scholarly journals Comparison of four decision aids for the early diagnosis of acute coronary syndromes in the emergency department

2019 ◽  
Vol 37 (1) ◽  
pp. 8-13 ◽  
Author(s):  
Richard Body ◽  
Niall Morris ◽  
Charles Reynard ◽  
Paul O Collinson
Keyword(s):  
Myocardial Infarction ◽  
Emergency Department ◽  
Early Diagnosis ◽  
Diagnostic Accuracy ◽  
Predictive Value ◽  
Cardiac Troponin ◽  
Acute Coronary Syndromes ◽  
Decision Aids ◽  
Coronary Syndromes ◽  
Rule Out

ObjectivesTo directly compare the diagnostic accuracy of four decision aids (Troponin-only Manchester Acute Coronary Syndromes (T-MACS), History, ECG, Age, Risk factors and Troponin (HEART), Thrombolysis in Myocardial Infarction (TIMI) and Emergency Department Assessment of Chest Pain (EDACS)) used to expedite the early diagnosis of acute coronary syndromes (ACS) in the ED.MethodsWe prospectively included patients who presented to 14 EDs in England (February 2015 to June 2017) with suspected ACS within 12 hours of symptom onset. Data to enable evaluation of the T-MACS, HEART, TIMI and EDACS decision aids (without recalibration) were prospectively collected, blinded to patient outcome. We tested admission blood samples for high-sensitivity cardiac troponin I (hs-cTnI; Siemens ADVIA Centaur). Patients also underwent serial cardiac troponin testing over 3–12 hours. The target condition was an adjudicated diagnosis of acute myocardial infarction (AMI). We also evaluated the incidence of major adverse cardiac events (including death, AMI or coronary revascularisation) at 30 days. Diagnostic accuracy of each decision aid and hs-cTnI alone (using the limit of quantification cut-off, 3 ng/L) was evaluated by calculating sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV).ResultsOf 999 included patients, 132 (13.2%) had AMI. C-statistics were 0.96 for T-MACS, 0.78 for HEART and 0.69 for TIMI. The sensitivities of T-MACS, HEART, TIMI, EDACS and hs-cTnI <3 ng/L for AMI were 99.2% (95% CI 95.7% to 100.0%), 91.8% (85.0% to 96.2%), 97.5% (92.9% to 99.5%), 96.2% (92.2% to 99.4%) and 99.2% (95.9% to 100.0%), respectively. The respective strategies would have ruled out 46.5%, 34.9%, 19.4%, 48.3% and 28.8% patients. PPVs for the decision aids that identify ‘high-risk’ patients were 80.4% (T-MACS), 51.9% (TIMI) and 37.2% (HEART).ConclusionsIn this study, T-MACS could rule out AMI in 46.5% patients with 99.2% sensitivity. EDACS could rule out AMI in 48.3% patients with lower sensitivity, although the difference was not statistically significant. The HEART and TIMI scores had lower diagnostic accuracy.

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.

Biomarkers in acute coronary syndromes

2017 ◽  
Author(s):  
Evangelos Giannitsis ◽  
Hugo A Katus
Keyword(s):  
Myocardial Infarction ◽  
Cardiac Troponin ◽  
Acute Coronary Syndromes ◽  
Pharmacological Therapy ◽  
Individual Risk ◽  
Strict Adherence ◽  
Risk Of Death ◽  
Coronary Syndrome ◽  
Coronary Syndromes ◽  
Rule Out

