Validation of a 0-/2-Hour High-Sensitivity Cardiac Troponin Algorithm for Suspected Acute Coronary Syndrome in the
Dustin G Mark1,2,3, Jie Huang1, Keane K Lee1,4
1Division of Research Kaiser Permanente Northern California Pleasanton CA USA.
Insights
This study shows a high-sensitivity cardiac troponin I algorithm effectively evaluates non-ST-elevation acute coronary syndrome in the ED. The algorithm demonstrates high accuracy, with minor reductions in predictive value for specific patient groups.
Area of Science:
- Cardiology
- Emergency Medicine
- Diagnostic Algorithms
Background:
- An integrated health system implemented a high-sensitivity cardiac troponin I (hs-cTnI) algorithm for emergency department (ED) evaluation of non-ST-segment-elevation acute coronary syndrome (NSTE-ACS).
- This algorithm aims to streamline the diagnostic process for chest pain presentations in the ED.
Purpose of the Study:
- To assess the performance of an hs-cTnI-based algorithm for NSTE-ACS evaluation in a large, integrated health system.
- To determine the algorithm's accuracy, including sensitivity, specificity, and predictive values, across diverse patient subgroups.
Main Methods:
- A retrospective study analyzed 104,025 adult ED encounters for chest pain between January 2023 and June 2024.
- The study excluded ST-segment-elevation myocardial infarction and evaluated the primary outcome of 30-day myocardial infarction or death.
- Subgroup analyses were conducted based on age, sex, coronary artery disease, chronic kidney disease, and ED disposition.
Main Results:
- The algorithm demonstrated high overall performance, with 70% of encounters meeting rule-out criteria (sensitivity 95.4%, NPV 99.7%) and 7% meeting rule-in criteria (specificity 96.7%, PPV 60.2%).
- Negative predictive value for rule-out criteria was slightly reduced in patients with stage 4+ chronic kidney disease (96.1%) and ischemic coronary artery disease (98.6%).
- These reductions were largely mitigated by ED discharge disposition decisions, with NPVs of 98.4% and 99.1% respectively.
Conclusions:
- The hs-cTnI-based NSTE-ACS evaluation algorithm exhibits excellent overall performance within the Kaiser Permanente Northern California system.
- While NPV is modestly diminished in patients with ischemic coronary artery disease or advanced chronic kidney disease, the risk is effectively managed through ED discharge decisions.
Background:
We implemented a hs-cTnI (high-sensitivity cardiac troponin I)-based algorithm for emergency department (ED) evaluation of possible non-ST-segment-elevation acute coronary syndrome within an integrated health system (Kaiser Permanente Northern California).
Methods:
Retrospective study of adult (18+ years) ED encounters for chest pain/discomfort with hs-cTnI testing (Access hsTnI, Beckman) at 21 medical centers between January 1, 2023 and June 30, 2024, excluding ST-segment-elevation myocardial infarction. The primary outcome was 30-day myocardial infarction or death. Sensitivity, specificity, negative predictive value, positive predictive value, and likelihood ratios were reported, with subgroup analyses by age, sex, coronary artery disease, chronic kidney disease, and ED disposition.
Results:
There were 104 025 encounters in the final cohort (median age 59 years, 45% male, 18% coronary artery disease, and 13% chronic kidney disease). The primary outcome occurred in 5.5% encounters. Rule-out criteria were present in 70% of encounters (sensitivity, 95.4% [95% CI, 94.8%-96.0%]; negative predictive value, 99.7% [95% CI, 99.6%-99.7%]; likelihood ratio, -0.05) and 7% of encounters met rule-in criteria (specificity, 96.7% [95% CI, 96.6-96.8%]; positive predictive value, 60.2% [95% CI, 59.3%-61.1%]; likelihood ratio, +24.4). In subgroup analyses, rule-out criteria negative predictive value was below 99% in stage 4+ chronic kidney disease (96.1% [95% CI, 94.6%-97.6%]) and ischemic coronary artery disease (98.6% [95% CI 98.3-98.9%]), though not among those selected for ED discharge (98.4% [95% CI, 96.7%-99.2%] and 99.1% [95% CI, 98.8%-99.4%], respectively).
Conclusions:
The Kaiser Permanente Northern California non-ST-elevation acute coronary syndrome evaluation algorithm demonstrated excellent overall performance. Negative predictive value was modestly diminished in ischemic coronary artery disease or advanced chronic kidney disease, but risk was largely mitigated by ED discharge disposition decisions.
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