Phác đồ 1 giờ chẩn đoán và loại trừ nhồi máu cơ tim cấp với Troponin T siêu nhạy - Trần Văn Huy
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
• 1-h algorithm for hs-cTnI
Rubini Gimenez M. et al., Am J Med 2015, Mar 31
ive; ED: Emergency department; NPV: Negative predictive value; PPV: Positive predictive value Phác đồ 0-1h cTnT chẩn đoán & loại trừ NMCTC A pilot study with 436 patients presenting at the ED <12 h from chest pain onset1 Algorithm based on cTnT-hs baseline value and absolute change within the first hour (∆1 h)1 The APACE study: a 1-hour cTnT-hs algorithm Advantageous Predictors of Acute Coronary Syndrome Evaluation The APACE study: Algorithm and results 1. Reichlin et al (2012). Arch Intern Med 172:1211-1218. 0 h ≥52 ng/L or ∆1 h ≥5 ng/L Rule-in Others Observational zone 0 h <12 ng/L and ∆1 h <3 ng/L Rule-out 60% of patients (n = 259) Sensitivity: 100% NPV: 100% cTnT-hs values in patients presenting to the ED with chest pain Proposed algorithm Results 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 • Definitive rule-in or rule-out of a total of 77 % of patients within 1 hour1 • Very high NPV for a safe rule-out of 60 % patients in 1 hour1 17% of patients (n = 76) Specificity: 97% PPV: 84% 23% of patients (n = 101) Prevalence of AMI: 8% Low mortality in patients ruled-out for AMI Survival at 30 days (A) and 24 months (B) according to cTnT-hs algorithm category Rule-out (n=491) Observational zone (n=212) Rule-in (n=169) 100 98 96 94 92 90 0 10 20 30 Time (days) Su rvi val (% ) p<0.001 A 99.8% 98.6% 95.3% 100 95 90 85 80 0 6 12 24 Time (months) Su rvi val (% ) 18 p<0.001 B 98.1% 89.1% 85.4% APACE 2012 results* Reichlin T. et al., Arch Int Med 2012; 172(16):1211-8 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 Bendig, Peter Dilba, Bertil Lindahl, for the TRAPID-AMI Investigators High sensitivity cardiac Troponin T assay for RAPID rule-out of Acute Myocardial Infarction Sponsored by Slide presented by Prof. Mueller at the ESC 2014. Results 95% CI 98.2-99.7% 95% CI 70.4-83.0% cTnT-hs values in1282 patients with chest pain <6h from 3 continents and 9 countries Slide presented by Prof. Mueller at the ESC 2014. Results 0.1% Slide presented by Prof. Mueller at the ESC 2014. The “APACE revalidation” study 2015: Safe and effective AMI rule-in and rule- out in 1 hour. Reichlin T. et al., CMAJ. 2015, April Aim 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, April, 187 (8) 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 nghi ngờ NMCT đã cho thấy an toàn loại trừ cũng như chẩn đoán chính xác NMCT cấp 3 trong 4 bệnh nhân. • Tỷ lệ tử vong 30 ngày ở bệnh nhân loại trừ là 0% trong phác đồ hs cTnT 1 giờ , Reichlin T. et al., CMAJ. 2015, April, 187 (8) Tóm lược chứng cứ phác đồ hs cTnT chẩn đoán nhanh NMCT cấp Giá trị cTnT-hs 0-1h trong đau ngực cấp tại phòng cấp cứu APACE-2012*, APACE -2015** TRAPI-AMI 2014*** 60% -63.4% NPV: 99.1-100% 22.2- 24% Tần suất NMCTC 8-22% 14.4 -17% PPV: 77.2 -84% 0 h <12 ng/L và ∆1 h <3 ng/L Rule out Khác Vùng quan sát 0 h ≥52 ng/L hoặc ∆1 h ≥5 ng/L Rule in Giá trị phác đồ 1h cTnT-hs ở 3038 bênh nhân 76-78% rule in - rule out NMCTC * Reichlin et al (2012). Arch Intern Med 172:1211-1218; ** Reichlin T. et al., CMAJ. 2015, April, 187 (8) *** Mueller et al: NPV: giá trị dự đoán âm., PPV: giá trị dự đoán dương Benefit 1: Medical value for patients Time is Life 1. Hamm et al (2011). Eur Heart J 32:2999–3054. 