Rapid Rule-out of Acute Myocardial Infarction With a Single High-Sensitivity Cardiac Troponin T Measurement Below the Limit of Detection

TY - JOUR

T1 - Rapid Rule-out of Acute Myocardial Infarction With a Single High-Sensitivity Cardiac Troponin T Measurement Below the Limit of Detection

T2 - A Collaborative Meta-analysis

AU - Pickering, John W

AU - Than, Martin P

AU - Cullen, Louise

AU - Aldous, Sally

AU - Ter Avest, Ewoud

AU - Body, Richard

AU - Carlton, Edward W

AU - Collinson, Paul

AU - Dupuy, Anne Marie

AU - Ekelund, Ulf

AU - Eggers, Kai M

AU - Florkowski, Christopher M

AU - Freund, Yonathan

AU - George, Peter

AU - Goodacre, Steve

AU - Greenslade, Jaimi H

AU - Jaffe, Allan S

AU - Lord, Sarah J

AU - Mokhtari, Arash

AU - Mueller, Christian

AU - Munro, Andrew

AU - Mustapha, Sebbane

AU - Parsonage, William

AU - Peacock, W Frank

AU - Pemberton, Christopher

AU - Richards, A Mark

AU - Sanchis, Juan

AU - Staub, Lukas P

AU - Troughton, Richard

AU - Twerenbold, Raphael

AU - Wildi, Karin

AU - Young, Joanna

PY - 2017/5/16

Y1 - 2017/5/16

N2 - Background: High-sensitivity assays for cardiac troponin T (hs-cTnT) are sometimes used to rapidly rule out acute myocardial infarction (AMI).Purpose: To estimate the ability of a single hs-cTnT concentration below the limit of detection (<0.005 µg/L) and a nonischemic electrocardiogram (ECG) to rule out AMI in adults presenting to the emergency department (ED) with chest pain.Data Sources: EMBASE and MEDLINE without language restrictions (1 January 2008 to 14 December 2016).Study Selection: Cohort studies involving adults presenting to the ED with possible acute coronary syndrome in whom an ECG and hs-cTnT measurements were obtained and AMI outcomes adjudicated during initial hospitalization.Data Extraction: Investigators of studies provided data on the number of low-risk patients (no new ischemia on ECG and hs-cTnT measurements <0.005 µg/L) and the number who had AMI during hospitalization (primary outcome) or a major adverse cardiac event (MACE) or death within 30 days (secondary outcomes), by risk classification (low or not low risk). Two independent epidemiologists rated risk of bias of studies.Data Synthesis: Of 9241 patients in 11 cohort studies, 2825 (30.6%) were classified as low risk. Fourteen (0.5%) low-risk patients had AMI. Sensitivity of the risk classification for AMI ranged from 87.5% to 100% in individual studies. Pooled estimated sensitivity was 98.7% (95% CI, 96.6% to 99.5%). Sensitivity for 30-day MACEs ranged from 87.9% to 100%; pooled sensitivity was 98.0% (CI, 94.7% to 99.3%). No low-risk patients died.Limitation: Few studies, variation in timing and methods of reference standard troponin tests, and heterogeneity of risk and prevalence of AMI across studies.Conclusion: A single hs-cTnT concentration below the limit of detection in combination with a nonischemic ECG may successfully rule out AMI in patients presenting to EDs with possible emergency acute coronary syndrome.Primary Funding Source: Emergency Care Foundation.

AB - Background: High-sensitivity assays for cardiac troponin T (hs-cTnT) are sometimes used to rapidly rule out acute myocardial infarction (AMI).Purpose: To estimate the ability of a single hs-cTnT concentration below the limit of detection (<0.005 µg/L) and a nonischemic electrocardiogram (ECG) to rule out AMI in adults presenting to the emergency department (ED) with chest pain.Data Sources: EMBASE and MEDLINE without language restrictions (1 January 2008 to 14 December 2016).Study Selection: Cohort studies involving adults presenting to the ED with possible acute coronary syndrome in whom an ECG and hs-cTnT measurements were obtained and AMI outcomes adjudicated during initial hospitalization.Data Extraction: Investigators of studies provided data on the number of low-risk patients (no new ischemia on ECG and hs-cTnT measurements <0.005 µg/L) and the number who had AMI during hospitalization (primary outcome) or a major adverse cardiac event (MACE) or death within 30 days (secondary outcomes), by risk classification (low or not low risk). Two independent epidemiologists rated risk of bias of studies.Data Synthesis: Of 9241 patients in 11 cohort studies, 2825 (30.6%) were classified as low risk. Fourteen (0.5%) low-risk patients had AMI. Sensitivity of the risk classification for AMI ranged from 87.5% to 100% in individual studies. Pooled estimated sensitivity was 98.7% (95% CI, 96.6% to 99.5%). Sensitivity for 30-day MACEs ranged from 87.9% to 100%; pooled sensitivity was 98.0% (CI, 94.7% to 99.3%). No low-risk patients died.Limitation: Few studies, variation in timing and methods of reference standard troponin tests, and heterogeneity of risk and prevalence of AMI across studies.Conclusion: A single hs-cTnT concentration below the limit of detection in combination with a nonischemic ECG may successfully rule out AMI in patients presenting to EDs with possible emergency acute coronary syndrome.Primary Funding Source: Emergency Care Foundation.

KW - Aged

KW - Chest Pain/etiology

KW - Electrocardiography

KW - Emergency Service, Hospital

KW - Female

KW - Humans

KW - Limit of Detection

KW - Male

KW - Middle Aged

KW - Myocardial Infarction/blood

KW - Troponin T/blood

U2 - 10.7326/M16-2562

DO - 10.7326/M16-2562

M3 - SCORING: Journal article

C2 - 28418520

VL - 166

SP - 715

EP - 724

JO - ANN INTERN MED

JF - ANN INTERN MED

SN - 0003-4819

IS - 10

ER -