Two-Hour Algorithm for Triage toward Rule-Out and Rule-In of Acute Myocardial Infarction by Use of High-Sensitivity Cardiac Troponin I

Abstract

BACKGROUND:The early triage of patients toward ruleout and rule-in of acute myocardial infarction (AMI) is challenging. Therefore, we aimed to develop a 2-h algorithm that uses high-sensitivity cardiac troponin I (hs-cTnI).

Acceptable Analytical Variation May Exceed High-Sensitivity Cardiac Troponin I Cutoffs in Early Rule-Out and Rule-In Acute Myocardial Infarction Algorithms

“…In patients presenting to the emergency department (ED) 1 with symptoms suggestive of acute coronary syndrome (ACS), clinical studies and guidelines have proposed earlier cardiac troponin sampling protocols and, specifically for high-sensitivity cardiac troponin, at 3, 2, or 1 h, depending on the algorithm and highsensitivity cardiac troponin assay (1 ). Because of this shorter time interval between high-sensitivity cardiac troponin measurements, there will be smaller changes in concentration (␦) for risk classification.…”

Temporal Relationship between Cardiac Myosin-Binding Protein C and Cardiac Troponin I in Type 1 Myocardial Infarction

“…However, the majority of patients presenting with chest pain have cardiac troponin concentrations that place them between these decision limits, in an indeterminate zone. These patients require repeat testing and subsequent second or third rounds of triage based on rates of change of cardiac troponin concentration over time (2 ). This introduces systematic delays in allocation of evidence-based treatments and prolongs stay in the pressured and precious environment of the emergency department.…”

“…This approach is useful for diagnosis, choice of a personalized treatment, prediction, or the monitoring of treatment response, and has been successfully performed on fresh frozen and formalin-fixed, paraffin-embedded tissue, and circulating cell-free DNA (1,2 ).…”

Fast track protocols using highly sensitive troponin assays for ruling out and ruling in non-ST elevation acute coronary syndrome

“…A 0-2 h version of the previously discussed algorithm has also been proposed, but the negative PV for ruling out chest pain patients did not significantly change when compared to that obtained with the 0-1 h version [31,32]. Conversely, the positive PV increased from 75% to 82%-85% tending to reach the value obtainable with the 0-3 h protocol, which is, however, considered suboptimal for AMI rule-in [12].…”