scholarly journals Outcomes of patients admitted with high-sensitive cardiac troponin T levels meeting the new rule out criteria for myocardial infarction

2021 ◽  
Vol 42 (Supplement_1) ◽  
Author(s):  
B C Cohen ◽  
S C Cohen ◽  
R T Tor ◽  
S F Fuchs ◽  
R K Kornowski ◽  
...  
Keyword(s):  
Myocardial Infarction ◽  
Negative Predictive Value ◽  
Predictive Value ◽  
Cardiac Troponin ◽  
Hospital Admissions ◽  
Troponin T ◽  
Cardiac Troponin T ◽  
Exercise Tests ◽  
High Negative Predictive Value ◽  
Rule Out

Abstract Background The 2020 ESC non-ST-elevation (NSTE) acute coronary syndromes (ACS) guidelines have adopted the paradigm that patients presenting with suspected NSTE-ACS and high-sensitive cardiac troponin T (hs-cTnT) values <99th percentile in a single test or small increment within 1/2 hours have a high negative predictive value for myocardial infarction (MI). Their management remains controversial. Purpose We examined the clinical outcomes and resource utilization of suspected NSTE-ACS patients who presented with hs-cTnT values meeting the early rule out criteria, but were nevertheless admitted. Methods Our single center retrospective cohort study included 4,263 visits for suspected NSTE-ACS triaged in the Emergency Room (ER), had hs-cTnT values that met the early rule-out criteria, and were admitted (Figure 1). Routine quality control and dedicated tests proved a coefficient of variance of <10% for hs-cTnT values <99th percentile (14 ng/L). Results There were no deaths in-hospital and at 30 days. Discharge diagnosis of MI was documented in 10 patients (∼0.2%). Median ER stay and hospital stay were 6 hours and 3 days, respectively. In hospital evaluation included 844 gated cardiac CT angiography (CTA), 580 SPECT heart scans, 101 ECG-exercise tests, and 178 coronary angiography, of which 70 (∼1.6% of cohort) culminated in percutaneous/surgical intervention. Conclusion Our findings highlight the high negative predictive value for MI applying the early rule out algorithm and supports a policy of ER discharge for further evaluation, sparing unnecessary and resource-consuming hospital admissions. FUNDunding Acknowledgement Type of funding sources: None. Figure 1

scholarly journals High-sensitivity cardiac troponin T and NT-proBNP for ruling-in and ruling-out of cardiac amyloidosis

2020 ◽  
Vol 41 (Supplement_2) ◽  
Author(s):  
V Castiglione ◽  
A Aimo ◽  
C Prontera ◽  
S Masotti ◽  
V Chubuchny ◽  
...  
Keyword(s):  
Negative Predictive Value ◽  
Predictive Value ◽  
Cardiac Troponin ◽  
Cardiac Amyloidosis ◽  
Troponin T ◽  
High Sensitivity ◽  
Al Amyloidosis ◽  
Cardiac Troponin T ◽  
False Negatives ◽  
Rule Out

