Over the last decade, intense collaboration between physician scientists and the diagnostic industry has enabled game-changing innovation in the rapid rule-out and/or rule-in of acute myocardial infarction (AMI). High sensitivity cardiac troponin (hs-cTn) assays enable reliable measurement of cardiac troponin (cTn) concentrations in the normal range, thereby increasing substantially the diagnostic accuracy for AMI already with the first blood draw performed at presentation to the emergency department (ED).
This was a prerequisite for the development and maturation of early rule-out and rule-in strategies for AMI into clinical practice worldwide.
While 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, the latest iterations including the European Society of Cardiology (ESC) 0/1h-algorithm are simple, as they are based on hs-cTn concentrations only, and allow the safe rule-out AND/OR rule-in of AMI in about 75% of patients.
The ESC 0/1h-algorithm is a combination of the single measurement approach with the original 0/1h-algorithm. It has all the advantages of the single measurement approach (speed and simplicity), but further extends the number of patients eligible for triage towards rule-out of AMI to those patients with low hs-cTnT/I concentrations at presentation and NO relevant change (rise AND/OR fall) in hs-cTnT/I concentrations after 1h.
It also adds the possibility to triage patients towards rule-in of AMI using high initial hs-cTnT/I concentrations and/or relevant changes in hs-cTnT/I after 1h.
The ESC 0/1h-algorithm has been derived and validated for all currently available hs-cTnT/I assays, with unique data-driven cut-off values for each assay to achieve a sensitivity and NPV of 99% or higher, is recommended by the NSTEMI ESC Guidelines with a class I recommendation, and has recently been shown to be superior to 0/3h-protocols in both a randomized controlled trial, and in a large diagnostic study with central adjudication of final diagnoses.
Safe and effective implementation into clinical routine has also been documented.
Prof. Christian Eugene Mueller, FESC
Department of Cardiology
Resources below have been selected by Dr. Hrvoje Jurin
ACVC Clinical Decision-Making Toolkit
Chapter 2 Acute Coronary Syndroms
Acute Cardiovascular Care Congress Resources
ESC Congress Resources
A selection of resources from ESC congresses:
- Performance of the ESC 0/3-hour algorithm for rapid triage of myocardial infarction: systematic
review and meta-analysis
- Cardiac troponins - Rule in, rule out.
- Impact of Renal Dysfunction on Real-world Outcome of the ESC 0/1-hour Algorithm
- The clinical use of high-sensitivity troponin at the point-of-care in combination with ESC 1-hour algorithm
- Implementation of the ESC 1-hour algorithm for the evaluation of chest pain
ESC Clinical Practice Guidelines
- 2020 Acute Coronary Syndromes (ACS) in Patients Presenting without Persistent ST-Segment Elevation (Management of) Guidelines
European Heart Journal - Acute Cardiovascular Care
- Undetectable high-sensitivity troponin in combination with clinical assessment for risk stratification
of patients with chest pain and normal troponin at hospital arrival
- Differences in measurement of high-sensitivity troponin in an on-demand and batch-wise setting
- RAPID-CPU: a prospective study on implementation of the ESC 0/1-hour algorithm and safety of
discharge after rule-out of myocardial infarction
- Performance of the European Society of Cardiology 0/1-hour algorithm in the diagnosis of
myocardial infarction with high-sensitivity cardiac troponin: Systematic review and meta-analysis
COVID-19 and Cardiology
- Acute myocardial infarction due to unrecognized Kawasaki’s disease in a 14 year-old boy
- Triple trouble: an unusual case of MINOCA associated with extra-cardiac complications