Clinical impact of the troponin 99th percentile cut-off and clinical utility of myoglobin measurement in the early management of chest pain patients admitted to the Emergency Cardiology Department

Amodio, Gianfranco; Antonelli, G; Varraso, Lucia; Ruggieri, Vincenzo; Serio, Francesca Di

doi:10.1097/mca.0b013e32801682b6

Cited by 31 publications

(17 citation statements)

References 22 publications

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“…There were heterogeneous data on the use of troponin point-of-care testing (POCT) in the diagnosis of ACS: 5 studies supported the use of troponin POCT (LOE D2 145 ; LOE D4 145,160 -163 ), and 5 studies opposed the use of troponin POCT in the ED and cardiac short-stay units (LOE D3 164 ; LOE D4 [165][166][167][168] ). Two studies opposed the use of troponin POCT in the prehospital setting (LOE D4), 148,149 and 1 opposed the use of troponin POCT in the outpatient clinic setting (LOE D2).…”

Section: Consensus On Sciencementioning

confidence: 99%

“…151 Four studies showed increased sensitivity of new sensitive troponin assays compared with conventional troponin assays and supported their use to diagnose AMI (LOE D2 152,153 ; LOE D3 154 ; LOE D4 155 ). Nine studies supported multimarker testing (CK-MB, ischemia-modified albumin or myoglobin) in combination with cardiac troponin in the diagnosis of AMI (LOE D2 139,141,153,(156)(157)(158) LOE D4 145,156,159 ).There were heterogeneous data on the use of troponin point-of-care testing (POCT) in the diagnosis of ACS: 5 studies supported the use of troponin POCT (LOE D2 145 ; LOE D4 145,160 -163 ), and 5 studies opposed the use of troponin POCT in the ED and cardiac short-stay units (LOE D3 164 ; LOE D4 [165][166][167][168] ). Two studies opposed the use of troponin POCT in the prehospital setting (LOE D4), 148,149 and 1 opposed the use of troponin POCT in the outpatient clinic setting (LOE D2).…”

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confidence: 99%

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Part 9: Acute Coronary Syndromes

Bossaert

O’Connor²,

Arntz³

et al. 2010

Circulation

103

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These experts reviewed 25 topics related to the acute initial management of acute coronary syndrome (ACS), which was further categorized as unstable angina, non-ST-elevation MI (UA/NSTEMI) and ST-elevation MI (STEMI). Topics were identified based on previous recommendations, emerging science, and clinical importance, using an iterative writing process involving all Task Force members. The Task Force reviewed the evidence specifically related to diagnosis and treatment of ACS in the out-ofhospital setting and the first hours of care in the in-hospital setting, typically in the emergency department (ED). The evidence review took place over several years, with ongoing refinement of recommendations being made as new evidence was published. The purpose of the review was to generate current, evidence-based treatment recommendations for healthcare providers who serve as the initial point of contact for patients with signs and symptoms suggestive of ACS.The following is a summary of the most important changes in recommendations for diagnosis and treatment of ACS since the last ILCOR review in 2005. 1,2• The history and physical examination, initial ECG, and initial serum biomarkers, even when used in combination, cannot be used to reliably exclude ACS in the prehospital and ED settings.• In contrast, chest pain observation protocols are useful in identifying patients with suspected ACS and patients who require admission or may be referred for provocative testing for coronary artery disease (CAD) to identify reversible ischemia. Such strategies also reduce cost by reducing unnecessary hospital admissions and improve patient safety through more accurate identification of NSTEMI and STEMI.• The acquisition of a prehospital 12-lead ECG is essential for identification of STEMI patients before hospital arrival and should be used in conjunction with pre-arrival hospital notification and concurrent activation of the catheter laboratory.• Nonphysicians can be trained to independently interpret 12-lead ECGs for the purpose of identifying patients with STEMI, provided that appropriate and reliable STEMI criteria are used. This skill is of particular value in the prehospital setting where paramedics may independently identify STEMI, thus mitigating over-reliance on ECG transmission.• Computer-assisted ECG interpretation can be used to increase diagnostic accuracy of STEMI diagnosis when used alone or in combination with ECG interpretation by a trained healthcare provider.• STEMI systems of care can be implemented to improve the time to treatment. The following measures have been shown to reduce the time to primary percutaneous coronary intervention (PPCI): institutional commitment, use of a team-based approach, arranging single-call activation of the catheterization laboratory by the emergency physician or prehospital provider, requiring the catheterization laboratory to be ready in 20 minutes, having an experienced cardiologist always available, and providing real-time data feedback.• Intravenous (IV) ␤-blockers should not be give...

