Direct Comparison of 4 Very Early Rule-Out Strategies for Acute
Myocardial Infarction Using High-Sensitivity Cardiac Troponin I

BOEDDINGHAUS, J., T. NESTELBERGER, R. TWERENBOLD, K. WILDI, P. BADERTSCHER, J. CUPA, T. BURGE, P. MACHLER, S. CORBIERE, K. GRIMM, M.R. GIMENEZ, C. PUELACHER, S. SHRESTHA, D.F. WIDMER, J. FUHRMANN, P. HILLINGER, Z. SABTI, U. HONEGGER, N. SCHAERLI, N. KOZHUHAROV, K. RENTSCH, O. MIRO, B. LOPEZ, F.J. MARTIN-SANCHEZ, E. RODRIGUEZ-ADRADA, B. MORAWIEC, D. KAWECKI, Eva GANOVSKÁ, Jiří PAŘENICA, J. LOHRMANN, W. KLOOS, A. BUSER, N. GEIGY, D.I. KELLER, S. OSSWALD, T. REICHLIN and C. MUELLER. Direct Comparison of 4 Very Early Rule-Out Strategies for Acute Myocardial Infarction Using High-Sensitivity Cardiac Troponin I. Circulation. Philadelphia: Lippincott Williams Wilkins, 2017, vol. 135, No 17, p. "1597"-"+", 31 pp. ISSN 0009-7322. Available from: https://dx.doi.org/10.1161/CIRCULATIONAHA.116.025661.

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TY  - JOUR
ID  - 1390863
AU  - Boeddinghaus, J. - Nestelberger, T. - Twerenbold, R. - Wildi, K. - Badertscher, P. - Cupa, J. - Burge, T. - Machler, P. - Corbiere, S. - Grimm, K. - Gimenez, M.R. - Puelacher, C. - Shrestha, S. - Widmer, D.F. - Fuhrmann, J. - Hillinger, P. - Sabti, Z. - Honegger, U. - Schaerli, N. - Kozhuharov, N. - Rentsch, K. - Miro, O. - Lopez, B. - Martin-Sanchez, F.J. - Rodriguez-Adrada, E. - Morawiec, B. - Kawecki, D. - Ganovská, Eva - Pařenica, Jiří - Lohrmann, J. - Kloos, W. - Buser, A. - Geigy, N. - Keller, D.I. - Osswald, S. - Reichlin, T. - Mueller, C.
PY  - 2017
TI  - Direct Comparison of 4 Very Early Rule-Out Strategies for Acute Myocardial Infarction Using High-Sensitivity Cardiac Troponin I
JF  - Circulation
VL  - 135
IS  - 17
SP  - "1597"-"+"
EP  - "1597"-"+"
PB  - Lippincott Williams Wilkins
SN  - 00097322
KW  - diagnosis
KW  - myocardial infarction
KW  - rule-out strategies
N2  - BACKGROUND: Four strategies for very early rule-out of acute myocardial infarction using high-sensitivity cardiac troponin I (hs-cTnI) have been identified. It remains unclear which strategy is most attractive for clinical application. METHODS: We prospectively enrolled unselected patients presenting to the emergency department with symptoms suggestive of acute myocardial infarction. The final diagnosis was adjudicated by 2 independent cardiologists. Hs-cTnI levels were measured at presentation and after 1 hour in a blinded fashion. We directly compared all 4 hs-cTnI-based rule-out strategies: limit of detection (LOD, hs-cTnI<2 ng/L), single cutoff (hs-cTnI<5 ng/L), 1-hour algorithm (hs-cTnI<5 ng/L and 1-hour change<2 ng/L), and the 0/1-hour algorithm recommended in the European Society of Cardiology guideline combining LOD and 1-hour algorithm. RESULTS: Among 2828 enrolled patients, acute myocardial infarction was the final diagnosis in 451 (16%) patients. The LOD approach ruled out 453 patients (16%) with a sensitivity of 100% (95% confidence interval [CI], 99.2%-100%), the single cutoff 1516 patients (54%) with a sensitivity of 97.1% (95% CI, 95.1%-98.3%), the 1-hour algorithm 1459 patients (52%) with a sensitivity of 98.4% (95% CI, 96.8%-99.2%), and the 0/1-hour algorithm 1463 patients (52%) with a sensitivity of 98.4% (95% CI, 96.8%-99.2%). Predefined subgroup analysis in early presenters (<= 2 hours) revealed significantly lower sensitivity (94.2%, interaction P=0.03) of the single cutoff, but not the other strategies. Two-year survival was 100% with LOD and 98.1% with the other strategies (P<0.01 for LOD versus each of the other strategies). CONCLUSIONS: All 4 rule-out strategies balance effectiveness and safety equally well. The single cutoff should not be applied in early presenters, whereas the 3 other strategies seem to perform well in this challenging subgroup.
ER  -

