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

Abstract

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).

The Asia-Pacific Society of Cardiology (APSC) Expert Committee Consensus Recommendations for Assessment of Suspected Acute Coronary Syndrome Using High-Sensitivity Cardiac Troponin T in the Emergency Department

“…Overall efficacy was high by assigning three-quarters of patients either to rule-out (57%) or rule-in (18%). 17 Similarly, a recent prospective randomized comparison of a 0-1-h and 0-3-h protocols has confirmed a 30-day death or AMI rate of 0.4% among these receiving a rule-out recommendation with a NPV of 99.6% for those directly discharged from the ED. 18 An individual with chest pain and a hs-TnT concentration of 5-52 or 70 ng/L would require a second hs-TnT measurement after 1-3 h in order to assess the presence of a rising or falling pattern that defines acute myocardial injury.…”

“…Approximately 40% of patients could be classified using this approach. 17,19 Individuals stratified to the rule-out group using the rapid disposition hs-TnT algorithm should be carefully assessed clinically, which may include the use of a risk score validated in ACS, used alongside hs-TnT values, to inform decisions on possible discharge or further assessments on an outpatient basis. Serious non-cardiac causes of chest pain should also be considered before discharge.…”

High-Sensitivity Troponin T Testing: Consequences on Daily Clinical Practice and Effects on Diagnosis of Myocardial Infarction

“…Subsequently, we analyzed different subgroups: patients hospitalized in the cardiology department (Subgroup 1), patients hospitalized in other departments (Subgroup 2), and lastly, to investigate the findings in a cohort of patients with high a priori probability for the diagnosis of acute myocardial infarction (Subgroup 3), we applied clinically relevant laboratory criteria to all inpatients of the cardiology department in a separate analysis: with high-sensitivity troponin testing based on the ESC hs-TnT 0/1h algorithm [7,8,24,25] and regarding patients with conventional troponin testing with markedly elevated cTnI values (i.e., 5 times the normal upper limit) or a 50% dynamic change between two serial measurements.…”

“…Because many clinical situations necessitate time-consuming serial sampling to establish the diagnosis of myocardial infarction, the efficiency of cTnI assays has been questioned in the past. The introduction of new, high-sensitivity troponin assays (hs-Tn) aimed to solve the problem by lowering the limit of detection, and thus allowing a more rapid exclusion of myocardial infarction than any conventional or sensitive troponin assay [6][7][8]. However, because troponin is not specific for the etiology of cardiomyocyte death, the assay leaves the clinician with the responsibility to interpret elevated test results in each individual clinical setting, discriminating between different types of myocardial infarction or myocardial injury due to other causes [9][10][11].…”

“…Considering the expansion of non-selective troponin testing (e.g., in non-acute coronary syndrome (ACS) situations) and the associated growing number of test results above the 99th percentile in mixed medical and surgical cohorts [12], causal attribution of troponin elevation remains a challenging task, as elevated levels are not uncommon in a variety of different, possibly coexisting, non-cardiac morbidities, where acute coronary artery obstruction is not likely [13][14][15][16][17][18][19][20][21][22][23]. Reliable data and algorithms on high-sensitivity troponin testing and decision making in the emergency care setting, with regard to chest-pain patients or non-ST-elevation ACS, have been published [7,8,24], but no large study has investigated the consequences of using high-sensitivity troponin T (hs-TnT) on the diagnosis of myocardial infarction and resource utilization in an undifferentiated cohort of non-emergency department (ED), non-chest-pain, mixed surgical and medical patients. The present study aimed to test the hypothesis, that introduction of high-sensitivity troponin testing would result in an increase of resource utilization and diagnosis of acute myocardial infarction in an unselected patient population.…”