| 1. |
- Eggers, Kai M., et al.
(författare)
-
Consequences of implementing a cardiac troponin assay with improved sensitivity at Swedish coronary care units : an analysis from the SWEDEHEART registry
- 2016
-
Ingår i: European Heart Journal. - : Oxford University Press (OUP). - 0195-668X .- 1522-9645. ; 37:30, s. 2417-2424
-
Tidskriftsartikel (refereegranskat)abstract
- Aims: Cardiac troponin (cTn) assays with improved sensitivity are increasingly utilized for the assessment of patients admitted because of suspected acute coronary syndrome (ACS). However, data on the clinical consequences of the implementation of such assays are limited.Methods and results: In a retrospective register-based study (37 710 coronary care unit admissions; SWEDEHEART registry), we compared the case mix, the use of diagnostic procedures, treatments, and 1-year all-cause mortality 1 year before the implementation of a cTn assay with improved sensitivity (study period 1) and 1 year thereafter (study period 2). During study period 2, more at-risk patients were admitted and more patients had cTn levels above the myocardial infarction cut-off (ACS patients + 13.1%; non-ACS patients + 160.1%). cTn levels above this cut-off exhibited stronger associations with mortality risk in study period 2 (adjusted HR 4.45 [95% confidence interval, CI, 3.36-5.89]) compared with period 1 (adjusted HR 2.43 [95% CI 2.11-2.80]), similar as for the cTn ratio relative to the respective 99th percentile. While therewas no multivariable-adjusted increase in the use of diagnostic procedures, significant trends towards more differentiated treatment depending on the cause of cTn elevation, i. e. ACS or non-ACS, were noted.Conclusions: The implementation of a cTn assay with improved sensitivity was associated with an increase in the number of patients who due to their cTn-status were identified as suitable for beneficial therapies. There was no inappropriate increase in hospital resource utilization. As such, cTn assays with improved sensitivity provide an opportunity to improve the clinical management of patients with suspected ACS.
|
|
| 2. |
- Lindahl, Bertil, et al.
(författare)
-
An algorithm for rule-in and rule-out of acute myocardial infarction using a novel troponin I assay
- 2017
-
Ingår i: Heart. - : BMJ. - 1355-6037 .- 1468-201X. ; 103:2, s. 125-131
-
Tidskriftsartikel (refereegranskat)abstract
- Objective To derive and validate a hybrid algorithm for rule-out and rule-in of acute myocardial infarction based on measurements at presentation and after 2 hours with a novel cardiac troponin I (cTnI) assay. Methods The algorithm was derived and validated in two cohorts (605 and 592 patients) from multicentre studies enrolling chest pain patients presenting to the emergency department (ED) with onset of last episode within 12 hours. The index diagnosis and cardiovascular events up to 30 days were adjudicated by independent reviewers. Results In the validation cohort, 32.6% of the patients were ruled out on ED presentation, 6.1% were ruled in and 61.3% remained undetermined. A further 22% could be ruled out and 9.8% ruled in, after 2 hours. In total, 54.6% of the patients were ruled out with a negative predictive value (NPV) of 99.4% (95% CI 97.8% to 99.9%) and a sensitivity of 97.7% (95% CI 91.9% to 99.7%); 15.8% were ruled in with a positive predictive value (PPV) of 74.5% (95% CI 64.8% to 82.2%) and a specificity of 95.2% (95% CI 93.0% to 96.9%); and 29.6% remained undetermined after 2 hours. No patient in the rule-out group died during the 30-day follow-up in the two cohorts. Conclusions This novel two-step algorithm based on cTnI measurements enabled just over a third of the patients with acute chest pain to be ruled in or ruled out already at presentation and an additional third after 2 hours. This strategy maximises the speed of rule-out and rule-in while maintaining a high NPV and PPV, respectively.
|
|
| 3. |
- Ljung, Lina, et al.
