Exclusion Of Acute Coronary Syndrome Research Articles

Abstract 15666: Comprehensive Biopsy and Clinical Features In Coronavirus Disease 2019 Vaccine-Associated Myocarditis - From Nationwide Survey COMBAT Study in Japan -

Introduction: Few studies have reported on myocardial tissue findings of coronavirus disease 2019 (COVID-19) vaccine-associated myocarditis (CVAM). This study aimed to investigate the clinical and histopathological features of patients with CVAM. Methods: This is a multicenter and retrospective cohort study (COMBAT study) of patients who were clinically diagnosed with CVAM and underwent endomyocardial biopsy in 42 participating centers in Japan. The inclusion criteria were the following; 1. Occurrence of clinical symptoms within 30 days after getting the first or second dose of the COVID-19 vaccine between February 2021 and March 2022. 2. The exclusion of acute coronary syndrome using coronary angiography. 3. Abnormality of laboratory tests. Fulminant myocarditis (FM) was defined as catecholamine or mechanical support use during hospitalization. Results: A total of 44 patients were included. Fifteen of 44 (34%) patients were clinically diagnosed with FM. FM patients were older and showed fewer ratio of males than non-FM. Also, FM patients showed significantly a longer duration from vaccination to the occurrence of symptoms and less frequency of chest pain than non-FM (Table).In hematoxylin-eosin (HE) stained samples, 28 of 44 (64%) patients were histologically diagnosed with acute myocarditis. Among them, 24 patients were diagnosed with lymphocytic myocarditis (LM) and 4 with eosinophilic myocarditis (EM). In HE stained samples, 5 of 24 (21%) LM patients visually showed a high ratio of eosinophils compared to the common type of LM. The 5 LM patients had a significantly larger number of eosinophils using by immunohistochemistry of eosinophilic cationic protein and a higher ratio of eosinophils to CD3 than the common type of LM (Figure). Conclusions: In patients with CVAM, there may be a difference in clinical features between FM and non-FM patients. Also, a relatively larger number of eosinophils in the myocardium could be infiltrated in patients with CVAM.

Lesser Omental Infarction Presenting with ST-Segment Changes on Electrocardiography in A 37-Year Old Male: Coincidence or Causation?

Background: Omental infarction is a rare cause of acute abdominal pain. While the clinical presentation and diagnostic workup of omental infarction have been well-described in the literature, there is currently no published data on the relationship between omental infarction and Electrocardiogram (ECG) changes. Case presentation: A 37-year-old male presented with acute onset of epigastric pain, He had associated ECG changes, including ST elevation in V1 (1 mm), ST depression in leads II, aVF, and V4 so he was diagnosed with omental infarction after exclusion of acute coronary syndrome (ACS) via cardiac catheterization and echocardiography. The patient was managed conservatively with pain control and close observation and was discharged home in stable condition, The ECG changes resolved on follow-up 2 weeks later. Conclusion: Omental infarction should be considered in the differential diagnosis of patients presenting with acute abdominal pain and ECG changes. Further studies are needed to elucidate the pathophysiology of ECG changes in omental infarction and to develop optimal management strategies for these patients.

Predicting protective gene biomarker of acute coronary syndrome by the circRNA-associated competitive endogenous RNA regulatory network.

