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Observational Study
. 2015 Aug;128(8):861-870.e4.
doi: 10.1016/j.amjmed.2015.01.046. Epub 2015 Mar 31.

One-hour rule-in and rule-out of acute myocardial infarction using high-sensitivity cardiac troponin I

Maria Rubini Gimenez  1 , Raphael Twerenbold  2 , Cedric Jaeger  2 , Christian Schindler  3 , Christian Puelacher  2 , Karin Wildi  2 , Tobias Reichlin  2 , Philip Haaf  2 , Salome Merk  2 , Ursina Honegger  2 , Max Wagener  2 , Sophie Druey  2 , Carmela Schumacher  2 , Lian Krivoshei  2 , Petra Hillinger  2 , Thomas Herrmann  2 , Isabel Campodarve  4 , Katharina Rentsch  5 , Stefano Bassetti  6 , Stefan Osswald  2 , Christian Mueller  7
Affiliations
Observational Study

One-hour rule-in and rule-out of acute myocardial infarction using high-sensitivity cardiac troponin I

Maria Rubini Gimenez et al. Am J Med. 2015 Aug.

Abstract

Objective: We aimed to prospectively derive and validate a novel 1h-algorithm using high-sensitivity cardiac troponin I (hs-cTnI) for early rule-out and rule-in of acute myocardial infarction.

Methods: We performed a prospective multicenter diagnostic study enrolling 1811 patients with suspected acute myocardial infarction. The final diagnosis was centrally adjudicated by 2 independent cardiologists using all available information, including coronary angiography, echocardiography, follow-up data, and serial measurements of hs-cTnT (but not hs-cTnI). The hs-cTnI 1h-algorithm, incorporating measurements performed at baseline and absolute changes within 1 hour, was derived in a randomly selected sample of 906 patients (derivation cohort), and then validated in the remaining 905 patients (validation cohort).

Results: Acute myocardial infarction was the final diagnosis in 18% of patients. After applying the hs-cTnI 1h-algorithm developed in the derivation cohort to the validation cohort, 50.5% of patients could be classified as "rule-out," 19% as "rule-in," 30.5% as "observe." In the validation cohort, the negative predictive value for acute myocardial infarction in the "rule-out" zone was 99.6% (95% confidence interval, 98.4%-100%), and the positive predictive value for acute myocardial infarction in the "rule-in" zone was 73.9% (95% confidence interval, 66.7%-80.2%). Negative predictive value of the 1h-algorithm was higher compared with the classical dichotomous interpretation of hs-cTnI and to the standard of care combining hs-cTnI with the electrocardiogram (both P < .001). Positive predictive value also was higher compared with the standard of care (P < .001).

Conclusion: Using a simple algorithm incorporating baseline hs-cTnI values and the absolute change within the first hour allows safe rule-out as well as accurate rule-in of acute myocardial infarction in 70% of patients presenting with suspected acute myocardial infarction.

Trial registration: ClinicalTrials.gov NCT00470587.

Keywords: Accurate rule-in; Acute myocardial infarction; Safe rule-out; hs-cTn.

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