(författare)
-
A Rule-Out Strategy Based on High-Sensitivity Troponin and HEART Score Reduces Hospital Admissions
- 2019
-
Ingår i: Annals of Emergency Medicine. - : MOSBY-ELSEVIER. - 0196-0644 .- 1097-6760. ; 73:5, s. 491-499
-
Tidskriftsartikel (refereegranskat)abstract
- Study objective: We evaluate whether a combination of a 1-hour high-sensitivity cardiac troponin algorithm and History, ECG, Age, Risk Factors, and Troponin (HEART) score reduces admission rate (primary outcome) and affects time to discharge, health care-related costs, and 30-day outcome (secondary outcomes) in patients with symptoms suggestive of an acute coronary syndrome.Methods: This prospective observational multicenter study was conducted before (2013 to 2014) and after (2015 to 2016) implementation of a strategy including level of high-sensitivity cardiac troponin T or I at 0 and 1 hour, combined with the HEART score. Patients with a nonelevated baseline high-sensitivity cardiac troponin level, a 1-hour change in high-sensitivity cardiac troponin T level less than 3 ng/L, or high-sensitivity cardiac troponin I level less than 6 ng/L and a HEART score less than or equal to 3 were considered to be ruled out of having acute coronary syndrome. A logistic regression analysis was performed to adjust for differences in baseline characteristics.Results: A total of 1,233 patients were included at 6 centers. There were no differences in regard to median age (64 versus 63 years) and proportion of men (57% versus 54%) between the periods. After introduction of the new strategy, the admission rate decreased from 59% to 33% (risk ratio 0.55 [95% confidence interval {CI} 0.48 to 0.63]; odds ratio 0.33 [95% CI 0.26 to 0.42]; adjusted odds ratio 0.33 [95% CI 0.25 to 0.42]). The median hospital stay was reduced from 23.2 to 4.7 hours (95% CI of difference -20.4 to -11.4); median health care-related costs, from $1,748 to $1,079 (95% CI of difference -$953 to -$391). The number of clinical events was very low.Conclusion: In this before-after study, clinical implementation of a 1-hour high-sensitivity cardiac troponin algorithm combined with the HEART score was associated with a reduction in admission rate and health care burden, with very low rates of adverse clinical events.
|
|
| 4. |
- Ljung, Lina, et al.
(författare)
-
Sensitivity of undetectable level of high-sensitivity troponin T at presentation in a large non-ST-segment elevation myocardial infarction cohort of early presenters
- 2019
-
Ingår i: International Journal of Cardiology. - : Elsevier BV. - 0167-5273 .- 1874-1754. ; 284, s. 6-11
-
Tidskriftsartikel (refereegranskat)abstract
- BACKGROUND: We aimed to evaluate the diagnostic sensitivity for myocardial infarction (MI) when using an undetectable level of high-sensitivity cardiac troponin T (hs-cTnT < 5 ng/L) at presentation combined with a non-ischemic electrocardiogram (ECG), to rule out MI in a non-ST-segment elevation MI (NSTEMI) cohort presenting ≤2 h from symptom onset. We also aimed to compare baseline characteristics and 30-day outcome in NSTEMI patients presenting with and without hs-cTnT < 5 ng/L.METHODS: All patients admitted to five centers in Sweden 2011-2015, after the introduction of hs-cTnT, who presented ≤2 h from symptom onset and received a final diagnosis of NSTEMI, were identified through the SWEDEHEART registry. These data and data of hs-cTnT levels were verified in the hospitals' medical records. The registry provided baseline and outcome data.RESULTS: Twenty-four (2.6%) of 911 NSTEMI patients presented with hs-cTnT < 5 ng/L. In patients presenting >1-≤2 h from symptom onset the sensitivity for MI when combining hs-cTnT and ECG was 99.4% (95% CI 98.4%-99.8%). In patients presenting ≤1 h, and in patients aged ≤65 years without prior MI, the sensitivity was insufficient. NSTEMI patients presenting with hs-cTnT < 5 ng/L were younger and had less often a prior MI. A total of 62.5 vs. 63.5% of the NSTEMI patients presenting with and without hs-cTnT < 5 ng/L underwent revascularization within 30 days and 4.5 and 3.2% died respectively.CONCLUSIONS: Hs-cTnT < 5 ng/L at presentation combined with a non-ischemic ECG may be used to rule out MI in patients presenting as early as >1 h from symptom onset with a sufficient sensitivity.
|
|
| 5. |
- Löfmark, Henrik, et al.
