Jasper Boeddinghaus1, Thomas Nestelberger1, Raphael Twerenbold1, Karin Wildi1, Patrick Badertscher1, Janosch Cupa1, Tobias Bürge1, Patrick Mächler1, Sydney Corbière1, Karin Grimm1, Maria Rubini Giménez1, Christian Puelacher1, Samyut Shrestha1, Dayana Flores Widmer1, Jakob Fuhrmann1, Petra Hillinger1, Zaid Sabti1, Ursina Honegger1, Nicolas Schaerli1, Nikola Kozhuharov1, Katharina Rentsch1, Òscar Miró1, Beatriz López1, F Javier Martin-Sanchez1, Esther Rodriguez-Adrada1, Beata Morawiec1, Damian Kawecki1, Eva Ganovská1, Jiri Parenica1, Jens Lohrmann1, Wanda Kloos1, Andreas Buser1, Nicolas Geigy1, Dagmar I Keller1, Stefan Osswald1, Tobias Reichlin1, Christian Mueller2. 1. From Cardiovascular Research Institute Basel and Department of Cardiology, University Hospital Basel, University of Basel, Switzerland (J.B., T.N., R.T., K.W., P.B., J.C., T.B., P.M., S.C., K.G., M.R.G., C.P., S.S., D.F.W., J.F., P.H., Z.S., U.H., N.S., N.K., J.L. W.K., S.O., T.R., C.M.); Department of Internal Medicine, University Hospital Basel, University of Basel, Switzerland (J.B., T.N., K.G., P.H., N.S.); GREAT Network (J.B., T.N., R.T., K.W., P.B., J.C., S.C., K.G., M.R.G., C.P., S.S., D.F.W., P.H., Z.S., U.H., N.S., N.K., O.M., B.L., E.G., J.P., T.R., C.M.); Emergency Department, University Hospital Zurich, Switzerland (T.B., P.M., D.I.K.); Laboratory Medicine, University Hospital Basel, Switzerland (K.R.); Emergency Department, Hospital Clinic, Barcelona, Catalonia, Spain (O.M., B.L.); Servicio de Urgencias, Hospital Clínico San Carlos, Madrid, Spain (F.J.M.-S., E.R.-A.); 2nd Department of Cardiology, Medical University of Silesia, Zabrze, Poland (B.M., D.K.); Department of Cardiology, University Hospital Brno, Czech Republic and Medical Faculty, Masaryk University (E.G., J.P.); Blood Transfusion Centre, Swiss Red Cross, Basel, Switzerland and Department of Hematology, University Hospital Basel (A.B.); and Emergency Department, Kantonsspital Liestal, Switzerland (N.G.). 2. From Cardiovascular Research Institute Basel and Department of Cardiology, University Hospital Basel, University of Basel, Switzerland (J.B., T.N., R.T., K.W., P.B., J.C., T.B., P.M., S.C., K.G., M.R.G., C.P., S.S., D.F.W., J.F., P.H., Z.S., U.H., N.S., N.K., J.L. W.K., S.O., T.R., C.M.); Department of Internal Medicine, University Hospital Basel, University of Basel, Switzerland (J.B., T.N., K.G., P.H., N.S.); GREAT Network (J.B., T.N., R.T., K.W., P.B., J.C., S.C., K.G., M.R.G., C.P., S.S., D.F.W., P.H., Z.S., U.H., N.S., N.K., O.M., B.L., E.G., J.P., T.R., C.M.); Emergency Department, University Hospital Zurich, Switzerland (T.B., P.M., D.I.K.); Laboratory Medicine, University Hospital Basel, Switzerland (K.R.); Emergency Department, Hospital Clinic, Barcelona, Catalonia, Spain (O.M., B.L.); Servicio de Urgencias, Hospital Clínico San Carlos, Madrid, Spain (F.J.M.-S., E.R.-A.); 2nd Department of Cardiology, Medical University of Silesia, Zabrze, Poland (B.M., D.K.); Department of Cardiology, University Hospital Brno, Czech Republic and Medical Faculty, Masaryk University (E.G., J.P.); Blood Transfusion Centre, Swiss Red Cross, Basel, Switzerland and Department of Hematology, University Hospital Basel (A.B.); and Emergency Department, Kantonsspital Liestal, Switzerland (N.G.). christian.mueller@usb.ch.
