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Wang G, Wang J, Wu S, Zheng W, Zhang H, Ma J, Zheng J, Xu F, Chen Y. Clinical impact of using a more sensitive troponin assay in patients with acute chest pain. Clin Cardiol 2019; 42:561-567. [PMID: 30887538 PMCID: PMC6522991 DOI: 10.1002/clc.23177] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2019] [Revised: 03/13/2019] [Accepted: 03/15/2019] [Indexed: 12/27/2022] Open
Abstract
Background More sensitive troponin assays have the potential to better evaluate patients with suspected acute coronary syndrome (ACS). Meanwhile, they may result in avoidable diagnostic testing. Hypothesis Our aim was to determine the clinical impact of implementing a more sensitive cardiac troponin I (cTnI) assay in patients with acute non‐traumatic chest pain presenting to the emergency department (ED). Methods This is a pre‐post cohort study. A total of 1201 consecutive patients with acute non‐traumatic chest pain or equivalent ischemic symptoms suggestive of ACS were allocated to two groups according to the cTnI assay used. The outcomes included the ED length of stay (LOS), hospital admission rate, the use of procedures and the incidence of major adverse cardiac events (MACE) at 30 days. Results The introduction of the more sensitive troponin assay shortened ED LOS (odds ratio [OR] 0.39, 95% confidence interval [CI] 0.28‐0.54) regarding patients discharged home directly, increased the hospital admission rate (OR 1.43, 95% CI 1.12‐1.84), the use of echocardiography (OR 1.58, 95% CI 1.22‐2.06), coronary computed tomography angiography (OR 1.78, 95% CI 1.04‐3.06), coronary angiography (OR 1.53, 95% CI 1.10‐2.12) and percutaneous coronary intervention (OR 2.42, 95% CI 1.58‐3.70) regarding patients discharged or admitted. The incidence of MACE did not decrease significantly (OR 0.61, 95% CI 0.27‐1.37). Conclusions The introduction of the more sensitive troponin assay appeared to result in less time spent in the ED regarding patients discharged home directly, but prompted more hospitalizations and procedures without impacting the incidence of MACE.
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Affiliation(s)
- Guangmei Wang
- Department of Emergency, Qilu Hospital, Shandong University, Jinan, China.,Chest Pain Center, Qilu Hospital, Shandong University, Jinan, China.,Key Laboratory of Emergency and Critical Care Medicine of Shandong Province, Qilu Hospital, Shandong University, Jinan, China.,Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education and Chinese Ministry of Public Health, Qilu Hospital, Shandong University, Jinan, China
| | - Jiali Wang
- Department of Emergency, Qilu Hospital, Shandong University, Jinan, China.,Chest Pain Center, Qilu Hospital, Shandong University, Jinan, China.,Key Laboratory of Emergency and Critical Care Medicine of Shandong Province, Qilu Hospital, Shandong University, Jinan, China.,Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education and Chinese Ministry of Public Health, Qilu Hospital, Shandong University, Jinan, China
| | - Shuo Wu
- Department of Emergency, Qilu Hospital, Shandong University, Jinan, China.,Chest Pain Center, Qilu Hospital, Shandong University, Jinan, China.,Key Laboratory of Emergency and Critical Care Medicine of Shandong Province, Qilu Hospital, Shandong University, Jinan, China.,Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education and Chinese Ministry of Public Health, Qilu Hospital, Shandong University, Jinan, China
| | - Wen Zheng
- Department of Emergency, Qilu Hospital, Shandong University, Jinan, China.,Chest Pain Center, Qilu Hospital, Shandong University, Jinan, China.,Key Laboratory of Emergency and Critical Care Medicine of Shandong Province, Qilu Hospital, Shandong University, Jinan, China.,Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education and Chinese Ministry of Public Health, Qilu Hospital, Shandong University, Jinan, China
| | - He Zhang
