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).

2nd Department of Cardiology Medical University of Silesia Zabrze Poland

Cardiovascular Research Institute Basel and Department of Cardiology University Hospital Basel University of Basel Basel Switzerland

Cardiovascular Research Institute Basel and Department of Cardiology University Hospital Basel University of Basel Basel Switzerland; Department of General and Interventional Cardiology University Heart Center Hamburg University Hospital Hamburg Eppendorf Hamburg Germany https twitter com RTwerenbold

Department of Cardiology University Hospital Brno Brno Czech Republic; Medical Faculty Masaryk University Brno Czech Republic

Department of General and Interventional Cardiology University Heart Center Hamburg University Hospital Hamburg Eppendorf Hamburg Germany

Department of General and Interventional Cardiology University Heart Center Hamburg University Hospital Hamburg Eppendorf Hamburg Germany; German Centre for Cardiovascular Research Partner Site Hamburg Luebeck Kiel Hamburg Germany

Emergency Department Hospital Clinic Barcelona Catalonia Spain

Emergency Department Kantonsspital Baselland Liestal Switzerland

Emergency Department University Hospital Zurich Zurich Switzerland

Servicio de Urgencias Hospital Clínico San Carlos Madrid Spain

J Am Coll Cardiol. 2018 Aug 7;72(6):633-635. doi: 10.1016/j.jacc.2018.05.041. PubMed

J Am Coll Cardiol. 2018 Dec 11;72(23 Pt A):2940. doi: 10.1016/j.jacc.2018.09.053. PubMed

J Am Coll Cardiol. 2018 Dec 11;72(23 Pt A):2941. doi: 10.1016/j.jacc.2018.09.054. PubMed

References provided by Crossref.org

Association of accompanying dyspnoea with diagnosis and outcome of patients presenting with acute chest discomfort