Ruling In Myocardial Injury and Ruling Out Myocardial Infarction With the European Society of Cardiology (ESC) 1-Hour Algorithm
High sensitivity cardiac troponin (hscTn) assays are used everywhere except in the United States.1 One potential advantage of these assays is the ability to triage patients with possible ischemia more rapidly and, there is an understandable desire to find easy, facile algorithms to do this. This was the approach taken with hscTn in the evaluation of patients with possible acute myocardial infarction (AMI) using an algorithm developed by the Advantageous Predictors of Acute Coronary Syndromes Evaluation (APACE) trial.2 Intrinsic to it is the concept that both ruling-out and ruling-in AMI rapidly (within one hour) is based on initially low concentrations (<2 ng/L for hscTnI Abbott and < 5 ng/L hscTnT Roche) or small changes over the first hour (<2 ng/L hscTnI and <3 ng/L hscTnT) for ruling out and the use of larger changes (6 ng/L hscTnI and 5 ng/L hscTnT) and fixed cut off concentrations for ruling in (see Figure 1 of the article by Pickering et al in this issue of Circulation).3 Unfortunately, the validation of this algorithm has often left a good deal to be desired. Despite that fact, it was incorporated into the European Society of Cardiology (ESC) guidelines.4
- Received August 22, 2016.
- Revision received September 30, 2016.
- Accepted October 3, 2016.