Comparison of fourteen rule-out strategies for acute myocardial infarction

Int J Cardiol. 2019 May 15:283:41-47. doi: 10.1016/j.ijcard.2018.11.140. Epub 2018 Dec 3.

Abstract

Background: The clinical availability of high-sensitivity cardiac troponin (hs-cTn) has enabled the development of several innovative strategies for the rapid rule-out of acute myocardial infarction (AMI). Due to the lack of direct comparisons, selection of the best strategy for clinical practice is challenging.

Methods: In a prospective international multicenter diagnostic study enrolling 3696 patients presenting with suspected AMI to the emergency department, we compared the safety and efficacy of 14 different hs-cTn-based strategies: hs-cTn concentrations below the limit of detection (LoD), dual-marker combining hs-cTn with copeptin, ESC 0 h/1 h-algorithm, 0 h/2 h-algorithm, 2 h-ADP-algorithm, NICE-algorithm, and ESC 0 h/3 h-algorithm, each using either hs-cTnT or hs-cTnI. The final diagnosis of AMI was adjudicated by two independent cardiologists using all available clinical information including cardiac imaging and serial hs-cTn concentrations.

Results: AMI was the final diagnosis in 16% of patients. Using hs-cTnT, safety quantified by the negative predictive value (NPV) and sensitivity was very high (99.8-100% and 99.5-100%) and comparable for all strategies, except the dual-marker approach (NPV 98.7%, sensitivity 96.7%). Similarly, using hs-cTnI, safety quantified by the NPV and sensitivity was very high (99.7-100% and 98.9-100%) and comparable for all strategies, except the dual-marker approach (NPV 96.9%, sensitivity 90.4%) and the NICE-algorithm (NPV 99.1%, sensitivity 94.7%). Efficacy, quantified by the percentage of patients eligible for rule-out, differed markedly, and was lowest for LoD-algorithm (15.7-26.8%).

Conclusion: All rapid rule-out algorithms, except the dual-marker strategy and the NICE-algorithm using hs-cTnI, favorably combine safety and efficacy, and can be considered for routine clinical practice.

Clinical trial registration: NCT00470587, http://clinicaltrials.gov/show/NCT00470587.

Keywords: Acute myocardial infarction; Diagnosis; Efficacy; High-sensitivity cardiac troponin T and I; Rule-out; Rule-out algorithm.

Publication types

  • Comparative Study
  • Multicenter Study

MeSH terms

  • Aged
  • Aged, 80 and over
  • Algorithms*
  • Biomarkers / blood
  • Coronary Angiography
  • Coronary Care Units
  • Electrocardiography
  • Female
  • Follow-Up Studies
  • Humans
  • Male
  • Middle Aged
  • Myocardial Infarction / diagnosis*
  • Practice Guidelines as Topic*
  • Predictive Value of Tests
  • Prospective Studies
  • Time Factors
  • Triage / standards*
  • Troponin I / blood*
  • Troponin T / blood*

Substances

  • Biomarkers
  • Troponin I
  • Troponin T

Associated data

  • ClinicalTrials.gov/NCT00470587