Two-Hour Algorithm for Rapid Triage of Suspected Acute Myocardial Infarction Using a High-Sensitivity Cardiac Troponin I Assay.

Nestelberger, Thomas; Boeddinghaus, Jasper; Greenslade, Jaimi; Parsonage, William A; Than, Martin; Wussler, Desiree; Lopez-Ayala, Pedro; Zimmermann, Tobias; Meier, Mario; Troester, Valentina; Badertscher, Patrick; Koechlin, Luca; Wildi, Karin; Anwar, Mahnoor; Freese, Michael; Keller, Dagmar I; Reichlin, Tobias; Twerenbold, Raphael; Cullen, Louise and Mueller, Christian (2019). Two-Hour Algorithm for Rapid Triage of Suspected Acute Myocardial Infarction Using a High-Sensitivity Cardiac Troponin I Assay. Clinical chemistry, 65(11), pp. 1437-1447. American Association for Clinical Chemistry 10.1373/clinchem.2019.305193

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BACKGROUND

We aimed to derive and externally validate a 0/2-h algorithm using the high-sensitivity cardiac troponin I (hs-cTnI)-Access assay.

METHODS

We enrolled patients presenting to the emergency department with symptoms suggestive of acute myocardial infarction (AMI) in 2 prospective diagnostic studies using central adjudication. Two independent cardiologists adjudicated the final diagnosis, including all available medical information including cardiac imaging. hs-cTnI-Access concentrations were measured at presentation and after 2 h in a blinded fashion.

RESULTS

AMI was the adjudicated final diagnosis in 164 of 1131 (14.5%) patients in the derivation cohort. Rule-out by the hs-cTnI-Access 0/2-h algorithm was defined as 0-h hs-cTnI-Access concentration <4 ng/L in patients with an onset of chest pain >3 h (direct rule-out) or a 0-h hs-cTnI-Access concentration <5 ng/L and an absolute change within 2 h <5 ng/L in all other patients. Derived thresholds for rule-in were a 0-h hs-cTnI-Access concentration ≥50 ng/L (direct rule-in) or an absolute change within 2 h ≥20 ng/L. In the derivation cohort, these cutoffs ruled out 55% of patients with a negative predictive value (NPV) of 99.8% (95% CI, 99.3-100) and sensitivity of 99.4% (95% CI, 96.5-99.9), and ruled in 30% of patients with a positive predictive value (PPV) of 73% (95% CI, 66.1-79). In the validation cohort, AMI was the adjudicated final diagnosis in 88 of 1280 (6.9%) patients. These cutoffs ruled out 77.9% of patients with an NPV of 99.8% (95% CI, 99.3-100) and sensitivity of 97.7% (95% CI, 92.0-99.7), and ruled in 5.8% of patients with a PPV of 77% (95% CI, 65.8-86) in the validation cohort.

CONCLUSIONS

Safety and efficacy of the l hs-cTnI-Access 0/2-h algorithm for triage toward rule-out or rule-in of AMI are very high.

TRIAL REGISTRATION

APACE, NCT00470587; ADAPT, ACTRN1261100106994; IMPACT, ACTRN12611000206921.

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:	0009-9147
Publisher:	American Association for Clinical Chemistry
Language:	English
Submitter:	Daria Vogelsang
Date Deposited:	10 Dec 2019 10:55
Last Modified:	05 Dec 2022 15:31
Publisher DOI:	10.1373/clinchem.2019.305193
PubMed ID:	31570634
URI:	https://boris.unibe.ch/id/eprint/134531