Abstract
BACKGROUND: Four strategies for very early rule-out of acute myocardial infarction using high-sensitivity cardiac troponin I (hs-cTnI) have been identified. It remains unclear which strategy is most attractive for clinical application. METHODS: We prospectively enrolled unselected patients presenting to the emergency department with symptoms suggestive of acute myocardial infarction. The final diagnosis was adjudicated by 2 independent cardiologists. Hs-cTnI levels were measured at presentation and after 1 hour in a blinded fashion. We directly compared all 4 hs-cTnI-based rule-out strategies: limit of detection (LOD, hs-cTnI<2 ng/L), single cutoff (hs-cTnI<5 ng/L), 1-hour algorithm (hs-cTnI<5 ng/L and 1-hour change<2 ng/L), and the 0/1-hour algorithm recommended in the European Society of Cardiology guideline combining LOD and 1-hour algorithm. RESULTS: Among 2828 enrolled patients, acute myocardial infarction was the final diagnosis in 451 (16%) patients. The LOD approach ruled out 453 patients (16%) with a sensitivity of 100% (95% confidence interval [CI], 99.2%-100%), the single cutoff 1516 patients (54%) with a sensitivity of 97.1% (95% CI, 95.1%-98.3%), the 1-hour algorithm 1459 patients (52%) with a sensitivity of 98.4% (95% CI, 96.8%-99.2%), and the 0/1-hour algorithm 1463 patients (52%) with a sensitivity of 98.4% (95% CI, 96.8%-99.2%). Predefined subgroup analysis in early presenters (≤2 hours) revealed significantly lower sensitivity (94.2%, interaction P=0.03) of the single cutoff, but not the other strategies. Two-year survival was 100% with LOD and 98.1% with the other strategies (P<0.01 for LOD versus each of the other strategies). CONCLUSIONS: All 4 rule-out strategies balance effectiveness and safety equally well. The single cutoff should not be applied in early presenters, whereas the 3 other strategies seem to perform well in this challenging subgroup. CLINICAL TRIAL REGISTRATION: URL: http://www.clinicaltrials.gov. Unique identifier: NCT00470587.
BACKGROUND: Four strategies for very early rule-out of acute myocardial infarction using high-sensitivity cardiac troponin I (hs-cTnI) have been identified. It remains unclear which strategy is most attractive for clinical application. METHODS: We prospectively enrolled unselected patients presenting to the emergency department with symptoms suggestive of acute myocardial infarction. The final diagnosis was adjudicated by 2 independent cardiologists. Hs-cTnI levels were measured at presentation and after 1 hour in a blinded fashion. We directly compared all 4 hs-cTnI-based rule-out strategies: limit of detection (LOD, hs-cTnI<2 ng/L), single cutoff (hs-cTnI<5 ng/L), 1-hour algorithm (hs-cTnI<5 ng/L and 1-hour change<2 ng/L), and the 0/1-hour algorithm recommended in the European Society of Cardiology guideline combining LOD and 1-hour algorithm. RESULTS: Among 2828 enrolled patients, acute myocardial infarction was the final diagnosis in 451 (16%) patients. The LOD approach ruled out 453 patients (16%) with a sensitivity of 100% (95% confidence interval [CI], 99.2%-100%), the single cutoff 1516 patients (54%) with a sensitivity of 97.1% (95% CI, 95.1%-98.3%), the 1-hour algorithm 1459 patients (52%) with a sensitivity of 98.4% (95% CI, 96.8%-99.2%), and the 0/1-hour algorithm 1463 patients (52%) with a sensitivity of 98.4% (95% CI, 96.8%-99.2%). Predefined subgroup analysis in early presenters (≤2 hours) revealed significantly lower sensitivity (94.2%, interaction P=0.03) of the single cutoff, but not the other strategies. Two-year survival was 100% with LOD and 98.1% with the other strategies (P<0.01 for LOD versus each of the other strategies). CONCLUSIONS: All 4 rule-out strategies balance effectiveness and safety equally well. The single cutoff should not be applied in early presenters, whereas the 3 other strategies seem to perform well in this challenging subgroup. CLINICAL TRIAL REGISTRATION: URL: http://www.clinicaltrials.gov. Unique identifier: NCT00470587.