- Department of Emergency, Qilu Hospital, Shandong University, Jinan, China.,Chest Pain Center, Qilu Hospital, Shandong University, Jinan, China.,Key Laboratory of Emergency and Critical Care Medicine of Shandong Province, Qilu Hospital, Shandong University, Jinan, China.,Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education and Chinese Ministry of Public Health, Qilu Hospital, Shandong University, Jinan, China
| | - Jingjing Ma
- Department of Emergency, Qilu Hospital, Shandong University, Jinan, China.,Chest Pain Center, Qilu Hospital, Shandong University, Jinan, China.,Key Laboratory of Emergency and Critical Care Medicine of Shandong Province, Qilu Hospital, Shandong University, Jinan, China.,Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education and Chinese Ministry of Public Health, Qilu Hospital, Shandong University, Jinan, China
| | - Jiaqi Zheng
- Department of Emergency, Qilu Hospital, Shandong University, Jinan, China.,Chest Pain Center, Qilu Hospital, Shandong University, Jinan, China.,Key Laboratory of Emergency and Critical Care Medicine of Shandong Province, Qilu Hospital, Shandong University, Jinan, China.,Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education and Chinese Ministry of Public Health, Qilu Hospital, Shandong University, Jinan, China
| | - Feng Xu
- Department of Emergency, Qilu Hospital, Shandong University, Jinan, China.,Chest Pain Center, Qilu Hospital, Shandong University, Jinan, China.,Key Laboratory of Emergency and Critical Care Medicine of Shandong Province, Qilu Hospital, Shandong University, Jinan, China.,Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education and Chinese Ministry of Public Health, Qilu Hospital, Shandong University, Jinan, China
| | - Yuguo Chen
- Department of Emergency, Qilu Hospital, Shandong University, Jinan, China.,Chest Pain Center, Qilu Hospital, Shandong University, Jinan, China.,Key Laboratory of Emergency and Critical Care Medicine of Shandong Province, Qilu Hospital, Shandong University, Jinan, China.,Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education and Chinese Ministry of Public Health, Qilu Hospital, Shandong University, Jinan, China
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Tecson KM, Arnold W, Barrett T, Birkhahn R, Daniels LB, DeFilippi C, Headden G, Peacock WF, Reed M, Singer AJ, Schussler JM, Smith S, Than MP, McCullough PA. Interpretation of positive troponin results among patients with and without myocardial infarction. Proc (Bayl Univ Med Cent) 2017; 30:11-15. [PMID: 28127121 DOI: 10.1080/08998280.2017.11929513] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Abstract
Measuring cardiac troponins is integral to diagnosing acute myocardial infarction (AMI); however, troponins may be elevated without AMI, and the use of multiple different assays confounds comparisons. We considered characteristics and serial troponin values in emergency department chest pain patients with and without AMI to interpret troponin excursions. We compared serial troponin in 124 AMI and non-AMI patients from the observational Performance of Triage Cardiac Markers in the Clinical Setting (PEARL) study who presented with chest pain and had at least one troponin value exceeding the 99th percentile of normal. Because 8 assays were used during data collection, we employed a method of scaling the troponin value to the corresponding assay's 99th percentile upper reference limit to standardize the results. In 81 AMI patients, 96% had elevated troponin at the first test following initial elevation, compared to 73% of the 43 non-AMI patients (P < 0.001). Scaling troponin to the 99th percentile of normal yielded a median value that was 4.8 [2.2, 14.1] times higher than the 99th percentile cutpoint among AMI patients, compared to 2.3 [1.5, 6.5] times higher among non-AMI patients (P = 0.04). The rise in serial scaled troponin values distinguished the AMI patients. Scaling to the 99th percentile was useful for comparing troponin when different assays were utilized.
