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Extended algorithm for MI prediction successfully rules out risk for 30-day events
Adding clinical judgment and ECG results to the European Society of Cardiology high-sensitivity cardiac troponin measurement algorithm for predicting major adverse CV events enhanced success at ruling out 30-day events, researchers reported.
However, the algorithm alone, which is based on high-sensitivity cardiac troponin readings at presentation and after 1 hour, was shown to have more balanced efficacy and safety compared with the extended algorithm with clinical judgment and ECG results added.
Very high safety
“Allocated for prediction of 30 day [major adverse CV events], both algorithms had a very high safety for rule-out, while the efficacy was better for the troponin algorithm,” Thomas Nestelberger, MD, fellow in interventional cardiology at the University Hospital Basel, Switzerland, told Healio. “However, the extended algorithm is the preferred option for rule-out of [major adverse CV events and unstable angina]. This finding was solely based on [unstable angina (UA)] patients, which were missed by the troponin algorithm, as the troponin algorithm was not created to identify UA patients.”
For the prospective multicenter study published in the Journal of the American College of Cardiology, 3,123 patients at 12 centers across five European countries who presented with suspected MI were enrolled.
The study compared the algorithm and the extended algorithm in predicting major adverse CV events including all-cause death, cardiac arrest, acute MI, cardiogenic shock, sustained ventricular arrhythmia and high-grade atrioventricular block within 30 days.
Patients with terminal kidney failure on chronic dialysis were excluded from the study.
“[The] ESC hs-cTn 0/1h algorithm has been developed to accurately identify patients for rule-out or rule-in for [acute MI] among patients presenting with chest pain to an emergency department,” Nestelberger said in an interview. “Two aspects are very important for every algorithm development, a high safety for rule-out and an efficacy quantified by the number of patients either ruled-out or ruled-in for [acute MI].”
Successful triage
Researchers found that the algorithm alone successfully triaged more patients to rule-out compared with the extended algorithm (algorithm, 60%; 95% CI, 59-62; extended algorithm, 45%; 95% CI, 43-46;P < .001) but yielded comparable 30 day major adverse CV events (algorithm, 0.6%; 95% CI, 0.3-1.1; extended algorithm, 0.4%; 95% CI,0.1-0.9%; P < .429).
“The troponin algorithm showed a very well and balanced efficacy and safety in the prediction of [major adverse CV],” Nestelberger told Healio. “The extended algorithm seems to be a valuable tool to additionally identify patients with UA.”
ESC hs-cTnT 0/1 h ruled in fewer patients compared with the extended algorithm, with higher positive predictive value (algorithm, 76.6%; 95% CI, 72.8-80.1; extended algorithm, 59%; 95% CI, 55.5-62.3; P < .001).
For predicting 30-day major adverse CV events plus unstable angina, the algorithm was shown to have a higher predictive value for rule-out, while the extended algorithm was found to have higher negative predictive value.
“A prospective evaluation of both algorithms in a randomized control trial would be optimal to validate the findings of our study,” Nestelberger said. “We suggest that for most patients with chest pain in the ED, the troponin algorithm will be a valuable tool to predict short term [major adverse CV events].” – by Scott Buzby
Disclosures: Nestelberger reports he received speaker honoraria from Beckman Coulter. Please see the study for all other authors’ relevant financial disclosures.