Validation of NICE diagnostic guidance for rule out of myocardial infarction using high-sensitivity troponin tests.
To validate the National Institute for Health and Care Excellence (NICE) recommended algorithms for high-sensitivity troponin (hsTn) assays in adults presenting with chest pain.



International post hoc analysis of three prospective, observational studies from tertiary hospital emergency departments. The primary endpoint was cardiac death or acute myocardial infarction (AMI) within 24 hours of presentation, and the secondary endpoint was major adverse cardiac events (MACE) at 30 days.



15% of patients were diagnosed with non-ST elevation myocardial infarction (MI) on admission. The hsTnI algorithm classified 2506/3128 (80.1%) of patients as 'ruled out' with 50 (2.0%) missed MI. 943/3128 (30.1%) of patients had a troponin I level below the limit of detection on admission with 2 (0.2%) missed MI. For the hsTnT algorithm, 1794/3374 (53.1%) of patients were 'ruled out' with 7 (0.4%) missed MI. 490/3374 (14.5%) of patients had a troponin T below the limit of blank on admission with no MI. MACE at 30 days occurred in 10.7% and 8.5% of patients 'ruled out' defined by the hsTnI and hsTnT algorithms, respectively.



The NICE algorithms could identify patients with low probability of AMI within 2 hours; however, neither strategy performed as predicted by the NICE diagnostic guidance model. Additionally, the rate of MACE at 30 days was sufficiently high that the algorithms should only be used as one component of a more extensive model of risk stratification.



ACTRN12611001069943, NCT00470587; post-results.
Royal Brisbane & Women's Hospital, Herston, Australia.
W A
WA
Parsonage
Cardiovascular Research Institute, University Hospital, Basel, Switzerland.
C
C
Mueller
Royal Brisbane & Women's Hospital, Herston, Australia.
J H
JH
Greenslade
Cardiovascular Research Institute, University Hospital, Basel, Switzerland.
K
K
Wildi
Christchurch Hospital, Christchurch, New Zealand.
J
J
Pickering
Christchurch Hospital, Christchurch, New Zealand.
M
M
Than
Christchurch Hospital, Christchurch, New Zealand.
S
S
Aldous
Cardiovascular Research Institute, University Hospital, Basel, Switzerland.
J
J
Boeddinghaus
Royal Brisbane & Women's Hospital, Herston, Australia.
C J
CJ
Hammett
Royal Brisbane & Women's Hospital, Herston, Australia.
T
T
Hawkins
Cardiovascular Research Institute, University Hospital, Basel, Switzerland.
T
T
Nestelberger
Cardiovascular Research Institute, University Hospital, Basel, Switzerland.
T
T
Reichlin
Cardiovascular Research Institute, University Hospital, Basel, Switzerland.
S
S
Reidt
Cardiovascular Research Institute, University Hospital, Basel, Switzerland.
M
M
Rubin Gimenez
Royal Brisbane & Women's Hospital, Herston, Australia.
J R
JR
Tate
Cardiovascular Research Institute, University Hospital, Basel, Switzerland.
R
R
Twerenbold
Royal Brisbane & Women's Hospital, Herston, Australia.
J P
JP
Ungerer
Royal Brisbane & Women's Hospital, Herston, Australia.
L
L
Cullen
D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000465:Algorithms; D000787:Angina Pectoris / Q000175:diagnosis / Q000209:etiology; D015415:Biomarkers / Q000097:blood*; D016507:Cardiology Service, Hospital / Q000592:standards; D003661:Decision Support Techniques; D004636:Emergency Service, Hospital / Q000592:standards; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D009203:Myocardial Infarction / Q000097:blood / Q000150:complications / Q000175:diagnosis*; D009520:New Zealand; D017410:Practice Guidelines as Topic / Q000592:standards*; D011237:Predictive Value of Tests; D011379:Prognosis; D011446:Prospective Studies; D011793:Queensland; D015203:Reproducibility of Results; D013557:Switzerland; D062606:Tertiary Care Centers; D013997:Time Factors; D019210:Troponin I / Q000097:blood*; D020107:Troponin T / Q000097:blood*; D015854:Up-Regulation; D055815:Young Adult
D015415:Biomarkers; D019210:Troponin I; D020107:Troponin T