Serial high-sensitivity cardiac troponin T measurements to rule out acute myocardial infarction and a single high baseline measurement for swift rule-in: A systematic review and meta-analysis

Arslan, Murat; Dedic, Admir; Boersma, Eric; Dubois, Éric

doi:10.1177/2048872618819421

Cited by 24 publications

(24 citation statements)

References 54 publications

(103 reference statements)

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“…Previous systematic reviews that analysed a single 0-hour sample of hs-cTn above the 99th percentile of a normal reference population to rule in AMI reported the specificity to be 77%–82% 17–19. In a recent meta-analysis, using a 50 ng/L cut-off at presentation to rule in AMI resulted in a pooled specificity of 95% 22. In parallel, the 0/1 hour algorithm could rule in patients at a comparable or a higher specificity of 93.6%.…”

Section: Discussionmentioning

confidence: 99%

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Safety and efficacy of the European Society of Cardiology 0/1-hour algorithm for diagnosis of myocardial infarction: systematic review and meta-analysis

Chiang

Lee

et al. 2020

Heart

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ObjectiveThe European Society of Cardiology (ESC) 0/1 hour algorithm has been primarily validated in Europe, America and Australasia with less knowledge of its performance outside of these settings. We aim to evaluate the performance of the ESC 0/1 hour algorithm across different contexts.MethodsWe searched PubMed, Embase, Scopus, Web of Science and the Cochrane Central Register of Controlled Trials for relevant studies published between 1 January 2008 and 31 May 2019. The primary outcome was index myocardial infarction and the secondary outcome was major adverse cardiac event or mortality. A bivariate random-effects meta-analysis was used to derive the pooled estimate of each outcome.ResultsA total of 11 014 patients from 10 cohorts were analysed for the primary outcome. The algorithm based on high-sensitivity cardiac troponin (hs-cTn)T (Roche), hs-cTnI (Abbott) and hs-cTnI (Siemens) had pooled sensitivity of 98.4% (95% CI=95.1% to 99.5%), 98.1% (95% CI=94.6% to 99.3%) and 98.7% (95% CI=97.3% to 99.3%), respectively. The algorithm based on hs-cTnT (Roche) and hs-cTnI (Siemens) had pooled specificity of 91.2% (95% CI=86.0% to 94.6%) and 95.9% (95% CI=94.1% to 97.2%), respectively. Among patients in the rule-out category, the pooled mortality rate at 30 days and at 1 year was 0.1% (95% CI=0.0% to 0.4%) and 0.8% (95% CI=0.5% to 1.2%), respectively. Among patients in the observation zone, the pooled mortality rate was 0.7% (95% CI=0.3% to 1.2%) at 30 days but increased to 8.1% (95% CI=6.1% to 10.4%) at 1 year, comparable to the mortality rate in the rule-in group.ConclusionThe ESC 0/1 hour algorithm has high diagnostic accuracy but may not be sufficiently safe if the 1% miss-rate for myocardial infarction is desired.PROSPERO registration numberCRD42019142280.

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Section: Discussionmentioning

confidence: 99%

“…Previous meta-analyses have focused on the utility of a single hs-cTn test at ED presentation to rule out AMI 17–22. The diagnostic accuracy of the 0/1 hour delta change of hs-cTn, which is central to the ESC algorithm, has not been evaluated.…”

Section: Introductionmentioning

confidence: 99%

Safety and efficacy of the European Society of Cardiology 0/1-hour algorithm for diagnosis of myocardial infarction: systematic review and meta-analysis

Chiang

Lee

et al. 2020

Heart

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“…1,2 Undetectable high-sensitivity troponin in combination with clinical assessment for risk stratification of patients with chest pain and normal troponin at hospital arrival Several algorithms based on hs-cTn have been derived for rapid rule-out of acute coronary syndrome. 3 They provide valuable though not completely optimal support. 4 Among algorithms, undetectable (below the limit of detection; LoD) concentrations of hs-cTn at arrival is the simplest, since it could allow a rapid discharge after a single hs-cTnT determination.…”

Section: Introductionmentioning

confidence: 99%

Undetectable high-sensitivity troponin in combination with clinical assessment for risk stratification of patients with chest pain and normal troponin at hospital arrival

