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23 November 2021

Performance of the European Society of Cardiology 0/1-Hour, 0/2-Hour, and 0/3-Hour Algorithms for Rapid Triage of Acute Myocardial Infarction: An International Collaborative Meta-analysis

Authors: Cho-Han Chiang, MD https://orcid.org/0000-0002-5757-6161, Cho-Hung Chiang, MD, John W. Pickering, PhD https://orcid.org/0000-0001-9475-0344, Kiril M. Stoyanov, MD, Derek P. Chew, MBBS, MPH, PhD https://orcid.org/0000-0003-3593-296X, Johannes T. Neumann, MD https://orcid.org/0000-0002-9478-2757, Francisco Ojeda, PhD https://orcid.org/0000-0003-4037-144X, Nils A. Sörensen, MD https://orcid.org/0000-0002-7571-4847, Ke-Ying Su, MSc, Peter Kavsak, PhD https://orcid.org/0000-0003-4576-4744, Andrew Worster, MD, MSc https://orcid.org/0000-0001-7085-5061, Kenji Inoue, MD, PhD, Tonje R. Johannessen, MD https://orcid.org/0000-0001-9368-1471, Dan Atar, MD, Michael Amann, MD, Willibald Hochholzer, MD, Arash Mokhtari, MD, PhD https://orcid.org/0000-0002-6808-3442, Ulf Ekelund, MD, PhD https://orcid.org/0000-0002-0951-1582, Raphael Twerenbold, MD https://orcid.org/0000-0003-3814-6542, Christian Mueller, MD, PhD https://orcid.org/0000-0002-1120-6405, Philipp Bahrmann, MD, MHBA https://orcid.org/0000-0002-5894-3402, Nicolas Buttinger, MD https://orcid.org/0000-0002-6308-7794, Maureen Dooley, MD, Onlak Ruangsomboon, MD https://orcid.org/0000-0002-0848-7162, Richard M. Nowak, MD https://orcid.org/0000-0002-7453-9426, Christopher R. DeFilippi, MD https://orcid.org/0000-0002-0660-4943, William F. Peacock, MD https://orcid.org/0000-0002-2730-6742, Tomas G. Neilan, MD, MPH https://orcid.org/0000-0002-1513-8833, Michael A. Liu, MD, MPH, Wan-Ting Hsu, MSc https://orcid.org/0000-0002-6677-0951, Gin Hoong Lee, MD, Pui-Un Tang, MD https://orcid.org/0000-0003-0462-1384, Kevin Sheng-Kai Ma, DDS, Dirk Westermann, MD https://orcid.org/0000-0002-7542-1956, Stefan Blankenberg, MD, Evangelos Giannitsis, MD, PhD, Martin P. Than, MBBS https://orcid.org/0000-0001-9399-5227, and Chien-Chang Lee, MD, ScD https://orcid.org/0000-0002-1243-2463Author, Article, & Disclosure Information
Publication: Annals of Internal Medicine
Volume 175, Number 1

Abstract

Background:

The 2020 European Society of Cardiology (ESC) guidelines recommend using the 0/1-hour and 0/2-hour algorithms over the 0/3-hour algorithm as the first and second choices of high-sensitivity cardiac troponin (hs-cTn)–based strategies for triage of patients with suspected acute myocardial infarction (AMI).

Purpose:

To evaluate the diagnostic accuracies of the ESC 0/1-hour, 0/2-hour, and 0/3-hour algorithms.

Data Sources:

PubMed, Embase, Cochrane Central Register of Controlled Trials, Web of Science, and Scopus from 1 January 2011 to 31 December 2020. (PROSPERO: CRD42020216479)

Study Selection:

Prospective studies that evaluated the ESC 0/1-hour, 0/2-hour, or 0/3-hour algorithms in adult patients presenting with suspected AMI.

Data Extraction:

The primary outcome was index AMI. Twenty unique cohorts were identified. Primary data were obtained from investigators of 16 cohorts and aggregate data were extracted from 4 cohorts. Two independent authors assessed each study for methodological quality.