Background: The mortality and disability rates of acute coronary syndrome (ACS) are quite high. Circular RNA (circRNA) is a competitive endogenous RNA (ceRNA) that plays an important role in the pathophysiology of ACS. Our goal is to screen circRNA-associated ceRNA networks for biomarker genes that are conducive to the diagnosis or exclusion of ACS, and better understand the pathology of the disease through the analysis of immune cells. Materials and methods: RNA expression profiles for circRNAs (GSE197137), miRNAs (GSE31568), and mRNAs (GSE95368) were obtained from the GEO database, and differentially expressed RNAs (DEcircRNAs, DEmiRNAs, and DEmRNAs) were identified. The circRNA-miRNA and miRNA-mRNA regulatory links were retrieved from the CircInteractome database and TargetScan databases, respectively. As a final step, a regulatory network has been designed for ceRNA. On the basis of the ceRNA network, hub mRNAs were verified by quantitative RT-PCR. Hub genes were validated using a third independent mRNA database GSE60993, and ROC curves were used to evaluate their diagnostic values. The correlation between hub genes and immune cells associated with ACS was then analyzed using single sample gene set enrichment analysis (ssGSEA). Results: A total of 17 DEcircRNAs, 229 DEmiRNAs, and 27 DEmRNAs were found, as well as 52 circRNA-miRNA pairings and 10 miRNA-mRNA pairings predicted. The ceRNA regulatory network (circRNA-miRNA-mRNA) was constructed, which included 2 circRNA (hsa_circ_0082319 and hsa_circ_0005654), 4 miRNA (hsa-miR-583, hsa-miR-661, hsa-miR-671-5p, hsa-miR-578), and 5 mRNA (XPNPEP1, UCHL1, DBNL, GPC6, and RAD51). The qRT-PCR analysis result showed that the XPNPEP1, UCHL1, GPC6 and RAD51 genes had a significantly decreased expression in ACS patients. Based on ROC curve analysis, we found that XPNPEP1 has important significance in preventing ACS occurrence and excluding ACS diagnosis. ACS immune infiltration analysis revealed significant correlations between the other 3 hub genes (UCHL1, GPC6, RAD51) and the immune cells (Eosinophils, T folliculars, Type 2T helper cells, and Imumature dendritic cells). Conclusion: Our study constructed a circRNA-related ceRNA network in ACS. The XPNPEP1 gene could be a protective gene biomarker for ACS. The UCHL1, GPC6 and RAD51 genes were significantly correlated with immune cells in ACS.

Diagnostic accuracy of a high-sensitivity troponin I assay and external validation of 0/3 h rule out strategies.

The timely diagnosis and exclusion of acute coronary syndromes in the Emergency Department (ED) remains a challenge. This study aims to evaluate the diagnostic accuracy of a high-sensitivity cardiac troponin I assay (Siemens TNIH) on serial sampling for ED patients as standalone test and in rule-out algorithms as recommendations remain assay specific. This secondary analysis from a prospective diagnostic accuracy study at 14 centres included ED patients presenting with chest pain of suspected cardiac nature. Serum drawn on arrival and 3 h later was batchtested for TNIH. The target condition was an adjudicated diagnosis of acute myocardial infarction (AMI). We evaluated the diagnostic accuracy of absolute and relative delta criteria and four rule-out strategies. Of 802 included patients, 13.8% had AMI. Absolute delta criteria had superior accuracy to relative criteria (C-statistic 0.94 vs. 0.76, P < 0.001). However, no delta criteria achieved >95.5% sensitivity for AMI when used alone. Ruling out AMI with TNIH below the 99th percentile at 0 and 3 h had 88.3% (95% confidence interval 80.8-93.6%) sensitivity. The adapted European Society of Cardiology (ESC) 0/2 h algorithm had higher sensitivity (98.2%) than both High-STEACS (93.7%, P = 0.03) and the ESC 0/3 h algorithm (79.3%, P < 0.001). These pathways ruled out 63%, 74%, and 88% patients, respectively. With serial sampling over 3 h, the Siemens TNIH assay should be used with a validated algorithm incorporating bespoke cut-offs and absolute delta criteria. In our analysis, the adapted ESC 0/2 h algorithm had greatest sensitivity. 'Ruling out' AMI using the 99th percentile of the assay cannot be recommended.

Аpplication of myocardial damage and heart failure biomarkers in preventive and early diagnosis of aki in acute coronary syndrome

INTRODUCTION . From 15 to 35% of cases of acute coronary syndrome (ACS) are complicated by the development of acute kidney injury (AKI), prevention and early intervention remain the most effective strategy for managing patients with AKI in ACS. THE AIM: This study aimed to explore a risk factors and biomarkers for predictive and early diagnostic of AKI in ACS. PATIENTS AND METHODS . The study included patients hospitalized with a diagnosis of ACS in Pavlov First Saint Petersburg State Medical University. In case of exclusion of ACS, patients were determined in the comparison group, in case of confirmation of the diagnosis of ACS – in the study group. Biomaterial (blood) was taken at admission (T1), 1 day after admission (T2) and 2 days after admission (T3). For the diagnosis of AKI, KDIGO 2012 criteria were used. The measured biomarkers at each point were sST2, troponin I, NTproBNP. RESULTS . The study included 132 patients, the diagnosis of ACS was confirmed in 91 patients and AKI development was in 30 patients, all from the ACS group. The most significant for predictive diagnosis was the assessment of GRACE score> 133 points (AUC=0.760, p=0.001), sST2 level> 27.2 ng / ml (AUC=0.737, p=0.001), Mehran score> 5 (AUC=0.916, p=0.001), modification of the Mehran score (adding 2 points if the patient has sST2> 27.2) increases the predictive ability of AKI, Mehran+sST2> 7 points – AUC=0.928, p=0.001. CONCLUSIONS . The use of a combination of clinical data (hemodynamic parameters, presence of heart failure, routine laboratory data, presence of AKI risk factors) and assessment of biomarkers level, in particular the sST2 level, seems to be an effective method for predictive diagnosis of AKI and requires further research.