(författare)
-
HEART-score can be simplified without loss of discriminatory power in patients with chest pain : Introducing the HET-score
- 2023
-
Ingår i: American Journal of Emergency Medicine. - : Elsevier. - 0735-6757 .- 1532-8171. ; 74, s. 104-111
-
Tidskriftsartikel (refereegranskat)abstract
- BackgroundThe History, Electrocardiogram (ECG), Age, Risk factors and Troponin, (HEART) score is useful for early risk stratification in chest pain patients. The aim was to validate previous findings that a simplified score using history, ECG and troponin (HET-score) has similar ability to stratify risk.MethodsPatients presenting with chest pain with duration of ≥10 min and an onset of last episode ≤12 h but without ST-segment elevation on ECG at 6 emergency departments were eligible for inclusion. The HEART-score and the simplified HET-score were calculated. The endpoint was a composite of myocardial infarction (MI) as index diagnosis, readmission due to new MI or death within 30 days.ResultsHEART-score identified 32% as low risk (0-2p), 47% as intermediate risk (3-5p), and 20% as high risk (6-10p) patients. The endpoint occurred in 0.5%, 7.3% and 35.7%, respectively. HET-score identified 39%, 42% and 19% as low- (0p), intermediate- (1-2p) and high-risk (3-6p) patients, with the endpoint occurring in 0.6%, 6.2% and 43.2%, respectively.When all variables included in the HEART-score were included in a multivariable logistic regression analysis, only History (OR, CI [95%]): 2.97(2.16–4.09), ECG (1.61[1.14–2.28]) and troponin level (5.21[3.91–6.95]) were significantly associated with cardiovascular events. When HEART- and HET-score were compared in a ROC-analysis, HET-score had a significantly larger AUC (0.887 vs 0.853, p < 0.001).ConclusionsCompared with HEART-score, HET-score is simpler and appears to have similar ability to discriminate between chest pain patients with and without cardiovascular event.
|
|
| 6. |
- McCord, James, et al.
(författare)
-
Prognostic Utility of a Modified HEART Score in Chest Pain Patients in the Emergency Department
- 2017
-
Ingår i: Circulation. Cardiovascular Quality and Outcomes. - : LIPPINCOTT WILLIAMS & WILKINS. - 1941-7713 .- 1941-7705. ; 10:2
-
Tidskriftsartikel (refereegranskat)abstract
- Background-The TRAPID-AMI trial study ( High-Sensitivity Troponin-T Assay for Rapid Rule-Out of Acute Myocardial Infarction) evaluated high-sensitivity cardiac troponin-T ( hs-cTnT) in a 1-hour acute myocardial infarction ( AMI) exclusion algorithm. Our study objective was to evaluate the prognostic utility of a modified HEART score ( m-HS) within this trial. Methods and Results-Twelve centers evaluated 1282 patients in the emergency department for possible AMI from 2011 to 2013. Measurements of hs-cTnT ( 99th percentile, 14 ng/L) were performed at 0, 1, 2, and 4 to 14 hours. Evaluation for major adverse cardiac events ( MACEs) occurred at 30 days ( death or AMI). Low-risk patients had an m-HS <= 3 and had either hs-cTnT<14 ng/L over serial testing or had AMI excluded by the 1-hour protocol. By the 1-hour protocol, 777 ( 60%) patients had an AMI excluded. Of those 777 patients, 515 ( 66.3%) patients had an m-HS <= 3, with 1 ( 0.2%) patient having a MACE, and 262 ( 33.7%) patients had an m-HS <= 4, with 6 ( 2.3%) patients having MACEs ( P=0.007). Over 4 to 14 hours, 661 patients had a hs-cTnT<14 ng/L. Of those 661 patients, 413 ( 62.5%) patients had an m-HS <= 3, with 1 ( 0.2%) patient having a MACE, and 248 ( 37.5%) patients had an m-HS >= 4, with 5 ( 2.0%) patients having MACEs ( P=0.03). Conclusions-Serial testing of hs-cTnT over 1 hour along with application of an m-HS identified a low-risk population that might be able to be directly discharged from the emergency department.
|
|
| 7. |
- McCord, James, et al.
