Optimizing Early Rule-Out Strategies for Acute Myocardial Infarction: Utility of 1-Hour Copeptin.
BACKGROUND
Combined testing of high-sensitivity cardiac troponin T (hs-cTnT) and copeptin at presentation provides a very high-although still imperfect-negative predictive value (NPV) for the early rule-out of acute myocardial infarction (AMI). We hypothesized that a second copeptin measurement at 1 h might further increase the NPV.


METHODS
In a prospective diagnostic multicenter study, we measured hs-cTnT and copeptin concentrations at presentation and at 1 h in 1439 unselected patients presenting to the emergency department with suspected AMI. The final diagnosis was adjudicated by 2 independent cardiologists blinded to copeptin concentrations. We investigated the incremental value of 1-h copeptin in the rule-out setting (0-h hs-cTnT negative and 0-h copeptin negative) and the intermediate-risk setting (0-h hs-cTnT negative and 0-h copeptin positive).


RESULTS
The adjudicated diagnosis was AMI in 267 patients (18.6%). For measurements obtained at presentation, the NPV in the rule-out setting was 98.6% (95% CI, 97.4%-99.3%). Whereas 1-h copeptin did not increase the NPV significantly, 1-h hs-cTnT did, to 99.6% (95% CI, 98.7%-99.9%, P = 0.008). Similarly, in the intermediate-risk setting (NPV 92.8%, 95% CI, 88.7%-95.8%), 1-h copeptin did not significantly increase the NPV (P = 0.751), but 1-h hs-cTnT did, to 98.6 (95% CI, 96%-99.7%, P < 0.001).


CONCLUSIONS
One-hour copeptin increased neither the safety of the rule-out process nor the NPV in the intermediate-risk setting. In contrast, the incremental value of 1-h hs-cTnT was substantial in both settings. ClinicalTrials.gov/NCT00470587.
Department of Cardiology and Cardiovascular Research Institute Basel and.
Petra
P
Hillinger
Department of Cardiology and Cardiovascular Research Institute Basel and.
Raphael
R
Twerenbold
Department of Cardiology and Cardiovascular Research Institute Basel and.
Cedric
C
Jaeger
Department of Cardiology and Cardiovascular Research Institute Basel and.
Karin
K
Wildi
Department of Cardiology and Cardiovascular Research Institute Basel and.
Tobias
T
Reichlin
Department of Cardiology and Cardiovascular Research Institute Basel and Servicio de Urgencias, Hospital del Mar - Institut Municipal d'Investigació Mèdica, Barcelona, Spain;
Maria
M
Rubini Gimenez
Department of Cardiology and Cardiovascular Research Institute Basel and.
Ulrike
U
Engels
Emergency Department, Hospital Clínic, Barcelona, Catalonia, Spain; Research Group "Emergencies: Processes and Pathologies," Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Catalonia, Spain;
Oscar
O
Miró
Department of Cardiology and Cardiovascular Research Institute Basel and.
Jasper
J
Boeddinghaus
Department of Cardiology and Cardiovascular Research Institute Basel and.
Christian
C
Puelacher
Department of Cardiology and Cardiovascular Research Institute Basel and.
Thomas
T
Nestelberger
Department of Cardiology and Cardiovascular Research Institute Basel and.
Michèle
M
Röthlisberger
Department of Internal Medicine, Kantonsspital Olten, Switzerland.
Susanne
S
Ernst
Laboratory Medicine, University Hospital Basel, Switzerland;
Katharina
K
Rentsch
Department of Cardiology and Cardiovascular Research Institute Basel and christian.mueller@usb.ch.
Christian
C
Mueller
D054058:Acute Coronary Syndrome / Q000097:blood / Q000175:diagnosis* / Q000503:physiopathology; D000368:Aged; D015415:Biomarkers / Q000097:blood; D002637:Chest Pain / Q000097:blood / Q000175:diagnosis* / Q000503:physiopathology; D003937:Diagnosis, Differential; D019317:Evidence-Based Medicine; D005260:Female; D006020:Glycopeptides / Q000097:blood*; D006801:Humans; D008297:Male; D008875:Middle Aged; D009203:Myocardial Infarction / Q000097:blood / Q000175:diagnosis* / Q000503:physiopathology; D011237:Predictive Value of Tests; D011446:Prospective Studies; D012306:Risk; D013997:Time Factors; D020107:Troponin T / Q000097:blood*
D015415:Biomarkers; D006020:Glycopeptides; D020107:Troponin T; C048197:copeptins