Maros Ferencik1,2,3, Thomas Mayrhofer2,3,4, Michael T Lu2,3, Pamela K Woodard5, Quynh A Truong6, W Frank Peacock7, Fabian Bamberg8, Benjamin C Sun9, Jerome L Fleg10, John T Nagurney11, James E Udelson12, Wolfgang Koenig13,14,15, James L Januzzi16, Udo Hoffmann2,3,16. 1. Knight Cardiovascular Institute, Oregon Health and Science University, Portland, OR; ferencik@ohsu.edu. 2. Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Boston, MA. 3. Cardiac MR PET CT Program, Massachusetts General Hospital and Harvard Medical School, Boston, MA. 4. School of Business Studies, Stralsund University of Applied Sciences, Stralsund, Germany. 5. Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, MO. 6. Dalio Institute of Cardiovascular Imaging, New York-Presbyterian Hospital and Weill Cornell Medical College, New York, NY. 7. Division of Emergency Medicine, Baylor College of Medicine, Houston, TX. 8. Department of Radiology, University of Tuebingen, Tuebingen, Germany. 9. Department of Emergency Medicine, Oregon Health and Science University, Portland, OR. 10. Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, Bethesda, MD. 11. Department of Emergency Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA. 12. Division of Cardiology and the Cardio-Vascular Center, Tufts Medical Center, Boston, MA. 13. Deutsches Herzzentrum München, Technische Universität München, Munich, Germany. 14. DZHK (German Centre for Cardiovascular Research), partner site Munich Heart Alliance, Munich, Germany. 15. Department of Internal Medicine II-Cardiology, University of Ulm Medical Center, Ulm, Germany. 16. Cardiology Division, Massachusetts General Hospital and Harvard Medical School, Boston, MA.
Abstract
BACKGROUND: Most patients presenting to the emergency department (ED) with suspected acute coronary syndrome (ACS) undergo noninvasive cardiac testing with a low diagnostic yield. We determined whether a combination of high-sensitivity cardiac troponin I (hs-cTnI) and cardiovascular risk factors might improve selection of patients for cardiac testing. METHODS: We included patients from the Rule Out Myocardial Infarction/Ischemia Using Computer Assisted Tomography (ROMICAT) I and II trials who presented to the ED with acute chest pain and were referred for cardiac testing. Based on serial hs-cTnI measurements and cardiovascular risk factors, we derived and validated the criterion for no need of cardiac testing. We predicted the effect of this criterion on the effectiveness of patient management. RESULTS: A combination of baseline hs-cTnI (<4 ng/L) and cardiovascular risk factors (<2) ruled out ACS with a negative predictive value of 100% in ROMICAT I. We validated this criterion in ROMICAT II, identifying 29% patients as not needing cardiac testing. An additional 5% of patients were identified by adding no change or a decrease between baseline and 2 h hs-cTnI as a criterion. Assuming those patients would be discharged from the ED without cardiac testing, implementation of hs-cTnI would increase ED discharge rate (24.3% to 50.2%, P < 0.001) and decrease the length of hospital stay (21.4 to 8.2 h, P < 0.001), radiation dose (10.2 to 7.7 mSv, P < 0.001), and costs of care (4066 to 3342 US$, P < 0.001). CONCLUSIONS: We derived and validated a criterion for combined hs-cTnI and cardiovascular risk factors that identified acute chest pain patients with no need for cardiac testing and could improve effectiveness of patient management. ClinicalTrials.gov Identifiers: NCT00990262 and NCT01084239.
BACKGROUND: Most patients presenting to the emergency department (ED) with suspected acute coronary syndrome (ACS) undergo noninvasive cardiac testing with a low diagnostic yield. We determined whether a combination of high-sensitivity cardiac troponin I (hs-cTnI) and cardiovascular risk factors might improve selection of patients for cardiac testing. METHODS: We included patients from the Rule Out Myocardial Infarction/Ischemia Using Computer Assisted Tomography (ROMICAT) I and II trials who presented to the ED with acute chest pain and were referred for cardiac testing. Based on serial hs-cTnI measurements and cardiovascular risk factors, we derived and validated the criterion for no need of cardiac testing. We predicted the effect of this criterion on the effectiveness of patient management. RESULTS: A combination of baseline hs-cTnI (<4 ng/L) and cardiovascular risk factors (<2) ruled out ACS with a negative predictive value of 100% in ROMICAT I. We validated this criterion in ROMICAT II, identifying 29% patients as not needing cardiac testing. An additional 5% of patients were identified by adding no change or a decrease between baseline and 2 h hs-cTnI as a criterion. Assuming those patients would be discharged from the ED without cardiac testing, implementation of hs-cTnI would increase ED discharge rate (24.3% to 50.2%, P < 0.001) and decrease the length of hospital stay (21.4 to 8.2 h, P < 0.001), radiation dose (10.2 to 7.7 mSv, P < 0.001), and costs of care (4066 to 3342 US$, P < 0.001). CONCLUSIONS: We derived and validated a criterion for combined hs-cTnI and cardiovascular risk factors that identified acute chest painpatients with no need for cardiac testing and could improve effectiveness of patient management. ClinicalTrials.gov Identifiers: NCT00990262 and NCT01084239.
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