title: Assessment of the European Society of Cardiology 0-Hour/1-Hour Algorithm to Rule-Out and Rule-In Acute Myocardial Infarction.
abstract: BACKGROUND
  The new European Society of Cardiology guidelines to rule-in and rule-out acute myocardial infarction (AMI) in the emergency department include a rapid assessment algorithm based on high-sensitivity cardiac troponin and sampling at 0 and 1 hour. Emergency department physicians require high sensitivity to confidently rule-out AMI, whereas cardiologists aim to minimize false-positive results.
  
  
  METHODS
  High-sensitivity troponin I and T assays were used to measure troponin concentrations in patients presenting with chest-pain symptoms and being investigated for possible acute coronary syndrome at hospitals in New Zealand, Australia, and Canada. AMI outcomes were independently adjudicated by at least 2 physicians. The European Society of Cardiology algorithm performance with each assay was assessed by the sensitivity and proportion with AMI ruled out and the positive predictive value and proportion ruled-in.
  
  
  RESULTS
  There were 2222 patients with serial high-sensitivity troponin T and high-sensitivity troponin I measurements. The high-sensitivity troponin T algorithm ruled out 1425 (64.1%) with a sensitivity of 97.1% (95% confidence interval [CI], 94.0%-98.8%) and ruled-in 292 (13.1%) with a positive predictive value of 63.4% (95% CI, 57.5%-68.9%).The high-sensitivity troponin I algorithm ruled out 1205 (54.2%) with a sensitivity of 98.8% (95% CI, 96.4%-99.7%)) and ruled-in 310 (14.0%) with a positive predictive value of 68.1% (95% CI, 62.6%-73.2%).
  
