[IL(E)13] High sensitivity cardiac troponin assays: How they are being used across the world for the evaluation of patients with suspected acute coronary syndromes ―Possible implications for Japan
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EDUCATION:
Michael Power High School1961 - 1966
Toronto, Ontario
Senior Matriculation (Grade 13)
University of Toronto1966 - 1968
Pre-Medicine
Toronto, Ontario, Canada
University of Toronto1968 - 1972
Medical School
Medical Doctor
Toronto, Ontario, Canada
Executive MBA Program1988 - 1990
Michigan State University
Business School
Broad Graduate School of Management
East Lansing, Michigan
Masters Business Administration
Member, Beta Gamma Sigma
GRADUATE TRAINING:
Montreal General Hospital1972 - 1973
Montreal, Quebec
Straight Medicine
Research Fellow1974 - 1975
Clinical Science Division
University of Toronto
LICENSURE AND CERTIFICATION:
National Board of Medicine Examinations1972
College of Physicians and Surgeons of Ontario1972 - 1976
1985 - 2013
California State Medical Licensure1973 - present
Michigan State Medical Licensure1975 - present
Diplomate of the American Board of Emergency Medicine1981 - 1991
Recertification - American Board of Emergency Medicine1991 - 2001
2001 - 2011
2011 - 2021
Fellow, American College of Emergency Physician1982 - present
Fellow, American Academy of Emergency Medicine2000 - present
HOSPITAL AND STAFF APPOINTMENTS:
Staff Physician1973 - 1974
Emergency Department
Belleville General Hospital
Belleville, Ontario
Staff Physician1974 - 1975
(East York Medical Emergency Group)
Emergency Department
Toronto East General Hospital
Toronto, Ontario
Senior Staff1975 - present
Division/Department of Emergency Medicine
Henry Ford Hospital
Detroit, Michigan
Associate Head 1981 - 1983
Division of Emergency Medicine
Henry Ford Hospital
Detroit, Michigan
Vice Chairperson1983 - 1988
Department of Emergency Medicine
Henry Ford Hospital
Detroit, Michigan
Associate Staff1989 - 1994
Emergency Medicine 2007 - present
Cottage Hospital
Grosse Pointe Farms, Michigan
Chairperson1988 - 1992
Department of Emergency Medicine
Henry Ford Hospital
Detroit, Michigan
Vice Chairperson1992 - 2006
Department of Emergency Medicine
Henry Ford Hospital
Detroit, Michigan
Past Chairperson 2006 - present
Department of Emergency Medicine
Henry Ford Hospital
Detroit, Michigan
High sensitivity cardiac troponin (hs-cTn) assays (as defined by the International Federation of Clinical Chemists) since 2015 have been recommended by the European Society of Cardiology (ESC) for the rapid (very low baseline value or the use of a 1 hour delta threshold value algorithm) rule-out and rule-in of acute myocardial infarction (AMI) in selected patients (chest pain complaint, symptoms of < 6 hours duration, excluding those receiving dialysis or with recent AMI) presenting to the Emergency Department (ED) with suspicion for AMI. The European based/published rapid assessments for AMI have not yet been assessed in and the results published for a large multicenter study performed in the (ED) in the United States (US) in all patients presenting with symptoms suspicious for an AMI and where troponin ordering is much broader than in Europe.
We have very recently reported the results of a single center US trial (REACTION-US) assessing the use of the ESC recommended hs-cTnT (Roche Diagnostics) rapid 1 hour or less rule-out and rule-in AMI algorithm for all patients presenting with any suspicious symptoms. The rapid rule-out assessment results are very similar (high negative predicted values and sensitivities) but the rule-in assessments are significantly different with lower positive predictive values and specificities for AMI in the US when compared to the hs-cTnT algorithm currently used in Europe.
A large US multicenter study (HIGH U.S.) assessing the use of a hs-cTnI assay (Siemens Diagnostics) as recommended by the ESC published rapid assessment guidelines but enrolling all comers with symptoms suspicious for AMI has been recently completed. The initial results in this patient population with many risk factors for coronary artery disease show similarly very high negative predicted values and sensitivities but lower and inadequate positive predictive values for AMI when using the ESC guidelines for this specific assay.
Given the combination of the European and more limited US data available there is movement in the US to utilize hs-cTn assays for the rapid rule-out of AMI (approximately 50 centers have implemented this approach) and for safe discharge when combined with a risk-stratification tool. This strategy will provide more efficient care and will lower costs for the evaluation for all patients presenting to the ED with any symptoms suspicions for AMI while maintaining a rate of missed AMI of less than one percent of patients. The algorithms for the rapid rule-in of AMI with appropriately high positive predictive values and specificities are most likely going to be determined in individual medical centers.
In Japan the use of hs-cTn assays for the evaluation of all patients with any symptoms suspicious for AMI would be helpful in all grades (urgent, emergency and critical care) of Emergency Medical care. More specifically this strategy would provide accurate rapid rule-out assessments for AMI. Given the experiences in Europe and the US it may not be necessary to validate this approach in a multicenter Japanese study.
We have very recently reported the results of a single center US trial (REACTION-US) assessing the use of the ESC recommended hs-cTnT (Roche Diagnostics) rapid 1 hour or less rule-out and rule-in AMI algorithm for all patients presenting with any suspicious symptoms. The rapid rule-out assessment results are very similar (high negative predicted values and sensitivities) but the rule-in assessments are significantly different with lower positive predictive values and specificities for AMI in the US when compared to the hs-cTnT algorithm currently used in Europe.
A large US multicenter study (HIGH U.S.) assessing the use of a hs-cTnI assay (Siemens Diagnostics) as recommended by the ESC published rapid assessment guidelines but enrolling all comers with symptoms suspicious for AMI has been recently completed. The initial results in this patient population with many risk factors for coronary artery disease show similarly very high negative predicted values and sensitivities but lower and inadequate positive predictive values for AMI when using the ESC guidelines for this specific assay.
Given the combination of the European and more limited US data available there is movement in the US to utilize hs-cTn assays for the rapid rule-out of AMI (approximately 50 centers have implemented this approach) and for safe discharge when combined with a risk-stratification tool. This strategy will provide more efficient care and will lower costs for the evaluation for all patients presenting to the ED with any symptoms suspicions for AMI while maintaining a rate of missed AMI of less than one percent of patients. The algorithms for the rapid rule-in of AMI with appropriately high positive predictive values and specificities are most likely going to be determined in individual medical centers.
In Japan the use of hs-cTn assays for the evaluation of all patients with any symptoms suspicious for AMI would be helpful in all grades (urgent, emergency and critical care) of Emergency Medical care. More specifically this strategy would provide accurate rapid rule-out assessments for AMI. Given the experiences in Europe and the US it may not be necessary to validate this approach in a multicenter Japanese study.