Ruling-In Myocardial Injury and Ruling-Out Myocardial Infarction With the European Society of Cardiology 1-Hour Algorithm
2016; Lippincott Williams & Wilkins; Volume: 134; Issue: 20 Linguagem: Inglês
10.1161/circulationaha.116.024687
ISSN1524-4539
AutoresAllan S. Jaffe, Harvey D. White,
Tópico(s)Cardiac electrophysiology and arrhythmias
ResumoHomeCirculationVol. 134, No. 20Ruling-In Myocardial Injury and Ruling-Out Myocardial Infarction With the European Society of Cardiology 1-Hour Algorithm Free AccessEditorialPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessEditorialPDF/EPUBRuling-In Myocardial Injury and Ruling-Out Myocardial Infarction With the European Society of Cardiology 1-Hour Algorithm Allan S. Jaffe, MD and Harvey White, MB, ChB, DSc Allan S. JaffeAllan S. Jaffe From Department of Cardiology and Department of Laboratory Medicine and Pathology, Division of Core Clinical Laboratory Service, Mayo Clinic, Rochester, MN (A.S.J.); and Coronary Care & Green Lane Cardiovascular Research Unit, Auckland City Hospital, Auckland, New Zealand (H.W.). and Harvey WhiteHarvey White From Department of Cardiology and Department of Laboratory Medicine and Pathology, Division of Core Clinical Laboratory Service, Mayo Clinic, Rochester, MN (A.S.J.); and Coronary Care & Green Lane Cardiovascular Research Unit, Auckland City Hospital, Auckland, New Zealand (H.W.). Originally published17 Oct 2016https://doi.org/10.1161/CIRCULATIONAHA.116.024687Circulation. 2016;134:1542–1545Other version(s) of this articleYou are viewing the most recent version of this article. Previous versions: November 15, 2016: Previous Version 1 Article, see p 1532High-sensitivity cardiac troponin (hscTn) assays are used everywhere in the world except in the United States.1 One potential advantage of these assays is their ability to triage patients with possible ischemia more rapidly, and there is an understandable desire to find easy, facile algorithms to do this. This approach was taken with hscTn in the evaluation of patients with possible acute myocardial infarction (AMI) with an algorithm developed by the APACE trial (Advantageous Predictors of Acute Coronary Syndromes Evaluation).2 Intrinsic to it is the concept that ruling-out and ruling-in AMI rapidly (within 1 hour) can be accomplished based on initially low concentrations (<2 ng/L for hscTnI Abbott and <5 ng/L hscTnT Roche) or small changes over the first hour (<2 ng/L hscTnI and <3 ng/L hscTnT) for ruling-out and the use of larger changes (6 ng/L hscTnI and 5 ng/L hscTnT) and fixed cut-off concentrations for ruling-in (see Figure 1 of the article by Pickering et al in this issue of Circulation).3 Unfortunately, validation of this algorithm has often left a good deal to be desired. Nevertheless, it was incorporated into the European Society of Cardiology guidelines.4In this issue of Circulation, Pickering and colleagues3 compare the hscTnI assay from Abbott and the hscTnT assay from Roche in terms of their sensitivity and specificity for ruling-in and ruling-out AMI with this algorithm. The pooled analysis included 5 prospective cohort studies from Australia, New Zealand, and Canada involving 2222 patients (mean 59.7 years of age: 53.5% male) who presented to the emergency department (ED) with chest pain suggestive of acute coronary syndrome. Of these patients, 240 (9.7%) were diagnosed as having an AMI. Troponins were measured at 0 and 90 minutes in 1 study and 0 and 2 hours in the others (ie, no study repeated the troponin measurement at 1 hour, as recommended in the European Society of Cardiology algorithm). The overall time from symptom onset to the first troponin measurement was 5.2 hours. Their retrospective observational evaluation followed the guidelines as written. The authors