Combination Algorithm for Fast Rule-Out and Rule-In of MACE
What is the diagnostic accuracy of the 1-hour algorithm based on high-sensitivity cardiac troponin T (hs-cTnT) testing at presentation and again 1 hour thereafter, supplemented with patient history and an electrocardiogram (ECG) for predicting 30-day major adverse cardiac events (MACE) compared with the algorithm using hs-cTnT alone?
This prospective observational study enrolled consecutive patients presenting to the emergency department (ED) with chest pain, for whom hs-cTnT was ordered at presentation. Hs-cTnT at 1 hour and the ED physician’s assessments of patient history and ECG were collected. The primary outcome was an adjudicated diagnosis of 30-day MACE defined as acute myocardial infarction (AMI), unstable angina, cardiogenic shock, ventricular arrhythmia, atrioventricular block, cardiac arrest, or death of a cardiac or unknown cause. The investigators assessed the diagnostic accuracy of the 1-hour algorithm based on hs-cTnT testing at presentation and again 1 hour thereafter supplemented with patient history and an ECG (the extended algorithm) for predicting 30-day MACE compared with the algorithm using hs-cTnT alone (the troponin algorithm). Sensitivity, specificity, positive and negative predictive value (PPV and NPV), and likelihood ratios (LRs) were calculated for the algorithms.
In the final analysis, 1,038 patients were included. The extended algorithm identified 60% of all patients for rule-out and had a higher sensitivity than the troponin algorithm (97.5% vs. 87.6%; p < 0.001). The NPV was 99.5% and LR was 0.04 with the extended algorithm versus 97.8% and 0.17, respectively, with the troponin algorithm. The extended algorithm ruled in 14% of patients with a higher sensitivity (75.2% vs. 56.2%; p < 0.001), but a slightly lower specificity (94.0% vs. 96.4%; p < 0.001) than the troponin algorithm. The rule-in arms of both algorithms had an LR >10.
The authors concluded that a 1-hour combination algorithm allowed fast rule-out and rule-in of 30-day MACE in a majority of ED chest pain patients, and performed better than the troponin-alone algorithm.
This study reports that a 1-hour combination algorithm incorporating patient history and an ECG allowed fast rule-out and rule-in of 30-day MACE in a majority of ED chest pain patients, and performed better than the 1-hour algorithm based on hs-cTnT alone. Additional prospective, larger, multicenter studies are indicated to assess the incremental performance of this extended algorithm as compared to the troponin-alone algorithm in a wide variety of care settings.
Clinical Topics: Acute Coronary Syndromes, Arrhythmias and Clinical EP, Heart Failure and Cardiomyopathies, Implantable Devices, EP Basic Science, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias, Acute Heart Failure
Keywords: Acute Coronary Syndrome, Algorithms, Angina, Unstable, Arrhythmias, Cardiac, Atrioventricular Block, Chest Pain, Electrocardiography, Emergency Service, Hospital, Heart Arrest, Heart Conduction System, Shock, Cardiogenic, Troponin, Troponin T
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