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Boeddinghaus J, Doudesis D, Lopez-Ayala P, Lee KK, Koechlin L, Wildi K, Nestelberger T, Borer R, Miró Ò, Martin-Sanchez FJ, Strebel I, Rubini Giménez M, Keller DI, Christ M, Bularga A, Li Z, Ferry AV, Tuck C, Anand A, Gray A, Mills NL, Mueller C. Machine Learning for Myocardial Infarction Compared With Guideline-Recommended Diagnostic Pathways. Circulation 2024; 149:1090-1101. [PMID: 38344871 DOI: 10.1161/circulationaha.123.066917] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Accepted: 01/16/2024] [Indexed: 02/29/2024]
Abstract
BACKGROUND Collaboration for the Diagnosis and Evaluation of Acute Coronary Syndrome (CoDE-ACS) is a validated clinical decision support tool that uses machine learning with or without serial cardiac troponin measurements at a flexible time point to calculate the probability of myocardial infarction (MI). How CoDE-ACS performs at different time points for serial measurement and compares with guideline-recommended diagnostic pathways that rely on fixed thresholds and time points is uncertain. METHODS Patients with possible MI without ST-segment-elevation were enrolled at 12 sites in 5 countries and underwent serial high-sensitivity cardiac troponin I concentration measurement at 0, 1, and 2 hours. Diagnostic performance of the CoDE-ACS model at each time point was determined for index type 1 MI and the effectiveness of previously validated low- and high-probability scores compared with guideline-recommended European Society of Cardiology (ESC) 0/1-hour, ESC 0/2-hour, and High-STEACS (High-Sensitivity Troponin in the Evaluation of Patients With Suspected Acute Coronary Syndrome) pathways. RESULTS In total, 4105 patients (mean age, 61 years [interquartile range, 50-74]; 32% women) were included, among whom 575 (14%) had type 1 MI. At presentation, CoDE-ACS identified 56% of patients as low probability, with a negative predictive value and sensitivity of 99.7% (95% CI, 99.5%-99.9%) and 99.0% (98.6%-99.2%), ruling out more patients than the ESC 0-hour and High-STEACS (25% and 35%) pathways. Incorporating a second cardiac troponin measurement, CoDE-ACS identified 65% or 68% of patients as low probability at 1 or 2 hours, for an identical negative predictive value of 99.7% (99.5%-99.9%); 19% or 18% as high probability, with a positive predictive value of 64.9% (63.5%-66.4%) and 68.8% (67.3%-70.1%); and 16% or 14% as intermediate probability. In comparison, after serial measurements, the ESC 0/1-hour, ESC 0/2-hour, and High-STEACS pathways identified 49%, 53%, and 71% of patients as low risk, with a negative predictive value of 100% (99.9%-100%), 100% (99.9%-100%), and 99.7% (99.5%-99.8%); and 20%, 19%, or 29% as high risk, with a positive predictive value of 61.5% (60.0%-63.0%), 65.8% (64.3%-67.2%), and 48.3% (46.8%-49.8%), resulting in 31%, 28%, or 0%, who require further observation in the emergency department, respectively. CONCLUSIONS CoDE-ACS performs consistently irrespective of the timing of serial cardiac troponin measurement, identifying more patients as low probability with comparable performance to guideline-recommended pathways for MI. Whether care guided by probabilities can improve the early diagnosis of MI requires prospective evaluation. REGISTRATION URL: https://www.clinicaltrials.gov; Unique identifier: NCT00470587.
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Affiliation(s)
- Jasper Boeddinghaus
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology (J.B., P.L.-A., L.K., K.W., T.N., R.B., I.S., M.R.G., C.M.), University Hospital Basel, University of Basel, Switzerland
- BHF/University Centre for Cardiovascular Science (J.B., D.D., K.K.L., A.B., Z.L., A.V.F., C.T., A.A., N.L.M.), University of Edinburgh, UK
| | - Dimitrios Doudesis
- BHF/University Centre for Cardiovascular Science (J.B., D.D., K.K.L., A.B., Z.L., A.V.F., C.T., A.A., N.L.M.), University of Edinburgh, UK
- Usher Institute (D.D., K.K.L., A.G., N.L.M.), University of Edinburgh, UK
| | - Pedro Lopez-Ayala
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology (J.B., P.L.-A., L.K., K.W., T.N., R.B., I.S., M.R.G., C.M.), University Hospital Basel, University of Basel, Switzerland
| | - Kuan Ken Lee
- BHF/University Centre for Cardiovascular Science (J.B., D.D., K.K.L., A.B., Z.L., A.V.F., C.T., A.A., N.L.M.), University of Edinburgh, UK
- Usher Institute (D.D., K.K.L., A.G., N.L.M.), University of Edinburgh, UK
| | - Luca Koechlin
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology (J.B., P.L.-A., L.K., K.W., T.N., R.B., I.S., M.R.G., C.M.), University Hospital Basel, University of Basel, Switzerland
- Departments of Cardiac Surgery (L.K.), University Hospital Basel, University of Basel, Switzerland
| | - Karin Wildi
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology (J.B., P.L.-A., L.K., K.W., T.N., R.B., I.S., M.R.G., C.M.), University Hospital Basel, University of Basel, Switzerland
- Intensive Care (K.W.), University Hospital Basel, University of Basel, Switzerland
| | - Thomas Nestelberger
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology (J.B., P.L.-A., L.K., K.W., T.N., R.B., I.S., M.R.G., C.M.), University Hospital Basel, University of Basel, Switzerland
| | - Raphael Borer
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology (J.B., P.L.-A., L.K., K.W., T.N., R.B., I.S., M.R.G., C.M.), University Hospital Basel, University of Basel, Switzerland
| | - Òscar Miró
- Emergency Department, Hospital Clinic, Barcelona, Catalonia, Spain (Ò.M.)
| | | | - Ivo Strebel
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology (J.B., P.L.-A., L.K., K.W., T.N., R.B., I.S., M.R.G., C.M.), University Hospital Basel, University of Basel, Switzerland
| | - Maria Rubini Giménez
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology (J.B., P.L.-A., L.K., K.W., T.N., R.B., I.S., M.R.G., C.M.), University Hospital Basel, University of Basel, Switzerland
| | - Dagmar I Keller
- Emergency Department, University Hospital Zurich, Switzerland (D.I.K.)
| | - Michael Christ
- Emergency Department, Kantonsspital Luzern, Switzerland (M.C.)
| | - Anda Bularga
- BHF/University Centre for Cardiovascular Science (J.B., D.D., K.K.L., A.B., Z.L., A.V.F., C.T., A.A., N.L.M.), University of Edinburgh, UK
| | - Ziwen Li
- BHF/University Centre for Cardiovascular Science (J.B., D.D., K.K.L., A.B., Z.L., A.V.F., C.T., A.A., N.L.M.), University of Edinburgh, UK
| | - Amy V Ferry
- BHF/University Centre for Cardiovascular Science (J.B., D.D., K.K.L., A.B., Z.L., A.V.F., C.T., A.A., N.L.M.), University of Edinburgh, UK
| | - Chris Tuck
- BHF/University Centre for Cardiovascular Science (J.B., D.D., K.K.L., A.B., Z.L., A.V.F., C.T., A.A., N.L.M.), University of Edinburgh, UK
| | - Atul Anand
- BHF/University Centre for Cardiovascular Science (J.B., D.D., K.K.L., A.B., Z.L., A.V.F., C.T., A.A., N.L.M.), University of Edinburgh, UK
| | - Alasdair Gray
- Usher Institute (D.D., K.K.L., A.G., N.L.M.), University of Edinburgh, UK
- Emergency Medicine Research Group Edinburgh, Royal Infirmary of Edinburgh, UK (A.G.)
| | - Nicholas L Mills
- BHF/University Centre for Cardiovascular Science (J.B., D.D., K.K.L., A.B., Z.L., A.V.F., C.T., A.A., N.L.M.), University of Edinburgh, UK
- Usher Institute (D.D., K.K.L., A.G., N.L.M.), University of Edinburgh, UK
| | - Christian Mueller
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology (J.B., P.L.-A., L.K., K.W., T.N., R.B., I.S., M.R.G., C.M.), University Hospital Basel, University of Basel, Switzerland
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2
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Liu L, Lewandrowski K. Establishing optimal cutoff values for high-sensitivity cardiac troponin algorithms in risk stratification of acute myocardial infarction. Crit Rev Clin Lab Sci 2024; 61:1-22. [PMID: 37466395 DOI: 10.1080/10408363.2023.2235426] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Revised: 06/11/2023] [Accepted: 07/07/2023] [Indexed: 07/20/2023]
Abstract
Acute myocardial infarction (AMI) is a leading cause of mortality globally, highlighting the need for timely and accurate diagnostic strategies. Cardiac troponin has been the biomarker of choice for detecting myocardial injury. A dynamic change in concentrations supports the diagnosis of AMI in the setting of evidence of acute myocardial ischemia. The new generation of high-sensitivity cardiac troponin (hs-cTn) assays has significantly improved analytical sensitivity but at the expense of decreased clinical specificity. As a result, sophisticated algorithms are required to differentiate AMI from non-AMI patients. Establishing optimal hs-cTn cutoffs for these algorithms to rule out and rule in AMI has been the subject of intensive investigations. These efforts have evolved from examining the utility of the hs-cTn 99th percentile upper reference limit, comparing the percentage versus absolute delta thresholds, and evaluating the performance of an early European Society of Cardiology-recommended 3 h algorithm, to the development of accelerated 1 h and 2 h algorithms that combine the admission hs-cTn concentrations and absolute delta cutoffs to rule out and rule in AMI. Specific cutoffs for individual confounding factors such as sex, age, and renal insufficiency have also been investigated. At the same time, concerns such as whether the small delta thresholds exceed the analytical and biological variations of hs-cTn assays and whether the algorithms developed in European study populations fit all other patient cohorts have been raised. In addition, the accelerated algorithms leave a substantial number of patients in a non-diagnostic observation zone. How to properly diagnose patients falling in this zone and those presenting with elevated baseline hs-cTn concentrations due to the presence of confounding factors or comorbidities remain open questions. Here we discuss the developments described above, focusing on criteria and underlying considerations for establishing optimal cutoffs. In-depth analyses are provided on the influence of biological variation, analytical imprecision, local AMI rate, and the timing of presentation on the performance metrics of the accelerated hs-cTn algorithms. Developing diagnostic strategies for patients who remain in the observation zone and those presenting with confounding factors are also reviewed.
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Affiliation(s)
- Li Liu
- Department of Pathology, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Kent Lewandrowski
- Department of Pathology, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
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4
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Meister R, Puelacher C, Glarner N, Gualandro DM, Andersson HA, Pargger M, Huré G, Virant G, Bolliger D, Lampart A, Steiner L, Hidvegi R, Lurati Buse G, Kindler C, Gürke L, Mujagic E, Schaeren S, Clauss M, Lardinois D, Hammerer-Lercher A, Chew M, Mueller C. Prediction of perioperative myocardial infarction/injury in high-risk patients after noncardiac surgery. Eur Heart J Acute Cardiovasc Care 2023; 12:729-739. [PMID: 37548292 PMCID: PMC10655147 DOI: 10.1093/ehjacc/zuad090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Revised: 07/24/2023] [Accepted: 07/26/2023] [Indexed: 08/08/2023]
Abstract
AIMS Perioperative myocardial infarction/injury (PMI) is a surprisingly common yet difficult-to-predict cardiac complication in patients undergoing noncardiac surgery. We aimed to assess the incremental value of preoperative cardiac troponin (cTn) concentration in the prediction of PMI. METHODS AND RESULTS Among prospectively recruited patients at high cardiovascular risk (age ≥65 years or ≥45 years with preexisting cardiovascular disease), PMI was defined as an absolute increase in high-sensitivity cTnT (hs-cTnT) concentration of ≥14 ng/L (the 99th percentile) above the preoperative concentration. Perioperative myocardial infarction/injury was centrally adjudicated by two independent cardiologists using serial measurements of hs-cTnT. Using logistic regression, three models were derived: Model 1 including patient- and procedure-related information, Model 2 adding routinely available laboratory values, and Model 3 further adding preoperative hs-cTnT concentration. Models were also compared vs. preoperative hs-cTnT alone. The findings were validated in two independent cohorts. Among 6944 patients, PMI occurred in 1058 patients (15.2%). The predictive accuracy as quantified by the area under the receiver operating characteristic curve was 0.73 [95% confidence interval (CI) 0.71-0.74] for Model 1, 0.75 (95% CI 0.74-0.77) for Model 2, 0.79 (95% CI 0.77-0.80) for Model 3, and 0.74 for hs-cTnT alone. Model 3 included 10 preoperative variables: age, body mass index, known coronary artery disease, metabolic equivalent >4, risk of surgery, emergency surgery, planned duration of surgery, haemoglobin, platelet count, and hs-cTnT. These findings were confirmed in both independent validation cohorts (n = 722 and n = 966). CONCLUSION Preoperative cTn adds incremental value above patient- and procedure-related variables as well as routine laboratory variables in the prediction of PMI.
