Document Detail

One-hour rule-out and rule-in of acute myocardial infarction using high-sensitivity cardiac troponin T.
MedLine Citation:
PMID:  22892889     Owner:  NLM     Status:  MEDLINE    
BACKGROUND: High-sensitivity cardiac troponin (hs-cTn) assays seem to improve the early diagnosis of acute myocardial infarction (AMI), but it is unknown how to best use them in clinical practice. Our objective was to develop and validate an algorithm for rapid rule-out and rule-in of AMI.
METHODS: A prospective multicenter study enrolling 872 unselected patients with acute chest pain presenting to the emergency department. High-sensitivity cardiac troponin T (hs-cTnT) was measured in a blinded fashion at presentation and after 1 hour. The final diagnosis was adjudicated by 2 independent cardiologists. An hs-cTnT algorithm incorporating baseline values as well as absolute changes within the first hour was derived from 436 randomly selected patients and validated in the remaining 436 patients. The primary prognostic end point was death during 30 days of follow-up.
RESULTS: Acute myocardial infarction was the final diagnosis in 17% of patients. After applying the hs-cTnT algorithm developed in the derivation cohort to the validation cohort, 259 patients (60%) could be classified as "rule-out," 76 patients (17%) as "rule-in," and 101 patients (23%) as in the "observational zone" within 1 hour. Overall, this resulted in a sensitivity and negative predictive value of 100% for rule-out, a specificity and positive predictive value of 97% and 84%, respectively, for rule-in, and a prevalence of AMI of 8% in the observational zone group. Cumulative 30-day survival was 99.8%, 98.6%, and 95.3% (P < .001) in patients classified as rule-out, observational zone, and rule-in, respectively.
CONCLUSIONS: Using a simple algorithm incorporating hs-cTnT baseline values and absolute changes within the first hour allowed a safe rule-out as well as an accurate rule-in of AMI within 1 hour in 77% of unselected patients with acute chest pain. This novel strategy may obviate the need for prolonged monitoring and serial blood sampling in 3 of 4 patients.
Tobias Reichlin; Christian Schindler; Beatrice Drexler; Raphael Twerenbold; Miriam Reiter; Christa Zellweger; Berit Moehring; Ronny Ziller; Rebeca Hoeller; Maria Rubini Gimenez; Philip Haaf; Mihael Potocki; Karin Wildi; Cathrin Balmelli; Michael Freese; Claudia Stelzig; Heike Freidank; Stefan Osswald; Christian Mueller
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Publication Detail:
Type:  Journal Article; Multicenter Study; Research Support, Non-U.S. Gov't; Validation Studies    
Journal Detail:
Title:  Archives of internal medicine     Volume:  172     ISSN:  1538-3679     ISO Abbreviation:  Arch. Intern. Med.     Publication Date:  2012 Sep 
Date Detail:
Created Date:  2012-09-11     Completed Date:  2012-11-20     Revised Date:  2013-05-03    
Medline Journal Info:
Nlm Unique ID:  0372440     Medline TA:  Arch Intern Med     Country:  United States    
Other Details:
Languages:  eng     Pagination:  1211-8     Citation Subset:  AIM; IM    
Department of Cardiology, University Hospital Basel, Switzerland.
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MeSH Terms
Acute Disease
Aged, 80 and over
Chest Pain / blood,  diagnosis*
Early Diagnosis
Middle Aged
Myocardial Infarction / blood,  diagnosis*
Prospective Studies
Troponin T / blood*
Reg. No./Substance:
0/Troponin T
Comment In:
JAMA Intern Med. 2013 Mar 25;173(6):478   [PMID:  23529558 ]
JAMA Intern Med. 2013 Mar 25;173(6):477-8   [PMID:  23529557 ]
JAMA Intern Med. 2013 Mar 25;173(6):477   [PMID:  23529556 ]
Arch Intern Med. 2012 Sep 10;172(16):1218-9   [PMID:  22892634 ]

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