P0579EVALUATION OF BIOMARKERS EFFICIENCY IN PREDICTIVE AND EARLY DIAGNOSTICS OF ACUTE KIDNEY INJURY IN ACUTE CORONARY SYNDROME

Abstract Background and Aims Acute Kidney Injury (AKI) is a common complication of acute coronary syndromes (ACS), and associated with higher mortality and adverse outcomes. Despite advances in research over the past years, effective treatments for current AKI are not available. Prevention and early intervention remain the most effective strategies for AKI of any entity. This study aimed to explore a risk factors and biomarkers for predictive and early diagnostic of AKI in ACS. Method Study was prospective and cohort, patients hospitalized with ACS in Pavlov First Saint Petersburg State Medical University were included. In case of exclusion of ACS, patients were determined in the comparison group, in case of confirmation of the diagnosis of ACS - in the study group. Biomaterial (blood and urine) was taken at admission (T1), 1 day after admission (T2) and 2 days after admission (T3). For the diagnosis of AKI, KDIGO 2012 criteria were used for the diagnosis of AKI. The measured biomarkers at each point were NGAL, KIM-1, cystatin C, sST2, troponin I. Results The study included 73 patients, the diagnosis of ACS was confirmed in 40 patients and AKI development was in 15 patients, all from the ACS group. The most significant for predictive diagnosis was the assessment of the parameters of systemic hemodynamics and the severity of acute heart failure (AHF): heart rate&amp;gt;90 (AUC=0,798, p=0,001), GRACE Risk Score&amp;gt;133 (AUC=0,926, p=0,005). In evaluation the suitability of biomarkers in terms of prognostic diagnosis of AKI, urine NGAL&amp;gt;32 ng/ml (AUC=0,814 p=0,04) and sST2&amp;gt;23.4 ng/ml (AUC=0,718, p=0,02) showed the best results. Conclusion In study of biomarkers efficiency, the use of urine sST2 and NGAL is most promising. Together with hemodynamic parameters, biomarkers have high predictive ability in the diagnosis of AKI in ACS.

Evaluation of biomarkers effi ciency in predictive and early diagnostics of acute kidney damage in acute coronary syndrome (pilot study)

INTRODUCTION. Acute Kidney Injury (AKI) is a common complication of acute coronary syndromes (ACS), and associated with higher mortality and adverse outcomes. Despite advances in research over the past years, effective treatments for current AKI are not available. Prevention and early intervention remain the most effective strategies for AKI of any entity. THE AIM: This study aimed to explore a risk factors and biomarkers for predictive and early diagnostic of AKI in ACS.PATIENTS AND METHODS. Study was prospective and cohort, patients hospitalized with ACS in Pavlov First Saint Petersburg State Medical University were included. In case of exclusion of ACS, patients were determined in the comparison group, in case of confirmation of the diagnosis of ACS – in the study group. Biomaterial (blood and urine) was taken at admission (T1), 1 day after admission (T2) and 2 days after admission (T3). For the diagnosis of AKI, KDIGO 2012 criteria were used. The measured biomarkers at each point were NGAL, KIM-1, cystatin C, sST2, troponin I. RESULTS. The study included 73 patients, the diagnosis of ACS was confirmed in 40 patients and AKI development was in 15 patients, all from the ACS group. The most significant for predictive diagnosis was the assessment of the parameters of systemic hemodynamics and the severity of acute heart failure (AHF): heart rate&gt;89 (AUC=0,798, p=0,001), GRACE Risk Score&gt;133 (AUC=0,926, p=0,005). In evaluation the suitability of biomarkers in terms of prognostic diagnosis of AKI, urine NGAL&gt;32 ng/ml (AUC=0,814 p=0,04) and sST2&gt;23.4 ng/ml (AUC=0,718, p=0,02) showed the best results.CONCLUSIONS. In study of biomarkers efficiency, the use of urine sST2 and NGAL is most promising. Together with hemodynamic parameters, biomarkers have high predictive ability in the diagnosis of AKI in ACS.

