Cost-Effectiveness Of High-Sensitive Troponin Assays For The Early Rule-Out Or Diagnosis Of Acute Myocardial Infarction (Ami) In People With Acute Chest Pain: A Nice Diagnostic Assessment

BackgroundEarly diagnosis of acute myocardial infarction (AMI) can ensure quick and effective treatment but only 20% of adults with emergency admissions for chest pain have an AMI. High-sensitivity cardiac troponin (hs-cTn) assays may allow rapid rule-out of AMI and avoidance of unnecessary hospital admissions and anxiety.ObjectiveTo assess the clinical effectiveness and cost-effectiveness of hs-cTn assays for the early (within 4 hours of presentation) rule-out of AMI in adults with acute chest pain.MethodsSixteen databases, including MEDLINE and EMBASE, research registers and conference proceedings, were searched to October 2013. Study quality was assessed using QUADAS-2. The bivariate model was used to estimate summary sensitivity and specificity for meta-analyses involving four or more studies, otherwise random-effects logistic regression was used. The health-economic analysis considered the long-term costs and quality-adjusted life-years (QALYs) associated with different troponin (Tn) testing methods. The de novo model consisted of a decision tree and Markov model. A lifetime time horizon (60 years) was used.ResultsEighteen studies were included in the clinical effectiveness review. The optimum strategy, based on the Roche assay, used a limit of blank (LoB) threshold in a presentation sample to rule out AMI [negative likelihood ratio (LR–) 0.10, 95% confidence interval (CI) 0.05 to 0.18]. Patients testing positive could then have a further test at 2 hours; a result above the 99th centile on either sample and a delta (Δ) of ≥ 20% has some potential for ruling in an AMI [positive likelihood ratio (LR+) 8.42, 95% CI 6.11 to 11.60], whereas a result below the 99th centile on both samples and a Δ of < 20% can be used to rule out an AMI (LR– 0.04, 95% CI 0.02 to 0.10). The optimum strategy, based on the Abbott assay, used a limit of detection (LoD) threshold in a presentation sample to rule out AMI (LR– 0.01, 95% CI 0.00 to 0.08). Patients testing positive could then have a further test at 3 hours; a result above the 99th centile on this sample has some potential for ruling in an AMI (LR+ 10.16, 95% CI 8.38 to 12.31), whereas a result below the 99th centile can be used to rule out an AMI (LR– 0.02, 95% CI 0.01 to 0.05). In the base-case analysis, standard Tn testing was both most effective and most costly. Strategies considered cost-effective depending upon incremental cost-effectiveness ratio thresholds were Abbott 99th centile (thresholds of < £6597), Beckman 99th centile (thresholds between £6597 and £30,042), Abbott optimal strategy (LoD threshold at presentation, followed by 99th centile threshold at 3 hours) (thresholds between £30,042 and £103,194) and the standard Tn test (thresholds over £103,194). The Roche 99th centile and the Roche optimal strategy [LoB threshold at presentation followed by 99th centile threshold and/or Δ20% (compared with presentation test) at 1–3 hours] were extendedly dominated in this analysis.ConclusionsThere is some evidence to suggest that hs-CTn testing may provide an effective and cost-effective approach to early rule-out of AMI. Further research is needed to clarify optimal diagnostic thresholds and testing strategies.Study registrationThis study is registered as PROSPERO CRD42013005939.FundingThe National Institute for Health Research Health Technology Assessment programme.

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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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Heparin Neutralizing Activity in the Diagnosis of Acute Myocardial Infarction

10.1055/s-0039-1689202 ◽

1975 ◽

Author(s):

J. R. O’Brien ◽

M. D. Etherington ◽

S. Jamieson ◽

J. Sussex

Keyword(s):

