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Circulation. 2017 Apr 25;135(17):1586-1596. doi: 10.1161/CIRCULATIONAHA.116.025021. Epub 2016 Dec 29.

Comparison of the Efficacy and Safety of Early Rule-Out Pathways for Acute Myocardial Infarction.

Author information

1
From British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, United Kingdom (A.R.C., A.A., A.V.F., D.S., P.D.A., J.A., S.T., S.F.C., M.D., K.O., F.E.S., A.G., A.S.V.S., D.E.N., N.L.M.); Cardiovascular Research Institute Basel and Department of Cardiology, University Hospital, Switzerland (J.B., T.N., R.T., P.B.., T.R., C.M.); and Department of Emergency Medicine (A.G.) and EMERGE Research Group (A.G.), Royal Infirmary of Edinburgh, United Kingdom. a.r.chapman@ed.ac.uk.
2
From British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, United Kingdom (A.R.C., A.A., A.V.F., D.S., P.D.A., J.A., S.T., S.F.C., M.D., K.O., F.E.S., A.G., A.S.V.S., D.E.N., N.L.M.); Cardiovascular Research Institute Basel and Department of Cardiology, University Hospital, Switzerland (J.B., T.N., R.T., P.B.., T.R., C.M.); and Department of Emergency Medicine (A.G.) and EMERGE Research Group (A.G.), Royal Infirmary of Edinburgh, United Kingdom.

Abstract

BACKGROUND:

High-sensitivity cardiac troponin assays enable myocardial infarction to be ruled out earlier, but the optimal approach is uncertain. We compared the European Society of Cardiology rule-out pathway with a pathway that incorporates lower cardiac troponin concentrations to risk stratify patients.

METHODS:

Patients with suspected acute coronary syndrome (n=1218) underwent high-sensitivity cardiac troponin I measurement at presentation and 3 and 6 or 12 hours. We compared the European Society of Cardiology pathway (<99th centile at presentation or at 3 hours if symptoms <6 hours) with a pathway developed in the High-STEACS study (High-Sensitivity Troponin in the Evaluation of Patients With Acute Coronary Syndrome) population (<5 ng/L at presentation or change <3 ng/L and <99th centile at 3 hours). The primary outcome was a comparison of the negative predictive value of both pathways for index type 1 myocardial infarction or type 1 myocardial infarction or cardiac death at 30 days. We evaluated the primary outcome in prespecified subgroups stratified by age, sex, time of symptom onset, and known ischemic heart disease.

RESULTS:

The primary outcome occurred in 15.7% (191 of 1218) patients. In those less than the 99th centile at presentation, the European Society of Cardiology pathway ruled out myocardial infarction in 28.1% (342 of 1218) and 78.9% (961 of 1218) at presentation and 3 hours, respectively, missing 18 index and two 30-day events (negative predictive value, 97.9%; 95% confidence interval, 96.9-98.7). The High-STEACS pathway ruled out 40.7% (496 of 1218) and 74.2% (904 of 1218) at presentation and 3 hours, missing 2 index and two 30-day events (negative predictive value, 99.5%; 95% confidence interval, 99.0-99.9; P<0.001 for comparison). The negative predictive value of the High-STEACS pathway was greater than the European Society of Cardiology pathway overall (P<0.001) and in all subgroups, including those presenting early or known to have ischemic heart disease.

CONCLUSIONS:

Use of the High-STEACS pathway incorporating low high-sensitivity cardiac troponin concentrations rules out myocardial infarction in more patients at presentation and misses 5-fold fewer index myocardial infarctions than guideline-approved pathways based exclusively on the 99th centile.

CLINICAL TRIAL REGISTRATION:

URL: http://clinicaltrials.gov. Unique identifier: NCT01852123.

KEYWORDS:

acute coronary syndrome; biomarkers; myocardial infarction; troponin

PMID:
28034899
PMCID:
PMC5404406
DOI:
10.1161/CIRCULATIONAHA.116.025021
[Indexed for MEDLINE]
Free PMC Article

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