Accelerated diagnostic protocol using high-sensitivity cardiac troponin T in acute chest pain patients
Bernadette Meller1, Louise Cullen2, William A Parsonage3
1Department of Cardiology, University Hospital, Basel, Switzerland.
Insights
An accelerated diagnostic protocol (ADP) using high-sensitivity cardiac troponin T (hs-cTnT) effectively identifies patients at very low risk for acute myocardial infarction (AMI). This approach enables safe, rapid rule-out of AMI and facilitates early discharge for a significant patient group.
Area of Science:
- Cardiology
- Emergency Medicine
- Biomarker Research
Background:
- Acute myocardial infarction (AMI) diagnosis relies on timely and accurate risk stratification.
- High-sensitivity cardiac troponin T (hs-cTnT) assays offer improved sensitivity for detecting myocardial injury.
- Accelerated diagnostic protocols (ADPs) aim to expedite the evaluation of patients with suspected AMI.
Purpose of the Study:
- To evaluate the efficacy and safety of an ADP incorporating hs-cTnT for rapid rule-out of AMI.
- To assess the protocol's performance in identifying low-risk patients for early discharge.
- To determine the negative predictive value and sensitivity of the ADP in large, independent cohorts.
Main Methods:
- Two large, multicenter studies involved consecutive patients presenting with symptoms suggestive of AMI.
- hs-cTnT levels at presentation and 2 hours were combined with the Thrombolysis In Myocardial Infarction (TIMI) risk score and ECG findings.
- The ADP identified low-risk candidates (normal hs-cTnT, TIMI score ≤1, normal ECG) for rapid AMI rule-out and discharge; 30-day major adverse cardiac events (MACE) were adjudicated.
Main Results:
- In the derivation cohort (1085 patients), the ADP identified 34.5% as low-risk, with 0 MACE (100% sensitivity, 100% NPV).
- In the validation cohort (1590 patients), the ADP identified 40.3% as low-risk, with 6 MACE (97.4% sensitivity, 99.1% NPV).
- The ADP demonstrated high sensitivity and negative predictive value for ruling out AMI.
Conclusions:
- The ADP integrating hs-cTnT enables early identification of 35-40% of patients at extremely low risk of MACE.
- These patients are suitable candidates for outpatient management, streamlining care pathways.
- The protocol supports safe and efficient early rule-out of AMI in selected emergency department populations.
Background:
We aimed to evaluate the efficacy and safety of using high-sensitivity cardiac troponin T (hs-cTnT) within an accelerated diagnostic protocol (ADP) in patients presenting with symptoms suggestive of acute myocardial infarction (AMI) for rapid rule-out of AMI.
Methods:
In two independent large multicenter studies, levels of hs-cTnT at presentation and at 2 h were combined with the Thrombolysis In Myocardial Infarction (TIMI) risk score and ECG findings. The ADP defined patients with normal levels of hs-cTnT at presentation and 2 h, a TIMI score ≤1, and normal ECG findings as candidates for rapid rule-out of AMI and rapid discharge. Major adverse cardiac events (MACEs) occurring within 30-days were centrally adjudicated by two independent cardiologists.
Results:
In the derivation cohort, among 1085 consecutive patients 198 patients (18.2%) had a MACE. The ADP classified 374 patients (34.5%) as low-risk. None of these patients had a MACE at 30 days, resulting in a negative predictive value (NPV) of 100% (95% CI, 99.0-100%) and a sensitivity of 100% (95% CI, 98.2%-100%). In the validation cohort, among 1590 consecutive patients 231 patients (14.5%) had a MACE. The ADP classified 641 patients (40.3%) as low-risk. 6 of these patients had a MACE at 30 days, resulting in a NPV of 99.1% (95% CI, 98.0-99.6%) and a sensitivity of 97.4% (95% CI, 94.5-98.8%).
Conclusions:
The ADP including hs-cTnT allows early identification 35 to 40% of patients to be at extremely low risk of MACE and therefore ideal candidates for outpatient management.
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