scholarly journals Role of High-sensitivity Cardiac Troponin in Acute Coronary Syndrome

2019 ◽  
Vol 13 (1) ◽  
pp. 5-10 ◽  
Author(s):  
Mahesh Anantha Narayanan ◽  
Santiago Garcia
Keyword(s):  
Acute Coronary Syndrome ◽  
Chest Pain ◽  
Literature Review ◽  
Cardiac Troponin ◽  
High Sensitivity ◽  
Emergency Setting ◽  
Coronary Syndrome ◽  
The Us ◽  
Rule Out

Chest pain is one of the most common reasons for an emergency room (ER) visit in the US, with almost 6 million ER visits annually. High-sensitivity cardiac troponin (hscTn) assays have the ability to rapidly rule in or rule out acute coronary syndrome with improved sensitivity, and they are increasingly being used. Though hscTn assays have been approved for use in European, Australian, and Canadian guidelines since 2010, the FDA only approved their use in 2017. There is no consensus on how to compare the results from various hscTn assays. A literature review was performed to analyze the advantages and limitations of using hscTn as a standard biomarker to evaluate patients with suspected ACS in the emergency setting.

3298Prehospital assessment of the one-hour rule-in/rule-out algorithm using a high-sensitivity cardiac troponin t assay in a low-prevalence population for acute coronary syndrome (OUT-ACS)

2019 ◽  
Vol 40 (Supplement_1) ◽  
Author(s):  
T R Johannessen ◽  
D Atar ◽  
S Halvorsen ◽  
A C Larstorp ◽  
I Mdala ◽  
...  
Keyword(s):  
Primary Care ◽  
Chest Pain ◽  
Predictive Value ◽  
Cardiac Troponin ◽  
Troponin T ◽  
High Sensitivity ◽  
Cardiac Troponin T ◽  
Emergency Setting ◽  
Coronary Syndrome ◽  
Rule Out

Abstract Background The majority of patients with chest pain in Norway initially present to the primary health care system, which serves to triage them to the specialist health care services including hospitals. In some emergency primary care institutions, patients who are not hospitalised directly undergo further diagnostic testing to rule out acute myocardial infarction (AMI). Purpose Several studies have shown the advantage of using high-sensitivity assays for fast interpretation of cardiac troponins. The majority of these studies included patient populations from hospital emergency departments. In contrast, we aimed to investigate whether the 1-hour algorithm for high-sensitivity cardiac troponin T (hs-cTnT) is safe and useful for implementation in a primary care emergency setting where the patients have a much lower pre-test probability for an acute coronary syndrome. Methods In this prospective cohort study, we included 1672 patients with acute non-specific chest pain from November 2016 to October 2018 at a primary care emergency outpatient clinic in Norway. Serial hs-cTnT samples were analysed after 0, 1 and 4 hours on the Cobas 8000 e602 analyzer. We divided the results into one of three groups (rule-out, rule-in, or further observation), according to the 0/1-hour algorithm for hs-cTn from the current ESC guidelines on non-ST-elevation myocardial infarction. In the rule-out group, the 0/1-hour results were compared to the standard 4-hour hs-cTnT. Final hospital diagnoses were collected as a gold standard for the patients in the rule-in group. Results A total of 44 (2.6%) of 1672 patients were diagnosed with AMI. By applying the algorithm, 1274 (76.2%) patients were assigned to the rule-out group. One of the rule-out patients had a significant increase in hs-cTnT in the 4-hour sample. This results in a sensitivity for AMI of 97.7% (95% confidence interval [CI] 88.0–99.9) and negative predictive value of 99.9% (95% CI 99.6–100.0). There were 50 (3.0%) patients in the rule-in group, amongst whom 35 had a verified AMI. This gives a specificity for AMI of 99.1% (95% CI 98.5–99.5) and a positive predictive value at 70.0% (95% CI 55.4–82.1). Among the 348 (20.8%) patients assigned to further observation, eight patients had an AMI. The 15 rule-in patients who did not have an AMI, had other acute illnesses that required further diagnostic work-up at the hospital. Conclusions With a negative predictive value at 99.9%, the 1-hour algorithm for hs-cTnT seems safe and applicable for a faster assessment of patients with non-specific chest pain in a primary care emergency setting. Prehospital implementation of this algorithm may reduce the need for hospitalisation of these patients and hence may probably lower the costs. ClinicalTrial.gov identifier: NCT02983123 Acknowledgement/Funding Norwegian Research Fund for General Practice, The Norwegian Physicians' Association Fund for Quality Improvement and Patient Safety

scholarly journals Variation of Cardiac Troponin I and T Measured with Sensitive Assays in Emergency Department Patients with Noncardiac Chest Pain