Abstract Background Cardiac amyloidosis (CA) is caused by the extracellular deposition of misfolded proteins into insoluble amyloid fibrils, the 2 most common forms being transthyretin (ATTR) and immunoglobulin light chain (AL) amyloidosis. Chronic elevation of cardiac troponins and natriuretic peptides is common in CA and predicts worse outcome. The diagnostic yield of biomarkers of cardiac damage for CA has been less investigated. Purpose We aimed to evaluate the ruling-in/out values for the diagnosis of CA of high-sensitivity cardiac troponin T (hs-cTnT) and of N-terminal fraction of pro-B-type natriuretic peptide (NT-proBNP). Methods We studied 275 consecutive patients referred to two tertiary Centers in Italy (n=184) and France (n=91) with the clinical suspicion of CA due to the presence of a plasma cell dyscrasia or an unexplained left ventricular (pseudo)hypertrophy. CA was confirmed by the combination of suggestive features on imaging techniques (echocardiography, cardiac magnetic resonance, diphosphonate scintigraphy) and biopsy examination. All patients underwent a full baseline characterization including hs-cTnT and NT-proBNP. Biomarkers values corresponding to a negative likelihood ratio <0.1 or a positive likelihood ratio >10 were respectively chosen as rule-out and rule-in cut-offs for CA. Results CA was confirmed in 161 (59%) patients, who had either AL amyloidosis (n=96, 60%) or ATTR amyloidosis (n=65, 40%). At time of evaluation, 97 (35%) patients (34 CA vs. 63 controls, p=0.112) were hospitalized for decompensated heart failure. Patients with CA showed higher hs-cTnT (65 ng/L [44–122] vs. 31 [18–42], p<0.001) and NT-proBNP (4260 ng/L [2006–8911] vs. 1199 [468–3357], p<0.001) than those without CA. The area under the curve (AUC) values for hs-cTnT and NT-proBNP were 0.832 and 0.744 respectively (p=0.002 for the difference). The combination of the two biomarkers (AUC=0.836) improved discrimination over NT-proBNP (p=0.004), but not over hs-cTnT (p=0.423). A hs-cTnT value <15 ng/L (sensitivity=100%, negative predictive value=100%, true negatives=13, false negatives=0) and a NT-proBNP <550 ng/L (sensitivity=98%, negative predictive value=89%, true negatives=33, false negatives=4) were selected as rule-out cut-offs. A hs-cTnT level ≥80 ng/L (specificity=96%, positive predictive value=93%, true positives=71, false positives=5) was optimal for ruling in amyloidosis, while no rule-in cut-off could be selected for NT-proBNP. hs-cTnT values of either ≥80 or <15 ng/dL could effectively rule-in/out 89 (32%) patients. Conclusions Plasma hs-cTnT and NT-proBNP have diagnostic value in patients with suspected CA. Stand-alone hs-cTnT levels <15 or ≥80 ng/L may help to exclude or confirm the diagnosis of CA in up to one third of patients undergoing a diagnostic screening for the disease. Figure 1 Funding Acknowledgement Type of funding source: None

scholarly journals Prospective validation of a 1-hour algorithm to rule-out and rule-in acute myocardial infarction using a high-sensitivity cardiac troponin T assay

2015 ◽  
Vol 187 (8) ◽  
pp. E243-E252 ◽  
Author(s):  
Tobias Reichlin ◽  
Raphael Twerenbold ◽  
Karin Wildi ◽  
Maria Rubini Gimenez ◽  
Nathalie Bergsma ◽  
...  
Keyword(s):  
Myocardial Infarction ◽  
Acute Myocardial Infarction ◽  
Cardiac Troponin ◽  
Troponin T ◽  
High Sensitivity ◽  
Cardiac Troponin T ◽  
Rule Out

scholarly journals Serial high-sensitivity cardiac troponin T measurements to rule out acute myocardial infarction and a single high baseline measurement for swift rule-in: A systematic review and meta-analysis

2019 ◽  
Vol 9 (1) ◽  
pp. 14-22 ◽  
Author(s):  
M Arslan ◽  
A Dedic ◽  
E Boersma ◽  
EA Dubois
Keyword(s):  
Myocardial Infarction ◽  
Systematic Review ◽  
Acute Myocardial Infarction ◽  
Cardiac Troponin ◽  
Troponin T ◽  
Meta Analysis ◽  
High Sensitivity ◽  
Cardiac Troponin T ◽  
Single Baseline ◽  
Rule Out

Aims: The purpose of this study was to determine (a) the ability of serial high-sensitivity cardiac troponin T measurements to rule out acute myocardial infarction and (b) the ability of a single high baseline high-sensitivity cardiac troponin T measurement to rule in acute myocardial infarction in patients presenting to the emergency department with acute chest pain. Methods and results: Embase, Medline, Cochrane, Web of Science and Google scholar were searched for prospective cohort studies that evaluated parameters of diagnostic accuracy of serial high-sensitivity cardiac troponin T to rule out acute myocardial infarction and a single baseline high-sensitivity cardiac troponin T value>50 ng/l to rule in acute myocardial infarction. The search yielded 21 studies for the systematic review, of which 14 were included in the meta-analysis, with a total of 11,929 patients and an overall prevalence of acute myocardial infarction of 13.0%. For rule-out, six studies presented the sensitivity of serial measurements <14 ng/l. This cut-off classified 60.1% of patients as rule-out and the summary sensitivity was 96.7% (95% confidence interval: 92.3–99.3). Three studies presented the sensitivity of a one-hour algorithm with a baseline high-sensitivity cardiac troponin T value<12 ng/l and delta 1 hour <3 ng/l. This algorithm classified 60.2% of patients as rule-out and the summary sensitivity was 98.9% (96.4–100). For rule-in, six studies reported the specificity of baseline high-sensitivity cardiac troponin T value>50 ng/l. The summary specificity was 94.6% (91.5–97.1). Conclusion: Serial high-sensitivity cardiac troponin T measurement strategies to rule out acute myocardial infarction perform well, and a single baseline high-sensitivity cardiac troponin T value>50 ng/l to rule in acute myocardial infarction has a high specificity.

