John W Pickering1, Jaimi H Greenslade1, Louise Cullen1, Dylan Flaws1, William Parsonage1, Sally Aldous1, Peter George1, Andrew Worster1, Peter A Kavsak1, Martin P Than2. 1. From Emergency Department (J.W.P., M.P.T.), and Cardiology Department (S.A.), Christchurch Hospital, Christchurch, New Zealand; Department of Medicine, University of Otago, Christchurch, New Zealand (J.W.P.); Department of Emergency Medicine, Royal Brisbane and Women's Hospital, The University of Queensland and School of Public Health, Queensland University of Technology, Brisbane, Australia (J.H.G., L.C., D.F.); Department of Cardiology, Royal Brisbane and Women's Hospital, Brisbane, Australia (W.P.); Canterbury Health Laboratories, Christchurch, New Zealand (P.G.); and McMaster University, Hamilton, Ontario, Canada (A.W., P.A.K.). 2. From Emergency Department (J.W.P., M.P.T.), and Cardiology Department (S.A.), Christchurch Hospital, Christchurch, New Zealand; Department of Medicine, University of Otago, Christchurch, New Zealand (J.W.P.); Department of Emergency Medicine, Royal Brisbane and Women's Hospital, The University of Queensland and School of Public Health, Queensland University of Technology, Brisbane, Australia (J.H.G., L.C., D.F.); Department of Cardiology, Royal Brisbane and Women's Hospital, Brisbane, Australia (W.P.); Canterbury Health Laboratories, Christchurch, New Zealand (P.G.); and McMaster University, Hamilton, Ontario, Canada (A.W., P.A.K.). martinthan@xtra.co.nz.
Abstract
BACKGROUND: The new European Society of Cardiology guidelines to rule-in and rule-out acute myocardial infarction (AMI) in the emergency department include a rapid assessment algorithm based on high-sensitivity cardiac troponin and sampling at 0 and 1 hour. Emergency department physicians require high sensitivity to confidently rule-out AMI, whereas cardiologists aim to minimize false-positive results. METHODS: High-sensitivity troponin I and T assays were used to measure troponin concentrations in patients presenting with chest-pain symptoms and being investigated for possible acute coronary syndrome at hospitals in New Zealand, Australia, and Canada. AMI outcomes were independently adjudicated by at least 2 physicians. The European Society of Cardiology algorithm performance with each assay was assessed by the sensitivity and proportion with AMI ruled out and the positive predictive value and proportion ruled-in. RESULTS: There were 2222 patients with serial high-sensitivity troponin T and high-sensitivity troponin I measurements. The high-sensitivity troponin T algorithm ruled out 1425 (64.1%) with a sensitivity of 97.1% (95% confidence interval [CI], 94.0%-98.8%) and ruled-in 292 (13.1%) with a positive predictive value of 63.4% (95% CI, 57.5%-68.9%).The high-sensitivity troponin I algorithm ruled out 1205 (54.2%) with a sensitivity of 98.8% (95% CI, 96.4%-99.7%)) and ruled-in 310 (14.0%) with a positive predictive value of 68.1% (95% CI, 62.6%-73.2%). CONCLUSIONS: The sensitivity of the European Society of Cardiology rapid assessment 0-/1-hour algorithm to rule-out AMI with high-sensitivity troponin may be insufficient for some emergency department physicians to confidently send patients home. These algorithms may prove useful to identify patients requiring expedited management. However, the positive predictive value was modest for both algorithms.
BACKGROUND: The new European Society of Cardiology guidelines to rule-in and rule-out acute myocardial infarction (AMI) in the emergency department include a rapid assessment algorithm based on high-sensitivity cardiac troponin and sampling at 0 and 1 hour. Emergency department physicians require high sensitivity to confidently rule-out AMI, whereas cardiologists aim to minimize false-positive results. METHODS: High-sensitivity troponin I and T assays were used to measure troponin concentrations in patients presenting with chest-pain symptoms and being investigated for possible acute coronary syndrome at hospitals in New Zealand, Australia, and Canada. AMI outcomes were independently adjudicated by at least 2 physicians. The European Society of Cardiology algorithm performance with each assay was assessed by the sensitivity and proportion with AMI ruled out and the positive predictive value and proportion ruled-in. RESULTS: There were 2222 patients with serial high-sensitivity troponin T and high-sensitivity troponin I measurements. The high-sensitivity troponin T algorithm ruled out 1425 (64.1%) with a sensitivity of 97.1% (95% confidence interval [CI], 94.0%-98.8%) and ruled-in 292 (13.1%) with a positive predictive value of 63.4% (95% CI, 57.5%-68.9%).The high-sensitivity troponin I algorithm ruled out 1205 (54.2%) with a sensitivity of 98.8% (95% CI, 96.4%-99.7%)) and ruled-in 310 (14.0%) with a positive predictive value of 68.1% (95% CI, 62.6%-73.2%). CONCLUSIONS: The sensitivity of the European Society of Cardiology rapid assessment 0-/1-hour algorithm to rule-out AMI with high-sensitivity troponin may be insufficient for some emergency department physicians to confidently send patients home. These algorithms may prove useful to identify patients requiring expedited management. However, the positive predictive value was modest for both algorithms.
Authors: Dirk Westermann; Johannes Tobias Neumann; Nils Arne Sörensen; Stefan Blankenberg Journal: Nat Rev Cardiol Date: 2017-04-06 Impact factor: 32.419
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Authors: Andrew R Chapman; Kuan Ken Lee; David A McAllister; Louise Cullen; Jaimi H Greenslade; William Parsonage; Andrew Worster; Peter A Kavsak; Stefan Blankenberg; Johannes Neumann; Nils A Sörensen; Dirk Westermann; Madelon M Buijs; Gerard J E Verdel; John W Pickering; Martin P Than; Raphael Twerenbold; Patrick Badertscher; Zaid Sabti; Christian Mueller; Atul Anand; Philip Adamson; Fiona E Strachan; Amy Ferry; Dennis Sandeman; Alasdair Gray; Richard Body; Brian Keevil; Edward Carlton; Kim Greaves; Frederick K Korley; Thomas S Metkus; Yader Sandoval; Fred S Apple; David E Newby; Anoop S V Shah; Nicholas L Mills Journal: JAMA Date: 2017-11-21 Impact factor: 56.272
Authors: Raphael Twerenbold; Patrick Badertscher; Jasper Boeddinghaus; Thomas Nestelberger; Karin Wildi; Christian Puelacher; Zaid Sabti; Maria Rubini Gimenez; Sandra Tschirky; Jeanne du Fay de Lavallaz; Nikola Kozhuharov; Lorraine Sazgary; Deborah Mueller; Tobias Breidthardt; Ivo Strebel; Dayana Flores Widmer; Samyut Shrestha; Òscar Miró; F Javier Martín-Sánchez; Beata Morawiec; Jiri Parenica; Nicolas Geigy; Dagmar I Keller; Katharina Rentsch; Arnold von Eckardstein; Stefan Osswald; Tobias Reichlin; Christian Mueller Journal: Circulation Date: 2017-11-03 Impact factor: 29.690