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Real-world Outcome of the ESC 0/1-hour Algorithm when Routinely Applied in Early Presenters

Session High sensitivity troponins in patients with suspected acute coronary syndromes

Speaker Raphael Twerenbold

Event : ESC Congress 2019

  • Topic : coronary artery disease, acute coronary syndromes, acute cardiac care
  • Sub-topic : Acute Coronary Syndromes – Epidemiology, Prognosis, Outcome
  • Session type : Advances in Science

Authors : R Twerenbold (Basel,CH), JP Costabel (Buenos Aires,AR), R Campos (Buenos Aires,AR), R Arbucci (Buenos Aires,AR), T Nestelberger (Basel,CH), J Boeddinghaus (Basel,CH), M Rubini (Basel,CH), D Wussler (Basel,CH), F Lambardi (Buenos Aires,AR), S Resi (Buenos Aires,AR), M Trivi (Buenos Aires,AR), C Mueller (Basel,CH)

Authors:
R. Twerenbold1 , J.P. Costabel2 , R. Campos2 , R. Arbucci2 , T. Nestelberger1 , J. Boeddinghaus1 , M. Rubini1 , D. Wussler1 , F. Lambardi2 , S. Resi2 , M. Trivi2 , C. Mueller1 , 1University Hospital Basel - Basel - Switzerland , 2Cardiovascular Institute of Buenos Aires (ICBA), Cardiology - Buenos Aires - Argentina ,

Citation:
European Heart Journal ( 2019 ) 40 ( Supplement ), 67

Background: The European Society of Cardiology (ESC) recommends the use of a 0/1h-algorithm for rapid triage of patients with suspected non-ST-elevation myocardial infarction (NSTEMI) using high-sensitivity cardiac troponin (hs-cTn). Concerns were articulated about its efficacy and particularly safety when applied in patients presenting early (≤3 hours) after chest pain onset, as hs-cTn concentrations might still be very low or even undetectable in these high-risk patients.

Purpose: We aimed to assess the real-world effectiveness, efficacy, and ultimately safety of the ESC 0/1h-algorithm when routinely applied in early presenters.

Methods: In a prospective international multicenter study enrolling unselected patients presenting with suspected NSTEMI to the ED, patients were assessed according to the ESC 0/1h-algorithm using high-sensitivity cardiac troponin T embedded in routine clinical care. Patients with ST-segment elevation myocardial infarctions were excluded. Safety was quantified by the 30-day incidence of major adverse cardiac events (MACE, defined as the composite of cardiovascular death and myocardial infarction including the index event) in the rule-out group and in outpatients.

Results: Among 2296 patients, 819 (36%) were early presenters. NSTEMI prevalence in early presenters was 11%. Effectiveness was very high as 97% of patients triaged towards rule-out by the ESC 0/1h-algorithm did not require additional cardiac investigations including hs-cTnT measurements at later time points (e.g. 3–12h) or coronary CT-angiography in the ED. Median time to discharge or transfer from the ED was 150 minutes [q1130, q3215]. Efficacy of the ESC 0/1h-algorithm was very high: 67% of patients were triaged towards rule-out and 14% towards rule-in of NSTEMI. Overall, 75% of early presenters underwent outpatient management. Safety of rule-out and outpatient management were excellent in early presenters with a 30-day MACE incidence of both 0% and comparable with 0.3% and 0.1% in late presenters, respectively (p=ns).

Conclusions: These real-world data document for the first time the excellent effectiveness, efficacy and particularly safety of the ESC 0/1h-algorithm when routinely applied in early presenters. No differences in safety could be observed when compared with late presenters.

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