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Circulation. 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.

Author information

1
Cardiovascular Research Institute Basel and Department of Cardiology, University Hospital Basel, University of Basel, Switzerland (R.T., P.B., J.B., T.N., K.W., C.P., Z.S., M.R.G., S.T., J.d.F.d.L., N.K., L.S., D.M., T.B., I.S., D.F.W., S.S., S.O., T.R., C.M.).
2
Department of General and Interventional Cardiology, University Heart Center Hamburg, University Hospital Hamburg-Eppendorf, Germany (R.T.).
3
Emergency Department, Hospital Clinic, Barcelona, Spain (O.M.).
4
Emergency Department, Hospital Clinico San Carlos, Madrid, Spain (F.J.M.S.).
5
2nd Cardiology Department, Zabrze, University Silesia, Katowice, Poland (B.M.).
6
Department of Cardiology, University Hospital Brno, Czech Republic (J.P.).
7
Medical Faculty, Masaryk University, Brno, Czech Republic (J.P.).
8
Emergency Department, Kantonsspital Liestal, Switzerland (N.G.).
9
Emergency Department, University Hospital Zürich, Switzerland (D.I.K.).
10
Department of Laboratory Medicine, University Hospital Basel, Switzerland (K.R.).
11
Department of Laboratory Medicine, University Hospital Zürich, Switzerland (A.v.E.).
12
Cardiovascular Research Institute Basel and Department of Cardiology, University Hospital Basel, University of Basel, Switzerland (R.T., P.B., J.B., T.N., K.W., C.P., Z.S., M.R.G., S.T., J.d.F.d.L., N.K., L.S., D.M., T.B., I.S., D.F.W., S.S., S.O., T.R., C.M.) christian.mueller@usb.ch.

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

PMID:
29101287
PMCID:
PMC5794234
DOI:
10.1161/CIRCULATIONAHA.117.028901
[Indexed for MEDLINE]
Free PMC Article

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