Optimising the use of high-sensitivity troponin assays for the early rule-out of myocardial infarction in patients presenting with chest pain: A systematic review

Marie E Westwood, Nigel Armstrong, Gill Worthy, Debra Fayter, Bram LT Ramaekers, Sabine Grimm, Titas Buksnys, Janine Ross, Nicholas L Mills, Richard Body, Paul O Collinson, Adam Timmis, Jos Kleijnen

Research output: Contribution to journalReview articlepeer-review

Abstract

Background: We assessed the accuracy and clinical effectiveness of high-sensitivity cardiac troponin (hs-cTn) assays for early rule-out of non-ST-segment elevation myocardial infarction (NSTEMI) in adults presenting with acute chest pain.
Methods: Sixteen databases were searched to September 2019. Review methods followed published guidelines. The bivariate model was used to estimate summary sensitivity and specificity with 95% confidence intervals for meta-analyses involving four or more studies, otherwise random-effects logistic regression was used.
Results: Thirty-seven studies (124 publications) were included in the review. The hs-cTn test strategies evaluated in the included studies were defined by the combination of four factors (assay, number of tests, timing of tests and threshold concentration or change in concentration between tests). Clinical opinion indicated a minimum acceptable sensitivity of 97%. A single test at presentation using a threshold at or near the assay limit of detection could reliably rule-out NSTEMI for a range of hs-cTn assays. Serial testing strategies, which include an immediate rule-out step, increased the proportion ruled out without loss of sensitivity. Finally, serial testing strategies without an immediate rule-out step had excellent sensitivity and specificity, but at the expense of the option for immediate patient discharge.
Conclusion: Test strategies that comprise an initial rule-out step, based on low hs-cTn concentrations at presentation and a minimum symptom duration, and a second step for those not ruled-out that incorporates a small absolute change in hs-cTn at 1, 2 or 3 hours, produce the highest rule-out rates with a very low risk of missed NSTEMI.
Original languageEnglish
JournalClinical Chemistry
Early online date22 Nov 2020
DOIs
Publication statusE-pub ahead of print - 22 Nov 2020

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