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Original article
Validation of NICE diagnostic guidance for rule out of myocardial infarction using high-sensitivity troponin tests
  1. W A Parsonage1,
  2. C Mueller2,
  3. J H Greenslade1,
  4. K Wildi2,
  5. J Pickering3,
  6. M Than3,
  7. S Aldous3,
  8. J Boeddinghaus2,
  9. C J Hammett1,
  10. T Hawkins1,
  11. T Nestelberger2,
  12. T Reichlin2,
  13. S Reidt2,
  14. M Rubin Gimenez2,
  15. J R Tate1,
  16. R Twerenbold2,
  17. J P Ungerer1,
  18. L Cullen1
  1. 1Royal Brisbane & Women's Hospital, Herston, Australia
  2. 2Cardiovascular Research Institute, University Hospital, Basel, Switzerland
  3. 3Christchurch Hospital, Christchurch, New Zealand
  1. Correspondence to Dr W A Parsonage, Department of Cardiology, Royal Brisbane & Women's Hospital, Herston, QLD 4029, Australia; w.parsonage{at}mac.com

Abstract

Objective To validate the National Institute for Health and Care Excellence (NICE) recommended algorithms for high-sensitivity troponin (hsTn) assays in adults presenting with chest pain.

Methods International post hoc analysis of three prospective, observational studies from tertiary hospital emergency departments. The primary endpoint was cardiac death or acute myocardial infarction (AMI) within 24 hours of presentation, and the secondary endpoint was major adverse cardiac events (MACE) at 30 days.

Results 15% of patients were diagnosed with non-ST elevation myocardial infarction (MI) on admission. The hsTnI algorithm classified 2506/3128 (80.1%) of patients as ‘ruled out’ with 50 (2.0%) missed MI. 943/3128 (30.1%) of patients had a troponin I level below the limit of detection on admission with 2 (0.2%) missed MI. For the hsTnT algorithm, 1794/3374 (53.1%) of patients were ‘ruled out’ with 7 (0.4%) missed MI. 490/3374 (14.5%) of patients had a troponin T below the limit of blank on admission with no MI. MACE at 30 days occurred in 10.7% and 8.5% of patients ‘ruled out’ defined by the hsTnI and hsTnT algorithms, respectively.

Conclusions The NICE algorithms could identify patients with low probability of AMI within 2 hours; however, neither strategy performed as predicted by the NICE diagnostic guidance model. Additionally, the rate of MACE at 30 days was sufficiently high that the algorithms should only be used as one component of a more extensive model of risk stratification.

Trial registration number ACTRN12611001069943, NCT00470587; post-results.

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