Evaluation of a Novel Rule-Out Myocardial Infarction Protocol Incorporating High-Sensitivity Troponin T in a US Hospital
2018; Lippincott Williams & Wilkins; Volume: 138; Issue: 18 Linguagem: Inglês
10.1161/circulationaha.118.033861
ISSN1524-4539
AutoresRebecca Vigen, Patricia Kutscher, Fernabelle Fernandez, Amy Yu, Bryan Bertulfo, Ibrahim A. Hashim, Kyle Molberg, Deborah B. Diercks, Jeffery C. Metzger, José Constancio Ruiz Soto, Dergham Alzubaidy, Lorie Thibodeaux, José A. Joglar, James A. de Lemos, Sandeep R. Das,
Tópico(s)Coronary Interventions and Diagnostics
ResumoHomeCirculationVol. 138, No. 18Evaluation of a Novel Rule-Out Myocardial Infarction Protocol Incorporating High-Sensitivity Troponin T in a US Hospital Free AccessLetterPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessLetterPDF/EPUBEvaluation of a Novel Rule-Out Myocardial Infarction Protocol Incorporating High-Sensitivity Troponin T in a US Hospital Rebecca Vigen, MD, MSCS, Patricia Kutscher, MT, ASCP, Fernabelle Fernandez, MLS, ASCP, Amy Yu, MLS, ASCP, Bryan Bertulfo, MLS, ASCP, Ibrahim A. Hashim, MSc, PhD, Kyle Molberg, MD, Deborah B. Diercks, MD, MPH, Jeffery C. Metzger, MD, MBA, Jose Soto, MD, Dergham Alzubaidy, MD, Lorie Thibodeaux, MHA, Jose A. Joglar, MD, James A. de Lemos, MD and Sandeep R. Das, MD, MPH Rebecca VigenRebecca Vigen Rebecca Vigen, MD, MSCS, 5323 Harry Hines Blvd, Dallas, TX 75390–8830. Email E-mail Address: [email protected] Department of Internal Medicine, Division of Cardiology (R.V., J.A.J., J.A.d.L., S.R.D), University of Texas Southwestern Medical Center, Dallas. , Patricia KutscherPatricia Kutscher Rapid Response Lab (P.K., F.F., A.Y., B.B.), Parkland Health and Hospital System, Dallas, TX. , Fernabelle FernandezFernabelle Fernandez Rapid Response Lab (P.K., F.F., A.Y., B.B.), Parkland Health and Hospital System, Dallas, TX. , Amy YuAmy Yu Rapid Response Lab (P.K., F.F., A.Y., B.B.), Parkland Health and Hospital System, Dallas, TX. , Bryan BertulfoBryan Bertulfo Rapid Response Lab (P.K., F.F., A.Y., B.B.), Parkland Health and Hospital System, Dallas, TX. , Ibrahim A. HashimIbrahim A. Hashim Department of Pathology (I.A.H., K.M.), University of Texas Southwestern Medical Center, Dallas. , Kyle MolbergKyle Molberg Department of Pathology (I.A.H., K.M.), University of Texas Southwestern Medical Center, Dallas. , Deborah B. DiercksDeborah B. Diercks Department of Emergency Medicine (D.B.D., J.C.M.), University of Texas Southwestern Medical Center, Dallas. , Jeffery C. MetzgerJeffery C. Metzger Department of Emergency Medicine (D.B.D., J.C.M.), University of Texas Southwestern Medical Center, Dallas. , Jose SotoJose Soto Department of Internal Medicine, Division of Hospitalist Medicine (J.S., D.A.), University of Texas Southwestern Medical Center, Dallas. , Dergham AlzubaidyDergham Alzubaidy Department of Internal Medicine, Division of Hospitalist Medicine (J.S., D.A.), University of Texas Southwestern Medical Center, Dallas. , Lorie ThibodeauxLorie Thibodeaux Performance Improvement Department, Quality Safety Division (L.T.), Parkland Health and Hospital System, Dallas, TX. , Jose A. JoglarJose A. Joglar Department of Internal Medicine, Division of Cardiology (R.V., J.A.J., J.A.d.L., S.R.D), University of Texas Southwestern Medical Center, Dallas. , James A. de LemosJames A. de Lemos Department of Internal Medicine, Division of Cardiology (R.V., J.A.J., J.A.d.L., S.R.D), University of Texas Southwestern Medical Center, Dallas. and Sandeep R. DasSandeep R. Das Department of Internal Medicine, Division of Cardiology (R.V., J.A.J., J.A.d.L., S.R.D), University of Texas Southwestern Medical Center, Dallas. Parkland Center for Healthcare Innovation and Clinical Outcomes (S.R.D.), Parkland Health and Hospital System, Dallas, TX. Originally published6 Aug 2018https://doi.org/10.1161/CIRCULATIONAHA.118.033861Circulation. 