Suspected MI: ESC 0/1-hour triage rule works, real-world data confirm

  • Twerenbold R & al.
  • J Am Coll Cardiol
  • 30 Jul 2019

  • International Clinical Digest
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Takeaway

  • For emergency department (ED) patients with suspected non-ST-segment elevation myocardial infarction (NSTE[MI]), routine use of the European Society of Cardiology (ESC) 0/1-hour triage algorithm with high-sensitivity cardiac troponin T (hs-cTnT) is feasible, fast, and accurate. 
  • Editorial: 
    • “Such impressive prospective safety and effectiveness data favor broader dissemination.”
    • “Further refinements (of existing accelerated diagnostic protocols) will be on the margin, at best.”

Why this matters

  • The 0/1-hour algorithm compares hs-cTnT at presentation and 1 hour later to rule NSTEMI in or out.
  • Though it is supported by evidence, real-world questions remained.

Key results

  • NSTEMI prevalence: 9.8%.
  • Median time between blood draws: 65 minutes.
  • Protocol violations occurred in 6%.
  • Median time in ED: 2 hours 30 minutes.
  • 62% ruled out:
    • Major adverse cardiac event (MACE) rate: 0.2% (95% CI, 0.0%-0.5%).
    • MI within 30 days: 0.1% (95% CI, 0%-0.4%).
  • 71% managed as outpatients: MACE rate, 0.1% (95% CI, 0.0%-0.2%).
  • Missed MI rate: 0%.

Study design

  • Prospective 2-center study of 0/1-hour rule in 2296 ED patients with symptoms suspicious for MI.
  • Outcomes: algorithm performance; 30-day MACE (cardiovascular death, MI).
  • Funding: Multiple industry, European governmental, and nonprofit funders.

Limitations

  • Many eligible patients not enrolled.
  • Only 36% women.
  • High-sensitivity troponin I not assessed.
  • No data on racial or ethnic subgroups.