indicate that hscTnI did not perform as well as hscTnT, and the early rule-out sensitivity was less than ED physicians want to ensure patient safety, which is a 1% event rate of adverse events at 30 days.5 From our perspective, the values calculated by the authors are better than we would suggest the data indicate. To understand the data and their ramifications, readers need to understand the problems associated with the approach, some of which were addressed by the authors and some of which were not.First, in the rule-out arm, low values or small changes are used to exclude AMI. These criteria may fail in patients with AMI who present early after the onset of symptoms before hscTn values can rise, as suggested in other studies.2,6,7 Only 53 patients with AMIs presented in 3 hours after symptom onset. In our opinion, this caveat also applies to the other rule-out criteria. Indeed, the authors of this analysis noted problems with the 1-hour rule-out criteria.3 In addition, when one has a large number of low-risk patients, the denominator is inflated; given the small numbers of early AMIs, the numerator will be low, making the data look better than they are. If one then includes patients who present later after the onset of symptoms and are unlikely to manifest overlap with the rule-out criteria, the numbers are further inflated. What is needed is an analysis of these rule-out strategies with larger numbers of patients with AMI who present early after symptom onset (ie, within the first 2 hours).Second, the reason that hscTnT outperforms hscTnI should be clear. When an approach is predicated on 1 assay extrapolated to another, with the first assay as a gold standard, the second assay is placed at a disadvantage. This is likely the case with this algorithm, which was built around hscTnT. Extrapolation to the hscTnI assay was done after measurement of stored samples years after the initial samples had been run for hscTnT.6,9 Hence, the hscTnI assay seemed extremely insensitive compared with hscTnT.9 Indeed, the cut-off value for hscTnI would need to be halved to match the sensitivity of hscTnT in the comparison reported.9 This result is surprising because the relative sensitivities of the assays based on the number of normal subjects in whom a value is found suggests exactly the opposite (ie, the hscTnI assay is more sensitive).10 Some have even questioned whether hscTnT is a high-sensitivity assay.10 This question raises issues about whether the cut-off values and suggested change criteria are optimal for hscTnI. The extrapolation to the change criteria is a particularly complex issue because the values used in the algorithm for hscTnT appear to be impossible to achieve given the imprecision of the assay,6 so it is hard to believe their extrapolation to hscTnI could have been robust. A recent article with a similar approach confirmed that different cut-off values and change criteria perform better with hscTnI.11Third, the population in the current study, as in other validation studies, was patients in whom the primary goal was assessment of possible AMI. This approach is appropriate for a rule-out AMI strategy but less ideal for a rule-in AMI evaluation. Ruling-in is more complex than ruling-out. Often patients in whom AMI is considered have complex presentations more than simply ischemic symptoms. Thus, patients who are critically ill, in whom such an evaluation may be necessary, and those who are elderly, many of whom present with fatigue and other nonspecific symptoms, are often excluded. Many of these patients with renal failure, in addition to those who are older, will have elevated baseline hscTn values. Their inclusion might increase the cut-off values needed for AMI diagnosis. The lower cut-point of values in