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Section: Consensus On Sciencementioning

confidence: 99%

mentioning

confidence: 99%

Part 9: Acute Coronary Syndromes

Bossaert

O’Connor²,

Arntz³

et al. 2010

Circulation

103

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“…Amodio et al showed that lowering the AMI cutoff concentration from the 10% CV to the 99th percentile (0.03 ng/mL) improved the sensitivity in the ED by 13% (from 64% [95% CI 54%-73%] to 77% [CI 68%-85%]) while reducing the specificity by only 9% (from 93% [CI 90%-95%] to 84% [CI 80%-88%]). 21 In this study, troponin was as early of an AMI marker as myoglobin. Melanson et al examined 103 patients who initially had a negative followed by a positive result on a subsequent sample using a firstgeneration troponin assay (99th percentile cutoff 0.1 ng/mL, 10% CV 0.12 ng/mL).…”

Section: Figurementioning

confidence: 98%

The clinical need for high-sensitivity cardiac troponin assays for acute coronary syndromes and the role for serial testing

Jaffe

2008

American Heart Journal

138

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“…Amodio and colleagues, in their study of 516 patients with non-ST-elevation admitted to a hospital, showed that lowering cutoff of cTnI concentration from the 10% CV at the 99th percentile to the 99th percentile cutoff (0.03 ng/mL) to diagnose AMI improved the sensitivity 13% (from 64% ͓95% CI: 54%-73%͔ to 77% ͓CI: 68%-85%͔) whereas reducing the specificity by only 9% (from 93% ͓CI: 90%-95%͔ to 84% ͓CI: 80%-88%͔). 30 With respect to risk prediction, Venge and colleagues studied commercially available assays of cTn in patients with unstable coronary artery disease in a substudy of the FRISC (Fast Revascularization during InStability in Coronary disease) II trial and showed that assays with superior analytical sensitivity identified more patients with poor prognosis who were candidates for early invasive procedures. 31 James et al compared cTnI point-of-care assay which had lower sensitivity against a more sensitive cTnT central laboratory assay.…”

Section: Need For Hstn Assays In the Setting Of Acsmentioning

confidence: 99%

Clinical Applications of Highly Sensitive Troponin Assays

Mohammed

Januzzi²

2010

Cardiology in Review

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Cardiac troponin is the biomarker of choice for the diagnosis of acute myocardial infarction. Recent consensus recommendations have adopted a concentration of troponin above the 99th percentile of a healthy population to diagnose myocardial infarction. Until recently, there was no assay capable of achieving recommended precision; however, with the development of "highly sensitive" troponin assays, it is now possible to accurately measure troponin concentrations at and below the current 99th percentile of a healthy population. These assays have enormous potential in not only identifying more patients with acute myocardial infarction, and providing superior risk prediction in those so afflicted, in addition highly sensitive troponins assays may be useful for long-term risk assessment of the patient with coronary disease. In this article, we will review the clinical applications, novel concepts, challenges, and limitations of using highly sensitive troponins assays.

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Clinical impact of the troponin 99th percentile cut-off and clinical utility of myoglobin measurement in the early management of chest pain patients admitted to the Emergency Cardiology Department

Abstract: The diagnostic accuracy in detecting myocardial damage early in the Emergency Cardiology Department improves when the 99th percentile is used as a decisional value of cardiac troponin I; the use of this cut-off makes the measurement of myoglobin unnecessary.

Cited by 31 publications

References 22 publications

Part 9: Acute Coronary Syndromes

Part 9: Acute Coronary Syndromes

The clinical need for high-sensitivity cardiac troponin assays for acute coronary syndromes and the role for serial testing

Clinical Applications of Highly Sensitive Troponin Assays

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