Single High-sensitivity Troponin Research Articles

Ruling out acute myocardial infarction based on a single high-sensitivity troponin measurement in the emergency department: a clinical practice review

Ruling out acute myocardial infarction based on a single high-sensitivity troponin measurement in the emergency department: a clinical practice review

GRACE-recurrent low-risk chest pain: A user's guide.

GRACE-recurrent low-risk chest pain: A user's guide.

Single high-sensitivity troponin levels to assess patients with potential acute coronary syndromes

ObjectiveWe tested the hypothesis that patients with a potential acute coronary syndrome (ACS) and very low levels of high-sensitivity cardiac troponin I can be efficiently and safely discharged from the...

Short-term prognosis of unstable angina in the era of high-sensitivity cardiac troponin: insights for early rule-out strategies.

It is unclear if strategies to rule-out myocardial infarction (MI) based on a single high-sensitivity troponin T (hsTnT) measurement at the emergency department (ED) presentation may also exclude unstable angina. We measured hsTnT ex-post on the admission frozen blood sample of 644 subjects with Braunwald IIIB CK-MB-negative unstable angina. This analysis included the 240 patients with hsTnT value ≤99th percentile reference limit (UA). We evaluated the clinical outcome of UA patients and the applicability of two rule-out strategies based on the combination of a non-ischemic ECG with (1) a single hsTnT value below the Limit-of-Detection (LoD), (2) a TIMI risk score ≤1. UA patients with hsTnT ≤99th percentile reference limit had a favorable 30-day outcome [0.8% MI, 0% cardiovascular death (CVD)], but the rate of CVD/MI at 180-day was 4.7%. Sensitivities for UA were 94.6% according to the 'TIMI ≤1-strategy' and 75.4% according to 'hsTnT-below-LoD-strategy', accounting for 5.4 and 24.6% missed diagnoses, respectively. A prognostic risk stratification to guide appropriate outpatient assessment in potential discharged unrecognized UA patients was developed: a risk score based on the combination of age >60 years and C-reactive protein >4.5 mg/L effectively stratified the 180-day CVD/MI occurrence: 0, 2.5 and 12.7% for score 0, 1 and 2 (log-rank = 0.001, C-statistic = 0.776). Single measurement hsTnT strategies, successfully tested to rule-out MI, may allow safe ED discharge of patients with a suspected acute coronary syndrome: even if UA may not be excluded, its short-term prognosis is favorable. UA patients with a C-reactive protein >4.5 mg/L and older than 60 years have a substantial medium-term cardiovascular risk and may benefit from a timely outpatient diagnostic assessment.

RAPID-CPU: a prospective study on implementation of the ESC 0/1-hour algorithm and safety of discharge after rule-out of myocardial infarction.

Background:Although the value of fast diagnostic protocols in suspected acute coronary syndrome has been validated, there is insufficient real world evidence including patients with lower pre-test probability, atypical symptoms and confounding comorbidities. The feasibility, efficacy and safety of European Society of Cardiology (ESC) 0/1 and 0/3-hour algorithms using high-sensitivity troponin T were evaluated in a consecutive cohort with suspected acute coronary syndrome.Methods:During 12 months, 2525 eligible patients were enrolled. In a pre-implementation period of 6 months, the prevalence of protocols, disposition, lengths of emergency department stay and treatments were registered. Implementation of the 0/1-hour protocol was monitored for another 6 months. Primary endpoints comprised the change of diagnostic protocols and 30-day mortality after direct discharge from the emergency department.Results:Use of the ESC 0/1-hour algorithm increased by 270% at the cost of the standard 0/3-hour protocol. After rule-out (1588 patients), 1309 patients (76.1%) were discharged directly from the emergency department, with an all-cause mortality of 0.08% at 30 days (one death due to lung cancer). Median lengths of stay were 2.9 (1.9–3.8) and 3.2 (2.7–4.4) hours using a single high-sensitivity troponin T below the limit of detection (5 ng/L) at presentation and the ESC 0/1-hour algorithm, respectively, as compared to 5.3 (4.7–6.5) hours using the ESC 0/3-hour rule-out protocol (P<0.001). Discharge rates increased from 53.9% to 62.8% (P<0.001), without excessive use of diagnostic resources within 30 days.Conclusion:Implementation of the ESC 0/1-hour algorithm is feasible and safe, is associated with shorter emergency department stay than the ESC 0/3-hour protocol, and an increase in discharge rates.Trial registration:ClinicalTrials.gov, Unique identifier: NCT03111862.

Randomised controlled trial of the Limit of Detection of Troponin and ECG Discharge (LoDED) strategy versus usual care in adult patients with chest pain attending the emergency department: study protocol

IntroductionObservational data suggest a single high-sensitivity troponin blood test taken at emergency department (ED) presentation could be used to rule out major adverse cardiac events (MACE) in 10%–60% of ED...

Rapid and safe discharge from the emergency department: A single troponin to exclude acute myocardial infarction.

