yValidation of high-sensitivity troponin I in a 2-h diagnostic strategy to assess 30-day outcomes in emergency-department patients with possible acute coronary syndrome.
J Am Coll Cardiol. 2013 Apr 10;
Authors: Cullen L, Müller C, Parsonage WA, Wildi K, Greenslade JH, Twerenbold R, Aldous S, Meller B, Tate JR, Reichlin T, Hammett CJ, Zellweger C, Ungerer Mmed JP, Gimenez MR, Troughton R, Murray K, Brown AF, Mueller M, George P, Mosimann T, Flaws DF, Reiter M, Lamanna A, Haaf P, Pemberton CJ, Richards AM, Chu K, Reid CM, Peacock WF, Jaffe AS, Florkowski C, Deely JM, Than M
OBJECTIVES: To validate a new high-sensitivity troponin I (hs-TnI) assay in a clinical protocol for assessing patients who present to the emergency department with chest pain. BACKGROUND: Protocols using sensitive troponin assays can accelerate the rule-out of acute myocardial infarction in low-risk (suspected) acute coronary syndrome (ACS) patients. METHODS: This study evaluated two prospective cohorts of emergency-department patients with ACS in an accelerated diagnostic pathway integrating 0- and 2-h high-sensitivity troponin I results, Thrombolysis In Myocardial Infarction (TIMI) risk scores, and electrocardiographs. Strategies to identify low-risk patients incorporated either TIMI-risk scores =0 or ≤1. The primary endpoint was adverse cardiac events (MACE) within 30 days. RESULTS: In the primary cohort, 1635 patients were recruited and had 30-day follow-up. 247 (15.1%) patients had a MACE. The finding of non-ischemic ECG and hs-TnI ≤26.2ng/L with the TIMI=0 and TIMI≤1 pathways, respectively, classified 19.6% (320) and 41.5% (678) of these patients as low-risk; 0% (0) and 0.8% (2) had a MACE respectively. In the secondary cohort, 909 patients were recruited. 156 (17.2%) had a MACE. The TIMI=0 and TIMI≤1 pathways, respectively, classified 25.3% (230) and 38.6% (351) of these patients as low risk with 0% (0) and 0.8% (1) having a MACE respectively. Sensitivity, specificity, and negative predictive value for TIMI=0 in the primary cohort were 100% (95% CI 98.5-100%), 23.1% (20.9-25.3%), and 100% (98.8-100%), respectively. Sensitivity, specificity, and negative predictive value for TIMI≤1in the primary cohort were 99.2 (97.1-99.8%), 48.7 (46.1-51.3%), and 99.7 (98.9-99.9%), respectively. Sensitivity, specificity, and negative value for TIMI≤1 in the secondary cohort were 99.4% (96.5-100%), 46.5% (42.9-50.1%), and 99.7% (98.4-100%), respectively. CONCLUSION: An early-discharge strategy utilizing a high-sensitivity troponin assay and TIMI score ≤1 had similar safety as previously reported, with the potential to decrease the observation periods and admissions for approximately 40% of patients with suspected ACS.
PMID: 23583250 [PubMed - as supplied by publisher]