Authors: Daniel E Forman; James A de Lemos; Leslee J Shaw; David B Reuben; Radmila Lyubarova; Eric D Peterson; John A Spertus; Susan Zieman; Marcel E Salive; Michael W Rich Journal: J Am Coll Cardiol Date: 2020-09-29 Impact factor: 24.094
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Authors: Atul Anand; Kuan Ken Lee; Andrew R Chapman; Amy V Ferry; Phil D Adamson; Fiona E Strachan; Colin Berry; Iain Findlay; Anne Cruikshank; Alan Reid; Paul O Collinson; Fred S Apple; David A McAllister; Donogh Maguire; Keith A A Fox; David E Newby; Chris Tuck; Ronald Harkess; Catriona Keerie; Christopher J Weir; Richard A Parker; Alasdair Gray; Anoop S V Shah; Nicholas L Mills Journal: Circulation Date: 2021-03-23 Impact factor: 39.918
Authors: José Carlos Nicolau; Gilson Soares Feitosa Filho; João Luiz Petriz; Remo Holanda de Mendonça Furtado; Dalton Bertolim Précoma; Walmor Lemke; Renato Delascio Lopes; Ari Timerman; José A Marin Neto; Luiz Bezerra Neto; Bruno Ferraz de Oliveira Gomes; Eduardo Cavalcanti Lapa Santos; Leopoldo Soares Piegas; Alexandre de Matos Soeiro; Alexandre Jorge de Andrade Negri; Andre Franci; Brivaldo Markman Filho; Bruno Mendonça Baccaro; Carlos Eduardo Lucena Montenegro; Carlos Eduardo Rochitte; Carlos José Dornas Gonçalves Barbosa; Cláudio Marcelo Bittencourt das Virgens; Edson Stefanini; Euler Roberto Fernandes Manenti; Felipe Gallego Lima; Francisco das Chagas Monteiro Júnior; Harry Correa Filho; Henrique Patrus Mundim Pena; Ibraim Masciarelli Francisco Pinto; João Luiz de Alencar Araripe Falcão; Joberto Pinheiro Sena; José Maria Peixoto; Juliana Ascenção de Souza; Leonardo Sara da Silva; Lilia Nigro Maia; Louis Nakayama Ohe; Luciano Moreira Baracioli; Luís Alberto de Oliveira Dallan; Luis Augusto Palma Dallan; Luiz Alberto Piva E Mattos; Luiz Carlos Bodanese; Luiz Eduardo Fonteles Ritt; Manoel Fernandes Canesin; Marcelo Bueno da Silva Rivas; Marcelo Franken; Marcos José Gomes Magalhães; Múcio Tavares de Oliveira Júnior; Nivaldo Menezes Filgueiras Filho; Oscar Pereira Dutra; Otávio Rizzi Coelho; Paulo Ernesto Leães; Paulo Roberto Ferreira Rossi; Paulo Rogério Soares; Pedro Alves Lemos Neto; Pedro Silvio Farsky; Rafael Rebêlo C Cavalcanti; Renato Jorge Alves; Renato Abdala Karam Kalil; Roberto Esporcatte; Roberto Luiz Marino; Roberto Rocha Corrêa Veiga Giraldez; Romeu Sérgio Meneghelo; Ronaldo de Souza Leão Lima; Rui Fernando Ramos; Sandra Nivea Dos Reis Saraiva Falcão; Talia Falcão Dalçóquio; Viviana de Mello Guzzo Lemke; William Azem Chalela; Wilson Mathias Júnior Journal: Arq Bras Cardiol Date: 2021-07 Impact factor: 2.667
Authors: Philip W Chui; Denise Esserman; Lori A Bastian; Jeptha P Curtis; Parul U Gandhi; Lindsey Rosman; Nihar Desai; Ronald G Hauser Journal: Med Care Date: 2020-12 Impact factor: 3.178
Authors: Eve Miller-Hodges; Atul Anand; Anoop S V Shah; Andrew R Chapman; Peter Gallacher; Kuan Ken Lee; Tariq Farrah; Nynke Halbesma; James P Blackmur; David E Newby; Nicholas L Mills; Neeraj Dhaun Journal: Circulation Date: 2017-10-04 Impact factor: 29.690