ESC 0/1-Hour Algorithm With hs-cTnT Among Patients With CAD

May 11, 2023
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Authors:
Ashburn NP, Snavely AC, O’Neill JC, et al.
Citation:
Performance of the European Society of Cardiology 0/1-Hour Algorithm With High-Sensitivity Cardiac Troponin T Among Patients With Known Coronary Artery Disease. JAMA Cardiol 2023;8:347-356.
Summary By:
Salim Hayek, MD, FACC

Quick Takes

  • This multisite, prospective study aimed to evaluate the safety and efficacy of the ESC 0/1-hour hs-cTnT algorithm in ruling out ACS among patients with and without known CAD using a diverse patient population across various US emergency departments.
  • The results revealed that the algorithm's negative predictive value (NPV) fell below the accepted 99% threshold for 30-day cardiac death or MI in patients with known CAD and demonstrated <99% NPV for patients without CAD.
  • The ESC 0/1-hour hs-cTnT algorithm is likely not safe for routine use in US emergency department patients presenting with chest pain, regardless of their CAD status.

Study Questions:

Can the European Society of Cardiology (ESC) 0/1-hour high-sensitivity cardiac troponin T (hs-cTnT) algorithm safely rule out acute coronary syndrome (ACS) in patients with known coronary artery disease (CAD) presenting with chest pain in the emergency department in the United States?

Methods:

The study is a preplanned subgroup analysis of the prospective, multicenter cohort study, STOP-CP (Strategies for the Evaluation of Chest Pain). It enrolled patients with acute chest pain or other symptoms suggestive of ACS at eight US emergency departments. The ESC 0/1-hour algorithm was used to stratify patients into rule-out, observation, and rule-in zones. The primary outcome was 30-day cardiac death or myocardial infarction (MI), with secondary outcomes including major adverse cardiovascular events and efficacy.

Results:

In this subgroup analysis of 1,430 patients, 449 (31.4%) had CAD. At 30 days, cardiac death or MI occurred in 183 individuals (12.8%). The ESC 0/1-hour algorithm classified more patients without known CAD into the rule-out zone (66.1%) than those with known CAD (39.6%). The negative predictive value (NPV) for 30-day cardiac death or MI was 96.6% in patients with known CAD and 98.9% in patients without known CAD. The ESC 0/1-hour algorithm classified more patients with CAD into the rule-in zone (19.6%) compared to those without CAD (10.4%). The positive predictive value (PPV) for 30-day cardiac death or MI was similar between both groups (59.1% in patients with known CAD and 57.8% in patients without known CAD).

Conclusions:

The ESC 0/1-hour hs-cTnT algorithm does not safely rule out ACS in patients presenting with chest pain in the US (NPV <99%, PPV <60%), and its performance may not be adequate for routine use among US emergency department patients with chest pain, regardless of their CAD status.

Perspective:

The performance of the ESC 0/1-hour hs-cTnT algorithm in this study differed from previous international studies, which reported similar diagnostic performance among patients with and without CAD. The differences in patient populations and outcomes used in these studies might have contributed to the discrepancy in results. The patient cohort in the current study was racially diverse and included patients from various US emergency departments, potentially affecting the algorithm’s performance. Understanding these differences is essential for tailoring diagnostic tools to specific populations and ensuring accurate results across diverse patient groups.

The study's results cast doubt on the safety of the ESC 0/1-hour algorithm, particularly in patients with known CAD. Emergency clinicians may need to consider alternative diagnostic methods or adjust their approach to ensure patient safety. Furthermore, The ESC 0/1-hour hs-cTnT algorithm may result in greater overtriage in a US population, with PPVs below 60% for both index and 30-day cardiac death or MI. Thus, a higher proportion of patients may be classified as requiring further intervention or admission, leading to unnecessary hospitalizations, increased health care costs, and heightened patient anxiety.

Last, the study underscores the significance of considering clinical variables in diagnostic algorithms. Combining the ESC 0/1-hour algorithm with the HEART score, for example, may improve the safety of the diagnostic process, albeit at the cost of efficacy.

Clinical Topics: Acute Coronary Syndromes, Prevention, Atherosclerotic Disease (CAD/PAD)

Keywords: Acute Coronary Syndrome, Algorithms, Chest Pain, Coronary Artery Disease, Emergency Service, Hospital, Myocardial Infarction, Myocardial Ischemia, Quality of Health Care, Secondary Prevention, Troponin T


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