Biomarker testing in the evaluation of a patient with acute chest pain is best established for cardiac troponins that allow the diagnosis of myocardial infarction, risk estimation of short- and long-term risk of death and myocardial infarction, and guidance of pharmacological therapy, as well as the need and timing of invasive strategy. Newer, more sensitive troponin assays have become commercially available and have the capability to detect myocardial infarction earlier and more sensitively than standard assays, but they are hampered by a lack of clinical specificity, i.e. the ability to discriminate myocardial ischaemia from myocardial necrosis not related to ischaemia such as myocarditis, pulmonary embolism, or decompensated heart failure. Strategies to improve clinical specificity (including strict adherence to the universal myocardial infarction definition and the need for serial troponin measurements to detect an acute rise and/or fall of cardiac troponin) will improve the interpretation of the increasing number of positive results. Other biomarkers of inflammation, activated coagulation/fibrinolysis, and increased ventricular stress mirror different aspects of the underlying disease activity and may help to improve our understanding of the pathophysiological mechanisms of acute coronary syndromes. Among the flood of new biomarkers, there are several novel promising biomarkers, such as copeptin that allows an earlier rule-out of myocardial infarction in combination with cardiac troponin, whereas MR-proANP and MR-proADM appear to allow a refinement of cardiovascular risk. GDF-15 might help to identify candidates for an early invasive vs conservative strategy. A multi-marker approach to biomarkers becomes more and more attractive, as increasing evidence suggests that a combination of several biomarkers may help to predict individual risk and treatment benefits, particularly among normal-troponin subjects. Future goals include the acceleration of rule-in and rule-out of patients with suspected acute coronary syndrome, in order to shorten lengths of stay in the emergency department, and to optimize patient management and the use of health care resources. New algorithms using high-sensitivity cardiac troponin assays at low cut-offs alone, or in combination with additional biomarkers, allow to establish accelerated rule-out algorithms within 1 or 2 hours.

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.

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.

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

Diagnostic accuracy of the Troponin-only Manchester Acute Coronary Syndromes (T-MACS) decision aid with a point-of-care cardiac troponin assay

2020 ◽  
Vol 37 (4) ◽  
pp. 223-228 ◽  
Author(s):  
Abdulrhman Alghamdi ◽  
Charles Reynard ◽  
Niall Morris ◽  
Phil Moss ◽  
Heather Jarman ◽  
...  
Keyword(s):  
Diagnostic Accuracy ◽  
Predictive Value ◽  
Cardiac Troponin ◽  
Acute Coronary Syndromes ◽  
Decision Aid ◽  
Troponin I ◽  
Limit Of Detection ◽  
Point Of Care ◽  
Serial Sampling ◽  
Coronary Syndromes

ObjectivePoint-of-care (POC) cardiac troponin (cTn) assays have a rapid turnaround time but are generally less sensitive than laboratory-based assays. Previous research found that the Abbott i-Stat cardiac troponin I (cTnI) assay has good diagnostic accuracy when used with the Troponin-only Manchester Acute Coronary Syndromes (T-MACS) decision aid and serial sampling over 3 hours. Accuracy of other assays may differ. We therefore evaluated the diagnostic accuracy of a different POC cTnI assay with serial sampling over 3 hours, both with T-MACS and when used alone.MethodsIn a prospective diagnostic accuracy study at eight EDs in England (July 2015–October 2017), we collected clinical data from consenting adults with suspected ACS at the time of assessment in the ED. Blood samples were drawn on arrival and 3 hours later for POC cTnI (Cardio 3 Triage, Alere). The target condition was an adjudicated diagnosis of acute myocardial infarction (AMI), based on reference standard serial laboratory-based cTn testing. We calculated test characteristics for POC cTnI using the limit of detection (LoD, 0.01 µg/L) and the T-MACS decision aid.ResultsOf 347 participants, 59 (14.9%) had AMI. With serial POC cTnI testing over 3 hours, POC cTnI at the LoD cut-off ruled out AMI in 193 (55.6%) patients with 98.1% sensitivity (95% CI 89.9% to 100.0%) and 99.5% negative predictive value (NPV, 95% CI 96.5% to 99.9%). T-MACS ruled out AMI in 117 (33.7%) patients with 98.1% sensitivity (95% CI 89.9% to 100%) and 99.2% NPV (95% CI 94.3% to 99.9%). T-MACS ruled in AMI with 97.9% specificity (95% CI 95.8% to 99.5%) and 83.7% positive predictive value (95% CI 70.6% to 91.7%).ConclusionsWith serial sampling over 3 hours, the Alere Cardio 3 Triage cTnI assay has relatively high NPV for AMI using either the LoD cut-off alone or the T-MACS decision aid. However, wide CIs around the measures of diagnostic accuracy mean that further prospective testing of this strategy is required before clinical implementation.Trial registration numberUKCRN 18000.

