scholarly journals Diagnostic Performance of High Sensitivity Cardiac Troponin T Strategies and Clinical Variables in a Multisite United States Cohort

Circulation ◽  
2021 ◽  
Author(s):  
Brandon R. Allen ◽  
Robert H. Christenson ◽  
Scott A. Cohen ◽  
Richard Nowak ◽  
R. Gentry Wilkerson ◽  
...  
Keyword(s):  
Diagnostic Performance ◽  
Troponin T ◽  
Coronary Revascularization ◽  
High Sensitivity ◽  
Low Risk ◽  
Cardiac Events ◽  
Limit Of Quantification ◽  
Clinical Trial Registration ◽  
Heart Score ◽  
Coronary Syndrome

Background: European data support the use of low high-sensitivity troponin (hs-cTn) measurements or a 0/1-hour (0/1-h) algorithm for myocardial infarction (MI) or to exclude major adverse cardiac events (MACE) among Emergency Department (ED) patients with possible acute coronary syndrome (ACS). However, modest US data exist to validate these strategies. This study evaluated the diagnostic performance of an initial hs-cTnT measure below the limit of quantification (LOQ: 6 ng/L), a 0/1-h algorithm, and their combination with HEART scores for excluding MACE in a multisite US cohort. Methods: A prospective cohort study was conducted at 8 US sites, enrolling adult ED patients with symptoms suggestive of ACS and without ST-elevation on electrocardiogram. Baseline and 1-hour blood samples were collected and hs-cTnT (Roche, Basel Switzerland) measured. Treating providers blinded to hs-cTnT results prospectively calculated HEART scores. MACE (cardiac death, MI, and coronary revascularization) at 30-days was adjudicated. The proportion of patients with initial hs-cTnT measures <LOQ and risk based on a 0/1-h algorithm was determined. The negative predictive value (NPV) was calculated for both strategies when used alone or with a HEART score. Results: Among 1,462 participants with initial hs-cTnT measures, 46.4% (678/1,462) were women and 37.1% (542/1,462) were African American with a mean age of 57.6 (SD±12.9) years. MACE at 30-days occurred in 14.4% (210/1,462). Initial hs-cTnT measures <LOQ occurred in 32.8% (479/1,462), yielding a NPV of 98.3% (95%CI: 96.7-99.3%) for 30-day MACE. A low risk HEART score with an initial hs-cTnT < LOQ occurred in 20.1% (294/1,462) yielding a NPV of 99.0% (95%CI: 97.0-99.8%) for 30-day MACE. A 0/1-h algorithm was complete in 1,430 patients, ruling-out 57.8% (826/1,430) with a NPV of 97.2% (95%CI: 95.9-98.2%) for 30-day MACE. Adding a low HEART score to the 0/1-h algorithm ruled-out 30.8% (441/1430) with a NPV of 98.4% (95%CI: 96.8-99.4%) for 30-day MACE. Conclusions: In a prospective multisite US cohort, an initial hs-cTnT <LOQ combined with a low risk HEART score has 99% NPV for 30-day MACE. The 0/1-h hs-cTnT algorithm did not achieve a NPV > 99% for 30-day MACE when used alone or with a HEART score. Clinical Trial Registration: URL: https://clinicaltrials.gov Unique Identifier: NCT02984436

P2677A combination of HEART score and a 0-hour/1-hour algorithm for early and safe triage tool for patients in observe zone

2019 ◽  
Vol 40 (Supplement_1) ◽  
Author(s):  
M Shiozaki ◽  
K Inoue ◽  
S Suwa ◽  
C C Lee ◽  
S J Chiang ◽  
...  
Keyword(s):  
Troponin T ◽  
High Sensitivity ◽  
Final Diagnosis ◽  
Low Risk ◽  
Observation Group ◽  
Abdominal Ultrasonography ◽  
Diagnostic Uncertainty ◽  
Heart Score ◽  
Coronary Syndrome ◽  
Risk Score System

