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Comparison of the Efficacy and Safety of Early Rule Out Pathways for Acute Myocardial Infarction

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  • Jasper Boeddinghaus
  • Amy Ferry
  • Dennis Sandeman
  • Jack P Andrews
  • Stephanie Tan
  • Sheun F Cheng
  • Michelle D'Souza
  • Kate Orme
  • Thomas Nestelberger
  • Raphael Twerenbold
  • Patrick Badertscher
  • Tobias Reichlin
  • Anoop S V Shah
  • Christian Mueller

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    Rights statement: Circulation is published on behalf of the American Heart Association, Inc., by Wolters Kluwer. This is an open access article under the terms of the Creative Commons Attribution Non-Commercial-NoDervis License (http://creativecommons.org/licenses/by-nc-nd/3.0/), which permits use, distribution, and reproduction in any medium, provided that the original work is properly cited, the use is noncommercial, and no modifications or adaptations are made.

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    Licence: Creative Commons: Attribution-NonCommercial-NoDerivatives (CC BY-NC-ND)

Original languageEnglish
JournalCirculation
DOIs
Publication statusPublished - 29 Dec 2016

Abstract

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: -https://clinicaltrials.gov Identifier: NCT:01852123.

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