Diagnosis of acute coronary syndrome in the emergency room: the dictatorship of high-sensitivity cardiac troponin and major adverse cardiac events

Evaluation of HEAR score to rule-out major adverse cardiac events without troponin test in patients presenting to the emergency department with chest pain

“…The percentage of MACE and the upper limit of the 95% CI were below the predefined values of 1 and 3%. This rate is considered a relevant estimation of the acceptable false negative rate for diagnostic strategy in suspected ACS/NSTEMI by most emergency physicians [7,15]. Moreover, in a probabilistic study, Kline et al [16] show that the threshold value of ACS prevalence, at which the risk of pursuing testing exceeds the risk of missing diagnosis, is 2.4%.…”

“…For most of them, the result is negative, and the usefulness of the testing is questionable. Second, troponin elevation (i.e., upper the threshold value defined by the 99th percentile of a young and healthy population) is not a specific feature of ACS [7]. In emergency department chest pain patients, about 40% of troponin tests are above this threshold, but only half of them have myocardial infarction [6,8].…”

Clinical translation of diagnostic studies: pitfalls of the usual reported characteristics

“…NPV and PPV are not test-related, but patient-related. The most common example is the one of a rapid test that is able to identify patients at very low risk for an acute disease, such as D-dimer for pulmonary embolism, or troponin for acute coronary syndrome [6][7][8]. In medicine, nothing is 100%, thus we can never 'rule out' or 'rule in' a disease with 100% certainty, but we can define a test threshold, below which the risk of further testing with potential false-positive results outweighs the low probability of failing the diagnosis and we can define a treatment threshold, above which we can treat the disease without further testing [9].…”

The contemporary significance of Framingham risk factors

“…Since it is not only important to diagnose an AMI, but predominantly to determine the presence of CAD as a cause of the chest pain [4], major adverse cardiac events (MACE) became the general accepted composite endpoint in the validation of these risk scores in patients with chest pain. In most studies, MACE consisted of myocardial infarction, revascularization and death within 30 days after presentation.…”

“…So, one might argue, if in current and future risk stratification tools a role is reserved for the good old Framingham risk factors. However, knowing its role in the development of CAD and realizing that the role of the emergency physician is not only to exclude an AMI [4], many emergency physicians still heavily rely on them in their risk assessment and patient disposition.…”