High Sensitivity

Troponins
Considerations for implementing
ED protocols
Stephen W. Smith, MD
Professor of Emergency
Medicine
Hennepin County Medical Center
University of Minnesota School
of Medicine
Accelerated Diagnostic
Protocols (ADP)
• Combine clinical rule with:
• Troponin
• Negative ECG
• Predict risk of 30-day Major
Adverse Cardiac Events (MACE)
• Many clinical rules
• EDACS
• HEART
ED Assessment of Chest
Pain Score (EDACS)
EDACS continued

Negative ADP
• Negative risk score
– HEART < 4 (≤ 3)
– ADAPT (TIMI) ≤ 0, 1
– EDACS < 16 (≤ 15)
• No New ECG changes
 – ST-segment depression of at
least 0.05 mV in 2 or more
contiguous leads (including
reciprocal changes)
– T-wave​ inversion of at least 0.1
mV
– Q waves greater than 30 ms in
width and 0.1 mV or greater in
depth in at least 2 contiguous
leads
• 2 troponins < 99​th​ %-ile
EDACS
Included all patients with
ischemic sx’s, not just CP
External validation: Flaws et al. EM Journal.
https://emj.bmj.com/content/33/9/618

• Score ≤ 15
• Non-ischemic ECG
• 2 contemporary (4​th​ gen) trops
< 99% (0.030 ng/mL)
– NOT Level of Detection (LoD)
• 30-day MACE < 1%
• Derived and Validated.
• Externally validated:
– N=763, 42% low risk, Sens 100%

Accelerated Diagnostic
Protocols (ADP)
Low risk in combo with 2 serial
contemporary trops < 99%
Won’t discuss TIMI score (ADAPT)
• HEART = 3 (≤ 4)
• More widely used and
validated, however:
• “H” very dependent on
expertise of clinician
• Less face validity
• Ischemic ECG = 2 points!
• Trop > 99% = 2 points!
• Age 46 risk = age 64 risk
• EDACS < 16 (≤ 15)
• Adjusted for pleuritic and
reproducible pain
• 5 year increments
• Does not include ECG or trop
– If either are (+), patient no
longer low risk
• Risk factors only count for
those of age < 40
 Shared Decision Making
Using HEART score
High Sensitivity
Troponins
• Are they revolutionary?
• Or incremental? ​–​correct
answer
• Do not diagnose more MI
– Diagnose them earlier
• Do not have more false
positives
– Still use 99​th​ %-ile reference
Essentials to hs troponin
assay
• Level of detection (LoD)
 – lowest value that can be measured with
reliability*
– “minimal amount that can be consistently
detected”
• 99​th​ %-ile reference (99% of “normals”
are ​<​ this level)
– Normals variously defined
– Usually: No DM, no HTN, no chronic
disease, no Sxs
• Coefficient of variation (CV):
imprecision
– Level at which CV < 10%; this is a reliable
level
– The 99% reference level should have CV
≤ 10%
– ≤ 20% is “acceptable”
• Different laboratories have different
limits
• Definition of hs: ​> 50% of normals
(< 99​th​ %-ile) have a measurable
value with good CV
 Troponin
Sensitive biomarker for myocardial
injury
• Elevated in many disease states
– Up to 85% of true positive troponins
not​ ACS
– Acute myocardial injury, chronic
myocardial injury, Type 2 MI
• In HCMC population, of all
patients with TnI measured:
– 30.2% have at least one value >
99​th​%-ile
– 4.7% type 1 MI
– 8.5% type 2 MI
– 17% myocardial injury (acute or
chronic)
– 15% of positives are type 1 MI
• MI: Levels rise and fall
– both type I and II
• Non-MI acute myocardial injury
also has rise and/or fall
• Chronic myocardial injury:
relatively steady state (e.g., HF,
renal failure)
• Elevated troponin of any etiology
(ACS or not)
– Associated with higher mortality
• Chronically elevated troponins
– Predict increased mortality risk over
time
– Not necessarily an indication to be in
ED or be admitted