Abstract Background The European Society Cardiology guidelines recommend that a 0-hour/1-hour (0–1hr) algorithm using high sensitivity cardiac troponin T (hs-cTnT) improves the early triage of patients with suspected non-ST elevation acute coronary syndrome (NSTE-ACS). However, diagnostic uncertainty remains in the 25–30% of patients assigned to “observe” group. Purpose To establish a step wise risk score system using HEART score and 0-hour/1-hour algorithm to identify the low risk group from observation group. Methods This study was a prospective, multi-center, observational study of patients with suspected NSTE-ACS admitted to five hospitals in Japan and Taiwan from 2014 to 2018, respectively. We applied the algorithm and calculated HEART score simultaneously. Patients were divided into three groups according to the algorithm: hs-cTnT below 12 ng/L and delta 1 hour below 3 ng/L were the “rule out” group; hs-cTnT at least 52 ng/L or delta 1 hour at least 5 ng/L were in the “rule in” group; the remaining patients were classified as the “observe” group. All patients underwent a clinical assessment the included medical history, physical examination, 12-lead ECG, continuous ECG monitoring, pulse oximetry, standard blood test, chest radiography, cardiac and abdominal ultrasonography. Patients presenting with congestive heart failure, terminal kidney disease on hemodialysis state, arrhythmia, or infection disease (which causes to increase troponin level) were excluded. Thirty-day MACE was defined as acute myocardial infarction, unstable angina (UA), or death. Results Of the 1,332 patients enrolled, 933 patients were analyzed after exclusion. NSTE-ACS was the final diagnosis for 122 (13.1%) patients and none of death. The HEART score less than 4 points in observation groups identified as very low risk with a negative predictive value (NPV) of 98.1% (95% confidential interval (CI); 90.1%-100%) and sensitivity of 98.0% (95% CI; 89.6%-100%). There were only one patient (0.5%) with AMI. In case of the HEART score less than 5 points, it could also identify as very low risk with a NPV of 96.7% (95% CI; 90.8%-99.3%%) and sensitivity of 94.1% (95% CI; 83.8%-98.8%). There were only three patients (1.2%) with AMI. Conclusion A combination of HEART score and the 0-hour/1-hour algorithm strategy rapidly identified the patient in observation group of 30-day MACE including UA where nor further cardiac testing would be needed. Acknowledgement/Funding JSPS KAKENHI Grant Number JP18K09554

Risk stratifying chest pain patients in the emergency department using HEART, GRACE and TIMI scores, with a single contemporary troponin result, to predict major adverse cardiac events

2018 ◽  
Vol 35 (7) ◽  
pp. 420-427 ◽  
Author(s):  
Peter D W Reaney ◽  
Hamish I Elliott ◽  
Awsan Noman ◽  
Jamie G Cooper
Keyword(s):  
Chest Pain ◽  
High Sensitivity ◽  
Tertiary Hospital ◽  
Low Risk ◽  
Cardiac Events ◽  
Heart Score ◽  
Coronary Syndrome ◽  
C Statistic ◽  
Diagnostic Characteristics ◽  
Coronary Events

