One-hour rule-out and rule-in of acute myocardial infarction using high-sensitivity cardiac troponin T

Reichlin, T. and Schindler, C. and Drexler, B. and Twerenbold, R. and Reiter, M. and Zellweger, C. and Moehring, B. and Ziller, R. and Hoeller, R. and Rubini, Gimenez and Haaf, P. and Potocki, M. and Wildi, K. and Balmelli, C. and Freese, M. and Stelzig, C. and Freidank, H. and Osswald, S. and Mueller, C.. (2012) One-hour rule-out and rule-in of acute myocardial infarction using high-sensitivity cardiac troponin T. Archives of internal medicine, Vol. 172, H. 16. pp. 1211-1218.

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Official URL: http://edoc.unibas.ch/dok/A6094303

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BACKGROUND High-sensitivity cardiac troponin (hs-cTn) assays seem to improve the early diagnosis of acute myocardial infarction (AMI), but it is unknown how to best use them in clinical practice. Our objective was to develop and validate an algorithm for rapid rule-out and rule-in of AMI. METHODS A prospective multicenter study enrolling 872 unselected patients with acute chest pain presenting to the emergency department. High-sensitivity cardiac troponin T (hs-cTnT) was measured in a blinded fashion at presentation and after 1 hour. The final diagnosis was adjudicated by 2 independent cardiologists. An hs-cTnT algorithm incorporating baseline values as well as absolute changes within the first hour was derived from 436 randomly selected patients and validated in the remaining 436 patients. The primary prognostic end point was death during 30 days of follow-up. RESULTS Acute myocardial infarction was the final diagnosis in 17% of patients. After applying the hs-cTnT algorithm developed in the derivation cohort to the validation cohort, 259 patients (60%) could be classified as 'rule-out,' 76 patients (17%) as 'rule-in,' and 101 patients (23%) as in the 'observational zone' within 1 hour. Overall, this resulted in a sensitivity and negative predictive value of 100% for rule-out, a specificity and positive predictive value of 97% and 84%, respectively, for rule-in, and a prevalence of AMI of 8% in the observational zone group. Cumulative 30-day survival was 99.8%, 98.6%, and 95.3% (P > .001) in patients classified as rule-out, observational zone, and rule-in, respectively. CONCLUSIONS Using a simple algorithm incorporating hs-cTnT baseline values and absolute changes within the first hour allowed a safe rule-out as well as an accurate rule-in of AMI within 1 hour in 77% of unselected patients with acute chest pain. This novel strategy may obviate the need for prolonged monitoring and serial blood sampling in 3 of 4 patients
Faculties and Departments:09 Associated Institutions > Swiss Tropical and Public Health Institute (Swiss TPH) > Department of Epidemiology and Public Health (EPH) > Biostatistics
UniBasel Contributors:Schindler, Christian
Item Type:Article, refereed
Article Subtype:Research Article
Bibsysno:Link to catalogue
Publisher:American Medical Association
Note:Publication type according to Uni Basel Research Database: Journal article
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Last Modified:16 Aug 2013 07:34
Deposited On:16 Aug 2013 07:28

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