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Smith SW, Meyers HP. ST Elevation is a poor surrogate for acute coronary occlusion. Let's Replace STEMI with Occlusion MI (OMI)!! Int J Cardiol 2024; 407:131980. [PMID: 38513733 DOI: 10.1016/j.ijcard.2024.131980] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2024] [Accepted: 03/17/2024] [Indexed: 03/23/2024]
Affiliation(s)
- Stephen W Smith
- Hennepin Healthcare, ER R-2, 701 S. Park Ave, Minneapolis, MN 55419, United States; Department of Emergency Medicine, Hennepin Healthcare and The University of Minnesota School of Medicine, United States.
| | - H Pendell Meyers
- Hennepin Healthcare, ER R-2, 701 S. Park Ave, Minneapolis, MN 55419, United States
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2
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Giannitsis E, Frey N, Katus HA. Accelerated high sensitivity troponin diagnostics: ready for an even faster pace? Eur Heart J 2024:ehae344. [PMID: 38860689 DOI: 10.1093/eurheartj/ehae344] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/12/2024] Open
Affiliation(s)
- Evangelos Giannitsis
- Cardiovascular Medicine, University Hospital Heidelberg, Im Neuenheimer Feld 410, D-69120 Heidelberg, Germany
| | - Norbert Frey
- Cardiovascular Medicine, University Hospital Heidelberg, Im Neuenheimer Feld 410, D-69120 Heidelberg, Germany
| | - Hugo A Katus
- Cardiovascular Medicine, University Hospital Heidelberg, Im Neuenheimer Feld 410, D-69120 Heidelberg, Germany
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3
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Cullen L, Greenslade J, Parsonage W, Stephensen L, Smith SW, Sandoval Y, Ranasinghe I, Gaikwad N, Khorramshahi Bayat M, Mahmoodi E, Schulz K, Than M, Apple FS. Point-of-care high-sensitivity cardiac troponin in suspected acute myocardial infarction assessed at baseline and 2 h. Eur Heart J 2024:ehae343. [PMID: 38842324 DOI: 10.1093/eurheartj/ehae343] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Revised: 04/15/2024] [Accepted: 05/16/2024] [Indexed: 06/07/2024] Open
Abstract
BACKGROUND AND AIMS Strategies to assess patients with suspected acute myocardial infarction (AMI) using a point-of-care (POC) high-sensitivity cardiac troponin I (hs-cTnI) assay may expedite emergency care. A 2-h POC hs-cTnI strategy for emergency patients with suspected AMI was derived and validated. METHODS In two international, multi-centre, prospective, observational studies of adult emergency patients (1486 derivation cohort and 1796 validation cohort) with suspected AMI, hs-cTnI (Siemens Atellica® VTLi) was measured at admission and 2 h later. Adjudicated final diagnoses utilized the hs-cTn assay in clinical use. A risk stratification algorithm was derived and validated. The primary diagnostic outcome was index AMI (Types 1 and 2). The primary safety outcome was 30-day major adverse cardiac events incorporating AMI and cardiac death. RESULTS Overall, 81 (5.5%) and 88 (4.9%) patients in the derivation and validation cohorts, respectively, had AMI. The 2-h algorithm defined 66.1% as low risk with a sensitivity of 98.8% [95% confidence interval (CI) 89.3%-99.9%] and a negative predictive value of 99.9 (95% CI 99.2%-100%) for index AMI in the derivation cohort. In the validation cohort, 53.3% were low risk with a sensitivity of 98.9% (95% CI 92.4%-99.8%) and a negative predictive value of 99.9% (95% CI 99.3%-100%) for index AMI. The high-risk metrics identified 5.4% of patients with a specificity of 98.5% (95% CI 96.6%-99.4%) and a positive predictive value of 74.5% (95% CI 62.7%-83.6%) for index AMI. CONCLUSIONS A 2-h algorithm using a POC hs-cTnI concentration enables safe and efficient risk assessment of patients with suspected AMI. The short turnaround time of POC testing may support significant efficiencies in the management of the large proportion of emergency patients with suspected AMI.
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Affiliation(s)
- Louise Cullen
- Emergency and Trauma Centre, Royal Brisbane and Women's Hospital, Butterfield Street, Herston, 4029 Queensland, Australia
- Australian Centre for Health Services Innovation, Centre for Healthcare Transformation, School of Public Health and Social Work, Faculty of Health, Queensland University of Technology, Musk Avenue, Kelvin Grove, 4059 Queensland, Australia
- Faculty of Medicine, The University of Queensland, Herston Road, Herston, 4006 Queensland, Australia
| | - Jaimi Greenslade
- Emergency and Trauma Centre, Royal Brisbane and Women's Hospital, Butterfield Street, Herston, 4029 Queensland, Australia
- Australian Centre for Health Services Innovation, Centre for Healthcare Transformation, School of Public Health and Social Work, Faculty of Health, Queensland University of Technology, Musk Avenue, Kelvin Grove, 4059 Queensland, Australia
- Faculty of Medicine, The University of Queensland, Herston Road, Herston, 4006 Queensland, Australia
| | - William Parsonage
- Australian Centre for Health Services Innovation, Centre for Healthcare Transformation, School of Public Health and Social Work, Faculty of Health, Queensland University of Technology, Musk Avenue, Kelvin Grove, 4059 Queensland, Australia
- Department of Cardiology, Royal Brisbane and Women's Hospital, Brisbane, Australia
| | - Laura Stephensen
- Emergency and Trauma Centre, Royal Brisbane and Women's Hospital, Butterfield Street, Herston, 4029 Queensland, Australia
| | - Stephen W Smith
- Department of Emergency Medicine at Hennepin Healthcare/Hennepin County Medical Center, University of Minnesota School of Medicine, Minneapolis, MN, USA
| | - Yader Sandoval
- Minneapolis Heart Institute, Abbott Northwestern Hospital and Center for Coronary Artery Disease, Minneapolis Heart Institute Foundation, Minneapolis, MN, USA
| | - Isuru Ranasinghe
- Faculty of Medicine, The University of Queensland, Herston Road, Herston, 4006 Queensland, Australia
- Department of Cardiology, The Prince Charles Hospital, Brisbane, Australia
| | - Niranjan Gaikwad
- Department of Cardiology, The Prince Charles Hospital, Brisbane, Australia
| | | | - Ehsan Mahmoodi
- Department of Cardiology, The Prince Charles Hospital, Brisbane, Australia
| | - Karen Schulz
- Department of Laboratory Medicine and Pathology, University of Minnesota, Minneapolis, MN, USA
| | - Martin Than
- Emergency Department, Christchurch Hospital, Christchurch, New Zealand
| | - Fred S Apple
- Department of Laboratory Medicine and Pathology, University of Minnesota, Minneapolis, MN, USA
- Clinical and Forensic Toxicology Laboratory, Hennepin Healthcare/Hennepin County Medical Center, Minneapolis, MN, USA
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4
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Koirala S, Danley K, Kerolos M, Chu J, Yucebay E, Purim-Shem-Tov Y, Volgman AS, Attanasio S. Effect of transitioning from conventional cardiac troponin to high-sensitivity cardiac troponin on resource utilization- a single center experience. Am J Emerg Med 2024; 80:174-177. [PMID: 38613986 DOI: 10.1016/j.ajem.2024.04.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Revised: 03/09/2024] [Accepted: 04/06/2024] [Indexed: 04/15/2024] Open
Abstract
BACKGROUND Compared to conventional cardiac troponin (cTn), the high-sensitivity cardiac troponin (hs-cTn) assay is associated with improved detection of myocardial infarction (MI). METHODS We performed a descriptive retrospective analysis of resource utilization at Rush University Medical Center over the transition period (July 1, 2021) from a cTn to a hs-cTn assay. Inclusion criteria included emergency department (ED) encounters between January 1 to December 31, 2021, with chief complaints of "chest pain" or "dyspnea" with associated troponin orders. The primary endpoint was the percentage of ED discharges. Secondary endpoints included the number of cardiac studies ordered. Univariable comparisons of these endpoints were performed using Student's t-test for continuous variables and Chi-square tests for binary/categorical variables. RESULTS A total of 5113 encounters were analyzed. Hs-cTn was associated with an overall increase in ED patient discharges with negative troponin tests (44.1% vs. 29.9%, P < 0.01). In terms of cardiac testing per encounter, hs-cTn was associated with significant increases in the number of troponin tests (1.9 vs. 1.6, P < 0.01), electrocardiograms (3.0 vs. 2.9, P = 0.01), and echocardiograms (0.5 vs. 0.4, P < 0.01). There was a significant decrease in the utilization of stress testing (0.21 vs. 0.26, P < 0.01). There was a significant increase in total coronary angiography use during the hs-cTn period compared to cTn (227/2471 (9.2%) vs. 195/2642 (7.4%), P = 0.02). CONCLUSION Transitioning from cTn to hs-cTn was associated with significantly increased ED discharges and an increase in troponin tests, ECG, echocardiograms, and coronary angiograms. There was a decrease in the number of stress tests.
