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

Carlton, Edward; Cullen, Louise; Than, Martin; Gamble, James; Khattab, Ahmed; Greaves, Kim

doi:10.1136/heartjnl-2014-307288

Cited by 74 publications

(90 citation statements)

References 26 publications

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“…Current data suggest that the diagnostic performance of high-sensitivity assays when used in isolation is too low to allow immediate discharge of patients presenting to ED after a single blood draw on arrival (6,7). Therefore, to reduce door-to-discharge times further, it has been suggested that the adjunctive use of clinical chest pain risk scores (which give an estimate of pre-test probability), in combination with hs-cTn testing will improve the diagnostic performance (8,9). Although these combination strategies are gaining acceptance, the optimum choice of 4 rapid rule-out protocol remains undetermined.…”

Section: Background and Importancementioning

confidence: 99%

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

Carlton

Khattab

Greaves

2015

Annals of Emergency Medicine

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ObjectiveTo compare the ability of five established risk scores to identify patients with suspected acute coronary syndromes (ACS) suitable for discharge after a single presentation highsensitivity troponin (hs-cTn) result. MethodsProspective observational study conducted in a U.K. District General Hospital Emergency Department. Consecutive adults recruited with suspected ACS whom attending physicians determined evaluation with serial troponin testing was required. Index tests were definitions of low risk applied to Goldman, TIMI, GRACE, HEART and Vancouver risk scores, incorporating either hs-cTnT or hs-cTnI results. The endpoint was acute myocardial infarction (AMI) within 30 days. A test sensitivity threshold for AMI of 98% was chosen.Clinical utility was defined as a negative predictive value (NPV) ≥99.5% and identification of >30% suitable for discharge. Results959 patients underwent hs-cTnT and 867 hs-cTnI analysis. In the hs-cTnT group, 79/959 (8.2%) had an AMI and 66/867 (7.6%) in the hs-cTnI group. Two risk scores (GRACE<80, HEART≤3) did not have the potential to achieve a sensitivity of 98% with hs-cTnT and three 2 scores (Goldman≤1, TIMI≤1, GRACE<80) with hs-cTnI. TIMI 0 or ≤1 and m-Goldman≤1 with hs-cTnT, and TIMI 0 and HEART≤3, with hs-cTnI have the potential to achieve an NPV ≥99.5% while identifying >30% for discharge. ConclusionUsing established risk scores, it may be possible to identify >30% of patients suitable for discharge with an NPV ≥99.5% for the diagnosis of AMI using a single hs-cTn result taken at presentation. There is variation in hs-cTn assays which may have implications in introducing rapid rule-out protocols.

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Section: Background and Importancementioning

confidence: 99%

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

Carlton

Khattab

Greaves

2015

Annals of Emergency Medicine

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“…[61][62][63][64][65][66][67][68][69][70][71][72][73][74][75][76] Although most of the research in this area is observational, there have been 2 single-center RCTs, and there has been widespread implementation of such strategies in Australasia. The Australian state of Queensland and the country of New Zealand, with combined populations of nearly 10 million people, now have fully adopted accelerated diagnostic pathways.…”

Section: Combining Troponin With Risk Scoring Systems For Acceleratedmentioning

confidence: 99%

“…This validation study classified a percentage of patients as low risk (39.8%) similar to the ADAPT and APACE studies with good sensitivity (98.8%) and NPV (99.7%; Table 4). 63,65,66 The HEART score 67 was derived on the basis of clinical logic and simplicity rather than statistical derivation from a prospective trial. The manner in which the score was developed is interesting.…”

Section: Combining Troponin With Risk Scoring Systems For Acceleratedmentioning

confidence: 99%

State-of-the-Art Evaluation of Emergency Department Patients Presenting With Potential Acute Coronary Syndromes

