- The document presents a 1-hour algorithm using high-sensitivity cardiac troponin T (hs-cTnT) to rule-in and rule-out acute myocardial infarction (AMI) in patients with suspected cardiac chest pain. - A pilot study of 436 patients found that the algorithm could definitively rule-in or rule-out AMI within 1 hour for 77% of patients, with a very high negative predictive value of 100% for ruling out AMI in 60% of patients. - A multicenter study of 1282 patients from 9 countries validated the 1-hour hs-cTnT algorithm, finding sensitivity of 99.7% and specificity of 83.0% for ruling-in AMI,

1. Phác Đồ 1 Giờ Chẩn Đoán Và Loại Trừ Nhồi Máu Cơ
Tim Cấp Với Troponin T Siêu Nhạy
The one-hour algorithm to rule-out and rule-in of Acute Myocardial Infarction with
cardiac Troponin T-high sensitive
PGS TS Trần Văn Huy FACC FESC
Phó Chủ Tịch Phân Hội THA VN,
Trưởng Khoa TM BV Tỉnh Khánh Hòa
Giảng Viên Thỉnh Giảng ĐHYD Huế, ĐHTN
Test early.
Treat right.
Save lives.

2. Có gì mới nổi bật trong khuyến cáo về chẩn đoán NMCT cấp
2015? Khuyến Cáo ESC 9/2015 NSTEAMI
Initial assessment of patients with suspected acute coronary syndromes.
ESC GUIDELINES NSTAMI European Heart Journal Advance Access published August 29, 2015

3. Khuyến cáo ESC 2015 về chẩn đoán, phân tầng nguy cơ và vai trò
troponin ở bệnh nhân nghi ngờ hội chứng mạch vành ST không chênh
Recommendations Class Level Ref.c
Diagnosis and risk stratification
It is recommended to base diagnosis and initial short-term ischaemic
and bleeding risk stratification on a combination of clinical history,
symptoms, vital signs, other physical findings, ECG and laboratory
results.
I A 28,109–112
A rapid rule-out and rule-in protocol at 0 h and 1 h is
recommended if a high-sensitivity cardiac troponin test with a
validated 0 h/1 h algorithm is available. Additional testing after
3–6 h is indicated if the first two troponin measurements are not
conclusive and the clinical condition is still suggestive of ACS.
I B 30–34, 36,
39,
51–55
It is recommended to use established risk scores for prognosis
estimation
I B 84,94,106
ESC GUIDELINES NSTAMI European Heart Journal Advance Access published August 29, 2015

4. 0 h/3 h rule-out algorithm of non-ST-elevation acute coronary
syndromes using high-sensitivity cardiac troponin assays
ESC GUIDELINES NSTAMI European Heart Journal Advance Access published August 29, 2015

5. Phác đồ rule-in và rule out 0 h/1 h bằng hs-cTn ở bệnh nhân nghi
ngờ NMCT không ST chênh lên (NSTEMI)
ESC GUIDELINES NSTAMI European Heart Journal Advance Access published August 29, 2015

6. Chứng cứ nào cho phác đồ 0-1h hs cTn?
14 nghiên cứu về phác đồ 0-1h, trong đó hs cTnT 10/14
• APACE (Advantageous Predictors of Acute Coronary Syndrome Evaluation ) 2012
• TRAPID-AMI (High sensitivity cardiac Troponin T assay for RAPID rule-out of
Acute Myocardial Infarction) is a Roche-sponsored clinical trial presented at the
meeting ESC 2014
• APACE : 2015. The “APACE revalidation” study.(Prospective validation of a 1-hour
algorithm to rule-out and rule-in acute myocardial infarction using a high-sensitivity
cardiac troponin T assay)
Reichlin T. et al., CMAJ. 2015, April
• 1-h algorithm for hs-cTnI
Rubini Gimenez M. et al., Am J Med 2015, Mar 31

7. Acute myocardial infarction (AMI)
Time is life
Each year over
7 million people have an AMI
worldwide1
Every 30 minutes of delay between symptoms and
treatment increases the relative risk of 1-year
mortality by 7.5% in patients with AMI2
AMI is a life-threatening
condition
STEMI mortality: ≈ 9 %
(1 year)
NSTEMI mortality: ≈ 11.6 %
(1 year)
This is a race against the clock where every minute
counts
1. White and Chew (2008). Lancet 372:570-584.
2. De Luca et al (2004). Circulation 109:1223-1225.

