Home > Uncategorized > Validation Study High Sensitivity Troponin (0,3 hour) Rule In/Rule Out for Myocardial Infarction

Validation Study High Sensitivity Troponin (0,3 hour) Rule In/Rule Out for Myocardial Infarction

Pickering et al report an important validation study for the ESC rule in testing for myocardial infarction for patients presenting with suspected acute coronary syndrome.
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The authors found that hs-TnI and hs-TnI had good positive predictive value (diagnosing 50% of the acute myocardial infarctions). However, the sensitivity of the 99th percentile (and hence rule out) was too low for clinical practice.

Summary

Objective

International guidelines to rule-in acute myocardial infarction (AMI) in patients presenting with chest pain to the emergency department (ED) recommend an algorithm using high-sensitivity cardiac troponin (hs-cTn) sampling on presentation and 3 h following presentation. We tested the diagnostic accuracy of this algorithm by pooling data from five distinct cohorts from three countries of prospectively recruited patients with independently adjudicated outcomes.

Method

We measured high-sensitivity cardiac troponin I (hs-cTnI) and high-sensitivity cardiac troponin T (hscTnT) on presentation (0 h) and 3 h post-presentation samples in adult patients attending an ED with possible AMI to validate the European Society of Cardiology (ESC) Working Group on Acute Cardiac Care rule-in algorithm (ESC-rule-in). Specifically, (i) in patients witha 0 h hs-cTn concentration ≤99th percentile and a 3 h hs-cTn >99th percentile, positive patients are those with an absolute change in troponin ≥50% of the 99th percentile, and (ii) in patients with a 0 and 3 h hs-cTn >99th percentile, positive patients are those with a relative change in troponin of ≥20%. We concurrently assessed the efficacy of the 0 and 3 h hs-cTn <99th percentile to rule-out AMI. Results 1061 patients with hs-cTnI and 985 with hscTnT
were included. The ESC-rule-in positive predictive value (PPV) was 83.5% (95% CI 74.9% to 90.1%) for hs-cTnI and 72.0% (95% CI 62.1% to 80.5%) for hs-cTnT. Forty-six AMIs (34.9%) were not ruled in using hs-cTnI and 62 (46.2%) using hs-cTnT. The sensitivity of the 99th percentile to rule-out AMI was 93.2% (95% CI 87.5% to 96.8%) for hs-cTnI and 94.8% (95% CI
89.5% to 97.9%) for hs-cTnT.

Conclusions

The ESC-rule-in algorithm has good PPV with hs-cTnI and reasonable with hs-cTnT and can rule in over 50% of AMIs. However, the sensitivity of the 99th percentile to rule-out AMI is too low for clinical use.

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The editorial is available here

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