To determine variables that could facilitate safe discharge from the ED following a single high-sensitivity troponin I (HsTnI) result to exclude acute myocardial infarction (AMI). A retrospective cohort study was performed at a tertiary hospital of all patients that had serial HsTnI performed within 12 h of arrival to the ED over a 3 year period. The primary exposure variable of interest was a very low troponin initial result (HsTnI <5 ng/L). Medical record review and risk stratification score calculations were undertaken for all patients with the exposure variable of interest and an abnormal second troponin measurement (HsTnI ≥16 ng/L in women and HsTnI ≥26 ng/L in men). There were 11 970 patients who presented between 1 July 2013 and 30 June 2016 that had serial HsTnI measurements performed. Of these, 4172 (34.9%) patients had an initial HsTnI measurement <5 ng/L. Of the patients with an initial HsTnI <5 ng/L that met inclusion criteria, 56 (1.3%) had a second troponin result above the 99th percentile and 32 (0.8%) cases of non-ST elevation myocardial infarction were diagnosed as well as 15 (0.4%) cases of ST elevation myocardial infarction. There were 44 (93.6%) of all AMI cases that met criteria for high-risk presentations under the National Heart Foundation of Australia guidelines. The negative predictive value of an initial HsTnI <5 ng/L to exclude AMI was 98.9% (95% confidence interval 98.5-99.1). This supports the utilisation of a rapid rule out strategy to exclude AMI for patients that have an initial HsTnI measurement <5 ng/L in conjunction with a robust risk assessment.

LO97: Validation of the HEART score in Canadian emergency department chest pain patients using a high-sensitivity troponin T assay

Introduction: The HEART score is a validated tool created to risk stratify emergency department (ED) chest pain patients using 5 simple criteria (History, ECG findings, Age, Risk factors, and Troponin). Several studies have demonstrated the superiority of HEART over other well known risk stratification tools in identifying low risk chest pain patients suitable for early discharge. All but one of these studies used conventional troponin assays, and most were conducted in European populations. This study aims to validate the HEART score using a high-sensitivity troponin T assay in a Canadian population. Methods: This prospective cohort study was conducted at a single urban tertiary centre and regional percutaneous coronary intervention site in Calgary, Alberta. Patients were eligible for enrolment if they presented to the ED with chest pain, were age 25-years or older and required biomarker testing to rule out AMI at the discretion of the attending emergency physician. Patients were excluded if they had clear acute ischemic ECG changes, new arrhythmia or renal failure requiring hemodialysis. Clinical data were recorded by the emergency physician at the time of enrolment and outcomes were obtained from administrative data. High-sensitivity troponin-T (Roche Elecsys hs-cTnT) results were obtained in all patients at presentation. The primary outcome was AMI within 30-days of ED visit, the secondary outcome was 30-day major adverse cardiac events (MACE). Results: A total of 984 ED patients with complete HEART scores were enrolled from August 2014 to September 2016. The 30-day incidence of AMI and MACE in the overall population was 3.3% and 20.6%, respectively. HEART scores were predictive of 30-day AMI incidence: low risk (0-3): 0.77% (95%CI 0.0-1.5%), moderate risk (4-6): 4.3% (95%CI 2.3-6.2%) and high risk (7-10): 12.2% (95%CI 5.5-19.0%). HEART scores also predicted 30-day MACE: low risk (0-3): 5.0% (95%CI 3.1-6.9%), moderate risk (4-6): 31.8% (95%CI 27.2-36.4%) and high-risk (7-10): 61.4% (95%CI 51.2-71.5%). More than half of patients, 522 (53.0%) could be identified as low risk based on the HEART score using a single troponin result. Conclusion: Using a single high-sensitivity troponin result collected at ED presentation, the HEART score can rapidly and effectively identify more than half of ED chest pain patients as low risk for 30-day AMI, but is less sensitive for 30-day MACE.

A DIRECT COMPARISON OF ACCELERATED DISCHARGE STRATEGIES UTILISING A SINGLE HIGH SENSITIVITY TROPONIN T IN SUSPECTED ACUTE CORONARY SYNDROMES: PROSPECTIVE COHORT STUDY OF UNDETECTABLE TROPONIN T VERSUS LOW RISK TIMI, GRACE AND HEART SCORES (THE MACROS STUDY- MERSEY ACUTE CORONARY SYNDROME RULE-OUT STUDY)

Background: A single undetectable high sensitivity troponin T (hstnT) versus low risk scores as the optimum discharge tool for suspected acute coronary syndromes (ACS) presentations remains untested. Methods: Consecutive patients with a primary symptom of chest pain (CP) presenting to the emergency

The HEART score with high-sensitive troponin T at presentation: ruling out patients with chest pain in the emergency room.