(författare)
-
Symptoms Predictive of Acute Myocardial Infarction in the Troponin Era : Analysis From the TRAPID-AMI Study.
- 2019
-
Ingår i: Critical Pathways in Cardiology. - 1535-282X .- 1535-2811. ; 18:1, s. 10-15
-
Tidskriftsartikel (refereegranskat)abstract
- The TRAPID-AMI (High Sensitivity Cardiac Troponin T assay for rapid Rule-out of Acute Myocardial Infarction) study evaluated a rapid "rule-out" acute myocardial infarction (AMI). We evaluated what symptoms were associated with AMI as part of a substudy of TRAPID-AMI. There were 1282 patients evaluated from 12 centers in Europe, the United States of America, and Australia from 2011 to 2013. Multiple symptom variables were prospectively obtained and evaluated for association with the final diagnosis of AMI. Multivariate logistic regression analysis was done, and odds ratios (OR) were calculated. There were 213/1282 (17%) AMIs. Four independent predictors for the diagnosis of AMI were identified: radiation to right arm or shoulder [OR = 3.0; confidence interval (CI): 1.8-5.0], chest pressure (OR = 2.5; CI: 1.3-4.6), worsened by physical activity (OR = 1.7; CI: 1.2-2.5), and radiation to left arm or shoulder (OR = 1.7; CI: 1.1-2.4). In the entire group, 131 (10%) had radiation to right arm or shoulder, 897 (70%) had chest pressure, 385 (30%) worsened with physical activity, and 448 (35%) had radiation to left arm or shoulder. Duration of symptoms was not predictive of AMI. There were no symptoms predictive of non-AMI. Relationship between AMI size and symptoms was also studied. For 213 AMI patients, cardiac troponins I values were divided into 4 quartiles. Symptoms including pulling chest pain, supramammillary right location, and right arm/shoulder radiation were significantly more likely to occur in patients with larger AMIs. In a large multicenter trial, only 4 symptoms were associated with the diagnosis of AMI, and no symptoms that were associated with a non-AMI diagnosis.
|
|
| 8. |
- Melki, Dina
(författare)
-
Assessment of patients with symptoms suggestive of acute coronary syndrome : the use of high sensitive cardiac troponin T and a risk score
- 2013
-
Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- The aim of this thesis was to evaluate patients with symptoms suggestive of acute coronary syndrome with regard to early diagnosis and prognosis by the use of high sensitive cardiac troponin T and a risk score: a low-risk group in which admission and further investigations may not be necessary. In paper I, the early diagnostic value of high sensitive cardiac troponin T (hs-cTnT) was compared with conventional cardiac troponin assays in 233 patients with symptoms suggestive of acute coronary syndrome (ACS). When acute myocardial infarction (MI) was defined according to conventional cardiac troponins and the lowest level with a coefficient of variation (CV) ≤ 10% for each method was used as decision limit, hs-cTnT had a higher sensitivity than the conventional cardiac troponins. When acute MI was defined according to hs-cTnT, hs-cTnT performed better than the conventional cardiac troponins at different decision limits and had the largest Area Under Curve (AUC) in ROC analysis. In paper II, the prognostic value of hs-cTnT was compared with conventional cardiac troponin assays in 231 patients with symptoms suggestive of ACS. When the lowest level with a CV ≤ 10% for each method was used as decision limit,hs-cTnT identified more high-risk patients. After adjusting for differences in clinical baseline characteristics, hs-cTnT and N-terminal pro B-type natriuretic peptide (NT-proBNP) were independently associated with outcome. By combining hs-cTnT and NT-proBNP, patients could be divided into low-, intermediate- and high-risk groups. In paper III, HEART score was validated in 410 consecutive patients with chest pain. Of 247 (60.2 %) patients in HEART score 0-3, one patient (0.4%) had a combined endpoint. Of 144 (35.1 %) patients in heart score 4-6, 19 (13.2 %) patients had a combined endpoint. Of 19 (4.6%) patients in HEART score 7-10, 10 (52.6 %) patients had a combined endpoint. Of all admitted patients, 34.3 % had a HEART score 0-3. In paper IV: 48,594 patients admitted because of symptoms suggestive of ACS were included to examine the effects of introducing hs-cTnT into clinical practice. 