Abstract link:http://www.onlinejacc.org/content/74/4/483.abstract
Full citation: Twerenbold R, Costabel JP, Nestleberger T, et al. Outcome of applying the ESC 0/1-hour algorithm in patients with suspected myocardial infarction. J Am Coll Cardiol 2019;74(4):483–94.
Article type: Diagnosis
Ratings: Methods – 3/5 Usefulness – 4/5
INTRODUCTION
Background
The European Society of Cardiology (ESC) recommends the 0/1-hour troponin dosage algorithm for rapid triage of patients with chest pain and suspected non-ST segment elevation myocardial infarction (MI).
Objectives
To determine safety, performance, and applicability of the 0/1-hour troponin triage algorithm when routinely applied in the emergency room
METHODS
Design
Prospective cohort study
Setting
Two university centres in Switzerland and Argentina
Subjects
Adult patients presenting with chest pain suggestive of MI; exclusion if STEMI diagnosis
Intervention
Standard assessment with history and physical examination plus determination of hs-cTnT at presentation and 1 hour after initial medical encounter. Management of patients was left to the discretion of the attending clinicians who were blinded to the study's outcomes.
Outcomes
Primary outcomes were triage performance when using the algorithm and 30-day rate of major adverse clinical events (MACE): cardiovascular death and MI. Secondary outcomes were feasibility and adherence to the triage algorithm and impact on emergency department (ED) resources use and length of stay.
MAIN RESULTS
The ESC 0/1-hour algorithm triaged 62% of patients towards “rule-out” category with a 0 h troponin T < 5 ng/L or a 0 h < 12 ng/L and 1 h change < 3 ng/L. In the “rule-out” group, 88% of patients underwent outpatient management with a 0,1% occurrence of 30-day MACE. The remaining patients (12%) were treated as inpatients without justification provided, and 28% of these patients underwent revascularization therapy with 0,2% of 30-day MACE. The overall 30-day MACE in the “rule-out” category was 0,2% and does not include revascularization therapy. The algorithm was strictly adhered in 94% of patients’ encounters with an average time between the blood draws of 65 minutes. The median time to discharge from the ED or transfer to a hospital ward was 2 hrs, 30 min.
APPRAISAL
Strengths
• Patient-oriented outcomes.
• Strong internal validity due to high adherence to algorithm.
• A complete patient follow-up for 30-day MACE – no lost to follow-up.
Limitations
• Data collection performed in EDs where 0–1 h protocol is already a standard of care and clinicians' awareness of the goal of the study sets a potential Hawthorne effect.
• Level and specialty of the clinicians performing the evaluation are unknown.
• Potential selection bias: recruitment method is unknown.
• Current algorithm cutoffs are only applicable to hs-cTnT assay (Elecsys 2010 high-sensitivity troponin T) not available in all EDs.
• No standardization of the “rule-out” patient cohort ED or post-ED management. Decision criteria to admit patients and to investigate as outpatients were not described. Early access to stratification testing and revascularization could have led to lower rates of 30-day MACE in this group.
• Revascularization was not considered as a primary outcome or an MACE. Interestingly, in the “rule-out” cohort, 4.4% of patients underwent revascularization following their ED visit.
CONTEXT
This study builds on the emerging literature showing the capacity of high-sensitivity troponin assays and short interval blood draws to reduce MI diagnosis delays and therefore allows for a more rapid initiation of adequate therapy. The ESC 0/1 hour algorithm appears to be safe and to effectively decrease time to ED discharge with a 30-day MACE rate of 0.1% in the outpatient cohort of 1,619 patients. Furthermore, a recent study showed the 0/1 hour TnT protocol to be non-inferior to the standardized 0/3 hours hs-cTnT protocol.Reference Chew, Lambrakis and Blyth1
BOTTOM LINE
The ESC 0/1 h hs-cTnT algorithm allows for safe early discrimination of patients presenting to the ED with chest pain and suspected NSTEMI in the presented cohort.Reference Roffi, Patrono and Collet2 Nevertheless, 4.4% of patients in the “rule-out” low-risk group underwent revascularization procedure, which was not considered an MACE in this study. Moreover, this algorithm is not applicable to early presenters (< 3 hrs), patient with ongoing pain, or known renal insufficiency. Further studies acknowledging the safety with the different types of troponin assay are required for general applicability.Reference Levy and Mahler3
Abstract link:http://www.onlinejacc.org/content/74/4/483.abstract
Full citation: Twerenbold R, Costabel JP, Nestleberger T, et al. Outcome of applying the ESC 0/1-hour algorithm in patients with suspected myocardial infarction. J Am Coll Cardiol 2019;74(4):483–94.
