Key result
One-hour troponin algorithm accurately diagnoses acute MI but leaves ~36% of patients unclassified.
Why the study?
The guideline-recommended 1-hour troponin algorithm for NSTEMI was developed in cohorts with an MI prevalence under 20%, leaving its diagnostic performance unclear in high-prevalence settings.
Does the 1-hour high-sensitivity troponin algorithm accurately diagnose NSTEMI in high-risk patients with suspected MI?
Cohort (n=1,317)
No
Does the 1-hour high-sensitivity troponin algorithm accurately diagnose NSTEMI in high-risk patients with suspected MI?
The 1-hour high-sensitivity troponin algorithm provides high sensitivity for rule-out and specificity for rule-in of NSTEMI in high-risk patients, but leaves over a third of patients undiagnosed and struggles to differentiate type 1 from type 2 MI.
Supports 1-hour troponin algorithm for NSTEMI rule-out in high-risk patients; leaves open prospective validation before routine adoption.
Objective This study sought to evaluate the diagnostic performance of the 1-hour troponin algorithm for diagnosis of myocardial infarction (MI) without persistent ST-segment elevations (non-ST-segment MI (NSTEMI)) in a cohort with a high prevalence of MI. This algorithm recommend by current guidelines was previously developed in cohorts with a prevalence of MI of less than 20%. Design Prospective cohort study from November 2015 until December 2016. Setting Dedicated chest pain unit of a single referral centre. Participants Consecutive patients with suspected MI were screened. Patients with subacute symptoms lasting more than 24 hours, new ST-segment elevations at presentation, or an already diagnosed or ruled-out acute MI were excluded. All enrolled patients (n=1317) underwent a full clinical assessment and measurements of high-sensitivity troponin, and were scheduled for an early invasive strategy if clinically indicated. Main outcome measures Final diagnosis of MI according to the Fourth Universal Definition of MI. Results The prevalence of NSTEMI in the present cohort was 36.9%. The sensitivity for rule-out of MI was 99.8%. The specificity for rule-in of MI was found to be 94.3%. However, in 35.7% of patients neither rule-in nor rule-out was possible. In 51.4% of patients diagnosed with MI, a primary non-coronary reason for MI was found (type 2 MI). Different receiver operating characteristic-curve derived cut-offs for troponin and its dynamics did not provide a sufficient differentiation between type 1 and 2 MI for clinical decision making (negative predictive value for rule-out of type 1 MI <70%). Conclusions The 1-hour diagnosis algorithm for patients with suspected NSTEMI can accurately diagnose acute MI in high-risk cohorts. However, discrimination between patients needing an early invasive strategy or not is limited. Trial registration number DRKS00009713.
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A�mann et al. (2019) conducted a cohort in Suspected myocardial infarction (n=1,317). 1-hour troponin algorithm was evaluated on Final diagnosis of MI according to the Fourth Universal Definition of MI. The 1-hour troponin algorithm accurately diagnosed acute MI in a high-risk cohort with 99.8% sensitivity for rule-out and 94.3% specificity for rule-in, though 35.7% remained unclassified.
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