Key result
Serial hs-cTnT protocols rule out AMI with up to ~99% sensitivity and high specificity.
Why the study?
The study aimed to evaluate serial high-sensitivity cardiac troponin T measurements to rule out acute myocardial infarction and a single high baseline measurement to rule in acute myocardial infarction in emergency department patients with acute chest pain.
Do serial high-sensitivity cardiac troponin T measurements accurately rule out acute myocardial infarction and does a single baseline hs-cTnT >50 ng/l accurately rule in acute myocardial infarction in patients presenting to the emergency department with acute chest pain?
Meta-Analysis (n=11,929)
Yes
Do serial high-sensitivity cardiac troponin T measurements accurately rule out acute myocardial infarction and does a single baseline hs-cTnT >50 ng/l accurately rule in acute myocardial infarction in patients presenting to the emergency department with acute chest pain?
Answers are grounded in this paper and cite their sources.
Serial hs-cTnT strategies safely rule out AMI in approximately 60% of emergency department chest pain patients with >96% sensitivity, while a single baseline hs-cTnT >50 ng/l provides ~95% specificity for direct rule-in.
AIMS: The purpose of this study was to determine (a) the ability of serial high-sensitivity cardiac troponin T measurements to rule out acute myocardial infarction and (b) the ability of a single high baseline high-sensitivity cardiac troponin T measurement to rule in acute myocardial infarction in patients presenting to the emergency department with acute chest pain. METHODS AND RESULTS: Embase, Medline, Cochrane, Web of Science and Google scholar were searched for prospective cohort studies that evaluated parameters of diagnostic accuracy of serial high-sensitivity cardiac troponin T to rule out acute myocardial infarction and a single baseline high-sensitivity cardiac troponin T value>50 ng/l to rule in acute myocardial infarction. The search yielded 21 studies for the systematic review, of which 14 were included in the meta-analysis, with a total of 11,929 patients and an overall prevalence of acute myocardial infarction of 13.0%. For rule-out, six studies presented the sensitivity of serial measurements <14 ng/l. This cut-off classified 60.1% of patients as rule-out and the summary sensitivity was 96.7% (95% confidence interval: 92.3-99.3). Three studies presented the sensitivity of a one-hour algorithm with a baseline high-sensitivity cardiac troponin T value<12 ng/l and delta 1 hour <3 ng/l. This algorithm classified 60.2% of patients as rule-out and the summary sensitivity was 98.9% (96.4-100). For rule-in, six studies reported the specificity of baseline high-sensitivity cardiac troponin T value>50 ng/l. The summary specificity was 94.6% (91.5-97.1). CONCLUSION: Serial high-sensitivity cardiac troponin T measurement strategies to rule out acute myocardial infarction perform well, and a single baseline high-sensitivity cardiac troponin T value>50 ng/l to rule in acute myocardial infarction has a high specificity.
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Arslan et al. (2019) conducted a meta-analysis in Acute chest pain / suspected acute myocardial infarction (n=11,929). Serial high-sensitivity cardiac troponin T (hs-cTnT) measurements (<14 ng/l or 1-hour algorithm <12 ng/l with Δ1h <3 ng/l) for rule-out, and single baseline hs-cTnT >50 ng/l for rule-in vs. Reference standard admission diagnosis of acute myocardial infarction based on the universal definition of AMI was evaluated on Diagnostic accuracy (summary sensitivity for rule-out and summary specificity for rule-in) for admission diagnosis of acute myocardial infarction (Summary sensitivity 96.7% (serial <14 ng/l); 98.9% (1-hour algorithm); Summary specificity 94.6% (baseline >50 ng/l), 95% CI 92.3-99.3). Serial hs-cTnT strategies ruled out AMI with 96.7% (<14 ng/l) and 98.9% (1-h algorithm) sensitivity, while baseline hs-cTnT >50 ng/l ruled in AMI with 94.6% specificity.
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