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Affiliation(s)
- Rebecca Meister
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Spitalstrasse 2, CH-4031 Basel, Basel-Stadt, Switzerland
| | - Christian Puelacher
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Spitalstrasse 2, CH-4031 Basel, Basel-Stadt, Switzerland
- Department of Internal Medicine, University Hospital Basel, University of Basel, Spitalstrasse 21, 4031 Basel, Basel-Stadt, Switzerland
| | - Noemi Glarner
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Spitalstrasse 2, CH-4031 Basel, Basel-Stadt, Switzerland
| | - Danielle Menosi Gualandro
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Spitalstrasse 2, CH-4031 Basel, Basel-Stadt, Switzerland
- Interdisciplinary Medicine in Cardiology Unit, Cardiology Department, Heart Institute (InCor), University of Sao Paulo Medical School, Av. Dr. Enéas Carvalho de Aguiar, 44, Cerqueira César, 05403-900 São Paulo, Brazil
| | - Henrik A Andersson
- Department of Anaesthesiology and Intensive Care Medicine, Linköping University Hospital, SE-581 83 Linköping, Sweden
| | - Mirjam Pargger
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Spitalstrasse 2, CH-4031 Basel, Basel-Stadt, Switzerland
| | - Gabrielle Huré
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Spitalstrasse 2, CH-4031 Basel, Basel-Stadt, Switzerland
| | - Georgiana Virant
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Spitalstrasse 2, CH-4031 Basel, Basel-Stadt, Switzerland
| | - Daniel Bolliger
- Department of Anaesthesiology, University Hospital Basel, University of Basel, Spitalstrasse 21, 4031 Basel, Basel-Stadt, Switzerland
| | - Andreas Lampart
- Department of Anaesthesiology, University Hospital Basel, University of Basel, Spitalstrasse 21, 4031 Basel, Basel-Stadt, Switzerland
| | - Luzius Steiner
- Department of Anaesthesiology, University Hospital Basel, University of Basel, Spitalstrasse 21, 4031 Basel, Basel-Stadt, Switzerland
- Department of Clinical Research, University Basel, Spitalstrasse 21, 4031 Basel, Basel-Stadt, Switzerland
| | - Reka Hidvegi
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Spitalstrasse 2, CH-4031 Basel, Basel-Stadt, Switzerland
- Department of Anaesthesiology, Cantonal Hospital St. Gallen, Rorschacher Str. 95/Haus 03, 9007 St. Gallen, Switzerland
| | - Giovanna Lurati Buse
- Department of Anaesthesiology, University Hospital Dusseldorf, Moorenstr. 5 40225 Düsseldorf, NRW, Germany
| | - Christoph Kindler
- Department of Anaesthesiology, Cantonal Hospital Aarau, Tellstrasse 25, 5001 Aarau, Aargau, Switzerland
| | - Lorenz Gürke
- Department of Vascular Surgery, University Hospital Basel, University Basel, Spitalstrasse 21, 4031 Basel, Basel-Stadt, Switzerland
| | - Edin Mujagic
- Department of Vascular Surgery, University Hospital Basel, University Basel, Spitalstrasse 21, 4031 Basel, Basel-Stadt, Switzerland
| | - Stefan Schaeren
- Department of Spinal Surgery, University Hospital Basel, University Basel, Spitalstrasse 21, 4031 Basel, Basel-Stadt, Switzerland
| | - Martin Clauss
- Department of Orthopedics and Center of Musculoskeletal Infections, University Hospital Basel, University Basel, Spitalstrasse 21, 4031 Basel, Basel-Stadt, Switzerland
| | - Didier Lardinois
- Department of Thoracic Surgery, University Hospital Basel, University of Basel, Spitalstrasse 21, 4031 Basel, Basel-Stadt, Switzerland
| | - Angelika Hammerer-Lercher
- Department of Laboratory Medicine, Cantonal Hospital Aarau, Tellstrasse 25, 5001 Aarau, Aargau, Switzerland
| | - Michelle Chew
- Department of Anaesthesiology and Intensive Care Medicine, Linköping University Hospital, SE-581 83 Linköping, Sweden
| | - Christian Mueller
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Spitalstrasse 2, CH-4031 Basel, Basel-Stadt, Switzerland
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5
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Doudesis D, Lee KK, Boeddinghaus J, Bularga A, Ferry AV, Tuck C, Lowry MTH, Lopez-Ayala P, Nestelberger T, Koechlin L, Bernabeu MO, Neubeck L, Anand A, Schulz K, Apple FS, Parsonage W, Greenslade JH, Cullen L, Pickering JW, Than MP, Gray A, Mueller C, Mills NL. Machine learning for diagnosis of myocardial infarction using cardiac troponin concentrations. Nat Med 2023; 29:1201-1210. [PMID: 37169863 PMCID: PMC10202804 DOI: 10.1038/s41591-023-02325-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Accepted: 03/28/2023] [Indexed: 05/13/2023]
Abstract
Although guidelines recommend fixed cardiac troponin thresholds for the diagnosis of myocardial infarction, troponin concentrations are influenced by age, sex, comorbidities and time from symptom onset. To improve diagnosis, we developed machine learning models that integrate cardiac troponin concentrations at presentation or on serial testing with clinical features and compute the Collaboration for the Diagnosis and Evaluation of Acute Coronary Syndrome (CoDE-ACS) score (0-100) that corresponds to an individual's probability of myocardial infarction. The models were trained on data from 10,038 patients (48% women), and their performance was externally validated using data from 10,286 patients (35% women) from seven cohorts. CoDE-ACS had excellent discrimination for myocardial infarction (area under curve, 0.953; 95% confidence interval, 0.947-0.958), performed well across subgroups and identified more patients at presentation as low probability of having myocardial infarction than fixed cardiac troponin thresholds (61 versus 27%) with a similar negative predictive value and fewer as high probability of having myocardial infarction (10 versus 16%) with a greater positive predictive value. Patients identified as having a low probability of myocardial infarction had a lower rate of cardiac death than those with intermediate or high probability 30 days (0.1 versus 0.5 and 1.8%) and 1 year (0.3 versus 2.8 and 4.2%; P < 0.001 for both) from patient presentation. CoDE-ACS used as a clinical decision support system has the potential to reduce hospital admissions and have major benefits for patients and health care providers.
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Grants
- FS/18/25/33454 British Heart Foundation
- MR/V007254/1 Medical Research Council
- CH/F/21/90010 British Heart Foundation
- RG/20/10/34966 British Heart Foundation
- MR/N013166/1 Medical Research Council
- RE/18/5/34216 British Heart Foundation
- MR/W000598/1 Medical Research Council
- British Heart Foundation (BHF)
- RCUK | Medical Research Council (MRC)
- The University of Basel, the University Hospital of Basel, the Swiss Academy of Medical Sciences, the Gottfried and Julia Bangerter-Rhyner Foundation, the Swiss National Science Foundation
- Swiss Heart Foundation, the University of Basel, the Swiss Academy of Medical Science, the Gottfried and Julia Bangerter-Rhyner Foundation, and the “Freiwillige Akademische Gesellschaft Basel.”
- Advance Queensland Fellowship
- the Swiss National Science Foundation, the Swiss Heart Foundation, the Commission for Technology and Innovation, and the University Hospital Basel.
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Affiliation(s)
- Dimitrios Doudesis
- British Heart Foundation/University Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
- Usher Institute, University of Edinburgh, Edinburgh, UK
| | - Kuan Ken Lee
- British Heart Foundation/University Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Jasper Boeddinghaus
- British Heart Foundation/University Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
- Cardiovascular Research Institute Basel and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Anda Bularga
- British Heart Foundation/University Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Amy V Ferry
- British Heart Foundation/University Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Chris Tuck
- British Heart Foundation/University Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Matthew T H Lowry
- British Heart Foundation/University Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Pedro Lopez-Ayala
- Cardiovascular Research Institute Basel and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Thomas Nestelberger
- Cardiovascular Research Institute Basel and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Luca Koechlin
- Cardiovascular Research Institute Basel and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- Department of Cardiac Surgery, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Miguel O Bernabeu
- Usher Institute, University of Edinburgh, Edinburgh, UK
- The Bayes Centre, The University of Edinburgh, Edinburgh, UK
| | - Lis Neubeck
- School of Health and Social Care, Edinburgh Napier University, Edinburgh, UK
| | - Atul Anand
- British Heart Foundation/University Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Karen Schulz
- Cardiac Biomarkers Trials Laboratory, Hennepin Healthcare Research Institute, Minneapolis, MN, USA
| | - Fred S Apple
- Departments of Laboratory Medicine and Pathology, Hennepin County Medical Center and University of Minnesota, Minneapolis, MN, USA
| | - William Parsonage
- Australian Centre for Health Service Innovation, Centre for Healthcare Transformation, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Jaimi H Greenslade
- Emergency and Trauma Centre, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
- School of Medicine, University of Queensland, Brisbane, Queensland, Australia
- Faculty of Health, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Louise Cullen
- Emergency and Trauma Centre, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
- School of Medicine, University of Queensland, Brisbane, Queensland, Australia
- Faculty of Health, Queensland University of Technology, Brisbane, Queensland, Australia
| | - John W Pickering
- Department of Medicine, University of Otago, Christchurch, New Zealand
- Emergency Department, Christchurch Hospital, Christchurch, New Zealand
| | - Martin P Than
- Department of Medicine, University of Otago, Christchurch, New Zealand
| | - Alasdair Gray
- Emergency Medicine Research Group Edinburgh, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Christian Mueller
- Cardiovascular Research Institute Basel and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Nicholas L Mills
- British Heart Foundation/University Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK.
- Usher Institute, University of Edinburgh, Edinburgh, UK.
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Ohtake H, Terasawa T, Zhelev Z, Iwata M, Rogers M, Peters JL, Hyde C. Serial high-sensitivity cardiac troponin testing for the diagnosis of myocardial infarction: a scoping review. BMJ Open 2022; 12:e066429. [PMID: 36414302 PMCID: PMC9685223 DOI: 10.1136/bmjopen-2022-066429] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVES We aimed to assess the diversity and practices of existing studies on several assays and algorithms for serial measurements of high-sensitivity cardiac troponin (hs-cTn) for risk stratification and the diagnosis of myocardial infarction (MI) and 30-day outcomes in patients suspected of having non-ST-segment elevation MI (NSTEMI). METHODS We searched multiple databases including MEDLINE, EMBASE, Science Citation Index, the Cochrane Database of Systematic Reviews and the CENTRAL databases for studies published between January 2006 and November 2021. Studies that assessed the diagnostic accuracy of serial hs-cTn testing in patients suspected of having NSTEMI in the emergency department (ED) were eligible. Data were analysed using the scoping review method. RESULTS We included 86 publications, mainly from research centres in Europe, North America and Australasia. Two hs-cTn assays, manufactured by Abbott (43/86) and Roche (53/86), dominated the evaluations. The studies most commonly measured the concentrations of hs-cTn at two time points, at presentation and a few hours thereafter, to assess the two-strata or three-strata algorithm for diagnosing or ruling out MI. Although data from 83 studies (97%) were prospectively collected, 0%-90% of the eligible patients were excluded from the analysis due to missing blood samples or the lack of a final diagnosis in 53 studies (62%) that reported relevant data. Only 19 studies (22%) reported on head-to-head comparisons of alternative assays. CONCLUSION Evidence on the accuracy of serial hs-cTn testing was largely derived from selected research institutions and relied on two specific assays. The proportions of the eligible patients excluded from the study raise concerns about directly applying the study findings to clinical practice in frontline EDs. PROSPERO REGISTRATION NUMBER CRD42018106379.
