Direct comparison of 4 very early rule-out strategies for acute myocardial infarction using high-sensitivity cardiac troponin i
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Direct comparison of 4 very early rule-out strategies for acute myocardial infarction using high-sensitivity cardiac troponin i. / Boeddinghaus, Jasper; Nestelberger, Thomas; Twerenbold, Raphael; Wildi, Karin; Badertscher, Patrick; Cupa, Janosch; Bürge, Tobias; Mächler, Patrick; Corbière, Sydney; Grimm, Karin; Giménez, Maria Rubini; Puelacher, Christian; Shrestha, Samyut; Widmer, Dayana Flores; Fuhrmann, Jakob; Hillinger, Petra; Sabti, Zaid; Honegger, Ursina; Schaerli, Nicolas; Kozhuharov, Nikola; Rentsch, Katharina; Miró, Òscar; López, Beatriz; Martin-Sanchez, F. Javier; Rodriguez-Adrada, Esther; Morawiec, Beata; Kawecki, Damian; Ganovská, Eva; Parenica, Jiri; Lohrmann, Jens; Kloos, Wanda; Buser, Andreas; Geigy, Nicolas; Keller, Dagmar I.; Osswald, Stefan; Reichlin, Tobias; Mueller, Christian.
in: CIRCULATION, Jahrgang 135, Nr. 17, 25.04.2017, S. 1597-1611.Publikationen: SCORING: Beitrag in Fachzeitschrift/Zeitung › SCORING: Zeitschriftenaufsatz › Forschung › Begutachtung
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TY - JOUR
T1 - Direct comparison of 4 very early rule-out strategies for acute myocardial infarction using high-sensitivity cardiac troponin i
AU - Boeddinghaus, Jasper
AU - Nestelberger, Thomas
AU - Twerenbold, Raphael
AU - Wildi, Karin
AU - Badertscher, Patrick
AU - Cupa, Janosch
AU - Bürge, Tobias
AU - Mächler, Patrick
AU - Corbière, Sydney
AU - Grimm, Karin
AU - Giménez, Maria Rubini
AU - Puelacher, Christian
AU - Shrestha, Samyut
AU - Widmer, Dayana Flores
AU - Fuhrmann, Jakob
AU - Hillinger, Petra
AU - Sabti, Zaid
AU - Honegger, Ursina
AU - Schaerli, Nicolas
AU - Kozhuharov, Nikola
AU - Rentsch, Katharina
AU - Miró, Òscar
AU - López, Beatriz
AU - Martin-Sanchez, F. Javier
AU - Rodriguez-Adrada, Esther
AU - Morawiec, Beata
AU - Kawecki, Damian
AU - Ganovská, Eva
AU - Parenica, Jiri
AU - Lohrmann, Jens
AU - Kloos, Wanda
AU - Buser, Andreas
AU - Geigy, Nicolas
AU - Keller, Dagmar I.
AU - Osswald, Stefan
AU - Reichlin, Tobias
AU - Mueller, Christian
N1 - Publisher Copyright: © 2017 American Heart Association, Inc.
PY - 2017/4/25
Y1 - 2017/4/25
N2 - BACKGROUND: Four strategies for very early rule-out of acute myocardial infarction using high-sensitivity cardiac troponin I (hs-cTnI) have been identified. It remains unclear which strategy is most attractive for clinical application. METHODS: We prospectively enrolled unselected patients presenting to the emergency department with symptoms suggestive of acute myocardial infarction. The final diagnosis was adjudicated by 2 independent cardiologists. Hs-cTnI levels were measured at presentation and after 1 hour in a blinded fashion. We directly compared all 4 hs-cTnI-based rule-out strategies: limit of detection (LOD, hs-cTnI<2 ng/L), single cutoff (hs-cTnI<5 ng/L), 1-hour algorithm (hs-cTnI<5 ng/L and 1-hour change<2 ng/L), and the 0/1-hour algorithm recommended in the European Society of Cardiology guideline combining LOD and 1-hour algorithm. RESULTS: Among 2828 enrolled patients, acute myocardial infarction was the final diagnosis in 451 (16%) patients. The LOD approach ruled out 453 patients (16%) with a sensitivity of 100% (95% confidence interval [CI], 99.2%-100%), the single cutoff 1516 patients (54%) with a sensitivity of 97.1% (95% CI, 95.1%-98.3%), the 1-hour algorithm 1459 patients (52%) with a sensitivity of 98.4% (95% CI, 96.8%-99.2%), and the 0/1-hour algorithm 1463 patients (52%) with a sensitivity of 98.4% (95% CI, 96.8%-99.2%). Predefined subgroup analysis in early presenters (≤2 hours) revealed significantly lower sensitivity (94.2%, interaction P=0.03) of the single cutoff, but not the other strategies. Two-year survival was 100% with LOD and 98.1% with the other strategies (P<0.01 for LOD versus each of the other strategies). CONCLUSIONS: All 4 rule-out strategies balance effectiveness and safety equally well. The single cutoff should not be applied in early presenters, whereas the 3 other strategies seem to perform well in this challenging subgroup.
AB - BACKGROUND: Four strategies for very early rule-out of acute myocardial infarction using high-sensitivity cardiac troponin I (hs-cTnI) have been identified. It remains unclear which strategy is most attractive for clinical application. METHODS: We prospectively enrolled unselected patients presenting to the emergency department with symptoms suggestive of acute myocardial infarction. The final diagnosis was adjudicated by 2 independent cardiologists. Hs-cTnI levels were measured at presentation and after 1 hour in a blinded fashion. We directly compared all 4 hs-cTnI-based rule-out strategies: limit of detection (LOD, hs-cTnI<2 ng/L), single cutoff (hs-cTnI<5 ng/L), 1-hour algorithm (hs-cTnI<5 ng/L and 1-hour change<2 ng/L), and the 0/1-hour algorithm recommended in the European Society of Cardiology guideline combining LOD and 1-hour algorithm. RESULTS: Among 2828 enrolled patients, acute myocardial infarction was the final diagnosis in 451 (16%) patients. The LOD approach ruled out 453 patients (16%) with a sensitivity of 100% (95% confidence interval [CI], 99.2%-100%), the single cutoff 1516 patients (54%) with a sensitivity of 97.1% (95% CI, 95.1%-98.3%), the 1-hour algorithm 1459 patients (52%) with a sensitivity of 98.4% (95% CI, 96.8%-99.2%), and the 0/1-hour algorithm 1463 patients (52%) with a sensitivity of 98.4% (95% CI, 96.8%-99.2%). Predefined subgroup analysis in early presenters (≤2 hours) revealed significantly lower sensitivity (94.2%, interaction P=0.03) of the single cutoff, but not the other strategies. Two-year survival was 100% with LOD and 98.1% with the other strategies (P<0.01 for LOD versus each of the other strategies). CONCLUSIONS: All 4 rule-out strategies balance effectiveness and safety equally well. The single cutoff should not be applied in early presenters, whereas the 3 other strategies seem to perform well in this challenging subgroup.
KW - Diagnosis
KW - Myocardial infarction
KW - Rule-out strategies
UR - http://www.scopus.com/inward/record.url?scp=85015249150&partnerID=8YFLogxK
U2 - 10.1161/CIRCULATIONAHA.116.025661
DO - 10.1161/CIRCULATIONAHA.116.025661
M3 - SCORING: Journal article
C2 - 28283497
AN - SCOPUS:85015249150
VL - 135
SP - 1597
EP - 1611
JO - CIRCULATION
JF - CIRCULATION
SN - 0009-7322
IS - 17
ER -