Extending the no objective testing rules to patients triaged by the European Society of Cardiology 0/1-hour algorithms

Abstract

Background After rule-out of non-ST elevation myocardial infarction (NSTEMI) with the European Society of Cardiology (ESC) 0/1h-algorithms, it is unclear which patients require further anatomical or functional cardiac testing. Objective To test the safety and efficacy of the no-objective-testing (NOT)-rules after NSTEMI rule-out by the ESC 0/1h-algorithms. Methods International, prospective, diagnostic multicenter study enrolling adult patients presenting with chest pain to the emergency department. Central adjudication of final diagnosis by two independent cardiologists using information including cardiac imaging. Primary endpoints were the safety and efficacy of the NOT-rules for the rule-out of major adverse cardiovascular events (MACE). Secondary endpoints included 365-day and 2-year MACE. Results Among 4804 and 4569 patients with available 0/1h high-sensitivity cardiac troponin (hs-cTn)T-Elecsys or hs-cTnI-Architect concentrations, 2783 (58%) and 2252 (49%) were eligible for application of the NOT-rules after rule-out of NSTEMI by the ESC hs-cTnT/I-0/1h-algorithm. The first rule identified 26% of patients with a sensitivity of 100% (95%CI 98.3-100%) and a negative predictive value (NPV) of 100% (95%CI, n.c.). The second and third rules both identified 31% of patients with a sensitivity of 99.5% (95%CI 97.4-99.9%) and a NPV of 99.9% (95%CI 99.2-99.9%). Similar findings emerged for hs-cTnI. High safety was confirmed for rule-out of 365-day and 2-year MACE and proven to be superior to the HEART Score. Conclusion All three NOT-rules performed very well for rule-out of MACE. The third NOT-rule best balanced feasibility, safety, and efficacy by identifying nearly one out of three patients as low-risk and may not require further cardiac testing.

Chest Pain in Cancer Patients

“…This was a secondary analysis from the APACE (Advantageous Predictors of Acute Coronary Syndromes Evaluation) study. APACE is a multicenter, international, prospective diagnostic study ( NCT00470587 ), 15 , 16 , 17 , 18 , 19 , 20 , 21 , 22 conducted in 12 EDs in 5 different European countries, enrolling patients >18 years of age presenting to EDs with nontraumatic acute chest pain as the main symptom. Patients were excluded if they had had prehospital cardiopulmonary resuscitation, were in shock, or had terminal kidney failure on long-term hemodialysis.…”

Cardiac Biomarkers in 2022 – a Vital Tool for Emergency Care

“…35 The implementation of hs-cTn assays resulted in an increase of diagnosis of HF (increase of 2.1%, p <0.001) or atrial arrythmia (increase of 0.9%, p <0.001), in parallel with an increased likelihood of receiving stress test (increase of 2.3%, p <0.001). 36 On the other hand, NT-proBNP has also been demonstrated to be a reliable biomarker associated with the prognosis of ACS. In a study on 3,986 patients with ACS, NT-proBNP values were significantly correlated with peak values of cTn (r = 0.4) and with the risk of composite MACE, all-cause death, and nonfatal myocardial infarction.…”