Two-hour algorithm for triage toward rule-out and rule-in of acute myocardial infarction using high-sensitivity cardiac troponin T.
- Reichlin T Department of Cardiology, University Hospital Basel, Switzerland; Department of Internal Medicine, University Hospital Basel, Switzerland.
- Cullen L Royal Brisbane and Women's Hospital, Australia; Queensland University of Technology, Brisbane, Australia; University of Queensland, Brisbane, Australia.
- Parsonage WA Royal Brisbane and Women's Hospital, Australia; University of Queensland, Brisbane, Australia.
- Greenslade J Royal Brisbane and Women's Hospital, Australia; Queensland University of Technology, Brisbane, Australia; University of Queensland, Brisbane, Australia.
- Twerenbold R Department of Cardiology, University Hospital Basel, Switzerland; Department of Internal Medicine, University Hospital Basel, Switzerland.
- Moehring B Department of Cardiology, University Hospital Basel, Switzerland.
- Wildi K Department of Cardiology, University Hospital Basel, Switzerland.
- Mueller S Department of Cardiology, University Hospital Basel, Switzerland.
- Zellweger C Department of Cardiology, University Hospital Basel, Switzerland.
- Mosimann T Department of Cardiology, University Hospital Basel, Switzerland.
- Rubini Gimenez M Department of Cardiology, University Hospital Basel, Switzerland.
- Rentsch K Laboratory Medicine, University Hospital Basel, Switzerland.
- Osswald S Department of Cardiology, University Hospital Basel, Switzerland.
- Müller C Department of Cardiology, University Hospital Basel, Switzerland; Department of Internal Medicine, University Hospital Basel, Switzerland. Electronic address: muellerch@uhbs.ch.
- 2014-12-03
Published in:
- The American journal of medicine. - 2015
Acute myocardial infarction
Diagnostic algorithm
High-sensitive troponin
Aged
Aged, 80 and over
Algorithms
Angina Pectoris
Biomarkers
Chest Pain
Diagnosis, Differential
Early Diagnosis
Female
Humans
Kaplan-Meier Estimate
Male
Middle Aged
Myocardial Infarction
Predictive Value of Tests
Prospective Studies
Risk Factors
Sensitivity and Specificity
Time Factors
Triage
Troponin T
English
BACKGROUND
High-sensitivity cardiac troponin (hs-cTn) may allow an earlier diagnosis of acute myocardial infarction (AMI).
METHODS
We prospectively enrolled 1148 (derivation cohort) and 517 (external validation cohort) unselected patients presenting with suspected AMI to the emergency department. Final diagnosis was adjudicated by 2 independent cardiologists. Hs-cTnT was measured at presentation and after 2 hours. A diagnostic algorithm incorporating hs-cTnT values at presentation and absolute changes within the first 2 hours was derived.
RESULTS
AMI was the final diagnosis in 16% of patients in the derivation and 9.1% in the validation cohort. The 2-hour algorithm developed in the derivation cohort classified 60% of patients as "rule-out," 16% as "rule-in," and 24% in the "observational-zone." Resulting sensitivity and negative predictive value (NPV) were 99.5% and 99.9%, respectively, for rule-out, and specificity and positive predictive value (PPV) were 96% and 78%, respectively, for rule-in. Applying the 2-hour triage algorithm in the external validation cohort, 78% of patients could be classified as "rule-out," 8% as "rule-in," and 14% in the "observational-zone." Resulting sensitivity and NPV were 96% and 99.5%, respectively, for rule-out, and specificity and PPV were 99% and 85%, respectively, for rule-in. Cumulative 30-day survival rates were 100%, 98.9%, and 95.2% (P < .001), and 100%, 100%, and 95% (P < .001) in patients classified as "rule-out," "observational-zone," and "rule-in" in the 2 cohorts, respectively.
CONCLUSIONS
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.
High-sensitivity cardiac troponin (hs-cTn) may allow an earlier diagnosis of acute myocardial infarction (AMI).
METHODS
We prospectively enrolled 1148 (derivation cohort) and 517 (external validation cohort) unselected patients presenting with suspected AMI to the emergency department. Final diagnosis was adjudicated by 2 independent cardiologists. Hs-cTnT was measured at presentation and after 2 hours. A diagnostic algorithm incorporating hs-cTnT values at presentation and absolute changes within the first 2 hours was derived.
RESULTS
AMI was the final diagnosis in 16% of patients in the derivation and 9.1% in the validation cohort. The 2-hour algorithm developed in the derivation cohort classified 60% of patients as "rule-out," 16% as "rule-in," and 24% in the "observational-zone." Resulting sensitivity and negative predictive value (NPV) were 99.5% and 99.9%, respectively, for rule-out, and specificity and positive predictive value (PPV) were 96% and 78%, respectively, for rule-in. Applying the 2-hour triage algorithm in the external validation cohort, 78% of patients could be classified as "rule-out," 8% as "rule-in," and 14% in the "observational-zone." Resulting sensitivity and NPV were 96% and 99.5%, respectively, for rule-out, and specificity and PPV were 99% and 85%, respectively, for rule-in. Cumulative 30-day survival rates were 100%, 98.9%, and 95.2% (P < .001), and 100%, 100%, and 95% (P < .001) in patients classified as "rule-out," "observational-zone," and "rule-in" in the 2 cohorts, respectively.
CONCLUSIONS
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.
- Language
-
- English
- Open access status
- green
- Identifiers
-
- DOI 10.1016/j.amjmed.2014.10.032
- PMID 25446294
- Persistent URL
- https://sonar.ch/global/documents/90310
Statistics
Document views: 27
File downloads:
- fulltext.pdf: 0