Multimarker Panel to Rule Out Acute Coronary Syndromes in Low-risk Patients

Alice Mitchell, Joseph Lee Garvey, Jeffrey Kline

Research output: Contribution to journalArticle

19 Citations (Scopus)

Abstract

Objectives: To test novel markers of acute coronary syndrome (ACS), monocyte chemoattractant protein-1 (MCP), myeloperoxidase (MPO), C-reactive protein (CRP), and brain natriuretic peptide (BNP) in low-risk emergency department (ED) patients who were evaluated for ACS in a chest pain unit (CPU). Methods: A convenience sample of 414 patients underwent CPU evaluation, including provocative testing, and were followed prospectively for 45 days for ACS, which was defined as death, myocardial infarction (MI), revascularization, or >60% coronary artery stenosis prompting new medical treatment, adjudicated by three blinded reviewers. Published diagnostic thresholds were used to calculate diagnostic indices for each marker and for the multimarker panel. Results: The prevalence of ACS was 7 in 414 (1.7%; 95% CI = 0.7% to 3.5%). Only MCP demonstrated a negative likelihood ratio [LR(-)] of less than 0.5, with a sensitivity of 85% (95% CI = 42% to 99%), specificity of 72% (95% CI = 67% to 76%), and LR(-) of 0.20 (95% CI = 0.04 to 0.71). For MPO, CRP, and BNP, LR(-) was 0.89 (95% CI = 0.26 to 2.05), 0.79 (95% CI = 0.40 to 1.01), and 0.90 (95% CI = 0.51 to 1.03), respectively. The sensitivity, specificity, and LR(-) of an abnormal multimarker panel were 86% (95% CI = 42% to 100%), 17% (95% CI = 13% to 21%), and 0.84 (95% CI = 0.15 to 3.12), respectively. Conclusions: The prevalence of ACS was very low but was similar to reports from other CPUs. BNP and CRP had high specificities, but had limited sensitivities, whereas MPO had a low specificity. Only MCP had a low LR(-) and should be studied further. The combined multimarker panel had an unexpectedly low sensitivity and specificity, yielding an LR(-) of 0.84, suggesting that the panel would not be an efficient screening test to decrease unnecessary CPU testing.

Original languageEnglish (US)
Pages (from-to)803-806
Number of pages4
JournalAcademic Emergency Medicine
Volume13
Issue number7
DOIs
StatePublished - Jul 2006
Externally publishedYes

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Acute Coronary Syndrome
Chemokine CCL2
Brain Natriuretic Peptide
Chest Pain
C-Reactive Protein
Peroxidase
Sensitivity and Specificity
Myocardial Revascularization
Coronary Stenosis
Hospital Emergency Service
Myocardial Infarction
Therapeutics

Keywords

  • biological markers
  • chest pain
  • coronary artery disease
  • emergency treatment
  • evidence based medicine
  • myocardial ischemia

ASJC Scopus subject areas

  • Emergency Medicine

Cite this

Multimarker Panel to Rule Out Acute Coronary Syndromes in Low-risk Patients. / Mitchell, Alice; Garvey, Joseph Lee; Kline, Jeffrey.

In: Academic Emergency Medicine, Vol. 13, No. 7, 07.2006, p. 803-806.

