Two-hour Algorithm for Triage Toward Rule-out and Rule-in of Acute Myocardial Infarction Using High-sensitivity Cardiac Troponin T

Reichlin, Tobias; Cullen, Louise; Parsonage, William; Greenslade, Jaimi; Twerenbold, Raphael; Moehring, Berit; Wildi, Karin; Mueller, Sandra; Zellweger, Christa; Mosimann, Tamina; Giménez, María Rubini; Rentsch, Katharina; Oßwald, Stefan; Müller, Christian

doi:10.1016/j.amjmed.2014.10.032

Cited by 126 publications

(118 citation statements)

References 42 publications

Supporting

Mentioning

109

Contrasting

Order By: Relevance

“…These data are consistent with previous studies, including those that overlap with this population, demonstrating that measurement of high-sensitivity cardiac troponin at presentation and 1-2 h later can deliver a NPV near or above 99% (11,12 ). In light of these and similar data, the 2015 European Society of Cardiology (ESC) practice guidelines for management of non-ST-elevation ACS recommend that, for hospitals using a highsensitivity cardiac troponin assay, when pain starts Ͼ6 h before presentation, a single high-sensitivity cardiac troponin below the upper reference limit, together with lowrisk clinical features, is sufficient to exclude ACS.…”

Section: Current State Of the Rapid Rule-outsupporting

confidence: 82%

In Search of the 1-Hour Rule-Out for Acute Myocardial Infarction

Scirica

Morrow

2015

Clinical Chemistry

View full text Add to dashboard Cite

Section: Current State Of the Rapid Rule-outsupporting

confidence: 82%

In Search of the 1-Hour Rule-Out for Acute Myocardial Infarction

Scirica

Morrow

2015

Clinical Chemistry

View full text Add to dashboard Cite

“…35,50,51 The lack of a relevant absolute change from presentation to 2 hours, in conjunction with the fact that both baseline and 2-hour hs-cTn concentrations are within the normal range, obviates the need to use a predefined risk score and allows one to safely rule out AMI even in patients with mild, nonspecific ECG abnormalities. This strategy allows the rapid rule-out of AMI in up to 60% of patients.…”

Section: -And 2-hour Esc Algorithmmentioning

confidence: 99%

“…This strategy allows the rapid rule-out of AMI in up to 60% of patients. 35,52 Moreover, this strategy includes a rule-in algorithm that provides a PPV of >75% for AMI and allows the early rule-in of ≈10% to 15% of patients with acute chest pain within 2 to 3 hours of presentation.…”

Section: -And 2-hour Esc Algorithmmentioning

confidence: 99%

State-of-the-Art Evaluation of Emergency Department Patients Presenting With Potential Acute Coronary Syndromes

2016

View full text Add to dashboard Cite

ABSTRACT:It is well established that clinicians cannot use clinical judgment alone to determine whether an individual patient who presents to the emergency department has an acute coronary syndrome. The history and physical examination do not distinguish sufficiently between the many conditions that can cause acute chest pain syndromes. Cardiac risk factors do not have sufficient discriminatory ability in symptomatic patients presenting to the emergency department. Most patients with non-ST-segment-elevation myocardial infarction do not present with electrocardiographic evidence of active ischemia. The improvement in cardiac troponin assays, especially in conjunction with well-validated clinical decision algorithms, now enables the clinician to rapidly exclude myocardial infarction. In patients in whom unstable angina remains a concern or there is a desire to evaluate for underlying coronary artery disease, coronary computed tomography angiography can be used in the emergency department. Once a process that took ≥24 hours, computed tomography angiography now can rapidly exclude myocardial infarction and coronary artery disease in patients in the emergency department.A bout 20 million patients present with symptoms possibly suggestive of acute coronary syndrome (ACS) to emergency departments (ED) in North America and Europe each year.1-3 Patients with ACS and acute myocardial infarction (AMI) present with a wide variety of symptoms such as chest pain, shortness of breath, weakness, nausea, vomiting, and even fatigue, making the diagnosis difficult. Demographics, cardiac risk factors, chest pain characteristics, and physical examination can assist disposition decisions but are insufficient to identify who does and does not have an ACS.4-7 Some patients may have objective evidence of a clearcut diagnosis, but the majority do not. 8 The majority ultimately will be found not to have ACS, but symptoms caused by noncardiac and often benign disorders such as musculoskeletal pain, pleuritis, or gastroesophageal reflux make the rapid rule-out of ACS more difficult and result in huge medical expenses. Safe and early rule-out of ACS contributes to more efficient and high-value healthcare delivery. History And PHysicAl ExAminAtionClinical features, alone or in combination with an ECG, are poorly predictive for AMI (Table 1). 9,10 In addition, they have variable reliability. Features classically associated with a lower probability of AMI such as pleuritic, positional, and sharp chest pain have poor to fair interphysician reliability (κ=0.27-0.44), 11 whereas high-risk features (radiation to left arm, substernal location, and history of AMI) are more reliable (κ=0.74-0.89). 11Traditional cardiac risk factors, derived from population-based longitudinal cohort studies of asymptomatic patients, are poor predictors of risk for AMI or ACS in symptomatic patients in the ED. 6,7 Similarly, the physical examination seldom is useful for distinguishing patients with ACS from patients with noncardiac chest pain.Trials of medications, onc...

show abstract

“…Given the rather low positive predictive value (PPV) of mildly increased high-sensitivity cardiac troponin concentrations for AMI (3,4,12,23 ), guidance for rule-in is of particular importance when using high-sensitivity cardiac troponin in clinical practice (24 ). Very high negative predictive value (NPV) for rule-out (Ͼ99.5%), very high efficacy of about 80%, detailed guidance for rule-in, and independent external validation are currently the unique features of the hs-cTnT 2-h algorithm (18 ). On the basis of patient flow and emergency department (ED) and laboratory logistics related to sampling at this short interval, a 2-h protocol may be preferable for many institutions.…”

mentioning

confidence: 99%

Two-Hour Algorithm for Triage toward Rule-Out and Rule-In of Acute Myocardial Infarction by Use of High-Sensitivity Cardiac Troponin I

et al. 2016

Self Cite

View full text Add to dashboard Cite

show abstract

Two-hour Algorithm for Triage Toward Rule-out and Rule-in of Acute Myocardial Infarction Using High-sensitivity Cardiac Troponin T

Abstract: A simple algorithm incorporating hs-cTnT baseline values and absolute changes over 2 hours allowed a triage toward safe rule-out, or accurate rule-in, of AMI in the vast majority of patients, with only 20% requiring more prolonged monitoring and serial blood sampling.

Cited by 126 publications

References 42 publications

In Search of the 1-Hour Rule-Out for Acute Myocardial Infarction

In Search of the 1-Hour Rule-Out for Acute Myocardial Infarction

State-of-the-Art Evaluation of Emergency Department Patients Presenting With Potential Acute Coronary Syndromes

Two-Hour Algorithm for Triage toward Rule-Out and Rule-In of Acute Myocardial Infarction by Use of High-Sensitivity Cardiac Troponin I

Contact Info

Product

Resources

About