Abstract
The recently published analysis of Aldous et al. 1 contributes important information for the interpretation of high-sensitivity troponin (hs-cTn) assays in patients with acute chest pain presenting to the emergency department (ED). A new finding of their analysis is that the introduction of the ‘delta change criterion’ of hs-cTn levels for the diagnosis of acute myocardial infarction (MI) increases specificity at the cost of sensitivity. These results clearly indicate that diagnostic reasoning cannot be reduced on mere mathematical calculations of time-dependent changes of biomarker levels as currently discussed.
Although mathematical calculations and models are important tools in evaluating new biomarkers, diagnostic reasoning in emergency medicine is a complex process including the combination of intuitive and analytical components. 2 Therefore, the correct working hypothesis and deduced therapeutic management strategies can only be made using all available information, including clinical signs and symptoms of the patient, results of 12-lead electrocardiogram and levels and dynamics of cTn concentrations to calculate post-test probabilities. Because physician-based subjective calculation of post-test probabilities for an individual patient is prone to errors, 3 diagnostic reasoning in patients with acute coronary syndrome should include formal risk assessment using validated risk assessment tools such as GRACE, TIMI or PURSUIT risk scores. 4 Moreover, the aim of disposition decisions in the ED is not to identify patients with acute MI or risk of death alone, but to identify patients at increased risk for adverse outcome, who may benefit from hospitalization and/or tailored treatment strategies.
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