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Published on: April 25, 2014
Prospective Validation of the 0/1-h Algorithm for Early Diagnosis of Myocardial Infarction
Raphael Twerenbold1, Johannes Tobias Neumann2, Nils Arne Sörensen2
1Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland; Department of General and Interventional Cardiology, University Heart Center Hamburg, University Hospital Hamburg-Eppendorf, Hamburg, Germany. Electronic address: https://twitter.com/RTwerenbold.
Insights
The European Society of Cardiology 0/1-h algorithm for non-ST-segment elevation myocardial infarction (NSTEMI) using high-sensitivity cardiac troponin is safe and effective. This validated approach rapidly rules out or in NSTEMI, improving patient triage in emergency settings.
Area of Science:
- Cardiology
- Emergency Medicine
- Biomarkers
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.
- Validation of this diagnostic algorithm is crucial for emergency department patient management.
Purpose of the Study:
- To validate the diagnostic performance and safety of the ESC 0/1-h algorithm in a large, multicenter study.
- To assess the algorithm's efficacy in rapidly triaging patients with suspected NSTEMI.
Main Methods:
- Prospective enrollment of unselected patients presenting to emergency departments with NSTEMI symptoms across 6 countries.
- Measurement of high-sensitivity cardiac troponin T (hs-cTnT) and I (hs-cTnI) at presentation and 1 hour.
- Central adjudication of final diagnoses by independent cardiologists to determine algorithm performance metrics (NPV, PPV).
Main Results:
- The ESC 0/1-h algorithm demonstrated high safety and efficacy in both hs-cTnT and hs-cTnI assays.
- For hs-cTnT, the negative predictive value (NPV) for rule-out was 99.8% and the positive predictive value (PPV) for rule-in was 74.5%.
- For hs-cTnI, the NPV was 99.7% and the PPV was 62.3%, with a majority of patients triaged within 1 hour.
Conclusions:
- The ESC 0/1-h algorithm utilizing hs-cTnT and hs-cTnI is a safe and effective tool for triaging patients with suspected NSTEMI.
- The algorithm's performance was confirmed in subgroup analyses, including early presenters.
- This study supports the widespread adoption of the 0/1-h algorithm in clinical practice for efficient NSTEMI diagnosis.
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).
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