Validation of the ESC Algorithm for Acute MI Rule Out

Study Questions:

What is the validity of the European Society of Cardiology (ESC) 0/1h algorithm to rule out and rule in acute myocardial infarction (AMI) for the Roche high-sensitivity troponin T (hs-cTnT) and Abbott hs-cTnI assays in a non-European cohort of chest pain patients without ischemic changes on electrocardiography (ECG)?


hs-cTnI and hs-cTnT assays were used to measure troponin concentrations in patients presenting with chest pain symptoms and being investigated for possible acute coronary syndrome at hospitals in New Zealand, Australia, and Canada. AMI outcomes were independently adjudicated by at least two physicians. The ESC algorithm performance with each assay was assessed by the sensitivity and proportion with AMI ruled out, and the positive predictive value (PPV) and proportion ruled in.


There were 2,222 patients with serial hs-cTnT and hs-cTnI measurements. The hs-cTnT algorithm ruled out 1,425 (64.1%) with a sensitivity of 97.1% (95% confidence interval, 94.0%-98.8%) and ruled in 292 (13.1%) with a PPV of 63.4% (57.5-68.9%). The hs-cTnI algorithm ruled out 1,205 (54.2%) with a sensitivity of 98.8% (96.4-99.7%) and ruled in 310 (14.0%) with a PPV of 68.1% (62.6-73.2%).


The authors concluded that the sensitivity of the ESC rapid assessment 0/1h algorithm to rule out AMI with hs-cTn may be insufficient for some emergency department (ED) physicians to confidently send patients home.


These study findings do not support broad application of the 2015 ESC 0/1h algorithm to rule-out AMI with hs-cTn assays if the safety goal is 99.0% sensitivity for AMI. Neither algorithm exceeded 99% sensitivity, a safety level which most ED physicians consider a requirement. The algorithm which incorporated hs-cTnT missed approximately 3% of AMIs in the ED, which is a concern. These algorithms may prove useful to identify patients requiring expedited management, but with only modest PPV for both algorithms. It would appear that the ESC guideline 0/1h algorithm should ideally be implemented with safeguards, including robust clinical risk assessment.

Clinical Topics: Acute Coronary Syndromes, Prevention, ACS and Cardiac Biomarkers

Keywords: Acute Coronary Syndrome, Algorithms, Biological Markers, Chest Pain, Electrocardiography, Emergency Service, Hospital, Myocardial Infarction, Risk Assessment, Secondary Prevention, Troponin I, Troponin T

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