Why the study?
Rapid high-sensitivity cardiac troponin algorithms perform worse in real-world emergency department populations than in clinical validation studies because routine patients are older, less clinically preselected, and more frequently have impaired renal function and pre-existing cardiac diseases.
Does adjusting high-sensitivity cardiac troponin rapid algorithm decision limits for age, sex, and renal function improve diagnostic performance for acute myocardial infarction in real-world emergency department patients compared to uniform thresholds?
Does adjusting high-sensitivity cardiac troponin rapid algorithm decision limits for age, sex, and renal function improve diagnostic performance for acute myocardial infarction in real-world emergency department patients compared to uniform thresholds?
Standard hs-cTn rapid algorithms classify roughly half of unselected real-world ED patients into the gray zone with reduced positive predictive value for AMI, underscoring the clinical need for higher age- and renal-adjusted rule-in thresholds alongside comprehensive clinical and imaging assessment.
The introduction of rapid, high-sensitivity cardiac troponin (hs-cTn)-based algorithms has markedly changed the work-up of patients admitted to the emergency department (ED) with suspected acute coronary syndrome (ACS). However, when applied to real-world ED populations, these algorithms perform worse than in clinical studies of derivation and validation. The main reasons for this discrepancy are that patients tested for hs-cTn in real-world settings tend to be older and less clinically preselected. Nevertheless, ACS must often be ruled out in patients with atypical presentations. Routine patients also more frequently have impaired renal function and pre-existing cardiac diseases, such as atrial fibrillation, heart failure, or coronary artery disease. These conditions do not necessarily cause the actual acute ED presentation. Using the standard decision limits of the 0 h, 0/1 h, or 0/2 h algorithms does not hinder the exclusion of ACS in the ED. However, using them in real-world conditions substantially decreases the positive predictive value for acute myocardial infarction (AMI) and classifies a higher percentage of patients into the “observe (gray) zone” than reported in clinical studies. Patients classified with a working diagnosis of “rule-in AMI” often require hospital admission for other reasons, though their discharge diagnosis may differ from AMI. A major challenge in real-world EDs is the high proportion of gray zone hs-cTn concentrations in approximately 50% of tested patients. Therefore, additional hs-cTn sampling at 3 h after admission is often necessary to rule out acute myocardial injury. This review summarizes and critically discusses the evidence for adjusting hs-cTn ED algorithm decision limits according to age, sex, and renal function. It also discusses the critical differential diagnosis of acute and chronic myocardial injury in the ED.
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Middleton et al. (2008) conducted a review in Suspected acute coronary syndrome and acute or chronic myocardial injury in the emergency department. High-sensitivity cardiac troponin (hs-cTn) rapid diagnostic algorithms (0 h, 0/1 h, 0/2 h) with adjusted decision limits for age, sex, and renal function vs. Standard uniform 99th percentile upper reference limit (URL) decision thresholds was evaluated on Diagnostic performance (positive predictive value and observe/gray zone classification) for acute myocardial infarction (AMI) and acute myocardial injury.
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