AIMS: We aimed to evaluate the impact of age on the performance of the European Society of Cardiology (ESC) 0/1h-algorithms and to derive and externally validate alternative cut-offs specific to older patients. METHODS AND RESULTS: We prospectively enrolled patients presenting to the emergency department (ED) with symptoms suggestive of acute myocardial infarction in three large diagnostic studies. Final diagnoses were adjudicated by two independent cardiologists. High-sensitivity cardiac troponin (hs-cTn) T and I concentrations were measured at presentation and after 1 h. Patients were stratified according to age [<55 years (young), ≥55 to <70 years (middle-age), ≥70 years (old)]. Rule-out safety of the ESC hs-cTnT 0/1h-algorithm was very high in all age-strata: sensitivity 100% [95% confidence interval (95% CI) 94.9-100] in young, 99.3% (95% CI 96.0-99.9) in middle-age, and 99.3% (95% CI 97.5-99.8) in old patients. Accuracy of rule-in decreased with age: specificity 97.0% (95% CI 95.8-97.9) in young, 96.1% (95% CI 94.5-97.2) in middle-age, and 92.7% (95% CI 90.7-94.3) in older patients. Triage efficacy decreased with increasing age (young 93%, middle-age 80%, old 55%, P < 0.001). Similar results were found for the ESC hs-cTnT 0/1h-algorithm. Alternative, slightly higher cut-off concentrations optimized for older patients maintained very high safety of rule-out, increased specificity of rule-in (P < 0.01), reduced overall efficacy for hs-cTnT (P < 0.01), while maintaining efficacy for hs-cTnI. Findings were confirmed in two validation cohorts (n = 2767). CONCLUSION: While safety of the ESC 0/1h-algorithms remained very high, increasing age significantly reduced overall efficacy and the accuracy of rule-in. Alternative slightly higher cut-off concentrations may be considered for older patients, particularly if using hs-cTnI. CLINICAL TRIAL REGISTRATION: https://clinicaltrials.gov/ct2/show/NCT00470587, number NCT00470587 and NCT02355457 (BACC).

2nd Department of Cardiology School of Medicine with the Division of Dentistry in Zabrze Medical University of Katowice ul M Curie Sklodowskiej 9 Zabrze Poland

Blood Transfusion Centre Swiss Red Cross Hebelstrasse 10 Basel Switzerland

Department of Cardiology Cardiovascular Research Institute Basel University Hospital Basel University of Basel Petersgraben 4 Basel Switzerland

Department of Cardiology University Hospital Brno Jihlavská 20 CZ Brno Czech Republic

Department of General and Interventional Cardiology Hamburg University Heart Center Martinistraße 52 Hamburg Germany

Department of Hematology University Hospital Basel University of Basel Petersgraben 4 Basel Switzerland

Department of Medical Sciences Uppsala University and Uppsala Clinical Research Centre Uppsala University Akademiska sjukhuset Ing 40 5 tr Uppsala Sweden

Division of Internal Medicine University Hospital Basel University of Basel Petersgraben 4 Basel Switzerland

Emergency Department Hospital Clinic Calle Villarroel Barcelona Catalonia Spain

Emergency Department Kantonsspital Liestal Rheinstrasse 26 Liestal Switzerland

Emergency Department University Hospital Zurich Rämistrasse 100 Zürich Switzerland

GREAT Network Via Antonio Serra 54 Rome Italy

Laboratory Medicine University Hospital Basel University of Basel Petersgraben 4 Basel Switzerland

Medical Faculty Masaryk University Kamenice 5 Brno Bohunice Czech Republic

Medizinische Klinik 3 University Heidelberg Im Neuenheimer Feld 410 Heidelberg Germany

Servicio de Urgencias Hospital Clínico San Carlos Profesor Martín Lagos S N Madrid Spain

Eur Heart J. 2018 Nov 7;39(42):3795-3797. doi: 10.1093/eurheartj/ehy526. PubMed

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ClinicalTrials.gov
NCT00470587, NCT02355457