Predicting Major Adverse Events in Patients With Acute Myocardial Infarction - Nestelberger, T.; Boeddinghaus, J.; Wussler, D.; Twerenbold, R.; Badertscher, P.; Wildi, K.; Miro, O.; Lopez, B.; Martin-Sanchez, F. J.; Muzyk, P.; Koechlin, L.; Baumgartner, B.; et al. (J Am Coll Cardiol, 2019)
BACKGROUND: Early and accurate detection of short-term major adverse cardiac events (MACE) in patients with suspected acute myocardial infarction (AMI) is an unmet clinical need. OBJECTIVES: The goal of this study was to test the hypothesis that adding clinical judgment and electrocardiogram findings to the European Society of Cardiology (ESC) high-sensitivity cardiac troponin (hs-cTn) measurement at presentation and after 1 h (ESC hs-cTn 0/1 h algorithm) would further improve its performance to predict MACE. METHODS: Patients presenting to an emergency department with suspected AMI were enrolled in a prospective, multicenter diagnostic study. The primary endpoint was MACE, including all-cause death, cardiac arrest, AMI, cardiogenic shock, sustained ventricular arrhythmia, and high-grade atrioventricular block within 30 days including index events. The secondary endpoint was MACE + unstable angina (UA) receiving early (</=24 h) revascularization. RESULTS: Among 3,123 patients, the ESC hs-cTnT 0/1 h algorithm triaged significantly more patients toward rule-out compared with the extended algorithm (60%; 95% CI: 59% to 62% vs. 45%; 95% CI: 43% to 46%; p < 0.001), while maintaining similar 30-day MACE rates (0.6%; 95% CI: 0.3% to 1.1% vs. 0.4%; 95% CI: 0.1% to 0.9%; p = 0.429), resulting in a similar negative predictive value (99.4%; 95% CI: 98.9% to 99.6% vs. 99.6%; 95% CI: 99.2% to 99.8%; p = 0.097). The ESC hs-cTnT 0/1 h algorithm ruled-in fewer patients (16%; 95% CI: 14.9% to 17.5% vs. 26%; 95% CI: 24.2% to 27.2%; p < 0.001) compared with the extended algorithm, albeit with a higher positive predictive value (76.6%; 95% CI: 72.8% to 80.1% vs. 59%; 95% CI: 55.5% to 62.3%; p < 0.001). For 30-day MACE + UA, the ESC hs-cTnT 0/1 h algorithm had a higher positive predictive value for rule-in, whereas the extended algorithm had a higher negative predictive value for the rule-out. Similar findings emerged when using hs-cTnI. CONCLUSIONS: The ESC hs-cTn 0/1 h algorithm better balanced efficacy and safety in the prediction of MACE, whereas the extended algorithm is the preferred option for the rule-out of 30-day MACE + UA. (Advantageous Predictors of Acute Coronary Syndromes Evaluation [APACE]; NCT00470587).
Keywords: journalArticle; *Algorithms; Aged; Angina, Unstable/diagnosis/epidemiology; Arrhythmias, Cardiac/diagnosis/epidemiology; Atrioventricular Block/diagnosis/epidemiology; Biomarkers/blood; Electrocardiography; Emergency Service, Hospital; Female; Heart Arrest/diagnosis/epidemiology; Humans; Male; Middle Aged; Myocardial Infarction/blood/diagnosis/*epidemiology; Myocardial Revascularization; Predictive Value of Tests; Prospective Studies; Sensitivity and Specificity; Shock, Cardiogenic/diagnosis/epidemiology; Troponin/*blood; acute myocardial infarction; clinical assessment; high-sensitivity cardiac troponin; major adverse cardiac events