1
|
Shinkins B, Allen AJ, Karichu J, Garrison LP, Monz BU. Evidence Synthesis and Linkage for Modelling the Cost-Effectiveness of Diagnostic Tests: Preliminary Good Practice Recommendations. APPLIED HEALTH ECONOMICS AND HEALTH POLICY 2024; 22:131-144. [PMID: 38316713 PMCID: PMC10864520 DOI: 10.1007/s40258-023-00855-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 11/05/2023] [Indexed: 02/07/2024]
Abstract
OBJECTIVES To develop preliminary good practice recommendations for synthesising and linking evidence of treatment effectiveness when modelling the cost-effectiveness of diagnostic tests. METHODS We conducted a targeted review of guidance from key Health Technology Assessment (HTA) bodies to summarise current recommendations on synthesis and linkage of treatment effectiveness evidence within economic evaluations of diagnostic tests. We then focused on a specific case study, the cost-effectiveness of troponin for the diagnosis of myocardial infarction, and reviewed the approach taken to synthesise and link treatment effectiveness evidence in different modelling studies. RESULTS The Australian and UK HTA bodies provided advice for synthesising and linking treatment effectiveness in diagnostic models, acknowledging that linking test results to treatment options and their outcomes is common. Across all reviewed models for the case study, uniform test-directed treatment decision making was assumed, i.e., all those who tested positive were treated. Treatment outcome data from a variety of sources, including expert opinion, were utilised for linked clinical outcomes. Preliminary good practice recommendations for data identification, integration and description are proposed. CONCLUSION Modelling the cost-effectiveness of diagnostic tests poses unique challenges in linking evidence on test accuracy to treatment effectiveness data to understand how a test impacts patient outcomes and costs. Upfront consideration of how a test and its results will likely be incorporated into patient diagnostic pathways is key to exploring the optimal design of such models. We propose some preliminary good practice recommendations to improve the quality of cost-effectiveness evaluations of diagnostics tests going forward.
Collapse
Affiliation(s)
- Bethany Shinkins
- Health Sciences, Warwick Medical School, University of Warwick, Coventry, CV4 7AL, UK.
- Leeds Institute for Health Sciences, University of Leeds, Clarendon Way, Leeds, UK.
- NIHR Leeds In Vitro Diagnostics Co-operative (MIC), Leeds, UK.
| | - A Joy Allen
- Access and Innovation, Roche Diagnostics UK and Ireland, Burgess Hill, UK
| | - James Karichu
- Global Access & Policy, Roche Diagnostics Solutions, Pleasanton, California, USA
| | - Louis P Garrison
- The Comparative Health Outcomes, Policy, and Economics (CHOICE) Institute, University of Washington, Seattle, USA
| | - Brigitta U Monz
- Global Access & Policy, Roche Diagnostics International AG, Forrenstrasse 2, 6343, Rotkreuz, Switzerland
| |
Collapse
|
2
|
Mu D, Zhong J, Li L, Cheng J, Zou Y, Qiu L, Cheng X. Copeptin with high-sensitivity cardiac troponin to rule out non-ST-elevation myocardial infarction early on: A systematic review and meta-analysis. Clin Biochem 2023; 112:24-32. [PMID: 36435204 DOI: 10.1016/j.clinbiochem.2022.11.009] [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: 07/14/2022] [Revised: 11/18/2022] [Accepted: 11/19/2022] [Indexed: 11/25/2022]
Abstract
High-sensitivity cardiac troponin (hs-cTn) with copeptin in rapidly ruling out non-ST-elevation myocardial infarction (NSTEMI) remains controversial. We aimed to evaluate the diagnostic accuracy of this combination compared to hs-cTn alone. A literature search of electronic databases was performed from inception to 26 March 2022. Primary studies that evaluated the diagnostic accuracy of hs-cTn with and without copeptin in patients with NSTEMI were eligible. The reference standard consisted of all available medical results, including a significant rise or fall of cTn with at least one value above the 99th percentile of the reference population. The QUality Assessment of Diagnostic Accuracy Studies (QUADAS-2) was used to assess the quality of the included studies. Thirteen studies involving 8,966 patients, 1,405 of whom were diagnosed with NSTEMI (prevalence, 15.67 %), were included. Combining copeptin with hs-cTn (99th percentile of the healthy population as the threshold) at admission improved the sensitivity from 0.89 to 0.96 (95 % confidence interval [CI] 0.84-0.93 vs 0.93-0.98); the specificity reduced from 0.79 to 0.56 (95 % CI 0.71-0.86 vs 0.51-0.60). In five studies with 6,073 participants (900 NSTEMI), the hs-cTn alone (with 'very low' or limit of detection [LoD] threshold) had higher diagnostic sensitivity than the dual-marker strategy (0.98 vs 0.96). Combining copeptin with hs-cTn (99th percentile of the population as the threshold) at admission improved sensitivity in NSTEMI identification at the expense of specificity. However, with the LoD threshold for hs-cTn, copeptin had no additional value, deterring the widespread use of copeptin if the hs-cTn assay is clinically available.
Collapse
Affiliation(s)
- Danni Mu
- Department of Laboratory Medicine, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Science, Beijing 100730, China
| | - Jian Zhong
- Department of Laboratory Medicine, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Science, Beijing 100730, China
| | - Lei Li
- Department of Laboratory Medicine, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Science, Beijing 100730, China
| | - Jin Cheng
- Department of Laboratory Medicine, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Science, Beijing 100730, China
| | - Yutong Zou
- Department of Laboratory Medicine, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Science, Beijing 100730, China
| | - Ling Qiu
- Department of Laboratory Medicine, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Science, Beijing 100730, China; State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China.
| | - Xinqi Cheng
- Department of Laboratory Medicine, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Science, Beijing 100730, China.
| |
Collapse
|
3
|
Mu D, Cheng J, Qiu L, Cheng X. Copeptin as a Diagnostic and Prognostic Biomarker in Cardiovascular Diseases. Front Cardiovasc Med 2022; 9:901990. [PMID: 35859595 PMCID: PMC9289206 DOI: 10.3389/fcvm.2022.901990] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Accepted: 06/07/2022] [Indexed: 12/11/2022] Open
Abstract
Copeptin is the carboxyl-terminus of the arginine vasopressin (AVP) precursor peptide. The main physiological functions of AVP are fluid and osmotic balance, cardiovascular homeostasis, and regulation of endocrine stress response. Copeptin, which is released in an equimolar mode with AVP from the neurohypophysis, has emerged as a stable and simple-to-measure surrogate marker of AVP and has displayed enormous potential in clinical practice. Cardiovascular disease (CVD) is currently recognized as a primary threat to the health of the population worldwide, and thus, rapid and effective approaches to identify individuals that are at high risk of, or have already developed CVD are required. Copeptin is a diagnostic and prognostic biomarker in CVD, including the rapid rule-out of acute myocardial infarction (AMI), mortality prediction in heart failure (HF), and stroke. This review summarizes and discusses the value of copeptin in the diagnosis, discrimination, and prognosis of CVD (AMI, HF, and stroke), as well as the caveats and prospects for the application of this potential biomarker.
