Both the European Society of Cardiology 0/1-hour algorithm (ESC 0/1h-algorithm) and the high-sensitivity troponin in the evaluation of patients with acute coronary syndrome 0/2-hour or 0/3-hour pathway (High-STEACS 0/2h-0/3h-pathway) demonstrated "comparable and excellent performance" in diagnosing patients presenting with acute chest discomfort, according to a prospective, multicenter study published in JACC.

Jonas Glaeser, MD, et al., included 4,663 patients (median age 61 years; 32% women) who presented to the emergency department with acute chest discomfort. They compared the ESC 0/1h-algorithm and High STEACS 0/2h-0/3h-pathway using three high-sensitivity troponin (hs-cTn) assays: hs-cTnI-Architect, hs-cTnI-Centaur/Atellica, and hs-cTnT-Elecsys. The primary diagnostic endpoint was NSTEMI type 1.

Results showed that 14% of patients had the primary endpoint. When using hs-cTnI, the ESC-0/1h-algorithm demonstrated greater sensitivity while the High-STEACS 0/2h-0/3h-pathway had greater efficacy. With hs-cTnI-Architect specifically, the ESC 0/1h-algorithm had a sensitivity of 100% vs. 98% for the High-STEACS 0/2h-pathway (p<0.001 for both), but the proportion of patients assigned to the rule-out group was 52% vs. 72.5%, respectively (p<0.001).

Overall, the ESC 0/1h-algorithm consistently exhibited higher specificity for NSTEMI type 1 for all hs-cTn assays used. These findings were validated with an external cohort of 2,485 patients.

"The findings of this study suggest that sites that have successfully implemented the ESC 0/1h-algorithm should likely continue using it, whereas those with the High-STEACS pathway in place should likely continue with the latter, as both strategies demonstrate overall excellent and comparable performance and are guideline-compatible," write the authors.

In an accompanying editorial comment, Christopher W. Baugh, MD, MBA, et al., note that "the most remarkable and provocative findings from the present analyses are the large differences in efficacy (the proportion of patients ruled out) and the proportion classified in the observation zone...The ideal method for further risk-stratifying observation zone patients remains undefined, making these patients challenging for clinicians to manage."