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

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.

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

2020 ◽  
Vol 6 (3) ◽  
pp. 193-198 ◽  
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 &lt; 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.

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

CJEM ◽  
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.

P2679Normal high sensitive troponin I and suspected myocardial infarction, is the rapid rule out algorythm for all?

2019 ◽  
Vol 40 (Supplement_1) ◽  
Author(s):  
E Marcusohn ◽  
D Epstein ◽  
A Roguin ◽  
R Zukermann
Keyword(s):  
Myocardial Infarction ◽  
Emergency Department ◽  
Chest Pain ◽  
Smoking History ◽  
Coronary Ct ◽  
All Cause Mortality ◽  
Group 2 ◽  
High Sensitive Troponin ◽  
Rule Out ◽  
Group 1

Abstract Introduction Since the introduction of High sensitive troponin assays, many studies showed that patients presenting to the ED with cardiac chest pain and HsTnI under 5 ng/dl have very good prognosis and extremely low risk for major cardiovascular events at follow up. These studies led to a few rapid rule out algorythms for MI according to undetectable HsTnI in first hours following admission. Purpose The aim of the study was to examine whether a maximal HsTnI under 5 ng/dl, in a hemodynamicaly stable patient, is sufficient to discharge a patient without further testing. Methods Retrospective analysis of patients admitted to the emergency depatment due to suspected myocardial infarction between February 2016 and December 2018. All patients had a HsTnI under 5 ng/dl and were either discharged home or admitted for further observation and testing. The collection of data was performed by the MDCLONE software from the electronic medical records in our medical center. Results Between February 2016 and December 2018, 10,936 patients were admitted to the emergency department due to chest pain or suspected MI. In 7925 (72%) the maximal HsTnI value was under 5 ng/dl. Group 1 included 6699 (85%) patients who did not undergo any further test and group 2 included 1226 (15%) who were admitted for further testing. Further testing included Coronary CT in 999 (81%) and Stress myocardial perfusion imaging (MPI) in 227 (19%). 11 patients underwent both tests. Out of the 999 patients examined with coronary CT, 114 (11%) needed further evaluation with coronary angiogiography and 41 required angioplasty and stening. 18 (7%) patients that were evaluated using stress MPI needed angio and 7 (3%) required stenting. Comparing the group 1 and 2, patients who went through further testing were more likely to be older, with higher prevalence of diabetes, hypertenstion, smoking history and after CABG in the past. Group 1 had 0.07%, 0.16% and 0.33% all cause mortality in 30, 90 and 360 days respectivly. Group 2 had no mortality in 30 and 90 days, and 0.25% all cause mortality in 360 days. No statistical significance was reached in all time points. There was no difference in re-admissions in the first 90 days after discharge between the groups. Conclusions Based on our data, patients admitted to the emergency department due to suspected myocardial infarction and known cardiovascular risk factors but with HsTnI under the 5 ng/dl, the use of rapid rule out algorithms may be questionable. Acknowledgement/Funding None

Role of Biochemical Markers in Detection of Myocardial Infarction

2021 ◽  
Vol 15 (11) ◽  
pp. 3346-3348
Author(s):  
Fareeha Cheema ◽  
Zahid Mahmood ◽  
Nasir Iqbal ◽  
Hassan Jamil ◽  
Saima Rubab Khan ◽  
...  
Keyword(s):  
Myocardial Infarction ◽  
Acute Myocardial Infarction ◽  
Emergency Department ◽  
Chest Pain ◽  
Cardiac Troponin ◽  
Biochemical Markers ◽  
Troponin I ◽  
Troponin T ◽  
Care Hospital ◽  
Observational Cohort

Introduction: Acute myocardial infarction causes significant mortality and morbidity. Timely conclusion permits clinicians to risk stratify their patients and select suitable treatment. Biomarkers have been utilized to help with timely decision, whereas an expanding number of novel markers have been recognized to predict result taking after an acute myocardial infarction or acute coronary disorder. This may encourage tailoring of appropriate treatment to high-risk patients. This survey focuses on an assortment of promising biomarkers which give symptomatic and prognostic data. Objective: To compare the early demonstrative efficiency of the cardiac troponin I (cTn-I) level with that of the cardiac troponin T (cTn-T) level, as well as the creatine kinase (CK), CK-MB, and myoglobin levels, for acute myocardial infarction (AMI) in patients without an initially diagnostic ECG presenting to the Emergency department within 24 hours of the onset of their symptoms. Material and Methods Study design: Prospective Observational Cohort Settings: Punjab Institute of Cardiology Duration: Six months i.e. 1st January 2020 to 30th June 2020 Data Collection procedure: A planned, observational, cohort study was performed including chest pain patients admitted to territory care hospital. Members were sequential consenting through Emergency department with chest pain and age more than 30 years. Exclusion included having symptoms >24 hours, failure to total information collection, receipt of CPR, and ST-segment elevation on the starting ECG. Estimations included levels of Trop-I, Trop- T, CK, CK-MB, and myoglobin at the time of introduction and 1, 2, 6, and 12-24 hours after presentation as well as showing ECG and clinical follow-up. The collected data was analyzed by using SPSS version 23. Results: 140 included for study out of the 200 patients, 21 (14%) were analyzed as having acute myocardial infarction after diagnostic ECG testing. The sensitivities of all 5 biochemical markers for acute myocardial infarction were poor at the time of emergency department induction. The sensitivity of Trop-T was essentially superior to that of Trop-I over the starting 2 hours (3.2-33.1), but both markers' sensitivities were low (<60%) during this time outline. The Trop-I was significantly more particular for acute myocardial infarction than was the Trop-T, but not essentially better than CK-MB or myoglobin. Likelihood proportion analysis appeared that the biochemical markers with the most elevated positive ratios for acute myocardial infarction amid the primary 2 hours taking after emergency department admission were myoglobin and CK-MB. From 6 through 24 hours, the positive probability proportions for Trop I, CK-MB, and myoglobin were predominant to those of CK and Trop-T. Conclusion: Trop-I, CK-MB, and myoglobin are essentially more particular for acute myocardial infarction than are CK and Trop-T. Myoglobin is the biochemical marker having the most elevated combination of sensitivity, specificity, and negative predictive value for acute myocardial infarction inside 2 hours of emergency department induction. Not one or the other Trop-I nor Trop-T offers significant advantages over myoglobin and CK-MB within the early less than 2 hours starting screening for acute myocardial infarction. The cardiac troponins are of advantage in recognizing acute myocardial infarction greater than 6 hours after presentation. Key words: Myocardial Infarction, CKMB, Trop t, Trop I, Myoglobin

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

2015 ◽  
Vol 48 (18) ◽  
pp. 1219-1224 ◽  
Author(s):  
John W. Pickering ◽  
Joanna M. Young ◽  
Peter George ◽  
Sally Aldous ◽  
Louise Cullen ◽  
...  
Keyword(s):  
Myocardial Infarction ◽  
Acute Myocardial Infarction ◽  
Emergency Department ◽  
Troponin I ◽  
High Sensitivity ◽  
High Sensitivity Troponin ◽  
Rule Out
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