OBJECTIVES: This paper sought to evaluate whether high sensitivity troponin (hs-cTnT) can immediately exclude acute myocardial infarction (AMI) at a novel 'rule out' cut-off. BACKGROUND: Subgroup analysis of recent evidence suggests that undetectable hs-cTnT may exclude AMI at presentation. METHODS: In a cohort study, we prospectively enrolled patients with chest pain, evaluating them with standard troponin T and testing for hs-cTnT (Roche Diagnostics, Basel, Switzerland) at presentation. The primary outcome was a diagnosis of AMI. We also followed up patients for adverse events within 6 months. After subsequent clinical implementation of hs-cTnT, we again evaluated whether initially undetectable hs-cTnT ruled out a subsequent rise. RESULTS: Of 703 patients in the cohort study, 130 (18.5%) had AMI, none of whom initially had undetectable hs-cTnT (sensitivity: 100.0%, 95% confidence interval [CI]: 95.1% to 100.0%, negative predictive value: 100.0%, 95% CI: 98.1% to 100.0%). This strategy would rule out AMI in 27.7% of patients, 2 (1.0%) of whom died or had AMI within 6 months (1 periprocedural AMI, 1 noncardiac death). We evaluated this approach in an additional 915 patients in clinical practice. Only 1 patient (0.6%) with initially undetectable hs-cTnT had subsequent elevation (to 17 ng/l), giving a sensitivity of 99.8% (95% CI: 99.1% to 100.0%) and a negative predictive value of 99.4% (95% CI: 96.6% to 100.0%). CONCLUSIONS: Undetectable hs-cTnT at presentation has very high negative predictive value, which may be considered to rule out AMI, identifying patients at low risk of adverse events. Pending further validation, this strategy may reduce the need for serial testing and empirical treatment, enabling earlier reassurance for patients and fewer unnecessary evaluations and hospital admissions.
OBJECTIVES: This paper sought to evaluate whether high sensitivity troponin (hs-cTnT) can immediately exclude acute myocardial infarction (AMI) at a novel 'rule out' cut-off. BACKGROUND: Subgroup analysis of recent evidence suggests that undetectable hs-cTnT may exclude AMI at presentation. METHODS: In a cohort study, we prospectively enrolled patients with chest pain, evaluating them with standard troponin T and testing for hs-cTnT (Roche Diagnostics, Basel, Switzerland) at presentation. The primary outcome was a diagnosis of AMI. We also followed up patients for adverse events within 6 months. After subsequent clinical implementation of hs-cTnT, we again evaluated whether initially undetectable hs-cTnT ruled out a subsequent rise. RESULTS: Of 703 patients in the cohort study, 130 (18.5%) had AMI, none of whom initially had undetectable hs-cTnT (sensitivity: 100.0%, 95% confidence interval [CI]: 95.1% to 100.0%, negative predictive value: 100.0%, 95% CI: 98.1% to 100.0%). This strategy would rule out AMI in 27.7% of patients, 2 (1.0%) of whom died or had AMI within 6 months (1 periprocedural AMI, 1 noncardiac death). We evaluated this approach in an additional 915 patients in clinical practice. Only 1 patient (0.6%) with initially undetectable hs-cTnT had subsequent elevation (to 17 ng/l), giving a sensitivity of 99.8% (95% CI: 99.1% to 100.0%) and a negative predictive value of 99.4% (95% CI: 96.6% to 100.0%). CONCLUSIONS: Undetectable hs-cTnT at presentation has very high negative predictive value, which may be considered to rule out AMI, identifying patients at low risk of adverse events. Pending further validation, this strategy may reduce the need for serial testing and empirical treatment, enabling earlier reassurance for patients and fewer unnecessary evaluations and hospital admissions.
Authors: Tobias Reichlin; Raphael Twerenbold; Karin Wildi; Maria Rubini Gimenez; Nathalie Bergsma; Philip Haaf; Sophie Druey; Christian Puelacher; Berit Moehring; Michael Freese; Claudia Stelzig; Lian Krivoshei; Petra Hillinger; Cedric Jäger; Thomas Herrmann; Philip Kreutzinger; Milos Radosavac; Zoraida Moreno Weidmann; Kateryna Pershyna; Ursina Honegger; Max Wagener; Thierry Vuillomenet; Isabel Campodarve; Roland Bingisser; Òscar Miró; Katharina Rentsch; Stefano Bassetti; Stefan Osswald; Christian Mueller Journal: CMAJ Date: 2015-04-13 Impact factor: 8.262
Authors: Christopher Layfield; John Rose; Aaron Alford; Susan R Snyder; Fred S Apple; Farah M Chowdhury; Michael C Kontos; L Kristin Newby; Alan B Storrow; Milenko Tanasijevic; Elizabeth Leibach; Edward B Liebow; Robert H Christenson Journal: Clin Biochem Date: 2015-02-07 Impact factor: 3.281
Authors: James L Januzzi; Umesh Sharma; Pearl Zakroysky; Quynh A Truong; Pamela K Woodard; J Hector Pope; Thomas Hauser; Thomas Mayrhofer; J Toby Nagurney; David Schoenfeld; W Frank Peacock; Jerome L Fleg; Stephen Wiviott; Peter S Pang; James Udelson; Udo Hoffmann Journal: Am Heart J Date: 2015-01-09 Impact factor: 4.749
Authors: Maros Ferencik; Ting Liu; Thomas Mayrhofer; Stefan B Puchner; Michael T Lu; Pal Maurovich-Horvat; J Hector Pope; Quynh A Truong; James E Udelson; W Frank Peacock; Charles S White; Pamela K Woodard; Jerome L Fleg; John T Nagurney; James L Januzzi; Udo Hoffmann Journal: JACC Cardiovasc Imaging Date: 2015-10-14