Author + information
- Received November 18, 2015
- Revision received January 12, 2016
- Accepted January 21, 2016
- Published online April 5, 2016.
- Arash Mokhtari, MDa,b,c,∗ (, )
- Catharina Borna, MDc,d,
- Patrik Gilje, MDb,
- Patrik Tydén, MD, PhDb,
- Bertil Lindahl, MD, PhDe,
- Hans-Jörgen Nilsson, MD, PhDb,
- Ardavan Khoshnood, MDa,c,
- Jonas Björk, PhDf and
- Ulf Ekelund, MD, PhDa,c
- aDepartment of Internal and Emergency Medicine, Skåne University Hospital, Lund, Sweden
- bDepartment of Cardiology, Skåne University Hospital, Lund, Sweden
- cDepartment of Clinical Sciences at Lund, Lund University, Lund, Sweden
- dDivision Specialised Local Health Care, Helsingborg General Hospital, Helsingborg, Sweden
- eDepartment of Medical Sciences and Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
- fOccupational and Environmental Medicine, Lund University, Lund, Sweden
- ↵∗Reprint requests and correspondence:
Dr. Arash Mokhtari, Department of Internal and Emergency Medicine, Department of Cardiology, Skåne University Hospital, Klinikgatan 15, 221 85 Lund, Sweden.
Background A 1-h algorithm based on high-sensitivity cardiac troponin T (hs-cTnT) testing at presentation and again 1 h thereafter has been shown to accurately rule out acute myocardial infarction.
Objectives The goal of the study was to evaluate the diagnostic accuracy of the 1-h algorithm when supplemented with patient history and an electrocardiogram (ECG) (the extended algorithm) for predicting 30-day major adverse cardiac events (MACE) and to compare it with the algorithm using hs-cTnT alone (the troponin algorithm).
Methods This prospective observational study enrolled consecutive patients presenting to the emergency department (ED) with chest pain, for whom hs-cTnT testing was ordered at presentation. Hs-cTnT results at 1 h and the ED physician’s assessments of patient history and ECG were collected. The primary outcome was an adjudicated diagnosis of 30-day MACE defined as acute myocardial infarction, unstable angina, cardiogenic shock, ventricular arrhythmia, atrioventricular block, cardiac arrest, or death of a cardiac or unknown cause.
Results In the final analysis, 1,038 patients were included. The extended algorithm identified 60% of all patients for rule-out and had a higher sensitivity than the troponin algorithm (97.5% vs. 87.6%; p < 0.001). The negative predictive value was 99.5% and the likelihood ratio was 0.04 with the extended algorithm versus 97.8% and 0.17, respectively, with the troponin algorithm. The extended algorithm ruled-in 14% of patients with a higher sensitivity (75.2% vs. 56.2%; p < 0.001) but a slightly lower specificity (94.0% vs. 96.4%; p < 0.001) than the troponin algorithm. The rule-in arms of both algorithms had a likelihood ratio >10.
Conclusions A 1-h combination algorithm allowed fast rule-out and rule-in of 30-day MACE in a majority of ED patients with chest pain and performed better than the troponin-alone algorithm.
- acute coronary syndrome
- chest pain
- myocardial infarction
- sensitivity and specificity
- unstable angina
The study was funded by an ALF research grant at Skåne University Hospital and by a grant from Region Skåne. These are national grants from the Swedish government; there was no industry involvement. Funding organizations had no role in the planning, design, or conduct of the study; collection, analysis, or interpretation of data; or preparation, review, or approval of the manuscript. Dr. Lindahl has received research support from bioMerieux and Fiomi; and speaker/consulting honoraria from bioMerieux, Roche, Radiometer, Philips, ThermoFisher, and Fiomi. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received November 18, 2015.
- Revision received January 12, 2016.
- Accepted January 21, 2016.
- 2016 American College of Cardiology Foundation