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Affiliation(s)
- Sushant Koirala
- Department of Internal Medicine, Rush University Medical Center, 600 S. Paulina St., Chicago, IL 60612, USA.
| | - Kelsey Danley
- Department of Internal Medicine, Rush University Medical Center, Chicago, IL, USA.
| | - Mina Kerolos
- Department of Internal Medicine, Rush University Medical Center, Chicago, IL, USA.
| | - Jian Chu
- Department of Internal Medicine, Rush University Medical Center, Chicago, IL, USA.
| | - Elif Yucebay
- Department of Emergency Medicine, Rush University Medical Center, Chicago, IL, USA.
| | | | - Annabelle Santos Volgman
- Division of Cardiology, Department of Internal Medicine, Rush University Medical Center, Chicago, IL, USA.
| | - Steve Attanasio
- Division of Cardiology, Department of Internal Medicine, Rush University Medical Center, Chicago, IL, USA.
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Fabre-Estremera B, Schulz K, Ladd A, Sexter A, Apple FS. Analytical validation of the Mindray CL1200i analyzer high sensitivity cardiac troponin I assay: MERITnI study. Clin Chem Lab Med 2024; 0:cclm-2024-0352. [PMID: 38801528 DOI: 10.1515/cclm-2024-0352] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2024] [Accepted: 05/13/2024] [Indexed: 05/29/2024]
Abstract
OBJECTIVES This study performed an analytical validation study of the Mindray high-sensitivity cardiac troponin I (hs-cTnI) assay addressing limit of blank (LoB), limit of detection (LoD), precision, linearity, analytical specificity and sex-specific 99th percentile upper reference limits. METHODS LoB, LoD, precision, linearity and analytical specificity were studied according to Clinical and Laboratory Standards Institute. We used one reagent lot and one CL1200i analyzer. Skeletal troponin I and T, cardiac troponin T, troponin C, actin, tropomyosin, myosin light chain, myoglobin and creatine kinase (CK-MB) were studied for cross-reactivity. Interference with biotin was examined. Lithium heparin samples (one freeze thaw cycle) from healthy males and females were measured to determine the 99th percentiles by using the non-parametric method. Analyses were performed before and after excluding subjects with clinical conditions and/or increased surrogate biomarkers. RESULTS The Mindray hs-cTnI assay met criteria to be considered as a hs-cTn assay. LoB and LoD was <0.1 ng/L and 0.1 ng/L, respectively. Repeatability had a coefficient of variation 1.2-3.8 %, and within-laboratory imprecision 1.7-5.0 %. The measuring interval ranged from 1.1 to 28,180 ng/L. The analytical specificity was clinically acceptable for the interferents studied. After exclusions, the 99th percentile URLs obtained were 10 ng/L overall, 5 ng/L for females and 12 ng/L for males. CONCLUSIONS Analytical observations of the Mindray hs-cTnI assay demonstrated excellent LoB, LoD, precision, linearity and analytical specificity, that were in alignment with the manufacturer's claims and regulatory guidelines for hs-cTnI. The assay is suitable for clinical investigation for patient-oriented studies.
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Affiliation(s)
- Blanca Fabre-Estremera
- Department of Laboratory Medicine, 16268 La Paz University Hospital , Madrid, Spain
- Department of Preventive Medicine and Public Health, Universidad Autónoma de Madrid, Madrid, Spain
| | - Karen Schulz
- 20298 Hennepin Healthcare Research Institute , Minneapolis, MN, USA
| | - Alanna Ladd
- 20298 Hennepin Healthcare Research Institute , Minneapolis, MN, USA
| | - Anne Sexter
- 20298 Hennepin Healthcare Research Institute , Minneapolis, MN, USA
| | - Fred S Apple
- 20298 Hennepin Healthcare Research Institute , Minneapolis, MN, USA
- Department of Laboratory Medicine & Pathology, 5532 Hennepin Healthcare/Hennepin County Medical Center , Minneapolis, MN, USA
- Department of Laboratory Medicine & Pathology, University of Minnesota School of Medicine, Minneapolis, MN, USA
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De Iuliis V, Gabriele AR, De Santis F, De Rugeriis R, Di Quinzio L, Aloisi S, Rosati AC, Benvenuto M, Fabiani D, Chiatamone Ranieri S. Diagnostic performance of a point of care high-sensitivity cardiac troponin I assay and single measurement evaluation to rule out and rule in acute coronary syndrome. Clin Chem Lab Med 2024; 0:cclm-2024-0225. [PMID: 38669209 DOI: 10.1515/cclm-2024-0225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2024] [Accepted: 04/16/2024] [Indexed: 04/28/2024]
Abstract
OBJECTIVES About 10 million individuals in USA presented annually in the emergency department (ED) with chest pain or with signs and symptoms of acute coronary syndrome (ACS). The advent of point of care (POC) devices, able to measure high sensitivity troponin, are a very interesting tool in the ED setting for its rapid turnaround time (<10 min). METHODS The present study evaluates the diagnostic performance of the Atellica VTLi (Siemens) in real life setting using the clinical data derived from integrated diagnoses of emergency room staff and cardiologist and in comparison with standard laboratory hs-cTnT assay (Cobas 8000, Elecsys, Roche). 966 patients admitted to the emergency department of "G. Mazzini Hospital" in Teramo, Italy, from July 27, 2022, through June 09, 2023, were enrolled. RESULTS The diagnostic performance of POC hs-cTnI was evaluated. An appropriate POC hs-cTnI threshold values <4 ng/L supplied a sensitivity and an NPV of 100 % (95 % CI: 99.5-100) in order to achieve rapid rule out for MI through a single measurement at patient presentation in the ED. Furthermore, a derivation POC hs-cTnI concentration >54 ng/L provided a specificity of 97.2 % (95 % CI: 95.9-98.1) and a PPV of 43.5 % (95 % CI: 40.3-46.7) for ruling in MI. CONCLUSIONS This platform showed comparable diagnostic performance for myocardial infarction to the central laboratory. Our data suggest the possible use of the Atellica VTLi hs-cTnI POC assay either in emergency department of urban medical centre, either in rural hospital for triage and patient management.
