Validation of presentation and 3 h high-sensitivity troponin to rule-in and rule-out acute myocardial infarction

Pickering, John W., Greenslade, Jaimi H., Cullen, Louise, Flaws, Dylan, Parsonage, William, George, Peter, Worster, Andrew, Kavsak, Peter A. and Than, Martin P. (2016) Validation of presentation and 3 h high-sensitivity troponin to rule-in and rule-out acute myocardial infarction. Heart, 102 16: 1270-1278. doi:10.1136/heartjnl-2015-308505


Author Pickering, John W.
Greenslade, Jaimi H.
Cullen, Louise
Flaws, Dylan
Parsonage, William
George, Peter
Worster, Andrew
Kavsak, Peter A.
Than, Martin P.
Title Validation of presentation and 3 h high-sensitivity troponin to rule-in and rule-out acute myocardial infarction
Journal name Heart   Check publisher's open access policy
ISSN 1468-201X
1355-6037
Publication date 2016-08
Year available 2016
Sub-type Article (original research)
DOI 10.1136/heartjnl-2015-308505
Open Access Status Not Open Access
Volume 102
Issue 16
Start page 1270
End page 1278
Total pages 9
Place of publication London, United Kingdom
Publisher B M J Group
Collection year 2017
Language eng
Formatted abstract
Objective: International guidelines to rule-in acute myocardial infarction (AMI) in patients presenting with chest pain to the emergency department (ED) recommend an algorithm using high-sensitivity cardiac troponin (hs-cTn) sampling on presentation and 3 h following presentation. We tested the diagnostic accuracy of this algorithm by pooling data from five distinct cohorts from three countries of prospectively recruited patients with independently adjudicated outcomes.

Method: We measured high-sensitivity cardiac troponin I (hs-cTnI) and high-sensitivity cardiac troponin T (hscTnT) on presentation (0 h) and 3 h post-presentation samples in adult patients attending an ED with possible AMI to validate the European Society of Cardiology (ESC) Working Group on Acute Cardiac Care rule-in algorithm (ESC-rule-in). Specifically, (i) in patients with a 0 h hs-cTn concentration =99th percentile and a 3 h hs-cTn >99th percentile, positive patients are those with an absolute change in troponin =50% of the 99th percentile, and (ii) in patients with a 0 and 3 h hs-cTn >99th percentile, positive patients are those with a relative change in troponin of =20%. We concurrently assessed the efficacy of the 0 and 3 h hs-cTn <99th percentile to rule-out AMI.

Results: 1061 patients with hs-cTnI and 985 with hscTnT were included. The ESC-rule-in positive predictive value (PPV) was 83.5% (95% CI 74.9% to 90.1%) for hs-cTnI and 72.0% (95% CI 62.1% to 80.5%) for hs-cTnT. Forty-six AMIs (34.9%) were not ruled in using hs-cTnI and 62 (46.2%) using hs-cTnT. The sensitivity of the 99th percentile to rule-out AMI was 93.2% (95% CI 87.5% to 96.8%) for hs-cTnI and 94.8% (95% CI 89.5% to 97.9%) for hs-cTnT.

Conclusions: The ESC-rule-in algorithm has good PPV with hs-cTnI and reasonable with hs-cTnT and can rulein over 50% of AMIs. However, the sensitivity of the 99th percentile to rule-out AMI is too low for clinical use
Keyword Acute myocardial infarction (AMI)
Emergency department (ED)
High-sensitivity cardiac troponin (hs-cTn)
European Society of Cardiology (ESC)
Cardiac risk factors
Q-Index Code C1
Q-Index Status Provisional Code
Institutional Status UQ

Document type: Journal Article
Sub-type: Article (original research)
Collections: HERDC Pre-Audit
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