title: Early Rule-Out and Rule-In Strategies for Myocardial Infarction.
abstract: BACKGROUND
  Patients with chest pain comprise a large proportion of emergency presentations and place a major burden on healthcare resources. Therefore, efforts to safely and rapidly identify those with and without acute myocardial infarction (AMI) are needed. The challenge for clinicians is to accurately identify patients with acute coronary syndromes, while balancing the need to safely and rapidly reassure and discharge those without serious conditions.
  
  
  BACKGROUND
  This review summarizes the evidence to date on optimum accelerated strategies for the rule-in and rule-out of AMI, using strategies focused on optimum use of troponin results. Evidence based on both sensitive and highly sensitive troponin assay results is presented. The use of novel biomarkers is also addressed and the combination of biomarkers with other clinical information in accelerated diagnostic strategies is discussed.
  
  
  CONCLUSIONS
  The majority of patients, who are not at risk of myocardial infarction or other serious harm, may be suitable for discharge directly from the emergency setting using approaches focused on troponin algorithms and accelerated diagnostic protocols. Evidence about the clinical and health economic impact of use of such strategies is needed, as they may have major benefits for both patients and healthcare providers.
authors.affiliation: Royal Brisbane and Women's Hospital, Brisbane, Australia; louise.cullen@health.qld.gov.au.
authors.forename: Louise A
authors.initials: LA
authors.lastname: Cullen
authors.affiliation: BHF Centre for Cardiovascular Sciences, University of Edinburgh, Edinburgh, UK.
authors.forename: Nicholas L
authors.initials: NL
authors.lastname: Mills
authors.affiliation: Wake Forest School of Medicine, Winston-Salem, NC.
authors.forename: Simon
authors.initials: S
authors.lastname: Mahler
authors.affiliation: Central Manchester University Hospitals NHS Foundation Trust, UK.
authors.forename: Richard
authors.initials: R
authors.lastname: Body
mesh_terms: D000208:Acute Disease; D000465:Algorithms; D015415:Biomarkers / Q000032:analysis; D006801:Humans; D009203:Myocardial Infarction / Q000175:diagnosis*; D014336:Troponin / Q000032:analysis
chemical_list: D015415:Biomarkers; D014336:Troponin