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Affiliation(s)
- Kristen M Tecson
- Baylor Heart and Vascular Institute, Dallas, Texas (Tecson, McCullough); Baylor Scott & White Research Institute, Dallas, Texas (Tecson); Texas A&M Health Science Center College of Medicine, Dallas, Texas (Tecson, Schussler, McCullough); Department of Clinical Affairs, Alere Inc., San Diego, California (Arnold); Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee (Barrett); New York Methodist Hospital, Brooklyn, New York (Birkhahn); Division of Cardiovascular Medicine, University of California San Diego Health, La Jolla, California (Daniels); Inova Heart and Vascular Institute, Falls Church, Virginia (DeFilippi); Medical University of South Carolina, Charleston, South Carolina (Headden); Baylor University Ben Taub Hospital, Houston, Texas (Peacock); International Heart Institute of Montana, Missoula, Montana (Reed); Department of Emergency Medicine, Stony Brook University Hospital, Stony Brook, New York (Singer); Division of Cardiology, Baylor University Medical Center, Dallas, Texas (Schussler, McCullough); Baylor Jack and Jane Hamilton Heart and Vascular Hospital, Dallas, Texas (Schussler, McCullough); Hennepin County Medical Center Emergency Department, Minneapolis, Minnesota (Smith); Emergency Department, Christchurch Hospital, and University of Otago, Christchurch, New Zealand (Than); and The Heart Hospital Baylor Plano, Plano, Texas (McCullough)
| | - William Arnold
- Baylor Heart and Vascular Institute, Dallas, Texas (Tecson, McCullough); Baylor Scott & White Research Institute, Dallas, Texas (Tecson); Texas A&M Health Science Center College of Medicine, Dallas, Texas (Tecson, Schussler, McCullough); Department of Clinical Affairs, Alere Inc., San Diego, California (Arnold); Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee (Barrett); New York Methodist Hospital, Brooklyn, New York (Birkhahn); Division of Cardiovascular Medicine, University of California San Diego Health, La Jolla, California (Daniels); Inova Heart and Vascular Institute, Falls Church, Virginia (DeFilippi); Medical University of South Carolina, Charleston, South Carolina (Headden); Baylor University Ben Taub Hospital, Houston, Texas (Peacock); International Heart Institute of Montana, Missoula, Montana (Reed); Department of Emergency Medicine, Stony Brook University Hospital, Stony Brook, New York (Singer); Division of Cardiology, Baylor University Medical Center, Dallas, Texas (Schussler, McCullough); Baylor Jack and Jane Hamilton Heart and Vascular Hospital, Dallas, Texas (Schussler, McCullough); Hennepin County Medical Center Emergency Department, Minneapolis, Minnesota (Smith); Emergency Department, Christchurch Hospital, and University of Otago, Christchurch, New Zealand (Than); and The Heart Hospital Baylor Plano, Plano, Texas (McCullough)
| | - Tyler Barrett
- Baylor Heart and Vascular Institute, Dallas, Texas (Tecson, McCullough); Baylor Scott & White Research Institute, Dallas, Texas (Tecson); Texas A&M Health Science Center College of Medicine, Dallas, Texas (Tecson, Schussler, McCullough); Department of Clinical Affairs, Alere Inc., San Diego, California (Arnold); Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee (Barrett); New York Methodist Hospital, Brooklyn, New York (Birkhahn); Division of Cardiovascular Medicine, University of California San Diego Health, La Jolla, California (Daniels); Inova Heart and Vascular Institute, Falls Church, Virginia (DeFilippi); Medical University of South Carolina, Charleston, South Carolina (Headden); Baylor University Ben Taub Hospital, Houston, Texas (Peacock); International Heart Institute of Montana, Missoula, Montana (Reed); Department of Emergency Medicine, Stony Brook University Hospital, Stony Brook, New York (Singer); Division of Cardiology, Baylor University Medical Center, Dallas, Texas (Schussler, McCullough); Baylor Jack and Jane Hamilton Heart and Vascular Hospital, Dallas, Texas (Schussler, McCullough); Hennepin County Medical Center Emergency Department, Minneapolis, Minnesota (Smith); Emergency Department, Christchurch Hospital, and University of Otago, Christchurch, New Zealand (Than); and The Heart Hospital Baylor Plano, Plano, Texas (McCullough)
