Characterization of the observe zone of the ESC 2015 high-sensitivity cardiac troponin 0 h/1 h-algorithm for the early diagnosis of acute myocardial infarction

Abstract

"Observe" patients are typically elderly men with pre-existing CAD and high long-term mortality. Absolute hs-cTn-changes within 3h, functional stress imaging and coronary angiography are the key diagnostic modalities.

Combining High-Sensitivity Cardiac Troponin I and Cardiac Troponin T in the Early Diagnosis of Acute Myocardial Infarction

“…The findings from this study corroborate and extend previous work aiming to further improve the safety and efficacy of the rule-out and rule-in of AMI among patients presenting with acute chest discomfort to the ED. [2][3][4]6,7,8,[42][43][44] The findings from this study corroborate and extend previous work aiming to further improve the safety and efficacy of the rule-out and rule-in of AMI among patients presenting with acute chest discomfort to the ED (quote), including 2 large meta-analyses providing exact estimates for the performance of single measurement rule-out strategies using very low Diagnostic performance of hs-cTn for non-ST segment myocardial infarction at presentation to the emergency department with acute chest pain. ROC curves show the diagnostic accuracy of hs-cTnI and hs-cTnT, their ratio, sum, and product.…”

“…Nevertheless, rapid and safe clinical decision making based on a single hs-cTn measurement at presentation seems to be approaching its limits, and the exploration of new diagnostic strategies including combinations of biomarkers, risk-assessment scores, or imaging seems to be indicated. 8 From this point of view, overcoming these logistic obstacles by close collaboration between diagnostic companies, hospital laboratories, medical doctors, and researchers would be able to provide substantial medical value for patients and physicians, and economic value for hospitals and the health care system in general. Future studies are necessary to identify the best strategy and to better quantify the possible clinical benefit associated with the combination of cTnI and cTnT.…”

“…[3][4][5][6][7] Despite major improvements in diagnostic accuracy owing to the introduction of high-sensitivity cardiac troponin (hs-cTn) assays and data-driven optimized diagnostic algorithms, rapid, accurate, and safe rule-out based on a single measurement of hs-cTn is still possible only in a minority of patients. 2,3,8,9 Current guidelines recommend measurement of 1 of the cardiac specific isoforms of the cardiac troponin (cTn) complex: cTnI or cTnT. 2,10 The development of high-sensitivity methods for the measurements of cTnT and cTnI concentrations has allowed the delineation of pathophysiological and analytical differences between cTnT and cTnI.…”

Trends in admissions for chest pain after the introduction of high-sensitivity cardiac troponin T

“…Since the publication of the three first observational studies [8,25,26] that indicated that it may be safe to discharge chest pain patients after one single hs-cTnT measurement if the level was undetectable, the safety of this strategy has been discussed extensively [27,28]. Later prospective studies have found similar low negative predictive values for ruling out MI by using only one measurement of hs-cTn [29].…”

Fast track protocols using highly sensitive troponin assays for ruling out and ruling in non-ST elevation acute coronary syndrome

“…What is probably innovative and noteworthy in using repeated close measures of hsTn is the early partition of patients into three groups (rule-out, observe, and rule-in) that allows to quickly move forward with different management strategies. For instance, non-invasive imaging procedures could be concentrated on the "observe" patients, typically including elderly men with pre-existing coronary artery disease and other non-cardiac complications [42].…”