Data Synthesis:

A total of 32 studies (20 cohorts) with 30 066 patients were analyzed. The 0/1-hour algorithm had a pooled sensitivity of 99.1% (95% CI, 98.5% to 99.5%) and negative predictive value (NPV) of 99.8% (CI, 99.6% to 99.9%) for ruling out AMI. The 0/2-hour algorithm had a pooled sensitivity of 98.6% (CI, 97.2% to 99.3%) and NPV of 99.6% (CI, 99.4% to 99.8%). The 0/3-hour algorithm had a pooled sensitivity of 93.7% (CI, 87.4% to 97.0%) and NPV of 98.7% (CI, 97.7% to 99.3%). Sensitivity of the 0/3-hour algorithm was attenuated in studies that did not use clinical criteria (GRACE score <140 and pain-free) compared with studies that used clinical criteria (90.2% [CI, 82.9 to 94.6] vs. 98.4% [CI, 88.6 to 99.8]). All 3 algorithms had similar specificities and positive predictive values for ruling in AMI, but heterogeneity across studies was substantial. Diagnostic performance was similar across the hs-cTnT (Elecsys; Roche), hs-cTnI (Architect; Abbott), and hs-cTnI (Centaur/Atellica; Siemens) assays.

Limitation:

Diagnostic accuracy, inclusion and exclusion criteria, and cardiac troponin sampling time varied among studies.

Conclusion:

The ESC 0/1-hour and 0/2-hour algorithms have higher sensitivities and NPVs than the 0/3-hour algorithm for index AMI.

Primary Funding Source:

National Taiwan University Hospital.

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Supplemental Material

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Information & Authors

Information

Published In

cover image Annals of Internal Medicine
Annals of Internal Medicine
Volume 175Number 1January 2022
Pages: 101 - 113

