The role of cardiac testing with the 0/1-hour high-sensitivity cardiac troponin algorithm evaluating for acute
James McCord1, Aeman Hana2, Bernard Cook3
1Henry Ford Heart and Vascular Institute, Detroit, MI.
Insights
The 0/1-hour algorithm using high-sensitivity troponin effectively rules out acute myocardial infarction (AMI), with very low adverse events in the rule-out zone. Noninvasive testing in this zone showed limited diagnostic value.
Area of Science:
- Cardiology
- Emergency Medicine
- Diagnostic Testing
Background:
- The 0/1-hour algorithm for acute myocardial infarction (AMI) evaluation, utilizing high-sensitivity cardiac troponin (hs-cTnI), requires further study regarding its three zones: rule-out, observation, and rule-in.
- The diagnostic role and utility of cardiac testing within these specific zones of the algorithm remain underexplored.
Purpose of the Study:
- To evaluate the performance of the 0/1-hour algorithm with an hs-cTnI assay in diagnosing AMI.
- To investigate the effectiveness and yield of cardiac testing within the rule-out, observation, and rule-in zones of the algorithm.
Main Methods:
- A prospective study enrolled 552 patients presenting for AMI evaluation.
- hs-cTnI levels were measured at presentation, 1 hour, and 3 hours.
- Echocardiograms, stress tests, and coronary angiography results were recorded, with 30-45 day follow-up for death/AMI.
Main Results:
- Of 552 patients, 45 (8.2%) had AMI (27 Type 1, 18 Type 2).
- The rule-out zone demonstrated a 99.6% negative predictive value for AMI, with a 0.4% major adverse cardiac event (MACE) rate at follow-up.
- Noninvasive testing in the rule-out zone yielded a low diagnostic value, with 4 of 6 abnormal stress tests being false positives.
Conclusions:
- The 0/1-hour algorithm exhibits high sensitivity and negative predictive value for AMI, with a favorable safety profile in the rule-out zone.
- Cardiac testing within the rule-out zone of the 0/1-hour algorithm provides limited diagnostic utility.
Background:
The role of cardiac testing in the 3 zones (rule-out, observation, and rule-in) of the 0/1-hour algorithm to evaluate for acute myocardial infarction (AMI) has not been well studied. This study evaluated the 0/1-hour algorithm with a high-sensitivity cardiac troponin (hs-cTnI) assay and investigated cardiac testing in the 3 zones.
Methods:
Patients (n = 552) at a single urban center were enrolled if they were evaluated for AMI. Blood samples were obtained at presentation, 1 hour, and 3 hours for hs-cTnI. Follow-up at 30 to 45 days for death/AMI was done. The results of echocardiograms, stress testing, and coronary angiography were recorded.
Results:
In total, 45 (8.2%) had AMI (27 Type 1 and 18 Type 2) during the index hospitalization while at follow-up death/AMI occurred in 11 (2.0%) of patients. The rule-out algorithm had a negative predictive value for AMI of 99.6% while the rule-in zone had a positive predictive value of 56.6%. The MACE rate at follow-up was 0.4% for those in the rule-out group. There were 6/95 (6.3%) abnormal stress tests in the rule-out zone and 4 of these were false positives.
Conclusions:
The 0/1-hour algorithm had high diagnostic sensitivity and negative predictive value for AMI, and adverse events were very low in patients in the rule-out zone. Noninvasive testing in rule-out zone patients had low diagnostic yield.
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