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Diagnostic accuracy of contemporary and high-sensitivity cardiac troponin assays used in serial testing, versus single-sample testing as a comparator, to triage patients suspected of acute non-ST-segment elevation myocardial infarction: a systematic review protocol.

ABSTRACT: INTRODUCTION:Although the new generation of cardiac troponin assays have revolutionised the diagnosis of myocardial infarction (MI), their application in triaging patients with suspected acute coronary syndrome requires further investigation. The objectives of the current systematic review are to evaluate the diagnostic accuracy of contemporary and high-sensitivity cardiac troponin assays used in serial testing, versus single-sample testing as a comparator, to identify patients with non-ST-segment-elevation MI in the emergency department. METHODS AND ANALYSIS:We will conduct systematic searches of MEDLINE, EMBASE, Science Citation Index, the Cochrane Database of Systematic Reviews and the CENTRAL database covering the period from 1 January 2006 to present, with no restrictions on language or publication status. Two review authors will independently screen studies for inclusion, extract data from eligible studies and assess their methodological quality using Quality Assessment of Diagnostic Accuracy Studies version 2. Studies will be included if they evaluate contemporary or high-sensitivity cardiac troponin assays used in serial testing, in patients presenting to the ED with suspicion of MI. Estimates of sensitivity and specificity from each study will be presented in forest plots and in the receiver-operating characteristics space. If appropriate, we will pool the results using Bayesian hierarchical models that allow correction for imperfect reference standard. We will obtain summary estimates of sensitivity and specificity of alternative testing protocols and compare their accuracy. We will also investigate the impact of prespecified sources of heterogeneity and methodological quality items. If pooling of results is considered inappropriate, we will present our findings in tables and diagrams and will describe them narratively. ETHICS AND DISSEMINATION:No formal ethical approval will be sought, but we will report on the ethical approval of the included studies. Dissemination of findings will be through publications in peer-reviewed journals, presentations at conferences and the websites of the universities. PROSPERO REGISTRATION NUMBER:CRD42018106379.

SUBMITTER: Zhelev Z

PROVIDER: S-EPMC6475186 | biostudies-literature | 2019 Mar

REPOSITORIES: biostudies-literature

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Diagnostic accuracy of contemporary and high-sensitivity cardiac troponin assays used in serial testing, versus single-sample testing as a comparator, to triage patients suspected of acute non-ST-segment elevation myocardial infarction: a systematic review protocol.

Zhelev Zhivko Z Ohtake Hirotaka H Iwata Mitsunaga M Terasawa Teruhiko T Rogers Morwenna M Peters Jaime L JL Hyde Chris C

BMJ open 20190330 3

<h4>Introduction</h4>Although the new generation of cardiac troponin assays have revolutionised the diagnosis of myocardial infarction (MI), their application in triaging patients with suspected acute coronary syndrome requires further investigation. The objectives of the current systematic review are to evaluate the diagnostic accuracy of contemporary and high-sensitivity cardiac troponin assays used in serial testing, versus single-sample testing as a comparator, to identify patients with non- ...[more]

PMID: 30928947

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Project description:BACKGROUND:Prior studies suggest that low-risk ST-segment-elevation myocardial infarction (STEMI) patients undergoing primary percutaneous coronary intervention can be considered for early discharge. We describe the implementation of an STEMI risk score to decrease cost while maintaining optimal patient outcomes. METHODS AND RESULTS:We determined the impact of risk-guided STEMI care on healthcare value through the retrospective application of the Zwolle Risk Score to 967 patients receiving primary percutaneous coronary intervention between 2009 and 2011. Of these patients, 540 (56%) were categorized as low risk, indicating they may be safely triaged directly to a telemetry unit rather than the intensive care unit and targeted for early discharge. We subsequently developed and implemented a modified Zwolle Risk Calculator into the electronic medical record to support application of the fast-track protocol for low-risk STEMI patients. Among 549 prospective patients with STEMI, 62% were low risk, and the fast-track protocol was followed in 75% of cases. Prospective results confirmed lower rates of complications (low risk 8.3% versus high risk 38.7%; P<0.001) and in-hospital mortality (low risk 0.4% versus High risk 12.5%; P<0.001) in the low-risk cohort. Low-risk patients had a shorter median length of stay (median and [25th, 75th percentiles]: low risk 2 [2, 3] versus high risk: 3 [2, 6]; P<0.001) and lower overall costs (low risk $6720 [$5280-$9030] versus high risk $11?783 [$7953-$25?359]; P<0.001). Low-risk patients treated on-protocol had shorter median length of stay (on-protocol 2 [1, 2] versus off-protocol 2 [2, 3]; P<0.001) and hospital costs (on-protocol $6090 [$4730, $7356] versus off-protocol $11?783 [$7953, $25?359]; P<0.001) than those treated off-protocol. On-protocol low-risk patients in the prospective cohort also had lower costs and shorter length of stay than low-risk patients in the retrospective cohort (P<0.001 for both). CONCLUSIONS:In our study, risk-guided triage and discharge after primary percutaneous coronary intervention for STEMI improved healthcare value by reducing costs of care without compromising quality of care or patient outcomes.

Project description:BACKGROUND:Symptoms indicating acute coronary syndrome are commonly seen in emergency rooms, but only 10% of patients are actually diagnosed with acute myocardial infarction (AMI). The Guidelines for the diagnosis of patients with suspected AMI include either multiple testing of cardiac troponin (cTN) or a single combined test of cTN and copeptin, which facilitates earlier diagnosis or exclusion of AMI. The aim of the present analysis was to investigate the impact of combined copeptin/cTN testing on health care resource consumption and related costs both during and after initial hospital treatment. METHODS AND RESULTS:The analysis was based on the BIC-8 trial and financial data of participating study sites. A cost analysis was carried out primarily from the hospital perspective and secondarily from the perspective of German statutory health insurers. The underlying assumptions of the investigation were tested for robustness in additional sensitivity analyses. In total, the data of 713 patients (n = 359 combined copeptin/cTN testing, n = 354 serial cTN testing) were evaluated. From a hospital perspective, the combined copeptin/cTN testing showed a reduced number of medical procedures and a lower frequency of inpatient admissions. The average staff time was significantly reduced by a mean of 49 minutes (95% confidence interval (CI) 46 to 53) per patient, accompanied by a significant mean reduction of 131 minutes (95%CI 104 to 158) in the time patients stayed in the emergency room. The initial hospital treatment was less cost-intensive. Over the entire study period, no significant cost differences were observed between the groups for health insurance. CONCLUSION:The combined copeptin/cTN testing has the potential to save costs and staff time in acute care and for the entire hospital stay. The primary explanations for these findings are early identification and ruling out patients without AMI along with the associated reduced need for acute medical treatment. TRIAL REGISTRATION:ClinicalTrials.gov NCT01498731.

Dataset Information

Diagnostic accuracy of contemporary and high-sensitivity cardiac troponin assays used in serial testing, versus single-sample testing as a comparator, to triage patients suspected of acute non-ST-segment elevation myocardial infarction: a systematic review protocol.

Publications

Diagnostic accuracy of contemporary and high-sensitivity cardiac troponin assays used in serial testing, versus single-sample testing as a comparator, to triage patients suspected of acute non-ST-segment elevation myocardial infarction: a systematic review protocol.

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