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Comparison of safety and efficacy of rule-out strategies in myocardial infarction: copeptin in combination with troponin versus 2h algorithm
Authors : KS Wildi (Basel,CH), R Twerenbold (Basel,CH), M Rubini Gimenez (Basel,CH), T Reichlin (Basel,CH), M Wagener (Basel,CH), J Boeddinghaus (Basel,CH), T Nestelberger (Basel,CH), S Osswald (Basel,CH), C Mueller (Basel,CH)
K.S. Wildi1
,
R. Twerenbold1
,
M. Rubini Gimenez1
,
T. Reichlin1
,
M. Wagener1
,
J. Boeddinghaus1
,
T. Nestelberger1
,
S. Osswald1
,
C. Mueller1
,
1University Hospital Basel - Basel - Switzerland
,
Topic(s): Acute cardiac care in the emergency department
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 (dual marker strategy with high-sensitivity cardiac troponin (hs-cTn) and copeptin at presentation versus the hs-cTn 2h-algorithm).
Methods: In a prospective international multicentre diagnostic study enrolling 1194 patients presenting with suspected AMI to the emergency department, 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 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. Both strategies were applied using a very well validated hs-cTn assay (hs-cTnT Roche: 99th percentile 14ng/l; 2h-algorithm 0h and 2h<14ng/l and Δ0–2h<4ng/l), the cutoff value of copeptin was determined to be 9pmol/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 18% of patients. The safety was very high and comparable with both algorithms (dual marker strategy: NPV 97.2%, 95% CI 95.6–98.4% versus 2h-algorithm: NPV 99.9%, 95% CI 99.3–100%, p<0.001). Regarding efficacy, copeptin in combination with hs-cTnT allowed rule-out in 48.6% of patients versus 62.1% with the 2h-algorithm (p<0.001).
Conclusion: Both investigated rule-out strategies allow a safe rule-out of AMI, but the 2h-algorithm clearly performed better. While the dual marker strategy has the obvious advantage of allowing rule-out already with the measurement at presentation, the 2h-algorithm is more effective and increases the number of patients eligible for rule-out.
