Diagnostic validation and prognostic implications of serial 0/1/3h stratification in patients with suspected
Jonas Lehmacher1,2,3, Betül Toprak1,2,3, Nils Arne Sörensen1,2
1Department of Cardiology, University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Germany.
Insights
The 0/1/3-hour algorithm for myocardial infarction (MI) triage using high-sensitivity cardiac troponin T (hs-cTnT) is safe and prognostic. Delayed rule-out indicates significantly higher long-term cardiovascular risk and mortality.
Area of Science:
- Cardiology
- Emergency Medicine
- Biomarker Research
Background:
- European Society of Cardiology (ESC) guidelines recommend 0/1h algorithms for suspected myocardial infarction (MI) triage.
- Recent 3-hour triage cut-offs for high-sensitivity cardiac troponin T (hs-cTnT) lack external validation and clear prognostic implications.
Purpose of the Study:
- To externally validate the diagnostic performance of the 0/1/3h algorithm for cardiovascular events.
- To assess the prognostic impact of the 0/1/3h algorithm in an all-comer MI cohort.
Main Methods:
- Prospective enrollment of emergency department patients with suspected MI.
- Measurement of hs-cTnT at presentation, 1h, and 3h.
- Follow-up for all-cause mortality and major adverse cardiovascular events (MACE) over three years.
Main Results:
- The 0/1/3h algorithm showed excellent rule-out safety (NPV 99.7%) and moderate rule-in capacity (PPV 60.8%).
- Patients ruled-out at 3h had doubled MACE risk (HR 2.11) and quadrupled mortality risk (HR 4.33) compared to immediate rule-out.
- Significant prognostic value was demonstrated for the 3-hour assessment.
Conclusions:
- The 0/1/3h algorithm offers excellent diagnostic safety for suspected MI.
- The algorithm provides significant prognostic information, identifying patients at higher long-term risk.
- Delayed rule-out by the 0/1/3h algorithm is linked to substantially increased cardiovascular risk and mortality.
Background:
The European Society of Cardiology (ESC) recommends 0/1h-algorithms for triage of patients with suspected myocardial infarction (MI). Recently, cut-offs allowing 3h triage using high-sensitivity cardiac troponin T (hs-cTnT) have been derived, but their prognostic implications remain unclear, and external validation is lacking.
Objective:
To externally validate the diagnostic performance and assess the prognostic impact of the 0/1/3h algorithm for cardiovascular events in an all-comer cohort with suspected MI.
Methods:
We prospectively enrolled patients presenting to the emergency department with suspected MI. hs-cTnT was measured at presentation, 1h, and 3h. Patients were followed up to evaluate all-cause mortality and major adverse cardiovascular events (MACE). Diagnostic accuracy was assessed by stratifying patients using the 0/1/3h algorithm. Cox regression analyses compared cardiovascular risk at 90 days and three years between rule-in and rule-out groups.
Results:
Among 2,514 patients (median age 64 years; 63.6% men), the algorithm demonstrated excellent rule-out safety (sensitivity 98.6% [95% CI, 96.8, 99.4]; NPV 99.7% [99.2, 99.9]) and moderate rule-in capacity (specificity 89.3% [87.9, 90.5]; PPV 60.8% [56.8, 64.7]). Over three years, 646 patients experienced MACE, and 256 died (68 cardiac deaths). Patients ruled-out at 3h had doubled MACE risk (HR 2.11 [1.44, 3.08]) and quadrupled mortality risk (HR 4.33 [1.85, 10.12]) compared to immediate rule-out (p<0.001).
Conclusion:
The 0/1/3h algorithm shows excellent diagnostic safety and adds prognostic value, with delayed rule-out associated with significantly increased long-term cardiovascular risk and mortality.
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