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

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

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.

Publication types

  • Multicenter Study
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Aged
  • Aged, 80 and over
  • Algorithms*
  • Biomarkers / blood
  • Creatinine / blood
  • Decision Support Techniques*
  • Europe / epidemiology
  • Female
  • Glomerular Filtration Rate*
  • Humans
  • Kidney / physiopathology*
  • Kidney Diseases / blood
  • Kidney Diseases / diagnosis
  • Kidney Diseases / epidemiology
  • Kidney Diseases / physiopathology*
  • Male
  • Middle Aged
  • Non-ST Elevated Myocardial Infarction / blood*
  • Non-ST Elevated Myocardial Infarction / diagnosis*
  • Non-ST Elevated Myocardial Infarction / epidemiology
  • Predictive Value of Tests
  • Prevalence
  • Prognosis
  • Prospective Studies
  • Reproducibility of Results
  • Risk Assessment
  • Risk Factors
  • Time Factors
  • Triage*
  • Troponin / blood*
  • Up-Regulation

Substances

  • Biomarkers
  • Troponin
  • Creatinine

Associated data

  • ClinicalTrials.gov/NCT00470587