High-sensitivity cardiac troponin and the early rule out of myocardial infarction: time for action

BackgroundThe instant, single-sampling rule-out of acute myocardial infarction (AMI) is still an unmet clinical need. We aimed at testing and comparing diagnostic performance and prognostic value of two different single-sampling biomarker strategies for the instant rule-out of AMI.MethodsFrom the Biomarkers in Acute Cardiac Care (BACC) cohort, we recruited consecutive patients with acute chest pain and suspected AMI presenting to the Emergency Department of the University Medical Center Hamburg-Eppendorf, Hamburg, Germany. We compared safety, effectiveness and 12-month incidence of the composite endpoint of all-cause death and myocardial infarction between (i) a single-sampling, dual-marker pathway combining high-sensitivity cardiac troponin I (hs-cTnI) and ultra-sensitive copeptin (us-Cop) at presentation (hs-cTnI ≤ 27 ng/L, us-Cop < 10 pmol/L and low-risk ECG) and (ii) a single-sampling pathway based on one-off hs-cTnI determination at presentation (hs-cTnI < 5 ng/L and low-risk ECG). As a comparator, we used the European Society of Cardiology (ESC) 0/1-h dual-sampling algorithm.ResultsWe enrolled 1,136 patients (male gender 65%) with median age of 64 years (interquartile range, 51–75). Overall, 228 (20%) patients received a final diagnosis of AMI. The two single-sampling instant rule-out pathways yielded similar negative predictive value (NPV): 97.4% (95%CI: 95.4–98.7) and 98.7% (95%CI: 96.9–99.6) for dual-marker and single hs-cTnI algorithms, respectively (P = 0.11). Both strategies were comparably safe as the ESC 0/1-h dual-sampling algorithm and this was consistent across subgroups of early-comers, low-intermediate risk (GRACE-score < 140) and renal dysfunction. Despite a numerically higher rate of false-negative results, the dual-marker strategy ruled-out a slightly but significantly higher percentage of patients compared with single hs-cTnI determination (37.4% versus 32.9%; P < 0.001). There were no significant between-group differences in 12-month composite outcome.ConclusionsInstant rule-out pathways based on one-off determination of hs-cTnI alone or in combination with us-Cop are comparably safe as the ESC 0/1 h algorithm for the instant rule-out of AMI, yielding similar prognostic information. Instant rule-out strategies are safe alternatives to the ESC 0/1 h algorithm and allow the rapid and effective triage of suspected AMI in patients with low-risk ECG. However, adding copeptin to hs-cTn does not improve the safety of instant rule-out compared with the single rule-out hs-cTn at very low cut-off concentrations.

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“…But is this truly required in practice? Arguably not, and indeed very few tests in clinical practice have achieved such a goal ( 43 ).…”

Section: Discussionmentioning

confidence: 99%

High-sensitivity troponin I with or without ultra-sensitive copeptin for the instant rule-out of acute myocardial infarction

Ricci

Neumann

Rübsamen³

et al. 2022

Front. Cardiovasc. Med.

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“…To date, there have been no whole blood or prospective studies, either observational or randomized controlled trials, that have demonstrated that POC testing with high sensitivity analytical performance is clinically reliable, safe, and confers patient benefit. This is in contrast with central laboratory hs-cTn methods, demonstrated by meta-analysis of trials ( 30 , 31 ). While one assay (Pathfast) has FDA clearance for POC with preliminary data that meets hs-criteria along IFCC guidelines ( 32 ), in practice users of this large instrument are often laboratorians and not designated POC operators.…”

Section: Recommendations Of Fourth Universal Definition Of Myocardialmentioning

confidence: 91%

Implementation of High-Sensitivity and Point-of-Care Cardiac Troponin Assays into Practice: Some Different Thoughts

