Predicting Major Adverse Events in Patients With Acute Myocardial Infarction.

Nestelberger, Thomas; Boeddinghaus, Jasper; Wussler, Desiree; Twerenbold, Raphael; Badertscher, Patrick; Wildi, Karin; Miró, Òscar; López, Beatriz; Martin-Sanchez, F Javier; Muzyk, Piotr; Koechlin, Luca; Baumgartner, Benjamin; Meier, Mario; Troester, Valentina; Rubini Giménez, Maria; Puelacher, Christian; du Fay de Lavallaz, Jeanne; Walter, Joan; Kozhuharov, Nikola; Zimmermann, Tobias; ... (2019). Predicting Major Adverse Events in Patients With Acute Myocardial Infarction. Journal of the American College of Cardiology, 74(7), pp. 842-854. Elsevier 10.1016/j.jacc.2019.06.025

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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).

Item Type:	Journal Article (Original Article)
Division/Institute:	04 Faculty of Medicine > Department of Cardiovascular Disorders (DHGE) > Clinic of Cardiology
UniBE Contributor:	Reichlin, Tobias Roman
Subjects:	600 Technology > 610 Medicine & health
ISSN:	0735-1097
Publisher:	Elsevier
Language:	English
Submitter:	Daria Vogelsang
Date Deposited:	11 Dec 2019 07:21
Last Modified:	05 Dec 2022 15:31
Publisher DOI:	10.1016/j.jacc.2019.06.025
PubMed ID:	31416527
Uncontrolled Keywords:	acute myocardial infarction clinical assessment electrocardiography high-sensitivity cardiac troponin major adverse cardiac events
URI:	https://boris.unibe.ch/id/eprint/134534