Collapse
Affiliation(s)
- Danni Mu
- Department of Laboratory Medicine, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Jin Cheng
- Department of Laboratory Medicine, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Ling Qiu
- Department of Laboratory Medicine, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China.,State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Xinqi Cheng
- Department of Laboratory Medicine, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| |
Collapse
|
4
|
Westwood M, Ramaekers B, Grimm S, Worthy G, Fayter D, Armstrong N, Buksnys T, Ross J, Joore M, Kleijnen J. High-sensitivity troponin assays for early rule-out of acute myocardial infarction in people with acute chest pain: a systematic review and economic evaluation. Health Technol Assess 2021; 25:1-276. [PMID: 34061019 PMCID: PMC8200931 DOI: 10.3310/hta25330] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Early diagnosis of acute myocardial infarction is important, but only 20% of emergency admissions for chest pain will actually have an acute myocardial infarction. High-sensitivity cardiac troponin assays may allow rapid rule out of myocardial infarction and avoid unnecessary hospital admissions. OBJECTIVES To assess the clinical effectiveness and cost-effectiveness of high-sensitivity cardiac troponin assays for the management of adults presenting with acute chest pain, in particular for the early rule-out of acute myocardial infarction. METHODS Sixteen databases were searched up to September 2019. Review methods followed published guidelines. Studies were assessed for quality using appropriate risk-of-bias tools. The bivariate model was used to estimate summary sensitivity and specificity for meta-analyses involving four or more studies; otherwise, random-effects logistic regression was used. The health economic analysis considered the long-term costs and quality-adjusted life-years associated with different troponin testing methods. The de novo model consisted of a decision tree and a state-transition cohort model. A lifetime time horizon (of 60 years) was used. RESULTS Thirty-seven studies (123 publications) were included in the review. The high-sensitivity cardiac troponin test strategies evaluated are defined by the combination of four factors (i.e. assay, number and timing of tests, and threshold concentration), resulting in a large number of possible combinations. Clinical opinion indicated a minimum clinically acceptable sensitivity of 97%. When considering single test strategies, only those using a threshold at or near to the limit of detection for the assay, in a sample taken at presentation, met the minimum clinically acceptable sensitivity criterion. The majority of the multiple test strategies that met this criterion comprised an initial rule-out step, based on high-sensitivity cardiac troponin levels in a sample taken on presentation and a minimum symptom duration, and a second stage for patients not meeting the initial rule-out criteria, based on presentation levels of high-sensitivity cardiac troponin and absolute change after 1, 2 or 3 hours. Two large cluster randomised controlled trials found that implementation of an early rule-out pathway for myocardial infarction reduced length of stay and rate of hospital admission without increasing cardiac events. In the base-case analysis, standard troponin testing was both the most effective and the most costly. Other testing strategies with a sensitivity of 100% (subject to uncertainty) were almost equally effective, resulting in the same life-year and quality-adjusted life-year gain at up to four decimal places. Comparisons based on the next best alternative showed that for willingness-to-pay values below £8455 per quality-adjusted life-year, the Access High Sensitivity Troponin I (Beckman Coulter, Brea, CA, USA) [(symptoms > 3 hours AND < 4 ng/l at 0 hours) OR (< 5 ng/l AND Δ < 5 ng/l at 0 to 2 hours)] would be cost-effective. For thresholds between £8455 and £20,190 per quality-adjusted life-year, the Elecsys® Troponin-T high sensitive (Roche, Basel, Switzerland) (< 12 ng/l at 0 hours AND Δ < 3 ng/l at 0 to 1 hours) would be cost-effective. For a threshold > £20,190 per quality-adjusted life-year, the Dimension Vista® High-Sensitivity Troponin I (Siemens Healthcare, Erlangen, Germany) (< 5 ng/l at 0 hours AND Δ < 2 ng/l at 0 to 1 hours) would be cost-effective. CONCLUSIONS High-sensitivity cardiac troponin testing may be cost-effective compared with standard troponin testing. STUDY REGISTRATION This study is registered as PROSPERO CRD42019154716. FUNDING This project was funded by the National Institute for Health Research (NIHR) Evidence Synthesis programme and will be published in full in Health Technology Assessment; Vol. 25, No. 33. See the NIHR Journals Library website for further project information.
Collapse
Affiliation(s)
| | - Bram Ramaekers
- Department of Clinical Epidemiology and Medical Technology Assessment, Maastricht University, Maastricht, the Netherlands
| | - Sabine Grimm
- Department of Clinical Epidemiology and Medical Technology Assessment, Maastricht University, Maastricht, the Netherlands
| | | | | | | | | | | | - Manuela Joore
- Department of Clinical Epidemiology and Medical Technology Assessment, Maastricht University, Maastricht, the Netherlands
| | - Jos Kleijnen
- Kleijnen Systematic Reviews Ltd, York, UK
- School for Public Health and Primary Care, Care and Public Health Research Institute, Maastricht University, Maastricht, the Netherlands
| |
Collapse
|
5
|
Redón P, Shahzad A, Iqbal T, Wijns W. Benefits of Home-Based Solutions for Diagnosis and Treatment of Acute Coronary Syndromes on Health Care Costs: A Systematic Review. SENSORS (BASEL, SWITZERLAND) 2020; 20:E5006. [PMID: 32899338 PMCID: PMC7506920 DOI: 10.3390/s20175006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/02/2020] [Revised: 08/29/2020] [Accepted: 09/01/2020] [Indexed: 01/06/2023]
Abstract
Diagnosing and treating acute coronary syndromes consumes a significant fraction of the healthcare budget worldwide. The pressure on resources is expected to increase with the continuing rise of cardiovascular disease, other chronic diseases and extended life expectancy, while expenditure is constrained. The objective of this review is to assess if home-based solutions for measuring chemical cardiac biomarkers can mitigate or reduce the continued rise in the costs of ACS treatment. A systematic review was performed considering published literature in several relevant public databases (i.e., PUBMED, Cochrane, Embase and Scopus) focusing on current biomarker practices in high-risk patients, their cost-effectiveness and the clinical evidence and feasibility of implementation. Out of 26,000 references screened, 86 met the inclusion criteria after independent full-text review. Current clinical evidence highlights that home-based solutions implemented in primary and secondary prevention reduce health care costs by earlier diagnosis, improved patient outcomes and quality of life, as well as by avoidance of unnecessary use of resources. Economical evidence suggests their potential to reduce health care costs if the incremental cost-effectiveness ratio or the willingness-to-pay does not surpass £20,000/QALY or €50,000 limit per 20,000 patients, respectively. The cost-effectiveness of these solutions increases when applied to high-risk patients.
Collapse
Affiliation(s)
- Pau Redón
- CÚRAM Center for Research in Medical Devices, H91 W2TY Galway, Ireland;
- Smart Sensor Lab, School of Medicine, National University of Ireland, Galway (NUIG), H91 TK33 Galway, Ireland; (A.S.); (T.I.)
| | - Atif Shahzad
- Smart Sensor Lab, School of Medicine, National University of Ireland, Galway (NUIG), H91 TK33 Galway, Ireland; (A.S.); (T.I.)
| | - Talha Iqbal
- Smart Sensor Lab, School of Medicine, National University of Ireland, Galway (NUIG), H91 TK33 Galway, Ireland; (A.S.); (T.I.)
| | - William Wijns
- CÚRAM Center for Research in Medical Devices, H91 W2TY Galway, Ireland;
- Smart Sensor Lab, School of Medicine, National University of Ireland, Galway (NUIG), H91 TK33 Galway, Ireland; (A.S.); (T.I.)
- Saolta University Healthcare Group, University Hospital Galway, Newcastle Road, H91 YR71 Galway, Ireland
| |
Collapse
|
6
|
Fitzgerald G, Kerley RN, Kiernan TJ. High-sensitivity troponin assays: development and utility in a modern health-care system. Expert Rev Cardiovasc Ther 2019; 17:763-770. [PMID: 31574239 DOI: 10.1080/14779072.2019.1675514] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Introduction: The introduction of cardiac troponin (cTn) assays have revolutionized the diagnosis and management of acute myocardial infarction in Emergency Departments worldwide. Its success has led to significant research and development investment in this area culminating in the development of newer high-sensitivity cardiac troponin assays (hs-cTn). While these newer assays allow for more rapid diagnosis by decreasing the time interval between serial data points, there is an inevitable trade off between increasing sensitivity and specificity. This review examines in detail the introduction and implementation of hs-cTN and its implications for clinical practice.Areas covered: This article reviews the history and development of high-sensitivity troponin assays and their application to clinical practice and current evidence base. It also discusses both the positive and negative aspects of the continuing increasing sensitivity of biochemical assays and the translation of this into clinical practice. Potential future developments are also discussed.Expert commentary: It is clear that there are many benefits to detecting extremely low concentration of cardiac troponin including the development of rapid rule out algorithms and the cost and time-saving advantages associated with the quicker movement of patients through the health-care system. It is important to note however that detecting troponin at very low concentrations also dramatically increases the false-positive rates and leads to a potentially large increase in invasive testing and diagnosis of myocardial infarction.
