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Clinical criteria replenish high-sensitive troponin and inflammatory markers in the stratification of patients with suspected acute coronary syndrome.

Stähli BE, Yonekawa K, Altwegg LA, Wyss C, Hof D, Fischbacher P, Brauchlin A, Schulthess G, Krayenbühl PA, von Eckardstein A, Hersberger M, Neidhart M, Gay S, Novopashenny I, Wolters R, Frank M, Wischnewsky MB, Lüscher TF, Maier W - PLoS ONE (2014)

Bottom Line: Eleven out of 15 biomarkers were elevated in patients with CE compared to those without.Equivalence testing of AUCs of risk models and non-inferiority testing demonstrated that the clinical TIMI risk score alone was non-inferior to its combination with hs-cTnT in predicting CE.In patients presenting without ST-elevations, identification of those prone to CE is best based on clinical assessment based on TIMI risk score criteria and hs-cTnT.

View Article: PubMed Central - PubMed

Affiliation: Department of Cardiology, Cardiovascular Center, University Hospital Zurich, Zurich, Switzerland.

ABSTRACT

Objectives: In patients with suspected acute coronary syndrome (ACS), rapid triage is essential. The aim of this study was to establish a tool for risk prediction of 30-day cardiac events (CE) on admission. 30-day cardiac events (CE) were defined as early coronary revascularization, subsequent myocardial infarction, or cardiovascular death within 30 days.

Methods and results: This single-centre, prospective cohort study included 377 consecutive patients presenting to the emergency department with suspected ACS and for whom troponin T measurements were requested on clinical grounds. Fifteen biomarkers were analyzed in the admission sample, and clinical parameters were assessed by the TIMI risk score for unstable angina/Non-ST myocardial infarction and the GRACE risk score. Sixty-nine (18%) patients presented with and 308 (82%) without ST-elevations, respectively. Coronary angiography was performed in 165 (44%) patients with subsequent percutaneous coronary intervention--accounting for the majority of CE--in 123 (33%) patients, respectively. Eleven out of 15 biomarkers were elevated in patients with CE compared to those without. High-sensitive troponin T (hs-cTnT) was the best univariate biomarker to predict CE in Non-ST-elevation patients (AUC 0.80), but did not yield incremental information above clinical TIMI risk score (AUC 0.80 vs 0.82, p = 0.69). Equivalence testing of AUCs of risk models and non-inferiority testing demonstrated that the clinical TIMI risk score alone was non-inferior to its combination with hs-cTnT in predicting CE.

Conclusions: In patients presenting without ST-elevations, identification of those prone to CE is best based on clinical assessment based on TIMI risk score criteria and hs-cTnT.

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Related in: MedlinePlus

Predictiveness curves illustrating the prognostic performance of two different risk models in predicting cardiac events (CE).Risk model I: clinical TIMI risk score and gender; Risk model II: clinical TIMI risk score, gender, and hs-cTnT, respectively.
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pone-0098626-g005: Predictiveness curves illustrating the prognostic performance of two different risk models in predicting cardiac events (CE).Risk model I: clinical TIMI risk score and gender; Risk model II: clinical TIMI risk score, gender, and hs-cTnT, respectively.

Mentions: To further elucidate the impact of hs-TnT on risk prediction based on the clinical TIMI risk score, two risk models were established, i.e. clinical TIMI risk score and gender alone (model I) and combined with hs-TnT (model II). Female gender negatively predicted CE in binary logistic regression analysis. The AUC was 0.84 (95% CI 0.78–0.89; p<0.001) for model I, and 0.87 (95% CI 0.83–0.92; p<0.001) for model II, respectively. We could neither conclude equality (test of (AUC(model I)-AUC(model II)) = 0; diff value = 0.067; p = 0.002) nor equivalence of the AUCs at the 5% significance level (p = 0.087). An empirical non-inferiority test for AUCs showed that model I is no worse than model II with a non-inferiority bound of 5% (p<0.001), i.e. that the AUC for model I is no less than the AUC for model II at the 5% significance level. The addition of hs-TnT to base model I with an IDI of 0.054 indicates that the difference in average predicted risks between the individuals with and without CE increased by 5.4% in model II compared to model I. The performance of the two risk models is illustrated by predictiveness curves (figure 5).