the European Society of Cardiology algorithm might not provide adequate triage of this large group of patients. Even with these constraints, the specificity for AMI in the TRAPID-AMI trial (T Assay for Rapid Rule-Out of Acute Myocardial Infarction) was only 77% because often other clinical entities can present with elevated hscTn and even a rising and falling pattern.8 The clinical specificity of an elevated hscTn was high in the current analysis despite the exclusion of patients with ischemic ECG changes. It is not clear whether patients with other reasons for elevated hscTn such as stress cardiomyopathy, pulmonary embolism, or myocarditis were excluded. Given these considerations, "ruling-in myocardial injury" would be a better term than ruling-in AMI and a more accurate way of describing what the algorithm is capable of providing. This term would also avoid confusion with how one should diagnose AMI.From the perspective of calculating the sensitivity and specificity of the approach, we have already indicated concerns about its use in early presenters. For the rest of the population with a median time from symptom onset to presentation of 5.2 hours, we would argue that the relevant calculations should come from the population presenting within 4 hours of symptom onset. Here this approach might add value. Data indicate that a normal troponin level at 6 hours after symptom onset effectively excludes AMI.12 Given that the second samples in this analysis were taken 90 to 120 minutes later than the first samples, those taken after 4 hours would meet the 6-hour criteria. Thus, the new information, and therefore calculation of metrics, should come from the <4-hour group. Accordingly, the remaining patients simply add to the denominator and falsely increase the sensitivity for the rule-out numbers. That is not to say that it is unreasonable to test the entire cohort to be sure that the algorithm works in patients presenting late and those presenting early, but it is less informative in a cohort of patients with a low frequency of AMI.It may be assumed from the European Society of Cardiology algorithm and this study that ruling-out AMI in the ED is sufficient and that follow-up is not needed. When one uses an end point such as 30-day event rates, follow-up may be terribly relevant. In previous studies from Pickering's colleagues, evaluating a different rule-out strategy, outpatient follow-up was robust and perhaps decreased the occurrence of ischemic events in some patients whom the algorithm may have disadvantaged.13 There is no information about follow-up in the present analysis. This critical gap needs to be remedied before a comprehensive algorithm can be developed. If the algorithm depends on excellent follow-up, then knowing that is key so one can modify the approach when that is not possible.No matter how the metrics are calculated, they are less than the miss rate of <1% with which ED physicians are comfortable.3 The numbers can be argued about, but the reality that ED physicians face cannot be debated. Fortunately, there are ways forward. Physicians should never implement a protocol without the superimposition of good clinical judgment, and in high-quality institutions, that is a given. However, that may not always be the case. Thus, the way forward is to mandate a few simple elements that should help:It is clear that the superimposition of either clinical risk stratification14 or the use of a nearly normal ECG15 substantially improves the rule-out approach with the limit of detection. In addition, care is required until additional data have been provided about those who present <2 hours after the onset of symptoms for all the rule-out approaches.The rule-in arm should be renamed the "rule in myocardial injury arm" so