HIGH STEACS
randomized trial
Lancet 9/15/18; 392(10151):919-928
• No improved outcomes in hs
trop group
• Social media uses this to bash
hs troponin
• Very complex analysis
• Bottom line:
• hs troponin ​does​ improve
early​ diagnosis of rule out of
acute MI.
• It does not decrease specificity
High Sensitivity
Troponins
• Roche hs cTnT is available now in the U.S.
• Abbott hs cTnI is still not FDA approved
• Siemens hs-cTnI approved
– No ED clinical studies published
• Many others on the way -- 10 assays in
existence now
• Which one to use?
– Not just based on performance
– Platform is crucial
• e.g., Abbott “Architect”

• E.g., Roche “Cobas”

Considerations when evaluating

hs trop study
• Rule out MI (Diagnostic
Sensitivity)
• “Prognostic sensitivity” usually
30-day death or MI
• Does it rule out Unstable
Angina? No
• 30-day MACE, includes
intervention
• NPV vs. Sensitivity
 – 1000 patients, 200 w/MI, 10
missed
– 95% sensitivity results in 99%
NPV
• Size of study (n), % and
number of MI
• % ruled out by the protocol
• Risk tolerance: 1%? 2%?
• Raw sensitivity/NPV or lower
limit of 95% CI?
• Rule-in MI
• Intermediate zones
• If low risk (no admit), what
further testing?
• None of these are randomized
trials! (observational only)
 High Sensitivity Troponin
Assays Strategies
when used alone, they do not rule out ACS or
30-day MACE
• Use of undetectable initial trop
(below LoD)
• Use of single hscTn < some defined
cutoff
– E.g., HighSTEACS Abbott hscTnI cutoff
of <5 (</= 4) ng/L
• Accelerated serial hs-cTn (e.g.: 0h
and 1, 2, 3h)
– Rules in or out AMI, or intermediate
zone
– Uses Initial plus delta
• hs-cTn in combination with a risk
score
– (i.e., accelerated diagnostic protocols
[ADPs])
 – Predicts 30 day major adverse cardiac
events (MACE)
– Using single hsTn less than LoD or less
than specified cutoff
– Using 0/1,2,3 hour hs Tn at various
cutoffs
NPV vs. sensitivity
Example: 10% pretest prob, 97.0%
sensitivity, 60% ruled out
• 2000 patients with CP
• 200 have Type 1 MI
(NonSTEMI)
• 1200 ruled out by
protocol
• Sensitivity of 97%: 194
MI detected, 6 missed
MI
• 1194/1200 (-)
protocols are true
negatives for an NPV
of 99.5%
• Of 2000 CP patients,
you missed only 6 MI:
– NPV in CP patients
of 1994/2000 =
99.7%
• In other words, it will
take you 333 CP
patients to miss one
MI.
• It will take 200
negative protocols to
miss 1 MI (NPV =
99.5%)
• It will take 33 MI
patients to miss 1 MI
(sens = 97%)
 Rule out strategies:
Primarily in pts with an initial trop <
​ ​ %-ile
99​th​
97% sens, 60% rule out, 10% MI rate
1​st​ trop > 99​th ​%-ile in 70% of NSTEMI
with 85% specificity.
• 2000 patients, 200 MI
• 60 MI: 1​st​ trop < 99​th ​%; 140 MI with
initial trop > 99​th ​%
• 300/1800 with no-MI have 1​st​ trop >
99​th ​%;
– many will be ruled out by (-) delta
• 440 initial trop > 99​th​ %
• 1560 initial trop < 99​th​ %
 – (finding the 60 MI out of 1560 is
the challenge)
• 6 MI missed by protocol (sens =
97% of 200)
• 6/60 tough MI missed of ~1560
difficult cases
– gives NPV of 99.6%
• 54/60 are detected by protocol
• Most of those 54 have 2​nd​ trop
above 99​th​ %-ile
• Very few are distinguished by the
low cutoffs and low deltas

Single Roche Trop T < LoD or

specified threshold
Roche hs-cTnT is FDA approved
Ann Int Med 2017;166:715-24
• Meta-analysis 9241 patients
• hsTnT < 5 ng/mL
• 30.6% (2825) qualified as low risk
• 14/1077 MI missed
• NPV = 99.5% (99.1-99.7)
• Diagnostic sensitivity = 98.7
(96.6-99.5)
• Prognostic sensitivity = 97.9
(93.7-99.3)
Single Abbott hs cTnI <
LoD or < 5 ng/L
JAMA 2017; 318:1913-24
• Meta-analysis of 22,457 patients
• < LoD (1.9 ng/L)
– Sensitivity and NPV = 100% for MI,
but only 13% meet this
• Our HCMC UTropIA study was too

late for inclusion:

