Assessment of the European Society of Cardiology 0 Hour/1 Hour Algorithm to Rule Out and Rule In Acute Myocardial Infarction
Background—The European Society of Cardiology (ESC) new guidelines to rule-in and rule-out acute myocardial infarction (AMI) in the emergency department (ED) include a rapid assessment algorithm based on high-sensitivity cardiac troponin and sampling at zero and one hour. ED physicians require very high sensitivity to confidently rule-out AMI, while cardiologists aim to minimise false positive results.
Methods—High-sensitivity troponin I (hs-cTnI) and T (hs-cTnT) assays were used to measure troponin concentrations in patients presenting with chest-pain symptoms and being investigated for possible acute coronary syndrome at hospitals in New Zealand, Australia and Canada. AMI outcomes were independently adjudicated by at least two physicians. The ESC algorithm performance with each assay was assessed by the sensitivity and proportion with AMI ruled out, and the positive predictive value (PPV) and proportion ruled-in.
Results—There were 2222 patients with serial hs-cTnT and hs-cTnI measurements. The hs-cTnT algorithm ruled out 1425 (64.1%) with a sensitivity of 97.1% (95%CI: 94.0% to 98.8%) and ruled-in 292 (13.1%) with a PPV of 63.4% (57.5% to 68.9%)). The hs-cTnI algorithm ruled out 1205 (54.2%) with a sensitivity of 98.8% (96.4% to 99.7%)) and ruled-in 310 (14.0%) with a PPV of 68.1% (62.6% to 73.2%).
Conclusions—The sensitivity of the ESC rapid assessment 0/1h algorithm to rule-out AMI with hs-cTn may be insufficient for some ED physicians to confidently send patients home. These algorithms may prove useful to identify patients requiring expedited management. However, the PPV was modest for both algorithms.
- High-sensitivity cardiac troponin
- myocardial infarction
- emergency department
- emergency medicine
- Received March 31, 2016.
- Revision received August 3, 2016.
- Accepted September 22, 2016.