there is no ambiguity about the lack of specificity it implies.Additional trials in an all-comer ED population are needed to refine the cut-off values needed for all patients and not just chest pain patients. They will require validation of each assay independently.Patients with the small changes suggested by the algorithm (2ng/L hscTnI and 3 ng/L hscTnT) should be required to undergo additional hscTn testing at 3 hours.A randomized trial where patients are managed according to a 1-hour rule-out algorithm or a standard 3-hour algorithm is needed.Trials need to include scrutiny of follow-up investigations to determine whether good follow-up and testing are essential to the outcomes that were achieved.These suggested modifications will likely allow the metrics that ED physicians feel strongly about to be achieved. If so, widespread successful implementation of these approaches can be achieved, markedly facilitating and improving patient care.DisclosuresDr Jaffe has consulted or presently consults for most of the major diagnostic companies, including those whose assays were used in the study being discussed: Beckman, Alere, Abbott, Siemens, Roche, ET Healthcare, Sphingotec, NeruogeneX, Novartis, and theheart.org.Dr White reports grants from GlaxoSmithKline, Sanofi Aventis, Eli Lilly and Company, National Institutes of Health, AstraZeneca, Omthera Pharmaceuticals, Pfizer New Zealand, Elsai Inc., and DalGen, and grants and consultancy fees from AstraZeneca outside the submitted work.FootnotesCirculation is available at http://circ.ahajournals.org.The opinions in this article are not necessarily those of the editors or of the American Heart Association.Correspondence to: Allan S. Jaffe, MD, Department of Internal Medicine, Department of Cardiovascular Diseases, Mayo Clinic College of Medicine, 200 First St SW, Rochester, MN 55905. E-mail [email protected]References1. Korley FK, Jaffe AS. Preparing the United States for high-sensitivity cardiac troponin assays.J Am Coll Cardiol. 2013; 61:1753–1758. doi: 10.1016/j.jacc.2012.09.069.CrossrefMedlineGoogle Scholar2. Reichlin T, Schindler C, Drexler B, Twerenbold R, Reiter M, Zellweger C, Moehring B, Ziller R, Hoeller R, Rubini Gimenez M, Haaf P, Potocki M, Wildi K, Balmelli C, Freese M, Stelzig C, Freidank H, Osswald S, Mueller C. One-hour rule-out and rule-in of acute myocardial infarction using high-sensitivity cardiac troponin T.Arch Intern Med. 2012; 172:1211–1218. doi: 10.1001/archinternmed.2012.3698.CrossrefMedlineGoogle Scholar3. Pickering JW, Greenslade JH, Cullen L, Flaws D, Parsonage W, Aldous S, George P, Worster A, Kavsak PA., Than M. Assessment of the European Society of Cardiology 0-hour/1-hour algorithm to rule-out and rule-in acute myocardial infarction.Circulation. 2016; 134:1534–1543. doi: 10.1161/CIRCULATIONAHA.116.022677.LinkGoogle Scholar4. Roffi M, Patrono C, Collet JP, Mueller C, Valgimigli M, Andreotti F, Bax JJ, Borger MA, Brotons C, Chew DP, Gencer B, Hasenfuss G, Kjeldsen K, Lancellotti P, Landmesser U, Mehilli J, Mukherjee D, Storey RF, Windecker S, Baumgartner H, Gaemperli O, Achenbach S, Agewall S, Badimon L, Baigent C, Bueno H, Bugiardini R, Carerj S, Casselman F, Cuisset T, Erol Ç, Fitzsimons D, Halle M, Hamm C, Hildick-Smith D, Huber K, Iliodromitis E, James S, Lewis BS, Lip GY, Piepoli MF, Richter D, Rosemann T, Sechtem U, Steg PG, Vrints C, Luis Zamorano J; Management of Acute Coronary Syndromes in Patients Presenting without Persistent ST-Segment Elevation of the European Society of Cardiology. 