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Comparison of the Efficacy and Safety of Early Rule-Out Pathways for Acute Myocardial Infarction

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Comparison of the Efficacy and Safety of Early Rule-Out Pathways for Acute Myocardial Infarction. / Chapman, Andrew R; Anand, Atul; Boeddinghaus, Jasper; Ferry, Amy V; Sandeman, Dennis; Adamson, Philip D; Andrews, Jack; Tan, Stephanie; Cheng, Sheun F; D'Souza, Michelle; Orme, Kate; Strachan, Fiona E; Nestelberger, Thomas; Twerenbold, Raphael; Badertscher, Patrick; Reichlin, Tobias; Gray, Alasdair; Shah, Anoop S V; Mueller, Christian; Newby, David E; Mills, Nicholas L.

In: CIRCULATION, Vol. 135, No. 17, 25.04.2017, p. 1586-1596.

Research output: SCORING: Contribution to journal › SCORING: Journal article › Research › peer-review

Harvard

Chapman, AR, Anand, A, Boeddinghaus, J, Ferry, AV, Sandeman, D, Adamson, PD, Andrews, J, Tan, S, Cheng, SF, D'Souza, M, Orme, K, Strachan, FE, Nestelberger, T, Twerenbold, R, Badertscher, P, Reichlin, T, Gray, A, Shah, ASV, Mueller, C, Newby, DE & Mills, NL 2017, 'Comparison of the Efficacy and Safety of Early Rule-Out Pathways for Acute Myocardial Infarction', CIRCULATION, vol. 135, no. 17, pp. 1586-1596. https://doi.org/10.1161/CIRCULATIONAHA.116.025021

APA

Chapman, A. R., Anand, A., Boeddinghaus, J., Ferry, A. V., Sandeman, D., Adamson, P. D., Andrews, J., Tan, S., Cheng, S. F., D'Souza, M., Orme, K., Strachan, F. E., Nestelberger, T., Twerenbold, R., Badertscher, P., Reichlin, T., Gray, A., Shah, A. S. V., Mueller, C., ... Mills, N. L. (2017). Comparison of the Efficacy and Safety of Early Rule-Out Pathways for Acute Myocardial Infarction. CIRCULATION, 135(17), 1586-1596. https://doi.org/10.1161/CIRCULATIONAHA.116.025021

Vancouver

Chapman AR, Anand A, Boeddinghaus J, Ferry AV, Sandeman D, Adamson PD et al. Comparison of the Efficacy and Safety of Early Rule-Out Pathways for Acute Myocardial Infarction. CIRCULATION. 2017 Apr 25;135(17):1586-1596. https://doi.org/10.1161/CIRCULATIONAHA.116.025021

