The utility of presentation and 4-hour high sensitivity troponin I to rule-out acute myocardial infarction in the emergency department

Pickering, John W., Young, Joanna M., George, Peter, Aldous, Sally, Cullen, Louise, Greenslade, Jaimi H., Richards, A. Mark, Troughton, Richard, Ardagh, Michael, Frampton, Christopher M. and Than, Martin P. (2015) The utility of presentation and 4-hour high sensitivity troponin I to rule-out acute myocardial infarction in the emergency department. Clinical Biochemistry, 48 18: 1219-1224. doi:10.1016/j.clinbiochem.2015.07.033

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Author Pickering, John W.
Young, Joanna M.
George, Peter
Aldous, Sally
Cullen, Louise
Greenslade, Jaimi H.
Richards, A. Mark
Troughton, Richard
Ardagh, Michael
Frampton, Christopher M.
Than, Martin P.
Title The utility of presentation and 4-hour high sensitivity troponin I to rule-out acute myocardial infarction in the emergency department
Journal name Clinical Biochemistry   Check publisher's open access policy
ISSN 1873-2933
Publication date 2015-07-29
Sub-type Article (original research)
DOI 10.1016/j.clinbiochem.2015.07.033
Open Access Status File (Author Post-print)
Volume 48
Issue 18
Start page 1219
End page 1224
Total pages 6
Place of publication Philadelphia, PA, United States
Publisher Elsevier
Language eng
Formatted abstract
Objectives:  International guidance recommends that early serial sampling of high sensitivity troponin be used to accurately identify acute myocardial infarction (AMI) in chest pain patients. The background evidence for this approach is limited. We evaluated whether on presentation and 4-hour high-sensitivity troponin I (hs-cTnI) could be used to accurately rule-out AMI.

Design and methods:  hs-cTnI was measured on presentation and at 4-hours in adult patients attending an emergency department with possible acute coronary syndrome. We determined the sensitivity for AMI for at least one hs-cTnI above the 99th percentile for a healthy population or alone or in combination with new ischemic ECG changes. Both overall and sex-specific 99th percentiles were assessed. Patients with negative tests were designated low-risk.

Results:  63 (17.1%) of 368 patients had AMI. The median (interquartile range) time from symptom onset to first blood sampling was 4.8 h (2.8–8.6). The sensitivity of the presentation and 4 h hs-cTnI using the overall 99th percentile was 92.1% (95% CI 82.4% to 97.4%) and negative predictive value 95.4% (92.3% to 97.4%) with 78.3% low-risk. Applying the sex-specific 99th percentile did not change the sensitivity. The addition of ECG did not change the sensitivity.

Conclusion:  Hs-cTnI > 99th percentile thresholds measured on presentation and at 4-hours was not a safe strategy to rule-out AMI in this clinical setting irrespective of whether sex-specific 99th percentiles were used, or whether hs-cTnI was combined with ECG results.

Abbreviations:  ADP, accelerated diagnostic pathway; AMI, acute myocardial infarction; NSTEMI, non-ST elevated myocardial infarction; ECG, electrocardiogram; ESC, European Society of Cardiology; hs-cTnI, high sensitivity cardiac troponin I; hs-cTnT, high sensitivity cardiac troponin T; LoD, limit Of detection; NICE, National Institute for Health Care and Excellence
Keyword Accelerated diagnostic pathway
Acute coronary syndrome
Acute myocardial infarction
Emergency department
Q-Index Code C1
Q-Index Status Confirmed Code
Institutional Status UQ

Document type: Journal Article
Sub-type: Article (original research)
Collections: Official 2016 Collection
School of Medicine Publications
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