2018;138:2061–2063Other version(s) of this articleYou are viewing the most recent version of this article. Previous versions: August 6, 2018: Ahead of Print The US Food and Drug Administration recently approved a high-sensitivity (hs) troponin T (cTnT) assay that has greater sensitivity and precision than the conventional fourth-generation cTnT assay currently in use in the United States.1 Using this assay, European Society of Cardiology (ESC) guidelines endorse a 0/1-hour "rule-out" of myocardial infarction (MI) in low-risk individuals,2 as well as a more traditional 3-hour algorithm.3 However, the safety and effectiveness of rapid MI rule-out algorithms using hs-cTnT in US practice have not been established.A multidisciplinary team at Parkland Health and Hospital System developed a novel hs-cTnT protocol modified from published data.2–4 An important difference from previous protocols was the addition of a 3-hour hs-cTnT measurement for patients classified into the indeterminate zone at 1 hour (Figure [A]). An observational study of unselected patients undergoing MI rule-out was performed to evaluate the safety of the protocol and its potential impact on patient disposition. The proportion of patients who would have been eligible for early rule-out with the new protocol incorporating hs-cTnT was compared with existing practice in which the conventional fourth-generation cTnT assay was tested at baseline and ≥3 hours after presentation. The negative predictive value was calculated to assess safety. Both cTnT and hs-cTnT were measured at 0, 1, and 3 hours after presentation to the Parkland Health and Hospital System emergency department in 536 patients with symptoms warranting MI rule-out (60% chest pain, 16% shortness of breath, 24% other complaints), but no ST elevations on ECG, between August and October of 2017. Individuals were classified into 2 mutually exclusive categories, "ruled out" or "abnormal," based on hs-cTnT levels and change values (Figure [A]). Individuals were classified as ruled out with the conventional assay if cTnT was <0.01 ng/mL at all time points and abnormal if any value was ≥ 0.01 ng/mL. The final diagnosis was adjudicated by 3 cardiologists based on all available clinical information, including the conventional cTnT assay, using the Third Universal Definition of MI. A second adjudication was performed as a sensitivity analysis using the hs-cTnT assay instead of the conventional assay.2,5 Finally, we compared our new hs-cTnT algorithm with the 0/1 hour ESC algorithm.3 The University of Texas Southwestern institutional review board approved this quality improvement study with a waiver of informed consent.Download figureDownload PowerPointFigure. High-sensitivity (hs) troponin T(cTnT) algorithm and comparisons with conventional cTnT algorithm and European Society of Cardiology (ESC) 0/1 algorithm.A, Parkland Hospital/UT Southwestern protocol for rapid myocardial infarction rule-out using the hs-cTnT assay. B, Proportions of patients ruled out for acute myocardial infarction based on the conventional cTnT algorithm and new hs-cTnT algorithm. C, Comparison of ESC 0/1 algorithm and new hs-cTnT algorithm. NPV indicates negative predictive value; and PPV, positive predictive value.In this cohort (N=536, mean age 55 years, 44% women), the final adjudicated diagnosis was MI in 2.1%, unstable angina in 0.4%, and nonischemic myocardial injury in 17.0%. With the conventional assay, 80.4% of patients ruled out for MI at 3 hours. With the new hs-cTnT protocol, 83.8% ruled out by 3 hours, including 30.0% at baseline, 24.8% at 1 hour, and 28.9% at 3 hours. Compared with 19.6% of patients considered abnormal by the conventional assay, 16.2% of patients were abnormal under the new protocol (P=0.03; McNemar's test; Figure [B]). The new protocol had a sensitivity and negative predictive value of 100%, specificity of 86%, and positive predictive value of 13% for a final adjudicated diagnosis of MI. After readjudication using hs-cTnT as the gold standard, operating characteristics were identical except for a slightly lower positive predictive value of 12%. Of the patients who ruled out, no recurrent MI events were detected over 30 days of follow-up. When compared with the ESC 0/1 hour algorithm, a higher proportion ruled out with our new algorithm (83.8 versus 55.4%, P<0.0001), resulting from movement of 152/154 patients assigned to observation status with the ESC 0/1 hour algorithm to the rule-out group with the new protocol (Figure [C]).In summary, a new protocol for rapid rule-out of MI using the hs-cTnT assay, applied to a contemporary US emergency department population, ruled out more patients than the existing protocol using the conventional assay, and did so sooner, with more than half of all patients ruled out by 1 hour after presentation. This protocol also appropriately ruled out a much higher proportion than the ESC 0/1 hour algorithm. This early rule-out protocol appears safe, with a sensitivity and negative predictive value of 100%. The positive predictive value of an abnormal hs-cTnT value was notably lower in this population than in prior studies,1 reflecting similar specificity applied to a population with much lower MI prevalence. Thus, clinical judgment remains essential in the interpretation of abnormal troponin values as the hs-cTnT assay becomes adopted in the United States, where troponin is measured more indiscriminately than in many other countries. A subtle but important distinction of our protocol from the ESC 0/1 protocol is the classification of individuals as "abnormal" rather than "rule-in." We recommend a similar approach in other centers with an anticipated low MI prevalence among those undergoing troponin measurement. This study is limited by its small size and lack of external validation; thus, future studies are needed to externally validate this novel algorithm and determine its resource implications.Sources of FundingDr Vigen was supported by the National Center for Advancing Translational Sciences of the National Institutes of Health under award UL1TR001105. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.DisclosuresDr Diercks reports consulting income from Roche Diagnostics, and consulting income and research support from Siemens Diagnostics. Dr de Lemos reports grant support from Roche Diagnostics and Abbott Diagnostics and consulting income from Roche Diagnostics, Abbott Diagnostics, Ortho Clinical Diagnostics, and Endpoint Committees for Radiometer and Siemen's Health Care Diagnostics. Dr Das reports consulting income from Roche Diagnostics. The other authors report no conflicts.Footnoteshttps://www.ahajournals.org/journal/circData sharing: The data and study materials will not be made available to other researchers.Guest Editor for this article was Evangelos Giannitsis, MD.Rebecca Vigen, MD, MSCS, 5323 Harry Hines Blvd, Dallas, TX 75390–8830. Email Rebecca.