3298Prehospital assessment of the one-hour rule-in/rule-out algorithm using a high-sensitivity cardiac troponin t assay in a low-prevalence population for acute coronary syndrome (OUT-ACS)

2019 ◽  
Vol 40 (Supplement_1) ◽  
Author(s):  
T R Johannessen ◽  
D Atar ◽  
S Halvorsen ◽  
A C Larstorp ◽  
I Mdala ◽  
...  
Keyword(s):  
Primary Care ◽  
Chest Pain ◽  
Predictive Value ◽  
Cardiac Troponin ◽  
Troponin T ◽  
High Sensitivity ◽  
Cardiac Troponin T ◽  
Emergency Setting ◽  
Coronary Syndrome ◽  
Rule Out

Abstract Background The majority of patients with chest pain in Norway initially present to the primary health care system, which serves to triage them to the specialist health care services including hospitals. In some emergency primary care institutions, patients who are not hospitalised directly undergo further diagnostic testing to rule out acute myocardial infarction (AMI). Purpose Several studies have shown the advantage of using high-sensitivity assays for fast interpretation of cardiac troponins. The majority of these studies included patient populations from hospital emergency departments. In contrast, we aimed to investigate whether the 1-hour algorithm for high-sensitivity cardiac troponin T (hs-cTnT) is safe and useful for implementation in a primary care emergency setting where the patients have a much lower pre-test probability for an acute coronary syndrome. Methods In this prospective cohort study, we included 1672 patients with acute non-specific chest pain from November 2016 to October 2018 at a primary care emergency outpatient clinic in Norway. Serial hs-cTnT samples were analysed after 0, 1 and 4 hours on the Cobas 8000 e602 analyzer. We divided the results into one of three groups (rule-out, rule-in, or further observation), according to the 0/1-hour algorithm for hs-cTn from the current ESC guidelines on non-ST-elevation myocardial infarction. In the rule-out group, the 0/1-hour results were compared to the standard 4-hour hs-cTnT. Final hospital diagnoses were collected as a gold standard for the patients in the rule-in group. Results A total of 44 (2.6%) of 1672 patients were diagnosed with AMI. By applying the algorithm, 1274 (76.2%) patients were assigned to the rule-out group. One of the rule-out patients had a significant increase in hs-cTnT in the 4-hour sample. This results in a sensitivity for AMI of 97.7% (95% confidence interval [CI] 88.0–99.9) and negative predictive value of 99.9% (95% CI 99.6–100.0). There were 50 (3.0%) patients in the rule-in group, amongst whom 35 had a verified AMI. This gives a specificity for AMI of 99.1% (95% CI 98.5–99.5) and a positive predictive value at 70.0% (95% CI 55.4–82.1). Among the 348 (20.8%) patients assigned to further observation, eight patients had an AMI. The 15 rule-in patients who did not have an AMI, had other acute illnesses that required further diagnostic work-up at the hospital. Conclusions With a negative predictive value at 99.9%, the 1-hour algorithm for hs-cTnT seems safe and applicable for a faster assessment of patients with non-specific chest pain in a primary care emergency setting. Prehospital implementation of this algorithm may reduce the need for hospitalisation of these patients and hence may probably lower the costs. ClinicalTrial.gov identifier: NCT02983123 Acknowledgement/Funding Norwegian Research Fund for General Practice, The Norwegian Physicians' Association Fund for Quality Improvement and Patient Safety

scholarly journals High-Sensitivity Cardiac Troponin T for Early Prediction of Evolving Non–ST-Segment Elevation Myocardial Infarction in Patients with Suspected Acute Coronary Syndrome and Negative Troponin Results on Admission

2010 ◽  
Vol 56 (4) ◽  
pp. 642-650 ◽  
Author(s):  
Evangelos Giannitsis ◽  
Meike Becker ◽  
Kerstin Kurz ◽  
Georg Hess ◽  
Dietmar Zdunek ◽  
...  
Keyword(s):  
Myocardial Infarction ◽  
Acute Coronary Syndrome ◽  
Unstable Angina ◽  
Predictive Value ◽  
Cardiac Troponin ◽  
Troponin T ◽  
High Sensitivity ◽  
Cardiac Troponin T ◽  
Coronary Syndrome ◽  
St Segment

