Meta-analysis of ischemia-modified albumin to rule out acute coronary syndromes in the emergency department

Abstract Background The European Society of Cardiology (ESC) 0/1-hour algorithm has been recommended for early rule-out and rule-in of non ST-segment elevation acute coronary syndromes. This algorithm has primarily been validated in Europe, America, and Australasia, with less knowledge of its performance outside of these settings. Purpose We aim to conduct a systematic review and meta-analysis to evaluate the performance of the ESC 0/1-hour algorithm across different contexts. Methods We 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. Results A total of 11,014 patients from 10 cohorts were included in this meta-analysis. The algorithm based on hs-cTnT (Roche), hs-cTnI (Abbott), and hs-cTnI (Siemens) had pooled sensitivity of 98.4% [95% CI=95.1%-99.5%], 98.1% [95% CI=94.6%-99.3%], and 98.7% [95% CI=97.3%-99.3%], respectively. The algorithm based on hs-cTnT (Roche) and hs-cTnI (Siemens) had pooled specificity of 91.2% [95% CI=86.0%-94.6%] and 95.9% [95% CI=94.1%-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%-0.4%] and 0.8% [95% CI=0.5%-1.2%], respectively. Among patients in the observation zone, the pooled mortality rate was 0.7% [95% CI=0.3%-1.2%] at 30-days but increased to 8.1% [95% CI=6.1%-10.4%] at 1-year, comparable to the mortality rate in the rule-in group. Conclusion Our results support the use of the 0/1-hour algorithm to triage patients with suspected non-ST segment elevation acute coronary syndromes. However, the algorithm may not be sufficiently safe if the 1% miss-rate for myocardial infarction is desired. Patients in the observation zone have a poor prognosis and management strategies for these patients are urgently needed. Performance of the 0/1-hour algorithm Funding Acknowledgement Type of funding source: Public Institution(s). Main funding source(s): Ministry of Science and Technology, R.O.C

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Comparison of four decision aids for the early diagnosis of acute coronary syndromes in the emergency department

Emergency Medicine Journal ◽

10.1136/emermed-2019-208898 ◽

2019 ◽

Vol 37 (1) ◽

pp. 8-13 ◽

Cited By ~ 5

Author(s):

Richard Body ◽

Niall Morris ◽

Charles Reynard ◽

Paul O Collinson

Keyword(s):

Myocardial Infarction ◽

Emergency Department ◽

Early Diagnosis ◽

Diagnostic Accuracy ◽

Predictive Value ◽

Cardiac Troponin ◽

Acute Coronary Syndromes ◽

Decision Aids ◽

Coronary Syndromes ◽

Rule Out

ObjectivesTo directly compare the diagnostic accuracy of four decision aids (Troponin-only Manchester Acute Coronary Syndromes (T-MACS), History, ECG, Age, Risk factors and Troponin (HEART), Thrombolysis in Myocardial Infarction (TIMI) and Emergency Department Assessment of Chest Pain (EDACS)) used to expedite the early diagnosis of acute coronary syndromes (ACS) in the ED.MethodsWe prospectively included patients who presented to 14 EDs in England (February 2015 to June 2017) with suspected ACS within 12 hours of symptom onset. Data to enable evaluation of the T-MACS, HEART, TIMI and EDACS decision aids (without recalibration) were prospectively collected, blinded to patient outcome. We tested admission blood samples for high-sensitivity cardiac troponin I (hs-cTnI; Siemens ADVIA Centaur). Patients also underwent serial cardiac troponin testing over 3–12 hours. The target condition was an adjudicated diagnosis of acute myocardial infarction (AMI). We also evaluated the incidence of major adverse cardiac events (including death, AMI or coronary revascularisation) at 30 days. Diagnostic accuracy of each decision aid and hs-cTnI alone (using the limit of quantification cut-off, 3 ng/L) was evaluated by calculating sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV).ResultsOf 999 included patients, 132 (13.2%) had AMI. C-statistics were 0.96 for T-MACS, 0.78 for HEART and 0.69 for TIMI. The sensitivities of T-MACS, HEART, TIMI, EDACS and hs-cTnI <3 ng/L for AMI were 99.2% (95% CI 95.7% to 100.0%), 91.8% (85.0% to 96.2%), 97.5% (92.9% to 99.5%), 96.2% (92.2% to 99.4%) and 99.2% (95.9% to 100.0%), respectively. The respective strategies would have ruled out 46.5%, 34.9%, 19.4%, 48.3% and 28.8% patients. PPVs for the decision aids that identify ‘high-risk’ patients were 80.4% (T-MACS), 51.9% (TIMI) and 37.2% (HEART).ConclusionsIn this study, T-MACS could rule out AMI in 46.5% patients with 99.2% sensitivity. EDACS could rule out AMI in 48.3% patients with lower sensitivity, although the difference was not statistically significant. The HEART and TIMI scores had lower diagnostic accuracy.

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Is there Sex-related Outcome Difference According to oral P2Y12 Inhibitors in Patients with Acute Coronary Syndromes? A Systematic Review and Meta-Analysis of 107,126 Patients

Current Vascular Pharmacology ◽

10.2174/1570161116666180123092054 ◽

2019 ◽

Vol 17 (2) ◽

pp. 191-203

Author(s):

Oliver Brown ◽

Jennifer Rossington ◽

Gill Louise Buchanan ◽

Giuseppe Patti ◽

Angela Hoye

Keyword(s):

Systematic Review ◽

Acute Coronary Syndromes ◽

Meta Analysis ◽

Indirect Comparison ◽

Bleeding Risk ◽

Cardiovascular Death ◽

P2y12 Inhibitors ◽

Significant Difference ◽

Coronary Syndromes ◽

Randomised Controlled

Background and Objectives: The majority of patients included in trials of anti-platelet therapy are male. This systematic review and meta-analysis aimed to determine whether, in addition to aspirin, P2Y12 blockade is beneficial in both women and men with acute coronary syndromes. Methods: Electronic databases were searched and nine eligible randomised controlled studies were identified that had sex-specific clinical outcomes (n=107,126 patients). Risk Ratios (RR) and 95% Confidence Intervals (CI) were calculated for a composite of cardiovascular death, myocardial infarction or stroke (MACE), and a safety endpoint of major bleeding for each sex. Indirect comparison analysis was performed to statistically compare ticagrelor against prasugrel. Results: Compared to aspirin alone, clopidogrel reduced MACE in men (RR, 0.79; 95% CI, 0.68 to 0.92; p=0.003), but was not statistically significant in women (RR, 0.88; 95% CI, 0.75 to 1.02, p=0.08). Clopidogrel therapy significantly increased bleeding in women but not men. Compared to clopidogrel, prasugrel was beneficial in men (RR, 0.84; 95% CI, 0.73 to 0.97; p=0.02) but not statistically significant in women (RR, 0.94; 95% CI, 0.83 to 1.06; p=0.30); ticagrelor reduced MACE in both men (RR, 0.85; 95% CI, 0.77 to 0.94; p=0.001) and women (RR, 0.84; 95% CI, 0.73 to 0.97; p=0.02). Indirect comparison demonstrated no significant difference between ticagrelor and prasugrel in either sex. Compared to clopidogrel, ticagrelor and prasugrel increased bleeding risk in both women and men. Conclusion: In summary, in comparison to monotherapy with aspirin, P2Y12 inhibitors reduce MACE in women and men. Ticagrelor was shown to be superior to clopidogrel in both sexes. Prasugrel showed a statistically significant benefit only in men; however indirect comparison did not demonstrate superiority of ticagrelor over prasugrel in women.

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