[email protected]eduReferences1. Reichlin T, Hochholzer W, Bassetti S, Steuer S, Stelzig C, Hartwiger S, Biedert S, Schaub N, Buerge C, Potocki M, Noveanu M, Breidthardt T, Twerenbold R, Winkler K, Bingisser R, Mueller C. Early diagnosis of myocardial infarction with sensitive cardiac troponin assays.N Engl J Med. 2009; 361:858–867. doi: 10.1056/NEJMoa0900428CrossrefMedlineGoogle 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.2012.3698CrossrefMedlineGoogle Scholar3. 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; ESC Scientific Document Group. 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. doi: 10.1093/eurheartj/ehv320CrossrefMedlineGoogle Scholar4. McRae AD, Innes G, Graham M, Lang E, Andruchow JE, Ji Y, Vatanpour S, Abedin T, Yang H, Southern DA, Wang D, Seiden-Long I, DeKoning L, Kavsak P. Undetectable concentrations of a Food and Drug Administration-approved high-sensitivity cardiac troponin t assay to rule out acute myocardial infarction at emergency department arrival.Acad Emerg Med. 2017; 24:1267–1277. doi: 10.1111/acem.13229CrossrefMedlineGoogle Scholar5. Reichlin T, Twerenbold R, Wildi K, Rubini Gimenez M, Bergsma N, Haaf P, Druey S, Puelacher C, Moehring B, Freese M, Stelzig C, Krivoshei L, Hillinger P, Jäger C, Herrmann T, Kreutzinger P, Radosavac M, Weidmann ZM, Pershyna K, Honegger U, Wagener M, Vuillomenet T, Campodarve I, Bingisser R, Miró Ò, Rentsch K, Bassetti S, Osswald S, Mueller C. Prospective validation of a 1-hour algorithm to rule-out and rule-in acute myocardial infarction using a high-sensitivity cardiac troponin T assay.CMAJ. 2015; 187:E243–E252. doi: 10.1503/cmaj.141349CrossrefMedlineGoogle 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.Sandoval Y, Lewis B, Mehta R, Ola O, Knott J, De Michieli L, Akula A, Lobo R, Yang E, Gharacholou S, Dworak M, Crockford E, Rastas N, Grube E, Karturi S, Wohlrab S, Hodge D, Tak T, Cagin C, Gulati R and Jaffe A (2022) Rapid Exclusion of Acute Myocardial Injury and Infarction With a Single High-Sensitivity Cardiac Troponin T in the Emergency Department: A Multicenter United States Evaluation, Circulation, 145:23, (1708-1719), Online publication date: 7-Jun-2022. Chiang C, Chiang C and Ruangsomboon O (2022) Utilizing the European Society of Cardiology 0/3-h algorithm to triage the 0/1-h algorithm observe-zone, European Heart Journal. Acute Cardiovascular Care, 10.1093/ehjacc/zuac025 Thibodeau J, Pham D, Kelly S, Ayers C, Garg S, Grodin J and Drazner M (2022) Subclinical Myocardial Injury and the Phenotype of Clinical Congestion in Patients With Heart Failure and Reduced Left Ventricular Ejection Fraction, Journal of Cardiac Failure, 10.1016/j.cardfail.2021.09.002, 28:3, (422-430), Online publication date: 1-Mar-2022. Harrington J and Felker G (2022) Leveraging Multiple Biomarkers to Assess Risk of Acute Heart Failure: Is More Better?, Journal of Cardiac Failure, 10.1016/j.cardfail.2021.11.015, 28:2, (234-236), Online publication date: 1-Feb-2022. Sarıyer G and Ataman M (2020) The likelihood of requiring a diagnostic test: Classifying emergency department patients with logistic regression, Health Information Management Journal, 10.1177/1833358320908975, 51:1, (13-22), Online publication date: 1-Jan-2022. Kong N, Chua R, Besser S, Heelan L, Nathan S, Spiegel T, van Wijk X and Tabit C (2021) A retrospective analysis of high sensitivity cardiac troponin-T ranges in non-myocardial infarction emergency department visits, BMC Cardiovascular Disorders, 