Fast track protocols using highly sensitive troponin assays for ruling out and ruling in non-ST elevation acute
Insights
Highly sensitive troponin assays (hsTn) improve acute myocardial infarction diagnosis through serial testing algorithms. Guidelines require reassessment of evidence for 0-1 hour vs. 0-3 hour protocols and validated hsTn use.
Area of Science:
- Cardiology
- Clinical Diagnostics
- Biomarker Assays
Background:
- Highly sensitive cardiac troponin assays (hsTn) have advanced acute myocardial infarction (AMI) diagnosis.
- Serial testing within algorithms is crucial for accurate AMI diagnosis.
Purpose of the Study:
- To evaluate evidence supporting fast-track protocols for non-ST elevation myocardial infarction (NSTEMI) rule-out and rule-in.
- To compare current evidence with recent European Society of Cardiology (ESC) guidelines.
- To identify areas needing clarification or revision in diagnostic guidelines.
Main Methods:
- Review of available scientific evidence on hsTn assays and fast-track protocols.
- Comparative analysis of evidence with ESC guidelines for NSTEMI diagnosis.
- Assessment of the validity and limitations of 0-1 hour and 0-3 hour algorithms.
Main Results:
- Evidence does not support equal classification for 0-3 hour and 0-1 hour algorithms.
- Fast-track protocols, especially the 0-1 hour algorithm for NSTEMI rule-in, require cautious application due to limitations.
- Recommendations for using commercially available, validated hsTn assays are essential.
Conclusions:
- ESC guidelines require revision regarding the evidence levels for different hsTn algorithms.
- Caution is advised for the 0-1 hour NSTEMI rule-in algorithm.
- Diagnostic protocols must utilize validated hsTn assays, avoiding recommendations for unreleased assays.
Abstract:
The introduction of "highly sensitive" cardiac troponin assays (hsTn) has reinforced the evidence that only serial testing incorporated in running algorithms allows a more accurate diagnosis of acute myocardial infarction. In this report, we consider the available evidence supporting the use of fast track protocols for ruling out and ruling in non-ST elevation myocardial infarction (NSTEMI) and compare it with the content of recently released guideline by the European Society of Cardiology, noting some uncomfortable aspects that need urgent clarification and/or revision. Firstly, the guideline drafters have to reconsider the available evidence that does not permit to assign the same class and level of evidence to the very well-validated 0-3 h algorithm and to the 0-1 h algorithm. In agreement with the validity of available data, the limitations of fast track protocols, in particular of the 0-1 h algorithm for NSTEMI rule-in, calls for caution. Secondly, as the current diagnostics guidance by the UK National Institute for Health and Care Excellence recommends, rapid diagnostic protocols should be performed only using well-validated hsTn; recommending the use of an assay before being commercially available is not fair and scientifically sound.
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