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Effectiveness of practices for improving the diagnostic accuracy of Non ST Elevation Myocardial Infarction in the Emergency Department: A Laboratory Medicine Best Practices™ systematic review.

Publication ,  Journal Article
Layfield, C; Rose, J; Alford, A; Snyder, SR; Apple, FS; Chowdhury, FM; Kontos, MC; Newby, LK; Storrow, AB; Tanasijevic, M; Leibach, E ...
Published in: Clin Biochem
March 2015

OBJECTIVES: This article is a systematic review of the effectiveness of four practices (assay selection, decision point cardiac troponin (cTn) threshold selection, serial testing, and point of care testing) for improving the diagnostic accuracy Non-ST-Segment Elevation Myocardial Infarction (NSTEMI) in the Emergency Department. DESIGN AND METHODS: The CDC-funded Laboratory Medicine Best Practices (LMBP) Initiative systematic review method for quality improvement practices was used. RESULTS: The current ACC/AHA guidelines recommend using cardiac troponin assays with a 99th percentile upper reference limit (URL) diagnostic threshold to diagnose NSTEMI. The evidence in this systematic review indicates that contemporary sensitive cTn assays meet the assay profile requirements (sensitivity, specificity, PPV, and NPV) to more accurately diagnose NSTEMI than alternate tests. Additional biomarkers did not increase diagnostic effectiveness of cTn assays. Sensitivity, specificity, and NPV were consistently high and low PPV improved with serial sampling. Evidence for use of point of care cTn testing was insufficient to make recommendation, though some evidence suggests that use may result in reduction to patient length of stay and costs. CONCLUSIONS: Based on the review of and the LMBP(TM) A-6 Method criteria, we recommend the use of cardiac troponin assays without additional biomarkers using the 99th percentile URL as the clinical diagnostic threshold for the diagnosis of NSTEMI. We recommend serial sampling with one sample at presentation and at least one additional second sample taken at least 6h later to identify a rise or fall in the troponin level. No recommendation is made either for or against the use of point of care tests. DISCLAIMER: The findings and conclusions in this article are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention/the Agency for Toxic Substances and Disease Registry (CDC/ATSDR).

Duke Scholars

Published In

Clin Biochem

DOI

EISSN

1873-2933

Publication Date

March 2015

Volume

48

Issue

4-5

Start / End Page

204 / 212

Location

United States

Related Subject Headings

  • Troponin T
  • Troponin I
  • Troponin
  • Practice Guidelines as Topic
  • Myocardial Infarction
  • Humans
  • General Clinical Medicine
  • Emergency Service, Hospital
  • Biomarkers
  • 3205 Medical biochemistry and metabolomics
 

Citation

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MLA
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Layfield, C., Rose, J., Alford, A., Snyder, S. R., Apple, F. S., Chowdhury, F. M., … Christenson, R. H. (2015). Effectiveness of practices for improving the diagnostic accuracy of Non ST Elevation Myocardial Infarction in the Emergency Department: A Laboratory Medicine Best Practices™ systematic review. Clin Biochem, 48(4–5), 204–212. https://doi.org/10.1016/j.clinbiochem.2015.01.014
Layfield, Christopher, John Rose, Aaron Alford, Susan R. Snyder, Fred S. Apple, Farah M. Chowdhury, Michael C. Kontos, et al. “Effectiveness of practices for improving the diagnostic accuracy of Non ST Elevation Myocardial Infarction in the Emergency Department: A Laboratory Medicine Best Practices™ systematic review.Clin Biochem 48, no. 4–5 (March 2015): 204–12. https://doi.org/10.1016/j.clinbiochem.2015.01.014.
Layfield, Christopher, et al. “Effectiveness of practices for improving the diagnostic accuracy of Non ST Elevation Myocardial Infarction in the Emergency Department: A Laboratory Medicine Best Practices™ systematic review.Clin Biochem, vol. 48, no. 4–5, Mar. 2015, pp. 204–12. Pubmed, doi:10.1016/j.clinbiochem.2015.01.014.
Layfield C, Rose J, Alford A, Snyder SR, Apple FS, Chowdhury FM, Kontos MC, Newby LK, Storrow AB, Tanasijevic M, Leibach E, Liebow EB, Christenson RH. Effectiveness of practices for improving the diagnostic accuracy of Non ST Elevation Myocardial Infarction in the Emergency Department: A Laboratory Medicine Best Practices™ systematic review. Clin Biochem. 2015 Mar;48(4–5):204–212.
Journal cover image

Published In

Clin Biochem

DOI

EISSN

1873-2933

Publication Date

March 2015

Volume

48

Issue

4-5

Start / End Page

204 / 212

Location

United States

Related Subject Headings

  • Troponin T
  • Troponin I
  • Troponin
  • Practice Guidelines as Topic
  • Myocardial Infarction
  • Humans
  • General Clinical Medicine
  • Emergency Service, Hospital
  • Biomarkers
  • 3205 Medical biochemistry and metabolomics