Validation of High-Sensitivity Troponin I in a 2-Hour Diagnostic Strategy to Assess 30-Day Outcomes in Emergency Department Patients With Possible Acute Coronary Syndrome

Abstract

An early-discharge strategy using an hs-TnI assay and TIMI score ≤ 1 had similar safety as previously reported, with the potential to decrease the observation periods and admissions for approximately 40% of patients with suspected ACS. (Advantageous Predictors of Acute Coronary Syndromes Evaluation [APACE] Study, NCT00470587; A 2 hr Accelerated Diagnostic Protocol to Assess patients with chest Pain symptoms using contemporary Troponins as the only biomarker [ADAPT]: a prospective observational validation study, ACTRN12611001069943).

Prospective validation of a 1-hour algorithm to rule-out and rule-in acute myocardial infarction using a high-sensitivity cardiac troponin T assay

“…Thereby, the high-sensitivity cardiac troponin T 1-hour algorithm was even more effective in the early triage of patients with acute chest pain than, for example, the recently developed accelerated diagnostic protocol combining the Thrombolysis in Myocardial Infarction Score with high-sensitivity cardiac troponin levels at baseline and 2 hours, or the dual-marker approach combining high-sensitivity cardiac troponin with copeptin, which assign 20%-40% of patients for rapid rule-out. [20][21][22][23][24][25][26][27] This difference is at least partly explained by the fact that the latter approaches exclusively select patients for rule-out, but do not provide guidance for rule-in.…”

Opinion paper on utility of point-of-care biomarkers in the emergency department pathways decision making

“…In fact, the landmark ASPECT study, which used an accelerated POCT protocol in 3582 suspected acute coronary syndrome (ACS) patients, reported that only 9.8% could be safely discharged 2 h after presentation [16]. In contrast, the ADAPT/APACE studies, which investigated the utility of a slower central laboratory assay albeit with a higher sensitivity to troponin in 2044 patients, showed that this platform resulted in 41.5% of patients being discharged from the ED early [17]. Therefore, there is a need for improved sensitivity with POCT assays.…”

“…As tested by Cullen et al in their validation study, a possible solution of this problem could be to perform a rapid POCT and a higher sensitivity but slower central laboratory cTn assay simultaneously. A positive cTn result from the rapid POCT leads to immediate hospitalization, whereas an undetectable reading (as occurs in nearly 90% of patients [17]), results in the patient being admitted to the chest pain unit (CPU) for higher sensitivity central laboratory cTn testing. This approach allows a rapid diagnosis in the acute MI patient, and facilitates prompt referral for follow-up analysis when the POCT assay is inconclusive.…”

“…However, the situation may change with the introduction of high-sensitivity POCT as high-sensitive troponin tests have been shown to effectively rule out acute MI in as little as 2 h [16,17], meaning that more than 40% of patients reporting chest pain can be immediately discharged from the ED. Moreover, for patients at high risk of ACS a myocardial perfusion evaluation should be performed on the same day rather than waiting for the 6 h of serial marker evaluation [17].…”

“…Moreover, for patients at high risk of ACS a myocardial perfusion evaluation should be performed on the same day rather than waiting for the 6 h of serial marker evaluation [17].…”