Myocardial Infarction ◽

Acute Myocardial Infarction ◽

Chest Pain ◽

Acute Chest Pain ◽

Platelet Factor 4 ◽

Clotting Time ◽

Platelet Factor ◽

Neutralizing Activity ◽

Platelet Poor Plasma ◽

Activated Platelets

We have previously demonstrated that, relative to controls, patients long after myocardial infarction and patients with atherosclerosis have highly significantly shorter heparin thrombin clotting times (HTCT) using platelet poor plasma; but there was considerable overlap between the two groups.We have now studied 89 patients admitted with acute chest pain. In 54 of these a firm diagnosis of acute myocardial infarction (ac-MI) was made and the HTCT was very short (mean 12.8 sees) and in 48 it was less than 16 sees. In 34 patients, ac-MI was excluded and the diagnosis was usually “angina”; the HTCT was much longer (mean 25.1 sees) and in 32 it was over 16 sees. Thus there was almost no overlap between these two groups. It is suggested that this test should be adopted as a quick and reliable further test to establish a diagnosis of ac-MI (providing other reasons for very short HTCTs can be excluded, e.g. D. I. C., and provinding the patient’s thrombin clotting time is normal).This HTCT measures non-specific heparin neutralizing activity; nevertheless the evidence suggests that it is measuring platelet factor 4 liberated from damaged or “activated” platelets into the plasma. These findings underline the probable important contribution of platelets in ac-MI.

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Gender-Related Differences of Cardiac Troponin-I Levels in Patients with Acute Myocardial Infarction at Time of Acute Chest Pain

Journal of Pharmaceutical Research International ◽

10.9734/jpri/2021/v33i52a33576 ◽

2021 ◽

pp. 199-205

Author(s):

Mahir Abdulkadhum Khudhair Alzughaibi ◽

Ammar Waheeb Obeiad ◽

Nassar Abdalaema Abdalhadi Mera ◽

Mohammed Sadeq Hamzah Al-Ruwaiee

Keyword(s):

Myocardial Infarction ◽

Acute Myocardial Infarction ◽

Chest Pain ◽

Troponin I ◽

Statistical Significance ◽

Acute Chest Pain ◽

Blood Analysis ◽

P Value ◽

Cross Sectional ◽

Time Of Admission

Background: Cardiac Troponins-I (CTNI) are myoregulatory polypeptides that control the actin-myosin interface, considered specific to cardiomyocytes. Age and sex variances in the extent of CTNI levels have arisen a recent debatable emphasis. Existing revisions do not display a reliable clinical power of sex-specific CTNI 99th centiles, which actually might mirror procedural aspects. Nevertheless, from a biochemical viewpoint, the trends of sex-specific CTNI 99th centiles seem sensible for the ruling-in of acute myocardial infarction AMI. Vulnerable females may be missed when applying the male sex-specific threshold. This study aimed to determine whether gender differences in CTNI exist in patients with AMI presented with chest pain. Methodology: The study was a cross-sectional, single-center, included 236-patients with AMI diagnosis by cardiologists at Merjan teaching hospital during the period from April to July 2020 from patients attending the hospital for cardiac consultation complaining of acute chest pain suggestive of AMI. Blood analysis had initiated at the time of admission included serum creatinine, blood urea, R/FBS, WBCs, PCV, and serum CTNI. A p-value below 0.05 specifies statistical significance. All statistical bioanalyses had performed by IBM-SPSS, version-25 for Windows. Results: The mean age of participants was 67.5 years, the men were dominant 76.2%. The incidence of DM and hypertension were significantly high and 24.5% of the patients were current smokers. Biochemical serum analysis revealed mean creatinine, urea, sugar, and STI values were 79.8±4.2 mmol/l, 15.9±1.7 mmol/l, 10.9±0.9 mmol/l, and 7.9±0.6 ng/ml separately. Both hypertension and smoking were significantly (p-0.001) more among males compared to the females, which is not the case for the prevalence of DM. The males were heavier significantly than females (p-0.001). Almost, there was no impact of gender on most of the other study variables other than serum TNI levels, which were significantly higher among the males (p-0.001). Conclusion: In patients with AMI presented with acute chest pain, the routine of CTNI in the diagnosis of AMI is based on the patient's gender. The application of gender-dependent cutoff levels for CTNI analyses appears to be highly suggested.

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Comparison of the ability of paramedics with that of cardiologists in diagnosing ST-segment elevation acute myocardial infarction in patients with acute chest pain

The American Journal of Cardiology ◽

10.1016/s0002-9149(02)02685-1 ◽

2002 ◽

Vol 90 (9) ◽

pp. 995-998 ◽

Cited By ~ 19

Author(s):

Maria Sejersten ◽

Dwayne Young ◽

Peter Clemmensen ◽

Jonathan Lipton ◽

Debra VerSteeg ◽

...

