Background: We report the results of a prospective randomized controlled trial comparing point-of-care testing (POCT) with central laboratory testing (CLT) in a six-bed coronary care unit in a district general hospital. Methods: 263 consecutive admissions with chest pain and suspected acute coronary syndrome were randomized to measurement of cardiac troponin T by POCT or CLT only. Patient management was according to a pre-specified protocol utilizing clinical features, electrocardiographic changes and cardiac biomarkers (creatine kinase and cardiac troponin T) to define management. Outcome measures were diagnostic accuracy compared with CLT as 'gold standard', result turnaround time, mortality and length of stay in all patients and those with a protocol-driven early discharge policy. Results: Diagnostic accuracy and mortality was equivalent in the POCT and CLT arm. Overall there was no difference in length of stay. In the pre-specified early discharge group ( n = 64) there was a significant reduction in median length of non-coronary care unit stay (145.3 h versus 79.5 h) and overall hospital stay (209.3 h versus 149.9 h) in those randomized to POCT. Conclusion: A combination of rapid biochemical diagnosis and structured decisionmaking reduces length of hospital stay.

Serial measurements of creatine kinase (CK) and its MB isoenzyme (CK-MB) and calculation of area under the curve (AUC) or peak value can be used to estimate infarct size. Peak values usually occur 20–24 hours postinfarction but release kinetics are affected by reperfusion (spontaneous or therapeutic). Regular, frequent samples must be obtained following admission, not a convenient approach for busy clinical or nursing staff. In a previous retrospective study1 we demonstrated that an angiographically determined left ventricular ejection fraction (LVEF) < 40 % could be identified by a single cardiac troponin T (cTnT) measurement at the diagnostically efficient time point of 12–24 hours from admission. We performed a larger prospective study and compared the measurement of cTnT and peak CK with early estimation of LVEF by echocardiography. Consecutive admissions to a typical UK district general hospital (DGH) with suspected acute coronary syndromes (ACS) and a final diagnosis of acute myocardial infarction (AMI) had measurement of cTnT and LVEF performed. Myocardial infarction was diagnosed according to World Health Organization criteria2 if two of the following were present: cardiac chest pain; S-T segment elevation of at least 2 mm in chest leads or 1 mm in limb leads or new …

Background: Assessment of the relative diagnostic accuracy of investigation strategies for patients with suspected acute coronary syndromes (ACS). Methods: A prospective observational study followed two groups of patients over a 3-month period in a UK district general hospital. Group one: all admissions with suspected ACS (n = 576); group two: non-cardiac in-patients who were suspected of developing ACS (n = 87). Both were investigated by full clinical history, examination and serial electrocardiographs (ECGs). Conventional World Health Organization (WHO) criteria for myocardial damage were compared with diagnosis based on cardiac troponin T (cTnT). Clinical discharge diagnosis based on conventional WHO criteria was compared with the review diagnosis based on measurement of cTnT. Results: Diagnosis based on WHO criteria missed 58 patients (8·7%) admitted with suspected ACS who had high risk unstable angina. Thirty-three patients (5% of all admissions) who were diagnosed as non-Q wave acute myocardial infarction (AMI) were found to have normal troponin values and to have been incorrectly classified as AMI. Conclusions: Diagnostic strategies based on WHO criteria are inaccurate. The measurement of cTnT in all patients with suspected ACS would have increased the number of those with a diagnosis of AMI by 58 (8·7%), while avoiding inaccurate diagnosis in 33 (5%), therefore producing an absolute increase of 25/663 (3·8%) but a relative increase of 58/138 (42%). In patients with a primary diagnosis of suspected ACS, the overall increase in patients with a diagnosis of AMI will be 55 (9·5%), a relative increase of 55/118 (46·6%) but an absolute increase of 36/576 (6·3%).

Aim To determine whether elective direct current (dc) cardioversion of atrial fibrillation/flutter causes myocardial damage. Methods and results Cardiac troponin T and creatine kinase were estimated 20–28 hours after dc cardioversion in 51 patients who received dc shocks for elective cardioversion of chronic atrial fibrillation/flutter. Although creatine kinase was raised in 44 patients, cardiac troponin T was undetectable in all patients. Conclusion Cardiac damage does not occur as a result of cardioversion.

Aim-To determine whether measurement of serum troponin T concentration after first acute myocardial infarction can be used to identify patients with a left ventricular ejection fraction of < 40%, who have an adverse prognosis.Methods-Troponin T concentration was measured, and coronary and left ventriculography performed in 50 consecutive patients with acute myocardial infarction. Angiographic left ventricular ejection fraction was compared with serum troponin T concentration. Patients with previous myocardial infarction were excluded.Results-There was a strong negative correlation between left ventricular ejection fraction and troponin T concentration. Spearman's rank correlation coefficient (corrected for ties) was -0.72 (95% confidence intervals (CI) -0.55 to -0.83; p < 0.0001). Analysis by receiver operator characteristic curve produced an area under the curve of 0.9773 (95% CI 0.9409 to 1.0136). A troponin T concentration of > 2.8 mu g/l predicted a left ventricular ejection fraction of < 40% with a sensitivity of 100% (CI 84.6 to 100.0) and specificity of 92.9% (CI 76.5 to 99.1). Exclusion of patients who did not receive thrombolytic treatment did not significantly affect the results.Conclusion-Serum troponin T concentration measured 12-48 hours after admission for first myocardial infarction is a reliable, simple, quick, inexpensive, noninvasive method for identifying patients with a left ventricular ejection fraction of < 40% for whom there is a poor prognosis.

Recent studies have confirmed the benefit of cholesterol reduction in the secondary prevention of ischaernic heart disease! and a recent editorial has cogently summarized the reasons why.? The objective of therapy is to reduce total cholesterol values to 5·2 mrnol/L or less. The fibric acid derivative class of lipid lowering agent have been demonstrated to be useful agents for the treatment of hyperlipidaemia! and for regression of atheroma.' They are considered particularly useful when there is hyperlipidaemia associated with increased triglycerides and for their documented effect on increasing the highdensity lipoprotein fraction (HDL) as well as decreasing low-density lipoprotein (LDL).4 Such patients may be routinely monitored by following the total cholesterol. We present a case report of paradoxical reduction in HDL due to fenofibrate and illustrate the importance of lipoproteins in monitoring therapy.