Rapid exclusion of acute myocardial infarction in patients with undetectable troponin using a high-sensitivity assay

Richard Body, Simon Carley, Garry McDowell, Allan S. Jaffe, Michael France, Kennedy Cruickshank, Christopher Wibberley, Michelle Nuttall, Kevin MacKway-Jones

Research output: Contribution to journalArticlepeer-review

267 Scopus citations


Objectives: This paper sought to evaluate whether high sensitivity troponin (hs-cTnT) can immediately exclude acute myocardial infarction (AMI) at a novel 'rule out' cut-off. Background: Subgroup analysis of recent evidence suggests that undetectable hs-cTnT may exclude AMI at presentation. Methods: In 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. Results: Of 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%). Conclusions: Undetectable 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.

Original languageEnglish (US)
Pages (from-to)1332-1339
Number of pages8
JournalJournal of the American College of Cardiology
Issue number13
StatePublished - Sep 20 2011


  • acute coronary syndromes
  • acute myocardial infarction
  • diagnosis
  • high sensitivity
  • sensitivity and specificity
  • troponins

ASJC Scopus subject areas

  • Cardiology and Cardiovascular Medicine


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