BackgroundThe majority of patients presenting to the ED with cardiac sounding chest pain have a non-diagnostic ECG and the problem of differentiating those suffering an acute coronary syndrome from those without is familiar to all ED clinical staff. To stratify risk in these patients, specific scores have been developed. Recent work has focused on incorporating newer high-sensitivity cardiac troponin (hs-cTn) assays; however, issues regarding performance and availability of these assays remain.AimProspectively compare HEART, Global Registry of Acute Coronary Events (GRACE) and Thrombolysis in Myocardial Infarction (TIMI) scores, using a single contemporary cTn at admission, to predict a major adverse cardiac event (MACE) at 30 days.MethodProspective observational cohort study performed in a UK tertiary hospital in patients with suspected cardiac chest pain and no significant ST elevation on initial ECG. Data collection took place 2 December 2014 to 8 February 2016. The treating clinician recorded risk score data real time and a single contemporary cTn taken at presentation was used in score calculation. The primary endpoint was 30-day MACE. C-statistic was determined for each score and diagnostic characteristics of high-risk and low-risk cut-offs were calculated.Results189/1000 patients in the study developed a 30-day MACE. The c-statistic of HEART for 30-day MACE (0.87 (95% CI 0.84 to 0.90)) was higher than TIMI (0.78 (95% CI 0.74 to 0.81)) and GRACE (0.74 (95% CI 0.70 to 0.78)).HEART score ≤3 identified low-risk patients with sensitivity 99.5% (95% CI 97.1% to 99.9%) and negative predictive value (NPV) 99.6% (95% CI 97.3% to 99.9%) exceeding TIMI 0 (sensitivity 97.4% (95% CI 93.9% to 99.1%) and NPV 97.8% (95% CI 94.8% to 99.1%)) and GRACE score 0–55 (sensitivity 95.2% (95% CI 91.1% to 97.8%) and NPV 95.8% (95% CI 92.2% to 97.7%)).ConclusionHEART outperformed both TIMI and GRACE in overall discriminative capacity for 30-day MACE. Using a single contemporary cTn at presentation, a HEART score of ≤3 demonstrated sensitivity and NPV of ≥99.5% for 30-day MACE. These results reach the threshold for a safe discharge strategy but should be interpreted thoughtfully in light of other work.

scholarly journals Prospective comparative evaluation of the European Society of Cardiology (ESC) 1-hour and a 2-hour rapid diagnostic algorithm for myocardial infarction using high-sensitivity troponin-T

CJEM ◽  
2020 ◽  
Vol 22 (5) ◽  
pp. 712-720
Author(s):  
James E. Andruchow ◽  
Timothy Boyne ◽  
Isolde Seiden-Long ◽  
Dongmei Wang ◽  
Shabnam Vatanpour ◽  
...  
Keyword(s):  
Myocardial Infarction ◽  
High Risk ◽  
Diagnostic Performance ◽  
Troponin T ◽  
High Sensitivity ◽  
Low Risk ◽  
Secondary Outcome ◽  
Cardiac Events ◽  
Patient Disposition ◽  
High Sensitivity Troponin

ABSTRACTObjectiveBoth 1- and 2-hour rapid diagnostic algorithms using high-sensitivity troponin (hs-cTn) have been validated to diagnose acute myocardial infarction (MI), leaving physicians uncertain which algorithm is preferable. The objective of this study was to prospectively evaluate the diagnostic performance of 1- and 2-hour algorithms in clinical practice in a Canadian emergency department (ED).MethodsED patients with chest pain had high-sensitivity cardiac troponin-T (hs-cTnT) collected on presentation and 1- and 2-hours later at a single academic centre over a 2-year period. The primary outcome was index MI, and the secondary outcome was 30-day major adverse cardiac events (MACE). All outcomes were adjudicated.ResultsWe enrolled 608 patients undergoing serial hs-cTnT sampling. Of these, 350 had a valid 1-hour and 550 had a 2-hour hs-cTnT sample. Index MI and 30-day MACE prevalence was ~12% and 14%. Sensitivity of the 1- and 2-hour algorithms was similar for index MI 97.3% (95% CI: 85.8–99.9%) and 100% (95% CI: 91.6–100%) and 30-day MACE: 80.9% (95% CI: 66.7–90.9%) and 83.3% (95% CI: 73.2–90.8%), respectively. Both algorithms accurately identified about 10% of patients as high risk.ConclusionsBoth algorithms were able to classify almost two-thirds of patients as low risk, effectively ruling out MI and conferring a low risk of 30-day MACE for this group, while reliably identifying high-risk patients. While both algorithms had equivalent diagnostic performance, the 2-hour algorithm offers several practical advantages, which may make it preferable to implement. Broad implementation of similar algorithms across Canada can expedite patient disposition and lead to resource savings.

