title: Validation of presentation and 3 h high-sensitivity troponin to rule-in and rule-out acute myocardial infarction.
abstract: International guidelines to rule-in acute myocardial infarction (AMI) in patients presenting with chest pain to the emergency department (ED) recommend an algorithm using high-sensitivity cardiac troponin (hs-cTn) sampling on presentation and 3 h following presentation. We tested the diagnostic accuracy of this algorithm by pooling data from five distinct cohorts from three countries of prospectively recruited patients with independently adjudicated outcomes.
  
  
  
  We measured high-sensitivity cardiac troponin I (hs-cTnI) and high-sensitivity cardiac troponin T (hs-cTnT) on presentation (0 h) and 3 h post-presentation samples in adult patients attending an ED with possible AMI to validate the European Society of Cardiology (ESC) Working Group on Acute Cardiac Care rule-in algorithm (ESC-rule-in). Specifically, (i) in patients with a 0 h hs-cTn concentration ≤99th percentile and a 3 h hs-cTn >99th percentile, positive patients are those with an absolute change in troponin ≥50% of the 99th percentile, and (ii) in patients with a 0 and 3 h hs-cTn >99th percentile, positive patients are those with a relative change in troponin of ≥20%. We concurrently assessed the efficacy of the 0 and 3 h hs-cTn <99th percentile to rule-out AMI.
  
  
  
  1061 patients with hs-cTnI and 985 with hs-cTnT were included. The ESC-rule-in positive predictive value (PPV) was 83.5% (95% CI 74.9% to 90.1%) for hs-cTnI and 72.0% (95% CI 62.1% to 80.5%) for hs-cTnT. Forty-six AMIs (34.9%) were not ruled in using hs-cTnI and 62 (46.2%) using hs-cTnT. The sensitivity of the 99th percentile to rule-out AMI was 93.2% (95% CI 87.5% to 96.8%) for hs-cTnI and 94.8% (95% CI 89.5% to 97.9%) for hs-cTnT.
  
  
  
  The ESC-rule-in algorithm has good PPV with hs-cTnI and reasonable with hs-cTnT and can rule-in over 50% of AMIs. However, the sensitivity of the 99th percentile to rule-out AMI is too low for clinical use.
authors.affiliation: Emergency Department, Christchurch Hospital, Christchurch, New Zealand Department of Medicine, University of Otago, Christchurch, New Zealand.
authors.forename: John W
authors.identifier: 0000-0001-9475-0344
authors.initials: JW
authors.lastname: Pickering
authors.affiliation: Department of Emergency Medicine, Royal Brisbane and Women's Hospital, and The University of Queensland and School of Public Health, Queensland University of Technology Brisbane, Brisbane, Australia.
authors.forename: Jaimi H
authors.initials: JH
authors.lastname: Greenslade
authors.affiliation: Department of Emergency Medicine, Royal Brisbane and Women's Hospital, and The University of Queensland and School of Public Health, Queensland University of Technology Brisbane, Brisbane, Australia.
authors.forename: Louise
authors.initials: L
authors.lastname: Cullen
authors.affiliation: Department of Emergency Medicine, Royal Brisbane and Women's Hospital, and The University of Queensland and School of Public Health, Queensland University of Technology Brisbane, Brisbane, Australia.
authors.forename: Dylan
authors.initials: D
authors.lastname: Flaws
authors.affiliation: Department of Cardiology, Royal Brisbane and Women's Hospital, Brisbane, Australia.
authors.forename: William
authors.initials: W
authors.lastname: Parsonage
authors.affiliation: Canterbury Health Laboratories, Christchurch, New Zealand.
authors.forename: Peter
authors.initials: P
authors.lastname: George
authors.affiliation: McMaster University, Hamilton, Ontario, Canada.
authors.forename: Andrew
authors.initials: A
authors.lastname: Worster
authors.affiliation: McMaster University, Hamilton, Ontario, Canada.
authors.forename: Peter A
authors.initials: PA
authors.lastname: Kavsak
authors.affiliation: Emergency Department, Christchurch Hospital, Christchurch, New Zealand.
authors.forename: Martin P
authors.initials: MP
authors.lastname: Than
mesh_terms: D000368:Aged; D000465:Algorithms; D000787:Angina Pectoris / Q000175:diagnosis / Q000209:etiology; D015415:Biomarkers / Q000097:blood; D003661:Decision Support Techniques; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D009203:Myocardial Infarction / Q000097:blood / Q000150:complications / Q000175:diagnosis*; D009520:New Zealand; D009864:Ontario; D011237:Predictive Value of Tests; D011379:Prognosis; D011446:Prospective Studies; D011793:Queensland; D015203:Reproducibility of Results; D012307:Risk Factors; D013997:Time Factors; D019210:Troponin I / Q000097:blood*; D020107:Troponin T / Q000097:blood*; D015854:Up-Regulation
chemical_list: D015415:Biomarkers; D019210:Troponin I; D020107:Troponin T