Bibtex

@article{2076a0a22f8d409c8e6af1124b7a06c0,
title = "Comparison of the Efficacy and Safety of Early Rule-Out Pathways for Acute Myocardial Infarction",
abstract = "BACKGROUND: High-sensitivity cardiac troponin assays enable myocardial infarction to be ruled out earlier, but the optimal approach is uncertain. We compared the European Society of Cardiology rule-out pathway with a pathway that incorporates lower cardiac troponin concentrations to risk stratify patients.METHODS: Patients with suspected acute coronary syndrome (n=1218) underwent high-sensitivity cardiac troponin I measurement at presentation and 3 and 6 or 12 hours. We compared the European Society of Cardiology pathway (<99th centile at presentation or at 3 hours if symptoms <6 hours) with a pathway developed in the High-STEACS study (High-Sensitivity Troponin in the Evaluation of Patients With Acute Coronary Syndrome) population (<5 ng/L at presentation or change <3 ng/L and <99th centile at 3 hours). The primary outcome was a comparison of the negative predictive value of both pathways for index type 1 myocardial infarction or type 1 myocardial infarction or cardiac death at 30 days. We evaluated the primary outcome in prespecified subgroups stratified by age, sex, time of symptom onset, and known ischemic heart disease.RESULTS: The primary outcome occurred in 15.7% (191 of 1218) patients. In those less than the 99th centile at presentation, the European Society of Cardiology pathway ruled out myocardial infarction in 28.1% (342 of 1218) and 78.9% (961 of 1218) at presentation and 3 hours, respectively, missing 18 index and two 30-day events (negative predictive value, 97.9%; 95% confidence interval, 96.9-98.7). The High-STEACS pathway ruled out 40.7% (496 of 1218) and 74.2% (904 of 1218) at presentation and 3 hours, missing 2 index and two 30-day events (negative predictive value, 99.5%; 95% confidence interval, 99.0-99.9; P<0.001 for comparison). The negative predictive value of the High-STEACS pathway was greater than the European Society of Cardiology pathway overall (P<0.001) and in all subgroups, including those presenting early or known to have ischemic heart disease.CONCLUSIONS: Use of the High-STEACS pathway incorporating low high-sensitivity cardiac troponin concentrations rules out myocardial infarction in more patients at presentation and misses 5-fold fewer index myocardial infarctions than guideline-approved pathways based exclusively on the 99th centile.CLINICAL TRIAL REGISTRATION: URL: http://clinicaltrials.gov. Unique identifier: NCT01852123.",
keywords = "Acute Coronary Syndrome/blood, Age Factors, Aged, Aged, 80 and over, Biomarkers/blood, Decision Support Techniques, Female, Health Status, Humans, Male, Middle Aged, Myocardial Infarction/blood, Predictive Value of Tests, Prognosis, Risk Assessment, Risk Factors, Scotland, Sex Factors, Time Factors, Troponin I/blood, Up-Regulation",
author = "Chapman, {Andrew R} and Atul Anand and Jasper Boeddinghaus and Ferry, {Amy V} and Dennis Sandeman and Adamson, {Philip D} and Jack Andrews and Stephanie Tan and Cheng, {Sheun F} and Michelle D'Souza and Kate Orme and Strachan, {Fiona E} and Thomas Nestelberger and Raphael Twerenbold and Patrick Badertscher and Tobias Reichlin and Alasdair Gray and Shah, {Anoop S V} and Christian Mueller and Newby, {David E} and Mills, {Nicholas L}",
note = "{\textcopyright} 2016 The Authors.",
year = "2017",
month = apr,
day = "25",
doi = "10.1161/CIRCULATIONAHA.116.025021",
language = "English",
volume = "135",
pages = "1586--1596",
journal = "CIRCULATION",
issn = "0009-7322",
publisher = "Lippincott Williams and Wilkins",
number = "17",

}

RIS

TY - JOUR

T1 - Comparison of the Efficacy and Safety of Early Rule-Out Pathways for Acute Myocardial Infarction

AU - Chapman, Andrew R

AU - Anand, Atul

AU - Boeddinghaus, Jasper

AU - Ferry, Amy V

AU - Sandeman, Dennis

AU - Adamson, Philip D

AU - Andrews, Jack

AU - Tan, Stephanie

AU - Cheng, Sheun F

AU - D'Souza, Michelle

AU - Orme, Kate

AU - Strachan, Fiona E

AU - Nestelberger, Thomas

AU - Twerenbold, Raphael

AU - Badertscher, Patrick

AU - Reichlin, Tobias

AU - Gray, Alasdair

AU - Shah, Anoop S V

AU - Mueller, Christian

AU - Newby, David E

AU - Mills, Nicholas L

N1 - © 2016 The Authors.

PY - 2017/4/25

Y1 - 2017/4/25

N2 - BACKGROUND: High-sensitivity cardiac troponin assays enable myocardial infarction to be ruled out earlier, but the optimal approach is uncertain. We compared the European Society of Cardiology rule-out pathway with a pathway that incorporates lower cardiac troponin concentrations to risk stratify patients.METHODS: Patients with suspected acute coronary syndrome (n=1218) underwent high-sensitivity cardiac troponin I measurement at presentation and 3 and 6 or 12 hours. We compared the European Society of Cardiology pathway (<99th centile at presentation or at 3 hours if symptoms <6 hours) with a pathway developed in the High-STEACS study (High-Sensitivity Troponin in the Evaluation of Patients With Acute Coronary Syndrome) population (<5 ng/L at presentation or change <3 ng/L and <99th centile at 3 hours). The primary outcome was a comparison of the negative predictive value of both pathways for index type 1 myocardial infarction or type 1 myocardial infarction or cardiac death at 30 days. We evaluated the primary outcome in prespecified subgroups stratified by age, sex, time of symptom onset, and known ischemic heart disease.RESULTS: The primary outcome occurred in 15.7% (191 of 1218) patients. In those less than the 99th centile at presentation, the European Society of Cardiology pathway ruled out myocardial infarction in 28.1% (342 of 1218) and 78.9% (961 of 1218) at presentation and 3 hours, respectively, missing 18 index and two 30-day events (negative predictive value, 97.9%; 95% confidence interval, 96.9-98.7). The High-STEACS pathway ruled out 40.7% (496 of 1218) and 74.2% (904 of 1218) at presentation and 3 hours, missing 2 index and two 30-day events (negative predictive value, 99.5%; 95% confidence interval, 99.0-99.9; P<0.001 for comparison). The negative predictive value of the High-STEACS pathway was greater than the European Society of Cardiology pathway overall (P<0.001) and in all subgroups, including those presenting early or known to have ischemic heart disease.CONCLUSIONS: Use of the High-STEACS pathway incorporating low high-sensitivity cardiac troponin concentrations rules out myocardial infarction in more patients at presentation and misses 5-fold fewer index myocardial infarctions than guideline-approved pathways based exclusively on the 99th centile.CLINICAL TRIAL REGISTRATION: URL: http://clinicaltrials.gov. Unique identifier: NCT01852123.