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Affiliation(s)
- Hirotaka Ohtake
- Department of Emergency and General Internal Medicine, Fujita Health University, Toyoake, Aichi, Japan
| | - Teruhiko Terasawa
- Department of Emergency and General Internal Medicine, Fujita Health University, Toyoake, Aichi, Japan
| | - Zhivko Zhelev
- University of Exeter Medical School, University of Exeter, Exeter, UK
| | - Mitsunaga Iwata
- Department of Emergency and General Internal Medicine, Fujita Health University, Toyoake, Aichi, Japan
| | - Morwenna Rogers
- NIHR CLAHRC South West Peninsula, University of Exeter, Exeter, UK
| | - Jaime L Peters
- Peninsula Technology Assessment Group (PenTAG), University of Exeter, Exeter, UK
- Peninsula Technology Assessment Group (PenTAG), University of Exeter, Exeter, UK
| | - Chris Hyde
- Exeter Test Group, University of Exeter, Exeter, UK
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Ravanavena A, Ravindra C, Igweonu-Nwakile EO, Ali S, Paul S, Yakkali S, Teresa Selvin S, Thomas S, Bikeyeva V, Abdullah A, Radivojevic A, Abu Jad AA, Balani P. Absolute Versus Relative Changes in Cardiac Troponins in the Diagnosis of Myocardial Infarction: A Systematic Review and Meta-Analysis. Cureus 2022; 14:e27414. [PMID: 35915617 PMCID: PMC9338783 DOI: 10.7759/cureus.27414] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Accepted: 07/27/2022] [Indexed: 11/30/2022] Open
Abstract
Ischemic heart disease (IHD) is one of the leading causes of death globally. Rapid diagnosis of myocardial infarction (MI) will enable earlier initiation of the treatment and improve patient outcomes. Practice guidelines for non-ST-elevation acute coronary syndromes by the American College of Cardiology (ACC)/American Heart Association (AHA) had listed the diagnostic performance of absolute versus relative changes in evidence gaps. We aimed to address this evidence gap by examining the diagnostic accuracy of absolute versus relative changes in cardiac troponins at various time intervals in diagnosing MI. Grey literature, conference abstracts, animal studies, and reports published before 2009 and in languages other than English were excluded. We included reports that investigated absolute or relative changes in highly sensitive cardiac troponin T (hs-cTnT) or sensitive/highly sensitive cardiac troponin I (s/hs-cTnI) assays after specific time intervals (1, 2, or 3 h) in patients presenting with symptoms suggestive of the acute coronary syndrome. After screening, we arranged the reports in 12 separate groups based on the variables for which the data was reported. Quality assessment of the diagnostic accuracy studies-2 (QUADAS-2) was used to assess the risk of bias in the included studies. The weighted summary area under the curve (AUC) was calculated for each pool. We then performed two-sided (or two-tailed) tests to compare independent receiver operating characteristic (ROC) curves. MedCalc version 20.106 (MedCalc Software Ltd., Ostend, Belgium) was used for all statistical analysis. We included eight reports with 23,450 patients in the meta-analysis. Weighted summary estimates and their respective 95% confidence intervals (CI) under random-effects model for ROC-AUC are as follows: absolute hs-cTnI at 1 h - 0.94 (95% CI: 0.922 to 0.959, p < 0.001); absolute hs-cTnT at 1 h - 0.921 (95% CI: 0.902 to 0.941, p < 0.001); absolute s/hs-cTnI at 2 h - 0.953 (95% CI: 0.926 to 0.980, p < 0.001); absolute hs-cTnT at 2 h 0.951 (95% CI: 0.940 to 0.962, p < 0.001); relative hs-cTnT at 2 h - 0.818 (95% CI: 0.733 to 0.903, p < 0.001); relative s/hs-cTnI at 2 h - 0.762 (95% CI: 0.726 to 0.798, p < 0.001); absolute hs-cTnI at 3 h - 0.967 (95% CI: 0.95 to 0.984, p < 0.001); absolute hs-cTnT at 3 h - 0.959 (95% CI: 0.950 to 0.968, p < 0.001); and relative hs-cTnT at 3 h - 0.926 (95% CI: 0.907 to 0.945, p < 0.001). P-values of comparison of absolute and relative changes are as follows: hs-cTnT at 1 h: <0.0001; hs-cTnI at 1 h: <0.0001; hs-cTnT at 2 h: 0.0024; s/hs-cTnI at 2 h: <0.0001; hs-cTnT at 3 h: 0.0022; and hs-cTnI at 3 h: 0.0005. Our analysis found absolute changes to be superior to relative changes in both hs-cTnT and s/hs-cTnI at 1, 2, and 3 h in the diagnosis of MI. There was no statistically significant difference in comparing s/hs-cTnI vs. hs-cTnT using absolute or relative changes at any time interval. Our findings suggest that future research investigating a potential 0 h/30 min algorithm should use absolute Δ over relative Δ. A suboptimal number of reports in the groups limited our ability to establish the robustness of the results. We did not receive any funding for this review.
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8
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van den Berg P, Collinson P, Morris N, Body R. Diagnostic accuracy of a high-sensitivity troponin I assay and external validation of 0/3 h rule out strategies. Eur Heart J Acute Cardiovasc Care 2022; 11:127-136. [PMID: 35136994 DOI: 10.1093/ehjacc/zuab102] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Revised: 10/06/2021] [Accepted: 10/26/2021] [Indexed: 06/14/2023]
Abstract
AIMS The timely diagnosis and exclusion of acute coronary syndromes in the Emergency Department (ED) remains a challenge. This study aims to evaluate the diagnostic accuracy of a high-sensitivity cardiac troponin I assay (Siemens TNIH) on serial sampling for ED patients as standalone test and in rule-out algorithms as recommendations remain assay specific. METHODS AND RESULTS This secondary analysis from a prospective diagnostic accuracy study at 14 centres included ED patients presenting with chest pain of suspected cardiac nature. Serum drawn on arrival and 3 h later was batchtested for TNIH. The target condition was an adjudicated diagnosis of acute myocardial infarction (AMI). We evaluated the diagnostic accuracy of absolute and relative delta criteria and four rule-out strategies. Of 802 included patients, 13.8% had AMI. Absolute delta criteria had superior accuracy to relative criteria (C-statistic 0.94 vs. 0.76, P < 0.001). However, no delta criteria achieved >95.5% sensitivity for AMI when used alone. Ruling out AMI with TNIH below the 99th percentile at 0 and 3 h had 88.3% (95% confidence interval 80.8-93.6%) sensitivity. The adapted European Society of Cardiology (ESC) 0/2 h algorithm had higher sensitivity (98.2%) than both High-STEACS (93.7%, P = 0.03) and the ESC 0/3 h algorithm (79.3%, P < 0.001). These pathways ruled out 63%, 74%, and 88% patients, respectively. CONCLUSION With serial sampling over 3 h, the Siemens TNIH assay should be used with a validated algorithm incorporating bespoke cut-offs and absolute delta criteria. In our analysis, the adapted ESC 0/2 h algorithm had greatest sensitivity. 'Ruling out' AMI using the 99th percentile of the assay cannot be recommended.
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Affiliation(s)
- Patricia van den Berg
- Manchester University NHS Foundation Trust, Oxford Road, Manchester M13 9WL, UK
- Division of Cardiovascular Science, The University of Manchester, Oxford Road, Manchester M13 9PL, UK
| | - Paul Collinson
- St George's University Hospitals NHS Foundation Trust and St Georges University of London, Cranmer Terrace, London SW17 0QT, UK
| | - Niall Morris
- Manchester University NHS Foundation Trust, Oxford Road, Manchester M13 9WL, UK
- Division of Cardiovascular Science, The University of Manchester, Oxford Road, Manchester M13 9PL, UK
| | - Richard Body
- Manchester University NHS Foundation Trust, Oxford Road, Manchester M13 9WL, UK
- Division of Cardiovascular Science, The University of Manchester, Oxford Road, Manchester M13 9PL, UK
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9
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Lan NSR, Nguyen LT, Vasikaran SD, Wilson C, Jonsson J, Rankin JM, Bell DA. Short- and long-term biological variation of cardiac troponin I in healthy individuals, and patients with end-stage renal failure requiring haemodialysis or cardiomyopathy. Clin Chem Lab Med 2021; 58:1941-1949. [PMID: 32598297 DOI: 10.1515/cclm-2020-0046] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Accepted: 05/20/2020] [Indexed: 11/15/2022]
Abstract
Objectives High-sensitivity (hs) cardiac troponin (cTn) assays can quantitate small fluctuations in cTn concentration. Determining biological variation allows calculation of reference change values (RCV), to define significant changes. We assessed the short- and long-term biological variation of cardiac troponin I (cTnI) in healthy individuals and patients with renal failure requiring haemodialysis or cardiomyopathy. Methods Plasma samples were collected hourly for 4 h and weekly for seven further weeks from 20 healthy individuals, 9 renal failure patients and 20 cardiomyopathy patients. Pre- and post-haemodialysis samples were collected weekly for 7 weeks. Samples were analysed using a hs-cTnI assay (Abbott Alinity ci-series). Within-subject biological variation (CVI), analytical variation (CVA) and between-subject biological variation (CVG) was used to calculate RCVs and index of individuality (II). Results For healthy individuals, CVI, CVA, CVG, RCV and II values were 8.8, 14.0, 43.1, 45.8% and 0.38 respectively for short-term, and 41.4, 14.0, 25.8, 121.0% and 1.69 for long-term. For renal failure patients, these were 2.6, 5.8, 50.5, 17.6% and 0.30 respectively for short-term, and 19.1, 5.8, 11.2, 55.2% and 1.78 for long-term. For cardiomyopathy patients, these were 4.2, 10.0, 65.9, 30.0% and 0.16 respectively for short-term, and 17.5, 10.0, 63.1, 55.8% and 0.32 for long-term. Mean cTnI concentration was lower post-haemodialysis (15.2 vs. 17.8 ng/L, p < 0.0001), with a 16.9% mean relative change. Conclusions The biological variation of cTnI is similar between end-stage renal failure and cardiomyopathy patients, but proportionately greater in well-selected healthy individuals with very low baseline cTnI concentrations.
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Affiliation(s)
- Nick S R Lan
- Department of Cardiology, Fiona Stanley Hospital, Perth, Western Australia, Australia.,Medical School, The University of Western Australia, Perth, Western Australia, Australia
| | - Lan T Nguyen
- Department of Clinical Biochemistry, PathWest Laboratory Medicine WA, Fiona Stanley Hospital, Perth, Western Australia, Australia
| | - Samuel D Vasikaran
- Department of Clinical Biochemistry, PathWest Laboratory Medicine WA, Fiona Stanley Hospital, Perth, Western Australia, Australia.,Department of Clinical Biochemistry, PathWest Laboratory Medicine WA, Royal Perth Hospital, Perth, Western Australia, Australia
| | - Catherine Wilson
- Department of Cardiology, Fiona Stanley Hospital, Perth, Western Australia, Australia
| | - Jacqueline Jonsson
- Department of Cardiology, Fiona Stanley Hospital, Perth, Western Australia, Australia
| | - James M Rankin
- Department of Cardiology, Fiona Stanley Hospital, Perth, Western Australia, Australia
| | - Damon A Bell
- Medical School, The University of Western Australia, Perth, Western Australia, Australia.,Department of Clinical Biochemistry, PathWest Laboratory Medicine WA, Fiona Stanley Hospital, Perth, Western Australia, Australia.,Department of Clinical Biochemistry, PathWest Laboratory Medicine WA, Royal Perth Hospital, Perth, Western Australia, Australia.,Department of Cardiology, Lipid Disorders Clinic, Royal Perth Hospital, Perth, Western Australia, Australia.,Department of Clinical Biochemistry, Clinipath Pathology, Perth, Western Australia, Australia
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10
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Lopez-Ayala P, Nestelberger T, Boeddinghaus J, Koechlin L, Ratmann PD, Strebel I, Gehrke J, Meier S, Walter J, Rubini Gimenez M, Mutschler E, Miro O, Lopez-Barbeito B, Martin-Sanchez FJ, Rodriguez-Adrada E, Keller DI, Newby LK, Twerenbold R, Giannitsis E, Lindahl B, Mueller C. Novel Criteria for the Observe-Zone of the ESC 0/1h-hs-cTnT Algorithm. Circulation 2021; 144:773-787. [PMID: 34376064 DOI: 10.1161/circulationaha.120.052982] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background: The non-ST elevation myocardial infarction (NSTEMI) guidelines of the European Society of Cardiology (ESC) recommend a 3h cardiac troponin determination in patients triaged to the observe-zone of the ESC 0/1h-algorithm; however, no specific cut-off for further triage is endorsed. Recently, a specific cut-off for 0/3h high-sensitivity cardiac troponin T (hs-cTnT) change (7ng/L) was proposed warranting external validation. Methods: Patients presenting with acute chest discomfort to the emergency department were prospectively enrolled into an international multicenter diagnostic study. Final diagnoses were centrally adjudicated by two independent cardiologists applying the 4th universal definition of MI, based on complete cardiac work-up, cardiac imaging and serial hs-cTnT. Hs-cTnT concentrations were measured at presentation, after 1h and 3h. The objective was to externally validate the proposed cut-off, and if necessary, derive and internally as well as externally validate novel 0/3h-criteria for the observe-zone of the ESC 0/1h-hs-cTnT-algorithm in an independent multicenter cohort. Results: Among 2076 eligible patients, application of the ESC 0/1h-hs-cTnT-algorithm triaged 1512 patients (72.8%) to either rule-out or rule-in of NSTEMI, remaining 564 patients (27.2%) in the observe-zone (adjudicated NSTEMI prevalence 120/564 patients, 21.3%). The suggested 0/3h-hs-cTnT-change of <7ng/L triaged 517 patients (91.7%) towards rule-out, resulting in a sensitivity of 33.3% (95%CI 25.5-42.2), missing 80 patients with NSTEMI, and ≥7ng/L triaged 47 patients towards rule-in (8.3%), resulting in a specificity of 98.4% (95%CI 96.8-99.2). Novel derived 0/3h-criteria for the observe-zone patients ruled-out NSTEMI with a 3h hs-cTnT concentration <15 ng/L and a 0/3h-hs-cTnT absolute change <4 ng/L, triaging 138 patients (25%) towards rule-out, resulting in a sensitivity of 99.2% (95%CI 96.0-99.9), missing 1 patient with NSTEMI. A 0/3h-hs-cTnT absolute change ≥6 ng/L triaged 63 patients (11.2%) towards rule-in, resulting in a specificity of 98% (95%CI 96.2-98.9) Thereby, the novel 0/3h-criteria reduced the number of patients in the observe zone by 36%, and the number of T1MI by 50%. Findings were confirmed in both internal and external validation. Conclusions: A combination of a 3h hs-cTnT concentration (<15 ng/L) and a 0/3h absolute change (<4 ng/L) is necessary to safely rule-out NSTEMI in patients remaining in the observe-zone of the ESC 0/1h-hs-cTnT-algorithm. Clinical Trial Registration: URL: https://clinicaltrials.gov Unique Identifier: NCT00470587.
