Response by Than et al to Letter Regarding Article, “Assessment of the European Society of Cardiology 0-Hour/1-Hour Algorithm to Rule-Out and Rule-In Acute Myocardial Infarction”
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We appreciate the interest shown in our article1 by Mueller and Roffi as well as Irfan. Mueller and Roffi should be acknowledged as key innovators in this field and have been leaders in emphasizing the importance of absolute rather than relative changes in troponin concentrations and the use of thresholds below the 99th percentile for rule-out.
Mueller and Roffi suggest that methodological limitations of our study may have affected our conclusions. We welcome the opportunity to address these issues.
First, patients with new ischemia on ECG were excluded because the guidelines don’t explicitly state how to incorporate ECG to allocate patients to risk categories. It is important to note that emergency department physicians are unlikely to consider early discharge with possible ischemic ECG findings.
Second, we acknowledge that if adjudication had been done using the same assay as being evaluated, then the positive predictive value may have been greater.2
Third, we acknowledge that despite the use of standardized adjudication at each site, different adjudication results may have been discovered if central adjudication had …