A single high-sensitivity cardiac troponin T compared to the HEART score for a rapid rule-out of acute myocardial infarction at a prehospital emergency clinic

2020 ◽  
Vol 41 (Supplement_2) ◽  
Author(s):  
T.R Johannessen ◽  
D Atar ◽  
O.M Vallersnes ◽  
A.C.K Larstorp ◽  
I Mdala ◽  
...  
Keyword(s):  
Primary Care ◽  
Cardiac Troponin ◽  
Troponin T ◽  
High Sensitivity ◽  
Low Risk ◽  
Symptom Duration ◽  
Funding Source ◽  
Emergency Setting ◽  
Heart Score ◽  
Rule Out

Abstract Background Patients presenting with acute chest pain outside of hospitals represent a diagnostic challenge. Purpose We aimed to validate whether a single high-sensitivity cardiac troponin T (hs-cTnT) safely can rule out acute myocardial infarction (AMI) in a primary care emergency setting. In addition, we aimed to investigate if the hs-HEART (History, Electrocardiogram (ECG), Age, Risk factors, and hs-Troponin) score would add valuable diagnostic information. Methods This is a secondary analysis from a prospective diagnostic study, including 1711 patients with acute non-specific chest pain presenting to a primary care emergency clinic from November 2016 to October 2018. The European Society of Cardiology (ESC) 0/1-hour algorithm triages patients towards direct rule-out if the 0-hour hs-cTnT is below 5 ng/L, combined with a normal ECG and a 3-hour symptom duration. The hs-HEART score (0–10 points) was calculated retrospectively, and a score ≤3 points was considered low-risk. In addition, a modified hs-HEART score, with more comparable hs-cTnT cut-off values, was applied. The primary endpoint was AMI during the index episode; the secondary the 90-day incidence of AMI (including index) and all-cause death. Results Among 1711 patients, 61 (3.6%) had an AMI, and 525 (30.7%) were assigned towards direct rule-out. With no AMIs in this group, the rule-out safety was high (negative predictive value (NPV) and sensitivity 100%). The hs-HEART score triaged more patients (n=966) as low-risk, but missed six AMIs (NPV 99.4% and sensitivity 90.2%). The modified hs-HEART score (n=707, AMI=3) increased the low-risk sensitivity to 95.1%. The 90-day incidence of AMI and all-cause death in the direct rule-out, low-risk hs-HEART, and modified hs-HEART group, were 0.0%, 0.7%, and 0.4%, respectively. Conclusions The ESC direct rule-out approach, with a single hs-cTnT below 5 ng/L, combined with a normal ECG, and a 3-hour symptom duration, is superior to the two hs-HEART scores in ruling out AMI in a primary care emergency setting. Funding Acknowledgement Type of funding source: Public Institution(s). Main funding source(s): The Norwegian Research Fund for General Practice

scholarly journals LO97: Validation of the HEART score in Canadian emergency department chest pain patients using a high-sensitivity troponin T assay

CJEM ◽  
2017 ◽  
Vol 19 (S1) ◽  
pp. S61-S62 ◽  
Author(s):  
J. Andruchow ◽  
A. McRae ◽  
T. Abedin ◽  
D. Wang ◽  
G. Innes ◽  
...  
Keyword(s):  
Emergency Department ◽  
Chest Pain ◽  
Troponin T ◽  
High Sensitivity ◽  
Low Risk ◽  
Moderate Risk ◽  
Heart Score ◽  
High Sensitivity Troponin ◽  
High Sensitivity Troponin T ◽  
Pain Patients

