Accelerated -Rule-Out of acute Myocardial Infarction using prehospital copeptin and in-hospital troponin: The AROMI study

AIMS

The present acute myocardial infarction (AMI) rule-out strategies are challenged by the late temporal release of cardiac troponin. Copeptin is a non-specific biomarker of endogenous stress and rises early in AMI, covering the early period where troponin is still normal. An accelerated dual-marker rule-out strategy combining prehospital copeptin and in-hospital high-sensitivity troponin T could reduce length of hospital stay and thus the burden on the health care systems worldwide. The AROMI trial aimed to evaluate if the accelerated dual-marker rule-out strategy could safely reduce length of stay in patients discharged after early rule-out of AMI.

METHODS AND RESULTS

Patients with suspected AMI transported to hospital by ambulance were randomized 1:1 to either accelerated rule-out using copeptin measured in a prehospital blood sample and high-sensitivity troponin T measured at arrival to hospital or to standard rule-out using a 0 h/3 h rule-out strategy. The AROMI study included 4351 patients with suspected AMI. The accelerated dual-marker rule-out strategy reduced mean length of stay by 0.9 h (95% confidence interval 0.7-1.1 h) in patients discharged after rule-out of AMI and was non-inferior regarding 30-day major adverse cardiac events when compared to standard rule-out (absolute risk difference -0.4%, 95% confidence interval -2.5 to 1.7; P-value for non-inferiority = 0.013).

CONCLUSION

Accelerated dual marker rule-out of AMI, using a combination of prehospital copeptin and first in-hospital high-sensitivity troponin T, reduces length of hospital stay without increasing the rate of 30-day major adverse cardiac events as compared to using a 0 h/3 h rule-out strategy.

Analytical assessment and performance of the 0/3h algorithm with novel high sensitivity cardiac troponin I

BACKGROUND

Recently, Ortho Clinical Diagnostics have launched a high sensitivity cardiac troponin I assay adapted on Vitros3600 / 5600. We aimed at evaluating the analytical and clinical performances using the 0/3-hour algorithm, of the Ortho hs-cTnI assay on the Vitros 3600® (Ortho Clinical Diagnostics, Illkirch, France) analyzer with comparison to Roche hs-cTnT assay on the Cobas8000/e801® module (Roche diagnostics, Meylan, France) and the Abbott STAT hs-cTnI assay on the Alinity i® (Abbott, Rungis, France) analyzer.

METHODS

Imprecision studies, linearity, limit of detection, and the interference to hemolysis were performed for Ortho hs-cTnI assay. The concordance study was based on results of troponin obtained from 160 patients with chest pain to the emergency department. Testing was performed simultaneously measuring the Roche hs-cTnT and the Ortho hs-cTnI, then on remaining sample the concentration of Abbott hs-cTnI (n = 150). We applied the 0/3h algorithm to rule out/rule in, in acute myocardial infarction.

RESULTS

Analytical performances were acceptable and in accordance with manufacturer's data. For late presenters 100, 92.8 and 88.8% patients could be rule-out with Roche, Ortho and Abbott assay, respectively with one NSTEMI missed with both hs-TnI assays. Applying the hs-cTn cut-offs from 0/3-hour algorithm, 107 (66.8%) could be rule out with Roche hs-cTnT with no AMI missed (sensitivity 100% [95%CI: 90.5 to 100] and NPV 100%); 89 with Ortho hs-cTnI (sensitivity 97.3% [95%CI: 85.8-99.9] and NPV 98.8% [95%CI:92.7-99.8]); and 61 with Abbott hs-cTnI (sensitivity 97% [95%CI: 84.2-99.9] and NPV 98.4% [95%CI: 89.8-99.7]). For rule-in, 23.7% (n = 37) from the total population would be designated in this group, with a specificity of 86.9% (95%CI: 79.7-92.4) and PPV of 69.8% (95%CI: 59.4-78.5) vs specificity of 72.3% (95%CI:63.5-80.0) and PPV of 51.4% (95%CI: 44.1-58.2)with Roche hs-cTnT vs Ortho hs-cTnI respectively; and with Abbott, 33 patients had constitued this group with a specificity of 52.1% (95%CI:42.7-61.4) and PPV of 36.4% (95%CI: 32.0-41.0).

CONCLUSION

In conclusion, according to ESC guidelines, our results indicate that the Ortho hs-cTnI assay for the Vitros 3600 instrument is a method that may be used in the clinical practice using 0/3-hour algorithm.

First comes the A, then the B: what we learned from the COVID-19 outbreak

The SARS-CoV-2 epidemic, which has spread to many countries around the world, has hit Europe particularly hard. From our point of view, in a rural emergency department (with an annual patient census of around 25,000) in northeastern Italy, it is necessary to preserve the hospital and prevent it from becoming an outbreak of infection. In our experience, we reevaluated the negative predictive value of lung ultrasound to rule out lung involvement. Since severe acute respiratory failure appears to be the leading cause of death for COVID-19 patients, it is essential to focus on this clinical feature. We currently believe that a patient suspected of COVID-19, if he has a normal ultrasound examination (a so-called "A-profile"), can be discharged home to continue isolation and be treated without being hospitalized.

Dual-cutoff of sFlt-1/PlGF ratio in the stratification of preeclampsia: a systematic review and meta-analysis

PURPOSE

To systematically review the approach of using two independent sFlt-1/PlGF cutoffs that has better sensitivity (cutoff-sen) and specificity (cutoff-spe) separately for risk stratification in the detection of preeclampsia.

METHODS

PubMed and Embase databases and reference lists were searched up to June 2016. Inclusion criteria were blood samples for sFlt-1/PlGF with separate cutoffs (cutoff-sen and cutoff-spe) provided. Six relevant studies were identified. Pooling of results was done based on three studies and a systematic review was performed based on all six.

RESULTS

The strategy of using a cutoff of ≤33 and ≥85 for early onset preeclampsia, and ≤33 and ≥110 for the late onset preeclampsia was proposed and examined. The pooled sensitivity for cutoff-sen was: 95.3% (90.6-98.1%) and 88.6% (82.9-92.9%) for early and late onset preeclampsia, respectively. The pooled specificity for cutoff-spe was: 97.6% (95.2-98.9%) and 94.2% (91.4-96.3%) for early and late onset preeclampsia respectively. The pooled estimation of the early onset pre-eclamptic pregnancies and control normal pregnancies classified in the equivocal zone was 4.9% (2.0-8.8%) and 32.4% (25.7-39.5%), respectively, and 26.8% (10.3-47.6%) and 8.7% (3.0-17.6%) for late onset patients.

CONCLUSION

The new dual-cutoff diagnostic system optimizes the predictive performance of the single cutoff system. Further studies are required to assess the performance of this system and to define the approach and frequency at which subjects in the equivocal zone should be screened.