Getting Cardiac Troponin Right: Appraisal of the 2020 European Society of Cardiology Guidelines for the Management of Acute Coronary Syndromes in Patients Presenting without Persistent ST-Segment Elevation by the International Federation of Clinical Chemistry and Laboratory Medicine Committee on Clinical Applications of Cardiac Bio-Markers

Apple, Fred S.; Collinson, Paul; Kavsak, Peter A.; Body, Richard; Ordóñez-Llanos, Jordi; Saenger, Amy K.; Omland, Torbjørn; Hammarsten, Ola; Jaffe, Allan S.

doi:10.1093/clinchem/hvaa337

Cited by 30 publications

(35 citation statements)

References 38 publications

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“…The 0/1-h algorithm is recommended by the ESC guideline, based on its high safety and efficacy observed in multiple observational studies [ 14 ]. However, the clinical implementation of the 0/1-h algorithm in Europe and recently Northern America has not been without controversy due to the fact that the majority of the findings related to the 0/1-h algorithm were derived from highly controlled settings of observational, diagnostic studies [ 30 , 31 ]. Similarly, the 0/1-h algorithm was derived in Central European patients.…”

Section: Discussionmentioning

confidence: 99%

An international, stepped wedge, cluster-randomized trial investigating the 0/1-h algorithm in suspected acute coronary syndrome in Asia: the rational of the DROP-Asian ACS study

Inoue

Chieh

Yeh

et al. 2022

Trials

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Background More than half of the world’s population lives in Asia. With current life expectancies in Asian countries, the burden of cardiovascular disease is increasing exponentially. Overcrowding in the emergency departments (ED) has become a public health problem. Since 2015, the European Society of Cardiology recommends the use of a 0/1-h algorithm based on high-sensitivity cardiac troponin (hs-cTn) for rapid triage of patients with suspected non-ST elevation acute coronary syndrome (NSTE-ACS). However, these algorithms are currently not recommended by Asian guidelines due to the lack of suitable data. Methods The DROP-Asian ACS is a prospective, stepped wedge, cluster-randomized trial enrolling 4260 participants presenting with chest pain to the ED of 12 acute care hospitals in five Asian countries (UMIN; 000042461). Consecutive patients presenting with suspected acute coronary syndrome between July 2022 and Apr 2024 were included. Initially, all clusters will apply “usual care” according to local standard operating procedures including hs-cTnT but not the 0/1-h algorithm. The primary outcome is the incidence of major adverse cardiac events (MACE), the composite of all-cause death, myocardial infarction, unstable angina, or unplanned revascularization within 30 days. The difference in MACE (with one-sided 95% CI) was estimated to evaluate non-inferiority. The non-inferiority margin was prespecified at 1.5%. Secondary efficacy outcomes include costs for healthcare resources and duration of stay in ED. Conclusions This study provides important evidence concerning the safety and efficacy of the 0/1-h algorithm in Asian countries and may help to reduce congestion of the ED as well as medical costs.

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Section: Discussionmentioning

confidence: 99%

An international, stepped wedge, cluster-randomized trial investigating the 0/1-h algorithm in suspected acute coronary syndrome in Asia: the rational of the DROP-Asian ACS study

Inoue

Chieh

Yeh

et al. 2022

Trials

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“…In 2015 European Society of Cardiology guidelines, a 0/1‐h algorithm of cTn results was recommended for earlier diagnosis of NSTEMI 14 . Similar algorithms were proposed by several other studies and, in all these studies, the increase of cTn results between two sequential tests may give a hint of NSTEMI earlier than a traditional one‐time cut‐off 9,11,14–17 . In principle, a patient taking two serial cTn tests should stay at ED/CPC for 2 h with a cTn TAT of 60 min, whereas the length of stay is 1.5 h with a TAT of 30 min.…”

Section: Discussionmentioning

confidence: 79%

“…14 Similar algorithms were proposed by several other studies and, in all these studies, the increase of cTn results between two sequential tests may give a hint of NSTEMI earlier than a traditional one‐time cut‐off. 9 , 11 , 14 , 15 , 16 , 17 In principle, a patient taking two serial cTn tests should stay at ED/CPC for 2 h with a cTn TAT of 60 min, whereas the length of stay is 1.5 h with a TAT of 30 min. The 25% reduction of the length of stay indicates that the use of cTn algorithms adds an economic value to the time control of cTn testing.…”

