Comparison of the Efficacy and Safety of Early Rule-Out Pathways for Acute Myocardial Infarction

• DOI: 10.1161/circulationaha.116.025021
• Publication Date: 2016-12-30T02:15:24Z
• Authors: Andrew R. Chapman; Atul Anand; Jasper Boeddinghaus; Amy V. Ferry; Dennis Sandeman; Philip D. Adamson; Jack Andrews; Stephanie Tan; Sheun F. Cheng; Michelle D’Souza; Kate Orme; Fiona E. Strachan; Thomas Nestelberger; Raphael Twerenbold; Patrick Badertscher; Tobias Reichlin; Alasdair Gray; Anoop S.V. Shah; Christian Mueller; David E. Newby; Nicholas L. Mills
• Keywords: Troponin T

Background: High-sensitivity cardiac troponin assays enable myocardial infarction to be ruled out earlier, but the optimal approach is uncertain. We compared European Society of Cardiology rule-out pathway with a that incorporates lower concentrations risk stratify patients. Methods: Patients suspected acute coronary syndrome (n=1218) underwent high-sensitivity I measurement at presentation and 3 6 or 12 hours. (<99th centile hours if symptoms <6 hours) developed in High-STEACS study (High-Sensitivity Troponin Evaluation With Acute Coronary S yndrome) population (<5 ng/L change <3 <99th hours). The primary outcome was comparison negative predictive value both pathways for index type 1 death 30 days. evaluated prespecified subgroups stratified by age, sex, time symptom onset, known ischemic heart disease. Results: occurred 15.7% (191 1218) In those less than 99th presentation, 28.1% (342 78.9% (961 hours, respectively, missing 18 two 30-day events (negative value, 97.9%; 95% confidence interval, 96.9–98.7). 40.7% (496 74.2% (904 2 99.5%; 99.0–99.9; P <0.001 comparison). greater overall ( <0.001) all subgroups, including presenting early have Conclusions: Use incorporating low rules more patients misses 5-fold fewer infarctions guideline-approved based exclusively on centile. Clinical Trial Registration: URL: http://clinicaltrials.gov . Unique identifier: NCT01852123.