The introduction of high-sensitivity cardiac troponin (hs-cTn) assays has improved the early assessment of chest pain patients. A number of hs-cTn-based algorithms and accelerated diagnostic ...protocols (ADPs) have been developed and tested subsequently. In this review, we summarize the data on the performance and clinical utility of these strategies.
We reviewed studies investigating the diagnostic and prognostic performance of hs-cTn algorithms level of detection (LoD) strategy, 0/1-h, 0/2-h, and 0/3-h algorithms) and of hs-cTn-based ADPs, together with the implications of these strategies when implemented as clinical routine. The LoD strategy, when combined with a nonischemic electrocardiogram, is best suited for safe rule-out of myocardial infarction and the identification of patients eligible for early discharge from the emergency department. The 0/1-h algorithms appear to identify most patients as being eligible for rule-out. The hs-cTn-based ADPs mainly focus on prognostic assessment, which is in contrast with the hs-cTn algorithms. They identify smaller proportions of rule-out patients, but there is increasing evidence from prospective studies on their successful clinical implementation. Such information is currently lacking for hs-cTn algorithms.
There is a trade-off between safety and efficacy for different hs-cTn-based strategies. This trade-off should be considered for the intended strategy, along with its user-friendliness and evidence from clinical implementation studies. However, several gaps in knowledge remain. At present, we suggest the use of an ADP in conjunction with serial hs-cTn results to optimize the early assessment of chest pain patients.
We evaluate whether a combination of a 1-hour high-sensitivity cardiac troponin algorithm and History, ECG, Age, Risk Factors, and Troponin (HEART) score reduces admission rate (primary outcome) and ...affects time to discharge, health care–related costs, and 30-day outcome (secondary outcomes) in patients with symptoms suggestive of an acute coronary syndrome.
This prospective observational multicenter study was conducted before (2013 to 2014) and after (2015 to 2016) implementation of a strategy including level of high-sensitivity cardiac troponin T or I at 0 and 1 hour, combined with the HEART score. Patients with a nonelevated baseline high-sensitivity cardiac troponin level, a 1-hour change in high-sensitivity cardiac troponin T level less than 3 ng/L, or high-sensitivity cardiac troponin I level less than 6 ng/L and a HEART score less than or equal to 3 were considered to be ruled out of having acute coronary syndrome. A logistic regression analysis was performed to adjust for differences in baseline characteristics.
A total of 1,233 patients were included at 6 centers. There were no differences in regard to median age (64 versus 63 years) and proportion of men (57% versus 54%) between the periods. After introduction of the new strategy, the admission rate decreased from 59% to 33% (risk ratio 0.55 95% confidence interval {CI} 0.48 to 0.63; odds ratio 0.33 95% CI 0.26 to 0.42; adjusted odds ratio 0.33 95% CI 0.25 to 0.42). The median hospital stay was reduced from 23.2 to 4.7 hours (95% CI of difference –20.4 to –11.4); median health care–related costs, from $1,748 to $1,079 (95% CI of difference –$953 to –$391). The number of clinical events was very low.
In this before-after study, clinical implementation of a 1-hour high-sensitivity cardiac troponin algorithm combined with the HEART score was associated with a reduction in admission rate and health care burden, with very low rates of adverse clinical events.
To derive and validate a hybrid algorithm for rule-out and rule-in of acute myocardial infarction based on measurements at presentation and after 2 hours with a novel cardiac troponin I (cTnI) assay.
...The algorithm was derived and validated in two cohorts (605 and 592 patients) from multicentre studies enrolling chest pain patients presenting to the emergency department (ED) with onset of last episode within 12 hours. The index diagnosis and cardiovascular events up to 30 days were adjudicated by independent reviewers.
In the validation cohort, 32.6% of the patients were ruled out on ED presentation, 6.1% were ruled in and 61.3% remained undetermined. A further 22% could be ruled out and 9.8% ruled in, after 2 hours. In total, 54.6% of the patients were ruled out with a negative predictive value (NPV) of 99.4% (95% CI 97.8% to 99.9%) and a sensitivity of 97.7% (95% CI 91.9% to 99.7%); 15.8% were ruled in with a positive predictive value (PPV) of 74.5% (95% CI 64.8% to 82.2%) and a specificity of 95.2% (95% CI 93.0% to 96.9%); and 29.6% remained undetermined after 2 hours. No patient in the rule-out group died during the 30-day follow-up in the two cohorts.