2012 ◽  
Vol 58 (8) ◽  
pp. 1208-1214 ◽  
Author(s):  
Volkher Scharnhorst ◽  
Krisztina Krasznai ◽  
Marcel van 't Veer ◽  
Rolf H Michels
Keyword(s):  
Emergency Department ◽  
Acute Coronary Syndrome ◽  
Chest Pain ◽  
Cardiac Troponin ◽  
Myocardial Necrosis ◽  
High Sensitivity ◽  
Noncardiac Chest Pain ◽  
Short Term ◽  
Coronary Syndrome ◽  
Concentration Changes

Abstract BACKGROUND New-generation high-sensitivity assays for cardiac troponin have lower detection limits and less imprecision than earlier assays. Reference 99th-percentile cutoff values for these new assays are also lower, leading to higher frequencies of positive test results. When cardiac troponin concentrations are minimally increased, serial testing allows discrimination of myocardial infarction from other causes of increased cardiac troponin. We assessed various measures of short-term variation, including absolute concentration changes, reference change values (RCVs), and indices of individuality (II) for 2 cardiac troponin assays in emergency department (ED) patients. METHODS We collected blood from patients presenting with cardiac chest pain upon arrival in the ED and 2, 6, and 12 h later. Cardiac troponin was measured with the high-sensitivity cardiac troponin T (hs-cTnT) assay (Roche Diagnostics) and a sensitive cTnI assay (Siemens Diagnostics). Cardiac troponin results from 67 patients without acute coronary syndrome or stable angina were used in calculating absolute changes in cardiac troponin, RCVs, and II. RESULTS The 95th percentiles for absolute change in cardiac troponin were 8.3 ng/L for hs-cTnT and 28 ng/L for cTnI. Within-individual and total CVs were 11% and 14% for hs-cTnT and 18% and 21% for cTnI, respectively. RCVs were 38% (hs-cTnT) and 57% (cTnI). The corresponding log-normal RCVs were +46%/−32% for hs-cTnT and +76%/−43% for cTnI. II values were 0.31 (cTnI) and 0.12 (hs-cTnT). CONCLUSIONS The short-term variations and IIs of cardiac troponin were low in ED patients free of ischemic myocardial necrosis. The detection of cardiac troponin variation exceeding reference thresholds can help to identify ED patients with acute myocardial necrosis whereas variation within these limits renders acute coronary syndrome unlikely.

scholarly journals High-sensitivity cardiac troponin concentrations at presentation in patients with ST-segment elevation myocardial infarction

2020 ◽  
Vol 41 (Supplement_2) ◽  
Author(s):  
R Wereski ◽  
K.K Lee ◽  
S Smith ◽  
A.R Chapman ◽  
D Lowe ◽  
...  
Keyword(s):  
Myocardial Infarction ◽  
Acute Coronary Syndrome ◽  
Cardiac Troponin ◽  
High Sensitivity ◽  
Funding Source ◽  
St Segment Elevation ◽  
Coronary Syndrome ◽  
Segment Elevation Myocardial Infarction ◽  
St Segment ◽  
Rule Out