History

Published online: 23 November 2021
Published in issue: January 2022

Keywords

Authors

Affiliations

Harvard Medical School, Boston, Massachusetts, and National Taiwan University College of Medicine, Taipei, Taiwan (Cho-Han Chiang)
Cho-Hung Chiang, MD
Taipei Tzu Chi Hospital, Buddhist Tzu Chi Foundation, New Taipei City, Taiwan (Cho-Hung Chiang)
Christchurch Hospital and University of Otago Christchurch, Christchurch, New Zealand (J.W.P.)
Kiril M. Stoyanov, MD
University Hospital of Heidelberg, Heidelberg, Germany (K.M.S., E.G.)
Derek P. Chew, MBBS, MPH, PhD https://orcid.org/0000-0003-3593-296X
Flinders University of South Australia, Adelaide, Australia (D.P.C.)
Monash University, Melbourne, Australia, and University Heart & Vascular Center Hamburg, Hamburg, Germany (J.T.N.)
University Heart & Vascular Center Hamburg, Hamburg, Germany (F.O., N.A.S., D.W., S.B.)
University Heart & Vascular Center Hamburg, Hamburg, Germany (F.O., N.A.S., D.W., S.B.)
Ke-Ying Su, MSc
National Taiwan University Hospital, Taipei, Taiwan (K.S., G.H.L., P.T.)
McMaster University, Hamilton, Ontario, Canada (P.K., A.W.)
McMaster University, Hamilton, Ontario, Canada (P.K., A.W.)
Kenji Inoue, MD, PhD
Juntendo University Nerima Hospital, Tokyo, Japan (K.I.)
Tonje R. Johannessen, MD https://orcid.org/0000-0001-9368-1471
University of Oslo and Oslo Accident and Emergency Outpatient Clinic, Oslo, Norway (T.R.J.)
Dan Atar, MD
Oslo University Hospital, Ullevaal, and University of Oslo, Oslo, Norway (D.A.)
Michael Amann, MD
University Heart Center Freiburg-Bad Krozingen, Bad Krozingen, Germany (M.A., W.H.)
Willibald Hochholzer, MD
University Heart Center Freiburg-Bad Krozingen, Bad Krozingen, Germany (M.A., W.H.)
Skåne University Hospital, Lund University, Lund, Sweden (A.M., U.E.)
Skåne University Hospital, Lund University, Lund, Sweden (A.M., U.E.)
University of Basel, Basel, Switzerland, University Heart and Vascular Center Hamburg, Hamburg, Germany, and German Center for Cardiovascular Research (DZHK) Partner Site Hamburg–Kiel–Lübeck (R.T.)
Christian Mueller, MD, PhD https://orcid.org/0000-0002-1120-6405
University of Basel, Basel, Switzerland (C.M.)
Philipp Bahrmann, MD, MHBA https://orcid.org/0000-0002-5894-3402
Friedrich-Alexander-University Erlangen-Nuremberg, Nuremberg, Germany (P.B.)
Brighton and Sussex University Hospitals NHS Trust, Brighton, United Kingdom (N.B., M.D.)
Maureen Dooley, MD
Brighton and Sussex University Hospitals NHS Trust, Brighton, United Kingdom (N.B., M.D.)
Siriraj Hospital, Mahidol University, Bangkok, Thailand (O.R.)
Henry Ford Health System, Detroit, Michigan (R.M.N.)
Christopher R. DeFilippi, MD https://orcid.org/0000-0002-0660-4943
Inova Heart and Vascular Institute, Falls Church, Virginia (C.R.D.)
Baylor College of Medicine, Houston, Texas (W.F.P.)
Tomas G. Neilan, MD, MPH https://orcid.org/0000-0002-1513-8833
Cardiovascular Imaging Research Center, Massachusetts General Hospital, Boston, Massachusetts (T.G.N.)
Michael A. Liu, MD, MPH
Warren Alpert Medical School of Brown University, Providence, Rhode Island (M.A.L.)
Harvard School of Public Health, Boston, Massachusetts (W.H.)
Gin Hoong Lee, MD
National Taiwan University Hospital, Taipei, Taiwan (K.S., G.H.L., P.T.)
National Taiwan University Hospital, Taipei, Taiwan (K.S., G.H.L., P.T.)
Kevin Sheng-Kai Ma, DDS
Center for Global Health, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, and National Taiwan University, Taipei, Taiwan (K.S.M.)
University Heart & Vascular Center Hamburg, Hamburg, Germany (F.O., N.A.S., D.W., S.B.)
Stefan Blankenberg, MD
University Heart & Vascular Center Hamburg, Hamburg, Germany (F.O., N.A.S., D.W., S.B.)
Evangelos Giannitsis, MD, PhD
University Hospital of Heidelberg, Heidelberg, Germany (K.M.S., E.G.)
Christchurch Hospital and Christchurch Heart Institute, University of Otago Christchurch, Christchurch, New Zealand (M.P.T.)
Chien-Chang Lee, MD, ScD https://orcid.org/0000-0002-1243-2463
The Centre for Intelligent Healthcare, National Taiwan University Hospital, Taipei, Taiwan (C.L.).