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Affiliation(s)
- Vincenzo De Iuliis
- Department of Clinical Pathology, 92708 G. Mazzini Civil Hospital , Teramo, Italy
| | | | - Francesca De Santis
- Department of Clinical Pathology, 92708 G. Mazzini Civil Hospital , Teramo, Italy
| | - Roberta De Rugeriis
- Department of Clinical Pathology, 92708 G. Mazzini Civil Hospital , Teramo, Italy
| | - Luigi Di Quinzio
- Emergency Department, 92708 G. Mazzini Civil Hospital , Teramo, Italy
| | - Steeve Aloisi
- Emergency Department, 92708 G. Mazzini Civil Hospital , Teramo, Italy
| | - Anna Carla Rosati
- Cardiology Division, 92708 G. Mazzini Civil Hospital , Teramo, Italy
| | - Manuela Benvenuto
- Cardiology Division, 92708 G. Mazzini Civil Hospital , Teramo, Italy
| | - Donatello Fabiani
- Cardiology Division, 92708 G. Mazzini Civil Hospital , Teramo, Italy
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7
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Cullen L, Greenslade JH, Stephensen L, Ranasinghe I, Gaikwad N, Khorramshahi Bayat M, Mahmoodi E, Than M, Apple F, Parsonage W. External validation of a rapid algorithm using high-sensitivity troponin assay results for evaluating patients with suspected acute myocardial infarction. Emerg Med J 2024; 41:313-319. [PMID: 38316538 DOI: 10.1136/emermed-2023-213539] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Accepted: 01/22/2024] [Indexed: 02/07/2024]
Abstract
OBJECTIVE We sought to validate the clinical performance of a rapid assessment pathway incorporating the Siemens Atellica IM high sensitivity cardiac troponin I (hs-cTnI) assay in patients presenting to the emergency department (ED) with suspected acute myocardial infarction (AMI). METHODS This was a multicentre prospective observational study of adult ED patients presenting to five Australian hospitals between November 2020 and September 2021. Participants included those with symptoms of suspected AMI (without ST-segment elevation MI on presentation ECG). The Siemen's Atellica IM hs-cTnI laboratory-based assay was used to measure troponin concentrations at admission and after 2-3 hours and cardiologists adjudicated final diagnoses. The HighSTEACS diagnostic algorithm was evaluated, incorporating hs-cTnI concentrations at presentation and absolute changes within the first 2 to 3 hours. The primary outcome was index AMI, including type 1 or 2 non-ST segment elevation MI (NSTEMI) or ST-elevation MI (STEMI) following presentation. 30-day major adverse cardiac outcomes (including AMI, urgent revascularisation or cardiac death) were also reported. The trial was registered with the Australian and New Zealand Clinical Trials Registry. RESULTS 1994 patients were included. The average age was 56.2 years (SD=15.6), and 44.9% were women. 118 (5.9%) patients had confirmed index AMI. The 2-hour algorithm defined 61.3% of patients as low risk. Sensitivity was 99.1% (94.0%-99.9%) and negative predictive value was 99.9% (99.3%-100%). 24.4% of patients were deemed intermediate risk. When applying the parameters for high risk, 252 (14.3%) were identified, with a specificity of 91.5% (88.7%-93.6%) and a PPV of 42.0% (35.6-48.7%). CONCLUSIONS A 2-hour algorithm based on the HighSTEACS strategy using the Siemens Atellica IM hs-cTnI laboratory-based assay enables safe and efficient risk assessment of emergency patients with suspected AMI. TRIAL REGISTRATION NUMBER ACTRN12621000053820.
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Affiliation(s)
- Louise Cullen
- Emergency and Trauma Centre, Royal Brisbane and Women's Hospital, Herston, Queensland, Australia
| | - Jaimi H Greenslade
- Department of Emergency Medicine, Royal Brisbane and Women\'s Hospital, Herston, Queensland, Australia
- School of Public Health, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Laura Stephensen
- Department of Emergency Medicine, Royal Brisbane and Women\'s Hospital, Herston, Queensland, Australia
- School of Public Health, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Isuru Ranasinghe
- Cardiology, The University of Queensland, Saint Lucia, Queensland, Australia
- The Prince Charles Hospital, Chermside, Queensland, Australia
| | | | | | - Ehsan Mahmoodi
- The Prince Charles Hospital, Chermside, Queensland, Australia
| | - Martin Than
- Emergency Department, Christchurch Hospital, Christchurch, New Zealand
| | - Fred Apple
- Hennepin County Medical Center, Minneapolis, Minnesota, USA
| | - William Parsonage
- Royal Brisbane & Women's Hospital, Brisbane, Queensland, Australia
- Queensland University of Technology, Brisbane, Queensland, Australia
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8
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Curran JM, Mergo A, White S, Croal BL, Cooper JG. High-sensitivity troponin testing at the point of care for the diagnosis of myocardial infarction: a prospective emergency department clinical evaluation. Emerg Med J 2024; 41:320-321. [PMID: 38302279 DOI: 10.1136/emermed-2023-213633] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/22/2024] [Indexed: 02/03/2024]
Affiliation(s)
| | - Aleksandra Mergo
- University of Aberdeen, School of Medicine, Medical Sciences and Nutrition, Aberdeen, UK
| | - Sarah White
- Emergency Department, Aberdeen Royal Infirmary, Aberdeen, UK
| | - Bernard L Croal
- Department of Clinical Biochemistry, Aberdeen Royal Infirmary, Aberdeen, UK
| | - Jamie G Cooper
- Emergency Department, Aberdeen Royal Infirmary, Aberdeen, UK
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9
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Pickering JW, Hamill L, Aldous S, Joyce L, Stothart RA, Williams O, Florkowski CM, Than M. Determination of a whole-blood single-test low-risk threshold for a point-of-care high-sensitivity troponin assay. Emerg Med J 2024; 41:322-323. [PMID: 38429073 DOI: 10.1136/emermed-2023-213689] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/12/2024] [Indexed: 03/03/2024]
Affiliation(s)
- John W Pickering
- Department of Medicine, University of Otago Christchurch, Christchurch, New Zealand
- Emergency Department, Christchurch Hospital, Christchurch, New Zealand
| | - Laura Hamill
- Pegasus Health 24 Hour Surgery Ltd, Christchurch, New Zealand
| | - Sally Aldous
- Cardiology, Christchurch Hospital, Christchurch, New Zealand
| | - Laura Joyce
- Emergency Department, Christchurch Hospital, Christchurch, New Zealand
- Department of Surgery and Critical Care, University of Otago Christchurch, Christchurch, New Zealand
| | - R Alex Stothart
- Emergency Department, Christchurch Hospital, Christchurch, New Zealand
| | - Otis Williams
- Emergency Department, Christchurch Hospital, Christchurch, New Zealand
| | | | - Martin Than
- Department of Medicine, University of Otago Christchurch, Christchurch, New Zealand
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10
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Koechlin L, Boeddinghaus J, Lopez-Ayala P, Wildi K, Nestelberger T, Wussler D, Guzman Tacla CA, Holder T, Muench-Gerber T, Glaeser J, Sanchez AY, Miró Ò, Martin-Sanchez FJ, Kawecki D, Buergler F, Buser A, Huré G, Giménez MR, Keller DI, Christ M, Mueller C. External validation of the 0/1h-algorithm and derivation of a 0/2h-algorithm using a new point-of-care Hs-cTnI assay. Am Heart J 2024; 268:104-113. [PMID: 38042459 DOI: 10.1016/j.ahj.2023.11.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Revised: 11/14/2023] [Accepted: 11/18/2023] [Indexed: 12/04/2023]
Abstract
