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Direct Comparison of the Safety and Efficacy of two Rule-out Strategies for Acute Myocardial Infarction: 1h-algorithm using troponin versus a dual marker strategy combining copeptin and troponin

Session Knowing more about STEMI and non-STEMI

Speaker Raphael Twerenbold

Event : ESC Congress 2015

  • Topic : coronary artery disease, acute coronary syndromes, acute cardiac care
  • Sub-topic : Unstable Angina
  • Session type : Moderated Posters

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

R. Twerenbold1 , M. Rubini Gimenez1 , K. Wildi1 , K. Grimm1 , T. Reichlin1 , P. Hillinger1 , C. Puelacher1 , J. Boeddinghaus1 , S. Osswald1 , C. Mueller1 , 1University Hospital Basel - Basel - Switzerland ,

European Heart Journal ( 2015 ) 36 ( Abstract Supplement ), 174

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 (The high-sensitivity cardiac troponin (hs-cTn) 1h-algorithm versus the dual marker strategy combining copeptin and hs-cTn (copeptin/hs-cTn) at presentation).

Methods: In a prospective international multicentre diagnostic study enrolling 1502 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 the two best-validated hs-cTn assays (hs-cTnT Roche: 1h-algorithm rule-out if 0h<12ng/l and Δ0–1h<3ng/l; Copeptin/hs-cTnT if 0h Copeptin <9pmol/l and 0h hs-cTnT<14ng/l; hs-cTnI Abbott: 1h-algorithm rule-out if 0h <5ng/L and Δ0–1h<2ng/l; Copeptin/hs-cTnI if 0h Copeptin <9pmol/l and 0h hs-cTnI<26.2ng/l) to ensure that findings are independent from the hs-cTn assay used. Patients presenting with ST-elevation myocardial infarction were excluded from the analysis.

Results: Acute myocardial infarction was the final diagnosis in 19% of patients. Using hs-cTnT, the safety was higher for the 1h-algorithm (NPV 99.9%, 95% CI 99.4–100%) as compared to copeptin/hs-cTnT (NPV 98.7%, 95% CI 97.6–99.4%, p=0.007). Regarding efficacy, 1h-algorithm allowed rule-out in 57% of patients versus 47% with copeptin/hs-cTnT (p<0.001). Using hs-cTnI, the safety was higher for the 1h-algorithm (NPV 99.2%, 95% CI 98.2–99.7%) as compared to copeptin/hs-cTnI (NPV 96%, 95% CI 94.3–97.2%, p<0.001). Regarding efficacy, 1h-algorithm allowed rule-out in 51% of patients versus 54% with copeptin/hs-cTnI (p=ns).

Conclusion: The safety of the investigated 1h-algorithm based on hs-cTn at presentation and after 1h is superior to the combination of copeptin and hs-cTn at presentation, irrespective of the underlying hs-cTn assay. Furthermore, even though requiring a second blood draw after 1h, efficacy tends to be superior using the 1h-algorithm.

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