Sanchís

Valero

Barba

et al. 2020

European Heart Journal. Acute Cardiovascular Care

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Background Undetectable high-sensitivity cardiac troponin (hs-cTn) in a single determination upon admission may rule out acute coronary syndrome. We investigated undetectable hs-cTnT (<detection limit; <5 ng/l) together with clinical risk scores (GRACE, TIMI, HEART and a previously published simple score), for one-year outcomes in patients with chest pain and normal hs-cTnT (<99th percentile; <14 ng/l) upon admission. Methods This study was a retrospective design involving 2254 consecutive patients (July 2016–November 2017). The primary endpoint was one-year death or acute myocardial infarction; the secondary endpoint added unstable angina requiring revascularization. Early (<90 minutes since pain onset, n = 661) and late ( n = 1593) presenters were separately considered. Results A total of 56 (2.5%) patients reached the primary endpoint and 91 (4%) the secondary endpoint. Undetectable hs-cTnT had a poor C-statistic in early and late presenters (0.648 and 0.703, respectively). Adding hs-cTnT measurable concentrations above the detection limit (as continuous variable) significantly enhanced the C-statistics (0.754 and 0.847, respectively). Addition of the HEART (0.809, p = 0.005) or simple clinical scores (0.804, p = 0.02) further improved the model and significantly reclassified patient risk, in early presenters. The results were similar for the secondary endpoint. The TIMI risk score performed worse and the GRACE score did not give additional information. In late presenters, no clinical score provided significant additional information over hs-cTnT. Conclusions Diagnostic algorithms should consider not only whether hs-cTnT is above or below the detection limit but also its concentration if above, for risk stratification over one year in patients with initial normal hs-cTnT. The clinical scores provide valuable additional information in early presenters.

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“…[5][6][7][8][9] The advent of high-sensitivity cardiac troponin assays has allowed for the development of several triage algorithms that can rapidly rule-out or rule-in suspected non-ST-segment elevation myocardial infarction (NSTEMI) during the index ED visit. [10][11][12][13][14][15][16][17][18] The 0/1-hour (0/1-h) algorithm uses high-sensitivity cardiac troponin T (hs-cTnT) concentrations at presentation and its absolute changes within the first hour to "rule-in" and "rule-out" suspected NSTEMIs and is recommended by the European Society of Cardiology (ESC) with a Class I recommendation. 19 The HEART score is a scoring system designed to aid in the risk stratification of patients with undifferentiated chest pain.…”

Section: Introductionmentioning

confidence: 99%

The HEART score in the era of the European Society of Cardiology 0/1-hour algorithm

Cortés

Haseeb

Lambardi

et al. 2019

European Heart Journal: Acute Cardiovascular Care

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Background: The European Society of Cardiology’s 0/1-hour algorithm improves the early triage of patients towards “rule-out” or “rule-in” of non-ST-segment elevation myocardial infarction. The HEART score is a risk stratification tool for patients with undifferentiated chest pain. We sought to evaluate the performance of the European Society of Cardiology 0/1-hour algorithm and the HEART score to evaluate chest pain patients in the emergency department. Methods: In this prospective study, we applied the European Society of Cardiology 0/1-hour algorithm and the HEART score in 1355 consecutive patients who presented to the emergency department with symptoms suggestive of acute coronary syndrome without ST-segment elevation. Patients were followed for non-ST-segment elevation myocardial infarctions and major adverse cardiac events at 30 days: death, non-ST-segment elevation myocardial infarction, or unplanned coronary revascularization. Results: The European Society of Cardiology 0/1-hour algorithm classified 921 (68.0%) patients as “rule-out” and the HEART score classified 686 (50.6%) patients as “low-risk”. The 30-day incidence of non-ST-segment elevation myocardial infarctions was 0.32% in the European Society of Cardiology 0/1-hour algorithm “rule-out” patients versus 0.29% in the HEART score “low-risk” patients ( p=0.75). The rate of major adverse cardiac events was 7.7% in the European Society of Cardiology 0/1-hour algorithm “rule-out” patients versus 1.1% in the HEART score “low-risk” patients ( p<0.001). Conclusion: The European Society of Cardiology 0/1-hour algorithm identified more patients with low risk of non-ST-segment elevation myocardial infarctions at 30 days whereas for major adverse cardiac events, the HEART score had a greater capacity to detect low-risk patients.

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Serial high-sensitivity cardiac troponin T measurements to rule out acute myocardial infarction and a single high baseline measurement for swift rule-in: A systematic review and meta-analysis

Cited by 24 publications

References 54 publications

Safety and efficacy of the European Society of Cardiology 0/1-hour algorithm for diagnosis of myocardial infarction: systematic review and meta-analysis

Safety and efficacy of the European Society of Cardiology 0/1-hour algorithm for diagnosis of myocardial infarction: systematic review and meta-analysis

Undetectable high-sensitivity troponin in combination with clinical assessment for risk stratification of patients with chest pain and normal troponin at hospital arrival

The HEART score in the era of the European Society of Cardiology 0/1-hour algorithm

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