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Affiliation(s)
- Pedro Lopez-Ayala
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland; GREAT network, Rome, Italy
| | - Thomas Nestelberger
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland; GREAT network, Rome, Italy; Division of Cardiology, Vancouver General Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Jasper Boeddinghaus
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland; GREAT network, Rome, Italy
| | - Luca Koechlin
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland; GREAT network, Rome, Italy; Department of Cardiac Surgery, University Hospital Basel, University of Basel, Switzerland
| | - Paul David Ratmann
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland; GREAT network, Rome, Italy
| | - Ivo Strebel
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland; GREAT network, Rome, Italy
| | - Juliane Gehrke
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland; GREAT network, Rome, Italy
| | - Severin Meier
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Joan Walter
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland; GREAT network, Rome, Italy; Institute of Diagnostic and Interventional Radiology, University Hospital Zurich, Switzerland
| | | | - Eugenio Mutschler
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Oscar Miro
- GREAT network, Rome, Italy; Emergency Department, Hospital Clinic, University of Barcelona, Barcelona, Catalonia, Spain
| | - Beatriz Lopez-Barbeito
- GREAT network, Rome, Italy; Emergency Department, Hospital Clinic, University of Barcelona, Barcelona, Catalonia, Spain
| | | | | | - Dagmar I Keller
- Emergency Department, University Hospital Zurich, Zurich, Switzerland
| | - L Kristin Newby
- Division of Cardiology, Department of Medicine and Duke Clinical Research Institute, Duke University Medical Center, Durham, NC
| | - Raphael Twerenbold
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland; GREAT network, Rome, Italy; University Center of Cardiovascular Science and Department of Cardiology, University Heart and Vascular Center Hamburg, Hamburg, Germany
| | | | - Bertil Lindahl
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden; Uppsala Clinical Research Center, Uppsala, Sweden
| | - Christian Mueller
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland; GREAT network, Rome, Italy
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11
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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] [What about the content of this article? (0)] [Affiliation(s)] [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.
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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
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12
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Collinson P. High sensitivity troponin, analytical advantages, clinical benefits and clinical challenges - An update. Clin Biochem 2021; 91:1-8. [PMID: 33610525 DOI: 10.1016/j.clinbiochem.2021.02.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2021] [Revised: 01/29/2021] [Accepted: 02/05/2021] [Indexed: 12/26/2022]
Abstract
The measurement of cardiac troponin (cTn) by a high sensitivity method now represents the standard method for cTn measurement in the laboratory. High sensitivity method are not measuring a novel form of troponin but have undergone methodological improvement in assay sensitivity to allow both very low level detection and repeat measurements at low levels with very low degrees of analytical imprecision. The methods identify additional patients with myocardial injury who would benefit from evidence-based interventions. Rapid predictive algorithms utilising measurement on admission as well as short sampling periods (1-2 h) allow much more rapid categorisation of patients to appropriate clinical pathways. The shift in the diagnosis from traditional "cardiac enzymes" to troponin based on the 99th percentile has accounted for the majority of the detection of myocardial injury in patients without acute coronary syndromes. These patients have a worse prognosis irrespective of the underlying cause of their hospital admission. The appropriate management strategy in this group, beyond managing the underlying problem, remains to be defined. Measurement of cTn in otherwise asymptomatic individuals may have a role for patient selection for preventive treatment or for patients monitoring. Clinical trials in this area are awaited.
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13
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Ren D, Huang T, Liu X, Xu G. High-sensitive cardiac troponin for the diagnosis of acute myocardial infarction in different chronic kidney disease stages. BMC Cardiovasc Disord 2021; 21:100. [PMID: 33596833 PMCID: PMC7888109 DOI: 10.1186/s12872-020-01746-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Accepted: 10/19/2020] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Chronic kidney disease (CKD) are associated with acute myocardial infarction (AMI). High-sensitive cardiac troponin (hs-cTn) has been evidenced to enhance the early diagnostic accuracy of AMI, but hs-cTn levels are often chronically elevated in CKD patients, which reduces their diagnostic utility. The aim of this study was to derive optimal cutoff-values of hs-cTn levels in patients with CKD and suspected AMI. METHODS In this retrospective paper, a total of 3295 patients with chest pain (2758 in AMI group and 537 in Non-AMI group) were recruited, of whom 23.1% were had an estimated glomerular filtration rate (eGFR) of < 60 mL min-1 (1.73 m2)-1. Hs-cTnI values were measured at presentation. RESULTS AMI was diagnosed in 83.7% of all patients. The optimal value of hs-TnI in diagnosing AMI was 1.15 ng mL-1, which were higher in males than females comparing different cutoff-values of subgroups divided by age, gender and renal function, and which increased monotonically with decreasing of eGFR because in patients with CKD without AMI, the correlation between hs-cTnI and renal function is low but significant (r2 = 0.067, P < 0.001). CONCLUSIONS Different optimal cutoff-values of hs-cTnI in the diagnosis of AMI in patients with CKD were helpful to the clinical diagnosis of AMI in various populations and were higher in males than females, but which was needed to be validated by multicenter randomized controlled clinical studies in the future.
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Affiliation(s)
- Daijin Ren
- Department of Nephrology, The Second Affiliated Hospital of Nanchang University, No. 1, Minde Road, Donghu District, Nanchang, 330006, People's Republic of China
| | - Tianlun Huang
- Department of Nephrology, The Second Affiliated Hospital of Nanchang University, No. 1, Minde Road, Donghu District, Nanchang, 330006, People's Republic of China
| | - Xin Liu
- Department of Nephrology, The Second Affiliated Hospital of Nanchang University, No. 1, Minde Road, Donghu District, Nanchang, 330006, People's Republic of China
| | - Gaosi Xu
- Department of Nephrology, The Second Affiliated Hospital of Nanchang University, No. 1, Minde Road, Donghu District, Nanchang, 330006, People's Republic of China.
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14
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Huet F, Dupuy AM, Cristol JP, Roubille F. Absolute Change in High Sensitivity Cardiac Troponin I for Three Hours is Useful for Diagnosing Acute Myocardial Infarction in the Emergency Department: How to Get to Best Benefit From HS-Troponins in Clinical Practice? Ann Lab Med 2020; 40:488-489. [PMID: 32539305 PMCID: PMC7295961 DOI: 10.3343/alm.2020.40.6.488] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Revised: 04/13/2020] [Accepted: 05/19/2020] [Indexed: 11/19/2022] Open
Affiliation(s)
- Fabien Huet
- Cardiology Department, University of Montpellier, INSERM U1046, CNRS UMR 9214, Montpellier,
France
- PhyMedExp, Department of Biochemistry, University of Montpellier, INSERM U1046, CNRS UMR 9214, Montpellier,
France
| | - Anne Marie Dupuy
- Department of Biochemistry, University Hospital of Montpellier, Montpellier,
France
| | - Jean Paul Cristol
- PhyMedExp, Department of Biochemistry, University of Montpellier, INSERM U1046, CNRS UMR 9214, Montpellier,
France
- Department of Biochemistry, University Hospital of Montpellier, Montpellier,
France
| | - François Roubille
- Cardiology Department, University of Montpellier, INSERM U1046, CNRS UMR 9214, Montpellier,
France
- PhyMedExp, Department of Biochemistry, University of Montpellier, INSERM U1046, CNRS UMR 9214, Montpellier,
France
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15
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Park J, Yang K, Lee SH, Lee JH, Min JJ, Kwon JH, Oh AR, Yeo J, Kim J, Choi JH, Lee SC, Gwon HC, Kim K, Ahn J, Lee SM. Comparison of acute and chronic myocardial injury in noncardiac surgical patients. PLoS One 2020; 15:e0234776. [PMID: 32614840 PMCID: PMC7332041 DOI: 10.1371/journal.pone.0234776] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Accepted: 06/02/2020] [Indexed: 12/14/2022] Open
Abstract
PURPOSE Perioperative myocardial injury is a predictor of postoperative mortality, but the clinical impact of chronic injury during the perioperative period has not been fully investigated. This study aimed to evaluate chronic myocardial injury during the perioperative period in comparison with normal and acute myocardial injury. METHODS Patients with serial cardiac troponin measurements before and within 30 days following noncardiac surgery were divided into three groups: normal, acute injury, and chronic injury groups. Acute and chronic myocardial injuries were stratified according to 2018 recommendations by the International Federation of Clinical Chemistry and Laboratory Medicine's Task Force on Clinical Applications of Bio-Markers. Thirty-day and one-year mortalities after surgery were compared. RESULTS Of the 22,969 patients reviewed, 17,671 (76.9%) were classified into the normal, 5,179 (22.5%) into the acute injury, and 119 (0.5%) into the chronic injury groups. The acute and chronic injury groups had higher 30-day mortalities compared with the normal group (0.8% vs. 8.0%; hazard ratio [HR], 11.00; 95% confidence interval [CI], 9.05-13.37; P < 0.001 and 0.8% vs. 7.6%; HR, 10.55; 95% CI, 5.37-20.72; P < 0.001, respectively). In a direct comparison between the acute and chronic injury groups using an inverse probability of weighting adjustments, the 30-day and one-year mortalities were not significantly different. CONCLUSION Chronic myocardial injury during the perioperative period may show similar clinical impacts on postoperative mortality compared with acute injury. Further studies are needed.
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Affiliation(s)
- Jungchan Park
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Kwangmo Yang
- Center for Health Promotion, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Seung-Hwa Lee
- Division of Cardiology, Department of Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jong Hwan Lee
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jeong Jin Min
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Ji-Hye Kwon
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Ah Ran Oh
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Junghyun Yeo
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jihoon Kim
- Division of Cardiology, Department of Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jin-Ho Choi
- Division of Cardiology, Department of Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.,Department of Emergency Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Sang-Chol Lee
- Division of Cardiology, Department of Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Hyeon-Cheol Gwon
- Division of Cardiology, Department of Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Kyunga Kim
- Statistics and Data Center, Research Institute for Future Medicine, Samsung Medical Center, Seoul, Korea.,Department of Digital Health, SAIHST, Sungkyunkwan University, Seoul, Korea
| | - Joonghyun Ahn
- Statistics and Data Center, Research Institute for Future Medicine, Samsung Medical Center, Seoul, Korea
| | - Sangmin Maria Lee
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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16
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Kim JW, Kim H, Yun YM, Lee KR, Kim HJ. Absolute Change in High-Sensitivity Cardiac Troponin I at Three Hours After Presentation is Useful for Diagnosing Acute Myocardial Infarction in the Emergency Department. Ann Lab Med 2020; 40:474-480. [PMID: 32539303 PMCID: PMC7295960 DOI: 10.3343/alm.2020.40.6.474] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Revised: 03/30/2020] [Accepted: 06/01/2020] [Indexed: 11/22/2022] Open
Abstract
Background A rise and/or fall in cardiac troponin value with at least one value above the 99th percentile upper reference limit is essential for acute myocardial infarction (AMI) diagnosis. We evaluated the clinical usefulness of serial high-sensitivity cardiac troponin I (hs-cTnI) measurements in AMI diagnosis, in terms of the predictability of absolute and relative changes. Methods For this retrospective, forward observational study, we enrolled 281 patients older than 18 years who presented with chest pain at the emergency department (ED) between August 2015 and December 2016. The patients were grouped as AMI and non-AMI, and 73 (26%) were diagnosed as having AMI. Hs-cTnI (Abbott Diagnostics, Abbott Park, IL, USA) was measured at presentation and 3 hours later. We assessed the diagnostic performance of the absolute and relative changes in hs-cTnI. Results The cut-off values to predict AMI were 16.2 ng/L and 42.1% for the absolute and relative hs-cTnI changes, respectively. The area under the curve of hs-cTnI for AMI diagnosis was larger for absolute changes than for relative changes [0.96 (95% confidence interval [CI], 0.92–0.98) vs 0.89 (95% CI, 0.85–0.93)] (P=0.014). Conclusions The absolute hs-cTnI change at 3 hours after presentation was superior to the relative change, and a rise and/or fall in hs-cTnI of >16.2 ng/L at 3 hours after presentation was useful to identify AMI in patients presenting at the ED.