BACKGROUND The high-sensitivity cardiac troponin (hs-cTn) I point-of-care (POC) hs-cTnI-PATHFAST assay has recently become clinically available. METHODS We aimed to externally validate the hs-cTnI-PATHFAST 0/1h-algorithm recently developed for the early diagnosis of non-ST-segment-elevation myocardial infarction (NSTEMI) and derive and validate a 0/2-algorithm in patients presenting to the emergency department with acute chest discomfort included in a multicenter diagnostic study. Two independent cardiologists centrally adjudicated the final diagnoses using all the clinical and study-specific information available including serial measurements of hs-cTnI-Architect. RESULTS Among 1,532 patients (median age 60 years, 33% [n = 501] women), NSTEMI was the final diagnosis in 13%. External validation of the hs-cTnI-PATHFAST 0/1h-algorithm showed very high negative predictive value (NPV; 100% [95%CI, 99.5%-100%]) and sensitivity 100% (95%CI, 98.2%-100%) for rule-out of NSTEMI. Positive predictive value (PPV) and specificity for rule-in of NSTEMI were high (74.9% [95%CI, 68.3%-80.5%] and 96.4% [95%CI, 95.2%-97.3%], respectively). Among 1,207 patients (median age 61 years, 32% [n = 391] women) available for the derivation (n = 848) and validation (n = 359) of the hs-cTnI-PATHFAST 0/2h-algorithm, a 0h-concentration <3 ng/L or a 0h-concentration <4 ng/L with a 2h-delta <4ng/L ruled-out NSTEMI in 52% of patients with a NPV of 100% (95%CI, 98-100) and sensitivity of 100% (95%CI, 92.9%-100%) in the validation cohort. A 0h-concentration ≥90ng/L or a 2h-delta ≥ 55ng/L ruled-in 38 patients (11%): PPV 81.6% (95%CI, 66.6-90.8), specificity 97.7% (95%CI, 95.4-98.9%). CONCLUSIONS The POC hs-cTnI-PATHFAST assay allows rapid and effective rule-out and rule-in of NSTEMI using both a 0/1h- and a 0/2h-algorithm with high NPV/sensitivity for rule-out and high PPV/specificity for rule-in. CLINICAL TRIAL REGISTRATION NCT00470587.
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Affiliation(s)
- Luca Koechlin
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland; Department of Cardiac Surgery, University Hospital Basel, University of Basel, Switzerland; GREAT network.
| | - Jasper Boeddinghaus
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland; GREAT network; BHF/University Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
| | - Pedro Lopez-Ayala
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland; GREAT network
| | - Karin Wildi
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland; GREAT network; Critical Care Research Group and the University of Queensland, Brisbane, Queensland, Australia
| | - Thomas Nestelberger
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland; GREAT network
| | - Desiree Wussler
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland; GREAT network
| | - Caroline A Guzman Tacla
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland; GREAT network
| | - Timothy Holder
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Tamar Muench-Gerber
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland; GREAT network
| | - Jonas Glaeser
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland; GREAT network
| | - Ana Yufera Sanchez
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland; GREAT network
| | - Òscar Miró
- GREAT network; Emergency Department, Hospital Clinic, Barcelona, Catalonia, Spain
| | | | - Damian Kawecki
- GREAT network; 2nd Department of Cardiology, School of Medicine with the Division of Dentistry in Zabrze, Medical University of Katowice, Zabrze, Poland
| | - Franz Buergler
- Emergency Department, Kantonsspital Liestal, LIestal, Switzerland
| | - Andreas Buser
- Department of hematology and Blood Bank, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Gabrielle Huré
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland; GREAT network
| | - Maria Rubini Giménez
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland; Department of Cardiology, Heart Center Leipzig, University of Leipzig, Leipzig, Germany
| | - Dagmar I Keller
- Emergency Department, University Hospital Zurich, Zurich, Switzerland
| | - Michael Christ
- Emergency Department, Kantonsspital Luzern, Luzern, Switzerland
| | - Christian Mueller
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland; GREAT network.
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Abstract
Rapid and accurate triage of patients presenting with chest pain to an emergency department (ED) is critical to prevent ED overcrowding and unnecessary resource use in individuals at low risk of acute myocardial infarction (AMI) and to efficiently and effectively guide patients at high risk to definite therapy. The use of biomarkers for rule-out or rule-in of suspected AMI has evolved substantially over the last several decades. Previously well-established biomarkers have been replaced by cardiac troponin (cTn). High-sensitivity cTn (hs-cTn) assays represent the newest generation of cTn assays and offer tremendous advantages, including improved sensitivity and precision. Still, implementation of these assays in the United States lags behind several other areas of the world. Within this educational review, we discuss the evolution of biomarker testing for detection of myocardial injury, address the specifics of hs-cTn assays and their recommended use within triage algorithms, and highlight potential challenges in their use. Ultimately, we focus on implementation strategies for hs-cTn assays, as they are now clearly ready for prime time.
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Affiliation(s)
| | - L Kristin Newby
- Duke Clinical Research Institute, Durham, North Carolina, USA; ,
- Division of Cardiology, Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
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12
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Tiwari D, Aw TC. Optimizing the Clinical Use of High-Sensitivity Troponin Assays: A Review. Diagnostics (Basel) 2023; 14:87. [PMID: 38201396 PMCID: PMC10795745 DOI: 10.3390/diagnostics14010087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Revised: 12/14/2023] [Accepted: 12/29/2023] [Indexed: 01/12/2024] Open
Abstract
Ischemic heart diseases (IHDs) remain a global health concern. Many IHD cases go undiagnosed due to challenges in the initial diagnostic process, particularly in cases of acute myocardial infarction (AMI). High-sensitivity cardiac troponin (hs-cTn) assays have revolutionized myocardial injury assessment, but variations in diagnostic cut-off values and population differences have raised challenges. This review addresses essential laboratory and clinical considerations for hs-cTn assays. Laboratory guidelines discuss the importance of establishing standardized 99th-percentile upper reference limits (URLs) considering factors such as age, sex, health status, and analytical precision. The reference population should exclude individuals with comorbidities like diabetes and renal disease, and rigorous selection is crucial. Some clinical guidelines emphasize the significance of sex-specific URL limits while others do not. They highlight the use of serial troponin assays for AMI diagnosis. In addition, timely reporting of accurate hs-cTn results is essential for effective clinical use. This review aims to provide a clearer understanding among laboratory professionals and clinicians on how to optimize the use of hs-cTn assays in clinical settings in order to ensure accurate AMI diagnosis and thus improve patient care and outcomes.