2. De Luca et al (2004). Circulation 109:1223-1225. cTn: Cardiac troponin; ECG: Electrocardiogram; ED: Emergency department; ESC: European Society of Cardiology 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 Reduce time to diagnosis Faster rule-in Faster appropriate therapy Faster rule-out Reduced ED crowding 1. 2. Conventional troponin test1 2. High sensitivity troponin test1 2. APACE 2012-2015 0 6 3 1 Time since admission (hours) with cTnT-hs 3 h saving time: Estimated reduction in1 year mortality2 ≈ 45% Benefit 2: Medical value for physicians Time is Myocardium 1. Hamm et al (2011). Eur Heart J 32:2999–3054. cTn: Cardiac troponin; ECG: Electrocardiogram; ED: Emergency department; ESC: European Society of Cardiology 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» Reduce time to diagnosis Faster rule-in Faster appropriate therapy Faster rule-out Reduced ED crowding 1. 2. Conventional troponin test1 2. High sensitivity troponin test1 2. APACE 2012-15 0 6 3 1 Time since admission (hours) with cTnT-hs Benefit 3: Medical value for healthcare system Time is Money 1. Hamm et al (2011). Eur Heart J 32:2999–3054. cTn: Cardiac troponin; ECG: Electrocardiogram; ED: Emergency department; ESC: European Society of Cardiology 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” Reduce time to diagnosis Faster rule-in Faster appropriate therapy Faster rule-out Reduced ED crowding 1. 2. Conventional troponin test1 2. High sensitivity troponin test1 2. 0 6 3 1 Time since admission (hours) with cTnT-hs APACE 2012-15 Còn vai trò của hs cTnI như thế nào trong phác đồ 1h ? 1-h algorithm for hs-cTnI (Abbott) One-hour rule-in and rule-out of acute myocardial infarction using high-sensitivity cardiac troponin I Aim: • To derive a 1h-algorithm for early rule-out and rule-in of AMI in APACE similar to cTnT-hs using hs-cTnI from Abbott. Study population 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 Only 1 publication with Abbott’s hs–TnI 1-h algorithm Results suggest that performance of is better for Roche’s cTnT-hs Algorithm safety confirmed by 30d-mortality of the patients rule-out (0.1%) and high NPV (>99.1-100%) cTnT-hs 1-h performs well for early AMI rule-out and rule-in and reduces diagnosis time to 1h in 76-78% of acute chest pain patients Three studies use Roche’s cTnT-hs 1-hour algorithm (n>3’000) and Roche cTnT-hs Roche cTnT-hs validates the use of hs-cTn with a recommended delta change 0-1h hs TNT : Key messages Safe and effective AMI rule-in and rule-out in 1 hour cTnT-hs APACE APACE re-validation TRAPID-AMI n>3’000 99.1-100%NPV 30 day mortality More patients More rule-in/out 1h cTnT-hs cTnT-hs diagnosed in 1 hour 76-78% How to use the PoC cTnT with cTnT-hs in full confidence Test all pre-hospital patients with chest pain using Point of Care Troponin T GP’s office Emergency Room with lab test turn around time>1 hour Use POC Troponin T ≥50 <50 ≥50 <50 POC cTnT ≥50 ng/L PreHAP1 LAB cTnT-hs 1-h algo: APACE I2, II3, TRAPID-AMI4 Final diagnose Early triage and initial diagnose Pre-hospital Hospital Coronary Intensive Care Unit or Cath Lab Slide 27 See slide notes for ref Rule out: Other reason for chest pain <12 and <3 ng/L ≥52 Or ≥5 ng/L Rule-out/Rule-in using cTnT-hs and 1 h algorithm APACE 2015 Phác đồ rule in-rule out 0-1h với hs cTnT (Elecsys) NSTAMI theo khuyến cáo ESC 2015 5 12 3 52 5 hs cTnT Re-test hs cTnT: 3h 76-78% rule in- rule out Test early. Treat right. Save lives. Thank you
File đính kèm:
- phac_do_1_gio_chan_doan_va_loai_tru_nhoi_mau_co_tim_cap_voi.pdf