2016

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ABSTRACT:It is well established that clinicians cannot use clinical judgment alone to determine whether an individual patient who presents to the emergency department has an acute coronary syndrome. The history and physical examination do not distinguish sufficiently between the many conditions that can cause acute chest pain syndromes. Cardiac risk factors do not have sufficient discriminatory ability in symptomatic patients presenting to the emergency department. Most patients with non-ST-segment-elevation myocardial infarction do not present with electrocardiographic evidence of active ischemia. The improvement in cardiac troponin assays, especially in conjunction with well-validated clinical decision algorithms, now enables the clinician to rapidly exclude myocardial infarction. In patients in whom unstable angina remains a concern or there is a desire to evaluate for underlying coronary artery disease, coronary computed tomography angiography can be used in the emergency department. Once a process that took ≥24 hours, computed tomography angiography now can rapidly exclude myocardial infarction and coronary artery disease in patients in the emergency department.A bout 20 million patients present with symptoms possibly suggestive of acute coronary syndrome (ACS) to emergency departments (ED) in North America and Europe each year.1-3 Patients with ACS and acute myocardial infarction (AMI) present with a wide variety of symptoms such as chest pain, shortness of breath, weakness, nausea, vomiting, and even fatigue, making the diagnosis difficult. Demographics, cardiac risk factors, chest pain characteristics, and physical examination can assist disposition decisions but are insufficient to identify who does and does not have an ACS.4-7 Some patients may have objective evidence of a clearcut diagnosis, but the majority do not. 8 The majority ultimately will be found not to have ACS, but symptoms caused by noncardiac and often benign disorders such as musculoskeletal pain, pleuritis, or gastroesophageal reflux make the rapid rule-out of ACS more difficult and result in huge medical expenses. Safe and early rule-out of ACS contributes to more efficient and high-value healthcare delivery. History And PHysicAl ExAminAtionClinical features, alone or in combination with an ECG, are poorly predictive for AMI (Table 1). 9,10 In addition, they have variable reliability. Features classically associated with a lower probability of AMI such as pleuritic, positional, and sharp chest pain have poor to fair interphysician reliability (κ=0.27-0.44), 11 whereas high-risk features (radiation to left arm, substernal location, and history of AMI) are more reliable (κ=0.74-0.89). 11Traditional cardiac risk factors, derived from population-based longitudinal cohort studies of asymptomatic patients, are poor predictors of risk for AMI or ACS in symptomatic patients in the ED. 6,7 Similarly, the physical examination seldom is useful for distinguishing patients with ACS from patients with noncardiac chest pain.Trials of medications, onc...

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“…The hope is that high-sensitivity troponin assays will lead to earlier diagnosis of acute coronary syndrome and, with their enhanced sensitivity and sex-specific cutoffs, may improve patient outcomes, especially in women. However, there is insufficient evidence yet to conclude whether these outcomes have been achieved [3][4][5][6].…”

Section: Introductionmentioning

confidence: 99%

High incidence of macrotroponin I with a high-sensitivity troponin I assay

Warner

Marshall

2016

Clinical Chemistry and Laboratory Medicine (CCLM)

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Background:Cardiac troponin is the preferred biomarker of myocardial injury. High-sensitivity troponin assays allow measurement of very low levels of troponin with excellent precision. After the introduction of a high-sensitivity troponin I assay the laboratory began to receive enquiries from clinicians about clinically discordant elevated troponin I results. This led to a systematic investigation and characterisation of the cause.Methods:Routine clinical samples were measured by the Architect High Sensitive Troponin-I (hsTnI) and the VITROS Troponin I ES assays (VitrosTnI). Results that were elevated according to the Architect but not the VITROS assay (Group 1) or results elevated by both assays but disproportionately higher on the Architect (Group 2) were re-analysed for hsTnI after re-centrifugation, multiple dilutions, incubation with heterophilic blocking reagents, polyethylene glycol (PEG) precipitation, and Protein A/G/L treatment. Sephacryl S-300 HR gel filtration chromatography (GFC) was performed on selected specimens.Results:A high molecular weight complex containing immunoreactive troponin I and immunoglobulin (macrotroponin I) was identified in 5% of patients with elevated hsTnI. Patients with both macrotroponin and myocardial injury had higher and longer elevation of hsTnI compared with VitrosTnI with peaks of both macrotroponin and free troponin I-C complex on GFC.Conclusions:Circulating macrotroponin I (macroTnI) causes elevated hsTnI results with the Architect High Sensitive Troponin-I assay with the potential to be clinically misleading. The assay involved in this investigation may not be the only assay affected by macrotroponin. It is important for laboratories and clinicians to be aware of and develop processes to identify and manage specimens with elevated results due to macrotroponin.

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

Cited by 74 publications

References 26 publications

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

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

State-of-the-Art Evaluation of Emergency Department Patients Presenting With Potential Acute Coronary Syndromes

High incidence of macrotroponin I with a high-sensitivity troponin I assay

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