Clinical Outcome of Takotsubo Cardiomyopathy Diagnosed With or Without Coronary Angiography

Takotsubo cardiomyopathy (TC) is definitively diagnosed following the exclusion of acute coronary syndrome. We aimed to examine the rate of coronary angiography in patients diagnosed with TC and also the outcome of patients with TC diagnosed with or without coronary angiography. We analyzed the National Inpatient Sample database from 2010 to 2014 and identified patients hospitalized with a primary diagnosis of TC. We compared in-hospital mortality between patients who underwent coronary angiography and those who did not. We also evaluated the association between coronary angiography and in-hospital mortality using a propensity score-adjusted multivariable analysis. Among 22 818 patients diagnosed with TC, 87.4% underwent coronary angiography and 12.6% did not. Patients who did not undergo coronary angiography had a higher in-hospital mortality than those who did (3.0% vs 0.9%; P < .001). Increased mortality in patients who did not undergo coronary angiogram was observed in both male (8.0% vs 2.8%; P = .03) and female patients (2.6% vs 0.7%; P < .001) and in patients 61 to 80 years old and ≥81 years old, but not in patients ≤60 years old. Multivariable analysis demonstrated that the lack of coronary angiography was independently associated with higher in-hospital mortality (adjusted odds ratio: 2.92; 95% confidence interval: 1.52-5.65; P = .001).

PERFORMANCE OF HIGH-SENSITIVITY TROPONINS IN THE EXCLUSION OF ACUTE CORONARY SYNDROME IN PATIENTS WITH CHEST PAIN IN THE EMERGENCY DEPARTMENT

Although chest pain is one of the leading presenting complaints in the Emergency Department (ED), only 12-15% account for Acute Coronary Syndrome (ACS). Hence early triage and exclusion of ACS is crucial to improve ED throughput and workflow. We aim to determine and compare the accuracy of the

A higher volume of fibrotic tissue on virtual histology prior to coronary stent implantation predisposes to more pronounced neointima proliferation

Background: Since neointima smooth muscle cells (SMC) mainly originate from the vessel wall, we investigated whether atherosclerotic plaque composition influences subsequent in-stent neointima proliferation and restenosis.Methods: We performed intravascular ultrasound (IVUS) with virtual histology in 98 patients prior to elective bare-metal stent (BMS) implantation in de novo coronary artery lesions. Virtual histology variables pre-percutaneous coronary intervention (PCI) were related to in-stent neointima proliferation six months after implantation assessed as late luminal loss of 0.88 mm (interquartile range (IQR) 0.37–1.23 mm) on angiography and as maximal percentage area stenosis of 42% (IQR 33–59%) and percentage volume intima hyperplasia of 27% (IQR 20–36%) on IVUS. A ridge-trace based multiple linear regression model was constructed to account for multicollinearity of the virtual histology variables and was corrected for implanted stent length (18 mm, IQR 15–23 mm), stent diameter (3.0 mm, IQR 2.75–3.5 mm) and lesion volume (146 mm³, IQR 80–201 mm³) prior to PCI.Results: Fibrous tissue volume prior to PCI (49 mm³, IQR 30–77 mm³) was significantly and independently related to late luminal loss (p = .038), maximal percentage area stenosis (p = .041) and percentage volume intima hyperplasia (p = .004). Neither absolute nor relative amounts of fibrofatty, calcified or necrotic core tissue appeared related to any of the restenosis parameters. Subgroup analysis after exclusion of acute coronary syndrome (ACS) patients yielded similar results.Conclusion: Lesions with more voluminous fibrotic tissue pre-PCI show more pronounced in-stent neointima proliferation, even after correction for lesion plaque volume.

P4689Comparison of high-sensitivity troponin T (hs-TnT) and high-sensitivity troponin I (hs-TnI) in the exclusion of acute coronary syndrome in patients with chest pain in the emergency department

P4689Comparison of high-sensitivity troponin T (hs-TnT) and high-sensitivity troponin I (hs-TnI) in the exclusion of acute coronary syndrome in patients with chest pain in the emergency department

P3674Using an outpatient protocol for exclusion of acute coronary syndrome from the emergency department: is it safe?

P3674Using an outpatient protocol for exclusion of acute coronary syndrome from the emergency department: is it safe?

Improving early exclusion of acute coronary syndrome in primary care: the added value of point-of-care troponin as stated by general practitioners.

