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Direct Comparison of the Safety and Efficacy of two Rule-out Strategies for Acute Myocardial Infarction: 1h-algorithm versus 2h-algorithm

Session Poster session 4

Speaker Raphael Twerenbold

Event : ESC Congress 2015

  • Topic : coronary artery disease, acute coronary syndromes, acute cardiac care
  • Sub-topic : Acute Cardiac Care
  • Session type : Poster Session

Authors : R Twerenbold (Basel,CH), M Rubini Gimenez (Basel,CH), K Wildi (Basel,CH), T Reichlin (Basel,CH), C Puelacher (Basel,CH), P Hillinger (Basel,CH), M Wagener (Basel,CH), J Boeddinghaus (Basel,CH), S Osswald (Basel,CH), C Mueller (Basel,CH)

R. Twerenbold1 , M. Rubini Gimenez1 , K. Wildi1 , T. Reichlin1 , C. Puelacher1 , P. Hillinger1 , M. Wagener1 , J. Boeddinghaus1 , S. Osswald1 , C. Mueller1 , 1University Hospital Basel - Basel - Switzerland ,

European Heart Journal ( 2015 ) 36 ( Abstract Supplement ), 590

Purpose: Addressing the increasingly recognized, yet unmet clinical need for rapid rule-out of acute myocardial infarction (AMI), several novel strategies have been developed. Due to the lack of direct comparisons in the same dataset, selection of the best strategy for clinical practice is challenging. We therefore aimed to directly compare the safety and efficacy of two previously defined strategies (High-sensitivity cardiac troponin (hs-cTn) based 1h-algorithm vs hs-cTn based 2h-algorithm).

Methods: In a prospective international multicentre diagnostic study enrolling 1697 patients presenting with suspected AMI to the emergency department, the final diagnosis of AMI was adjudicated by two independent cardiologists using all available clinical information including serial hs-cTnT concentrations. Safety was quantified as the negative predictive value for AMI in the rule-out zone of the respective rule-out strategies. Efficacy was quantified as the percentage of the overall cohort assigned to the rule-out zone by the respective strategy. Both strategies were applied using the best-validated hs-cTn assay (hs-cTnT Roche). The 1h-algorithm rule-out was defined as 0h<12ng/l and Δ0–2h<3ng/l; and the 2h-algorithm rule-out was defined as 0h and 2h<14ng/l and Δ0–2h<4ng/l. As both strategies should only be applied once ST-elevation MI (STEMI) has been excluded by the initial ECG, STEMI patients were excluded from the analysis.

Results: Acute myocardial infarction was the final diagnosis in 16% of patients. The safety was very high and comparable with both algorithms (1h-algorithm: NPV 99.9%, 95% CI 99.5–100% versus 2h-algorithm: NPV 100%, 95% CI 99.7–100%, p=ns). Regarding efficacy, the 1h-algorithm allowed rule-out in 60% of patients versus 64% with the 2h-algorithm (p=0.018).

Conclusion: Both investigated rule-out strategies allow a safe rule-out of AMI. While the 1h-algorithm has the obvious advantage of allowing rule-out already after 1h, the 2h-algorithm tends to be slightly more effective in detecting patients eligible for rule-out.

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