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Multicenter Study
. 2018 Aug 7;72(6):620-632.
doi: 10.1016/j.jacc.2018.05.040.

Prospective Validation of the 0/1-h Algorithm for Early Diagnosis of Myocardial Infarction

Raphael Twerenbold  1 , Johannes Tobias Neumann  2 , Nils Arne Sörensen  2 , Francisco Ojeda  3 , Mahir Karakas  2 , Jasper Boeddinghaus  4 , Thomas Nestelberger  4 , Patrick Badertscher  4 , Maria Rubini Giménez  4 , Christian Puelacher  4 , Karin Wildi  4 , Nikola Kozhuharov  4 , Dominik Breitenbuecher  4 , Ewelina Biskup  4 , Jeanne du Fay de Lavallaz  4 , Dayana Flores  4 , Desiree Wussler  4 , Òscar Miró  5 , F Javier Martín Sánchez  6 , Beata Morawiec  7 , Jiri Parenica  8 , Nicolas Geigy  9 , Dagmar I Keller  10 , Tanja Zeller  2 , Tobias Reichlin  4 , Stefan Blankenberg  2 , Dirk Westermann  11 , Christian Mueller  4
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Free article
Multicenter Study

Prospective Validation of the 0/1-h Algorithm for Early Diagnosis of Myocardial Infarction

Raphael Twerenbold et al. J Am Coll Cardiol. .
Free article

Abstract

Background: The safety of the European Society of Cardiology (ESC) 0/1-h algorithm for rapid rule-out and rule-in of non-ST-segment elevation myocardial infarction (NSTEMI) using high-sensitivity cardiac troponin (hs-cTn) has been questioned.

Objectives: This study aimed to validate the diagnostic performance of the 0/1-h algorithm in a large multicenter study.

Methods: The authors prospectively enrolled unselected patients in 6 countries presenting to the emergency department with symptoms suggestive of NSTEMI. Final diagnosis was centrally adjudicated by 2 independent cardiologists. Hs-cTnT and hs-cTnI blood concentrations were measured at presentation and after 1 h. Safety of rule-out was quantified by the negative predictive value (NPV) for NSTEMI, accuracy of rule-in by the positive predictive value (PPV), and overall efficacy by the proportion of patients triaged towards rule-out or rule-in within 1 h.

Results: Prevalence of NSTEMI was 17%. Among 4,368 patients with serial hs-cTnT measurements available, safety of rule-out (NPV 99.8%, 2,488 of 2,493), accuracy of rule-in (PPV 74.5%, 572 of 768), and overall efficacy were high by assigning three-fourths of patients either to rule-out (57%, 2,493 to 4,368) or rule-in (18%, 768 to 4,368). Similarly, among 3,500 patients with serial hs-cTnI measurements, safety of rule-out (NPV 99.7%, 1,528 of 1,533), accuracy of rule-in (PPV 62.3%, 498 of 800), and overall efficacy were high by assigning more than two-thirds of patients either to rule-out (44%, 1,533 of 3,500) or rule-in (23%, 800 of 3,500). Excellent safety was confirmed in multiple subgroup analyses including patients presenting early (≤3 h) after chest pain onset.

Conclusions: The ESC 0/1-h algorithm using hs-cTnT and hs-cTnI is very safe and effective in triaging patients with suspected NSTEMI. (Advantageous Predictors of Acute Coronary Syndromes Evaluation [APACE]; NCT00470587; and Biomarkers in Acute Cardiac Care [BACC]; NCT02355457).

Keywords: diagnosis of myocardial infarction; diagnostic algorithms; myocardial infarction; rule-in; rule-out; troponin.

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