2015 ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation: Task Force for the Management of Acute Coronary Syndromes in Patients Presenting without Persistent ST-Segment Elevation of the European Society of Cardiology (ESC).Eur Heart J. 2016; 37:267–315.CrossrefMedlineGoogle Scholar5. Than M, Herbert M, Flaws D, Cullen L, Hess E, Hollander JE, Diercks D, Ardagh MW, Kline JA, Munro Z, Jaffe A. What is an acceptable risk of major adverse cardiac event in chest pain patients soon after discharge from the emergency department? A clinical survey.Int J Cardiol. 2013; 166:752–754. doi: 10.1016/j.ijcard.2012.09.171.CrossrefMedlineGoogle Scholar6. Jaffe AS CP, Hamm CW, Lindahl B, Mills NL, Thygesen KA. Sometimes earlier may not be better.Eur Heart J. 2016; in press.MedlineGoogle Scholar7. Roffi M PC, Collet JP, Mueller C, Valgimigli M, Andreotti F, Bax JJ, Borger MA, Brotons C, Chew DP, Gencer B, Hasenfuss G, Kjeldsen K, Lancellotti P, Landmesser U, Mehilli J, Mukherjee D, Storey RF, Windecker S, Baumgartner H, Gaemperli O, Achenbach S, Agewall S, Badimon L, Baigent C, Bueno H, Bugiardini R, Carerj S, Casselman F, Cuisset T, Erol Ç, Fitzsimons D, Halle M, Hamm C, Hildick-Smith D, Huber K, Iliodromitis E, James S, Lewis BS, Lip GY, Piepoli MF, Richter D, Rosemann T, Sechtem U, Steg PG, Vrints C, Luis Zamorano J; Management of Acute Coronary Syndromes in Patients Presenting without Persistent ST-Segment Elevation of the European Society of Cardiology. 2015 ESC guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation.Eur Heart J. 2016; 37:267–315. doi: 10.1093/eurheartj/ehv320.MedlineGoogle Scholar8. Jaffe AS. TRAPID or trapped?Ann Emerg Med. 2016; 68:88–91. doi: 10.1016/j.annemergmed.2016.01.009.CrossrefMedlineGoogle Scholar9. Wildi K, Gimenez MR, Twerenbold R, Reichlin T, Jaeger C, Heinzelmann A, Arnold C, Nelles B, Druey S, Haaf P, Hillinger P, Schaerli N, Kreutzinger P, Tanglay Y, Herrmann T, Moreno Weidmann Z, Krivoshei L, Freese M, Stelzig C, Puelacher C, Rentsch K, Osswald S, Mueller C. Misdiagnosis of myocardial infarction related to limitations of the current regulatory approach to define clinical decision values for cardiac troponin.Circulation. 2015; 131:2032–2040. doi: 10.1161/CIRCULATIONAHA.114.014129.LinkGoogle Scholar10. Sandoval Y, Smith SW, Apple FS. Present and future of cardiac troponin in clinical practice: a paradigm shift to high-sensitivity assays.Am J Med. 2016; 129:354–365. doi: 10.1016/j.amjmed.2015.12.005.CrossrefMedlineGoogle Scholar11. Neumann JT, Sörensen NA, Schwemer T, Ojeda F, Bourry R, Sciacca V, Schaefer S, Waldeyer C, Sinning C, Renné T, Than M, Parsonage W, Wildi K, Makarova N, Schnabel RB, Landmesser U, Mueller C, Cullen L, Greenslade J, Zeller T, Blankenberg S, Karakas M, Westermann D. Diagnosis of myocardial infarction using a high-sensitivity troponin I 1-hour algorithm.JAMA Cardiol. 2016; 1:397–404. doi: 10.1001/jamacardio.2016.0695.CrossrefMedlineGoogle Scholar12. Hamm CW, Ravkilde J, Gerhardt W, Jørgensen P, Peheim E, Ljungdahl L, Goldmann B, Katus HA. The prognostic value of serum troponin T in unstable angina.N Engl J Med. 1992; 327:146–150. doi: 10.1056/NEJM199207163270302.CrossrefMedlineGoogle Scholar13. Than M, Cullen L, Aldous S, Parsonage WA, Reid CM, Greenslade J, Flaws D, Hammett CJ, Beam DM, Ardagh MW, Troughton R, Brown AF, George P, Florkowski CM, Kline JA, Peacock WF, Maisel AS, Lim SH, Lamanna A, Richards AM. 2-Hour accelerated diagnostic protocol to assess patients with chest pain symptoms using contemporary troponins as the only biomarker: the ADAPT trial.J Am Coll Cardiol. 2012; 59:2091–2098. doi: 10.1016/j.jacc.2012.02.035.CrossrefMedlineGoogle Scholar14. Mokhtari A, Borna C, Gilje P, Tydén P, Lindahl B, Nilsson HJ, Khoshnood A, Björk J, Ekelund U. A 1-h combination algorithm allows fast rule-out and rule-in of major adverse cardiac events.J Am Coll Cardiol. 2016; 67:1531–1540. doi: 10.1016/j.jacc.2016.01.059.CrossrefMedlineGoogle Scholar15. Sandoval Y, Smith S, Love SA, Schulz K, Cao J, Apple F. Rapid rule out of myocardial injury using a single high-sensitivity cardiac troponin measurement.J Am Coll Cardiol. 