| | - Robert Birkhahn
- Baylor Heart and Vascular Institute, Dallas, Texas (Tecson, McCullough); Baylor Scott & White Research Institute, Dallas, Texas (Tecson); Texas A&M Health Science Center College of Medicine, Dallas, Texas (Tecson, Schussler, McCullough); Department of Clinical Affairs, Alere Inc., San Diego, California (Arnold); Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee (Barrett); New York Methodist Hospital, Brooklyn, New York (Birkhahn); Division of Cardiovascular Medicine, University of California San Diego Health, La Jolla, California (Daniels); Inova Heart and Vascular Institute, Falls Church, Virginia (DeFilippi); Medical University of South Carolina, Charleston, South Carolina (Headden); Baylor University Ben Taub Hospital, Houston, Texas (Peacock); International Heart Institute of Montana, Missoula, Montana (Reed); Department of Emergency Medicine, Stony Brook University Hospital, Stony Brook, New York (Singer); Division of Cardiology, Baylor University Medical Center, Dallas, Texas (Schussler, McCullough); Baylor Jack and Jane Hamilton Heart and Vascular Hospital, Dallas, Texas (Schussler, McCullough); Hennepin County Medical Center Emergency Department, Minneapolis, Minnesota (Smith); Emergency Department, Christchurch Hospital, and University of Otago, Christchurch, New Zealand (Than); and The Heart Hospital Baylor Plano, Plano, Texas (McCullough)
| | - Lori B Daniels
- Baylor Heart and Vascular Institute, Dallas, Texas (Tecson, McCullough); Baylor Scott & White Research Institute, Dallas, Texas (Tecson); Texas A&M Health Science Center College of Medicine, Dallas, Texas (Tecson, Schussler, McCullough); Department of Clinical Affairs, Alere Inc., San Diego, California (Arnold); Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee (Barrett); New York Methodist Hospital, Brooklyn, New York (Birkhahn); Division of Cardiovascular Medicine, University of California San Diego Health, La Jolla, California (Daniels); Inova Heart and Vascular Institute, Falls Church, Virginia (DeFilippi); Medical University of South Carolina, Charleston, South Carolina (Headden); Baylor University Ben Taub Hospital, Houston, Texas (Peacock); International Heart Institute of Montana, Missoula, Montana (Reed); Department of Emergency Medicine, Stony Brook University Hospital, Stony Brook, New York (Singer); Division of Cardiology, Baylor University Medical Center, Dallas, Texas (Schussler, McCullough); Baylor Jack and Jane Hamilton Heart and Vascular Hospital, Dallas, Texas (Schussler, McCullough); Hennepin County Medical Center Emergency Department, Minneapolis, Minnesota (Smith); Emergency Department, Christchurch Hospital, and University of Otago, Christchurch, New Zealand (Than); and The Heart Hospital Baylor Plano, Plano, Texas (McCullough)
| | - Christopher DeFilippi
- Baylor Heart and Vascular Institute, Dallas, Texas (Tecson, McCullough); Baylor Scott & White Research Institute, Dallas, Texas (Tecson); Texas A&M Health Science Center College of Medicine, Dallas, Texas (Tecson, Schussler, McCullough); Department of Clinical Affairs, Alere Inc., San Diego, California (Arnold); Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee (Barrett); New York Methodist Hospital, Brooklyn, New York (Birkhahn); Division of Cardiovascular Medicine, University of California San Diego Health, La Jolla, California (Daniels); Inova Heart and Vascular Institute, Falls Church, Virginia (DeFilippi); Medical University of South Carolina, Charleston, South Carolina (Headden); Baylor University Ben Taub Hospital, Houston, Texas (Peacock); International Heart Institute of Montana, Missoula, Montana (Reed); Department of Emergency Medicine, Stony Brook University Hospital, Stony Brook, New York (Singer); Division of Cardiology, Baylor University Medical Center, Dallas, Texas (Schussler, McCullough); Baylor Jack and Jane Hamilton Heart and Vascular Hospital, Dallas, Texas (Schussler, McCullough); Hennepin County Medical Center Emergency Department, Minneapolis, Minnesota (Smith); Emergency Department, Christchurch Hospital, and University of Otago, Christchurch, New Zealand (Than); and The Heart Hospital Baylor Plano, Plano, Texas (McCullough)