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Affiliation(s)
- Jong Won Kim
- Department of Emergency Medicine, Konkuk University School of Medicine, Konkuk University Medical Center, Seoul, Korea
| | - Hanah Kim
- Department of Laboratory Medicine, Konkuk University School of Medicine, Konkuk University Medical Center, Seoul, Korea
| | - Yeo-Min Yun
- Department of Laboratory Medicine, Konkuk University School of Medicine, Konkuk University Medical Center, Seoul, Korea
| | - Kyeong Ryong Lee
- Department of Emergency Medicine, Konkuk University School of Medicine, Konkuk University Medical Center, Seoul, Korea
| | - Hyun Joong Kim
- Division of Cardiology, Department of Internal Medicine, Konkuk University School of Medicine, Konkuk University Medical Center, Seoul, Korea
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17
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Abstract
Chest pain is one of the most common reasons for an emergency room (ER) visit in the US, with almost 6 million ER visits annually. High-sensitivity cardiac troponin (hscTn) assays have the ability to rapidly rule in or rule out acute coronary syndrome with improved sensitivity, and they are increasingly being used. Though hscTn assays have been approved for use in European, Australian, and Canadian guidelines since 2010, the FDA only approved their use in 2017. There is no consensus on how to compare the results from various hscTn assays. A literature review was performed to analyze the advantages and limitations of using hscTn as a standard biomarker to evaluate patients with suspected ACS in the emergency setting.
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Affiliation(s)
- Mahesh Anantha Narayanan
- Division of Cardiovascular Disease, Department of Medicine, University of Minnesota, Minneapolis, MN
| | - Santiago Garcia
- Minneapolis Heart Institute at Abbott Northwestern Hospital, Minneapolis, MN
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18
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Boeddinghaus J, Nestelberger T, Badertscher P, Twerenbold R, Fitze B, Wussler D, Strebel I, Rubini Giménez M, Wildi K, Puelacher C, du Fay de Lavallaz J, Oehen L, Walter J, Miró Ò, Martin-Sanchez FJ, Morawiec B, Potlukova E, Keller DI, Reichlin T, Mueller C, Sabti Z, Freese M, Stelzig C, Shrestha S, Schaerli N, Kozhuharov N, Flores D, Lohrmann J, Biskup E, Kloos W, Osswald S, Mueller D, Sazgary L, López B, Adrada ER, Kawecki D, Muzyk P, Nowalany-Kozielska E, Parenica J, Ganovská E, Meissner K, Kulangara C, Mahfouz R, Hartmann B, Ferel I, Campodarve I, Rentsch K, von Eckardstein A, Buser A, Geigy N. Predicting Acute Myocardial Infarction with a Single Blood Draw. Clin Chem 2019; 65:437-450. [DOI: 10.1373/clinchem.2018.294124] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2018] [Accepted: 11/28/2018] [Indexed: 11/06/2022]
Abstract
Abstract
BACKGROUND
We desired to determine cardiac troponin (cTn) concentrations necessary to achieve a positive predictive value (PPV) of ≥75% for acute myocardial infarction (AMI) to justify immediate admission of patients to a monitored unit and, in general, early coronary angiography.
METHODS
In a prospective multicenter diagnostic study enrolling patients presenting to the emergency department with symptoms suggestive of AMI, final diagnoses were adjudicated by 2 independent cardiologists based on clinical information including cardiac imaging. cTn concentrations were measured using 5 different sensitive and high-sensitivity cTn (hs-cTn) assays in a blinded fashion at presentation and serially thereafter. The diagnostic end point was PPV for rule-in of AMI of initial cTn concentrations alone and in combination with early changes.
RESULTS
Among 3828 patients, 616 (16%) had an AMI. At presentation, 7% to 14% of patients had cTnT/I concentrations associated with a PPV of ≥75%. Adding absolute or relative changes did not significantly further increase the PPV. PPVs increased from 46.5% (95% CI, 43.6–49.4) for hs-cTnT at presentation >14 ng/L to 78.9% (95% CI, 74.7–82.5) for >52 ng/L (P < 0.001), whereas PPVs in higher hs-cTnT strata remained largely unchanged [e.g., 82.4% (95% CI, 77.5–86.7) for >80 ng/L vs 83.9% (95% CI, 76.0–90.1) for >200 ng/L (P = 0.72)]. The addition of early changes in hs-cTnT further increased the PPV up to 60 ng/L, but not for higher concentrations.
CONCLUSIONS
Serial sampling does not seem necessary for predicting AMI and concurrent decision-making in about 10% of patients, as it only marginally increases the PPV for AMI and not in a statistically or clinically significant way.
ClinicalTrials.gov Identifier
NCT00470587.
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Affiliation(s)
- Jasper Boeddinghaus
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- Division of Internal Medicine, University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT Network, Rome, Italy
| | - Thomas Nestelberger
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT Network, Rome, Italy
| | - Patrick Badertscher
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT Network, Rome, Italy
| | - Raphael Twerenbold
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT Network, Rome, Italy
- Department of General and Interventional Cardiology, Hamburg University Heart Center, Hamburg, Germany
| | - Brigitte Fitze
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Desiree Wussler
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- Division of Internal Medicine, University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT Network, Rome, Italy
| | - Ivo Strebel
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT Network, Rome, Italy
| | - Maria Rubini Giménez
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT Network, Rome, Italy
| | - Karin Wildi
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT Network, Rome, Italy
| | - Christian Puelacher
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT Network, Rome, Italy
| | - Jeanne du Fay de Lavallaz
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT Network, Rome, Italy
| | - Loris Oehen
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Joan Walter
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT Network, Rome, Italy
| | - Òscar Miró
- GREAT Network, Rome, Italy
- Emergency Department, Hospital Clinic, Barcelona, Catalonia, Spain
| | | | - Beata Morawiec
- GREAT Network, Rome, Italy
- 2nd Department of Cardiology, School of Medicine with the Division of Dentistry in Zabrze, Medical University of Katowice, Katowice, Poland
| | - Eliska Potlukova
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- Division of Internal Medicine, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Dagmar I Keller
- Emergency Department, University Hospital Zurich, Zurich, Switzerland
| | - Tobias Reichlin
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT Network, Rome, Italy
| | - Christian Mueller
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT Network, Rome, Italy
| | - Zaid Sabti
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT Network, Rome, Italy
| | - Michael Freese
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT Network, Rome, Italy
| | - Claudia Stelzig
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT Network, Rome, Italy
| | - Samyut Shrestha
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT Network, Rome, Italy
| | - Nicolas Schaerli
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT Network, Rome, Italy
- Division of Internal Medicine, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Nikola Kozhuharov
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT Network, Rome, Italy
| | - Dayana Flores
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT Network, Rome, Italy
| | - Jens Lohrmann
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Ewalina Biskup
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- Division of Internal Medicine, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Wanda Kloos
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Stefan Osswald
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Deborah Mueller
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT Network, Rome, Italy
| | - Lorraine Sazgary
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT Network, Rome, Italy
| | - Beatriz López
- GREAT Network, Rome, Italy
- Emergency Department, Hospital Clinic, Barcelona, Catalonia, Spain
| | | | - Damian Kawecki
- GREAT Network, Rome, Italy
- 2nd Department of Cardiology, School of Medicine with the Division of Dentistry in Zabrze, Medical University of Katowice, Katowice, Poland
| | - Piotr Muzyk
- GREAT Network, Rome, Italy
- 2nd Department of Cardiology, School of Medicine with the Division of Dentistry in Zabrze, Medical University of Katowice, Katowice, Poland
| | - Ewa Nowalany-Kozielska
- 2nd Department of Cardiology, School of Medicine with the Division of Dentistry in Zabrze, Medical University of Katowice, Katowice, Poland
| | - Jiri Parenica
- GREAT Network, Rome, Italy
- Department of Cardiology, University Hospital Brno, Brno, Czech Republic and Medical Faculty, Masaryk University, Brno, Czech Republic
| | - Eva Ganovská
- GREAT Network, Rome, Italy
- Department of Cardiology, University Hospital Brno, Brno, Czech Republic and Medical Faculty, Masaryk University, Brno, Czech Republic
| | - Kathrin Meissner
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT Network, Rome, Italy
| | - Caroline Kulangara
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT Network, Rome, Italy
| | - Riham Mahfouz
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Beate Hartmann
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT Network, Rome, Italy
| | - Ina Ferel
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Isabel Campodarve
- GREAT Network, Rome, Italy
- Emergency Medicine, Hospital del Mar, Barcelona, Spain
| | | | | | - Andreas Buser
- Blood Transfusion Centre, Swiss Red Cross, Basel, Switzerland and Department of Hematology, University Hospital Basel, Basel, Switzerland
| | - Nicolas Geigy
- Emergency Department, Kantonsspital Liestal, Switzerland
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19
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Abstract
Cardiac troponin assays have become more sensitive over the years leading to the clinical introduction of high-sensitivity cardiac troponin assays in 2010. Their use has revolutionized the assessment of patients with chest pain in the emergency department by allowing earlier rule-in and rule-out of myocardial infarction leading to shorter stays in the emergency department and reduced admissions for chest pain. The incidence of myocardial infarction has increased slightly, and patients with myocardial infarction diagnosed with high-sensitivity cardiac troponins have been found to have a reduced risk of reinfarction, though without an impact on survival. High-sensitivity cardiac troponins are powerful predictors of long-term mortality and cardiovascular disease in the general population as well as in patients with chest pain with or without cardiovascular disease. The increase in risk for death and cardiovascular disease associated with high-sensitivity cardiac troponins is graded and starts already at detectable levels, well below the upper normal level. The aim of this review was to describe the clinical use and consequences of the introduction of high-sensitivity cardiac troponins. In addition, the importance of persistently elevated troponin levels for prognosis and what investigations may be appropriate to perform in patients with stable troponin elevations are discussed.
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Affiliation(s)
- M J Holzmann
- Department of Medicine, Karolinska Institutet, Solna, Sweden.,Functional area of Emergency Medicine, Karolinska University Hospital, Huddinge, Sweden
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20
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Puelacher C, Lurati Buse G, Seeberger D, Sazgary L, Marbot S, Lampart A, Espinola J, Kindler C, Hammerer A, Seeberger E, Strebel I, Wildi K, Twerenbold R, du Fay de Lavallaz J, Steiner L, Gurke L, Breidthardt T, Rentsch K, Buser A, Gualandro DM, Osswald S, Mueller C, Christ-Crain M, Cuculi F, Badertscher P, Nestelberger T, Wussler D, Flores D, Boeddinghaus J, Sabti Z, Giménez MR, Kozhuharov N, Shrestha S, Kloos W, Lohrmann J, Reichlin T, Freese M, Meissner K, Kaiser C, Buser A. Perioperative Myocardial Injury After Noncardiac Surgery: Incidence, Mortality, and Characterization. Circulation 2017; 137:1221-1232. [PMID: 29203498 DOI: 10.1161/circulationaha.117.030114] [Citation(s) in RCA: 276] [Impact Index Per Article: 39.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2017] [Accepted: 10/10/2017] [Indexed: 12/12/2022]
Abstract
BACKGROUND Perioperative myocardial injury (PMI) seems to be a contributor to mortality after noncardiac surgery. Because the vast majority of PMIs are asymptomatic, PMI usually is missed in the absence of systematic screening. METHODS We performed a prospective diagnostic study enrolling consecutive patients undergoing noncardiac surgery who had a planned postoperative stay of ≥24 hours and were considered at increased cardiovascular risk. All patients received a systematic screening using serial measurements of high-sensitivity cardiac troponin T in clinical routine. PMI was defined as an absolute high-sensitivity cardiac troponin T increase of ≥14 ng/L from preoperative to postoperative measurements. Furthermore, mortality was compared among patients with PMI not fulfilling additional criteria (ischemic symptoms, new ECG changes, or imaging evidence of loss of viable myocardium) required for the diagnosis of spontaneous acute myocardial infarction versus those that did. RESULTS From 2014 to 2015 we included 2018 consecutive patients undergoing 2546 surgeries. Patients had a median age of 74 years and 42% were women. PMI occurred after 397 of 2546 surgeries (16%; 95% confidence interval, 14%-17%) and was accompanied by typical chest pain in 24 of 397 patients (6%) and any ischemic symptoms in 72 of 397 (18%). Crude 30-day mortality was 8.9% (95% confidence interval [CI], 5.7-12.0) in patients with PMI versus 1.5% (95% CI, 0.9-2.0) in patients without PMI (P<0.001). Multivariable regression analysis showed an adjusted hazard ratio of 2.7 (95% CI, 1.5-4.8) for 30-day mortality. The difference was retained at 1 year with mortality rates of 22.5% (95% CI, 17.6-27.4) versus 9.3% (95% CI, 7.9-10.7). Thirty-day mortality was comparable among patients with PMI not fulfilling any other of the additional criteria required for spontaneous acute myocardial infarction (280/397, 71%) versus those with at least 1 additional criterion (10.4%; 95% CI, 6.7-15.7, versus 8.7%; 95% CI, 4.2-16.7; P=0.684). CONCLUSIONS PMI is a common complication after noncardiac surgery and, despite early detection during routine clinical screening, is associated with substantial short- and long-term mortality. Mortality seems comparable in patients with PMI not fulfilling any other of the additional criteria required for spontaneous acute myocardial infarction versus those patients who do. CLINICAL TRIAL REGISTRATION URL: https://www.clinicaltrials.gov. Unique identifier: NCT02573532.
