Diagnosis and risk stratification of acute coronary syndromes

ESC CardioMed ◽  
2018 ◽  
pp. 1232-1241
Author(s):  
Christian Mueller
Keyword(s):  
Myocardial Infarction ◽  
Emergency Department ◽  
Risk Stratification ◽  
Cardiac Troponin ◽  
Vital Signs ◽  
High Sensitivity ◽  
Coronary Syndromes ◽  
Precise Quantification ◽  
Time Required ◽  
Rule Out

Detailed clinical assessment including vital signs; physical examination; a thorough patient history including chest pain characteristics, the electrocardiogram, and high-sensitivity cardiac troponin; and cardiac imaging are the four pillars in the early diagnosis and risk stratification of patients presenting with a suspected myocardial infarction. High-sensitivity cardiac troponin assays for the first time allowed the precise quantification of cardiomyocyte injury around the 99th percentile and thereby substantially increased the accuracy of myocardial infarction detection from blood obtained at presentation to the emergency department. Higher accuracy at emergency department presentation enabled the development and extensive validation of early high-sensitivity cardiac troponin-based diagnostic algorithms, which substantially reduced the time required for the safe rule-out or rule-in of myocardial infarction. More rapid rule-out and rule-in of myocardial infarction provides substantial medical value to patients, physicians, and institutions.

Diagnosis and risk stratification of acute coronary syndromes

ESC CardioMed ◽  
2018 ◽  
pp. 1232-1241
Author(s):  
Christian Mueller
Keyword(s):  
Myocardial Infarction ◽  
Emergency Department ◽  
Risk Stratification ◽  
Cardiac Troponin ◽  
Vital Signs ◽  
High Sensitivity ◽  
Coronary Syndromes ◽  
Precise Quantification ◽  
Time Required ◽  
Rule Out

Detailed clinical assessment including vital signs; physical examination; a thorough patient history including chest pain characteristics, the 12-lead electrocardiogram, high-sensitivity cardiac troponin, and cardiac imaging are the four pillars in the early diagnosis and risk stratification of patients presenting with a suspected myocardial infarction. High-sensitivity cardiac troponin assays allow the precise quantification of cardiomyocyte injury around the 99th percentile and thereby substantially increase the accuracy of myocardial infarction detection from blood obtained at presentation to the emergency department. Higher accuracy at emergency department presentation enabled the development and extensive validation of early high-sensitivity cardiac troponin-based diagnostic algorithms, which substantially reduced the time required for the safe rule-out or rule-in of myocardial infarction. More rapid rule-out and rule-in of myocardial infarction provides substantial medical value to patients, physicians, and institutions.

scholarly journals Economic Considerations of Early Rule-In/Rule-Out Algorithms for The Diagnosis of Myocardial Infarction in The Emergency Department Using Cardiac Troponin and Glycemic Biomarkers

2017 ◽  
Vol 63 (2) ◽  
pp. 593-602 ◽  
Author(s):  
Colleen Shortt ◽  
Feng Xie ◽  
Richard Whitlock ◽  
Jinhui Ma ◽  
Natasha Clayton ◽  
...  
Keyword(s):  
Myocardial Infarction ◽  
Emergency Department ◽  
Cardiac Troponin ◽  
Troponin I ◽  
High Sensitivity ◽  
Cost Effective ◽  
Coronary Syndrome ◽  
Hb A1c ◽  
The Cost ◽  
Rule Out

Abstract BACKGROUND We have previously demonstrated the utility of a rule-in/rule-out strategy for myocardial infarction (MI) using glycemic biomarkers in combination with cardiac troponin in the emergency department (ED). Given that the cost of assessing patients with possible MI in the ED is increasing, we sought to compare the health services cost of our previously identified early rule-in/rule-out approaches for MI among patients who present to the ED with symptoms suggestive of acute coronary syndrome (ACS). METHODS We compared the cost differences between different rule-in/rule-out strategies for MI using presentation cardiac troponin I (cTnI), high-sensitivity cTnI (hs-cTnI), high-sensitivity cardiac troponin T (hs-cTnT), glucose, and/or hemoglobin A1c (Hb A1c) in 1137 ED patients (7-day MI n = 133) as per our previously defined algorithms and compared them with the European Society of Cardiology (ESC) 0-h algorithm-cutoffs. Costs associated with each decision model were obtained from site-specific sources (length of stay) and provincial sources (Ontario Case Costing Initiative). RESULTS Algorithms incorporating cardiac troponin and glucose for early rule-in/rule-out were the most cost effective and clinically safest methods (i.e., ≤1 MI missed) for early decision making, with hs-cTnI and glucose yielding lower costs compared to cTnI and glucose, despite the higher price for the hs-cTnI test. The addition of Hb A1c to the algorithms increased the cost of these algorithms but did not miss any additional patients with MI. Applying the ESC 0-h algorithm-cutoffs for hs-cTnI and hs-cTnT were the most costly. CONCLUSIONS Rule-in/rule-out algorithms incorporating presentation glucose with high-sensitivity cardiac troponin are the safest and most cost-effective options as compared to the ESC 0-h algorithm-cutoffs.

