Fast track protocols using highly sensitive troponin assays for ruling out and ruling in non-ST elevation acute coronary syndrome

2017 ◽  
Vol 55 (11) ◽  
Author(s):  
Simona Ferraro ◽  
Alberto Dolci ◽  
Mauro Panteghini
Keyword(s):  
Myocardial Infarction ◽  
Fast Track ◽  
Level Of Evidence ◽  
Coronary Syndrome ◽  
Serial Testing ◽  
Highly Sensitive ◽  
St Elevation ◽  
Highly Sensitive Troponin ◽  
European Society Of Cardiology ◽  
The Uk

Abstract:The introduction of “highly sensitive” cardiac troponin assays (hsTn) has reinforced the evidence that only serial testing incorporated in running algorithms allows a more accurate diagnosis of acute myocardial infarction. In this report, we consider the available evidence supporting the use of fast track protocols for ruling out and ruling in non-ST elevation myocardial infarction (NSTEMI) and compare it with the content of recently released guideline by the European Society of Cardiology, noting some uncomfortable aspects that need urgent clarification and/or revision. Firstly, the guideline drafters have to reconsider the available evidence that does not permit to assign the same class and level of evidence to the very well-validated 0–3 h algorithm and to the 0–1 h algorithm. In agreement with the validity of available data, the limitations of fast track protocols, in particular of the 0–1 h algorithm for NSTEMI rule-in, calls for caution. Secondly, as the current diagnostics guidance by the UK National Institute for Health and Care Excellence recommends, rapid diagnostic protocols should be performed only using well-validated hsTn; recommending the use of an assay before being commercially available is not fair and scientifically sound.

scholarly journals Rule-out of non-ST elevation myocardial infarction by five point of care cardiac troponin assays according to the 0 h/3 h algorithm of the European Society of Cardiology

2018 ◽  
Vol 56 (4) ◽  
pp. 649-657 ◽  
Author(s):  
Durie Suh ◽  
Dagmar I. Keller ◽  
Danielle Hof ◽  
Arnold von Eckardstein ◽  
Joanna Gawinecka
Keyword(s):  
Myocardial Infarction ◽  
European Society ◽  
Clinical Utility ◽  
Point Of Care ◽  
The Other ◽  
St Elevation Myocardial Infarction ◽  
Coronary Syndrome ◽  
St Elevation ◽  
European Society Of Cardiology ◽  
Rule Out

Abstract Background: Point of care (POC) assays for cardiac troponins I or T (cTnI or cTnT) may accelerate the diagnosis of patients with suspected acute coronary syndrome (ACS). However, their clinical utility according to the 0 h/3 h algorithm recommended by the European Society of Cardiology (ESC) for non-ST elevation myocardial infarction (NSTEMI) is unknown. Methods: Blood samples from 90 patients with suspected ACS were obtained at hospital admission and 3 h later. Concentrations of cTn were determined using five POC assays (AQT90 FLEX cTnI and cTnT; PATHFAST™ cTnI; Stratus CS 200 cTnI; and Triage MeterPro cTnI) and two guideline-acceptable high-sensitivity (hs) immunoassays. Results: For the diagnosis of NSTEMI (n=15), AUCs for Abbott hs-cTnI and Roche hs-cTnT were 0.86 [95% confidence interval (CI), 0.75–0.96] and 0.88 (95% CI, 0.80–0.95), respectively, at admission, and 0.96 and 0.94, respectively, 3 h later. With the 99th percentile cutoff, their sensitivities were 62% and 92%, respectively, at admission, and 77% and 100%, respectively, 3 h later. The PATHFAST™ cTnI assay showed AUCs of 0.90 (95% CI, 0.82–0.97) and 0.94 (95% CI, 0.89–1.00), respectively, and sensitivities of 67% and 75% at admission and 3 h later, respectively. The other cTn POC assays had AUCs of 0.71 (95% CI, 0.53–0.89) to 0.84 (95% CI, 0.71–0.96) and 0.86 (95% CI, 0.72–0.99) to 0.87 (95% CI, 0.75–0.99) and sensitivities of 39%–50% and 62%–77% at admission and 3 h later, respectively. Conclusions: PATHFAST™ cTnI assay proved itself as comparable to ESC-guideline acceptable hs-cTn assays. The lower sensitivity of the other POC assays limits their clinical utility and would require longer follow-up monitoring of patients for the safe NSTEMI rule-out.