AB - BACKGROUND: High-sensitivity cardiac troponin assays enable myocardial infarction to be ruled out earlier, but the optimal approach is uncertain. We compared the European Society of Cardiology rule-out pathway with a pathway that incorporates lower cardiac troponin concentrations to risk stratify patients.METHODS: Patients with suspected acute coronary syndrome (n=1218) underwent high-sensitivity cardiac troponin I measurement at presentation and 3 and 6 or 12 hours. We compared the European Society of Cardiology pathway (<99th centile at presentation or at 3 hours if symptoms <6 hours) with a pathway developed in the High-STEACS study (High-Sensitivity Troponin in the Evaluation of Patients With Acute Coronary Syndrome) population (<5 ng/L at presentation or change <3 ng/L and <99th centile at 3 hours). The primary outcome was a comparison of the negative predictive value of both pathways for index type 1 myocardial infarction or type 1 myocardial infarction or cardiac death at 30 days. We evaluated the primary outcome in prespecified subgroups stratified by age, sex, time of symptom onset, and known ischemic heart disease.RESULTS: The primary outcome occurred in 15.7% (191 of 1218) patients. In those less than the 99th centile at presentation, the European Society of Cardiology pathway ruled out myocardial infarction in 28.1% (342 of 1218) and 78.9% (961 of 1218) at presentation and 3 hours, respectively, missing 18 index and two 30-day events (negative predictive value, 97.9%; 95% confidence interval, 96.9-98.7). The High-STEACS pathway ruled out 40.7% (496 of 1218) and 74.2% (904 of 1218) at presentation and 3 hours, missing 2 index and two 30-day events (negative predictive value, 99.5%; 95% confidence interval, 99.0-99.9; P<0.001 for comparison). The negative predictive value of the High-STEACS pathway was greater than the European Society of Cardiology pathway overall (P<0.001) and in all subgroups, including those presenting early or known to have ischemic heart disease.CONCLUSIONS: Use of the High-STEACS pathway incorporating low high-sensitivity cardiac troponin concentrations rules out myocardial infarction in more patients at presentation and misses 5-fold fewer index myocardial infarctions than guideline-approved pathways based exclusively on the 99th centile.CLINICAL TRIAL REGISTRATION: URL: http://clinicaltrials.gov. Unique identifier: NCT01852123.

KW - Acute Coronary Syndrome/blood

KW - Age Factors

KW - Aged

KW - Aged, 80 and over

KW - Biomarkers/blood

KW - Decision Support Techniques

KW - Female

KW - Health Status

KW - Humans

KW - Male

KW - Middle Aged

KW - Myocardial Infarction/blood

KW - Predictive Value of Tests

KW - Prognosis

KW - Risk Assessment

KW - Risk Factors

KW - Scotland

KW - Sex Factors

KW - Time Factors

KW - Troponin I/blood

KW - Up-Regulation

U2 - 10.1161/CIRCULATIONAHA.116.025021

DO - 10.1161/CIRCULATIONAHA.116.025021

M3 - SCORING: Journal article

C2 - 28034899

VL - 135

SP - 1586

EP - 1596

JO - CIRCULATION

JF - CIRCULATION

SN - 0009-7322

IS - 17

ER -