Comparison of fourteen rule-out strategies for acute myocardial infarction

Wildi, Karin; Boeddinghaus, Jasper; Nestelberger, Thomas; Twerenbold, Raphael; Badertscher, Patrick; Wussler, Desiree; Giménez, María Rubini; Puelacher, Christian; Lavallaz, Jeanne du Fay de; Dietsche, Sebastian; Walter, Joan; Kozhuharov, Nikola; Morawiec, Beata; Miró, Òscar; Martín‐Sánchez, Francisco Javier; Subramaniam, Sinthuri; Geigy, Nicolas; Keller, Dagmar I.; Reichlin, Tobias; Mueller, Deborah; Sazgary, Lorraine; Marbot, Stella; Sabti, Zaid; Flores, Dayana; Meissner, Kathrin; Kulangara, Caroline; Freese, Michael; Oßwald, Stefan; Stelzig, Claudia; Bingisser, Roland; López, Beatriz; Agüero, María Martínez; Nowalany-Kozielska, Ewa; Kawecki, Damian; Pařenica, Jiří; Ganovská, Eva; Lohrmann, Jens; Buser, Andreas; Grimm, Karin; Hartmann, Beate; Muzyk, Piotr; Rentsch, Katharina; Eckardstein, Arnold von

doi:10.1016/j.ijcard.2018.11.140

Cited by 51 publications

(31 citation statements)

References 36 publications

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“…to provide data to support direct comparisons of performance between assays). This assessment includes 25 new publications, 54,55,58-60,70,74,75,90-94,[103][104][105][106][107][108]111,113,123,132,170,173 relating to the APACE study, which have been published since our previous systematic review. Of particular significance is the fact that eight different hs-cTn assays (i.e.…”

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confidence: 99%

High-sensitivity troponin assays for early rule-out of acute myocardial infarction in people with acute chest pain: a systematic review and economic evaluation

Westwood

Ramaekers

Grimm

et al. 2021

Health Technol Assess

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Background Early diagnosis of acute myocardial infarction is important, but only 20% of emergency admissions for chest pain will actually have an acute myocardial infarction. High-sensitivity cardiac troponin assays may allow rapid rule out of myocardial infarction and avoid unnecessary hospital admissions. Objectives To assess the clinical effectiveness and cost-effectiveness of high-sensitivity cardiac troponin assays for the management of adults presenting with acute chest pain, in particular for the early rule-out of acute myocardial infarction. Methods Sixteen databases were searched up to September 2019. Review methods followed published guidelines. Studies were assessed for quality using appropriate risk-of-bias tools. The bivariate model was used to estimate summary sensitivity and specificity for meta-analyses involving four or more studies; otherwise, random-effects logistic regression was used. The health economic analysis considered the long-term costs and quality-adjusted life-years associated with different troponin testing methods. The de novo model consisted of a decision tree and a state–transition cohort model. A lifetime time horizon (of 60 years) was used. Results Thirty-seven studies (123 publications) were included in the review. The high-sensitivity cardiac troponin test strategies evaluated are defined by the combination of four factors (i.e. assay, number and timing of tests, and threshold concentration), resulting in a large number of possible combinations. Clinical opinion indicated a minimum clinically acceptable sensitivity of 97%. When considering single test strategies, only those using a threshold at or near to the limit of detection for the assay, in a sample taken at presentation, met the minimum clinically acceptable sensitivity criterion. The majority of the multiple test strategies that met this criterion comprised an initial rule-out step, based on high-sensitivity cardiac troponin levels in a sample taken on presentation and a minimum symptom duration, and a second stage for patients not meeting the initial rule-out criteria, based on presentation levels of high-sensitivity cardiac troponin and absolute change after 1, 2 or 3 hours. Two large cluster randomised controlled trials found that implementation of an early rule-out pathway for myocardial infarction reduced length of stay and rate of hospital admission without increasing cardiac events. In the base-case analysis, standard troponin testing was both the most effective and the most costly. Other testing strategies with a sensitivity of 100% (subject to uncertainty) were almost equally effective, resulting in the same life-year and quality-adjusted life-year gain at up to four decimal places. Comparisons based on the next best alternative showed that for willingness-to-pay values below £8455 per quality-adjusted life-year, the Access High Sensitivity Troponin I (Beckman Coulter, Brea, CA, USA) [(symptoms > 3 hours AND < 4 ng/l at 0 hours) OR (< 5 ng/l AND Δ < 5 ng/l at 0 to 2 hours)] would be cost-effective. For thresholds between £8455 and £20,190 per quality-adjusted life-year, the Elecsys® Troponin-T high sensitive (Roche, Basel, Switzerland) (< 12 ng/l at 0 hours AND Δ < 3 ng/l at 0 to 1 hours) would be cost-effective. For a threshold > £20,190 per quality-adjusted life-year, the Dimension Vista® High-Sensitivity Troponin I (Siemens Healthcare, Erlangen, Germany) (< 5 ng/l at 0 hours AND Δ < 2 ng/l at 0 to 1 hours) would be cost-effective. Conclusions High-sensitivity cardiac troponin testing may be cost-effective compared with standard troponin testing. Study registration This study is registered as PROSPERO CRD42019154716. Funding This project was funded by the National Institute for Health Research (NIHR) Evidence Synthesis programme and will be published in full in Health Technology Assessment; Vol. 25, No. 33. See the NIHR Journals Library website for further project information.