Biomarkers in acute coronary syndromes

2018 ◽  
Author(s):  
Evangelos Giannitsis ◽  
Hugo A Katus
Keyword(s):  
Myocardial Infarction ◽  
Cardiac Troponin ◽  
Acute Coronary Syndromes ◽  
Pharmacological Therapy ◽  
Individual Risk ◽  
Strict Adherence ◽  
Risk Of Death ◽  
Coronary Syndrome ◽  
Coronary Syndromes ◽  
Rule Out

Biomarker testing in the evaluation of a patient with acute chest pain is best established for cardiac troponins that allow the diagnosis of myocardial infarction, risk estimation of short- and long-term risk of death and myocardial infarction, and guidance of pharmacological therapy, as well as the need and timing of invasive strategy. Newer, more sensitive troponin assays have become commercially available and have the capability to detect myocardial infarction earlier and more sensitively than standard assays, but they are hampered by a lack of clinical specificity, i.e. the ability to discriminate myocardial ischaemia from myocardial necrosis not related to ischaemia such as myocarditis, pulmonary embolism, or decompensated heart failure. Strategies to improve clinical specificity (including strict adherence to the universal myocardial infarction definition and the need for serial troponin measurements to detect an acute rise and/or fall of cardiac troponin) will improve the interpretation of the increasing number of positive results. Other biomarkers of inflammation, activated coagulation/fibrinolysis, and increased ventricular stress mirror different aspects of the underlying disease activity and may help to improve our understanding of the pathophysiological mechanisms of acute coronary syndromes. Among the flood of new biomarkers, there are several novel promising biomarkers, such as copeptin that allows an earlier rule-out of myocardial infarction in combination with cardiac troponin, whereas MR-proANP and MR-proADM appear to allow a refinement of cardiovascular risk. GDF-15 might help to identify candidates for an early invasive vs conservative strategy. A multi-marker approach to biomarkers becomes more and more attractive, as increasing evidence suggests that a combination of several biomarkers may help to predict individual risk and treatment benefits, particularly among normal-troponin subjects. Future goals include the acceleration of rule-in and rule-out of patients with suspected acute coronary syndrome, in order to shorten lengths of stay in the emergency department, and to optimize patient management and the use of health care resources. New algorithms using high-sensitivity cardiac troponin assays at low cut-offs alone, or in combination with additional biomarkers, allow to establish accelerated rule-out algorithms within 1 or 2 hours.

Biomarkers in acute coronary syndromes

2015 ◽  
Author(s):  
Evangelos Giannitsis ◽  
Hugo A Katus
Keyword(s):  
Myocardial Infarction ◽  
Cardiac Troponin ◽  
Acute Coronary Syndromes ◽  
Pharmacological Therapy ◽  
Individual Risk ◽  
Strict Adherence ◽  
Risk Of Death ◽  
Coronary Syndrome ◽  
Coronary Syndromes ◽  
Rule Out

