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Am Heart J. 2016 Jan;171(1):92-102.e1-5. doi: 10.1016/j.ahj.2015.07.022. Epub 2015 Jul 26.

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

Author information

1
Department of Cardiology, University Hospital, Basel, Switzerland; Cardiovascular Research Institute Basel (CRIB), University Hospital, Basel, Switzerland.
2
Department of Cardiology, University Hospital, Basel, Switzerland; Cardiovascular Research Institute Basel (CRIB), University Hospital, Basel, Switzerland; Servicio de Urgencias y Pneumologia, CIBERES ISC III, Hospital del Mar-Institut Municipal d'Investigació Mèdica, Barcelona, Spain.
3
Cardiovascular Research Institute Basel (CRIB), University Hospital, Basel, Switzerland.
4
Department of Internal Medicine, Kantonsspital, Olten, Switzerland.
5
Laboratory Medicine, University Hospital, Basel, Switzerland.
6
Department of Cardiology, University Hospital, Basel, Switzerland.
7
Department of Cardiology, University Hospital, Basel, Switzerland; Cardiovascular Research Institute Basel (CRIB), University Hospital, Basel, Switzerland. Electronic address: Christian.Mueller@usb.ch.

Abstract

We aimed to prospectively derive and validate a novel 0-/1-hour algorithm using high-sensitivity cardiac troponin I (hs-cTnI) for the early "rule-out" and "rule-in" of acute myocardial infarction (AMI).

METHODS:

In a prospective multicenter diagnostic study, we enrolled 1,500 patients presenting with suspected AMI to the emergency department. The final diagnosis was centrally adjudicated by 2 independent cardiologists blinded to hs-cTnI concentrations. The hs-cTnI (Siemens Vista) 0-/1-hour algorithm incorporated measurements performed at baseline and absolute changes within 1 hour, was derived in the first 750 patients (derivation cohort), and then validated in the second 750 (validation cohort).

RESULTS:

Overall, AMI was the final diagnosis in 16% of patients. Applying the hs-cTnI 0-/1-hour algorithm developed in the derivation cohort to the validation cohort, 57% of patients could be classified as "rule-out"; 10%, as "rule-in"; and 33%, as "observe." In the validation cohort, the sensitivity and the negative predictive value for AMI in the "rule-out" zone were 100% (95% CI 96%-100%) and 100% (95% CI 99%-100%), respectively. The specificity and the positive predictive value (PPV) for AMI in the "rule-in" zone were 96% (95% CI 94%-97%) and 70% (95% CI 60%-79%), respectively. Negative predictive value and positive predictive value of the 0-/1-hour algorithm were higher compared to the standard of care combining hs-cTnI with the electrocardiogram (both P < .001).

CONCLUSION:

The hs-cTnI 0-/1-hour algorithm performs very well for early rule-out as well as rule-in of AMI. The clinical implications are that used in conjunction with all other clinical information, the 0-/1-hour algorithm will be a safe and effective approach to substantially reduce time to diagnosis.

PMID:
26699605
DOI:
10.1016/j.ahj.2015.07.022
[Indexed for MEDLINE]

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