Clinical criteria replenish high-sensitive troponin and inflammatory markers in the stratification of patients with suspected acute coronary syndrome.

Stähli BE, Yonekawa K, Altwegg LA, Wyss C, Hof D, Fischbacher P, Brauchlin A, Schulthess G, Krayenbühl PA, von Eckardstein A, Hersberger M, Neidhart M, Gay S, Novopashenny I, Wolters R, Frank M, Wischnewsky MB, Lüscher TF, Maier W - PLoS ONE (2014)

Predictiveness curves illustrating the prognostic performance of two different risk models in predicting cardiac events (CE).Risk model I: clinical TIMI risk score and gender; Risk model II: clinical TIMI risk score, gender, and hs-cTnT, respectively.
© Copyright Policy
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC4043791&req=5

pone-0098626-g005: Predictiveness curves illustrating the prognostic performance of two different risk models in predicting cardiac events (CE).Risk model I: clinical TIMI risk score and gender; Risk model II: clinical TIMI risk score, gender, and hs-cTnT, respectively.
Mentions: To further elucidate the impact of hs-TnT on risk prediction based on the clinical TIMI risk score, two risk models were established, i.e. clinical TIMI risk score and gender alone (model I) and combined with hs-TnT (model II). Female gender negatively predicted CE in binary logistic regression analysis. The AUC was 0.84 (95% CI 0.78–0.89; p<0.001) for model I, and 0.87 (95% CI 0.83–0.92; p<0.001) for model II, respectively. We could neither conclude equality (test of (AUC(model I)-AUC(model II)) = 0; diff value = 0.067; p = 0.002) nor equivalence of the AUCs at the 5% significance level (p = 0.087). An empirical non-inferiority test for AUCs showed that model I is no worse than model II with a non-inferiority bound of 5% (p<0.001), i.e. that the AUC for model I is no less than the AUC for model II at the 5% significance level. The addition of hs-TnT to base model I with an IDI of 0.054 indicates that the difference in average predicted risks between the individuals with and without CE increased by 5.4% in model II compared to model I. The performance of the two risk models is illustrated by predictiveness curves (figure 5).

Bottom Line: Eleven out of 15 biomarkers were elevated in patients with CE compared to those without.Equivalence testing of AUCs of risk models and non-inferiority testing demonstrated that the clinical TIMI risk score alone was non-inferior to its combination with hs-cTnT in predicting CE.In patients presenting without ST-elevations, identification of those prone to CE is best based on clinical assessment based on TIMI risk score criteria and hs-cTnT.

View Article: PubMed Central - PubMed

Affiliation: Department of Cardiology, Cardiovascular Center, University Hospital Zurich, Zurich, Switzerland.

ABSTRACT

Objectives: In patients with suspected acute coronary syndrome (ACS), rapid triage is essential. The aim of this study was to establish a tool for risk prediction of 30-day cardiac events (CE) on admission. 30-day cardiac events (CE) were defined as early coronary revascularization, subsequent myocardial infarction, or cardiovascular death within 30 days.

Methods and results: This single-centre, prospective cohort study included 377 consecutive patients presenting to the emergency department with suspected ACS and for whom troponin T measurements were requested on clinical grounds. Fifteen biomarkers were analyzed in the admission sample, and clinical parameters were assessed by the TIMI risk score for unstable angina/Non-ST myocardial infarction and the GRACE risk score. Sixty-nine (18%) patients presented with and 308 (82%) without ST-elevations, respectively. Coronary angiography was performed in 165 (44%) patients with subsequent percutaneous coronary intervention--accounting for the majority of CE--in 123 (33%) patients, respectively. Eleven out of 15 biomarkers were elevated in patients with CE compared to those without. High-sensitive troponin T (hs-cTnT) was the best univariate biomarker to predict CE in Non-ST-elevation patients (AUC 0.80), but did not yield incremental information above clinical TIMI risk score (AUC 0.80 vs 0.82, p = 0.69). Equivalence testing of AUCs of risk models and non-inferiority testing demonstrated that the clinical TIMI risk score alone was non-inferior to its combination with hs-cTnT in predicting CE.

Conclusions: In patients presenting without ST-elevations, identification of those prone to CE is best based on clinical assessment based on TIMI risk score criteria and hs-cTnT.

Show MeSH
Related in: MedlinePlus