Collapse
Affiliation(s)
- Gerald Fitzgerald
- Department of Cardiology, University Hospital Limerick, Limerick, Ireland
| | - R N Kerley
- Department of Cardiology, University Hospital Limerick, Limerick, Ireland
| | - Thomas J Kiernan
- Department of Cardiology, University Hospital Limerick, Limerick, Ireland
| |
Collapse
|
7
|
Wright SJ, Newman WG, Payne K. Accounting for Capacity Constraints in Economic Evaluations of Precision Medicine: A Systematic Review. PHARMACOECONOMICS 2019; 37:1011-1027. [PMID: 31087278 PMCID: PMC6597608 DOI: 10.1007/s40273-019-00801-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/17/2023]
Abstract
BACKGROUND AND OBJECTIVE Precision (stratified or personalised) medicine is underpinned by the premise that it is feasible to identify known heterogeneity using a specific test or algorithm in patient populations and to use this information to guide patient care to improve health and well-being. This study aimed to understand if, and how, previous economic evaluations of precision medicine had taken account of the impact of capacity constraints. METHODS A meta-review was conducted of published systematic reviews of economic evaluations of precision medicine (test-treat interventions) and individual studies included in these reviews. Due to the volume of studies identified, a sample of papers published from 2007 to 2015 was collated. A narrative analysis identified whether potential capacity constraints were discussed qualitatively in the studies and, if relevant, which quantitative methods were used to account for capacity constraints. RESULTS A total of 45 systematic reviews of economic evaluations of precision medicine were identified, from which 222 studies focusing on test-treat interventions, published between 2007 and 2015, were extracted. Of these studies, 33 (15%) qualitatively discussed the potential impact of capacity constraints, including budget constraints; quality of tests and the testing process; ease of use of tests in clinical practice; and decision uncertainty. Quantitative methods (nine studies) to account for capacity constraints included static methods such as capturing inefficiencies in trials or models and sensitivity analysis around model parameters; and dynamic methods, which allow the impact of capacity constraints on cost effectiveness to change over time. CONCLUSIONS Understanding the cost effectiveness of precision medicine is necessary, but not sufficient, evidence for its successful implementation. There are currently few examples of evaluations that have quantified the impact of capacity constraints, which suggests an area of focus for future research.
Collapse
Affiliation(s)
- Stuart J Wright
- Manchester Centre for Health Economics, Division of Population Health, Health Services Research and Primary Care, The University of Manchester, Oxford Road, Manchester, M13 9PL, UK.
| | - William G Newman
- Manchester Centre for Genomic Medicine, Division of Evolution and Genomic Sciences, The University of Manchester, Manchester, UK
- North West Genomic Laboratory Hub, Manchester Centre for Genomic Medicine, Manchester University NHS Foundation Trust, Manchester, UK
| | - Katherine Payne
- Manchester Centre for Health Economics, Division of Population Health, Health Services Research and Primary Care, The University of Manchester, Oxford Road, Manchester, M13 9PL, UK
| |
Collapse
|
8
|
Veličković VM, Rochau U, Conrads-Frank A, Kee F, Blankenberg S, Siebert U. Systematic assessment of decision-analytic models evaluating diagnostic tests for acute myocardial infarction based on cardiac troponin assays. Expert Rev Pharmacoecon Outcomes Res 2018; 18:619-640. [DOI: 10.1080/14737167.2018.1512857] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- Vladica M. Veličković
- Department of Public Health, Health Services Research and Health Technology Assessment, Institute of Public Health, Medical Decision Making and Health Technology Assessment, UMIT - University for Health Sciences, Medical Informatics and Technology, Hall i.T., Austria
- Faculty of Medicine, University of Niš, Nis, Serbia
| | - Ursula Rochau
- Department of Public Health, Health Services Research and Health Technology Assessment, Institute of Public Health, Medical Decision Making and Health Technology Assessment, UMIT - University for Health Sciences, Medical Informatics and Technology, Hall i.T., Austria
- Area 4 Health Technology Assessment and Bioinformatics, ONCOTYROL - Center for Personalized Cancer Medicine, Innsbruck, Austria
| | - Annette Conrads-Frank
- Department of Public Health, Health Services Research and Health Technology Assessment, Institute of Public Health, Medical Decision Making and Health Technology Assessment, UMIT - University for Health Sciences, Medical Informatics and Technology, Hall i.T., Austria
| | - Frank Kee
- UKCRC Centre of Excellence for Public Health Research, Queens University Belfast, Belfast, United Kingdom
| | - Stefan Blankenberg
- Department of General and Interventional Cardiology, University Heart Center Hamburg, Hamburg, Germany
- German Center for Cardiovascular Research (DZHK), Hamburg, Germany
| | - Uwe Siebert
- Department of Public Health, Health Services Research and Health Technology Assessment, Institute of Public Health, Medical Decision Making and Health Technology Assessment, UMIT - University for Health Sciences, Medical Informatics and Technology, Hall i.T., Austria
- Area 4 Health Technology Assessment and Bioinformatics, ONCOTYROL - Center for Personalized Cancer Medicine, Innsbruck, Austria
- Center for Health Decision Science, Department of Health Policy and Management, Harvard School of Public Health, Boston, MA, USA
- Program on Cardiovascular Research, Institute for Technology Assessment and Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| |
Collapse
|
9
|
Diagnostic and prognostic value of H-FABP in acute coronary syndrome: Still evidence to bring. Clin Biochem 2018; 58:1-4. [DOI: 10.1016/j.clinbiochem.2018.04.021] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2018] [Revised: 04/20/2018] [Accepted: 04/23/2018] [Indexed: 11/19/2022]
|
10
|
Shin H, Jang BH, Lim TH, Lee J, Kim W, Cho Y, Ahn C, Choi KS. Diagnostic accuracy of adding copeptin to cardiac troponin for non-ST-elevation myocardial infarction: A systematic review and meta-analysis. PLoS One 2018; 13:e0200379. [PMID: 29979797 PMCID: PMC6034895 DOI: 10.1371/journal.pone.0200379] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2018] [Accepted: 06/24/2018] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION This study aimed to determine the diagnostic accuracy of adding copeptin to cardiac troponin (cTn) on admission to the emergency department (ED) for non-ST elevation myocardial infarction (NSTEMI) compared to cTn alone. MATERIALS AND METHODS A literature search of MEDLINE, EMBASE, and the Cochrane Library was performed (search date: April 13, 2018). Primary studies were included if they accurately reported on patients with symptoms suggestive of acute myocardial infarction and measured both cTn alone and cTn with copeptin upon admission to the ED. The patients with evidence of ST elevation myocardial infarction were excluded. To assess the risk of bias for the included studies, the QUADAS-2 tool was used. RESULTS The study participants included a total of 7,998 patients from 14 observational studies. The addition of copeptin to cTn significantly improved the sensitivity (0.81 [0.74 to 0.87] vs. 0.92 [0.89 to 0.95], respectively, p <0.001) and negative predictive value (0.96 [0.95 to 0.98] vs. 0.98 [0.96 to 0.99], respectively, p <0.001) at the expense of lower specificity (0.88 [0.80 to 0.97] vs. 0.57 [0.49 to 0.65], respectively, p <0.001) compared to cTn alone. Furthermore, adding copeptin to cTn showed significantly lower diagnostic accuracy for NSTEMI compared to cTn alone (0.91[0.90 to 0.92] vs. 0.85 [0.83 to 0.86], respectively, p < 0.001). CONCLUSIONS Adding copeptin to cTn improved the sensitivity and negative predictive value for the diagnosis of NSTEMI compared to cTn alone. Thus, adding copeptin to cTn might help to screen NSTEMI early upon admission to the ED.