| | - Gary Headden
- Baylor Heart and Vascular Institute, Dallas, Texas (Tecson, McCullough); Baylor Scott & White Research Institute, Dallas, Texas (Tecson); Texas A&M Health Science Center College of Medicine, Dallas, Texas (Tecson, Schussler, McCullough); Department of Clinical Affairs, Alere Inc., San Diego, California (Arnold); Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee (Barrett); New York Methodist Hospital, Brooklyn, New York (Birkhahn); Division of Cardiovascular Medicine, University of California San Diego Health, La Jolla, California (Daniels); Inova Heart and Vascular Institute, Falls Church, Virginia (DeFilippi); Medical University of South Carolina, Charleston, South Carolina (Headden); Baylor University Ben Taub Hospital, Houston, Texas (Peacock); International Heart Institute of Montana, Missoula, Montana (Reed); Department of Emergency Medicine, Stony Brook University Hospital, Stony Brook, New York (Singer); Division of Cardiology, Baylor University Medical Center, Dallas, Texas (Schussler, McCullough); Baylor Jack and Jane Hamilton Heart and Vascular Hospital, Dallas, Texas (Schussler, McCullough); Hennepin County Medical Center Emergency Department, Minneapolis, Minnesota (Smith); Emergency Department, Christchurch Hospital, and University of Otago, Christchurch, New Zealand (Than); and The Heart Hospital Baylor Plano, Plano, Texas (McCullough)
| | - W Frank Peacock
- Baylor Heart and Vascular Institute, Dallas, Texas (Tecson, McCullough); Baylor Scott & White Research Institute, Dallas, Texas (Tecson); Texas A&M Health Science Center College of Medicine, Dallas, Texas (Tecson, Schussler, McCullough); Department of Clinical Affairs, Alere Inc., San Diego, California (Arnold); Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee (Barrett); New York Methodist Hospital, Brooklyn, New York (Birkhahn); Division of Cardiovascular Medicine, University of California San Diego Health, La Jolla, California (Daniels); Inova Heart and Vascular Institute, Falls Church, Virginia (DeFilippi); Medical University of South Carolina, Charleston, South Carolina (Headden); Baylor University Ben Taub Hospital, Houston, Texas (Peacock); International Heart Institute of Montana, Missoula, Montana (Reed); Department of Emergency Medicine, Stony Brook University Hospital, Stony Brook, New York (Singer); Division of Cardiology, Baylor University Medical Center, Dallas, Texas (Schussler, McCullough); Baylor Jack and Jane Hamilton Heart and Vascular Hospital, Dallas, Texas (Schussler, McCullough); Hennepin County Medical Center Emergency Department, Minneapolis, Minnesota (Smith); Emergency Department, Christchurch Hospital, and University of Otago, Christchurch, New Zealand (Than); and The Heart Hospital Baylor Plano, Plano, Texas (McCullough)
| | - Michael Reed
