0/1-Hour Triage Algorithm for Myocardial Infarction in Patients with Renal Dysfunction
Background—The European Society of Cardiology (ESC) recommends a 0/1h-algorithm for rapid rule-out and rule-in of Non-ST-Segment-Elevation Myocardial Infarction (NSTEMI) using high-sensitivity cardiac troponin (hs-cTn) concentrations irrespective of renal function. As patients with renal dysfunction (RD) frequently present with increased hs-cTn concentrations even in absence of NSTEMI, concern has been raised regarding the performance of the 0/1h-algorithm in RD.
Methods—In a prospective multicenter diagnostic study enrolling unselected patients presenting with suspected NSTEMI to the emergency department, we assessed the diagnostic performance of the ESC 0/1h-algorithm using hs-cTnT and hs-cTnI in patients with RD, defined as an estimated glomerular filtration rate below 60mL/min/1.73m2, and compared it to patients with normal renal function (NRF). The final diagnosis was centrally adjudicated by two independent cardiologists using all available information including cardiac imaging. Safety was quantified as sensitivity in the rule-out zone, accuracy as the specificity in the rule-in zone, and efficacy as the proportion of the overall cohort assigned to either rule-out or rule-in based on the 0h- and 1h-sample.
Results—Among 3254 patients, RD was present in 487 patients (15%). The prevalence of NSTEMI was substantially higher in patients with RD as compared to patients with normal renal function (31% versus 13%, p<0.001). Using hs-cTnT, patients with RD had comparable sensitivity of rule-out (100.0% (95%CI, 97.6-100.0) versus 99.2% (95%CI, 97.6-99.8), p=0.559), lower specificity of rule-in (88.7% (95%CI, 84.8-91.9) versus 96.5% (95%CI, 95.7-97.2), p<0.001), and lower overall efficacy (51% versus 81%, p<0.001), mainly driven by a much lower percentage of patients eligible for rule-out (18% versus 68%, p<0.001), as compared to patients with normal renal function. Using hs-cTnI, patients with RD had comparable sensitivity of rule-out (98.6% (95%CI, 95.0-99.8) versus 98.5% (95%CI, 96.5-99.5), p=1.0), lower specificity of rule-in (84.4% (95%CI, 79.9-88.3) versus 91.7% (95%CI, 90.5-92.9), p<0.001), and lower overall efficacy (54% versus 76%, p<0.001; proportion ruled-out, 18% versus 58%, p<0.001) as compared to patients with normal renal function.
Conclusions—In patients with RD the safety of the ESC 0/1h-algorithm is very high, but specificity of rule-in and overall efficacy are decreased. Modifications of the rule-in and rule-out thresholds did not improve the safety or overall efficacy of the 0/1h-algorithm.
Clinical Trial Registration—URL: https://www.clinicaltrials.gov. Unique Identifier: NCT00470587
- High-sensitivity cardiac troponin
- renal dysfunction
- renal disease
- acute myocardial infarction
- Received April 24, 2017.
- Revision received September 18, 2017.
- Accepted October 19, 2017.
Circulation is published on behalf of the American Heart Association, Inc., by Wolters Kluwer. This is an open access article under the terms of the Creative Commons Attribution Non-Commercial-NoDervis License (http://creativecommons.org/licenses/by-nc-nd/3.0/), which permits use, distribution, and reproduction in any medium, provided that the original work is properly cited, the use is noncommercial, and no modifications or adaptations are made.