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A 1-h Combination Algorithm Allows Fast Rule-Out and Rule-In of Major Adverse Cardiac Events

MOKHTARI, ARASH LU ; Cedercrantz-Borna, Catharina LU ; GILJE, PATRIK LU ; Tydén, Patrik LU ; Lindahl, Bertil ; Nilsson, Hans-Jörgen ; KHOSHNOOD, ARDAVAN LU ; Björk, Jonas LU and Ekelund, Ulf LU (2016) In Journal of the American College of Cardiology 67(13). p.1531-1540
Abstract
Background
A 1-h algorithm based on high-sensitivity cardiac troponin T (hs-cTnT) testing at presentation and again 1 h thereafter has been shown to accurately rule out acute myocardial infarction.

Objectives
The goal of the study was to evaluate the diagnostic accuracy of the 1-h algorithm when supplemented with patient history and an electrocardiogram (ECG) (the extended algorithm) for predicting 30-day major adverse cardiac events (MACE) and to compare it with the algorithm using hs-cTnT alone (the troponin algorithm).

Methods
This prospective observational study enrolled consecutive patients presenting to the emergency department (ED) with chest pain, for whom hs-cTnT testing was ordered at presentation.... (More)
Background
A 1-h algorithm based on high-sensitivity cardiac troponin T (hs-cTnT) testing at presentation and again 1 h thereafter has been shown to accurately rule out acute myocardial infarction.

Objectives
The goal of the study was to evaluate the diagnostic accuracy of the 1-h algorithm when supplemented with patient history and an electrocardiogram (ECG) (the extended algorithm) for predicting 30-day major adverse cardiac events (MACE) and to compare it with the algorithm using hs-cTnT alone (the troponin algorithm).

Methods
This prospective observational study enrolled consecutive patients presenting to the emergency department (ED) with chest pain, for whom hs-cTnT testing was ordered at presentation. Hs-cTnT results at 1 h and the ED physician’s assessments of patient history and ECG were collected. The primary outcome was an adjudicated diagnosis of 30-day MACE defined as acute myocardial infarction, unstable angina, cardiogenic shock, ventricular arrhythmia, atrioventricular block, cardiac arrest, or death of a cardiac or unknown cause.

Results
In the final analysis, 1,038 patients were included. The extended algorithm identified 60% of all patients for rule-out and had a higher sensitivity than the troponin algorithm (97.5% vs. 87.6%; p < 0.001). The negative predictive value was 99.5% and the likelihood ratio was 0.04 with the extended algorithm versus 97.8% and 0.17, respectively, with the troponin algorithm. The extended algorithm ruled-in 14% of patients with a higher sensitivity (75.2% vs. 56.2%; p < 0.001) but a slightly lower specificity (94.0% vs. 96.4%; p < 0.001) than the troponin algorithm. The rule-in arms of both algorithms had a likelihood ratio >10.

Conclusions
A 1-h combination algorithm allowed fast rule-out and rule-in of 30-day MACE in a majority of ED patients with chest pain and performed better than the troponin-alone algorithm. (Less)
Please use this url to cite or link to this publication:
author
organization
publishing date
type
Contribution to journal
publication status
published
subject
keywords
Troponin, ACS, Chest pain, Acute coronary syndrome
in
Journal of the American College of Cardiology
volume
67
issue
13
pages
10 pages
publisher
Elsevier USA
external identifiers
  • wos:000372893300006
  • pmid:27150684
  • scopus:85008912351
ISSN
0735-1097
DOI
10.1016/j.jacc.2016.01.059
project
AIR Lund Chest pain - More efficient and equal emergency care with advanced medical decision support tools
language
English
LU publication?
yes
id
4ffbe584-a2d9-48bb-89b9-4a50e47be0b2
alternative location
https://www.sciencedirect.com/science/article/pii/S0735109716006112?via%3Dihub
date added to LUP
2016-05-02 08:56:49
date last changed
2020-06-24 04:10:18
@article{4ffbe584-a2d9-48bb-89b9-4a50e47be0b2,
  abstract     = {Background<br>
A 1-h algorithm based on high-sensitivity cardiac troponin T (hs-cTnT) testing at presentation and again 1 h thereafter has been shown to accurately rule out acute myocardial infarction.<br>
<br>
Objectives<br>
The goal of the study was to evaluate the diagnostic accuracy of the 1-h algorithm when supplemented with patient history and an electrocardiogram (ECG) (the extended algorithm) for predicting 30-day major adverse cardiac events (MACE) and to compare it with the algorithm using hs-cTnT alone (the troponin algorithm).<br>
<br>
Methods<br>
This prospective observational study enrolled consecutive patients presenting to the emergency department (ED) with chest pain, for whom hs-cTnT testing was ordered at presentation. Hs-cTnT results at 1 h and the ED physician’s assessments of patient history and ECG were collected. The primary outcome was an adjudicated diagnosis of 30-day MACE defined as acute myocardial infarction, unstable angina, cardiogenic shock, ventricular arrhythmia, atrioventricular block, cardiac arrest, or death of a cardiac or unknown cause.<br>
<br>
Results<br>
In the final analysis, 1,038 patients were included. The extended algorithm identified 60% of all patients for rule-out and had a higher sensitivity than the troponin algorithm (97.5% vs. 87.6%; p &lt; 0.001). The negative predictive value was 99.5% and the likelihood ratio was 0.04 with the extended algorithm versus 97.8% and 0.17, respectively, with the troponin algorithm. The extended algorithm ruled-in 14% of patients with a higher sensitivity (75.2% vs. 56.2%; p &lt; 0.001) but a slightly lower specificity (94.0% vs. 96.4%; p &lt; 0.001) than the troponin algorithm. The rule-in arms of both algorithms had a likelihood ratio &gt;10.<br>
<br>
Conclusions<br>
A 1-h combination algorithm allowed fast rule-out and rule-in of 30-day MACE in a majority of ED patients with chest pain and performed better than the troponin-alone algorithm.},
  author       = {MOKHTARI, ARASH and Cedercrantz-Borna, Catharina and GILJE, PATRIK and Tydén, Patrik and Lindahl, Bertil and Nilsson, Hans-Jörgen and KHOSHNOOD, ARDAVAN and Björk, Jonas and Ekelund, Ulf},
  issn         = {0735-1097},
  language     = {eng},
  number       = {13},
  pages        = {1531--1540},
  publisher    = {Elsevier USA},
  series       = {Journal of the American College of Cardiology},
  title        = {A 1-h Combination Algorithm Allows Fast Rule-Out and Rule-In of Major Adverse Cardiac Events},
  url          = {http://dx.doi.org/10.1016/j.jacc.2016.01.059},
  doi          = {10.1016/j.jacc.2016.01.059},
  volume       = {67},
  year         = {2016},
}