The utility of presentation and 4-hour high sensitivity troponin I to rule-out acute myocardial infarction in the emergency department

Abstract AIMS Serial measurements of high-sensitivity troponin are used to rule out acute myocardial infarction (AMI) with an assay specific cutoff at the 99th percentile. Here, we evaluated the performance of a single admission troponin with a lower cutoff combined with a low risk electrocardiogram (ECG) to rule out AMI. METHODS Troponin I measured with a high-sensitivity assay (hs-TnI) was determined at admission in 1040 patients presenting with suspected AMI (BACC study). To rule out AMI we calculated the negative predictive value (NPV) utilizing the optimal hs-TnI cutoff combined with a low risk ECG. The results were validated in 3566 patients with suspected AMI [2-h Accelerated Diagnostic Protocol to Assess Patients With Chest Pain Symptoms Using Contemporary Troponins as the Only Biomarker (ADAPT) studies]. Patients were followed for 6 or 12 months. RESULTS 184 of all patients were diagnosed with AMI. An hs-TnI cutoff of 3 ng/L resulted in a NPV of 99.3% (CI 97.3–100.0), ruling out 35% of all non-AMI patients. Adding the information of a low risk ECG resulted in a 100% (CI 97.5–100.0) NPV (28% ruled out). The 2 validation cohorts replicated the high NPV of this approach. The follow-up mortality in the ruled out population was low (0 deaths in BACC and Stenocardia, 1 death in ADAPT). CONCLUSIONS A single hs-TnI measurement on admission combined with a low risk ECG appears to rule out AMI safely without need for serial troponin testing. Trial Registration: www.clinicaltrials.gov (NCT02355457).

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LO61: Test characteristics of high sensitivity troponin T performed at emergency department arrival for acute myocardial infarction in patients with reduced kidney function

CJEM ◽

10.1017/cem.2018.123 ◽

2018 ◽

Vol 20 (S1) ◽

pp. S28-S28

Author(s):

A. D. McRae ◽

S. Vatanpour ◽

J. Ji ◽

H. Yang ◽

D. Southern ◽

...

Keyword(s):

Myocardial Infarction ◽

Acute Myocardial Infarction ◽

Emergency Department ◽

Chest Pain ◽

Troponin T ◽

High Sensitivity ◽

Test Characteristics ◽

High Sensitivity Troponin ◽

High Sensitivity Troponin T ◽

Rule Out

Introduction: Patients with chronic kidney disease (CKD) are at high risk of cardiovascular events, and have worse outcomes following acute myocardial infarction (AMI). Cardiac troponin is often elevated in CKD, making the diagnosis of AMI challenging in this population. We sought to quantify test characteristics for AMI of a high-sensitivity troponin T (hsTnT) assay performed at emergency department (ED) arrival in CKD patients with chest pain, and to derive rule-out cutoffs specific to patient subgroups stratified by estimated glomerular filtration rate (eGFR). We also quantified the sensitivity and classification performance of the assays limit of detection (5 ng/L) and the FDA-approved limit of quantitation (6 ng/L) for ruling out AMI at ED arrival. Methods: Consecutive patients in four urban EDs from the 2013 calendar year with suspected cardiac chest pain who had a Roche Elecsys hsTnT assay performed on arrival were included f. This analysis was restricted to patients with an eGFR< 60 ml/min/1.73m2. The primary outcome was 7-day AMI. Secondary outcomes included major adverse cardiac events (death, AMI and revascularization). Test characteristics were calculated and ROC curves were generated for eGFR subgroups. Results: 1416 patients were included. 7-day AMI incidence was 10.1%. 73% of patients had an initial hsTnT concentration greater than the assays 99th percentile (14 ng/L). TCurrently accepted cutoffs to rule out MI at ED arrival ( 5 ng/L and 6 ng/L) had 100% sensitivity for AMI, but no patients with an eGFR less than 30 ml/min/1.73M had hsTnT concentrations below these thresholds. We derived eGFR-adjusted cutoffs to rule out MI with sensitivity >98% at ED arrival, which were able to rule out 6-42% of patients, depending on eGFR category. The proportion of patients able to be accurately ruled-in with a single hsTnT assay was substantially lower among patients with an eGFR <30 ml/min/1.73m2 (6-20% vs 25-43%). We also derived eGFR-adjusted cutoffs to rule-in AMI with specificity >90%, which accurately ruled-in up to 18% of patients. Conclusion: Cutoffs achieving acceptable diagnostic performance for AMI using single hsTnT sampling on ED arrival may have limited clinical utility, particularly among patients with very low eGFR. The ideal diagnostic strategy for AMI in patients with CKD likely involves serial high-sensitivity troponin testing with diagnostic thresholds customized to different eGFR categories.

