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.


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


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

It is recommended to base diagnosis and initial short-term ischaemic


84,94,106

Diagnosis and risk stratification

ESC GUIDELINES NSTAMI European Heart Journal Advance Access published August 29, 2015


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


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


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

treatment increases the relative risk of 1-year
mortality by 7.5% in patients with AMI2

White and Chew (2008). Lancet 372:570-584.
De Luca et al (2004). Circulation 109:1223-1225.


Time is life

Is a safe AMI diagnosis possible in a shorter time?
• 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 ruleout protocol using high sensitivity Troponin1
Conventional troponin tests 1
High sensitivity troponin tests1

0
1.

2.

2.

1.

Faster rule-in
Faster rule-out

Reduce time to diagnosis

0 h
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


Low mortality in patients ruled-out for AMI
APACE 2012 results*
Survival at 30 days (A) and 24 months (B) according to cTnT-hs algorithm category
B

100

99.8%

98
Survival (%)

100

95

96
95.3%

94

Observational


98.1%

98.6%

Survival (%)

A

0

Time (days)

Reichlin T. et al., Arch Int Med 2012;
172(16):1211-8

6

12
Time (months)

18

24


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

To prospectively validate the cTnT-hs 1-h algorithm in the same APACE study (2006-2009), but
recruiting new patients (2009-2013)
Study population
1714 patients with chest pain with onset/peak within 12 h of ED presentation from APACE 6 centres in
3 countries (CH, Italy, Spain)

Final study population: 1320 patients with presentation and 1-hour cTnT-hs values

Reichlin T. et al., CMAJ. 2015,


The “APACE revalidation” study (2015)
Results

Performance of the high-sensitivity cardiac troponin T (cTnT) 1-hour algorithm for rapid diagnosis of acute myocardial
infarction (MI).
CMAJ, May 19, 2015, 187(8)


Kaplan–Meier curves showing cumulative mortality within 30 days (A) and 2
years (B) of follow-up according to the classification into “rule-out” (n = 786),
“observational zone” (n = 318) and “rule-in” (n = 216) as determined by the
high-sensitivity cardiac troponin T 1-hour algorithm

CMAJ, May 19, 2015, 187(8)


Kết Luận Nghiên Cứu “APACE 2015”
• Chiến lược sử dụng những giá trị nền và những thav đổi tuyệt đối
của hs cTnT trong vòng 1 giờ để chẩn đoán những bệnh nhân

Vùng quan sát

Rule in

60% -63.4%
NPV: 99.1-100%

22.2- 24%
Tần suất NMCTC 8-22%

14.4 -17%
PPV: 77.2 -84%

76-78% rule in - rule out NMCTC
NPV: giá trị dự đoán âm., PPV: giá trị dự đoán dương
* Reichlin et al (2012). Arch Intern Med 172:1211-1218; ** Reichlin T. et al., CMAJ. 2015, April, 187 (8)
*** Mueller et al: http://www.medscape.com/viewarticle/830723


Benefit 1: Medical value for patients

Time is Life

 APACE 2012- 2015, TRAPID-AMI cTnT-hs 1 h algorithm is faster than the 3–6 h proposed by 2011
guidelines1
 Every 30 minutes of delay between symptoms and treatment increases the relative risk of 1-year mortality
by 7.5% in patients with AMI2
 Faster time to diagnosis likely to reduce patient’s anxiety
3 h saving time:
Estimated reduction in1 year mortality2 ≈ 45%


Faster appropriate therapy
Reduced ED crowding

2.

6
cTn: Cardiac troponin; ECG: Electrocardiogram;
ED: Emergency department;
ESC: European Society of Cardiology


Benefit 2: Medical value for physicians

Time is Myocardium

Used in conjunction with ECG & other clinical information

 APACE 2012-2015, TRAPID-AMI with cTnT-hs will allow:

 rapid rule-out with safety and peace of mind in decision to discharge patients
 rapid rule-in for faster initiation of the appropriate therapy

«The beauty of the 1 hour algorithm is that we can accelerate our diagnostic procedure»

APACE 2012-15
with
cTnT-hs

1.

ED: Emergency department;
ESC: European Society of Cardiology


Benefit 3: Medical value for healthcare system

Time is Money

 Faster diagnosis with the application of APACE, TRAPID-AMI algorithm will:
 reduce the need for extended observation or repeated testing
 optimize resources saves cost for hospital stay

“This is a critical help in the allocation of resources in the ED”

APACE 2012-15
with
cTnT-hs

1.

0
1.

Conventional troponin test1

High sensitivity troponin test 1

2.

Reduce time to diagnosis

 Patients with chest pain with onset/peak within 12 h of ED presentation from APACE (9 centres in 3 countries) (Switzerland,
Spain, Italy)
 Final study population: 1811 patients with presentation and 1 hour- hs-cTnI-hs values
Methods
• Algorithm: Derivation cohort (n= 906), Validation cohort (n= 905)

Rubini Gimenez M. et al., Am J Med 2015,


1-h algorithm for hs-cTnI (Abbott): Results

Rubini Gimenez et al American J Medicine, Vol 128, No 8, August 2015


0-1h hs TNT : Key messages

Safe and effective AMI rule-in and rule-out in 1 hour
cTnT-hs

99.1-100%NPV

n>3’000

cTnT-hs

APACE
APACE re-validation
TRAPID-AMI

Roche cTnT-hs validates the

More rule-in/out
Only 1 publication with
Abbott’s hs–TnI 1-h algorithm
Results suggest that
performance of is better for
Roche’s cTnT-hs