7 Recommendations for further research
7.1 The Committee recommended that robust evidence be generated to show the clinical effectiveness of the AccuTnI+3 assay for the early rule out of non‑ST‑segment elevation myocardial infarction (NSTEMI) in people presenting to an emergency department with acute chest pain. Where possible the accuracy of the AccuTnI+3 assay and its resulting clinical outcomes should be compared with both high‑sensitivity troponin assays recommended in section 1.1 and standard troponin assays.
7.2 The Committee recommended the collection of further outcome data through clinical audit in centres adopting 'early rule‑out protocols' with high‑sensitivity troponin testing (see recommendation 1.4). The data collected through audit should be sufficient to allow analysis of the optimal timing of samples taken after presentation to an emergency department and the optimal high‑sensitivity troponin test cut‑offs for both ruling out and ruling in NSTEMI.
7.3 The Committee recommended further research comparing the clinical effectiveness of different early rule‑out test protocols using high‑sensitivity assays which meet the criteria applied for this assessment. The Committee recommended that future studies should include consideration of the clinical effectiveness of different test strategies including those employing low diagnostic thresholds, and the impact of different test strategies on both clinician behaviour and the health system, with a view to reducing uncertainty in the economic model. Future studies should also investigate the role of sex and age‑specific 99th percentile thresholds in the assessment of suspected acute coronary syndrome. The Committee also considered that it would be appropriate to include adjudication with high‑sensitivity troponin assays at time points earlier than 10–12 hours as the reference standard in future studies.
7.4 The Committee recommended further research to understand the underlying biological causes and the clinical implications of chronically elevated troponin levels in older people, and people with conditions known to cause troponin elevation in the absence of ischaemia.