Thomas Nestelberger1, Jasper Boeddinghaus2, Desiree Wussler3, Raphael Twerenbold4, Patrick Badertscher5, Karin Wildi6, Òscar Miró7, Beatriz López8, F Javier Martin-Sanchez9, Piotr Muzyk10, Luca Koechlin11, Benjamin Baumgartner4, Mario Meier4, Valentina Troester4, Maria Rubini Giménez4, Christian Puelacher3, Jeanne du Fay de Lavallaz4, Joan Walter4, Nikola Kozhuharov4, Tobias Zimmermann4, Danielle M Gualandro4, Eleni Michou4, Eliska Potlukova12, Nicolas Geigy13, Dagmar I Keller14, Tobias Reichlin15, Christian Mueller16. 1. Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland; GREAT Network. Electronic address: https://twitter.com/thomas_nest. 2. Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland; GREAT Network; Department of Internal Medicine, University Hospital Basel, University of Basel, Basel, Switzerland. Electronic address: https://twitter.com/J_Boeddinghaus. 3. Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland; GREAT Network; Department of Internal Medicine, University Hospital Basel, University of Basel, Basel, Switzerland. 4. Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland; GREAT Network. 5. Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland; GREAT Network; Division of Cardiology, University of Illinois at Chicago, Chicago, Illinois. 6. Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland; GREAT Network; Critical Care Research Institute, The Prince Charles Hospital, Brisbane and University of Queensland, Brisbane, Queensland, Australia. 7. GREAT Network; Emergency Department, Hospital Clinic, Barcelona, Spain. 8. Emergency Department, Hospital Clinic, Barcelona, Spain. 9. GREAT Network; Servicio de Urgencias, Hospital Clínico San Carlos, Madrid, Spain. 10. GREAT Network; 2(nd) Department of Cardiology, School of Medicine with the Division of Dentistry, Zabrze, Medical University of Katowice, Katowice, Poland. 11. Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland; GREAT Network; Department of Cardiac Surgery, University Hospital Basel, University of Basel, Basel, Switzerland. 12. Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland; Department of Internal Medicine, University Hospital Basel, University of Basel, Basel, Switzerland. 13. Emergency Department, Kantonsspital Baselland, Liestal, Switzerland. 14. Emergency Department, University Hospital Zürich, Zürich, Switzerland. 15. GREAT Network; Department of Cardiology, University Hospital Bern, University of Bern, Bern, Switzerland. 16. Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland; GREAT Network. Electronic address: christian.mueller@usb.ch.
Abstract
BACKGROUND: Early and accurate detection of short-term major adverse cardiac events (MACE) in patients with suspected acute myocardial infarction (AMI) is an unmet clinical need. OBJECTIVES: The goal of this study was to test the hypothesis that adding clinical judgment and electrocardiogram findings to the European Society of Cardiology (ESC) high-sensitivity cardiac troponin (hs-cTn) measurement at presentation and after 1 h (ESC hs-cTn 0/1 h algorithm) would further improve its performance to predict MACE. METHODS: Patients presenting to an emergency department with suspected AMI were enrolled in a prospective, multicenter diagnostic study. The primary endpoint was MACE, including all-cause death, cardiac arrest, AMI, cardiogenic shock, sustained ventricular arrhythmia, and high-grade atrioventricular block within 30 days including index events. The secondary endpoint was MACE + unstable angina (UA) receiving early (≤24 h) revascularization. RESULTS: Among 3,123 patients, the ESC hs-cTnT 0/1 h algorithm triaged significantly more patients toward rule-out compared with the extended algorithm (60%; 95% CI: 59% to 62% vs. 45%; 95% CI: 43% to 46%; p < 0.001), while maintaining similar 30-day MACE rates (0.6%; 95% CI: 0.3% to 1.1% vs. 0.4%; 95% CI: 0.1% to 0.9%; p = 0.429), resulting in a similar negative predictive value (99.4%; 95% CI: 98.9% to 99.6% vs. 99.6%; 95% CI: 99.2% to 99.8%; p = 0.097). The ESC hs-cTnT 0/1 h algorithm ruled-in fewer patients (16%; 95% CI: 14.9% to 17.5% vs. 26%; 95% CI: 24.2% to 27.2%; p < 0.001) compared with the extended algorithm, albeit with a higher positive predictive value (76.6%; 95% CI: 72.8% to 80.1% vs. 59%; 95% CI: 55.5% to 62.3%; p < 0.001). For 30-day MACE + UA, the ESC hs-cTnT 0/1 h algorithm had a higher positive predictive value for rule-in, whereas the extended algorithm had a higher negative predictive value for the rule-out. Similar findings emerged when using hs-cTnI. CONCLUSIONS: The ESC hs-cTn 0/1 h algorithm better balanced efficacy and safety in the prediction of MACE, whereas the extended algorithm is the preferred option for the rule-out of 30-day MACE + UA. (Advantageous Predictors of Acute Coronary Syndromes Evaluation [APACE]; NCT00470587).
