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Real-World Outcome of the ESC 0/1-h Algorithm
Study Questions:
What are the outcomes associated with the implementation of the European Society of Cardiology (ESC) 0/1-hour (0/1-h) high-sensitivity troponin T (hs-cTnT) algorithm for rapid triage of patients with suspected non–ST-segment elevation myocardial infarction (NSTEMI)?
Methods:
In a prospective study, the ESC 0/1-h algorithm was implemented in two large University hospitals between 2015 and 2017, enrolling 2,296 with suspected NSTEMI. hs-cTnT was measured at presentation to the emergency department (ED) and 1 hour later. Outcomes examined included feasibility, adherence to 0/1-h protocol, ED resource utilization and patient flow, triage performance, and lastly, 30-day major adverse cardiac events (MACE). Findings were compared to the same measures obtained from a preimplementation cohort.
Results:
Overall, the protocol was applied to 2,296 patients presenting with suspected MI, of whom 62% were ruled out (0h <5 ng/L or 0h <12 ng/L + 1-h change <2 ng/L), 13% were ruled in (0h >52 ng/L or 1-h change >5 ng/L), and 25% were in the observe zone (0h 12-52 ng/L, 1-h change 4 ng/L). Ten percent were diagnosed with NSTEMI. None of the patients were incorrectly triaged as a rule-out. Median time interval between blood draws was 65 minutes, and 94% were managed without protocol violations, suggesting excellent feasibility. Only 2% of patients ruled out by the algorithm required additional investigation such as additional hs-cTnT sampling or cardiac computed tomography. Among those ruled-in, 46% were hospitalized and 67% underwent early coronary angiography. Median time to discharge or transfer from the ED was 2 hours 30 minutes, which was significantly shorter than the preimplementation cohort (4 hours 45 minutes). The 30-day MACE rate was 0.2% in the rule-out group and 0.1% in the rule-in group, both significantly lower than the MACE rate of 1.7% in the preimplementation cohort. The 30-day MACE rates did not differ according to subgroup including time of symptom onset, gender, age, known coronary disease, known chronic kidney disease, and implementation sites.
Conclusions:
The ESC 0/1-h algorithm for the management of patients with suspected NSTEMI is feasible, shortened time to discharge, and was associated with a low 30-day MACE rate, without increased ED resource utilization.
Perspective:
After much deliberation and numerous studies examining various protocols for the implementation of high-sensitivity troponin in the ED, we are getting close to establishing the optimal strategy for ruling out NSTEMI and expediting the care of patients presenting with chest pain. In this study, done in seven busy EDs, time to discharge was much shortened using the ESC 0/1-h protocol down to 2 hours 30 minutes, even compared to the ESC 0/3-h protocol, in which median ED stay was 5 hours. Most importantly, event rates were low and 71% of patients were managed as outpatients. While not assessed directly, cost-savings are likely substantial. The ESC 0/1-h algorithm appears to be a feasible and well-performing triage strategy for patients presenting with chest pain.
Clinical Topics: Acute Coronary Syndromes, Cardiovascular Care Team, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Interventions and ACS, Interventions and Imaging, Angiography, Nuclear Imaging
Keywords: Acute Coronary Syndrome, Algorithms, Angiography, Chest Pain, Coronary Angiography, Emergency Service, Hospital, Myocardial Infarction, Outpatients, Patient Discharge, Renal Insufficiency, Chronic, Tomography, Triage, Troponin T
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