2015 ESC Guidelines for the Management of Acute Coronary Syndromes in Patients Presenting Without Persistent ST-segment Elevation

Roffi, Marco; Patrono, Carlo; Collet, Jean‐Philippe; Müeller, Christian; Valgimigli, Marco; Andreotti, Felicita; Bax, Jeroen J.; Borger, Michael A.; Brotons, Carlos; Chew, D.; Gencer, Baran; Hasenfuß, Gerd; Kjeldsen, Keld; Lancellotti, Patrizio; Landmesser, Ulf; Mehilli, Julinda; Mukherjee, Debabrata; Storey, Robert F.; Windecker, Stephan

doi:10.1016/j.rec.2015.10.009

Cited by 157 publications

(232 citation statements)

References 562 publications

Supporting

Mentioning

220

Contrasting

Unclassified

Order By: Relevance

“…That level of risk compares favorably with previous reports suggesting that, in practice, 2% of AMIs are missed in the ED . Although we do not have the data to present a direct comparison, this also compares favorably with a 3‐hour rule‐out strategy (sensitivity = 98.2%) that has been advocated for use in clinical practice . Taken in conjunction with the findings of previous work, our multicenter, prospective study therefore provides compelling evidence that AMI may be excluded at the time of arrival in the ED in patients who have an initial hs‐cTnT concentration below the LoD and no ECG ischemia, particularly in younger (<65 years) patients and those undergoing blood tests at least 2 hours after peak symptoms.…”

Section: Discussionsupporting

confidence: 80%

The Use of Very Low Concentrations of High‐sensitivity Troponin T to Rule Out Acute Myocardial Infarction Using a Single Blood Test

Body

Müeller

Giannitsis

et al. 2016

Academic Emergency Medicine

Self Cite

View full text Add to dashboard Cite

BackgroundRecent single‐center and retrospective studies suggest that acute myocardial infarction (AMI) could be immediately excluded without serial sampling in patients with initial high‐sensitivity cardiac troponin T (hs‐cTnT) levels below the limit of detection (LoD) of the assay and no electrocardiogram (ECG) ischemia. ObjectiveWe aimed to determine the external validity of those findings in a multicenter study at 12 sites in nine countries. MethodsTRAPID‐AMI was a prospective diagnostic cohort study including patients with suspected cardiac chest pain within 6 hours of peak symptoms. Blood drawn on arrival was centrally tested for hs‐cTnT (Roche; 99th percentile = 14 ng/L, LoD = 5 ng/L). All patients underwent serial troponin sampling over 4–14 hours. The primary outcome, prevalent AMI, was adjudicated based on sensitive troponin I (Siemens Ultra) levels. Major adverse cardiac events (MACE) including AMI, death, or rehospitalization for acute coronary syndrome with coronary revascularization were determined after 30 days. ResultsWe included 1,282 patients, of whom 213 (16.6%) had AMI and 231 (18.0%) developed MACE. Of 560 (43.7%) patients with initial hs‐cTnT levels below the LoD, four (0.7%) had AMI. In total, 471 (36.7%) patients had both initial hs‐cTnT levels below the LoD and no ECG ischemia. These patients had a 0.4% (n = 2) probability of AMI, giving 99.1% (95% confidence interval [CI] = 96.7% to 99.9%) sensitivity and 99.6% (95% CI = 98.5% to 100.0%) negative predictive value. The incidence of MACE in this group was 1.3% (95% CI = 0.5% to 2.8%). ConclusionsIn the absence of ECG ischemia, the detection of very low concentrations of hs‐cTnT at admission seems to allow rapid, safe exclusion of AMI in one‐third of patients without serial sampling. This could be used alongside careful clinical assessment to help reduce unnecessary hospital admissions.

show abstract

Section: Discussionsupporting

confidence: 80%

The Use of Very Low Concentrations of High‐sensitivity Troponin T to Rule Out Acute Myocardial Infarction Using a Single Blood Test

Body

Müeller

Giannitsis

et al. 2016

Academic Emergency Medicine

Self Cite

View full text Add to dashboard Cite

show abstract

“…However, despite this clear association, evidence on the optimal management of these patients remains relatively weak. 6,44 Therefore, further studies are required to determine the underlying pathophysiology and causative factors of new-onset TP in the context of ACS and shape evidence-based guidelines on the optimal medical management of these patients.…”

Section: Discussionmentioning

confidence: 99%

The effect of in-hospital acquired thrombocytopenia on the outcome of patients with acute coronary syndromes: A systematic review and meta-analysis

Oikonomou

Repanas²,

Papanastasiou

et al. 2016

Thrombosis Research

View full text Add to dashboard Cite

Background In-hospital acquired thrombocytopenia (TP) is relatively common among patients hospitalized with acute coronary syndromes (ACS). However, its effect on short-term and long-term outcomes has yet to be reviewed systematically. Methods We conducted a systematic review and meta-analysis of clinical studies assessing the relationship between new-onset in-hospital TP and adverse outcomes among ACS patients. MEDLINE, Scopus and the Cochrane Library were searched for eligible studies published before March 20 2016. Results Ten studies reporting on a total of 142,161 ACS patients were identified. 8,133 patients showed evidence of new-onset TP during the course of their hospitalization. Compared with patients with normal platelet counts, patients with new-onset TP had a prolonged in-hospital stay, significantly higher risk of both short-term mortality (<30 days) (Odds ratio (OR) [95% confidence interval (CI)]: 5.58 [3.63–8.57]) and late death (6 months to 1 year) (OR [95%CI]: 3.45 [2.35–5.07]), as well as a significantly higher risk of major bleeding events in the first 30 days (OR [95%CI]: 6.93 [5.13–9.38]). In addition, risk for other secondary cardiovascular endpoints, including recurrent myocardial infarction, stroke, in-hospital heart failure, stent thrombosis and unplanned revascularization was also significantly higher in the TP versus the no TP group. Conclusions Development of TP during the in-hospital management of ACS patients is a significant predictor of both short- and long-term adverse events, including mortality. In the light of this evidence, clinicians should be cautious and closely monitor abnormal platelet counts that present early following an ACS.