Excluding acute coronary syndrome (ACS) in primary care remains a diagnostic challenges for GPs. Consequently, referral rates of chest pain patients are high, while the incidence of a cardiovascular problem is only 8-15%. Previous studies have shown that GPs are interested in a POC troponin test. This test could enhance rapid exclusion of ACS, thereby preventing unnecessary patient distress, without compromising safety and while reducing costs. However, using this test is not recommended in current guidelines due to uncertainty in the test's potential added value, and the lower sensitivity early after symptom onset as compared with troponin tests in a regular laboratory. An online survey containing 34 questions was distributed among 837 Dutch GPs in June 2015. Findings A total of 126 GPs (15.1%) completed at least 75% of the questions. 67.1% of GPs believe that POC troponin tests have moderate to very high added value. Although the availability of a POC test is expected to increase the frequency at which troponin tests are used, it likely decreases (immediate) referral rates. Of the responding GPs, 78.3% only accept 10 min as the maximum test duration, 78.1% think reimbursement of the POC device is required for implementation, and 68.9% consider it necessary that it can be performed with a finger prick blood sample. In conclusion, according to GPs, the POC troponin test can be of added value to exclude ACS early on. Actual test implementation will depend on test characteristics, including test duration, type of blood sample required, and reimbursement of the analyzer.

The prognostic value of CT coronary angiography in patients attending hospital with troponin-negative acute chest pain and inconclusive exercise treadmill tests.

Once acute coronary syndrome (ACS) is excluded in patients presenting to hospital with acute chest pain, usual practice is to stratify future risk of adverse cardiovascular events. Commonly this is performed by pre-discharge exercise treadmill testing (ETT). Often however, patients are unable to perform the test for various reasons, or the final result is inconclusive. This potentially could lead to uncertainty and to unnecessary invasive coronary angiography. We wished to evaluate the potential prognostic significance of CT coronary angiography (CTCA) in patients with prior inconclusive ETTs. Two hundred and thirty-two consecutive patients underwent CTCA and calcium scoring following hospital attendance with acute chest pain and following exclusion of ACS. All patients were followed up for a combined primary outcome of death, non-fatal myocardial infarction, and late revascularization. The mean follow-up period was 2.5 ± 0.9 years. The combined primary outcome occurred in 26 patients (11.2%). Calcium score (HR 1.16; 95% CI 1.02-1.31, P = 0.023 per 100 Agatston unit increase), the presence of coronary artery disease (CAD) on CTCA (non-obstructive CAD, HR 4.52; 95% CI 1.30-15.73, P = 0.018; obstructive CAD, HR 17.00; 95% CI 4.60-62.85, P < 0.001), and ≥3 segments with non-calcified plaque (HR 3.30; 95% CI 1.24-8.76, P = 0.017) were significant univariable predictors of the primary outcome. CTCA was the only significant multivariable predictor of adverse outcome. The presence of CAD assessed by CTCA is a strong predictor of adverse events in patients with troponin-negative acute chest pain and could potentially be used as an alternative, non-invasive risk stratifier in patients with inconclusive exercise tests.

Rapid rule out of myocardial infarction with the use of copeptin as a biomarker for cardiac injury.

Copeptin is a non-specific marker of an endogenous stress response. A dual biomarker marker approach involving the simultaneous use of troponin and copeptin assays may assist early exclusion of acute coronary syndrome in Australian emergency departments. The utility and limitations of this approach are discussed.

Cardiac biomarkers for infarct diagnosis and early exclusion of acute coronary syndrome.

The acute coronary syndrome (ACS) represents a diagnostic challenge: on the one hand patients need to be quickly identified to initiate treatment and on the other hand early exclusion of patients without ACS is important to relieve patient stress as well as overcrowded emergency departments. A growing number of biomarkers are becoming available to aid physicians with this task. This review gives an overview of the current research concerning early exclusion with an emphasis on the clinically most important biomarker: cardiac troponin.

Reliable exclusion of acute coronary syndrome among hospitalized patients with elevated troponin.

