• Richard Body, Simon Carley, Garry McDowell, Allan S Jaffe, Michael France, Kennedy Cruickshank, Christopher Wibberley, Michelle Nuttall, and Kevin Mackway-Jones.
• University of Manchester, Manchester, United Kingdom. richard.body@manchester.ac.uk
• J. Am. Coll. Cardiol. 2011 Sep 20;58(13):1332-9.

ObjectivesThis paper sought to evaluate whether high sensitivity troponin (hs-cTnT) can immediately exclude acute myocardial infarction (AMI) at a novel 'rule out' cut-off.BackgroundSubgroup analysis of recent evidence suggests that undetectable hs-cTnT may exclude AMI at presentation.MethodsIn a cohort study, we prospectively enrolled patients with chest pain, evaluating them with standard troponin T and testing for hs-cTnT (Roche Diagnostics, Basel, Switzerland) at presentation. The primary outcome was a diagnosis of AMI. We also followed up patients for adverse events within 6 months. After subsequent clinical implementation of hs-cTnT, we again evaluated whether initially undetectable hs-cTnT ruled out a subsequent rise.ResultsOf 703 patients in the cohort study, 130 (18.5%) had AMI, none of whom initially had undetectable hs-cTnT (sensitivity: 100.0%, 95% confidence interval [CI]: 95.1% to 100.0%, negative predictive value: 100.0%, 95% CI: 98.1% to 100.0%). This strategy would rule out AMI in 27.7% of patients, 2 (1.0%) of whom died or had AMI within 6 months (1 periprocedural AMI, 1 noncardiac death). We evaluated this approach in an additional 915 patients in clinical practice. Only 1 patient (0.6%) with initially undetectable hs-cTnT had subsequent elevation (to 17 ng/l), giving a sensitivity of 99.8% (95% CI: 99.1% to 100.0%) and a negative predictive value of 99.4% (95% CI: 96.6% to 100.0%).ConclusionsUndetectable hs-cTnT at presentation has very high negative predictive value, which may be considered to rule out AMI, identifying patients at low risk of adverse events. Pending further validation, this strategy may reduce the need for serial testing and empirical treatment, enabling earlier reassurance for patients and fewer unnecessary evaluations and hospital admissions.Copyright © 2011 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

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