A 3-Hour Diagnostic Algorithm for Non-ST-Elevation Myocardial Infarction Using High-Sensitivity Cardiac Troponin T in Unselected Older Patients Presenting to the Emergency Department

Bahrmann P, Christ M, Bahrmann A, Rittger H, Heppner HJ, Achenbach S, Bertsch T, Sieber C (2013)

Publication Status: Published

Publication Type: Journal article

Publication year: 2013

Journal

Journal of the American Medical Directors Association Elsevier

Publisher: ELSEVIER SCIENCE INC

Book Volume: 14

Pages Range: 409-416

Journal Issue: 6

DOI: 10.1016/j.jamda.2012.12.005

Abstract

Objectives: To determine if an algorithm implementing a serial high-sensitive cardiac troponin T (hs-cTnT) measurement at presentation (0h) and at 3 hours after presentation (3h) is helpful for early diagnosis of non-ST-elevation myocardial infarction (NSTEMI) in older patients.Design: Prospective observational cohort study.Setting: An emergency department (ED) of a city hospital covering a population of approximately 1 million in Germany.Participants: A total of 332 consecutive unselected patients were recruited, of whom 25 had one or more of the prespecified exclusion criteria and 1 had a missing hs-cTnT at 3h, resulting in a final population of 306 patients.Measurements: In addition to clinical examination, hs-cTnT was measured at 0h and 3h. The final diagnosis of NSTEMI was adjudicated by two independent consultants and an algorithm for rule-in and rule-out of NSTEMI was developed using classification and regression tree analysis. All patients were followed-up for cardiovascular outcome within 12 months.Results: Among 306 patients (mean age 81 +/- 6 years), 38 (12%) patients had NSTEMI. Accuracy to diagnose NSTEMI was significantly higher for hs-cTnT measurements at 3h versus 0h (area under the receiver operating characteristic curve [AUC] 0.88 vs. 0.82, P = .0038) and for absolute versus relative hs-cTnT delta changes (AUC 0.89 versus 0.69, P < .001). A diagnostic algorithm using hs-cTnT values at presentation and absolute delta changes values ruled-in NSTEMI in 23% and ruled-out NSTEMI in 35% of patients. For patients neither fulfilling the rule-in nor the rule-out criteria, an observational zone was established. Cumulative 1-year survival was 79.4%, 88.5%, and 99.1% in patients classified as rule-in, observational zone, and rule-out, respectively.Conclusion: In older patients, serial hs-cTnT measurements and absolute delta-changes at 3h were valuable for early diagnosis of NSTEMI. An algorithm ruled-in NSTEMI in one quarter of patients with high risk and ruled-out NSTEMI in one-third with low risk. Copyright (c) 2013 - American Medical Directors Association, Inc.

Authors with CRIS profile

Philipp Bahrmann Lehrstuhl für Innere Medizin (Geriatrie) Harald Rittger Department of Medicine 2 – Cardiology and Angiology Hans Jürgen Heppner Medizinische Fakultät Stephan Achenbach Department of Medicine 2 – Cardiology and Angiology Cornel Sieber Lehrstuhl für Innere Medizin (Geriatrie)

Involved external institutions

Klinikum Nürnberg DE Germany (DE)

How to cite

APA:

Bahrmann, P., Christ, M., Bahrmann, A., Rittger, H., Heppner, H.J., Achenbach, S.,... Sieber, C. (2013). A 3-Hour Diagnostic Algorithm for Non-ST-Elevation Myocardial Infarction Using High-Sensitivity Cardiac Troponin T in Unselected Older Patients Presenting to the Emergency Department. Journal of the American Medical Directors Association, 14(6), 409-416. https://doi.org/10.1016/j.jamda.2012.12.005

MLA:

Bahrmann, Philipp, et al. "A 3-Hour Diagnostic Algorithm for Non-ST-Elevation Myocardial Infarction Using High-Sensitivity Cardiac Troponin T in Unselected Older Patients Presenting to the Emergency Department." Journal of the American Medical Directors Association 14.6 (2013): 409-416.

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