Two-hour Algorithm for Triage Toward Rule-out and Rule-in of Acute Myocardial Infarction Using High-sensitivity Cardiac Troponin T - 20/03/15
Abstract |
Background |
High-sensitivity cardiac troponin (hs-cTn) may allow an earlier diagnosis of acute myocardial infarction (AMI).
Methods |
We prospectively enrolled 1148 (derivation cohort) and 517 (external validation cohort) unselected patients presenting with suspected AMI to the emergency department. Final diagnosis was adjudicated by 2 independent cardiologists. Hs-cTnT was measured at presentation and after 2 hours. A diagnostic algorithm incorporating hs-cTnT values at presentation and absolute changes within the first 2 hours was derived.
Results |
AMI was the final diagnosis in 16% of patients in the derivation and 9.1% in the validation cohort. The 2-hour algorithm developed in the derivation cohort classified 60% of patients as “rule-out,” 16% as “rule-in,” and 24% in the “observational-zone.” Resulting sensitivity and negative predictive value (NPV) were 99.5% and 99.9%, respectively, for rule-out, and specificity and positive predictive value (PPV) were 96% and 78%, respectively, for rule-in. Applying the 2-hour triage algorithm in the external validation cohort, 78% of patients could be classified as “rule-out,” 8% as “rule-in,” and 14% in the “observational-zone.” Resulting sensitivity and NPV were 96% and 99.5%, respectively, for rule-out, and specificity and PPV were 99% and 85%, respectively, for rule-in. Cumulative 30-day survival rates were 100%, 98.9%, and 95.2% (P < .001), and 100%, 100%, and 95% (P < .001) in patients classified as “rule-out,” “observational-zone,” and “rule-in” in the 2 cohorts, respectively.
Conclusions |
A simple algorithm incorporating hs-cTnT baseline values and absolute changes over 2 hours allowed a triage toward safe rule-out, or accurate rule-in, of AMI in the vast majority of patients, with only 20% requiring more prolonged monitoring and serial blood sampling.
Le texte complet de cet article est disponible en PDF.Keywords : Acute myocardial infarction, Diagnostic algorithm, High-sensitive troponin
Plan
| Funding: The study was supported by research grants from the Swiss National Science Foundation, the Swiss Heart Foundation, Abbott, BRAHMS, Roche, Siemens, 8sense, Nanosphere, Alere, and the Department of Internal Medicine, University Hospital Basel, and by research grants from the Queensland Emergency Medical Research Foundation (QEMRF PROJ-2008-002). |
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| Conflicts of Interest: The sponsors had no role in designing or conducting the study and no role in gathering or analyzing the data or writing the manuscript. The manuscript and its contents have not been published previously and are not being considered for publications elsewhere in whole or in part in any language, including publicly accessible Web sites or e-print servers. We disclose that TR has received research grants from the Swiss National Science Foundation (PASMP3-136995), the Swiss Heart Foundation, the Professor Max Cloëtta Foundation, the Uniscientia Foundation Vaduz, the University of Basel, and the Department of Internal Medicine, University Hospital Basel, as well as speaker honoraria from Brahms and Roche. LC and WAP have received research support from Alere, Radiometer Pacific, Abbott Diagnostics, Roche, and Siemens. LC has received speakers’ fees, expenses, and honorarium from Boehringer-Ingelheim, Alere, Pfizer, Abbott Diagnostics, Astra Zeneca, and Radiometer Pacific. WAP has received honoraria and expenses from Abbott Diagnostics, Abbott Pharmaceuticals, Astra Zeneca, Hospira, and Sanofi Aventis. SM has received research support from the Swiss National Science Foundation, the Swiss Heart Foundation, Abbott, Alere, Brahms, Nanosphere, Roche, Siemens, 8sense, Nanosphere, and the Department of Internal Medicine, University Hospital Basel, as well as speaker honoraria from Abbott, Alere, Brahms, Novartis, Roche, and Siemens. All other authors declare that they have no conflict of interest with this study. The hs-cTnT assay was donated by Roche, who had no role in the design of the study, the analysis of the data, the preparation of the manuscript, or the decision to submit the manuscript for publication. |
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| Authorship: The authors designed the study, gathered and analyzed the data, vouch for the data and analysis, wrote the paper, and decided to publish. TR and SM had full acess to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. All authors have read and approved the manuscript. |
Vol 128 - N° 4
P. 369 - avril 2015 Retour au numéro
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