Journal
JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY
Volume 72, Issue 6, Pages 620-632Publisher
ELSEVIER SCIENCE INC
DOI: 10.1016/j.jacc.2018.05.040
Keywords
diagnosis of myocardial infarction; diagnostic algorithms; myocardial infarction; rule-in; rule-out; troponin
Categories
Funding
- Swiss National Science Foundation
- Swiss Heart Foundation
- KTI
- European Union
- Stiftung fur kardiovaskulare Forschung Basel
- Abbott
- Beckman Coulter
- Biomerieux
- Brahms
- Roche
- Siemens
- Singulex
- German Center of Cardiovascular Research
- Abbott Diagnostics
- Swiss National Science Foundation [P300PB_167803, PASMP3-136995]
- University Hospital of Basel
- University of Basel
- Cardiovascular Research Foundation Basel
- German Heart Foundation/German Foundation of Heart Research
- Else Kroner Fresenius Stiftung
- FAG Basel
- Gottfried and Julia Bangerter-Rhyner Foundation
- Goldschmidt-Jacobson-Foundation
- Professor Max Cloetta Foundation
- Uniscientia Foundation Vaduz
- Department of Internal Medicine, University Hospital Basel
- Bayer
- Boehringer Ingelheim
- Thermo Fisher
- Alere
- AstraZeneca
- Sphingotec
- Swiss National Science Foundation (SNF) [P300PB_167803] Funding Source: Swiss National Science Foundation (SNF)
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BACKGROUND The safety of the European Society of Cardiology (ESC) 0/1-h algorithm for rapid rule-out and rule-in of non-ST-segment elevation myocardial infarction (NSTEMI) using high-sensitivity cardiac troponin (hs-cTn) has been questioned. OBJECTIVES This study aimed to validate the diagnostic performance of the 0/1-h algorithm in a large multicenter study. METHODS The authors prospectively enrolled unsetected patients in 6 countries presenting to the emergency department with symptoms suggestive of NSTEMI. Final diagnosis was centrally adjudicated by 2 independent cardiologists. Hs-cTnT and hs-cTnI blood concentrations were measured at presentation and after 1 h. Safety of rule-out was quantified by the negative predictive value (NPV) for NSTEMI, accuracy of rule-in by the positive predictive value (PPV), and overall efficacy by the proportion of patients triaged towards rule-out or rule-in within 1 h. RESULTS Prevalence of NSTEMI was 17%. Among 4,368 patients with serial hs-cTnT measurements available, safety of rule-out (NPV 99.8%, 2,488 of 2,493), accuracy of rule-in (PPV 74.5%, 572 of 768), and overall efficacy were high by assigning three-fourths of patients either to rule-out (57%, 2,493 to 4,368) or rule-in (18%, 768 to 4,368). Similarly, among 3,500 patients with serial hs-cTnI measurements, safety of rule-out (NPV 99.7%, 1,528 of 1,533), accuracy of rule-in (PPV 62.3%, 498 of 800), and overall efficacy were high by assigning more than two-thirds of patients either to rule-out (44%, 1,533 of 3,500) or rule-in (23%, 800 of 3,500). Excellent safety was confirmed in multiple subgroup analyses including patients presenting early h) after chest pain onset. CONCLUSIONS The ESC 0/1-h algorithm using hs-cTnT and hs-cTnI is very safe and effective in triaging patients with suspected NSTEMI. (C) 2018 by the American College of Cardiology Foundation.
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