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A Common Algorithm for Cardiac Troponin to Rule Out and Rule in Acute Myocardial Infarction
Niklas Thieβen1, John W Pickering2, Caroline Kellner3
1Department of Cardiology, University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
Insights
The 3C algorithm provides a universal approach for diagnosing myocardial infarction (MI) using high-sensitivity cardiac troponin (hs-cTn) levels, simplifying current methods.
Area of Science:
- Cardiology
- Biomarker Analysis
- Diagnostic Algorithm Development
Background:
- Current diagnostic algorithms for myocardial infarction (MI) rely on specific high-sensitivity cardiac troponin (hs-cTn) cutoff values and change criteria, posing a limitation.
- Evaluating a common change criteria algorithm (3C) for hs-cTn is crucial for improving MI diagnosis.
- Comparison with established European Society of Cardiology (ESC) algorithms for MI rule-out and rule-in is needed.
Purpose of the Study:
- To evaluate the 3C algorithm for hs-cTn in diagnosing MI.
- To compare the diagnostic performance of the 3C algorithm against established ESC algorithms.
- To assess the effectiveness and reclassification improvement of the 3C algorithm.
Main Methods:
- The 3C algorithm was applied to prospective cohort studies involving patients with suspected MI and serial hs-cTn measurements.
- Diagnostic performance metrics including sensitivity, specificity, predictive values, and likelihood ratios were calculated for the 3C and ESC algorithms.
- Analyses included confusion matrices, net reclassification improvement, and effectiveness (rule-in/rule-out percentages).
Main Results:
- Comparable diagnostic accuracy was observed between the 3C and ESC algorithms.
- The 3C algorithm ruled in more MI patients compared to the ESC algorithm.
- Effectiveness varied by hs-cTn assay, with higher effectiveness for 3C with hs-cTnI but not hs-cTnT.
Conclusions:
- The 3C algorithm presents a uniform, assay-agnostic alternative for MI diagnosis.
- This algorithm is independent of the timing of serial hs-cTn sampling.
- The 3C algorithm simplifies MI diagnosis by removing the need for assay-specific criteria.
Background:
A limitation of diagnostic algorithms in patients with suspected myocardial infarction (MI) is the requirement for assay-specific high-sensitivity cardiac troponin (hs-cTn) cutoff concentrations and change criteria. In this study we evaluated a common change criteria algorithm (3C) for hs-cTn and compared it with established algorithms for the rule out and rule in of MI.
Methods:
We applied the 3C algorithm in 2 prospective cohort studies (with 3 different hs-cTn assays) of patients who presented to the emergency department with suspected MI who had serial hs-cTn results available. Diagnostic performance measures (sensitivity, specificity, predictive values, likelihood ratios) for MI were obtained for the 3C (change criteria > |3| ng/L for < 10 ng/L, > |30|% between 10 and 100 ng/L, and > |15|% for > 100 ng/L), and the European Society of Cardiology (ESC) algorithms for rule in and rule out. Confusion matrices, net reclassification improvement, and effectiveness (percentage rule in and rule out) analyses were also performed.
Results:
In 5011 patients, the MI prevalence was 16.12% (n = 811). Comparable diagnostic accuracy in terms of sensitivity, specificity, and predictive values were observed between the 3C and ESC algorithms. Direct comparison of the algorithms via net reclassification improvement showed no decisive advantage for either algorithm. Confusion matrices for all 3 assays for the 0- and/or 1-hour and 0- and/or 2-hour sampling identified that the 3C ruled in more patients with an MI who were ruled out using the ESC algorithm. Effectiveness was higher for 3C (83.2%-88.8%) vs ESC (64.4%-74.5%) for hs-cTnI but not for hs-cTnT (64.5%-71.8% vs 72.4%-80.6%, respectively).
Conclusions:
The 3C algorithm offers a uniform, assay agnostic alternative to established algorithms, independent of timing of serial sampling.
Clinical Trial Registrations:
NCT02355457, ACTR,12611001069943, ANZCTR12610000766011, and ANZCTR12613000745741.
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