scholarly journals Hemodynamic studies for prediction of acute myocardial infarction outcomes

Medicina ◽  
2008 ◽  
Vol 44 (8) ◽  
pp. 640
Author(s):  
Andrius Macas ◽  
Algimantas Kriščiukaitis ◽  
Kristina Buivydaitė ◽  
Giedrė Bakšytė ◽  
Remigijus Žaliūnas
Keyword(s):  
Myocardial Infarction ◽  
Acute Myocardial Infarction ◽  
Clinical Laboratory ◽  
Epidemiological Data ◽  
Management Options ◽  
St Segment Elevation ◽  
Coronary Syndrome ◽  
St Elevation ◽  
The 1960S ◽  
European Society Of Cardiology

Prediction of outcomes after acute myocardial infarction was initiated more than 40 years ago. Improvement of the management options significantly reduced mortality of patients with acute myocardial infarction. In the 1960s, the mortality rate of inpatients was around 25–30%, whereas in 2007, according to the guidelines for the diagnosis and treatment of non-ST-segment elevation acute coronary syndromes, issued by the European Society of Cardiology, hospital mortality in patients with ST-elevation acute myocardial infarction was 7%, while in patients with non-ST-elevation acute coronary syndrome just 5%, but at 6 months, mortality rates were very similar in both conditions (12% vs. 13%, respectively). There are different criteria for prediction of acute myocardial infarction: demographic, clinical, laboratory, instrumental, and epidemiological. Data of hemodynamic studies are ones of the possible criteria for prediction of outcomes after acute myocardial infarction. Methods and findings of hemodynamic studies used for prediction of the outcomes are presented in this article.

scholarly journals International comparison of acute myocardial infarction care and outcomes using quality indicators

Heart ◽  
2019 ◽  
Vol 105 (11) ◽  
pp. 820-825 ◽  
Author(s):  
Oren Zusman ◽  
Owen Bebb ◽  
Marlous Hall ◽  
Tatendashe Bernadette Dondo ◽  
Adam Timmis ◽  
...  
Keyword(s):  
Myocardial Infarction ◽  
Acute Myocardial Infarction ◽  
Healthcare Delivery ◽  
International Comparisons ◽  
Coronary Intervention ◽  
Coronary Syndrome ◽  
Coronary Events ◽  
European Society Of Cardiology ◽  
The Uk ◽  
Country Specific

ObjectiveTo compare temporal changes in European Society of Cardiology (ESC) acute myocardial infarction (AMI) quality indicator (QI) attainment in the UK and Israel.MethodsData cross-walking using information from the Myocardial Ischaemia National Audit Project and the Acute Coronary Syndrome in Israel Survey for matching 2-month periods in 2006, 2010 and 2013 was used to compare country-specific attainment of 14 ESC AMI QIs.ResultsPatients in the UK (n=17 068) compared with Israel (n=5647) were older, more likely to be women, and had less diabetes, dyslipidaemia and heart failure. Baseline ischaemic risk was lower in Israel than the UK (Global Registry of Acute Coronary Events (GRACE) risk, 110.5 vs 121.0). Overall, rates of coronary angiography (87.6% vs 64.8%) and percutaneous coronary intervention (70.3% vs 41.0%) were higher in Israel compared with the UK. Composite QI performance increased more in the UK (1.0%–86.0%) than Israel (70.2%–78.0%). Mortality rates at 30 days declined in each country, with lower rates in Israel in 2013 (4.2% vs 7.6%). Composite QI adherence adjusted for GRACE risk score was inversely associated with 30-day mortality (OR 0.95; CI 0.95 to 0.97, p<0.001).ConclusionsInternational comparisons of guideline recommended AMI care and outcomes can be quantified using the ESC AMI QIs. International implementation of the ESC AMI QIs may reveal country-specific opportunities for improved healthcare delivery.