Collapse
Affiliation(s)
- Hyungoo Shin
- Department of Emergency Medicine, College of Medicine, Hanyang University, Seoul, Korea
| | - Bo-Hyoung Jang
- Department of Preventive Medicine, College of Korean Medicine, Kyung Hee University, Seoul, Korea
| | - Tae Ho Lim
- Department of Emergency Medicine, College of Medicine, Hanyang University, Seoul, Korea
- Convergence Technology Center for Disaster Preparedness, Hanyang University, Seoul, Korea
| | - Juncheol Lee
- Department of Emergency Medicine, College of Medicine, Hanyang University, Seoul, Korea
| | - Wonhee Kim
- Department of Emergency Medicine, College of Medicine, Hallym University, Seoul, Korea
- Department of Biomedical Engineering, Graduate School of Medicine, Hanyang University, Seoul, Korea
| | - Youngsuk Cho
- Department of Emergency Medicine, College of Medicine, Hallym University, Seoul, Korea
- Department of Biomedical Engineering, Graduate School of Medicine, Hanyang University, Seoul, Korea
| | - Chiwon Ahn
- Department of Biomedical Engineering, Graduate School of Medicine, Hanyang University, Seoul, Korea
- Department of Emergency Medicine, Armed Forces Yangju Hospital, Yangju, Korea
| | - Kyu-Sun Choi
- Department of Neurosurgery, College of Medicine, Hanyang University, Seoul, Korea
| |
Collapse
|
11
|
Shinkins B, Yang Y, Abel L, Fanshawe TR. Evidence synthesis to inform model-based cost-effectiveness evaluations of diagnostic tests: a methodological review of health technology assessments. BMC Med Res Methodol 2017; 17:56. [PMID: 28410588 PMCID: PMC5391551 DOI: 10.1186/s12874-017-0331-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2016] [Accepted: 03/27/2017] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Evaluations of diagnostic tests are challenging because of the indirect nature of their impact on patient outcomes. Model-based health economic evaluations of tests allow different types of evidence from various sources to be incorporated and enable cost-effectiveness estimates to be made beyond the duration of available study data. To parameterize a health-economic model fully, all the ways a test impacts on patient health must be quantified, including but not limited to diagnostic test accuracy. METHODS We assessed all UK NIHR HTA reports published May 2009-July 2015. Reports were included if they evaluated a diagnostic test, included a model-based health economic evaluation and included a systematic review and meta-analysis of test accuracy. From each eligible report we extracted information on the following topics: 1) what evidence aside from test accuracy was searched for and synthesised, 2) which methods were used to synthesise test accuracy evidence and how did the results inform the economic model, 3) how/whether threshold effects were explored, 4) how the potential dependency between multiple tests in a pathway was accounted for, and 5) for evaluations of tests targeted at the primary care setting, how evidence from differing healthcare settings was incorporated. RESULTS The bivariate or HSROC model was implemented in 20/22 reports that met all inclusion criteria. Test accuracy data for health economic modelling was obtained from meta-analyses completely in four reports, partially in fourteen reports and not at all in four reports. Only 2/7 reports that used a quantitative test gave clear threshold recommendations. All 22 reports explored the effect of uncertainty in accuracy parameters but most of those that used multiple tests did not allow for dependence between test results. 7/22 tests were potentially suitable for primary care but the majority found limited evidence on test accuracy in primary care settings. CONCLUSIONS The uptake of appropriate meta-analysis methods for synthesising evidence on diagnostic test accuracy in UK NIHR HTAs has improved in recent years. Future research should focus on other evidence requirements for cost-effectiveness assessment, threshold effects for quantitative tests and the impact of multiple diagnostic tests.
Collapse
Affiliation(s)
- Bethany Shinkins
- Test Evaluation Group, Academic Unit of Health Economics, Leeds Institute of Health Sciences, University of Leeds, Worsely Building, Clarendon Way, Leeds, LS2 9LJ, UK.
| | - Yaling Yang
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG, UK
| | - Lucy Abel
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG, UK
| | - Thomas R Fanshawe
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG, UK
| |
Collapse
|
12
|
Kaambwa B, Ratcliffe J, Horsfall M, Astley C, Karnon J, Coates P, Arstall M, Zeitz C, Worthley M, Beltrame J, Chew DP. Cost effectiveness of high-sensitivity troponin compared to conventional troponin among patients presenting with undifferentiated chest pain: A trial based analysis. Int J Cardiol 2017; 238:144-150. [PMID: 28325612 DOI: 10.1016/j.ijcard.2017.02.141] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2016] [Revised: 01/05/2017] [Accepted: 02/27/2017] [Indexed: 10/20/2022]
Abstract
BACKGROUND Patients with low and intermediate risk chest pain features comprise the greatest proportion presenting to emergency services for evaluation of suspected acute coronary syndromes (ACS). The efficient and timely identification of patients with these features remains a major challenge within clinical practice. Troponin assays are increasingly being used for the determination of risk among patients presenting with chest pain potentially facilitating more appropriate care. To date, no economic evaluation comparing high-sensitivity troponin T (hs-TnT) reporting to standard troponin T (c-TnT) reporting in the routine management of suspected ACS and based on longer-term clinical outcomes has been conducted. METHODS AND RESULTS An economic evaluation was conducted with 1937 participants randomized to either hs-TnT (n=973) or c-TnT (n=964) with 12month follow-up. The primary outcome measure was the number of cumulative combined outcomes of all-cause mortality and new or recurrent ACS avoided. Mean per participant Australian Medicare costs were higher in the hs-TnT arm compared to the c-TnT arm (by $1285/patient). Mean total adverse clinical outcomes avoided were higher in the hs-TnT arm (by 0.0120/patient) resulting in an incremental cost-effectiveness ratio (ICER) of $108,552/adverse clinical outcome avoided. An ICER of $49,030/adverse clinical outcome avoided was obtained when the analysis was restricted to patients below the threshold of normal Troponin testing (actual c-TnT levels <30ng/L). CONCLUSIONS hs-TnT reporting leads to fewer adverse clinical events but at a high ICER. For the routine implementation of hs-TnT to be more cost-effective, substantial changes in clinical practice will be required. CLINICAL TRIAL REGISTRATION Australian New Zealand Clinical Trials Registry (ACTRN12614000189628). https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=365726.
Collapse
Affiliation(s)
| | - Julie Ratcliffe
- Health Economics Unit, Flinders University, Adelaide, Australia
| | - Matthew Horsfall
- Health Systems Research, South Australian Health and Medical Research Institute (SAHMRI), Adelaide, Australia
| | - Carolyn Astley
- Flinders University, Adelaide, South Australia, Australia; Heart Foundation, South Australia, Australia
| | - Jonathan Karnon
- SA Pathology, SA Health Adelaide, South Australia, Australia
| | | | | | | | | | | | - Derek P Chew
- Flinders Medical Centre, Flinders Drive, Bedford Park, South Australia, Australia
| |
Collapse
|
13
|
Spencer TR, Sidhu MS, Bisaillon J, Christopher King C. Novel Cardiac Biomarkers for Emergency Department Evaluation of Acute Coronary Syndrome: The Recent Evidence on Non-troponin Biomarkers and Their Limitations. CURRENT EMERGENCY AND HOSPITAL MEDICINE REPORTS 2016. [DOI: 10.1007/s40138-016-0104-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
|
14
|
Cao RY, Zheng H, Guo J, Redfearn DP. Prognostic value of plasma biomarkers in patients with acute coronary syndrome: a review of advances in the past decade. Biomark Med 2016; 10:525-35. [PMID: 27089223 DOI: 10.2217/bmm-2015-0029] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Acute coronary syndrome (ACS), especially myocardial infarction, commonly known as a heart attack, is a serious life-threatening cardiovascular disease. Despite dramatic therapeutic advances, there have still been more than 20% patients with ACS suffering recurrent adverse cardiovascular events 3 years after disease onset. Therefore, the aim to prevent cardiac death caused by the heart attack remains challenging. Plasma biomarkers, originally developed to complement clinical assessment and electrocardiographic examination for the diagnosis of ACS, have been reported to play important prognostic roles in predicting adverse outcomes. These biomarkers mirror different pathophysiological mechanisms in association with ACS. In this review, we focus on advances of prognostic biomarkers in the past decade for short- and long-term risk assessment and management of patients with ACS.
