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Direct comparison of the safety and efficacy of two rule-out strategies for acute myocardial infarction:2h-algorithm versus undetectable levels at presentation

Session Acute cardiac care in the emergency department

Speaker Maria Rubini Gimenez

Event : ESC Congress 2015

  • Topic : coronary artery disease, acute coronary syndromes, acute cardiac care
  • Sub-topic : Acute Cardiac Care
  • Session type : Rapid Fire Abstracts

Authors : M Rubini Gimenez (Basel,CH), R Twerenbold (Basel,CH), K Wildi (Basel,CH), T Reichlin (Basel,CH), J Boeddinghaus (Basel,CH), C Puelacher (Basel,CH), K Grimm (Basel,CH), S Osswald (Basel,CH), C Mueller (Basel,CH)

Authors:
M. Rubini Gimenez1 , R. Twerenbold1 , K. Wildi1 , T. Reichlin1 , J. Boeddinghaus1 , C. Puelacher1 , K. Grimm1 , S. Osswald1 , C. Mueller1 , 1University Hospital Basel, Department of Cardiology - Basel - Switzerland ,

Citation:
European Heart Journal ( 2015 ) 36 ( Abstract Supplement ), 5

Purpose: Addressing the increasingly recognized, yet unmet clinical need for rapid rule-out of acute myocardial infarction (AMI), several novel strategies have been developed. Due to the lack of direct comparisons in the same dataset, selection of the best strategy for clinical practice is challenging. We therefore aimed to directly compare the safety and efficacy of two previously defined strategies: hs-cTnT 2h-algorithm versus LOD (Undetectable levels of high-sensitivity cardiac troponin (hs-cTn) T at presentation).

Methods: In a prospective international multicentre diagnostic study enrolling 1814 patients presenting with suspected AMI to the emergency department (ED), the final diagnosis of AMI was adjudicated by two independent cardiologists using all available clinical information including serial hs-cTnT concentrations. Safety was quantified as the negative predictive value (NPV) for AMI in the rule-out zone of the respective rule-out strategies. Efficacy was quantified as the percentage of the overall cohort assigned to the rule-out zone by the respective strategy. The 2h-algoritm was defined as 0h and 2h values <14ng/l and Δ0–2h<4ng/l; LOD was defined as <5ng/L. As both strategies should only be applied once ST-elevation MI (STEMI) has been excluded by the initial ECG, STEMI patients were excluded from the analysis.

Results: Acute myocardial infarction was the final diagnosis in 16% of patients. The safety was very high and comparable with both algorithms (2h algorithm: NPV 99.9%, 95% CI 99.5–100% versus LOD: NPV 99.8%, 95% CI 98.7–100%, p=ns)

Regarding efficacy, 2h-algorithm allowed rule-out in 64% of patients versus 24% with LOD (p<0.001).

Conclusion: Both investigated rule-out strategies allow a safe rule-out of AMI. The 2h-algorithm has a significantly higher efficacy having similar safety; however the LOD strategy has the obvious advantage of allowing rule-out in 1 of each 4 patients at presentation to the ED without the need of further serial sampling.

Trial Registration: ClinicalTrials.gov number, NCT00470587

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