Predicting Major Adverse Events in Patients With Acute Myocardial Infarction

J Am Coll Cardiol. 2019 Aug 20;74(7):842-854. doi: 10.1016/j.jacc.2019.06.025.

Abstract

Background: Early and accurate detection of short-term major adverse cardiac events (MACE) in patients with suspected acute myocardial infarction (AMI) is an unmet clinical need.

Objectives: The goal of this study was to test the hypothesis that adding clinical judgment and electrocardiogram findings to the European Society of Cardiology (ESC) high-sensitivity cardiac troponin (hs-cTn) measurement at presentation and after 1 h (ESC hs-cTn 0/1 h algorithm) would further improve its performance to predict MACE.

Methods: Patients presenting to an emergency department with suspected AMI were enrolled in a prospective, multicenter diagnostic study. The primary endpoint was MACE, including all-cause death, cardiac arrest, AMI, cardiogenic shock, sustained ventricular arrhythmia, and high-grade atrioventricular block within 30 days including index events. The secondary endpoint was MACE + unstable angina (UA) receiving early (≤24 h) revascularization.

Results: Among 3,123 patients, the ESC hs-cTnT 0/1 h algorithm triaged significantly more patients toward rule-out compared with the extended algorithm (60%; 95% CI: 59% to 62% vs. 45%; 95% CI: 43% to 46%; p < 0.001), while maintaining similar 30-day MACE rates (0.6%; 95% CI: 0.3% to 1.1% vs. 0.4%; 95% CI: 0.1% to 0.9%; p = 0.429), resulting in a similar negative predictive value (99.4%; 95% CI: 98.9% to 99.6% vs. 99.6%; 95% CI: 99.2% to 99.8%; p = 0.097). The ESC hs-cTnT 0/1 h algorithm ruled-in fewer patients (16%; 95% CI: 14.9% to 17.5% vs. 26%; 95% CI: 24.2% to 27.2%; p < 0.001) compared with the extended algorithm, albeit with a higher positive predictive value (76.6%; 95% CI: 72.8% to 80.1% vs. 59%; 95% CI: 55.5% to 62.3%; p < 0.001). For 30-day MACE + UA, the ESC hs-cTnT 0/1 h algorithm had a higher positive predictive value for rule-in, whereas the extended algorithm had a higher negative predictive value for the rule-out. Similar findings emerged when using hs-cTnI.

Conclusions: The ESC hs-cTn 0/1 h algorithm better balanced efficacy and safety in the prediction of MACE, whereas the extended algorithm is the preferred option for the rule-out of 30-day MACE + UA. (Advantageous Predictors of Acute Coronary Syndromes Evaluation [APACE]; NCT00470587).

Keywords: acute myocardial infarction; clinical assessment; electrocardiography; high-sensitivity cardiac troponin; major adverse cardiac events.

Publication types

  • Multicenter Study
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Aged
  • Algorithms*
  • Angina, Unstable / diagnosis
  • Angina, Unstable / epidemiology
  • Arrhythmias, Cardiac / diagnosis
  • Arrhythmias, Cardiac / epidemiology
  • Atrioventricular Block / diagnosis
  • Atrioventricular Block / epidemiology
  • Biomarkers / blood
  • Electrocardiography
  • Emergency Service, Hospital
  • Female
  • Heart Arrest / diagnosis
  • Heart Arrest / epidemiology
  • Humans
  • Male
  • Middle Aged
  • Myocardial Infarction / blood
  • Myocardial Infarction / diagnosis
  • Myocardial Infarction / epidemiology*
  • Myocardial Revascularization
  • Predictive Value of Tests
  • Prospective Studies
  • Sensitivity and Specificity
  • Shock, Cardiogenic / diagnosis
  • Shock, Cardiogenic / epidemiology
  • Troponin / blood*

Substances

  • Biomarkers
  • Troponin

Associated data

  • ClinicalTrials.gov/NCT00470587