Abstract Background The widespread adoption of high-sensitivity cardiac troponin testing has encouraged the use of pathways to accelerate the rule-out and rule-in myocardial infarction in the Emergency Department. These pathways are not recommended for patients with ST-segment elevation, but there is a risk they may be applied incorrectly given that interpretation of the electrocardiogram is subjective, dependent on experience, and signs may be masked in those with posterior myocardial infarction. Methods Consecutive patients with suspected acute coronary syndrome were enrolled in a stepped-wedge cluster randomized controlled trial across ten hospitals in Scotland. The index diagnosis was adjudicated two clinicians independently in all patients with high-sensitivity cardiac troponin I concentrations above the sex-specific 99th centile on serial testing and abnormalities on the electrocardiogram recorded. The proportion of patients with ST-segment elevation myocardial infarction and concentrations below the rule-out threshold (<5 ng/L), 99th centile (<16 ng/L and <34 ng/L for women and men) and rule-in threshold (<52 ng/L) at presentation were determined. Results In total 48,282 patients were recruited between June 2013, and March 2016 of which 22% (10,360/48,282) had peak cardiac troponin concentrations above the 99th centile. The adjudicated diagnosis was type 1 myocardial infarction in 55% (4,981/9,115) of patients and 10% (925/9,115) had ST-segment elevation myocardial infarction (age 65 [14] years, 68% men). The majority presented within 6 hours of symptom onset (67%, 619/925), and 84% (772/925) had cardiac troponin concentrations above the 99th centile at presentation. However, troponin concentrations were below the rule-out threshold in 2% (20/925) and the rule-in threshold in 26% (240/925) of patients with ST-segment elevation myocardial infarction. Discussion In patients with suspected acute coronary syndrome who have a final diagnosis of ST-segment elevation myocardial infarction, high-sensitivity cardiac troponin concentrations are below the rule-out and rule-in threshold at presentation in 1 in 50 and 1 in 4 patients, respectively. Clinicians should not rely on cardiac troponin concentrations to guide initial treatment decisions in patients with possible ST-segment elevation myocardial infarction. Funding Acknowledgement Type of funding source: Foundation. Main funding source(s): British Heart Foundation

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 Can the Addition of NT-proBNP and Glucose Measurements Improve the Prognostication of High-Sensitivity Cardiac Troponin Measurements for Patients with Suspected Acute Coronary Syndrome?

2021 ◽  
Vol 8 (9) ◽  
pp. 106
Author(s):  
Peter A. Kavsak ◽  
Shawn E. Mondoux ◽  
Mark K. Hewitt ◽  
Craig Ainsworth ◽  
Stephen Hill ◽  
...  
Keyword(s):  
Acute Coronary Syndrome ◽  
Cardiac Troponin ◽  
Primary Outcome ◽  
Secondary Analysis ◽  
Area Under The Curve ◽  
High Sensitivity ◽  
Ambulatory Setting ◽  
Emergency Setting ◽  
Cardiac Events ◽  
Coronary Syndrome

Guidelines published in 2021 have supported natriuretic peptide (NP) testing for the prognostication in patients with acute coronary syndrome (ACS) and for the diagnosis of chronic and acute heart failure (HF). Our objective was to determine if the addition of N-terminal pro B-type NP (NT-proBNP) and glucose to high-sensitivity cardiac troponin (hs-cTn) could better identify emergency department (ED) patients with potential ACS at low- and high-risk for a serious cardiovascular outcome over the next 72 h. The presentation sample in two different ED cohorts which enrolled patients with symptoms suggestive of ACS within six hours of pain onset (Cohort-1, n = 126 and Cohort-2, n = 143) that had Abbott hs-cTnI, Roche hs-cTnT, NT-proBNP and glucose were evaluated for NT-proBNP alone and combined with hs-cTn and glucose for the primary outcome (composite which included death, myocardial infarction, HF, serious arrhythmia and refractory angina) via receiver-operating characteristic (ROC) curve analyses with area under the curve (AUC) and diagnostic estimates derived. The AUC for NT-proBNP for the primary outcome was 0.68 (95% confidence interval (CI): 0.59–0.76) and 0.75 (95%CI: 0.67–0.82) in Cohort-1 and 2, respectively, with the 125 ng/L cutoff yielding a higher sensitivity (≥75%) as compared to the 300 ng/L cutoff (≥58%). Using the 125 ng/L cutoff for NT-proBNP with the published glucose and hs-cTn cutoffs for risk-stratification produced a new score (GuIDER score for Glucose, Injury and Dysfunction in the Emergency-setting for cardiovascular-Risk) and yielded higher AUCs as compared to NT-proBNP (p < 0.05). GuIDER scores of 0 and 5 using either hs-cTnI/T yielded sensitivity estimates of 100% and specificity estimates > 92% for the primary outcome. A secondary analysis assessing MI alone in the overall population (combined Cohorts 1 and 2) also achieved 100% sensitivity for MI with a GuIDER cutoff ≥ 2, ruling-out 48% (Roche) and 38% (Abbott) of the population at presentation for MI. Additional studies are needed for the GuIDER score in both the acute and ambulatory setting to further refine the utility, however, the preliminary findings reported here may present a pathway forward for inclusion of NP testing for ruling-out serious cardiac events and MI in the emergency setting.