Section: Discussionmentioning

confidence: 99%

Evaluation of a cardiac troponin process flow at the chest pain center with the shortest turnaround time

Wang

et al. 2022

Clinical Laboratory Analysis

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Background Early diagnosis of myocardial infarction is crucial in chest pain management and cardiac troponin (cTn) test is an important step in it. Process improvement to shorten the test turnaround time (TAT) may improve patients’ outcomes. The cTn test at chest pain center (CPC) of Zhongshan Hospital had the shortest TAT ever reported, but its process flow was not fully evaluated. Methods We performed a stepwise evaluation of CPC cTn TAT and explored the potential factor that might cause delay. The performance of CPC cTn test was also compared with cTn test and human chorionic gonadotropin (HCG) test ordered from emergency department (ED). Results At least 95% of CPC cTn tests were completed in 60 min, while 62% in 30 min. The medians of monthly order‐to‐collect time, collect‐to‐received time, and received‐to‐result time were ~7 min, ~3 min, and ~13 min, respectively. The samples collected at the bedside had longer collect‐to‐received time than the ones collected at the blood draw site next to the laboratory. Compared to ED cTn test and ED HCG test, CPC cTn test took less time in each step. A combination of the sample type switch and the centrifugation time reduction contributed the most to the shortening of TAT, which was reflected in the received‐to‐result time. Conclusions The current process flow of CPC cTn test satisfied the requirements of chest pain management, giving an example of how to implement process improvement for emergency medicine to shorten TAT of laboratory tests.

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“…Therefore, our study is based on cardiac troponin I rather than hs-cTn, which is a newer method. Newer algorithms (0/1 or 0/2 hours; standard algorithms ≥ 3 hours) were not used for diagnosing NSTEMI with type 1 MI in our patients [ 3 , 32 ]. However, our study had a more accurate prediction in diagnosing SIMD than another study that used hs-cTn [ 9 ].…”

Section: Discussionmentioning

confidence: 99%

Troponin I Cutoff for Non-ST-Segment Elevation Myocardial Infarction in Sepsis

Tsai

Lai

Hung

et al. 2022

Mediators of Inflammation

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The diagnostic value and optimal cutoff level of cardiac troponin I in patients with sepsis have not been studied. In this single hospital retrospective study, we assessed the optimal cutoff value of troponin I for diagnosing non-ST-segment elevation myocardial infarction (NSTEMI) with type 1 myocardial infarction (MI) in patients with sepsis who had undergone a percutaneous coronary intervention from 2009 to 2019. In total, 5,341 patients (excluding patients with chronic kidney disease) were included, of whom 277 had sepsis or septic shock. Of the 123 patients with non-ST-segment elevation acute coronary syndrome (NSTE-ACS) and sepsis, 77 (62.6%) were diagnosed with NSTEMI with type 1 MI. The receiver-operating characteristic curve showed an area under the curve (AUC) of 0.705 for diagnosis of NSTEMI with type 1 MI with a troponin I cutoff of >300 ng/L (sensitivity: 68.4%, specificity: 70.2%, Youden index: 0.386). Multiple linear regression showed no significant predictors of NSTEMI with type 1 MI. Troponin level and the Global Registry of Acute Coronary Events (GRACE) scores were correlated ( R 2 = 0.0625 , p = 0.032 ) and showed comparable predictive value for 6-month mortality (AUC: 0.637 and 0.611, respectively, p = 0.7651 ). The optimal troponin I cutoff to effectively diagnose NSTEMI with type 1 MI in patients with sepsis was 300 ng/L.

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Cited by 30 publications

References 38 publications

An international, stepped wedge, cluster-randomized trial investigating the 0/1-h algorithm in suspected acute coronary syndrome in Asia: the rational of the DROP-Asian ACS study

An international, stepped wedge, cluster-randomized trial investigating the 0/1-h algorithm in suspected acute coronary syndrome in Asia: the rational of the DROP-Asian ACS study

Evaluation of a cardiac troponin process flow at the chest pain center with the shortest turnaround time

Troponin I Cutoff for Non-ST-Segment Elevation Myocardial Infarction in Sepsis

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