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Affiliation(s)
- Christian Puelacher
- Department of Cardiology and Cardiovascular Research Institute Basel (C.P., D.S., L.S., S.M., J.E., I.S., K.W., R.T., J.d.F.d.L., S.O., C.M.)
| | | | - Daniela Seeberger
- Department of Cardiology and Cardiovascular Research Institute Basel (C.P., D.S., L.S., S.M., J.E., I.S., K.W., R.T., J.d.F.d.L., S.O., C.M.)
| | - Lorraine Sazgary
- Department of Cardiology and Cardiovascular Research Institute Basel (C.P., D.S., L.S., S.M., J.E., I.S., K.W., R.T., J.d.F.d.L., S.O., C.M.)
| | - Stella Marbot
- Department of Cardiology and Cardiovascular Research Institute Basel (C.P., D.S., L.S., S.M., J.E., I.S., K.W., R.T., J.d.F.d.L., S.O., C.M.)
| | | | | | | | | | | | - Ivo Strebel
- Department of Cardiology and Cardiovascular Research Institute Basel (C.P., D.S., L.S., S.M., J.E., I.S., K.W., R.T., J.d.F.d.L., S.O., C.M.)
| | - Karin Wildi
- Department of Cardiology and Cardiovascular Research Institute Basel (C.P., D.S., L.S., S.M., J.E., I.S., K.W., R.T., J.d.F.d.L., S.O., C.M.)
| | - Raphael Twerenbold
- Department of Cardiology and Cardiovascular Research Institute Basel (C.P., D.S., L.S., S.M., J.E., I.S., K.W., R.T., J.d.F.d.L., S.O., C.M.)
| | - Jeanne du Fay de Lavallaz
- Department of Cardiology and Cardiovascular Research Institute Basel (C.P., D.S., L.S., S.M., J.E., I.S., K.W., R.T., J.d.F.d.L., S.O., C.M.)
| | | | | | | | | | - Andreas Buser
- Department of Hematology (A.B.), University Hospital of Basel, University of Basel, Switzerland.,Blood Bank Basel, Switzerland (A.B.)
| | - Danielle M Gualandro
- Department of Interventional Cardiology at the Heart Institute, University of São Paulo, Brazil (D.M.G.)
| | - Stefan Osswald
- Department of Cardiology and Cardiovascular Research Institute Basel (C.P., D.S., L.S., S.M., J.E., I.S., K.W., R.T., J.d.F.d.L., S.O., C.M.)
| | - Christian Mueller
- Department of Cardiology and Cardiovascular Research Institute Basel (C.P., D.S., L.S., S.M., J.E., I.S., K.W., R.T., J.d.F.d.L., S.O., C.M.)
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Andruchow JE, Kavsak PA, McRae AD. Contemporary Emergency Department Management of Patients with Chest Pain: A Concise Review and Guide for the High-Sensitivity Troponin Era. Can J Cardiol 2017; 34:98-108. [PMID: 29407013 DOI: 10.1016/j.cjca.2017.11.012] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2017] [Revised: 11/23/2017] [Accepted: 11/23/2017] [Indexed: 11/17/2022] Open
Abstract
This article synthesizes current best evidence for the evaluation of patients with suspected acute coronary syndrome (ACS) using high-sensitivity troponin assays, enabling physicians to effectively incorporate them into practice. Unlike conventional assays, high-sensitivity assays can precisely measure blood cardiac troponin concentrations in the vast majority of healthy individuals, facilitating the creation of rapid diagnostic algorithms. Very low troponin concentrations on presentation accurately rule out acute myocardial infarction (AMI) and enable the discharge of approximately 20% of patients after a single test, whereas an additional 30%-40% of patients can be safely discharged after short-interval serial sampling in as little as 1 or 2 hours. In contrast, highly abnormal troponin concentrations on presentation (more than 5 times the upper reference limit) or rapidly rising levels on serial testing can rapidly rule in AMI with high specificity. However, approximately one-third of patients remain in a biomarker-indeterminate "observation zone" even after serial sampling. These patients pose a disposition challenge to clinicians because although the differential diagnosis of elevated troponin concentrations is broad, these patients have an increased risk for short-term major adverse cardiac events. Use of repeated serial troponin sampling and structured clinical prediction tools may assist disposition for these patients, because no validated pathways currently exist to guide clinicians. Ongoing research to tailor diagnostic thresholds to individual patient characteristics may enable improved diagnostic accuracy and usher in a new era of personalized medicine in the evaluation of suspected ACS.
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Affiliation(s)
- James E Andruchow
- Department of Emergency Medicine, University of Calgary, Calgary, Alberta, Canada; Alberta Health Services, Calgary, Alberta, Canada.
| | - Peter A Kavsak
- Department of Pathology and Molecular Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Andrew D McRae
- Department of Emergency Medicine, University of Calgary, Calgary, Alberta, Canada; Alberta Health Services, Calgary, Alberta, Canada
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Biener M, Giannitsis E, Kuhner M, Zelniker T, Mueller-Hennessen M, Vafaie M, Trenk D, Neumann FJ, Hochholzer W, Katus HA. Prognostic Value of High-Sensitivity Cardiac Troponin T Compared with Risk Scores in Stable Cardiovascular Disease. Am J Med 2017; 130:572-82. [PMID: 28011313 DOI: 10.1016/j.amjmed.2016.11.028] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2016] [Revised: 11/16/2016] [Accepted: 11/16/2016] [Indexed: 11/21/2022]
Abstract
BACKGROUND Risk stratification of patients with cardiovascular disease remains challenging despite consideration of risk scores. METHODS We aimed to evaluate the prognostic performance of high-sensitivity cardiac troponin T in a low-risk outpatient population presenting for nonsecondary and secondary prevention. All-cause mortality, a composite of all-cause mortality, acute myocardial infarction, and stroke (end point 2), and a composite of all-cause mortality, acute myocardial infarction, stroke and rehospitalization for acute coronary syndrome, and decompensated heart failure (end point 3) were defined. The prognostic performance of high-sensitivity cardiac troponin T on index visit was compared with the PROCAM score and 3 FRAMINGHAM subscores. RESULTS In 693 patients with a median follow-up of 796 days, we observed 16 deaths, 32 patients with end point 2, and 83 patients with end point 3. All risk scores performed better in the prediction of all-cause mortality in nonsecondary prevention (area under the curve [AUC]: PROCAM: 0.922 vs 0.523, P = .001, consistent for all other scores). In secondary prevention, high-sensitivity cardiac troponin T outperformed all risk scores in the prediction of all-cause mortality (ΔAUC: PROCAM: 0.319, P <.001, consistent for all other scores) and performed superiorly in the prediction of end point 2 compared with the PROCAM, FRAMINGHAM-Coronary Heart Disease, and FRAMINGHAM-Hard Coronary Heart Disease scores (ΔAUC: PROCAM: 0.176, P = .047, consistent for FRAMINGHAM-Coronary Heart Disease and FRAMINGHAM-Hard Coronary Heart Disease). In nonsecondary prevention, we observed a comparable prognostic performance of high-sensitivity cardiac troponin T and multivariable risk scores. Our findings on the prediction of all-cause mortality compared with the FRAMINGHAM-Hard Coronary Heart Disease score were confirmed in an independent validation cohort on 2046 patients. CONCLUSIONS High-sensitivity troponin T provides excellent risk stratification regarding all-cause mortality and all-cause mortality, acute myocardial infarction, and stroke in a secondary prevention cohort in whom risk scores perform poorly.
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Kozinski M, Krintus M, Kubica J, Sypniewska G. High-sensitivity cardiac troponin assays: From improved analytical performance to enhanced risk stratification. Crit Rev Clin Lab Sci 2017; 54:143-172. [DOI: 10.1080/10408363.2017.1285268] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Affiliation(s)
- Marek Kozinski
- Department of Principles of Clinical Medicine, Nicolaus Copernicus University, Collegium Medicum, Bydgoszcz, Poland
| | - Magdalena Krintus
- Department of Laboratory Medicine, Nicolaus Copernicus University, Collegium Medicum, Bydgoszcz, Poland
| | - Jacek Kubica
- Department of Cardiology and Internal Medicine, Nicolaus Copernicus University, Collegium Medicum, Bydgoszcz, Poland
| | - Grazyna Sypniewska
- Department of Laboratory Medicine, Nicolaus Copernicus University, Collegium Medicum, Bydgoszcz, Poland
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van Waes JAR, Peelen LM, Kemperman H, Grobben RB, Nathoe HM, van Klei WA. Kinetics of troponin I in patients with myocardial injury after noncardiac surgery. Clin Chem Lab Med 2017; 55:586-594. [PMID: 27732551 DOI: 10.1515/cclm-2016-0301] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2016] [Accepted: 08/29/2016] [Indexed: 11/15/2022]
Abstract
BACKGROUND Myocardial injury after noncardiac surgery, as measured by troponin elevation, is strongly associated with mortality. However, it is unknown in which patients prognosis can be improved. The presence of kinetic changes of troponin may be associated with a worse prognosis and warrant more aggressive management. Therefore, we aimed to study the kinetics of troponin in patients with postoperative myocardial injury, and to determine the added predictive value of kinetic changes of troponin on mortality. METHODS This cohort study included patients with myocardial injury after noncardiac surgery. Troponin I (TnI) was measured on the first three postoperative days. The primary outcome was all-cause 1-year mortality. We studied both absolute and relative TnI changes, and determined the delta TnI that was associated with mortality to distinguish a rise-and-fall TnI pattern from a stable TnI pattern. Next, we determined the added predictive value of a rise-and-fall TnI pattern for mortality. RESULTS In total, 634 patients were included. The risk ratio (RR) for mortality increased significantly with an absolute delta TnI of ≥200 ng/L (RR 1.5, 99.4% CI 1.0-2.2, p=0.003). Using this delta TnI to define a rise-and-fall pattern, 459 patients (72%) had a stable TnI pattern and 175 patients (28%) had a rise-and-fall pattern. When added to a model including the highest TnI value and variables from the revised cardiac risk index (RCRI), the TnI pattern did not increase the predictive value for mortality. CONCLUSIONS A postoperative TnI rise-and-fall pattern was associated with 1-year mortality, but had no added value in addition to the highest TnI level to predict 1-year mortality. Therefore, postoperative TnI kinetics are not useful for further mortality risk stratification in patients with myocardial injury after noncardiac surgery.
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van der Linden N, Klinkenberg LJJ, Bekers O, Loon LJCV, Dieijen-Visser MPV, Zeegers MP, Meex SJR. Prognostic value of basal high-sensitive cardiac troponin levels on mortality in the general population: A meta-analysis. Medicine (Baltimore) 2016; 95:e5703. [PMID: 28033267 PMCID: PMC5207563 DOI: 10.1097/md.0000000000005703] [Citation(s) in RCA: 57] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Interest in the use of cardiac troponin T (cTnT) and cardiac troponin I (cTnI) has expanded from diagnosis of acute myocardial infarction to risk assessment for morbidity and mortality. Although cTnT and cTnI were shown to have equivalent diagnostic performance in the setting of suspected acute myocardial infarction, potential prognostic differences are largely unexplored.The aim of this study is to quantify and compare the relationship between cTnT and cTnI, and cardiovascular and all-cause mortality in the general population.Medline, Embase, and the Cochrane Library (from inception through October 2016) were searched for prospective observational cohort studies reporting on the prognostic value of basal high-sensitive cTnT and/or cTnI levels on cardiovascular and all-cause mortality in the general population. Data on study characteristics, participants' characteristics, outcome parameters, and quality [according to the Effective Public Health Practice Project (EPHPP) "Quality Assessment Tool For Quantitative Studies] were retrieved. Hazard ratios per standard deviation increase in basal cardiac troponin level (HR per 1-SD; retrieved from the included articles or estimated) were pooled using a random-effects model.On a total of 2585 reviewed citations, 11 studies, with data on 65,019 participants, were included in the meta-analysis. Random effects pooling showed significant associations between basal cardiac troponin levels and HR for cardiovascular and all-cause mortality [HR per 1-SD 1.29 (95% confidence interval, 95% CI, 1.20-1.38) and HR per 1-SD 1.18 (95% CI, 1.11-1.26), respectively]. Stratified analyses showed higher HRs for cTnT than cTnI [cardiovascular mortality: cTnT HR per 1-SD 1.37 (95% CI, 1.23-1.52); and cTnI HR per 1-SD 1.21 (95% CI, 1.16-1.26); all-cause mortality: cTnT HR per 1-SD 1.31 (955 CI, 1.13-1.53); and cTnI HR per 1-SD 1.14 (95% CI, 1.06-1.22)]. These differences were significant (P < 0.01) in meta-regression analyses for cardiovascular mortality but did not reach statistical significance for all-cause mortality.Elevated, basal cTnT, and cTnI show robust associations with an increased risk of cardiovascular and all-cause mortality during follow-up in the general population.Systematic review registration number PROSPERO CRD42014006964.
