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

Abstract

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.

Accelerated ­Rule-Out of acute Myocardial Infarction using prehospital copeptin and in-hospital troponin: The AROMI study

“…However, our results regarding reduction in LOS are comparable to the LOS reduction seen in studies comparing the ESC 0 h/1 h algorithm to the 0 h/3 h algorithm, and the diagnostic properties of the accelerated DMS are similar to those of both the ESC 0 h/1 h algorithm and a single-sample rule-out algorithm ( Table 5 ). 38 , 48 , 50 In the nature of an open-label trial, our results are prone for bias. In particular, our primary efficacy endpoint (LOS) was susceptible to influence from the clinical personnel.…”

Invasive imaging modalities in a spontaneous coronary artery dissection: when “believing is seeing”

“…However, the diagnosis of SCAD among patients with ACS might be challenging when relying exclusively on clinical presentation ( 4 ). Differential diagnosis of SCAD from common atherothrombotic ACS events is difficult due to the overlapping findings obtained from non-invasive diagnostic modalities such as cardio-specific biomarkers and electrocardiographic or echocardiographic examinations ( 5 ). Contemporary non-invasive diagnostic modality for coronary artery visualization, such as multislice computed tomography coronary angiography (MSCT-CA), has several disadvantages, including the fact that it is not commonly employed for streamlining of ACS cases and has a lower spatial resolution, which poses challenges in accurately identifying the pathognomonic features that are crucial for SCAD diagnosis ( 6 ).…”

Prognostic Value of High-Sensitivity Cardiac Troponin in Women

“…Cardiac biomarkers are objectively measured features of physiological and disease-related processes with a plethora of possible applications, ranging from disease diagnosis to staging, prognosis, and the prediction of response to interventions [ 8 , 9 ]. Among all proposed cardiac biomarkers, cardiac troponins and natriuretic peptides have emerged as some of the most powerful and cost-effective clinical tools to diagnose and risk-stratify patients with suspected CVD [ 10 , 11 , 12 ]. In 2018, the European Society of Cardiology, American College of Cardiology, American Heart Association, and World Heart Foundation issued the fourth universal definition of myocardial infarction (MI), defining MI as a rise and/or fall in cardiac troponin with at least one value above the 99th percentile upper reference limit (URL) [ 13 ].…”