Basic information
Original name	Direct Comparison of 4 Very Early Rule-Out Strategies for Acute Myocardial Infarction Using High-Sensitivity Cardiac Troponin I
Authors	BOEDDINGHAUS, J. (380 Italy), T. NESTELBERGER (380 Italy), R. TWERENBOLD (380 Italy), K. WILDI (380 Italy), P. BADERTSCHER (380 Italy), J. CUPA (380 Italy), T. BURGE (756 Switzerland), P. MACHLER (756 Switzerland), S. CORBIERE (380 Italy), K. GRIMM (380 Italy), M.R. GIMENEZ (380 Italy), C. PUELACHER (380 Italy), S. SHRESTHA (380 Italy), D.F. WIDMER (380 Italy), J. FUHRMANN (756 Switzerland), P. HILLINGER (380 Italy), Z. SABTI (380 Italy), U. HONEGGER (380 Italy), N. SCHAERLI (380 Italy), N. KOZHUHAROV (380 Italy), K. RENTSCH (756 Switzerland), O. MIRO (724 Spain), B. LOPEZ (724 Spain), F.J. MARTIN-SANCHEZ (724 Spain), E. RODRIGUEZ-ADRADA (724 Spain), B. MORAWIEC (616 Poland), D. KAWECKI (616 Poland), Eva GANOVSKÁ (703 Slovakia, belonging to the institution), Jiří PAŘENICA (203 Czech Republic, guarantor, belonging to the institution), J. LOHRMANN (756 Switzerland), W. KLOOS (756 Switzerland), A. BUSER (756 Switzerland), N. GEIGY (756 Switzerland), D.I. KELLER (756 Switzerland), S. OSSWALD (756 Switzerland), T. REICHLIN (756 Switzerland) and C. MUELLER (756 Switzerland).
Edition	Circulation, Philadelphia, Lippincott Williams Wilkins, 2017, 0009-7322.

Other information
Original language	English
Type of outcome	Article in a journal
Field of Study	30201 Cardiac and Cardiovascular systems
Country of publisher	United States of America
Confidentiality degree	is not subject to a state or trade secret
Impact factor	Impact factor: 18.881
RIV identification code	RIV/00216224:14110/17:00097703
Organization unit	Faculty of Medicine
Doi	http://dx.doi.org/10.1161/CIRCULATIONAHA.116.025661
UT WoS	000400006400010
Keywords in English	diagnosis; myocardial infarction; rule-out strategies
Tags	EL OK
Tags	International impact, Reviewed
Changed by	Changed by: Soňa Böhmová, učo 232884. Changed: 21/3/2018 16:03.

Abstract

BACKGROUND: Four strategies for very early rule-out of acute myocardial infarction using high-sensitivity cardiac troponin I (hs-cTnI) have been identified. It remains unclear which strategy is most attractive for clinical application. METHODS: We prospectively enrolled unselected patients presenting to the emergency department with symptoms suggestive of acute myocardial infarction. The final diagnosis was adjudicated by 2 independent cardiologists. Hs-cTnI levels were measured at presentation and after 1 hour in a blinded fashion. We directly compared all 4 hs-cTnI-based rule-out strategies: limit of detection (LOD, hs-cTnI<2 ng/L), single cutoff (hs-cTnI<5 ng/L), 1-hour algorithm (hs-cTnI<5 ng/L and 1-hour change<2 ng/L), and the 0/1-hour algorithm recommended in the European Society of Cardiology guideline combining LOD and 1-hour algorithm. RESULTS: Among 2828 enrolled patients, acute myocardial infarction was the final diagnosis in 451 (16%) patients. The LOD approach ruled out 453 patients (16%) with a sensitivity of 100% (95% confidence interval [CI], 99.2%-100%), the single cutoff 1516 patients (54%) with a sensitivity of 97.1% (95% CI, 95.1%-98.3%), the 1-hour algorithm 1459 patients (52%) with a sensitivity of 98.4% (95% CI, 96.8%-99.2%), and the 0/1-hour algorithm 1463 patients (52%) with a sensitivity of 98.4% (95% CI, 96.8%-99.2%). Predefined subgroup analysis in early presenters (<= 2 hours) revealed significantly lower sensitivity (94.2%, interaction P=0.03) of the single cutoff, but not the other strategies. Two-year survival was 100% with LOD and 98.1% with the other strategies (P<0.01 for LOD versus each of the other strategies). CONCLUSIONS: All 4 rule-out strategies balance effectiveness and safety equally well. The single cutoff should not be applied in early presenters, whereas the 3 other strategies seem to perform well in this challenging subgroup.

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