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Affiliation(s)
- Noreen van der Linden
- Department of Clinical Chemistry, Cardiovascular Research Institute Maastricht (CARIM) Department of Human Movement Sciences, NUTRIM School of Nutrition and Translational Research in Metabolism Department of Complex Genetics, School of Public Health and Primary Care (CAPHRI), Maastricht University Medical Centre (MUMC), Maastricht, The Netherlands
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Biener M, Giannitsis E, Lamerz J, Mueller-Hennessen M, Vafaie M, Katus HA. Prognostic value of elevated high-sensitivity cardiac troponin T levels in a low risk outpatient population with cardiovascular disease. European Heart Journal: Acute Cardiovascular Care 2016; 5:409-418. [DOI: 10.1177/2048872615610869] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/30/2015] [Accepted: 09/20/2015] [Indexed: 11/15/2022]
Affiliation(s)
- Moritz Biener
- Zentrum für Innere Medizin, Klinik für Kardiologie, Angiologie und Pneumologie, Universitätsklinikum Heidelberg, Germany
| | - Evangelos Giannitsis
- Zentrum für Innere Medizin, Klinik für Kardiologie, Angiologie und Pneumologie, Universitätsklinikum Heidelberg, Germany
| | - Judith Lamerz
- Zentrum für Innere Medizin, Klinik für Kardiologie, Angiologie und Pneumologie, Universitätsklinikum Heidelberg, Germany
| | - Matthias Mueller-Hennessen
- Zentrum für Innere Medizin, Klinik für Kardiologie, Angiologie und Pneumologie, Universitätsklinikum Heidelberg, Germany
| | - Mehrshad Vafaie
- Zentrum für Innere Medizin, Klinik für Kardiologie, Angiologie und Pneumologie, Universitätsklinikum Heidelberg, Germany
| | - Hugo A Katus
- Zentrum für Innere Medizin, Klinik für Kardiologie, Angiologie und Pneumologie, Universitätsklinikum Heidelberg, Germany
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Kreutzinger P, Wildi K, Twerenbold R, Rubini Gimenez M, Reichlin T, Jaeger C, Hillinger P, Boeddinghaus J, Nestelberger T, Puelacher C, Stallone F, Rentsch K, Osswald S, Jeger R, Kaiser C, Mueller C. Incidence and Predictors of Cardiomyocyte Injury in Elective Coronary Angiography. Am J Med 2016; 129:537.e1-8. [PMID: 26763753 DOI: 10.1016/j.amjmed.2015.12.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2015] [Revised: 12/01/2015] [Accepted: 12/02/2015] [Indexed: 01/18/2023]
Abstract
OBJECTIVE Coronary angiography is considered to be a safe tool for the evaluation of coronary artery disease and performed in approximately 12 million patients each year worldwide. The aim of our study was to investigate the frequency and predictors of cardiomyocyte injury in patients undergoing elective coronary angiography. METHODS A total of 749 consecutive patients who were scheduled to undergo elective coronary angiography were prospectively analyzed. High-sensitivity cardiac troponin T concentrations were measured both before and after elective coronary angiography (without intervention). Acute cardiomyocyte injury was predefined as an absolute increase in high-sensitivity cardiac troponin T of at least 7 ng/L (if also fulfilling a relative change of >20%). RESULTS Acute cardiomyocyte injury was observed in 101 patients (13.5%, 95% confidence interval [CI], 11.1-16.2). It was independently associated with aortic valve stenosis (odds ratio [OR], 5.4; 95% CI, 3.0-9.8; P <.001), age (OR, 1.05; 95% CI, 1.02-1.08; P <.001), female sex (OR, 3.5; 95% CI, 1.8-6.8; P <.001), contrast volume (OR, 1.006; 95% CI, 1.001-1.012; P = .019 per 10 mL of contrast volume), documented cardiomyopathy (OR, 2.5; 95% CI, 1.0-6.0; P = .045), and mitral regurgitation (OR, 2.3; CI, 1.0-4.9; P = .033). In contrast, operator experience and extent of coronary artery disease were not found to be associated with acute cardiomyocyte injury. CONCLUSIONS Cardiomyocyte injury accompanies elective coronary angiography in 1 of 8 patients. Sex, age, contrast agent volume, and ventricular disease, rather than the extent of coronary artery disease, independently predict cardiomyocyte injury. Further research aiming to reduce the incidence of cardiomyocyte injury seems warranted.
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Affiliation(s)
- Philipp Kreutzinger
- Department of Cardiology and Cardiovascular Research Institute Basel, University Hospital Basel, Switzerland
| | - Karin Wildi
- Department of Cardiology and Cardiovascular Research Institute Basel, University Hospital Basel, Switzerland; Department of Internal Medicine, University Hospital Basel, Switzerland
| | - Raphael Twerenbold
- Department of Cardiology and Cardiovascular Research Institute Basel, University Hospital Basel, Switzerland
| | - Maria Rubini Gimenez
- Department of Cardiology and Cardiovascular Research Institute Basel, University Hospital Basel, Switzerland; Department of Internal Medicine, University Hospital Basel, Switzerland
| | - Tobias Reichlin
- Department of Cardiology and Cardiovascular Research Institute Basel, University Hospital Basel, Switzerland
| | - Cedric Jaeger
- Department of Cardiology and Cardiovascular Research Institute Basel, University Hospital Basel, Switzerland; Department of Internal Medicine, University Hospital Basel, Switzerland
| | - Petra Hillinger
- Department of Cardiology and Cardiovascular Research Institute Basel, University Hospital Basel, Switzerland; Department of Internal Medicine, University Hospital Basel, Switzerland
| | - Jasper Boeddinghaus
- Department of Cardiology and Cardiovascular Research Institute Basel, University Hospital Basel, Switzerland
| | - Thomas Nestelberger
- Department of Cardiology and Cardiovascular Research Institute Basel, University Hospital Basel, Switzerland
| | - Christian Puelacher
- Department of Cardiology and Cardiovascular Research Institute Basel, University Hospital Basel, Switzerland
| | - Fabio Stallone
- Department of Cardiology and Cardiovascular Research Institute Basel, University Hospital Basel, Switzerland; Department of Internal Medicine, University Hospital Basel, Switzerland
| | | | - Stefan Osswald
- Department of Cardiology and Cardiovascular Research Institute Basel, University Hospital Basel, Switzerland
| | - Raban Jeger
- Department of Cardiology and Cardiovascular Research Institute Basel, University Hospital Basel, Switzerland
| | - Christoph Kaiser
- Department of Cardiology and Cardiovascular Research Institute Basel, University Hospital Basel, Switzerland
| | - Christian Mueller
- Department of Cardiology and Cardiovascular Research Institute Basel, University Hospital Basel, Switzerland.
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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] [What about the content of this article? (0)] [Affiliation(s)] [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.
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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
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Alquézar Arbé A, Santaló Bel M, Sionis A. Interpretación clínica de la determinación de troponina T de elevada sensibilidad. Med Clin (Barc) 2015; 145:258-63. [DOI: 10.1016/j.medcli.2014.11.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2014] [Revised: 11/11/2014] [Accepted: 11/13/2014] [Indexed: 02/03/2023]
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Crowder KR, Jones TD, Lang ES, Wang DM, Clark SM, Innes GD, McMeekin JD, Graham MM, McRae AD. The impact of high-sensitivity troponin implementation on hospital operations and patient outcomes in 3 tertiary care centers. Am J Emerg Med 2015; 33:1790-4. [PMID: 26387473 DOI: 10.1016/j.ajem.2015.08.041] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2015] [Revised: 08/14/2015] [Accepted: 08/20/2015] [Indexed: 10/23/2022] Open
Abstract
OBJECTIVE High-sensitivity troponin T (hs-TnT) assays detect myocardial injury sooner, possibly improving throughput times for emergency department (ED) assessment of suspected acute myocardial infarction (AMI). This study evaluates the influence of hs-TnT implementation on ED length of stay (LOS), consultations and admissions, as well as ED revisits with cardiology admissions for patients undergoing testing for suspected AMI. METHODS This control pre-post design analysis included patients evaluated using hs-TnT or conventional troponin T. Data were collected from 3 ED databases for patients who had a troponin assay for suspected AMI for the periods February 12, 2011-April 22, 2011 (Ctrl); November 20, 2011-January 28, 2012 (Pre); and February 12, 2012-April 21, 2012 (Post). The primary outcome was ED LOS; secondary outcomes included the proportions of patients who received ED cardiology consultations, patients who were admitted to hospital, and discharged patients who revisited the ED within 30 days. RESULTS Data were analyzed from 6650 (Ctrl), 6866 (Pre), and 5754 (Post) patients. Median ED LOS decreased following hs-TnT implementation (6.60 hours in Ctrl and Pre vs 6.10 hours in Post, P < .001). There was no change in cardiology consultations or admissions following hs-TnT implementation. Fewer ED revisits occurred within 30 days in Post (16.0% Ctrl, 16.5% Pre vs 14.9% Post; P < .01). These results were preserved after adjusting for age and Canadian Triage Acuity Score. CONCLUSIONS This hs-TnT implementation strategy, using an equivalent cutoff for the conventional troponin T and hs-TnT assays, decreased ED LOS for patients with suspected AMI and did not increase cardiology resource utilization or ED revisits.
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Affiliation(s)
- Kathryn R Crowder
- University of Calgary, Foothills Campus, 3330 Hospital Dr NW, Calgary, AB, Canada T2N 4N1; Alberta Health Services, Foothills Medical Center 1403-29 St NW, Calgary, AB, Canada T2N 2T9
| | - Tristan D Jones
- University of Calgary, Foothills Campus, 3330 Hospital Dr NW, Calgary, AB, Canada T2N 4N1
| | - Eddy S Lang
- University of Calgary, Foothills Campus, 3330 Hospital Dr NW, Calgary, AB, Canada T2N 4N1; Alberta Health Services, Foothills Medical Center 1403-29 St NW, Calgary, AB, Canada T2N 2T9
| | - Dongmei M Wang
- University of Calgary, Foothills Campus, 3330 Hospital Dr NW, Calgary, AB, Canada T2N 4N1; Alberta Health Services, Foothills Medical Center 1403-29 St NW, Calgary, AB, Canada T2N 2T9
| | - Steven M Clark
- University of Calgary, Foothills Campus, 3330 Hospital Dr NW, Calgary, AB, Canada T2N 4N1; Alberta Health Services, Foothills Medical Center 1403-29 St NW, Calgary, AB, Canada T2N 2T9
| | - Grant D Innes
- University of Calgary, Foothills Campus, 3330 Hospital Dr NW, Calgary, AB, Canada T2N 4N1; Alberta Health Services, Foothills Medical Center 1403-29 St NW, Calgary, AB, Canada T2N 2T9
| | - James D McMeekin
- University of Calgary, Foothills Campus, 3330 Hospital Dr NW, Calgary, AB, Canada T2N 4N1; Alberta Health Services, Foothills Medical Center 1403-29 St NW, Calgary, AB, Canada T2N 2T9
| | - Michelle M Graham
- Alberta Health Services, Foothills Medical Center 1403-29 St NW, Calgary, AB, Canada T2N 2T9; University of Alberta, 8440 112 St NW, Edmonton, AB, Canada T6G 2B7
| | - Andrew D McRae
- University of Calgary, Foothills Campus, 3330 Hospital Dr NW, Calgary, AB, Canada T2N 4N1; Alberta Health Services, Foothills Medical Center 1403-29 St NW, Calgary, AB, Canada T2N 2T9.