2016; 67:2354–2354.CrossrefGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetailsCited BySandoval Y, Apple F, Mahler S, Body R, Collinson P and Jaffe A (2022) High-Sensitivity Cardiac Troponin and the 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guidelines for the Evaluation and Diagnosis of Acute Chest Pain, Circulation, 146:7, (569-581), Online publication date: 16-Aug-2022. Johannessen T, Vallersnes O, Halvorsen S, Larstorp A, Mdala I and Atar D (2020) Pre-hospital One-Hour Troponin in a Low-Prevalence Population of Acute Coronary Syndrome: OUT-ACS study, Open Heart, 10.1136/openhrt-2020-001296, 7:2, (e001296), Online publication date: 1-Jul-2020. Anand A and Mills N (2019) A look back: diagnosing myocardial infarction in the era of high-sensitivity troponin after the High-STEACS trial, Cardiovascular Research, 10.1093/cvr/cvz274, 115:14, (e158-e160), Online publication date: 1-Dec-2019. Chew D, Lambrakis K, Blyth A, Seshadri A, Edmonds M, Briffa T, Cullen L, Quinn S, Karnon J, Chuang A, Nelson A, Wright D, Horsfall M, Morton E, French J and Papendick C (2019) A Randomized Trial of a 1-Hour Troponin T Protocol in Suspected Acute Coronary Syndromes, Circulation, 140:19, (1543-1556), Online publication date: 5-Nov-2019. Jaffe A and Hayes S (2019) It Will Take More Than Better Diagnostics to Improve the Care of Women With ACS, Journal of the American College of Cardiology, 10.1016/j.jacc.2019.08.1012, 74:16, (2044-2046), Online publication date: 1-Oct-2019. Bang C, Hansen C, Lauridsen K, Frederiksen C, Schmidt M, Jensen T, Hornung N and Løfgren B (2019) Rapid use of high-sensitive cardiac troponin I for ruling-in and ruling-out of acute myocardial infarction (RACING-MI): study protocol, Open Heart, 10.1136/openhrt-2018-000995, 6:1, (e000995), Online publication date: 1-Apr-2019. Anand A, Shah A, Beshiri A, Jaffe A and Mills N (2019) Global Adoption of High-Sensitivity Cardiac Troponins and the Universal Definition of Myocardial Infarction, Clinical Chemistry, 10.1373/clinchem.2018.298059, 65:3, (484-489), Online publication date: 1-Mar-2019. Sandoval Y, Sharain K, Saenger A, Smith S, Apple F and Jaffe A Clinical use of cardiac troponin for acute cardiac care and emerging opportunities in the outpatient setting, Minerva Medica, 10.23736/S0026-4806.18.05874-3, 110:2 Thygesen K, Alpert J, Jaffe A, Chaitman B, Bax J, Morrow D, White H, Thygesen K, Alpert J, Jaffe A, Chaitman B, Bax J, Morrow D, White H, Mickley H, Crea F, Van de Werf F, Bucciarelli-Ducci C, Katus H, Pinto F, Antman E, Hamm C, De Caterina R, Januzzi J, Apple F, Alonso Garcia M, Underwood S, Canty J, Lyon A, Devereaux P, Zamorano J, Lindahl B, Weintraub W, Newby L, Virmani R, Vranckx P, Cutlip D, Gibbons R, Smith S, Atar D, Luepker R, Robertson R, Bonow R, Steg P, O'Gara P, Fox K, Hasdai D, Aboyans V, Achenbach S, Agewall S, Alexander T, Avezum A, Barbato E, Bassand J, Bates E, Bittl J, Breithardt G, Bueno H, Bugiardini R, Cohen M, Dangas G, de Lemos J, Delgado V, Filippatos G, Fry E, Granger C, Halvorsen S, Hlatky M, Ibanez B, James S, Kastrati A, Leclercq C, Mahaffey K, Mehta L, Müller C, Patrono C, Piepoli M, Piñeiro D, Roffi M, Rubboli A, Sharma S, Simpson I, Tendera M, Valgimigli M, van der Wal A, Windecker S, Chettibi M, Hayrapetyan H, Roithinger F, Aliyev F, Sujayeva V, Claeys M, Smajić E, Kala P, Iversen K, El Hefny E, Marandi T, Porela P, Antov S, Gilard M, Blankenberg S, Davlouros P, Gudnason T, Alcalai R, Colivicchi F, Elezi S, Baitova G, Zakke I, Gustiene O, Beissel J, Dingli P, Grosu A, Damman P, Juliebø V, Legutko J, Morais J, Tatu-Chitoiu G, Yakovlev A, Zavatta M, Nedeljkovic M, Radsel P, Sionis A, Jemberg T, Müller