• Our Sensitivity was 98.8%
• For hsTnI < 5 ng/mL, NPV for MI =
99.5%
– 30-day Prognostic sensitivity 97.8%
(97.2-98.3)
• Missed 60/2786 MI, no deaths
• Unknown ACS or intervention within 30
days
– 11,012 (49%) patients qualify
• Chest pain duration < 2 hours:
slightly lower sensitivity

Single Abbott Trop I < LoD or

specified threshold
for acute MI
UTropIA ​–​ HCMC data
• 1631 patients, 170 with MI
(T1MI or T2MI)
• hscTnI < LoD; 1.9 ng/L
– (n = 440, ​27% -- ​2 missed)
 – NPV = 99.6 (98.9-100), sens =
98.8 (97.2-100)
• For < 5 ng/L (</= 4 ng/L) (​50%​)
– N = 815, 9 missed
– NPV 98.9 (98.2-99.6), sens =
94.7%​ (91.3-98.1)

• In combo w normal or near

normal ECG:
• < LoD
– NPV 99.6 (98.9-100); sens 99.4
(98.3-100) (​16%​ of patients)
• < 5 ng/L
– NPV 99.5 (98.8-100); sens 98.8
(97.2-100) (​25%​ of patients)
 Limitation of MI as
endpoint
• Does not have ACS as endpoint
• Unstable Angina ​cannot be ruled out by troponin
– Absence of Changes below the 99​th​ %-ile
does not rule out UA
• Mortality endpoint does not compensate for this.
• Intervening invasive procedures
– PCI in the absence of AMI but prior to the
outcome date
• Thelin et. al. Eur Ht J, Acute Card Care 2014;
4(5):403-9
• Initial hs-cTnT among 478 patients presenting
with chest pain as the primary symptom
• 160 (33.5%) had values below 5 ng/L
• NPV of 100% for NSTEMI (70 NSTEMI; 37 UA)
• NPV of only 94% for any ACS (includes Unstable
Angina)
• Sensitivity 91% (80-95)
– Missed 10 of 107 ACS as diagnosed by
angiography; 8 PCI
• Clinical judgment and pre-test probability of ACS
is critical
 0/3 hour ESC algorithm
Pickering, Heart 2016;102:1270
• Abbott hs cTnI or Roche hs
cTnT
• Uses 2 values < 99​th​ %-ile
• The sensitivity of the 99th
percentile to rule-out AMI
– 93.2% (87.5% to 96.8%) for
hs-cTnI
– 94.8% (89.5% to 97.9%) for
hs-cTnT
• Not good sensitivity by itself
0/3 hour ​delta
algorithm
Outcome (prognostic sensitivity): MI or
cardiac death 30 days
 (but not all 30-day MACE)
30-day MI always includes both index
and subsequent MI
• Abbott hs cTnI only
• Initial < 5 ng/L (40.7% of
patients)
• 3 hour delta < 3 ng/L
• 97.9% prognostic sensitivity
– (94.7-99.1; 187/191)
– Compared to 93.2% (87.5-96.8)
at 99​th​ %-ile without delta
• (see previous slide)
• 99.5% NPV (98.9-99.8)
• 74.2% suitable for early rule
out
 TRAPID-AMI: 0/1 hour
algorithms; hs-cTnT
Annals of EM 2016; 68(1):76-87
• Algorithm​​:
– < 12 ng/L and Δ1 hour < 3 ng/L
to rule out
– ≥ 52 ng/L or Δ1 hour ≥ 5 ng/L to
rule in
– remaining patients to the
“observational zone”
• 1282 patients, 213 MI
• 813 (63.4%) patients were
classified as rule out, 7 missed
MI
• 184 (14.4%) were classified as
rule in
• 285 (22.2%) were triaged to
the observational zone.
• NPV for AMI
– 99.1% (98.2% to 99.7%)
• Sensitivity for AMI
– 96.7% (93.4% to 98.7%)
• Main Criticism​​:
– No data on number of early
presenters. Median time from
sx onset to presentation was 1.9
hours, to first sampling was 3.5
hours.
– Calculations imply very low
numbers of early presenters.
Following slides: Two 0/1 hour
algorithms
one for hsTnI, one for hsTnT
 n = 4350
Twerenbold et al. Circulation 137(23); 2018
• Endpoint: diagnosis of AMI
– not​ 30-day MACE, not 30-day death/MI
• All patients:
– hsTnT (57%): NPV 99.8%
(99.5-99.9), sens 99.3 (98.4-99.8)
– hsTnI (46%): NPV 99.6%
(99.1-99.8), sens 98.8 (97.7-99.4)
• Early presenters (< 2 hours):
– hsTnT (59%): NPV 99.5 (98.7-99.9),
Sens 98.2 (95.4-99.5)
– hsTnI (49%): NPV 99.2 (98.2-99.7),
Sens 97.7 (94.8-99.3)

