Use of Biomarkers in Triage of Patients with Suspected Stroke

• Published in: The Journal of emergency medicine 2011-05, Vol.40 (5), p.499-505
• Main Authors: Vanni, Simone, MD, PHD, Polidori, Gianluca, MD, Pepe, Giuseppe, MD, PHD, Chiarlone, Melisenda, MD, Albani, Alberto, MD, Pagnanelli, Adolfo, MD, Grifoni, Stefano, MD
• Format: Article
• Language: English
• Subjects: Adult; Aged; Aged, 80 and over; Analysis of Variance; Area Under Curve; biomarkers; Biomarkers - blood; BNP; Cerebral Angiography; Cincinnati prehospital stroke scale; D-dimer; Emergency; Emergency Service, Hospital; Female; Fibrin Fibrinogen Degradation Products - metabolism; Humans; Italy; Magnetic Resonance Imaging; Male; Matrix Metalloproteinase 9 - blood; Middle Aged; Natriuretic Peptide, Brain - blood; Nerve Growth Factors - blood; Regression Analysis; ROC Curve; S100 Calcium Binding Protein beta Subunit; S100 Proteins - blood; stroke; Stroke - diagnosis; Tomography, X-Ray Computed; Triage
• ISSN: 0736-4679; 2352-5029
• DOI: 10.1016/j.jemermed.2008.09.028

Abstract Background: The absence of a rapidly available and sensitive diagnostic test represents an important limitation in the triage of patients with suspected stroke. Objectives: The aim of the present study was to investigate the triage accuracy of a novel test that measures blood-borne biomarkers (triage stroke panel, TSP) and to compare its accuracy with that of the Cincinnati Prehospital Stroke Scale (CPSS). Methods: Consecutive patients with suspected stroke presenting to the Emergency Departments of three Italian hospitals underwent triage by a trained nurse according to the CPSS and had blood drawn for TSP testing. The TSP simultaneously measures four markers (B-type natriuretic peptide, D-dimer, matrix metalloproteinase-9, and S100β) presenting a single composite result, the Multimarker Index (MMX). Stroke diagnosis was established by an expert committee blinded to MMX and CPSS results. Results: There were 155 patients enrolled, 87 (56%) of whom had a final diagnosis of stroke. The area under the receiver operating characteristic (ROC) curve for CPSS was 0.77 (95% confidence interval [CI] 0.70–0.84) and that of MMX was 0.74 (95% CI 0.66–0.82) ( p = 0.285). Thus, both tests, when used alone, failed to recognize approximately 25% of strokes. The area under the ROC curve of the combination of the two tests (0.86, 95% CI 0.79–0.91) was significantly greater than that of either single test ( p = 0.01 vs. CPSS and p < 0.001 vs. TSP). Conclusions: In an emergency care setting, a panel test using multiple biochemical markers showed triage accuracy similar to that of CPSS. Further studies are needed before biomarkers can be introduced in the clinical work-up of patients with suspected stroke.