C, Abid L, Abaci A, Parkhomenko A and Corbett S (2018) Fourth universal definition of myocardial infarction (2018), European Heart Journal, 10.1093/eurheartj/ehy462, 40:3, (237-269), Online publication date: 14-Jan-2019. Lan N and Bell D (2019) Revisiting the Biological Variability of Cardiac Troponin: Implications for Clinical Practice, Clinical Biochemist Reviews, 10.33176/AACB-19-00032, 40:4, (201-216), . Thygesen K, Alpert J, Jaffe A, Chaitman B, Bax J, Morrow D and White H (2018) Fourth Universal Definition of Myocardial Infarction (2018), Global Heart, 10.1016/j.gheart.2018.08.004, 13:4, (305-338), Online publication date: 1-Dec-2018. Thygesen K, Alpert J, Jaffe A, Chaitman B, Bax J, Morrow D and White H (2018) Fourth Universal Definition of Myocardial Infarction (2018), Circulation, 138:20, (e618-e651), Online publication date: 13-Nov-2018. Thygesen K, Alpert J, Jaffe A, Chaitman B, Bax J, Morrow D and White H (2018) Fourth Universal Definition of Myocardial Infarction (2018), Journal of the American College of Cardiology, 10.1016/j.jacc.2018.08.1038, 72:18, (2231-2264), Online publication date: 1-Oct-2018. Sandoval Y and Jaffe A (2017) Using High-Sensitivity Cardiac Troponin T for Acute Cardiac Care, The American Journal of Medicine, 10.1016/j.amjmed.2017.07.033, 130:12, (1358-1365.e1), Online publication date: 1-Dec-2017. Vasile V and Jaffe A (2017) High-Sensitivity Cardiac Troponin for the Diagnosis of Patients with Acute Coronary Syndromes, Current Cardiology Reports, 10.1007/s11886-017-0904-4, 19:10, Online publication date: 1-Oct-2017. Mokhtari A, Lindahl B, Schiopu A, Yndigegn T, Khoshnood A, Gilje P, Ekelund U and Diercks D (2017) A 0-Hour/1-Hour Protocol for Safe, Early Discharge of Chest Pain Patients, Academic Emergency Medicine, 10.1111/acem.13224, 24:8, (983-992), Online publication date: 1-Aug-2017. Ahmed H and Hazen S (2017) Novel Risk Stratification Assays for Acute Coronary Syndrome, Current Cardiology Reports, 10.1007/s11886-017-0880-8, 19:8, Online publication date: 1-Aug-2017. Kaambwa B, Ratcliffe J, Horsfall M, Astley C, Karnon J, Coates P, Arstall M, Zeitz C, Worthley M, Beltrame J and Chew D (2017) Cost effectiveness of high-sensitivity troponin compared to conventional troponin among patients presenting with undifferentiated chest pain: A trial based analysis, International Journal of Cardiology, 10.1016/j.ijcard.2017.02.141, 238, (144-150), Online publication date: 1-Jul-2017. Crea F, Binder R and Lüscher T (2017) The year in cardiology 2016: acute coronary syndromes, Cardiologia Croatica, 10.15836/ccar2017.200, 12:5-6, (200-215) Irfan A (2017) Letter by Irfan Regarding Article, "Assessment of the European Society of Cardiology 0-Hour/1-Hour Algorithm to Rule-Out and Rule-In Acute Myocardial Infarction", Circulation, 135:16, (e919-e920), Online publication date: 18-Apr-2017. Ferraro S, Dolci A and Panteghini M Fast track protocols using highly sensitive troponin assays for ruling out and ruling in non-ST elevation acute coronary syndrome, Clinical Chemistry and Laboratory Medicine (CCLM), 10.1515/cclm-2017-0044, 55:11 Crea F, Binder R and Lüscher T (2017) The year in cardiology 2016: acute coronary syndromes, European Heart Journal, 10.1093/eurheartj/ehw620, (ehw620) Crea F, Binder R and Luscher T (2017) The year in cardiology 2016: Acute coronary syndromes, Srce i krvni sudovi, 10.5937/siks1701011C, 36:4, (11-20), . November 15, 2016Vol 134, Issue 20 Advertisement Article InformationMetrics © 2016 American Heart Association, Inc.https://doi.org/10.1161/CIRCULATIONAHA.116.024687PMID: 27754880 Originally publishedOctober 17, 2016 KeywordstroponinEditorialsmyocardial infarctionbiomarkerPDF download Advertisement SubjectsBiomarkers
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