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Rapid Rule-out of Acute Myocardial Infarction With a Single High-Sensitivity Cardiac Troponin T Measurement Below the Limit of Detection: A Collaborative Meta-analysis.

Pickering, JW; Than, MP; Cullen, L; Aldous, S; Ter Avest, E; Body, R; Carlton, EW; Collinson, P; Dupuy, AM; Ekelund, U; et al. Pickering, JW; Than, MP; Cullen, L; Aldous, S; Ter Avest, E; Body, R; Carlton, EW; Collinson, P; Dupuy, AM; Ekelund, U; Eggers, KM; Florkowski, CM; Freund, Y; George, P; Goodacre, S; Greenslade, JH; Jaffe, AS; Lord, SJ; Mokhtari, A; Mueller, C; Munro, A; Mustapha, S; Parsonage, W; Peacock, WF; Pemberton, C; Richards, AM; Sanchis, J; Staub, LP; Troughton, R; Twerenbold, R; Wildi, K; Young, J (2017) Rapid Rule-out of Acute Myocardial Infarction With a Single High-Sensitivity Cardiac Troponin T Measurement Below the Limit of Detection: A Collaborative Meta-analysis. Ann Intern Med, 166 (10). pp. 715-724. ISSN 1539-3704 https://doi.org/10.7326/M16-2562
SGUL Authors: Collinson, Paul

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Abstract

Background: High-sensitivity assays for cardiac troponin T (hs-cTnT) are sometimes used to rapidly rule out acute myocardial infarction (AMI). Purpose: To estimate the ability of a single hs-cTnT concentration below the limit of detection (<0.005 µg/L) and a nonischemic electrocardiogram (ECG) to rule out AMI in adults presenting to the emergency department (ED) with chest pain. Data Sources: EMBASE and MEDLINE without language restrictions (1 January 2008 to 14 December 2016). Study Selection: Cohort studies involving adults presenting to the ED with possible acute coronary syndrome in whom an ECG and hs-cTnT measurements were obtained and AMI outcomes adjudicated during initial hospitalization. Data Extraction: Investigators of studies provided data on the number of low-risk patients (no new ischemia on ECG and hs-cTnT measurements <0.005 µg/L) and the number who had AMI during hospitalization (primary outcome) or a major adverse cardiac event (MACE) or death within 30 days (secondary outcomes), by risk classification (low or not low risk). Two independent epidemiologists rated risk of bias of studies. Data Synthesis: Of 9241 patients in 11 cohort studies, 2825 (30.6%) were classified as low risk. Fourteen (0.5%) low-risk patients had AMI. Sensitivity of the risk classification for AMI ranged from 87.5% to 100% in individual studies. Pooled estimated sensitivity was 98.7% (95% CI, 96.6% to 99.5%). Sensitivity for 30-day MACEs ranged from 87.9% to 100%; pooled sensitivity was 98.0% (CI, 94.7% to 99.3%). No low-risk patients died. Limitation: Few studies, variation in timing and methods of reference standard troponin tests, and heterogeneity of risk and prevalence of AMI across studies. Conclusion: A single hs-cTnT concentration below the limit of detection in combination with a nonischemic ECG may successfully rule out AMI in patients presenting to EDs with possible emergency acute coronary syndrome. Primary Funding Source: Emergency Care Foundation.

Item Type: Article
Additional Information: This is the prepublication, author-produced version of a manuscript accepted for publication in Annals of Internal Medicine. This version does not include post-acceptance editing and formatting. The American College of Physicians, the publisher of Annals of Internal Medicine, is not responsible for the content or presentation of the author-produced accepted version of the manuscript or any version that a third party derives from it. Readers who wish to access the definitive published version of this manuscript and any ancillary material related to this manuscript (e.g., correspondence, corrections, editorials, linked articles) should go to Annals.org or to the print issue in which the article appears. Those who cite this manuscript should cite the published version, as it is the official version of record.
Keywords: Aged, Chest Pain, Electrocardiography, Emergency Service, Hospital, Female, Humans, Limit of Detection, Male, Middle Aged, Myocardial Infarction, Troponin T, General & Internal Medicine, 11 Medical And Health Sciences
SGUL Research Institute / Research Centre: Academic Structure > Molecular and Clinical Sciences Research Institute (MCS)
Academic Structure > Molecular and Clinical Sciences Research Institute (MCS) > Cardiac (INCCCA)
Journal or Publication Title: Ann Intern Med
ISSN: 1539-3704
Language: eng
Dates:
DateEvent
16 May 2017Published
18 April 2017Published Online
Publisher License: Publisher's own licence
PubMed ID: 28418520
Web of Science ID: WOS:000401240200015
Go to PubMed abstract
URI: https://openaccess.sgul.ac.uk/id/eprint/108972
Publisher's version: https://doi.org/10.7326/M16-2562

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