Performance of the European Society of Cardiology 0/1-Hour Algorithm With High-Sensitivity Cardiac Troponin T Among
Nicklaus P Ashburn1,2, Anna C Snavely1,3, James C O'Neill1
1Department of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina.
Insights
The European Society of Cardiology (ESC) 0/1-hour algorithm for acute coronary syndrome is less reliable for patients with known coronary artery disease (CAD). The algorithm’s negative predictive value was below the 99% threshold in this population.
Area of Science:
- Cardiology
- Emergency Medicine
- Biomarker Analysis
Background:
- The European Society of Cardiology (ESC) 0/1-hour algorithm using high-sensitivity cardiac troponin (hs-cTn) is standard for diagnosing acute coronary syndrome (ACS).
- Limited data exist on its efficacy in patients with pre-existing coronary artery disease (CAD), including prior myocardial infarction (MI) or revascularization.
Purpose of the Study:
- To evaluate the diagnostic performance of the ESC 0/1-hour algorithm in patients with and without known CAD.
- To determine if the algorithm can achieve a negative predictive value (NPV) of 99% or higher for 30-day cardiac death or MI in these groups.
Main Methods:
- A subgroup analysis of the prospective STOP-CP cohort study involving 1430 emergency department patients with ACS symptoms.
- Patients were stratified using the ESC 0/1-hour high-sensitivity cardiac troponin T (hs-cTnT) algorithm.
- Outcomes (30-day cardiac death or MI) were adjudicated by experts.
Main Results:
- The ESC 0/1-hour algorithm classified fewer patients with known CAD (39.6%) into the rule-out zone compared to those without CAD (66.1%).
- Among rule-out patients, 30-day cardiac death or MI occurred in 3.4% with known CAD versus 1.1% without CAD.
- The NPV for 30-day cardiac death or MI was 96.6% in patients with known CAD and 98.9% in those without.
Conclusions:
- The ESC 0/1-hour hs-cTnT algorithm is not sufficiently accurate to rule out 30-day cardiac death or MI in patients with known CAD.
- Clinicians should exercise caution when applying this algorithm to patients with a history of CAD.
- The NPV was significantly lower in patients with known CAD, falling below the desired 99% threshold.
Importance:
The European Society of Cardiology (ESC) 0/1-hour algorithm is a validated high-sensitivity cardiac troponin (hs-cTn) protocol for emergency department patients with possible acute coronary syndrome. However, limited data exist regarding its performance in patients with known coronary artery disease (CAD; prior myocardial infarction [MI], coronary revascularization, or ≥70% coronary stenosis).
Objective:
To evaluate and compare the diagnostic performance of the ESC 0/1-hour algorithm for 30-day cardiac death or MI among patients with and without known CAD and determine if the algorithm could achieve the negative predictive value rule-out threshold of 99% or higher.
Design, Setting, And Participants:
This was a preplanned subgroup analysis of the STOP-CP prospective multisite cohort study, which was conducted from January 25, 2017, through September 6, 2018, at 8 emergency departments in the US. Patients 21 years or older with symptoms suggestive of acute coronary syndrome without ST-segment elevation on initial electrocardiogram were included. Analysis took place between February and December 2022.
Interventions/Exposures:
Participants with 0- and 1-hour high-sensitivity cardiac troponin T (hs-cTnT) measures were stratified into rule-out, observation, and rule-in zones using the ESC 0/1-hour hs-cTnT algorithm.
Main Outcomes And Measures:
Cardiac death or MI at 30 days determined by expert adjudicators.
Results:
During the study period, 1430 patients were accrued. In the cohort, 775 individuals (54.2%) were male, 826 (57.8%) were White, and the mean (SD) age was 57.6 (12.8) years. At 30 days, cardiac death or MI occurred in 183 participants (12.8%). Known CAD was present in 449 (31.4%). Among patients with known CAD, the ESC 0/1-hour algorithm classified 178 of 449 (39.6%) into the rule-out zone compared with 648 of 981 (66.1%) without CAD (P < .001). Among rule-out zone patients, 30-day cardiac death or MI occurred in 6 of 178 patients (3.4%) with known CAD and 7 of 648 (1.1%) without CAD (P < .001). The negative predictive value for 30-day cardiac death or MI was 96.6% (95% CI, 92.8-98.8) among patients with known CAD and 98.9% (95% CI, 97.8-99.6) in patients without known CAD (P = .04).
Conclusions And Relevance:
Among patients with known CAD, the ESC 0/1-hour hs-cTnT algorithm was unable to safely exclude 30-day cardiac death or MI. This suggests that clinicians should be cautious if using the algorithm in patients with known CAD. The negative predictive value was significantly higher in patients without a history of CAD but remained less than 99%.
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