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Affiliation(s)
- Dipti Tiwari
- Independent Researcher, Singapore 069046, Singapore;
| | - Tar Choon Aw
- Department of Laboratory Medicine, Changi General Hospital, Singapore 529889, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore (NUS), Singapore 119228, Singapore
- Pathology Academic Clinical Program, Duke-NUS Graduate School of Medicine, Singapore 169857, Singapore
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13
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Thulin IVL, Jordalen SMF, Lekven OC, Krishnapillai J, Steiro OT, Collinson P, Apple F, Cullen L, Norekvål TM, Wisløff T, Vikenes K, Omland T, Bjørneklett RO, Aakre KM. Aiming toWards Evidence baSed inTerpretation of Cardiac biOmarkers in patients pResenting with chest pain using Point of Care Testing (WESTCOR-POC): study design. SCAND CARDIOVASC J 2023; 57:2272585. [PMID: 37905548 DOI: 10.1080/14017431.2023.2272585] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Accepted: 10/15/2023] [Indexed: 11/02/2023]
Abstract
OBJECTIVES Patients presenting with symptoms suggestive of acute coronary syndrome (ACS) contribute to a high workload and overcrowding in the Emergency Department (ED). Accelerated diagnostic protocols for non-ST-elevation myocardial infarction have proved challenging to implement. One obstacle is the turnaround time for analyzing high-sensitivity cardiac troponin (hs-cTn). In the WESTCOR-POC study (Clinical Trials number NCT05354804) we aim to evaluate safety and efficiency of a 0/1 h hs-cTn algorithm utilizing a hs-cTnI point of care (POC) instrument in comparison to central laboratory hs-cTnT measurements. DESIGN This is a prospective single-center randomized clinical trial aiming to include 1500 patients admitted to the ED with symptoms suggestive of ACS. Patients will receive standard investigations following the European Society of Cardiology 0/1h protocols for centralized hs-cTnT measurements or the intervention using a 0/1h POC hs-cTnI algorithm. Primary end-points are 1) Safety; death, myocardial infarction or acute revascularization within 30 days 2) Efficiency; length of stay in the ED, 3) Cost- effectiveness; total episode cost, 4) Patient satisfaction, 5) Patient symptom burden and 6) Patients quality of life. Secondary outcomes are 12-months death, myocardial infarction or acute revascularization, percentage discharged after 3 and 6 h, total length of hospital stay and all costs related to hospital contact within 12 months. CONCLUSION Results from this study may facilitate implementation of POC hs-cTn testing assays and accelerated diagnostic protocols in EDs, and may serve as a valuable resource for guiding future investigations for the use of POC high sensitivity troponin assays in outpatient clinics and prehospital settings.
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Affiliation(s)
| | | | - Ole Christian Lekven
- Emergency Care Clinic, Haukeland University Hospital, Bergen, Norway
- Department of Heart Disease, Haukeland University Hospital, Bergen, Norway
| | - Jeyaseelan Krishnapillai
- Emergency Care Clinic, Haukeland University Hospital, Bergen, Norway
- Department of Heart Disease, Haukeland University Hospital, Bergen, Norway
| | - Ole Thomas Steiro
- Department of Heart Disease, Haukeland University Hospital, Bergen, Norway
| | - Paul Collinson
- Departments of Clinical Blood Sciences and Cardiology, St George's University Hospitals NHS Foundation Trust, London, UK
- St George's University of London, London, UK
| | - Fred Apple
- Department of Laboratory Medicine and Pathology, Hennepin Healthcare/HCMC, Minneapolis, MN, USA
- Department of Laboratory Medicine and Pathology, University of Minnesota, Minneapolis, MN, USA
| | - Louise Cullen
- Department of Emergency Medicine, Royal Brisbane and Women's Hospital, Brisbane, Australia
- School of Medicine, University of Queensland, Brisbane, Australia
- Faculty of Health, Queensland University of Technology, Brisbane, Australia
| | - Tone M Norekvål
- Department of Heart Disease, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Science, University of Bergen, Bergen, Norway
| | - Torbjørn Wisløff
- Health Services Research Unit, Akershus University Hospital, Lørenskog, Norway
| | - Kjell Vikenes
- Department of Heart Disease, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Science, University of Bergen, Bergen, Norway
| | - Torbjørn Omland
- Department of Cardiology, Akershus University Hospital, Lørenskog, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Rune O Bjørneklett
- Emergency Care Clinic, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Kristin Moberg Aakre
- Department of Heart Disease, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Science, University of Bergen, Bergen, Norway
- Department of Medical Biochemistry and Pharmacology, Haukeland University Hospital, Bergen, Norway
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14
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Aspromonte N, Zaninotto M, Aimo A, Fumarulo I, Plebani M, Clerico A. Measurement of Cardiac-Specific Biomarkers in the Emergency Department: New Insight in Risk Evaluation. Int J Mol Sci 2023; 24:15998. [PMID: 37958981 PMCID: PMC10648028 DOI: 10.3390/ijms242115998] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Revised: 11/02/2023] [Accepted: 11/04/2023] [Indexed: 11/15/2023] Open
Abstract
The aim of this article review is to analyze some models and clinical issues related to the implementation of accelerated diagnostic protocols based on specific cardiac biomarkers in patients admitted to the emergency department (ED) with symptoms compatible with acute cardiac disorders. Four specific clinical issues will be discussed in detail: (a) pathophysiological and clinical interpretations of circulating hs-cTnI and hs-cTnT levels; (b) the clinical relevance and estimation of the biological variation of biomarkers in patients admitted to the ED with acute and severe diseases; (c) the role and advantages of the point-of-care testing (POCT) methods for cardiac-specific biomarkers in pre-hospital and hospital clinical practice; and (d) the clinical role of specific cardiac biomarkers in patients with acute heart failure (AHF). In order to balance the risk between a hasty discharge versus the potential harms caused by a cardiac assessment in patients admitted to the ED with suspected acute cardiovascular disease, the measurement of specific cardiac biomarkers is essential for the early identification of the presence of myocardial dysfunction and/or injury and to significantly reduce the length and costs of hospitalization. Moreover, specific cardiac biomarkers (especially hs-cTnI and hs-cTnT) are useful predictors of mortality and major adverse cardiovascular events (MACE) in patients admitted to the ED with suspected acute cardiovascular disease. To guide the implementation of the most rapid algorithms for the diagnosis of Non-ST-Elevation Myocardial Infarction (NSTEMI) into routine clinical practice, clinical scientific societies and laboratory medicine societies should promote collaborative studies specifically designed for the evaluation of the analytical performance and, especially, the cost/benefit ratio resulting from the use of these clinical protocols and POCT methods in the ED clinical practice.
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Affiliation(s)
- Nadia Aspromonte
- Department of Cardiovascular and Thoracic Sciences, Catholic University of the Sacred Heart, 00168 Rome, Italy; (N.A.); (I.F.)
- Department of Cardiovascular and Thoracic Sciences, A. Gemelli University Policlinic Foundation IRCCS, 00168 Rome, Italy
| | - Martina Zaninotto
- Department of Laboratory Medicine, University-Hospital of Padova, 35129 Padova, Italy;
| | - Alberto Aimo
- CNR Foundation—Regione Toscana G. Monasterio, 56127 Pisa, Italy;
| | - Isabella Fumarulo
- Department of Cardiovascular and Thoracic Sciences, Catholic University of the Sacred Heart, 00168 Rome, Italy; (N.A.); (I.F.)
