Emergency Department, Monash Health, Melbourne, Victoria, Australia
Medicine, Monash University, Melbourne, Victoria, Australia.
Emerg Med J. 2022 Nov;39(11):847-852. doi: 10.1136/emermed-2020-210812. Epub 2021 Nov 10.
High-sensitivity cardiac troponin I (hs-cTnI) assays promise high diagnostic accuracy for myocardial infarction (MI). In an ED where conventional cTnI was in use, we evaluated an assessment pathway using the new Access hsTnI assay.
This retrospective analysis recruited ED patients with suspected MI between June and September 2019. All patients received routine care with a conventional cTnI assay (AccuTnI +3: limit of detection (LoD) 10 ng/L, 99th centile upper reference limit (URL) 40 ng/L, abnormal elevation cut-point 80 ng/L). Arrival, then 90-minute or 360-minute cTnI levels for low and non-low risk patients, respectively (ED Assessment of Chest pain score) guided diagnosis and disposition which was at treating physician discretion. The same patients had arrival and 90-minute or 180-minute samples drawn for hs-cTnI levels (Access hsTnI: LoD 2 ng/L, 99th centile URL 10 ng/L (females) and 20 ng/L (males); abnormal elevation above the URL and delta >30%). Treating physicians were blinded to the hs-cTnI results. Using the hs-cTnI values, investigators retrospectively assigned likely diagnosis, disposition and likelihood of a 30-day major adverse cardiac event (MACE). Admission was recommended for significantly rising hs-cTnI elevations. The primary objective was to demonstrate an acceptable unexpected 30-day post-discharge MACE rate of <1%. cTnI elevation rates, diagnostic outcomes and ED disposition were also compared between pathways.
For the 935 patients, unexpected 30-day post-discharge MACE rates were 0/935 (0%, 95% CI 0% to 0.4%) with the conventional or novel pathway. For the high-sensitivity and conventional assays, respectively, abnormal elevation rates were 29% (95% CI 26% to 32%) and 19% (95% CI 17% to 22%), for MI were 9% (95% CI 8% to 11%) and 8% (95% CI 6% to 10%), and for hospital admission were 42% (95% CI 39% to 45%) and 43% (95% CI 40% to 47%).
The novel pathway using the Access hsTnI assay has an acceptably low 30-day MACE rate.
高敏心肌肌钙蛋白 I（hs-cTnI）检测对心肌梗死（MI）具有较高的诊断准确性。在一个使用传统 cTnI 的急诊科中，我们评估了一种使用新型 Access hsTnI 检测的评估方法。
这项回顾性分析招募了 2019 年 6 月至 9 月期间疑似 MI 的急诊科患者。所有患者均接受常规 cTnI 检测（AccuTnI+3：检测限（LoD）为 10ng/L，第 99 百分位上限（URL）为 40ng/L，异常升高截断值为 80ng/L）。低危和非低危患者分别根据就诊时（胸痛评分）和 90 分钟或 360 分钟的 cTnI 水平来指导诊断和处置，处置方案由主治医生决定。同样的患者在就诊时和 90 分钟或 180 分钟时采集 hs-cTnI 样本（Access hsTnI：LoD 为 2ng/L，第 99 百分位 URL 为 10ng/L（女性）和 20ng/L（男性）；异常升高超过 URL 且 delta >30%）。主治医生对 hs-cTnI 结果不知情。根据 hs-cTnI 值，研究者回顾性地分配了可能的诊断、处置和 30 天内主要不良心脏事件（MACE）的可能性。hs-cTnI 显著升高时建议住院。主要目标是证明使用新型检测方法后，30 天的意外出院后 MACE 发生率＜1%是可接受的。比较了两种检测方法的 cTnI 升高率、诊断结果和急诊科处置情况。
在 935 例患者中，传统或新型检测方法的 30 天意外出院后 MACE 发生率均为 0/935（0%，95%CI 0%至 0.4%）。高敏和传统检测的异常升高率分别为 29%（95%CI 26%至 32%）和 19%（95%CI 17%至 22%），MI 的检出率分别为 9%（95%CI 8%至 11%）和 8%（95%CI 6%至 10%），以及住院率分别为 42%（95%CI 39%至 45%）和 43%（95%CI 40%至 47%）。
使用新型 Access hsTnI 检测的新方法具有可接受的低 30 天 MACE 发生率。
