Informace o publikaci

Direct Comparison of 4 Very Early Rule-Out Strategies for Acute Myocardial Infarction Using High-Sensitivity Cardiac Troponin I

Autoři	BOEDDINGHAUS J. NESTELBERGER T. TWERENBOLD R. WILDI K. BADERTSCHER P. CUPA J. BURGE T. MACHLER P. CORBIERE S. GRIMM K. GIMENEZ M.R. PUELACHER C. SHRESTHA S. WIDMER D.F. FUHRMANN J. HILLINGER P. SABTI Z. HONEGGER U. SCHAERLI N. KOZHUHAROV N. RENTSCH K. MIRO O. LOPEZ B. MARTIN-SANCHEZ F.J. RODRIGUEZ-ADRADA E. MORAWIEC B. KAWECKI D. GANOVSKÁ Eva PAŘENICA Jiří LOHRMANN J. KLOOS W. BUSER A. GEIGY N. KELLER D.I. OSSWALD S. REICHLIN T. MUELLER C.
Rok publikování	2017
Druh	Článek v odborném periodiku
Časopis / Zdroj	Circulation
Fakulta / Pracoviště MU	Lékařská fakulta
Citace
Doi	http://dx.doi.org/10.1161/CIRCULATIONAHA.116.025661
Obor	Kardiovaskulární nemoci včetně kardiochirurgie
Klíčová slova	diagnosis; myocardial infarction; rule-out strategies
Popis	BACKGROUND: Four strategies for very early rule-out of acute myocardial infarction using high-sensitivity cardiac troponin I (hs-cTnI) have been identified. It remains unclear which strategy is most attractive for clinical application. METHODS: We prospectively enrolled unselected patients presenting to the emergency department with symptoms suggestive of acute myocardial infarction. The final diagnosis was adjudicated by 2 independent cardiologists. Hs-cTnI levels were measured at presentation and after 1 hour in a blinded fashion. We directly compared all 4 hs-cTnI-based rule-out strategies: limit of detection (LOD, hs-cTnI<2 ng/L), single cutoff (hs-cTnI<5 ng/L), 1-hour algorithm (hs-cTnI<5 ng/L and 1-hour change<2 ng/L), and the 0/1-hour algorithm recommended in the European Society of Cardiology guideline combining LOD and 1-hour algorithm. RESULTS: Among 2828 enrolled patients, acute myocardial infarction was the final diagnosis in 451 (16%) patients. The LOD approach ruled out 453 patients (16%) with a sensitivity of 100% (95% confidence interval [CI], 99.2%-100%), the single cutoff 1516 patients (54%) with a sensitivity of 97.1% (95% CI, 95.1%-98.3%), the 1-hour algorithm 1459 patients (52%) with a sensitivity of 98.4% (95% CI, 96.8%-99.2%), and the 0/1-hour algorithm 1463 patients (52%) with a sensitivity of 98.4% (95% CI, 96.8%-99.2%). Predefined subgroup analysis in early presenters (<= 2 hours) revealed significantly lower sensitivity (94.2%, interaction P=0.03) of the single cutoff, but not the other strategies. Two-year survival was 100% with LOD and 98.1% with the other strategies (P<0.01 for LOD versus each of the other strategies). CONCLUSIONS: All 4 rule-out strategies balance effectiveness and safety equally well. The single cutoff should not be applied in early presenters, whereas the 3 other strategies seem to perform well in this challenging subgroup.