Related Experiment Video
Updated: Mar 19, 2026
Signal Acquisition, Score Interpretation, and Economics of a Non-Invasive Point-of-Care Test for Coronary Artery Disease
Published on: August 9, 2024
Validation of NICE diagnostic guidance for rule out of myocardial infarction using high-sensitivity troponin tests
W A Parsonage1, C Mueller2, J H Greenslade1
1Royal Brisbane & Women's Hospital, Herston, Australia.
Insights
The National Institute for Health and Care Excellence (NICE) algorithms for high-sensitivity troponin (hsTn) assays can identify low-risk acute myocardial infarction (AMI) patients but require further risk stratification due to significant major adverse cardiac events (MACE).
Area of Science:
- Cardiology
- Emergency Medicine
- Diagnostic Assay Validation
Background:
- Chest pain is a common emergency department presentation.
- Accurate and rapid diagnosis of acute myocardial infarction (AMI) is critical.
- High-sensitivity troponin (hsTn) assays are increasingly used for AMI rule-out.
Purpose of the Study:
- To validate the National Institute for Health and Care Excellence (NICE) recommended algorithms for hsTn assays.
- To assess the performance of NICE algorithms in identifying patients with low probability of AMI.
- To evaluate the rate of major adverse cardiac events (MACE) within 30 days for patients ruled out by these algorithms.
Main Methods:
- International post hoc analysis of three prospective, observational studies.
- Inclusion of adult patients presenting with chest pain to tertiary hospital emergency departments.
- Primary endpoint: cardiac death or AMI within 24 hours; Secondary endpoint: MACE at 30 days.
Main Results:
- hsTnI algorithm ruled out 80.1% of patients, with 2.0% missed MI. hsTnT algorithm ruled out 53.1%, with 0.4% missed MI.
- A significant proportion of patients had troponin levels below the limit of detection/blank.
- 30-day MACE rates were 10.7% (hsTnI) and 8.5% (hsTnT) for 'ruled out' patients.
Conclusions:
- NICE algorithms can identify low-probability AMI patients within 2 hours.
- Algorithm performance did not fully align with NICE diagnostic guidance predictions.
- The observed MACE rates necessitate using these algorithms as part of a broader risk stratification model.
Objective:
To validate the National Institute for Health and Care Excellence (NICE) recommended algorithms for high-sensitivity troponin (hsTn) assays in adults presenting with chest pain.
Methods:
International post hoc analysis of three prospective, observational studies from tertiary hospital emergency departments. The primary endpoint was cardiac death or acute myocardial infarction (AMI) within 24 hours of presentation, and the secondary endpoint was major adverse cardiac events (MACE) at 30 days.
Results:
15% of patients were diagnosed with non-ST elevation myocardial infarction (MI) on admission. The hsTnI algorithm classified 2506/3128 (80.1%) of patients as 'ruled out' with 50 (2.0%) missed MI. 943/3128 (30.1%) of patients had a troponin I level below the limit of detection on admission with 2 (0.2%) missed MI. For the hsTnT algorithm, 1794/3374 (53.1%) of patients were 'ruled out' with 7 (0.4%) missed MI. 490/3374 (14.5%) of patients had a troponin T below the limit of blank on admission with no MI. MACE at 30 days occurred in 10.7% and 8.5% of patients 'ruled out' defined by the hsTnI and hsTnT algorithms, respectively.
Conclusions:
The NICE algorithms could identify patients with low probability of AMI within 2 hours; however, neither strategy performed as predicted by the NICE diagnostic guidance model. Additionally, the rate of MACE at 30 days was sufficiently high that the algorithms should only be used as one component of a more extensive model of risk stratification.
Trial Registration Number:
ACTRN12611001069943, NCT00470587; post-results.
More Related Videos
07:40Impact of High-intensity Interval Exercise and Moderate-Intensity Continuous Exercise on the Cardiac Troponin T Level at an Early Stage of Training
Published on: October 10, 2019
18:11A Research Method For Detecting Transient Myocardial Ischemia In Patients With Suspected Acute Coronary Syndrome Using Continuous ST-segment Analysis
Published on: December 28, 2012
Related Concept Videos
01:30Acute Coronary Syndrome III: Diagnostic Studies
01:20Blood Studies for Cardiovascular System I: Cardiac Biomarkers
The essential diagnostic tools for detecting myocardial necrosis and monitoring individuals suspected of having acute coronary syndrome (ACS) include:
Troponins
Troponins, particularly cardiac troponins I and T, are the most precise and sensitive markers of myocardial injury. They are detectable within 4-6 hours of myocardial injury and remain...
01:27Myocarditis II: Clinical Features and Diagnostic Tests
01:25Imaging Studies for Cardiovascular System VI: Calcium -Scoring CT
01:30Acute Coronary Syndrome I: Introduction
01:29Angina III: Clinical Manifestations and Assessment