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urements was 80% (95% CI: 61-91%) (6). It is important to be fully aware that CK and CK-MB do not identify patients with ACI, because they do not identify UAP. Patients with UAP comprise about half of patients with ACI. Underscoring this is the study by Hedges et al., which showed that even serial CK-MB measurements had a sensitivity of only 31% for ACI (83).

Despite improvements in the diagnostic performance and practicality of CK and CK-MB assays, there is no randomized controlled clinical impact trial showing that these tests are effective for decisions to send a patient home or to the appropriate level of care of admission for patients with suspected ACI, either as one-time or serial tests. The Systematic Review found only one study that showed a small but important clinical effect of serial CK-MB testing on triage decisions (83). Further prospective trials with follow-up of all (including nonadmitted) patients are needed before a strategy incorporating CK-MB into medical decision making can be fully evaluated. The results of the Systematic Review's final ratings of the quality of evidence evaluating this technology and of its ED diagnostic performance and clinical impact are shown in Table 10.

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