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Multicenter Study
. 2018 Jan 30;137(5):436-451.
doi: 10.1161/CIRCULATIONAHA.117.028901. Epub 2017 Nov 3.

0/1-Hour Triage Algorithm for Myocardial Infarction in Patients With Renal Dysfunction

Raphael Twerenbold  1   2 , Patrick Badertscher  1 , Jasper Boeddinghaus  1 , Thomas Nestelberger  1 , Karin Wildi  1 , Christian Puelacher  1 , Zaid Sabti  1 , Maria Rubini Gimenez  1 , Sandra Tschirky  1 , Jeanne du Fay de Lavallaz  1 , Nikola Kozhuharov  1 , Lorraine Sazgary  1 , Deborah Mueller  1 , Tobias Breidthardt  1 , Ivo Strebel  1 , Dayana Flores Widmer  1 , Samyut Shrestha  1 , Òscar Miró  3 , F Javier Martín-Sánchez  4 , Beata Morawiec  5 , Jiri Parenica  6   7 , Nicolas Geigy  8 , Dagmar I Keller  9 , Katharina Rentsch  10 , Arnold von Eckardstein  11 , Stefan Osswald  1 , Tobias Reichlin  1 , Christian Mueller  12
Affiliations
Multicenter Study

0/1-Hour Triage Algorithm for Myocardial Infarction in Patients With Renal Dysfunction

Raphael Twerenbold et al. Circulation. .

Abstract

Background: The European Society of Cardiology recommends a 0/1-hour algorithm for rapid rule-out and rule-in of non-ST-segment elevation myocardial infarction using high-sensitivity cardiac troponin (hs-cTn) concentrations irrespective of renal function. Because patients with renal dysfunction (RD) frequently present with increased hs-cTn concentrations even in the absence of non-ST-segment elevation myocardial infarction, concern has been raised regarding the performance of the 0/1-hour algorithm in RD.

Methods: In a prospective multicenter diagnostic study enrolling unselected patients presenting with suspected non-ST-segment elevation myocardial infarction to the emergency department, we assessed the diagnostic performance of the European Society of Cardiology 0/1-hour algorithm using hs-cTnT and hs-cTnI in patients with RD, defined as an estimated glomerular filtration rate <60 mL/min/1.73 m2, and compared it to patients with normal renal function. The final diagnosis was centrally adjudicated by 2 independent cardiologists using all available information, including cardiac imaging. Safety was quantified as sensitivity in the rule-out zone, accuracy as the specificity in the rule-in zone, and efficacy as the proportion of the overall cohort assigned to either rule-out or rule-in based on the 0- and 1-hour sample.

Results: Among 3254 patients, RD was present in 487 patients (15%). The prevalence of non-ST-segment elevation myocardial infarction was substantially higher in patients with RD compared with patients with normal renal function (31% versus 13%, P<0.001). Using hs-cTnT, patients with RD had comparable sensitivity of rule-out (100.0% [95% confidence interval {CI}, 97.6-100.0] versus 99.2% [95% CI, 97.6-99.8]; P=0.559), lower specificity of rule-in (88.7% [95% CI, 84.8-91.9] versus 96.5% [95% CI, 95.7-97.2]; P<0.001), and lower overall efficacy (51% versus 81%, P<0.001), mainly driven by a much lower percentage of patients eligible for rule-out (18% versus 68%, P<0.001) compared with patients with normal renal function. Using hs-cTnI, patients with RD had comparable sensitivity of rule-out (98.6% [95% CI, 95.0-99.8] versus 98.5% [95% CI, 96.5-99.5]; P=1.0), lower specificity of rule-in (84.4% [95% CI, 79.9-88.3] versus 91.7% [95% CI, 90.5-92.9]; P<0.001), and lower overall efficacy (54% versus 76%, P<0.001; proportion ruled out, 18% versus 58%, P<0.001) compared with patients with normal renal function.

Conclusions: In patients with RD, the safety of the European Society of Cardiology 0/1-hour algorithm is high, but specificity of rule-in and overall efficacy are decreased. Modifications of the rule-in and rule-out thresholds did not improve the safety or overall efficacy of the 0/1-hour algorithm.

Clinical trial registration: URL: https://www.clinicaltrials.gov. Unique identifier: NCT00470587.

Keywords: 0/1-hour algorithm; chronic kidney disease; diagnosis of acute myocardial infarction; high-sensitivity cardiac troponin; renal dysfunction.