scholarly journals Circulating Levels of Dephosphorylated-Uncarboxylated Matrix Gla Protein in Patients with Acute Coronary Syndrome

Molecules ◽  
2021 ◽  
Vol 26 (4) ◽  
pp. 1108
Author(s):  
Admira Bilalic ◽  
Tina Ticinovic Kurir ◽  
Marko Kumric ◽  
Josip A. Borovac ◽  
Andrija Matetic ◽  
...  
Keyword(s):  
Myocardial Infarction ◽  
Acute Coronary Syndrome ◽  
High Risk ◽  
Hospital Mortality ◽  
Vascular Calcification ◽  
Matrix Gla Protein ◽  
St Elevation Myocardial Infarction ◽  
Coronary Syndrome ◽  
Increased Risk ◽  
St Elevation

Vascular calcification contributes to the pathogenesis of coronary artery disease while matrix Gla protein (MGP) was recently identified as a potent inhibitor of vascular calcification. MGP fractions, such as dephosphorylated-uncarboxylated MGP (dp-ucMGP), lack post-translational modifications and are less efficient in vascular calcification inhibition. We sought to compare dp-ucMGP levels between patients with acute coronary syndrome (ACS), stratified by ST-elevation myocardial infarction (STEMI) and non-ST-elevation myocardial infarction (NSTEMI) status. Physical examination and clinical data, along with plasma dp-ucMGP levels, were obtained from 90 consecutive ACS patients. We observed that levels of dp-ucMGP were significantly higher in patients with NSTEMI compared to STEMI patients (1063.4 ± 518.6 vs. 742.7 ± 166.6 pmol/L, p < 0.001). NSTEMI status and positive family history of cardiovascular diseases were only independent predictors of the highest tertile of dp-ucMGP levels. Among those with NSTEMI, patients at a high risk of in-hospital mortality (adjudicated by GRACE score) had significantly higher levels of dp-ucMGP compared to non-high-risk patients (1417.8 ± 956.8 vs. 984.6 ± 335.0 pmol/L, p = 0.030). Altogether, our findings suggest that higher dp-ucMGP levels likely reflect higher calcification burden in ACS patients and might aid in the identification of NSTEMI patients at increased risk of in-hospital mortality. Furthermore, observed dp-ucMGP levels might reflect differences in atherosclerotic plaque pathobiology between patients with STEMI and NSTEMI.

scholarly journals Comparison of Short- and Long-Term Prognosis between ST-Elevation and Non-ST-Elevation Myocardial Infarction

2021 ◽  
Vol 10 (2) ◽  
pp. 180
Author(s):  
Frédéric Bouisset ◽  
Jean-Bernard Ruidavets ◽  
Jean Dallongeville ◽  
Marie Moitry ◽  
Michele Montaye ◽  
...  
Keyword(s):  
Myocardial Infarction ◽  
Mortality Rate ◽  
Confounding Factors ◽  
Coronary Syndrome ◽  
Short And Long Term ◽  
St Elevation ◽  
Probability Of Death ◽  
Long Term Prognosis

