Direct comparison of 4 very early rule-out strategies for acute myocardial infarction using high-sensitivity cardiac troponin i

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 -