Biomarker testing in the evaluation of a patient with acute chest pain is best established for cardiac troponins that allow the diagnosis of myocardial infarction, risk estimation of short- and long-term risk of death and myocardial infarction, and guidance of pharmacological therapy, as well as the need and timing of invasive strategy. Newer, more sensitive troponin assays have become commercially available and have the capability to detect myocardial infarction earlier and more sensitively than standard assays, but they are hampered by a lack of clinical specificity, i.e. the ability to discriminate myocardial ischaemia from myocardial necrosis not related to ischaemia such as myocarditis, pulmonary embolism, or decompensated heart failure. Strategies to improve clinical specificity (including strict adherence to the universal myocardial infarction definition and the need for serial troponin measurements to detect an acute rise and/or fall of cardiac troponin) will improve the interpretation of the increasing number of positive results. Other biomarkers of inflammation, activated coagulation/fibrinolysis, and increased ventricular stress mirror different aspects of the underlying disease activity and may help to improve our understanding of the pathophysiological mechanisms of acute coronary syndromes. Among the flood of new biomarkers, there are several novel promising biomarkers, such as copeptin that allows an earlier rule-out of myocardial infarction in combination with cardiac troponin, whereas MR-proANP and MR-proADM appear to allow a refinement of cardiovascular risk. GDF-15 might help to identify candidates for an early invasive vs conservative strategy. A multi-marker approach to biomarkers becomes more and more attractive, as increasing evidence suggests that a combination of several biomarkers may help to predict individual risk and treatment benefits, particularly among troponin-negative subjects. Future goals include the acceleration of rule-in and rule-out of patients with suspected acute coronary syndrome, in order to shorten lengths of stay in the emergency department, and to optimize patient management and the use of health care resources. New algorithms using high-sensitivity cardiac troponin assays at low cut-offs alone, or in combination with additional biomarkers, allow to establish accelerated rule-out algorithms within 1 or 2 hours.

scholarly journals PRe-hospital Evaluation of Sensitive TrOponin (PRESTO) Study: multicentre prospective diagnostic accuracy study protocol

BMJ Open ◽  
2019 ◽  
Vol 9 (10) ◽  
pp. e032834 ◽  
Author(s):  
Abdulrhman Alghamdi ◽  
Eloïse Cook ◽  
Edward Carlton ◽  
Aloysius Siriwardena ◽  
Mark Hann ◽  
...  
Keyword(s):  
Chest Pain ◽  
Hospital Admission ◽  
Diagnostic Accuracy ◽  
Blood Sample ◽  
Acute Coronary Syndromes ◽  
Venous Blood ◽  
Prehospital Setting ◽  
Registration Number ◽  
Coronary Syndromes ◽  
Rule Out

IntroductionWithin the UK, chest pain is one of the most common reasons for emergency (999) ambulance calls and the most common reason for emergency hospital admission. Diagnosing acute coronary syndromes (ACS) in a patient with chest pain in the prehospital setting by a paramedic is challenging. The Troponin-only Manchester Acute Coronary Syndromes (T-MACS) decision rule is a validated tool used in the emergency department (ED) to stratify patients with suspected ACS following a single blood test.We are seeking to evaluate the diagnostic accuracy of the T-MACS decision aid algorithm to ‘rule out’ ACS when used in the prehospital environment with point-of-care troponin assays. If successful, this could allow paramedics to immediately rule out ACS for patients in the ‘very low risk’ group and avoid the need for transport to the ED, while also risk stratifying other patients using a single blood sample taken in the prehospital setting.Methods and analysisWe will recruit patients who call emergency (999) ambulance services where the responding paramedic suspects cardiac chest pain. The data required to apply T-MACS will be prospectively recorded by paramedics who are responding to each patient. Paramedics will be required to draw a venous blood sample at the time of arrival to the patient. Blood samples will later be tested in batches for cardiac troponin, using commercially available troponin assays. The primary outcome will be a diagnosis of acute myocardial infarction, established at the time of initial hospital admission. The secondary outcomes will include any major adverse cardiac events within 30 days of enrolment.Ethics and disseminationThe study obtained approval from the National Research Ethics Service (reference: 18/ES/0101) and the Health Research Authority. We will publish our findings in a high impact general medical journal.Trial registration numberRegistration number: ClinicalTrials.gov, study ID: NCT03561051

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