Keyword(s):

Myocardial Infarction ◽

Acute Myocardial Infarction ◽

Chest Pain ◽

Acute Chest Pain ◽

St Segment Elevation ◽

St Segment ◽

Elevation Acute Myocardial Infarction

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The Relationship Between Chest Pain Duration and the Incidence of Acute Myocardial Infarction Among Patients With Acute Chest Pain

Critical Pathways in Cardiology ◽

10.1097/hpc.0b013e31829274ff ◽

2013 ◽

Vol 12 (3) ◽

pp. 150-153 ◽

Cited By ~ 4

Author(s):

Mahmoud C. Assaad ◽

Carlos Calle-Muller ◽

Musa Dahu ◽

Richard M. Nowak ◽

Michael P. Hudson ◽

...

Keyword(s):

Myocardial Infarction ◽

Acute Myocardial Infarction ◽

Chest Pain ◽

Acute Chest Pain ◽

Pain Duration ◽

The Relationship

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High-sensitivity troponin assays for early rule-out of acute myocardial infarction in people with acute chest pain: a systematic review and economic evaluation

Health Technology Assessment ◽

10.3310/hta25330 ◽

2021 ◽

Vol 25 (33) ◽

pp. 1-276

Author(s):

Marie Westwood ◽

Bram Ramaekers ◽

Sabine Grimm ◽

Gill Worthy ◽

Debra Fayter ◽

...

Keyword(s):

Myocardial Infarction ◽

Acute Myocardial Infarction ◽

Chest Pain ◽

Cardiac Troponin ◽

High Sensitivity ◽

Cost Effective ◽

Quality Adjusted Life Year ◽

Test Strategies ◽

Quality Adjusted Life ◽

Rule Out

Background Early diagnosis of acute myocardial infarction is important, but only 20% of emergency admissions for chest pain will actually have an acute myocardial infarction. High-sensitivity cardiac troponin assays may allow rapid rule out of myocardial infarction and avoid unnecessary hospital admissions. Objectives To assess the clinical effectiveness and cost-effectiveness of high-sensitivity cardiac troponin assays for the management of adults presenting with acute chest pain, in particular for the early rule-out of acute myocardial infarction. Methods Sixteen databases were searched up to September 2019. Review methods followed published guidelines. Studies were assessed for quality using appropriate risk-of-bias tools. The bivariate model was used to estimate summary sensitivity and specificity for meta-analyses involving four or more studies; otherwise, random-effects logistic regression was used. The health economic analysis considered the long-term costs and quality-adjusted life-years associated with different troponin testing methods. The de novo model consisted of a decision tree and a state–transition cohort model. A lifetime time horizon (of 60 years) was used. Results Thirty-seven studies (123 publications) were included in the review. The high-sensitivity cardiac troponin test strategies evaluated are defined by the combination of four factors (i.e. assay, number and timing of tests, and threshold concentration), resulting in a large number of possible combinations. Clinical opinion indicated a minimum clinically acceptable sensitivity of 97%. When considering single test strategies, only those using a threshold at or near to the limit of detection for the assay, in a sample taken at presentation, met the minimum clinically acceptable sensitivity criterion. The majority of the multiple test strategies that met this criterion comprised an initial rule-out step, based on high-sensitivity cardiac troponin levels in a sample taken on presentation and a minimum symptom duration, and a second stage for patients not meeting the initial rule-out criteria, based on presentation levels of high-sensitivity cardiac troponin and absolute change after 1, 2 or 3 hours. Two large cluster randomised controlled trials found that implementation of an early rule-out pathway for myocardial infarction reduced length of stay and rate of hospital admission without increasing cardiac events. In the base-case analysis, standard troponin testing was both the most effective and the most costly. Other testing strategies with a sensitivity of 100% (subject to uncertainty) were almost equally effective, resulting in the same life-year and quality-adjusted life-year gain at up to four decimal places. Comparisons based on the next best alternative showed that for willingness-to-pay values below £8455 per quality-adjusted life-year, the Access High Sensitivity Troponin I (Beckman Coulter, Brea, CA, USA) [(symptoms > 3 hours AND < 4 ng/l at 0 hours) OR (< 5 ng/l AND Δ < 5 ng/l at 0 to 2 hours)] would be cost-effective. For thresholds between £8455 and £20,190 per quality-adjusted life-year, the Elecsys® Troponin-T high sensitive (Roche, Basel, Switzerland) (< 12 ng/l at 0 hours AND Δ < 3 ng/l at 0 to 1 hours) would be cost-effective. For a threshold > £20,190 per quality-adjusted life-year, the Dimension Vista® High-Sensitivity Troponin I (Siemens Healthcare, Erlangen, Germany) (< 5 ng/l at 0 hours AND Δ < 2 ng/l at 0 to 1 hours) would be cost-effective. Conclusions High-sensitivity cardiac troponin testing may be cost-effective compared with standard troponin testing. Study registration This study is registered as PROSPERO CRD42019154716. Funding This project was funded by the National Institute for Health Research (NIHR) Evidence Synthesis programme and will be published in full in Health Technology Assessment; Vol. 25, No. 33. See the NIHR Journals Library website for further project information.