BACKGROUND: Early and accurate detection of short-term major adverse cardiac events (MACE) in patients with suspected acute myocardial infarction (AMI) is an unmet clinical need. OBJECTIVES: The goal of this study was to test the hypothesis that adding clinical judgment and electrocardiogram findings to the European Society of Cardiology (ESC) high-sensitivity cardiac troponin (hs-cTn) measurement at presentation and after 1 h (ESC hs-cTn 0/1 h algorithm) would further improve its performance to predict MACE. METHODS:Patients presenting to an emergency department with suspected AMI were enrolled in a prospective, multicenter diagnostic study. The primary endpoint was MACE, including all-cause death, cardiac arrest, AMI, cardiogenic shock, sustained ventricular arrhythmia, and high-grade atrioventricular block within 30 days including index events. The secondary endpoint was MACE + unstable angina (UA) receiving early (≤24 h) revascularization. RESULTS: Among 3,123 patients, the ESC hs-cTnT 0/1 h algorithm triaged significantly more patients toward rule-out compared with the extended algorithm (60%; 95% CI: 59% to 62% vs. 45%; 95% CI: 43% to 46%; p < 0.001), while maintaining similar 30-day MACE rates (0.6%; 95% CI: 0.3% to 1.1% vs. 0.4%; 95% CI: 0.1% to 0.9%; p = 0.429), resulting in a similar negative predictive value (99.4%; 95% CI: 98.9% to 99.6% vs. 99.6%; 95% CI: 99.2% to 99.8%; p = 0.097). The ESC hs-cTnT 0/1 h algorithm ruled-in fewer patients (16%; 95% CI: 14.9% to 17.5% vs. 26%; 95% CI: 24.2% to 27.2%; p < 0.001) compared with the extended algorithm, albeit with a higher positive predictive value (76.6%; 95% CI: 72.8% to 80.1% vs. 59%; 95% CI: 55.5% to 62.3%; p < 0.001). For 30-day MACE + UA, the ESC hs-cTnT 0/1 h algorithm had a higher positive predictive value for rule-in, whereas the extended algorithm had a higher negative predictive value for the rule-out. Similar findings emerged when using hs-cTnI. CONCLUSIONS: The ESC hs-cTn 0/1 h algorithm better balanced efficacy and safety in the prediction of MACE, whereas the extended algorithm is the preferred option for the rule-out of 30-day MACE + UA. (Advantageous Predictors of Acute Coronary Syndromes Evaluation [APACE]; NCT00470587).
Authors: W Frank Peacock; Alan S Maisel; Christian Mueller; Stefan D Anker; Fred S Apple; Robert H Christenson; Paul Collinson; Lori B Daniels; Deborah B Diercks; Salvatore Di Somma; Gerasimos Filippatos; Gary Headden; Brian Hiestand; Judd E Hollander; Juan C Kaski; Joshua M Kosowsky; John T Nagurney; Richard M Nowak; Donald Schreiber; Gary M Vilke; Marvin A Wayne; Martin Than Journal: Clin Exp Emerg Med Date: 2022-06-30
Authors: Valentina Troester; Ivo Strebel; Thomas Nestelberger; Jasper Boeddinghaus; Maria Rubini Gimenez; Pedro Lopez-Ayala; Luca Koechlin; Noemi Glarner; Alexandra Prepoudis; Òscar Miró; F Javier Martin-Sanchez; Damian Kawecki; Dagmar I Keller; Raphael Twerenbold; Christian Mueller Journal: J Am Heart Assoc Date: 2020-12-26 Impact factor: 5.501
Authors: Dennis Sandeman; Maaz B J Syed; Dorien M Kimenai; Kuan Ken Lee; Atul Anand; Shruti S Joshi; Lorraine Dinnel; Philip R Wenham; Ken Campbell; Mary Jarvie; Donna Galloway; Mhairi Anderson; Bappa Roy; Jack P M Andrews; Fiona E Strachan; Amy V Ferry; Andrew R Chapman; Sarah Elsby; Mark Francis; Robert Cargill; Anoop S V Shah; Nicholas L Mills Journal: Open Heart Date: 2021-11
Authors: Bernard Cook; James McCord; Michael Hudson; Waleed Al-Darzi; Michele Moyer; Gordon Jacobsen; Richard Nowak Journal: Crit Pathw Cardiol Date: 2021-03-01