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Acad Emerg Med. 2016 Sep;23(9):1004-13. doi: 10.1111/acem.13012. Epub 2016 Sep 7.

The Use of Very Low Concentrations of High-sensitivity Troponin T to Rule Out Acute Myocardial Infarction Using a Single Blood Test.

Author information

  • 1Emergency Department, Central Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Sciences Centre, Manchester, United Kingdom. richard.body@manchester.ac.uk.
  • 2Cardiovascular Sciences Research Group, University of Manchester, Oxford Road, Manchester, United Kingdom. richard.body@manchester.ac.uk.
  • 3Department of Cardiology, Universitätsspital Basel, Basel, Switzerland.
  • 4Abteilung Innere Medizin III Kardiologie, Angiologie und Pneumologie, Medizinische Universitätsklinik (Krehl-Linik), Heidelberg, Germany.
  • 5Klinik für Notfallmedizin und Internistische Intensivmedizine, Klinikum Nürnberg Nord, Nürnberg, Germany.
  • 6IIB-Hospital de la Santa Creu i Sant Pau and Universitat Autònoma, Barcelona, Spain.
  • 7Division of Cardiology, University of Maryland, Baltimore, MD.
  • 8Henry Ford West Bloomfield Hospital, West Bloomfield, MI.
  • 9Azienda Ospedaliera Luigi Sacco Laboratorio Analisi Chimico Cliniche, Milan, Italy.
  • 10Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden.
  • 11Servizio Medicina di Laboratorio Azienda Ospedaliera, Università di Padova Via Giustinianeo, Padova, Italy.
  • 12Department of Acute Medicine, Cliniques Universitaires St-Luc, Université Catholique de Louvain, Brussels, Belgium.
  • 13Department of Cardiology, Liverpool Hospital, Liverpool, New South Wales, Australia.
  • 14University of Maryland School of Medicine, Baltimore, MD.
  • 15Roche Diagnostics Germany, Penzberg, Germany.
  • 16Department of Medical Sciences and Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden.

Abstract

BACKGROUND:

Recent single-center and retrospective studies suggest that acute myocardial infarction (AMI) could be immediately excluded without serial sampling in patients with initial high-sensitivity cardiac troponin T (hs-cTnT) levels below the limit of detection (LoD) of the assay and no electrocardiogram (ECG) ischemia.

OBJECTIVE:

We aimed to determine the external validity of those findings in a multicenter study at 12 sites in nine countries.

METHODS:

TRAPID-AMI was a prospective diagnostic cohort study including patients with suspected cardiac chest pain within 6 hours of peak symptoms. Blood drawn on arrival was centrally tested for hs-cTnT (Roche; 99th percentile = 14 ng/L, LoD = 5 ng/L). All patients underwent serial troponin sampling over 4-14 hours. The primary outcome, prevalent AMI, was adjudicated based on sensitive troponin I (Siemens Ultra) levels. Major adverse cardiac events (MACE) including AMI, death, or rehospitalization for acute coronary syndrome with coronary revascularization were determined after 30 days.

RESULTS:

We included 1,282 patients, of whom 213 (16.6%) had AMI and 231 (18.0%) developed MACE. Of 560 (43.7%) patients with initial hs-cTnT levels below the LoD, four (0.7%) had AMI. In total, 471 (36.7%) patients had both initial hs-cTnT levels below the LoD and no ECG ischemia. These patients had a 0.4% (n = 2) probability of AMI, giving 99.1% (95% confidence interval [CI] = 96.7% to 99.9%) sensitivity and 99.6% (95% CI = 98.5% to 100.0%) negative predictive value. The incidence of MACE in this group was 1.3% (95% CI = 0.5% to 2.8%).

CONCLUSIONS:

In the absence of ECG ischemia, the detection of very low concentrations of hs-cTnT at admission seems to allow rapid, safe exclusion of AMI in one-third of patients without serial sampling. This could be used alongside careful clinical assessment to help reduce unnecessary hospital admissions.

PMID:
27178492
DOI:
10.1111/acem.13012
[PubMed - in process]
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