Diagnostic Accuracy of a New High-Sensitivity Troponin I Assay and Five Accelerated Diagnostic Pathways for Ruling
Jaimi H Greenslade1, Edward W Carlton2, Christopher Van Hise3
1Department of Emergency Medicine, Royal Brisbane and Women's Hospital, Herston, Queensland, Australia; School of Medicine, The University of Queensland, Brisbane, Queensland, Australia.
Insights
The Vancouver Chest Pain Rule and No Objective Testing Rule demonstrated high sensitivity for acute myocardial infarction and acute coronary syndrome, allowing safe discharge for one-third of patients. Other pathways identified half of emergency department patients for rapid testing.
Area of Science:
- Cardiology
- Emergency Medicine
- Clinical Diagnostics
Background:
- Chest pain is a common emergency department presentation.
- Accurate risk stratification is crucial for timely diagnosis and management of acute coronary syndromes.
- High-sensitivity troponin assays have improved the detection of myocardial injury.
Purpose of the Study:
- To evaluate the diagnostic accuracy of five accelerated chest pain pathways using a new high-sensitivity troponin I assay.
- To compare the performance of the Vancouver Chest Pain Rule, No Objective Testing Rule, modified accelerated diagnostic protocol (m-ADAPT), Emergency Department Assessment of Chest Pain Score (EDACS), and History, ECG, Age, Risk Factors, and Troponin (HEART) pathway.
Main Methods:
- A diagnostic accuracy study involving 1,811 emergency department patients in Australia.
- Measurement of high-sensitivity troponin I at presentation and 2 hours.
- Classification of patients as low-risk using five distinct chest pain rules.
- Calculation of diagnostic accuracy measures for 30-day acute myocardial infarction and acute coronary syndrome endpoints.
Main Results:
- The Vancouver Chest Pain Rule and No Objective Testing Rule showed 100% sensitivity for acute myocardial infarction and high sensitivity for acute coronary syndrome.
- The m-ADAPT, EDACS, and HEART pathways demonstrated high sensitivity for acute myocardial infarction but lower sensitivity for acute coronary syndrome.
- The Vancouver Chest Pain Rule and No Objective Testing Rule identified fewer low-risk patients (28.2% and 34.5%) compared to m-ADAPT, EDACS, and HEART (64.3%, 62.5%, and 49.8%).
Conclusions:
- The Vancouver Chest Pain Rule and No Objective Testing Rule, combined with the Beckman's Access assay, enable safe discharge for approximately one-third of patients after 2-hour risk stratification.
- The EDACS, m-ADAPT, and HEART pathways facilitate rapid referral for objective testing in about half of emergency department patients.
- These accelerated pathways can optimize emergency department workflow for chest pain evaluation.
Study Objective:
This diagnostic accuracy study describes the performance of 5 accelerated chest pain pathways, calculated with the new Beckman's Access high-sensitivity troponin I assay.
Methods:
High-sensitivity troponin I was measured with presentation and 2-hour blood samples in 1,811 patients who presented to an emergency department (ED) in Australia. Patients were classified as being at low risk according to 5 rules: modified accelerated diagnostic protocol to assess patients with chest pain symptoms using troponin as the only biomarker (m-ADAPT), the Emergency Department Assessment of Chest Pain Score (EDACS) pathway, the History, ECG, Age, Risk Factors, and Troponin (HEART) pathway, the No Objective Testing Rule, and the new Vancouver Chest Pain Rule. Endpoints were 30-day acute myocardial infarction and acute coronary syndrome. Measures of diagnostic accuracy for each rule were calculated.
Results:
Data included 96 patients (5.3%) with acute myocardial infarction and 139 (7.7%) with acute coronary syndrome. The new Vancouver Chest Pain Rule and No Objective Testing Rule had high sensitivity for acute myocardial infarction (100%; 95% confidence interval [CI] 96.2% to 100% for both) and acute coronary syndrome (98.6% [95% CI 94.9% to 99.8%] and 99.3% [95% CI 96.1% to 100%]). The m-ADAPT, EDACS, and HEART pathways also yielded high sensitivity for acute myocardial infarction (96.9% [95% CI 91.1% to 99.4%] for m-ADAPT and 97.9% [95% CI 92.7% to 99.7%] for EDACS and HEART), but lower sensitivity for acute coronary syndrome (≤95.0% for all). The m-ADAPT, EDACS, and HEART rules classified more patients as being at low risk (64.3%, 62.5%, and 49.8%, respectively) than the new Vancouver Chest Pain Rule and No Objective Testing Rule (28.2% and 34.5%, respectively).
Conclusion:
In this cohort with a low prevalence of acute myocardial infarction and acute coronary syndrome, using the Beckman's Access high-sensitivity troponin I assay with the new Vancouver Chest Pain Rule or No Objective Testing Rule enabled approximately one third of patients to be safely discharged after 2-hour risk stratification with no further testing. The EDACS, m-ADAPT, or HEART pathway enabled half of ED patients to be rapidly referred for objective testing.
More Related Videos
06:16Signal Acquisition, Score Interpretation, and Economics of a Non-Invasive Point-of-Care Test for Coronary Artery Disease
Published on: August 9, 2024
10:12A Sensitive and Specific Quantitation Method for Determination of Serum Cardiac Myosin Binding Protein-C by Electrochemiluminescence Immunoassay
Published on: August 8, 2013
Related Concept Videos
01:30Acute Coronary Syndrome III: Diagnostic Studies
01:30Acute Coronary Syndrome I: Introduction
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...
01:19Acute Coronary Syndrome II: Pathophysiology and Clinical Manifestations
01:27Myocarditis II: Clinical Features and Diagnostic Tests
01:28Acute Coronary Syndrome IV: Interprofessional Care