BACKGROUND: High-sensitivity cardiac troponin (hs-cTn) assays seem to improve the early diagnosis of acute myocardial infarction (AMI), but it is unknown how to best use them in clinical practice. Our objective was to develop and validate an algorithm for rapid rule-out and rule-in of AMI. METHODS: A prospective multicenter study enrolling 872 unselected patients with acute chest pain presenting to the emergency department. High-sensitivity cardiac troponin T (hs-cTnT) was measured in a blinded fashion at presentation and after 1 hour. The final diagnosis was adjudicated by 2 independent cardiologists. An hs-cTnT algorithm incorporating baseline values as well as absolute changes within the first hour was derived from 436 randomly selected patients and validated in the remaining 436 patients. The primary prognostic end point was death during 30 days of follow-up. RESULTS: Acute myocardial infarction was the final diagnosis in 17% of patients. After applying the hs-cTnT algorithm developed in the derivation cohort to the validation cohort, 259 patients (60%) could be classified as "rule-out," 76 patients (17%) as "rule-in," and 101 patients (23%) as in the "observational zone" within 1 hour. Overall, this resulted in a sensitivity and negative predictive value of 100% for rule-out, a specificity and positive predictive value of 97% and 84%, respectively, for rule-in, and a prevalence of AMI of 8% in the observational zone group. Cumulative 30-day survival was 99.8%, 98.6%, and 95.3% (P < .001) in patients classified as rule-out, observational zone, and rule-in, respectively. CONCLUSIONS: Using a simple algorithm incorporating hs-cTnT baseline values and absolute changes within the first hour allowed a safe rule-out as well as an accurate rule-in of AMI within 1 hour in 77% of unselected patients with acute chest pain. This novel strategy may obviate the need for prolonged monitoring and serial blood sampling in 3 of 4 patients.
BACKGROUND: High-sensitivity cardiac troponin (hs-cTn) assays seem to improve the early diagnosis of acute myocardial infarction (AMI), but it is unknown how to best use them in clinical practice. Our objective was to develop and validate an algorithm for rapid rule-out and rule-in of AMI. METHODS: A prospective multicenter study enrolling 872 unselected patients with acute chest pain presenting to the emergency department. High-sensitivity cardiac troponin T (hs-cTnT) was measured in a blinded fashion at presentation and after 1 hour. The final diagnosis was adjudicated by 2 independent cardiologists. An hs-cTnT algorithm incorporating baseline values as well as absolute changes within the first hour was derived from 436 randomly selected patients and validated in the remaining 436 patients. The primary prognostic end point was death during 30 days of follow-up. RESULTS:Acute myocardial infarction was the final diagnosis in 17% of patients. After applying the hs-cTnT algorithm developed in the derivation cohort to the validation cohort, 259 patients (60%) could be classified as "rule-out," 76 patients (17%) as "rule-in," and 101 patients (23%) as in the "observational zone" within 1 hour. Overall, this resulted in a sensitivity and negative predictive value of 100% for rule-out, a specificity and positive predictive value of 97% and 84%, respectively, for rule-in, and a prevalence of AMI of 8% in the observational zone group. Cumulative 30-day survival was 99.8%, 98.6%, and 95.3% (P < .001) in patients classified as rule-out, observational zone, and rule-in, respectively. CONCLUSIONS: Using a simple algorithm incorporating hs-cTnT baseline values and absolute changes within the first hour allowed a safe rule-out as well as an accurate rule-in of AMI within 1 hour in 77% of unselected patients with acute chest pain. This novel strategy may obviate the need for prolonged monitoring and serial blood sampling in 3 of 4 patients.
Authors: Jasper Boeddinghaus; Tobias Reichlin; Thomas Nestelberger; Raphael Twerenbold; Yvette Meili; Karin Wildi; Petra Hillinger; Maria Rubini Giménez; Janosch Cupa; Lukas Schumacher; Marie Schubera; Patrick Badertscher; Sydney Corbière; Karin Grimm; Christian Puelacher; Zaid Sabti; Dayana Flores Widmer; Nicolas Schaerli; Nikola Kozhuharov; Samyut Shrestha; Tobias Bürge; Patrick Mächler; Michael Büchi; Katharina Rentsch; Òscar Miró; Beatriz López; F Javier Martin-Sanchez; Esther Rodriguez-Adrada; Beata Morawiec; Damian Kawecki; Eva Ganovská; Jiri Parenica; Jens Lohrmann; Andreas Buser; Dagmar I Keller; Stefan Osswald; Christian Mueller Journal: Clin Res Cardiol Date: 2017-02-01 Impact factor: 5.460
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: Dirk Westermann; Johannes Tobias Neumann; Nils Arne Sörensen; Stefan Blankenberg Journal: Nat Rev Cardiol Date: 2017-04-06 Impact factor: 32.419
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