A FABP-ulous 'rule out' strategy? Heart fatty acid binding protein and troponin for rapid exclusion of acute myocardial infarction

Objective: Many Emergency Departments (EDs) utilise 'triple marker' testing with CK-MB, myoglobin and troponin I (cTnI) to exclude acute myocardial infarction (AM!) within hours of presentation. We evaluated the ability of 8 biomarkers to rapidly exclude AMI at the point of presentation and investigated whether 'triple marker' testing represents the optimal multimarker strategy. Methods: We recruited patients who presented to the ED with suspected cardiac chest pain occurring within 24 h. Blood was drawn at the time of presentation. Diagnostic value was assessed by calculating the area under the ROC curve (AUC) and a multivariate model was constructed by logistic regression. The primary outcome was a diagnosis of AM!, established by >= 12-h troponin testing in all patients. Results: 705 included patients underwent venepuncture a median of 3.5 h after symptom onset. Heart fatty acid binding protein (H-FABP) had an AUC of 0.86(95% Cl 0.82-0.90), which was significantly higher than any other biomarker including cTnl. While no single biomarker could enable exclusion of AM!, multivariate analysis identified cTnl and H-FABP as the optimal biomarker combination. Combined with clinical risk stratification, this strategy had a sensitivity of 96.9%, specificity of 54.7%, PPV 32.4% and NPV 98.8%. Conclusions: We have derived an algorithm that would enable AMI to be immediately excluded in 315 (44.7%) patients at the cost of missing 6 AMIs per 1000 patients treated. While the risk is likely to be unacceptable for clinical implementation, we have highlighted an area for future development using serial testing and increasingly sensitive assays. (C) 2011 Elsevier Ireland Ltd. All rights reserved.