The utility of the 1-hour high-sensitivity cardiac troponin T algorithm compared with and combined with five early rule-out scores in high-acuity chest pain emergency patients

Ruangsomboon, Onlak; Thirawattanasoot, Netiporn; Chakorn, Tipa; Limsuwat, Chok; Monsomboon, Apichaya; Praphruetkit, Nattakarn; Surabenjawong, Usapan; Riyapan, Sattha; Nakornchai, Tanyaporn

doi:10.1016/j.ijcard.2020.08.099

Cited by 8 publications

(4 citation statements)

References 27 publications

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“…Regional differences in the management of NSTE-ACS persist in Asian countries even after extensive adjustment for baseline characteristics and treatment [ 12 ]. Indeed, in previous studies, the MACE rates tend to be higher than in Central European or North American countries and vary from 1 to 4% [ 10 , 18 , 22 , 23 ]. We estimated that, in the standard care arm, patients managed as outpatients by usual care would experience an event rate of 3%, for the primary outcome of MACE including all-cause death, subsequent myocardial infarction, unstable angina, or unexpected revascularization in 30 days.…”

Section: Methodsmentioning

confidence: 99%

“…Compared with western countries, some countries in Asia showed much lower rates of coronary angiography and revascularization for patient with ACS, and also some of the highest post-discharge mortality rates [12,22,[33][34][35][36]. This discrepancy highlights that quality of care is not only a matter of availability of resources but also depends on knowledge of guidelines and application of its recommendations, organization of care, including effective referral systems from secondary centers to tertiary centers with full coronary revascularization facilities, and issues related to social security coverage and/or need for reimbursement for procedures.…”

Section: Characteristic Of Asiamentioning

confidence: 99%

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An international, stepped wedge, cluster-randomized trial investigating the 0/1-h algorithm in suspected acute coronary syndrome in Asia: the rational of the DROP-Asian ACS study

Inoue

Chieh

Yeh

et al. 2022

Trials

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Background More than half of the world’s population lives in Asia. With current life expectancies in Asian countries, the burden of cardiovascular disease is increasing exponentially. Overcrowding in the emergency departments (ED) has become a public health problem. Since 2015, the European Society of Cardiology recommends the use of a 0/1-h algorithm based on high-sensitivity cardiac troponin (hs-cTn) for rapid triage of patients with suspected non-ST elevation acute coronary syndrome (NSTE-ACS). However, these algorithms are currently not recommended by Asian guidelines due to the lack of suitable data. Methods The DROP-Asian ACS is a prospective, stepped wedge, cluster-randomized trial enrolling 4260 participants presenting with chest pain to the ED of 12 acute care hospitals in five Asian countries (UMIN; 000042461). Consecutive patients presenting with suspected acute coronary syndrome between July 2022 and Apr 2024 were included. Initially, all clusters will apply “usual care” according to local standard operating procedures including hs-cTnT but not the 0/1-h algorithm. The primary outcome is the incidence of major adverse cardiac events (MACE), the composite of all-cause death, myocardial infarction, unstable angina, or unplanned revascularization within 30 days. The difference in MACE (with one-sided 95% CI) was estimated to evaluate non-inferiority. The non-inferiority margin was prespecified at 1.5%. Secondary efficacy outcomes include costs for healthcare resources and duration of stay in ED. Conclusions This study provides important evidence concerning the safety and efficacy of the 0/1-h algorithm in Asian countries and may help to reduce congestion of the ED as well as medical costs.

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Section: Methodsmentioning

confidence: 99%

Section: Characteristic Of Asiamentioning

confidence: 99%

An international, stepped wedge, cluster-randomized trial investigating the 0/1-h algorithm in suspected acute coronary syndrome in Asia: the rational of the DROP-Asian ACS study

Inoue

Chieh

Yeh

et al. 2022

Trials

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“…After excluding 549 perused full-text articles, we finally included 86 publications, including 72 reports on test accuracy and 52 on 30-day clinical outcomes (online supplemental appendix table 1). 17–102 The excluded articles are listed in online supplemental appendix table 2.…”

