Validation of ESC 0/1-h Algorithm for MI

Study Questions:

What is the diagnostic performance of measuring high-sensitivity cardiac troponin (hs-cTn) levels at 0 and 1 hour (based on the European Society of Cardiology [ESC] hs-cTn 0/1-h algorithm) in patients presenting to the emergency department with chest pain?

Methods:

Data from two large multicenter diagnostic studies of patients with suspected myocardial infarction were pooled and analyzed, based on whether hs-cTnT (n = 4,368) or hs-cTnI (n = 3,500) measurements were used. The primary diagnostic endpoint was non−ST-segment elevation myocardial infarction (NSTEMI) (type 1 and 2). Patients with STEMI and those on dialysis were excluded.

Results:

Based on the ESC hs-cTn 0/1-h algorithm, of 2,493 patients (47%) with hs-cTnT measurements falling in the rule-OUT range, only five were diagnosed with NSTEMI, yielding a negative predictive value of 99.8% and a likelihood ratio of 0.01. Of those with measurements in the rule-IN range (n = 768, 18%), 572 were diagnosed with NSTEMI, yielding a positive predictive value of 74.5% and likelihood ratio of 14.43. Similar results were noted in the hs-cTnI data set, as well as in a subgroup analysis of early presenters (0-3 hours of chest pain onset, 30% of the pooled cohort) and those with type 1 NSTEMI.

Conclusions:

A triage strategy for patients presenting with suspected NSTEMI, based on the ESC 0/1-h algorithm for interpreting hs-cTn levels, is safe and effective.

Perspective:

The availability of hs-cTn testing has provided both opportunities and challenges with regard to the early diagnosis of NSTEMI. The initial response to the ESC 0/1-h algorithm offering guidance in interpreting hs-cTn levels was one of reluctance, notably due to prior studies having enrolled smaller proportions of patients with NSTEMI and very low number of early presenters. This validation study addresses these concerns, and highlights the effectiveness of the strategy in ruling out NSTEMI within 1 hour of presentation. It is the largest study to date examining the question, and its findings were replicated robustly in relevant subgroups, including early presenters. The authors appropriately highlight that this diagnostic algorithm, like all others, is no replacement for clinical judgment and should be used in conjunction with all information available.

Clinical Topics: Acute Coronary Syndromes, ACS and Cardiac Biomarkers

Keywords: Acute Coronary Syndrome, Algorithms, Biological Markers, Chest Pain, Early Diagnosis, Emergency Service, Hospital, Myocardial Infarction, Triage, Troponin, Troponin I, Troponin T


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