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PCV43 High Sensitivity Troponin POINT of Care Testing for Cost-Effective EARLY Rule out of ACUTE Myocardial Infarction within the Emergency Department: An EARLY Economic Evaluation

Value in Health ◽

10.1016/j.jval.2020.08.534 ◽

2020 ◽

Vol 23 ◽

pp. S494

Author(s):

M. Bajre ◽

J. Hart ◽

A. Stainthorpe

Keyword(s):

Myocardial Infarction ◽

Acute Myocardial Infarction ◽

Emergency Department ◽

Economic Evaluation ◽

Point Of Care ◽

High Sensitivity ◽

Cost Effective ◽

Point Of Care Testing ◽

High Sensitivity Troponin ◽

Rule Out

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Single test rule-out of acute myocardial infarction using the limit of detection of a new high-sensitivity troponin I assay

Clinical Biochemistry ◽

10.1016/j.clinbiochem.2020.02.014 ◽

2020 ◽

Vol 78 ◽

pp. 4-9

Author(s):

Richard Body ◽

Niall Morris ◽

Paul Collinson

Keyword(s):

Myocardial Infarction ◽

Acute Myocardial Infarction ◽

Troponin I ◽

Limit Of Detection ◽

High Sensitivity ◽

Single Test ◽

High Sensitivity Troponin ◽

Rule Out

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Combining presentation high-sensitivity cardiac troponin I and glucose measurements to rule-out an acute myocardial infarction in patients presenting to emergency department with chest pain

Clinical Biochemistry ◽

10.1016/j.clinbiochem.2014.11.019 ◽

2015 ◽

Vol 48 (4-5) ◽

pp. 288-291 ◽

Cited By ~ 6

Author(s):

J.H. Greenslade ◽

P. Kavsak ◽

W. Parsonage ◽

C. Shortt ◽

M. Than ◽

...

Keyword(s):

Myocardial Infarction ◽

Acute Myocardial Infarction ◽

Emergency Department ◽

Chest Pain ◽

Cardiac Troponin ◽

Troponin I ◽

High Sensitivity ◽

Cardiac Troponin I ◽

Rule Out

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Faculty Opinions recommendation of One-hour rule-in and rule-out of acute myocardial infarction using high-sensitivity cardiac troponin I.

Faculty Opinions – Post-Publication Peer Review of the Biomedical Literature ◽

10.3410/f.725420089.793507697 ◽

2015 ◽

Author(s):

Patrick Ray

Keyword(s):

Myocardial Infarction ◽

Acute Myocardial Infarction ◽

Cardiac Troponin ◽

Troponin I ◽

High Sensitivity ◽

Cardiac Troponin I ◽

Rule Out

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Acceptable Analytical Variation May Exceed High-Sensitivity Cardiac Troponin I Cutoffs in Early Rule-Out and Rule-In Acute Myocardial Infarction Algorithms

Clinical Chemistry ◽

10.1373/clinchem.2016.255448 ◽

2016 ◽

Vol 62 (6) ◽

pp. 887-889 ◽

Cited By ~ 36

Author(s):

Peter A Kavsak ◽

Andrew C Don-Wauchope ◽

Stephen A Hill ◽

Andrew Worster

Keyword(s):

Myocardial Infarction ◽

Acute Myocardial Infarction ◽

Cardiac Troponin ◽

Troponin I ◽

High Sensitivity ◽

Cardiac Troponin I ◽

Analytical Variation ◽

Rule Out

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P2673Challenging time limits: Using a single high-sensitive troponin I to rule-out acute myocardial infarction in early presenters

European Heart Journal ◽

10.1093/eurheartj/ehz748.0991 ◽

2019 ◽

Vol 40 (Supplement_1) ◽

Author(s):

C Hansen ◽

C Bang ◽

K G Lauridsen ◽

C A Frederiksen ◽

M Schmidt ◽

...

Keyword(s):

Myocardial Infarction ◽

Acute Myocardial Infarction ◽

Emergency Department ◽

Chest Pain ◽

Troponin I ◽

Regional Hospital ◽

Late Presenters ◽

Siemens Healthcare ◽

High Sensitive Troponin ◽

Rule Out

Abstract Introduction According to ESC guidelines, an acute myocardial infarction (MI) can be excluded without serial troponin measurements in patients presenting with a single high-sensitive troponin below the 99th percentile and chest pain starting >6 hours prior to admission. However, it is unclear if single-testing of high-sensitive troponin can rule-out MI in early presenters. Purpose To investigate the diagnostic performance of a single value of high-sensitive cardiac troponin I (hs-cTnI) at presentation for ruling-out MI in patients presenting with chest pain to the Emergency Department irrespective of chest pain onset. Methods We conducted a substudy of preliminary data from the RACING-MI trial. We included patients presenting with chest pain suggestive of MI to the Emergency Department of a Regional Hospital. We used the Siemens hs-cTnI (Siemens Healthcare, TNIH, Limit of detection: 2.21 ng/L) and a diagnostic cut-off value <3 ng/L to rule-out MI at presentation. Two physicians independently adjudicated the final diagnosis based on all clinical information. Patients were stratified based on time from chest pain onset to hospital admission as very early (0–3 hours), early (3–6 hours) and late presenters (>6 hours). Results We included 989 patients with available hs-cTnI results at admission. MI was confirmed in 82 (8.3%) patients. Using hs-cTnI <3 ng/L as diagnostic cut-off value at presentation, 302 (30.5%) patients without MI were classified as rule-out. Overall, the negative predictive value (NPV) for MI was 100% (95% CI 98.7–100). Based on chest pain onset, 33.8% of patients were classified as very early, 12.8% as early, and 42.7% as late presenters, with 10.7% patients with unreported/unknown onset. NPV was 100% (95% CI 96.5–100) for very early, 100% (95% CI 88.3–100) for early and 100% (95% CI 97.3–100) for late presenters. Conclusions Using a single hs-cTnI value <3ng/L as diagnostic cut-off to rule-out MI seems to be safe and to allow rapid rule-out of MI in patients presenting with chest pain to the emergency department, even in very early presenters. ClinicalTrials.gov Identifier: NCT03634384. Acknowledgement/Funding Randers Regional Hospital, A.P Møller Foundation, Boserup Foundation, Korning Foundation, Højmosegård Grant, Siemens Healthcare (TNIH assays), etc.

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