Section: Resultsmentioning

confidence: 99%

Serial high-sensitivity cardiac troponin testing for the diagnosis of myocardial infarction: a scoping review

et al. 2022

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ObjectivesWe aimed to assess the diversity and practices of existing studies on several assays and algorithms for serial measurements of high-sensitivity cardiac troponin (hs-cTn) for risk stratification and the diagnosis of myocardial infarction (MI) and 30-day outcomes in patients suspected of having non-ST-segment elevation MI (NSTEMI).MethodsWe searched multiple databases including MEDLINE, EMBASE, Science Citation Index, the Cochrane Database of Systematic Reviews and the CENTRAL databases for studies published between January 2006 and November 2021. Studies that assessed the diagnostic accuracy of serial hs-cTn testing in patients suspected of having NSTEMI in the emergency department (ED) were eligible. Data were analysed using the scoping review method.ResultsWe included 86 publications, mainly from research centres in Europe, North America and Australasia. Two hs-cTn assays, manufactured by Abbott (43/86) and Roche (53/86), dominated the evaluations. The studies most commonly measured the concentrations of hs-cTn at two time points, at presentation and a few hours thereafter, to assess the two-strata or three-strata algorithm for diagnosing or ruling out MI. Although data from 83 studies (97%) were prospectively collected, 0%–90% of the eligible patients were excluded from the analysis due to missing blood samples or the lack of a final diagnosis in 53 studies (62%) that reported relevant data. Only 19 studies (22%) reported on head-to-head comparisons of alternative assays.ConclusionEvidence on the accuracy of serial hs-cTn testing was largely derived from selected research institutions and relied on two specific assays. The proportions of the eligible patients excluded from the study raise concerns about directly applying the study findings to clinical practice in frontline EDs.PROSPERO registration numberCRD42018106379.

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“…T-MACS has been externally validated in 1,459 patients from three prospective studies in the United Kingdom [5], 1,244 patients from Australasia [6], and multicentre prospective trials from the United Kingdom [7], Thailand [8] and Norway [9], each of which demonstrated acceptable predictive performance. A pilot randomized controlled trial of a precursor version of the algorithm showed that its use led to significantly more safe discharges from the ED within 4 hours of arrival than standard care [10].…”

Section: Introductionmentioning

confidence: 99%

Advanced cardiovascular risk prediction in the emergency department: updating a clinical prediction model – a large database study protocol

et al. 2021

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Background Patients presenting with chest pain represent a large proportion of attendances to emergency departments. In these patients clinicians often consider the diagnosis of acute myocardial infarction (AMI), the timely recognition and treatment of which is clinically important. Clinical prediction models (CPMs) have been used to enhance early diagnosis of AMI. The Troponin-only Manchester Acute Coronary Syndromes (T-MACS) decision aid is currently in clinical use across Greater Manchester. CPMs have been shown to deteriorate over time through calibration drift. We aim to assess potential calibration drift with T-MACS and compare methods for updating the model. Methods We will use routinely collected electronic data from patients who were treated using TMACS at two large NHS hospitals. This is estimated to include approximately 14,000 patient episodes spanning June 2016 to October 2020. The primary outcome of acute myocardial infarction will be sourced from NHS Digital’s admitted patient care dataset. We will assess the calibration drift of the existing model and the benefit of updating the CPM by model recalibration, model extension and dynamic updating. These models will be validated by bootstrapping and one step ahead prequential testing. We will evaluate predictive performance using calibrations plots and c-statistics. We will also examine the reclassification of predicted probability with the updated TMACS model. Discussion CPMs are widely used in modern medicine, but are vulnerable to deteriorating calibration over time. Ongoing refinement using routinely collected electronic data will inevitably be more efficient than deriving and validating new models. In this analysis we will seek to exemplify methods for updating CPMs to protect the initial investment of time and effort. If successful, the updating methods could be used to continually refine the algorithm used within TMACS, maintaining or even improving predictive performance over time. Trial registration ISRCTN number: ISRCTN41008456

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The utility of the 1-hour high-sensitivity cardiac troponin T algorithm compared with and combined with five early rule-out scores in high-acuity chest pain emergency patients

Cited by 8 publications

References 27 publications

An international, stepped wedge, cluster-randomized trial investigating the 0/1-h algorithm in suspected acute coronary syndrome in Asia: the rational of the DROP-Asian ACS study

An international, stepped wedge, cluster-randomized trial investigating the 0/1-h algorithm in suspected acute coronary syndrome in Asia: the rational of the DROP-Asian ACS study

Serial high-sensitivity cardiac troponin testing for the diagnosis of myocardial infarction: a scoping review

Advanced cardiovascular risk prediction in the emergency department: updating a clinical prediction model – a large database study protocol

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