Comparison of the Efficacy and Safety of Early Rule-Out Pathways for Acute Myocardial Infarction
Authors' conclusion
Use of the High-STEACS pathway incorporating low high-sensitivity cardiac troponin concentrations rules out myocardial infarction in more patients at presentation and misses 5-fold fewer index myocardial infarctions than guideline-approved pathways based exclusively on the 99th centile.
Study context
- Population
- Patients with suspected ACS, high-sensitivity cardiac troponin I at presentation and 3 and 6 or 12 hours
- Participants
- 1,218 patients
- Comparison
- High-STEACS rule-out pathway vs ESC rule-out pathway
- Outcome
- NPV of both pathways for index type 1 MI or type 1 MI or cardiac death
- Follow-up
- 30 days
Methodological detailsprespecified subgroups
- Prespecified subgroups
Performance
As reported in the abstract
NPV for index type 1 MI or type 1 MI or cardiac death at 30 days
| Test or model | NPV | Ruled out at presentation | Ruled out at 3 hours | Missed events |
|---|---|---|---|---|
| ESC | 97.9% (95% CI 96.9-98.7) | 28.1% (342 of 1218) | 78.9% (961 of 1218) | 18 index and two 30-day events |
| High-STEACS | 99.5% (95% CI 99.0-99.9) | 40.7% (496 of 1218) | 74.2% (904 of 1218) | 2 index and two 30-day events |
NPV
ESC97.9% (95% CI 96.9-98.7)
High-STEACS99.5% (95% CI 99.0-99.9)
Ruled out at presentation
ESC28.1% (342 of 1218)
High-STEACS40.7% (496 of 1218)
Ruled out at 3 hours
ESC78.9% (961 of 1218)
High-STEACS74.2% (904 of 1218)
Missed events
ESC18 index and two 30-day events
High-STEACS2 index and two 30-day events
- High-STEACS vs ESC: P < 0.001
- Primary outcome occurred
- 15.7% (191 of 1218)
Further findings
NPV in prespecified subgroups (age, sex, time of symptom onset, known ischemic heart disease)
- NPV of High-STEACS greater than ESC in all subgroups, including those presenting early or with known ischemic heart disease
Original publication
Comparison of the Efficacy and Safety of Early Rule-Out Pathways for Acute Myocardial Infarction. Circulation. Published 29 December 2016. doi:10.
Summarised from the published abstract; every number is checked against it