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Figures

Figure 1.
Figure 1.
Performance of the European Society of Cardiology 0/1-hour algorithm using high-sensitivity cardiac troponin T in patients with renal dysfunction and normal renal function. Flow charts depicting the diagnostic performance of the European Society of Cardiology 0/1-hour algorithm for rule-out and rule-in of non–ST-segment elevation myocardial infarction in (A) patients with renal dysfunction (defined as an estimated glomerular filtration rate <60 mL/min/1.73 m2), and (B) patients with normal renal function using high-sensitivity cardiac troponin T (hs-cTnT, Elecsys analyzer). 1h-change indicates absolute (unsigned) change of high-sensitivity cardiac troponin within 1 hour; n.a., not applicable; NPV, negative predictive value; NSTEMI, non–ST-segment elevation myocardial infarction; PPV, positive predictive value; Sens, Sensitivity; and Spec, specificity. *If chest pain onset >3 hours before presentation to the emergency department.
Figure 2.
Figure 2.
Performance of the European Society of Cardiology 0/1-hour algorithm using high-sensitivity cardiac troponin T in different stages of renal function. hs-cTnT indicates high-sensitivity cardiac troponin T; and NSTEMI, non–ST-segment elevation myocardial infarction.
Figure 3.
Figure 3.
Performance of the European Society of Cardiology 0/1-hour algorithm using high-sensitivity cardiac troponin I in patients with renal dysfunction and normal renal function. Flow charts depicting the diagnostic performance of the European Society of Cardiology 0/1-hour algorithm for rule-out and rule-in of non–ST-segment elevation myocardial infarction in patients with (A) renal dysfunction and (B) normal renal function using high-sensitivity cardiac troponin I (hs-cTnI, Architect analyzer). 1-h change indicates absolute (unsigned) change of high-sensitivity cardiac troponin within 1 hour; NPV, negative predictive value; NSTEMI, non–ST-segment elevation myocardial infarction; PPV, positive predictive value; Sens, sensitivity; and Spec, specificity. *If chest pain onset >3 hours before presentation to the emergency department.
Figure 4.
Figure 4.
Performance of the European Society of Cardiology 0/1-hour algorithm using high-sensitivity cardiac troponin I in different stages of renal function. hs-cTnI indicates high-sensitivity cardiac troponin I; and NSTEMI, non–ST-segment elevation myocardial infarction.
Figure 5.
Figure 5.
Short- and midterm survival according to risk stratification group by the European Society of Cardiology 0/1-hour algorithm using high-sensitivity cardiac troponin T and I in patients with normal renal function and renal dysfunction. Kaplan-Meier curves depicting overall survival within 30 and 720 days for patients with normal renal function (dashed lines) and renal dysfunction (solid lines) stratified by the European Society of Cardiology 0/1-hour algorithm to the rule-out (green lines), observational (orange lines), and rule-in (red lines) groups. A, Using high-sensitivity cardiac troponin T. B, Using high-sensitivity cardiac troponin I.
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References

    1. Roffi M, Patrono C, Collet JP, Mueller C, Valgimigli M, Andreotti F, Bax JJ, Borger MA, Brotons C, Chew DP, Gencer B, Hasenfuss G, Kjeldsen K, Lancellotti P, Landmesser U, Mehilli J, Mukherjee D, Storey RF, Windecker S, Baumgartner H, Gaemperli O, Achenbach S, Agewall S, Badimon L, Baigent C, Bueno H, Bugiardini R, Carerj S, Casselman F, Cuisset T, Erol Ç, Fitzsimons D, Halle M, Hamm C, Hildick-Smith D, Huber K, Iliodromitis E, James S, Lewis BS, Lip GY, Piepoli MF, Richter D, Rosemann T, Sechtem U, Steg PG, Vrints C, Luis Zamorano J Management of Acute Coronary Syndromes in Patients Presenting without Persistent ST-Segment Elevation of the European Society of Cardiology. 2015 ESC guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation: task force for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation of the European Society of Cardiology (ESC). Eur Heart J. 2016;37:267–315. doi: 10.1093/eurheartj/ehv320. - PubMed
    1. Amsterdam EA, Wenger NK, Brindis RG, Casey DE, Jr, Ganiats TG, Holmes DR, Jr, Jaffe AS, Jneid H, Kelly RF, Kontos MC, Levine GN, Liebson PR, Mukherjee D, Peterson ED, Sabatine MS, Smalling RW, Zieman SJ Members AATF, Society for Cardiovascular A, Interventions and the Society of Thoracic S. 2014 AHA/ACC guideline for the management of patients with non-ST-elevation acute coronary syndromes: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. 2014;130:2354–2394. doi: 10.1161/CIR.0000000000000133. - PubMed
    1. Thygesen K, Alpert JS, White HD, Jaffe AS, Apple FS, Galvani M, Katus HA, Newby LK, Ravkilde J, Chaitman B, Clemmensen PM, Dellborg M, Hod H, Porela P, Underwood R, Bax JJ, Beller GA, Bonow R, Van der Wall EE, Bassand JP, Wijns W, Ferguson TB, Steg PG, Uretsky BF, Williams DO, Armstrong PW, Antman EM, Fox KA, Hamm CW, Ohman EM, Simoons ML, Poole-Wilson PA, Gurfinkel EP, Lopez-Sendon JL, Pais P, Mendis S, Zhu JR, Wallentin LC, Fernández-Avilés F, Fox KM, Parkhomenko AN, Priori SG, Tendera M, Voipio-Pulkki LM, Vahanian A, Camm AJ, De Caterina R, Dean V, Dickstein K, Filippatos G, Funck-Brentano C, Hellemans I, Kristensen SD, McGregor K, Sechtem U, Silber S, Tendera M, Widimsky P, Zamorano JL, Morais J, Brener S, Harrington R, Morrow D, Lim M, Martinez-Rios MA, Steinhubl S, Levine GN, Gibler WB, Goff D, Tubaro M, Dudek D, Al-Attar N Joint ESC/ACCF/AHA/WHF Task Force for the Redefinition of Myocardial Infarction. Universal definition of myocardial infarction. Circulation. 2007;116:2634–2653. doi: 10.1161/CIRCULATIONAHA.107.187397. - PubMed
    1. Taylor MJ, Scuffham PA, McCollam PL, Newby DE. Acute coronary syndromes in Europe: 1-year costs and outcomes. Curr Med Res Opin. 2007;23:495–503. doi: 10.1185/030079906X167462. - PubMed
    1. Tiemann O. Variations in hospitalisation costs for acute myocardial infarction: a comparison across Europe. Health Econ. 2008;17(s)(uppl 1):S33–S45. doi: 10.1002/hec.1322. - PubMed

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