show abstract

“…Recent studies show that, in ED patients with chest pain, a high‐sensitivity cardiac troponin T (hsTnT) result below the assay's limit of blank (LoB, <3 ng/L) or limit of detection (LoD, <5 ng/L) at the time of ED arrival can rule out acute myocardial infarction (AMI) with high sensitivity and negative predictive value (NPV) . The 2015 European Society for Cardiology guidelines for non‐ST‐elevation ACS state that a single hsTnT level below 5 ng/L taken greater than 3 hours after symptom onset is sufficient to rule out AMI . The ability to rule out AMI without serial testing is a paradigm‐changing innovation that has profound implications for ED efficiency and diagnostic utilization.…”

mentioning

confidence: 99%

Undetectable Concentrations of a Food and Drug Administration–approved High‐sensitivity Cardiac Troponin T Assay to Rule Out Acute Myocardial Infarction at Emergency Department Arrival

McRae

Innes

Graham

et al. 2017

Academic Emergency Medicine

View full text Add to dashboard Cite

BackgroundThe objective of this study was to quantify the sensitivity of very low concentrations of high‐sensitivity cardiac troponin T (hsTnT) at ED arrival for acute myocardial infarction (AMI) in a large cohort of chest pain patients evaluated in real‐world clinical practice.MethodsThis retrospective study included consecutive ED patients with suspected cardiac chest pain evaluated in four urban EDs, excluding those with ST‐elevation AMI, cardiac arrest or abnormal kidney function. The primary outcomes were AMI at 7, 30, and 90 days. Secondary outcomes included major adverse cardiac events (MACE; all‐cause mortality, AMI, and revascularization) and the individual MACE components. Test characteristics were calculated for hsTnT values from 3 to 200 ng/L .ResultsA total of 7,130 patients met inclusion criteria. AMI incidences at 7, 30, and 90 days were 5.8, 6.0, and 6.2%. When the hsTnT assay was performed at ED arrival, the limit of blank of the assay (3 ng/L) ruled out 7‐day AMI in 15.5% of patients with 100% sensitivity and negative predictive value (NPV). The limit of detection of the assay (5 ng/L) ruled out AMI in 33.6% of patients with 99.8% sensitivity and 99.95% NPV for 7‐day AMI. The limit of quantification (the Food and Drug Administration [FDA]‐approved cutoff for lower the reportable limit) of 6 ng/L ruled out AMI in 42.2% of patients with 99.8% sensitivity and 99.95% NPV. The sensitivities of the cutoffs of <3, <5, and <6 ng/L for 7‐day MACE were 99.6, 97.4, and 96.6%, respectively. The NPVs of the cutoffs of <3, <5, and <6 ng/L for 7‐day MACE were 99.8, 99.5, and 99.4%, respectively. A secondary analysis was performed in a subgroup of 3,549 higher‐risk patients who underwent serial troponin testing. In this subgroup, a cutoff of 3 ng/L ruled out 7‐day AMI in 9.6% of patients with 100% sensitivity and NPV, a cutoff of 5 ng/L ruled out 7‐day AMI in 23.3% of patients with 99.7% sensitivity and 99.9% NPV, and a cutoff of 6 ng/L ruled out 7‐day AMI in 29.8% of patients with 99.7 and 99.9% NPV. In the higher‐risk subgroup, the sensitivities of cutoffs of <3, <5, and <6 ng/L for 7‐day MACE were 99.8, 97.4, and 96.6%, respectively. In this higher‐risk subgroup, the NPV of cutoffs of <3, <5, and <6 ng/L for 7‐day MACE were 99.7, 98.5, and 98.4%, respectively.ConclusionsWhen used in real‐world clinical practice conditions, hsTnT concentrations < 6 ng/L (below the lower reportable limit for an FDA‐approved assay) at the time of ED arrival can rule out AMI with very high sensitivity and NPV. The sensitivity for MACE is unacceptably low, and thus a single‐troponin rule‐out strategy should only be used in the context of a structured risk evaluation.

show abstract

2015 ESC Guidelines for the Management of Acute Coronary Syndromes in Patients Presenting Without Persistent ST-segment Elevation

Cited by 157 publications

References 562 publications

The Use of Very Low Concentrations of High‐sensitivity Troponin T to Rule Out Acute Myocardial Infarction Using a Single Blood Test

The Use of Very Low Concentrations of High‐sensitivity Troponin T to Rule Out Acute Myocardial Infarction Using a Single Blood Test

The effect of in-hospital acquired thrombocytopenia on the outcome of patients with acute coronary syndromes: A systematic review and meta-analysis

Undetectable Concentrations of a Food and Drug Administration–approved High‐sensitivity Cardiac Troponin T Assay to Rule Out Acute Myocardial Infarction at Emergency Department Arrival

Contact Info

Product

Resources

About