Biomarkers in acute coronary syndromes

2021 ◽  
pp. 400-408
Author(s):  
Jasper Boeddinghaus ◽  
Thomas Nestelberger ◽  
Raphael Twerenbold ◽  
Christian Mueller
Keyword(s):  
Myocardial Infarction ◽  
Heart Failure ◽  
Risk Stratification ◽  
Diagnostic Accuracy ◽  
Predictive Value ◽  
Acute Coronary Syndromes ◽  
Acute Chest Pain ◽  
High Sensitivity ◽  
Coronary Syndromes ◽  
Rule Out

Biomarkers, particularly high-sensitivity cardiac troponin T/I (hs-cTnT/I), play a major role in the early diagnosis and risk stratification of patients presenting with symptoms suggestive of an acute coronary syndrome such as acute chest pain. As heart specific markers of cardiomyocyte injury, hs-cTnT/I complement clinical assessment and the 12-lead electrocardiogram in the diagnosis of myocardial infarction, the risk stratification for life-threatening arrhythmias and death, and the triage towards early revascularization. Hs-cTnT/I allow the reliable measurement of cTnT/I concentrations around the 99th-percentile and in the normal range and increased the diagnostic accuracy for myocardial infarction at presentation. Absolute short-term changes in hs-cTnT/I within 1h or 2h further increase the diagnostic accuracy for myocardial infarction. The ESC hs-cTnT/I 0/1h-algorithms are assay-specific early triage algorithms optimized for the early rule-out and/or rule-in of myocardial infarction. They triage patients towards rule-out (about 60%), observe (about 25%), and rule-in (about 15%). Triage towards rule-out provides very high sensitivity (99%) and negative predictive value (>99%) for the safe rule-out of myocardial infarction, while triage towards rule-in provides high specificity (about 96%) and positive predictive value (about 75%) for myocardial infarction. Other biomarkers quantifying cardiomyocyte injury (e.g. CK-MB, CK, LDH, myosin-binding protein C) or other pathophysiological processes involved in acute coronary syndromes (e.g. copeptin, BNP, NT-proBNP) provide no or only very little incremental diagnostic value for myocardial infarction on top of the ESC hs-cTnT/I 0/1h-algorithms. However, the later provide incremental prognostic value for death and heart failure. Therefore, the use of BNP or NT-proBNP, as quantitative markers of hemodynamic stress and heart failure, should be considered.

scholarly journals Novel high-sensitivity cardiac troponin I assay in patients with suspected acute coronary syndrome

Heart ◽  
2018 ◽  
pp. heartjnl-2018-314093 ◽  
Author(s):  
Andrew R Chapman ◽  
Takeshi Fujisawa ◽  
Kuan Ken Lee ◽  
Jack Patrick Andrews ◽  
Atul Anand ◽  
...  
Keyword(s):  
Myocardial Infarction ◽  
Acute Coronary Syndrome ◽  
Risk Stratification ◽  
Cardiac Troponin ◽  
Cardiac Death ◽  
Troponin I ◽  
High Sensitivity ◽  
Cardiac Troponin I ◽  
Coronary Syndrome ◽  
Rule Out

BackgroundHigh-sensitivity cardiac troponin assays enable the early risk stratification of patients with suspected acute coronary syndrome to identify those at low risk of myocardial infarction or cardiac death. We evaluated the performance of a novel high-sensitivity cardiac troponin I assay in early rule out pathways.MethodsIn 1920 patients with suspected acute coronary syndrome, cardiac troponin was measured using the Siemens Atellica high-sensitivity cardiac troponin I assay (99th centile: 34 ng/L women, 53 ng/L men). We evaluated three pathways which use either low risk-stratification thresholds of cardiac troponin (High-SensitivityTroponin in the Evaluation of patients with Acute Coronary Syndrome (High-STEACS) and the European Society of Cardiology (ESC) 1 hour pathway) or the 99th centile diagnostic threshold (ESC 3 hour pathway) to rule out myocardial infarction.ResultsThe primary outcome of myocardial infarction or cardiac death at 30 days occurred in 14.4% (277/1920). The High-STEACS pathway ruled out 63% of patients (1218/1920), with five missed events for a negative predictive value (NPV) of 99.5% (95% CI (CI) 99.1% to 99.8%). Similar performance was observed for the ESC 1 hour pathway with an NPV of 99.0% (97.6% to 99.8%). In contrast, the ESC 3 hour pathway ruled out 65% of patients (1248/1920), but missed 25 events for an NPV of 98.0% (97.1% to 98.7%).ConclusionsA novel high-sensitivity cardiac troponin I assay can safely identify patients at low risk of myocardial infarction or cardiac death. Diagnostic pathways that use low cardiac troponin concentrations for risk stratification miss fewer events than those that rely on the 99th centile to rule out myocardial infarction.Trial registrationNCT1852123.