This novel two-step algorithm based on cTnI measurements enabled just over a third of the patients with acute chest pain to be ruled in or ruled out already at presentation and an additional third after 2 hours. This strategy maximises the speed of rule-out and rule-in while maintaining a high NPV and PPV, respectively.
BackgroundPatients with rheumatoid arthritis (RA) are, on average, at increased risk of acute coronary syndrome (ACS) compared to the general population, but it remains unknown whether RA remains an ...ACS risk factor also in settings where the ACS risk is already high elevated, such as among individuals presenting to the emergency department (ED) with chest pain.Methods and resultsWe included 49 283 individuals (514 (1.0%) had RA) presenting with chest pain at the four hospital EDs in Stockholm, Sweden, 2013–2016 in a cohort study. Information on exposure (RA), outcome (ACS) and comorbidities was provided through national registers. The association between RA and ACS was assessed, overall and by levels of high-sensitivity cardiac troponin T (hs-cTnT) and number of ACS risk factors, using logistic regression models adjusted for age, sex, hospital, calendar year and cardiovascular risk factors. ACS was more common in patients with (8.2%) than without (4.6%) RA, adjusted OR =1.4, 95% CI 1.0 to 2.0. This association was particularly strong in individuals with initial hs-cTnT levels between 5 and 14 ng/L, or no additional ACS risk factors (adjusted ORs above 2), but no longer detectable in those with hs-cTnT >14 ng/L or with three or more additional ACS risk factors.ConclusionRA is a risk factor for ACS also among patients at the ED with chest pain. This association is not explained by traditional ACS risk factors, and most pronounced in patients with normal hs-cTnT and few other ACS risk factors, prompting particular ACS vigilance in this RA patient group.
BACKGROUND: The introduction of high-sensitivity cardiac troponin (hs-cTn) assays has improved the early assessment of chest pain patients. A number of hs-cTn-based algorithms and accelerated ...diagnostic protocols (ADPs) have been developed and tested subsequently. In this review, we summarize the data on the performance and clinical utility of these strategies. CONTENT: We reviewed studies investigating the diagnostic and prognostic performance of hs-cTn algorithms level of detection (LoD) strategy, 0/1-h, 0/2-h, and 0/3-h algorithms) and of hs-cTn-based ADPs, together with the implications of these strategies when implemented as clinical routine. The LoD strategy, when combined with a nonischemic electrocardiogram, is best suited for safe rule-out of myocardial infarction and the identification of patients eligible for early discharge from the emergency department. The 0/1-h algorithms appear to identify most patients as being eligible for rule-out. The hs-cTn-based ADPs mainly focus on prognostic assessment, which is in contrast with the hs-cTn algorithms. They identify smaller proportions of rule-out patients, but there is increasing evidence from prospective studies on their successful clinical implementation. Such information is currently lacking for hs-cTn algorithms. CONCLUSIONS: There is a trade-off between safety and efficacy for different hs-cTn-based strategies. This trade-off should be considered for the intended strategy, along with its user-friendliness and evidence from clinical implementation studies. However, several gaps in knowledge remain. At present, we suggest the use of an ADP in conjunction with serial hs-cTn results to optimize the early assessment of chest pain patients. (C) 2018 American Association for Clinical Chemistry
The History, Electrocardiogram (ECG), Age, Risk factors and Troponin, (HEART) score is useful for early risk stratification in chest pain patients. The aim was to validate previous findings that a ...simplified score using history, ECG and troponin (HET-score) has similar ability to stratify risk.
Patients presenting with chest pain with duration of ≥10 min and an onset of last episode ≤12 h but without ST-segment elevation on ECG at 6 emergency departments were eligible for inclusion. The HEART-score and the simplified HET-score were calculated. The endpoint was a composite of myocardial infarction (MI) as index diagnosis, readmission due to new MI or death within 30 days.
HEART-score identified 32% as low risk (0-2p), 47% as intermediate risk (3-5p), and 20% as high risk (6-10p) patients. The endpoint occurred in 0.5%, 7.3% and 35.7%, respectively. HET-score identified 39%, 42% and 19% as low- (0p), intermediate- (1-2p) and high-risk (3-6p) patients, with the endpoint occurring in 0.6%, 6.2% and 43.2%, respectively.