Article type: Diagnosis
Ratings: Methods – 3/5 Usefulness – 4/5
INTRODUCTION
Background
The European Society of Cardiology (ESC) recommends the 0/1-hour troponin dosage algorithm for rapid triage of patients with chest pain and suspected non-ST segment elevation myocardial infarction (MI).
Objectives
To determine safety, performance, and applicability of the 0/1-hour troponin triage algorithm when routinely applied in the emergency room
METHODS
Design
Prospective cohort study
Setting
Two university centres in Switzerland and Argentina
Subjects
Adult patients presenting with chest pain suggestive of MI; exclusion if STEMI diagnosis
Intervention
Standard assessment with history and physical examination plus determination of hs-cTnT at presentation and 1 hour after initial medical encounter. Management of patients was left to the discretion of the attending clinicians who were blinded to the study's outcomes.
Outcomes
Primary outcomes were triage performance when using the algorithm and 30-day rate of major adverse clinical events (MACE): cardiovascular death and MI. Secondary outcomes were feasibility and adherence to the triage algorithm and impact on emergency department (ED) resources use and length of stay.
MAIN RESULTS
The ESC 0/1-hour algorithm triaged 62% of patients towards “rule-out” category with a 0 h troponin T < 5 ng/L or a 0 h < 12 ng/L and 1 h change < 3 ng/L. In the “rule-out” group, 88% of patients underwent outpatient management with a 0,1% occurrence of 30-day MACE. The remaining patients (12%) were treated as inpatients without justification provided, and 28% of these patients underwent revascularization therapy with 0,2% of 30-day MACE. The overall 30-day MACE in the “rule-out” category was 0,2% and does not include revascularization therapy. The algorithm was strictly adhered in 94% of patients’ encounters with an average time between the blood draws of 65 minutes. The median time to discharge from the ED or transfer to a hospital ward was 2 hrs, 30 min.
APPRAISAL
Strengths
• Patient-oriented outcomes.
• Strong internal validity due to high adherence to algorithm.
• A complete patient follow-up for 30-day MACE – no lost to follow-up.
Limitations
• Data collection performed in EDs where 0–1 h protocol is already a standard of care and clinicians' awareness of the goal of the study sets a potential Hawthorne effect.
• Level and specialty of the clinicians performing the evaluation are unknown.
• Potential selection bias: recruitment method is unknown.
• Current algorithm cutoffs are only applicable to hs-cTnT assay (Elecsys 2010 high-sensitivity troponin T) not available in all EDs.
• No standardization of the “rule-out” patient cohort ED or post-ED management. Decision criteria to admit patients and to investigate as outpatients were not described. Early access to stratification testing and revascularization could have led to lower rates of 30-day MACE in this group.
• Revascularization was not considered as a primary outcome or an MACE. Interestingly, in the “rule-out” cohort, 4.4% of patients underwent revascularization following their ED visit.
CONTEXT
This study builds on the emerging literature showing the capacity of high-sensitivity troponin assays and short interval blood draws to reduce MI diagnosis delays and therefore allows for a more rapid initiation of adequate therapy. The ESC 0/1 hour algorithm appears to be safe and to effectively decrease time to ED discharge with a 30-day MACE rate of 0.1% in the outpatient cohort of 1,619 patients. Furthermore, a recent study showed the 0/1 hour TnT protocol to be non-inferior to the standardized 0/3 hours hs-cTnT protocol.Reference Chew, Lambrakis and Blyth1
BOTTOM LINE
The ESC 0/1 h hs-cTnT algorithm allows for safe early discrimination of patients presenting to the ED with chest pain and suspected NSTEMI in the presented cohort.Reference Roffi, Patrono and Collet2 Nevertheless, 4.4% of patients in the “rule-out” low-risk group underwent revascularization procedure, which was not considered an MACE in this study. Moreover, this algorithm is not applicable to early presenters (< 3 hrs), patient with ongoing pain, or known renal insufficiency. Further studies acknowledging the safety with the different types of troponin assay are required for general applicability.Reference Levy and Mahler3
Competing interests
None declared.