Collapse
Affiliation(s)
- Richard Y Cao
- Department of Cardiology, Shanghai Xuhui Central Hospital/Shanghai Clinical Research Center, Chinese Academy of Sciences, Shanghai, China
| | - Hongchao Zheng
- Department of Cardiology, Shanghai Xuhui Central Hospital/Shanghai Clinical Research Center, Chinese Academy of Sciences, Shanghai, China
| | - Junjun Guo
- Department of Cardiology, Shanghai Xuhui Central Hospital/Shanghai Clinical Research Center, Chinese Academy of Sciences, Shanghai, China
| | - Damian P Redfearn
- Department of Biomedical & Molecular Sciences, Queen's University, Kingston, Ontario, Canada.,Department of Medicine, Kingston General Hospital, Kingston, Ontario, Canada
| |
Collapse
|
15
|
Westwood M, van Asselt T, Ramaekers B, Whiting P, Thokala P, Joore M, Armstrong N, Ross J, Severens J, Kleijnen J. High-sensitivity troponin assays for the early rule-out or diagnosis of acute myocardial infarction in people with acute chest pain: a systematic review and cost-effectiveness analysis. Health Technol Assess 2016; 19:1-234. [PMID: 26118801 DOI: 10.3310/hta19440] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Early diagnosis of acute myocardial infarction (AMI) can ensure quick and effective treatment but only 20% of adults with emergency admissions for chest pain have an AMI. High-sensitivity cardiac troponin (hs-cTn) assays may allow rapid rule-out of AMI and avoidance of unnecessary hospital admissions and anxiety. OBJECTIVE To assess the clinical effectiveness and cost-effectiveness of hs-cTn assays for the early (within 4 hours of presentation) rule-out of AMI in adults with acute chest pain. METHODS Sixteen databases, including MEDLINE and EMBASE, research registers and conference proceedings, were searched to October 2013. Study quality was assessed using QUADAS-2. The bivariate model was used to estimate summary sensitivity and specificity for meta-analyses involving four or more studies, otherwise random-effects logistic regression was used. The health-economic analysis considered the long-term costs and quality-adjusted life-years (QALYs) associated with different troponin (Tn) testing methods. The de novo model consisted of a decision tree and Markov model. A lifetime time horizon (60 years) was used. RESULTS Eighteen studies were included in the clinical effectiveness review. The optimum strategy, based on the Roche assay, used a limit of blank (LoB) threshold in a presentation sample to rule out AMI [negative likelihood ratio (LR-) 0.10, 95% confidence interval (CI) 0.05 to 0.18]. Patients testing positive could then have a further test at 2 hours; a result above the 99th centile on either sample and a delta (Δ) of ≥ 20% has some potential for ruling in an AMI [positive likelihood ratio (LR+) 8.42, 95% CI 6.11 to 11.60], whereas a result below the 99th centile on both samples and a Δ of < 20% can be used to rule out an AMI (LR- 0.04, 95% CI 0.02 to 0.10). The optimum strategy, based on the Abbott assay, used a limit of detection (LoD) threshold in a presentation sample to rule out AMI (LR- 0.01, 95% CI 0.00 to 0.08). Patients testing positive could then have a further test at 3 hours; a result above the 99th centile on this sample has some potential for ruling in an AMI (LR+ 10.16, 95% CI 8.38 to 12.31), whereas a result below the 99th centile can be used to rule out an AMI (LR- 0.02, 95% CI 0.01 to 0.05). In the base-case analysis, standard Tn testing was both most effective and most costly. Strategies considered cost-effective depending upon incremental cost-effectiveness ratio thresholds were Abbott 99th centile (thresholds of < £6597), Beckman 99th centile (thresholds between £6597 and £30,042), Abbott optimal strategy (LoD threshold at presentation, followed by 99th centile threshold at 3 hours) (thresholds between £30,042 and £103,194) and the standard Tn test (thresholds over £103,194). The Roche 99th centile and the Roche optimal strategy [LoB threshold at presentation followed by 99th centile threshold and/or Δ20% (compared with presentation test) at 1-3 hours] were extendedly dominated in this analysis. CONCLUSIONS There is some evidence to suggest that hs-CTn testing may provide an effective and cost-effective approach to early rule-out of AMI. Further research is needed to clarify optimal diagnostic thresholds and testing strategies. STUDY REGISTRATION This study is registered as PROSPERO CRD42013005939. FUNDING The National Institute for Health Research Health Technology Assessment programme.
Collapse
Affiliation(s)
| | - Thea van Asselt
- Department of Clinical Epidemiology and Medical Technology Assessment, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Bram Ramaekers
- Department of Clinical Epidemiology and Medical Technology Assessment, Maastricht University Medical Centre, Maastricht, The Netherlands
| | | | - Praveen Thokala
- Health Economics and Decision Science Group, School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Manuela Joore
- Department of Clinical Epidemiology and Medical Technology Assessment, Maastricht University Medical Centre, Maastricht, The Netherlands
| | | | | | - Johan Severens
- Institute of Health Policy and Management, Erasmus University Rotterdam, Rotterdam, The Netherlands
| | - Jos Kleijnen
- School for Public Health and Primary Care (CAPHRI), Maastricht University, Maastricht, The Netherlands
| |
Collapse
|
16
|
Oosterhoff M, van der Maas ME, Steuten LMG. A Systematic Review of Health Economic Evaluations of Diagnostic Biomarkers. APPLIED HEALTH ECONOMICS AND HEALTH POLICY 2016; 14:51-65. [PMID: 26334528 PMCID: PMC4740568 DOI: 10.1007/s40258-015-0198-x] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/03/2023]
Abstract
BACKGROUND Diagnostic biomarkers have multiple applications along the care process and have a large potential in optimizing treatment decisions. However, many diagnostic biomarkers struggle to gain market access and obtain appropriate coverage because of a lack of evidence on their health economic impact. OBJECTIVES The aim was to review the (methodological) characteristics of recent economic evaluations on diagnostic biomarkers and examine whether these studies dealt with specific issues such as different payer perspectives, preference heterogeneity, and multiple applications in subpopulations. METHODS The PubMed database and the National Health Service Economic Evaluation Database were searched. Full economic evaluations published after 2009 assessing diagnostic biomarkers for the main non-communicable diseases in middle-income or high-income countries were considered eligible. Empirical and methodological study characteristics were summarized, as was the handling of specific issues related to the economic evaluation of personalized medicine. RESULTS Thirty-three economic evaluations were included, of which 25 were model-based analyses. The number of strategies compared ranged from two to 17 per study, and was especially large in studies assessing genetic testing in patients and their relatives. Cost-effectiveness results were most sensitive to test accuracy and costs of the biomarker (N = 7), the relative risk of an event (N = 4), and the proportion of people accepting genetic testing (N = 2). One study incorporated patient preferences, and none of the studies considered different payer perspectives, cost sharing arrangements or variable opportunity costs due to population density variability. CONCLUSIONS Published health economic evaluations of biomarkers used for diagnosing, staging diseases, and guiding treatment selection are characterized by a large number of comparators to model the potential clinical applications and to determine their value. Assessing outcomes beyond health as well as specific issues, such as different payer perspectives and patient preferences, is crucial to fully capture the potential health economic impact of diagnostic biomarkers and to inform value-based reimbursement.
Collapse
Affiliation(s)
- Marije Oosterhoff
- Panaxea b.v., Hengelosestraat 221, 7521 AC, Enschede, The Netherlands.
| | | | - Lotte M G Steuten
- Panaxea b.v., Hengelosestraat 221, 7521 AC, Enschede, The Netherlands.
