■急性冠脉综合征的诊断和评估合作(CoDE-ACS)是一种经过验证的临床决策支持工具,可在灵活的时间点使用具有或不具有连续心肌肌钙蛋白测量的机器学习来计算心肌梗塞(MI)的概率。CoDE-ACS如何在不同时间点执行串行测量,并与指南推荐的依赖于固定阈值和时间点的诊断路径进行比较是不确定的。
■在5个国家的12个地点招募了可能的MI而没有ST段抬高的患者,并在0、1和2小时进行了连续的高敏心肌肌钙蛋白I浓度测量。确定了CoDE-ACS模型在每个时间点的1型MI的诊断性能,以及与指南推荐的欧洲心脏病学会(ESC)0/1小时相比,先前验证的低概率和高概率评分的有效性。ESC0/2小时,和高STEACS(高敏肌钙蛋白在评估疑似急性冠脉综合征患者中的应用)途径。
■总共,4105名患者(平均年龄,61年[四分位数范围,50-74];32%的女性)被包括在内,其中575人(14%)患有1型MI。在介绍时,CoDE-ACS将56%的患者识别为低概率,阴性预测值和灵敏度分别为99.7%(95%CI,99.5%-99.9%)和99.0%(98.6%-99.2%),排除比ESC0小时和高STEACS(25%和35%)途径更多的患者。结合第二次心脏肌钙蛋白测量,CoDE-ACS将65%或68%的患者识别为1或2小时的低概率。对于99.7%(99.5%-99.9%)的相同阴性预测值;19%或18%的高概率,阳性预测值为64.9%(63.5%-66.4%)和68.8%(67.3%-70.1%);中间概率为16%或14%。相比之下,在连续测量之后,ESC0/1小时,ESC0/2小时,和高STEACS途径鉴定了49%,53%,71%的患者为低风险,阴性预测值为100%(99.9%-100%),100%(99.9%-100%),和99.7%(99.5%-99.8%);和20%,19%,或29%的高风险,阳性预测值为61.5%(60.0%-63.0%),65.8%(64.3%-67.2%),和48.3%(46.8%-49.8%),占31%,28%,或0,需要在急诊科进一步观察,分别。
■无论连续测量心肌肌钙蛋白的时间如何,CoDE-ACS的表现始终一致。将更多患者识别为低概率,其表现与指南推荐的MI途径相当.以概率为指导的护理是否可以改善MI的早期诊断需要前瞻性评估。
■URL:https://www。clinicaltrials.gov;唯一标识符:NCT00470587。
Collaboration for the Diagnosis and Evaluation of Acute Coronary Syndrome (CoDE-ACS) is a validated clinical decision support tool that uses machine learning with or without serial cardiac troponin measurements at a flexible time point to calculate the probability of myocardial infarction (MI). How CoDE-ACS performs at different time points for serial measurement and compares with
guideline-recommended diagnostic pathways that rely on fixed thresholds and time points is uncertain.
Patients with possible MI without ST-segment-elevation were enrolled at 12 sites in 5 countries and underwent serial high-sensitivity cardiac troponin I concentration measurement at 0, 1, and 2 hours. Diagnostic performance of the CoDE-ACS model at each time point was determined for index type 1 MI and the effectiveness of previously validated low- and high-probability scores compared with
guideline-recommended European Society of Cardiology (ESC) 0/1-hour, ESC 0/2-hour, and High-STEACS (High-Sensitivity Troponin in the Evaluation of Patients With Suspected Acute Coronary Syndrome) pathways.
In total, 4105 patients (mean age, 61 years [interquartile range, 50-74]; 32% women) were included, among whom 575 (14%) had type 1 MI. At presentation, CoDE-ACS identified 56% of patients as low probability, with a negative predictive value and sensitivity of 99.7% (95% CI, 99.5%-99.9%) and 99.0% (98.6%-99.2%), ruling out more patients than the ESC 0-hour and High-STEACS (25% and 35%) pathways. Incorporating a second cardiac troponin measurement, CoDE-ACS identified 65% or 68% of patients as low probability at 1 or 2 hours, for an identical negative predictive value of 99.7% (99.5%-99.9%); 19% or 18% as high probability, with a positive predictive value of 64.9% (63.5%-66.4%) and 68.8% (67.3%-70.1%); and 16% or 14% as intermediate probability. In comparison, after serial measurements, the ESC 0/1-hour, ESC 0/2-hour, and High-STEACS pathways identified 49%, 53%, and 71% of patients as low risk, with a negative predictive value of 100% (99.9%-100%), 100% (99.9%-100%), and 99.7% (99.5%-99.8%); and 20%, 19%, or 29% as high risk, with a positive predictive value of 61.5% (60.0%-63.0%), 65.8% (64.3%-67.2%), and 48.3% (46.8%-49.8%), resulting in 31%, 28%, or 0%, who require further observation in the emergency department, respectively.
CoDE-ACS performs consistently irrespective of the timing of serial cardiac troponin measurement, identifying more patients as low probability with comparable performance to
guideline-recommended pathways for MI. Whether care guided by probabilities can improve the early diagnosis of MI requires prospective evaluation.
URL: https://www.clinicaltrials.gov; Unique identifier: NCT00470587.