Critical Appraisal of the Negative Predictive Performance of the European Society of Cardiology 0/1-Hour Algorithm for Evaluating Patients With Chest Pain in the US

Abstract

High-sensitivity assays for cardiac troponin (hs-cTn) provide superior analytical performance and accuracy to detect myocardial infarction (MI) compared with conventional cTn assays and are recommended by professional society guidelines as the preferred biomarker for evaluating patients with acute chest pain. 1,2 Clinical decision pathways, including the European Society of Cardiology (ESC) 0/1-hour hs-cTn algorithm, integrate serial measurement of hs-cTn with clinical information to stratify prognosis and the probability of MI. 1,2 Evaluated mostly in European and Australian cohorts, the ESC 0/1-hour algorithm has demonstrated excellent diagnostic performance to rule out MI among patients presenting to the emergency department (ED) with chest pain (Table ). 15 However, fewer studies have evaluated the 0/1-hour strategy in the US, where testing patterns in the ED and regulatory requirements for reporting hs-cTn values differ from elsewhere in the world. With the inclusion of the 0/1-hour algorithm among recommended clinical decision pathways in the 2021 American Heart Association/American College of Cardiology (AHA/ACC) chest pain guidelines, such studies are meaningful for US practice. 2 In 2021, the High-Sensitivity Cardiac Troponin T to Optimize Chest Pain Risk Stratification (STOP-CP) study, 13 a prospective observational cohort study in 8 US EDs, suggested that the negative predictive performance of the 0/1hour algorithm using hs-cTnT might be lower in the US and that adding a clinical score is necessary to improve such performance into an acceptable range. Ashburn and colleagues 14 report a subgroup analysis from STOP-CP focusing on patients Opinion