Prospective Validation of the 0/1-h Algorithm for Early Diagnosis of Myocardial Infarction.

Abstract

BACKGROUND:

The safety of the European Society of Cardiology (ESC) 0/1-h algorithm for rapid rule-out and rule-in of non-ST-segment elevation myocardial infarction (NSTEMI) using high-sensitivity cardiac troponin (hs-cTn) has been questioned.

OBJECTIVES:

This study aimed to validate the diagnostic performance of the 0/1-h algorithm in a large multicenter study.

METHODS:

The authors prospectively enrolled unselected patients in 6 countries presenting to the emergency department with symptoms suggestive of NSTEMI. Final diagnosis was centrally adjudicated by 2 independent cardiologists. Hs-cTnT and hs-cTnI blood concentrations were measured at presentation and after 1 h. Safety of rule-out was quantified by the negative predictive value (NPV) for NSTEMI, accuracy of rule-in by the positive predictive value (PPV), and overall efficacy by the proportion of patients triaged towards rule-out or rule-in within 1 h.

RESULTS:

Prevalence of NSTEMI was 17%. Among 4,368 patients with serial hs-cTnT measurements available, safety of rule-out (NPV 99.8%, 2,488 of 2,493), accuracy of rule-in (PPV 74.5%, 572 of 768), and overall efficacy were high by assigning three-fourths of patients either to rule-out (57%, 2,493 to 4,368) or rule-in (18%, 768 to 4,368). Similarly, among 3,500 patients with serial hs-cTnI measurements, safety of rule-out (NPV 99.7%, 1,528 of 1,533), accuracy of rule-in (PPV 62.3%, 498 of 800), and overall efficacy were high by assigning more than two-thirds of patients either to rule-out (44%, 1,533 of 3,500) or rule-in (23%, 800 of 3,500). Excellent safety was confirmed in multiple subgroup analyses including patients presenting early (≤3 h) after chest pain onset.

CONCLUSIONS:

The ESC 0/1-h algorithm using hs-cTnT and hs-cTnI is very safe and effective in triaging patients with suspected NSTEMI. (Advantageous Predictors of Acute Coronary Syndromes Evaluation [APACE]; NCT00470587; and Biomarkers in Acute Cardiac Care [BACC]; NCT02355457).

• Authors: Raphael Twerenbold, Johannes Tobias Neumann, Nils Arne Sörensen, Francisco Ojeda, Mahir Karakas, Jasper Boeddinghaus, Thomas Nestelberger, Patrick Badertscher, Maria Rubini Giménez, Christian Puelacher, Karin Wildi, Nikola Kozhuharov, Dominik Breitenbuecher, Ewelina Biskup, Jeanne du Fay de Lavallaz, Dayana Flores, Desiree Wussler, Òscar Miró, F Javier Martín Sánchez, Beata Morawiec, Jiri Parenica, Nicolas Geigy, Dagmar I Keller, Tanja Zeller, Tobias Reichlin, Stefan Blankenberg, Dirk Westermann, Christian Mueller
• Journal: Journal of the American College of Cardiology (J Am Coll Cardiol) Vol. 72 Issue 6 Pg. 620-632 (08 07 2018) ISSN: 1558-3597 [Electronic] United States
• PMID: 30071991 (Publication Type: Journal Article, Multicenter Study)
• Copyright: Copyright © 2018 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

Topics

• Aged
• Algorithms
• Chest Pain (diagnosis, epidemiology, physiopathology)
• Early Diagnosis
• Female
• Follow-Up Studies
• Humans
• Internationality
• Male
• Middle Aged
• Myocardial Infarction (diagnosis, epidemiology, physiopathology)
• Predictive Value of Tests
• Prospective Studies
• Reproducibility of Results