- Department of Cardiovascular and Thoracic Sciences, A. Gemelli University Policlinic Foundation IRCCS, 00168 Rome, Italy
| | - Mario Plebani
- Department of Medicine-DIMED, University of Padova, 35129 Padova, Italy;
| | - Aldo Clerico
- CNR Foundation—Regione Toscana G. Monasterio, 56127 Pisa, Italy;
- Coordinator of the Study Group on Cardiac Biomarkers of the Italian Societies of Laboratory Medicine, 56127 Pisa, Italy
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15
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Alghamdi A, Hann M, Carlton E, Cooper JG, Cook E, Foulkes A, Siriwardena AN, Phillips J, Thompson A, Bell S, Kirby K, Rosser A, Body R. Diagnostic Accuracy of Clinical Pathways for Suspected Acute Myocardial Infarction in the Out-of-Hospital Environment. Ann Emerg Med 2023; 82:439-448. [PMID: 37306636 DOI: 10.1016/j.annemergmed.2023.04.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2022] [Revised: 04/06/2023] [Accepted: 04/10/2023] [Indexed: 06/13/2023]
Abstract
STUDY OBJECTIVE Chest pain is one of the most common reasons for emergency ambulance calls. Patients are routinely transported to the hospital to prevent acute myocardial infarction (AMI). We evaluated the diagnostic accuracy of clinical pathways in the out-of-hospital environment. The Troponin-only Manchester Acute Coronary Syndromes decision aid and History, ECG, Age, Risk Factors, Troponin score require cardiac troponin (cTn) measurement, whereas the History and ECG-only Manchester Acute Coronary Syndromes decision aid and History, ECG, Age, Risk Factors score do not. METHODS We conducted a prospective diagnostic accuracy study at 4 ambulance services and 12 emergency departments between February 2019 and March 2020. We included patients who received an emergency ambulance response in whom paramedics suspected AMI. Paramedics recorded the data required to calculate each decision aid and took venous blood samples in the out-of-hospital environment. Samples were tested using a point-of-care cTn assay (Roche cobas h232) within 4 hours. The target condition was a diagnosis of type 1 AMI, adjudicated by 2 investigators. RESULTS Of 817 included participants, 104 (12.8%) had AMI. Setting the cutoff at the lowest risk group, Troponin-only Manchester Acute Coronary Syndromes had 98.3% sensitivity (95% confidence interval 91.1% to 100%) and 25.5% specificity (21.4% to 29.8%) for type 1 AMI. History, ECG, Age, Risk Factors, Troponin had 86.4% sensitivity (75.0% to 98.4%) and 42.2% specificity (37.5% to 47.0%); History and ECG-only Manchester Acute Coronary Syndromes had 100% sensitivity (96.4% to 100%) and 3.1% specificity (1.9% to 4.7%), whereas History, ECG, Age, Risk Factors had 95.1% sensitivity (88.9% to 98.4%) and 12.1% specificity (9.8% to 14.8%). CONCLUSION With point-of-care cTn testing, decision aids can identify patients at a low risk of type 1 AMI in the out-of-hospital environment. When used alongside clinical judgment, and with appropriate training, such tools may usefully enhance out-of-hospital risk stratification.
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Affiliation(s)
- Abdulrhman Alghamdi
- College of Applied Medical Sciences, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia; King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | - Mark Hann
- Division of Population Health, Health Services Research & Primary Care, The University of Manchester, Manchester, United Kingdom
| | - Edward Carlton
- University of Bristol Medical School, Translational Health Sciences, Southmead Hospital Learning and Research, Bristol, United Kingdom
| | - Jamie G Cooper
- Emergency Department, Aberdeen Royal Infirmary, NHS Grampian, Aberdeen, United Kingdom; School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Aberdeen, United Kingdom
| | - Eloïse Cook
- Emergency Department, Manchester University NHS Foundation Trust, Manchester, United Kingdom
| | - Angela Foulkes
- Patient Representative, HeartHelp Support Group, Withington Methodist Church Building, Manchester, United Kingdom
| | - Aloysius N Siriwardena
- Community and Health Research Unit, School of Health and Social Care, University of Lincoln, Lincoln, United Kingdom
| | - John Phillips
- The Ticker Club (A Cardiac Patient Support Group), Wythenshawe Hospital, Manchester, United Kingdom
| | - Alexander Thompson
- Division of Population Health, Health Services Research & Primary Care, The University of Manchester, Manchester, United Kingdom
| | - Steve Bell
- Medical Directorate, North West Ambulance Service NHS Foundation Trust, Waterfront Way, Bolton, United Kingdom
| | - Kim Kirby
- Centre for Health and Clinical Research, School of Health and Social Wellbeing, University of the West of England, Glenside Bristol, United Kingdom
| | - Andy Rosser
- West Midlands Ambulance Service University NHS Foundation Trust, Waterfront Way, Brierley Hill, United Kingdom
| | - Richard Body
- Emergency Department, Manchester University NHS Foundation Trust, Manchester, United Kingdom; Division of Cardiovascular Science, The University of Manchester, Manchester, United Kingdom; Manchester Metropolitan University, Manchester, United Kingdom.
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16
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Tolsma RT, de Koning ER, Fokkert MJ, van der Waarden NW, van 't Hof AW, Backus BE. Management of patients suspected for non-ST elevation-acute coronary syndrome in the prehospital phase. Future Cardiol 2023; 19:639-647. [PMID: 37916603 DOI: 10.2217/fca-2023-0049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Accepted: 10/03/2023] [Indexed: 11/03/2023] Open
Abstract
The management of patients with suspected acute coronary syndrome, especially in prehospital settings, is challenging. This Special Report focuses on studies in emergency medical services concerning chest pain patients' triage and risk stratification. In addition, it emphasizes advancements in point-of-care cardiac troponin testing. These developments are compared with in-hospital guidelines, proposing an initial framework for a new acute care pathway. This pathway integrates a risk stratification tool with high-sensitivity cardiac troponin testing, aiming to deliver optimal care and collaboration within the acute care chain. It has the potential to contribute to a significant reduction in hospital referrals, reduce observation time and overcrowding at emergency departments and hospital admissions.
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Affiliation(s)
- Rudolf T Tolsma
- Emergency Medical Service, Ambulance IJsselland, Zwolle, 8013 PM, The Netherlands
| | - Enrico R de Koning
- Department of Cardiology, Leiden University Medical Center, Leiden, 2333 ZA, The Netherlands
| | - Marion J Fokkert
- Department of Clinical Chemistry, Isala, Zwolle, 8025 AB, The Netherlands
| | | | - Arnoud Wj van 't Hof
- Department of Cardiology, Maastricht University Medical Center, Maastricht, 6229 HX, The Netherlands
- Department of Cardiology, Zuyderland MC, Heerlen, 6419 PC, The Netherlands
| | - Barbra E Backus
- Emergency Department, Franciscus Gasthuis & Vlietland, Rotterdam, 3043 PM, The Netherlands
- Emergency Department, Elisabeth-Tweesteden hospital, Tilburg, 5000 LC, The Netherlands
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17
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Tolsma RT, Fokkert MJ, Ottervanger JP, van Dongen DN, Badings EA, der Sluis AV, Van't Hof AW, Slingerland RJ. Consequences of different cut-off values for high-sensitivity cardiac troponin for risk stratification of patients suspected for NSTE-ACS with a modified HEART score. Future Cardiol 2023; 19:497-504. [PMID: 37702223 DOI: 10.2217/fca-2023-0038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/14/2023] Open
Abstract
Aim: This study aims to enhance prehospital risk assessment for suspected non-ST-elevation acute coronary syndrome (NSTE-ACS) patients using the HEART-score. By incorporating novel point-of-care high-sensitivity cardiac troponin devices, a modified HEART-score was developed and compared with the conventional approach. Patients & methods: Troponin points within the modified HEART-score are based on values below the limit of quantitation (LoQ), between the LoQ and 99th percentile and above the 99th percentile of the used device. A total HEART-score of three or lower is considered low-risk for major adverse cardiac events. Results & conclusion: The number of low-risk patients decreased based on the modified HEART-score. The sensitivity and negative predictive value increased which suggests increasing safety in ruling out patients with suspected NSTE-ACS.