25% had hs-cTnT < 14 ng/L (group 1), 22 % had hs-cTnT 14-49 ng/L group 2) and 53 % had hs-cTnT ≥ 50 ng/L (group 3). From group 1 to 3, there was a stepwise increase with regard to proportion of patients with significant coronary stenoses, left ventricular systolic dysfunction and death during follow-up. Thus, the introduction of hs-cTnT has led to a large proportion of patients with minor cardiac troponin elevation (14-49 ng/L). The majority with minor elevation do not have myocardial infarction but are still at high risk. When dividing patients into 20 groups according to hs-cTnT level, the adjusted mortality started to increase at hs-cTnT level of 14 ng/L. Conclusion: hs-cTnT improves early diagnosis and risk stratification compared with conventional cardiac troponin assays. An excellent risk prediction can be achieved by combining hs-cTnT and NT-proBNP in an easily used algorithm. The introduction of hs-cTnT has resulted in identification of a large population with only minor elevation of hs-cTnT (14-49 ng/L) but are still at high risk. HEART score may be a useful tool for evaluation of chest pain patients and identify a low-risk group in which admission and further investigations may not be necessary.
|
|
| 9. |
- Melki, Dina, et al.
(författare)
-
Implications of Introducing High-Sensitivity Cardiac Troponin T Into Clinical Practice Data From the SWEDEHEART Registry
- 2015
-
Ingår i: Journal of the American College of Cardiology. - : Elsevier BV. - 0735-1097 .- 1558-3597. ; 65:16, s. 1655-1664
-
Tidskriftsartikel (refereegranskat)abstract
- BACKGROUND Cardiac troponin is the preferred biomarker for diagnosing myocardial infarction (MI). OBJECTIVES The aim of this study was to examine the implications of introducing high-sensitivity cardiac troponin T (hs-cTnT) into clinical practice and to define at what hs-cTnT level risk starts to increase. METHODS We analyzed data from 48,594 patients admitted because of symptoms suggesting an acute coronary syndrome and who were entered into a large national registry. Patients were divided into Group 1, those with hs-cTnT <6 ng/l; Group 2, those with hs-cTnT 6 to 13 ng/l; Group 3, those with hs-cTnT 14 to 49 ng/l (i.e., a group in which most patients would have had a negative cardiac troponin T with older assays); and Group 4, those with hs-cTnT >= 50 ng/l. RESULTS There were 5,790 (11.9%), 6,491 (13.4%), 10,476 (21.6%), and 25,837 (53.2%) patients in Groups 1, 2, 3, and 4, respectively. In Groups 1 to 4, the proportions with MI were 2.2%, 2.6%, 18.2%, and 81.2%. There was a stepwise increase in the proportion of patients with significant coronary stenoses, left ventricular systolic dysfunction, and death during follow-up. When dividing patients into 20 groups according to hs-cTnT level, the adjusted mortality started to increase at an hs-cTnT level of 14 ng/l. CONCLUSIONS Introducing hs-cTnT into clinical practice has led to the recognition of a large proportion of patients with minor cardiac troponin increases (14 to 49 ng/l), the majority of whom do not have MI. Although a heterogeneous group, these patients remain at high risk, and the adjusted mortality rate started to increase at the level of the 99th percentile in healthy controls.
|
|