Performance of the European Society of Cardiology 0/1-hour algorithm in the diagnosis of myocardial infarction with high-sensitivity cardiac troponin: Systematic review and meta-analysis

2020 ◽  
pp. 204887262093539 ◽  
Author(s):  
Lucrecia M Burgos ◽  
Marcelo Trivi ◽  
Juan P Costabel
Keyword(s):  
Myocardial Infarction ◽  
Acute Coronary Syndrome ◽  
Diagnostic Accuracy ◽  
Likelihood Ratio ◽  
European Society ◽  
Cardiac Troponin ◽  
High Sensitivity ◽  
Coronary Syndrome ◽  
European Society Of Cardiology ◽  
Rule Out

Introduction: A rapid rule-out or rule-in protocol based on the 0-hour/1-hour algorithm using high-sensitivity cardiac troponin (hs-cTn) is recommended by the European Society of Cardiology (ESC); recently multiple studies have validated it in their settings. We aimed to assess the diagnostic accuracy of the 2015 ESC guidelines for management of acute coronary syndrome in patients without ST-segment elevation 0-hour/1-hour algorithm using hs-cTn for the early rule-out and rule-in of acute myocardial infarction (AMI) on presentation. Methods: Systematic searches were conducted using PubMed, the Cochrane Library and the International Clinical Trials Registry Platform to identify prospective studies from 2015 to October 2019 involving adults presenting to the emergency department with possible acute coronary syndrome in which hs-cTn measurements were obtained according to the ESC algorithm and AMI outcomes were adjudicated during the initial hospitalization. Results: Eleven studies, involving 19,213 patients, were identified. Pooled prevalence of AMI during the index hospitalization was 11.3% (95% confidence interval (CI) 3.9–18.8%). Summary sensitivity and specificity in diagnosing AMI were 99% (95% CI 98–99%; I2 63%) and 91% (95% CI 91–92%; I2 96%) respectively. The summary positive likelihood ratio was 11.6 (95% CI 8.5–15.8; I2 97%) and the pooled likelihood ratio negative 0.02 (0.01–0.03; I2 52%). Cumulative all-cause mortality at 30 days in the rule-out group was 0.11%, and 2.8% in the rule-in group, and 30 days AMI in the rule-out group was 0.08%. Conclusion: The ESC 0-hour/1-hour algorithm using high-sensitivity cardiac troponin has high diagnostic accuracy; it allows safe rule-out as well as accurate rule-in of AMI, with low cumulative 30-day mortality and AMI in patients assigned the rule-out zone.

scholarly journals Implementation of an early rule-out pathway for myocardial infarction using a high-sensitivity cardiac troponin T assay

Open Heart ◽  
2021 ◽  
Vol 8 (2) ◽  
pp. e001769
Author(s):  
Dennis Sandeman ◽  
Maaz B J Syed ◽  
Dorien M Kimenai ◽  
Kuan Ken Lee ◽  
Atul Anand ◽  
...  
Keyword(s):  
Myocardial Infarction ◽  
Acute Coronary Syndrome ◽  
Cardiac Troponin ◽  
Standard Care ◽  
Limit Of Detection ◽  
Intervention Group ◽  
High Sensitivity ◽  
Duration Of Stay ◽  
Coronary Syndrome ◽  
Rule Out

