Abstract
BackgroundCommon ECG criteria such as ST-segment changes are of limited value in patients with suspected acute myocardial infarction (AMI) and bundle branch block or wide QRS complex. A large proportion of these patients do not suffer from an AMI, whereas those with ST-elevation myocardial infarction (STEMI) equivalent AMI benefit from an aggressive treatment. Aim of the present study was to evaluate the diagnostic information of cardiac troponin I (cTnI) in hemodynamically stable patients with wide QRS complex and suspected AMI.MethodsIn 417 out of 1818 patients presenting consecutively between 01/2007 and 12/2008 in a prospective multicenter observational study with suspected AMI a prolonged QRS duration was observed. Of these, n = 117 showed significant obstructive coronary artery disease (CAD) used as diagnostic outcome variable. cTnI was determined at admission.ResultsPatients with significant CAD had higher cTnI levels compared to individuals without (median 250ng/L vs. 11ng/L; p<0.01). To identify patients needing a coronary intervention, cTnI yielded an area under the receiver operator characteristics curve of 0.849. Optimized cut-offs with respect to a sensitivity driven rule-out and specificity driven rule-in strategy were established (40ng/L/96ng/L). Application of the specificity optimized cut-off value led to a positive predictive value of 71% compared to 59% if using the 99th percentile cut-off. The sensitivity optimized cut-off value was associated with a negative predictive value of 93% compared to 89% provided by application of the 99th percentile threshold.ConclusioncTnI determined in hemodynamically stable patients with suspected AMI and wide QRS complex using optimized diagnostic thresholds improves rule-in and rule-out with respect to presence of a significant obstructive CAD.
Highlights
In patients presenting to an emergency room (ER) with acute chest pain, the electrocardiogram (ECG) is a major cornerstone for timely diagnose of an acute myocardial infarction (AMI) based on the presence of ST-elevations
Patients presenting with an ST-elevation myocardial infarction (STEMI) require aggressive and immediate further treatment including an early percutaneous coronary intervention (PCI) or fibrinolytic therapy according to current guidelines[1,2]
According to former guidelines of the European Society of Cardiology (ESC) and the American Heart Association (AHA), patients presenting with acute chest pain, whose ECG shows an assumingly new left bundle branch block (LBBB) should be treated as STelevation myocardial infarction (STEMI) with immediate emergency coronary angiography / fibrinolytic therapy [2,5]
Summary
In patients presenting to an emergency room (ER) with acute chest pain, the electrocardiogram (ECG) is a major cornerstone for timely diagnose of an acute myocardial infarction (AMI) based on the presence of ST-elevations. Patients presenting with an ST-elevation myocardial infarction (STEMI) require aggressive and immediate further treatment including an early percutaneous coronary intervention (PCI) or fibrinolytic therapy according to current guidelines[1,2]. Patients suffering from acute chest pain, presenting without electrocardiographic ST elevations, undergo serial biomarker testing, preferably cardiac troponin I/T, to diagnose or to rule out a non-ST-elevation myocardial infarction (NSTEMI)[3]. In these patients, an early interventional strategy is not always the preferred therapeutic approach[4]. Common ECG criteria such as ST-segment changes are of limited value in patients with suspected acute myocardial infarction (AMI) and bundle branch block or wide QRS complex. Aim of the present study was to evaluate the diagnostic information of cardiac troponin I (cTnI) in hemodynamically stable patients with wide QRS complex and suspected AMI
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