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confidence: 99%

High-sensitivity troponin assays for early rule-out of acute myocardial infarction in people with acute chest pain: a systematic review and economic evaluation

Westwood

Ramaekers

Grimm

et al. 2021

Health Technol Assess

View full text Add to dashboard Cite

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“…An important point is the type of troponin analysed, which is troponin T or I in most places. A large study showed similar safety properties for these assays when used in a 0/3‐hour setting 19 …”

Section: Discussionmentioning

confidence: 86%

Impact of more conservative European Society of Cardiology guidelines on the management of patients with acute chest pain

Kienbacher

Fuhrmann

Tulder

et al. 2021

Int J Clinical Practice

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Objective Early diagnosis or rule‐out of acute coronary syndrome (ACS) is a key competence of emergency medicine. Changes in the NSTE‐ACS guidelines of the European Society of Cardiology (ESC) in 2015 and 2020 both warranted a henceforth more conservative approach regarding high‐sensitivity troponin t (hsTnt) testing. We aimed to assess the impact of more conservative guidelines on the frequency of early rule‐out and prolonged observation with repeated hsTnt testing at a high‐volume tertiary care emergency department. Patients and Methods We conducted a pre‐ and post‐changeover analysis 3 months before and 3 months after transition from less (hsTnt cut‐off 30 ng/L, 3‐hour rule‐out) to more conservative (hsTnt cut‐off 14 ng/L, 1‐hour rule‐out) guidelines in 2015, comparing proportions of patients requiring repeated testing. Results We included 5442 cases of symptoms suspicious of acute cardiac origin (3451 before, 1991 after, 2370 (44%) female, age 55 (SD 19) years). The proportion of patients fulfilling early‐rule out criteria decreased from 68% (2348 patients) before to 60% (1195 patients) with the 2015 guidelines (P < .01). Those requiring repeated testing significantly (P < .01) increased from 22% (743 patients) to 25% (494 patients). Positive results in repeated testing significantly (P = .02) decreased from 43% (320 patients) to 37% (181 patients). Invasive diagnostics were performed in 91 patients (2.6%) before and in 75 patients (3.8%) after (P = .02) the guideline revision. Conclusion The implementation of the more conservative 2015 ESC guidelines led to a minor rise in prolonged observations because of an increase in negative repeated testing and to an increase in invasive procedures.

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“…Several hs-cTnT/I based rapid algorithms have been developed in the last decade [3,18,20,28,[54][55][56][57][58]. First introduced in 2011 by the ESC guidelines for non-ST-elevation (NSTE) ACS, the ESC 0/3h algorithm was the first hs-cTnT/I based rapid algorithm that was used widely throughout the world.…”

Section: Esc 0/1h and 0/2h-algorithmsmentioning

confidence: 99%