10.1186/s12872-021-02089-0, 21:1, Online publication date: 1-Dec-2021. Sariyer G and Ataman M (2021) How machine learning facilitates decision making in emergency departments: Modelling diagnostic test orders, International Journal of Clinical Practice, 10.1111/ijcp.14980, 75:12, Online publication date: 1-Dec-2021. Kontos M and Villines T (2020) Observations from stress testing in the troponin twilight zone, Journal of Nuclear Cardiology, 10.1007/s12350-020-02147-8, 28:6, (2949-2951), Online publication date: 1-Dec-2021. Reynard C, Prager G, Oliver G, Jafar A, Naquib M, Body R and Carley S (2021) Journal update monthly top five, Emergency Medicine Journal, 10.1136/emermed-2021-212053, 38:11, (858-859), Online publication date: 1-Nov-2021. Lopez-Ayala P, Nestelberger T, Boeddinghaus J, Koechlin L, Ratmann P, Strebel I, Gehrke J, Meier S, Walter J, Rubini Gimenez M, Mutschler E, Miró Ò, López-Barbeito B, Martín-Sánchez F, Rodríguez-Adrada E, Keller D, Newby L, Twerenbold R, Giannitsis E, Lindahl B, Mueller C, Zimmermann T, Schoepfer H, Coscia T, Troester V, Reichlin T, Kaeslin M, Christ M, Meier M, Badertscher P, Puelacher C, du Fay de Lavallaz J, Potlukova E, Kawecki D, Geigy N, Rentsch K, Shrestha S, Morawiec B, Munzk P, Breidthardt T, Freese M, Martinez-Nadal G, Fuenzalida C, Calderón S, Rodriguez Adrada E, Ganovská E, Parenica J, von Eckardstein A, Campodarve I, Gea J, Mccord J, Nowak R, Body R, deFilippi C, Christenson R, Panteghini M, Plebani M, Verschuren F, French J, Weiser S and Jernberg T (2021) Novel Criteria for the Observe-Zone of the ESC 0/1h-hs-cTnT Algorithm, Circulation, 144:10, (773-787), Online publication date: 7-Sep-2021. Ganguli I, Cui J, Thakore N, Orav E, Januzzi J, Baugh C, Sequist T and Wasfy J (2021) Downstream Cascades of Care Following High-Sensitivity Troponin Test Implementation, Journal of the American College of Cardiology, 10.1016/j.jacc.2021.04.049, 77:25, (3171-3179), Online publication date: 1-Jun-2021. Westwood M, Ramaekers B, Grimm S, Worthy G, Fayter D, Armstrong N, Buksnys T, Ross J, Joore M and Kleijnen J (2021) High-sensitivity troponin assays for early rule-out of acute myocardial infarction in people with acute chest pain: a systematic review and economic evaluation, Health Technology Assessment, 10.3310/hta25330, 25:33, (1-276) Allen B, Christenson R, Cohen S, Nowak R, Wilkerson R, Mumma B, Madsen T, McCord J, Huis in't Veld M, Massoomi M, Stopyra J, Montero C, Weaver M, Yang K and Mahler S (2021) Diagnostic Performance of High-Sensitivity Cardiac Troponin T Strategies and Clinical Variables in a Multisite US Cohort, Circulation, 143:17, (1659-1672), Online publication date: 27-Apr-2021. Furmaga J, McDonald S, Hall H, Muthukumar A, Willett K, Basit M and Diercks D (2020) Impact of High‐sensitivity Troponin Testing on Operational Characteristics of an Urban Emergency Department, Academic Emergency Medicine, 10.1111/acem.13956, 28:1, (114-116), Online publication date: 1-Jan-2021. Mumma B, Casey S, Dang R, Polen M, Kaur J, Rodrigo J, Tancredi D, Narverud R, Amsterdam E and Tran N (2020) Diagnostic Reclassification by a High-Sensitivity Cardiac Troponin Assay, Annals of Emergency Medicine, 10.1016/j.annemergmed.2020.06.047, 76:5, (566-579), Online publication date: 1-Nov-2020. Mungai E, Hamilton B and Burns D (2020) Comparison of High-Sensitivity Troponin T Assay to Conventional Troponin T Assay for Rule Out of Acute Coronary Syndrome in the Emergency Department, Advanced Emergency Nursing Journal, 10.1097/TME.0000000000000324, 42:4, (304-314), Online publication date: 