Abstract Background: We sought to determine the diagnostic performance of the new high-sensitivity cardiac troponin T (hs-cTnT) assay for early detection of non–ST-segment myocardial infarction (NSTEMI) in patients with acute coronary syndrome. Methods: We enrolled patients with retrospectively confirmed unstable angina or NSTEMI and an initially negative cTnT concentration and compared the performance of baseline concentrations and serial changes in concentration within 3 and 6 h. Percentage change criteria included ≥20% δ change and ROC-optimized value. Results: Based on the standard fourth-generation cTnT result of ≥0.03 μg/L, an evolving NSTEMI was diagnosed in 26 patients, and 31 patients were classified as having unstable angina. With the use of the hs-cTnT assay at the 99th-percentile cutoff, the percentage of NSTEMI cases detected increased gradually from 61.5% on presentation to 100% within 6 h, and the overall number of MI diagnoses increased by 34.6% (35 vs 26 cases). A δ change ≥20% or ≥ROC-optimized value of &gt;117% within 3 h or ≥243% within 6 h yielded a specificity of 100% at sensitivities between 69% and 76%. The standard cTnT at the 99th percentile was less sensitive than hs-cTnT for early diagnosis of MI on presentation, and follow-up samples obtained within the initial 3 h demonstrated very low specificity of cTnT compared with hs-cTnT. Conclusions: The high-sensitivity cTnT assay increases the number of NSTEMI diagnoses and enables earlier detection of evolving NSTEMI. A doubling of the hs-cTnT concentration within 3 h in the presence of a second concentration ≥99th percentile is associated with a positive predictive value of 100% and a negative predictive value of 88%.

scholarly journals Predictive value of routine point-of-care cardiac troponin T measurement for prehospital diagnosis and risk-stratification in patients with suspected acute myocardial infarction

2017 ◽  
Vol 8 (4) ◽  
pp. 299-308 ◽  
Author(s):  
Martin B Rasmussen ◽  
Carsten Stengaard ◽  
Jacob T Sørensen ◽  
Ingunn S Riddervold ◽  
Troels M Hansen ◽  
...  
Keyword(s):  
Myocardial Infarction ◽  
Acute Myocardial Infarction ◽  
Confidence Interval ◽  
Predictive Value ◽  
Cardiac Troponin ◽  
Troponin T ◽  
Point Of Care ◽  
Hazard Ratio ◽  
Cardiac Troponin T ◽  
Suspected Acute Myocardial Infarction

Objective: The purpose of this study was to determine the predictive value of routine prehospital point-of-care cardiac troponin T measurement for diagnosis and risk stratification of patients with suspected acute myocardial infarction. Methods and results: All prehospital emergency medical service vehicles in the Central Denmark Region were equipped with a point-of-care cardiac troponin T device (Roche Cobas h232) for routine use in all patients with a suspected acute myocardial infarction. During the study period, 1 June 2012–30 November 2015, prehospital point-of-care cardiac troponin T measurements were performed in a total of 19,615 cases seen by the emergency medical service and 18,712 point-of-care cardiac troponin T measurements in 15,781 individuals were matched with an admission. A final diagnosis of acute myocardial infarction was confirmed in 2187 cases and a total of 2150 point-of-care cardiac troponin T measurements (11.0%) had a value ≥50 ng/l, including 966 with acute myocardial infarction (sensitivity: 44.2%, specificity: 92.8%). Patients presenting with a prehospital point-of-care cardiac troponin T value ≥50 ng/l had a one-year mortality of 24% compared with 4.8% in those with values <50 ng/l, log-rank: p<0.001. The following variables showed the strongest association with mortality in multivariable analysis: point-of-care cardiac troponin T≥50 ng/l (hazard ratio 2.10, 95% confidence interval: 1.90–2.33), congestive heart failure (hazard ratio 1.93, 95% confidence interval: 1.74–2.14), diabetes mellitus (hazard ratio 1.42, 95% confidence interval: 1.27–1.59) and age, one-year increase (hazard ratio 1.08, 95% confidence interval: 1.08–1.09). Conclusions: Patients with suspected acute myocardial infarction and a prehospital point-of-care cardiac troponin T ≥50 ng/l have a poor prognosis irrespective of the final diagnosis. Routine troponin measurement in the prehospital setting has a high predictive value and can be used to identify high-risk patients even before hospital arrival so that they may be re-routed directly for advanced care at an invasive centre.

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