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Biener M, Mueller M, Vafaie M, Katus HA, Giannitsis E. Impact of Leading Presenting Symptoms on the Diagnostic Performance of High-Sensitivity Cardiac Troponin T and on Outcomes in Patients with Suspected Acute Coronary Syndrome. Clin Chem 2015; 61:744-51. [DOI: 10.1373/clinchem.2014.235317] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2014] [Accepted: 02/03/2015] [Indexed: 12/23/2022]
Abstract
Abstract
BACKGROUND
Diagnostic performance of high-sensitivity cardiac troponin T (hs-cTnT) varies depending on presenting symptoms in patients with suspected acute coronary syndrome (ACS).
METHODS
We compared performance measures of hs-cTnT among patients admitted to the emergency department with typical chest pain (angina), dyspnea, and atypical symptoms and assessed outcomes by leading presenting symptoms.
RESULTS
A total of 658 patients suspected of ACS and presenting with typical chest pain (n = 241, 36.6%), dyspnea (n = 142, 21.6%), or atypical symptoms (n = 275, 41.8%) were included. Diagnostic accuracy of hs-cTnT on admission was higher among patients with typical chest pain compared to those with atypical symptoms [area under the curve (AUC) 0.823 vs AUC 0.776 vs AUC 0.705, P > 0.05 and P = 0.04]. Absolute concentration changes within 6 h improved accuracy among all subgroups, with the smallest added benefit in typical chest pain and dyspnea (ΔAUC, 0.078; P = 0.02 and 0.05, P > 0.05). During 1-year follow-up, dyspnea was associated with a higher risk of death (hazard ratio, 2.36; 95% CI, 1.26–4.43, P = 0.008) and death/AMI (hazard ratio, 2.23; 95% CI, 1.21–4.11, P = 0.01) compared to typical chest pain. Optimal discriminating values for hs-cTnT were higher among patients presenting with dyspnea compared to those with typical chest pain (91.2 vs 14.1 ng/L, P < 0.001).
CONCLUSION
The diagnostic performance of hs-cTnT in patients with suspected ACS depends on the leading presenting symptom. Patients admitted with dyspnea represent a high-risk cohort in which the diagnosis of ACS is less frequent and with inferior performance of serial hs-cTnT measurements. Higher hs-cTnT cutoffs at baseline and absolute changes after 6 h help to identify non-STEMI (ST segment elevation myocardial infarction) in this population.
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Affiliation(s)
- Moritz Biener
- Medizinische Klinik, Abteilung für Innere Medizin III, Universitätsklinikum Heidelberg, Germany
| | - Matthias Mueller
- Medizinische Klinik, Abteilung für Innere Medizin III, Universitätsklinikum Heidelberg, Germany
| | - Mehrshad Vafaie
- Medizinische Klinik, Abteilung für Innere Medizin III, Universitätsklinikum Heidelberg, Germany
| | - Hugo A Katus
- Medizinische Klinik, Abteilung für Innere Medizin III, Universitätsklinikum Heidelberg, Germany
| | - Evangelos Giannitsis
- Medizinische Klinik, Abteilung für Innere Medizin III, Universitätsklinikum Heidelberg, Germany
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Dupuy AM, Sebbane M, Roubille F, Coste T, Bargnoux AS, Badiou S, Kuster N, Cristol JP. Analytical evaluation of point of care cTnT and clinical performances in an unselected population as compared with central laboratory highly sensitive cTnT. Clin Biochem 2015; 48:334-9. [DOI: 10.1016/j.clinbiochem.2014.09.027] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2014] [Revised: 09/17/2014] [Accepted: 09/23/2014] [Indexed: 10/24/2022]
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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] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [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.
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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
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Abstract
Background The introduction of troponin assays with higher analytical sensitivity and enhanced performance has produced new challenges for both laboratory and clinician in the optimal investigation of patients with cardiovascular disease. After some years of collective experience with this new generation of assays, this survey aimed to assess the level of consensus that exists regarding their application. Methods A questionnaire was designed, based on a review of published evidence and current opinion, to obtain information on a number of key areas relating to troponin analysis and reporting and was circulated to lead laboratory consultants across the UK and Ireland. Results Completed questionnaires were received from 94 laboratory contacts. Sixty per cent of those who responded had implemented a high-sensitivity troponin assay, with the Roche Cobas troponin T high sensitivity assay the most widely used. It is evident that some confusion remains regarding the definition of high-sensitivity assays and there was considerable variation in practice, even among those using the same manufacturer’s assay. Conclusions There is a need for greater consensus in the approach to the clinical utilization of troponin assays with improved sensitivity and it is important that laboratories are fully aware of the capabilities of their assay and provide useful guidance to users. On the basis of survey findings and the existing evidence base, a number of recommendations have been proposed to improve current practice and enhance patient safety.
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Affiliation(s)
- Gareth C McKeeman
- Department of Clinical Biochemistry, Belfast Health & Social Care Trust, Royal Victoria Hospital, Grosvenor Road, Belfast, UK
| | - Peter W Auld
- Department of Clinical Biochemistry, Belfast Health & Social Care Trust, Royal Victoria Hospital, Grosvenor Road, Belfast, UK
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Mayer O, Seidlerová J, Bruthans J, Vaněk J, Černá L, Wohlfahrt P, Filipovský J, Cífková R, Windrichová J, Topolčan O. The predictive potential of asymptomatic mild elevation of cardiac troponin I on mortality risk of stable patients with vascular disease. Clin Biochem 2014; 48:353-7. [PMID: 25091937 DOI: 10.1016/j.clinbiochem.2014.07.022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2014] [Revised: 06/19/2014] [Accepted: 07/23/2014] [Indexed: 11/29/2022]
Abstract
OBJECTIVES Due to improved analytical performance of the newest generation of troponin assays, several patients have mild elevations of this parameter. Nevertheless, they do not show any signs of acute coronary syndrome. We speculated whether non-acute cardiac troponin I (cTnI) concentrations may improve prediction of residual mortality risk in clinically stable outpatients with chronic vascular disease. DESIGN AND METHODS We followed 830 patients (mean age 65.2years) after myocardial infarction, coronary revascularization or first ischemic stroke (pooled Czech samples of EUROASPIRE III and EUROASPIRE-stroke surveys, interviewed in 2006/2007) in a prospective cohort study. In addition to standard protocol, troponin I and brain natriuretic peptide (BNP) was estimated from frozen samples. Vital status and declared cause of death from death certificates was registered to ascertain a 5-year all-cause and cardiovascular mortality. RESULTS During a median follow up of 2050days (5.6years) 168 patients died. In the multivariate Cox proportional hazard model, cTnI≥0.03ng/mL independently predicted an all-cause 5-year mortality with HRR 1.76 (95% CI: 1.09-2.83). In the Cox model, the better predictor of mortality was BNP >150ng/L [HRR 3.47 (95% CI: 2.23-5.41)]. However, the combination of BNP with cTnI did not substantially improve its sensitivity or predictive power. CONCLUSION We cannot confirm the utility of asymptomatic mild cTnI elevation as a tool to detect residual risk of stable patients with vascular disease. On the other hand, BNP seems to be more appropriate for this purpose.
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Affiliation(s)
- Otto Mayer
- 2nd Department of Internal Medicine, Medical Faculty of Charles University and University Hospital, Pilsen, Czech Republic; Biomedical Center, Medical Faculty of Charles University, Pilsen, Czech Republic.
| | - Jitka Seidlerová
- 2nd Department of Internal Medicine, Medical Faculty of Charles University and University Hospital, Pilsen, Czech Republic; Biomedical Center, Medical Faculty of Charles University, Pilsen, Czech Republic
| | - Jan Bruthans
- 2nd Department of Internal Medicine, Medical Faculty of Charles University and University Hospital, Pilsen, Czech Republic; Centre for Cardiovascular Prevention of the First Faculty of Medicine, Charles University and Thomayer Hospital, Prague, Czech Republic
| | - Jiří Vaněk
- 2nd Department of Internal Medicine, Medical Faculty of Charles University and University Hospital, Pilsen, Czech Republic
| | - Lenka Černá
- Department of Neurology, University Hospital, Pilsen, Czech Republic
| | - Peter Wohlfahrt
- Centre for Cardiovascular Prevention of the First Faculty of Medicine, Charles University and Thomayer Hospital, Prague, Czech Republic; International Clinical Research Centre, St. Anne's University Hospital Brno, Czech Republic
| | - Jan Filipovský
- 2nd Department of Internal Medicine, Medical Faculty of Charles University and University Hospital, Pilsen, Czech Republic; Biomedical Center, Medical Faculty of Charles University, Pilsen, Czech Republic
| | - Renata Cífková
- Centre for Cardiovascular Prevention of the First Faculty of Medicine, Charles University and Thomayer Hospital, Prague, Czech Republic; International Clinical Research Centre, St. Anne's University Hospital Brno, Czech Republic
| | - Jindra Windrichová
- Department of Immunodiagnostics, University Hospital, Pilsen, Czech Republic
| | - Ondřej Topolčan
- Department of Immunodiagnostics, University Hospital, Pilsen, Czech Republic
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Abstract
High-sensitivity troponin (hsTn) assays are used clinically in most parts of the world and are expected to be approved by the US FDA for clinical use in the USA soon. Clinical use of hsTn leads to improvements in the detection of myocardial injury, shorter time to ruling out acute myocardial infarction, improved risk-stratification of patients with heart failure and atrial fibrillation among others. HsTn may also guide strategies for primary and secondary prevention of cardiovascular disease. However, unmet challenges remain, including distinguishing between acute and chronic hsTn elevations, distinguishing between type 1 and type 2 acute myocardial infarction and determining whether to use gender-neutral or gender-specific reference values.
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Affiliation(s)
- Frederick K Korley
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Davis Building, Suite 3220, 5801 Smith Avenue, Baltimore, MD 21209, USA
| | - Allan S Jaffe
- Cardiovascular Division & Division of Core Clinical Laboratory Services, Departments of Medicine & Laboratory Medicine and Pathology, Mayo Clinic and Medical School, Rochester, MN, USA
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Al-Saleh A, Alazzoni A, Al Shalash S, Ye C, Mbuagbaw L, Thabane L, Jolly SS. Performance of the high-sensitivity troponin assay in diagnosing acute myocardial infarction: systematic review and meta-analysis. CMAJ Open 2014; 2:E199-207. [PMID: 25295240 PMCID: PMC4183183 DOI: 10.9778/cmajo.20130074] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND High-sensitivity cardiac troponin assays have been adopted by many clinical centres worldwide; however, clinicians are uncertain how to interpret the results. We sought to assess the utility of these assays in diagnosing acute myocardial infarction (MI). METHODS We carried out a systematic review and meta-analysis of studies comparing high-sensitivity with conventional assays of cardiac troponin levels among adults with suspected acute MI in the emergency department. We searched MEDLINE, EMBASE and Cochrane databases up to April 2013 and used bivariable random-effects modelling to obtain summary parameters for diagnostic accuracy. RESULTS We identified 9 studies that assessed the use of high-sensitivity troponin T assays (n = 9186 patients). The summary sensitivity of these tests in diagnosing acute MI at presentation to the emergency department was estimated to be 0.94 (95% confidence interval [CI] 0.89-0.97); for conventional tests, it was 0.72 (95% CI 0.63-0.79). The summary specificity was 0.73 (95% CI 0.64-0.81) for the high-sensitivity assay compared with 0.95 (95% CI 0.93-0.97) for the conventional assay. The differences in estimates of the summary sensitivity and specificity between the high-sensitivity and conventional assays were statistically significant (p < 0.01). The area under the curve was similar for both tests carried out 3-6 hours after presentation. Three studies assessed the use of high-sensitivity troponin I assays and showed similar results. INTERPRETATION Used at presentation to the emergency department, the high-sensitivity cardiac troponin assay has improved sensitivity, but reduced specificity, compared with the conventional troponin assay. With repeated measurements over 6 hours, the area under the curve is similar for both tests, indicating that the major advantage of the high-sensitivity test is early diagnosis.
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Affiliation(s)
- Ayman Al-Saleh
- Department of Cardiology, Hamilton Health Sciences, McMaster University, Hamilton, Ont
| | - Ashraf Alazzoni
- Department of Cardiology, Hamilton Health Sciences, McMaster University, Hamilton, Ont
| | - Saleh Al Shalash
- Department of Internal Medicine, McMaster University, Hamilton, Ont
| | - Chenglin Ye
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ont. ; Biostatistics Unit, St Joseph's Healthcare, Hamilton, Ont
| | - Lawrence Mbuagbaw
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ont. ; Biostatistics Unit, St Joseph's Healthcare, Hamilton, Ont. ; Centre for Development of Best Practices in Health, Yaoundé Central Hospital, Yaoundé, Cameroon
| | - Lehana Thabane
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ont. ; Departments of Anesthesia and Pediatrics, McMaster University, Hamilton, Ont. ; Population Health Research Institute, Hamilton Health Sciences, Hamilton, Ont
| | - Sanjit S Jolly
- Department of Cardiology, Hamilton Health Sciences, McMaster University, Hamilton, Ont. ; Population Health Research Institute, Hamilton Health Sciences, Hamilton, Ont
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