1-Oct-2020. Wu A, Kavsak P, Aakre K, Christenson R, Greene D, Apple F, Peacock W, Hollander J, de Lemos J, Morrow D, Januzzi J and Jaffe A (2020) Lot-to-Lot Variation for Commercial High-Sensitivity Cardiac Troponin: Can We Realistically Report Down to the Assay's Limit of Detection?, Clinical Chemistry, 10.1093/clinchem/hvaa160, 66:9, (1146-1149), Online publication date: 1-Sep-2020. Sandoval Y, Apple F, Saenger A, Collinson P, Wu A and Jaffe A (2020) 99th Percentile Upper-Reference Limit of Cardiac Troponin and the Diagnosis of Acute Myocardial Infarction, Clinical Chemistry, 10.1093/clinchem/hvaa158, 66:9, (1167-1180), Online publication date: 1-Sep-2020. Forman D, de Lemos J, Shaw L, Reuben D, Lyubarova R, Peterson E, Spertus J, Zieman S, Salive M and Rich M (2020) Cardiovascular Biomarkers and Imaging in Older Adults, Journal of the American College of Cardiology, 10.1016/j.jacc.2020.07.055, 76:13, (1577-1594), Online publication date: 1-Sep-2020. Chiang C, Chiang C, Lee G, Gi W, Wu Y, Huang S, Yeo Y, Giannitsis E and Lee C (2020) Safety and efficacy of the European Society of Cardiology 0/1-hour algorithm for diagnosis of myocardial infarction: systematic review and meta-analysis, Heart, 10.1136/heartjnl-2019-316343, 106:13, (985-991), Online publication date: 1-Jul-2020. Nowak R, Christenson R, Jacobsen G, McCord J, Apple F, Singer A, Limkakeng A, Peacock W and deFilippi C (2020) Performance of Novel High-Sensitivity Cardiac Troponin I Assays for 0/1-Hour and 0/2- to 3-Hour Evaluations for Acute Myocardial Infarction: Results From the HIGH-US Study, Annals of Emergency Medicine, 10.1016/j.annemergmed.2019.12.008, 76:1, (1-13), Online publication date: 1-Jul-2020. Kontos M and Turlington J (2020) High-Sensitivity Troponins in Cardiovascular Disease, Current Cardiology Reports, 10.1007/s11886-020-01279-0, 22:5, Online publication date: 1-May-2020. Vigen R, Diercks D, Hashim I, Pandey A, Zhong L, Kutscher P, Fernandez F, Yu A, Bertulfo B, Molberg K, Metzger J, Soto J, Alzubaidy D, Thibodeaux L, Joglar J, Das S and de Lemos J (2020) Association of a Novel Protocol for Rapid Exclusion of Myocardial Infarction With Resource Use in a US Safety Net Hospital, JAMA Network Open, 10.1001/jamanetworkopen.2020.3359, 3:4, (e203359) Gore M and de Lemos J (2020) Clinical Relevance of the 99th Percentile Upper Reference Limit for High-Sensitivity Cardiac Troponin Assays, Clinical Chemistry, 10.1093/clinchem/hvz038, 66:3, (403-405), Online publication date: 1-Mar-2020. Agusala V, Khera R, Cheeran D, Mody P, Reddy P and Link M (2019) Diagnostic and prognostic utility of cardiac troponin in post-cardiac arrest care, Resuscitation, 10.1016/j.resuscitation.2019.06.004, 141, (69-72), Online publication date: 1-Aug-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 McCord J, Newby L and deFilippi C (2019) Response by McCord et al to Letter Regarding Article, "Designing a Better Mousetrap: Reflections on the November 28, 2017, US Food and Drug Administration Meeting on Next-Generation "High-Sensitivity" Cardiac Troponin Assays to Diagnose Myocardial Infarction", Circulation, 139:4, (564-565), Online publication date: 22-Jan-2019. October 30, 2018Vol 138, Issue 18 Advertisement Article InformationMetrics © 2018 American Heart Association, Inc.https://doi.org/10.1161/CIRCULATIONAHA.118.033861PMID: 30372140 Originally publishedAugust 6, 2018 Keywordstroponinspecificitysensitivitymyocardial infarctionPDF download Advertisement SubjectsBiomarkersMyocardial InfarctionQuality and Outcomes
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