- Baylor Heart and Vascular Institute, Dallas, Texas (Tecson, McCullough); Baylor Scott & White Research Institute, Dallas, Texas (Tecson); Texas A&M Health Science Center College of Medicine, Dallas, Texas (Tecson, Schussler, McCullough); Department of Clinical Affairs, Alere Inc., San Diego, California (Arnold); Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee (Barrett); New York Methodist Hospital, Brooklyn, New York (Birkhahn); Division of Cardiovascular Medicine, University of California San Diego Health, La Jolla, California (Daniels); Inova Heart and Vascular Institute, Falls Church, Virginia (DeFilippi); Medical University of South Carolina, Charleston, South Carolina (Headden); Baylor University Ben Taub Hospital, Houston, Texas (Peacock); International Heart Institute of Montana, Missoula, Montana (Reed); Department of Emergency Medicine, Stony Brook University Hospital, Stony Brook, New York (Singer); Division of Cardiology, Baylor University Medical Center, Dallas, Texas (Schussler, McCullough); Baylor Jack and Jane Hamilton Heart and Vascular Hospital, Dallas, Texas (Schussler, McCullough); Hennepin County Medical Center Emergency Department, Minneapolis, Minnesota (Smith); Emergency Department, Christchurch Hospital, and University of Otago, Christchurch, New Zealand (Than); and The Heart Hospital Baylor Plano, Plano, Texas (McCullough)
| | - Adam J Singer
- Baylor Heart and Vascular Institute, Dallas, Texas (Tecson, McCullough); Baylor Scott & White Research Institute, Dallas, Texas (Tecson); Texas A&M Health Science Center College of Medicine, Dallas, Texas (Tecson, Schussler, McCullough); Department of Clinical Affairs, Alere Inc., San Diego, California (Arnold); Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee (Barrett); New York Methodist Hospital, Brooklyn, New York (Birkhahn); Division of Cardiovascular Medicine, University of California San Diego Health, La Jolla, California (Daniels); Inova Heart and Vascular Institute, Falls Church, Virginia (DeFilippi); Medical University of South Carolina, Charleston, South Carolina (Headden); Baylor University Ben Taub Hospital, Houston, Texas (Peacock); International Heart Institute of Montana, Missoula, Montana (Reed); Department of Emergency Medicine, Stony Brook University Hospital, Stony Brook, New York (Singer); Division of Cardiology, Baylor University Medical Center, Dallas, Texas (Schussler, McCullough); Baylor Jack and Jane Hamilton Heart and Vascular Hospital, Dallas, Texas (Schussler, McCullough); Hennepin County Medical Center Emergency Department, Minneapolis, Minnesota (Smith); Emergency Department, Christchurch Hospital, and University of Otago, Christchurch, New Zealand (Than); and The Heart Hospital Baylor Plano, Plano, Texas (McCullough)
| | - Jeffrey M Schussler
- Baylor Heart and Vascular Institute, Dallas, Texas (Tecson, McCullough); Baylor Scott & White Research Institute, Dallas, Texas (Tecson); Texas A&M Health Science Center College of Medicine, Dallas, Texas (Tecson, Schussler, McCullough); Department of Clinical Affairs, Alere Inc., San Diego, California (Arnold); Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee (Barrett); New York Methodist Hospital, Brooklyn, New York (Birkhahn); Division of Cardiovascular Medicine, University of California San Diego Health, La Jolla, California (Daniels); Inova Heart and Vascular Institute, Falls Church, Virginia (DeFilippi); Medical University of South Carolina, Charleston, South Carolina (Headden); Baylor University Ben Taub Hospital, Houston, Texas (Peacock); International Heart Institute of Montana, Missoula, Montana (Reed); Department of Emergency Medicine, Stony Brook University Hospital, Stony Brook, New York (Singer); Division of Cardiology, Baylor University Medical Center, Dallas, Texas (Schussler, McCullough); Baylor Jack and Jane Hamilton Heart and Vascular Hospital, Dallas, Texas (Schussler, McCullough); Hennepin County Medical Center Emergency Department, Minneapolis, Minnesota (Smith); Emergency Department, Christchurch Hospital, and University of Otago, Christchurch, New Zealand (Than); and The Heart Hospital Baylor Plano, Plano, Texas (McCullough)
| | - Stephen Smith