- Fred Hutchinson Cancer Research Center, Seattle, USA.
| |
Collapse
|
17
|
Alley W, Mahler SA. Clinical decision aids for chest pain in the emergency department: identifying low-risk patients. Open Access Emerg Med 2015; 7:85-92. [PMID: 27147894 PMCID: PMC4806811 DOI: 10.2147/oaem.s71282] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Chest pain is one of the most common presenting complaints in the emergency department, though only a small minority of patients are subsequently diagnosed with acute coronary syndrome (ACS). However, missing the diagnosis has potential for significant morbidity and mortality. ACS presentations can be atypical, and their workups are often prolonged and costly. In order to risk-stratify patients and better direct the workup and care given, many decision aids have been developed. While each may have merit in certain clinical settings, the most useful aid in the emergency department is one that finds all cases of ACS while also identifying a substantial subset of patients at low risk who can be discharged without stress testing or coronary angiography. This review describes several of the chest pain decision aids developed and studied through the recent past, starting with the thrombolysis in myocardial infarction (TIMI) risk score and Global Registry of Acute Coronary Events (GRACE) scores, which were developed as prognostic aids for patients already diagnosed with ACS, then subsequently validated in the undifferentiated chest pain population. Asia-Pacific Evaluation of Chest Pain Trial (ASPECT); Accelerated Diagnostic Protocol to Assess Patients With Chest Pain Symptoms Using Contemporary Troponins (ADAPT); North American Chest Pain Rule (NACPR); and History, Electrocardiogram, Age, Risk factors, Troponin (HEART) score have been developed exclusively for use in the undifferentiated chest pain population as well, with improved performance compared to their predecessors. This review describes the relative merits and limitations of these decision aids so that providers can determine which tool fits the needs of their clinical practice setting.
Collapse
Affiliation(s)
- William Alley
- Department of Emergency Medicine, Wake Forest Baptist Medical Center, Winston-Salem, NC, USA
| | - Simon A Mahler
- Department of Emergency Medicine, Wake Forest Baptist Medical Center, Winston-Salem, NC, USA
| |
Collapse
|
18
|
Goodacre S, Thokala P. The economics of cardiac biomarker testing in suspected myocardial infarction. Clin Biochem 2015; 48:213-7. [DOI: 10.1016/j.clinbiochem.2014.08.012] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2014] [Revised: 08/06/2014] [Accepted: 08/18/2014] [Indexed: 11/28/2022]
|
19
|
Schoenenberger AW, Stallone F, Walz B, Bergner M, Twerenbold R, Reichlin T, Zogg B, Jaeger C, Erne P, Mueller C. Incremental value of heart-type fatty acid-binding protein in suspected acute myocardial infarction early after symptom onset. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2015; 5:185-92. [PMID: 25681485 DOI: 10.1177/2048872615571256] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/22/2014] [Accepted: 01/15/2015] [Indexed: 01/29/2023]
Abstract
BACKGROUND The early diagnosis of acute myocardial infarction (AMI) very soon after symptom onset remains a major clinical challenge, even when using high-sensitivity cardiac troponin (hs-cTnT). METHODS AND RESULTS We investigated the incremental value of heart-type fatty acid-binding protein (hFABP) in a pre-specified subgroup analysis of patients presenting with suspected AMI within 1 h of symptom onset to the emergency department (ED) in a multicentre study. HFABP was measured in a blinded fashion. Two independent cardiologists using all available clinical information, including hs-cTnT, adjudicated the final diagnosis. Overall, 1411 patients were enrolled, of whom 105 patients presented within 1 h of symptom onset. Of these, 34 patients (32.4%) had AMI. The diagnostic accuracy as quantified by the area under the receiver-operating characteristics curve (AUC) of hFABP was high (0.84 (95% CI 0.74-0.94)). However, the additional use of hFABP only marginally increased the diagnostic accuracy of hs-cTnT (AUC 0.88 (95% CI 0.81-0.94) for hs-cTnT alone to 0.90 (95% CI 0.83-0.98) for the combination; p=ns). After the exclusion of 18 AMI patients with ST-segment elevation, similar results were obtained. Among the 16 AMI patients without ST-segment elevation, six had normal hs-cTnT at presentation. Of these, hFABP was elevated in two (33.3%) patients. CONCLUSIONS hFABP does not seem to significantly improve the early diagnostic accuracy of hs-cTnT in the important subgroup of patients with suspected AMI presenting to the ED very early after symptom onset.
Collapse
Affiliation(s)
- Andreas W Schoenenberger
- Division of Geriatrics, Department of General Internal Medicine, Inselspital, Bern University Hospital, and University of Bern, Switzerland
| | - Fabio Stallone
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Switzerland Department of Internal Medicine, University Hospital Basel, Switzerland
| | - Brigitte Walz
- Central Laboratory, Luzerner Kantonsspital, Switzerland
| | - Michael Bergner
- Department of Cardiology, Luzerner Kantonsspital, Switzerland
| | - Raphael Twerenbold
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Switzerland
| | - Tobias Reichlin
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Switzerland
| | - Bernhard Zogg
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Switzerland
| | - Cedric Jaeger
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Switzerland
| | - Paul Erne
- Department of Cardiology, Luzerner Kantonsspital, Switzerland Cardiovasc Schweiz AG, Hirslanden Klinik St Anna, Switzerland
| | - Christian Mueller
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Switzerland
| |
Collapse
|
20
|
Zhelev Z, Hyde C, Youngman E, Rogers M, Fleming S, Slade T, Coelho H, Jones-Hughes T, Nikolaou V. Diagnostic accuracy of single baseline measurement of Elecsys Troponin T high-sensitive assay for diagnosis of acute myocardial infarction in emergency department: systematic review and meta-analysis. BMJ 2015; 350:h15. [PMID: 25646632 PMCID: PMC4300724 DOI: 10.1136/bmj.h15] [Citation(s) in RCA: 139] [Impact Index Per Article: 15.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/10/2014] [Indexed: 12/29/2022]
Abstract
OBJECTIVE To obtain summary estimates of the accuracy of a single baseline measurement of the Elecsys Troponin T high-sensitive assay (Roche Diagnostics) for the diagnosis of acute myocardial infarction in patients presenting to the emergency department. DESIGN Systematic review and meta-analysis of diagnostic test accuracy studies. DATA SOURCES Medline, Embase, and other relevant electronic databases were searched for papers published between January 2006 and December 2013. STUDY SELECTION Studies were included if they evaluated the diagnostic accuracy of a single baseline measurement of Elecsys Troponin T high-sensitive assay for the diagnosis of acute myocardial infarction in patients presenting to the emergency department with suspected acute coronary syndrome. STUDY APPRAISAL AND DATA SYNTHESIS The first author screened all titles and abstracts identified through the searches and selected all potentially relevant papers. The screening of the full texts, the data extraction, and the methodological quality assessment, using the adapted QUADAS-2 tool, were conducted independently by two reviewers with disagreements being resolved through discussion or arbitration. If appropriate, meta-analysis was conducted using the hierarchical bivariate model. RESULTS Twenty three studies reported the performance of the evaluated assay at presentation. The results for 14 ng/L and 3-5 ng/L cut-off values were pooled separately. At 14 ng/L (20 papers), the summary sensitivity was 89.5% (95% confidence interval 86.3% to 92.1%) and the summary specificity was 77.1% (68.7% to 83.7%). At 3-5 ng/L (six papers), the summary sensitivity was 97.4% (94.9% to 98.7%) and the summary specificity was 42.4% (31.2% to 54.5%). This means that if 21 of 100 consecutive patients have the target condition (21%, the median prevalence across the studies), 2 (95% confidence interval 2 to 3) of 21 patients with acute myocardial infarction will be missed (false negatives) if 14 ng/L is used as a cut-off value and 18 (13 to 25) of 79 patients without acute myocardial infarction will test positive (false positives). If the 3-5 ng/L cut-off value is used, <1 (0 to 1) patient with acute myocardial infarction will be missed and 46 (36 to 54) patients without acute myocardial infarction will test positive. CONCLUSIONS The results indicate that a single baseline measurement of the Elecsys Troponin T high-sensitive assay could be used to rule out acute myocardial infarction if lower cut-off values such as 3 ng/L or 5 ng/L are used. However, this method should be part of a comprehensive triage strategy and may not be appropriate for patients who present less than three hours after symptom onset. Care must also be exercised because of the higher imprecision of the evaluated assay and the greater effect of lot-to-lot reagent variation at low troponin concentrations. SYSTEMATIC REVIEW REGISTRATION PROSPERO registration number CRD42013003926.