Acknowledgment: The authors thank the staff of the Core Labs, Department of Medical Research, National Taiwan University Hospital, for technical support and Professor Jeroen K. Vermunt for statistical advice. They also thank Professor Louise Cullen, Dr. Jaimi Greenslade, Dr. James Andruchow, and Mr. Connor O’Rielly for providing their data.
Grant Support: By the National Taiwan University Hospital (grant 107-FTN11).
Reproducible Research Statement: Study protocol: Available in the Supplement. Statistical code and data set: Available from Dr. Cho-Han Chiang (e-mail, [email protected]) or Professor C.C. Lee (e-mail, [email protected]).
Corresponding Author: Chien-Chang Lee, MD, ScD, Department of Emergency Medicine, National Taiwan University Hospital, 7 Chung-Shan South Road, Taipei, Taiwan; e-mail, [email protected].
Author Contributions: Conception and design: Cho-Han Chiang, Cho-Hung Chiang, K.M. Stoyanov, R. Twerenbold, C. Mueller, P. Bahrmann, K.S.K. Ma, D. Westermann, S. Blankenberg, E. Giannitsis, C.C.C. Lee.
Analysis and interpretation of the data: Cho-Han Chiang, Cho-Hung Chiang, J.W. Pickering, K.M. Stoyanov, J.T. Neumann, N.A. Sörensen, K.Y. Su, P. Kavsak, A. Worster, D. Atar, M. Amann, C. Mueller, P. Bahrmann, N. Buttinger, M. Dooley, R.M. Nowak, C.R. DeFilippi, T.G. Neilan, W.T. Hsu, G.H. Lee, K.S.K Ma, S. Blankenberg, E. Giannitsis, C.C. Lee.
Drafting of the article: Cho-Han Chiang, Cho-Hung Chiang, D.P. Chew, T.R. Johannessen, C. Mueller, P. Bahrmann, R.M. Nowak, C.R. DeFilippi, T.G. Neilan, M.A. Liu, W.T. Hsu, K.S.K. Ma, S. Blankenberg, E. Giannitsis, C.C. Lee.
Critical revision for important intellectual content: Cho-Han Chiang, Cho-Hung Chiang, J.W. Pickering, K.M. Stoyanov, D.P. Chew, J.T. Neumann, N.A. Sörensen, P. Kavsak, A. Worster, K. Inoue, T.R. Johannessen, D. Atar, M. Amann, W. Hochholzer, A. Mokhtari, U. Ekelund, R. Twerenbold, C. Mueller, P. Bahrmann, R.M. Nowak, C.R. DeFilippi, W.F. Peacock, T.G. Neilan, M.A. Liu, W.T. Hsu, K.S.K. Ma, D. Westermann, S. Blankenberg, E. Giannitsis, M.P. Than, C.C. Lee.
Final approval of the article: Cho-Han Chiang, Cho-Hung Chiang, J.W. Pickering, K.M. Stoyanov, D.P. Chew, J.T. Neumann, F. Ojeda, N.A. Sörensen, K.Y. Su, P. Kavsak, A. Worster, K. Inoue, T.R. Johannessen, D. Atar, M. Amann, W. Hochholzer, A. Mokhtari, U. Ekelund, R. Twerenbold, C. Mueller, P. Bahrmann, N. Buttinger, M. Dooley, O. Ruangsomboon, R.M. Nowak, C.R. DeFilippi, W.F. Peacock, T.G. Neilan, M.A. Liu, W.T. Hsu, G.H. Lee, P.U. Tang, K.S.K. Ma, D. Westermann, S. Blankenberg, E. Giannitsis, M.P. Than, C.C. Lee.
Provision of study materials or patients: Cho-Hung Chiang, K.M. Stoyanov, N.A. Sörensen, P. Kavsak, K. Inoue, T.R. Johannessen, D. Atar, W. Hochholzer, R. Twerenbold, C. Mueller, M. Dooley, O. Ruangsomboon, R.M. Nowak, K.S.K. Ma, D. Westermann, E. Giannitsis, C.C. Lee, J.W. Pickering, P. Bahrmann.
Statistical expertise: Cho-Hung Chiang, J.W. Pickering, F. Ojeda, K.Y. Su, C. Mueller, P. Bahrmann, W.T. Hsu, K.S.K. Ma, C.C. Lee.
Obtaining of funding: D.P. Chew, P. Kavsak, R. Twerenbold, P. Bahrmann, K.S.K. Ma, S. Blankenberg, C.C. Lee.
Administrative, technical, or logistic support: Cho-Han Chiang, Cho-Hung Chiang, K.Y. Su, P. Kavsak, M. Amann, W. Hochholzer, R. Twerenbold, U. Ekelund, C. Mueller, P. Bahrmann, W.T. Hsu, P.U. Tang, K.S.K. Ma, D. Westermann, C.C. Lee.
Collection and assembly of data: Cho-Han Chiang, Cho-Hung Chiang, J.W. Pickering, K.M. Stoyanov, D.P. Chew, J.T. Neumann, N.A. Sörensen, P. Kavsak, T.R. Johannessen, D. Atar, M. Amann, W. Hochholzer, A. Mokhtari, U. Ekelund, R. Twerenbold, C. Mueller, P. Bahrmann, N. Buttinger, M. Dooley, C.R. DeFilippi, P.U. Tang, K.S.K. Ma, D. Westermann, S. Blankenberg, E. Giannitsis, C.C. Lee.
This article was published at Annals.org on 23 November 2021.
* Drs. Cho-Han Chiang and Cho-Hung Chiang contributed equally to this work.

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Cho-Han Chiang, Cho-Hung Chiang, John W. Pickering, et al. Performance of the European Society of Cardiology 0/1-Hour, 0/2-Hour, and 0/3-Hour Algorithms for Rapid Triage of Acute Myocardial Infarction: An International Collaborative Meta-analysis. Ann Intern Med.2022;175:101-113. [Epub 23 November 2021]. doi:10.7326/M21-1499

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