Accelerated diagnostic protocol using high-sensitivity cardiac troponin T in acute chest pain patients

• Published in: International journal of cardiology 2015-04, Vol.184, p.208-215
• Main Authors: Meller, Bernadette, Cullen, Louise, Parsonage, William A, Greenslade, Jaimi H, Aldous, Sally, Reichlin, Tobias, Wildi, Karin, Twerenbold, Raphael, Jaeger, Cedric, Hillinger, Petra, Haaf, Philip, Puelacher, Christian, Kern, Vera, Rentsch, Katharina, Stallone, Fabio, Rubini Gimenez, Maria, Ballarino, Paola, Bassetti, Stefano, Walukiewicz, Astrid, Troughton, Richard, Pemberton, Christopher J, Richards, A. Mark, Chu, Kevin, Reid, Christopher M, Than, Martin, Mueller, Christian
• Format: Article
• Language: English
• Subjects: Acute chest pain; Acute Disease; Aged; Aged, 80 and over; Biomarkers - blood; Cardiac troponin; Cardiovascular; Cardiovascular Diseases - blood; Cardiovascular Diseases - diagnosis; Chest Pain - blood; Chest Pain - diagnosis; Cohort Studies; ECG; Female; Follow-Up Studies; Humans; Internationality; MACE; Male; Middle Aged; Prospective Studies; Time Factors; TIMI score; Troponin T - blood
• ISSN: 0167-5273; 1874-1754
• DOI: 10.1016/j.ijcard.2015.02.006

Abstract Background We aimed to evaluate the efficacy and safety of using high-sensitivity cardiac troponin T (hs-cTnT) within an accelerated diagnostic protocol (ADP) in patients presenting with symptoms suggestive of acute myocardial infarction (AMI) for rapid rule-out of AMI. Methods In two independent large multicenter studies, levels of hs-cTnT at presentation and at 2 h were combined with the Thrombolysis In Myocardial Infarction (TIMI) risk score and ECG findings. The ADP defined patients with normal levels of hs-cTnT at presentation and 2 h, a TIMI score ≤ 1, and normal ECG findings as candidates for rapid rule-out of AMI and rapid discharge. Major adverse cardiac events (MACEs) occurring within 30-days were centrally adjudicated by two independent cardiologists. Results In the derivation cohort, among 1085 consecutive patients 198 patients (18.2%) had a MACE. The ADP classified 374 patients (34.5%) as low-risk. None of these patients had a MACE at 30 days, resulting in a negative predictive value (NPV) of 100% (95% CI, 99.0–100%) and a sensitivity of 100% (95% CI, 98.2%–100%). In the validation cohort, among 1590 consecutive patients 231 patients (14.5%) had a MACE. The ADP classified 641 patients (40.3%) as low-risk. 6 of these patients had a MACE at 30 days, resulting in a NPV of 99.1% (95% CI, 98.0–99.6%) and a sensitivity of 97.4% (95% CI, 94.5–98.8%). Conclusions The ADP including hs-cTnT allows early identification 35 to 40% of patients to be at extremely low risk of MACE and therefore ideal candidates for outpatient management.