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Affiliation(s)
- Rudolf T Tolsma
- Emergency Medical Service, Ambulance IJsselland, 8013 PM, Zwolle, The Netherlands
| | - Marion J Fokkert
- Department of Innovation & Science, Isala, 8025 AB, Zwolle, The Netherlands
- Department of Clinical Chemistry, Isala, 8025 AB, Zwolle, The Netherlands
| | | | | | - Erik A Badings
- Department of Cardiology, Deventer Hospital, 7416 SE, Deventer, The Netherlands
| | - Aize van der Sluis
- Department of Cardiology, Deventer Hospital, 7416 SE, Deventer, The Netherlands
| | - Arnoud Wj Van't Hof
- Department of Cardiology, MUMC, 6229 HX, Maastricht, The Netherlands
- Department of Cardiology, Zuyderland MC, 6419 PC, Heerlen, The Netherlands
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18
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Jaffe AS, Body R, Mills NL, Aakre KM, Collinson PO, Saenger A, Hammarsten O, Wereski R, Omland T, Sandoval Y, Ordonez-Llanos J, Apple FS. Single Troponin Measurement to Rule Out Myocardial Infarction: JACC Review Topic of the Week. J Am Coll Cardiol 2023; 82:60-69. [PMID: 37380305 DOI: 10.1016/j.jacc.2023.04.040] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Revised: 04/05/2023] [Accepted: 04/10/2023] [Indexed: 06/30/2023]
Abstract
The term "single-sample rule-out" refers to the ability of very low concentrations of high-sensitivity cardiac troponin (hs-cTn) on presentation to exclude acute myocardial infarction with high clinical sensitivity and negative predictive value. Observational and randomized studies have confirmed this ability. Some guidelines endorse use of a concentration of hs-cTn at the assay's limit of detection, while other studies have validated the use of higher concentrations, allowing this approach to identify a greater proportion of patients at low risk. In most studies, at least 30% of patients can be triaged with this approach. The concentration of hs-cTn varies according to the assay used and sometimes how regulations permit reporting. It is clear that patients need to be at least 2 hours from the onset of symptoms being evaluated. Caution is warranted, particularly with older patients, women, and patients with underlying cardiac comorbidities.
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Affiliation(s)
- Allan S Jaffe
- Department of Cardiology, Mayo Clinic, Rochester, Minnesota, USA; Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA.
| | - Richard Body
- Emergency Department, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, United Kingdom; Division of Cardiovascular Sciences, University of Manchester, Manchester, United Kingdom; Healthcare Sciences Department, Manchester Metropolitan University, Manchester, United Kingdom
| | - Nicholas L Mills
- Usher Institute, University of Edinburgh, Edinburgh, United Kingdom; British Heart Foundation/University Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
| | - Kristin M Aakre
- Department of Medical Biochemistry and Pharmacology, Haukeland University Hospital, Bergen, Norway; Department of Heart Disease, Haukeland University Hospital, Bergen, Norway; Department of Clinical Science, University of Bergen, Bergen, Norway
| | - Paul O Collinson
- Department of Clinical Blood Sciences, St George's University Hospitals NHS Foundation Trust, London, United Kingdom; Department of Cardiology, St George's University Hospitals NHS Foundation Trust, London, United Kingdom; St George's University of London, London, United Kingdom
| | - Amy Saenger
- Department of Laboratory Medicine and Pathology, Hennepin Healthcare/Hennepin County Medical Center, Minneapolis, Minnesota, USA; Department of Laboratory Medicine and Pathology, University of Minnesota, Minneapolis, Minnesota, USA
| | - Ole Hammarsten
- Department of Clinical Chemistry and Transfusion Medicine, University of Gothenburg, Gothenburg, Sweden
| | - Ryan Wereski
- Usher Institute, University of Edinburgh, Edinburgh, United Kingdom
| | - Torbjørn Omland
- Department of Cardiology, Akershus University Hospital, Lørenskog, Norway; Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Yader Sandoval
- Minneapolis Heart Institute, Abbott Northwestern Hospital, and Minneapolis Heart Institute Foundation, Minneapolis, Minnesota, USA
| | - Jordi Ordonez-Llanos
- Clinical Biochemistry Department, Hospital de Sant Pau, Barcelona, Spain; Foundation for Biochemistry and Molecular Pathology, Barcelona, Spain
| | - Fred S Apple
- Department of Laboratory Medicine and Pathology, Hennepin Healthcare/Hennepin County Medical Center, Minneapolis, Minnesota, USA; Department of Laboratory Medicine and Pathology, University of Minnesota, Minneapolis, Minnesota, USA
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van den Bulk S, Petrus AHJ, Willemsen RTA, Boogers MJ, Meeder JG, Rahel BM, van den Akker-van Marle ME, Numans ME, Dinant GJ, Bonten TN. Ruling out acute coronary syndrome in primary care with a clinical decision rule and a capillary, high-sensitive troponin I point of care test: study protocol of a diagnostic RCT in the Netherlands (POB HELP). BMJ Open 2023; 13:e071822. [PMID: 37290947 PMCID: PMC10255045 DOI: 10.1136/bmjopen-2023-071822] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Accepted: 05/12/2023] [Indexed: 06/10/2023] Open
Abstract
INTRODUCTION Chest pain is a common reason for consultation in primary care. To rule out acute coronary syndrome (ACS), general practitioners (GP) refer 40%-70% of patients with chest pain to the emergency department (ED). Only 10%-20% of those referred, are diagnosed with ACS. A clinical decision rule, including a high-sensitive cardiac troponin-I point-of-care test (hs-cTnI-POCT), may safely rule out ACS in primary care. Being able to safely rule out ACS at the GP level reduces referrals and thereby alleviates the burden on the ED. Moreover, prompt feedback to the patients may reduce anxiety and stress. METHODS AND ANALYSIS The POB HELP study is a clustered randomised controlled diagnostic trial investigating the (cost-)effectiveness and diagnostic accuracy of a primary care decision rule for acute chest pain, consisting of the Marburg Heart Score combined with a hs-cTnI-POCT (limit of detection 1.6 ng/L, 99th percentile 23 ng/L, cut-off value between negative and positive used in this study 3.8 ng/L). General practices are 2:1 randomised to the intervention group (clinical decision rule) or control group (regular care). In total 1500 patients with acute chest pain are planned to be included by GPs in three regions in The Netherlands. Primary endpoints are the number of hospital referrals and the diagnostic accuracy of the decision rule 24 hours, 6 weeks and 6 months after inclusion. ETHICS AND DISSEMINATION The medical ethics committee Leiden-Den Haag-Delft (the Netherlands) has approved this trial. Written informed consent will be obtained from all participating patients. The results of this trial will be disseminated in one main paper and additional papers on secondary endpoints and subgroup analyses. TRIAL REGISTRATION NUMBERS NL9525 and NCT05827237.
