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Validation of the European Society of Cardiology 0/1-hour algorithm for rule-out and rule-in of acute myocardial infarction

Session Chest pain in the emergency department: the "Biomarkers-Versus-Imaging-Dilemma"

Speaker Raphael Twerenbold

Event : ESC Congress 2017

  • Topic : coronary artery disease, acute coronary syndromes, acute cardiac care
  • Sub-topic : Non-ST-Elevation Myocardial Infarction (NSTEMI)
  • Session type : Advances in Science

Authors : R Twerenbold (Basel,CH), JT Neumann (Hamburg,DE), NA Soerensen (Hamburg,DE), M Karakas (Hamburg,DE), M Rubini Gimenez (Basel,CH), J Boeddinghaus (Basel,CH), C Puelacher (Basel,CH), O Miro (Barcelona,ES), FJ Martin-Sanchez (Madrid,ES), B Morawiec (Katowice,PL), J Parenica (Brno,CZ), T Reichlin (Basel,CH), S Blankenberg (Hamburg,DE), D Westermann (Hamburg,DE), C Mueller (Basel,CH)

Authors:
R. Twerenbold1 , J.T. Neumann2 , N.A. Soerensen2 , M. Karakas2 , M. Rubini Gimenez1 , J. Boeddinghaus1 , C. Puelacher1 , O. Miro3 , F.J. Martin-Sanchez4 , B. Morawiec5 , J. Parenica6 , T. Reichlin1 , S. Blankenberg2 , D. Westermann2 , C. Mueller1 , 1University Hospital Basel - Basel - Switzerland , 2University Heart Center Hamburg, Department of General and Interventional Cardiology - Hamburg - Germany , 3Hospital Clinic de Barcelona - Barcelona - Spain , 4Hospital Clinic San Carlos - Madrid - Spain , 5Medical University of Silesia, Cardiology department - Katowice - Poland , 6University Hospital Brno, Department of Cardiology - Brno - Czech Republic ,

Citation:
European Heart Journal ( 2017 ) 38 ( Supplement ), 453

Background: The European Society of Cardiology (ESC) recommends a 0/1-hour algorithm for rapid rule-out and rule-in of non-ST-segment elevation myocardial infarction (NSTEMI) using high-sensitivity cardiac troponin (hs-cTn) concentrations.

Purpose: We aimed to validate the diagnostic performance of the 0/1-hour algorithm using hs-cTnT and hs-cTnI in a large European multicentre study.

Methods: We prospectively enrolled unselected patients presenting to the emergency department with symptoms suggestive of NSTEMI in six European countries. The final diagnosis was centrally adjudicated by two independent cardiologists. Hs-cTnT (Elecsys) and hs-cTnI (Architect) blood concentrations were measured at presentation and after one hour. Safety of the 0/1-hour-hs-cTn rule-out, which should be used in conjunction with clinical assessment and the ECG, was quantified by the negative predictive value (NPV) and sensitivity for rule-out of NSTEMI. Performance of the 0/1-hour-hs-cTn rule-in, which aims to identify patients eligible for early coronary angiography, was quantified by the positive predictive value (PPV) and specificity for NSTEMI. Efficacy of the 0/1-hour algorithm was quantified by the proportion of patients triaged to either rule-out or rule-in.

Results: Among 4350 patients, NSTEMI was the final diagnosis in 743 (17%) patients. Safety of the 0/1-hour-hs-cTn rule-out was very high for hs-cTnT and hs-cTnI (Figure 1): the NPV was 99.8% (95% CI, 99.5–99.9) and 99.6% (95% CI, 99.1–99.8), and the sensitivity was 99.3% (95% CI, 98.4–99.8) and 98.8% (95% CI, 97.7–99.4), respectively. PPV and specificity of the 0/1-hour algorithm for NSTEMI were 74.7% (95% CI, 71.5–77.7) and 94.5% (95% CI, 93.7–95.2) for hs-cTnT, and 64.2% (95% CI, 61.0–67.2) and 90.4% (95% CI, 89.4–91.4) for hs-cTnI. Efficacy was high by assigning more than two thirds of patients either to rule-out or rule-in (75% and 68%, respectively).

Conclusions: The ESC 0/1-hour algorithm is very safe and effective in triaging patients with suspected NSTEMI.

Clinical trial registration: ClinicalTrials.gov registry, number NCT00470587 (APACE) and NCT02355457 (BACC).

Figure 1

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