Immediate Rule-Out of Acute Myocardial Infarction Using Electrocardiogram and Baseline High-Sensitivity Troponin I
Johannes Tobias Neumann1,2, Nils Arne Sörensen3, Francisco Ojeda3
1Department of General and Interventional Cardiology, University Heart Center Hamburg Eppendorf, Hamburg, Germany; j.neumann@uke.de.
Insights
A single high-sensitivity troponin I measurement and low-risk ECG can safely rule out acute myocardial infarction (AMI). This approach avoids serial troponin testing, improving efficiency in diagnosing chest pain patients.
Area of Science:
- Cardiology
- Biomarker Research
- Emergency Medicine
Background:
- Current guidelines for ruling out acute myocardial infarction (AMI) rely on serial high-sensitivity troponin measurements.
- This study investigates an alternative strategy using a single troponin measurement and electrocardiogram (ECG) to expedite diagnosis.
Purpose of the Study:
- To evaluate the performance of a single admission high-sensitivity troponin I (hs-TnI) measurement with a lower cutoff, combined with a low-risk ECG, for ruling out AMI.
- To determine the negative predictive value (NPV) and safety of this accelerated diagnostic protocol.
Main Methods:
- Prospective study (BACC) of 1040 patients with suspected AMI, measuring hs-TnI at admission.
- Calculated NPV for ruling out AMI using an optimal hs-TnI cutoff (3 ng/L) and low-risk ECG.
- Validated findings in 3566 patients from the ADAPT studies, with 6-12 month follow-up.
Main Results:
- A single hs-TnI cutoff of 3 ng/L achieved a 99.3% NPV, ruling out 35% of non-AMI patients.
- Combining hs-TnI with a low-risk ECG yielded a 100% NPV, ruling out 28% of patients.
- Validation cohorts confirmed high NPV; follow-up showed low mortality in ruled-out populations.
Conclusions:
- A single hs-TnI measurement on admission, coupled with a low-risk ECG, can safely rule out AMI.
- This strategy potentially eliminates the need for serial troponin testing in suspected AMI cases.
Aims:
Serial measurements of high-sensitivity troponin are used to rule out acute myocardial infarction (AMI) with an assay specific cutoff at the 99th percentile. Here, we evaluated the performance of a single admission troponin with a lower cutoff combined with a low risk electrocardiogram (ECG) to rule out AMI.
Methods:
Troponin I measured with a high-sensitivity assay (hs-TnI) was determined at admission in 1040 patients presenting with suspected AMI (BACC study). To rule out AMI we calculated the negative predictive value (NPV) utilizing the optimal hs-TnI cutoff combined with a low risk ECG. The results were validated in 3566 patients with suspected AMI [2-h Accelerated Diagnostic Protocol to Assess Patients With Chest Pain Symptoms Using Contemporary Troponins as the Only Biomarker (ADAPT) studies]. Patients were followed for 6 or 12 months.
Results:
184 of all patients were diagnosed with AMI. An hs-TnI cutoff of 3 ng/L resulted in a NPV of 99.3% (CI 97.3-100.0), ruling out 35% of all non-AMI patients. Adding the information of a low risk ECG resulted in a 100% (CI 97.5-100.0) NPV (28% ruled out). The 2 validation cohorts replicated the high NPV of this approach. The follow-up mortality in the ruled out population was low (0 deaths in BACC and Stenocardia, 1 death in ADAPT).
Conclusions:
A single hs-TnI measurement on admission combined with a low risk ECG appears to rule out AMI safely without need for serial troponin testing.
Trial Registration:
www.clinicaltrials.gov (NCT02355457).
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