The HEART score is a simple scoring system, ranging from 0 to 10, specifically developed for risk stratification of patients with undifferentiated chest pain. It has been validated for the conventional troponin, but not for high-sensitive troponin. We assess a modified version of the HEART score using a single high-sensitivity troponin T dosage at presentation, regardless of symptom duration, and with different ECG criteria to evaluate if the patients with a low HEART score could be safely discharged early. The secondary aim was to confirm a statistically significant difference in each HEART score group (low 0-3, intermediate 4-6, high 7-10) in the occurrence of major adverse cardiac events at 30 and 180days. We retrospectively analyzed the HEART score of 1597 consecutive patients admitted to the Emergency Department of our Hospital for chest pain between January 1 and June 30, 2014. Of these, 190 did not meet the inclusion criteria and 29 were lost to follow-up. None of the 512 (37.2%) patients with a low HEART score had an event within 180days. The difference between the cumulative incidences of events in the three HEART score groups was statistically significant (P<0.0001). We demonstrate that it might be possible to safely discharge Emergency Department chest pain patients with a low modified HEART score after an initial determination of high-sensitive troponin T, without a prolonged observation period or an additional cardiac testing.

Identifying Patients Suitable for Discharge After a Single-Presentation High-Sensitivity Troponin Result: A Comparison of Five Established Risk Scores and Two High-Sensitivity Assays

We compare the ability of 5 established risk scores to identify patients with suspected acute coronary syndromes who are suitable for discharge after a modified single-presentation high-sensitivity troponin result. This was a prospective observational study conducted in a UK district general hospital emergency department. Consecutive adults recruited with suspected acute coronary syndrome for whom attending physicians determined evaluation with serial troponin testing was required. Index tests were definitions of low risk applied to modified Goldman, Thrombolysis in Myocardial Infarction (TIMI), Global Registry of Acute Cardiac Events (GRACE), History, ECG, Age, Risk Factors, Troponin (HEART), and Vancouver Chest Pain Rule risk scores, incorporating either high-sensitivity troponin T or I results. The endpoint was acute myocardial infarction within 30 days. A test sensitivity threshold for acute myocardial infarction of 98% was chosen. Clinical utility was defined as a negative predictive value greater than or equal to 99.5% and identification of greater than 30% suitable for discharge. Nine hundred fifty-nine patients underwent high-sensitivity troponin T analysis and 867 underwent high-sensitivity troponin I analysis. In the high-sensitivity troponin T group, 79 of 959 (8.2%) had an acute myocardial infarction and 66 of 867 (7.6%) in the high-sensitivity troponin I group. Two risk scores (GRACE <80 and HEART ≤3) did not have the potential to achieve a sensitivity of 98% with high-sensitivity troponin T, and 3 scores (Goldman ≤1, TIMI ≤1, and GRACE <80) with high-sensitivity troponin I. A TIMI score of 0 or less than or equal to 1 and modified Goldman score less than or equal to 1 with high-sensitivity troponin T, and TIMI score of 0 and HEART score of less than or equal to 3 with high-sensitivity troponin I had the potential to achieve a negative predictive value greater than or equal to 99.5% while identifying greater than 30% of patients as suitable for immediate discharge. With established risk scores, it may be possible to identify greater than 30% of patients suitable for discharge, with a negative predictive value greater than or equal to 99.5% for the diagnosis of acute myocardial infarction, using a single high-sensitivity troponin test result at presentation. There is variation in high-sensitivity troponin assays, which may have implications in introducing rapid rule-out protocols.

7 Is a Single Sample High Sensitivity Troponin I (HS-CTNI) At Point of Entry to Hospital Safe and is it Effective at Reducing Length of Stay in the Management of Acute Chest Pain – A Six Month Evaluation

Introduction A chest pain pathway was introduced in 2013 using the Abbott hs-cTnI assay. This incorporates a zero hour subnormal limit of less than 2 ng/l. If a patient has a hs-cTnI of Methods We examined data from 3853 patients presenting to the Emergency Department with chest pain from July 2013 to January 2014. We also looked at 473 patients from July 2012 before the new troponin test was introduced to compare lengths of stay. All chest pain presentations and patients who had a hs-cTnI sent were included. Trauma calls, patients who did not wait and those under 16 years of age were excluded. In 2573 patients there was a clinical suspicion of ACS and hs-cTnI levels were taken immediately. Results 1280 patients (33.2%) had an ACS ruled out clinically. 2573 (66.8%) had a zero hour hs-cTnI sent. 849 of these 2573 (32%) had a hs-cTnI of The introduction of the new hs-cTnI test at zero hours compared with a single 12 h troponin reduced admissions with chest pain from 60.9% to 53.2% (p Conclusions In patients presenting with acute chest pain who are felt unlikely to have an ACS and whose ECGs are normal, a single hs-cTnI of

A novel diagnostic protocol to identify patients suitable for discharge after a single high-sensitivity troponin

ObjectiveTo establish whether a novel accelerated diagnostic protocol (ADP) for suspected acute coronary syndrome (ACS) could successfully identify low-risk patients suitable for discharge after a single high-sensitivity troponin T (hs-cTnT)...

A MODIFIED GOLDMAN RISK SCORE IN COMBINATION WITH HIGH-SENSITIVITY TROPONIN PROVES SUPERIOR TO TIMI IN THE EVALUATION OF SUSPECTED ACUTE CARDIAC CHEST PAIN

A single high-sensitivity Troponin (hsTn) result below the 99th centile value taken at presentation in Emergency Department (ED) patients with suspected cardiac chest pain has sensitivity too low for clinical use. The combination of clinical risk scoring and early hsTn testing improves sensitivity