Research output: Contribution to journalArticle

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title = "Multimarker Panel to Rule Out Acute Coronary Syndromes in Low-risk Patients",
abstract = "Objectives: To test novel markers of acute coronary syndrome (ACS), monocyte chemoattractant protein-1 (MCP), myeloperoxidase (MPO), C-reactive protein (CRP), and brain natriuretic peptide (BNP) in low-risk emergency department (ED) patients who were evaluated for ACS in a chest pain unit (CPU). Methods: A convenience sample of 414 patients underwent CPU evaluation, including provocative testing, and were followed prospectively for 45 days for ACS, which was defined as death, myocardial infarction (MI), revascularization, or >60{\%} coronary artery stenosis prompting new medical treatment, adjudicated by three blinded reviewers. Published diagnostic thresholds were used to calculate diagnostic indices for each marker and for the multimarker panel. Results: The prevalence of ACS was 7 in 414 (1.7{\%}; 95{\%} CI = 0.7{\%} to 3.5{\%}). Only MCP demonstrated a negative likelihood ratio [LR(-)] of less than 0.5, with a sensitivity of 85{\%} (95{\%} CI = 42{\%} to 99{\%}), specificity of 72{\%} (95{\%} CI = 67{\%} to 76{\%}), and LR(-) of 0.20 (95{\%} CI = 0.04 to 0.71). For MPO, CRP, and BNP, LR(-) was 0.89 (95{\%} CI = 0.26 to 2.05), 0.79 (95{\%} CI = 0.40 to 1.01), and 0.90 (95{\%} CI = 0.51 to 1.03), respectively. The sensitivity, specificity, and LR(-) of an abnormal multimarker panel were 86{\%} (95{\%} CI = 42{\%} to 100{\%}), 17{\%} (95{\%} CI = 13{\%} to 21{\%}), and 0.84 (95{\%} CI = 0.15 to 3.12), respectively. Conclusions: The prevalence of ACS was very low but was similar to reports from other CPUs. BNP and CRP had high specificities, but had limited sensitivities, whereas MPO had a low specificity. Only MCP had a low LR(-) and should be studied further. The combined multimarker panel had an unexpectedly low sensitivity and specificity, yielding an LR(-) of 0.84, suggesting that the panel would not be an efficient screening test to decrease unnecessary CPU testing.",
keywords = "biological markers, chest pain, coronary artery disease, emergency treatment, evidence based medicine, myocardial ischemia",
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N2 - Objectives: To test novel markers of acute coronary syndrome (ACS), monocyte chemoattractant protein-1 (MCP), myeloperoxidase (MPO), C-reactive protein (CRP), and brain natriuretic peptide (BNP) in low-risk emergency department (ED) patients who were evaluated for ACS in a chest pain unit (CPU). Methods: A convenience sample of 414 patients underwent CPU evaluation, including provocative testing, and were followed prospectively for 45 days for ACS, which was defined as death, myocardial infarction (MI), revascularization, or >60% coronary artery stenosis prompting new medical treatment, adjudicated by three blinded reviewers. Published diagnostic thresholds were used to calculate diagnostic indices for each marker and for the multimarker panel. Results: The prevalence of ACS was 7 in 414 (1.7%; 95% CI = 0.7% to 3.5%). Only MCP demonstrated a negative likelihood ratio [LR(-)] of less than 0.5, with a sensitivity of 85% (95% CI = 42% to 99%), specificity of 72% (95% CI = 67% to 76%), and LR(-) of 0.20 (95% CI = 0.04 to 0.71). For MPO, CRP, and BNP, LR(-) was 0.89 (95% CI = 0.26 to 2.05), 0.79 (95% CI = 0.40 to 1.01), and 0.90 (95% CI = 0.51 to 1.03), respectively. The sensitivity, specificity, and LR(-) of an abnormal multimarker panel were 86% (95% CI = 42% to 100%), 17% (95% CI = 13% to 21%), and 0.84 (95% CI = 0.15 to 3.12), respectively. Conclusions: The prevalence of ACS was very low but was similar to reports from other CPUs. BNP and CRP had high specificities, but had limited sensitivities, whereas MPO had a low specificity. Only MCP had a low LR(-) and should be studied further. The combined multimarker panel had an unexpectedly low sensitivity and specificity, yielding an LR(-) of 0.84, suggesting that the panel would not be an efficient screening test to decrease unnecessary CPU testing.

AB - Objectives: To test novel markers of acute coronary syndrome (ACS), monocyte chemoattractant protein-1 (MCP), myeloperoxidase (MPO), C-reactive protein (CRP), and brain natriuretic peptide (BNP) in low-risk emergency department (ED) patients who were evaluated for ACS in a chest pain unit (CPU). Methods: A convenience sample of 414 patients underwent CPU evaluation, including provocative testing, and were followed prospectively for 45 days for ACS, which was defined as death, myocardial infarction (MI), revascularization, or >60% coronary artery stenosis prompting new medical treatment, adjudicated by three blinded reviewers. Published diagnostic thresholds were used to calculate diagnostic indices for each marker and for the multimarker panel. Results: The prevalence of ACS was 7 in 414 (1.7%; 95% CI = 0.7% to 3.5%). Only MCP demonstrated a negative likelihood ratio [LR(-)] of less than 0.5, with a sensitivity of 85% (95% CI = 42% to 99%), specificity of 72% (95% CI = 67% to 76%), and LR(-) of 0.20 (95% CI = 0.04 to 0.71). For MPO, CRP, and BNP, LR(-) was 0.89 (95% CI = 0.26 to 2.05), 0.79 (95% CI = 0.40 to 1.01), and 0.90 (95% CI = 0.51 to 1.03), respectively. The sensitivity, specificity, and LR(-) of an abnormal multimarker panel were 86% (95% CI = 42% to 100%), 17% (95% CI = 13% to 21%), and 0.84 (95% CI = 0.15 to 3.12), respectively. Conclusions: The prevalence of ACS was very low but was similar to reports from other CPUs. BNP and CRP had high specificities, but had limited sensitivities, whereas MPO had a low specificity. Only MCP had a low LR(-) and should be studied further. The combined multimarker panel had an unexpectedly low sensitivity and specificity, yielding an LR(-) of 0.84, suggesting that the panel would not be an efficient screening test to decrease unnecessary CPU testing.

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KW - evidence based medicine

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