scholarly journals Use of historical high-sensitivity cardiac troponin T levels to rule out myocardial infarction

Open Heart ◽  
2021 ◽  
Vol 8 (1) ◽  
pp. e001682
Author(s):  
Andreas Roos ◽  
Martin J Holzmann
Keyword(s):  
Myocardial Infarction ◽  
Emergency Department ◽  
Chest Pain ◽  
Cardiac Troponin ◽  
Troponin T ◽  
High Sensitivity ◽  
Cardiac Troponin T ◽  
All Cause Mortality ◽  
European Society Of Cardiology ◽  
Rule Out

ObjectiveSeveral high-sensitivity cardiac troponin (hs-cTn)-based strategies exist for rule-out of myocardial infarction (MI). It is unknown whether historical hs-cTnT concentrations can be used. This study aim to evaluate the performance of a rule-out strategy based on the European Society of Cardiology (ESC) 0/1-hour algorithm, using historical hs-cTnT concentrations.MethodsAll visits among patients with chest pain in the emergency department at nine different hospitals in Sweden from 2012 to 2016 were eligible (221 490 visits). We enrolled patients with a 0-hour hs-cTnT of <12 ng/L, a second hs-cTnT measured within 3.5 hours, and ≥1 historical hs-cTnT available. We calculated the risks of MI and all-cause mortality using two rule-out strategies: (1) a delta hs-cTnT of <3 ng/L between the 0-hour hs-cTnT and the second hs-cTnT (modified ESC algorithm) and (2) a historical hs-cTnT <12 ng/L and a delta hs-cTnT of <3 ng/L in relation to the 0-hour hs-cTnT (historical-hs-cTnT algorithm).ResultsA total of 8432 patients were included, of whom 84 (1.0%) had an MI. The modified ESC algorithm triaged 8100 (96%) patients toward ruled-out, for whom 30-day MI risk and negative predictive value (NPV) for MI (95% CI) were 0.4% (0.3% to 0.6%) and 99.6% (99.4% to 99.7%), respectively. The historical-hs-cTnT algorithm ruled out 6700 (80%) patients, with a 30-day MI risk of 0.5% (0.4% to 0.8%) and NPV of 99.5% (99.2% to 99.6%).ConclusionsThe application of algorithm resulted in similar MI risk and NPV to an established algorithm. The usefulness of historical hs-cTnT concentrations should merit further attention.

scholarly journals Prospective validation of 0-hour/1-hour algorithm using high-sensitivity cardiac troponin I in Japanese patients presenting to emergency department

2020 ◽  
Vol 41 (Supplement_2) ◽  
Author(s):  
H Ohtake ◽  
J Ishii ◽  
H Nishimura ◽  
H Kawai ◽  
T Muramatsu ◽  
...  
Keyword(s):  
Myocardial Infarction ◽  
Emergency Department ◽  
Predictive Value ◽  
Cardiac Troponin ◽  
Troponin I ◽  
High Sensitivity ◽  
Japanese Patients ◽  
Cardiac Troponin I ◽  
St Segment Elevation ◽  
Rule Out

Abstract Background The diagnostic performance of 0-hour/1-hour algorithm using high-sensitivity cardiac troponin I (hsTnI) for non-ST-segment elevation myocardial infarction (NSTEMI) has not been evaluated in an Asian population. Purpose We aimed to prospectively validate the 0-hour/1-hour algorithm using hsTnI in a Japanese population. Method We enrolled 754 Japanese patients (mean age of 70 years, 395 men) presenting to our emergency department with symptoms suggestive of NSTEMI. The hsTnI concentration was measured using the Siemens ADVIA Centaur hsTnI assay at presentation and after 1 hour. Patients were divided into three groups according to the algorithm: hsTnI below 3 ng/L (only applicable if chest pain onset &gt;3 hours) or below 6 ng/L and delta 1 hour below 3 ng/L were the “rule-out” group; hsTnI at least 120 ng/L or delta 1 hour at least 12 ng/L were in the “rule-in” group; the remaining patients were classified as the “observe” group. Based on the Fourth Universal Definition of Myocardial Infarction, the final diagnosis was adjudicated by 2 independent cardiologists using all available information, including coronary angiography, coronary computed tomography, and follow-up data. Safety of rule-out was quantified by the negative predictive value (NPV) for NSTEMI, accuracy of rule-in by the positive predictive value (PPV), and overall efficacy by the proportion of patients triaged towards rule-out or rule-in within 1 hour. Results Prevalence of NSTEMI was 6.5%. The safety of rule-out (NPV 100%), accuracy of rule-in (PPV 26%), and overall efficacy (54%) were shown in Figure. Conclusion The 0-hour/1-hour algorithm using hsTnI is very safe and effective in triaging Japanese patients with suspected NSTEMI. Funding Acknowledgement Type of funding source: None

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