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Eur Heart J. 2017 Nov 1;38(41):3049-3055. doi: 10.1093/eurheartj/ehx492.

Early diagnosis of acute coronary syndrome.

Author information

1
Medizinische Klinik III, University of Heidelberg, Im Neuenheimer Feld 410, 69120 Heidelberg, Germany.
2
Roche Diagnostics, Basel, Switzerland.
3
Siemens Healthineers, Erlangen, Germany.
4
University College Dublin, Dublin, Ireland.
5
Campbell University College of Pharmacy and Health Sciences, Cary, NC, USA.
6
Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany.
7
Universitares Herzzentrum, Hamburg, Germany.
8
Boehringer-Ingelheim GmbH & Co. KG, Ingelheim am Rhein, Germany.
9
Faculty of Medicine Mannheim, University of Heidelberg, Mannheim, Germany.
10
St. George's University Hospitals NHS Foundation Trust, London, UK.
11
St. Georges, University of London, London, UK.
12
Universita Cattolica del Sacro Cuore, Rome, Italy.
13
Bayer AG Pharmaceuticals, Drug Discovery, Wuppertal, Germany.
14
Department of Cardiology, HELIOS Clinic Wuppertal, University Hospital Witten/Herdecke, Wuppertal, Germany.
15
Hôpital Bichat, Paris, France.
16
Department of Medical Sciences, Clinical Physiology/Cardiology, Uppsala University, Uppsala, Sweden.
17
Centre for Cardiovascular Science, University and Royal Infirmary of Edinburgh, Edinburgh, UK.
18
Departments of Medicine and Diagnostic Radiology, McGill University Health Centre, Montreal, Canada.
19
Heidelberg University, Heidelberg, Germany.
20
GE Healthcare, Waukesha, WI, USA.
21
Astra Zeneca R&D, Gothenburg, Sweden.
22
Stanford University School of Medicine, Stanford, CA, USA.
23
Merck & Co., Inc., Kenilworth, NJ, USA.
24
Department of Medical Sciences, Cardiology, Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden.
25
BHF Center for Cardiovascular Sciences, University of Edinburgh, Edinburgh, UK.
26
University Campus Bio-Medico, Rome, Italy.
27
Charité-Universitätsmedizin, Berlin, Germany.
28
Akershus University Hospital and University of Oslo, Oslo, Norway.
29
Philips, Eindhoven, The Netherlands.

Abstract

The diagnostic evaluation of acute chest pain has been augmented in recent years by advances in the sensitivity and precision of cardiac troponin assays, new biomarkers, improvements in imaging modalities, and release of new clinical decision algorithms. This progress has enabled physicians to diagnose or rule-out acute myocardial infarction earlier after the initial patient presentation, usually in emergency department settings, which may facilitate prompt initiation of evidence-based treatments, investigation of alternative diagnoses for chest pain, or discharge, and permit better utilization of healthcare resources. A non-trivial proportion of patients fall in an indeterminate category according to rule-out algorithms, and minimal evidence-based guidance exists for the optimal evaluation, monitoring, and treatment of these patients. The Cardiovascular Round Table of the ESC proposes approaches for the optimal application of early strategies in clinical practice to improve patient care following the review of recent advances in the early diagnosis of acute coronary syndrome. The following specific 'indeterminate' patient categories were considered: (i) patients with symptoms and high-sensitivity cardiac troponin <99th percentile; (ii) patients with symptoms and high-sensitivity troponin <99th percentile but above the limit of detection; (iii) patients with symptoms and high-sensitivity troponin >99th percentile but without dynamic change; and (iv) patients with symptoms and high-sensitivity troponin >99th percentile and dynamic change but without coronary plaque rupture/erosion/dissection. Definitive evidence is currently lacking to manage these patients whose early diagnosis is 'indeterminate' and these areas of uncertainty should be assigned a high priority for research.

KEYWORDS:

Acute coronary syndrome; Troponin

PMID:
29029109
DOI:
10.1093/eurheartj/ehx492
[Indexed for MEDLINE]

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