期刊
JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY
卷 74, 期 7, 页码 842-854出版社
ELSEVIER SCIENCE INC
DOI: 10.1016/j.jacc.2019.06.025
关键词
acute myocardial infarction; clinical assessment; electrocardiography; high-sensitivity cardiac troponin; major adverse cardiac events
资金
- Swiss National Science Foundation [P300PB-167803_1, P400PM_180828, PASMP3-136995]
- Swiss Heart Foundation
- European Union
- Cardiovascular Research Foundation Basel
- University Hospital Basel
- Abbott
- Beckman Coulter
- Biomerieux
- BRAHMS
- Roche
- Nanosphere
- Siemens
- Ortho Diagnostics
- Singulex
- University of Basel
- Division of Internal Medicine
- Swiss Academy of Medical Sciences
- Gottfried and Julia Bangerter-Rhyner-Foundation
- Swiss Society of Cardiology
- Cardiovascular Research Foundation
- Stiftung fur Herzschrittmacher und Elektrophysiologie
- Freiwillige Akademische Gesellschaft Basel
- Roche Diagnostics
- FAPESP (Foundation for Research Support of the State of Sao Paulo, Brazil)
- Bangerter Foundation [YTCR 23/17]
- Spanish Ministry of Health
- FEDER
- Mapfre
- Novartis
- Bayer
- MSD
- Orion-Pharma
- Goldschmidt-Jacobson-Foundation
- Professor Max Cloetta Foundation
- Uniscientia Foundation Vaduz
- Department of Internal Medicine, University Hospital Basel
- KTI
- Stiftung fur kardiovaskulare Forschung Basel
- Indorsia
- Ortho Clinical Diagnostics
- Quidel
- Sphingotec
- Swiss National Science Foundation (SNF) [P400PM_180828] Funding Source: Swiss National Science Foundation (SNF)
BACKGROUND Early and accurate detection of short-term major adverse cardiac events (MACE) in patients with suspected acute myocardial infarction (AMI) is an unmet clinical need. OBJECTIVES The goal of this study was to test the hypothesis that adding clinical judgment and electrocardiogram findings to the European Society of Cardiology (ESC) high-sensitivity cardiac troponin (hs-cTn) measurement at presentation and after 1 h (ESC hs-cTn 0/1 h algorithm) would further improve its performance to predict MACE. METHODS Patients presenting to an emergency department with suspected AMI were enrolled in a prospective, multicenter diagnostic study. The primary endpoint was MACE, including all-cause death, cardiac arrest, AMI, cardiogenic shock, sustained ventricular arrhythmia, and high-grade atrioventricular block within 30 days including index events. The secondary endpoint was MACE thorn unstable angina (UA) receiving early (# 24 h) revascularization. RESULTS Among 3,123 patients, the ESC hs-cTnT 0/1 h algorithm triaged significantly more patients toward rule-out compared with the extended algorithm (60%; 95% CI: 59% to 62% vs. 45%; 95% CI: 43% to 46%; p < 0.001), while maintaining similar 30-day MACE rates (0.6%; 95% CI: 0.3% to 1.1% vs. 0.4%; 95% CI: 0.1% to 0.9%; p = 0.429), resulting in a similar negative predictive value (99.4%; 95% CI: 98.9% to 99.6% vs. 99.6%; 95% CI: 99.2% to 99.8%; p = 0.097). The ESC hs-cTnT 0/1 h algorithm ruled-in fewer patients (16%; 95% CI: 14.9% to 17.5% vs. 26%; 95% CI: 24.2% to 27.2%; p < 0.001) compared with the extended algorithm, albeit with a higher positive predictive value (76.6%; 95% CI: 72.8% to 80.1% vs. 59%; 95% CI: 55.5% to 62.3%; p < 0.001). For 30-day MACE thorn UA, the ESC hs-cTnT 0/1 h algorithm had a higher positive predictive value for rule-in, whereas the extended algorithm had a higher negative predictive value for the rule-out. Similar findings emerged when using hs-cTnI. CONCLUSIONS The ESC hs-cTn 0/1 h algorithm better balanced efficacy and safety in the prediction of MACE, whereas the extended algorithm is the preferred option for the rule-out of 30-day MACE thorn UA. (Advantageous Predictors of Acute Coronary Syndromes Evaluation [APACE]; NCT00470587). (C) 2019 the American College of Cardiology Foundation. Published by Elsevier. All rights reserved.
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