When all variables included in the HEART-score were included in a multivariable logistic regression analysis, only History (OR, CI 95%): 2.97(2.16–4.09), ECG (1.611.14–2.28) and troponin level (5.213.91–6.95) were significantly associated with cardiovascular events. When HEART- and HET-score were compared in a ROC-analysis, HET-score had a significantly larger AUC (0.887 vs 0.853, p < 0.001).
Compared with HEART-score, HET-score is simpler and appears to have similar ability to discriminate between chest pain patients with and without cardiovascular event.
•HET-score had a similar ability as HEART score in predicting prognosis in the ED•Both among those without and with elevated troponin at presentation, HET-score had a similar ability as HEART-score to stratify individuals risk•The score variable reflecting the troponin level had the strongest association with the risk of cardiovascular event•Age and risk factors were significantly associated with a lower risk of events
Background
Characteristics and prognosis of patients admitted with strong suspicion of myocardial infarction (MI) but discharged without an MI diagnosis are not well‐described.
Objectives
To compare ...background characteristics and cardiovascular outcomes in patients discharged with or without MI diagnosis.
Methods
The DETermination of the role of Oxygen in suspected Acute Myocardial Infarction (DETO2X‐AMI) trial compared 6629 patients with strong suspicion of MI randomized to oxygen or ambient air. The main composite end‐point of this subgroup analysis was the incidence of all‐cause death, rehospitalization with MI, heart failure (HF) or stroke during a follow‐up of 2.1 years (median; range: 1–3.7 years) irrespective of randomized treatment.
Results
1619 (24%) received a non‐MI discharge diagnosis, and 5010 patients (76%) were diagnosed with MI. Groups were similar in age, but non‐MI patients were more commonly female and had more comorbidities. At thirty days, the incidence of the composite end‐point was 2.8% (45 of 1619) in non‐MI patients, compared to 5.0% (250 of 5010) in MI patients with lower incidences in all individual end‐points. However, for the long‐term follow‐up, the incidence of the composite end‐point increased in the non‐MI patients to 17.7% (286 of 1619) as compared to 16.0% (804 of 5010) in MI patients, mainly driven by a higher incidence of all‐cause death, stroke and HF.
Conclusions
Patients admitted with a strong suspicion of MI but discharged with another diagnosis had more favourable outcomes in the short‐term perspective, but from one year onwards, cardiovascular outcomes and death deteriorated to a worse long‐term prognosis.
We aimed to evaluate the diagnostic sensitivity for myocardial infarction (MI) when using an undetectable level of high-sensitivity cardiac troponin T (hs-cTnT < 5 ng/L) at presentation combined with ...a non-ischemic electrocardiogram (ECG), to rule out MI in a non-ST-segment elevation MI (NSTEMI) cohort presenting ≤2 h from symptom onset. We also aimed to compare baseline characteristics and 30-day outcome in NSTEMI patients presenting with and without hs-cTnT < 5 ng/L.
All patients admitted to five centers in Sweden 2011–2015, after the introduction of hs-cTnT, who presented ≤2 h from symptom onset and received a final diagnosis of NSTEMI, were identified through the SWEDEHEART registry. These data and data of hs-cTnT levels were verified in the hospitals' medical records. The registry provided baseline and outcome data.
Twenty-four (2.6%) of 911 NSTEMI patients presented with hs-cTnT < 5 ng/L. In patients presenting >1–≤2 h from symptom onset the sensitivity for MI when combining hs-cTnT and ECG was 99.4% (95% CI 98.4%–99.8%). In patients presenting ≤1 h, and in patients aged ≤65 years without prior MI, the sensitivity was insufficient. NSTEMI patients presenting with hs-cTnT < 5 ng/L were younger and had less often a prior MI. A total of 62.5 vs. 63.5% of the NSTEMI patients presenting with and without hs-cTnT < 5 ng/L underwent revascularization within 30 days and 4.5 and 3.2% died respectively.
Hs-cTnT < 5 ng/L at presentation combined with a non-ischemic ECG may be used to rule out MI in patients presenting as early as >1 h from symptom onset with a sufficient sensitivity.
•High-sensitivity troponin T < 5 ng/L combined with a non-ischemic ECG can rule out NSTEMI.•The rule-out algorithm may be used in the second hour from symptom onset.•Younger patients with no prior myocardial infarction should be assessed with caution.•NSTEMI patients with and without T < 5 ng/L have a similar 30-day outcome.
