The Use of Very Low Concentrations of High-sensitivity Troponin T to Rule Out Acute Myocardial Infarction Using a Single Blood Test.

Abstract

BACKGROUND:

Recent single-center and retrospective studies suggest that acute myocardial infarction (AMI) could be immediately excluded without serial sampling in patients with initial high-sensitivity cardiac troponin T (hs-cTnT) levels below the limit of detection (LoD) of the assay and no electrocardiogram (ECG) ischemia.

OBJECTIVE:

We aimed to determine the external validity of those findings in a multicenter study at 12 sites in nine countries.

METHODS:

TRAPID-AMI was a prospective diagnostic cohort study including patients with suspected cardiac chest pain within 6 hours of peak symptoms. Blood drawn on arrival was centrally tested for hs-cTnT (Roche; 99th percentile = 14 ng/L, LoD = 5 ng/L). All patients underwent serial troponin sampling over 4-14 hours. The primary outcome, prevalent AMI, was adjudicated based on sensitive troponin I (Siemens Ultra) levels. Major adverse cardiac events (MACE) including AMI, death, or rehospitalization for acute coronary syndrome with coronary revascularization were determined after 30 days.

RESULTS:

We included 1,282 patients, of whom 213 (16.6%) had AMI and 231 (18.0%) developed MACE. Of 560 (43.7%) patients with initial hs-cTnT levels below the LoD, four (0.7%) had AMI. In total, 471 (36.7%) patients had both initial hs-cTnT levels below the LoD and no ECG ischemia. These patients had a 0.4% (n = 2) probability of AMI, giving 99.1% (95% confidence interval [CI] = 96.7% to 99.9%) sensitivity and 99.6% (95% CI = 98.5% to 100.0%) negative predictive value. The incidence of MACE in this group was 1.3% (95% CI = 0.5% to 2.8%).

CONCLUSIONS:

In the absence of ECG ischemia, the detection of very low concentrations of hs-cTnT at admission seems to allow rapid, safe exclusion of AMI in one-third of patients without serial sampling. This could be used alongside careful clinical assessment to help reduce unnecessary hospital admissions.

• Authors: Richard Body, Christian Mueller, Evangelos Giannitsis, Michael Christ, Jorge Ordonez-Llanos, Christopher R de Filippi, Richard Nowak, Mauro Panteghini, Tomas Jernberg, Mario Plebani, Franck Verschuren, John K French, Robert Christenson, Silvia Weiser, Garnet Bendig, Peter Dilba, Bertil Lindahl, TRAPID-AMI Investigators
• Journal: Academic emergency medicine : official journal of the Society for Academic Emergency Medicine (Acad Emerg Med) Vol. 23 Issue 9 Pg. 1004-13 (09 2016) ISSN: 1553-2712 [Electronic] United States
• PMID: 27178492 (Publication Type: Journal Article, Multicenter Study, Validation Study)
• Copyright: © 2016 by the Society for Academic Emergency Medicine.

Chemical References

• Biomarkers
• Troponin I
• Troponin T

Topics

• Acute Coronary Syndrome (complications)
• Aged
• Aged, 80 and over
• Biomarkers (blood)
• Chest Pain (etiology)
• Cohort Studies
• Electrocardiography
• Female
• Humans
• Male
• Middle Aged
• Myocardial Infarction (blood, diagnosis)
• Prospective Studies
• Retrospective Studies
• Troponin I (blood)
• Troponin T (blood)