  
  CONCLUSIONS
  The sensitivity of the European Society of Cardiology rapid assessment 0-/1-hour algorithm to rule-out AMI with high-sensitivity troponin may be insufficient for some emergency department physicians to confidently send patients home. These algorithms may prove useful to identify patients requiring expedited management. However, the positive predictive value was modest for both algorithms.
authors.affiliation: From Emergency Department (J.W.P., M.P.T.), and Cardiology Department (S.A.), Christchurch Hospital, Christchurch, New Zealand; Department of Medicine, University of Otago, Christchurch, New Zealand (J.W.P.); Department of Emergency Medicine, Royal Brisbane and Women's Hospital, The University of Queensland and School of Public Health, Queensland University of Technology, Brisbane, Australia (J.H.G., L.C., D.F.); Department of Cardiology, Royal Brisbane and Women's Hospital, Brisbane, Australia (W.P.); Canterbury Health Laboratories, Christchurch, New Zealand (P.G.); and McMaster University, Hamilton, Ontario, Canada (A.W., P.A.K.).
authors.forename: John W
authors.initials: JW
authors.lastname: Pickering
authors.affiliation: From Emergency Department (J.W.P., M.P.T.), and Cardiology Department (S.A.), Christchurch Hospital, Christchurch, New Zealand; Department of Medicine, University of Otago, Christchurch, New Zealand (J.W.P.); Department of Emergency Medicine, Royal Brisbane and Women's Hospital, The University of Queensland and School of Public Health, Queensland University of Technology, Brisbane, Australia (J.H.G., L.C., D.F.); Department of Cardiology, Royal Brisbane and Women's Hospital, Brisbane, Australia (W.P.); Canterbury Health Laboratories, Christchurch, New Zealand (P.G.); and McMaster University, Hamilton, Ontario, Canada (A.W., P.A.K.).
authors.forename: Jaimi H
authors.initials: JH
authors.lastname: Greenslade
authors.affiliation: From Emergency Department (J.W.P., M.P.T.), and Cardiology Department (S.A.), Christchurch Hospital, Christchurch, New Zealand; Department of Medicine, University of Otago, Christchurch, New Zealand (J.W.P.); Department of Emergency Medicine, Royal Brisbane and Women's Hospital, The University of Queensland and School of Public Health, Queensland University of Technology, Brisbane, Australia (J.H.G., L.C., D.F.); Department of Cardiology, Royal Brisbane and Women's Hospital, Brisbane, Australia (W.P.); Canterbury Health Laboratories, Christchurch, New Zealand (P.G.); and McMaster University, Hamilton, Ontario, Canada (A.W., P.A.K.).
authors.forename: Louise
authors.initials: L
authors.lastname: Cullen
authors.affiliation: From Emergency Department (J.W.P., M.P.T.), and Cardiology Department (S.A.), Christchurch Hospital, Christchurch, New Zealand; Department of Medicine, University of Otago, Christchurch, New Zealand (J.W.P.); Department of Emergency Medicine, Royal Brisbane and Women's Hospital, The University of Queensland and School of Public Health, Queensland University of Technology, Brisbane, Australia (J.H.G., L.C., D.F.); Department of Cardiology, Royal Brisbane and Women's Hospital, Brisbane, Australia (W.P.); Canterbury Health Laboratories, Christchurch, New Zealand (P.G.); and McMaster University, Hamilton, Ontario, Canada (A.W., P.A.K.).
authors.forename: Dylan
authors.initials: D
authors.lastname: Flaws
authors.affiliation: From Emergency Department (J.W.P., M.P.T.), and Cardiology Department (S.A.), Christchurch Hospital, Christchurch, New Zealand; Department of Medicine, University of Otago, Christchurch, New Zealand (J.W.P.); Department of Emergency Medicine, Royal Brisbane and Women's Hospital, The University of Queensland and School of Public Health, Queensland University of Technology, Brisbane, Australia (J.H.G., L.C., D.F.); Department of Cardiology, Royal Brisbane and Women's Hospital, Brisbane, Australia (W.P.); Canterbury Health Laboratories, Christchurch, New Zealand (P.G.); and McMaster University, Hamilton, Ontario, Canada (A.W., P.A.K.).
authors.forename: William
authors.initials: W
authors.lastname: Parsonage
authors.affiliation: From Emergency Department (J.W.P., M.P.T.), and Cardiology Department (S.A.), Christchurch Hospital, Christchurch, New Zealand; Department of Medicine, University of Otago, Christchurch, New Zealand (J.W.P.); Department of Emergency Medicine, Royal Brisbane and Women's Hospital, The University of Queensland and School of Public Health, Queensland University of Technology, Brisbane, Australia (J.H.G., L.C., D.F.); Department of Cardiology, Royal Brisbane and Women's Hospital, Brisbane, Australia (W.P.); Canterbury Health Laboratories, Christchurch, New Zealand (P.G.); and McMaster University, Hamilton, Ontario, Canada (A.W., P.A.K.).
authors.forename: Sally
authors.initials: S
authors.lastname: Aldous
authors.affiliation: From Emergency Department (J.W.P., M.P.T.), and Cardiology Department (S.A.), Christchurch Hospital, Christchurch, New Zealand; Department of Medicine, University of Otago, Christchurch, New Zealand (J.W.P.); Department of Emergency Medicine, Royal Brisbane and Women's Hospital, The University of Queensland and School of Public Health, Queensland University of Technology, Brisbane, Australia (J.H.G., L.C., D.F.); Department of Cardiology, Royal Brisbane and Women's Hospital, Brisbane, Australia (W.P.); Canterbury Health Laboratories, Christchurch, New Zealand (P.G.); and McMaster University, Hamilton, Ontario, Canada (A.W., P.A.K.).
authors.forename: Peter
authors.initials: P
authors.lastname: George
authors.affiliation: From Emergency Department (J.W.P., M.P.T.), and Cardiology Department (S.A.), Christchurch Hospital, Christchurch, New Zealand; Department of Medicine, University of Otago, Christchurch, New Zealand (J.W.P.); Department of Emergency Medicine, Royal Brisbane and Women's Hospital, The University of Queensland and School of Public Health, Queensland University of Technology, Brisbane, Australia (J.H.G., L.C., D.F.); Department of Cardiology, Royal Brisbane and Women's Hospital, Brisbane, Australia (W.P.); Canterbury Health Laboratories, Christchurch, New Zealand (P.G.); and McMaster University, Hamilton, Ontario, Canada (A.W., P.A.K.).
authors.forename: Andrew
authors.initials: A
authors.lastname: Worster
authors.affiliation: From Emergency Department (J.W.P., M.P.T.), and Cardiology Department (S.A.), Christchurch Hospital, Christchurch, New Zealand; Department of Medicine, University of Otago, Christchurch, New Zealand (J.W.P.); Department of Emergency Medicine, Royal Brisbane and Women's Hospital, The University of Queensland and School of Public Health, Queensland University of Technology, Brisbane, Australia (J.H.G., L.C., D.F.); Department of Cardiology, Royal Brisbane and Women's Hospital, Brisbane, Australia (W.P.); Canterbury Health Laboratories, Christchurch, New Zealand (P.G.); and McMaster University, Hamilton, Ontario, Canada (A.W., P.A.K.).
authors.forename: Peter A
authors.initials: PA
authors.lastname: Kavsak
authors.affiliation: From Emergency Department (J.W.P., M.P.T.), and Cardiology Department (S.A.), Christchurch Hospital, Christchurch, New Zealand; Department of Medicine, University of Otago, Christchurch, New Zealand (J.W.P.); Department of Emergency Medicine, Royal Brisbane and Women's Hospital, The University of Queensland and School of Public Health, Queensland University of Technology, Brisbane, Australia (J.H.G., L.C., D.F.); Department of Cardiology, Royal Brisbane and Women's Hospital, Brisbane, Australia (W.P.); Canterbury Health Laboratories, Christchurch, New Zealand (P.G.); and McMaster University, Hamilton, Ontario, Canada (A.W., P.A.K.). martinthan@xtra.co.nz.
authors.forename: Martin P
authors.initials: MP
authors.lastname: Than
mesh_terms: D005060:Europe; D005260:Female; D006801:Humans; D008297:Male; D009203:Myocardial Infarction / Q000175:diagnosis*; D019210:Troponin I / Q000737:chemistry*; D020107:Troponin T / Q000737:chemistry*
chemical_list: D019210:Troponin I; D020107:Troponin T
keywords: diagnosis; emergency department; emergency medicine; myocardial infarction; troponin