Collapse
Affiliation(s)
- Zhivko Zhelev
- Institute of Health Research, University of Exeter Medical School, Exeter EX2 4SG, UK
| | - Christopher Hyde
- Institute of Health Research, University of Exeter Medical School, Exeter EX2 4SG, UK
| | - Emily Youngman
- Institute of Health Research, University of Exeter Medical School, Exeter EX2 4SG, UK
| | - Morwenna Rogers
- Institute of Health Research, University of Exeter Medical School, Exeter EX2 4SG, UK
| | - Simon Fleming
- Clinical Chemistry, Royal Cornwall Hospital, Treliske, Truro TR1 3LQ, UK
| | - Toby Slade
- Emergency Department, Royal Cornwall Hospital, Truro TR1 3LJ, UK
| | - Helen Coelho
- Institute of Health Research, University of Exeter Medical School, Exeter EX2 4SG, UK
| | - Tracey Jones-Hughes
- Institute of Health Research, University of Exeter Medical School, Exeter EX2 4SG, UK
| | - Vasilis Nikolaou
- Institute of Health Research, University of Exeter Medical School, Exeter EX2 4SG, UK
| |
Collapse
|
21
|
Lipinski MJ, Baker NC, Escárcega RO, Torguson R, Chen F, Aldous SJ, Christ M, Collinson PO, Goodacre SW, Mair J, Inoue K, Lotze U, Sebbane M, Cristol JP, Freund Y, Chenevier-Gobeaux C, Meune C, Eggers KM, Pracoń R, Schreiber DH, Wu AHB, Ordoñez-Llanos J, Jaffe AS, Twerenbold R, Mueller C, Waksman R. Comparison of conventional and high-sensitivity troponin in patients with chest pain: a collaborative meta-analysis. Am Heart J 2015; 169:6-16.e6. [PMID: 25497242 DOI: 10.1016/j.ahj.2014.10.007] [Citation(s) in RCA: 68] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2014] [Accepted: 10/10/2014] [Indexed: 02/07/2023]
Abstract
BACKGROUND Multiple studies have evaluated the diagnostic and prognostic performance of conventional troponin (cTn) and high-sensitivity troponin (hs-cTn). We performed a collaborative meta-analysis comparing cTn and hs-cTn for diagnosis of acute myocardial infarction (AMI) and assessment of prognosis in patients with chest pain. METHODS MEDLINE/PubMed, Cochrane CENTRAL, and EMBASE were searched for studies assessing both cTn and hs-cTn in patients with chest pain. Study authors were contacted and many provided previously unpublished data. RESULTS From 17 included studies, there were 8,644 patients. Compared with baseline cTn, baseline hs-cTn had significantly greater sensitivity (0.884 vs 0.749, P < .001) and negative predictive value (NPV; 0.964 vs 0.935, P < .001), whereas specificity (0.816 vs 0.938, P < .001) and positive predictive value (0.558 vs 0.759, P < .001) were significantly reduced. Based on summary receiver operating characteristic curves, test performance for the diagnosis of AMI was not significantly different between baseline cTn and hs-cTn (0.90 [95% CI 0.85-0.95] vs 0.92 [95% CI 0.90-0.94]). In a subanalysis of 6 studies that alternatively defined AMI based on hs-cTn, cTn had lower sensitivity (0.666, P < .001) and NPV (0.906, P < .001). Elevation of baseline hs-cTn, but negative baseline cTn, was associated with increased risk of death or nonfatal myocardial infarction during follow-up (P < .001) compared with both negative. CONCLUSION High-sensitivity troponin has significantly greater early sensitivity and NPV for the diagnosis of AMI at the cost of specificity and positive predictive value, which may enable early rule in/out of AMI in patients with chest pain. Baseline hs-cTn elevation in the setting of negative cTn is also associated with increased nonfatal myocardial infarction or death during follow-up.
Collapse
Affiliation(s)
- Michael J Lipinski
- MedStar Cardiovascular Research Network, MedStar Heart Institute, Medstar Washington Hospital Center, Washington, DC
| | - Nevin C Baker
- MedStar Cardiovascular Research Network, MedStar Heart Institute, Medstar Washington Hospital Center, Washington, DC
| | - Ricardo O Escárcega
- MedStar Cardiovascular Research Network, MedStar Heart Institute, Medstar Washington Hospital Center, Washington, DC
| | - Rebecca Torguson
- MedStar Cardiovascular Research Network, MedStar Heart Institute, Medstar Washington Hospital Center, Washington, DC
| | - Fang Chen
- MedStar Cardiovascular Research Network, MedStar Heart Institute, Medstar Washington Hospital Center, Washington, DC
| | - Sally J Aldous
- Department of Cardiology, Christchurch Hospital, Christchurch, New Zealand
| | - Michael Christ
- Department of Emergency and Critical Care Medicine, Paracelsus Medical University, Nuremberg, Germany
| | - Paul O Collinson
- Clinical Blood Sciences Laboratory, St George's Hospital, London, United Kingdom
| | - Steve W Goodacre
- School of Health and Related Research, University of Sheffield, Sheffield, United Kingdom
| | - Johannes Mair
- Department of Internal Medicine, Innsbruck Medical University, Innsbruck, Austria
| | - Kenji Inoue
- Department of Cardiology, Juntendo University Nerima Hospital, Tokyo, Japan
| | - Ulrich Lotze
- Department of Internal Medicine, DRK-Manniske-Krankenhaus Bad Frankenhausen, Frankenhausen, Germany
| | - Mustapha Sebbane
- Départment des urgences, Centre Hospitalier Régional Universitaire Lapeyronie, Montpellier, France
| | - Jean-Paul Cristol
- Département de Biochimie, Centre Hospitalier Régional Universitaire Lapeyronie, Montpellier, France
| | - Yonathan Freund
- Department of Emergency Medicine and Surgery, Hôspital Pitié-Salpétrière, APHP, Université Pierre et Marie Curie-Paris 6 (UPMC), Paris, France
| | - Camille Chenevier-Gobeaux
- Clinical Chemistry Laboratory, Groupe Hospitalier Cochin-Broca-Hôtel Dieu, Université Paris Descartes, Assistance Publique des Hôpitaux de Paris, Paris, France
| | - Christophe Meune
- Cardiology Department, Groupe Hospitalier Cochin-Broca-Hôtel Dieu, Université Paris Descartes, Assistance Publique des Hôpitaux de Paris, Paris, France; Cardiology Department, Paris XIII University, Avicenne Hospital, Bobigny, France
| | - Kai M Eggers
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - Radosław Pracoń
- Department of Coronary and Structural Heart Diseases, National Insititute of Cardiology, Warsaw, Poland
| | - Donald H Schreiber
- Division of Emergency Medicine, Stanford University School of Medicine, Stanford, CA
| | - Alan H B Wu
- Department of Laboratory Medicine, University of California, San Francisco, CA
| | - Jordi Ordoñez-Llanos
- Servei de Bioquímica Clínica, Hospital de Sant Pau, Barcelona, Spain; Biochemistry and Molecular Biology Department, Universitat Autònoma, Barcelona, Spain
| | - Allan S Jaffe
- Division of Cardiology, Mayo Clinic College of Medicine, Rochester, MN; Department of Laboratory Medicine and Pathology, Mayo Clinic College of Medicine, Rochester, MN
| | - Raphael Twerenbold
- Department of Cardiology, University Hospital Basel, Basel, Switzerland; Universitäres Herz-Zentrum Bad Krozingen, Bad Krozingen, Germany
| | - Christian Mueller
- Department of Cardiology, University Hospital Basel, Basel, Switzerland
| | - Ron Waksman
- MedStar Cardiovascular Research Network, MedStar Heart Institute, Medstar Washington Hospital Center, Washington, DC.