Background: Chest pain is one of the most common symptoms in patients presenting to the emergency department (ED). Identifying the minority of patients with an acute coronary syndrome (ACS) is a ...challenge. The introduction of high-sensitivity cardiac troponin (hs-cTn T and I) assays has radically improved the assessment. The aim of this thesis was to evaluate four methods of assessing patients presenting with suspected ACS in the era of hs-cTn.Methods and results: In Study I, we retrospectively evaluated the value of predischarge exercise ECG testing in 951 chest pain patients in whom myocardial infarction (MI) had been ruled out by means of hs-cTnT. We found no significant differences regarding death or MI between patients with a positive or a negative test, neither at 90 (n=1 1.1% vs. n=1 0.2%), nor at 365 days (n=2 2.1% vs. n=4 0.7%) of follow-up. In total, there were 9 (0.9%) deaths and 10 (1.1%) MIs within 365 days. The one-year rates of death (1.3%) and MI (0.5%) in a matched Swedish population were comparable.Study II was a retrospective evaluation of the diagnostic sensitivity of an undetectable level of hs-cTnT at presentation, with and without information from the electrocardiogram (ECG), to rule out MI in a non-ST-segment elevation MI (NSTEMI) population presenting early. Twenty-four (2.6%) of the 911 early presenting NSTEMI patients initially had an undetectable level of hs-cTnT. In patients presenting >1–≤2 hours from symptom onset, the sensitivity for MI when combining hs-cTnT and ECG was 99.4% (95% confidence interval CI 98.4%–99.8%). In patients presenting =1 hour from symptom onset and in patients aged =65 years without prior MI, the sensitivity was insufficient. NSTEMI patients presenting with an undetectable level of hs-cTnT were younger but had a similar 30-day outcome to NSTEMI patients presenting with a detectable level of hs-cTnT.In Study III, we retrospectively evaluated a one-hour hs-cTnT algorithm in 1,091 chest pain patients with a non-elevated hs-cTnT when presenting to the ED and examined early dynamic changes in hs-cTnT. Dynamic one-hour changes (Δ ≥3 ng/L) occurred in 23 patients (2.1%). Fifteen patients (65.2%) in the dynamic group were admitted, compared to 148 patients (13.9%) in the non-dynamic group (p<0.001). Four of the patients admitted (26.7%) in the dynamic and one (0.7%) in the non-dynamic group were diagnosed with an MI (p<0.001). No death or MI occurred within 30 days among those discharged from the ED.In Study IV, we evaluated the clinical effects of implementing a one-hour hs-cTnT or I algorithm combined with the HEART score in a prospective observational before-after study including 1,233 patients at six centres. The new strategy was associated with a reduction in admission rate (59% to 33%, p<0.001, adjusted odds ratio 95% CI: 0.33 0.25–0.42), median time to discharge (23.2 to 4.7 hours, p<0.001) and median health care-related costs (€1,651 to €1,019, p<0.001). The rates of death and MI were very low.Conclusions: Rapid hs-cTn algorithms improve the prognostic assessment in patients with suspected ACS, making routine admission and predischarge exercise ECG testing redundant.
Background:
The value of family history of coronary artery disease (CAD) in diagnosing acute coronary syndrome (ACS) in chest pain patients is uncertain, especially in relation to high-sensitivity ...assays for cardiac troponin T (hs-cTnT), which have improved ACS diagnostics. Our objective was to investigate the association between verified family history of CAD and ACS in chest pain patients, overall and in different strata of initial hs-cTnT.
Methods:
Data on chest pain patients visiting four emergency departments in Sweden during 2013–2016 were cross-referenced with national registers of kinship, diseases and prescriptions. Family history of early CAD was defined as the occurrence of myocardial infarction or coronary revascularization before the age of 55 years in male and 65 years in female first-degree relatives. The outcome was combined including ACS and cardiovascular death within 30 days of presentation.
Results:
Of 28,188 patients, 4.7% of patients had ACS. In total, 8.2% and 32.4% had a family history of early and ever-occurring CAD, respectively. Family history of CAD was positively associated with the outcome, independently of age, gender, cardiovascular risk factors and electrocardiogram findings. The strongest association was observed for family history of early CAD (odds ratio 1.62, 95% confidence interval 1.35–1.94). Stronger associations were observed in young patients (e.g. <65 years) and in patients with non-elevated initial hs-cTnT levels (p-value for interaction = 0.004 and 0.001, respectively).
Conclusions:
Family history of CAD is associated with ACS in chest pain patients, especially in patients of young age or with non-elevated initial hs-cTnT levels.
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