- Baylor Heart and Vascular Institute, Dallas, Texas (Tecson, McCullough); Baylor Scott & White Research Institute, Dallas, Texas (Tecson); Texas A&M Health Science Center College of Medicine, Dallas, Texas (Tecson, Schussler, McCullough); Department of Clinical Affairs, Alere Inc., San Diego, California (Arnold); Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee (Barrett); New York Methodist Hospital, Brooklyn, New York (Birkhahn); Division of Cardiovascular Medicine, University of California San Diego Health, La Jolla, California (Daniels); Inova Heart and Vascular Institute, Falls Church, Virginia (DeFilippi); Medical University of South Carolina, Charleston, South Carolina (Headden); Baylor University Ben Taub Hospital, Houston, Texas (Peacock); International Heart Institute of Montana, Missoula, Montana (Reed); Department of Emergency Medicine, Stony Brook University Hospital, Stony Brook, New York (Singer); Division of Cardiology, Baylor University Medical Center, Dallas, Texas (Schussler, McCullough); Baylor Jack and Jane Hamilton Heart and Vascular Hospital, Dallas, Texas (Schussler, McCullough); Hennepin County Medical Center Emergency Department, Minneapolis, Minnesota (Smith); Emergency Department, Christchurch Hospital, and University of Otago, Christchurch, New Zealand (Than); and The Heart Hospital Baylor Plano, Plano, Texas (McCullough)
| | - Martin P Than
- Baylor Heart and Vascular Institute, Dallas, Texas (Tecson, McCullough); Baylor Scott & White Research Institute, Dallas, Texas (Tecson); Texas A&M Health Science Center College of Medicine, Dallas, Texas (Tecson, Schussler, McCullough); Department of Clinical Affairs, Alere Inc., San Diego, California (Arnold); Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee (Barrett); New York Methodist Hospital, Brooklyn, New York (Birkhahn); Division of Cardiovascular Medicine, University of California San Diego Health, La Jolla, California (Daniels); Inova Heart and Vascular Institute, Falls Church, Virginia (DeFilippi); Medical University of South Carolina, Charleston, South Carolina (Headden); Baylor University Ben Taub Hospital, Houston, Texas (Peacock); International Heart Institute of Montana, Missoula, Montana (Reed); Department of Emergency Medicine, Stony Brook University Hospital, Stony Brook, New York (Singer); Division of Cardiology, Baylor University Medical Center, Dallas, Texas (Schussler, McCullough); Baylor Jack and Jane Hamilton Heart and Vascular Hospital, Dallas, Texas (Schussler, McCullough); Hennepin County Medical Center Emergency Department, Minneapolis, Minnesota (Smith); Emergency Department, Christchurch Hospital, and University of Otago, Christchurch, New Zealand (Than); and The Heart Hospital Baylor Plano, Plano, Texas (McCullough)
| | - Peter A McCullough
- Baylor Heart and Vascular Institute, Dallas, Texas (Tecson, McCullough); Baylor Scott & White Research Institute, Dallas, Texas (Tecson); Texas A&M Health Science Center College of Medicine, Dallas, Texas (Tecson, Schussler, McCullough); Department of Clinical Affairs, Alere Inc., San Diego, California (Arnold); Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee (Barrett); New York Methodist Hospital, Brooklyn, New York (Birkhahn); Division of Cardiovascular Medicine, University of California San Diego Health, La Jolla, California (Daniels); Inova Heart and Vascular Institute, Falls Church, Virginia (DeFilippi); Medical University of South Carolina, Charleston, South Carolina (Headden); Baylor University Ben Taub Hospital, Houston, Texas (Peacock); International Heart Institute of Montana, Missoula, Montana (Reed); Department of Emergency Medicine, Stony Brook University Hospital, Stony Brook, New York (Singer); Division of Cardiology, Baylor University Medical Center, Dallas, Texas (Schussler, McCullough); Baylor Jack and Jane Hamilton Heart and Vascular Hospital, Dallas, Texas (Schussler, McCullough); Hennepin County Medical Center Emergency Department, Minneapolis, Minnesota (Smith); Emergency Department, Christchurch Hospital, and University of Otago, Christchurch, New Zealand (Than); and The Heart Hospital Baylor Plano, Plano, Texas (McCullough)
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