curve of 0.84. CONCLUSIONS Among 29 biomarkers, 7 were identified to be the most relevant discriminators between subtypes of MI or myocardial injury. Regression models based on these biomarkers allowed good discrimination. (Biomarkers in Acute Cardiac Care [BACC]; NCT02355457).
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Affiliation(s)
- Johannes T Neumann
- Department of Cardiology, University Heart & Vascular Center, Hamburg, Germany; German Center for Cardiovascular Research, Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany; Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia.
| | - Jessica Weimann
- Department of Cardiology, University Heart & Vascular Center, Hamburg, Germany
| | - Nils A Sörensen
- Department of Cardiology, University Heart & Vascular Center, Hamburg, Germany; German Center for Cardiovascular Research, Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - Tau S Hartikainen
- Department of Cardiology, University Heart & Vascular Center, Hamburg, Germany
| | - Paul M Haller
- Department of Cardiology, University Heart & Vascular Center, Hamburg, Germany; German Center for Cardiovascular Research, Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - Jonas Lehmacher
- Department of Cardiology, University Heart & Vascular Center, Hamburg, Germany
| | - Celine Brocks
- Department of Cardiology, University Heart & Vascular Center, Hamburg, Germany
| | - Sophia Tenhaeff
- Department of Cardiology, University Heart & Vascular Center, Hamburg, Germany
| | - Mahir Karakas
- Department of Cardiology, University Heart & Vascular Center, Hamburg, Germany; German Center for Cardiovascular Research, Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - Thomas Renné
- Institute of Clinical Chemistry and Laboratory Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Stefan Blankenberg
- Department of Cardiology, University Heart & Vascular Center, Hamburg, Germany; German Center for Cardiovascular Research, Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - Tanja Zeller
- Department of Cardiology, University Heart & Vascular Center, Hamburg, Germany; German Center for Cardiovascular Research, Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - Dirk Westermann
- Department of Cardiology, University Heart & Vascular Center, Hamburg, Germany; German Center for Cardiovascular Research, Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany
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Brichko L, Schneider HG, Chan W, Seah J, Smit DV, Dart A, Stevens JP, Mitra B. Rapid and safe discharge from the emergency department: A single troponin to exclude acute myocardial infarction. Emerg Med Australas 2018; 30:486-493. [DOI: 10.1111/1742-6723.12919] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2017] [Accepted: 11/24/2017] [Indexed: 11/26/2022]
Affiliation(s)
- Lisa Brichko
- Emergency and Trauma Centre; The Alfred Hospital; Melbourne Victoria Australia
| | - Hans G Schneider
- Clinical Biochemistry Unit; The Alfred Hospital; Melbourne Victoria Australia
- Central Clinical School; Monash University; Melbourne Victoria Australia
| | - William Chan
- Cardiology Department; The Alfred Hospital; Melbourne Victoria Australia
- Cardiology Department; Western Health; Melbourne Victoria Australia
- Melbourne Medical School; The University of Melbourne; Melbourne Victoria Australia
| | - Jarrel Seah
- Emergency and Trauma Centre; The Alfred Hospital; Melbourne Victoria Australia
| | - De Villiers Smit
- Emergency and Trauma Centre; The Alfred Hospital; Melbourne Victoria Australia
- National Trauma Research Institute; The Alfred Hospital; Melbourne Victoria Australia
- Department of Epidemiology and Preventive Medicine; Monash University; Melbourne Victoria Australia
| | - Anthony Dart
- Cardiology Department; The Alfred Hospital; Melbourne Victoria Australia
| | - Jeremy P Stevens
- Emergency and Trauma Centre; The Alfred Hospital; Melbourne Victoria Australia
| | - Biswadev Mitra
- Emergency and Trauma Centre; The Alfred Hospital; Melbourne Victoria Australia
- National Trauma Research Institute; The Alfred Hospital; Melbourne Victoria Australia
- Department of Epidemiology and Preventive Medicine; Monash University; Melbourne Victoria Australia
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