Introduction: The HEART score is a validated tool created to risk stratify emergency department (ED) chest pain patients using 5 simple criteria (History, ECG findings, Age, Risk factors, and Troponin). Several studies have demonstrated the superiority of HEART over other well known risk stratification tools in identifying low risk chest pain patients suitable for early discharge. All but one of these studies used conventional troponin assays, and most were conducted in European populations. This study aims to validate the HEART score using a high-sensitivity troponin T assay in a Canadian population. Methods: This prospective cohort study was conducted at a single urban tertiary centre and regional percutaneous coronary intervention site in Calgary, Alberta. Patients were eligible for enrolment if they presented to the ED with chest pain, were age 25-years or older and required biomarker testing to rule out AMI at the discretion of the attending emergency physician. Patients were excluded if they had clear acute ischemic ECG changes, new arrhythmia or renal failure requiring hemodialysis. Clinical data were recorded by the emergency physician at the time of enrolment and outcomes were obtained from administrative data. High-sensitivity troponin-T (Roche Elecsys hs-cTnT) results were obtained in all patients at presentation. The primary outcome was AMI within 30-days of ED visit, the secondary outcome was 30-day major adverse cardiac events (MACE). Results: A total of 984 ED patients with complete HEART scores were enrolled from August 2014 to September 2016. The 30-day incidence of AMI and MACE in the overall population was 3.3% and 20.6%, respectively. HEART scores were predictive of 30-day AMI incidence: low risk (0-3): 0.77% (95%CI 0.0-1.5%), moderate risk (4-6): 4.3% (95%CI 2.3-6.2%) and high risk (7-10): 12.2% (95%CI 5.5-19.0%). HEART scores also predicted 30-day MACE: low risk (0-3): 5.0% (95%CI 3.1-6.9%), moderate risk (4-6): 31.8% (95%CI 27.2-36.4%) and high-risk (7-10): 61.4% (95%CI 51.2-71.5%). More than half of patients, 522 (53.0%) could be identified as low risk based on the HEART score using a single troponin result. Conclusion: Using a single high-sensitivity troponin result collected at ED presentation, the HEART score can rapidly and effectively identify more than half of ED chest pain patients as low risk for 30-day AMI, but is less sensitive for 30-day MACE.

scholarly journals Impact of Leading Presenting Symptoms on the Diagnostic Performance of High-Sensitivity Cardiac Troponin T and on Outcomes in Patients with Suspected Acute Coronary Syndrome

2015 ◽  
Vol 61 (5) ◽  
pp. 744-751 ◽  
Author(s):  
Moritz Biener ◽  
Matthias Mueller ◽  
Mehrshad Vafaie ◽  
Hugo A Katus ◽  
Evangelos Giannitsis
Keyword(s):  
Chest Pain ◽  
Cardiac Troponin ◽  
Diagnostic Performance ◽  
Troponin T ◽  
High Sensitivity ◽  
Cardiac Troponin T ◽  
Atypical Symptoms ◽  
Presenting Symptoms ◽  
Coronary Syndrome ◽  
Typical Chest Pain

Abstract BACKGROUND Diagnostic performance of high-sensitivity cardiac troponin T (hs-cTnT) varies depending on presenting symptoms in patients with suspected acute coronary syndrome (ACS). METHODS We compared performance measures of hs-cTnT among patients admitted to the emergency department with typical chest pain (angina), dyspnea, and atypical symptoms and assessed outcomes by leading presenting symptoms. RESULTS A total of 658 patients suspected of ACS and presenting with typical chest pain (n = 241, 36.6%), dyspnea (n = 142, 21.6%), or atypical symptoms (n = 275, 41.8%) were included. Diagnostic accuracy of hs-cTnT on admission was higher among patients with typical chest pain compared to those with atypical symptoms [area under the curve (AUC) 0.823 vs AUC 0.776 vs AUC 0.705, P &gt; 0.05 and P = 0.04]. Absolute concentration changes within 6 h improved accuracy among all subgroups, with the smallest added benefit in typical chest pain and dyspnea (ΔAUC, 0.078; P = 0.02 and 0.05, P &gt; 0.05). During 1-year follow-up, dyspnea was associated with a higher risk of death (hazard ratio, 2.36; 95% CI, 1.26–4.43, P = 0.008) and death/AMI (hazard ratio, 2.23; 95% CI, 1.21–4.11, P = 0.01) compared to typical chest pain. Optimal discriminating values for hs-cTnT were higher among patients presenting with dyspnea compared to those with typical chest pain (91.2 vs 14.1 ng/L, P &lt; 0.001). CONCLUSION The diagnostic performance of hs-cTnT in patients with suspected ACS depends on the leading presenting symptom. Patients admitted with dyspnea represent a high-risk cohort in which the diagnosis of ACS is less frequent and with inferior performance of serial hs-cTnT measurements. Higher hs-cTnT cutoffs at baseline and absolute changes after 6 h help to identify non-STEMI (ST segment elevation myocardial infarction) in this population.

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