Background: Available data comparing long-term prognosis according to the type of acute coronary syndrome (ACS) are scarce, contradictory, and outdated. Our aim was to compare short- and long-term mortality in ST-elevated (STEMI) and non-ST-elevated myocardial infarction (non-STEMI) ACS patients. Methods: Patients presenting with an inaugural ACS during the year 2006 and living in one of the three areas in France covered by the Monitoring of Trends and Determinants in Cardiovascular Disease (MONICA) registry were included. Results: A total of 1822 patients with a first ACS—1121 (61.5%) STEMI and 701 (38.5%) non-STEMI—were included in the study. At the 28-day follow-up, the mortality rates were 6.7% and 4.7% (p = 0.09) for STEMI and non-STEMI patients, respectively, and after adjustment of potential confounding factors, the 28-day probability of death was significantly lower for non-STEMI ACS patients (Odds Ratio = 0.58 (0.36–0.94), p = 0.03). At the 10-year follow-up, the death rates were 19.6% and 22.8% (p = 0.11) for STEMI and non-STEMI patients, respectively, and after adjustment of potential confounding factors, the 10-year probability of death did not significantly differ between non-STEMI and STEMI events (OR = 1.07 (0.83–1.38), p = 0.59). Over the first year, the mortality rate was 7.2%; it then decreased and stabilized at 1.7% per year between the 2nd and 10th year following ACS. Conclusion: STEMI patients have a worse vital prognosis than non-STEMI patients within 28 days following ACS. However, at the 10-year follow-up, STEMI and non-STEMI patients have a similar vital prognosis. From the 2nd year onwards following the occurrence of a first ACS, the patients become stable coronary artery disease patients with an annual mortality rate in the 2% range, regardless of the type of ACS they initially present with.

scholarly journals Pericardial Effusion in a Patient with Non-ST-Elevation Myocardial Infarction: Beware of a Hidden Malefactor

2013 ◽  
Vol 2013 ◽  
pp. 1-3
Author(s):  
Mamatha Punjee Raja Rao ◽  
Prashanth Panduranga ◽  
Mahmood Al-Jufaili
Keyword(s):  
Myocardial Infarction ◽  
Pericardial Effusion ◽  
Aortic Dissection ◽  
Acute Aortic Dissection ◽  
St Elevation Myocardial Infarction ◽  
Elderly Hypertensive Patient ◽  
Coronary Syndrome ◽  
Elderly Hypertensive ◽  
St Elevation ◽  
Suspected Diagnosis

Pericarditis with pericardial effusion in acute coronary syndrome is seen in patients with ST-elevation myocardial infarction specifically when infarction is anterior, extensive, and Q wave. It is very uncommon to have pericardial effusion in a patient with non-ST-elevation myocardial infarction. We present an elderly hypertensive patient who was diagnosed as non-ST-elevation myocardial infarction with pericardial effusion that turned out to be acute aortic dissection with catastrophic end. We conclude that, in patients with suspected diagnosis of non-ST-elevation myocardial infarction or unstable angina, if pericardial effusion is detected on echocardiography, aortic dissection needs to be considered.

scholarly journals Clomiphene Associated Inferior STEMI in a Young Female due to Right Coronary Artery Dissection

2017 ◽  
Vol 2017 ◽  
pp. 1-3 ◽  
Author(s):  
Feras Husain Abuzeyad ◽  
Eltigani Seedahmed Ibnaouf ◽  
Mudhaffar Al Farras
Keyword(s):  
Myocardial Infarction ◽  
Coronary Artery ◽  
Hormonal Therapy ◽  
Ovulation Induction ◽  
Final Diagnosis ◽  
Young Female ◽  
Artery Dissection ◽  
Coronary Artery Dissection ◽  
Coronary Syndrome ◽  
St Elevation

Nonatherosclerotic spontaneous coronary artery dissection (NA-SCAD) is an uncommon cause of myocardial infarction. It most commonly affects females in the perimenopausal age. NA-SCAD has been associated with many predisposing factors including pregnancy and hormonal therapy for both contraception and ovulation induction. The presented case is a previously healthy 41-year-old woman diagnosed with inferior ST-elevation myocardial infarction due to right descending coronary artery dissection associated with recent use of clomiphene monotherapy for ovulation induction (a previously fertile woman), which was not previously reported. Learning Objectives. Emergency physicians (EPs) should be aware about NA-SCAD as a cause of acute coronary syndrome (ACS) especially in perimenopausal women even with no risk factors. NA-SCAD occurs more commonly in the postpartum period and in females following hormonal therapy. Here, clomiphene monotherapy was reported as a possible contributing factor to NA-SCAD. Guidelines for NA-SCAD management are not up to date, and EPs should avoid some interference before the final diagnosis of the cause of myocardial infarction.

