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0/1-Hour Triage Algorithm for Myocardial Infarction in Patients With Renal Dysfunction

Circulation (New York, N.Y.), 2018-01, Vol.137 (5), p.436-451 [Peer Reviewed Journal]

2018 by the American College of Cardiology Foundation and the American Heart Association, Inc. ;2017 The Authors. ;2017 The Authors. 2017 ;ISSN: 0009-7322 ;EISSN: 1524-4539 ;DOI: 10.1161/CIRCULATIONAHA.117.028901 ;PMID: 29101287

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Title:
0/1-Hour Triage Algorithm for Myocardial Infarction in Patients With Renal Dysfunction
Author: Twerenbold, Raphael ; Badertscher, Patrick ; Boeddinghaus, Jasper ; Nestelberger, Thomas ; Wildi, Karin ; Puelacher, Christian ; Sabti, Zaid ; Rubini Gimenez, Maria ; Tschirky, Sandra ; du Fay de Lavallaz, Jeanne ; Kozhuharov, Nikola ; Sazgary, Lorraine ; Mueller, Deborah ; Breidthardt, Tobias ; Strebel, Ivo ; Flores Widmer, Dayana ; Shrestha, Samyut ; Miró, Òscar ; Martín-Sánchez, F Javier ; Morawiec, Beata ; Parenica, Jiri ; Geigy, Nicolas ; Keller, Dagmar I ; Rentsch, Katharina ; von Eckardstein, Arnold ; Osswald, Stefan ; Reichlin, Tobias ; Mueller, Christian
Subjects: Aged ; Aged, 80 and over ; Algorithms ; Biomarkers - blood ; Creatinine - blood ; Decision Support Techniques ; Europe - epidemiology ; Female ; Glomerular Filtration Rate ; Humans ; Kidney - physiopathology ; Kidney Diseases - blood ; Kidney Diseases - diagnosis ; Kidney Diseases - epidemiology ; Kidney Diseases - physiopathology ; Male ; Middle Aged ; Non-ST Elevated Myocardial Infarction - blood ; Non-ST Elevated Myocardial Infarction - diagnosis ; Non-ST Elevated Myocardial Infarction - epidemiology ; Original s ; Predictive Value of Tests ; Prevalence ; Prognosis ; Prospective Studies ; Reproducibility of Results ; Risk Assessment ; Risk Factors ; Time Factors ; Triage ; Troponin - blood ; Up-Regulation
Is Part Of: Circulation (New York, N.Y.), 2018-01, Vol.137 (5), p.436-451
Description: BACKGROUND:The European Society of Cardiology recommends a 0/1-hour algorithm for rapid rule-out and rule-in of non–ST-segment elevation myocardial infarction using high-sensitivity cardiac troponin (hs-cTn) concentrations irrespective of renal function. Because patients with renal dysfunction (RD) frequently present with increased hs-cTn concentrations even in the absence of non–ST-segment elevation myocardial infarction, concern has been raised regarding the performance of the 0/1-hour algorithm in RD. METHODS:In a prospective multicenter diagnostic study enrolling unselected patients presenting with suspected non–ST-segment elevation myocardial infarction to the emergency department, we assessed the diagnostic performance of the European Society of Cardiology 0/1-hour algorithm using hs-cTnT and hs-cTnI in patients with RD, defined as an estimated glomerular filtration rate <60 mL/min/1.73 m, and compared it to patients with normal renal function. The final diagnosis was centrally adjudicated by 2 independent cardiologists using all available information, including cardiac imaging. Safety was quantified as sensitivity in the rule-out zone, accuracy as the specificity in the rule-in zone, and efficacy as the proportion of the overall cohort assigned to either rule-out or rule-in based on the 0- and 1-hour sample. RESULTS:Among 3254 patients, RD was present in 487 patients (15%). The prevalence of non–ST-segment elevation myocardial infarction was substantially higher in patients with RD compared with patients with normal renal function (31% versus 13%, P<0.001). Using hs-cTnT, patients with RD had comparable sensitivity of rule-out (100.0% [95% confidence interval {CI}, 97.6–100.0] versus 99.2% [95% CI, 97.6–99.8]; P=0.559), lower specificity of rule-in (88.7% [95% CI, 84.8–91.9] versus 96.5% [95% CI, 95.7–97.2]; P<0.001), and lower overall efficacy (51% versus 81%, P<0.001), mainly driven by a much lower percentage of patients eligible for rule-out (18% versus 68%, P<0.001) compared with patients with normal renal function. Using hs-cTnI, patients with RD had comparable sensitivity of rule-out (98.6% [95% CI, 95.0–99.8] versus 98.5% [95% CI, 96.5–99.5]; P=1.0), lower specificity of rule-in (84.4% [95% CI, 79.9–88.3] versus 91.7% [95% CI, 90.5–92.9]; P<0.001), and lower overall efficacy (54% versus 76%, P<0.001; proportion ruled out, 18% versus 58%, P<0.001) compared with patients with normal renal function. CONCLUSIONS:In patients with RD, the safety of the European Society of Cardiology 0/1-hour algorithm is high, but specificity of rule-in and overall efficacy are decreased. Modifications of the rule-in and rule-out thresholds did not improve the safety or overall efficacy of the 0/1-hour algorithm. CLINICAL TRIAL REGISTRATION:URLhttps://www.clinicaltrials.gov. Unique identifierNCT00470587.
Publisher: United States: by the American College of Cardiology Foundation and the American Heart Association, Inc
Language: English
Identifier: ISSN: 0009-7322
EISSN: 1524-4539
DOI: 10.1161/CIRCULATIONAHA.117.028901
PMID: 29101287
Source: Geneva Foundation Free Medical Journals at publisher websites
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0/1-Hour Triage Algorithm for Myocardial Infarction in Patients With Renal Dysfunction

2018 by the American College of Cardiology Foundation and the American Heart Association, Inc. ;2017 The Authors. ;2017 The Authors. 2017 ;ISSN: 0009-7322 ;EISSN: 1524-4539 ;DOI: 10.1161/CIRCULATIONAHA.117.028901 ;PMID: 29101287

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