Publication details

Comparison of fourteen rule-out strategies for acute myocardial infarction

Authors	WILDI Karin BOEDDINGHAUS Jasper NESTELBERGER Thomas TWERENBOLD Raphael BADERTSCHER Patrick WUSSLER Desiree GIMENEZ Maria Rubini PUELACHER Christian LAVALLAZ Jeanne du Fay de DIETSCHE Sebastian WALTER Joan KOZHUHAROV Nikola MORAWIEC Beata MIRO Oscar MARTIN-SANCHEZ Javier F. SUBRAMANIAM Sinthuri GEIGY Nicolas KELLER Dagmar I. REICHLIN Tobias MUELLER Christian MUELLER Deborah SAZGARY Lorraine MARBOT Stella SABTI Zaid FLORES Dayana MEISSNER Kathrin KULANGARA Caroline FREESE Michael OSSWALD Stefan STELZIG Claudia BINGISSER Roland LOPEZ Beatriz AGUERO María M. NOWALANY-KOZIELSKA Ewa KAWECKI Damian PAŘENICA Jiří GANOVSKÁ Eva LOHRMANN Jens BUSER Andreas FLORES Dayana GRIMM Karin HARTMANN Beate MUZYK Piotr RENTSCH Katharina ECKARDSTEIN Arnold von
Year of publication	2019
Type	Article in Periodical
Magazine / Source	International Journal of Cardiology
MU Faculty or unit	Faculty of Medicine
Citation
web	http://dx.doi.org/10.1016/j.ijcard.2018.11.140
Doi	http://dx.doi.org/10.1016/j.ijcard.2018.11.140
Keywords	Acute myocardial infarction; Diagnosis; Rule-out; High-sensitivity cardiac troponin T and I; Rule-out algorithm; Efficacy
Description	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. (c) 2018 Elsevier B.V. All rights reserved.