A 0/1-Hour Algorithm Using High-Sensitivity Cardiac Troponin
Kenji Inoue1, Masayuki Shiozaki1, Satoru Suwa2
1Juntendo University Nerima Hospital Department of Cardiology Tokyo Japan.
Insights
The European Society of Cardiology (ESC) recommends high-sensitivity cardiac troponin (hs-cTn) 0-hour/1-hour algorithms for suspected non-ST elevation myocardial infarction (NSTEMI). This approach accurately rules out myocardial infarction (MI) and can reduce emergency department crowding and unnecessary procedures.
Area of Science:
- Cardiology
- Biomarkers
- Emergency Medicine
Background:
- The European Society of Cardiology (ESC) guidelines advocate for high-sensitivity cardiac troponin (hs-cTn) 0-hour/1-hour algorithms in patients with suspected non-ST elevation myocardial infarction (NSTEMI).
- These algorithms stratify patients into rule-out, observe, and rule-in groups, incorporating a critical time element.
- The development of highly sensitive hs-cTn assays with low limits of detection and precise 99th percentiles is crucial for algorithm efficacy.
Purpose of the Study:
- To evaluate the effectiveness of hs-cTn 0-hour/1-hour algorithms in diagnosing non-ST elevation myocardial infarction (NSTEMI).
- To assess the potential of these algorithms to reduce emergency department (ED) crowding and unnecessary invasive procedures like coronary angiography (CAG).
Main Methods:
- Application of the ESC-recommended hs-cTn 0-hour/1-hour algorithm in a prospective Asian study of approximately 400 patients with suspected NSTEMI.
- Analysis of patient stratification into rule-out, observe, and rule-in groups based on hs-cTn levels and time points.
- Evaluation of outcomes including need for urgent CAG and diagnosis of myocardial infarction (MI) or unstable angina (UA) within 30 days.
Main Results:
- The hs-cTn algorithm demonstrated high specificity and negative predictive value (>95%) for ruling out MI.
- In a prospective Asian study, no patients in the rule-out or observe groups required urgent CAG within 30 days, despite some undergoing elective procedures.
- The introduction of hs-cTn assays correlated with an increase in NSTEMI diagnoses and a decrease in unstable angina diagnoses.
Conclusions:
- The hs-cTn 0-hour/1-hour algorithm is a valuable tool for the rapid and accurate assessment of patients with suspected NSTEMI.
- This algorithm shows potential to significantly decrease emergency department workload and avoid unnecessary invasive cardiac interventions.
- Combining hs-cTn algorithms with novel risk scores may further enhance diagnostic performance in NSTEMI evaluation.
Abstract:
The European Society of Cardiology (ESC) guidelines recommend the use of high-sensitivity cardiac troponin (hs-cTn) 0-hour/1-hour algorithms in patients presenting with suspected non ST elevation myocardial infarction (NSTEMI) as Class I, Level B. This algorithm stratified patients into three group including, rule-out, observe, and rule-in. The introduction of a time axis consisting of a relatively short time, 0-hour/1-hour, is worth mentioning in this algorithm. The specificity and negative predictive value to rule-out of myocardial infarction (MI) was more than 95%, respectively. In prospective Asian study consist of around 400 patients with suspected NSTEMI, "elective" catheter intervention was performed on 13 patients in both rule-out and observe group. None of them had MI, or needed an urgent coronary angiography (CAG) within 30 days. Although there was two patients on whom CAG and percutaneous coronary intervention (PCI) were performed less than 7 hours after presenting to the emergency department (ED), they were classified as moderate risk according to the Framingham Risk Score. The diagnostic performance for patients with suspected NSTEMI to combine the novel risk score with the algorithm would be much improved. The development of excellent assays was also key to establish the algorithm. The hs-cTn assay has limits of detection (LoD) approximately 10-fold lower than those of conventional assays, and their 99th percentiles are analytically very precise. After the emergence of the hs-cTn assays, rises in the cases of NSTEMI were accompanied by a reciprocal reduction in the percentage of patients diagnosed with unstable angina (UA). This excellent algorithm has a possibility to reduce ED crowding and unnecessary CAG.
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