8. • Serial blood samples at variable time intervals are required for the diagnosis of AMI and to
differentiate acute from chronic cardiac disease1
• 2011 ESC guidelines recommend, in conjunction with full clinical assessment including
12–lead ECG, either a 6-9 hours observation time with conventional cTn tests or 3 hours rule-
out protocol using high sensitivity Troponin1
Time is life
Is a safe AMI diagnosis possible in a shorter time?
1. Hamm et al (2011). Eur Heart J 32:2999–3054. cTn: Cardiac troponin; ECG: Electrocardiogram;
ED: Emergency department;
ESC: European Society of Cardiology
1. 2.
Conventional troponin tests 1
2.
High sensitivity troponin tests1
2.
Possible ?
0 6
3
1
Time since admission (hours)
Reduce time to diagnosis Faster rule-in Faster appropriate therapy
Faster rule-out Reduced ED crowding

9. 0 h ≥52 ng/L or
∆1 h ≥5 ng/L
Rule-in
Others
Observational zone
0 h <12 ng/L and
∆1 h <3 ng/L
Rule-out
cTnT-hs values in patients presenting
to the ED with chest pain
Proposed algorithm
1. Reichlin et al (2012). Arch Intern Med 172:1211-1218.
0 h: Presentation to the ED; ∆1 h: Absolute change of cTnT-hs within the first
hour; AMI: Acute myocardial infarction; cTnT-hs: Cardiac Troponin T high-sensitive;
ED: Emergency department; NPV: Negative predictive value; PPV: Positive predictive
value
Phác đồ 0-1h cTnT chẩn đoán & loại trừ NMCTC
 A pilot study with 436 patients presenting at the ED <12 h from chest pain onset1
 Algorithm based on cTnT-hs baseline value and absolute change within the first hour (∆1 h)1
The APACE study: a 1-hour cTnT-hs algorithm
Advantageous Predictors of Acute Coronary Syndrome Evaluation

10. The APACE study: Algorithm and results
1. Reichlin et al (2012). Arch Intern Med 172:1211-1218.
0 h ≥52 ng/L or
∆1 h ≥5 ng/L
Rule-in
Others
Observational zone
0 h <12 ng/L and
∆1 h <3 ng/L
Rule-out
60% of patients
(n = 259)
Sensitivity: 100%
NPV: 100%
cTnT-hs values in patients presenting
to the ED with chest pain
Proposed algorithm
Results
0 h: Presentation to the ED; ∆1 h: Absolute change of cTnT-hs within the first
hour; AMI: Acute myocardial infarction; cTnT-hs: Cardiac Troponin T high-sensitive;
ED: Emergency department; NPV: Negative predictive value; PPV: Positive predictive
value
• Definitive rule-in or rule-out of a total of 77 % of patients within 1 hour1
• Very high NPV for a safe rule-out of 60 % patients in 1 hour1
17% of patients
(n = 76)
Specificity: 97%
PPV: 84%
23% of patients
(n = 101)
Prevalence of AMI: 8%

11. Low mortality in patients ruled-out for AMI
Survival at 30 days (A) and 24 months (B) according to cTnT-hs algorithm category
Rule-out
(n=491)
Observational
zone (n=212)
Rule-in
(n=169)
100
98
96
94
92
90
0 10 20 30
Time (days)
Survival
(%)
p<0.001
A
99.8%
98.6%
95.3%
100
95
90
85
80
0 6 12 24
Time (months)
Survival
(%)
18
p<0.001
B
98.1%
89.1%
85.4%
APACE 2012 results*
Reichlin T. et al., Arch Int Med 2012;
172(16):1211-8

12. Multicenter evaluation of a 1h-algorithm in the diagnosis of myocardial infarction
using high-sensitivity cardiac Troponin T
Christian Mueller, Evangelos Giannitsis, Michael Christ, Jorge Ordóñez-Llanos, Christopher R. deFilippi, James K. McCord, Richard Body,
Mauro Panteghini, Tomas Jernberg, Mario Plebani, Franck Verschuren, John K. French, Robert H. Christenson, Silvia Weiser, Garnet
Bendig, Peter Dilba, Bertil Lindahl,
for the TRAPID-AMI Investigators
High sensitivity cardiac Troponin T assay for RAPID rule-out of Acute Myocardial Infarction
Sponsored by
Slide presented by Prof. Mueller at the ESC 2014. http://www.medscape.com/viewarticle/830723
Tải bản FULL (28 trang): https://bit.ly/3coHM6U
Dự phòng: fb.com/TaiHo123doc.net

13. Results
95% CI 98.2-99.7% 95% CI 70.4-83.0%
cTnT-hs values in1282 patients with chest pain <6h from 3
continents and 9 countries
Slide presented by Prof. Mueller at the ESC 2014. http://www.medscape.com/viewarticle/830723

14. Results
0.1%
Slide presented by Prof. Mueller at the ESC 2014. http://www.medscape.com/viewarticle/830723
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