Troponin I
rule out MI, not rule out 30-day
MACE
 Troponin T
Rule out MI, not rule out 30-day MACE
Same protocol as TRAPID-AMI, but more
data and data on early presenters
0/1 better than 0/3 ESC
0/1 hour algorithms
• Randomized trial pending:
• A randomized trial of a ​1-hour troponin vs.
usual care
• Design of the Rapid Assessment of Possible
ACS In the emergency Department with high
sensitivity Troponin T (RAPID-TnT) study
• hs cTnT protocol in suspected acute coronary
syndromes
• 5400 patients, 5 hospitals
– 2700 each group
• Expect ~450 MIs in intervention group

• Expect ~98% sensitivity for MI

– 9 missed MI
• Expect ~90% sensitivity for ~600 ACS
 – ~60 missed ACS, ~51 missed unstable
angina

Not high risk by Gestalt

0/1 hour algorithm, with vs. w/o
ECG and Gestalt
Mokhtari et al. JACC 2016;67:1531
• Only 0/1 hour protocol looked at 30-day MACE. N
= 1038.
• 0/1 hour protocol alone (same as other 0/1 hour
hs-TnT protocols)
– Rules out 65% (n = 682)
– 87% sens for ACS ​if one includes unstable
angina as a 30 day MACE
• 0/1 hour protocol + ECG non-ischemic + Gestalt
not high risk
– Gestalt risk = very low, low, or intermediate
(not high risk)
– Rules out 60% (n = 625)
• 97.5% (92.9-99.5)​ sensitivity, 99.5% NPV

(98.6-99.9).

Mokhtari Protocol
 0/2 hour hs Troponin I
Boeddinghaus et al. Clin Chem 64(9);
2018
• Derivation (1435) and Validation
(1194)
• AMI in 13% of validation group
• 30-day survival 100% in rule out
group
• Don’t know how many had
intervention
0/2 hour hs Troponin T
Reichlin T et al Am J Med 128(4):369,
2015
• Derivation (1148) and Validation
(517)
• AMI in 9.1% of validation group (n
= 47 in validation group)
• 30-day survival in rule out group =
100%
Compare 4 hs ​troponin
- only​ strategies
Abbott hs cTnI
Circulation April 2017; 135(17):1597; n
= 2828; 451 MI
Diagnosis of MI, not 30-day MACE
• < LoD (< 2 ng/L)
– 16%​, sens 100% (99.2-100) --
similar to JAMA meta-analysis
(13%, 100%)
– 94.2% sensitivity in early
presenters (< 2 hours)
• < 5 ng/L
 – 54%​, sens 97.1% (95.1-98.3);
NPV 99.1 (98.5-99.5); miss 13
MI’s
• 0/1 hour: < 5 ng/L and 1 hour
change < 2 ng/L
– 52%​, sens 98.4% (96.8-99.2);
NPV 99.5 (99.0-99.8); miss 7
MI’s
• ESC 0/1 combining LoD and 1
hour algorithm
– 0h < 2 ng/L, or 0h < 5 ng/L AND
delta < 2 ng/L
– 52%​, sens 98.4 (96.8-99.2); NPV
99.5 (99.0-99.8); miss 7 MI’s
• 2 year survival
– 100% with LoD (99.1-100)
– 98.1% with all other strategies
 Gestalt and single hs cTnT < 99​th
%-ile
Can emergency physicians ‘rule in’ and ‘rule out’ MI
with clinical judgment?
Body R et al. EMJ ​Emerg Med J 2014; 31:872
• Blinded to Trop but not ECG
• ‘Definitely not,’ ‘probably not’ ​vs​​.​ not
sure, probably, definitely
– AUC of 0.76 for ACS
• 451 patients, 81 AMI (small)
• Immediately discharge
– normal initial ECG and ​contemporary​ troponin <
99​th​ %-ile
– clinician felt the diagnosis was ‘probably not’ or
‘definitely not’ ACS
– avoided admission for 104 patients (​23.1%​)
– 100% sensitivity (CI: ​95.6% to 100%​). 1 30-day
MACE
• With hs-cTnT
– Roche Elecsys, 99​th​ % 14 ng/mL
– Single initial troponin
– This allowed 188 patients (​41.7%)​ to be discharged
immediately.
– 100% sensitivity (97.5-100) for ACS even with ‘not
sure’ added.
– 3 30-day MACE. (98.4% (95.5-99.5)
Contemporary troponin
• Neg EDACS or HEART
• Neg ECG
• 2 Troponins below the 99​th
%-ile
• Delta below 99​th​ was not
accurate
• Should result in < 1% 30-day
MACE
• Generally EDACS rules out
more patients
• HEART more widely used
Combine EDACS, neg ECG,
and specified threshold of
single hs-cTn T or I?
Pickering, Flaws, Smith. Acad EM 2018;
25(4):434-443
• 2536 patients, both hsTnT and hsTnI
– Looking for thresholds with 99% sensitivity
• 2258 without positive ECG
– Threshold of 98.5% sensitivity among this
group
• 433 MACE; 272 with MACE who had
non-ischemic ECG
• hs cTnI < 7 with EDACS < 16; 37% low risk
– 98.5% (97.7-99.4) sensitive for 30-day MACE
• hs cTnT < 8 with EDACS < 15; 30% low
risk
– 98.5% (97.5-99.4) sensitive for 30-day MACE
• 4 missed MACE
• 99.8% NPV
• Compare to 99% sens of ESC 0/1 hour: but that
was for MI only
• Not validated

