Immediate Rule-Out of Acute Myocardial Infarction Using Electrocardiogram and Baseline High-Sensitivity Troponin I

Neumann, Johannes; Sörensen, Nils Arne; Ojeda, Francisco; Schwemer, Tjark; Lehmacher, Jonas; Gönner, Saskia; Jarsetz, Nikolas; Keller, Till; Schaefer, S.; Renné, Thomas; Landmesser, Ulf; Clemmensen, Peter; Makarova, Nataliya; Schnabel, Renate B.; Zeller, Tanja; Karakas, Mahir; Pickering, John W.; Than, Martin; Parsonage, William; Greenslade, Jaimi; Cullen, Louise; Westermann, Dirk; Blankenberg, Stefan

doi:10.1373/clinchem.2016.262659

Cited by 59 publications

(42 citation statements)

References 19 publications

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“…[13,16] In summary, 1,641 patients with suspected AMI presenting to the ED or chest pain unit of the University Hospital Hamburg-Eppendorf between 19.07.2013 and 01.04.2016 were included. All individuals were above the age of 18 and gave written informed consent.…”

Section: Methodsmentioning

confidence: 99%

Early diagnosis of acute myocardial infarction using high-sensitivity troponin I

Neumann¹,

Sörensen²,

Ojeda³

et al. 2017

PLoS ONE

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ObjectiveThere is a clinical need for early and accurate diagnosis of acute myocardial infarction (AMI). Current European Society of Cardiology (ESC) guidelines recommend diagnosis of non-ST-elevation AMI based on serial troponin measurements. We aimed to challenge the ESC guidelines using 1) a high-sensitivity troponin I (hs-TnI) baseline cutoff, 2) an absolute hs-TnI change after 1 hour and 3) additional application of an ischemic ECG.Methods1,516 patients with suspected AMI presenting to the emergency department were included. Hs-TnI was measured directly at admission, after 1 and 3 hours. We investigated baseline concentrations, absolute changes of hs-TnI and additional application of an ischemic ECG to diagnose AMI. A positive predictive value (PPV) of more than 85% was targeted.ResultsThe median age of the study population was 65 years; 291 patients were diagnosed with AMI. The PPV of the 3-hours ESC algorithm was 85.5% (CI 79.7, 90.1) and 65.8% (CI 60.5,70.8) for the 1-hour algorithm. Using a high baseline hs-TnI concentration of 150 ng/L resulted in a PPV of 87.8% (CI 80.9,92.9). Alternatively, a hs-TnI change of 20 ng/L after 1 hour, resulted in a PPV of 86.5% (80.9,91.0), respectively for the diagnosis of AMI. Additional use of an ischemic ECG increased the PPV to 90.5% (CI 83.2,95.3), while reducing the efficacy.ConclusionThe diagnosis of AMI based on hs-TnI is challenging. The application of absolute hs-TnI changes after 1 hour may facilitate rapid rule-in of patients.Trial registrationwww.clinicaltrials.gov (NCT02355457).

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Section: Methodsmentioning

confidence: 99%

Early diagnosis of acute myocardial infarction using high-sensitivity troponin I

Neumann¹,

Sörensen²,

Ojeda³

et al. 2017

PLoS ONE

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“…Accumulating evidence summarised in a recent editorial18 and based on two meta-analyses19 20 on more than 9000 patients each, and individual observational cohorts21 22 support the use of a single admission hsTnT at the LoB or the LoD to rule-out MI. Correspondingly, several studies demonstrate excellent instant rule-out of MI using hsTnI at cut-offs at or close to the LoD including the UTROPIA study23 (Use of TROPonin In Acute coronary syndromes) in the USA, High-STEACS Study24 in Scotland, a High-STEACS substudy,25 the Biomarkers in Acute Cardiac Care (BACC) Study26 in Germany and a pooled analysis of five international (Australia, New Zealand and England) observational cohort studies 27. As an alternative to the single hsTn value-based instant rule-out of MI, the dual marker strategy (DMS) based on copeptin and cTn/hsTn has been recommended by ESC guidelines as an alternative based on numerous clinical trials3 and two meta-analyses, and because DMS has been demonstrated in a large randomised intervention trial28 to allow an earlier discharge that is at least as safe as a standard diagnostic strategy.…”

Section: Introductionmentioning

confidence: 99%

Troponins: established and novel indications in the management of cardiovascular disease

Giannitsis

Katus

2018

Heart

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“…A final clinical diagnosis of acute myocardial infarction (AMI) was established for 45 of the 426 patients (10.5%), with a significant difference ( p < 0.05) between females (9.2%) and males (11.6%); these data are in lower end of the range (9.2–23.2%) reported by other studies [7–14]. The number and rates of different diagnoses are reported in Table 3; the most frequent ones being nonspecific chest pain (92 cases) and neurological diseases (74, mostly syncope).…”

Section: Resultsmentioning

confidence: 82%

“…Indeed some recent publications have documented this approach as being clinically accurate, especially for ruling out [12–14, 16]. Even if in our experience the second draw was obtained after 3 hours, we tried to apply this “accelerated” algorithm by using only the results obtained by the hsTnI assay at baseline.…”

Section: Resultsmentioning

confidence: 99%

A Rational Adoption of the High Sensitive Assay for Cardiac Troponin I in Diagnostic Routine

et al. 2017

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We describe the adoption of high sensitive troponin I (hsTnI) in clinical practice in two hospital settings in Italy. Samples from 426 consecutive patients (mean age 68.8 ± 17.0) admitted to the Emergency Department with a suspected acute coronary syndrome (ACS) have been tested at admittance and after 3 and 6 hours by contemporary TnI and hsTnI. Results have been compared to the final clinical diagnosis. Troponin was detectable in 68.6% by TnI and 89.9% by hsTnI. Since hsTnI has a lower threshold for females, 38/41 patients with positive values only by hsTnI were women. The correlation between the assays was very high (r = 0.92). A diagnosis of acute myocardial infarction (AMI) was made in 45 cases (10.5%). The negative and positive predictive values for a 50% troponin variation at 3 hours were 95.8% and 66.7% for hsTnI and 95.0% and 52.6% for TnI and at 6 hours 90.3% and 100% for hsTnI and 88.9% and 78.9% for TnI, respectively. Receiver operating characteristic (ROC) curve analysis demonstrated a greater efficiency by hsTnI at 3 hours versus 6 hours (AUC = 0.91 versus 0.72). The main benefits of hsTnI are the adoption of gender-specific 99th percentile and the shortening of time to decision.

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Immediate Rule-Out of Acute Myocardial Infarction Using Electrocardiogram and Baseline High-Sensitivity Troponin I

Abstract: www.clinicaltrials.gov (NCT02355457).

Cited by 59 publications

References 19 publications

Early diagnosis of acute myocardial infarction using high-sensitivity troponin I

Early diagnosis of acute myocardial infarction using high-sensitivity troponin I

Troponins: established and novel indications in the management of cardiovascular disease

A Rational Adoption of the High Sensitive Assay for Cardiac Troponin I in Diagnostic Routine

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