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A 1-h Combination Algorithm Allows Fast Rule-Out and Rule-In of Major Adverse Cardiac Events
Skane Univ Hosp, Dept Internal & Emergency Med, Lund, Sweden.;Skane Univ Hosp, Dept Cardiol, Lund, Sweden.;Lund Univ, Dept Clin Sci Lund, Lund, Sweden..
Lund Univ, Dept Clin Sci Lund, Lund, Sweden.;Helsingborg Gen Hosp, Div Specialised Local Hlth Care, Helsingborg, Sweden..
Skane Univ Hosp, Dept Cardiol, Lund, Sweden..
Skane Univ Hosp, Dept Cardiol, Lund, Sweden..
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2016 (English)In: Journal of the American College of Cardiology, ISSN 0735-1097, E-ISSN 1558-3597, Vol. 67, no 13, 1531-1540 p.Article in journal (Refereed) PublishedText
Abstract [en]

BACKGROUND: A 1-h algorithm based on high-sensitivity cardiac troponin T (hs-cTnT) testing at presentation and again 1 h thereafter has been shown to accurately rule out acute myocardial infarction.

OBJECTIVES: The goal of the study was to evaluate the diagnostic accuracy of the 1-h algorithm when supplemented with patient history and an electrocardiogram (ECG) (the extended algorithm) for predicting 30-day major adverse cardiac events (MACE) and to compare it with the algorithm using hs-cTnT alone (the troponin algorithm).

METHODS: This prospective observational study enrolled consecutive patients presenting to the emergency department (ED) with chest pain, for whom hs-cTnT testing was ordered at presentation. Hs-cTnT results at 1 h 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, unstable angina, cardiogenic shock, ventricular arrhythmia, atrioventricular block, cardiac arrest, or death of a cardiac or unknown cause.

RESULTS: 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 negative predictive value was 99.5% and the likelihood ratio 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 a likelihood ratio >10. CONCLUSIONS A 1-h combination algorithm allowed fast rule-out and rule-in of 30-day MACE in a majority of ED patients with chest pain and performed better than the troponin-alone algorithm.

Place, publisher, year, edition, pages
2016. Vol. 67, no 13, 1531-1540 p.
Keyword [en]
acute coronary syndrome, chest pain, diagnosis, myocardial infarction, sensitivity and specificity, unstable angina
National Category
Cardiac and Cardiovascular Systems
URN: urn:nbn:se:uu:diva-292997DOI: 10.1016/j.jacc.2016.01.059ISI: 000372893300006OAI: oai:DiVA.org:uu-292997DiVA: diva2:927489
Region Skåne
Available from: 2016-05-12 Created: 2016-05-11 Last updated: 2016-05-12Bibliographically approved

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