2 other risk scores

• No Objective Testing,
• New Vancouver rule, Can J EM
March 2014
• See next 2 slides

New Vancouver Rule

Canadian JEM.
2014;16:106-119
No objective testing
Rule
Ann Emerg Med. 2016;67:478-489

hs-Troponin I and 5 risk

th​
scores; 0/2 < 99​ %-ile
Ann EM 2018;71(4):439
1811 patients, 96 AMI, 139 ACS
• 1811 patients, 96 MI + 43 Unstable
angina (139 ACS)
• 0/2 hour rule out
• Both troponins < 99​th​ %-ile
• No delta used
• New Vancouver Rule and No
Objective Testing rule
– Sensitivity 100%/10% for AMI
– 98.6% and 99.3% for ACS
– Only 28.2% and 34.5% classified as
low risk
• EDACS & HEART
– Sensitivity = 97.9% for MI, < 95%
for ACS
– Classified 62.5% and 49.8% as low
risk
 New​ Troponin-only
Protocols
for Rule out MI
• UltraRapid 30 minute
• 3 troponin: 0/1, then 3 hour
for those in intermediate zone
• See next slides
UltraRapid 30 min rule
out
Ann Emerg Med online Aug 2018:
https://doi.org/10.1016/j.annemergm
ed.2018.06.021
• 569 study patients (7.7% MI =
44 MI)
• Initial hs-cTnT < 6 ng/L, 100%
sensitivity
• Initial hs-cTnT , 8 ng/L and 30
min delta < 3 ng/L.
• Extremely small study that
needs repeating

0/1 hour, then 3 hour

protocol
Vigen R et al. Circulation 2018. n = 536. 11 MI
(!)
for rule out MI, not r/o ACS, not
30-day MACE
0/1 hour, then 3 hour
protocol
Circulation 2018. n = 536. ​11
MI (!)
for rule out MI, not r/o ACS,
not 30-day MACE
Implementation Of
EDACS-ADP
In 7 New Zealand hospitals, variable
protocols, no red flags:
5 hospitals: EDACS < 16, neg ECG, 2 hs cTnI < 99% at
0- and ​3-hours
2 hospitals with ADAPT (TIMI = 0), neg ECG, 2 cTnI <
99% at 0- and ​3-hours
Circulation 2018:137:354-63

