An algorithm for rule-in and rule-out of acute myocardial infarction using a novel troponin i assay

TY - JOUR

T1 - An algorithm for rule-in and rule-out of acute myocardial infarction using a novel troponin i assay

AU - Lindahl, Bertil

AU - Jernberg, Tomas

AU - Badertscher, Patrick

AU - Boeddinghaus, Jasper

AU - Eggers, Kai M.

AU - Frick, Mats

AU - Rubini Gimenez, Maria

AU - Linder, Rickard

AU - Ljung, Lina

AU - Martinsson, Arne

AU - Melki, Dina

AU - Nestelberger, Thomas

AU - Rentsch, Katharina

AU - Reichlin, Tobias

AU - Sabti, Zaid

AU - Schubera, Marie

AU - Svensson, Per

AU - Twerenbold, Raphael

AU - Wildi, Karin

AU - Mueller, Christian

PY - 2017/1/15

Y1 - 2017/1/15

N2 - Objective To derive and validate a hybrid algorithm for rule-out and rule-in of acute myocardial infarction based on measurements at presentation and after 2 hours with a novel cardiac troponin I (cTnI) assay. Methods The algorithm was derived and validated in two cohorts (605 and 592 patients) from multicentre studies enrolling chest pain patients presenting to the emergency department (ED) with onset of last episode within 12 hours. The index diagnosis and cardiovascular events up to 30 days were adjudicated by independent reviewers. Results In the validation cohort, 32.6% of the patients were ruled out on ED presentation, 6.1% were ruled in and 61.3% remained undetermined. A further 22% could be ruled out and 9.8% ruled in, after 2 hours. In total, 54.6% of the patients were ruled out with a negative predictive value (NPV) of 99.4% (95% CI 97.8% to 99.9%) and a sensitivity of 97.7% (95% CI 91.9% to 99.7%); 15.8% were ruled in with a positive predictive value (PPV) of 74.5% (95% CI 64.8% to 82.2%) and a specificity of 95.2% (95% CI 93.0% to 96.9%); and 29.6% remained undetermined after 2 hours. No patient in the rule-out group died during the 30-day follow-up in the two cohorts. Conclusions This novel two-step algorithm based on cTnI measurements enabled just over a third of the patients with acute chest pain to be ruled in or ruled out already at presentation and an additional third after 2 hours. This strategy maximises the speed of rule-out and rule-in while maintaining a high NPV and PPV, respectively.

AB - Objective To derive and validate a hybrid algorithm for rule-out and rule-in of acute myocardial infarction based on measurements at presentation and after 2 hours with a novel cardiac troponin I (cTnI) assay. Methods The algorithm was derived and validated in two cohorts (605 and 592 patients) from multicentre studies enrolling chest pain patients presenting to the emergency department (ED) with onset of last episode within 12 hours. The index diagnosis and cardiovascular events up to 30 days were adjudicated by independent reviewers. Results In the validation cohort, 32.6% of the patients were ruled out on ED presentation, 6.1% were ruled in and 61.3% remained undetermined. A further 22% could be ruled out and 9.8% ruled in, after 2 hours. In total, 54.6% of the patients were ruled out with a negative predictive value (NPV) of 99.4% (95% CI 97.8% to 99.9%) and a sensitivity of 97.7% (95% CI 91.9% to 99.7%); 15.8% were ruled in with a positive predictive value (PPV) of 74.5% (95% CI 64.8% to 82.2%) and a specificity of 95.2% (95% CI 93.0% to 96.9%); and 29.6% remained undetermined after 2 hours. No patient in the rule-out group died during the 30-day follow-up in the two cohorts. Conclusions This novel two-step algorithm based on cTnI measurements enabled just over a third of the patients with acute chest pain to be ruled in or ruled out already at presentation and an additional third after 2 hours. This strategy maximises the speed of rule-out and rule-in while maintaining a high NPV and PPV, respectively.

UR - http://www.scopus.com/inward/record.url?scp=84982860655&partnerID=8YFLogxK

U2 - 10.1136/heartjnl-2016-309951

DO - 10.1136/heartjnl-2016-309951

M3 - SCORING: Journal article

C2 - 27486143

AN - SCOPUS:84982860655

VL - 103

SP - 125

EP - 131

JO - HEART

JF - HEART

SN - 1355-6037

IS - 2

ER -