2020

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Background The primary role of the International Federation of Clinical Chemistry (IFCC) Committee on Clinical Application of Cardiac Bio-Markers (C-CB) is to provide educational materials about cardiac biomarker use, emphasizing high-sensitivity cardiac troponin assays. Content This mini-review, regarding high-sensitivity cardiac and point-of-care troponin assays, addresses 1) new IFCC C-CB/AACC Academy laboratory practice recommendations; 2) new and updated concepts from the Fourth Universal Definition of Myocardial Infarction; 3) the role of point-of-care assays in practice and research; 4) regulatory challenges concerning point-of-care assays; e) testing in the COVID-19 world. Summary Implementation of high-sensitivity cardiac troponin assays makes a difference now and into the future in clinical practice and research. Providing point-of-care high-sensitivity cardiac troponin assays and optimizing studies to allow clearance of these assays by regulatory agencies, in a timely fashion, may provide improved patient management and outcomes.

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“…High-sensitivity troponin (HST) assays are creating a paradigm shift in the workup and management of patients presenting to emergency departments (EDs) with chest discomfort. 1 These HSTs more rapidly and accurately detect clinically significant acute myocardial injury than contemporary troponins. 2 Additionally, integrating initial and serial HST values with electrocardiogram (ECG) findings as part of an accelerated diagnostic protocol (ADP) has been shown to stratify patients into discreet groups that better predict the risk of 30-day acute coronary syndrome (ACS).…”

Section: Introductionmentioning

confidence: 99%

Clinician Perception of Risk As a Barrier to Implementation of a High-sensitivity Troponin Accelerated Diagnostic Protocol

Matuskowitz

Hall

Gregoski

et al. 2022

Critical Pathways in Cardiology: A Journal of Evidence-Based Medicine

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Background: To assess emergency department (ED) clinician perception of patient risk, we measured willingness to discharge patients categorized as increased risk by traditional risk stratification modalities for acute coronary syndrome but low risk by a validated high-sensitivity troponin accelerated diagnostic protocol (HST-ADP). Methods: This was a cross-sectional descriptive survey study distributed to ED clinicians at an urban academic medical center. Four clinical vignettes classified hypothetical patients as low risk for 30-day acute coronary syndrome according to the 0-/1-hour HST-ADP. Vignettes additionally identified patients with History, Electrocardiogram, Age, Risk factors, and initial Troponin (HEART) scores of 4 or 6 (2 cases each). One patient in each subset had preexisting coronary artery disease (CAD). ED clinicians selfreported willingness to discharge patients from the ED on a 10-point Likert scale. Results: Among 66 eligible participants, 36 (55%) participated in the survey. ED clinicians reported a mean willingness to discharge patients of 6.07 (95% confidence interval, 5.34-6.80). They reported higher mean willingness to discharge patients with HEART scores of 4 compared with those with HEART scores of 6 (mean difference, 3.61; 95% confidence interval, 2.19-5.03). There were no differences in willingness to discharge regarding presence or absence of CAD or between clinician types (attending, resident, advanced practice provider). Conclusions: ED clinicians accustomed to the HEART Pathway demonstrated limited willingness to discharge patients from the ED categorized as moderate risk by the HEART score despite simultaneous classification as low risk by the 0-/1-hour HST-ADP. Willingness to discharge was higher with lower HEART scores but not affected by the presence of CAD and did not vary between clinician types.

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High-sensitivity cardiac troponin and the early rule out of myocardial infarction: time for action

Cited by 13 publications

References 12 publications

High-sensitivity troponin I with or without ultra-sensitive copeptin for the instant rule-out of acute myocardial infarction

High-sensitivity troponin I with or without ultra-sensitive copeptin for the instant rule-out of acute myocardial infarction

Implementation of High-Sensitivity and Point-of-Care Cardiac Troponin Assays into Practice: Some Different Thoughts

Clinician Perception of Risk As a Barrier to Implementation of a High-sensitivity Troponin Accelerated Diagnostic Protocol

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