Mahler Simon A, Stopyra Jason P, Apple Fred S, Riley Robert F, Russell Gregory B, Hiestand Brian C, Hoekstra James W, Lefebvre Cedric W, Nicks Bret A, Cline David M, Askew Kim L, Herrington David M, Burke Gregory L, Miller Chadwick D
Department of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, NC, USA.
Department of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, NC, USA.
Clin Biochem. 2017 May;50(7-8):401-407. doi: 10.1016/j.clinbiochem.2017.01.003. Epub 2017 Jan 10.
The HEART Pathway combines a decision aid and serial contemporary cardiac troponin I (cTnI) measures to achieve >99% sensitivity for major adverse cardiac events (MACE) at 30days and early discharge rates >20%. However, the impact of integrating high-sensitivity troponin (hs-cTn) measures into the HEART Pathway has yet to be determined. In this analysis we compare test characteristics of the HEART Pathway using hs-cTnI, hs-cTnT, or cTnI.
DESIGN & METHODS: A secondary analysis of participants enrolled in the HEART Pathway RCT was conducted. Each patient was risk stratified by the cTn-HEART Pathway (Siemens TnI-Ultra at 0- and 3-h) and a hs-cTn-HEART Pathway using hs-cTnI (Abbott) or hs-cTnT (Roche) at 3-h. The early discharge rate, sensitivity, specificity, and negative predictive value (NPV) for MACE (death, myocardial infarction, or coronary revascularization) at 30days were calculated.
hs-cTnI measures were available on 133 patients. MACE occurred in 11/133 (8%) of these patients. Test characteristics for the HEART Pathway using serial cTnI vs 3hour hs-cTnI were the same: sensitivity (100%, 95%CI: 72-100%), specificity (49%, 95%CI: 40-58%), NPV (100%, 95%CI: 94-100%), and early discharge rate (45%, 95%CI: 37-54%). The HEART Pathway using hs-cTnT missed one MACE event (myocardial infarction): sensitivity (91%, 95%CI: 59-100%), specificity (48%, 95%CI: 39-57%), NPV (98%, 95%CI: 91-100%), and early discharge rate (45%, 95%CI: 37-54%).
There was no difference in the test characteristics of the HEART Pathway whether using cTnI or hs-cTnI, with both achieving 100% sensitivity and NPV. Use of hs-cTnT with the HEART Pathway was associated with one missed MACE.
HEART路径结合了决策辅助工具和连续的当代心肌肌钙蛋白I（cTnI）检测，以实现30天时主要不良心脏事件（MACE）的敏感性>99%，早期出院率>20%。然而，将高敏肌钙蛋白（hs-cTn）检测纳入HEART路径的影响尚未确定。在本分析中，我们比较了使用hs-cTnI、hs-cTnT或cTnI的HEART路径的检测特征。
对参与HEART路径随机对照试验的参与者进行二次分析。每位患者通过cTn-HEART路径（0小时和3小时时使用西门子TnI-Ultra）和3小时时使用hs-cTnI（雅培）或hs-cTnT（罗氏）的hs-cTn-HEART路径进行风险分层。计算30天时MACE（死亡、心肌梗死或冠状动脉血运重建）的早期出院率、敏感性、特异性和阴性预测值（NPV）。
133例患者有hs-cTnI检测结果。这些患者中有11/133（8%）发生了MACE。使用连续cTnI与3小时hs-cTnI的HEART路径的检测特征相同：敏感性（100%，95%CI：72-100%）、特异性（49%，95%CI：40-58%）、NPV（100%，95%CI：94-100%）和早期出院率（45%，95%CI：37-54%）。使用hs-cTnT的HEART路径漏诊了1例MACE事件（心肌梗死）：敏感性（91%，95%CI：59-100%）、特异性（48%，95%CI：39-57%）、NPV（98%，95%CI：91-100%）和早期出院率（45%，95%CI：37-54%）。
无论使用cTnI还是hs-cTnI，HEART路径的检测特征均无差异，二者均实现了100%的敏感性和NPV。在HEART路径中使用hs-cTnT与1例MACE漏诊相关。
