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Coronary artery disease
Original research article
Assessment of the 2016 National Institute for Health and Care Excellence high-sensitivity troponin rule-out strategy
  1. Edward Watts Carlton1,
  2. John William Pickering2,3,
  3. Jaimi Greenslade4,5,
  4. Louise Cullen4,5,
  5. Martin Than3,
  6. Jason Kendall1,
  7. Richard Body6,
  8. William A Parsonage4,5,
  9. Ahmed Khattab7,
  10. Kim Greaves8
  1. 1 Emergency Department, Southmead Hospital, North Bristol NHS Trust, Bristol, Avon, UK
  2. 2 Department of Medicine, University of Otago, Christchurch, Canterbury, New Zealand
  3. 3 Department of Emergency Medicine, Christchurch Hospital, Christchurch, New Zealand
  4. 4 Department of Emergency Medicine, Royal Brisbane and Women’s Hospital, Brisbane, Australia
  5. 5 School of Medicine, The University of Queensland, Brisbane, Australia
  6. 6 Department of Emergency Medicine, Central Manchester University Hospitals NHS Foundation Trust, Manchester UK
  7. 7 School of Health and Social Care, Bournemouth University, Poole, UK
  8. 8 Sunshine Coast Hospital and Health Services, University of the Sunshine Coast, Nambour, Australia
  1. Correspondence to Dr Edward Watts Carlton, Emergency Department, North Bristol NHS Trust, Westbury-on-Trym, Bristol, BS10 5NB, UK; eddcarlton{at}gmail.com

Abstract

Objective We aimed to evaluate the limit of detection of high-sensitivity troponin (hs-cTn) and Thrombolysis In Myocardial Infarction (TIMI) score combination rule-out strategy suggested within the 2016 National Institute for Health and Care Excellence (NICE) Chest Pain of Recent Onset guidelines and establish the optimal TIMI score threshold for clinical use.

Methods A pooled analysis of adult patients presenting to the emergency department with chest pain and a non-ischaemic ECG, recruited into six prospective studies, from Australia, New Zealand and the UK. We evaluated the sensitivity of TIMI score thresholds from 0 to 2 alongside hs-cTnT or hs-cTnI for the primary outcome of major adverse cardiac events within 30 days.

Results Data were available for 3159 patients for hs-cTnT and 4532 for hs-cTnI, of these 376 (11.9%) and 445 (9.8%) had major adverse cardiac events, respectively. Using a TIMI score of 0, the sensitivity for the primary outcome was 99.5% (95% CI 98.1% to 99.9%) alongside hs-cTnT and 98.9% (97.4% to 99.6%)%) alongside hs-cTnI, identifying 17.9% and 21.0% of patients as low risk, respectively. For a TIMI score ≤1 sensitivity was 98.9% (97.3% to 99.7%)%) alongside hs-cTnT and 98.4% (96.8% to 99.4%)%) alongside hs-cTnI, identifying 28.1% and 35.7% as low risk, respectively. For TIMI≤2, meta-sensitivity was <98% with either assay.

Conclusions Our findings support the rule-out strategy suggested by NICE. The TIMI score threshold suggested for clinical use is 0. The proportion of patients identified as low risk (18%–21%) and suitable for early discharge using this threshold may be sufficient to encourage change of practice.

Trial registration numbers ADAPT observational study/IMPACT intervention trial ACTRN12611001069943.

ADAPT-ADP randomised controlled trial ACTRN12610000766011. EDACS-ADP randomised controlled trial ACTRN12613000745741. TRUST observational study ISRCTN no. 21109279.

  • acute coronary syndrome

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/

https://doi.org/10.1136/heartjnl-2017-311983

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    Footnotes

    • Twitter @eddcarlton

    • Contributors EWC and JWP have had full access to all data in the study and take full responsibility for the integrity of the data and accuracy of data analysis. Study concept and design: EWC, JG, LC, MT, RB, KG, JK, JWP. Acquisition of data: EWC, JG, LC, MT, JWP, WAP, AK, KG. Analysis and interpretation of data, critical revision of manuscript for important intellectual content: all authors. Drafting of manuscript: EWC, JWP. Statistical analysis: EWC, JG, JWP. Obtained funding: EWC, LC, RB, MT, KG. Administrative technical and material support: EWC, JG, JK, JWP, AK. Study supervision: LC, RB, MT, AK, KG.

    • Funding Australia/New Zealand cohorts: Funding for the ADAPT observational study was predominantly provided by the Christchurch Heart Institute and the Queensland Emergency Medicine Research Foundation with a small (20%) contribution from industry (Abbott and Alere). Funding for the EDACS randomised controlled trial was from the Health Research Council of New Zealand (grant 12-249). UK Cohort: The TRUST study was funded by a Royal College of Emergency Medicine research grant and Bournemouth University. Kits for the measurement of hs-cTnT in the Christchurch studies were supplied by Roche free of Charge. Kits for measurement of hs-cTnI in the UK study were supplied by Abbott free of charge.

    • Competing interests RB was funded by a Fellowship from the United Kingdom National Institute for Health Research (NIHR). JWP was funded by the Emergency Care Foundation, Canterbury Medical Research Foundation, and Canterbury District Health Board. EC reports grants from the Royal College of Emergency Medicine, UK and Bournemouth University; grants and personal fees from Abbott Diagnostics. JG reports grants from the Queensland Medical Research Foundation during the conduct of the study. LC reports grants from Roche during the conduct of the study; grants and personal fees from Abbott Diagnostics, personal fees from Alere, and personal fees from Siemens outside the submitted work. MPT reports grants and personal fees from Abbott and Alere, grants from Beckman, and personal fees from Roche outside the submitted work. RB has undertaken research under collaborative agreements with Roche, Siemens Diagnostics, Alere and Randox Laboratories and has accepted travel and accommodation for conferences from Roche Diagnostics and Randox Laboratories. WAP received funding from the Queensland Emergency Medicine Research Foundation, Abbott Diagnostics, Roche, Alere and Beckmann Coulter for research.

    • Patient consent Obtained.

    • Ethics approval Various local ethics committees.

    • Provenance and peer review Not commissioned; externally peer reviewed.

    • Data sharing statement No additional unpublished data from this study are available.

    • Correction notice Since this paper was first published online the author affiliations have been updated.

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