• Observational study (n =
31,332), implementation
of the EDACS-ADP or of
the modified ADAPT-ADP
 (uses TIMI score = 0) at 7
hospitals in New Zealand
• Increase in proportion of
discharged patients from
8.3% to 18.4%
• Shorter ED stay, No
adverse effect on
outcome
• For patients discharged
within 6 hours, there was
no change in 30-day
major adverse cardiac
event rates (0.52% versus
0.44%; P=0.96).
• 16 adverse events out of
3632 patients ​(0.44%) in
the intervention cohort
• (8 NonSTEMI, 1 STEMI, 1
stable VT, 1 asystolic
pause requiring
permanent pacemaker
insertion, and 5 all-cause
deaths).
• Case review revealed that
14 of the 16 involved a
deviation from the local
clinical pathway (12 had a
positive troponin and 2
 had risk scores identifying
them as not low risk).
• 2 cases incorrectly coded
– Both returned next day
as planned after clinical
pathway guidance for
stress testing, one of
which was positive
• Pathway extremely safe

Specific protocols in
New Zealand
 New Zealand
accelerated CP pathway
“yes” ​from previous slide
Implementation of
HEART
hs-cTnT and hs-cTnI
Eur Heart J 2017;38 Suppl:454 (abstract)
https://academic.oup.com/eurheartj/article/38
/suppl_1/ehx502.2272/4088376

• HEART pathway. Before/after.

N = 621 in after group (small).
• (1) troponin 0h was ≤ upper
limit of normal
• (2) delta-value at ​1h​ was <3
ng/L (hs-TnT) or <6 ng/L
(hs-TnI) and
• (3) HEART score was < 4 (≤ 3)
• Then ACS could be considered
highly unlikely
• The admission rate decreased
from 59% before to 33% after
(p<0.001).
• Admission rate lower in phase
2 (OR, 95% CI; 0.33,
0.25–0.42).
• For patients discharged from
the ED
– no differences regarding death,
myocardial infarction (MI), new
 ED presentation or new
admissions.
• For patients admitted to
hospital
– no differences regarding
presence of MI or time to
discharge
• NPV = 419/421 = 99.5% (2
patients readmitted with MI
after discharge)
• Sensitivity = 42/44 ​= 95% (95%
CI: 85-99)
Bottom Line:
Sensitivity for 30-day MACE >
99%
• I. ​Non-ischemic ECG ​and
• II. ​(-) Risk score or low Gestalt
and
• III. ​One of the below troponin
protocols:

A​​. > 6 hours pain: ​single hs-cTn (I

or T) < 99​th​ %-ile

B​​. < 6 hours of pain: ​(see next

slide)

Bottom Line:
Sensitivity for 30-day MACE > 99%
 Non-ischemic ECG, (-) risk score or low
Gestalt
B​. ​< 6 hours of pain

• 0-hour protocols (only for

pain duration ​> 2 hours​​)
• 0h hs-cTnT < LoD (5 ng/L) or
0h hs-cTnI < LoD (2ng/L)
• 0/3 hour protocol
• 2 hs-cTn at 0 and 3 hrs < 99%
(sex specific for hs-cTnI)
• No rise > 3 ng/L (New Zealand)
• 0/1 h protocol (#1)
• 0h hs-cTnT < 12 ng/L ​AND​ Δ1
hour < 3 ng/L
• 0h hs cTnI < 5 ng/L ​AND​ Δ1
hour < 2 ng/L
 • Positive is any value > 52 ng/L,
or any delta > 4 ng/L (T) or > 5
ng/L (I)
• 0/1 hour protocol (#2; this is
the HEART implementation
above) ​Beware
• 0h < 99​th​ %-ile, and
• Δ1 hour <3 ng/L (hs-TnT)
or <6 ng/L (hs-TnI)
• 0/1 hour, then 3 hour
(hs-cTnT only)​ Beware
• Not ruled out or ruled in by (3)
above
• Delta hs-cTnT at 3 hours < 7
ng/L ruled out (this is based on
insufficient numbers
 • I can’t find any good study with
0- and 3-hour that establishes a
safe delta

Follow Up
• Wake Forest HEART score:
– "These patients are encouraged
to Follow Up with their primary
provider”
• New Zealand
– ETT within 72 hours
– Consider consenting patient for
GP rather than ETT follow up
• Stress Test vs. CTCA
 If all you need is to rule
out MI
• ESC 0/1 hour protocol works
very well