Performance of the European Society of Cardiology 0/1-Hour Algorithm With High-Sensitivity Cardiac Troponin T Among Patients With Known Coronary Artery Disease

Abstract

ImportanceThe European Society of Cardiology (ESC) 0/1-hour algorithm is a validated high-sensitivity cardiac troponin (hs-cTn) protocol for emergency department patients with possible acute coronary syndrome. However, limited data exist regarding its performance in patients with known coronary artery disease (CAD; prior myocardial infarction [MI], coronary revascularization, or ≥70% coronary stenosis).ObjectiveTo evaluate and compare the diagnostic performance of the ESC 0/1-hour algorithm for 30-day cardiac death or MI among patients with and without known CAD and determine if the algorithm could achieve the negative predictive value rule-out threshold of 99% or higher.Design, Setting, and ParticipantsThis was a preplanned subgroup analysis of the STOP-CP prospective multisite cohort study, which was conducted from January 25, 2017, through September 6, 2018, at 8 emergency departments in the US. Patients 21 years or older with symptoms suggestive of acute coronary syndrome without ST-segment elevation on initial electrocardiogram were included. Analysis took place between February and December 2022.Interventions/ExposuresParticipants with 0- and 1-hour high-sensitivity cardiac troponin T (hs-cTnT) measures were stratified into rule-out, observation, and rule-in zones using the ESC 0/1-hour hs-cTnT algorithm.Main Outcomes and MeasuresCardiac death or MI at 30 days determined by expert adjudicators.ResultsDuring the study period, 1430 patients were accrued. In the cohort, 775 individuals (54.2%) were male, 826 (57.8%) were White, and the mean (SD) age was 57.6 (12.8) years. At 30 days, cardiac death or MI occurred in 183 participants (12.8%). Known CAD was present in 449 (31.4%). Among patients with known CAD, the ESC 0/1-hour algorithm classified 178 of 449 (39.6%) into the rule-out zone compared with 648 of 981 (66.1%) without CAD (P < .001). Among rule-out zone patients, 30-day cardiac death or MI occurred in 6 of 178 patients (3.4%) with known CAD and 7 of 648 (1.1%) without CAD (P < .001). The negative predictive value for 30-day cardiac death or MI was 96.6% (95% CI, 92.8-98.8) among patients with known CAD and 98.9% (95% CI, 97.8-99.6) in patients without known CAD (P = .04).Conclusions and RelevanceAmong patients with known CAD, the ESC 0/1-hour hs-cTnT algorithm was unable to safely exclude 30-day cardiac death or MI. This suggests that clinicians should be cautious if using the algorithm in patients with known CAD. The negative predictive value was significantly higher in patients without a history of CAD but remained less than 99%.

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

“…Ashburn and colleagues assessed the diagnostic and prognostic performance of the ESC 0/1-hour algorithm using hs-cTnT (Roche Diagnostics) among patients in EDs and with a history of CAD. Compared to those without known CAD, patients with CAD (449 of 1430 [31.4%]) were older (62.3 vs 55.4 years), more likely to be male (297 of 449 [66.2%] vs 478 of 981 [48.7%]) and White (293 of 449 [65.3%] vs 533 of 981 [54.3%]), and to have prevalent CAD risk factors.…”

“…These additional findings 14 from STOP-CP are noteworthy and suggest the importance of integrating patient history and biomarkers when stratifying risk among patients presenting to the ED with chest pain. The results also raise the possibility of diminished performance of the 0/1-hour algorithm in the US ED population.…”

“…Turning to the subgroup analysis from Ashburn et al 14 in those with vs without known CAD, after failing to achieve greater than 99% NPV for 30-day cardiac death or MI in the total population, a further decrement in the NPV is expected in the CAD subgroup with its approximately 3-fold higher risk for cardiac events. However, in contrast, in 2 of 3 European studies reporting data in patients with known CAD, the NPV for index MI exceeded 99.4% and was 99.6% for 30-day events in 1 study.…”

“…The subgroup analysis from STOP-CP 14 raises considerations relevant for clinical practice. The findings of a diminished NPV both for index MI and 30-day events in patients presenting with chest pain and known CAD reinforce recommendations in the 2021 AHA/ACC chest pain guidelines that support an integrated approach for risk stratification that includes patient history, electrocardiogram, and serial hs-cTn, using evidencebased clinical decision pathways.…”

“…In 2021, the High-Sensitivity Cardiac Troponin T to Optimize Chest Pain Risk Stratification (STOP-CP) study, a prospective observational cohort study in 8 US EDs, suggested that the negative predictive performance of the 0/1-hour 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 report a subgroup analysis from STOP-CP focusing on patients with a history of coronary artery disease (CAD). This cohort is clinically relevant given that approximately one-third of patients with acute chest pain have known CAD and are at substantially higher risk of coronary events.…”