High-sensitivity troponin assays: analytical and clinical aspects

2016 ◽  
Vol 51 (4) ◽  
pp. 315-320
Author(s):  
Magdalena Krintus
Keyword(s):  
Myocardial Infarction ◽  
Clinical Symptoms ◽  
High Sensitivity ◽  
Reference Population ◽  
Clinical Aspects ◽  
Analytical Sensitivity ◽  
Reference Limit ◽  
Highly Sensitive ◽  
Time Required ◽  
Highly Sensitive Troponin

Cardiac troponins are considered the most sensitive and specific biomarkers for the diagnosis of acute coronary syndromes (ACS). According to the Third Universal Definition of Acute Myocardial Infarction, the diagnosis requires a rise / or fall of troponin concentration with at least one value exceeding the 99th percentile upper reference limit (URL) in a reference population with the coexistence of clinical symptoms of ischemia. The introduction of highly sensitive assays has resulted in lower detection limits for the concentration of troponin, allowing for early diagnosis of, as well as the detection of quantifiable concentrations of this biomarker in healthy subjects. According to current guidelines, the use of high-sensitivity tests can shorten the time required to make clinical decisions from the current 3-6 hours to 1-2 hours. The use of highly sensitive troponin assays also carries other potential benefits associated with their predictive value, as well as challenges that include reduced specificity for myocardial infarction, lack of standardization or the presence of biological variability. Given the increasing availability of new, highly sensitive troponin assays we should be aware that their increased analytical sensitivity and precision is accompanied by accurate clinical assessment of the patient, and takes into account other non-cardiac causes of their increased concentrations.

scholarly journals Pre-hospital risk assessment in suspected non-ST-elevation acute coronary syndrome: A prospective observational study

2018 ◽  
Vol 9 (1_suppl) ◽  
pp. 5-12 ◽  
Author(s):  
Dominique N van Dongen ◽  
Rudolf T Tolsma ◽  
Marion J Fokkert ◽  
Erik A Badings ◽  
Aize van der Sluis ◽  
...  
Keyword(s):  
Myocardial Infarction ◽  
High Risk ◽  
Risk Stratification ◽  
Risk Group ◽  
High Risk Group ◽  
Low Risk ◽  
Heart Score ◽  
Coronary Syndrome ◽  
Risk Patients ◽  
St Elevation

Background: Pre-hospital risk stratification of non-ST-elevation acute coronary syndrome (NSTE-ACS) by the complete HEART score has not yet been assessed. We investigated whether pre-hospital risk stratification of patients with suspected NSTE-ACS using the HEART score is accurate in predicting major adverse cardiac events (MACE). Methods: This is a prospective observational study, including 700 patients with suspected NSTE-ACS. Risk stratification was performed by ambulance paramedics, using the HEART score; low risk was defined as HEART score ⩽ 3. Primary endpoint was occurrence of MACE within 45 days after inclusion. Secondary endpoint was myocardial infarction or death. Results: A total of 172 patients (24.6%) were stratified as low risk and 528 patients (75.4%) as intermediate to high risk. Mean age was 53.9 years in the low risk group and 66.7 years in the intermediate to high risk group ( p<0.001), 50% were male in the low risk group versus 60% in the intermediate to high risk group ( p=0.026). MACE occurred in five patients in the low risk group (2.9%) and in 111 (21.0%) patients at intermediate or high risk ( p<0.001). There were no deaths in the low risk group and the occurrence of acute myocardial infarction in this group was 1.2%. In the high risk group six patients died (1.1%) and 76 patients had myocardial infarction (14.4%). Conclusions: In suspected NSTE-ACS, pre-hospital risk stratification by ambulance paramedics, including troponin measurement, is accurate in differentiating between low and intermediate to high risk. Future studies should investigate whether transportation of low risk patients to a hospital can be avoided, and whether high risk patients benefit from immediate transfer to a hospital with early coronary angiography possibilities.

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