Dr Lee Chien-Chang
Deputy Director of Intelligent Healthcare and Professor of Emergency Medicine, National Taiwan University Hospital, Taiwan

Comparing the ESC high sensitivity cardiac troponin (hs-cTn) rapid algorithms for triage of AMI patients


  • ESC 0/1hr and 0/2hr algorithms with hs-cTn are the preferred algorithms to use in EDs due to efficiency and safety.
  • Acute Myocardial infarction can be detected earlier for early evidence-based interventions.
  • Successful implementation requires education, improvements in Lab turnaround time and decision support with IT tools.

Q1. What are the current unmet needs in triaging patients presenting with chest pain symptoms to the Emergency Department (ED)?

High-sensitivity cardiac troponin assay have become the preferred biomarker for diagnosing acute myocardial injury in ED patients with chest pain. Several high sensitive cardiac troponin testing pathways are now recommended to rule in or rule out acute myocardial infarction, including the European Society of Cardiology (ESC) 0/1-, 0/2- and 0/3-hour algorithms. Until recently, these algorithms were considered to be equally safe and interchangeable. Clinicians and institutions, however, are unsure which algorithm to use.

Q2. How can the results of this meta-analysis support ED physicians to address the unmet needs?

Having collected more than 400 000 patients from more than 20 cohorts, our international collaborative meta-analysis is the largest to date. In the studies, we found that the ESC 0/1-hour and 0/2-hour algorithms had higher sensitivities and negative predictive values than the 0/3-hour algorithm for triaging patients with suspected acute myocardial infarction. The 0/3-hour algorithm without combination of clinical criteria such as GRACE score or TIMI score shows significantly lower sensitivity (90.2 versus 99.8%). In our results, ESC 0/1-hour and 0/2-hour algorithms are the preferred algorithms to use, not only for their efficiency but also for their safety. Among one thousand patients with chest pain, the 0/1-hour algorithm would miss three cases of AMI, while the 0/3-hour algorithm would miss 15 cases of AMI.

Q3. What are the clinical and economic benefits of using the hs-Tn 0/1hr algorithm in the ED setting?

Using the hs-Tn 0/1hr algorithm in an ED would facilitate quick triage of chest pain patients into three categories, namely, rule out, observe and rule in. Low-risk patients can be safely discharged sooner and AMI can be detected earlier with early evidence-based interventions. The adoption of the 0/1hr algorithm in ED would also help reduce ED overcrowding because chest pain patients account for nearly 10% of all ED visits.

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