Elevated cardiac troponin I (cTnI) occurs in acute coronary syndrome (ACS) as well as various scenarios not associated with ACS. Simple clinical criteria can reliably exclude ACS among hospitalized patients with elevated cTnI. Records for patients hospitalized from January to April 2011 with elevated cTnI (>0.29 ng/dL) and an available echocardiogram were retrospectively reviewed. Patients with ST-segment elevation myocardial infarction were excluded. Based on available clinical data, patients were classified as having ACS or elevation of cTnI unrelated to ACS (non-ACS). Median follow-up was 365 days. Of 265 records meeting inclusion criteria, 82 (31%) had ACS and 183 (69%) had non-ACS. In multivariable analysis, odds ratios for non-ACS were 7.6 (95% confidence interval [CI]: 3.8-15.3) for peak cTnI <2 ng/dL, 6.3 (95% CI: 3.1-13.0) for absent wall-motion abnormality, and 4.4 (95% CI: 2.2-8.6) for no prior coronary artery disease history. The area under the receiver operating curve for amodel using these 3 variables was 0.86, with a 98% negative predictive value for excluding ACS. Patients who met these 3 criteria had no ACS-related deaths over 1-year follow-up. Hospitalized patients with peak Tn level<2 ng/dL, no prior history of coronary artery disease, and no new echocardiographic wall-motion abnormality appear to have a very low likelihood of ACS. Prospective validation of these results is needed to determine whether additional diagnostic testing could be safely avoided in hospitalized patients meeting these simple clinical criteria.

MRT bei Myokarditis

Cardiovascular magnetic resonance imaging (CMRI) has become the primary tool for the non-invasive assessment in patients with suspected myocarditis, especially after exclusion of acute coronary syndrome (ACS) for the differential diagnosis. Various MRI parameters are available which have different accuracies. Volumetric and functional ventricular assessment and the occurrence of pericardial effusion alone demonstrate only a poor sensitivity and specificity. The calculation of the T2-ratio (edema assessment), the early or global relative myocardial enhancement (gRE) and the late gadolinium enhancement (LGE), which represents irreversibly injured myocardium, are more specific parameters. All MRI parameters demonstrate the best accuracy in infarct-like acute myocarditis, whereas in chronic myocarditis sensitivity and specificity are less accurate. Therefore, a multisequential (at least two out of three parameters are positive) approach is recommended. The assessment of the value of newer, more quantitative MRI sequences, such as T1 and T2-mapping is still under investigation.

Cardiac Troponins I and T: Molecular Markers for Early Diagnosis, Prognosis, and Accurate Triaging of Patients with Acute Myocardial Infarction

Acute myocardial infarction (AMI) is the leading cause of death worldwide, with early diagnosis still being difficult. Promising new cardiac biomarkers such as troponins and creatine kinase (CK) isoforms are being studied and integrated into clinical practice for early diagnosis of AMI. The cardiac-specific troponins I and T (cTnI and cTnT) have good sensitivity and specificity as indicators of myocardial necrosis and are superior to CK and its MB isoenzyme (CK-MB) in this regard. Besides being potential biologic markers, cardiac troponins also provide significant prognostic information. The introduction of novel high-sensitivity troponin assays has enabled more sensitive and timely diagnosis or exclusion of acute coronary syndromes. This review summarizes the available information on the potential of troponins and other cardiac markers in early diagnosis and prognosis of AMI, and provides perspectives on future diagnostic approaches to AMI.

Abstract 217: Reliable Exclusion of Acute Coronary Syndrome Among Hospitalized Patients With Elevated Troponin

Background: Elevated cardiac troponin-I (cTn) occurs in acute coronary syndrome (ACS) as well as a variety of non-ACS settings with oxygen supply - demand mismatch. This study sought to test the ability to reliably exclude ACS using simple clinical data in the setting of elevated cTn. Methods: Records for patients hospitalized January - April 2011 with elevated cTn (&gt;0.29ng/dl) and an echocardiogram were retrospectively reviewed. STEMI was excluded. Patients were classified as having ACS (NSTEMI) versus Non-ACS (demand). Delta cTn was defined as the absolute difference between the highest and initial cTn values. Results: Of 266 records meeting inclusion criteria, 82 (31%) had ACS and 184 (69%) had Non-ACS. Clinical variables that were significantly associated with ACS vs. Non-ACS are shown in the table. Echocardiographic wall motion abnormality (WMA) had a negative predictive value of 80% and positive predictive value of 63%. In multivariable analysis, odds ratios for Non-ACS were 7.6 (95% CI 3.8-15.2) for peak cTn less than 2ng/dl, 6.3 (95% CI 3.1-13.1) for absent WMA, and 4.4 (95% CI 2.2-8.7) for no prior coronary artery disease (CAD) history. The area under the receiver operating curve for a model using these 3 variables was 0.86, with a 98% negative predictive value. Conclusion: Among hospitalized patients with elevated cTn, no history of CAD, peak troponin less than 2ng/dl, and no new echocardiographic WMA reliably identifies patients at very low likelihood for ACS.