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Gemella Endocarditis Presenting as an ST-Segment-Elevation Myocardial Infarction

Texas Heart Institute Journal ◽

10.14503/thij-15-5170 ◽

2016 ◽

Vol 43 (3) ◽

pp. 258-260 ◽

Cited By ~ 3

Author(s):

Jonathan Winkler ◽

Sunit-Preet Chaudhry ◽

Philip H. Stockwell

Keyword(s):

Myocardial Infarction ◽

Acute Myocardial Infarction ◽

Chest Pain ◽

Cardiac Catheterization ◽

Acute Chest Pain ◽

Initial Presentation ◽

St Segment Elevation ◽

Segment Elevation Myocardial Infarction ◽

Septic Embolization ◽

St Segment

Acute myocardial infarction from septic embolization is a rare initial presentation of endocarditis. We report the case of a 67-year-old man who presented with acute chest pain, in whom emergency cardiac catheterization revealed findings that suggested coronary embolism. The patient was found to have Gemella endocarditis, with its initial presentation an embolic acute ST-segment-elevation myocardial infarction. We suggest that endocarditis be considered among the potential causes of acute myocardial infarction.

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Rapid rule out for suspected myocardial infarction: is the algorithm appropriate for all?

European Heart Journal - Quality of Care and Clinical Outcomes ◽

10.1093/ehjqcco/qcaa005 ◽

2020 ◽

Vol 6 (3) ◽

pp. 193-198 ◽

Cited By ~ 2

Author(s):

Erez Marcusohn ◽

Danny Epstein ◽

Ariel Roguin ◽

Robert Zukermann

Keyword(s):

Myocardial Infarction ◽

Chest Pain ◽

Troponin I ◽

Low Risk ◽

Risk Of Death ◽

Coronary Syndrome ◽

Risk Patients ◽

Grace Score ◽

High Sensitive Troponin ◽

Rule Out

Abstract Aims Patients presenting to the emergency department (ED) with cardiac chest pain and high-sensitive troponin I (HsTnI) less than 5 ng/L have very good prognosis and low risk for major adverse cardiovascular events. The 2015 European Society of Cardiology (ESC) guidelines for non-ST-elevation myocardial infarction (MI)/acute coronary syndrome (ACS) suggests that patients with normal high-sensitive troponin, which are free of chest pain and have a global registry of acute coronary events (GRACE) score less than 140 are eligible for discharge from the hospital for outpatient workup. Our hypothesis suggests that not all patients with GRACE score under 140 should be discharged for ambulatory tests even with undetectable HsTnI as recommended in the guidelines. Methods and results Population-based retrospective cohort study in a large tertiary care centre. The study population included all patients discharged from the hospital between 1 February 2016 and 28 February 2019 following rule out of MI. During the study period, a total of 13 800 patients were discharged from the hospital after rule out of MI. Among them, 9236 (67%) had HsTnI below 5 ng/L. A total of 7705 patients (83%) met the criteria for low (n = 7162) or moderate (n = 543) GRACE risk score. Moderate-risk patients had significantly more adverse events than low-risk patients (4.6% vs. 2.1%, P < 0.001). They are in higher risk of death (0.5% vs. 0.1%, P = 0.042), revascularization (3.9% vs. 1.8%, P = 0.0047), and readmission due to ACS (1.1% vs. 0.4%, P = 0.031). Conclusion Patients presenting to the ED with chest pain and HsTnI less than 5 ng/L and GRACE score under 140 have 2–4% adverse event in 60 days. The differences between the groups suggest using rapid rule out algorithms for only low-risk patients with GRACE score under 73.

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