Accelerated diagnostic pathways for myocardial infarction using a Siemens High-Sensitivity cardiac troponin I assay
Hiroyuki Azuma1, Masafumi Tada2, Hideyuki Matano3
1Department of Emergency Medicine, Fukui Prefectural Hospital, Fukui, Japan.
Insights
The High-STEACS pathway efficiently diagnosed myocardial infarction (MI) in early presenters using high-sensitivity cardiac troponin I (hs-cTnI) testing. This pathway ruled out many patients without missing any MI cases, ensuring safety and efficiency.
Area of Science:
- Cardiology
- Emergency Medicine
- Biomarker Assays
Background:
- Limited research exists on high-sensitivity cardiac troponin I (hs-cTnI) diagnostic pathways for myocardial infarction (MI) in early presenters.
- The Siemens ADVIA Centaur hs-cTnI assay is widely used, necessitating evaluation of its associated diagnostic strategies.
Purpose of the Study:
- To comprehensively evaluate the efficiency and safety of various hs-cTnI-based diagnostic pathways for suspected MI in emergency department patients.
- To compare pathways utilizing hs-cTnI alone versus those incorporating clinical data.
Main Methods:
- A prospective multicenter cohort study involving 414 patients presenting to the Emergency Department within 6 hours of symptom onset.
- Evaluation of three hs-cTnI-only pathways (High-STEACS, ESC 0/1-h, 0/2-h) and four clinical data-inclusive pathways (ADAPT, EDACS, HEART, GRACE).
- Assessment of negative predictive value (NPV), sensitivity, and percentage of patients ruled out for a primary outcome of type 1 MI or cardiac death within 30 days.
Main Results:
- The High-STEACS pathway ruled out 62.0% of patients with no missed MI cases, demonstrating superior efficiency.
- ESC 0/1-h and 0/2-h pathways had high NPV and sensitivity but ruled out fewer patients (35.9%-45.2%).
- Clinical pathways (ADAPT, EDACS, HEART) showed good safety but lower efficiency (15-27% ruled out); GRACE pathway missed two outcomes.
Conclusions:
- The High-STEACS pathway is the most efficient hs-cTnI-based strategy for early MI presenters.
- This pathway maintains excellent safety performance, making it a valuable tool in emergency cardiology.
- Consideration of hs-cTnI levels in elderly patients without MI is crucial, as many show elevated baseline concentrations.
Background:
Few studies have comprehensively examined high-sensitivity cardiac troponin I (hs-cTnI) based diagnostic pathways for myocardial infarction (MI) in early presenters using a Siemens ADVIA Centaur hs-cTnI assay.
Methods:
We conducted a prospective multicenter cohort study in Emergency Departments involving 414 patients suspected of MI within 6 h of symptom onset. We evaluated three hs-cTnI-based pathways (High-STEACS, ESC 0/1-h, 0/2-h); and four pathways incorporating medical history and physical findings (ADAPT, EDACS, HEART, GRACE). We evaluated negative predictive value (NPV) and sensitivity as safety measures, and percentage ruled out as an efficiency measure for a primary outcome of type 1 myocardial infarction or cardiac death within 30 days.
Results:
Median age was 72 years (interquartile range 58-82), and 30.4 % (126/414) of patients were over 80. Females comprised 44.2 % (183/414) of patients, 87.7 % (363/414) had chest pain, and the primary outcome occurred in 9.2 % (38/414). The High-STEACS pathway ruled out 62.0 % of patients without missing a case of an MI. The ESC 0/1-h and 0/2-h pathways showed high NPV and sensitivities; however, they ruled out fewer patients (35.9 % and 45.2 %, respectively). The ADAPT, EDACS, and HEART pathways demonstrated high NPV and sensitivities but ruled out fewer patients (15-27 %). The GRACE pathway missed 2 cases with primary clinical outcomes. Among patients over 80 without MI, initial hs-cTnI concentration was ≥ 3 ng/L in 99.1 % and ≥ 5 ng/L in 84.1 %.
Conclusions:
The High-STEACS pathway was the most efficient among the hs-cTnI-based pathways while maintaining excellent safety performance in early presenters.
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