| |
Collapse
|
22
|
Lipinski MJ, Escárcega RO, D'Ascenzo F, Magalhães MA, Baker NC, Torguson R, Chen F, Epstein SE, Miró Ò, Llorens P, Giannitsis E, Lotze U, Lefebvre S, Sebbane M, Cristol JP, Chenevier-Gobeaux C, Meune C, Eggers KM, Charpentier S, Twerenbold R, Mueller C, Biondi-Zoccai G, Waksman R. A systematic review and collaborative meta-analysis to determine the incremental value of copeptin for rapid rule-out of acute myocardial infarction. Am J Cardiol 2014; 113:1581-91. [PMID: 24731654 DOI: 10.1016/j.amjcard.2014.01.436] [Citation(s) in RCA: 97] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2013] [Revised: 01/20/2014] [Accepted: 01/20/2014] [Indexed: 02/08/2023]
Abstract
Multiple studies have evaluated copeptin, a surrogate for arginine vasopressin, in the diagnosis of acute myocardial infarction (AMI) with mixed results. A systematic review and collaborative meta-analysis were performed for diagnosis of AMI and assessment of prognosis in patients presenting to the emergency department with chest pain. MEDLINE/PubMed, Cochrane CENTRAL, and EMBASE were searched for studies assessing copeptin in such patients. Study investigators were contacted, and many provided previously unpublished data. Random-effects methods were used to compare the data for copeptin, troponin, and their combination. There were a total of 9,244 patients from the 14 included studies. Mean age was 62 years; 64% were men; and 18.4% were ultimately diagnosed with AMI. Patients with AMI had a higher presentation copeptin level than those without AMI (22.8 vs 8.3 pmol/L, respectively, p <0.001). Although troponin had better diagnostic accuracy than copeptin for AMI, the combination of copeptin and troponin significantly improved the sensitivity (0.905 [0.888 to 0.921] vs 0.686 [0.661 to 0.710], respectively, p <0.001) and negative predictive value (0.97 [0.964 to 0.975] vs 0.93 [0.924 to 0.936], respectively, p <0.001) compared with troponin alone. Elevation in copeptin carried a similar risk of all-cause mortality to an elevation in troponin (odds ratio 5.84 vs 6.74, respectively, p = 0.67). In conclusion, copeptin not only identifies patients at risk of all-cause mortality, but its addition to troponin improved the sensitivity and negative likelihood ratio for diagnosis of AMI compared with troponin alone. Thus, copeptin may help identify patients who may be safely discharged early from the emergency department.
Collapse
|
23
|
Glatz JFC, Renneberg R. Added value of H-FABP as plasma biomarker for the early evaluation of suspected acute coronary syndrome. ACTA ACUST UNITED AC 2014. [DOI: 10.2217/clp.13.87] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
|
24
|
Raskovalova T, Twerenbold R, Collinson PO, Keller T, Bouvaist H, Folli C, Giavarina D, Lotze U, Eggers KM, Dupuy AM, Chenevier-Gobeaux C, Meune C, Maisel A, Mueller C, Labarère J. Diagnostic accuracy of combined cardiac troponin and copeptin assessment for early rule-out of myocardial infarction: a systematic review and meta-analysis. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2013; 3:18-27. [PMID: 24562800 DOI: 10.1177/2048872613514015] [Citation(s) in RCA: 81] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
AIMS This systematic review aimed to investigate the diagnostic accuracy of combined cardiac troponin (cTn) and copeptin assessment in comparison to cTn alone for early rule-out of acute myocardial infarction (AMI). METHODS Primary studies were eligible if they evaluated diagnostic accuracy for cTn with and without copeptin in patients with symptoms suggestive of AMI. AMI was defined according to the universal definition, using detection of cTn as a marker for myocardial necrosis. Eligible studies were identified by searching electronic databases (Medline, EMBASE, Science Citation Index Expanded, CINAHL, Pascal, and Cochrane) from inception to March 2013, reviewing conference proceedings and contacting field experts and the copeptin manufacturer. RESULTS In 15 studies totalling 8740 patients (prevalence of AMI 16%), adding copeptin improved the sensitivity of cTn assays (from 0.87 to 0.96, p=0.003) at the expense of lower specificity (from 0.84 to 0.56, p<0.001). In 12 studies providing data for 6988 patients without ST-segment elevation, the summary sensitivity and specificity estimates were 0.95 (95% CI 0.89 to 0.98) and 0.57 (95% CI 0.49 to 0.65) for the combined assessment of cTn and copeptin. When a high-sensitivity cTnT assay was used in combination with copeptin, the summary sensitivity and specificity estimates were 0.98 (95% CI 0.96 to 1.00) and 0.50 (95% CI 0.42 to 0.58). CONCLUSION Despite substantial between-study heterogeneity, this meta-analysis demonstrates that copeptin significantly improves baseline cTn sensitivity. Management studies are needed to establish the effectiveness and safety of measuring copeptin in combination with high-sensitivity cTnT for early rule-out of AMI without serial testing.
Collapse
|
25
|
Kossaify A, Garcia A, Succar S, Ibrahim A, Moussallem N, Kossaify M, Grollier G. Perspectives on the value of biomarkers in acute cardiac care and implications for strategic management. Biomark Insights 2013; 8:115-26. [PMID: 24046510 PMCID: PMC3771707 DOI: 10.4137/bmi.s12703] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Biomarkers in acute cardiac care are gaining increasing interest given their clinical benefits. This study is a review of the major conditions in acute cardiac care, with a focus on biomarkers for diagnostic and prognostic assessment. Through a PubMed search, 110 relevant articles were selected. The most commonly used cardiac biomarkers (cardiac troponin, natriuretic peptides, and C-reactive protein) are presented first, followed by a description of variable acute cardiac conditions with their relevant biomarkers. In addition to the conventional use of natriuretic peptides, cardiac troponin, and C-reactive protein, other biomarkers are outlined in variable critical conditions that may be related to acute cardiac illness. These include ST2 and chromogranin A in acute dyspnea and acute heart failure, matrix metalloproteinase in acute chest pain, heart-type fatty acid binding protein in acute coronary syndrome, CD40 ligand and interleukin-6 in acute myocardial infarction, blood ammonia and lactate in cardiac arrest, as well as tumor necrosis factor-alpha in atrial fibrillation. Endothelial dysfunction, oxidative stress and inflammation are involved in the physiopathology of most cardiac diseases, whether acute or chronic. In summary, natriuretic peptides, cardiac troponin, C-reactive protein are currently the most relevant biomarkers in acute cardiac care. Point-of-care testing and multi-markers use are essential for prompt diagnostic approach and tailored strategic management.
Collapse
Affiliation(s)
- Antoine Kossaify
- CCU Acute Cardiac Care Unit (CCU), Cardiology Division, University Hospital Notre Dame de Secours, St. Charbel Street, Byblos, Lebanon
| | | | | | | | | | | | | | | |
Collapse
|
26
|
Gamble JHP, Carlton EW, Orr WP, Greaves K. High-sensitivity cardiac troponins: no more 'negatives'. Expert Rev Cardiovasc Ther 2013; 11:1129-39. [PMID: 23977868 DOI: 10.1586/14779072.2013.828978] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
According to recently published expert guidelines, cardiac troponins are the only accepted biomarkers to define acute myocardial infarction. New high sensitivity cardiac troponin assays provide exciting opportunities for early rule-out and rule-in strategies and for identifying high-risk patients early in their presentation to guide early treatment and intervention. This review briefly discusses the history of troponin testing, before going on to cover clinical uses of the new highly sensitive assays in the early assessment of acute myocardial infection. Common clinical pitfalls with the use of these assays are discussed, as is the use of highly sensitive troponins more widely as prognostic markers. Likely future developments in this area are discussed.
Collapse
Affiliation(s)
- James H P Gamble
- Cardiovascular Clinical Research Facility, John Radcliffe Hospital, Oxford OX3 9DU, UK
| | | | | | | |
Collapse
|