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Performance of the ESC 0/1-hour algorithm for rapid rule-out and rule-in of acute myocardial infarction using high-sensitivity cardiac troponin I in patients with impaired and normal renal function

Session Best Posters 3

Speaker Raphael Twerenbold

Event : ESC Congress 2017

  • Topic : coronary artery disease, acute coronary syndromes, acute cardiac care
  • Sub-topic : Coronary Artery Disease and Comorbidities
  • Session type : Best ePosters

Authors : R Twerenbold (Basel,CH), M Rubini Gimenez (Basel,CH), T Reichlin (Basel,CH), J Boeddinghaus (Basel,CH), T Nestelberger (Basel,CH), T Badertscher (Basel,CH), C Puelacher (Basel,CH), O Miro (Barcelona,ES), FJ Martin-Sanchez (Madrid,ES), B Morawiec (Barcelona,ES), S Osswald (Basel,CH), C Mueller (Basel,CH)

Authors:
R. Twerenbold1 , M. Rubini Gimenez1 , T. Reichlin1 , J. Boeddinghaus1 , T. Nestelberger1 , T. Badertscher1 , C. Puelacher1 , O. Miro2 , F.J. Martin-Sanchez3 , B. Morawiec2 , S. Osswald1 , C. Mueller1 , 1University Hospital Basel - Basel - Switzerland , 2Hospital Clinic de Barcelona - Barcelona - Spain , 3Hospital Clinic San Carlos - Madrid - Spain ,

Citation:
European Heart Journal ( 2017 ) 38 ( Supplement ), 465-466

Background: The European Society of Cardiology (ESC) recommends a 0/1-hour algorithm for rapid rule-out and rule-in of non-ST-segment elevation myocardial infarction (NSTEMI) using high-sensitivity cardiac troponin (hs-cTn) concentrations irrespective of renal function. Patients with impaired renal function (IRF) are at higher risk of NSTEMI and are presenting more often with elevated levels of hs-cTn even in absence of NSTEMI, which may both contribute to a different diagnostic performance of such an algorithm as compared to patients with normal renal function (NRF).

Purpose: We aimed to assess and directly compare the diagnostic performance of the 0/1-hour algorithm using hs-cTnI in patients with IRF and NRF.

Methods: In a prospective international multicentre diagnostic study enrolling 2949 patients presenting with suspected NSTEMI to the ED, hs-cTn was determined at baseline and after one hour using hs-cTnI (Architect). Patients presenting with STEMI were excluded. The final diagnosis was centrally adjudicated by two independent cardiologists based on hs-cTnT using all available data. Safety of the algorithm was quantified as the sensitivity and negative predictive value (NPV) for AMI in the rule-out zones, selectivity as the specificity and positive predictive value (PPV) for AMI in the rule-in zones and efficacy as the percentage of the overall cohort assigned to the rule-out or rule-in zone within one hour. All diagnostic performance measures were directly compared between patients with IRF (CKD-EPI GFR <60ml/min/1.73m2) and NRF.

Results: IRF was present in 445 of total 2949 patients (15%) with a median GFR of 44.7 ml/min/1.73m2 [IQR 33.7–51.7]. Prevalence of NSTEMI (total, n=472) was substantially higher in patients with IRF as compared to NRF (32% versus 13%, p<0.001). Sensitivity of rule-out for AMI (98.6% (95% CI, 95.0–99.8) versus 98.5% (95% CI, 96.5–99.5), p=0.920) was comparable between IRF and NRF while NPV (97.4% (95% CI, 90.5–99.4) versus 99.7% (95% CI, 99.2–99.9), p=0.005) was significantly reduced in IRF (Figure 1). Specificity of rule-in (84.4% (95% CI, 79.9–88.3) versus 91.7% (95% CI, 90.5–92.9), p<0.001) was lower in IRF while PPV (70.8% (95% CI, 64.8–76.2) versus 60.7% (95% CI, 57.1–64.2), p<0.001) was higher in IRF as compared to NRF. Overall efficacy (53% versus 76%, p<0.001) was substantially lower in IRF as compared to NRF.

Conclusion: While safety of the ESC 0/1-hour algorithm using hs-cTnI is high in patients with IRF and comparable to NRF, specificity and PPV of rule-in as well as overall efficacy substantially differ. Adjustments of the existing algorithm to IRF may seem warranted to improve optimal and effective triage of these high-risk patients in the ED.

Trial Registration: ClinicalTrials.gov number, NCT00470587

Figure 1

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