External Validation and Extension of a Clinical Score for the Discrimination of Type 2 Myocardial Infarction - Nestelberger, T.; Lopez-Ayala, P.; Boeddinghaus, J.; Strebel, I.; Rubini Gimenez, M.; Huber, I.; Wildi, K.; Wussler, D.; Koechlin, L.; Prepoudis, A.; Gualandro, D. M.; Puelacher, C.; et al. (J Clin Med, 2021)
BACKGROUND: The early non-invasive discrimination of Type 2 versus Type 1 Myocardial Infarction (T2MI, T1MI) is a major unmet clinical need. We aimed to externally validate a recently derived clinical score (Neumann) combing female sex, no radiating chest pain, and high-sensitivity cardiac troponin I (hs-cTnI) concentration </=40.8 ng/L. METHODS: Patients presenting with acute chest discomfort to the emergency department were prospectively enrolled into an international multicenter diagnostic study. The final diagnoses of T2MI and T1MI were centrally adjudicated by two independent cardiologists using all information including cardiac imaging and serial measurements of hs-cTnT/I according to the fourth universal definition of MI. Model performance for T2MI diagnosis was assessed by formal tests and graphical means of discrimination and calibration. RESULTS: Among 6684 enrolled patients, MI was the adjudicated final diagnosis in 1079 (19%) patients, of which 242 (22%) had T2MI. External validation of the Neumann Score showed a moderate discrimination (C-statistic 0.67 (95%CI 0.64-0.71)). Model calibration showed underestimation of the predicted probabilities of having T2MI for low point scores. Model extension by adding the binary variable heart rate >120/min significantly improved model performance (C-statistic 0.73 (95% CI 0.70-0.76, p < 0.001) and had good calibration. Patients with the highest score values of 3 (Neumann Score, 9.9%) and 5 (Extended Neumann Score, 3.3%) had a 53% and 91% predicted probability of T2MI, respectively. CONCLUSION: The Neumann Score provided moderate discrimination and suboptimal calibration. Extending the Neumann Score by adding heart rate >120/min improved the model's performance.
Keywords: journalArticle; (FF20079), outside the submitted work. Boeddinghaus has received research grants; (FF20079), the Max Cloetta Foundation, the Margarete und Walter; Abbott, Alere, Astra Zeneca, Beckman Coulter,; Abbott, Ortho Clinical Diagnostics, Roche, and Siemens, outside the submitted; Academy of Medical Sciences, and the Gottfried and Julia Bangerter-Rhyner; Academy of Medical Sciences, the Gottfried and Julia Bangerter-Rhyner-Foundation,; Bayer, Ortho Clinical Diagnostics, and Orion Pharma, outside the submitted work; Biomerieux, Brahms, Roche, Siemens, Singulex, Sphingotec, and the Department of; Boehringer Ingelheim, BMS, Brahms, Cardiorentis, Novartis, Roche, Siemens, and; CRE Action Fund (NHMRC), the Wesley Medical Research Foundation, and a PhD n UQ; Company, Otsuka, Thermo Fisher, Cardiorentis, Sanofi, and research grants from; Foundation, as well as the "Freiwillige Akademische Gesellschaft Basel", outside; Gottfried Bangerter-Rhyner Stiftung, the Prince Charles Hospital Foundation, the; Internal Medicine, University Hospital Basel, as well as speaker; Koechlin has received a research grant from the University of Basel, the Swiss; Lichtenstein-Stiftung (3MS1038), and the University Hospital Basel as well as; Lopez-Ayala has received research funding from the Swiss Heart Foundation; National Science Foundation (P400PM_191037/1), the Swiss Heart Foundation; Science Foundation (P400PM_180828) as well as speakers/consulting honoraria from; Science Foundation, the Swiss Heart Foundation, the KTI, the Stiftung fur; Singulex, outside the submitted work. All other authors declare that they have no; and Orion-Pharma, outside the submitted work. Twerenbold has received research; and speaker honoraria from Siemens, outside the submitted work. Rubini Gimenez; by the manufacturer, who had no role in the design of the study, the analysis of; conflict of interest with this study. The investigated hs-cTn assay were donated; consulting fees from Novartis, MSD, Bristol-Myers Squibb, Pfizer, The Medicine; differentiation; external validation; from the University of Basel and the Division of Internal Medicine, the Swiss; has received research grants from the Swiss Heart Foundation and Swiss National; honoraria/consulting honoraria from Abbott, Alere, Astra Zeneca, Biomerieux,; honoraria/consulting honoraria from Roche, Abbott, Brahms and Siemens, outside; kardiovaskulare Forschung Basel; manuscript for publication; outside the submitted work. Martin-Sanchez has received speaker, advisory or; risk scores; scholarship from the University of Queensland, all outside the submitted work; speaker honoraria/consulting honoraria from B.Braun, Siemens, Beckman Coulter,; support from the Swiss National Science Foundation (P300PB-167803/1) and speaker; the Spanish Ministry of Health and FEDER, Mapfre, Novartis, Bayer, MSD, Abbott,; the data, the preparation of the manuscript, or the decision to submit the; the submitted work. Gualandro has received consulting honoraria from Roche,; the submitted work. Mueller has received research support from the Swiss National; type 1 myocardial infarction; type 2 myocardial infarction; work. Wildi has received research funding from the FAG Basel, and the Julia und