ObjectivesPatients with suspected acute coronary syndrome and high-sensitivity cardiac troponin (hs-cTn) concentrations below the limit of detection at presentation are low risk. We aim to determine whether implementing this approach facilitates the safe early discharge of patients.MethodsIn a prospective single-centre cohort study, consecutive patients with suspected acute coronary syndrome were included before (standard care) and after (intervention) implementation of an early rule-out pathway. During standard care, myocardial infarction was ruled out if hs-cTnT concentrations were <99th centile (14 ng/L) at presentation and at 6–12 hours after symptom onset. In the intervention, patients were ruled out if hs-cTnT concentrations were <5 ng/L at presentation and symptoms present for ≥3 hours or were ≥5 ng/L and unchanged within the reference range at 3 hours. We compared duration of stay (efficacy) and all-cause death at 1 year (safety) before and after implementation.ResultsWe included 10 315 consecutive patients (64±16 years, 46% women) with 6642 (64%) and 3673 (36%) in the standard care and intervention groups, respectively. Duration of stay was reduced from 534 (IQR, 220–2279) to 390 (IQR, 218–1910) min (p<0.001) after implementation. At 1 year, all-cause death occurred in 10.9% (721 of 6642) and 10.4% (381 of 3673) of patients in the standard care group (referent) and intervention group, respectively (adjusted OR 1.02, 95% CI 0.88 to 1.18).ConclusionIn patients with suspected acute coronary syndrome, implementing an early rule-out pathway using hs-cTnT concentrations <5 ng/L at presentation reduced the duration of stay in hospital without compromising safety.

Rapid rule-out of suspected acute coronary syndrome in the Emergency Department by high-sensitivity cardiac troponin T levels at presentation

2018 ◽  
Vol 14 (3) ◽  
pp. 403-410 ◽  
Author(s):  
Andrea Fabbri ◽  
Cristina Bachetti ◽  
Filippo Ottani ◽  
Alice Morelli ◽  
Barbara Benazzi ◽  
...  
Keyword(s):  
Emergency Department ◽  
Acute Coronary Syndrome ◽  
Cardiac Troponin ◽  
Troponin T ◽  
High Sensitivity ◽  
Cardiac Troponin T ◽  
Coronary Syndrome ◽  
Rule Out

scholarly journals Pre-hospital One-Hour Troponin in a Low-Prevalence Population of Acute Coronary Syndrome: OUT-ACS study

Open Heart ◽  
2020 ◽  
Vol 7 (2) ◽  
pp. e001296
Author(s):  
Tonje R Johannessen ◽  
Odd Martin Vallersnes ◽  
Sigrun Halvorsen ◽  
Anne Cecilie K. Larstorp ◽  
Ibrahimu Mdala ◽  
...  
Keyword(s):  
Primary Care ◽  
Acute Coronary Syndrome ◽  
Chest Pain ◽  
Predictive Value ◽  
Troponin T ◽  
Diagnostic Study ◽  
Emergency Setting ◽  
Large Hospital ◽  
Coronary Syndrome ◽  
Rule Out

ObjectiveThe European Society of Cardiology 0/1-hour algorithm for high-sensitivity cardiac troponin T (hs-cTnT) has demonstrated high rule-out safety in large hospital validation cohorts. We aimed to validate the algorithm in a primary care setting, where patients have a lower pretest probability for acute coronary syndrome.MethodsThis prospective, observational, diagnostic study included patients with acute non-specific chest pain admitted to a primary care emergency clinic in Oslo, Norway, from November 2016 to October 2018. hs-cTnT was measured after 0, 1 and 4 hours. The primary outcome measure was the diagnostic performance of the 0/1-hour algorithm, the 90-day incidence of AMI or all-cause death the secondary.ResultsAmong 1711 included patients, 61 (3.6%) were diagnosed with AMI. By applying the algorithm, 1311 (76.6%) patients were assigned to the rule-out group. The negative predictive value was 99.9% (95% CI 99.5% to 100.0%), the sensitivity and specificity 98.4% (91.2–100.0) and 79.4% (77.4–81.3), respectively. Sixty-six (3.9%) patients were triaged towards rule-in, where 45 were diagnosed with AMI. The corresponding positive predictive value was 68.2% (58.3–76.7), sensitivity 73.8% (60.9–84.2), and specificity 98.7% (98.1–99.2). Among 334 (19.5%) patients assigned to the observation group in need of further tests, 15 patients had an AMI. The following 90 days, five new patients experienced an AMI and nine patients died, with a low incidence in the rule-out group (0.3%).ConclusionThe 0/1-hour algorithm for hs-cTnT seems safe, efficient and applicable for an accelerated assessment of patients with non-specific chest pain in a primary care emergency setting.Trial registration numberNCT02983123.

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