ESC 0/1-Hour Algorithm Leads the Field in Rapid Troponin-Based MI Rule-Out
Early rule-out strategies for myocardial infarction have evolved from complex multi-component protocols that identified only 10% of low-risk patients to simple hs-cTn-only algorithms that safely classify up to 75% of chest pain patients for rapid rule-out or rule-in. The ESC 0/1-hour algorithm, validated for all currently available hs-cTnT and hs-cTnI assays, best balances safety and efficacy among current options. This review addresses algorithm selection, patient subgroups requiring special attention, implementation challenges, and guidance for safe clinical deployment.
The original study
Early Rule-Out Strategies in the Emergency Department Utilizing High-Sensitivity Cardiac Troponin Assays.
- Authors
- Lopez-Ayala P, Boeddinghaus J, Koechlin L, Nestelberger T, Mueller C
- Journal
- Clinical chemistry
- Type
- Journal Article, Review
- PMID
- 33279982
Original abstract
BACKGROUND: Over the past decade, intense collaboration between academic investigators and the diagnostic industry have allowed the integration of high-sensitivity cardiac troponin (hs-cTn) assays into clinical practice worldwide. The hs-cTn assays, with their increased diagnostic accuracy for acute myocardial infarction (AMI), have facilitated the maturation of early rule-out strategies. The first iteration was complex and required the combination of a biomarker panel, the electrocardiogram, and a clinical risk score and allowed the safe rule-out of AMI in only 10% of patients with acute chest pain. In contrast, the latest iterations, including the European Society of Cardiology (ESC) 0/1-h algorithm, are simple. They are based on hs-cTn concentrations only and allow the safe rule-out or rule-in of AMI in up to 75% of patients. CONTENT: The purposes of this minireview are (a) to describe the best validated hs-cTn-based strategies for early rule-out of AMI, (b) to discuss the advantages and limitations of the different strategies, (c) to identify patient subgroups requiring particular attention, (d) to recognize challenges for widespread clinical implementation, and (e) to provide guidance on strategies for their safe and effective clinical implementation. SUMMARY: Physicians and institutions may choose among several well-validated rule-out algorithms. The ESC 0/1-h algorithm for hs-cTnT or hs-cTnI seems to be the most attractive option today. It best balances safety and efficacy, and it has been derived and validated for all currently available hs-cTnT/I assays, facilitating widespread clinical implementation.