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Affiliation(s)
- Simone van den Bulk
- Public Health and Primary Care, Leiden Universitair Medisch Centrum, Leiden, The Netherlands
| | - Annelieke H J Petrus
- Public Health and Primary Care, Leiden Universitair Medisch Centrum, Leiden, The Netherlands
| | - Robert T A Willemsen
- Department of Family Medicine, Maastricht University, Maastricht, The Netherlands
| | - Mark J Boogers
- Cardiology, Leiden Universitair Medisch Centrum, Leiden, The Netherlands
| | - Joan G Meeder
- Cardiology, VieCuri Medisch Centrum voor Noord-Limburg, Venlo, The Netherlands
| | - Braim M Rahel
- Cardiology, VieCuri Medisch Centrum voor Noord-Limburg, Venlo, The Netherlands
| | | | - Mattijs E Numans
- Public Health and Primary Care, Leiden Universitair Medisch Centrum, Leiden, The Netherlands
| | - Geert-Jan Dinant
- Department of Family Medicine, Maastricht University, Maastricht, The Netherlands
| | - Tobias N Bonten
- Public Health and Primary Care, Leiden Universitair Medisch Centrum, Leiden, The Netherlands
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20
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Xiong-Hang K, Schulz K, Sandoval Y, Smith SW, Saenger AK, Apple FS. Analytical performance comparing siemens whole blood point of care Atellica VTLi to the central laboratory plasma Atellica IM high-sensitivity cardiac troponin I assays. Clin Biochem 2023; 114:79-85. [PMID: 36780933 DOI: 10.1016/j.clinbiochem.2023.02.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2022] [Revised: 01/27/2023] [Accepted: 02/09/2023] [Indexed: 02/13/2023]
Abstract
INTRODUCTION This study examined the analytical performance of a whole blood (WB) point of care (POC) hs-cTnI assay compared to a plasma central laboratory hs-cTnI assay in patients presenting with ischemic symptoms to a US emergency department. METHODS Fresh WB specimens collected at 0 and 2 h from 1089 consecutive patients (2152 total from 1076 matched specimens) were analyzed for hs-cTnI using WB on POC Siemens Atellica VTLi assay and plasma on central laboratory Siemens Atellica IM assay. Concordances were determined based on concentrations ranging from < limit of detection (LoD), LoD to overall and sex specific 99th percentiles from both the IFCC manufacturer package inserts and Universal Sample Bank (USB) data, and > 99th percentiles. Method comparisons were calculated using Passing Bablok regression and Bland Altmann plots, and linear regression determined by Pearson correlation coefficient. RESULTS Baseline concentration comparisons showed: POC VTLi < LoD 4-5 %, ≥ LoD 95 %; Atellica IM < LoD 5-7 %, and ≥ LoD 94-95 %. From the 2152 paired 0 and 2-hour samples, based on 99th percentiles, overall concordance was 91-92 % (kappa 0.72-0.77) and discordance 8 %. Passing Bablok regression analysis using 1924 specimens between LoD to 500 ng/L showed: slopes 0.469-0.490; y-intercepts 1.753-2.028; r values 0.631-0.817. Pearson correlation coefficient showed moderate to strong correlation strength, even with up to 53 % cTnI concentrations variance (Passing Bablok slopes) vs 27.0-40.1 % (Bland-Altmann plots). CONCLUSIONS Up to 95 % of measured samples were > LoD for both the POC (Atellica VTLi) and central laboratory (Atellica IM) hs-cTnI assays. Moderate to strong concordance and correlation were observed between assays, despite up to 53 % variances in cTnI concentration.
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Affiliation(s)
- Kang Xiong-Hang
- Department of Laboratory Medicine and Pathology, Hennepin Healthcare/HCMC, Minneapolis, MN, USA
| | - Karen Schulz
- Hennepin Healthcare Research Institute, Minneapolis, MN, USA
| | - Yader Sandoval
- Minneapolis Heart Institute, Abbott Northwestern Hospital, and Minneapolis Heart Institute Foundation, Minneapolis, MN, USA
| | - Stephen W Smith
- Departments of Emergency Medicine at Hennepin Healthcare/Hennepin County Medical Center & University of Minnesota School of Medicine, Minneapolis, MN, USA
| | - Amy K Saenger
- Department of Laboratory Medicine and Pathology, Hennepin Healthcare/HCMC, Minneapolis, MN, USA; Department of Laboratory Medicine and Pathology, University of Minnesota, Minneapolis, MN, USA
| | - Fred S Apple
- Department of Laboratory Medicine and Pathology, Hennepin Healthcare/HCMC, Minneapolis, MN, USA; Hennepin Healthcare Research Institute, Minneapolis, MN, USA; Department of Laboratory Medicine and Pathology, University of Minnesota, Minneapolis, MN, USA.
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Collinson P, Aakre KM, Saenger A, Body R, Hammarsten O, Jaffe AS, Kavsak P, Omland T, Ordonez-Lianos J, Karon B, Apple FS. Cardiac troponin measurement at the point of care: educational recommendations on analytical and clinical aspects by the IFCC Committee on Clinical Applications of Cardiac Bio-Markers (IFCC C-CB). Clin Chem Lab Med 2023; 61:989-998. [PMID: 36637984 DOI: 10.1515/cclm-2022-1270] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Accepted: 12/16/2022] [Indexed: 01/14/2023]
Abstract
The International Federation of Clinical Chemistry and Laboarator Medicine (IFCC) Committee on Clinical Applications of Cardiac Bio-Markers (C-CB) has provided evidence-based educational resources to aid and improve the understanding of important analytical and clinical aspects of cardiac biomarkers. The present IFCC C-CB educational report focuses on recommendations for appropriate use, analytical performance, and gaps in clinical studies related to the use of cardiac troponin (cTn) by point of care (POC) measurement, often referred to as a point of care testing (POCT). The use of high-sensitivity (hs)-cTn POC devices in accelerated diagnostic protocols used in emergency departments or outpatient clinics investigating acute coronary syndrome has the potential for improved efficacy, reduction of length of stay and reduced costs in the health care system. POCT workflow integration includes location of the instrument, assignment of collection and testing responsibility to (non-lab) staff, instrument maintenance, in-service and recurrent training, quality control, proficiency assessments, discrepant result trapping, and troubleshooting and inventory management.
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Affiliation(s)
- Paul Collinson
- Departments of Clinical Blood Sciences and Cardiology, St George's University Hospitals NHS Foundation Trust, London, UK.,St George's University of London, London, UK
| | - Kristin M Aakre
- Department of Medical Biochemistry and Pharmacology and Department of Heart Disease, Haukeland University Hospital, Bergen, Norway.,Department of Clinical Science, University of Bergen, Bergen, Norway
| | - Amy Saenger
- Department of Laboratory Medicine and Pathology, Hennepin Healthcare/HCMC, Minneapolis, MN, USA.,Department of Laboratory Medicine and Pathology, University of Minnesota, Minneapolis, MN, USA
| | - Rick Body
- Emergency Department, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK.,Division of Cardiovascular Sciences, The University of Manchester, Manchester, UK.,Healthcare Sciences Department, Manchester Metropolitan University, Manchester, UK
| | - Ole Hammarsten
- Department of Clinical Chemistry and Transfusion Medicine, University of Gothenburg, Gothenburg, Sweden
| | - Allan S Jaffe
- Departments of Laboratory Medicine and Pathology and Cardiology, Mayo Clinic, Rochester, MN, USA
| | - Pete Kavsak
- Department of Pathology and Molecular Medicine, McMaster University, Hamilton, ON, Canada
| | - Torbjørn Omland
- Department of Cardiology, Akershus University Hospital, Lørenskog, Norway.,Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Jordi Ordonez-Lianos
- Servicio de Bioquímica Clínica, Institut d'Investigacions Biomèdiques Sant Pau, Barcelona, Spain.,Departamento de Bioquímica y Biología Molecular, Universidad Autònoma de Barcelona, Barcelona, Spain
| | - Brad Karon
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | - Fred S Apple
- Department of Laboratory Medicine and Pathology, Hennepin Healthcare/HCMC, Minneapolis, MN, USA.,Department of Laboratory Medicine and Pathology, University of Minnesota, Minneapolis, MN, USA
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