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A novel diagnostic protocol to identify patients suitable for discharge after a single high-sensitivity troponin
OBJECTIVE: To establish whether a novel accelerated diagnostic protocol (ADP) for suspected acute coronary syndrome (ACS) could successfully identify low-risk patients suitable for discharge after a single high-sensitivity troponin T (hs-cTnT) taken at presentation to the emergency department. We al...
Autores principales: | , , , , , |
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Formato: | Online Artículo Texto |
Lenguaje: | English |
Publicado: |
BMJ Publishing Group
2015
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Materias: | |
Acceso en línea: | https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4484040/ https://www.ncbi.nlm.nih.gov/pubmed/25691511 http://dx.doi.org/10.1136/heartjnl-2014-307288 |
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author | Carlton, Edward W Cullen, Louise Than, Martin Gamble, James Khattab, Ahmed Greaves, Kim |
author_facet | Carlton, Edward W Cullen, Louise Than, Martin Gamble, James Khattab, Ahmed Greaves, Kim |
author_sort | Carlton, Edward W |
collection | PubMed |
description | OBJECTIVE: To establish whether a novel accelerated diagnostic protocol (ADP) for suspected acute coronary syndrome (ACS) could successfully identify low-risk patients suitable for discharge after a single high-sensitivity troponin T (hs-cTnT) taken at presentation to the emergency department. We also compared the diagnostic accuracy of this ADP with strategies using initial undetectable hs-cTnT. METHODS: This prospective observational study evaluated the ability of the Triage Rule-out Using high-Sensitivity Troponin (TRUST) ADP to identify low-risk patients with suspected ACS. The ADP incorporated a single presentation hs-cTnT of <14 ng/L, a non-ischaemic ECG and a modified Goldman risk score. Diagnostic performance of the ADP was compared with the detection limit cut-offs of hs-cTnT (<5 ng/L and <3 ng/L). The primary end point was fatal/non-fatal acute myocardial infarction (AMI) within 30 days. RESULTS: 960 participants were recruited, mean age 58.0 years, 80 (8.3%) had an AMI. The TRUST ADP classified 382 (39.8%) as low-risk with a sensitivity for identifying AMI of 98.8% (95% CI 92.5% to 99.9%). hs-cTnT detection limits (<5 ng/L and <3 ng/L) had a sensitivity of 100% (94.3 to 100) and 100% (94.4 to 100), respectively. The TRUST ADP identified more patients suitable for early discharge at 39.8% vs 29.3% (<5 ng/L) and 7.9% (<3 ng/L) (p<0.001) with a lower false-positive rate for AMI detection; specificity 43.3% (95% CI 42.7% to 43.4%) vs 32.0% (95% CI 31.5% to 32.0%) and 8.6% (95% CI 8.1% to 8.6%), respectively. CONCLUSIONS: The TRUST ADP, which incorporates structured risk-assessment and a single presentation hs-cTnT blood draw, has potential to allow early discharge in 40% of patients with suspected ACS and has greater clinical utility than undetectable hs-cTnT strategies. TRIAL REGISTRATION NUMBER: ISRCTN No. 21109279. |
format | Online Article Text |
id | pubmed-4484040 |
institution | National Center for Biotechnology Information |
language | English |
publishDate | 2015 |
publisher | BMJ Publishing Group |
record_format | MEDLINE/PubMed |
spelling | pubmed-44840402015-07-10 A novel diagnostic protocol to identify patients suitable for discharge after a single high-sensitivity troponin Carlton, Edward W Cullen, Louise Than, Martin Gamble, James Khattab, Ahmed Greaves, Kim Heart Coronary Artery Disease OBJECTIVE: To establish whether a novel accelerated diagnostic protocol (ADP) for suspected acute coronary syndrome (ACS) could successfully identify low-risk patients suitable for discharge after a single high-sensitivity troponin T (hs-cTnT) taken at presentation to the emergency department. We also compared the diagnostic accuracy of this ADP with strategies using initial undetectable hs-cTnT. METHODS: This prospective observational study evaluated the ability of the Triage Rule-out Using high-Sensitivity Troponin (TRUST) ADP to identify low-risk patients with suspected ACS. The ADP incorporated a single presentation hs-cTnT of <14 ng/L, a non-ischaemic ECG and a modified Goldman risk score. Diagnostic performance of the ADP was compared with the detection limit cut-offs of hs-cTnT (<5 ng/L and <3 ng/L). The primary end point was fatal/non-fatal acute myocardial infarction (AMI) within 30 days. RESULTS: 960 participants were recruited, mean age 58.0 years, 80 (8.3%) had an AMI. The TRUST ADP classified 382 (39.8%) as low-risk with a sensitivity for identifying AMI of 98.8% (95% CI 92.5% to 99.9%). hs-cTnT detection limits (<5 ng/L and <3 ng/L) had a sensitivity of 100% (94.3 to 100) and 100% (94.4 to 100), respectively. The TRUST ADP identified more patients suitable for early discharge at 39.8% vs 29.3% (<5 ng/L) and 7.9% (<3 ng/L) (p<0.001) with a lower false-positive rate for AMI detection; specificity 43.3% (95% CI 42.7% to 43.4%) vs 32.0% (95% CI 31.5% to 32.0%) and 8.6% (95% CI 8.1% to 8.6%), respectively. CONCLUSIONS: The TRUST ADP, which incorporates structured risk-assessment and a single presentation hs-cTnT blood draw, has potential to allow early discharge in 40% of patients with suspected ACS and has greater clinical utility than undetectable hs-cTnT strategies. TRIAL REGISTRATION NUMBER: ISRCTN No. 21109279. BMJ Publishing Group 2015-07-01 2015-02-17 /pmc/articles/PMC4484040/ /pubmed/25691511 http://dx.doi.org/10.1136/heartjnl-2014-307288 Text en Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/ |
spellingShingle | Coronary Artery Disease Carlton, Edward W Cullen, Louise Than, Martin Gamble, James Khattab, Ahmed Greaves, Kim A novel diagnostic protocol to identify patients suitable for discharge after a single high-sensitivity troponin |
title | A novel diagnostic protocol to identify patients suitable for discharge after a single high-sensitivity troponin |
title_full | A novel diagnostic protocol to identify patients suitable for discharge after a single high-sensitivity troponin |
title_fullStr | A novel diagnostic protocol to identify patients suitable for discharge after a single high-sensitivity troponin |
title_full_unstemmed | A novel diagnostic protocol to identify patients suitable for discharge after a single high-sensitivity troponin |
title_short | A novel diagnostic protocol to identify patients suitable for discharge after a single high-sensitivity troponin |
title_sort | novel diagnostic protocol to identify patients suitable for discharge after a single high-sensitivity troponin |
topic | Coronary Artery Disease |
url | https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4484040/ https://www.ncbi.nlm.nih.gov/pubmed/25691511 http://dx.doi.org/10.1136/heartjnl-2014-307288 |
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