Mario Cavazza Medicina d Urgenza e Pronto Soccorso Azienda Ospedaliero Universitaria di Bologna

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Lora Harmon
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2 Mario Cavazza Medicina d Urgenza e Pronto Soccorso Azienda Ospedaliero Universitaria di Bologna

4 In the emergency physicians perspective, the rapid identification of high risk patients and the concomitant rule out of low risk conditions is of pivotal importance.

7 The throutful evaluation necessitates that the physicians keep in mind the myriad of often subtle and atypical presentations of ischemic heart disease, especially in certain patient populations such as the elderly ones. Cervellin G, Rastelli G., Ann Transl Med 2016

8 As such, every EP should keep in mind that a normal or nonspecific ECG finding cannot, per se, be used to rule out cardiac ischemia or MI. Cervellin G, Rastelli G., Ann Transl Med 2016

10 BIOMARKERS SHORT HISTORY Garg P et al. Intern Emerg Med (2017) 12:

11 The analytical characteristics of both ctni and ctnt assays tend to be misrepresented along with how appropriate cutoffs, 99th percentile upper reference limits (URLs), are defined from study to study.

12 Contemporanee Alta sensibilità Ultima generazione CV Percentile

14 SI DOVREBBERO DEFINIRE AD ALTA SENSIBILITÀ QUELLE METODICHE IMMUNOMETRICHE IN GRADO DI MISURARE IL 99 PERCENTILE DI DISTRIBUZIONE DEL BIOMARCATORE TROPO I O T NELLA POPOLAZIONE DI RIFERIMENTO CON UN COEFFICIENTE DI VARIABILITÀ (CV) UGUALE O INFERIORE AL 10%.

15 Fred Apple

16 Galli C, Lippi G. Ann Transl Med 2016;4(13):257

18 Garg P et al. Intern Emerg Med (2017) 12:

22 emergency physician

23 Positive ctn equals MI is erroneous, though still difficult to be erased from many physicians attitude. Galli C, Lippi G, Ann Transl Med 2016;

24 CUT OFF < 6 ng/l VS 99 percentile ( < 26 ng/l) 1 hr algorhythm

28 La danza delle ore

36 2017

We therefore ask the authors whether they believe that such an investigative approach is ready for widespread international uptake without

38 We therefore ask the authors whether they believe that such an investigative approach is ready for widespread international uptake without further external validation using robust recruitment and follow-up processes? W. Frank Peacock, MD Emergency Medicine Royal Brisbane and Women s Hospital

39 Quanta hs-tropo? TANTA We suggest that kinetic changes may not be required in chest pain patients suggestive of AMI and highly abnormal hs-ctnt at presentation.

42 Quanta hs-tropo? POCA emergency physician

43 Livelli undetectable, < sia a LOB che a LOD, possono essere sicuri per rule out un infarto (alto NPV) Un rule out deve avere valori udetectable di VERA hstroponina.

44 PITTFALLS DELL UNDETECTABLE LA STRATEGIA PUO ESSERE APPLICATA SENZA CONSIDERARE L INSORGENZA DEL SINTOMO? QUALE È IL CV A LIVELLI UNDETECTABLE?

48 sens NPV

51 Among unselected patients undergoing hs-ctni measurements on clinical indication, a single hs-ctni concentration < LoD at presentation may facilitate the rule-out of acute myocardial injury, regardless of the etiology or ECG findings, with an excellent NPV and diagnostic sensitivity.

52 2017 A single hs-ctnt concentration below the LOD in combination with a nonischemic ECG may successfully rule out AMI in patients presenting to EDs with possible emergency acute coronary syndrome.

54 When used alone, serial high-sensitivity cardiac troponin testing delivers an NPV ranging from 92% to 100%. Still, the NPV falls to 90% when a single cardiac troponin is measured soon after the onset of symptoms (e.g.3 h) Benjamin M. Scirica and David A. Morrow,Clin Chem 2015

57 We directly compared 4 hs-ctni based rule-out strategies: a- limit of detection (LOD, hs-ctni<2 ng/l), b- single cutoff (hs-ctni<5 ng/l), c- 1-hour algorithm (hs-ctni<5 ng/l and 1-hour change<2 ng/l), d- the 0/1-hour algorithm recommended in the ESC guideline combining LOD and 1-hour algorithm.

58 CONCLUSIONS: All 4 rule-out strategies balance effectiveness and safety equally well. The single cutoff should not be applied in early presenters, whereas the 3 other strategies seem to perform well in this challenging subgroup.

61 West J Emerg Med This review article discusses the Asia-Pacific Evaluation of Chest Pain Trial (ASPECT) score, the Accelerated Diagnostic Protocol for Chest Pain Trial (ADAPT) score, the Emergency Department Assessment of Chest Pain Score (EDACS), the HEARTScore and the HEART pathway.

64 HS-TROPO single determination

65 It might be possible to safely discharge ED chest pain patients with a low modified HEART score after an initial determination of high-sensitive troponin T, without a prolonged observation period or an additional cardiac testing.

67 A single hs-tni measurement on admission combined with a low risk ECG appears to rule out AMI safely without need for serial troponin testing.

68 Outcome in the BACC study.

70 We conclude that the HEART score is an accurate risk-stratification instrument and is safe to use when assessing patients with chest pain in the emergency department. Hesitance to refrain from admission and testing in patients with low scores could explain the small effect on health care costs.

71 Garg P et al. Intern Emerg Med (2017) 12:

73 Most probably, the role of clinical judgment will assume greater importance than with the old generation immunoassays.

74 Gestalt alone cannot be used to rule in or rule out ACS. By combining clinician gestalt with the admission ECG and troponin level, we found 100% sensitivity without the need for serial troponin testing.

75 COSA HA CAMBIATO LA INTRODUZIONE DELLE TROPONINE AD ALTA SENSIBILITA EFFICACIA EFFICIENZA SICUREZZA APPROPRIATEZZA COSTI ECONOMICI COSTI TEMPORALI COSTI LOGISTICI

80 Standard ctn Hs-cTn

81 S T A N D A R D H S - T R O P O

82 Conclusions: We did not observe overdiagnosis and overtreatment issues in presenters with suspected ACS managed by appropriate evaluation changes in hs-ctnt levels, despite the increase in the number of patients presenting with abnormal troponin levels.

83 E CAMBIATO QUALCOSA CON COSA HA CAMBIATO LA INTRODUZIONE DELLE TROPONINE AD ALTA SENSIBILITA EFFICACIA EFFICIENZA SICUREZZA APPROPRIATEZZA COSTI ECONOMICI COSTI TEMPORALI COSTI LOGISTICI

86 A systematic review and meta-analysis of diagnostic strategies for suspect ACS has revealed that hsctn measurement was the most effective strategy, with an incremental cost-effectiveness ratio (ICER) of less than the 20,000 30,000/QALY (qualityadjusted life years) (ICER 7,487 17,191/QALY). This aspect was further investigated by the UK National Institute for Clinical Excellence, reaching rather similar conclusions.

IFCC Task Force on Clinical Applications of Cardiac Biomarkers (TF-CB) Report to the General Conference 2016 Madrid

IFCC Task Force on Clinical Applications of Cardiac Biomarkers (TF-CB) Report to the General Conference 2016 Madrid 1 CREATED By the EB in 2011, following to the Committee on Standardization of Cardiac