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Background: High-sensitivity cardiac troponin assays enable myocardial infarction to be ruled out earlier, but the optimal approach is uncertain. We compared the European Society of Cardiology (ESC) rule-out pathway, with a pathway that incorporates lower cardiac troponin concentrations to risk stratify patients.
Methods: Patients with suspected acute coronary syndrome (n=1,218) underwent high-sensitivity cardiac troponin I measurement at presentation, 3 and 6 or 12 hours. We compared the ESC pathway (<99th centile at presentation, or at 3 hours if symptoms <6 hours) with a pathway developed in the High-Sensitivity Troponin in the Evaluation of patients with Acute Coronary Syndrome (High-STEACS) study population (<5 ng/L at presentation, or change <3 ng/L and <99th centile at 3 hours). The primary outcome was a comparison of the negative predictive value (NPV) of both pathways for index type 1 myocardial infarction, or type 1 myocardial infarction or cardiac death at 30 days. We evaluated the primary outcome in pre-specified subgroups stratified by age, gender, time of symptom onset and known ischaemic heart disease.
Results: The primary outcome occurred in 15.7% (191/1,218) patients. In those <99th centile at presentation, the ESC pathway ruled out myocardial infarction in 28.1% (342/1,218) and 78.9% (961/1,218) at presentation and 3 hours respectively, missing 18 index and two 30-day events (NPV 97.9%, 95% confidence intervals [CI] 96.9-98.7%). The High-STEACS pathway ruled out 40.7% (496/1,218) and 74.2% (904/1,218) at presentation and 3 hours, missing two index and two 30-day events (NPV 99.5%, 95% CI 99.0-99.9%; P<0.001 for comparison). The NPV of the High-STEACS pathway was greater than the ESC pathway overall (P<0.001), and in all subgroups including those presenting early or known to have ischaemic heart disease.
Conclusions: Use of the High-STEACS pathway incorporating low high-sensitivity cardiac troponin concentrations rules out myocardial infarction in more patients at presentation and misses 5-fold fewer index myocardial infarctions than guideline approved pathways based exclusively on the 99th centile.
Clinical Trial Registration: URL: https://clinicaltrials.gov Unique Identifier: NCT:01852123.
- acute coronary syndrome
- myocardial infarction
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- 5 Finished
2/02/16 → 1/02/21
1/07/15 → 30/09/18